Squash(ed): Craniofacial and vertebral injury from collision on squash court.

Squash is a popular racquet sport not usually associated with severe head or spinal injury. The incidence of squash-related injury ranges from 35.5 to 80.9 per 100,000 players, with the most common sites being the lower-limbs and eyes. We present a case of extensive traumatic craniomaxillofacial and vertebral injury resulting from collision on a squash court, without use of protective gear. The patient sustained fractures of the frontal bone, orbits, maxillae, zygomas, the first and second cervical vertebrae and the spinous process of the seventh cervical vertrebra. This is the first case of squash-related injury with such extensive craniofacial and vertebral involvement. This unique case required multiple surgical procedures as well as an extensive admission to the intensive care unit and highlights the risk of significant craniomaxillofacial trauma in sports not usually associated with such injuries.

INTRODUCTION

Studies have shown the incidence of injury from squash to range from 35.5 to 80.9 per 100,000 players.[12] Trauma to the head (including the eyes) is the most common cause of squas-related hospital presentation, comprising 48.7% of all emergency department presentations.[1] Craniofacial and spinal fractures typically result from high-energy blunt force to the skeleton, as seen in motor vehicle accidents.[3] This is the first case reported of a patient sustaining such extensive head, neck and spinal injuries from a squash-related injury.

CASE REPORT

A 55-year-old man was brought in by ambulance after colliding with the corner of the wall and floor of a squash court, without the use of protective eye-glasses or mouth-guard. He was chasing a ball toward the corner of the court when he fell and hit the junction of the wall and floor with his head.

On examination in the Emergency Department, the patient had a Glasgow coma scale (GCS) of 14, with confusion to time and place. Initially, the patient reported diplopia at primary position but examination by the surgical team elicited normal eye movements with nil complaint of diplopia. There was intermittent epistaxis bilaterally. Examination of the oral cavity showed jaw and teeth misalignment. There was significant boggyness to palpation of the forehead with a palpable defect of the frontal bone. The cervical spine was slightly tender over/C1-2 and C5-6. Upper limb examination was limited by pain maximal over the distal radii but bilateral arm weakness was noted with nil sensory dysfunction. No lower-limb abnormalities were apparent. Primary and secondary surveys did not elicit any further findings. A non-contrast computed tomography (CT) scan of the facial bones, brain and cervical spine was performed.

Imaging of the facial bones [Figure 1] showed a Le Fort Type II fracture, with comminuted fractures of the roofs of the orbit bilaterally and a depressed fracture of the left orbital floor. This was associated with slight inferior depression of the globe. There was also fracture of the right maxilla at the junction of the maxilla and zygomatic arch, extending towards but not involve the right orbital floor. On the left, there was fracture of the anterior part of the left zygomatic arch which extended into the anterolateral wall of the left maxillary sinus. A large, depressed fracture of the frontal bone was also evident, extending superiorly from the superior lateral wall of the right orbit and extending across the frontal bone and inferiorly toward the mid-portion of the roof of the left orbit. The fracture involved the inner and outer tables of the frontal bone and was depressed by at least 3.5 mm. There was also a comminuted fracture of the nasal bone, which was not significantly displaced.

Figure 1

Anterior and anterolateral views of three-dimensional CT reconstructions demonstrating LeFort Type II, frontal, orbital and zygomatic fractures

CT brain showed tiny subarachnoid or intraparenchymal haemorrhages but there was no evidence of extensive intra- or extra-axial haemorrhage.

Imaging of the cervical spine [Figure 2] showed an undisplaced fracture of the posterior arch of C1 on the right side and a Type 3 dens fracture with posterior displacement of 4mm but no contact with the spinal cord. A spinous process fracture of C7 was also seen.

Figure 2

Anterolateral view 3 dimensional CT reconstruction demonstrating Type 3 dens fracture with posterior displacement and fracture of C7 spinous process

Subsequent CT of the thoracic spine showed a comminuted T6 vertebral body fracture with loss of vertebral height and extension into the left costovertebral joint. There was a small bony fragment projecting posteriorly into the spinal canal and making contact with the cord, but there was nil evidence of compression. Associated with this finding were two to three hyperdense foci within the spinal cord likely to represent small contusions. The above findings were confirmed on magnetic resonance imaging (MRI) of the spine, which also demonstrated a small cortical buckle at the T6 level without significant cord impingement.

The patient underwent craniotomy, obliteration of the frontal sinus and open reduction internal fixation (ORIF) of the frontal bone. ORIF of the maxilla bilaterally, ORIF of the infra-orbital rim and supra-orbital rim bilaterally and inter-maxillary screw fixation was also performed. The patient was admitted to the neurosurgical intensive care unit post-operatively and underwent cervical fusion with odontoid screw fixation of the C2 fracture one week after surgical correction of the head injuries. The C7 fracture was treated conservatively. The inter maxillary fixation was removed one month after application without complication.

Post-operative CT scans demonstrated complete bony union in the C2 fracture site [Figure 3] and uncomplicated fixation of the facial bone fractures [Figure 4].

Figure 3

Post-operative lateral X-ray of the cervical spine in extension demonstrating union of dens fracture with overall alignment in-tact

Figure 4

Post-operative coronal CT demonstrating surgical correction of multiple craniofacial fracture sites

DISCUSSION

Squash has a relatively high incidence of severe injury when compared to other sports.[2] Our patient suffered injuries to multiple sites in the cranium, facial bones and the vertebrae that have previously not reported in the literature.

The orbit is a common site of fracture in craniofacial injuries.[3] The thinnest and weakest segment of the orbit is the floor, which is the most common site of fracture.[4] Maxillary fractures commonly result from high velocity direct blows. Our patient suffered a Le Fort Type II fracture, which is pyramid shaped and passes through the posterior alveolar ridge, lateral walls of maxillary sinuses, inferior orbital rim and nasal bones. He also suffered a depressed frontal bone fracture involving the inner and outer tables, an extremely rare complication of sport seen in only 1.3% of sports related craniofacial fractures.[5]

Spinal injury is associated with sports in approximately 8.7% of cases,[6] usually in relation to contact sports such as wrestling.[7] Our patient had a fracture of the posterior arch of C1 on the right side and a type 3 dens fracture, which required cervical fusion. There was also fracture of the C7 cervical process, from forceful flexion of the cervical spine. The fracture is usually quite stable and can be treated conservatively.

CONCLUSION

We report the first case of extensive head and spinal injury resulting from collision with the wall of a squash court. The injuries ranged from the frontal bone to the thoracic vertebra and are usually seen in high velocity trauma. This case highlights the importance of protective gear during sport.