Maxillofacial Injuries in Sports 401

Maxillofacial Injuries in Sports 24

Anja Bernaerts, Philippe Ehlinger, and Karen Chapelle

CONTENTS dentoalveolar fractures and minor facial bone frac- tures (Hill et al. 1998; Tuli et al. 2002). The most 24.1 Introduction 401 frequently recorded maxillofacial bone fractures involve the mandible, the zygomatic and nasal bone 24.2 Correlation Between Injury Type and (Maladiere et al. 2001). Injury Mechanism Among Sports 402 24.2.1 Dentoalveolar Fractures 403 According to different reports, sports-related facial 24.2.2 Facial Bone Fractures 403 fractures account for 4%–18% of all sports injuries and 6%–33% of all facial bone fractures (Bayliss 24.3 Imaging Strategy 404 and Bedi 1996; Carroll et al. 1995; Mourouzis and 24.3.1 Plain Radiography 404 Koumoura 2005). This variation in occurrence may 24.3.2 Computed Tomography 406 24.3.3 Magnetic Resonance Imaging 407 refl ect the geographic differences in the level of par- ticipation in sports activities and the type of popular 24.4 Specifi c Sports-Related Maxillofacial sports. Which sport is responsible for the majority of Injuries 408 injuries varies above all according to the popularity 24.4.1 Soft-Tissue Injuries 404 24.4.2 Dentoalveolar Injuries 408 that each sporting activity has in a particular coun- 24.4.3 Mandibular Fractures 408 try (Cerulli et al. 2002; Flanders and Bhat 1995; 24.4.4 Central Midface Fractures 409 Lim et al. 1993; Tanaka et al. 1996). The majority 24.4.5 Lateral Midface Fractures 410 of facial fractures in Western countries today occur 24.4.6 Frontal Sinus Fractures 412 during team sports, such as soccer, basketball and Cerulli Maladiere 24.5 Conclusions 412 rugby ( et al. 2002; et al. 2001; Mourouzis and Koumoura 2005). Fractures of Things to Remember 412 the maxillofacial region are more frequent in males and between the ages of 20 and 30 years, most likely References 413 refl ecting the high levels of physical activity in this sex and age group (Mourouzis and Koumoura 2005). Sports are also a primary cause of maxillofa- 24.1 cial fractures in the paediatric population, probably Introduction because of the learning stages of sports ability and the ignorance of the consequences of taking greater Trauma due to sports can have a signifi cant impact risks (Gassner et al. 2004). A recent study has shown on unprotected sites of the body such as the maxil- that 26% of paediatric facial fractures were caused by lofacial region. The commonest sports related maxil- bicycle accidents (Iida and Matsuya 2002). lofacial injuries are soft tissue lacerations followed by Various sports committees have adopted specifi c guidelines for the prevention of dental and cranio- maxillofacial injuries. Sports such as hockey and A. Bernaerts, MD Department of Radiology, Sint-Augustinus Hospital, Ooster- American football have adopted full facial and cra- veldlaan 24, 2610 Wilrijk, Belgium nial protective headgear. Evolution of these protec- P. Ehlinger, MD tive devices has signifi cantly reduced many types of Department of Oral and Maxillofacial Surgery, Sint-Augustinus head and neck injuries in these sports (Greenberg Hospital, Oosterveldlaan 24, 2610 Wilrijk, Belgium Haug K. Chapelle, MD and 2005). Nevertheless, there are an increas- Department of Oral and Maxillofacial Surgery, Sint-Maarten ing number of people who are engaged in sporting Hospital, Rooienberg 25, 2570 Duffel, Belgium activities and new, high-velocity vehicular and high 402 A. Bernaerts, P. Ehlinger, and K. Chapelle

Box 24.1. Panoramic radiograph Box 24.3. Computed tomography (CT) with 2D and 3D reformations ● Easy interpretation ● High accuracy ● Isolated trauma of the mandibula ● ● Dentoalveolar injuries Midface trauma ● Mandibular fractures ● Complex fractures

● Screening in all patients with maxillofacial ● Multiplicity of fragments fracture ● Degree of dislocation and rotation

● Skull base involvement

Box 24.2. Conventional radiographs ● Cribriform plate, lacrimal duct, optic canal, (Waters view; Caldwell view; lateral view and superior orbital fi ssure or infraorbital canal submentovertex view) involvement ● ● Diffi cult interpretation Further characterization and classifi cation of solitary fractures ● Solitary, low-impact, fractures ● Posttraumatic osteomyelitis ● Nasal trauma

altitude activities are introduced. Moreover, amateur the maxillary incisors, is more likely to cause a tooth athletes often do not use any protective clothing or fracture, whereas a low velocity trauma is expected equipment in sports in which the use of protective to cause a displacement injury (e.g., an avulsion). gear is recommended. Children with a type 2 malocclusion (so-called ret- rognathism or overbite) in particular will be prone to sports-related dentoalveolar injuries of the upper incisors. Another mechanism, indirect trauma, occurs when 24.2 the mandible whiplashes into collision with the max- Correlation Between Injury Type and illa. This trauma can occur from a blow to the chin, Injury Mechanism Among Sports such as an uppercut in boxing, a football tackle, or a hockey stick. The concussion is capable of shattering There have been few studies that have been directed posterior teeth. toward the biomechanics of maxillofacial injuries asso- Enamel infraction can be caused by acute or ciated with sports. Perhaps the diffi culty of engaging in chronic trauma such as grinding or clenching (e.g., such a study is the large variety of sports activities that weightlifting) (Kurtz et al. 2005). are available today, ranging from those with minimal interpersonal contact to those with high-energy con- tact. In addition, comparative analysis of these studies 24.2.2 is hampered by varied selection criteria and the use of Facial Bone Fractures retrospective non-consecutive data. Sporting activities can be grouped into differ- ent categories in order to understand better the 24.2.1 injury mechanism in sports related facial bone Dentoalveolar Fractures fractures: •Team sports: soccer, rugby, basketball, football, In dentoalveolar fractures, a high-velocity trauma, handball such as a baseball that takes a bad hop and strikes •Vehicular sports: bicycling, mountainbiking, Maxillofacial Injuries in Sports 403

ries reported in contact sports such as boxing (Hill Box 24.4. Magnetic resonance (MR) imaging et al. 1998). In vehicular, non-car, sports, a fall to the ground is ● Cranial nerve palsy the most commonly reported type of impact. Frac- tures of the mandible and zygoma are most prominent ● Nerve compression due to haematoma in vehicular sports as well, but, unlike team sports, ● Nerve transsection the frontal sinus and central midface are commonly affected too (Gassner et al. 1999a; Maladiere et al. ● Axonal injury 2001). Generally, mountainbikers sustain more severe maxillofacial injuries in comparison with bicyclists. ● Traumatic damage to the temporomandibular The dominant fracture site in bicyclists is the zygoma, joint disc whereas mountainbikers encounter more serious ● Brain concussion midface fractures such as Le Fort I, II, and III frac- tures (Gassner et al. 1999b). In horse-riding, being ● Posttraumatic meningocele kicked by the horse is correlated with more severe injuries (Fig. 24.1) (Ueeck et al. 2004). ● Posttraumatic meningitis

● Infl ammatory collections

● Abscess formation

● Posttraumatic ischemic necrosis of the condy- lar head of the mandible

horse-riding, skiing, snowboarding, ice-hockey, in-line skating •Sports with small balls: tennis, baseball, cricket, golf a c •Combat sports: boxing, karate, Kung-fu, wres- tling •Individual sports: swimming, diving, gymnastics, body-building etc.

In team sports the main type of impact in facial bone fractures appears to be a collision with another player that takes place mainly when the ball is played with the forehead. At this instant there can be an elbow-head impact or a head-head impact. An analy- sis of the anatomic distribution of facial fractures sus- tained during team sports showed that the mandible, b followed by the zygomatic region, is most commonly affected (Maladiere et al. 2001; Mourouzis and Fig. 24.1a–c. Horsewoman with a complex maxillofacial injury Koumoura 2005). Football players do not encounter after being kicked in the face. A clinical photograph immedi- ately following injury shows severe soft-tissue lacerations (a). orofacial injuries as often as other athletes because A postoperative panoramic radiograph (b) and Waters view (c) faceguards and mouth protectors are now mandatory after reduction and internal fi xation demonstrate the involve- (Flanders and Bhat 1995; Sane 1988). This might ment of the mandible, maxilla, nose and zygoma. [Reprinted also explain the relative low incidence of facial inju- with permission from Raghoebar et al. (2005)] 404 A. Bernaerts, P. Ehlinger, and K. Chapelle

A missile type of injury to the head caused by the 24.3.1 ball or other implement is most mentioned in sports Plain Radiography with small balls such as baseball (Bak and Doerr 2004; Delilbasi et al. 2004; Maladiere et al. 2001). Con- The panoramic radiograph is still a highly cost-effec- tact with the racquet, the bat or club also is a common tive and accurate method for the determination of the cause of injury in this category (Lim et al. 1993). presence of mandibular and dentoalveolar fractures Sport diving carries inherent risk to the maxillo- (Fig. 24.2). In addition, it is used as an initial survey facial region in its own way. Atypical facial pain and fi lm in all maxillofacial fractures to spot associated temporomandibular joint dysfunction may result lesions such as dentoalveolar fractures or infl amma- from repeated use of the mouthpiece of the regulator. tory lesions of the jaws which could complicate the The mechanical effects from changes in ambient pres- postoperative course (Box 24.1). In case of dental sure may cause paranasal sinus barotraumas, cranial trauma, supplementary intraoral periapical fi lms nerve injury, and barodontalgia (Brandt 2004). always are required to obtain adequate image detail (Fig. 24.3) (White and Pharoah 2000). When trauma of the viscerocranium occurs as an isolated injury due to a blow or fall, like in sports injuries, it can be investigated by conventional radio- 24.3 graphs fi rst. A basic facial series consists of three Imaging Strategy or four fi lms: a Waters view (PA view with cephalad angulation), a Caldwell view (PA view), a lateral view, The diagnosis of facial fractures is usually accom- and occasionally a submentovertex view (Fig. 24.4b– plished by a combination of clinical and imaging e). A Waters view allows recognition of interruption examinations. Often, deformity of the facial skeleton of the zygomaticoalveolar arch and of the orbital is initially concealed by overlying edema, haemor- fl oor and lateral wall, while a Caldwell view permits rhage, and soft tissue injury. Therefore, the clinician delineation of the lamina papyracea, zygomatico- is primarily concerned with the detection of maloc- frontal suture, fl oor of the nasal cavity and maxil- clusion, abnormal mobility, and crepitation as signs lary sinus. Delineation of zygomatic arch fractures of fractures. Any evidence of a palpable step-off at the is best performed by a submento-vertex view. Nasal orbital rim, diplopia, hypertelorism, midfacial elon- and anterior nasal spine fractures and posterior dis- gation, cerebrospinal fl uid rhinorrhea, or fl attening placement of the midface are recognized on a lateral of the cheek further helps the clinician identify the fi lm. A focussed lateral, Waters and superior-inferior type of fracture present. However, only after imaging view may be requested for documentation of a nasal studies can the fracture be completely identifi ed and fracture (Fig. 24.5a) (Box 24.2) (Schuknecht and characterized (Greenberg and Haug 2005). Graetz 2005; Som and Brandwein 2003).

Fig. 24.2. Panoramic radiograph demonstrating an oblique fracture of the left mandibular body and an extracapsular fracture of the right condylar process (arrowheads) Maxillofacial Injuries in Sports 405

Fig. 24.3. Periapical radiograph shows a transverse root fracture of the left primary central maxillary incisor with some distraction of the fragments (arrowheads)

a b c

d e

Fig. 24.4a–e. Three-dimensional (3D) surface shaded CT reconstruction (a) of a trimalar (zygomatic) fracture in a young male soccer player after being struck in the face by an opponent’s knee. Radiographic evaluation after osteosynthesis includes a Waters view (b), a Caldwell view (c), a lateral (d) and submento-vertex view (e). The latter view best delineates the zygomatic arch (arrowheads) 406 A. Bernaerts, P. Ehlinger, and K. Chapelle

a

b c

Fig. 24.5a–c. A 25-year-old male soccer player who sustained a complex nasal fracture after being kicked in the face by an opponent’s foot. Radiographic evaluation of the nasal bone including a frontal, superior-inferior and lateral view (a) confi rms a fracture of the nasal bone (white arrows). A deviation of the cartilaginous portion of the nasal septum is noted (black arrow). Axial CT scans viewed at “bone” (b) and “soft-tissue” (c) window settings show comminuted fractures of both nasal bones and right frontal process of the maxilla (white arrows). Also note the presence of a septal haematoma (black arrow) and an associ- ated displaced fracture at the right zygomaticosphenoid suture

24.3.2 tial, cribriform plate, lacrimal duct, optic canal (optic Computed Tomography nerve), superior orbital fi ssure (cranial nerve III–VI) or infraorbital canal (infraorbital nerve) involvement. The traditional strong role of conventional images in Maxillofacial trauma with suspicion of osseous involve- patients with facial bone fractures, however, is cur- ment requires thin collimation of slices (0.75–1 mm) to rently decreasing. Spiral multislice computed tomog- detail the location and course of fracture lines. The data raphy (CT) is progressively replacing the panoramic set provides high-resolution two-dimensional (2D) radiograph and conventional radiographs for maxil- multiplanar reconstructions (MPR) with contiguous lofacial trauma, and is increasingly being performed 2-mm slices in the axial and coronal plane displayed in in addition to conventional fi lms to detail and classify high resolution bone window (window width, 3200 HU; trauma to the mandible as well. Metal artefacts from center level, 700) and in soft tissue settings (window tooth fi llings however may degrade bone visualisation. width, 300 HU; center level, 100). Additional sagittal CT is the imaging technique of choice to display the reconstructions are reserved for central midface and multiplicity of fragments, the degree of dislocation mandibular condylar fractures. Three-dimensional and rotation, or skull base involvement (Fig. 24.5b,c). (3D) surface shaded CT reconstructions add the third CT is also particularly important to recognize poten- dimension at one glance and are particularly help- Maxillofacial Injuries in Sports 407

ful for treatment in case of multiple fragments and/ Early and late complications of trauma related or severe fragment dislocation (Fig. 24.4a) (Box 24.3) to the orbit, anterior cranial fossa, or lateral skull (Reuben et al. 2005; Schuknecht and Graetz 2005; base due to infection, brain concussion, or her- Som and Brandwein 2003; Turner et al. 2004). niation require CT to visualize the osseous pre- requisites of complications, and MR to define the adjacent brain and soft tissue involvement. MR is 24.3.3 more sensitive to display dural defects, recognize Magnetic Resonance Imaging inflammatory collections following meningitis, or distinguish brain concussion from abscess forma- Magnetic resonance (MR) imaging does not visual- tion. In patients with suspicion of posttraumatic ize the bone directly and therefore small yet unsta- osteomyelitis, CT is superior to MR, as it pro- ble nondisplaced facial fractures may not be seen. vides additional information with respect to a Nevertheless, supplementary MR examinations are likely incomplete stability of the osteosynthesis, required when cranial nerve palsy occurs in order to the degree of callus formation, or the presence of recognize neural compression. MR imaging is more sequestra as sequela of osteomyelitis. MR imaging, sensitive to detect nerve compression due to haema- however, is more sensitive to detect early osteomy- toma, nerve transsection, or axonal injury. MR imag- elitis or ischemic necrosis of the condylar head of ing also is the most sensitive technique to evaluate the mandible (Reuben et al. 2005; Schuknecht traumatic damage to the temporomandibular joint and Graetz 2005; Som and Brandwein 2003; disc (Fig. 24.6) (Box 24.4). Turner et al. 2004).

a b

c d

Fig. 24.6a–d. Posttraumatic disk adhesion demonstrated by T1-weighted MR images. Closed-mouth image (a) shows a normal position of the disk (white arrowhead) and the condyle (black arrowhead) relative to the glenoid fossa. Upon opening of the mouth (b–d), the condyle moves inferior to the articular eminence; however the disk (white arrowhead) remains stuck in the glenoid fossa. Courtesy of Dr. J. Casselman 408 A. Bernaerts, P. Ehlinger, and K. Chapelle

24.4 Specifi c Sports-Related Maxillofacial Injuries

24.4.1 Soft-Tissue Injuries

Soft-tissue injuries are by far the most common max- illofacial injuries associated with sports (Hill et al. 1998). Soft-tissue injuries may be classifi ed as abra- sions, lacerations, cuts, haematomas and burns. Ocular soft tissue injuries also are frequently seen in sports related trauma, mainly in racquet sports (squash, tennis, and badminton) and soccer (Barr Fig. 24.7. Spot view of a panoramic radiograph demonstrat- et al. 2000). Problems such as hyphema (bleeding in ing a crown fracture of the right lateral maxillary incisor (tooth 12) the anterior chamber), retinal tears, lens dislocation, penetrating globe injury, optic nerve compression, superior orbital fi ssure syndrome (cranial nerve III ligament space (radiolucency between the cementum to VI paralysis) and retrobulbar hematoma should of the root and the lamina dura of the bony socket). be cautiously thought about (Greenberg and Haug Luxation of teeth is dislocation of the articula- 2005). tion (represented by the periodontal ligament) of Radiologic examination should be carefully con- the tooth. Traumatic forces, depending on their sidered in each patient to spot underlying fractures. nature and orientation, can cause intrusive luxa- tion (displacement of teeth into the alveolar bone), extrusive luxation (partial displacement of teeth out 24.4.2 of the sockets), or lateral displacement (movement Dentoalveolar Injuries of teeth other than axial displacement). In intrusive and lateral luxation, comminution or fracture of the Dental injuries range from minor enamel fragments, supporting alveolar bone accompanies dislocation of to complete crown-root fractures, or complete tooth the tooth. Radiographic examination of luxated teeth avulsion. When the dental fracture involves the alveo- may demonstrate the direction of the displacement lar bone, whether in the maxilla or the mandible, these by the widening and/or obliteration of the periodon- injuries are classifi ed as dentoalveolar fractures. tal ligament space and shows associated fractures of These types of injuries are common in sports and the alveolar bone (Fig. 24.8). are highly preventable with the use of mouthguards Avulsion is the complete displacement of the tooth (Greenberg and Haug 2005). Children have a dis- from its socket. The maxillary incisors are the most advantage with regard to dentition. When the tooth frequently avulsed teeth. Avulsion is not an uncom- germ lies in the fracture, the tooth can fall during mon occurrence in sports (Kurtz et al. 2005; White healing or have delayed development and deformity and Pharoah 2000). that does not manifest clinically until the permanent tooth erupts (Som and Brandwein 2003). Crown fractures are very common. They can 24.4.3 involve only the enamel (infraction) or can in addi- Mandibular Fractures tion involve the dentine (uncomplicated fracture) and pulp (complicated fracture) (Fig. 24.7). Dental There is a variety of causes for mandibular fractures root fractures (Fig. 24.3) and crown-root fractures predominated by assaults and motor vehicle colli- are less common. The term “concussion” indicates a sions, with sports as a smaller aetiology (2%–6%) crushing injury to the vascular structures at the tooth (Greenberg and Haug 2005). However, according to apex and to the periodontal ligament, resulting in the investigations of Emshoff et al. (1997) sports are infl ammatory edema. The radiographic appearance increasingly implicated in the causes of mandibular of a dental concussion is widening of the periodontal fractures. His study showed sporting activities to be Maxillofacial Injuries in Sports 409

Nasal fractures are the most common sports related facial fractures with sports accounting for up to 27% of all nasal fractures (Greenberg and Haug 2005). There is, however, a large discrepancy of preva- lence amongst papers. Nose fractures can be treated by other specialities (ENT and plastic surgeons) than maxillofacial surgeons in some hospitals and therefore might be underestimated in some studies (Frenguelli et al. 1991; Maladiere et al. 2001). The majority of nasal bone fractures involve the thinner, distal third of the nasal bones. A lateral blow to the nose usually causes a simple cartilage depression or fracture of only the ipsilateral nasal bone. On the other hand, a frontal nasal blow usually fractures both nasal bones at their lower ends, and the septum is also dis- placed and fractured. With a greater force, the entire nasal pyramid, including the frontal processes of the maxillae, may become detached (Fig. 24.5) (Som and Brandwein 2003). Nasoethmoid fractures are most often caused by Fig. 24.8. Oblique view of the mandible dem- onstrating a vertical fracture of the mandibular a blow over the bridge of the nose resulting in pos- body. There is a concomitant extrusive luxation terior displacement of the nasal bone and frontal of the right canine. Note the widening of the peri- process of the maxilla with telescope-like deforma- odontal ligament space that is accentuated at the tion and foreshortening of the anterior ethmoid. The apical region (white arrow) lacrimal bone and cribriform plate are frequently involved (Schuknecht and Graetz 2005; Som and Brandwein 2003). the main causative factor of mandibular fractures, Isolated maxillary fractures, other than alveolar accounting for 31.5%. The difference may be attrib- fractures, can result from a blow directly over the utable to the extensive sports facilities and tourism anterior maxillary wall. The fractures involve the industry in the studied region (Innsbruck). anterior and lateral antral walls and extend toward Mandibular fractures can be categorized based on the pyramid aperture and down into the maxillary anatomic location: (para)-symphyseal, body, angle, alveolus (Fig. 24.9) (Som and Brandwein 2003). and ascending ramus (Figs. 24.2 and 24.8). Fractures Complex midface fractures are typically referred affecting the ramus mandibulae are subdivided into to in the context of Le Fort’s early anatomic studies. those directed to the coronoid or condylar process. Although visualization of injury to the struts and Condylar fractures may be intracapsular or extracap- buttresses of the face is required for repair of these sular in location. In extracapsular fractures, the frac- fractures with restoration of the 3D stability and ture line is below the insertion of the lateral pterygoid symmetry of the face, the Le Fort classifi cation still muscle. Displacement is usually in an anteromedial appears to be a succinct way of summarizing and direction (Schuknecht and Graetz 2005). In sports- communicating the major planes of certain fractures. related mandibular fractures, the subcondylar region The greatest frequency of Le Fort types of fractures is most commonly affected (Emshoff et al. 1997). results from assaults and motor-vehicle collisions, with sports accounting for 5%–8% of such fractures (Greenberg and Haug 2005). 24.4.4 Common to all Le Fort fractures is fracture of the Central Midface Fractures pterygoid processes. In addition, each Le Fort frac- ture has a unique component (Fig. 24.10) (Rhea and Central midface fractures are classifi ed into fractures Novelline 2005). The Le Fort I fracture runs hori- of the nose and nasoethmoid complex, isolated max- zontally above maxillary alveolar process and is the illary fractures and Le Fort I, II and III types of frac- only one that involves the anterolateral margin of the tures, (Som and Brandwein 2003). nasal fossa just above the maxillary alveolar process. 410 A. Bernaerts, P. Ehlinger, and K. Chapelle

Fig. 24.9. Axial CT scan in bone window setting of an iso- lated maxillary fracture involving the left anterior antral wall (arrow) in a 19-year-old woman after falling from her bicycle. Fig. 24.11. Three-dimensional (3D) surface shaded CT recon- Note the presence of a haemorrhage within the right antrum struction of a left hemi-Le Fort II fracture caused by a skiing with an air-fl uid level accident (black arrow). This type of Le Fort fracture is the only one that involves the orbital rim

Le Fort

24.4.5 Lateral Midface Fractures

Lateral midface fractures consist of zygomatic frac- tures (trimalar, or tripod), zygomatic arch fractures, zygomaticomaxillary fractures, zygomaticomandib- ular fractures and fractures of the fl oor of the orbit (blow-out fractures) (Som and Brandwein 2003). Sports injuries account for 4%–11% of all zygomatic fractures (Greenberg and Haug 2005). In a so-called trimalar or tripod fracture, the frac- Fig. 24.10. Drawing in frontal projection showing Le Fort I, ture line extends from the lateral orbital wall (zygo- II, and III types of fractures. [Modifi ed from Rhea and maticofrontal suture and the zygomaticosphenoid Novelline (2005)] suture) to the inferior orbital fi ssure, then across the orbital fl oor near the orbital canal, down the anterior maxilla near the zygomaticomaxillary suture, and The Le Fort II fracture is pyramidal in shape with up the posterior maxillary wall back to the inferior teeth at base of pyramid and nasofrontal suture at orbital fi ssure. There is also a fracture through the apex of pyramid. This type of fracture is the only one weakest part of the zygomatic arch, which is about that involves the inferior orbital rim. Posterior and 1.5 cm dorsal to the zygomaticotemporal suture lateral walls of maxillary sinus are broken (Fig. 24.11). (Figs. 24.4 and 24.12). The Le Fort III fracture separates bones of face from When there is an isolated fracture of the zygomatic the rest of the skull. The fracture crosses the naso- arch, there are usually at least three discrete fracture maxillary suture, the lamina papyracea medially, and lines, creating two fracture segments. These pieces the superior orbital fi ssure and courses laterally to are displaced medially and downwards, refl ecting the involve the sphenozygomatic and frontozygomatic direction of the impact force (Fig. 24.13). suture. The Le Fort III fracture is the only one that Zygomaticomaxillary fractures differ from trima- involves the zygomatic arch. lar fractures in that the former fractures involve the Maxillofacial Injuries in Sports 411

a

Fig. 24.13. Spot view of a submentovertical view shows a depressed fracture of the left zygomatic arch sustained during an elbow-head impact in a soccer game. [Reprinted with permission from Raghoebar et al. (2005)]

b orbital fl oor, extend down the anterior maxilla (often more medially than in a typical trimalar fracture), run to the premolar region, and then extend across the palate to the maxillary tuberosity and lower pter- ygoid plates. Zygomaticomandibular fractures differ from zygomatic fractures only by the additional fracture of the mandibular condyle, coronoid process, or both (Som and Brandwein 2003). One-third of orbital blow-out fractures are sus- tained during sports. Soccer is most commonly involved (Jones 1994). A blow to the orbit by an object that is too large to enter the orbit (baseball, fi st, etc.) c may cause a blow-out fracture resulting in fracture Fig. 24.12a–c. Axial CT images through the orbit (a), the zygo- of the orbital fl oor and – by defi nition – leaving the matic arch (b), and the maxilla (c) show a left trimalar fracture inferior orbital rim intact. Herniation of orbital fat, sustained during a bicycling accident due to a fall. The left inferior rectus muscle and inferior oblique muscle frontosphenoid fracture is minimally displaced (arrow in a). can occur (Fig. 24.14). Additionally, or rarely alter- The zygomatic arch is also fractured in two places (arrows in natively, the medial orbital wall may be displaced b ). The most caudal image shows the complex fracture near into the ethmoid resulting in the so-called “medial the zygomaticomaxillary suture (arrow in c) with involvement of the orbital fl oor, the orbital canal, and anterior and poste- blow-out fracture” with potential herniation of the rior maxillary wall. There is orbital and subcutaneous emphy- medial rectus muscle. Supraorbital roof fractures are sema, and haemorrhage is present in the left antrum. Also note uncommon (Schuknecht and Graetz 2005; Som the presence of a prolapsed fracture segment in the antrum and Brandwein 2003). 412 A. Bernaerts, P. Ehlinger, and K. Chapelle

a b

Fig. 24.14a,b. A Waters view (a) and coronal CT image (b) of a blow out fracture. A completely displaced piece of bone, a trap- door fracture (arrow), can be identifi ed as can the typical “teardrop” herniation of orbital contents

24.4.6 Frontal Sinus Fractures Things to Remember

Frontal fractures are less common than other frac- tures of the craniomaxillofacial skeleton because of 1. The majority of sports-related craniomaxillo- their greater thickness and biomechanical advan- facial injuries are of a minor nature including tages. Sports injuries account for 3%–5% of all frac- soft tissue lacerations followed by dentoalveo- tures (Greenberg and Haug 2005). lar fractures and minor facial bone fractures Frontal bone fractures are classifi ed according respectively. to the involvement of the supraorbital rim, anterior wall, posterior wall, or sinus fl oor (Fig. 24.15) (Som 2. The most frequently recorded facial fractures and Brandwein 2003). in sports include nasal, mandibular, and zygo- matic fractures.

3. The majority of facial fractures occur during team sports, such as soccer and rugby, and as 24.5 a consequence of an impact against another Conclusions player.

In conclusion, the majority of sports-related cranio- 4. In vehicular sports, a fall to the ground is the maxillofacial injuries are of a minor nature including most commonly reported type of impact and soft tissue lacerations followed by dentoalveolar frac- the frontal sinus and central midface are com- tures and minor facial bone fractures. The most fre- monly affected. quently recorded maxillofacial bone fractures involve the mandible, the zygomatic and nasal bone and 5. Dentoalveolar fractures always require intra- occur during team sports, such as soccer and rugby, oral periapical fi lms to obtain adequate image as a consequence of an impact against another player. detail. CT is the modality of choice for the Dentoalveolar fractures always require intraoral peri- most complete evaluation of the facial skel- apical fi lms to obtain adequate image detail. CT is the eton and facial soft tissues. modality of choice for the most complete evaluation of the facial skeleton and facial soft tissues. Maxillofacial Injuries in Sports 413

a b

c

Fig. 24.15a–d. Young male soccer player who sustained a frontal sinus fracture in a heading duel. A preoperative axial CT scan (a) shows a depressed comminuted fracture of both the anterior and posterior frontal sinus tables. Peroperative photographs before (b) and after (c) repositioning and osteosynthesis show the impact site. Postoperative lateral view (d) shows an anatomic alignment of the fracture frag- ments. [Reprinted with permission from Raghoebar et al. (2005)] d

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