In this section
In all aspects of trauma management,
the primary survey is the first priority
The secondary survey should include visual acuity
testing (even in the presence of marked periorbital
Adequate exposure is imperative to facilitate a thorough examination.
Airway assessment is of primary
importance in evaluating facial injuries.
A chest x-ray to exclude aspiration of dental fragments or foreign bodies may be indicated.
A detailed craniomaxillofacial examination should be performed during the secondary survey, after initial stabilization of the patient.
Open wounds should be covered with moist, clean dressings and tetanus prophylaxis administered if required.
While facial injuries in children are rarely fatal, they may have significant functional and cosmetic sequelae. Paediatric mortality in trauma is usually secondary to airway compromise or associated neurological injuries. Consultation with a Maxillo-facial Service should be arranged early in
the evaluation of patients with facial injuries.
The principles of managing paediatric facial trauma are the same as for adults. However, there are anatomical differences that influence the approach to treatment.
Factors to consider in the paediatric maxillofacial skeleton:
Isolated nasal fractures are the most commonly seen fractures in facial trauma. However, nasal injuries may be associated with severe mid-facial trauma involving the naso-orbito-ethmoidal (NOE) complex, the frontal sinuses and the orbito-zygomatic complex.
Nasal bones should be X-rayed when:
However, interpretation of nasal fractures on plain films is difficult due to complex sutural anatomy and cartilaginous components. The need for treatment of an isolated nasal fracture is usually based on clinical evaluation, and X-rays are not considered
routine unless suspicion of other facial injuries exists
ZMC fractures in children are usually greenstick fractures, and can be managed conservatively. However, when there is marked displacement of the orbital rim, zygomatic prominence and/or arch, open reduction - with or without internal fixation - is indicated.
The development of proptosis of the
globe, reduced or lost vision and severe orbital pain, are features
of retrobulbar haemorrhage. This is an emergency with the potential
for permanent blindness, and requires urgent surgical intervention.
If a retrobulbar haemorrhage is suspected, a facial trauma surgeon
and an ophthalmologist should be contacted immediately, and the
child kept fasted in preparation for surgery.
Fig 1: Campbell's and Trapnell's lines to guide the survey of an occipitomental x-ray
Orbital fractures may present as either:
Fig 2: A 4 year old child with right orbital 'blow out' fracture associated with entrapment
Fig 3: Isolated right orbital floor fracture
Maxillary fractures are uncommon in childhood. The maxillae are proportionately smaller and denser than in adults, with a relative lack of sinus development. Consequently, isolated displacement of part or all of the maxillary complex is rare.
When fractures do occur, however, they are generally a component of more extensive craniofacial injuries. Approximately 40% of children with mid-facial fractures have associated skull fractures, and CSF rhinorrhoea may also be present. There is also a high incidence of
cervical spine injuries in patients with severe mid-facial fractures. The cervical spine must be stabilized until a cervical spine injury can be excluded.
Fig 4: Le Fort fractures
Le Fort I
Le Fort II
Le Fort III
Fractures of the frontal bone may occur:
Some frontal sinus fractures may be clinically obvious, with a depression or an open wound permitting direct visualization. In other cases, however, there may be no clinical signs.
A high degree of suspicion is therefore required, based on the presenting history and mechanism of injury.
Considerable force is required to
fracture the frontal bone and the patient should be maintained in
cervical spine precautions until an injury to the cervical spine is
Mandibular fractures occur in all age groups. Fractures of the condyle and subcondylar regions, are the most common due to trauma to the chin from falls.
Fig 5: Common sites of mandible fractures. (a) symphyseal / parasymphyseal, (b) body, (c) angle, (d) subcondylar, (e) condylar head
Fig 6: Avulsion of 2 lower incisors and a step in the occlusal plane associated with a mandibular symphyseal fracture
The mandible is ideally imaged in two planes -Orthopantomogram (OPG) -PA mandible (may require paramedian PA view) -Reverse Towne's view (for suspected condylar injuries)
In uncooperative patients, or patients unable to sit or stand for an OPG, right and left lateral oblique views of the mandible or a CT scan are imaged.
Fig 7: Right parasymphyseal and left angle mandibular fractures - (a) OPG (b) PA mandible
Condylar fractures and temporo-mandibular joint
Intra-articular injuries of the
condyle constitute the highest risk of growth disturbance and joint
hypomobility. Treatment should aim for continued normal jaw growth
to maintain symmetry and a balanced occlusion.