Facial and Dental Injuries in Sports Medicine

 

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Eye Injuries

Ocular injuries in sports are common, and mostly preventable. Sports at high risk for eye injury include baseball, hockey, football, basketball, lacrosse, racquet sports, tennis, fencing, golf, and water polo. Screens should be conducted prior to beginning one of these sports to monitor for preexisting eye conditions or a family history that could predispose an athlete to an eye injury.

The most common mechanism of eye injury is blunt trauma; however, other types include radiation and penetration. Impact from an object smaller than the eye tends to cause more internal eye trauma, while objects larger than the eye tend to cause more orbital fractures. Penetrating injuries can be caused by fish hooks or broken eyeglasses, while radiation tends to occur while skiing.

When examining a patient, a thorough patient interview should be conducted to determine the mechanism of injury. The physical exam should include testing of the visual field, ocular muscles, pupil size and reflexes, and fundoscopic evaluation of the red reflex. The examiner may be able to treat simple abrasions and foreign body removals on site, however should refer if any of the following signs and symptoms are found upon examination.

-Sudden decrease in or loss of vision
-Loss of field of vision
-Pain on movement of the eye
-Photophobia
-Diplopia
-Proptosis of the eye
-Light flashes or floaters
-Irregularly shaped pupil
-Foreign-body sensation/embedded foreign body
-Red and inflamed eye
-Hyphema (blood in anterior chamber)
-Halos around lights (corneal edema)
-Laceration of the lid margin or near medial canthus
-Subconjunctival hemorrhage
-Broken contact lens or shattered eyeglasses
-Suspected globe perforation

Returning to play after an eye injury requires careful consideration. The athlete needs to be cleared by an eye doctor, have full visual return, and wear protective glasses.

To prevent these injuries from occurring, athletes in high risk sports should consider donning protective eyewear during play. Eyewear should be tailored to each sport, but always made of high-impact resistant plastic that reduces ultraviolet radiation and can be made with or without a prescription.

Facial Fractures

Common sports for facial fractures to occur include baseball, softball, soccer, and horseback riding, and the most common bones fractured include nasal, orbital and skull bones. A collision, fall, or being struck with a ball is usually the mechanism of injury for facial fractures.

The patient interview is important to help gauge the severity of the injury on site, including ruling out a concussion. After a blow to the head, a player should be screened for a concussion with a test such as the Sport Concussion Assessment Tool 3 (SCAT), which evaluates signs, symptoms, balance, and memory along with a neurologic and cognitive screening. It also gives recommendations on when an athlete should return to play based on the severity of his or her score.

Management of facial fractures depends on the location and severity. On site, if a fracture is suspected, the player should be transported to the nearest hospital. Fractures sites that are especially concerning are the orbit, which could cause damage to the eye, or nasal fractures, which could impair breathing. Return to play will depend on the severity of the injury, as well as other injuries incurred with the fracture. Fracture healing time (typically up to 8 weeks) must be considered, as well as if the player is continuing to have pain or other symptoms.

To help prevent facial fractures from occurring, coaches should always adhere to the rules of the game to decrease unnecessary roughness. Protective helmets and eyewear should be worn when appropriate. Coaches also need to keep an eye on novice players because their level of skill and knowledge of the game could lead to injury of themselves or other players. Finally, coaches should ensure players get adequate rest, especially when there are multiple practices or games in a day.

Facial Abrasions & Lacerations

Sports are a tremendous contributor to facial lacerations and abrasions, causing up to 29% of all reported facial injuries . The primary fear with any athlete who has experienced a facial injury is underlying damage that may have affected consciousness, respiration, or vision. Because of the severity of these types of injuries, evaluations always start with the emergency medical response “ABCDE” approach: Airway, Breathing, Circulation, Disability, and Exposure/Environmental control . After the medical professional rules out a life threatening injury and/or concussion, then he or she can bandage the wound for the athlete to return to competition.

 Facial abrasions are a non-severe, superficial injury involving the epidermal and possibly superficial dermal layers of the skin. Most abrasions occur because of shear forces caused by an athlete sliding over a rough playing surface such as grass or turf . Athletes with facial abrasions can easily return to competition after a medical professional has washed out the wound with soap and water and removed any foreign debris from the area. If there is too much debris or if it is too deep in the wound to be removed safely, then the athlete should be taken to a doctor for removal . However, abrasions can easily become infected, so it is important to use an aseptic dressing to protect the wound. Most abrasions will heal in a few days .

Lacerations are the most common sports-related injuries to the face . Sharp objects are not the only cause of lacerations. “Burst lacerations” occur when blunt trauma of the soft tissue over a bony area will cause a tear in the skin. These injuries usually occur on the forehead, cheek, teeth, or chin . Lacerations bleed easily, so it is important to put pressure over the wound to control it. Once the bleeding is under control, the medical professional should sterilize the cut with saline to prevent infection. Many trainers will choose to close the wound with sutures, but if it is not a significant laceration then some will opt to use a Band-Aid or other type of adhesive bandage until after the game is over and the athlete can be taken to a doctor . Most studies recommend that adhesive should be used for superficial cuts smaller than 4 cm while sutures are used for deeper and larger lacerations. One randomized control trial shows that Dermabond (a brand of tissue adhesive) had a better cosmetic outcome than sutures at 1 year following facial plastic surgery, and it had no increased risk for wound dehiscence or infection . As physical therapists, it is better to use adhesives in competition settings until a doctor can evaluate whether the athlete will need stitches or not.

Eyelid lacerations are also a big concern because of the possibility of foreign bodies or penetrating injuries into the eye itself. Eyelid lacerations can cause vision loss since the cornea will dry out when the eyelid is unable to close properly . Lacerations to the medial part of the eyelid can damage the tear ducts while lacerations to the upper eyelid can damage the levator palpebrae muscle, which can cause the eyelid to permanently droop . Eyelid lacerations during competition are cared for a little differently than other facial lacerations due to the possibility of the eye drying out and causing permanent damage. The primary goal immediately following an injury to the eyelid is to apply an antibiotic ointment or artificial tears to the wound and cover the entire eye with moistened gauze to prevent the cornea from getting too dry; athletes with an eyelid laceration are taken to the doctor immediately for surgical repair .

If lacerations are not treated properly, excessive scar tissue can form and alter the cosmetic appearance of the face . This can cause significant psychological and psychosocial effects on the athlete, especially if they are female. Some lacerations may have significant complications if they involve a severed nerve, vessel, or gland . A laceration of the facial nerve will cause a possibly permanent facial droop and asymmetry. The earlier that a facial nerve laceration is diagnosed, the better chance the athlete has for nerve regeneration. Deep cheek lacerations typically involve the parotid duct, so saliva draining from the laceration is a common symptom . In summary, many underlying structures are apt to be injured with a facial laceration. The job of athletic trainers and physical therapists is to clean and dress the wound, and any complicated laceration injuries should be immediately referred to a surgeon .

According to Romeo, Hawley, Romeo, Romeo, & Honsik (2007) , athletic trainers and/or physical therapists should adhere to the following steps in the sideline management of facial injuries:
- Assess the athlete’s airway, breathing, and circulation following typical emergency response guidelines
- Evaluate for an intracranial or cervical spine injury
- Inspect all parts of the face for bleeding, swelling, bruising, and asymmetry
- Palpate the bony aspects of the face (forehead, cheekbones, jaw, etc.) for pain, instability, and/or subluxation
- Assess cranial nerve function

Romeo et al.  also provide a list of criteria for the athlete to be able to return to competition following a facial laceration:
- Trainer/therapist has ruled out any underlying injury including eye injuries, fractures, nerve lacerations, and cervical spine injuries
- Bleeding stopped and hemostasis achieved
- Vision is normal
- Athlete has decided to return to competition after being informed of the risks
- The rules allow the athlete to return to play with an open wound OR if the rules do not allow an open wound then it is closed and bandaged temporarily

Medical professionals should follow these rules to ensure that athletes will not worsen the injury if they decide to return to play. It is important to know the rules about returning to competition with an open wound for each specific sport that the trainer or therapist is covering.

References

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