Download Upper Cross System Head Injuries & Neck Injuries

Upper Cross System
Head Injuries
& Neck Injuries
Upper Cross System
• When a chain reaction evolved muscle
shortening and reciprocal weakening in
predictable patterns causing predictable
imbalances or “syndromes”:
Upper Cross System Imbalances
Weak Muscles
Rhomboids
Serratus Anterior
Low/Mid Trap
Tight Muscles
Pectoralis
Major/minor
Levator Scapula
Stenomastoid
Upper Trapezius
Changes due to Lower Cross
System
• Occiput and C1/2 hyperextend with the head
pushed forward
• Lower cervical to 4th thoracic vertebrae are
stressed through posture
• Rotation and abduction of the scapulae
• Altered direction of the glenoid fossa
– Results in the need for humeral stability (increases
levator and upper trap activity & supraspinatus)
Cervical Spine Forces
• A) Absolute rotation
angle (ARA) of
overall lordosis
magnitude. B)
Relative rotation
angle (RRA) or
magnitude of
intersegmental
angle. C) Linear
measure of forward
displacement of
head relative to
upper dorsal spine
Results of Postural Imbalance
• Greater cervical segment strain with possible
referred pain to the chest (“trigger points”)
– Pain mimicking angina may be noted
• Rotator Cuff strain/tendonitis
• TMJ
• Lower Cross System may occur due to eye gaze
– In order to see straight ahead, individual must anteriorly
tilt pelvis
• Breathing dysfunction – reduce in diaphragmatic
efficiency due to postural restriction of lower rib
cage
Head Evaluation and Treatment
Boney Anatomy
• The Skull has many
specialized areas. We
sill focus on Major
areas
–
–
–
–
Frontal
Parietal
Temporal
Occipital
Special Boney Areas
• External Occipial
Protuberance (notch in
occipital area
• Mastoid Process
(behind Ear)
• Zygomatic Arch
(Cheekbone)
• Orbit (eye socket)
• Maxilla (upper jaw)
• Mandible (lower Jaw)
Anatomical Locations of Cranial
Nerves
Meninges
Bone/Skull
Dura
Mater
Pia Mater
Cerebral
Cortex
Arachnoid
Mater
Protection of Brain and Spinal
Cord
• Protection is through the bony anatomy and the
MENINGES
– Dura Mater A very tough and thick covering (highly
vascular between dura mater and bone (aterires here)
– Arachnoid: The subarachnoid space exists between
arachnoid and pia mater and is C.S.F. and passage for
veins in the cranial cavity(veins in this area)
– Pia Mater: a thin and “invisible” covering attached
intimately to the neural structures
Head Injury Background
• Skull - Hard casing
with pudding like
substance inside
– Protected by coverings
– Nutrients by rich blood
supply
– Neural Components at
base of skull
Head Injury
• Mechanism
– Coupe
– Contra-Coupe
• These mechanisms can
cause injury and
swelling:
– Concussion
– Epidural/subdural
Hematoma
Bleeding in the Brain
Assessing Head Injury
• Check
– Visual Acuity & eye
movement
– Facial movement
– Headache
– ringing in the ears
– Nausea
– Behavioral Changes (unlike
normal personality)
– Amnesia (retrograde/ postconcussive)
• MUST SIT OUT 20
MINUTES AND
REASSESS
– If symptoms increase
send to emergency
• This is a limited list
Head Injury
• First Degree
– No Concussion - Bell
rung resolution of
symptoms within
Lucid Interval
• Second Degree
– Loss of Consciousness
brief less than 15
seconds. No resolution
within lucid interval
• Third Degree
– Loss of Consciousness
more than 15 seconds
– increasing severity
within lucid interval
• This is only one type
of scale many
variations
Post-Concussive Syndrome
• Residual symptoms post concussion including
–
–
–
–
Nausea
Headache
Tinnitus
etc.
• These may occur with movement, daily activities,
rising from bed etc.
• Must not participate during this period of time
Second Impact Syndrome
• Injury while still recovering from initial
concussion
• 100% morbidity
• Very important that post-concussive
syndrome has resolved
Decisions on Head Injuries
• MUST SEND TO EMERGENCY IF:
– Blood out of ears &/or nose (from blow to
head)
– Any unconscious episode
– Symptoms increase during 20 minute waiting
period or when activity resumes
• DO NOT RETURN TO ACTIVITY IF:
– Symptoms are not resolved
– Activity exacerbates headache
Blood Supply to the Brain
• CSF is main nutrition
to the neural
structures.
• Blood supply to the
brain is via a paired
arteriole system
– Two internal carotid
arteries enter the brain
through the neck
– Two vertebral arteries travel up
the posterior aspect of the neck
through the transverse foramen
and at the level of the pons. This
then becomes the basilar artery.
– The basilar will nourish the pons
and the cerebellum along the way
to the area of the midbrain where
it will divide into the posterior
cerebral arteries
Athlete Return to Activity
• First Concussion 1º
– 1 week post resolution
of Symptoms
• Second Concussion or
2º
• Third Concussion or
3º
– End of Season needs
discussion of career
• Start with bike activity
- if no symptoms
– 1 month post
resolution of symptoms
increase functional
activity before full
return
• Above subject to Dr
Discretion
Circle of Willis
• Two communicating
links exist:
– Posterior
communicating artery
links the posterior and
middle cerebral
arteries’
– The anterior
communicating artery
unites the two anterior
cerebral arteries
Circle of Willis
– 1. Anterior Cerebral
Arteries
– 2. Inter-Carotid
Arteries
– 3/5. Middle Cerebral
– 4. Posterior
Communicating
Arteries
– 6/7.Posterior Cerebral
Arteries
– 8. Basilar Arteries
– 9. Vertebral Arteries
Where the Head Ends and Neck
Begins
• Plane between the
external occipital
protuberance and
inferior surface of the
mandible
• Neck
– Anterior triangle is
bordered by Mandible
(above), Cervical
midline(laterally) and
Sternomastoid
(anteriorly
Where the Head Ends and Neck
Begins
• Neck
– Posterior triangle is
bordered by Clavicle
(below), trapezius
(posteriorly) and
Sternomastoid
(anteriorly)
Arteries
Middle Cerebral Artery
Posterior Cerebral
Artery
ICA
Anterior Cerebral
Artery
Neck Anatomy, Evaluation and
Treatment
Boney Anatomy of the Neck
• Typical Vertebrae are
C3-C6
• Characteristics
– Small bodies with large
vertebral foramen
– bifed spinous process
– foramen in each
transverse process
– articular facets lie at
45° in transverse plane
• Atypical Vertebrae
– Atlas - 1st cervical
vertebrae
– Axis - 2nd Cervical
Vertebrae
Atlas
• Has a short anterior
and long posterior
arch
• Atlas has no actual
body
• Has Circular facet
(Fovia Dentis) in the
anterior arch which is
for the articulation of
the dens of C2
Atlas/Axis Ligaments
• Anterior Atlanto-Axial
and atlanto-Occipital
Ligaments
– Lie on the anterior
surface of the axis and
passes to the anterior
surface of the anterior
arch of the atlas and
onto the the tubercle of
the occiput
This is an extension of the
anterior longitudinal
Ligament
Atlas/Axis Ligaments
• Posterior AtlantoAxial and atlantoOccipital Ligaments
– Extends for the lamina
of the axis to the
posterior arch of the
atlas and on up to the
occiput.
Atlas/Axis Ligaments
• Tectorial Membrane
– Extends on the
posterior aspect of the
body of the axis
covering the dens and
its associated ligaments
but not touching it. It
continues up to the
anterior edge of the
foramen magnum
Axis Anatomy
• Second Cervical
Vertebra
Lateral View
Overhead View
– DENS which is fused
body of the atlas and
axis
– helps in the formation
of the first
intervertebral foramen
which the second
cervical nerve passes
through
Axis Anatomy
• Cruciform Ligament
Lateral View
Odontoid Anterior View
– Most vital of the
ligaments. IF consists
of 2 ligaments (Apical
& Alar) which cross.
– Apical: Attaches the tip
to the occiput
– Alar: Also attaches to
occiput
– Transverse lig: over
apical but does not
attach to it
Jefferson Fracture “Burst
Fracture”
• Etiology:
– Axial Loading of the head/compression of the
atlas between occiptial condyles
• Pathology
– Bilateral burst fracture of both the anterior and
posterior arched of C-1 with lateral
displacement of masses - increasing the
distance between anterior arch of the atlas and
odontoid process of axis (> 3mm). AN
UNSTABLE INJURY WITHOUT SPINAL
CORD TRAUMA
Avulsion “teardrop” Fracture
(Axis)
• Etiology:
– Hyperextension
• Pathology
– Triangular shaped avulsion fracture of the
anterior-inferior margin of the C-2 vertebral
body at the insertion of the anterior longitudinal
ligament
Teardrop Fracture (vertebral
Body)
• Etiology:
– Axial Loading/compression and Flexion
“Buckling”
• Pathology
– A “Burst” fracture of the vertebral body with
associated rupture of the posterior ligament,
posterior displacement of the posterior fracture
fragment and spinal cord encroachment “acute
anterior spinal cord injury syndrome” TYPE
IV compression fracture
Fractures of Neural Arch
• Etiology
– Axial Loading/flexion or extension “buckling”
• Pathology
– Unilateral or bilateral fractures of the lamina
and/or pedicles
– Avulsion fracture of the spinous process
usually involving C-6, C-7 (most common)
Unilateral Facet
Subluxation/Dislocation
• Etiology
– Axial Loading/flexion-rotation
• Pathology
– Rupture of the anterior and posterior ligaments,
capsular ligaments (bilateral) and intervertebral
disc with anterior subluxation (less than 50% of
vertebral body) or dislocation (more than 50%
of vertebral body/”locked facets). An unstable
injury
Atlantoaxial
Subluxation/Dislocation
• Etiology
– Flexion or axial loading/flexion “buckling”
• Pathology
– Rupture of transverse and alar ligaments with
anterior dislocation of C-1 on C-2/increase in
ADI (distance between anterior arch of atlas
and odontoid process of axis greater than 3mm)
Fracture of Posterior Arch (atlas)
• Etiology
– Extreme hyperextension or axial
loading/compression of the atlas between the
occipital condyle and the axis
• Pathology
– Fracture of the posterior arch , most commonly
at the thin, weak junction. Possible associated
fracture including pedicle of C2 (hangman’s
fracture) avulsion “teardrop”fracture of the axis
etc.
Odontoid Fractures (Axis)
• Etiology
– Axial Loading/Compression shearing forces
• Pathology
– Type I - Avulsion fracture (Alar ligament) of
the tip of the odontoid unstable
– Type II - Fracture at the junction of odontoid
and body of axis (unstable
– Type III - Fracture of the body of the axis
(unstable)
Hangman’s Fracture
• Etiology
– Hyperextension or axial loading/extension
“Buckling”
• Pathology
– A bilateral arch fracture of C-2 (traumatic
spondylolysis) with anterior dislocation of C-2
and C-3 (spondylolithesis) An unstable injury
Face Injury - LaForte Fracture
• LaForte I:
• LaForte II
• LaForte III