General Principles
Epidemiology
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3%–29% of facial injuries are a result of sporting activities
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60%–90% of facial injuries in sports occur in males aged 10–29 years
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Approximately 75% of facial fractures involve the zygoma, mandible, or nose.
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The most commonly injured teeth are the maxillary central incisors, followed by the lateral incisors and the mandibular incisors.
Initiation of Care of the Head-Injured Athlete
Airway Injury or Compromise
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Follow the ABCs (airway, breathing, and circulation) of basic life support.
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May need to secure airway before making any other assessment
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If the neck is injured, use the jaw thrust maneuver.
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May be difficult to maintain airway with unstable mandibular fracture and certain soft tissue injuries
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Can use oral airway or endotracheal tube as indicated in unconscious patients. A nasal trumpet works well in an awake patient without a midface fracture.
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Cricothyrotomy may be the only option in emergency.
Cervical Spine Injury and Concussion (See Chapter 46, Neck Injuries and Chapter 45, Head Injuries )
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The spine must be stabilized if there is any doubt regarding injury or if the athlete shows altered mental status.
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With facial injuries, the physician must check for associated cervical spine injuries or concussion.
History
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Check for history of abnormalities such as crooked nose, missing teeth, or anisocoria.
Physical Examination
Inspection
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Observe for facial asymmetry, widening of the midface, ocular asymmetry, and malocclusion from multiple angles.
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Early examination is optimal before the swelling causes any asymmetry.
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Observe for malocclusion.
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Bleeding or bruising sites may be indicative of other possible injuries.
Palpation
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Systematically palpate bony structures, including the maxilla and mandible, bimanually with gloved fingers in the oral cavity.
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Conduct sensory examination for possible nerve injuries. Three branches of the trigeminal nerve supply the face: the ophthalmic nerve innervates the forehead, maxillary nerve innervates the cheek and midface, and mandibular nerve innervates the jaw ( Fig. 48.1 ).
Figure 48.1
Cutaneous nerves of head and neck.
Range of Motion
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Assess mandibular motion. Pain with opening or closing can indicate fracture.
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Ocular motions can be altered in certain facial fractures, indicating ocular muscle entrapment or nerve injury, which may require more immediate treatment.
Imaging Studies
Conventional Radiography
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Conventional radiography is rarely used for facial bone evaluation because imaging adds little to the clinical examination. However, if needed, most common radiographs:
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For nose: Right and left lateral, superoinferior axial occlusal, and Waters’ views
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For facial bones: Submentovertex, Waters’, right and left lateral obliques, Towne’s, and posteroanterior views
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Panoramic radiographs often used for dental root injuries
Cross-Sectional Imaging
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Computed tomography (CT) and magnetic resonance imaging (MRI) are much superior to conventional radiographs in identifying both normal and abnormal anatomy, particularly in the pediatric population. These provide more information regarding severity and displacement in case of an injury, which aids surgical planning.
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Facial bone CT offers better anatomic details, particularly bony anatomy, and is the study of choice over plain radiographs in trauma. Three-dimensional CT reconstructions can be a valuable tool in diagnosis.
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MRI is superior in soft tissue imaging, does not utilize ionizing radiation, and displays vascular anatomy without using contrast, but it is rarely used in trauma.
Common Injuries
Soft Tissue Injuries
Lacerations
Examination: Assess for both sensory and motor nerve injuries as well as underlying bone damage.
Treatment: Cleanse with sterile water or irrigating solution. Administer local anesthesia with lidocaine and epinephrine to help with hemostasis. Certain experts advocate not using epinephrine on ear or nose; may need layered closure of deep wounds with a dissolving suture to re-approximate subcuticular tissues. Skin closure can be with a 5-0 or 6-0 suture or tissue adhesive if skin edges closely aligned; appropriate alignment of vermilion border of lip important for cosmetic purposes. If the laceration is minor and bleeding can be controlled and can be covered with occlusive dressing, the athlete can return to competition.
Ear Injuries
Auricular Hematoma (“Cauliflower Ear”)
Mechanism of injury: Caused by shear forces: e.g., in wrestlers without head protection; this results in blood and/or serum accumulation between the ear cartilage and the perichondrium or between sheared layers of perichondrium.
Examination: Swelling or fluctuant areas in the cartilaginous area, usually in outer or lateral regions ( Fig. 48.2 )
Figure 48.2
Cauliflower ear.
Treatment: May usually continue participation in the event wherein the injury occurs; initially treated by aspiration of hematoma or incision and drainage after anesthetizing:
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Permanent disfigurement can occur if not appropriately treated.
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Field-block anesthesia by infiltrating the posterior sulcus as well as the skin anterior to the helix and tragus with 1% or 2% lidocaine without epinephrine; care should be taken to avoid injecting near the facial nerve.
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Hematoma will reoccur if not bolstered to hold the packing onto the area with slight pressure. Bolster can be a dental roll on both sides of the pinna held in place by a 3-0 or 4-0 monofilament nonabsorbable suture. Alternatively, a button or silicone splint can be placed on either side of the ear. To prevent further trauma, the wrestler must use headgear and leave the bolster in place for 7 days (see Fig. 48.2 ).
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Always use antibiotics with Staphylococcus coverage with a bolster in place.
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If infection occurs, bolster must be removed and the area must be incised, drained, and treated with an antibiotic that covers Staphylococcus and Pseudomonas.
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Prevention: Appropriately fitted headgear
Ear Laceration (Including Aforementioned Lacerations)
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Sew the ear in layers with cartilage, perichondrium, and finally skin. On the lateral portion of ear, all three layers may have to be sutured together.
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Attempt to minimize sutures in cartilage.
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Use an undyed absorbable 6-0 suture for cartilage and perichondrium.
Otitis Externa (“Swimmer’s Ear”)
Mechanism of injury: Disruption of the thin ear canal skin. Water-sport athletes are at a particularly high risk; usually caused by Pseudomonas aeruginosa or Staphylococcus aureus
Examination:
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Pain and discomfort with motion of pinna
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Swollen, inflamed, and erythematous external auditory canal
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Purulent discharge
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Treatment:
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Suction ear to remove debris.
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Antibiotics: corticosteroid-combination drops; quinolones are the best choice but can be costly
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May need a wick to allow antibiotics to penetrate to innermost portion of the ear canal if marked swelling present; leave in place for 3–5 days
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Consider treating significant infections with an oral antibiotic that has Pseudomonas coverage.
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Stay out of water until asymptomatic.
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Prevention: Dry ears after swimming; use of a hair dryer to ear can help reduce moisture. A combination of alcohol and vinegar or commercially available alcohol-based products such as Swim Ear® can help lessen moisture and may reduce the incidence of otitis externa.
Tympanic Membrane Perforation
Mechanism of injury: Can occur after skydiving or scuba diving with pressure changes; a blow to the ear or a fall onto the ear while water skiing
Examination:
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Hearing loss and serous or bloody drainage from ear
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Visible perforation in tympanic membrane
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Associated vertigo can signify ossicular disruption
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Treatment: Most (85%–90%) will heal without treatment; if it does not heal within 2–3 weeks, refer to an otolaryngologist. In water sports, use earplugs to keep water out of ear canals until perforation heals. Avoid sports with large changes in pressure, such as platform diving, until perforation heals. If injury occurred in river or lake, consider antibiotic eardrops. For suspected ossicular disruption, the athlete must be immediately referred to an otolaryngologist.
Dental Injuries
History:
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Spontaneous pain may indicate pulp exposure.
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Tender teeth with chewing may indicate injury to the periodontal ligament.
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Teeth sensitivity to extremes of temperature may indicate pulp exposure or inflammation.
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Changes in bite patterns (e.g., malocclusion) suggest facial fracture or dental subluxation.
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Examination: Examine teeth for fractures and laxity and soft tissues for associated lacerations and bruising. Panoramic radiographs or CT should be performed with dental fractures or luxation (loosening). Assess for root or bony fractures or in case of younger athletes, for permanent tooth bud displacement.
Treatment:
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Primary Teeth: Primary goal is to prevent injury to permanent teeth.
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Injuries needing urgent dental evaluation:
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Displaced or significantly loose primary teeth
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Do not replace avulsed or extruded (completely dislocated) teeth because this may injure the underlying permanent teeth.
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Crown fractures involving the pulp need prompt referral to prevent infection.
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Injuries needing dental evaluation within a few days:
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Mildly subluxed teeth, which appear in normal position but have pain with chewing, should be treated with a soft diet
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Crown fractures not involving the pulp
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Root fractures
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Permanent Teeth: Subluxed permanent teeth that are crooked should be examined by a dentist as soon as possible, but no on-field reduction is needed. Fractures involving the pulp can be painful. Fractures of teeth can be treated hours after the injury.
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Avulsed or displaced teeth: Survival of the delicate periodontal ligament cells on the root of a tooth is necessary for tooth survival. Little chance for dental survival after 1 hour out of the socket. Needs immediate dental referral for emergent reimplantation. Field care:
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Handle only by crown
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May rinse with saline or tap water, but do not rub or clean root
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Athlete can keep tooth in place with finger pressure or by biting on a gauze pad
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Alternatively transport by storing in Hank balanced salt solution, (e.g., Save-A-Tooth®). This will maintain the viability of the periodontal ligament cells longer, increasing the likelihood of successful reimplantation. Cold milk is a good alternative to this. Saline solution is another alternative. Water is not helpful in extending the viability of the periodontal ligament cells.
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Tetanus prophylaxis should be given if tooth is contaminated with dirt and last tetanus shot was more than 5 years previous.
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Prevention: Mouth guards can prevent dental injury. Basketball players are seven times more likely to have an orofacial injury when not wearing a mouth guard.
Nasal Fracture
Mechanism of injury: Trauma to nose. Nasal fractures constitute 50% of facial fractures in adults. Injury to bone–cartilage interface can be similar to nasal bone fracture, and diagnosis is made clinically.
Examination: Signs and symptoms include epistaxis, nasal asymmetry, crepitus on palpation, swelling, and nasal airway obstruction. Assess for septal hematoma ( Fig. 48.3 ), submucosal swelling on one or both sides of septum. Septal hematoma causes injury to blood supply to nasal cartilage.
