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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:

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head and neck

Head and Neck

Orthopedic Assessment III – Head, Spine, and Trunk with Lab

PET 5609C

clinical anatomy2
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 anatomy4
Brain: Cerebrum


Motor function

Sensory information:






Special senses:



Olfactory and taste

Functions (cont.)


Spatial relationships





Right hemisphere → controls left side of body

Left hemisphere → controls right side of body

Clinical Anatomy
clinical anatomy5
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 anatomy7
Brain: Diencephalon

Processing center for conscious and unconscious brain input





Clinical Anatomy
clinical anatomy8
Brain: Thalamus


Translates information (inputs) for cerebral cortex

Processes and relays sensory information

Helps regulate states/levels of sleep and consciousness

Clinical Anatomy
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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 anatomy11
Brain: Brain Stem

Lower part of the brain (continuous with spinal cord)

Medulla Oblongata



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
clinical anatomy12
Clinical Anatomy
  • Brain: Meninges
    • 3 connective tissue layers which protect the CNS
      • Supports blood vessels
      • Contains cerebrospinal fluid
    • Pia mater:
      • Innermost layer (outer “skin” of brain)
    • Dura Mater:
      • Outermost layer
        • Serves as periosteum for skull’s inner layer
    • Arachnoid Mater:
      • Middle layer
      • Subdural space – area between dura mater and arachnoid mater
      • Subarachnoid space – beneath the arachnoid
        • Contains cerebrospinal fluid
clinical anatomy14
Cerebrospinal Fluid:

Clear, colorless liquid that bathes the brain and spinal cord (circulates within subarachnoid space)


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
clinical anatomy15
Brain blood demand:

20% of body’s O2 uptake at rest

↑ 10 Celsius, brains demand ↑ 7%

Supplying vessels:

Vertebral arteries

Carotid arteries:



Circle of Willis

Clinical Anatomy
clinical evaluation
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 athlete’s head
      • Initial evaluation:
        • Palpation
        • Sensory and motor tests
clinical evaluation2
Clinical Evaluation
  • Initial Evaluation:
    • Assess ABC’s: (airways, breathing, circulation)
      • Moving, speaking athlete → ABC’s 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 evaluation3
Initial Evaluation:

Primary Survey:

Look, listen, feel for breathing

Absent breathing → modified jaw thrust to open airway

Absent pulse → CPR

Initiate EMS!

Secondary Survey:


Possible fractures, dislocations

Clinical Evaluation
clinical evaluation4
Clinical Evaluation
  • History:
    • Location of symptoms:
      • Cervical pain or muscle spasm:
        • Pain
        • Numbness
        • Burning
      • Head pain:
        • Headaches
clinical evaluation5
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 evaluation8
Mechanism of Injury: Head

Repeated subconcussive forces:

Repeated trauma:


Heading in soccer

Rotational or shear forces:


Acceleration and deceleration

Clinical Evaluation
clinical evaluation9
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 evaluation12
Clinical Evaluation
  • History:
    • Loss of consciousness:
      • Record athlete’s initial responses:
        • “Seeing stars”
        • “Blacking out”
      • “Do you remember being hit?”
    • History of concussion:
      • Recent concussions → increased risk
        • Second impact syndrome
    • Complaints of weakness:
      • Fatigue
      • Muscular weakness:
        • More serious:
          • Trauma to brain, spinal cord, spinal nerve roots
clinical evaluation13
Clinical Evaluation
  • Inspection: Bony Structures
    • Position of head:
      • Head should be upright in all planes
      • Laterally flexed and rotated head → possible cervical vertebrae dislocation
    • Cervical vertebrae:
      • View athlete from behind (positioning of spinous processes)
    • Mastoid process:
      • Battle’s sign → ecchymosis over mastoid process
        • Basilar skull fracture
    • Skull and scalp:
      • Bleeding, swelling, deformity
clinical evaluation14
Inspection: Eyes


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
clinical evaluation15
Inspection: Nose and Ears


Bleeding and/or cerebrospinal fluid

Skull fracture



Nose fracture or skull fracture


Raccoon eyes → skull or nasal fracture

Clinical Evaluation
clinical evaluation16
Palpation: Bony Structures

Spinous Processes:

Patient seated, leaning slightly forward

C7 and ↑

Transverse Processes


Occipital and temporal

Sphenoid and zygomatic

Parietal and frontal

Palpation: Soft Tissue





Clinical Evaluation
clinical evaluation17
Clinical Evaluation
  • Special Test: Halo Test
    • Patient position:
      • Lying or seated
    • Examiner position:
      • At patient’s side
    • Procedure:
      • 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:
      • Pale yellow “halo” will form on the gauze
    • Implications:
      • Cerebrospinal fluid leakage
clinical evaluation18
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
clinical evaluation19
Clinical Evaluation
  • Functional Testing: Cognitive Function
    • Cerebral trauma → Unusual athlete behavior
      • Behavior:
        • Violent, irrational, inappropriate behavior
      • Analytical Skills:
        • Serial 7’s (count backwards from 100)
      • Information Processing:
        • Provide command → can athlete follow?
clinical evaluation20
Clinical Evaluation
  • Balance and Coordination:
    • Affected secondary to trauma involving cerebellum and inner ear
    • Tests:
      • Romberg Test
      • Tandem Walking
      • Balance Error Scoring System
clinical evaluation21
Romberg Test:

Patient Position:

Standing, feet shoulder width apart

ATC Position:

Ready to support patient


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:

Patient unsteadiness


Cerebellar dysfunction

Clinical Evaluation
clinical evaluation22
Clinical Evaluation
  • Tandem Walking:
    • Patient Position:
      • Athlete standing with feet straddling a straight line
    • ATC Position:
      • Beside patient to provide support
    • Evaluation:
      • Athlete walks heel-to-toe along a straight line for approximately 10 yards
      • Athlete returns to starting position by walking backwards
    • Positive Test:
      • Athlete unable to maintain a steady balance
    • Implications:
      • Cerebral or inner ear dysfunction that inhibits balance
clinical evaluation23
Clinical Evaluation
  • Balance Error Scoring System:
    • Patient Position:
      • Patient barefoot or wearing socks (no tape); hands on iliac crest; eyes closed
      • Phase 1:
        • Double Leg Stance
      • Phase 2:
        • 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 evaluation24
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 evaluation25
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 patient’s baseline
      • Impaired cerebral function
clinical evaluation26
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 evaluation27
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 evaluation28
Clinical Evaluation
  • Vital Signs:
    • Respirations:
      • Number of breaths per minute and quality of respirations
    • Pulse:
      • 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 evaluation29
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

Clinical Evaluation