Background:

Tanaka and colleagues showed that 10.4% of all maxillofacial fractures are related to sports. These injuries can occur as a result of contact with other players (rugby and soccer), contact with equipment (baseball), or contact with objects within the field of play, ie, skiing.

The majority of sports-related facial injuries are minor; however, the potential for serious damage exists. A physician examining these injuries must rapidly assess the patient in a consistent and methodical manner, allowing for prompt diagnosis and appropriate treatment.

Sports participation is the most common cause of mandibular fractures (31.5%), followed closely by motor vehicle accidents (27.2%). Fractures of the facial bones require a significant amount of force. The physician must take into account the mechanism of injury as well as the physical examination findings when assessing the patient.

Forces required to produce a fracture of the facial bones are as follows:

Frequency:

In the US: In a 1977 report, Schulz notes that athletic injuries account for 11% of all facial fractures, and that facial injuries occur in 2% of all athletes.

In a 2000 report, Laskin states that 250,000 individuals, many of whom are children, experience facial trauma while engaged in athletic activities. Moreover, over 100,000 sport-related injuries could be prevented by wearing appropriate head and face protection.

Functional Anatomy:

Sport Specific Biomechanics:

In general, facial fractures in athletics result from direct trauma over a small surface area. Sports that present a higher risk are those that involve small objects that are propelled at high velocity, such as baseball, softball, hockey, lacrosse, jai alai, and racquetball. Athletes who participate in sports with high levels of physical contact and collision are at risk as well; these sports include football, basketball, rugby, hockey, martial arts, and boxing.

Many of these sports have safety measures to limit the incidence of facial injuries, and attention should be paid to the rules of use. Racquetball players should always play with goggles to limit orbital blow-out injuries. In hockey, face guards with helmets are required in lower levels of play but not at the professional level. High school football players should all have mouthpieces fitted for them, and mouthpieces should be worn in place before every play.

An athlete's vision should be checked as part of a preparticipation physical examination yearly. Visual risk factors include corrected visual acuity of 20/40 or less or spectacle correction greater than 6 diopters. These athletes need an ophthalmologist's evaluation before competing in sports.

A one-eyed athlete is defined as one with visual acuity in one eye of 20/200 or less. These athletes may be able to participate with proper protection, and an ophthalmologist's evaluation is essential.

History:

Injuries to the head and neck frequently involve the airway or major vessels. The initial assessment, therefore, should begin with airway, breathing, and circulation (ABCs). First, protect the airway by removing any foreign bodies and by placing the patient in a sitting position or on the side to facilitate expectoration of blood. If severe maxillofacial trauma is present, the athlete is at risk for airway obstruction because of a lack of tongue support from the mandibular structures. Consider placing an oral airway or, if necessary, endotracheal intubation. Second, assess for breathing and circulation. Lastly, evaluate the cervical spine. In the literature, cervical spine injuries have been shown to be present in 1-4% of patients with facial fractures, and because of the force necessary to fracture the facial bones, one should consider the cervical spine fractured until proven otherwise and should maintain cervical spine immobilization.

Following initial stabilization of the ABCs, the examiner should proceed with the history and physical examination. The patient should be questioned regarding the mechanism of the injury, the presence of numbness or pain over any parts of the face, and visual disturbances. Specific questions regarding specific fractures of the face include the following:

Frontal sinus fractures:This injury results from a severe blow to the frontal or supraorbital region, which can result in fracture of the anterior and/or posterior wall. The patient may report numbness in the distribution of the supraorbital nerve.

Orbital fractures: Blow-out fractures generally occur with blunt trauma to the orbit with an object larger in diameter than the orbital entrance (eg, baseball, fist). A blow in fracture results when a fracture fragment is displaced into the orbit, resulting in decreased orbital volume and impingement on orbital soft tissues, such as from high-velocity trauma (eg, falls from height, severe blows to orbit with weapon). Patients may report diplopia.

Nasal fractures: With the exception of nasoorbitoethmoid fractures, nasal fractures are typically diagnosed based upon history and physical examination findings. Often a history of a blow to the nose and epistaxis is present.

Zygomatic/zygomaticomaxillary complex fractures: The athlete may report a forceful blow to the cheek with a bat or an elbow. Fractures of the zygomaticomaxillary complex may result in trismus or numbness in the distribution of the infraorbital nerve.

Maxillary (Le Fort) fractures: Le Fort I is a transverse fracture of the maxilla just above the teeth. Le Fort II is a pyramid fracture of the maxilla, the apex of which is above the bridge of the nose and extends laterally and inferiorly through the infraorbital rims. Le Fort III is a complete craniofacial disruption and involves fractures of the zygoma, infraorbital rims, and maxilla. This injury requires significant force and, therefore, is relatively uncommon in athletes; however, it may be observed with an injury from a hockey puck, baseball pitch, or baseball bat. Athletes with this injury may report diplopia, malocclusion, or numbness.

Mandibular fractures: The patient may report malocclusion and jaw pain or numbness.

Physical:

Physical examination should be performed in a methodic sequential manner. One approach organizes the examination from inside out and bottom up and involves inspection, palpation, and sensory and motor testing.

Examine the oral pharynx for lacerations, tooth fragments, or other foreign bodies. Look closely at the dentition to assess for tooth avulsion or tooth mobility, which can indicate underlying skeletal fractures. Then, carefully evaluate each region of the face, including the mandible, maxilla, zygoma, nasal, orbital, and frontal bones.

Any areas of obvious trauma, such as laceration, swelling, depression, or ecchymosis, should be examined more closely. Evaluate the mandible for trismus and mobility. The mid face should be assessed for stability and depression of bones.

After inspection and palpation, test the motor and sensory function of the facial nerves and muscles. Hypoesthesia in the region of the infraorbital or supraorbital nerve may suggest an orbital fracture, whereas decreased sensation of the chin may result from inferior alveolar nerve compression from a mandibular fracture. Trismus, spasm of the muscles of the jaw, which results in the ability to open and close the mouth, can be secondary to mandibular or zygomatic fractures.

Any fluid from the nose should be inspected for possible CSF rhinorrhea, indicating disruption of the anterior cranial base. Lastly, examine the eyes, including pupils, extraocular movements, visual acuity, and if clinically indicated, intraocular pressure and corneal fluorescein. Findings for specific fractures include the following:

Frontal sinus fractures: Look for visible or palpable depression in the region of the frontal sinus. A fracture of the posterior wall implies fracture of the dura and may be manifested by CNS depression, CSF rhinorrhea, or visible brain matter.

Orbital fractures: Patients with orbital fractures may present with ecchymosis and edema of eyelids, subconjunctival hemorrhage, diplopia with limitation in upgaze or downgaze, enophthalmos, infraorbital nerve anesthesia, or emphysema of orbits/eyelids.

Nasal fractures: Evidence of a nasal fracture includes epistaxis, swelling, tenderness, deformity, crepitus, nasal airway obstruction, and periorbital ecchymosis. Always evaluate for septal deviation or septal hematoma. A bulging, bluish, tender septal mass requires evacuation. Failure to do so can result in necrosis of the nasal septum. Widening of the intercanthal distance suggests the possibility of a nasoorbitoethmoid fracture.

Zygomatic/zygomaticomaxillary complex fractures: Impingement of the temporalis muscle may result in trismus, although this is only occasionally observed. Depression of the inferior orbital rim, paresthesia in the distribution of the infraorbital nerve, or diplopia suggests extension into the orbit or maxilla.

Maxillary (Le Fort) fractures: Physical examination findings include facial distortion in the form of an elongated face, a mobile maxilla, or midface instability and malocclusion.

Mandibular fractures: In a 1998 report, Schwab et al looked at physical examination characteristics that predicted a mandibular fracture. The tongue blade test assesses the ability of patients to grasp a tongue depressor in between the teeth and patients' ability to hold the blade against mild resistance by the examiner on each hemimandible. Inability to hold the tongue depressor had a negative predictive value of 96%, whereas malocclusion, facial asymmetry, and trismus have a negative predictive value of 87%, 76%, and 75%, respectively.