Pediatric Dental Health

October 1, 2003

MANAGEMENT OF FACIAL TRAUMA IN CHILDREN
The face allows recognition and communication among people. No other part of the body is as aesthetically important as the face. Facial injuries can range from a minor inconvenience to a lifetime disfigurement. For this reason, any injury to this area requires particular care and attention during treatment.

In the United States, approximately 3 million people are treated in a hospital emergency department for traumatic facial injuries each year. Five percent of pediatric trauma patients have facial fractures. Falls are the most common cause of facial fractures in children younger than 3 years of age. After 5 years of age, the leading cause of facial fractures is motor vehicle collisions.

The nasal bones and mandible (jaw) are the two most frequent sites of facial fracture. Mandibular fractures occur in 7.7% of children younger than 16 years of age. An equal incidence of mandibular fractures exists between both sexes. Trauma to the condylar growth center (the neck of the jaw) beneath the articular disk may cause delayed growth of the affected side of the jaw.

EMERGENCY EVALUATION OF FACIAL TRAUMA:

First, perform a primary survey and assess airway, breathing and circulation. Note that mobile fracture segments, edema (swelling), hemorrhage (bleeding), vomitus, bone fragments, and foreign bodies may cause obstruction of the airway. The airway is always the first priority in treatment of the trauma patient. In any trauma patient, be sure to obtain cervical spine x-rays to rule out neck injury. A complete set of vital signs including: temperature, pulse, blood pressure, and pulse oximetry should be obtained on every patient.
Second, perform a thorough trauma physical examination.
Third, inspect the face inspected for symmetry, swelling, or ecchymosis (bruising). The face is palpated bimanually in an orderly fashion – beginning at the cranial vault, then proceeding to the forehead, orbital rims (bone surrounding the eyes), zygomatic arch (cheek bone), maxillary alveolus (upper jaw bone), and the mandible (lower jaw). Numbness of the infraorbital, supraorbital, and mental nerve distributions may indicate a cut or stretched nerve. Gently palpate the nasal area for crepitus, tenderness, or subcutaneous emphysema (air). Swelling, ecchymosis (bruising), crepitation (fine crackling), and facial asymmetry may indicate an underlying fracture. Look for enopthlalmus (sunken-in eyes), exopthalmus (protruding eyes), periorbital ecchymosis, and postauricular ecchymosis (bruising behind the ears - Battle’s sign). Note that Battle’s sign is associated with basilar skull fractures. Examination of the inside of the ear with an otoscope may reveal a hemotympanum (bleeding of the eardrum), which indicates either a basilar skull or temporal bone fracture.
Fourth, check for maxillary, mandibular, and zygomatic fractures.
Check for maxillary Le Forte fractures by grasping the maxilla intraorally, and attempt to gently “rock” it back and forth. Movement of the maxilla indicates a fracture.
Check for mandibular fractures by having the patient attempt to bite on a tongue depressor while you gently twist it – mandibular fracture patients cannot accomplish this task.
Examine the zygomatic (cheekbone) region by visual inspection, external palpation, and intraoral palpation. Palpate intraorally above the buccal surface of the upper molars to differentiate a zygomatic arch fracture from tenderness.
Fifth, perform an intraoral examination. Check the oral cavity for dentoalveolar trauma . It is important to account for all teeth, since the patient may have aspirated or ingested them. Check to see that the patient’s bite is normal. The mandible should not deviate to any side during opening.
Sixth, inspect for signs of nerve deficit. Cranial nerve VII (facial nerve) controls the muscles of facial expression and should be checked by having the patient smile, frown, wrinkle the forehead, and close the eyes tightly. The three branches of cranial nerve V (trigeminal nerve) should then be examined, since it controls sensation to the face.
Eyebrows that cannot be raised, and eyelids that cannot be closed – injury to the temporal and zygomatic branches of the facial nerve.
Inability to frown – injury to the marginal mandibular branch of the facial nerve.
Inability to smile – injury to the buccal branch of the facial nerve.
Wrinkles on the cheek – infraorbital nerve injury (a branch of the trigeminal nerve).
The following screening questions can help evaluate sites of injury:
"Where does your face hurt?" This helps uncover hidden problems.
"Do you notice a difference in vision?" Binocular diplopia (a different image in each eye) is often caused by impaired extraocular muscle movement due do an orbital bone fracture. Monocular diplopia (two images seen by the same eye) usually results from retinal detachment or globe rupture.
"Do your teeth fit together?" Most maxillary or mandibular fractures will cause a malocclusion (a poor fit of the teeth).
"Does it hurt when you open your mouth?" Pain during opening can indicate that a fracture has occurred – perhaps in the zygoma, mandible, or elsewhere.

EMERGENCY MANAGEMENT OF FACIAL TRAUMA:
The primary survey should be conducted rapidly, with evaluation of the ABC’s of Airway, Breathing, and Circulation.
The first priority in managing a child with trauma is ensuring that the airway is clear and open. Foreign objects and blood must be removed from the airway. Carefully suction blood and debris from the oropharynx. Presume that a cervical spine injury exists until excluded. One method of controlling the airway in such cases is the jaw thrust maneuver. Pulling the tongue forward also opens the airway. A patient who is awake and free of cervical spine injury may be allowed to sit up and lean forward - and use a suction device himself.
Note that orotracheal intubation may be necessary to manage the airway in an unconscious patient. In addition, intubation should be considered if oxygen desaturation occurs. The usual approach for airway intubation in a facial trauma case is the rapid sequence oral intubation technique, with the Selick maneuver. Using a nondepolarizing muscle relaxant such as Vecuronium may prevent the elevation of intracranial pressure in the presence of head trauma. Intubation should be performed with the head in the midline and cervical immobilization. Oral intubation with in-line stabilization of the C-spine has now been incorporated into the ATLS protocol. Cricothyrotomy may be needed in patients who have massive pharyngeal edema.
Assessment of breathing and circulation are next. The evaluation of circulation includes monitoring the child’s pulse, perfusion, blood pressure, and oxygen saturation (pulse oximetry). Vascular access should be obtained and isotonic crystalloid boluses, 20 ml/kg, are administered as needed.
Control of hemorrhage is the next priority. Intranasal packing may help if direct pressure does not stop severe epistaxis (nasal bleeding).

ANESTHESIA:
The facial nerve (cranial nerveVII) provides motor innervation to the muscles of facial expression. The facial nerve divides into the temporal, zygomatic, buccal, mandibular, and cervical branches.
Sensory innervation of the face derives almost entirely from the trigeminal nerve (cranial nerve V). The trigeminal nerve is divided into three sections: the ophthalmic division, the maxillary division, and the mandibular division (which are mixed sensory and motor nerves). Four regional nerve blocks can be used to treat injuries to the outside of the face: the supratrocheal, supraorbital, mental, and infraorbital. By using nerve blocks, there is decreased systemic toxicity and less volume-related tissue distortion. For injuries to the mucosal membranes of the nose, cocaine 5% is the topical anesthetic agent of choice – which can be introduced with a cotton-tipped applicator.
Lidocaine 1%, with or without epinephrine, is commonly used for facial local anesthesia. Local anesthetics have a low margin of safety between the effective dose and the toxic dose. The lethal dose for many local anesthetics is only 3 times that of the effective dose. The maximum safe dose of lidocaine for a child is 4.5 mg/kg per dental appointment. Bupivicaine (Marcaine) is an amide local anesthetic with a high toxic potential, and should not be used in children. Lidocaine is less toxic than many other local anesthetics, because its interactions with the cardiac sodium channel are “fast in – fast out,” whereas a local anesthetic such as bupivicaine is "fast in – slow out.” When sedating a child, the local anesthetic dose should be lowered to decrease the risk of toxicity and complications.

WOUND DECONTAMINATION, EXPLORATION, AND CLOSURE:
Removing bacteria and devitalized tissue is critical in wound treatment. Irrigation with an 18-gauge catheter attached to a 60 ml syringe is required for wound irrigation. Use normal saline to irrigate facial wounds. Wounds that have gross contamination should be carefully scrubbed with a fine-pore sponge, because foreign particles which are allowed to remain in the skin can cause “tattoing.” Devitalized tissue needs to be removed, using a number-15 blade or iris scissors. The skin surrounding the wound may then be prepared with a 1% solution of provodine iodine, and the laceration area draped in a sterile fashion before suturing.
After adequate anesthesia and wound cleansing has been provided, explore the wound with tissue forceps or tip of a scalpel blade to search for foreign bodies and sources of bleeding. Radiographic film can be used to visualize foreign bodies – especially glass and gravel.
Wounds of the face may be closed up to 24 hours, but ideally within 8 hours after the injury, in healthy children. Wound edges should not be ragged or irregular, so it may be necessary to remove a small amount of devitalized tissue to create perpendicular wound edges prior to suturing. To avoid tension on the skin sutures, the wound edges may need to be undermined with a scalpel blade before they can be approximated. Simple interrupted sutures (6- monofilament) should be used for most skin closures. The wound edges should be everted during suturing to prevent a future wound edge concavity. Small wounds that are under minimal tension may be closed with “skin glue” (butyl-2-cyanoacrylate).
Prophylactic coverage with a cephalosporin is usually necessary to prevent infection of the face after trauma. A first-generation cephalosporin acts on most skin flora.
If bone has been exposed through an intraoral or cutaneous laceration, then antibiotics are definitely indicated. A sinus blow-out fracture also required antibiotics. Penicillin acts on most mouth flora.
Antibiotic ointment should be applied for the first 2 days after the skin repair. Washing and showering can begin 24 hours after the repair. Facial sutures are removed 4-5 days after placement, but eyelid sutures are removed 3-4 days after placement. Sutures placed in the ear are left in place for 11-14 days.

MIDFACE INJURY:
A. Evaluation:
Midface fractures can be classified as Le Fort I, II, or III. Le Forte I is a fracture separating the palate and alveolus from the rest of the maxilla – a fracture which occurs above the roots of the teeth. This mobile maxillary segment moves like a “loose denture.”
Le Fort II separates the midface from the skull, creating a free-floating pyramidal segment. This fracture also includes a mobile palate.
Le Fort III involves a complete separation of the face from the cranial base. The mobile segment includes the maxilla, palate, zygoma, and ethmoid bones. It is a “craniofacial separation”.

B. Imaging and radiology:
The standard facial film series for trauma includes four projections: the Waters’ (occipitomental), Caldwell’s (occipitofrontal), lateral, and submentovertex (“jug handle”) views.
The Waters’ projection is the most valuable view of the midface: the zygoma, nasal bones, orbital rims, maxilla, and floor of the orbit are shown. It is a posterior-anterior projection with the x-ray beam angled 37 degrees caudad to the canthomeatal line. The patient is prone (face down) for this view.
The Caldwell’s projection shows the middle and upper parts of the face: superior orbital rim, frontal sinuses, and orbital region. The x-ray beam is angled 15 degrees caudad to the canthomeatal line.
The lateral view shows: the anterior wall of the frontal sinus, nasal bones, and walls of the maxillary sinuses.
The submentovertex projection shows the zygomatic arches. This view also requires that the patient be prone – but with hyperextension of the neck. Therefore, the cervical spine must be cleared first.

C. Definitive care:
Rapid healing occurs in pediatric bone. Therefore, perform definitive rigid fixation of the mobile bony segments within 5 days after the injury. Strive to establish normal occlusion, facial proportions, and facial symmetry. To avoid disturbing long-term growth and development, the surgeon needs to fixate malposed fragments using as little dissection as possible.

NASAL INJURY:
A. Evaluation:
First, gently palpate the nasal area for crepitus, tenderness, or subcutaneous emphysema. A gross midline deviation of the nose usually indicates underlying fractured nasal bones or cartilage. Using a nasal speculum, perform a careful inspection of the nasal cavity to exclude a nasal septal hematoma.
A septal hematoma should be promptly aspirated with an 18-gauge needle, and then drained to avoid infection and necrosis. This step will prevent development of a “saddle-nose” deformity. A septal hematoma appears as a purplish swelling of the nasal septum. To determine the presence of CSF in the blood, place a drop of blood on a piece of gauze or filter paper. Then observe for the appearance of the “target sign” – a ring of cerebrospinal fluid surrounding a ring of blood.

B. Emergency care:
Drain septal hematomas quickly to prevent collapse of the dorsum of the nose, due to necrosis or superinfection. Use a simple incision or 18-gauge needle, nasal packing, and penicillin prescription.
Any nasal cartilage laceration requires thorough irrigation. For full-thickness lacerations of the nose, close the mucous membranes first – then align and close the cartilage and skin with non-absorbable interrupted sutures.
If there is swelling due to a fractured nose, the patient should be re-examined in 2-5 days. The child should then have the nose fracture corrected under general anesthesia.
Treatment options for anterior epistaxis (nose bleed) include: application of direct pressure, vasoconstrictors, cautery, and nasal packing. Direct pressure can be applied by squeezing the nares with thumb and forefinger. Vasoconstrictor agents may be sprayed into the nose, or placed on a large cotton ball – and then put into the nasal cavity. Chemical cautery with silver nitrate sticks work well on small bleeders. Anterior nasal packing is done with half-inch gauge impregnated with antibiotic ointment – but proper anesthesia must be obtained first. Posterior epistaxis is treated with posterior nasal packing. Posterior packing can be accomplished using nasal sponges, gauze roll, or special epistaxis balloons.

ORBITAL INJURY:
A. Evaluation :
After lifesaving measures, maintenance of vision is the most important priority in treating maxillofacial trauma.
The orbit of the eye consists of 7 bones which have varying thickness. Orbital wall and floor fractures may be associated with entrapment of extraocular muscles, which can result in: restricted gaze, double vision, ecchymosis, and ptosis. Large orbital roof fractures may cause exopthalmos (eyeball protrusion), vertical dystopia (displacement), and orbital encephalocoele (herniation of part of the brain).
The thinnest part of the orbital wall is the floor of the orbit. A true blowout fracture involves the orbital floor, while sparing the orbital rim. Blowout fractures are caused when an object larger than the size of the orbit impacts the orbit. Symptoms of orbital floor fracture include: periorbital echymosis, eyelid edema, subconjunctival hemorrhage, diplopia (double vision), bony step-offs, and pain.

B. Imaging and radiology:
Orbital floor fractures are best visualized with coronal CT scanning.

EYE INJURY:
A. Evaluation:
An examination of the eyes includes evaluating: visual acuity, pupil symmetry and reactivity, papillary reflexes, evidence of diplopia, and extraocular muscle movements. The eyelids, sclera, and conjunctiva should be examined for hemorrhage, lacerations, and foreign bodies. The cornea should also be evaluated for laceration, tears, abrasions, and foreign bodies. Fluorescein staining should be performed with a cobalt blue light to find corneal disruption. The examiner should ask whether the patient was close to a metal grinder or other power tool when the accident occurred – because there could be some metal fragments which have penetrated into the globe of the eye.
An affected upward gaze is due to entrapment of the inferior rectus muscle in a blow-out fracture of the orbital floor. Entrapped oculomotor muscles result in restricted eye movement. Monocular diplopia (blurring of vision through one eye) requires immediate referral to an ophthalmologist because it usually indicates a detached lens, hyphema, or other injury to the globe. A teardrop pupil suggests a penetrated or ruptured globe - immediate referral to an ophthalmologist. A funduscopic examination will reveal any retinal injury - immediate referral to an ophthalmologist.

B. Imaging and radiology:
A CT scan with lateral oblique “cuts” through the globe will help visualize the bone surrounding the orbit.

C. Emergency care:
A chemical injury calls for immediate flushing of the eye for 30 seconds, or until an eye pH of 7.5 is attained. Alkali chemical burns of the eye cause progressive destruction of ocular tissues, and are actually more serious than acid burns of the eye.
The eyebrow should not be shaved for any reason. When repairing deep lacerations ot the eyebrow, a layered repair will prevent abnormal eyebrow movements.
For corneal abrasions, do not give the patient topical anesthetics, because this may cause irreversible corneal damage. Treatment of corneal abrasions involves irrigating the eye with a sterile saline solution to remove the debris. Treatment of a corneal foreign body involves using a topical anesthetic, and then using the tip of a hypodermic needle to remove superficially embedded foreign bodies. In the case of a metallic foreign body, a rust ring may develop if the particle remains – so this requires referral to an ophthalmologist.

D. Definitive care:
The eyelid is the most delicate structure of the face, and consists of several layers of fine muscle. Improper eyelid repair may result in ptosis or a retracted eyelid. The key suture must be placed in the ciliary margin of the eyelid, and wound margins must be carefully aligned. Injuries of the eyelid margins or lacrimal apparatus, or any injury involving loss of lid tissue should be repaired by a specialist.

Treatment of hyphema (blood in the anterior chamber) needs to be treated by an ophthalmologist and admission to the hospital. Lens subluxation requires prompt referral to an ophthalmologist for surgical repair. A ruptured globe is an ophthalmologic emergency – this patient should not be allowed to eat or drink and should be transferred to an eye trauma center for treatment.

EAR INJURY:
A. Evaluation:
Examine the ears for injury or CSF leak. A shearing force or blow to the ear can result in “cauliflower ear.” This problem is caused by a subperichondrial hematoma – which should be aspirated immediately.
Blood or pain in the external auditory canal may indicate a mandibular condylar fracture. During an otoscopic examination, appearance of a tympanic membrane rupture or hemotympanum (bleeding eardrum) may also suggest a basilar skull fracture.

B. Emergency care:
Carefully clean and debride ear injuries. Anesthetics without vasocontrictors should be used to prevent ischemia of ear tissue.
The main goal of treating an ear injury is protecting cartilaginous structures. Treatment of otohematomas involves repeated aspiration and compression to prevent fluid accumulation. Any subperichondrial hematoma should be aspirated with an 18-gauge needle, and a compression dressing should be applied for 7-14 days. Any ear injury should be splinted by placing cotton balls between the ear and head – and then wrapping with a circumferential dressing around the head.

C. Definitive care:
A linear laceration of the ear usually requires closure in 3 layers – the cartilage, perichondrium, and skin. Avulsions and amputations of the ear tend to heal well after reattachment, because the ear has a highly vascular pedicle.

MANDIBULAR INJURY:
A. Evaluation:
After the nose and zygoma, the mandible is the third most likely bone in the face to fracture. Mandibular condylar fractures account for 60% of all mandibular fractures in children. Mandibular fractures in children often occur through developing tooth crypts. Fractures of the mandible are usually associated with tearing of the gingival tissue – and hematomas on the buccal and lingual sides of the intraoral aspect of the mandible.
First, examine the patient’s face for swelling and asymmetry. Palpate the borders of the mandible to find any sharp irregularities – which would indicate a mandibular fracture. Palpation of the external auditory canal during jaw movement may reveal a condylar fracture. A chin laceration in a young child may indicate that the force may have damaged the condyles. Restricted jaw motion can indicate either a condylar fracture, or a displaced zygomatic fracture impinging on the coronoid process of the mandible. Before performing an intraoral examination, assess the sensitivity in the distribution of the mental nerve using a cotton swab with the patient’s eyes closed – comparing one side to the other.
Next, palpate the tooth-bearing regions of the mandible (the alveolus), using two gloved hands for comparison. The patient should also be asked to bite together to assess the dental occlusion.

B. Imaging and radiology:
The mandibular series and panoramic projections are useful for visualizing mandibular fractures. The standard mandibular series includes four projections: posteroanterior (PA), Towne’s, and left and right lateral oblique. The occlusal view demonstrates a symphysis fracture. The panorex is the radiograph of choice for mandibular fractures, but plain radiographs are often easier to obtain in a hospital setting.
The PA view is obtained with the patient lying prone.
The Towne occipitofrontal view (an AP view) demonstrates condylar fractures very well. It is an AP projection created by having the patient lay supine. For this view, the x-ray beam is directed 35 degrees caudad through the frontal bone. In the resulting image, the patient’s head appears to be very elongated.
The lateral oblique views are best suited for viewing fractures of the condylar process, coronoid process, body, ramus, and angle of the mandible. For this projection, the x-ray beam is directed 20 degrees cephalad to the occlusal plane, and towards the center of the x-ray cassette.

C. Emergency care:
In patients with bilateral condylar fractures, the mandible will be displaced posteriorly, which occasionally results in airway compromise. Prophylactic antibiotics (penicillin G or penicillin VK) should be started as soon as possible when there is a mandibular fracture – to protect the wounds from intraoral bacterial contamination. Clindamycin can be used for patients who are allergic to penicillin.

D. Definitive care:
Surgical treatment and fixation of mandibular fractures must restore occlusion, function, and facial harmony. Surgery is not indicated in most pediatric condylar fractures, however. Most pediatric patients with condylar fractures may be treated non-operatively. For greenstick and nondisplaced fractures of the mandible, management is limited to analgesics and a soft diet. Range of motion excercises should be encouraged after the initial edema has subsided.
Jaw immobilization is required when there is a bilateral condylar fracture, or a severe limitation or deviation of movement. If immobilization is necessary, 2-3 weeks are usually adequate in children, followed by 6-8 weeks use of guiding elastics.

PAROTID GLAND INJURY:
A. Evaluation:
The parotid gland is located superficially in the cheek, and is vulnerable to facial trauma. A clear discharge from a cheek wound indicates parotid gland injury. Patency of the parotid duct should be ensured by milking the parotid gland, and observing the flow of saliva from Stensen’s duct (located in the cheek opposite the upper first molar).
To determine if the parotid duct was transected, a small catheter is placed in the parotid duct orfice. If there is duct transaction, the cathether will exit out of the distal end of the duct and become visible in the wound area. The proximal end of the severed duct may be identified by massaging the gland to express saliva. The severed ends can then be reconnected.

B. Definitive care:
A severed parotid duct can be anastamosed over the exploratory catheter using 7-0 monofilament sutures. The catheter may be left in place for 5-7 days to ensure duct patency.

LIP INJURY:
A. Evaluation:
Be sure to inspect the inside of the lips for through-and-through lacerations.

B. Definitive care:
Lacerations across the vermilion border require an exacting technique, because a 1mm step-off at the lip border is apparent at a conversational distance. Therefore, the edge of the vermilion border should be marked with a surgical marker before performing any injection or cleansing of the area.
The first anchoring suture should approximate the two sides of the laceration at the white roll. Since the area of the philtrum (Cupid’s bow) is irreplaceable, this area should also be marked before edema sets in – to prevent improper suture placement. Regional blocks (of the infraorbital and mental nerve) are preferred to infiltration to prevent lip distortion during suturing. The musculature is closed first, then the mucosal surface of the lip (absorbable sutures), and the outside of the lip last (6-0 interrupted nonabsorbable sutures).

ANIMAL BITES:
A. Evaluation:
The nose, mouth, and parotid gland areas are the primary targets for dog bites. The better the blood supply to the wound, and the easier it is to clean the wound – the lower the risk of infection. Most deaths in children occur due to hemorrhage from the great blood vessels of the neck.

B. Emergency care:
Copiously irrigate the facial wound with isotonic sodium chloride solution. Excise macerated or necrotic tissue.
Check the child’s shot record to see when the last tetanus shot was given. If child has not had a tetanus booster within 5 years, another one will need to be administered within 3 days. If there is any possibility of rabies, the dog should be carefully observed for 10 days for any signs of sickness.

C. Definitive care:
The dog bite injury should be documented with photographs and diagrams, if necessary. Proper medical treatment for dog bites requires an understanding of the canine oral bacteria which cause infections. The most common aerobic bacteria in bite wounds are: Pasturella, alpha-hemolytic Streptococci, and Staphylococcus aureus – occurring in 20 to 30 percent of infected dog bite wounds. The most common anaerobic organisms are Bacteroides and Fusobacterium – which are found in up to 41% of dog bite wounds.
X-rays may be necessary to determine underlying bone or joint injury, because dogs can exert a tremendous force when biting.
Animal bites should be separated into high risk and low risk groups when deciding on whether to suture the wounds or provide antibiotic coverage. Proper bite wound care includes: inspection, debridement, irrigation, and if indicated – closure.
High-risk wounds generally require antibiotics. The bite wound should be cleansed carefully and irrigated with normal saline under pressure using a 19-gauge blunt needle, and a large syringe. Bacterial cultures obtained at the time of injury are not useful, because they do not predict infections. High-risk wounds include: wounds of the hand or foot; deep puncture wounds; surgically debrided wounds; wounds involving the joints, ligaments, tendons, and bones; dog bites where treatment has been delayed more than 12 hours; and bites in immunocompromised patients. High-risk wounds should not be sutured, but should receive antibiotic treatment. In that case, a beta-lactam antibiotic, such as Augmentin, should be prescribed for at least 10 days.
Low-risk wounds include bites to the face and body. After a thorough search for damaged salivary ducts, facial nerve, and blood vessels – many facial wounds can be sutured. Low-risk wounds may be sutured, especially in the face.
If the wound is less than 6 hours old, and the margins of the wound are clearly delineated – then close the wound with fine interrupted sutures. If the wound is more than 6 hours old, closure of the wound may be deferred to prevent infection and wound dehiscence.
Appropriate tetanus and rabies prophylaxis should be provided based on the child’s medical history. Rabies vaccine must be administered, unless it can be proven that the animal was not rabid. If the animal can be observed, it will develop signs of rabies in 10-14 days – if it is rabid. Antibiotics are always administered in cases of animal bites.

REFERENCE ARTICLE
An article in Journal of the American Academy of Physician Assistants discusses the management of facial fractures. The article describes: performing the facial trauma workup, how to perform a physical examination of the trauma patient, taking radiographs of the trauma area, and initial management in the emergency department.

Ponsell, MR. Assessing facial fractures in the emergency department. JAAPA. May 2003.

Copyright ©2003 Daniel Ravel, DDS