Trauma




(2)
Department of Orthopaedics, Denver Health Medical Center, 777 Bannock Street, Denver, 80204, CO, USA

 



Take-Home Message





  • Know the different cord syndromes, anterior, posterior (rare), central, and Brown-Sequard (hemisection).


  • Use of steroids for spinal cord injury is controversial, may cause root sparing, and complication rate is high in some series.


  • Know how to define level of injury.


Definition





  • Damage to tissue of the spinal cord altering its function and causing varying degrees of paralysis


  • Level of spinal cord injury defined by lowest level of normal sensory and motor function bilaterally


Etiology





  • Blunt trauma


  • Penetrating trauma – this is where hemisection is more likely.


Pathophysiology





  • Direct trauma


  • Edema


  • Vascular insult


  • Free radicals


Radiographs





  • Needs myelogram/CT or MRI to look at the cord


  • MRI – only way to see substance of the cord


Classification





  • ASIA (American Spinal Injury Association)


  • A – complete, B – sensory preservation distally, C – sensory and motor activity less than Grade 3, D – sensory and motor activity greater than Grade 3, E – normal


Treatment





  • Steroids are controversial.


  • Stabilize the spine injury from the field to the ER.


  • Decompress the spinal canal when appropriate and operatively stabilize the spine.


  • DVT prophylaxis – rate of DVT and PE high


  • Gunshot wound – leave alone unless intrathecal or causing progressive neurologic deficit


Complications





  • DVT


  • Pressure sores


  • Urinary tract infection


  • Autonomic dysfunction – bradycardia, hypotension, autonomic dysreflexia from visceral distention especially the bladder



Bibliography

1.

Eidelberg E. The pathophysiology of spinal cord injury. Radiol Clin North Am. 1977;15(2):241–6.

 



2 Cervical Spine Injury



Samuel E. Smith3 


(3)
Department of Orthopaedics, Denver Health Medical Center, 777 Bannock Street, Denver, 80204, CO, USA

 


Take-Home Message





  • Look for other injuries – head, chest.


  • Look for noncontiguous spine fractures, vertebral artery injury.


  • Protect the spinal cord.


  • Know protocol or have one in place at your institution for collar removal.


Definition





  • Injury to the bone and ligamentous structure of the cervical spine from the occiput to C7


Etiology





  • Trauma:



    • Fall, MVC, penetrating trauma


  • Beware of spine injury associated with ankylosing spondylitis, diffuse idiopathic skeletal hyperostosis, ossification of the posterior longitudinal ligament, osteoporosis, and cervical spondylosis (risk of central cord syndrome even without fracture).


  • Risk by mechanism: high-speed MVC, fall greater than 10 ft, head injuries.


Pathophysiology





  • Fracture


  • Ligament injury


  • Cord injury


  • Edema


  • Bleeding


  • Vertebral artery injury


Radiographs





  • Clearance protocols


  • CT scans for intoxicated patients, distracting injuries, i.e., other fractures, midline tenderness


  • CT-angiogram for high risk of vertebral artery injury (C1/C2 or transverse foramen injuries)


Classification





  • Depends on specific injury


Treatment





  • Depends on specific injury


Complications





  • Airway compromise


  • Respiratory failure


  • Neurologic injury

Bleeding into the canal or cord



  • DVT/PE


  • Pressure sores


Pediatric Cervical Spine Trauma





  • Occiput/C1 injuries more common.


  • X-rays interpreted differently due to immature skeleton.


  • More physiologic motion can be confused with instability.


  • Soft tissues anterior to the cervical spine wider than in the adult, i.e., 6 mm at C2 and 22 mm at C6.


  • ADI in kids 5 mm compared to 3 mm in adults.


  • Account for the size of the child’s head compared to the thorax when stabilizing the cervical spine, relatively large head causes flexion on a flat surface.


  • Beware that atlantoaxial instability can occur with pharyngitis.



Bibliography

1.

Lebl DR, Bono CM, Velmahos G, Metkar U, Nguyen J, Harris MB. Vertebral artery injury associated with blunt cervical spine trauma: a multivariate regression analysis. Spine (Phila Pa 1976). 2013;38(16):1352–61. doi:10.​1097/​BRS.​0b013e318294bacb​.

 

2.

McCall T, Fassett D, Brockmeyer D. Cervical McCall T, Fassett D, Brockmeyer D. Cervical spine trauma in children: a review. Neurosurg Focus. 2006;20(2):E5.

 


3 Occiput/C1 Injuries



Samuel E. Smith4 


(4)
Department of Orthopaedics, Denver Health Medical Center, 777 Bannock Street, Denver, 80204, CO, USA

 


Take-Home Message





  • Rarely survive but survival more common with improved resuscitation of patients at the scene


  • By definition occiput/C1 dissociation unstable


  • Always needs surgery


Definition





  • Disruption of ligamentous connection between occiput, C1, and C2


Etiology





  • High-energy trauma:



    • Children more susceptible due to relatively large size of the head compared to the trunk


Pathophysiology





  • Disruption of occiput/C1 joint capsule


  • Disruption of paired alar ligaments of the dens


Radiographs





  • Difficult to see, review Power’s ratio – establishes anterior/posterior relationship of occiput to C1


  • CT – essential to see bony relationships


  • MRI to look for soft tissue and spinal cord injuries


Classification





  • Anterior


  • Posterior


  • Distractive


Treatment





  • Operative always as it is grossly unstable:



    • Occiput to C1 or more commonly C2 fusion, wiring or screw, occipital plate and rods


Complications





  • Neurologic injury pentaplegia


  • CSF leak from occipital screws


  • Injury to transverse sagittal sinus with potential for death


  • DVT/PE


  • Infection



Bibliography

1.

Gire JD, Roberto RF, Bobinski M, Klineberg EO, Durbin-Johnson B. The utility and accuracy of computed tomography in the diagnosis of occipitocervical dissociation. Spine J. 2013;13(5):510–9. doi:10.​1016/​j.​spinee.​2013.​01.​023. Epub 2013 Feb 22.

 

2.

Lador R, Ben-Galim PJ, Weiner BK, Hipp JA. The association of occipitocervical dissociation and death as a result of blunt trauma. Spine J. 2010;10(12):1128–32. doi:10.​1016/​j.​spinee.​2010.​09.​025.

 


4 Fractures of the Atlas



Samuel E. Smith5 


(5)
Department of Orthopaedics, Denver Health Medical Center, 777 Bannock Street, Denver, 80204, CO, USA

 


Take-Home Message





  • 7 mm of lateral mass displacement combined defines rupture of the transverse ligament of the atlas.


  • Otherwise atlas fractures mostly stable.


  • The canal of the occiput to C2 is wide and accounts in part for reduced risk of neurologic injury with these fractures.


  • Beware of high rate of contiguous and noncontiguous spine fractures and head injury.


Definition





  • Fracture of one or both arches of C1 with or without displacement of the lateral masses


Etiology





  • Usually axial trauma


Pathophysiology





  • Trauma with axial load to the lateral masses causing a disruption of the C1 ring typically involving the arches


Radiographs





  • X-ray: open mouth, shows widening between dens and lateral masses and overhang of C1 lateral masses on C2 superior facets


  • CT: shows best and defines fracture complexity


  • MRI sometimes to show rupture of TAL from bone


Classification





  • Type I: anterior arch fracture


  • Type II: bilateral arch fractures from bursting injury to C1


  • Type III: unilateral mass displacement


Treatment

Nonoperative



  • Typically bracing with semirigid collar for 6–8 weeks

Operative



  • If transverse ligament of the atlas is ruptured, C1/C2 fusion with instrumentation needed


  • C1 lateral mass and C2 pedicle screws or Magerl’s transarticular technique


  • Preop CT needed to make sure that screws can be passed safely without entering the foramen transversarium


Complications





  • Neurologic injury: rare


  • Infection


  • DVT/PE


  • Greater occipital nerve injury


  • Vertebral artery injury


  • Dural tear or leak



Bibliography

1.

Jackson RS, Banit DM, Rhyne 3rd AL, Darden 2nd BV. Upper cervical spine injuries. J Am Acad Orthop Surg. 2002;10(4):271–80. Review.

 

2.

Vergara P, Bal JS, Hickman Casey AT, Crockard HA, Choi D. C1-C2 posterior fixation: are 4 screws better than 2? Neurosurgery. 2012;71(1 Suppl Operative):86–95. doi:10.​1227/​NEU.​0b013e318243180a​.

 


5 Hangman’s Fracture



Samuel E. Smith6 


(6)
Department of Orthopaedics, Denver Health Medical Center, 777 Bannock Street, Denver, 80204, CO, USA

 


Take-Home Message



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Sep 18, 2016 | Posted by in ORTHOPEDIC | Comments Off on Trauma

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