Spinal Fractures Flashcards
Occipital condyle type 1
Compression, stable, minimum displacement, collar and 6 week follow up
Occipital condyle type 2
Basilar skull fracture that extends into occipital condyle, directo blow to skull, stable as alar ligament and transvere ligament are saved, collar and 6 week follow up
Occipital condyle type 3
Avulsion of condyle in region of alar ligament, suspect carniocervical dissociation, forced rotation with lateral bending, potential instability, can try collar and follow, may need O-C fusion
Basilar invagination vs impression, lines, 4
Invagination = congenital, impression = weaknening of bones with age, cranial settling = rheumatoid arthritis
McRae - foramen magnum opening, symptomatic if violated because dens normally 5mm below this line, if violated then BI+
Chamberlain, hard palate to opisthion, dens > 3mm above then BI+
McGregor, like Chamberlain but if can’t see opisthion on XR, then to lowest point of occipit, if dens >4.5mm above then BI+
Wackenheim line, basilar line, normally, the tip of the dens is ventral and tangential to this line 1) Dens above line in BI 2) in posterior AOD, line posterior to dens 3) in anterior AOD, line anterior to dens - low sensitivity but high specificity [so BI and anterior AOD similar]
Name 4 measures of atlanto-occipital dislocation and their cutoffs in adults and children
Best is C1-Condyle
1. >1.5mm adults, 4mm children
Basion-Dens Interval
1. >10 mm adults, 12 mm children
Power’s Ratio
1. >1 is AOD
BAI
1. 12mm to -4mm adults, 0-12mm children
Also recall Wackenheim line
What is a measure of atlantoaxial dislocation, cutoff, treatment
Atlanto-dental interval is the measurement
-Atlantoaxial dislocation is defined as ADI greater than 3 mm in adults older than 18 years of age and greater than 5 mm in children
-See in Rheumatoid Arthritis, ADI 3 or less is normal, posterior ADI 14mm or less is more risk of injury, 15 or more is normal
ADI>10 means surgery, PADI most indicative (for RA)
Treatment is O-C2 fusion, or C1-C2 fusion
What are types of transverse ligament injuries and it’s significance
Dickman classification
1. Type 1, ligament itself disrupted, won’t heal, needs C1-C2 fusion
2. Type 2, ligament attachment on C1 avulsed, can do cervical orthosis or halo
Assess with MRI, and CT
Type 1 needs surgery
Type 2, treat collar/halo, 75% bone will heal at 3-4 moths, 25% will need C1-C2 fusion
Comes from BNI, Sonntag
Types of C1 fractures, mechanism, what matters most
Jefferson Classification, 5 types
1. Posterior arch, hyperextension (collar)
2. Anterior arch, hyperflexion (collar)
3. Anterior plus posterior, burst C1 fx, “Jefferson” - transverse ligament integrity matters most (if disrupted, follow Dickman)
4. Lateral mass fracture, axial load plus rotation, unstable (collar, if very dislocated, O-C2 fusion)
5. C1 transverse process fracture (collar)
C2 Hangman’s fracture types, mechanism, treatment
Effendi classification, typically hyperextension then rebound flexion
* Type I, less than 3mm, collar
* Type II, >3mm and >11 degree angulation, can reduce then collar or halo, C2-3 disc disrupted or can’t reduce then if C2 pedicle screws possible, C2-C3 posterior fusion. If pedicle screws not possible, then C1-C3, or C2-3 ACDF
* Type IIa, <3mm and >11 degree, reducable do halo, if cannot reduce or C2-C3 disc disrupted, do C2-C3 fusion
* Type III, requires C2-C3 ACDF or C1-C3 posterior fusion
Type II Odontoid Fracture management types
Nonunion risk factors: 5 mm of displacement, angulation > 10 degrees, age > 50, and posterior displacement
* Young patient without risk factors do halo or collar
* Young with risk factors, do C1-C2 fusion, or anterior odontoid screw
* Older, do C1-C2 fusion (C1 lateral mass, C2 pedicle)
Odontoid screw, indications, contraindications
Indications: Grauer 2b, anteriosuper to posteriorinferior angle, acute/subacture
Contraindications: disrupted transverse ligament, barrel chest or short neck, Grauer 2c, fracture older than 6 months - cortication, osteoporosis or too old
Cervical A0 fracture
Minor, non structural
A is for compression
Cervical A1 fracture
c
Wedge Compression
Involves one endplate, not the posterior wall of vertebral body
Cervical A2 fracture
Compression
Coronal Split involving both endplates
But NOT the posterior wall
Cervical A3 fracture
Compression
Incomplete burst involving one endplate and posterior wall
Cervical A4 fracture
Compression
Complete burst
Involves both endplates and posterior wall
Cervical B1 fracture
Tension band injury
Posterior tension band, bony only
Cervical B2 fracture
Tension band injury
Posterior tension band plus discoligamentous or capsule involvement
Cervical B3 fracture
Tension band injury
Anterior tension band injury
Cervical C fracture
Any translation in any axis of one body to another
Cervical F1 fracture
Nondisplaced facet fracture, <40% height of lateral mass and <1cm piece
Cervical F2 fracture
Displaced facet fracture, >40% height of lateral mass or >1cm piece
Cervical F3 fracture
Floating lateral mass
Cervical F4 fracture
Subluxed, perched, or dislocated facet
Cervical Flexion Teardrop
Hyperflexion, usually injure all columns, facet dislocation, bony retropulsion, SCI, anterior cord syndrome, unstable, emergency, usually C4-C7
Cervical Extension Teardrop
Hyperextension, ALL disrupts, holds onto inferior vertebral body piece, associated with central cord, usually stable, just needs hard collar
What is TLICS score, components, and thresholds
Thoracolumbar A0
Minor, nonstructural fractures
Thoracolumbar A1
Wedge-compression of single endplate, no involvement of posterior wall, from compression-flexion
Factors of instability: > 50% loss of vertebral body height, > 30 degrees of anterior to posterior angulation, > 30 degrees of focal kyphosis
Thoracolumbar A2
Split or pincer compression fracture, both endplates, no posterior wall involvement, from compression-flexion
Factors of instability: > 50% loss of vertebral body height, > 30 degrees of anterior to posterior angulation, > 30 degrees of focal kyphosis
Thoracolumbar A3
Incomplete burst, fracture of a single endplate plus any involvement of posterior wall or canal, from axial compression
Surgery is usually indicated, especially when presenting with neurologic deficit, angular deformity > 20 degrees, > 50% spinal canal compromise, anterior body height < 50% of posterior height, and/or progressive kyphosis
Thoracolumbar A4
Complete burst, both endplates and posterior wall, split fracture into posterior vertebral body, from axial compression
Surgery is usually indicated, especially when presenting with neurologic deficit, angular deformity > 20 degrees, > 50% spinal canal compromise, anterior body height < 50% of posterior height, and/or progressive kyphosis
Thoracolumbar B1
Chance fracture, one level osseus failure including posterior tension band and vertebral body, flexion distraction injury, seatlbelt
A bony Chance fracture without ligamentous injury, with absence of disk injury, or with no dislocation may be treated with a hyperextension brace, such as a thoracolumbar sacral orthosis (TLSO). Otherwise, surgery
Thoracolumbar B2
Posterior tension band injury, with or without osseus involvement, almost always need surgery
Thoracolumbar B3
Disrupt ALL through hyperextension/distraction injury, surgery indicated, if neurological damage, go anterior. Often associaed with akylosing spondylitis, DISH
Thoracolumbar C
Displacement or dislocation in any direction, often have severe polytrauma, so surgery when safe
3 types
Flexion rotation: Anterior compression and total rupture of the middle and posterior columns under rotational and tension forces. Imaging finding include subluxation or dislocation, increased interspinous distance, decreased canal diameter, jumped facets, and an intact posterior vertebral body.
Shear: All three columns, including anterior longitudinal ligament, disrupted; force directed most commonly in posteroanterior direction fracturing the posterior arch, resulting in “free-floating lamina” and the superior facet of the inferior vertebra. Often results in complete spinal cord injury (SCI).
Flexion distraction: Radiographically similar to a Chance-type fracture ± subluxation due to torn annulus fibrosus.
Treatment with urgent decompression and stabilization is indicated in cases with incomplete neurologic deficit, > 50% loss of height with angulation and kyphotic angulation of > 40%
Dennis classification of sacral fractures, implications
Dennis found that neurologic injuries occurred in 5.9% of fractures lateral to the sacral foramina (Zone 1). In transforaminal fractures (Zone 2), 28.4% of patients had a neurologic deficit. Meanwhile, central fractures (Zone 3) had the highest likelihood of neurologic injury (56.7%)
Sacral A1
Sacral A all occur below SI joint, no instability
Coccygeal of sacral compression fracture or ligamentous avulsion fracture
Sacral A2
Non-displaced transverse fracture below SI joint
low likelihood of cauda equina injury
Sacral A3
Transverse fracture below SI joint, displaced, so possible neurological injury, if neural compromise consider laminectomies and sacral alar plating, also consider ORIF if extreme deformity
Sacral B1
posterior pelvic ring, impacts posterior pelvic stability, screw fixation if unstable, low likelihood of neurological compromise, corresponds to Denis III fracture, usually immbolization and heals
Sacral B2
Transalar, posterior ring, only 5% chance of neurological compromise, longitudinal, Denis type I fracture, only needs surgery if extreme deformity
Sacral B3
Transforaminal longitudinal fracture, posterior ring, Denis type II, 25% chance of neurological injury, surgery for extreme deformity, or sacral decompression for nerve roots
Sacral C0
Sacropelvic, U type, non displaced, non operative unless extreme pain, then iliosacral screw fixation
Sacral C1
Sacropelvic, any B type (longitudinal) injury, but also ipsilateral S1 facet is discontinuous with medial sacrum, i.e. theres L5-S1 facet fracture, needs spinopelvic fixation
Sacral C2
Sacropelvic, bilateral B type fracture, no transverse fracture, unstable and higher risk of neurological injury than C1, spinopelvic fixation
Sacral C3
Sacropelvic, U shaped but displaced, like C2 but also has transverse fracture i.e. more likelihood of neurological injury, more unstable than C2, needs spinopelvic fixation
