Strange and Schafermeyer's Pediatric Emergency Medicine, Fourth Edition (Strange, Pediatric Emergency Medicine), 4th Ed.

CHAPTER 28. Maxillofacial Trauma

Stacy Reynolds

JoAnna York

Stephen A. Colucciello

HIGH-YIELD FACTS

• Maxillofacial trauma in children more often results in soft-tissue injury than facial fractures.

• Up to 55% of seriously injured children with facial trauma also have intracranial injury.

• The most urgent complication of facial trauma is airway compromise.

• Computed tomography (CT) scan is the definitive diagnostic test for precise delineation of maxillofacial fractures.

• The mandible is most frequently involved in posttraumatic developmental deformities.

• Timely referral of nasal fractures is important, as these injuries may have a profound effect on subsequent nasal and maxillofacial development.

Missed facial fractures or inappropriate treatment of such fractures may result in permanent facial deformity in the growing child. A child with severe maxillofacial injury requires a team approach involving emergency physicians, pediatricians, general surgeons, maxillofacial specialists, and radiologists. Emergency specialists must recognize and prioritize injuries, manage the airway, stabilize the patient, read initial radiographs, and make appropriate consultations.

INCIDENCE

Pediatric facial fractures comprise less than 15% of all facial fractures.1,2 Facial fractures occur in less than 1% of children under the age of 5 years.2 Fracture patterns reflect the unique anatomic considerations in children and match adult patterns by age 15.

Certain developmental characteristics of the growing face protect children from fractures. These features include the low face to cranium ratio for children, the increased elasticity of the bones, less sinus pneumatization, larger fat pads, and stability imparted by unerupted teeth to the mandible and maxilla.2 For example, mandible fractures in infants occur rarely in falls and motor vehicle crashes and raise suspicion for nonaccidental trauma such as a direct, violent blow to the jaw.3 Finally, children’s higher ratio of cancellous bone to cortical bone provides resilience but produces more incomplete and greenstick fractures.46

Worldwide, the incidence of facial fractures is higher in boys than girls, attributed to more dangerous sporting activities and increased rates of physical violence in boys.1 In a study of the National Trauma Data Bank from 2001 to 2005, the most common mechanisms for facial fracture were motor vehicle collisions (55.1%), violence (11.8%) and falls (8.6%).7 This data bank demonstrated that facial fractures occur in 4.6% of admitted patients and 25% of these fractures required operative intervention.7 Nasal and maxillary fractures occurred most commonly in infants and toddlers aged 0 to 1 year and mandible fractures occurred most commonly in adolescents aged 15 to 18 years.

Fractures occur consistent with age-related fracture patterns. In early childhood, the skull is particularly prominent with a cranial to face ratio of 8:1.1 This ratio is 2.5:1 in an adult patient. The small face and limited sinus development transfer force to the cranial base resulting in a high incidence of skull fractures in the younger age group. Aerated sinuses in adults absorb energy and protect against propagation of fractures into the skull.8 These paranasal sinuses, however, weaken the anterior facial skeleton. This helps to explain why LeForte fractures are uncommon in pediatrics and are almost never seen before age 2. By the early teen years, the frequency and pattern of maxillofacial injury begins to mirror that found in adults.4,6

The sinuses develop in a predictable pattern. The maxillary sinuses pneumatize by age 3 years and the frontal bone begins pneumatization at age 5. Orbital floor fractures do not occur until the maxillary sinus becomes aerated. The frontal sinus is not fully developed until adolescence.

COMPLICATIONS AND ASSOCIATED INJURIES

The intricate growth centers of the pediatric face and the complexities of surgical repair produce unique complications. Long-term sequelae include damage to growth centers, fracture malposition, iatrogenic complications during surgical repair, and soft-tissue scarring.9 Skull fractures and intracranial trauma commonly accompany facial trauma in children in predictable patterns. Up to 47% of all pediatric patients with facial fractures and 55% of seriously injured children with facial trauma have intracranial injury, a much higher percentage than that occurs in adults.10,11 Temporal bone fractures, though rare, often accompany mandibular fractures in children, secondary to force transmitted along the mandible to the temporal bone. Orbital fractures lead to intraocular injury and potential blindness, mandating a careful ophthalmologic examination. In one study, 50% of pediatric orbital fractures were associated with ocular injuries.8 Other associated injuries include soft-tissue injuries, dentoalveolar injuries, cervical spine injury, and blunt cerebrovascular accident.2,7

EMERGENCY MANAGEMENT

Airway obstruction and compromise, often associated with mid- and lower-face injury, pose the greatest complication from facial trauma. Simple maneuvers, such as chin-lift jaw thrust, oropharyngeal suctioning, and oral or nasal airway, when appropriate provide immediate benefit.10 If simple airway maneuvers do not suffice, orotracheal intubation with in-line immobilization is necessary. Nasotracheal intubation is difficult in the young child secondary to the large adenoids but should be completely avoided with midface trauma to prevent passage of the tube into the cranial vault.10 In rare circumstances, the physician must establish an airway surgically. Avoid emergency cricothyroidotomy in children younger than 12 years.12 However, there are other authors who may consider it in slightly younger children. Emergency tracheostomy results in fewer long-term complications, but requires great expertise. Percutaneous transtracheal jet ventilation provides a temporizing measure in these situations (see Chapter 17).

Nasal or midface trauma produces complete airway obstruction in infants less than 3 months of age. Mandibular fractures cause loss of support of the tongue or hematomas of the floor of the mouth and occlusion of the upper airway. The physician should open the mouth and pull the tongue forward, either manually or with a large suture or towel clip.

In children at low risk for cervical spine injury, the child should be allowed to sit up and lean forward. Uncontrolled bleeding into the pharynx requires intubation. If severe oropharyngeal bleeding persists, the pharynx may be packed with absorbent gauze to control bleeding and prevent aspiration when uncuffed endotracheal tubes are used.

Severe nasal hemorrhage may lead to aspiration and initially requires direct pressure to the external nares. If bleeding continues, consider nasopharyngeal packing. A Foley catheter provides an effective emergency intervention. Insert the catheter along the floor of the nose, inflate the balloon in the nasopharynx, pull it anteriorly, and then place an anterior pack.10

HISTORY AND PHYSICAL EXAMINATION

If possible, determine the mechanism, time of injury, and assess for loss of consciousness. Question the child about any visual problems, facial anesthesia, or pain with jaw movement. Assess the patient for risk of concomitant intracranial injury.

Inspection of the face may reveal signs of facial fracture such as areas of swelling, ecchymosis, deformity, asymmetry, trismus, and malocclusion. Inspect the child’s head looking down or examine the chin looking up to reveal otherwise unappreciated asymmetries. Posttraumatic Bell’s palsy provides evidence of a temporal bone fracture. Palpate the entire face symmetrically starting with the skull and inferior to the mandible.6

Evaluate the eyes for the pupillary light reflex, hyphema, subconjunctival hemorrhage, proptosis, enophthalmos, and intact extraocular motions. Unequal pupil height may indicate orbital floor fracture. Retract the lids to visualize the globe and document visual acuity. Complete ocular examination is important in periorbital trauma to exclude globe injury (see Chapter 97). Periorbital ecchymosis may occur in a wide variety of settings. Raccoon’s eyes secondary to basal skull fracture usually occur 4 to 6 hours after a traumatic event, whereas direct trauma to the periorbital region may result in more immediate bruising. Palpate the entire orbital rim for tenderness or deformity. Anesthesia above or below the eye may indicate supraorbital or infraorbital nerve injury in conjunction with fractures.10 Telecanthus, an increased width between the medial canthi of the eyelids, with flattening of the medial canthus is associated with nasal ethmoidal injury. In this situation, the medial canthal ligaments are torn or underlying bone is avulsed from the nasal orbital complex (Fig. 28-1). Subcutaneous emphysema about the eyes and maxillary area indicates a communication with a sinus or nasal antrum and may erupt when the child blows his or her nose.

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FIGURE 28-1. Telecanthus: torn medial canthal ligament or bone avulsion causes flattening of the medial canthus.

Examine the pinna for presence of subperichondral hematoma. Examine the ear canal for lacerations and inspect the patient for leaking cerebrospinal fluid (CSF). The best test to distinguish CSF from nasal secretions, blood, or ear drainage is the α2-transferrin assay. The detection of α2-transferrin confirms a CSF fistula. The specificity nears 100% and the sensitivity is 91%.13,14 This is a send-out laboratory test for many hospitals. A simple test from the emergency department is the glucose concentration of the liquid in question. CSF will contain glucose whereas mucus will not. In addition, there is a double ring sign when blood and CSF drip on cloth or filter paper.

Ecchymosis over the mastoid area, known as a battle sign, appears several hours after basilar skull fracture. The presence of hemotympanum should also raise suspicion for this injury. Tympanic membrane rupture may occur with mandibular condyle fractures.

Careful simultaneous palpation of the zygomatic arches detects flattening of the arch. Intraoral palpation of the arch may help detect minimally displaced fractures. LeForte III fractures produce elongation of the midface. LeForte fractures may also be identified by manipulation of the central maxillary arch. Grasp the central maxillary arch above the central incisors and attempt to mobilize the midface. LeForte classification is based upon which structures move anteriorly with traction. Specific LeForte fractures are outlined in detail below.

Palpate the nose for crepitus and deformity, as edema may obscure bony anatomy. Examine the nose for septal hematoma, recognized by a bluish, bulging mass on the septum, or by the subjective impression of an abnormally wide septum (Fig. 28-2). Pressure with a cotton swab will detect the presence of a soft, doughy swelling.6

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FIGURE 28-2. Photograph of nasal hematoma.

Injury of the inferior orbital nerve or inferior alveolar/mental nerve produces anesthesia of the upper or lower lip, respectively, from fracture of the bony canal or direct nerve contusion.

Observe movement of the patient’s jaw through a full range of motion. Deviation to one side usually indicates ipsilateral subcondylar fracture, since dislocation of the jaw occurs infrequently in children. Difficulty in jaw movement may be secondary to mandibular fractures, injury to the temporomandibular joint (TMJ), or a depressed zygoma impinging upon the mandible or muscles of mastication. Trismus and malocclusion also occur with such injuries.10 It is important to palpate the condyles during jaw motion. Place the examining fingers in the external ear canal, and feel the motion of the TMJ while the child opens and closes his or her mouth.10

Children, unlike adults, may suffer traumatic diastasis of the hard palate along the midline. To detect this injury, the physician must apply a distracting pressure upon the dental arches. Grasp and manipulate each tooth to assess for laxity and remove teeth that are in danger of falling into the airway. Permanent teeth may be saved in saline moistened gauze. Stress the mandible with lateral and medial pressures on the dental arches, and subsequently apply up and down manual pressure to test for bony disruption.10 Ask the cooperative child to bite down upon a tongue blade. Subsequent torque applied to the tongue blade will result in pain and reflex opening of the child’s mouth in the presence of a mandibular fracture.

image FACIAL LACERATIONS

Key to evaluating facial lacerations is an understanding of the relationship between the skin and the underlying vital structures. Injuries to the medial third of the upper or lower eyelids may result in lacrimal apparatus disruption. The course of the facial nerve and parotid duct must be kept in mind during examination (Fig. 28-3). Facial nerve injury reproduces paralysis on the ipsilateral side. Suspect laceration of the parotid duct if saliva appears in the wound, or if blood is expressed at Stensen’s duct with massage of the parotid gland. Parotid duct injury is possible if a deep wound crosses a line drawn from the tragus to the midportion of the upper lip. The buccal branch of the facial nerve also parallels this line. Facial nerve injuries must be surgically repaired if they are posterior to a vertical line drawn through the lateral canthus. Injuries anterior to such a line are usually not repaired.

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FIGURE 28-3. Diagram of relationship of facial nerve and parotid duct.

IMAGING STUDIES

Obtaining facial imaging studies depends on the degree of injury and clinical stability of the child. Management of associated intracranial, thoracic, and abdominal injuries always takes precedence over imaging of the face. Modern computed tomography (CT) scan images provide excellent detail of the midface structures, cranium, and mandibular condyle15 and offer dramatically increased diagnostic accuracy of facial fractures in the pediatric patient.16 CT scans provide consistently greater diagnostic accuracy of pediatric condylar fractures and sensitivity than panoramic radiographs.17 Specialized CT scan techniques, such as coronal views, thin-slice scans (1.5–3 mm), and three-dimensional reconstructions, assist in surgical planning for these complex injuries. CT scan is particularly helpful in the presence of orbital fractures and evaluates the status of orbital contents.

SPECIFIC INJURIES

image NASAL FRACTURES

Nasal fractures are the most commonly encountered pediatric facial fracture, accounting for up to 50% of the total.4 External digital pressure controls hemorrhage in most cases. If nasal packing is used, care must be taken to avoid intracranial placement of packing in the patient with midface trauma or signs of a basilar skull fracture. A particularly severe type of nasal fracture that occurs in children is the “open book” type, where nasal bones separate in the midline along the suture.

Early edema and pain with intranasal speculum examinations complicate the diagnosis of nasal fractures.4,5 A repeat examination is generally recommended 3 to 4 days after the initial injury in children.6 For optimal repair of displaced nasal fractures, consultation should take place within 5 to 6 days postinjury, after which time fractures begin to unite and manipulation becomes increasingly difficult. Of note, early reduction of pediatric nasal fractures has been challenged in the recent literature.18 Surgical reconstruction remains controversial in the growing child until the nasal growth centers close.19 Closed reduction with packing or splinting establishes anatomic realignment and hemostasis in the majority of displaced nasal fractures.4

Nasal fractures produce specific complications. These include nasal deviation, dorsal hump, obstructed breathing from septal malalignment, and saddle nose deformity. Untreated septal hematoma results in collapse of the septum and a “saddle” deformity due to septal cartilage necrosis. These hematomas may, on rare occasion, become infected and lead to septal perforation. Upon diagnosing a septal hematoma, the physician should anesthetize the area and then use a No. 11 blade to make an L-shaped incision through the mucoperiosteum along the floor of the nose and extend the incision vertically. The hematoma will then be evacuated through the flap (Fig. 28-4). Subsequent packing of the nasal antrum prevents reaccumulation, and the child must be referred to the appropriate specialist. Timely referral of nasal fractures and treatment of nasal septal hematoma are of significant medical and legal concern, as these injuries may have a profound effect on subsequent nasal and maxillofacial development.5

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FIGURE 28-4. How to drain and pack a nasal hematoma. A. Apply topical anesthetic. B. Incise hematoma. C. Place packing in nasal antrum

image ORBITAL FRACTURES

The most common orbital fracture is the blowout fracture, which occurs when a blunt object, often a ball or fist, strikes the globe (Fig. 28-5). The intraorbital pressures increase suddenly and contents decompress through the orbit, most commonly the floor. Blowout fractures can also occur through the medial wall, the roof, and even the greater wing of the sphenoid bone. This may lead to entrapment of the inferior ocular muscles, with subsequent diplopia on upward gaze.10 Urgent consultation is required in the presence of exophthalmus or extraocular muscle entrapment. If not treated early, ischemic muscle necrosis leads to muscle fibrosis, restriction of ocular motion, and persistent diplopia.20 In these situations, orbital contents must be surgically released and the area of blowout covered with implants or bone grafts.

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FIGURE 28-5. Orbital blowout fracture. Fracture of the orbital floor can lead to entrapment of fat and ocular muscles.

Evaluate for entrapment by examination and orbital CT scan.10 Enophthalmos, vertical orbital dystopia, and symptomatic muscle entrapment provide more useful indications for surgical intervention.21Evaluation for associated ocular injury such as hyphema, retinal contusion, lens dislocation, and corneal lacerations must be performed and visual acuity documented.

image FRONTAL SINUS AND SUPRAORBITAL FRACTURES

Supraorbital fractures involve the superior orbital rim or orbital roof. Exophthalmus and ptosis may be present with impairment of upward gaze. The superior orbital fissure syndrome results in paralysis of extraocular muscles, ptosis, and anesthesia in the ophthalmic division of the trigeminal nerve. The orbital apex syndrome is a combination of the superior orbital fissure syndrome plus optic nerve damage and results in blindness. These syndromes represent surgical emergencies and require immediate consultation and decompression.

Linear nondisplaced fractures of the anterior wall of the frontal sinus may be treated with observation and antibiotics in either an inpatient or an outpatient setting. If the posterior wall is involved, a CT scan will evaluate the possibility of depression and underlying brain injury. Posterior wall fractures should prompt neurosurgical as well as maxillofacial consultation.

Frontal sinus fractures cause significant complications without proper management. These complications include cosmetic deformity, mucoceles, occult or delayed CSF leaks, and meningitis.22 Antibiotics are still routinely recommended for CSF leak in frontal sinus fracture but antibiotic prophylaxis does not routinely prevent meningitis.8 The increased risk of meningitis persists even after the fracture heals in some patients.8 Frontal sinus fracture is associated with ocular injury 26% of the time and ophthalmologic evaluation should be considered.8 Recommendations also include coronal evaluation of the skull base once patients are stable.22

image MAXILLARY FRACTURES

Maxillary fractures are very uncommon in young children, but the incidence increases with age, as the paranasal sinuses develop. Because of the high degree of energy required to fracture the pediatric face, associated injuries, particularly intracranial, must be suspected.6 Maxillary fracture complications include malocclusion, tooth loss, and growth arrest.9

image MALAR FRACTURES

The malar complex is often broken in a tripod fashion, with fractures at the infraorbital rim, across the zygomatic–frontal suture, and along the zygomatic–temporal junction. Inward displacement of this fragment may result in impingement upon the mandible, causing difficulty opening the mouth and trismus. The zygomatic arch is frequently fractured in isolation. If a zygomatic complex fracture has no displacement, diplopia, or sensory deficits, the patient’s injury may be managed by observation. Open reduction and internal fixation is necessary for comminuted fractures.4

image NEO AND LEFORTE FRACTURES

LeForte fractures and nasal–ethmoidal–orbital fractures (NEO) are rare in children. NEO fractures occur when the bony structures of the nose are driven backward into the intraorbital space. The NEO complex joins the upper and middle thirds of the face. Careful clinical examination combined with three-dimensional CT scans diagnose this fracture type. On examination, NEO collapse causes shortened palpebral fissure, telecanthus from lateral migration of the medial canthus, and a shortened nose with possible saddle deformity.1 CT offers superior sensitivity and specificity for accurately distinguishing fractures from open suture lines.1

Associated injuries include orbital and optic nerve problems, as well as lacrimal system disruption.23

Patients with NEO or orbital fractures should be instructed not to blow their nose. Many practitioners prescribe antibiotics to cover common sinus pathogens. First-generation cephalosporins, trimethoprim/sulfamethoxazole, amoxicillin, or erythromycin is frequently used in outpatients. Such prophylaxis, however, has not conclusively proven to reduce complications.10

Children with LeForte fractures require admission and careful assessment for associated injury. A maxillofacial specialist should be involved in their care. LeForte I is a transverse fracture that separates the hard palate from the lower portion of the pterygoid plate and nasal septum. Traction on the upper incisors produces movement of only the hard palate and dental arch. LeForte II or pyramidal fracture separates the central maxilla and palate from the rest of the craniofacial skeleton. Mobilization of the upper incisors will move the central pyramid of the face, including the nose. LeForte III, also known as craniofacial dysjunction, separates the facial skeleton from the rest of the cranium. The entire face including inferior and lateral portions of the orbital rim moves as a unit with this fracture. “Pure” LeForte fractures are less common and are usually a mixed pattern—perhaps a LeForte II on one side and a LeForte III on the other. LeForte fractures may result in lengthening of the midface, occlusal abnormalities, orbital ecchymosis, and may be associated with basilar skull fractures.6

image MANDIBLE FRACTURES

Mandible fractures are the second most common facial fracture, following nasal bone injury. Because of its U-shaped structure, fractures of the mandible are often multiple. Blows or falls to the chin result in symphyseal or perisymphyseal injury, whereas lateral blows are more likely to produce body or angle fractures on the injured or contralateral side. The most frequently injured areas are the condyle (70%), followed by the body, angle, and symphysis.10

Physical examination may raise suspicion for mandibular injuries. Younger children suffer isolated condylar fractures and may present with deviation of the jaw to the affected side and trismus. Chin lacerations may herald condylar injuries. Dislocation of the TMJ rarely occurs in this age group.

Facial CT scan diagnoses suspected mandible fracture in this age group with maximum accuracy.17 CT scan compared with panoramic radiographs in children 2 to 15 years old provided diagnostic accuracy of 90% and 73%, respectively. For patients 16 years and older, oral pan tomogram (Panorex) and posteroanterior mandible radiographs provide appropriate initial tests.24 Consultants, however, may request a facial CT scan for follow-up care. Treatment of mandibular fractures is based on age, state of dentition, fracture location, bony integrity, and the presence of associated injuries. In general, mandibular fractures without displacement and malocclusion are managed by a liquid/soft diet, pain control, avoidance of physical activities, and close observation. Displaced mandibular fractures require reduction and immobilization.4

Arrested development occurs most often with mandibular fractures and results in severe facial deformity, micrognathia, and ankylosis of the TMJ.9 Crush injuries to the condyle prior to the age of 5 years have the greatest potential for developmental arrest, whereas condylar fractures in later childhood may be self-correcting. Inform the parents about the possibility of subsequent growth disturbances—the younger the child is, the more likely are the complications.25

image SOFT-TISSUE INJURIES

Devitalized tissues need conservative debridement. Soft tissues require irrigation, foreign-body removal, and cosmetic approximation of important landmarks such as the vermilion border of the lip and margins of the eyebrows. Eyebrows must not be shaved, as their regrowth is unpredictable. Hematomas of the pinna must be relieved to avoid a permanent cosmetic defect, cauliflower ear. Drain hematomas of the external ear by needle aspiration or formal incision, and then apply a pressure dressing to prevent reaccumulation.

Repair of lacerations to the salivary duct or to the lacrymal drainage system must be performed by a specialist. These repairs are achieved over a stent. Despite the possibility of brisk bleeding, never blindly clamp inside a facial laceration due to the risk of injury to nerves or parotid duct. Direct pressure will control bleeding. Children may require sedation to ensure cooperation in the treatment of either complex or intraoral lacerations. Control of the tongue is necessary in glossal injury, and a large stitch placed in the tip of the tongue will retract it during suturing.

Penetrating wounds to the posterior pharynx occur when a child falls while carrying a pencil or foreign body in his or her mouth. Such wounds endanger carotid artery, jugular vein, and cranial nerves. Imaging studies, such as color-flow Doppler, angiography, CT angiography, or MRI may be indicated. Delayed thrombosis of carotid or jugular vessels can occur.

PAIN MANAGEMENT AND ANESTHESIA

Acute maxillofacial trauma produces injuries that are often extremely painful. Local anesthesia or nerve block provides the primary method of achieving immediate pain control (mental, inferior alveolar, infraorbital, and supraorbital nerve blocks). Local wound infiltration with or without procedural sedation may be necessary.26

Consider systemic analgesia, either enteral or parenteral, when needed.

CONCLUSIONS

Maxillofacial trauma in children more often results in soft-tissue injury than facial fractures. When fractures do occur, associated injuries, particularly intracranial, may be present. Fractures heal rapidly over 2 to 3 weeks, and repair must be undertaken before bony union occurs. Conservative management is often the rule.

Late reduction of a fracture may result in unsatisfactory cosmesis secondary to arrested growth and distorted dentition. Aggressive airway management, assiduous search for associated injuries, and early consultation are the keys to successful emergency management of pediatric facial trauma.

REFERENCES

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15. Hogg N, Horswell B. Hard tissue pediatric facial trauma: a review. J Can Dental Assoc. 2006;72(6):555–558.

16. Cole P, Kaufman Y, Hollier LH: Managing the pediatric facial fracture. Craniomaxillofac Trauma Reconstr. 2009;2(2):77–83.

17. Chacon G, Dawson K, Myall R. A comparative study of 2 imaging techniques for the diagnosis of condylar fractures in children. J Oral Maxillofac Surg. 2003;61:668–672.

18. Yabe T, Tsuda T, Hirose S, et al. Comparison of pediatric and adult nasal fractures. J Craniofacial Surg. 2012;23(5):1364–1366.

19. Wright RJ, Murakami CS, Ambro BT. Pediatric nasal injuries and management. Facial Plast Surg. 2011;27(5):483–490.

20. Tse R, Allen L, Matic D. The white-eyed medial blowout fracture. Plast Reconstr Surg. 2007;119:277–286.

21. Lossee JE, Afifi A, Jiang S, et al. Pediatric orbital fractures: classification, management, and early follow-up. Plast Reconstr Surg. 2008;122(3):886–897.

22. Whatley WS, Allison DW, Chandra RK, et al. Frontal sinus fractures in children. Laryngoscope. 2005;115:1741–1745.

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24. Ceallaigh PO, Ekanaykaee K, Beirne CJ, et al. Diagnosis and management of common maxillofacial injuries in the emergency department. Part 2: Mandibular fractures. Emerg Med J. 2006;23:927–928.

25. Dodson TB, Kaban LB. Special considerations for the pediatric emergency patient. Emerg Med Clin North Am. 2000;18:539–547.

26. Yagiela JA. Anesthesia and pain management. Emerg Med Clin North Am. 2000;18:449–470.