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Neck trauma sport: diagnostic and therapeutic management.

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by Dr. Denis Herman ENT Surgeon

The trauma of the face and neck, in sport and especially for team sports, is more frequently observed. This increase is explained by the intensification of the physical preparation of athletes, amateur and professional, of course, the physical mass and velocity involve contacts increasingly violent and repeated.


PLAN:

Introduction
The three priorities
The elimination diagnoses
The wounds of the face
The trauma of the face according to the region:
1) The front region
2) The cheekbone
3) The orbital region
4) The pre-auricular region
5) The ear
6) The nasal pyramid
7) plays
8) The jaw and chin
9) The cervical region
Conclusion

INTRODUCTION
The trauma of the face and neck, in sport and especially for team sports, is more frequently observed. This increase is explained by the intensification of the physical preparation of athletes, amateur and professional, of course, the physical mass and velocity involve contacts increasingly violent and repeated.
The face and neck are not immune to this commitment. If, in the majority of cases there are simple contusions, larger lesions are not uncommon and require, from the scene of the accident that is to say in the field, an accurate diagnosis and a to behave beyond reproach.
It is in this context that we will position ourselves by playing us in the role of sports doctor accompanying a team in a championship and attending the meeting.
Paradoxically, the examination of the facial injury will not start with the face and bruised region in question but the practitioner must first and foremost ensure the control of breathing, consciousness and possible bleeding , and check the integrity of adjacent organs indirectly affected by the trauma, but showing the true emergency. This approach is against nature, and embarrassment of the physician is increased by the impressive and dramatic side of facial lesion (hemorrhage and easy and sometimes spectacular hematoma), but he must not forget that, regardless of injury, she is in most cases no prognostic impact. This does not have even a brain impairment, eye and cervical spine among others.
Diagnosis and course of action will then be detailed by region by taking each region fracture type, this approach we pretend to correspond more closely to reality, describing beforehand the management of wounds of the face. In each region, we will focus on the first three decisions facing the sports physician on the ground following the first review:
- This is a simple contusion without associated injury, and sports can resume the match.
- This is an isolated lesion without potential severity that requires a temporary exit, sports can resume play after treatment of the injury to the locker room.
- This is a traumatic condition more serious, complicated with a doubt about an injury to a neighboring organ, the athlete must definitely leave the field and be possibly deliver urgently on a hospital structure for imaging and balance therapeutic care.
Moreover, it is interesting to note that sports federations have adapted the regulation of their sport to authorize removal and temporary replacement of an injured athlete.
Consultation of sports the day after the match to the sports physician's office matches the same description, but the initial three decisions to make, but with the same approach in doubt ask for additional tests and treatment in a specialized environment.

THREE PRIORITIES

Arrived on the ground to consider a sports injury with head and neck impact, the practitioner must first ensure the following three priorities:

1) BREATHING.
The injured is sometimes lying on the ground, and immediately, the doctor must remove his tooth protects (more commonly worn by athletes) do an oral exam by removing fragments of earth and possible dental fragments, and check his breathing. If consciousness disorders occur, the recovery position will prevent the inhalation risk in case of vomiting. The notion drop language, too often cited, actually corresponds to a flip of the tongue base on the floor above subglottic larynx, blocking the air passageway.
Recall that an obstacle to breathing sitting in the larynx and above results in an inspiratory bradypnea, with roaring and drawing by setting in motion accessory respiratory muscles (intercostal particular).
It is necessary to have a Guedel airways game in its emergency kit (Table 1), because it allows the jaw dislocating restore the patency of the airway, at a wounded unconscious. This situation is exceptional but the sports physician must be able to cope.

2) CONSCIENCE.
It reflects the state of the brain and must be an obsession for the practitioner who examines the wounded.
The primary clinical sign is of course unconsciousness which immediately should lead the physician to the following decisions:
- Final output of the athlete, even if last regains consciousness and wants to continue the game: This output is not negotiable.
- Transfer by one of the club officers to emergencies of the nearby hospital to get a brain scan without injection will eliminate extra dural hematoma possible.
- Surveillance, for normal scanner and when doubt is raised (no vomiting and new impaired consciousness, strictly normal neurological examination), by a relative or hospitalization in any doubt about the first 24 hours.

3) BLEEDING.
This is in most cases of epistaxis or nasal bleeding.
The player must leave the field course. The doctor is wearing examination gloves.
It is sufficient, initially, to blow nose to remove clots in the nasal cavity and then make him sit and squeeze his nostrils with his fingers helped a compress, her head, so that the bleeding stops .
This bi-digital compression can be facilitated by a vestibular buffering, going position in the nostril of the haemostatic product, or better SURGICEL Coalgan * * * HEC coated ointment. The compression lasts 10 minutes, checking that there is no flow at the posterior oropharynx. In the absence of obvious injury (see broken nose), the player can resume its status as the course of the game.
Sometimes that is not enough, and we must put in place an anteroposterior tamponade hemostatic pad, sort of "Tampax" nose, introduced through the nostril in a strictly perpendicular to the face level, and especially not towards the bridge of the nose and eye. This buffering is sometimes difficult, even impossible in case of pre-existing nasal septum deviation that bar and access to the nasal cavity.
At a final stage, and at the failure of the preceding means, particularly in cases of uncontrollable bleeding after vomiting with clots and blood, the use of a urinary catheter (No. 12) swollen with 10 cubic centimeter saline to seal the hole and choanal nasopharyngeal helps control bleeding before transferring the injured to the nearest hospital emergency room.

Bleeding wounds on them easily curb by a local compression with sterile gauze and antiseptic.
The player must leave temporarily if the simple suture is sufficient to treat the wound without gravity, but in case of complications before this wound (see corresponding chapter), the suture will be specializing in middle and outlet will be final.

Table 1: the minimum of the sports doctor's kit.
- Cannulas Gu├ędel
- Otoscope (Heine *)
- Compress Coalgan * and Surgicel *
- Ointment HEC
- Pads hemostatic nasal (Merocel *)
- Urinary catheter No. 12
- Sutures Transmission (needle holder, tweezers of Hadson, GILLIES hooks, scissors son)
- Injectable Xylocaine 2% without adrenaline
- Suture Son nonabsorbable 3 and 4/0
- Sterile compresses, disposable needles and sterile syringes.
- Skin and mucous antiseptics (Betadine * yellow and green)
- Compresses sterile ophthalmic
- Antiseptic eye drops (Biocidan *)
- Examination gloves, sterile surgical gloves
- Cervical Minerva.

INJURIES NEIGHBOURHOOD / THE DISPOSAL DIAGNOSTICS.

The paradox of maxillofacial examination is that considers first what is not maxillofacial, ie adjacent organs likely to be harmed by the physiological mechanism of the injury. This priority is justified by the potential severity of injuries that vicinity are among others, the cervical spine, the eye and brain. We will not dwell on it (see previous section).
This search should again be an obsession, and it is only once the certainty achieved by the normality of the examination that we can we devoted to the care of the actual facial injury.

1) THE CERVICAL SPINE.
Achieving associated cervical spine after trauma of the face is entirely conventional and is seen regularly. This joint achievement is explained by the movement of cervical hyperextension followed by a sudden high flexural impact on the face ( "whiplash").
All lesions can see, the sprained dislocation through the fractured vertebral body. The examination focuses first on pain in the neck, tingling sensation in the upper limbs and the exam will test the strength of the upper limbs and pain caused to the careful palpation of the cervical spine. When in doubt, wearing a neck brace, spine extension is the rule, the sport is definitely out of the elongated field stretcher.

2) THE GLOBE EYE.
Control of the eyeball and vision is also a priority, the visual prognosis in case of injury not suffering from any delay.
Two tables are to be feared:
- The wound of the eyeball.
This circumstance is rare, but the diagnosis is not always easy. Indeed, the impact in the orbital region causes a lid closure reflex that is difficult to overcome for the uninitiated. We must be patient to achieve separate the two eyelids, but a sign is already very evocative before this stage: the difference of intraocular pressure by palpating the two globes through comparatively eyelids. The player comes out of the ground anyway, and examination in the locker room for assessing visual acuity view to identify the wound. The transfer to emergencies closest eye (check that neighboring emergencies have a child ... ophthalmologist) in emergency, after closing the orbit by a sterile ophthalmic compress is the rule.

- The physiological section of the optic nerve.

This diagnosis is more difficult to discuss, yet it is not difficult to install. The physiological mechanism is that of a violent impact on the eyeball by a ball (tennis, hand ball ...). The eyeball is kind pendant in orbit by a thread that is the optic nerve. Under the impact of the shock, it will be pushed to the bottom of the orbit and then snap back causing a pull back and forth on the optic nerve that will have the effect of intra neural edema, blocking the transmission of visual information cortex.
After the release of the player, it will confirm a decline of unilateral visual acuity, but more often blindness with light perception or not. The diagnosis will be clinically claimed by the search engine picture reflex (narrowing of the pupil diameter to light stimulation): direct motor Photo reflex (the injured side) will be gone, the pupil remaining in mydriasis position. For cons, the contralateral, stimulating the healthy side, will lead to a closure of the pupil of the injured side, this confirming the break of the visual pathways.
The emergency is so absolute.
The sportsman is transferred to the time in a reference ophthalmologic center.
The additional assessment will be twofold:
The functional examinations, including visual evoked potentials whose prognostic value is paramount in finding a path or not.
Imaging: the scanner orbit without injection but especially nuclear magnetic resonance that goes authenticated edema, see the hematoma within the optic nerve.
The patient is hospitalized to receive medical treatment with intravenous corticosteroids with very high doses of the order of one gram per 24 hours, optionally coupled to a decompression intervention of the optic nerve.
Two surgical approaches are possible for this decompression:
- The neurosurgical approach, by the upper first sup├ęrointerne face of the orbit.
- The ethmo├»dosph├ęno├»dale trans way, by lower first internal wall and the optical channel, made of otorhinolaryngolologie service.
The hospital stay is 8 to 15 days off work depends on the applicant's professional activity (3-6 months), his athletic career is over and the recovery rate is variable depending on the teams.

WOUNDS OF THE FACE AND NECK.

We must immediately distinguish simple wounds of complex wounds or potentially dangerous, to be supported by specialist surgeon.

The management of the simple wound is relatively stereotyped:
- The wounded out of the field temporarily.
- The suture is in the locker room on a subject lying at rest.
- After disinfection of the wound and local anesthesia with Xylocaine * without adrenaline, we use two GILLIES hooks to move the two edges of the wound, removing any foreign bodies (soil or other) and check for underlying bone fracture. One plane is sufficient using a non-absorbable 5/0 or 4 wire.
- The wound is covered by a bandage and sterile gauze.
- The player can resume the game.
The son will be removed on day 5 post suture and there will be no stopping of sports activity and / or professional.
Note that we avoid the use of Xylocaine adrenaline for two reasons:
- It is potentially allergenic by sulphites which are used to stabilize the mixture, allergy to pure xylocaine being much rarer.
- Adrenaline has cardiovascular effects that do not seem desirable from an athlete who just stopped his effort.
It goes without saying that the anti tetanus vaccination of the player will update ...

The criteria leading to delay the closure of the wound due to the complex nature of the wound are:
- The achievement of a face port: nostril, mouth, eyelid.
- The achievement of a noble organ underlying: the facial nerve, the trigeminal nerve, lacrimal, the parotid duct.
- Exposure of a cartilaginous structure: nose, pinna.
- The existence of a fracture underlying synonymous with open fracture.
- The contused and complex wounds.
- The cervical wound.
- The special case of bites and amputations.
Given these criteria, the athlete must definitely leave the field, the wound should be disinfected and sealed with sterile gauze, but not sutured, and the athlete must be forward to the appropriate specialist for a specific treatment within six hours.

1) Achieving a hole da face.

Whatever this hole, from the time the wound is transfixing and severs either the orbicularis muscle (mouth, eyelids) or the alar cartilage (nose), closing the wound exposed to functional or aesthetic effects that should discourage non-specialist (notch of the nasal aperture or lip, lagophthalmos to the eyelid, salivary leak to the mouth).
The sports definitely out of the ground, the wound will be disinfected and not sutured, and conveys a simple protective dressing, the injured will be conducted within 12 hours for specialized care.
Emphasize the particular case of the deep wound of the upper eyelid that will cut the levator muscle of the eyelid, if it is not diagnosed, lead to scarring obvious ptosis of the eyelid called a few days later in the comparative examination .

2) Achieving a noble organ underlying.

A ┬░) The facial nerve
Motor nerve of the face, diagnosis lesion is relatively easy provided that rigorous and stimulating by contracting the muscle group located downstream of the wound, his paralysis in a comparative examination attesting to the section of the nerve branch that controls .
This is wound sitting in the following areas:
- Behind the brow bone to the frontal branch, which controls forehead wrinkles
- The region of the bridle for the orbicularis branch, which controls the closing of the eyelids, especially the upper.
- Cheek to the branches of the wing of the nose and lip commissure.
- The mandibular rim to the mental branch, which controls the lower lip and chin.
The wound is not sutured, the final player exiting the field and being fed within six hours in a specialized center for micro suture the nerve, recovery ranging from 12 to 18 months, the judgment of the sport being according to the sequelae caused by nerve injury (eg a section of the orbicularis branch with inability to close the eye will lead to a cessation of activity for at least 12 months).

B ┬░) The trigeminal nerve.
This is the sensory nerve of the face. It branches into three terminal branches that come with bone juxtaposition openings, explaining that their achievement is seen especially when associated fracture:

- V1 or upper leg, emerging in the inner part of the eyebrow, near the bridge of the nose. His injury by direct wound results in anesthesia hemi forehead
- The V2 or average branch out below the orbital rim, and is observed in case of fracture of the orbital floor or malar. The observed anesthesia regarding the inner part of the cheek juxtaposition nostril, Ala, hemi upper lip and gum of the incisor-canine block.
- The V3 or lower branch of which a large part of the journey is in the mandible, explaining that his achievement is seen especially in the context of fractures of the horizontal portion of the mandible. Anesthesia relates hemi lower lip and gum of the lower canine incisor block.
The treatment follows the same principles as the facial nerve, knowing
as micro suture is very seldom feasible due to the proximity of the bone. Only a release bruised nerve by a bony fragment can leave hope for a recovery within 8 to 12 months, but the consequences of anesthesia in a region of the face are less restrictive than paralysis, except the achievement of V1 which results in leakage and salivary fluids during feeding.

C ┬░) The lacrimal.
Their opening at a wound sitting next to the lower eyelid near the inner angle of the eye, resulting in the conclusion of tears through the edges of the wound when the pressure of the lacrimal sac, located in the lower part of the inner corner of the eye;
When in doubt, the exploration of the wound after catheterization of the tear duct by a qualified ophthalmologist is the rule.


D ┬░) The parotid duct.
This is the drainage channel of the parotid gland, salivary gland located in front of the ear flap and extending around the lobule.
The wound is cheek, anterior and deep enough, and massaging the parotid gland causes the arrival of saliva between the two edges of the wound.
The suture will be made by an experienced ENT, after catheterization parotid duct from its stoma in the oral cavity, in front of the upper premolar. The catheter is left in place for four to six weeks to prevent secondary stenosis, source of infectious parotitis, which corresponds to the stop term of any sport.

3) The display of a cartilaginous structure underlying.

This is essentially the nose and in the lower part of the pinna.
It must nevertheless qualify this type of wound depending on the condition of skin flaps in front of the wound:
- Either the wound is clean, the skin is vital, not bruised, with a minimal degree of sepsis and distance of an orifice, nostril or ear canal: the suture in the locker room can be realized and the resumption of planned match under a protective dressing.
- Either the wound is at once more complex, with skin fragments whose color casts doubt on his survival (bruise or hematoma, dermabrasion): better to abstain, and accompany the athlete injured in the six hours for a decision specific management by an experienced ENT (photo 1).
The latter will carry out after trimming and thorough disinfection of the wound, suturing the skin fragments reconstituting "the puzzle" and sacrificing skin fragments whose vitality is doubtful. Local anesthesia is usually sufficient time, a tight bandage with sterile saline soaked cotton filling support to remould all reliefs including flag and avoid secondary hematoma. This type of dressing will be held ten days the son being removed after 10 to 12 days, interruption of sport amounting to 15 days, with protection on resumption of the championship.
Staphylococcal anti antibiotic and a control of the anti tetanus vaccination are also necessary. The stitches on the cartilage are irrelevant, because the molding at dressing, and they may tear the cartilage.

Get closer to this situation oth├ęmatome or blood effusion of the pinna. This subcutaneous bleeding is secondary to cartilage fracture. It is observed very commonly in front in Rugby, including players from the first line. Preventing this type of injury is wearing a headband or even today a helmet that avoids direct contact with the pavilion during scrums.
Treatment is based on the puncture blood collection from its appearance in the locker room to the sterile trocar, with a thick sterile circular dressing with helmet authorize resumption of the game. The sterile tight bandage to reapply skin flag on its cartilaginous support is d a great help and should be kept in place five days. In case of repetition, after further unsuccessful puncture trocar, drainage will be by an ENT This will practice either skin incisions of a few millimeters, a fenestration, that is to say an opening of cartilage in the form of a square, next to the collection posteriorly in the retroauricular groove, supplemented by a new tight bandage and antibiotic therapy. Bolsters, transfixing points pavilion taken in the "sandwich" with tulle gras are inevitable then reapply for good skin.
Doing nothing leads to fibrosis of the pinna, and the famous pavilion aspects "cauliflower" everyone knows.

4) The underlying fracture.

It represents the perfect trap. Always assets in mind that a wound may correspond to a deep fracture, synonymous with open fracture. This trap is even more unforgivable that the wound will prevent the formation of edema in the neighboring soft parts, which makes the maxillofacial examination easy. The other means of diagnosis are the Gillies hook, which, by separating the edges of the wound, will allow direct visualization of the fracture, and or bone fragments. Some sites are very often involved in such an association, wound and fracture, such as nasal awning, the cheekbones, the zygomatic arch (photos 2 and 3).
If one is in such a case, it is best not to close the suture, to avoid the creation of edema. The player definitely out and is loaded on a hospital structure for an imaging record. Two possibilities then at the end of the balance sheet:
- Whether the fracture is non-displaced and only the suture will be performed with antibiotic coverage, and a stop sporting activity 3 to 4 weeks depending on the location of the fracture.
- Either the fracture is displaced, and reduction with osteosynthesis under general anesthesia with wound closure will be carried out urgently in six to twelve hours, during hospitalization of 3 to 7 days depending on the location of the fracture, the stop any sports activity up to 6 weeks.

5) The contused and complex wounds.

When the wound to be treated is unusual in its scope, the dubious vitality of neighborhood integument, by associating frank wound and dermabrasion, it is best left to an experienced sports surgeon who follow the wounded on the first day at secondary the primary closure, and will be able to use appropriate means (directed healing, cover flap when cartilage exhibition, screening for sepsis) for a complete healing with minimal aesthetic or functional sequelae.

6.) The cervical wound

The neck is a very particular topography in case of wound of the richness of the underlying vessels present and by the presence of the larynx, the first stage of the air.
We specifically meet again blunt trauma and cervical problem larynx.
Regarding wounds, anatomical limit in depth, as the peritoneum for abdominal wounds is the platysma muscle.
Any wound that does not reach the platysma can be considered superficial, and can be supported to the locker room. Must still be able to explore the wound properly discarding the banks, and controlling bleeding. If in doubt, abstention is the rule.
Any wound that reaches the platysma should be an exploration under general anesthesia to control the large vessels of the neck, including venous axes at the origin of rebleeding after a deceptive lull.

7 ┬░) amputations and bites.

Regarding grubbing, especially the pinna, we must keep safe all pedicle same narrow that still connects the fragment torn face. In this case, a suture with replacement can be performed with good chances of success, the suture being made within six hours post trauma, and monitoring daily and being attentive to a specialist.
When amputation is complete, a relocation can be attempted if the fragment was stored at a temperature close to 5 ┬░ C (do not put in direct contact with ice), dating back to the accident within eight hours. If these conditions are not met, it will appeal to sophisticated surgical techniques involving nurse the cartilaginous freed of its husks under the skin and reused four weeks later, or if it is useless to appeal to technical more complex reconstruction.
Human bites in sport are exceptional and fit in a forensic setting. They are particularly skeptical and needed trimming and thorough disinfection by suturing them within 12 hours. Beyond places is to move towards a healing dressings and directed, with a secondary correction flap one year after the bite, antibiotic therapy is imperative.


TRAUMA OF THE FRONT REGION BY REGION.

We will, for each region, a typical fracture, fracture most often encountered. We will eliminate immediately disjunctions fractures of facial bones (called Lefort) and nasal orbitofrontal dislocations and orbitofrontal naso-maxillary fractures that I have never encountered in sport, because for the time of a kinetic and a power impact fortunately insufficient in team sports.

1) THE FRONT REGION.

The frontal impact is very common in contact sports team, especially rugby. It can cause a loss of consciousness and the problem of extra dural hematoma fracture of the frontal bone, fortunately rare event.
The peculiarity of this region is the fracture of the frontal sinus, located above the bridge of the nose and brow bone in his inner third. In fact, there is great variability in the size and pneumatization of the frontal sinus from one subject to another. The fracture of the frontal sinus is open about having a highly developed frontal sinus, the latter being an area of ??weakness for any direct impact.
The clinical picture is relatively poor. In the absence of wound, swelling and bruising sit very strong very quickly to the root of the nose. The deformation of the soft parts is obvious, and sometimes palpation seen through the integument of the forehead, a snowy crepitus reflecting the presence of air from the sinuses and signing the fracture.
The player must somehow permanently leave the field.
On reaching the nearest hospital structure, the scanner with and without injection is needed to detect the dreaded complication of this fracture: fracture of the posterior wall of the sinus, causing a possible intra cranial hematoma due the adhesion of the dura to the posterior wall and cerebrospinal rhinorrhea.
When dealing with an isolated fracture of the anterior wall, if it is not moved, there is no indication for surgery, the athlete is arrested for four weeks (photo 4).
When the fracture is displaced, it can also be accompanied by a frontal lesion V1 anesthesia, and surgical exploration is the rule, generally bi coronal to avoid too visible scar. The ENT check the permeability of nasofrontal channel because the obstruction of the latter may be the source of deadly infectious complications secondary. After a possible release of the sensory branch of the bone fragments, these will be replaced with a micro osteosynthesis plates son or steel to reconstruct the bone contour. If the permeability of the naso-frontal channel is uncertain, the surgeon will decide to definitively exclude the sinuses by removing all the mucous lining
and filling the bone powder among others.

When the fracture concerns the anterior and posterior wall, the surgery on the same principle, but it takes place in neurosurgical environment with simultaneous repair of a hard gap mater and a possible hematoma.
THE COMPLICATIONS is actually cerebrospinal fluid rhinorrhea breach with a spinal fracture radiating on the floor of the anterior skull base. This rhinorrhea is causing secondarily a formidable meningitis. This means all the attention to be given to this type of trauma. Rhinorrhea may appear to be offset within fifteen days after the accident. It is characterized by its positional syndrome, occurring leaning forward, spring water, it is especially UNILATERALE. His diagnosis will be confirmed by a test strip identical to that used for the urine that detect the presence of sugar, which are in any case in nasal secretions. The injured will then be immediately addressed in neurosurgical environment for further investigations in search of the origin of the breach, then surgical exploration of the anterior floor of the skull base with filling of the fistula, and as a sequel anosmia due to the section of the olfactory branches during this exploration.
The unavailability of the sport will be in the range of 4 to 6 months.

2) THE POMMETTE.

This area responds primarily to the malar bone, representing the type of fracture.
The trauma of the region is also common in sports.
In most cases, it is a simple bruising with opposite edema without fracture sign. The player can get a few minutes to benefit from the application of an ice pack on impact, and in the absence of loss of consciousness and visual gene, he will regain his position on the field.
malar fracture of the signs are pretty easy to highlight the player is definitely out of the field:
- Bruising around the eyes asymmetrical bezel
- Edema of the eyelids and chemosis
- Pain on palpation of the bony insertions: inner third of the orbital rim, malar foot of the finger being engaged in the mouth at the upper vestibule, outer third of the eyebrow.
In addition there are any signs of complications of this divide:
- Sinking of the cheekbone compared to the healthy side, signing moving.
- Double vision in the eye upward, with respect to irradiated fracture on the orbital floor.
- Anesthesia under orbital injury by V2, extended to the wing of the nose, upper lip and the upper hall.
- Limitation of mouth opening by prolonged to the zygomatic arch fracture.
The player will be conducted in hospital for a CT scan of the face without injection that will appreciate the movement and condition of the orbital floor. The ophthalmological assessment with visual acuity test and Lancaster to enjoy any diplopia complete the balance sheet.

- Either this closed fracture is without displacement and without complication, there is no indication for surgery. The athlete should stop all activity for four weeks before resuming championship.
- Either this fracture is displaced and / or complicated, and the wounded must have surgery once the missing edematous phase, that is to say, between the 5th and the 10th day after the accident. The reduction of the fracture is through the hook GINESTET placed under the skin per malar or in the upper vestibule, the bone is usually maintained by an osteosynthesis (mini hob, plate or steel wire) after the first frontomalaire suture and the orbital rim which will be carried out these consolidation movements. The orbital rim addressed by sub eyelid under ciliary or trans conjunctival will host a release of the infraorbital nerve (V2) in the case of anesthesia and an exploration of the orbital floor in case of diplopia. The hospital stay is 2 to 3 days, the activity stopping four to six weeks depending on the complexity and visual effects. Diplopia sequelar led to the end of the career of the athlete.

3) ORBIT.

Trauma of this region immediately involves controlling the vision and integrity of the eyeball to eliminate two major emergencies in this region that can plague the eyeball and physiological section of the optic nerve (see the elimination of diagnoses ).
The player must goes out of bounds because the inability to properly open the eyelids of the traumatized side prevents him to pursue any athletic activity. The review made to the locker room on a sitting player, after having optionally removed the lenses must lead to the diagnosis of fracture of the orbital floor fracture type of the region.
This fracture occurs in the absence of associated fracture of the malar, due to the movement of the orbital contents, which will come under the shock hit the orbital floor, the latter yielding the impact. Signs of this fracture are quite stereotyped:
- Hematoma lower eyelid and upper quickly formed
- Edema of the eyelids.
- Enophthalmos.
These signs will prevent UNILATERAL soon a reliable test, the examiner attempts to keep the eyelids open with one hand to search diplopia at the eye upward. The sensitivity of the sub orbital nerve territory is explored, the latter being often injured during this type of fracture. The athlete must in no case blow his nose, the brutal blowing air into the nasal cavity and the maxillary sinus beneath the orbit causing the passage of air into the orbit through the fracture of the floor, with a pneumo orbit, palpation of a snowy crepitus eyelids and a compression increased risk of intra orbital content.
The injured was transferred to a nearby hospital for a CT scan of the facial structure without injection which will confirm the diagnosis, assessment being completed by an ophthalmologic examination, visual acuity test with Lancaster.


There operative indication of the orbital floor with exploration in the following situations:
- Anesthesia under orbital nerve
- Muscle hernia or musculoskeletal graiseuse manifests scanner, source of enophthalmos.
- Diplopia confirmed by the test Lancaster.
The surgery is done in an offset between the 5th and 10th day post trauma, once the edema regressed phase. The incision is trans conjunctival, ciliary under eyelid or under, according to the extent of bone loss from the floor and the habits of the surgeon. Repair, after checking by a production test forced taking the right muscle below the tweezers under AG, makes the muscle blocking his incarceration, and have reduced it, is through the bone fragments in place yet for small losses of substance to autologous (taken from the patient himself) bone (parietal bone) or cartilage (ear concha) and organic materials (fine mesh vicryl or silastic blade) for the largest. The autograft have the advantage of a very good tolerance, but it extends the operating time due to sampling. Organic materials face the risk of rejection and extrusion, including the silastic with myositis secondary lower right and definitive diplopia, but avoid the operating time of sampling.
The length of hospitalization is an average of three days and the unavailability of four to six weeks. Orthoptic rehabilitation is sometimes necessary, the final diplopia condemning the player to end his career.
In the absence of these three situations, there is no surgical indication, the sports to be put to rest four weeks.

4) THE REGION PRE EAR.

The fracture of this region is that of the zygomatic arch.
This is the bony arch buttress side of the face, and is highly exposed to side impacts.
The clinical picture consists of spontaneous pain and caused opposite impact and fracture, a palpable and visible depression in comparison with the other side and especially a limited mouth opening contusion in the temporal muscle underlying.
The athlete is transported to hospital in reference to benefit from imaging with clich├ęs Hirtz lateralized and especially scanner facial bones without injection.
The surgery is performed in cases of limited mouth opening and / or unsightly sag of the arcade. The reduction under general anesthesia is usually carried out with the hook of Ginestet, but other techniques have been described by balloon or a rasp slid surgically under the arch. Sometimes in unstable reduction, internal fixation is required by steel plates placed son or mini hemi coronal. The length of stay is two days and the sport stop an average of three weeks.

5) EAR.

We will return here on wounds and other flag, but to a particular circumstance of this region: the atrial blast.
This blast is not due to an explosion, but a slap simply that, given a priori accidentally will cause a shock wave on the eardrum.
Clinical features of immediate signs with ear pain and hearing loss and tinnitus shrill or instability and rotary vertigo.
The fate of the sports field and an otoscope research otorragie moderate rule, hyperemia of the eardrum or tympanic perforation with rupture.
The instillation of ear drops is strictly prohibited, the ear is occluded by an occlusive dressing. The opinion from an ENT is imperative within 24 hours, making it an audiogram. This will help to differentiate the following tables:
- Perceptionnelle Fall on acute tinnitus with intact eardrum, this requiring medical treatment by Vastarel *, with 15 days off.
- Fall perceptionnelle largest, over a wide frequency band with disabling tinnitus, the condition of the eardrum being variable, treatment using corticosteroids and Vastarel, sometimes hospitalized for four to eight days, and a stop four weeks without warranty recovery.
- Fall perceptionnelle much stronger, vertigo, tympanic rupture. The injured was hospitalized, has a scanner rock in search of a labyrinth Pneumo synonymous opening of the inner ear, this imposing surgical exploration of the middle ear under general anesthetic to fill the aperture (the fistula) of the inner ear. This surgery is framed by the medical intravenous corticosteroids, antibiotics and oral Vastarel *, the length of hospital stay is ten days, stopping any sports activity up to two months.

6 ┬░) PYRAMID NOSE.

The nose is probably the most frequently affected in sports traumatology area, and for reasons that Edmond ROSTANT perfectly explained in Cyrano de Bergerac.
We must distinguish four entities to trauma nose:
- Simple contusion.
- The broken nose closed without displacement.
- The nasal fracture with displacement.
- The open fracture of the nose.
Simple contusion results in a localized edema on impact, with transient pain without epistaxis and perfect integrity of the nose in form. The sports out temporarily. The review confirms the absence of wall hematoma (see next chapter), the ice pack limit edema and the player can take his place.
Fracture closed undisplaced nose is expressed by a hematoma bezel of the two orbits relatively quick onset with epistaxis and marked unilateral or bilateral edema. There is no wound opposite impact. The player definitely goes wide. The epistaxis is controlled by the usual means and gentle palpation of the nasal awning include pain caused next to the fracture site, and confirms the lack of movement. Moving quickly difficult to assess because the swelling settles. Anyway, the sport is taken to the nearby hospital for radiological assessment including an incidence own bone (profile), a Blondeau, a Gosserez enjoying moving laterally.
The fracture line is visualized, the absence of confirmed travel. If in doubt, a secondary examination by an ENT, five days after the trauma, once past the edematous phase reassess the move. If in doubt, a CT scan of the facial structure without injection allows better visualize lesions. There is no indication for surgery, anti-inflammatory treatment may be prescribed antibiotics is questionable. The athlete will be sidelined three weeks, the time of consolidation of the fracture.


The closed displaced fracture is the same clinical picture except for movement. The most frequent displacements are:
- Unilateral lateral fracture trauma causes depression of bone trauma and a lateral deviation of the nasal awning
- The disjunction fracture of the nasal canopy, where two bones are fractured and dislocated own block the side opposite the side trauma, nose, taking the form of S.
- The depressed fracture of the nasal bone awning where own profile recede under the impact anterior posterior nose taking the form of saddle or saddle nose nasal.
The indication for surgery is justified to reduce the movement and remove a possible sequel aesthetics. The operation took place between the 5th day and el 12Eme day posttraumatic under general anesthesia during a 24-hour hospitalization or outpatient surgery. The surgeon will close the gap by introducing a tutor in the nasal cavity clean broken bone and applying external pressure with his other hand to replicate the inverse movement of the cause of displacement. The contention is performed by a cast and a bilateral wicking removed the next day. The plaster is kept seven days, stopping the sport being three weeks.
Open fracture is defined as a wound facing the impact. The paradox in this case is very reduced edema due to the skin incision. This fact allows us to appreciate much more easily moving and the reality of the divide separating the edges of the wound with Gillies hooks. A bone fragment sometimes hernia through the wound. The physician must not suturing the wound, as we have seen in a previous chapter. The player steps out of the ground and is accompanied to a nearby hospital for radiological assessment. Following this assessment, there are two cases:
- Either the fracture is non-displaced. The skin closure is performed under local anesthesia, no hospitalization, anti staphylococcal antibiotic is prescribed seven days and the player's unavailability period is three weeks.
- Either the fracture is displaced, and the player is operated within 24 hours, with fracture reduction and skin closure in the same operation. Hospitalization is 24 hours, leaving the injured on antibiotics, plaster being removed on the 7th postoperative day and the son, stopping sports being three weeks.

The particular case of the partition. The wall hematoma (photo 5).

All traumatized nose must have an endo nasal examination, using an otoscope to visualize the wall. If the latter is deflected, nothing says that this deviation is secondary to trauma, it may be old. If the partition is totally dislocated, obstructing the nasal cavity, with a wound in the nasal mucosa, its newness is little doubt. The reduction of the fracture own bone is then accompanied by a test of realignment of the partition with the splints share establishment side thereof to hold it in place over a period of 8 to 10 days. This realignment is random due to the unstable character of cartilage with respect to the bone.
The wall hematoma occurs in adolescents because of the preponderance of the nose cartilage (lower half) while in adults, the bone becomes majority, cartilage forming only a third of the nasal pyramid. The fracture of the cartilage of the septum without mucosal wound causes the formation of a hematoma of the anterior nasal cavity, soft to the touch and purplish under review, obstructing the nasal pathway. Its diagnosis is important because unrecognized, the hematoma becomes infected by rule between the 10th and 15├Ęmejour post trauma with consequent melting of purulent nasal cartilage that supports awning leading to ensellure very unsightly nose and difficult to correct. The hematoma is drained identified under general anesthesia, the injured are hospitalized 24 hours, antibiotic treatment with broad spectrum being prescribed orally for 8 days.

Cerebrospinal rhinorrhea.

We have already mentioned in the fracture of the frontal sinus. It can also be observed in case of fracture of the said nose "outdated", that is to say, in case of fracture of the nose with impact on the root of the nose, the fracture line irradiating on the prior stage of the skull base. The diagnosis is suggested by the extent of damage to the scanner, the attention to be focused on a flow of liquid "rock water" with positional syndrome, occurring to one or both sides, a dipstick identifier of sugar within it, which means it is cerebrospinal fluid with certainty. What to do is the same as the frontal sinus.

7.) THE PLAYS.

We mean by plays, the region below the cheekbone and which corresponds to the anterior wall of the maxillary sinus. The fracture type is the fracture of the maxillary sinus, mainly its front wall. This type of fracture is relatively rare, because this region is protected by other more in relief (nose and cheekbone).
Diagnosis is based on a local edema, possible defects perceptible to the touch, a discreet epistaxis and perception of snow crackling synonymous with air suffusion in T & eacu
Diagnosis is based on a local edema, possible defects perceptible to the touch, a discreet epistaxis and perception of snow crackling synonymous with air suffusion in T & eacu

Doctor Serge HERMAN. - 9 f├ęvrier 2011.

Conflicts of interest: the author or authors have no conflicts of interest concerning the data published in this article.

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