Chapter Ten: Orthoses for spinal trauma and postoperative care Flashcards
Orthotic treatment of spinal trauma may be indicated only with what type of fractures
Stable spinal fractures with the exception of upper cervical spine and bilateral facet fractures.
In, general how can you telll if the injury is stable or not?
If the integrity of the anterior and/or posterior ligamentous complex is compromised, the injury is unstable.
What is a Jefferson’s fracture?
Fracture of the ring of the first cervical vertebra.
Typically C1 is split into multiple fragments and the injury is unstable in all anatomical planes.
How can a Jefferson’s fracture occur?
Axial load applied to the top of th ehead and transferred through the condyles of the occiput
With the absence of external support, what can happen to a patient with a Jefferson’s fracture?
Neurologic damage because motion of the head is not constrained.
What is a hangman’s fracture?
A fracture through the pedicles of C2 that separates the posterior neural arch from the vertebral body.
This fracture is unstable in all anatomical planes.
What is the mechanism of injury for a hangman fracture?
Hyperextension followed by distraction, also called traumatic spondylolisthesis.
Odontoid fractures are caused by what?
A combination of shear and compression oading and may result from a blow to the back of the head.
What are the different types of odontoid fractures?
Type I: Fracture is through the tip of the odontoid
Type II: odontoid fracture is through the base of the odontoid
Type III: Fracture line is through the body of the vertebra.
Which of the odontoid fractures are stable or unstable?
Type I stable
Type II and III unstable
Compression fractures in the region of C3-7 are caused how?
hyperflexion injuries where the endplates of the vertebra may be damaged and the vertebral body fractures.
What is the most common level of compression fractures in the region of C3-7?
C5
What is bad about the fracture at C5?
The brachial plexus could be involved.
Hyperextension injuries of the cervical vertebra are usually what?
Due to whiplash
Soft-tissue injuries, and the anterior longitudinal ligament may be ruptured.
Facet joint dislocations involve what?
Disruption of the joint capsule and possibly the posterior ligament.
Unilateral facet fractures are caused by what?
Lateral flexion and rotation and result in narrowing of the spinal canal and neural foramen.
What is an example of an event that could cause a unilateral facet fracture and may result in what?
Shoulder belt injury from a motor vehicle accident. The vertebral body is usually dislocated less than 50% anteriorly and 75% of patients have no neurologic involvement. However it may result in isolated paralysis, such as Brown-Sequard syndrome.
In bilateral facet dislocations, what are disrupted?
Facet capsules
Posterior ligament
Intervertebral disc
What is the mechanism of injury for bilateral facet dislocations?
Severe flexion with some rotation with the vertebral body displaced by more than half of its anterior-posterior dimension.
What percent of patients have neurologic lesions due to bilateral facet dislocations?
85%
What is the most common level of injury of bilateral facet dislocations?
C5-6
What are risk factors for Bilateral facet dislocations?
Spondylosis
Degenerative disc disease
Decreased ROM
Age over 50 years.
What are Thoracic compression fractures?
Impaction of the anterior aspect of the vertebral body
What is the mechanism of injury for thoracic compression fractures?
Flexion and compression of the affected segments.
What has to be intact for thoracic compression fractures to be stable?
Anterior and posterior longitudinal igaments as well as the posterior ligmentous complex
The spinous process must not be separated.
If the anterior column of the spine alone is injured, what was the mechanism of injury?
Flexion followed by compression
If the anterior and middle columns are injured, causing a burst fracture, what was the mechanism of injury?
Compression followed by flexion
The posterior and middle columns can be injured through what?
Flexion followed by distraction, they can be through bone or soft tissue or both.
Fractures through soft tissue are usually treated how/
Surgery
The chance fracture often results from what/
A motor vehicle accident, referred to as a lap belt injury. It could also be caused by the abdomen hitting a solid object.
The most common type of chance fracture involves what?
The posterior elements of the involved vertebra and possibly the posterior aspect of the vertebra.
The second type of chance fracture involves what?
The posterior elements, in addition there is a significant transverse fracture of the vertebral body.
The third type of chance fracture involves what/
Interspinous ligaments, facets and disc.
In all types of chance fractures, what is intact?
The pedicles and the transverse and spinous processes are intact.
Approximately what percent of fracture occur between T11-12 and L1-L2?
50%
What percent of thoracolumbar fracctures are compression fractures?
50%
Compression fractures in the lumbar spine usually occur where?
In the upper part
What ligament is extremely important for stability in the lumbar spine and needs to be intact in order to treat?
Anterior longitudinal ligament
Spondylolysis is what?
The fracture of the pars interacrticularis and is a stable condition.
Spondylolisthesis is what?
The anterior migration of one vertebral body over another and may or may not be stable.
What is in the patient’s best interest postoperatively?
Early ambulation, however additional loads that may be placed on the spine during gait must not damage the surgical construct of the spinal fusion.
In what posture could greater loads be placed on the spine?
A seated position.
The primary orthotic goal of cervical fractures is what?
To immobilize the fracture.
In the elderly, what is the most common fracture?
C1-C2 with the odontoid fracture the most common
What were the results of elderly patient with odontoid fracture being treated with a halo vest?
21% mortality
High rate of complication such as pneumonia and cariac arrest compared to patients with rigid cervical collars.
What is a primary risk factor for chronic pain in whiplash associated disorders?
Cervical kyphosis,
What can reduce the pain in whiplash associated disorders?
Correcting the cervical posture
An orthosis should use the mechanism of retraction of the head rather than extension.
30% of single-column thoracolumbar anterior compression fractures may be treated how?
With early ambulation and hyperextension exercises and an orthosis is not required.
Research and evidence appears to support what type of treatment for thoracolumbar burst fractures/
Nonsurgical management as an alternative to surgery.
What are implants used for surgical treatement of spinal trauma designed for?
Support the construct until fusion is established
What are the benefits of an orthosis after spinal fusion?
Orthoses are thought to protect the construct from unwanted external loads that may compromise the healing process.
For patients presenting with fractures or instrumentation at or supieror to T3, what should be included in the bracing postoperatively?
Over-the-shoulder straps to extend the lever of the existing TLSO
Nonoperative management of spinal trauma consists of what/
Bed rest
Moderate activity
Orthotic management
What is the primary orthotic goal for the majority of spinal injuries a the macro level?
Protecting the spinal column from loads and stresses that would likely cause progression of the spinal deformity and not allow for adequate healing of the injury.
The orthotic desgn should have the ability to what in nonoperative managment?
Limit gross vertebral sway or the spinal column
Limit intersegmental motion at the injured site,
Provide proper spinal alignment/realignment as it relates to the injured site.
When orthotic management is indicated for Denis classification of types I, II, and III, the mechanism of action for this orthosis should include what/
Sagittal hyperextension
What are the denis classification for I, II, III?
Compression fractures
Burst fractures
Seat belt injuries
What is the Denis classification for IV?
Fracture dislocations
Single-column compression fractures with a loss of one third or less of the original anterior height of the vertebra can be managed how?
Initial bed rest to allow elastic recoil of the injury. This can be followed with a regimen of specific exercises and activities.
With more involved compression fractures than Single-column compression fractures with a loss of one third or less of the original anterior height of the vertebra, they can be managed how?
TLSO anterior control, but it is dependent on the percent loss of segmental stiffness.
50% loss of segmental stiffness can be managed with a Jewett-style TLSO
With loss of segmental stiffness between 50-80%, The orthosis plus restricted patient activity level may work
85% or more: The orthosis does not appear effective
What is the common mechanism of injury of burst fractures?
Axial compression plus sagittal flexion.
Burst fractures can have persisting deformity and result in what?
Further flexion,
Loss of vertebral height
Instability in the transverse plane
The transverse instability of burst fractures should cause you to choose which orthotic design?
Total-contact polymer TLSO
What are the functional outcomes needed for treating burst fractures?
Reduced kyphotic angle (neutral)
Decreased percentage of sagittal vertevral compression
Decreased percentage of canal compromise
No change in neurologic status
Decreased level of pain
Improvement or return to previous activities of daily living
Ability to return to work.
Seat belt injuries are the result of mechanism of what/
Flexion and distraction.
For a bony chance fracture, what is compromised?
The posterior and middle columns but the ligamentous structures are intact.
For Ligamentous chance fracture or slice fracture, what is compromised?
The ligaments
What are the most common orthotic treatments for seat belt fractures/
TLSO anterior control and total-contact polymer TLSO
For hangman’s fractures without facet dislocation, what type of treatment can be performed?
Cervical orthosis with a longer lever arm posteriorly and short anteriorly in order to encourage cervical flexion through kinesthetic reminder and the patient’s intact righting reflex.
What is the conservative treatment of a type II odontoid fracture?
Cervical collar
Halo vest
What are the conservative treatments of Type III odontoid fracture?
Cervical orthosis
What is the jefferson fracture again?
A fracture of the C1 atlas that results from axial compression. The downward force of the occipital condyles causes the lateral masses of C1 to fracture and be displaced laterally. The degree of lateral displacement determines the level of stability. Associated with the lateral displacement are fractures of the anterior and posterior arches of C1.
Conservative treatment of Jefferson fractures includes what? When should it be done?
Halo
Lateral displacement of less than 7mm
In a TLSO used postoperatively, which limb should the thigh extension be placed?
Autograph harvested from the iliac crest
Lower limb weakness that is greater than the contralatearl limb
The limb nearest the inside of the car door for ease of getting in and out of a vehicle.
What is the average time that a patient is in a TLSO post surgerically?
4-6 months or until fusion.
A male patient, 35 of age, presents with a stable anterior compression fracture of L1 from a motor vehicle accident. His main complaint was pain. On the sagittal plane x-ray film, there is approximately 20%-25% reduction in the height of the anterior column, supporting the clinical characterization of a stable fracture. A transverse plane magnetic resonance image shows evidence of an asymmetric insult to the vertevral body, with more damage on the left side. A coronal plane x-ray film reveals a small lateral curvature of the lumbar spine. A Jewett brace is prescribed, but the patient’s symptoms did not resolve, and the pain increased. The Jewett orthosis, appears to be shifting in the transverse and coronal plane. What should be done?
The asymmetry of the damage to the L1 vertebra causes greater mobility, therefore, pushing more in that direction with the posterior pad force increases the deformity and may contribute to the patients increased pain. The damage to the left is more consistent with a two-column burst fracture. Considering this, a more likely recommendation might be a TLSO to provide transverse plane stability,
