Spinal Fractures Flashcards
How are fractures usually classified?
I (stable), II (unstable), III (unstable)
What things factor into management of fractures?
fracture stability, alignment, neurologic involvement, age, compliance, etc
What are the most commonly injured areas of the spine?
lower cervical spine and thoracolumbar junction
2/3 involve C-spine
lower injuries common in adults, upper injuries in children
40% associated with neurologic involvement
What are the three columns of spine?
Anterior column: anterior longitudinal ligament, anterior 2/3 of vertebral body and annulus fibrosis
Middle column: posterior longitudinal ligament, posterior 1/3 of vertebral body and annulus
Posterior column: posterior ligament complex and vertebral arch structures
What is stability?
refers to immediate or subsequent risk of spinal cord and spinal nerve root injury
What makes an injury stable?
do not have significant bone or joint displacement; ligamentous structures remain in intact
What are examples of stable injuries?
compression fractures, traumatic disc herniations, unilateral facet dislocations
What makes an injury unstable?
show or have potential for significant displacement
What are examples of unstable injuries?
fracture dislocations, bilateral facet dislocations;
Fractures involving 1 column
stable
Fractures involving 3 columns
unstable
Fractures involving 2 columns
usually follow middle column, if it’s stable the injury is stable
What are causes of cervical fractures?
usually traumatic: MVA, fall, violence, sports, etc
How are cervical fractures grouped?
can be occipital cervical or subaxial (C3-C7)
What is the nature of cervical injuries?
usually avulsive or due to compression or impaction
What is outcome of cervical injuries?
high mortality above C4
relativelty large cord space compared to T and L spine
What are 4 treatment components of c spine injuries?
immobilization
ongoing neurological examination
imaging
stabilization
What are the two stabilization options?
Conservative: closed reduction, traction, bracing
Surgical: decompression, posterior and/or anterior fusion (posterior approach appears to offer increased stability)
What are 4 different braces used for conservative stabilization?
aspen 4 post
Halo
Miami J collar
Philadelphia collar
What are treatments for occipital condyle fracture?
Type I and II: cervical orthosis (6-8 wks) or halo (8-12 wks)
Type III: cervical orthosis is no AO instability, Halo if minimally displaced, Occ-C2 PSP if unstable (bilateral facet dislocation)
What is treatment for atlanto-occipital dislocation?
associated with spinal cord involvement
careful immobilization and reduction with positioning and halo
often require occ-C2 PSF
very rare to have and few survive
What is MOI for atlas fracture?
usually due to axial loading of the occiput: burst fracture of bilateral anterior and posterior arches
AKA jeffersons fracture
Are atlas fractures are associated with other injuries?
Yes. associated with other C-spine injuries, especially fracture of dens C2. Often accompanied by transverse ligament tear or avulsion fracture. rarely associated with neurologic injury
What is treatment for atlas fracture?
cervical orthosis if minimally displaced (2mm or if accompanied by other fractures
AA fusion if significant instability
What is cause of C2 (odontoid) fracture?
bimodal distribution of incidence: risk taking behavior in young population, osteoporosis in elderly population
What is C2 fracture associated with?
High non-union rates, other C spine fractures, 10% incidence of neurologic compromise
What are treatment options for the 3 types of odontoid fracture?
type I: cervical orthosis
Type II: 5 mm displacement, 10 degree angulation-traction and PSF or anterior screw placement
Type III: 5 mm displacement and 10 degree angulation- traction and halo
What is MOI for C2 (axis) fracture?
AKA hangman’s fracture or traumatic spondylolisthesis
traumatic hyperextension causes bilateral pars interarticularis fractures
What is treatment for C2 fracture?
Distraction (not fracture) causes neuro compromise
Type I: cervical orthosis
Type II: halo, with or without traction
Type III: ORIF of C2, with C2-3 PSF
How are subaxial cervical injuries treated?
lower C spine injury is assumed until proven otherwise
early corticosteroid use and surgical stabilization are indicated for all cases of radiographic neuro compromise
usually managed with anterior decompression/fusion
What are types of subaxial cervical fractures?
distraction-flexion unilateral facet dislocation (bowtie sign) vertical compression compression-flexion lateral flexion
What is distraction flexion injury? MOI?
distraction load on flexed neck
facet dislocation (uni or bilateral) and posterior longitudinal ligament (PLL) compromise
MOI: MVA, sports
What are the most vulnerable regions for distraction flexion injuries?
C5-6 and C6-7
What is a bowtie sign?
unilateral dislocation/subluxation resulting in bowtie appearance at level of injury in lateral view
AP view reveals shift in spinous processes at level of injury
What is treatment of unilateral facet dislocation
immediate closed reduction
posterior stabilization, anterior decompression and stabilization if disc is herniated
immobilization with cervical orthotic: soft collar, Miami J, aspen collar, Philadelphia collar
What is MOI of vertical compression injury?
compresses and shortens anterior and middle columns
pattern associated with MVA or diving
What is affected in vertical compression injury?
C5, C6, C7 more vulnerable
What is treatment for stable vertical compression injury?
little kyphosis
cervical orthosis
What is treatment for unstable vertical compression injury
with kyphosis or canal compromise
ACDF with/without PSF
rigid orthosis, potentially a halo
What is another name for compression flexion injury?
tear drop fracture
What often accompanies compression flexion injury?
compromised stability (facet dislocation, ligament rupture, disk tearing)
What is treatment for compression flexion?
ACDF with/without PSF and cervical orthosis
What is MOI of lateral flexion injury?
MVA, blow to the head
What is treatment of lateral flexion injury?
rarely involve ligamentous injury requiring surgical stabilization
often managed with soft/rigid collars
What is more commonly affected in thoracic spine fractures?
bimodal distribution of incidence
transitional vertebrae (cervicothoracic, T1-4; thoracolumbar, T9-12) commonly affected
T12 and L1 injured most frequently
neurological compromise occurs in 15-20%
What is MOI?
compression, metastatic disease, trauma, flexion force usually contributes to injury
How are thoracic fractures managed?
varies based on:
stability, spinal cord compromise
presence of rib or sternal involvement
loss of vertebral height
What are the high risk areas of spine?
Transitional zone: opposition of flexible C and L spine against rigid T spine
Where does cauda equine begin?
approximately L2
What is compression thoracic spine fracture?
failure of anterior column, low risk of neurologic compromise
What is a thoracic spine burst fracture?
result of axial loading, often associated with neurologic compromise
What is thoracic spine flexion distraction (seatbelt) fracture?
transverse fracture line, rather rare
What is a thoracic spine dislocation?
considered unstable, often involving failure of all 3 columns and transverse process fracture or costal articulation
What is conservative treatment for thoracic dislocation?
postural reduction, bedrest (with or without bracing), functional bracing
What is surgical treatment for thoracic dislocation?
anterior/posterior decompression and fusion
What causes lumbar spine fractures?
hyperflexion with/without shear, rotation, and axial compression are most common mechanisms
commonly associated with hindfoot and burst fractures
When is surgery considered for lumbar spine fractures?
need for surgical stabilization predicted by presence of lumbar kyphosis
What lumbar region is more susceptible for lumbar spine fractures?
T11-L2 region
What is T11-L2 are susceptible too?
injury and instability
Does L2-L5 region get a lot of fractures?
structure size and protective musculature stabilize joint
L5-S1 fractures?
unstable, largely due to force necessary to cause injury
What is treatment for lumbar spine fractures?
surgical stabilization as indicated by instability, displacement, or neurologic deficit
Rigid orthotics (e.g. TLSO, LSO)
Molded jackets, braces, corsets
What do you focus on for acute PT interventions?
MOBILITY
immobilization is common post surgical stabilization
Focus on mobility, rather than strengthening specific back musculature
Progressive mobility training within neurologic prognosis
log rolling strategies for bed mobility
avoidance of flexion and rotational movements with ADLs
use of assistive device to promote early ambulation
discontinuation of spinal orthotic allows for progression of activity
What is two treatment options for scoliosis?
conservative: bracing and physical therapy
surgical: usually if curvature >40-50 degrees, ideally after growth is complete
What do we focus on for interventions for PT?
treatment similar to fusion
recovery depends on extent of surgery, need for thoracotomy
early use of device to initiate ambulation
activity limitations remain for approximately 1 year
