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Incidence of facial fractures in the AFL
Dr Jodi Richardson   
Monday, 12 November 2012
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Facial fractures can be devastating injuries in the Australian Football League, but thankfully they're becoming less common.
Image: FKolbz/iStockphoto

Horrific. The only word fit to describe the facial fractures suffered by some of AFL’s greatest players including James Hird and Jonathan Brown. So severe were Hird’s and Brown’s injuries that they were likened to those of a high-speed car crash victim. These injuries rank amongst some of the worst the AFL has seen and have repercussions extending beyond the footy field.

Such is the severity of some facial fractures that they have the potential to ‘cause the temporary or permanent loss of function thereby threatening a player’s earning potential and length of playing career’ according to a recent research paper published in the ANZ Journal of Surgery. Thankfully, the research shows that there has been a trend of decreased incidence of facial fractures in the AFL.

Researchers, including Sports Physician and AFL injury report co-author Dr John Orchard, reviewed facial fractures from the injury records collected by the AFL over seventeen seasons between 1992 and 2008. To get a comprehensive understanding of these injuries, they investigated facial fractures by frequency, location, time of season, player recovery, fracture incidence per season and geographical location of the injury.

Over the 17 years of the study, AFL players were reported to have sustained a total of 175 facial fractures, accounting for less than 2% of total injuries to AFL players in that time frame. Players missed 517 games as a result of their injury, averaging 3 games per injury.

The facial skeleton is comprised of fourteen bones where there are eight bones forming the nasal cavity as well as contributing to other parts of the face. The most common facial fracture sustained in the AFL over the period of the research was to the zygomaticomaxillary complex (41%), also known as a tripod fracture. Fractures of this kind damage the bone around the eye, under the eye and the cheekbone. The next most common type of fracture was to the lower jawbone (37%).

A long standing definition for an injury to be included in the stats is that the player must miss a game as a result of that injury. Consequently, many broken noses and other facial fractures are not recorded in any injury survey if the player does not miss a game. Chris Judd’s broken nose in Round 12, 2009 was such an injury.

Judd’s nose was broken just minutes into the second half of the game against the Saints when he collided with his team mate Stephen Browne. He sustained a broken nose and returned to play but left the field multiple times under the blood rule as the team doctors found it very hard to stop the bleeding. If you’ve ever had a hard knock to the nose, you’ll know the experience is very painful. Judd’s nose was badly broken and he just kept going back on to play. After plugging his nose with gauze was unsuccessful, doctors inserted a bladder into his nose and inflated it in an attempt to compress the blood vessels to stem the bleeding. Judd had surgery the day after the injury, was lucky to have the bye week the following weekend, and then returned for Carlton’s next game.

Dr Jason Savage, Trainee Maxillofacial Surgeon and author of the research paper on facial fractures in the AFL explains that the surgical management of these injuries can be influenced by what the player wants to do.

“Football is a profession and players want to get back to playing. There are several cases where players have had a significant facial fracture, consult a surgeon, undergo surgery and then play the following week,” Dr Savage said.

The authors of the report have recommended that the AFL change the injury definition and extend the scope of injury reporting to include other forms of maxillofacial trauma so that they can get a true picture of these injuries and so that injury prevention measures can be implemented accordingly.

Facial fractures can have serious short term and lifelong consequences. Depending on the location and severity of the injury they can result in permanent eye damage, blindness, facial deformity, scarring, poor healing (non-union of the fracture site), infection and the loss of sensation.  For example if the lower jaw is fractured teeth may be damaged, the dental occlusion may change affecting the bite and sensory nerves could be damaged affecting speech. Of course given that facial fractures are the result of a severe blow to the head, concussion is a big consideration with any of these injuries.

Though surgeons do their utmost to avoid so, at times they cannot reconnect the facial bones in exactly the same way that they were positioned prior to the injury.

“Warnings for patients include bleeding, bruising, pain, swelling and the possibility of infection,” Dr Savage explained.

“For the two most common AFL facial fractures, players are warned of a change in their occlusion, where their teeth may not bite together in the way they did prior to the injury. We try to reposition their occlusion exactly the way it was, but if you have ever had a filling and it’s even half a millimetre too high, it doesn’t feel quite right. Sometimes a patient will have a 1-2 centimetre gap where they used to touch as a result of the way they fractured their maxilla (upper) or mandible (lower jawbone).”

It’s hard to believe but it was ten years ago when James Hird suffered shocking facial injuries after colliding with the knee of his team mate Mark McVeigh.

Dr Peter Larkins reported on Channel 9 at the time that Hird suffered a compound or open fracture, meaning that parts of bone were visible after the injury. He explained that Hird’s injury was a five-part fracture incorporating most of the left eye socket, and parts of the forehead, nose and upper teeth.

“His whole middle third of his face got shifted to the right side when he got hit on the left side. This is an injury we normally see in motor-car accidents where the middle third of the face gets caved in. It's a common trauma injury in high-velocity accidents,” Dr Larkins said.

Players undergo general anaesthetic for facial fracture surgery. To avoid scarring, surgeons make their incisions inside the mouth to repair facial fractures wherever possible. Often, surgeons use malleable titanium plates called ‘mini plates’ to fixate fractures. The plates are screwed to the bones to fix them in place so the bones can heal themselves. These plates remain within the patient.

“Occasionally, if you have a fracture with a lot of displacement, such as a mandibular fracture (of the lower jawbone) or if a player wants to return to play straight away, surgeons can attach larger ‘reconstruction plates’ which are a lot thicker and bulkier and can be taken out after a period of time requiring a second operation. However, this does not happen very often,” Dr Savage explained.

“Patients are then put on pain relief medication and antibiotics, and are normally advised to go on a soft food diet for six weeks so as not to put too much pressure on the plates as the bone heals."

Six weeks of rest is recommended after facial fracture surgery to allow enough time for the bones to heal well, however, three weeks is the average number of games missed. Players undoubtedly have concerns over re-injury when they take to the field so soon after surgery but statistically, there is not a high rate of recurrence.

“There is increased risk of more damage when players return to play before the bone is repaired but they are prepared to take the risk,” Dr Orchard said.

“Players roll the dice with facial fractures and factors such as finals contention come into play when they are making these decisions.”

Dr Orchard explains that for the general community a facial fracture is a significant injury psychologically and many would struggle to get back to playing hard football after the event but AFL players are different.

“The majority of players would prefer a facial fracture to an injury that will affect their ability to run,” Dr Orchard said.

The good news is that the last three years of the facial fractures study between 2006 and 2008 showed a trend of decreased incidence of facial fractures in the AFL. Much of this reduction is likely due to the introduction of the match review panel in 2005 as the report shows marked differences in facial fracture incidence after this change.

“In the thirteen seasons prior to the rule change, a mean of 11.2 fractures per season were recorded. This was reduced to a mean of 7.5 in the four seasons from 2005 to 2008,” Dr Savage and his colleagues reported.

“The introduction in 2007 of a free kick for any front on contact to a player with his head over the ball or for high contact to a player may have also encouraged safer play but with few seasons since its introduction this is difficult to assess on facial fracture results.”

In the 2011 AFL season there was an increase in the number of games missed as a result of concussion. There is more publicity around concussion than ever before and it is possible that club doctors, players and coaches are taking a more conservative approach which will influence this injury statistic. This apparent increase in concussion means that concussion is being taken more seriously. The AFL is trying to decrease the incidence of head contact and the results from the facial fractures article suggest that related rule changes are in fact effective.  

“The documented recent fall in facial fractures shows that head high contact is actually dropping in AFL. Because concussion is so hard to measure, we can't really rely on comparison of past and current concussion rates as the reporting threshold is changing as much as the actual incidence. However, missed games due to facial fractures are a much more objective measure,” Dr Orchard said.

Editor's Note: This article was originally published in Inside Football magazine on 31/10/12. Read more of Jodi Richardson's articles on sport science here.
 
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