Jan 29, 2015Watch the Face!
Facial injuries in sports run the gamut from simple black eyes and knocked-out teeth to serious damage that can have lasting consequences. Are you prepared to deal with all the injuries you may face?
By Dr. Jaime Garza
Jaime Garza, MD, DDS, is Clinical Professor of Surgery and Otolaryngology at the University of Texas Health Science Center in San Antonio. He has served as contributing team physician for the New Orleans Saints, the University of Texas-San Antonio, and Trinity University.
Facial protection in athletics has come a long way since the days of leather football helmets and bare-knuckle boxing. The evolution hasn’t always been smooth–Jacques Plante, the first NHL goalie to regularly wear a mask in games, was famously accused of cowardice by his coach in the 1950s when he donned the device after a slap shot broke his nose, and debate over the value of masks in hockey lasted for years.
Thankfully, common sense has prevailed throughout the sports world. Today it’s very common to see cages on baseball and softball batting helmets, protective eyewear on field hockey and women’s lacrosse players, state-of-the-art mouthguards on football fields and basketball courts, and many other types of highly effective protection.
Nonetheless, thousands of facial injuries occur among athletes at all levels each year. According to one report, facial injuries are present in somewhere between 11 and 40 percent of all athletic injuries.
Sports injuries to the face can run the gamut from superficial skin damage to potentially life-threatening trauma affecting the integrity of the airway. While the former are happily much more common than the latter, the best athletic trainers are prepared to treat and manage the full range of possibilities.
SKIN & SOFT TISSUE
The most common soft tissue injuries to the face include abrasions, contusions, and lacerations. Not surprisingly, these injuries usually occur over the most prominent areas–the nose, cheeks, and upper and lower lips. Lacerations to the face are often described as “burst” injuries, with compression from an external source essentially pinching the skin and other tissue against bone or teeth until the skin breaks.
After any such injury, the immediate priorities are to stop bleeding and decrease swelling, typically through the application of pressure and ice. The standard rules of wound care apply–keeping the site clean and covered while it heals, irrigating it when necessary, and monitoring it for any signs of infection.
Beyond immediate concerns, a longer-term priority with facial injuries is to minimize the potential for scars. Besides the aesthetic impact of facial scars, scar tissue is more vulnerable to reinjury in the future. To reduce scarring, an athlete can be instructed to gently self-massage the area near a facial abrasion as it heals, as this helps break up dense collagen bonds that contribute to visible scar formation. Applying antibiotic ointment can also help minimize scarring. A common home remedy for scar prevention is applying vitamin E to the wound site, but this should be avoided–studies have found it to be ineffective, and it causes contact dermatitis in some people.
The ears are especially susceptible to deformity due to athletic injury. If you’ve spent time around experienced wrestlers or boxers, you’ve likely seen examples of hematoma auris, commonly known as cauliflower ear. While some grapplers consider this condition to be almost a badge of honor, it is medically undesirable, since it increases the risk of ear infections and can even contribute to hearing loss.
Cauliflower ear is caused by shearing forces on the ear that lead to bleeding below the skin surface, often accompanied by separation of the skin from the cartilage beneath it. Because ear cartilage receives its blood and nutrients from the skin of the ears, the separation causes scarring (fibrosis) and death of the cartilage, leading to deformation.
This condition can almost always be prevented with proper treatment. An ear that has been subject to blunt trauma or shearing forces typically presents as swollen, tender, and bruised. A physician can treat the subsurface bleeding with an incision and drainage under sterile conditions. A compression bandage is usually placed over the site and left there for at least 48 hours. The physician will often prescribe an antibiotic to ward off infection, and return to full activity usually occurs within a week.
The use of headgear is an obvious protective measure against cauliflower ear and other ear injuries. In sports like wrestling, which involve direct physical contact with the bare head, ear guards should be standard equipment. And in any sport, after an injury to the ear that requires incision and drainage, headgear should be worn for at least two to four weeks.
TO THE BONE
Facial bone and joint injuries occur most commonly to the nasal bones, dentoalveolar complex (the bony area that anchors the teeth), cheekbones and orbital bones, and upper and lower jaw. These injuries often occur in combination, and the most prominent facial bones–those in the nose, cheeks, and lower jaw–are the most susceptible.
When examining the face for signs of injury, one of the best visible indicators of fracture is asymmetry. Soft tissue injuries to the face can cause rapid swelling that produces obvious asymmetry, but it can also be due to fracture of an underlying bone. With fractures around the orbital cavity, the athlete may report double vision (diplopia) or loss of sensitivity around the cheek and gums of the affected side, and you may observe recession of the eyeball within the orbit (enophthalmos).
Another part of any facial examination is asking the athlete to produce their normal bite with their lips open. In addition to helping identify dental injuries, an abnormal bite (for instance, one in which the upper and lower teeth are not properly aligned) may indicate trauma to the upper or lower jaw or the temple-mandible joint (TMJ). If there is any blood in or around the mouth, it’s essential to determine the source–if no laceration can be found, the presence of blood is another potential sign of a jaw injury. (For more on injuries to the TMJ, see “Slide and Slam” below).
When an athlete presents with a bloody nose (epistaxis), nasal septal fracture is a strong possibility. Bleeding due to a broken nose usually occurs only anteriorly (with blood draining from the nostrils), and it can be stopped with ordinary cotton rolls. However, any sign of posterior nasal bleeding, with blood draining at the back of the throat, may be a sign of a more serious injury for which the athlete should be treated by a physician or taken to the emergency room.
If the nose doesn’t appear crooked and bleeding stops within a few minutes, the injury may heal on its own with only the application of ice and short-term use of over-the-counter nasal decongestants to aid in breathing. But with any sign of external deformity, a physician will likely recommend surgery. Persistent facial pain or headaches after a broken nose may indicate the fracture has extended into the peri-orbital bone or down to the upper jaw, also possibly requiring surgery.
Any time a facial fracture is suspected, the athlete should not return to activity before seeing a physician, preferably one who specializes in orofacial injuries. Diagnostic x-rays can determine the extent of any damage, and surgical intervention may be required to ensure that the fractures heal properly.
It typically takes six to eight weeks for full healing. But depending on the location and severity of the fracture, a physician may allow return to play as quickly as one to two weeks post-injury, particularly if surgery isn’t required and an appropriate facemask can be found to protect the injured area.
THE ORAL CAVITY
The mouth and teeth are highly susceptible to athletic injury, particularly when athletes don’t wear mouthguards. Among oral injuries, roughly 80 percent occur at the anterior maxilla (upper jaw), and the most common are lacerations of the lips and surrounding tissue.
A knocked-out tooth is one injury for which an athletic trainer’s immediate response can play a major role in the outcome. Acting fast and correctly may make the difference between a simple one-time trip to the dentist and much more complex and lengthy treatment.
First, a brief primer on dental anatomy: The outside of the tooth is covered with enamel, the middle lining consists of a substance called dentin, and the internal portion is pulp, which contains neurovascular tissue that supplies sensation and blood. At its base, each tooth is surrounded by tiny connective tissue fibers collectively known as the periodontal ligament, which connect it to surrounding spongy bone and essentially attach it to the skull.
Even when a tooth is not completely knocked out, this connection can be damaged, typically resulting in intra-oral bleeding, pain or altered sensation in the area, and the tooth being visibly out of position. When a tooth is loose but not completely out of its socket, there has been some degree of damage to the periodontal ligament. In these cases, the tooth should be gently manipulated back into its normal position, allowing the athlete to assume a normal-looking and normal-feeling bite. The athlete should visit a dentist immediately.
If a tooth is completely avulsed (knocked out), the best immediate step is to replant it in its socket as quickly as possible and refer the athlete to a dentist. Note that this only applies to adult teeth, and not deciduous “baby” teeth–when a youth athlete loses one of these, it should not be replanted, as the risk of infection outweighs any potential benefit.
In the case of multiple knocked-out teeth and other situations where replanting is not possible or practical, or if the athlete finds it very painful, the tooth must be kept surrounded by moisture. Tooth-saving kits consisting of a small vessel of sterile liquid can easily be stored in first-aid bags. If none is available, workable substitutes include milk, saline solution, and saliva. The tooth should never be scraped or brushed to remove debris, as this can further damage remnants of the periodontal ligament. In fact, the tooth should only be handled by its crown (the non-root end) to avoid damaging or contaminating the root.
If the tooth is replanted or otherwise surrounded by moisture and the athlete quickly sees a dentist, this injury can usually be treated quite simply. The dentist will examine the injury site to determine whether any damage has occurred to the alveolar bone that holds the teeth in place, and if there is any such damage, oral surgery is usually required.
When a tooth is chipped but not loosened or removed from its socket, any retrievable pieces should likewise be stored in moisture. Depending on their size, a dentist may be able to reattach tooth chips through a simple cosmetic procedure.
Chipped teeth are often accompanied by lacerations inside the mouth, and any such wounds should be inspected to ensure they do not contain tooth fragments, which pose a serious infection risk. Significant lacerations of the mouth should always be referred to a physician, who may recommend sutures. Allowing intraoral lacerations to heal without treatment could lead to scarring and uneven surfaces that cause problems with chewing and speech.
An important final note on treating all facial injuries is that it’s critical to establish priorities before deciding how to proceed with immediate treatment. For instance, after a serious blow to the chin and mouth, knocked-out teeth may be the most conspicuous visible injury, but before reaching for a tooth-saving kit, first ensure that the athlete’s airway is not affected. Trauma to this area may have damaged the trachea or larynx, and recognizing the more serious injury is essential.
Likewise, a blow to the upper face may result in a bloody nose, but if there’s also potential damage to the eye or its socket, that should usually take precedence when providing first-aid care and arranging for further treatment. When in doubt, bring a physician into the picture as quickly as possible.
Today’s facemasks, eye protection, and mouthguards are more advanced than ever, and happily, more and more athletes are using them. But as long as sports exist, there will be facial injuries. Armed with knowledge to handle all types of them, you can keep your athletes as safe as possible in any sport.
Sidebar: SLIDE AND SLAM
The temple-mandible joint (TMJ) is the most targeted and traumatized structure in boxing, and it’s vulnerable in other contact sports as well. The condyles, or posterior extensions of the lower jawbone, are located in a socket near the base of the skull, accompanied by a cartilage meniscus that’s very similar to the meniscus of a knee joint.
When an athlete receives a lateral blow to the chin or lower jaw, it can result in something called the slide and slam phenomenon. In essence, as the jaw is forced to move laterally, one condyle gets forced up into the mandibular fossa (the place on the skull’s temporal bone where the jaw hinge is situated), causing damage to the meniscus, microfractures of the tympanic plate or the base of the skull, and even trauma to the temporal lobe of the brain. Repeated instances of this phenomenon in an athlete can result in progressive chronic injuries to the TMJ and the brain.
The best protection against slide and slam injury comes from a quality custom-made mouthguard. Besides cushioning the teeth to prevent dental injury, an adequate mouthguard acts as a shock absorber that allows the condyles to pull away from the skull base properly, which helps prevent transmitted forces from reaching the delicate structures of the skull and brain.
Great article. I recently graduated dental school & my husband is finishing up his DPT at Northeastern–hence I came upon this article and found it both helpful and interesting.
I’m interested to find out how Dr. Garza deals with immediately reimplanted teeth, when the patient presents to the clinic the day of or the day after an athlete has had a partially or completely avulsed tooth. Does he typically splint the teeth–and if so, for how long and using a rigid or nonrigid splint?
Thanks, Jade Lyles, DMD