1 Chapter 9 Injuries to the Head, Neck and Face 2 The skull The skull 8 cranial bones & 14 facial...

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Chapter 9Chapter 9Injuries to the Head, Neck and Injuries to the Head, Neck and

FaceFace

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The skullThe skull 8 cranial bones & 14 8 cranial bones & 14

facial bonesfacial bones parietals (2), parietals (2),

temporals (2), frontal, temporals (2), frontal, occipital, sphenoid & occipital, sphenoid & ethmoidethmoid

cranial bones, cranial bones, articulations of the articulations of the suture typesuture type

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Soft TissueSoft Tissue

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Anatomy ReviewAnatomy ReviewCentral Nervous System (CNS)Central Nervous System (CNS)

brain and spinal cord comprise the CNSbrain and spinal cord comprise the CNSCNS protected by meninges, cranium and CNS protected by meninges, cranium and

vertebraevertebraeCNS consists of gray and white matter and CNS consists of gray and white matter and

weighs 3.0 to 3.5 lbs.weighs 3.0 to 3.5 lbs.

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The NeckThe Neck Cervical spineCervical spine

7 vertebrae providing 7 vertebrae providing support for the head support for the head and protection for the and protection for the spinal cordspinal cord

C-1 (Atlas) C-1 (Atlas) articulates with the articulates with the occipital boneoccipital bone

C-2 (Axis) articulates C-2 (Axis) articulates with C-1 via atlanto-with C-1 via atlanto-axial jointsaxial joints

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Head Injuries in SportsHead Injuries in SportsMinor trauma can result in serious Minor trauma can result in serious

injury.injury.brain tissue is unable to repair itself -- any brain tissue is unable to repair itself -- any

damage is permanentdamage is permanentpossible mechanisms of injury are nearly possible mechanisms of injury are nearly

infiniteinfinitecoaches can learn to recognize head coaches can learn to recognize head

injuries and render aidinjuries and render aid

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Head Injuries in SportsHead Injuries in SportsFrom 1982-91, 1.5 million high school From 1982-91, 1.5 million high school

tackle football participants annually tackle football participants annually generated the greatest number of direct, generated the greatest number of direct, catastrophic injuries in fall sports.catastrophic injuries in fall sports.

1/5 high school players have sustained a 1/5 high school players have sustained a concussion annuallyconcussion annually

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Head Injuries in SportsHead Injuries in SportsCranial injuryCranial injury

involves the bones of the skullinvolves the bones of the skullmay be associated soft tissue injurymay be associated soft tissue injurydepressed skull fracturedepressed skull fracture

involves bone fragments being pushed into the involves bone fragments being pushed into the cranial regioncranial region

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Head Injuries in SportsHead Injuries in SportsCerebral concussionCerebral concussion

““clinical syndrome characterized by clinical syndrome characterized by immediate and transient impairment of immediate and transient impairment of neurologic function secondary to neurologic function secondary to mechanical forces”mechanical forces”

unconsciousness, disorientation, amnesia, unconsciousness, disorientation, amnesia, dizziness, disequilibrium dizziness, disequilibrium

related to temporary disruption of blood related to temporary disruption of blood supplysupply

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Head Injuries in SportsHead Injuries in SportsColorado Medical Society classificationColorado Medical Society classification

grade 1 - most common -- no amnesiagrade 1 - most common -- no amnesiagrade 2 - either posttraumatic or retrograde grade 2 - either posttraumatic or retrograde

amnesiaamnesiagrade 3 - unique due to loss of consciousnessgrade 3 - unique due to loss of consciousness

Second Impact Syndrome (SIS) – Second Impact Syndrome (SIS) – recently recognized as a potentially serious recently recognized as a potentially serious

problemproblema concussion followed by another such injury prior a concussion followed by another such injury prior

to the resolution of symptoms related to the first to the resolution of symptoms related to the first injuryinjury

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Head Injuries in SportsHead Injuries in Sports involves rapid, involves rapid,

catastrophic catastrophic swelling of the swelling of the brain -- putting brain -- putting pressure on the pressure on the brain stem, often brain stem, often resulting in deathresulting in death

Shaded areas of the brain stem represent areas of compression.

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Head Injuries in Sports Head Injuries in Sports (continued)(continued)

Any athlete Any athlete sustaining a head sustaining a head injury, no matter injury, no matter how minor, should how minor, should be assessed prior be assessed prior to returning to to returning to competition.competition.

Intracranial injuryIntracranial injury potentially life potentially life

threateningthreatening majority result from majority result from

blunt traumablunt trauma disruption of blood disruption of blood

vessels results in intra-vessels results in intra-cranial bleeding and cranial bleeding and hematomahematoma

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Head Injuries in Sports Head Injuries in Sports (continued)(continued)

major forms of intracranial bleeding include:major forms of intracranial bleeding include: epidural hematomaepidural hematoma subdural hematomasubdural hematoma intracerebral hematomaintracerebral hematoma cerebral contusioncerebral contusion

epidural hematoma develops quickly due to epidural hematoma develops quickly due to arterial bleeding while subdural hematoma arterial bleeding while subdural hematoma develops slowly due to venous bleeding.develops slowly due to venous bleeding.

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Initial Treatment Initial Treatment GuidelinesGuidelines

Primary surveyPrimary surveyalways assume a always assume a

neck injuryneck injurycheck vitals firstcheck vitals firstnote body and note body and

limb position, limb position, helmet, face helmet, face mask, and mouth mask, and mouth guardguard

Stabilizing the athlete’s head and neck

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if unconscious, attempt to arouseif unconscious, attempt to arouse note approx. time on injurynote approx. time on injury immobilize head and neck immediately, not immobilize head and neck immediately, not

removing athlete’s helmet.removing athlete’s helmet. detect breathing by listening near the airway and detect breathing by listening near the airway and

looking for movements of the abdomen and/or looking for movements of the abdomen and/or thoraxthorax

check carotid pulse with two fingerscheck carotid pulse with two fingers monitor pulse for 30 seconds; if none, alert EMSmonitor pulse for 30 seconds; if none, alert EMS

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Secondary surveySecondary survey conscious athlete less complicated than unconscious conscious athlete less complicated than unconscious

conscious or unconscious?conscious or unconscious? extremity strengthextremity strength mental functionmental function eye signseye signs pain specific to the neckpain specific to the neck spasm of the neck musculaturespasm of the neck musculature

determining level of consciousness is not always easydetermining level of consciousness is not always easy if conscious, ask a few simple questionsif conscious, ask a few simple questions loss of short term memory can indicate more serious loss of short term memory can indicate more serious

injuryinjury

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Don’t arouse someone with ammonia Don’t arouse someone with ammonia capsules.capsules.

if conscious, use quick neurological tests, if conscious, use quick neurological tests, such as grip strength and skin sensationsuch as grip strength and skin sensation

examine the eyes, noting pupil size, examine the eyes, noting pupil size, responsiveness to light and side-to-side responsiveness to light and side-to-side movementmovement

palpate the neck for deformitypalpate the neck for deformity

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Emergency Emergency procedures for procedures for footballfootballequipment creates equipment creates

special problemsspecial problemshelmet, face helmet, face

mask, chin strap mask, chin strap and mouth guardand mouth guard

Trainer’s Angel

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management of the management of the helmeted player is helmeted player is a major issuea major issue

if airway must be if airway must be established, established, removal of the face removal of the face mask is necessarymask is necessary

cut the clips with cut the clips with a device like the a device like the “Trainer’s Angel”“Trainer’s Angel”

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Plastic clips secure the face mask.

If a Trainer’s Angel is not available, removal of screws that hold the clips is an option.

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Once the clips are Once the clips are removed the face removed the face mask can be rolled mask can be rolled up, out of the way up, out of the way of the airwayof the airway

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In the event of a neck injury, the helmet provides an excellent meansof cervical immobilization.

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General GuidelinesGeneral GuidelinesDon’t move the athlete until the secondary Don’t move the athlete until the secondary

survey is complete.survey is complete. if the athlete is recovered, escort to the if the athlete is recovered, escort to the

bench for observationbench for observationany suspicious signs/symptom -immobilize any suspicious signs/symptom -immobilize

and summon EMSand summon EMS in most cases, there is NO reason to move in most cases, there is NO reason to move

the athlete prior to arrival of EMSthe athlete prior to arrival of EMS

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level of consciousness - single most important level of consciousness - single most important factorfactor

in the majority of incidents, the athlete never in the majority of incidents, the athlete never loses consciousnessloses consciousness

athlete with a head injury usually appears athlete with a head injury usually appears dazed and unstabledazed and unstable

may also have tinnitus and memory lossmay also have tinnitus and memory loss if there any doubts about severity, refer to a if there any doubts about severity, refer to a

physician immediatelyphysician immediately

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Finger-to-Nose Test Romberg’s Test

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CMS guidelines -- CMS guidelines -- pull any athlete pull any athlete with a grade I with a grade I concussion for a concussion for a minimum of 20 minimum of 20 minutes for minutes for observationobservation

Anyone Anyone sustaining a sustaining a Grade II or III Grade II or III concussion concussion should be should be referred to a referred to a physician physician immediately.immediately.

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Cervical InjuriesCervical Injuries Neck injuriesNeck injuries

majority occur in football, rugby, ice hockey, soccer, majority occur in football, rugby, ice hockey, soccer, diving and gymnastics, however cervical injuries can diving and gymnastics, however cervical injuries can occur in almost any sportoccur in almost any sport

catastrophic injuries are rare -- 2/100,000 of all neck catastrophic injuries are rare -- 2/100,000 of all neck injuries, since 1977 less than 10 players/year suffer injuries, since 1977 less than 10 players/year suffer permanent cord injuriespermanent cord injuries

mechanisms include: hyperflexion, hyperextension, mechanisms include: hyperflexion, hyperextension, rotation, lateral flexion, and axial loadingrotation, lateral flexion, and axial loading

axial loading places the neck in a slightly flexed axial loading places the neck in a slightly flexed positionposition

1976 NCAA enacted the rule barring “spearing” 1976 NCAA enacted the rule barring “spearing” however recent research indicates that the rule may however recent research indicates that the rule may not be effective.not be effective.

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Axial Loading Flexion with Axial Loading Extension

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Background Information Background Information (continued)(continued)

Spearing incidence Spearing incidence has not changed has not changed much from 1975.much from 1975.

cervical injuries cervical injuries include sprains, include sprains, strains, strains, intervertebral disks intervertebral disks and brachial plexusand brachial plexus

strains generally strains generally more painful than more painful than seriousserious

severe injuries severe injuries involve fractures involve fractures that are displacedthat are displaced

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Cervical InjuriesCervical Injuries

spinal cord may sustain secondary injury due to spinal cord may sustain secondary injury due to disruption of blood supplydisruption of blood supply

neck strains rarely involve nerve damageneck strains rarely involve nerve damage brachial plexus injuries can produce significant, brachial plexus injuries can produce significant,

but transient, symptomsbut transient, symptoms critical that coaching personnel take great care critical that coaching personnel take great care

when conducting a primary and secondary survey when conducting a primary and secondary survey of an athlete suspected of having a neck injuryof an athlete suspected of having a neck injury

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Initial Treatment of Neck Initial Treatment of Neck Injury GuidelinesInjury Guidelines

Determine if the Determine if the athlete is athlete is conscious, if conscious, if unconscious, the unconscious, the first priority is basic first priority is basic life support.life support.

Emergency plan Emergency plan should designate a should designate a “team leader.”“team leader.”

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Initial Treatment of Injury Initial Treatment of Injury GuidelinesGuidelines

If conscious, If conscious, question the question the athlete regarding athlete regarding numbness, numbness, weakness, weakness, dysesthesia.dysesthesia.

Appearance of Appearance of such symptoms -- such symptoms -- immediately immediately stabilize head and stabilize head and neck and summon neck and summon EMS.EMS.

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Spine Boarding an AthleteSpine Boarding an Athlete

1 2

3 4

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Injuries to the Injuries to the Maxillofacial RegionMaxillofacial Region

Jaw, teeth, eyes, ears, nose, throat, facial Jaw, teeth, eyes, ears, nose, throat, facial bones and skinbones and skin NEISS recorded 170,000 sports related injuries NEISS recorded 170,000 sports related injuries

within the U.S. to these body areas.within the U.S. to these body areas. Protective equipment has been developed and Protective equipment has been developed and

improved for many of these areas:improved for many of these areas: mouth guardsmouth guards protective eye wearprotective eye wear face shieldsface shields

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Maxillofacial RegionMaxillofacial Region Dental injuriesDental injuries

jaw has 32 teethjaw has 32 teeth teeth are vulnerable to teeth are vulnerable to

external blows external blows common in many common in many sportssports

teeth are secured by teeth are secured by cementum and cementum and periosteumperiosteum

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Maxillofacial RegionMaxillofacial Regionmajority of dental injuries result from direct majority of dental injuries result from direct

blows that loosen or knock teeth outblows that loosen or knock teeth outWhen rendering first aid, take precautions to When rendering first aid, take precautions to

avoid bloodborne pathogens.avoid bloodborne pathogens.Examining dental injuriesExamining dental injuries

open/close mouth without pain?open/close mouth without pain?general symmetry of the teeth?general symmetry of the teeth?irregularities in adjacent teeth?irregularities in adjacent teeth?bleeding, especially along gum line?bleeding, especially along gum line?

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Injuries to the Maxillofacial Injuries to the Maxillofacial RegionRegion

Loosened or knocked outLoosened or knocked outgently push back into placegently push back into placeif knocked out, clean with saline and put back into if knocked out, clean with saline and put back into

placeplace

High risk sports -- use mouth guardHigh risk sports -- use mouth guardrequired in high school since 1966, NCAA in 1974required in high school since 1966, NCAA in 1974stock, mouth-formed and custom fittedstock, mouth-formed and custom fitted

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Eye InjuriesEye Injuries

Eye injuriesEye injuries– eye consists of a eye consists of a

round ball-like round ball-like structure housed structure housed within the orbitwithin the orbit

– globe is filled with globe is filled with vitreous bodyvitreous body

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– posterior/inferior eye posterior/inferior eye is covered by the is covered by the retinaretina

– eyeball is encased eyeball is encased in the sclerain the sclera

– eye injuries in the eye injuries in the U.S. are on the U.S. are on the increase (basketball increase (basketball and cycling).and cycling). Proper position of the fingers for an

initial examination of the eye

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Eye InjuriesEye Injuries– two categories -- contusional and two categories -- contusional and

penetratingpenetratingcontusional injuries vary in severity -- contusional injuries vary in severity --

simple abrasions to rupture of the eyesimple abrasions to rupture of the eyedetached retinadetached retinapenetrating injuries are less common -- penetrating injuries are less common --

shooting sports.shooting sports.

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Eye InjuriesEye Injuries Initial evaluation guidelinesInitial evaluation guidelines

majority are simple corneal abrasions or small majority are simple corneal abrasions or small foreign objectsforeign objects

hold upper eyelid away from anterior eyehold upper eyelid away from anterior eyesmall foreign bodies usually found by small foreign bodies usually found by

observationobservationvisible foreign object can be removed with a visible foreign object can be removed with a

moist cue-tip, if imbedded, cover both eyes moist cue-tip, if imbedded, cover both eyes and transport to medical facilityand transport to medical facility

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if nothing can be seen in the eye, probably a if nothing can be seen in the eye, probably a corneal abrasioncorneal abrasion

contusions may result in hemorrhage around contusions may result in hemorrhage around the eye known as a “black eye”the eye known as a “black eye”

more severe cases may involve bleeding into more severe cases may involve bleeding into the anterior eye known as “hyphema” -- the anterior eye known as “hyphema” -- refer refer to medical facility immediatelyto medical facility immediatelysymptoms: pain, visual deficit (diplopia) and symptoms: pain, visual deficit (diplopia) and

obvious bleeding into the eyeobvious bleeding into the eye

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retinal injuries develop slowly -- early retinal injuries develop slowly -- early symptoms include:symptoms include:floating particles in field of visionfloating particles in field of visiondistorted visiondistorted visionchanges in the amount of light seenchanges in the amount of light seen

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Eye InjuriesEye Injuries Contact lens problemsContact lens problems

many athletes wear contacts with few problems; many athletes wear contacts with few problems; however, data show more problems related to hard however, data show more problems related to hard lenseslenses

biggest problem -- lens slipping or debris getting biggest problem -- lens slipping or debris getting trapped between the lens and the eyetrapped between the lens and the eye

coach should have first aid kit to treat common coach should have first aid kit to treat common problems including: wetting solution, small mirror, problems including: wetting solution, small mirror, contact lens casecontact lens case

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Nose InjuriesNose Injuries Nose injuriesNose injuries

often injured due to location -- often injured due to location -- bloody nose (epistaxis) may bloody nose (epistaxis) may be the most common facial be the most common facial injury in sportsinjury in sports

Anatomically, the nose Anatomically, the nose consists of mostly cartilage consists of mostly cartilage and skin along with the R & L and skin along with the R & L nasal bones.nasal bones.

Evaluation & treatment Evaluation & treatment guidelinesguidelines any blow to the nose can any blow to the nose can

cause a fracturecause a fracture deformity and swelling at the deformity and swelling at the

bridge of the nosebridge of the nose If a fracture is suspected, treat If a fracture is suspected, treat

the bleeding and refer to a the bleeding and refer to a medical doctor.medical doctor.

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Ear InjuriesEar Injuries

Ear injuriesEar injuries anatomically, the ear is similar to the noseanatomically, the ear is similar to the nose external opening and extensive internal structureexternal opening and extensive internal structure

external ear (auricula)external ear (auricula) external acoustic meatusexternal acoustic meatus middle earmiddle ear inner ear (labyrinth)inner ear (labyrinth)

inner ear has a role in equilibriuminner ear has a role in equilibrium

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Anatomy of the EarSemicircular Canals Vestibular

nerve Auditorynerve

Stapes

Malleus

Incus

Cochlearnerve

Cochlea OvalWindowRoundWindow

Eustachiantube

Tympanicmembrane

External auditorymeatus (canal)

Pinna

Temporalbone

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Ear InjuriesEar Injuries

majority of ear problems are related to majority of ear problems are related to the external earthe external ear

sports such as wrestling are related to sports such as wrestling are related to numerous ear problems because of numerous ear problems because of contact with opponents and/or playing contact with opponents and/or playing surface, required head gear has surface, required head gear has reduced incidence of such injuriesreduced incidence of such injuries

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Ear InjuriesEar Injuries Cauliflower ear Cauliflower ear

should be treated should be treated with cold pack and with cold pack and immediately referred immediately referred to a medical doctor.to a medical doctor.

severe blows to the severe blows to the outer ear can result outer ear can result in a ruptured ear in a ruptured ear drumdrum

inner ear infections inner ear infections can result in can result in problems in high risk problems in high risk sportssports

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Fractures of the Fractures of the facefacecertain sites are certain sites are

more common:more common:lower jawlower jaw

signs/symptoms signs/symptoms include:include:pain/swellingpain/swellingdeformity & deformity &

malocclusionmalocclusion

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Face InjuriesFace Injuries– Signs/symptoms include:Signs/symptoms include:

• extreme pain/deformity in the region of the extreme pain/deformity in the region of the TMJTMJ

• inability to move lower jawinability to move lower jaw• jaw is “locked”jaw is “locked”

– Do NOT attempt to put back into place.Do NOT attempt to put back into place.– treatment includes: application of ice pack treatment includes: application of ice pack

and medical referral.and medical referral.– zygomatic bone may be fracturedzygomatic bone may be fractured

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– signs/symptoms include:signs/symptoms include:• pain and swelling pain and swelling • discoloration that spreads to the region of the discoloration that spreads to the region of the

orbitorbit

– treatment includes: application of ice pack treatment includes: application of ice pack and medical referraland medical referral

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Face InjuriesFace InjuriesWounds of the facial regionWounds of the facial region

wounds can take many forms and treatment wounds can take many forms and treatment should follow basic first aid protocolshould follow basic first aid protocol

carefully clean with mild soap and apply carefully clean with mild soap and apply sterile dressingsterile dressing

such wounds can present cosmetic problemssuch wounds can present cosmetic problems In general, any wound with observable space In general, any wound with observable space

between margins may require suturing.between margins may require suturing.after suturing, return to play decisions are after suturing, return to play decisions are

made by the doctormade by the doctor

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