Athletic Injuries ATC 222 Head Face Eyes Ears

Athletic Injuries ATC 222 Head, Face, Eyes, Ears, Nose, and Throat Chapter 27

Facial Injuries • Mandible Fracture – – – deformity malocclusion malalignment bleeding around teeth/gums lower lip anesthesia pain with biting • Treatment

Facial Injuries • Mandible Dislocation/Subluxation – commonly from lateral force – malalignment – malocclusion – open, locked jaw

Dental Injuries • Types – fracture – dislocation/subluxation • Treatment – realign subluxation – replace/preserve dislocation or fracture – 30 minute survival rate

Nasal Injuries • Fracture or Cartilage Separation – S/S • • deformity profuse bleeding immediate swelling crepitus – treatment • control hemorrhaging • referral • most return to activity in 3 -4 days

Nasal Injuries • Epistaxis (nosebleed) – – – sit upright ice (nose and ipsilateral carotid) direct pressure on nostril cotton/gauze plug refrain from nose blowing for 2 hours

Eye Injuries • Causes and Prevention • S/S or Serious Eye Injury – – – prolonged blurred vision loss of part/all of visual field sharp, stabbing, throbbing pain double vision embedded object blood in anterior chamber (hyphema)

Treatment of Serious Eye Injury • immediate referral • cover both eyes with embedded object • ice only to surrounding tissue • no pressure applied to eyes

• • Orbital Blowout Fx Blunt trauma Inability to look upward Diplopia Sunken eye

What is wrong with this picture?

Orbital Hematoma • “Black Eye” • Bleeding in orbit area and poss. Sclera • Rule out serious eye injury

Foreign Body in Eye • Embedded? • Removal – Close eye – eye rinse – removal with gauze pad

The ole finger in the eye play!!!!

Ear Injuries • Hematoma Auris (cauliflower ear) – causes – S/S • swelling • redness, warmth • pain – treatment • ice • protection • aspirate

Otitis Media and Externa • Etiology • Signs and Symptoms • Treatment

Neurological System and Evaluation

Neuron (Nerve Cell) • • • dendrites cell body axon Schwann cells motor end plate

Functional Classification of Neurons • Sensory • Associational – Inter-neurons • Motor – Upper motor neuron – Lower motor neuron

Synapse • Functional connection between 2 neurons – chemical or electrical • Neurotransmitters – acetylcholine – norepinephrine • Motor Unit

Nervous System Divisions • Central Nervous System (CNS) – Brain – Spinal Cord • Peripheral Nervous System (PNS) – Cranial Nerves – Spinal Nerves • R. T. D. C. B.

PNS – Somatic NS – Autonomic NS • sympathetic • parasympathetic • enteric NS

Somatic Nervous System • Functions – voluntary control of skeletal muscle – convey conscious/unconscious sensory (afferent) information • vision, pain, touch, unconscious muscle sense

Autonomic Nervous System • Functions • convey sensory input from visceral organs, glands and cardiovascular system • involuntary control of smooth and cardiac muscle • maintain homeostasis • Divisions of ANS – Sympathetic Nervous System • thoracolumbar – Parasympathetic Nervous System • craniosacral – Enteric Nervous System

Sympathetic Nervous System • Dominates in stress conditions – physical and psychological – very rapid effects • “Fight or Flight” theory – increased sweating, HR, RR – blood diverted to skeletal muscles – pupil dilation – conversion of glycogen to glucose

Parasympathetic Nervous System • Opposite actions of sympathetic nervous system • dominates in relaxed states – decreased HR and RR – increased peristalsis – increased saliva and intestinal secretions – pupil constriction

Enteric Nervous System • innervates GI tract, pancreas, gall bladder

CNS • Gray matter = nerve cell bodies • White matter = axons • Efferent neurons – motor neurons • Afferent neurons – sensory neurons

Meninges • Dura Mater – tough, inelastic membrane – adheres to inner part of cranium • Arachnoid Mater – delicate, web-like tissue – avascular • Pia Mater – thin, delicate tissue hugging brain – no space between pia mater and brain – capillary rich to supply brain with blood

Meninges Cont. • Epidural Space – “potential space” – between cranium and dura mater – space created due to epidural hematoma – middle meningeal artery • Subdural Space – filled with a serous lubricant – prevents dura mater and arachnoid from adhering to each other • Subarachnoid Space – relatively large – filled with cerebrospinal fluid – ventricles

Cerebrum • Basal Ganglia • Limbic system

Cerebrum • general appearance and behavior • level of consciousness (loc) • intellectual performance – short term memory (STM) – long term memory (LTM) • amnesia? – calculation – reasoning • emotional control • language skills • voluntary movement (cerebral cortex)

Basal Ganglia and Limbic System • Basal Ganglia – part of extra-pyramidal system – inter-connects several part of CNS – fine tune motor control • Limbic System – emotion, hunger, biological rhythms, smell

Diencephalon • • epithalamus hypothalamus subthalamus

Thalamus/Hypothalamus • Thalamus – receives input from every sensory system – sensory and motor integration • Hypothalamus – homeostasis (temp), hunger, thirst, emotions

Cerebellum • Coordination – control of timing, speed, and direction of movement • Equilibrium – balance, posture

Brain Stem • midbrain – eye tracking; voluntary movement • medulla – decussation of UMN • pons – relay info. from cortex to cerebellum; respiration • medulla oblongata – reflexes for vomiting, swallowing, coughing, salivation, pupils • cranial nerves III, IV, V, VII, VIII, IX, X, XII

Movie Time Rated PG

Reticular Formation • Extends throughout the length of the brain stem • Reticular activating system – wakefulness – modification of sensory input – controls motor function via reticulospinal tract – receives input from hypothalamus and limbic system (emotion)

Vestibular Nuclei • located in brain stem • receive input from labyrinthine system, reticular formation, and cerebellum • controls/interprets balance, head control, and eye tracking

Spinal Cord • Function – pathway for efferent and afferent nerve fibers • ascending and descending spinal tracts – connects peripheral and spinal nerves to brain – center for spinal (monosynaptic) reflexes • Location – foramen magnum to app. L 2 • Gives rise to 31 pair of spinal root nerves • Cauda equina – lumbrosacral plexus from L 2 on down

Spinal Nerves • 31 pair – dorsal spinal root = afferent = sensory – ventral spinal root = efferent = motor • Doral and ventral root join to form the peripheral nerve • Spinal nerves exit below respective vertebral level except for cervical • Myotome – voluntary muscle group receiving motor innervation from a specific spinal nerve • Dermatome – section of skin that receives sensory innervation from a specific spinal nerve – adjacent dermatomes overlap – partial loss = peripheral complete loss = cord

Descending Tracts “Motor” • corticospinal (Pyramidal Tract) – voluntary skilled movement in extremities • reticulospinal – facilitate or inhibit motor neurons; – posture • tectospinal – postural reflexes of head for vision • rubrospinal – facilitate/inhibit motor neurons – posture • vestibulospinal – facilitate/inhibit postural muscles of abdomen, back, neck

Ascending Tracts • Exteroceptive, Proprioceptive, and Interoceptive • ventral and lateral spinothalamic – pain and temperature • spinocerebellar – proprioceptive and exteroceptive – vestibular nuclei and joint receptors • spinoreticular – muscle, joints, and skin • gracile and cuneate – touch, pressure, conscious joint sense

Cranial Nerves • Sensory and/or Motor Function – 12 pairs • On Old Olympus’ Towering Top A Fin And German Viewed Some Hops • Oh Oh Oh To Touch and Feel a Girl/Guy Very Sexy and Hot • Motor and/or Sensory Function – Some say marry money but my brother says bad boys marry money.

Cranial Nerves • I. Olfactory • function: smell • testing: identify common odors • II. Optic • function: vision • testing: check visual fields, check vision • III. Oculomotor • function: eye movement, pupil reflex • testing: tracking, direct/consensual pupil reflex, accommodation, nystagmus, drooping eyelid • IV. Trochlear • function: eye movement • testing: tracking, nystagmus

Cranial Nerves Cont. • V. Trigeminal • function: muscles of mastication, facial sensation, corneal reflex • testing: check facial sensation, muscles of mastication • VI. Abducens • function: eye movement • testing: tracking, nystagmus • VII. Facial • function: muscles of facial expression, taste to anterior tongue • testing: facial expressions, taste • VIII. Vestibulocochlear • function: hearing, equilibrium • testing: hearing, check for tinnitus, check balance

Cranial Nerves Cont. • IX. Glossopharyngeal • function: taste to posterior tongue, muscles of larynx/pharynx • testing: taste, gag reflex, speak/swallowing, coughing • X. Vagus • function: swallowing, phonation, taste • testing: speak/swallowing, gag reflex, taste, cough • XI. Spinal Accessory • function: motor control of upper trap and sternocleidomastoid • testing: SMT/DMT of trap and SCM • XII. Hypoglossal • function: tongue movement • testing: tongue protrusion (deviation? )

Cranial Nerve Quick Test • • • Vision Visual Fields Eye Tracking Facial Sensation Muscles of Facial Expression Muscles of Mastication Hearing/Balance Swallowing Upper Trap/SCM Strength Tongue Protrusion Pupil Reflexes

Movie Time Rated PG

Proprioception • The awareness of posture, movement, muscle length/tension, changes in equilibrium, weight, resistance of objects, and speed/range, angle of movement • Proprioceptors – muscle spindle – Golgi tendon organ (GTO) – mechanoreceptors

Muscle Spindle • Detects length and rate of length • Extrafusal vs. Intrafusal fibers • extrafusal = skeletal muscle fibers – innervated by alpha motor neurons • intrafusal = muscle spindle fibers – innervated by gamma motor neurons

Muscle Spindles • Intrafusal fibers – located within muscle belly – stretching a muscle also stretches the muscle spindle – most sensitive to rapid stretching • Types – Nuclear Bag 1 (Dynamic) • rate of change in length • Ia afferent; fires rapidly but adapts quickly – Nuclear Chain (Static) • overall length • II afferent; slow firing and non-adapting

Golgi Tendon Organ – located within tendons – Ib afferent • slow firing and non-adapting – most sensitive to excessive stretch – sensitive to excessive tension due to muscle contraction – excessive tension will cause a reflexive inhibition of alpha mn

Myotatic or Stretch Reflexes • Deep Tendon Reflex – biceps brachii: C 5 -C 6 – brachioradialis: C 5 -C 6 – triceps brachii: C 7 – infrapatellar: L 3 -L 4 – posterior tibialis: L 5 – achilles: S 1 • Jendrassik Maneuver – increases facilitative activity of spinal cord

Superficial Reflexes • Abdominal – upper: T 6 -T 9 – lower: T 9 -T 12 • • Cremasteric: L 1 -L 2 Plantar: S 1 -S 2 Gag Corneal

Visceral Reflexes • Pupillary reflex – direct – consensual – accommodation • Blink reflex

Pathological Reflexes • • Babinski sign Oppenheim sign Decorticate rigidity ** Decerebrate rigidity ** • ** due to lack of cortical/cerebral control

Lower Motor Neuron Lesions • weakness/paralysis/paresis of a voluntary motor group • decreased tone (flaccidity) of involved motor group • decreased/absent deep tendon reflex (hyporeflexia or areflexia) • atrophy of muscle/muscle group • radicular pain specific to a spinal nerve path • decreases/absent sensation of specific dermatomes (hypoesthesia or anesthesia)

Upper Motor Neuron Lesion • pathological reflex present (eg: Babinski sign) • weakness distal to lesion • hemiplegia/paraplegia • increased deep tendon reflex (hypereflexia) ** • hypertonicity – spasticity – rigidity • decreased/absent superficial reflexes • ** due to lack of cortical control

Reflex Grading Scale • • • 0 = 1+ = 2+ = 3+ = 4+ = Absent Decreased (elicited with reinforcement) Normal Increased Clonus

Movie Time Rated R

Head Injuries • Incidence of serious injury has decreased – neck injuries? – protective gear • Appr. 250, 000 concussions/year • Focal vs. Diffuse Injuries

Concussion • Definition – clinical syndrome characterized by immediate and transient impairment of normal neurological function • Causes – coup Vs. contrecoup • • Grades Return to Play Criteria Post-concussion Syndrome Second Impact Syndrome

Intracranial Hemorrhaging • Epidural hematoma – arterial bleeding – rapid onset (poss. 10 -20 min. ) • Subdural hematoma – venous/capillary bleeding – slow onset • Intracerebral hematoma – compressive mechanism/aneurysm – rapid onset

Evaluation Process • Primary Assessment? – ABC’s • Secondary Assessment – Mental Status – Cranial Nerve Exam – Motor System Exam – Proprioception, balance, and coordination – Sensory Exam – Reflex Examination

Cranial Nerve Exam • Test for: – Vision – Tracking – Visual Fields – Pupil Reflex – Hearing – Swallowing – Shoulder Shrug – Facial Sensation – Facial Expression – Tongue Protrusion – Mastication

Other Signs and Symptoms • • • headache nausea, vomiting seizures unequal pupils tinnitus unusual drowsiness

Treatment • Recheck athlete on regular basis • Refer if in doubt or in more severe cases • Monitor throughout the night • No alcohol, aspirin, ibuprofen • No activity until asymptomatic • No new s/s or no worsening of current s/s