Palatal fracture in a child.
|Article Type:||Case study|
Children (Care and treatment)
Children (Patient outcomes)
Skull (Care and treatment)
Skull (Patient outcomes)
Keith, Karen M.
Clark, Tyler L.
|Publication:||Name: U.S. Army Medical Department Journal Publisher: U.S. Army Medical Department Center & School Audience: Professional Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 U.S. Army Medical Department Center & School ISSN: 1524-0436|
|Issue:||Date: Jan-March, 2011|
|Geographic:||Geographic Scope: United States Geographic Code: 1USA United States|
Oral and maxillofacial surgeons are often consulted to evaluate
intraoral trauma in children. The pediatric population is exceptionally
susceptible to penetrating trauma of the palate due to developing
coordination issues and the tendency to put objects into mouths. (1)
While the vast majority of such cases are easily managed on an
outpatient basis, clinicians should have a high index of suspicion for
the potential devastating effects of these types of injuries. They can
appear rather innocuous at initial presentation, but can actually lead
to potentially fatal or highly morbid complications. We present a case
of penetrating palatal trauma with a unique etiology and approach to
treatment, and discuss some of the consequences that have been presented
in the literature, with a treatment protocol to remind providers of the
need for vigilance in this trauma scenario.
A 6-year-old female reported to the Emergency Department at Madigan Army Medical Center with a complaint of pain and bleeding from the roof of her mouth. She had been running on the playground at school. She tripped and fell toward a friend, who was holding a tree branch. One of the smaller branches penetrated her palatal mucosa and bone. Upon examination in the Emergency Department, her vitals were noted to be within normal limits for her age. Her medical history was significant only for a history of jaundice as an infant and an allergy to penicillin. Immunizations were up-to-date. The patient was hemodynamically and neurologically intact. Examination of the oral cavity revealed a hemostatic, stellate puncture wound just to the left of the patient's midline at the junction of the hard and soft palate (Figure 1). Closer intraoral examination of the wound revealed a palatal fracture just lateral to the midline suture, with the fractured bone vertically displaced into the nasal vestibule toward the caudal septal cartilage. The computed tomography scan image (Figure 2) demonstrates the degree of displacement of the fractured piece. Due to concern for scarring and future septal deviation as well as potential infection, the patient was taken to the operating room for general anesthesia to manually reduce the fractured bone and to better explore the wound. Intraoperatively, a combination of digital manipulation intraorally and the use of a #15 scaler intranasally successfully repositioned the maxillary bone (Figure 3). Inspection of the septum revealed no deviation, laceration, or hematoma. Fast absorbing gut suture was used to close the palatal mucosa and the patient was placed on postoperative antibiotics for 5 days (Figure 4). A palatal stent was fabricated from a preoperative model and secured to the dentition with suture for 5 days. Instructions were provided to the patient and parents. The patient had an uneventful postoperative course and healed without incident or sequela (Figure 5).
Penetrating injury to the palate can range from relatively innocuous to rather significant and dangerous, depending on the location of the entry wound intraorally. Most bleeding is self-limited unless the palatine artery is injured. Management of most such injuries can be on an outpatient basis, but clinicians must remain vigilant should the patient's status deteriorate. Potentially devastating effects of penetrating palatal trauma include overt carotid vessel disruption with significant hemorrhage and intimal tearing with thrombus formation and propagation that can result in ischemic infarcts. Oral bacterial contamination can cause severe infections into major fascial planes or the mediastinum. (2) If the injury is located off the palatal midline, the proximity of the carotid vasculature cannot be discounted. Occlusion of the middle cerebral artery and ischemic infarctions have been reported. (3,4) The subsequent neurologic deficits can manifest as partial or complete hemiparesis, homonymous hemianopsia, Horner's syndrome, facial nerve paralysis, gait issues, or death. (5,6) The concern is that initially the patient will have a "lucid interval" with neurologic deterioration not evident for up to 2 days after the injury when the thrombus has had time to form and propagate toward the cerebral circulation. (7) Clinicians should watch for development of irritability, vomiting, drowsiness, visual changes, seizures, and motor deficits. Transtentorial herniation and death can ensue with progression of a thrombus to the anterior and middle cerebral arteries that produces infarction, edema and mass effect. (8) While only 32 cases of internal carotid artery thrombus have been reported in the English literature prior to 2006, (9) clinicians should be cognizant of its significance.
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Raska et al (5) did a review of the literature to provide a recommended treatment protocol for penetrating trauma in children. Some authors suggest that noninvasive angiography studies are as accurate as traditional angiography without the potential complications of catheterization. (10,11) Raska et al recommended angiography to rule out vascular injury once the patient was appropriately resuscitated, and also proposed a more aggressive protocol than some. They felt that traditional angiography remained the gold standard as computed tomography angiography and magnetic resonance angiography have proved inferior in detecting vascular injuries in adults. Studies are not available in children because of the infrequency of significant vascular pathology in this population. Biffl et al (12) and Miller et al (13) did prospective studies that support Raska's claim that traditional catheter angiography appears more sensitive at detecting vascular injuries. Hellman's group, (14) however, reviewed 131 cases of impalement injuries over a 17-year period where diagnostic imaging was not performed until development of neurologic deficits and concluded that management and outcomes of oral-pharyngeal palate injuries were not enhanced by prior diagnostic maneuvers.
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Some providers will recommend hospitalization and anticoagulation, but this is not a universal approach. Because significant damage to the carotid vasculature is very rare and development of symptoms has been reported to take 96 hours, routine hospitalization for 48 to 72 hours is not universally recommended. (8) Routine hospitalization for observation incurs impractical costs in the current healthcare environment. Hengerer et al (7) reported improvement in neurologic symptoms after initiating anticoagulation, but Frantzen et al (15) did a case series of 8 patients where no difference was noted in outcome. Before considering anticoagulation, dissection must be ruled out. Cothren et al (16) reviewed more than 13,000 blunt trauma cases at a level one trauma center over a 7-year period. Most patients sustained multiple trauma. One hundred fourteen patients had a diagnosed carotid artery injury. Seventy-three were anticoagulated and none developed a stroke. Forty-six percent of the remaining 41 patients not receiving anticoagulation for one reason or another sustained cerebral ischemia. Fabian et al (17) concluded similar benefits of anticoagulation with their 11-year study of blunt carotid injuries. Angiography demonstrated dissections, pseudoaneurysms, thromboses and carotid-cavernous sinus fistulae. The fistulae were surgically repaired. Anticoagulation with heparin resulted in 20% mortality, whereas lack of anticoagulation resulted in 100% mortality. Miller et al (18) noted a stroke reduction from 64% to 6.8% in their study using anticoagulation. Raska et al (5) recommend using enoxaparin sodium, since antiplatelet therapy can be as effective as anticoagulation, while acknowledging that randomized studies do not exist to establish a definitive regimen in the pediatric population.
Recent literature remains inconclusive as to the most appropriate and beneficial regimen for penetrating palatal trauma in children, given the infrequency of damage to the internal carotid artery (0.6%) and the preferences of various providers, weighing costs and risks. (19) Conservative management is prudent in the majority of cases with judicious use of antibiotics, debridement and repair, and initial consideration of noninvasive imaging. Invasive studies might be indicated if the injury location is more lateral and, thus, more likely to involve the internal carotid artery. Aggressive therapy is warranted in the face of neurologic deficits.
Our case represents an unusual etiology for this type of injury, as the child was not holding the source of impalement, and enough force was generated to actually fracture the bone and not merely rupture the soft tissue. This injury was also located more midline than the majority of cases reported in the literature. She was managed surgically due to the extent of the open wound and consideration for infection, as well as the degree of displacement of bone. Only mild consideration for vascular involvement was entertained. Too often, children are running, playing, or even riding in a moving vehicle with lollipops, popsicles, wands, and other similar "stick items" in their hands or in their mouths. While most patients will never present to medical personnel, impalement injuries should be examined and the possibility of serious consequences considered. It is incumbent upon parents and caregivers to monitor the actions of children. Not all accidents can be prevented, but in doing a risk assessment of certain activities, many traumatic injuries can be prevented. Should a child sustain a penetrating injury to the palate, providers must have a high index of suspicion and use appropriate monitoring and diagnostic modalities to avoid serious morbidity.
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(16.) Cothren CC, Moore EE, Biffl WL, Ciesla DJ, Ray CE Jr, Johnson JL, et al. Anticoagulation is the gold standard therapy for blunt carotid injuries to reduce stroke rate. Arch Surg. 2004;139(5): 540-546.
(17.) Fabian TC, Patton JH Jr, Croce MA, Minard G, Kudsk KA, Pritchard FE. Blunt carotid injury: importance of early diagnosis and anticoagulant therapy. Ann Surg. 1996;223(5):513-522.
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(19.) Pereira KD, Wang BS, Webb BD. Impalement injuries of the pediatric craniofacial skeleton with retained foreign bodies. Arch Otolaryngol Head Neck Surg. 2005;131(2):158-162.
COL Karen M. Keith, DC, USA
CPT Tyler L. Clark, DC, USA
COL Keith is Chief and Program Director, Oral and Maxillofacial Surgery, Madigan Army Medical Health Care System, Joint Base Lewis McChord, Washington.
CPT Clark is Chief Resident, Oral and Maxillofacial Surgery, Madigan Army Medical Health Care System, Joint Base Lewis McChord, Washington.
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