الرحیم الرحمن الله الرحیم بسم الرحمن الله بسم

HEAD &HEAD &neckneck INJURYINJURY

mohammad mohammad saleki MDsaleki MD

Sport medicine specialistSport medicine specialist IUMS IUMS

HEAD &HEAD &neckneck INJURYINJURY

mohammad mohammad saleki MDsaleki MD

Sport medicine specialistSport medicine specialist IUMS IUMS

Head InjuryHead Injury Occur by head to head or Occur by head to head or

head to kneehead to knee Concussion by contact matConcussion by contact mat Injury rate:1-8%of all injInjury rate:1-8%of all inj Most inj are mildMost inj are mild

WrestlingWrestling

Injury rate:Injury rate:22.7-50 inj per 100 wrestler22.7-50 inj per 100 wrestler 42-50% all inj associated takedowns42-50% all inj associated takedowns Injury rate increase with ageInjury rate increase with age incidence rate increase durig incidence rate increase durig

competittoncompetitton prevalence rate increase durig practiceprevalence rate increase durig practice Catastrophic inj increase durig Catastrophic inj increase durig

competittoncompetitton

Head InjuryHead InjuryHead InjuryHead Injury

Scalp lacerationScalp laceration ConcussionConcussion Subarachnoid Subarachnoid

HemorrhageHemorrhage Subdural/Subdural/

Epidural Epidural HematomaHematoma

Skull FxSkull Fx

- کوفتگی- -پارگی کوفتگی- كبودي، كبودي، پارگیخراشيدگيخراشيدگي

اسیب مکانیسم به اسیب توجه مکانیسم به توجههمراه همراه وضایعات وضایعات

اسکالپ غنی اسکالپ خونگیری غنی خونگیریعروق انقباض عروق وعدم انقباض وعدم

شدید خونریزی شدید باعث خونریزی باعث :کردن رد کردن: درمان رد درمان

کنترل- کنترل- شکستگی شکستگی- شستشو - -خونریزی شستشو - خونریزی

- کزاز زخم -بستن کزاز زخم بستن

ConcussionConcussion

DefinitionDefinition

A concussion is an alteration of mental A concussion is an alteration of mental status due to biomechanical forces status due to biomechanical forces affectingaffectingthe brain. A concussion may or may not the brain. A concussion may or may not cause loss of consciousness.cause loss of consciousness.

ConcussionConcussion

Centers for Disease Control and Centers for Disease Control and Prevention (CDC) Prevention (CDC) estimates 300,000 estimates 300,000 sports-related sports-related concussions occur per concussions occur per yearyear 100,000 in football alone100,000 in football alone

An An estimated 900 sports-related estimated 900 sports-related traumatic brain injury deaths traumatic brain injury deaths occur per yearoccur per year

ConcussionConcussion

Concussion occurs most often in Concussion occurs most often in males and childrenmales and children, adolescents , adolescents and young adultsand young adults

Risk of Risk of concussion in concussion in is 4-6 times higher in players is 4-6 times higher in players with a previous concussionwith a previous concussion

Concussions per every 100,000 games Concussions per every 100,000 games and/or practices at the collegiate leveland/or practices at the collegiate level Football: 27Football: 27 Ice Hockey: 25Ice Hockey: 25 Men’s soccer: 25 Men’s soccer: 25 Women’s soccer: 24Women’s soccer: 24 Wrestling: 20Wrestling: 20 Women’s basketball: 15Women’s basketball: 15 Men’s basketball: 12Men’s basketball: 12

(Head and Neck Injury in Sports, (Head and Neck Injury in Sports, R.W. DickR.W. Dick

Concussion Concussion (1 of 2)(1 of 2)

Minor traumatic brain injury Minor traumatic brain injury (TBI)(TBI)

Temporary loss or alteration in Temporary loss or alteration in brain functionbrain function

May result in unresponsiveness, May result in unresponsiveness, confusion, or amnesiaconfusion, or amnesia

Retrograde amnesiaRetrograde amnesia: forgetting : forgetting events leading up to injury events leading up to injury

Concussion Concussion (2 of 2)(2 of 2)

Anterograde (posttraumatic) Anterograde (posttraumatic) amnesiaamnesia: forgetting events after : forgetting events after the injury the injury

Perseveration: Perseveration: repetitive speech repetitive speech patternspatterns

..

Immediate Signs of Immediate Signs of ConcussionConcussion

(occurring within seconds to (occurring within seconds to minutes)minutes) Impaired attention , delayed Impaired attention , delayed

responses, inability to focusresponses, inability to focus Slurred or incoherent speechSlurred or incoherent speech Gross incoordinationGross incoordination DisorientationDisorientation Emotional reactions out of proportionEmotional reactions out of proportion Memory deficitsMemory deficits Any loss of consciousnessAny loss of consciousness

Later Signs of Later Signs of ConcussionConcussion

(occurring within hours (occurring within hours to days)to days) Persistent headachePersistent headache

Dizziness/vertigoDizziness/vertigo Poor attention and concentrationPoor attention and concentration Memory dysfunctionMemory dysfunction Nausea or vomitingNausea or vomiting Fatigue easilyFatigue easily IrritabilityIrritability Intolerance of bright lightsIntolerance of bright lights Intolerance of loud noisesIntolerance of loud noises Anxiety and/or depressionAnxiety and/or depression Sleep disturbancesSleep disturbances

Immediate TransportImmediate TransportImmediate TransportImmediate Transport

DiplopiaDiplopia Severe or Severe or

increasing emesisincreasing emesis SeizureSeizure Focal neurologic Focal neurologic

findingsfindings Pupillary changesPupillary changes

Rapidly progressive Rapidly progressive headache headache Penetrating injuryPenetrating injury

LOC > 5 minLOC > 5 min Confusion > 30 minConfusion > 30 min High risk patientHigh risk patient > 1 concussion this > 1 concussion this

seasonseason

کانتو بندی کانتو درجه بندی درجهسوم سوم دفعه دفعه دوم دوم دفعه دفعه اول اول دفعه دفعه

- ورزش فصل پایان - تا ورزش فصل پایان تازودتر برخوردی زودتر غیر برخوردی غیر

هفته هفته 11 دقیقه دقیقه 2020 -11درجه درجه بیهوشی -بدون بیهوشی بدونفراموشی فراموشی

دقیقهدقیقه3030کمترازکمتراز

ای حرفه ورزش ای ختم حرفه ورزش ختم ماه ماه 11 هفته هفته 11 کمتراز 22درجه درجه کمتراز بیهوشی بیهوشیفراموشی 55 فراموشی دقیقه دقیقه

دقیقه دقیقه 3030بیشتراز بیشتراز

ای حرفه ورزش ای ختم حرفه ورزش ختم فصل پایان فصل تا پایان تا ماه ماه 11 از 33درجهدرجه بیشتر از بیهوشی بیشتر بیهوشیفراموشی 55 فراموشی دقیقه دقیقه

از از بیشتر ساعت ساعت 2424بیشتر

Who to Scan?Who to Scan?Who to Scan?Who to Scan?

GCS < 15GCS < 15

? Any LOC? Any LOC Focal neurologic Focal neurologic

findingsfindings

Return to Return to PlayPlay

Return to Return to PlayPlay

No symptomatic athlete No symptomatic athlete should be allowed to should be allowed to

competecompete

Post-concussive Post-concussive SyndromeSyndrome

Post-concussive Post-concussive SyndromeSyndrome 20% to 40% @ 3 20% to 40% @ 3

months post injurymonths post injury Neuropsychiatric Neuropsychiatric

impairmentsimpairments attention concentrationattention concentration

SomaticSomatic headache (71%)headache (71%) fatigue (60%)fatigue (60%) dizziness (53%)dizziness (53%)

Affective – depression Affective – depression or or anxiety anxiety

Second impact Second impact syndromessyndromes

– شایعتر مرد شایعتر – نوجوانان مرد نوجوانان قبل مسابقه به قبل برگشت مسابقه به برگشت

کامل بهبودی کامل از بهبودی از اختالل اول ضربه از اختالل بعد اول ضربه از بعد

- از پس مغز - عروقی از پس مغز عروقیمغز تورم دوم مغز ضربه تورم دوم ضربه

:کاهشسطح کاهشسطح: عالئم عالئم - در- مرگ کما - هوشیاری در- مرگ کما هوشیاری

دقیقه دقیقه 22عرض عرض

Skull FractureSkull Fracture

Indicates Indicates significant forcesignificant force

Signs:Signs:– Obvious deformityObvious deformity– Visible crack in Visible crack in

skullskull– Raccoon eyesRaccoon eyes– Battle’s signBattle’s sign– Cerebrospinal fluidCerebrospinal fluid

Intracranial BleedingIntracranial Bleeding

Major TBIMajor TBI Laceration or Laceration or

rupture of blood rupture of blood vessel in brainvessel in brain– SubduralSubdural– IntracerebralIntracerebral– EpiduralEpidural

h\h\

Complications of Head Complications of Head InjuryInjury

Cerebral edema is one of the most Cerebral edema is one of the most serious complications.serious complications.– Ensure airway and provide oxygen.Ensure airway and provide oxygen.

Seizure (convulsion) may occur.Seizure (convulsion) may occur. Vomiting may occur.Vomiting may occur.

– Common in children Common in children Leakage of cerebrospinal fluid Leakage of cerebrospinal fluid

may occur.may occur.– Do not pack ears or nose.Do not pack ears or nose.

Evaluation and Evaluation and TreatmentTreatment

CAB’sCAB’s If unconscious, immobilize C-spineIf unconscious, immobilize C-spine Examine for chest, abdominal, limb Examine for chest, abdominal, limb

injuriesinjuries Glascow Coma ScaleGlascow Coma Scale Mental Status ExamMental Status Exam Brain imaging-for fracture or contusionBrain imaging-for fracture or contusion C-spine X-raysC-spine X-rays

Cervical spine Cervical spine and Neck and Neck InjuriesInjuries

EpidemiologyEpidemiology 10,000 C-spine 10,000 C-spine

injuries/yr in USinjuries/yr in US 5-10% related to 5-10% related to

sportssports Football, Football,

wrestling, wrestling, gymnastics, diving, gymnastics, diving, surfing, skiing, surfing, skiing, hockey, rugbyhockey, rugby

Neck injuryNeck injury Inj Inj associated takedowns in associated takedowns in

hyperextentionhyperextention Most inj sprain/strain/stingerMost inj sprain/strain/stinger

(noncatastrophic)(noncatastrophic) sprain/strain up 50% neck sprain/strain up 50% neck injinj Cumulative effect mild inj Cumulative effect mild inj

increase incidence of increase incidence of djddjd

مطالعهمطالعه

4040 ( حداقل سابقه با حرفه‌اي حداقل ) كشتي‌گير سابقه با حرفه‌اي سال سال 1010كشتي‌گيرو كشتي( كشتي( الكترودياگنوستيك و بررسيهاي الكترودياگنوستيك MRIMRIبررسيهاي

45%45% دچار مطالعه مورد دچار افراد مطالعه مورد ريشه افراد مزمن ريشه ضايعه مزمن ضايعه. عصبي عصبي بودند . گردن بودند گردن

( دژنراتيو دژنراتيو ) تغييرات مواردموارد% % 6161در در ( ( degenerativedegenerativeتغييرات ( ديسك زدگي ديسك ) بيرون زدگي مواردموارد% % 2828در در ( ( protrusionprotrusionبيرون در نخاعي كانال در تنگي نخاعي كانال موارد موارد % % 1919تنگي ديسك ديسك خروج موارد% موارد% 99در در ( ( extrusionextrusion) ) خروج

مطالعهمطالعه

در درگير عصبي ريشه در شايعترين درگير عصبي ريشه ( ( C6C6الكترودياگنوز ) الكترودياگنوز ) شايعترين . بود طرفه دو . بشكل بود طرفه دو بشكل

5/27%5/27% دچار مطالعه تحت دچار افراد مطالعه تحت عصب افراد عصب آسيب آسيبفوقاني اندام فوقاني محيطي اندام بودند بودند محيطي

تونل كارپال تونل سندرم كارپال با سندرم با دوطرفه سپس% 1515دوطرفه سپس% و وبا درگيري درگيري آرنج در اولنار با عصب آرنج در اولنار را% 1212عصب آمار را% بيشترين آمار بيشترين

. دادند اختصاص . بخود دادند اختصاص بخود کشتی در گردن میدهدآسیب نشان مطالعات کشتی بعضی در گردن میدهدآسیب نشان مطالعات بعضی

گیران کشتی از بیشتر داری معنی طور به آزاد گیران گیران کشتی از بیشتر داری معنی طور به آزاد گیراناست است فرنگی فرنگی

Injury ClassificationsInjury Classifications Catastrophic and Potentially Catastrophic InjuriesCatastrophic and Potentially Catastrophic Injuries

Cervical SubluxationCervical Subluxation Unilateral and bilateral facet dislocationUnilateral and bilateral facet dislocation Unstable cervical fractures -- axial load Unstable cervical fractures -- axial load

teardrop fractureteardrop fracture

Noncatastrophic InjuriesNoncatastrophic Injuries Nerve root -- brachial plexus injuryNerve root -- brachial plexus injury Cervical sprain and strainsCervical sprain and strains Intervertebral disc injuryIntervertebral disc injury Cervical cord neuropraxia-transient Cervical cord neuropraxia-transient

quadriplegiaquadriplegia Stable fracturesStable fractures

گردنی عضالت گردنی کشیدگی عضالت کشیدگی

Collision-type injuryCollision-type injuryPainPainLimitation of motionLimitation of motionRadiographs are Radiographs are

normalnormalresolve withoutresolve without

treatmenttreatmentTreatmentTreatment

soft collarsoft collaranalgesics agentsanalgesics agentsTapingTaping

Acute Cervical Sprain Acute Cervical Sprain SyndromeSyndrome

Collision-type injuryCollision-type injury Pain localized to cervical areaPain localized to cervical area Limitation of cervical spine motion without Limitation of cervical spine motion without

radiation of pain or paresthesiaradiation of pain or paresthesia Neurologic exam negativeNeurologic exam negative Radiographs are normalRadiographs are normal Eventually resolve without treatmentEventually resolve without treatment Test AROM -- if abnormal then further work-Test AROM -- if abnormal then further work-

up warrantedup warranted TreatmentTreatment

neck immobilization in a soft collarneck immobilization in a soft collar analgesics and anti-inflammatory agentsanalgesics and anti-inflammatory agents

Burner” or StingersBurner” or Stingers Transient UE Transient UE

neuropraxia of root neuropraxia of root or brachial plexusor brachial plexus Traction-plexusTraction-plexus Compression-rootCompression-root

Burning in armBurning in arm Shock likepainShock likepain Dysesthesia Dysesthesia

paresthesiaparesthesia Few sec to few minFew sec to few min Limit ROM-tendernesLimit ROM-tendernes

2. “Burner” or “Stinger”2. “Burner” or “Stinger” Weakness in C5 and C6 Weakness in C5 and C6

distributiondistribution Deltoid, biceps, wrist extensors, Deltoid, biceps, wrist extensors,

pronator terespronator teres Positive Spurling’sPositive Spurling’s Is not a spinal cord injury. Is not a spinal cord injury. Generally symptoms resolve Generally symptoms resolve

in 5 minutes, in 5 minutes, Is return before pain Is return before pain

tenderness to normal tenderness to normal recurrence is highrecurrence is high

Repeated osteoghyte Repeated osteoghyte foramen narrowing foramen narrowing

Continued symptom despite stopping Continued symptom despite stopping truma(37%)truma(37%)

Treat:ROM.rehab.streght Treat:ROM.rehab.streght

Complicated StingersComplicated Stingers

Recurrent, Recurrent, prolonged disabilityprolonged disability

Consider EMG and Consider EMG and MRI of C-spine and MRI of C-spine and plexusplexus

Consider Consider equipment changes equipment changes upon returnupon return

Cervical Cervical strengtheningstrengthening

گذرا وپای دست چهار گذرا فلج وپای دست چهار فلج

burning pain, burning pain, numbness, tingling, numbness, tingling, and loss of and loss of sensationsensation

weakness to weakness to complete paralysis complete paralysis involving upper and involving upper and lower extremitieslower extremities

Axial loding causedAxial loding caused In wrestler 2%In wrestler 2% Stenosis Stenosis

&hypermobility is &hypermobility is causativecausative

transient quadriplegiatransient quadriplegia (recovery usually occurs in 10-15 (recovery usually occurs in 10-15

minutesminutes)) Radiographs are negative for Radiographs are negative for

fracture, subluxation, or dislocation fracture, subluxation, or dislocation Does Does notnot predispose to neurologic predispose to neurologic

sequelaesequelae

فقرات ستون اسیبهای فقرات عالئم ستون اسیبهای عالئم

روی وحساسیت روی درد وحساسیت دردها ها مهره مهره

ستون شکل ستون تغییر شکل تغییرها ها مهره مهره

ومورمور ومورمور بیحسی بیحسیوضعف وضعف شدن شدن

عضالنیعضالنی ادرار اختیاری ادرار بی اختیاری بی

Cervical SubluxationCervical Subluxation

UncommonUncommon Up to 2 mm of translatory Up to 2 mm of translatory

displacement is normaldisplacement is normal 3.5 mm translation and 11 degrees 3.5 mm translation and 11 degrees

of rotation are indications for of rotation are indications for surgical stabilizationsurgical stabilization

Unilateral and Bilateral Unilateral and Bilateral Facet DislocationFacet Dislocation

Prompt reduction indicated to Prompt reduction indicated to relieve cord deformationrelieve cord deformation

Unstable Cervical Unstable Cervical Fractures- Axial-Load Fractures- Axial-Load

Teardrop FractureTeardrop Fracture Three-part, two-plane axial-load teardrop Three-part, two-plane axial-load teardrop

fracture is most frequently occurring cervical fracture is most frequently occurring cervical spine fracture associated with instability, spine fracture associated with instability, cord compromise and major neurologic cord compromise and major neurologic sequelaesequelae

85% of tackle football players sustaining this 85% of tackle football players sustaining this injury were rendered and remain injury were rendered and remain quadriplegicquadriplegic

Intervertebral Disc Intervertebral Disc InjuryInjury

Acute cervical disc herniation rare in athletesAcute cervical disc herniation rare in athletes Acute central disc deforming the cord, or lateral Acute central disc deforming the cord, or lateral

disc associated with pain, limited cervical ROM, disc associated with pain, limited cervical ROM, or neurologic symptoms are absolute or neurologic symptoms are absolute contraindications to athletic participationcontraindications to athletic participation

Degenerative disc changesDegenerative disc changes associated with repetitive microtraumaassociated with repetitive microtrauma disc space narrowing, anterior bony ridging, disc space narrowing, anterior bony ridging,

loss of cervical lordosisloss of cervical lordosis treatment consists of rest, heat, analgesics, treatment consists of rest, heat, analgesics,

neck collar until pain freeneck collar until pain free

Assessment of Spinal Assessment of Spinal InjuriesInjuries

Assess CABAssess CAB Avoid any excessive motion.Avoid any excessive motion. Assess strength in each extremity Assess strength in each extremity

and compare. and compare. Absence of pain does not rule out Absence of pain does not rule out

injury. injury. Ability to move or walk does not Ability to move or walk does not

rule out injury.rule out injury.

Stabilization of the Stabilization of the Cervical Spine Cervical Spine (1 of 3)(1 of 3)

Hold patient’s head Hold patient’s head firmly with both hands.firmly with both hands.

Support the lower jaw.Support the lower jaw. Move to patient’s head Move to patient’s head

to eyes-forward to eyes-forward position.position.

Maintain position until Maintain position until patient is secured to patient is secured to backboard.backboard.

Cervical Collar Cervical Collar Provides preliminary, Provides preliminary,

partial support partial support Applied to every Applied to every

patient with a patient with a suspected spinal injurysuspected spinal injury

Used with manual Used with manual stabilization until stabilization until patient is secured to patient is secured to spinal immobilization spinal immobilization device device

Must be correctly Must be correctly sizedsized