Key Points
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Trauma is a predominant cause of morbidity in the pediatric population and the most common cause of death in children over 1 year of age.
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Anatomic and behavioral factors contribute to the increasing incidence of facial fractures with age.
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Concomitant intracranial injury and/or concussion occur in approximately one third of pediatric patients with facial fractures.
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Nonaccidental trauma or child abuse should be suspected when there are inconsistencies in the presentation, prolonged duration between injury and seeking care, noncompliance, or history of multiple emergency room visits for injury.
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The guiding principle for all pediatric facial fractures is to accomplish treatment with minimal disruption of surrounding periosteum and soft tissue.
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Complications of permanent plating systems include transcranial migration, growth disturbance, bone atrophy, and interference with radiographic imaging.
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Resorbable plating systems provide temporary stabilization of fracture segments, avoid the need for plate removal, and have proven to be effective in the management of non–load-bearing facial fractures.
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Orbital fractures in the pediatric population most commonly involve the roof, although floor fractures remain the most common type of orbital fracture to require repair.
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Given the elasticity of the pediatric facial skeleton, children are at greater risk for orbital trapdoor fractures with entrapment. Although sophisticated imaging techniques are available, entrapment remains a clinical diagnosis that requires urgent evaluation and intervention.
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The nasal bone is the most common site of pediatric facial fractures. In addition, children have a high risk for nasal cartilage and perichondrial injury, and it is imperative that evaluation for septal hematoma be performed during the trauma evaluation. Parents must be counseled regarding the signs and symptoms of septal hematoma, as it may develop in a delayed fashion.
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Goals of management for mandibular fractures include restoration of normal occlusion and achievement of bony union with minimal impact on skeletal and dental development.
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Conservative management of condylar fractures is considered first-line treatment in pediatric patients and is generally more successful in younger patients. Surgical management should be reserved for significantly displaced or dislocated fractures.
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Open reduction and internal fixation should be performed with monocortical screws, orienting the plate along the lower border of the mandible in order to avoid trauma to unerupted dentition. Maxillomandibular fixation should be limited to a short duration (2 weeks) followed by guiding elastics for early mobilization.
Trauma is the predominant cause of morbidity within the pediatric population and is the most common cause of death of children between the ages of 1 and 19 years. Trauma is the cause of 12,000 deaths annually in the United States and is the cause of temporary or permanent disability for millions each year, contributing to an enormous economic burden on society in the form of health care costs and lost productivity. Motor vehicle crashes are the most common cause of death in children; falls result in the largest number of nonfatal injuries. Also troubling is that among children who are injured, minority race continues to predict worse clinical and functional outcomes as compared with outcomes for white children. Socioeconomic factors, insurance status, and access to hospitals with a trauma center, as well as provider bias and stereotyping, continue to lead to disparities in health care.
Management of the child with facial trauma should direct attention not only to the anatomic issues that need to be addressed but also to the developmental, socioeconomic, and environmental considerations that surround the repair. Injury to or death of family members as well as the subsequent hospitalization can be psychologically traumatic for a child; such trauma may affect development and nutrition and predispose to behavioral disturbances. Early recruitment of support through child-life services, psychology, and social work is vital in facilitating the comprehensive recovery of the child.
Epidemiology and Etiology
Although facial fractures make up only 4.6% of pediatric traumas and pediatric facial fractures are 14.7% of facial fractures of all ages, these injuries carry significant morbidity. Given anatomic features of the pediatric facial skeleton, considerable force is required to cause a fracture, such that pediatric patients with facial fractures have a higher incidence (55.6%) of severe associated injuries than those without facial fractures. Patients with pediatric facial fractures spend twice as long in the hospital and three times as long in the intensive care unit compared with those without facial fractures. Facial fracture patients have a doubled risk for severe head, chest, and brain injury and a 63% higher mortality rate.
The incidence of pediatric facial fractures is age-group dependent, with the lowest proportion among infants and children less than 5 years of age (5.6%) and the highest among teenagers, with 55.9% occurring in the 15- to 17-year-old age group. Facial fractures occur predominantly in males, with 2 to 5.7 times more males than females affected; greater male predominance is observed in older children.
Concomitant brain injury occurs in 32.3% of patients with facial fractures. Excluding identified intracranial injuries, 22.3% to 31.7% of pediatric facial fractures are diagnosed with concomitant concussion as well. Skull base fractures are observed in 27.3% of patients. Infants and toddlers have a higher incidence of cranial vault fractures.
The epidemiologic trends in pediatric facial fractures as well as the salient differences from adult facial fractures are related to both anatomic and environmental factors. Anatomic factors relate to architectural changes of the craniofacial skeleton during development. At birth, the cranium-to-face ratio is 8 : 1, which leads to a greater proportion of head trauma cases with skull and intracranial injury. The cranium-to-face ratio decreases to 4 : 1 by the age of 5, 3 : 2 by early adolescence, and 2.5 : 1 at adulthood. Not only does the cranium make up a larger proportion of the head as an infant, but the face slants away and is protected by buccal soft tissue and incompletely pneumatized sinuses.
The facial skeleton is more vascular in children and has a higher ratio of cancellous to cortical bone. The periosteum is more substantial and serves as the main contributor to new bone formation. Less calcification and increased woven bone contribute to greater elasticity of the developing skeleton, conferring protection and predisposing to “greenstick” rather than displaced fractures. The presence of unerupted tooth buds, incomplete pneumatization of the sinuses, and generous facial soft tissue provide additional support and confer protection from fracture. With craniofacial development, protection from these factors diminishes, while simultaneously the child’s environment presents increasing risks for facial trauma.
Motor vehicle collisions (55.1%), assaults (14.5%), and falls (8.6%) are the most common mechanisms for pediatric facial fractures, in a proportion consistent with developmental milestones. Falls are seen more often among infants and toddlers, bicycle and pedestrian versus motor vehicle accidents are seen more commonly among school-aged children, and violence is more frequently a cause of facial fracture among older teenagers. Violence has been reported to be responsible for 12.3% of pediatric facial traumas and is more likely to be the mechanism of injury in older male patients of lower socioeconomic status.
Trauma Evaluation
In most health care settings, initial evaluation and management of the pediatric facial trauma patient begins with activation of Basic Life Support (BLS) and/or Advanced Trauma Life Support (ATLS) by the emergency department staff. BLS and ATLS are often led by either emergency medicine physicians or a trauma surgeon, and initial treatment consists of a primary survey, resuscitation, secondary survey, diagnostic evaluation, and definitive management. The primary survey serves to evaluate and correct life-threatening injury; the secondary survey is a more comprehensive head-to-toe examination accompanied by diagnostic evaluations.
The 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care now recommend a CAB compressions, airway, breathing approach for resuscitation during cardiac arrest. Asphyxial cardiac arrest is more common in the pediatric population, making effective ventilations more important in pediatric resuscitation than in the adult population. However, the sequence is recommended to simplify training and improve consistency, with the hopes that more individuals will feel comfortable performing bystander cardiopulmonary resuscitation.
The pediatric population presents unique considerations for ATLS. The relatively smaller size and smaller blood volume in children are risk factors for multisystem injury, hypovolemia, and hypothermia. Direct pressure should be applied to sites of bleeding with early and aggressive fluid resuscitation. A small shoulder roll should be placed to compensate for the prominent occiput and prevent excessive neck flexion in infants and toddlers. Cervical spine (C-spine) immobilization should be maintained throughout evaluation and management. Children are at greater risk for spinal cord injury without radiographic abnormality, given their large proportion of body mass in the head with a greater cartilaginous component of the vertebral column.
With C-spine immobilization in mind, the airway must be opened via jaw-thrust, reserving a head tilt–chin lift for failure of the jaw-thrust to open the airway. Placement of nasopharyngeal or oropharyngeal airways can also augment the airway while maintaining C-spine immobilization. Glossoptosis secondary to mandibular fracture with airway obstruction can be managed with placement of a tongue suture as an oral airway.
As consultants, otolaryngologists should not underestimate their role during the primary survey. Loss of normal landmarks on the neck, signs of oral and/or nasal bleeding, and presence of stridor or stertor can signify upper airway compromise. Evaluation of the airway and clearance of foreign bodies, blood, and secretions within the oral and nasal cavities and the oropharynx and nasopharynx will optimize early ventilation. Orotracheal intubation should be performed if airway compromise persists. Regular reevaluation regarding airway stability for signs of evolving airway compromise such as stridor, stertor, hematoma, and/or bleeding should be performed. Concern for laryngeal trauma should prompt airway evaluation in the operating room, with a low threshold for a surgical airway via tracheostomy.
Given the chaotic nature of the trauma bay, a systematic approach to head and neck examination is vital when performing the evaluation for facial trauma. An attempt at gathering a complete history should be made, but it may be difficult because of the patient’s age or neurologic status, as well as the lack of witnesses present. Abuse or nonaccidental trauma (NAT) should be suspected with any inconsistencies in the history of presentation, prolonged duration between injury and care, noncompliance, or history of multiple emergency department visits for injury. NAT is associated with higher injury severity scores, higher intensive care unit readmission rates, and increased mortality. The head and neck region accounts for more than two thirds of the injuries observed following child abuse. Infants are particularly susceptible to NAT, often first manifested by minor abusive injuries, which commonly occur in the head and neck region. Sentinel injury has been reported in 27.5% of victims of NAT. Eleven percent of sentinel injuries present as intraoral trauma such as dental injury, oral burns, ecchymosis, or signs of sexually transmitted disease. As a consultant, it is imperative to convey any concerns for NAT to the trauma service and the child protection team.
Regardless of when it is performed, the head and neck examination should be methodical, comprehensive, and consistent. In some instances, the age of the patient precludes compliance with or tolerance of a thorough evaluation; sedation or general anesthesia may be necessary to perform assessment, followed immediately by management as indicated. Inspection may also be compromised by the presence of bandages, a cervical collar, and/or blood, secretions, or debris. The cervical collar should be removed, and the patient should be rolled while immobilized for complete visualization and palpation of the occiput and neck. Examination of all abrasions, lacerations, and contusions should be performed, clearing away or removing all bandages and secretions. Lacerations are explored for tissue loss, viability, and depth, while evaluating the options for repair as well as the possibility of using these wounds as surgical access for fracture repair. Foreign bodies should be identified and removed as well.
Inspection of the craniofacial skeleton should key in particular signs that are characteristic for associated facial fractures. Pseudohypertelorism, Battle sign, malocclusion, trismus, raccoon eyes, and clear otorrhea and/or rhinorrhea would suggest an underlying craniofacial fracture and indicate the need for radiographic imaging.
Otoscopic evaluation for external auditory canal skin lacerations, tympanic membrane perforation, and hemotympanum may also prompt additional radiographic evaluation. Anterior rhinoscopy may be supplemented by flexible or rigid nasoendoscopy to evaluate for septal injury, hematoma, and mucosal violation.
Palpation of the cranium and facial skeleton is effectively performed in a top-down fashion. Regions of asymmetry, crepitus, induration, and fluctuance should be noted.
Comparison of the zygomatic arches, orbital rims, and malar eminences improves identification of step-offs and depressions. Bimanual palpation of the oral cavity identifies palatal stability, presence of loose or missing dentition, and mandibular stability.
A thorough neurologic evaluation should be performed as well, with attention directed to the cranial nerves. Documentation of deficits should be performed before intervention, with particular attention to branches of the facial nerve and maxillary and mandibular branches of the trigeminal nerve, as these nerves are susceptible to both traumatic and iatrogenic injuries.
Examination of the eye and orbits can be challenging in the pediatric trauma population. Assessment of pupillary reactivity, ocular mobility, globe position, visual acuity, and the presence of diplopia should be attempted. Disturbance in nasoorbital-frontal topography such as telecanthus, nasal root flattening, vertical dystopia, and enophthalmos should be noted. There should be a low threshold for requesting ophthalmology consultation, as pediatric facial fractures frequently have associated intraocular injury. Forced duction testing (described later) should be performed when feasible to rule out entrapment. Management of complex orbital trauma, which is defined as soft tissue and bony injury with or without lacrimal system involvement, frequently requires the assistance of an oculoplastic surgeon.
Traumatic brain injury (TBI) is a significant cause of childhood morbidity and mortality and is of paramount concern when evaluating children who have sustained facial fractures. However, the signs of TBI in children may be very subtle, which leads to significant variation among criteria to pursue additional neuroimaging. The pediatric Glasgow Coma Scale is an important predictor of TBI. A pediatric Glasgow Coma Scale rating of 15 carries a 2% to 3% risk of TBI, whereas a decline to 14 or 13 increases this risk to 7% to 8% and 25%, respectively. It is important to remember that even pediatric patients without radiographic evidence of intracranial injury are at elevated risk for concussion, with higher rates of concussion in patients who have sustained skull and orbital fractures.
Digital photography plays a vital role in documentation, and most electronic medical records allow these files to be easily imported into the patient’s medical record. Photodocumentation can assist with counseling families regarding aesthetic challenges in the future as well as playing a role in litigation in cases of abuse, negligence, or accidental injury. Despite the ease of use and ubiquitous role that mobile phones currently play in digital photography, it is important to have a consistent consent and file storage process in place for photographs in order to maintain patient confidentiality and compliance with the standards of the Health Insurance Portability and Accountability Act of 1996.
Imaging Studies
Imaging of pediatric facial fractures may be limited by both anatomic and behavioral factors. The presence of tooth buds, lack of ossification, predisposition for greenstick-type fractures, and extensive soft tissue injury can obscure evaluation of bony anatomy. Poor patient cooperation may preclude obtaining the positioning required for optimal imaging.
Traditionally, numerous radiographic projections are effective in visualizing the facial skeleton (e.g., Caldwell, Towne, Waters, or lateral views). However, plain films play a limited role in evaluation of pediatric facial trauma. It is often not feasible to position the patient adequately to obtain the various projections, and attempting to obtain plain films has been associated with delays in diagnosis. Panorex or panoramic views are essential for evaluating the mandible and are useful for operative planning.
Computed tomography (CT) has become the mainstay of diagnostic evaluation for pediatric facial fractures. CT allows for detailed assessment and identification of unsuspected injuries when the history may not be entirely reliable. Anatomic mapping with CT allows for accurate surgical planning, which can be further aided with sagittal and coronal reformatting and three-dimensional reconstructions. Risks related to radiation dosing can be minimized with low-dose scanning protocols.
Considerations for Management
With soft tissue trauma, it is best to avoid debridement of marginal tissues. Timing of management is often affected by coexisting soft tissue injuries, as lacerations can be used to gain access to bony fractures for repair. Definitive closure should be performed as soon as feasible, relying on primary closure and the rich vascularity of the face to contribute to recovery of lacerations.
Approximately 40% of patients sustaining pediatric facial fractures are managed on an outpatient basis. The most common pediatric facial fracture that requires inpatient admission and management is mandibular fracture, which accounts for 32.7% to 44.8% of pediatric facial fracture admissions. Of mandibular fractures, 25.1% to 36% require operative repair and the likelihood increases with age.
Permanent Plating Systems
The ideal fixation system would confer the strength of rigid fixation during the duration of bone healing without long-term complications or interference with growth and development. Titanium plating systems have proven to be an effective fixation system for management of facial fractures because they are reliable and clinically inert. Anatomic reduction and fixation of physiologic buttresses provide an appropriate scaffold during recovery of intrinsic bone strength. However, permanent plating systems are less useful for fractures involving the growing craniofacial skeleton. Craniofacial growth progresses with deposition on the outer surface of the bone with resorption of the inner surface. Introduction of a static structure such as a metallic plate into a dynamic structure can lead to transcranial or even intracranial migration. Rates of transcranial and intracranial migration have been reported at 14% and 6%, respectively. In addition to plate migration, other complications of permanent plating systems include growth disturbance, bone atrophy, interference with radiographic imaging, need for removal, thermal sensitivity, and palpability.
Whether or not to remove asymptomatic plates and screws remains controversial. Many advocate scheduled removal of asymptomatic plates, whereas others recommend waiting until clinically indicated. Retained plates carry a risk not only of migration but also of growth restriction, palpability, infection, and pain. A consensus statement issued at the Third Strasbourg Osteosynthesis Group meeting stated that plate removal is desirable “provided that the procedure does not cause undue risk to the patient.” The current consensus appears to favor leaving asymptomatic plates in place.
Resorbable Plating Systems
Resorbable plating has revolutionized pediatric craniofacial surgery and management of trauma alike. Resorbable plating provides temporary stabilization of fracture segments while obviating the need for eventual plate removal. In addition, the risk of permanent plates in the developing facial skeleton is also avoided. Current resorbable plating systems offer a clear benefit in the treatment of pediatric facial trauma.
Resorbable plating systems have been derived from polydioxanone or polymers of glycolic and/or lactic acid. Subsequent plate strength and rate of resorption differ as related to the ratios of these monomers. The physical properties of the common polymers used in resorbable plating are summarized in Tables 11-1 and 11-2 .
| Monomer | Glass Transition Temperature (°C) | Flexural Strength (MPa) | In Vivo Degradation Time | |
|---|---|---|---|---|
| Strength | Mass | |||
| Polyglycolic acid | 35-40 | 320 | 4-6 wk | 6-12 mo |
| Poly l -lactic acid | 60-65 | 190 | 6 mo | 1-6 yr |
| Poly d , l -lactic acid | 55-60 | 150 | 8-12 wk | 12-16 mo |
| Polydioxanone | 16 | 120 | 4-6 wk | 6-12 mo |
| System and Date Introduced | Polymer Composition | In Vitro Time | |
|---|---|---|---|
| Remaining Strength | Complete Resorption | ||
| LactoSorb (W. Lorenz Surgical Inc., Jacksonville, FL), 1996 | PLLA 82%, PGA 18% | 8 wk: 70% 12 wk: 30% | 6-12 mo |
| Macropore (Medtronic, Minneapolis, MN), 1998 | PLLA 70%, PDLLA 30% | 6 mo: 90% 12 mo: 50% | 1-3 yr |
| Bionx (Bionx Implants Inc., Blue Bell, PA), 1998 | PLLA 70%, PDLLA 30% | 8 wk: 90% 6 mo: 30% | 1-2 yr |
| Resorbable Fixation System (Synthes, Paoli, PA), 2000 | PLLA 70%, PDLLA 30% | 8 wk: 68% 6 mo: 30% | 1-6 yr |
| DeltaSystem (Stryker-Leibinger, Kalamazoo, MI), 2000 | PLLA 85%, PDLLA 5%, PGA 10% | 8 wk: 81% 6 mo: 50% | 1.5-3 yr |
While resorbable plating offers clear long-term benefits, potential complications must be considered, including insufficient fracture stabilization, plate and screw bulkiness, and lack of resistance to deformation. Resorbable plating systems have a higher profile than their titanium counterparts, which increases the risk of palpability, particularly in regions with thin skin. These systems require a heat source for plate sculpting and become rigid once they are cooled below their thermoplastic range. Placement of screws is technically more challenging than for titanium, but ease of placement has improved with newer plating systems. Excessive molding and/or heat will weaken the plating material. Some plating systems require drilling and tapping, adding operative time. During the hydrolysis phase of resorption, which is typically 6 to 18 months postoperatively, there are risks of fluid collection or infection. Long-term foreign body reactions, granulation, and wound breakdown have been reported.
Controversy remains in the use of resorbable plating systems in the management of pediatric mandibular fractures. Currently, resorbable plating systems are not approved by the U.S. Food and Drug Administration for use in load-bearing situations. Reports of pathologic fracture requiring titanium refixation have been reported. With the introduction of stronger biomechanical materials, preliminary studies have demonstrated tolerance and surgical success, suggesting that there may eventually be a role for resorbable plating in the repair of mandibular fractures.
Frontal Bone Fracture/NasoOrbital-Ethmoid Fracture
Frontal sinus fractures in children are extremely rare due to the lack of pneumatization of the sinus until around 8 years of age. Completion of frontal sinus development does not occur until late adolescence. Given the lack of the protection conferred by a pneumatized frontal sinus, the rate of intracranial injury with frontal bone fracture is high; rates have been reported from 35% to 64%. Younger patients have a higher incidence of intracranial injuries accompanying frontal bone fractures than do older patients.
The goals for intervention include management of concomitant intracranial injuries and cosmetic concerns ( Fig. 11-1 ). Cerebrospinal fluid leak is common, reported in 18% to 36%, but most patients respond well to conservative management consisting of bed rest, head-of-bed elevation, and stool softeners. Concomitant intracranial injuries frequently lead to cranialization, but the role of obliteration in the pediatric population has not been well studied. Long-term sinonasal surveillance is critical in this population; bony compromise or an intracranial pathway from the original fracture site may increase the risk of intracranial complications once the sinus becomes pneumatized.
Nasoorbital-ethmoid (NOE) trauma is extremely rare in the pediatric population and results from high-energy impact. A multidisciplinary approach is almost always required, given the impact required for injury as well as risk to vital neighboring structures. Because of the lack of pneumatization of the frontal sinus system in young children as well as the differences in proportion of the pediatric midface to the neurocranium, pediatric NOE fractures have different manifestations than those of adults ( Fig. 11-2 ). The classic adult classification system as described by Markowitz (type 1, intact medial canthus with large, single-segment fracture; type 2, intact canthal tendon with comminution; type 3, disinsertion of the canthus with comminution) does not accurately reflect the most common fracture patterns seen in children. Burstein describes frontal basilar trauma as a presentation of a pediatric NOE grading system that places greater emphasis on the concomitant injuries to the central frontal bone, superior orbital rims, and the NOE complex’s intimate relationship with the cranial vault.
The Burstein classification system ( Box 11-1 ) addresses the multidisciplinary concerns required in management of pediatric NOE fractures, including craniotomy sites, surgical approach, and the extent of intracranial repair needed. Whereas many repair strategies hinge on minimal exposure and disruption of intact periosteum and bone, Burstein reports success with elective osteotomies and craniotomy bone flaps to improve exposure for neurosurgical intervention as well as side-table reassembly of fracture segments.
Type 1: Involves central frontal bone, upper NOE, medial superior rims, bilateral frontal sinus
Type 2: Unilateral, involving frontal bone, ipsilateral superior/lateral orbital rims, NOE, and entire frontal sinus
Type 3: Bilateral, involving both superior orbital rims, NOE, entire frontal sinuses
Orbital Fracture
Pediatric orbital fractures encompass a clinical entity distinct from adult orbital fractures. The incidence ranges widely, comprising from 3% to 45% of all facial fractures. Fractures of the supraorbital rim and orbital roof are frequently characterized as skull fractures given their continuity with the frontal bone and sinuses that have not yet pneumatized. Orbital roof fractures are the most common orbital fracture seen in children younger than age 7 years. With advancing age, the neurocranium becomes proportionately smaller in relation to the growing viscerocranium. Correspondingly, at age 7 years, orbital fractures involving the roof decrease in incidence, while those involving the orbital floor increase. Anatomic factors include the size and projection of the frontal bone in toddlers and young children, whereas by age 7, radiographically apparent pneumatization of the frontal sinuses confers protection to the roof, creating a “crumple zone.”
Orbital fractures are thought to occur by two predominant mechanisms, although clinically most fractures exhibit features of both. The “hydraulic” theory proposes that direct globe pressure and compression force the thin bone of the orbital walls to yield, particularly the medial and inferior walls, resulting in fracture and/or blowout. The “bone conduction” theory describes force that is directly placed along the orbit rim, dissipating along the framework of the orbit.
Clinical evaluation of pediatric orbital fracture should include thorough ophthalmologic and neurologic examinations. Once again, disparities are seen in different age groups; younger patients with orbital fracture are more susceptible to neurologic injury and skull fracture, as the orbit is more intimately associated with the neurocranium. In contrast, older patients are more likely to sustain midface and ophthalmic injury.
CT scanning is the gold standard for evaluation of orbital fractures. High-resolution thin-slice axial views with coronal and sagittal reconstructions can help identify bony discontinuity and soft tissue displacement or entrapment, as well as the presence of a foreign body. Three-dimensional reconstruction improves definition of bony segments and is valuable in preoperative planning.
Several classifications of pediatric orbital fracture have been proposed, based on the region of involvement, involvement of adjacent structures, and clinical, radiographic, and prognostic criteria. In general, most recommend that urgent surgical intervention take place within 48 hours of diagnosis, but these grading systems serve to refine these recommendations. Matteini classified fractures as grade I (fractures involving the orbital border), grade II (orbital wall fractures with no functional impairment), grade IIIa (orbital wall fracture with diplopia—adult) and IIIb (orbital wall fracture with diplopia—child), grade IV (open/penetrating wounds, with exposure and/or cerebrospinal fluid leak), and grade V (involving the orbital apex, causing compression or ischemia to the globe or optic nerve). Losee proposed a classification system that characterizes fractures in association with neighboring injuries: type 1 fractures and their subsets consist of pure orbital injuries, type 2 fractures have associated craniofacial features, and type 3 fractures have common fracture patterns.
Roof Fracture
There are three main types of orbital roof fractures: nondisplaced, superiorly displaced with or without dural or brain disruption (orbital roof blowout), or inferiorly displaced (orbital roof blowin) ( Fig. 11-3 ). Management of orbital roof fractures is typically conservative, with surgical intervention reserved for cosmetic concerns and for possible ocular or intracranial compromise. If possible, the approach to the supraorbital rim and roof should accommodate existing lacerations. Brow and lid crease incisions each have risks of scarring and poor cosmesis, whereas coronal incisions require a large field of dissection to fully expose the distal extent at the orbit. Long-term surveillance is necessary to monitor for sequelae such as encephalocele and mucocele, which may evolve over time.
