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In this article, we review the available data on sporting injuries to the head and neck and discuss sport-specific injury risk and prevention strategies, as well as the costs of head and neck injuries.
Although significant research efforts have been made to determine the tolerance for the adult neck, relatively little research has been conducted to derive the pediatric neck injury parameters. The existing approach to determine injury for the one, three and six year old pediatric populations is based on extrapolations from the adult male and calcaneal tendon tensile data. This study addresses the scale factors for pediatric age groups using data obtained from spinal components and neck geometry. The analysis included the determination of scale factors under extension, tension, compression and flexion loading modes as a function of age. The variations in biomechanical properties of each spinal component were determined from human cadaver studies. Active spinal components were identified under each loading mode and relationships were established for each component to obtain material-based scale factors. The scale factors and resulting injury tolerance values based on spine component material properties are more appropriate than values extrapolated from the calcaneal tendon.
We evaluated the impact of routine arteriography on the management of 105 patients with penetrating injuries to the neck and upper chest. Of 72 patients with bullet wounds and 33 with knife wounds, surgical exploration on an emergency basis was performed in three patients because of shock; the remaining 102 underwent aortic arch or selective arteriography. Surgical exploration was performed in 18 patients because of abnormal arteriograms and in 13 (10 with normal arteriograms) because of shock or suspected hemorrhage. Operative findings confirmed the angiographic interpretation in 26 of the 31 patients who were explored. The angiogram underestimated the arterial injury in two patients and failed to identify an associated venous injury in three. Seventy-two patients with negative arteriograms received expectant treatment without subsequent complications. Routine arteriography is integral to expeditious triage and accurate diagnosis of patients with brachiocephalic trauma. A negative study in almost 80% of patients permits safe nonoperative management, whereas a positive study allows the surgeon to plan his operative approach more judiciously. Endoscopic procedures are important adjuncts in selected patients.
This article, part of a recently completed research project on safety belts, presents results on neck injuries. A total of 3927 injured front-seat occupants (drivers and passengers) involved in two-car crashes were studied. Among them, 725 sustained neck sprains (ICD-9 code 847.0); some of them may have sustained other injuries as well. The more serious injuries to the cervical spine were more prevalent among the unbelted occupants. Neck sprains were relatively more numerous among belted occupants compared with unbelted ones, with a relative risk estimate of 1.68. Similar results hold also for subsets of the data on different types of collisions; the relative risks ranged from 1.39 to 2.42. A log linear model was constructed for the odds ratio (neck sprain vs. no neck sprain) taking into account the following factors: (1) seatbelt use, (2) direction of impact, (3) authorized speed limit, and (4) vehicle weight. The resulting relative risk estimate (belted vs. unbelted) became 1.58. The results raise questions about seatbelts and their protection against neck sprains.
This article presents clear, concise guidelines for classification, evaluation, and emergency management of injuries that occur to the head and neck as a result of competitive and recreational sports. There are several principles that must be considered by individuals responsible for an athlete who sustains a serious head or neck injury: a person who "captains" the medical/first-aid team; knowledge of the appropriate emergency management techniques; availability of emergency medical equipment including a spine board, telephone, and ambulance; and a clear understanding of the philosophy that emergency management should "do no further harm."
This case report illustrates the value of intravenous digital subtraction angiography (DSA) in cases of penetrating neck injury. The debate continues between a policy of mandatory exploration of all penetrating neck wounds versus one of selective exploration with observation of the remainder. The argument for the former policy is that vascular trauma can occur without clinical signs. Whichever policy is followed a DSA provides invaluable information in strengthening the decision either not to operate or if operating which operation to perform and which approach to use. DSA is a quick, simple and safe investigation that can be carried out at any time of day or night.
In the last 5 years there has been a dramatic decrease in the deaths directly related to football participation. The incidence of serious spinal cord injuries, however, appears to be increasing. The number of quadriplegic athletes varies from an estimated 1 per 7,000 to 1 per 58,000 participants per year in different areas of the country. The majority of catastrophic head and neck injuries occurs while tackling or blocking, and defensive players are much more liable to sustain these injuries than offensive players. In addition to permanent and irreversible spinal cord damage, football players may suffer spinal concussions as well as spinal contusions. The latter may be manifested by severe burning paresthesias and dysesthesias in the extremities as the only symptoms. Furthermore, fracture-dislocations with ligamentous tears may be present in this syndrome, with no complaint of cervical pain. Adequate preconditioning and strengthening of the head and neck musculature prior to football participation are essential for the prevention of catastrophic head and neck injury. Furthermore, proper blocking and tackling techniques must be taught, and such punishing maneuvers as spearing, goring, and butt-blocking and tackling must be eliminated. Arbitrarily, most physicians discourage further football participation if an athlete has suffered three cerebral concussions. Strong consideration must be given, however, not only to the number and severity of the concussion, but also to any CAT scan evidence of cerebral edema, contusion, or hemorrhage. With this incredibly sensitive diagnostic tool, one concussion, which is associated with radiographic evidence of structural brain damage, may be enough to strongly discourage or forbid further football participation.
PURPOSE: To report an experience with helical computed tomographic (CT) angiography as the initial procedure to rule out arterial lesions caused by penetrating neck injuries. MATERIALS AND METHODS: During 27 months, 175 patients were referred for helical CT angiography of the neck because of clinical suspicion of arterial injuries. The protocol included a 100-mL bolus of nonionic contrast material injected at 4.5 mL/sec, with 11-second scanning delay, 3-mm collimation, and pitch of 1.3-2.0. CT images were interpreted prospectively by the emergency radiologist, and two radiologists retrospectively interpreted studies with consensus. Outcome was determined with examination of patients and their charts. The sensitivity, specificity, and positive and negative predictive values were calculated. RESULTS: Studies in two patients were considered inadequate for diagnosis; these patients were referred for conventional arteriography and had normal findings. In 27 patients (15.6%), arterial lesions were detected. One patient had two arterial injuries. Lesions demonstrated with helical CT angiography were arterial occlusion (n = 14), pseudoaneurysm (n = 8), pseudoaneurysm and arteriovenous fistulae (n = 4), and partial thrombosis (n = 2). The remaining 146 patients had normal arteries. On the basis of these findings, patients were treated with surgery (n = 21), endovascular intervention (n = 7), and observation alone (n = 146). CONCLUSION: Results indicate that helical CT angiography can be used as the initial method for evaluation in patients with possible arterial injuries of the neck.
We described two cases of the lateral medullary syndrome (Wallenberg's syndrome) due to vertebral artery dissection following minimal neck injuries. The first case was a 45-year-old man, who hit his head and often rotated his head because of posterior neck discomfort. Two years after the injury, he suffered from sudden sharp neck pain, nausea, and vertigo, which was followed by left hand numbness and difficulty in walking due to the right lateral medullary syndrome. Angiography showed right vertebral artery dissection at the fourth segment. The second case, a 48-year-old man, suffered from neck pain immediately after he hyperextended his neck for painting a wall. Within several hours, he experienced left hand numbness and difficulty in walking due to the lateral medullary syndrome. Angiography showed a saccular aneurysm and dissection of the right vertebral artery at the fourth segment. In both cases, minor traumas were thought to be the causes of vertebral artery dissection. We surveyed previously reported 84 cases (men: 50, women: 34) of the vertebral artery dissection due to minor traumas. Seventy per cent of patients were in their third or fourth decade of life. The main causes of trauma preceding the dissection were neck manipulation especially chiropractics (52%). The third segment was most vulnerable. Delay in onset following neck trauma could be more than a week, but in most cases the delay was less than 24 hours. Cervical rotation and extension were thought to precipitate dissection.
OBJECTIVE: To study the demographics and treatment outcome of penetrating neck injuries presenting to a major trauma centre in order to develop a treatment protocol. DESIGN: A case review. SETTING: A trauma centre at a tertiary care institution. PATIENTS: One hundred and thirty consecutive patients who had 134 neck wounds penetrating the platysma and presented to the trauma service between 1979 and 1997. INTERVENTION: Surgical exploration or observation alone. MAIN OUTCOME MEASURES: The location of injury, patient management, number of significant injuries, duration of hospital stay and outcome. RESULTS: Injuries were caused by stab wounds in 124 patients (95%) and gunshot wounds in 6 (5%). The location of injury was zone I (lower neck) in 20 cases (15%), zone II (midportion of the neck) in 108 (81%) and zone III (upper neck) in 5 (4%). The location was not recorded in 1 case. Fifty patients were managed by observation alone and 80 were managed surgically. Neck exploration in 48 asymptomatic patients was negative in 32 (67%). Significant injuries, including major vascular (12), nerve (13) and aerodigestive tract (19) injuries, were identified in 34 patients. Two of the 130 patients (1.5%) died of major vascular injuries. Seventy-six percent of significant injuries, including all zone II major vascular injuries, were symptomatic on presentation. The mean (and standard deviation) hospital stay for asymptomatic patients treated with observation alone and surgical exploration was similar (3.5 [6.02] versus 4.3 [5.46] days respectively, p = 0.575). Long-term disability, all neurologic in nature, was documented in 3 patients managed by observation alone and 6 patients managed by surgical exploration. CONCLUSIONS: Penetrating neck trauma, in particular stab wounds to zone II in asymptomatic patients, is associated with low morbidity and mortality. A selective management protocol with investigations directed by symptoms is the most appropriate approach for the patient population and resource base in this setting.
Patients presenting to the emergency departments in Kingston, Ontario, between 1 October 1992 and 30 April 1993 with head, face, and neck injuries from playing ice hockey, regardless of the age of the player or whether the play was recreational or league, were enrolled in this prospective descriptive case series analysis to document the type and mechanism of injury in relation to the use of protective head and neck gear. A total of 119 such injuries were seen, 84 (71%) of which were lacerations. Players aged 20-34 years were most frequently injured, most commonly through contact with sticks and pucks while wearing helmets but no face shields. Strict enforcement of the rules is required to minimize injuries. Further study is required to determine the reasons for the incomplete protection afforded by helmets and face shields noted here.
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Head and cervical spine sports-related injuries are intimately associated. The on-field evaluation and management of the athlete with these injuries is of paramount importance to stabilize the athlete and prevent further injury. Clinicians need to be aware of the differential diagnoses and consider each possibility based on the mechanism of injury. Although recognition of head and cervical spine injuries has resulted in significant reductions of catastrophic neurological injuries, especially in the cervical spine, further advances to decrease the incidence and long-term sequelae of head and neck injuries are needed. The first step is education of the athlete and the individuals involved in the care of that athlete.
A short cut review was carried out to establish the potential utility of flexion/extension views of the cervical spine in children with neck injuries. Using the reported search, 51 papers were found, of which three presented the best evidence to answer the clinical question. The author, date, and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these best papers are tabulated. A clinical bottom line is stated.
BACKGROUND: Among adolescents, risk behaviors often cluster together and lead to risk behaviour syndromes. Multiple risk behaviors in turn become important determinants of health outcomes, including injuries. METHODS: A national sample (n = 11,415) of Canadian youth aged 11-15 years was examined from the 1997-1998 Health Behaviour in School-Aged Children Survey. Principal components analyses were used to characterize how adolescent risk behaviors cluster together into factors. Associations between these behavioral factors and injury outcomes were explored via multiple logistic regression analyses. RESULTS: Two factors of risk behaviors emerged: lifestyle risks and psychological risks. Strong associations between the lifestyle risk scale and the occurrence of head and neck injuries were identified (P < 0.001 for trend). The relative odds for the highest quintile versus the lowest quintile were 6.96 (95% CI: 3.95-12.26). Similar injury risks were not identified in association with the psychological risk scale. CONCLUSIONS: The findings provide novel information about potential causes of injury to young people and provide a reliable method by which researchers can quantify two determinants of health. These are helpful for injury control research in that they provided a means by which health risk behaviors can be measured and then related to the injury experiences of young people.
BACKGROUND: Technological advances in military equipment have resulted in more devices being mounted on the helmet to enhance the capability of the soldier. The soldier's neck must bear this head-supported mass (HSM) and the resulting dynamic characteristics of the head and neck system are changed. The purpose of this study was to vary the conditions of impact as well as the design criteria to quantify the effect of HSM on neck injury risk through computational modeling. METHODS: The TNO MADYMO detailed neck model was used for a matrix of 196 simulations designed to vary the impact conditions and HSM properties added to the model. These parameters included seven impact directions, three impact magnitudes, nine mass locations, and three mass magnitudes. The data collected from these simulations were evaluated for injury risk using the lower neck beam criterion equation. RESULTS: The results from these simulations provide detailed information regarding the risk of injury based on a particular HSM configuration and the acceleration of the body. The predominant factor in increasing risk in the lower neck is the increase in pulse magnitude. The effect of pulse magnitude is more dominant in the directions that create a flexion or lateral bending moment. CONCLUSION: HSM increases the level of injury, but the impact level that the subject is exposed to is a more dominating factor in determining injury risk.
PURPOSE: Our preliminary experience with physical examination alone in the evaluation of penetrating zone 2 neck injuries for vascular trauma was previously reported in 28 patients over a 2-year period (1991-1993). The purpose of the current study was to examine the results of this approach in a much larger group of patients over an 8-year period. METHODS: The medical records for all patients admitted to our level I trauma center (all of them entered into our prospective protocol) between December 1991 and April 1999 with penetrating zone 2 neck trauma were reviewed for their initial presentation and any documented vascular injury. RESULTS: A total of 145 patients made up the study group; in 30 of these patients, the penetrating trajectory also traversed zone 1 or 3. Thirty-one patients (21%) had hard signs of vascular injury (active bleeding, expanding hematoma, bruit/thrill, pulse deficit, central neurologic deficit) and were taken immediately to the operating room; 28 (90%) of these 30 patients had either major arterial or venous injuries requiring operative repair (the false-positive rate for physical examination thus being 10%). Of the 114 patients with no hard signs, 23 underwent arteriography because of proximity of the injury to the vertebral arteries or because the trajectory included another zone. Of these 23 arteriograms, three showed abnormalities, but only one required operative repair. This case had no complications relating to the initial delay. The remaining 91 patients with no hard signs were observed without imaging or surgery for a minimum of 23 hours, and none had any evidence of vascular injury during hospitalization or during the initial 2-week follow-up period (1/114; false-negative rate for physical examination, 0.9%). CONCLUSIONS: This series confirms the earlier report indicating that patients with zone 2 penetrating neck wounds can be safely and accurately evaluated by physical examination alone to confirm or exclude vascular injury. The missed-injury rate is 0.7% (1/145) with this approach, which is comparable to arteriography in accuracy but less costly and noninvasive. Long-term follow-up is needed to confirm this management option.