Todd Fedoruk, all-time facial fracture champion.

 

Your face is made up of fourteen bones, just about all of which will break when met with a swift hockey puck (or fist, or stick, or ice). Not all facial fractures need surgery, but when they do they can lead to impressive postoperative CT scans, learning to be okay with a visor, and a new style of play.

Orbital fractures are common, second only to noses in the realm of broken face problems. While plenty of NHL players have broken noses, the ones with orbital fractures are less obvious. Montreal’s Alexei Emelin shattered the bones under his left eye thanks to a punch from Alexander Svitov in 2009, and has been known to avoid fights whenever possible ever since. He took an elbow to the repaired part of his face in the KHL during the lockout, and started the season in a full cage. He took it off for an intra-squad scrimmage, and promptly took a puck in the face. Emelin’s face is trying to rival Markov’s knees for the Habs’ all-time shittiest anatomy.

 

Providence Bruin Jordan Caron (occasionaly of the Boston Bruins) found out the hard way that Colby Cohen has a hard shot, and per Mark Divver of the Providence Journal…

 

 

 

And of course Caron’s injury came with the requisite jaw-dropping self-portrait:

 

Nobody wants to see this, Caron (yes we do).

 

No discussion of facial fractures is complete without Todd Fedoruk, who tweeted a horrifying picture of his CT scan showing the fallout of fights with Derek Boogaard (right side) and Eric Cairns (left side). Every conceivable breaking point on his face has been broken.

 

Wow. Just… Wow.

What’s an orbit?

The orbits are the holes your eyes sit in. An orbit isn’t a single bone, it’s a complicated combination of seven different bones that a lot of really important things run through – the nerves and blood supply for your eye muscles and eyeball, specifically. Your orbit is responsible for holding your eye in the right position, keeping it from poking out too far or sinking too far in, and keeping your eyes and sinuses separate. Each orbit is packed with fat, the glands that make tears, and an eyeball. That eyeball has six muscles attached to it and a great big important nerve coming out the back (the optic nerve, whose importance should be self-explanatory).

 

Your orbital bones are not this pretty.

 

The bones that make up the orbit aren’t particularly thick, and have a habit of breaking when things hit the eye. The object (puck, fist, stick) hits the eye, the eye squishes back into the orbital cavity, and the sudden increase in pressure blows out the floor or wall of the orbit. Hence the name of one of the coolest-sounding terms in medicine: The orbital blowout fracture.

Orbital blowouts are bad.

As if breaking your eye socket wasn’t bad enough, you can get the contents of the socket caught in the fracture (gross). The inferior rectus muscle is on the bottom of the eye, and its job is to move your eye down and out. If it gets caught in the fracture you can find yourself having problems moving your eye up and down. The floor of the orbit is what the eye sits on, so if it’s moved out of its normal position you could end up with a sunken eye. Any eye screwup (muscle entrapment, position changes) can lead to double vision.

 

A left orbital floor blowout (the skull’s left, not your left)

 

The big black hole under the eye in the picture above is a normal maxillary sinus. The one under the fracture is a maxillary sinus filled with blood and some of the eye socket’s contents. When you connect the eye and the sinus, you can get stuff moving back and forth between the two like the blood above, or like an eye socket full of air after blowing your nose.

That’s nasty. How do you fix it?

Despite all the potential for disgusting side effects, an orbital fracture isn’t always a surgical fix. Reasons to go in and plate the bones back together would be significant cosmetic issues (your eye is in the wrong place) or entrapment of orbital contents by bone fragments. If the fracture isn’t that displaced and nothing’s hung up, you’ll usually be fine with painkillers and taking it easy for a while.

The surgery is done by any one of a variety of incredibly smart/usually kind of weird specialists with training in facial plastics – opthalmology, plastic surgery, oral-maxillofacial surgery, even otolaryngology (ear, nose and throat). The incision is usually made inside the lower eyelid, so there’s no visible scarring. A newer technique involves making an incision inside the upper lip and going up through the face to get to the orbital floor, which sounds horrifying, but they’re actually pretty close together (stick your finger inside your upper lip under your eye. I’ll wait). The surgery doesn’t necessarily happen immediately after the injury unless there’s a chance that whatever is caught in there might lose blood supply and die. Generally the patient gets a few days of painkillers and antibiotics, the swelling goes down a bit, and it makes the surgery easier to do. More than a week or two out from the injury repairs get problematic as the tissue inside the orbit starts to stick to the healing bone.

The orbital floor may need to be pieced back together and held in place with plates, or if it’s seriously destroyed it can be completely replaced by titanium or plastic mesh. The same goes for the orbital rim – plates or mesh depending on the extent of the damage. Why titanium? It’s light, it’s strong, and it’s biocompatible, meaning it won’t rust once it’s buried in your face. It’s also really good at osseointegration – bone grows into microscopic pores in the metal and integrates the implant into the actual structure of the bone. Osseointegration takes months, hence the need to add additional protective equipment during the healing period. The implant that doesn’t ever move is the implant that’s going to heal well.

 

No orbital floor? No Problem! Have it replaced with shiny new titanium!

 

It’s three weeks to a month post-implant before heavy activity is allowed, and if vision was affected it can be as long as six to nine months before that’s completely normal. The other issue with injuries like this is that they’re frequently accompanied by problems with the eye itself and/or by concussions.

Next, go ahead and shut it down if you’re contemplating starting the old visors can hurt you argument using Caron, because you’re wrong. Excuse me while I quote myself in a post from November of 2011, which you can read in its entirety here.

 

Players in visors actually tend to incur more severe lacerations to the upper half of the face (says this study done in the ECHL). Now before you go running off to make a BAN VISORS NOW poster for your next trip to an NHL game, consider the following: Players who wear visors suffer fewer eye and non-concussion head injuries than those who don’t (says this study done in the NHL). So overall fewer injuries, a free ticket out of permanent vision loss, and in exchange when you DO get a laceration, it’s a little more severe. That’s a solid deal. I’d take it.

 

Thanks to @charlesbreton for the heads-up on Emelin’s cruddy face issues. I had no idea, probably because I was so distracted by Markov’s knees.

Comments (8)

  1. Jo, I’ve missed reading your posts through my fingers and shuddering.

  2. The Boston Bruins Merlot Line (Paille-Campell-Thornton) had a blog last season (Boston Globe I think), and in one post Campbell describes his many facial injuries including the ones you described above. I remember being particularly creeped out by his description of making an incision in the upper lip…ick.

    Another great post as usual! I really move reading your posts, and I learn a lot even if I am severely grossed out in the process!

    • Oh and in that blog post, Campbell also mentions how much dental work he has had to have because having his face broken so many times caused his teeth to rot. Is this actually a thing? I’ll try to find the link for it..

  3. Great article, that CAT Scan is sick!

  4. One of my friends had an orbital fracture in high school. Someone was in the batting cage and hit a ball. Well, my friend was walking by and was right next to the mesh. When the ball hit the mesh netting, it pushed the netting (and the ball) directly into my friends face. We heard the *crack* as the ball hit the bat, and another (just as loud) *crack* when the ball hit his face.

    It was pretty amazing how fast his who face swelled up. It was a full 9 months before he could play any sports.

    Maybe I’m weird, but the injury posts are always interesting to me.

  5. Just as a point of interest, what sort of pain would one experience after having plates/mesh implanted and how might they affect surrounding facial muscles? My experience with titanium implants usually requires PT or rehab of some sort.

  6. Wow, thats gross…all of it. I missed your articles.

    So basically re the visor. Bobby Ryan took a puck to the side of the visor last night. Fell down, got up and kept playing. Beats having stuff cleaned up in your skull.

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