Facial injuries are a relatively frequent occurrence while playing sports. Injuries are most commonly incurred by player-to-player contact, falls, or direct hits with equipment. Ball sports or sports with projectiles also can be a cause of soft-tissue injury. Common injuries to the soft tissues include laceration, abrasions, and contusions.
Overall, approximately 11% to 40% of all sports injuries involve the face, and 8% of all facial soft tissue injuries are sports-related. The incidence is even higher in pediatrics where craniofacial injuries represent up to 20% of all sports-related injuries (11). There are several studies that examine the incidence, causes, and sports associated with facial trauma. U.S. studies indicate that most facial trauma in the pediatric population is associated with baseball and softball, which accounted for 43.3% of one article's population (11). A Dutch study indicates soccer and hockey are the most common cause of maxillofacial trauma, and an Irish study finds that Gaelic football and soccer the most likely sports in which to incur facial trauma (12,18).
Contusions and abrasions can be treated similarly to other areas of the body. Keep in mind that the face is highly vascular with bruising and swelling being more pronounced. Conservative treatment is usually adequate. These injuries can be expected to resolve over a few days to a week.
Regardless of sport or country, soft tissue injuries and fractures of the nose, zygoma, and mandible are most common. The same Dutch study mentioned above identifies specific fracture patterns associated with certain sports. In this study of 108 patients, coronoid process fractures are only found in soccer players, and mandibular angle fractures are most commonly associated with Rugby (18).
The broad variety of facial injuries associated with athletics and the complexity of facial structures makes assessment and treatment of these problems highly important for the sideline physician and provider. Team physicians and health care providers for athletes should posses an understanding of the most common facial injuries, the anatomy of the face, and the associated management of facial trauma in athletics. The knowledge of which injuries are stable, those that can be treated on the sideline, and those requiring emergent transfer is crucial for all athletic health care providers.
The blood supply to the face is derived from both the internal and external carotid arteries. The soft tissue of the facial region is one of the most vascular regions of the body. The abundant blood supply can make bleeding a complication, but it also makes infections and ischemic tissue flaps less common.
The three branches of the trigeminal nerve (ophthalmic [V1], maxillary [V2], mandibular [V3]) provide sensation to the face as well as motor for the muscles of mastication. The five branches of the facial nerve provide motor innervation to the muscles of facial expression (Figs. 1–3).
There are three primary divisions of the facial skeleton. The upper third encompasses the frontal bone and ends at the supraorbital ridge. The middle third is from the supraorbital ridge to the upper teeth. The lower third is composed of the mandible, lower teeth, and condylar processes (Fig. 4).
The middle third of the face has the highest incidence of injury. This part of the face also is the most prominent and complex, comprising the orbits, nasal bones, maxillary bones, and the zygoma. MacIsaac et al. (11) examine sports-related craniofacial fractures in pediatric patients presenting to the emergency department of a children’s hospital. One hundred sixty-seven injuries are represented in this study. Their incidence findings for specific fractures are below:
- Nasal: 35.9%
- Orbital: 33.5%
- Skull: 30.5%
- Maxillary: 12.6%
- Mandibular: 7.2%
Approach to Evaluating Facial Injury
All trauma evaluations regardless of injury location should begin with the ABC: airway, breathing, and circulation. Vital signs, if available, as well as a basic assessment of mental status are crucial before proceeding to a more specific evaluation. Many of these injuries involve blood and other bodily fluids and although the risk of disease transmission when the provider has intact skin in minimal, it is still recommended to follow universal precautions and techniques.
Maxillofacial injuries often present with head and/or cervical spine injuries. An appropriate evaluation is warranted once the athlete is stabilized. In-line cervical spine immobilization should be performed liberally if there is appropriate clinical concern as this can be lifesaving and/or prevent significant neurologic disability. The Glasgow coma scale is a useful tool for initial assessment of a trauma patient, and a working familiarity of this evaluation is helpful for all sideline providers. Although not discussed here, if concussion is suspected the athlete should be held from activity followed by further evaluation, appropriate rest until symptom resolution, and then finally completion of a graduated return to activity protocol.
Airway issues such as dislodged teeth, facial fractures making breathing difficult, or dental appliances should be addressed. Maintaining a clear airway to ensure adequate breathing is an important, potentially life-saving part of the evaluation. After the initial assessment and stabilization (if needed) are performed, the provider can proceed to a more focused facial examination.
Begin by examining the upper third of the face focusing on the stability of the supraorbital rims and the frontal branch of the facial nerve. Have patients lift their eyebrows and lightly touch their forehead to assess for nerve damage. Palpate over the supraorbital rims next assessing for tenderness or bony deformities.
The middle third of the face begins with palpation of the infraorbital rims, assessing for stability and tenderness. Observe the patient for any differences in globe position, which could suggest a fractured orbit. Next, assess the patient's extraocular muscles by having patients gaze in an “H” pattern. If a light is available assess the pupils for asymmetry and light response. Have the athlete then close their eyes and press gently over the closed eyes, assessing for discrepancies in globe turgidity. A globe that is too flaccid or overly tense mandates immediate evaluation by an ophthalmologist.
Examine the nose looking for symmetry, epistaxis, and septal hematoma. While examining the zygoma look for zygomatic arch fattening and widening of the midface, which can be associated with fractures. Conclude the examination of the midface by grasping the maxillary teeth and assessing for any maxillary instability.
The lower face focuses on the mandible. An initial inspection should assess overall symmetry and look for any gross anatomical abnormalities. Ask the athlete to open and close their mouth, and to smile. The “popsicle stick bite test” also may be performed by asking the athlete to bite down on a tongue depressor with the incisors while you attempt to twist/move it. Asymmetry with or inability to perform any of these actions indicates there may be a possible fracture or temporomandibular joint dislocation. Examine for any cosmetic defects, such as lacerations involving the lips. Lacerations involving the vermillion border may require more delicate approximation than can be completed on the sidelines.
Dental injuries are not discussed in this article. Please refer to “Dental Problems in Athletes” by Inouye et al. for a comprehensive review. To briefly mention an injury requiring emergent intervention, avulsed teeth should be re-inserted into the affected socket(s) if possible with immediate referral/evaluation by a dentist.
Examine the ears for hematoma formation, which may, if not treated, develop into “cauliflower ear.” Whispering can assess gross auditory function. Examine the tympanic membranes and the external auditory canals with an otoscope paying close attention to any leakage of blood, cerebrospinal fluid, or perforated tympanic membrane.
Lacerations are the most common facial injury in the athletic setting. Because of the abundant blood supply to the face and scalp, bleeding is often brisk and abundant. Usually, direct pressure is sufficient for hemostatic control allowing for better visualization to explore the wound more thoroughly. Because of the large number of bony prominences on the face, complex burst or stellate lacerations may occur, making the repair more challenging. Because it is the face, you must consider the cosmetic, social, and psychosocial aspects of the injury. If you do not believe a good aesthetic outcome is possible or probable, referral to a plastic surgeon within 24 h will always be indicated.
Lacerations associated with facial fractures or severed nerves should not be closed on site. Instead, keep the wound moist with saline-soaked gauze, which helps prevent eschar formation. Then, referral to a facility capable of comprehensive care should be initiated promptly. Also, if a laceration involves the lacrimal apparatus, parotid gland, facial nerve, or any anatomic borders, referral to surgery is the appropriate treatment plan. Consider parotid ductal injury with any deep cheek laceration. Drainage of saliva from the wound is the most common sign seen with this injury. Be suspicious of lacrimal damage if the laceration involves the medial one third of the eyelid. Oftentimes, epiphora will be present.
In general, routine antibiotics are not warranted for simple facial lacerations. However, if the wound is contaminated or the result of a bite, prophylactic antibiotics should be initiated. If appropriate, tetanus prophylaxis also should be administered. The U.S. Centers for Disease Control and Prevention (CDC) recommendations should be followed as detailed in the Table.
Before a repair is undertaken, the wound should be thoroughly cleaned. Start with antibacterial soap and water followed by irrigation with sterile saline under the pressure of an 18-gauge angiocatheter attached to a 20-mL syringe. This process will adequately flush debris as well as bacteria from the wound. Consider application of topical anesthetics before cleansing for large painful abrasions. It is very important to make sure all debris is removed from the wound before repair to avoid “tattooing” the debris into the skin. If unable to remove all of the debris, transfer to a medical facility capable of further removal with definitive care to be performed within 24 h.
After appropriate cleansing of the wound, small linear superficial wounds can be closed with adhesive bandages or tissue adhesive. Strongly consider tissue adhesive for facial lacerations less than 4 cm and not in areas of high skin tension. There are several advantages to tissue adhesives (such as Dermabond) over traditional suture repairs. In most cases, it can be applied quicker with less preparation and without anesthetics. It prevents the permanent suture tracts that develop when sutures are not removed in a timely fashion. Tissue adhesives are especially good for pediatric patients because it avoids the pain and trauma of suturing and the need to sit still for an extended period. One disadvantage is that deep wounds may still need a few subcutaneous sutures to avoid the formation of a depressed scar. If tissue adhesives are used around the eye, it is imperative to take measures to avoid contact with the ocular surface and structures, a drape is recommended. A randomized controlled study of 111 patients by Toriumi et al. (22) shows that with Dermabond compared with sutures, there is a superior cosmetic outcome at 1 yr without an increase in complications (infections or wound dehiscence).
For areas with increased muscle contraction, like the forehead, perioral region, and over the mandible, consider sutures for closure. Those areas also likely do better with subcutaneous sutures to decrease the wound tension and allow for proper skin eversion (22,23). When choosing suture size and material for the face, in general 6.0 or smaller should be used. Ideally, the use of 7.0 monofilament nylon subcuticular closure is preferable (20), 5.0 may be appropriate for the scalp. For lip repairs, strongly consider the use of nerve blocks instead of local anesthesia. This prevents the distortion created with local infiltration. Infraorbital blocks for the upper lip and a mental block for the lower lip are appropriate.
If athletes return to sport with a repaired laceration, appropriate measures should be taken to prevent wound disruption and contamination. A padded bandage with adhesive covering is usually sufficient.
Epistaxis is very common with facial injuries and nasal fractures. Most cases involve Keisselbach's plexus which is located in the anterior inferior aspect of the nasal septum. Hemostasis is usually achieved by placing direct pressure distal to the nasal bones for 15 min. Decongestants and vasoconstrictors, such as oxymetazoline and phenylphrine can be used along with anterior packing to help with persistent bleeds (10). Posterior bleeds are rare but are usually more brisk and harder to control when they do occur. This type of bleed usually arises from a branch of the Sphenopalatine artery as it enters the lateral wall of the nasal cavity (10). Posterior nasal bleeds may require arterial ligation or possibly interventional arterial embolization, so after posterior packing, transfer these athletes to emergency facilities for further treatment (10).
Facial fractures account for 4% to 18% of all sports-related fractures (14). A high index of suspicion is necessary when evaluating facial fractures as midface and mandibular fractures can cause profuse bleeding and be a threat to the airway, whereas orbital and zygomatic fractures can lead to permanent vision loss (14). Prompt referral to an emergency center capable of imaging and management is necessary. Most athletes with facial fractures should not return to play the same day as a second blow to the injured area may cause a simple fracture to become compounded and convert it to a disfiguring injury that may present a surgical challenge (7). Although most facial fractures are diagnosed clinically, maxillofacial computed tomography (CT) scan is the imaging modality of choice for detailed characterization of fracture patterns and affected adjacent anatomical structures.
Zygomaticomaxillary Complex (ZMC) Fractures
Fractures of the ZMC account for 10% of sports-related fractures. This is an important structure because it makes up the malar eminences or cheekbones. The ZMC's anatomy is unique because it forms parts of the orbit, provides an attachment point for the superior masseter muscle, and forms the lateral facial prominences and frame. Because of this unique anatomy, a fracture of this complex can possibly impact vision, function of the jaw, and cause great cosmetic disruption by altering the width and structure of the face (9,14). Fractures to this area generally are a result of blunt trauma and can be quite dramatic in appearance due to a facial flattening deformity. Signs of ZMC fracture are periorbital ecchymosis, subconjunctival hemorrhage, hypoesthesia in the region of infraorbital nerve, palpable step-offs of the orbital rim and upper buccal surfaces, orbital subcutaneous emphysema, enophthalmos, other malpositions of the globe, and diplopia.
There are many different classifications of zygomatic fractures, and most are described based on CT findings, which is the best imaging choice for investigation of acute injuries. The Le Fort and Manson CT classifications are probably the most widely used with the Manson system being the more straightforward approach.
Not all ZMC fractures require active treatment or surgery. The indications for treatment include the need for restoration of normal facial contour for both cosmesis and to reestablish skeletal protection of the globe, to correct any resulting diplopia, and to remove any interference of mandible range of motion (1). If surgical repair is indicated, it should be ideally performed within 7 to 10 d. This serves to prevent early consolidation of the fracture. The transoral approach is the most common method of reduction, and rigid fixation with bone plating is now more frequent than transosseous wiring (1). This approach minimizes scarring as the bone plates are well hidden. A review by Chao (5) illustrates the advantages of this approach as it results in more predictable, stable, and long-term results. They also note that this fixation is not as strong as an intact noninjured skeleton, and a second injury to that area is usually more severe and damaging (5). Return to play is discussed later in this article, but a conservative approach should be encouraged given the devastation that can occur with a repeat injury.
Nasal fractures are the most common facial fracture, accounting for up to 50% of sports-related fractures, with 15% of them being recurrent (5). The perception that a broken nose is not harmful often leads to undertreatment of this condition. This misconception can lead to chronic nasal deformities and breathing difficulties, which impair peak performance in the athletic population. Epistaxis, as discussed earlier, is a common occurrence with nasal fractures. Diagnosis is usually made clinically, and x-rays are generally unnecessary. If imaging is necessary to confirm diagnosis, maxillofacial CT scan is the preferred modality. Plain x-rays may miss subtle fractures and are often unable to distinguish acute from chronic injuries. Athletes may present with a visible deformity, epistaxis, tenderness, periorbital ecchymosis, and crepitus with palpation which all provide evidence of a nasal fracture. It is very important to make sure the athlete has a proper airway before proceeding with the exam.
On examination, it is important to have adequate lighting. If visibility is obscured by epistaxis or drainage, vasoconstrictors can be used to facilitate the examination. It is important to identify any clear rhinorhea or fluid drainage from the nose. Athletes also may describe a sweet taste in their mouth. If any of these findings are encountered, suspect possible CSF leak and cribiform plate fracture (8,15). This injury puts the athlete at an increased risk for meningitis requiring antibiotic coverage and referral to maxillofacial surgery on an urgent basis (8).
The septum also should be thoroughly examined and investigated, especially if the athlete complains of nasal obstruction during inspiration. This is highly suggestive of nasal/septal fracture or dislocation. It is important to also look for any purple or blue grape-like swelling of the septum, which indicates the presence of a septal hematoma. These require urgent incision and drainage to prevent abscess formation or chondral necrosis, which can result in a saddle-nose deformity. Incision and drainage with anterior packing is appropriate, and follow-up is necessary because these can recur.
Before considering treatment options, a prior history of any previous nasal fractures or surgeries should be obtained, because this may impact your treatment decisions. If the patient is unsure or unable to answer your questions ask for an old picture or driver's license for comparison. If there is a previously untreated deformity, surgery for an acute injury is difficult, and oftentimes the repaired nose will return to the previous deformed state (8).
If the patient presents before significant swelling has occurred, and there is persistent bleeding or an obvious external deformity, closed reduction can be performed (14). It is important to let the athlete know that closed reduction is unlikely to completely correct the deformity, and the need for subsequent rhinoplasty is 14% to 50% (17). If the athlete presents with significant edema that obscures the deformity, waiting 4 to 7 d for swelling to decrease is appropriate. Edema will likely be resolved by then allowing for repeat examination and the development of a definitive treatment plan.
Mandibular fractures account for 10% of all sports-related fractures. The mandible is a strong cortical bone but has several weak areas. It is thin at the angles, the neck of the condyles, and the distal body at the root of the canine teeth. These multiple weak points account for why 50% of all mandibular fractures are multiple in nature (14). If one fracture is identified then a prompt search for additional fractures is necessary. Airway obstruction is possible with a fracture to the mandible, and particular attention is warranted if there is a bilateral anterior fracture. The tongue is attached to the anterior mandible, and this type of fracture can shift the tongue posterior and result in airway obstruction (2). A simple pulling of the tongue and jaw forward can open the airway, and the athlete should then be stabilized in this position and immediately transferred to an emergency facility (2).
The most common signs of mandibular fracture on examination are malocclusion, pain, swelling, trismus, and intraoral bleeding. Tenderness to palpation along with palpable and visible step-offs between the teeth also helps make the diagnosis (5). Panorex and maxillofacial CT combined are the most reliable imaging modalities.
Once diagnosed, referral to oral and maxillofacial surgery for reduction and fixation is indicated. Consider subspecialty referral for pediatric patients as conventional fixation can cause damage to unerupted teeth (5).
Orbital Blowout Fractures
This topic will not be discussed in detail because it has been extensively covered recently in reviews by Shane Cass and Paul Reehal:
“Ocular Injuries in Sports,“ by Shane P. Cass
Current Sports Medicine Reports 2012; 11(1):11–15.
“Facial Injury in Sport,” by Paul R. Reehal
Current Sports Medicine Reports 2010; 9(1):27–34.
If an ocular blowout fracture is suspected, then a STAT CT is required as this can be vision-threatening. Also, muscle necrosis can occur rapidly if there is entrapment of the extraocular muscles.
Protective Facial Devices
Injury prevention should be the primary focus of protective facial devices. Facemasks became mandatory in 1959 for football players. Before 1960, 50% of all football injuries involved the dental or facial areas and according to a 1988 study, the incidence decreased to 1.4% (5,24). Rampton et al. (13) shows in their study that full-face protection and helmets also decrease the rate of facial injuries in ice hockey, but half-visors do not. They show that half-visors in hockey are essentially the same as no face shield at all for protection against upper facial injuries (13). Helmets without face shields or facemasks protect the cranium and decrease morbidity and mortality, but do little to protect the midface and lower face. This is illustrated in sports, such as biking and skiing, where participants generally wear helmets but do not have face protection (19).
Return to Play
Unfortunately there is a lack of evidence-based studies on return to play after facial trauma and currently no specific guidelines exist. Roccia et al. (16) provide recommendations based on the bone healing process. They recommend no activity for the first 20 d after fracture and then a stepwise progression after that. Days 21 to 30 include light aerobic exercise only. Days 31 to 40 add noncontact training drills with full contact after 41 d. The 41-d mark was chosen because they show callus formation to take anywhere from 4 to 40 d. They also note that the athlete can only proceed to the next stage if they are asymptomatic at the previous stage. They also place a caveat for combat sports, recommending return to activity no sooner than 3 months in that population (16).
Fowell and Earl (6) also look at return to sport, and they published a prospective study of 20 cases where athletes return to play after the 3-wk period. It is 3 wk from the date of injury for those not requiring surgery, and 3 wk after surgery for those who do. This proposed timeframe is independent of the type, location, and severity of maxillofacial injury sustained. They follow a 3-wk real-time transport (RTP) protocol that includes only 2 d of no activity followed by a similar, albeit, shorter stepwise progression. They report no complications or reinjuries from return to play at 3 wk (6).
A variety of sports-related facial injuries can occur. They can range from simple abrasions and bruises to life threatening bleeding, airway compromise, threats to vision, and facial disfiguring injuries. Understanding the variety of injuries and the proper diagnosis and management is important to the safety and long-term health of athletes. Facial and head protection should be encouraged, especially in the pediatric population. Future studies on return to play guidelines and protective equipment can further help improve safety for athletes of all levels and ages.
The authors declare no conflict of interest and do not have any financial disclosures.