Trauma

Presented By:Joseph S. Ferezy, D.C.

Introduction1.25 Million Major Injuries Worldwide Per YearIncludes

AccidentsAssaultsFallsSportsIndustrial

Scalp InjuriesAbrasions and Contusions

Bleed ProfuselyUsually Stop Spontaneously With Good OutcomeCheck For FractureCephalohematoma (Neonates)

Skull FractureLinear Fracture

Both Tables Of Skull (Multiple Bones = Comminuted)15% Extend To Brain (Depressed Skull Fracture)

Basilar FractureDifficult To See On Plain FilmsFluid From Ear/Nose

Raccoon (Panda) Sign Battles Sign

Skull FractureOccipital Fracture

Immediate DeathAnterior Base Of Skull

Common SiteOlfactory Nerve CutSinus Films Show Air/Fluid Level

ComplicatedCSF Leak

Brain“Post-Concussion” Syndrome“Coup Contracoup”ConcussionContusionLaceration

Traumatic Intracranial HemorrhageEpidural Hematoma

Clinical 20% Mortality History of Head Injury With Loss of Consciousness 50% Have “Lucid Interval” Before Decrease in Level of

Consciousness As Intracranial Pressure Increases (Better Prognosis)

Rostral-caudal Deterioration

Traumatic Intracranial Hemorrhage Acute Subdural Hematoma

Clinical 80% Mortality History of Severe Head Injury Rupture of a Berry Aneurysm A/V Malformation Rapid Decrease in Intracranial Pressure Bleeding Diathesis or Anticoagulant Therapy See Epidural Hematoma

Traumatic Intracranial Hemorrhage • Subacute Subdural Hematoma

Clinical Patient Seems to Recover From Injury 1-10 Days Neurologic Deterioration

Chronic Subdural HematomaDefinition - Encapsulated Blood; At Least 10 Days to DevelopClinical

Usually in Elderly, Demented, or Alcoholics With Atrophied Brains Waxing and Waning of Symptoms C/O Headache, Memory Problems, and Decrease in Intellectual Capacity Contralateral Hemiparesis See Epidural Hematoma

Traumatic Intracranial Hemorrhage• Subdural Hygroma

Definition - Accumulation of CSF in Subdural Space

Subarachnoid HemorrhagePrimary - Rupture of Vessel (A/v or Berry Aneurysm)Secondary - to Trauma

Traumatic Intracerebral HematomaDefinition - Blood in Substance of BrainSigns Depend Upon Site of Lesion

Closed Head InjuryDefinition - Meninges Remain IntactClinical

Usually No Loss of ConsciousnessJuvenile Head Trauma Syndrome - Mild Head Injury Followed by Recovery, Few Hours Later C/o Headache, Becomes Irritable, Somnolent, and May Vomit

Possible Confusion, Blindness and Coma Terminates in Minutes to Hours Complete Recovery May Have Future Migraines After Trivial Head Trauma

Concussion-immediate, Transient Impairment of Consciousness, No Macroscopic Brain Damage

Closed Head Injury Contusion-same Only With Neurologic Deficits - Changes in Personality, Loss of Memory, Confusion, Aphasia, and DementiasPossible “Post-traumatic” Syndrome-vascular Headache, Inattention, Poor Memory, Anxiety, Irritability, Lethargy, Unsteadiness of Gait - Usually Complete Recovery - Symptoms Exacerbated With Alcohol IngestionMay Be Coma

Traumatic EncephalopathyRepeated Head Trauma“Punch Drunk” BoxerEvidence of Chronic TraumaParkinson-like Features

Post-traumatic SeizuresCommon After Severe Head Trauma

Cranial Nerve InjuryOptic Nerve

III, IV, V, VI, VII, VIII

CSF Rhinorrhea or OtorrheaClinical

C/O Clear Fluid From Nose, Ear or Down Posterior PharynxWorse With Head Flexion, or Increase Intrathecal Pressure

Fat EmbolismEtiology and Pathology

Usually Follow Fracture of Long BonesOcclude Capillaries - Become Toxic and UFA - Hemorrhagic Interstitial PneumonitisClinical

Symptoms Occur Approx. 48 Hours Later Prodroma of Cough, Dyspnea, Chest Pain, Wheezing Agitation, Confusion, Disorientation, Delirium, Seizures, and Coma Focal Neurologic Deficits Death

Air EmbolismRare - Usually After Injury, Cardiac or Thoracic Surgery, Arterial CatheterizationClinical - See Fat Embolism

Near DrowningEtiology and PathologyHypoxia Due to Aspiration of Fluid

Fresh Water Causes Surfactant Concentration Decrease - Worse - Alveoli CollapseCold Water to Face Causes “Diving Reflex” - Blood Shunted to Brain

Electrical Injury to CNSElectrocution or LighteningResult of AnoxiaClinical

SeizuresFlaccid Paralysis - Complete RecoveryPeripheral Neuropathy

Radiation InjuryUsually Follows Treatment for CancerSecondary to Ischemia and InfarctionClinical Features

Signs of Infarction From Circle of Willis by Arteritis and ThrombosisProgressive Dementia, Spasticty, and RigidityCord Radiation May Cause Sensory Symptoms About Three Months After Radiation - Resolve Without SequellaeVascular Sequellae Months or Years After - Usually Infarction

Decompression Damage (The Bends)

From Higher to Lower Atmospheric PressureNitrogen GasFocal Neurologic Signs

Spinal Cord TraumaEtiology and Pathology

Fracture of VertebraDislocation – C1-2, C5-6, T11-12Penetrating Wounds

Epidural Hemorrhage Usually Follows Trauma Radicular Pain Paraparesis

Subdural HematomaSee Epidural - Less Common

Other Traumatic InjuriesIndirect Injury - ExplosionIntramedullary InjuryIschemic DamageNerve RootCord Compression - Spinal ShockCord Transection - Spinal Shock - Gradual Spasticty

Hemisection of Cord (Brown-Sequard Syndrome) - Pain and Temperature Contralateral - Ipsilateral Proprioception Loss and Hemiparesis

HematomyeliaDirectIndirect

Conus MedullarisFirst Lumbar Area Fracture

No Motor DeficitSacral Dermatome Sensory Loss (Buttocks and Perineum)Urinary RetentionImpotence

Cauda EquinaLarge Central Disc Lesion

See Above

Herniated IVDDefinition - Protruded Nucleus Pulposus Into Spinal Canal - May Be Metaplastic Fibrous MaterialClinical

Common Usually in Young to Middle AgeL4-5, L5-S1, 10 Times As Common As C5-6 - Rare in Thoracics (Maybe)Anterior or PosteriorUsually Some History of TraumaPain, Paresis and Paresthesias, LMN Radicular SignsCervical and Thoracic Can Produce Cord Compression - Lumbars Cannot.

Hyperextension-flexion Injury to Cervical Spine and Cord

ClinicalSevere Pain for Months Following InjuryMay Be Radicular PainOccipital - Bitemporal HA (Sub Occipital Neuralgia)Can Injure Vertebral ArteryFocal Injury and SignsCervical Hypolordosis and Subluxation

Cervical SpondylosisDefinition - Degenerative Arthrosis - Cord, Root or Artery CompressionEtiology and Pathology - Usually Secondary to Disc Degeneration

Cervical Spondylosis Diabetes Mellitus?CervicalgiaOccipital HAMay Be AsymptomaticRadicular Pain After TraumaLMN Disease SignsCord Compress - SpastictyRotation - Extension VBI