- Email: [email protected]
Characterizing Craniomaxillofacial Injuries in American Professional Sports Leagues
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CRANIOMAXILLOFACIAL TRAUMA
Characterizing Craniomaxillofacial Injuries in American Professional Sports Leagues
Q1
Brendan W. Wu, MMSc,* Hossein E. Jazayeri, BS,y Kevin C. Lee, DDS,z Nima Khavanin, MD,x Amir H. Dorafshar, MBChB,k and Zachary S. Peacock, DMD, MD{
Q5
Purpose:
The purpose of the present study was to characterize the types of craniomaxillofacial (CMF) injuries that occur in professional sports leagues and the associated recovery times.
Materials and Methods:
A retrospective cohort study was designed and implemented using the Pro Sports Transaction Archive. The database was queried for all registered CMF injuries in the 4 main men’s major professional sports leagues in the United States from 2013 to 2018. The sport, injury location, and season were the predictor variables, and the frequency and length of time on the injured list were the outcome variables. Descriptive statistics were computed, and Fisher’s exact tests were used to determine the association between the predictor and outcome variables. Analysis of variance was used to compare the injury frequency and duration.
Results:
Of the 198 injuries that met the inclusion criteria, 60 were from Major League Baseball (MLB) (30%), 49 from the National Basketball Association (25%), 8 from the National Football League (8%), and 81 from the National Hockey League (NHL) (41%). Injuries to the midface were most common (mean, 25.2 3.6 injuries per season; P < .001) compared with the upper face (mean, 6.0 2.0 injuries per season) and lower face (mean, 8.4 2.3 injuries per season). The mean time on the injured list after CMF trauma was 8.4 10.4 days, with MLB injuries requiring the shortest duration (mean, 3.9 6.6 days; P = .001). A significant association was found between the injury location and sport (P < .001). However, no statistically significant difference was found in the number of injuries per season from 2013 to 2018 for each league (P = .818). Conclusions: Midface trauma was significantly more common than upper or lower face trauma in professional sports leagues during the past 5 seasons. The NHL had the greatest injury rate, even after adjustment for games played. Ó 2019 Published by Elsevier Inc. on behalf of the American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg -:1-6, 2019
Q3
*DMD Candidate, Harvard School of Dental Medicine, Boston,
Conflict of Interest Disclosures: None of the authors have any
MA.
relevant financial relationship(s) with a commercial interest.
yDMD Candidate, School of Dental Medicine, University of
Address correspondence and reprint requests to Dr Peacock: Department of Oral and Maxillofacial Surgery, Massachusetts Gen-
Pennsylvania, Philadelphia, PA. zResident, Division of Oral and Maxillofacial Surgery, New York-
eral Hospital, 55 Fruit St, Warren 1201, Boston, MA 02114; e-mail:
Presbyterian/Columbia University Irving Medical Center, New
[email protected]
York, NY.
Received October 5 2019
xResident, Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD.
Ó 2019 Published by Elsevier Inc. on behalf of the American Association of Oral
Accepted November 26 2019
kProfessor and Chief, Division of Plastic and Reconstructive
and Maxillofacial Surgeons
Surgery, Rush University Medical Center, Chicago, IL.
0278-2391/19/31358-8
{Assistant Professor, Department of Oral and Maxillofacial
https://doi.org/10.1016/j.joms.2019.11.031
Surgery, Massachusetts General Hospital and Harvard School of Dental Medicine, Boston, MA.
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2
CMF INJURIES IN AMERICAN PROFESSIONAL SPORTS LEAGUES
Injuries to the craniomaxillofacial (CMF) skeleton in the context of professional sports has been commonly reported because their frequency and severity have functional and esthetic consequences.1 In children, participation in sports has been one of the leading causes of craniofacial trauma, and the CMF complex is the second-most common site of trauma in youth sports.2 The increasing incidence of traumatic injuries is reflective of the greater number of participants in sporting events. Most sport-related CMF injuries at all ages will require operative treatment3; thus, a multidisciplinary dialogue regarding prevention strategies and timely surgical protocols is warranted.4 Although CMF injuries in the context of professional sports have been reported, generally little information on the anatomic site of injury has been reported.5,6 Mandibular and zygomatic injuries have been the most common overall in sports-related events.5 However, the prevalence of different CMF injuries in professional sports is unknown. Team physicians and dentists will typically be available to professional sports teams and can provide accurate diagnoses. However, what has been reported has varied owing to different team and league reporting rules. To the best of our knowledge, CMF injuries in professional sports leagues have not been extensively reported. Thus, the purpose of the present study was to characterize the types and prognoses of CMF injuries in different professional sporting leagues, as reported by the Pro Sports Transactions Archive. We hypothesized that professional sports with high amounts of physical contact (ie, hockey, American football) would result in a greater frequency of CMF injuries and longer associated recovery times. However, the mandatory helmet use by all National Football League (NFL) and National Hockey League (NHL) players could influence the injury rate, severity, and location. We queried the database for CMF injuries in 4 professional sports leagues (ie, National Basketball Association [NBA], Major League Baseball [MLB], NFL, NHL), recorded the type and setting of CMF injury, and determined the length of time in which the injured player was inactive.
Materials and Methods STUDY DESIGN
To address the research aims, we designed and implemented a retrospective cohort study. The Pro Sports Transaction Archive was searched for the movement of players to and from injured lists between the start and end dates of the 2013 to 2014, 2014 to 2015, 2015 to 2016, 2016 to 2017, and 2017 to 2018 seasons for professional baseball (MLB), basketball (NBA), football (NFL), and hockey (NHL). Injuries to the CMF region were included and grouped by lower face (ie, mandible), midface (ie, maxilla, zygoma, nose,
orbits), and upper face (ie, frontal bone). When the location of a CMF injury was unspecified in the archive, news articles and replay footage were analyzed to determine the appropriate anatomic classification of the injury. Concussions and trauma to the occiput were excluded. STUDY VARIABLES
The primary predictor variables were the sports league (ie, MLB, NBA, NFL, NHL), injury location (ie, lower face, midface, upper face), and season (ie, 2013 to 2014, 2014 to 2015, 2015 to 2016, 2016 to 2017, 2017 to 2018). The secondary predictor variables were the injury type (ie, fracture, laceration, contusion) and injury sublocation (ie, eye, orbit, nose, ear, zygoma, maxilla, mandible, teeth). The primary outcome variables were the frequency of the injury and length of time on the injured list. STATISTICAL ANALYSIS
Descriptive statistics were calculated and stratified by sports league, injury location, and season. Associations between the sports league and injury location and between the sports league and season were assessed using Fisher’s exact test. Injury frequencies and durations were compared using analysis of variance test. Data are reported as the mean standard deviation. P < .05 was considered to indicate statistical significance. All statistical analyses were performed using IBM SPSS Statistics, version 25.0 (IBM Corp, Armonk, NY).
Results A total of 198 CMF injuries met the inclusion criteria (Table 1). Of the 198 CMF injuries, 60 (30%) were in the MLB, 49 (25%) in the NBA, 8 (4%) in the NFL, and 81 (41%) in the NHL. Of the 198 injuries, 42 (21%) were to the lower face, 126 (64%) to the midface, and 30 (15%) to the upper face. The midface injuries often involved the orbit/globe (n = 66; 52%) and the nose (n = 20; 16%; Table 2). Of the eye injuries, 39 (59%) were trauma to the globe, 12 (18%) were lacerations to the soft tissue, and 15 (23%) were fractures of the orbit. Midface lacerations included 12 to the ear, 7 to the nose, 7 to the cheek, and 4 to the upper lip. In addition, 15 zygomatic, 13 nasal, 9 mandibular, and 2 maxillary fractures had occurred. Trauma to the dentition was documented in 12 patients. During the 5-season period from 2013 to 2017, 45 (23%), 46 (23%), 38 (19%), 33 (17%), and 36 (18%) injuries had occurred per season, chronologically. LEAGUE AND INJURY LOCATION
The location of the CMF injuries varied for each sports league (Fig 1). MLB had 12 lower, 29 mid-, and
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3
WU ET AL
225 226 227 228 229 230 231 232 233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260 261 262 263 264 265 266 267 268 269 270 271 272 273 274 275 276 277 278 279 280
SEASON AND LEAGUE
Table 1. DISTRIBUTION OF CMF INJURIES
Variable Total League MLB NBA NFL NHL Location Lower face Midface Upper face Season 2013-2014 2014-2015 2015-2016 2016-2017 2017-2018
n (%) 198 (100.0) 60 (30.3) 49 (24.7) 8 (4.0) 81 (40.9) 42 (21.2) 126 (63.6) 30 (15.2) 45 (22.7) 46 (23.2) 38 (19.2) 33 (16.7) 36 (18.2)
Abbreviations: CMF, craniomaxillofacial; MLB, Major League Baseball; NBA, National Basketball Association; NFL, National Football League; NHL, National Hockey League. Wu et al. CMF Injuries in American Professional Sports Leagues. J Oral Maxillofac Surg 2019.
19 upper face injuries. The NBA had 5 lower, 41 mid-, and 3 upper face injuries. The NFL had only 8 cases of midface trauma, with no records of lower or upper face trauma. Finally, the NHL had 25 lower, 48 mid-, and 8 upper face injuries. Midface injuries were the most common for all 4 leagues, comprising 48% of MLB injuries, 84% of NBA injuries, 100% of NFL injuries, and 59% of NHL injuries. We found a significant association between the sports league and injury location (P < .001).
Table 2. DISTRIBUTION OF MIDFACE INJURIES
Variable Total Eye Globe Orbit Eyelid Ear Nose Bone Cartilage Zygoma Cheek Maxilla Lip
n (%) 126 (100.0) 66 (52.4) 39 (59.1) 15 (22.7) 12 (18.2) 12 (9.5) 20 (15.9) 13 (65.0) 7 (35.0) 15 (11.9) 7 (5.6) 2 (1.6) 4 (3.2)
Wu et al. CMF Injuries in American Professional Sports Leagues. J Oral Maxillofac Surg 2019.
The number of CMF injuries for each league was relatively stable throughout the 5 seasons (Fig 2). The mean number of injuries per season was 9.9 6.1 (range, 1 to 23). The NFL had the fewest number of CMF injuries for all 5 seasons, and the NHL had the highest number for all season, except for the 2015 to 2016 season. We found no statistically significant association between the season and the sports league (P = .818). INCIDENCE
The mean number of CMF injuries per season for all 4 leagues combined was 39.6 5.7 (Table 2). The MLB, NBA, NFL, and NHL had 12.0 2.6, 9.8 1.9, 1.6 0.6, and 16.2 5.2 injuries per season, respectively (P < .001). The NFL had significantly fewer injuries compared with MLB (P < .001), the NBA (P = .003), and the NHL (P < .001). Furthermore, the NBA had significantly fewer injuries than the NHL (P = .020). We also found a statistically significant difference between the mean number of lower face (8.4 2.3), midface (25.2 3.6), and upper face (6.0 2.0) injuries per season (P < .001; Table 3). Midface trauma occurred more frequently than either lower face (P < .001) or upper face (P < .001) trauma. DURATION
The overall mean length of time on the injured list for athletes with CMF trauma was 8.4 10.4 days (Table 4). When stratified by sports league, the mean injury duration was 3.9 6.6 days for MLB, 9.9 12.5 days for the NBA, 12.1 5.9 days for the NFL, and 10.9 10.7 days for the NHL (P = .001). The range was 1 to 45 days for MLB, 2 to 58 days for the NBA, 7 to 23 days for the NFL, and 1 to 47 days for the NHL. MLB players had significantly shorter injury durations than did the NBA and NHL players (P = .017 and P = .001, respectively). No statistically significant differences were found in the mean duration of injuries to the lower face (11.0 13.6 days), midface (8.1 9.4 days), or upper face (6.2 9.2 days; P = .185). The time on the injured list ranged from 1 to 47 days for the lower face, 1 to 58 days for the midface, and 1 to 45 days for the upper face. Of the 198 injuries, 28 (14.1%) were season ending. However, 26 of the 28 had occurred within the last month of the regular season; the 2 mid-season injuries were an orbital fracture and a zygomaticomaxillary complex fracture. Eight injury reports had specified facial bone fractures: 2 mandibular, 2 orbital, 2 nasal, and 2 zygomaticomaxillary. An additional 5 seasonending facial fractures had been reported with an
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print & web 4C=FPO
CMF INJURIES IN AMERICAN PROFESSIONAL SPORTS LEAGUES
FIGURE 1. Distribution of craniomaxillofacial injuries stratified by sports league and injury location. For each professional sports league, the total number of lower face (blue), midface (orange), and upper face (gray) injuries for 5 seasons is shown. MLB, Major League Baseball; NBA, National Basketball Association; NFL, National Football League; NHL, National Hockey League. Wu et al. CMF Injuries in American Professional Sports Leagues. J Oral Maxillofac Surg 2019.
unspecified location. The NHL had the most seasonending CMF injuries (n = 18), followed by MLB (n = 6), the NBA (n = 3), and the NFL (n = 1).
Discussion The purpose of the present study was to characterize CMF injuries in professional athletes of 4 major American men’s sports leagues (ie, MLB, NBA, NFL, NHL) during the course of 5 seasons (2013 to 2017). A total of 198 CMF injuries were responsible for missed games in all 4 leagues. We found a significant difference in the frequency and duration of injuries among the 4 leagues. The NHL had the greatest number of injuries and MLB had the shortest duration of missed action. Midface trauma, comprising 64% of all
injuries, was significantly more common than was lower and upper face trauma. Midface injuries were the most common in all 4 sports, constitution most of the injuries overall. The high frequency of eye injuries on the inactive lists might have resulted from the inability to compete if one’s vision is impaired. In epidemiologic studies, mandible fractures were the most frequent type of CMF injury in the general public,7-9 and the orbit was the most frequent site of injury in the present study. The general public will usually sustain CMF injuries from falls, physical altercations, and motor vehicle accidents.7 In contrast, professional athletes will be exposed to high-speed balls, pucks, and collisions with objects or other players.
print & web 4C=FPO
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4
FIGURE 2. Trends of craniomaxillofacial injuries stratified by season and sports league for five seasons (2013 to 2014 through 2017 to 2018). MLB, Major League Baseball; NBA, National Basketball Association; NFL, National Football League; NHL, National Hockey League. Wu et al. CMF Injuries in American Professional Sports Leagues. J Oral Maxillofac Surg 2019.
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WU ET AL
449 450 451 452 453 454 455 456 457 458 459 460 461 462 463 464 465 466 467 468 469 470 471 472 473 474 475 476 477 478 479 480 481 482 483 484 485 486 487 488 489 490 491 492 493 494 495 496 497 498 499 500 501 502 503 504
Table 3. NUMBER OF CMF INJURIES PER SEASON
Variable Total League MLB NBA NFL NHL Location Lower face Midface Upper face
Mean SD
P Value*
39.60 5.68
< .001y
12.00 2.55 9.80 1.92 1.60 0.55 16.20 5.17
< .001y
8.40 2.30 25.20 3.56 6.00 2.00
Abbreviations: CMF, craniomaxillofacial; MLB, Major League Baseball; NBA, National Basketball Association; NFL, National Football League; NHL, National Hockey League; SD, standard deviation. * Analysis of variance test. y Statistically significant. Wu et al. CMF Injuries in American Professional Sports Leagues. J Oral Maxillofac Surg 2019.
The nature of the sport and the use of protective equipment could explain the observed patterns in injury frequency and location. The NHL had the greatest injury rate, even after adjustment for the number of games. This could have resulted from the projectile motion of the hockey puck and the high frequency of physical contact, such as checking opponents at high speeds. Furthermore, fighting is permitted, and sometimes even encouraged, with combatants exchanging blows to the face.10 NHL helmets do not
Table 4. DURATION OF CMF INJURIES
Variable
Duration (d)
Injuries (n)
Total League MLB NBA NFL NHL Location Lower face Midface Upper face
8.44 10.42
170
3.91 6.55 9.89 12.50 12.14 5.90 10.86 10.73
54 46 7 63
10.97 13.59 8.11 9.37 6.17 9.18
36 110 24
P Value* .001y
.185
Data presented as mean standard deviation. Abbreviations: CMF, craniomaxillofacial; MLB, Major League Baseball; NBA, National Basketball Association; NFL, National Football League; NHL, National Hockey League. * Analysis of variance test. y Statistically significant. Wu et al. CMF Injuries in American Professional Sports Leagues. J Oral Maxillofac Surg 2019.
shield the mid- or lower face as well as do NFL helmets,11 resulting in a greater occurrence of mandibular and dental injuries. Although NFL helmets with facemasks were the most effective at preventing facial trauma, concussions have remained common.12,13 Hockey and football helmets will cover most of the frontal bone, and upper face injuries were rare in the NHL and NFL. Clear eye shields that extend from the helmet inferiorly to the bottom of the orbit were mandated for players with fewer than 25 games of experience starting in the 2013 season. Few grandfathered players remain in the league, and it has been estimated that more than 89% were wearing a shield during the 2015 season.14 MLB had the most upper face injuries and the most uniform distribution of injury locations. Other than the batter and catcher, fielders do not wear any head or facial protection and can experience facial trauma from airborne baseballs, running into the outfield wall, and collisions with other players.15 Batting helmets with earflaps were mandated in 1983 and thus were factored into the present study. The increase in popularity (but not a requirement) of the C-flap (an attachment to the earflap that covers 1 side of the jaw) during the 2018 season could help reduce lower face injuries in MLB in the future. NBA players do not wear helmets or facial protection, with variable mouth guard use, and most (84%) injuries were to the midface. Impact between the orbital and nasal bones with another player’s elbow, knee, or shoulder regularly sideline basketball players.16 Although many games were missed because of CMF injuries, the average duration on the injured list was relatively short (8 days). Nearly all season-ending injuries (93%) had occurred within the final days of the regular season, when teams’ postseason status was likely already known. MLB injuries had the shortest duration, which might be related to the high frequency of games, resulting in earlier injury list movement. The injury duration can be minimized and could have been underestimated in the present study if a star player were needed for a high-stakes game or overestimated if a player were rested for a game with minimal consequences. The present study had several limitations. First, the injury frequencies were likely underestimated owing to the limitations in data collection. In the archive, most NFL head injuries were listed as ‘‘concussion’’ but did not specify any comorbid CMF trauma. Also, facial injuries in the NHL could have been reported as ‘‘upper body injury’’ and thus not included in the present study. Furthermore, injuries to the CMF region could have been underreported if they lacked functional consequences (eg, maxillary sinus wall fractures) that could affect the player’s performance. Gamesmanship could also play a role, with teams
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CMF INJURIES IN AMERICAN PROFESSIONAL SPORTS LEAGUES
trying to limit information available to opposing teams.17 Minor injuries, such as facial lacerations sutured during or after a game might not have been reported on the injured list. In the NHL, players might not even miss time in the game in which the injury has occurred if it were a facial laceration. Dental injuries in NHL players have been underreported in the database because they most often do not result in missed games. One of us (Z.S.P.) serves as a team physician for an NHL team and has encountered far more than 12 dentoalveolar injuries per season. Additionally, when the location of the injury was not detailed in the injury report, video footage was consulted with subjective interpretation. However, slow motion replays were usually available to precisely determine the impact location. Finally, only information on men’s professional sports leagues were available. Women’s professional sports (eg, WNBA) are not included in the Pro Sports Transaction Archive and do not have a comparable database. Future studies should investigate the association between the mechanism of injury and injury location and duration, potentially steering changes to rules or equipment to protect players. For example, the MLB, NBA, NFL, and NHL currently do not mandate their players to wear mouth guards, which could have prevented or lessened the severity of the 12 dental injuries in the present study. Additional insights into the management and outcomes of CMF injuries among professional athletes compared with the general public would better inform surgical decision making in these complex situations that often weigh the interests of both patients and the team. Major League Soccer, which was added to the database in 2017, could also be examined, especially because soccer is the most popular and fastest growing sport internationally.18 Finally, it would be of value for future studies to investigate the similarities and differences in the outcomes in trauma reconstruction among women’s professional sports leagues. To help eradicate gender disparity, addressing the role of trauma management equally in both genders, including the risk factors that predispose men and women to these injury patterns, would be a beneficial addition to the craniofacial data. In conclusion, to the best our knowledge, the present study is the first to compare CMF trauma in professional
athletes across America’s largest sports leagues. The costs of the injuries in these leagues are in the hundreds of millions of dollars annually,19 and players require education, protection, and treatment of orofacial trauma to reduce the number of missed games.
References 1. Bak MJ, Doerr TD: Craniomaxillofacial fractures during recreational baseball and softball. J Oral Maxillofac Surg 62:1209, 2004 2. MacIsaac ZM, Berhane H, Cray J Jr, et al: Nonfatal sport-related craniofacial fractures: Characteristics, mechanisms, and demographic data in the pediatric population. Plast Reconstr Surg 131:1339, 2013 3. Leinhart J, Toldi J, Tennison M: Facial trauma in sports. Curr Sports Med Rep 16:23, 2017 4. Rodriguez JO, Lavina AM, Agarwal A: Prevention and treatment of common eye injuries in sports. Am Fam Physician 67:1481, 2003 5. Murphy C, O’Connell JE, Kearns G, Stassen L: Sports-related maxillofacial injuries. J Craniofac Surg 26:2120, 2015 6. Lee K: Global trends in maxillofacial fractures. Craniomaxillofac Trauma Reconstr 5:213, 2012 7. Ghosh R, Gopalkrishnan K: Facial fractures. J Craniofac Surg 29: e334, 2018 8. Samieirad S, Aboutorabzade MR, Tohidi E, et al: Maxillofacial fracture epidemiology and treatment plans in the Northeast of Iran: A retrospective study. Med Oral Patol Oral Cir Bucal 22: e616, 2017 9. Manodh P, Prabhu Shankar D, Pradeep D, et al: Incidence and patterns of maxillofacial trauma—A retrospective analysis of 3611 patients—An update. Oral Maxillofac Surg 20:377, 2016 10. Engelhardt GM: Fighting behavior and winning National Hockey League games: A paradox. Percept Mot Skills 80:416, 1995 11. Clark JM, Post A, Hoshizaki TB, Gilchrist MD: Protective capacity of ice hockey helmets against different impact events. Ann Biomed Eng 44:3693, 2016 12. Yengo-Kahn AM, Johnson DJ, Zuckerman SL, Solomon GS: Concussions in the National Football League: A current concepts review. Am J Sports Med 44:801, 2016 13. Clark MD, Asken BM, Marshall SW, Guskiewicz KM: Descriptive characteristics of concussions in National Football League games, 2010-2011 to 2013-2014. Am J Sports Med 45:929, 2017 14. Visor-less NHLers an increasingly rare site. Available at: https:// www.sportsnet.ca/hockey/nhl/visor-less-nhlers-an-increasinglyrare-sight2/. Accessed November 18, 2019 15. Carniol ET, Shaigany K, Svider PF, et al: "Beaned": A 5-year analysis of baseball-related injuries of the face. Otolaryngol Head Neck Surg 153:957, 2015 16. Azodo CC, Odai CD, Osazuwa-Peters N, Obuekwe ON: A survey of orofacial injuries among basketball players. Int Dent J 61:43, 2011 17. Whatman C, Walters S, Schluter P: Coach and player attitudes to injury in youth sport. Phys Ther Sport 32:1, 2018 18. Myrick KM: Head injuries in soccer. Rehabil Nurs 41:197, 2016 19. Donaldson L, Li B, Cusimano MD: Economic burden of time lost due to injury in NHL hockey players. Inj Prev 20:347, 2014
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CRANIOMAXILLOFACIAL TRAUMA
Characterizing Craniomaxillofacial Injuries in American Professional Sports Leagues
Q1
Brendan W. Wu, MMSc,* Hossein E. Jazayeri, BS,y Kevin C. Lee, DDS,z Nima Khavanin, MD,x Amir H. Dorafshar, MBChB,k and Zachary S. Peacock, DMD, MD{
Q5
Purpose:
The purpose of the present study was to characterize the types of craniomaxillofacial (CMF) injuries that occur in professional sports leagues and the associated recovery times.
Materials and Methods:
A retrospective cohort study was designed and implemented using the Pro Sports Transaction Archive. The database was queried for all registered CMF injuries in the 4 main men’s major professional sports leagues in the United States from 2013 to 2018. The sport, injury location, and season were the predictor variables, and the frequency and length of time on the injured list were the outcome variables. Descriptive statistics were computed, and Fisher’s exact tests were used to determine the association between the predictor and outcome variables. Analysis of variance was used to compare the injury frequency and duration.
Results:
Of the 198 injuries that met the inclusion criteria, 60 were from Major League Baseball (MLB) (30%), 49 from the National Basketball Association (25%), 8 from the National Football League (8%), and 81 from the National Hockey League (NHL) (41%). Injuries to the midface were most common (mean, 25.2 3.6 injuries per season; P < .001) compared with the upper face (mean, 6.0 2.0 injuries per season) and lower face (mean, 8.4 2.3 injuries per season). The mean time on the injured list after CMF trauma was 8.4 10.4 days, with MLB injuries requiring the shortest duration (mean, 3.9 6.6 days; P = .001). A significant association was found between the injury location and sport (P < .001). However, no statistically significant difference was found in the number of injuries per season from 2013 to 2018 for each league (P = .818). Conclusions: Midface trauma was significantly more common than upper or lower face trauma in professional sports leagues during the past 5 seasons. The NHL had the greatest injury rate, even after adjustment for games played. Ó 2019 Published by Elsevier Inc. on behalf of the American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg -:1-6, 2019
Q3
*DMD Candidate, Harvard School of Dental Medicine, Boston,
Conflict of Interest Disclosures: None of the authors have any
MA.
relevant financial relationship(s) with a commercial interest.
yDMD Candidate, School of Dental Medicine, University of
Address correspondence and reprint requests to Dr Peacock: Department of Oral and Maxillofacial Surgery, Massachusetts Gen-
Pennsylvania, Philadelphia, PA. zResident, Division of Oral and Maxillofacial Surgery, New York-
eral Hospital, 55 Fruit St, Warren 1201, Boston, MA 02114; e-mail:
Presbyterian/Columbia University Irving Medical Center, New
[email protected]
York, NY.
Received October 5 2019
xResident, Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, MD.
Ó 2019 Published by Elsevier Inc. on behalf of the American Association of Oral
Accepted November 26 2019
kProfessor and Chief, Division of Plastic and Reconstructive
and Maxillofacial Surgeons
Surgery, Rush University Medical Center, Chicago, IL.
0278-2391/19/31358-8
{Assistant Professor, Department of Oral and Maxillofacial
https://doi.org/10.1016/j.joms.2019.11.031
Surgery, Massachusetts General Hospital and Harvard School of Dental Medicine, Boston, MA.
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57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112
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CMF INJURIES IN AMERICAN PROFESSIONAL SPORTS LEAGUES
Injuries to the craniomaxillofacial (CMF) skeleton in the context of professional sports has been commonly reported because their frequency and severity have functional and esthetic consequences.1 In children, participation in sports has been one of the leading causes of craniofacial trauma, and the CMF complex is the second-most common site of trauma in youth sports.2 The increasing incidence of traumatic injuries is reflective of the greater number of participants in sporting events. Most sport-related CMF injuries at all ages will require operative treatment3; thus, a multidisciplinary dialogue regarding prevention strategies and timely surgical protocols is warranted.4 Although CMF injuries in the context of professional sports have been reported, generally little information on the anatomic site of injury has been reported.5,6 Mandibular and zygomatic injuries have been the most common overall in sports-related events.5 However, the prevalence of different CMF injuries in professional sports is unknown. Team physicians and dentists will typically be available to professional sports teams and can provide accurate diagnoses. However, what has been reported has varied owing to different team and league reporting rules. To the best of our knowledge, CMF injuries in professional sports leagues have not been extensively reported. Thus, the purpose of the present study was to characterize the types and prognoses of CMF injuries in different professional sporting leagues, as reported by the Pro Sports Transactions Archive. We hypothesized that professional sports with high amounts of physical contact (ie, hockey, American football) would result in a greater frequency of CMF injuries and longer associated recovery times. However, the mandatory helmet use by all National Football League (NFL) and National Hockey League (NHL) players could influence the injury rate, severity, and location. We queried the database for CMF injuries in 4 professional sports leagues (ie, National Basketball Association [NBA], Major League Baseball [MLB], NFL, NHL), recorded the type and setting of CMF injury, and determined the length of time in which the injured player was inactive.
Materials and Methods STUDY DESIGN
To address the research aims, we designed and implemented a retrospective cohort study. The Pro Sports Transaction Archive was searched for the movement of players to and from injured lists between the start and end dates of the 2013 to 2014, 2014 to 2015, 2015 to 2016, 2016 to 2017, and 2017 to 2018 seasons for professional baseball (MLB), basketball (NBA), football (NFL), and hockey (NHL). Injuries to the CMF region were included and grouped by lower face (ie, mandible), midface (ie, maxilla, zygoma, nose,
orbits), and upper face (ie, frontal bone). When the location of a CMF injury was unspecified in the archive, news articles and replay footage were analyzed to determine the appropriate anatomic classification of the injury. Concussions and trauma to the occiput were excluded. STUDY VARIABLES
The primary predictor variables were the sports league (ie, MLB, NBA, NFL, NHL), injury location (ie, lower face, midface, upper face), and season (ie, 2013 to 2014, 2014 to 2015, 2015 to 2016, 2016 to 2017, 2017 to 2018). The secondary predictor variables were the injury type (ie, fracture, laceration, contusion) and injury sublocation (ie, eye, orbit, nose, ear, zygoma, maxilla, mandible, teeth). The primary outcome variables were the frequency of the injury and length of time on the injured list. STATISTICAL ANALYSIS
Descriptive statistics were calculated and stratified by sports league, injury location, and season. Associations between the sports league and injury location and between the sports league and season were assessed using Fisher’s exact test. Injury frequencies and durations were compared using analysis of variance test. Data are reported as the mean standard deviation. P < .05 was considered to indicate statistical significance. All statistical analyses were performed using IBM SPSS Statistics, version 25.0 (IBM Corp, Armonk, NY).
Results A total of 198 CMF injuries met the inclusion criteria (Table 1). Of the 198 CMF injuries, 60 (30%) were in the MLB, 49 (25%) in the NBA, 8 (4%) in the NFL, and 81 (41%) in the NHL. Of the 198 injuries, 42 (21%) were to the lower face, 126 (64%) to the midface, and 30 (15%) to the upper face. The midface injuries often involved the orbit/globe (n = 66; 52%) and the nose (n = 20; 16%; Table 2). Of the eye injuries, 39 (59%) were trauma to the globe, 12 (18%) were lacerations to the soft tissue, and 15 (23%) were fractures of the orbit. Midface lacerations included 12 to the ear, 7 to the nose, 7 to the cheek, and 4 to the upper lip. In addition, 15 zygomatic, 13 nasal, 9 mandibular, and 2 maxillary fractures had occurred. Trauma to the dentition was documented in 12 patients. During the 5-season period from 2013 to 2017, 45 (23%), 46 (23%), 38 (19%), 33 (17%), and 36 (18%) injuries had occurred per season, chronologically. LEAGUE AND INJURY LOCATION
The location of the CMF injuries varied for each sports league (Fig 1). MLB had 12 lower, 29 mid-, and
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3
WU ET AL
225 226 227 228 229 230 231 232 233 234 235 236 237 238 239 240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258 259 260 261 262 263 264 265 266 267 268 269 270 271 272 273 274 275 276 277 278 279 280
SEASON AND LEAGUE
Table 1. DISTRIBUTION OF CMF INJURIES
Variable Total League MLB NBA NFL NHL Location Lower face Midface Upper face Season 2013-2014 2014-2015 2015-2016 2016-2017 2017-2018
n (%) 198 (100.0) 60 (30.3) 49 (24.7) 8 (4.0) 81 (40.9) 42 (21.2) 126 (63.6) 30 (15.2) 45 (22.7) 46 (23.2) 38 (19.2) 33 (16.7) 36 (18.2)
Abbreviations: CMF, craniomaxillofacial; MLB, Major League Baseball; NBA, National Basketball Association; NFL, National Football League; NHL, National Hockey League. Wu et al. CMF Injuries in American Professional Sports Leagues. J Oral Maxillofac Surg 2019.
19 upper face injuries. The NBA had 5 lower, 41 mid-, and 3 upper face injuries. The NFL had only 8 cases of midface trauma, with no records of lower or upper face trauma. Finally, the NHL had 25 lower, 48 mid-, and 8 upper face injuries. Midface injuries were the most common for all 4 leagues, comprising 48% of MLB injuries, 84% of NBA injuries, 100% of NFL injuries, and 59% of NHL injuries. We found a significant association between the sports league and injury location (P < .001).
Table 2. DISTRIBUTION OF MIDFACE INJURIES
Variable Total Eye Globe Orbit Eyelid Ear Nose Bone Cartilage Zygoma Cheek Maxilla Lip
n (%) 126 (100.0) 66 (52.4) 39 (59.1) 15 (22.7) 12 (18.2) 12 (9.5) 20 (15.9) 13 (65.0) 7 (35.0) 15 (11.9) 7 (5.6) 2 (1.6) 4 (3.2)
Wu et al. CMF Injuries in American Professional Sports Leagues. J Oral Maxillofac Surg 2019.
The number of CMF injuries for each league was relatively stable throughout the 5 seasons (Fig 2). The mean number of injuries per season was 9.9 6.1 (range, 1 to 23). The NFL had the fewest number of CMF injuries for all 5 seasons, and the NHL had the highest number for all season, except for the 2015 to 2016 season. We found no statistically significant association between the season and the sports league (P = .818). INCIDENCE
The mean number of CMF injuries per season for all 4 leagues combined was 39.6 5.7 (Table 2). The MLB, NBA, NFL, and NHL had 12.0 2.6, 9.8 1.9, 1.6 0.6, and 16.2 5.2 injuries per season, respectively (P < .001). The NFL had significantly fewer injuries compared with MLB (P < .001), the NBA (P = .003), and the NHL (P < .001). Furthermore, the NBA had significantly fewer injuries than the NHL (P = .020). We also found a statistically significant difference between the mean number of lower face (8.4 2.3), midface (25.2 3.6), and upper face (6.0 2.0) injuries per season (P < .001; Table 3). Midface trauma occurred more frequently than either lower face (P < .001) or upper face (P < .001) trauma. DURATION
The overall mean length of time on the injured list for athletes with CMF trauma was 8.4 10.4 days (Table 4). When stratified by sports league, the mean injury duration was 3.9 6.6 days for MLB, 9.9 12.5 days for the NBA, 12.1 5.9 days for the NFL, and 10.9 10.7 days for the NHL (P = .001). The range was 1 to 45 days for MLB, 2 to 58 days for the NBA, 7 to 23 days for the NFL, and 1 to 47 days for the NHL. MLB players had significantly shorter injury durations than did the NBA and NHL players (P = .017 and P = .001, respectively). No statistically significant differences were found in the mean duration of injuries to the lower face (11.0 13.6 days), midface (8.1 9.4 days), or upper face (6.2 9.2 days; P = .185). The time on the injured list ranged from 1 to 47 days for the lower face, 1 to 58 days for the midface, and 1 to 45 days for the upper face. Of the 198 injuries, 28 (14.1%) were season ending. However, 26 of the 28 had occurred within the last month of the regular season; the 2 mid-season injuries were an orbital fracture and a zygomaticomaxillary complex fracture. Eight injury reports had specified facial bone fractures: 2 mandibular, 2 orbital, 2 nasal, and 2 zygomaticomaxillary. An additional 5 seasonending facial fractures had been reported with an
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CMF INJURIES IN AMERICAN PROFESSIONAL SPORTS LEAGUES
FIGURE 1. Distribution of craniomaxillofacial injuries stratified by sports league and injury location. For each professional sports league, the total number of lower face (blue), midface (orange), and upper face (gray) injuries for 5 seasons is shown. MLB, Major League Baseball; NBA, National Basketball Association; NFL, National Football League; NHL, National Hockey League. Wu et al. CMF Injuries in American Professional Sports Leagues. J Oral Maxillofac Surg 2019.
unspecified location. The NHL had the most seasonending CMF injuries (n = 18), followed by MLB (n = 6), the NBA (n = 3), and the NFL (n = 1).
Discussion The purpose of the present study was to characterize CMF injuries in professional athletes of 4 major American men’s sports leagues (ie, MLB, NBA, NFL, NHL) during the course of 5 seasons (2013 to 2017). A total of 198 CMF injuries were responsible for missed games in all 4 leagues. We found a significant difference in the frequency and duration of injuries among the 4 leagues. The NHL had the greatest number of injuries and MLB had the shortest duration of missed action. Midface trauma, comprising 64% of all
injuries, was significantly more common than was lower and upper face trauma. Midface injuries were the most common in all 4 sports, constitution most of the injuries overall. The high frequency of eye injuries on the inactive lists might have resulted from the inability to compete if one’s vision is impaired. In epidemiologic studies, mandible fractures were the most frequent type of CMF injury in the general public,7-9 and the orbit was the most frequent site of injury in the present study. The general public will usually sustain CMF injuries from falls, physical altercations, and motor vehicle accidents.7 In contrast, professional athletes will be exposed to high-speed balls, pucks, and collisions with objects or other players.
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FIGURE 2. Trends of craniomaxillofacial injuries stratified by season and sports league for five seasons (2013 to 2014 through 2017 to 2018). MLB, Major League Baseball; NBA, National Basketball Association; NFL, National Football League; NHL, National Hockey League. Wu et al. CMF Injuries in American Professional Sports Leagues. J Oral Maxillofac Surg 2019.
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WU ET AL
449 450 451 452 453 454 455 456 457 458 459 460 461 462 463 464 465 466 467 468 469 470 471 472 473 474 475 476 477 478 479 480 481 482 483 484 485 486 487 488 489 490 491 492 493 494 495 496 497 498 499 500 501 502 503 504
Table 3. NUMBER OF CMF INJURIES PER SEASON
Variable Total League MLB NBA NFL NHL Location Lower face Midface Upper face
Mean SD
P Value*
39.60 5.68
< .001y
12.00 2.55 9.80 1.92 1.60 0.55 16.20 5.17
< .001y
8.40 2.30 25.20 3.56 6.00 2.00
Abbreviations: CMF, craniomaxillofacial; MLB, Major League Baseball; NBA, National Basketball Association; NFL, National Football League; NHL, National Hockey League; SD, standard deviation. * Analysis of variance test. y Statistically significant. Wu et al. CMF Injuries in American Professional Sports Leagues. J Oral Maxillofac Surg 2019.
The nature of the sport and the use of protective equipment could explain the observed patterns in injury frequency and location. The NHL had the greatest injury rate, even after adjustment for the number of games. This could have resulted from the projectile motion of the hockey puck and the high frequency of physical contact, such as checking opponents at high speeds. Furthermore, fighting is permitted, and sometimes even encouraged, with combatants exchanging blows to the face.10 NHL helmets do not
Table 4. DURATION OF CMF INJURIES
Variable
Duration (d)
Injuries (n)
Total League MLB NBA NFL NHL Location Lower face Midface Upper face
8.44 10.42
170
3.91 6.55 9.89 12.50 12.14 5.90 10.86 10.73
54 46 7 63
10.97 13.59 8.11 9.37 6.17 9.18
36 110 24
P Value* .001y
.185
Data presented as mean standard deviation. Abbreviations: CMF, craniomaxillofacial; MLB, Major League Baseball; NBA, National Basketball Association; NFL, National Football League; NHL, National Hockey League. * Analysis of variance test. y Statistically significant. Wu et al. CMF Injuries in American Professional Sports Leagues. J Oral Maxillofac Surg 2019.
shield the mid- or lower face as well as do NFL helmets,11 resulting in a greater occurrence of mandibular and dental injuries. Although NFL helmets with facemasks were the most effective at preventing facial trauma, concussions have remained common.12,13 Hockey and football helmets will cover most of the frontal bone, and upper face injuries were rare in the NHL and NFL. Clear eye shields that extend from the helmet inferiorly to the bottom of the orbit were mandated for players with fewer than 25 games of experience starting in the 2013 season. Few grandfathered players remain in the league, and it has been estimated that more than 89% were wearing a shield during the 2015 season.14 MLB had the most upper face injuries and the most uniform distribution of injury locations. Other than the batter and catcher, fielders do not wear any head or facial protection and can experience facial trauma from airborne baseballs, running into the outfield wall, and collisions with other players.15 Batting helmets with earflaps were mandated in 1983 and thus were factored into the present study. The increase in popularity (but not a requirement) of the C-flap (an attachment to the earflap that covers 1 side of the jaw) during the 2018 season could help reduce lower face injuries in MLB in the future. NBA players do not wear helmets or facial protection, with variable mouth guard use, and most (84%) injuries were to the midface. Impact between the orbital and nasal bones with another player’s elbow, knee, or shoulder regularly sideline basketball players.16 Although many games were missed because of CMF injuries, the average duration on the injured list was relatively short (8 days). Nearly all season-ending injuries (93%) had occurred within the final days of the regular season, when teams’ postseason status was likely already known. MLB injuries had the shortest duration, which might be related to the high frequency of games, resulting in earlier injury list movement. The injury duration can be minimized and could have been underestimated in the present study if a star player were needed for a high-stakes game or overestimated if a player were rested for a game with minimal consequences. The present study had several limitations. First, the injury frequencies were likely underestimated owing to the limitations in data collection. In the archive, most NFL head injuries were listed as ‘‘concussion’’ but did not specify any comorbid CMF trauma. Also, facial injuries in the NHL could have been reported as ‘‘upper body injury’’ and thus not included in the present study. Furthermore, injuries to the CMF region could have been underreported if they lacked functional consequences (eg, maxillary sinus wall fractures) that could affect the player’s performance. Gamesmanship could also play a role, with teams
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CMF INJURIES IN AMERICAN PROFESSIONAL SPORTS LEAGUES
trying to limit information available to opposing teams.17 Minor injuries, such as facial lacerations sutured during or after a game might not have been reported on the injured list. In the NHL, players might not even miss time in the game in which the injury has occurred if it were a facial laceration. Dental injuries in NHL players have been underreported in the database because they most often do not result in missed games. One of us (Z.S.P.) serves as a team physician for an NHL team and has encountered far more than 12 dentoalveolar injuries per season. Additionally, when the location of the injury was not detailed in the injury report, video footage was consulted with subjective interpretation. However, slow motion replays were usually available to precisely determine the impact location. Finally, only information on men’s professional sports leagues were available. Women’s professional sports (eg, WNBA) are not included in the Pro Sports Transaction Archive and do not have a comparable database. Future studies should investigate the association between the mechanism of injury and injury location and duration, potentially steering changes to rules or equipment to protect players. For example, the MLB, NBA, NFL, and NHL currently do not mandate their players to wear mouth guards, which could have prevented or lessened the severity of the 12 dental injuries in the present study. Additional insights into the management and outcomes of CMF injuries among professional athletes compared with the general public would better inform surgical decision making in these complex situations that often weigh the interests of both patients and the team. Major League Soccer, which was added to the database in 2017, could also be examined, especially because soccer is the most popular and fastest growing sport internationally.18 Finally, it would be of value for future studies to investigate the similarities and differences in the outcomes in trauma reconstruction among women’s professional sports leagues. To help eradicate gender disparity, addressing the role of trauma management equally in both genders, including the risk factors that predispose men and women to these injury patterns, would be a beneficial addition to the craniofacial data. In conclusion, to the best our knowledge, the present study is the first to compare CMF trauma in professional
athletes across America’s largest sports leagues. The costs of the injuries in these leagues are in the hundreds of millions of dollars annually,19 and players require education, protection, and treatment of orofacial trauma to reduce the number of missed games.
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