Abstract
As many as 30% of all maxillofacial fractures (MFFs) and skull base fractures (SBFs) are reported to be sports-related. Participation in sporting activities has grown worldwide and the number of cases of sports-related injuries has also increased. The aim of this study was to evaluate the data of 3596 patients hospitalized by MFF or SBF over a 6-year period; 147 (4%) of these cases were sports-related (mean age 29.7 ± 12.8 years). The highest incidence was found in patients aged 20–29 years (35%), and the fractures resulted mostly from ball sports (74%), especially soccer (59%) and handball (8%). The injuries involved different areas, with a significant prevalence of the midface complex (67%) compared with the mandible region (29%) and the skull base (4%). The commonest diagnoses associated with MFF and SBF were brain concussion (19%), laceration of the skin and soft tissue (16%), and dental injury (8%). Surgery was required for 88% of midface fractures. In cases of mandible fractures 52% were supplied with osteosynthesis. This study identified the significant number of severe sports-related injuries that occur each year, suggesting that changes of rules and safety standards are needed for the prevention of such injuries.
There has been increasing improvement in employee protection in many fields of the modern economy, including shorter working days and more opportunity for recreation. Widespread media coverage suggesting that participation in sports is associated with health and beauty benefits has contributed to increasing sports activity in Western countries. One result is that the number of sports-related accidents at the amateur level has increased steadily since the late 1980s . Sports-related maxillofacial area fractures (MFFs) and skull base fractures (SBFs) are estimated to account for 3–33% of all maxillofacial and skull base trauma . This wide range results from differences in geography of countries, socioeconomic status of each area and different populations with different regional traditions and cultures. For example, most sports-related injuries occurred during soccer games in Italy and France , while skiing in Switzerland and Austria , during ice hockey in Finland , and during baseball in Japan . The number of sports-related injuries that result in hospitalization is relatively small compared with those that are treated in emergency departments or out-patient clinics, but they represent the more serious end of the spectrum of injuries .
The purpose of this study in Germany was to provide an overview of recent sports-related MFF and SBF with demographic patterns, seasonal differences, type of sports, anatomical sites of MFF and concomitant injuries. The results are discussed along with findings in comparable studies from several countries, and the need for protective measures is reviewed.
Materials and methods
A retrospective review was performed on data collected over a 6-year period for patients admitted to the Department of Oral and Maxillofacial Surgery, Center Hospital, Bremen, Germany, for in-patient treatment. Data for all cases of head injuries were selected from the trauma registry of the trauma centre and relevant information was stored in a computer database. Data for sports-related MFF and SBF were analysed regarding patient age and gender, type of sport, cause of injury, site of lesion, and date the injury occurred. Concomitant non-maxillofacial injuries, including brain, spinal cord, limbs, teeth, soft tissue and others, as well as delay before admission, duration of hospitalization and mode of surgical treatment were recorded. Fractures were classified according to the anatomical site of injury. Differences above the 95% confidence interval were determined by the χ 2 test, with statistical significance set at p ≤ 0.05. All calculations were done with SPSS (version 14.0).
Results
From January 2002 to December 2007, 3596 patients suffering fractures of the maxillofacial and skull base areas were treated. Of these, 147 patients (4%; 117 males, 30 females) with an average age of 29.7 ± 12.8 years (range 9–66 years) sustained sports-related MFF or SBF. The highest incidence (35%) was for patients aged 20–29 years, with the frequency in the other age groups decreasing in the order 30–39 years (26%), 10–19 years (19%), 40–49 years (14%), 50+ years (5%), and <10 years (1%).
The fractures resulted mostly from ball sports (74%), especially from soccer (59%) and handball (8%), followed by horse riding (7%) and inline-skating (7%). MFF and SBF were not common in fighting sports (6%) ( Table 1 ). The seasonal incidence of sports-related MFF and SBF tended to be high during April–September (57%) compared with October–March (43%), although the difference did not reach statistical significance. The mean sample size per month was 12.25 cases, with peaks in April ( n = 19) and August ( n = 16). The peak in April was significantly different from the incidence in December ( n = 7; p = 0.014) and January ( n = 6; p = 0.009), while the peak in August was significantly different from the incidence in January ( p = 0.04) ( Fig. 1 ). There was no significant difference between the yearly values for incidence, type of sport causing injury, or seasonal trends.
| Sport | % | Male ( n ) | Female ( n ) |
|---|---|---|---|
| Ball sports | 74 | 100 | 9 |
| Soccer | 59.2 | 86 | 1 |
| Handball | 8.2 | 9 | 3 |
| Basketball | 1.4 | 1 | 1 |
| Volleyball | 1.4 | 1 | 1 |
| Baseball | 0.7 | 1 | 0 |
| Rugby | 0.7 | 1 | 0 |
| Squash | 0.7 | 0 | 1 |
| Hockey | 0.7 | 1 | 0 |
| Tennis | 0.7 | 0 | 1 |
| Golf | 0.7 | 0 | 1 |
| Horse riding | 6.8 | 0 | 10 |
| Skiing | 4.8 | 6 | 1 |
| Combat sports | 5.5 | 4 | 4 |
| Tea-Kwon-Do | 1.4 | 1 | 1 |
| Karate | 2.7 | 2 | 2 |
| Boxing | 1.4 | 1 | 1 |
| Others | 8.9 | 7 | 6 |
| Biking | 0.7 | 1 | 0 |
| Jogging | 1.4 | 2 | 0 |
| Inline-skating | 6.8 | 4 | 6 |
| Total | 100 | 117 | 30 |
Sports-related fractures and concomitant injury
The head injuries involved different areas of the face with a significant prevalence of the midface complex (67%) compared with the mandibular region (29%; p < 0.05) and to the skull base (4%; p < 0.05). In the midface area, fractures of the zygomatic bone including the orbital floor (47%) occurred significantly more often than isolated fractures of the orbital floor (18%; p = 0.002) or nasal bone fractures (26%; p = 0.006). No Le Fort fracture was recorded. Fractures can be distributed among different sites in the mandible; fractures of the sub-/condylar region (45%) tended to occur more often than fractures of the corpus (38%) including nine (21%) fractures of the mandible angle. There was no significant difference among fracture sites of the mandible. No combination of midface and mandible fractures occurred in the sports-related injuries. There were some combined fractures of different regions of the midface (11%) and the mandible (17%) ( Fig. 2 ). The greatest number of midface (84%) and mandibular fractures (81%) resulted from soccer. In general, ball sports-related accidents led to significantly more midface than mandible fractures ( p < 0.001). SBFs occurred only sporadically. No other further significant correlation was found between fracture localization and sport type. As a tendency, SBFs seemed to be more common in horse riding accidents compared with all other sporting activities ( Table 2 ). Seventy-nine concomitant injuries, other than those to the facial bone or the skull base, were diagnosed in 34% ( n = 50) of all patients, and 13 patients (9%) had multiple associated injuries. The commonest diagnoses associated with MFF and SBF were brain concussion (19%), laceration of the skin and soft tissue (16%), dental injury (8%) and contusion of the limbs (5%). Injuries of the cervical spine, pelvis, acoustic meatus or fractures of the limbs were rare ( Table 3 ). There was no case of thoracic or abdominal injury associated with sports-related MFF. Every case of SBF was associated with severe brain concussion, while there was no significant association with concomitant injury in cases of midface or mandible fracture.
| Fracture sites ( n ) | |||
|---|---|---|---|
| Sport | Midface | Mandible | Skull base |
| Ball sports | 83 * | 34 | 2 |
| Skiing | 5 | 1 | 0 |
| Horse riding | 1 | 3 | 2 |
| Combat sports | 5 | 2 | 0 |
| Others | 5 | 2 | 2 |
| Concomitant injury | Counts ( n ) | % * |
|---|---|---|
| Brain concussion | 28 ** | 19 |
| Laceration of soft tissue | 23 | 15.6 |
| Teeth injury | 12 | 8.2 |
| Contusion of limbs | 8 | 5.4 |
| Spinal cord injury | 3 | 2 |
| Pelvis injury | 2 | 1.4 |
| Fracture of limbs | 2 | 1.4 |
| Acoustic meatus injury | 1 | 0.7 |
| Total | 79 | 53.7 |
Surgery and duration of in-patient treatment
Patients attended the clinical centre on the day of the sports-related injury in 44% of cases, 26% arriving 1 day after sustaining the injury, 12% arriving 2 days after, and 11% of patients attended the clinic after a delay of 7–18 days. In cases of mandible fractures, 48% of the patients received only maxilla-mandibular fixation, 52% were supplied with both osteosynthesis and maxilla-mandibular fixation. Surgery was performed in 88% of midface fractures, of those 62% of midface fractures were supplied with osteosynthesis. Of the patients undergoing surgery, 93% were treated adequately within 5 days of admission to the clinical centre. No surgery was performed in the cases of SBF; patients were monitored during in-patient treatment. The duration of in-patient treatment varied between an average of 10.5 days in cases of SBF and an average of 2.6 days in cases of isolated fracture of the zygomatic arch ( Table 4 ). The duration of in-patient treatment was dependent on the severity of the primary injury as well as that of any concomitant injury.
| Fracture site | Mean (days) ± SD |
|---|---|
| Skull base | 10.5 ± 2.5 |
| Orbital/zygomatic complex | 7.2 ± 1.5 |
| Zygomatic arch | 2.6 ± 0.6 |
| Mandibular corpus | 6.9 ± 2.2 |
| Condylar/subcondylar | 3.6 ± 2.1 |
| Nasal bone | 6 ± 1.3 |
Results
From January 2002 to December 2007, 3596 patients suffering fractures of the maxillofacial and skull base areas were treated. Of these, 147 patients (4%; 117 males, 30 females) with an average age of 29.7 ± 12.8 years (range 9–66 years) sustained sports-related MFF or SBF. The highest incidence (35%) was for patients aged 20–29 years, with the frequency in the other age groups decreasing in the order 30–39 years (26%), 10–19 years (19%), 40–49 years (14%), 50+ years (5%), and <10 years (1%).
The fractures resulted mostly from ball sports (74%), especially from soccer (59%) and handball (8%), followed by horse riding (7%) and inline-skating (7%). MFF and SBF were not common in fighting sports (6%) ( Table 1 ). The seasonal incidence of sports-related MFF and SBF tended to be high during April–September (57%) compared with October–March (43%), although the difference did not reach statistical significance. The mean sample size per month was 12.25 cases, with peaks in April ( n = 19) and August ( n = 16). The peak in April was significantly different from the incidence in December ( n = 7; p = 0.014) and January ( n = 6; p = 0.009), while the peak in August was significantly different from the incidence in January ( p = 0.04) ( Fig. 1 ). There was no significant difference between the yearly values for incidence, type of sport causing injury, or seasonal trends.
