4 Trauma Emergencies
4.1 Spinal Injury
Initial assessment of any injured footballer always starts as a joint assessment of the airway at the same time as the cervical spine.
The cervical spine is affected in 55% of all spinal injuries. The remaining 45% is split equally between the thoracic, thoracolumbar, and lumbosacral spines. The mechanism of injury is helpful in suggesting the type of pathology that will occur. For example, axial loading, which could be caused by falling from a height onto the head, is more likely to result in a burst fracture of the C1, whereas a hyperextension injury is more commonly associated with a fracture of the C2.
A fracture of the cervical spine is also associated with a 10% likelihood of spine fracture at another location.
The spine should be thought of in terms of the anatomy, physiology, and pathology. Maintaining normal anatomical alignment will help prevent the extension of any primary spinal injury. Ensuring that physiological problems such as hypoxia and hypotension do not occur will help prevent secondary complications such as spinal cord ischemia or edema—the causes of secondary cord injury.
The spinal column is the supporting structure that protects the cord. It consists of 7 cervical, 12 thoracic, 5 lumbar, and 5 sacral vertebrae, along with the coccyx. The vertebral bodies are located anteriorly and provide much of the strength of the column. The vertebral arch is posterior to the body and consists of two pedicles united posteriorly by the laminae. The function of the arch is to protect the spinal cord, which it encircles. The vertebral bodies are supported by strong ligaments anteriorly and posteriorly, while the intervertebral disks separate the vertebral bodies from each other.
The spinal cord runs from the medulla oblongata at the base of the skull down to about L1–L2 in the adult, terminating in the conus below which is the cauda equina. The cord can be injured at any point along its path, but the most devastating injuries occur in the cervical region as it is at this point that the nerves supplying the respiratory muscles are found. The spinal canal is relatively wide—most notably down to the level of the C2—and it is not until you reach the thoracic spine that the canal width decreases significantly. The increased risk to the cord at this area due to decreased physical space is offset purely by the limited mobility afforded by the thoracic spine due to the rigid thoracic cage. The areas where one part of the spine can act as a fulcrum against a more mobile adjacent area (namely, the cervicothoracic and thoracolumbar) are common sites of injury.
4.1.2 Classification of Injury
Injuries can be classified in a number of different ways:
As primary or secondary.
By the anatomical structures affected.
By the level of cord injury.
As complete or incomplete.
By the association of hemodynamic collapse in the form of shock.
Remember, it is possible to have a spinal injury without a cord injury, so the absence of neurological symptoms or signs should not allow the neck to be cleared.
Primary versus Secondary Injury
A primary injury is an actual initial injury to the cord, usually caused by a direct compressive force from unstable bony architecture, i.e., fracture or subluxation. Our main goal is to prevent worsening of this by performing inline immobilization and securing the cervical spine.
Secondary injury is caused at cellular level by such factors as hypoxia or hypovolemia. Its effects can be minimized by administering high-flow oxygen and maintaining a systolic blood pressure (BP) of not less than 90 mmHg.
At its most basic level, this can be divided into the affected anatomical region (cervical, thoracic, etc.). Specific fractures can occur at specific sites.
C1 (atlas)—Jefferson: burst fracture, usually caused by axial loading.
C2 (axis)—odontoid peg fracture: hangman’s fracture, usually caused by a hyperextension injury.
C5: the most common site of fracture.
C5/C6: the most common site of subluxation.
Wedge fracture: occurs due to axial load with flexion; usually stable.
Burst fracture: much more significant due to increased likelihood of bony fragment within the canal.
Again, may be wedge or burst fracture.
Less likely to be significant than thoracic burst due to cord ending around L1.
Injury around L1 may result in cauda equina syndrome.
Specific attention needs to be given to anyone with a cervical or high thoracic fracture, as their ventilatory status may decline if the muscles of respiration become paralyzed. The diaphragm is supplied by the phrenic nerve C3–C5, and dependency on the accessory and abdominal muscles may develop with “abdominal breathing,” a highly concerning sign.
Level of Cord Injury
Note that the level of cord injury may differ from that of the bone injury, as the spinal nerves enter and exit the spinal canal and ascend or descend prior to entering the cord. The cord level is determined by clinical examination and is the lowest cord neurological level where the examination is normal on both sides of the body.
A number of different cord syndromes exist.
Central cord—Usually the result of a forward fall onto the face. The central cord is supplied by the anterior spinal artery, and the pattern of neurology classically shows greater loss of power in the upper limbs compared with the lower. Recovery occurs with lower limbs resolving first. There can be variable sensory loss.
Cauda equina syndrome—Nerve root pain in either or both legs with “saddle” anesthesia (i.e., around the anus), decreased anal tone, urinary retention, and bowel dysfunction.
Spinal cord injury without radiological abnormality (SCIWORA)—Not a pitchside problem as this diagnosis is made once imaging has been completed by either computed tomography (CT) scan or X-ray. This highlights the ongoing level of concern that should be placed on the symptoms and signs and not just the imaging. SCIWORA is more prevalent in children due to their larger head-to-body ratio.
There are other cord syndromes, but it is not important that the nature of the type of injury is identified at pitchside—as long as focus is placed on correctly immobilizing the cervical spine.
Complete versus Incomplete Cord Injury
If motor or sensory function can be elicited at a region below the level of the cord injury, the patient has an incomplete injury.
Associated Neurogenic or Spinal Shock
In neurogenic shock, interruption of the sympathetic innervation of the heart results in bradycardia and hypotension. The heart cannot mount the usual tachycardia in response to hypovolemia and the BP will not respond to fluid. The player will be warm and hypotensive compared with an athlete suffering from hypovolemia, who will become progressively colder and hypotensive. Treatments include atropine and vasopressors.
Spinal shock is not shock as classically defined (failure to perfuse vital organs). It refers to the immediate loss of reflexes and flaccidity seen after cord injury with subsequent hyperreflexia found weeks after the injury.
The two terms “spinal shock” and “neurogenic shock” are not interchangeable.
4.1.3 Spine Assessment
Consider a cervical spine injury in anyone with the following:
A head injury.
An injury above the clavicles.
A decreased Glasgow Coma Scale (GCS) score.
A concerning mechanism of injury, e.g., fall while in midair, tackle where mechanism is unclear.
The cervical spine should be immobilized by gently holding either side of the head until the airway has been assessed. Assuming there is no issue with the airway, an assessment of the neck can then be made.
Guidelines such as the Canadian Cervical Spine Rule published by Stiel et al in the Journal of the American Medical Association (JAMA) in 2001 suggest that the cervical spine can be considered “cleared” if the following criteria are met:
An absence of posterior midline cervical spine tenderness.
A GCS of 15.
An absence of focal neurological deficit—on motor or sensory testing.
An absence of any distracting injuries.
The ability to achieve active 45-degree lateral neck rotation in both directions.
No concern over the mechanism of injury—such as an axial load to the head or a fall greater than 3 ft.
A distracting injury is one deemed significant enough by the assessing clinician to cause so much pain as to distract the athlete from the possibility of recognizing that they also have a cervical spine injury—a long bone fracture, visceral injury, etc.
If all of the above criteria are met, then the neck can be “cleared” and hands removed from the head. If any of the above criteria are not met, then the cervical spine should be immobilized fully using an appropriately sized hard (also known as a semirigid) cervical collar and a scoop or a spinal board, with blocks applied to each side of the head and taped. The player should only be moved on and off the scoop or spinal board by logroll with sufficient people to assist. They should then be transferred to an appropriate hospital for imaging.
There can be confusion as to when the spine is considered fully immobilized. The cervical spine is considered immobilized in either of the following cases:
The player has been placed on a scoop or a spinal board, a hard collar applied, the forehead taped onto the scoop or a spinal board (by placing tape across the board from one side of the board to the other across the forehead and over the chin), and sandbags or blocks have then been applied on either side of the head.
Your hands are placed either side of the head to stop movement (with or without a hard collar on).
The neck is not considered fully immobilized if the player only has a hard collar on.
If you are unable to clear the spine for whatever reason, then you must remove the player for a more structured assessment away from the pitch, keeping the spine immobilized at all times.
4.1.4 Fitting a Hard or Semi-Rigid Collar
A number of these products are available and typically come in a variety of sizes. It is highly recommended that you use a single multiadjustable collar as this negates the need to carry round multiple collars of different sizes. The collar will typically come flat-packed and you should familiarize yourself with being able to construct the collar before you need to use it. Instructions are provided, but in terms of professionalism and reassuring the player, it is vital that you know how to size the collar before you need to use it on the pitch. Always fit according to the manufacturer’s instructions.
The collar is usually sized by taking a measurement (in your fingerbreadths) from the angle of the player’s mandible down to the “bulk of the trapezius muscle.” This is the angle formed where the neck meets the trapezius (see ▶ Fig. 4.1a).
Fig. 4.1 Fitting a collar. (a) Measuring from the mandible to the bulk of the trapezius in fingerbreadths. (Note: the bulk of the trapezius is the point formed where the arrows meet.) (b) Sizing from the sizing point to the lowermost edge of (dark) plastic. (Note: the white is foam, not plastic.) (c) Sizing is made from the relevant multiadjustable point in the collar down to the sizing post (seen adjacent to the lowermost point of the ring finger). (d) Failure to apply a correctly sized collar can easily worsen the position of the neck and potentially cause movement of an unstable fracture.
This equates to the same distance from the multiadjustable point on the collar down either to its lowermost plastic edge or to its sizing marker as is shown in ▶ Fig. 4.1b. This will depend on the type of collar and the manufacturer’s instructions. If the collar is multiadjusting, then simply click it into position at the appropriate point (see ▶ Fig. 4.1b).
The collar is applied by sliding the flattest (posterior) part underneath the player’s neck while someone else maintains control over the spine ( ▶ Fig. 4.1c). The curved front of the collar can then be positioned across the front of the neck and secured with Velcro ( ▶ Fig. 4.1d). The Velcro should never be forced into position as this, in turn, could force the spine into an incorrect position.
4.1.5 Performing a Logroll
The increasing utilization of scoop stretchers and decline in the use of spinal boards has meant less emphasis has been placed on the skills required to perform a log roll. The log roll is however an important skill to acquire—it takes practice and an understanding of the impact on the spine if done incorrectly. A spinal board may be the only piece of extrication equipment you have and so knowledge of how to roll a patient onto it is important. The decision to perform a logroll should only be made once an ABC assessment has been carried out and the player has had an assessment of their cervical spine. Ideally a hard collar will have been applied, but this is not absolutely necessary as the team leader will have control of the spine during the roll.
The player should ideally already be positioned lying flat on the ground. If the hips are flexed, these should gently and gradually be lowered so that the legs and spine are in a straight line. The player’s hands can be either placed across the chest or straightened out with the palms facing inward.
For an adult, the logroll requires four people to move the player and one to assess the spine and remove or place the spinal board.
The leader is at the head of the player and takes control of the head and neck ( ▶ Fig. 4.2a). The three assistants stay on one side of the player who is rolled toward them ( ▶ Fig. 4.2b). If there is an injury on one side (e.g., broken humerus), the assistants should be placed on the uninjured side.
Fig. 4.2 Log roll. (a) Step 1. (b) Step 2. (c) Step 3. (d) Step 4.
(e) Step 5. (f) Step 6. (g) Step 7. (h) Step 8.
(i) Step 9. (j) Step 10. (k) Step 11
In a situation where a player is to be turned from their back onto their right hand side, do the following:
Chest—The first assistant reaches across the player’s chest, placing one hand on the player’s left shoulder and the other on the player’s hip. Both hand are palm down ( ▶ Fig. 4.2c).
Pelvis—The second person places one hand on the player’s waist just above the first assistant’s hand (palm down). Their other hand is placed under the player’s left knee (palm up; ▶ Fig. 4.2d).
Legs—The third assistant places their left hand (palm up) under the player’s left calf and their right hand under the ankle ( ▶ Fig. 4.2e).
The leader will state at which point the player is to be turned over and to what extent—usually 90 degrees.
The leader should ensure everyone is versed in what will happen, and will initiate the roll by saying: “One, two, three, roll” ( ▶ Fig. 4.2f). It is vital that everyone moves the player at the same time, so that the spine effectively remains in a straight line at all times ( ▶ Fig. 4.2g).
Once the player has been rolled to the optimum position, an assessment will be made by the fifth person ( ▶ Fig. 4.2h). Once finished, the leader will again say: “One, two, three, roll,” and the initial movement will be reversed so that the player is lying flat on their back again—with or without the spinal board having been moved into position by the fifth person ( ▶ Fig. 4.2i).
Note that it is not necessary to move the patient through 90 degrees just to get the spinal board underneath them. The assistants have to watch the leader and take their cues about how far the player should be rolled ( ▶ Fig. 4.2j and ▶ Fig. 4.2k).
The assessor will be able to examine the spine once the player has been rolled onto his side. A quick but thorough look and palpation of the thoracolumbosacral spine is necessary. This will give an idea of the site of any tenderness, swelling, bruising, or palpable deformities. If an athlete has a head injury, remember to have a look at the occiput at the same time, as any wounds will be hidden once lying flat. Once finished, the assessor can either move a spinal board into position or remove the board as in the hospital setting.
It is acceptable to perform a logroll with only three movers and one assessor, when instead of three assistants there are only two. This can be done safely with a smaller person or child and may be necessary if there are only a few trained people available to help.
In the situation described earlier (logroll to the player’s right-hand side), the first assistant would place their left hand onto the player’s shoulder and their right hand on the player’s left hip. The second assistant would place their left hand on the player’s wrist and their right hand on the lower leg. This is not as satisfactory as a three-assistant maneuver, but is still acceptable in the cases described above.
What to Do If the Player Is Already Face Down
This is a difficult situation because of the possibility of associated airway compromise. Here, the leader positions their hands on the player’s head such that they are already crossed over, i.e., imagine taking a beach ball and turning it upside down. This way, as long as the athlete is turned in the correct direction, the leader’s hands will also uncross as the player moves through 180 degrees. In this situation, the other option is to use a second leader who can take control of the head when the roll reaches 90 degrees.
In the setting of the pitchside assessment, all that actually matters is identifying the potential for injury, protecting the spine, maximizing the hemodynamic status (by doing simple things such as applying high-flow oxygen), and early definitive transfer.
4.2 Head and Facial Trauma
Head injuries are prevalent in certain sports and caution must be exercised when assessing these injuries especially if the player is to be returned to play. As detailed above, the structured assessment is key to ensuring injuries are not missed. Any head injury requiring treatment will by definition require the airway and cervical spine to be assessed as well. If there is any doubt at all about the conscious level, cervical spine immobilization procedures should be followed and the player should be removed from the field of play.
The Consensus Statement on Concussion in Sport from the Fourth International Conference on Concussion in Sport held in Zurich in November 2012 has been adopted by FIFA and contains information regarding return-to-play guidelines and assessment of concussion.
The bones of the skull are divided into those of the cranium and those of the face ( ▶ Fig. 4.3).
The cranium is further subdivided into the vault and the skull base.
The vault is the aspect of the skull that overlies the brain. It comprises the frontal, parietal, squamous temporal, and occipital bones.
The base of the skull is the lowermost portion of the skull—the area of the skull upon which the brain rests. It consists of the sphenoid and ethmoid bones, the mastoid and petrous portions of the temporal bone, and finally the base of the occipital bone.
The face consists of the midface and jaw.
The midface consists of the zygomatic, maxilla, nasal, lacrimal, vomer, and palatine bones.
The jaw is comprised solely of the mandible.
Fig. 4.3 Bones of the skull.
4.2.2 Types of Head/Brain Injury
This is the most common wound you are likely to be required to treat in football.
The anatomy of the scalp should be thought of in terms of the following:
C: connective tissue.
L: loose connective tissue.
The scalp is highly vascular, which is beneficial in terms of healing and infection but also has the potential for significant bleeding. The aponeurosis or galea is a thin tendon-like tough sheet of tissue that attaches laterally to the temporal fascia and connects the frontal and occipital aspects of the occipitofrontalis muscle. There is potential for a space to form beneath this, and if the galea is not closed over when suturing a full-thickness scalp wound, a significant extra cranial collection may occur, which can become infected and require operative removal. The galea itself is so tough that when you assess a full-thickness scalp wound it may appear that you can feel a depressed skull fracture, when in fact you are feeling the torn galea.
There are many ways to treat a scalp wound during a competitive game, and these will be discussed as part of the course itself. You must make sure that you are completely happy with your assessment of the entire player and not just the wound. Ultimately, it is not a bleeding scalp wound that is going to cause problems, but failure to assess and manage risks associated with the intracranial (IC) aspects of their head injury because of time spent patching up the laceration.
If a player has a bleeding scalp wound, this should be assessed and treated as part of the circulation assessment, i.e., perform your A and B assessment first. Direct pressure applied to the wound is a vital first step. In fact, as long as you are carrying a gauze swab with you onto the pitch, you are likely to be in a position to manage most problems.
If you have never been taught to perform a procedure (e.g., suture), do not start at pitchside—remove the player to a place of safety and call for help.
Skull fractures are common sequelae to head trauma and therefore a common cause of morbidity. In isolation, they are not usually a direct cause of mortality unless they cause a catastrophic depression of the vault directly into the brain. This is exceptionally rare and would only occur as the result of a very high-impact collision—more the realms of a high-speed road traffic accident than a “traditional” footballing injury.
Direct mortality from head injury is usually the consequence of bleeding that occurs with or without a skull fracture. It is this associated bleeding that causes an increase in the IC pressure and ultimately brain herniation if this pressure is not released.
Linear Skull Fracture This is common, especially in children. A linear skull fracture is a relatively straight-line break in the skull. In itself, it is not a serious injury unless there is an additional injury to the brain itself.
Depressed Skull Fracture This type of fracture usually results from blunt trauma (e.g., from a knee) causing a dent to the skull. Such injuries can result in depressions of the bone into the brain. Depending on the depth of the depression, surgical intervention may be required to elevate the fracture fragment.
Basal Skull Fracture This is a fracture usually resulting from significant force applied to the bones of the base of the skull. A classic physical appearance may appear with periorbital bruising (raccoon eyes) or Battle’s sign characterized by tracking bruising over the mastoid (i.e., bruising not as a consequence of direct trauma to the mastoid area). Leakage of fluid from the cerebrospinal fluid (CSF) spaces may result in rhinorrhea or otorrhea. Although a possible source of infection tracking back into the CSF, meningitis is actually very rare after a base of skull fracture and antibiotics are not currently recommended for prophylaxis of infection.
The dura is a thick, fibrous membrane that covers the brain and extends inferiorly through the foramen magnum. It is the outermost of the three meninges (dura, arachnoid, and pia mater) and divides into two layers. The middle meningeal artery lies between the two layers of the dura, and it is usually bleeding from this vessel that results in an extradural collection of blood. The bleeding fills a space between the dura and the internal table of the skull. The skull cannot expand and, as a result, the bleeding causes the dura to compress inward against the brain. Because of its relative thinness as a bone, and the position of the middle meningeal artery beneath it, trauma to the temporal area is the most likely cause of an extradural hematoma.
The “classic” clinical picture is one of the players having a lucid period prior to the pressure building to a critical point, at which time they will collapse. Timely neurosurgical intervention is required in all but the smallest of cases.
A subdural hematoma arises from bleeding between the potential space of the dura and the brain, as opposed to the extradural which is bleeding between the skull and the dura. The origin of the bleed is usually bridging veins sheared and torn in this potential space. A footballer suffering from this injury will have an acute subdural which will develop suddenly. This is in comparison with the chronic subdural often seen classically in elderly patients who have had relatively minor trauma but become gradually confused as a result of the slowly expanding bleed. Again, neurosurgical intervention is likely to be required. The job of the team clinician is to ensure that maximum efforts are directed toward ensuring that secondary brain injury is minimized.
Bleeding between the arachnoid and the closely adherent pia mater overlying the brain results in a subarachnoid hemorrhage. This may occur as a result of trauma, although it would be rare to find this in isolation without another type of bleed (either extra or subdural or even contusions). This type of presentation may also occur without trauma, as the result of a rupture of a “berry” aneurysm of the arteries supplying the brain. The player may collapse without warning or complain of a sudden headache, “as if someone has just hit me on the back of the head with a baseball bat.” In view of this presentation of headache, a CT scan and a lumbar puncture would be required and therefore hospital transfer is necessary.
Other symptoms the player may complain of are neck stiffness, vomiting, or photophobia, which may make the diagnosis difficult to distinguish from meningitis. Management involves minimizing secondary brain injury, analgesia, and transfer to hospital.
A contusion is bleeding into the brain tissue itself and can be likened to a brain bruise. With the advent of modern CT and magnetic resonance imaging, the diagnosis of these lesions has become much more commonplace, whereas in the past the symptoms were probably attributed to concussion. The management of cerebral contusions is usually nonsurgical unless there are other IC problems that require operative fixation ( ▶ Table 4.1).
Risk of operable intracranial bleeding
No other features
No skull fracture
No skull fracture
4.2.3 Pitchside Assessment of Players with Head Injuries
Ascertaining a history is vital when assessing a player with a head injury. If a player is unconscious when you arrive by their side, management can be relatively straightforward.
Perform an ABC assessment and protect their cervical spine.
They should not be returned to the field of play and will require assessment in hospital.
The framework for initial assessment should be followed and the player should be managed with oxygen, airway techniques if appropriate, cervical spine immobilization, and removal from the pitch on an appropriate extrication device such as a scoop or a spinal board.
If the player is fully conscious when you get to them, then again assess the cervical spine and take a history to elicit whether or not there has been a brief episode of loss of consciousness. An assessment should be made to ensure they are “topline” in the Alert, Verbal, Pain, Unresponsive (AVPU) or Glasgow Coma Scale (GCS) scoring systems. It does not matter which scoring system you use as long as you are thoroughly familiar with it. Anything less than “Alert” or GCS 15 mandates removal from the pitch and a hospital assessment.
If the ABCs are fine, the player is “Alert” or GCS 15 and there are no neurological symptoms or signs, an assessment should be made as to whether or not the player is fit to return to the field of play.
A series of questions should be asked of the player to ensure their “topline” mental status, and that no subtle confusion is present. The modified Maddocks questions are typically used in this situation:
What venue are we at?
What half is it?
Who scored last?
When did you last play?
Did we win the last game?
These questions form a part of the Sport Concussion Assessment Tool 3 (SCAT 3) assessment published as part of the Zurich Consensus Guidelines.1 The main difference in sideline assessment between SCAT 2 and the updated SCAT 3 (Appendix I)2 is that the update puts more emphasis on simply recognizing potential symptoms and signs of concussion. The aim is clearly to ensure that the player is given the best opportunity to convey any subtle symptoms of concussion he may have—symptoms that may previously have been dismissed as trivial. For medicolegal purposes as well as consistency of assessment, it is highly recommended that you use the SCAT 3 sideline assessment to assess for concussion (see Appendix II).1
Sport Concussion Assessment Tool 3 (SCAT 3).2