The incidence of sports-related facial trauma in children.
We conducted a survey of physician members of the American Academy of Facial Plastic and Reconstructive Surgery to determine the incidence and nature of facial traumas seen in their practices. We solicited information on the anatomic location of each injury, the severity of the trauma, and whether the injury occurred during a sports activity. According to the responses, 21% of facial fractures and 29% of nasal fractures were experienced by patients aged 17 years and younger who were participating in sports. We believe that many such injuries can be prevented with greater use of protective equipment.
Despite the use of protective gear, the incidence of sports-related facial trauma among children remains significant. In its most recent report, the U.S. Consumer Product Safety Commission (CPSC) in 1991 reported that more than 100,000 cases of facial trauma occurred in children younger than 14 years while they participated in sports activities.  In private practice, we have found that the number of nasal injuries incurred during youth softball games is surprisingly high, particularly among female pitchers who are hit by a batted ball.
In the past 2 decades, the incidence and severity of facial trauma from all causes have steadily declined. [2,3] Among the reasons cited for this decline are laws requiring the use of seat belts, use of airbags, higher legal drinking ages, tighter enforcement of drunk driving laws, and the more widespread use of protective facial gear in sports. In 1989, Beck and Blakeslee reported that 12% of all facial injuries were incurred during sports activities; the only causes more common were motor vehicle accidents and assaults.  Other published studies have shown that sports-related injuries account for 3 to 29% of all facial injuries. [4-6]
Numerous studies have documented the effectiveness of protective equipment in preventing sports injuries. [7-10] Studies of populations ranging from professional hockey players to Little League baseball players have shown that helmets, facemasks, mouthguards, and similar devices all reduce fracture and injury rates.
According to estimates, between 1.5 and 15% of all facial fractures occur in children.  Three reasons are thought to explain this relatively low incidence among children. First, a child's bony structures are highly elastic. The presence of cartilaginous growth centers makes the pediatric facial skeleton more pliable. As a result, the facial structures can undergo significant distortion without fracturing. Second, a child's face constitutes a relatively smaller area of the cranium than does an adult's face. Third, the soft tissue in children is thicker and contains a higher proportion of fat, which provides a cushion atop the underlying framework. Even so, U.S. emergency rooms treated more than 1.3 million cases of injury to the face, eyes, and mouth in patients younger than 15 years during a recent 1-year period.
Materials and methods
We mailed 800 surveys to physician members of the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) in 1991, and received 53 usable responses (6.6%). We asked respondents to describe the number and nature of facial traumas in their practices during the previous 5 years. We solicited information on the anatomic location of each injury, the severity of the trauma, and whether the injury occurred during a sports activity.
Facial fractures. The AAFPRS respondents reported a total of 767 facial fractures in males and females of all ages (table 1). Males experienced 76% of all facial fractures. In the two sexes combined, the fracture rate among those aged 17 years and younger was 52%.
Sports-related facial fractures. Some 42% of all facial fractures were sports-related, and males experienced 83% of these injuries (table 2). The percentage of sports-related facial fractures was equally distributed between the two age groups. In the two sexes combined, 23% of the injuries in the younger group were experienced during softball or baseball games.
Nasal fractures. Of the 767 facial fractures, 482(63%) were nasal fractures, as documented by radiographic or clinical examinations (table 3). Just as they did with facial fractures, males accounted for 76% of all nasal fractures. In both sexes combined, a higher rate of nasal fracture (58%) was seen in those aged 18 and older. Of all the nasal fractures, 80% required surgical intervention.
Sports-related nasal fractures. Of the 482 nasal fractures, 237 (49%) were sports-related (table 4). Categorized by sex and age, the rates were higher in the male group and in the younger group--84 and 61%, respectively. In both sexes combined, 32% of these injuries in the younger group were experienced during softball or baseball games.
Of all patients with sports-related nasal fractures, 29% had associated injuries, including, in order of decreasing incidence, malar complex fractures, orbital fractures, and soft-tissue lacerations.
We found that 42% of all facial fractures were sports-related, a significant figure in light of the preventable nature of these injuries. The vast majority of these injuries (83%) were experienced by males, a finding that is in accord with previous studies, where the incidence of facial trauma among males has been reported to range from 60 to 88%. [2,4,12]
As the leading structure on the face, the nose is especially vulnerable to injury.  Previous studies have reported that nasal fractures accounted for 23 to 45% of all pediatric facial fractures.  We believe that these figures might underestimate the true number of pediatric nasal injuries. We found that more than 60% of all facial fractures included a nasal fracture, and that 42% of these cases involved patients aged 17 years and younger. But when only sports-related nasal fractures were evaluated, the younger group experienced 61% of these injuries.
Perhaps the difference between our findings and those of other studies can be explained in part by the different experiences of the referral networks' individual authors. For example, published reports in dental journals reveal a much higher percentage of dentoalveolar fractures.  Our data reflect the practices of otolaryngologists and facial plastic surgeons, whose patients represent a select population of traumatized patients. These patients, who were often referred by primary care physicians, frequently demonstrated more severe injuries and more significant anatomic deformities. Additionally, these patients were much more likely to require surgical intervention.
Of the many physical and aggressive sports that are played, softball and baseball account for the most facial fractures. Facial fractures are much more common in softball than in baseball because softball has a much higher number of participants, including a great number of females. Another factor in the higher incidence of softball injuries might be the greater mass and volume of the ball itself.
But while injuries tend to be more common in softball, they tend to be more severe in baseball. Little League baseball has an estimated 6 million participants between the ages of 5 and 14 years.  A CPSC study found that 40% of sports-related injuries in children between the ages 5 and 14 occurred during baseball games.  In 1995, 162,100 baseball-related injuries were treated in hospital emergency rooms, 75% of which involved children between the ages of 10 and 14 years. 
We believe that particular attention should be paid to those in the under-11 age group, who have less skill and coordination, slower reaction times, and less maturity. The CPSC reported that more than half of the injuries in this group occurred in the head or neck.  Unlike adults, children can experience a septal or bony fracture with only minimal external signs of trauma. 
Baseball-related injuries exceed those of all other sports as a cause of death; the CPSC recorded 88 baseball-related fatalities between 1973 and 1995.  Twenty-one of these fatalities occurred when a ball hit a player's head. Overall, most baseball injuries occur to batters. Even though batting helmets with two-sided protective earflaps are required in all parts of the country, helmets equipped with facemasks are not (figure). We believe the use of facemasks throughout the United States would be of great benefit. Since the Dixie Baseball League, an organization based in 11 southern states, instituted a mandatory facemask rule, the injury rate there has fallen. 
After reviewing our data as well as those of other investigators, the CPSC updated its safety recommendations for baseball equipment in 1996. The CPSC estimated that 58,000 baseball injuries--including approximately one-third of those treated in emergency rooms--could be prevented. For example, the CPSC estimated that facemasks on batting helmets could prevent or lessen the severity of 3,900 facial injuries. The CPSC also recommended other protective measures, such as safety-release bases and softer balls.
In conclusion, our data clearly identify the risk of facial fractures in children who play softball and baseball. We endorse the CPSC's position on the use of facemasks, not only for young batters but for young pitchers as well because of their proximity to batted balls.
From the Department of Otolaryngology-Head and Neck Surgery, Indiana University, Indianapolis (Dr. Perkins and Dr. Hamilton), the Department of Otolaryngology-Head and Neck Surgery, the University of Illinois-Chicago (Dr. Dayan and Dr. Bussell), and the Division of Otolaryngology-Head and Neck Surgery, University of Maryland, Kensington (Dr. Sklarew).
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(12.) U.S. Consumer Product Safety Commission. Overview of sports-related injuries to persons 5-14 years of age. Washington, D.C., 1981.
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|Author:||Bussell, Gregory S.|
|Publication:||Ear, Nose and Throat Journal|
|Date:||Aug 1, 2000|
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