Facial Injuries in the Athleteforms.acsm.org/16tpc/PDFs/40 Olson.pdf · 2016-01-21 · Nose...
Transcript of Facial Injuries in the Athleteforms.acsm.org/16tpc/PDFs/40 Olson.pdf · 2016-01-21 · Nose...
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Facial Injuries in the Athlete
David E. Olson, M.D. ACSM Team Physician Course
San Antonio, TX
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Skull Fracture! • Usually d/t blunt trauma to the head • Palpate for step-offs/deformities, look for bleeding in scalp • Red flags suggesting skull fx: -hemotympanum (blood behind tympanic membrane) - battle sign (bruising behind -ear auricle d/t basilar fx) - raccoon eyes (periorbital eccymosis) - clear otorrhea (CSF fluid) - clear rhinorrhea (CSF fluid) • Diagnosis is made by CT scan of skull/face • Complications include infection/meningitis, wound contamination, communication with underlying brain or CSF • Ask for headache, nausea/vomiting, AMS to r/o intra-cranial trauma.... May need to rule out with brain CT or MRI 7
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I have no disclosures to report
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Outline
• Objectives • Introduction • Epidemiology • Anatomy • On-Field Assessment
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Outline
• Injuries – Nose – Ear – Mouth and Teeth
• Prevention • References
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Introduction
• The face is frequently exposed to injury during sports that involve body or implement contact
• Direct contact with – Opponent: head, fist, elbow – Equipment: ball, puck,
racquet – Stationary objects:
goalpost, mat, tree limb
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Introduction
• General Classification – Soft tissue injury without damage to underlying structures
• Most common type • Usually bruises and lacerations Often
from low speed trauma • Fist or elbow
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Introduction
• General Classification (cont.) • Soft tissue injury with damage to
underlying structures • Underlying structures include bone,
cartilage, teeth, blood vessels, nerves or muscle
• Usually from high speed trauma – balls, pucks, sticks
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Introduction
• Facial injuries can result in both functional and cosmetic deficits if not managed properly
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Epidemiology
• Facial injury rates are difficult to quantify since they are so common
• – Occur in many settings (playground, practice field, backyard)
• – Majority are minor and not reported
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Epidemiology
• 3-29% of facial injuries occur from participation in sports
• 60-90% occur in males age 10-29 yrs • Mechanism of injury is usually known
and is usually direct impact
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Epidemiology
• Recent study showed 23% incidence
rate (incidence/total players) of head and face injuries over two regular seasons of NCAA field hockey in Big Ten conference
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Epidemiology
• Most injuries were from contact with ball (56%), followed by stick contact (33%), then contact with another player (11%)
• Types of injuries: – lacerations (32%) – bruises & hematomas (26%)
– concussions (18%) – facial fractures (13%) – dental injuries (6%) – other (5%)
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Anatomy
• Facial bones are subcutaneous and easily palpated
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Anatomy
• Zygomatic arch forms the prominence of the cheek
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Anatomy
• Mandible forms the lower jaw • Horseshoe shaped • Body, angle, ramus easily palpated • Coronoid process – palpated by direct
intra-oral approach • Alveolar ridge
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On Field Assessment
• Airway, Breathing, Circulation – Blood, mouth guard, dislodged tooth may
obstruct airway • Cervical spine precautions if c-spine
tenderness, unexplained neurologic symptoms or unconsciousness
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On-Field Assessment
• History – Ask if loss of consciousness – Look for mental status change
• Ascertain mechanism of injury – Ask if associated injuries – Consider concussion
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On Field Assessment
• Exam • Observe for facial asymmetry or structural
depressions • Inspect face from two planes - AP and
inferior positions • Allows for visualization of subtle
changes suspect underlying fracture • Identify areas of bruising or bleeding
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On Field Assessment
• Inspection should be done as soon after
injury as possible as facial swelling will quickly mask abnormal contours
• Systematically palpate the orbital bones, nasal bone, maxilla, mandible, TMJ looking for pain, numbness, crepitus, step-off
• Palpate intra-orally as well
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On Field Assessment
• Look for sunken eye globe • Abnormalities in extra-ocular eye
movements (CN III, IV, & VI) • Reduced sensation of skin below the
eye (infra-orbital nerve) • All suggestive of orbital blowout
fracture with nerve or muscle entrapment
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On Field Assessment
• Inspect mastoid process for ecchymosis (“battle sign”)
• May signify a basilar skull fracture - rare – Often associated with vertigo, headache or hearing changes
• Change – Assess for flattening of the cheek
• May indicate fracture of zygomatic arch - common
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On Field Assessment
• Maxilla - assess stability by grasping central incisors and attempting to move jaw
• Mobility of hard palate indicates maxilla fracture
• Mandible – look for malocclusion Fx – teeth won’t feel right
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On Field Assessment
• Inspect nares and auditory canals for obstruction, hematoma or CSF leak – CSF leak – rare, but emergency; meningitis risk
• CSF will be positive for glucose on a urinary dipstick
• Differentiates CSF from normal rhinorrhea
• CSF leaking into mouth will give salty taste
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On Field Assessment
• Consider diagnostic imaging – X-rays may be useful
• Facial series Panorex views of mandible
• Nasal views usually not helpful! • CT scan if fracture is suspected
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On Field Assessment
• Return to Play • Decision based on above exam –
Precluded by • Airway obstruction • Altered mental status • Suspected fracture • Active bleeding • Visual difficulty
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Nose Injuries
• Epistaxis-Nosebleed • Usually arises from plexus of vessels in
anterior septum (95%) called Kiesselbach’s area
• Bleeding site often visualized • Posterior bleeds are rare (5%) not directly
visualized • Anterior bleeds drip from the nostrils,
posterior bleeds drain into the throat
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Nose Injuries
• Epistaxis – Initial treatment of most nosebleeds is prolonged
direct pressure (up to 20 minutes) to lower nose which compresses vessels on the septum
• Cold compress to nasal bridge and back of neck may encourage vasoconstriction
• If bleeding continues may apply epinephrine 1:1,000,000 to the septum
• If bleeding still continues, consider referral since you need great lighting and suction
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Epistaxis
• If bleeding site is localized may cauterize
with silver nitrate applicators • Consider packing • If emergency hemostasis needed, may
place Foley catheter in nose, inflate and pull back until snug to tamponade bleeding
• Use Vaseline BID to septal mucosa for prophylaxis of recurrent nosebleeds
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Nose Injuries
• Nasal Fractures • Patients may report
feeling a crack, severe pain, nosebleed, inability to breathe through nose, deformity, crepitus, and mobility
• Lateral blow: simple fracture with deviation to one side
• End-on blow: may result in comminution
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Nasal Fractures
• Evaluate for deformity, crepitus,
mobility • Look for septal hematoma, CSF leak –
Swelling often precludes adequate assessment of deformity
• X-rays seldom helpful with diagnosis or treatment decisions
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Nasal Fractures
• Reduction indicated
for nasal obstruction or cosmetic deformity
• Successful reduction is usually possible if done immediately after injury (< 1 hour)
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Nasal Fractures
• A soft probe placed inside the nares
can sometimes move the depressed or deviated septum back into anatomical position
• There is risk of arterial injury and severe hemorrhage with immediate reduction of nasal fractures
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Nasal Fractures
• Delayed reduction is preferable with
referral to ENT within 7 days of injury • Delayed reduction is often under
general anesthesia • Displaced nasal fractures in young
athletes are frequently reduced due to smaller nasal passages and tendency for increased sinus infections if not reduced
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Nasal Fractures
• Avoid return to play for at least a
week after nasal fracture (debatable) • External protection devices usually
worn for four weeks
• Some athletes have delayed reduction until after the end of the season
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Nose Injuries
• Septal Hematoma • A TRUE EMERGENCY • Caused by hemorrhage between
septal cartilage and mucosa • Often associated with nasal fractures
but can be from minor trauma • Prone to abscess formation and may
cause pressure necrosis to underlying cartilage
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Septal Hematoma
• If bilateral, cartilage can die in 24
hours • Saddle nose deformity or chronic nasal
obstruction may result • Patients present with nasal obstruction,
pain, fever • Exam reveals a dull blue to red,
cherry- like structure occluding the nasal passage
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Septal Hematoma
• Treatment is immediate evacuation by
needle aspiration or small incision followed by packing for several days
• Prophylactic antibiotics to prevent
septal abscess and subsequent cartilage necrosis
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Ear Injuries
• Auricular Hematoma • Collection of blood between
the skin and auricular cartilage
• Secondary to contusion or shearing trauma to the pinna (external ear)
• Presents with throbbing pain and swelling in fossa
• Treat with ice, aspiration with sterile technique and compression
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Auricular Hematoma
• Monitor daily • May develop into chronic swelling
known as “cauliflower ear” • Return to sport can be immediate if
ear protection is worn • Repeat contact without ear protection
increases chance of poor cosmetic result
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Splinting
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Ear Injuries
• Auricular Injuries • Always inspect for lacerations after
ear trauma • Lacerations between scalp and ear
are easily missed • Can lead to cosmetic deformity or loss of
ear if they involve the cartilage • Refer to ENT
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Ear Lacerations
• Suspect if history of ear being pulled
forward • Analgesia of ear gained by raising a
wheel of lidocaine around entire base of ear
• Tears of cartilage should be carefully aligned and sutured with 5.0 absorbable suture
• Prophylactic antibiotics are recommended to prevent infections
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Ear Injuries
• Tympanic Membrane Rupture • Occurs from a blow to the side of the
head – hard object or hitting water at high speed
• Usually presents with painful pop and often bleeding, unilateral hearing loss, vertigo, nausea
• Hole in TM seen on otoscopic exam – may have blood in external canal
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Tympanic Membrane Rupture • Usually heal spontaneously (90% in 8
weeks) • No treatment necessary usually
except for frequent re-examination • Antibiotics can be given if infection
develops or if contamination suspected (Cortisporin Otic drops or amoxicillin orally)
• Keep water out! –silly putty
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Tympanic Membrane Rupture
• Tympanic Membrane Rupture • Advise patient to sneeze with
mouth open and avoid blowing nose for a few weeks
• If vertigo present with TMR then should be seen by ENT
• Possible fistula with drainage of perilymph and permanent hearing loss
• Return to play after vertigo has resolved and depends on type of sport
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Tympanic Membrane Rupture
If sport with significant pressure changes (platform diving, scuba, high altitude mountain climbing) then no return until TM healed
• If water sport without significant pressure
changes then athlete can return with custom fabricated earplug before TM is healed (debatable)
• If dry land sport without pressure changes, athlete may return before TM is healed as long as ear protection is worn
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Mouth and Teeth Injuries
• Lip Lacerations • Result from traumatic compression of
lip onto the teeth • Bleed profusely • Look for associated dental injury • Most superficial lacerations of the lips
(and those involving the tongue) heal without suture repair
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Lip Lacerations • Deep lacerations of
the lip should be repaired but require good anatomical approximation for the outside
• If vermilion border involved, place first suture at mucocutaneous junction to insure accurate alignment
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Mouth and Teeth Injuries
• TMJ Dislocation • Mandible dislocates anteriorly and then
muscle spasm pulls it superiorly • May occur when athlete whose mouth is open
is struck in the mandible • May also occur atraumatically if mouth is
opened too wide during a yawn or shout • Presents with inability to close mouth
and moderate pain
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Mouth and Teeth Injuries
• TMJ Dislocation – Usually dislocated mandible head is
palpable anterior to articular eminence of glenoid fossa
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TMJ Dislocation
• Relocation performed by placing
thumbs on line of lower teeth as posterior as possible and applying downward and slightly posterior force – wrap your thumbs
• May need mild sedation (benzodiazepines)
• Longstanding dislocations may require general anesthesia
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TMJ Dislocation
• 10 days of mouth rest
with minimal opening, soft diet, analgesics
• Contact sports should be avoided for 2 weeks; boxers should not spar for at least 6 weeks
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Mouth and Teeth Injuries
• Tooth Fracture • Occur from direct trauma • Tooth fragment should be
retained in best medium available (descending order) – Hank's Balanced Salt
Solution (H.B.S.S.) – Milk – Saline – Saliva (buccal vestibule) – Water
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Tooth Fractures
• Enamel chip fractures
– Painless – Enamel at fracture site is uniform in color – Non-urgent dental follow-up – Only requires smoothing of rough edges
• Fractures of the dentin
– Moderately painful – Sensitivity to air at the fracture site – Yellow dentin visible at the fracture site – Should be seen by a dentist within 24 hours
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Tooth Fractures
• Pulp Fractures
• Severe pain • Pink or red pulp at the fracture site • Require immediate dental evaluation • Treatment with root canal and cap
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Tooth Avulsion
• Results from direct trauma • Quick and appropriate action may
save the tooth • Handle the tooth by the crown only • Rinse debris off with HBSS, milk,
saline or suck clean under the tongue
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Tooth Avulsion
• Do not scrape debris off the root – Get
to dentist immediately
• If patient is conscious and alert, then re-implant the tooth and splint by biting gauze or wet tea bag
• If patient unconscious then store in best available medium, and transport for emergency dental care
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Tooth Avulsion
• With appropriate storage a tooth
can often be successfully be re-implanted up to 2 hours after the injury
• Likely no chance of salvage after 6 hours
• Prophylactic antibiotics along with tetanus booster are usually given
• If a tooth or fragment is missing then consider chest and abdominal x-rays to help locate it
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Luxation of Tooth
• Tooth still in socket, but abnormal
position
–Reposition tooth in socket
–Stabilize tooth by gently biting on towel or gauze
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Luxation
– Athlete may require local anesthetic to reposition tooth – Stabilize tooth by gently biting on towel or gauze Transport to dentist
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Extruded
Tooth partially pulled out Gentle reduction attempt and transport
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Intruded
Tooth pushed into gum - appears short Do nothing (don’t reposition and
transport)
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Prevention • Facemasks, face shields, eye shields,
mouth-guards, helmets available for many sports
• Equipment is designed to protect the athlete without interfering with sporting activity
• It should fit comfortably and allow the athlete to speak and breathe during play
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Prevention
• Customized equipment is preferred • May provide a psychological benefit
by • Increasing athlete’s confidence • Remove oral jewelry
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Prevention
• Numerous studies show face protection reduces incidence of facial injuries
• Few sports mandate their use Face masks and mouth-guards have dramatically
• reduced facial injuries in football since they became mandatory in 1962
• – Still inadequate face protection in baseball
• Mouth-guards specifically reduce dental and mandible injuries –even with braces
• No strong evidence that mouth-guards protect against concussion
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Summary
• Nasal fxs - no X-rays • Septal hematomas – refer to ENT • Ear lacerations – refer to ENT • Tympanic membrane ruptures – keep
water out • Dental avulsions, luxations, fractures
(except chip) – refer to Dentist
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References
• Academy for Sports Dentistry. Farmersville, IL 62533. 800-273-1788
• ACSM. Selected issues in injury and illness prevention and the team physician: a consensus statement. Medicine & Science in Sports & Exercise, 2007; 39(11):2058-68.
• Brukner P, Kahn K. Facial injuries, Ch 15. In: Clinical Sports Medicine 3rd edition, McGraw-Hill, 2006; pp 216-228.
• Cassisi, Nicholas J. ENT, UFCOM. personal interview 3/25/09
• Echlin P, McKeag DB. Maxillofacial injuries in sport. Current Sports Medicine Reports, 2004; 3:25-32.
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References
• Hendrickson CD. Head and facial injuries in collegiate field hockey. American Medical Society for Sports Medicine: Overland Park, KS. press release May 15, 2007.
• Ranalli DN. Dental injuries in sports. Current Sports Medicine Reports, 2005; 4:12-17.
• Romeo SJ, Hawley CJ, Romeo MW, Romeo JP, Honsik KA. Sideline management of facial injuries. Current Sports Medicine Reports, 2007; 6:155-161.
• Sallis RE. Facial injuries in the athlete. ACSM Team Physician Course Part I, 2005.