Lacerations “Cuts” in Boxing

Fig. 1 Klitschko vs Lewis 2003

Fig. 1 Klitschko vs Lewis 2003

The head and the face are targets in boxing. It is intuitive that injuries to this region of the body may occur during a bout. The most common sites injured in boxing are the head, neck, face, and hands. Bledsoe et al. reported facial lacerations accounted for 51% of all injuries. The British Journal of Sports Medicine in 2003 reported that the head, neck and face are the most commonly injured areas on a boxer, comprising 89.8% of injuries, with 75% being facial lacerations. Specifically lacerations to the eye region account for 45.8% of all injuries. Facial Lacerations are the primary reason a ringside physician stops a fight. It is imperative that ringside physicians, referees, officials and corner men have a understanding regarding facial lacerations.

Figure 2: Scalp laceration, note excessive bleeding (photo by Sandy Hackenmueller)

Figure 2: Scalp laceration, note excessive bleeding (photo by Sandy Hackenmueller)

Before we discuss the evaluation of lacerations by a ringside physician it is it is important to understand some of the fundamental mechanism regarding this type of injury. A typical laceration that is caused by a sharp object (e.g. a knife or piece of glass) is an outside insult that extends into the deeper tissues from the skin. A punch to the face is a bursting type of injury. In other words the tissue is compressed against the bony ridges of the facial skeleton and the tissue is cut from the inside out. Therefore, the external cut as seen on the skin represents only the “tip of the iceberg”. The cut is actually larger in thedeeper tissues. Some regions of the facial skeleton have a rougher surface under the skin and they are more prone to lacerations. Examples include the eyebrow and cheek bone region immediately under the eye. This is known as the peri-orbital region (see figure 1).

Figure 4: Laceration resulting in impaired vision

Figure 4: Laceration resulting in impaired vision

The face and scalp are very vascular regions therefore small cuts can bleed quite profusely. The scalp in particular is composed of rigid connective tissue that does not allow blood vessels to collapse and bleeding can appear rather dramatic. It is important that the ringside physician and the referee do not panic when a cut appears to aggressively bleed. The good news is that the extensive vascular supply allows facial and scalp lacerations to heal quickly and makes them less prone to infection after they are properly repaired.

Ringside Evaluation of Facial lacerations

Figure 5: Location Location of Tarsal Plate and nasolacrimal duct. Lacerations in these areas may require stoppage of fight

Figure 5: Location Location of Tarsal Plate and nasolacrimal duct. Lacerations in these areas may require stoppage of fight

The ringside physician must decide when the laceration is too severe for the fight to continue. This can be a complicated decision that is based on medical knowledge and experience, however there are some fundamental considerations.

The first consideration is location of the laceration. If a laceration is in an area that impairs vision the fight needs to be stopped (fig 4). Inability to see renders a fighter more susceptible to brain injury. The ability to anticipate a blow to the head allows a boxer to better defend himself and thus is a primary factor in avoiding a concussion or other brain injury. Lacerations on the eyelid may damage an area known as the tarsal plate. Injury to the tarsal plate may result in a defective blinking mechanism which can cause longterm damage to a fighters vision. If the tarsal plate is injured or at an increased risk of being injured a fight must be stopped.

Figure 6

Figure 6

Also there are structures on the face primarily arteries and nerves which can be exposed by a laceration and if injured could cause significant or permanent damage. Lacerations to the corner of the eye may damage a structure known as the lacrimal duct and impair the tearing mechanism (figs 5,6,&7. Lacerations that involve the lip and progress onto the skin (this area is known as the vermillion border) may result in a significant tear and require stoppage (fig 8).

Lacerations over medical eye

Figure 7

The ringside physician must decide when the laceration is too severe for the fight to continue. This can be a complicated decision that is based on medical knowledge and experience, however there are some fundamental considerations.

The first consideration is location of the laceration. If a laceration is in an area that impairs vision the fight needs to be stopped (fig 4). Inability to see renders a fighter more susceptible to brain injury. The ability to anticipate a blow to the head allows a boxer to better defend himself and thus is a primary factor in avoiding a concussion or other brain injury. Lacerations on the eyelid may damage an area known as the tarsal plate. Injury to the tarsal plate may result in a defective blinking mechanism which can cause longterm damage to a fighters vision. If the tarsal plate is injured or at an increased risk of being injured a fight must be stopped.

Figure 8

Figure 8

Also there are structures on the face primarily arteries and nerves which can be exposed by a laceration and if injured could cause significant or permanent damage. Lacerations to the corner of the eye may damage a structure known as the lacrimal duct and impair the tearing mechanism (figs 5,6,&7. Lacerations that involve the lip and progress onto the skin (this area is known as the vermillion border) may result in a significant tear and require stoppage (fig 8).

Figure 9: Facial laceration demonstrating multiple reasons to stop the fight. Note length and depth, vision impairment, and exposure of underlying nerves and arteries. This injury also demonstrates that lacerations are larger in the deep tissues below the skin layer. The bleeding was controlled at this point point but at the time of injury bleeding was excessive and vision was impaired by the bleeding.

Figure 9:
Facial laceration demonstrating multiple reasons to stop the fight. Note length and depth, vision impairment, and exposure of underlying nerves and arteries. This injury also demonstrates that lacerations are larger in the deep tissues below the skin layer. The bleeding was controlled at this point point but at the time of injury bleeding was excessive and vision was impaired by the bleeding.

A second consideration is the length and depth of a laceration. Keep in mind that  lacerations in combative sports occur from the inside out. Therefore, the laceration is generally much larger than than the exposed cut on the surface of the skin. Deep  lacerations can involve muscle and other structures and are a more serious injury. Lastly excessive bleeding may warrant a medical stoppage (Figure 9).

Repair of Facial Lacerations

As stated before the facial region is very vascular and subsequently facial lacerations will heal quickly after repair. Remember that the lacerations occur from the inside out and are generally deeper on the inside i.e. the deeper tissues. The ringside physician therefore needs to repair the injuries from the inside out. Sutures (stitches) are placed in the deeper tissues to bring those structures closer together. This material will dissolve over time and does not need to be removed. After the deeper layers are closed sutures are placed in the skin. These sutures are generally removed in five days. Facial lacerations usually require a 45 day suspension. More severe cuts may require a longer suspension. At 45 days the tissue has reached about 75% of the strength of the original tissue. In approximately 6 months to 1 year the healed wound will be about 90% as strong as the original tissue. Even the best repaired cut is never as strong as the original tissue and therefore, is susceptible to repeat injury and a second laceration.

Figure 10: Repaired facial laceration from figure 9. Note that this wound required placement of several sutures in multiple tissue layers below the visible skin sutures.

Figure 10: Repaired facial laceration from figure 9. Note that this wound required placement of several sutures in multiple tissue layers below the visible skin sutures.

A final word about lacerations. Often when a fighter is cut and bleeding those in attendance will cry out “he has been cut”. Lacerations are very visible and get the crowds attention. However, after the fight the laceration will be repaired and heal with little long term consequence to the boxer. The ringside physician, referee, and other officials must be sensitive to the fact that repeated blows to the head pose the real long term health threat to the boxer. One needs to respect lacerations and if necessary stop the bout. However, it is brain injury that may cause irreparable damage to the athlete.

Author: Don Muzzi MD

Dr. Muzzi

Dr. Muzzi