KIN 188 – Prevention and KIN 188 – Prevention and Care of Athletic InjuriesCare of Athletic Injuries

Head and Neck Evaluation Head and Neck Evaluation

and Injuriesand Injuries

AnatomyAnatomy

AnatomyAnatomy

• Bony anatomyBony anatomy

• BrainBrain

• MeningesMeninges

Bony AnatomyBony Anatomy

• SkullSkull– Provides protection for brainProvides protection for brain– Reduces forces transmitted to brain (thickness and Reduces forces transmitted to brain (thickness and

shape)shape)

• Occipital boneOccipital bone– Inion – “bump of knowledge”Inion – “bump of knowledge”

• Parietal bonesParietal bones

• Frontal boneFrontal bone

• Temporal bonesTemporal bones

• Sphenoid bonesSphenoid bones

Bony AnatomyBony Anatomy

BrainBrain

• CerebrumCerebrum

• CerebellumCerebellum

• BrainstemBrainstem

BrainBrain

CerebrumCerebrum

• AnatomyAnatomy– Two hemispheres separated by longitudinal fissureTwo hemispheres separated by longitudinal fissure– Each hemisphere has frontal, parietal, temporal and Each hemisphere has frontal, parietal, temporal and

occipital lobesoccipital lobes– Sulci and fissures form contoursSulci and fissures form contours

• FunctionFunction– Controls primary motor functionsControls primary motor functions

• Gross and sequenced, coordinated movementsGross and sequenced, coordinated movements– Processes sensory informationProcesses sensory information

• Temp, touch, pain, pressure, proprioception, vision, hearing, Temp, touch, pain, pressure, proprioception, vision, hearing, smell, tastesmell, taste

– Cognitive functionCognitive function• Spatial relationships, behavior, memorySpatial relationships, behavior, memory

CerebellumCerebellum

• Located at posterior and inferior aspect of brainLocated at posterior and inferior aspect of brain

• Two hemispheres separated by fissureTwo hemispheres separated by fissure

• Processing center for incoming and outgoing Processing center for incoming and outgoing information relative to maintaining balance and information relative to maintaining balance and coordinationcoordination– Quick link to cerebrum for processing sensory Quick link to cerebrum for processing sensory

informationinformation– Quick link to musculoskeletal system to carry out Quick link to musculoskeletal system to carry out

proper muscular contractions and joint movementsproper muscular contractions and joint movements

BrainstemBrainstem

• Relays info to and from central nervous system Relays info to and from central nervous system and controls involuntary systemsand controls involuntary systems

• Medulla oblongataMedulla oblongata– Links cerebrum to brainstem and spinal cordLinks cerebrum to brainstem and spinal cord– Regulates heart and respiratory rates, vascular Regulates heart and respiratory rates, vascular

changes, coughing, vomitingchanges, coughing, vomiting

• Pons (“bridge”)Pons (“bridge”)– Links cerebellum to brainstem and spinal cordLinks cerebellum to brainstem and spinal cord– Regulates respiratory rateRegulates respiratory rate

MeningesMeninges

• Collectively, support and protect brain and Collectively, support and protect brain and spinal cordspinal cord

• Dura mater (“tough/hard mother”)Dura mater (“tough/hard mother”)

• Arachnoid mater (spider web appearance)Arachnoid mater (spider web appearance)

• Pia mater (“little mother”)Pia mater (“little mother”)

MeningesMeninges

EvaluationEvaluation

Primary SurveyPrimary Survey

• Stabilize cervical spineStabilize cervical spine

• A – AirwayA – Airway– Ensure that airway is clear (mouthpiece, tongue, Ensure that airway is clear (mouthpiece, tongue,

etc.)etc.)

• B – BreathingB – Breathing– Look, listen and feelLook, listen and feel

• C – CirculationC – Circulation– Evaluate for presence carotid pulseEvaluate for presence carotid pulse

• D – Disorientation/DysfunctionD – Disorientation/Dysfunction– Conscious vs. unconsciousConscious vs. unconscious

Unconscious AthleteUnconscious Athlete

• Activate EMSActivate EMS• Must assume that athlete has head and/or Must assume that athlete has head and/or

cervical spine injurycervical spine injury• If ABCs not intact, must initiate rescue If ABCs not intact, must initiate rescue

breathing or CPRbreathing or CPR• If ABCs intact:If ABCs intact:

– Establish and monitor vital signsEstablish and monitor vital signs– Evaluate pupil response (PEARL)Evaluate pupil response (PEARL)– Palpate skull and c-spine for deformity, Palpate skull and c-spine for deformity,

swelling, etc.swelling, etc.

Conscious Athlete – Secondary Conscious Athlete – Secondary SurveySurvey

• Assumes ABCs intact – establish and monitor vital signsAssumes ABCs intact – establish and monitor vital signs• HistoryHistory

– Loss of consciousness, mechanism of injury, symptoms (pain, Loss of consciousness, mechanism of injury, symptoms (pain, numbness/tingling, etc.)numbness/tingling, etc.)

– Orientation x 4 (self, others, place, time)Orientation x 4 (self, others, place, time)• InspectionInspection

– Skull/c-spine alignmentSkull/c-spine alignment• PalpationPalpation

– For bony deformity, swelling, muscle spasm (guarding)For bony deformity, swelling, muscle spasm (guarding)• Neurological screeningNeurological screening

– Sensory testing (dermatomes) compared bilaterallySensory testing (dermatomes) compared bilaterally– Motor testing not performed clinically – if all other symptoms Motor testing not performed clinically – if all other symptoms

negative, may ask to wiggle fingers and toes to establish distal negative, may ask to wiggle fingers and toes to establish distal motor functionmotor function

HistoryHistory

• Location of symptomsLocation of symptoms

• Mechanism of injury/etiologyMechanism of injury/etiology– Head vs. cervical spineHead vs. cervical spine

• Loss of consciousnessLoss of consciousness

• Prior history of head injuryPrior history of head injury

• Complaints of weaknessComplaints of weakness

Location of SymptomsLocation of Symptoms

• Cervical pain or muscle spasmCervical pain or muscle spasm– More concerning if accompanied by numbness, More concerning if accompanied by numbness,

tingling, burning sensations and/or radiating tingling, burning sensations and/or radiating painpain

• Head painHead pain– If localized, may indicate contusion, skull If localized, may indicate contusion, skull

fracture and/or intracranial bleedingfracture and/or intracranial bleeding– Most common complaint is headacheMost common complaint is headache

Mechanism of InjuryMechanism of Injury

• Head injuriesHead injuries– Coup – stationary skull struck by high velocity object, results in Coup – stationary skull struck by high velocity object, results in

trauma at site of impacttrauma at site of impact– Contrecoup – moving skull strikes a non-moving object, brain Contrecoup – moving skull strikes a non-moving object, brain

“floats” and strikes skull opposite impact causing trauma“floats” and strikes skull opposite impact causing trauma– Repeated subconcussive forces – cumulative neurological Repeated subconcussive forces – cumulative neurological

deficitsdeficits– Rotational or shear forces – sudden acceleration/deceleration Rotational or shear forces – sudden acceleration/deceleration

forces, can disrupt CNS activity and result in concussive forces, can disrupt CNS activity and result in concussive symptomssymptoms

• Cervical spine injuriesCervical spine injuries– May involve any ROM (flexion, extension, lateral flexion and/or May involve any ROM (flexion, extension, lateral flexion and/or

rotation – may be combined)rotation – may be combined)– If flexed ~30 degrees, lordotic curve is lost and cervical spine If flexed ~30 degrees, lordotic curve is lost and cervical spine

most susceptible to axial load injury (unable to dissipate forces)most susceptible to axial load injury (unable to dissipate forces)

Other Historical ElementsOther Historical Elements

• Loss of consciousnessLoss of consciousness– Component of memory evaluationComponent of memory evaluation– Can athlete or others establish whether there was Can athlete or others establish whether there was

or was not momentary loss of consciousnessor was not momentary loss of consciousness

• History of concussionHistory of concussion– Recent history of prior concussion increases risk of Recent history of prior concussion increases risk of

second impact syndromesecond impact syndrome

• Complaints of weaknessComplaints of weakness– Reports of weakness in extremities may indicate Reports of weakness in extremities may indicate

brain, spinal cord and/or nerve root injurybrain, spinal cord and/or nerve root injury

InspectionInspection

• Bony structuresBony structures

• EyesEyes

• Nose and earsNose and ears– OtorrheaOtorrhea– RhinorrheaRhinorrhea

Bony InjuriesBony Injuries

Eye EcchymosisEye Ecchymosis

PalpationPalpation

Palpation of Bony StructuresPalpation of Bony Structures

• SkullSkull– Palpate all cranial bones for pain and Palpate all cranial bones for pain and

deformitydeformity

• Spinous processesSpinous processes– Palpate cervical spinous processes for Palpate cervical spinous processes for

pain and crepitus associated with pain and crepitus associated with fracturefracture

Palpation of Soft TissuesPalpation of Soft Tissues

• MusculatureMusculature– Palpate sternomastoid and upper trapezius Palpate sternomastoid and upper trapezius

muscles for spasm secondary to strain, muscles for spasm secondary to strain, sprain, fracture and/or dislocationsprain, fracture and/or dislocation

• ThroatThroat– Palpate thyroid cartilage, cricoid cartilages Palpate thyroid cartilage, cricoid cartilages

and hyoid bone to rule out larynx and and hyoid bone to rule out larynx and tracheal injurytracheal injury

Special TestsSpecial Tests

Special TestsSpecial Tests

• Range of motionRange of motion

• Functional testing – evaluates function Functional testing – evaluates function of central nervous system (CNS)of central nervous system (CNS)– Orientation x 4Orientation x 4– MemoryMemory– Cognitive functionCognitive function– Balance and coordinationBalance and coordination– Vital signsVital signs

Range of MotionRange of Motion

• Active/passive/resistive neck flexion Active/passive/resistive neck flexion – Chin to chestChin to chest

• Active/passive/resistive neck extensionActive/passive/resistive neck extension– Look directly above headLook directly above head

• Active/passive/resistive neck rotationActive/passive/resistive neck rotation– Chin almost in line with shoulderChin almost in line with shoulder

• Active/passive/resistive neck lateral Active/passive/resistive neck lateral bendingbending– Approximately 45 degrees to each sideApproximately 45 degrees to each side

OrientationOrientation

• Orientation x 4Orientation x 4– SelfSelf

•Own nameOwn name

– PlacePlace•General sense of locationGeneral sense of location

– TimeTime•General sense, use point in game practiceGeneral sense, use point in game practice

– OthersOthers•Athletic trainer, coaches, teammates, etc.Athletic trainer, coaches, teammates, etc.

MemoryMemory

• Retrograde amnesiaRetrograde amnesia– Difficulty or inability to remember events preceding Difficulty or inability to remember events preceding

the injury – more severe if can’t remember events the injury – more severe if can’t remember events of day before as opposed to more recent eventsof day before as opposed to more recent events

– Some assessed with orientation x 4, pre-game Some assessed with orientation x 4, pre-game meal?, who played last game?meal?, who played last game?

• Anterograde amnesiaAnterograde amnesia– Difficulty or inability to remember events after the Difficulty or inability to remember events after the

onset of injuryonset of injury– Athlete given verbal list of items and asked to Athlete given verbal list of items and asked to

repeat them serially over timerepeat them serially over time

Cognitive FunctionCognitive Function

• Brain injury can present as abnormal Brain injury can present as abnormal behavior, personality changes, inability to behavior, personality changes, inability to process information accuratelyprocess information accurately

• BehaviorBehavior– May become violent, belligerent, etc. - abnormalMay become violent, belligerent, etc. - abnormal

• Analytical abilityAnalytical ability– Typically assessed with serial number Typically assessed with serial number

repetitions or spelling forward/backwardrepetitions or spelling forward/backward

• Information processingInformation processing– Cannot follow simple instructionsCannot follow simple instructions

Balance and CoordinationBalance and Coordination

• Evaluation for possible cerebellar Evaluation for possible cerebellar injury affecting muscle coordinationinjury affecting muscle coordination – Romberg test – single leg stance with Romberg test – single leg stance with

shoulders abducted 90 degrees, eyes shoulders abducted 90 degrees, eyes closed and head backclosed and head back

– Tandem walking – heel to toe walking Tandem walking – heel to toe walking forward and backward along straight lineforward and backward along straight line

– Finger to nose – rapid alternating Finger to nose – rapid alternating movementsmovements

Vital SignsVital Signs

• Pulse rate, respiratory rate, blood Pulse rate, respiratory rate, blood pressure taken early in evaluation pressure taken early in evaluation process to establish baseline and process to establish baseline and repeated serially for comparisonrepeated serially for comparison

InjuriesInjuries

InjuriesInjuries

• Head injuriesHead injuries– ConcussionConcussion– Post-concussion syndromePost-concussion syndrome– Second impact syndromeSecond impact syndrome– Intracranial hemorrhageIntracranial hemorrhage

• Epidural hematomaEpidural hematoma• Subdural hemtomaSubdural hemtoma

– Skull fractureSkull fracture

• Cervical spinal cord injuriesCervical spinal cord injuries– Cervical spine fracture/dislocationCervical spine fracture/dislocation– QuadraplegiaQuadraplegia

ConcussionConcussion

• Cerebral concussion = mild traumatic brain injury (MTBI)Cerebral concussion = mild traumatic brain injury (MTBI)

• Hallmark symptoms include mental confusion, altered Hallmark symptoms include mental confusion, altered mental status, amnesia and potential loss of mental status, amnesia and potential loss of consciousnessconsciousness

• Multiple occurrences may produce cumulative Multiple occurrences may produce cumulative degenerative effectsdegenerative effects

• Ultimate assessment based upon duration of loss of Ultimate assessment based upon duration of loss of consciousness (if any) and neuropsychological findingsconsciousness (if any) and neuropsychological findings

ConcussionConcussion

• Additional symptoms of concussion may Additional symptoms of concussion may include but are not limited to:include but are not limited to:– HeadacheHeadache– DizzinessDizziness– TinnitusTinnitus– Nausea/vomitingNausea/vomiting– Motor impairmentMotor impairment– Memory lossMemory loss

Concussion Rating SystemsConcussion Rating Systems

• Guidelines for identifying concussion severity Guidelines for identifying concussion severity and determining return to play timeline – often and determining return to play timeline – often considered conservative for athletic populationconsidered conservative for athletic population

• Significant differences between scales – be Significant differences between scales – be consistent with scale utilizedconsistent with scale utilized

• American Academy of NeurologyAmerican Academy of Neurology• Cantu Concussion Rating GuidelinesCantu Concussion Rating Guidelines• Colorado Medical Society Concussion Rating Colorado Medical Society Concussion Rating

GuidelinesGuidelines

Return to Play CriteriaReturn to Play Criteria

• Multiple factors to consider include whether Multiple factors to consider include whether or not loss of consciousness occurred, or not loss of consciousness occurred, duration of symptoms, total number of duration of symptoms, total number of concussive episodes, exertional testingconcussive episodes, exertional testing

• Universal agreement that individual who lost Universal agreement that individual who lost consciousness for any period of time should consciousness for any period of time should not be allowed to return to activity on the not be allowed to return to activity on the same day even if all symptoms have resolvedsame day even if all symptoms have resolved

Post-Concussion SyndromePost-Concussion Syndrome

• Individuals may present with concussion Individuals may present with concussion symptoms long after “normal” resolution symptoms long after “normal” resolution would have occurredwould have occurred

• Common symptoms includeCommon symptoms include– Decreased attention spanDecreased attention span– Difficulty concentratingDifficulty concentrating– Memory impairmentMemory impairment– Prolonged headachesProlonged headaches– Balance impairmentsBalance impairments– Decreased cognitive functionDecreased cognitive function

Second Impact SyndromeSecond Impact Syndrome

• Defined as symptoms resulting from second Defined as symptoms resulting from second concussive episode before symptoms of first concussive episode before symptoms of first concussive episode have resolvedconcussive episode have resolved– Entirely preventable, return to play considerationsEntirely preventable, return to play considerations

• Second trauma typically not as violent as initial Second trauma typically not as violent as initial injury – thought to affect brain blood supply injury – thought to affect brain blood supply causing increased intracranial pressure which causing increased intracranial pressure which impacts brainstem functionimpacts brainstem function

• Quick progression from mild concussive Quick progression from mild concussive symptoms to comatose statesymptoms to comatose state

• Even if treated appropriately, has ~50% mortality Even if treated appropriately, has ~50% mortality raterate

Intracranial HemorrhageIntracranial Hemorrhage

• Named for location relative to meningeal Named for location relative to meningeal layerslayers– Epidural hematomaEpidural hematoma– Subdural hematoma Subdural hematoma

• Caused by injury to blood vessels supplying Caused by injury to blood vessels supplying brain blood supplybrain blood supply

• Increased pressure from bleeding in confined Increased pressure from bleeding in confined space compresses neural tissuespace compresses neural tissue

• Onset of symptoms associated with nature of Onset of symptoms associated with nature of bleeding – venous vs. arterial (lucid interval)bleeding – venous vs. arterial (lucid interval)

Epidural HematomaEpidural Hematoma

• Arterial bleeding between skull and dura materArterial bleeding between skull and dura mater• Initially may present with concussive symptomsInitially may present with concussive symptoms• Short lucid interval (typically <48 hours)– Short lucid interval (typically <48 hours)–

individual appears “OK”individual appears “OK”– Due to arterial nature of bleedingDue to arterial nature of bleeding

• Subsequently may c/o disorientation, confusion, Subsequently may c/o disorientation, confusion, drowsiness, increasing headache intensity, signs drowsiness, increasing headache intensity, signs of cranial nerve changes (esp. pupil changes)of cranial nerve changes (esp. pupil changes)

• If untreated, can be fatalIf untreated, can be fatal

Subdural HematomaSubdural Hematoma

• Venous bleeding between brain and dura materVenous bleeding between brain and dura mater• May not present with symptoms of concussionMay not present with symptoms of concussion• Longer lucid interval – may be hours, days or Longer lucid interval – may be hours, days or

weeks before symptoms presentweeks before symptoms present– Due to venous nature of bleedingDue to venous nature of bleeding

• Subsequent development of headaches, Subsequent development of headaches, confusion, changes in cognitive/motor abilities, confusion, changes in cognitive/motor abilities, cranial nerve changescranial nerve changes

• More likely to cause death due to lack of More likely to cause death due to lack of recognition of nature/source of symptoms and recognition of nature/source of symptoms and delay in subsequent treatmentdelay in subsequent treatment

Skull FracturesSkull Fractures

• Minimal risk with head protection, but may still Minimal risk with head protection, but may still suffer bony injurysuffer bony injury

• May cause CSF leakage from nose/ear, may have May cause CSF leakage from nose/ear, may have residual/secondary ecchymosisresidual/secondary ecchymosis

• LinearLinear– Hairline fractures in boneHairline fractures in bone

• ComminutedComminuted– Multiple fracture fragmentsMultiple fracture fragments

• DepressedDepressed– Easier to identify on evaluation – gross deformityEasier to identify on evaluation – gross deformity– Potential for fragments to injure meninges/brainPotential for fragments to injure meninges/brain

Cervical Spinal Cord InjuriesCervical Spinal Cord Injuries

Cervical Spinal Cord InjuriesCervical Spinal Cord Injuries

• Risk minimized with rules and coaching emphasis Risk minimized with rules and coaching emphasis changeschanges

• Spinal cord injury caused bySpinal cord injury caused by– Impingement/laceration from bony displacementImpingement/laceration from bony displacement– Compression from bleeding, swelling, ischemia to cordCompression from bleeding, swelling, ischemia to cord

• Mechanism of injury is key to decisions on Mechanism of injury is key to decisions on managementmanagement– Must assume worst case scenario until proven otherwiseMust assume worst case scenario until proven otherwise

• Trauma at spinal cord level affects function distal Trauma at spinal cord level affects function distal to level of injuryto level of injury– At or above C4 level – death is likely due to impact on At or above C4 level – death is likely due to impact on

brainstem and vital functionsbrainstem and vital functions

Cervical Cervical Fracture/DislocationFracture/Dislocation• Spinal cord injury typically secondary to actual Spinal cord injury typically secondary to actual

bony injury from swelling, bony fragment bony injury from swelling, bony fragment displacement, etc.displacement, etc.

• With dislocation, diameter of canal for spinal cord With dislocation, diameter of canal for spinal cord is impacted and can compress spinal cordis impacted and can compress spinal cord

• Must differentiate between spinal cord symptoms Must differentiate between spinal cord symptoms and brachial plexus injury symptoms (longer and brachial plexus injury symptoms (longer duration vs. transient symptoms)duration vs. transient symptoms)

• Often treat with steroid injections to limit swelling Often treat with steroid injections to limit swelling and subsequent pressure on spinal cord with these and subsequent pressure on spinal cord with these injuriesinjuries

QuadriplegiaQuadriplegia

• Transient quadriplegia often results from Transient quadriplegia often results from cervical hyperextension, hyperflexion cervical hyperextension, hyperflexion and/or axial loadingand/or axial loading

• Several predisposing factorsSeveral predisposing factors– Cervical stenosisCervical stenosis– Cervical spine instabilityCervical spine instability– Posterior arch abnormalities of cervical spinePosterior arch abnormalities of cervical spine

• If truly transient, symptoms often resolve If truly transient, symptoms often resolve within 48 hourswithin 48 hours