Chap2 Magee

C H A P T E R 2
Head and Face

Casualty officers and clinicians working in emergency care nerves generally contain both sensory and motor fibers.
settings are often the ones who assess the head and face. However, some cranial nerves are strictly sensory (olfac-
In these settings, the assessment involves the bony aspects tory and optic), whereas others are strictly motor (oculo-
of the head and face as well as the soft tissues. The soft- motor, trochlear, and hypoglossal).
tissue assessment involves primarily the sensory organs, The external eye is composed of the eyelids (upper
such as the skin, eyes, nose, and ears, whereas the muscles and lower), conjunctiva (a transparent membrane cover-
are tested only as they relate to injury to these structures. ing the cornea, iris, pupil, lens, and sclera), lacrimal gland,
Joints and their integrity are not the main objects of the eye muscles, and bony skull orbit (Figure 2-3). Muscles
assessment. Because the temporomandibular joints and of the eye, their actions, and their nerve supply are shown
cervical spine are discussed in Chapters 3 and 4, this in Table 2-2. The muscles and movements of the eye are
chapter deals with only the head, the face, and their asso- shown in Figure 2-4. To produce some of the actions,
ciated structures. the various muscles of the eye must work in concert. The
eyelids protect the eye from foreign bodies, distribute
tears over the surface of the eye, and limit the amount of
APPLIED ANATOMY light entering the eye. The conjunctiva is a thin mem-
The head and face are made up of the cranial vault and brane covering the majority of the anterior surface of the
facial bones. The cranial vault, or skull, is composed of eye. It helps to protect the eye from foreign bodies and
several bones: one frontal, two sphenoid, two parietal, desiccation (drying up). The lacrimal gland provides tears,
two temporal, and one occipital (Figure 2-1). Of these, which keep the eye moist (Figure 2-5). The eye itself is
the strongest is the occipital bone, and the weakest are made up of the sclera, cornea, and iris as well as the lens
the temporal bones. The frontal bone forms the forehead, and retina (Figure 2-6). The sclera is the dense white
and the temporal and sphenoid bones form the antero- portion of the eye that physically supports the internal
lateral walls of the skull, or the temples of the head. The structures. The cornea is very sensitive to pain (e.g., the
parietal bones form the top and posterolateral portions of extreme pain that accompanies corneal abrasion) and
the skull, and the occipital bones form the posterior separates the watery fluid of the anterior chamber of the
portion of the skull. The cranial vault reaches 90% of its eye from the external environment. It permits transmis-
ultimate size by age 5. sion of light through the lens to the retina. The iris is
In addition to the cranial vault bones, there are 14 a circular, contractile muscular disc that controls the
facial bones. These bones develop more slowly than the amount of light entering the eye and contains pigmented
cranial bones, reaching only 60% of their ultimate size by cells that give color to the eye. The lens is a crystalline
age 6. The facial skeleton is composed of the mandible, structure located immediately behind the iris that permits
which forms the lower jaw; the maxilla, which forms the images from varied distances to be focused on the retina.
upper jaw on each side; the nasal bones, which form the It is primarily the lens and its supporting ligaments that
bridge of the nose; and the palatine, lacrimal, zygomatic, separate the eye into chambers: the anterior chamber
and ethmoid bones, which form the remainder of the (aqueous humor) and the posterior chamber (vitreous
face. It is the zygomatic bone that gives the cheek its humor). Finally, the retina is the primary sensory
prominence. The sphenoid bones also form part of the structure of the eye that transforms light impulses into
orbital cavity. The facial skull has several cavities for the electrical impulses that are then transmitted by the optic
eyes (orbital), nose (nasal), and mouth (oral), as well as nerve to the brain, which interprets the impulses as the
spaces for nerves and blood vessels to penetrate the bony objects seen.
structure. Weight is saved in the skull area by the addition The external ear consists of cartilage covered with
of sinus cavities (Figure 2-2). skin. Its primary purpose is to direct sound and to protect
The muscles of the head and face are controlled pri- the external auditory meatus, through which sound is
marily by the 12 cranial nerves. The cranial nerves and transmitted to the eardrum. The external ear, which is
their chief functions are shown in Table 2-1. The cranial sometimes called the pinna, auricle, or trumpet, consists
84
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Chapter 2 Head and Face 85
Parietal bone Frontal bone
Temporal bone
Frontal sinus
Ethmoid bone
Concavity for Sphenoid bone
pituitary gland
Nasal septum
Occipital bone
Hard palate
Foramen magnum
Sphenoid sinus
A Mandible
Frontal bone
Parietal bone
Orbit Nasal bone
Zygomatic bone
Maxilla
Mandible
B
Squamous suture Coronal suture
Parietal bone
Frontal bone
Temporal bone Sphenoid bone

Lambdoid
suture
Nasal bone
Occipital bone Ethmoid bone

External auditory Zygomatic bone
meatus
Maxilla
Mastoid process
Temporomandibular joint
C Zygomatic arch Mandible
Figure 2-1 Bones of the head and face. A, Interior view. B, Anterior view. C, Lateral view. (Redrawn from Jenkins DB: Hollinsheads functional
anatomy of the limbs and back, Philadelphia, 1991, WB Saunders, pp. 332333.)
86 Chapter 2 Head and Face
of the helix and lobule around the outside and the (anvil), and stapes (stirrup)to the cochlea. The cochlea,
triangular fossa, antihelix, concha, tragus (a cartilaginous which is part of the inner ear, transmits the sound waves
projection anterior to external auditory meatus), and anti- to the vestibulocochlear nerve (cranial nerve VIII), which
tragus on the inside (Figure 2-7). The middle ear struc- transmits electrical impulses to the brain for interpreta-
tures consist of the tympanic membrane, or eardrum, tion. The semicircular canals, the other part of the inner
which vibrates when sound hits it and sends vibrations ear, play a significant role in maintaining balance.
through the ossiclescalled the malleus (hammer), incus The external nose, like the external ear, consists pri-
marily of cartilage covered with skin. However, its proxi-
mal portion contains bone covered with skin. Figure 2-8
shows the bone and cartilage makeup of the nose. The
floor of the nose consists of the hard and soft palates and
forms the roof of the mouth (Figure 2-9). Cartilage and
the nasal, frontal, ethmoid, and sphenoid bones form the
roof of the nose. The frontal and maxillary bones form
Frontal sinus the nasal bridge. Three bony structures called turbinates
(superior, middle, and inferior) form the lateral aspects of
the nose, which increase the surface area of the nose and
Ethmoid sinus
thereby warm, humidify, and filter more of the inspired
air. The nose is divided into two chambers (vestibules)
Maxillary sinus by a septum. These chambers are lined with a mucous
membrane containing hairs that collect debris and other
foreign substances from the inspired air. The cribriform
plate of the ethmoid bone contains the sensory fibers of
the olfactory nerve (cranial nerve I) for smell.
PATIENT HISTORY
Figure 2-2 The nasal sinuses. (Modified from Swartz HM: Textbook In addition to the questions listed under Patient History
of physical diagnosis, Philadelphia, 1989, WB Saunders, p. 166.) in Chapter 1, the examiner should obtain the following
TABLE 2-1
Cranial Nerves and Methods of Testing

Nerve Afferent (Sensory) Efferent (Motor) Test
I. Olfactory Smell: Nose Identify familiar odors (e.g.,
chocolate, coffee)
II. Optic Sight: Eye Test visual fields
III. Oculomotor Voluntary motor: Levator of Upward, downward, and
eyelid; superior, medial, and medial gaze
inferior recti; inferior oblique Reaction to light
muscle of eyeball
Autonomic: Smooth muscle of
eyeball
IV. Trochlear Voluntary motor: Superior Downward and lateral gaze
oblique muscle of eyeball
V. Trigeminal Touch, pain: Skin of face, Voluntary motor: Muscles of Corneal reflex
mucous membranes of mastication Face sensation
nose, sinuses, mouth, Clench teeth; push down on
anterior tongue chin to separate jaws
VI. Abducens Voluntary motor: Lateral rectus Lateral gaze
muscle of eyeball
VII. Facial Taste: Anterior tongue Voluntary motor: Facial Close eyes tight
muscles Smile and show teeth
Autonomic: Lacrimal, Whistle and puff cheeks
submandibular, and Identify familiar tastes (e.g.,
sublingual glands sweet, sour)
TABLE 2-1
Cranial Nerves and Methods of Testingcontd

Nerve Afferent (Sensory) Efferent (Motor) Test
VIII. Vestibulocochlear Hearing: Ear Hear watch ticking
(acoustic nerve) Balance: Ear Hearing tests
Balance and coordination test
IX. Glossopharyngeal Touch, pain: Posterior Voluntary motor: Unimportant Gag reflex
tongue, pharynx muscle of pharynx Ability to swallow
Taste: Posterior tongue Autonomic: Parotid gland
X. Vagus Touch, pain: Pharynx, Voluntary motor: Muscles of Gag reflex
larynx, bronchi palate, pharynx, and larynx Ability to swallow
Taste: Tongue, epiglottis Autonomic: Thoracic and Say Ah
abdominal viscera
XI. Accessory Voluntary motor: Resisted shoulder shrug
Sternocleidomastoid and
trapezius muscle
XII. Hypoglossal Voluntary motor: Muscles of Tongue protrusion (if
tongue injured, tongue deviates
toward injured side)
Adapted from Hollinshead WH, Jenkins DB: Functional anatomy of the limbs and back, Philadelphia, 1981, WB Saunders, p. 358; and Reid DC:
Sports injury assessment and rehabilitation, New York, 1992, Churchill Livingstone, p. 860.
Sclera and Eyebrow Pupil Eyelashes (cilia) TABLE 2-2

conjunctiva
Muscles of the Eye: Their Actions and Nerve Supply
Action Muscles Acting Nerve Supply
Upper eyelid
Moves pupil Superior rectus Oculomotor
Lacus upward (CN III)
Lateral palpebral
lacrimalis commissure Moves pupil Inferior rectus Oculomotor
downward (CN III)
Moves pupil Medial rectus Oculomotor
Palpebral fissure medially (CN III)
Medial palpebral Lower
Iris Moves pupil Lateral rectus Abducens
commissure eyelid
laterally (CN VI)
Figure 2-3 External features of the eye. Moves pupil Superior oblique Trochlear
downward (CN IV)
and laterally
Moves pupil Inferior oblique Oculomotor
information from the patient who has sustained an injury upward and (CN III)
to the head or the face: laterally
1. What happened? This question determines the mech- Elevates upper Levator Oculomotor
anism of injury and, potentially, the area of the brain eyelid palpebrae (CN III)
or face injured (Table 2-3). A pathological classifica- superioris
tion for acute traumatic brain injuries is shown in the
box on p. 89.1 A forceful blow to a resting, movable CN, Cranial nerve.
head usually produces maximum brain injury beneath
the point of impact (Figure 2-10). This type of injury,
called a coup injury, is usually caused by linear or
translational acceleration.2 It often causes focal isch- maximum brain injury is usually sustained in an area
emic lesions, especially in the cerebellum, leading to opposite the site of impact.
alterations in smooth, coordinated movements, equi- This contrecoup injury is the result of impact
librium, and posture. If the head is moving and deceleration. The injury occurs on the side of the
strikes an unyielding object, such as the ground, head opposite to that receiving the blow, because the
Lacrimal gland
Superior oblique
Superior rectus Puncta
Medial rectus
Lateral rectus Tear sac
Inferior rectus
Inferior oblique
Nasolacrimal duct
Canaliculi
A
Elevation
Extorsion Intorsion
Figure 2-5 The lacrimal apparatus. (Modified from Swartz HM: Text-
book of physical diagnosis, Philadelphia, 1989, WB Saunders, p. 126.)
Abduction Adduction
B Depression
Figure 2-4 Muscles (A) and movements (B) of the eye. (Modified from
Swartz HM: Textbook of physical diagnosis, Philadelphia, 1989, WB
Saunders, pp. 125126.)
Levator palpebrae muscle

Mllers muscle
Orbicularis oculi muscle Superior rectus muscle
Upper eyelid
Conjunctiva Vitreous humor
Tarsal plate Retina and
Meibomian glands retinal vessels
Iris Optic nerve head
Lens Optic nerve
Pupil
Eyelashes
Cornea Nervous layer of retina
Anterior chamber Choroid
Posterior chamber Sclera
Limbus
Ciliary body
Inferior rectus muscle
Zonules
Lower eyelid
Figure 2-6 Cross section of the eye. (Modified from Swartz HM: Textbook of physical diagnosis, Philadelphia, 1989, WB Saunders, p. 132.)
INNER MIDDLE EXTERNAL

EAR EAR EAR
Malleus Temporal
bone
Incus
Semicircular canals Triangular fossa
Antihelix
Helix (lobe)
Tragus AURICLE
Cochlea (PINNA)
Stapes Antitragus
Eustachian tube
Lobule
Eardrum
(tympanic membrane)
External auditory meatus
or canal
Figure 2-7 A cross-sectional view through the ear.
Pathological Classification of Acute Traumatic

Brain Injury
Nasofrontal Frontal bone

Diffuse brain injury
suture Cerebral concussion
Nasal bone Diffuse axonal injury
Nasomaxillary
suture Focal brain injury
Bridge bone Epidural hematoma
Maxillary bone Subdural hematoma
Upper cartilage Cerebral contusion
Intracerebral hemorrhage
Septal cartilage Subarachnoid hemorrhage
Intraventricular hemorrhage
Apex (tip)
Skull fracture
Penetrating brain injury
Ala nasi Greater alar cartilage
Modified from Jordan BD: Brain injury in boxing. Clin Sports Med 28:561578,
External naris (nostril) 2009.
Philtrum
point of impact. Because of the lack of cushioning on

the trailing edge, greater injury is likely to occur to
the brain on the side opposite the impact. The brain
may also experience a shaking caused by repeated
Figure 2-8 The bony and cartilaginous structures of the nose.
reverberation within the brain after the head has been
struck. This type of injury often results in the signs
and symptoms of a concussion with the degree of the
head is accelerating before impact, which squeezes concussion depending on the severity of the injury
the cerebrospinal fluid away from the trailing edge (Table 2-4). Concussion severity is only determined
(the side away from the impact). The fluid moves after signs and symptoms have disappeared and any
toward the impact side, thereby thickening the cere- neurological and cognitive testing is normal.3 If the
brospinal fluid and offering a cushioning effect at the cervical spine is taken beyond its normal range of
Frontal sinus
Cribriform plate of ethmoid
Nasal bone
Sphenoid sinus
Septal cartilage
Turbinates (superior,
middle, and inferior)
Opening for External naris (nostril)

eustacian tube
Hard palate
Soft palate
Figure 2-9 Cross section of the nose and nasopharynx.
TABLE 2-3 concussion before? These questions are often difficult

for the patient to answer or the examiner to know,
Areas of the Brain and Their Function
because the patient may have been momentarily
Area of the Brain Function stunned and the time may have been so short that the
patient believed there was no loss of consciousness. In
Cerebrum Cognitive aspects of motor control
Memory other words, loss of consciousness may have been
Sensory awareness (e.g., pain, touch) only momentary or, more traditionally, it may have
Speech lasted seconds to minutes. If the examiner is working
Special senses (e.g., taste, vision) with a sports team, accurate records are essential to
Cerebellum Coordinate and integrate motor record the severity (see later discussion) and the
behavior number of concussions suffered by the athlete and to
Balance ensure that proper care is instituted so that the athlete
Motor learning is not allowed to return to competition too soon. A
Motor control (muscle contraction concussion (a subset of mild traumatic brain injury)
and force production)
is a pathophysiological process that affects the brain
Diencephalon Regulation of body temperature and
and is caused by direct or indirect biomechanical
(thalamus) water balance
Control of emotions forces. At present, there is no known threshold for a
Information processing to cerebrum consussion.58 Risk factors are shown in Table 2-5,9
Brain stem Control of respiratory and heart rates and stages of concussion are shown in Table 2-6.10
Peripheral blood flow control Signs and symptoms of concussions are shown in
Table 2-7.1113 Women appear to be more susceptible
to concussions than men,14 and traumatic brain injury
is different in children than adults.9,15,16 Concussions
motion, especially into rotation or side flexion, there can result from a blow to the head or jaw or a fall
may be a twisting of the cerebral hemisphere, brain on the buttocks from a height and can result in an
stem, carotid artery, or carotid sinus that can result inability to process information. Their effect is cumu-
in injury to these structures or ischemia to the brain. lative, and the risk of having another concussion fol-
Those areas of the brain that are most susceptible to lowing an initial concussion is four to six times greater
damage include the temporal lobes, anterior frontal than someone who has not had a concussion.12,17
lobe, posterior occipital lobe, and upper portion of Concussions can lead to continued and severe prob-
the midbrain.4 lems (e.g., post-concussion syndrome, second-impact
2. Did the patient lose consciousness? If so, how long was syndrome).10,12,1720 To be maximally effective,
the patient unconscious? Has the patient suffered a athletes should have done baseline tests in their
Point of Point of
maximum injury injury Impact
Direction
of head
Direction Direction
of head of head
Impact
IMPACT DECELERATION ROTATIONAL ACCELERATION

LINEAR ACCELERATION (Contracoupe injury) (Rotation and side flexion of head)
(Coupe injury)
Figure 2-10 Mechanisms of injury to the brain.
TABLE 2-4
Signs and Symptoms* of Concussion (Torg Classification)

Grade 1 Grade 2 Grade 3 Grade 4 Grade 5
Confusion None or Slight Moderate Severe Severe
momentary
Amnesia No Posttraumatic Posttraumatic Posttraumatic Posttraumatic
amnesia <30min amnesia <30min amnesia >30min amnesia >24 hours
Retrograde amnesia Retrograde amnesia Retrograde anmesia
Residual No Perhaps Sometimes Yes Yes
symptoms
Loss of No No No Yes (<5min) Yes (>5min)
consciousness
Tinnitus No Mild Moderate Severe Often severe
Dizziness No Mild Moderate Severe Usually severe
Headache No May be present Often Often Often
(dull)
Disorientation and None or Some Moderate Severe Often severe
unsteadiness minimal (5 to 10min) (>10min)
Blurred vision No No No Not usually Possible
Post-concussion No Possible Possible Possible Possible
syndrome
Personality No No No Possible Possible
changes
Data from Vegso JJ, Torg JS: Field evaluation and management of intracranial injuries. In Torg JS, editor: Athletic injuries to the head, neck and
face, St Louis, 1991, Mosby, pp. 226227.
*These signs and symptoms should only be used as a guide in acute situations.
pre-participation evaluation and have an extensive evaluation method for concussion by including mea-
concussion history taken covering somatic, neurobe- sures of orientation, immediate memory, concentra-
havioral, and cognitive symptoms (Table 2-8).3,12,2126 tion, delayed recall, and other parameters. Lovell and
In 2012, the International Conference on Concus- Burke have developed a similar form for ice hockey.29
sion in Sport updated a Sideline Concussion Assess- These tests are often combined with computerized
ment Tool3rd edition (SCAT3) (Figure 2-11) and neurocognitive testing to try to predict how long
added the Sport Concussion Assessment Tool recovery will take.30,31 Ideally, this neurocognitive
for children ages 5 to 12 years (Child-SCAT3)8 testing should be done individually at preseason
(Figure 2-12). Kelly and Rosenberg12,13 have devel- evaluations to establish a baseline and should be
oped a Standardized Assessment of Concussion updated every 2 years.32,33 If pre-injury values are
(SAC) (Figure 2-13),27,28 which provides a concise not available, normative data may be used.34 An
TABLE 2-5
Risk Factors That May Prolong or Complicate Recovery from Concussion

Factors Modifier
Symptoms Number of concussions
Duration of symptoms (>10 days)
Severity (intensity and duration)
Signs Prolonged loss of consciousness (>1min), amnesia (anterograde and/or retrograde)
Sequelae Concussive convulsions
Temporal Frequencyrepeated concussions over time
Timinginjuries close together in time
Recencyrecent concussion or traumatic brain injury
Threshold Repeated concussions occurring with progressively less impact force or slower recovery after each
successive concussion
Age Child and adolescent (<18-years-old) may recover slower
Co- and pre-morbidities Migraine
Depression or other mental health disorders
Attention deficit hyperactivity disorder
Learning disabilities
Sleep disorders
Medication Psychoactive drugs
Anticoagulants
Behavior Dangerous style of play
Sport High risk activity
Contact and collision sport
High sporting level
Modified from McCrory P, Meeuwisse W, Johnston K, etal: Consensus statement on concussion in sportThe 3rd International Conference on
Concussion in Sport held in Zurich, November 2008. Clin J Sport Med 19(3):189, 2009.
TABLE 2-6
Severity Stages of Concussive Injury

Post-Concussion Prolonged Post- Chronic Traumatic
Acute Concussion Syndrome Concussion Syndrome Encephalopathy
Physical (somatic) symptoms: Persistent concussion Symptoms lasting Latency period (usually
Headache, dizziness, hearing symptoms over 6 to 10 years)
loss, balance difficulty, sleep Usually lasting 1 to 6 6 months Personality disturbances
disturbances, nausea/vomiting, weeks after MTBI Lowered concussion Emotional lability
sensitivity to light or noise, Self-limiting threshold Marriage/personal
diminished athletic performance Diminished athletic relationship failures
Cognitive deficits: Loss of performance Depression
short-term memory (anterograde Diminished work or Alcohol/substance abuse
and/or retrograde), difficulty school performance Suicide attempt/
with focus or concentration, completion
confusion, loss of consciousness,
disorientation, inability to focus,
delayed verbal and/or motor
responses, excessive drowsiness,
decreased attention, diminished
work or school performance
Emotional (affective)
disturbances: Irritability, anger,
fear, mood swings, decreased
libido
Modified from Sedney CL, Orphanos J, Bailes JE: When to consider retiring an athlete after sports-related concussion. Clin Sports Med 30(1):189
200, 2011.
MTBI, Mild traumatic brain injury.
TABLE 2-7 example of such a computerized post-concussion

assessment is the ImPACT test; ImPACT stands for
Signs and Symptoms of Concussions
Immediate Post-Concussion Assessment and Cogni-
Acute Late (Delayed) tive Testing.31,32,3537
Lightheadedness Persistent low grade There are several different grading systems for
Delayed motor and/or headache concussions (Table 2-9). It should be pointed out,
verbal responses Easy fatiguability however, that the International Conference on Con-
Memory or cognitive Sleep irregularities cussion in Sport3 recommended that grade scales be
dysfunction Inability to perform abandoned, because concussion severity can only be
Disorientation daily activities determined retrospectively after all signs and symp-
Amnesia Depression/anxiety toms have cleared, the neurological examination is
Headache Lethargy normal, and cognitive function has returned to
Balance problems/ Memory dysfunction normal.38 The conference group felt concussions
incoordination Lightheadedness
should be grouped as simple or complex. Simple
Vertigo/dizziness Personality changes
concussion implies that the injury resolves over 7 to
Concentration difficulties Low frustration
Loss of consciousness tolerance/irritability 10 days without complications. Neurophysiological
Blurred vision Intolerance to bright screening does not play a role, but mental status
Vacant stare (befuddled lights, loud sounds screening is part of the assessment. Complex concus-
facial expression) sions are those in which persistent symptoms and
Photophobia specific sequelae (i.e., convulsions, loss of conscious-
Tinnitus ness for longer than 1 minute, prolonged cognitive
Nausea impairment) occur.3 This includes people with more
Vomiting than one concussion. In this case, neurophysiological
Increased emotionality testing does play a role.13,3942 Table 2-10 shows some
Slurred or incoherent speech
neurophysiological tests that could be used for post-
concussion assessment.
Grades of concussion, such as those advocated by
TABLE 2-8
Torg (see later discussion and Table 2-4), can play a
Concussion Symptoms role in the acute phase but should be used with
caution if making return to activity decisions.43 With
Somatic Neurobehavioral Cognitive
each grade, the signs and symptoms worsen, and the
Headache Sleeping Feeling slowed sequelae are more evident. No signs and symptoms
Nausea more or less down under exertion (i.e., simulating the activity the person
Vomiting than usual Feeling in a will return to) should be evident, even with simple
Balance Drowsiness fog concussions.
problems Fatigue Concentration
With a grade I concussion, the patient is slightly
Light/ Sadness difficulty
sound Nervousness Remembering
confused and may have a dazed look. The patient is
sensitivity Trouble difficulty completely lucid within 5 to 15 minutes; has no
Numbness/ falling asleep Confusion amnesia, sequelae, or residual symptoms; and has had
tingling Amnesia no loss of consciousness. Some people refer to the
Dizziness (anterograde grade I concussion as the patients having his or her
and/or bell rung.
retrograde) With a grade II concussion, there is slight confu-
Loss of sion, and posttraumatic amnesia becomes evident.
consciousness Posttraumatic (anterograde) amnesia is the loss of
Inability to focus memory for events occurring immediately after wak-
Delayed motor
ening or from the moment of injury. Posttraumatic
and verbal
responses
amnesia is considered to be the length of time from
Excessive injury until conscious memory returns. In the acute
drowsiness state, it may take time for posttraumatic amnesia to
become obvious. Sometimes, the patient will remem-
Data from Piland SG, Motl RW, Guskiewicz KM, etal: Structural valid- ber what happened immediately after the injury, but
ity of a self-report concussion-related symptoms scale, Med Sci Sports as time goes on (up to 1 to 2 hours after the injury),
Exerc 38(1):2732, 2006; Herring SA, Cantu RC, Guskiewicz KM, posttraumatic amnesia becomes evident. This is one
etal: Concussion (mild traumatic brain injury) and the team physician:
a consensus statement2011 update. Med Sci Sports Exerc 43(12): of the reasons it is advisable to reassess acute head
2414, 2011. Text continued on p. 102
Figure 2-11 Sport Concussion Assessment Tool3rd edition (SCAT3). ( 2013 Concussion in Sport Group. Br J Sports Med 47:259262,
2013.)
Figure 2-11, contd Continued
Figure 2-11, contd
Figure 2-11, contd
Figure 2-12 Sport Concussion Assessment Tool for children ages 5 to 12 years (Child-SCAT3). ( 2013 Concussion in Sport Group. Br J
Sports Med 47:263266, 2013.)
Figure 2-12, contd Continued
Figure 2-12, contd
z
n v
Figure 2-12, contd
Figure 2-13 Standardized Assessment of Concussion (SAC). (Redrawn from McCrea M, Kelly JP, Kluge J, etal: Standard assessment of concus-
sion in football players. Neurology 48[3]:586588, 1997.)
injuries every 15 to 30 minutes. Manzi and Weaver may experience mild tinnitus (ringing in the ears),
reported that a patient who had sustained a period mild dizziness, and a dull headache with some disori-
of posttraumatic amnesia of less than 60 minutes was entation. Dizziness at the time of injury has been
considered to have sustained a mild head injury.44 If reported to be a sign of risk for protracted recovery.45
the period of posttraumatic amnesia lasted from 1 to The patient who experienced a grade II concussion
24 hours, moderate head injury was considered to may also develop a post-concussion syndrome (i.e.,
have occurred. If the posttraumatic amnesia lasted have continual neurological problems after the con-
for more than 1 week, the patient was considered to cussion), which is observed in about 10% of concus-
have sustained a serious head injury. If the duration sion cases. The signs and symptoms of this syndrome
of the posttraumatic amnesia was more than 7 days, include persistent headaches, especially with exertion;
full return to neurological function was highly inability to concentrate; and irritability. The symp-
unlikely.44 With a grade II concussion, the patient toms may last from several weeks to several years.
TABLE 2-9
Classification Systems for Concussions

System Grade I (Mild) Grade Ia Grade II (Moderate) Grade III (Severe) Grade IV
Cantu No LOC or PTA < N/A LOC < 5min, PTA LOC > 5min, PTA N/A
30min 30min to 24hrs > 24hrs
Torg (Grade I to II) No (Grade IIIIV) (Grade VVI)
LOC or amnesia LOC < few LOC/coma,
(except PTA) minutes, PTA confusion,
or retrograde amnesia
amnesia
Colorado Confusion without N/A Confusion and LOC N/A
Consortium amnesia, no LOC amnesia, no LOC
Virginia Short LOC, Short LOC, PTA LOC < 5min, PTA LOC < 5min, PTA LOC 5 to 60min,
Neurological PTA < 1hr, GCS 1 to 24hrs, 24h, GCS score N/A, GCS score PTA N/A,
Institute score = 15 GCS score > 15 for < 5min < 15 for < 1hr GCS score < 12
= 15 for > 5min or
< 15 for > 1hr
American No LOC, N/A No LOC, Any LOC N/A
Academy of Symptoms < 15min Symptoms > 15min
Neurology
From Durand P, Adamson GJ: On-the-field management of athletic head injuries, J Am Acad Orthop Surg 12:194, 2004. Adapted with permission
from Macciocchi SN, Barth JT, Littlefield LM: Outcome after mild head injury. Clin Sports Med 17:2736, 1998.
GCS, Glasgow Coma Scale; LOC, loss of consciousness; PTA, posttraumatic amnesia.
TABLE 2-10
Examples of Neurophysiological Tests

Test Ability Evaluated
Continuous Performance Test Sustained attention, reaction time
Controlled Oral Word Association Test Word fluency, word retrieval
Delayed Recall (from Hopkins Verbal Learning Test) Delayed learning from previously learned word list
Digit Span (from Wechsler Memory Scalerevised) Attention span
Grooved-Pegboard Test Motor speed and coordination
Hopkins Verbal Learning Test Verbal memory (memory for words)
Immediate Measurement of Performance and Attention span, sustained and selective attention,
Cognitive Testing (IMPACT) reaction time, memory
Number/Symbol Matching Processing speed, visual motor speed
Orientation Questionnaire Orientation, post traumatic amnesia
Sequential Digit Tracking Sustained attention, reaction time
Stroop Test Mental flexibility, attention
Symbol Digit Modalities Visual scanning, attention
Symbol Memory Immediate visual memory
Trail-Making Test Visual scanning, mental flexibility
Verbal Working Memory Word memory, working memory
Visual Span Visual attention, immediate memory
Visual Symbol Search Visual scanning, reaction time
Word/Colour Tracking Focused attention, response inhibition
Data from Maroon JC, Lovell MR, Norwig J, etal: Cerebral concussion in athletes: evaluation and neurophysiological testing. Neurosurg 47:659
672, 2000.
Hopkins Verbal Learning Test,48 Trail Making Test,

Head Injury Severity Based on Length Wisconsin Card Sorting Test, Digit Symbol Substitu-
of Posttraumatic Amnesia tion Test [DSST],49 and measures of decision time49)
as well as considering all signs and symptoms the
Less than 60 minutes: Mild
patient demonstrates.6,8,15,5053 To ensure adequate
1 to 24 hours: Moderate
data, however, these tests must also have been admin-
More than 1 week: Serious (full return of neurological
function unlikely) istered before the injury (e.g., in a pre-participation
evaluation in sports).6,35
A patient with a grade III concussion has the

same symptoms as someone with a grade II concus-
Levels of Consciousness
sion and also experiences retrograde amnesia. Retro-
grade amnesia is loss of memory of events that Alertness Is readily aroused, oriented, and fully aware of
occurred before the injury. It may take 5 to 10 surroundings
minutes for retrograde amnesia to develop after the
Confusion Memory is impaired
concussion, and amnesia may involve only a few
Is confused and disoriented
minutes before the injury. For this reason, the patient
should be questioned frequently about what hap- Lethargy Sleeps when not stimulated
pened before the injury occurred and how it occurred, Is drowsy and inattentive
to see if there is any change in the patients memory Responds to name
Loses train of thought
pattern. There is always some degree of permanent
Shows decreased spontaneous movement
retrograde amnesia with these patients.
Has slow and fuzzy thinking
With a grade IV concussion, the patient loses
consciousness for 5 minutes or less. The level of Obtundity Responds to loud voice or shaking
consciousness may vary; the patient may be coma- Responds to painful stimulus (withdrawal)
tose, stuporous, obtunded, lethargic, confused, or Is confused when aroused
Talks in monosyllables
fully alert. The patient goes through the following
Mumbles and is incoherent
stages of recovery: unconsciousness (also called para- Needs constant stimulation to cooperate
lytic coma), stupor, obtundity, lethargy, confusion
(with or without delirium), near lucidity with autom- Stupor Responds to painful stimuli (withdrawal), shaking
atism, and finally full alertness. Stupor implies that (semicoma) Groans, mumbles
Exhibits reflex activity
the patient is only partially conscious and has reduced
responsiveness. Obtundity implies the patient has Coma Does not respond to painful or any other stimuli
reduced sensitivity to painful or unpleasant stimuli.
Lethargy implies a state of sluggishness, dullness,
or serious drowsiness. Confusion implies that the With a grade V concussion, the patient has expe-
patient is disoriented in terms of time, place, or rienced a paralytic coma or unconsciousness for 5
person. Delirium means that the patient may experi- minutes or longer. This grade of concussion involves
ence illusions, hallucinations, restlessness, or incoher- bruising of the brain, and there is prolonged retro-
ence. Lucidity with automatism implies that the grade amnesia as well as posttraumatic amnesia. The
patient appears to be alert and fully recovered but patient complains of severe tinnitus, unsteadiness for
acts only mechanically and is not really aware of what longer than 10 minutes, blurred vision, poor light
he or she is doing. With a grade IV concussion, there accommodation, and a headache that feels differ-
may be subtle changes in the patients personality and ent from most headaches. Both the autonomic
memory function. Both retrograde and posttraumatic and the peripheral nervous systems can be affected
amnesia are evident, and the patient demonstrates through their control by the brain. These patients
mental confusion and complains of tinnitus and diz- may also experience nausea, vomiting, and sometimes
ziness to a greater degree than is seen with a grade convulsions. The recovery after a grade V concussion
III concussion. The patient also has residual head- may be one of two types. In type A, the patient goes
aches and is unsteady for 5 to 10 minutes after from a paralytic coma through stupor, confusion,
regaining consciousness. The literature has reported lucidity, and full alertness, which is similar to a grade
that loss of consciousness, by itself, is not a good IV concussion but more severe. The individual with
predictor of the degree of neurophysiological loss or a type B grade V concussion experiences a paralytic
damage with a head injury.46 The severity of the head coma that is associated with secondary cardiorespira-
injury is best determined by the administration of tory collapse and is of much greater concern to the
different neurophysiological tests (e.g., GOAT test,47 examiner, especially during the initial assessment,
when the bodys essential functions must be TABLE 2-11

maintained.
Type of Headache Pain and Usual Causes
More severe diffuse brain injuries are associated
with more severe neurological dysfunction. With Type of Pain Usual Causes
these injuries, loss of consciousness lasts for more Acute Trauma, acute infection,
than 24 hours, and recovery is never complete, impending cerebrovascular
leading to deficits in intelligence, reasoning, and accident, subarachnoid
memory and to changes in personality. Shearing hemorrhage
brain injuries tend to be more severe than diffuse Chronic, recurrent Migraine (definite pattern of
brain injuries and lead to abnormal brain stem signs, irregular interval); eyestrain;
such as decerebrate rigidity.43 noise; excessive eating,
3. If the patient has had an injury to the head, are there drinking, or smoking;
any associated symptoms in the neck or problems with inadequate ventilation
Continuous, recurrent Trauma
breathing, altered vision, discharge from the nose or
Severe, intense Meningitis, aneurysm
ears, or urinary or fecal incontinence? These symp-
(ruptured), migraine, brain
toms indicate severe brain or spinal cord injury, and tumor
the patient must be handled with extreme care. Intense, transient, Neuralgia
4. What are the sites and boundaries of pain? This ques- shocklike
tion helps the examiner determine what structures Throbbing, pulsating Migraine, fever, hypertension,
have been injured. It is important to keep in mind (vascular) aortic insufficiency, neuralgia
that the patient may be experiencing a referral of Constant, tight Muscle contraction
pain. (bandlike), bilateral
5. What type of pain is the patient experiencing? The type
of pain indicates the type of structure injured (see
Table 1-3). TABLE 2-12
6. Is there any paresthesia, abnormal sensation, or lack
of sensation? Are smell (cranial nerve I), vision Location of Headache and Usual Causes
(cranial nerve II), taste (cranial nerve VII), and Location Usual Causes
hearing (cranial nerve VIII) normal? These questions
Forehead Sinusitis, eye or nose disorder, muscle
give the examiner some idea of whether neurological
spasm of occipital or suboccipital region
structures (especially the cranial nerves) have been Side of head Migraine, eye or ear disorder,
injured and, if so, which ones. auriculotemporal neuralgia
Occipital Myofascial problems, herniated disc,
eyestrain, hypertension, occipital
Head Signs and Symptoms Requiring neuralgia
Specialist Care Parietal Hysteria (viselike), meningitis,
constipation, tumor
Presence of amnesia Face Maxillary sinusitis, trigeminal neuralgia,
Prolonged residual symptoms dental problems, tumor
Loss of consciousness
Prolonged headache
Post-concussion syndrome constant-pressure type of headache? Is the pain of the
Personality changes headache aggravated by movement or by rest? What
More than one first- or second-degree concussion
is the exact location of the headache? Is the headache
Prolonged disorientation, unsteadiness, or confusion (more than 2
affected by position or time of day (Table 2-13)?
to 3 minutes)
Blurred vision Does it cover the entire head, the sinus region, or
Dizziness (more than 5 minutes) behind the eyes? Does it present a hat band distri-
Tinnitus (more than 5 minutes) bution, or does it affect the neck or the occiput area?
It is important for the examiner to record the loca-
tion, character, duration, and frequency of the head-
7. What activities aggravate the particular problem? ache, as well as any factors that appear to either
8. What activities ease the particular problem? aggravate or relieve the pain so that a diagnosis can
9. Does the patient have a headache, and, if so, be made and any changes can be noted (Table 2-14).
where (Tables 2-11 and 2-12)? Is the headache Figure 2-14 shows a headache disability question-
tolerable? What type of headache is it? Is it a throb- naire that may be used to determine the severity of
bing, pounding, boring, shocklike, dull, nagging, or headache and its effect on everyday activity.54
TABLE 2-13 patients static memory ability. The examiner must

ensure that he or she or someone present at the time
Effect of Position or Time of Day on Headache
of the examination knows the answer to these ques-
Position or Time of Day tions. Although it is common to ask these orientation
When Headache Is Worst Usual Causes questions (e.g., time, place), it has been shown that
Morning Sinusitis, migraine, hypertension, these questions can be unreliable in sporting situa-
alcoholism, sleeping position tions when compared with memory assessment.55,56
Afternoon Eyestrain, muscle tension The examiner can assess recent memory by asking
Night Intracranial disease, the patient to remember the names for two to five
osteomyelitis, nephritis persons or common objects, such as the color red,
Bending Sinusitis the number five, the name Mr. Smith, and the
Lying horizontal Migraine word pride, and then asking the patient to name
them 5 or 10 minutes later. The patient may be asked
to repeat the words two or three times when the
examiner initially says them to test immediate recall
10. Is the patient dizzy, unsteady, or having problems with or to ensure that the patient can say and recall the
balance? The examiner should also note whether the words. Immediate recall, another form of memory,
dizziness occurs when the patient suddenly stands up, is best tested by asking the patient to repeat a series
turns, or bends, or whether it occurs without move- of single digits. Normally, a person can repeat at least
ment. Remember that dizziness is a word that six digits, and many people can repeat eight or nine.
patients sometimes use to indicate unsteadiness in The examiner may also ask the patient to repeat the
walking. Dizziness is usually associated with prob- months of the year backward in a similar type of test.
lems of the middle ear, vertebrobasilar insufficiency, Memory is generally thought to be formed and stored
or problems in the upper cervical spine. Vertigo in certain regions of the temporal lobes. The parietal
implies a rotary component; the patients environ- lobe of the brain is thought to enable one to appreci-
ment seems to whirl around the patient, or the ate the environment, to interpret visual stimuli, and
patients body seems to rotate in relation to the envi- to communicate.
ronment. If the patient complains of dizziness or
vertigo, the time of onset and duration of these
attacks should be noted. A description of the type of
motion that occurs and any other associated symp- Common Head Injury Tests
toms should be included. Balance may be affected by
Static memory (What day is it? Whos winning?)
problems within the brain or the semicircular canals
Immediate recall (repeat series of single digits)
in the inner ear. The examiner should also note Recent memory (recall three common objects or names after
whether the patient is talking about unsteadiness, loss 15 minutes)
of balance, or actual falling. Short term memory (What is the game plan?)
11. Is the patient unduly irritated or having trouble con- Processing and concentration ability (minus-7 test, multiplying)
centrating? The patients state indicates the severity Abstract relationships
of the injury. Coordination (eye-hand tests)
12. Does the patient know where he or she is, who he or she Balance (Romberg test)
is, the day, and the time of day? Does the patient have Myotomes
some idea of what was happening when the injury Eye coordination
occurred? These types of questions reveal the severity Visual disturbance tests
of the injury.
13. Does the patient have any memory of past events or
what occurred before or after the injury? This type 14. Can the patient solve simple problems? Because con-
of question tests for retrograde amnesia, posttrau- cussions reduce ones ability to process information,
matic amnesia, and injury severity, which can be it is important to determine the patients reasoning
determined by asking the patient straightforward and processing ability. For example, does the
questions about events in the patients own past, such patient know his or her home telephone number? Is
as birth date or year of graduation from high school the patient able to do the minus 7 or serial 7
or university. The examiner may also ask questions test (i.e., count backward from 100 by sevens)? This
about the injury, preceding events, and posttraumatic test gives the examiner some idea of the patients
events. Questions such as What day is it? Who calculating ability and concentration skills. Mathe-
is the opposition? Who is winning? and What matic ability (the ability to add, subtract, multiply,
is your telephone number and address? test the and divide) can also be evaluated to test processing
TABLE 2-14
Headaches: A Differential Diagnosis

Sex/Age Prodromal Precipitating Familial Other Possible
Disorder Predominance Nature of Pain Frequency Location Duration Events Factors Cause Predisposition Symptoms
Migraine Female/20 to Builds to Usually not Usually Several Visual Unknown, Vasomotor Yes Nausea,
40 years throbbing more than unilateral hours to disturbances may be vomiting,
and intense twice a week; days can occur physical, pallor,
may be contralateral emotional, photophobia,
noctural to pain site hormonal, mood
dietary disturbances,
fluid
retention
Cluster Male/40 to Excruciating, 1 to 4 episodes Unilateral, Minutes to Sleep Unknown, Vasomotor Minor Ipsilateral
(histamine) 60 years stabbing, per 24 hours; eye, hours disturbances may be sweating
headache burning, nocturnal temple, or serotonin, of face,
pulsating manifestation forehead personality histamine, lacrimation,
changes can hormonal nasal
occur blood flow congestion
or discharge
Hypertension None Dull, Variable Entire Variable None Activity that High blood Only as
headache throbbing, cranium, increases pressure; related to
nonlocalized especially blood diastolic hypertension
occipital pressure >120mm Hg
region
Trigeminal Female/40 to Excruciating, Can occur Unilateral 30 seconds Disagreeable Touch (cold) Neurological None Reddened
neuralgia (tic 60 years spontaneous, many (12 or along to 1 tingling to affected conjunctiva,
douloureux) lancinating, more) times trigeminal minute area lacrimation
lightning per day nerve area
Glossopharyngeal Male/40 to Excruciating, Can occur Unilateral 30 seconds None Movement Neurological None
neuralgia 60 years spontaneous, many (12 or retrolingual to 1 or contact
lancinating, more) times area to ear minute of the
lightning per day pharynx
Cervical None Dull pain or Bilateral, Variable None Posture Neurological, None Dizziness,
neuralgia pressure in occipital, or head pressure on auditory
head frontal, or movement roots of spinal disturbances
facial nerves
Eye disorders None Generalized Intensify with Entire During None Impairment Cornea, iris, or Possible Diminished
discomfort sustained cranium and after of eye intraocular vision,
in or around visual effort visual function pain sensitivity to
the eyes effort light
Sinus, ear, and None Dull, persistent Variable Frontal, Variable None Infection, Blockage, None
Chapter 2 Head and Face
nasal disorders temporal, allergy, inflammation,

ear, nose, chemical, infection
occipital bending,
straining
107
Modified from Esposito CJ, Grim GA, Binkley TK: Headaches: a differential diagnosis. J Craniomand Pract 4:320321, 1986.
HEADACHE DISABILITY QUESTIONNAIRE
Name: ........................................ Date: ....................................

/ / Score / 90
Please read each question and circle the response that best applies to you.
1. How would you rate the usual pain of your headache on a scale from 0 to 10?
0 1 2 3 4 5 6 7 8 9 10 WORST
NO PAIN
PAIN
2. When you have headaches, how often is in the pain severe?
NEVER 19% 1019% 2029% 3039% 4049% 5059% 6069% 7079% 8089%90100% ALWAYS
0 1 2 3 4 5 6 7 8 9 10
3. On how many days in the last month did you actually lie down for an hour or more because
of your headaches?
NONE 13 46 79 1012 1315 1618 1921 2224 2527 2831 EVERY DAY
0 1 2 3 4 5 6 7 8 9 10
4. When you have a headache, how often do you miss work or school for all or part of the day?
NEVER 19% 1019% 2029% 3039% 4049% 5059% 6069% 7079% 8089% 90100% ALWAYS
0 1 2 3 4 5 6 7 8 9 10
5. When you have a headache while you work (or school), how much is your ability to work reduced?
NOT 19% 1019% 2029% 3039% 4049% 5059% 6069% 7079% 8089% 90100% UNABLE
0 1 2 3 4 5 6 7 8 9 10 TO WORK
REDUCED
6. How many days in the last month have you been kept from performing housework or chores
for at least half of the day because of your headaches?
NONE 13 46 79 1012 1315 1618 1921 2224 2527 2831 EVERY DAY
0 1 2 3 4 5 6 7 8 9 10
7. When you have a headache, how much is your ability to perform housework or chores reduced?
NOT 19% 1019% 2029% 3039% 4049% 5059% 6069% 7079% 8089% 90100% UNABLE
0 1 2 3 4 5 6 7 8 9 10 TO PERFORM
REDUCED
8. How many days in the last month have you been kept from non-work activities (family, social
or recreational) because of your headaches?
NONE 13 46 79 1012 1315 1618 1921 2224 2527 2831 EVERY DAY
0 1 2 3 4 5 6 7 8 9 10
9. When you have a headache, how much is your ability to engage in non-work activities (family,
social or recreational) reduced?
NOT 19% 1019% 2029% 3039% 4049% 5059% 6069% 7079% 8089% 90100% UNABLE
0 1 2 3 4 5 6 7 8 9 10 TO PERFORM
REDUCED
Figure 2-14 Headache Disability Questionnaire. (From Niere K, Quin A: Development of a headache-specific disability questionnaire for patients
attending physiotherapy. Man Ther 14:4551, 2009.)
ability. In addition, the examiner can ask the patient TABLE 2-15
to name several important people from the present
Common Visual Eye Symptoms and Disease States
in reverse chronological order (e.g., the last three
presidents of the United States) or to give the names Visual Symptom Associated Causes
of some familiar capital cities. Finally, the patient Loss of vision Optic neuritis
should be tested on his or her ability to comprehend Detached retina
abstract relations. For example, the examiner may Retinal hemorrhage
quote a common proverb, such as A bird in the Central retinal vascular
hand is worth two in the bush, and then ask the occlusion
patient to explain what the expression means. Patients Spots No pathological significance*
with organic mental impairment and certain patients Flashes Migraine
with schizophrenia may give a concrete answer, Retinal detachment
failing to recognize the abstract principle involved.44 Posterior vitreous detachment
Loss of visual field or Retinal detachment
The ability to conceptualize, abstract, plan ahead,
presence of shadows Retinal hemorrhage
and formulate rational judgments of problems or
or curtains
events is largely a function of the frontal lobes. Glare, photophobia Iritis (inflammation of the iris)
15. Can the patient talk normally? Patients with lesions Meningitis (inflammation of
of the parietal lobe have difficulty communicating the meninges)
and understanding what is occurring around them. Distortion of vision Retinal detachment
Dysarthria indicates defects in articulation, enuncia- Macular edema
tion, or rhythm of speech. It usually results from Difficulty seeing in dim Myopia
extraneural problems, such as poor-fitting dentures, light Vitamin A deficiency
malformation of the oral structures, or impairment of Retinal degeneration
the musculature of the tongue, palate, pharynx, or Colored haloes around Acute narrow angle glaucoma
lips because of incoordination, weakness, or abnor- lights Opacities in lens or cornea
Colored vision changes Cataracts
mal innervation. It is characterized by slurring, slow-
Drugs (digitalis increases
ness of speech, indistinct speech, and breaks in normal yellow vision)
speech rhythm. Dysphonia is a disorder of vocaliza- Double vision Extraocular muscle paresis or
tion characterized by the abnormal production of paralysis
sounds from the larynx. Dysphonia is usually caused
by various abnormalities of the larynx itself or of its From Swartz MH: Textbook of physical diagnosis, Philadelphia, 1989,
innervation. The principal complaint of dysphonia is WB Saunders, p. 132.
hoarseness, ranging from mild roughness of the voice *May precede a retinal detachment or be associated with fertility drugs.
to an inability to produce sound. Dysphasia denotes
the inability to use and understand written and
spoken words as a result of disorders involving corti- something is affecting the free movement of the eyes
cal centers of speech or their interconnections in (Tables 2-15 and 2-16).
the dominant cerebral hemisphere. With all of these 18. Does the patient wear glasses or contact lenses? If the
conditions, the peripheral mechanisms for speech patient wears glasses, are the lenses treated (hard-
remain intact. ened) or made of polycarbonate? If they are hard-
16. Does the patient have any allergies, or is the patient ened, how long ago were they treated? If the patient
receiving any medication? Allergies may affect the wears contact lenses, are they hard, soft, or extended-
eyes and nose, as may medications. Medications wear lenses? Did the patient wear eye protectors? If
themselves may mask some symptoms. so, what type were they? Are the patients eyes water-
17. Is the patient having any problems with the eyes? Mon- ing? Is there any pain in the eyes? Small perforating
ocular diplopia (blurred vision when looking with injuries may be painless. If the patient complains of
one eye) may result from hyphema, a detached lens, flashes of bright light, a curtain falling in front of
or other trauma to the globe of the eye.57 Binocular the eye, or floating black specks, these findings may
diplopia (blurred vision when looking through both indicate retinal detachment. These questions tell the
eyes) occurs in 10% to 40% of patients with a zygoma examiner whether the eyewear or eyes need to be
fracture. It may be caused by soft-tissue entrapment, examined in greater detail.
neuromuscular injury (intraorbital or intramuscular), 19. Is the patient having any problem with hearing? Does
hemorrhage, or edema. It disappears when one eye the patient complain of an earache? If so, when was
is closed. Double vision, which occurs when the good the onset, and what is the duration of the earache?
eye is closed, indicates that some structure of the Does the patient complain of pain or a discharge
eye is injured. If it occurs with both eyes open, from the ear? Is the earache associated with an upper
TABLE 2-16 much, how often, and for how long? Does the patient
have any nasal discharge, and if so, is its character
Common Nonvisual Eye Symptoms and Disease States
watery, mucoid, purulent, crusty, or bloody? Does
Nonvisual Symptom Associated Causes the discharge have any odor (indicative of infection),
Itching Dry eyes and is it unilateral or bilateral? Does the patient
Eye fatigue exhibit any associated nasal symptoms, such as sneez-
Allergies ing, nasal congestion, itching, or mouth breathing?
Tearing Emotional states Does the patient complain of a nosebleed, and has
Hypersecretion of tears the patient had many nosebleeds? If so, how frequent
Blockage of drainage are the nosebleeds, what is the amount of the bleed-
Dryness Sjgren syndrome ing, and what appears to be causing the bleeding?
Decreased secretion as a result Positive responses to any of these questions indicate
of aging that the nose must be examined in greater detail.
Sandiness, grittiness Conjunctivitis
21. If the examiner is concerned about the mouth and
Fullness of eyes Proptosis (bulging of the
teeth or the temporomandibular joints, questions
eyeball)
Aging changes in the lids related to these areas can be found in Chapter 4. It
Twitching Fibrillation of orbicularis oculi is important, however, to ensure that the patients
Eyelid heaviness Fatigue dental occlusion and biting alignment have not been
Lid edema altered. Are all the teeth present, and are they sym-
Dizziness Refractive error metrical? Is there any swelling or bleeding around the
Cerebellar disease teeth? Are the teeth mobile, or is part of a tooth
Blinking Local irritation missing? Is the pulp exposed? Each of these questions
Facial tic helps determine whether the teeth have been injured.
Lids sticking together Inflammatory disease of lids or Teeth that have been avulsed, if intact, should be
conjunctivae reimplanted as quickly as possible. If reimplanted
Foreign body sensation Foreign body
after cleansing (rinsed in saline solution or water)
Corneal abrasion
within less than 30 minutes, the tooth has a 90%
Burning Uncorrected refractive error
Conjunctivitis chance of being retained. If it is not possible to reim-
Sjgren syndrome plant the tooth, it should be kept moist in saline, or
Throbbing, aching Acute iritis (inflammation of the patient should keep it between the gum and
the iris) cheek while dental care is sought.
Sinusitis (inflammation of the 22. Questions concerning the neck and cervical spine can
sinuses) be found in Chapter 3.
Tenderness Lid inflammations
Conjunctivitis
Iritis OBSERVATION
Headache Refractive errors
For proper observation5861 of the head and face, any hat,
Migraine
helmet, mouth guard, or face guard should be removed.
Sinusitis
Drawing sensation Uncorrected refractive errors If a neck injury is suspected or if the patient presents an
emergency situation, the examiner may take the time to
From Swartz MH: Textbook of physical diagnosis, Philadelphia, 1989,
remove only those items that are interfering with immedi-
WB Saunders, p. 133. ate emergency care. If a neck injury is suspected, extreme
caution should be observed when removing the item.
When assessing the head and face, the examiner must also
observe and assess the posture of the cervical spine and
respiratory tract infection, swimming, or trauma? The the temporomandibular joints; see Chapters 3 and 4 for
patient should also be questioned on his or her detailed descriptions of observation of these areas.
method of cleaning the ear. If there appears to be a When observing the head and face, it is essential that
hearing loss, the patient should be asked whether the the examiner look at the face to note the position and
hearing loss came on quickly or slowly, whether the shape of the eyes, nose, mouth, teeth, and ears and look
patient hears best on the telephone (amplified sound) for deformity, asymmetry, facial imbalance, swelling, lac-
or in a quiet or noisy environment, and whether erations, foreign bodies, or bleeding during rest, with
speech is heard soft or loud. Does the patient use a movement, or with different facial expressions.62 One
hearing aid? should also note, as much as possible, the individuals
20. Is the patient having any problems with the nose? Has normal facial expression. A patients facial expression
the patient used nose drops or spray? If so, how often reflects the patients general feeling and well-being.
A dazed or vacant look often indicates problems. While tissues (such as, the eyelids, eyebrows, cheeks, lips, nose,
talking to the patient, the examiner should watch for any and chin) should be inspected for lacerations, bruising,
asymmetry of facial motion or change in facial expression or hematoma (Figures 2-16 and 2-17). The eyes should
when the patient answers; slight facial asymmetry is be level. For example, a zygoma fracture causes the eye
common. In addition, small degrees of paralysis may not on the affected side to drop (Figure 2-18). The two eyes
be obvious unless one attempts an exaggerated expres- should be compared for prominence or retraction (Figure
sion. If some facial paralysis is suspected, the examiner 2-19). If there appears to be any bulging, especially uni-
should ask the patient to make exaggerated facial expres- laterally, the examiner should tilt the patients head
sions that will demonstrate the paralysis. If facial asym- forward or back and, looking from above, compare each
metry is present, one should note whether all of the cornea with the lid below, noting whether one or both
features on one side of the face are affected or only a corneas bulge beyond the lid margins. If one or both eyes
portion of the face is affected. For example, with facial appear to bulge, the examiner can use a pocket ruler to
nerve (cranial nerve VII) paralysis, the entire side of the roughly measure the distance from the angle of the eye
face is affected, although the most noticeable differences to the corneal apex.
will occur around one eye and one side of the mouth. If Immediate referral for further examination by a spe-
only one side of the mouth is involved, then a problem cialist is required for an embedded corneal foreign body;
with the trigeminal nerve (cranial nerve V) should haze or blood in the anterior chamber (hyphema);
be suspected. Any changes in the shape of the face or decreased or partial vision; irregular, asymmetric, or poor
unusual features (such as, masses, edema, puffiness, pupil action; diplopia or double vision; laceration of the
coarseness, prominent eyes, amount of facial hair, exces- eyelid or impaired lid function; perforation or laceration
sive perspiration, or skin color) should be noted. Eye of the globe; broken contact lens or shattered eyeglass in
puffiness is often one of the earliest signs of edema in the the eye; unexplained eye pain that is stabbing or deep and
face. Skin color may include cyanosis, pallor, jaundice, or throbbing; blurred vision that does not clear with blink-
pigmentation, and each may be indicative of different ing; loss of all or part of the visual field; protrusion of one
systemic problems. eye relative to the other; an injured eye that does not
The examiner should view the patient from the front, move as fully as the uninjured eye; or abnormal pupil size
side, behind, and above, noting the area behind the ears, or shape. A teardrop pupil usually indicates iris entrap-
at the hairline, and around the crown of the head as well ment in a corneal or scleral laceration. In addition, the
as on the face (Figure 2-15). An examiner who suspects eyes should be observed from the lateral aspect. The
a skull (cranial vault) injury should look behind the ears, normal distance from the cornea to the angle of the eye
at the hairline, and around the crown of the head for any is 16mm or less. The distances between the upper and
deformity, bruising, or laceration. lower lids should be the same for both eyes. When the
Viewing from the front, the examiner should observe eyes open, the superior eyelid should cover a portion of
the patients hairline, noting any abnormalities. The soft the iris but not the pupil itself. If it covers more of the
A B C
Figure 2-15 Views of the head and face. A, Anterior. B, Side. C, Posterior.
Figure 2-16 Lacerations to the upper eyelid and eyebrow.
Figure 2-19 A severe glancing or direct blow to this right eye has
resulted in a ruptured globe. Note the depressed eye. (From Pashby TJ,
Pashby RC: Treatment of sports eye injuries. In Schneider RC, etal,
editors: Sports injuries: mechanisms, prevention and treatment, Balti-
more, 1985, Lippincott Williams & Wilkins p. 589.)
Figure 2-17 Contusion to the forehead caused by a racquetball ball. Figure 2-20 Black eye (periorbital ecchymosis).
iris than the other upper eyelid does or if it extends over

the iris or pupil, ptosis or drooping of that eyelid should
be suspected. If the eyelid does not cover part of the iris,
retraction of the eyelid should be suspected. Are the
eyelids everted or inverted? Normally, they are neither.
1 The examiner should also note whether the patient can
close both eyes completely. If an eye injury is suspected,
this action should be done carefully, because closing the
2 eyes can increase intraocular pressure. The lids should be
1 pressed together only enough to bring the eyelashes
together. Any inflammation or masses, especially on the
lid margin, should be noted. If present, a black eye, or
periorbital contusion, should also be noted (Figure 2-20).
The lashes should be viewed to see if there is even distri-
Figure 2-18 Inferior displacement of the zygoma (1) results in depres- bution along the lid margins. Raccoon eyes, which are
sion of the lateral canthus and pupil (2) because of depression of the
purple discolorations of the eyelids and orbital regions,
suspensory ligaments that attach to the lateral orbital, Whitnall tubercle.
(Modified from Ellis E: Fractures of the zygomatic complex and arch. may indicate orbital fractures, basilar skull fractures, or a
In Fonseca RJ, Walker RV, editors: Oral and maxillofacial trauma, fracture of the base of the anterior cranial fossa.58 This
Philadelphia, 1991, WB Saunders, p. 446.) sign takes several hours to develop.
A B
Figure 2-21 A, Posttraumatic conjunctival hemorrhage without

other ocular or orbital damage. B, Posttraumatic conjunctival hem-
orrhage from blunt injury with a small hyphema (arrow). In this
case, the injury was significant because of the presence of blood in
the anterior chamber. C, Subconjunctival ecchymosis with no lateral
limit should suggest osseous orbital fractures. (A and B, From Paton
D, Goldberg MF: Management of ocular injuries, Philadelphia,
1976, WB Saunders, p. 182. C, From Lew D, Sinn DP: Diagnosis
and treatment of midface fractures. In Fonseca RJ, Walker RV,
editors: Oral and maxillofacial trauma, Philadelphia, 1991, WB
C
Saunders, p. 250.)
of the lower lid may be examined by having the patient

Eye Signs and Symptoms Requiring look upward while the examiner draws the lower lid
Specialist Care downward. The conjunctiva should be examined as being
a continuous sheet of epithelium from the globe to the
Foreign body that is not easily removed lids. The color of the sclera should also be noted. Post-
Eye does not move properly
traumatic conjunctival hemorrhage (Figure 2-21) and
Altered pupil action
Abnormal pupil size or shape
possible scleral lacerations (Figure 2-22) should be noted,
Double vision if present. In dark-skinned patients, pigmented areas may
Blurred vision show up as small dark spots or patches near the limbus.
Decreased or partial vision The shape and color of the cornea should be inspected.
Loss of part or all of visual field The anterior chambers of the eye should be inspected and
Laceration of eye or eyelid compared for clarity and depth.63 If present, hyphema in
Blood between cornea and iris (hyphema) the form of haze or actual blood pooling (Figure 2-23)
Impaired eyelid function in the anterior eye chamber should be noted.57 If there is
Penetration of eye or eyelid any potential for or evidence of bleeding in the anterior
Eye pain chamber of the eye, the patients activity should be cur-
Sharp or throbbing eye pain
tailed, because increased activity increases the chances of
Protrusion or retraction of eye
secondary hemorrhage during the first week after injury.
Examination of the cornea with a penlight shone obliquely
on the eye should be carried out to look for foreign
bodies, abrasions, or lacerations. Corneal injuries can lead
The conjunctiva should be inspected for hemorrhage, to lacrimation (tearing), photophobia (intolerance to
laceration, and foreign bodies.62 If the patient complains light), or blepharospasm (spasm of the eyelid orbicular
of something in the eye, eversion of the upper eyelid muscle) as well as extreme pain from exposure of sensory
usually reveals a foreign body that can often be easily nerve endings. A fluorescein strip dipped into tears that
brushed away. Displaced contact lenses are often found are exposed as the lower lid is pulled downward will
in this upper area of the eye. The conjunctival covering readily outline abrasions.
The nose should be inspected for any deviations in

shape, size, or color.62 The skin should be smooth without
swelling and should conform to the color of the face. The
airways are usually oval and symmetrically proportioned.
If a discharge is present, its character (i.e., color, smell,
texture) should be noted and described. Bloody discharge
occurs as a result of epistaxis or trauma, such as a nasal
fracture, zygoma fracture, or skull fracture. Mucoid dis-
charge is typical of rhinitis. Bilateral purulent discharge
can occur with upper respiratory tract infection. Unilat-
eral purulent, thick, greenish, and often malodorous dis-
charge usually indicates the presence of a foreign body.
Depression of the nasal bridge can result from a frac-
ture of the nasal bone. Nasal flaring is associated with
Figure 2-22 Scleral rupture (arrow) at the limbus after blunt trauma.
respiratory distress, whereas narrowing of the airways on
The iris and ciliary body have prolapsed into the subconjunctival space.
(From Paton D, Goldberg MF: Management of ocular injuries, Phila- inspiration may indicate chronic nasal obstruction and
delphia, 1976, WB Saunders, p. 310.) be associated with mouth breathing. The nasal mucosa
should be deep pink and glistening. A film of clear dis-
charge is often apparent on the nasal septum. The nasal
septum should be close to midline and fairly straight,
appearing thicker anteriorly than posteriorly. If present, a
hematoma in the septal area should be noted. Asymmetric
posterior nasal cavities may indicate a deviation of the
nasal septum.
With the patients mouth closed, the lips should be
observed for symmetry, color, edema, and surface abnor-
malities. Lipstick should be removed before the assess-
ment. The lips should be pink and have vertical and
horizontal symmetry, both at rest and with movement.
Dry, cracked lips may be caused by dehydration from
wind or low humidity, whereas deep fissures at the corners
of the mouth may indicate overclosure of the mouth or
riboflavin deficiency.
Drooping of the mouth on one side, sagging of the
lower eyelid, and flattening of the nasolabial fold suggest
Figure 2-23 Hyphema in the anterior chamber of the eye. (From possible facial nerve (cranial nerve VII) involvement. The
Easterbrook M, Cameron J: Injuries in racquet sports. In Schneider RC, patient is also unable to pucker the lips to whistle.
etal, editors: Sports injuries: mechanisms, prevention and treatment,
Baltimore, 1985, Lippincott Williams & Wilkins, p. 556.)
The shape and position of the jaw and teeth should
also be noted anteriorly and from the side.62 Asymmetry
may indicate a fracture of the jaw (Figure 2-24), whereas
The pupillary size (diameter range, 2 to 6mm; mean, bleeding around the gums of the teeth may indicate frac-
3.5mm), shape (round), and symmetry should be com- ture, avulsion, or loosening of the teeth (Figure 2-25). If
pared with those of the other eye. Elliptical pupils often teeth are missing, they must be accounted for. If they are
indicate a corneal laceration. The color of the irises of the not accounted for, an x-ray may be required to ensure
eyes should be compared. When looking at the pupils, that the teeth have not entered the abdominal or chest
the examiner should note whether the pupils are equal. cavity. Pain on percussion of the teeth often indicates
Are the pupils smaller or larger than normal? Are they damage to the periodontal ligament.
round or irregularly shaped? The pupils are normally From the side, the examiner should look for any asym-
slightly unequal in 5% of the population, but inequality metry or depression, which may indicate pathology. The
of pupil size should initially be viewed with suspicion. examiner should inspect the auricles of the ears for
For example, unilateral dilation may be the result of a size, shape, symmetry, landmarks, color, and position
sympathetic nerve response following a blow to the face.4 on the head. To determine the position of the auricle,
Pupils tend to be smaller in infants, the elderly, and the examiner can draw an imaginary line between the
persons with hyperopia (farsightedness), whereas they outer canthus of the eye and occipital protuberance
tend to be slightly dilated in persons with myopia (near- (Figure 2-26). The top of the auricle should touch or be
sightedness) or light-colored irises. above this line.50 The examiner can then draw another
Figure 2-24 Fracture of the neck of the condyle on the right (upper
arrows) with fracture through the mandible on the same side (lower
arrow). When one fracture is shown in the mandible, search carefully
for the second. (From ODonoghue DH: Treatment of injuries to
athletes, Philadelphia, 1984, WB Saunders, p. 115.)
imaginary line perpendicular to the previous line and just B

anterior to the auricle. The auricles position should be Figure 2-25 A 9-year-old boy was hit in the mouth with a ball while he
almost vertical. If the angle is more than 10 posterior or was playing baseball. The right maxillary central and lateral incisors were
anterior, it is considered abnormal. An auricle that is set chipped. A, Avulsed teeth reimplanted with finger pressure. B, Radio-
low or is at an unusual angle may indicate chromosomal graph of root canal with wide-open apex. Reimplanted quickly, these
aberrations or renal disorders. In addition, the lateral and teeth may not require root canal treatment. (From Torg JS: Athletic
injuries to the head, neck and face, Philadelphia, 1982, Lea & Febiger,
medial surfaces and surrounding tissues should be exam- p. 247.)
ined, noting any deformities, lesions, or nodules. The
auricles should be the same color as the facial skin without
moles, cysts, or other lesions or deformities. Athletes,
especially wrestlers, may exhibit a cauliflower ear (hema-
toma auris), which is a keloid scar forming in the auricle
because of friction to or twisting of the ear (Figure 2-27).
Blueness may indicate some degree of cyanosis. Pallor or
excessive redness may be the result of vasomotor instabil-
ity or increased temperature. Frostbite can cause extreme
pallor or blistering (Figure 2-28).
The examiner should look posteriorly for any asym-
metry or depression. The positions of the ears (height,
protrusion) can be compared by observing them from
behind. A low hairline may indicate conditions such as
Klippel-Feil syndrome. The examiner should also look
for the presence of Battle sign. This sign, which takes as
long as 24 hours to appear, is demonstrated by purple
and blue discoloration of the skin in the mastoid area and
may indicate a temporal bone or basilar skull fracture.
The examiner then views the patient from overhead
(superior view) to note any asymmetry from above
(Figure 2-29). This method is especially useful when Figure 2-26 Auricle alignment. Normal position shown.
Figure 2-27 Cauliflower ear (hematoma auris).
Figure 2-29 View of the patient from above to look for bilateral sym-
metry of the face.
Figure 2-28 Auricular frostbite with development of massive vesicles that

are beginning to resolve spontaneously. (From Schuller DE, Bruce RA: Figure 2-30 Typical fracture of zygomatic arch on the right (arrow).
Ear, nose, throat and eye. In Strauss RH, editor: Sports medicine, Note normal arch on the left. (From ODonoghue DH: Treatment of
ed 2, Philadelphia, 1991, WB Saunders, p. 191.) injuries to athletes, Philadelphia, 1984, WB Saunders, p. 114.)
looking for a possible fracture of the zygoma (Figure temporomandibular joints, and these joints are discussed
2-30). The deformity is easier to detect if the examiner in Chapter 4.
carefully places the index fingers below the infraorbital
margins along the zygomatic bodies and then gently
Examination of the Head
pushes into the edema to reduce the effect of the edema
(Figure 2-31). Many problems in the head and face may be problems
referred from the cervical spine, temporomandibular
joint, or teeth. However, if one suspects a head injury, it
EXAMINATION is necessary to keep a close watch on the patient, noting
The examination of the head and face differs from any changes and when these changes occur. The examiner
the orthopedic assessment of other areas of the body should implement a Neural Watch so that any changes
because the assessment does not involve joints. The only that occur over time can be determined easily (Table
joints that could be included in the assessment are the 2-17). The testing should occur at 15- or 30-minute
Signs and Symptoms of Maxillary

and Zygomatic Fractures
Facial asymmetry
Loss of cheek prominence
Palpable steps
Infraorbital rim (zygomaticomaxillary suture)
Lateral orbital rim (frontozygomatic suture)
Root of zygoma intraorally
Zygomatic arch between the ear and the eye
(zygomaticotemporal suture)
Hypoesthesia/anesthesia Figure 2-31 Method of assessing posterior displacement of the zygo-
Cheek, side of nose, upper lip, and teeth on the injured side
matic complex from behind the patient. The examiner should firmly but
carefully depress the fingers into the edematous soft tissues while palpat-
Compression of the infraorbital nerve as it courses along the
ing along the infraorbital areas. (Modified from Ellis E: Fractures of the
floor of the orbit to exit into the face via the foramen beneath zygomatic complex and arch. In Fonseca RJ, Walker RV, editors: Oral
the orbital rim and maxillofacial trauma, Philadelphia, 1991, WB Saunders, p. 443.)
TABLE 2-17
Neural Watch Chart

Time 1 Time 2 Time 3 Time 1 Time 2 Time 3
Unit ( ) ( ) ( ) Unit ( ) ( ) ( )
I Vital signs Blood pressure VI Pupils Size on right
Pulse Size on left
Respiration Reacts on right
Temperature Reacts on left
II Conscious Oriented VII Ability to Right arm
and Disoriented move Left arm
Restless Right leg
Combative Left leg
III Speech Clear VII Sensation Right side
Rambling (normal/
Garbled abnormal)
None Left side
IV Will awaken Name (normal/
to Shaking abnormal)
Light pain Dermatome
Strong pain affected
V Nonverbal Appropriate (specify)
reaction to Inappropriate Peripheral nerve
pain Decerebrate affected
None (specify)
Modified from American Academy of Orthopedic Surgeons: Athletic training and sports medicine, Park Ridge, IL, 1984, AAOS, p. 399.
TABLE 2-18
Graduated Return-to-Play Protocol for Returning an Individual to Sport

Rehabilitation Stage Functional Exercise at Each Stage of Rehabilitation Objective of Each Stage
1. No activity Symptom limited physical and cognitive rest Recovery
2. Light aerobic exercise Walking, swimming or stationary cycling keeping Increase heart rate
intensity less than 70% maximum permitted
heart rate; no resistance training
3. Sport-specific exercise Skating drills in ice hockey, running drills in soccer; Add movement
no head impact activities
4. Non-contact training drills Progression to more complex training drills (e.g., Exercise, coordination, and cognitive
passing drills in football and ice hockey); may load
start progressive resistance training
5. Full-contact practice Following medical clearance participate in normal Restore confidence and assess
training activities functional skills by coaching staff
6. Return to play Normal game play
Modified from McCrory P, Meeuwisse WH, Aubry M, etal: Consensus statement on concussion in sport: the 4th International Conference on
Concussion in Sport held in Zurich, November 2012. Br J Sports Med 47(5):250258, 2013.
athletes,71 which may lead to symptoms.4,72 Although the

Head Examination guidelines outlined in Table 2-19 may appear excessively
precautionary, they are designed to prevent second
Concussion impact syndrome, which is potentially catastrophic
Headache injury with a mortality rate close to 50% or permanent
Memory tests brain injury.18,64,7377
Neural Watch (Glasgow Coma Scale)
The examiner should always be looking for the possi-
Expanding intracranial lesion
bility of an expanding intracranial lesion resulting from a
Proprioception
Coordination leaking or torn blood vessel. Normally, the brain has a
Head injury card fixed volume that is enclosed in a nonexpansile structure,
namely, the skull and dura mater. These lesions may be
caused by epidural hemorrhage (usually tearing of one
of the meningeal arteries as a result of high-speed
intervals, depending on the severity of the injury and the impact), subarachnoid hemorrhage (usually as a result
changes recorded. of an aneurysm), or subdural hemorrhage (usually as a
The issue of whether a patient should be allowed to result of tearing of bridging veins between the brain and
return to competition or high-level activity following a cavernous sinus).64 These injuries are emergency condi-
concussion, and how soon, is one that has not been com- tions that must be looked after immediately because of
pletely settled, although clinicians are becoming more their high mortality rate (as much as 50%). An expanding
concerned about the consequences of concussions.11,6470 intracranial lesion is indicated by an altered lucid state
Research has shown that the brain is vulnerable to rein- (state of consciousness), development of inequality of the
jury for 3 to 5 days following concussions because of pupils, unusual slowing of the heart rate that primarily
altered blood flow and metabolic dysfunction.11 If the occurs after a lucid interval, irregular eye movements, and
examiner is contemplating allowing the patient to return eyes that no longer track properly. There is also a ten-
to activity because all symptoms have disappeared, gradu- dency for the patient to demonstrate increased body tem-
ated provocative stress tests (Table 2-18) should be con- perature and irregular respirations. Normal intracranial
sidered before allowing the patient to return. These tests pressure measures from 4 to 15mm Hg, and an intracra-
are commonly related to the sport but may include nial pressure of more than 20mm Hg is considered
jumping jacks, sit-ups, pushups, deep knee bends, and abnormal. Intracranial pressure of 40mm Hg causes neu-
lying supine for 1 minute with feet elevated or similar rological dysfunction and impairment. Although in the
activities that may be related to what the patient will emergency care setting there is no way of determining the
return to functionally (e.g., rapid head movements, intracranial pressure, the signs and symptoms mentioned
straining or holding breath). These activities should be indicate that the pressure is increasing. Most patients who
viewed as actions that increase intracranial pressure and experience an increase in intracranial pressure complain
can cause a different physiological response in concussed of severe headache, and this symptom is often followed
TABLE 2-19
Return-to-Play Guidelines Following Head Injury

Grade of Concussion On-the-Field Treatment First Concussion Second Concussion Third Concussion
Simple: Loss of Remove athlete from the Athlete may return to Obtain CT scan; Athlete sidelined a
consciousness competition play if asymptomatic athlete may return minimum of 1
<1 minute; for 1 week in 2 weeks if month; may return
posttraumatic asymptomatic for then if asymptomatic
amnesia <30 minutes 1 week for 1 week
Complex: Loss of Remove athlete from the Obtain CT scan, Obtain CT Terminate athlete for
consciousness competition;transport remove from play scan; consider season; athlete may
>1 minute; athlete to a hospital for for a minimum of 1 terminating for return next season
posttraumatic emergency evaluation month; athlete may season if asymptomatic,
amnesia of the player by a then return to play but permanent
>30 minutes neurosurgeon and if asymptomatic for retirement from
to obtain diagnostic 1 week contact sports
neuroimaging should be considered
Modified from Warren WL, Bailes JE, Cantu RC: Guidelines for safe return to play after athletic head and neck injuries. In Cantu RC, editor:
Neurologic athletic head and spine injuries, Philadelphia, 2000, WB Saunders.
CT, Computed tomography.
by vomiting (sometimes projectile vomiting). Finally, an It is important when examining the unconscious or
expanding intracranial lesion causes increased weakness conscious patient for a possible head injury to determine
on the side of the body opposite that on which the lesion the individuals level of consciousness, which may be
has occurred. determined using the Glasgow Coma Scale (Table
Signs and symptoms that indicate a good possibility of 2-20). The first test relates to eye opening. Eye opening
recovery from a head injury, especially after the patient may occur spontaneously, in response to speech, or in
experiences unconsciousness, include response to noxious response to pain, or there may be no response at all. Each
stimuli, eye opening, pupil activity, spontaneous eye of these responses is given a numerical value: spontaneous
movement, intact oculovestibular reflexes, and appropri- eye opening, 4; response to speech, 3; response to pain,
ate motor function responses. Neurological signs that 2; and no response, 1. Spontaneous opening of the eyes
indicate a poor prognosis after a head injury include non- indicates functioning of the ascending reticular activating
reactive pupils, absence of oculovestibular reflexes, severe system. This finding does not necessarily mean that the
extension patterns or no motor function response at all, patient is aware of the surroundings or of what is happen-
and increased intracranial pressure.44 ing, but it does imply that the patient is in a state of
arousal. A patient who opens his or her eyes in response
to the examiners voice is probably responding to the
stimulus of sound, not necessarily to the command to
open the eyes. If unsure, the examiner may use different
Signs and Symptoms of an Expanding sound-making objects (e.g., bell, horn) to elicit an appro-
Intracranial Lesion priate response.
The second test involves motor response; the patient
Altered state of consciousness is given a grade of 6 if there is a response to a verbal
Nystagmus command. Otherwise, the patient is graded on a 5-point
Pupil inequality
scale depending on the motor response to a painful stimu-
Irregular eye movements
Abnormal slowing of heart
lus (see Table 2-20). When scoring motor responses, it is
Irregular respiration the ease with which the motor responses are elicited that
Severe headache constitutes the criterion for the best response. Commands
Intractable vomiting given to the patient should be simple, such as, Move
Positive expanding intracranial lesion tests (lateralizing) your arm. The patient should not be asked to squeeze
Positive coordination tests the examiners hand, nor should the examiner place
Decreasing muscle strength something in the patients hand and then ask the patient
Seizure to grasp it. This action may cause a reflex grasp, not a
response to a command.44
TABLE 2-20
Glasgow Coma Scale*

Time 1 Time 2
( ) ( )
Eyes Open Spontaneously 4
To verbal command 3
To pain 2
No response 1 _____ _____
Best motor response To verbal command Obeys 6
To painful stimulus Localizes pain 5
Flexionwithdrawal 4
Flexionabnormal (decorticate rigidity) 3
Extension (decerebrate rigidity) 2

Best verbal response Oriented and converses 5
Disoriented and converses 4
Inappropriate words 3
Incomprehensible sounds 2
Total 315 _____ _____
*The Glasgow Coma Scale, which is based on eye opening and verbal and motor responses, is a practical means of monitoring changes in level of
consciousness. If responses on the scale are given numerical grades, the overall responsiveness of the patient can be expressed in a score that is the
summation of the grades. The lowest score is 3, and the highest is 15.
Apply knuckles to sternum; observe arms.
Arouse patient with painful stimulus if necessary.
If the patient does not give a motor response to a Decerebrate posturing, which has a poorer prognosis,
verbal command, then the examiner should attempt to involves extension, adduction, and hyperpronation of the
elicit a motor response to a painful stimulus. It is the type arms, whereas the lower limbs are the same as for decor-
and quality of the patients reaction to the painful stimu- ticate posturing.78 Decerebrate rigidity is usually bilateral.
lus that constitute the scoring criteria. The stimulus If the patient exhibits no reaction to the painful stimulus,
should not be applied to the face, because painful stimu- a value of 1 is given. It is important to be sure the no
lus in the facial area may cause the eyes to close tightly response is caused by a head injury and not a spinal cord
as a protective reaction. The painful stimulus may consist injury leading to lack of feeling or sensation. Any differ-
of applying a knuckle to the sternum, squeezing the tra- ence in reaction between limbs should be carefully noted;
pezius muscle, or squeezing the soft tissue between the this finding may indicate a specific focal injury.44
thumb and index finger (Figure 2-32). If the patient In the third test, verbal response is graded on a 5-
moves a limb when the painful stimulus is applied to more point scale to measure the patients speech in response to
than one point or tries to remove the examiners hand simple questions, such as Where are you? or Are you
that is applying the painful stimulus, the patient is local- winning the game? For verbal responses, the patient who
izing, and a value of 5 is given. If the patient withdraws converses appropriately and shows proper orientation,
from the painful stimulus rapidly, a normal reflex with- being aware of oneself and the environment, is given a
drawal is being shown, and a value of 4 is given. grade of 5. The patient who is confused is disoriented
However, if application of a painful stimulus creates and unable to completely interact with the environment;
a decorticate or decerebrate posture (Figure 2-33), an this patient is able to converse using the appropriate
abnormal response is being demonstrated, and a value of words and is given a grade of 4. The patient exhibiting
3 is given for the decorticate posture (injury above red inappropriate speech is unable to sustain a conversation
nucleus) or a value of 2 is given for decerebrate posture with the examiner; this person would be given a grade of
(brain stem injury). Decorticate posturing results 3. A vocalizing patient only groans or makes incompre-
from lesions of the diencephalon area, whereas decere- hensible sounds; this finding leads to a grade of 2. Again,
brate posturing results from lesions of the midbrain. the examiner should note any possible mechanical reason
With decorticate posturing, the arms, wrists, and fingers for the inability to verbalize. If the patient makes no
are flexed, the upper limbs are adducted, and the legs sounds and thus has no verbal response, a grade of 1 is
are extended, medially rotated, and plantar flexed. assigned.
A B
C D
Figure 2-32 Examples of painful stimuli applied

by the examiner. A, Knuckle to sternum.
B, Squeezing trapezius muscle. C, Squeezing
tissue between the thumb and index finger.
E D, Squeezing a fingertip. E, Squeezing an object
between two fingers.
emergency care is required. With the Glasgow Coma

Scale, the initial score is used as a basis for determining
the severity of the patients head injury. Patients who
maintain a score of 8 or lower on the Glasgow Coma
A Scale for 6 hours or longer are considered to have a
serious head injury. A patient who scores between 9 and
11 is considered to have a moderate head injury, and
one who scores 12 or higher is considered to have a mild
head injury.44
B
Figure 2-33 A, Decorticate rigidity. B, Decerebrate rigidity.
Head Injury Severity Based on Score Maintained

It is vital that the initial score on the Glasgow Coma on Glasgow Coma Scale (6 or More Hours)
Scale be obtained as soon as possible after the onset
of the injury. The scale can then be repeated at 15- or 8 or less: Severe head injury
9 to 11: Moderate head injury
30-minute intervals, especially in the early stages, if
12 or more: Mild head injury
changes are noted. If the score is between 3 and 8,
TABLE 2-21
Rancho Los Amigos Scale of Cognitive Function

Level I No response
Level II Generalized response
Level III Localized response
Level IV Confused, agitated
Level V Confused, inappropriate
Level VI Confused, appropriate
Level VII Automatic, appropriate
Level VIII Purposeful, appropriate
From Hagen C, Malkmus D, Durham P: Levels of cognitive function-

ing. In Rehabilitation of the brain injured adultcomprehensive man-
agement, Downey, CA, 1980, Professional Staff Association of Rancho
Los Amigos.
The Rancho Los Amigos Scale of Cognitive Function

may also be used to assess the patients cognitive abilities.
This scale is an eight-level progression from level I, in
which the patient is nonresponsive, to level VIII, in which
the patients behavior is purposeful and appropriate
(Table 2-21). The Rancho Los Amigos Scale provides an
assessment of cognitive function and behavior only, not
of physical functioning.44
If a person receives a head injury, such as a mild con-
cussion, and is not referred to the hospital, the examiner
should ensure that someone accompanies the person
home and that someone at home knows what has hap-
pened so he or she can monitor the patient in case the
patients condition worsens. Appropriate written instruc-
tions should be sent home concerning the individual. The
Head Injury Card is an example (Figure 2-34).
Levin and colleagues reported the use of the Galveston
Orientation and Amnesia Test (GOAT),47 which they
believe measures orientation to person, place, and time,
and the memory of events preceding and following head
trauma (Figure 2-35). As the patient improves, the total
GOAT score should increase.
The examiner may also wish to determine whether the
patient has suffered an upper motor neuron lesion.
Testing the deep tendon reflexes (see Table 1-31) or the
pathological reflexes (see Table 1-33) or having the
patient perform various balance and coordination tests
may help to determine whether this type of lesion has
occurred. However, the pathological reflexes may not be Figure 2-34 Home health care guidelines for patients with head
injuries. (Modified from Allman FL, Crow RW: On-field evaluation of
elicited owing to shock. Deep tendon reflexes are accen-
sports injuries. In Griffin LY, editor: Orthopedic knowledge update:
tuated on the side of the body opposite that on which sports medicine, Rosemont, IL, American Academy of Orthopaedic
the brain injury has occurred. Balance can play an impor- Surgeons, 1994, p. 14.)
tant role in the assessment of a head-injured patient.
Balance involves the integration of several inputs (e.g.,
visual, proprioceptive, and vestibular systems) that are to maintain proper standing posture. Balance and coor-
analyzed by the brain to allow a proper action. For dination can be tested in several ways. The examiner can
example, in standing, the body is inherently unstable, and ask the patient to stand and walk a straight line with the
only the integration of input from various sources enables eyes open and then with the eyes closed while the exam-
the patient to stand and to make appropriate corrections iner is noting any difference. He or she can then ask the
Figure 2-35 Galveston Orientation and Amnesia Test. Examiner adds up only error points, not positive responses. For example, if patient remem-
bers the first name but not the last name, he or she would get 1 error point. (Modified from Levin HS, ODonnell VM, Grossman RG: The
Galveston Orientation and Amnesia Test: a practical scale to assess cognition after head injury. J Nerve Ment Dis 167[11]:677, 1979.)
patient to bring the finger to the nose or the heel of the and hands on iliac crests. The examiner counts the number
foot to the opposite knee with the eyes closed (Figure of errors for each test (Table 2-22). Provided one has a
2-36). The Balance Error Scoring System (BESS) has baseline score, a score of three or more errors than base-
been developed as an objective test for balance. The test line indicates balance impairment.25,7982 These tests and
has six partsthree on a solid floor and three on a foam others described under Special Tests assess balance and
surface (Figure 2-37). On each surface, three progressive coordination.
stances are attempted: double leg stance, single leg stance, Muscle tone and strength may also play a role in assess-
and heel-to-toe tandem stance. Each of the six stances is ing the patient for head injury. Increased unilateral muscle
evaluated for 20 seconds with the patient closing the eyes tone usually implies contralateral cerebral peduncle
patient may initially be tested for fractures with the use

of a tongue depressor if the patient can open her or his
mouth. The patient is asked to bite down as hard as pos-
sible on the tongue depressor (Figure 2-38, A). The
examiner should note whether the patient is able to bite
down strongly and hold the contraction and where any
pain is elicited.
A
Facial Examination
Bone and soft tissue contours

Fractures
Mandible
Maxilla
Zygoma
Skull
Cranial nerves
Facial muscles
B To test for a maxillary fracture, the examiner grasps the

Figure 2-36 Performing coordination exercises. A, Touching knee anterior aspect of the maxilla with the fingers of one hand
with opposite heel. B, Touching nose with index finger with eyes closed. and places the fingers of the other hand over the bridge
of the patients nose or forehead. The examiner then
gently pulls the maxilla forward (Figure 2-39). If the
TABLE 2-22 fingers of the other hand at the nose feel movement or
the examiner feels the test hand moving forward, a Le
Balance Error Scoring System (BESS) Countable Errors Fort II or III fracture may be present (Figure 2-40). If
Errors the maxilla moves without movement at the nose, either
the maxilla is horizontally fractured, or a Le Fort I frac-
Hands lifted off the iliac crests ture is present. With a Le Fort I fracture, the palate is
Opening eyes separated from the superior portion of the maxilla, and
Step, stumble, or fall
the upper tooth-bearing segment of the face moves alone.
Moving a hip into more than 30 of flexion or extension
Lifting the forefoot or heel
The nasal bones, midportion of the face, and maxilla
Remaining out of the testing position for more than move if a Le Fort II fracture is present. With a Le Fort
5 seconds III fracture, the middle third of the face separates from
the upper third of the face; this is often called a cranio-
From Guskiewicz KM, Ross SE, Marshall SW: Postural stability and facial separation. The patient may complain of lip or
neuropsychological deficits after concussion in collegiate athletes. J Athl cheek anesthesia and double vision (diplopia) with any of
Train 36(3):265, 2001. these fractures.
The examiner then asks the patient to open his or her
mouth slightly. The examiner carefully applies pressure
compression. Flaccid muscle tone implies brain stem bilaterally at the angles of the mandible (Figure 2-38, B).
infarction, spinal cord transaction, or spinal shock. Uni- Localized pain, lower lip anesthesia, and intraoral lacera-
lateral effects, such as hemiparesis, may be seen with a tion may indicate a fracture of the mandible. Malocclu-
stroke. sion of the teeth is often seen with fractures of the
mandible or maxilla (Figure 2-41). Alterations in smell
(cranial nerve I) are often seen with frontobasal and
Examination of the Face5963,83
naso-ethmoidal fractures. Skull fractures are often associ-
Once a head injury has been ruled out or if no head injury ated with clear nasal discharge (spinal fluid rhinorrhea),
is suspected, the examiner can inspect the face for injury. clear ear discharge (otorrhea), or a salty taste. If blood
Major trauma and subsequent injury to the face should accompanies the fluid, the examiner can use a gauze pad
be assessed first. If major trauma has not occurred, to collect the fluid. If cerebrospinal fluid is mixed with
only those areas of the face that have been affected by the blood, the examiner may observe a halo effect as
the trauma (e.g., eyes, nose, ears) need be assessed. The the fluid collects on the gauze pad (Figure 2-42). If the
A B C
D E F
Figure 2-37 Stances for the Balance Error Scoring System (BESS). A, Double leg stance on a solid floor. B, Single leg stance on a solid floor.
C, Heal to toe tandem stance on a solid floor. D, Double leg stance on a foam surface. E, Single leg stance on a foam surface. F, Heel to toe
tandem stance on a foam surface.
Fracture
line
A
A
Fracture
line
B
Figure 2-38 Testing for mandibular fracture. A, Patient bites down

on tongue depressor while examiner tries to pull it away. B, Pressure at
the angles of the mandible.
Stabilize Fracture
line
C
Figure 2-40 Le Fort fractures. A, Le Fort I. B, Le Fort II. C, Le
Fort III.
Uneven line
of teeth
Figure 2-41 Malocclusion of teeth may be associated with fracture of

Figure 2-39 Testing for maxillary fracture. mandible or maxilla.
Eye Examination
Six cardinal gaze positions

Blood Pupils (size, equality, reactivity)
Orange halo of
Nystagmus
cerebrospinal fluid Visual field (peripheral vision)
Visual acuity
Gauze pad
Symmetry of gaze
Foreign objects/corneal abrasion
Surrounding bone and soft tissue
Hyphema
Figure 2-42 An orange halo will form around the blood on a gauze pad
if cerebrospinal fluid is present.
examiner asks the patient to move through the six cardi-
nal positions of gaze (Figure 2-43). The examiner holds
the patients chin steady with one hand and asks the
eardrum has not been perforated, blood may be visible patient to follow the examiners other hand while the
behind it. Skull fractures may also result in blurred or examiner traces a large H in the air. The examiner
double vision, loss of smell (anosmia), dizziness, tinnitus, should hold the index finger or pencil approximately
and nausea and vomiting as well as signs and symptoms 25cm (10 inches) from the patients nose. From the
of concussion. Orbital floor fractures or dislocations are midline, the finger or pencil is moved approximately
often accompanied by anesthesia of the skin in the midface 30cm (12 inches) to the patients right and held. It is
or anesthesia of the cheek, lip, maxillary teeth, and then moved up approximately 20cm (8 inches) and held,
gingiva.84 Zygoma fractures are detected by observation moved down 40cm (16 inches) (20cm relative to
(see Figure 2-31). They may also cause unilateral epi- midline) and held, and moved slowly back to midline.
staxis, double vision, and anesthesia and be associated The same movement is repeated on the other side. The
with eye injuries. Mouth opening may also be affected. examiner should observe movement of both eyes, noting
After major trauma has been ruled out, the examiner whether the eyes follow the finger or pencil smoothly.
may test the muscles of the face (Table 2-23) especially The examiner should also observe any parallel movement
if injury to these structures is suspected. Excluding the of the eyes in all directions. If the eyes do not move in
temporomandibular joint, the muscles of the face are dif- unison or if only one eye moves, something is affecting
ferent from most muscles in that they move the skin and the action of the muscles. One of the most common
soft tissues rather than joints. For example, the frontalis causes of one eyes not moving after trauma to the eye is
muscle may be weak if the eyebrows do not raise sym- a blowout fracture of the orbital floor (Figure 2-44).
metrically. The corrugator muscle draws the eyebrows Because the inferior muscles become caught in the
medially and downward (frowning). The orbicularis oris fracture site, the affected eye demonstrates limited move-
muscle approximates and compresses the lips, whereas the ment (Figure 2-45), especially upward. The patient with
zygomaticus muscles raise the lateral angle of the mouth this type of fracture may also demonstrate depression of
(smiling). the eye globe, blurred vision, double vision, and conjunc-
tival hemorrhage.
Occasionally, when looking to the extreme side, the
Examination of the Eye5962
eyes will develop a rhythmic motion called end-point nys-
If the eyelids are swollen shut, the examiner should tagmus. Nystagmus is a rhythmic movement of the eyes
initially assume that the globe has been ruptured. A with an abnormal slow drifting away from fixation and
penetrating wound of the eyelid should be assessed care- rapid return. With end-point nystagmus, there is a quick
fully, because it may be associated with a globe injury. motion in the direction of the gaze followed by a slow
The examiner should not force the eyelid open, because return. This test differentiates end-point nystagmus from
intraocular pressure can force extrusion of the ocular pathological nystagmus, in which there is a quick move-
contents if the globe has been ruptured. The patient ment of the eyes in the same direction regardless of gaze.
should also be instructed not to squeeze the eyelids tight, Pathological nystagmus exists in the region of full binocu-
because this action can increase the intraocular pressure lar vision, not just at the periphery. Cerebellar nystagmus
from a normal value of 15mm Hg up to approximately is greater when the eyes are deviated toward the side of
70mm Hg. the lesion.
To examine the normal functioning of the eye muscles While testing the cardinal positions, the examiner
and several of the cranial nerves (II, III, IV, and VI), the should also watch for lid lag. Normally, the upper lid
TABLE 2-23
Muscles of the Face

Action Cranial Nerve
Muscles of the Mouth
Orbicularis oris Compresses lips against anterior teeth, VII (Zygomatic, buccal, and mandibular
closes mouth, protrudes lips branches)
Depressor anguli oris Depresses angle of mouth VII (Buccal and mandibular branches)
Levator anguli oris Elevates angle of mouth VII (Zygomatic and buccal branches)
Zygomaticus major Draws angle of mouth upward and back VII (Zygomatic and buccal branches)
Risorius Draws angle of mouth laterally VII (Zygomatic and buccal branches)
Muscle of the Lips

Levator labii superioris Elevates upper lip, flares nostril VII (Zygomatic and buccal branches)
Muscle of the Cheek

Buccinator Compresses cheeks against molar teeth; VII (Buccal branches)
sucking and blowing
Muscle of the Chin

Mentalis Puckers skin of chin, protrudes lower lip VII (Mandibular branches)
Muscle of the Nose

Nasalis Compresses nostrils VII (Zygomatic and buccal branches)
Dilates or flares nostrils
Muscle of the Eye

Orbicularis oculi Closes eye forcefully VII (Temporal and zygomatic branches)
Closes eye gently
Squeezes lubricating tears against eyeball
Muscles of the Forehead

Procerus Transverse wrinkling of bridge of nose VII (Temporal and zygomatic branches)
Corrugator Vertical wrinkling of bridge of nose VII (Temporal branches)
Frontalis Pulls scalp upward and back VII (Temporal branches)
Adapted from Liebgott B: The anatomical basis of dentistry, St Louis, 1986, Mosby, pp. 242243.
Inferior Superior Superior Inferior covers the top of the iris, rising when the patient looks
oblique, rectus, rectus, rectus,
CN III CN III CN III CN III
up and quickly lowering as the eye lowers. With lid lag,
the upper lid delays lowering as the eye lowers.
Medial
Peripheral vision, or the visual field (peripheral limits
rectus,
CN III of vision), can be tested with the confrontation test
Lateral Lateral (Figure 2-46). The patient is asked to cover the right eye
rectus, rectus, while the examiner covers his or her own left eye so that
CN VI CN VI the open eyes of the examiner and of the patient are
directly opposite each other. While the examiner and the
Superior Inferior Inferior Superior patient look into each others eye, the examiner fully
oblique, rectus, rectus, oblique, extends his or her right arm to the side, midway between
CN IV CN III CN III CN IV the patient and the examiner, and then moves it toward
Figure 2-43 The six cardinal fields of gaze, showing eye muscles and them with the fingers waving. The patient tells the exam-
cranial nerves involved in the movement. iner when he or she first sees the moving fingers. The
examiner then compares the patients response with
the time or distance at which the examiner first noted the
fingers. The test is then repeated to the other side.
Figure 2-46 Confrontation eye test.
fields as before), the patient must be referred for further

examination.
Figure 2-44 Blowout fracture of the orbital floor. The dashed line The eyelids should be everted to look at the underside
indicates normal position of the globe. The inferior oblique and inferior of the eyelid and to give a clearer view of the globe,
rectus muscles are caught in the fracture site, preventing the eye from especially if the patient complains of a foreign body. The
returning to its normal position. (Modified from Paton D, Goldberg upper eyelid may be everted with the use of a special lid
MF: Management of ocular injuries, Philadelphia, 1976, WB Saunders,
p. 63.)
retractor or a cotton swab (Figure 2-47). The patient is
asked to look down and to the right and then down and
to the left while the superior aspect of the eye is exam-
ined. The examiner can check the inferior aspect of the
eye and its conjunctival lining by carefully pulling the
lower eyelid downward and gently holding it against
the bony orbit. Next, the patient is asked to look up and
to the right and then up and to the left while the inferior
aspect of the eye is examined. These two techniques may
also be used to look for a contact lens that has migrated
away from the cornea.
Both eyelids should be checked for laceration. Lacera-
tions in the area of the lacrimal gland are especially impor-
tant to detect because, if they are not looked after properly,
the tearing function of the lacrimal gland may be lost
(Figure 2-48).
The reaction of the pupils to light should then be
tested. First, the light in the room is dimmed. The pupils
Figure 2-45 Fresh blowout fracture of left orbit with limitation of dilate in a dark environment or with a long focal distance
upward (top) and downward (bottom) movements of the left eye. (Mod-
ified from Paton D, Goldberg MF: Management of ocular injuries,
and constrict in a light environment or with a short focal
Philadelphia, 1976, WB Saunders, p. 65.) distance. The examiner shines a pen light directly into one
of the patients eyes for approximately 5 seconds (Figure
2-49). Normally, constriction of the pupil occurs, fol-
The nasal, temporal, superior, and inferior fields should lowed by slight dilation. The pupillary reaction is classi-
all be tested in a similar fashion. The visual field should fied as brisk (normal), sluggish, nonreactive, or fixed. An
describe angles of 60 nasally, 90 temporally, 50 supe- oval or slightly oval pupil or one that is fixed and dilated
riorly, and 70 inferiorly. Double simultaneous testing indicates increased intracranial pressure. The fixation and
may also be performed. This method uses two stimuli dilation of both pupils is a terminal sign of anoxia and
(e.g., moving fingers) that are simultaneously presented ischemia to the brain. If the dilation is significant, an
in the right and left visual fields, and the patient is asked injury to the optic nerve may be suspected. If both pupils
which finger is moving. Normally, the patient should are midsize, midposition, and nonreactive, midbrain
say both, without hesitation. With any loss of vision damage is usually indicated. In a fully conscious, alert
field (i.e., if the patient is unable to see in the same visual patient who has sustained a blow near the eye, a dilated,
A B C
Figure 2-47 Eversion of the eyelid. A, Grasping eyelash. B, Putting moistened cotton-tipped applicator over eyelid. C, Everting eyelid over the
cotton-tipped applicator.
Figure 2-48 A lower lid laceration (arrow). (From Pashby TJ, Pashby
RC: Treatment of sports eye injuries. In Schneider RC, etal, editors:
Sports injuries: mechanisms, prevention and treatment, Baltimore,
1985, Lippincott Williams & Wilkins, p. 576.)
fixed pupil usually implies injury to the ciliary nerves of

the eye rather than brain injury. The other eye is tested
similarly, and the results are compared.
Normally, both pupils constrict when a light is shined
in one eye. The reaction of the eye being tested is called
the direct light reflex; the reaction of the other pupil is
called the consensual light reflex. This reaction is brisker B
in the young and people with blue eyes.63 If the optic
nerve is damaged, the affected pupil constricts in response Figure 2-49 Testing the pupils for reaction to light. A, Light shining
to light in the opposite eye (consensual) and dilates in in eye. B, Light shining away from eye.
response to light shined into it (direct). If the oculomotor
nerve is affected, the affected pupil is fixed and dilated
and does not respond to light, either directly or con pupils dilate when the patient looks at a far object and
sensually. If the pupils do not react, it is an indication of constrict when the patient focuses on the near object.
injury to the oculomotor nerve and its connections or of The eyes also adduct (go cross-eyed) when the patient
injury to the head. The eye also appears laterally displaced looks at the close object. These actions are called the
owing to paresis of the medial rectus muscle. accommodation-convergence reflex.63 When looking at
The pupil is then tested for constriction to accommo- distant objects, the eyes should be parallel. Deviation or
dation. The patient is asked to look at a distant object lack of parallelism is called strabismus and indicates
and then at a test objecta pencil or the examiners finger weakness of one of the extraocular muscles or lack of
held 10cm (4 inches) from the bridge of the nose. The neural coordination.85
Cornea
Anterior chamber
Iris
Lens
Normal angle
Narrow angle
Figure 2-51 Normal and narrow corneal angle (depth of anterior
chamber). (Modified from Swartz HM: Textbook of physical diagnosis,
Philadelphia, 1989, WB Saunders, p. 144.)
B
Figure 2-50 Corneal abrasion. A, Without fluorescein. B, With fluo-
rescein. (From Torg JS: Athletic injuries to the head, neck and face,
Philadelphia, 1982, Lea & Febiger, p. 262.)
When inspected under normal overhead light, the lens

of the eye should be transparent. Shining a light on the
lens may cause it to appear gray or yellow. The cornea
should be smooth and clear. If the patient has extreme
pain in the corneal area, a corneal abrasion should be
suspected (Figure 2-50). An appropriate specialist may
test for corneal abrasion by using a fluorescein strip and
a slit lamp. The cornea should be crystal clear when it is
viewed, and the iris details should match those of the
other eye. Figure 2-52 Symmetry of gaze. Note white dots of light on pupils.
To check for depth of the anterior chamber of the eye
or a narrow corneal angle, the examiner shines a light
obliquely across each eye. Normally, it illuminates the noting the position of the reflection. Each millimeter of
entire iris. If the corneal angle is narrow because of a displacement in the reflection represents approximately
shallow anterior chamber, the examiner will be able to see 7 of ocular deviation. To bring out a mild deviation,
a crescent-shaped shadow on the side of the iris away from the examiner may use a cover-uncover test (Figure 2-53).
the light (Figure 2-51). This finding indicates an ana- The patient looks at a specific point, such as the bridge
tomical predisposition to narrow-angled glaucoma. of the examiners nose. One of the patients eyes is then
To test for symmetry of gaze, the examiner aims a covered with a card. Normally, the uncovered eye will
light source approximately 60cm (24 inches) from the not move. If it moves, it was not straight before the
patient while standing directly in front of the patient and other eye was covered. The other eye is then tested in a
holding the light distant enough to prevent convergence similar fashion.
of the patients gaze. The patient is asked to stare at the Visual acuity is tested using a vision chart. Visual
light. The dots of reflected light on the two corneas acuity is the ability of the eye to perceive fine detail, for
should be in the same relative location (Figure 2-52). example, when reading. If a standard eye wall chart is not
When one eye does not look directly at the light, the available, a pocket visual acuity card may be used. This
reflected dot of light moves to the side opposite the devia- pocket card is usually viewed at a distance of 35 to 36cm
tion. For example, if the eye deviates medially, the reflec- (14 inches). As with the wall chart, the patient is asked
tion appears more laterally placed than in the other eye. to examine the smallest line possible. If neither eye chart
The examiner can approximate the angle of deviation by is available, any printed material may be used. A patient
A B
Figure 2-53 Cover-uncover test for mild ocular deviation. As patient gazes at a specific point (A), examiner covers one eye and looks for move-
ment in uncovered eye (B).
who wears glasses or contact lenses should be tested both If available, a nasal speculum and light may be used to
without and with the corrective lenses. The test is done inspect the nasal cavity. The nasal mucosa and turbinates
quickly so that the patient cannot memorize the chart. can be inspected for color, foreign bodies, and abnormal
Visual acuity is recorded as a fraction in which the numer- masses (e.g., polyp). The nasal septum should be in
ator indicates the distance of the patient from the chart midline and straight and is normally thicker anteriorly
(e.g., 20 ft) and the denominator indicates the distance than posteriorly. If the nasal cavities are asymmetric, it
at which the normal eye can read the line. Thus, 20/100 may indicate a deviated septum. If the patient demon-
means the patient can read at 20 ft what the average strates a septal hematoma, it must be treated fairly quickly,
person can read at 100 ftthe smaller the fraction, the because the hematoma may cause excessive pressure on
worse the myopia (nearsightedness). Patients with cor- the septum, making it avascular. This avascularity can
rected vision of less than 20/40 should be referred to the result in a saddle nose deformity owing to necrosis and
appropriate specialist.63 Intraocular examination with an absorption of the underlying cartilage (Figure 2-54).
ophthalmoscope, if available, may reveal lens, vitreous, or Illumination of the frontal and maxillary sinuses may
retinal damage. be performed if sinus tenderness is present or infection
is suspected. The examination must be performed in a
completely darkened room. To illuminate the maxillary
Examination of the Nose5965
sinuses, the examiner places the light source lateral to the
Patency of the nasal passages can be determined by patients nose just beneath the medial aspect of the eye.
occluding one of the patients nostrils by pushing a finger The examiner then looks through the patients open
against the side of the nostril. The patient is then asked mouth for illumination of the hard palate. To illuminate
to breathe in and out of the opposite nostril with the the frontal sinuses, the examiner places the light source
mouth closed. The process is repeated on the other side. against the medial aspect of each supraorbital rim. The
Normally, no sound is heard, and the patient can breathe examiner looks for a dim red glow as light is transmitted
easily through the open nostril. just below the eyebrow. The sinuses usually show differ-
ing degrees of illumination. The absence of a glow indi-
cates either that the sinus is filled with secretions or that
it has never developed.
Nasal Examination
Examination of the Teeth5965
Patency The examiner should observe the teeth to see if they are
Nasal cavities in normal position and whether any teeth are missing,
Sinuses chipped, or depressed (see Figure 2-25). Using the gloved
Fracture
index finger and thumb, the examiner applies mild pres-
Nasal discharge (bloody, straw-colored, clear)
sure to each tooth, pressing inward toward the tongue
Ear Examination
Tenderness (exterior and interior)

Ear discharge (bloody, straw-colored, clear)
Hearing
Balance
she no longer hears the sound, and the examiner notes

the number of seconds. The examiner then quickly posi-
tions a still-vibrating tine 1 to 2cm (0.5 to 0.8 inch) from
the auditory canal and asks patient to indicate when he
or she no longer hears the sound. The examiner then
compares the number of seconds the sound was heard by
bone conduction and by air conduction. The counting or
timing of the interval between the two sounds determines
the length of time that sound is heard by air conduction
(see Figure 2-56). Air-conducted sound should be heard
twice as long as bone-conducted sound. For example, if
bone conduction is heard for 15 seconds, the air conduc-
tion should be heard for 30 seconds.5860
Figure 2-54 Saddle nose deformity (arrow) that occurred as a result
Schwabach Test. This test compares the patients
of loss of septal cartilage support secondary to septal hematoma and and examiners hearing by bone conduction. The exam-
abscess. (From Handler SD: Diagnosis and management of maxillofacial iner alternately places the vibrating tuning fork against
injuries. In Torg JS, editor: Athletic injuries to the head, neck and face, the patients mastoid process and against the examiners
Philadelphia, 1982, Lea & Febiger, p. 232.) mastoid bone until one of them no longer hears a sound.
The examiner and patient should hear the sound for equal
amounts of time.58,59
and outward toward the lips. Normally, a small amount Ticking Watch Test. The ticking watch test uses a
of movement is observed. If a tooth is loose, excessive nonelectric ticking watch to test high-frequency hearing.
movement or increased pain or numbness relative to The examiner positions the watch approximately 15cm
other teeth indicates a positive test. A tooth that has (6 inches) from the ear to be tested, slowly moving it
been avulsed may be cleansed with warm water and rein- toward the ear. The patient then indicates when he or she
serted into the socket. The patient is then referred to the hears the ticking sound. The distance can be measured
appropriate specialist. and will give some idea of the patients ability to hear
high-frequency sound.58,59
Weber Test. The examiner places the base of a
vibrating tuning fork on the midline vertex of the patients
Tooth Examination head. The patient should hear the sound equally well in
both ears (Figures 2-55 and 2-56). If the patient hears
Number of teeth
better in one ear (i.e., the sound is lateralized), the patient
Position of teeth
Movement of teeth
is asked to identify which ear hears the sound better. To
Condition of teeth test the reliability of the patients response, the examiner
Condition of gums repeats the procedure while occluding one ear with a
finger and asks the patient which ear hears the sound
better. It should be heard better in the occluded ear.58,59
Whispered Voice Test. The patients response to the
Examination of the Ear5862
examiners whispered voice can be used to determine
Examination of the ear deals primarily with whether hearing ability. The examiner masks the hearing in one
the patient is able to hear. Several tests may be used to of the patients ears by placing a finger gently in the
examine hearing. patients ear canal. Standing approximately 30 to 60cm
Rinne Test. The Rinne test is performed by placing (12 to 24 inches) away from the patient, the examiner
the base of the vibrating tuning fork against the patients whispers one- or two-syllable words and asks the patient
mastoid bone. The examiner counts or times the interval to repeat them. If the patient has difficulty, the examiner
with a watch. The patient tells the examiner when he or gradually increases his or her volume until the patient
Figure 2-55 The Weber test. A, When a

vibrating tuning fork is placed on the center
of the forehead, the sound is heard in the
center without lateralization to either side
(normal response). B, In the presence of a
conductive hearing loss, the sound is heard on
the side of the conductive loss. C, In the pres-
ence of sensorineural loss, the sound is better A B C
heard on the opposite (unaffected) side.
responds appropriately. The procedure is repeated in and downward, the test is considered positive for an
the other ear. The patient should be able to hear whis- expanding intracranial lesion on the side opposite the
pered words in each ear at a distance of 30 to 60cm side with the drift.
(12 to 24 inches) and respond correctly at least 50% of Neurological Control TestLower Limb. The examiner
the time.58,59 asks the patient to sit on the edge of a table or in a chair
with his or her legs extended in front and not touching
Conductive hearing loss implies that the patient the ground. The patient closes his or her eyes for approxi-
experiences a reduction of all sounds rather than difficulty mately 20 to 30 seconds. If the examiner notes that one
in interpreting sounds. Sensorineural or perceptual leg tends to move or drift, the test is considered positive
hearing loss indicates that the patient has difficulty inter- for an expanding intracranial lesion on the side opposite
preting the sounds. that with the drift.
To examine the internal structure of the ear, the exam- Romberg Test. The examiner asks the patient to
iner may use an otoscope if one is available. In this case, stand with feet together and arms by the sides with the
the examiner would observe the canal as well as the eyes open. The examiner notes whether the patient has
eardrum (tympanic membrane), noting any blockage, any problem with balance. The patient then closes his or
excessive wax, swelling, redness, transparency (usually her eyes for at least 20 seconds, and the examiner notes
pearly gray), bulging, retraction, or perforation of the any differences. A positive Romberg test is elicited if the
eardrum. patient sways or falls to one side when the eyes are closed,
and this reaction indicates an expanding intracranial
lesion, possible disease of the spinal cord posterior
Special Tests
columns, or proprioceptive problems.
Examiners perform only those special tests that they Walk or Stand in Tandem Test. Patients with expand-
think will have value in helping to confirm a diagnosis. ing intracranial lesions demonstrate increasing difficulty
For example, the tests for expanding intracranial lesions in walking in tandem (walking the line) or standing in
would not be performed with a facial injury unless an tandem (one foot in front of other). Standing in tandem
associated injury to the brain or other neurological tissues is more difficult to perform than walking in tandem.
is suspected.
For the reader who would like to review them, the Tests for Coordination
reliability, validity, specificity, sensitivity, and odds ratios Balance Error Scoring System. See earlier discussion
of some of the special tests used for the head and face are of BESS on p. 123.
available on the Evolve website. Finger Drumming Test. The patient drums the index
and middle finger of one hand up and down as quickly
Tests for Expanding Intracranial Lesions as possible on the back of the other hand. The test is
For each of these tests, the patient must be able to stand repeated with the opposite hand. The examiner compares
normally when the eyes are open. the two sides for coordination and speed.
Neurological Control TestUpper Limb. The exam- Finger-Thumb Test. The patient touches each finger
iner asks the patient to stand with his or her arms with the thumb of the same hand. The normal or unin-
forward flexed 90 and eyes closed. The patient holds jured side is tested first, followed by the injured side. The
this position for approximately 30 seconds. If the exam- examiner compares the two sides for coordination and
iner notes that one arm tends to move or drift outward timing.
Chapter 2 Head and Face 134.e1
APPENDIX 2-1
Reliability, Validity, Specificity, and Sensitivity of Special/Diagnostic Tests Used
in the Head and Face
CALORIC TEST
Sensitivity
To recognize presence of spontaneous and positional nystagmus warm monothermal test 97%, cool monothermal test
89%87
FINGER DRUMMING TEST

Reliability
Interrater r = 0.6788
FINGER-TO-NOSE TEST
Reliability Validity
Intrarater dymetria k = 0.54, tremor k = 0.18, Time of Correlation with coin pick up r = 0.77, pouring water
execution ICC = 0.9789 r = 0.70 to 0.84, pick up phone r = 0.70 to 0.8490
Interrater dymetria k = 0.36, tremor k = 0.26, Time of
execution ICC = 0.9189
Interrater kinetic tremor: For starting position specify
k = 0.37 to 0.64, no starting position specified k = 0.4 to
0.57, arm 90 degrees of abduction and elbow extended
k = 0.38 to 0.66, arm 90 degrees of abduction touching
nose for 5sec k = 0.33 to 0.6490
Intention tremor: for starting position specify k = 0.67 to
0.83, no starting position specified k = 0.63 to 0.84, arm
90 degrees of abduction and elbow extended k = 0.55
to 0.87, arm 90 degrees of abduction touching nose for
5sec k = 0.61 to 0.8390
GLASGOW COMA SCALE

Test-retest k = 0.39 to 0.80 91
Correlation with a videotape and discussion within a
Test-retest k = 0.72, interrater k = 0.64 (severe group of experts p = 0.00091
commitment k = 0.59, minor commitment k = 0.69)92
Test-retest: Experienced nurses reliability coefficient
= 0.94, new graduates reliability coefficient = 0.94,
student nurses reliability coefficient = 0.8693
Test-retest: Eye opened r = 0.89, best motor response
r = 0.85, best verbal response r = 0.9794
Interrater: Eye r = 0.75, k = 0.72, verbal r = 0.66,
k = 0.48, motor r = 0.81, k = 0.63, total r = 0.86,
k = 0.4095
ONE LEG STANCE TEST

Reliability
Interrater: Eyes open ICC = 0.99, eyes closed ICC = 0.9996
Test-retest: Eyes open ICC = 0.90, eyes closed ICC = 0.7496
RINNE TEST
Sensitivity
72.9% using a force of 72.9% (accuracy is 76%)97
134.e2 Chapter 2 Head and Face
APPENDIX 2-1
Reliability, Validity, Specificity, and Sensitivity of Special/Diagnostic Tests Used
in the Head and Facecontd
ROMBERG TEST
Between morning and afternoon p > 0.84, five Association with sway speed r = 0.4699
consecutive days p > 0.7898
Interrater: Eyes open ICC = 0.99, eyes close
ICC = 0.9996
Test-retest: Eyes open ICC = 0.90, eyes close
ICC = 0.7696
SIT-TO-STAND
Reliability
Interrater ICC = 0.9896
Test-retest ICC = 0.9296
87. Jacobson CP, Means ED: Efficacy of a monothermal warm water caloric screening test. Ann Otol Rhinol Laryngol 94:377381, 1985.
88. Arceneaux JM: Validity and reliability of rapidly alternating movements tests. Int J Neurosci 89:281286, 1997.
89. Swaine BR, Sullivan SJ: Reliability of the cores for the finger to nose tests in adults with traumatic brain injury. Phys Ther 73(2):7178, 1993.
90. Feys PG, Davies-Smith A, Jones R, et al: Intention tremor rated according to different finger-to-nose test protocols: a survey. Arch Phys Med Rehabil
84:7982, 2003.
91. Juarez VJ, Lyons M: Interrater reliability of the Glasgow Coma Scale. J Neurosci Nurs 27(5):283286, 1995.
92. Pettigrew LEL, Wilson JTL, Teasdale GM: Reliability of rating on the Glasgow Outcome Scales from in-person and telephone structured interviews.
J Head Trauma Rehabil 18(3):252258, 2003.
93. Rowley G, Fielding K: Reliability and accuracy of the Glasgow Coma Scale with experienced and inexperienced users. Lancet 337:535538, 1991.
94. Fielding K, Rowley G: Reliability of assessments by skilled observers using the Glasgow Coma Scale. Aust J Adv Nurs 7(4):1317, 1990.
95. Gill MR, Reiley DG, Green SM: Interrater reliability of Glasgow Coma Scale scores in the emergency department. Ann Emerg Med 43(2):215223,
2004.
96. Franchignoni F, Tesio L, Martino MT, et al: Reliability of four simple, quantitative tests of balance and mobility in health elderly females. Aging Clin
Exp Res 10(1):2631, 1998.
97. Johnston DF: A new modification of the Rinne test. Clin Otolaryngol 17:322326, 1992.
98. Thyssen HH, Brynskov J, Jansen EC, et al: Normal ranges and reproducibility for the quantitative Rombergs test. Acta Neurol Scand 66:100104, 1982.
99. Geer F, Letz R, Green RC: Relationships between quantitative measures and neurologists clinical rating of tremor and standing steadiness in two epi-
demiological studies. Neurotoxicology 21(5):753760, 2000.
Weber (away from the lesion)
Patient
Air >> bone Rinne (air >> bone)
30 cm 13 cm
Watch tick Watch tick

Finger twitching Finger twitching
SENSORINEURAL LOSS
Weber (to the left)
Air >> bone Rinne (air < bone) Examiner
30 cm 13 cm
Figure 2-57 Past pointing. (Redrawn from Reilly BM: Practical strate-
gies in outpatient medicine, Philadelphia, 1991, WB Saunders, p. 195.)
Watch tick Watch tick
Finger twitching Finger twitching
CONDUCTIVE LOSS
Tuning fork > 512cos Weber (midline) opposite hand with the posterior aspect of the fingers.
Rinne (air >> bone) The movement is repeated several times with both sides
being tested. The examiner compares the two sides for
coordination and speed.
Hand-Thigh Test. The patient pats his or her thigh
with the hand as quickly as possible. The uninjured side
Air >> bone is tested first. The patient may be asked to supinate and
pronate the hand between each hand-thigh contact to
30 cm 13 cm make the test more complex. The examiner watches for
speed and coordination and compares the two sides.
Heel-to-Knee Test. The patient, who is lying
Watch tick
Finger twitching
supine with the eyes open, takes the heel of one foot
Whispered voice and touches the opposite knee with the heel and then
slides the heel down the shin. The test is repeated with
NORMAL the eyes closed, and both legs are tested. The test can
Figure 2-56 Bedside hearing tests and results with sensorineural or con- be repeated several times with increasing speed; the
ductive loss in left ear and with normal hearing. examiner notes any differences in coordination or the
presence of tremor. Normally, the test should be accom-
Finger-to-Nose Test. The patient stands or sits with plished easily, smoothly, and quickly with the eyes open
the eyes open and brings the index finger to the nose. and closed.
The test is repeated with the eyes closed. Both arms are Past Pointing Test. The patient and examiner face
tested several times with increasing speed. Normally, the each other. The examiner holds up both index fingers
tests should be accomplished easily, smoothly, and quickly approximately 15cm (6 inches) apart. The patient is
with the eyes open and closed. asked to lift the arms over the head and then bring the
Hand Flip Test. The patient touches the back of arms down to touch the patients index fingers to the
the opposite, stationary hand with the anterior aspect of examiners index fingers (Figure 2-57). The test is
the fingers, flips the test hand over, and touches the repeated with the patients eyes closed. Normally, the test
can be performed without difficulty. Patients with ves-

tibular disease have problems with past pointing. The test
may also be used to test proprioception.
Tests for Proprioception

Past Pointing Test. The test is performed as described
under Tests for Coordination.
Proprioceptive Finger-Nose Test. The patient keeps
the eyes closed. The examiner lightly touches one of the
patients fingers and asks the patient to touch the patients
nose with that finger. The examiner then touches another
finger on the other hand, and the patient again touches
the nose. Patients with proprioceptive loss have difficulty
doing the test without visual input.
Proprioceptive Movement Test. With the patients
eyes closed, the examiner moves the patients finger or
toe up or down by grasping it on the sides to lessen clues
given by pressure. The patient then tells the examiner
which way the digit moved.
Proprioceptive Space Test. With the patients eyes
closed, the examiner places one of the patients hands or
Figure 2-58 Test of corneal reflex.
feet in a selected position in space. The patient then imi-
tates that position with the other limb or to find the hand
or foot with the other limb. True proprioceptive loss
causes the patient to be unable to properly position or to
find the normal limb with the limb that has propriocep- 1 C1
tive loss. C2
7
C2
2 6
Reflexes and Cutaneous Distribution C3
3 5
With a head injury patient, deep tendon reflexes (see
Table 1-31) should be tested. Accentuation of one or C3
more of the reflexes may indicate trauma to the brain on 4
C4
the opposite side. Pathological reflexes (see Table 1-33) C3
may also be altered with a head injury. 8
9
The corneal reflex (trigeminal nerve, cranial nerve V) C4
is used to test for damage or dysfunction to the pons. In
some cases, the patient may look to one side to avoid A B
involuntary blinking. The examiner touches the cornea Figure 2-59 A, Sensory nerve distribution of the head, neck and face.
1, Ophthalmic nerve; 2, maxillary nerve; 3, mandibular nerve; 4, trans-
(not the eyelashes or conjunctiva) with a small, fine point
verse cutaneous nerve of neck (C2C3); 5, greater auricular nerve
of cotton (Figure 2-58). The normal response is a bilat- (C2C3); 6, lesser auricular nerve (C2); 7, greater occipital nerve (C2
eral blink, because the reflex arc connects both facial C3); 8, cervical dorsal rami (C3C5); 9, suprascapular nerve (C5C6).
nerve nuclei. If the reflex is absent, the test is considered B, Dermatome pattern of the head, neck, and face. Note the overlap
positive. of C3.
The gag reflex may be tested using a tongue depressor
that is inserted into the posterior pharynx and depressed
toward the hypopharynx. The reflex tests cranial nerves The examiner should check the sensation of the
IX and X, and its absence in a trauma setting may indicate head and face, keeping in mind the differences in derma-
caudal brain stem dysfunction. tome and sensory nerve distributions (Figure 2-59). Lip
Consensual light reflex may be tested by shining a anesthesia or paresthesia is often seen in patients with
light into one eye. This action causes the lighted pupil to mandibular fracture.
constrict. If there is normal communication between
the two oculomotor nerves, the nonlighted pupil also Nerve Injuries of the Head and Face
constricts. Bells palsy involves paralysis of the facial nerve (cranial
The jaw reflex is usually tested only if the temporo- nerve VII) and usually occurs where the nerve emerges
mandibular joint or cervical spine is being examined. from the stylomastoid foramen. Pressure in the foramen
caused by inflammation or trauma affects the nerve and,

Palpation
therefore, the muscles of the face (occipitofrontalis,
corrugator, orbicularis oculi, and the nose and mouth During palpation of the head and face, the examiner
muscles) on one side. The inflammation may result from should note any tenderness, deformity, crepitus, or other
a middle ear infection, viral infection, chilling of the face, signs and symptoms that may indicate the source of
or tumor. The observable result is smoothing of the face pathology. The examiner should note the texture of the
on the affected side owing to loss of muscle action, the skin and surrounding bony and soft tissues. Normally, the
eye on the affected side remaining open, and the lower patient is palpated in the sitting or supine position, begin-
eyelid sagging. The patient is unable to wink, whistle, ning with the skull and moving from anterior to posterior,
purse the lips, or wrinkle the forehead. Speech sounds, to the face, and finally to the lateral and posterior struc-
especially those requiring pursing of the lips, are affected, tures of the head.
resulting in slurred speech. The mouth droops, and it and The skull is palpated by a gentle rotary movement of
the nose may deviate to the opposite side, especially in the fingers, progressing systematically from front to back.
longstanding cases, of which there are remarkably few Normally, the skin of the skull moves freely and has no
(90% of patients recover completely within 2 to 8 weeks). tenderness, swelling, or depressions.
Facial sensation on the affected side is lost, and taste The temporal area and temporalis muscle should be
sensation is sometimes lost as well. The House-Brackmann laterally palpated for tenderness and deformity. The exter-
Facial Nerve Grading System (Table 2-24) may be used nal ear or auricle and the periauricular area should also
to grade the level of facial nerve involvement.86 be palpated for tenderness or lacerations.
The occiput should be palpated posteriorly for tender-
ness. The presence of Battle sign should be noted, if
Joint Play Movements
observed, because this signals a possible basilar skull
Because no articular joints are involved in the assessment fracture.
of the head and face, there are no joint play movements The face is palpated beginning superiorly and working
to test. inferiorly in a systematic manner. Like the skull, the
TABLE 2-24
House-Brackmann Facial Nerve Grading System

Parameter Grade I Grade II Grade III Grade IV Grade V Grade VI
Overall Normal Slight weakness Obvious but not Obvious weakness Only barely No
appearance on close disfiguring and/or disfiguring perceptible movement
inspection difference asymmetry motion
between both
sides
At rest Normal Normal Normal symmetry Normal symmetry Asymmetry Asymmetry
symmetry symmetry
Forehead Normal with Moderate-to- Slight-to- None None None
movement excellent good function moderate
function function
Eyelid Normal Complete with Complete with Incomplete closure Incomplete No
closure closure minimum maximal effort with maximal closure with movement
effort effort maximal effort
Mouth Normal and Slight asymmetry Slight asymmetry Asymmetry with Slight movement No
symmetric with maximum maximum effort movement
effort
Synkinesis None May have Obvious but not Synkinesis Synkinesis No
contracture very slight disfiguring contracture and/or contracture movement
and/or synkinesis; no synkinesis asymmetrical facial and/or
hemifacial contracture contracture spasm leading to hemifacial
spasm or hemifacial and/or disfiguring severe spasm usually
spasm hemifacial enough to interfere absent
spasm with function
Modified from Dutton M: Orthopedic examination, evaluation, and intervention, New York, 2004, McGraw Hill, p. 1130. Adapted from House
JW, Brackmann DE: Facial nerve grading system. Otolaryngol Head Neck Surg 93:146147, 1985.
forehead is palpated by gentle rotary movements of the The frontal and maxillary sinuses should be inspected
fingers, feeling the movement of the skin and the occipi- for swelling. To palpate the frontal sinuses, the examiner
tofrontalis muscle underneath. Normally, the skin of the uses the thumbs to press up under the bony brow on each
forehead moves freely and is smooth and even with no side of the nose (Figure 2-61, A). The examiner then
tender areas. The examiner then palpates around the eye presses under the zygomatic processes using either the
socket or orbital rim, moving over the eyebrow and supra- thumbs or index and middle fingers to palpate the maxil-
orbital rims, around the lateral side of the eye, and along lary sinuses (Figure 2-61, B). No tenderness or swelling
the zygomatic arch to the infraorbital rims, looking for over the soft tissue should be present. The sinus areas may
deformity, crepitus, tenderness, and lacerations (Figure also be percussed to detect tenderness. A light tap directly
2-60, A and B). The orbicularis oculi muscles surround over each sinus with the index finger can be used to detect
the orbit, and the medial side of the orbital rim and nose tenderness.
are then palpated for tenderness, deformity, and fracture. The examiner then moves inferiorly to palpate the jaw.
The nasal bones, including the lateral and alar cartilage, The examiner palpates the mandible along its entire
are palpated for any crepitus or deviation (Figure 2-60, C). length, noting any tenderness, crepitus, or deformity. The
The septum should be inspected to see if it has widened, examiner, using a rubber glove, may also palpate along
possibly indicating a septal hematoma, which often occurs the mandible interiorly, noting any tenderness or pain
with a fracture. It should also be determined whether the (Figure 2-60, D). The outside hand may be used to sta-
patient can breathe through the nose or smell. bilize the jaw during this procedure. The mandible may
A B C
D E
Figure 2-60 Palpation of the face. A, Upper orbital rim. B, Lower orbital rim. C, Nose. D, Mandible. E, Maxilla.
A B
Figure 2-61 A, Palpation of frontal sinuses. B, Palpation of maxillary sinuses.
The trachea should be palpated for midline position.

The examiner places a thumb along each side of the
trachea, comparing the spaces between the trachea
and the sternocleidomastoid muscle, which should be
symmetric. The hyoid bone and the thyroid and cricoid
cartilages should be identified. Normally, they are smooth
and nontender and move when the patient swallows.
Diagnostic Imaging
Plain Film Radiography
Common x-rays taken involving the head and face are
outlined in the following box.
Common X-Ray Views of the Head and Face Depending

Figure 2-62 Palpation of maxillary fracture with anteroposterior rocking on Pathology
motion.
Anteroposterior view (Figure 2-63)
Lateral view (Figure 2-64)
also be tapped with a finger along its length to see if signs Anteroposterior View. The examiner should note the
of tenderness are elicited. The muscles of the cheek (buc- normal bone contours, looking for fractures of the various
cinator) and mouth (orbicularis oris) should be palpated bones (Figures 2-65 and 2-66; see Figure 2-63).
at the same time. Lateral View. The examiner should again note bony
The maxilla may be palpated in a similar fashion, both contours, looking for the possibility of fractures (Figure
internally and externally, noting position of the teeth, 2-67).
tenderness, and any deformity (Figure 2-60, E). The
examiner may grasp the teeth anteriorly to see if the Computed Tomography
teeth and mandible or maxilla move in relation to Computed tomography scans help to differentiate
the rest of the face, which may indicate a Le Fort fracture between bone and soft tissue and give a more precise view
(Figure 2-62). of fractures (Figures 2-68 and 2-69). The Canadian
Figure 2-64 Normal lateral view of the head and face.
Figure 2-63 Normal anteroposterior view of the head and face showing
a depressed parietal skull fracture (large arrow) with multiple bony
fragments into the brain (small arrows). (From Albright JP, etal:
Head and neck injuries in sports. In Scott WN, etal, editors: Principles
of sports medicine, Baltimore, 1984, Lippincott Williams & Wilkins,
p. 53.)
A B
Figure 2-65 Incomplete fracture of angle of mandible on the left side (arrows). A, Anteroposterior view. B, Lateral view. (From ODonoghue DH:
Treatment of injuries to athletes, Philadelphia, 1984, WB Saunders, p. 114.)
Figure 2-66 Plain posteroanterior view showing blowout fracture of the Figure 2-67 Lateral radiograph of the nasal bones demonstrating a nasal
orbit (arrows). (From Paton D, Goldberg MF: Management of ocular fracture (arrow). (From Torg JS: Athletic injuries to the head, neck and
injuries, Philadelphia, 1976, WB Saunders, p. 70.) face, Philadelphia, 1982, Lea & Febiger, p. 229.)
Figure 2-68 Axial computed tomogram of orbital blowout fracture

showing fracture of the orbit (1) with orbital contents herniated into
the maxillary sinus. (From Sinn DP, Karas ND: Radiographic evaluation Figure 2-69 The computed tomographic scan is ideal for condylar frac-
of facial injuries. In Fonseca RJ, Walker RV, editors: Oral and maxil- tures as seen in the right condyle. (From Bruce R, Fonseca RJ: Man-
lofacial trauma, Philadelphia, 1991, WB Saunders.) dibular fractures. In Fonseca RJ, Walker RV, editors: Oral and
maxillofacial trauma, Philadelphia, 1991, WB Saunders, p. 389.)
A B
Figure 2-70 Magnetic resonance images showing blowout fracture. Sagittal (A) and coronal (B) T1-weighted scans demonstrate a blowout
fracture of the right orbit with depression of the orbital floor (white arrows) into the superior maxillary sinus. The inferior rectus muscle (long arrow)
is clearly identified and is not entrapped by the floor fracture. (From Harms SE: The orbit. In Edelman RR, Hesselink JR, editors: Clinical magnetic
resonance imaging, Philadelphia, 1990, WB Saunders, p. 619.)
Computed Tomography (CT) Head Rule has been devel-

Canadian Computed Tomography Head Rule oped to help the clinician decide when to use CT scans
for Minor Head Injury5
in minor head injury patients.5 The authors of the
HIGH RISK (FOR NEUROLOGICAL INTERVENTION) Rule have defined minor head injury as witnessed loss
Failure to reach 15 on the Glasgow Coma Scale within 2 hours of consciousness, definite amnesia, or witnessed disorien-
Suspected open skull fracture tation in patients with a Glasgow Coma Scale score
Any sign of basal skull fracture of 1315.
Two or more vomiting episodes
65-years-old or older Magnetic Resonance Imaging
Magnetic resonance imaging is especially useful for dem-
MEDIUM RISK (FOR BRAIN INJURY ON CT) onstrating lesions of the soft tissues of the head and face
Retrograde amnesia (before impact) more than 30 minutes and for differentiating between bone and soft tissue
Dangerous mechanism of injury
(Figures 2-70 and 2-71).
Maxillary sinus
Coronoid process Temporalis muscle

of mandible
Masseter
Lateral pterygoid Adenoid tissue
muscle
Pharyngobasilar fascia
Longus capitis muscle Mandibular condyle
Internal jugular vein
Internal carotid artery Hypoglossal nerve
Medulla
Cerebellar tonsil Vallecula
Nasolacrimal duct
Orbital fat
Maxillary sinus
Zygomatic arch Temporalis muscle
Lateral pterygoid
muscle
Clivus
Medullary cistern Pyramid
Medulla Olive
Mastoid sinus
Cerebellar bemisphere PICA, tonsillar

segment
Figure 2-71 T1-weighted axial magnetic resonance images of the head and brain at two levels. PICA, Posterior inferior cerebellar artery. (From
Greenberg JJ, etal: Brain: indications, techniques, and atlas. In Edelman RR, Hesselink JR, editors: Clinical magnetic resonance imaging, Philadel-
phia, 1990, WB Saunders, p. 384.)
PRCIS OF THE HEAD AND FACE ASSESSMENT*

History (sitting) Nystagmus
Observation (sitting) Surrounding bone and soft tissue
Examination* (sitting) Nasal injury
Head injury Patency
Neural Watch Nasal cavities
Glasgow Coma Scale Sinuses
Concussion Fracture
Memory tests Nose discharge (bloody, straw-colored, clear)
Headache Tooth injury
Expanding intracranial lesion Number of teeth
Proprioception Position of teeth
Coordination Movement of teeth
Head injury card Condition of teeth
Facial injuy Condition of gums
Bone and soft tissue contours Ear injury
Fractures Tenderness or pain
Cranial nerves Ear discharge (bloody, straw-colored, clear)
Facial muscles Hearing tests
Eye injury Balance
Six cardinal gaze positions Special tests
Pupils (size, equality, reactivity) Tests for expanding intracranial lesions
Visual field (peripheral vision) Tests for coordination
Visual acuity Tests for proprioception
Symmetry of gaze Reflexes and cutaneous distribution
Hyphema Palpation
Foreign objects, corneal abrasion Diagnostic imaging
*When examining the head and face, if only one area has been injured (e.g., the nose), then only that area needs to be examined, provided the examiner is certain that
adjacent structures have not also been injured. After any examination, the patient should be warned of the possibility of exacerbation of symptoms as a result of the
assessment.
CASE STUDIES
When doing these case studies, the examiner should list the appropriate questions to be asked and why they are being
asked, identify what to look for and why, and specify what things should be tested and why. Depending on the patients
answers (and the examiner should consider different responses), several possible causes of the patients problem may
become evident (examples are given in parentheses). A differential diagnosis chart should be made up (see Table 2-25 as
an example). The examiner can then decide how different diagnoses may affect the treatment plan.
1. A 27-year-old man was playing football. He was riding hit another car that had run a red light.
received a knee to the head, rendering him The womans face hit the dashboard, and she
unconscious for approximately 3 minutes. How received a severe facial injury. Describe your
would you differentiate between a first-time, assessment plan for this patient (Le Fort fracture
fourth-degree concussion and an expanding versus mandibular fracture).
intracranial lesion? 4. An 83-year-old man tripped in the bathroom and
2. A 13-year-old boy received an elbow in the hit his chin against the bathtub, knocking himself
nose and cheek while play-wrestling. The nose unconscious. Describe your assessment plan for
is crooked and painful and bled after the injury, this patient (cervical spine lesion versus mandibular
and the cheek is sore. Describe your assessment fracture).
plan for this patient (nasal fracture versus zygoma 5. An 18-year-old woman was playing squash. She
fracture). was not wearing eye protectors and was hit in the
3. A 23-year-old woman was in an automobile eye with the ball. Describe your assessment plan
accident. She was a passenger in the front seat and for this patient (ruptured globe versus blowout
was not wearing a seat belt. The car in which she fracture).
CASE STUDIEScontd
6. A 15-year-old boy was playing field hockey. He match, which he lost. Describe your assessment
was not wearing a mouth guard and was hit in the plan for this patient (cauliflower ear versus
mouth and jaw by the ball. There was a large external otitis).
amount of blood. Describe your assessment plan 8. A 17-year-old female basketball player comes to
for this patient (tooth fracture versus mandible you complaining of eye pain. She says she received
fracture). a finger in the eye when she went up to get the
7. A 16-year-old male wrestler comes to you ball. Describe your assessment plan for this patient
complaining of ear pain. He has just finished a (hyphema versus corneal abrasion).
TABLE 2-25
Differential Diagnosis of 4 Concussion and Intracranial Lesion

Sign or Symptom 4 Concussion Intracranial Lesion
Confusion Yes, but should improve with time Will have increased confusion with time
Amnesia Posttraumatic, retrograde Not usually
Loss of consciousness Yes, but recovers Lucid interval varies
Tinnitus Severe Not a factor
Dizziness Severe, but improves May get worse
Headache Often Severe
Nystagmus or irregular eye movements Not usually Possible
Pupil inequality Not usually Possible early; present later
Irregular respiration No Possible early; present later
Slowing of heart No Possible early; present later
Intractable vomiting Not usually Possible
Lateralization No Yes
Coordination affected Yes, but improves Yes, and gets worse
Seizure Not usually Possible early; probable late
Personality change Possible Possible
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C H A P T E R 2

Head and Face

Parietal bone Frontal bone

Orbit Nasal bone

Squamous suture Coronal suture

Temporal bone Sphenoid bone

Occipital bone Ethmoid bone

C Zygomatic arch Mandible

Cranial Nerves and Methods of Testing

Cranial Nerves and Methods of Testingcontd

Sclera and Eyebrow Pupil Eyelashes (cilia) TABLE 2-2

Levator palpebrae muscle

INNER MIDDLE EXTERNAL

Semicircular canals Triangular fossa

Pathological Classification of Acute Traumatic

Nasofrontal Frontal bone

Maxillary bone Subdural hematoma

Upper cartilage Cerebral contusion

Septal cartilage Subarachnoid hemorrhage

point of impact. Because of the lack of cushioning on

Opening for External naris (nostril)

Figure 2-9 Cross section of the nose and nasopharynx.

TABLE 2-3 concussion before? These questions are often difficult

IMPACT DECELERATION ROTATIONAL ACCELERATION

Signs and Symptoms* of Concussion (Torg Classification)

Risk Factors That May Prolong or Complicate Recovery from Concussion

Severity Stages of Concussive Injury

TABLE 2-7 example of such a computerized post-concussion

Figure 2-11, contd Continued

Figure 2-11, contd

Figure 2-11, contd

Figure 2-12, contd Continued

Figure 2-12, contd

Figure 2-12, contd

Classification Systems for Concussions

Examples of Neurophysiological Tests

Hopkins Verbal Learning Test,48 Trail Making Test,

A patient with a grade III concussion has the

when the bodys essential functions must be TABLE 2-11

TABLE 2-13 patients static memory ability. The examiner must

Headaches: A Differential Diagnosis

nasal disorders temporal, allergy, inflammation,

HEADACHE DISABILITY QUESTIONNAIRE

Name: ........................................ Date: ....................................

2. When you have headaches, how often is in the pain severe?

Figure 2-16 Lacerations to the upper eyelid and eyebrow.

iris than the other upper eyelid does or if it extends over

Figure 2-21 A, Posttraumatic conjunctival hemorrhage without

of the lower lid may be examined by having the patient

The nose should be inspected for any deviations in

imaginary line perpendicular to the previous line and just B

Figure 2-27 Cauliflower ear (hematoma auris).

Figure 2-28 Auricular frostbite with development of massive vesicles that

Signs and Symptoms of Maxillary

Lateral orbital rim (frontozygomatic suture)

Root of zygoma intraorally

Zygomatic arch between the ear and the eye

Neural Watch Chart

Graduated Return-to-Play Protocol for Returning an Individual to Sport

athletes,71 which may lead to symptoms.4,72 Although the