Knee Surgery, Sports Traumatology, Arthroscopy

, Volume 26, Issue 4, pp 1295–1302 | Cite as

Injury mechanism of midfacial fractures in football causes in over 40% typical neurological symptoms of minor brain injuries

  • Volker Krutsch
  • Markus Gesslein
  • Oliver Loose
  • Johannes Weber
  • Michael Nerlich
  • Axel Gaensslen
  • Viktor Bonkowsky
  • Werner Krutsch
Sports Medicine

Abstract

Purpose

The injury mechanisms of midfacial fractures may be typical causes of concussion, but hardly any scientific data on midfacial injuries sustained in football are available. Head and brain trauma represent frequent injuries in athletes of different sports that require appropriate treatment by sports and trauma physicians. This study investigated the management of midfacial fractures in football and the association of such fractures with concomitant brain injury.

Methods

In a prospective cohort study lasting 24 months (2012 to 2013), midfacial injuries of football players were analysed with regard to the injury mechanisms, first aid procedures on the field, treatment and return-to-play. To analyse concomitant and potentially overlooked minor brain injuries due to the trauma, we retrospectively investigated the neurological symptoms of the study population.

Results

The study included 132 football players (37 semi-professionals and 95 amateurs) with midfacial fractures. The main injury mechanisms were head-to-head and head-to-elbow trauma. The mean period of return-to-play after trauma was 33.5 days, which was significantly shortened if a protective face mask was worn (mean 10.4 days earlier, p = 0.0006). Semi-professional football players returned to play earlier (p = 0.009) and more often used protective face masks (p = 0.001). 55 players (41.6%) had neurological symptoms immediately after trauma as a possible sign of concomitant minor brain injury. 5 of 132 players with concussion had been hospitalised for 24 h, but no persistent neurological symptoms were detected.

Conclusion

In football, midfacial fractures represent moderate-to-severe injuries with time away from sports of more than 4 weeks. Over 40% of athletes with a midfacial fracture showed concomitant neurological symptoms as a sign of minor brain injury. Therefore, sports physicians and other staff supervising athletes in daily practice should be aware of the presence of neurological symptoms.

Level of evidence

Level III.

Keywords

Midfacial fracture Concussion Football Soccer Prevention Return-to-play 

Introduction

The incidence of midfacial injuries due to sports trauma has been increasing, but specific injury statistics of midfacial injuries in team sports are rare [1, 8, 32, 46]. Despite the thorough documentation of football-specific injuries in the scientific literature, head injuries and particularly brain injuries such as concussion remain a controversial topic in current sports medicine [10, 17, 23, 33]. Particularly football as the number one sports in the world [9] is frequently associated with head injuries that require appropriate treatment by sports physicians, trauma physicians and other medical staff on the field and in other medical settings. Many valuable statistics on football-specific injuries have been published, including statistics on head trauma [5, 11, 12, 21, 23, 27, 32]. The reason why specifically midfacial injuries are less represented in these publications may be extenuation of the trauma mechanism or underestimation of the severity of such injuries. Scientific studies on professional football showed a percentage of 9% for head and neck injuries during the FIFA World Cup in 2010 [11], which had increased to 18% during the subsequent FIFA World Cup in 2014 [23]. In amateur football, the current incidence rate of head and neck injuries is 6.6% in seasonal statistics [29] and 5.7% in tournament surveys [27].

Facial injuries, which only represent one type of head injury in football, may be associated with less severity and long-term consequences than other types of head trauma, such as concussion. However, midfacial injuries, particularly in the case of midfacial fractures, are usually caused by enormous force, which may potentially damage brain tissue and subsequently lead to minor or even major brain injuries. So far, hardly any scientific data have been available on concomitant neurological symptoms or brain injuries, particularly in athletes with midfacial injuries [36, 39, 45], and detailed data on improving injury prevention of midfacial injuries are completely lacking.

More scientific data on severe midfacial injuries such as fractures and their adequate emergency management are urgently required to reduce the time for rehabilitation and return-to-play and to avoid overlooking brain injuries. Studies on prevention and return-to-play in football have mainly concentrated on injuries of the lower extremities [20, 29] but not on facial injuries. Although scientific evidence is still lacking, early return-to-play wearing a face mask after midfacial injuries is still very common at all skill levels in football. The ongoing problem of head and brain injuries in football and their subsequent problems due to concomitant and inadequately treated brain injuries was the reason for conducting this study. This study investigated for the first time the injury mechanisms of midfacial fractures, concomitant neurological symptoms and the effectiveness of treatment in football players at different skill levels with regard to outcome.

Materials and methods

In a prospective cohort study, patients of an out-patient ear-nose-throat (ENT) clinic of a level 1 trauma centre were analysed over 24 months (1 January 2012–31 December 2013). Patients with midfacial fractures were included in the study. To investigate sports-specific injuries with regard to prevention, treatment and time of return-to-play, we only included athletes with midfacial fractures who had sustained their injury while playing football. Football players of both sexes aged between 18 and 60 years were included, who had sustained a midfacial fracture during football training or matches. Exclusion criteria were injuries caused by other types of sports, facial injuries without any bone fracture, patients with multiple injuries with more than one injury outside the head and professional football players of the first to third league. Further exclusion criteria were missing follow-up data and incomplete data on injury or time of return-to-play. To investigate concomitant neurological symptoms of head trauma and the potential trivialisation of head injuries, we only included midfacial fractures because this type of injury requires enormous forces on the head. This fact should illustrate the interaction of this injury mechanism between the midface and concomitant brain injury. All included patients gave their written consent and filled in a detailed pseudonymous questionnaire on personal and injury data. The study participants were followed up after presenting to the hospital, after 24 h of hospitalisation, after return-to-football and 6 months after sustaining the injury.

Study participants were analysed at their first visit to the ENT trauma centre by means of a written questionnaire as well as clinical and radiological examination of the midface. All patients received a radiograph of the nose and, if indicated, a computer-tomography scan of the head to exclude complex midfacial trauma suspected in the clinical examination. The treatment strategy for each patient depended on the individual diagnosis. All patients underwent reposition of the nasal fracture in general anaesthesia on an out-patient basis. The initial questionnaire included anthropometric data of the player, such as age, sex, height and weight as well as football-specific data, for instance position on the field, the football level and injury mechanism. Emergency management, treatment procedures, clinical outcome, and the return-to-play process were documented. The time of return-to-play was defined as the first official match after injury completed without any symptoms. The question of who influenced the return-to-play decision of football players after midfacial trauma was also investigated by this study. Additionally, the questionnaire included questions on potential injury prevention strategies such as the risk of and the influencing factors on the trauma mechanism or use of protective devices. Data collection was based on the consensus statement on injury definitions and on the football data collected by Fuller et al. [16]. The follow-up examinations at the time of return-to-play and 6 months after trauma consisted of a second questionnaire that investigated the specific outcome after midfacial injury, the use of protective face masks, any re-injury or other complications as well as the clinical outcome parameters.

The study participants were divided into semi-professional football players in the 4th to 6th division (salaried players insured by a public trauma insurance for athletes receiving a salary) and amateur football players playing in the 7th division and lower. This difference was made because semi-professional football players have higher training exposure and intensity (measured by played hours per week) than amateur footballers; furthermore, semi-professionals are salaried football players who have a trauma insurance for this specific activity.

Neurological symptoms as a sign of minor brain injury were investigated in the documentation of clinical symptoms of patients with midfacial fractures. We analysed the neurological diagnosis (e.g. concussion, contusion and brain injury), if available, and the clinical examination regarding neurological symptoms. At the end of the study period, we also retrospectively evaluated the treatment management and other therapeutic steps regarding the neurological symptoms as well as any adaptations of therapy in the case of persisting neurological symptoms. Typical symptoms of minor brain injuries were evaluated to find out about the quantity and quality of neurological symptoms during midfacial injury mechanisms and the extent of minor brain injuries as concomitant symptoms. Typical neurological symptoms after head trauma were investigated in a standardised manner according to the symptoms of the Sport Concussion Assessment Tool (SCAT) 3 [33]. Concussion detected as a result of the original trauma mechanism during football was defined by clinical diagnosis that included analysis of symptoms and use of the Glasgow coma scale. In this study, the symptoms leading to the diagnosis of traumatic sports concussion were unconsciousness, anterograde or retrograde amnesia, vision disorders or repetitive emesis. In the case of confirmation of a neurological diagnosis and adaptation of therapy, the neurological diagnosis was defined as concomitant injury of the midfacial fracture. During the 24-h hospitalisation, patients were monitored by pupillary reflex and blood pressure examination every second hour and continuous measurements of the heart rate. In the absence of progressing neurological symptoms or any other additional symptoms, patients were discharged after 24 h. The Ethical Committee of the University of Regensburg approved this study design (ID-No: 15-101-0134).

Statistical analysis

Because of the exploratory design of the prospective cohort study, we did not conduct any a priori sample size calculation. All eligible patients of the 2-year period (2012 to 2013) were considered for statistical analyses. All statistical analyses were done with IBM SPSS Statistics, version 21.0. The ×2-test was used for comparing the proportions between the two groups. The significance level was set at p < 0.05 and high significance at p < 0.01. Tables were generated with the software programme Microsoft Excel.

Results

Between 1 January 2012 and 31 December 2013, 795 patients with traumatic midfacial injuries were documented in the ENT out-patient clinic of a level 1 trauma centre. 219 patients presented sports-related midfacial fractures, of whom 132 had sustained a midfacial fracture while playing football (Fig. 1). 636 patients were excluded because of injury due to another mechanism or cause. 122 male (92.4%) and 10 female (7.6%) football players presented midfacial fractures sustained in football. Semi-professional players had higher football exposure per week over the course of the football season (12.1 h) than amateur players (5.5 h; Table 1).

Fig. 1

Flow chart of study participants

Table 1

Anthropometric and football-specific data

 

Semi-professional

Amateur

Sex (m/f)

37/0

85/10

Mean age (in years)

22.8 (18–32)

26.1 (18–50)

Height (in cm)

180.6 (170–191)

179.6 (165–192)

Weight (in kg)

76.4 (69–83)

77.2 (68–86)

Position on field n (%)

 Goalkeeper

2/37 (5.4%)

7/95 (7.4%)

 Defender

17/37 (45.9%)

40/95 (42.1%)

 Midfielder

12/37 (32.4%)

33/95 (34.7%)

 Striker

6/37 (16.2%)

15/95 (15.8%)

Football exposure per seasonal week (in mean/range)

 
 

12.1 h (10–14)

5.5 h (2–7)

m male, f female

The most frequent injury mechanism was head-to-head trauma (semi-professionals: 43%; amateurs: 41%) and head-to-elbow trauma (semi-professionals: 43%; amateurs: 46%). Trauma to the face caused by a ball was only seen in a goalkeeper who had been hit with a ball from short distance (Table 2; Fig. 2). Emergency treatment of midfacial fractures on the field was mainly provided by non-medical staff. Most players of both groups presented at a trauma centre immediately after sustaining the injury (semi-professionals: 86.5%; amateurs: 75.8%). Injured players were only immediately hospitalised for 24 h when diagnosed with concussion or a complex midfacial fracture (Table 3).

Table 2

Injury data of midfacial fractures

  

Semi-professional

Amateur

n (%)

n (%)

Time of injury

 Match

30 (81.1%)

71 (74.7%)

 Training

7 (18.9%)

24 (25.3%)

Midfacial fracture

 Mono-trauma of the nose

35 (94.6%)

87 (91.6%)

 Complex fracture

2 (5.4%)

8 (8.4%)

Local symptoms

 Epistaxis

36 (97.3%)

91 (95.8%)

 Swelling

35 (94.6%)

90 (94.7%)

 Breathing problems

23 (62.2%)

65 (68.4%)

 Pain of the nose

37 (100%)

95 (100%)

Clinical findings

 Visible dislocation

37 (100%)

94 (98.9%)

 Sensitivity disorders

2 (5.4%)

10 (10.5%)

 Septum hematoma

2 (5.4%)

12 (9.1%)

 Skin lesion

2 (5.4%)

11 (11.6%)

Fig. 2

Injury mechanisms of midfacial fractures in football

Table 3

Treatment steps for midfacial injuries in football

 

Semi-professional

Amateur

n (%)

n (%)

First aid provided by

 Players

20 (54.1%)

71 (74.4%)

 Team mates

31 (83.8%)

64 (67.4%)

 Coach or manager

10 (27%)

45 (47.4%)

 Paramedics

2 (5.4%)

7 (7.4%)

First aid procedure

 Cooling pack

31 (83.8%)

52 (54.7%)

 Direct nose compression

25 (67.6%)

71 (74.7%)

 Compress/pad

34 (91.9%)

82 (86.3%)

Presentation at the hospital

 Immediately

32 (86.5%)

72 (75.8%)

 After 1 day

5 (13.5%)

23 (24.2%)

Treatment

 Surgical

33 (89.2%)

79 (83.1%)

 Non-surgical

4 (10.8%)

16 (16.9%)

24-h hospitalisation because of concussion

1 (2.7%)

4 (4.2%)

The mean time of return-to-play of the entire study population with midfacial fractures was 33.5 days, and all players had returned to the same level of football. Semi-professionals had returned significantly earlier than amateurs (25 to 37 days; p = 0.009). For semi-professional football players, the decision of return-to-play was mainly assisted by a member of the professional medical staff such as a medical doctor (94.6%). This rate was much lower for amateur players (54.7%, p = 0.01). The earlier return-to-play of semi-professionals was associated with a significantly higher use of protective face masks (semi-professionals: 40.5%; amateurs: 7.4%; p = 0.001). Players wearing face masks generally returned to play football 10.4 days earlier than players who did not wear any protective masks (p = 0.0006). No re-injury was documented, neither with nor without wearing a face mask (Table 4). 41.6% of players had experienced concomitant neurological symptoms such as a headache in the first 24 h after trauma and 9.8% reported dizziness (Table 5). In the follow-up examinations at the time of return-to-play or 6 months after trauma, none of the football players with midfacial fractures and with or without concussion had presented any persistent neurological symptoms.

Table 4

Clinical outcome and return-to-play after midfacial fracture

 

Semi-professional

Amateur

Return-to-play in days: mean (range)

25 (3–49)

37.2 (5–70)**

Use of a face mask: n (%)

15 (40.5%)

7 (7.4%)**

Return-to-play & wearing a face mask in days: mean (range)

8.7 (3–25)

14.2 (5–27)

Decision of return-to-play made by: n (%)

 Doctor

35 (94.5%)

52 (54.7%)**

 Player

2 (5.4%)

41 (43.2%)

 Team coach or manager

0

2 (2.1%)

Complications after therapy: n (%)

 Secondary bleeding

1 (2.7%)

1 (1.1%)

 Septal perforation

0

1 (1.1%)

Re-injury/re-fracture

0

0

Persisting problems with breathing through nose: n (%)

5 (13.5%)

12 (12.6%)

Visual deformation of the nose: n (%)

4 (10.8%)

7 (7.4%)

*Significant = p < 0.05, **Highly significant = p < 0.01

Table 5

Symptoms of minor traumatic brain injury and concussion at the different examinations

 

First 24 h n (%)

After 24 h n (%)

Time of return-to-play n (%)

After 6 months n (%)

Symptoms of minor traumatic brain injury or concussion

 Headache

55 (41.6%)

11 (8.3%)

0

0

 Dizziness

13 (9.8%)

3 (2.3%)

0

0

 Nausea

1 (0.7%)

0

0

0

 Blurred vision

1 (0.7%)

0

0

0

 Amnesia

0

0

0

0

 Loss of consciousness

0

0

0

0

 Seizure/convulsion

0

0

0

0

 Balance problems/incoordination

1 (0.7%)

0

0

0

 Irritability

0

0

0

0

 Sadness

0

0

0

0

 Fatigue/low energy

2 (1.5%)

0

0

0

 Nervous/anxious

0

0

0

0

 Confusion

0

0

0

0

 Feeling slowed down

0

0

0

0

 Pressure in head

1 (0.7%)

0

0

0

 Sensitivity to light

0

0

0

0

 Neck pain

1 (0.7%)

0

0

0

 Sensitivity to noise

0

0

0

0

 Difficulty concentrating

0

0

0

0

 Difficulty remembering

0

0

0

0

 Higher level of emotionality

0

0

0

0

Discussion

The most important finding in this detailed analysis of midfacial fractures in football players was that this trauma mechanism in football caused typical neurological symptoms of brain injuries in more than 40% of players. Midfacial fractures represent moderate-to-severe injuries with few complications, with time away from football of over 1 month and return to the same football level in 100% of players. The difference between semi-professional and amateur football players was significant in the return-to-play procedure, with earlier return-to-play of semi-professionals and higher use of protective face masks. This general differences in the management of injuries between the different football levels have been well described in the literature [28], but this study was the first to report on midfacial injuries.

In football, the time of return-to-play after midfacial fractures is strongly associated with the use of protective face masks. However, detailed data on wearing a face mask after nasal and facial fracture are rare [13, 38]. The healing process of nasal fractures takes at least 4 weeks, but match rules allow football players to wear a face mask as potential protection against re-injury. Whether such masks in football provide effective protection against re-injury or further hits in the face has not yet been sufficiently analysed [3, 18]. Material, design or the period of wearing these masks are still not standardised, so that several different types of masks are available that give players the feeling of protection. The general availability of protective devices after injury and the official permission for their use granted by the football rules is an exception in sports and shows the importance of preventing recurrent midfacial fractures. The mean time of return-to-play of more than 1 month in this study population showed that this affliction is a moderate-to-severe injury. The decision to return-to-play was based on decreased swelling of the nose, free breathing through the nose and reduced pain. The heeling process for nose fractures takes more than 4 weeks. Therefore, the decision to return-to-play in our study was neither based on the healing process of the midfacial fracture nor on the presence of concussion or neurological symptoms but on a player’s subjective feeling.

Yet, the use of protective masks directly after trauma and the subsequent return-to-play within a few days after trauma, which is frequently seen in professional football, increases the risk of re-injury and other complications. General complications after midfacial fractures have been well documented in the literature but rarely in clinical studies such as our investigation [14, 22, 25, 41]. None of our study participants had sustained any re-injury or re-fracture after return-to-play, although not all players did wear a face mask. Absence from football after midfacial fractures represents an important reason for increasing science-based injury prevention strategies and improving the standards for early and safe return-to-play in the future.

By investigating concomitant neurological symptoms of football players with midfacial fractures, this study highlighted the problem of head injuries and concomitant minor brain injuries beyond concussion [37]. Minor head and brain injuries are suspected to be a potential risk for long-term complications [6, 15, 30]. Particularly recurrent head and brain injuries seem to have cumulative effects on the brain and should be prevented [7, 19]. In this study, over 40% of all players had experienced neurological symptoms directly after midfacial fractures and during the first 24 h after trauma, but only 5 players had been diagnosed with concussion. Thus, also minor brain injuries with mild neurological symptoms require attention and time for recovery. In this study, none of the players had presented any neurological symptoms, neither at return-to-play nor at the last follow-up examination 6 months after trauma. This fact shows that neurological symptoms are frequently present in players with midfacial fractures, but the time of return-to-play in semi-professional and amateur football players with midfacial fractures allows enough time for recovery. Another problem in professional football may be that players with midfacial fractures try to return-to-play within a few days after trauma. Mild brain injuries, sometimes caused by midfacial trauma as in our study, generally have no mid-term effect on the brain after sufficient rest and regeneration time for both the brain and the player [24]. Thus, during the vulnerable period of the first few days after a head or brain injury, any ‘second hits’ should be avoided [34]. Athletes sustaining concussion and mild traumatic brain injuries require appropriate medical service, starting with 24-h hospitalisation and referral to a neurological expert. However, correct diagnosis and adequate treatment are necessary to avoid overlooked brain injuries, which is difficult because players sometimes insufficiently describe their neurological symptoms [35]. Important for sufficient management of head and brain injuries in these situations is the detailed anamnesis of neurological symptoms in the case of head trauma or a hit of the midface. In football, the injury mechanisms of midfacial fractures are the same as those of concussion. Fracture of a facial bone is caused by high impact forces on the player’s head, which are likely to lead to neurological symptoms as a sign of minor brain injury and should be adequately monitored.

This study also showed injury mechanisms of midfacial fractures similar to those found by Andersen et al. [2], i.e. mainly head-to-head or head-to-elbow injury mechanisms [2]. Head-to-head trauma as a common injury mechanism is difficult to completely avoid in contact sports such as football. Head-to-elbow trauma is a typical injury mechanism that seems to be preventable in different ways [4, 26]. Prohibiting headers in football does not seem to be a solution to the problem and does not improve injury prevention of head injuries or midfacial trauma. This study has confirmed previous literature reports [2, 31] that heading a football does not cause severe injuries such fractures or concussion. This result is rather important, particularly in view of the current discussion on the potential danger of sustaining a head injury during a header, which was one reason for prohibiting headers in junior football in the US in 2015 [31, 40]. Several other prevention strategies could be improved, for instance training heading techniques or anticipating potential head-to-head or head-to-elbow contacts that may result in head injury [10, 42, 43, 44]. Wearing a protective device is no reasonable primary prevention method of facial trauma and should only be used as a secondary prevention method for return-to-play after injury [3].

The results of this study have long-ranging effects and are clinically relevant for the management of head injuries in football. Particularly trauma surgeons, sports physicians and other medical and non-medical staff on the football field have to be vigilant about minor brain injuries in the case of midfacial fracture. Concussion and other minor brain injuries with mild symptoms show less obvious signs of trauma, but midfacial fractures should be considered as an injury with concomitant brain injury. An adequate medical process is necessary until the decision of return-to-play.

This study has also some limitations, for instance, it only includes a descriptive data sample for interpreting the current situation of midfacial injuries and concomitant concussion or mild traumatic brain injuries in football. The study lacks a clinical outcome score, which would be an important issue for future projects. Long-term effects after facial trauma also still remain unclear. The high number of excluded patients because of facial injuries unrelated to sports may be seen as a principle bias of the results. Yet, the strict exclusion criteria enabled the analysis of sports-specific prevention methods and return-to-play details in the case of facial fractures in football. Additionally, the lack of randomisation should be considered when interpreting our data.

Conclusion

Midfacial fractures represent moderate-to-severe injuries and trauma situations in football that frequently involve neurological symptoms indicating brain injury. Strategies to prevent head trauma in football are one of the most important topics in football medicine in the future. Standards for adequate diagnostics after head trauma for medical and non-medical staff on the football field are necessary in the future.

Notes

Acknowledgements

We are grateful for the support of the Centre of Clinical Studies at the University Medical Centre Regensburg, the support by the ZNS-Hannelore-Kohl-Stiftung in Bonn/Germany and the “AG Prävention” of the German Society of Orthopaedic and Trauma Surgery (DGOU).

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Funding

This study received no funding to compete.

Ethical approval

The study design of this study was approved by the Ethical committee of the University of Regensburg (ID-No: 15-101-0134).

Informed consent

Patients gave informed consent prior to study inclusion.

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Copyright information

© European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2017

Authors and Affiliations

  • Volker Krutsch
    • 1
  • Markus Gesslein
    • 2
  • Oliver Loose
    • 3
  • Johannes Weber
    • 4
  • Michael Nerlich
    • 4
  • Axel Gaensslen
    • 5
  • Viktor Bonkowsky
    • 1
  • Werner Krutsch
    • 4
  1. 1.Department of Otorhinolaryngology, Head and Neck SurgeryParacelsus Medical University, General Hospital NurembergNurembergGermany
  2. 2.Department of Trauma SurgeryParacelsus Medical University, General Hospital NurembergNurembergGermany
  3. 3.Clinic for Paediatric Surgery, Clinic St. HedwigRegensburgGermany
  4. 4.Department of Trauma SurgeryUniversity Medical Centre Regensburg, FIFA Medical Centre of ExcellenceRegensburgGermany
  5. 5.Clinic Wolfsburg, Department of Trauma SurgeryWolfsburgGermany

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