CASE REVIEW
Katie Walsh, EdD, ATC, Report Editor
Return to Play Following Facial Fractures
in a Division I Basketball Athlete
Morgan L. Cooper, MA, ATC, LAT • East Carolina University
M
ULTIPLE FACIAL FRACTURES are usually
associated with automobile collisions and
rarely occur in athletics (Table 1). When
facial fractures occur in sports, it is usually associated with contact sports (Table 2) and may
include complications such as vision loss, diplopia,
severe facial deformity, or loss of sensation.1,2 Athletic
trainers should be aware of the availability of customfitted face shields for athletes with multiple facial
fractures, which may facilitate return to play. This case
report involves an injury to a basketball player’s face
that occurred in open gym. With a custom-fitted face
shield, she was able to participate in NCAA Division I
basketball with no restrictions.
History/ Physical Evaluation
An eighteen year-old female basketball athlete received
a direct blow to the right side of the face by a teammate’s head during free play in the preseason. Due
to nasal deformity and excessive bleeding, she was
immediately taken to a hospital emergency department by her teammates. An ice pack was applied to
the nose/eye area and a towel was used in an attempt
to stop nasal bleeding. The athlete was evaluated by
an emergency room physician and a plastic surgeon
for multiple facial fractures. The physicians noted that
there was no visual impairment and that her pupils
were equal and reactive to light, but a pronounced right
eye droop was evident. The athlete reported dizziness
but no loss of consciousness. She had a headache, loss
of sensation along the right cheek, and bleeding from
the right nostril. Radiographs and CT scan revealed a
Table 1. The Cause of the Blowout Fractures3
Cause
No. of patients
Assault
Falls
Sport
Road-traffic accident
Work
Total
33 (53)
3 (5)
23 (37)
2 (3)
1 (2)
62 (100)
Note. Values in parentheses are percentages
Table 2. The Sport Involved in
Blowout Fractures3
Sport
No. of patients
Large ball field sports
Soccer
Rugby
Total
7
4
11
Small ball sports
Indoor Cricket
Hockey
Squash
Fives
Total
3
1
1
1
6
Combat sports
Karate
Thai Boxing
Total
Swimming
Gymnastics
Total
2
1
3
2
1
3
© 2008 Human Kinetics - Att 13(6), pp. 30-32
30  november 2008
Athletic Therapy Today
fracture at the superior and lateral walls of the right
maxillary sinus, with depressed bone fragments. The
lateral fracture extended into the zygomatic arch. The
CT scan revealed that both the right zygomatic arch
and the lateral pterygoid plate were fractured and the
right maxillary sinus was filled with blood (Figure 1).
The diagnosis was an orbital blowout fracture.3 She
was released from the emergency department with
follow-up evaluation by the athletic trainer and team
physician scheduled for the next morning.
Anatomy
The orbit consists of seven bones that form a bony
cavity that encases the eye, which includes the frontal,
sphenoid, zygomatic, maxilla, palatine, lacrimal, and
ethmoid bones. The sphenoid bone, which is part of
the lateral pterygoid plate, is broad and thin. Its outer
surface forms part of the medial wall of the infratemporal fossa. The medial surface of the infratemporal
fossa forms part of the pterygoid fossa.4 The muscles
within the eye orbit are the corrugator supercolii, which
is superior to the eye and the orbicularis oculi, which
is inferior to the eye.4 The olfactory nerve, which is
located adjacent to the ethmoid bone, carries afferent impulses associated with the sense of smell.4 The
optic, oculomotor, and trochlear nerves conduct afferent and motor impulses associated with vision. The
Figure 1 CT scan postinjury.
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trigeminal nerve is located adjacent to the eye orbit,
which conducts afferent impulses associated with
touch and pain.4
Treatment and Clinical Course
Successful orbit reconstruction surgery was performed
at four days post-injury. One plate was placed along the
superior orbital rim, a second plate was placed from
the medial naso-maxillary area to the lateral orbital
rim, and a third plate was placed from the medial
naso-maxillary area to the zygomatic-maxillary area.
Following surgery, the athlete remained hospitalized
for 24 hours and was restricted from class attendance
for three days.
A strict liquid diet was prescribed for two weeks,
which was progressed to a soft diet for an additional
four weeks to promote healing and decrease pressure
on the plates from chewing. A normal diet was resumed
at approximately six weeks postsurgery. Activity was
limited to walking to class for the first three weeks,
which was followed by initiation of stationary biking
for cardiovascular training. At five weeks postsurgery,
the athlete gradually incorporated running, sprinting,
and weight lifting (including Valsalva-type lifts) without
pain presenting any limitations.
A follow-up CT scan was performed at eleven weeks
post-surgery to assess healing and to consider readiness for return to participation in basketball (Figure
2). Because the injury was healing well, the athlete
was instructed to obtain a custom-fitted face shield
for protection during all basketball-related activities.
The surgeon required the face shield to distribute any
pressure applied to the original injury site over a broad
area. Because noncustom nasal shields do not protect
orbital or zygoma fractures, a custom face shield had
to be fabricated by a prosthetist (Figure 3).
Multiple prosthetic facilities were contacted to find
one that was capable of constructing a custom face
shield. A plaster mold was made of the athlete’s face
to permit fabrication of a shield that would conform to
the facial contours. Approximately one week later, the
athlete returned to the prosthetic facility for the first of
three fitting sessions. The face shield was constructed
from transparent fiberglass material that evenly distributes pressure over a broad area around the site of
the fracture and the surgically implanted metal plates.
Velcro straps were used to secure the face shield to the
head. The surgeon approved the final mask design and
november 2008  31
Figure 2 CT scan 11 weeks postsurgery.
cleared the athlete to return to all normal physical activity, with the understanding that the face shield would
be worn for one year postinjury.
Discussion/Conclusion
A noncustom face mask can protect a nasal fracture by
dispersing pressure along the zygomatic arch, but the
existence of multiple facial fractures requires a customfitted face shield. There were a few concerns associated
with the process of obtaining a custom-fabricated face
shield for the athlete. The device was not covered by
insurance, which could make it cost prohibitive for
athletic programs with limited budgets. Second, locating an accessible prosthetic facility that can fabricate a
customized face shield may be difficult. In such a case,
the injured athlete might not be allowed to participate
for eight to twelve months. For the reported case, the
athlete would have been unable to participate for the
entire basketball season if not for the face shield.
The timing of return to activity following multiple
facial fractures is highly dependent on the availability
32  november 2008
Figure 3 Custom fitted face shield.
of adequate protection. The athletic trainer should be
aware that some prosthetists can provide a customfabricated face shield. The coordinated efforts of
the surgeon, the athletic trainer, and the prosthetist
enabled the athlete to return to collegiate basketball
within three months of injury without restrictions.
Having missed only two regular season games, the
athlete was able to participate fully for the majority of
the basketball season with no complications. 
References
1.Anderson M, Hall S, Martin M. Sports Injury Management 2nd ed.
Philadelphia, PA: Lippincott Williams & Wilkins; 2000:206.
2.Cruz AA, Echinberger GC. Epidemiology and management of orbital
fractures. Curr Opin Ophthalmol. 2004;Oct,15(5):416-21.
3.Jones NP. Orbital blowout fractures in sport. Brit J Sports Med. 1994;
December, 28(4):272–275.
4.Marieb E. Human Anatomy and Physiology. 4th ed. Menlo Park, CA:
Addison Wesley Longman Inc; 1998:200-203.
Morgan L. Cooper is the Associate Head Athletic Trainer/lecturer at East
Carolina University in Greenville, NC. E-mail: [email protected].
Athletic Therapy Today