What is Pediatric Facial Fractures?
Trauma is a major cause of illness and death in children. Head injuries are the most common type of trauma. Facial fractures (broken bones in the face) are rare in very young children because their faces contain more bendy cartilage and their heads are proportionally larger compared to adults. However, when they do occur, these injuries can be severe and have long-term impacts.
The way a child’s face grows makes their fracture patterns different from adults. These differences are mainly due to the growth of children’s secondary teeth and the development of their nasal sinuses. Facial fractures can occur on their own in children, but when a child has been involved in a serious accident, doctors also need to consider the possibility of other injuries, particularly to the head, eyes, brain, neck, and airway.
The facial bones include the maxillae (upper jaw bones), mandibles (lower jaw bone), zygomae (cheekbone), and nasal and frontal bones. The nasal bones, which form the bridge of the nose, are relatively thin and prone to fractures. In a newborn, the head is proportionally much larger than the face. As a child grows, the face expands until it reaches adult proportions in the teenage years.
Due to their higher cartilage content, children’s facial bones are more bendable and resilient than adults’, making them more likely to absorb impact rather than fracture. When facial fractures do occur in children, they’re often small and don’t follow the same patterns seen in adults. Nose fractures are the most common in kids, followed by mandible fractures, due to the prominence of these features and their positions in relation to the developing sinus and teeth.
The development of the facial bones and sinuses play a major role in their susceptibility to fractures. Maxillary sinus development starts at birth and ends around age 7. During this time, the middle of the face is thicker and has more give than the top of the face, making upper face fractures more likely. As children grow, their teeth contribute additional strength to the facial bones. At the same time, the thinning of the orbital floor (bone at the bottom of the eye socket) makes orbital injuries more common.
From age 12 onwards, the midfacial bones lose their cartilage and thin out, behave more like adult bones. Injuries tend to affect the upper maxilla (upper jaw), leading to an increased incidence of fractures to the orbital floor in teenagers compared to younger kids.
What Causes Pediatric Facial Fractures?
In children, facial fractures usually happen because of blunt trauma. This can be from things like falls, sports injuries, car crashes, assaults, and even child abuse. There are also cases of penetrating facial injuries, often from gunshot wounds. However, these types of injuries are becoming less common in the United States.
Risk Factors and Frequency for Pediatric Facial Fractures
Pediatric trauma, or injuries in children, causes about 12,000 deaths and leads to over 8 million visits to the emergency room every year in the United States. However, less than 15% of facial fractures happen in children. Most facial injuries in kids are confined to soft tissues, with only about 10% to 15% resulting in craniomaxillofacial fractures, or fractures in the facial and skull bones. Nonetheless, most facial trauma cases are associated with other serious injuries. Minor facial injuries are often treated at home and might be underreported. On the other hand, fractures cause a lot of pain and swelling and could be reported more accurately.
Teenage boys are twice as likely to have facial fractures as girls. Facial fractures are rare in children under the age of six, and skull fractures are more common in this age group. Half of all fracture cases occur in patients aged 10 to 18. About half of the facial fractures in children result from motor vehicle accidents. Bicycle accidents and sports injuries cause most of the remaining injuries in school children. Infants and toddlers sustain more injuries from falls. Facial injuries related to assaults are less common, often involving teenage boys. Where the fractures are located depend on the child’s age, the kinds of physical activities they engage in, and how their bones grow and develop as they age.
Nasal fractures are thought to be the most common but are likely underreported since it’s not required to evaluate these at trauma centres. The facial bone most often affected in traumatic injuries across all age groups is the lower jaw or mandible. It affects 40% to 60% of children with facial fractures and its incidence increases with age. Injuries to the alveolar ridge, the part where the teeth are anchored, are more common in young patients, affecting 60% of children under six who have fractures and become less common as they get older. Fractures of the orbital (eye socket) and midface are the next most common. Frontal bone fractures can be associated with brain injuries in 35% to 64% of cases and leaks of cerebrospinal fluid, which cushions the brain and spine, in 18% to 36%. This kind of leakage can occur in younger patients, where the frontal bone absorbs the impact before it fully develops and still has some give.
Nasoorbitoethmoid fractures, or fractures involving the nose, eye socket, and the ethmoid bone (a light, porous bone at the front of the skull and the nose), are not common. They represent only 1% to 8% of all facial fractures in children. Certain kinds of fractures, like Le Fort midfacial injuries, are rare in kids. These injuries are usually only seen in older teenagers and account for fewer than 2% of pediatric facial fractures.
Signs and Symptoms of Pediatric Facial Fractures
If a child suffers a facial bone fracture, this usually indicates a significant force was involved. Therefore, a thorough check for associated injuries, like airway compromise, spinal or neck fractures, or traumatic brain damage, is important. Doctors usually assess patients with traumatic facial injuries according to the Advanced Trauma Life Support (ATLS) guidelines. Issues like significant midfacial and nasal bleeding and the tongue being displaced due to fractures in the jaw may lead to airway compromise. A more detailed evaluation of the facial structure is done after identifying and stabilizing any life-threatening injuries.
Getting Details about the Incident
Gathering an accurate report, including information about changes in mental status, sensory and motor functions, range of motion, vision, and associated symptoms, is crucial when evaluating trauma. Usually, this history is provided by parents, coaches or first responders, particularly for younger patients. Though children rarely have underlying medical conditions which contribute to trauma, routine historical questions should still be asked because they can affect the treatment plan. These questions should include information about allergies, immunizations, particularly for tetanus, and when the last meal was consumed as emergency surgery may be required.
Children may not be able to give a full account of the incident or their symptoms but common complaints could be the feeling of something being stuck in the face or mouth, persistent double vision, or these teeth feel loose. These should raise concern for facial fractures.
Physical Examination
While facial injuries may be visible, a careful physical examination is important, particularly in children. A facial examination should cover all aspects and can be done following these three dimensions: top to bottom, side to side, and surface to depth. Nerve tests for the head and neck should be carried out as part of the examination. Children often cooperate better if they can be held by their parents and their pain, distraction, and anxiety are managed well.
- During the musculoskeletal and skin examination, wounds should be checked for the extent of damage to the muscles, tendons, vessels, nerves, and ducts. Pain and stiffness are likely to limit range of movement after trauma. Swelling of the soft tissue and tenderness of the bone can suggest facial bone fractures but are not definitive signs. That said, strange sounds near the sinus or the movement of facial bones when touched could indicate a fracture.
- For the eye examination, if there has been trauma to the eye, this should be done early as swelling of the tissue around the eye can develop and hinder a full facial examination. Issues with the range of muscle motion of the eye can suggest that the bottom of the eye socket (orbital floor) is trapped, possibly caused by a fracture. Particularly with pediatric patients, this can cause a ‘white-eyed’ blowout fracture where the floor of the eye socket breaks, swinging into the sinus cavity in the cheeks, allowing the soft tissue within the eye socket to move through the fracture. This can cause the entrapped soft tissue to be choked when the fractured bone returns to place.
- During the oral examination, the upper and lower jaws, teeth, and the joint connecting the jaw to the skull (TMJ) should be the focus. Signs of a fracture in the jaw or maxilla could be tenderness in the bone, trouble opening the mouth, misalignment of the teeth when the mouth is closed, teeth being loose when touched, bloody gums, and tears in the skin. If the jaw is fractured in two places, the tongue could move back and block the airway if the central part of the jawbone becomes a large moving segment. This could be life-threatening and needs immediate treatment.
Testing for Pediatric Facial Fractures
For children who have suffered only facial fractures without signs of brain injury, there’s usually no need for lab tests. However, if there’s uncertainty regarding surgery, special pre-surgery test protocols may be followed.
If a doctor suspects facial trauma, regardless of the patient’s age, the best method for checking it is a CT (computerized tomography) scan. This technique is better than an MRI (magnetic resonance imaging), which is usually better for examining soft tissues but is not as good at picking up small fractures.
Regular x-rays or wide-view dental x-rays can be used for dental evaluation, but they’re not reliable for identifying facial fractures. There’s no need for imaging if it’s just a soft tissue injury without any broken bones. Also, if a nasal bone fracture is already clear through physical examination, further imaging won’t be of much help and treatment should be started based on the doctor’s clinical judgement.
Treatment Options for Pediatric Facial Fractures
When patients arrive with severe bleeding, unstable vital signs, or signs of cardiac arrest, immediate resuscitation is necessary. The patient’s airway, breathing, circulation, disability, and exposure need to be addressed as soon as possible, following the ATLS (Advanced Trauma Life Support) guidelines. While doing this, efforts to stabilize the patient and treat any injuries, especially those bleeding heavily, should begin.
For children with facial fractures due to trauma, softening the pain with ice, rest and controlling the pain are beneficial. Once fractures are detected, specialists such as facial surgeons, ophthalmologists, and neurosurgeons should be consulted for further treatment. Child-specific comfort and pain control methods might be necessary for younger patients, such as a parent holding the child, using oral sucrose solution, or giving them teething toys or popsicles. Pain medication including acetaminophen, ibuprofen or carefully dosed opioids may be used. There are also options like nitrous oxide, fentanyl, ketamine, and midazolam which can be administered via a nasal spray to avoid intravenous access.
If there are open wounds or dental injuries, the patient’s tetanus vaccination status must be confirmed. Although there isn’t definite proof that antibiotics reduce mortality rates or complications, they are usually prescribed for open fractures and lacerations.
The overall approach to facial fractures in children leans toward non-surgical treatments in consultation with a pediatric facial surgeon. The body’s natural healing and growth processes can usually handle deformation. Cosmetic or structural surgery is considered only if non-surgical interventions aren’t enough. Frontal fractures are uncommon in young children and older patients may only require fixation if there are significant displacements or visible deformities. When dealing with nasoorbitoethmoid fractures, surgery is only recommended if certain conditions are present, such as traumatic telecanthus.
Nasal fractures in teenagers could be treated with general anesthesia, similar to adults. Rhinoplasty can be performed later if initial methods aren’t adequate. Orbital fractures require urgent care if there is muscle entrapment causing an oculocardiac reflex. That said, the repair of certain injuries may be postponed for a few days until swelling has reduced.
Zygomaticomaxillary Complex Fractures might be managed conservatively with a soft diet, unless there are visible deformities or functional limitations, requiring surgical intervention.
Most fractures to the mandible in children can be handled non-surgically with soft diets and pain control, although braces or wiring might be necessary. Certain kinds of fractures might need surgical reconstruction.
Once discharged, patients with jaw or tooth injuries should be ADVISED to maintain a soft or liquid diet and avoid extreme food temperatures. Liquid medication prescriptions are often needed.
Following up with a pediatric facial surgeon is recommended within a week if no urgent surgical intervention is required. If the injury affects the teeth, the child should be referred to a pediatric dentist. It is also crucial to reduce unnecessary radiation exposure by providing caregivers with any images and radiological reports obtained in the emergency department. These can also be useful for outside clinicians to observe the changes post injury.
What else can Pediatric Facial Fractures be?
Children can get face fractures from serious accidents, and these can be linked to other severe injuries. These injuries could be damage to the airway from the facial trauma or nerve damage from head injuries. Here is a list of why most kids get face fractures:
- Child abuse or neglect
- Physical or sexual abuse
- Dangerous behaviors
- Not using or not having safety gear
- Trying to hurt themselves on purpose
In addition to fractures in their face bones, children who get these injuries could also have these problems:
- Damage to bones
- Jaw dislocation
- Fractures that affect the sinus
- Skull or neck fractures
- Injuries to cartilage, which could include the nose or ear
- Teeth being knocked out or fractured
- Damage to soft tissue
- lacerations and bruises
- Penetrating wounds or any objects left
- Blood accumulation in the septal or ear
- Eyes injuries which could be a break in the eyeball, backside blood accumulation, and corneal damage
- Injuries to ducts and glands
- Damage to nerves and vessels
Understanding and treating facial injuries correctly can be a big help in the normal functioning recovery of the face and its look, also it can prevent long-term problems.
What to expect with Pediatric Facial Fractures
The outlook for children experiencing facial injuries is usually quite positive. Still, deep wounds may lead to long-lasting changes in appearance, possibly requiring surgery to fix. Thankfully, the bones and cartilage in children are skilled at repairing and restructuring themselves. As a result, most kids recover well with little to no visible signs of their injury.
Possible Complications When Diagnosed with Pediatric Facial Fractures
Pediatric facial fractures could lead to a number of complications such as:
- Abnormal growth or long-term changes in appearance
- Infections, particularly if they involve the teeth or sinuses, or if foreign objects penetrate the skin
- Long-term dental problems
- Social and emotional consequences
- Changes in vision, especially if muscles around the eyes were trapped and not quickly released
- Persistent numbness or muscle weakness if nerves are damaged
- Long-term or chronic facial pain occurring after the trauma
The early diagnosis and timely assessment of facial fractures are key for early detection of these potential complications and for the initiation of appropriate treatment.
Preventing Pediatric Facial Fractures
Most injuries to the face in children are accidents, but there are several ways we can lessen both the number and seriousness of these injuries. This can be accomplished by checking for signs of child abuse or self-harm, as well as behavior that could be dangerous, such as participating in high-energy sports and activities. Both adults and children can reduce their risk of injury and death by using restraints in cars that are suitable for their age and size.
Protective gear, especially helmets with face shields or visors, can also help prevent injuries during activities with high chances of impact. These activities include riding all-terrain vehicles, snowmobiling, skiing, skateboarding, and bicycling. Encouraging the use of this equipment can prevent a large number of these accidents.
