What is Pediatric Facial Trauma (Face Injury in Abused Children)?
Trauma is the major cause of injury and death in children. The most frequent type of trauma in children is head trauma, with facial trauma being less common. Facial trauma can include injuries to the skin, bones, and nerves in the face, eyes, nose, mouth, and facial bones. For infants and young children, the head, which is relatively larger in size, is more commonly injured than the face.
In this context, “pediatrics” means patients who are under the age of 18. Most facial injuries in children involve the soft tissues, nose, or teeth and their supporting structures. While facial injuries frequently occur alone, it’s important always to consider possible additional injuries to the head or neck. Although facial injuries alone usually do not pose a threat to life, certain conditions such as facial fractures, bleeding, injuries to the throat, and particularly burn injuries might jeopardise breathing.
This section is mainly about how to care for children presenting with injuries to the face’s soft tissues. However, other articles by StatPearls go into detail about other related topics, such as facial fractures in children, child abuse leading to head injuries, head trauma in children, fractures of the skull in children, traumatic brain injury, trauma to the spine in children, neck injuries, tooth fractures, tooth loss due to trauma, and various types of injuries to the ears, tongue, face, eyes, and eyelids.
What Causes Pediatric Facial Trauma (Face Injury in Abused Children)?
Kids can suffer from injuries to their face due to several causes, with the most common being blunt force trauma from falls, car accidents, bike accidents, sports incidents, or even assault. Sometimes, they can also get hurt from sharp or penetrating objects.
When we look at the cause of these injuries, it can change as the children grow. For example, non-accidental trauma like abuse can happen especially in babies, while teenagers might suffer from injuries inflicted by themselves or others, during suicide attempts or assaults. Rarely, injuries can happen due to work-related accidents or through weapons in adolescents.
When a child is born, their skull is a lot bigger than their face which grows over time. Because of this, particularly in children less than five years old, they are more likely to suffer from head injuries instead of facial injuries. Younger children’s facial bones and cartilage are more flexible and pliable, so if they do fracture a bone, it often doesn’t move out of place much. As a result, most of their facial injuries are usually to the soft tissues instead of the bones.
Cuts and bruises are common when younger kids hit their face against hard objects like the floor, steps, or furniture. Most frequently, they get cuts on their chin, cheeks, or forehead.
There’s a unique kind of injury that can happen to children because of their age and accidental behavior. For example, a specific kind of burn at the corners of the mouth can happen when a young child bites into or sucks on a live electrical wire. These burns are usually superficial and do not cause deep damage to the tissues or affect the heart’s rhythm. The burn usually forms a crust quickly and is often present when the child first sees a doctor. Though there’s no initial bleeding, doctors should keep in mind that once the crust falls off, which usually happens 1 or 2 weeks after the incident, the wound might start to bleed.
Risk Factors and Frequency for Pediatric Facial Trauma (Face Injury in Abused Children)
Pediatric trauma, or injuries in children, account for over 11,000 deaths and more than 8 million visits to emergency departments (EDs) every year. Most of these injuries only involve the soft tissues of the face, as it usually requires a lot of force to cause fractures. In fact, fractures are seen only in 8-15% of children with facial injuries who visit the ED.
- Injuries to the soft tissues of the face are common, making up about 34 to 92% of facial injuries in children.
- These injuries usually involve bruises or cuts, and about 15 to 69% of them also have dental injuries.
- More than 22,000 cases of dental injuries in children are reported each year, with 10 to 60% of young athletes reporting having had a dental injury at some point.
- Many minor injuries can be taken care of at home, so these figures might underestimate the actual number of facial injuries in children.
While new-borns and toddlers have an almost equal chance of getting injured regardless of their gender, this changes as kids grow older. Boys become more likely to get injured, with late adolescents being two to four times more likely to present with facial trauma than girls. The most common age for children to come to hospital with facial trauma is between 1 and 6 years, accounting for 26 to 58% of all cases. The next most common age is mid-adolescence.
What causes the injury can vary with the child’s age. In general, 38 to 55% of injuries are due to a fall or play, typically in children under six years of age. Motor vehicle collisions, sports, and assault make up 5 to 21%, 11 to 32%, and 4 to 17% of cases respectively. Young boys, especially teenagers, are often the victims of assault, whereas sports injuries are more evenly spread out among all patients over 5 years old.
Signs and Symptoms of Pediatric Facial Trauma (Face Injury in Abused Children)
When examining a child who may have gotten hurt, it’s important to first understand the situation that led to the injury. This information can be gathered from people who saw what happened, such as parents, teachers, coaches, or emergency medical workers. Depending on the injury, the child may express pain in different parts of their body like the head, face, teeth, eyes, and nose; they might also feel dizziness, have a stuffy nose, hear less than normal, cough, feel numb or tingling in part of their face, have blurred vision, feel confused, or have even passed out.
It’s also crucial to ask about the child’s medical background, current medications they are taking, any allergies they might have, vaccinations they’ve received, and what was the last thing they ate or drank (especially if the child might need to be sedated).
The physical check-up is especially vital in children who aren’t old enough to clearly explain what’s wrong or where it hurts. First, medical providers follow a standard procedure to check if the injury is severe. It’s important to look over the face carefully, as severe facial injuries can lead to additional problems, such as difficulty in breathing, brain trauma, neck or spinal cord injuries, or other serious harm. Even if the injury appears to only be on the face, it’s important to check the rest of the body to ensure no other hidden injuries. Getting the child comfortable can greatly help in a successful check-up. Looking at all facial structures systematically, like from top to bottom and side to side, ensures no injuries are missed.
Any cuts or wounds need to be carefully checked to understand their depth and whether any muscles, tendons, blood vessels, nerves, salivary ducts, and fascial planes are affected. If there’s fat visible in the face wound, there might be nerve or duct injuries and a specialist should be consulted. Look for any changes in facial sensations and movement. Remember, some degree of stiffness and pain are common; however, significant swelling and crepitus (crackling feeling) on the sinuses could suggest facial fractures.
- Examine the eyes, looking for pupil’s response to light, check eye movements and the patient’s report on their visual acuity. Swelling around eyes, abnormal pupil size, and restricted eye movements could suggest serious problems like brain bleeding or eye muscle entrapment.
- Check the ears for hematomas or cuts, and review if the ear drum is intact; if there’s blood in the ear, this could suggest skull injuries.
- Check the nose for swelling, asymmetry, and what’s going on inside it. If there’s continuous nose bleeding, its location should be determined.
- The lips, tongue, teeth and inside of their mouth need to be carefully examined. In case of any fractures, you may note an inability to open the mouth completely, tenderness, disturbed alignment of teeth, or loosening of teeth upon touch.
Testing for Pediatric Facial Trauma (Face Injury in Abused Children)
If a child has only suffered injuries to their face, it’s generally not necessary to perform lab tests. In fact, these might only cause more discomfort and stress.
If there’s reason to believe the child might have facial fractures, a computerized tomography (commonly known as a CT scan) is usually the first type of imaging test done. Plain x-rays can be useful for checking the teeth. However, if the injuries are only to the soft tissues of the face, there’s no need for more detailed imaging. In the same way, if there’s only a broken nose suspected, it’s not necessary to have a plain x-ray or a CT scan done urgently.
For deeper or more complex cuts, it might be helpful to consult with a specialist surgeon who focuses on the face, such as a plastic surgeon or an ear, nose, and throat (ENT) doctor.
If there are complaints or signs of eye problems, care must be taken not to put any pressure on the eye, especially if there’s concern about a possible rupture of the eyeball. A Seidel test with a special dye called fluorescein can help to assess this. In a patient who is able to cooperate, a further examination with fluorescein can check for a foreign object on the surface of the eye, bruising inside the eye, inflammation, or a scratch on the surface of the eye. If there’s a pooling of fluorescein dye near the corner of the eye, particularly if there’s also a cut nearby, it could indicate an injury to the tear duct. If the vision has changed at all, it’s important to measure the pressure inside the eye to check for a hematoma at the back of the eye.
If it’s possible, a point of care ultrasound of the eye, done by an experienced operator, can check for problems like a dislocated lens, bleeding inside the eye, a detached retina, or increased pressure inside the skull.
Treatment Options for Pediatric Facial Trauma (Face Injury in Abused Children)
For children with facial injuries such as bruises or scrapes, regular wound care, rest, cold compresses, and anti-inflammatory pain relief are usually enough. More serious cases may require additional treatments.
Relief from anxiety and pain can be achieved in various ways. Distraction is often a simple and effective method, but in some cases, medication may be necessary. For babies under six months, sucrose solution can be used. Acetaminophen and ibuprofen can be used for general pain relief in minor injuries. Applying ice can help with both pain and swelling, especially for bruises. Ice lollies or frozen teething toys can offer some comfort, particularly for mouth injuries.
Breathed in or up-the-nose treatments such as nitrous oxide, fentanyl, or ketamine can also be considered to help with pain or anxiety. This can avoid the need for putting in an intravenous line.
For procedures like inserting an IV line or treating a wound, local anesthetics applied to the skin can be useful. There are also techniques called nerve blocks that provide anesthesia for certain areas, particularly useful in treating dental injuries or cuts. These don’t require advanced equipment and can last for a longer time.
Remember to check vaccination records for all open wounds. For properly cleaned wounds, antibiotics aren’t usually necessary, but deep or contaminated wounds will require antibiotics.
Minor cuts should be cleaned before any attempt at repair. Bigger and more complex wounds may require a specialist for repair. Ice and pressure are the main treatments for nose contusions and swelling. If your ear is injured, any hematoma should be drained and then wrapped tightly. Dental injuries management could vary based on the type of the tooth involved.
For more grave injuries like burns or major eye injuries, transfer to a specialist or burn center is recommended.
What else can Pediatric Facial Trauma (Face Injury in Abused Children) be?
In kids, accident to the face can come with other minor or critical injuries, especially in high-energy accidents like car crashes. It’s also important to think about situations that can lead to high-risk injuries, such as physical attacks or neglect (like not enough supervision leading to a child hurting themselves).
Here are some specific injuries that doctors should look for when checking a child for facial trauma:
- Bone Injuries
- Dislocation of the jaw
- Fractures of the facial bones, including those to the sinuses
- Breaches in the skull
- Breaks or instability in the neck vertebrae
- Damage to cartilage
- Broken or knocked-out teeth
- Cuts
- Scrapes or deep cuts, including inside the mouth
- Stab wounds or gunshot wounds
- Animal or human bites
- Other Injuries
- Bruises and swelling
- Nosebleeds
- Blood clots in the septum (the wall dividing the nostrils)
- Blood clots in the ear
- Burst eardrums
- Injuries from inhaling toxic or dangerous substances
- Burns (including chemical, heat, or electric)
- Eye injuries the muscles around the eyes, rupture of the eyeball, a blood clot behind the eye or a scratch on the cornea
- Damage to ducts and glands
- Nerve damage
- Blood vessel damage
- Mental stress from the trauma
- Injury to the spinal cord
- Head injury or concussion
Causes of Injuries:
- Abuse (including shaking baby syndrome)
- Attack (including domestic violence)
- Attempted suicide
- Exposure to harmful substances (such as inhaling toxic fumes)
What to expect with Pediatric Facial Trauma (Face Injury in Abused Children)
In general, the outcome for most children with facial injuries is excellent, particularly if there are no underlying bone fractures. Even with bone fractures, children’s bodies have a fantastic capacity to repair and reshape the bone so they seldom require surgery or face lasting changes to their bone structure.
The most common lasting effect is scarring, often from burns or cuts near the lips or eyes. While this is usually a cosmetic issue, it can also impact function. Scarring can be lessened by diligently applying sunscreen daily to the wound area for about 6 to 12 months after the stitches have been removed or the adhesive has dissolved.
Possible Complications When Diagnosed with Pediatric Facial Trauma (Face Injury in Abused Children)
Possible complications after a surgery can occur in various stages, listed below in order of when they might typically appear:
- Infection, which is particularly common with burns or animal bites.
- Delayed bleeding, especially when an injury has been caused by an electrical cord on the labial artery.
- Necessity for advanced dental repair and long-term dental issues, including orthodontics.
- Scarring and keloid formation, which is an overgrowth of scar tissue.
- Delayed psycho-social consequences, which can affect a person’s emotional and social well-being.
- Posttraumatic facial pain, which is pain that occurs after a facial injury.
Preventing Pediatric Facial Trauma (Face Injury in Abused Children)
Anyone can experience a traumatic injury, but there are ways to lessen the chance of it happening and the severity of the injury if it does. For children of all ages, it’s crucial to consistently be alert and check if their living environments are safe or if there’s a risk of them being abused. For teenagers and young adults, it’s necessary to look for signs that they may harm themselves, be in a harmful relationship, or participate in dangerous activities.
People of all ages also benefit from using the correct vehicle safety measures, such as seatbelts and child car seats, which can significantly decrease the risk of serious injury if an accident occurs. It’s also highly recommended to use protective gear while playing sports or participating in recreational activities. Following the advice of coaches and trainers on how to correctly perform activities can also lower the risk of getting hurt.
