Cervicofacial traumatology in sports practice

 

Cervicofacial traumatology in sports practiceIntroduction:

The traumatology of the face and neck, in sports practice and especially for team sports, is more and more frequently observed. This increase is explained by the intensification of the physical preparation of sportsmen, amateur and of course professional, whose physical mass and speed imply increasingly violent and repeated contacts.

The face and the neck do not escape this commitment. If, in the majority of cases, these are simple bruises, larger lesions are not uncommon and require, from the site of the accident, that is, from the field, a precise diagnosis and a course to be kept irreproachable.

Paradoxically, examination of the facial wounded person will not begin with the face and contuse region involved, but the practitioner must first and foremost ensure control of breathing, consciousness and eventual bleeding , and verify the integrity of neighboring bodies indirectly affected by the trauma, but representing the real urgency. This approach is unnatural and the physician’s discomfort is increased by the impressive and theatrical side of the facial lesion (haemorrhage and hematoma, easy and sometimes spectacular), but the latter must not lose sight of the fact that, whatever the injury, is in the vast majority of cases without a prognostic impact. It is not the same with an attack of the brain, the eye and the cervical spine, among others.

For each region, we will insist on the first three decisions that the sports physician must take in the field following his first examination:

• a simple contusion without the associated lesion and the athlete may resume the match;

• an isolated lesion without potential gravity which requires a temporary exit, the athlete being able to resume the match after treatment of the wound in the locker room;

• a more severe traumatic pathology, with a doubt about a lesion of a neighboring organ, the athlete must leave the field permanently and eventually be transported to a hospital structure for imaging assessment and therapeutic management.

The consultation, the day after the match in the sports doctor’s office, corresponds to the same approach, with, at the slightest doubt, a request for further examinations and treatment in specialized settings.

The three priorities:

Arriving in the field to examine an injured sportsman with cervicofacial impact, the practitioner must first of all ensure the following three priorities: breathing, consciousness and bleeding.

Breathing:

The injured person is sometimes lying on the ground and, from the outset, the doctor has to remove his tooth protector (more and more often worn by sportsmen), make an oral examination by removing the fragments of earth and possible dental flakes and check his breathing. If consciousness disorders occur, the lateral safety position will avoid the risk of inhalation in case of vomiting. The notion of falling language, too often referred to, corresponds in fact to a rocking of the base of language on the susglottic stage of the larynx, blocking the air passage.

Let us recall that an obstacle to breathing sitting at the level of the larynx and above is translated by an inspiratory bradypnea, with cornea and pulling by bringing into play the accessory respiratory muscles (notably intercostals).

It is necessary to have a set of Guédel cannulas in his emergency kit because it allows, by luxating the jaw, to restore airway permeability in an unconscious wounded. This situation is exceptional but the sports physician must be able to cope with it.

Consciousness:

It is a reflection of the state of the brain and must be an obsession for the practitioner who examines the wounded.

The main clinical sign is of course the loss of consciousness which, immediately, must lead the doctor to the following decisions:

• the final exit of the athlete, even if the latter resumes his mind and wants to continue the game: this exit is not negotiable;

• the transfer by one of the club’s leaders to the emergency room of the neighboring hospital to benefit from a cerebral CT without injection which will eliminate a possible extradural hematoma;

• monitoring by a close relative in the case of a normal CT scan and when any doubt is raised (no vomiting or new consciousness disorders, strictly normal neurological examination) or hospitalization at the slightest doubt in the first 24 hours.

Bleeding:

In the vast majority of cases, this is a nasal or epistaxis hemorrhage.

The player must of course leave the field. The doctor wears examination gloves. It is enough, first, to blow it to eliminate the clots present in the nasal pit, then to make sit and compress his nostrils with his fingers aided with a compress, head leaning forward so that the bleeding ceases .

This bidigital compression can be facilitated by a vestibular tampon, by positioning in the nostril of the haemostatic product, Coalgan or better Surgicel coated with HEC ointment. The compression lasts ten minutes, checking that there is no posterior flow at the level of the oropharynx. In the absence of obvious lesion (fracture of the nose), the player can, depending on his condition, resume the course of the game.

Sometimes this is not enough, and an anteroposterior tamponing by hemostatic tampon, introduced by the nostril in a plane strictly perpendicular to the face, and especially not in the direction of the root of the nose and the eyes, must be put in place. This tamponage is sometimes difficult to perform, if not impossible in case of preexisting deflection of the nasal septum which thus blocks access to the nasal cavity.

At an ultimate stage, and in the face of the failure of these previous means, particularly in the case of uncontrollable posterior bleeding with vomiting of clots and blood, the use of a urine catheter (No. 12) swollen with 10 cm 3 of physiological saline to block the choanal orifice and the cavum allows the haemorrhage to be controlled before transferring the injured person to the nearest hospital emergencies.

Haemorrhage on wounds is easily controlled by local compression with sterile and antiseptic compresses.

The player must exit temporarily if the simple suture is sufficient to treat the wound without seriousness, but in case of complication, the suture will be carried out in a specialized medium and the exit will be definitive.

Neighborhood lesions / elimination diagnoses:

The paradox of the maxillofacial examination is that it examines first what is not maxillofacial, in other words the organs of the vicinity likely to be harmed by the physiological mechanism of the wound. This priority is justified by the potential severity of neighboring lesions such as the cervical spine, the eye and the brain.

We shall not return to the latter (previous chapter).

Once again, this research must be an obsession, and it is only once the certainty has been obtained from the normality of the examination that we can devote ourselves to the management of the facial wound itself.

The cervical spine:

The associated involvement of the cervical spine during trauma of the face is quite conventional and is observed regularly. This joint involvement is explained by the hyperextension movement followed by a brutal cervical flexion secondary to the impact on the face (shot of the rabbit).

All lesions can be seen, from the sprain to the dislocation, through the fracture of the vertebral body.

The examination begins with neck pains, tingling sensations in the upper limbs and examination verifies the muscular strength of the upper limbs and pain caused by the careful palpation of the cervical spine. At the slightest doubt, the wearing of the minerva, split into extension, is the rule; the athlete having definitively left the field lying on a stretcher.

The eyeball:

The control of the eyeball and the sight is also a priority, the visual prognosis in the case of a lesion suffering from no delay.

Two pictures must be feared: the wound of the eyeball and the physiological section of the optic nerve.

The wound of the eyeball:

This circumstance is extremely rare, but the diagnosis is not always easy. Indeed, the impact in the orbital region causes a reflex palpebral occlusion which it is difficult to overcome for the uninitiated. It will be necessary to be patient to succeed in spreading both eyelids, but a sign is already very evocative before this stage: the difference of intraocular pressure by palpating the two globes through the eyelids in a comparative way. The player goes out of the field anyway and the examination in the locker room allows to evaluate the visual acuity or even to identify the wound.The illico transfer to the nearest ophthalmological emergencies (make sure that neighboring emergencies have a guard ophthalmologist …), after having closed the orbit with a sterile ophthalmic compress, is the rule.

The physiological section of the optic nerve:

This diagnosis is more difficult to evoke and yet it is not difficult to ask. The physiological mechanism is that of a violent impact on the eyeball by a ball (tennis, handball …). The ocular globe is in some sort appended in the orbit by a wire which is the optic nerve.

Under the impact of the shock, it will be propelled towards the bottom of the orbit and then return suddenly causing traction back and forth on the optic nerve which will result in an intraneural edema, thus blocking the transmission of visual information to the cortex.

After the player’s exit, the latter will confirm a decrease in unilateral visual acuity, but most often blindness with luminous perception or not. The diagnosis will be confirmed clinically by the search for the photomotor reflex (shrinking of the pupillary diameter to the luminous stimulation): the direct photomotor reflex (on the injured side) will have disappeared, the pupil remaining in a position of mydriasis. On the other hand, the contralateral, by stimulating the healthy side, will cause the pupil to close on the injured side, this attesting to the cut of the visual channels.

The urgency is then absolute.

The athlete is transferred within one hour to a reference ophthalmological center.

The complementary review will comprise two parts:

• functional examinations, in particular visual evoked potentials, the prognostic value of which is paramount in finding or not a trace;

• Imaging: the CT of the orbit without injection but especially the nuclear magnetic resonance which will authenticate the edema or even the hematoma within the optic nerve.

The patient is hospitalized for intravenous medical treatment of corticosteroids at high doses, of the order of 1 g per 24 hours, possibly coupled with an operation of decompression of the optic nerve.

There are two possibilities for this decompression:

• the neurosurgical approach, by the superior approach of the super-internal surface of the orbit;

• the transethmoidosphenoidal pathway, at the lower end of the inner wall and the optical canal, performed in otolaryngol- ogology.

The duration of hospitalization is eight to 15 days, the work stoppage depends on the professional activity of the person concerned (three to six months), his sports career is over and the rate of recovery varies according to the teams.

The wounds of the face and neck:

It is important to distinguish simple wounds from complex or potentially dangerous wounds that must be taken care of by the specialist surgeon.

The treatment of the simple wound is relatively stereotyped:

• the casualty leaves the court temporarily;

• the suture is made in the locker room on an elongated subject at rest;

• after wound disinfection and local anesthesia with adrenaline-free xylocaine, we use two Gillies hooks to remove both sides of the wound, remove any foreign bodies (earth or other) and check bone fracture. A single plane is sufficient using a nonabsorbable wire 4 or 5/0;

• the wound is protected by a bandage and sterile compresses;

• the player can resume the course of the game;

• the threads will be withdrawn on the fifth day post and there will be no stoppage of sporting and / or professional activity.

Note that we avoid the use of adrenaline xylocaine for two reasons:

• it is potentially allergenic by the sulfites that are used to stabilize the mixture, allergy to pure xylocaine being much rarer;

• Adrenaline has cardiovascular effects that we do not consider desirable in an athlete who has just stopped his effort.

It goes without saying that the player’s anti-tetanus vaccination will be up to date. . .

The criteria for delaying the wound suture, due to its complex nature, are as follows:

• reaching an orifice of the face: nostril, mouth, eyelid;

• the attainment of an underlying noble organ: the facial nerve, the trigeminal nerve, the lacrimal ducts, the Stenon canal;

• Exposure of cartilage: nose, auricle;

• the existence of an underlying fracture, synonymous with an open fracture;

• contused and complex wounds;

• the cervical sore;

• the particular case of bites and amputations.

In accordance with these criteria, the athlete must leave the field permanently, the wound must be disinfected and sealed with sterile compresses but not sutured, and the athlete must be taken to a competent specialist for a specific treatment within six hours.

The attainment of an orifice of the face:

Whatever the orifice, from the moment the wound is transfixing and the orbicular muscle (mouth, eyelid), or wing cartilage (nose), the closure of this wound exposes to functional or aesthetic sequelae which must discourage the non-specialist (notch of the nasal orifice or the lip, lagophthalmia for the eyelid, salivary leak for the mouth).

The athlete will definitely leave the field, the wound will be disinfected and not sutured, and, carrying a simple protective dressing, the injured person will be conducted within 12 hours for a specialized management.

Let us emphasize the particular case of the deep wound of the upper eyelid which will sever the levator muscle of the eyelid; if not diagnosed, it will lead to a cicatricial ptosis of the eyelid, evident a few days later to the comparative examination.

The attainment of an underlying noble organ:

The facial nerve:

The motor nerve of the face, the lesional diagnosis is relatively easy provided it is rigorous and stimulates by contracting the muscle group located downstream of the wound; his paralysis in a comparative examination attests to the section of the nerve branch which commands it.

This is the case with wounds in the following regions:

• behind the brow for the frontal branch, which controls the wrinkles of the forehead;

• the region of the crow’s feet for the orbicular branch, which controls the closing of the eyelids, in particular the upper one;

• the cheek for the wings of the nose and the labial commissure;

• the mandibular rim for the chin strap, which controls the lower lip and chin.

The wound will not be sutured, the player leaving the field definitely is sent within six hours to a specialized center for a microsuture of the nerve, the recovery being able to go from 12 to 18 months. The discontinuation of sports activity is a function of the sequelae caused by the nerve injury (eg a section of the orbicular branch with an inability to close the eye will result in a cessation of activity for at least 12 months).

The trigeminal nerve:

It is the sensory nerve of the face. It is branched into three terminal branches which emerge through juxta-osseous orifices, explaining that their involvement is seen mainly in the case of associated fractures:

• V1, or upper branch, emerging at the internal part of the eyebrow, in the vicinity of the root of the nose.

Its lesion by direct wound leads to an anesthesia of the hemifront;

• The V2, or middle branch, exits under the orbital rim and is threatened in the event of fracture of the orbital floor or of the mite. The anesthesia observed concerns the internal part of the juxtanarinary cheek, the wing of the nose, the upper hemilèvre and the gingiva of the incisivocanin block;

• the V3, or lower branch; a great part of the journey is made in the mandible, explaining that its attack is seen mainly in fractures of the horizontal portion of the mandible. The anesthesia concerns the lower hemilèvre and the gingiva of the lower incisivocanin block.

The treatment obeys the same principles as for the facial nerve, knowing that microsuture is very rarely achievable because of the proximity of the bone. Only a release of the nerve, contused by a bony fragment, can lead to recovery within eight to 12 months, but the consequences of anesthesia in a region of the face are less restrictive than paralysis, with the exception of V1, which results in salivary leakage and fluids during feeding.

The lacrymal pathways:

Their opening in a wound facing the lower eyelid near the inner canthus results in tears emerging through the wound edges when the lacrimal sac is pressed in the lower part of the lid the internal angle of the eye.

In the slightest doubt, exploration of the wound after catheterization of the lachrymal tract by a competent ophthalmologist is the rule.

The Stenon Canal:

It is the drainage channel of the parotid gland, salivary gland located in front of the ear lining and extending around the lobule.

The wound is jugal, rather anterior and deep, and the massage of the parotid gland causes the arrival of saliva between the two edges of the wound.

The suture will be made by an experienced ENT, after catheterization of the Stenon canal from its opening in the oral cavity, in front of the upper premolar.

The catheter is left in place for four to six weeks to avoid secondary stenosis, a source of infectious parotitis; the sports stop is of the same duration.

Exposure of an underlying cartilaginous structure:

It is basically the nose in the lower part and the auricle.

However, it is necessary to qualify this type of wound according to the state of the cutaneous wounds in front of the wound:

• the wound is clear, the skin is vital, not contused, with a minimal degree of septicity and at a distance from an orifice, nostril or external auditory canal: the suture in the locker room can be carried out and the resumption of the match envisaged under cover of a protective dressing;

• either the wound is more complex from the start, with fragments of skin whose coloring makes one doubt its survival (ecchymosis or hematoma, dermabrasion): it is better to abstain and accompany the injured athlete within six hours for a catch in specific charge by a confirmed ENT.

The latter will realize, after trimming and careful disinfection of the wound, the suture of the cutaneous fragments by reconstituting  the puzzle  and sacrificing those whose vitality is doubtful. Local anesthesia is usually sufficient, a dressing molded by sterile cotton impregnated with physiological saline supplementing the management, to remould all the reliefs, especially of the pavilion, and to avoid a secondary hematoma. This type of dressing will be maintained for about ten days, the threads being removed after ten to twelve days; the interruption of the sport goes up to 15 days, with protection during the recovery.

Antistaphylococcal antibiotherapy and control of tetanus vaccination are also necessary.

The stitches on the cartilage are of no interest because of the molding during the dressing and, moreover, they can tear the cartilage.

We shall draw nearer to this situation the otumatoma or effusion of blood from the auricular. This subcutaneous bleeding is secondary to a cartilaginous fracture.

It is observed very frequently in the fronts in rugby, especially players in the front row. The prevention of this type of injury is the wearing of a headband, or even today a helmet, which avoids direct contact with the flag during the melee.

The treatment is based on the puncture of the blood collection as soon as it appears in the locker rooms with the sterile trocar; then applying a thick circular bandage maintained by a helmet allowing the game to resume. The sterile molding dressing helps to apply the skin of the horn to its cartilaginous support and must be kept five days in place. In case of recurrence, after new puncture with the unsuccessful trocar, the drainage will be done by an ENT. The latter will practice either cutaneous incisions of a few millimeters or a fenestration, that is to say an opening of the cartilage in the form of a square, opposite the collection posteriorly, in the retro-auricular groove, supplemented by a new tight dressing and antibiotic therapy. Bourdonnets, transfixing points of the pavilion caught in  sandwich  with tulle fat, are then inevitable to reapply the skin.

Do nothing, leads to fibrosis of the auricular pavilion and to those famous aspects of  cauliflower  pavilion that everyone knows.

The underlying fracture:

It is the perfect trap. It should always be borne in mind that a wound may correspond to a deep fracture, synonymous with an open fracture. This trap is all the more unforgivable because the wound will prevent the formation of edema at the level of the adjacent soft parts, which makes the maxillofacial examination easy. The other means of diagnosis are the hooks of Gillies, which, by spreading the banks of the wound, will allow to see directly the fracture and / or fragments bone. Some sites are very often affected by such an association, wound and fracture, as the nasal awning, the cheekbone, the zygomatic arch.

If this happens, it is preferable not to close the suture, to avoid the creation of the edema. The player leaves definitively and is routed on a hospital structure for an imaging balance. Two possibilities then exist at the end of the balance sheet:

• either the fracture is not displaced and only the suture will be performed, with antibiotic coverage and a stoppage of sport activity of three to four weeks depending on the site of the fracture;

• either the fracture is displaced and the reduction with osteosynthesis under general anesthesia and suture of the wound will be carried out urgently within six to 12 hours, then hospitalization of three to seven days depending on the site of the fracture. The end of any sporting activity can last up to six weeks.

Contused and complex wounds:

When the wound to be treated is unusual in its extent, the doubtful vitality of the integument of the neighboring body, the combination of the open wound and the dermabrasion, it is better to entrust the sportsman to an experienced surgeon who will follow the wounded person, use appropriate means (directed healing, cover flap in case of cartilage exposure, screening for sepsis) to achieve complete healing with minimal aesthetic or functional sequelae.

The cervical sore:

The neck represents a very special topography in the event of a wound, because of the richness of the underlying vessels present and the presence of the larynx, the first stage of the airway.

With regard to wounds, the anatomical limit in depth, like the peritoneum for the abdominal wounds, is the skin muscle.

Any wound that does not reach the skin can be considered superficial and can be taken care of in locker rooms. Still it is necessary to be able to explore this wound correctly by spreading the banks and controlling the bleeding. In case of doubt, abstention is the rule.

Any wound that reaches the muscle of the skin should be examined under general anesthesia to control the large vessels in the neck, especially the venous arteries leading to a bleeding recurrence after a misleading period of calm.

Amputations and bites:

With regard to the tearing, particularly of the auricular, it is necessary to preserve carefully any pedicle, even narrow, which still connects the fragment torn from the face. In this case, a suture with reinsertion can be performed with a good chance of success, the suture being done within six hours post-traumatic and the careful and daily follow-up in specialized environment.

When the amputation is complete, reimplantation may be attempted if the fragment has been stored at a temperature close to 5  C (do not place it directly in contact with ice), with the accident going back to less than eight hours. If these conditions are not met, sophisticated surgical techniques should be used by nursing the cartilaginous model, which has been removed from its skin under the skin and reused four weeks later or, if it is unusable, more complex reconstruction techniques.

The human bites in sports practice are exceptional and come within a forensic framework. They are particularly septic and require careful dressing and disinfection by suturing them within a maximum of 12 hours. Beyond that, it is better to move towards dressings and directed healing, with a secondary correction per flap one year after the bite.

The trauma of the face region by region:

For each region concerned, we will take the most frequently encountered break. We will eliminate the fractures disjunctions of the facial mass (called de Lefort) and the orbitonasal and orbitonasomaxillary dislocations, which I have never encountered in sporting practice, because at the moment, a fortunately insufficient impact power in team sport.

The frontal region:

Frontal impact is very common in contact team sport, rugby in particular. It can be the cause of a loss of consciousness and poses the problem of an extradural hematoma on fracture of the frontal bone, happily rare eventuality.

The peculiarity of this region is the fracture of the frontal sinus, situated above the root of the nose and the arch of the eyebrow in its internal third. In fact, there is great variability in the size and pneumatization of the frontal sinus from one subject to another. The fracture of the frontal sinus is aimed at the subject with a highly developed frontal sinus, the latter representing an area of ​​weakness with direct impact.

The clinical picture is relatively poor. In the absence of a wound, edema and a very pronounced ecchymosis quickly sit at the root of the nose. The deformation of the soft parts is evident and sometimes the palpation perceives, through the integuments of the forehead, a snowy crepitus reflecting the presence of air coming from the sinus and signing the fracture.

The player must leave the field permanently.

In the nearest hospital, a CT scan without and with injection is needed to detect the dreaded complication of this fracture: fracture of the posterior wall of the sinus, causing a possible intracranial hematoma made of the adhesion of the dura mater to the posterior wall and of a cerebrospinal rhinorrhea.

In the case of an isolated fracture of the anterior wall, if it is not displaced, there is no operative indication. The sportsman is arrested for four weeks.

When the fracture is displaced, it can also be accompanied by a frontal anesthesia by lesion of the V1 and surgical exploration is the rule, usually by bicoronal way to avoid a scar that is too visible. The ENT will check the permeability of the nasofrontal canal, as obstruction of the latter may be the source of second-rate infectious complications. After a possible release of the sensitive branch of the bone fragments, the latter will be replaced with an osteosynthesis by microplates or steel wires to reconstitute the bone curve. When the permeability of the nasofrontal canal is uncertain, the surgeon will make the decision to permanently exclude the sinus by removing the entire mucous membrane lining it and filling it with bone powder (among others).

When the fracture involves the anterior and posterior walls, the surgical procedure responds to the same principle, but it takes place in a neurosurgical environment, with simultaneous repair of a hard-merian breccia and a possible hematoma.

The complication is the cerebrospinal breccia with rhinorrhea of ​​cerebrospinal fluid on a fracture irradiating on the anterior stage of the base of the skull. This rhinorrhea is the second cause of a formidable meningitis. That is to say all the attention that must be given to this type of trauma. The rhinorrhea may appear in a staggered manner within 15 days of the accident. It is characterized by its positional syndrome, occurring leaning forward, rock water, especially one-sided. Its diagnosis will be confirmed by a test strip identical to that used for the urine, which will detect the presence of sugar, which in no case exists in the nasal secretions. The injured person must then be immediately addressed in a neurosurgical environment for further examination in the search for the origin of the breach and then a surgical exploration of the anterior stage of the base of the skull with fistula filling with, as a sequel, an anosmia due to the section of the olfactory branches during this exploration.

The athlete’s unavailability will be of the order of four to six months.

Cheekbone:

This region mainly responds to the malar bone that represents the typical fracture.

The trauma of this region is frequent in sporting practice.

In most cases, it is a simple ecchymosis with edema in front, with no sign of fracture. The player may leave a few minutes to benefit from the application of an ice bladder on the impact, and in the absence of loss of knowledge and visual discomfort, he may return to his field position.

The signs of fracture of the malar are quite easy to highlight, the player having left the field definitely:

• an asymmetric periorbital glare;

• edema and chemosis of the eyelids;

• a pain in palpation of the bone insertions: an internal third of the orbital border, the foot of the malarus, the finger being engaged in the mouth at the level of the upper vestibule, an external third of the eyebrow.

There are also possible signs of complications of this fracture:

• a depression of the cheekbone with respect to the healthy side, signing the displacement.

• diplopia in the glance upwards, by fracture line irradiated on the orbital floor.

• sub-orbital anesthesia by V2 lesion, extended to the nose wing, upper lip and vestibule.

• limitation of the mouth opening by prolonged fracture in the zygomatic arch.

The player will be driven in hospital for a CT without injection of the face that will appreciate the displacement and the state of the orbital floor. The ophthalmological assessment with visual acuity and Lancaster’s test to assess a possible diplopia will complete the assessment:

• either this closed fracture is without displacement and without complication: there is no operative indication. The athlete must stop any activity for four weeks before resuming the championship;

• either this fracture is displaced and / or complicated: the injured person must undergo surgery once the oedematous phase has disappeared, ie between the fifth and the tenth day after the accident. The fracture is reduced by the Ginestet hook placed percutaneously under the malar or the upper vestibule, the bone usually being maintained by an osteosynthesis (miniplaque, microplate or steel wire) after the suture frontal and orbital rims where these consolidation gestures will be performed.

The orbital border, which is approached by the subpalilebral, subciliary or transconjunctival route, will be the site of a release of the suborbital nerve (V2) in the event of anesthesia and an exploration of the orbital floor in the event of diplopia. The duration of hospitalization is two to three days. Stopping activity for four to six weeks depending on the complication and visual sequelae. The sequellar diplopia leads to the end of the athlete’s career.

The orbit:

Trauma to this region immediately involves controlling the visual acuity and integrity of the eyeball to eliminate the two major emergencies in this region, the wound of the eyeball and the physiological section of the optic nerve (elimination diagnoses) .

The player is forced out of the field because the inability to properly open the eyelids on the traumatized side prevents him from pursuing any sporting activity. Examination in locker room made on a seated player, after possibly removing his lenses, must lead to the diagnosis of fracture of the floor of the orbit, typical fracture of this region.

This fracture is encountered in the absence of an associated fracture of the malar, due to the movement of the orbital contents which, under the impact, will strike the orbital floor, which yields under the impact. The signs of this fracture are rather stereotyped:

• a lower and upper palpebral hematoma quickly formed;

• edema of the eyelids;

• an enophthalmos.

These unilateral signs will very quickly prevent a reliable examination, the examiner trying to hold the eyelids open with one hand to look for a diplopia when looking up. The sensitivity of the territory of the suborbital nerve is explored, the latter being often injured in this type of fracture. The athlete must under no circumstances blow his or her nose, the sudden insufflation of air into the nasal cavity and the maxillary sinus situated under the orbit causing the air to pass through the fracture of the floor with a pneumo-orbit, palpation of a snowy crepitation of the eyelids and an increased compressive risk on the intraorbital content.

The injured person is transferred to the neighboring hospital for CT without injection of the facial mass confirming the diagnosis.

The assessment will be completed by an ophthalmologic examination, with visual acuity and Lancaster test.

There is an operative indication with exploration of the orbital floor in the following situations:

• sub-orbital nerve anesthesia;

• muscle or muscular hernia manifested in CT, the source of an enophthalmia;

• a diplopia confirmed by the Lancaster test.

The surgical procedure is delayed between the fifth and tenth post-traumatic days, once the edematous phase is regressed. The pathway is transconjunctival, subciliary or subpalilebral, depending on the extent of bone loss of the floor and the surgeon’s habits. After checking for reduction in the blockage of the right lower muscle by incarceration and then reducing the latter, repair is performed by the bone fragments still in place for small losses of substance up to the autografts (taken from the patient himself) bone (parietal bone) or cartilaginous (auricular conch) and biomaterials (vicryl trellis or fine silastic blade) for the larger ones. The autografts have the advantage of very good tolerance, but they prolong the operating time due to their removal. Biomaterials are exposed to the risk of rejection and extrusion, especially for silastic, with myositis of the secondary lower right and final diplopia, but avoid the surgical time of the sampling.

The duration of the hospitalization is on average three days and the unavailability of four to six weeks. Orthoptic rehabilitation is sometimes necessary, the final diplopia condemning the player to stop his career.

In the absence of these three situations, there is no surgical indication, the athlete simply having to be put to rest for four weeks.

The preauricular region:

The fracture of this region is that of the zygomatic arch which constitutes the lateral counterforce of the face and is very exposed to lateral impacts.

The clinical picture is composed of spontaneous pain caused by impact and fracture, palpable and visible depression in comparison with the other side, and especially limitation of buccal opening by contusion of the temporal muscle under ( Table 1 ).

The athlete is sent to the reference hospital to benefit from imaging with lateral Hirtz images and especially CT without injection of the facial mass.

Surgery is performed in case of limitation of the mouth opening and / or unattractive penetration of the arch. Reduction under general anesthesia is most often done with the Ginestet hook, but other techniques have been described by balloon or rugine slipped surgically under the arch. Sometimes, in the case of unstable reduction, osteosynthesis is required by steel wires or mini pipes arranged by the hemicoronal route. The duration of the hospitalization is two days and the sport stopped for an average of three weeks.

The ear:

We shall not return here to the wounds and others of the pavilion, but to a particular circumstance of this region: the auricular blast.

This blast is not due to an explosion, but to a simple slap that, given a priori accidentally, will cause a shock wave on the eardrum.

The clinical picture associates immediate signs, with otalgia and deafness then tinnitus of acute timbre, even instability and rotatory vertigo.

The athlete leaves the field and the otoscopy seeks moderate otorrhagia, hyperemia of the eardrum, or even a perforation with tympanic rupture.

The instillation of auricular drops is formally forbidden, the ear being occluded by an occlusive dressing.

The opinion with an ENT is imperative within 24 hours, in order to realize an audiogram. This will make it possible to differentiate the following tables:

• a perceptual fall on the treble with tinnitus, intact tympanum, requiring medical treatment by Vastarel, with 15 days rest;

• a greater perceptual fall in a wider frequency band, with disabling tinnitus, the state of the eardrum being variable.Treatment involves corticosteroids and Vastarel, sometimes hospitalization of four to eight days and a four-week stop, with no guarantee of recovery;

• a much more marked perceptual fall, dizziness, tympanic rupture. The patient is hospitalized and has CT scan of the rock in search of a pneumolabyrinthe synonymous with opening of the inner ear, which requires a surgical exploration of the middle ear under general anesthesia to fill the opening (the fistula) of the inner ear. This surgery is framed by intravenous medical treatment of corticosteroids, antibiotics and Vasterel per os. The duration of hospitalization is ten days; the end of any sporting activity can last up to two months.

The nasal pyramid:

The nose is surely the area most frequently affected in sports traumatology for reasons that Edmond Rostand has perfectly explained in Cyrano de Bergerac.

Four entities must be distinguished from nasal trauma:

• simple contusion;

• fracture of the nose closed without displacement;

• fracture of the nose closed with displacement;

• open fracture of the nose.

The simple contusion results in localized edema on impact, with transient pain without epistaxis and perfect integrity of the nose in its form. The sportsman leaves temporarily. The examination confirms the absence of a septum hematoma (see next chapter), the bladder limits the edema and the player can resume his place.

The fracture of the nose not displaced closed is expressed by a hematoma in the bezel of the two orbits of fairly rapid appearance with marked edema and uni- or bilateral epistaxis.

There is no wound in relation to impact. The player leaves the field definitely. The epistaxis is controlled by the usual means and the gentle palpation of the nasal awning regains pain caused in relation to the fracture focus and confirms the absence of displacement. It is quickly difficult to evaluate because the edema settles. In any case, the athlete is brought to the neighboring hospital for a radiological assessment including an incidence of the clean bones (profile), a Blondeau, a Gosserez appreciating the displacement in the lateral direction.

The fracture line is visualized, the absence of confirmed displacement. In case of doubt, a secondary examination by an ENT, five days after the trauma, once the oedematous phase has passed, will reassess the displacement. In case of doubt, CT without injection of the facial mass allows better visualization of the lesions. There is no surgical indication, anti-inflammatory treatment may be prescribed; antibiotic therapy is debatable. The athlete will be unavailable for three weeks, the time of consolidation of the fracture.

The displaced closed fracture corresponds to the same clinical picture with the exception of displacement. The most frequent trips are:

• unilateral lateral trauma fracture resulting in traumatic bone depression and lateral deflection of the nasal aperture;

• the fracture disjunction of the nasal aperture where the two clean bones are fractured and dislocated as a whole on the opposite side to the lateral trauma, the nose taking an S-shape;

• the fracture of the nasal aperture where the clean bones retreat in profile under the anteroposterior impact, the nose taking the form of a horse saddle or nasal saddle.

The surgical indication is justified in order to reduce displacement and eliminate any aesthetic sequelae.

The operation takes place between the fifth day and the 12th post-traumatic day, under general anesthesia during a 24-hour hospitalization or even outpatient surgery.

The surgeon will reduce the fracture by introducing a guardian into the nasal cavity of the fractured clean bone and exerting external pressure with his other hand to reproduce the reverse movement of that at the origin of the displacement. The restraint is ensured by a plaster and a bilateral wiping removed the next day.   The plaster is kept for seven days, with the sport stopped for three weeks.

The open fracture is defined by a wound facing the impact. The paradox in this case is the very small edema due to cutaneous opening. This fact makes it possible to appreciate much more easily the displacement and the reality of the fracture by spreading the banks of the wound with the hooks of Gillies. A bony fragment sometimes causes hernia through the wound. The doctor must refrain from suturing the wound, as we saw in a previous chapter.

The player leaves the field definitely and is accompanied to the nearby hospital for a radiological assessment.

At the end of this assessment, there are two scenarios:

• either the fracture is not moved. The cutaneous suture is performed under local anesthesia. There is no hospitalization; antistaphylococcal antibiotic therapy is prescribed over seven days and the duration of the player’s unavailability is three weeks;

• either the fracture is displaced and the player is operated within 24 hours, with reduction of the fracture and suture at the same operative time. The hospitalization is 24 hours, the injured is discharged under antibiotic therapy, the plaster is removed on the seventh day postoperatively and the sons, the sports activity being stopped for three weeks.

The particular case of the partition. The bulk hematoma:

Any traumatized nose must have an endonarinary examination, using an otoscope to visualize the septum. If the latter is deviated, nothing says that this deviation is secondary to the trauma, it can be ancient. If the septum is flatly dislocated, obstructing the nasal cavity, with a wound of the nasal mucosa, its recent character is hardly doubtful. The reduction of the fracture of the clean bones is then accompanied by a trial of realignment of the partition with the installation of splints on either side of it to keep it in place over a period of eight to ten days. This realignment is random because of the unstable nature of the cartilage relative to the bone.

The hematoma of the septum is observed in adolescents because of the predominance of the cartilaginous nose (lower half) whereas in adults, the bone becomes the majority, the cartilage constituting only a third of the nasal pyramid.

The fracture of the cartilage of the septum without mucous wound causes the formation of an anterior hematoma of the nasal fossa, soft on palpation and purplish under examination, obstructing the nasal process. Its diagnosis is fundamental because, unknown, the hematoma is infected between the tenth and the 15th post-traumatic day, resulting in a purulent melt of the cartilage which supports the nasal awning leading to a very unsightly and difficult nose to correct. The identified hematoma is drained under general anesthesia, the patient being hospitalized for 24 hours, with a broad-spectrum antibiotic prescribed over a period of eight days.

Cerebrospinal rhinorrhea:

We have already mentioned this in the fracture of the frontal sinus.

It can also be observed in the case of a so-called  outdated  nose fracture, that is to say in the case of a fracture with impact on the root of the nose, the fracture line irradiating on the anterior floor of the base of the nose skull. Diagnosis is made in relation to the extent of CT lesions, all attention to be focused on a flow of  rock water  liquid with positional syndrome, occurring on one or both sides, a reagent strip identifying sugar in its breast, which means that it is with certainty cerebrospinal fluid.

The procedure to be followed is the same as for the frontal sinus.

The cheek:

We mean by cheek the region situated below the cheekbone and which corresponds to the anterior wall of the maxillary sinus. The typical fracture is the fracture of the maxillary sinus, essentially its anterior wall. This type of lesion is relatively rare, because it is protected by other more significant reliefs (the nose and the cheekbone).

The diagnosis is based on local edema, a possible perceptible sinking on palpation, a discrete epistaxis and the perception of snowy crepitation, synonymous with air suffocation in the skin of the cheek due to the opening of the sinus. It may be associated with anesthesia in the sub-orbital nerve area in case of fracture irradiated to the orbital rim.

The player must leave the field permanently and be taken to the neighboring hospital for CT of the facial mass.

Any fouling is forbidden to avoid any insufflation of air in the soft parts of the cheek. There is no surgical indication, because this type of fracture has no consequence, neither aesthetic nor functional. The only exception is an involvement of the suborbital nerve which must be treated surgically and freed from any bone and / or edema. The player’s unavailability is three weeks.

The jaw and the chin:

This region corresponds to the mandible, whose fracture possibilities are very varied. They are responsible for possible aesthetic and functional sequelae, but also disorders of the dental articulation that make it specific.

They are frequent in sports traumatic pathology.

Their classification is above all topographical and we will distinguish schematically the fractures:

• the toothed portion or horizontal branch, including the symphysis;

• the angle;

• the rising branch;

• the condyle.

The most frequent fractures in the adult are parasymphyseal, adjacent to the median line and the angle, due to the areas of weakness represented by the wisdom tooth socket (angle) and the orifice of exit of the lower dental nerve (parasymphyseal). They are sometimes bifocal, parasymphyseal and angle, or rising branch for example.

In children and young adolescents, it is the fracture of the condyle that dominates, most of the time following a fall on the chin.

Due to the frequency of the mucous and gingival wounds, because of the adhesion of the latter to the bone, the fractures of the mandible, especially the toothed portion, are open fractures, although the gravity is less severe than open fractures on the skin.

The clinical picture is stereotyped, following a direct impact on the jaw or chin:

• pain with spontaneous impact and palpation;

• limitation of mouth opening;

• a modification of the dental articulation (the injured person will say that he does not feel his teeth as before), with a lateral deviation of the jaw at the mouth opening (fracture of the condyle);

• a wound of the gum and mucosa on the endobuccal examination, in case of fracture of the horizontal toothed portion.

The player must leave the field for a close examination in the locker room after the removal of his mouth guard. Dental articulation disorder (limitation or deviation), endobuccal wound or dental nerve anesthesia (loss of sensitivity of the lower vestibule and lower hemilèvre) confirm the probable fracture.

The injured person is taken to the nearest hospital to benefit from the following radiological assessment:

• orthopantomography, the most frequent radiological incidence for exploring the mandible;

• condylar incidences, open mouth, closed mouth;

• CT without injection of the facial mass;

• at the end of imaging, the fracture is confirmed and the treatment is put in place.

For condyle fractures, two types of treatment are currently proposed according to the surgeon’s training school:

• functional treatment, with re-education of liquid chewing initially for three weeks if the occlusion is good, or by a preliminary intermaxillary blockage of five to eight days, then mixed, then normal that allows a good recovery of the function without necessarily a good anatomical reduction of the fragments;

• or surgical treatment (osteosynthesis or screws) to restore good continuity of the bone fragments. The proponents of the functional treatment emphasize the difficulties of this surgery: risk of facial nerve injury during the approach, devascularization of the condyle, infectious risk due to the opening of the articular cavity.

For fractures of the horizontal portion, the angle and the rising branch, here again two types of treatment are conceived, but in a complementary way:

• in the first 24 hours, osteosynthesis is favored by mini- or maxiplaques, possibly supplemented by intermaxillary blockade in case of unstable fracture. It will make it possible to resume a feeding by natural way rather quickly and to prevent any ankylosis of the temporomandibular joints.

This surgery is done under general anesthesia, the first ways to position the osteosynthesis being endobuccales. In the first step of a parasymphyseal fracture, the surgeon controls the exit of the lower dental nerve, trying to release it in the case of a bone splinter or local compression causing anesthesia in the lower territory ;

• when the diagnosis is made after the first 24 hours, it will be wiser to set up an intermaxillary blockage to prevent the fracture of the fracture site, blocking fractures and being left in place for three weeks. The resumption of mastication will be more difficult here, with a greater risk of ankylosis.

The duration of hospitalization in case of mandibular osteosynthesis is on average five days, the duration of the discontinuation of sports activity from six to eight weeks.

The luxation of the temporomandibular joint is, on the other hand, rather rare outside a preexisting laxity known to the player. The jaw is blocked in opening, the injured being unable to close his mouth. It is not recommended, except for certain preexisting laxity, to attempt a Nelaton maneuver to reduce this dislocation, as it may involve a fracture of the condylar region on one or both sides. A radiological assessment at the neighboring hospital is a prerequisite before any attempt, which sometimes requires general anesthesia.

The neck:

The traumatology of the cervical region was quite exceptional in the practice of team sports until the last few years when rare and serious accidents appeared.

The cervical region corresponds to the larynx, and the closed trauma of the larynx leads to emergency situations, with dyspnea, the larynx being the first stage of the respiratory tract. The direct impact is prohibited by the regulation of all team sports, but it is observed when the defender, taken against the foot, tends desperately to the arm to prevent the advance of the attacker (we speak of  tie  ), or when the attacker opposes the defender’s opposition using his elbow.. .

These are closed trauma and the examination of the wounded player, lying on the ground, obeys the same rules that we listed at the beginning of this chapter:

• reassure the conscious casualty;

• release the buccal cavity from any secretion, foreign body and dental apparatus;

• dislocate the jaw, avoiding excessive manipulation of the cervical spine (associated lesion);

• placing the injured person in a lateral position;

• fit a Guedel cannula to remove the base of the tongue.

Intubation should only be considered in cases of acute asphyxia, as it is particularly uncertain in the case of fracture of the larynx. In practice, if the injured person breathes properly by himself, it is important to do nothing.

Wearing a cervical spine should be easy because of the risk of the associated lesion; the wounded man emerged from the field in a stretcher, in an elongated position.

The cervical examination looks for subcutaneous emphysema synonymous with laryngeal breccia, the injured complaining of an embarrassment to swallow and a possible change of voice.

The injured person is immediately transferred to the nearest hospital by a medical vehicle.

Arrived at the hospital emergency room, the ORL examination by fibroscopy and the degree of respiratory discomfort will make it possible to distinguish three stages:

• there is no respiratory discomfort, fibroscopy does not find any abnormality, the injured person can benefit from cervical and laryngeal CT without injection which will confirm the integrity of the airway: the athlete can go home. He will be at rest for eight days;

• same situation, but fibroscopy finds mucosal lesions and hematomas within a larynx with conserved anatomy, there is no laryngeal mobility disorder, no detectable fracture. The injured passes his cervical CT, little modified with, sometimes, however a fracture of the larynx isolated and simple. It will be kept 24 hours in surveillance because of the risk of secondary respiratory worsening by edema, treated then by aerosols, corticosteroids and antibiotherapy. The player’s unavailability is three weeks;

• respiratory discomfort, inspiration dyspnea with bradypnea, larynx with fibroscopy is the site of minor lesions with edema, hematoma and mucosal lesions: a tracheotomy under local anesthesia is necessary.

This has a triple advantage:

• ensuring an adequate aviation sector;

• allow general anesthesia if necessary;

• avoid aggravating laryngeal lesions by intubation.

Once the tracheotomy is performed, the injured person receives a CT scan to assess the lesions and decide on a possible intervention, sometimes by external anesthesia to restore the anatomy. The duration of the hospitalization is eight days, the cessation of activity from two to three months. The sequelae are not uncommon, especially in the form of dysphonia.

Conclusion:

All these cervicofacial lesions are at the origin of any sequelae and / or handicaps leading to a premature end of career or a recovery without ever being able to recover the previous level, especially in professional sport. In addition, the impacts at the origin of these injuries are sometimes at the limit of the practice of the game, punishable on the ground, but also before a civil or criminal court sometimes. That is to say the importance of the initial management by the doctor of the sport accompanying the team, or receiving the athlete the day after the match and redressing a diagnosis.

The orientation of the player to a competent surgeon or to the right emergency structure for ophthalmological care, for example, is of prime importance.

But the role of the sports doctor goes beyond that. In association with his colleagues, he must alert the federations in the event of a resurgence of some cervicofacial lesions previously absent from the ground, this recrudescence testifying to a sporting evolution which will have to be framed and prevented by an evolution of the rules of the sport in question sports practices to be abandoned.

 

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