Chapter 9

Injuries to the Head, Neck, and Face

Anatomy Review

Skull• The skull has *

cranial bones &

* facial bones.• Cranial bones

have articulations

called suture joints.

Anatomy Review (cont.)

• Soft tissue structures protect the cranium and the

brain.• * soft-tissue

layers of protection for the brain

Meninges

The Meninges

• Soft tissue structures that protect the brain as well.

• Located between the underside of the cranium and the surface of the brain, consisting the dura mater, arachnoid,

and pia mater.

Meninges (cont.)

• The outermost layer is called *. It is dense, highly vascularized and consists of tough fibrous connective tissue.

• * (middle layer) is less dense and avascular (no blood supply).

• Sub-arachnoid space contains cerebrospinal fluid (CSF).

CSF cushions the brain and spinal cord from external forces.

• *(innermost layer) is thin, delicate, highly vascularized, and is physically attached to the brain.

Central Nervous System

Central Nervous System (CNS)• Brain (encephalon) and spinal cord compose

the CNS.• CNS is protected by *, cranium, and *.• CNS consists of gray and white matter and

weighs 3 to 3.5 lbs (adult).

3 Basic Parts of the Brain

• * – the largest of the three and is involved in complex functions such as cognition, reasoning, and intellectual reasoning

• * – located in the lower posterior portion of the cranial area and performs functions related to complex motor skills,

• *– located at the base of the brain and serves to connect the brain to the spinal cord.

Peripheral Nervous System

• *of cranial nerves that are directly attached to the base of the brain and exit the CNS through openings at the base of the skull

• * of spinal nerves are attached to either side of the spinal cord and exit the CNS a precise intervals through openings in the spinal column (12 thoracic, 5 lumbar, 5 sacral, and 1 coccygeal)

The Face

• The face is composed of * over underlying bones.

- Subcutaneous muscles, cartilage, and fat provide minor protection.

• Several areas of the face are prone to injury, particularly orbits of the eyes, nasal bones, and mandible.

The Neck

The Neck (cervical spine)• The * provide

support for the head and protection for the spinal cord.

The Neck (cont.)

• The first cervical vertebra (C-1) is called the *.• The atlas articulates with the occipital

bone to form R and L atlanto-occipital joints.

• The second cervical vertebra (C-2) is called the *.

• The skull and C-1 articulate as a unit with C-2 to form the atlantoaxial joint.

Head Injuries in Sports

Even minor head trauma can result in serious injury.

• Brain tissue is *.• Any tissue loss results in some level of

permanent disability.• Severe injuries can *. • Coaches can learn to recognize head injuries

and render first aid when necessary.

Mechanisms of Head Injury

• Direct mechanism of injury involves a blow to the head that causes injury at impact site (*) or on the opposite side of the skull from impact (*).

• Indirect injury to the head results from damaging forces traveling from other parts of the body.

• Players sustaining a concussion are 3x more likely to sustain an additional concussion when compared to their nonconcussed teammates.

Treat every head injury as if there is a neck injury and vice versa.

Concussions

A concussion is “a clinical syndrome characterized by immediate and transient impairment of neurologic function secondary to mechanical forces.”• Symptoms include unconsciousness,

disorientation, headache, amnesia (anterograde or retrograde), dizziness, and disequilibrium.

Concussions (cont.)

Cantu classification

• Grade 1 (mild) involves no amnesia but are difficult to identify.

• Grade 2 (moderate) involves loss of consciousness for less than 1 minute and/or PTA lasting longer than 30 minutes.

• Grade 3 (severe) involves loss of consciousness for more than a minute and PTA lasting more than 24 hours.

Second Impact Syndrome

Second Impact Syndrome (SIS) can be a serious problem.

• Results when an athlete with a head injury receives another head injury before the symptoms of the initial injury have resolved.

• Involves rapid, catastrophic brain swelling.• SIS can result in death.

Any athlete sustaining a head injury, no matter how minor, should be referred to a physician before being cleared to return to participation.

Head Injuries in Sports

Cranial injury:

• Involves the bones of the skull (*).• Sometimes the force is so great that there may

also be an associated soft tissue injury.• More severe forms of cranial injury involve *

- Involves bone fragments being pushed into the cranial region.

Head Injuries in Sports (cont.)

Intracranial Injury:• These injuries are potentially life threatening.• Majority result from *.• The injury is characterized by disruption of blood

vessels resulting in the development of a hematoma or swelling in the confines of the cranium.

• The brain tissue is in extreme jeopardy because they are very sensitive to *.

Intracranial Injuries

Major forms of intracranial injury include:1. * (bleeding between the dura and the cranial bones).

• Signs and symptoms of injury will develop rather quickly

2. * (bleeding below the dura mater).• Signs and symptoms may be present within minutes

(arterial bleeding) or hours/days (venous)3. * (bleeding within the brain tissues).4. * (bruising of the brain tissue).

Any of these conditions can result in some degree of permanent neurologic damage and even death.

Initial CheckAlways assume a neck

injury has also occurred.• *• Note body and limb

positions, as well as helmet, face mask, and mouth guard positions.

• If unconscious, attempt to arouse and note approx. time of injury.

Immobilize head and neck immediately; do not remove athlete’s helmet.

Initial Check (cont.)

If unconscious, detect breathing by:• Listening near the athlete’s

face for *• Looking for movements of the

thorax and/or abdomen.

If no signs of circulation are present, begin *.

Physical Examination

The physical exam must include assessments of:C - * or unconsciousness.E - *(if conscious) without moving the neck.M - *(if conscious).E - * signs and movements.P - * specific to the neck.S - * of neck musculature.

Physical Exam (cont.)

If head injury is suspected:

• Do NOT remove *.

• Do NOT move the athlete.

• Do NOT use ammonia capsules to revive athlete.

• Do NOT rush through *.

Physical Exam (cont.)If athlete is conscious: • Perform *.• Check bilateral strength by asking athlete to dorsiflex feet.• Check for sensations on both sides of body by pinch tests.• Monitor athlete’s eyes by checking *, and eyes’ ability to

follow moving object side to side.• Note loss of peripheral vision or jerking eyeball

movements.• Palpate neck for *, moving from base of skull to bottom of

neck.

Physical Exam (cont.)

• If the athlete passes the above tests, they can be moved to the sideline

• With an athlete that was originally in the laying down position, have them sit up first to collect themselves, then move to the standing position

• Always * on the athlete as you are helping them to the sideline

• Once on the sideline, *

Quick Neurological Tests

Finger-to-Nose Test Romberg’s Test

Courtesy of Ron Pfeiffer

Cervical Spine Injuries

• Cervical injuries can occur in almost any sport.

• Majority occur in *, rugby, ice hockey, *, diving, and gymnastics.

• Catastrophic injuries are rare – less than 2 in 100,000 of all neck injuries reported in the United States.

Cervical Spine Injuries (cont.)

• Mechanisms of injury include:• Hyperflexion• *• Rotation• Lateral flexion• *

• Serious injuries occur when intact vertebra or fragments of fractured vertebra are displaced or an intervertebral disk ruptures and places pressure on spinal cord or nerve roots.

Mechanism of Cervical Spine Injuries

• Any forced movement of cervical spine can result in injury.

• Most cervical spine injuries result from an *.

• Spearing in football produces axial load (NCAA prohibited technique in 1976).

• In 2005, there was an increased emphasis on proper technique to eliminate spearing and minimize neck injuries.

Brachial Plexus Injury

• Known commonly has *

• Occurs when the athlete’s body may be forced in one direction while the arm is pulled in the opposite direction

• Involves abnormal traction or compression of one or more of the large nerves that comprise the entire plexus

• Signs/Symptoms: pain radiating down the affected arm, *, or arm hanging by their side

• Treatment: Symptoms should resolve within *, hold from play until strength is normal compared to the opposite side

Cervical Spine Sprains

• Sprains of the major ligaments that serve to stabilize the vertebrae in the neck

• MOI: hyperflexion, hyperextension, *, rotation• Injuries are usually self correcting and resolve

themselves within a few days• Signs/Symptoms: localized pain in the C-spine region,

point tenderness over the site of injury, *, no obvious neurologic defects

• Treatment: remove athlete from play, ice, ROM as pain allows, return to play when symptom free

Cervical Spine Strains

• Strains to the muscles and tendons in the C-spine region

• Typically are more *• MOI is the same as cervical spine sprains• Signs/Symptoms: localized pain in the C-spine region,

point tenderness over the site of injury, limited ROM, no obvious neurologic defects

• Treatment: remove athlete from play, ice, ROM as pain allows, *

Cervical Spine Fractures and Dislocations

• The most extreme form of cervical injury because of the pressure that can be applied on the spinal cord from the fractures

• Spinal cord may also suffer secondary damage as a result of circulatory problems

• Signs/Symptoms: • athlete reports hearing or feeling

something pop in their neck• severe pain in the area associated with

muscle spasm• *• deformity in the vertebrae• numbness in extremities or trunk• *• loss of sensation• *

Cervical Spine Fractures and Dislocations

• Complete initial check and ascertain status of vitals• Stabilize *• Leave the helmet on!• Summon EMS• Do not move the athlete until EMS gets there or vitals

decrease (*)

Initial Treatment of Neck Injury

• Medical care team leader supervises the process.

• Determine if the athlete is conscious. If unconscious, *, breathing, and pulse (circulation).

• Stabilize the head and neck.• *.• Continue monitoring “*”

Initial Treatment of Injury Guidelines

• If *, question the athlete regarding extremity numbness or loss of feeling, *, and/or neck pain.

• If athlete reports the inability to move a limb or limbs or significant strength loss, stabilize head and neck and summon EMS.

Initial Treatment of Neck Injury (continued)

If EMS arrival is delayed, place the injured athlete on a properly constructed spine board.

This requires the coordinated effort of at least *.

Spine Boarding an Athlete

1 2

Spine Boarding an Athlete

3 4

Football Face Mask Removal

• If airway must be established, removal of the face mask is *.• Cut the clips with a device like the “*.”• Once the clips are removed, the face mask

can be rolled up, and out of the way of the airway.

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

Injuries to the Maxillofacial Region

• Maxillofacial injuries include those to the *, teeth, *, ears, nose, *, facial bones, and skin.

• Modern protective equipment has reduced significantly the incidence of these injuries. Such equipment includes:

• Mouth guards.• Protective eye wear.• *.

Dental Injuries

• The human jaw has * teeth.

• Teeth are vulnerable to external blows that are common in many sports.

• Teeth are secured by * and periosteum.

Dental Injuries (cont.)

• Majority of dental injuries result from direct blows that result in tooth displacement or *, a tooth fracture, or * or other facial bones.

• When rendering first aid, take precautions to avoid *.

• When examining dental injuries:• Can athlete open and close mouth w/o pain?• What is the general symmetry of the teeth?• Are there any irregularities in adjacent teeth?• Is there bleeding, especially along *?

Dental Injuries (signs/symptoms)

• *: tooth is pushed either forward or backward, bleeding along the gum line

• *: obvious defects, chipped tooth, fractures can occur above or below the gum line (more painful)

• *: fractures will result in loosening of the adjacent teeth, bleeding gums, numbness, inability to open or close the mouth

• *: missing tooth with bleeding from the exposed socket, poor prognosis if more than 2 hours elapses

Dental Injuries (cont.)

Loosened tooth:• *.• If tooth is avulsed, place in sterile saline and refer

athlete to dentist or physician immediately.High-risk sports should require use of *.• Required for high school football players since

1966; NCAA followed suit in 1974.

Mouth Guards

• Three types of mouth guards are *, mouth-formed, and *.

Eye Injuries

• Eye consists of a ball-like structure housed within the orbit.

• Globe is filled with *.

• Cornea – pupil – lens

• The posterior surface of the eye is covered by the * which contains specialized cells called rods and cones

• Most of the eyeball is encased in the *.

Eye Injuries (cont.)Approximately 40,000 sports-

related eye injuries occur annually in the United States.

Majority of eye injuries are *.

Eye injuries in the U.S. are on the increase; basketball, baseball, and softball are leading sports for eye injuries. Racket sports are also responsible for eye injuries.

Proper position of the fingers for an initial examination of the eye

2 Categories of Eye Injuries

* Injuries

• The result of a blow from a blunt object (tennis ball, baseball)

• Vary in severity • Simple corneal * • Rupture of the eye• *• Detached retina can also

occur.

* Injuries

• Less common than contusional injuries

• Can occur in *• Can be the result of defective

eye equipment

Eye Injuries (cont.)Initial Check and Treatment

Guidelines

• Majority of injuries are simple * or small foreign object in eye.

• Hold upper eyelid away from anterior eye.

• Small foreign bodies usually found * or in the medial canthus.

• Visible foreign object can be removed with a moist cotton swab; if imbedded, cover both eyes and transport to medical facility.

Eye Injuries (cont.)• If nothing can be seen in the eye,

injury is probably a corneal abrasion.• Contusions may result in hemorrhage

around the eye known as a “*.”• More severe cases may involve

bleeding into the anterior eye (“hyphema”) and orbital blowout. Refer to medical facility immediately.• Symptoms of * include eye pain,

double vision (diplopia), and obvious bleeding within the eye.

Eye Injuries (cont.)Symptoms of retinal injuries

develop slowly. Early symptoms include:

• Floating particles in field of vision.

• *.• Changes in the amount of

light seen.

Any athlete with a history of blunt trauma to the eye who later complains of these symptoms should be *.

Nose Injuries• The nose is often injured because

of *• The nosebleed (epistaxis) may be

the most * facial injury in sports.• Anatomically, the nose is a bone-

cartilage framework with skin attached. The nose includes R & L nasal bones and the frontal processes of the maxilla.

• Inside the nose, the two nostrils are separated by the cartilaginous *.

Nose Injuries (cont.)

Evaluation & Treatment Guidelines• Any blow to the nose can cause a *.

Signs of fracture are a nosebleed, *, and swelling at the bridge of the nose.

• If a fracture is suspected, control the nosebleed and refer to a medical doctor.

Ear Injuries (Anatomy)

• Ear has a cartilaginous framework covered with a layer of skin.

• The external ear has large expanded portion (auricula) and opening to ear canal (external acoustic meatus).

• The middle ear contains small group of bones that transmit sound vibrations to tympanic membrane (*).

• Inner ear contains the labyrinth, which has a role in equilibrium.

Injuries to the Ear (cont.)

• Majority of ear problems are related to the *.• Some athletes, such as wrestlers, develop ear

problems because of contact with opponents and/or playing surface.

• Such contact can result in abrasions and contusions to auricle.

• Required head gear has reduced incidence of such injuries.

• Auricle has some vascularity and can develop a hematoma leading to *.

Injuries to the Ear (cont.)

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

• Severe blows to the outer ear can result in a *.• Ruptured eardrum results in significant *, a loss of

equilibrium, *, or even bleeding from the ear• Athletes with ear infections should not participate in

aquatic sports until *.

Fractures of the Face

• In collision sports, a * is a common injury.

• Signs and symptoms include:

• Pain and swelling.• Deformity and * of

the maxillary and mandibular teeth.

Jaw Dislocation

Signs and symptoms include:

• Extreme pain and deformity in the region of the temporomandibular joint (TMJ).

• The TMJ is held together by numerous * and joint capsules

• Inability to move lower jaw.

• Jaw is “locked.”

– Do NOT attempt to put back into place.

– Treatment includes application of ice pack and *.

Zygomatic bone fracture

Signs and symptoms:

• Pain and swelling at site of injury.

• Swelling and discoloration spreads to the region of the orbit.

Refer athlete to a physician for diagnosis and treatment.

Wounds of the Facial Region

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

• Carefully clean with mild soap and warm water; apply sterile dressing.

• Any facial wound, even abrasion, can present *.• Refer to a physician. • In general, any wound with observable space between

margins should be *.• After suturing, the return-to-play decision is made by the

physician.