Pediatric Trauma results in over 8 million emergency department visits and 11,000 deaths annually. Unintentional injuries continue to be the leader in morbidity and mortality in pediatric and adolescent populations in the United States. More than 10% of all visits to pediatric emergency rooms (ER) present with craniofacial injuries. The most common etiologies for facial injuries in children and adolescence are motor vehicle accidents, assault, accidental injuries, sports injuries, nonaccidental injuries (eg, child abuse) and penetrating injuries. In the United States, head trauma secondary to abuse is the leading cause of mortality among non-accidental trauma in this population.
Key points
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Isolated soft tissue trauma is the most common type of facial injury in the pediatric population.
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Because of the resilience of the pediatric maxillofacial skeleton, a considerable amount of force is necessary to fracture bones. Therefore, children usually present with concomitant injuries.
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Most pediatric trauma is preventable.
Overview of pediatric maxillofacial trauma
Pediatric trauma results in over 8 million ED visits and 11,000 deaths annually in the United States (US). Traumatic unintentional injuries continue to be the leader in morbidity and mortality in pediatric and adolescent populations in the US. More than 10% of all visits to pediatric emergency rooms have been estimated to be a result of injuries to the craniofacial skeleton. Most pediatric facial injuries are a result of isolated trauma to soft tissues of craniofacial skeleton (ie, 34%–92% of all facial trauma in children). Only 10% to 15% of those injuries result in facial fractures. The elasticity of the pediatric craniofacial skeleton allows for natural protection of the face. Because of this elasticity and resilience, majority of all facial fractures in the pediatric population present with concomitant injuries. , Pediatric facial fractures account for approximately 5% to 15% of all facial fractures in children.
Pediatric craniofacial fractures are rare below the age of 5 years; incidence ranges from 0.6% to 1.4%. , Craniofacial fractures become more common as children get older. This is likely due to the increase of various activities that the child and adolescence population began to engage in (eg, accidental injuries from falls, contact sports and motor vehicle accidents) and their associated risks. Because children under the age of 5 years are not likely to drive a car or participate in contact sports, the mechanisms of injury for facial fractures in this population are different. In this age group, etiology of craniofacial injuries raises concerns regarding nonaccidental injury and child abuse (with child abuse being less common but an important consideration). , Male individuals make up the majority of those who are involved in injuries.
Facial injuries do not often pose a direct risk of mortality, though in some cases they may be fatal due to damage to the nearby airway, digestive, and central nervous system. In an analysis of data from over 61,000 pediatric patients with facial injuries from the National Trauma Data Bank, Hebballi and colleagues found that risk factors for in-hospital pediatric mortality included ages 5 to 17 years, severity of facial injury, insurance status, and mental health comorbidities. Other studies identified midface fractures as having a particularly high-risk of mortality, likely due to their association with concomitant traumatic brain injury and damage to nearby neurovasculature. ,
Skeletal maturity
Maturity of the craniofacial skeleton occurs around ages 14 to 16 in girls and 16 to 18 in boys. The immature craniofacial skeleton has unique features that allow it to respond to trauma in different ways than that of the adult. Bones in children are less ossified and are more likely to bend (ie, greenstick fractures) rather than break. The mandible and maxilla in children are insulated from external forces by additional facial fat pads. In adults, the facial skeleton acts as a crumple zone to help decrease trauma to the brain. In addition, sinuses protect the vital structures in craniofacial skeleton and continue to develop until they reach their full adult size during the teenage years. The only exception is the frontal sinus that continues to enlarge into the second decade of life. Furthermore, children have a decreased ratio of facial to cranial volume, and thus less structures overall to absorb impact.
Etiology of injuries
The most common etiologies for facial injuries in children and adolescence are as follows , ,
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Motor vehicle accidents (55.1%)
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Assault (14.5%)
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Accidental injuries (eg, blunt trauma from falls) (8.6%)
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Sports injuries
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Child abuse
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Penetrating injuries (eg, stab injuries, animal bites, etc.)
Age-related development should be considered when deciphering the etiology of facial injuries. This is paramount to arriving at the appropriate treatment for each situation. Accidental injuries and falls are more common in children below the age of 5 years (accounting for around 43% of all facial injuries in this age group). , For example, nonambulatory patients that suffer facial fractures require a skeletal survey and social work assistance for concern for child abuse. Another common example is the need for a rabies vaccination and/or antibiotics a patient that suffers a penetrating or an avulsion injury from an animal/human bite, or a foreign body. Based on the etiologies shown above, it is believed that most pediatric facial injuries and complications are preventable in nature. For example, up to date immunizations in children and their pets can prevent post-trauma complications (eg, tetanus and rabies vaccines). An increase in supervision could reduce risky behavior by children. However, with the increased push in independence in children at younger ages and less supervision in the adolescence population, this leads to an increase in risk-taking behaviors which puts them at higher risk of injury.
Injury Sites and Patterns
The distribution of soft and hard tissue injuries to the craniofacial varies considerably with age as the facial skeleton becomes more pronounced and mineralized. Most of the elasticity of the craniofacial bones is lost by the age of 2 or 3 years of life. , Younger children, because of the larger size of the cranium, usually suffer more injuries to this area. This relationship shifts to the face and the mandible as they get older. For example, midface fractures are less common in infants because of the high elasticity and lower percentage of the face covered by it. Midface fractures are more common as children become adolescents because of the decrease in elasticity and the increase in growth. Fractures in order of frequency have been represented by age group in Table 1 , and facial growth is represented by Fig. 1 .
| Infant | Child | Adolescent | |
|---|---|---|---|
| Skull | 1 | 2 | 5 |
| Midface | 5 | 5 | 3 |
| Orbit | 3 | 4 | 4 |
| Nasal | 4 | 3 | 2 |
| Mandible | 2 | 1 | 1 |
