Dr. Kevin Yip

Dr Kevin Yip
Orthopaedic Surgeon
MBBS(UK), FRCS(EDIN), FAM(SING), FHKCOS(ORTHO)

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Head Injuries and Concussion

Key Points

  • Traumatic events can lead to both primary injuries [e.g., scalp lacerations, intracranial bleeds, skull fractures, concussion, and diffuse axonal injury, (DAI)] and later, secondary injuries (e.g., herniation syndromes, diffuse edema, and hypoxic/ischemic injuries).
  • Initial evaluation and treatment should progress through the ABCs (airway, breathing, and circulation) of trauma resuscitation. Glasgow Coma Scale is a standard measure of level of consciousness.
  • Orientation (time, place, and person), retrograde amnesia, dizziness, visual changes, nausea, tinnitus, pupils, and head/neck pain should also be assessed.
  • Physical examination should include detailed head and neck assessment for crepitus/deformity, bruising (e.g., the Battle sign), blood or fluid leakage [e.g., cerebrospinal fluid (CSF) leak], and tenderness. A careful neurologic examination, including cranial nerve assessment, is important; mini-mental status examinations can be helpful in the evaluation of neurocognitive function.
  • Intracranial hemorrhage can be divided into epidural, subdural, and subarachnoid.
  • The most common definition of concussion is a “clinical syndrome characterized by immediate and transient posttraumatic impairment of neural functions, such as alteration of consciousness, disturbance of vision, equilibrium, etc. due to brain stem involvement.” A concussion is sometimes called mild traumatic brain injury (MTBI).
  • Any head trauma associated with a loss of consciousness is a concussion. Headache (46%), dizziness (42%), and blurred vision (16%) are the most common symptoms.
  • It is estimated that 20% of patients with head trauma will suffer postconcussive symptoms (impaired memory and concentration, persistent headache, fatigue, mood and sleep disturbances, and dizziness).
  • Second-impact syndrome is a rare, potentially life-threatening event that results when a second impact occurs before complete recovery from the initial concussion. It can occur with a relatively minor impact. Clinically, the athlete appears to be stunned, then collapses within minutes. Pupils become dilated, and patient is semicomatose and develops respiratory distress.
  • Dementia puglistica (ataxia, pyramidal tract dysfunction, tremor, impaired memory, dysarthria, and behavioral changes) is a chronic brain injury that results from multiple concussions. Chronic traumatic brain injury (CTBI) is the term that has been used more recently. It includes decreased processing speed, short-term memory impairment, concentration deficit, irritability or depression, fatigue and sleep disturbance, a general feeling of fogginess, and academic difficulties.
  • The management of concussions has three crucial components: identifying neurologic emergencies, preventing second-impact syndrome, and avoiding the effects of repetitive concussions.
  • Once an athlete is asymptomatic, progression of activity is instituted over several days and is followed with continued monitoring. Each step takes a minimum of 1 day. The recommended steps from the 2001 Vienna Conference on Concussions in Sport are

(a) no activity, rest until asymptomatic;

(b) light aerobic activity;

(c) sport-specific training;

(d) noncontact training drills;

(e) full-contact training; and

(f) game play.

Head injuries are a major concern to the team physicians, and these injuries represent a wide spectrum of trauma. Concussion remains the most common type of sports-related head injury and is the focus of this chapter. However, more severe intracranial lesions, such as intracranial hemorrhage, cerebral contusion, and related complications, must be considered with any head injury.

Primary injuries arise from an initial traumatic event and include scalp and skull injuries, extraparenchymal hemorrhage, cortical contusion, concussion, and diffuse axonal injury.

As with any trauma, patients are at risk of subsequent secondary injury, which in the setting of head injury can be particularly devastating because of the limited and fixed cranial space and the inability of cerebral tissue to repair or to regenerate.

Secondary injury includes herniation syndromes, secondary infarcts and bleeds, diffuse cerebral edema, hypoxic and ischemic injuries, and hydrocephalus. The fundamental goals in treating head injury are to recognize primary injuries and to prevent secondary lesions.

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