Controversies in the management of pediatric facial fractures.

The treatment of pediatric maxillofacial fractures demands consideration of different factors than those in the adult and, therefore, a different therapeutic approach. We currently believe that certain principles in the management of these injuries can be outlined, recognizing that they may require modification as additional experience accumulates. These management principles are as follows: 1. Maintain a high index of suspicion for maxillofacial injury in the pediatric patient, especially when multiple trauma exists. 2. In addition to careful physical examination, utilize CT scanning on a routine basis, even for apparently trivial injuries. 3. Give consideration to observation only for minimally displaced fractures. 4. Respect the functional matrix and employ the least invasive surgical approach that will access the fracture and allow stable reduction. 5. Employ methods of fixation that adequately stabilize the facial skeleton without rigidly immobilizing long segments. 6. If rigid internal stabilization is necessary, in the form of conventional plate and screw fixation, give consideration to interval removal. 7. Microplates appear to provide enough stability so that their use can be advocated whenever possible. 8. Avoid the use of alloplastic materials, especially in the very young patient. 9. Use bone grafts sparingly, except in instances in which inlay reconstruction is necessary and onlay reconstruction is required to maintain soft-tissue support. 10. Be aware of the pediatric dentition and avoid iatrogenic injury to evolving teeth and tooth buds. Perhaps the most important principle of all is to document injuries and their method of treatment and to follow patients serially. This will allow further definition of fracture patterns and the effects of injury and its treatment on growth, thereby giving the surgeon a better understanding and ability to develop more concise treatment philosophies for the future.     

Reduction and pinning of pediatric supracondylar humerus fractures in the prone position

Supracondylar humerus fractures are common pediatric injuries; the preferred treatment for displaced fractures is closed reduction and percutaneous pin fixation. We present a technique for closed reduction and pinning using prone-patient positioning. Prone positioning facilitates fracture reduction and safe pin placement while avoiding elbow hyperflexion. We prefer this technique to the commonly described method of fracture reduction and pinning with the patient supine.     

Impact of automobile restraint device utilization on facial fractures and fiscal implications for plastic surgeons

In 2009, the National Highway Traffic Safety Administration projected that 33,963 people would die and millions would be injured in motor vehicle collisions (MVC). Multiple studies have evaluated the impact of restraint devices in MVCs. This study examines longitudinal changes in facial fractures after MVC as result of utilization of restraint devices. The Pennsylvania Trauma Systems Foundation-Pennsylvania Trauma Outcomes Study database was queried for MVCs from 1989 to 2009. Restraint device use was noted, and facial fractures were identified by International Classification of Diseases-ninth revision codes. Surgeon cost data were extrapolated. More than 15,000 patients sustained ≥1 facial fracture. Only orbital blowout fractures increased over 20 years. Patients were 2.1% less likely every year to have ≥1 facial fracture, which translated into decreased estimated surgeon charges. Increased use of protective devices by patients involved in MVCs resulted in a change in incidence of different facial fractures with reduced need for reconstructive surgery.     

俯卧位闭合复位经皮克氏针内固定治疗儿童移位肱骨髁上骨折

目的评价俯卧位闭合复位经皮克氏针内固定治疗儿童移位肱骨髁上骨折的疗效。方法回顾性分析自2010-06—2013-05采用俯卧位闭合复位经皮克氏针内固定治疗的38例儿童移位肱骨髁上骨折。取俯卧位,患肢前臂悬垂于手术床边,在C型臂X线机透视下闭合复位肱骨髁上骨折满意后经皮从肱骨远端内外侧穿针固定。结果本组手术时间35~118 min,平均70 min。所有患者均达到闭合复位。35例获得随访8~12个月,平均10个月。末次随访时35例骨折均愈合,无Volkman挛缩和肘内翻畸形,内侧穿针无医源性尺神经损伤。末次随访时患侧肘关节伸直-10°~4°,平均-4°;健侧肘关节伸直-14°~0°,平均-10°。患侧肘关节屈曲110°~140°,平均125°;健侧肘关节屈曲120°~150°,平均135°。同健侧相比,5例患侧丢失屈伸功能5°~10°,Flynn临床功能评定为良。患侧携带角0°~10°,平均7°;健侧携带角0°~15°,平均9°。3例患侧携带角丢失5°~10°,Flynn临床功能评定为良。患侧肘关节Baumann角变化值1°~6°,平均3.5°。结论俯卧位闭合复位经皮克氏针内固定治疗儿童移位肱骨髁上骨折具有复位容易,方便穿针和利于术中透视等优点。     

The role of lateral-entry Steinmann pins in the treatment of pediatric supracondylar humerus fractures

Purpose  

Loss of pin fixation in supracondylar fractures can occur with failure to achieve bicortical fixation. Bicortical fixation may be challenging for those pins that attempt to penetrate the diaphyseal cortex, where the bone is thick. Lateral-entry Steinmann pins may allow for better penetration through cortical bone because they are more rigid than typical Kirschner wires.     

The position of laparoscopic surgery in pediatric urology

With growing experience in laparoscopic techniques there is a switch in pediatrics from ablative surgery to reconstructive procedures. Besides the established procedures such as laparoscopic nephrectomy and orchidopexy, procedures like heminephrectomy and pyeloplasty have proven practicable and become standard therapies in children and infants. Due to technical advances, as shown for our own patients, the number of treated infants is still increasing. However, laparoscopic reconstructive procedures presuppose a good deal of experience in preparation and suture techniques, and remain reserved for centers with daily experience in laparoscopy. Daily experience with difficult urological laparoscopic procedures in adults will remain more common than in pediatric centres.     

The role of facial skeletal augmentation and dental restoration in facial rejuvenation

Facial aging is almost exclusively a result of soft tissue changes in patients with full dentition. Loss of teeth can hasten facial aging and make aging more pronounced as a result of bony erosion of the alveolar ridges. This article describes these changes and demonstrates that properly selected oral implants and precisely placed hydroxyapatite implants can integrate with facelifts to produce superior facial rejuvenation in edentulous patients.     

The treatment of pediatric supracondylar humerus fractures

Based on the best current evidence and a systematic review of published studies, 14 recommendations have been created to guide clinical practice and management of supracondylar fractures of the humerus in children. Two each of these recommendations are graded Weak and Consensus; eight are graded Inconclusive. The two Moderate recommendations include nonsurgical immobilization for acute or nondisplaced fractures of the humerus or posterior fat pad sign, and closed reduction with pin fixation for displaced type II and III and displaced flexion fractures.