Soft tissue injuries can predict risk of facial fractures in trauma patients

Trauma patients with specific types of facial soft tissue injuries should have a CT (computed tomography) scan of the face as well as a standard head scan to determine the presence and severity of facial fractures, according to a study published in the May issue of the Journal of Oral and Maxillofacial Surgery.

Certain soft tissue injury zones correlate with a higher incidence of facial fractures in trauma patients who undergo head CT, the retrospective study of more than 9,800 trauma patients found.

The injuries most closely linked with facial fractures were: lip lacerations (cuts), intraoral lacerations (cuts in the mouth), periorbital contusions (bruises around the eyes), subconjunctival hemorrhages (broken blood vessels under the transparent tissue that covers the outer surface of the eyes) and nasal lacerations.

"In the high pressure environment of a trauma center, these findings could help trauma surgeons decide more quickly whether to order facial CT in conjunction with head CT in facial trauma patients," says principal author Oral and Maxillofacial Surgeon Eric P. Holmgren, DDS, MD, MS, a resident in the department of oral and maxillofacial surgery at Oregon Health and Sciences University in Portland.

As a result of their findings, Dr. Holmgren and his co-authors propose the acronym LIPS-N [Lip laceration, Intraoral laceration, Periorbital contusion, Subconjunctival hemorrhage and Nasal laceration) as a tool to assess when a trauma patient who is getting head CT should also get facial CT.

"The use of the mnemonic LIPS-N could help providers make the best use of facial CT in conjunction with head CT, especially when they're confronted with other, more pressing concerns," Dr. Holmgren says. Intubated, intoxicated or unresponsive patients and patients who don't speak English can make a thorough head and neck examination unfeasible. In some cases, the patient may already be in the scanner, or a facial trauma surgeon may not be immediately available for consultation.

Pointing to the finding that 39% of patients who received both head and facial CT did not have facial fractures, Dr. Holmgren notes that use of LIPS-N could help minimize the overuse of facial CT as well.

"The timely use of proper imaging is important for early diagnosis of facial fractures, and facial CT is the best diagnostic tool for identifying and characterizing the extent of a fracture, especially when a fracture is suspected or discovered on initial examination," Dr. Holmgren says.

"Although nothing substitutes for a thorough head and neck examination and patient history in determining whether a facial trauma patient needs facial CT, trauma doctors often do not have the luxury of time and may have to rely on soft tissue markers alone," he says.

Cuts in the lips, nose and inside the mouth, as well as wounds leading to a black eye and subconjunctival hemorrhage, were significantly more prevalent in patients found by facial CT scan to have facial fractures, according to the study.

Conversely, scalp lacerations and contusions were significantly more prevalent in patients found not to have facial fractures than in patients who did. The incidence of soft tissue injuries of the tongue, chin, forehead, cheek, ear, eyelid and eyebrow were indistinguishable between the two groups.

Dr. Holmgren and his colleagues reviewed the trauma registry spanning a five-year period at Legacy Emanuel Hospital, a level I trauma center in Portland, OR. Fifty percent of trauma patients during this period required head CT as part of their initial evaluations. A total of 777 (16%) patients received a combination head and facial CT. Of those, 477 (62%) had a facial fracture and 300 (39%) did not.

Dr. Holmgren cautions that the LIPS-N mnemonic should only be used for trauma center patients. "We do not recommend using this tool as a sole aid in determining whether to order a facial scan or as a guide to evaluate patients who do not require head CT," he stresses. "The patients in this study were admitted to the trauma service at a level 1 trauma center and required head CT. The mechanism of injury was more often high impact. The soft tissue injuries of these patients differ from ambulatory patients in the emergency department who are not admitted by the trauma team."