1. Sideline Evaluation of the Eye, Face, and Related Structures Orthopedic Assessment III – Head, Spine, and Trunk with Lab PET 5609C

2. Orbital Fractures Asymptomatic Fractures: Asymptomatic Fractures: Ice to injured area (loosely applied) Ice to injured area (loosely applied) Avoid direct pressure on the globe Avoid direct pressure on the globe Symptomatic Fractures: Symptomatic Fractures: Pain with eye movement Pain with eye movement Shield the Eye Shield the Eye Instruct athlete to gaze straight ahead with uninvolved eye (limits voluntary eye movement → eyes move in unison) Instruct athlete to gaze straight ahead with uninvolved eye (limits voluntary eye movement → eyes move in unison)

3. Contact Lens Removal Hard Lenses Removal: Hard Lenses Removal: Open eyes wide Open eyes wide Laterally pull outer margin of eyelids Laterally pull outer margin of eyelids Patient blinks, forcing lens out Patient blinks, forcing lens out Soft Lenses Removal: Soft Lenses Removal: Patient looks up Patient looks up Clean finger placed on inferior edge of lens Clean finger placed on inferior edge of lens Lens manipulated inferiorly and laterally Lens manipulated inferiorly and laterally Pinch between fingers Pinch between fingers

4. Penetrating Eye Injury Penetrating Eye Injuries: Penetrating Eye Injuries: Do NOT attempt to remove the object Do NOT attempt to remove the object Do NOT apply direct pressure on the eye Do NOT apply direct pressure on the eye Shield the eye Shield the eye If object is protruding far from the eye, use a paper/plastic cup to cover If object is protruding far from the eye, use a paper/plastic cup to cover Immediate transportation to hospital Immediate transportation to hospital

5. Chemical Burns Chemical Eye Burns: Chemical Eye Burns: Injury caused by an acid, alkali substance or an irritant Injury caused by an acid, alkali substance or an irritant Causes: Causes: Chemical is splashed in eye Chemical is splashed in eye Exposure to concentrated fumes and aerosols Exposure to concentrated fumes and aerosols Severity depends on substance causing it and exposure time Severity depends on substance causing it and exposure time Usually, damage is limited to the front of the eye Usually, damage is limited to the front of the eye

6. Chemical Burns Chemical Eye Burns: Chemical Eye Burns: Symptoms: Symptoms: Eye pain and redness Eye pain and redness Sensitivity to light Sensitivity to light Eye irritation and tearing Eye irritation and tearing Inability to keep the eye open Inability to keep the eye open Sensation of something in the eye Sensation of something in the eye Swelling of the eyelids Swelling of the eyelids Chemical Burns: Types Alkali Burns: Alkalis - chemicals that have a high pH Most dangerous type of chemical burn Alkalis penetrate the surface of the eye Common alkali substances contain the hydroxides of ammonia, potassium, sodium, calcium, and magnesium Lye, drain cleaner, metal polishes, oven cleaners, cement, lime, and ammonia

7. Chemical Burns Chemical Burns: Types Chemical Burns: Types Acid Burns: Acid Burns: Caused by chemicals with a low pH Caused by chemicals with a low pH Less severe than alkali burns Less severe than alkali burns Acids usually damage the very front of the eye Acids usually damage the very front of the eye Sulfuric acid, sulfurous acid, hydrochloric acid, nitric acid, acetic acid, chromic acid, muriatic acid, and hydrofluoric acid Sulfuric acid, sulfurous acid, hydrochloric acid, nitric acid, acetic acid, chromic acid, muriatic acid, and hydrofluoric acid automobile battery explosion automobile battery explosion Chemical Burns: Types Irritants: Neutral pH. Effect - Significant pain but does not cause damage to the eye Pepper spray

8. Chemical Burns Treatment: Treatment: Medical emergency Medical emergency Wash your eye with water and/or saline immediately Wash your eye with water and/or saline immediately Longer exposure – increased damage Longer exposure – increased damage Wash the eye for at least 10 minutes Wash the eye for at least 10 minutes Patch the eye Patch the eye Transport immediately Transport immediately

9. Lacerations Initial Care: Initial Care: Control bleeding Control bleeding After controlled, palpate area for tenderness (possible underlying fracture) After controlled, palpate area for tenderness (possible underlying fracture) Imbedded object → leave in place Imbedded object → leave in place Facial laceration → refer to physician (prevention of scars) Facial laceration → refer to physician (prevention of scars) Within 24 hours Within 24 hours Throat laceration → assess ABCs Throat laceration → assess ABCs Avulsed tissue: (ear, nose, tongue) Avulsed tissue: (ear, nose, tongue) Clean tissue (sterile water), wrap in gauze, put on ice, transport with athlete to hospital Clean tissue (sterile water), wrap in gauze, put on ice, transport with athlete to hospital

10. Lacerations March 22, 1989: Clint Malarchuk (Buffalo Saber) caught a skate to the throat → severed jugular vein March 22, 1989: Clint Malarchuk (Buffalo Saber) caught a skate to the throat → severed jugular vein Jim Pizzutelli (ATC) reached into Malarchuk's neck and pinched off the bleeding until doctors arrived to begin suturing the wound Jim Pizzutelli (ATC) reached into Malarchuk's neck and pinched off the bleeding until doctors arrived to begin suturing the wound Within minutes of death Within minutes of death 300 stitches 300 stitches Back to practice 4 days later Back to practice 4 days later

11. Lacerations Feb. 12, 2008: Richard Zednik → lacerated right neck (another players was upended, skate swung up hitting Zednik in the right side of the neck, nearly severing his carotid artery) Feb. 12, 2008: Richard Zednik → lacerated right neck (another players was upended, skate swung up hitting Zednik in the right side of the neck, nearly severing his carotid artery) Underwent emergency surgery Underwent emergency surgery Five units of blood Five units of blood Dr. Noor: “The slashed artery was hanging by a thread.” She stressed if the artery had been completely severed it would have recessed into the neck, requiring even more extensive surgery Dr. Noor: “The slashed artery was hanging by a thread.” She stressed if the artery had been completely severed it would have recessed into the neck, requiring even more extensive surgery

12. Lacerations

13. Lacerations Laryngeal Injuries: Laryngeal Injuries: Can be life-threatening Can be life-threatening Signs: Signs: Progressive swelling Progressive swelling Crepitation (presence of subcutaneous air) Crepitation (presence of subcutaneous air) Stridor – harsh, high-pitched sound during respiration (resembles blowing wind) Stridor – harsh, high-pitched sound during respiration (resembles blowing wind) Bleeding from oral cavity Bleeding from oral cavity Treatment: Treatment: Stabilize and transport Stabilize and transport

14. Facial Fractures MOI → Significant blunt trauma MOI → Significant blunt trauma May also cause head injury (concussion) May also cause head injury (concussion) Unconscious Unconscious Head injury takes precedence Head injury takes precedence Stable facial fracture: (airway intact) Stable facial fracture: (airway intact) Move athlete to sideline Move athlete to sideline Obvious fracture present Obvious fracture present

15. Facial Fractures Sept. 28, 2008 – Anquan Boldin injury Sept. 28, 2008 – Anquan Boldin injury Knocked unconscious Knocked unconscious Fractured paranasal sinuses and other facial injuries Fractured paranasal sinuses and other facial injuries Surgery: Eight plates in his face and wiring in his jaw Surgery: Eight plates in his face and wiring in his jaw Only missed three weeks Only missed three weeks http://www.youtube.com/watch?v=j9RfJwSkMU8 http://www.youtube.com/watch?v=j9RfJwSkMU8 http://www.youtube.com/watch?v=j9RfJwSkMU8

16. TMJ Injuries MOI: Blow to the jaw MOI: Blow to the jaw Mandible injury Mandible injury Signs/Symptoms: Signs/Symptoms: Malocclusion – remove athlete from participation Malocclusion – remove athlete from participation Immediate referral Immediate referral Dislocation – can immobilize athlete with Philadelphia collar Dislocation – can immobilize athlete with Philadelphia collar

17. Nasal Fractures/Epistaxis Nasal Fractures: Nasal Fractures: With Epistaxis → control the bleeding With Epistaxis → control the bleeding Traditional Method – should it be used? Traditional Method – should it be used? With Fracture: With Fracture: Pack nose with gauze Pack nose with gauze Ice Ice Rolled cotton gauze placed between anterior upper lip and gum Rolled cotton gauze placed between anterior upper lip and gum Pressure placed on nasal mucosa arteries Pressure placed on nasal mucosa arteries

18. Nasal Fractures/Epistaxis Nasal Fractures: Nasal Fractures: Treatment: Treatment: Control bleeding Control bleeding Nose, Cartilage, maxillary, zygomatic, and frontal bones can be palpated for tenderness Nose, Cartilage, maxillary, zygomatic, and frontal bones can be palpated for tenderness Deformity present: Deformity present: Athlete discourage to look Athlete discourage to look Shock Shock

19. Dental Injuries Tooth Injury (other than class I fracture) → remove from competition Tooth Injury (other than class I fracture) → remove from competition Immediate referral to dentist Immediate referral to dentist Avulsed tooth – Find It! Avulsed tooth – Find It! Death of tooth – primary reason due to death of periodontal ligament attached to avulsed tooth Death of tooth – primary reason due to death of periodontal ligament attached to avulsed tooth

20. Dental Injuries Avulsed Tooth: Avulsed Tooth: Tooth separated from bony socket → tearing of the periodontal ligament Tooth separated from bony socket → tearing of the periodontal ligament First aid: Survival depends on rapid replacement into socket First aid: Survival depends on rapid replacement into socket Replantation: Preferably done at the site of injury (minimize extra-alveolar time - tooth out of socket) Replantation: Preferably done at the site of injury (minimize extra-alveolar time - tooth out of socket) Attempt to replant tooth within first 15-20 min (stabilize by biting down gently on towel or gauze Attempt to replant tooth within first 15-20 min (stabilize by biting down gently on towel or gauze If the thin gum tissue (periodontal ligament) that is attached to the roots of the tooth dries before the tooth is replaced (extra-alveolar period >1 hour) – chance of tooth loss ↑ If the thin gum tissue (periodontal ligament) that is attached to the roots of the tooth dries before the tooth is replaced (extra-alveolar period >1 hour) – chance of tooth loss ↑ Minimal consequences if periodontal ligament is left attached to the root surface and does not dry out (extra-alveolar period <1 hour) Minimal consequences if periodontal ligament is left attached to the root surface and does not dry out (extra-alveolar period <1 hour)

21. Dental Injuries Do not handle tooth on Root Surface Do not handle tooth on Root Surface Never brush/scrub tooth Never brush/scrub tooth Do NOT sterilize with disinfecting solutions Do NOT sterilize with disinfecting solutions If debris present, gently rinse with saline or water (10 seconds) and than replant If debris present, gently rinse with saline or water (10 seconds) and than replant Other alternatives: (Transporting mediums) Other alternatives: (Transporting mediums) Best: Save-A-Tooth container Best: Save-A-Tooth container Should be in ATC’s kit Should be in ATC’s kit 2nd best: Milk 2nd best: Milk 3rd best: Under athlete's tongue ONLY if athlete is conscious and alert or in a container into which the athlete spits 3rd best: Under athlete's tongue ONLY if athlete is conscious and alert or in a container into which the athlete spits 4th best: Wrap in saline-soaked gauze 4th best: Wrap in saline-soaked gauze 5th best: Water 5th best: Water Least desirable storage medium Least desirable storage medium Transport immediately Transport immediately