Pediatric Facial Fractures

Excerpt

Trauma is a significant cause of morbidity and mortality in the pediatric population. The head is the most common site of trauma. Facial fractures in very young children are rare due to their greater facial elastic cartilage content and cranial-to-facial volume ratio than adults. While facial fractures are infrequent in this age group, these injuries can be severe enough to produce lifelong consequences.

Facial growth dictates age-specific fracture patterns different from adults mainly due to secondary dentition eruption and paranasal sinus pneumatization. Isolated facial fractures can occur in pediatric patients. However, the potential for concurrent injuries must be considered in the setting of acute trauma, particularly in the head, eyes, brain, neck, and airway.

Anatomy, Development, and Vulnerabilities of the Pediatric Facial Skeleton

The bones forming the facial framework include the paired maxillae, mandibles, zygomae, and nasal and frontal bones. The maxilla forms part of the cheek and the upper jaw and its tooth sockets. The mandible forms the lower jaw and is the only movable bone in the skull. The zygoma contributes to the cheeks' prominence and supports the orbit. The nasal bones form the nose's bridge and are susceptible to fractures due to their relative thinness. The frontal bone comprises the forehead and upper part of the orbit, protecting the brain from the anterior side. Cranial bones protecting the rest of the brain include the parietal bones superolaterally, temporal bones laterally, occipital bones posteriorly, and the sphenoid and ethmoids inferiorly.

The neonatal skull is much larger than the face, with an 8:1 volume ratio compared to adults' 2:1 proportions. The forehead protrudes over the face more in infants than adults. With growth, the face expands to comprise a greater relative area of the head until adult proportions are reached in the teenage years. Thus, head trauma in young children is more likely to affect the skull than the face.

Pediatric facial bones have more elastic cartilage than adult bones, making them resilient and more likely to compress than fracture after traumatic impact. Consequently, children develop fewer facial fractures from mechanisms that can easily break adult bones. If they occur, pediatric facial fractures tend to be minimally displaced and do not assume the classic adult fracture patterns, such as Le Fort injuries.

Nasal fractures are the most common facial fractures in children overall due to the nasal bridge's prominence and minimal surrounding structural support. Mandible fractures are the 2nd most common, accounting for nearly half of pediatric facial fractures. Fracture location relates to the sinus' age-dependent development and, to a lesser degree, the dentition stage. During development, facial bones thicken before becoming fully pneumatized and thinning into the final adult configuration. Active growth and early pneumatization make children's facial bones thicker and more resistant to fractures than more developed, thin adult bones.

Maxillary sinus pneumatization occurs at birth but may continue until around age 7. Thus, the midface at this time is thicker and more elastic than the upper face. Blunt trauma to the midface in this age group often transmits impact forces superiorly toward the thinner frontal bone, increasing the likelihood of orbital roof fractures, which are less frequent in older children. Mixed dentition forms and progresses in the midface between ages 6 and 12, adding further stability and strength to the region while maxillary pneumatization slows. However, orbital floor thinning during this period makes orbital floor and wall injuries, including blowout fractures, more common with increasing age in this group.

Beyond age 12, the maxillary sinuses become fully pneumatized, midfacial bones thin, cartilages ossify, and frontal sinuses continue to thicken and develop. Mid- or upper-face blunt trauma transmits impact forces downward, away from the thick, elastic frontal sinus toward the thin, adult-like upper maxilla. Hence, orbital floor fractures are more prevalent in adolescents than younger children.