Concomitant Injuries in 31.7% of Facial Fracture Patients

Key Takeaways

• Among 4,170 patients with facial fractures evaluated at a Finnish tertiary trauma center, 31.7% had a concomitant injury outside the facial region.
• The proportion was 57.5% after high-energy injuries and 17.2% after low-energy injuries.
• The proportion rose with age, exceeding 55% among patients aged 90–94 years.
• The authors encouraged routinely ruling out concomitant injuries with the Advanced Trauma Life Support (ATLS) protocol, but their risk groupings are exploratory and not validated decision rules.

Facial fractures can occur alongside injuries outside the face, some potentially life-threatening and requiring urgent attention. The fracture itself may not reveal the full extent of a patient’s injuries. Investigators examined how often injuries beyond the facial region accompanied fractures and how prevalence and types varied with injury energy, sex, and age.

In a facial-fracture cohort analysis, investigators retrospectively examined 4,170 patients evaluated at the Töölö and Children’s Hospital trauma centers of Helsinki University Hospital from January 2013 to October 2020. Most patients were male (70.9%), and the mean age was 45.7 years. Concomitant injuries were defined as radiologically confirmed injuries elsewhere in the body, such as traumatic brain injury, skull fracture, and upper or lower limb, chest, spinal, and abdominal injuries. The investigators used a data-driven approach, applying decision-tree models to injury energy, age, and sex to explore risk groups. Only groups with at least 10 cases were reported.

Overall, 31.7% of patients had a concomitant injury. Among patients with high-energy injuries, 57.5% had at least one, compared with 17.2% among those with low-energy injuries. High-energy mechanisms, mainly traffic accidents and falls from a height, accounted for 36.0% of injuries, while 64.0% were low-energy, most often ground-level falls and assaults. Among patients with a concomitant injury, 41.1% had two or more. Traumatic brain injury was the most common concomitant injury (14.3%), followed by skull fracture (10.3%) and upper limb injury (10.1%). In-hospital mortality was 1.3%.

The proportion with a concomitant injury rose with age, from 19.8% at ages 20–24 to over 46% at ages 70–74 and over 55% at ages 90–94. It was also notable in younger patients, such as nearly 30% at ages 15–19, and the injury types varied considerably across age groups. Women had more concomitant injuries than men (34.0% vs 30.8%), and the types differed: upper limb injuries were more common in women (14.8% vs 8.2%), while skull fractures were more common in men (11.6% vs 7.0%). This is a descriptive comparison with no significance test reported in the text and no adjustment for age or injury mechanism.

The decision-tree analysis identified exploratory subgroups. Among high-energy injuries, patients aged about 19.7 to 21.4 years had a 43.5% probability of an upper limb injury, a 2.4-fold increase over baseline. Among low-energy injuries, women aged about 89.8 years or older had a 29.5% probability of an upper limb injury, a 5.4-fold increase. The age cutoffs are model output, and these groups were not validated in a separate dataset.

The authors encouraged using the ATLS protocol to routinely rule out concomitant injuries alongside the assessment and imaging of facial trauma, with special attention to high-risk groups, particularly patients with low-energy injuries. They also noted the value of identifying low-risk groups who would not benefit from extensive trauma imaging. This study did not test whether that approach improves outcomes, and the authors stated the risk groups should not be considered validated clinical decision rules.

The analysis was retrospective and single-center, and some data on injury mechanisms may be missing. Patients with high-energy trauma were more likely to undergo extensive imaging, which may have increased detection of concomitant injuries in that group, and imaging practices varied over the study period. Mortality may be underestimated because some patients were transferred to other hospitals. The models used only early clinically available variables and did not include injury severity or fracture location. Because injuries were identified by radiological confirmation, the risk groups reflect patterns of diagnosed injuries, not a demonstrated reduction in missed diagnoses. The authors described the findings as hypothesis-generating and preliminary.

Clinician Questions

How did concomitant-injury rates compare after high- versus low-energy facial fractures?

Among facial fracture patients, 57.5% of those with high-energy injuries had at least one concomitant injury, compared with 17.2% of those with low-energy injuries. Because most facial fractures follow low-energy mechanisms (64.0% of patients), many patients with concomitant injuries come from the low-energy group. Neither high-energy nor low-energy mechanisms alone reliably ruled out concomitant injuries, according to the authors.

Are the facial-fracture concomitant-injury risk groups validated imaging decision rules?

No. The investigators explored risk groups using age, sex, and injury energy, and stated that these groups are exploratory and should not be considered validated clinical decision rules. They proposed that the groups may serve as a supplemental guide to heighten clinical suspicion, particularly for low-energy injuries, and that they may inform future targeted studies.