Missed or inappropriately treated facial fractures may result in permanent facial deformity in the growing child. A child with severe maxillofacial injury requires a team approach involving emergency physicians, pediatricians, general surgeons, maxillofacial specialists, and radiologists. Emergency specialists must recognize and prioritize injuries, provide emergent management of complications and associated injuries, interpret radiographic studies, make appropriate consultations, and ensure safe transitions of care.

Pediatric facial fractures are relatively rare but important injuries. Craniofacial trauma accounts for 12.3% of pediatric ED visits but only 1% to 15% of all craniofacial injuries.¹ In a study of the National Trauma Data Bank from 2001 to 2005, the most common mechanisms for facial fracture were motor vehicle collisions (55.1%), violence (11.8%), and falls (8.6%);² facial fractures occurred in 4.6% of admitted patients, and 25% of these fractures required operative intervention.²

The frequency and mechanisms of facial skeletal injury vary with age. Nasal and maxillary fractures occur most commonly in infants and toddlers aged 0 to 1 year, and mandible fractures occur most commonly in adolescents aged 15 to 18 years. Young children demonstrate fractures from falls and low supervision, and older children are associated with sports-related or violent injuries.³ Facial fractures occur in less than 1% of children under the age of 5 years.⁴ Young children rarely present with severe facial trauma, and nonaccidental injury should be considered if this occurs. Sports-related craniofacial injuries comprise one-third of all pediatric facial fractures.^6,7 Sports-related mechanisms peak between ages 13 and 15 years.⁸ Violent injuries also become more prevalent in adolescence, with estimates ranging from 11.8% to 12.4% of pediatric facial fractures.^2,9 Teen violence most commonly results in nasal or mandible fractures.⁹ Comminuted fractures are rare except with gunshot wounds.¹⁰ These patterns of injury help physicians identify patients requiring a more thorough assessment.

The unique developmental features of the growing face create unique injury patterns in children.¹¹ The cranial-to-face volume ratio is only 8:1 at birth, compared to 2.5:1 at adult maturity.¹¹ As a result of the small midface, intracranial injuries are more common and facial fractures are rare.¹¹ The prominent foreheads and small, flat facies of young children lead to fewer facial fractures.¹² When fractures do occur, the upper third of the face is most at risk.¹³ Greenstick fractures occur more commonly secondary to the high ratio of cancellous to cortical bone.^6,14,15 Comminuted fractures are extremely rare except with gunshot wounds.¹⁰ In addition, the larger facial fat pads and the unerupted teeth of the mandible and maxilla impart stability.⁴ Overall, pediatric bones confer increased elasticity and more resilience against fractures.¹²

Aerated sinuses absorb force in injury and protect against propagation of the fractures into the skull.¹⁶ The paranasal sinuses, however, weaken the facial skeleton. This helps to explain why LeForte fractures are uncommon in pediatrics and are almost never seen before age 2. Newborns technically have paranasal sinuses, mainly ethmoid, but with minimal development.¹¹ The maxillary sinuses pneumatize by 1 year of age but are not functional until 8 years.¹³ As a result, superior orbital rim fractures are more common in younger children, as orbital floor fractures do not occur until the maxillary sinus becomes aerated. The frontal bone begins pneumatization last, at around 2 years of age, but is not recognized radiographically until age 8.¹⁷ Frontal sinus fractures are rarely seen until adolescence for this reason.

The intricate growth centers of the pediatric face and the complexities of surgical repair produce unique complications. Long-term sequelae include damage to growth centers, fracture malposition, iatrogenic complications during surgical repair, and soft-tissue scarring.¹⁷ Each type of fracture has its own unique complications that are discussed with the specific injury types below. Important associated injuries with all facial skeletal injuries include skull fracture, soft-tissue injuries, significant midface bleeding, dentoalveolar injuries, cervical spine injury, intracranial injury, and blunt cerebrovascular accident.^2,4

The prevalence of concomitant intracranial trauma warrants discussion. Up to 47% of all pediatric patients with facial fractures and 55% of seriously injured children with facial trauma have intracranial injury.^18,19 More than half of children under the age of 5 years with a facial fracture will have an intracranial injury.¹¹ Depressed Glasgow Coma Scale (GCS) and loss of consciousness at the time of injury are strongly associated with both intracranial hemorrhage (ICH) and cervical spine fractures.²⁰ Concussion is estimated to occur in nearly one-third of pediatric patients with facial fracture.²¹ Concussion precautions should be considered in patients discharged with facial fractures.

First address life-threatening complications of facial injury. Airway obstruction, while rare, poses the greatest complication from facial trauma to the mid or lower face. When appropriate, use simple maneuvers, such as chin-lift jaw thrust, oropharyngeal suctioning, and oral or nasal airway for immediate benefit.¹⁸ Open the mouth and look for displacement of the tongue; if recognized, pull the tongue forward either manually or with a large suture or towel clip.

Some patients may require orotracheal intubation with in-line immobilization to protect the airway. Anticipate a difficult intubation with a team assembled that can rapidly escalate airway management maneuvers. In rare circumstances, the team must establish an airway surgically. As a conservative recommendation, avoid emergency cricothyroidotomy in children younger than 12 years.²² Some consider surgical cricothyroidotomy in children as young as 8 years of age. This depends, however, on the size and unique anatomy of the individual child. Percutaneous transtracheal jet ventilation provides a temporizing measure when a surgical airway is not possible (see Chapter 23). Emergency tracheostomy results in fewer long-term complications, but requires expertise that may not be urgently available at all centers.

Severe bleeding into the oropharynx mandates rapid reversal and resuscitation. In children at low risk for cervical spine injury, allow the child to sit up and lean forward. Uncontrolled bleeding into the pharynx may require intubation to facilitate aggressive efforts to stop bleeding, such as oropharyngeal packing. A three-step approach is recommended to control midface bleeding in rare cases when direct pressure fails.¹² First, place anterior and posterior nasal packing. Next, repair lacerations and immediately attempt fracture reduction, if required. Finally, attempt arterial embolization.¹²

The emergency physician has three goals when assessing facial trauma: (1) Assess the stability of the airway and manage hemorrhage. (2) Diagnose any fractures suggested by the mechanism and physical findings. (3) Look for associated injuries within the head and neck such as ICH and cervical spine injury.

The emergency management of the patient with an unstable airway or ongoing hemorrhage is discussed under emergency management. To diagnose possible facial fractures, determine the age of the patient and mechanism of injury, and inspect the face for signs of facial fracture. Such signs include facial swelling, ecchymosis, deformity, asymmetry, trismus, and malocclusion. Inspect the child’s head looking down or examine the chin looking up to reveal otherwise unappreciated asymmetries. Palpate the entire face symmetrically starting with the skull and inferior to the mandible to assess for subtle step-off or crepitus.¹⁵

Complete ocular examination is important in periorbital trauma to exclude globe injury (see Chapter 97). Evaluate the eyes for the pupillary light reflex, hyphema, subconjunctival hemorrhage, proptosis, enophthalmos, and intact extraocular motions. Retract the lids to visualize the globe and document visual acuity. Include an assessment for diplopia, extraocular movements, pupil height and reactivity, and visual acuity in a complete assessment of the orbit.¹¹ Periorbital ecchymosis may be an important clue to injury. Raccoon’s eyes secondary to basilar skull fracture usually occur 4 to 6 hours after a traumatic event, whereas direct trauma to the periorbital region may result in more immediate bruising. Palpate the entire orbital rim for tenderness or deformity. Anesthesia above or below the eye may indicate supraorbital or infraorbital nerve injury in conjunction with fractures.¹⁸ Telecanthus, an increased width between the medial canthi of the eyelids, with flattening of the medial canthus is associated with nasal ethmoidal injury. In this situation, the medial canthal ligaments are torn or underlying bone is avulsed from the nasal orbital complex (Fig. 29-1). Subcutaneous emphysema about the eyes and maxillary area indicates a communication with a sinus or nasal antrum and may erupt when the child blows his or her nose.

Examination around the ear reveals important findings. Examine the pinna for presence of subperichondral hematoma. Ecchymosis over the mastoid area, known as a battle sign, appears several hours after basilar skull fracture. Temporal bone fracture presentations include hearing loss, vertigo, balance disturbances, dizziness, tinnitus, hemorrhagic otorrhea, facial weakness including Bell’s palsy, and battle signs.²³ The presence of hemotympanum should also raise suspicion for both basilar skull fractures and temporal bone fractures. Tympanic membrane rupture may occur with mandibular condyle fractures. Examine the ear canal for lacerations and inspect the patient for leaking cerebrospinal fluid (CSF). The β2-transferrin assay is the best test to distinguish CSF from nasal secretions, blood, or ear drainage: detection of β2-transferrin confirms a CSF fistula with specificity near 100% and sensitivity of 91%.^24,25 This is a send-out laboratory test for many hospitals. A simple test from the ED is the glucose concentration of the liquid in question. CSF will contain glucose, whereas mucus will not.

Palpate the nose and midface for key findings. Examine the nose for crepitus and deformity, as edema may obscure bony anatomy. A septal hematoma appears as a bluish, bulging mass on the septum, or by the subjective impression of an abnormally wide septum (Fig. 29-2). ­Pressure with a cotton swab will detect the presence of a soft, doughy swelling.¹⁵ LeForte fractures are extremely rare in children. Carefully palpate the zygomatic arches simultaneously to detect flattening of the arch. Intraoral palpation of the arch may help detect minimally displaced LeForte fractures. LeForte III fractures produce elongation of the midface. LeForte fractures may also be identified by manipulation of the central maxillary arch. Grasp the central maxillary arch above the central incisors and attempt to mobilize the midface. Finally, injury of the inferior orbital nerve or inferior alveolar/mental nerve produces anesthesia of the upper or lower lip, respectively, from fracture of the bony canal or direct nerve contusion.