Despite the fact that appropriate face and mouth protection has been shown in numerous studies to reduce the incidence of injuries, few sports mandate their use. As a result, facial structures are frequently exposed during sports and are at risk for injury. Injury rates have been difficult to determine due to the following reasons: 1) the wide variety of settings in which facial injuries occur (eg, little league practice, unsupervised skating park); 2) the wide variety of settings in which injuries are treated (eg, school nurse, athletic trainers, urgent care centers, emergency rooms); and 3) the high number of injuries that go unreported. Based on available published data, 3% to 29% of all facial injuries seen in a variety of clinical settings occurred during participation in sports [1–7]. The majority of injuries (60%–90%) occur in boys and men between the ages of 10 and 29 years old [4–9]. The mechanism of injury in usually self-evident and frequently results from the direct impact of the facial structure with other participants (eg, fist in boxing, head in soccer), the ground (eg, field, floor, wrestling mat), equipment (eg, baseball, puck, goalpost), the environment (hitting a tree branch while skiing, running into the outfield wall in baseball).
Sideline Evaluation: “To Play or Not to Play…”
The primary goal of sideline management is to make a swift, accurate diagnosis and determine what can be definitively treated at the sporting event, what needs immediate attention at a health care facility, and what can be initially managed on the sidelines with follow-up care at a health care facility after the competition. In order to make this decision, clinicians must have a comprehensive and methodical approach to evaluating facial structures and an awareness of the commonly encountered injuries. Gloves, gauze, a tongue blade, and an otoscope are necessary to complete a comprehensive sideline examination.
As is the case with most sports-related injuries, determining and understanding the mechanism of injury is analogous to mentally recreating a crime in order to solve the case. Obviously, a witnessed crime is easiest to solve, so physicians along the sidelines should pay close attention to the action in order to act as their own eyewitness. In determining the mechanism of an injury, the athlete's ability to recount the details provides initial clues about mental status. With facial injuries, the most important component of mechanism of injury is the force transmitted at impact. Nasal injuries can occur from a glancing low-impact blow from a flailing hand in soccer to a television-worthy high-impact injury involving a speeding outfielder in baseball running into an outfield wall face first. The morbidity and mortality would be greater in the latter because greater force is acting on the facial structure and should be at least considered when determining whether an athlete can immediately return to play. Protective equipment such as a face mask, mouth guard, or throat guard can dramatically disperse impact forces and should be noted when in use and duly noted when not in use [10,11].
Initial assessments should commence with the fundamental “ABCs” of trauma management; insure the patient has a patent airway, is breathing normally, and has uncompromised circulatory status (Fig. 1). Fortunately for the sideline medical team, the airway is rarely compromised in sports without also involving a closed head or cervical spine injury. After determining that the athlete's airway, breathing, and circulation are uncompromised, the athlete who sustained a facial injury involving significant force should be approached by asking the following series of questions: What's your name? Do you know where we are and who you're playing? Do you know what today's date is (to assess alertness and orientation for closed head injuries)? Do you have any neck pain? Can you move your arms and legs? Do you have any numbness, tingling, burning, weakness of you arms or legs (to determine cervical spine injury symptoms)? Do you have any change in vision such as blurred or double vision (to determine concussion symptoms, symptoms seen with orbital blow-out fractures)? . Cervical spine precautions should be taken in the following scenarios: any unconscious athlete, any athlete with persistent, unexplained neurologic symptoms, and any athlete with bony tenderness of the cervical spine. If the athlete has symptoms consistent with an unstable head injury or a cervical spine injury, cervical spine precautions should always be taken and the patient should be immediately transported to the nearest emergency center.
Sideline Physical Examinations
Once the athlete has been cleared of an unstable head or neck injury, attention should turn toward hemostasis, as facial injuries are highly vascular and frequently associated with brisk bleeding. It is important to have gloves and gauze readily available so direct pressure can be applied with gloved hands to actively bleeding areas while performing the rest of the clinical evaluation. If hemostasis cannot be achieved on the sidelines with direct pressure, the athlete should be referred to the nearest health care facility for further evaluation and management. On occasion, an injured branch of the external carotid artery, such as the maxillary, facial, or superficial temporal artery, will require ligation to achieve hemostasis and should be done in the appropriate health care setting.
Because the key role of the sideline physician is to determine who can continue playing and who must seek immediate care in a health care setting, initial attention should focus on identifying traumatic injuries that require immediate care beyond the scope of the sidelines. The examiner should immediately look for facial asymmetry (such as a depressed zygomatic arch, widening of the midface, or sunken eye globe) . The face should be inspected from two planes, the anteroposterior position and the inferior position, to detect subtle changes. The inferior position is easily performed by asking athletes to fully extend their necks (“look straight up”), which can help identify midface depressions, septal deviation, and some septal hematomas. The reason for quickly assessing facial symmetry is because areas of structural depression or asymmetry may quickly become clinically undetectable once filled in with swelling, making it difficult to distinguish between simple soft tissue injuries and underlying fractures. All areas of ecchymosis, edema, and active bleeding should be noted. Athletes should then be asked to point to painful areas of the face with one finger. By having the athlete point to painful areas, the clinician can assess the fine motor control of the patient's finger when pointing and the cognitive function of following directions. Careful and early attention should be paid to all areas identified by the athlete as painful.
The external ear is a common site of hematoma formation in combat sports such as boxing, mixed martial arts, and wrestling and should be carefully inspected for “hot spots,” erythematous areas that are painful and indicative of friction injuries . Finally, the mastoid process should be inspected as ecchymosis in this area (the “battle sign”), when associated with severe headaches, hearing changes, and/or vertigo, can indicate a basilar skull fracture requiring emergent intervention .
Palpation of the facial bones and structures should be systematic and comprehensive. Palpation should include the orbital rims, zygomatic arches, nasal bones, and temporomandibular joints. The maxilla and mandible should be palpated bimanually with one gloved hand palpating intraorally. The oral cavity should be assessed for lacerations to the tongue and cheek and all teeth should be accounted for so as to avoid accidental aspiration. Upon completion of the intraoral assessment, midface stability should then be confirmed by gently pulling on the maxillary incisors with the gloved hand while stabilizing the forehead with the other hand. Any areas with numbness, significant bony tenderness, crepitus, contour irregularities, or instability should raise concern about fractures.
Range of motion
The movements of the eyes and mandible are essential to assess and can be done rapidly on the sidelines. Extraocular eye movements are done by keeping the athlete's chin in a fixed position while he or she tracks the examiner's finger movements in all quadrants. The ability to do so without diplopia or visual disturbance rules out injury to cranial nerves III, IV, and VI, as well as acute extraocular muscle entrapment caused by an orbital blow-out fracture . The injured athlete should then be instructed to open his or her mouth. If the athlete experiences trismus, severe pain along the lateral aspect of the cheek when attempting to open his or her mouth, then fractures of the mandible, temporal bone, or zygoma must be considered. The athlete should then be instructed to close his or her mouth down on a tongue blade and try to leave teeth marks; if he or she experiences a sense of malocclusion not attributable to injured teeth, then a fracture of the mandible, maxilla, temporal bone, or palate must be ruled out.
Nerve testing should be done with special attention being given to the trigeminal (CNV) and facial nerves (CNVII). The three main sensory branches of the trigeminal nerve (V1 ophthalmic, V2 maxillary, and V3 mandibular) can be tested by lightly touching each side of the forehead, cheekbone, and jaw respectively. Areas of asymmetric sensation should be noted. The motor division of the trigeminal nerve innervates the muscles of mastication and can be tested while testing for malocclusion. Inability to do so secondary to pain should raise suspicion for fracture. The facial nerve, CNVII, and its various branches can be quickly tested through the following maneuvers. The athlete should follow the examiner through the following movements: 1) raise the eyebrows (temporal branch); 2) close eyes tightly (zygomatic branch with cross-innervation from the buccal branch); 3) wide smile (forehead-temporal branch, midface-buccal branch with some cross-innervation from zygomatic branch, corner of mouth'marginal mandibular branch); 4) pucker lips (lower lip'marginal mandibular branch; upper lip'buccal branch) [15•].
To complete the sideline physical examination gross hearing should also be tested. Due the frequent noise accompanying sideline evaluations, the easiest method of testing is to ask the athlete to repeat a word or phrase that is whispered directly in his or her ear. An alternative way of testing would be to rub the thumb and long finger together next to the athlete's ear and ask if he or she can hear it. An otoscope should be routinely available on the sidelines to inspect the external canal for the presence of blood or cerebrospinal fluid, which can be indicative of a basilar skull fracture [15•]. The integrity of the tympanic membrane should then be assessed.
Soft tissue injuries
Few sports mandate the use of facial protection. As a result, facial skin and underlying soft tissues are frequently exposed and vulnerable to damage. The most commonly encountered facial injuries on the sidelines are contusions, hematomas, abrasions, and lacerations.
Contusions usually result from blunt trauma to the face. The key to managing facial contusions on the sidelines is early evaluation and accurate diagnosis. Fractures must be ruled out prior to the onset of swelling, which distorts the appearance of underlying structures and may conceal facial asymmetry. Contusions should be initially treated with ice to minimize early swelling. Ice can be applied with gentle pressure when the athlete is not in action (eg, at half-time, between rounds in boxing) and athletes may immediately return to competition if vision is not impaired. Acetaminophen may be used to control pain if necessary. Contusions can be problematic for athletes if they are associated with periorbital swelling or hematoma formation that obstructs vision. As a rule of thumb, athletes with contusions with periorbital swelling or significant hematomas (local collections of blood) around the eyes must be pulled from competition if they are at significant risk for injury to themselves or others due to visual obstruction. Both factors must be considered, visual obstruction and risk of injury, when deciding whether to remove an athlete from participation. For example, if a boxer has an eye swollen shut and is sustaining repeated or undefended blows to the head as a result of not seeing punches coming, the competition should be stopped to protect the athlete. However, if the athlete is staying out of harm's way with good movement and is not sustaining repeated blows to the head, than the athlete should be allowed to continue. Although complications are rare, athletes (and their parents if under age 18) should be given instruction to continue icing the injured area 20 minutes at a time, several times per day, for the first 48 to 72 hours to minimize swelling and minimize the risk of developing a disfiguring hematoma .
Auricular and septal hematomas must be looked out for in order to advise athletes on appropriate follow-up care. Auricular hematomas are caused by shearing forces applied to the external ear most commonly when a wrestler's ear or mixed martial artist is thrust into or pulled along the mat. Auricular hematomas can be acute or delayed and are characterized by moderate to severe throbbing or burning pain. There is often varying degrees of swelling of the external ear with loss of anatomic landmarks such as the helix and antihelix. Athletes may continue with competition if they so desire and tolerate the pain. They must be informed that untreated acute auricular hematomas can enlarge and even rupture with continued participation in contact sports. Unlike other highly vascularized areas of the face where infections to open wounds are uncommon, the poorly vascularized cartilage of the external ear makes it susceptible to infection . Acutely ruptured auricular hematomas place the underlying cartilage at risk for infection which could lead to loss of some or all of the external ear. Upon conclusion of the competition (end of wrestling tournament, boxing match), athletes (and their parents/guardians if under age 18) should all be advised to follow-up in a clinic setting for definitive management by incision and drainage if they want to avoid disfiguring changes to the external ear .
Trauma to the nose, most commonly associated with nasal contusions or fractures, can result in septal hematomas. These bulging, bluish masses are diagnosed by direct visualization of the nasal septum and usually occur within hours of the initial injury. Septal hematomas require surgical drainage to avoid pressure necrosis to the underlying bone and cartilage. This intervention should occur as soon as possible but does not require immediate restriction from participation. Sideline management should focus on reducing bleeding and blood accumulation with ice and direct pressure (pinching the nasal septum or inserting nasal packing). It is imperative to inform athletes and their parents or guardians that failure to follow-up for definitive management with surgical drainage can lead to collapse of the septal bone and cartilage and an extremely poor cosmetic appearance known as a saddle nose deformity . Athletes should be instructed to follow-up in an outpatient setting for evaluation and definitive management within 48 hours.
Abrasions are partial-thickness disruptions of the epidermis that commonly occur when blunt or shearing forces are applied to the face. Protruding or prominent structures such as the nose, cheek, eyebrow, and nose are the most common sites of abrasions. As with all soft tissue injuries, once underlying injuries are ruled out and the diagnosis is confirmed, then treatment can be initiated during a break in participation. Using universal precautions, hemostasis can usually be achieved with direct pressure for up to 5 minutes. If bleeding persists, aluminum chloride 20% solution can be applied directly to the wounds to stop bleeding. Prior to application of aluminum chloride, athletes should be warned that it is going to burn and eyes should be avoided so as to not cause irritation. The skin should be cleansed of all debris. This process can usually be achieved using water from a clean water source such as an unused water bottle or a clean drinking fountain to irrigate the skin while wiping with gauze. Once the skin has been irrigated, prepackaged povidone-iodine solution swabs, which are easy to store in medical sports bags, make an excellent antiseptic. Wounds should then be covered when possible using antibiotic ointment and a sterile bandage. In most cases, getting bandages to stick to sweaty, wet skin is quite challenging. Therefore, benzoin swabs, which are usually used as an adhesive for Steri-Strips (3M, St. Paul, MN), can be used to help hold routine bandages in place. Another benefit of benzoin is that it acts as an antiseptic and provides additional wound protection.
Sideline management of lacerations, or full-thickness skin disruptions, is similar to abrasions and requires ruling out underlying injuries such as fractures, then cleaning the wound and achieving hemostasis (Table 1). If hemostasis is obtained, than physicians must be familiar with the rules of the sport to determine what should be done on the sidelines. For example, in boxing, athletes may return to competition without delay or further intervention as long as vision is not impaired and athletes can defend themselves. The wounds can be definitively repaired immediately after the sporting event. However, in basketball or children's soccer, the risk tolerance is much lower and athletes are prohibited from participation with exposed blood. In these cases, athletes can be treated quickly with irrigation and povidone-iodine solution to clean wounds, direct pressure to achieve hemostasis and dry skin, temporary wound closure with Steri-Strips (3M) adhered with benzoin, and sterile bandages to protect the wound and cover bloody areas as required by the rules of the sport. Beyond the simple wounds that will heal well with the above outlined treatment, athletes should be advised to follow-up in the appropriate health care setting for definitive management of the wound immediately after the event.
When treating lacerations or abrasions, it is important to consider tetanus status. More than 40% of all reported cases of tetanus between 1998 and 2000 resulted from abrasions and lacerations [17,18]. For those whose tetanus status is not up to date at the time of injury, one should review the Centers for Disease Control and Prevention Guidelines for Tetanus Wound Management (Table 2) . Vaccination against tetanus does not protect individuals until weeks after intramuscular injection. Tetanus immune globulin infiltrated in a wound can decrease risk of infection from the present injury in athletes who are not up-to-date with immunizations. Tetanus immune status is most important to address prior to injury and should be routinely administered, when indicated, at the preparticipation physical examination.
With any blunt trauma to the ear or potential barotraumas from swimming, diving, or altitude changes, the tympanic membranes should be visualized to assess for perforations. Although they are still much more likely to occur as a result of infections, traumatic perforations are occasionally seen on the sidelines and range in presentation from asymptomatic to any collection of the following symptoms: hearing loss, vertigo, bloody or serous discharge in the external canal, and sensitivity of the involved side to wind or cold. The diagnosis is readily made with direct visualization of the defect in the membrane using an otoscope and no movement of the tympanic membrane with pneumatic testing. To rule out a perilymph fistula, pneumatic testing may also elicit a burst of nystagmus with positive or negative insuflation . Injured athletes with vertigo should be referred to a head and neck surgeon for examination and audiologic testing before returning to sports. Athletes participating in water sports such as swimming and water polo need to keep water from entering the middle ear. As a result, athletes should be advised to get custom-fabricated ear plugs from their local head and neck surgeon or audiologist prior to returning to the water. In sports in which significant pressure changes occur, such as platform diving, underwater diving, and high-altitude mountain climbing, athletes should not return to play until the membrane has healed. In all cases, sideline management includes insuring the ear canals are kept dry and athletes need to be instructed to follow-up with a primary care physician within 1 day to receive oral and/or ototopical antibiotics .
For physicians in a clinical or hospital setting, most fractures are diagnosed easily with diagnostic tools such as radiographs, CT scans, and MRIs. Outside of elite sports settings where these tools are readily available onsite, most physicians on the sidelines are left to diagnose facial fractures the old fashion way, with sound physical examinations. With injuries in which a facial fracture or dislocation is plausible, sports medicine physicians must perform thorough examinations so as to decide who can continue playing safely and who cannot. In this context, it is important to know that nearly 75% of facial fractures occur in the mandible, zygoma, and nose . Because edema can distort the soft tissue in the orbital rims, nose, zygomatic arches, maxilla, and mandible, and potentially reduce the sensitivity of the physical examination, particular attention must be paid initially to facial symmetry. Fractures of the face have characteristic signs and symptoms and all but one must all be sent urgently for a definitive work-up when clinical suspicion exists (Table 3). The facial fracture that may not require immediate removal from sport is a closed nasal fracture. Although most nasal fractures are usually associated with brisk anterior epistaxis, hemostasis can usually be achieved by slightly reclining the patient and applying direct pressure with a bag of ice to the nasal septum for up to 10 minutes. Ice can also be applied to the back of the neck to cause reflex vasoconstriction. Although not readily available on most sidelines, persistent epistaxis occasionally requires packing with a Merocel sponge (Medtronic Xomed, Jacksonville, FL) covered in topical antibiotic (such as mucopirocin).
If breathing is not compromised and adequate hemostasis is achieved, athletes may be allowed to return to play if they understand that there is a risk for worsening the injury. Failure to control nasal bleeding may indicate a more serious problem such as a complex nasoethmoid fracture and damage to the ethmoid artery. This type of fracture may be associated with a cribriform plate fracture and cerebrospinal fluid leak and should be evaluated in an emergency room setting . Onsite management of a displaced, closed nasal fracture can include a reduction of the deviated septum if performed within an hour of injury. A soft probe can be placed inside the nares and the depressed or displaced septum can sometimes be moved into anatomic position. All nasal fractures require in-office evaluations within 48 hours to assess for septal hematomas that require surgical drainage.
If an athlete has suffered a traumatic depression of the mandible with resultant malocclusion and mandibular deviation away from the dislocated condyle, then mandibular dislocation must be considered. Although difficult to distinguish between a mandibular dislocation and a displaced fracture of the condyle, a physician that palpates the dislocated mandibular head anterior to the articular eminence of the glenoid fossa can immediately try to reduce a dislocation without sedation. By applying steady downward and posterior traction to the mandible of a seated athlete, the condyle can slide back into position in the glenoid fossa and instantly reduce pain. When in doubt, the patient should be referred to the local emergency room for definitive work-up and management.
Sporting activities lead to a significant number of facial injuries that are commonly encountered problem on the sidelines. The key to sideline management is determining which injuries need immediate referral to an emergency room or comprehensive urgent care center and which injuries can be temporarily managed on the sidelines with follow-up after competition as needed. With a focused history and a thorough physical examination, the majority of diagnoses can be established on the sidelines. With accurate diagnoses, physicians covering athletic events can implement sideline treatment strategies and make return to play decisions that keep athletes safe while maximizing their chances to return to competition.
The authors of this article have no significant relationship with any manufacturer of any commercial product mentioned in this article. No drug is mentioned in this article for an unlabeled use.