Working Diagnosis:
Concussion without loss of consciousness, complicated by an acute, mildly displaced right orbitozygomaticomaxillary complex fracture.

Treatment:
Rest

Outcome:
Given her position as a goalie, she was not allowed to return for the remainder of the season in order to allow time for her fracture to heal. We considered a face shield, but thought it would not provide adequate protection from further trauma which could lead to fracture displacement. Through standard concussion protocol, she was able to return to non-contact exercise and conditioning in two weeks. Three months after the injury, she was cleared to return to full activity by the Plastic Surgeon. Her right facial V2 numbness persisted four months later.

Author's Comments:
This patient did sustain a concussion, but it was not her only injury. Maxillofacial injuries represent approximately 3.4% of all injuries sustained by NCAA athletes. Fractures of the zygomaticomaxillary bony complex account for approximately 10% of sports-related facial fractures. There are no existing clear return to play guidelines, but literature suggests refraining from practice or competition for at least 6-8 weeks and up to 2-3 months based on two separate sources. There is potential to return 40 days following trauma for non-combat sports. More research is need to improve prevention and to develop effective protective equipment. This clinical case highlights the importance of the team physician, patient, and athletic trainer working together as a medical team. For this particular injury, she was closely examined on the day of injury and the day after injury. This prevented a delay in the diagnosis of her fracture.

Editor's Comments:
Concussion can be the result of direct impact anywhere on the skull but also to the facial bones. This case highlights the importance of prompt follow-up and a thorough physical examination not only evaluating for concussion but also for additional sequelae of blunt force trauma, which in this case lead to appropriate diagnostic imaging and subsequent diagnosis of fracture. Importantly, palpation, cranial nerve examination, and evaluation for cerebrospinal fluid (CSF) leak (CSF rhinorrhea and otorrhea) were included in the physical examination.

Following completion of the diagnostic work up, which appropriately included CT of the facial bones, she was referred to plastic surgery for expert management of her injury. Safe return to play for this athlete included not only treatment of her concussion but appropriate management of her zygomaticomaxillary complex fracture.

References:
1. Chorney SR, Sobin L, Goyal P, Suryadevara AC. Maxillofacial injuries among National Collegiate Athletic Association athletes: 2004-2014. Laryngoscope. 2017 Jun;127(6):1296-1301.
2. "Sports-Related Facial Trauma: Facial Injuries, Basic Anatomy of the Face, Evaluation of Facial Injury." EMedicine, 7 Apr. 2023, emedicine.medscape.com/article/1284288-overview.
3. Roccia F, Diaspro A, Nasi A, Berrone S. Management of sport-related maxillofacial injuries. J Craniofac Surg. 2008 Mar;19.

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