Facio-max Problems Of The Athlete

Fractures of the Mandible Mandibular fractures are the most common maxillo-facial injury from sporting accidents. Common fracture patterns are condyle, body, angle, symphysis, ramus (rare) and coronoid process (rare) (Fig. 1). Condylar Fractures Condylar fractures are the most common site of mandibular fracture. Most fractures are “sub-condylar” (fracturing through the weak area at the neck of the condyle). This fortunate anatomical design prevents the head of the condyle from being forced through the thin plate of bone lining the glenoid fossa into the middle cranial fossa. The diagnosis is often missed. The Orthopantomogram (OPG) and PA Mandible x-rays should always be carefully studied by outlining the contour of the condyles bilaterally (Fig. 2). There is pain and tenderness from the temporo-mandibular joint, pre-auricular swelling, limitation in oral opening, alteration in occlusion with gagging of occlusion on the posterior molars, and deviation in mandibular movements on opening towards the side of fracture. These fractures may be undisplaced displaced (antero-medial from pull of the lateral period muscle, condyle remains within glenoid fossa) or dislocated (Fig. 3).  

The management of children with condyle fractures is non-surgical (remodeling occurs with complete regeneration of normal condylar anatomy post-injury). Jaw exercises to attain normal occlusion is sufficient. If the occlusion is not consistently attainable then a short period of intermaxillary fixation (2 weeks) followed by a period of guiding elastics may be required.  

1 In children intracapsular pattern of fracture is common. Accurate diagnosis with early jaw function is essential to prevent ankylosis and future growth asymmetry problems. The treatment of adults with sub-condylar fractures remain controversial to (open versus closed reduction). I believe that open reduction is indicated for Gross fracture dislocations and when the occlusion is not able to be attained by closed reduction. In most cases, the occlusion is minimally altered and the patient is able to attain their correct occlusion with minimal effort. Simple jaw exercises to achieve a repeatable occlusion may be all that is required. If the correct occlusion is not readily achieved by the patient then a closed reduction is indicated. Arch bars are placed and the patient is placed into intermaxillary fixation (for two weeks). Intermaxillary fixation is then released and guiding elastics used for the next two to four weeks (Fig.4).  

In body and angle fractures, there may also be altered sensation of the lower lip. A mandibular fracture is diagnosed by (a change in occlusion) asking the patient if their bite feels different and to check the occlusion by manually directing the chin point upwards (note if the teeth interdigitate well into occlusion). A change in occlusion means a displaced mandibular fracture. Displaced or undisplaced. A displaced fractured mandible (except for condylar fractures) is always open and requires early antibiotic therapy with adequate stabilisation of the fracture.  

Altered sensation to the lower lip (injury to the inferior alveolar nerve) is often present with fractures at the angle and body of the mandible. X-rays required are the OPG and PA mandible x-rays.  

Angle fractures often occur through or adjacent to an impacted third molar tooth(“wisdom tooth”) (a line of weakness) and may be associated with a concomitant body fracture or sub-condylar fracture on the contralateral side. A bilateral angle fracture is less common and presents as an anterior open-bite occlusion (where the teeth do not meet anteriorly) (Fig. 5). Fractures of the body of the mandible are commonly located by the canine tooth (“parasymphyeseal” fractures). Displaced parasymphyseal fractures can be extremely mobile and painful (Fig. 6). There may be loose teeth present on either side of the fracture. Stabilisation of the fracture with a simple wire passed inter-dentally and on either side of the fracture can improve patient comfort prior to definitive surgery. A displaced fracture resulting in altered occlusion requires open reduction and fixation (rigid fixation using titanium mini-plates to avoid inter-maxillary fixation for the traditional six week period) (Fig 7). Post-operative care include antibiotics (penicillin), soft diet, and strict oral hygiene. Contact sports are banned for a minimum of six weeks. An undisplaced fracture may not require any surgical treatment but antibiotics, soft diet with regular review.  

Fractures of the Maxilla Much less common than mandibular fractures (classified according to the “Le Fort” patterns of fracture (Rene Le Fort (Paris, 1900) from cadaver experiments). In all Le Fort fractures the middle third of the facial skeleton is displaced downwards and backwards resulting in an elongated lower third of the face with the mandible “gagging” open with an anterior open bit occlusion and a retropositioning of the upper incisor teeth behind the lower incisors (Fig 8). Signs and symptoms of Le Fort 11 and III fractures are bilateral circumorbital and subconjunctival ecchymosis (“raccoon eyes”) and facial oedema (“balloon face”);

downward and backward displacement of the middle third of the face (“dished face”), mobility of the middle third of the face; paraesthesia (infra-orbital nerve distribution); CSF rhinorrhoea (ethmoid dural tear) and diplopia and enothalmos (when orbital floor comminuted). Fractures of the middle third of the face cause serious airway problems which can be life threatening.

The middle third of the face cause serious airway problems which can be

life threatening. The middle third of the face is displayed downward and backward, the soft palate impacts against the posterior pharynx and the base of the tongue along with massive bleeding from the fracture site. Treat by disimpacting the maxilla (manually pull the maxilla forwards and upwards). This clears the posterior airway obstruction and reduces the fracture so resulting in decreased bleeding. The conscious patient should be nursed in a sitting position with regular oral suction at hand. Sometimes endotracheal intubation is necessary. Surgical treatment depends upon the severity and involves a combination of open and closed reduction techniques.  

Fractures of the Zygoma Common facial injuries in sporting accidents because of the zygoma’s prominent position. The zygoma is a four sided anatomical pyramid (not a tripod structure) (Fig 9).  

The first priority in examining a zygomatic complex fracture is to asses the globe and exclude ocular damage. (Ocular injuries occur in 5%). Signs and symptoms of these fractures include: periorbital ecchymosis and oedema, flattening of the zygomatic prominence, indentation, deformity (palpable step defect) of the infra-orbital margin, ecchymosis and tenderness to palpation at the maxillary buttress, subconjunctival ecchymosis, diplopia, limited oral opening, and mandibular lateral extrusion towards the side of fracture, paraesthesia of infraorbital nerve distribution, epistaxis, air emphysema and enopthalmos (rare) (Fig. 10). X-rays to be taken include: occipitomental views, submentovertex and CT scan (coronal) (Fig. 11). For minimally displaced cases, a simple elevation of the zygoma (via a Gillies’ temporal approach) is all that is required. More often an open reduction with internal fixation is required (rigid fixation rather than traditional wire fixation). The frontozygomatic suture represents the thickest bony buttress of the zygoma and fixation by a plate in this region has been shown to be effective. Tow point fixation is often necessary in severely displaced fractures and with plates placed at a combination of either the frontozygomatic suture, infra-orbital rim or maxillary buttress. The orbital floor may need to be explored and fixed if diplopia is present.

A fracture of the zygomatic arch alone without involvement of the body of the zygoma may require elevation (Fig. 12). Orbital Blow-Out Fracture A fracture of the orbital floor, without a fracture of the orbital rim, caused by a blow to the orbit resulting in a sudden rise in intraocular pressure (thin orbital floor). This mechanism acts like a safety valve and spares the globe. Often described as a “trap-door” fracture because the fracture gives way in the infra-orbital canal appearing like a trap-door. Paraesthesia of the infra-orbital nerve is common. The orbital contents may herniated through the fracture into the maxillary sinus or become entrapped in the fracture site (gives diplopia or enopthalmos). Signs and symptoms include paraesthesia of infra-orbital nerve, diplopia, and enopthlamos. X-rays include the occipitomental views and a coronal CT scan (Fig 13). Treatment is controversial. Surgery necessary for enopthalmos, diplopia (persisting after 10 to 14 days) and in the presence of large blow-out defect (greater than 1.5 cm) with orbital content herniation. Small blow out fractures without diplopia need no surgery. Antibiotics (cephalosporin) needed and avoid nose-blowing to prevent periorbital emphysema).  

Nasal Fractures Can be either low or high velocity type fractures. Most from sport are low velocity and can be treated by closed reduction. Signs and symptoms include nasal swelling, epistaxis, nasal deviation and deformity, mobility and crepitus, septal deviation, and obstruction to breathing. Radiographs include nasal bone views. Often the nose has previously been broken. Treated by closed reduction with internal packing. Temporomandibular Joint Injury (TMJ) A blow to the TMJ area may cause haemarthrosis, capsulitis, discal damage or subluxation/dislocation. Check for limited mouth opening with pain or deviation, mal occlusion, clicking or difficulty closing the mouth. Treatment includes initial ace bandages, soft diet, moist heat, NSAIDs (7-10 days) or surgery (arthroplasty). A dislocation is reduced by grasping each side of the jaw with thumb (inside mouth away from teeth) and pushing down and posteriorly. Post surgery avoid contact sports for 2 to 3 months and use mouth guard. Dental Injury Teeth may be impacted, displaced, avulsed or broken (Fig. 14). Exclude associated facial injuries and organise careful dental assessment including x-rays (CXR to find inhaled tooth).

    Treatment ∙              Replace avulsed tooth (Into  clean socket)   ∙              Light bite   ∙              Antibiotic cover   ∙              Suture lacerations   ∙              Exclude alveolar fractures   ∙              Light diet (2 to 3 weeks)   ∙              Use mouthguard      

Figure 7   Types of Intracranial Haematomas  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1 Contusion

2 Intracerebral  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3 Extradural

4 Subdural  

    Sub­condylar Fractures   Undisplaced Fracture     Displaced Fracture       Fracture Dislocation       Le Fort Pattern of Maxillary Fractures  

 

 

Type 1

 

 

  Le Fort I Fracture

 

 

 

  This is a horizontal fracture affecting   

only the tooth bearing portion of the 

 

maxilla. Produces a mobile maxilla 

 

(displaced downwards and  backwards).  Treatment is an open 

 

reduction and internal fixation of (mini­    

plates at the pyriform and zygomatic  buttresses).          

 

 

Type 2

 

 

 

 

Le Fort II Fracture

 

 

 

The “pyramidal” fracture (involves the    nasal bones, the floor of the orbit, the    maxillary sinus, the pterygoid plates).            

 

     

 

 

Type 3

 

 

 

 

Le Fort III Fracture

 

 

 

From a severe blow to the face with 

 

separation of the facial skeleton from    the base of the skull (“cranio­facial    dysfunction”).

 

 

 

 

 

            Common Fracture Pattern in Zygomatic Complex