The incidence of sports-related faciai trauma in children

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1 ORIGINAL ARTICLE The incidence of sports-related faciai trauma in children Stephen W. Perkins, MD, FACS Steven H. Dayan, MD Eric C. Sklarew. MD Mat-k Hamilton. MD Gregory S. Bussell, MD Abstract We condmled a.fun'ey of physician members of the American Academy of Facial Plastic and Reconstructive Surgery to determine the incidence and nature of facial traumas seen in their practices. We solicited information on the anatomic location of each injury, the severity ofthe trauma, and whether the injury occurred during a sports activity. According to the responses, 21% of facial fractures and 29% of were experienced hy patients aged 17 years and younger who were participating in sports. We believe that many such injuries can he prevented with greater use of protective equipment. Introduction Despite ihc use al" protective gear, the incidence of sportsrelated facial trauma among children remains significant. In its most recent report, the U.S. Consumer Product Safety Commission (CPSC) In 1991 reported that more than cases of facial trauma occurred in children younger than 14 years while they participated in sports activities.' In private practice, we have found that the number of nasal injuries incurred during youth softball games is surprisingly high, particularly among female pitchers who are hit by a batted ball. In the past 2 decades, the incidence and severity of facial trauma from all causes have steadily declined.-' Among the reasons cited for this decline are laws requiring the u.se of seat belts, use of airbags. higher legal drinking ages, lighter enforcement of drunk driving laws. and the more widespread use of protective facial gear in From (lie Depanment oi" Otolaryngology-Head atid Neck Stirjiery. Indiana University. Indianapolis (Dr. Perkins atiti Dr. Hamilton). the Deparltiient ofot(il:iryngolna,y-head and Neck.Surgery, the University of lllinois-chicaco (Dr. Dayan and Dr. Busscll). and ihc Division ot'otnlaryngology-head and Neck Surgery. University ol' Maryland. Kensington (Dr..Sklarew). Reprint requests: Steven H. Dayan. Tardy-Dayan Facial Plastics Instilule. 29! 3 Common wealth. Chicago. IL Phone: (773) : fax: (773) sports. In Beck and Blakeslee reported that 11% of all facial injuries were incurred during sports activities; the only causes more common were motor vehicle accidents and assaults.- Other published studies have shown that sports-related injuries account for 3 to 29% of all facial injuries.""' Numerous studies have documented the effectiveness of protective equipment in preventing sports injuries.^'" Studies of populations ranging from professional hockey players to Little League baseball players have shown that helmets, facemasks. mouthguards. and similar devices all reduce fracture and injury rates. According to estimates, between \.5 and 15% of all facial fractures occur in children." Three reasons are thought to explain this relatively low incidence among children. First, a child's bony structures are highly elastic. The presence of cartilaginous growth centers makes the pediatric facial skeleton more pliable. As a result, the facial structures can undergo signiucant distortion without fracturing. Second, a child's face constitutes a relatively smaller area of the cranium than does an adult's face. Third, the soft tissue in children is thicker and contains a higher proportion of fat. which provides a cushion atop the underlying framework. Even so.. U.S. emergency rooms treated more than 1.3 million cases of injury to the face. eyes, and mouth in patients younger than 15 years during a recent I-year period.' Materials and methods We mailed 800 surveys to physician members of the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) in and received 53 usable responses (6.6%). We asked respondents to describe the number and nature of facial traumas in their practices during the previous 5 years. We solicited information on the anatomic location of each injury, the severity ofthe trauma, and whether the injury occurred during a sports activity. 632 ENT-Ear, Nose & Throat Journal August 2000

2 PERKINS, DAYAN, SKLAREW. HAMILTON, BUSSELL Table 1. Facial fractures All ages, n (%) Aqe <17vr n 1{%) Age > n (^ Atl facial fractures 767(100) 246 (32) 80(10) 335 (44) 106(14) 323 (42) 131 (17) 32(4) 136(18) 24(3) Nasal fractures 482 (63) 178(23) 55(7) 1 77 (23) 72 (9) Table 2. facial fractures All ages. n C/o) Aqe <17vr n 1(%) Aqe>18 vr n ( /o) facial fractures 323(100) 131 (41) 32 (10) 136 (42) 24(7) From softball 98 (30) 45 (14) 11 (3) 33(10) 9(3) From baseball 29 (9) 20 (6) 8(2) 1«1) Softball/baseball combined 127 (39) 65 (20) 11 (3) 41 (13) 10(3) Results Facial fractures. The AAFPRS respondents reported a total ol" 767 facial IVaclures in males and females of all ages (table 1). s experienced 76% of all facial fractures. In the two sexes combined, the fracture rate among those aged 17 years and younger was 52%. facial fractures. Some 42% of all facial fractures were sports-related, and males experienced 83'ii of these injuries (table 2). The peri;entage of sportsrelated facial fractures was equally distributed between the two age groups. In the two sexes combined. 23% ofthe injuries in the younger group were experienced during Softball or baseball games. Nasal fractures. Ofthe 767 facial fractures. 482 (63%) were, as documented by radiographic or clinical examinations (table 3). Just as they did with facial fractures, males accounted for 76% of all. In combined, a higher rate of nasal fracture (58%) was seen in those aged 18 and older. Of all the nasal fractures. 80% required surgical intervention.. Of the (49%) were sports-related (table 4). Categorized by sex and age. the rales were higher in the male group and in the younger group ^84 and 6\%, respectively. In combined, 32% of these injuries in ihe younger group were experienced during softball or baseball sames. Of all patients with sports-related. 29% had associated injuries, including. In order of decreasing incidence, malar complex fractures, orbital fractures, and soft-tissue lacerations. Discussion We found thai 42'^ of all facial fractures were sportsrelated, a significant figure in light of the preventable nature of these injuries. The vast majority of these injuries (83%) were experienced by males, a finding that is in accord with previous studies, where the incijence of facial trauma among males has been reported to range from 60 to 88%.-^ '- As the leading structure on the face, the nose is especially vulnerable to injury.'^ Previous studies have reported ihat accounted for 23 to 45% of all pediatric facial fractures."*' We believe that these figures might underestimate the true number of pediatric nasal injuries. We found that more than 60% of all facial fractures included a nasal fracture, and that 42%' of these cases involved patients aged 17 years and younger. But when only sports-related were e\ aluated, the younger group experienced 61% of these injuries. Perhaps the difference between our findings and those of other studies can be explained in part by the different experiences ofthe referral networks' individual authors. 634 ENT-Ear, Nose & Throat Journal August 2000

3 PERKINS, DAYAN, SKLAREW, HAMILTON, BUSSELL Table 3. Nasal fractures All Afl ages. 482(100) Aae <17vr n (32) m 55(10) Aae >18 vr n (Vo) 177 (44) 72 (14) 237 (49) 118(24) 25(5) 81 (17) 13(3) Nasal fractures requiring surgical reduction 386 (80) 127 (26) 37 (8) 160 (33) 62(13) Table 4. All ages. Aae n 1 <17vr Age n >18vr 237 (100) 118 (50) 25(11) 81 (34) 13(5) From softball 95 (40) 45(19) 11 (5) 32(14) 7(3) From baseball 24 (10) 19(8) 5(2) Softball/baseball combined 119 (50) 64 (27) 11 (5) 37 (1 6) 7(3) For example, published reports in dental journals reveal a much higher percentage of dentoalveolar fractures."" Our data reflect the practices of otolaryngologists and facial pla.stic surgeons, whose patients represent a select population of traumatized patients. These patients, who were often referred by primary care physicians, frequently demonstrated more severe injuries and more significant anatomic deformities. Additionally, these patients were much more likely to require surgical intervention. Of the many physical and aggressive sports that are played, softball and baseball account for the most facial fractures. Facial fractures are much more common in softball than in baseball because softball has a much higher number of participants, including a great number of females. Another factor in the higher incidence of softball injuries might be the greater mass and volume of the ball itself. But while injuries tend to be more common in softball. they tend to be more severe in baseball. Little League baseball has an estimated 6 million participants between the ages of 5 and 14 years.''' A CPSC study found that 40% of sports-related injuries in children between the ages 5 and 14occuiTedduringbaseballgames.'-ln 1995, 162.l()() baseball-related injuries were treated in hospital emergency rooms. 159r of which involved children between tbe ages of 10 and 14 years.'"* Most basfhati injuries occur to batters. The use of facemasks woiittl prevent or reduce the severity of many of them. 636 ENT-Ear, Nose & Throat Journat August 2000

4 PERKINS, DAYAN. SKLAREW, HAMILTCN, BUSSELL We believe that particular attention should be paid to those in the under-11 age group, who have less skill and coordination, slower reaction times, and less maturity. The CPSC reported that more than half of the injuries in this group occurred in the head or neck." Unlike adults, children can experience a septal or bony fracture with only minimal external signs of trauma.''^ Baseball-related injuries exceed those ofall other sports as a cause of death; the CPSC recorded 88 baseballrelated fatalities between 1973and 1995.'"'Twenty-one of these fatalities occurred when a ball hit a player's head. Overall, most baseball injuries occur to batters. Even though batting helmets with two-sided protective eartlaps are required in all parts of the country, helmets equipped with facemasks are not (figure). We believe the use of facemasks throughout the United States would be of great benefit. Since the Dixie Baseball League, an organization based in I 1 southern states, instituted a mandatory facemask rule, the injury rate there has fallen." After reviewing our data LIS well as those of other investigators, the CPSC updated its safety reeoniniendations for baseball equipment in The CPSC estimated that baseball injuries including approximately t)ne-third of those treated in emergency rooms could be prevented. For example, the CPSC estimated that facemasks on batting helmets could prevent or lessen the severity of facial injuries. The CPSC also recommended other protective measures, such as safetyrelease bases and softer balls. In conclusion, our data clearly identify the risk of facial fractures in children who play softball and baseball. We endorse Ihe CPSC's position on the use of facemasks. not only for young batters but for young pitchers as well because of their proximity to batted balls. References 1. NLitinriiil Electronic Injury.Surveillance System, U.S, Consumer Product Sulely Commission Direclorale for Epidemiology. Washington. D.C.. 199t, 2. Beck RA. Blakeslee DB. The changing picture of facial fraclures. 5-year review. Arch Otolaryngol Head Neck Surg 1989:115: Dodson TB. Kaban LB. Caiiforiii;i lujiidaiory seat belt law: Tlie efl'ecl of recent legislation on motor vehicle accident related maxillofacial injuries. J Oral Miixilloliic Surg MEDICAI. AND SCIENCES AUDIOLOGICAL ROOMS AND SUITES NOISE CONTROL TECHNOLdcilBS CAM LOCK PANEL SYSTEMS Eckel ofleis a udde range D1 siana^id tugtnm-maim sultis Iu mosi a leglcat clinlcil md reseinih Mlcomtiirre iso ACIXISTIC K d tconomy ATTtNIWIING NCI OSURE FOB HEWING IMPAIRMENTS in INFANTS US9C emission * AudHory tyamstwn I Infant hearing schrenino IBSIS rpies or CANaDa LI RESEARCH CLINICAL SCREENING HF.AHINC; AID MODELS AB.ZDO, AB-2000 and Ae-4330 and AS-4240 ENGINEESEO FOfl HIGH READYTO USE UNSURPASSED VALUE IN PREASSEMBLED (jnefllor McdicsioflicesS Clinical aotilicatidn SciiDOihBarlnoiesnno inousirlaitieanngconservattanf Box Allison Ave. Morrisbutg QK K0C1XD Tel SI3-5« * Fax 613-5«-^t73 Web site, www edel.co/eckel E-moil: e(kal(uecblco Visit us at AAO-HNS Booth #402 1 (J Linn EW. Vrijhoef MM. de Wijn JR. ct al. Facial injurie.s sustained during sports and games. J Maxillofac Surg 1986:14:83-8, Frengtielli A. Ruscito P. Bicciolo G. el al. Head and neck trauma in sporling activities. Review of 208 cases. J CraniomaxillotacSurg tyyi;]9: Muraoka M. Nakai Y. Twenty years of stati.stics and observatit>n of facial bone fracture. Acta Otolaryngol Suppl 1998:538: Castaldi CR. oral and facial injuries in the young athlete: A new challenge for the pediairic demist. Pediatr Dent 1986:8:311-6, Hildebrandt JR. Dental and ma\iilofacial injuries, Clin Sports Med 1982:1: Diamond GR. Quinn GE, Pashby T.T, Eastcrbrook M. Ophthalmologic injuries. C!in Sports Med 1982:1: Handler SD, Wettiiore R. Otolaryngologic injuries. Clin Sports Med 1982:1: Koltai PJ.RabkinD. Managementof facial trauma in children. Pediair Clin North Am 1996:43: U.S. Consumer Product Safety Commission. Overview of sports-related injuries to persons 5-14 years of age. Washington. D.C Dinginan RO. The nose. In: Dingman RO. Natvig P. eds. Surgery of Facial Fractures. Philadelphia: W.B. Saunders. 1964:267-94, U.S. Consumer Product Stifeiy Commission. Sitidy of protective equipment for baseball. Washington. D.C Olsen KD. Carpenter RJ. Kern EB, Nasal septal injury in children. Diagnosis and management Arch Otolaryngol 1980:106: For more information Circle 149 on Reader Service Card 638 ENT-Ear, Nose & Throat Journal - August 2000

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