Children versus Adults

Pediatric anatomy and developmental concerns influence the management of facial fractures in children.

ETIOLOGY Be suspicious of nonaccidental trauma in cases of pediatric maxillofacial injury. Associated skull fractures, a torn frenulum, and facial bruising may signify child abuse. Children with facial injuries should be completely undressed and examined for other stigmata of nonaccidental trauma. Some may require a radiographic skeletal survey to detect occult or prior trauma.

FRACTURE PATTERNS Fracture patterns relate to developmental anatomy. Young children have a higher incidence of frontal bone injury due to its prominence. Infants and toddlers almost never suffer midface fractures. The dearth of maxillary fractures under age 6 is due to the lack of sinuses in the midface. It is these sinuses that weaken the facial buttresses and predispose adults and adolescents to LeFort injury. As the child grows, the sinuses pneumatize, and fractures shift to the midface and lower face. By age 12 to 15, the fracture pattern resembles that in adults.

ASSOCIATED INJURIES Children with facial trauma also have dissimilar associated injuries than adults. Because the pediatric skull is more prominent, children have much higher incidence of intracranial injuries. Up to 60 percent of children with significant facial fractures have head injury. In addition, the dynamics of cervical injury vary between children and adults. Children are more likely to suffer an upper, rather than lower, cervical spine injury and are also prone to spinal cord injury without radiographic abnormality (SCIWORA).

AIRWAY MANAGEMENT A young child's airway is subject to subglottic stenosis and tracheomalacia. For this reason, avoid cricothyroidotomy in children younger than age 12. Intubation is the definitive airway of choice in children who need emergency airway management. If intubation is impossible, percutaneous transtracheal jet ventilation provides temporary airway control until a formal tracheotomy is feasible.

COMPLICATIONS AND TIMING OF FOLLOW-UP Because subsequent facial growth may be asymmetric, pediatric facial fractures can lead to serious cosmetic deformities. Subcondylar fractures of the jaw and displaced nasal fractures are of particular concern in children under age 5. Condylar fractures in this age group predispose children to facial deformity, micrognathia, and ankylosis of the TMJ. Consultation is essential.

Early follow-up is important in all pediatric facial fractures, because a child's facial skeleton heals faster than that of an adult. Within a week, early callous formation makes delayed reduction troublesome.

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