Infantile Hemangioma Mimics Dermatofibrosarcoma Protuberans.

Infantile hemangiomas are commonly encountered at all levels of medical practice. Clinicians should be aware of their typical clinical history and findings in order to expedite early diagnosis and management. It is also necessary to be aware of differential diagnoses that may mimic infantile hemangiomas but have a more concerning prognosis. The objective of this report is to describe the clinical case of one such mimic, dermatofibrosarcoma protuberans. This report highlights key clinical findings of infantile hemangiomas, while also identifying "red flags" that necessitate urgent additional investigations and referral to a multidisciplinary team. Additionally, key features in the management of both infantile hemangiomas and extremity masses are discussed.

Motorcycle Accidents are the Strongest Risk Factor for Panfacial Fractures Among Pediatric Patients.

Study Design: A retrospective cohort study was conducted using the Kids' Inpatient Database from 2000 to 2014. Subjects were included if they were 18 years and younger and suffered any type of facial fracture. Objective: The purpose this study was to determine the risk factors for incurring panfacial fractures among the pediatric population. Methods: The primary predictor variables were a set of heterogenous variables that included patient characteristics, injury characteristics, hospitalization outcomes. The primary outcome variable was panfacial fracture. Logistic regression was used to determine the independent risk factors for panfacial fractures. Results: Relative to infants and toddlers, teenagers were nearly three times more likely to sustain panfacial fractures (P < .01). Relative to no chronic conditions, patients with one or more chronic conditions were more likely to incur panfacial fractures. Motorcycle accidents were over three times more likely (P < .01) to result in panfacial fractures while car accidents were over two times more likely (P < .01) to result in panfacial fractures. Falls were less likely (OR, .39; P < .01) to result in panfacial fractures. Conclusions: Motor vehicle accidents was a major risk factor for panfacial fractures. Teenagers are also found to have an increased risk for panfacial fractures relative to infants and toddlers. Each additional chronic condition was a significant risk factor for suffering panfacial fractures relative to not having any chronic condition at all. In contrast, falls independently decreased the risk of incurring a panfacial fractures. Special attention should be given to safety precautions when occupying a motor vehicle.

Dorsal Augmentation: A Review of Current Graft Options.

Background: Dorsal augmentation is one of the more complication-prone procedures in rhinoplasty, demanding ample skill and experience to produce an aesthetic and functional result. Numerous autologous grafts, allografts, xenografts, and alloplastic materials have been attempted for augmentation with varying success. Each graft material has its own unique properties that require varying surgical intricacies. The relative risks and benefits of these strategies and materials are also variable and must be weighed. Alloplastic implants are commonly used in eastern countries, but, due to different patient populations and complication profiles, have found less acceptance among western surgeons. Methods: A PubMed search was done using the terms "dorsal augmentation rhinoplasty," "liquid rhinoplasty," and "grafts used for rhinoplasty." Publication dates ranging from 1957-2022 were included. Abstracts were screened for relevance, and references from each article were reviewed to identify further articles. Chapters on dorsal augmentation from two key rhinoplasty textbooks were also reviewed. Results: A total of 79 articles and 2 textbooks were formally screened; of these, 65 resources were included. Findings were grouped under the headings "facial analysis," "ethnic factors in graft selection," "graft characteristics," "septal cartilage," "auricular cartilage," "costal cartilage," "diced cartilage grafts," "bone grafts," "soft tissue grafts," "nonsurgical/liquid rhinoplasty," and "alloplastic implants." Conclusions: Current dorsal augmentation literature focuses on retrospective studies and expert experiences. There are limited quantitative and prospective studies present to delineate an ideal graft. With consistently advancing technology and knowledge of facial aesthetics, a surgeon must maintain a thorough understanding of the current graft and implant options to offer a specialized treatment plan for each deformity and patient.

Cleft Palate Fistula: A Review.

Background: The development of postoperative oronasal fistulae (ONF) is a complication that plagues all cleft surgeons to varying degrees. There is extensive literature discussing the incidence, functional impact, and treatment of ONF. The goal of this article is to provide an extensive review of the literature discussing the incidence, causative factors, functional impact, classification systems, and treatment of ONF. Methods: A literature review was performed using PubMed using the Medical Subject Heading terms "cleft palate" AND "fistula" OR "palatal fistula" OR "oronasal fistula". After review, a total of 356 articles were deemed relevant for this study. Results: Information regarding ONF care, prevention, and management in patients with cleft palate was collected from the articles included in this review. Treatment of ONF remains a challenging problem as there is not a consensus in the available literature on the best palatoplasty techniques for their prevention and treatment. A myriad of reconstructive options and adjunctive therapies exist, and their use is guided by the size and location of the fistula. Conclusions: Fistula treatment should be tailored to the specific needs of the patient, and consideration must be given to not only the ONF itself but also the patient's stage of growth and development. Large-scale, multicenter studies are needed in which ONF are described using standardized nomenclature, and improved outcomes reporting is necessary to better define an algorithm for a truly holistic approach to palate surgery and reduce the incidence of palatal fistula.

Novel Approach of Femur Shortening With Insertion of Expandable Rod to Achieve End-to-End Repair of Sciatic Nerve Laceration.

BACKGROUND: Sciatic nerve injuries are challenging for diagnosis and treatment. Particularly in proximally located high-grade injuries, neurorrhaphy often has poor outcomes. Most advocate autologous grafting and some more recently have suggested the value of knee flexion braces to facilitate end-to-end repair. OBJECTIVE: To describe a case of femur shortening to facilitate tension-free, end-to-end sciatic nerve neurorrhaphy. METHODS: The patient was a 17-year-old man who was injured by the propeller of a motor boat and suffered a series of lacerations to both lower extremities including transection of his right sciatic nerve in the proximal thigh. After extensive mobilization of the nerve, a greater than 7-cm gap was still present. The patient was treated with femur shortening to facilitate end-to-end coaptation. He subsequently had an expandable rod placed which was lengthened 1 mm per day until his leg length was symmetric. RESULTS: Within 7 months postoperatively, the patient had an advancing Tinel sign and paresthesias to the dorsum of his foot. Nine months postoperatively, he had early mobility in his plantarflexion. CONCLUSION: We present a novel method of femur shortening with insertion of an expandable rod to facilitate direct end-to-end and tension-free sciatic nerve neurorrhaphy in a proximally located injury. Furthermore, larger scale and comparative studies are warranted to further explore this and other techniques.

Design and Validation of a 3D Printed Cranio-Facial Simulator: A Novel Tool for Surgical Education.

OBJECTIVE: To assess the ability of current 3D printing technology to generate a craniofacial bony and soft tissue anatomical model for use in simulating the performance of a fronto-orbital advancement (FOA) osteotomy and then to further assess the value of the model as an educational tool. DESIGN: Anatomic models were designed with a process of serial anatomic segmentation/design, 3D printing, dissection, and device refinement. A validation study was conducted with 5 junior and 5 senior plastic surgery residents. The validation study incorporated a multiple-choice Knowledge Assessment test (KA), an Objective Structured Assessment of Technical skills (OSATs), a Global Rating Scale (GRS) and a Michigan Standard Simulation Experience Scale (MiSSES). We compared the scores of both the junior and senior residents and compared junior resident scores, before and after viewing a lecture/demonstration. RESULTS: MiSSES showed high face validity with a score of 85.1/90, signifying high satisfaction with the simulator learning experience. Simulation and the lecture/demonstration improved the junior resident average KA score from 5.6/10 to 9.6/10 (P = .02), OSATs score from 32.4/66 to 64.4/66 (P < .001) and GRS score from 13.9/35 to 27.5/35 (P < .001). The senior residents OSATs score of 56.3/66 was higher than the pre-lecture juniors (32.4/66) (P < .001), but lower than the post-lecture juniors (64.4/66) (P < .001). CONCLUSION: We have successfully fabricated a 3D printed craniofacial simulator capable of being used as an educational tool alongside traditional surgical training. Next steps would be improving soft tissue realism, inclusion of patient and disease specific anatomy and creation of models for other surgical specialties.

The Incidence of Thromboembolic Events During Hospitalizations Following Surgical Resection of Lower Extremity Sarcomas in Children: Utilizing the Pediatric Health Information System Database.

BACKGROUND: Venous thromboembolism (VTE) is a frequent occurrence during treatment for adults with sarcoma. The incidence and underlying risk factors of postsurgical VTE in children and adolescents undergoing resection of sarcoma are unknown. METHODS: Using International Classification of Disease revision-9 diagnostic and procedure codes, the Pediatric Health Information System database was queried for patients aged 18 years and younger, discharged from 2004 to 2015 with a diagnosis of lower extremity malignant neoplasm who had a tumor resection or amputation performed during the encounter. Malignant neoplasms of the pelvic bones and soft tissues were categorized as "pelvis tumors", whereas malignant neoplasms of bone and soft tissues of the lower limbs were categorized as "lower limb tumors". Hospitalizations were evaluated for the occurrence of VTE. Demographic characteristics (age at admission, sex, race, and race/ethnicity) and incidence of VTE were reported. RESULTS: There were 2400 patients identified. Of these, 19 experienced VTE (0.79%) during their surgical hospitalization encounter. By anatomic group, the rate of VTE was 1.4% (CI: 0.5%-3.2%) for tumors in the pelvis and 0.6% (CI: 0.3%-1.0%) in lower limb tumors. Categorizing by age, the incidence of VTE was 1.2% in patients aged zero to 5, 0.3% in patients 6 to 13, and 1.2% in patients 14 to 18 years old. (Table 1). The extremely low rate of VTE occurrence precluded further analysis of risk factors. CONCLUSIONS: In this analysis, postsurgical VTE during hospitalization after pelvic and lower extremity sarcoma resection was an uncommon event in children and adolescents. There seemed to be an increased incidence of postsurgical VTE in pelvic tumors when compared with lower limb tumors, however, the rarity of all events precluded formal statistical analysis. A more robust data set would be required to determine if there are subsets of children and adolescents with sarcoma at higher risk of VTE that could benefit from thromboprophylaxis in the postoperative setting. LEVEL OF EVIDENCE: Level II.

Laparoscopic-Assisted Relocation of the Umbilicus With Umbilicoplasty in Complex Abdominal Wall Reconstruction.

Patients with complex abdominal wall pathology often present with significant distortion of their umbilicus. Ventral and umbilical hernias often create widening or protrusion of the umbilicus, while obesity and laxity of the skin and subcutaneous tissue of the abdominal wall further exacerbates the deformity. The primary goal of hernia repair is always reduction of the hernia with a tension-free repair; however, an important secondary goal is esthetic improvement of the abdominal wall. Often, in patients with complex hernia defects involving the umbilicus, there is discussion of not salvaging the umbilicus altogether. Although this certainly remains an option for many patients, we present a technique that would not only allow for hernia reduction under direct laparoscopic visualization but also an improved esthetic to the umbilicus.

An Algorithmic Approach for Deploying Buccal Fat Pad Flaps and Buccal Myomucosal Flaps Strategically in Primary and Secondary Palatoplasty.

OBJECTIVE: Recent publications have introduced the use of buccal myomucosal and fat pad flaps to augment palatal repairs with autologous tissue. We propose a workflow for intraoperative decision-making to introduce these adjuncts into standard palatoplasty procedures. DESIGN/PATIENTS: A retrospective chart review of a single-surgeon series of patients undergoing primary and secondary palatoplasties performed between October 2017 and November 2020 was completed after Institutional Review Board approval. MAIN OUTCOME MEASURES: Patient demographics, phenotype, operative details, and postoperative complications were recorded. RESULTS: Fifty-eight patients were included in a review. For those undergoing primary repair, 23.3% underwent a Furlow palatoplasty alone, 46.3% had a Furlow palatoplasty accompanied with acellular dermal matrix (ADM) and/or a buccal fat flap (BFF). A unilateral buccal myomucosal flap (BMMF) with or without augmentation with BFF or ADM was employed in 16.3% of the cases. Fourteen percent required a bilateral BMMF+/- ADM. Fistula occurrence was 2.3% (n = 1). For revisions, 27% underwent only a conversion Furlow palatoplasty, 26% had a conversion Furlow palatoplasty accompanied with ADM and/or a BFF, 33% had a unilateral BMMF or BMMF/ADM, and 14% required a bilateral BMMF+/- ADM. CONCLUSIONS: In severe phenotypes or complicated cases, buccal fat flaps and myomucosal flaps may be utilized. This approach has mostly replaced the use of ADM over time. An algorithmic approach to palatoplasty allows surgeons to tailor the extent of surgery to the needs of each patient.

The Impact of Race and Ethnicity on Surgical Risk and Outcomes Following Palatoplasty: An Analysis of the NSQIP Pediatric Database.

OBJECTIVE: To determine how race and ethnicity affect palatoplasty 30-day outcomes. DESIGN: Retrospective review. PATIENTS/SETTING: The 2012 to 2019 National Surgical Quality Improvement Program (NSQIP) Pediatric database was used to identify patients ≤ 2 years who underwent primary palatoplasty. We compared demographics, comorbidities, and 30-day outcomes among different racial and ethnic groups. Logistic regression was used to determine independent risk factors for adverse events. MAIN OUTCOME MEASURES: Increased risk for adverse events and postoperative surgical outcomes, including complications, readmission, and prolonged length of stay. RESULTS: A total of 8537 patients were identified in the database. African-American patients had the highest proportion of premature infants and infants with a BMI < 15% at the time of repair. Asian patients underwent palatoplasty at a later age compared to other races (12.7 months vs 11.7-12.1 months). Postoperatively, the odds of a complication were significantly higher in Asian patients (aOR = 1.73, 95% CI: 1.17-2.57) and other/unknown patients (aOR = 1.40, 95% CI: 1.05-1.86), but not among African American (aOR = 1.02, 95% CI: 0.70-1.47) or Hispanic (aOR = 0.93, 95% CI: 0.69-1.26) patients. Other/unknown patients were more likely to require postoperative ventilation (aOR = 2.34, 95% CI: 1.38-3.95). The odds of readmission were highest in Asian and other/unknown patients. African American, Hispanic, and other/unknown patients were more likely than Caucasian patients to be hospitalized > 2 days postoperatively. CONCLUSION: This study highlights ethnic differences in presentation and 30-day outcomes following palatoplasty. Further evaluation of disparities in cleft care should be performed to improve healthcare access and surgical outcomes.

A Survey of Bone Grafting Practice Patterns in North American Cleft Surgeons.

INTRODUCTION: Alveolar bone grafting aims to restore bony continuity of the alveolus and provide optimal periodontal support for teeth adjacent to the cleft. We created a survey of cleft surgeons to assess the current standard of care regarding this procedure. METHODS: A multiple choice survey was implemented using Qualtrics software and emailed to a list of 708 surgeons from the ACPA membership directory. Correlation between various provider factors and treatment practices was assessed with Fisher's exact test and likelihood ratio tests. RESULTS: The response rate was 17.5%. Eighty-seven percent of providers preferred to perform grafts prior to secondary canine eruption while 10% favored before central incisor eruption. Eighty-one percent favored palatal expansion prior to bone grafting. Wide variability existed regarding the time to initiate postoperative orthodontics; 43% waited 4 to 6 months. Sixty-four percent of surgeons now utilize cone beam CT to assess graft take. The majority of respondents utilized cancellous bone autograft (92%) from the anterior iliac crest (97%) as graft material. Seventy percent used three or more modalities for post-operative pain control management. Early career surgeons (0-5 years) appeared more likely to use non-autologous materials (p < .01) for grafting. CONCLUSION: Alveolar bone grafting prior to secondary canine eruption remains the most common strategy but other protocols are employed. Surgeons utilize multiple modalities for radiographic evaluation and most often use autologous cancellous bone as the primary grafting material. There is no true consensus on the perioperative timing and sequencing of orthodontic manipulation while principles of multimodal perioperative pain control appear widely accepted.

Acute Intentional Deformation of Open Tibial Fractures for Complex Soft Tissue Closure in the Pediatric Patient.

Background. Lower extremity injuries in the pediatric population that are associated with Gustillo 3B/3C fractures require special consideration. Limb salvage should be attempted in the pediatric patient if at all possible, and oftentimes the soft tissue defect that is present over the bony fracture is substantial. The traditional algorithm used in the management of Gustillo 3B/3C fractures in plastic surgery, referred to as the reconstructive ladder, would recommend flap reconstruction with free tissue transfer in most cases because regional options are often unavailable or do not provide adequate coverage. Free tissue transfer procedures are extensive and necessitate a donor site; they often require multiple procedures and subsequent revisions. Furthermore, when concomitant injuries or medical conditions are present, a patient may not be an appropriate candidate for a free flap. Another option, however, does exist for the pediatric patient with a significant lower extremity injury that is often overlooked by the plastic surgeon. Several articles in the orthopedic literature describe the utility of temporary limb deformation to allow for soft tissue closure, with gradual correction of the bony deformity over time. Although the healing process for these procedures take several months, there is no need for extensive soft tissue reconstruction and the ultimate result is a leg that is functional with adequate coverage. This article reports a case where this type of bone and soft tissue reconstruction was performed in a patient with an excellent overall outcome. This technique could be useful in select cases as an option in pediatric lower extremity reconstruction.

Early Childhood (0 to 5 years) Presents the Greatest Risk for Facial Dog Bites.

PURPOSE: The purpose of the present study is to compare the characteristics of dog bite wounds to the face and that of the rest of the body among the pediatric population in the United States and to determine independent risk factors for dog bite wounds to the face. METHODS: A retrospective cohort study was conducted using the Kids' Inpatient Database. There were multiple, heterogenous predictor variables. The primary outcome variable was a facial dog bite. A multivariate logistic regression was employed to identify independent risk factors for the primary outcome variable. A P value less than .05 was the threshold for statistical significance. RESULTS: Our final sample consisted of 9,057 patients who suffered dog bite injuries, of which 2,913 (32.2%) occurred on the face. Relative to individuals aged 16-20 years, individuals aged 0-5 (odds ratio [OR] 5.7; confidence interval [CI] 4.0, 8.1), 6-10 (OR 3.8; CI 2.6, 5.5), and 11-15 years (OR 1.6; CI 1.1, 2.5) were all independently associated with increased odds of incurring a facial dog bite injury. Patients who were not admitted electively were 2.5 times (CI 1.4, 4.6) more likely to incur a facial dog bite injury relative to patients who were admitted electively. CONCLUSIONS: Young children (0-5 years) were at the greatest risk for facial dog bites relative to children aged 16-20 years. Dog bites that were admitted on emergency were more likely to occur on the face relative to those that were electively admitted to the hospital. To reduce the risk for facial dog bites and the host of chronic psychological ramifications that accompany them, established preventative strategies ought to be exercised.

Head Computed Tomography Versus Maxillofacial Computed Tomography: An Evaluation of the Efficacy of Facial Imaging in the Detection of Facial Fractures.

Background: In an initial trauma evaluation, computed tomography of the head (CTH) is performed to assess for life-threatening intracranial injury. Given the high incidence of concomitant facial injuries, many facial fractures are diagnosed incidentally during this evaluation. Although maxillofacial CT (CTMF) is widely accepted as the most sensitive method for evaluating facial fractures, it is often excluded from the initial survey. Failure to obtain dedicated imaging can lead to increased costs related to a missed or delayed facial fracture diagnosis. Our study investigates the location and type of missed facial fractures on CTH by reviewing imaging data from patients who presented at a level 1 trauma center and underwent both CTH and CTMF. Methods: A retrospective review of all facial fractures diagnosed at a single institution from 2002 through 2016 was conducted. Inclusion criteria included adults aged 18 years or older who received CTH and then subsequent CTMF. Patients who had either CTH or CTMF only or combined CTH/CTMF were excluded. The facial fractures were further subdivided by location. Results: There were 501 patients with 1743 total facial fractures. CTH successfully identified 788 (45.21%) fractures, versus 1743 (100%) for CTMF. The most common fractures, in both cohorts, were nasal bone (15.7%) and orbital floor (12.8%) fractures. Using CTMF to identify missed fractures on CTH, significant differences were noted in the following locations: anterior table frontal sinus, medial/lateral pterygoid, maxillary sinus, lateral orbital wall, zygomatic arch, palate, and all types of mandible fractures excluding the mandibular condyle. Conclusions: CTH for initial trauma evaluation often misses facial fractures. CTH alone was only sufficient in detecting posterior frontal sinus, orbital (excluding lateral wall), and mandibular condyle fractures. In patients with suspected facial injury, dedicated imaging should be performed to detect the location and extent of injury because CTH inadequately identifies most facial fractures.

Radiographic imaging modalities for perinatal brachial plexus palsy: a systematic review.

PURPOSE: Perinatal brachial plexus palsy (PBPP) has a wide spectrum of clinical symptoms that can range from incomplete paresis of the affected extremity to flaccid arm paralysis. Although there is a high rate of spontaneous recovery within the first two years of life, it remains challenging to determine which patients will benefit most from surgical intervention. The diagnostic and predictive use of various imaging modalities has been described in the literature, but there is little consensus on approach or algorithm. The anatomic, pathophysiological, and neurodevelopmental characteristics of the neonatal and infant patient population affected by PBPP necessitate thoughtful consideration prior to selecting an imaging modality. METHODS: A systematic review was conducted using six databases. Two reviewers independently screened articles published through October 2021. RESULTS: Literature search produced 10,329 publications, and 22 articles were included in the final analysis. These studies included 479 patients. Mean age at time of imaging ranged from 2.1 to 12.8 months and investigated imaging modalities included MRI (18 studies), ultrasound (4 studies), CT myelography (4 studies), and X-ray myelography (1 study). Imaging outcomes were compared against surgical findings (16 studies) or clinical examination (6 studies), and 87.5% of patients underwent surgery. CONCLUSION: This systematic review addresses the relative strengths and challenges of common radiologic imaging options. MRI is the most sensitive and specific for identifying preganglionic nerve injuries such as pseudomeningoceles and rootlet avulsion, the latter of which has the poorest prognosis in this patient population and often dictates the need for surgical intervention.

Syringocystadenocarcinoma Papilliferum in a Fifteen-Year-Old Girl: A Case Report and Review of the Literature.

Syringocystadenocarcinoma papilliferum (SCACP) is a rare malignant neoplasm arising from adnexal tissues and is the malignant complement to the benign neoplasm syringocystadenoma papilliferum (SCAP). SCACP lesions appear as raised nodules or inflammatory plaques and can be associated with SCAP or nevus sebaceous. There have been fewer than 100 described cases of this neoplasm in the literature, and all previously published cases have been described in adults, with the majority occurring in the elderly. We present a case of an adolescent female with a syringocystadenocarcinoma papilliferum arising from a large thigh mass harboring an in-frame alteration in MAP2K1 along with a brief review of the literature.

A new visual design language for biological structures in a cell.

As part of a project to build a spatiotemporal model of the pancreatic ß-cell, we are creating an immersive experience called "World in a Cell" that can be used to integrate and create new educational tools. To do this, we have developed a new visual design language that uses tetrahedral building blocks to express the structural features of biological molecules and organelles in crowded cellular environments. The tetrahedral language enables more efficient animation and user interaction in an immersive environment.

Management of Pediatric Nasoorbitoethmoid Complex Fractures at a Level 1 Trauma Center.

PURPOSE: A universally accepted treatment algorithm for rare pediatric nasoorbitoethmoid (NOE) fractures has yet to be established. In this study, the authors examine how severity of pediatric NOE fractures interplays with patient characteristics, management choices, and complications from injury and surgical intervention at our institution. METHODS: A retrospective chart review was performed for all cases of pediatric NOE fracture at a level 1 trauma center (University Hospital in Newark, New Jersey) between 2002 and 2014. RESULTS: Fifteen of 1922 patients met our inclusion criteria. Ten (66.7%) demonstrated Markowitz type I injuries, 2 (13.3%) had type II NOEs, and 3 (20%) sustained type III fractures. Five (33.3%) of our patients were only monitored. Six (40.0%) were treated with plate fixation. One patient (6.7%) required enucleation alone, while 1 (6.7%) warranted enucleation with medial canthoplasty and plate fixation. Transnasal canthopexy was performed for 1 patient (6.7%). Zero patients managed without surgery had complications at 1-year follow-up. Surgical intervention was associated with complications in 4 of 15 patients. Both nonoperative treatment and plate fixation were associated with a higher rate of complications from initial injury or subsequent therapy when than other mentioned forms of treatment (P = .004). CONCLUSION: Nonoperative management for nondisplaced fractures is associated with zero complications at 1-year follow-up in our data; plate fixation and watchful waiting yield significantly fewer postoperative complications and injury sequelae than surgical intervention for medial canthal tendon and globe injuries.

Periorbital and Globe Injuries in Pediatric Orbital Fractures: A Retrospective Review of 116 Patients at a Level 1 Trauma Center.

STUDY DESIGN: Retrospective chart review of pediatric and globe injuries associated with orbital fractures. OBJECTIVE: Our study seeks to examine these injuries and their association with orbital fractures at our trauma center to gain a better understanding of how to approach pediatric patients with orbital fractures. METHODS: A retrospective review of all facial fractures in pediatric patients at an urban level 1 trauma center was performed for the years 2002 to 2014. Patient demographics were collected, as well as orbital fracture location, mechanism of injury, concomitant injuries, ophthalmologic documentation, imaging, and perioperative records. RESULTS: One hundred sixteen pediatric patients over a 12-year period sustained an orbital fracture. The orbital floor was the most commonly fractured orbital bone in our series (60%). Thirty-four (30%) of the pediatric patients with orbital fractures had documented periorbital and/or globe injuries at the time of presentation. The most common periorbital injury was entrapment related to orbital floor fractures. Significant eyelid lacerations were present in seven patients, with five of these patients had canalicular injuries and two had canthal malposition. Five pediatric patients presented with traumatic optic neuropathy. Two patients had ruptured globes requiring enucleation. CONCLUSIONS: Periorbital soft tissue and globe injuries associated with orbital fractures occurs in a substantial number of pediatric patients. There are no guidelines for treatment of these type of injuries in the pediatric population. Further research should be performed to better understand the appropriate management of periorbital injuries in conjunction with surgical management of the orbital fractures.

Pediatric Palate Fractures: An Assessment of Patterns and Management at a Level 1 Trauma Center.

STUDY DESIGN: Literature discussing palate fractures in the pediatric population is limited. We performed a retrospective review of pediatric palatal fractures at our institution to better understand the impact of this fracture pattern in the pediatric patient. OBJECTIVES: The goal of our study is to analyze our institutional experience with pediatric palate fractures, focusing on epidemiology, concomitant injuries, and fracture management. METHODS: Records were collected for all palatal fractures in pediatric patients diagnosed between 2000 and 2016 at an urban Level I trauma center. Patient imaging was reviewed. Demographic characteristics and inpatient clinical data were recorded. RESULTS: Nine pediatric patients were diagnosed with fracture of the bony palate. Average age was twelve with male predominance (66%). Pedestrian struck injuries (33%) and motor vehicle accidents (33%) were the most common etiologies. Five patients sustained skull fractures. Three patients were found to have intracranial hemorrhage, two required emergent bolt placement. Two patients sustained cervical spine injury. One patient had severe facial hemorrhage requiring embolization. According to the Hendrickson classification, there were three type I fractures, two type II fractures, one type III fracture, one type IV fracture, and one type V fracture. Lefort I and/or alveolar fracture was present in every patient. Four patients underwent surgical treatment with open reduction and restoration of facial height with maxillomandibular fixation. Three patients underwent concomitant mandible fracture repair. CONCLUSIONS: Pediatric palatal fractures are rare and are usually accompanied by devastating concomitant injuries. Surgical repair of the palate in the pediatric patient is often necessary to restore facial height.