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Head and

Neck
Orthopedic Assessment III
Head, Spine, and Trunk
with Lab
PET 5609C

Clinical Anatomy

Clinical Anatomy

Clinical Anatomy

Brain: Cerebrum
Largest section of brain (most
anterior and superior region of CNS)
Formed by 2 hemispheres:

Longitudinal fissure separates 2 sides


Right and Left Hemisphere:

Frontal lobe
Parietal lobe
Temporal lobe
Occipital lobe

Clinical Anatomy

Clinical Anatomy

Brain: Cerebrum

Functions:

Temperature
Touch
Pain
Pressure
Proprioception

Visual
Auditory
Olfactory and taste

Spatial
relationships
Behavior
Memory
Association

Communication:

Special senses:

Cognition:

Motor function
Sensory
information:

Functions (cont.)

Right hemisphere
controls left side
of body
Left hemisphere
controls right side
of body

Clinical Anatomy

Brain: Cerebellum

Quick processor of incoming/outgoing


information:
Integrates sensory perception, coordination
and motor control: Cerebellum linked to
cerebral motor cortex (sends info to muscles)
and spinocerebellar tract (proprioceptive
feedback)
Constant feedback on body position fine
tunes motor movements
Key: Maintains BALANCE and
COORDINATION

Clinical Anatomy

Clinical Anatomy

Brain:
Diencephalon

Processing center
for conscious and
unconscious
brain input
Parts:
Thalamus
Hypothalamus
Epithalamus

Clinical Anatomy

Brain: Thalamus

Functions:
Translates
information
(inputs) for
cerebral cortex
Processes and
relays sensory
information
Helps regulate
states/levels of
sleep and
consciousness

Hypothalamic
Regulation

Posterior Pituitary Effect

Neurosecratory
Neuron

Vasopressin
(ADH)

Water Retention

Neurosecratory
Neuron

Oxytocin

Milk ejection
(mammary gland)

Hypothalamic
Regulation

Anterior Pituitary

Effect

Thyrotropin Releasing Thyrotropin


Hormone

Involved Thyroxin
from Thyroid
Gland

Corticotropin
Releasing Hormone

Adrenocorticotrop Cortisol Release


hic Hormone
(adrenal gland)

Growth-Hormone
Releasing Hormone

GH

Whole body
growth

Gonadotropin
Releasing Hormone

FSH, LH

Reproductive
function

Prolactin Releasing
Hormones

Prolactin

Milk production

MSH Releasing Factor Melanocyte

Skin pigments

Clinical Anatomy

Clinical Anatomy

Brain: Hypothalamus

Control of Hydration: Supraoptic nuclei


and Paraventricular nuclei (Hypothalamus)
What Happens?

Hydration Level too LOW


Osmoreceptors in blood detect increased
concentration of salt in blood
Hypothalamus stimulated neurosecratory
hormones
Vasopressin released from Posterior Pituitary
ADH causes kidneys to retain water
Level of water increases in the body

Clinical Anatomy

Brain: Brain Stem

Lower part of the brain


(continuous with spinal cord)

Medulla Oblongata
Pons

Functions:

Main motor and sensory


innervation to face and neck

Cranial nerves

Regulation of cardiac and


respiratory function
(medulla)
Relays information to and
from the CNS

Pons: Link between


cerebellum to brain stem and
spinal cord

Clinical Anatomy

Brain: Meninges

3 connective tissue layers which protect the


CNS

Pia mater:

Supports blood vessels


Contains cerebrospinal fluid

Innermost layer (outer skin of brain)

Dura Mater:

Outermost layer

Serves as periosteum for skulls inner layer

Arachnoid Mater:

Middle layer
Subdural space area between dura mater and
arachnoid mater
Subarachnoid space beneath the arachnoid

Contains cerebrospinal fluid

Clinical Anatomy

Clinical Anatomy

Cerebrospinal Fluid:

Clear, colorless liquid


that bathes the brain
and spinal cord
(circulates within
subarachnoid space)
Functions:

Cushions the brain


within the skull
Shock absorber for the
CNS
Circulates nutrients
and chemicals filtered
from the blood and
removes waste products
from the brain

Clinical Anatomy

Brain blood
demand:

20% of bodys O2
uptake at rest

1 Celsius, brains
demand 7%
0

Supplying vessels:

Vertebral arteries
Carotid arteries:

Internal

External

Circle of Willis

Clinical Evaluation

Key Points:
All unconscious athletes must be
managed as if a fracture or dislocation
of the cervical spine exists until the
presence of these injuries can be
definitively ruled out
Ideally, 2 responders are available to
evaluate:

In-line stabilization and immobilization of


athletes head
Initial evaluation:

Palpation
Sensory and motor tests

Clinical Evaluation

Clinical Evaluation

Initial Evaluation:

Assess ABCs: (airways, breathing,


circulation)

Moving, speaking athlete ABCs present

Still suspect cervical spine injury (until ruled


out)

Level of Consciousness:
Communicate with athlete (verbal)
Unresponsive athlete:

Apply painful stimulus:


Lunula of fingernail
Pressure to sternum

Clinical Evaluation

Initial Evaluation:

Primary Survey:

Look, listen, feel for


breathing
Absent breathing
modified jaw thrust to
open airway
Absent pulse CPR
Initiate EMS!

Secondary Survey:

Bleeding
Possible fractures,
dislocations

Clinical Evaluation

History:

Location of
symptoms:

Signs and Symptoms

Brain

Amnesia
Confusion and
Disorientation

Cervical pain
or muscle
spasm:

Area

Pain
Numbness
Burning

Irritability and
Uncoordination
Dizziness
Headache
Ocular

Head pain:

Headaches

Blurred vision and


Photophobia
Nystagmus

Ears

Tinnitus
Dizziness

Stomach

Nausea
Vomiting

Clinical Evaluation

Mechanism of Injury:
Head

Coup Injury:

Stationary skull is hit by object


traveling at high velocity (i.e.
hit in head with baseball)
Trauma side of head where
contact occurred

Contrecoup Injury:

Skull is moving at high velocity


and is suddenly stopped (i.e.
falling and hitting head on the
ground)
Brain strikes the skull on side
opposite of the impact

Clinical Evaluation

Clinical Evaluation

Clinical Evaluation

Mechanism of
Injury: Head

Repeated
subconcussive
forces:

Repeated trauma:

Boxing
Heading in soccer

Rotational or
shear forces:

Twisting
Acceleration and
deceleration

Clinical Evaluation

Mechanism of Injury: Cervical spine


Most forces dissipated by cervical
musculature and intervertebral discs
Flexion, extension, lateral bending,
rotation
Flexion:

Removes natural lordotic curvature (30


degrees)

Forces directed to cervical vertebrae


Axial load through vertical axis of vertebral column

Catastrophic injuries

Clinical Evaluation

Clinical Evaluation

Clinical Evaluation

History:

Loss of consciousness:

Record athletes initial responses:

Do you remember being hit?

History of concussion:

Recent concussions increased risk

Seeing stars
Blacking out

Second impact syndrome

Complaints of weakness:

Fatigue
Muscular weakness:

More serious:
Trauma to brain, spinal cord, spinal nerve roots

Clinical Evaluation

Inspection: Bony Structures

Position of head:

Cervical vertebrae:

Head should be upright in all planes


Laterally flexed and rotated head possible
cervical vertebrae dislocation
View athlete from behind (positioning of spinous
processes)

Mastoid process:

Battles sign ecchymosis over mastoid process

Basilar skull fracture

Skull and scalp:

Bleeding, swelling, deformity

Clinical Evaluation

Inspection: Eyes

General:

Nystagmus:

Dazed, distant stare may


indicate mental confusion
Involuntary cyclical movement
of the eyes

Pupil size:

Unilateral dilation (pressure


on cranial nerve III)

Note: Anisocoria (normal


unequal pupil size)

Pupil reaction to light

Clinical Evaluation

Inspection:
Nose and Ears

Ears:

Nose:

Bleeding and/or
cerebrospinal
fluid
Skull fracture
Bleeding
Nose fracture or
skull fracture

Nose/eyes:

Raccoon eyes
skull or nasal
fracture

Clinical Evaluation

Palpation: Bony
Structures

Spinous Processes:

Patient seated, leaning


slightly forward
C7 and

Transverse Processes
Skull:

Occipital and temporal


Sphenoid and
zygomatic
Parietal and frontal

Palpation: Soft
Tissue

Musculature:

Trapezius
SCM

Throat

Clinical Evaluation

Special Test: Halo Test

Patient position:

Examiner position:

Fold a piece of sterile gauze into a triangle


Using the point of the gauze, collect a sample of
the fluid leaking from the ear or nose (allow it to
be absorbed)

Positive test:

At patients side

Procedure:

Lying or seated

Pale yellow halo will form on the gauze

Implications:

Cerebrospinal fluid leakage

Clinical Evaluation

Functional Testing: Memory

Retrograde amnsesia:

Inability to recall events before injury

Anterograde amnesia:
Inability to recall events after injury
Fading memory progressive
deterioration of cerebral function

ATHLETE
POSITION:

On-field: athletes current position


Sideline: standing, seated

EXAMINER
POSITION:

In a position able to hear athletes responses

PROCEDURE:

Ask patient series of questions beginning with the time of the


injury
Each successive question progresses backward in time
What happened?
running?

What play were you

Where are you?


Who are we playing?

Who am I?
What quarter is it?

What did you have for a pregame meal?


Who did we play last week?
POSITIVE TEST:

Athlete has difficulty remembering or cannot remember events


occurring before the injury

IMPLICATIONS:

Retrograde amnesia:
Not remembering events from the day before is more
significant that not
remembering more recent events
The same set of questions should be repeated to determine
whether memory
is returning, deteriorating, or staying the same
Further deterioration of memory or acutely profound

Clinical Evaluation: Anterograde


Amnesia
PATIENT
Sitting or standing
POSITION:

EXAMINER
POSITION:

Positioned to hear athletes response

EVALUATION:

Athlete is given a list of 4 unrelated items


(ask them to memorize the list)
Hubcap
Rabbit
Dog tags
Film
Ivy

POSITIVE TEST:

Inability to completely recite the list

IMPLICATIONS:

Anterograde amnesia, possibly the result


of intracranial bleeding

COMMENT:

Perform the test after test for retrograde


amnesia

Clinical Evaluation

Functional Testing: Cognitive


Function

Cerebral trauma Unusual athlete


behavior

Behavior:

Analytical Skills:

Violent, irrational, inappropriate behavior


Serial 7s (count backwards from 100)

Information Processing:

Provide command can athlete follow?

Clinical Evaluation

Balance and Coordination:


Affected secondary to trauma
involving cerebellum and inner ear
Tests:

Romberg Test
Tandem Walking
Balance Error Scoring System

Clinical Evaluation

Romberg Test:

Patient Position:

ATC Position:

Patient shuts eyes and abducts


arms to 900
Patient tilts head backwards
and lifts 1 foot off ground
Patient touches index finger to
nose (eyes closed)

Positive Test:

Ready to support patient

Procedure:

Standing, feet shoulder width


apart

Patient unsteadiness

Implications:

Cerebellar dysfunction

Clinical Evaluation

Tandem Walking:

Patient Position:

ATC Position:

Athlete walks heel-to-toe along a straight line for


approximately 10 yards
Athlete returns to starting position by walking
backwards

Positive Test:

Beside patient to provide support

Evaluation:

Athlete standing with feet straddling a straight line

Athlete unable to maintain a steady balance

Implications:

Cerebral or inner ear dysfunction that inhibits


balance

Clinical Evaluation

Balance Error Scoring System:

Patient Position:
Patient barefoot or wearing socks (no
tape); hands on iliac crest; eyes closed
Phase 1:

Phase 2:

Double Leg Stance


Single Leg Stance standing on the
nondominant leg; non-weight-bearing hip flexed
to 200 and knee flexed to 400-500

Phase 3:

Tandem Leg Stance nondominant leg placed


behind the dominant leg and the patient stands
in a heel-toe manner

Clinical Evaluation

Balance Error Scoring System:

ATC Position:

In front of the athlete; trials are timed

Procedure:

First battery performed with athlete


standing on a firm surface

DL stance, holds position for 20 seconds


SL stance
Tandem stance

Second battery performed with athlete


standing on foam

Clinical Evaluation

Balance Error Scoring System:

Scoring: One point is scored for each of the


following errors

Hands lifted off iliac crest


Opening eyes
Step, stumble or fall
Moving hip into > 30 degrees abduction
Lifting forefoot or heel
Remaining out of testing position > 5 sec.
Note:

If more than 1 error scores simultaneously, only 1 error is


scored
Patients unable to hold the test position for 5 seconds are
assigned the score of 10

Positive Test:

Scores that are 25% ABOVE patients baseline


Impaired cerebral function

Clinical Evaluation

Standardized Assessment of
Concussion (SAC)

Abbreviated neuropsychological test


Immediate objective data

Presence and severity of neurocognitive


impairment

On or off field evaluation


Tests:
Orientation
Immediate Memory Recall
Concentration
Delayed Recall

Clinical Evaluation

Neuropsychological Testing:

Allow ATCs to objectively quantify athlete


cognitive dysfunction
Tests:

Hopkins Verbal Learning Test (HVLT) 12 word list;


athlete recalls several times
Brief Visuospatial Memory Test (BVMT-R) visual
memory
Trail Making Test spatial scanning, speed, cognitive
flexibility
Controlled Oral Word Association Test (COWAT) recall
as many words as possible in 1 min. (starting with a
given letter)
Digit Span Test repeat strings of numbers
Symbol Digit Modalities Test (SDMT) visual scanning
and processing speed; match numbers/symbols under
pressure

Clinical Evaluation

Vital Signs:

Respirations:

Pulse:

Number of breaths per minute and quality of


respirations
Pulse rate and quality

Blood pressure
Pulse pressure:

Systolic pressure diastolic pressure

Normal: 40 mm HG
Pulse pressure > 50 mm HG may indicate
increased intracranial bleeding

Clinical Evaluation

Cranial Nerve
Assessment:

12 nerves that emerge


directly from the brain
stem

spinal nerves which


emerge from segments of
the spinal cord

Ganglia of sensory
component outside
CNS
Ganglia of motor
component within CNS

intracranial pressure
impairs motor component

Cranial
Nerve

Function

Test

(I) Olfactory

Transmits sense of Check athletes


smell
ability to smell

(II) Optic

Transmits visual
information to
brain

Check athletes
vision

(III)
Occulomotor

Innervates
superior, medial,
and inferior rectus
muscles and
inferior oblique

Ask athlete to
elevate the eyelid,
elevate, depress,
and adduct the eye

(IV) Trochlear Innervates


superior oblique
muscle

Ask athlete to
elevate the eyes

(V)
Trigeminal

Check sensation of
face, ask athlete to
elevate, depress,
protrude, retrude,

Receives sensation
from the face,
innervates
muscles of

Cranial
Nerve

Function

Test

(VII) Facial

Motor innervation
to muscles of facial
expression,
receives special
sense of taste from
anterior 2/3 of the
tongue, provides
secremotor
innervation to
salivary glands and
lacrimal gland

Check athletes
ability to taste along
anterior portion of
tongue; elevate,
abduct, depress
eyebrows, open/close
eyes, dilate and
constrict nostrils,
open and close
mouth, protrude lips

(VIII)
Vestibulocochle
ar

Senses sound,
rotation, and
gravity (essential
for balance and
movement)

Romberg Test,
athletes ability to
hear

(IX)
Glossopharyng

Receives taste from Check athletes


posterior 1/3 of
ability to taste on

Cranial
Nerve

Function

Test

(X) Vagus

Supplies innervation to
most laryngeal and
pharyngeal muscles,
provides parasympathetic
fibers to thoracic and
abdominal viscera,
receives special sense of
taste from epiglottis

Assess
athletes
ability to
breathe

(XI)
Accessory

Controls muscles of neck


and overlaps with
functions of vagus nerve

Ask athlete to
shrug
shoulders

(XII)
Motor innervation to
Hypoglossal intrinsic muscles of the
tongue

Ask athlete to
stick out
their tongue