Chapter 28: Maxillofacial Trauma

High-Yield Facts

• Maxillofacial trauma in children more often results in soft-tissue injury than facial fractures.

• Up to 55% of seriously injured children with facial trauma also have intracranial injury.

• The most urgent complication of facial trauma is airway compromise.

• Computed tomography (CT) scan is the definitive diagnostic test for precise delineation of maxillofacial fractures.

• The mandible is most frequently involved in posttraumatic developmental deformities.

• Timely referral of nasal fractures is important, as these injuries may have a profound effect on subsequent nasal and maxillofacial development.

Missed facial fractures or inappropriate treatment of such 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, manage the airway, stabilize the patient, read initial radiographs, and make appropriate consultations.

Incidence

Pediatric facial fractures comprise less than 15% of all facial fractures.^1,2 Facial fractures occur in less than 1% of children under the age of 5 years.² Fracture patterns reflect the unique anatomic considerations in children and match adult patterns by age 15.

Certain developmental characteristics of the growing face protect children from fractures. These features include the low face to cranium ratio for children, the increased elasticity of the bones, less sinus pneumatization, larger fat pads, and stability imparted by unerupted teeth to the mandible and maxilla.² For example, mandible fractures in infants occur rarely in falls and motor vehicle crashes and raise suspicion for nonaccidental trauma such as a direct, violent blow to the jaw.³ Finally, children's higher ratio of cancellous bone to cortical bone provides resilience but produces more incomplete and greenstick fractures.^4–6

Worldwide, the incidence of facial fractures is higher in boys than girls, attributed to more dangerous sporting activities and increased rates of physical violence in boys.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%).⁷ This data bank demonstrated that facial fractures occur in 4.6% of admitted patients and 25% of these fractures required operative intervention.⁷ Nasal and maxillary fractures occurred most commonly in infants and toddlers aged 0 to 1 year and mandible fractures occurred most commonly in adolescents aged 15 to 18 years.

Fractures occur consistent with age-related fracture patterns. In early childhood, the skull is particularly prominent with a cranial to face ratio of 8:1.¹ This ratio is 2.5:1 in an adult patient. The small face and limited sinus development transfer force to the cranial base resulting in a high incidence of skull fractures in the younger age group. Aerated sinuses in adults absorb energy and protect against propagation of fractures into the skull.^8...