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Pediatric Facial Fractures


Pediatric Facial Fractures

Article Author:
Daniel Rogan
Article Editor:
Abraham Ahmed
Updated:
9/27/2020 3:30:45 PM
For CME on this topic:
Pediatric Facial Fractures CME
PubMed Link:
Pediatric Facial Fractures

Introduction

Trauma is a significant cause of morbidity and death in children.[1] Trauma to the head is the most common anatomic site, and while facial fractures are infrequent, they can be severe and have life-long consequences.[2]

Younger patients have more elastic cartilaginous and bony structures in the face and a larger cranium: face ratio; thus, fractures in very young children are rare. The growth patterns of the face dictate age-specific fracture patterns that differ from adults.

Though isolated facial fractures can occur, concurrent traumatic injuries to other nearby sites must always be considered, including injuries affecting the head, eyes, brain, neck, and airway.

This discussion highlights the pediatric-specific issues in the initial evaluation of facial fractures as these related topics are covered in detail in other StatPearls sections:

  • Pediatric Facial Trauma [3]
  • Pediatric Abusive Head Trauma [4]
  • Pediatric Head Trauma [5]
  • Pediatric Skull Fractures [6]
  • Nasal (Nasoorbitoethmoid) Fracture [7]
  • Nasal Septal Fracture [8]
  • Nasal Fracture Reduction [9]
  • Le Fort Fractures [10]
  • Frontal Sinus Fractures [11]
  • Maxillary Sinus Fracture [12]
  • Zygomatic Arch Fracture [13]
  • Mandible Fracture [14]
  • Basilar Skull Fractures [15]
  • Traumatic Brain Injury [16]
  • Tooth Fracture [17]
  • Avulsed Tooth [18]
  • Penetrating Head Trauma [19]
  • Facial Nerve Trauma [20]
  • Blunt Eye Trauma [21]
  • Globe Rupture [22]
  • Orbital Floor (Blowout) Fracture [23]

Etiology

Facial fractures in children are typically caused by blunt trauma such as falls, sports injuries, transportation incidents (including automobiles, bicycles, skateboards, etc.), assault, and child abuse. Penetrating facial injuries, while rare, may also occur. 

The neonatal skull is proportionally much larger than the face, and the forehead protrudes over the face. As the child grows, the face expands to comprise a greater relative area of the head until adult proportions are reached in the teenage years.[2][24][25][26] Subsequently, traumatic head injuries in young children are more likely to spare the face while a skull injury is sustained.

Pediatric facial bones are more elastic and have more cartilage than adult bones; this allows more flexibility and compression. Given similar mechanisms to adult injuries, children have fewer relative facial fractures for this reason. When fractures occur, they are often minimally displaced and do not show the classic fracture patterns, such as Le Fort injuries described in adults.[10]

Nasal fractures are the most common fracture overall due to the prominence of the nasal bridge and minimal surrounding structural support.

Fracture sites relate to age-dependent development of the sinuses and, to a lesser degree, the stage of dentition.[11][26][27] During development, bone initially thickens before becoming fully pneumatized and thinning into the final adult structural bone. The site of active bone growth and early pneumatization will be thicker and more resistant to fractures than later thin adult-like bone.

Until around seven years of age, there is some degree of maxillary sinus pneumatization occurring, with the midface subsequently being more elastic and thicker than the upper face. Thus blunt force to the mid-face in this age group is more likely to result in force transmission upward to the thinner frontal bone, leading to orbital roof fractures.[2][26] Between ages 7 to 12 years, mixed dentition is forming and progressing in the midface, adding further stability and strength to the region with slowing of maxillary pneumatization; however, as the orbital floor is overall thinning during this period, orbital floor and orbital wall fractures, including blowout fractures, become more common with increasing age in this range.[2][26] 

Above 12 years of age, the maxillary sinuses have fully pneumatized, and the midface bone has thinned with a less cartilaginous structure, while the frontal sinuses are in the process of thickening and developing.[2][26][27] This means that in mid or upper face blunt trauma, force transmission is downward away from the thick elastic frontal sinus and toward the thin, adult-like upper maxilla, with the result being that orbital floor fractures are more common in adolescents.

Epidemiology

Each year in the United States, pediatric trauma causes approximately 12,000 deaths, and at least 8 million ER encounters.[2][28]

Among all patients with facial fractures, fewer than 15% are children. Most facial injuries in children are limited to soft tissues, with only 10 to 15% of pediatric facial injuries resulting in facial fractures.[29][30][31] However, more than half of all facial trauma presentations are associated with concurrent additional severe injuries beyond the face.[29]

Many minor facial traumas are treated at home and maybe underreported; fractures are likely to cause significant pain and swelling and are, therefore, most likely more accurately reported than soft tissue trauma to the face.

Males are more likely to have facial fractures than females, especially during adolescence, when males are approximately twice as likely to present with fractures than females.[24][27][29]

Facial fractures are rare below the age of six, wherein skull fractures are more likely to be the result of head or facial trauma.[29] Half of all fracture presentations are seen in ages 10 to 18 years.[32] When fractures occur, roughly half are the result of motor vehicle collisions.[2][27][32] Beyond motor vehicle collisions, bicycle accidents and sports injuries comprise most of the remaining trauma etiologies in school-age children, while infants and toddlers are more likely to suffer from falls.[2][27][29][32] Adolescent males are the demographic group most likely to become injured from assault.[32]

Fracture location can be age-dependent, both due to activities undertaken affecting the location of likely blunt trauma and differential areas of bone growth and laxity with age.

Nasal fractures are generally thought to be the most common facial fractures, though they are likely underreported as they do not necessitate evaluation at a trauma center from which most pediatric facial trauma data are drawn.[2][24]

The most common reported fracture across age groups is a mandibular fracture, affecting 40 to 60% of pediatric facial fracture patients and increasing with age.[27][29] Conversely, alveolar fractures are more common in young patients, affecting 60% of fracture patients below six years, decreasing incidence with age.[27] Orbital and midface fractures are the next most common across all age groups, with age-variable sites discussed above in “Etiology.”[2][26][27] Frontal bone fractures are associated with intracranial injuries in 35 to 64% of cases, and cerebrospinal fluid leak in 18 to 36% of cases; this is generally in younger patients, fracture of the frontal bone pre-pneumatization of the frontal sinus may be considered a skull fracture equivalent.[2] Nasoorbitoethmoid fractures are uncommon, representing only 1 to 8% of all pediatric fracture patients.[24]

Fracture patterns described in adults, such as Le Fort injuries, are rare in pediatric patients. The changes made through facial development correspond to different stress points for fracture locations; these patterns are generally only seen in older adolescents and account for less than 2% of fractures.[27]

History and Physical

Facial injuries may be distracting to both the patient and the examiner. Eye-catching injuries to the face mustn't delay or prevent the consideration and evaluation of other severe and life-threatening conditions. Recall that there is a significant amount of force required to fracture a child's facial structures, and concomitant injuries are common.

The evaluation of a patient with a traumatic facial injury should follow advanced trauma life support (ATLS) concepts, particularly noting the effect of facial injury on the potential for airway compromise, spinal or neck injuries, or other head trauma, including traumatic brain injuries. Once life-threatening and other severe conditions are accounted for and stabilized, you may return for a more detailed facial structure evaluation.

History

An accurate account of the events in a traumatic injury, including changes in mental status, sensory and motor function, range of motion, vision, and associated symptoms, is critical in evaluating trauma. Considering the child's age, supporting history from parents, coaches, and first responders are likely needed. Children rarely have underlying medical conditions that contribute to a traumatic presentation or offer complications such as the use of anticoagulation; nonetheless, these routine historical questions should still be pursued as they may change management, along with reports of allergies, vaccinations (particularly tetanus), and last meal.

Patients might report swelling or stiffness in the head, neck, jaw, eyes, or nose. Feeling that teeth are loose, or the presence of or history of epistaxis does not change the likelihood of facial fractures. Sensations that something is stuck or catching, persistent diplopia, subjective malocclusion, or paresthesias of the face should raise concern for fractures.

Physical Exam

A careful physical exam is critical in children. Depending on age, they may not communicate a complete history of the traumatic event or relay all of their symptoms.

A calm, relaxed patient will be more accommodating to an extensive and careful examination. Examination success can be improved by being held by a parent and consideration of pain control, distraction, and anxiolysis.[33][34]

A facial examination should be systematic. The exact approach is not as important as long as all aspects are examined. One method is to attempt the exam in 3 dimensions: superior to inferior, lateral to medial, then superficial to deep. 

Musculoskeletal and Skin

For wound evaluations, determine the depth and explore any damage to muscles, tendons, vessels, nerves, and ducts. Facial nerve palsy after blunt trauma is suspicious for fracture of the temporal bone.[20][35] Some amount of pain and stiffness with the range of motion is expected after trauma. Bony tenderness and soft tissue swelling are suggestive of, but nonspecific for, facial bone fractures; however, crepitus near a sinus more strongly correlates with an underlying fracture.[25]

Eyes

If direct eye trauma has occurred, an examination of the eye should occur early as periorbital swelling can develop and hinder a later exam. An extraocular range of motion impairment suggests entrapment, possibly in a fracture of the orbital rim. Telecanthus concerns for a nasoorbitoethmoid fracture. The remaining ocular exam maneuvers evaluate for non-fracture related injuries and are discussed in other StatPearls articles.[3]

Mouth and Intraoral Examination

The examination of the mouth for fractures focuses on the upper and lower jaws, teeth, and temporomandibular joint (TMJ). In addition to bony tenderness, particularly trismus, malocclusion, or dental laxity with palpation, gingival ecchymosis, or lacerations may be signs of fractures in the mandible or maxilla.

Evaluation

Laboratory tests are not necessary for pediatric patients with isolated facial fractures without suspected intracranial involvement. However, if there is concern that operative intervention will be needed, testing may be indicated according to local pre-operative protocols.

The preferred imaging study for evaluating suspected facial trauma at any patient age is a computerized tomography (CT). Magnetic resonance imaging (MRI), typically used to assess soft-tissue structures, is less sensitive for subtle fractures, and should not be used as a primary imaging modality. X-rays can be used for dental evaluation but do not reliably show facial fractures. Isolated soft tissue injuries without clinical suspicion for fractures do not benefit from imaging or isolated clinically suspected nasal bone fractures, which should be treated empirically.[2][24]

Treatment / Management

As with most traumatic injuries, pediatric facial fractures benefit from ice, rest, and pain control. Once fractures are identified, the appropriate specialists should be consulted for further management and treatment recommendations. These specialists may include any of the following: pediatric specialists in facial surgery (both otolaryngology and plastic surgery, depending on local resources), ophthalmology, neurosurgery, anesthesia (for advanced airway stabilization), psychiatry (if self-harm is suspected), as well as any other team that is clinically indicated for consultation.

Child-specific approaches to anxiolysis, pain control, and soft tissue facial injuries in pediatric facial trauma patients are addressed further in an alternative StatPearls article, and these concepts apply well to pediatric facial fracture patients.[3] For pain control, the primary addition is that fractures, beyond soft tissue injuries, may be more likely to see symptomatic relief using opiate agents. Further specific alterations are discussed below.

Antibiotics and Vaccination

For any dental injuries or open wounds, the patient’s tetanus vaccination status should be confirmed. There is no evidence that antibiotics give any mortality benefit or reduce the rate of complications, such as infections or poor healing.[36][37] That being said, antibiotics are commonly prescribed for fractures considered open, which may include sinus or intraoral involvement; it is reasonable to defer to the recommendation of the local surgeon or receiving center pediatric facial specialist for recommendations as they will be following the patient after that. If antibiotics are recommended, coverage for intraoral flora is usually sufficient, including amoxicillin-clavulanate or clindamycin.

Fracture Management

In general, most facial fractures in children can be managed conservatively without surgery, in consultation with a pediatric facial specialist. As the child grows, even greatly deformed structures can remodel during the healing and normal growth processes. A trial of watchful waiting and observation may be a reasonable approach. Facial and jaw restructuring can also be accomplished with orthodontic manipulation, particularly for injuries causing malocclusion.[2][24] Surgery is avoided if possible, though children may need delayed surgery for cosmetic or structural purposes even if surgery is not indicated for the initial injury. Indications for urgent surgery are more often due to associated injuries requiring evaluation and repair.

Fractures Requiring Operative Repair

  • Frontal bone fractures: only if more than minimally displaced, especially after initiation of pneumatization.
  • Zygomaticomaxillary complex fractures: with significant facial height or contour deficits, dental occlusion, or visual deficits, isolated fractures to the zygomatic arch may be treated conservatively.
  • Orbital fractures: with extraocular muscle entrapment, traumatic optic neuropathy, or floor defects >1 cm; should be treated within 24-48 hours to prevent long-term vision deficits.
  • Nasoorbitoethmoid fractures: typically, all treated surgically.
  • Mandible fractures: only if substantial deformation or severe malocclusion, displacement of condylar fragments into the external auditory canal or middle cranial fossa, or lateral extracapsular dislocation; otherwise, a trial 4-6 weeks of jaw rest, soft diet, possible immobilization, and delayed orthodontic evaluation is preferred.

Isolated Nasal Fractures and Eye, Ear, and Dental Injuries

Management of pediatric soft tissue injuries, pediatric dental injuries, and nasal fractures are discussed in other StatPearls articles.[3][8][9]

Differential Diagnosis

Facial fractures in children are often only produced by dramatic impacts and are therefore highly associated with severe concomitant traumatic injuries. Of primary concern are airway consequences from severe facial trauma and neurological damage from head injuries.

Causes of injury must always be considered, including:

  • Non-accidental trauma (such as child abuse or neglect)
  • Intimate partner violence
  • Physical or sexual assault
  • Risk-taking behaviors
  • Lack of protective equipment use or availability
  • Suicide attempt or other self-injurious behavior

In addition to specific bony facial fractures, the following must also be considered:

Bony Injuries

  • Mandible dislocation
  • Sinus involvement in fractures
  • Skull or cervical spine fractures
  • Cartilage injuries (including nose and ear)
  • Tooth avulsions or fractures

Soft Tissue Wounds and Injuries

  • Lacerations and contusions
  • Penetrating wounds and retained foreign bodies
  • Septal or auricular hematomas
  • Eye injuries (including globe rupture, retrobulbar hematoma, corneal damage)
  • Ductal and glandular injuries
  • Neurovascular damage

Prognosis

Pediatric facial trauma prognosis is generally good, though the more bones involved adds to the chance for long term deformity and need for surgical repair. Reassuringly, pediatric osteochondral tissues are adept at remodeling, and most patients heal well with minimal later discernable evidence of injury.

Complications

Possible complications include:

  • Growth abnormality or long term disfiguration
  • Infection (especially if dental or sinus involvement, or penetration of foreign objects)
  • Long term dental effects
  • Psycho-social effects
  • Visual acuity distortion (especially for delayed relief of entrapped orbital muscles)
  • Persistent paresthesia or muscle weakness if peripheral nerves damaged
  • Posttraumatic or chronic facial pain

Deterrence and Patient Education

Though trauma is typically incidental, some methods remain to reduce the chance of occurrence and severity of injuries. This involves evaluating the potential risk of child abuse, suicidal tendencies, and risky social behavior (including injurious sports or recreational activities). Adults and children alike see a decreased rate of injury or death when using age- and size-appropriate car seats and restraints.[38][39] Additionally, the use of personal protective equipment should be encouraged for recreational and sporting participation.[40][41]

Pearls and Other Issues

Home Medications and Diet

Injuries involving the upper or lower jaw or teeth should prompt recommendations for a soft or liquid diet and avoid extremes in food temperature. The provision of liquid-form medication prescriptions is often necessary. Patients with injuries involving the sinuses or nasal cavity should be given sinus precautions.

Follow Up

Follow up for most pediatric fractures will involve a pediatric facial specialist; timing of follow up should be discussed with the specialist, though usually within one week is reasonable if there are no urgent operative indications. Dental injuries should be referred to a pediatric dentist. If possible, any images and radiological reports obtained in the emergency department should be provided to the patient’s caregivers to minimize the need for subsequent radiation when re-imaging; this also allows outside providers to compare later stages of healing to the initial injury.

Enhancing Healthcare Team Outcomes

Pediatric facial fractures are uncommon despite the large incidence of pediatric facial trauma in general. Cases involving fractures are typically evaluated in the emergency room and involve emergency providers and nurses, a facial surgeon, a radiologist, and variably a trauma surgeon, child-life specialist, social worker, emergency medical service (EMS) personnel, and other specialty services. Facial fractures in children are often conservatively managed, though an organized team approach can prevent missing subtle or dangerous injuries and improve patient outcomes.

Much of the data presented above is derived from small randomized controlled trials (RCTs) or large cohort studies. [Level 2-3]


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