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Facial Lacerations at Ringside

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Facial Lacerations at Ringside 4/27/17 FACIAL LACERATIONS AT RINGSIDE USA BOXING - MEDICAL HANDBOOK and MEDICAL RULES of AIBA OPEN BOXING - As adapted for use in the United States from the 2013 AIBA EdiLon 1 4/27/17 2 4/27/17 MED SCHOOL ANATOMY 3 4/27/17 Surface Anatomy of the Face Major Structures of the Superficial Face Supraorbital Ridge • Eye, nose and pie Holes • Muscles of Facial Infraorbital Orbit Margin Nares Expression Philtrum of Superior • ParoLd gland and duct Zygoma Pinna Lip (Labia) • BrancHes of the facial Parotid Nasolabial Fold nerVe Mandible Vermilion Border • BrancHes of the trigeminal Buccal region Mental Protuberance nerVe Submental Region • Facial artery and the Labial Commisure superficial temporal Submandibular Gland artery • Veins draining to the internal and external jugular Veins DissecLon of the Superficial Face Arteries to the Face Superficial Temporal A&V Anterior Branch Orbicularis Auriculotemporal N Oculi Posterior Branch Transverse Facial A Angular Artery Superior Labial Artery Transverse Facial A. Inferior Labial Parotid Gland Artery Superficial Temporal A Parotid Duct Zygomaticus Major Buccinator Branches of the facial N Facial Artery Lingual Artery There would also be Greater Auricular N Facial Artery is a supra- and infra- Sternomastoid M anterior to the Facial orbital arteries, External Jugular V V, in front of lacrimal artery and a Platysma M. Masseter M. few other small ones. Mentalis M. Facial A&V 4 4/27/17 Cranial Nerves Associated With the Face • Trigeminal NerVe Cavernous Sinus – Sensory to the skin Orbit Cranial Cavity – Three divisions • Facial NerVe – Motor to Muscles of Facial Expression Pterygoid Plexus – Lacrimal and all SaliVary SecreLons (Except 1) • GlossopHaryngeal NerVe – ParoLd SecreLons Motor BrancHes of the Facial NerVe – CN VII To – Temporal (Frontal) (Top of Orbic Oculi) Zanzibar – Zygomatic (Bottom of Orbic Oculi) By – Buccal (Top of Orbic Oris) Posterior Auricular Motor – Mandibular (Bottom of Orbic Oris) Exits Stylomastoid Foramen Car - Cervical 5 4/27/17 USA BOXING MANUAL RINGSIDE PRACTICE THIS WAS THE STANDARD 6 4/27/17 Updated Image 7 4/27/17 8 4/27/17 A DEEP CUT NEAR THESE 6 HOLES IS DANGEROUS Trigeminal Major PorLons Supplies THEY ALL LINE UP Cutaneous NerVes of the Face W THE PUPIL 9 4/27/17 DANGEROUS IF DEEP! 10 4/27/17 90% OF ALL LACS DANGEROUS IF DEEP! Injuries Around the Eyes: ABSOLUTE Tarsal Plates and Nasolacrimal Duct 11 4/27/17 12 4/27/17 Injuries that include the eye/obscure Vision Eye by Escher, 1946 ! THe basic principle of Handling cuts around the eye is that, if a cut causes enougH bleeding to impair Vision, the bout should be stopped. ! Most cuts will NOT require that the bout be stopped. SHOWSTOPPER? 13 4/27/17 14 4/27/17 15 4/27/17 Updated Image DANGEROUS IF DEEP! 16 4/27/17 Summary of Zones Summery of Facial Laceraons Larry LoVelace, DO, FACEP & Daniel O’DonogHue, PA-C, PHD Summary of Zones Larry LoVelace, DO, FACEP & Daniel O’DonogHue, PA-C, PHD 17 4/27/17 Pressure Points to Stop Bleeding Angular Artery Superficial Temporal Artery Superior Labial Artery Inferior Labial Artery TransVerse Facial Artery Facial Artery Laceraon Zones Larry LoVelace, DO, FACEP & Daniel O’DonogHue, PA-C, PHD 18 4/27/17 19 4/27/17 20 4/27/17 21 4/27/17 Laceraon Zones LARRY LOVELACE, DO, FACEP, DABEM, DABFM, DABFE, ACSM/ARP Larry LoVelace, DO, FACEP & Daniel O’DonogHue, PA-C, PHD RINGSIDEARP.ORG 22 4/27/17 DANGEROUS DANGEROUS IF DEEP! IF DEEP! 23 4/27/17 Trigeminal Major PorLons Supplies Cutaneous NerVes of the Face 24 4/27/17 25 4/27/17 Trigeminal Major PorLons Supplies Cutaneous NerVes of the Face Trigeminal Major PorLons Supplies Cutaneous NerVes of the Face Pressure Points to Stop Bleeding Angular Artery Superficial Temporal Artery Superior Labial Artery Inferior Labial Artery TransVerse Facial Artery Facial Artery 26 4/27/17 Injuries of the Face Blowout of Orbit Superficial Temporal A Hit in the eye (black or swollen eye) And either or both of the next two – Numbness toward upper teeth MRI of Transverse Facial A. – Double Vision on upward gaze Face Anterior Answer! Cranial THe floor of the orbit is blown! Fossa – Infraorbital nerVe is interrupted Orbit – Inferior Rectus may be entrapped 5.3.1. Maxillary Occasionally a cut will be in an area wHere deep structures may be injured. In boxing, as these Sinus are blunt injuries and not sHarp injuries, it is sLll unusual to HaVe to stop a bout unless these laceraons are quite deep and seVere. HoweVer, the following laceraons sHould be eValuated with this in mind. Injuries around the Eye Injuries around the Eye – Supraorbital/SupratrocHlear Infraorbital NerVe and Artery This muscle is superficial to the nerve and artery so that a cut in this region would have to be very deep to injure the nerve and artery 27 4/27/17 Facial NerVe Video Laceraons oVer medial eye Laceraons to the eye lid 5.3.1.1.2. Cuts medially oVer 5.3.1.1.4. the larcrimal duct Cuts on the eyelid area may extend itself could into the damage the tarsal plate or the globe nasolacHrymal duct. itself may HaVe been injured. 28 4/27/17 Laceraons of the lip Cuts oVer the Eye 5.3.1.1.5. 5.3.1.1.1. VerLcal cuts througH the Cuts oVer the Vermillion border of the lip supraorbital nerVe or sHould stop the bout because the supratrocHlear of the potenLal for further nerVe, if they are deep tearing of the lip from enougH, may damage subsequent trauma. the nerVe. Laceraon inferior to the eye 5.3.1.1.3. Cuts oVer the infraorbital nerVe, if deep enough, could damage the nerVe. 29 4/27/17 ResponsibiliLes for Laceraons THe pHysician must be prepared to eValuate cuts at ringside. THe basic principle of Handling cuts around the eye is that, if a cut causes enougH bleeding to impair vision, the bout should be stopped. Most cuts will NOT require that the bout be stopped. Cuts around or on the bridge of the nose Anterior Nose Bleed • Most nose bleed will be anterior and in the absence of fracture self-liming • In any nose bleed it is important to look down the throat • If there is only a linle blood in the pHarynx it is probably an anterior Bleed • Most nosebleeds will stop on their own or with external pressure. • A messy nosebleed is not necessarily a serious nosebleed 30 4/27/17 Posterior Nose Bleeds WHat can be done about the • Determinaon of posterior Laceraon bleeding sHould also be done by 5.3.3. tongue depression and penligHt obserVaon. No dressing of cuts is allowed except for collodion or steristrips. SubcuLcular closure of • BrigHt blood in the oral pHarynx – certain cuts with a coVering of collodion or beHind the posterior pillar is a clear sign of a posterior bleed steristrips may allow winning boxers to conLnue in a tournament. If they cHoose this approacH, • If there are clots in the pHarynx or the boxer is sping clots, the they sHould be made aware that there is a risk bout sHould be stopped that the wound may reopen during the bout and • Most nosebleeds will stop on require further repair aer the bout. It could be their own or with external bad enougH if it reopens to terminate the bout. pressure. It could cause further damage. • A messy nosebleed is not necessarily a serious nosebleed 5.4.1. How to Handle nosebleeds THe iniLal eValuaon sHould determine the presence of a fracture. Gentle Handling of a nose bleed is necessary so as not to further aggraVate or compound a fracture. 5.4.2. If no fracture is felt, the pHysician must then eValuate the cHaracter of the bleeding (i.e. Venous Vs. brisk arterial gusHing). Bouts are stopped for arterial bleeding (rare in this situaon). 5.4.3. Determinaon of posterior bleeding sHould also be done by tongue depression and penligHt obserVaon. If there are clots in the posterior pHarynx or the boxer is sping clots, the bout should be stopped. 5.4.4. MassiVe Venous bleeding may be cause to stop a bout. 5.4.5. Nosebleeds sHould stop bouts for medical reasons. Most nosebleeds will stop on their own or with external pressure. A messy nosebleed is not necessarily a serious nosebleed. 5.4.6. THe doctor may also stop the bout if the boxer does not want to conLnue or in young boxers wHere the experience can be frigHtening. 31 4/27/17 Summary of Zones Summary of Zones Larry LoVelace, DO, FACEP & Daniel O’DonogHue, PA-C, PHD Larry LoVelace, DO, FACEP & Daniel O’DonogHue, PA-C, PHD Summary of Zones Laceraon Zones Larry LoVelace, DO, FACEP & Daniel O’DonogHue, PA-C, PHD Larry LoVelace, DO, FACEP & Daniel O’DonogHue, PA-C, PHD 32 4/27/17 Laceraon Zones Pressure Points to Stop Bleeding Angular Artery Superficial Temporal Artery Superior Labial Artery Inferior Labial Artery TransVerse Facial Artery Facial Artery Larry LoVelace, DO, FACEP & Daniel O’DonogHue, PA-C, PHD Pressure Points to Stop Bleeding Pressure Points to Stop Bleeding Angular Artery Angular Artery Superficial Temporal Superficial Temporal Artery Artery Superior Labial Artery Superior Labial Artery Inferior Labial Artery Inferior Labial Artery TransVerse Facial TransVerse Facial Artery Artery Facial Artery Facial Artery 33 .
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