Chapter 22

### INTRODUCTION

Having looked at it on YouTube, I don’t like to look at it too much because it freaks me out a bit. The bail hit me in the eye and went two centimetres back.

South African cricket player Mark Boucher on his career-ending eye injury

Injuries to the face in sport usually result from direct trauma. After reviewing clinical assessment and soft tissue injury management, we outline management of injuries to the nose, ear, eye, teeth and facial bones.

### FUNCTIONAL ANATOMY

The bones of the face are shown in Figure 22.1. As most of these bones are subcutaneous, they are easily examined. Examination should include palpation of the forehead and supraorbital rims for irregularities and contour deformities.

###### Figure 22.1

Facial bones

The orbit is a cone-shaped cavity, with a margin that consists of the supraorbital ridge above, the infraorbital margin below, the zygomatic arch laterally and the nasal bone medially. The recess formed protects the eye from a blow from a large object. A smaller, deformable object such as a squash ball may, nevertheless, compress the globe and orbital contents, leading to a ‘blow-out’ fracture in the orbital floor that orbital content can herniate through.

The zygomatic arch of the malar bone creates the prominence of the cheek. Fractures in this region may cause flattening of the cheek and a palpable irregularity in the inferior orbital margin.

The maxilla forms the upper jaw. Its superior surface helps create the floor of the orbit and the inferior surface forms the major part of the hard palate. Mobility of the hard palate, determined by grasping the central incisors, may indicate a maxillary fracture.

The lower jaw consists of the horseshoe-shaped mandible. The mandible is made up of body, angle and ramus, which are easily palpated. The coronoid process can be palpated by a direct intraoral approach. The gingiva overlying the alveolar ridge may be lacerated in mandibular body fractures.

### CLINICAL ASSESSMENT

Facial injuries1 are frequently associated with profuse bleeding. While it is important to control the bleeding, it is also vital to fully assess the underlying structures. All head and neck injuries should be considered closed head injuries. Cervical spine precautions should be taken if the patient is unconscious, has neurological deficits or cervical spine tenderness, or if cervical spine injury is feasible considering the mechanism of injury. The airway is particularly vulnerable to obstruction because of bleeding, structural compromise of bony structures (e.g. mandible), or dislodged teeth, tooth fragments or dental appliances. The practical steps to assess facial injuries are:

• ascertain the mechanism of injury and locate the source of the patient’s pain

• check for blurred vision, diplopia (double vision), concussion or cerebrospinal ...

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