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Injuries related to Vehicular accidents:
Whiplash
Sprains and Strains
Shoulder and Neck Pain
Headaches
Numbness
Dizziness & Vertigo
Lower Back Pain
Pain in Legs or Arms
Car Seat-belt Injury
Whiplash Overview
Whiplash is a nonmedical term used to describe neck pain following an injury to the soft tissues of your
neck (specifically ligaments, tendons, and muscles). It is caused by an abnormal motion or force applied
to your neck that causes movement beyond the neck's normal range of motion.
Whiplash happens in motor vehicle accidents, sporting activities, accidental falls, and assault.
The term whiplash was first used in 1928, and despite its replacement by synonyms (such as
acceleration flexion-extension neck injury and soft tissue cervical hyperextension injury), it continues to
be used to describe this common soft tissue neck injury. Your doctor may use the more specific terms
of cervical sprain, cervical strain, or hyperextension injury.
Whiplash Causes
The most frequent cause of whiplash is a car accident. The speed of the cars involved in the accident or
the amount of physical damage to the car may not relate to the intensity of neck injury; speeds as low as
15 miles per hour can produce enough energy to cause whiplash in occupants, whether or not they wear
seat belts.
Other common causes of whiplash include contact sport injuries and blows to the head from a falling
object or being assaulted.
Repetitive stress injuries or chronic strain involving the neck (such as using your neck to hold the
phone) are a common, non-acute causes.
Child abuse, particularly the shaking of a child, can also result in this injury as well as in more serious
injuries to the child's brain or spinal cord.
Whiplash Symptoms
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These signs and symptoms may occur immediately or minutes to hours after the initial injury; the sooner
after the injury that symptoms develop, the greater the chance of serious damage.
Neck pain
Neck swelling
Tenderness along the back of your neck
Muscle spasms (in the side or back of your neck)
Difficulty moving your neck around
Headache
Pain shooting from your neck into either shoulder or arm
When to Seek Medical Care
The best time to call your doctor is immediately after the injury. If the patient cannot determine whether an
emergency department visit is needed for the symptoms, then contact the doctor and ask for advice. If the
doctor is unavailable at the time of the injury, then call 911 for transport to the emergency department.
The risks associated with a possible neck injury are far too great to attempt to diagnose and self -treat.
See a doctor and have the patient's neck braced to keep the head from moving during transport.
Depending upon the severity of a car accident, emergency medical personnel may take the patient to an
emergency department immediately. In this case, a cervical collar will be placed around the patient's
neck, and the body will be strapped to a long, firm board to prevent any movements until a doctor sees
the patient.
With less severe car accidents, sports injuries, or other accidental injuries, emergency medical services
may or may not be involved in the patient's pre-hospital care. You should call 911 emergency medical
services if the patient develops any of the following symptoms shortly after the injury:
Neck pain
Pain in either or both arms
Shoulder pain
Headache
Dizziness
Weakness, tingling, or loss of function in the arms or legs
Exams and Tests
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Apply ice to the neck for 20 minutes at a time each hour for the first 24 hours while awake. Do not
apply ice directly to the skin. Place a towel between the ice and the neck. Continue to use ice therapy
until the pain stops. (After you see the doctor, follow his or her directions for ice therapy.)
Take acetaminophen for pain relief or ibuprofen for anti-inflammatory action. Avoid ibuprofen if you
have a past medical history of gastritis, duodenitis, peptic ulcer disease, reflux, or other stomach
problems
Medical Treatment
The doctor most likely will recommend a treatment plan including a mixture of the following:
Neck massage
Neck rest
Bed rest
Ice therapy
Heat therapy
Oral pain relievers and muscle relaxers
Immobilization of the neck with a soft cervical collar (only a minimal benefit if any at all)
Early range of motion exercises combined with heat therapystarting 72 hours after the injury to restore
flexibility
Avoidance of excessive neck strain for the next week and then increased activity as tolerated in thefollowing weeks
Sprains and Strains Overview
The body is meant to move. Muscles allow that movement to happen by contracting and making joints
flex, extend and rotate. Muscles attach on each side of the joint to bone by thick bands of fibrous tissue
called tendons. When a muscle contracts, it shortens and pulls on the tendon, which allows the joint to go
through a range of motion.
A strain occurs when the muscle tendon unit is stretched or torn. The most common reason is the
overuse and stretching of the muscle. The damage may occur in three areas:
The muscle itself may tear.
The area where the muscle and tendon blend can tear.
The tendon may tear partially or completely (rupture).
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Joints are stabilized by thick bands of tissue called ligaments which surround them. These ligaments
allow the joint to move only in specific directions. Some joints move in multiple planes; therefore, they
need more than one group of ligaments to hold the joint in proper alignment. The ligaments are anchored
to bone on each side of the joint. If a ligament is stretched or torn, the injury is called a sprain.
Sprains and Strains Causes
Sprains and strains occur when the body is put under stress. In these situations, muscles and joints are
forced to perform movements for which they are not prepared or designed to perform. An injury can occur
from a single stressful incident, or it may gradually arise after many repetitions of a motion.
Sprains and Strains Symptoms
The first symptom of a sprain or strain injury is pain. Other symptoms, such as swelling and spasm, can
take time (from minutes to hours) to develop.
Pain is always a symptom that indicates that there is something wrong with the body. It is the message
to the brain that warns that a muscle or joint should be protected from further harm. In work, exercise,or sport, the pain may come on after a specific incident or it may gradually progress after many
repetitions of a motion.
Swelling almost always occurs with injury, but it may take from minutes to hours to be noticed. Any
time fibers of a ligament, muscle, or tendon are damaged, some bleeding occurs. The bleeding (such
as bruising on the surface of the skin) may take time to be noticed.
Because of pain and swelling, the body starts to favor the injured part. This may cause the muscles
that surround the injured area to go into spasm. Hard knots of muscle might be felt near the site of the
injury.
The combination of pain, swelling, and spasm causes the body to further protect the injured part,
which results in difficulty with use. Limping is a good example of the body trying to protect an injured
leg.
Sprains and Strains Treatment
Self-Care at Home
Initial treatment for sprains and strains should occur as soon as possible. Remember RICE!
Rest the injured part. Pain is the body's signal to not move an injury.
Ice the injury. This will limit the swelling and help with the spasm.
Compress the injured area. This again, limits the swelling. Be careful not to apply a wrap so tightly that
it might act as a tourniquet and cut off the blood supply.
Elevate the injured part. This lets gravity help reduce the swelling by allowing fluid and blood to drain
downhill to the heart.
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Over-the-counter pain medication is an option. Acetaminophen (Tylenol) is helpful for pain, but ibuprofen
(Motrin, Advil) or naproxen (Aleve) might be better because these medications relieve both pain and
inflammation. Remember to follow the guidelines on the bottle for appropriate dose of the medicine,
especially for children and teens. Underlying medical conditions or use of other prescription medicines
may limit the use of over the counter pain medications.
Medical Treatment
Sprains and strains can usually be treated with home therapy using the RICE interventions. However, if
the injury is more severe, your care provider may suggest splinting or casting to rest the injured joint. In
some cases, operations are required to fix complete tears of muscles or tendons to allow complete return
of function and to allow those muscles to do their job of moving the body. Significant tears of ligaments
that stabilize joints also may need repair, but again, most are treated with short-term immobilization and
early return to activity. Sometimes, resting the injury requires some help. Slings for arm injuries or
crutches for leg injuries can be used, in addition to a variety of removable splints to protect the injured
area from further damage and movement. Resting also helps relieve some of the muscle spasm
associated with the injury.
Occasionally, if the injury is especially severe, the physician may want to use a nonremovable splint
made of plaster or fiberglass. Although the splint may look like a cast, it doesn't have plaster or
fiberglass completely encircling the injured area. Instead, by only going partially around an injury, there
is some room to allow for swelling that may occur during the next few days.
Surgery
If the need for an operation is considered, an orthopedic (or bone) specialist is likely to become
involved. Many times these decisions are made over a period of a few days and not immediately,
unless there is concern about the stability of a joint or damage to an artery or nerve.
Shoulder and Neck Pain Overview
Your neck and shoulders contain muscles, bones, nerves, arteries, and veins, as well as many
ligaments and other supporting structures. Many conditions can cause pain in the neck and
shoulder area. Some are life-threatening (such as heart attack and major trauma), and others are
not so dangerous (such as simple strains or contusions).
Shoulder and Neck Pain Causes
The most common cause of shoulder pain and neck pain is injury to the soft tissues, including the
muscles, tendons, and ligaments within these structures. This can occur from whiplash or other injury
to these areas. Degenerative arthritis of the spine in the neck (cervical spine) can pinch nerves that
can cause both neck pain and shoulder pain. Degenerative disc disease in the neck (cervical
spondylosis) can cause local neck pain or radiating pain from disc herniation, causing pinching of
nerves (cervical radiculopathy). Abnormal conditions involving the spinal cord, heart, lungs, and someabdominal organs also can cause neck and shoulder pain. Here are some examples:
Broken collarbone: Falling on your outstretched arm can cause your collarbone to break. This is
particularly common when cyclers fall off of their bicycles.
Bursitis: A bursa is a sac over the joints to provide a cushion to the joints and muscles. These bursae
can become swollen, stiff, and painful after injuries.
Heart attacks: Although the problem is the heart, heart attacks can cause shoulder or neck pain,
known as "referred" pain.
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Broken shoulder blade: An injury to the shoulder blade usually is associated with relatively forceful
trauma.
Rotator cuff injuries: The rotator cuff is a group of tendons that support the shoulder. These tendons
can be injured during lifting, when playing sports with a lot of throwing, or after repetitive use over a
long time. This can lead to pain with motion of the shoulder due to shoulder impingement syndrome
and eventually to a chronic loss of range of motion of the shoulder (frozen shoulder).Shoulder or A-C separation: The collarbone (clavicle) and shoulder blade (scapula) are connected by
ligaments. With trauma to the shoulder, these ligaments can be stretched or torn.
Whiplash injury: Injury to the ligamentous and muscular structures of the neck and shoulder can be
caused by sudden acceleration or deceleration, as in a car accident. This can also cause muscle
spasms in the neck and shoulder areas.
Tendonitis: The tendons connect the muscles to the bones. With strain, the tendons can become
swollen and cause pain. This is also referred to as tendinitis.
Gallbladder disease: This can cause a pain referred to the right shoulder.
Any cause of inflammation under the diaphragm can also cause referred pain in the shoulder.
Shoulder and Neck Pain Symptoms and Signs
Pain: All pain seems sharp, but pain can also be described as dull, burning, crampy, shocklike, or
stabbing. Pain can lead to a stiff neck or shoulder and loss of range of motion. Headache may result.
The character of each symptom is important to your doctor because the particular features can be
clues to the cause of your pain.
Weakness: Weakness can be due to severe pain from muscle or bone movement. The nerves that
supply the muscles, however, also could be injured. It is important to distinguish true weakness
(muscle or nerve damage) from inability or reluctance to move because of pain or inflammation.
Numbness: If the nerves are pinched, bruised, or cut, you may not be able to feel things normally. This
may cause a burning or tingling sensation, a loss of sensation, or an altered sensation similar to
having your arm "fall asleep."
Coolness: A cool arm or hand suggests that the arteries, veins, or both have been injured or blocked.This may mean that not enough blood is getting into the arm.
Color changes: A blue or white tinge to the skin of your arm or shoulder is another sign that the
arteries or veins could have been injured. Redness can indicate infection or inflammation. Rashes may
be noted as well. Bruising may be evident.
Swelling: This may be generalized to the whole arm or may be localized over the involved structures (a
fracture area or an inflamed bursa, for example). Muscle spasms or tightness may simulate actual
swelling. Dislocation or deformity may cause a swollen appearance or, paradoxically, a sunken area.
Deformity: A deformity may be present if you have a fracture or a dislocation. Certain ligament tears
can cause an abnormal positioning of the bony structures.
When to Seek Medical Care
If pain or other symptoms start to worsen, call your doctor or immediately go to a hospital emergency
department.
For milder cases, basic home-care measures (see below) are adequate until your doctor can see you.
In many cases, simple injuries, such as strains and bruises, heal themselves and do not require an
office visit.
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For persisting pain in the shoulder or neck, an evaluation by a health-care professional is appropriate.
If you have severe or worsening pain, weakness, numbness, coolness, deformity, or color changes,
you should go to a hospital emergency department immediately.
If you develop a high fever (temperature >102.5 F), severe headache, chest pain, shortness of breath,
dizziness, nausea, or sweatiness, or if you develop the sudden onset of numbness or weakness,
particularly on one side of the body, call 911 for emergency services to go to the nearest emergencydepartment by ambulance.
Shoulder and Neck Pain Treatment
Self-Care at Home
Minor injuries that have only slight pain can be treated at home. If the source of the pain and the cause of
the pain are not known, or if symptoms suggest you might have a more serious condition, you should
contact your doctor while initiating basic care measures.
Rest: Use the injured area as little as possible for the first two to three days, then slowly begin to
exercise the injured area. This speeds recovery.
Ice: Place the ice in a plastic bag, wrap the bag with a towel, and then apply to the injured area for 15-
20 minutes every hour. Directly applying ice can damage the skin.
Elevation: Elevation of the injured area above your heart helps the swelling go down. This reduces
your pain. Use pillows to prop yourself up.
Pain control: Acetaminophen (Tylenol) or ibuprofen (Advil, Motrin) can help control swelling and pain.
Heat: Do not apply heat in the first week after an injury because it can increase the swelling in the
injured area and worsen your pain.
Medical Treatment
A treatment plan will be developed after a complete history and physical examination (and any tests, ifindicated). Treatment options vary for each condition. Clearly, a simple strain is treated far differently than
a heart attack.
If you have a minor sprain or strain, then you can expect a combination of the following treatments:
o Pain medications: It may take several days to settle the pain down using acetaminophen (Tylenol)
with or without an anti-inflammatory medicine such as ibuprofen (Advil or Motrin) or naproxen
(Aleve). Stronger narcotic-containing medicines are usually not necessary, but your doctor may
provide these for the first few days.
o Immobilization: This may be accomplished possibly using a splint, cast, or sling. It is very important
to follow your doctor's instructions regarding the use of these devices, particularly when it is
advised to discontinue the use and begin moving the area.o Instructions: It's best to rest and elevate the injured area. Continued use of the injured area may not
necessarily make the injury worse, but it can prolong the symptoms. In most cases, limited use is
acceptable within normal ranges of motion and without weight or strain.
o Hospital stay: If you are more severely injured, you may need to be admitted to the hospital for
further testing or may be referred to an orthopedist (bone and joint specialist) for care.
Low Back Pain Overview
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Picture of a herniated lumbar disc, a common cause of sciatica
o Spondylosis occurs as intervertebral discs lose moisture and volume with age, which decreases the
disc height. Even minor trauma under these circumstances can cause inflammation and nerve root
impingement, which can produce classic sciatica without disc rupture.
o Spinal disc degeneration coupled with disease in joints of the low back can lead to spinal-canal
narrowing (spinal stenosis). These changes in the disc and the joints produce symptoms and can
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be seen on an X-ray. A person with spinal stenosis may have pain radiating down both lower
extremities while standing for a long time or walking even short distances.
o
Cauda equina syndrome is a medical emergency whereby the spinal cord is directly compressed.Disc material expands into the spinal canal, which compresses the nerves. A person would
experience pain, possible loss of sensation, and bowel or bladder dysfunction. This could include
inability to control urination causing incontinence or the inability to begin urination.
Musculoskeletal pain syndromes that produce low back pain include myofascial pain syndromes
and fibromyalgia.
o Myofascial pain is characterized by pain and tenderness over localized areas (trigger points), loss
of range of motion in the involved muscle groups, and pain radiating in a characteristic distribution
but restricted to a peripheral nerve. Relief of pain is often reported when the involved muscle group
is stretched.
o Fibromyalgia results in widespread pain and tenderness throughout the body. Generalized
stiffness, fatigue, and muscle aches are reported.
Infections of the bones (osteomyelitis) of the spine are an uncommon cause of low back pain.
Noninfectious inflammation of the spine (spondylitis) can cause stiffness and pain in the spine that is
particularly worse in the morning. Ankylosing spondylitis typically begins in adolescents and young
adults.
Tumors, possibly cancerous, can be a source of skeletal pain.
Inflammation of nerves from the spine can occur with infection of the nerves with the herpes zoster
virus that causes shingles. This can occur in the thoracic area to cause upper back pain or in the
lumbar area to cause low back pain.
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As can be seen from the extensive, but not all inclusive, list of possible causes of low back pain, it is
important to have a thorough medical evaluation to guide possible diagnostic tests.
Low Back Pain Symptoms
Pain in the lumbosacral area (lower part of the back) is the primary symptom of low back pain.
The pain may radiate down the front, side, or back of your leg, or it may be confined to the low back.
The pain may become worse with activity.
Occasionally, the pain may be worse at night or with prolonged sitting such as on a long car trip.
You may have numbness or weakness in the part of the leg that receives its nerve supply from a
compressed nerve.
o This can cause an inability to plantar flex the foot. This means you would be unable to stand on
your toes or bring your foot downward. This occurs when the first sacral nerve is compressed or
injured.
o Another example would be the inability to raise your big toe upward. This results when the
fifth lumbar nerve is compromised.
When to Seek Medical Care
The Agency for Healthcare Research and Quality has identified 11 red flags that doctors look for when
evaluating a person with back pain. The focus of these red flags is to detect fractures (broken bones),
infections, or tumors of the spine. Presence of any of the following red flags associated with low back pain
should prompt a visit to your doctor as soon as possible for complete evaluation.
Recent significant trauma such as a fall from a height, motor vehicle accident, or similar incident
Recent mild trauma in those older than 50 years of age: A fall down a few steps or slipping and landing
on the buttocks may be considered mild trauma.
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History of prolonged steroid use: People with asthma, COPD, and rheumatic disorders, for example,
may be given this type of medication.
Anyone with a history of osteoporosis: An elderly woman with a history of a hip fracture, for example,
would be considered high risk.
Any person older than 70 years of age: There is an increased incidence ofcancer, infections, and
abdominal causes of the pain.
Prior history of cancer
History of a recent infection
Temperature over 100 F
IV drug use: Such behavior markedly increases risk of an infectious cause.
Low back pain worse at rest: This is thought to be associated with an infectious or malignant cause of
pain but can also occur with ankylosing spondylitis.
Unexplained weight loss
The presence of any of the above would justify a visit to a hospital's emergency department, particularly if
your family doctor is unable to evaluate you within the next 24 hours.
The presence of any acute nerve dysfunction should also prompt an immediate visit. These would
include the inability to walk or inability to raise or lower your foot at the ankle. Also included would be
the inability to raise the big toe upward or walk on your heels or stand on your toes. These might
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indicate an acute nerve injury or compression. Under certain circumstances, this may be an acute
neurosurgical emergency.
Loss of bowel or bladder control, including difficulty starting or stopping a stream of urine orincontinence, can be a sign of an acute emergency and requires urgent evaluation in an emergency
department.
If you cannot manage the pain using the medicine you are currently prescribed, this may be an
indication for a reevaluation or to go to an emergency department if your doctor is not available.
Generally, this problem is best addressed with the doctor writing the prescription who is overseeing
your care.
Low Back Pain Exams and Tests
Medical history
Because many different conditions may cause back pain, a thorough medical history will be performed
as part of the examination. Some of the questions you are asked may not seem pertinent to you but
are very important to your doctor in determining the source of your pain.
Your doctor will first ask you many questions regarding the onset of the pain. (Were you lifting a heavy
object and felt an immediate pain? Did the pain come on gradually?) He or she will want to know what
makes the pain better or worse. The doctor will ask you questions referring to the red flag symptoms.
He or she will ask if you have had the pain before. Your doctor will ask about recent illnesses and
associated symptoms such as coughs,fevers, urinary difficulties, or stomach illnesses. In females, the
doctor will want to know about vaginal bleeding, cramping, or discharge. Pain from the pelvis, in thesecases, is frequently felt in the back.
Physical examination
To ensure a thorough examination, you will be asked to put on a gown. The doctor will watch for signs
of nerve damage while you walk on your heels, toes, and soles of the feet. Reflexes are usually tested
using a reflex hammer. This is done at the knee and behind the ankle. As you lie flat on your back, one
leg at a time is elevated, both with and without the assistance of the doctor. This is done to test the
nerves, muscle strength, and assess the presence of tension on the sciatic nerve. Sensation is usually
tested using a pin, paper clip, broken tongue depressor, or other sharp object to assess any loss of
sensation in your legs.
Depending on what the doctor suspects is wrong with you, the doctor may perform an abdominal
examination, a pelvic examination, or a rectal examination. These exams look for diseases that can
cause pain referred to your back. The lowest nerves in your spinal cord serve the sensory area and
muscles of the rectum, and damage to these nerves can result in inability to control urination and
defecation. Thus, a rectal examination is essential to make sure that you do not have nerve damage in
this area of your body.
Imaging
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tone. Very few experts recommend more than a 48-hour period of decreased activity or bed rest. In
other words, get up and get moving to the extent you can.
Medical Treatment
Initial treatment of low back pain is based on the assumption that the pain in about 90% of people will goaway on its own in about a month. Many different treatment options are available. Some of them have
been proven to work while others are of more questionable use. You should discuss all remedies you
tried with your health-care provider.
Home care is recommended for the initial treatment of low back pain. Bed rest remains of unproven
value, and most experts recommend no more than two days of bed rest or decreased activity. Some
people with sciatica may benefit from two to fours days of rest. Application of local ice and heat provide
relief for some people and should be tried.Acetaminophen and ibuprofen are useful for controlling pain.
Many studies have called into question the usefulness of our present treatment of back pain. For any
given person, it is not known if a particular therapy will provide benefit until it is tried. Your doctor may
try treatments known to be helpful in the past.
Low Back Pain Medications
Medication treatment options depend on the precise diagnosis of the low back pain. Your doctor will
decide which medication, if any, is best for you based on your medical history, allergies, and other
medications you may be taking.
Nonsteroidal anti-inflammatory medications (NSAIDs) are the mainstay of medical treatment for the
relief of back pain. Ibuprofen, naproxen, ketoprofen, and many others are available. No
particular NSAIDhas been shown to be more effective for the control of pain than another. However,
your doctor may switch you from one NSAID to another to find one that works best for you.
COX-2 inhibitors, such as celecoxib(Celebrex), are more selective members of NSAIDs. Although
increased cost can be a negative factor, the incidence of costly and potentially fatal bleeding in the
gastrointestinal tract is clearly less with COX-2 inhibitors than with traditional NSAIDs. Long-term
safety (possible increased risk for heart attack or stroke) is currently being evaluated for COX-2
inhibitors and NSAIDs.
Acetaminophen is considered effective for treating acute pain as well. NSAIDs do have a number of
potential side effects, including gastric irritation and kidney damage, with long-term use.
Muscle relaxants: Muscle spasm is not universally accepted as a cause of back pain, and most
relaxants have no effect on muscle spasm. Muscle relaxants may be more effective than a placebo
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(sugar pill) in treating back pain, but none has been shown to be superior to NSAIDs. No additional
benefit is gained by using muscle relaxants in combination with NSAIDs over using NSAIDs alone.
Muscle relaxants cause drowsiness in up to 30% of people taking them. Their use is not routinely
recommended.
Opioid analgesics: These drugs are considered an option for pain control in acute back pain. The use
of these medications is associated with serious side effects, including dependence, sedation,
decreased reaction time, nausea, and clouded judgment. One of the most troublesome side effects
isconstipation. This occurs in a large percentage of people taking this type of medication for more than
a few days. A few studies support their short-term use for temporary pain relief. Their use, however,
does not speed recovery.
Steroids: Oral steroids can be of benefit in treating acute sciatica. Steroid injections into the epidural
space have not been found to decrease duration of symptoms or improve function and are not
currently recommended for the treatment of acute back pain without sciatica. Benefit in chronic
pain with sciatica remains controversial. Injections into the posterior joint spaces, the facets, may be
beneficial for people with pain associated with sciatica. Trigger point injections have not been proven
helpful in acute back pain. Trigger point injections with a steroid and a local anesthetic may be helpful
in chronic back pain. Their use remains controversial.
Low Back Pain Surgery
Surgery is seldom considered for acute back pain unless sciatica or the cauda equina syndrome is
present. Surgery is considered useful for people with certain progressive nerve problems caused by
herniated discs.
Head Injury Overview
Traumatic head injuries are a major cause of death, and disability but it might be best to refer to the
damage done as traumatic brain injury.
The purpose of the head, including the skull and face, is to protect the brain against injury. In addition to
the bony protection, the brain is covered in tough fibrous layers called meninges and bathed in fluid that
may provide a little shock absorption.
When an injury occurs, loss of brain function can occur even without visible damage to the head. Force
applied to the head may cause the brain to be directly injured or shaken, bouncing against the inner wall
of the skull. The trauma can potentially cause bleeding in the spaces surrounding the brain, bruise the
brain tissue, or damage the nerve connections within the brain.
Caring for the victim with a head injury begins with making certain that the ABCs of resuscitation are
addressed (airway, breathing, circulation). Many individuals with head injuries are multiple trauma victims
and the care of their brain may take place at the same time other injuries are stabilized and treated.
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Skull Fracture
The skull is made up of many bones that form a solid container for the brain. The face is the front part of
the head and also helps protect the brain from injury. Depending upon the location of the fracture, there
may or may not be a relationship between a fractured skull and underlying brain injury. Of note, a
fracture, break, and crack all mean the same thing, that the integrity of the bone has been compromised.
One term does not presume a more severe injury than the others. Fractures of the skull are described
based on their location, the appearance of the fracture, and whether the bone has been pushed in.
Location is important because some skull bones are thinner and more fragile than others. For example,
the temporal bone above the ear is relatively thin and can be more easily broken than the occipital bone
at the back of the skull. The middle meningeal artery is located in a groove within the temporal bone. It is
susceptible to damage and bleeding if the fracture crosses that groove.
Basilar skull fractures occur because of blunt trauma and describe a break in the bones at the base
of the skull. These are often associated with bleeding around the eyes (raccoon eyes) or behind the
ears (Battle's sign). The fracture line may extend into the sinuses of the face and allow bacteria from
the nose and mouth to come into contact with the brain, causing a potential infection.
In infants and young children, whose skull bones have not yet fused together, a skull fracture may
cause a diastasis fracture, in which the bone junctions (called suture lines) widen.
Fractures can be linear (literally a line in the bone) or stellate (a starburst like pattern) and the pattern
of the break is associated with the type of force applied to the skull.
Penetrating skull fractures describe injuries caused by an object entering the brain. This includes
gunshot and stab wounds, and impaled objects to the head.
A depressed skull fracture occurs when a piece of skull is pushed toward the inside of the skull
(think of pressing in on a ping pong ball). Depending upon circumstances, surgery may be required toelevate the depressed fragment.
It is important to know whether the fracture is open or closed (this describes the condition of the skin
overlying the broken bone). An open fracture occurs when the skin is torn or lacerated over the
fracture site. This increases the risk of infection, especially with a depressed skull fracture in which
brain tissue is exposed. In a closed fracture, the skin is not damaged and continues to protect the
underlying fracture from contamination from the outside world.
Intracranial Bleeding
Intracranial (intra=within + cranium=skull) describes any bleeding within the skull. Intracerebralbleeding describes bleeding within the brain itself. More specific descriptions are used based upon
where the blood is located.
Bleeding in the skull may or may not be associated with a skull fracture. An intact skull is no guarantee
that there is not underlying bleeding, or hemorrhage, in the brain or its surrounding spaces. For that
reason, plain X-rays of the skull are not routinely performed.
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Epidural, subdural, and subarachnoid bleeding are terms that describe bleeding in the spaces between
the meninges, the fibrous layered coverings of the brain. Sometimes, the terms hemorrhage (bleeding)
and hematoma (blood clot) are interchanged. Because the skull is a solid box, any blood that
accumulates within the skull can increase the pressure within it and compress the brain. Moreover,
blood is irritating and can cause edema or swelling as excess fluid leaks from the surrounding blood
vessels. This is no different than the swelling that can occur surrounding a bruise on an arm or leg. The only difference is that there is no room within the skull to accommodate that swelling.
Subdural Hematoma
When force is applied to the head, bridging veins that cross through the subdural space (sub=beneath
+dura= one of the meninges that line the brain) can tear and bleed. The resultant blood clot increases
pressure on the brain tissue. Subdural hematomas can occur at the site of trauma, or may occur on
the opposite side of the injury (contracoup: contra=opposite + coup=hit) when the brain accelerates
toward the opposite side of the skull and crushes or bounces against the opposite side.
Chronic subdural hematoma may occur in patients who have had atrophy (shrinkage) of their brain
tissue. These include the elderly and chronic alcoholics. The subdural space increases and the
bridging veins get stretched as they cross a much wider distance. Minor or unnoticed injuries can lead
to some bleeding, but because there is enough space in the skull to accommodate the blood, there
may be minimal initial symptoms. Asymptomatic (producing no symptoms) chronic subdural
hematomas may be left to resolve on their own; however, it may require attention if the individual's
mental status changes or further bleeding occurs.
Depending upon the neurologic status of the affected individual, surgery may be required.
Epidural Hematoma
Thee dura is one of the meninges or lining membranes that covers the brain. It attaches at the suturelines where the bones come together. If the head trauma is epidural (epi=outside +dura) the blood is
trapped in a small area and cause a hematoma or blood clot to form. Pressure can increase quickly
within the epidural space, pushing the clot up against the brain and causing significant damage.
While individuals who sustain small epidural hematomas may be observed, most require surgery.
Patients have improved survival and brain function recovery if the operation to remove the hematoma
and relieve pressure on the brain occurs before they have lost consciousness and become comatose.
An epidural hematoma may often occur with trauma to the temporal bone located on the side of the
head above the ear. Aside from the fact that the temporal bone is thinner than the other skull bones
(frontal, parietal, occipital), it is also the location of the middle meningeal artery that runs just beneath
the bone. Fracture of the temporal bone is associated with tearing of this artery and may lead to an
epidural hematoma.
Subarachnoid Hemorrhage
In a subarachnoid hemorrhage, blood accumulates in the space beneath the inner arachnoid layer of
the meninges. The injury is often associated with an intracerebral bleed (see below). This is also the
space where cerebral spinal fluid (CSF) flows and affected individuals can develop
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severe headache,nausea, vomiting, and a stiff neck because the blood causes significant irritation to
this meningeal layer. It is the same response that can be seen in patients who have a leaking cerebral
aneurysm or meningitis. Treatment is often observation and controlling the symptoms.
Intraparenchymal Hemorrhage/Intracerebral Hemorrhage/Cerebral Contusion
These terms describe bleeding within the brain tissue itself and can be considered a bruise to the brain
tissue.
Aside from the direct damage to the brain tissue that was injured, swelling or edema is the major
complication of an intracerebral bleed.
Surgery is not often considered except in situations in which the pressure within the skull increases to
the point at which part of the bone is temporarily removed to allow the brain to expand. When and if
the brain swelling resolves, another operation replaces the piece of skull that was removed.
Diffuse Axonal Injury or Shear Injury
A potentially devastating brain injury occurs when the brain injury occurs to the axons, the part of the
neurons or brain cell that allows those cells to send messages to each other. Because of the damage
of electrical flow between cells, the affected individual often appears comatose with no evidence of
bleeding within the brain. The mechanism of injury is usually acceleration-deceleration, and the nerve
endings that connect the brain cells rip apart.
Treatment is supportive, meaning that there is no surgery or other treatment presently available. The
patient's basic needs are met hoping that the brain will recover on its own. Most don't.
Concussions may be potentially considered a milder form of this type of injury.
Picture of the areas of the brain subject to injury
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Picture of an epidural, subdural, and intracerebral hematomas
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Head Injury Causes
Traumatic head injury affects more than 1.7million people in the United States each year including almost
a half million children; 52,000 people die.
Adults suffer head injuries most frequently due to falls, motor vehicle crashes, colliding or being struck by
an object, and assaults. Falls and being struck are the most common causes of head injury in children.
National traumatic brain injury estimates from the CDC
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Head Injury Symptoms
It is important to remember that a head injury can have different symptoms and signs, ranging from a
patient experiencing no initial symptoms to coma.
A high index of suspicion that a head injury may exist is important, depending upon the mechanism of
injury and the initial symptoms displayed by the patient. Being unconscious, even for a short period of
time is not normal. Prolonged confusion, seizures, and multiple episodes of vomiting should be signs that
prompt medical attention is needed.
In some situations, concussion-type symptoms can be missed. Patients may experience difficulty
concentrating, increased mood swings, lethargy or aggression, and altered sleep habits among other
symptoms. Medical evaluation is always wise even well after the injury has occured.
Head Injury in Infants and Young Children
Infants often visit health care practitioner because of a head injury. Toddlers tend to fall as they learn to
walk, and falls remain the number one cause of head injury in children. While guidelines exist regarding
the evaluation of head injury victims, they tend to be applied to those older than 2 years of age.
A minor head injury in an infant is described by the American Academy of Pediatrics as the following: a
history or physical signs of blunt trauma to the scalp, skull, or brain in an infant or child who is alert or
awakens to voice or light touch.
Infants are usually unable to complain about headache or other symptoms. Therefore, basic guidelines as
to when to seek medical care can include the following:
Altered mental status. The child is not acting or behaving normally for that child.
Vomiting
Scalp abnormalities including lacerations and swelling that may be associated with skull fracture
Forehead contusions tend to be less worrisome than occipital (back of the head) contusions
Seizure
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Often a careful physical examination is all that is needed to assess the infant's risk for intracranial
hemorrhage, but some testing may be considered.
CT scan may be indicated based upon the health care practitioner's assessment of the child. Plain skull
X-rays may be considered to look for a fracture, as a screening tool to decide about the need for a CT
scan.
Usually, if the health care practitioner finds no evidence for concern, the infant can be discharged home
for observation. While parents may choose to, there is no need to keep the infant awake or waken them
should they fall asleep.
Head Injury Guidelines and Assessment: Glasgow Coma Scale
The Glasgow Coma Scale was developed to provide a simple way for health care practitioners of different
skill levels and training to quickly assess a patient's mental status and depth of coma based upon
observations of eye opening, speech, and movement. Patients in the deepest level of coma:
do not respond with any body movement to pain,
do not have any speech, and
do not open their eyes.
Those in lighter comas may offer some response, to the point they may even seem awake, yet meet the
criteria of coma because they do not respond to their environment.
When to Seek Medical Care
Call 911 or activate your local emergency response service should any person sustain a significant
head injury. This includes all persons with loss of consciousness who do not immediately waken andreturn to normal as well as those who show signs of weakness or numbness on one side of their body,
complain of difficulty speaking, or have vision loss. These are the same symptoms as a person having
a stroke.
Mechanism of injury is also an important consideration. Persons in a motor vehicle collision or who
have fallen from a height should be kept still with their neck protected, in case there is an associated
spinal cord injury.
Other symptoms that should prompt seeking medical care include confusion, loss of short-term
memory, and repeatedvomiting.
A less specific symptom but one that can also be used with children is to decide whether the person is
acting like his or herself. This is a subtle and non specific way of evaluating an injured person, but if
there is concern that they are not acting "normal", medical care should be accessed.
Persons with head injuries who are impaired because of alcohol or drugs should be brought for
medical attention and evaluation.
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Those who are taking prescription blood thinning medications such as warfarin(Coumadin), dabigatran
etexilate (Pradaxa), enoxaparin (Lovenox), and heparinshould seek medical care for all head injuries,
even if it is very minor.
Head Injury Diagnosis
The physical examination and the history of the exact details of the injury are the first steps in caring for a
patient with head injury. The patient's past medical history and medication usage will also be important
factors in deciding the next steps. Plain skull X-rays are rarely done for the evaluation of head injury. It is
more important to assess brain function than to look at the bones that surround the brain. Plain X-ray
films may be considered in infants to look for a fracture, depending upon the clinical situation.
Computerized tomography (CT) scan of the head allows the brain to be imaged and examined for
bleeding and swelling in the brain. It can also evaluate bony injuries to the skull and look for bleeding in
the sinuses of the face associated with basilar skull fractures. CT does not assess brain function, and
patients suffering axonal shear injury may be comatose with a normal CT scan of the head.
Numerous guidelines exist to give direction as to when a CT should be completed in patients who presentawake after sustaining a minor head injury.
The Ottawa CT head rules apply to patients age 2 to 65.
High Risk
Glasgow Coma Scale less than 15, two hours after injury
Suspect open or depressed skull fracture
Sign of basilar skull fracture
Vomiting more than once
Older than 65 years of age
Medium Risk
Amnesia before impact greater than 30 minutes
Dangerous mechanism of injury
Head Injury Treatment
Head Injury Self-Care at Home
Many people who hit their heads do not need to seek medical attention. People often hit their heads on a
cupboard or trip and fall on a soft surface, get up and dust themselves off and are otherwise well.
Occasionally, a bump can occur underneath the skin of the scalp or forehead. This 'goose egg' is a
hematoma on the outside of the skull and is not necessarily related to any potential bleeding that can
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affect the brain. Treatment is the same as any other bruise or contusion and includes ice, and over-the-
counter pain medication.
Car accidents can cause many different injuries, to virtually any part of your body, depending on the circumstances ofthe crash and the severity of the impact. But if you take a closer look at the range of insurance claims and personal
injury lawsuits related to auto accidents, you'll see that certain injuries crop up more than others. This
article discusses the most common car accident injuries.
Brain and Head Injuries - In an injury after, an accident, one of the most common injuries suffered by drivers and
passengers is a closed head injury, which can range from a mild concussion to a traumatic brain injury (TBI). Even
when there is no physical sign of trauma (i.e. cuts or bruises), the brain is at risk of being jostled inside the
skull because of the impact of a car crash, so that bruising and other injuries can result.
Neck Injuries - Another common form of injury from a car accident is neck injuries, which can occur in more mild
forms such as whiplash and neck strain, to more serious injuries like cervical radiculopathy and disc injury.
Back Injuries - The impact of a car accident and the resulting torque on the bodies of drivers and passengers can
cause back injuries such as a sprain, strain, fracture, disc injury, thoracic spine injury, lumbar radiculopathy, and
lumbar spine injury. Like neck injuries, sometimes the symptoms of even the most serious back injuries can take
some time to show up after an accident, and just as often a back injury can cause longlasting pain and discomfort.
Face Injuries - In a car accident, injuries to the face can be caused by almost anything -- including a steering wheel,
dashboard, airbag, windshield, side window, car seats or shattered glass. These injuries range in severity
from scrapes and bruises, to laceration and fractures, even Temporomandibular disorders of the jaw (TMJ) and
serious dental injuries.
Psychological Injuries - Injuries caused by car accidents aren't limited to the physical. Especially after serious caraccidents involving severe injuries and even loss of life, drivers and passengers may suffer short or long-term
psychological injuries such as emotional distress, and may even develop conditions that closely resemble post
traumatic stress disorder (PTSD).