Facial fractures are relatively uncommon in children, owing largely to close caretaker supervision, increased skeletal flexibility due to pliability of the bones, incomplete pneumatization of the sinuses and increased padding around the face via relatively large fat pads compared to their adult counterparts. However, when these fractures occur, they can pose a challenge in coordination of management among the trauma, facial surgery, and pediatric protection teams.

In regard to pediatric mandibular fractures specifically, the condylar process and subcondylar region are most frequently affected with highest occurrence in the age of 5 years or younger (1-3). Mandibular fractures make up approximately 33% of all pediatric facial fractures, but only 1% of such fractures are in children younger than 5 years (4,5). Condylar fractures most often occur following direct impact, when the energy is translated posteriorly to the condylar process. It is paramount to identify, manage, and investigate mandibular fractures, and particularly condylar fractures, in infant and children, as the condyle is one of the primary centers for osteogenic potential and growth in their mandibles. Further, it is critical to recognize and ideally, corroborate injury mechanisms in early identification of non-accidental trauma (NAT). We discuss an infant case of mandibular condyle fracture, as well as surgical and non-surgical considerations of their care. The infant’s parents provided written informed consent for publication, as well as for sharing a portion of relevant home surveillance video (Appendix [https://doi.org/10.22470/pemj.2026.01613]).

An otherwise healthy 2-month-old male infant presented to the pediatric emergency department (ED) of the American Family Children’s Hospital, Madison, WI for evaluation of fussiness and refusal to feed. Per his parental report, the infant and 15-month-old sibling were in the care of a babysitter while the parents were working outside of the home. Per the babysitter’s report, the infant was in a “boppy” type pillow on a blanket on the countertop with an approximate height of 83–86 cm. The babysitter turned away when the sibling pulled the pillow with blanket, making the infant fall onto the floor. The babysitter heard the infant crying and saw his face down on the floor. The infant cried immediately; there was no loss of consciousness, bleeding, or bruising noted.

The parents were notified and the infant was brought to a local community ED. At that time, the infant was well-appearing and discharged home with no laboratory or imaging studies done. Upon returning home, the infant took 2 naps, became fussy, and refused bottles. When the parents subsequently brought the infant to the abovementioned pediatric ED the same night, the vital signs were as follows: blood pressure, 119/67 mmHg; heart rate, 150 beats/minute; respiratory rate, 36 breaths/minute; and oxygen saturation, 99% on room air. He weighed 6.2 kg, and was alert and content with no evidence of injuries over the head, face, or the intraoral cavity.

An infantogram was initially obtained and was unremarkable. Head computed tomography (CT) was ordered by an on-call trauma surgeon, of which the initial interpretation was an “inconclusive lucency to the left mandible.” The parents were again reassured and the infant was discharged following an uneventful observation period and tolerance of oral intake.

The following morning, the head CT scan was overread by a senior radiologist as a “minimally displaced comminuted, intra-articular fracture of the left mandibular condyle.” The infant was recalled back to the ED and the fracture pattern was then confirmed on subsequent maxillofacial CT scan (Figure). The Division of Plastic Surgery was consulted at this point. Their craniofacial examination showed benign and atraumatic findings, without appreciable ecchymosis or obvious tenderness to palpation of the midface, mandible, or temporomandibular joint (TMJ). There was seemingly normal excursion with mouth-opening and closing, without tenderness or clicking over the TMJ.

Due to the diagnosis of mandible fracture in a young infant not yet cruising, the Division of Child Protection was consulted. As recommended by the team, a full NAT evaluation with laboratory assays was performed and all returned normal. It is widely accepted among child abuse medical providers that most short falls do not result in serious injury (6). Thus, the injury was reported to the county child protective services as concerning for physical abuse. When investigators interviewed the caregivers, they were provided a home surveillance video (Appendix), which had captured the inciting event exactly as the babysitter had described. Because the video confirmed the injury mechanism, our conclusion was updated to reflect that the injury was consistent with the accidental mechanism as seen. At his 6-week follow-up with the plastic surgeon, the infant was well, had no tenderness, obvious deformity, or functional limitations in the mouth opening.

Complex mandibular fractures raise concern for NAT, particularly fractures of the mandibular condyle (7). The presence of such a rare but serious injury as a result of a short fall warrants consideration of NAT and a full evaluation of a child’s developmental milestones (4,6). If the reported injury mechanism seems implausible or inconsistent with the injury, a child abuse team should be consulted and a thorough evaluation completed (6). In this case, the injury was attributed to a 15-month-old sibling pulling a pillow and a blanket with the infant.

To the authors’ knowledge, this is the first reported case involving video confirmation of a short fall with frontal impact causing a complex mandibular condyle fracture. In this case, it was important to confirm the home surveillance video because the infant was in the care of a babysitter while parents were away from the home. Without the video evidence, it would be more difficult to imagine how the fall could have occurred such that it produced a frontal impact strong enough to cause the fracture without external signs of trauma. This case suggests an essential role that video surveillance could play in the assessment of potential NAT cases. We should utilize all potential sources of information in case of questionable injury mechanisms at the time of evaluation.

It is challenging to diagnose this type of fracture in young children given that they are still developing communication skills to verbally report key manifestations, such as malocclusion, inferior alveolar nerve anesthesia, TMJ pain with excursion, or trismus. This challenge is highlighted in this case, given that the infant was sent home twice prior to the accurate diagnosis by the senior radiologist.

Therapeutic options in general for mandibular condyle fractures include conservative, closed, and open techniques. Conservative management is generally standard of care due to their remarkable ability of the mandibular condyle to remodel at the fracture site, leading to favorable functional outcomes despite noted displacement or comminution. This option typically consists of observation, soft diet, and gentle range of motion and opening exercises during the recovery, in order to prevent ankylosis in the case of intracapsular condylar head fractures.

If conservative management is deemed insufficient, the next, more invasive option can be closed management via surgical immobilization with intermaxillary fixation. Open reduction with internal fixation may be considered for displaced fractures. When this invasive option is required, it is recommended to avoid vulnerable tooth buds in mixed dentition and to use resorbable plating systems (8). Mandibular growth progresses via endochondral ossification, and as such, titanium hardware can become embedded in the bone and restrict growth in the pediatric population, requiring removal once bony healing is achieved (9). Importantly, regardless of the therapeutic options chosen, fractures in this location must be followed longitudinally for ongoing assessment of mandibular or occlusive asymmetries, deficiencies in excursion/range of motion, persistent pain at TMJ, and TMJ ankylosis as the child continues to grow.

This case highlights the difficulty in diagnosing the mandibular condyle fracture, and the acknowledgement of the short-fall as a feasible mechanism for the fracture in an infant not yet cruising. We recommend education around safe locations for young infants, and promotion of caregivers’ “within arm’s reach” supervision of infants or toddlers. NAT evaluations may be necessary in cases where the mechanism described is not consistent with the injuries. It is important to collaborate with child abuse teams as well as with subspecialty clinicians for identifying young children at risk of NAT, while reducing the stigma associated with this challenging role.