Vol. 132 No.

5 November 2021

Management of pediatric facial fractures during

COVID-19 pandemic
Shelly Abramowicz, DMD, MPH,a,b Dina Amin, DDS,c,d Steven L. Goudy, MD, MBA,e
Thomas M. Austin, MD, MS,f,g Matthew T. Santore, MD,h,i Megan J. Milder, DMD,j and
Steven M. Roser, DMD, MDk

Objective. The coronavirus disease 2019 (COVID-19) pandemic caused delays in medical and surgical interventions in most
health care systems worldwide. Oral and maxillofacial surgeons (OMSs) delayed operations to protect themselves, patients, and
staff. This article (1) presents one institution’s experience in the management of pediatric craniomaxillofacial trauma during the
COVID-19 pandemic and (2) suggests recommendations to decrease transmission.
Methods. This was a retrospective review of children aged 18 years or younger who underwent surgery at Children’s Healthcare
of Atlanta in Atlanta, GA, between March and August 2020. Patients (1) were aged 18 years old or younger, (2) had one or more
maxillofacial fractures, and (3) underwent surgery performed by an OMS, otolaryngologist, or plastic surgeon. Medical records
were reviewed regarding (1) fracture location, (2) COVID-19 status, (3) timing, (4) personal protective equipment, and (5) infec-
tion status. Descriptive statistics were computed.
Results. Fifty-eight children met the inclusion criteria. The most commonly injured maxillofacial location was the nose. Opera-
tions were performed 50.9 hours after admission. Specific prevention perioperative guidelines were used with all patients, with
no transmission occurring from a patient to a health care worker.
Conclusions. With application of our recommendations, there was no transmission to health care workers. We hope that these
guidelines will assist OMSs during the COVID-19 pandemic. (Oral Surg Oral Med Oral Pathol Oral Radiol 2021;132:e169 e174)

During December 2019, a series of unexplained cough)3-5 that can rapidly progress to acute respiratory
pneumonia cases were reported in Wuhan, China. The distress syndrome, need for ventilator support, and
causative organism was found to be severe acute respi- potentially death.6 Some children develop multisystem
ratory syndrome coronavirus 2. In February 2020, the inflammatory syndrome, but most children are unaf-
World Health Organization officially named the dis- fected.7 The mechanism for resilience is unknown.
ease “coronavirus disease 2019” (COVID-19).1,2 The Therefore, children have the potential to be asymptom-
virus causes mild symptoms (e.g., mild rhinorrhea, atic carriers and may contribute to virus transmission
in the community.
a
Associate Professor of Surgery and Pediatrics, Emory University Human-to-human transmission occurs9,10 via symp-
School of Medicine, Atlanta, GA, USA.
b
tomatic and asymptomatic carriers.11,12 Transmission
Chief of Oral and Maxillofacial Surgery, Children’s Healthcare of is thought to occur mainly through respiratory drop-
Atlanta, Atlanta, GA, USA.
c
Assistant Professor, Oral and Maxillofacial Surgery, Emory Univer-
lets.13 Droplets can be detectable in aerosols for up to
sity School of Medicine, Atlanta, GA, USA. 3 hours. Contaminated surfaces also transmit the virus
d
Director, Oral and Maxillofacial Surgery Outpatient Clinic, Grady (e.g., copper, 4 hours; cardboard, 24 hours; plastic/
Memorial Hospital, Atlanta, GA, USA.
e
glass/stainless steel, 2-3 days).14 Other similar viruses
Professor and Chief, Division of Pediatric Otolaryngology, Depart- (e.g., severe acute respiratory syndrome coronavirus,
ment of Otolaryngology, Emory University School of Medicine,
Children’s Healthcare of Atlanta, Atlanta, GA, USA.
Middle East respiratory syndrome coronavirus, or
f
Associate Professor, Anesthesiology and Pediatrics, Department of endemic human coronaviruses) have been shown to
Anesthesia, Emory University School of Medicine, Atlanta, GA, USA. persist on fomites for up to 9 days.13-15 Viral RNA has
been found in stool samples from infected patients.8,16
g
Director, Operative Services, Children’s Healthcare of Atlanta,
Atlanta, GA, USA. The structure of this virus consists of a lipid enve-
h
Assistant Professor, Surgery and Pediatrics, Department of Surgery,
Emory University School of Medicine, Atlanta, GA, USA.
lope, which is disrupted by specific disinfectants within
i
Medical Director, Pediatric Surgery, Children’s Healthcare of Atlanta,
Atlanta, GA, USA.
j
Oral and Maxillofacial Surgery resident-in-training, Division of Oral Statement of Clinical Relevance
and Maxillofacial Surgery, Department of Surgery, Emory University
School of Medicine, Atlanta, GA, USA. The coronavirus disease 2019 pandemic brought
k
DeLos Hill Chair and Professor of Surgery and Chief, Division of unprecedented challenges to oral and maxillofacial
Oral and Maxillofacial Surgery, Department of Surgery, Emory Uni-
versity School of Medicine, Atlanta, GA, USA.
surgeons. Some operations were modified to protect
Received for publication Apr 1, 2021; returned for revision May 4, patients and staff. In this article, we present our cen-
2021; accepted for publication May 5, 2021. ter’s guidelines and recommendations for treating
Ó 2021 Elsevier Inc. All rights reserved. children with craniomaxillofacial trauma during a
2212-4403/$-see front matter pandemic.
https://doi.org/10.1016/j.oooo.2021.05.004

e169

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ORAL AND MAXILLOFACIAL SURGERY OOOO
e170 Abramowicz et al. November 2021

1 minute (e.g., 60% ethanol, 0.5% hydrogen peroxide, to August 2020 (first 6 months of the COVID-19 pan-
0.1% sodium hypochlorite).17,18 Other biocidal agents, demic in the United States). Of these patients, 58 met
such as 0.05%-0.2% benzalkonium chloride or 0.02% the inclusion criteria. Injury locations were the nose
chlorhexidine digluconate, are less effective. The ulti- (n = 24 [41.4%]), mandible (n = 16 [27.6%]), soft tis-
mate disinfectant has not yet been discovered. sue (n = 8 [13.8%]), zygomatic complex (n = 4
The COVID-19 pandemic has posed unprecedented [6.9%]), orbit (n = 3 [5.2%]), or complex involving
challenges for the global medical community. To more than one operative site (n = 3 [5.2%]). Surgical
decrease the impact and mitigate the number of interventions took place 50.9 hours after admission
COVID-19 cases, national and local government agen- (range, 4 hours to 11 days). PPE was used with all
cies instituted social distancing guidelines, limited patients. Strict COVID-19 prevention guidelines
social gatherings, and encouraged appropriate hand (described later in this article) were used with all
hygiene. Many states, counties, and cities declared a patients. Following these guidelines, there was no
state of emergency with orders to close all nonessential transmission from a patient to a health care worker.
businesses and shelter in place. The potential for
domestic violence, physical altercations, unsupervised DISCUSSION
children, burglary, and crimes was expected to surge. Definitions
Therefore, pediatric craniomaxillofacial (CMF) trauma Every child with CMF trauma requiring admission was
continued to occur. screened for COVID-19 infection. Suspicion for
Guidelines for the diagnosis and treatment of COVID-19 was based on recent travel, sick contacts,
COVID-19 have been constantly changing since the and symptoms. Each child was placed in an appropriate
pandemic arrived in the United States.19,20 Uniform category on the basis of COVID-19 status: unknown
guidelines for surgical interventions in a child with status (before investigation), patient under investiga-
CMF trauma do not exist. The purpose of this article is tion, COVID-19 positive patient (as a result of a posi-
to (1) present our institution’s experience in the man- tive test), or COVID-19 negative patient (as a result
agement of pediatric CMF trauma during the COVID- of a negative test). Providers treated all patients (even
19 pandemic and (2) suggest guidelines and recom- COVID-19 negative patients) with the same precau-
mendations to decrease COVID-19 transmission. tions.

METHODS Preoperative testing

This study was approved by the Children’s Healthcare Procedures involving the upper airway mucosa (intuba-
of Atlanta (CHOA) Institutional Review Board (17- tion, tracheostomy, oropharyngeal procedures) were
039). A retrospective chart review was conducted of considered high risk because of aerosolization of the
children aged 18 years or younger who presented to virus, which is known to be in high concentration in
CHOA between March and August 2020. Patients were these areas.1,22 When viral particles become aerosol-
identified by reviewing the operating room (OR) case ized, they stay until complete air exchange or settling
logs. Patients were included if they (1) were aged (1-3 hours).1,2
18 years old or younger; (2) were diagnosed with one We recommend obtaining a preoperative COVID-19
or more maxillofacial fractures; and (3) had undergone status for all patients when operating in and around the
an operative intervention by oral and maxillofacial sur- face as close as possible to the time of the operation.
gery, otolaryngology, or plastic surgery services. Instrumenting potentially infected mucosal tissue for
Exclusion criteria were patients (1) receiving nonoper- the purposes of fracture fixation is equivalent to the
ative treatment (i.e., bridle wire, diet modifications), powered microdebriders/shavers used in sinus surgery.
(2) with isolated dental trauma, (3) with isolated odon- This process would likely lead to increased risk of
togenic infection, and (4) with incomplete medical transmission and droplet diffusion throughout the
records. Medical records were reviewed for (1) fracture OR.22,23 At CHOA, when a patient is admitted with
location, (2) patient COVID-19 status, (3) timing of CMF trauma, he or she undergoes rapid COVID-19
repair, (4) use of personal protective equipment (PPE), testing in preparation for potential surgical interven-
and (5) conversion/infection status (i.e., positive tion. However, because of the potential for a false-neg-
patient infecting staff). Descriptive statistics were com- ative result, health care providers should assume that
puted to summarize findings and transmission rate all patients have a positive status and should maintain
according to our newly developed guidelines. appropriate precautions.

RESULTS Treatment indications

A total of 9423 patients underwent a surgical interven- The available literature presents various indications for
tion in an OR at CHOA during the period from March surgical treatment of pediatric facial fractures. In

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OOOO ORIGINAL ARTICLE
Volume 132, Number 5 Abramowicz et al. e171

children, surgeons achieve accurate bone reduction and Table I. Timing of surgical intervention
stable fixation to permit bone healing and avoid dis-
Timing to completion Examples
turbing future skeletal growth and dental development.
Elective Can be postponed  Revisions
Thus, fracture management in younger patients can
>4 wk  Bone/cartilage grafts
sometimes be nonsurgical. As the facial skeleton
matures, more conventional and “adult-like” surgical Time sensitive Completed Displaced nasal bone/
approaches become appropriate (Lorenz 24). Children within 1-2 wk septum fracture causing
can often follow a soft diet as they slowly return to nor- nasal airway obstruc-
mal function. During the COVID-19 pandemic, this tion
process allowed some patients to receive appropriate NOE (Markowitz type 2
or 3)
treatment without additional risk of exposure to Le Fort fracture (I, II,
COVID-19 in the OR. III)
Displaced ZMC frac-
tures
Timing of surgical intervention Orbital wall fracture
without evidence of
During the first 3 months of the COVID-19 pandemic, muscle entrapment
most health care systems nationwide canceled all elec- Mandible fracture
tive operations. Surgeons continued to provide care in Repair of CMF trauma
emergent and urgent situations.21 In general, pediatric that will expedite dis-
facial fractures that require surgical intervention should charge from hospital
Urgent Completed  Orbital blowout frac-
receive definitive care as soon as it is safe or within 7 to within 24 h ture with muscle
10 days. If the repair of a facial fracture is delayed lon- entrapment
ger, compromised functional and/or cosmetic outcomes  Extensive facial

may occur. These secondary deformities (e.g., tempo- lacerations

 Ear avulsion
romandibular joint ankylosis, enophthalmos, facial  Unstable dentoalveolar
deformity) are typically difficult to correct secondarily. fracture
Accordingly, in our cohort, CMF trauma that required
operative intervention occurred within 50.9 hours after Emergent Completed  Fracture resulting in
admission. immediately uncontrolled bleeding
We recommend dividing all operations into 4 cate- or causing airway
compromise
gories: emergent, urgent, time sensitive, and elective  Uncontrolled bleeding
(Table I). Emergent cases consist of fractures resulting from facial structures
in uncontrolled bleeding or causing airway compro- that resulted from other
mise and those resulting in uncontrolled bleeding from conditions (e.g., aneu-
facial structures caused by other conditions (e.g., rysm, anterior/posterior
nasal bleeding) that
pseudo aneurysm, anterior/posterior nasal bleeding)
would lead to airway
that would lead to airway compromise. Urgent cases compromise
cannot be treated at the bedside, and surgical interven-
tion should be completed within 12 hours (e.g., orbital
blowout fracture with muscle entrapment, extensive CMF, craniomaxillofacial; NOE, naso-orbito-ethmoid; ZMC, zygo-
maticomaxillary complex.
facial lacerations, ear avulsion, unstable dentoalveolar
fracture). Time-sensitive cases should be treated within
5 to 7 days, but sooner if possible. Examples are dis- provided adequate time to obtain COVID-19 results
placed nasal bone/septum fracture with airway obstruc- and prepare the OR and equipment.
tion; displaced naso-orbito-ethmoid; Le Fort I, II, or III A tracheostomy is sometimes performed as part of
fracture; displaced zygomaticomaxillary complex frac- complex CMF repair. Tracheostomy has a high risk of
ture; orbital wall fracture without muscle entrapment; transmission via inhalation, contact with infected respi-
and/or mandible fracture (with malocclusion/deformity ratory secretions, close proximity, and positive pressure
requiring open reduction and internal fixation [ORIF]). ventilation.22 In order to decrease viral transmission, we
In addition, any surgical repair of CMF trauma that recommend avoiding tracheostomy if at all possible.
would expedite discharge from the hospital should Instead, surgeons should consider submental intubation
occur as soon as possible. Elective cases do not inter- or dividing a prolonged operation into multiple shorter
fere with daily form and function and should take place ones in order to decrease the potential need for pro-
only when it is safe to do so. In our cohort, all fractures longed intubation and/or a tracheostomy. In our cohort
were in the time-sensitive category. This suggestion of patients, none required a tracheostomy.

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ORAL AND MAXILLOFACIAL SURGERY OOOO
e172 Abramowicz et al. November 2021

Table II. US Food and Drug Administration approved maintain positive pressure for surgical infection con-
personal protective equipment trol. ORs are kept at 20 air changes per hour. Our insti-
tution designated one specific OR as the COVID-19
Equipment Protection
OR. When a surgical procedure took place in a patient
Fit-tested N95 mask Against inhalation of virus positive for COVID-19, that OR was used for subse-
Disposable surgical mask Protects N95 mask
Head/neck cover Decreases skin/hair exposure
quent operations in patients with COVID-19. All non-
Goggles Eyes, decreases conjunctival exposure essential equipment and supplies were removed from
Face shield Skin not covered by above that room and from the path to the room. In general,
Fluid-resistant gown Clothes, skin the anesthesia ventilators have appropriate filtration to
Double gloves Hands, wrists prevent aerosolization. In case a patient requires a hand
Shoe covers Protects shoes
mask/bag, high-efficiency particulate air filters are in
place. If a patient positive for COVID-19 remains intu-
PPE equipment bated postoperatively, transportation should occur on a
Universal precautions consist of a high level of PPE ventilator to a specified COVID-19 room in the inten-
and enhanced vigilance to appropriate fitting of PPE sive care unit (ICU). Handoff will occur at the bedside
(Table II). Health care workers must be trained in put- in the COVID-19 ICU with both the OR and ICU teams
ting on PPE (i.e., donning), performing clinical duties present. None of our patients required prolonged intu-
with PPE, and removing PPE (i.e., doffing) in the con- bation and/or transport on a ventilator.
text of their current and potential duties.24 Training Our institution developed a specific protocol for
material should be easy to understand and available in cleaning the OR and recovery room after the presence
the appropriate language and literacy level for all of a patient with COVID-19. After aerosolizing proce-
workers.25,26 It is important to note that a recent dures, we recommend closing and taping the OR doors
Cochrane review found low to very low certainty of for 15 minutes without allowing entry to anyone. Then,
evidence that covering more parts of the body leads to a terminal clean should be completed via ultraviolet
better protection but usually at the cost of more diffi- protocol.25
cult donning or doffing and less user comfort, and it
may therefore lead to even more contamination. More OR staff
breathable types of PPE may lead to similar contamina- The OR staff consisted of 3 teams (anesthesia, surgery,
tion but may have greater user satisfaction.27 Powered staff) with 2 members on each team (attending and res-
air-purifying respirators have certain limitations (e.g., ident/fellow or circulator and surgical tech), except in
emission of unfiltered air flow) and may not be safe for extenuating circumstances. Many institutions sus-
members of a surgical team not using a powered air- pended clinical rotations by medical students, includ-
purifying respirators, may lack disposable parts or abil- ing participation in operations. All personnel in the
ity to be sterilized, and may have inability to accom- room should wear N95 masks and similar PPE second-
modate a headlight, and so forth.28 ary to the high risk of aerosolization. Only anesthesia
We recommend using the most effective PPE possible staff should be in the room during induction. When
that allows completion of an operation without indicated, the OR team can assign an additional outside
compromising surgical steps. We recommend the follow- circulator/runner.
ing head and neck protection: respirator or fit-tested N95
mask covered by a disposable surgical mask, head/neck CMF treatment modifications
cover, goggles, and face shield. We recommend a fluid- The purpose of modifications in the treatment of pedi-
resistant gown, double gloves, and shoe covers29 atric CMF trauma is to decrease the length of operating
(Table II). Doffing should consist of a one-step glove and time, which decreases overall exposure to the virus
gown removal and extensive hand washing after all PPE among the surgeon and OR staff.30,31 When appropri-
is removed.24 We also recommend donning and doffing ate, nonsurgical interventions (i.e., dietary modifica-
with a partner, discussing the process, and providing real- tions) are preferred (e.g., a child with primary
time feedback. PPE should be discarded in a dedicated dentition). We present the following specific strategies
and labeled COVID-19 container. Nondisposable equip- that we have been following which resulted in a zero
ment, such as goggles and face shields, should be cleaned transmission rate during the COVID-19 pandemic:
according to individual institutional guidelines.
1. The oral cavity should be irrigated with 0.5% perox-
ide for 60 seconds before the procedure to decrease
OR equipment viral load.
Typically, every institution has separate guidelines 2. Electrocautery and bipolar electrocautery should be
with some similarities between hospitals. All ORs used at the lowest voltage possible to minimize plume.

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OOOO ORIGINAL ARTICLE
Volume 132, Number 5 Abramowicz et al. e173

3. All attempts should be made to treat fractures with 7. Lu X, Zhang L, Du H, et al. SARS-CoV-2 infection in children.
N Engl J Med. 2020;382:1663-1665.
closed reduction (i.e., maxillomandibular fixation).
8. Tang A, Tong ZD, Wang HL, et al. Detection of novel coronavi-
4. When performing closed reduction, if possible and rus by RT-PCR in stool specimen from asymptomatic child,
appropriate, all attempts should be made to use China. Emerg Infect Dis. 2020;26:1337-1339.
hybrid arch bars, intermaxillary fixation screws, ivy 9. Chan KW, Wong VT, Tang SCW. COVID-19: an update on the
loops, and so forth instead of traditional arch bars. epidemiological, clinical, preventive and therapeutic evidence
and guidelines of integrative Chinese-Western medicine for the
This is done in an effort to decrease time in the OR.
management of 2019 novel coronavirus disease. Am J Chin Med.
5. For ORIF, choose a transcutaneous approach 2020;48:737-762.
instead of an intraoral approach when possible and 10. Yuen KS, Ye ZW, Fung SY, Chan CP, Jin DY. SARS-CoV-2
appropriate. and COVID-19: the most important research questions. Cell Bio-
6. During ORIF, use self-drilling screws when possible. sci. 2020;10:40.
11. Bai Y, Yao L, Wei T, et al. Presumed asymptomatic carrier
7. Consider removal of maxillomandibular fixation
transmission of COVID-19. JAMA. 2020;323:1406-1407.
appliances at the end of the case if appropriate. This 12. Rothe C, Schunk M, Sothmann P, et al. Transmission of 2019-
will likely decrease the possibility of the need to nCoV infection from an asymptomatic contact in Germany. N
return to the OR for removal. Engl J Med. 2020;382:970-971.
8. If possible, resorbable sutures should be used. 13. van der Geer J, Hanraads JAJ, Lupton RA. The art of writing a
scientific article. J Sci Commun. 2010;163:51-59.
9. Follow-up care:
14. Zou L, Ruan F, Huang M, et al. SARS-CoV-2 viral load in upper
a. Inpatient visit provided by only one member of respiratory specimens of infected patients. N Engl J Med.
the surgical team 2020;382:1177-1179.
b. In-person postoperative visit 5 to 7 days after the 15. Kampf G, Todt D, Pfaender S, Steinmann E. Persistence of coro-
operation only if absolutely necessary; this naviruses on inanimate surfaces and their inactivation with bio-
cidal agents. J Hosp Infect. 2020;104:246-251.
decreased patient traffic in the hospital/outpatient
16. van Doremalen N, Bushmaker T, Morris DH, et al. Aerosol and
clinic surface stability of SARS-CoV-2 as compared with SARS-CoV-
c. Telemedicine should be used if possible and for 1. N Engl J Med. 2020;382:1564-1567.
additional postoperative visits, if appropriate.32 17. Holshue ML, DeBolt C, Lindquist S, et al. First case of 2019
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should enter the patient’s room.
18. Fathizadeh H, Maroufi P, Momen-Heravi M, et al. Protection
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CONCLUSIONS 19. Trading Economics. United States unemployment rate. Avail-
Oral and maxillofacial surgeons have never faced chal- able at: https://tradingeconomics.com/united-states/unemploy-
lenges similar to the COVID-19 pandemic. The sudden ment-rate. Accessed March 25, 2020.
arrival of the pandemic did not decrease the need for 20. American College of Surgeons, American Society of Anesthesi-
ologists, Association of Perioperative Registered Nurses, Ameri-
surgical interventions of CMF trauma in children. Fol- can Hospital Association. Joint statement: roadmap for resuming
lowing our specific recommendations, we have had no elective surgery after COVID-19 pandemic. April 17, 2020.
transmission to health care workers. Therefore, it is our Available at: https://www.asahq.org/about-asa/newsroom/news-
hope that the guidelines presented in this article will releases/2020/04/joint-statement-on-elective-surgery-after-
assist oral and maxillofacial surgeons when providing covid-19-pandemic. Accessed April 20, 2020.
21. Prachand VN, Milner R, Angelos P, et al. Medically necessary,
treatment to children with CMF trauma during the time-sensitive procedures: scoring system to ethically and effi-
COVID-19 pandemic. ciently manage resource scarcity and provider risk during the
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