Chapter 9

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

2. Injuries to Head, Neck, and Face • Concussions, neck sprains and strains, skull or neck fractures, facial lacerations (cuts), vision or hearing loss are only a few of the traumatic injuries that can affect the head, neck, and face. • Unfortunately, mismanagement can be the difference between complete recovery, permanent disability or death.

3. Anatomy Review • Skull • 8 cranial bones • Where they meet are called suture joints. • Housing and protection of the brain. • 14 facial bones • Facial form and structure. • Protection of eyes, ears, nose, and throat.

4. Anatomy Review (cont.) • Soft tissue structures including the skin, connective tissue, periosteum, cranial bones, and the meninges help to protect the brain. • Meninges lay underneath cranial bones. • Dura, arachnoid, and pia maters.

5. Meninges • Dura mater is dense and highly vascularized. • Arachnoid (middle layer) is less dense and avascular (no blood flow). • Sub-arachnoid space contains cerebrospinal fluid (CSF). • CSF cushions the brain and spinal cord from external forces. • Pia mater (innermost layer) is thin, delicate, and highly vascularized (high blood flow).

7. The Face • The face is composed of skin placed over underlying bones. • Muscles, cartilage, and fat provide minor protection. • Several areas of the face are prone to injury, particularly orbits of the eyes (eye sockets), nasal bones, and mandible (jaw).

8. Central Nervous System (CNS) • Brain and spinal cord make-up the CNS. • Highly protected by bony and soft tissue. • CNS consists of gray and white matter and weighs 3 to 3.5 lbs (adult). • Brain has three basic components – cerebrum, cerebellum, and brain stem. • Neural impulses travel to and from the CNS via 12 pairs of cranial nerves and 31 pairs of spinal nerves (8 cervical)

9. The Neck • Cervical spine • The 7 cervical vertebrae provide support for the head and protection for the spinal cord. • Construction allows for wide range of motion. • Trade off between stability and range of motion.

10. The Neck • The first cervical vertebra (C-1) is called the atlas. • The atlas articulates (connects) with the occipital bone to form R and L atlanto-occipital joints. • The second cervical vertebra (C-2) is called the axis (allows for rotation of head on neck). • The skull and C-1 articulate as a unit with C-2 to form the atlantoaxial joint.

11. Head and Neck Injuries in Sports • Even minor head trauma can result in serious injury. • Coaches need to learn to recognize head and neck injuries and give first aid when necessary. • Brain tissue is unable to repair itself. • Adolescents brains are especially susceptible (more impressionable, still growing). • Many will result in permanent disability (catastrophic injury). • Severe injuries can result in death.

12. Head and Neck Injuries in Sports • Many descriptive classifications for head injuries. Three general categories: • Mild traumatic brain injury or concussion • Intracranial hemorrhage (bleeding inside skull) • Skull fracture • Head injuries can occur in any sport. • Alarming increase in the sport of cheerleading. • Approximately 300,000 traumatic head injuries over a 3-year study of high school and collegiate football players. (Guskiewicz K, et al., 2000)

13. Mechanisms of Head Injury • Direct mechanism of injury involves a blow to the head that causes injury at impact site (coup injury) or on the opposite side of the skull from impact (contrecoup injury). • Indirect injury to the head results from damaging forces traveling from other parts of the body. • Blow to jaw, nose, or landing on tailbone. • Treat every head injury as if there is a neck injury and vice versa.

14. Coup Contrecoup http://www.traumaticbraininjuryatoz.org/mild-tbi/coup-contrecoup

15. Concussions(Mild Traumatic Head Injury) • A concussion is “a complex pathophysiological process affecting the brain, induced by biomechanical forces.”(McCory et al., 2013) • Signs and symptoms may include • unconsciousness, disorientation, headache, vision changes, amnesia (anterograde or retrograde), dizziness, nausea, vomiting, ringing in ears, memory loss, and disequilibrium. • An athlete MUST only experience one sign or symptom to have experienced a concussion. • Signs and symptoms can evolve over a number of minutes to hours.

16. Signs and Symptoms of Concussion • Physical • Numbness/tingling, ringing of ears, sensitivity to light or noise, loss of consciousness, unstable gait • Balance disturbances • Inability to maintain equilibrium, visual problems, diminished pupil reaction • Somatic changes • Headache, vomiting, nausea, confusion, poor concentration, forgetful, and sleepiness

17. Signs and Symptoms of Concussion • Memory loss • Anterograde amnesia: inability to recall events after the time of the injury. • Retrograde amnesia: inability to recall events before the injury. • Concentration deficits • Information processing deficits – slurred speech, unable to follow directions. • Emotional changes • Excessive anger or apathy. Depression or sadness.

18. Concussions • No two concussions are alike • Current medical practice has moved away from classification systems. • The best way to determine the required treatment for a concussion is to monitor the intensity and severity of the signs and symptoms. • The majority of concussions resolve in less than 10 days, with adolescents taking longer. • Symptoms lasting more than 10 days should be managed involving physicians.

19. Concussions • Recent research has demonstrated: • Loss of consciousness happens in only 9% • Amnesia only happens in 27% • Therefore, follow-up functional assessments utilizing a standardized list of typical symptoms, concentration tests, and balance/neurological assessments may provide for better care of the concussed athlete.

20. Concussions • Recent evidence suggests that there is some level of structural damage in all concussions. • Minor changes may include decreases in blood flow, increases in intracranial pressure, or tissue anoxia. • Any brain cells not destroyed remain extremely vulnerable to subsequent trauma. • Players sustaining a concussion have 3x increased risk of sustaining an additional concussion. • Current guidelines recommend that athletes NOT return the same day of a concussion and NOT return until free of signs and symptoms.

21. Second Impact Syndrome • Second Impact Syndrome (SIS) is a serious problem. • Results when an athlete with a head injury receives another head injury before the symptoms of the initial injury have resolved. • Involves rapid, catastrophic brain swelling that can result in death. • Any athlete sustaining a head injury, no matter how minor, should be referred to a physician before being cleared to return to participation.

22. Head Injuries in Sports • Skull fracture • May also have associated soft tissue injury. • More severe forms of cranial injury involve depressed skull fractures. • Involves bone fragments being pushed into the cranial region.

23. Head Injuries in Sports • Intracranial Injury • These injuries are potentially life threatening. • Majority result from blunt trauma to the head causing rapid deceleration or even rapid rotational motions of the head. • Disruption of blood vessels results in intra-cranial bleeding (hematoma) and swelling within the cranium. • Some degree of permanent neurologic damage and even death can result.

24. Intracranial Injury • Epidural hematoma • Develops quickly due to arterial bleeding. • Subdural hematoma • Develops slowly due to venous bleeding. • In some cases, symptoms don’t appear for hours or even days after the initial injury. • Intracerebral hematoma • Bleeding within brain tissue. • Cerebral contusion • Brain tissue bruising.

26. Initial Treatment of a Suspected Head Injury • Include an initial check and physical exam • An athlete sustaining any level of concussion should not be allowed to return to play until cleared by a physician • Site of injury • Initial check and brief physical exam. • If any signs and/or symptoms of head or neck injury, he or she should not be moved until emergency medical services (EMS) personnel have arrived. • Secondary site (sideline, courtside, etc.). • More complete physical exam.

27. Initial Check • Always assume a neck injury has also occurred. • Check vitals first. • Note body and limb positions, as well as helmet, face mask, and mouth guard positions. • If unconscious, attempt to arouse and note approx. time of injury. Immobilize head and neck immediately; do not remove athlete’s helmet.

28. Initial Check • If unconscious: • Do NOT remove helmet. • Do NOT move the athlete. • Do NOT use ammonia capsules to revive athlete. • Listen near the athlete’s face for typical breathing sounds and look for movements of the thorax and/or abdomen. • If no signs of breathing or circulation are present, begin CPR and summon EMS.

29. Physical Examination • Coach collects as much information about the suspected head injury. • Do NOT rush through physical exam. • The physical exam must include assessments of: • Consciousness or unconsciousness. • Extremity strength (if conscious) without moving the neck. • Mental function (if conscious). • Eye signs and movements. • Neck pain. • Neck musculature spasm.

30. Physical Examination • It is important to remember the following statements when evaluating a helmeted athlete with a suspected head injury: • Don’t remove the helmet of a football player. Remove other helmets only if they are impeding stabilization and evaluation efforts. • Don’t move the athlete. • Don’t rush through the physical exam.

31. Physical Exam • If athlete is conscious: • Perform bilateral grip strength tests and dorsiflexion strength. • Check for sensations on both sides of body by pinch tests. • Check pupil sizes and response to light. Evaluate ability of eyes to follow moving object side to side. • Note loss of peripheral vision or jerking eyeball movements. • Palpate neck for deformity, moving from base of skull to bottom of neck.

32. Physical Exam • Based on these observations, determine level of consciousness. • Athlete with any loss of consciousness should not be moved. • Monitor vital signs. • Summon EMS.

33. Physical Exam • Upon determination of consciousness, the athlete should carefully be moved from a laying-down position to a sitting position. • Monitor vitals and behavior for 1-2 minutes • If the athlete appears normal, move them to a standing position and continue to monitor vitals and behavior. • As the athlete moves towards the sidelines, the emergency team should provide continued physical support.

34. Sideline Assessment • The objective of this phase of the evaluation is to determine the presence of any signs or symptoms of head injury that may have developed since the time of the initial injury. • This information is of vital importance when confronted with making decisions regarding medical referral, as well as clearance for return to participation.

35. Sideline Assessment Tools • Standardized Assessment of Concussion (SAC) • a convenient and reliable way to quickly assess neurocognitive function in the areas of orientation, immediate memory, concentration and delayed recall. • Sports Concussion Assessment Tool (SCAT3) • Glasgow Coma Scale, an interview for determining if consciousness was lost, Maddocks Score, graded symptom scale checklist, a cognitive, a neck examination, balance error scoring system [BESS], a coordination test, and a delayed-recall test.

36. Home Instructions • Take home information should be given in written from and discussed with the caregiver. • A list of red flags that warrant transportation to a hospital and advice to avoid cognitive and physical exertion. • Athletes should be allowed to sleep and should not be awakened every 2 hours. • Acetaminophen is recommended.

37. Return to Play • After the no activity period ends (signs and symptoms free), each step of the gradual return to play should be performed in no less than a 24 hour time period • No activity—limited cognitive and physical activity; general rest • Light aerobic exercise • Sport-specific exercise • Noncontact training drills and resistance training • Full contact practice • Return to play

38. Cervical Spine Injuries • Cervical injuries can occur in almost any sport. • Majority occur in football, rugby, ice hockey, soccer, diving, and gymnastics. • Mechanisms of injury include hyperflexion, hyperextension, rotation, lateral flexion, and axial loading. • Serious injuries occur when intact vertebra or fragments of fractured vertebra are displaced or an intervertebral disk ruptures and places pressure on spinal cord or nerve roots.

39. Mechanism of Cervical Spine Injuries • Most cervical spine injuries result from an axial load. • Spearing in football produces axial load (NCAA prohibited technique in 1976). • In 2005, there was a renewed increased emphasis on proper technique to eliminate spearing and minimize neck injuries.

40. Types of Cervical Spine Injuries • Neck fractures and dislocations • Neck sprains • Neck strains • Muscle strains in the neck rarely involve neurologic damage. • Nerve compression or stretching • Brachial plexus injuries can produce significant but transient symptoms.

41. Signs and Symptoms of Cervical Injuries • Neck fractures and dislocations • Pop of snap heard. • Burning, numbness, or tingling and extremity dysfunction is likely. • Neck sprains and strains. • Very similar – location of tenderness and mechanism will vary. • Brachial Plexus Nerve Injury • Pain radiates into the affected arm. • Decrease in voluntary use of the arm (often the arm appears limp).

42. General Treatment Guidelines • In the absence of a medical care provider, coaching personnel must take great care when conducting an examination of an athlete suspected of having a neck injury. • Stabilize the head and neck. • Determine if the athlete is conscious. If unconscious, check airway, breathing, and pulse (circulation). • Summon EMS. • Continue monitoring “ABCs.”

43. Initial Treatment of Injury Guidelines • If conscious, question the athlete regarding extremity numbness or loss of feeling, weakness, and/or neck pain. • If athlete reports the inability to move a limb or limbs or significant strength loss, stabilize head and neck and summon EMS.

44. Initial Treatment of Neck Injury • If EMS arrival is delayed and trained medical personnel available then the injured athlete can be placed on a properly constructed spine board. • This requires the coordinated effort of at least 5 people.

45. Spine Boarding an Athlete

46. Spine Boarding an Athlete

47. Removal of Athlete’s Helmet • Management of the helmeted player is a major issue. • Football head and face protective equipment create special problems. • In cases involving a neck injury, a football helmet provides means of cervical immobilization. • Coaches should not remove the helmet.

48. Football Face Mask Removal • If airway must be established, removal of the face mask is necessary. • Cut the clips with a device like the “Trainer’s Angel.” • If Trainer’s Angel is not available, removal of screws that hold the clips with a screwdriver is an option. • Once the clips are removed, the face mask can be rolled up, and out of the way of the airway.

49. Injuries to the Maxillofacial Region • Maxillofacial injuries include those to the jaw, teeth, eyes, ears, nose, throat, facial bones, and skin. • Modern protective equipment has reduced significantly the incidence of these injuries. Such equipment includes: • Mouth guards. • Protective eye wear. • Face shields.

50. Dental Injuries • Majority of dental injuries result from direct blows that result in tooth displacement or avulsion, a tooth fracture, or fracture of jaw or other facial bones. • Teeth are vulnerable to external blows that are common in many sports. • The human jaw has 32 teeth that are secured by cementum and periosteum.