Pediatric Facial Fractures: Rebaked Morsel

Ped EM Morsel fans and aficionados, welcome to Rebaked Morsels! Now with >580 Morsels, it was time to start adding some extra flavor and spic to some prior Morsels. I have been fortunate to “hire” (or gently persuade with senses of allegiance and guilt) some additional bakers to help me. Today, we are joined by master baker, Dr. Alison Rosser, one of our fabulous Ped EM Fellows at Carolinas Medical Center! Since it currently feels like summer in Charlotte, NC, we know “Trauma season” will be upon us soon once again (does it ever really end?). While kids are not aliens, they are a special population of patients and often require some additional attention. Any good baker knows that not all doughnuts are created the same, but before you reflexively toss that pediatric patient with facial trauma into the “doughnut of truth” let us reconsider pediatric facial fractures, how anatomy changes as children age, and finish with the Shakespearian question of “to scan or not to scan”.

Facial Fractures: Basics

  • Facial Fractures occur less frequently in children than adults.
    • Children account for ~15% of all facial fractures [Grunwaldt, 2011]
  • Occurs as the result of motor vehicle accidents, sports, falls and violence [Alcala-Galiano, 2008, Grunwaldt, 2011
    • ~2.3% of facial fractures are the result of child maltreatment [Ryan, 2011]
    • Always consider the possibility of child abuse
  • Often caused by severe traumatic mechanisms in conjunction with other associated injuries (~88%) [Alcala-Galiano, 2008, Ferreira, 2016]
    • Mid-face fractures are associated with intra-cranial and cervical spine injuries [Hoppe, 2014]

Facial Fractures: Changing Anatomy

  • Bone and Soft Tissues
    • Pediatric patients have protection from injuries in the form of fat pad cushioning, flexibility within the bones and compliant sutures [Braun, 2017]
  • Skull-to-Face ratio [Braun, 2017]
    • Protrusion of frontal skull of young children “protects” face from impact 
    • As children age, their face grows both forward and downward, exposing the mid face to injury
  • Sinus Development [Alcala-Galiano, 2008]
    • Prior to pneumatization of sinuses, the bone is more resistant to stress
    • As pneumatization occurs:
      • Ethmoids → maxillary → sphenoid → frontal 
      • The sinuses are more likely to fracture, but also provide cushioning (dissipation) of force
  • Dentition
    • Un-erupted teeth add strength to the maxilla and mandible. [Alcala-Galiano, 2008]

Facial Fractures: Types

  • Orbital Fractures [Alcala-Galiano, 2008]
    • After development of frontal sinus (~6-7 years), the medial and lateral walls and floor of the orbit are more susceptible to traumatic stress
    • Evaluate for globe injuries
    • Look for orbital blowout fracture! [Joseph, 2011]
      • Physical examination findings:
        • Diplopia
        • Decreased extra-ocular movements
        • May see enophthalmos with large defects
      • Check for entrapment
        • Limitation of extra-ocular movements
          • Sometimes this is difficult to discern even in cooperative adults, let alone squirmy children! 
        • Oculocardiac reflex  [Brasileiro, 2020, Arnold, 2021]
          • Increased muscle tension on extra-ocular muscles elicits vagal-mediated response
          • Have patient look upwards while connected to the monitor 
          • Reflex bradycardia of ~20% with upward gaze if entrapment present 
  • Frontal Skull
    • More commonly seen in younger children due to large size of forehead
    • Look for associated cranial injuries [Alcala-Galiano, 2008]
  • Midface
    • Rare in young children but frequency increases as children develop maxillary sinuses and permanent teeth
    • Zygomatic fractures
      • Often are non-displaced or greenstick fractures [Braun, 2017]
  • Le Fort = Complex Naso-Orbital
    • Very rare in children, but carry significant morbidity if not properly treated

To Scan Or Not To Scan

  • Do children need a dedicated facial CT scan in evaluation for facial fractures?  [Nguyen, 2022]
    • No validated clinical tool to guide need for facial CT.
    • Argument against:
      • Increased ionizing radiation exposure
      • Vast majority of fractures are managed conservatively
      • Most children with severe traumatic mechanisms will get non-contrast CT scan of head
        • In this study 89% of facial fractures were visualized on CT head
          • Fractures missed were minimally-displaced nasal bone fractures, mandibular fractures and dental injuries
            • All mandibular and dental injuries had significant physical examination findings 
  • Pay careful attention to your HEENT physical examination in trauma patients!

Moral of the Morsel

  • Risk with Age: In the beginning, the Face is Protected, but age exposes the face to injury!
  • Often with other problems! Look for other associated injuries! 
  • A cool party trick! Use the oculocardiac reflex if concerned for orbital entrapment!
  • Just having a face doesn’t mean you need a Face CT! Consider the need for dedicated facial CT after a careful history and physical examination
  • Alcalá-Galiano A, Arribas-García IJ, Martín-Pérez MA, Romance A, Montalvo-Moreno JJ, Juncos JM. Pediatric facial fractures: children are not just small adults. Radiographics. 2008 Mar-Apr;28(2):441-61; quiz 618. doi: 10.1148/rg.282075060. PMID: 18349450.
  • Arnold RW. The Oculocardiac Reflex: A Review. Clin Ophthalmol. 2021 Jun 24;15:2693-2725. doi: 10.2147/OPTH.S317447. PMID: 34194223; PMCID: PMC8238553.
  • Brasileiro BF, Sickels JEV, Cunningham LL. Oculocardiac reflex in an adult with a trapdoor orbital floor fracture: case report, literature review, and differential diagnosis. J Korean Assoc Oral Maxillofac Surg. 2020 Dec 31;46(6):428-434. doi: 10.5125/jkaoms.2020.46.6.428. PMID: 33377469; PMCID: PMC7783186.
  • Braun TL, Xue AS, Maricevich RS. Differences in the Management of Pediatric Facial Trauma. Semin Plast Surg. 2017 May;31(2):118-122. doi: 10.1055/s-0037-1601380. PMID: 28496392; PMCID: PMC5423796.
  • Grunwaldt L, Smith DM, Zuckerbraun NS, Naran S, Rottgers SA, Bykowski M, Kinsella C, Cray J, Vecchione L, Saladino RA, Losee JE. Pediatric facial fractures: demographics, injury patterns, and associated injuries in 772 consecutive patients. Plast Reconstr Surg. 2011 Dec;128(6):1263-1271. doi: 10.1097/PRS.0b013e318230c8cf. PMID: 21829142.
  • Ferreira PC, Barbosa J, Braga JM, Rodrigues A, Silva ÁC, Amarante JM. Pediatric Facial Fractures: A Review of 2071 Fractures. Ann Plast Surg. 2016 Jan;77(1):54-60. doi: 10.1097/SAP.0000000000000346. PMID: 25275475.
  • Hoppe IC, Kordahi AM, Paik AM, Lee ES, Granick MS. Examination of life-threatening injuries in 431 pediatric facial fractures at a level 1 trauma center. J Craniofac Surg. 2014 Sep;25(5):1825-8. doi: 10.1097/SCS.0000000000001055. PMID: 25203578.
  • Joseph JM, Glavas IP. Orbital fractures: a review. Clin Ophthalmol. 2011 Jan 12;5:95-100. doi: 10.2147/OPTH.S14972. PMID: 21339801; PMCID: PMC3037036.
  • Oleck NC, Dobitsch AA, Liu FC, Halsey JN, Le TT, Hoppe IC, Lee ES, Granick MS. Traumatic Falls in the Pediatric Population: Facial Fracture Patterns Observed in a Leading Cause of Childhood Injury. Ann Plast Surg. 2019 Apr;82(4S Suppl 3):S195-S198. doi: 10.1097/SAP.0000000000001861. PMID: 30730318.
  • Nguyen BN, Edwards MJ, Srivatsa S, Wakeman D, Calderon T, Lamoshi A, Wallenstein K, Fabiano T, Cantor B, Bass K, Narayan A, Zohn R, Chess M, Thomas RD. Clinical and radiographic predictors of the need for facial CT in pediatric blunt trauma: a multi-institutional study. Trauma Surg Acute Care Open. 2022 Apr 24;7(1):e000899. doi: 10.1136/tsaco-2022-000899. PMID: 35529807; PMCID: PMC9039460.
  • Ryan ML, Thorson CM, Otero CA, Ogilvie MP, Cheung MC, Saigal GM, Thaller SR. Pediatric facial trauma: a review of guidelines for assessment, evaluation, and management in the emergency department. J Craniofac Surg. 2011 Jul;22(4):1183-9. doi: 10.1097/SCS.0b013e31821c0d52. PMID: 21772215.
  • Wong FK, Adams S, Coates TJ, Hudson DA. Pediatric Facial Fractures. J Craniofac Surg. 2016 Jan;27(1):128-30. doi: 10.1097/SCS.0000000000002185. PMID: 26674891.
Ali Rosser
Ali Rosser
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