Facial Fractures Alone May Hide Serious Brain Injury in Older Adults, 16-Year Study Finds

When an older person falls and fractures a facial bone, emergency physicians face a deceptively simple question: is the brain injured too? A sweeping new study suggests the answer is far more often yes than many clinicians have assumed. Researchers analyzing more than 16,000 craniomaxillofacial trauma cases over 16 years found that nearly half of older adults who arrived with facial fractures showed signs of acute intracranial injury on their first computed tomography scan, a burden almost double that seen in young adults with similar injuries.

The research, published in BMC Medical Imaging, followed 16,069 patients with CT-confirmed craniomaxillofacial fractures treated at a single major trauma center in Shanghai between 2010 and 2025. Rather than relying on manual chart review, the team deployed a rule-based natural language processing pipeline to extract fracture patterns and intracranial findings from thousands of radiology reports, then validated the algorithm against independent review by experienced radiologists. That combination of scale and verification allowed the investigators to track how trauma patterns shifted across an entire era of demographic change.

What they found was a population quietly transforming. The mean age of patients with facial trauma rose steadily year after year, climbing at a rate of 0.74 years annually, a trend so consistent that it explained roughly three quarters of the variation in patient age across the study period. The statistical strength of this drift, reflected in a coefficient of determination of 0.77, points to a structural change in who is getting hurt: as societies age, the typical facial trauma patient is no longer a young man in a road accident but an older adult after a ground-level fall.

Even more striking was the shift in fracture patterns. In 2010, isolated facial fractures, meaning breaks confined to the facial skeleton without any accompanying skull fracture, accounted for 28.1 percent of cases. By 2025, that proportion had more than doubled to 56.4 percent, making isolated facial fractures the single most common pattern of craniomaxillofacial trauma. The change likely reflects the mechanics of geriatric injury: older adults tend to sustain lower-energy impacts, and their facial bones, often thinned by age-related bone loss, fracture before the thicker cranial vault does.

That shift might sound reassuring, since isolated facial fractures are traditionally viewed as the benign end of the facial trauma spectrum. The new data dismantle that assumption. Acute intracranial injury, which includes cerebral contusions, traumatic hemorrhages, and related acute brain findings visible on initial CT, rose in lockstep with age across the cohort. Among young adults, the burden of acute intracranial injury was 25.5 percent. Among older adults, it reached 49.1 percent, meaning nearly one in two older patients with facial trauma carried an acute brain injury on their very first scan.

To isolate age as a risk factor from confounders such as injury mechanism and fracture severity, the team turned to multivariable logistic regression, a statistical technique that estimates the independent effect of each variable while holding the others constant. Across the entire cohort, each additional year of age carried a 2 percent increase in the adjusted odds of acute intracranial injury, with an adjusted odds ratio of 1.02 per year and a 95 percent confidence interval of 1.02 to 1.03. Small as it sounds, that annual increment compounds powerfully across a lifetime of aging.

The most clinically consequential finding emerged when the researchers narrowed their lens to the isolated facial fracture subgroup. Among these patients, those aged 65 and older faced more than three times the adjusted odds of acute intracranial injury compared with younger patients, with an adjusted odds ratio of 3.26 and a confidence interval of 2.74 to 3.88, a result significant at P less than 0.001. In practical terms, an older patient whose CT shows only a fractured cheekbone or orbital floor may still harbor a bruised or bleeding brain that the same scan, read carefully, will reveal.

The physiological explanation lies in the anatomy of the aging head. Facial bones are designed to absorb and dissipate impact energy, but in older adults, reduced bone mineral density makes the midface and mandible more fragile and less effective as a crumple zone. At the same time, the aging brain shrinks slightly within the skull, stretching the bridging veins that anchor it to the dura and rendering it more vulnerable to tearing during even modest acceleration or deceleration. Add to this the prevalence of anticoagulant and antiplatelet medications among older adults, which amplify intracranial bleeding, and the combination of a fragile skeleton and a fragile brain becomes a recipe for occult injury.

The study’s methodology deserves attention as much as its conclusions. Manual review of 16,000 radiology reports would have taken years and introduced reader fatigue; the rule-based natural language processing approach converted free-text CT reports into structured data at scale, and its validation against radiologist review addressed the central weakness of automated text mining, namely silent error. The retrospective, single-center design does impose limits: the findings reflect one institution’s catchment and practice patterns, and the requirement for CT-confirmed fractures means the cohort excludes patients too unstable to scan or not scanned at all. Still, the sheer duration of the observation window, spanning a decade and a half of demographic change, gives the temporal trends unusual credibility.

For emergency departments, the implications are immediate. Clinical decision rules such as the Canadian CT Head Rule were built largely on younger populations and may under-triage older patients who present with facial fractures and only mild or ambiguous symptoms. The study’s numbers argue that age 65 should function as a red flag in facial trauma: an older adult with an isolated facial fracture has roughly a one-in-two chance of concurrent acute brain injury, and imaging of the head should be considered even when the face alone appears to be the problem. As populations worldwide continue to gray, the researchers suggest that facial fracture patterns will keep shifting toward these isolated, facial-predominant injuries, and that the hidden brain trauma accompanying them will remain an underappreciated burden unless imaging practice evolves to match the epidemiology.

Subject of Research: Age-related risk of acute intracranial injury in patients with craniomaxillofacial fractures

Article Title: Age-related risk of acute intracranial injury in craniomaxillofacial trauma: a 16-year cohort study with focus on older adults with isolated facial fractures

Article References: Cao, Z., Zhang, R., Wang, P., Song, X., Yang, Y., Tu, Y., Tang, Y., Wang, M., Li, Y., Wang, J., Zhang, H., Wei, X., Wang, D., & Li, Y. (2026). Age-related risk of acute intracranial injury in craniomaxillofacial trauma: a 16-year cohort study with focus on older adults with isolated facial fractures. BMC Medical Imaging. https://doi.org/10.1186/s12880-026-02801-6

Image Credits: AI Generated

DOI: 10.1186/s12880-026-02801-6

Keywords: facial fractures, intracranial injury, older adults, computed tomography, craniomaxillofacial trauma, aging population, geriatrics, risk factors, head injury, emergency imaging, cohort study, maxillofacial surgery