Restraint Status Influences Fracture Phenotypes and Operative Management in Pediatric MVC-Related Facial Trauma

BACKGROUND: Motor vehicle collisions (MVCs) are a leading cause of pediatric facial fractures. While the protective effects of restraints are well-established, the impact on surgical management remains underexplored. This study evaluated operative rates by restraint status and fracture phenotype. METHODS: The authors reviewed patients aged 18 years or younger with facial fractures after MVCs (January 2006-February 2025), comparing restrained (Rmvc) versus unrestrained (Umvc) groups. Outcomes included operative management, fracture patterns, traumatic brain injury (TBI), cervical spine injury (CSI), skull fracture, and intensive care unit (ICU) admission. Multivariable logistic regression identified predictors of operative management. RESULTS: Among 578 patients, 313 (54.2%) were Rmvc, and 265 (45.8%) were Umvc. Umvc patients had higher fracture burden (2.6 versus 2.2, P=0.04), zygomatic (19.6% versus 11.8%), maxillary sinus (41.1% versus 30.7%), pterygoid (11.7% versus 5.8%), and Le Fort fractures (10.6% versus 4.8%) (all P<0.05). Umvc was associated with increased operative management (37.7% versus 27.2%, P<0.01), ICU admission (48.7% versus 36.1%, P<0.01) and concomitant injuries, including CSI (11.3% versus 6.4%, P=0.04), TBI (46.8% versus 36.5%, P=0.01), and skull fractures (45.3% versus 34.8%, P=0.01). After adjustment, Umvc had higher odds of operative management (aOR: 1.86, 95% CI: 1.26-2.75, P<0.01). CONCLUSIONS: Restraint use was associated with lower fracture burden, less complex injury patterns, fewer concomitant injuries, and a reduced likelihood of surgery in pediatric facial fractures. These findings reinforce the importance of age-appropriate restraint use and may aid in early risk stratification. LEVEL OF EVIDENCE: Level III-retrospective cohort study.