The challenges of treating facial trauma in children and the medicolegal implications

The face is associated with both functions vital to maintain life and cosmetic appearance. Therefore, injuries in this area are clinically significant (1).  When facial injuries occur at a young age, they can have lasting consequences and result in significant disability (2, 3). Not only is paediatric facial trauma a leading cause of mortality and morbidity (2, 4), but it differs from that in adults in presentation, mode of injury  and subsequent treatment (2).  

Facial trauma includes injuries to soft tissue, bones and the neurovascular system. In very young children, boys and girls are equally represented in facial trauma presentations (4). However, as age progresses, male involvement increases, until by late adolescence boys are at least twice as likely as girls to experience facial trauma (1-5). Boys account for nearly all cases related to assault, while sports injuries are more evenly distributed between the sexes (4).  

Overall, most cases are caused by falls or road traffic accidents (2, 3, 5, 6) but there is a strong correlation between cause and age (4). Not surprisingly, younger children, who tend to be more closely supervised by adults, are more likely to be injured at home, usually sustaining blunt force trauma through a fall (2, 4). Non-accidental trauma is also more likely to occur in this age group (4, 6).   

Injury patterns in older children and adolescents are similar to those in young adults (4). More incidents occur outside the home environment and while accidental falls are still the primary cause, sports-related injuries and interpersonal violence, including assault with weapons, each account for a significant minority of cases (3, 4, 6-8). Self-injury is also more prevalent in this age group (4, 6). At all ages, paediatric facial trauma is more common in areas with higher poverty levels, which may be due to less frequent use of protective equipment such as car seats (5).  

Due to the relatively large size of the skull compared to the face, which is comparatively flat (5), patients aged under 5 years tend to experience cranial, rather than facial injuries (3, 4, 6, 7). However, as the bone and cartilage of the facial structures in younger patients is more elastic, fractures are rare (3, 4, 6), and occur in only around 10% of all paediatric facial trauma cases  (4). Instead, soft tissue lacerations are the most frequently seen isolated injury (4, 7). These are particularly likely to occur when acutely edged bony structures strike against hard objects, such as the floor, stairs or furniture, resulting in lacerations to the chin, cheek and forehead (4). Up to 70% of these cases also result in dental injury (4, 7).  

When fractures do occur, they are most likely to be in the nasal bones (7), due to their prominence (3). Long-term issues are rare, although septal haematomas should be drained immediately to prevent complications. Conversely, fractures at other sites can result in high levels of morbidity and disability (7). Damage to the mandible, second in frequency only to a broken nose (3, 8), carries a risk of growth disturbance, which can lead to facial asymmetry. This happens most often following a comminuted intra-articular fracture; unfortunately, these injuries are often very difficult to identify as the patient may present with only chin lacerations and jaw pain (8).  

The mechanism of causation usually dictates the pattern of injury and thus the likelihood of subtle injuries (4, 6). Facial fractures result from severe injuries and associated morbidity is common (3, 7). Even with an apparently isolated facial injury it is important to consider the possibility of concomitant trauma in the head, neck or other body regions. While facial lacerations alone are not often life-threatening, fractures, bleeding, oropharyngeal injuries and burns may compromise the patient’s airway (3, 4), particularly as this tends to be more precarious in young patients due to its smaller size and relatively large and more flaccid oral and pharyngeal tissues, both of which also impede intubation and ventilation. Due to their higher metabolic rate and lower blood volume, young trauma patients are also more likely to experience hypotension, hypoxia and hypothermia (7).  

Symptoms typically observed with facial trauma include pain, stiffness in the jaw, the sensation of sinus and nasal congestion, nosebleeds, loose teeth and subjective malocclusion, hearing loss, cough, sensory disturbance in the face and eyes, confusion and loss of consciousness. As very young patients may be nonverbal, thorough physical examination of a paediatric trauma patient is even more important than in an adult (4). Once initial stabilisation of the patient has been achieved (4, 7), a systematic examination of the facial structures can take place. There is no set protocol for this, but an example approach is to proceed from top to bottom, lateral to medial and superficial to deep (4).  

Lacerations should be carefully examined for damage to deeper structures. The observation of fat in the cheek may indicate possible nerve or duct injury, which requires prompt input from a facial surgery specialist. Sensation and motor function in the facial and trigeminal nerves should be assessed, as traumatic facial nerve palsy is often associated with temporal bone fracture (4). Other indicators of fractures include bony tenderness, profound soft tissue swelling and crepitus overlying the sinuses (3, 4).  

Eye examination should be performed as early as possible, before periorbital swelling prevents the eye from being opened fully (3, 4). Abnormal pupillary response may indicate intracranial haemorrhage, which must be investigated promptly. A reduced range of eye movement can be a sign of extraocular muscle entrapment in a bone fracture (4, 7). These often arise due to ‘trapdoor’ fractures, which can cause diagnostic difficulties as they sometimes present with a lack of typical symptoms. Cases of muscular entrapment must be treated within 48 hours to prevent muscle fibrosis and resultant diplopia (3, 7).  

The most useful imaging technique for the assessment of paediatric facial trauma is computed tomography (CT) (3, 4, 7), as magnetic resonance imaging is less sensitive to subtle fractures (3). Plain film x-rays can also be used for dental evaluation (3, 4). Ultrasound of the eyes can help identify orbital lens dislocation, vitreous haemorrhage, retinal detachment and elevated intracranial pressure (4). There is no benefit from imaging for isolated soft tissue injuries or nasal fractures (3). 

Lacerations should be closed with tissue tape or sutures, depending on wound size. Suture removal, which is often traumatic in young patients, can be avoided by using absorbable material. Outcomes, in terms of cosmetic appearance and infection rate, are similar to non-absorbable sutures. Wounds in highly cosmetic or structurally complex areas, such as the eyelid and ductal or cartilaginous structures, or suspected nerve injuries, may require referral to a facial surgery specialist (4). Antibiotics should be administered for deep or contaminated wounds, bites and any wound not addressed within the first 24 hours (3, 4).  

While secondary teeth can be re-implanted and splinted into place, primary teeth should not be replaced, as this can damage the formation of the underlying permanent tooth. Imaging can help to determine if there is adequate spacing in the affected area to allow for the natural eruption of the secondary tooth (4).   

The elasticity of the craniofacial skeleton in young patients, along with added cushioning from fat pads, means that fractures in this area are usually minimally displaced. This, coupled with the potential for remodelling of the fracture site as the patient grows, means that paediatric fractures are managed differently to those in adults (7, 8) and most do not require surgical intervention (3, 7). Furthermore, the developing dentition in young children is often able to self-correct a reasonable degree of malocclusion (7, 8).  

If it is required, surgery should be performed as early as possible, because healing is more rapid in young patients. It is also important to preserve growth centres where possible (7). A particular concern withmandible fractures is the dentition developmental stage. In younger children, the parasymphysis and body of the mandible contain developing tooth buds, and the location of these must be considered when attempting to place plate-and-screw fixation materials (1, 3, 7, 8).  

Intra-articular condylar fractures of the mandible require early mobilisation and range of movement exercises (7, 8). In children, the condyle is very vascular and can fragment under traumatic compression, resulting in haemarthrosis and ankylosis. Ankylosis of the temporomandibular joint is extremely difficult to treat successfully (8) and can result in significant deformity if the injured side fails to grow sufficiently(1, 8). Restricting the duration of rigid fixation reduces the risk of ankylosis (3, 7).  

In general, children with facial trauma experience fewer complications than adults (7, 8). However, some complications can have a considerably delayed onset (4). Infection is the biggest concern (4, 8), particularly for burns and animal bites (4) and may lead to wound dehiscence (8). Delayed bleeding, commonly associated with arterial injuries, may also be an issue. Dental injuries can result in long term dental problems, which may need advanced repair techniques, including orthodontics (3, 4). Complications arising from fractures include hardware failure, nonunion or malunion of bony fragments, and osteomyelitis (7, 8). Cerebrospinal fluid leaks and intracranial and brain parenchymal haematomas can also occur, particularly in younger children (6). Scarring is a common issue and may lead to the formation of keloid tissue. Alteration in cosmetic appearance, as well as the psychological trauma of the event itself, can have psycho-social consequences, which may also be triggered by chronic facial pain(3, 4).  

The outcome of paediatric facial trauma depends on the location and severity of the injury, and the treatment given (3, 6). Young patients have a remarkable ability to remodel bone and correct malocclusion.Accurate diagnosis and early identification of complications is essential and ensures that appropriate management, which should be tailored to the child’s age, developmental stage and specific injuries, is initiated. The child should also be closely monitored for subsequent growth and development, with referral to an appropriate specialist if necessary (3). This will help to ensure that the best possible outcome is achieved.