KIN 191B – Advanced Assessment of Upper Extremity Injuries Head Anatomy, Evaluation and Injuries

Anatomy Bony anatomy Brain Meninges Cerebrospinal fluid Circulatory anatomy

Bony anatomy

Brain

Meninges

Cerebrospinal fluid

Circulatory anatomy

Bony Anatomy Skull Provides protection for brain Reduces forces transmitted to brain (thickness and shape) Occipital bone Inion – “bump of knowledge” Parietal bones Frontal bone Temporal bones Sphenoid bones

Skull

Provides protection for brain

Reduces forces transmitted to brain (thickness and shape)

Occipital bone

Inion – “bump of knowledge”

Parietal bones

Frontal bone

Temporal bones

Sphenoid bones

Bony Anatomy

Brain Cerebrum Cerebellum Diencephalon Brainstem

Cerebrum

Cerebellum

Diencephalon

Brainstem

Brain

Cerebrum Anatomy Two hemispheres separated by longitudinal fissure Each hemisphere has frontal, parietal, temporal and occipital lobes Sulci and fissures form contours Function Controls primary motor functions Gross and sequenced, coordinated movements Processes sensory information Temp, touch, pain, pressure, proprioception, vision, hearing, smell, taste Cognitive function Spatial relationships, behavior, memory

Anatomy

Two hemispheres separated by longitudinal fissure

Each hemisphere has frontal, parietal, temporal and occipital lobes

Sulci and fissures form contours

Function

Controls primary motor functions

Gross and sequenced, coordinated movements

Processes sensory information

Temp, touch, pain, pressure, proprioception, vision, hearing, smell, taste

Cognitive function

Spatial relationships, behavior, memory

Cerebrum

Cerebellum Located at posterior and inferior aspect of brain Two hemispheres separated by fissure Processing center for incoming and outgoing information relative to maintaining balance and coordination Quick link to cerebrum for processing sensory information Quick link to musculoskeletal system to carry out proper muscular contractions and joint movements

Located at posterior and inferior aspect of brain

Two hemispheres separated by fissure

Processing center for incoming and outgoing information relative to maintaining balance and coordination

Quick link to cerebrum for processing sensory information

Quick link to musculoskeletal system to carry out proper muscular contractions and joint movements

Diencephalon Formed by thalamus and hypothalamus– processing center for conscious and unconscious brain input Thalamus “ gatekeeper”, routes sensory info to appropriate area of brain Hypothalamus Center of autonomic nervous system (sympathetic and parasympathetic nervous systems) Body temperature, GI activity, hunger, emotions Regulates some of body’s hormones

Formed by thalamus and hypothalamus– processing center for conscious and unconscious brain input

Thalamus

“ gatekeeper”, routes sensory info to appropriate area of brain

Hypothalamus

Center of autonomic nervous system (sympathetic and parasympathetic nervous systems)

Body temperature, GI activity, hunger, emotions

Regulates some of body’s hormones

Diencephalon

Brainstem Relays info to and from central nervous system and controls involuntary systems Medulla oblongata Links cerebrum to brainstem and spinal cord Regulates heart and respiratory rates, vascular changes, coughing, vomiting Pons (“bridge”) Links cerebellum to brainstem and spinal cord Regulates respiratory rate

Relays info to and from central nervous system and controls involuntary systems

Medulla oblongata

Links cerebrum to brainstem and spinal cord

Regulates heart and respiratory rates, vascular changes, coughing, vomiting

Pons (“bridge”)

Links cerebellum to brainstem and spinal cord

Regulates respiratory rate

Brainstem

Meninges Collectively, support and protect brain and spinal cord Provide vascular supply and production of CSF Dura mater Arachnoid mater Pia mater

Collectively, support and protect brain and spinal cord

Provide vascular supply and production of CSF

Dura mater

Arachnoid mater

Pia mater

Meninges

Dura Mater “ hard/tough mother” Outermost meningeal layer - is periosteum for skulls inner aspect Falx cerebri and falx cerebelli – folds between cerebral and cerebellar hemispheres Contains meningeal arteries which provide blood supply to bones of skull Venous sinuses Dura separates into two layers at various points Space between layers are venous sinuses Route venous blood from skull to jugular veins of neck

“ hard/tough mother”

Outermost meningeal layer - is periosteum for skulls inner aspect

Falx cerebri and falx cerebelli – folds between cerebral and cerebellar hemispheres

Contains meningeal arteries which provide blood supply to bones of skull

Venous sinuses

Dura separates into two layers at various points

Space between layers are venous sinuses

Route venous blood from skull to jugular veins of neck

Arachnoid Mater Middle meningeal layer Layer has similar appearance to cobweb Separated from dura mater by subdural space Beneath arachnoid mater is subarachnoid space which contains cerebrospinal fluid

Middle meningeal layer

Layer has similar appearance to cobweb

Separated from dura mater by subdural space

Beneath arachnoid mater is subarachnoid space which contains cerebrospinal fluid

Pia Mater “ tender/little mother” Innermost meningeal layer “ Attaches”/adjacent to brain and spinal cord tissue, including following contour into fissures and sulci

“ tender/little mother”

Innermost meningeal layer

“ Attaches”/adjacent to brain and spinal cord tissue, including following contour into fissures and sulci

Cerebrospinal Fluid Originates in choroid plexuses deep within brain Circulates around entire CNS Ventricle system Allows CNS to “float” in subarachnoid space Protects against injury

Originates in choroid plexuses deep within brain

Circulates around entire CNS

Ventricle system

Allows CNS to “float” in subarachnoid space

Protects against injury

CSF Circulation

Circulatory Anatomy Internal carotid arteries branch into anterior and middle cerebral arteries Vertebral arteries unite at level of pons and become basilar artery, which then branches into posterior cerebral arteries Circle of Willis Posterior communicating arteries connect posterior and middle cerebral arteries Anterior communicating arteries connect anterior cerebral arteries

Internal carotid arteries branch into anterior and middle cerebral arteries

Vertebral arteries unite at level of pons and become basilar artery, which then branches into posterior cerebral arteries

Circle of Willis

Posterior communicating arteries connect posterior and middle cerebral arteries

Anterior communicating arteries connect anterior cerebral arteries

Brain Blood Supply

Primary Survey Stabilize cervical spine A – Airway Ensure that airway is clear (mouthpiece, tongue, etc.) B – Breathing Look, listen and feel C – Circulation Evaluate for presence carotid pulse D – Disorientation/Dysfunction Conscious vs. unconscious

Stabilize cervical spine

A – Airway

Ensure that airway is clear (mouthpiece, tongue, etc.)

B – Breathing

Look, listen and feel

C – Circulation

Evaluate for presence carotid pulse

D – Disorientation/Dysfunction

Conscious vs. unconscious

Position and Posture Position Ideal circumstances have athlete supine If prone or side laying, will eventually need to be rolled to supine position Posture Decerebrate posture – indicative of brainstem injury Extension of extremities, retraction of head Decorticate posture – injury above brainstem Flexion of elbows/wrists, clenched fists, extension of LEs Flexion contracture – spinal cord injury at C5-C6 level Arms flexed across chest

Position

Ideal circumstances have athlete supine

If prone or side laying, will eventually need to be rolled to supine position

Posture

Decerebrate posture – indicative of brainstem injury

Extension of extremities, retraction of head

Decorticate posture – injury above brainstem

Flexion of elbows/wrists, clenched fists, extension of LEs

Flexion contracture – spinal cord injury at C5-C6 level

Arms flexed across chest

Abnormal Postures

Unconscious Athlete Activate EMS Must assume that athlete has head and/or cervical spine injury If ABCs not intact, must initiate rescue breathing or CPR If ABCs intact: Establish and monitor vital signs Evaluate pupillary response (PEARL) Palpate skull and c-spine for deformity, swelling, etc.

Activate EMS

Must assume that athlete has head and/or cervical spine injury

If ABCs not intact, must initiate rescue breathing or CPR

If ABCs intact:

Establish and monitor vital signs

Evaluate pupillary response (PEARL)

Palpate skull and c-spine for deformity, swelling, etc.

Equipment Considerations Consensus that helmet should not be removed during pre-hospital care of head/c-spine injury Facemask removal allows for access to airway Shoulder pads should not be removed during pre-hospital care of head/c-spine injury Straps and laces are cut to expose chest for auscultation and/or chest compressions Justifiable reasons for removing helmet and shoulder pads Necessity or likelihood of defibrillation Inability to remove facemask to access airway If remove one, must remove other to avoid imbalance

Consensus that helmet should not be removed during pre-hospital care of head/c-spine injury

Facemask removal allows for access to airway

Shoulder pads should not be removed during pre-hospital care of head/c-spine injury

Straps and laces are cut to expose chest for auscultation and/or chest compressions

Justifiable reasons for removing helmet and shoulder pads

Necessity or likelihood of defibrillation

Inability to remove facemask to access airway

If remove one, must remove other to avoid imbalance

Conscious Athlete – Secondary Survey Assumes ABCs intact – establish and monitor vital signs History Loss of consciousness, mechanism of injury, symptoms (pain, numbness/tingling, etc.) Orientation x 4 (self, others, place, time) Inspection Skull/c-spine alignment Palpation For bony deformity, swelling, muscle spasm (guarding) Neurological screening Sensory testing (dermatomes) compared bilaterally Motor testing not performed clinically – if all other symptoms negative, may ask to wiggle fingers and toes to establish distal motor function

Assumes ABCs intact – establish and monitor vital signs

History

Loss of consciousness, mechanism of injury, symptoms (pain, numbness/tingling, etc.)

Orientation x 4 (self, others, place, time)

Inspection

Skull/c-spine alignment

Palpation

For bony deformity, swelling, muscle spasm (guarding)

Neurological screening

Sensory testing (dermatomes) compared bilaterally

Motor testing not performed clinically – if all other symptoms negative, may ask to wiggle fingers and toes to establish distal motor function

Clinical Scenario Assumes that all field scenario evaluations are benign and it’s determined to be safe to allow the athlete to leave the field for further evaluation on sideline or in clinical environment – continuous monitoring of athlete occurs (vital signs, level of orientation, etc.) History Inspection Palpation Special Tests Functional testing Neurological testing

Assumes that all field scenario evaluations are benign and it’s determined to be safe to allow the athlete to leave the field for further evaluation on sideline or in clinical environment – continuous monitoring of athlete occurs (vital signs, level of orientation, etc.)

History

Inspection

Palpation

Special Tests

Functional testing

Neurological testing

History Location of symptoms Mechanism of injury/etiology Head vs. cervical spine Loss of consciousness Prior history of head injury Complaints of weakness

Location of symptoms

Mechanism of injury/etiology

Head vs. cervical spine

Loss of consciousness

Prior history of head injury

Complaints of weakness

Location of Symptoms Cervical pain or muscle spasm More concerning if accompanied by numbness, tingling, burning sensations and/or radiating pain Head pain If localized, may indicate contusion, skull fracture and/or intracranial bleeding Most common complaint is headache

Cervical pain or muscle spasm

More concerning if accompanied by numbness, tingling, burning sensations and/or radiating pain

Head pain

If localized, may indicate contusion, skull fracture and/or intracranial bleeding

Most common complaint is headache

Mechanism of Injury Head injuries Coup – stationary skull struck by high velocity object, results in trauma at site of impact Contrecoup – moving skull strikes a non-moving object, brain “floats” and strikes skull opposite impact causing trauma Repeated subconcussive forces – cumulative neurological deficits Rotational or shear forces – sudden acceleration/deceleration forces, can disrupt CNS activity and result in concussive symptoms Cervical spine injuries May involve any ROM (flexion, extension, lateral flexion and/or rotation – may be combined) If flexed ~30 degrees, lordotic curve is lost and cervical spine most susceptible to axial load injury (unable to dissipate forces)

Head injuries

Coup – stationary skull struck by high velocity object, results in trauma at site of impact

Contrecoup – moving skull strikes a non-moving object, brain “floats” and strikes skull opposite impact causing trauma

Repeated subconcussive forces – cumulative neurological deficits

Rotational or shear forces – sudden acceleration/deceleration forces, can disrupt CNS activity and result in concussive symptoms

Cervical spine injuries

May involve any ROM (flexion, extension, lateral flexion and/or rotation – may be combined)

If flexed ~30 degrees, lordotic curve is lost and cervical spine most susceptible to axial load injury (unable to dissipate forces)

Other Historical Elements Loss of consciousness Component of memory evaluation Can athlete or others establish whether there was or was not momentary loss of consciousness History of concussion Recent history of prior concussion increases risk of second impact syndrome Complaints of weakness Reports of weakness in extremities may indicate brain, spinal cord and/or nerve root injury

Loss of consciousness

Component of memory evaluation

Can athlete or others establish whether there was or was not momentary loss of consciousness

History of concussion

Recent history of prior concussion increases risk of second impact syndrome

Complaints of weakness

Reports of weakness in extremities may indicate brain, spinal cord and/or nerve root injury

Inspection Bony structures Eyes Nose and ears

Bony structures

Eyes

Nose and ears

Bony Structures Position of head Should be centered - if rotated/laterally flexed, may indicate cervical dislocation Cervical vertebrae Observe spinous processes for normal alignment - if displaced or rotated, may indicated cervical dislocation Mastoid processes Ecchymosis indicative of basilar skull fracture - “Battle’s sign” Skull and scalp Evaluate for deformity, swelling and bleeding

Position of head

Should be centered - if rotated/laterally flexed, may indicate cervical dislocation

Cervical vertebrae

Observe spinous processes for normal alignment - if displaced or rotated, may indicated cervical dislocation

Mastoid processes

Ecchymosis indicative of basilar skull fracture - “Battle’s sign”

Skull and scalp

Evaluate for deformity, swelling and bleeding

Bony Injuries

Eyes Dazed stare may indicate abnormal function Nystagmus Presence of involuntary flutter and/or eye movements May indicate cranial nerve and/or inner ear injury Pupil size Unilaterally dilated pupil indicative of intracranial bleeding Must be aware of anisocoria – “normal” unequal pupils Pupils reaction to light Should be ipsilateral and contralateral constriction with exposure to light Absence may indicate cranial nerve injury

Dazed stare may indicate abnormal function

Nystagmus

Presence of involuntary flutter and/or eye movements

May indicate cranial nerve and/or inner ear injury

Pupil size

Unilaterally dilated pupil indicative of intracranial bleeding

Must be aware of anisocoria – “normal” unequal pupils

Pupils reaction to light

Should be ipsilateral and contralateral constriction with exposure to light

Absence may indicate cranial nerve injury

Pupil Reaction

Nose and Ears Bleeding from nose may indicate nasal and/or skull fracture Bleeding from ears may indicate skull fracture Halo test – gauze placed in ear to absorb leaking fluids, if “halo” forms around sample it indicates leakage of CSF = skull fracture Ecchymosis around eyes (“raccoon’s eyes”) may indicate nasal and/or skull fracture

Bleeding from nose may indicate nasal and/or skull fracture

Bleeding from ears may indicate skull fracture

Halo test – gauze placed in ear to absorb leaking fluids, if “halo” forms around sample it indicates leakage of CSF = skull fracture

Ecchymosis around eyes (“raccoon’s eyes”) may indicate nasal and/or skull fracture

Eye Ecchymosis

Palpation of Bony Structures Skull Palpate all cranial bones for pain and deformity Spinous processes Palpate cervical spinous processes for pain and crepitus associated with fracture Transverse processes Can only directly palpate C1, but palpate area over remaining transverse processes for pain and crepitus

Skull

Palpate all cranial bones for pain and deformity

Spinous processes

Palpate cervical spinous processes for pain and crepitus associated with fracture

Transverse processes

Can only directly palpate C1, but palpate area over remaining transverse processes for pain and crepitus

Palpation of Soft Tissues Musculature Palpate sternomastoid and upper trapezius muscles for spasm secondary to strain, sprain, fracture and/or dislocation Throat Palpate thyroid cartilage, cricoid cartilages and hyoid bone to rule out larynx and tracheal injury

Musculature

Palpate sternomastoid and upper trapezius muscles for spasm secondary to strain, sprain, fracture and/or dislocation

Throat

Palpate thyroid cartilage, cricoid cartilages and hyoid bone to rule out larynx and tracheal injury

Special Tests Functional testing – evaluates function of CNS Memory Cognitive function Neuropsychological testing (computer based also) Balance and coordination Standardized Assessment of Concussion (SAC) Vital signs Neurological testing Cranial nerve function Nerve root evaluation

Functional testing – evaluates function of CNS

Memory

Cognitive function

Neuropsychological testing (computer based also)

Balance and coordination

Standardized Assessment of Concussion (SAC)

Vital signs

Neurological testing

Cranial nerve function

Nerve root evaluation

Memory Retrograde amnesia Difficulty or inability to remember events preceding the injury – more severe if can’t remember events of day before as opposed to more recent events Some assessed with orientation x 4, pre-game meal?, who played last game? Anterograde amnesia Difficulty or inability to remember events after the onset of injury Athlete given verbal list of items and asked to repeat them serially over time

Retrograde amnesia

Difficulty or inability to remember events preceding the injury – more severe if can’t remember events of day before as opposed to more recent events

Some assessed with orientation x 4, pre-game meal?, who played last game?

Anterograde amnesia

Difficulty or inability to remember events after the onset of injury

Athlete given verbal list of items and asked to repeat them serially over time

Cognitive Function Brain injury can present as abnormal behavior, personality changes, inability to process information accurately Behavior May become violent, belligerent, etc. - abnormal Analytical ability Typically assessed with serial number repetitions Information processing Cannot follow simple instructions

Brain injury can present as abnormal behavior, personality changes, inability to process information accurately

Behavior

May become violent, belligerent, etc. - abnormal

Analytical ability

Typically assessed with serial number repetitions

Information processing

Cannot follow simple instructions

Neuropsychological Testing Multiple neuropsychological test methods (six in text – not responsible for exam) Hopkins Verbal Learning Test (HVLT) Wechsler Digit Span Test (WDST) Controlled Oral Word Association Test (COWAT) Used to objectively quantify amount of dysfunction demonstrated by athlete More and more common to see these tests employed during PPE as baseline upon which to compare results after head injuries and for return to play considerations

Multiple neuropsychological test methods (six in text – not responsible for exam)

Hopkins Verbal Learning Test (HVLT)

Wechsler Digit Span Test (WDST)

Controlled Oral Word Association Test (COWAT)

Used to objectively quantify amount of dysfunction demonstrated by athlete

More and more common to see these tests employed during PPE as baseline upon which to compare results after head injuries and for return to play considerations

Computerized Neuropsychological Testing Limited applications due to financial constraints and personnel to implement the recommended models (pre- and post-injury testing and comparisons) Most computerized testing takes 20-30 minutes per athlete – can be done in group format (all at computers at same time) for efficiency Allows for more precise measurement of subtle deficits associated with concussion including reaction time, cognitive processing speed, and response latency Essential benefits to research on concussions and return to play criteria Also allows for easy storage/access of data

Limited applications due to financial constraints and personnel to implement the recommended models (pre- and post-injury testing and comparisons)

Most computerized testing takes 20-30 minutes per athlete – can be done in group format (all at computers at same time) for efficiency

Allows for more precise measurement of subtle deficits associated with concussion including reaction time, cognitive processing speed, and response latency

Essential benefits to research on concussions and return to play criteria

Also allows for easy storage/access of data

Computerized Neuropsychological Testing HeadMinder Concussion Resolution Index (CRI) - 1999 Internet-based neuropsychological test to compare post-concussion performance to pre-injury baseline Measures memory, reaction time, speed of decision making and speed of information processing University of Pittsburgh Medical Center Immediate Post-concussion Assessment and Cognitive Testing (ImPact) – mid-1990’s Software includes Self-Report Symptom Questionnaire, a Concussion History Form and tests to evaluate the elements listed below Measures attention span, working memory, sustained attention, selective attention, non-verbal problem solving, reaction time, visual and verbal memory, and response variability

HeadMinder Concussion Resolution Index (CRI) - 1999

Internet-based neuropsychological test to compare post-concussion performance to pre-injury baseline

Measures memory, reaction time, speed of decision making and speed of information processing

University of Pittsburgh Medical Center Immediate Post-concussion Assessment and Cognitive Testing (ImPact) – mid-1990’s

Software includes Self-Report Symptom Questionnaire, a Concussion History Form and tests to evaluate the elements listed below

Measures attention span, working memory, sustained attention, selective attention, non-verbal problem solving, reaction time, visual and verbal memory, and response variability

Balance and Coordination Evaluation for possible cerebellar injury affecting muscle coordination (ataxia) Romberg test – single leg stance with shoulders abducted 90 degrees, eyes closed and head back Tandem walking – heel to toe walking forward and backward along straight line Balance Error Scoring System (BESS) Double leg, single leg, and tandem leg stance on firm and then foam surfaces with eyes closed and hands on hips Attempt to hold for 20 seconds, points for errors Scores can be used as baseline for comparison following head injuries and for return to play considerations

Evaluation for possible cerebellar injury affecting muscle coordination (ataxia)

Romberg test – single leg stance with shoulders abducted 90 degrees, eyes closed and head back

Tandem walking – heel to toe walking forward and backward along straight line

Balance Error Scoring System (BESS)

Double leg, single leg, and tandem leg stance on firm and then foam surfaces with eyes closed and hands on hips

Attempt to hold for 20 seconds, points for errors

Scores can be used as baseline for comparison following head injuries and for return to play considerations

Standardized Assessment of Concussion Standardized Assessment of Concussion (SAC) Quick (5 minutes) screening instrument to administer and assess four domains of cognition Orientation Immediate Memory Concentration Delayed Recall Composite score is identified to provide index of cognitive impairment and injury severity

Standardized Assessment of Concussion (SAC)

Quick (5 minutes) screening instrument to administer and assess four domains of cognition

Orientation

Immediate Memory

Concentration

Delayed Recall

Composite score is identified to provide index of cognitive impairment and injury severity

Vital Signs Pulse rate, respiratory rate, blood pressure taken early in evaluation process to establish baseline and repeated serially for comparison

Pulse rate, respiratory rate, blood pressure taken early in evaluation process to establish baseline and repeated serially for comparison

Neurological Testing Cranial nerve function Serial evaluations must be performed initially to evaluate for changes Cranial nerves arise from brain and are susceptible to impairment secondary to intracranial bleeding and resulting pressure Nerve root evaluation Sensory (dermatome), motor (myotome) and reflex testing necessary to rule out or identify level of spinal cord injury

Cranial nerve function

Serial evaluations must be performed initially to evaluate for changes

Cranial nerves arise from brain and are susceptible to impairment secondary to intracranial bleeding and resulting pressure

Nerve root evaluation

Sensory (dermatome), motor (myotome) and reflex testing necessary to rule out or identify level of spinal cord injury

Cranial Nerve Evaluation Olfactory Optic Oculomotor Trochlear Trigeminal Abducens Facial Acoustic/Vestibulocochlear Glossopharyngeal Vagus Accessory (spinal) Hypoglossal On Old Olympus Towering Top A Fin And German Viewed A Hop

Olfactory

Optic

Oculomotor

Trochlear

Trigeminal

Abducens

Facial

Acoustic/Vestibulocochlear

Glossopharyngeal

Vagus

Accessory (spinal)

Hypoglossal

On

Old

Olympus

Towering

Top

A

Fin

And

German

Viewed

A

Hop

Cranial Nerve Evaluation I – Olfactory Sense of smell II – Optic Visual acuity III – Oculomotor Pupillary size and reaction Eye adduction and downward rolling Elevation of upper eyelid (blink)

I – Olfactory

Sense of smell

II – Optic

Visual acuity

III – Oculomotor

Pupillary size and reaction

Eye adduction and downward rolling

Elevation of upper eyelid (blink)

Cranial Nerve Evaluation IV – Trochlear Upward eye rolling V – Trigeminal Muscles of mastication (chewing) Facial sensation VI – Abducens Lateral eye movements

IV – Trochlear

Upward eye rolling

V – Trigeminal

Muscles of mastication (chewing)

Facial sensation

VI – Abducens

Lateral eye movements

Cranial Nerve Evaluation VII – Facial Taste Facial expressions VIII – Acoustic/Vestibulocochlear Hearing Equillibrium/balance IX – Glossopharyngeal Taste Swallowing

VII – Facial

Taste

Facial expressions

VIII – Acoustic/Vestibulocochlear

Hearing

Equillibrium/balance

IX – Glossopharyngeal

Taste

Swallowing

Cranial Nerve Evaluation X – Vagus Gag reflex Swallowing Involved in heart rate, respirations, digestion, etc. XI – Accessory Shrug shoulders and rotate cervical spine XII – Hypoglossal Symmetrical stick out of tongue

X – Vagus

Gag reflex

Swallowing

Involved in heart rate, respirations, digestion, etc.

XI – Accessory

Shrug shoulders and rotate cervical spine

XII – Hypoglossal

Symmetrical stick out of tongue

Injuries Head injuries Concussion Post-concussion syndrome Second impact syndrome Intracranial hemorrhage Epidural hematoma Subdural hemtoma Skull fracture Cervical spinal cord injuries Cervical spine fracture/dislocation Quadraplegia

Head injuries

Concussion

Post-concussion syndrome

Second impact syndrome

Intracranial hemorrhage

Epidural hematoma

Subdural hemtoma

Skull fracture

Cervical spinal cord injuries

Cervical spine fracture/dislocation

Quadraplegia

Concussion Cerebral concussion = mild/traumatic brain injury (M/TBI) Hallmark symptoms include mental confusion, altered mental status, amnesia and potential loss of consciousness Multiple occurrences may produce cumulative degenerative effects Ultimate assessment based upon duration of loss of consciousness (if any) and neuropsychological findings

Cerebral concussion = mild/traumatic brain injury (M/TBI)

Hallmark symptoms include mental confusion, altered mental status, amnesia and potential loss of consciousness

Multiple occurrences may produce cumulative degenerative effects

Ultimate assessment based upon duration of loss of consciousness (if any) and neuropsychological findings

Concussion Additional symptoms of concussion may include but are not limited to: Dizziness Tinnitus Nausea/vomiting Motor impairment Memory loss Glasgow coma scale Allows for objective evaluation of symptoms of brain injury Normal score is 15 – scores >11 likely to recover

Additional symptoms of concussion may include but are not limited to:

Dizziness

Tinnitus

Nausea/vomiting

Motor impairment

Memory loss

Glasgow coma scale

Allows for objective evaluation of symptoms of brain injury

Normal score is 15 – scores >11 likely to recover

Classification of Concussions Concussion rating systems Injury graded at time of injury based upon existing signs/symptoms within 15 minutes of injury American Academy of Neurology Concussion Grading Scale Injury graded after all signs/symptoms have resolved Cantu Evidence-Based Grading Scale Recommendations from 2001 & 2004 Vienna Conference on Concussion in Sport Individual’s recovery attended to based upon symptoms, neuropsychological tests and postural stability tests

Concussion rating systems

Injury graded at time of injury based upon existing signs/symptoms within 15 minutes of injury

American Academy of Neurology Concussion Grading Scale

Injury graded after all signs/symptoms have resolved

Cantu Evidence-Based Grading Scale

Recommendations from 2001 & 2004 Vienna Conference on Concussion in Sport

Individual’s recovery attended to based upon symptoms, neuropsychological tests and postural stability tests

Concussion Rating Systems Guidelines for identifying concussion severity and determining return to play timeline – often considered conservative for athletic population Significant differences between scales – be consistent with scale utilized – more than 16 rating systems have been identified American Academy of Neurology Concussion Grading Scale Cantu Evidence-Based Grading Scale

Guidelines for identifying concussion severity and determining return to play timeline – often considered conservative for athletic population

Significant differences between scales – be consistent with scale utilized – more than 16 rating systems have been identified

American Academy of Neurology Concussion Grading Scale

Cantu Evidence-Based Grading Scale

Vienna Conference Recommendations Simple vs. complex concussions Simple concussions Most common concussion but most difficult to recognize Complex concussions Involves persistent symptoms and also individuals suffering multiple concussions over time

Simple vs. complex concussions

Simple concussions

Most common concussion but most difficult to recognize

Complex concussions

Involves persistent symptoms and also individuals suffering multiple concussions over time

Simple Concussions Signs & symptoms No LOC Only neurological deficit is brief post-traumatic confusion and/or post-traumatic amnesia Symptoms typically resolve within 30 minutes – if persist for more than 30 minutes, a more serious (complex) concussion exists

Signs & symptoms

No LOC

Only neurological deficit is brief post-traumatic confusion and/or post-traumatic amnesia

Symptoms typically resolve within 30 minutes – if persist for more than 30 minutes, a more serious (complex) concussion exists

Simple Concussions Management Removed from activity with serial evaluations following initial evaluation at ~5 minute intervals until asymptomatic Once asymptomatic, introduce exertion – if exertion exacerbates symptoms, disqualify from activity If asymptomatic for 15 minutes at rest and with exertion, can return to activity Second episode during same activity session disqualifies individual from further activity that day If symptoms progress – ultimate progression of evaluation for return to activity is; at rest, with exertion, with sport-specific activities, return to full activity

Management

Removed from activity with serial evaluations following initial evaluation at ~5 minute intervals until asymptomatic

Once asymptomatic, introduce exertion – if exertion exacerbates symptoms, disqualify from activity

If asymptomatic for 15 minutes at rest and with exertion, can return to activity

Second episode during same activity session disqualifies individual from further activity that day

If symptoms progress – ultimate progression of evaluation for return to activity is; at rest, with exertion, with sport-specific activities, return to full activity

Complex Concussions Signs & symptoms Persistent symptoms (with and/or without exertion), specific sequelae (prolonged LOC), or prolonged cognitive impairment Also includes those with multiple concussions over time Protracted post-traumatic amnesia is typical, usually lasting 30 minutes – 24 hours

Signs & symptoms

Persistent symptoms (with and/or without exertion), specific sequelae (prolonged LOC), or prolonged cognitive impairment

Also includes those with multiple concussions over time

Protracted post-traumatic amnesia is typical, usually lasting 30 minutes – 24 hours

Complex Concussions Management Removed from activity that day Serial evaluations to identify or rule out potential development of intracranial pathology – may require referral to physician for special test evaluation (CT/MRI) Formal neuropsychological testing should be considered – performance utilized to make decisions regarding return to activity (return to baseline – ideally pre-injury baseline is available)

Management

Removed from activity that day

Serial evaluations to identify or rule out potential development of intracranial pathology – may require referral to physician for special test evaluation (CT/MRI)

Formal neuropsychological testing should be considered – performance utilized to make decisions regarding return to activity (return to baseline – ideally pre-injury baseline is available)

Return to Play Criteria Multiple factors to consider include whether or not loss of consciousness occurred, duration of symptoms, total number of concussive episodes, exertional testing Universal agreement that individual who lost consciousness for any period of time should not be allowed to return to activity on the same day even if all symptoms have resolved

Multiple factors to consider include whether or not loss of consciousness occurred, duration of symptoms, total number of concussive episodes, exertional testing

Universal agreement that individual who lost consciousness for any period of time should not be allowed to return to activity on the same day even if all symptoms have resolved

Post-Concussion Syndrome Individuals may present with concussion symptoms long after “normal” resolution would have occurred Common symptoms include Decreased attention span Difficulty concentrating Memory impairment Prolonged headaches Balance impairments Decreased cognitive function

Individuals may present with concussion symptoms long after “normal” resolution would have occurred

Common symptoms include

Decreased attention span

Difficulty concentrating

Memory impairment

Prolonged headaches

Balance impairments

Decreased cognitive function

Second Impact Syndrome Defined as symptoms resulting from second concussive episode before symptoms of first concussive episode have resolved Entirely preventable, return to play considerations Second trauma typically not as violent as initial injury – thought to affect brain blood supply causing increased intracranial pressure which impacts brainstem function Quick progression from mild concussive symptoms to comatose state Even if treated appropriately, has ~50% mortality rate

Defined as symptoms resulting from second concussive episode before symptoms of first concussive episode have resolved

Entirely preventable, return to play considerations

Second trauma typically not as violent as initial injury – thought to affect brain blood supply causing increased intracranial pressure which impacts brainstem function

Quick progression from mild concussive symptoms to comatose state

Even if treated appropriately, has ~50% mortality rate

Intracranial Hemorrhage Named for location relative to meningeal layers Caused by injury to blood vessels supplying brain blood supply Increased pressure from bleeding in confined space compresses neural tissue Onset of symptoms associated with nature of bleeding – venous vs. arterial (lucid interval) Epidural hematoma Subdural hematoma

Named for location relative to meningeal layers

Caused by injury to blood vessels supplying brain blood supply

Increased pressure from bleeding in confined space compresses neural tissue

Onset of symptoms associated with nature of bleeding – venous vs. arterial (lucid interval)

Epidural hematoma

Subdural hematoma

Epidural Hematoma Arterial bleeding between skull and dura mater Initially may present with concussive symptoms Short lucid interval (typically <48 hours)– individual appears “OK” Due to arterial nature of bleeding Subsequently may c/o disorientation, confusion, drowsiness, increasing headache intensity, signs of cranial nerve changes (esp. pupil changes) If untreated, can be fatal

Arterial bleeding between skull and dura mater

Initially may present with concussive symptoms

Short lucid interval (typically <48 hours)– individual appears “OK”

Due to arterial nature of bleeding

Subsequently may c/o disorientation, confusion, drowsiness, increasing headache intensity, signs of cranial nerve changes (esp. pupil changes)

If untreated, can be fatal

Epidural Hematoma

Subdural Hematoma Venous bleeding between brain and dura mater May not present with symptoms of concussion Longer lucid interval – may be hours, days or weeks before symptoms present Due to venous nature of bleeding Subsequent development of headaches, confusion, changes in cognitive/motor abilities, cranial nerve changes More likely to cause death due to lack of recognition of nature/source of symptoms and delay in subsequent treatment

Venous bleeding between brain and dura mater

May not present with symptoms of concussion

Longer lucid interval – may be hours, days or weeks before symptoms present

Due to venous nature of bleeding

Subsequent development of headaches, confusion, changes in cognitive/motor abilities, cranial nerve changes

More likely to cause death due to lack of recognition of nature/source of symptoms and delay in subsequent treatment

Subdural Hematoma

Skull Fractures Minimal risk with head protection, but may still suffer bony injury May cause CSF leakage from nose/ear, may have residual/secondary ecchymosis Linear Hairline fractures in bone Comminuted Multiple fracture fragments Depressed Easier to identify on evaluation – gross deformity Potential for fragments to injure meninges/brain

Minimal risk with head protection, but may still suffer bony injury

May cause CSF leakage from nose/ear, may have residual/secondary ecchymosis

Linear

Hairline fractures in bone

Comminuted

Multiple fracture fragments

Depressed

Easier to identify on evaluation – gross deformity

Potential for fragments to injure meninges/brain

Skull Fractures

Cervical Spinal Cord Injuries Risk minimized with rules and coaching emphasis changes Spinal cord injury caused by Impingement/laceration from bony displacement Compression from bleeding, swelling, ischemia to cord Mechanism of injury is key to decisions on management – must assume worst case scenario until proven otherwise Trauma at spinal cord level affects function distal to level of injury At or above C4 level – death is likely due to impact on brainstem and vital functions

Risk minimized with rules and coaching emphasis changes

Spinal cord injury caused by

Impingement/laceration from bony displacement

Compression from bleeding, swelling, ischemia to cord

Mechanism of injury is key to decisions on management – must assume worst case scenario until proven otherwise

Trauma at spinal cord level affects function distal to level of injury

At or above C4 level – death is likely due to impact on brainstem and vital functions

Cervical Fracture/Dislocation Spinal cord injury typically secondary to actual bony injury from swelling, bony fragment displacement, etc. With dislocation, diameter of canal for spinal cord is impacted and can compress spinal cord Must differentiate between spinal cord symptoms and brachial plexus injury symptoms (longer duration vs. transient symptoms) Often treat with steroid injections to limit swelling and subsequent pressure on spinal cord with these injuries

Spinal cord injury typically secondary to actual bony injury from swelling, bony fragment displacement, etc.

With dislocation, diameter of canal for spinal cord is impacted and can compress spinal cord

Must differentiate between spinal cord symptoms and brachial plexus injury symptoms (longer duration vs. transient symptoms)

Often treat with steroid injections to limit swelling and subsequent pressure on spinal cord with these injuries

Quadriplegia Transient quadriplegia often results from cervical hyperextension, hyperflexion and/or axial loading Several predisposing factors Cervical stenosis Cervical spine instability Posterior arch abnormalities of cervical spine If truly transient, symptoms often resolve within 48 hours

Transient quadriplegia often results from cervical hyperextension, hyperflexion and/or axial loading

Several predisposing factors

Cervical stenosis

Cervical spine instability

Posterior arch abnormalities of cervical spine

If truly transient, symptoms often resolve within 48 hours