By Dr. Bradley Eli, DMD, MS
Facial injuries are a significant concern for sports medicine providers and include trauma to the oral, TMJ, and maxillofacial regions.
Facial injuries are a significant aspect of sports medicine, given the face’s vulnerability to impacts and collisions in diverse sports. The unique challenges posed by these injuries necessitate specialized attention. They often involve a multidisciplinary approach to comprehensive care, particularily to sports-related jaw injuries.
This article on facial injuries in sports medicine categorizes basic types of facial injuries based on the affected anatomical regions, aiming to establish a foundational understanding. The objective is to offer athletes and medical professionals a fundamental guide for making informed treatment decisions. It also assists in taking appropriate action at the time of the sports injury.
Table of Contents
- Facial Injuries in Sports Medicine
- What Is Sports Medicine?
- Facial Injuries in Sports
- Nasal Injuries That Sports Medicine Treats
- Facial Fractures Diagnosed in Sports Medicine
- TMJ Injuries Recognized by Sports Medicine Doctors
- Common Soft Tissue Injuries in Sports Medicine
- Oral and Dental Injuries in Contact Sports
- Sports-Related Eye Injuries
- Facial Injury Prevention in Sports Medicine
- SUMMARY: Key Issues Sports Medicine Providers Address in Facial Injury
What Is Sports Medicine?
Sports medicine is a specialized branch of that focuses on prevention, diagnosis, treatment, and rehabilitation of injuries and medical conditions related to sports and physical activity. It’s a multidisciplinary field that involves a variety of healthcare providers who work together to optimize the health and performance of athletes and active individuals.
Athlete-to-athlete contact, falls, and blows from equipment account for the majority of demand for sports medicine intervention. [1]
Facial Injuries in Sports
Facial injuries are highly prevalent in sports. In a recent multi-country study, the prevalence of facial injury in athletes was 40%, with individual studies reaching a prevalence as high as 68% [2]. These rates vary widely by injury type and sport type, with sports involving balls and cycling rated as the sports with the highest number of maxillofacial injuries [3]. Boxing is rated as the sport with the highest percentage of dental injuries, with a prevalence of 74% [4].
While any part of the body can be injured during sports, facial injuries are particularly concerning given their complexity. The human face, with vital sensory organs, intricate bone structures, and muscles for expressions, is a delicate and complex area. Facial injuries in sports pose unique challenges, ranging from the aesthetic concerns to the potential impact on crucial functions like breathing, vision, and communication.
Orofacial pain specialists role in sports medicine
Facial injuries often necessitate the expertise of multiple specialists. For instance, sports dentistry plays a vital role in a sports medicine team due to the frequent occurrence of dental-related injuries. Orofacial pain specialists are integral to the team, capable of addressing the intricate issues associated with temporomandibular joint (TMJ) injuries and the ensuing chronic TMD pain.
In cases of facial fractures, otolaryngologists and facial plastic surgeons may be enlisted. Eye specialists, including ophthalmologists, might be essential for injuries involving the eyes. Table 1 outlines prevalent facial injuries in sports and the corresponding healthcare professionals for their treatment.
| Table of Common Types of Facial Injuries in Sports | ||
|---|---|---|
| Body Region | Common Sports Injury Type | Appropriate Medical Professional |
| Nasal/Septal | Nasal and septal fractures | Emergency Physician, ENT, Plastic Surgeon |
| Facial bone fractures | Facial, orbital, mandibular, dentoalveolar fractures | ENT, Plastic Surgeon, Oromaxillofacial surgeon |
| TMJ | Dislocations, jaw and muscle sprain/strain (JAMSS) injuries | OMFS, Orofacial Pain Specialist, TMJ Specialist, (may work with ENT provider) |
| Soft Tissue | Contusions, lacerations, abrasions | Emergency Physician, ENT, Plastic Surgeon |
| Oral/Dental | Dental injuries, tooth fractures, avulsions | Dentist, Oromaxillofacial surgeon |
| Eye | Corneal abrasions, hyphemia, traumatic optic neuropathy | Emergency Physician, Ophthalmologist |
Nasal Injuries That Sports Medicine Treats
Nasal injuries are frequent due to the exposed position of the nose on the face and they can occur even in helmeted sports. In a multisport study on the incidence of nasal fractures, basketball accounted for the highest percentage of injuries among all patients (23.2%), followed by baseball (17.1%), softball (9.8%), soccer (7.4%), and football (7%) [4].
Breakdown of the main nasal fracture types:
- Lateral Nasal Fracture: Involves a break or displacement of the nasal bones on one or both sides.
- Nasal Septal Fracture: Affecting the nasal septum, which is the cartilage and bone dividing the nasal cavity into two nostrils.
- Comminuted Nasal Fracture: Involves the nasal bones being broken into three or more pieces.
- Depressed Nasal Fracture: Results in a portion of the nasal bones being pushed inward, causing a depression in the nasal contour.
- Greenstick Nasal Fracture: Characterized by an incomplete break in the nasal bones, similar to a greenstick fracture seen in long bones.
- Open Nasal Fracture: Refers to fractures where the cartilage or bones of the nose are exposed through a tissue laceration or avulsion.
Nasal fractures often require closed reduction for realignment, either immediately after the injury or approximately a week later to allow soft tissue swelling to subside. It is crucial not to postpone reduction beyond two weeks, as delayed intervention may result in healing with a deviated position.
In athletes considering rhinoplasty surgery for nasal deformities due to trauma, they are often advised to postpone treatment until they are finished with their competitive careers. This is because rhinoplasties significantly destabilize the nasal bones, making them more susceptible to reinjury.
As noted above, trauma to the nose can also lead to fractures or dislocation of the nasal septum, resulting in a nasal septal deviation. For athletes, this can pose significant challenges, as it may impede airflow and directly impact athletic performance. Repetitive trauma or a significant single injury can result in irreversible damage to the nasal septum, causing the collapse of the bridge, as indicated by the term “boxer’s nose.”
Facial Fractures Diagnosed in Sports Medicine
Facial bone fractures are an uncommon but serious injury in sports. There are multiple distinct fracture types that can occur in sports. For instance, there can be isolated orbital bone fractures, zygomatic arch fractures, or maxillary sinus wall fractures.
The National Institute of Health reports on the September 23, 2021 Sports-based distribution of facial fractures – findings from a four-season country study. Author Tero Puolakkainen found that “Unilateral zygomatic-maxillary-orbital and isolated mandibular fractures accounted for 74.2% of all fracture types.” He also reports that the percentage of sports-related facial injuries has rised over recent decades mostly due to the surging popularity of ice hockey and football-related facial trauma or fractures.
In more serious cases, the facial bones fracture in predictable patterns called Le Fort fractures.
There are three basic types of Le Fort fractures:
Le Fort I Fracture:
- Maxilla (including the upper jaw and hard palate).
Le Fort II Fracture:
- Maxilla.
- Nasal bones.
- Orbital floor (may involve the lacrimal, ethmoid, and zygomatic bones).
Le Fort III Fracture:
- Maxilla.
- Nasal bones.
- Orbital floor and medial walls.
- Zygomatic bones.
- Ethmoid bones.
- Sphenoid bone.
Many of these fractures are severe and require surgical correction. Failure to correct them can lead to functional impairment. For instance, if an orbital fracture entraps one of the eye muscles, coordinated vision can be affected. If a fracture of the maxilla is not address, the bite can be off or altered.
The mandible (jaw) is the most vulnerable bone to fracture in sports [5]. Mandible fractures can be seen in isolation or in combination with the above fractures. These fractures frequently require surgical intervention, typically involving the use of plates for stabilization. Additionally, wiring the jaw shut is a common practice after plating, restricting jaw movement during the recovery period. This combination of surgical fixation and immobilization aids in achieving proper alignment and stability, facilitating optimal healing.
Dentoalveolar fractures involve injuries to teeth and their supporting structures within the oral cavity. These fractures can result in broken or displaced teeth, damage to the alveolar bone, and injuries to surrounding soft tissues. Prompt dental and medical attention is crucial for assessment and appropriate treatment, which may include procedures like splinting, tooth repositioning, and, in some cases, surgical intervention to restore oral function and aesthetics.
TMJ Injuries Recognized by Sports Medicine Doctors
The TMJ is commonly injured in sports, both in helmeted and non-helmeted sports, and even with and without mouthguards. This is because of TMJ’s complex anatomy, which is comprised of much more than a joint.
Components of TMJ Deep tissue injuries:
Muscles:
- Temporalis Muscle: A large muscle of mastication that aids in closing the jaw.
- Masseter Muscle: Another muscle of mastication responsible for elevating the jaw and closing the mouth.
- Medial Pterygoid Muscle: One of the muscles of mastication that assists in jaw closure.
- Lateral Pterygoid Muscle: Plays a crucial role in jaw movement, particularly in opening the mouth and protruding the jaw.
Ligaments:
- Temporomandibular Ligament: Connects the zygomatic arch (part of the skull) to the neck of the mandible, providing stability to the TMJ.
- Stylomandibular Ligament: Extends from the styloid process of the temporal bone to the angle of the mandible, contributing to TMJ stability.
- Sphenomandibular Ligament: Connects the spine of the sphenoid bone to the lingula of the mandible, offering additional support to the TMJ.
Nerves:
- Trigeminal Nerve (V3 – Mandibular Division): The primary nerve associated with the TMJ, responsible for sensory innervation of the joint and motor control of the muscles of mastication.
There are also complex anatomical connections between the jaw and the neck, via portion of the brainstem called the trigeminocervical complex.
Most sports-related TMJ injuries are categorized as jaw and muscle sprain/strain injuries (JAMSS). Jaw muscle sprains involve injury to the ligaments surrounding the TMJ, often caused by a lateral blow to the jaw affecting the lateral TMJ ligament. Jaw muscle strain injuries can result from sudden eccentric stretching, akin to whiplash [6].
Addressing JAMSS injuries promptly is crucial to prevent prolonged pain.
Repetitive blunt trauma can also harm the TMJ, particularly in helmeted sports where the chinstrap directs force through the mandible, pushing the head of the mandible into the highly innervated joint space. Activation of chemical mediators in the trigeminal nerve from these tissues can contribute to more widespread pain, including chronic headaches or myofascial pain.
TMJ dislocations are much less common in sports injuries. They result from a forceful impact to the face, jaw, or head, leading to the displacement of the jaw joint out of its socket. Symptoms include jaw pain, limited mouth movement, and jaw misalignment. Medical intervention is involves manual repositioning or, in severe cases, surgery. Timely treatment is essential for pain relief, restoring jaw function, and minimizing long-term impact on oral and facial health.
Common Soft Tissue Injuries in Sports Medicine
There are a host of different soft tissue injuries that can happen in sports. The treatment for each depends on the severity and nature of the condition.
Common soft tissue injury types:
- Contusion: Bruising or localized bleeding under the skin due to blunt force or impact.
- Abrasion: Superficial injuries involving the removal of the outer layer of skin due to friction or scraping.
- Avulsion: Tearing away of a portion of the skin and underlying tissue.
- Laceration: Deep cuts or tears in the skin and underlying tissues.
- Hematoma: Collection of blood outside blood vessels, often forming a lump or swelling.
- Crush injuries: Compression of a body part that can lead to soft tissue damage, swelling, and potential complications.
The management of soft tissue injuries depends on the type and severity of the injury, ranging from rest, ice, compression, and elevation (RICE) for mild injuries to surgical intervention for more severe cases. Seeking medical attention is important for proper diagnosis and treatment.
Facial lacerations pose significant cosmetic concerns due to the visibility of the face and its impact on overall appearance. Seeking repair from a facial plastic surgeon is advisable whenever possible, as they specialize in addressing facial injuries with a keen understanding of aesthetic outcomes. Facial plastic surgeons possess the expertise to meticulously close wounds, minimize scarring, and restore the natural contours of the face.
Athletes’ risk of injury to the face and jaw
Deep tissue injuries to the face and jaw can damage the facial nerve. Such injuries can lead to partial facial paralysis (called “facial palsy”), affecting the muscles responsible for facial expressions.
The extent of the paralysis can vary, resulting in symptoms like drooping of the mouth, difficulty closing the eye, and impaired facial movements. Recognizing and addressing these injuries promptly is crucial, as it enables timely medical intervention to assess the severity of nerve damage and formulate an appropriate treatment plan.
Crush injuries and hematomas can pose the risk of developing compartment syndrome, a potentially limb-threatening condition characterized by increased pressure within a closed muscle compartment. In this condition, swelling or bleeding within the muscles results in elevated pressure, impeding blood flow to the affected area. This can lead to tissue damage, nerve compression, and, if left untreated, severe complications such as permanent muscle and nerve damage.
Oral and Dental Injuries in Contact Sports
Various types of oral and dental injuries can occur in sports, ranging from minor to severe.
Types of traumatic oral and dental injuries:
- Avulsion of Teeth: Complete displacement of a tooth from its socket due to a traumatic impact.
- Fractured Teeth: Breakage or chipping of the tooth structure.
- Tooth Intrusion: The tooth is forced into the jawbone or maxilla.
- Tooth Luxation: Displacement of a tooth without complete avulsion, including subluxation (tooth slightly moved) and lateral luxation (tooth displaced sideways).
- Alveolar Fractures: Fractures to the bony sockets in which the teeth are housed.
- Soft Tissue Injuries: Cuts, abrasions, and bruising to the lips or tongue.
- Temporomandibular Joint (TMJ) Injuries: Injuries to the jaw joint, such as JAMSS injuries.
- Jaw Fractures: Fractures to the upper or lower jawbones due to high-impact trauma.
Traumatic dental injuries are uncommon, accounting for less than 1% of all athlete injuries [7]. However, when they do happen, around 75% of the time the injured athlete was not wearing a mouthguard. Many of these injuries can be addressed by a dentist trained to treat trauma, such as sports dentists.
In the event of a dental injury, immediate first aid includes rinsing the injured area with saline solution and, if needed, attempting to reposition a displaced tooth gently. Treatments may involve splinting or bonding fractured teeth, re-implantation of avulsed teeth, and addressing soft tissue injuries. In cases of severe trauma, collaboration between dentists, oral surgeons, and other specialists may be necessary for surgical interventions.
While intraoral lacerations typically do not require repair, careful attention is required when addressing lip lacerations and avulsions. Meticulous repair of the vermillion border, the junction between lip mucosa and skin, is crucial for avoiding noticeable cosmetic deformities. For this reason, full-thickness lip lacerations are best addressed by a facial plastic surgeon due to the intricate nature of the repair [8].
Sports-Related Eye Injuries
Eye injuries in sports are diverse and can range from minor irritations to severe trauma, posing a risk to both vision and overall eye health. These injuries often result from direct impacts, collisions, or from foreign bodies. A recent study revealed an approximate 11% incidence of sports-related eye injuries among athletes [9]. Handball, water polo, and diving were identified as the primary activities associated with these injuries.
Common types of eye injuries in sports:
- Corneal Abrasions: Scratches on the surface of the cornea.
- Orbital Fractures: Fractures of the bones surrounding the eye.
- Conjunctival Injuries: Injuries to the conjunctiva (the thin, transparent membrane covering the white part of the eye and the inner surface of the eyelids).
- Hyphema: Bleeding within the anterior chamber of the eye.
- Detached Retina: Separation of the retina from the underlying tissue.
- Traumatic Iritis: Inflammation of the iris, usually resulting from blunt trauma to the eye.
- Foreign Body Injuries: Penetration or lodging of foreign objects, such as small particles or splinters, into the eye.
- Traumatic Optic Neuropathy: Damage to the optic nerve, with potential implications for vision loss.
Timely detection and treatment of facial injuries
Eye injuries are becoming more important in the sports world. The International Olympic Committee consensus statement on eye injuries called for a “critical evaluation of the current state of the science and practice of ophthalmologic issues and illness in high-level sports.” [10]
Athletes rely significantly on vision, which constitutes 80% of perceptual input in sports. [10] The intersection of eye health and sports medicine is vital due to the elevated risk of ocular injuries. Collaborations between sports medicine professionals and ophthalmologists are essential for comprehensive eye care.
Immediate medical attention is pivotal in case of an eye injury, ensuring an accurate assessment of damage, preventing complications, and facilitating optimal recovery. Timely detection and treatment of subtle symptoms are imperative to prevent systemic injuries and maintain peak athletic performance.
Facial Injury Prevention in Sports Medicine
There are several fronts where the sports community is aiming to help prevent facial injuries. For instance, sports dentistry plays a vital role by specializing in custom mouthguards. Tailored to individual needs, these mouthguards are designed to specifically reduce oral and dental injuries among athletes. This personalized approach ensures an optimal fit, offering both comfort and enhanced protection compared to generic alternatives. The proactive use of custom mouthguards exemplifies the sports community’s commitment to minimizing facial injuries and promoting athletes’ well-being.
Athletic professionals are also engaged in reducing the risk of facial injuries in sports. A key strategy involves the implementation of rule changes designed to enhance player safety. By revising and enforcing regulations, sports organizations aim to minimize the factors contributing to facial injuries during gameplay. These changes may include stricter penalties for high-risk actions, the promotion of fair play, and the adoption of advanced technologies and equipment that prioritize athlete protection.
Enhanced education is crucial among athletic professionals for effective injury prevention. Notably, a study revealed that less than 10% of these professionals possess adequate knowledge of first aid measures for traumatic dental injuries, emphasizing the need for comprehensive educational programs [11]. Closing this knowledge gap is essential to empower sports professionals to respond promptly and effectively to injuries, contributing significantly to a safer sports environment.
Lastly, specific prevention protocols are currently accessible to address conditions that may progress into chronic pain. For example, in the case of TMJ injuries, timely intervention during the acute phase with conservative treatments proves effective in averting the onset of chronic pain. These interventions encompass the use of oral appliances to alleviate neuromuscular tension, cryotherapy, and various physical therapy techniques.
SUMMARY: Key Issues Sports Medicine Providers Address in Facial Injury
This exploration of facial injuries in sports reveals the intricate challenges within this branch of sports medicine, often demanding a multidisciplinary approach. The spectrum of facial injuries in sports is wide, ranging from minor injuries addressable with home first aid to severe, potentially life-threatening emergencies. Strategies like the integration of sports dentistry, safety oriented rule changes, enhanced education of athletic professionals, and specific prevention protocols, including those for TMJ injuries, can collectively minimize the risks of sports-related facial injuries. Continuous research and collaboration are crucial for honing preventive measures and cultivating a secure sports environment.
Author bio
Dr. Brad Eli, DMD, MS is a graduate of UCLA post-doctoral Orofacial Pain program. The field of orofacial pain and temporomandibular disorders also has referrals from sports medicine providers to treat athletes. Over the past 30 years of clinical practice specializing in orofacial pain and TMJ, Dr. Eli has also been on the educational staff at university hospitals, pain centers, and the clinical staff of Southern California hospitals.
References
[1] James Leinhartm, et al., “Facial Trauma in Sports,” Jan 2017, https://pubmed.ncbi.nlm.nih.gov/28067737/
[2] Nitesh Tewari, et al., “Prevalence of sports-related traumatic orofacial and dental injuries in Asian countries: a systematic review and meta-analysis,” Sep 2023, https://pubmed.ncbi.nlm.nih.gov/37314438/
[3] Ricardo Grillo, et al., “Which sports have a higher risk of maxillofacial injuries?,” Feb 2023, https://pubmed.ncbi.nlm.nih.gov/36414173/
[4] Helena Polmann, et al., “Prevalence of dentofacial injuries among combat sports practitioners: A systematic review and meta-analysis,” Apr. 2020, https://pubmed.ncbi.nlm.nih.gov/31420968/.
[5] Christopher C. Xiao, et al., “Sport and Recreational Causes of Nasal Bone Fractures,” Jul. 2022, https://pubmed.ncbi.nlm.nih.gov/34467777/
[6] Yeon Hee Lee, et al., “MRI-Based Assessment of Masticatory Muscle Changes in TMD Patients after Whiplash Injury,” Apr. 2021, https://pubmed.ncbi.nlm.nih.gov/33915742/
[7] E. N. Azadani, et al., “Traumatic dental injuries in high school athletes in the United States of America from 2005 to 2020,” Apr. 2023, https://pubmed.ncbi.nlm.nih.gov/36317716/
[8] Jessica Tsao and C. E. Hwang, “Emergency Facial Injuries in Athletics,” Jul. 2023, https://pubmed.ncbi.nlm.nih.gov/37208059/
[9] Jingkai Zhang, et al., “Epidemiology of Sports-Related Eye Injuries Among Athletes in Tianjin, China,” Sept 2021, https://pubmed.ncbi.nlm.nih.gov/34604250/
[10] M. C. Moe et al., “International Olympic Committee (IOC) consensus paper on sports-related ophthalmology issues in elite sports,” August 2023, https://bmjopensem.bmj.com/content/9/3/e001644
[11] N. Tewari et al., “Global status of knowledge for prevention and emergency management of traumatic dental injuries in sports persons and coaches: A systematic review,” Apr. 2021, doi: 10.1111/edt.12629.
Facial Injuries in Sports Medicine
By Dr. Bradley Eli, DMD, MS
Facial injuries are a significant concern for sports medicine providers and include trauma to the oral, TMJ, and maxillofacial regions.
Facial injuries are a significant aspect of sports medicine, given the face’s vulnerability to impacts and collisions in diverse sports. The unique challenges posed by these injuries necessitate specialized attention. They often involve a multidisciplinary approach to comprehensive care, particularily to sports-related jaw injuries.
This article categorizes basic types of facial injuries based on the affected anatomical regions, aiming to establish a foundational understanding. The objective is to offer athletes and medical professionals a fundamental guide for making informed treatment decisions. It also assists in taking appropriate action at the time of the sports injury.
Table of Contents
- Facial Injuries in Sports Medicine
- What Is Sports Medicine?
- Facial Injuries in Sports
- Nasal Injuries That Sports Medicine Treats
- Facial Fractures Diagnosed in Sports Medicine
- TMJ Injuries Recognized by Sports Medicine Doctors
- Common Soft Tissue Injuries in Sports Medicine
- Oral and Dental Injuries in Contact Sports
- Sports-Related Eye Injuries
- Facial Injury Prevention in Sports Medicine
- SUMMARY: Key Issues Sports Medicine Providers Address in Facial Injury
What Is Sports Medicine?
Sports medicine is a specialized branch of that focuses on prevention, diagnosis, treatment, and rehabilitation of injuries and medical conditions related to sports and physical activity. It’s a multidisciplinary field that involves a variety of healthcare providers who work together to optimize the health and performance of athletes and active individuals.
Athlete-to-athlete contact, falls, and blows from equipment account for the majority of demand for sports medicine intervention. [1]
Facial Injuries in Sports
Facial injuries are highly prevalent in sports. In a recent multi-country study, the prevalence of facial injury in athletes was 40%, with individual studies reaching a prevalence as high as 68% [2]. These rates vary widely by injury type and sport type, with sports involving balls and cycling rated as the sports with the highest number of maxillofacial injuries [3]. Boxing is rated as the sport with the highest percentage of dental injuries, with a prevalence of 74% [4].
While any part of the body can be injured during sports, facial injuries are particularly concerning given their complexity. The human face, with vital sensory organs, intricate bone structures, and muscles for expressions, is a delicate and complex area. Facial injuries in sports pose unique challenges, ranging from the aesthetic concerns to the potential impact on crucial functions like breathing, vision, and communication.
What is Orofacial Pain Specialists role in sports medicine?
Facial injuries often necessitate the expertise of multiple specialists. For instance, sports dentistry plays a vital role in a sports medicine team due to the frequent occurrence of dental-related injuries. Orofacial pain specialists are integral to the team, capable of addressing the intricate issues associated with temporomandibular joint (TMJ) injuries and the ensuing chronic TMD pain.
In cases of facial fractures, otolaryngologists and facial plastic surgeons may be enlisted. Eye specialists, including ophthalmologists, might be essential for injuries involving the eyes. Table 1 outlines prevalent facial injuries in sports and the corresponding healthcare professionals for their treatment.
Table of Common Types of Facial Injuries in Sports |
||
|---|---|---|
| Body Region | Common Sports Injury Type | Appropriate Medical Professional |
| Nasal/Septal | Nasal and septal fractures | Emergency Physician, ENT, Plastic Surgeon |
| Facial bone fractures | Facial, orbital, mandibular, dentoalveolar fractures | ENT, Plastic Surgeon, Oromaxillofacial surgeon |
| TMJ | Dislocations, jaw and muscle sprain/strain (JAMSS) injuries | OMFS, Orofacial Pain Specialist, TMJ Specialist, (may work with ENT provider) |
| Soft Tissue | Contusions, lacerations, abrasions | Emergency Physician, ENT, Plastic Surgeon |
| Oral/Dental | Dental injuries, tooth fractures, avulsions | Dentist, Oromaxillofacial surgeon |
| Eye | Corneal abrasions, hyphemia, traumatic optic neuropathy | Emergency Physician, Ophthalmologist |
Nasal Injuries That Sports Medicine Treats
Nasal injuries are frequent due to the exposed position of the nose on the face and they can occur even in helmeted sports. In a multisport study on the incidence of nasal fractures, basketball accounted for the highest percentage of injuries among all patients (23.2%), followed by baseball (17.1%), softball (9.8%), soccer (7.4%), and football (7%) [4].
Breakdown of the main nasal fracture types:
- Lateral Nasal Fracture: Involves a break or displacement of the nasal bones on one or both sides.
- Nasal Septal Fracture: Affecting the nasal septum, which is the cartilage and bone dividing the nasal cavity into two nostrils.
- Comminuted Nasal Fracture: Involves the nasal bones being broken into three or more pieces.
- Depressed Nasal Fracture: Results in a portion of the nasal bones being pushed inward, causing a depression in the nasal contour.
- Greenstick Nasal Fracture: Characterized by an incomplete break in the nasal bones, similar to a greenstick fracture seen in long bones.
- Open Nasal Fracture: Refers to fractures where the cartilage or bones of the nose are exposed through a tissue laceration or avulsion.
Nasal fractures often require closed reduction for realignment, either immediately after the injury or approximately a week later to allow soft tissue swelling to subside. It is crucial not to postpone reduction beyond two weeks, as delayed intervention may result in healing with a deviated position.
In athletes considering rhinoplasty surgery for nasal deformities due to trauma, they are often advised to postpone treatment until they are finished with their competitive careers. This is because rhinoplasties significantly destabilize the nasal bones, making them more susceptible to reinjury.
As noted above, trauma to the nose can also lead to fractures or dislocation of the nasal septum, resulting in a nasal septal deviation. For athletes, this can pose significant challenges, as it may impede airflow and directly impact athletic performance. Repetitive trauma or a significant single injury can result in irreversible damage to the nasal septum, causing the collapse of the bridge, as indicated by the term “boxer’s nose.”
Facial Fractures Diagnosed in Sports Medicine
Facial bone fractures are an uncommon but serious injury in sports. There are multiple distinct fracture types that can occur in sports. For instance, there can be isolated orbital bone fractures, zygomatic arch fractures, or maxillary sinus wall fractures.
The National Institute of Health reports on the September 23, 2021 Sports-based distribution of facial fractures – findings from a four-season country study. Author Tero Puolakkainen found that “Unilateral zygomatic-maxillary-orbital and isolated mandibular fractures accounted for 74.2% of all fracture types.” He also reports that the percentage of sports-related facial injuries has rised over recent decades mostly due to the surging popularity of ice hockey and football-related facial trauma or fractures.
In more serious cases, the facial bones fracture in predictable patterns called Le Fort fractures.
There are three basic types of Le Fort fractures:
Le Fort I Fracture:
- Maxilla (including the upper jaw and hard palate).
Le Fort II Fracture:
- Maxilla.
- Nasal bones.
- Orbital floor (may involve the lacrimal, ethmoid, and zygomatic bones).
Le Fort III Fracture:
- Maxilla.
- Nasal bones.
- Orbital floor and medial walls.
- Zygomatic bones.
- Ethmoid bones.
- Sphenoid bone.
Many of these fractures are severe and require surgical correction. Failure to correct them can lead to functional impairment. For instance, if an orbital fracture entraps one of the eye muscles, coordinated vision can be affected. If a fracture of the maxilla is not address, the bite can be off or altered.
The mandible (jaw) is the most vulnerable bone to fracture in sports [5]. Mandible fractures can be seen in isolation or in combination with the above fractures. These fractures frequently require surgical intervention, typically involving the use of plates for stabilization. Additionally, wiring the jaw shut is a common practice after plating, restricting jaw movement during the recovery period. This combination of surgical fixation and immobilization aids in achieving proper alignment and stability, facilitating optimal healing.
Dentoalveolar fractures involve injuries to teeth and their supporting structures within the oral cavity. These fractures can result in broken or displaced teeth, damage to the alveolar bone, and injuries to surrounding soft tissues. Prompt dental and medical attention is crucial for assessment and appropriate treatment, which may include procedures like splinting, tooth repositioning, and, in some cases, surgical intervention to restore oral function and aesthetics.
TMJ Injuries Recognized by Sports Medicine Doctors
The TMJ is commonly injured in sports, both in helmeted and non-helmeted sports, and even with and without mouthguards. This is because of TMJ’s complex anatomy, which is comprised of much more than a joint.
Components of TMJ Deep tissue injuries:
Muscles:
- Temporalis Muscle: A large muscle of mastication that aids in closing the jaw.
- Masseter Muscle: Another muscle of mastication responsible for elevating the jaw and closing the mouth.
- Medial Pterygoid Muscle: One of the muscles of mastication that assists in jaw closure.
- Lateral Pterygoid Muscle: Plays a crucial role in jaw movement, particularly in opening the mouth and protruding the jaw.
Ligaments:
- Temporomandibular Ligament: Connects the zygomatic arch (part of the skull) to the neck of the mandible, providing stability to the TMJ.
- Stylomandibular Ligament: Extends from the styloid process of the temporal bone to the angle of the mandible, contributing to TMJ stability.
- Sphenomandibular Ligament: Connects the spine of the sphenoid bone to the lingula of the mandible, offering additional support to the TMJ.
Nerves:
- Trigeminal Nerve (V3 – Mandibular Division): The primary nerve associated with the TMJ, responsible for sensory innervation of the joint and motor control of the muscles of mastication.
There are also complex anatomical connections between the jaw and the neck, via portion of the brainstem called the trigeminocervical complex.
Most sports-related TMJ injuries are categorized as jaw and muscle sprain/strain injuries (JAMSS). Jaw muscle sprains involve injury to the ligaments surrounding the TMJ, often caused by a lateral blow to the jaw affecting the lateral TMJ ligament. Jaw muscle strain injuries can result from sudden eccentric stretching, akin to whiplash [6].
Addressing JAMSS injuries promptly is crucial to prevent prolonged pain.
Repetitive blunt trauma can also harm the TMJ, particularly in helmeted sports where the chinstrap directs force through the mandible, pushing the head of the mandible into the highly innervated joint space. Activation of chemical mediators in the trigeminal nerve from these tissues can contribute to more widespread pain, including chronic headaches or myofascial pain.
TMJ dislocations are much less common in sports injuries. They result from a forceful impact to the face, jaw, or head, leading to the displacement of the jaw joint out of its socket. Symptoms include jaw pain, limited mouth movement, and jaw misalignment. Medical intervention is involves manual repositioning or, in severe cases, surgery. Timely treatment is essential for pain relief, restoring jaw function, and minimizing long-term impact on oral and facial health.
What are Common Soft Tissue Injuries in Sports Medicine?
There are a host of different soft tissue injuries that can happen in sports. The treatment for each depends on the severity and nature of the condition.
Common soft tissue injury types:
- Contusion: Bruising or localized bleeding under the skin due to blunt force or impact.
- Abrasion: Superficial injuries involving the removal of the outer layer of skin due to friction or scraping.
- Avulsion: Tearing away of a portion of the skin and underlying tissue.
- Laceration: Deep cuts or tears in the skin and underlying tissues.
- Hematoma: Collection of blood outside blood vessels, often forming a lump or swelling.
- Crush injuries: Compression of a body part that can lead to soft tissue damage, swelling, and potential complications.
The management of soft tissue injuries depends on the type and severity of the injury, ranging from rest, ice, compression, and elevation (RICE) for mild injuries to surgical intervention for more severe cases. Seeking medical attention is important for proper diagnosis and treatment.
Facial lacerations pose significant cosmetic concerns due to the visibility of the face and its impact on overall appearance. Seeking repair from a facial plastic surgeon is advisable whenever possible, as they specialize in addressing facial injuries with a keen understanding of aesthetic outcomes. Facial plastic surgeons possess the expertise to meticulously close wounds, minimize scarring, and restore the natural contours of the face.
Athletes’ risk of injury to the face and jaw
Deep tissue injuries to the face and jaw can damage the facial nerve. Such injuries can lead to partial facial paralysis (called “facial palsy”), affecting the muscles responsible for facial expressions.
The extent of the paralysis can vary, resulting in symptoms like drooping of the mouth, difficulty closing the eye, and impaired facial movements. Recognizing and addressing these injuries promptly is crucial, as it enables timely medical intervention to assess the severity of nerve damage and formulate an appropriate treatment plan.
Crush injuries and hematomas can pose the risk of developing compartment syndrome, a potentially limb-threatening condition characterized by increased pressure within a closed muscle compartment. In this condition, swelling or bleeding within the muscles results in elevated pressure, impeding blood flow to the affected area. This can lead to tissue damage, nerve compression, and, if left untreated, severe complications such as permanent muscle and nerve damage.
Oral and Dental Injuries in Contact Sports
Various types of oral and dental injuries can occur in sports, ranging from minor to severe.
Types of traumatic oral and dental injuries:
- Avulsion of Teeth: Complete displacement of a tooth from its socket due to a traumatic impact.
- Fractured Teeth: Breakage or chipping of the tooth structure.
- Tooth Intrusion: The tooth is forced into the jawbone or maxilla.
- Tooth Luxation: Displacement of a tooth without complete avulsion, including subluxation (tooth slightly moved) and lateral luxation (tooth displaced sideways).
- Alveolar Fractures: Fractures to the bony sockets in which the teeth are housed.
- Soft Tissue Injuries: Cuts, abrasions, and bruising to the lips or tongue.
- Temporomandibular Joint (TMJ) Injuries: Injuries to the jaw joint, such as JAMSS injuries.
- Jaw Fractures: Fractures to the upper or lower jawbones due to high-impact trauma.
Traumatic dental injuries are uncommon, accounting for less than 1% of all athlete injuries [7]. However, when they do happen, around 75% of the time the injured athlete was not wearing a mouthguard. Many of these injuries can be addressed by a dentist trained to treat trauma, such as sports dentists.
In the event of a dental injury, immediate first aid includes rinsing the injured area with saline solution and, if needed, attempting to reposition a displaced tooth gently. Treatments may involve splinting or bonding fractured teeth, re-implantation of avulsed teeth, and addressing soft tissue injuries. In cases of severe trauma, collaboration between dentists, oral surgeons, and other specialists may be necessary for surgical interventions.
While intraoral lacerations typically do not require repair, careful attention is required when addressing lip lacerations and avulsions. Meticulous repair of the vermillion border, the junction between lip mucosa and skin, is crucial for avoiding noticeable cosmetic deformities. For this reason, full-thickness lip lacerations are best addressed by a facial plastic surgeon due to the intricate nature of the repair [8].
Sports-Related Eye Injuries
Eye injuries in sports are diverse and can range from minor irritations to severe trauma, posing a risk to both vision and overall eye health. These injuries often result from direct impacts, collisions, or from foreign bodies. A recent study revealed an approximate 11% incidence of sports-related eye injuries among athletes [9]. Handball, water polo, and diving were identified as the primary activities associated with these injuries.
Common types of eye injuries in sports:
- Corneal Abrasions: Scratches on the surface of the cornea.
- Orbital Fractures: Fractures of the bones surrounding the eye.
- Conjunctival Injuries: Injuries to the conjunctiva (the thin, transparent membrane covering the white part of the eye and the inner surface of the eyelids).
- Hyphema: Bleeding within the anterior chamber of the eye.
- Detached Retina: Separation of the retina from the underlying tissue.
- Traumatic Iritis: Inflammation of the iris, usually resulting from blunt trauma to the eye.
- Foreign Body Injuries: Penetration or lodging of foreign objects, such as small particles or splinters, into the eye.
- Traumatic Optic Neuropathy: Damage to the optic nerve, with potential implications for vision loss.
Timely detection and treatment of facial injuries
Eye injuries are becoming more important in the sports world. The International Olympic Committee consensus statement on eye injuries called for a “critical evaluation of the current state of the science and practice of ophthalmologic issues and illness in high-level sports.” [10]
Athletes rely significantly on vision, which constitutes 80% of perceptual input in sports. [10] The intersection of eye health and sports medicine is vital due to the elevated risk of ocular injuries. Collaborations between sports medicine professionals and ophthalmologists are essential for comprehensive eye care.
Immediate medical attention is pivotal in case of an eye injury, ensuring an accurate assessment of damage, preventing complications, and facilitating optimal recovery. Timely detection and treatment of subtle symptoms are imperative to prevent systemic injuries and maintain peak athletic performance.
Facial Injury Prevention in Sports Medicine
There are several fronts where the sports community is aiming to help prevent facial injuries. For instance, sports dentistry plays a vital role by specializing in custom mouthguards. Tailored to individual needs, these mouthguards are designed to specifically reduce oral and dental injuries among athletes. This personalized approach ensures an optimal fit, offering both comfort and enhanced protection compared to generic alternatives. The proactive use of custom mouthguards exemplifies the sports community’s commitment to minimizing facial injuries and promoting athletes’ well-being.
Athletic professionals are also engaged in reducing the risk of facial injuries in sports. A key strategy involves the implementation of rule changes designed to enhance player safety. By revising and enforcing regulations, sports organizations aim to minimize the factors contributing to facial injuries during gameplay. These changes may include stricter penalties for high-risk actions, the promotion of fair play, and the adoption of advanced medical technologies and sports equipment that prioritize athlete protection.
Enhanced education is crucial among athletic professionals for effective injury prevention. Notably, a study revealed that less than 10% of these professionals possess adequate knowledge of first aid measures for traumatic dental injuries, emphasizing the need for comprehensive educational programs [11]. Closing this knowledge gap is essential to empower sports professionals to respond promptly and effectively to injuries, contributing significantly to a safer sports environment.
Lastly, specific prevention protocols are currently accessible to address conditions that may progress into chronic pain. For example, in the case of TMJ injuries, timely intervention during the acute phase with conservative treatments proves effective in averting the onset of chronic pain. These interventions encompass the use of oral appliances to alleviate neuromuscular tension, cryotherapy, and various physical therapy techniques.
SUMMARY: Key Issues Sports Medicine Providers Address in Facial Injury
This exploration of facial injuries in sports medicine reveals the intricate challenges within this branch of sports medicine, often demanding a multidisciplinary approach. The spectrum of facial injuries in sports is wide, ranging from minor injuries addressable with home first aid to severe, potentially life-threatening emergencies. Strategies like the integration of sports dentistry, safety oriented rule changes, enhanced education of athletic professionals, and specific prevention protocols, including those for TMJ injuries, can collectively minimize the risks of sports-related facial injuries. Continuous research and collaboration are crucial for honing preventive measures and cultivating a secure sports environment.
Author bio
Dr. Brad Eli, DMD, MS is a graduate of UCLA post-doctoral Orofacial Pain program. The field of orofacial pain and temporomandibular disorders also has referrals from sports medicine providers to treat athletes. Over the past 29 years of clinical practice specializing in orofacial pain and TMJ, Dr. Eli has also been on the educational staff at university hospitals, pain centers, and the clinical staff of Southern California hospitals.
References
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