BPK 241 Lecture 6

Thorax

• Neck

• Diaphragm

• Thoracic vertebrae - protect vital organs

• Ribs, sternum, muscles

Bones

• 12 thoracic vertebrae

• Sternum

  • Manubrium, body, xiphoid process

• 12 pairs of ribs

Ribs 1 to 7

Attach to sternum by individual cartilage (costochondral) - have their own attachment at the front of the sternum

Ribs 8 to 10

Share one attachment

Ribs 11 and 12

Do not attach to the sternum

Respiratory muscles

• Diaphragm → increase space of thoracic cavity (have negative pressure inside)

• Intercostal muscles

• Sternocleidomastoid

• Accessory muscles of respiration

Inspiration

Ribs + intercostal muscles expand → diaphragm contracts (negative lung pressure)

Expiration

Diaphragm relaxes back to parachute shape → push up on lungs

Thorax Contents

• Lungs

• Heart

• Aorta and various branches

• Superior vena cava and tributaries

• Azygous vein

• Trachea

• Esophagus (oesophagus)

• Vagus nerve & others

Muscle strains

• Common in running - forceful breathing

• Intercostals, diaphragm, others

• SSx:

  • Pain under the thoracic cage on deep inspiration, dyspnea (difficulty breathing)

  • Tenderness

• Tx:

  • Rest, analgesics

Rib fracture

• Direct blow; compression (tackle)

• SSx:

  • Severe inspiratory pain & dyspnea

  • Tenderness, maybe crepitus

  • X-Ray often not helpful

  • Difficult to spot it cuz of movement

• Tx:

  • Rest, analgesics (pain meds - no codine)

Costochondral sprain or dislocation

• Same Hx, SSx, Tx as strain, plus crepitus, deformity?(surgery?)

• localized pain, difficulty pain

Prolotherapy

Injection of sucrose solution(sugar water) - stabilize water. “Helps aid the healing of rib”

Costovertebra

Back of the the thorax where ribs join the spine (joint). Sprain ribs might puncture the lungs from treatment

Thorax life threatening injuries

• Pneumothorax (air into the thoracic cavity/ collapse lung)

• Open vs closed

• SSx: Severe dyspnea, shock, cyanosis (decrease in blood oxygen), rapid RR (respiratory rate), Hx of puncture if open, lips blue

• Tx: cover opening, NPO, hospital ASAP

Open thorax injury

Air goes in (rushing into opening) - pierce thoracic cage; more common in shooting/stabbings than sports

Closed thorax injury

Tear in lung cause lung to collapse (air escape the cavity) - no oxygenated blood

Flail chest

• Multiple rib fractures

• Paradoxical (opposite motion) motion of part of chest wall

• SSx & Tx = as for pneumothorax

• Free body segment in middle sucked in. When we breathe, free body segment is pushed out

Commotio cortis

• Impacts/blows to the chest causing heart to stop

• Affects electrical activity in the heart

Abdomen boundaries

• Diaphragm (superior) , pelvis (Inferior), abdominal muscles (lateral)

• Vertebrae, lower ribs, back muscles (posterior)

Inguinal area

• Inguinal ligament

• ASIS (anterior superior iliac spine) to pubic tubercle - bony prominence in front of pelvis

Inguinal ligament

• Above Inguinal canal and site of inguinal herniation. Internal and external inguinal rings

Inguinal canal

Passage in lower part of anterior abdominal wall for spermatic cord in ales or round ligament of uterus for females

Femoral triangle

• Below inguinal ligament

• Femoral artery, nerve & vein are subcutaneous

• Site of femoral herniation

Abdominal contents

• Solid organs (bleed profusely)

  • Liver (RUQ)

  • Spleen (LUQ)

  • Kidneys (flanks)

• Intestines and glands

  • Stomach, duodenum, ileum, jejunum, colon (appendix in RUQ)

  • Pancreas, gall bladder

Abdomen Vessels

• Abdominal aorta, inferior vena cava

• “Visitors”

  • Uterus in pregnancy

  • Bladder if distended (quite full)

Blow to coeliac (solar) plexus

• Mechanism:

  • Trauma to central abdomen leads to nerve concussion (wind knocked out which contuse solar plexus)

  • Transient paralysis of diaphragm

• SSx:

  • Ache, shortness of breathing/dyspnea, anxiety

• Tx:

  • Relaxation (short inhalation, long exhalation), reassurance, observe!

  • Knees to chest

“Side Stitch”

• Strain or contusion of abdominal muscle (any muscles wrapped around abdominal area - can get cramping)

• SSx:

  • Crampy pain, worse with inspiration

• Tx:

  • Stretching, analgesics, rest

Hernia

• Intestine being pushed down onto inguinal canal, stretching up the internal inguinal ring and may come out the external inguinal ring - can feel intestines pushing out

• Protrusion of abdominal contents through defect in muscle/fascia

  • Predisposition (weakness)

  • Valsalva or direct blow

• Degrees:

  • Reducible (reposition of abdominal muscles)

  • Incarcerated (head to reposition - hard to push off)

  • Strangulated (being strangled - blood + oxygen cut off))

• Types:

  • Inguinal (majority, male or female)

  • Femoral (uncommon; more common in females)

Hernia Symptoms and Treatment

• SSx:

  • “pull” or weakness

  • Aching pain

  • Swelling & tenderness above (inguinal) or below (femoral) inguinal ligament

  • Pain & swelling worsen with cough or repeated valsalva

  • Shock, nausea

• Tx:

  • Strengthening abdomen

  • Surgery

• Strangulated = emergency

  • Nausea, vomiting, intense pain

  • NPO, transport to Hospital ASAP

Sports Hernia

• Athletic pubulga

• SSx: Chronic groin pain, pain with twisting, hip extension, possible pain into testicle

• Ax: pt history, physical exam, MRI

• Tear of abdominal muscles or tendon (rectus abdominis, external oblique, internal oblique) at attachment to pubic tubercle

• Entrapment of inguinal or genitofemoral nerve

• Often labral tear and adductor strain associated with it

• Tx: rest, surgery

Mononucleosis

Enlarged spleen (no contact sports until MD approved). Delayed abdominal pain after contusion to abdomen? send to MD!

Cervical spine

• C1 = atlas (skull flexion/extension) - circular ring

• C2 = axis (rotation - C1 pivots on C2 odontoid (dens)) - bony projection

• C7 = Vertebrae prominens

Spinal nerves

• C1 - C7 exit above same vertebrae

• C8 exits between C7 & T1

• C5 - T1 form brachial plexus

• C3 - C5 innervate diaphragm

Skull

Inexpansible; brain & sense organs

Facial bones

Fragile (except mandible); TMJ

Neck Mechanisms

• Flexion & extension (whiplash)

• Torsion (twisting)

• Compression (load down through the spine)

Neck injuries

• SSx:

  • Pain, tenderness

  • Spasm (delayed?)

  • Restricted ROM

  • Headaches

  • N.B. check for evidence of bony and/or neurologic injury (ABCDs)

    • Numbness? Weakness or paralysis?

    • Point tenderness over spinous process?

    • Stabilize; to hospital ASAP

Neck Management

• Stabilize; physician to access

• If Hx severe trauma, or neurologic SSx exist, assume fracture/ nerve damage

  • May not be apparent at first

  • May lead to permanent brachial plexus or spinal cord injury

• Follow up for strain or sprain

  • Rest (soft collar) - stabilizes neck

  • NSAID

  • Physiotherapy or massage therapy

  • Flexibility & strengthening exercises - ROM

  • Recurrence is common

• Primum non nocere

Neck injury or Concussion?

• For a cervical spine injury (sprain or strain) to occur, only require 4.5G of force

• For a concussion need 70 to 120G of force

• There you CANNOT have a concussion without injuring your neck

• Many neck injuries produce symptoms similar to a concussion

Concussion

• Immediate, transient neurologic dysfunction due to trauma to brain

• Aka Mild Traumatic Brain Injury (mTBI)

• Concussion represent 8.9% of high school athletic injuries and 5.8% of all collegiate athletic injuries

Coup

Initial

Contre Coup

After

Neurons and Axons

Neurons form grey matter and axons form white matter. Together they carry down signals to dendrites

Normal Neuron Function

• Signal arrives at neuron

• Signal travels down axon to another cell

• Neurotransmitters are released in an organized manner, triggering the next cell with a specific coded message

Neuron During Injury

During injury, potassium ions (K+) rush out of the cell and toxic calcium ions (Ca2+) rush into the cell, leading to metabolic dysfunction

Neurometabolic Cascade Following Cerebral Concussion

• Decreased cerebral blood flow for 10 days - protective measure

• Increase of calcium within few minutes up to 3-6 days

• Increase of glucose as body attempts to heal itself but after 6 days it decreases for 10 days

• Increase of Potassium for 12 minutes

Neurometabolic Cascade of Concussion

Excitation Phase and Spreading Depression Phase

Excitation Phase

• Calcium elevated 500% for up to 6 days

• Potassium elevated 400% within 12 minutes

• Glutamate elevated 133% for 6 minutes

• Glucose elevated to 200% of normal in first 20 minutes slowly, but then drops below normal for up to 10 days

• 40% decrease in cerebral blood flow

Neuron Following Concussion

• Metabolic dysfunction results in ENERGY CRISIS

• Massive release of neurotransmitters interferes with cell communications

• It may take many days for the nerve cells to return to their normal condition

• Nerve cells is extremely vulnerable in this condition, and further injury or stress may cause cell death or serious cell damage

Spreading Depression Phase

• Energetic management problem

• How do we maintain balance of Na+, Ca+ inside cells and K+ outside cells\

• Na/K pump (lots of it)

• Requires ATP from mitochondria but high levels of Ca+ is poisonous for mitochondria

• Energy crisis

  • Increased ATP demand from Na/K pump

  • Decreased ATP production by mitochondria

  • Decrease blood glucose for up to 10 days

Concussion Signs & Symptoms

• SSx:

  • Physical

  • Behavioural/Emotional

  • Thinking/ Cognitive

Physical Symptoms of Concussion

• Headache

• Dizziness

• Ringing in the ears

• Pressure in the head

• Neck pain/ stiffness

• See stars/ flashing lights

• Vision problems

• Balance problems

• Nausea/ vomiting

Behavioural/ Emotional Symptoms of Concussion

• Personality change

• Concentration problems

• Confusion, disorientation

• Sleeping more of less than usual

• Trouble falling asleep or staying asleep

• Drowsiness/ fatigue

• Emotional/ irritable/ anxious/ depressed

Thinking/Cognitive Symptoms of Concussion

• Memory problems - events loading up to the injury and events after the injury

• Concentration problems

• Feeling mentally foggy

• Slow to respond to questions

• Trouble finding words

• Confusion/ disorientation

Concussion Assessment Tools

SCAT - sport concussion assessment tool

Concussion Assessment Tools

• Online concussion testing problems

  • imPACT neurocognitive testing

  • Concussion Vital Signs

  • HeadCheck

  • King Devick

Concussion Treatment

• Tx:

  • In unconscious - stabilize (neck too); to hospital ASAP

  • ABCD’s (serial assessments, 24 hours)

  • Limit screen time, gradually increase physical activity, moderate rest 24 to 48 hours

  • No sports until SSx absent for week(s)

Symptoms gone = Recovered right?

• SCAT normalized in 2 to 5 days

• Balance (BESS) scores return to normal by 3 to 5 days

• Cognitive processing and memory normalizes by 7 days

• Ca+ levels normalize, cerebral blood flow 7 to 10 days

• Symptoms resolution 7 to 10 days

• BUT full metabolic recovery 30 to 45 days!

• What happens if we get another impact in that time?

  • 2nd impact during this time may have axonal damage that has not recovered

  • 2nd impact syndrome

• What happens if don’t recover energy balance?

  • Persisted concussion symptoms

  • Post concussion syndrome

Concussion: Return to Play

• Absence of symptoms before Return to Play protocol

• Clearance from medical professional

• Return to play protocol

• Physical testing

  • Buffalo treadmill test

  • Blackwork test

Concussion - Complications

• Epidural haematoma (arterial)

• Subdural haematoma (venous)

• Airway obstruction

• Skull fracture (leads to infection)

NFL Return to Play Protocol

• Phase 1: Symptom Limited Activity

• Phase 2: Aerobic Exercise

• Phase 3: Football Specific Exercise

• Phase 4: Club-Based Non-Contact Training Drills

• Phase 5: Full Football Activity/ Clerance

Head Injuries

• Mandibular fracture or/and temporomandibular dislocation

  • Hx: direct blow

  • SSx: deformity, spasm+++

    • Airway is threatened

  • Tx: ABCD’s, stabilize, hospital ASAP

Nasal Injuries

• Fracture

  • Hx: direct blow

  • SSx: pain, swelling, crepitus, deformity, epistasis, uneven air entry

  • Tx: cold compress; to MD soon

Epistaxis

• Hx: direct blow, sinusitis, “digital”

• Tx: elevation, cold, pressure

• MD to assess & Tx if persists or recurs

External air contusion

• Hx: direct blow

• SSx: swelling, bruising, tenderness

• Complication = deformity

• Tx: cold pack, compress, MD may aspirate

• Prevention (ear protection)

Eye Injuries

• All are important - MD to see!

  • Contusion

  • Foreign body, laceration, abrasion

  • Infection

Teeth fractures

• Save fragment (cold milk)

• To dentist within 2 hours

What can we do to decrease the incidence of concussions in sports?

• Helmets, guardian cps, head protection equipment

• Less tackles during practice

• New policy on hitting and impact to head

Impermeable barrier

• Creating negative pressure

• Air can escape from untaped area