Chapte

r6
- Injuries ­  
The eye 
and face

  The eye  

• Introduction

• Assessing an eye injury

○ Necessary equipment

○ History

○ Eye examination

• Types of injuries

○ Orbital haemorrhage

○ Lid lacerations

○ Conjuctival foreign body

○ Corneal foreign body

○ Corneal abrasions

○ Conjuctival lacerations

○ Subconjuctival haemorrhage

○ Chemical burns

○ Hyphaema

○ Macular injuries

○ Choroidal injuries

○ Injuries to the lens

○ Lens dislocation

○ Retinal injuries

 Retinal detachment

 Retinal haemorrhage and oedema

○ Optic nerve injuries

○ Orbital injuries

○ Blowout fracture
 ○ Medial wall orbital fracture

○ Penetrating injuries

• Prevention of eye injuries

○ Spectacles and goggles

○ Contact lenses

○ Refractive surgery

○ Face protection

○ Athletes with high risk of eye injuries

The face

• Introduction

• Fractures of the mandible

○ Condylar fractures

○ Fractures of the angle

○ Fractures of the body

• Fractures of the maxilla

• Zygomatico-maxillary complex fractures

• Nasal fractures

• Temperomandibular joint injuries

• Dental injuries

1 Galloway NR. Ocular sports injuries. In: Hutson MA (ed) (1990). Sports injuries: recognition and management.

pp. 25-29. Oxford: Oxford University Press.

2 Hollenbach E and Ho I. Eye. In: Sherry E and Bokor D (eds)(1997), Sports medicine – problems and practical
   
management. pp. 91-103. London: GMM.

3 Lim L. Facial skeleton. In: Sherry E and Bokor D (Eds)(1997), Sports medicine – problems and practical

management. pp. 83-90. London: GMM.

  Introduction
Although the eye accounts for only 0.002% of the body's surface area1 and has many
protective mechanisms including rapid reflex lid closure, production of tears, and protection by
bony orbital ridges, eye injuries due to sport are nevertheless common, accounting for one to
two per cent of all sports injuries. High risk sports include basketball, squash, and contact sports
such as football and boxing. A thorough examination is required for all eye injuries, even those
that appear to be minor. All serious eye injuries and ideally all eye injuries should be examined
by an ophthalmologist, but this is not always possible or practical. The clinician dealing with eye
injuries must therefore have a thorough knowledge of the anatomy (Fig. 6.1) and physiology of
the eye, and be able to treat minor eye injuries whilst being able to recognize and refer serious
injuries to an ophthalmologist.
1 Jones NP (1989). Eye injury in sport. Sports Medicine. 7: 163-81.

Assessing an eye injury

Necessary equipment (see also Chapter 25)

• ophthalmoscope, torch, visual acuity card, and eyelid speculum

• sterile single use vials of fluorescein stain, mydriatic drops, anaesthetic drops and
saline for irrigation

• sterile eye pads, eye shield (plastic/metal), cotton-tipped swabs, and tape

History
In all eye injuries a thorough history detailing the mechanism of injury is vital. Of most
importance is visual status - whether there has been any decrease in visual acuity after the
injury. It is also important to ask what the patient’s visual acuity prior to the injury was like.
A detailed history should include:
Symptoms experienced. Ask the patient whether there is pain, blurred vision, double vision, or a
decrease in visual acuity. Photophobia is suggestive of traumatic iritis whilst floaters and
flashing lights suggest a retinal detachment, tear, or vitreous haemorrhage. Diplopia is
associated with blowout fractures. Loss of consciousness or altered mental status suggests
significant trauma and additional injuries. Ask whether there has been any discharge, tearing,
itching, burning, redness, headache, or altered facial sensation.
Mechanism of injury - velocity of injury causing particles, nature of particles involved, blunt injury
versus projectiles, whether protective equipment was worn at time of injury.
Ophthalmic history - previous eye injuries and eye problems, and whether spectacles or contact
lenses are worn normally.
General medical and surgical history.

Eye examination
In order to perform a satisfactory eye examination a clean location with good illumination is
required. A thorough eye examination should always be performed with the unaffected eye used
for comparison. The following routine is suggested:

• Visual acuity should be tested first as other examinations may require the instillation of
mydriatics. The exception to this rule is chemical injuries where irrigation of the eye
takes precedence over examination. Visual acuity is tested using a Snellen chart or
card. If unavailable a newspaper should be used. Each eye should be tested
 individually, while the other is covered by a small card or the palm of the hand, using
the best corrected vision (if glasses are normally used by the patient these should be
worn during the test). A patient unable to read the largest letter should be asked to
count the number of fingers the examiner holds up. If this cannot be done then the
perception of hand movement should be tested. Failing this perception of light using a
torch should be tested.

• Inspect the eyelids for lacerations, haemotoma and bruising.

• Evert the eyelids (instruct the patient to look down with their chin elevated) and inspect
the conjuctival sac for signs of trauma and for foreign bodies. See Fig. 6.2

• Examine the cornea and sclera for surface irregularities, perforations, subconjuctival
haemorrhages, iris prolapses, and foreign bodies. A magnifying lens or
ophthalmoscope should be used. Fluorescein dye may aid in outlining corneal
abrasions, which appear bright green under blue cobalt light.

• Examine the anterior chamber. Any haziness, the presence of blood and the depth
should be noted. Examine the optic disc and retina. Look for the red reflex (reduced
with retinal detachment, haemorrhage, or cataract). A thorough ocular examination
should also include examination with a slit lamp.

• Inspect pupils. Note size and shape. Test light reflexes - direct and consensual
responses, and perform the swinging torch test.

• Compare the iris colours of each eye and look for iridodonesis (trembling of the iris
with quick visual movements due to lack of support e.g. in lens subluxation).

• Examine visual fields carefully and note any defects.

• Examine the face looking for signs of orbital fractures, nerve palsies, and altered face
sensation.

• General examination. Ensure that no other more urgent injuries have been sustained.

Types of injuries (see Fig. 6.3)

Orbital haemorrhage (black eye)

May occur after blunt trauma to the orbital region. Clinical features - proptosis of affected eye,
haemorrhage into the eyelids and beneath the conjunctiva, and restriction of eye movements. In
cases of severe haemorrhage, there may be visual loss due to interruption of vascular supply to
the optic nerve and retina, whereupon the patient should be transported urgently with head
elevated and ice applied to a hospital with an ophthalmology department. Treatment –if the eye
is difficult to examine or the lid is swollen shut, do not force it open. Instead an ophthalmologist
should be consulted. In most cases the swelling is usually self-limiting and the interstitial blood
resorbed within a few weeks. Ice packs should be applied during the first 24 hours.
Lid lacerations
May be the result of sharp objects, blunt trauma, or an object catching the lid and causing a
tear. Treatment - control bleeding with direct pressure and assess extent of injury. A thorough
ocular examination must be performed to exclude ocular injury and any foreign body in the eye
must be identified and recorded. The eye should be padded and the patient referred for surgical
repair of the laceration to minimize cosmetic deformity. Complications - lacerations near the
medial canthus may also involve the lacrimal canaliculus and if not repaired, the patient may
have permanent tearing.

Conjuctival foreign bodies

Are very painful and are usually the result of dirt or mud thrust into the eye when there is
contact with the ground after a tackle in a contact sport. They are most commonly located under
the upper eyelid. Treatment - removal of the foreign body by irrigation with sterile saline and
light brushing with a cotton bud. The upper and lower eyelids are everted by asking the patient
to look downward whilst the examiner pulls the lid away from the eyeball. Ophthalmologic
consultation should be sought if the foreign body is not removed easily.

Corneal foreign body.

These arise from the same mechanism as conjuctival foreign bodies. In most cases the foreign
body is readily removed by irrigation with saline and use of a cotton bud. If the foreign body is
embedded the eye should be anaesthetised and stained with fluorescein dye to assist with
examination and treatment. Treatment - should be performed by an ophthalmologist if available
(if the foreign body overlies the pupil it must be referred to an ophthalmologist for removal). The
patient's eyes should be stabilized by asking him or her to fix on an object in the distance. The
foreign object is removed by carefully scraping with a sterile 24-gauge needle held at a tangent
to the cornea under magnification and bright illumination. Chloromphenicol ointment should be
applied and the eye padded.

Corneal abrasions
One of the most common ocular injuries in contact sports and also seen in leisure activities.
Frank injury (blown dust particles and fingernails), wearing of contact lenses for extended
periods of time, chemicals, and ultraviolet light may cause denuding of the corneal epithelium.
Symptoms - may include severe pain, blurred vision, photophobia, lacrimation and
blepharospasm. Signs - decreased visual acuity if the central cornea is extensively denuded.
Careful examination with a slit-lamp and fluorescein dye to aid in revealing the extent of the
injured area is indicated. The eyelids should also be everted to ensure foreign bodies are not
present. Treatment -antibiotic drops such as chloromphenicol and daily review for the presence
of infection until the fluorescein stain is no longer visible. Corneal abrasions normally heal within
48h. Contact lenses must not be worn until healing is complete. If the abrasion persists for more
than 48h or increases in size, consultation with an ophthalmologist is advisable. Complications -
ulcer formation and infection.
Conjuctival lacerations
Result in severe tearing pain, photophobia, blepharospasm. Do not forcibly open the eye lids,
squeeze the eye closed, or put pressure on the eye as this may cause further damage by
increasing the intraocular pressure. If the eye can be opened easily, an irregular pupil may be
seen, along with a shallow anterior chamber and an iris adherent to the wound outside. Lightly
pad and transfer to a hospital with an ophthalmology department.

Subconjuctival haemorrhage (SCH)

May result from trauma, severe hypertension, blood dyscrasias, or can occur spontaneously1. It
also occurs in sports such as weightlifting and scuba diving where there is a change in
intravascular pressure, and in mountain climbing where there is strenuous exertion under
conditions of reduced oxygen saturation. Symptoms - in cases of extensive haemorrhage,
photophobia and decreased visual acuity may be present, otherwise this condition is usually
asymptomatic. Signs - a SCH appears as a bright red area in the white conjuctiva. Treatment -
blood pressure should be measured and hypertension if present, investigated further. In cases
of trauma a thorough eye examination should be performed. In most cases no further action
other than reassurance of the athlete is required as SCH is a benign condition which resolves
without treatment within 2 weeks of onset.

1 Fong LP (1994). Sports-related eye injuries. Medical Journal of Australia. 160: 743-50

Chemical burns

An ocular emergency. May be the result of lime used in line markings on playing fields or
chlorine and other swimming pool chemicals. Treatment - first aid involves holding the eyes
open and irrigating with water for 20 minutes. The eyelids must be everted to ensure that the
chemical is completely removed. Neutralizing agents should be used if available. The initial
injury may appear deceptively mild but later examination may reveal generalized superficial
corneal scarring and injury which may require hospital treatment. Complications - iritis, uveitis,
secondary glaucoma and phthisis bulbi.

Hyphaema.

A hyphaema is a collection of free blood in the anterior chamber of the eye, arising from
bleeding of the small vessels of the iris as a result of blunt trauma to the eye e.g. being struck
by a ball. It is by far the most common sports-related intraocular injury requiring hospital
admission. Symptoms – Immediate: pain, blurring of vision. Within minutes: photophobia,
redness. The patient may also feel drowsy due to concussion or due to the hyphaema itself.
Signs - at the time of injury a hazy anterior chamber is seen, which with rest settles to form a
fluid level. The iris appears muddy in comparison to the unaffected eye, and the pupils are
irregular and slow to react to light. A corneal abrasion may also be present. Treatment -
although most hyphaemas self-resolve by absorption within a few days, in about an eighth of
cases rebleeding occurs. Hence immediate referral to an ophthalmologist is necessary.
Treatment involves padding of both eyes, and absolute bed rest (usually with sedation) for 5 to
6 days. The patient should be instructed to avoid aspirin. Complications - ocular hypertension,
secondary glaucoma, blood staining of the cornea, and permanent visual impairment. In some
patients anti-glaucoma medical therapy and surgery may be required.

Posterior Chamber Injuries

Macular injuries.

Concussion of the globe with a contrecoup force may cause macular oedema resulting in the
formation of a macular cyst. Severe impairment of central vision results, which may become
permanent if the cyst ruptures and causes a macular hole. There is no treatment.

Choroidal injuries

Choroidal ruptures are usually the result of a blow to the eye by a blunt object such as a squash
ball. Visual acuity is markedly reduced in the affected eye if splitting of the macular area occurs.
On examination circumscribed white areas concentric to the optic disc can be observed.
Choroidal haemorrhages without rupture can also occur, resulting in necrosis of the choroid and
retina in the area involved. In both conditions there is no specific treatment, but ophthalmologic
consultation should be sought and prolonged rest is necessary for healing.

Injuries to the lens

Occur after blunt trauma. Cataract formation due to opacification of the crystalline substance of
the lens may follow immediately, or after a few days, weeks, or months. Severe blows can
cause the lens to rupture and allow aqueous humour from the anterior chamber to enter the
lens and lead to formation of a cataract (usually in the shape of a rosette in the subcapsular
area. Treatment of cataracts involves removal of the lens. Contact lenses are used to restore
refractive power.

Lens dislocation

After blunt trauma or a collision in a contact sport the lens zonule may rupture and allow the
unanchored lens to displace itself into the vitreous or migrate anteriorly into the anterior
chamber. Symptoms - partial dislocations are usually asymptomatic. Complete dislocations
result in blurred vision which may also be accompanied by monocular diplopia and pain. Signs -
the classical sign is quivering of the iris when the patient moves the affected eye (iridodonesis).
Other signs include decreased visual acuity and a decentred lens. Treatment - immediate
ophthalmologic consultation is advisable. Surgical removal of the lens may be required.
Complications - iritis and glaucoma.
Retinal injuries

Are sustained by blunt trauma to the eye and may occur independently of anterior segment
injuries. All retinal injuries require referral to an ophthalmologist.

Retinal haemorrhage and oedema

The macular area is usually involved, resulting in blurred central vision. On examination a
whitish elevated retina is seen and there is a decreased pupillary reflex.
Retinal detachments

Commonly follow a blow to the eye. The temporal quadrant is most commonly affected.
Symptoms - flashes of light, floaters, or curtains coming down over the field of view are
commonly reported. In some cases there is a delay of weeks after the injury before the onset of
symptoms. Signs - an early detached retina appears elevated and progresses to a grey colour.
The overlying retinal vessels appear almost black. The red reflex becomes grey and there is a
decreased pupillary reflex. Treatment - an ocular emergency requiring immediate treatment by
an ophthalmologist. Successful recovery requires early treatment because if the detachment is
allowed to progress to involve the macular area, there will be a degree of permanent loss of
central vision even if the retina is successfully reattached later. The majority of detachments are
now surgically treated with a laser.

Optic nerve injuries

May result from severe direct injuries to the eye but more commonly follow blunt injury to the
head producing permanent blindness. The visual loss usually is the result of shearing of the
nutrient vessels to the nerve rather than a fracture of the optic canal. On examination there is an
abnormal pupillary response to light and a pale, swollen disc can be seen though the
ophthalmoscope.

Orbital injuries

Blow out orbital fractures are sustained after blunt trauma to the eye, usually the result of being
hit by a squash ball or being punched or kicked. The eye is forced back into the orbit and this
causes a sudden increase in intraorbital pressure and a blowout fracture of the weakest part of
the orbit, the thin orbital floor. Herniation of intraorbital contents may then occur through the
defect in bone. The orbital margins, however, usually remain intact as the thicker bone there
offers higher resistance.
Clinical features include:
• Weakness in ocular movement - elevation is particularly affected because of entrapment of
the inferior rectus and inferior oblique muscles. For the same reason diplopia, which is
commonly present, is more marked on vertical gaze.
• Enophthalmos - usually with a downward displacement due to orbital herniation into the
maxillary sinus.
• Paraesthesia or anaesthesia - around the cheek below the eye due to injury of the
intraorbital nerve.
• Other signs may include ecchymosis, oedema, and subcutaneous emphysema.

Treatment1:
• On diagnosis antibiotics should be started to prevent orbital cellulitis.
• Examination of the eye by an ophthalmologist and investigation of the fracture with x-ray and
CT scan is mandatory.
• In some cases the trapped inferior ocular muscles can be freed by elevating the eye with
forceps after topical anaesthesia, otherwise surgical exploration and repair will be necessary.

1 Forrest LA, Schuller DE and Strauss RH (1989). Management of orbital blow-out fractures. Case reports and

discussion. American Journal of Sports Medicine. 17(2): 217-20.

Medial wall orbital fractures

Occur in a similar manner to orbital blow out fractures but are less common. Clinical features
may include:
• subcutaneous emphysema around the nose and eyelids which can be accentuated if the
patient blows his/her nose. This however should be discouraged as infected sinus contents
could be blown intraorbitally.
• epiphora if there is involvement of the nasolacrimal duct and it is occluded. Secondary
dacryocystitis may follow later.
• weakness of lateral eye movements and diplopia during lateral gaze if the medial rectus
muscle is entrapped.

Treatment - X-rays may demonstrate clouding of the maxillary sinus, herniated contents in the
maxillary sinus, air in the orbit and rarely, the fracture itself. CT scans offer higher resolution and
should be performed when there is doubt. Treatment is usually conservative unless there is
entrapment of the medial rectus muscle in which case surgical repair is indicated. Antibiotics
should be prescribed to prevent orbital cellulitis, the eye padded and the patient instructed not
to blow their nose. The fracture will unite in most cases, otherwise surgery is required.

Penetrating injuries

Penetrating injuries must always be suspected and excluded in all ocular injuries. The following
conditions and signs suggest that a penetrating may have occurred: hyphaema, subconjuctival
haemorrhage, asymmetrical depth of the anterior chamber, and difference in intraocular
pressure. If a penetrating injury is suspected urgent ophthalmologic referral is indicated as the
longer the delay the greater the risk of the lens being damaged or the ocular contents being
extruded or infected. Further damage can also be caused by attempting to remove the object or
forcefully open the eye for examination. The patient should be transported to hospital supine
and the injured eye supported by light padding. The unaffected eye should also be padded to
prevent damage from conjugate movement. A CT or skull X-ray should be performed to exclude
an intraocular foreign object.

Prevention of eye injuries

Many eye injuries are preventable. All too often eye injuries occur because advice is ignored or
because of careless regard for the rules of a particular sport. The role of the sports medicine
physician in prevention therefore not only involves giving advice about forms of eye protection
but to ensure that that this advice is followed. Strict enforcement of rules by umpires, referees,
and governing bodies will also prevent many eye injuries and make the sport safer.

Spectacles and goggles

Adequate visual acuity is necessary not only for effective performance but also for the
prevention of injuries to the eye. Spectacles or goggles, in addition to correcting vision, should
also afford adequate eye protection for the sport concerned. Many spectacles and goggles are
available that have been specifically designed for use in sports, and should be encouraged to
be worn wherever there is a risk of eye injury. Prescription lenses should ideally be made of
polycarbonate lenses with a thickness of at least 3mm at the centre as it is able to with stand
not only the impact of a squash ball but also a gunshot. If the prescription is too high for
polycarbonate CR39TM plastic is the best alternative.1 Glass lenses even of the 'toughened' or
'safety' types should never be used. A sturdy polycarbonate frame with a steep posterior lip
should be used, so that the lens does not dislodge posteriorly. Use of metal frames is not
advisable as they can cut the face and also cause eye injuries. Those not requiring a
prescription should wear a wrap-around eye-guard with good lateral protection.
CR39 is a registered trademark of PPG Industrial.

1 Pashby TJ and Pashby RC. Treatment of sports eye injuries. In: Fu FH and Stone DA (eds) (1994). Sports

injuries: mechanisms, prevention, and treatment. Ch. 48, pp.833-851. Baltimore: Williams and Wilkins.

Contact lenses

Contact lenses have become popular among athletes as they overcome the disadvantages of
spectacles which may have heavy frames, become knocked off, or fog up. There are some
disadvantages though: hard contact lenses may break and injure the eye, and should not be
used in any contact sport (soft lenses appear to be safe), whilst all lenses may become
displaced from the eye and lost on the playing field. In addition contact lenses offer no
protection whatsoever from eye injury so it is still important to wear eye protection during all
high risk sporting activities.

Refractive surgery

Refractive surgery to visually rehabilitate refractive errors of the eye continues to evolve at a
significant pace and will play an increasingly important role on the sporting field as its
advantages are more widely realized. One of the first corrective refractive procedures was radial
keratotomy, used to correct ametropia, which involved carefully planned incisions in the cornea.
More recently, techniques such as Photo Astigmatic Refractive Keratectomy, Photo Therapeutic
Keratectomy (PTK), and Photo Refractive Keratomy (PRK) using a laser to ablate and recontour
the corneal surface have been developed. They will be increasingly employed to correct
myopia, hyperopia, astigmatism, and age-related presbyopia as the safety and effectiveness of
these techniques improve.

Face protection (see also Chapter 24)

In certain sports (e.g. cricket, American football, ice hockey) it is important not only to protect
the eye but facial structures as well with protective helmets and faceguards. It is imperative that
these offer adequate eye protections as well.

Athletes with high risk of eye injuries

Athletes with certain eye conditions are at a very high risk of eye injury and should be evaluated
by an ophthalmologist prior to participating in a high risk sport. These problems are:
one good eye
• severe amblyopia (lazy eye)
• history of retinal detachments or tears
• diabetic retinopathy
• Marfan's syndrome
• homocystinuria
• severe myopia (>6 dioptres) as an elongated globe is a strong risk factor for retinal
detachment
• recent eye surgery

Protective eyewear should be encouraged to be worn whenever playing a sport that could lead
to eye injury, and if possible persons with these conditions should be discouraged from
participating in high risk sports altogether.

The face

Introduction

Maxillofacial injuries in sport are usually the result of direct trauma and include fractures of the
facial skeleton, intra- and extraoral lacerations, and dental trauma. Although face masks,
helmets and mouth guards have reduced the number of facial injuries in sports such as
American football, cricket, and ice hockey1, the incidence of facial injuries is still significant.

1 LaPrade RF, Burnett QM, Zarzour R and Moss R (1995). The effect of the mandatory use of face masks on facial

lacerations and head and neck injuries in ice hockey. A prospective study. American Journal of Sports Medicine.

23(6): 773-5.

Fractures of the mandible

Fractures of the mandible are the most common maxillofacial injury from sport and are usually
the result of a direct blow. Mandibular fracture patterns include condyle, angle, body, symphysis,
ramus (rare) and coronoid process (rare).

Condylar fractures

The condyle is the most common site of mandibular fracture. Most fractures are sub-condylar
fracturing through the weak area at the neck of the condyle. The fracture may be undisplaced,
displaced (anterior-medially due to pull of the lateral pterygoid muscle, condyle remains within
the glenoid fossa), or dislocated.
Symptoms – pain and tenderness from the tempero-mandibular joint, exacerbated if the patient
opens his mouth or clenches his teeth.
Signs – swelling in front of the ear, alteration of the natural bite (occluded) position with gagging
of the posterior molars, deviation in mandibular movements on opening towards the side of the
fracture.
Investigations – the diagnosis is frequently missed. The orthopantomogram (OPG) and
posterior-anterior (PA) mandible x-ray must be carefully studied by outlining the contour of the
condyles bilaterally.
Treatment – maintenance of the airway is the first priority in fractures of the mandible. If the
patient is conscious they should be advised to support the lower jaw with their hands in a
forward sitting position. If the fracture is comminuted or displaced then a bandage or cervical
collar may be applied taking care not to compromise the airway by causing backward
displacement of the mandible. Unconscious patients should be placed in a lateral (‘coma’)
position so that blood and saliva can drain from the mouth. The mouth should be cleared of any
dislodged teeth, dentures, blood and other foreign bodies then the head tilted and jaw
supported.
In children management of condylar fractures is non-surgical because remodeling occurs with
complete regeneration of the normal condylar anatomy. Jaw exercises to achieve normal
occlusion is usually all that is required. If normal occlusion is not consistently attainable then
intermaxillary fixation for 2 weeks followed by a period of guiding elastics may be required.
In adults, the management of sub-condylar fracture is controversial. There are opposing views
on whether displaced condylar fractures should be treated by open or closed reduction. Lim1
suggests that open reduction should be reserved for gross fracture dislocations and when
correct occlusion can not be attained by closed reduction. In the majority of cases of condylar
fracture in adults there is minimal alteration to the occlusion position. The patient is able to
achieve a correct occlusion with a minimum of effort and simple jaw exercises may be all that is
required to achieve a consistent occlusion. Good results have been achieved by both
conservative management and open reduction but it seems preferable to avoid surgery if it is
possible to do so without compromise to the outcome. If the occlusion is not readily achieved
then this is an indication for closed reduction. Arched bars are placed and the patient is placed
into intermaxillary fixation for a period of two weeks after which it is released and guiding
elastics used for a further two to four weeks.

1 Lim L. Facial skeleton. In: Sherry E and Bokor D (eds)(1997), Sports medicine – problems and practical

management. pp. 83-90. London: GMM.

Fractures of the angle

The angle is the second most common site of mandibular fracture, usually occurring through the
unerupted lower third molar. A concomitant body fracture or sub-condylar fracture contralaterally
may be present. Bilateral angle fractures are not common.
Symptoms – the patient will state that their bit feels different from normal (change in occlusion).
There may also be altered sensation of the lower lip and chin due to injury to the inferior
alveolar nerve.
Signs – the teeth do not interdigitate well into the occlusion.

Fractures of the body

Fracture of the body of the mandible may be midline (symphyseal), lateral to the midline
(parasymphyseal), or midbody (molar and premolar area).
Symphyseal fractures usually present with little displacement. They are difficult to demonstrate
an X-ray.
Parasymphyseal fractures usually present with considerable displacement and can be very
mobile. Clinical features - there is pain and discomfort as well as swelling and ecchymosis.
There may be loose teeth present on either side of the fracture. Treatment – with undisplaced
surgery is not usually required. Treatment is with antibiotics, a soft diet and regular review. The
treatment for displaced fracture is open reduction and fixation. Whilst the patient is awaiting
definitive surgery, stabilization of the fracture with a simple wire passed interdentally and on
either side of the fracture can improve patient comfort. Post-operative care includes antibiotics,
a soft diet, strict oral hygiene and avoidance of contact sports for at least 6 weeks.
Midbody fractures are usually unilateral and present with very little displacement since the
muscles on either side of the fracture site have a counteracting action on each other.
Fractures of the maxilla

Maxillary fractures are usually caused by direct trauma to the middle third of the facial skeleton
and are much less common than fractures of the mandible. They are classified according to the
system devised by Rene Le Fort in 1900 from cadaver experiments, as Le Fort I, II, and II,
depending on the involvement of the maxillary, nasal, and zygomatic bones. Clinical features –
the signs and symptoms of Le Fort I and II fractures appear very similar and can only be
differentiated with careful examination by palpation and X-ray of the zygomatic bone which is
not fractured in a Le Fort II fracture. They include bilateral circumorbital and subconjuctival
ecchymosis (‘racoon eyes’), facial oedema, mobility of the third of the face, paraesthesia in the
distribution of the infra-orbital nerve, CSF rhinorrhoea indicating fracture of the cribiform plate,
diplopia and enopthalmos. In all Le Fort fractures lengthening of the face also occurs because
the middle third of the facial skeleton is displaced downward and backward causing an anterior
open bite occlusion due to retropositioning of the anterior incisors behind the lower incisor teeth.
Treatment – maxillary fractures can cause life threatening embarrassment to the airways. Initial
treatment therefore should be to ensure maintenance of the airways. Unconscious patients
should be placed in the coma position whist conscious patients nursed in the forward sitting
position as is the case with mandibular fractures. In some cases endotracheal intubation may
be necessary. The patient should then be urgently transferred to a hospital for definitive surgical
treatment which may involve closed reduction or open reduction and fixation with screws, wires,
or plates.

Zygomatico-maxillary complex fractures

Fractures of the zygomatico-maxillary complex are the second most common fracture of the
facial skeleton due to sporting accidents, occurring from direct trauma to the cheek in sports
such as hockey, baseball, and boxing. Clinical features – peri-orbital swelling and bruising of
the, flatness of the cheek, limited mandibular opening and tenderness to palpation at the
maxillary butress. If there is a concomitant orbital fracture then there may be paraesthesia in the
distribution of the infra-orbital nerve, diplopia, enopthalmos, and limitation of ocular movement.
Investigations – coronal CT scan, X-ray (occipitomental and submentovertex). Treatment – the
first priority is to assess the globe and protect it from any further injury as ocular injuries occur in
5% of fractures of the zygoma. The patient should be transported to a hospital for definitive
treatment which in most cases will involve open reduction and internal fixation. For minimally
displaced fractures, a simple elevation of the zygoma via a Gilles’ temporal approach may be all
that is required.

Nasal fractures

Fractures of the nasal bone and cartilage are usually caused by a direct blow and can be either
high or more commonly low velocity type fractures. Clinical features – pain, epistaxis, nasal
swelling, crepitus over the nasal bridge, nasal deviation and deformity, and nasal airway
obstruction. Investigations – radiographs of the nasal bone views may be of aid. Treatment –
secure the airways and control bleeding with external pressure and intranasal packing.
Undisplaced fractures do not require any further treatment whilst displaced fractures should be
reduced if there is obstruction of the nasal passages or for cosmetic reasons.

Temperomandibular joint injuries

Blows to the TMJ area can produce a variety of injuries including haemarthrosis, capsulitis,
meniscal displacement and intracapsular fracture of the head of the condyle. TMJ dislocation
result if the mandible is hit whilst the mouth is open. Some injuries may be occult with
complications arising months after the traumatic event. Clinical features – limitation of mouth
opening with pain or deviation, malocclusion, clicking, pain and difficulty closing the mouth.
Treatment – rest with limitation of mouth opening for 1 week, a soft diet, and NSAIDs or surgery
(arthroplasty). A dislocation can be reduced by grasping each side of the jaw with thumbs inside
the mouth as far back as possible (away from teeth) and pushing down and posteriorly. After
surgery contact sports the patient should be advised to avoid contact sports for at least 2
months and use a mouth guard participation in such sports is resumed.

Dental injuries

Teeth may be impacted, displaced, avulsed or broken through collisions with other participants
during contact sports or from direct trauma with equipment such as bats, sticks, and balls. In all
cases of facial trauma a thorough examination of the oral cavity should be performed and if a
tooth or tooth fragment can not be located then X-rays of the chest and abdomen should be
performed.