Head Injury - US Rugby 7's

HISTORY: A 26-year-old men’s club Division I rugby-7 s winger injured the non-dominant left side of his face after attempting to tackle the opposing side’s ball-carrier in open play. The ball-carrier was running forward and the tackler was injured by impact of the ball-carriers knee to his face, when the tackler attempted to get in front of the ball-carrier to execute a low shoulder tackle. Post-collision, the injured player hit his head on the grass surface, and immediately grabbed his head and face. He complained of 10/10 facial pain. PHYSICAL EXAM: Sideline healthcare providers noted a lethargic player with depressed left cheek bone and deformed face, with ruled out cervical compromise. No lacerations or open wounds were noted. The ED examination documented a concussed male with a deformed and impacted left inferior orbital rim and zygomatic arch with crepitus. No lacerations or open wounds were noted. Eye exam showed 5/5 motor function and freedom in all directions, with no entrapment or visual disturbances noted. Mild neuropraxia of the temporal branch of the facial nerve noted with decreased ability to elevate his left eyebrow fully. Limited jaw opening with pain. DIFFERENTIAL DIAGNOSIS: 1. Orbital inferior floor fracture 2. Orbital rim fracture 3. Zygomatic arch fracture 4. TMJ dislocation 5. Temporal nerve palsy TEST AND RESULTS: Initial facial and head MRI -Impacted multi-comminuted left zygomatic arch and inferior orbital fractures with the inferior orbit floor in multiple fractures FINAL/WORKING DIAGNOSIS: 1. Left inferior orbital floor fracture with no muscular entrapment and concomitant left zygomatic arch fracture TREATMENT AND OUTCOMES: 1. Emergency. Clearly seen on MRI 2. Pain management employed 3. Immediate emergency department consultation of ophthalmology and plastic reconstructive services; recommendation of no surgery 4. Patient stabilized and observed to ensure symptoms remained stable, and then released with no further interventions 5. Follow-up with an oral maxillofacial surgeon to assess recovery one-week post injury a. Mild neuropraxia improved upon examination b. Jaw ROM improved with OMF manipulation 6. Patient reports no limited ROM in eye movements, no double or blurry vision, and no difficulties with chewing or speaking. Patient still complained of some limited ROM with jaw opening