Secondary CT Signs of Occult Craniofacial Fractures in Patients With Head and Facial Trauma

OBJECTIVE: To characterize secondary CT signs, anatomic distribution, diagnostic delay, and clinical consequences among patients with head and facial trauma who had subsequently confirmed occult craniofacial fractures on CT imaging. METHODS: A retrospective data set was generated for 80 eligible cases, covering December 2022 through December 2025. Eligible CT examinations were initial head, facial, or maxillofacial trauma CT scans in which no definite fracture was reported initially or the fracture was visible only through subtle secondary signs, followed by confirmation on subspecialty re-review, thin-section multiplanar reconstruction, cone-beam CT, follow-up CT, or intraoperative correlation. Variables included demographic factors, trauma mechanism, fracture site, secondary CT sign, acquisition and reconstruction features, artifacts, confirmation method, time to detection, and whether diagnosis changed management. Proportions were summarized with Wilson 95% CIs. Skewed time intervals were summarized as medians with IQRs. Associations with clinically significant management change were explored with univariate odds ratios and a parsimonious logistic model. RESULTS: The most common sites were the mandibular condyle (17/80) and the nasal bone (16/80). Management changed in 30/80 cases (37.5%; 95% CI: 27.7-48.5). Median time to detection was 24 hours (IQR=10-37). Univariate analysis showed higher odds of management change with axial-only reconstruction, moderate motion artifact, and delayed detection of 24 hours or longer; the multivariable model showed directionally similar but imprecise estimates. CONCLUSION: Occult craniofacial fractures on CT clustered in thin cortical and complex multiplanar regions. Secondary signs such as sinus fluid, orbital emphysema, fat stranding, periodontal air, and joint-space asymmetry were central to recognition. Systematic thin-section multiplanar review may reduce delayed diagnosis and improve clinically relevant triage.