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Clinical Evaluation of Head Injuries-On-the-Bench Evaluation

Athletes should be questioned for specific symptoms when they are taken off the field. In particular, athletes should be questioned about dizziness, visual changes (e.g., photophobia, double vision, or blurriness), headache, nausea, vertigo, and tinnitus. Many of these symptoms may not be present immediately but may occur in a delayed fashion. Vomiting may be indicative of a significant head injury with elevated intracranial pressure.

Physical examination should be directed at careful inspection and palpation of the head and neck. Facial bones should be evaluated carefully for crepitus and fracture. Mandibular fractures can be detected based on pain or malorientation with teeth clenching and grinding. Nasal fractures can be determined by palpation or visualization of deformity.

Certain findings are indicative of specific fracture patterns. Leakage of cerebral spinal fluid from the nose is suggestive of a cribiform plate fracture of the skull. Spinal fluid adjacent to the tympanic membrane is suggestive of a fracture in the temporal bone. The Battle sign (i.e., ecchymosis posterior to the ear in the mastoid region) is indicative of a posterior skull fracture.

A careful cranial nerve examination should be performed. Salient features of this examination include changes in pupil size, which can suggest increased intracranial pressures or a unilateral sympathetic nerve response; deficient oculomotor function caused by injury to the third cranial nerve from a skull fracture or subdural hematoma; asymmetric upward case because of infraorbital blow-out fractures resulting in entrapment of the inferior rectus muscle; and cranial nerve VII palsy from basilar skull fractures.

In addition, transient nystagmus often is seen after shearing or rotatory injury to the brainstem. A complete neurologic examination, including assessment for strength, sensation, and coordination, should be performed.

A neurocognitive assessment should include the athlete’s orientation to person, place, and time; recent memory, new learning, and delayed recall can be tested using short word recalls. Concentration can be evaluated by having the patient say the months of the year in reverse or by subtracting with serial sevens.

The Mini-Mental Status Exam is a formalized, brief screening tool that discriminates patients with moderate or severe deficits. Other structured sideline assessments of neurocognitive dysfunction may be employed to standardize evaluation after head trauma.

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