Blair DF, Anderson CA, Betancourt C, Nygard BM: Wenatchee High School, Wenatchee, WA.
Background: A fifteen-year-old football player sustained a
facial injury while playing on his varsity high school football team. A
teammateÕs hand inadvertently entered the opening in the facemask cage of his
Riddell Revolution helmet. There was obvious deformity of the left side of the
nose as well as three small lacerations in the infraorbital region. No loss of
consciousness was noted. The patient was transported to the emergency room of
the local hospital. All three lacerations were sutured. Emergency room
physicians determined his facial injuries would require advanced trauma care. The patient was transported from the local
hospital to a regional trauma center via ambulance. Differential Diagnosis: LeFort II fracture,
nasal fracture, nasomaxillary buttress fracture, zygomaticomaxillary buttress fracture, pterygomaxillary
buttress fracture, orbital ÒblowoutÓ fracture. Treatment: X-rays and a CT scan at the
regional trauma center revealed a displaced fracture of the left nasomaxillary
buttress in addition to the fractured nasal bone. The nasomaxillary buttress is
the junction between the nasal and maxilla bones. The risks, benefits, and
alternatives of open reduction and internal fixation were discussed with the
patient and his parents, and they decided to proceed with surgical
reconstruction because of the instability of this fracture. Under a general
anesthesia, a sublabial incision was made and revealed, in its entirety, the
nasomaxillary buttress fracture. The sutures of the largest laceration were
removed to provide a view of the superior portion of the fracture. The fracture
was elevated and subsequently reduced with a trach hook. A four-hole, 1 mm
titanium plate was used to stabilize the superior portion of the fracture
through the largest infraorbital laceration. The inferior portion of the
fracture was secured with a 1.3 mm five-hole titanium plate. A Sayre elevator
was used to perform closed reduction.
A Merocel pack was inserted to maintain the reduction. A nasal splint was applied at the end
of the surgery. After the surgery, swelling impaired the vision and function of
his left eye for approximately ten days.
The patient regained normal vision and full ocular movement in the
following two weeks. His face
returned to normal symmetry and the infraorbital lacerations have left no
visible scarring. He returned to
baseball with standard equipment the following spring and football this last
season with the addition of a clear face shield in his facemask. Uniqueness: The uniqueness of this case stems from
the angle and force in which the patient was injured. It is very unusual for a football player to receive trauma
of this severity through a relatively small opening in his facemask. Even though the patientÕs facemask did
not have a center bar, it seems improbable that a hand would be able deliver a
blow of this magnitude into a facemask. Another unusual aspect is the original appearance of
the deformity. On the field, the
injury appeared to be an isolated nasal fracture. However, the trauma had
caused a more serious concomitant fracture. The patientÕs nasomaxillary buttress fracture is a
relatively uncommon fracture for a football player considering the protection
afforded by the facemask. Conclusion: In the event of a significant on-the-field
facial trauma, medical personnel must consider all the possibilities of facial
injuries. What may appear to be a simple nasal injury may actually be a complex
facial fracture. Proper on
the-field management of these injuries should include adequate stabilization of
the head and neck to prevent further neurologic, ocular, or airway trauma as
well as rapid referral to a medical facility. Word Count: 597