General Guidelines and Initial Evaluation

Most athletes who sustain facial bones fractures should not return to the game. A second impact to a facial bone that is already fractured may compound the fracture and convert a simple, nonoperative fracture into a complex and disfiguring surgical challenge.

When evaluating an athlete with a potential facial fracture, the care provider should maintain a high index of suspicion and promptly refer the patient to a facility that can adequately image and manage the injury. The following fractures discussed are those most commonly encountered in sports-related facial trauma.

Nasal Fractures

Because of its prominent location on the face, the nose is the most commonly fractured facial structure associated with sports-related facial injuries. [8] Nasal fractures account for approximately 50% of sports-related facial fractures; 15% of those fractures are recurrent. The common perception of the broken nose as innocuous may account for its high rate of undertreatment. However, a poorly managed acute nasal fracture leads to chronic nasal deformities and, sometimes, breathing difficulties that may impair the performance of competitive athletes.

Examination and diagnosis

The diagnosis of a nasal fracture is made clinically. The most common findings in a nasal fracture include epistaxis, swelling and tenderness of the nasal dorsum, bruising around the eyes, and an obvious nasal deformity. Widening of the nasal bridge or telecanthus may indicate a naso-orbitoethmoid (NOE) fracture pattern. [18] Palpation of the nasal bones can demonstrate mobility, irregular surface, or crepitus. If the injured athlete reports a nasal obstruction during inspiration, the examiner should strongly consider a nasal/septal fracture or dislocation.

The intranasal examination should be conducted under proper lighting with a nasal speculum. The examiner can spray the intranasal structures with a vasoconstrictor, such as phenylephrine or oxymetazoline, to allow for better visualization.

Treatment

The indications for treatment of nasal/septal injuries by a physician are persistent bleeding and obvious nasal deformity. Treat any open wounds with copious irrigation, and apply ice to minimize swelling.

Swelling that occurs over time obscures the deformity and makes acute closed reduction difficult. If considerable swelling has occurred, waiting at least 4-7 days for the swelling to subside before treating the nasal fracture is prudent. Treatment can be limited to a simple closed reduction of the nasal bones using topical and local anesthesia in a physician's office setting or can be a more involved reduction of a fractured or severely dislocated septum in the operating room. The realigned septum or nasal bones are then splinted externally and internally. The splints are usually removed in 7-10 days. For an illustrated demonstration of nasal fracture reduction, see Nasal Fracture Reduction.

Carefully consider the decision to return the athlete to competition and the need for nasal protection. The nasal bones generally heal sufficiently within 4-8 weeks, allowing the athlete to return to competition in contact sports. If the athlete resumes competition soon after repair, strongly recommend that he or she use a protective facial device of sufficient strength to prevent further injury.

Orbital Fractures

One third of all orbital fractures are secondary to sports injuries [6] and can almost always be prevented with the use of protective eyewear. The risk of injury to the eye is highly related to the type of sport. High-risk sports are those with high-speed projectile objects, clubs, or aggressive body contacts.

Examination and diagnosis

When an injury occurs near the eye, a thorough eye examination should be performed, as previously described. A circumferential bony framework protects the vital structures of the orbital complex. The aperture of the circumferential bony rim does not allow objects with a radius greater than 5 cm to penetrate to the globe. During the examination, the circumferential bony rim should be palpated. Fractures of the orbital rim can occur at any point on the rim; however, fractures of the inferior rim are most common. These fractures can occur independently or in combination with orbital wall fractures; orbital wall fractures can also occur alone.

A blow to the eye can cause an increase in intraorbital pressure, with or without fracturing of the orbital rim. The thin bones of the orbital floor actually fracture to increase the volume of the orbit and dissipate the pressure that would otherwise rupture the globe. This protective fracturing is called an orbital blowout fracture. It can manifest with ecchymosis, enophthalmos, hypoglobus, periorbital emphysema, and numbness of the area on the ipsilateral cheek supplied by the infraorbital nerve.

Diplopia upon upward gaze can be due to a restriction of movement of the eye because of herniation of orbital fat and the inferior rectus muscle through the orbital floor or due to swelling or contusion of the muscle. A facial bone CT scan with coronal views evaluating the floor of the orbit can help to differentiate the causes. Forced duction test is also helpful in differentiating the causes of diplopia and gaze limitation. In the forced duction test, the affected eye is anesthetized with a topical anesthetic, the sclera is grasped with a fine-toothed forceps at the level of the insertion of the inferior rectus muscle, and the eye is gently moved in a superior and inferior direction. If the globe moves easily, entrapment of the ocular contents can be excluded. Entrapment of the inferior or medial rectus is more likely to be seen in pediatric patients and warrants immediate evaluation by an ophthalmologist.

Treatment

Absolute indications for surgical repair include noticeable enophthalmos, limitation in extraocular movements, and persistent diplopia due to entrapment of the orbital contents in the fracture line.

For details regarding surgical repair of orbital blowout fracture, please visit the Medscape Drugs & Diseases topic Facial Trauma, Orbital Floor Fractures (Blowout).

If an orbital fracture is suspected, the patient should avoid any nose blowing or Valsalva maneuvers to prevent periorbital emphysema. After the injury, if the player returns to competition before 4-8 weeks have passed, strongly recommend protective facial devices sufficient to prevent reinjury. When protective eyewear has been used in racquet sports and face protection devices have been used in hockey, eye injuries have been virtually eliminated. [19]

Zygomaticomaxillary Complex Fractures

The bones of the zygomaticomaxillary complex (ZMC) make up the prominences of the face known as the cheekbones. Fractures of this bony complex account for approximately 10% of sports-related facial fractures. The zygomatic bone articulates with the frontal bone, maxilla, temporal bone, and the wing of the sphenoid, and fractures of this complex usually involve several of these articulations. This type of fracture typically occurs when significant force is directed at the prominence of the cheekbone. The bony complex is forced posteriorly and rotates laterally and inferiorly.

Examination and diagnosis

A thorough examination of the head and neck should be conducted when a ZMC fracture is suspected. Clinical findings commonly associated with ZMC fractures are periorbital ecchymosis, numbness in the distribution of the infraorbital nerve over the cheek, enophthalmos, restriction of movement of the eye upon upward gaze, lateral subconjunctival hemorrhage, and depression of the cheekbone with an associated downward slant of the eye. The medial and lateral canthal tendons that support the eye attach to the medial and lateral orbital rims, respectively, so that any change in the position of the orbital rim changes the axis of the intercanthal line. Any combination of these signs and symptoms may be evident. The most accurate and most commonly used radiologic examination to diagnose ZMC fractures is a computed tomography (CT) scan, which is also used to aid surgical planning.

If a ZMC fracture is suggested, the player should not return to competition, and a specialist should be consulted.

Treatment

Treatment varies depending on the severity of the fracture. If surgical repair is needed, perform it within 7-14 days to prevent early fracture consolidation. Rigid fixation of these fractures is usually obtained with titanium miniplates and screws specifically designed to be used on the facial bones, using surgical approaches that minimize facial scars.

The use of rigid fixation has decreased the need for extended intermaxillary fixation and resulted in more predictable, stable, long-term results. However, research has shown that rigid internal fixation is not as strong as the patient's own intact facial skeleton. A similar blow to the repaired fracture site before the bones have healed puts the athlete at risk for a more severe fracture pattern than the initial injury, and the risk of damage to the underlying vital structures is significant. Therefore, strongly recommend that the athlete refrain from practice or competition for at least 6-8 weeks to allow the fractured bones to heal. Protective facial devices, if properly constructed, may allow the athlete to return to competition earlier.

For details regarding surgical repair of ZMC fractures, please visit the Medscape Drugs & Diseases topic Zygomaticomaxillary Complex Fractures.

Mandibular Fractures

Fractures of the mandible make up approximately 10% of all sports-related facial fractures. Results from a study in Austria indicate that sports accidents are the most common cause of mandibular fractures, occurring in 31.5% of the patients in that series.

The mandible is a horseshoe-shaped structure that articulates with the base of the skull at the temporomandibular joints. It is a strong cortical bone that has several weak areas. It is thin at the angles, at the neck of the condyles (subcondylar area), and at the distal body where the long root of the canine tooth and the mental foramen are located. Because of the mandible's U-shape and several weak, thin areas, the mandible commonly fractures in more than one place.

The tongue is attached to the lingual surface of the anterior mandible; therefore, the anterior segment of a bilateral fracture in the parasymphyseal region has the potential to shift posteriorly, causing the tongue to block the airway. The simple act of pulling the tongue or the anterior jaw forward can open the airway. The tongue or jaw should be stabilized in this position, and the athlete should be transported to the emergency department, with proper cervical spine immobilization if necessary.

Examination and diagnosis

Malocclusion, pain, swelling, difficulty opening the mouth, and intraoral bleeding are the most common signs and symptoms of a lower jaw fracture. Palpation of the mandible, visible step-offs between the teeth, and pain upon stressing the mandible also aid in the diagnosis of a fracture. Panorex view or facial bone CT scan is a reliable image modality for diagnosing most mandibular fractures.

The subcondylar regions are the most commonly fractured areas of the lower jaw. These areas are thinner than the rest of the mandible, and forces generated at impact are transmitted to these areas. The condylar region of the lower jaw is considered a growth center. Fractures of this region in a younger athlete who has not completed growth can result in altered growth of the mandible with associated occlusal problems. Injuries to this region can also result in hemorrhage into the temporomandibular joint spaces and lead to fibrosis and possibly ankylosis with associated inability to move the joint.

Treatment

For details regarding the nonoperative and operative management of mandibular fractures, please see the Medscape Drugs & Diseases topic Facial Trauma, Mandibular Fractures.

Special referral may be required for adolescent athletes. Prior to the full eruption of permanent dentition, referral to a craniofacial or pediatric plastic surgeon may be warranted, since the unerupted teeth are vulnerable to damage with conventional fixation techniques.

Athletes with fractured jaws should not be allowed to return to play until healing has occurred and they are out of maxillomandibular fixation (which generally takes 4-6 weeks). A protective cage or helmet with a jaw extension can allow athletes in selected sports to return to competition earlier.

Dentoalveolar Injuries

Dentoalveolar fractures are fractures of the alveolar bone and the associated teeth. Injuries to the mouth are particularly common in team sports. Any trauma to the lower face can result in an injury to the dentoalveolar complex. Lacerations of the lips and intraoral mucosa are frequently associated with injury to the teeth and their supporting structures. The most commonly injured teeth are the maxillary central incisors.

Examination and diagnosis

When assessing dentoalveolar injuries it is important to take into account the age of the patient and the presence of primary dentition. The normal adult has 28-32 permanent teeth (8 incisors, 4 canines, 8 premolars, and 8-12 molars). However, children under age 5 years have primary dentition, and those aged 6-12 may have mixed dentition. It is often helpful to ask parents about their child’s dentition status when performing an examination. [7] As reported by Ranalli, signs and symptoms of dentoalveolar trauma include intraoral bleeding, tooth malposition, malocclusion, mobility of the affected structures, pain, and altered sensation of the teeth. [20, 21]

The examiner should always count the athlete's teeth after an injury. If any teeth are missing, every effort should be made to retrieve them. Teeth may lodge in the surrounding soft tissues, such as the lips and tongue. Teeth also may be lodged in the airway or aspirated into the lungs. Appropriate airway precautions should be taken and radiographs obtained to exclude these possibilities. The potential for permanent loss of a tooth is high in more severe injuries.

The teeth involved in dentoalveolar fractures may or may not have associated fractures of the crown or root, or they may be luxated or avulsed. Treat dentoalveolar fractures as open fractures. A specialist must address tetanus prophylaxis, antibiotic coverage, and reduction and fixation of the fracture. Referral to a dental specialist for outpatient follow up should be arranged.

Tooth Fractures

Tooth fractures can involve the crown or the root. The most common traumatic injury seen by the general dentist is the crown fracture (79%). [7] Fractures of the crown in which only the enamel is fractured do not usually require urgent attention. Treatment for this includes smoothing any sharp edges and relieving the occlusion of the athlete's tooth.

However, if the fracture involves the neurovascular tissue, it exposes the vital nerve center (pulp) of the tooth and can be quite painful. Pulp injury with pain to air exposure requires immediate dental referral. Treatment includes covering the exposed pulp of the tooth with calcium hydroxide within 24 hours and acid-etch bonding of the fractured piece of tooth with a composite resin. If the fractured piece of crown is retrieved, it may be saved by placing it in Hank’s balanced salt solution (Save-A-Tooth), saline or cold milk, and it may then be rebonded directly to the fractured tooth by means of acid-etch bonding or light-cured glass ionomer resin material. This treatment alleviates discomfort and allows healing to begin.

Root fractures can be more difficult to diagnose. They usually occur in teeth that are fully formed. Any mobility of a tooth or pain upon palpation suggests a root fracture. The athlete should be referred to a dentist for dental radiographs, definitive testing of the involved teeth, and management of these types of injuries.

Tooth Displacement

Luxation, or displacement of a tooth, occurs when the tooth is malpositioned in its bone socket. There can be subluxation (loosening), extrusion (partial avulsion), or intrusion of a tooth. Treatment for subluxation is occlusal adjustment, observation, and vitality testing. Treatment for extrusion is repositioning and splinting, periodic vitality testing, and possible root canal intervention. Treatment of luxation and extrusion usually requires the use of a local anesthetic because manipulation can be quite painful. Lastly, intrusion of a tooth with incomplete root development, as in a child, is treated by allowing the tooth to re-erupt, and manipulation should not be performed by a nondental health care provider. Teeth with complete root development that suffer intrusion are repositioned and possibly treated with calcium hydroxide root canal therapy. Patients with tooth displacement should be seen within 24 hours by a dental specialist. [7]

Tooth Avulsion

Avulsion is the complete separation of the tooth from the alveolus (socket), which is an urgent situation. The prognosis for viability of the tooth and successful replantation is inversely proportional to the length of time the tooth is out of the socket. Treatment principles are to replant and stabilize the avulsed permanent tooth as quickly as possible. According to the American Academy of Pediatric Dentistry 2001-2002 Reference Manual, pulp and periodontal healing are more likely to occur when the permanent tooth is replanted immediately (<5 min).

Reimplantation of a tooth within 30 minutes has >90% chance to save the tooth; after more than 2 hours, the chance of survival is 5%. [22] The key to successful replantation is the continued nourishment and maintenance of the periodontal ligament of the tooth. If the periodontal ligament fibers become desiccated or necrotic or are removed as a result of rough handling, the tooth may undergo resorption or can ankylose to the surrounding bone and may ultimately be lost. Gentle handling of the root of the tooth at the point where the ligaments are attached is imperative (although handling of this area should be avoided altogether, if possible). The athletic trainer should not scrub or brush the root of the avulsed tooth; instead, he or she should gently handle the tooth by its crown and irrigate it with saline, if available. If the tooth cannot be immediately replanted into its socket, it should be cleaned gently and simply placed in the buccal vestibule of the mouth (between the cheek and gums), and the athlete should be immediately transported to a dentist.

If the athlete is unable to hold the tooth this way, the tooth should be placed in fresh, cold milk; sterile saline; Hank’s balanced salt solution (Save-A-Tooth); or saliva. Tap water should not be used, due to the low osmolality that can disrupt cells. According to the article "Best face forward: athletic facial injuries," published by the University of Pittsburgh Medical Center, milk is an ideal storage medium; mitotic activity in periodontal cells has been maintained for up to 6 hours when a tooth is stored in milk. [23, 7]

A diet of soft foods and analgesics should be prescribed for the management of pain. According to the American Academy of Pediatric Dentistry, antibiotic therapy should be considered and tetanus immunization status should be addressed. Additionally, often the tooth requires endodontic treatment (root canal therapy) for ultimate salvage.