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


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)


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


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


“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


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


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


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


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


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


Zygomatic Fracture◦ S&S

Pain and swelling at site of injury

Swelling and Raccoon eyes maybe

accompanied by


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

injuries to the head, neck, and face

Documents