When to Suspect Facial Injury in Head Trauma Patients
In head injury patients, suspect facial injury when you identify specific clinical signs during secondary survey: tenderness/contusion/edema over facial bones, malocclusion, facial deformity, periorbital findings, or the LIPS-N pattern (Lip laceration, Intraoral laceration, Periorbital contusion, Subconjunctival hemorrhage, Nasal laceration), and obtain CT maxillofacial imaging in addition to head CT given the 68% incidence of concurrent facial fractures in head-injured patients. 1
Clinical Context and Risk Assessment
Head trauma patients require systematic evaluation because 68% of patients with facial fractures have associated head injuries, making concurrent injury the rule rather than the exception 1. The forces required to cause significant head trauma frequently result in facial skeletal damage, particularly in high-energy mechanisms like motor vehicle collisions, assaults, and falls 2.
High-Risk Injury Mechanisms
- High-energy blunt trauma (motor vehicle collisions, significant falls, assaults) should automatically raise suspicion for facial injury 2
- Associated cranial fractures increase TBI risk 4.7-fold, indicating severe force transmission that commonly affects facial structures 3
- Associated neck injury increases TBI risk 2.1-fold and suggests force vectors likely affecting the face 3
Specific Clinical Signs to Identify
Upper Face/Frontal Region
Suspect frontal bone injury when you find: 2
- Tenderness to palpation over frontal bone
- Contusion or edema over frontal bone
- Critical consideration: Frontal bone fractures occur in 5-15% of facial fractures and require forces exceeding 1,000 kg, making them markers of severe trauma 2
- 75% have additional facial fractures and 33% have concomitant intracranial injury 2
- 8-10% require surgical intervention for subdural or epidural hematoma 2
Midface Region
Suspect midface injury when you identify: 2
- Pain with upper jaw manipulation
- Pain overlying zygoma
- Zygomatic deformity
- Facial elongation (indicates maxillary displacement)
- Malocclusion (direct indicator of midface or mandible injury) 4
- Infraorbital nerve paresthesia (V2 distribution: upper teeth, gingiva, upper lip, lateral nose)
Soft Tissue Injury Patterns (LIPS-N)
The LIPS-N acronym identifies facial fracture risk in trauma patients: 5
- Lip laceration
- Intraoral laceration
- Periorbital contusion
- Subconjunctival hemorrhage
- Nasal laceration
These specific soft tissue injuries significantly correlate with underlying facial fractures (61.4% fracture rate when present), while scalp lacerations and scalp contusions do NOT predict facial fractures 5.
Systematic Evaluation Approach
Primary Survey First
Complete airway, breathing, circulation stabilization before facial evaluation, as maxillofacial trauma can cause life-threatening airway compromise from bleeding, soft tissue edema, and loss of facial architecture 1. This is non-negotiable.
Secondary Survey Components
After stabilization, perform systematic facial assessment: 2, 1
- Palpation of all facial bones for tenderness, step-offs, crepitus
- Visual inspection for deformity, asymmetry, edema
- Complete visual acuity evaluation (critical for orbital injuries)
- Cranial nerve evaluation (particularly V2 for infraorbital nerve, VII for facial nerve)
- Detection of cerebrospinal fluid leak (clear rhinorrhea suggests skull base involvement)
- Dental occlusion assessment (malocclusion is a direct indicator of skeletal injury) 4
Imaging Strategy
When to Image
Obtain CT maxillofacial in addition to head CT when: 1
- Any LIPS-N soft tissue injury pattern present 5
- Clinical signs of frontal or midface injury present 2
- High-energy mechanism with head injury (given 68% concurrent injury rate) 1
Imaging Modality
Multidetector CT (MDCT) maxillofacial is the gold standard for facial trauma evaluation 2, 6:
- Provides thin-section acquisitions detecting subtle nondisplaced fractures
- Offers multiplanar and 3-D reconstructions critical for surgical planning
- Faster acquisition than radiography or MRI
- Less dependent on patient positioning than plain films
Head CT should be obtained concurrently given the high rate of intracranial injury, particularly with frontal bone fractures 2.
Critical Pitfalls to Avoid
Common Missed Injuries
- Facial fractures are commonly missed on initial imaging evaluation when facial CT is not obtained 5
- History and physical examination alone are insufficient to accurately diagnose the full extent of facial trauma 2, 1
- Posterior table frontal sinus fractures imply dural disruption and CSF communication, requiring specific identification 2
Don't Be Distracted
Severe facial injuries can be distracting—always complete primary survey first before addressing facial trauma 6. Life-threatening injuries take precedence.