Pediatric craniofacial skeleton fractures can be challenging to manage. The patterns of trauma and the possible long-term growth disturbances, makes the clinical considerations and treatment approach unique. This chapter describes the common facial fractures in the growing child, and the recommended treatment.
54 Facial Trauma in Pediatric Patient
Facial injuries in children are relatively rare compared with adults. 1 , 2 This relatively low incidence is related to anatomic reasons on one hand, such as facial bone flexibility, the lack of paranasal sinuses pneumatization, and the protection of the buccal fat pad in infants, and environmental reasons on the other hand, such as parents’ close supervision, and “child friendly environment.” Later in childhood, when involvement at school and playground rises, children become more vulnerable to facial trauma, and therefore the incidence of facial trauma increases. 3 , 4
During the past few decades, there have been considerable advances in the diagnosis and treatment of craniofacial injuries. Diagnosis improved by using new imaging techniques, with computer tomography (CT) availability, which provides better understanding of fracture complexity using three-dimensional reconstruction. 5 , 6 The introduction of rigid internal fixation has changed the treatment outcomes, allowing reduction and fixation of bone fractures, without the need for long period of maxillomandibular fixation (MMF).
The management of pediatric maxillofacial fractures is complex. In a growing patient, soft tissue and periosteal injury, both because of the trauma itself, as well as for fracture exposure and fixation reasons, may cause scarring and possible growth disturbances. Moreover, fracture mobilization, reduction, and fixation (with hardware) may also alter future growth of the facial skeleton. 2 , 7 , 8 , 9
The presence of tooth buds inside the jaws reduces the available bone for fracture fixation. The relatively small, sometimes mobile deciduous teeth do not retain wires as good as permanent dentition due to its shape (with minimal undercut area needed for the wire retention). Children’s comprehension of their situation may be also problematic, and MMF (with the mouth wired shut) is not tolerated well in the pediatric population. 10
However, malocclusion problems can be compensated by growth of the patient, and fractures tend to heal much quicker in children. Longitudinal follow-up is mandatory in this population, in order to identify, treat, and avoid any possible complications or growth disturbances.
In the past, and to some degree today, the management of pediatric maxillofacial trauma was relatively more conservative, with nonsurgical management preferred sometimes to prevent disruption in growth and development of the growing child. However today, with the increasing use of rigid fixation techniques, displaced fractures can be reduced accurately and fixated with rigid fixation (screws and plates), avoiding the usage of MMF. 10
This chapter describes common fracture types in pediatric maxillofacial trauma, and their treatment, as recommended by the authors. Dentoalveolar fractures and dental trauma are not discussed in this chapter. It is beyond the scope of this chapter to describe all fracture subtypes and all possible treatment plans. The reader should bear in mind that each patient is unique, and the treatment plan should be tailored to a specific case.
54.2 Growth and Development
In early life, facial development is closely linked to the functional demands of the growing child.
The cranial vault (neurocranium) develops through intramembranous bone ossification, and grows rapidly in the first year of life as the brain tissues expand. Head circumference reaches about 86% by the first year of life, and 90% of its adult size by the age of 3 to 5 years. Growth of the cranial vault reaches a plateau by the age of 5 to 7 years. The cranium width further develops until the age of 14 years in girls and 15 years in boys. 5 , 6 , 9 , 11
The skull base is the junction between the cranial vault and the facial skeleton. It is formed mainly by endochondral ossification. It includes the structures of the brain, orbits, and olfactory system and expands in the synchondrosis areas of the frontal, sphenoid, ethmoid, and occipital bones. Once ossified, the inner and outer surfaces of each bone extend their growth and remodel through appositional growth. 7 , 12 , 13
The orbit consists of both cranio-orbital and nasomaxillary complexes. Most of the growth occurs at the sutures between these bones. As in the growth of the neurocranium, so do the orbits rapidly grow through the first year of life and reaches its adult volume by the age of 5 to 7 years. Intercanthal width is about 93% of its adult size by the age of 5 years, and is fully mature by 8 years of age in girls and 11 years of age in boys. 7 , 13
Zygomatic bones’ growth is more gradual compared to the cranium. The bizygomatic width reaches 83% of its mature size by the age of 5 years, and its final maturation is at 13 years in girls and 15 years in boys.
The maxillary growth is by intramembranous ossification, with forward and downward suture growth and surface remodeling. Its final maturation is at 13 years in girls and 15 years in boys.
The mandible is unique by having different areas of bone growth. The temporomandibular joint (TMJ) is formed by endochondral ossification, whereas the other parts of the mandible are formed by remodeling and apposition of bone. At the end of the first year, symphysial cartilage is replaced by bone. During the coming years, appositional growth occurs on the posterior border of the ramus and on the alveolar ridge, while resorption occurs along the anterior border of the ramus. Condyles grow upward and backward to maintain contact with the skull base.
Mandibular width is reached by the age of 1 year; however, its height is not complete until the teenage years. Mandibular depth (anterior posterior position) is 85% complete at the age of 5 years. Its mature dimensions are not final until 14 to 16 years in girls and 16 to 18 years in boys.
As the child is growing, the cranium-to-face ratio becomes less prominent. 10 – 12 The cranium-to-face ratio is about 8:1 in infancy and becomes around 2.5:1 in adulthood (▶ Fig. 54.1).
This is the main reason for higher incidence of cranial trauma in early childhood, and increasing incidence of midface and mandibular fractures with decreasing cranial trauma as the child grows up. Other well-accepted reasons for the low incidence of fractures in the early childhood are the retrusive position of the midface, the gradual pneumatization of the paranasal sinuses, and the elasticity of the child’s facial bones.
The theory of functional matrix growth (Moss 1960) has gained general acceptance. It proposes that “origin, growth and maintenance of skeletal units are always secondary, compensatory and mechanically obligatory responses to prior events and processes occurring in related non-skeletal tissues, organs and functional spaces.” Facial bones grow in response to the expansion of the cranium and development of the facial masticatory and oropharyngeal apparatus. Therefore, scar tissue, traumatically or surgically induced, can restrict further skeletal growth in the growing child. Surgical attention should be addressed to avoid scar formation and allowing normal function, in order to maintain functional growing tissue.
Facial trauma comprises up to 11% of pediatric emergency department visits, and about 4% of pediatric trauma admissions. 13 Out of all maxillofacial fracture patients, children younger than 17 years old comprise about 14% of patients. However, most of the emergency department visits are related to soft tissue or dentoalveolar injury.
The proportion of patients with facial fractures increases substantially with age, with the peak in the age group of 6 to 12 years. Fractures in children younger than 5 years are rare with rate of up to 1.4%. 9 The risk to sustain facial fracture in a child increases by 14% with every year of age.
The etiology of trauma changes with age, but the most common causes are sport injuries and falls. The various etiologies depend on the age groups examined. Young children sustain injuries from low-velocity forces like falls, while older children are more exposed to high-velocity forces like road traffic accidents and sports injuries. 8 , 9 , 12 , 14 – 15
Male gender also increases the likelihood of maxillofacial trauma. Boys are twice more injured than girls (2:1 ratio). This is related to more participation in sports events, and a tendency in attending dangerous activities. 7 , 16 , 17
Fracture sites change with different age groups. Nasal fractures and dentoalveolar fractures are the most common facial fractures in children, but are not reported as frequently as expected, because most of these fractures can be treated on an outpatient basis, and therefore these fractures are under-reported in the hospital and admission statistics. Mandibular fractures are the most common facial fractures reported in hospitalized children. Their incidence increases with age. Zygomatic complex fractures and orbital fractures are the next prevalent fracture type, whereas midface and Le Fort fractures (at all levels) are uncommon, and can occur in children of 13 to 15 years of age. Orbital roof fractures and cranial vault fractures occur in young children, with undeveloped frontal sinus, usually before the age of 7 years, because of the relatively prominent frontal bone. 16 , 18 , 19
54.4 Preoperative Evaluation
As in every trauma patient, life-threatening injuries should be addressed first, before treatment of the facial injury. Advanced trauma life support algorithm should be used. The small size of the face relative to the cranium usually indicates that whenever facial trauma occurs, it is probably caused by high-energy impact. It has been found that up to 57% of children younger than 5 years of age with facial fractures have concomitant intracranial injury, whereas concomitant cervical spine injury is less likely (0.9–2.3%). 2 , 9 , 18 , 20
Airway maintenance, bleeding control, and early resuscitation in children are very important due to the higher metabolic rate, oxygen demand (with less oxygen reservation), and lower blood volume and stroke volume. Intubation is preferred in all cases of airway compromise. Cricothyroidotomy is contraindicated in children less than 12 years of age, because of the risk of subglottic stenosis. Hypothermia in resuscitation of trauma in children is common, so elevation of room temperature, warmed normal saline for intravenous use, and warming devices are recommended. As for IV access which may be difficult in children, intraosseous access can be a good alternative. Blood transfusion and fluid resuscitation should be considered for possible volume loss. Maintenance fluids in babies are usually one-quarter normal saline with dextrose, and one-half normal saline for older children and teenagers. Urine output should be around 1 to 2 mL/kg/h. 7 , 12 , 14
Assessment of craniofacial injury begins with history and physical examination. However, sometimes an adult may not have witnessed the trauma, and obtaining history from a child can be very difficult. Moreover, physical examination may be compromised because of poor cooperation, especially shortly after experiencing a traumatic injury.
A comprehensive thorough facial physical examination is mandatory. The examination should start from the scalp and proceed in a systematic fashion to the lower face and neck. Special focus should be addressed to facial lacerations, orbital exam, sensory disturbances, bone stability and step-offs, and occlusion of the teeth. Orbital examination should include pupils’ reactivity, visual acuity, extraocular muscle function, possible diplopia, and assessment of exophthalmos and hypoglobus. In case of questionable extraocular muscle restriction, forced-duction test should be considered; however, the exam cannot be performed when the child is awake, so consider doing it when the child is under sedation for imaging purposes or before definitive treatment. Children with orbital injury may also experience pain with eye movement, nausea, vomiting, and bradycardia. Bony step-offs of the orbits should be palpated, in addition to malar bone prominence evaluation and zygomatic arch continuity, in order to assess for zygomatico-maxillary fractures. Paresthesia of cranial nerve V distributions can suggest for possible fracture, with V1 (ophthalmic) suggestive for possible frontal fracture, V2 (maxillary) for orbital floor and zygomatico-maxillary fracture, and V3 (mandibular) for mandibular body or angle fracture. Intraoral examination should evaluate the dentition and occlusion, possible fractured teeth or alveolar bone fractures with malocclusion and inability to close the teeth, different than premorbid occlusion. Any hemorrhage should alert for possible adjacent fracture, such as sublingual hematoma as a sign for mandibular fracture, and palatal hematoma for maxillary or palatal fracture.
Plain radiographs are no longer the selected imaging modality, as the CT scan has become the standard of care in pediatric population. 21 The plain films are unreliable in pediatric trauma because of the undeveloped sinuses, incompletely ossified areas, potential green stick fractures, possible soft tissue entrapment, and the developing teeth buds. The CT scan is quick, provides good resolution, and the radiation dose decreases as technology improves. Sometimes, especially in young children, sedation or general anesthesia is essential for the CT scan.
This chapter will discuss different fracture types in the pediatric population and the recommended treatment. It is beyond the scope of this chapter to discuss multiple fractures treatment or panfacial trauma in children.
54.5 Fractures Sites and Surgical Treatment (by Fracture Site)
54.5.1 Frontal Bone, Frontal Sinus, and Superior Orbital Fractures
In the years of infancy, there is rapid expansion of the cranial vault and skull base. As this process proceed, the nonpneumatized frontal sinus (before the age of 6 years), and the relative prominent frontal bone and superior orbital rim, orbital roof fractures are more common in children younger than 10 years of age (▶ Fig. 54.2). These fractures are cranial fractures, and as such, neurosurgical and ophthalmologic evaluation is mandatory. It can also involve the globe and lead to muscle entrapment, exophthalmos, and in severe cases even to direct globe injury. 22 – 24
In general, indications for frontal and orbital roof fracture reduction include possible ocular involvement, and a fracture displaced more than full-thickness width of the bone involved. Ocular muscle entrapment can result in increased ocular pressure, diplopia, exophthalmos, and in severe cases even in superior orbital fissure syndrome. Fracture displaced more than full-thickness width can result in future esthetic concerns. Surgery should be coordinated with neurosurgeons to evaluate possible dural tear, CSF leak, or brain injury. The patient should have long-term neurosurgical follow-up because of the possibility of future brain herniation to the site of dural tears (and sometimes may need cranioplasty).
As the child grows up and the frontal sinus develops (after the age of 6 years), frontal sinus fractures are more common. Treatment indications and approach are the same as in adults. For posterior table fractures, if there are dural tears (with possible CSF leak), it should be treated by cranialization. It is important to seal the anterior cranial fossa to minimize the risk for postoperative meningitis. For displaced anterior table fractures, simple reduction and stabilization can be performed. This can be performed through an existing incision, or through a coronal flap. Minimally displaced anterior table fractures that will probably have no aesthetic concern can be treated with observation only. Significant disruption of the nasofrontal duct will mandate intervention. Sinus obliteration is generally avoided in children. With the new endoscopic technologies, preservation of the sinus is preferred, with regular follow-up visits and imaging as needed, in order to assure proper sinus function.
Step by Step: Superior Orbital Roof Fracture
Evaluation—Is there an indication for fracture reduction: fracture displacement more than full-thickness width, ocular involvement, increased ocular pressure, or neurosurgical brain involvement?
Surgical approach—If laceration exists in the area of the fracture, try using it (extend as needed). If the fracture is on the mid-to-lateral side of the rim, use supraorbital eyebrow or upper eyelid approach. If neurosurgical intervention is also needed or fracture cannot be approached through the above incisions, coronal flap should be considered.
Fracture reduction and fixation.
Follow-up (including neurosurgery follow-up).