2015 HSC Section 1 Book of Articles

Facial Fractures in Children

ranges from less than 1% to 5%. 16,19 It has been reported that the risk of a child with facial trauma to sustain a fracture of the facial skeleton increases by 14% with every year of age. 13 The cause of pediatric facial fractures also changes with age, but most are related to falls or recreational sports. 13,20 However, motor vehicle accidents are the most com- mon cause of severe facial fractures or fractures in those children with multisystem in- juries. 18 It should also be noted that craniofacial injuries are commonly seen in cases of child maltreatment. 21 Male gender also increases the likelihood of facial trauma, with boys outnumbering girls almost 2 to 1. 13,22 It is thought that increased participation in sporting activities or a tendency toward dangerous activities may be responsible for this difference. Inter- personal violence, which is a common cause of maxillofacial fractures in adults, is less common; however, its incidence increases in the teenage population. 23 The most common site of injury varies according the study population. Becausemost studies are conducted based on data from trauma databases or from patients seen at trauma centers, many minor, isolated fractures are likely underreported, such as den- toalveolar and nasal bone fractures. Imahara and colleagues 18 examined the National Trauma Data Bank and found the most common pediatric fractures to be mandible (32.7%), nasal bone (30.2%), and maxilla/zygoma (28.6%). Mandible fractures were found more commonly in teenagers. 18 Grunwaldt and colleagues 14 examined the frequency of fractures seen at their emergency room based on age group. In 0 to 5 year olds and in 6 to 11 year olds, orbital fractures were the most commonly seen frac- tures. 14 However, in 12 to 18 year olds mandible fractures were the most common. 14 The initial evaluation of a child sustaining facial trauma is to confirm and maintain adequate airway, breathing, and circulation, just as in an adult patient. However, a child’s airway is much smaller and therefore can be more prone to airway compromise from swelling or bleeding. Furthermore, children have lower blood volumes and can quickly lose hemodynamic stability. As with any trauma patient, once the patient is stabilized it is necessary to give pri- ority to diagnosing and addressing life-threatening or high morbidity injuries before focusing on their facial injuries. Because of the previously mentioned small size of the face and its increased bony density, a pediatric facial fracture often indicates high-energy trauma and concomitant injuries to other organ systems must be evalu- ated. In fact, concomitant injuries have been reported in up to 55% of pediatric facial trauma patients. 14 Among pediatric trauma service admissions, those with facial fractures have been reported to have almost double the mean Injury Severity Score, and much higher rates of cerebrovascular injuries. 18 In these children, facial fractures were associated with a 63% higher mortality rate. 18 Given the cranial to facial proportions in the growing pa- tient, infants and toddlers have a significantly higher incidence of severe intracranial injuries, and 57% of children younger than 5 years of age with a facial fracture have been found to have a concomitant intracranial injury. 14,18 In contrast to adults, who may experience cervical spine injuries in around 10% of cases, children are less likely to suffer a concomitant cervical spine injury (0.9%–2.3%). 14,24,25 However, concomi- tant ocular injuries are just as common in children as in adults and because orbital fractures are more frequently seen in children, a thorough ophthalmic examination is crucial. Fifty percent of orbital fractures in children result in ocular injuries and 0.5% to 3% of these may be blinding. 14,26,27 DIAGNOSIS AND INITIAL MANAGEMENT

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