Pediatric emergency medicine trisk 822

CHAPTER 107 ■ FACIAL TRAUMA
PAUL L. ARONSON, MARK I. NEUMAN

RELATED CHAPTERS
Resuscitation and Stabilization
Airway: Chapter 8
Signs and Symptoms
Epistaxis: Chapter 26
Injury: Head: Chapter 41
Trauma
ENT Trauma: Chapter 106
Ocular Trauma: Chapter 114
Surgical Emergencies
Ophthalmic Emergencies: Chapter 123
Procedure
Procedures: Chapter 130
The Children’s Hospital of Philadelphia Clinical Pathway
Clinical Pathway for Evaluation/Treatment of Child With a
Laceration
URL: />Authors: S. Fesnak, MD; E. Friedlander, MD; E. Lichtman, RN
Posted: February 2019
KEY POINTS


Stabilization of the airway is the primary concern for children with facial
trauma.
Computerized tomography is the optimal imaging study for suspected
facial fractures.
Prompt recognition of extraocular muscle entrapment associated with
orbital floor fractures is critical to prevent muscle ischemia and fibrosis.
Displaced nasal bone fractures should be repaired within 7 days of

injury.
Fast-absorbing plain gut sutures have demonstrated similar cosmetic
performance to nonabsorbable sutures for the repair of facial
lacerations.

GOALS OF EMERGENCY THERAPY
Stabilization of the Airway
While injuries sustained as a result of facial trauma are rarely life threatening,
patients who have sustained enough force to cause significant facial injury may
have other associated serious injuries. Stabilization of the airway is therefore the
primary concern in the management of facial injuries in children. Airway
obstruction may result from blood in the mouth, loose teeth, and pharyngeal
edema. Thus, the airway should be cleared and examined for patency. Loss of
support of subglottic musculature can result from severe mandibular fractures,
and the tongue can fall posteriorly and occlude the airway in a patient with a
depressed mental status. An oral or nasal airway may serve as an adjuvant to
positioning in order to achieve airway patency. Tracheal intubation may be
required if the airway remains unstable. Cricothyrotomy or tracheostomy may be
necessary if these measures fail to secure the airway but should be attempted only
as a last resort because of the technical difficulty and complications associated
with such procedures, particularly in young children.

Cervical Spine Protection
Up to 10% of patients with maxillofacial trauma have an associated cervical spine
injury. Patients with tenderness of the cervical spine, impaired sensorium, focal
neurologic deficits, or major distracting injury should be placed in a hard cervical
collar until an injury to the cervical spine can be excluded.


Identification of Specific Bony Injuries and Facial Neurologic

Deficits
Following airway stabilization and cervical spine protection, examination for
specific bony injuries should be performed. After careful observation for
deformity and asymmetry, the clinician should palpate the facial bones in a
systematic fashion ( Fig. 107.1 ). Tenderness, crepitus, and “step off” are signs of
underlying fracture. Particular attention should be paid to the malar eminences,
zygomatic arches, and superior and inferior orbital rims.
Assessment for a fracture of the maxilla can be performed by grasping and
attempting to move the upper central teeth. Any laxity of the maxilla or crepitus
is suggestive of fracture. External and intraoral palpation of the mandibular
symphysis, body, angle, and ramus can help diagnose fractures in these areas.
Inspection of the mouth and oral cavity should also be performed to assess for
injury to the maxilla and mandible. Occlusal disharmony is an indication of
mandibular and/or maxillary displacement. Older children will be able to report if
their bite “feels normal.” Opposing teeth that do not come together, but that
exhibit wear facets (smoothing of mammillations along the incisal surfaces of the
teeth) suggest a traumatic malocclusion. An inability to hold a tongue blade
between occluded teeth on each side of the mouth is suggestive of a mandibular
fracture.
Examination of the eyes should include the assessment of pupillary reactivity
and size, examination of extraocular movements, visual acuity, and a thorough
inspection for surrounding orbital injuries. Orbital dystopia and/or enophthalmos
are suggestive of a fracture of the orbit. Examination of the nose should include
documentation of focal tenderness, swelling and asymmetry, bleeding, or other
nasal discharge, as well as the presence or absence of a septal hematoma.


FIGURE 107.1 Sequential steps in examination for facial fractures. A: The supraorbital ridges
are palpated while keeping the patient’s head steady. B: The infraorbital ridges are palpated
using the index, middle, and ring fingers to assess for areas of point tenderness. C: The

zygomatic arch is palpated on each side to determine continuity and the possible presence of