Facial Trauma in a Softball Player
Brian L. Patterson, MD, MS; Thomas Anan, MD
THE PHYSICIAN AND SPORTSMEDICINE - VOL 31 - NO. 12 - DECEMBER 2021
In Brief: Facial trauma frequently results in fracture of the facial bones. A blowout fracture involves the eye orbit and usually transpires when the object hitting the eye (eg, baseball, softball, fist, elbow) is larger than the orbit itself. The mechanism of injury will provide the physician with a clue to the diagnosis. Prompt recognition of any significant complications, proper imaging, and referral to an ophthalmology specialist are usually required. Facial reconstruction by a plastic surgeon may also be necessary.
Primary care physicians—particularly those who treat young, active patients—often must evaluate facial injuries. Trauma sufficient to cause significant swelling and contusion should prompt evaluation for an orbital fracture with associated injuries, including cervical spine injury. Imaging techniques can help visualize the extent of the damage, and abnormal physical findings will guide the decision either to refer the patient to an ophthalmologist or plastic surgeon immediately or wait until swelling recedes.
A 33-year-old man was playing softball and attempting to catch a fly ball when he lost sight of it in the sunlight. The ball hit him directly over the left eye. He bled profusely from both nasal passages, and his eye began to swell. He was rushed to the emergency department for further evaluation. X-rays of the facial bones were inconclusive, but computed tomography (CT) of the facial bones revealed multiple fractures in the left orbit. A visual exam revealed mild diplopia and minimally blurred vision in the left eye. He was discharged in stable condition, instructed to take extra-strength acetaminophen for pain, and advised to follow up with his primary care physician.
Physical exam. At his primary care physician's office 24 hours later, he was alert, oriented, and in no acute distress, but his left eye was swollen and bruised. His blood pressure was 117/ 80 mm Hg, heart rate was 86/min, respiration was 18/min, and his temperature was 2021.8°F (37.1°C). He was examined for head trauma with tape still in place covering a small laceration under his left eye (figure 1). Severe swelling and ecchymosis accompanied pain to palpation around the left orbit. His pupils were equal, round, and reactive. His left globe, visual acuity, and extraocular muscle movements were normal.
No blood was visualized behind the left tympanic membrane or in the left ear canal. His nasal septum appeared straight with no visible lacerations. He had swelling in the left nares, but both nares were patent. He reported no pain to palpation over the bridge of the nose. No swelling in the pharynx or posterior neck was observed, and no palpable step-off deformities or pain to palpation in the cervical spine were evident. He had good range of motion on flexion, extension, and rotation of the neck, and his cranial nerves were intact.
Imaging and diagnosis. X-ray revealed mild opacification of the left maxillary sinus and an osseous deformity at the inferior orbital ridge; however, this was poorly visualized in the film. CT of the facial bones (figure 2A) revealed a "blowout" fracture involving the floor of the left orbit with opacification of the left maxillary and ethmoid sinuses. CT also revealed a fracture of the left lamina papyracea, deviation of the nasal septum, and significant soft-tissue swelling (figure 2B).
Treatment. The patient was referred to an ophthalmologist for evaluation and to an oral and maxillary plastic surgeon for facial reconstruction. Because his diplopia had resolved within 48 hours and the globe, muscle, and nerves did not appear to be damaged, no eye patch was needed. Continuation of the over-the-counter analgesia for pain was recommended, and he was advised to follow up with his referrals within 2 weeks. No data are available on long-term outcome for this patient.
Exploring the Orbit
Orbital fractures are frequently seen in a primary care or urgent care setting. They occur most commonly in patients between the ages of 10 and 40 and in those older than 70. One third of orbital fractures are sustained during athletic competition, most notably while playing baseball, rugby, soccer, basketball, or hockey.1 Most other cases result from altercations, traffic accidents, and falls.
Orbital fractures usually occur when the object hitting the eye is larger than the orbit itself, such as a baseball or dashboard. Our patient's mechanism of injury (being hit with a softball at high velocity) increased the likelihood of a blowout fracture to the orbit. A blowout fracture is a fracture to the thin orbital floor (maxilla) or the lamina papyracea (ethmoid) of the medial orbital wall.2 After impact, the globe expands, increasing the intraorbital pressure, and this results in the fracture of both the floor and medial wall of the orbit.
Signs and symptoms associated with a blowout orbital fracture include swelling, epistaxis, double vision, blurred vision, paresthesia of the infraorbital nerve, and pain during ocular movement. Our patient experienced pain, blurred vision, diplopia, swelling, and epistaxis; his globe, ocular movements, and periorbital sensation were normal when examined. A visual acuity exam completed in the emergency department revealed minimally blurred vision in the left eye; however, this resolved over the following 48 hours.
A great amount of force is necessary to fracture the orbits; therefore, a careful head, eye, ear, nose, throat, and neck exam should be completed when a patient has experienced facial trauma. Close examination of the neck will help rule out a cervical spine injury.
Imaging for possible orbital fractures should include x-ray with Waters' view and a CT scan of the orbits. CT will allow the examiner to assess the extent of a fracture by visualizing both the orbits and the facial bones.
A major complication with blowout fractures is herniation of the ocular contents into the maxillary sinus (figure 3). The periorbital fat and the inferior oblique muscle may be pushed through the fracture site and into the maxillary sinus, culminating in a loss of orbital volume. Enophthalmos may result from orbital volume loss and is frequently missed during an exam because of swelling in the surrounding tissue; however, it can be confirmed by CT. Another major complication occurs when the inferior oblique "catches" in the fracture site, limiting the patient's ability to gaze upward. This deficiency will be observed during gross examination of the ocular muscles, and it requires immediate ophthalmology referral. Superior orbital fissure syndrome is defined as pain, proptosis, and paralysis of cranial nerves III, IV, and VI,3 and is an infrequent but major complication of blowout fractures. Eye movement is limited by direct compression or narrowing, thrombosis, or infection of the superior orbital fissure after trauma. A ruptured globe occurs in 5% to 10% of all orbital fractures.4
Primary care management of patients who have orbital fractures involves an updated tetanus vaccination, recommendations on avoiding Valsalva's maneuvers (eg, blowing the nose), pain control, and proper referral. Broad-spectrum antibiotics are recommended for patients with periorbital lacerations, orbital emphysema, or penetrating trauma.
If no evidence of ocular globe, muscle, or nerve damage exists, the follow-up with ophthalmology can wait for up to 2 weeks to allow periorbital swelling to resolve. Otherwise, patching of the eye and immediate referral to an ophthalmologist, oral and maxillofacial surgeon, or an ear, nose, and throat specialist, are necessary. The eye patch is generally worn just until the follow-up visit with a specialist. Pain medications vary from over-the-counter analgesia to prescription pain control.
Long-term sequelae, including enophthalmos, are more prevalent in large orbital wall defects. Enophthalmos occurs when atrophy of the periorbital fat and muscles in the orbit herniate through the fracture site, and permanent damage may result. Weeks after the injury, retraction of the globe in the orbit may be seen.
Orbital Injury Basics
Knowing the mechanism of injury is key to diagnosing an orbital fracture. In a blowout fracture, the floor of the orbit gives way when pressure from the force of the blow or from the swelling globe exceeds the structural limits of the bone. Careful imaging will reveal the extent of the damage, and referral to a specialist is recommended. The patient should be cautioned that blowing the nose may cause further damage.
Dr Patterson is a spinal cord injury fellow in the physical medicine and rehabilitation department at Harvard Medical School in Boston. Dr Anan is the medical director at Providence Medical Center in South Lyon, Michigan, and research director in the department of family practice at Providence Hospital and Medical Centers in Southfield, Michigan. Address correspondence to Brian L. Patterson, MD, MS, 3 Carol Ave, Unit 5, Brighton, MA 02135; e-mail to [email protected].
Disclosure information: Drs Patterson and Anan disclose no significant relationship with any manufacturer of any commercial product mentioned in this article. No drug is mentioned in this article for an unlabeled use.