Pediatric Facial Fractures: A Multi-Institutional Level 1 Trauma Center Analysis of Incidence, Interventions, and Outcomes

Abstract

Study Design: Retrospective chart review. Objective: The management of pediatric facial fractures presents distinctive considerations compared to adults. This study aims to provide a unique perspective on the correlations between the mechanism of injury, types of facial fractures, and fracture interventions and management utilized in 2 North Carolina Level 1 Trauma Centers to determine the optimal management options for this patient population. Methods: An IRB-approved retrospective chart review was performed of pediatric facial trauma patients ages <18 years old between January 2020 and December 2022 at Atrium Health Wake Forest Baptist Medical Center and Atrium Health Charlotte Medical Center. Data on patient demographics, mechanism of injury, facial fractures, interventions, and outcomes were collected. Results: Of 2977 pediatric facial trauma patients, 582 patients sustained at least 1 facial fracture at the time of injury. Adolescents were significantly less likely to be transferred from outside institutions and to be admitted for further care (p = 0.002). Adolescents experienced higher levels of residual symptoms following initial discharge (p = 0.001) and were less likely to have a symptom resolution within 1 year (p < 0.0001). Neonates and infants were significantly more likely to receive conservative interventions and to sustain calvarium and skull base fractures (p < 0.0001). Conclusions: This study identifies differences in pediatric age groups related to transfers, admittance, fracture type, management, and outcomes. Our data suggests adolescent patients may experience a higher incidence of residual symptoms with lower levels of symptom resolution within 1 year. Further investigation into these differences may elicit optimized methods of fracture management in pediatric age groups and allow for effective, individualized care with improved long-term outcomes.

Introduction

Facial Trauma in the Developing Child and Adolescent

The pediatric patient population presents unique challenges to healthcare and injury management due to the type of injuries these patients sustain, the mechanism by which pediatric patients in different age groups sustain injuries, and the physiology of the developing face. The frequency of different fracture types, the management of these fractures, and the potential residual symptoms that may arise from these injuries depend on the age of these patients [1]. It is important to consider that children are susceptible to various injury types according to their age and learning and motor milestones they have reached, as well as general environmental factors, including caretaker status, pets in the home, and safety measures implemented in the home and vehicle [2]. Pre-adolescent pediatric patients present with increased bone stability and anatomic protection, lowering the rate of incidence of common adult facial fractures, including maxillary and zygomatic fractures [3]. The underdeveloped facial skeleton and expansion of the paranasal sinuses in preadolescent children create craniofacial disproportion in the facial skeleton; along with unerupted dentition, larger fat pads, and elastic cancellous bone, this additional strength lowers the incidence of facial fractures in pediatrics under 12 years old [4]. At birth, the skull-to-face ratio is 8:1 and transitions to 2.5:1 by adulthood; this physiologic development in the facial skeleton promotes skull fractures at a young age and facial fractures during pre-adolescence and young adulthood from facial trauma [4,5]. Neonatal skulls are proportionally larger than the face with prominent protrusion of the forehead, resulting in a higher incidence of cranial injuries over facial. During early childhood development, children under 7 years old contain more elastic midface structures while the maxillary sinuses pneumatize, causing displacement of blunt facial trauma to the thinner frontal bone and orbital roof, increasing the incidence of frontal bone and orbital roof fractures. Up until the age of twelve, the combination of mixed dentition stabilizes and strengthens the midface while the maxillary sinuses continue to pneumatize, promoting orbital floor and wall fractures from facial trauma. Following complete pneumatization of the maxillary sinuses after 12 years of age, the frontal sinuses continue to thicken and develop while the midface thins out, displacing blunt facial trauma downward to the upper maxilla, increasing the rate of orbital floor fractures in adolescents [1,2].

Pediatric Consequences from Facial Trauma

Pediatric facial trauma may result in both immediate and long-term complications which are influenced by the severity of injury, type and location of trauma, and treatment effectiveness of facial injuries. Injuries to the face may involve soft tissue, bone, and neurovascular structures. Although isolated facial fractures are more likely to present in adolescents and young adults, head and neck trauma are essential to consider in all pediatric patients, as injuries secondary to craniofacial trauma, including hemorrhaging, traumatic brain injury, and oropharyngeal compromise, may be life-threatening or prolong recovery [1]. Cranial bone, cerebrospinal fluid (CSF) leaks, and intracranial and brain parenchymal hematomas are more common residual injuries in infants and young children. In contrast, traumatic brain injury (TBI), seizures, and cosmetic complaints are more common residual symptoms in adolescents [6]. The mechanism by which such injuries are sustained is critical to consider when evaluating the risk of secondary injuries and residual symptoms that may occur alongside facial trauma. High-energy trauma in particular yields the highest likelihood of life-threatening injuries and post-trauma residual symptoms. Pediatric facial trauma is often a result of blunt force trauma, including motor vehicle accidents, falls, sports-related injuries, and interpersonal violence [7]. Although less common, pediatric patients are susceptible to penetrating facial injuries, such as gunshot wounds and significant dog bites. Age-related etiology is an important consideration in how pediatrics in various age groups sustain injuries [8]. In neonates and infants, these patients are particularly susceptible to non-accidental trauma and caregiver neglect, whereas toddlers and pre-adolescent children are more susceptible to animal attacks and unintentional self-injurious behavior [9]. Adolescents and young adults have a higher incidence of weapon and ballistic, sport, all-terrain vehicle (ATV), and intentional selfinflicted injuries [10,11]. The incorporation of the various features of pediatric anatomy, the mechanisms by which they sustain facial fractures, and the potential residual symptoms and concomitant injuries they may encounter related to their facial injuries are critical to consider for longterm care. Considering the mechanism of injury and the consequences head and facial trauma may have on this population is essential in the role of injury management, prevention, and clinical care improvement. Ultimately, it is important to consider the implications of the mechanism of injury, the type of injury management utilized, and the age the patient sustained their facial injuries for short and longterm care.

Methods and Materials

Data Acquisition

Pediatric facial trauma patients evaluated at 2 high-volume Level 1 Trauma Centers, Atrium Health Wake Forest Baptist Medical Center and Atrium Health Charlotte Medical Center, between January 2020 and December 2022 were included in this study. Patients were identified by their age at the time of their injury, initial evaluation, and fracture management at either Level 1 Trauma Center with a diagnosis of at least 1 facial fracture at the time of their injury within the given timeframe. Patients seen for injuries involving isolated dental complaints without midface or mandible fractures, patients without a definitive facial fracture, patients presenting with isolated cranial fractures, or patients only assessed at outside network facilities were excluded from the analysis. Cranial fractures were defined as parietal, temporal, occipital, sphenoid, and mastoid bone fractures for this study. 2977 patients were charted during the selected time frame as having at least 1 cranial or facial fracture at either facility or affiliated practice. Following the application of exclusion criteria and access to patient charts, 582 patients were reviewed Figure 1.

Trauma Type

Data was refined under the categorization of the mechanism of injury (MOI) into high or low-energy trauma to analyze the prevalence of distinct fracture locations, fracture patterns, and management of facial fracture injuries. The mechanism of trauma and criteria for each type of trauma were categorized using a compilation of emergency medical service and trauma activation protocols utilized throughout North Carolina hospitals. The severity of trauma was defined using the Injury Severity Score (ISS) calculator as follows: minor trauma was defined as an ISS <9, moderate trauma was defined as an ISS of 9-15, and severe trauma was defined as an ISS >15 [12,13]. Criteria for high and lowenergy trauma for this study are shown in Figure 2.

Database Creation

Study data were collected and managed using REDCap electronic data capture tools hosted at Wake Forest Baptist Medical Center [14,15]. Patient demographic information was collected, along with known social determinants of health, past medical history, past surgical history, and birth history. Data on the mechanism of injury, location and type of soft tissue injuries sustained, location and type of facial fractures sustained, initial interventions utilized for facial injuries, post-discharge residual symptoms, known readmission to the hospital related to facial injuries, facial injury management following discharge, follow-up outcomes, and known mortality information were collected. The analysis of patients, injuries, management, and outcomes was divided using the following pediatric age categories according to the National Institutes of Health (NIH): neonates and infants (0-1 year), toddlers (1-2 years), children (2-12 years) and adolescents (12-17 years) [16].

Data Analysis

The data collected within the REDCap database was analyzed using the REDCap software export and data extrapolation tools to obtain reports and statistical measures of the data, including, mean, standard deviation, percentiles, and percentages. Statistical analysis of data was performed using Chi-Square and Kruskal-Wallis tests. Chi-Square test was used to analyze demographics, hospital transfer, mechanism of injury, polytrauma, interventions, fracture type, facial bone affected, residual symptoms, and resolution of residual symptoms. Kruskal-Wallis test was used to analyze the length of stay. A logistic regression model was employed to identify relationships between surgical interventions and reported residual symptoms and their resolution. A significance value of 5% was used.

Results

Pediatric Facial Fractures, Interventions, Management, and Outcomes by Age Group

The analysis of patient age, institution transfer for higher-level trauma care, admittance for trauma care, mechanism of injury, types of facial fracture sustained, initial and follow-up management of fracture injuries, readmission, known outcomes, and mortality were divided by age categories to analyze distinct characteristics of facial fracture management. The mean age of patients was 10.5 ± 5.7 years old with a male predominance (66%). The prevalence of institution transfer, admittance, trauma type, interventions, length of hospital stay, facial bones affected, readmission, residual symptoms, and outcomes are presented in

Table 1. Representation of Pediatric Patient Population Seen for Facial Trauma Care on Initial Evaluation, Separated by Age Groups.

. The frontal bones were the most common bone fracture in the pediatric patients evaluated, followed by the orbital walls and nasal bones (

Table 2. Representation of Facial Bones Affected at Time of Injury, Separated by Age Groups.

, Figure 3). The correlations between residual symptoms, symptom resolution, and interventions are presented in

Table 3. Logistic Regression Relationship Between Facial Surgical Interventions and Reported Residual Symptoms.

and

Table 4. Logistic Regression Relationship Between Facial Surgical Interventions and Resolution of Residual Symptoms.

. Specific residual symptoms for each pediatric age group are presented in Figure 4.

Neonates and Infants. Neonates and infants had a significantly higher incidence of calvarium and skull base fractures compared to other age groups (P < 0.0001, Table 1). The most common fracture reported in this age group were frontal bone fractures (Table 2, Figure 3). Operative interventions performed for facial fractures were significantly lower in this age group (P < 0.0001, Table 1). Pediatrics in this age group were also more likely to experience nondisplaced fractures (P = 0.04, Table 1). The most reported residual symptoms following discharge in this age category were traumatic brain injuries and nasal congestion or obstruction (Figure 4). No difference was seen in the type of surgical operation they received for their facial injuries.

Toddlers. The most common fracture reported in this age group were frontal bone fractures (Table 2, Figure 3). 67% of patients in this age group received conservative interventions for their facial fractures (Table 1). The most reported residual symptoms following discharge in this age category were visual impairments (Figure 4). Visual impairments included traumatic optic neuropathy, and visual field defects. No difference was seen in the type of surgical operation they received for their facial injuries.

Children. The most common fracture reported in this age group were frontal bone fractures (Table 2, Figure 3). 55% of patients in this age group received conservative interventions for their facial fractures (Table 1). Children who had fewer surgical interventions for their facial trauma were significantly more likely to report residual symptoms (P < 0.001, Table 3) and were less likely to report residual symptom resolution (P = 0.002, Table 4). Children who sustained facial lacerations alongside facial fractures were significantly more likely to report residual symptoms (P = 0.03, Table 3) and were significantly more likely to report residual symptom resolution (P = 0.002, Table 4). The most reported residual symptoms following discharge in this age category were scarring or scar contractures. Children were significantly more likely to report scarring-related residual symptoms following initial discharge compared to adolescents (P = 0.0001, Figure 4).

Adolescents. Outside institution transfers were significantly lower in this age group compared to other age groups (P = 0.002, Table 1). Admittance to the hospital for further trauma care was significantly lower in this age group (P < 0.0001, Table 1). Adolescents reported a significantly higher incidence of residual symptoms following discharge compared to the other age groups (P = 0.001, Table 1) and a lower incidence of residual symptom resolution within 1 year of sustaining their facial injuries (P < 0.0001, Table 1). Adolescents were significantly less likely to receive facial trauma follow-up care compared to other age groups (P = 0.006, Table 1). The most common fractures reported in this age group were orbital wall and nasal bone fractures (Table 2, Figure 3). 52% of patients in this age group received surgical interventions for their facial fractures (Table 1). Adolescents who had fewer surgical interventions were less likely to report residual symptoms (P = 0.003, Table 3). Adolescents who received fewer surgical interventions were more likely to report residual symptoms (P = 0.002, Table 3). Patients in this age group who received ORIF were less likely to report residual symptom resolution (P = 0.01, Table 4). Patients in this age group who received hardware, mesh, or orbital plates were more likely to report residual symptom resolution (P = 0.02, Table 4). The most reported residual symptoms following discharge in this age category were cosmetic complaints. Adolescents were significantly more likely to report headache-related residual symptoms following initial discharge compared to other age groups (P = 0.004, Figure 4).

Discussion

Analysis of Pediatric Facial Trauma

Neonates, Infants, and Toddlers. This study identifies significant differences in pediatric age groups related to transfers, admittance, fracture type, management, and reported residual symptoms. Similar to previous studies, there was a strong preponderance of neonates and infants who received conservative management for their facial and cranial fractures [9,17]. Neonates and infants had significantly lower reported residual symptoms following discharge with the highest resolution of symptoms within a year compared to the other age groups. This significant difference may be attributed to the facial skeletal structure of this age group, as the facial skeleton at this developmental stage is more elastic with smaller sinus structures and higher osteogenic potential for increased healing responses [5,18]. Although 62% of these patients sustained facial injuries from low-energy trauma, patients in this age group had the highest rate of hospital admission for continued care following their initial injury evaluation. These patients were also significantly more likely to sustain non-displaced fractures compared to other age groups. As patients in this age group were less likely to receive operative interventions at the time of admission, it may be suggested that patients in this age group had a higher admittance rate due to hospital precautions to ensure a safe environment for the child to be discharged into. Outside hospitals, including community and rural centers, may not have pediatric specialists readily available to effectively evaluate and manage pediatrics with facial trauma, thus prompting transfer to trauma centers in the setting of over-precaution. In pediatric patients within these age groups who did receive operative interventions for facial fractures, the specific type of surgical intervention they received was not positively or negatively correlated with residual symptoms or symptom resolution. Alongside previous studies, our data reinforces conservative management as an optimal management option for neonates and infants at the time of injury based on the type and characteristics of this age group’s facial fractures.

Children. This study provides further valuable insights into the management of facial fractures in children, highlighting distinct considerations on management modalities. 55% of patients in this age group received conservative interventions rather than surgical interventions for their facial trauma. Children who underwent fewer surgical procedures tended to report more residual symptoms post-discharge, and these symptoms were less likely to resolve compared to those who had more extensive surgical interventions. Moreover, children who sustained facial lacerations alongside fractures were more likely to report residual symptoms; however, they had a higher likelihood of residual symptom resolution compared to other patients in their age group. The most reported residual symptoms in this age group were related to scarring or scar contracture and were notably more likely to sustain these symptoms compared to adolescents. While lacerations may increase initial symptoms due to soft tissue damage, they may also prompt earlier interventions and meticulous wound care, contributing to better overall healing and resolution of symptoms. Scarring and scar contractures may be more pronounced in children due to their skin’s elasticity, potentially contributing to the higher reports of these symptoms in this age group. The facial skeleton developmental stage of patients in this age group may contribute to how fractures heal. Conservative treatments may be preferred to avoid interfering with growth plates to promote natural healing at this stage but may leave more potential for residual symptoms if fracture alignment isn’t precise. Surgical interventions must balance the need for correction with the risks of disrupting growth and realignment. Children who undergo more extensive surgeries might initially have a more controlled alignment of fractures, potentially reducing immediate symptoms but may introduce further complications or affect long-term healing and growth patterns. These insights underscore the complexity of managing facial fractures and trauma in children, as operative and conservative treatment decisions independently affect growth, healing, and longer-term impact on this age group’s outcomes [19].

Adolescents. Our study further highlights the unique challenges faced by adolescents in the context of facial trauma. Adolescents were significantly more likely to have a higher incidence of residual symptoms following discharge with a lower incidence of symptom resolution within a year of initial injury in the adolescent age group. Although 52% of these patients received operative interventions for their facial fracture management, adolescents were significantly less likely to be transferred from outside institutions for advanced care and to be admitted for further trauma care at either trauma institution. 42% of adolescents sustained midface fractures compared to other facial bones, most commonly the orbital walls and nasal bones. As one of the most reported complications in this age group was cosmetic complaints, aesthetic residual symptoms related to nasal deviation with and without operative management may contribute to the higher incidence of reported residual symptoms. Adolescents were significantly more likely to experience persistent headache symptoms compared to other age groups, which may be due to various physiological, psychological, or facial skeletal differences compared to other pediatrics. Notably, adolescents who did not undergo surgical interventions exhibited a lower likelihood of reporting residual symptoms, suggesting conservative management may be effective in minimizing long-term symptoms for this age group. Conversely, adolescents who underwent fewer total surgical interventions reported a higher incidence of residual symptoms, indicating partial surgical interventions might not sufficiently address the underlying cause of persistent facial trauma residual symptoms. Specifically, patients who received open reduction and internal fixation (ORIF) were less likely to experience residual symptom resolution, which may imply this type surgical intervention could be associated with a higher risk of prolonged symptoms due to the complexity of the procedure. Patients who received hardware, mesh, or orbital plates were more likely to report residual symptom resolution, suggesting this procedure may be more effective at addressing the underlying cause of persistent facial trauma residual symptoms. Overall, these findings highlight the need for careful consideration of treatment options for adolescents, weighing the effectiveness of surgical interventions with their potential to cause prolonged residual symptoms.

Future Directions

Understanding the differences seen in pediatric facial fractures may help tailor management strategies to optimize outcomes. This data supports conservative treatment for neonates and infants while highlighting the need for enhanced approaches and interventions for children and adolescents to minimize residual symptoms and improve recovery trajectories in this age group. These findings provide valuable insights that can refine the care of pediatric facial trauma related to tailored management strategies, resource allocation, improved longterm management and follow-up, and focused research and treatment innovation for this patient population. The use of conservative management in neonates and infants is reinforced by this age group’s high healing potential and unique facial skeletal characteristics, allowing for more confidence in nonoperative treatments, while reducing the risks associated with surgical procedures. The higher admittance rates despite lowenergy trauma in this age group may suggest the need for specialized monitoring protocols, such as hospital guidelines that ensure safe discharge predispositions, reducing unnecessary admissions while providing appropriate care. In adolescents, care strategies and management modalities may continue to be improved, as this age group experienced higher rates of operative interventions and residual symptoms. Future research may focus on detailed pre-operative planning, innovating surgical interventions and techniques, and reinforcing post-operative care and follow-up focused on cosmetic outcomes for this age group.

This data further accentuates the importance of having specialized pediatric care available in hospitals and trauma centers. By increasing efforts to distribute and promote access to pediatric specialists in community and rural hospitals, initial management and the need for hospital transfer may improve. Additionally, healthcare providers in non-specialized settings may benefit from pediatric facial trauma training, which may lead to better initial management and decision-making regarding transfers and treatment options. Monitoring and follow-up may be further improved by establishing long-term follow-up protocols for pediatric patients, especially adolescents, that focus on addressing residual symptoms effectively and long-term. Regular assessment post-discharge may detect and preemptively treat complications early on, improving overall outcomes in the long term. Symptom tracking at these visits may further allow for treatment protocol refinement based on the modalities that work for each age group, leading to personalized and effective care plans. Overall, this study highlights areas in pediatric facial trauma care that require further investigation, including optimization of children and adolescent fracture management and understanding factors that contribute to residual symptoms in each age group. Research focusing on treatment modalities, post-care strategies, and the unique healing characteristics of pediatrics may drive innovations in surgical technology that can be applied across pediatric care. These collective changes, research avenues, and plans of action may lead to better long-term outcomes, fewer complications, and higher satisfaction for patients and families.

Limitations

While our study provides valuable insights into the outcomes of pediatric facial trauma patients at 2 trauma institutions, it is important to acknowledge its limitations. One limitation of our study is the short timeframe of our retrospective study, which restricts our ability to comprehensively assess the long-term effects of both operative and conservative management strategies. This limitation is pertinent in evaluating long-term aesthetic concerns in younger pediatric patients, including nasal deformity or septal deviation, as well as mandible and occlusal disturbances. Furthermore, due to the retrospective study design, this patient group was not recalled for follow-up examinations aimed at evaluating these outcomes. Additionally, the 3-year duration of our study imposes restrictions on the availability of longitudinal data. Thus, while our current findings contribute valuable insights to the existing body of knowledge of pediatric facial trauma, further research with longer follow-up periods and more comprehensive assessment of outcomes is warranted to expand upon our findings.

Conclusion

This study aims to elucidate the optimal management options of pediatric facial fractures by examining injury mechanisms, fracture types, and interventions utilized at 2 North Carolina Level 1 Trauma Centers. The findings reveal significant differences across pediatric age groups regarding transfers, admittance, fracture types, interventions, and outcomes. Neonates and infants, with their healing potential and elastic facial skeletal structures, often received conservative management and had lower residual symptoms with higher resolution rates within a year. Conversely, adolescents experienced higher residual symptoms and lower resolution rates despite integrated surgical and conservative management. These differences underscore the need for age-specific management strategies to improve outcomes in this patient population. This study highlights the importance of specialized pediatric care and the necessity for long-term follow-up care to monitor and address residual symptoms effectively. These insights suggest that conservative management is optimal for neonates and infants, while enhanced surgical and postoperative strategies are needed for children and adolescent facial trauma patients. Recognizing the consequences of pediatric facial trauma is vital for comprehensive care and plays an important role in promoting safety and injury prevention in this population. Future research in these areas may lead to a better understanding of the mechanisms, patterns, and clinical aspects of pediatric patients with facial fractures, and should focus on refining approaches to improve long-term outcomes for pediatric facial trauma patients.