Pediatric Facial Trauma

Etiology

Pediatric facial trauma is most often the result of blunt force (e.g., falls, motor vehicle collision, bicycle injury, sports-related, assault), though penetrating injuries may occur.

Age-related etiology considerations include non-accidental trauma, particularly in infants, accidental self-injurious behavior, suicide attempts, and assaults, which are more common in adolescents, and less frequently occupational exposure or weapons-based injuries.

At birth, the skull is relatively much larger than the face, which grows over time.[2][22][23] This results in a tendency, especially in patients under five years of age, to be more likely to sustain cranial rather than facial injuries. Younger patients also have more elastic bony and cartilaginous facial structures with flexible suture lines, with a subsequent propensity for fractures to be minimally displaced when they occur. As such, soft tissue injuries comprise the vast majority of presentations for isolated facial trauma.

Lacerations and contusions are common in young patients when more acutely edged bony structures strike against hard objects, such as the floor, stairs, or furniture, resulting in common presentations of lacerations to the chin, cheek, and forehead (often overlying the lower mandible, zygomatic arch, or superior orbital rim respectively).

Special Consideration

Children are at risk of unique facial injuries due to age-related accidental self-injurious behavior. A distinctive oral commissure electrical burn may occur if a young child bites into or sucks on an active electrical cable.[24] With this injury type, an arc burns briefly sear the corner of the mouth. Still, unlike other classic electrical burns, it rarely causes deep tissue penetration and is not associated with cardiac arrhythmias. Given the brevity of contact and intensity of the heat, eschar rapidly forms and is frequently seen at first presentation. These wounds typically do not initially present with bleeding. However, providers should be aware that the injury can lead to bleeding after the eschar peels off, usually 1 to 2 weeks after the initial presentation.

Epidemiology

Pediatric trauma results in over 11,000 deaths and over 8 million ED visits annually.[2][25] Isolated facial injuries in children are typically restricted to soft tissues as substantial force is needed to generate fractures. Fractures occur in only 8-15% of pediatric facial trauma cases that present to the ED.[26][27][28]

Soft tissue injuries to the face are common, with approximately 34 to 92% of facial trauma presentations in children having soft tissue injury, generally contusions or lacerations, and around 15 to 69% having a dental injury.[28][29][30][31] About half the time, the primary soft tissue injury is a laceration, with the remaining cases being contusions, abrasions, bites, and more rarely burns or eye injuries.[23][29][31]

There are more than 22,000 pediatric dental trauma cases annually, with 10 to 60% of pediatric athletes report having experienced dental trauma at some point.[32]

Many minor facial traumas can be treated in the home without contacting the medical system. Thus there is likely underreporting of facial trauma as care at home or in stand-alone clinics may not be captured in a hospital or systems-based data collection.

Neonates and toddlers generally have an equal gender representation or a slight male bias. However, with increasing age, there is an increasing predominance of male involvement, attaining a case gender ratio of male-to-female 2 to 1 to 4 to 1 by late adolescence.[2][22][26][27][28][29] Patients aged approximately 1 to 6 years old are most likely to present for evaluation of facial trauma, accounting for 26 to 58% of all cases.[28][29][30][31] Mid-adolescence was the next most likely age of presentation.[28][29][30][31]

The cause of injury is highly correlated with age. Overall, 38 to 55% of presentations were due to a fall or play, typically in children under six years of age.[28][29][33] Motor vehicle collisions, sports, and assault, respectively, accounted for 5 to 21%, 11 to 32%, and 4 to 17% of presentations.[28][29][33] Adolescent males, in particular, represented many of the assault cases, while sports injuries were more evenly distributed among all patients above the age of 5 years.

History and Physical

History

The history will dictate both the likely pattern of injuries as well as the level of suspicion for subtle injuries requiring more advanced imaging.[34] Depending on the child’s age, it will likely be necessary to attain corroborating history from additional witnesses (such as parents, teachers, or coaches) and emergency medical services personnel.

Depending on the type of injury, the patient may complain of head, facial, dental, ocular, or nasal pain, as well as stiffness of the jaw, the sensation of sinus and nasal congestion, epistaxis, loose teeth or subjective malocclusion, hearing loss, cough, tingling or numbness of a portion of the face, vision problems, confusion, or history of loss of consciousness.

It is also essential to gather information regarding the patient’s medical history, medications, allergies, vaccinations, and last oral intake (especially if procedural sedation is anticipated).

Physical Exam

The physical exam has extreme importance in pediatric patients relative to adults as younger children may be nonverbal or unable to provide a detailed history. The initial evaluation of any significant traumatic injury should follow advanced trauma life support (ATLS) principles. Extensive facial injuries may be associated with airway compromise, traumatic brain injuries, neck or spinal trauma, or other significant injuries. After completion of the trauma survey and stabilization of the patient, it is crucial to perform a more focused examination of the facial structures. 

Even when there is a seemingly isolated injury to the face and ATLS activation is not necessary, a thorough skin and musculoskeletal exam of the body and extremities should be conducted to identify any concurrently sustained traumatic injuries.

After a trauma, the exam benefits from a calm and cooperative pediatric patient. Calming measures such as being held on a parent’s lap, pain control, and anxiolysis or distraction can dramatically improve examination success.[35][36] When examining the face, it is important to remain systematic so as not to miss any injuries. One example approach is to proceed from top to bottom, lateral to medial, and superficial to deep.

Musculoskeletal and Skin

For lacerations or wound exams, note the depth and gently explore for injury to underlying structures, including muscles, tendons, blood vessels, nerves, salivary ducts, and disruption of fascial planes. Visualization of fat in the cheek is concerning for possible nerve or duct injury and should prompt consultation with a facial specialist.[37][38] Particular attention should be paid to sensation and motor function in the facial and trigeminal nerve dermatomes. Traumatic facial nerve palsy, in particular, is associated with temporal bone fracture, though penetrating trauma may result in direct injury to either the facial or trigeminal nerves.[15][39] Some stiffness and pain with range of motion are expected. While bony tenderness or profound soft tissue swelling is often the most obvious hints of facial fractures, crepitus overlying the sinuses may also suggest a fracture.[23]

Eyes

For cases with no suspected direct trauma to the eyes and no reported or apparent loss of visual acuity, a visual inspection, pupillary response, and assessment of extraocular movement is sufficient.

The eye exam should occur early in the patient’s course because periorbital swelling can become profound, making it difficult to open the eye for evaluation if delayed. Care should be taken to note brisk, equal, and symmetric pupillary response to light, intact extraocular movements, and patient report of grossly normal visual acuity (with corrective glasses if available). The abnormal pupillary response, especially inequality of size, is most urgently concerning for intracranial hemorrhage. The inability of an eye to fully range raises concern for entrapment of the responsible extraocular muscle. The presence of chemosis or subconjunctival hemorrhage concerns for blunt eye injury, which is further addressed in the associated StatPearls article “Blunt Eye Trauma.”[17]

Ears

The external exam should evaluate for hematoma or lacerations with exposed cartilage (management of these conditions is discussed in the associated StatPearls articles.[11][12]) An internal examination should primarily evaluate the integrity of the tympanic membrane and hemotympanum, which is concerning for a basilar skull injury. Hearing can be grossly assessed.

Nose

Examination of the nose should focus on swelling, palpation of bony and cartilaginous structures, and whether the nasal bridge appears midline. Providers can compare the exam to patient photos before the injury. Always inspect internally for the presence of a septal hematoma, a foreign body, and bleeding. If epistaxis is ongoing, an attempt to determine location should be made, though traumatic epistaxis is often anterior.[40]

Mouth

Examine the lips, mucus membranes, tongue, teeth, and posterior oropharynx. Evaluation for a fracture or dislocation involves evaluation for trismus, bony tenderness, malocclusion, or dental laxity with palpation; gingival tears or ecchymosis may be a subtle sign of underlying mandibular or maxillary fracture. For mucus membrane lacerations, note whether they are deep, gaping, or through-and-through.

Evaluation

Laboratory studies are generally not indicated in pediatric patients with isolated facial injuries and may cause more pain and anxiety in the younger population. 

The initial radiographic study for the evaluation of suspected facial fractures is a computerized tomography (CT). Plain film X-rays can be valuable for dental evaluation. However, if only soft tissue injuries present, there is no indication for further imaging. Similarly, if an isolated nasal fracture is suspected, there is no role for either plain film or urgent CT imaging.[2][22]

Deep or complex lacerations may warrant consultation with a facial surgical specialist such as plastic surgery, otolaryngology, or maxillofacial surgery.

For patients with any eye complaints or abnormalities on the exam, if there is any concern for globe rupture, no pressure (such as tonometry) should be applied to the eye.[17] A Seidel test with fluorescein may assist with evaluation for globe rupture.[41] In a cooperative patient, a slit lamp exam with fluorescein can evaluate for a corneal foreign body, hyphema, cells and flare, and corneal abrasion. The pooling of fluorescein at the medial canthus, especially when there is a nearby laceration, is concerning for a lacrimal duct injury. Tonometry should be performed if there is any change in vision, primarily to evaluate for retrobulbar hematoma.[17]

Point of care ocular ultrasound, when performed by an experienced operator, can evaluate for the presence of orbital lens dislocation, vitreous hemorrhage, retinal detachment, and elevated intracranial pressure.[42][43]

Treatment / Management

For most pediatric patients with facial soft tissue trauma, particularly isolated contusions or abrasions, it will be sufficient to provide local wound care, ice, rest, and anti-inflammatory pain control. More advanced management strategies are described below.

Anxiolysis and Pain Control

While distraction is often the safest and fastest method of anxiolysis and pain control in pediatric trauma patients, pharmacotherapy is often needed for procedures.[35][36] Sucrose solutions may be used for neonates and infants less than six months of age.[36] Acetaminophen and ibuprofen are both reasonable initial medications for general pain relief after minor pediatric trauma. If tolerated by the patient, ice can offer both pain relief and reduction of swelling, especially for contusions. Popsicles or frozen teething toys can provide a distraction as well as local pain relief and swelling reduction, especially for intraoral injuries.(A1)

Inhaled and Intranasal Agents

Inhaled pharmacologic agents such as nitrous oxide can be considered, especially if there are contraindications for intranasal product use, or a brief detailed examination such as the ear, eye, or mouth is needed without sedation in a patient unwilling or unable to cooperate with the exam.[36][44] Intranasal agents include fentanyl for pain and ketamine or midazolam for anxiolysis or sedation.[36][45] Intranasal medication may help avoid unnecessary intravenous access.(A1)

Topical Agents

For topical procedures, such as intravenous access or wound care, consider early use of topical local anesthetic agents and allow for adequate time for anesthesia before reassessing. Traditionally a compounded mixture of lidocaine-epinephrine-tetracaine (LET) has been favored for open wounds. Some commercial products have a package-insert prohibition against use on open wounds and are not FDA-approved for open wounds though the evidence for this prohibition is unclear. Commercial agents have been demonstrated to be safe and effective when applied directly to wounds.[36][46][47][48] The choice of the agent should be driven by availability, time to onset, and formulation (gel or ointment preparations are more effective than liquids).(A1)

Nerve Blocks

Nerve blocks are an under-utilized practice to provide anesthesia that relies on fewer needlepoint introductions and smaller volumes of anesthetic agents, especially for laceration repair or dental injuries.[48][49] Nerve blocks of the face can be accomplished by landmark palpation and do not require advanced imaging or equipment. Longer-acting local anesthetic agents can offer better analgesia for dental injuries. Specific nerve blocks are discussed elsewhere in StatPearls.[50][51][52][53]

Antibiotics and Vaccination

For all open wounds or dental avulsions, confirm the patient’s vaccination status. Tetanus is part of the pediatric vaccine series, so as long as general vaccinations are up to date, then the patient is protected. For well-cleaned wounds requiring closure, systemic antibiotics are not beneficial.[23] Deep wounds, bites, contaminated wounds, or wounds not addressed within 24 hours should receive empiric antibiotics.(B3)

Lacerations and Wounds

Simple Lacerations

Once pain and anxiety are adequately managed, wounds must be cleaned before any attempt at repair. Copious, high-pressure irrigation minimizes the chance of infection.[48] Small lacerations (less than 4 cm in length) in areas of the face not under tension may be reasonably considered for closure with a tissue adhesive.[54] Simple lacerations are usually repaired by an emergency medicine or urgent care provider. Either absorbable or non-absorbable suture material may be used. Still, for younger patients (especially those requiring sedation for the repair), the use of fast-absorbing suture material prevents a need for potentially traumatic suture removal in the clinic with similar cosmetic and infection rate outcomes.[11][20][23][55][56](A1)

Facial sutures should generally remain in place for 3-5 days, at which time they should be reassessed for healing and need for removal if non-absorbable.[46] Non-absorbable sutures used are typically made of nylon or polypropylene. Deep absorbable sutures applied for complicated facial wound repair should be of polydioxanone, polyglactin, or polyglycolic acid[48]; surface wounds closed with absorbable sutures should utilize fast-acting absorbable sutures such as the fast-absorbing gut. If absorbable sutures with a longer time until complete absorption are used, the stitches can be removed or trimmed at the usual 3-5 day mark to minimize skin irritation or scarring.

For younger children, especially, covering the wound with a sterile dressing can reduce the tendency of the child to touch or irritate the wound directly. There is no conclusive evidence that topical ointments (either sterile petroleum gel or containing topical antibiotics) affect wound healing or infection rates. However, it is unlikely to be harmful, and it is reasonable to apply to closed wounds.[23][46](B3)

Dog Bites

Detailed animal bite management is discussed in the StatPearls article “Bites, Animals.” In general, dog bites to the face should be treated with amoxicillin-clavulanic acid.[21] Dog bites to the face may benefit from improved cosmesis with closure, though this increases the risk of infection.[57](B3)

Intraoral Lacerations

Tongue laceration management is described in the StatPearls article “Tongue Lacerations,” though some pediatric considerations bear mention.[13] Intraoral lacerations in children are common and are difficult to repair, frequently requiring procedural sedation. The abundant vascular supply to the region results in rapid wound healing even without repair, such that only intra-oral wounds that are through-and-through the lip, cheek, or tongue are necessary to repair.[58][59] Mucosal repairs need only be sufficiently approximated such that food chunks will not become entrapped.(B3)

Wounds that Need a Specialist

Wounds in highly cosmetic or structurally complex regions may be considered for exploration and closure by a facial or ophthalmologic specialist, either at the bedside or in the operating room. These generally include involvement of the eyelid, injuries to ductal or cartilaginous structures, suspected nerve injuries, and depending on provider comfort, may involve the vermillion border, nasolabial fold, and the ear. Facial wounds may also be closed up to 24 hours after the occurrence, so next-day specialty follow-up for closure can also be considered.

Nose Soft Tissue Injuries

Nasal contusions and swelling are primarily treated with the application of ice. Septal hematomas should be drained and packing applied.[60] Traumatic epistaxis generally resolves with ice and pressure, though thrombogenic or vasoconstrictive agents (such as oxymetazoline), cauterization, or packing may be needed.[40]

Ear Injuries

Auricular hematomas should be drained and covered with a pressure dressing.[12] Ruptured tympanic membranes without other otic injuries, with small areas of perforation (less than 25-33% tympanic membrane area), and minimal hearing loss, can be followed in the clinic by a primary care provider.[61][62][63] Patients with moderate hearing loss or large tympanic membrane defects should follow up with otolaryngology in the clinic within four weeks. Guidelines on keeping the ear dry while the tympanic membrane heals (such as no swimming and care while bathing) should be discussed with the patient, parent, and guardian.[63] Antibiotic ear drops, such as ciprofloxacin, can be prescribed for perforations occurring with water contamination.(B3)

Dental Injury

Management of dental injuries, including fractures and avulsions, is discussed elsewhere.[9][10] However, a few caveats are important for pediatric patients. Pediatric patients undergo a series of tooth eruptions, first primary (deciduous, “baby teeth”) and then secondary (permanent, “adult teeth”). Avulsed secondary teeth may be re-implanted and splinted in place. However, primary teeth should not be re-implanted if completely avulsed, as this can damage the formation of the underlying permanent tooth. In the outpatient setting, a dentist will generally review the exam and radiographs of the affected area to decide if spacing or orthodontics are needed to maintain adequate spacing to allow for the natural eruption of the secondary tooth at the affected area.

Burns

Evaluation and treatment of burns are covered elsewhere in StatPearls.[16][64] In general, patients with facial or electrical burns, as well as those with multiple traumatic injuries, should be transferred to a trauma or burn center or close outpatient follow-up with a burn specialist.[64] Isolated oral commissure burns, despite being electrical burns, do not necessitate transfer to a burn center.

Eye Injuries

Comprehensive approaches to eye trauma are discussed elsewhere in StatPearls.[16][17][18] In general, ophthalmology should be consulted for any traumatic eye injury with associated vision deficit, particularly if globe rupture, extra-ocular muscle entrapment, or retrobulbar hematoma is suspected.[17][18]

Differential Diagnosis

Facial trauma in children can be associated with additional sites of both minor and severe injury, especially in high-energy blunt force trauma such as motor vehicle collisions. It is also essential to consider high-risk situations that lead to trauma, such as assault or neglect (including lack of supervision leading to self-injurious behavior).

Specific injuries to consider during the evaluation of pediatric facial trauma include:

• Bony Injuries
  • Mandibular dislocation
  • Facial bone fractures, including sinus involvement
  • Skull fractures
  • Spinal fractures or cervical instability
  • Cartilaginous injuries
  • Dental fractures and avulsions
• Wounds
  • Lacerations and abrasions, including intraoral
  • Penetrating injuries (including stab wounds and gunshot wounds)
  • Animal and human bites
• Miscellaneous Injuries
  • Contusions and swelling
  • Epistaxis
  • Septal hematoma
  • Auricular hematoma
  • Tympanic membrane perforation
  • Inhalation injuries
  • Burns (including chemical, thermal, electrical)
  • Ocular injuries (extra-ocular muscle entrapment, globe rupture, retrobulbar hematoma, corneal abrasion)
  • Ductal and glandular injuries
  • Nerve injuries
  • Vascular injuries
  • Psychosocial trauma
  • Spinal cord trauma
  • Traumatic brain injury and concussion
• Injury Etiologies
  • Non-accidental trauma (including shaken baby syndrome)
  • Assault (including intimate partner violence)
  • Suicide attempt
  • Irritant exposure (inhalation injuries)

Prognosis

The prognosis of most pediatric facial trauma is excellent, especially in the absence of underlying fractures. Even if fractures are present, children have a remarkable ability to remodel bone and rarely have either need for surgical intervention or any lasting bony deformity. The most common sequela is scarring, particularly from burns or lacerations near the lips or around the eyes; generally, this is cosmetic but can have functional deficits. Scarring can be reduced with meticulous daily application of sunscreen to the site of the wound for 6-12 months after suture removal or adhesive dissolution.[65]

Complications

Complications, listed in approximate order of later presentation:

• Infection (especially burns or animal bites)
• Delayed bleeding (especially electrical cord labial arterial injury)
• Need for advanced dental repair and long term dental issues, including orthodontics
• Scarring and keloid formation
• Delayed psycho-social consequences
• Posttraumatic facial pain