Pediatric Facial Trauma: A Review of Guidelines for Assessment, Evaluation, and Management in the Emergency Department

Pediatric Panfacial Fractures

Pediatric panfacial trauma is a rare occurrence with poorly understood implications for the growing child. Treatment algorithms largely mirror adult panfacial protocols with notable exceptions including augmented healing and remodeling capacities that favor nonoperative management, limited exposure to avoid disruption of osseous suture and synchondroses growth centers, and creative fracture fixation techniques in the setting of an immature craniomaxillofacial skeleton. The following article provides a review of our institutional philosophy in the management of these challenges injuries with important anatomic, epidemiologic, examination, sequencing, and postoperative considerations.

Underreporting of Traumatic Brain Injuries in Pediatric Craniomaxillofacial Trauma: A 20-Year Retrospective Cohort Study

BACKGROUND

Despite clinical concerns associated with pediatric traumatic brain injuries (TBIs), they remain grossly underreported. This is the first retrospective study to characterize concomitant pediatric TBIs and craniomaxillofacial (CMF) trauma patients, including frequency, presentation, documentation, and outcomes.

METHODS

An institutional review board-approved retrospective cohort study was performed to identify all pediatric patients presenting with CMF fractures at a high-volume, tertiary trauma center between the years 1990 and 2010. Patient charts were reviewed for demographic information, presentation, operative management, length of stay, mortality at 2 years, dentition, CMF fracture patterns, and concomitant TBIs. Data were analyzed using two-tailed t tests and chi-square analysis. A value of P≤ 0.05 was considered statistically significant.

RESULTS

Of the 2966 pediatric CMF trauma patients identified and included for analysis [mean age, 7 ± 4.7 years; predominantly White (59.8%), and predominantly male (64.0%)], 809 had concomitant TBI (frequency, 27.3%). Only 1.6% of the TBI cases were documented in charts. Mortality at 2 years, length of stay in the hospital, and time to follow-up increased significantly from mild to severe TBIs. Concomitant TBIs were more common with skull and upper third fractures than CMF trauma without TBIs (81.8% versus 61.1%; P < 0.05).

CONCLUSIONS

Concomitant TBIs were present in a significant number of pediatric CMF trauma cases but were not documented for most cases. CMF surgeons should survey all pediatric CMF trauma patients for TBI and manage with neurology and/or neurosurgery teams. Future prospective studies are necessary to characterize and generate practice-guiding recommendations.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Clinical and radiographic predictors of the need for facial CT in pediatric blunt trauma: a multi-institutional study

Background

Facial injuries are common in children with blunt trauma. Most are soft tissue lacerations and dental injuries readily apparent on clinical examination. Fractures requiring operative intervention are rare. Guidelines for utilization of maxillofacial CT in children are lacking. We hypothesized that head CT is a useful screening tool to identify children requiring dedicated facial CT.

Methods

We conducted a multicenter retrospective review of children aged 18 years and under with blunt facial injury who underwent both CT of the face and head from 2014 through 2018 at five pediatric trauma centers. Penetrating injuries and animal bites were excluded. Imaging and physical examination findings as well as interventions for facial fracture were reviewed. Clinically significant fractures were those requiring an intervention during hospital stay or within 30 days of injury.

Results

322 children with facial fractures were identified. Head CT was able to identify a facial fracture in 89% (287 of 322) of children with facial fractures seen on dedicated facial CT. Minimally displaced nasal fractures, mandibular fractures, and dental injuries were the most common facial fractures not identified on head CT. Only 2% of the cohort (7 of 322) had facial injuries missed on head CT and required an intervention. All seven had mandibular or alveolar plate injuries with findings on physical examination suggestive of injury.

Discussion

In pediatric blunt trauma, head CT is an excellent screening tool for facial fracture. In the absence of clinical evidence of a mandibular or dental injury, a normal head CT will usually exclude a clinically significant facial fracture.

Level of evidence

III.

Head injuries in early childhood in the UK; is there a social gradient?

OBJECTIVES

To examine if there is a social gradient in early childhood head injuries among UK children.

METHODS

Cross-sectional study, using data from the UK Millennium Cohort Study (MCS). The second, third and fourth sweeps of the MCS were analysed separately, when children were 3, 5 and 7 years old. Logistic regression models were used to explore the associations between head injuries and family socioeconomic position (social class, household income, maternal education and area deprivation).

RESULTS

The unadjusted analyses showed different associations with socioeconomic indicators at different ages. At age 3 and 5 years, head injuries were associated with higher area deprivation, lower household income and parents not being in work or in the routine social class. At age 5 years head injuries were also associated with lower maternal education. At age 7 years only associations with area deprivation and maternal education were found. In adjusted analyses (mutually adjusted for all four socioeconomic indicators, maternal age, child age and child sex), the following associations were observed: at ages 3 and 5 years, higher levels of area deprivation were related to higher odds of head injuries. At age 3 years only, lower levels of maternal education were related to lower odds of head injuries. No social gradients were observed. At age 7 years, there were no significant associations between head injuries and any of the SEP measures.

CONCLUSION

We observed no social gradients in early childhood head injuries. However, at ages 3 and 5 years, head injuries were more frequently reported for children living in more deprived areas.

Patterns of pediatric cervical spine fractures in association with mandibular and facial fractures

OBJECTIVES

To determine the incidence, demographics, and outcomes of concurrent cervical spine (C-spine) fractures in pediatric facial trauma.

METHODS

The Kids' Inpatient Database (KID) from the 2016 Healthcare Cost Utilization Project (HCUP) was queried for various facial fractures using International Classification of Diseases Tenth Revision (ICD-10) diagnosis codes. Mandible fractures were further subdivided into fracture site. Patients aged 0-18 were included, and rates of C-spine fracture were analyzed with regards to demographic factors, length of stay, total charges, mortality rate, hospital characteristics, and concurrent facial fractures.

RESULTS

Of 5568 patients included, 4.18% presented with C-spine fracture. Children with C-spine fractures were significantly older (15.02 vs 12.76 years, p < 0.001) and length of stay was significantly longer (11.33 vs 6.44 days, p < 0.001). There was no difference in rate of C-spine fracture when stratified by gender, time of week/year, hospital location/type, or facial fracture other than subcondylar fractures. Subcondylar fractures were positively associated with C-spine fractures (OR 2.08, p = 0.002). C-spine fractures were associated with significantly higher mortality, length of stay, rate of tracheostomy, transfer out of index hospital, and total hospital charges.

CONCLUSIONS

A significant association exists between subcondylar mandible and C-spine fractures. Awareness of this information is vital for clinicians who manage pediatric facial trauma and alerts them to the need to rule out C-spine fractures in this group as these patients have significantly higher lengths of stay, total mean hospital costs, mortality and tracheostomy rates.

Traumatic Falls in the Pediatric Population: Facial Fracture Patterns Observed in a Leading Cause of Childhood Injury

PURPOSE

Falls are a leading cause of nonfatal injury in the pediatric population, resulting in numerous hospitalizations. Children may not have fully developed reflexive and balancing abilities, rendering them more susceptible to traumatic falls. Here the authors present their findings regarding patterns of facial fracture and concomitant injury seen in the pediatric population secondary to falls.

METHODS

A retrospective chart review was performed of all facial fractures as a result of falls in the pediatric population in a level 1 trauma center in an urban environment (University Hospital in Newark, NJ). Patient demographics were collected, as well as location of fractures, concomitant injuries, and surgical management strategies.

RESULTS

Fifty-five patients were identified as 18 years or younger and having sustained a facial fracture as the result of a fall. This cohort was compared with 418 pediatric patients with facial fractures due to nonfall etiologies. The mean age was 9.6 years (range, 0-18 years), with a male predominance of 67.3%. There were a total of 70 fractures identified on radiological imaging. The most frequently fractured bones were the orbit (n = 27), nasal bone (n = 15), and mandible (n = 11). Orbital and frontal sinus fractures each occurred more frequently due to falls compared with all other causes of injury. Patients with orbital fractures were significantly more likely to present with an additional facial fracture compared with those without (P < 0.01). The most common concomitant injuries were traumatic brain injury, skull fracture, and intracranial hemorrhage. Patients who suffered a facial fracture due to a fall were significantly more likely to sustain a concomitant skull fracture (P < 0.05) and intra-abdominal injury (P < 0.05) compared with all other etiologies. Fourteen patients required surgical intervention. One patient died.

CONCLUSIONS

Pediatric facial fractures are a unique entity. The general plasticity of the pediatric anatomy can predispose patients to significant injury without obvious external signs. A high level of clinical suspicion is required to avoid misdiagnosis and delay of treatment. The authors hope this study can address a preventable issue in child safety, educate caregivers, and provide insight towards fracture management that fosters functional and aesthetic recovery.

Assessment of Panfacial Fractures in the Pediatric Population

PURPOSE

Management of panfacial fractures is critical and often difficult in adults; however, there is little to no literature regarding these fractures in the pediatric population. In this study, we present our experience to provide insight and further investigation regarding prevention and management strategies within the pediatric population.

PATIENTS AND METHODS

We performed a retrospective chart review of all panfacial fractures in the pediatric population between 2002 and 2014 treated at an urban, level 1 trauma center (University Hospital, Newark, NJ). Data including patient demographic characteristics, mechanisms of injury, locations of fractures, concomitant injuries, and surgical management strategies were collected.

RESULTS

We identified 82 patients aged 18 years or younger who had sustained a panfacial fracture. The mean age at the time of injury was 12.9 years, with a male predominance of 64.9%. A total of 335 fractures were identified on radiologic imaging. The most common etiologies were motor vehicle accidents and pedestrians being struck. Orbital, frontal sinus, nasal, and zygoma fractures were the most common fractures. The mean score on the Glasgow Coma Scale on arrival was 12.0. A total of 29 patients were intubated on arrival-or before arrival-at the trauma bay. A surgical airway was required in 9 patients. The most common concomitant injuries were traumatic brain injury, intracranial hemorrhage, and skull fracture. Surgical repair was required in 38 patients. The cephalic-to-caudal approach was used most, followed by caudal to cephalic, medial to lateral, and lateral to medial. Within a year of the initial surgical procedure, 4 patients underwent reoperations for complications. Four patients died.

CONCLUSIONS

Pediatric panfacial fractures are rare occurrences; however, the impact of these injuries can be devastating, with concomitant life-threatening injuries and complications. Given the lack of literature, as well as the preventable nature of these injuries, we hope this study can address primary prevention strategies and provide insight toward the management and characteristics of these fractures.

Rattled: Analysis of Facial Trauma Among Toddlers

OBJECTIVE

The aim of this study was to determine the national incidence of facial trauma among toddlers and delineate patterns of injury and their causes.

METHODS

A retrospective review was designed to explore patterns of maxillofacial trauma within toddler-aged children using the National Electronic Injury Surveillance System from the Consumer Product Safety Commission. The database was searched for emergency department visits involving facial trauma sustained by children 12 months through 3 years of age from 2010 through 2014 and analyzed for patient demographics, primary diagnosis, and associated products/activities. Subset analyses were performed between age groups to determine the relationship between causes of injury and age using extrapolated national incidences.

RESULTS

A sample of 45,249 patients extrapolated to an estimated 1.3 million emergency department visits for facial trauma in toddlers from 2010 to 2014, averaging 260,000 annually. Injuries involving foreign bodies and fractures had a higher incidence in toddlers 2 years or older, and fractures comprised fewer than 1% of facial injuries in any age group. Furniture was the most common source of trauma overall, with a higher frequency among toddlers aged 12 to 17 months. Trauma in the setting of sports was more common in toddlers aged 3 years.

CONCLUSIONS

The low incidence of facial fractures further supports recommendations against routine imaging in toddler facial trauma and suggests that more focus should be placed on investigating for concurrent traumas and soft tissue injuries where fractures are involved. Our findings highlight prevention opportunities, particularly in furniture-related injuries for toddlers aged 12 to 17 months and sports-related traumas in toddlers aged 3 years. Our study also suggests restricting certain toys from 3-year-old toddlers to decrease the risk of aspiration.

Differences in the Management of Pediatric Facial Trauma

Craniofacial trauma is common in the pediatric population, with most cases limited to soft tissue and dentoalveolar injury. Although facial fractures are relatively rare in children compared with adults, they are often associated with severe injury and cause significant morbidity and disability. Initial evaluation of a child with facial trauma generally involves stabilizing the patient and identifying any severe concomitant injuries before diagnosing and managing facial injuries. The management of pediatric facial fractures is relatively more conservative than that of adults, and nonsurgical management is preferred when possible to prevent the disruption of future growth and development. Outcomes depend on the site of the injury, management plan, and subsequent growth, so children must be followed longitudinally for monitoring and the identification of any complications.

Analysis of Pediatric Maxillofacial Fractures Requiring Operative Treatment: Characteristics, Management, and Outcomes

Maxillofacial fractures in pediatric trauma patients require significant force and frequently are associated with concomitant injuries. The anatomic and developmental differences between the adult and child that impact patterns of injury also affect management and outcomes. The aim of this study was to analyze fracture location, mechanism, concomitant injuries as well as methods of surgical treatment and outcomes, to improve management of this patient population. A retrospective review was conducted of pediatric patients with maxillofacial fractures presenting to a level-1 trauma center during an 8-year span. Only patients requiring surgical intervention, 204, were included in this study. Data pertaining to the location of injury, mechanism, associated injuries, surgical treatment, outcomes, and complications were analyzed. The most common fracture location was the mandible (36.3%), then the nasal bone (35.3%), followed by the tripod fracture (10.8%). A total of 30.7% of patients were involved in motor vehicle accidents, with the next most common mechanisms being sports (24.4%), and assault (13.7%). A total of 46% of the patients sustained concomitant injuries, with the majority involving cerebral trauma (14.7%) or the extremities (9.3%). Total 75.4% of all fractures, excluding the nose, were treated with open reduction and internal fixation (ORIF). Our complication rate was 11.2%. Pediatric craniofacial trauma remains a frequent presentation to the emergency department of trauma centers. Facial fracture patterns and mechanism of trauma observed in the pediatric population presenting to this facility are consistent with incidences reported in the literature. Knowledge of treatment options and potential complications is an important tool in the management of the pediatric trauma patient.

Pediatric frontal sinus fractures: outcomes and treatment algorithm

Pediatric frontal sinus fractures are a rare clinical entity. Owing to the large amount of force required to fracture the frontal sinus, it is often associated with severe intracranial and craniofacial injuries. The treatment of frontal sinus fractures is controversial, with many different established algorithms based mainly on the adult population. The authors present their experience with pediatric frontal sinus fractures; they also present a treatment algorithm. A retrospective review of the Cincinnati Children's Hospital Medical Center trauma database was performed. From 1998 to 2010, the authors identified patients between the ages of 0 and 18 with frontal sinus fractures and analyzed demographics, fracture pattern, associated injuries, methods of treatment, and complications. Descriptive statistics and univariate analyses were performed.A total of 39 patients were included in the study with a mean follow-up of 31.2 months. Fractures of the anterior and posterior table with displacement greater than one table width were significantly associated with higher hospital costs, higher velocity mechanism of injuries, lower Glasgow Coma Scale scores, nasofrontal outflow tract (NFOT) involvement, and cerebrospinal fluid leak. There were no differences in short- and long-term complications. Additionally, these patients were more likely to be treated surgically in the form of obliteration or cranialization.Patients without NFOT involvement can be managed with observation only. Patients with NFOT involvement or persistent cerebrospinal fluid leak should be treated with obliteration or cranialization, respectively, to reduce the risk of severe complications.

Current management of facial fractures in the preadolescent

PURPOSE OF REVIEW

This article reviews the trends in management of preadolescent facial fractures - a challenging population because of the need to consider growth, dynamic changes in dentition, and evolving fracture patterns.

RECENT FINDINGS

Recent findings are a more thorough understanding of fracture patterns and distribution because of recent comprehensive studies isolating the preadolescent age cohort; the role of rigid internal fixation for significantly displaced fractures; and the potential applications and indications for the use of resorbable hardware for fracture fixation in the preadolescent.

SUMMARY

As preadolescent fractures occur in a period of growth and evolving dentition in the facial skeleton, it is mandatory for the treating surgeon to have a thorough knowledge of standard and alternative treatment options to optimally manage these patients.

Review article: Maxillofacial emergencies: Maxillofacial trauma

Fractures of the facial skeleton are a common reason for patients to present to EDs and general medical practice in Australia. Trauma to the maxillofacial region can lead to airway obstruction, intracranial injuries, loss of vision or long term cosmetic and functional deficits. This article focuses on the emergency assessment, triage and non-specialist management of traumatic injuries of the orbit and facial skeleton.

Emergency department visits with facial fractures among children and adolescents: an analysis of profile and predictors of causes of injuries

PURPOSE

The objectives of this study were to provide nationally representative estimates of hospital-based emergency department (ED) visits for facial fractures in children and adolescents, examine the burden associated with such visits, identify common types of facial fracture, and examine the role of patient-related demographic factors on the causes of facial fractures.

MATERIALS AND METHODS

The Nationwide Emergency Department Sample for 2008 to 2010 was used. All ED visits with a diagnosis of facial fractures in those no older than 21 years were selected. Demographic characteristics, types of facial fracture, causes of injuries, and hospital charges were examined.

RESULTS

During the study period, 336,124 ED visits were for facial fractures in those no older than 21 years. Late adolescents (18 to 21 yr old) and middle adolescents (15 to 17 yr old) comprised 45.6% and 26.6% of all ED visits, respectively. Male patients comprised 74.7% of ED visits. The most common facial fractures were those of the nasal bones and mandible. Younger children were more likely to have falls, pedal cycle accidents, pedestrian accidents, and transport accidents, whereas older groups were more likely to have firearm injuries, motor vehicle traffic accidents, and assaults (P < .05). Female patients were more likely to have falls, motor vehicle traffic accidents, and transport accidents, whereas male patients were more likely to have firearm injuries, pedal cycle accidents, and assaults (P < .05). Those residing at low annual income household levels were at a high risk for having firearm injuries, motor vehicle traffic accidents, and transport accidents (P < .05).

CONCLUSIONS

Late adolescents, middle adolescents, and male patients comprise a significant proportion of these ED visits. Age, gender, and household income levels are significantly associated with the causes of facial fracture injuries.

Primary and secondary management of pediatric soft tissue injuries

Injury is the most common cause of death in pediatric patients, with a large proportion related to head injury. The craniofacial region in children develops rapidly and at an early age, making the area more prominent compared with the remainder of the body, increasing the likelihood of injury. This article reviews the primary management of pediatric soft tissue injuries, including assessment, cleansing, surgical technique, anesthesia, and considerations for special wounds. The secondary management of pediatric facial injury is also discussed, including scar revision, management of scar hypertrophy/keloids, and staged surgical correction.