A 2-year-old child called Lucy is brought to your ED by ambulance. She was the right-sided rear seat passenger in a high-speed head-on road traffic collision. The driver of the other car died on impact. She was restrained in a car seat, however, the seatbelt holding the car seat in place had broken and the car seat was thrown forward. She had a 4-minute episode of loss of consciousness. She had a GCS of 14/15 on arrival, she was maintaining her airway and she was haemodynamically stable. She had significant swelling, bruising, and superficial abrasions to the right side of her face, and her right eye was swollen shut.
Facial injuries in children are relatively common. The most common facial injuries encountered in a paediatric population are dental trauma, oral trauma and facial lacerations. Facial fractures, however, are exceedingly rare in this population, with an incidence of <15% in those under the age of 16 years, and only 0.87% – 1% in those under the age of 5 years.
There are a number of factors which make children less prone to facial fractures. These include:
- Retruded position of the midface relative to the skull
- Structural stability increased by the presence of tooth buds within maxilla and mandible and lack of sinus pneumatisation
- A thick layer of adipose tissue coverage
- More elastic bones and flexible suture lines
- High level of adult supervision
These factors also make children more prone to greenstick and minimally displaced fractures as opposed to comminuted or complex fractures. These factors become less significant as the child grows older.
Common causes of facial fractures include falls, road traffic collisions, sports-related injuries and, less commonly, interpersonal violence. 2.3% of victims of non-accidental injury have facial fractures and the possibility of this should always be taken into account.
The presence of a midfacial fracture in a child implies that a significant velocity impact has occurred. 40% of children with a midfacial fracture have an associated skull fracture, and associated cervical spine injury is also common. The primary survey should be undertaken following APLS protocols, with particular attention paid to cervical spine immobilisation and airway management. A detailed craniomaxillofacial examination should be performed as part of the secondary survey, after initial stabilisation.
Fractures of different parts of the face will lead to different clinical signs.
Zygomatic arch and zygomaticomaxillary complex (ZMC)
The zygomaticomaxillary complex (ZMC) is made up of four parts:
- lateral orbital wall
- zygomatic-maxillary junction
- zygomatic arch
- orbital floor
An approach to the assessment of ZMC fractures includes:
- Inspect the orbit. There may be periorbital swelling or ecchymosis, enophthalmos, subconjunctival haemorrhage and diplopia (due to extraocular muscle dysfunction). The orbital examination should also include visual acuity, visual fields and extraocular muscle function.
- Palpate the facial bones. There may be a palpable depression or step in the infraorbital rim or zygomatic arch as well as tenderness or widening of the frontozygomatic suture.
- Oral assessment. There may be trismus (lock jaw) and bruising and tenderness of the upper buccal sulcus.
- Infraorbital nerve assessment, documenting any paraesthesia.
Maxillary fractures are classified according to the Le Fort classification system*
- Le Fort I: A horizontal fracture through the floor of maxillary sinuses with the teeth contained within the detached fragment. Only palate moves.
- Le Fort II: A fracture which can be one-sided or bilateral fracture through the maxilla extending into the floor of the orbit, the nasal cavity and hard palate. This results in a pyramidal shaped fracture.
- Le Fort III: A fracture through the orbits in which the entire maxilla and one or more facial bones, the entire midface, becomes separated from the base of the skull. This is called craniofacial disjunction.
*Rene Le Fort was a French physician at the turn of the 20th century. He discovered that the midface tended to fracture in three different ways when traumatising cadavers in quite gruesome, but scientifically important, ways.
Clinical signs of Le Fort fractures are much the same signs as for ZMC and zygomatic arch fractures but signs are, for the most part, bilateral. Facial asymmetry, flattening or elongation may be evident in older children.
Manage pain with non-pharmacologic and pharmacological measures. Oral and intravenous analgesia may be required but avoid intranasal analgesia in case of fracture.
Facial bone x-rays may give you some valuable information, but the caveat is that they can be difficult to interpret in children. If you have a high clinical suspicion of a facial bone fracture, a CT scan is the imaging modality of choice and can be argued to be the cornerstone of investigation for facial bone fractures in children.
A chest x-ray may be indicated to exclude aspiration of foreign bodies or dental fragments.
All fractures should be discussed with the local maxillofacial service and/or ophthalmology if orbital involvement is present. A formal ophthalmological review should be carried out as early as is feasible in children with any suspected midfacial fracture.
Most greenstick or minimally displaced fractures can be managed conservatively with soft diet, advice not to blow nose or hold nose closed while sneezing, antibiotic prophylaxis and a nasal decongestant.
There is no clear consensus on the best choice of antibiotic for facial fractures, and there is much variety among papers. The most commonly used would appear to be co-amoxiclav, cefuroxime, and clindamycin in penicillin-allergic patients.
Surgical intervention range from an intraoral approach for minimally displaced zygoma fractures to open reduction and internal fixation for comminuted fractures.
Potential complications, including mal/non-union, are less common in paediatric patients than in adults.
The do not miss bits
- Reduced or lost vision, severe eye pain or proptosis of the globe are all features of retro-orbital haemorrhage, an ophthalmological emergency which requires immediate surgical intervention to avoid permanent blindness.
- Although facial fractures are rare in children they have the potential to cause significant disruption to future growth, function & cosmesis and thus it is vital that they are recognised.
- It takes significant velocity to cause a facial fracture in a child, and examination & investigations must be thorough to identify any other potential injuries. Consideration should be given to the possibility of non-accidental injury when assessing a child with a facial fracture.
Lucy’s CT brain & c-spine showed no significant abnormalities. CT facial bones showed a minimally displaced fracture of the frontal process of the right zygoma. She was reviewed by ophthalmology & maxillofacial specialists & was treated conservatively with oral antibiotics with a soft diet until her fracture had healed.
Alcalá-Galiano A, Arribas-García IJ, Martín-Pérez MA, et al. Paediatric Facial Fractures: Children Are Not Just Small Adults. RadioGraphics. 2008; 28:441-461
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Braun TL, Xue AS, Maricevich RS. Differences in the Management of Paediatric Facial Trauma. Semin Plast Surg. 2017;31:118-122
Cole P, Kaufman Y, Hollier LH. Managing the Pediatric Facial Fracture. Craniomaxillofac Trauma Reconstruction. 2009;2:77-84
Kidd AJ, Beattie TF, Campbell-Hewson G. Facial injury patterns in a UK paediatric population aged under 13 years. Emergency Medicine Journal. 2010;27:603-606
Mundinger GS, Borsuk DE, Okhah Z, et al. Antibiotics and facial fractures: evidence-based recommendations compared with experience-based practice. Craniomaxillofac Trauma Reconstr. 2015;8(1):64–78
The Royal Children’s Hospital Melbourne.The Paediatric Trauma Manual. Maxillofacial Injury. https://www.rch.org.au/trauma-service/manual/maxillofacial-injury/