Head and Face Injuries

• Basic facts:

  • head and face injuries are common in sport
  • education and protective equipment are important
  • head trauma results in more fatalities
• Facial laceration:

  • cause = penetrating or blunt trauma causing direct or indirect compressive force
  • signs = pain and significant bleeding
  • care = clean with sterile saline, assessed for debris or damage, apply pressure, rule out skull/brain trauma, stitches
• Scalp injuries:

  • highly vascular area
  • cause = penetrating or blunt trauma
  • can occur with serious head trauma
  • signs = blow to head, bleeding, hard to pinpoint
  • care = clean with antiseptic soap and water, cut hair to expose, apply pressure, refer wounds longer than 1/2 inches in length, protective covering with gauze for smaller wounds
• Stitches?

  • tissue adhesive for lacerations less than 4cm in length and not at points of high skin tension
  • sutures for lacerations more than 4cm, or lacerations that cut through all skin layers
  • use gauze if patient is to be transported
  • other = butterfly bandages and steri-strips
• Head injuries:

  • due to direct blow causing --> compressive/tensile/shearing force
  • CSF --> converts focal force into compressive stress; dissipates force over larger area; minimal impact for tensile and shear forces, especially when combines with rotation
• Head trauma signs:

  • Battle's sign = periauricular ecchymosis (late finding)
  • Raccoon eyes = periorbital ecchymosis (late finding)
  • Halo sign = clear drainage that separates from blood; from nose or ears; clear/green/yellow
• PEARL:

  • pupils equal and react to light
  • equal but dilated/unresponsive = cardiac arrest or CNS injury
  • equal but constricted/unresponsive = CNS injury or disease
  • unequal/unresponsive = cerebrovascular accident, head trauma, direct trauma to eye
• Epidural hematoma:

  • due to blow to head/skull fracture
  • tears meningeal arteries
  • blood accumulation creates a hematoma and pressure
  • fast (minutes to hours)
• Epidural Hematoma signs:

  • maybe brief loss of consciousness followed by lucidity
  • maybe display signs and symptoms
  • gradual progression
  • head pain, dizzy, nauseous, degenerating consciousness, depressed pulse and respiration, convulsions, dilation of one pupil, occurs on same side as injury
• Epidural Hematoma care:

  • urgent neurosurgical care
  • relieve pressure ASAP to avoid disability and death
• Subdural hematoma:

  • due to acceleration/deceleration
  • tearing venous vessels that bridge dura and brain
  • venous bleeding
• Subdural hematoma signs:

  • loss of consciousness within seconds to minutes
  • unequal pupils
  • headache, dizzy, nauseous, sleepy if conscious
• Subdural hematoma care:

  • emergency medical attention
  • CT or MRI to determine extent of injury
• Facial Injuries:

  1. assess --> mental status and airways
  2. manage bleeding
  3. check nose and ears --> for CSF
  4. top-down approach --> forehead and orbitals/maxilla and nose/zygomatic bones/oral cavity and mandible
  5. evaluation criteria --> asymmetry, bony steps, bruising, mobility
• Forehead fractures:

  • due to blunt trauma
  • weak area = superior orbital
  • signs = headache, nausea, defects/deformations in skull, blood in ear or ear canal or nose, ecchymosis, CSF
• Orbital fractures:

  • due to direct trauma to eye
  • signs = posterior and inferior displacement, inability to look up, diplopia, swelling and hemorrhaging, subconjunctival hemorrhage, periorbital ecchymosis, unilateral epistaxis, numbness (injury to infra-orbital nerve)
  • care = ice, no blowing nose or valsalva maneuvers, x-ray/CT, surgery or allow to resolve on its own
• Maxillary fractures:

  • signs = assess airway and eyes, lengthening and flattening of face, mobile maxilla, nasal bleeding, ecchymosis, malocclusions
  • palpation --> maxilla, stabilize forehead and pull maxilla incisors
• Zygomatic fracture:

  • due to direct blow
  • signs = deformity, palpable step-offs (upper lateral/inferior orbital rim), cheek numbness due to injury to infra-orbital nerve, nosebleed on injured side, diplopia, subconjunctival hemorrhaging, periorbital ecchymosis
• Maxillary and zygomatic fracture:

  • care = airway, keep upright to drain blood and saliva, transport to emergency
• Mandible fractures:

  • due to direct blow at angle or condyle
  • signs = pain on biting, positive tongue blade bite test
  • deformity = palpate inferior border or mandibular condyle, loss of occlusion, bleeding, lower lip numbness
• Mandible fractures:

  • care = airway, immobilize with elastic wrap, reduction and fixation, medical referral
• Dental injuries:

  • mouth guards = main prevention
  • three types = stock mouthpiece, boil and bite, custom guards
• Tooth fractures:

  • due to impact to jaw or dental trauma
  • signs = uncomplicated, complicated, root fractures
• Uncomplicated tooth fracture:

  • produces fragments
  • no bleeding
• Complicated tooth fracture:

  • produce bleeding
  • tooth chamber is exposed
  • pain and sensitivity --> thermal changes, air, touch
• Root fracture:

  • difficult to determine
  • require x-ray
  • feels loose
• Tooth fractures care:

  • uncomplicated and complicated do not require immediate attention
  • place fractured pieces in milk or save-a-tooth solution
  • do not place fragments on ice
  • if not sensitive, can get checked out within 24 hours
  • bleeding controlled via gauze
  • root fractures, athlete can continue to play
• Tooth subluxation, luxation, avulsion, intrusion:

  • due to direct blow
  • tooth = loose or dislodged
• Tooth subluxation:

  • tooth may be loose
  • stays in socket
• Tooth luxation:

  • no fracture
  • there is displacement
  • intrusion = tooth driven up into socket; do not reposition
  • extrusion = tooth dislodged out of socket; reposition
  • laterally dislodged = forward, back, side; do not reposition
• Tooth avulsion:

  • tooth is completely removed from oral cavity
• Avulsion:

  • time-dependent
  • prognosis = 90% if replaced within 30 minutes
  • 95% failure rate if longer than 2 hours
• Avulsion management:

  • locate and protect
  • if soiled, rinse with milk or saline
  • do not rub or use tap water/drinking water --> may damage periodontal ligament cells and compromise implantation
  • reposition tooth
  • minutes matter --> try to get back in within 5-10 minutes
  • splint with hand or paper towel
  • immediate dental attention
  • unable to replace --> store in save-a-tooth solution, cold milk, cold saline, gauze on ice
• Nasal injuries:

  • fractures due to direct trauma
  • observe and palpate for crepitus or asymmetry
  • depression of nasal dorsum
  • deviation of septum
  • examine for septal hematoma --> breathe through each nostril
• Nasal fracture care:

  • airway
  • control bleeding by external or internal pressure
  • protect and transport for x-ray, examination, and reduction
  • uncomplicated or simple fractures allow for quick return
• Septal Hematoma:

  • due to hemorrhage between 2 layers of mucosa covering the septum
  • signs = blueish/dull red bulge on septum, nasal pain, inability to breathe out of one nostril
• Septal hematoma care:

  • neglected hematoma can cause formation of an abscess along with bone and cartilage loss and deformity
  • compression will be required
  • drain immediately; insert wick for further drainage
  • pack to prevent return of hematoma
• Epistaxis:

  • due to direct blow, foreign body, facial injury
  • signs = bleeding from anterior septum, usually minimal bleeding, resolves spontaneously, more severe needs more attention
• Epistaxis care:

  • blow each nostril
  • head-forward position to prevent blood in posterior pharynx
  • cold compress over nose to compress vessels
  • astringent or styptic applied along with gauze if bleeding lasts longer than 5 minutes
  • ice to back of head/neck to decrease vagal tone
  • after bleeding has ceased, athlete can return to play
• Ocular injuries:

  • severe injury
  • just trying to salvage what is left
  • high risk = basketball, football, baseball, soccer, racquet ball, lacrosse, tennis, hockey
  • very high risk = wrestling, martial arts, boxing