Head and Neck
Orthopedic Assessment III – Head,
Spine, and Trunk with Lab
PET 5609C
Clinical Anatomy
Clinical Anatomy
Clinical Anatomy

Brain: Cerebrum
Largest section of brain (most anterior and
superior region of CNS)
 Formed by 2 hemispheres:

Longitudinal fissure – separates 2 sides
 Right and Left Hemisphere:
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Frontal lobe
Parietal lobe
Temporal lobe
Occipital lobe
Clinical Anatomy
Clinical Anatomy

Brain: Cerebrum
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Functions:
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Temperature
Touch
Pain
Pressure
Proprioception
Special senses:
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Visual
Auditory
Olfactory and taste
Cognition:
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Motor function
Sensory information:
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Functions (cont.)
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Spatial relationships
Behavior
Memory
Association
Communication:
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Right hemisphere →
controls left side of body
Left hemisphere →
controls right side of
body
Clinical Anatomy

Brain: Cerebellum

Quick processor of incoming/outgoing
information:
Integrates sensory perception, coordination and
motor control: Cerebellum → linked to cerebral
motor cortex (sends info to muscles) and
spinocerebellar tract (proprioceptive feedback)
 Constant feedback on body position → fine tunes
motor movements
 Key: Maintains BALANCE and COORDINATION

Clinical Anatomy
Clinical Anatomy

Brain: Diencephalon
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Processing center for
conscious and
unconscious brain
input
Parts:
Thalamus
 Hypothalamus
 Epithalamus
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Clinical Anatomy

Brain: Thalamus
 Functions:
Translates
information (inputs)
for cerebral cortex
 Processes and
relays sensory
information
 Helps regulate
states/levels of
sleep and
consciousness

Hypothalamic Regulation
Posterior Pituitary
Effect
Neurosecratory Neuron
Vasopressin (ADH)
Water Retention
Neurosecratory Neuron
Oxytocin
Milk ejection (mammary
gland)
Hypothalamic Regulation
Anterior Pituitary
Effect
Thyrotropin Releasing
Hormone
Thyrotropin
Involved Thyroxin from
Thyroid Gland
Corticotropin Releasing
Hormone
Adrenocorticotrophic
Hormone
Cortisol Release
(adrenal gland)
Growth-Hormone Releasing
Hormone
GH
Whole body growth
Gonadotropin Releasing
Hormone
FSH, LH
Reproductive function
Prolactin Releasing
Hormones
Prolactin
Milk production
MSH Releasing Factor
Melanocyte Stimulating
Hormone
Skin pigments
Clinical Anatomy
Clinical Anatomy

Brain: Hypothalamus

Control of Hydration: Supraoptic nuclei and
Paraventricular nuclei (Hypothalamus)
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What Happens?
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Hydration Level too LOW
Osmoreceptors in blood detect increased concentration of salt
in blood
Hypothalamus stimulated – neurosecratory hormones
Vasopressin released from Posterior Pituitary
ADH causes kidneys to retain water
Level of water increases in the body
Clinical Anatomy
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Brain: Brain Stem
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Lower part of the brain (continuous
with spinal cord)
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Medulla Oblongata
Pons
Functions:
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Main motor and sensory
innervation to face and neck
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Cranial nerves
Regulation of cardiac and
respiratory function (medulla)
Relays information to and from the
CNS
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Pons: Link between cerebellum to
brain stem and spinal cord
Clinical Anatomy
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Brain: Meninges
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3 connective tissue layers which protect the CNS
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Pia mater:
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Supports blood vessels
Contains cerebrospinal fluid
Innermost layer (outer “skin” of brain)
Dura Mater:
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Outermost layer
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Serves as periosteum for skull’s inner layer
Arachnoid Mater:
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Middle layer
Subdural space – area between dura mater and arachnoid mater
Subarachnoid space – beneath the arachnoid
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Contains cerebrospinal fluid
Clinical Anatomy
Clinical Anatomy

Cerebrospinal Fluid:
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Clear, colorless liquid that
bathes the brain and
spinal cord (circulates
within subarachnoid
space)
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Functions:
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Cushions the brain within
the skull
Shock absorber for the CNS
Circulates nutrients and
chemicals filtered from the
blood and removes waste
products from the brain
Clinical Anatomy
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Brain blood demand:
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20% of body’s O2 uptake
at rest
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↑ 10 Celsius, brains
demand ↑ 7%
Supplying vessels:
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Vertebral arteries
Carotid arteries:
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Internal
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External
Circle of Willis
Clinical Evaluation
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Key Points:
All unconscious athletes must be managed as if
a fracture or dislocation of the cervical spine
exists until the presence of these injuries can be
definitively ruled out
 Ideally, 2 responders are available to evaluate:
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In-line stabilization and immobilization of athlete’s
head
 Initial evaluation:
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Palpation
Sensory and motor tests
Clinical Evaluation
Clinical Evaluation
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Initial Evaluation:
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Assess ABC’s: (airways, breathing, circulation)
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Moving, speaking athlete → ABC’s present
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Still suspect cervical spine injury (until ruled out)
Level of Consciousness:
Communicate with athlete (verbal)
 Unresponsive athlete:
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Apply painful stimulus:
 Lunula of fingernail
 Pressure to sternum
Clinical Evaluation
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Initial Evaluation:
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Primary Survey:
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Look, listen, feel for
breathing
Absent breathing →
modified jaw thrust to open
airway
Absent pulse → CPR
Initiate EMS!
Secondary Survey:
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Bleeding
Possible fractures, dislocations
Clinical Evaluation
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History:
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Location of
symptoms:
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Signs and Symptoms
Brain
Amnesia
Confusion and Disorientation
Irritability and Uncoordination
Cervical pain or
muscle spasm:
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Area
Pain
Numbness
Burning
Head pain:
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Headaches
Dizziness
Headache
Ocular
Blurred vision and Photophobia
Nystagmus
Ears
Tinnitus
Dizziness
Stomach
Nausea
Vomiting
Systemic
Unusually fatigued
Clinical Evaluation
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Mechanism of Injury: Head
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Coup Injury:
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Stationary skull is hit by object
traveling at high velocity (i.e. hit in
head with baseball)
Trauma → side of head where
contact occurred
Contrecoup Injury:
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Skull is moving at high velocity
and is suddenly stopped (i.e.
falling and hitting head on the
ground)
Brain strikes the skull on side
opposite of the impact
Clinical Evaluation
Clinical Evaluation
Clinical Evaluation
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Mechanism of Injury:
Head
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Repeated
subconcussive forces:
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Repeated trauma:
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Boxing
Heading in soccer
Rotational or shear
forces:
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Twisting
Acceleration and
deceleration
Clinical Evaluation
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Mechanism of Injury: Cervical spine
Most forces → dissipated by cervical
musculature and intervertebral discs
 Flexion, extension, lateral bending, rotation
 Flexion:
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Removes natural lordotic curvature (30 degrees)
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Forces directed to cervical vertebrae
Axial load → through vertical axis of vertebral column
Catastrophic injuries
Clinical Evaluation
Clinical Evaluation
Clinical Evaluation
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History:
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Loss of consciousness:
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Record athlete’s initial responses:
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“Do you remember being hit?”
History of concussion:
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Recent concussions → increased risk
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“Seeing stars”
“Blacking out”
Second impact syndrome
Complaints of weakness:
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Fatigue
Muscular weakness:
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More serious:
 Trauma to brain, spinal cord, spinal nerve roots
Clinical Evaluation
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Inspection: Bony Structures
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Position of head:
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Cervical vertebrae:
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Head should be upright in all planes
Laterally flexed and rotated head → possible cervical vertebrae
dislocation
View athlete from behind (positioning of spinous processes)
Mastoid process:
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Battle’s sign → ecchymosis over mastoid process
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Basilar skull fracture
Skull and scalp:
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Bleeding, swelling, deformity
Clinical Evaluation
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Inspection: Eyes
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General:
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Nystagmus:
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Dazed, distant stare may indicate
mental confusion
Involuntary cyclical movement of the
eyes
Pupil size:
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Unilateral dilation (pressure on cranial
nerve III)
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Note: Anisocoria (normal unequal
pupil size)
Pupil reaction to light
Clinical Evaluation
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Inspection: Nose
and Ears
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Ears:
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Nose:
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Bleeding and/or
cerebrospinal fluid
Skull fracture
Bleeding
Nose fracture or skull
fracture
Nose/eyes:
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Raccoon eyes → skull
or nasal fracture
Clinical Evaluation
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Palpation: Bony
Structures
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Palpation: Soft Tissue
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Spinous Processes:
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Patient seated, leaning
slightly forward
C7 and ↑
Transverse Processes
Skull:
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Occipital and temporal
Sphenoid and zygomatic
Parietal and frontal
Musculature:
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Trapezius
SCM
Throat
Clinical Evaluation
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Special Test: Halo Test
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Patient position:
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Examiner position:
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Fold a piece of sterile gauze into a triangle
Using the point of the gauze, collect a sample of the fluid
leaking from the ear or nose (allow it to be absorbed)
Positive test:
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At patient’s side
Procedure:
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Lying or seated
Pale yellow “halo” will form on the gauze
Implications:
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Cerebrospinal fluid leakage
Clinical Evaluation
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Functional Testing: Memory
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Retrograde amnsesia:
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Inability to recall events before injury
Anterograde amnesia:
Inability to recall events after injury
 Fading memory → progressive deterioration of
cerebral function
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ATHLETE POSITION:
On-field: athlete’s current position
Sideline: standing, seated
EXAMINER
POSITION:
In a position able to hear athlete’s responses
PROCEDURE:
Ask patient series of questions beginning with the time of the injury
Each successive question progresses backward in time
What happened?
What play were you running?
Where are you?
Who am I?
Who are we playing?
What quarter is it?
What did you have for a pregame meal?
Who did we play last week?
POSITIVE TEST:
Athlete has difficulty remembering or cannot remember events occurring before the
injury
IMPLICATIONS:
Retrograde amnesia:
Not remembering events from the day before is more significant that not
remembering more recent events
The same set of questions should be repeated to determine whether memory
is returning, deteriorating, or staying the same
Further deterioration of memory or acutely profound memory loss warrants
immediate termination of evaluation and transportation to emergency medical
facility
COMMENTS:
Record patient’s responses and verify answers with coaches/teammates
Clinical Evaluation: Anterograde Amnesia
PATIENT POSITION:
Sitting or standing
EXAMINER
POSITION:
Positioned to hear athlete’s response
EVALUATION:
Athlete is given a list of 4 unrelated items (ask them to
memorize the list)
Hubcap
Rabbit
Dog tags
Film
Ivy
POSITIVE TEST:
Inability to completely recite the list
IMPLICATIONS:
Anterograde amnesia, possibly the result of intracranial
bleeding
COMMENT:
Perform the test after test for retrograde amnesia
Clinical Evaluation
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Functional Testing: Cognitive Function
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Cerebral trauma → Unusual athlete behavior
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Behavior:
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Analytical Skills:
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Violent, irrational, inappropriate behavior
Serial 7’s (count backwards from 100)
Information Processing:
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Provide command → can athlete follow?
Clinical Evaluation
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Balance and Coordination:
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Affected secondary to trauma involving
cerebellum and inner ear
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Tests:
Romberg Test
 Tandem Walking
 Balance Error Scoring System
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Clinical Evaluation
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Romberg Test:
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Patient Position:
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ATC Position:
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Patient shuts eyes and abducts arms to
900
Patient tilts head backwards and lifts 1
foot off ground
Patient touches index finger to nose
(eyes closed)
Positive Test:
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Ready to support patient
Procedure:
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Standing, feet shoulder width apart
Patient unsteadiness
Implications:
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Cerebellar dysfunction
Clinical Evaluation
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Tandem Walking:
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Patient Position:
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ATC Position:
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Athlete walks heel-to-toe along a straight line for approximately
10 yards
Athlete returns to starting position by walking backwards
Positive Test:
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Beside patient to provide support
Evaluation:
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Athlete standing with feet straddling a straight line
Athlete unable to maintain a steady balance
Implications:
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Cerebral or inner ear dysfunction that inhibits balance
Clinical Evaluation
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Balance Error Scoring System:
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Patient Position:
Patient barefoot or wearing socks (no tape); hands
on iliac crest; eyes closed
 Phase 1:
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Phase 2:
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Double Leg Stance
Single Leg Stance – standing on the nondominant leg; nonweight-bearing hip flexed to 200 and knee flexed to 400-500
Phase 3:
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Tandem Leg Stance – nondominant leg placed behind the
dominant leg and the patient stands in a heel-toe manner
Clinical Evaluation
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Balance Error Scoring System:
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ATC Position:
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In front of the athlete; trials are timed
Procedure:
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First battery performed with athlete standing on a
firm surface
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DL stance, holds position for 20 seconds
SL stance
Tandem stance
Second battery performed with athlete standing on
foam
Clinical Evaluation
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Balance Error Scoring System:
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Scoring: One point is scored for each of the following errors
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Hands lifted off iliac crest
Opening eyes
Step, stumble or fall
Moving hip into > 30 degrees abduction
Lifting forefoot or heel
Remaining out of testing position > 5 sec.
Note:
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If more than 1 error scores simultaneously, only 1 error is scored
Patients unable to hold the test position for 5 seconds are assigned the
score of 10
Positive Test:
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Scores that are 25% ABOVE patient’s baseline
Impaired cerebral function
Clinical Evaluation
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Standardized Assessment of Concussion (SAC)
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Abbreviated neuropsychological test
Immediate objective data
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Presence and severity of neurocognitive impairment
On or off field evaluation
Tests:
Orientation
 Immediate Memory Recall
 Concentration
 Delayed Recall
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Clinical Evaluation
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Neuropsychological Testing:
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Allow ATCs to objectively quantify athlete cognitive
dysfunction
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Tests:
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Hopkins Verbal Learning Test (HVLT) – 12 word list; athlete
recalls several times
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Brief Visuospatial Memory Test (BVMT-R) – visual memory
Trail Making Test – spatial scanning, speed, cognitive
flexibility
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Controlled Oral Word Association Test (COWAT) – recall as
many words as possible in 1 min. (starting with a given letter)
Digit Span Test – repeat strings of numbers
Symbol Digit Modalities Test (SDMT) – visual scanning and
processing speed; match numbers/symbols under pressure
Clinical Evaluation
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Vital Signs:
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Respirations:
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Pulse:
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Number of breaths per minute and quality of respirations
Pulse rate and quality
Blood pressure
Pulse pressure:
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Systolic pressure – diastolic pressure
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Normal: 40 mm HG
Pulse pressure > 50 mm HG → may indicate increased
intracranial bleeding
Clinical Evaluation
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Cranial Nerve
Assessment:
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12 nerves that emerge
directly from the brain stem
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spinal nerves which emerge
from segments of the spinal
cord
Ganglia of sensory
component → outside CNS
Ganglia of motor
component → within CNS
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↑ intracranial pressure
impairs motor component
Cranial Nerve
Function
Test
(I) Olfactory
Transmits sense of smell Check athlete’s ability to
smell
(II) Optic
Transmits visual
information to brain
Check athlete’s vision
(III) Occulomotor Innervates superior,
medial, and inferior
rectus muscles and
inferior oblique
Ask athlete to elevate the
eyelid, elevate, depress,
and adduct the eye
(IV) Trochlear
Innervates superior
oblique muscle
Ask athlete to elevate the
eyes
(V) Trigeminal
Receives sensation from
the face, innervates
muscles of mastication
Check sensation of face,
ask athlete to elevate,
depress, protrude, retrude,
laterally deviate jaw
(VI) Abducens
Innervates lateral rectus
muscle
Ask athlete to abduct eyes
Cranial Nerve
Function
Test
(VII) Facial
Motor innervation to
muscles of facial
expression, receives
special sense of taste
from anterior 2/3 of the
tongue, provides
secremotor innervation to
salivary glands and
lacrimal gland
Check athlete’s ability to
taste along anterior portion
of tongue; elevate, abduct,
depress eyebrows,
open/close eyes, dilate and
constrict nostrils, open and
close mouth, protrude lips
(VIII)
Vestibulocochlear
Senses sound, rotation,
and gravity (essential for
balance and movement)
Romberg Test, athlete’s
ability to hear
(IX)
Glossopharyngeal
Receives taste from
posterior 1/3 of tongue,
provides secremotor
innervation to parotid
gland
Check athlete’s ability to
taste on posterior tongue
and have athlete swallow
Cranial Nerve Function
Test
(X) Vagus
Supplies innervation to most
laryngeal and pharyngeal muscles,
provides parasympathetic fibers to
thoracic and abdominal viscera,
receives special sense of taste from
epiglottis
Assess athletes
ability to breathe
(XI) Accessory
Controls muscles of neck and
overlaps with functions of vagus
nerve
Ask athlete to
shrug shoulders
(XII)
Hypoglossal
Motor innervation to intrinsic
muscles of the tongue
Ask athlete to
stick out their
tongue