Upper Extremity- Head, face, eyes, ears, throat

• 1. olfactory: smell
• 2. optic: vision
• 3. oculomotor: eye movement, opening of eyelid, pupil constriction, focusing
• 4. trochlear: inferior and lateral movement of eye
• 5. trigeminal: senssation to the face, mastication
• 6. Abducens: lateral movement of eye
• 7. Facial: motor nerve of facial expression, taste, control of tear, nasal, sublingual salivary and submaxillary glands
• 8. Vestibulocochlear: hearing and equilibrium
• 9. Glossopharyngeal: swallowing, salivation, gag feflex, sensation from tongue and ear
• 10. Vagus: swallowing, speech, regultaion of pulmonary, cardiovascular and gastrointestinal functions
• 11. Accessory: swallowing, innervation of sternocleidomastoid
• 12. Hypoglossal: tongue movement, speech, swallowing

MOI- blunt trauma

• severe headache and nausea
• unconscious
• may have palpable deformity
• racoon's eye, battle's sign
• cerebral spinal fluid in ear or nose

• intracranial bleeding
• bony fragments
• infection
•   hospitalization
•   neurosurgeon
•   refer to dr

• major public health concern, with return to play decisions remaining the most challenging task for any sports medicine clinician
• result of direct blow, acceleration/deceleration forces producing shaking of the brain
• coup (impact) and counter coup (opposite side)

• changes in level of consciousness (10% do lose consciousness, less than 1% are longer than 1 minute)
• post traumatic amnesia
• glasgow coma scale
• concentration deficits and attention span difficulties
• balance and coordination problems
• must monitor duration of signs and symptoms
• 2 primary symptoms: loss of consciousness (LOC) and post traumatic amnesia
• variety of scales and return to play criteria have been examined
•   *typically involve LOC or amnesia
• recent classification systems have included concentration deficits, attention span difficulties, and balance and coordination in addition to LOC and amnesia
•   *placing more emphasis on all S&S's may be a more logical approach
• usuing S&S's immediate post injury and 15 minutes post injury to provide an estimate of injury severity has also been suggested
• 3rd approach involves recovery of symptoms, neuropsychological testing, postural stability testing
• focus on patient symptomatology

• the decision to return any patient to competition following a brain injury is a difficult one that take a great deal of consideration
• if any LOC occurs the AT must remove the patient from competition
• wth and LOC a cervical spine injury should be assumed
• objective measures (BESS and SAC) should be used to determine readiness to play
• a # of guideline have been established in an effot to aid clinicians in their decisions
• return to normal baseline requires approx. 3-5 days
• all post-concussive symptoms should be resolved prior to returning to play- any return to play should be gradual
• recurrent concussions can produce cumulative traumatic injury to the brain
• following an initial concussion the chances of a 2nd episode are 3-6x greater
• must be able to determine need for dr.referral and be able to decide when patient should return home v. being admitted to hospital
• a system should be in place that allows for supervision and monitoring of patient when at home following concussive episode
• in the past, rest was deemed best treatment
• efficacy of dual task rehab is being explored
•   *involves postural stability and cognitive tasks
•   *little evidence available
• involves divided attention tasks
•    *balance training
•    *neurocognitive tasks
•    *simultaneously performed
• more research is necessary to establish efficiacy of treatment method
•    *which patients are best candidate
•    *how soon should technique be introduced

• result of rapid swelling and herniation of brain after a 2nd head injury before symptoms of initial injury have resolved
• 2nd impact may be relatively minimal and not involve contact with the cranium
• impact disrupts the brain's blood auto-regulatory system leading to swelling, increasing intracranial pressure

• often patient doesn't have LOC and may look stunned
• within 15 seconds to several minutes of injury patients condition degrades rapidly
•    *dilated pupils, loss of eye movement, LOC leading to coma and respiratory failure

• life threatening injury that must be addressed within 5 minutes with live saving measures performed at an emergency facility
• best mgmt is prevention from AT's perspective

• involves small hemorrhage and/or intercranial bleeding
• it is within the cortex, stem or cerebellum
• usually from an impact injury with an immovable object

• may vary significantly
• LOC, but will become very alert and talkative quickly
• normal neurological exam
• headaches, dizziness, and nausea will persist

• hospitilization w/ CT or MRI are standard
•   *rule out intracranial hematomas
•        *epidural        *subdural     *intracerebral
• treat like a concussion
• return to play when CT is normal and asymptomatic

• a blow to the head or a skull fx can cause a tear of the meningeal arteries
• blood will accumulate because of arterial pressure very quickly

• LOC
• once consciousness is regained the patiet will be lucid and show few signs of a serious head injury
• symptoms will gradually worsen
•    *head pains, dizziness, dilation of 1 pupil (usually on same side as the injury), sleepiness
•    *later stages include deteriorating consciousness level, neck rigidity, depression of pulse and respiration with convulsions

• life threatening
• CT is necessary to diagnose
• pressure must be surgically removed ASAP

• acute occur much more frequently than epidural
• most common cause of death in athletes
• acceleration/deceleration forces tear blood vessels thta connect the duramater and the brain
• 3 kinds of subdural:
•  1. acute- progresses rapidly and acts as an epidural hematoma (arterial bleeding)
•  2. associatied with other brain injuries (contusions) and skull injuries
•  3. chronic- due to venous bleeding

• simple: unconscious unlikely
• complicated: almost always unconscious and dilation of 1 pupil (usually on same side)
• headache, dizziness, sleepiness and nausea

• life threatening
• immediate medical attention
• Ct or MRI required to determine extent and location

• direct blow (generally fx's frontal angle)
• 2nd most common fx'd facial bone

deformity, loss of occlusion, pain w/ biting, bleeding around teeth, lower lip anesthesia

temporary immobilization with elastic wrap followed by reduction and fixation

• involves TMJ
• generally a blow to an open mouth from the side

dislocated jaw presents in locked-open position with ROM minimal with poor occlusion

• cold application, elastic wrap immobilization and reduction
• follow-up with soft diet, NSAIDs, and analgesics with a gradual return to activity 7-10 days following acute period
• can be recurrent or result in malocclusion or TMJ dysfunction

• MOI- direct blow
• 3rd most commonly fx'd facial bone
• LeFort fx: a fx of 1+ facial bones including zygomatic, maxillary, orbital and nasal bone

deformity or bony discrepancy, epistaxis (nose bleed), diplopia (double vision) and numbness in cheek

• cold application to control edema and immediate referral to dr
• healing will take 6-8 weeks and proper protective gear will be required upon return to play

• MOI- blow to upper jaw
• 4th most commonly fx'd facial bone

pain w/ chewing, malocclusion, noseblee, double vision, bumbness of lip and cheek region

• due to severe bleeding, maintain airway
• must be aware of possible brain injury (concussion)
• be aware of possible cervical injury
• transport hospital immediately upright and leaning forward if conscious
• allows for drainage of saliva and blood
• fx reduction, fixation and immobilization by dr.

impact to the mandible or maxilla, direct trauma

• uncomplicated fx: produce fragments w/o bleeding (chip)
• complicated fx: produce bleeding with the thooth chamber being exposed w/ a great deal of pain
• root fx's: are difficult to determine and require follow up with xray

• uncomplicated and complicated crown fx's do not require immediate attention
• fx'd pieces can be placed in a bag if not senstive to air or cold, follow up can wait 24-48 hours
• bleeding can be controlled via gauze
• cosmetic reconstruction of tooth
• in instances of root rx's the patient can continue to play but must follow up immediately following competition
• tooth repositioning may be required along with bracing and the use of mouth pieces in the future
• mandibular fx's and concussions must also be ruled out

direct blow

• tooth may be slightly loosened, dislodged
• when subluxed tooth may be loose within socket with little or no pain
• w/ luxations, no fx has occurred however there is displacement
• with an avulsion, the thooth is completely knocked from oral cavity

• subluxed tooth: referral should occur within the 1st 48 hours
• luxated tooth: repositioning should be attempted along with immediate follow up
• avulsed tooth: tooth should be re implanted if it can be easily done, if not use a save a tooth kid, milk, or saline

• direct blow
• most commonly fx'd facial bone

• separation of frontal process of maxilla of lateral cartilage or combo
• profuse bleeding and hemorrhaging, immediate swelling and deformity

• control bleeding and refer to dr. for xray, examination and reduction
• uncomplicated and simple fx's will pose little problem for athlete's quick return
• splinting may be necessary
• uncomplicated fx's may return to play within a few days

compression or lateral trauma

• bleeding and in some instances a septal hemotoma will form
• patient will complain of nasal pain

• at the site of hematoma compression will be required (and if present, drained immediately)
• following drainage, a wick is inserted to allow for further drainage
• packing will be necessary to prevent a return of hematoma
• a neglected hematoma will result in formation of an abscess along with bone and cartilage loss and deformity

occurs from either compression or shear injury to the ear (single or repeated)

• tearing of overlying tissue away from cartilage
• hemorrhaging and fluid accumulation
• if unattended- coagulation, organization and fibrosis occurs
• appears elevated, white, rounded, nodular formation that is firm and resembles cauliflower

• to prevent, wear proper ear protection
• cold application will minimize hemorrhaging
• if swelling occurs, measures must be taken to prevent fluid solidification
• dr. aspiration, packing, pressure

• protective devices must provide protection from front and lateral blows
• goggles with high impact-resistant polycarbonate lenses for refraction
• unfortunately googles may distort peripheral vision and or become fogged under certain conditions

• must utilize extreme caution in evaluating and caring for eye injuries
• multiple conditions require immediate referral for additional care to be provided
• transportation to hospital should take place with patient in recumbent position
• eyes should be covered together
•   *movement of unaffected eye will cause movement in affected eye

• Special Test
• Pupillary response
•       *dilation and accomodation
• Visual Acuity
•    *clarity, blurred vision, diplopia, floating black spots, flashes of light
• Ophthalmascope
•    *instrument used for observing the interior of the eye (retina)

blow to the eyeball forcing it posteriorly, compressing the orbital fat until a blowout rupture occurs to the floor of the orbit (muscle and fat can herniate)

• diplopia, restricted eye movement, downward displacement of the eye, soft-tissue swelling and hemorrhaging
• numbness associated with infraorbital nerve on the floor of the orbit

• x ray necessary to confirm fx
• antibiotics to decrease risk of infection (due to proximity of maxillary sinus and bacteria)
• treat surgically or allow to resolve spontaneously

frequent occurrence in sports and can be dangerous

• foreign object produces considerable pain and disability
• no attempt should be made to remove by rubbing or by recovering with fingers

• close eye and determine location (upper or lower lid)
• pull upper lid over lower lid to cause tearing
• wash eyes with saline, use protrolleum jelly to relieve soreness
• if object is embedded, close and patch eye and refer to dr.