Falls Drive Two Decades of Head and Neck Injuries in U.S. Emergency Rooms

Head, face, and neck injuries account for nearly one-third of all injury-related emergency department visits captured by a major U.S. surveillance system, and their numbers have climbed steadily over two decades, according to a new analysis of more than 2.3 million patient records published in BMC Emergency Medicine. The study, which examined records from 2006 through 2025, found that annual case counts rose 35.2 percent over the period, from 105,727 to 142,918 visits, with head injuries alone increasing by 83.4 percent and driving most of the overall growth.

NEISS collects standardized data from a stratified probability sample of approximately 100 hospital emergency departments across the United States. Of 7,365,561 NEISS-coded emergency visits recorded between 2006 and 2025, 2,345,287 involved injuries to the head, face, eyes, mouth, neck, or ears, representing 31.8 percent of all coded visits. The share of all NEISS-coded visits attributable to these regions rose from 29.1 percent in 2006 to 34.8 percent in 2025, an absolute increase of 5.7 percentage points.

The study team went beyond the database’s standard fields by building an automated rule-based classifier that read the brief free-text narratives accompanying each record and assigned one of 17 injury mechanisms. Because NEISS contains no structured mechanism variable, the researchers developed regular-expression rules matching narrative tokens, phrases, and abbreviations such as “TD&F” for tripped, down and fell, and “ETOH” for ethanol. After four refinement cycles, the proportion of cases left in a residual “Other/Unspecified” category fell from 20.3 percent to 5.9 percent. The final ruleset contained more than 200 distinct surface tokens and roughly 18 ordered rule blocks, and it achieved perfect agreement on a hand-curated validation panel of 54 narrative-category pairs.

The demographic picture that emerged was strikingly age-dependent. Patients ranged from newborns to 113 years old, with a median age of 14 years and a mean of 27.1 years. Males accounted for 56.4 percent of cases overall, but this pattern reversed in the oldest group: among adults aged 65 and older, females made up 60.6 percent of patients, the only age group in which female cases exceeded male cases. The researchers attribute this reversal to greater longevity among women and a higher burden of fall-related injury among elderly women, alongside factors such as osteoporosis and frailty that are not recorded in the NEISS database.

Anatomical patterns shifted across the life course in ways that mirror developmental stages. Among infants, 58.9 percent of injuries involved the head, while among toddlers aged 2 to 4 the face slightly overtook the head at 40.7 percent versus 38.8 percent. From age 5 onward, the head’s share rose progressively with age, reaching 69.1 percent in older adults. Head injuries showed a distinctly bimodal distribution, with one peak in early childhood and a second, larger peak among older adults, who accounted for 22.6 percent of all head injury cases. Mouth injuries clustered overwhelmingly in the young, with 74.8 percent occurring in patients younger than 15, while ear injuries peaked in school-aged children aged 5 to 14, who accounted for 44.2 percent of ear cases. Eye and neck injuries, by contrast, were most frequent among adults aged 25 to 45.

Falls dominated the mechanism landscape. Same-level falls were the single most common mechanism at 27.9 percent of cases, followed by falls from height at 21.0 percent and sports and recreation injuries at 14.2 percent. Combined, the three fall categories accounted for 53.0 percent of all cases. Falls from height were concentrated at the extremes of age: infants and toddlers made up 43.2 percent of these cases and older adults 24.2 percent, and such falls represented 41.6 percent of all injuries among infants. The researchers note that falls from height in this dataset predominantly represented low-level falls from beds, furniture, and stairs, a distinction that matters when comparing results with trauma center studies of high-energy falls.

The products and surfaces associated with injuries changed dramatically with age, offering what the authors describe as a life-course map of exposure. Beds were the most frequently coded associated product among infants at 17.8 percent, followed by floors and stairs. Among toddlers, tables led at 8.9 percent, followed by beds and stairs. Sports-related products, including bicycles, football, basketball, baseball, soccer, and swimming equipment, were most prominent among children and adolescents and young adults. Among older adults, floors were the most frequent associated surface at 26.6 percent, followed by beds, stairs, and bathtubs. Floors and stairs ranked among the top ten in every age group. The home was the most common injury setting overall, documented in 63.1 percent of records with a recorded location, ranging from 57.0 percent for neck injuries to 73.8 percent for eye injuries.

Clinical outcomes revealed a steep age gradient. Overall, 89.4 percent of patients were treated and released, 7.3 percent were admitted, 0.9 percent were transferred, 0.8 percent were held for observation, and 1,062 patients, or 0.045 percent, died. Admission rates rose roughly eighteen-fold from 1.28 percent among toddlers to 23.27 percent among older adults, and case-fatality rates increased twenty-five-fold, from 0.006 percent to 0.144 percent. The combined rate of admission, transfer, observation, and fatality, which the authors term non-routine ED disposition, was highest for head injuries at 12.8 percent and neck injuries at 12.7 percent, and lowest for ear injuries at 1.0 percent. By mechanism, syncope- or medical-related falls had the highest non-routine disposition rate at 33.9 percent, followed by substance-related cases at 23.6 percent and motor vehicle-related cases at 20.7 percent. The three fall categories accounted for 66.9 percent of all fatalities, and 899 of the 1,062 deaths, or 84.7 percent, involved the head.

The temporal trends carried important context. Annual case volume reached its lowest point in 2020, at 101,854 cases, 13.5 percent below the 2019 level, with reductions in every anatomical region, consistent with the documented collapse in emergency department utilization during the COVID-19 pandemic. Notably, the proportion of all NEISS-coded visits attributable to the target regions remained virtually unchanged between 2019 and 2020, at 32.8 percent versus 32.9 percent, indicating that the pandemic-related decline affected head and neck injuries to a similar degree as other injuries. The authors suggest that the long-term rise in head injuries may reflect population aging, increased clinical awareness of traumatic brain injury, lower thresholds for imaging and observation, and greater anticoagulant and antiplatelet use among older adults, though these factors could not be tested directly in the surveillance data.

The study has limitations the authors are careful to spell out. Because the analysis used unweighted case records rather than NEISS sampling weights, the counts reflect the observed sample and should not be interpreted as national population estimates, and the unweighted sample may over-represent pediatric presentations given the separate children’s hospital stratum. NEISS captures only injuries presenting to participating emergency departments, missing those treated in outpatient clinics, urgent care settings, or not at all, and it was designed to capture consumer-product-related injuries. The database also lacks clinical detail such as imaging findings, injury severity scores, comorbidities, and anticoagulant use, so emergency department disposition serves only as an indirect proxy for clinical severity. Mechanism classification from abbreviated free-text narratives remains subject to misclassification, and the analyses are purely descriptive, so the reported associations should not be interpreted as causal. Still, the authors argue that the sheer scale and integrated scope of the analysis, spanning six anatomical regions, seventeen mechanisms, seven age groups, and two decades of records, offers a resolution that smaller or shorter-term studies cannot achieve, and that effective prevention may need to be tailored specifically to age, mechanism, and setting rather than applied as a single uniform strategy.

Subject of Research: Epidemiology of head, face, and neck injuries in U.S. emergency departments over two decades

Article Title: Head, face, and neck injury patterns across the life course: a 20-year NEISS analysis of 2,345,287 emergency department visits in the U.S.

Article References: Alfertshofer, M., Hoch, C. C., Nolte, D., Machens, H.-G., Knoedler, L., Abu-Sirhan, S., Rahmayanti, S., Kühlman, D. C., Janis, J. E., Peacock, Z. S., Koerdt, S., Bucher, S., Heiland, M., Moellhoff, N., & Knoedler, S. (2026). Head, face, and neck injury patterns across the life course: a 20-year NEISS analysis of 2,345,287 emergency department visits in the U.S.. BMC Emergency Medicine, 26(1), Article 275. https://doi.org/10.1186/s12873-026-01821-3

Image Credits: AI Generated

DOI: 10.1186/s12873-026-01821-3

Keywords: emergency medicine, NEISS, head injury, facial trauma, falls, injury surveillance, pediatric injury, older adults, trauma epidemiology, consumer product safety, injury prevention, emergency department visits