The Eye Face The Eye Face And Sport

Chapte r6 - Injuries ­   The eye  and face    

 

The eye •

Introduction

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Assessing an eye injury

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Necessary equipment

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History

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Eye examination

Types of injuries

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Orbital haemorrhage

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Lid lacerations

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Conjuctival foreign body

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Corneal foreign body

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Corneal abrasions

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Conjuctival lacerations

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Subconjuctival haemorrhage

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Chemical burns

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Hyphaema

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Macular injuries

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Choroidal injuries

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Injuries to the lens

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Lens dislocation

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Retinal injuries 

Retinal detachment

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Retinal haemorrhage and oedema

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Optic nerve injuries

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Orbital injuries

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Blowout fracture

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Medial wall orbital fracture

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Penetrating injuries

Prevention of eye injuries ○

Spectacles and goggles

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Contact lenses

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Refractive surgery

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Face protection

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Athletes with high risk of eye injuries

The face •

Introduction

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Fractures of the mandible ○

Condylar fractures

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Fractures of the angle

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Fractures of the body

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Fractures of the maxilla

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Zygomatico-maxillary complex fractures

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Nasal fractures

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Temperomandibular joint injuries

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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

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

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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:

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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.

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Inspect the eyelids for lacerations, haemotoma and bruising.

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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

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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.

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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.

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

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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).

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Examine visual fields carefully and note any defects.

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

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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.

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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:

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On diagnosis antibiotics should be started to prevent orbital cellulitis.

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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)

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history of retinal detachments or tears

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diabetic retinopathy

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Marfan's syndrome

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homocystinuria

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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.