It is a Friday evening in September and you are notified that EMS is bringing in a 17-year-old athlete who sustained a head and neck injury while playing high school football.
As many as a quarter of catastrophic c-spine injuries from football collisions may be exacerbated by the poor removal of helmet and pads. here’s a detailed primer on safe removal, just in time for high school football season.
It is a Friday evening in September and you are notified that EMS is bringing in a 17-year-old athlete who sustained a head and neck injury while playing high school football. He had no LOC but complained of numbness and tingling in both arms after he tackled another player. He will be arriving via a volunteer rescue unit, and the radio report indicated that he remains in his helmet and shoulder pads with c-spine immobilization achieved with towel rolls. You have 10 minutes to gather your team and the tools you will need to remove his equipment.
Background
Each year thousands of athletes are transported to emergency departments after suffering injuries to the head or cervical spine. Fortunately, most are treated and released after physical exam and radiographic clearance, but roughly 250-300 athletes per year are found to have suffered c-spine fractures. Nine to twelve of these will be catastrophic, resulting in incomplete recovery with some form of life-long disability [1]. The financial burden alone can be overwhelming, initially costing upwards of 1 million dollars and approximately $150,000 annually thereafter [2]. Importantly, it has been estimated that 25% of these injuries are actually made worse by the “handling” of the equipment-laden athlete during the transportation and evaluation processes [3]. Often paramedics and ED personnel have little, if any, experience in the proper techniques of safely removing the facemask, helmet, and shoulder pads of a football player with suspected cervical spine injury. Special care must be taken to maintain a neutral cervical spine throughout the entire process. Removing the equipment is essential in keeping with ATLS guidelines, and no effective radiographic studies can be completed prior to removal [4,5].
Prehospital Care
Effective care of the athlete begins immediately after injury. Research by Hordosky and Rechtine has shown the traditional log-roll maneuver to be ineffective in maintaining cervical neutrality while placing the equipment-laden athlete on a longboard. The 6-person lift or the lift and slide maneuver reduces cervical spine motion during the transfer process [6]. If possible, the helmet and pads should be removed prior to transport to permit access to the patient’s airway and chest, and a Certified Athletic Trainer, present at most games, can provide crucial assistance to EMS personnel in immobilizing the patient and removing equipment. Wet undergarments should be cut and removed to maintain core temperature and permit application of an AED, if needed.
Emergency Department Care
The patient in the case above presented to the ED with all his protective gear in place, leaving it up to the trauma team to undertake removal before assessment and intervention could begin. A list of necessary equipment is located in the sidebar. These tools should be made available prior to patient presentation.
The helmet and facemask must be removed to gain access to the patient’s airway. As long as the chin strap remains in place, a bag valve mask cannot be used to venti- late the athlete due to excessive air leakage around the chin strap. However, if the chin strap is cut while the helmet remains affixed to the board, the head and cervical spine can easily move within the helmet. Therefore, it is essential that the helmet should be removed immediately after the chin strap is cut.
Figure 1: Placing the athlete on the longboard with the 6 person lift and slide maneuver
Figure 2: Riddell helmet push button release
In the past 6 years, the design of the football helmet and facemask have improved dramatically and they can now be removed in a safe, efficient manner without the use of special tools. Of the four most popular types of football helmets, only those manufactured by Riddell and Schutt have a quick release feature. The Riddell helmets have push button releases on the loop strap that hold the facemask in place (Figure 2). The loop straps can be easily removed by pushing the center of the button and lifting the entire strap. Schutt helmets have a quarter turn release that holds the loop strap. This can be removed by turning the screw a quarter turn so that the screw “pops up.” Once this occurs, the loop strap can be removed with the facemask (Figure 1). Fortunately, the Riddell and Schutt models are the most commonly used helmets at the high school and collegiate levels. Those helmets without quick release facemasks, manufactured by Xenith and Rawlings, pose significant challenges. In some cases, an ordinary screwdriver can be used to release the loop strap. However, the screws are often stripped or the t-nut spins and the screw remains stuck in place. If this occurs, the medical team is left with the daunting task of removing the helmet with the facemask in place. In these instances, a special tool called an FMX extractor can be used to cut the loop straps.
In an effort to reduce the incidence of closed head injuries, the football helmet has been redesigned to transfer and absorb energy more effectively. Older helmets had a more convex opening that required removal of the cheek pad prior to helmet removal in an emergency. The newly designed models can be removed with cheek pads in place, and because they splay open when the chin strap is cut, they can be removed easily by ED personnel. Utilizing a 2-person technique, one individual positions himself anteriorly to stabilize the neck while the other gently pulls the helmet off using cephalad traction (Figure 3).
Figure 3: Schutt helmet quarter turn release
Figure 4: Proper helmet removal with facemask off
Maintaining cervical neutrality while removing the shoulder pads is often the most difficult step in the process. Some models can be split with trauma shears while other models cannot be cut open in the front (Figure 4). Hordosky and Rechtine have shown that if the front of the pads can be split open, the elevated torso or levitation techniques are often the simplest and most effective methods of removal (Figure 5). Four people are needed for the elevated torso technique – one to maintain in-line stabilization, one to straddle the patient, and two on either side to support the shoulders. The athlete’s torso is elevated sufficiently to slip the shoulder pads from under him and then out to the side (Figure 5). Similarly, the levitation technique utilizes 6-8 people (depending on the weight of the athlete) to raise the entire body allowing the pads to drop on the gurney and be pulled to the side. Both techniques require significant practice and adequate personnel to be performed correctly. Additionally, the lumbar spine must be cleared prior to using the elevated torso technique since this method causes significant motion in the lumbar region. Currently, Riddell is the only shoulder pad manufacturer that offers quick release shoulder pads (Riddell RipKord). The RipKord shoulder pads can be removed without lifting or rolling the athlete (Figure 7). A cervical collar should be applied as soon as the pads are removed, and ED staff should maintain full spinal precautions during subsequent procedures, transfer to radiology, etc. A patient can always be placed back on a longboard should transport be necessary.
Figure 5: Elevated torso technique
Figure 6: Shoulder pads with solid front unable to be cut with trauma shears
Figure 7: Riddell RipKord
Even after airway, breathing, and circulation issues have been addressed, removal of athletic equipment is an essential part of the “exposure” aspect of the primary survey. Head and c-spine injuries should be evaluated via computed tomography, but neither CT scans nor plain radiographs can be undertaken while the athletic gear remains. Urgent transfer to a higher level of care should not be delayed to obtain films, but gear should be removed so transport personnel have access to the patient’s airway and torso, as emergent removal in an ambulance or helicopter carries high risk of further injury.
Case Conclusion
The patient’s helmet and facemask were removed on arrival, his shoulder pads were removed via the levitation technique, and he was placed in a cervical collar. C-spine CT showed a non-displaced fracture of the vertebral body of C6 and he was transferred to a tertiary care center for surgical stabilization.
REFERENCES
1. Mueller F. The Annual Survey of Catastrophic Football Injuries. National Center for Catastrophic Sports Injury Research, 2010
2. National Spinal Cord Injury Statistic Center. The UAB Dept of Physical Medicine and Rehabilitation Center for Disease Control and Prevention, 2011.
3. Schouten R, Albert T, Kwon B. The Spine-injured patient: Initial Assessment and Emergency Treatment. JAAOS 2012;Vol 20, No 6.
4. Palumbo MA, Hulstyn MJ, Fadale PD, O’Brien T, Shall L. The Effect of Protective Football Equipment on Alignment of the Injured Cervical Spine: Radiographic analysis in a cadaveric model. AJSM 1996;24(4):446-453.
5. Swenson TM, Laurerman WC, Blane RO, Donaldson WF III, Fu FH. Cervical Spine Alignment in the Immobilized Football Player: Radiographic analysis before and after helmet removal. AJSM 1997;25(2):226-230.
6. Del Rossi G, Horodyski MB, Conrad BP, DiPaola CP, DiPaola MJ, Rechtine GR. The 6-plus-Person Lift Transfer Technique Compared with Other Methods of Spine Boarding. J ATHL TRAINING 2008;43(1).
7. Horodyski MB, DiPaola CP, DiPaola MJ, Conrad BP, DelRossi G, Rechtine GR. Comparison of the flat torso versus the elevated torso shoulder pad removal techniques in a cadaveric cervical spine instability model. Spine 2009;34(7):687-691
1 Comment
Dr Makowski and Mr Kordecki have written an excellent primer on equipment removal in modern football gear. In particular, I appreciate their well-reasoned argument that the helmet and pads should be removed prior to transport. This will likely generate some mild controversy!
However, they are on shakier ground when they state in the summary that “As many as a quarter of catastrophic c-spine injuries from football collisions may be exacerbated by the poor removal of helmet and pads.” This is unnecessarily inflammatory, and is based on highly questionable research. They cite a 2012 review article, [1] which does not mention football specifically, or even helmet removal, but only that in “as many as 25% of patients, poor immobilization and improper handling have been implicated in causing further neurologic injury after the initial accident.” Only a single reference is cited – Toscano. [2]
This 1988 article is oft-cited, but apparently not oft-read. Despite being routinely deployed to bolster arguments that poor prehospital care is a significant cause of post-injury morbidity in the spine-injured patient, the actual study has not received the critical scrutiny it ought to.
It is a single-center retrospective study of spine-injured patients. (Oddly, not only is a single-author paper, but it is also a single-reference paper, with only one supporting citation.) The author conducted a chart review of the 123 patients that had been admitted to the spine-injury unit at a hospital in Melbourne, examining the temporal course of their disability. He also interviewed patients, accident witnesses, and prehospital personnel, and apparently also did his own accident site investigations. He was at pains to point out both that “all data was collected and recorded by the author,” and that he traveled over 60,000 km in the course of doing so. After this careful review, he concludes that 32 of the 123 patients had neurologic deterioration prior to admission, due mostly to inadequate immobilization or inappropriate lifting.
It is hard to imagine a similar paper being considered for publication at any reputable journal currently. For example, the methods section is essentially absent. Indeed, the study is better described as a “personal communication,” or even as an editorial or “perspectives” piece, rather than true original research.
Many EMS systems are abandoning time-honored, but evidence-deficient practices such as backboards or routine cervical-spine immobilization. Other EMS systems, however, may be wary of adopting new protocols. I fear that the rote citation of terrible old research, and the use of provocative article summaries, may dissuade such services from moving forward.
1. Schouten R, Albert T, Kwon BK. The spine-injured patient: initial assessment and emergency treatment. J Am Acad Orthop Surg. 2012;20(6):336-346. doi:10.5435/JAAOS-20-06-336.
2. Toscano J. Prevention of neurological deterioration before admission to a spinal cord injury unit. Paraplegia. 1988;26(3):143-150. doi:10.1038/sc.1988.23.