Jeffrey S. Fichera MS PA-C The Ear, Nose, Throat and Plastic Surgery Assoc. Inc.

Facial Injuries in Sports The Athletic Trainer must be prepaired to manage facial injuries, including Contusions Abrasions Laserations Nasal fractures

The Athletic Trainer must be prepaired to manage facial injuries, including

Contusions

Abrasions

Laserations

Nasal fractures

Facial Injuries in Sports Septal hematomas Auricular hematoms Ruptured tympanic membranes Fractures of the facial bones

Septal hematomas

Auricular hematoms

Ruptured tympanic membranes

Fractures of the facial bones

Sports Acitivies Account for 3% to 29% of all facial injuries Approx. 10% to 42% of all facial fractures 60% to 90% of injures occur in male participants between 10 and 29 years old.

Account for 3% to 29% of all facial injuries

Approx. 10% to 42% of all facial fractures

60% to 90% of injures occur in male participants between 10 and 29 years old.

Mechanism of Injury Direct Impact – with another players body part (eg, head, fist, elbow) Equipment (eg, ball, puck, goalpost, handlebars ) The Ground ( eg, wrestling mat, gym floor) Enviroment ( eg, tree, outfield wall )

Direct Impact – with another players body part (eg, head, fist, elbow)

Equipment (eg, ball, puck, goalpost, handlebars )

The Ground ( eg, wrestling mat, gym floor)

Enviroment ( eg, tree, outfield wall )

Return-to-Play Treament requires knowledge of the injury Type and serverity of injury Physicial demands of the sport

Treament requires knowledge of the injury

Type and serverity of injury

Physicial demands of the sport

Initial Exam and Evaluation Pertinent History Physicial Exam Remember the “ WOW FACTOR ”

Pertinent History

Physicial Exam

Remember the “ WOW FACTOR ”

Soft-Tissue Injuries Contusions Abrasions Lacerations

Contusions

Abrasions

Lacerations

Contusions Most commonly encountered facial injury Results from blunt trauma to the face Treatment aimed at minimizing inflammatory response ( ice, nonsteroidals)

Most commonly encountered facial injury

Results from blunt trauma to the face

Treatment aimed at minimizing inflammatory response ( ice, nonsteroidals)

Abraisions Partial-thickness disruptions of the epidermas Commonly results from blunt trauma or sudden forcible friction Always consider underlying injury 40% of all Tetanus (1998-2000) resulted from abrasions and lacerations

Partial-thickness disruptions of the epidermas

Commonly results from blunt trauma or sudden forcible friction

Always consider underlying injury

40% of all Tetanus (1998-2000) resulted from abrasions and lacerations

Nasal Injuries Epistaxis Septal Hematoma Fracture

Epistaxis

Septal Hematoma

Fracture

Epistaxis 80% of all nose bleeds are from the anterior source ( ie. Kiesselbach’s Plexus ) 20% are posterior and usually a disease of the middle aged and elderly

80% of all nose bleeds are from the anterior source ( ie. Kiesselbach’s Plexus )

20% are posterior and usually a disease of the middle aged and elderly

Nasal Blood Supply Why the WOW FACTOR? External Carotid Facial artery ( 2 branchs ant. Septum, ala ) Internal maxillary ( most important ) Terminal branch of EC gives rise to Sphenopalatine Nasopaltine Greater palatine

Why the WOW FACTOR?

External Carotid

Facial artery ( 2 branchs ant. Septum, ala )

Internal maxillary ( most important )

Terminal branch of EC gives rise to

Sphenopalatine

Nasopaltine

Greater palatine

Nasal Blood Supply Internal Carotid Opthalmic artery Anterior and Posterior ethmoid artery

Internal Carotid

Opthalmic artery

Anterior and Posterior ethmoid artery

Nasal Blood Supply

EPISTAXIS Cosider nasal fracture as source of epistaxis. Athlete may report having heard a “crunch” or “crack”. Nasal fractures are diagnosed clinically.

Cosider nasal fracture as source of epistaxis.

Athlete may report having heard a “crunch” or “crack”.

Nasal fractures are diagnosed clinically.

Focus of Initial Treatment Hemostasis Minimizing swelling Treatment of Nasal Fracture Ice and Pain control Aspirin contraindicated Nasal decongestants for up to 3 days Nasal fractures are reduced or refered to ENT in 3 – 5 days.

Hemostasis

Minimizing swelling

Treatment of Nasal Fracture

Ice and Pain control

Aspirin contraindicated

Nasal decongestants for up to 3 days

Nasal fractures are reduced or refered to ENT in 3 – 5 days.

Anterior Epistaxis Best controlled by slightly reclining the patient and applying direct pressure to the nasal septum for 5 to 10 min. Apply ice to the back of the neck may help by causing reflex vasoconstriction

Best controlled by slightly reclining the patient and applying direct pressure to the nasal septum for 5 to 10 min.

Apply ice to the back of the neck may help by causing reflex vasoconstriction

Persistent Epistaxis Occasionally requires nasal packing with: Mericel Sponge Topical Antibiotic Topical Coagulant FloSeal May use phenylephrine hydrochloride or oxymetazoline hydrochloride for vasoconstriction

Occasionally requires nasal packing with:

Mericel Sponge

Topical Antibiotic

Topical Coagulant

FloSeal

May use phenylephrine hydrochloride or oxymetazoline hydrochloride for vasoconstriction

Return to Play Can be immediate if bleeding is controlled. Custom face shields, helmets with face masks, or protective devices should be worn for 4 weeks after injury. Noncontact sports, return to play can be immediate if hemostasis controlled.

Can be immediate if bleeding is controlled.

Custom face shields, helmets with face masks, or protective devices should be worn for 4 weeks after injury.

Noncontact sports, return to play can be immediate if hemostasis controlled.

Nasal Fracture

Complications from Nasal Fracture Chronic nasal obstruction Deviated septum Septal hematoma Must Rule Out

Chronic nasal obstruction

Deviated septum

Septal hematoma

Must Rule Out

Septal Hematoma Bulging bluish mass Genarally form within hours after injury Requires prompt I&D, nasal pack and antibiotics Must refer to ENT if present

Bulging bluish mass

Genarally form within hours after injury

Requires prompt I&D, nasal pack and antibiotics

Must refer to ENT if present

Nasal Fracture

Septal Deviation

Ear Injuries Contusions caused by shearing forces applied to the external ear are common. Most common in wrestling. Mechanism of injury is blunt trauma against the wrestling mat. RESULT = AURICULAR HEMATOMA

Contusions caused by shearing forces applied to the external ear are common.

Most common in wrestling.

Mechanism of injury is blunt trauma against the wrestling mat.

RESULT = AURICULAR HEMATOMA

The External Ear

Auricular Hematoma Diagnosis established by early Ecchymosis Erythema and pain Palpable collection of fluid Swelling of external ear with loss of anatomical landmarks

Diagnosis established by early

Ecchymosis

Erythema and pain

Palpable collection of fluid

Swelling of external ear with loss of anatomical landmarks

Auricular Hematoma

Early Treatment Ice apllied eary with continued compression can minimize the risk of developing an auricular hematoma. If hematoma present – prompt aspiration required

Ice apllied eary with continued compression can minimize the risk of developing an auricular hematoma.

If hematoma present – prompt aspiration required

Treatment Options Aspiration with 18 or 20-gauge needle Incision and Drainage using sterile technique Compression applied for 7 to 14 days Dental roll with through & through sutures. Antibiotics for 7 – 10 dayes recommended Cephalosporins

Aspiration with 18 or 20-gauge needle

Incision and Drainage using sterile technique

Compression applied for 7 to 14 days

Dental roll with through & through sutures.

Antibiotics for 7 – 10 dayes recommended

Cephalosporins

Auricular Hematoma I & D Evacuation of hematoma

I & D

Evacuation of hematoma

Auricular Hematoma Dental Roll Application

Dental Roll Application

Auricular Hematoma

Auricular Hematoma

Return to Play Noncontact sports may return to play immediately Contact sports require ear protection and athletes may return to play 48 hours after dental rolls are removed.

Noncontact sports may return to play immediately

Contact sports require ear protection and athletes may return to play 48 hours after dental rolls are removed.

Complications Pressure necrosis of the underlying cartilage by seperating the perichondrial blood supply from the underlying cartilage, results in CAULIFLOWER EAR.

Pressure necrosis of the underlying cartilage by seperating the perichondrial blood supply from the underlying cartilage, results in CAULIFLOWER EAR.

Cauliflower Ear

Tympanic Membrane Perforation Most common Cause – pressure caused from OM Blunt trauma – Barotrauma Swimming, diving, highaltitude changes, direct contact to the ear

Most common Cause – pressure caused from OM

Blunt trauma – Barotrauma

Swimming, diving, highaltitude changes, direct contact to the ear

TM Anatomy

Normal TM

TM Perforation

TM Perforation

TM Perforation

TM Perforation Symptoms May be Asymptomatic or Hearing loss Vertigo Bloody or serous discharge Discomfort worsened by wind or cold

May be Asymptomatic or

Hearing loss

Vertigo

Bloody or serous discharge

Discomfort worsened by wind or cold

Diagnosis Always consider if mechanism of injury present. Otoscopic evaluation

Always consider if mechanism of injury present.

Otoscopic evaluation

Treatment Keep ear canal dry ENT evaluation Audiogram Otic drops may be required Return to play will depend on sport and symptoms

Keep ear canal dry

ENT evaluation

Audiogram

Otic drops may be required

Return to play will depend on sport and symptoms

Facial Fractures 75 % of facial fractures occur in the: Mandable Zygoma Nose All Facial Fractures Require Referal

75 % of facial fractures occur in the:

Mandable

Zygoma

Nose

All Facial Fractures Require Referal

Diagnosis Malocclusion, abnormal mandibular movement Trauma to lower face Mandible Signs and Symptoms Mechanism of injury Type

Diagnosis Heard “crack”; ecchymosis; tearing; epistaxis; crepitus Direct or glancing blow Nasal Pain, swelling; ecchymosis over fracture site; numbness along infraorbital nerve Blunt trauma to the cheek Zygoma

Diagnosis Elongated, distored face; mobile maxilla; maloccusion High-velosity shearing force to midface Maxilla or LeFort’s Central depression or asymmetry of cheek bone; trismus Blunt trauma to cheek Zygomatic Arch

Diagnosis Periorbital edema; ecchymosis; subconjunctival hemorrhage; numbness along infraorbital nerve; diplopia; Decreased upward gaze; sunken globe Direct trauma to globe (eg, from ball, elbow) Orbital Blowout

Questions ?