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

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ae_228
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Upper Extremity- Head, face, eyes, ears, throat
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2014-11-18 15:47:18
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upper extremity head face eyes ears throat
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injuries of eyes ears face head throat
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  1. Cranial Nerves
    • 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
  2. Skull Fx's-Etiology
    MOI- blunt trauma
  3. Skull Fx's-S&S
    • severe headache and nausea
    • unconscious
    • may have palpable deformity
    • racoon's eye, battle's sign
    • cerebral spinal fluid in ear or nose
  4. Skull Fx's-Mgmt
    • intracranial bleeding
    • bony fragments
    • infection
    •   hospitalization
    •   neurosurgeon
    •   refer to dr
  5. Cerebral Concussions (Mild Traumatic Brain Injuries)-Etiology
    • 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)
  6. Cerebral Concussions (Mild Traumatic Brain Injuries)-S&S
    • 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
  7. Cerebral Concussions (Mild Traumatic Brain Injuries)-Mgmt
    • 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
  8. 2nd Impact Syndrome-Etiology
    • 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
  9. 2nd Impact Syndrome-S&S
    • 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
  10. 2nd Impact Syndrome-Mgmt
    • 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
  11. Cerebral Contusion-Etiology
    • involves small hemorrhage and/or intercranial bleeding
    • it is within the cortex, stem or cerebellum
    • usually from an impact injury with an immovable object
  12. Cerebral Contusion-S&S
    • may vary significantly
    • LOC, but will become very alert and talkative quickly
    • normal neurological exam
    • headaches, dizziness, and nausea will persist
  13. Cerebral Contusion-Mgmt
    • 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
  14. Epidural Hematoma-Etiology
    • 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
  15. Epidural Hematoma-S&S
    • 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
  16. Epidural Hematoma-Mgmt
    • life threatening
    • CT is necessary to diagnose
    • pressure must be surgically removed ASAP
  17. Subdural Hematoma-Etiology
    • 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
  18. Subdural Hematoma-S&S
    • simple: unconscious unlikely
    • complicated: almost always unconscious and dilation of 1 pupil (usually on same side)
    • headache, dizziness, sleepiness and nausea
  19. Subdural Hematoma-Mgmt
    • life threatening
    • immediate medical attention
    • Ct or MRI required to determine extent and location
  20. Mandible Injuries-Etiology
    • direct blow (generally fx's frontal angle)
    • 2nd most common fx'd facial bone
  21. Mandible Injuries-S&S
    deformity, loss of occlusion, pain w/ biting, bleeding around teeth, lower lip anesthesia
  22. Mandible Injuries-Mgmt
    temporary immobilization with elastic wrap followed by reduction and fixation
  23. Mandibular Luxation-Etiology
    • involves TMJ
    • generally a blow to an open mouth from the side
  24. Mandibular Luxation-S&S
    dislocated jaw presents in locked-open position with ROM minimal with poor occlusion
  25. Mandibular Luxation-Mgmt
    • 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
  26. Zygomatic Complex (cheek bone) fx-Etiology
    • 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
  27. Zygomatic Complex (cheek bone) fx-S&S
    deformity or bony discrepancy, epistaxis (nose bleed), diplopia (double vision) and numbness in cheek
  28. Zygomatic Complex (cheek bone) fx-Mgmt
    • 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
  29. Maxillary fx-Etiology
    • MOI- blow to upper jaw
    • 4th most commonly fx'd facial bone
  30. Maxillary fx-S&S
    pain w/ chewing, malocclusion, noseblee, double vision, bumbness of lip and cheek region
  31. Maxillary fx-Mgmt
    • 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.
  32. Tooth Fx-Etiology
    impact to the mandible or maxilla, direct trauma
  33. Tooth Fx-S&S
    • 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
  34. Tooth Fx-Mgmt
    • 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
  35. Tooth Subluxation, Luxation, and Avulsion-Etiology
    direct blow
  36. Tooth Subluxation, Luxation, and Avulsion-S&S
    • 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
  37. Tooth Subluxation, Luxation, and Avulsion-Mgmt
    • 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
  38. Nasal Fx-Etiology
    • direct blow
    • most commonly fx'd facial bone
  39. Nasal Fx-S&S
    • separation of frontal process of maxilla of lateral cartilage or combo
    • profuse bleeding and hemorrhaging, immediate swelling and deformity
  40. Nasal Fx-Mgmt
    • 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
  41. Deviated Septum-Etiology
    compression or lateral trauma
  42. Deviated Septum-S&S
    • bleeding and in some instances a septal hemotoma will form
    • patient will complain of nasal pain
  43. Deviated Septum-Mgmt
    • 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
  44. Auricular (Pinna) Hematoma (Cauliflower ear)-Etiology
    occurs from either compression or shear injury to the ear (single or repeated)
  45. Auricular (Pinna) Hematoma (Cauliflower ear)-S&S
    • 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
  46. Auricular (Pinna) Hematoma (Cauliflower ear)-Mgmt
    • 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
  47. Preventing Eye Injuries
    • 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
  48. Assessment of the eye
    • 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
  49. Special Tests
    • 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)
  50. Orbital Fx-Etiology
    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)
  51. Orbital Fx-S&S
    • 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
  52. Orbital Fx-Mgmt
    • 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
  53. Foreign Bodies in the Eye-Etiology
    frequent occurrence in sports and can be dangerous
  54. Foreign Bodies in the Eye-S&S
    • foreign object produces considerable pain and disability
    • no attempt should be made to remove by rubbing or by recovering with fingers
  55. Foreign Bodies in the Eye-Mgmt
    • 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. 

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