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

Introduction 1.25 Million Major Injuries Worldwide Per Year Includes Accidents Assaults Falls Sports Industrial

Scalp Injuries Abrasions and Contusions Bleed Profusely Usually Stop Spontaneously With Good Outcome Check For Fracture Cephalohematoma (Neonates)

Skull Fracture Linear Fracture Both Tables Of Skull (Multiple Bones = Comminuted) 15% Extend To Brain (Depressed Skull Fracture) Basilar Fracture Difficult To See On Plain Films Fluid From Ear/Nose Raccoon (Panda) Sign Battles Sign

Skull Fracture Occipital Fracture Immediate Death Anterior Base Of Skull Common Site Olfactory Nerve Cut Sinus Films Show Air/Fluid Level Complicated CSF Leak

Brain “Post-Concussion” Syndrome “Coup Contracoup” Concussion Contusion Laceration

Traumatic Intracranial Hemorrhage Epidural 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 Hematoma Definition - Encapsulated Blood; At Least 10 Days to Develop Clinical 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 Hemorrhage Primary - Rupture of Vessel (A/v or Berry Aneurysm) Secondary - to Trauma Traumatic Intracerebral Hematoma Definition - Blood in Substance of Brain Signs Depend Upon Site of Lesion

Closed Head Injury Definition - Meninges Remain Intact Clinical Usually No Loss of Consciousness Juvenile 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 Dementias Possible “Post-traumatic” Syndrome-vascular Headache, Inattention, Poor Memory, Anxiety, Irritability, Lethargy, Unsteadiness of Gait - Usually Complete Recovery - Symptoms Exacerbated With Alcohol Ingestion May Be Coma

Traumatic Encephalopathy Repeated Head Trauma “Punch Drunk” Boxer Evidence of Chronic Trauma Parkinson-like Features

Post-traumatic Seizures Common After Severe Head Trauma

Cranial Nerve Injury Optic Nerve III, IV, V, VI, VII, VIII CSF Rhinorrhea or Otorrhea Clinical C/O Clear Fluid From Nose, Ear or Down Posterior Pharynx Worse With Head Flexion, or Increase Intrathecal Pressure

Fat Embolism Etiology and Pathology Usually Follow Fracture of Long Bones Occlude Capillaries - Become Toxic and UFA - Hemorrhagic Interstitial Pneumonitis Clinical 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 Embolism Rare - Usually After Injury, Cardiac or Thoracic Surgery, Arterial Catheterization Clinical - See Fat Embolism

Near Drowning Etiology and Pathology Hypoxia Due to Aspiration of Fluid Fresh Water Causes Surfactant Concentration Decrease - Worse - Alveoli Collapse Cold Water to Face Causes “Diving Reflex” - Blood Shunted to Brain

Electrical Injury to CNS Electrocution or Lightening Result of Anoxia Clinical Seizures Flaccid Paralysis - Complete Recovery Peripheral Neuropathy

Radiation Injury Usually Follows Treatment for Cancer Secondary to Ischemia and Infarction Clinical Features Signs of Infarction From Circle of Willis by Arteritis and Thrombosis Progressive Dementia, Spasticty, and Rigidity Cord Radiation May Cause Sensory Symptoms About Three Months After Radiation - Resolve Without Sequellae Vascular Sequellae Months or Years After - Usually Infarction

Decompression Damage (The Bends) From Higher to Lower Atmospheric Pressure Nitrogen Gas Focal Neurologic Signs

Spinal Cord Trauma Etiology and Pathology Fracture of Vertebra Dislocation – C1-2, C5-6, T11-12 Penetrating Wounds

Epidural Hemorrhage Usually Follows Trauma Radicular Pain Paraparesis

Subdural Hematoma See Epidural - Less Common

Other Traumatic Injuries Indirect Injury - Explosion Intramedullary Injury Ischemic Damage Nerve Root Cord Compression - Spinal Shock Cord Transection - Spinal Shock - Gradual Spasticty Hemisection of Cord (Brown-Sequard Syndrome) - Pain and Temperature Contralateral - Ipsilateral Proprioception Loss and Hemiparesis

Hematomyelia Direct Indirect

Conus Medullaris First Lumbar Area Fracture No Motor Deficit Sacral Dermatome Sensory Loss (Buttocks and Perineum) Urinary Retention Impotence

Cauda Equina Large Central Disc Lesion See Above

Herniated IVD Definition - Protruded Nucleus Pulposus Into Spinal Canal - May Be Metaplastic Fibrous Material Clinical Common Usually in Young to Middle Age L4-5, L5-S1, 10 Times As Common As C5-6 - Rare in Thoracics (Maybe) Anterior or Posterior Usually Some History of Trauma Pain, Paresis and Paresthesias, LMN Radicular Signs Cervical and Thoracic Can Produce Cord Compression - Lumbars Cannot.

Hyperextension-flexion Injury to Cervical Spine and Cord Clinical Severe Pain for Months Following Injury May Be Radicular Pain Occipital - Bitemporal HA (Sub Occipital Neuralgia) Can Injure Vertebral Artery Focal Injury and Signs Cervical Hypolordosis and Subluxation

Cervical Spondylosis Definition - Degenerative Arthrosis - Cord, Root or Artery Compression Etiology and Pathology - Usually Secondary to Disc Degeneration

Cervical Spondylosis Diabetes Mellitus? Cervicalgia Occipital HA May Be Asymptomatic Radicular Pain After Trauma LMN Disease Signs Cord Compress - Spasticty Rotation - Extension VBI