Chapter 9

1. Chapter 9 Injuries to the Head, Neck and Face

2. The skull • 8 cranial bones & 14 facial bones • parietals (2), temporals (2), frontal, occipital, sphenoid & ethmoid • cranial bones, articulations of the suture type

3. Soft Tissue

4. Anatomy Review • Central Nervous System (CNS) • brain and spinal cord comprise the CNS • CNS protected by meninges, cranium and vertebrae • CNS consists of gray and white matter and weighs 3.0 to 3.5 lbs.

5. The Neck • Cervical spine • 7 vertebrae providing support for the head and protection for the spinal cord • C-1 (Atlas) articulates with the occipital bone • C-2 (Axis) articulates with C-1 via atlanto-axial joints

6. Head Injuries in Sports • Minor trauma can result in serious injury. • brain tissue is unable to repair itself -- any damage is permanent • possible mechanisms of injury are nearly infinite • coaches can learn to recognize head injuries and render aid

7. Head Injuries in Sports • From 1982-91, 1.5 million high school tackle football participants annually generated the greatest number of direct, catastrophic injuries in fall sports. • 1/5 high school players have sustained a concussion annually

8. Head Injuries in Sports • Cranial injury • involves the bones of the skull • may be associated soft tissue injury • depressed skull fracture • involves bone fragments being pushed into the cranial region

9. Head Injuries in Sports • Cerebral concussion • “clinical syndrome characterized by immediate and transient impairment of neurologic function secondary to mechanical forces” • unconsciousness, disorientation, amnesia, dizziness, disequilibrium • related to temporary disruption of blood supply

10. Head Injuries in Sports • Colorado Medical Society classification • grade 1 - most common -- no amnesia • grade 2 - either posttraumatic or retrograde amnesia • grade 3 - unique due to loss of consciousness • Second Impact Syndrome (SIS) – • recently recognized as a potentially serious problem • a concussion followed by another such injury prior to the resolution of symptoms related to the first injury

11. Head Injuries in Sports • involves rapid, catastrophic swelling of the brain -- putting pressure on the brain stem, often resulting in death Shaded areas of the brain stem represent areas of compression.

12. Any athlete sustaining a head injury, no matter how minor, should be assessed prior to returning to competition. Intracranial injury potentially life threatening majority result from blunt trauma disruption of blood vessels results in intra-cranial bleeding and hematoma Head Injuries in Sports (continued)

13. Head Injuries in Sports (continued) • major forms of intracranial bleeding include: • epidural hematoma • subdural hematoma • intracerebral hematoma • cerebral contusion • epidural hematoma develops quickly due to arterial bleeding while subdural hematoma develops slowly due to venous bleeding.

14. Initial Treatment Guidelines • Primary survey • always assume a neck injury • check vitals first • note body and limb position, helmet, face mask, and mouth guard Stabilizing the athlete’s head and neck

15. Initial Treatment Guidelines • if unconscious, attempt to arouse • note approx. time on injury • immobilize head and neck immediately, not removing athlete’s helmet. • detect breathing by listening near the airway and looking for movements of the abdomen and/or thorax • check carotid pulse with two fingers • monitor pulse for 30 seconds; if none, alert EMS

16. Initial Treatment Guidelines • Secondary survey • conscious athlete less complicated than unconscious • conscious or unconscious? • extremity strength • mental function • eye signs • pain specific to the neck • spasm of the neck musculature • determining level of consciousness is not always easy • if conscious, ask a few simple questions • loss of short term memory can indicate more serious injury

17. Initial Treatment Guidelines • Don’t arouse someone with ammonia capsules. • if conscious, use quick neurological tests, such as grip strength and skin sensation • examine the eyes, noting pupil size, responsiveness to light and side-to-side movement • palpate the neck for deformity

18. Initial Treatment Guidelines • Emergency procedures for football • equipment creates special problems • helmet, face mask, chin strap and mouth guard Trainer’s Angel

19. management of the helmeted player is a major issue if airway must be established, removal of the face mask is necessary cut the clips with a device like the “Trainer’s Angel” Initial Treatment Guidelines

20. Initial Treatment Guidelines Plastic clips secure the face mask. If a Trainer’s Angel is not available, removal of screws that hold the clips is an option.

21. Initial Treatment Guidelines • Once the clips are removed the face mask can be rolled up, out of the way of the airway

22. Initial Treatment Guidelines In the event of a neck injury, the helmet provides an excellent means of cervical immobilization.

23. Initial Treatment Guidelines • General Guidelines • Don’t move the athlete until the secondary survey is complete. • if the athlete is recovered, escort to the bench for observation • any suspicious signs/symptom -immobilize and summon EMS • in most cases, there is NO reason to move the athlete prior to arrival of EMS

24. Initial Treatment Guidelines • level of consciousness - single most important factor • in the majority of incidents, the athlete never loses consciousness • athlete with a head injury usually appears dazed and unstable • may also have tinnitus and memory loss • if there any doubts about severity, refer to a physician immediately

25. Initial Treatment Guidelines Romberg’s Test Finger-to-Nose Test

26. CMS guidelines -- pull any athlete with a grade I concussion for a minimum of 20 minutes for observation Anyone sustaining a Grade II or III concussion should be referred to a physician immediately. Initial Treatment Guidelines

27. Cervical Injuries • Neck injuries • majority occur in football, rugby, ice hockey, soccer, diving and gymnastics, however cervical injuries can occur in almost any sport • catastrophic injuries are rare -- 2/100,000 of all neck injuries, since 1977 less than 10 players/year suffer permanent cord injuries • mechanisms include: hyperflexion, hyperextension, rotation, lateral flexion, and axial loading • axial loading places the neck in a slightly flexed position • 1976 NCAA enacted the rule barring “spearing” however recent research indicates that the rule may not be effective.

28. Axial Loading Flexion with Axial Loading Extension

29. Spearing incidence has not changed much from 1975. cervical injuries include sprains, strains, intervertebral disks and brachial plexus strains generally more painful than serious severe injuries involve fractures that are displaced Background Information (continued)

30. Cervical Injuries • spinal cord may sustain secondary injury due to disruption of blood supply • neck strains rarely involve nerve damage • brachial plexus injuries can produce significant, but transient, symptoms • critical that coaching personnel take great care when conducting a primary and secondary survey of an athlete suspected of having a neck injury

31. Initial Treatment of Neck Injury Guidelines • Determine if the athlete is conscious, if unconscious, the first priority is basic life support. • Emergency plan should designate a “team leader.”

32. If conscious, question the athlete regarding numbness, weakness, dysesthesia. Appearance of such symptoms -- immediately stabilize head and neck and summon EMS. Initial Treatment of Injury Guidelines

33. Spine Boarding an Athlete 1 2 3 4

34. Injuries to the Maxillofacial Region • Jaw, teeth, eyes, ears, nose, throat, facial bones and skin • NEISS recorded 170,000 sports related injuries within the U.S. to these body areas. • Protective equipment has been developed and improved for many of these areas: • mouth guards • protective eye wear • face shields

35. Maxillofacial Region • Dental injuries • jaw has 32 teeth • teeth are vulnerable to external blows common in many sports • teeth are secured by cementum and periosteum

36. Maxillofacial Region • majority of dental injuries result from direct blows that loosen or knock teeth out • When rendering first aid, take precautions to avoid bloodborne pathogens. • Examining dental injuries • open/close mouth without pain? • general symmetry of the teeth? • irregularities in adjacent teeth? • bleeding, especially along gum line?

37. Injuries to the Maxillofacial Region • Loosened or knocked out • gently push back into place • if knocked out, clean with saline and put back into place • High risk sports -- use mouth guard • required in high school since 1966, NCAA in 1974 • stock, mouth-formed and custom fitted

38. Eye Injuries • Eye injuries • eye consists of a round ball-like structure housed within the orbit • globe is filled with vitreous body

39. Eye Injuries • posterior/inferior eye is covered by the retina • eyeball is encased in the sclera • eye injuries in the U.S. are on the increase (basketball and cycling). Proper position of the fingers for an initial examination of the eye

40. Eye Injuries • two categories -- contusional and penetrating • contusional injuries vary in severity -- simple abrasions to rupture of the eye • detached retina • penetrating injuries are less common -- shooting sports.

41. Eye Injuries • Initial evaluation guidelines • majority are simple corneal abrasions or small foreign objects • hold upper eyelid away from anterior eye • small foreign bodies usually found by observation • visible foreign object can be removed with a moist cue-tip, if imbedded, cover both eyes and transport to medical facility

42. Eye Injuries • if nothing can be seen in the eye, probably a corneal abrasion • contusions may result in hemorrhage around the eye known as a “black eye” • more severe cases may involve bleeding into the anterior eye known as “hyphema” -- refer to medical facility immediately • symptoms: pain, visual deficit (diplopia) and obvious bleeding into the eye

43. retinal injuries develop slowly -- early symptoms include: floating particles in field of vision distorted vision changes in the amount of light seen Eye Injuries

44. Eye Injuries • Contact lens problems • many athletes wear contacts with few problems; however, data show more problems related to hard lenses • biggest problem -- lens slipping or debris getting trapped between the lens and the eye • coach should have first aid kit to treat common problems including: wetting solution, small mirror, contact lens case

45. Nose Injuries • Nose injuries • often injured due to location -- bloody nose (epistaxis) may be the most common facial injury in sports • Anatomically, the nose consists of mostly cartilage and skin along with the R & L nasal bones. • Evaluation & treatment guidelines • any blow to the nose can cause a fracture • deformity and swelling at the bridge of the nose • If a fracture is suspected, treat the bleeding and refer to a medical doctor.

46. Ear Injuries • Ear injuries • anatomically, the ear is similar to the nose • external opening and extensive internal structure • external ear (auricula) • external acoustic meatus • middle ear • inner ear (labyrinth) • inner ear has a role in equilibrium

47. Anatomy of the Ear Semicircular Canals Vestibular nerve Auditory nerve Incus Stapes Malleus Temporal bone Cochlear nerve Pinna Cochlea Oval Window External auditory meatus (canal) Tympanic membrane Round Window Eustachian tube

48. Ear Injuries • majority of ear problems are related to the external ear • sports such as wrestling are related to numerous ear problems because of contact with opponents and/or playing surface, required head gear has reduced incidence of such injuries

49. Ear Injuries • Cauliflower ear should be treated with cold pack and immediately referred to a medical doctor. • severe blows to the outer ear can result in a ruptured ear drum • inner ear infections can result in problems in high risk sports

50. Injuries to the Maxillofacial Region • Fractures of the face • certain sites are more common: • lower jaw • signs/symptoms include: • pain/swelling • deformity & malocclusion