The Head and Face

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The Head and Face

• Chapter 27

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Preventing Injuries to the Head, Face, Eyes,
Ears, Nose, and Throat

• Wearing proper protective equipment
• Instruct proper techniques of wearing the head
  and face equipment
• Instruct proper techniques of usage of head and
  face equipment

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Anatomy of the Head

• Skull (comprised of 22 bones)
• http//www.gwc.maricopa.edu/class/bio201/skull/sku
  lltt.htm
• Scalp
• http//www.lrc.bcm.tmc.edu/courses/anatomy/bighead
  neck/headneck22.html
• Brain
• http//www.pbs.org/wnet/brain/3d/index.html
• meninges
• cerebrospinal fluid

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Assessing Head Injuries

• History
• Observation
• Palpation (skull, cervical region)
• Special Test
• Eye function (PEARL, tracking, vision blurred)
• PEARL (pupils equal and reactive to light)
• Dilated or irregular
• Accommodation to light
• Eyes track smoothly (nystagmusinvoluntary back
  and forth or up and down motion indicates
  cerebral involvement)
• Vision blurry

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• Special Tests (continued)
• Balance Test (Rhombergs variations?)
• Rhombergseyes closed, stand with hands at side
  variations include single leg balance and tandem
  (heel toe) stance
• BESS (balance error scoring system) variations
  in stance and regaining lost balance
• Coordination Test (DUI, heel toe walk)
• Inability to perform indicates cerebrum injury
• Cognitive Test (counting backwards, months of the
  year, etc
• Neuropsychologiccal Assessments
• SAC(Standard Assessment of Concussion)
• Others?

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Assessing the Unconscious Athlete

• First priority to deal with life threatening
  injuries
• Breathing in particular
• Always suspect cervical injury
• Spine Board
• If no life threatening injury suspected
• Note length of time unconscious and do not remove
  if not necessary

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Recognition and Management of Specific Head
Injuries

• Skull Fracture
• Etiology blunt trauma
• Symptoms and Signsheadache, nausea, defect,
  blood from ear, nose, raccoon eyes(eechymosis
  around eyes) or battles sign(ecchymosis behind
  ears) straw colored fluid in ear canal or mouth
• Management
• Cerebral Concussion
• Defn immediate or transient posttraumatic
  impairment of neural function
• Etiology direct blow (coup or contrecoup)
• Symptoms and Signs (headache, tinnitus, nausea,
  etc)
• Management return to play?

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Concussions

• 2 primary symptoms disturbances in LOC and
  posttraumatic amnesia
• Retrograde nothing right before injury
• Anterograde no memory of events after injury
• Galscow Commas Scale
• Classifications
• Based primarily on length of LOC
• LOC appears in less than 10 of mild head
  injuries
• More recent classifications account for ability
  to concentrate, attention span difficulties,
  balance and coordination problems

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Determining when to return

• Dilemma
• If LOC, remove from competition
• Some tests say that even with mild injury (bell
  rung) that cognitive function does not return for
  3-5 days
• Should not return until all symptoms have
  subsided (conservative)
• Returning too early increases risk of second
  impact syndrome

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• Post Concussion Syndrome
• Poorly understood condition following concussion
• Etiology unknown
• Symptoms and Signs headache, lack of
  concentration, anxiety, vision problems, etc
• Management treat symptoms do not allow return
• Second Impact Syndrome
• Etiology rapid swelling and herniation of brain
  from 2nd injury before all symptoms have
  resolved minor blow may causes this brain
  autoregulation is disrupted
• Greater likelihood in athletes 20 or younger
• Symptoms and Signs initially looks minor but
  within 15secs to mins, rapidly worsens (dilated
  pupils, loss of eye movement, LOC, respiratory
  failure) 50 mortality
• Management Prevent it tx within 5 mons. Of
  dramatic life saving measures

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• Cerebral Contusion
• EtiologyIntracranial bleeding impact with
  immoveable object
• S/Svary LOC then alert and talking but have
  headaches, nausea and dizziness
• Management refer CT or MRI
• Epidural Hematoma
• Etiologytear of meningeal arteries direct blow
  or fracture
• S/S created very fast usually LOC regained and
  then gradual digression will go as far as
  convulsions, decrease in respirations and pulse
• Management life threatening refer for surgical
  relief

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• Subdural hematoma
• Etiologyvenous bleed into subdural space from
  acceleration/deceleration forces
• S/Sslow onset of symptoms LOC not required,
  headaches, dizziness, nausea, sleepy increases
  intracranial pressure
• Managementlife threatening
• Migraine headaches
• Etiology unknown but appear to be vascular
  related
• S/S flashes of light, blindness in half field of
  vision
• Management prevent (meds)
• Scalp injuries
• Etiology blunt or penetrating trauma
  (laceration, abrasions, contusions, hematomas)
• S/S bleeding
• Management clean areas (why is this difficult)

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Recognition and Management of Specific Head
Injuries

• Dental Injuries
• Anatomy(pg 801)
• gum, crown, root, dentin, pulp
• Prevention
• Tooth Fracture
• Etiology impact
• Symptoms and Signs varies
• Management refer

• Tooth Subluxation, Luxation, Avulsion
• Etiology impact
• Symptoms and Signsloose or dislodged
• Management
• Subluxation refer within 24 hours
• If possible, put back in normal position
• Avulsed tooth should be rinsed only and placed in
  Save-A Tooth, milk or saline
• Sooner it is re-implanted the better

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Facial Anatomy

• Bones
• Carry over form skull
• Maxillary, mandible(supports teeth, larynx,
  trachea, upper airway, upper digestive tract)
• Muscles
• TMJ
• Joint capsule
• Meniscus between mandibular condyle and temporal
  bone

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Facial Injuries

• Fractures
• Madibular
• Etiology collision sports direct blow 2nd most
  common
• S/S deformity, inability to bite normally,
  bleeding of gum, inability to fell lower lip
• Mange temp. immobilize and refer fixation
  approx 4-6 weeks
• Zygomatic complex (cheekbone)
• Etiology 3d most common direct blow
• S/S deformity on cheek region epistaxis
  (nosebleed), diplopia (double vision)
• Mange refer healing takes 6-8 weeks

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Facial Injuries

• TMJ
• Etiologydisk condyle derangement (disk moves
  anteriorly or stability problems at the joint
  (too much or too little)
• S/S headache, ear ache, neck pain and muscle
  guarding may report pain and clicking when jaw
  moves
• Mangeif cause is hypermobilty, strengthen
  hypomobility corrected with joint mobilizations
  treat pain PRN severe dental referral
• Facial Laceration
• Etiologydirect impact or indirect compressive
  force
• S/S
• Mange sutured require referral
• Special considerations eyebrows?

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Nasal Injuries

• Nasal Fracture
• Etiology most common fx to face direct blow
  from front or side
• S/S profuse hemorrhage, deformity, mobility or
  crepitus on palpation
• Manage control bleeding refer for x-ray and
  reduction
• Deviated Septum
• Etiology compression and lateral trauma
• S/S bleeding, septal hematoma, deformity
  painful
• Manage apply compression at site of hematoma
  (these are drained surgically), then nose packed
  and drainage allowed to continue. If this is
  mismanaged, the hematoma can complicate healing
  and cause difficult to correct deformities

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Nasal Injuries

• Epistaxis
• Etiology direct blow resulting in contusion
• S/S nose will bleed usually stops some will
  cauterize to prevent future problems
• Manage site upright with cold compress may
  place gauze between lip and gum (direct pressure
  to arties supplying nasal mucosa) if doesnt
  stop, try styptic solution on hemorrhage point
  may plug nose with guaze

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Ear Injuries

• Auricular Hematoma (cauliflower Ear)
• Etiology Compression or shearing injury that
  causes subcutaneous bleeding into auricular
  cartilage
• S/S deformity due to accumulation of fluid /
  hematoma / coagulation results in keloid
  (elevated, nodular) This can only be removed
  through surgery.
• Manageto prevent, ear headgear, apply lubricant
  to ear of those predisposed immediate
  application of cold pack will reduce hemorrhage

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Ear Injuries

• Otitis Externa (swimmers ear)
• Infection in ear canal caused by bacteria
• athlete will complain of pain, itching, and
  partial hearing loss
• Prevention clean and dry ears, do not stick
  objects in ear, avoid drastic environmental
  exposures
• Otitis Media (inner ear infection)
• Accumulation of fluid in middle ear caused by
  local and systemic infection
• results in intense pain, hearing loss, fever,
  headache, nausea
• Treat with antibiotics

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Eye injuries

• Orbital Fractures
• Etiology Direct Blow to orbit
• S/S diplopia, restricted movement, hemorrhage
• Mange refer for x-ray antibiotics
  prophylatically
• Foreign Body in eye
• Severe cases when the object cannot be wiped
  away or washed out, close eye, cover with patch
  and refer to doctor for further treatment

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• Retinal Detachment
• Blow to the eye separate retina from eth
  pigment more common among nearsighted athletes
• S/S painless, speaks floating before eye,
  flashes of light, burred vision
• Management immediate referral to ophthalmologist
• Acute conjunctivitis
• Etiology bacteria or allergens irritations
• S/S swelling of eyelid, discharge, itching,
  burning
• Mange highly infectious
• Sty (Hordeolum)
• Infection of eyelash follicle or sebaceous gland
  usually caused by organism that is spread by
  rubbing or dust particles
• S/S erythema of eye localizes to pustule in a
  few days
• Manage hot, moist compresses and ointment if
  reoccurs, refer t o ophthalmologist