1. Head and Facial Injuries
Chapter 14 & 15
Head and Facial Injuries

2. Anatomy of the Skull 22 bones Sutures Fontanelles Paranasal Sinuses
Cranium (8 bones)
Face (14 bones)
Sutures
4 Prominent sutures
Fontanelles
Paranasal Sinuses
Cranium – lodges and protects the brain
Consists of: Occipital, Parietal (2), Frontal, Temporal (2), Sphenoid, Ethmoid
Face – Consists of: Nasal (2), Maxillae (2), lacrimal (2), zygomatic (2), palatine (2), inferior nasal conchae (2), vomer, mandible
Sutures – immovable, fibrous joints found only between skull bones.
4 Prominent Sutures:
Coronal – between the frontal and parietal bones
Sagittal – between the parietal bones
Lambdoidal – between the parietal and occipital bones
Squamosal (2) – between the parietal and temporal bones
Fontanelles – membranous spaces between the skull bones of the fetus and infant
Often referred to as the “soft spot”
Ossification is not complete
Permits compression of the skull during birth
Paranasal Sinuses – paired cavities found in certain skull bones
Open into the nasal cavity
Lined w/mucous membranes
Functions include resonating the voice and lightening the skull
Named after the bones in which they are found: frontal sinuses, sphenoidal sinuses, ethmoidal sinuses, maxillary sinuses.

3. Occipital Bone
Forms the walls and base of the posterior portion of the cranium
Superior and inferior nuchal lines
Occipital Condyles
Hypoglossal Canal
Foramen Magnum
Superior and Inferior nuchal lines are for muscle attachment as are other external occipital protuberances.
Occipital condyles articulate with the superior facets of the atlas
Hypoglossal Canal – transmits the hypoglossal nerve (XII)
Foramen Magnum – transmits the medulla oblongata, spinal accessory nerve (XI), vertebral arteries, and anterior and posterior spinal arteries.

4. Parietal Bones
By their union, they form the sides and roof of the cranium
Temporal Lines
Temporal lines – site of muscle attachment

5. Frontal Bone Consists of two portions Frontal Squama Orbital Plates
Frontal squama (vertical plate) – forms the anterior part of the cranium
Orbital Plates (horizontal plates) – forms the roof of the orbit and most of the anterior part of the cranial floor

6. Temporal Bones Situated at the sides and base of the skull 5 portions:
1. Squamous portion
Zygomatic Process
Mandibular Fossa
2. Mastoid portion
Mastoid Process
3. Petrous portion
Internal Auditory Meatus
Carotid Canal
Stylomastoid Foramen
4. Tympanic portion
External Auditory Meatus
5. Styloid portion
Squamous portion – forms the anterior and upper part of the bone.
Zygomatic process – articulates with the temporal process of the zygomatic bone
Mandibular Fossa – articulates w/the condyle of the mandible
Mastoid portion – forms the posterior part of the bone
Mastoid Process – site for muscle attachment
Petrous portion – pyramidal in shape, wedged at the base of the skull between the sphenoid and the occipital; contains the structures of the middle and inner ear.
Internal Auditory Meatus – transmits the facial nerve (VII) and vestibulocochlear nerve (VIII).
Carotid Canal – Transmits the internal carotid artery.
Stylomastoid Foramen – transmits the facial nerve (VII).
Tympanic Portion – lies below the squama and anterior to the mastoid process.
External Auditory Meatus – leads to middle ear.
Styloid Process – projects downward and forward from under the surface of the temporal bone; site of attachment for ligaments and muscles of the neck.

7. Sphenoid Bone
Articulates with all of the other bones of the cranial floor.
Parts of the sphenoid:
Body
Greater Wings
Lesser Wings
Pterygoid Processes
Body – (Number 6 on illustration) The middle portion of the bone.
Greater Wings – (Number 8 in illustration) Form part of the middle cranial floor and lateral wall of orbit.
Lesser Wings – (number 1 in illustration) contribute to the anterior cranial floor and roof of orbit
Pterygoid Processes – (not pictured in either illustration) Each consists of a lateral and medial pterygoid plate; sites of muscle attachment; form part of the lateral wall and nasal cavity.

8. Ethmoid Bone
Forms part of the anterior cranial floor; contributes to the medial wall of each orbit
4 portions
Cribriform plate
Crista Galli
Perpendicular Plate
Labyrinths (Lateral Masses [2])
Superior and Middle Nasal Conchae
Ethmoid bone – Number 1 & 2 in first illustration
Cribriform Plate – Roofs of the nasal cavities, perforated by foramina for the passage of the olfactory nerves (I).
Crista Galli – Triangular process projecting upward from the midline of the cribriform plate.
Perpendicular plate – forms the superior portion of the nasal septum.
Labyrinths (lateral masses) (2) – Consist of a number of ethmoidal air cells; interposed between the orbits and nasal cavities.
Superior and Middle Nasal Conchae – Projections found in the lateral wall of each nasal cavity; increases the surface area of each nasal cavity.

9. Nasal Bones
2 separate bones
Form bridge of the nose

10. Maxillae 2 bones Maxilla = singular Maxillae = plural
Form the upper jaw, roof of mouth, floor and lateral wall of the orbit
Parts
Body
Alveolar Process
Palatine Process
Body – Contains the maxillary sinuses and intraorbital foramen; main part of bone.
Alveolar Process – deep cavities for reception of the teeth.
Palatine Process – horizontal, forms a considerable part of the floor of the nose and roof of the mouth; the anterior ¾ of the hard palate.

11. Lacrimal Bones
2 bones
Situated at the front part of the medial wall of the orbit

12. Zygomatic Bones
2 bones
Form the prominence of the cheek, part of the lateral wall and floor of the orbit
Temporal Process
Temporal Process – articulates with the zygomatic process of the temporal bone to create the zygomatic arch.

13. Palatine Bones
2 bones
Situated at the back part of the nasal cavities between the maxillae and the pterygoid processes of the sphenoid bone
Contribute to the floor and lateral wall of the nasal cavity, the roof of the mouth, and the floor of the orbit

14. Inferior Nasal Conchae
Projections found in the lateral wall of the nasal cavity
Increase the surface area of the nasal cavity

15. Vomer Bone Situated in the medial plane
Forms the inferior and posterior portion of the nasal septum

16. Mandible Largest, strongest bone of face Only movable bone of skull
Parts
Body
Ramus
Coronoid Process
Condylar Process
Mandibular Notch
Angle
Body – curved, somewhat like a horseshoe; contains mental foramen (nerves and blood vessels) and alveolar processes (for teeth)
Ramus – Quadrilateral in shape; contains mandibular foramen (medial surface; blood vessels and nerves for teeth)
Coronoid Process – Anterior/superior portion of mandible; site of muscle attachment
Condylar Process – (AKA mandibular condyle) articulates with the mandibular fossa of the temporal bone
Mandibular Notch – deep concavity located between the coronoid and condyloid processes
Angle – where each ramus meets the body

17. Sutures of the Skull Coronal Suture Sagittal Suture Lambdoidal Suture
Squamosal Suture
Coronal – Between frontal and parietal bones
Sagittal – Between the parietal bones
Lambdoidal – between the parietal and occipital bones
Squamosal (2) – between the parietal and temporal bones

18. Brain Brain facts 4 parts of the brain Cerebrum Diencephalon
Cerebellum
Brain Stem
Weighs only about 3 pounds
Requires 20% of total oxygen and 15% of total blood
Develops until 18
4-6 min. w/o oxygen = brain death
Cerebrum – (pink) spreads over the diencephalon like a mushroom cap and occupies most of the cranium
Diencephalon - (light blue) consists of the thalamus (receives data from sensory systems and projects to sensory areas of the cerebral cortex), hypothalamus (principle autonomic center of the brain, has controlling influence over the sympathetic and parasympathetic systems), epithalamus, and subthalamus
Cerebellum – (yellow) lies behind the pons and the medulla oblongata; separated from the cerebrum by a fold of dura mater (tentorium cerebelli); characterized by a foliated appearance (wrinkled), divided into 2 lateral hemispheres; produces changes in muscle tonus in relation to equilibrium, locomotion, and posture
Brain Stem – (green) continuous with the spinal cord; consists of the medulla oblongata (inferior to pons, attaches directly to spinal cord), pons (2 distinct parts; dorsal portion contains motor and sensory tracts; ventral portion provides connections between cerebral hemispheres and cerebellar hemispheres), and midbrain (connects pons and cerebellum with forebrain)

19. Brain Lobes Cerebrum divided into 4 lobes Frontal Parietal Temporal
Occipital
Frontal Lobe - The frontal lobes are considered our emotional control center and home to our personality. The frontal lobes are involved in motor function, problem solving, spontaneity, memory, language, initiation, judgement, impulse control, and social and sexual behavior. The frontal lobes are extremely vulnerable to injury due to their location at the front of the cranium, proximity to the sphenoid wing and their large size.
Parietal - The parietal lobes can be divided into two functional regions. One involves sensation and perception and the other is concerned with integrating sensory input, primarily with the visual system. The first function integrates sensory information to form a single perception (cognition). The second function constructs a spatial coordinate system to represent the world around us. Individuals with damage to the parietal lobes often show striking deficits, such as abnormalities in body image and spatial relations.
Temporal - The temporal lobes are involved in the primary organization of sensory input (vision, hearing, speech communication/interpretation). The temporal lobes are highly associated with memory skills (especially long-term memory).
Occipital - The occipital lobes are the center of our visual perception system. They are not particularly vulnerable to injury because of their location at the back of the brain, although any significant trauma to the brain could produce subtle changes to our visual-perceptual system.

20. Cerebrospinal Fluid Primary Function = shock absorption
Secondary Functions = circulate nutrients and chemicals from blood and remove waste products from brain
Cerebrospinal fluid (CSF) is a clear, colorless liquid which bathes the central nervous system. While the primary function of CSF is to cushion the brain within the skull and serve as a shock absorber for the central nervous system, CSF also circulates nutrients and chemicals filtered from the blood and removes waste products from the brain.

21. Preventing Head Injuries
Helmets
Mouth Guards
Rules
Common Sense
Helmets must fit properly and be secured porperly.
Mouthguards must be fitted properly and NOT BE CHEWED ON!!!
Rules are designed to prevent dangerous situations from arising

22. Head and Face Injuries Skull Fracture Concussion Intracranial Hematoma
Post-concussion Syndrome
Second Impact Syndrome
Corneal Abrasion or Laceration
Detached Retina
Black Eye
Foreign Body in Eye
Embedded Object
Subconjunctival Hematoma
Hyphema
Blowout Fracture
Fracture of the Orbital Roof
Sinus Fracture
Dislodged Contact Lens
Eyelid Laceration
Rupture Globe
Laceration of the Pinna
Cauliflower Ear
Otitis Externa
Foreign Body in Ear
Epistaxis
Deviateed Septum
Nasal Fracture
Mandible/Maxilla Fracture
Temporomandibular Dislocation
Tooth Dislocation
Fracture Tooth

23. Skull Fracture Types Etiology Signs and Symptoms Management Depressed
Compound
Linear
Penetrating
Etiology
Signs and Symptoms
Management
Types – Depressed (pushes a portion of the skull towards the brain), compound (portion of the skull sticking through the scalp), linear (goes across the skull), and penetrating (object has gone through the skull and likely into the brain).
Etiology –

24. Temporomandibular Dislocation
Etiology
Signs and Symptoms
Treatment
Etiology – usually a side blow to the lower jaw while the mouth is open. This forces the mandibular condyle forward out of the temporal fossa (yellow arrow). May occur as a luxation (complete dislocation) or subluxation (partial dislocation).
Signs and Symptoms – Mouth in a locked open position, jaw movement almost impossible, an overriding malocclusion (abnormality in the coming together of teeth) of the teeth, athlete will grab mouth, extreme pain, obvious deformity will be present, may be shifted to one side, palpation will reveal one or both condyles out of place.
Treatment – Initially, cold should be applied along w/elastic wrap to immobilize. Transport to physician for reduction of mandible. Follow-up care will include soft-food diet, NSAIDs (non-steriodal anti-inflammatory drugs), analgesics (A medication that reduces or eliminates pain) when needed for one to two weeks. Severe cases may require the jaw to be wired shut for several weeks.

25. Tooth Dislocation Etiology Signs and Symptoms Treatment Subluxated
Avulsed
Etiology – Direct impact to a tooth can knock it out.
Signs and symptoms – Tooth may be partially (subluxated) or completely dislocated (luxated) or avulsed (completely knocked out), athlete may feel little or no pain but may c/o tooth feeling different to severe pain, bleeding, swelling, and the tooth may be slightly loose, moved forward, backward or sideways, or completely gone.
Treatment – Using gloves the ATC should control the bleeding as much as possible. If the tooth is subluxated (loose), the athlete should follow-up with a dentist within 48 hours. If the tooth is luxated (knocked out of position, but still in mouth) the athlete should be referred to a dentist, the tooth can be pushed back into position only if it is easy to move. If the tooth is avulsed (knocked out completely) the tooth should be recovered, rinsed (but not scraped) clean. The tooth should be kept moist and can be placed in a designated saline container or a glass of milk. Once the tooth is recovered, cleaned, and kept most the athlete should be referred to the dentist immediately. The sooner the tooth can be reimplanted, the better the prognosis.

26. Fractured Tooth Etiology Signs and Symptoms Treatment
Etiology – Any direct impact to the upper or lower jaw or direct trauma can potentially fracture the teeth. 3 types of fractures can occur to the teeth: an uncomplicated crown fracture (no bleeding, no pulp is exposed), a complicated crown fracture (bleeding, pain, pulp is exposed), and a root fracture (hard to determine, require x-ray b/c it is below gum line, bleeding from the gum).
Signs and Symptoms – pain, difficulty closing mouth, portion of the tooth may be loose or missing, bleeding may be present.
Treatment – broken pieces should be cleaned, stored in saline or milk and transported with patient. As long as the athlete is not in a lot of pain, the athlete can return to play, but should follow-up with the dentist at the end of the game. Bleeding should be controlled with sterile gauze and direct pressure. Broken pieces may either be reattached or tooth may be capped for asthetics.