Injuries to the Head, Neck, and Face
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Transcript of Injuries to the Head, Neck, and Face
Injuries to the Head, Neck, and Face
18 year old high school football player Walked towards the sideline, athlete took off helmet
and appeared confused Fell to his knees and began to vomit Oriented to time, person and place Immediate c/o severe head pain, nausea and vertigo -neck pn or any lower or upper extremity
paresthesias Recalled being hit on 2 separate occasions during
the game ◦ Did not notify the coaching staff or ATC
Case Study…
Paramedics were summoned on field for transfer ◦ Due to 2 unreported episodes of head trauma and
S&S associated with a concussion While being prepared for transfer, level of
consciousness decreased, less responsive Neck was stabilized
◦ No cervical tenderness◦ Appeared to have a mild seizure◦ Temporarily unresponsive to stimuli◦ Attempts to incubate him were unsuccessful
Case Study…
On arrival at the ER◦ Orientated to time, person and
place◦ c/o severe HA, nausea and
retching◦ - back or neck pain◦ Neuologic exam revealed a
glasgow coma scare score of 15◦ Pupils were equal, round and
reactive to light◦ - nystagmus, or discoloration◦ Reflexes and sensations were
normal◦ CT scan suggested a left frontal-
temporal acute subdural hematoma 1.2 cm, with an equivalent left to
right shift
Case Study…
Case Study…
Admitted to surgical intensive care unit◦ For monitoring of neurologic status and additional CT
scan Additional CT scans did not indicate the need for
surgical intervention 24 hours later, CT scan revealed a significantly
smaller amount of blood than on the previous examination
Released under parents care c/o HA and inability to recall specific events
◦ No participation in sports or school until cleared my a physician
Case Study
SO???? The patient had a subdural hematoma◦ One week later the subdural hematoma resolved◦ Not to participate in football for remainder of the season◦ Medication was given for the seizures
Twelve days later, pt c/o continued headaches and nocturnal neck pn◦ Tenderness that measured 1 to 2 cm in diameter
beneath the left occipital protuberance◦ Increased pain when the patient turned his head to the
right◦ No x-rays or taken, = cervical ligament strain from the
previous injury
Case Study…
One month later pt doing well and increase daily activities
No contact sports for at least 1 year Findings
◦ Individual with a subdural hematoma typically presents with LOC
◦ Need immediate attention and transport for a CT scan
Case study…
Divided into 2 parts:◦ Simple subdural hematoma
w/o cerebral contusion or edema Mortality rate for is approximately 20%
◦ Brain contusion with swelling or bleeding Mortality rate is 50%
In closing, this case reveals how 2 unreported episodes of head trauma can be associated with an acute subdural hematoma
Case Study…
Injuries to the head, neck, and face present some of the most perplexing
problems associated with sports injury.
Consists of 8 cranial bones and 14 facial bones
Brain (encephalon) is housed in the cranium◦ Afforded considerable
protection via an ingenious system of bony and soft-tissue structures
Anatomy: Skull
Anatomy: Skull Bones of the cranium
◦ Are held together by specialized articulation known as suture joints
◦ Do not complete their ossification process until human beings are between 20 and 30 years old (Gray, 1985)
Soft-tissue structure serve as protective function include the five layers of tissues◦ Skin – layer of dense connective tissue◦ Galea aponeurotica –broad, flat tendon◦ Loose connective tissue◦ Periosteum of the cranial bone
Anatomy: Skull
Below the cranial bones a group of soft tissue is found called the cerebral meninges
3 distinct layers of tissue between the underside of the cranium and the surface of the brain◦ Dura mater
Outermost Tough fibrous connective tissue that function as a
periosteum to inside surfaces of cranial bones Protective membrane Highly vascular, has both arteries and veins transport
blood to and from the cranial bones
Anatomy: Meninges
◦ Arachnoid Middle layer Less strength and contains no blood supply
◦ Pia Mater Inner most layer Physically attached to the brain tissue and serves to provide a
framework for an extensive vasculature that supplies the brain Very thin, delicate membrane More susceptible to trauma than the dura mater
Subarachnoid space◦ Containing cerebrospinal fluid (CSF)◦ Cushion the brain and spinal cord from external forces
Like collision and contact sports
Anatomy: Meninges
Anatomy: Meninges
The brain (cencephalon) along with the spinal cord compose the central nervous system (CNS)
Brain and spinal cord are protected by the meninges and bony structure of the cranium and vertebrae
Consists of gray and white matter that represent two distinct types of neural tissues
Weights 3 to 3.5 lbs contains 100 billion neurons
Anatomy: Central Nervous System
3 basic parts◦ Cerebrum
Largest of the three Involved in complex
functions like cognition, reasoning, and intellectual functioning
◦ Cerebellum Lower posterior portion Performs functions related
to complex motor skills◦ Brain stem
Base of the brain Connects the brain to the
spinal cord
Anatomy: Central Nervous System
Composed of an outer layer of skin
Facial bones◦ Maxilla (upper jaw)◦ Right and left palatine◦ Right and left
zygomatic ◦ Right and left inferior
nasal concha◦ Vomer◦ Mandible (lower jaw)◦ hyoid
Anatomy: Face
Several areas around the face are especially prominent thus prone to injury
Orbits for the eyes (contusions) Nasal bones (fractures) Lower jaw (mandible)
◦ Excessive external forces
Anatomy: Face
7 cervical vertebral◦ The first cervical 9C-1)
vertebra (atlas) articulates directly with the occipital bone to form the right and left atlantoccipital joints
◦ The skull and C-1 articulate as a unit with the second cervical (C-2) vertebra (axis) to form the atlantoaxial joint Allows for rotation of the head on
the neck The remaining 5 cervical
vertebrae become larger as they approach the thoracic spine
Anatomy: Cervical Spine
Relatively minor trauma to the head can result in severe, sometimes life-threatening injury
Inability of brain tissue to repair itself, any loss of tissue results in some level of permanent disability◦ If severe enough can result in death
With appropriate education, coaches can learn to recognize head injuries and render effective first aid when necessary
Head Injuries in Sports
Surveys have provided additional insight into which sports appear to carry a higher risk
Guskiewicz and colleagues (2000) conducted a 3-year study of head/brain injuries in the US among high school and collegiate football players◦ Overall they estimated that approximately
300,000 traumatic head or brain injuries happened annually
◦ Players sustaining a concussion had a threefold increased risk of sustaining an additional concussion
Head Injuries in Sports
When examining high school and collegiate female activities, cheerleading leads the list of activities resulting in directly related catastrophic injuries
Attributed to the escalated degree of difficulty in cheerleading routines as it has become a competitive sport
26,786 hospital emergency room visits related to cheerleading injuries occurred in 2007◦ 783 concussions◦ 308 contusions◦ 69 lacerations◦ 1122 internal injuries 9Mueller & Cantu, 2010)
Head Injuries in Sports
All head injuries can be placed into three general categories: ◦ mild head injury or concussion◦ intracranial hemorrhage◦ skull fracture
Head Injuries in Sport
Involve either direct or indirect mechanisms Direct
◦ Blow to the head resulting in brain injury at site of impact Coup type injury – site of maximal injury is usually at the point of impact
Ex) accelerated force is generated when an opponent or the ball hits an athletes head
Countercoup type injury – the site of maximal injury is opposite the point of impact Ex) deceleration forces are generated when an athlete’s head strikes the
ground Indirect
◦ Damaging forces traveling from other areas of the body, such as blows to the face or jaw Rapid and violent movement of the cervical spine (whiplash)
Treat every head injury as if there is a neck injury, and every neck injury as if there is also a head injury
Mechanism of Injury
Coup vs. Counter Coup
Coup = site of maximal injury is at the site of impact (opponent or the ball hits an athletes headCounter Coup – site of maximal injury is opposite the point of impact (the brain rebounds against the skull )
Defined by Jordan (1989) as a clinical syndrome characterized by immediate and transient impairment of neurologic function secondary to mechanical forces
Clinical manifestations◦ Headache◦ Dizziness◦ Confusion◦ Unconsciousness◦ Inability to quickly answer questions about orientation◦ Irritability◦ Poor concentration◦ Pupils react to light◦ Poor ability to track with eyes◦ Poor depth perception◦ Ringing in the ears◦ Vomiting◦ Nausea◦ Actions uncharacteristic of the individual
Concussion (Mild Head Injury)
Recent evidence suggest in some concussion there is a level of structural damage
Brain cells are not destroyed remain extremely vulnerable to subsequent trauma ◦ Result in minor changes in blood flow◦ Intracranial pressure◦ Anoxia (Cantu, 2001)
The majority base the level of severity on duration of unconsciousness as well as the presence or absence of post-traumatic amnesia (PTA)
Extremely difficult to gauge the length of time a person is unconscious
Concussion (Mild Head Injury)
Cantu Evidence-Based Grading System for Concussion3 Grades:Grade 1 (mild)Grade 2 (moderate)Grade 3 (severe)
Grade FindingsMild (1) No loss of consciousness; PTA or
post concussion signs or symptoms lasting less than 30 mins
Moderate (2) Loss of consciousness lasting less than 1 min; PTA or post concussion signs or symptoms lasting longer than 30 mins but less than 24 hrs
Severe (3) Loss of consciousness lasting more than 1 minute or PTA lasting longer than 24 hrs; post concussion signs and symptoms lasting longer than 7 days
Grade 1 are the most difficult to identify Grade 3 are distinct because they involve
either a loss of consciousness lasting more than 1 minute or PTA of greater than 24 hours
Majority of sports-related concussions involve periods of unconsciousness lasting 1 minute or less
Concussions (Mild Head Trauma)
Two types of PTA:◦ Anterograde Amnesia
Involves an inability to recall events that have transpired since the time of the injury
◦ Retrograde Amnesia Present when the athlete is unable to recall events
that occurred just prior to the injury It is generally thought that retrograde
amnesia is indicative of more severe forms of head injury
Concussions (Mild Head Trauma)
Level of consciousness◦ First determining if the athlete is alert and will
respond to simple questions◦ Keep questions simple to evaluate the athlete’s
perspective of time and place Ex) game score, name of opponent, reciting four
words or numbers immediately and 2 minutes later to detect the presence of anterograde amnesia (Cantu, 2001)
Remember consciousness does not guarantee the absence of a potentially serious head injury
Concussions (Mild Head Trauma)
“Occurs when an athlete who has sustained an initial head injury, most often a concussion, then sustains a second head injury before symptoms associated with the first have fully cleared” (Cantu & Voy, 1995)◦ Rapid development of catastrophic swelling of the
brain◦ Puts pressure directly against the brain stem
Second Impact Syndrome (SIS)
Is a potentially life-threatening situation◦ Direct blows, rapid
deceleration, and even rapid rotational motions of the head
Result from blunt trauma to the head◦ Characterized by disruption
of blood vessels either veins or arteries result in the development of a hematoma or swelling in the confines of the cranium
Intracranial Injury
Epidural hematoma◦ Bleeding between the dura and the cranial bones◦ Involves arterial bleeding◦ Signs and symptoms of injury will develop rather quickly
Subdural hematoma◦ Bleeding below the dura mater◦ Involve rapid arterial bleeding ◦ Symptoms develop in minutes◦ Or pooling and clotting develop over many hours
Intracerebral hematoma◦ Bleeding within the brain tissues
Cerebral contusion◦ Bruising of the brain tissue
Intracranial Injury
Involve the bones of the skull May be come bleeding and soft-tissue
damage More severe forms of cranial injuries involve
depressed skull fractures◦ more serious because bone fragments have been
pushed into the cranial region◦ More likely to produce serious, perhaps life-
threatening, neurologic damage
Cranial injury
Divided into procedures while the athlete is at the site of injury
If any signs and/or symptoms of head and neck injury are present when evaluating the athlete at the site of initial injury, he/she should not be moved until emergency medical (EMS) personnel have arrived on site
Initial Treatment of a Suspected Head Injury: Guidelines
First step◦ Incorporates basic first aid procedures◦ Determine if athlete is either respiratory or
cardiac arrest◦ Accomplished by executing the initial check◦ Obstructed airway or cardiac arrest must be
attended to before continuing◦ First few seconds provide important information◦ Note body position, movement or lack thereof,
unusual limb positions and (if present) the position of helmet, face mask, and mouth guard
Initial Check
Unconscious◦ Awake him/her by placing hands on the shoulders,
chest, or upper back and speaking loudly directly toward the athlete's head
◦ Make a mental note of time Conscious
◦ Airway is probability open Great importance that the coaching staff be
trained and well rehearsed in dealing with such situations◦ Immobilization of the head and neck should also take
place at this time
Initial Check
Initial CheckPerson stationed at the athlete's head to stabilize it with both hands
Normally the ATC
In case of a helmeted football player it is not necessary to remove the helmet to determine breathing
Usually be detected by placing an ear near the athlete’s face and listening for sounds of respiration
Detect sounds indicating airway obstruction such as gagging, wheezing, or choking
Initial check
Responsive athlete who is breathing will have signs of circulation ◦ Breathing◦ Coughing◦ Movement
Determine if signs of circulation are present If no signs are present, can begin
cardiopulmonary resuscitation (CPR) and activate the EMS provider
Circulation Assessment
Proper guidelines for spine boarding◦ 1st the captain of the team stabilizes the head and neck in the exact
position in which they were found◦ Place the arms next to the body and legs straight◦ If lying face down roll the athlete supine◦ Four or five people are required to “log roll”◦ Position the arms in the cross arm technique◦ 2nd place spine board as close as possible beside individual◦ Each person is responsible for one body segment: one at the shoulder,
one at the hip, one at the knees, and if needed one at the feet◦ On command roll the individual on the board in a single motion◦ 3rd once on board the captain continues to stabilize the neck and head ◦ Coach’s primary responsibility is to keep the athlete alive and ensure
help is summoned ◦ No need to remove the athlete
Circulation Assessment
Once initial check is completed and the athletes vital signs have been ascertained, proceed to the physical exam
C - conscious or unconscious E – extremity strength (if conscious) M – mental function (if conscious) E – eye signs and movements P – pain specific to neck S – spasm of neck musculature DON’T REMOVE THE HELMET OF A FOOTBALL PLATER DON’T MOVE THE ATLETE DON’T RUSH THROUGH THE PHYSICAL EXAM
Physical Exam
If seem to be conscious, attempt to communicate by asking simple questions◦ Name of opposing team, what day it is, location of
the contest Not attempt to revive an unconscious
athlete by using a commercially made inhalant◦ Ammonia capsules◦ Athlete may jerk head result in aggravation of
existing neck injury
Physical Exam
If conscious can conduct a series of quick, simple test to determine if any significant neurologic damaged has occurred◦ Grip strength test◦ Place hands on tops of athletes feet and ask
player to dorsiflex Compare bilateral strength
Check dermatomes or myotomes
Physical Exam
A more detailed assessment of his/her condition Determine if any S&S of head injury have
developed since time of initial injury Single most important indicator of severity of
brain injury is level of consciousness (Jordan, 1989)
Use Standardized Assessment of Concussion (SAC)◦ Administered at the site of injury◦ Has sustained a concussion but – loss of consciousness
(LOC)
Sideline Assessment
Assess orientation, immediate memory, concentration and delayed recall (McCrea et al., 1998)
Asking a series of questions◦ Recall five words◦ Motor skills include push-ups, knee bends, sit-ups,
and jumping jacks Use SAC over the course of the athletes
recovery in conjunction with a physicians care
SAC
Neck (cervical) injuries occur in almost any sport
Extent and severity of neurologic damage depends on the magnitude of the mechanism of injury, resulting movement of the neck, and the extent of tissue damage
More serious◦ Displacement of an intact vertebra occurs◦ Fragments of a vertebral fx are displaced◦ Intervetebral disk ruptures
Placing pressure directly on the spinal cord or nerve roots
Cervical Spine Injuries
Historically, mechanism of injury was from excessive forced flexion (hyperflexion) of the cervical spine
Axial loading now produces the majority of serious cervical spine injuries◦ Occurs when head is lowered (flexed slightly) just
prior to impact◦ Straightening of the normal vertebral curve
(extension)
Cervical Spine Injuries
Commonly known as “burners” or “stingers”
Happens when the body may be forced in one direction while an arm may be pulled in the opposite direction◦ May have intense burning sensation in the
shoulder, arm, and hand to loss of sensation in the same areas
◦ Involves an abnormal traction or compression of one or more of the large nerves that comprise the entire plexus (Sallis, Jones, & Knopp, 1992)
Brachial Plexus Injuries
S&S involve:◦ Immediate, severe,
burning pain◦ Prickly paresthesia
that radiates from the clavicle into the hand
◦ Subsides in 5-10 minutes
◦ Tenderness and weakness may persist for hours or days
◦ Muscle atrophy
Brachial Plexus Injuries
Individual should be removed from competition
Continue to monitor the athlete’s recovery No participation until the symptoms have
abated◦ Grip strength in the affected extremity is normal
bilaterally◦ Full ROM, and sensation are restored
Treatment includes: ice massage to decrease pain and inflammation
Sling may be necessary
Brachial Plexus Injuries…
Involve portions of the major ligaments that serve to stabilize the vertebrae
Common mechanism are hyperflexion, hyperextension, lateral flexion and rotation
Involve a significant amount of force◦ Can be severe enough to result in an actual
displacement of vertebrae
Sprains…
S&S involve:◦ Localized pain in the region of the C-spine◦ Point tenderness over the site of the injury◦ Limited ROM in neck movements◦ No obvious neurologic deficits
Treatment:◦ Remove the athlete from practice/competition◦ Apply ice◦ Refer the athlete for a medical evaluation
Sprains
Involve muscles and tendons of the neck region◦ Normally more painful than serious
Whiplash is an exception◦ A combination of joint sprain and
musculotendinous strain to the region Mechanism of injury is the same as sprains
Strains…
S&S include:◦ Localized pain in the region of the C-spine◦ Muscle spasm◦ Limited ROM in neck movements◦ No obvious neurologic deficits
Treatment:◦ Remove the athlete from practice/competition◦ Apply ice◦ Refer the athlete for a medical evaluation
Strains
Most extreme forms of cervical injury happen when
that result in pressure applied to the spinal cord◦ Permanent can
occur◦ May suffer damage secondary to the initial
trauma Axial loading is associated with many of the
more severe forms of injury Represent
Fractures and Dislocations…
S&S include:◦ Reports having felt
or heard neck◦ Severe
associated with◦ Difficulty swallowing◦ Deformity in
vertebrae◦ Burning, in the
extremities or trunk
Fractures and Dislocations
◦ Weakness in grip strength and/or
◦ Complete absence of sensation
◦ Complete
◦ Loss of
Fractures and Dislocations
Treatment:◦ Complete initial check and ◦ Proceed to the physical examination◦ Stabilize the
Designate the In case of a helmeted football player, If CPR is necessary, front of the shoulder pads can be
opened to allow access Summon EMS Do NOT attempt to remove the athlete Continue to monitor
Fractures and Dislocations
Determine if athlete ◦ With an unconscious athlete, assume that both
Coaching staff should have a preplanned emergency protocol for handling athletes with head and neck injuries
One staff member ◦ Supervision of the entire management process◦ Monitor the
Initial Treatment of a Suspected Neck Injury
First, the team leader should and continue to do so
Second,
◦ If a pulse is found and athlete is breathing summon EMS
Initial Treatment of a Suspected Neck Injury
Spine board technique◦ Trained staff of a minimum of 5 people, including the
team leader◦ Team leader stabilizes the head and neck in a neutral
position and directs the actions of the other team members
◦ Members are stationed at the legs, hips, and shoulders, with the team leader providing stabilization to the head and neck
◦ Place the arms next to the body and legs straight◦ If the individual is lying down, roll the individual supine◦ Four or five people are required to “log roll” the
individual
Initial Treatment of a Suspected Neck Injury
Leader should position the arms in the cross arm technique
Place spine board as close as possible beside the individual
Each person is responsible for one body segment One at the shoulder, one at the hip, one at the
knees, one at the feet On command, roll the individual on the board in a
single motion Once on board, the leader continues to stabilize the
head and neck The chest is secured to the board first, then the feet
Initial Treatment of a Suspected Neck Injury
Includes the jaw and teeth,
Dental injuries◦ 32 teeth◦ Teeth are firmly
secured in the by way of the root
Injuries to the Region…
Result from
, a fracture or avulsion, and, in extreme cases, fracture of the jaw or facial bones
Dental Injuries…
Tooth Displacement◦ Single tooth or several teeth are
Tooth Fracture◦ Defects along crown◦ Visible fracture line
Fractures of the jaw or other bones◦ Loosening of ◦ Bleeding of gums and numbness◦ Obvious
Tooth avulsion◦ Missing tooth
Dental Injuries…
Initial Check◦ Avoid ◦ Bloodborne pathogen prevention steps should be
taken◦ Collect history◦ Check to see if athlete can
◦ Assess symmetry of teeth◦ Examine the
Dental Injuries…
Treatment◦ Direct ◦ Loose teeth
Gently push them back into their ◦ Avulsion
Locate the tooth and protect it by putting into a ◦ Send athlete to dentist or physician immediately◦ Time is of the essence◦ Prognosis of tooth is
Dental Injuries…
Dental protection ◦ Mouthguard◦ Significantly and
dislocations of the joint
Two groups◦ Mouth-formed◦ Custom
Dental Injuries
Complex structure located in the orbit of the skull
Two types of eye injuries◦ Contusional
Result of a
Eye Injuries…
Vary in severity from corneal abrasions to major distortions of the eyeball resulting in rupture of the eye,
Penetrating◦ Less common◦ Shooting sports or as a
Initial Check and Treatment:◦ Majority involve ◦ S&S are nearly identical:
Pain, irritation, and excessive tearing◦ Exam can be done by and away from the eye
while checking the eyeball for any problems
Eye Injuries…
Treatment:◦ Small foreign bodies
are usually ◦ Carefully removed with
a moist cotton swab◦ If object is imbedded in
the eye tissue,
Eye Injuries…
It is important to cover the
If no object can be seen in the eye, most likely it is a corneal abrasion
No participation until symptoms abate Contusions
◦ Normally ◦ Causes a black eye resulting
◦ Immediate care is to apply cold for 24 hours
Eye injuries…
Severe contusions◦ Bleeding into the anterior portion of the eye
◦ Potentially serious sign which may
◦ The eyeball itself may have been ruptured or the socket may be
◦ S&S Pain, double vision, obvious hemorrhaging in the eye
◦ Immediately referred for
Eye injuries…
Detached retina◦ Symptoms may not be immediately apparent◦ Retina may slowly fall ◦ S&S
Seeing particles floating inside the eye, Protective wear
◦ Not required by the NCAA or ◦ Wearing eye protection can prevent ◦ Goggles and face shields
Eye Injuries…
Classic nosebleed
Consists of mostly soft tissue (cartilage and skin)
Bones include R and L nasal bones and the
Nostrils are separated
Nose Injuries…
Initial Check◦ Once a hit is involved,
S&S include:◦ Obvious deformity of the bridge of the nose◦ If suspected, first control the bleeding then
Nose Injuries…
Septal injuries◦ Unique problems and
the ◦ Septum can be bruised
from external blows◦ Bleeding can occur
◦ S&S Swelling visible inside
and outside of nose Nose may
◦ Refer the patient
Nose injuries…
With the exception of aquatic sports, the majority of
◦ Wrestling accounts for abrasions and contusions to the auricular (large expanded portion outside)
Auricular Hematoma◦ Development of a hematoma
◦ Cauliflower if not treated properly or is repeatedly irritated
Ear injuries…
Auricular hematoma S&S◦ Skin redness, local
◦ TX Immediately with a cold
pack Refer to a physician if
Drainage of fluid
Ear Injuries…
Facial fracture involves the mandible◦ Occurs in boxing and
other collision sports◦ S&S
Obvious pain, swelling at the site of fx, observable deformity, and
◦ TX Gentle application of a cold
pack and immediate referral to the physician
If a
Fractures of the Face (non-nasal)
Dislocation of the jaw◦ Joint involved is the ◦ Held together by numerous ligaments and joint
capsules◦ Dislocates relatively ◦ S&S
Extreme pn, and deformity in the region of the TMJ,
In some cases, the mouth may be locked in an open position
◦ Treatment Involves the same as a fracture
Fractures of the Face (non-nasal)
Zygomatic Fracture◦ S&S
Pain and swelling at site of injury
Swelling and Raccoon eyes maybe
accompanied by
Fractures of the Face (non-nasal)
Treatment is based on first aid guidelines Carefully
Apply a sterile, commercially prepared dressing
Refer the athlete to a physician
Wounds of the Facial Region