Importance Men’s lacrosse is a fast-paced, high-collision sport with ball speeds in overabundance of 90 mph. Laryngeal fractures in lacrosse space a seldom reported injury. To increase awareness of this potential injury, we define 3 masculine lacrosse players who sustained laryngeal fractures from lacrosse sphere trauma to the neck.
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Observations The first patient sustained a minimally displaced, paramedian thyroid cartilage fracture and also was controlled with monitoring alone. The 2nd patient continual a depression fracture that the left thyroid ala and also was controlled with closed reduction. The 3rd case sustained a mildly displaced transcricoid fracture. He was controlled with open up reduction and internal fixation. Every 3 patients went back to regular tasks with near normal voice results by last follow-up.
Conclusions and also Relevance This is the first report that laryngeal fractures complying with lacrosse round trauma come the neck. Lacrosse players room at hazard for laryngeal injuries, and also neck defense is only worn through the goalie. That is ours hope that this series will raise awareness of this possibly lethal injury and prompt the sports to take into consideration mandatory neck security for every players.
Men’s lacrosse is a fast-paced, high-collision team sports that uses sticks come pass, catch, run, and score v a ball. The heavy rubber ball, weighing 145 g (approximately 5 oz) and also 63 mm in diameter, have the right to reach speeds in overabundance of 90 mph as soon as shot at the goal. Both offensive and also defensive players can be in the course of shots on goal. Helmets, challenge masks, mouth guards, gloves, and also upper human body padding are required for all field players.1 although lacrosse facemasks room elongated to market some neck protection, really throat security is only forced for the goalie, leaving the anterior necks of all other players potentially vulnerable to trauma.
Only 1 situation of a lacrosse-related laryngeal fracture exists in the literature, and also this was due to a pole injury.2 In recent years, 3 distinct situations of laryngeal fractures indigenous lacrosse balls were controlled at our school with 3 separate treatment modalities. This collection serves to boost awareness of this potential injury and also to promote more comprehensive adoption that neck protection in this increasingly renowned sport.
A 20-year-old guy with no significant medical history was to win on the ideal side of his neck by a high-speed lacrosse ball twice during practice. Automatically following the second trauma, he occurred voice changes, hemoptysis, dyspnea, and also odynophagia. He denied loss of awareness or an obstacle with neck flexion or extension. The was required to a level i trauma center, whereby on arrival, his dyspnea had actually resolved and also he remained in no apparent distress. He to be breathing comfortably without stridor, and an essential signs including pulse oximetry to be within normal limits.
He complained that right-sided neck pain and also odynophagia. Examination revealed a tender, 3.5-cm area that ecchymosis overlying the thyroid cartilage. No subcutaneous emphysema or step-offs to be detected by palpation. Versatile laryngoscopy revealed mild arytenoid edema and no mucosal lacerations, and both true vocal folds were symmetric and also mobile. Computed tomographic (CT) imaging the the neck revealed a left-sided, minimally displaced, paramedian thyroid cartilage fracture without evidence of hematoma (Figure 1).
Computed tomographic scan that the neck discover a left-sided, minimally displaced, paramedian thyroid cartilage fracture.
The patient was admitted come the intensive treatment unit for overnight airway observation. He to be treated with dexamethasone, antireflux medications, humidified oxygen, and also voice rest, with continuous pulse oximetry. No desaturations were listed overnight, and his voice quality and also odynophagia had improved through the next day. He was discharged house on the second hospital day v a tapering dosing that corticosteroids, antireflux precautions, and absolute voice rest. The patient stayed asymptomatic and returned to playing lacrosse 5 months complying with the injury.
An otherwise healthy and balanced 16-year-old male adolescent to be struck on the anterior neck by a high-speed lacrosse ball throughout a game. Automatically following the injury, he occurred odynophagia and also changes in vocal quality. He was taken to a level i trauma center, where on arrival, he refuse dyspnea and was in no apparent distress. He to be breathing comfortably there is no stridor, and also his critical signs, consisting of pulse oximetry, were within typical limits. On examination, his voice was provided to it is in “raspy” in quality. His thyroid cartilage to be tender come palpation there is no ecchymosis, subcutaneous emphysema, or palpable step-offs. Versatile laryngoscopy v stroboscopy revealed full mobility the both true vocal folds; however, there was a lack of vibration follow me the left true vocal fold. The posterior facet of the left true vocal fold consisted of ecchymosis, diffuse edema, and a little mucosal laceration. Computed tomography the the neck revealed a depression fracture that the left thyroid ala, together with a soft-tissue ede in the posterior glottis (Figure 2A).
A, Computed tomographic scan of the neck revealing a depressed fracture that the left thyroid ala. B, Intraoperative photograph throughout microdirect laryngoscopy demonstrating a posterior laceration the the left true vocal fold with an avulsed vocal process.
Intravenous dexamethasone to be administered, and the patience was instantly taken come the operation room for microdirect laryngoscopy. This revealed ecchymosis and edema throughout the larynx, with a laceration along the medial margin the the anterior one-third of the left true vocal fold. In addition, a posterior laceration v avulsion the the left vocal process was noted (Figure 2B). A straight blade laryngoscope was provided to execute closed palliation of the depression thyroid alar segment. The anterior laceration to be debrided, and also the edges were reapproximated. The posterior laceration and avulsed arytenoid fragment were secured in location with suture repair. Postoperatively, the patient to be monitored overnight in the intensive treatment unit and also discharged the following day on pure voice rest, antibiotics, and antireflux precautions. Three weeks later, stroboscopic check demonstrated enhanced vibration the his left vocal fold. Through 2 months, the patient had actually symmetric in-phase vibration, even in the upper registers.
A 17-year-old masculine adolescent through no significant medical background was to win on the left anterior neck with a lacrosse ball during a game. Immediately following the injury, he detailed throat pain, dysphagia, and also changes in vocal quality. The was required to a level ns trauma center, where on arrival, he remained in no apparent distress and also was breath comfortably without stridor, and also his an important signs consisting of pulse oximetry were within normal limits. Examination revealed tenderness over his anterior neck there is no ecchymosis or subcutaneous emphysema. Functional laryngoscopy revealed ecchymosis and also immobility the the left true vocal fold. A CT scan that the neck revealed a mildly displaced transcricoid fracture (Figure 3).
Figure 3. Situation 3: Computed Tomographic Scan
Computed tomographic scan the the neck revealing a mildly displaced transcricoid fracture.
Stroboscopic testimonial revealed soft ecchymosis and also edema that the left true vocal fold through minimal movement of the left arytenoid. However, his left true vocal fold demonstrated common vibratory behavior. The patient to be then taken to the operation room for more evaluation and also management. Microdirect laryngoscopy revealed symmetrical placing of the true vocal folds there is no visible mucosal lacerations. Palpation that the left arytenoid cartilage revealed hypermobility. The subglottic check was notable for ecchymosis of the anterior right and posterior left regions, without hematoma or stenosis. Open expedition through one anterior neck incision to be then performed. The right, anterior facet of the cricoid cartilage contained an evident fracture through 3 to 4 mm that displacement. The fracture was reduced and secured through a 2-0 polypropylene (Prolene; Ethicon Inc) suture in a figure-eight configuration. The wound was irrigated and also closed. Microdirect laryngoscopy was then repeated, which revealed a symmetric subglottis v no evident signs of submucosal collection or edema.
The patient to be observed postoperatively in the intensive care unit, during which time no airway worries arose. He was discharged on pure voice rest, antibiotics, and also antireflux precautions. An additional stroboscopic examination on postoperative day 6 revealed solving ecchymosis with continued immobility the the left vocal fold. Regardless of this, he to be able to achieve complete glottic closure. 6 weeks postoperatively, his speak voice was improved, and he ongoing to attain glottic closure. His left true vocal wrinkles mobility remained minimal at the time. Eight months after injury, the patient thought that his voice was “near normal.” Stroboscopy at the time revealed advancement in his left vocal wrinkles paresis with continued complete glottic closure.
Laryngeal fractures have the right to be life threaten if no identified and also managed in a fashionable fashion. Ratstatter and also colleagues2 report a single case the a laryngeal fracture from a lacrosse stick. Come our knowledge, our evaluation is the an initial to specifically define laryngeal fractures developing in patients being struck by a ball. This case series demonstrates the wide spectrum of monitoring options, consisting of observation that a nondisplaced fracture, closed palliation of a depressed thyroid alar fracture with main repair the mucosal laceration and vocal procedure avulsion, and open palliation with internal fixation that a displaced cricoid cartilage fracture. All modalities brought about successful outcomes in these patients.
Tracheotomies to be not important in any type of of the cases due to the fact that airway distress to be not present on arrival to the trauma center. This may be partly attributed to the prompt recognition of the injury, adhered to by instant transfer to the emergency department and early management of corticosteroids. Signs and symptoms suggestive of laryngeal trauma incorporate respiratory distress, dysphagia, hemoptysis, stridor, subcutaneous emphysema, neck ecchymoses, inflammation, loss of the laryngeal prominence, and hyoid elevation.3 any kind of of these need to alert coaches and also trainers of impending laryngeal edema, and also transfer come an emergency facility for instant airway evaluation and management have to be a height priority. Back this series focuses ~ above laryngeal fractures, dull neck trauma can also involve other surrounding structures including the carotid artery, resulting in potentially serious consequences if not promptly recognized.4
In addition to cultivating awareness the this hardly ever reported injury, this article likewise highlights the inadequacy that the required protective tools for men’s lacrosse. Helmets have evolved to much better protect football player from concussion, and also they save a lower chin profile to better cover the mandible and also anterior neck. However, together this report highlights, this protection have the right to be inadequate. The relaxing neck height of players can vary, and transforming head position throughout play might leave some locations of the neck exposed and susceptible to injury. At present, throat guards space commercially available, however they space only forced for lacrosse goalies. Because shot balls take trip the same velocity at all players in prior of the goal, the topic of mandatory throat protection must be handle at a national level and also brought to the fist of lacrosse rulemaking committees. Resistance come this adjust may occur, as interviews with regional players revealed the vanity was the most typical reason for no wearing a throat protector. In addition, over there is issue that neck protectors may limit downward neck motion, requiring the player come bend much more at the hip to look at the ground.
Although these instances highlight this injury in masculine lacrosse players, female lacrosse players may likewise be in ~ risk. Woman lacrosse enables less physics contact and also provides less protective equipment. However, as viewed in this collection and others, no physical contact is vital for ball-related fractures.1,5 The ball in woman lacrosse travel slightly slower, getting to speeds that 60 mph.1 even if it is this can cause a laryngeal fracture is unknown at this time.
Hockey is an additional sport that entails a goaltender, football player in prior of the goal, and also high-speed shots. Comparable to lacrosse, a hockey puck weighs 170 g (approximately 6 oz), has a diameter the 76 mm, and can with speeds in overabundance of 100 mph once shot at the goal. However, in hockey, many passes and shots are kept reasonably close come the ice. The hockey score is 1.2 m in height. In lacrosse, the round is “cradled” and passed in ~ shoulder level, and also shots top top the 1.8-m tall goal are made overhand, regularly at neck level. Similar to ours series, Liberman and also colleagues6 described 3 cases of laryngeal fractures developing during ice hockey games, 2 the which to be from shoot pucks. Nevertheless, provided the similarities between these series, ice hockey players other than the goalie may additionally benefit from improved neck protection.
In conclusion, although most lacrosse injuries happen from player-to-player contact,5 this series demonstrates 3 instances of laryngeal fractures in the lack of physics contact. Laryngeal fractures in lacrosse are a rarely reported injury. The feasible consequences the this injury mandate the all coaches and also trainers are acquainted with the presenting signs and symptoms, allowing early identification and also management the the airway if necessary. It is our hope that this collection will raise awareness the this possibly lethal injury and prompt the sports to think about mandatory neck security for all players.
Corresponding Author: Richard Kelley, MD, department of Otolaryngology, SUNY Upstate medical Center, 750 E Adams St, Syracuse, NY 13210 (KelleyR
Submitted because that Publication: January 21, 2013; final revision obtained February 24, 2013; accepted March 4, 2013.
Author Contributions: Both authors had actually full access to all the data in the study and also take responsibility for the verity of the data and the accuracy the the data analysis.
Study concept and design: Both authors.
Acquisition the data: Both authors.
Analysis and also interpretation the data: Both authors.
Drafting the the manuscript: French.
Critical review of the manuscript for important intellectual content: Both authors.
Administrative, technical, and also material support: Both authors.
Study supervision: Kelley.
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Conflict of attention Disclosures: none reported.
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