Pediatric emergency medicine trisk 823

displaced fractures. D: The infraorbital rims, zygomatic bodies, and maxilla are palpated and
examined from the top of the head to determine depressions and fracture displacement. E: The
nasal bone and maxilla are examined for stability and possible fracture displacement. F: The
nose is examined intranasally to determine the placement of the nasal septum and the possible
displacement of nasal bones or disruption of nasal mucosa. G: The occlusion is observed to
determine any disturbances of normal teeth relations. H: The mandible is palpated and then
retracted to determine sites of discomfort and possible mandibular fractures.

Neurologic examination of the face should include evaluation of both sensory
and motor functions. All three branches of the trigeminal nerve should be
evaluated for sensation. Anesthesia of the cheek suggests injury to the infraorbital
nerve, whereas anesthesia of the lower teeth and lower lip suggests inferior
alveolar nerve involvement. The facial nerve should be evaluated by asking the
patient to wrinkle the forehead, close and open the eyes fully, smile, show his or
her teeth, and close the mouth tightly.

Determination of Appropriate Imaging Modality
The use of radiography in the evaluation and management of children with facial
trauma should be considered if there is a concern for fracture based on history and
physical examination. The complexity of bony and soft tissue facial structures can
make the interpretation of plain radiographs difficult. In addition, plain
radiographs are often inadequate to determine whether a patient requires
operative intervention.
Computed tomography (CT) has mainly replaced plain radiographs in the
definitive assessment of bony facial injuries because it has a greater ability to
detect fractures and associated displacement as well as visualize soft tissue
structures. Axial views demonstrate fractures of the anterior and posterior walls
of the frontal sinus, medial and lateral orbital walls, posterior wall of the
maxillary sinus, zygomatic arches, and mandible. Coronal views demonstrate
fractures of the ethmoid, sphenoid, and paranasal sinuses; orbital floors and
infraorbital rims; the nasoethmoid region; and mandibular condyles and

symphyses. Coronal imaging requires hyperextension of the neck and thus
requires prior exclusion of a cervical spine injury. Three-dimensional CT imaging
can help guide operative repair.
Despite their limitations, there are specific plain radiograph views that may be
of utility for the evaluation of facial fractures in children. The Waters view
(occipitomental) is used to visualize the midface region: the orbital rims and floor
of the orbit, nasal bones, zygoma, and maxilla. This view may be particularly
useful in patients suspected of having a blowout fracture of the orbit, as well as
for detecting fluid in the maxillary sinus. The Caldwell view supplements the
Waters view for the evaluation of the upper two-thirds of the face, including


visualization of the superior orbital rim, frontal sinuses, and nasoethmoid
complex; however, the orbital floor is often obscured. The lateral view is useful
for the detection of fractures to the anterior wall of the frontal sinus, the anterior
and posterior walls of the maxillary sinus, and the nasal bones. The
submentovertex view provides visualization of the zygomatic body and arch.
Posterior–anterior, right and left lateral oblique, and Towne views are used to
detect fractures of the mandible; however, fractures of the symphysis may be
difficult to discern. Panorex views provide visualization of the entire mandible
and lower teeth.

Obtain Subspecialty Consultation When Indicated
The clinician must evaluate whether subspecialist input is warranted for the
management of facial trauma in children. Plastic surgeons, ophthalmologists,
otorhinolaryngologists, and oral and maxillofacial surgeons have expertise in the
management of patients with facial trauma. Once it is determined that
subspecialist input is warranted, the decision of which subspecialist to involve
will depend largely on availability and expertise of such individuals within the
institution.

FACIAL FRACTURES
Mandible Fracture
Goals of Treatment
The primary goals in treatment of mandible fractures include (1) airway
stabilization, (2) pain control, and (3) evaluation for the need for subspecialty
consultation and possible surgical intervention.
CLINICAL PEARLS AND PITFALLS
Clinical evaluation of any chin laceration should include palpation of the
mandible, particularly the mandibular condyles, to evaluate for
mandible fracture.
The majority of mandibular fractures can be managed conservatively
with closed reduction and/or maxilla–mandibular fixation.
Preauricular swelling and inability to fully close the mouth are key
features of temporomandibular joint dislocation.
Clinical Considerations


Fractures of the mandible can occur in one or more of the following regions: the
symphysis, body, angle, ramus, and condyle ( Fig. 107.2 ). The mechanism of
injury often determines the site of potential fracture in patients with trauma to the
mandible. Motor vehicle collisions and falls tend to cause fractures of the
condyles and symphysis because the force is directed against the chin, whereas
assaults tend to result in injuries to the body or angle of the mandible at the point
of impact. Patients with parasymphyseal fractures resulting from falls often have
an associated fracture in the contralateral subcondylar region. Pain and difficulty
opening the mouth are typically present with mandibular fractures. Numbness of
the lip and chin may also suggest a mandibular fracture because the inferior
alveolar nerve courses through the center of the mandible, from the middle of the
ramus, to its exit at the mental foramen. Mandibular fractures may result in

airway obstruction due to hemorrhage either from the floor of the mouth or from
a disruption in the bony support structure for the tongue.
Powerful muscles of mastication apply distracting forces to the fractured
mandibular segments, often resulting in bony displacement and occlusal
disharmony. The growth center for the mandible is located in the area of the
condyle, and damage to this area from a fracture can cause significant growth
disturbances, especially if sustained before the age of 3 years. Therefore, the
clinical evaluation of any chin laceration should include palpation of the
mandible, particularly the condyles. Malalignment of the lower central incisors
(i.e., step off in dentition) suggests a mandibular fracture at the symphysis.
Unilateral condyle fractures will most often result in the deviation of the jaw
toward the side of the fracture upon mouth opening.

FIGURE 107.2 Anatomy of the mandible. Common sites of fracture include the condyle and
subcondylar region, as well as the angle, body, and symphysis of the mandible.


Temporomandibular joint dislocation may not only result from a direct blow to
the chin but also may occur while yawning or opening the mouth widely. With
dislocation, the condyle of the mandible is displaced anteriorly and is prevented
from sliding back into place by spasm of the jaw muscles. Preauricular swelling
and inability to close the mouth fully are the key features on physical
examination.
Current Evidence
Mandibular fractures are treated more conservatively in children compared to
adults due to the risk of injury to the permanent tooth buds and mandibular
growth retardation. Most mandibular fractures can be treated with closed
reduction and maxillomandibular fixation. A soft or liquid diet is recommended.
Displaced fractures commonly require open reduction, internal fixation, or the use
of splints. Antibiotics are generally recommended as these fractures are often in

communication with the oral cavity, although there is limited data to support this
recommendation.
Reduction of temporomandibular joint dislocations may be facilitated with the
use of a benzodiazepine to decrease muscle spasm; procedural sedation may also
be required. Downward traction is applied to the posterior aspect of the mandible.
The chin is then pushed posteriorly to allow the condyle to return to its fossa.

Orbital Fracture
Goals of Treatment
The primary goals in treatment of orbital fractures are to recognize the signs of
extraocular muscle entrapment, and if present, to obtain prompt ophthalmologic
consultation to determine the need and timing of surgical repair to avoid muscle
ischemia and fibrosis.
CLINICAL PEARLS AND PITFALLS
In children, the floor of the orbit may fracture in a linear pattern that
snaps back to create a “trapdoor” fracture. Fractures at this site can
cause inferior rectus muscle entrapment, which may be identified by
limitation of upward gaze.
Decreased vision in a patient with orbital trauma may indicate a
retrobulbar hemorrhage.
Clinical Considerations