Facial fractures

Emergency room physicians frequently see facial fractures that can have serious consequences for patients if mismanaged. This article reviews the signs, symptoms, imaging techniques, and general modes of treatment of common facial fractures. It focuses on fractures of the mandible, zygomaticomaxillary region, orbital floor, and nose.

Conservative treatment of a traumatic subdural hematoma of the posterior fossa in a child: case report

Traumatic posterior fossa hematomas are uncommon. Subdural hematomas in this location are probably the rarest. The natural history in acute cases is one of rapid deterioration and death from brain-stem compression. Rapid surgical intervention is indicated in acute cases. We report a case of a traumatic posterior fossa subdural hematoma in a 3-year-old child treated conservatively with a good outcome.

Diagnosis and management of occipital condyle fractures

The authors recently treated three cases involving fractures of the occipital condyle. First described by Bell in 1817, this lesion has proven to be very rare, with only 32 cases previously reported in the literature. Plain films often do not reveal any abnormality, making diagnosis difficult. High-resolution computed tomography has been demonstrated to be very sensitive in diagnosing this lesion. This fact was borne out in the authors' series. All of the authors' patients were managed either with a Philadelphia collar or with halo fixation, with excellent outcomes.

Management of petrous bone fractures in children: analysis of 127 cases

Petrous bone fractures (PBF) in children are relatively frequent. They are mostly diagnosed after collisions and falls. The complications typically associated with PBF were different types of hearing disorders in 69.1% of the patients who had audiometry, liquorrhea in 16.5%, palsy of cranial nerves in 10.8% (facial nerve palsy in 9.4%), bacterial meningitis, stenosis of the external ear canal, and posttraumatic cholesteatoma in 0.7% of the fractures each. Most complications were transient; 8.6% of the patients underwent surgery because of PBF-related complications and 9.4% suffered from severe, irreversible sequelae. Management of PBF in children requires an interdisciplinary approach between pediatric surgeons and pediatric ear, nose, and throat (ENT) specialists. It basically includes daily examination for cranial nerve palsy, liquorrhea, and meningitis during hospitalization as well as routine audiometric examination and antibiotic prophylaxis. Routine vaccination against Streptococcus pneumoniae as a new standard procedure and subtotal petrosectomy after transverse fracture as a new surgical modality are strongly recommended in order to lower the incidence of posttraumatic meningitis. Severe complications such as persistent hearing loss, persistent liquorrhea, cranial nerve palsy, and posttraumatic meningitis require aggressive diagnostic and therapeutic measures in order to minimize further morbidity and irreversible deficits.

[Treatment of severe craniocerebral injuries]

During 1992. 19357 patients were examined at the Department for Neurosurgery of the Emergency Centre, Clinical Center of Serbia, out of which 15879 had head injury. In addition to those necessitating hospitalisation, there was also a large number of patients with mild head injury that were not admitted for hospital management and were sent home following initial first aid. The average incidence of these patients was 45 patients per day during 1992. During 1992. a total of 1,978 patients were hospitalised, out of which 1,520 (84%) were injured. A total of 633 patients (25%) were hospitalised due to injuries sustained in traffic accidents. All patients were examined and evaluated according to the standard protocol including GCS as well.

Primary care management of maxillofacial injuries in sports

Injuries to the maxillofacial region sustained in sports related trauma are increasing in the United States. The pediatric (age 12 and younger) and teenage populations account for the greatest number of these injuries primarily due to increased team sports participation in these younger age groups. A severe injury to the maxillofacial region can have devastating psychological effects as well as being physically debilitating. Therefore, early treatment of soft tissue and bony injuries will minimize scarring and decrease potentially adverse psychological implications. Sports trauma is a frequent source of maxillofacial injuries especially in the younger population. Basic protective equipment, such as proper fitting helmets, mouth guards and face masks, are still not mandatory, or rules not enforced, in many youth hockey and football leagues. In addition, the increased popularity of multispeed bicycles, dirt bikes, and off-road vehicles (e.g. snowmobiles, go-carts) in the hands of unrestrained and unprotected children and adolescents has contributed to an increasing number of maxillofacial injuries in these groups.

Elevation of depressed skull fracture in the neonate by obstetrical vacuum extractor

In this article, three cases of neonatal depressed skull fracture were successfully elevated by means of an obstetrical vacuum extractor. No complications from the procedure were observed. Neonatal depressed skull fractures which are not associated with neurological signs may be safely elevated without surgery by using the obstetrical vacuum extractor. This simple, atraumatic procedure should be considered first for the management of uncomplicated depressed skull fracture in the newborn.

The value of radiographs in the management of the fractured nose

Over a 6-month period a record was kept of all patients presenting to the accident and emergency (A&E) department with nasal injuries. The results of the nasal radiographs were analysed to gauge their benefit. It was found that there was poor correlation between the radiological findings and the presence of external deformity, the latter determining the decision to carry out treatment. Routine radiographs of the nose are unnecessary in patients with nasal trauma.

Intracranial placement of a nasogastric tube after complex craniofacial trauma

The complication of intracranial placement of a nasogastric tube in patients with complex facial and skull base fractures is rarely seen. A case report of a patient with complex craniofacial injury after trauma in whom a computerized tomogram scan showed passage of a nasogastric tube via a fracture of the anterior cranial fossa floor into the skull vault is presented. This case stresses the caution to be exercised in the emergency room resusitation of patients with craniofacial injury requiring nasogastric tube placement.

[Management of the patient with craniocerebral injuries at the accident site and clinic admission]

Between January 1991 and December 1992, there were 686 rescue operations involving patients with craniocerebral trauma in the catchment area of Ulm. There were 376 patients who had to be graded as seriously injured according to the NACA classification. In 178 cases there was a severe craniocerebral trauma, and 131 of these patients were admitted to the traumatology department of the University of Ulm. The pattern of injuries was analysed; multiple injuries were found in 63 patients, with injuries to the extremities and the thorax being most-frequent. The primary preclinical treatment for patients with craniocerebral trauma is demonstrated; the indications for intubation and artificial respiration are discussed, and also the selection of drugs. Diagnostic procedures and immediate treatment must initially be directed at securing vital functions. Treatment of life-threatening haemorrhage has priority over neurosurgical diagnosis and therapy. The urgent indications for neurosurgical intervention are: space-occupying intracranial bleeding, open craniocerebral traumas, and space-occupying depressed fractures.

Nonsurgical treatment of compound depressed skull fractures

Classical treatment of compound depressed skull fractures includes debridement and closure of all scalp wounds to minimize the risk of delayed intracranial infection. In selected situations, a nonsurgical approach may prove to be equally safe. Over a 33-month period, we evaluated 1075 patients for head trauma. There were 63 patients with non-missile, compound depressed skull fractures (9 of these 63 patients have been excluded for deaths that occurred within 4 days of admission). Patients with significant intracranial hematomas or dural violations over the convexity of the brain underwent formal surgical therapy. Surgical therapy was performed on 28 patients (52%; age 33 +/- 3 years; ISS 24 +/- 2) and it consisted of craniotomy with debridement, elevation of depressed fragments, repair of dural tears, and evacuation of hematomas. Nonsurgical treatment was used if there was no evidence of violation of the dura mater and of significant intracranial hematoma. If the following criteria were satisfied, then the nonsurgical approach was employed: no evidence of exposed brain or a cerebrospinal fluid leak, no pneumocephalus related to the fracture, no depressed fragments of bone more than 1 cm below the inner table of the skull, and no gross wound contamination. Nonsurgical therapy was used on 26 patients (48%; age 34 +/- 3 years; ISS 19 +/- 2) and it consisted of wound irrigation, debridement, and closure. In all 54 patients of both subsets of patients, intravenous antibiotics were administered for 5 to 7 days. After two additional days of observation, off antibiotics, the patients were discharged. There were no infectious complications related to the central nervous system.(ABSTRACT TRUNCATED AT 250 WORDS)

The use of orthodontic chain elastic for temporary intermaxillary fixation

A method of application of firm and resilient temporary intermaxillary fixation using readily available orthodontic elastomeric chain is described. Advantages lie in the time efficiency of its use, relative safety compared to tie-wiring techniques, flexibility of direction of pull, and the ease and rapidity with which it can be removed. Consideration is given to other potential uses of the material in the retention of various appliances used in orthognathic procedures.

Pediatric facial fractures: evolving patterns of treatment

This study reviews the treatment of facial trauma between October 1986 and December 1990 at a major pediatric referral center. The mechanism of injury, location and pattern of facial fractures, pattern of facial injury, soft tissue injuries, and any associated injuries to other organ systems were recorded, and fracture management and perioperative complications reviewed. The study population consisted of 137 patients who sustained 318 facial fractures. Eighty-one patients (171 fractures) were seen in the acute stage, and 56 patients (147 fractures) were seen for reconstruction of a secondary deformity. Injuries in boys were more prevalent than in girls (63% versus 37%), and the 6- to 12-year cohort made up the largest group (42%). Most fractures resulted from traffic-related accidents (50%), falls (23%), or sports-related injuries (15%). Mandibular (34%) and orbital fractures (23%) predominated; fewer midfacial fractures (7%) were sustained than would be expected in a similar adult population. Three quarters of the patients with acute fractures required operative intervention. Closed reduction techniques with maxillomandibular fixation were frequently chosen for mandibular condyle fractures and open reduction techniques (35%) for other regions of the facial skeleton. When open reduction was indicated, plate-and-screw fixation was the preferred method of stabilization (65%). The long-term effects of the injuries and the treatment given on facial growth remain undetermined. Perioperative complication rates directly related to the surgery were low.

Diagnosis and treatment of fractures of the facial bones in children 1943-1993

It is clear that the foundations for diagnosis and the basic principles of management have changed little since 1943 and probably since the work of Kazanjian in World War I. Major advances have occurred, with modern techniques of airway management (particularly fiberoptic laryngoscopy), anesthesia, and an understanding of fluid and electrolyte balance and behavioral issues in children. In addition, the advent of antibiotics; new imaging techniques (particularly CT), and availability of new instrumentation and rigid internal fixation have all revolutionized the specific treatment of pediatric facial fractures. Craniofacial techniques, pioneered by Dr Paul Tessler, have significantly altered and improved treatment of pediatric midface fractures. Progress in the biology of bone healing will surely mark the next 50 years.

The management of depressed skull fractures in children at Muhimbili Medical Centre, Dar es Salaam, Tanzania

Thirty eight consecutive children with depressed fracture of the skull admitted to the Paediatric Surgical Unit (PSU) of Muhimbili Medical Centre (MMC), Dar es Salaam between January 1986 to May 1992 were studied. There were 22 boys and 16 girls. Age range was from birth to 10 years. A fall of one form or another accounted for 25 (65.00%) patients. Falling from a sister's or mother's back occurred in 4 (10.5%) patients, while falling from trees was a cause in 8 (21%) patients. Objects hitting on the head accounted for 6 (15.8%) patients. The objects included stones in 3 and falling coconut fruits in three. Traffic motor accidents accounted for 5 (13.2%) patients. In 35 (92.1%) patients, the fractures were closed while in 3 (7.9%) they were open. The fractures were located in the frontal or parietal bone in 27 (76.3%) patients. The 3 coconut fractures were located at the sagittal area. Only 4 (10.5%) patients had focal neurological signs. Convulsions were recorded in 3 patients while loss of consciousness was observed in 4 patients. Surgery was performed on 22 (57.9%) patients while conservative approach was practised in 16 (42.1%). The indications for surgery were cosmetics in 15 patients, compound fracture in 3 patients, focal neurological deficit in 2 patients, and torn dura presenting with Pseudo-meningocele in 2 patients.

Management of low-risk head injuries in an entire area: results of an 18-month survey

All patients admitted following a minor head injury (GCS is without neurological deficits) during an 18 month period in an entire area were submitted to the same diagnostic and therapeutic protocol. Adult patients were x rayed and in the cases with skull fracture (even asymptomatic), a computed tomographic (CT) scan was performed. Children (below the age of 14) did not routinely receive skull X-rays but were admitted to one of the five regional hospitals where a CT scanner was available 24 hours per day. Neuroradiologic investigations (carried out in over 600 patients) showed posttraumatic lesions in 201 cases; 113 of these patients were transferred to the neurosurgical center. There were 49 patients with extradural hematomas, 41 with brain contusions, 17 with depressed skull fractures, and six with subdural hematomas. Of these 113, 40 patients were operated on (mainly extradural hematomas); surgical indications were based on appearance of clinical deterioration, lesion volume, presence of midline shift, and/or compressed third ventricle and basal cisterns. In eight cases there was a clinical deterioration to a GCS of 13 or less; in all of these patients, the CT diagnosis (and transfer to a neurosurgical center, preceded the onset of deterioration. All patients admitted to such a center had a good outcome, but a survey of deaths related to head injury in the area revealed two fatalities following minor head injury. The only avoidable death was a patient with multiple brain contusions who developed sudden brain swelling on day 12 post-trauma. We conclude that, even if management mortality is not zero, our protocol is sufficiently safe for the treatment of minor head injury.

[Management of fractures of the face]

During 1985-1989, 371 patients with fractures of the lower two thirds of the facial skeleton were treated. Mean age was 31.2 years and there was a male prevalence of 78%. An equal distribution was found between fractures of the middle and lower third of the face. Our clinical experience has shown that it is preferable to start treatment as early as possible, using an open approach for reduction of fractures and rigid methods of fixation. Rigid internal fixation enables the patient to keep his jaws functional postoperatively and prevents the need for maxillomandibular fixation for 6 weeks. 6-month follow-up showed a low incidence of bone infection (1.5%), although most fractures were exposed to contaminated spaces. The major complication of treatment was impaired sensation of the lips and infraorbital regions (23%). In a follow-up of up to 1 year, the occurrence of this complication decreased to 7%.

Frontal sinus fractures in the pediatric population

Full development of the frontal sinus is not achieved until approximately 19 years of age. An evaluation of frontal sinus injuries isolated to the subset of patients less than 20 years old has yet to be reported. In order to determine whether age was a factor in the clinical course of patients with frontal sinus fractures, 209 patients who sustained frontal sinus fractures from January 1985 to April 1990 were identified using the trauma registry from all six major trauma centers, one of which is a pediatric trauma center, in a county of 2.5 million people. Forty patients (19%) were between the ages of 6 and 19 years at the time of their injury. Computed tomography imaging of these pediatric patients identified associated head and neck fractures in 37 (93%) as well as significant central nervous system injury in 22 (55%). Seventeen pediatric patients were treated nonoperatively and 1 died prior to the planned surgery. A detailed analysis of extent of injury and treatment together with a comparison of the 169 adult and the 40 pediatric patients is presented.

Facial trauma. Assessment and treatment

Management of facial trauma requires immediate attention to patency of the airway and to circulation. This article outlines an assessment procedure for patients with facial injuries and presents treatment guidelines.

Maxillofacial trauma in severely injured patients

A study was made of maxillofacial trauma in seriously injured patients to determine the likely role of oral and maxillofacial surgeons working in the regional trauma centres proposed by the Royal College of Surgeons of England. There were 153 patients, aged 70 years or less, who sustained major trauma (injury severity score 16 or more) and were admitted directly to the accident departments of the Bristol Royal Infirmary or Derriford Hospital, Plymouth during 1989. Maxillofacial injuries occurred in 50 (33%) of these patients with lacerations present in 39, burns in 1 and facial bone fractures in 28 (18%); soft tissue abrasions and contusions were excluded. The aetiology, patterns of injury, surgical treatment and outcome were reviewed. The implications for the provision of maxillofacial surgical services in regional trauma centres is discussed.

Closed depressed skull fracture in childhood reduced with suction cup method: case report

A closed depressed skull fracture in a child was reduced with a suction cup. This method keeps the fracture closed and leaves no scar.

Diagnosis and management of sports-related injuries to the face

The face is often the most exposed part of the body during athletic competition. This article concentrates on sports-related injuries to the zygoma and periorbital area, the maxilla, the nose, and the external ear. Discussions of the management of soft-tissue injuries and the diagnosis and treatment of underlying disruption of bone and cartilage are presented. A new piece of protective athletic equipment for the prevention of facial injuries to baseball players is introduced.

Depressed skull fracture in a newborn successfully managed conservatively: a case report

A preterm baby was born to a multiparous mother by emergency caesarean section at 36 weeks of gestation. Apart from a depression on the right temporo-parietal region measuring 3 cm x 3 cm x 0.5 cm, no other abnormality was noted. A CT scan of the brain excluded the presence of intracranial haematoma and pressure effect on the brain. Spontaneous reduction of the fracture without any adverse neurological sequelae suggests that these fractures can be managed conservatively in some instances.

Head and neck trauma in sporting activities. Review of 208 cases

Head and neck injuries due to sports and games represent 22.7% of all injuries admitted to the E.N.T. Department of the University of Perugia between 1980 and 1988. Epidemiological and causative factors of these injuries are examined by the authors, together with their treatment: the majority of accidents occurred during soccer games as a consequence of collisions between players. In these cases the most frequently recorded lesion was a nasal fracture. Other sporting activities were responsible for more serious injuries to the maxillo-facial bony, cartilaginous and soft tissue structures. Good results were achieved both on the anatomical and functional planes, except for a few cases of facial disruption and multiple mandibular fractures. The authors stress the importance of preventive measures, consisting of periodical medical check-ups, an adequate level of umpiring and the wearing of protective equipment, such as helmets and masks.

Management of patients with facial trauma and associated ocular/orbital injuries

Ocular injury can be associated with facial fractures in a significant percentage of cases. It is mandatory for surgeons treating such fractures to be familiar with the types of orbital injuries, the appropriate physical examination and diagnostic tests, and the management techniques involved in treating traumatic visual loss. This article reviews the diagnostic and therapeutic approaches to this important problem.

Fractures of the facial bones in the Otago region 1979-1985

The aetiology, type, distribution, and treatment of fractures of the facial bones is described in the 484 patients with such injuries treated at Dunedin Hospital during the period 1979-1985. The mean annual rate was 51.7 per 100,000. The rate of facial bone fractures has remained relatively constant over a 32-year period in the Otago area. Interpersonal violence is now the most common cause of these injuries. Fractures of the zygomatic complex and fractures of the mandible remain the most common facial fractures. There is an increasing trend towards the use of direct internal fixation for fractures that require treatment.

Acute phase protein levels as an index of severity of physical injury

Inflammation resulting from any form of tissue injury causes an increase in plasma concentration of a number of liver-derived proteins (the acute phase reactant proteins), the measurement of which provides an indication of the magnitude of the inflammatory response. C reactive protein (CRP) is an example of an acute phase protein. Although concentrations increase particularly dramatically in response to inflammation and reflect the degree of ongoing tissue damage, this method has yet to be used to assess severity of injury in traumatology and forensic medicine. The rate at which the acute phase protein response occurred after injury was therefore explored in a series of 16 patients with maxillofacial skeletal injuries and in a series of 22 age- and sex-matched control patients. Increases in the plasma concentration of CRP were not detected until 6-12 h after injury and peaked at 48-72 h. Concentration of CRP was less than 10 mgm/l in all control patients. There was significant relation between peak levels and Abbreviated Injury Scale and Injury Severity scores. Results suggest that this method of assessing the severity of traumatic injury deserves further investigation and may be of use clinically, medico-legally and in relation to compensation awards.

[The microplate system: a new armamentarium for osteosynthesis in the child skull]

In certain ares of the craniofacial skeleton the plate systems commonly used for rigid internal fixation seem to be over-dimensioned. The newly developed Micro System for internal fixation with extremely tiny plates and screws provides a firm three-dimensional fixation of segments with minimal interference with the overlying soft tissues. Fields of application are traumatology and craniofacial surgery in infants, fractures of the naso-ethmoidal region and the orbit, reconstruction of the skull, and the fixation of cartilage and bone grafts.

Fracture of the occipital condyle. A report of 3 cases

The term fracture of the occipital condyle is a misnomer and usually represents an extensive fracture of the posterior fossa skull base extending onto the squamous portion of the occipital bone and even further forward. These fractures should be suspected when the lower cranial nerves are affected after severe cranial trauma. Conservative management appears to be indicated.

Sequencing LeFort fracture treatment (Organization of treatment for a panfacial fracture)

The types of midfacial fractures and their complexity were evaluated in admissions to the Maryland Institute of Emergency Medical Service Systems (MIEMSS) during the years of 1984 to 1988. Two hundred and sixty-eight LeFort fractures were treated and followed (3.2 percent of admissions). One half (50 percent) had skull fractures and 40 patients (15 percent) had LeFort, skull and mandibular fractures. Isolated nasoethmoidal fractures were observed in 176 patients and in 107 patients (39 percent) of patients with LeFort fractures. Isolated mandibular fractures were observed in 321 patients and in 104 patients with LeFort fractures (39 percent). Eleven percent of patients had midfacial, nasoethmoidal and frontal sinus fractures. Six percent of patients had midfacial, frontal bone, frontal sinus and nasoethmoidal fractures (Cranial Base Crush Syndrome). Twenty two percent of patients had LeFort and frontal sinus fractures. Reconstruction of multiple area injuries is simplified by a highly organized treatment sequence that conceptualizes the face in two groups of two units. Each unit is divided into sections, and each section is assembled in three dimensions. Sections are integrated into units and units into a single reconstruction. Conceptually, in each unit, facial width must first be controlled by orientation from cranial base landmarks. Projection is then (and often reciprocally with width) established. Finally, facial length is set both in individual units and in the upper and lower face. Soft tissue is considered the "fourth dimension" of facial reconstruction. Bone reconstruction should be completed as early as possible to minimize soft tissue shrinkage, stiffness and scarring of soft tissues in nonantomic positions.(ABSTRACT TRUNCATED AT 250 WORDS)

Maxillofacial fractures related to work accidents

Work-related maxillofacial fractures were studied retrospectively over a six-year period. There were 98 cases accounting for 4.5% of all facial bone fractures treated in our hospital between 1981 and 1986. Of the patients, 89.8% were male. The mean age of the injured was 36.4 years. The incidence of work-related maxillofacial fractures was 0.37 per 1000 workers. Most of the injuries (66%) occurred in factories and construction work. Such work was associated with an to 15 times higher risk of maxillofacial fracture than service and office work. Of the fractures, 20.4% were sustained on the way to or coming from work. At the place of work, the commonest causes of injury were blows from objects or falls from a height (70%). On the way to or coming from work, the aetiological factor was most often a traffic accident. Assault and battery had caused facial bone fractures in 11.2% of cases. Fifty-five patients with midface and 45 patients with mandibular fractures were found, of these, 8 patients had bimaxillary fractures. In 6 cases, only dentoalveolar fractures were found. Of the patients, 55.1% were treated operatively. Sixty-six patients were hospitalized, the mean length of hospital stay being 3.2 days (range 1-12 days).

Congenital depression of the fetal skull

One hundred forty-seven cases of congenital skull depression are analyzed, including two presented by the authors, and a review of the literature follows. A management plan emphasizing a conservative approach is outlined.

Toward CT-based facial fracture treatment

Facial fractures have formerly been classified solely by anatomic location. CT scans now identify the exact fracture pattern in a specific area. Fracture patterns are classified as low, middle, or high energy, defined solely by the pattern of segmentation and displacement in the CT scan. Exposure and fixation relate directly to the fracture pattern for each anatomic area of the face, including frontal bone, frontal sinus, zygoma, nose, nasoethmoidal-orbital region, midface, and mandible. Fractures with little comminution and displacement were accompanied by subtle symptoms and required simple treatment; middle-energy injuries were treated by standard surgical approaches and rigid fixation. Highly comminuted fractures were accompanied by dramatic instability and marked alterations in facial architecture; only multiple surgical approaches to fully visualize the "buttress" system provided alignment and fixation. Classification of facial fractures by (1) anatomic location and (2) pattern of comminution and displacement define refined guidelines for exposure and fixation.

Maxillofacial trauma

If a multiply injured patient with severe head injuries, intra-abdominal and intrathoracic injuries is admitted, the diagnosis and management of the facial fractures may be shunted into the background. With the tremendous methods of modern medicine at hand, we are adequately able to resuscitate, treat, and discharge those patients. If the maxillofacial injuries go undiagnosed or untreated, the patient is left with some fairly significant sequelae in function and appearance that are difficult to treat on a delayed basis. Initial management of those injuries can be done concomitantly with management of the other serious life-threatening injuries and a successful outcome achieved. The traditional approach of waiting "until all the swelling goes down" before definitive correction of bony or soft tissue problems are addressed, has been shown to produce inadequate and disabling results both from a structural and functional viewpoint. Following the first or at most second week after injury, the process of bone healing and scar formation have usually progressed quite quickly. This is especially true in children who normally have a very high metabolic rate. A displaced facial fracture not corrected during the initial "golden" period will require major manipulation and even refracture in order to adequately reduce the segments into the proper position and a less satisfactory result than acute management. Similar considerations with respect to the skin and soft tissues are also important. Once scar tissue has formed it becomes very difficult to restore normal or near-normal appearance.(ABSTRACT TRUNCATED AT 250 WORDS)

Maxillofacial trauma

Although the general principles for evaluation and management of facial fractures in children are the same as for adults, some modification in assessment, timing, and technique must be considered. This article has a double purpose: to re-emphasize acute assessment and medical management so that the pediatrician can function as the coordinator of the maxillofacial trauma team, and to present both established and new techniques for the reduction of simple and complex fractures in children.