What is the recommended management for a 9-year-old patient with a history of trauma (brawl) presenting with a hematoma bruise on the side of the face?

Management of Facial Hematoma in a 9-Year-Old Following Trauma

For a 9-year-old with a facial hematoma from a brawl, immediate assessment should focus on ruling out underlying facial fractures and ensuring hemodynamic stability, while also documenting the injury pattern to evaluate for non-accidental trauma. 1, 2

Initial Clinical Assessment

Perform a focused examination to identify:

• Signs of airway compromise from soft-tissue edema or hemorrhage 1
• Hemodynamic status using vital signs (heart rate, blood pressure, respiratory rate) 1, 3
• Palpation of facial bones for tenderness, step-offs, or crepitus suggesting fractures 1
• Visual acuity and cranial nerve function, particularly trigeminal nerve distribution 1
• Dental occlusion abnormalities 1
• Signs of deeper injuries beyond the visible hematoma 4

Document the injury pattern photographically to capture bruise location, size, shape, and any patterning, as bruise appearance changes rapidly and this documentation is critical if non-accidental trauma is suspected. 4

Red Flags Requiring Immediate Action

Evaluate for concerning features that mandate further investigation:

• Patterned bruising (belt marks, hand prints, or object imprints) indicating inflicted injury 1, 2
• Additional injuries unrelated to the reported trauma (burns, whip marks, frenulum tears) 1
• History inconsistent with the child's developmental capabilities or injury severity 2, 5
• Witnessed or confessed abuse, or history of domestic violence 1

At 9 years old, a single facial bruise from a reported brawl does not automatically trigger skeletal survey requirements, as this age group commonly sustains accidental injuries. 1, 4 However, if any of the above red flags are present, skeletal survey becomes necessary regardless of age. 1

Imaging Decisions

For hemodynamically stable patients with facial trauma:

• CT of the facial bones with contrast is the preferred imaging modality to identify fractures and active bleeding 1, 3
• Assaults are more likely to produce midface and zygomatic fractures compared to other mechanisms 1
• The most commonly fractured facial structures are nasal bones, orbital floor, zygomaticomaxillary complex, maxillary sinuses, and mandibular ramus 1

Imaging is not routinely required if the child is hemodynamically stable, has no bony tenderness on palpation, normal cranial nerve function, and the injury pattern is consistent with the reported mechanism. 1, 3

Hematoma-Specific Management

For the soft tissue hematoma itself:

• Apply direct pressure to limit expansion 3
• Monitor for compartment syndrome signs (the "5 P's": pain, pressure, pallor, paresthesias, pulselessness) and progressive swelling 3
• Most facial hematomas resolve spontaneously without intervention 6, 7
• Evacuation is only necessary if there is risk of overlying skin necrosis from increased tissue pressure or if the hematoma is causing functional impairment 6

Laboratory Evaluation

Bleeding disorder workup is NOT routinely indicated for a single facial bruise with a consistent trauma history in a 9-year-old. 2, 8

However, obtain CBC, PT, aPTT, and peripheral blood smear if:

• Bruising is disproportionate to the reported trauma severity 2, 4
• Multiple bruises are present in unusual locations (ears, neck, trunk, buttocks, genitals) 2, 4
• Personal or family history of bleeding symptoms exists 2, 8
• The child is on medications affecting coagulation (NSAIDs, anticoagulants, corticosteroids) 2

Critical pitfall: Normal PT/aPTT does not exclude all bleeding disorders, as von Willebrand disease and Factor XIII deficiency require specific testing. 2, 8 However, extensive bleeding disorder testing without clinical indication is inappropriate given the extreme rarity of these conditions. 2

Non-Accidental Trauma Evaluation

At 9 years old, location and pattern matter more than the mere presence of bruising. 4

Low-risk features suggesting accidental trauma:

• Bruise on bony prominences (forehead, chin, scalp) 1, 4
• Consistent history matching the injury pattern 4, 5
• No additional concerning injuries on examination 4
• Developmentally appropriate mechanism (school-age children commonly sustain facial injuries in fights) 4

High-risk features requiring child abuse pediatrician consultation:

• Patterned bruising 1, 2
• Bruising on ears, neck, or torso in addition to facial injury 2, 4
• Implausible or changing explanations 2, 5
• Delay in seeking care 5

Disposition and Follow-Up

Admit to the hospital if:

• Hemodynamic instability is present 3
• Facial fractures requiring surgical intervention are identified 1
• Compartment syndrome risk exists 3
• Non-accidental trauma is suspected and the child's safety cannot be ensured 2

For stable patients managed conservatively:

• Arrange follow-up within 48-72 hours to reassess 3
• Provide return precautions for worsening swelling, vision changes, or neurologic symptoms 1
• Ensure adequate tetanus prophylaxis 7