Sideline Evaluation Sideline Evaluation of the Eye, Face, and of the Eye, Face, and Related StructuresRelated Structures

Orthopedic Assessment III Orthopedic Assessment III – Head, Spine, and Trunk – Head, Spine, and Trunk

with Labwith Lab

PET 5609CPET 5609C

Orbital FracturesOrbital Fractures Asymptomatic Asymptomatic

Fractures:Fractures: Ice to injured area Ice to injured area

(loosely applied)(loosely applied) Avoid direct pressure on Avoid direct pressure on

the globethe globe Symptomatic Fractures:Symptomatic Fractures:

Pain with eye movementPain with eye movement Shield the EyeShield the Eye

Instruct athlete to gaze Instruct athlete to gaze straight ahead with straight ahead with uninvolved eye (limits uninvolved eye (limits voluntary eye movement → voluntary eye movement → eyes move in unison)eyes move in unison)

Contact Lens RemovalContact Lens Removal

Hard Lenses Hard Lenses Removal:Removal: Open eyes wideOpen eyes wide Laterally pull outer Laterally pull outer

margin of eyelidsmargin of eyelids Patient blinks, forcing Patient blinks, forcing

lens outlens out

Soft Lenses Removal:Soft Lenses Removal: Patient looks upPatient looks up Clean finger placed on Clean finger placed on

inferior edge of lensinferior edge of lens Lens manipulated Lens manipulated

inferiorly and laterallyinferiorly and laterally Pinch between fingersPinch between fingers

Penetrating Eye InjuryPenetrating Eye Injury Penetrating Eye Penetrating Eye

Injuries:Injuries: Do NOT attempt to Do NOT attempt to

remove the objectremove the object Do NOT apply direct Do NOT apply direct

pressure on the eyepressure on the eye Shield the eyeShield the eye

If object is protruding If object is protruding far from the eye, use a far from the eye, use a paper/plastic cup to paper/plastic cup to covercover

Immediate Immediate transportation to transportation to hospitalhospital

Chemical BurnsChemical Burns Chemical Eye Burns:Chemical Eye Burns:

Injury caused by an Injury caused by an acid, alkali substance acid, alkali substance or an irritantor an irritant

Causes:Causes: Chemical is splashed in Chemical is splashed in

eyeeye Exposure to concentrated Exposure to concentrated

fumes and aerosolsfumes and aerosols Severity depends on Severity depends on

substance causing it substance causing it and exposure timeand exposure time

Usually, damage is Usually, damage is limited to the front of the limited to the front of the eyeeye

Chemical BurnsChemical Burns Chemical Eye Chemical Eye

Burns:Burns: Symptoms:Symptoms:

Eye pain and Eye pain and rednessredness

Sensitivity to light Sensitivity to light Eye irritation and Eye irritation and

tearingtearing Inability to keep Inability to keep

the eye open the eye open Sensation of Sensation of

something in the something in the eye eye

Swelling of the Swelling of the eyelidseyelids

Chemical Burns: Chemical Burns: TypesTypes Alkali Burns:Alkali Burns:

Alkalis - chemicals that Alkalis - chemicals that have a high pHhave a high pH

Most dangerous type of Most dangerous type of chemical burnchemical burn

Alkalis penetrate the Alkalis penetrate the surface of the eye surface of the eye

Common alkali Common alkali substances contain the substances contain the hydroxides of ammonia, hydroxides of ammonia, potassium, sodium, potassium, sodium, calcium, and calcium, and magnesiummagnesium

Lye, drain cleaner, metal Lye, drain cleaner, metal polishes, oven cleaners, polishes, oven cleaners, cement, lime, and cement, lime, and ammoniaammonia

Chemical BurnsChemical Burns Chemical Burns: Chemical Burns:

TypesTypes Acid Burns:Acid Burns:

Caused by chemicals Caused by chemicals with a low pH with a low pH

Less severe than alkali Less severe than alkali burnsburns

Acids usually damage Acids usually damage the very front of the the very front of the eyeeye

Sulfuric acid, sulfurous Sulfuric acid, sulfurous acid, hydrochloric acid, acid, hydrochloric acid, nitric acid, acetic acid, nitric acid, acetic acid, chromic acid, muriatic chromic acid, muriatic acid, and hydrofluoric acid, and hydrofluoric acid acid

automobile battery automobile battery explosion explosion

Chemical Burns: Chemical Burns: TypesTypes Irritants:Irritants:

Neutral pH. Neutral pH. Effect - Significant Effect - Significant

pain but does not pain but does not cause damage to the cause damage to the eye eye

Pepper spray Pepper spray

Chemical BurnsChemical Burns

Treatment:Treatment: Medical emergencyMedical emergency Wash your eye with Wash your eye with

water and/or saline water and/or saline immediatelyimmediately

Longer exposure – Longer exposure – increased damage increased damage

Wash the eye for at Wash the eye for at least 10 minutesleast 10 minutes

Patch the eyePatch the eye Transport Transport

immediatelyimmediately

LacerationsLacerations Initial Care:Initial Care:

Control bleedingControl bleeding After controlled, palpate area for After controlled, palpate area for

tenderness (possible underlying fracture)tenderness (possible underlying fracture) Imbedded object → leave in placeImbedded object → leave in place Facial laceration → refer to physician Facial laceration → refer to physician

(prevention of scars)(prevention of scars) Within 24 hoursWithin 24 hours

Throat laceration → assess AThroat laceration → assess ABBCsCs Avulsed tissue: (ear, nose, tongue)Avulsed tissue: (ear, nose, tongue)

Clean tissue (sterile water), wrap in gauze, put Clean tissue (sterile water), wrap in gauze, put on ice, transport with athlete to hospitalon ice, transport with athlete to hospital

LacerationsLacerations March 22, 1989: Clint March 22, 1989: Clint

MalarchukMalarchuk (Buffalo (Buffalo Saber) caught a skate Saber) caught a skate to the throatto the throat → severed → severed jugular veinjugular vein Jim Pizzutelli (ATC) Jim Pizzutelli (ATC)

reached into Malarchuk's reached into Malarchuk's neck and pinched off the neck and pinched off the bleeding until doctors bleeding until doctors arrived to begin suturing arrived to begin suturing the woundthe wound

Within minutes of deathWithin minutes of death 300 stitches300 stitches Back to practice 4 days Back to practice 4 days

laterlater

LacerationsLacerations

Feb. 12, 2008: Richard ZednikFeb. 12, 2008: Richard Zednik → → lacerated right neck (another players was lacerated right neck (another players was upended, skate swung up hitting Zednik upended, skate swung up hitting Zednik in the right side of the neck, nearly in the right side of the neck, nearly severing his carotid artery)severing his carotid artery) Underwent emergency surgery Underwent emergency surgery Five units of bloodFive units of blood Dr. Noor: “The slashed artery was hanging by Dr. Noor: “The slashed artery was hanging by

a thread.” She stressed if the artery had been a thread.” She stressed if the artery had been completely severed it would have recessed completely severed it would have recessed into the neck, requiring even more extensive into the neck, requiring even more extensive surgerysurgery

LacerationsLacerations

LacerationsLacerations

Laryngeal Injuries:Laryngeal Injuries: Can be life-threateningCan be life-threatening

Signs:Signs: Progressive swellingProgressive swelling Crepitation (presence of subcutaneous air)Crepitation (presence of subcutaneous air) Stridor – harsh, high-pitched sound during Stridor – harsh, high-pitched sound during

respiration (resembles blowing wind)respiration (resembles blowing wind) Bleeding from oral cavityBleeding from oral cavity

Treatment:Treatment: Stabilize and transportStabilize and transport

Facial FracturesFacial Fractures

MOI → Significant blunt traumaMOI → Significant blunt trauma May also cause head injury May also cause head injury

(concussion)(concussion) UnconsciousUnconscious Head injury takes precedenceHead injury takes precedence

Stable facial fracture: (airway Stable facial fracture: (airway intact)intact) Move athlete to sidelineMove athlete to sideline Obvious fracture presentObvious fracture present

Facial FracturesFacial Fractures Sept. 28, 2008 – Sept. 28, 2008 –

Anquan Boldin injuryAnquan Boldin injury Knocked unconsciousKnocked unconscious Fractured paranasal Fractured paranasal

sinuses and other sinuses and other facial injuriesfacial injuries

Surgery: Eight plates Surgery: Eight plates in his face and wiring in in his face and wiring in his jawhis jaw

Only missed three Only missed three weeksweeks

http://www.youtube.com/watch?v=j9RfJwSkMU8

TMJ InjuriesTMJ Injuries

MOI:MOI: Blow to the Blow to the jawjaw Mandible injuryMandible injury

Signs/Symptoms:Signs/Symptoms: Malocclusion – Malocclusion –

remove athlete from remove athlete from participationparticipation

Immediate referralImmediate referral Dislocation – can Dislocation – can

immobilize athlete immobilize athlete with Philadelphia with Philadelphia collarcollar

Nasal Fractures/EpistaxisNasal Fractures/Epistaxis

Nasal Fractures:Nasal Fractures: With Epistaxis → With Epistaxis →

control the bleedingcontrol the bleeding Traditional Method – Traditional Method –

should it be used?should it be used? With Fracture:With Fracture:

Pack nose with gauzePack nose with gauze IceIce Rolled cotton gauze Rolled cotton gauze

placed between placed between anterior upper lip and anterior upper lip and gumgum

Pressure placed on Pressure placed on nasal mucosa nasal mucosa arteriesarteries

Nasal Fractures/EpistaxisNasal Fractures/Epistaxis

Nasal Fractures:Nasal Fractures: Treatment:Treatment:

Control bleedingControl bleeding Nose, Cartilage, Nose, Cartilage,

maxillary, zygomatic, maxillary, zygomatic, and frontal bones can and frontal bones can be palpated for be palpated for tendernesstenderness

Deformity present:Deformity present: Athlete discourage to Athlete discourage to

looklook ShockShock

Dental InjuriesDental Injuries Tooth Injury Tooth Injury

(other than class I (other than class I fracture)fracture) → remove → remove from competitionfrom competition Immediate referral Immediate referral

to dentistto dentist Avulsed tooth – Avulsed tooth –

Find It!Find It! Death of tooth – Death of tooth –

primary reason due primary reason due to death of to death of periodontal ligament periodontal ligament attached to avulsed attached to avulsed toothtooth

Dental InjuriesDental Injuries Avulsed Tooth:Avulsed Tooth:

Tooth separated from bony socket → tearing of the Tooth separated from bony socket → tearing of the periodontal ligamentperiodontal ligament

First aid: SurvivalFirst aid: Survival depends on rapid replacement depends on rapid replacement into socketinto socket

Replantation: Preferably done at the site of Replantation: Preferably done at the site of injury (minimize extra-alveolar time - tooth injury (minimize extra-alveolar time - tooth out of socket)out of socket) Attempt to replant tooth within first 15-20 min Attempt to replant tooth within first 15-20 min

(stabilize by biting down gently on towel or gauze(stabilize by biting down gently on towel or gauze If the thin gum tissue (periodontal ligament) that is If the thin gum tissue (periodontal ligament) that is

attached to the roots of the tooth dries before the tooth is attached to the roots of the tooth dries before the tooth is replaced (extra-alveolar period >1 hour) – chance of tooth replaced (extra-alveolar period >1 hour) – chance of tooth loss loss ↑↑

Minimal consequences if periodontal ligament is left Minimal consequences if periodontal ligament is left attached to the root surface and does not dry out attached to the root surface and does not dry out (extra-alveolar period <1 hour)(extra-alveolar period <1 hour)

Dental InjuriesDental Injuries Do not handle tooth on Root Do not handle tooth on Root

SurfaceSurface Never brush/scrub toothNever brush/scrub tooth Do NOT sterilize with disinfecting Do NOT sterilize with disinfecting

solutionssolutions If debris present, gently rinse with If debris present, gently rinse with

saline or water (10 seconds) and saline or water (10 seconds) and than replantthan replant

Other alternatives: (Transporting Other alternatives: (Transporting mediums)mediums) Best:Best: Save-A-Tooth container Save-A-Tooth container

Should be in ATC’s kitShould be in ATC’s kit 2nd best:2nd best: Milk Milk 3rd best:3rd best: Under athlete's tongue Under athlete's tongue

ONLY if athlete is conscious and ONLY if athlete is conscious and alert or in a container into which alert or in a container into which the athlete spitsthe athlete spits

4th best:4th best: Wrap in saline-soaked Wrap in saline-soaked gauzegauze

5th best:5th best: Water Water Least desirable storage medium  Least desirable storage medium  

Transport immediatelyTransport immediately