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. 2017 Nov 16;19(6):453–458. doi: 10.1001/jamafacial.2017.0332

Recreational Activity and Facial Trauma Among Older Adults

Andrea Plawecki 1, Michael Bobian 1, Aron Kandinov 1, Peter F Svider 1,✉, Adam J Folbe 1,2, Jean Anderson Eloy 3,4,5,6, Michael Carron 1,7,8
PMCID: PMC5710476  PMID: 28617897

Abstract

Importance

As the US population ages, public health agencies have released guidelines encouraging aerobic activity and muscle-strengthening exercises among older individuals. Facial trauma from such activities among elderly individuals has long been underappreciated.

Objectives

To evaluate the incidence of recreational activity–associated facial fractures among older adults and to further delineate injury characteristics including demographics, fracture location, and specific activities.

Design, Setting, and Participants

The National Electronic Injury Surveillance System was used to collect data on emergency department visits from January 1, 2011, to December 31, 2015, for individuals 55 years of age or older who sustained facial fractures from recreational activities. Individual entries were evaluated for activity code, fracture site, and demographics. Weighting data were used to extrapolate national incidence.

Main Outcomes and Measures

Incidence and location of facial fractures and associated recreational activity.

Results

During the study period, there were 20 519 emergency department visits for recreational activity–associated facial fractures among adults 55 years of age or older (8107 women and 12 412 men; mean [SD] age, 66.5 [9.1] years). The annual incidence of facial fractures increased by 45.3% from 2011 (n = 3174) through 2015 (n = 4612). Bicycling (26.6%), team sports (15.4%), outdoor activities (10.1%), and gardening (9.5%) were the most common causes of facial fractures. Walking and jogging caused 5.5% of fractures. In cases specifying site of fracture, nasal (65.4%) and orbital (14.1%) fractures were the most common. A greater proportion of men than women sustained bicycle-associated fractures (35.7% vs 14.9%; P = 3.1056 × 10−170), while more women than men sustained fractures associated with gardening (15.5% vs 6.1%; P = 2.1029 × 10−97), outdoor activities (14.6% vs 7.7%; P = 4.3156 × 10−50), and gym exercise (7.7% vs 1.3%; P = 3.0281 × 10−114). Men harbored a greater likelihood than women of orbital (14.9% vs 12.8%; P = 6.1468 × 10−5) and mandible fractures (9.3% vs 2.0%; P = 9.3760 × 10−64). Walking and jogging and gardening comprised a greater proportion of injuries in older cohorts.

Conclusions and Relevance

Facial fractures sustained from recreational activity increased by 45.3% during a 5-year period among older adults. Although bicycling was the most common activity facilitating these injuries, many other pursuits represent areas of concern. Nasal fractures predominated, although orbital fractures increased with age. These findings offer areas for targeted prevention and provide valuable information for patient counseling. Furthermore, initiatives encouraging greater activity among this population may need to be accompanied by guidelines for injury prevention.

Level of Evidence

NA.

This database analysis uses the National Electronic Injury Surveillance System to collect data to evaluate the incidence of recreational activity–associated facial fractures among older adults and to further delineate injury characteristics including demographics, fracture location, and activities.

Key Points

Question

What are the incidence and characteristics of recreational activity-associated facial fractures among elderly Americans?

Findings

In this analysis, which uses the National Electronic Injury Surveillance System for facial fractures from recreational activities, there were 20 519 emergency department visits for recreational activity–associated facial fractures among adults 55 years of age or older. The annual incidence of facial fractures from recreational activities increased by 45.3% from 2011 through 2015; bicycling and team sports were the most common activities involved, and men were more likely than women to sustain orbital and mandible fractures.

Meaning

These findings offer areas for targeted prevention and provide valuable information for patient counseling.

Introduction

Significant improvements in medicine and technology, adoption of preventive strategies, and decreasing smoking rates all contribute to an increasing life expectancy among US adults in the past century. As the baby boomer generation comes of age, the population of Americans older than 55 years of age continues to increase dramatically, making a greater understanding of age-specific health concerns important for individual practitioners as well as policymakers. Hence, programs such as the Centers for Disease Control and Prevention’s Healthy Aging Initiative have been developed in recent years. Specifically, guidelines have been released by the Centers for Disease Control and Prevention pertaining to physical activity among older adults, with specific recommendations detailing the appropriate amount of moderate-intensity aerobic activity and muscle-strengthening activities required for maintaining health.

An active and aging population carries increasingly important implications for patient counseling, injury patterns, and prevention. Although head injuries along with trauma affecting the hips and extremities have been well studied in this age group, facial trauma has long been underappreciated. Hanba and colleagues recently examined facial trauma patterns among American adults, noting that risk of facial fracture increased with advancing age, female sex, and race/ethnicity. Facial trauma among younger adults more frequently resulted from participation in recreational activities compared with injuries among older adults.

In light of the aging US population and recent public health initiatives, we had several objectives in the current analysis. We were interested in focusing on older adults (≥55 years of age) and determining a national incidence of facial fractures resulting from participation in recreational activities. In addition to calculating an incidence and elucidating temporal trends, our objectives also included exploring what activities most commonly facilitated these injuries among this cohort, delineating the anatomical locations of these fractures and comparing demographic trends. Particularly in our current health care environment, this information may be timely and invaluable for practitioners involved in the care of older patients, physicians managing facial trauma, and policymakers.

Methods

The National Electronic Injury Surveillance System (NEISS) was used to collect relevant data in this analysis. Initially offered by the US Consumer Product Safety Commission as a tool to evaluate emergency department (ED) visits associated with consumer products, the NEISS was expanded in the past decade to include injuries associated with sports and recreational activity, and it has demonstrated its value in numerous analyses. The NEISS database is publicly available and qualifies as nonhuman participant research. Therefore, institutional review board approval was not required. Because all data entries are deidentified in the NEISS database, informed consent was not obtained.

Emergency department visits from the most recent 5-year period available, January 1, 2011, to December 31, 2015, were evaluated for entries involving adults 55 years of age or older who sustained facial fractures. Each entry is assigned a unique product or activity code, and only entries specifying injury from a recreational activity (eg, not a consumer product) were included. There were ultimately 507 entries extrapolating to 20 519 ED visits included in this analysis.

We used methods detailed previously in the literature to ensure accurate reporting of NEISS trends. This resource provides weighted data, which allowed us to extrapolate national incidence using SAS statistical software (SAS Institute Inc). Patient demographics, including age and sex, were evaluated, along with specific activities facilitating facial fracture. In addition, the text narrative accompanying each entry was evaluated to determine the specific location of the facial fracture (orbit, nose, maxilla or zygoma, mandible, frontal, or other).

Statistical Analysis

To report clinically useful comparisons, multiple comparisons were performed individually for each respective group using χ2 analysis. The threshold for significance was set at P < .05.

Results

From 2011 through 2015, a total of 20 519 adults 55 years of age or older presented to EDs with facial fractures. Of these patients, 12 412 (60.5%) were identified as men, and the remaining 8107 (39.5%) as women. A total of 3927 individuals (19.1%) were 75 years of age or older. The weighted national incidence of cases increased through all years except from 2014 through 2015 (Figure 1). A plurality of facial fractures were sustained from bicycling (26.6%), followed by participation in team sports (15.4%), nature or outdoor activities (eg, hiking, fishing, or camping) (10.1%), and gardening (9.5%) (Figure 2). Walking and jogging comprised the mechanism of injury in 5.5% of injuries. The most common team sport activities resulting in facial fractures were baseball and softball (11.9% of all fractures), whereas the most common individual sport represented was golfing (2.7%). The anatomical location of the facial fracture was reported in 31 809 cases (67.3%); of those cases, a majority of fractures sustained were to the nose (20 803 [65.4%]) (Figure 3), followed by orbital fractures (4485 [14.1%]).

Figure 1. Annual Incidence of Recreational Activity–Associated Facial Fracture Among Patients 55 Years or Older Presenting to the Emergency Department.

Figure 1.

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The incidence of facial fractures increased 45.3% from 2011 to 2015.

Figure 2. Recreational Activities Leading to Facial Trauma Among Adults 55 Years or Older.

Figure 2.

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Bar graph illustrating the proportion of facial fractures associated with each recreational activity.

Figure 3. Anatomical Locations of Facial Fractures Sustained by Adults 55 Years or Older.

Figure 3.

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Bar graph illustrating the proportions of each facial fracture location due to recreational activities.

Sex

Differences between the sexes in mechanisms of injury were noted (Table 1), with a significantly larger proportion of men than women sustaining facial fractures from bicycling (35.7% vs 14.9%; P = 3.1056 × 10−170), whereas a greater proportion of women than men sustained facial fractures while gardening (15.5% vs 6.1%; P = 2.1029 × 10−97), participating in nature or outdoor activities (14.6% vs 7.7%; 4.3156 × 10−50), and exercising at a gym (7.7% vs 1.3%; P = 3.0281 × 10−114). Furthermore, a greater proportion of facial fractures among men than women were sustained to the orbit (14.9% vs 12.8%; P = 6.1468 × 10−5) and mandible (9.3% vs 2.0%; P = 9.3760 × 10−64), whereas a greater proportion of facial fractures among women than men were to the nose (74.9% vs 59.3%; P = 3.5619 × 10−21) (Table 2).

Table 1. Proportions of Facial Fractures Between Sexes and Among Age Groupsa.

Activity Type Men, %
(n = 12 412)		 Women, %
(n = 8107)		 55-64 y, %
(n = 9495)		 65-74 y, %
(n = 7095)		 ≥75 y, %
(n = 3927)
Bicycling 35.7 14.9 39.3 23.6 5.8
Gardening 6.1 15.5 3.3 10.8 23.8
Nature activities 7.7 14.6 13.8 6.8 8.7
Team sports 19.7 10.1 19.2 16.1 7.3
Individual sports 8.7 4.9 6.4 9.0 5.7
Walking and jogging 5.4 6.1 0.8 7.4 14.4
Dog walking 2.6 17.3 5.0 10.2 13.4
Gym exercise 1.3 7.7 2.9 6.2 2.0
Motorized recreational vehicle use 7.0 1.5 6.8 3.6 2.4
Other 5.8 7.6 2.5 6.3 16.6
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a

Percentages are weighted.

Table 2. Locations of Facial Fractures Among Older Americansa.

Location Men, %
(n = 12 412)		 Women, %
(n = 8107)		 55-64 y, %
(n = 9495)		 65-74 y, %
(n = 7095)		 ≥75 y, %
(n = 3927)
Orbit 14.9 12.8 11.7 16.1 16.0
Nose 59.3 74.9 54.4 71.7 78.3
Zygoma or maxilla 6.4 6.6 12.4 2.2 1.1
Mandible 9.3 2.0 9.8 4.0 3.5
Multiple locations 10.0 3.7 11.7 6.1 1.1
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a

Percentages are weighted.

Age

The breakdown of injury mechanism and location varied with increasing age. A decreasing proportion of facial fractures occurred owing to bicycling when broken down by decade of injury (55-64 years, 39.3%; 65-74 years, 23.6%; and ≥75 years, 5.8%) (Table 1). In contrast, walking and jogging and gardening comprised a greater proportion of injuries among the elderly (walking and jogging: 55-64 years, 0.8%; 65-74 years, 7.4%; and ≥75 years, 14.4%; gardening: 55-64 years, 3.3%; 65-74 years, 10.8%; and ≥75 years, 23.8%) (Table 1). Individuals 55 to 64 years of age were less likely to sustain orbital and nasal fractures (orbital, 11.7%; nasal, 54.4%) than those 65 to 74 years of age (orbital, 16.1%; P = 8.9578 × 10−13; nasal, 71.7%; P = 7.3508 × 10−42) or those 75 years of age or older (orbital, 16.0%; P = 3.3493 × 10−12; nasal, 78.3%; P = 2.1302 × 10−66) and were more likely to have fractures located in the maxilla or zygoma (55-64 years, 12.4%; 65-74 years, 2.2%; P = 7.9207 × 10−74; and ≥75 years, 1.1%; P = 2.1598 × 10−55) and mandible (55-64 years, 9.8%; 65-74 years, 4.0%; P = 5.7678 × 10−26; and ≥75 years, 3.5%; P = 5.1414 × 10−19) (Table 2). The mean age of individuals injured walking and jogging was 74.8 years (eFigure in the Supplement), while bicyclists had the lowest mean age (62.8 years) of individuals in this analysis.

Discussion

Many analyses have demonstrated a positive association between facial fractures among older adults, longer hospital stays, and mortality rates, all leading to a greater health care burden. There are several potential reasons for this association, including the profound effect that facial trauma may have on independence and functionality, including effects on breathing, speech, swallowing, and sight. Nonetheless, extensive investigations into fractures among adults focus largely on injuries elsewhere throughout the body, and there remains a paucity of literature detailing the causes of facial fractures among older adults. With an expanding and increasingly active older population, our study fills a gap in the current literature by delineating the epidemiologic factors and patterns of facial fractures in such settings.

The incidence of facial fractures among older adults stemming from recreational activities increased year by year during the period from 2011 to 2014 and increased by 45.3% from 2011 (n = 3174) to 2015 (n = 4612) (Figure 1). This is a concerning increase despite previous study into the proper amounts and methods of exercise for aging adults, suggesting that strategies for injury prevention and education should accompany the contemporary movement that has encouraged activity among this population. Our findings also demonstrate that activities such as bicycling and team sports are most associated with facial fractures in this vulnerable population (Figure 2). Furthermore, because we discovered that the proportion of facial fractures from various activities depends on age and sex, our study highlights areas for possible intervention and education for specific populations.

Exhaustive evidence has shown significantly decreased bone density throughout the skeletons of older adult women, contributing to an increased risk for fractures compared with men, even in those without osteoporosis. Although such changes in bone density have been shown to extend to facial bones, our data demonstrate an overall male predominance among this injury population (60.5%). This finding differs from fractures seen throughout the rest of the body, where certain fractures have a strong female predominance, as well as from previous studies showing significantly higher rates of facial fractures in women among the older population. This finding suggests that facial fractures specifically due to recreational activities do not follow the typical distributions seen among fractures in older adults as a whole, which is an important distinction for health care professionals to keep in mind when considering facial trauma diagnosis and management, as well as preventive counseling. Furthermore, a survey-based study exploring sex differences in the rates of participation in recreational activities may help further elucidate the considerations responsible for our findings. The greater rate of fractures in men coincides with differences in the causes of fracture between sexes, as a majority of men sustained fractures while participating in “higher-risk” activities associated with greater energy, such as bicycling and sports, compared with women, whose fractures were most frequently associated with activities such as gardening and dog walking (Table 1). Although injuries associated with more energetic and vigorous activities were more common overall, physicians should be aware that even activities characterized as having a low risk of injury such as gardening and walking still carry potential for trauma and facial fractures in this older patient population.

Differences in epidemiologic factors of facial fracture between sexes are further highlighted by differences in fracture location. Although the greatest proportions of fractures were of the nasal and orbital bones in both sexes, which are seen to increase with age, there were significantly higher rates of mandible fractures, which tend to regress with age, among men. Mandible fractures have previously been associated with facial fractures in younger patients. Hence, while results for women and men 65 years of age or older coincide with previous findings and depend largely on structural changes associated with sex and age, fractures sustained during recreation by men younger than 65 years of age are likely influenced more by the mechanism of injury and often display different fracture patterns.

Limitations

To our knowledge, this is the first investigation into the epidemiologic factors of facial fractures sustained during recreation in the older adult population. As the US population continues to age, issues that affect this segment of the population will have an increasingly greater effect on health care delivery and costs, and understanding the unique issues associated with older adults will take on greater importance. However, our study has some weaknesses inherent to the study design. Although the NEISS database is an excellent tool for estimating ED visits, it does not include patients who may have presented elsewhere; consequently, our extrapolated national incidence rates may potentially be underestimating the extent to which facial fractures among older adults is a public health concern. The database also does not provide detailed information on management or outcomes. Despite this limitation, we were able to collect a large sample size from across the country, and the NEISS focus on recreational activities makes it ideal for analyzing relevant trauma. Furthermore, our conclusions also possess a greater degree of external validity compared with individual institutional studies.

Conclusions

Concomitant with numerous initiatives encouraging exercise among older Americans, facial fractures sustained from recreational activity increased by 45.3% during a 5-year period among adults 55 years of age or older. Although bicycling was the most commonly identified activity associated with facial fracture, many other pursuits represent areas of concern. Nasal fractures predominated, although orbital fractures increased with age. These findings offer areas for targeted prevention and provide valuable information for patient counseling. Furthermore, initiatives encouraging greater activity among this population may need to be accompanied by guidelines for injury prevention.

Supplement.

eFigure. Mean Age of Injury by Specific Activity

Click here for additional data file. (34KB, pdf)

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplement.

eFigure. Mean Age of Injury by Specific Activity

Click here for additional data file. (34KB, pdf)

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