Face and Head ?>

Face and Head

Face and Head

Introduction
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). 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.1, 2 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.2

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 g
Zygoma fractures – 50 g
Mandibular (angle) fractures – 70 g
Frontal region fractures – 80 g
Maxillary (midline) fractures – 100 g
Mandibular (midline) fractures – 100 g
Supraorbital rim fractures – 200 g

For excellent patient education resources, visit eMedicine’s 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 eMedicine’s patient education articles Facial Fracture, Broken Nose, Broken Jaw, Concussion, Black Eye, and Broken or Knocked-out Teeth.

Related eMedicine topics:
Cervical Spine Sprain/Strain Injuries
Facial Trauma, Maxillary and Le Fort Fractures
Facial Trauma, Sports-Related Injuries

Related Medscape topics:
Resource Center Adolescent Medicine
Resource Center Exercise and Sports Medicine
Resource Center Trauma

Frequency
United States

Schulz noted that athletic injuries account for 11% of all facial fractures, and that facial injuries occur in 2% of all athletes.3

In another report, Laskin stated that 250,000 individuals, many of whom were children, experience facial trauma while engaged in athletic activities.4 Additionally, more than 100,000 sport-related injuries could be prevented by wearing appropriate head and face protection.

A review of facial fractures sustained by athletes during sports participation noted that in the medical literature, sporting activities account for 3-29% of facial injuries and 10-42% of all facial fractures.5 Tanaka and colleagues showed that 10.4% of all maxillofacial fractures are related to sports.6

Nearly 75% of facial fractures occur in the mandible, zygoma, and nose.7 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.8 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.1 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.9

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.10
Functional 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 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 (see Image 1).
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.10
Nasal: Nasal bone fractures are the most common of all facial fractures. 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.9 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 2).
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 can involve the symphysis, body, angle, ramus, condyle, and subcondyle regions. 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 (see Image 3).

Related eMedicine topics:
Facial Trauma, Maxillary and Le Fort Fractures
Orbit Anatomy

Related Medscape topics:
Facial Fractures May Be Safely Repaired in War Zones
Neuroimaging in Neuroophthalmology
Sport-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.

Related eMedicine topic:
Sports Physicals

Related Medscape topics:
Resource Center Adolescent Medicine
Resource Center Exercise and Sports Medicine

Clinical
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, performing endotracheal intubation. Second, assess the athlete 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. Because of the force necessary to fracture the facial bones, one should consider the cervical spine is fractured until proven otherwise, and cervical spine immobilization should be maintained.

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 a height, severe blows to the orbit with a weapon).
Patients may report diplopia.
Nasal fractures: With the exception of nasoorbitoethmoid fractures, nasal fractures are typically diagnosed based upon the 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 which 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 a significant causative 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.

Related eMedicine topics:
Cervical Spine Sprain/Strain Injuries
Facial Trauma, Maxillary and Le Fort Fractures
Facial Trauma, Sports-Related Injuries

Related Medscape topics:
Resource Center Adolescent Medicine
Resource Center Exercise and Sports Medicine
Resource Center Pain Management: Pharmacologic Approaches
Resource Center Resuscitation
Physical

The 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 mandibular, maxillary, zygomal, nasal, orbital, and frontal bones.

Any areas of obvious trauma, such as a 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 the 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 inability 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 the 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 a 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 the eyelids, subconjunctival hemorrhage, diplopia with limitation in upgaze or downgaze, enophthalmos, infraorbital nerve anesthesia, or emphysema of the orbits/eyelids.
One of the significant clinical features of a fracture to the orbital floor is entrapment of the inferior rectus muscle, resulting in impaired upward gaze on the affected side. Entrapment of the inferior orbital nerve may result from a fracture of the orbital floor and is manifested by decreased sensation to the cheek, upper lip, and upper gingival region on the affected side.
Entrapment of these structures may be more commonly encountered in children, whose bones may be more flexible and demonstrate a linear pattern that snaps back to create a “trap-door” fracture; in adults, the floor of the orbit is thinner and more likely to shatter completely. Other features commonly encountered with fractures of the orbit include enophthalmos, in which the eye appears to recede into the orbit, and orbital dystopia, in which the eye on the affected side appears lower in the horizontal plane relative to the unaffected side.10
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 mid-face instability and malocclusion.
Mandibular fractures
In a 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.11
Inability to hold the tongue depressor had a negative predictive value of 96%, whereas malocclusion had an NPV of 87%; facial asymmetry, 76%; and trismus, 75%.11

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