This study aimed to define better the clinical presentation, fracture patterns, and features predictive of associated injuries and need for surgery in pediatric facial trauma patients in an urban setting. Charts of patients 18 years or younger with International Classification of Disease 9th and 10th revision (ICD-9/ICD-10) codes specific for facial fractures (excluding isolated nasal fractures) at NY-Presbyterian/Weill Cornell Medical Center between 2008 and 2017 were retrospectively reviewed. Of 204 patients, most were referred to the emergency department by a physician's office or self-presented. Children (age 0–6 years) were most likely to have been injured by falls, while more patients 7 to 12 years and 13 to 18 years were injured during sporting activities (p < 0.0001). Roughly half (50.5%) of the patients had a single fracture, and the likelihood of surgery increased with greater numbers of fractures. Older patients with either orbital or mandibular fractures were more likely to undergo surgery than younger ones (p = 0.0048 and p = 0.0053, respectively). Cranial bone fractures, CSF leaks, and intracranial injuries were more common in younger patients (p < 0.0001) than older patients and were more likely after high energy injuries; however, 16.2% of patients sustaining low energy injuries also sustained cranial bone, CSF leak, or intracranial injury. In an urban environment, significant pediatric facial fractures and associated injuries may occur after nonclassic low kinetic energy traumatic events. The age of the patient impacts both the injuries sustained and the treatment rendered. It is essential to maintain a high index of suspicion for associated injuries in all pediatric facial trauma patients.
Among zygomaticomaxillary complex (ZMC) fractures presenting to a tertiary urban academic center, the authors hypothesized the presence of both clinical and radiographic predictors of operative management. The investigators conducted a retrospective cohort study of 1,914 patients with facial fractures managed at an academic medical center in New York City between 2008 and 2017. The predictor variables were based on both clinical data and features of pertinent imaging studies, and the outcome variable was an operative intervention. Descriptive and bivariate statistics were computed and the p-value was set at 0.05. In total, 196 patients sustained ZMC fractures (5.0%) and 121 (61.7%) ZMC fractures were treated surgically. All patients who presented with globe injury, blindness, retrobulbar injury, restricted gaze, or enophthalmos and a concurrent ZMC fracture were managed surgically. The most common surgical approach was the gingivobuccal corridor (31.9% of all approaches), and there were no significant immediate postoperative complications. Younger patients (38.9 ± 18 years vs. 56.1 ± 23.5 years, p < 0.0001) and patients with greater than or equal to 4 mm of orbital floor displacement were more likely to receive surgical treatment than observation (82 vs. 56%, p = 0.045), as were patients with comminuted orbital floor fractures (52 vs. 26%, p = 0.011). In this cohort, patients more likely to undergo surgical reduction were young patients with ophthalmologic symptoms on presentation and at least 4 mm displacement of the orbital floor. Low kinetic energy ZMC fractures may warrant surgical management as often as high-energy ZMC fractures. While orbital floor comminution has been shown to be a predictor for operative reduction, in this study we also demonstrated a difference in the rate of reduction based on the severity of orbital floor displacement. This may have significant implications in both the triage and selection of patients most suitable for operative repair.
Purpose: Among zygomaticomaxillary complex (ZMC) fractures presenting to a tertiary urban academic center, the authors hypothesized the presence of both clinical and radiographic predictors of operative management. Methods: The investigators implemented a retrospective cohort study of 1914 patients with ZMC fractures managed at an academic medical center in New York City between 2008 – 2017. The predictor variables were based on both clinical data and features of pertinent imaging studies, and the outcome variable was operative intervention. Descriptive and bivariate statistics were computed and the P value was set at .05. Findings: 196 patients sustained ZMC fractures (5.0%) and 121 (61.7%) ZMC fractures were treated surgically. All patients who presented with globe injury, blindness, retrobulbar injury, restricted gaze, or enophthalmos and a concurrent ZMC fracture were managed surgically. The most common surgical approach was the gingivobuccal corridor (31.9% of all approaches) and there were no significant immediate postoperative complications. Younger patients (38.9 + 18 years vs. 56.1 + 23.5 years, p<0.0001), patients with greater than or equal to 4mm of orbital floor displacement were more likely to receive surgical treatment than observation (82 vs. 56%, p=0.045), as were patients with comminuted orbital floor fractures (52 vs. 26%, p=0.011). Conclusion: In this cohort, patients more likely to undergo surgical reduction were young patients with ophthalmologic symptoms on presentation and at least 4mm displacement of the orbital floor. Low kinetic energy ZMC fractures may warrant surgical management as often as high energy ZMC fractures. While orbital floor comminution has been shown to be a predictor for operative reduction, in this study we also demonstrated a difference in rate of reduction based upon severity of orbital floor displacement. This may have significant implications in both the triage and selection of patients most suitable for operative repair.
We have used a simple geometric model to examine forces affecting the nasal valve after dorsal reduction and spreader graft placement. The study was designed on the geometric modeling of the internal nasal valve (INV). Published measurements of the leptorrhine nose were used to construct a geometric model of the INV. The changes in the cross-sectional area (CSA) occurring after reduction rhinoplasty were calculated algebraically, as was the effect of these changes on the tendency of the lateral wall of the INV to collapse. The effect of spreader grafting on the CSA was determined, and the total change in CSA of the INV in various scenarios was determined and compared with the reported normal CSA. Relative to published norms, the gain in CSA from spreader grafting can be significant if thick grafts are used. When the lateral wall of the INV is conceptualized as a cantilevered beam fixed medially, the reduction of length reduction of the lateral segment of the INV can significantly reduce the tendency for the inward collapse of the lateral wall. The reduction in CSA of the INV associated with dorsal nasal reduction can be ameliorated through the placement of spreader grafts. Moreover, the reduction in length of the INV sidewall also limits inward collapse, assuming it is firmly reattached to the dorsal septum. An enhanced appreciation of the physical properties of the INV anticipated through a simplified geometric analysis will be invaluable to the rhinological surgeon interested in enhancing nasal function.
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