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

Abstract

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.

Introduction

Palate fractures are known to be rare in the pediatric patient. This is due to the plasticity of the pediatric skeleton, delay in palatal suture synostosis, and the significant amount of force required to fracture the palate.[1,2] Pediatric facial fractures that result from high-velocity trauma or significant blunt or penetrating forces can lead to devastating sequelae. These devastating injuries are often accompanied by severe concomitant intracranial and/or cervical spine injuries.[3] Moreover, severe facial trauma in children and adolescents can lead to long-term growth impairment, causing functional and aesthetic deformity.[4,5]

Palate fractures were first described in 1901 by Rene LeFort in his sentinel publication on maxillary fractures. These fractures are relatively uncommon in both adults and children and rarely occur in isolation, as they are commonly found in conjunction with mid-face or pan-facial fractures.[2] In 1998, Hendrickson et al.[6] published a classification system based on the location and anatomical characteristics of the injury. The categories include alveolar (type I), sagittal (type II), parasagittal (type III), paraalveolar (type IV), complex (type V), and transverse (type VI) palatal fractures. However, since that time, various other adult palatal fracture classification and management algorithms have been proposed, reevaluated, and redefined, representing the challenging nature of these fractures and their subsequent management.[7,8,9,10,11,12,13,14,15] Notably, no classification systems are specific to pediatric palate fractures, as literature discussing presentation and management of these fractures in the pediatric population is limited. Surgical management of these fractures in children may differ from adults as there are concerns over restricted palatal growth following repair, implications of mixed dentition, and severe concomitant injuries upon presentation which may preclude or delay operative repair.

The goal of our study is to analyze our level 1 trauma center’s experience with pediatric palate fractures, focusing on epidemiologic data, concomitant injuries, and fracture management. We hope our study can provide a framework for future studies that will elicit an eventual evidence-based protocol for pediatric palatal fracture management.

Methods

Following Institutional Review Board approval, a retrospective chart review was performed, and data were collected for all palatal fractures in pediatric patients diagnosed between January 1, 2000 and December 31, 2016, at University Hospital in Newark, NJ, USA, a level 1 trauma center. Patient imaging was reviewed, and demographic characteristics were recorded, along with data related to clinical presentation and surgical treatment. Data organization and basic statistical analysis were conducted using Microsoft Excel. Statistical significance was set at a level of 5%.

Results

Of the 473 pediatric facial fractures diagnosed at our institution between 2002 and 2016, 9 (2%) pediatric patients were diagnosed with a fracture of the bony palate. The average age was 12(6-16) years with a male predominance (66%). Pedestrian struck injuries (33%) and motor vehicle accidents (MVA-33%) were the most common etiologies; two adolescent patients suffered a gunshot wound (GSW) to the face (Figure 1). Upon presentation, six patients had loss of consciousness (LOC), five were intubated prior to or upon arrival. Average Glasgow coma score (GCS) on presentation was 8.7, and six patients were diagnosed with traumatic brain injury (TBI). Five patients sustained skull fractures; three patients were found to have intracranial hemorrhage (ICH)—two of these patients required emergent bolt placement. Two patients were diagnosed with cervical spine injury. One patient had severe facial hemorrhage requiring IR embolization.

Table 1. Patient Characteristics and Concomitant Injuries.

Patient

Age

Sex

Etiology

Palate fracture type

Concomitant facial fractures

Skull fracture

TBI

Long bone fracture

LOC

Lowest GCS

C-spine fracture

ICH

1

6

F

Ped Struck

Type 2

ZMC, orbit, NOE, nasal bones,

Yes

Yes

No

Yes

13

No

No

frontal sinus

2

7

F

Ped Struck

Type 1

None

Yes

Yes

Yes

No

15

No

No

3

8

M

MVA

Type 2

Orbit

No

No

Yes

Yes

3

No

No

4

14

M

MVA

Type 3

Mandible-parasymphysis, body, and angle, orbit, NOE, nasal, frontal sinus

Yes

Yes

Yes

Yes

3

Yes

Yes

5

14

F

Fall

Type 1

Mandible-parasymphysis and body

No

Yes

Yes

Yes

15

No

No

6

14

M

GSW

Type 5

Zygoma

No

No

No

No

15

Yes

No

7

15

M

Ped Struck

Type 1

Nasal bones

No

No

No

No

15

No

No

8

16

M

GSW

Type 5

Mandible-ramus, zygoma, ZMC, orbit, nasal bones

Yes

Yes

No

Yes

7

No

Yes

9

16

M

MVA

Type 4

Orbit, NOE, nasal bones

Yes

Yes

Yes

Yes

3

No

Yes

Abbreviations: C-spine, cervical spine; GCS, Glasgow coma score; GSW, gunshot wound; ICH, intracranial hemorrhage; LOC, loss of consciousness; MVA, motor vehicle accident; NOE, nasoorbitoethmoid; Ped struck, pedestrian struck; TBI, traumatic brain injury; ZMC, zygomaticomaxillary complex.

illustrates the characteristics and concomitant injuries of our patient cohort.

According to the Hendrickson classification of palate fractures,[6] there were three type I fractures, two type II fractures, one type III fracture, one type IV fracture, and one type V fracture (Figure 2). Lefort I and/or alveolar fracture was present in every patient. Maxillofacial computed tomography (CT) images of three of our patients demonstrating their palatal fractures can be seen in Figure 3, Figure 4 and Figure 5. Four patients underwent surgical treatment of their palate with open reduction and restoration of facial height with maxillomandibular fixation. Three patients with mandible fractures underwent fracture repair at the time of the palate repair. Average hospital admission length was 13.67 days. One patient expired. The surgical management details of palatal fractures and other facial fractures and the hospital length of stay of patients are listed in

Table 2. Patient Operative Management and Hospital Length of Stay.

Patient	Age	Sex	Etiology	Palate fracture type	Concomitant facial fractures	OR	Surgical intervention	Hospital LOS
1	6	F	Ped Struck	Type 2	ZMC, orbit, NOE, nasal bones, frontal sinus	Yes	Closed nasal bone reduction	5
2	7	F	Ped Struck	Type 1	None	No	N/A	15
3	8	M	MVA	Type 2	Orbit	Yes	MMF, Plate Fixation of Orbital Fractures	35
4	14	M	MVA	Type 3	Mandible-parasymphysis, body, and angle, orbit, NOE, nasal, frontal sinus	Yes	MMF, Plate fixation of panfacial fractures	29
5	14	F	Fall	Type 1	Mandible-parasymphysis and body	Yes	MMF, Plate fixation of mandible	6
6	14	M	GSW	Type 5	Zygoma	No	N/A	11
7	15	M	Ped Struck	Type 1	Nasal bones	Yes	Open reduction and fixation of nasal bone fractures	2
8	16	M	GSW	Type 5	Mandible-ramus, zygoma, ZMC, orbit, nasal bones	Yes	MMF, plate fixation of ZMC/orbital fractures	17
9	16	M	MVA	Type 4	Orbit, NOE, nasal bones	No	N/A—death	2

Abbreviations: GSW, gunshot wound; LOS, length of stay; MMF, maxillomandibular fixation; MVA, motor vehicle accident; NOE, nasoorbitoethmoid; N/A, not applicable; OR, operating room; Ped struck, pedestrian struck; ZMC, zygomaticomaxillary complex.

.

4. Discussion

To our knowledge, this is the first study to investigate palatal fractures in the pediatric population, with focus on presentation, concomitant injuries, and management. Literature on pediatric palatal fractures is limited, likely due to their rarity. Of the 473 pediatric facial fractures treated at our institution in a 16-year period, only 9 of these patients had a diagnosed palate fracture. Furthermore, while studies exist for the adult population, there is some uncertainty surrounding the application of the same treatment principles in the pediatric population, considering their growing skeleton and mixed dentition.

With 9 palate fractures, the incidence of these injuries among all pediatric facial fractures in our study was 2% The male predominance was consistent with other studies of facial fractures, both in adults and children. The mean age (12 years) may not be representative, due to a small sample size; however, multiple studies conclude that in the pediatric population, adolescents more commonly suffer facial fractures.[16] These children begin to develop adultlike behavior and may be more prone to assault, or to motor vehicle-related trauma as they begin to drive. The mean age of 12 years (ie, adolescence) is of particular importance. Younger children have the benefit of skeletal plasticity; the palatal suture may be incompletely ossified, therefore resulting in pliable bone less susceptible to fracture. It is prudent to note that since palatal sutures fuse at varying points during adolescence, we cannot simply treat them with the same algorithm as adults, whose fused palatal sutures makes for a more fragile bone, susceptible to fracture secondary to high impact trauma.[17] The authors did ensure that the palatal fractures were true fractures rather than incomplete ossification of the palatal suture. For instance, if the fracture occurred along the suture alone, it would be difficult to tell these scenarios apart. However, in our study, the fractures were not just involving the palatal suture line, but also in the setting of malocclusion, high impact trauma, and other facial fractures. Hence, it was clear in our patients on imaging that these injuries were acute fractures rather than incomplete suture lines. MVAs were the most common etiology in our study, along with pedestrian struck injuries. Multiple prior studies have found that MVAs are the leading etiology of facial fractures in children, with interpersonal violence becoming more common in adolescents. Due to the small sample size and our setting in an urban environment, our study may have had a disproportionately high number of pedestrian-struck cases,[18] which may not be the case in other populations/ institutions. Facial fractures in children are much more commonly caused by low-energy impact such as falls which typically cannot generate the force required to cause a palatal fracture.

Two patients in our study had associated cervical-spine injuries, both C1 fractures. Prior studies have indicated that these associated injuries are not uncommon in pediatric facial fractures, especially high-energy traumas. Furthermore, cervical-spine injuries were found to be significantly associated with zygomatic and orbital fractures in pediatric patients, while these patients presented with lower GCS scores.[5] Mandible fractures have been significantly associated with C2 fractures, whereas LeFort and palate fractures approached statistical significance in the same study. In this study, one patient did have a concomitant orbital fracture, whereas both had LeFort fractures. Other studies conclude that orbital fractures are most commonly associated with cervical spine fractures in the pediatric population, consistent with one of the patients in our study. In our study, GCS ranged from 3 to 15, with an average of 8.7. Again, due to the limited sample size, further investigations are warranted to fully elucidate any associations with cervical spine injuries, especially due to the lifelong socioeconomic and health-care impact that could result from undiagnosed/ untreated cervical spine injuries in these patients.

As presented in Table 1, our patient cohort suffered numerous other concomitant injuries. Five patients sustained skull fractures, six suffered traumatic brain injury (TBI), three patients developed intracranial hemorrhage (ICH), and five had concurrent long bone fractures. Of note, these injuries typically occur following high-impact injuries. This is expected because the initial etiology must have generated enough force to cause a palate fracture and thus would likely have been enough to cause other injuries as well. A 2017 study by Halsey et al. showed an increased incidence of both cervical spine injuries and ICH in pediatric midface fractures, compared to other fractures.[19]

As with many injuries, the decision for operative intervention ultimately depends on clinical presentation and judgment. The choice of surgical modality in adults is based on factors such as fracture pattern and severity. Type 5 fractures are the most challenging due to their instability, and they often require multiple methods of fixation for complete stabilization. Multiple studies emphasize the need for maxillary buttress fixation to stabilize the palate because, although this buttress cannot single-handedly provide complete bony stability to the palate, the adjuncts of intermaxillary fixation and palatal splinting can provide the necessary stability and immobilization that ultimately enables bony union.[2] There lacks a consensus on a standard protocol for surgical intervention in the pediatric patient.

For isolated palate fractures, some authors recommend surgical intervention for non-comminuted fractures with large segments in the anterior–posterior plane.[20] Interventions may include MMF for 2 to 6 weeks. Furthermore, palatal splints may be used as adjuncts in complex fractures to achieve adequate vault stabilization.[20] Of the 9 pediatric palate fracture patients in our study, 6 patients underwent operative intervention. Two patients had combinations of maxillomandibular fixation (MMF), arch bars, and plates applied; one patient had both MMF and plates used, and one patient had solely plates used for fixation and stabilization. No palatal splints were used. Two patients did not receive surgical correction of the palatal fracture and instead underwent reduction of their nasal fractures. Of the 3 that were not treated operatively, 1 expired. It is important to note that for these specific patients, due to the complex nature of their presentations and concomitant injuries, operative interventions may have deviated slightly from what prior literature has described.

Of the 9 patients, 6 patients obtained postoperative CT scans showing appropriate fracture alignment; 2 patients were lost to follow-up and 1 patient expired. Given that these individuals were trauma patients, it is not uncommon to have a lack of follow-up. There were no cases of meningitis, encephalitis, abscess, osteomyelitis, wound infection, or hematoma reported in our population. Other sequelae described in follow-up records include traumatic middle crania fossa defects, cerebrospinal fluid rhinorrhea, cosmetic defects, recurrent sinusitis, stenotic ear canals, facial nerve paralysis, and nasal obstruction. All of these sequelae were related to concomitant injuries and not to the palate fracture itself. Palate and/or dental-related complications, including malocclusion or delayed/aberrant bony development of the midface were not described in the limited follow-up records of our patients. Future studies with more adequate and detailed follow-up could elucidate the true incidence of palate-related complications, perhaps in association with specific interventions (or lack thereof).

The results of our study were largely similar to those of Hoppe et al,[2] even though that was conducted in adult patients, and therefore resulted in a larger patient population. Of note, the 2 studies were conducted by some of the same authors at the same institutions. Furthermore, as the reviewer noted, this could be due, in part, to the fact that our study did not have enough younger children, not to mention a limited overall sample size of nine (N = 9) pediatric patients.

On the contrary, our results differed from a Chen et al’s retrospective review of 128 palate fractures[8] in that Chen’s incidence was much higher. Their study analyzed adults versus our investigation of pediatric patients. In adults, the palatal suture is ossified, meaning that fractures are likely to be true fractures and not just sutural diastasis. As noted in the introduction, our investigation of pediatric patients is significant because the skeletal plasticity could result in lesser fractures, perhaps explaining the far lower incidence. Furthermore, Chen’s study was much larger. Our small sample size is a limiting factor in discovering the true incidence of these injuries. However, it is important to note that our incidence is more aligned with that of other studies, whereas the study by Chen et al is more of an outlier (discussed below). The author of Chen’s study noted in their Discussion that the high incidence could be due to the specific mechanism of traumatic etiology that being motorcycle crashes. Motorcycles are quite commonly used in Taiwan, and thus, the frequency of these high-impact traumatic injuries could result in the higher incidence of palatal fractures. Since children cannot operate motor vehicles (in addition to the use of motorcycles being less frequent in the United States than in Taiwan), the much lower incidence of high-velocity traumatic injuries could result in a lower incidence of palatal fractures in our study. Interestingly, the authors proposed that structural differences in the facial anatomy between Asians and Caucasians could account for the higher incidence. More studies would be needed to discover the presence of a true link, but the results would certainly be interesting nonetheless.

Our study has some important limitations. First, this study is a retrospective analysis of a single institution. Despite being a level 1 trauma center, our final analysis included only 9 pediatric patients with palate fractures. This small sample size is subject to variability and may not be necessarily generalizable to a larger, more representative population. The limitation prevented us from conducting further statistical analysis on the associated injuries; with only 9 subjects, the authors would be unlikely to find significant associations between demographics and related injuries, such as concomitant facial fractures and LOC. Future studies with larger patient populations could elucidate the true relationship of palate fractures and associated injuries. Furthermore, because this was a single-instruction study, clinical judgement may be limited in variability, given that multiple practitioners may have had similar training or observe similar guidelines for clinical decision-making. As noted above, our lack of long-term follow-up limits our ability to draw long-term conclusions. Future studies with more rigid and long-term follow-up are warranted to fully discover links between palatal fractures, their management, and complications. More specifically in the pediatric population, follow-up examinations could include tests/examinations that address known adverse effects of untreated palatal fractures, such as speech development, breathing mechanics, and malocclusion. More evidence as to the possible sequelae can help guide a more definitive management protocol for palatal fractures in the pediatric population.

Conclusion

Palate fractures are a rare injury in the pediatric patient, usually accompanied by devastating concomitant injuries. Skull fracture and intracranial hemorrhage should be ruled out upon presentation, along with cervical spine injury. Surgical repair of the palate in the pediatric patient is often necessary to restore facial height and prevent malrotation of fracture segments and can be combined with the repair of other facial fractures.