Paediatric Facial Fracture
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Direct answer
Fractures in children obey different rules from adults: elastic bone with a thick periosteum fails in greenstick fashion, the condyle absorbs a disproportionate share of mandibular injuries, and the goals of treatment are restoration of function now and protection of growth afterwards — not anatomical perfection. Most paediatric condylar and greenstick fractures are treated conservatively with analgesia, a soft or liquid diet, short-duration guiding elastics or bite-raising splints and early physiotherapy, because prolonged maxillomandibular fixation invites the twin disasters of ankylosis and growth disturbance. Open reduction is reserved for grossly displaced fractures of the symphysis, body and ramus, using small plates and screws placed between the tooth buds, with resorbable plating attractive in the growing child. Every condylar injury is followed until facial growth is complete.
What you must remember
- Epidemiology anchors: paediatric maxillofacial fractures form a minority of all facial fractures (figures up to about fifteen per cent are quoted), the mandible is involved in roughly a fifth to half of them, and the condyle is the commonest mandibular site — falls dominate in the young, road traffic injuries in older children.
- Greenstick biomechanics: one cortex breaks while the elastic opposite cortex and dense periosteum bend — hence minimal displacement and frequent healing by remodelling.
- Condylar patterns: intracapsular fractures and the classic greenstick bowing occur in the young; higher-energy displaced and diacondylar (T-shaped) fractures cluster in the 5-12 year group; the Loukota classification (condylar head, neck, base, with Neff's modifications) standardises description.
- Conservative protocol: analgesia, liquid to soft diet advancing as tolerated, guiding elastics or a bite-raising splint with molar pads for an anterior open bite, jaw physiotherapy from the early weeks, and weekly review for the first month.
- Fixation, when needed: the tooth-free zones below the deciduous roots and above the buds host 2.0 millimetre or 1.5 millimetre plates; monocortical screws only; resorbable plates spare a second anaesthetic.
- The ankylosis axis: intracapsular condylar injuries in young children carry the highest ankylosis risk — hence early mobilisation — and established ankylosis presents years later with trismus and facial asymmetry.
- Growth surveillance: reviews at six and eighteen months, then annually until growth completion, watching for condylar hypoplasia, open bite and asymmetry.
A five-year-old with a swollen chin after a fall
A five-year-old falls from a slide onto the chin: pain, drooling, an anterior open bite, and refusal to close the teeth. The trauma survey comes first — chin laceration hints at the mechanism, and the clinician examines the condyles bilaterally, because a symphyseal blow commonly drives a condylar injury on the far side. Imaging today is a CT with three-dimensional reconstruction, since plain films miss intracapsular detail in a child's condyle.
The CT shows a minimally displaced greenstick fracture of the left condylar neck with haemarthrosis and a hairline symphyseal crack. Management: nothing operative. Analgesia, a liquid diet for a week advancing to soft solids, guiding elastics if the open bite persists, and active physiotherapy — chewing gum, stacking tongue blades — begun early, because in this age group remodelling is remarkable and stiffness is the enemy.
The tail of the plan is what students forget: reviews at six and eighteen months, then yearly until the mid-teens, because a condyle that stops growing yields asymmetry and an open bite years later — the fracture is not finished when the pain stops.
Viva angles examiners love
Three questions recur in Indian oral surgery vivas. First, why is conservative treatment the default in paediatric condylar fractures — the expected answer combines the child's remodelling potential, the ankylosis risk of open surgery near the disc, and excellent functional results of mobilisation protocols. Second, what makes plating a child's mandible different — tooth buds dictate screw position and monocortical length, resorbable hardware avoids late migration in growing bone, and periosteum stripped unnecessarily commits theft against growth. Third, the dentoalveolar companion question, since avulsed and luxated deciduous and permanent teeth are the commonest paediatric oral injuries of all; managing a permanent incisor with a companion alveolar fracture sits comfortably in the same viva. Mentioning that condylar dislocation into the middle cranial fossa, though exotic, is a described injury earns the examiner's raised eyebrow.
Frequently asked questions
Why are paediatric mandibular fractures so often greenstick?
Young bone is elastic with a thick periosteum, so one cortex fractures while the other bends, giving stable, minimally displaced injuries.
What is the default treatment for a child's condylar fracture?
Conservative functional care — analgesia, diet progression, brief guiding elastics or a bite-raising splint and early physiotherapy — reserving surgery for gross displacement.
Why is prolonged maxillomandibular fixation avoided in children?
Stiffness, poor nutrition and above all temporomandibular joint ankylosis, which converts a minor injury into a decade of surgeries.
Where are plates and screws placed in a child's mandible?
Low on the inferior border or in tooth-free windows, with monocortical screws avoiding the deciduous roots and the developing tooth buds, favouring resorbable plating.
How long must a condylar fracture in a child be followed?
Until facial growth is complete — typically reviews at six and eighteen months, then annually — watching for ramus shortening, asymmetry and malocclusion.