1. Injuries to the Head, Neck and Face
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 , 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. Head Injuries in Sports (continued)
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

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. Initial Treatment Guidelines
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”

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

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. Background Information (continued)
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

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

33. Spine Boarding an Athlete1 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. Eye Injuries
retinal injuries develop slowly -- early symptoms include:
floating particles in field of vision
distorted vision
changes in the amount of light seen

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 Evaluation & treatment guidelines
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 Incus
Stapes
Temporal
bone
Malleus
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

51. Face Injuries Signs/symptoms include:
extreme pain/deformity in the region of the TMJ
inability to move lower jaw
jaw is “locked”
Do NOT attempt to put back into place.
treatment includes: application of ice pack and medical referral.
zygomatic bone may be fractured

52. Injuries to the Maxillofacial Region
signs/symptoms include:
pain and swelling
discoloration that spreads to the region of the orbit
treatment includes: application of ice pack and medical referral

53. Face Injuries Wounds of the facial region
wounds can take many forms and treatment should follow basic first aid protocol
carefully clean with mild soap and apply sterile dressing
such wounds can present cosmetic problems
In general, any wound with observable space between margins may require suturing.
after suturing, return to play decisions are made by the doctor