Common Adult Fractures - Spine

Common Adult Injuries Spine

Prof. Mamoun Kremli

Objectives

• Revision of Anatomy
• Principles of spine injury
• Differentiation between:
  • Stable & Unstable injuries
• Common injuries of:
  • Cervical – Thoracic – Lumbar
• Treatment

Basic Anatomy

Spinal Column Structure

Cervical Vertebrae

• Number: 7
• Range: C₁ - C₇

Thoracic Vertebrae

• Number: 12
• Range: T₁ - T₁₂

Lumbar Vertebrae

• Number: 5
• Range: L₁ - L₅

Sacrum

• Number: 5 (fused)

Coccyx

• Number: 4 (fused together)

Special Vertebrae

Atlas (C1)

Axis (C2)

Regional Spine Characteristics

Thoracic Spine

• Lower thoracic not protected by ribs / more mobile

Lumbar Spine

• Main weight-bearing – very mobile

Spinal Cord and Roots

• Spinal cord in spinal canal – spinal roots

Structural Elements

Three-Column Classification System

• Posterior column:
  • Pedicles, Facet joints, Posterior bony arch, Interspinous and Supraspinous ligaments
• Middle column:
  • Posterior $\frac{1}{2}$ of vertebral body, Posterior part of IV disc, Posterior longitudinal ligament
• Anterior column:
  • Anterior $\frac{1}{2}$ of vertebral body, Anterior part of IV disc, Anterior longitudinal ligament

Types of Spine Injuries

Classification Overview

• Double threat:
  • Damage to vertebral column & to neural tissue
  • Stable: (90%)
    • Less risk of displacement
    • Little risk of neural elements damaged If it initially undamaged
  • Unstable: (10%)
• Unstable if:
  • Fracture of middle column + one more column
  • Risk of displacement / further damage to neural tissue

http://www.backpain-guide.com

Mechanism of Injury

Direct Injuries

• Penetrating injuries: firearms & knives

Indirect Injuries (more common)

• Traction: avulsion fractures
• Falls & violent free movements
  • Axial/lateral Compression
  • Flexion/Extension
  • Rotation
  • Shear

Suspicion of Spinal Injury

High-Risk Scenarios

• Head injury
• Loss of consciousness
• Severe facial injuries
• Blunt injury above clavicle
• Pain/stiffness in neck/back
• Fall from height
• Crushing accident
• High-speed deceleration
• Neurological symptoms in limbs
• Rib fractures or seat belt bruising
• Severe abdominal/pelvic and injuries

Cervical Spine Region

Thoracolumbar Spine Region

Principles of Management

Key Principles

• Diagnosis and management go hand in hand
• Follow ATLS protocol: ABC
• Inappropriate movement & examination worsen the injury
• Must immobilize the spine If any suspicion of spinal injury

Examination

Primary Assessment

• Look:
  • General, attitude, bruises on head, face, back
• Feel:
  • Tenderness, swelling
• Do NOT Move

Apley’s System of Orthop and Fr

Apley’s System of Orthopedics and Fractures

Log-Roll Technique

• Protect spine
• Log-roll patient to see back

Apley’s System of Orthop and Fr

Apley’s System of Orthopedics and Fractures

Neurological Examination

Comprehensive Assessment

• Full neurological examination is a must
• Dermatomes
• Myotomes
• Reflexes
• To be repeated over days

Imaging

Standard Views

• C-Spine:
  • AP – Lateral – Open-mouth
• T and L-Spine:
  • AP – Lateral
• Plain X-rays alone insufficient to show the true picture

Advanced Imaging

• CT for difficult areas (upper/lower C, upper T)
  • Shows structural damage of vertebrae and vertebral fragments into the canal
• MRI the best to show:
  • IV disc, Ligamentum flavum, Neural structures

Important Limitation

• Plain X-rays alone may be insufficient to show the true picture

X-rays for C-Spine Injuries

AP View

• Intact lateral outline
• Spinous processes & Trachea in the middle

Key Anatomical Landmarks:

• IntVS = Intervertebral Disk Space
• SpinPr = Spinous Process (of C6)
• TrnsP = Transverse Process (Lateral Body of C6)
• TR = Trachea
• Ped = Pedicle (of C7)

Lateral View

• All C- vertebrae & upper T1
• Prevertebral soft tissue width
• Four parallel curves
  • Front of vertebral bodies
  • Back of vertebral bodies
  • Posterior borders of lateral masses
  • Bases of spinous processes

Open-Mouth View

• For C1 and C2
  • Odontoid fractures
  • Lateral mass fractures
• Look for:
  • Symmetry
  • Continuity of bone

http://nypemergency.org/

Treatment

Treatment Factors

• Stable / Unstable
• With / without neurological injury

Objectives of Treatment

• Preserve neurological function
• Relieve reversible neural compression
• Restore alignment of spine
• Stabilize the spine
• Rehabilitate the patient

Stable Without Neurological Injury

• Conservative (support by orthotics, rest)

Unstable With/without Neurological Injury

• Secure stabilization:
  • Skin / Skeletal Traction
  • Surgery +/- Decompression

Comprehensive Treatment Approach

• Unstable With/without Neurological Injury:
  • Secure stabilization:
    • Skin / Skeletal Traction
    • Surgery +/- Decompression

Specific Fractures

Fractures of C2 (Hangman’s Fracture)

• Hyperextension/distraction injury
• In MVA when forehead strikes dashboard
• Unstable
• May cause death (why?)

discontinuity of the central axial spinal pillar

Fractures of C2-Odontoid

• Identified easily by:
  • Open mouth view
  • CT scan

www./ortho-teaching.feinberg.northwestern.edu/

http://www.casereports.in/articles/6/3/Anterior-Odontoid-Screw-Fixation-for-Type-II-Odontoid-Fracture.html

Cervical Wedge-Compression Fracture

• Pure flexion injury
• Mid- & lower cervical
• Stable if only anterior column affected

Cervical Burst Fracture

• Axial compression
• Diving
• Unstable
  • Neurological injury

http://radiopaedia.org/

http://www.learningradiology.com/

Fracture-Dislocation

• Flexion-Rotation
• Articular facets ride forwards over facets below
• Usually with fracture of articular mass
• Unilateral facet: stable
  • Displacement < 25% of vertebral body width
• Bilateral facet: Unstable
  • Displacement > 25% of vertebral body width

Sprained Neck (Whiplash Injury)

• Soft tissue sprain only - stable
• RTA: Rear-end collision:
  • Body thrown forwards, neck jerked backwards
  • Pain/stiffness over 48 hours
• Treatment:
  • Pain relief
  • C-Collar
  • Physiotherapy

Thoracic Spine Injuries

Wedge Compression

• Common in osteoporotic spine
  • Mild trauma to old lady
• Usually stable
• Causes ↑kyphosis

Severe Injuries in Young

• More in T11, T12 (not protected)
• May cause neurological injury

Upper T-Spine

• Lateral not clear
• Need CT

Transverse Processes Fracture

• Avulsion fracture of Transverse Processes
  • Isolated, stable
  • Supportive treatment
• Fracture of L5 transverse process (Red flag)
  • Might indicate a shear injury of pelvis

Lumbar Spine Injuries

Wedge Compression L-Spine

The Commonest Vertebral Injury

• Minor trauma in osteoporotic people

Normal vertebra

Osteoporotic vertebra

Osteoporotic compression fracture

http://www.neuros.net/

Stable Compression (posterior elements intact)

• Anterior vertebral body height reduced by < 50%

Unstable Compression (posterior elements injured)

• Anterior vertebral body height reduced by > 50%

Burst Injury L-Spine

• Axial compression: shattered vertebral body
• Posterior fragments into spinal canal
• Usually unstable
• CT required

Burst Injury Classification

Is this a compression or a burst fracture?

• A burst fracture
• Why?
  • Posterior displacement

Neurological Injuries

C4 Injury

• Quadriplegia/Tetraplegia
• Results in complete paralysis below the neck

7 Cervical Vertebrae

C6 Injury

• Results in partial paralysis of hands and arms as well as lower body

12 Thoracic Vertebrae

T6 Injury

• Paraplegia, results in paralysis below the chest

L1 Injury

• Paraplegia, results in paralysis below the waist

5 Lumbar Vertebrae

5 Sacral Vertebrae

4 Coccyx (fused together)

Summary

• Vertebral injuries are common
• Stable VS. Unstable
  • Which column(s) are injured
• Forces:
  • Axial compression, flexion, shear, combinations
• Imaging:
  • X-rays: AP, Lateral, Special views
• Always assess neurological status