بسم الله الرحمن الرحیم

1. بسم الله الرحمن الرحیم

2. HEAD &neck INJURYmohammadsaleki MDSport medicine specialist IUMS

3. Head Injury Occur by head to head or head to knee Concussion by contact mat Injury rate:1-8%of all inj Most inj are mild

4. Wrestling Injury rate:22.7-50 inj per 100 wrestler 42-50% all inj associated takedowns Injury rate increase with age incidence rate increase durigcompetitton prevalence rate increase durig practice Catastrophic inj increase durigcompetitton

5. Head Injury • Scalp laceration • Concussion • Subarachnoid Hemorrhage • Subdural/Epidural Hematoma • Skull Fx

6. پارگی-کوفتگی- كبودي، خراشيدگي • توجه به مکانیسم اسیب وضایعات همراه • خونگیری غنی اسکالپ وعدم انقباض عروق باعث خونریزی شدید • درمان:رد کردن شکستگی-کنترل خونریزی -شستشو-بستن زخم-کزاز

7. Concussion Definition A concussion is an alteration of mental status due to biomechanical forces affectingthe brain. A concussion may or may not cause loss of consciousness.

8. Concussion • Centers for Disease Control and Prevention (CDC) estimates 300,000 sports-related concussions occur per year • 100,000 in football alone • An estimated 900 sports-related traumatic brain injury deaths occur per year

9. Concussion Concussion occurs most often in males and children, adolescents and young adults Risk of concussion in is 4-6 times higher in players with a previous concussion

10. Concussions per every 100,000 games and/or practices at the collegiate level • Football: 27 • Ice Hockey: 25 • Men’s soccer: 25 • Women’s soccer: 24 • Wrestling: 20 • Women’s basketball: 15 • Men’s basketball: 12(Head and Neck Injury in Sports, R.W. Dick

11. Concussion (1 of 2) • Minor traumatic brain injury (TBI) • Temporary loss or alteration in brain function • May result in unresponsiveness, confusion, or amnesia • Retrograde amnesia: forgetting events leading up to injury

12. Concussion (2 of 2) • Anterograde (posttraumatic) amnesia: forgetting events after the injury • Perseveration: repetitive speech patterns .

13. Immediate Signs of Concussion(occurring within seconds to minutes) Impaired attention , delayed responses, inability to focus Slurred or incoherent speech Gross incoordination Disorientation Emotional reactions out of proportion Memory deficits Any loss of consciousness

14. Later Signs of Concussion(occurring within hours to days) Persistent headache Dizziness/vertigo Poor attention and concentration Memory dysfunction Nausea or vomiting Fatigue easily Irritability Intolerance of bright lights Intolerance of loud noises Anxiety and/or depression Sleep disturbances

15. Diplopia Severe or increasing emesis Seizure Focal neurologic findings Pupillary changes Rapidly progressive headache Penetrating injury LOC > 5 min Confusion > 30 min High risk patient > 1 concussion this season Immediate Transport

16. درجه بندی کانتو

17. Who to Scan? • GCS < 15 • ? Any LOC • Focal neurologic findings

18. Return to Play No symptomatic athlete should be allowed to compete

19. Post-concussive Syndrome • 20% to 40% @ 3 months post injury • Neuropsychiatric impairments • attention concentration • Somatic • headache (71%) • fatigue (60%) • dizziness (53%) • Affective – depression or anxiety

20. Second impact syndromes • نوجوانان –مرد شایعتر • برگشت به مسابقه قبل از بهبودی کامل • بعد از ضربه اول اختلال عروقی مغز-پس از ضربه دوم تورم مغز • علائم:کاهش سطح هوشیاری-کما-مرگ در عرض 2 دقیقه

21. Skull Fracture • Indicates significant force • Signs: • Obvious deformity • Visible crack in skull • Raccoon eyes • Battle’s sign • Cerebrospinal fluid

22. Intracranial Bleeding • Major TBI • Laceration or rupture of blood vessel in brain • Subdural • Intracerebral • Epidural

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28. Complications of Head Injury • Cerebral edema is one of the most serious complications. • Ensure airway and provide oxygen. • Seizure (convulsion) may occur. • Vomiting may occur. • Common in children • Leakage of cerebrospinal fluid may occur. • Do not pack ears or nose.

29. Evaluation and Treatment • CAB’s • If unconscious, immobilize C-spine • Examine for chest, abdominal, limb injuries • Glascow Coma Scale • Mental Status Exam • Brain imaging-for fracture or contusion • C-spine X-rays

30. Cervical spine and Neck Injuries

31. Epidemiology • 10,000 C-spine injuries/yr in US • 5-10% related to sports • Football, wrestling, gymnastics, diving, surfing, skiing, hockey, rugby

32. Neck injury Injassociated takedowns in hyperextention Most inj sprain/strain/stinger (noncatastrophic) sprain/strain up 50% neck inj Cumulative effect mild inj increase incidence of djd

33. مطالعه 40 كشتي‌گير حرفه‌اي (با سابقه حداقل 10 سال كشتي) بررسيهاي الكترودياگنوستيك و MRI 45% افراد مورد مطالعه دچار ضايعه مزمن ريشه عصبي گردن بودند. تغييرات دژنراتيو ( degenerative ) در 61% موارد بيرون زدگي ديسك ( protrusion ) در 28% موارد تنگي كانال نخاعي در 19% موارد خروج ديسك ( extrusion ) در 9% موارد

34. مطالعه شايعترين ريشه عصبي درگير در الكترودياگنوز ( C6 ) بشكل دو طرفه بود. 5/27% افراد تحت مطالعه دچار آسيب عصب محيطي اندام فوقاني بودند سندرم كارپال تونل دوطرفه با 15% و سپس درگيري عصب اولنار در آرنج با 12% بيشترين آمار را بخود اختصاص دادند. بعضی مطالعات نشان میدهدآسیب گردن در کشتی گیران آزاد به طور معنی داری بیشتر از کشتی گیران فرنگی است

35. Injury Classifications • Catastrophic and Potentially Catastrophic Injuries • Cervical Subluxation • Unilateral and bilateral facet dislocation • Unstable cervical fractures -- axial load teardrop fracture • Noncatastrophic Injuries • Nerve root -- brachial plexus injury • Cervical sprain and strains • Intervertebral disc injury • Cervical cord neuropraxia-transient quadriplegia • Stable fractures

36. کشیدگی عضلات گردنی Collision-type injury Pain Limitation of motion Radiographs are normal resolve withouttreatment Treatment soft collar analgesics agents Taping

37. Acute Cervical Sprain Syndrome • Collision-type injury • Pain localized to cervical area • Limitation of cervical spine motion without radiation of pain or paresthesia • Neurologic exam negative • Radiographs are normal • Eventually resolve without treatment • Test AROM -- if abnormal then further work-up warranted • Treatment • neck immobilization in a soft collar • analgesics and anti-inflammatory agents

38. Burner” or Stingers • Transient UE neuropraxia of root or brachial plexus • Traction-plexus • Compression-root • Burning in arm • Shock likepain • Dysesthesiaparesthesia • Few sec to few min • Limit ROM-tendernes

39. 2. “Burner” or “Stinger” • Weakness in C5 and C6 distribution • Deltoid, biceps, wrist extensors, pronatorteres • Positive Spurling’s • Is not a spinal cord injury. • Generally symptoms resolve in 5 minutes, • Is return before pain tenderness to normal recurrence is high • Repeated osteoghyte foramen narrowing

40. Continued symptom despite stopping truma(37%) Treat:ROM.rehab.streght

41. Complicated Stingers • Recurrent, prolonged disability • Consider EMG and MRI of C-spine and plexus • Consider equipment changes upon return • Cervical strengthening

42. فلج چهار دست وپای گذرا • burning pain, numbness, tingling, and loss of sensation • weakness to complete paralysis involving upper and lower extremities • Axial loding caused • In wrestler 2% • Stenosis &hypermobility is causative

43. transient quadriplegia • (recovery usually occurs in 10-15 minutes) • Radiographs are negative for fracture, subluxation, or dislocation • Does not predispose to neurologic sequelae

44. علائم اسیبهای ستون فقرات • درد وحساسیت روی مهره ها • تغییر شکل ستون مهره ها • بیحسی ومورمور شدن وضعف عضلانی • بی اختیاری ادرار

45. Cervical Subluxation • Uncommon • Up to 2 mm of translatory displacement is normal • 3.5 mm translation and 11 degrees of rotation are indications for surgical stabilization

46. Unilateral and Bilateral Facet Dislocation • Prompt reduction indicated to relieve cord deformation

47. Unstable Cervical Fractures- Axial-Load Teardrop Fracture • Three-part, two-plane axial-load teardrop fracture is most frequently occurring cervical spine fracture associated with instability, cord compromise and major neurologic sequelae • 85% of tackle football players sustaining this injury were rendered and remain quadriplegic

48. Intervertebral Disc Injury • Acute cervical disc herniation rare in athletes • Acute central disc deforming the cord, or lateral disc associated with pain, limited cervical ROM, or neurologic symptoms are absolute contraindications to athletic participation • Degenerative disc changes • associated with repetitive microtrauma • disc space narrowing, anterior bony ridging, loss of cervical lordosis • treatment consists of rest, heat, analgesics, neck collar until pain free

49. Assessment of Spinal Injuries • Assess CAB • Avoid any excessive motion. • Assess strength in each extremity and compare. • Absence of pain does not rule out injury. • Ability to move or walk does not rule out injury.

50. Stabilization of the Cervical Spine (1 of 3) • Hold patient’s head firmly with both hands. • Support the lower jaw. • Move to patient’s head to eyes-forward position. • Maintain position until patient is secured to backboard.