What is the recommended imaging for a patient with a facial injury from a fall?

Recommended Imaging for Facial Injury from a Fall

CT maxillofacial without contrast is the recommended first-line imaging for patients with facial injury from a fall, with complementary CT head imaging when intracranial injury is suspected. 1

Primary Imaging Recommendations

• CT Maxillofacial (without contrast): Provides superior delineation of osseous and soft-tissue structures with high resolution that can detect subtle nondisplaced fractures of the facial skeleton 1

  • Allows for multiplanar and 3D image reconstructions, which are critical for characterizing complex fractures and surgical planning 1
  • Three-dimensional reformatted images significantly improve surgeon confidence compared to axial CT images alone 1
  • Superior to conventional radiography, tomography, and MRI in detecting facial fractures, defining their direction, extent, and displacement 2

• CT Head (without contrast): Should be obtained when there is suspicion of intracranial injury, which commonly coexists with facial trauma 1

  • More than one-third of patients with frontal sinus fractures are likely to have concomitant intracranial injury 1
  • Allows for detection of hemorrhage, cerebral edema, and intracranial mass effect 1
  • Multiplanar reformation adds greater sensitivity for hemorrhage detection 1

Considerations Based on Facial Region Involved

Frontal Bone Injury

• Frontal bone fractures often result from high-energy blunt trauma, including falls 1
• CT head is complementary to maxillofacial CT for complete characterization of injury 1
• Displaced posterior table fractures may indicate disruption of the underlying dura 1

Midface and Zygomatic Complex

• Zygomatic complex is the most common fracture site in fall-related facial trauma, seen in 40% of patients with fractures 3
• CT with multiplanar reconstructions is particularly valuable for evaluating complex midface fractures 4

Nasal Fractures

• Most frequent isolated facial fractures 5
• While primarily diagnosed through clinical examination, CT is valuable for assessing associated injuries 5

Clinical Pearls and Pitfalls

• Pitfall: Focusing only on obvious facial injuries while missing associated intracranial trauma

  • Solution: Always consider obtaining complementary CT head imaging when facial fractures are present, especially with high-energy mechanisms 1

• Pitfall: Relying on the "clear sinus sign" (absence of fluid in paranasal sinuses) to rule out fractures

  • Solution: Be aware that 4% of patients may have fractures involving sinus walls without paranasal sinus effusions 3

• Pitfall: Missing orbital "blowout" fractures that can lead to extraocular muscle entrapment

  • Solution: Pay special attention to orbital walls on CT imaging, particularly the thin inferior orbital wall 6

• Caveat: Initial trauma series radiographs (portable AP chest and pelvis) should be obtained in major trauma cases before proceeding to CT imaging 1

  • These help evaluate for immediately life-threatening conditions and guide further imaging 1

Imaging Algorithm for Facial Trauma from Falls

1. Initial stabilization: Ensure airway, breathing, and circulation are addressed 1
2. Primary imaging: CT maxillofacial without contrast 1
3. Complementary imaging: CT head without contrast if there is suspicion of intracranial injury 1
4. Advanced reconstruction: Obtain multiplanar and 3D reconstructions to better characterize fractures and aid surgical planning 1, 4

By following this evidence-based approach to imaging facial trauma from falls, clinicians can accurately identify and characterize fractures and associated complications, leading to improved patient outcomes through timely management and appropriate surgical planning.