Facial Fractures

Background

Facial fractures occur for a variety of reasons related to sports participation: contact between players (eg, a head, fist, elbow); contact with equipment (eg, balls, pucks, handlebars); or contact with the environment, obstacles, or a playing surface (eg, wrestling mat, gymnastic equipment, goalposts, trees). Direct body contact accounts for the majority of sports-related injuries, and the most commonly associated soft tissue injuries were found in the head and neck region.[1]

Although most sports-related facial injuries are minor, 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, while considering the physical demands of the sport, as well as the athlete's return to play.

Facial fractures may be associated with head and cervical spine injuries.[2, 3] A review by Boden et al of catastrophic injuries associated with high school and college baseball demonstrated 1.95 direct catastrophic injuries annually, including severe head injuries, cervical injuries, and associated facial fractures.[3]

Fractures of the facial bones require a significant amount of force. The physician must take into account the mechanism of the injury as well as the physical examination findings when assessing the patient.

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

Nasal fracture – 30 gZygoma fractures – 50 gMandibular (angle) fractures – 70 gFrontal region fractures – 80 gMaxillary (midline) fractures – 100 gMandibular (midline) fractures – 100 gSupraorbital rim fractures – 200 g

For patient education resources, see the Back, Ribs, Neck, and Head Center; Breaks, Fractures, and Dislocations Center; Sports Injury Center; Eye and Vision Center; and Teeth and Mouth Center.

Also, see Facial Fracture, Broken Nose, Broken Jaw, Concussion, Black Eye, and Broken or Knocked-out Teeth.

NextEpidemiologyFrequencyUnited States

In 1977, Schulz noted that athletic injuries account for 11% of all facial fractures and that facial injuries occur in 2% of all athletes.[4] More recently, Reehal noted that facial fractures accounted for 4-18% of all sports injuries.[5] A review by Romeo of facial fractures sustained by athletes during sports participation noted that sporting activities account for 3-29% of facial injuries and 10-42% of all facial fractures.[6] Tanaka and colleagues showed that 10.4% of all maxillofacial fractures are related to sports.[7]

In another report, Laskin stated that 250,000 individuals, many of whom were children, experience facial trauma while engaged in athletic activities.[8] The review by Hwang et al demonstrated that athletes aged 11-20 years were the population that accounted for most (40.3%) sports-related facial bone fractures.[1] Additionally, it is estimated more than 100,000 sport-related injuries could be prevented by wearing appropriate head and face protection.[8]

Retrospective analysis demonstrated a significant male predominance (13.75:1) among athletes who sustained sports-related facial bone fractures.[1] The sports most commonly associated with facial fractures were soccer (38.1%), baseball (16.1%), basketball (12.7%), martial arts (6.4%), and skiing/snowboarding (4.7%).[1]

Nearly 75% of facial fractures occur in the mandible, zygoma, and nose.[9] Sports participation is the most common cause of mandibular fractures (31.5%), followed closely by motor vehicle accidents (27.2%). A study of facial fractures sustained during recreational baseball and softball demonstrated that the zygoma or zygomatic arch was the most common fracture subtype, followed by temporoparietal skull fractures and orbital blow-out fractures.[10] A number of studies in the medical literature, however, indicate that the nasal bones are the most commonly fractured bones in the face, but because many of these patients do not seek medical treatment or the injuries are managed in the outpatient setting, the statistics may not reflect this trend.[2] It is likely that the nasal bones are more commonly fractured because of the lesser degree of force that is required to fracture the bone.[11]

Fractures of the orbit occur more commonly in young adult and adolescent males: the mean age for adult males is 32 years; the mean age for children, 12.5 years, and the majority of orbital fractures occur in boys. In addition to sports-related injuries, injuries sustained in motor vehicle collisions, assaults, and occupational injuries account for the majority of orbital fractures.[12]

PreviousNextFunctional Anatomy

Frontal sinus: Both the anterior and posterior wall may be damaged. Because the posterior wall is adjacent to the dura mater, damage in this region could result in central nervous system (CNS) complications such as a cerebrospinal fluid (CSF) leak or meningitis.

Orbital: The bony orbit (see image below) is composed of 7 bones of varying thickness. The frontal bone forms the supraorbital rim and orbital roof. The medial surface consists of the ethmoid, whereas the greater wing of the sphenoid and the zygoma create the lateral margin. Inferiorly, the floor and infraorbital rim are formed by the zygoma and maxilla. This portion is very thin; therefore, it is the most common site of fracture within the orbit. Fracture of the orbital floor, also known as a blow-out fracture, can result in entrapment of the inferior rectus muscle, limiting upward gaze.

The bony walls of the orbit.

The most common fracture to the orbital rim involves the orbital zygomatic region; this fracture, which typically results from a high-impact blow to the lateral orbit, often results in a fracture to the orbital floor as well.[12]

Nasal: The nose is the most prominent feature of the facial structures and is the most commonly fractured of all facial bones.[5] The upper third of the nose is supported by the paired nasal bones and the frontal process of the maxilla, whereas the lower two thirds of the nose are maintained by cartilaginous structures.[11] A more serious injury, a nasoorbitoethmoid fracture, occurs with trauma to the bridge of the nose. This injury involves extension into the frontal and maxillary bones and can result in disruption of the cribriform plate with concomitant CSF rhinorrhea.

Zygomatic/zygomaticomaxillary complex: The zygoma, like the nasal bones, is a prominent facial bone and, therefore, is prone to injury. Commonly, a breakage in this area involves a central depression with fractures at both ends. The central fragment may impinge upon the temporalis muscles, resulting in trismus. Because of its thickness, isolated fractures of the zygoma are rare, often involving extension into the thinner bones of the orbit or maxilla, otherwise known as zygomaticomaxillary (ie, tetrapod or tripod fractures).

Maxillary (Le Fort): Rene Le Fort first described fractures of the maxillary region in the 1900s (see image below). Classification of maxillary fractures is based on the most superior level of the fracture site.[5]

Le Fort fractures.

Le Fort I injuries involve a transverse fracture of the maxilla above the level of the root apices and through or below the level of the nose.

Le Fort II injuries traverse the nose, infraorbital rim, and orbital floor and then proceed laterally through the lateral buttress and posteriorly through the pterygomaxillary buttress.

Le Fort III injuries, also known as craniofacial dysjunction, result from motor vehicle or motorcycle accidents and are the result of the mid face being separated from the cranial base.

Mandibular: Fractures of the mandible (see image below) can involve the symphysis, body, angle, ramus, condyle, and subcondyle regions. Fractures of the mandibular body, condyle, and angle occur with nearly equal frequency, followed by fractures of the ramus and coronoid process.[5] Generally, motor vehicle accidents result in fractures of the condylar and symphysis regions because the force is directed against the chin, whereas injuries from boxing are more likely to be located in the mandibular angle, as the result of a right-handed punch. Over 50% of mandible fractures are multiple; the presence of one mandibular fracture mandates evaluation for additional fractures, perhaps contralateral to the affected side.[5]

Mandibular fractures. PreviousNextSport-Specific Biomechanics

In general, facial fractures in athletic activities 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 a corrected visual acuity of 20/40 or less or spectacle correction greater than 6 diopters (D). These athletes need an ophthalmologist's evaluation before competing in sports.

A one-eyed athlete is defined as one with a 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.

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Sports-Related Facial Soft Tissue Injuries

Overview

Sports-related facial soft tissue injuries are not uncommon.[1, 2, 3, 4, 5, 6, 7] The position and anatomy of the face make it particularly vulnerable to trauma. In addition, few sports mandate the use of protective equipment, leaving the face susceptible to injury.

The mechanism of facial soft tissue injuries is often a direct impact from an external source (eg, sporting equipment, another participant, environment/playing surface). The forces exerted by the impact can lead to friction, shear, compression, and/or traction of the soft tissue and underlying structures. Injury patterns vary widely by sport, based on various factors (eg, rules, equipment).[8, 9, 10]

Although most such injuries are minor in nature, they should be evaluated promptly with a focused history and thorough examination. In addition, facial injuries should be treated early to reduce the likelihood of possible adverse outcomes (ie, infection, loss of function, poor cosmesis). In this article, common sports-related soft tissue facial injuries are discussed, with an emphasis on the initial evaluation, diagnosis, and treatment.

Prevention

The use of protective equipment, such as helmets and headgear, face masks, eye protection (shields or goggles), and mouthpieces are useful in preventing some types of facial soft tissue injuries. Importantly, make sure the rules of the sport allow for the use of such protective equipment before recommending or providing the protective equipment.

NextHistory and Physical Examination

A focused and thorough history should be obtained from the injured athlete, including his or her pertinent medical history, the mechanism of injury (if not witnessed by the medical staff), and the source of pain. If the patient is unable to report history information, family members can provide such information. The presence of symptoms such as visual changes or altered sensorium should also be ascertained at this time.

Physical examination

As with any head and neck injury, examination of an individual with trauma to the face must start with an evaluation of the patient's airway, breathing, and circulation (ABCs). Cervical spine injury should also be considered based on the mechanism of injury, and appropriate precautions should be taken. The physical examination should be focused on the specific injury site.

The face is extremely vascular, and even minor injuries may result in profuse bleeding. Copious irrigation should be used to clean and accurately assess the injury. Visual inspection and palpation should be used to systematically examine the face for symmetry. Start superiorly, with the scalp and frontal bones, and proceed inferiorly and laterally. Examine the oral cavity for any disrupted dentition or lacerations. During inspection, pay particular attention to any areas of swelling because this may indicate a more significant underlying injury.

Note the location, size, shape, and depth of any lacerations, and explore wounds for foreign bodies. Palpate for areas of crepitus or bony step-off. Gross asymmetry may signify underlying nerve damage. Assess neurologic function by evaluating sensation and motor function.

PreviousNextLaceration

As with the physical examination, a systematic approach to facial laceration repair ensures the best chance at an optimum outcome.[11] A summary of one methodologic approach follows.

Wound assessment

Familiarity with the pertinent anatomic aspects of the face is important. Clear anatomic boundaries are present that must be respected and carefully realigned to avoid obvious deformity. Cosmetic results are better when minimal tension is placed on the wound edges at the time of repair. Therefore, wounds with the long axis parallel to the natural skin tension lines have much better cosmetic outcomes. The degree of tension on the wound edges can be estimated by measuring the distance that the wound edges retract away from the center of the lesion. Marked retraction (>5 mm) indicates strong skin tension. With such wounds, placement of dermal sutures in a 2-layer closure should be considered.

Anesthesia

Anesthesia can be provided by topical, local, or regional block. An advantage of using regional block in the face is that the wound edges are not distorted from the local anesthetic. The areas for regional block injection are shown in the image below. Amide anesthetics (eg, lidocaine, bupivacaine, mepivacaine) are used most commonly. Allergic reactions are uncommon. When using anesthetics containing epinephrine, care should be used to avoid areas with end arteries (ie, the nose).

Distribution of nerves for regional anesthesia of the face.

The regional block and the area of anesthesia are as follows:

Supraorbital and supratrochlear blocks – Forehead, anterior one third of the scalpInfraorbital block – Lower lid, upper lip, and lateral aspect of the noseMental nerve block – Lower lip and chinWound cleaning and irrigation

All areas should be thoroughly explored, copiously irrigated, cleaned, and débrided of devitalized tissue before closure. Irrigation lessens the risk of infection. Interestingly, regardless of irrigation, noncontaminated wounds repaired within 6 hours of injury rarely develop infection, and the overall rate of infection of repaired scalp and facial wounds is 1%.

After irrigation, gentle cleansing of the wound should be performed with a dilute povidone-iodine solution (Betadine; Purdue Pharma, LP, Stamford, Conn) or iodine solution. The wound edge (1-2 mm) can be safely removed to rid the area of devitalized tissue. Attempts should be made to make the wound edges perpendicular with the skin surface because this results in a smoother, less noticeable scar. (See the image below).

Top: Improper repair of an angled laceration. Bottom: Proper repair of an angled laceration, with creation of perpendicular edges for a flush repair. Repair

Deep wounds should be repaired in layers. Unrepaired muscle layers are much more likely to produce noticeable scarring. When performing a 2-layer closure, the deep layers should be closed with absorbable suture. Importantly, use the minimum amount of subcutaneous suture necessary because the risk of infection is related to the amount of suture used. Nonabsorbable, monofilament suture should be used for skin closure. Monofilament suture is associated with a lower risk of infection compared with a polyfilament suture. (See the image below.)

Steps to repair lip laceration. A 3-layered approach is needed, as depicted.

The suture technique should be selected based on the site of the wound and the amount of tension on the wound edges. A simple interrupted technique can be used in areas of low tension or in wounds in which the tension has been reduced with a layer of subcutaneous sutures. This technique is also useful for realigning wounds with irregular wound edges. Areas of high tension are best closed using a vertical mattress technique. All facial wounds should be repaired in less then 24 hours to decrease the risk of infection and achieve the best cosmetic result. If a delay in closure is necessary, wounds should be covered with saline-moistened gauze until the repair can be made.

Dermal adhesives, such as 2-octyl cyanoacrylate, have been shown to be equivalent to sutures for the repair of simple, clean wounds in areas of low tension.[12] The adhesives are applied topically to the wound edges. Advantages of adhesives include shorter repair time, fewer supplies, less pain during repair, and elimination of the need to remove sutures or staples at a follow-up visit. Note that dermal adhesives should not be used on the lips or mucous membranes; avoid their use in patients with poor circulation or who have a propensity to form keloids.

Staples are good alternatives to sutures in the repair of scalp lesions. Stapling involves shorter repair time and less cost compared with suture repairs. Rates of infection and inflammatory response are not higher than those associated with suture repair. During the staple application, an assistant helps to evert and approximate the wound edges, while the primary operator uses the stapler. Disadvantages include the inability to accurately align the wound edges in irregular wounds and an increased likelihood of visible scarring, thus limiting the use of stapling to the scalp.

Follow-up

The athlete should be given instructions for proper wound care, including the normal healing process and signs that might indicate the presence of complications. Anticipate any complication (eg, infection, swelling, bleeding, dehiscence) and give precise instructions for early return. The following is a list of laceration sites and recommendations on suture size and typical time to removal:

Scalp - 4-0 suture or staple, with removal in 7-14 daysForehead - 5-0/6-0 sutures, with removal in 5 daysEyebrow - 5-0/6-0 sutures, with removal in 3-5 daysFace - 6-0 suture, with removal in 5 daysEyelid - 6-0/7-0 sutures, with removal in 3 daysNose - 5-0 sutures, with removal in 3-5 daysEars - 6-0 sutures, with removal in 10-14 daysLips - 6-0 sutures, with removal in 3-5 daysPreviousNextOther InjuriesContusion

Contusions are the most common facial soft tissue injury seen by a sports medicine team. They are usually the result of blunt trauma to the face. Ice should be applied for 10-20 minutes to minimize the immediate inflammatory response. This treatment should continue for the next 48-72 hours. Over-the-counter (OTC) nonsteroidal anti-inflammatory drugs (NSAIDs) are good for symptom relief. Complications are uncommon

Abrasion

Abrasions are partial-thickness disruptions of the epidermis as a result of sudden, forcible friction. These wounds should be gently cleansed of all debris. Failure to remove all debris can lead to "tattooing" of the skin and a poor cosmetic result. Local or regional anesthetic may be required to keep the patient comfortable and achieve adequate cleaning. Lubrication of the wound using an antibiotic ointment and covering with a sterile bandage may encourage healing.

Corneal abrasion

Corneal abrasions result from loss of the surface epithelium. Disruption near the central visual axis interferes with visual acuity. Such abrasions should be treated with a course of ophthalmic topical antibiotics. Topical analgesics may be used initially, but avoid prescribing them to the athlete for home use because this may delay reepithelialization and suppress the normal blink reflex.

Emergent consultation with an ophthalmologist is warranted for suspected retained intraocular foreign bodies, and urgent consultation is needed for suspected corneal ulcerations (microbial keratitis). These injuries require close follow-up. Referral to an ophthalmologist should also be made for any athlete with continued pain after 48 hours or inadequate healing by 72 hours.

Epistaxis

Epistaxis typically does not require invasive treatment. Most often, bleeding can be controlled by maintaining continuous pressure for 10 minutes. This is achieved by asking the athlete to grasp and pinch his or her nose. While this task is performed, have the athlete tilt the head forward to avoid bleeding into the pharynx, which can lead to aspiration. Pressure should be maintained for at least 5 minutes and for up to 20 minutes. If this is unsuccessful, a second attempt should be made.

Packing the affected nostril with gauze soaked in topical decongestant may be necessary to achieve hemostasis. If the bleeding site is clearly observed, chemical cautery can be attempted using silver nitrate directly at the site. If bleeding is not controlled despite these measures, the nasal cavity should be packed from posterior to anterior with ribbon gauze impregnated with petroleum jelly. Nasal tampons may also be helpful. For particularly resistant cases, referral to an otolaryngologist may be required.

PreviousNextReturn to Play

Return to play should be based on the location and severity of the injury, sport and position requirements, and risk of the injury causing a concomitant injury. Most athletes are able to return to play immediately after treatment on the sideline or in the training room. When making return-to-play decisions, attention should be given to whether the area in question can be protected from further injury.

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Facial Soft Tissue Injuries

Background

Facial soft-tissue injuries are not uncommon in athletics.[1, 2, 3, 4, 5, 6, 7] The position and anatomy of the face make it particularly vulnerable to trauma. In addition, few sports mandate the use of protective equipment, leaving the face susceptible to injury. Although most such injuries are minor in nature, they should be evaluated promptly with a focused history and thorough examination (see image below). In addition, facial injuries should be treated early to reduce the likelihood of possible adverse outcomes (ie, infection, loss of function, poor cosmesis). In this article, common sports-related soft-tissue facial injuries are discussed, with an emphasis on the initial evaluation, diagnosis, and treatment.

Location of the parotid gland and duct system.

For excellent patient education resources, visit eMedicineHealth's First Aid and Injuries Center and Eye and Vision Center. Also, see eMedicineHealth's patient education articles Facial Fracture, Black Eye, Nosebleeds, Bicycle and Motorcycle Helmets, and Bicycle Safety.

NextEpidemiologyFrequencyInternational

The exact frequency of facial soft-tissue injuries related to sports participation is unknown. This is, in part, due to the minor nature of many injuries, which can lead to underreporting. It may also be due to the wide variation that is seen between demographic groups and between specific sports.

Previous reports estimate sports participation to account for 3-29% of all facial injuries.[5] In terms of overall sports-related injury, facial trauma accounts for 11-40% of injuries attended to by medical professionals. Most injuries are reported in males, particularly those aged 10-29 years. Sports that mandate the use of helmets and face masks tend to have fewer soft-tissue injuries compared with sports that do not mandate the use of such equipment.

PreviousNextSport-Specific Biomechanics

The mechanism of facial soft-tissue injuries is often a direct impact from an external source (eg, sporting equipment, another participant, environment/playing surface). The forces exerted by the impact can lead to friction, shear, compression, and/or traction of the soft tissue and underlying structures. Injury patterns vary widely by sport, based on various factors (eg, rules, equipment).[8, 9, 10]

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