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Head and Neck

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  1. Head and Neck Orthopedic Assessment III – Head, Spine, and Trunk with Lab PET 5609C

  2. Clinical Anatomy

  3. Clinical Anatomy

  4. Clinical Anatomy • Brain: Cerebrum • Largest section of brain (most anterior and superior region of CNS) • Formed by 2 hemispheres: • Longitudinal fissure – separates 2 sides • Right and Left Hemisphere: • Frontal lobe • Parietal lobe • Temporal lobe • Occipital lobe

  5. Clinical Anatomy

  6. Brain: Cerebrum Functions: Motor function Sensory information: Temperature Touch Pain Pressure Proprioception Special senses: Visual Auditory Olfactory and taste Functions (cont.) Cognition: Spatial relationships Behavior Memory Association Communication: Right hemisphere → controls left side of body Left hemisphere → controls right side of body Clinical Anatomy

  7. Clinical Anatomy • Brain: Cerebellum • Quick processor of incoming/outgoing information: • Integrates sensory perception, coordination and motor control: Cerebellum → linked to cerebral motor cortex (sends info to muscles) and spinocerebellar tract (proprioceptive feedback) • Constant feedback on body position → fine tunes motor movements • Key: Maintains BALANCE and COORDINATION

  8. Clinical Anatomy

  9. Brain: Diencephalon Processing center for conscious and unconscious brain input Parts: Thalamus Hypothalamus Epithalamus Clinical Anatomy

  10. Brain: Thalamus Functions: Translates information (inputs) for cerebral cortex Processes and relays sensory information Helps regulate states/levels of sleep and consciousness Clinical Anatomy

  11. Clinical Anatomy

  12. Clinical Anatomy • Brain: Hypothalamus • Control of Hydration: Supraoptic nuclei and Paraventricular nuclei (Hypothalamus) • What Happens? • Hydration Level too LOW • Osmoreceptors in blood detect increased concentration of salt in blood • Hypothalamus stimulated – neurosecratory hormones • Vasopressin released from Posterior Pituitary • ADH causes kidneys to retain water • Level of water increases in the body

  13. Brain: Brain Stem Lower part of the brain (continuous with spinal cord) Medulla Oblongata Pons Functions: Main motor and sensory innervation to face and neck Cranial nerves Regulation of cardiac and respiratory function (medulla) Relays information to and from the CNS Pons: Link between cerebellum to brain stem and spinal cord Clinical Anatomy

  14. Clinical Anatomy • Brain: Meninges • 3 connective tissue layers which protect the CNS • Supports blood vessels • Contains cerebrospinal fluid • Pia mater: • Innermost layer (outer “skin” of brain) • Dura Mater: • Outermost layer • Serves as periosteum for skull’s inner layer • Arachnoid Mater: • Middle layer • Subdural space – area between dura mater and arachnoid mater • Subarachnoid space – beneath the arachnoid • Contains cerebrospinal fluid

  15. Clinical Anatomy

  16. Cerebrospinal Fluid: Clear, colorless liquid that bathes the brain and spinal cord (circulates within subarachnoid space) Functions: Cushions the brain within the skull Shock absorber for the CNS Circulates nutrients and chemicals filtered from the blood and removes waste products from the brain Clinical Anatomy

  17. Brain blood demand: 20% of body’s O2 uptake at rest ↑ 10 Celsius, brains demand ↑ 7% Supplying vessels: Vertebral arteries Carotid arteries: Internal External Circle of Willis Clinical Anatomy

  18. Clinical Evaluation • Key Points: • All unconscious athletes must be managed as if a fracture or dislocation of the cervical spine exists until the presence of these injuries can be definitively ruled out • Ideally, 2 responders are available to evaluate: • In-line stabilization and immobilization of athlete’s head • Initial evaluation: • Palpation • Sensory and motor tests

  19. Clinical Evaluation

  20. Clinical Evaluation • Initial Evaluation: • Assess ABC’s: (airways, breathing, circulation) • Moving, speaking athlete → ABC’s present • Still suspect cervical spine injury (until ruled out) • Level of Consciousness: • Communicate with athlete (verbal) • Unresponsive athlete: • Apply painful stimulus: • Lunula of fingernail • Pressure to sternum

  21. Initial Evaluation: Primary Survey: Look, listen, feel for breathing Absent breathing → modified jaw thrust to open airway Absent pulse → CPR Initiate EMS! Secondary Survey: Bleeding Possible fractures, dislocations Clinical Evaluation

  22. Clinical Evaluation • History: • Location of symptoms: • Cervical pain or muscle spasm: • Pain • Numbness • Burning • Head pain: • Headaches

  23. Mechanism of Injury: Head Coup Injury: Stationary skull is hit by object traveling at high velocity (i.e. hit in head with baseball) Trauma → side of head where contact occurred Contrecoup Injury: Skull is moving at high velocity and is suddenly stopped (i.e. falling and hitting head on the ground) Brain strikes the skull on side opposite of the impact Clinical Evaluation

  24. Clinical Evaluation

  25. Clinical Evaluation

  26. Mechanism of Injury: Head Repeated subconcussive forces: Repeated trauma: Boxing Heading in soccer Rotational or shear forces: Twisting Acceleration and deceleration Clinical Evaluation

  27. Clinical Evaluation • Mechanism of Injury: Cervical spine • Most forces → dissipated by cervical musculature and intervertebral discs • Flexion, extension, lateral bending, rotation • Flexion: • Removes natural lordotic curvature (30 degrees) • Forces directed to cervical vertebrae • Axial load → through vertical axis of vertebral column • Catastrophic injuries

  28. Clinical Evaluation

  29. Clinical Evaluation

  30. Clinical Evaluation • History: • Loss of consciousness: • Record athlete’s initial responses: • “Seeing stars” • “Blacking out” • “Do you remember being hit?” • History of concussion: • Recent concussions → increased risk • Second impact syndrome • Complaints of weakness: • Fatigue • Muscular weakness: • More serious: • Trauma to brain, spinal cord, spinal nerve roots

  31. Clinical Evaluation • Inspection: Bony Structures • Position of head: • Head should be upright in all planes • Laterally flexed and rotated head → possible cervical vertebrae dislocation • Cervical vertebrae: • View athlete from behind (positioning of spinous processes) • Mastoid process: • Battle’s sign → ecchymosis over mastoid process • Basilar skull fracture • Skull and scalp: • Bleeding, swelling, deformity

  32. Inspection: Eyes General: Dazed, distant stare may indicate mental confusion Nystagmus: Involuntary cyclical movement of the eyes Pupil size: Unilateral dilation (pressure on cranial nerve III) Note: Anisocoria (normal unequal pupil size) Pupil reaction to light Clinical Evaluation

  33. Inspection: Nose and Ears Ears: Bleeding and/or cerebrospinal fluid Skull fracture Nose: Bleeding Nose fracture or skull fracture Nose/eyes: Raccoon eyes → skull or nasal fracture Clinical Evaluation

  34. Palpation: Bony Structures Spinous Processes: Patient seated, leaning slightly forward C7 and ↑ Transverse Processes Skull: Occipital and temporal Sphenoid and zygomatic Parietal and frontal Palpation: Soft Tissue Musculature: Trapezius SCM Throat Clinical Evaluation

  35. Clinical Evaluation • Special Test: Halo Test • Patient position: • Lying or seated • Examiner position: • At patient’s side • Procedure: • Fold a piece of sterile gauze into a triangle • Using the point of the gauze, collect a sample of the fluid leaking from the ear or nose (allow it to be absorbed) • Positive test: • Pale yellow “halo” will form on the gauze • Implications: • Cerebrospinal fluid leakage

  36. Clinical Evaluation • Functional Testing: Memory • Retrograde amnsesia: • Inability to recall events before injury • Anterograde amnesia: • Inability to recall events after injury • Fading memory → progressive deterioration of cerebral function

  37. Clinical Evaluation: Anterograde Amnesia

  38. Clinical Evaluation • Functional Testing: Cognitive Function • Cerebral trauma → Unusual athlete behavior • Behavior: • Violent, irrational, inappropriate behavior • Analytical Skills: • Serial 7’s (count backwards from 100) • Information Processing: • Provide command → can athlete follow?

  39. Clinical Evaluation • Balance and Coordination: • Affected secondary to trauma involving cerebellum and inner ear • Tests: • Romberg Test • Tandem Walking • Balance Error Scoring System

  40. Romberg Test: Patient Position: Standing, feet shoulder width apart ATC Position: Ready to support patient Procedure: Patient shuts eyes and abducts arms to 900 Patient tilts head backwards and lifts 1 foot off ground Patient touches index finger to nose (eyes closed) Positive Test: Patient unsteadiness Implications: Cerebellar dysfunction Clinical Evaluation

  41. Clinical Evaluation • Tandem Walking: • Patient Position: • Athlete standing with feet straddling a straight line • ATC Position: • Beside patient to provide support • Evaluation: • Athlete walks heel-to-toe along a straight line for approximately 10 yards • Athlete returns to starting position by walking backwards • Positive Test: • Athlete unable to maintain a steady balance • Implications: • Cerebral or inner ear dysfunction that inhibits balance

  42. Clinical Evaluation • Balance Error Scoring System: • Patient Position: • Patient barefoot or wearing socks (no tape); hands on iliac crest; eyes closed • Phase 1: • Double Leg Stance • Phase 2: • Single Leg Stance – standing on the nondominant leg; non-weight-bearing hip flexed to 200 and knee flexed to 400-500 • Phase 3: • Tandem Leg Stance – nondominant leg placed behind the dominant leg and the patient stands in a heel-toe manner

  43. Clinical Evaluation • Balance Error Scoring System: • ATC Position: • In front of the athlete; trials are timed • Procedure: • First battery performed with athlete standing on a firm surface • DL stance, holds position for 20 seconds • SL stance • Tandem stance • Second battery performed with athlete standing on foam

  44. Clinical Evaluation • Balance Error Scoring System: • Scoring: One point is scored for each of the following errors • Hands lifted off iliac crest • Opening eyes • Step, stumble or fall • Moving hip into > 30 degrees abduction • Lifting forefoot or heel • Remaining out of testing position > 5 sec. • Note: • If more than 1 error scores simultaneously, only 1 error is scored • Patients unable to hold the test position for 5 seconds are assigned the score of 10 • Positive Test: • Scores that are 25% ABOVE patient’s baseline • Impaired cerebral function

  45. Clinical Evaluation • Standardized Assessment of Concussion (SAC) • Abbreviated neuropsychological test • Immediate objective data • Presence and severity of neurocognitive impairment • On or off field evaluation • Tests: • Orientation • Immediate Memory Recall • Concentration • Delayed Recall