eMedicine Specialties > Sports Medicine > Face and Head

Facial Soft Tissue Injuries

Author: Kyle D Parish, MD, Private Practice, Family Medicine and Sports Medicine
Coauthor(s): Valerie E Cothran, MD, Assistant Professor, Department of Family and Community Medicine, Director of Primary Care Sports Medicine Fellowship, University of Maryland School of Medicine; Assistant Team Physician, University of Maryland
Contributor Information and Disclosures

Updated: Jul 10, 2008

Introduction

Background

Facial soft-tissue injuries are not uncommon in athletics.^{1,2,3,4,5,6,7} The position and anatomy of the face make it particularly vulnerable to trauma. In addition, few sports mandate the use of protective equipment, leaving the face susceptible to injury. Although most such injuries are minor in nature, they should be evaluated promptly with a focused history and thorough examination. In addition, facial injuries should be treated early to reduce the likelihood of possible adverse outcomes (ie, infection, loss of function, poor cosmesis). In this article, common sports-related soft-tissue facial injuries are discussed, with an emphasis on the initial evaluation, diagnosis, and treatment.

For excellent patient education resources, visit eMedicine's Sports Injury Center; Eye and Vision Center; Nosebleeds Center; and Cuts, Scrapes, Bruises, and Blisters Center. Also, see eMedicine's patient education articles Facial Fracture, Black Eye, Nosebleeds, Bicycle and Motorcycle Helmets, and Bicycle Safety.

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Frequency

International

The exact frequency of facial soft-tissue injuries related to sports participation is unknown. This is, in part, due to the minor nature of many injuries, which can lead to underreporting. It may also be due to the wide variation that is seen between demographic groups and between specific sports.

Previous reports estimate sports participation to account for 3-29% of all facial injuries.⁵  In terms of overall sports-related injury, facial trauma accounts for 11-40% of injuries attended to by medical professionals. Most injuries are reported in males, particularly those aged 10-29 years. Sports that mandate the use of helmets and face masks tend to have fewer soft-tissue injuries compared with sports that do not mandate the use of such equipment.

Sport-Specific Biomechanics

The mechanism of facial soft-tissue injuries is often a direct impact from an external source (eg, sporting equipment, another participant, environment/playing surface). The forces exerted by the impact can lead to friction, shear, compression, and/or traction of the soft tissue and underlying structures. Injury patterns vary widely by sport, based on various factors (eg, rules, equipment).

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Clinical

History

A focused and thorough history should be obtained from the injured athlete, including his or her pertinent medical history, the mechanism of injury (if not witnessed by the medical staff), and the source of pain. If the patient is unable to report history information, family members can provide such information. The presence of symptoms such as visual changes or altered sensorium should also be ascertained at this time.

Physical

As with any head and neck injury, examination of an individual with trauma to the face must start with an evaluation of the patient's airway, breathing, and circulation (ABCs). Cervical spine injury should also be considered based on the mechanism of injury, and appropriate precautions should be taken. The physical examination should be focused on the specific injury site.

The face is extremely vascular, and even minor injuries may result in profuse bleeding. Copious irrigation should be used to clean and accurately assess the injury. Visual inspection and palpation should be used to systematically examine the face for symmetry. Start superiorly, with the scalp and frontal bones, and proceed inferiorly and laterally. Examine the oral cavity for any disrupted dentition or lacerations. During inspection, pay particular attention to any areas of swelling because this may indicate a more significant underlying injury.

Note the location, size, shape, and depth of any lacerations, and explore wounds for foreign bodies. Palpate for areas of crepitus or bony step-off. Gross asymmetry may signify underlying nerve damage. Assess neurologic function by evaluating sensation and motor function.   

Due to rich vascularity, the amount of bleeding present may not be proportionate to the size of a soft-tissue injury. This is particularly true of the scalp. After cleaning the wound, hemostasis should be attempted with direct pressure. The areas around any lacerations should be examined for bony step-off that would indicate a possible underlying skull fracture. Try to avoid removing hair at the border of any wound because this helps serve as a landmark for accurate repair and may have important cosmetic implications.

Orbital rim/Eyebrow

Inspect the orbital rim carefully because injury in the area of the eyebrow may indicate the presence of an underlying fracture. The rim should be palpated around its circumference. Subtle displacement of the rim may be identified by placing an index finger on each infraorbital rim and viewing from above or below with the patient's head tilted back. Check carefully for any deficit in sensation in the area. Attempt to maintain the alignment of the brow borders during repair. Never shave the eyebrow because this may result in significant cosmetic deformity. The brow is at significant risk of not growing back or growing back with an abnormal pattern or color.

Eyelids

Simple lacerations of the eyelid, without involvement of the margins, can be treated without concern for further eye injury. If the protective function of the lid is compromised in any way, serious ophthalmologic injury may result. Exploration for foreign bodies must be performed. Flip the eyelids over and examine the tarsal plate. Damage to either side of the tarsal plate should be referred to an ophthalmologist for repair. If ptosis is present, injury to the levator aponeurosis should be suspected, and this injury should also be referred to an ophthalmologist. Additional injuries that warrant an evaluation by an ophthalmologist are any injuries that involve the canthi, lacrimal system, or lid margin.

Eyes

Look for any gross injury or asymmetry in the globes. Check the papillary responses to light directly and indirectly. Using an ophthalmoscope, the anterior chamber should be visualized to look for blood, rupture of the iris, or asymmetry. Examine the cornea and look for foreign bodies, abrasions, tears, or lacerations. Fluorescein dye and tetracaine (or other topical ocular anesthetic) should be used to ensure an adequate examination.

Extraocular movements should be evaluated. Deficits in movement may indicate entrapment or injury to one of the extraocular muscles. Deficits may also indicate injury to one of the nerves that controls globe movement (cranial nerves [CNs] III, IV, and VI). Evaluate for conjugate gaze and smooth pursuit.

Visual acuity should also be assessed. On the sideline or in the locker room, a hand-held eye chart may be used for gross investigation. Significant loss of visual acuity may be due to injury of the globe, retina, or optic nerve or due to an injury that is more central. These injuries are an indication for more urgent ophthalmologic care than can be provided on the sideline, and the patient should be sent to the appropriate facility for definitive care. 

Ears

A direct blow or shearing force to the ear may result in tearing of the blood vessels at the level of the perichondrium. The result is a subperichondrial hematoma. These injuries can result in significant cosmetic deformity if missed or if not treated immediately. Fibrosis develops within 2 weeks of the injury, and the athlete can be left with abnormally shaped pinnae (a condition also known as cauliflower ear). Blunt trauma or barotrauma (in specific sports) may cause perforation of the tympanic membrane. An otoscope should be used to visualize the defect and to look for any serous or bloody discharge. Most athletes are asymptomatic, but vertigo and otalgia may be present.

Nose

When the nose is fractured, it usually appears deformed. Nevertheless, epistaxis without obvious nasal deformity may be the only clinical finding in some nasal fractures. Performing an adequate and thorough nasal examination is difficult without epistaxis control. The origin of most nosebleeds is the extremely vascular area on the anterior septum (Kiesselbach area). 

Once the bleeding is controlled, intranasal inspection using a nasal speculum should be performed, and the position and integrity of the nasal septum should be noted. The turbinates and inferior meatus should be visualized bilaterally, and the septum should be inspected for the presence of a septal hematoma. Any mucosal lacerations should be noted because they may be a sign of underlying fracture.

The presence of rhinorrhea associated with significant trauma should suggest a possible cerebrospinal fluid (CSF) leak. An athlete may report a very salty taste in the mouth. An easy way to objectively evaluate for a CSF leak is to look for the halo or ring sign. To perform this test, a drop of the rhinorrhea in question is placed on a piece of filter paper. A clear ring around a blood-tinged center is indicative of the presence of CSF. A positive test result may indicate a basilar skull fracture that requires more urgent tertiary care.

Mouth/Lips

Inspect the lips carefully. Any disruption of the vermilion border should be noted; failure to do so can lead to inadequate repair, which can result in significant cosmetic deformity (see Image 4, top). A step-off of the vermilion border as small as 1 mm is apparent at conversational distance.

Inspect the inside of the lip for through-and-through wounds. An intraoral examination is a necessary part of the facial evaluation. The inside of the lips and cheeks should be examined thoroughly for any through-and-through wounds. Special attention should be given to the area around the parotid duct (see Image 1). With any injury involving the mid cheek, an attempt should be made to milk the parotid gland and observe the flow of saliva from the Stensen duct in order to ensure duct patency. Any suspected injury should be referred for possible stenting and repair. Also, look for disrupted teeth and hematoma.

Tongue

Examine the tongue for lacerations; importantly, note the extent of the injury. Most lacerations, however, do not require repair. One exception is a complete anterior laceration, which can result in a bifid tongue if not properly repaired. Through-and-through and deep lacerations should be explored for the presence of foreign bodies and the potential need for repair.

Face

The bones of the face should be inspected for any asymmetry. Palpate all of the bones; be sure to include the temporomandibular joint. The movements of facial expression should be assessed by observing the patient as he or she raises the eyebrows, closes the eyes, smiles, and frowns. Any deficit is suggestive of injury to one of the branches of the facial nerve (CN VII). Examine sensation for each of the 3 branches of the trigeminal nerve (CN V) (see Image 2). Deficits in any area warrant further evaluation. Injuries along a topographic line extending from the tragus to the base of the nose, and lateral to the lateral canthus, should raise the suspicion of a parotid duct injury, and the evaluation should proceed as described above under Mouth/Lips.

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Causes

Most facial soft-tissue injuries are the result of direct trauma. The trauma can be a result of contact with another participant, sport-specific equipment, and/or the environment/playing surface.

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