Pediatric Facial Fracture Surgical Management at a Level 1 Trauma Center

Background:

Management of pediatric facial fractures is unique to that of the adult population due to the greater cranium to face ratio, lack of developed sinuses, greater elasticity, and their continued growth. Our study is one of the largest single institution studies performed looking at the surgical management of pediatric facial fractures.

Methods:

We performed an IRB approved retrospective review of pediatric patients (age≤18years) who presented to a level one pediatric trauma center with ≥1 facial fractures from January 2006 to December 2015. Data abstracted included demographics, fracture location, mechanism of injury, concomitant head and neck injuries, and surgical management. Statistical analysis employed Chi Square tests for categorical variables with p<0.05 for significance. Univariate logistic regression was conducted and variables with a p<0.20 were included in multivariate analysis.

Results:

1277 patients met inclusion criteria, of which 517 (40.5%) patients underwent surgical management for their facial fractures. Comparison of operation rates between gender, ethnicity, and median income based on zip code showed no significant difference. Surgery occurred at a median of 2 days (IQR 1-4 days) following admission with 467 patients (90.3%) receiving intervention during their primary admission. Mandible fractures had the highest operation rate (70.3%) and orbital fractures had the lowest (26.5%) (p<0.001). Other operative rates by bony location were nasal fractures 27.6%, maxillary fractures 46.0%, and zygomatic fractures 48.9%. 314 (24.6%) patients presented with a concomitant skull fracture and showed a lower operative rate (28.3%) for the management of their facial fractures as compared to patients without skull fractures (44.4%, p<0.001). Univariate analysis demonstrated that age, mechanism, type of fracture, and violence were associated with a higher risk of surgical intervention. Concomitant injuries of the skull and cervical spine, need for intensive care, traumatic brain injury, and Hispanic ethnicity were associated with reduced likelihood of surgery. Following multivariate analysis, associations for increased likelihood of surgery remained for increased age and mandible and LeFort pattern fractures. Decreased likelihood for surgery remained for traumatic brain injury. A ROC of the multivariate analysis yielded an area under the curve of 0.82. Looking closer at the patients with traumatic brain injury, they were found to have a higher mortality rate (13.3%) compared to non-TBI patients (1.1%) as well as significantly fewer mandible fractures and more orbital fractures (p <0.001).

Conclusion:

As patients age, their need for surgical management increases as their bones lose their more absorptive porous nature. Mandible and Le Fort fractures are associated with higher odds of surgical intervention. Presentation with concomitant traumatic brain injury is associated with reduced odds of operative management of facial fractures due to a higher mortality as well as a different fracture pattern such that orbital fractures are more common and mandible fractures are less common.