Children in Boxing and Martial Arts Should Be Better Guarded from Facial Injuries

Abstract

Study Design: Cross-sectional study. Objective: Childhood participation in boxing and martial arts has increased over the past decade, and these activities are well-known causes of traumatic injury. We hypothesized that the face is frequently injured in the setting of pediatric boxing and martial arts trauma in the United States and that there are identifiable injury patterns. Methods: We performed a cross-sectional study of consecutive pediatric patients in the National Electronic Injury Surveillance System (NEISS) from 1 January 2010 to 31 December 2019. Patients were included in our study if they were younger than 18 years of age and evaluated in the emergency department (ED) after boxing or martial arts trauma. Primary outcome was facial injury. Other variables of interest include age, sex, ED disposition, type and location of injury. Descriptive and univariate statistics of the primary outcome were computed with these variables. Results: There were 4978 total pediatric patients injured due to boxing and martial arts trauma reported by NEISS-participating EDs during the study period, and 264 patients experienced injury to the face (264/4978; 5.3%). Over 20% (n = 60) of reported facial injuries were fractures; the most fractured structure was the nose (42/60; 70), orbit (11/60; 18.3%), and mandible (6/60; 10%). Almost 20% (11/60%) of pediatric facial fractures due to boxing and martial arts trauma involved fighting a family member or friend, and a punch was the most common mode of fracture (42/58; 72.4%). Conclusions: Facial injuries comprise about 5% of injuries after boxing and martial arts trauma and 22% of these facial injuries are fractures. If children choose to participate, parents, coaches, trainers, officials, and community leaders should make the greatest effort possible to minimize risk, including the mandatory use of head and face protective gear and elimination of training fighting, or “sparring.”

Introduction

Participation in fighting-focused sports, including boxing and martial arts, has increased substantially over the past decade.[1,2] Much attention has been paid to head related injuries associated with these sports, and, as a result, head protection has become a ubiquitous recommendation.[3] Facial injury is also a common occurrence among these athletes; however, face protections have not been made as widely available. While the majority of participants in these sports are adults, the pediatric population comprises a not insignificant proportion,[4] and the long-term consequences from these injuries can be wide-ranging and potentially serious.[5,6] Though previous study has investigated all facial trauma generally related to combat sports, none have specifically focused on the pediatric population or facial fractures. As facial injuries after trauma in the pediatric population represent a significant treatment challenge with possibility for long-term implications, the purpose of this study is to analyze facial injuries after boxing and martial arts trauma to improve the prevention of these injuries. We hypothesized that the face is frequently injured in the setting of boxing and martial arts trauma in kids and that there are identifiable injury patterns. In this study, we aimed to perform a nationwide analysis of facial injuries in children after presenting to the emergency department due to boxing and martial arts trauma and identify variables of interest possibly contributing to the observed injury patterns.

Materials and Methods

Study Design and Sample

To address the research purpose, the investigators designed and implemented a cross-sectional study of consecutive cases reported to the U.S. Consumer Product Safety Commissions’ National Electronic Injury Surveillance System (NEISS) database between January 1, 2010, and December 31, 2019. Our institution did not require IRB approval for this population-based, retrospective descriptive study. The study population was composed of all patients presenting to the emergency department (ED) for evaluation and management of facial injury in the setting of boxing and martial arts trauma between January 1, 2010, and December 31, 2019. To be included in the study sample, patients had to have presented to the ED with facial injury in the setting of boxing, karate, or taekwondo trauma and be less than 18 years of age. Patients were excluded as study subjects if they did not present to the ED after injury, if they did not experience a boxing, karate, or taekwondo trauma, or if they were 18 years or older.

The NEISS is comprised of a stratified probability sample of 100 hospitals in the United States and its territories and is maintained by the US Consumer Product Safety Commission (CPSC).[7,8] Stratification is by ED annual census and geographic region. Each participating ED is assigned a statistical weight to represent other non-participating EDs in a similar stratum. Each injury case from a participating ED represents the same number of injuries as the statistical weight of the ED, and weighted data are then summed to generate national estimates.

Variables

The study population included pediatric patients who experienced injury due to boxing or martial arts trauma and presented to the emergency department. The primary outcome of interest for this study was facial injury. Other variables of interest include age, sex (male or female), ED disposition (left without being seen, treated and released, treated and admitted, treated and transferred, held for observation, treated and died), type of injury (laceration, contusion, abrasion, fracture, etc.), location of injury (forehead, nose, orbit, mandible, etc.), and certain associated phrases or words from the free text narrative.

Data Collection

The NEISS database is a collection of data, including but not limited to date, age, sex, diagnosis, body part, patient disposition, associated consumer product, and incident location, for everyone treated in the participating EDs. These variables are collected, entered, and uploaded each night into the national Consumer Product Safety Commission (CPSE) computer database, where it is coded and prepared for use. For this study, the authors queried the NEISS database for all injuries to the face recorded in patients under 18 years of age in the setting of boxing and martial arts trauma over the study period. Results were counted for analysis, and the statistical weight estimate for each counted case was also summed to produce an estimated total number of national cases. Analyses were also performed with the primary outcome and other variables of interest.

Statistical Analysis

Descriptive statistics were reported as a mean and standard deviation for continuous variables or frequency and percentage for categorical variables, respectively. 95% confidence intervals were provided as needed. Comparisons of proportions were performed with an “N-1” Chi-squared test. Comparisons of means were performed with a 2-tailed T-test. Before performing any tests, statistical significance was defined with a p-value <0.05. All statistical analyses were performed with commercially available software (SAS), and figures were created with Prism 7.0a (GraphPad Software, San Diego, CA, USA).

Results

During the study period, there were 4,978 total pediatric patients with an injury due to boxing and martial arts trauma reported from NEISS-participating emergency departments. The average (+standard deviation [SD]) age was 12.1 (+3.46) [95% CI: 12.0, 12.2] years. Seventy-one percent of patients with injury due to boxing and martial arts trauma were male (3,517/4,978). Eight types of injuries were recorded in at least 1% of patients; the most common type of injury was strain/sprain (1,252/4,978; 25.1%). The most common ED disposition after boxing and martial arts trauma was treated and released (4825/4978; 96.9%) (

Table 1. Baseline Clinical Profile for the Study Population.

Abbreviations: SD, standard deviation; ED, emergency department; DOA, dead on arrival; CI, confidence interval.

). During this time, there were a total of 577 patients with head injury after boxing and martial arts trauma reported from NEISS-participating EDs.

Facial Injuries

From the total pediatric injuries after boxing and martial arts trauma during the study period (n = 4,978), there were 264 patients with a facial injury due to boxing and martial arts trauma reported from NEISS-participating EDs over the 10-year study period. Using NEISS extrapolation to estimate the total number of cases presenting to all EDs across the United States, this totals approximately 8,500 total facial injuries after boxing and martial arts trauma during the 10-year study period. The most common facial injury due to boxing and martial arts trauma was facial laceration (82/264; 31.1%). Twenty-two percent (60/264) of facial injuries were fractures (

Table 2. Baseline Clinical Profile of Facial Injuries After Boxing and Martial Arts Trauma.

Abbreviations: SD, standard deviation; ED, emergency department; DOA, dead on arrival.

and Figure 1). When comparing pediatric patients with facial injuries due to boxing and martial arts trauma to patients with other (non-facial) injuries, the patients with facial injury were more likely to be male (85.2% vs 69.8%, p < 0.0001) than patients with other injuries. There were no age differences between pediatric patients with facial injuries and patients with other (non-facial) injuries due to boxing and martial arts trauma (

Table 3. Comparison of Age and Sex Between Patients With Facial (n = 264) and Other (n = 4,714) Injury Due to Boxing and Martial Arts Trauma.

Abbreviation: SD, standard deviation. *p-value of <0.05 considered significant.

).

Age Trends Among Pediatric Patients With Facial Injuries

Of the patients with a facial injury due to boxing and martial arts trauma, all had age recorded. The youngest patient was 2 years old, and the oldest patient was 17 years old. The most common age stratum of injury was 17 years (n = 45) (

Table 4. Number of Facial Injury Due to Boxing and Martial Arts Trauma for Each 1-Year Age Stratum.

). The number of injuries reported for each age stratum increased progressively after age 13, eventually reaching 45 injuries in the 17-year age stratum (Figure 2).

Sex Trends Among Pediatric Patients With Facial Injuries

Of the total primary facial injuries, all had sex recorded. There was no significant difference in age between male and female patients. Facial laceration was the most common type of injury for males (73/225; 32.4%), and contusion was the most common type of injury for females (12/39; 30.8%). Female patients were more likely to experience bleeding (10.3% vs 3.1%, p < 0.05), and male patients were more likely to experience fracture (24.9% vs 10.3%, p < 0.05). There were no statistically significant differences observed in post-ED dispositions between males and females (

Table 5. Comparison of Clinical Profiles Between Male (n = 225) and Female (n = 39) Patients With Facial Injuries After Boxing and Martial Arts Trauma.

Abbreviation: SD, standard deviation. *p-value of <0.05 considered significant.

).

Location and Characteristics of Pediatric Facial Fractures

There were 60 patients with primary facial fractures recorded in the EDs over the 10-year study period. The most fractured structure was the nose (42/60; 70%). Mode of facial fracture was mentioned in 58 cases with the most common being “punch” (42/58; 72.4%), “kick” (13/58; 22.4%), and “headbutt” (3/58; 5.2%). Location that the facial fracture took place was mentioned in 20 cases with most common locations including the “gym” (5/20; 25%), “practice” (5/20; 25%), and “class” (4/20; 20%). In 11 cases (11/60, 18.3%), a family member or friend was involved in the fracture (

Table 6. Clinical Profile of Patients With Facial Fractures After Boxing and Martial Arts Trauma.

Abbreviation: NOS, not otherwise specified.

).

Discussion

The purpose of this study is to analyze facial injuries after boxing and martial arts as these injuries represent a significant treatment challenge with possibility for long-term, life-altering implications. We hypothesized that the face is commonly injured in the setting of boxing and martial arts trauma in kids and that there are identifiable injury patterns. In this study, we aimed to measure facial injuries in the setting of boxing and martial arts trauma and identify variables of interest possibly contributing to the observed injury patterns. There were 4,978 total pediatric patients injured after boxing and martial arts trauma reported by NEISS-participating EDs during the study period, and, from those, 264 patients experienced a facial injury (264/4978; 5.3%). Face injuries occur only a little less than half as frequently has head injuries (head:face injury ratio: 2.2:1). Twenty-two percent (60/264) of facial injuries were fractures, and the most common structures involved were the nose (42/60; 70%), orbit (11/60; 18.3%), and mandible (6/60; 10%). Almost 20% (11/60%) of pediatric facial fractures due to boxing and martial arts trauma involved fighting a family member or friend.

Additional analyses of our variables of interest revealed other trends. The number of injuries reported for each age stratum increased substantially after age 13, and the yearly number of pediatric facial injuries after boxing and martial arts trauma was mostly stable over the study period. The most common pediatric facial injury after boxing and martial arts trauma was facial laceration (82/264; 31.1%). Female patients were more likely than males to experience facial bleeding (10.3% vs 3.1%, p = 0.04), but male patients were more likely than females to experience facial fracture (24.9% vs 10.3%, p = 0.04). The most common mode of facial fracture was “punch” (42/58; 72.4%) and the most common location that the facial fracture took place was the “gym” (5/20; 25%), “practice” (5/20; 25%), and “class” (4/20; 20%).

The most invasive facial injury after boxing and martial arts trauma, fracture, can be serious injuries that must be prevented in children at all costs. Review of the current literature documents abundant risks associated with facial fractures, including concomitant vision-threatening injuries to the globe, orbit and optic nerve [9,10] and life-threatening injuries to the brain and cervical spine.[11] Concomitant soft-tissue injuries are also reported in children with facial fractures, which, though seemingly non-life threatening, can lead to substantial scarring that requires revision [12] and be the cause of long-term morbidity.[13] Considering that over 20% (60/264) of the recorded pediatric facial injuries after boxing and martial arts trauma were fractures, we must urge careful consideration before choosing to participate. The American Academy of Pediatrics goes further to “vigorously opposes” boxing as a sport for children and adolescents due to the risk of head and face injuries, but they do list certain benefits provided to participants, including exercise, self-discipline and self-confidence.[14] Thus, if children decide to participate to gain these benefits, the greatest effort possible should be undertaken to minimize risk, including the mandatory use of head and face protective gear and eliminating training fighting, or “sparring.” Prior studies have recommended and demonstrated the need for improved facial protections during recreational sport to reduce the number of facial injuries, [15,16,17,18,19] and our current data represents a natural extension of these works.

Certain facial injury and fracture observations from our data set are also worth noting. When reviewing the injury narratives provided with each submission to the NEISS, we were able to identify that over 20% of facial fractures involved a family member or friend or were deemed an “accident.” These narratives raise the suspicion for play fighting in an unprotected home or school setting that might be a natural progression from structured, adequately protected training in a special gym. While play fighting is a natural activity for most children and young adolescents, having formal boxing and martial arts training in one individual naturally threatens injury in the other partner, especially considering the probable lack of protective gear. This scenario is most likely to occur in boys, and our data found that they presented to the ED at about almost a 6:1 ratio compared to girls. We would recommend that formal training in boxing and martial arts for children aggressively assert that these activities and skills are for structured use in the gymonly and include appropriate education regarding the possible complications of fighting with friends, family members, or “enemies” in an unstructured environment.

Limitations

There are limitations to our study. The NEISS is a useful tool for computing population health care trends, but the database only records injuries in persons who present for emergency care, so patients who do not seek medical care or present to a physician in an outpatient setting are not included. This database was originally created as a consumer protection device to report injuries occurring from product and equipment usage, so its design was not designed with medical researchers in mind and is not perfectly suited for nationwide epidemiologic studies. Lastly, helpful secondary variables are often not collected or poorly hidden in the “text narrative” which makes certain conclusions more challenging to draw. Nevertheless, the NEISS allows for high numbers of studied patients and has been of great importance to many specialties in numerous prior analyses.[15,16,20,21,22,23]

Conclusions

Facial injuries comprise about 5% of injuries after boxing and martial arts trauma and 20% of these facial injuries are fractures. If children choose to participate, parents, coaches, trainers, officials, and community leaders should make the greatest effort possible to minimize risk, including the mandatory use of head and face protective gear and elimination of training fighting, or “sparring.”