Between 2001 and 2006, 138 admissions took place

Management of Sport-Related Maxillofacial Injuries Fabio Roccia, MD, Alberto Diaspro, MD, Andrea Nasi, MD, Sid Berrone, MD, DDS Turin, Italy By analyzing sports-related maxillofacial fractures, we sought to describe preventive measures and recovery times until sporting activities could be resumed. Between January 2001 and December 2006, 1241 patients were hospitalized as a result of maxillofacial fractures. The patients with sports-related maxillofacial fractures were analyzed based on age, sex, type of sport, injury mechanism, trauma site, presence of associated fractures, hospitalization, treatment method, and recovery time until the resumption of sporting activities. One hundred thirty-eight patients (11.4%) sustained sports-related maxillofacial fractures: 121 males and 17 females (ratio 8:1), aged between 11 and 72 years. The sport producing the greatest number of injuries was soccer (62.3%), followed by skiing (14.5%), and horseback riding (6.5%). The injuries involved mainly the middle third of the face (71.6%), and the mandible was the most affected site (27.2%), followed by the maxillaryzygomatic-orbital complex (25.9%). Treatment was surgery in 93.5% of the patients, with an average hospitalization period of 3.5 days. The protocol created to manage the follow-up of maxillofacial injury patients advised resuming sports activities at least 40 days after the trauma, except in the case of combat sports, when a period of 3 months was required. Although the results of this study indicate a reduction in the total incidence of sports-related maxillofacial injuries, they also show an alarming secondary increase in trauma resulting from the most popular sport in ItalyVsoccer. Therefore, stricter regulations are needed to discourage violent play, rather than relying on the use of protective equipment. Moreover, patients should be advised when they can resume sports activities, particularly in the case of professionals and semiprofessionals. From the Division of Maxillofacial Surgery, Head & Neck Department, San Giovanni Battista Hospital, Turin, Italy. Address correspondence and reprint requests to Fabio Roccia, MD, Assistant Professor, Division of Maxillofacial Surgery, Head & Neck Department, San Giovanni Battista Hospital, Via Febo 19, 10133, Turin, Italy; E-mail: Fabio.Roccia@poste.it Key Words: Sport, maxillofacial fracture, recovery, injury prevention is a ritualized form of war, Sport 1 and it is slowly, but consistently, increasing as a result of the popularity of sports activities, the availability of facilities, and greater leisure time. Although preventive measures for sportsrelated injuries have been reviewed in several maxillofacial articles, it is equally important to establish when patients can resume sports activities, especially in the case of professionals or semiprofessionals. A study by Mahmood et al 2 showed that after a zygomatic fracture, disagreement exists over recovery times and when sports activities can be resumed. Therefore, this report not only evaluates the incidence of sports-related maxillofacial injuries and discusses preventive measures but also provides a protocol for recovery times before sports activities can be resumed. PATIENTS AND METHODS Between January 2001 and December 2006, 1214 patients with maxillofacial fractures were admitted to the Maxillofacial Surgery Division of San Giovanni Battista Hospital, Turin, Italy. Patients with sports-related fractures were included only if they had complete clinical and radiologic records and a minimum follow-up of 3 months. The retrospective study analyzed age, sex, type of sport, injury mechanism, trauma site, presence of associated fractures, hospitalization, treatment, and recovery times before sports activities could be resumed. RESULTS Between 2001 and 2006, 138 admissions took place because of maxillofacial fractures due to sports injuries, for an incidence rate of 11.4% (Table 1). The patients were between the ages of 11 and 72 years (mean age, 28.5 years), with the greatest incidence between the ages of 21 and 31 years. One hundred twenty-one (87.7%) males and 17 females (12.3%) were admitted, for a ratio of 8:1 (Table 2). 377

THE JOURNAL OF CRANIOFACIAL SURGERY / VOLUME 19, NUMBER 2 March 2008 Table 1. Causes of Maxillofacial s No. % MVA 374 30.8 Fall 311 25.6 Assault 295 24.3 Sport 138 11.4 Work 67 5.5 Other 29 2.4 Total 1214 100 Of the 19 types of sports that were responsible for maxillofacial fractures, soccer was the most common cause (62.3%), followed by skiing (14.5%), and horseback riding (6.5%), which was the most common cause of maxillofacial fractures in females (41.2%) (Table 3). The injury mechanisms were subdivided into 3 categories: impact with another player, impact with the ground, and impact with equipment. In the case of soccer, 92% of the trauma was the result of impact with another player, mainly involving blows with the head or knee. By contrast, in the case of skiing, fractures were sustained almost equally as a result of impact with the ground and collision with another skier. With horseback riding, 5 patients fell from their horses, whereas four were kicked, with 2 cases of rupture of the ocular bulb. Table 4 summarizes the fracture sites by sport. As shown in Table 5, of the 162 maxillofacial fractures, the middle third of the face was the region most affected by sports-related injury, whereas the mandible was the most common fracture site (27.2%), followed by the maxillary-zygomatic-orbital complex (25.9%). In addition, 9 patients had dental fractures or dislocations (3 cases each in soccer and horseback riding, 2 in skiing, and 1 in rugby). Twentytwo patients sustained facial soft tissue lacerocontusion injuries: the lip in 8 patients, the chin and eyebrow in 4 patients each, the eyelid in 3 patients, the mandibular body and zygomatic arch in 2 patients, and the laterocervical region in 1 patient. Twenty-two patients sustained multiple maxillofacial fractures (Table 6), whereas 9 patients (6.5%) sustained associated fractures in other areas of the body (Table 7). Treatment was conservative in 6.5% of the cases (9 patients). In 19.6% of the cases (27 patients), closed reduction was performed for 15 fractures of the zygomatic arch and 3 fractures each of the dentoalveolar bone, nasal bone, undisplaced condyle, and mandibular angle. In the remaining 73.9% of cases (102 patients), open reduction and internal fixation were performed. The mean hospitalization period was 3.5 days compared with 6.5 days for motor-vehicle accident (MVA) injuries, 4.4 days for falls, 3.9 days for assaults, and 5.1 days for work-related accidents. The recovery times before the resumption of sports activities depended on the type of sport. Maladiere et al subdivided sports activities into contact sports (team sports and combat sports) and noncontact sports (vehicular sports, ball sports, and other individual sports). In the case of combat sports, which applied to 2 patients in this study who practiced karate and kickboxing, the patients were advised to wait at least 3 months before resuming contact sports activities. In the case of other contact and noncontact sports, the patients were advised to wait 40 days before resuming sports activities if they had not sustained associated injuries to other areas of the body. Therefore, the resumption of sports activities was in accordance with the protocol shown in Table 8. Follow-up did not identify any complications in the periodic assessments scheduled during the 3- month period after hospitalization. DISCUSSION The literature on sports-related maxillofacial trauma reports that although a reduction has occurred in the number of MVA-related maxillofacial fractures as a result of the legal requirement to wear seat belts and the introduction of air bags, an increase is seen in the incidence of facial fractures resulting from assault and sports activities. 3Y8 In our experience, we have observed a slight decrease in the number of sports-related maxillofacial fractures when comparing our data with those cited in a previous article published by our division. 9 Between 1982 and 1998, of the 2925 admissions for maxillofacial injuries, the incidence of sports-related injuries was 12.9%. The incidence reported in this study falls within the range of the sports-related maxillofacial trauma literature published during the last 10 years, which varies between 6% 10 and 13.3%. 11 Table 2. Age Distribution of Patients Age, yr Males Females Total 0Y9 0 0 0 10Y20 33 6 39 21Y30 48 7 55 31Y40 23 3 26 41Y50 7 1 8 51Y60 3 0 3 61Y70 6 0 6 71Y80 1 0 1 Total 121 17 138 378

7-YEARS EXPERIENCE OF MAXILLOFACIAL FRACTURES AFTER SPORTS ACTIVITIES / Roccia et al Table 3. of Sports Distribution of Patients in Relation to Type Sport n Males Females Soccer 86 85 1 Skiing 20 14 6 Horseback riding 9 2 7 Motocross 3 3 0 Rugby 3 3 0 Cycling 2 2 0 Mountain bikini 2 2 0 Swimming 2 1 1 Baseball 1 1 0 Basketball 1 1 0 Bobsledding 1 1 0 Golf 1 1 0 Free climbing 1 0 1 Karate 1 1 0 Kickboxing 1 1 0 Skating 1 1 0 High jump 1 0 1 Water skiing 1 1 0 Tennis 1 1 0 Total 138 121 17 If the literature on the epidemiology of maxillofacial trauma is included, the range varies between 2% 12 and 31%. 13 Because no fractures were recorded for patients younger than 10 years, given that we are not a pediatric division, sports-related injuries were typically sustained by men younger than 40 years (86.9%). However, age cannot be considered a risk factor. Although youthful temperament and vigor may contribute to a style of play that predisposes one to injury, at older ages, we find less coordination and increased degenerative bone and ligament changes that may increase the chances of injury. 14 Young people certainly participate more in sports and probably in a more competitive and aggressive manner than older people. Because soccer is the most popular sport in Italy, it serves as the main outlet for sporting competitiveness and often aggressiveness, accounting for hospitalization of 62.3% of patients. This is a considerable increase compared with the 43.5% cited by De Gioanni et al 9 and is followed by skiing at 14.5%. Analyzing the causes of fractures by age, we found that for patients younger than 40 years, soccer remained in the top position at 67.5%, followed by skiing at 10%. However, in the case of patients older than 40 years, the positions were inverted with skiing at 44.4% (8 of 18 patients) and soccer at 27.7% (5 of 18 patients). The considerable increase in the incidence of maxillofacial injury related to soccer can be explained both by its popularityvwith 4,290,000 players in Italy 15 Vand more violent play. This is evidenced by 92% of maxillofacial fractures being caused by headto-head impact and head-to-elbow impact or by collision with another player. In skiing, fractures were caused almost equally by impact of the head with another skier or with the ground. This is often due to overcrowding of the slopes and because runs are better prepared and smoother, allowing higher speeds to be achieved. 16,17 In the case of horseback riding, the causes of maxillofacial fractures are falls and kicks to the face Table 4. Location of Sites in Different Sports Maxillo-Zygomatic- Complex Walls Zygomatic Arch Le Fort Frontal Sinus Dentoalveolar Maxilla Dentoalveolar Palatal Bone Baseball 1 Basketball 1 Bobsledding 2 Cycling 1 1 1 2 1 Free climbing 1 Golf 2 High jump 1 Horseback riding 5 2 1 1 2 1 1 Karate 1 Kickboxing 1 Motocross 1 1 1 Mountain biking 1 1 Rugby 1 2 1 Skating 1 Skiing 12 5 4 3 3 1 Soccer 21 31 22 13 2 1 1 1 Swimming 1 Tennis 1 Water skiing 1 Total 43 42 39 15 9 8 2 2 1 1 379

THE JOURNAL OF CRANIOFACIAL SURGERY / VOLUME 19, NUMBER 2 March 2008 Table 5. Incidence of Sports-Related s from horses, which are often due to the inexperience and inattention of the riders. 18 The rare type-o fractures that are attributable to impact with equipment are found in ball sports, such as golf, tennis, and baseball, where one orbital injury was recorded, with 3 orbit floor fractures, one of which was associated with the medial wall. As shown in Table 4, the middle third of the face was the area that was most affected, although the mandible was the most common fracture site, followed by the maxillary-zygomatic-orbital complex. Comparing our data with that in which soccer was the main cause of fractures (with the exception of Frenguelli et al 4 in which the nose was identified as the site that was most affected because that study was carried out by an ear, nose, and throat unit), the most common site of sports-related injury is the maxillaryzygomatic-orbital complex 9,19 or, as in the case of this study, the mandible. 10,11,20 The low incidence of Site No. s Upper third (1.2%) Frontal sinus 2 Middle third (71.6%) Maxillo-zygomatic-orbital complex 42 floor 29 medial wall 7 roof 3 Zygomatic arch 15 9 Le Fort 8 Dentoalveolar 2 Palatal bone 1 Lower third (27.2%) Angle 17 Parasymphyseal 11 Condyle 8 Body 5 Symphyseal 2 Dentoalveolar 1 Total 162 dentoalveolar fractures can be explained by the fact that at our hospital, these fractures are often treated at the odontostomatology unit, whereas fractures of the nose are treated at the ear, nose, and throat unit. Nevertheless, a general consensus holds that sports-related maxillofacial fractures are less severe than those caused by MVAs. Of the patients hospitalized for sports-related trauma, 15.9% presented with multiple fractures of the maxillofacial region and only 6.5% had associated nonmaxillofacial injuries, as shown in Tables 6 and 7. In addition, the mean period of hospitalization for sports-related injury was 3.5 days compared with 6.5 days for MVA injury. Treatment was mainly surgical (93.5%), involving both open and closed surgery, according to the site and type of fracture. After treatment, patients often realize that they are at greater risk of sustaining further injuries during sports activities in the immediate future, particularly in the case of contact sports. In the case of professional or semiprofessional athletes, maxillofacial surgeons must also advise trainers or sport physicians when competitive activities can be resumed. Given that the force required to cause a second fracture that has been rigidly fixed, or simply reduced with minimally invasive procedures, is less than that required to cause a fracture of integral bone, a sufficient amount of time must be allowed so that the fracture can heal before the patient resumes normal contact sports activities. Mahmood et al 2 reported that the advice given to patients after the treatment of zygomatic fractures in the United Kingdom varies markedly. Most specialists advised their patients to abstain from contact sports for a period of 3 to 12 weeks, the commonest time being 6 weeks. After anatomic reduction and appropriate stabilization of the fracture stumps, the bone healing Table 6. Patients Sustaining Multiple s Double Mandibular s Wall Maxillo- Zygomatic- Complex + Maxillo- Zygomatic- Complex + Maxillo- Zygomatic- Complex + Wall Wall + Le Fort II-III + Wall Le Fort I + + Le Fort I + Palatal Bone + Frontal Sinus + Bobsledding 1 Cycling 1 1 Golf 1 Horseback riding 2 1 Rugby 1 1 Skiing 3 1 1 1 1 Soccer 5 1 1 Total number of patients: 22. 380

7-YEARS EXPERIENCE OF MAXILLOFACIAL FRACTURES AFTER SPORTS ACTIVITIES / Roccia et al Table 7. Patients Sustaining Nonmaxillofacial Injuries Disruption of Eyeball Clavicular Wrist Vertebral Hand Humeral Plexus Brachial Injury Rib Cycling 1 Horseback riding 2 Motocross 1 Mountain biking 1 1 Skiing 1 1 Soccer 1 Water skiing 1 1 1 Total number of patients: 9 process begins with an inflammatory reaction hematoma stage (up to 5 days after fracture) and continues with a callus formation stage (4Y40 days after fracture). A remodeling phase occurs between 25 and 50 days. 21 Therefore, we advise abstaining from any sports activities during the 3 weeks after surgical treatment. During this period of time, for example, the presence of an intermaxillary block for a mandibular fracture, or the requirement not to create positive pressure in the upper airways with paranasal sinuses fractures to avoid the onset of subcutaneous emphysema, may be important limitations to light sports activities, even in patients who are in otherwise excellent health. Therefore, the resumption of sports activities is in accordance with the protocol shown in Table 8, except in the case of combat sports, for which patients are advised to resume activities after at least 3 months. This is because of the especially aggressive nature of these sports, particularly when protective helmets are not worn, as in the case of karate. In the case of soccer, as in other team sports, protective masks and mouth-guards may be worn after nose and dentoalveolar fractures, respectively, if sports activities need to be resumed sooner. This applies particularly to professionals and semiprofessionals. However, the introduction of these devices cannot be proposed in an attempt to reduce the Table 8. Step-Wise Return to Play Protocol (Except Combat Sports) Step Activity Days 1 No activity G20 2 Light aerobic exercise 21Y30 3 Noncontact training drills 31Y40 4 Full-contact training and game play 941 The patient should progress to next step only if completely asymptomatic at the current step. If any symptoms are experienced, the patient should drop back to previous asymptomatic level and try to progress after 7 days. incidence of facial fractures during soccer games, unlike the case of rugby, ice hockey, and some combat sports. Aggressive play and fouls should be prevented by stricter regulations. It was only in 2004 that the wearing of helmets became compulsory in Italy for skiers younger than 14 years. This requirement is likely to be extended to all ages in an attempt to reduce the numbers of deaths and injuries that are constantly increasing on the Italian slopes. In addition, speed should be limited on the slopes, as well as the capacity of ski facilities, to prevent overcrowding by skiers. In horseback riding, a helmet does not provide sufficient protection for the face. As stated by Ueeck et al, 18 we advise providing safety education for young or novice horse enthusiasts. CONCLUSIONS Owing to their lower incidence and lesser severity compared with MVA trauma, sports-related maxillofacial injuries are not considered as a possible result of participating in competitive or leisure sports activities, although they should be expected and prevented. Therefore, appropriate measures should be taken to ensure that sports remain a source of good health and do not become an excuse for mindless physical violence. This is especially true for sports that are not considered contact sports, yet show a high potential for maxillofacial injuries. Basic prevention must play a leading role in such sports, with strict regulations, appropriate training, and the actual use of protective equipment when this must be worn. Last, professionals and semiprofessionals especially should be informed about the healing stages of maxillofacial and associated injuries, general health recovery times, and nutritional requirements as well. They often need to be told how to pace their return to training regimens, and sometimes need to be told 381

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