Face and Eye Injuries in Sports. Katherine M Fox MD January 10, 2012

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1 Face and Eye Injuries in Sports Katherine M Fox MD January 10, 2012

2 Topics to be Covered Dental Injuries Eye Injuries Facial Injuries Guidelines for Protective Equipment

3 What sports put participants at risk for orofacial injuries?

4 All Sports! Every sport has some risk of orofacial injury due to falls, collisions, and contact with hard surfaces or sports related equipment.

5 Statistics Approximately 60-90% of all facial injuries occur in males between the ages of 10 and 29 Sports participation results in 10-39% of all dental injuries in children. Over 42,000 sport and recreation related eye injuries occurred in 2000.

6 Dental Injuries Maxillary dental incisors are most commonly injured teeth

7 Highest Risk Sports Include: Ice hockey Field Hockey Lacrosse Football National Federation of State High School Associations mandates mouthguard use in these sports

8 What about primary baby teeth? Main goal of treatment is to prevent an injury to permanent teeth DO NOT attempt to replace the tooth Replacing the primary tooth could damage the permanent tooth Treat subluxed primary teeth with a soft diet for a few days These children should also see a dentist ASAP

9 Damage to Permanent Teeth Displaced permanent teeth are a dental emergency Only successful treatment is reimplantation within 30 minutes Onsite medical staff should attempt to replace the tooth

10 Handling a Dislocated Permanent Tooth Handle tooth by crown, never by the root. Rinse with tap water Hold tooth in position with fingers or biting on gauze If immediate implanation is not possible place tooth in save a tooth, milk, or hold under tognue. If a tooth is only subluxed it SHOULD NOT be returned to prior position

11 To Keep Your Teeth... Required Mouthguards: Hockey, Lacrosse, Football Consider use in these sports: baseball, basketball, soccer, softball, wrestling, volleyball Face protectors may be especially helpful in baseball and softball

12 Take Home Points Regarding Teeth Never replace a baby tooth Always try to replace permanent tooth If impossible to replace permanent tooth, place in milk or save a tooth Mouthguards: required in football, hockey, lacrosse

13 Soft Tissue, Bony, and Others FACIAL INJURIES

14 Epistaxis Where do most nose bleeds originate from? What is the initial management?

15 Epistaxis Little s or Kiesselbach s area Direct digital pressure Cold compress across nasal bridge for vasoconstriction Cotton soaked in epinephrine or silver nitrate may be used If bleeding persists over 20 minutes, referral is usually indicated

16 Facial Trauma Fractures of mandible, maxilla, zygomatic process and nasal bones have been reported secondary to sports participation Nasal fractures are most common, especially in baseball and softball Needs to be considered when any athlete suffers a blow to the face

17 Nasal Fracture Direct blow to nose Epistaxis, asymmetry and/or swelling Xray usually not indicated Xray may be negative if fracture occurs at bony/cartilage surface Bleeding should be controlled with packing Monitor for development of septal hematoma Return to play is usually in 4 weeks with a face mask es/mask_photos_ html&usg= 6phQZLca31hoevLa_vtBx4G1Qjw=&h=240&w=320&sz=32&hl=en&start=2&zoom=1&um=1 &itbs=1&tbnid=ir1mexnywy7ocm:&tbnh=89&tbnw=118&prev=/images%3fq%3dbroken%2bnose%2bface%2bmask%26um%3d 1%26hl%3Den%26sa%3DG%26rls%3Dcom.microsoft:*%26ndsp%3D21%26tbs%3Disch:1&ei=M-9vTc68J86cOui0zb8G

18 Septal Hematoma Serious complication of epistaxis or nasal fracture Hemorrhage between layers of mucosa covering the septum Nasal exam reveals a cherry-like structure that occludes the nasal passages Needs drainage and abx prophylaxis

19 Displaced Nasal Fracture Reduction should be a few days after injury when swelling is reduced Complex fractures may need surgery and guidance from ENT to determine return to play.

20 Soft Tissue Injuries to Face/Scalp Common in football, ice hockey, martial arts and racquet sports Palpate for bony tenderness Neurologic exam indicated if LOC or suspected skull fracture

21 Soft Tissue Injuries to Face/Scalp Ice/pressure for swelling, bleeding Immediate removal from play Irrigate, irrigate, irrigate Lacerations >0.25 to 0.5cm should be closed if they appear clean Steristrips +/- benzoin may be used for small wounds

22 What is the primary reason to suture on the sideline?

23 Answer: Return to Play If you are not comfortable with the laceration or parents/player are concerned about cosmetic result it should not be sutured at the sideline Eyebrows and lips need anatomic alignment

24 What is the management of a human bite wound?

25 Human Bite Leave it open! Copious irrigation and keep it clean Oral Metronidazole Penicillin Close f/u

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27 Auricular Hematoma Acute injury is an auricular hematoma Recurrent contusions results in hemorrhage between the perichondrium and the cartilage Eventually this leads to chronic swelling, called cauliflower ear An acute hematoma can be treated with ice, compression, possibly drained, with a firm pressure dressing

28 Sports related Eye Injuries Adequate eye protection can reduce the risk by 90%

29 Highest Risk Sports Fast projectiles (rifles, paintball) Sports with sticks (baseball, softball, hockey, basketball, fencing, lacrosse, squash, racquetball, boxing, and martial arts). Moderate risk sports include fishing, volleyball, football and soccer.

30 MILD EYE INJURIES

31 Corneal Abraison Cutting, scratching, or abrading the ocular epithelium Children experience acute pain, eye redness, photophobia, tearing, and a gritty sensation Diagnose with fluorescein staining Infection is very infrequent except in contact lens wearers Topical anesthetics should never be prescribed for home use

32 Corneal Abrasion

33 Corneal Foreign Body Presents similar to abrasion Irrigate, Irrigate, Irrigate CT should be performed if there is concern for intraocular penetration. Topical antibiotics can be used to prevent infection.

34 Subconjunctival Hemorrhage Benign Check visual acuity Any change in visual acuity is reason to refer to ophthalmology Usually resolves spontaneously Location needs to be determined before athlete can return to play

35 Sport Related Eye Emergencies Hyphema Globe Rupture Orbital Fracture

36 Hyphema Results from direct blow to the globe not reflected by the bony rim of the eye Blood accumulates in the anterior chamber Treatment is directed at evacuating blood from the anterior chamber and restoring visual acuity

37 Identify the Injury

38 Globe Rupture Full thickness of cornea or sclera is breached via laceration or increased pressure Displaced or distorted pupil, loss of red reflex, or loss of visual acuity Emergent eye exam under anesthesia is needed to assess the extent of injury A rigid eye shield should be placed over the eye while awaiting evaluation Penetrating objects should not be removed

39 Orbital Fracture Most often occurs with blunt trauma Change in visual acuity, pain, diplopia especially with upward gaze Retinal detachment is possible and requires urgent surgery

40 AAP and AAO Recommendations 1.All youth involved in organized sports should be encouraged to wear appropriate eye protection. 2. The recommended sports protective eyewear as listed in Table 2 should be prescribed. Proper fit is essential. Because some children have narrow facial features, they may be unable to wear even the smallest sports goggles. These children may be fitted with 3-mm polycarbonate lenses in American National Standards Institute Z87.1 frames designed for children.12 The parents should be informed that this protection is not optimal, and the choice of eye-safe sports should be discussed. 3. Because contact lenses offer no protection, it is strongly recommended that athletes who wear contact lenses also wear the appropriate eye protection listed in Table An athlete who requires prescription spectacles has 3 options for eye protection: (a) polycarbonate lenses in a sports frame that passes ASTM F803 for the specific sport, (b) contact lenses plus an appropriate protector listed in Table 2, or (c) an over-the-glasses eye guard that conforms to the specifications of ASTM F803 for sports in which an ASTM F803 protector is sufficient. 5. All functionally one-eyed athletes should wear appropriate eye protection, for all sports.

41 AAP and AAO Recommendations 6. Functionally one-eyed athletes and those who have had an eye injury or surgery must not participate in boxing or full-contact martial arts. (Eye protection is not practical in boxing or wrestling and is not allowed in full-contact martial arts.) Wrestling has a low incidence of eye injury. Although no standards exist, eye protectors that are firmly fixed to the head have been custom made. The wrestler who has a custom eye protector made must be aware that the protector design may be insufficient to prevent injury. 7. For sports in which a facemask or helmet with an eye protector or shield must be worn, it is strongly recommended that functionally one-eyed athletes also wear sports goggles that conform to the requirements of ASTM F803 (for any selected sport). This is to maintain some level of protection if the face guard is elevated or removed, such as for hockey or football players on the bench. The helmet must fit properly and have a chinstrap for optimal protection. 8. Athletes should replace sports eye protectors that are damaged or yellowed with age, because they may have become weakened and are, therefore, no longer protective.

42 Take home points What type of eye injury needs evaluation by opthalmologist? Answer: any injury where vision is affected. What is initial sideline management of laceration? Answer: Irrigation How long should face protection be worn after a simple nasal fracture? Answer: 4 weeks

43 Summary Injuries to face, teeth, and eyes are common in sports. If you are concerned for significant trauma refer to ED for appropriate evaluation and management. Anyone who suffers eye trauma and subsequent visual change should be see by an ophthalmologist in an emergency department setting. Protective equipment in sports significantly reduces the frequency and severity of these injuries.

44 References AAP and American Academy of Ophthalmology Policy Statement on Protective Eyewear for Young Athletes. Pediatrics. (113) #4; March, American Academy of Pediatric Dentistry Policy on Prevention of Orofacial Related Injuries. Oral Health Policies. (32) #6; Escher S, Case M, Kent L. Netter s Sports Medicine: Maxillofacial Injuries. Olson, D, Sikka R, Pulling T, Broton M. Netter s Sports Medicine:Eye Injuries in Sports. Perkins S, Dayan S, Sklarew E, Hamilton M, Bussell G. The Incidence of Sports- Related Facial Trauma in Children. Ear, Nose, and Throat Journal. August 2000: