Fractures Of The Spine And Pelvis

Fractures of the spine and pelvis Bao heng

Anatomy of spine

Denis’ concept of three-column model

Anterior Column: Anterior longitudinal ligament Anterior half of vertebral body Anterior portion of annulus fibrosis

Middle column: Posterior longitudinal ligament Posterior half of vertebral body Posterior aspect of annulus fibrosis

Posterior column: Neural arch Ligamentum flavum Facet capsule Interspinous ligament

Types of fracture of the thoraco-lumbar spine  Wedge Compression fracture  Stable burst fracture  Unstable burst fracture  Chance fracture  Flexion-distraction injury  Translational injuries

Types of the fractures of cervical spine  Hyperflexion fracture  Vertical compression fracture  Hyperextension fracture  Odontoid process fracture

Whiplash injury

History of injury  Fall from a height  In the mining industry and building construction work and in the loading and unloading work in harbours  Dives into a shallow well or a swimming pool.

Clinical features  Pain  Difficulty in motion  Sensation and motor function  Head and chest  Examine the back for tenderness, kyphosis and a gap in the interspinous and supraspinous ligaments.

Physical exam  A general examination of head, chest and abdomen.  The legs must be examined for preliminary assessment of motory paralysis and sensory loss, and their extent is estimated.  Look for distension of the bladder, due to paralysis of the bladder function.  In cases of falls from a height, examine the heels for fracture calcaneum

Radiology

Emergency transport

Treatment of the thoracolumbar spine  1.Compression fracture  Compression<1/5: Bed rest, Back extension exercises, Back support  Compression>1/5 : closed reduction

 2. Burst fracture:  Closed reduction  Surgery

 Chance fracture: surgery

Treatment of fractures of cervical spine  1.Subluxation: traction  2. Stable fractures: skull traction  3.Burst fracture with neurological deficit:surgery  Hyperextesion injury: traction and plaster  Odontoid process fracture:traction and plaster for type1,3 and type2 without displacement;displacement>4mm:surgery

Spinal cord injury  Quadriplegia - Loss of function of any injured or diseased cervical spinal cord segment, affecting all four body limbs.  Paraplegia - Injury in the spinal cord in the thoracic, lumbar, or sacral segments, including the cauda equina and conus medullaris involving loss of movement and sensation in the lower half of the body

Pathology  Destruction from direct trauma  Compression by bone fragments, hematoma, or disk material  Ischemia from damage or impingement on the spinal arteries

Spinal cord syndromes  Anterior Cord Syndrome -An incomplete spinal injury in which all functions are absent below the level of injury except proprioception and sensation.  Brown-Sequard Syndrome - An incomplete spinal cord injury where half of the cord has been damaged. The Brown-Sequard syndrome is caused by a functional section of half of the spinal cord. This results in motor loss on the same side as the lesion and sensory loss on the opposite side.

Spinal cord syndromes  Central Cord Syndrome - A lesion in the cervical region, that produces sacral sensory sparing and greater weakness in the upper limbs than in the lower limbs.  Cauda Equina Syndrome - This usually occurs with fractures below the L2 level and results in flaccid-type paralysis and impairment of bladder and bowel

Spinal shock  Spinal shock involves a spinal cord concussion which usually invovles 24-72 hour period of paralysis, hypotonia, & areflexia, and at its conclusion there may be hyperreflexia, hypertonicity, and clonus; - return of reflex activity below level of injury (such as bulbocavernosus) indicates end of spinal shock;

 Complete - Absence of sensory and motor functions in the lowest sacral segments  Incomplete - Preservation of sensory or motor function below the level of injury, including the lowest sacral segments

Frankel scale  A complete paralysis  B sensory function only below the injury level  C incomplete motor function below injury level  D fair to good motor function below injury level E normal function

Complications  A Infection of urinary and genital tract  B. Pressure Sores : Prevention is the most important treatment.  C. Respiratory Complications : respiratory infection  D. Disorder of thermoregulation

Treatment  Traction  Prevention of complications  Steroid  Surgery

Prevention of complications  Pulmonary Care: - Tracheostomy w/ humidified air is used if pt cannot clear secretions;  Cardiovascular: - Central Monitoring:  Urologic: - Foley Catheter for initial 24-48 hrs, then intermittent rather than continued. catheter drainage (develops automatic reflex emptying of bladder

Steroid Protocol: for Spinal Cord Injury  Methylprednisolone given as bolus of 30 mg / kg body wt - followed by infusion at 5.4 mg / kg / hour for 23 hours;  Excluded pts: - patients who are more than 8 hours from injury (these patients may actually do worse w/ steroids);  Note: up to 40% of spine injured patients who receive steroids can be expected to develop some Gastrointenstinal bleeding

Indications for surgery  1.The spinal cord appears to be compressed  2.An progressive neurological deterioration.  3.Dislocation with facet joint locking  4.Unstable fracture of spine

Fracture of the pelvis  The pelvis consists of the two iliac bones and the sacrum which form a ring enclosing the pelvic cavity.  This ring can be divided functionally into a posterior weight transmitting segment and an anterior segment serving only for muscular attachment.  Injuries to the posterior segment are important from the locomotion point of view and are more disabling as they involve the weight transmitting part.

Classification  1. Single segment fracture of pelvic ring (Stable fracture)  2. Double segment fracture (Unstable fracture)  3. Avulsion fracture  4. Fractures of the Acetabulum  5. Fractures of Sacrum and Coccyx

Clinical Features  A history of injury  Shock is often due to intra pelvic haemorrhage from the veins in the pelvic wall, in unstable fractures.  Localised bony tenderness at the symphysis pubis or sacro iliac joint.  Pelvic compression and distraction tests will be positive and painful.

Complications  Rupture of the bladder or urethra  Rectum injury  Nerve injury: sciatic nerve  Massive haemorrhage from retropelvic vessels.

Management  As this injury is due to severe violence, shock must be looked for and prevented. complications of visceral injuries must be looked for and treated.

Conservative treatment  Single segment fractures of the ilium or publis. These need only rest in bed for about two weeks. Strapping can relief local pain

Surgical Treatment  Unstable injuries of the pelvis