Injuries to the head are relatively common in contact sports. Unfortunately they are poorly understood and poorly managed by the majority of the public, sports teams, coaches, referees and administrators. Knowing about head injuries is important – one day it may save someone's life (possibly your own!).

How Do Head Injuries Occur?

Most head injuries that occur while playing sport are due to an unexpected change in the motion of head. The head may be decelerated to a sudden stop (e.g. by a collision or a fall) or the head maybe suddenly accelerated (e.g. by a kick or punch).

Impact deceleration

Linear acceleration

Rotational acceleration

x = site of damage

Rotational acceleration forces produce more damage than linear forces.

Why Are These Forces Harmful?

The head is best thought of as two separate structures:

1. The "container'- scalp and skull bones
2. The 'contents' – brain and surrounding blood vessels

The contents float inside the skull cushioned by a sea of cerebrospinal fluid. A sudden change in motion causes the contents to accelerate or decelerate inside the skull. The brain may impact against the inside of the skull; blood vessels and nerves may also be stretched and torn.

What Damage Can Occur?

Let us look at all 4 structures in turn.

Scalp Injuries

• The scalp has lots of blood vessels running through it. If both the skin and underlying blood vessels are torn, a large amount of blood can be lost. If the blood vessels are torn but the skin remains intact a large bruise or haematoma (blood clot) can develop.
• Scalp wounds usually heal well but may become infected if hair or dirt are driven in. If there is a fracture underneath, infection may travel to the brain with serious consequences.
• Scalp injuries serve as a warning that there may be more serious injuries to the "contents".

Skull Injuries

If the skull is fractured, complications are 40 times more likely to occur. Fractures can only be detected by x-rays and CAT Scans.

Brain

Injuries to the brain cells can be either structural or functional. Structural damage means that the brain cells have been physically damaged e.g. bruised, lacerated or swollen. Functional damage means that the brain cells have temporarily stopped working but have not been physically damaged.

Blood Vessels

Numerous blood vessels run between the inside of the skull and the surface of the brain.

When the brain suddenly accelerates or decelerates inside the skull these delicate blood vessels may be torn. If the bleeding continues inside the skull a blood clot may form. Pressure from the blood clot on the brain will eventually interfere with vital functions such as the level of consciousness, pupil size, ability to move the limbs and finally, breathing and heart activity.

Diagram showing where clots can occur

The blood clot can develop immediately after the injury or it may be delayed for several hours. This is of vital importance because it means that a person can be completely well immediately after an injury, but can still develop serious and sometimes fatal complications later on (usually within 4-12 hours). Haematoma's are the most common cause of death amongst boxers injured in the ring.

How Do You Assess Injuries To The Brain?

Injuries to the brain cells result in changes to the person's level of consciousness, memory and motor skills. Hence, these are the areas that need to be assessed.

1. Has The Person Been Unconscious?

A person is unconscious when they are unable to open their eyes, speak or move their limbs either spontaneously, when asked or when a painful stimulus is applied (e.g. squeezing their trapezius muscle).

2. Is The Persons Memory Impaired?

Ask the patient a few simple questions e.g.

• what time is it?
• what day is it?
• what month is it?
• what year is it?
• who is the Prime Minister?

3. Does The Person Have Impaired Motor Skills?

Ask the patient to walk in a straight line and to balance on one leg.

Knowledge of these three areas allows us to categorise brain injuries as follows:

Severity	Loss of Consciousness	Memory	Motor Skills
Minimal	Nil	Normal	Normal
Moderate	Nil or brief (secs)	Impaired	Impaired
Severe	Prolonged (mins – hours)	Grossly impaired	Grossly impaired

This classification allows us to avoid using the term "concussion" which means different things to different people.

How Do You Know If There Is Bleeding Inside The Skull?

A blood clot pushing on the brain will cause:

• severe headache
• vomiting
• altered level of consciousness (e.g. drowsiness or confusion or disorientation)
• changes to pupils, breathing and circulation occur at a later stage (just before death!)

What Is Post-Concussion Syndrome?

After mild, moderate or severe brain injuries the following symptoms are common:

• headache (mild)
• dizziness
• tiredness
• clumsiness
• poor concentration
• poor memory
• altered behaviour

These symptoms may take several weeks or months to settle.

What Are The Dangers Of Repeated Head Injuries?

1. The brain takes time to recover after an injury. A second injury occurring within 3 weeks of the first is much more likely to produce complications, especially brain swelling (cerebral oedema) – this is often fatal within minutes of the second injury.
2. Repeated head injuries (even if minor) can lead to the "Punch-Drunk" syndrome. This consists of a multitude of problems including dizziness, poor co-ordination, poor memory, mood alterations, slurred speech, tremors, psychiatric symptoms and difficulty walking. These are often permanent – Mohammed Ali is a good example.

What Can Be Done To Minimise The Risks After A Head Injury?

1. Any athlete who receives a significant head injury should not be allowed to continue to fight or train.
2. A head-injured athlete should always be checked by a doctor.
3. A head-injured athlete should not be allowed to return home without supervision. Sometimes head-injured athletes lose their insight and common sense and may become irritable, aggressive and uncooperative. They may refuse to go to a doctor or to a hospital. If this happens someone responsible should stay with them until they have returned to normal.
4. After a head injury a player should not participate in competition or training for at least 4 weeks and then, only if cleared by a doctor.
5. If injured twice in a season, a player should not compete again that season. After four head injuries it is advisable to avoid all contact sport.
6. All head-injured players, upon recovery, should be made aware of the significance of their injury.
7. Alcohol and risky activities (e.g. driving and operating heavy machinery) should be avoided till fully recovered.
8. Rest is very important if "post-concussion" symptoms are present.

Does Wearing Protective Head Gear Help Prevent Complications?

Controversial!! Theoretically the use of helmets should minimise the accelerative and decelerative forces that are so destructive to the brain cells, nerves and blood vessels. While the wearing of helmets is commonplace in other sports such as motor-racing, cycling, climbing, American football, kayaking, high speed water and snow skiing and hang-gliding, these sports utilise rigid helmets which are much more efficient shock absorbers. Some studies have suggested that headgear, by making the head a larger target, may increase the chance of brain injury.

Worldwide there are mounting calls for boxing to be banned 'on moral, ethical and medical grounds'. Unless we take steps to make martial arts as safe as possible, we could soon be facing a similar situation.