Spinal Fractures

Question 1

Occipital condyle type 1

Answer 1

Compression, stable, minimum displacement, collar and 6 week follow up

Question 2

Occipital condyle type 2

Answer 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

Question 3

Occipital condyle type 3

Answer 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

Question 4

Basilar invagination vs impression, lines, 4

Answer 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]

Question 5

Name 4 measures of atlanto-occipital dislocation and their cutoffs in adults and children

Answer 5

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

Question 6

What is a measure of atlantoaxial dislocation, cutoff, treatment

Answer 6

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

Question 7

What are types of transverse ligament injuries and it’s significance

Answer 7

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

Question 8

Types of C1 fractures, mechanism, what matters most

Answer 8

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)

Question 9

C2 Hangman’s fracture types, mechanism, treatment

Answer 9

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

Question 10

Type II Odontoid Fracture management types

Answer 10

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)

Question 11

Odontoid screw, indications, contraindications

Answer 11

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

Question 12

Cervical A0 fracture

Answer 12

Minor, non structural
A is for compression

Question 13

Cervical A1 fracture

c

Answer 13

Wedge Compression
Involves one endplate, not the posterior wall of vertebral body

Question 14

Cervical A2 fracture

Answer 14

Compression
Coronal Split involving both endplates
But NOT the posterior wall

Question 15

Cervical A3 fracture

Answer 15

Compression
Incomplete burst involving one endplate and posterior wall

Question 16

Cervical A4 fracture

Answer 16

Compression
Complete burst
Involves both endplates and posterior wall

Question 17

Cervical B1 fracture

Answer 17

Tension band injury
Posterior tension band, bony only

Question 18

Cervical B2 fracture

Answer 18

Tension band injury
Posterior tension band plus discoligamentous or capsule involvement

Question 19

Cervical B3 fracture

Answer 19

Tension band injury
Anterior tension band injury

Question 20

Cervical C fracture

Answer 20

Any translation in any axis of one body to another

Question 21

Cervical F1 fracture

Answer 21

Nondisplaced facet fracture, <40% height of lateral mass and <1cm piece

Question 22

Cervical F2 fracture

Answer 22

Displaced facet fracture, >40% height of lateral mass or >1cm piece

Question 23

Cervical F3 fracture

Answer 23

Floating lateral mass

Question 24

Cervical F4 fracture

Answer 24

Subluxed, perched, or dislocated facet

Question 25

Cervical Flexion Teardrop

Answer 25

Hyperflexion, usually injure all columns, facet dislocation, bony retropulsion, SCI, anterior cord syndrome, unstable, emergency, usually C4-C7

Question 26

Cervical Extension Teardrop

Answer 26

Hyperextension, ALL disrupts, holds onto inferior vertebral body piece, associated with central cord, usually stable, just needs hard collar

Question 27

What is TLICS score, components, and thresholds

Answer 27

Question 28

Thoracolumbar A0

Answer 28

Minor, nonstructural fractures

Question 29

Thoracolumbar A1

Answer 29

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

Question 30

Thoracolumbar A2

Answer 30

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

Question 31

Thoracolumbar A3

Answer 31

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

Question 32

Thoracolumbar A4

Answer 32

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

Question 33

Thoracolumbar B1

Answer 33

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

Question 34

Thoracolumbar B2

Answer 34

Posterior tension band injury, with or without osseus involvement, almost always need surgery

Question 35

Thoracolumbar B3

Answer 35

Disrupt ALL through hyperextension/distraction injury, surgery indicated, if neurological damage, go anterior. Often associaed with akylosing spondylitis, DISH

Question 36

Thoracolumbar C

Answer 36

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%

Question 37

Dennis classification of sacral fractures, implications

Answer 37

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%)

Question 38

Sacral A1

Answer 38

Sacral A all occur below SI joint, no instability Coccygeal of sacral compression fracture or ligamentous avulsion fracture

Question 39

Sacral A2

Answer 39

Non-displaced transverse fracture below SI joint low likelihood of cauda equina injury

Question 40

Sacral A3

Answer 40

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

Question 41

Sacral B1

Answer 41

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

Question 42

Sacral B2

Answer 42

Transalar, posterior ring, only 5% chance of neurological compromise, longitudinal, Denis type I fracture, only needs surgery if extreme deformity

Question 43

Sacral B3

Answer 43

Transforaminal longitudinal fracture, posterior ring, Denis type II, 25% chance of neurological injury, surgery for extreme deformity, or sacral decompression for nerve roots

Question 44

Sacral C0

Answer 44

Sacropelvic, U type, non displaced, non operative unless extreme pain, then iliosacral screw fixation

Question 45

Sacral C1

Answer 45

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

Question 46

Sacral C2

Answer 46

Sacropelvic, bilateral B type fracture, no transverse fracture, unstable and higher risk of neurological injury than C1, spinopelvic fixation

Question 47

Sacral C3

Answer 47

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