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Fractures > Spinal Trauma > Flashcards

Spinal Trauma Flashcards

1
Q

What is the typical mechanism/aetiology of spinal fractures?

A
  • High energy e.g. falls from height/RTA/assault
  • Low energy wedge fractures in elderly/osteoporotic
  • Presume risk of spinal injury in all high energy trauma (protect spine until fracture excluded as in ATLS)
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2
Q

Summarise the initial assessment of a suspected spinal fracture.

A
  • Immobilise the patient
  • Full neurological examination
  • PR examination
  • Open/closed injury
  • Other sites of injury or polytrauma
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3
Q

Summarise the appropriate imaging in suspected spinal trauma.

A
  • X-RAYS : AP & LATERAL (& PEG VIEW IF C-SPINE)
  • +/- CT IF X-RAYS NOT SUFFICIENT TO MAKE DIAGNOSIS
  • +/- MRI IF NEUROLOGICAL INJURY OR ? LIGAMENTOUS INJURY
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4
Q

In what way should one consider the consequences of C-spine trauma?

A
  1. The container: C-spine
  2. The content: the spinal cord
  3. The outgoing nerve root
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5
Q

How should one assess damage to the vertebral structures?

A
  • TENDERNESS
  • OEDEMA
  • BRUISING
  • GAP OR STEP
  • SPASM OF ASSOCIATED MUSCLES
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6
Q

How should one assess damage to the spinal cord?

A
  • UMNL signs
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7
Q

How should one assess damage to the nerve roots?

A
  • LMNL signs
  • Exiting nerve roots
  • Cauda equina (below conus/L1 level)
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8
Q

Outline in detail the assessment of suspected spinal trauma.

A 
SENSATION (0-2 out of 2)
•MOTOR FUNCTION (0-5 out of 5)
•REFLEXES (UMNL VS LMNL)
•PR EXAMINATION ( motor, sensation, tone re: 
nerves of cauda equina) 
•+/- BULBO-CAVERNOSUS REFLEX
•DOCUMENT USING ASIA CHART (American 
spinal injury association)
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9
Q

Briefly outline spinal immobilisation.

A

• Whole spine should be immobilized in neutral
position on a firm surface.
- semi-rigid cervical collar, side head supports, & strapping (AKA sandbags, collar & tape)
- long spine board
- Log-roll until spinal injury excluded
- LEAVE IMMOBILISED! PRIORITY IN MULTIPLE SPINAL TRAUMA!
• IMAGING THE SPINE does NOT take precedence over life saving diagnostic and therapeutic procedures

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10
Q

Who needs C-spine imaging after trauma?

A

Image if ANY of these:

  1. Neck pain
  2. Midline neck tenderness
  3. Neurologic signs and symptoms
  4. Mental status less than alert or intoxicated
  5. Distracting injury (i.e. painful injuries elsewhere, e.g. limb fractures)
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11
Q

When may you “clinically clear” a patient after assessing their C-spine in a trauma?

A

Possible to “clinically clear” neck ONLY IF ALL of these:

  1. No neck pain,
  2. No neck tenderness on
    palpation, with full, painless,
    active range of motion of c-
    spine,
  3. No neurologic deficit
  4. No mental status change & no history of loss of consciousness
  5. No distracting symptoms.
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12
Q

What imaging is appropriate in suspected spinal trauma?

A
  • AP and lateral + peg view for C-spine
  • If C-spine views inadequate (cannot see from skull base to C7/T1 junction) then consider CT C-spine.
  • Flexion and extension views may be considered later to exclude ligamentous instability if no fracture but ongoing pain
  • Pan-scan whole body CT now common in polytrauma
  • MRI if neurological defect present (can also visualise ligamentous injury)

NB/remember 10% of patients with spinal fractures have another fracture elsewhere.

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13
Q

Why are flexion-extension view X-rays performed in suspected C-spine injuries?

A

• IF standard XR / CT scan normal but persistent pain
- Active Flexion/Extension views at day 10
• Eliminates instability

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14
Q

Outline the ABCDE analysis of C-spine X-rays.

A
  • ADEQUACY
  • BONE ABNORMALITY
  • CONTOURS
  • DISCS & SPACES
  • EXTRA-AXIAL SOFT TISSUES
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15
Q

Outline ‘adequacy’ in analysis of C-spine X-rays.

A 
Count Vertebrae (lateral): occiput to C7 must be seen.
If not seen, get a CT,  (or swimmer’s view / pull-down view)
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16
Q

Outline ‘bone abnormalities’ in analysis of C-spine X-rays.

A

Check the contour of each bone on AP & lateral, including shape of vertebral bony & position of pedicles & facets

17
Q

Outline ‘contours’ in analysis of C-spine X-rays.

A

Four lines:

  • Anterior vertical line
  • Posterior vertical line
  • Spinolaminar line
  • Posterior spinous line

NB/ also assess the general curvature e.g. lordosis in
cervical & lumbar, kyphosis in thoracic

Anterolisthesis indicates facet dislocation.

18
Q

Outline ‘discs and spaces’ in analysis of C-spine X-rays.

A
  • Predental space (< 3mm) sinon Fr. Odontoid process or transverse ligament rupture
  • Disc spaces should be the equal and symmetric
  • The height of the cervical vertebral bodies should be approximately equal
  • The height of each joint space & spaces between spinous processes should be roughly equal at all levels.
  • Spinous process should be in midline and in good alignment.
19
Q

Outline ‘extra-axial soft tissues’ in analysis of C-spine X-rays.

A
  • Prevertebral soft tissue shadow increase indicates bleeding/ swelling (>5mm at C3 or> width of vertebra at below level of larynx)
  • If normal, does not exclude injury
  • Difficult to interpret in crying infant, NG tube/ intubation, penetrating injury
20
Q

What is meant by an unstable spinal injury?

A 
• CLINICALLY UNSTABLE IF 
– DEFORMITY
– OR NEUROLOGICAL DAMAGE
– OR PAIN (NOT CONTROLLED ON SIMPLE 
ANALGESIA)
21
Q

How are stable vertebral fractures managed?

A

No reduction required - maintained with analgesia +/- supporting brace.

22
Q

How are unstable vertebral fractures managed?

A

GA ORIF i.e. spinal stabilisation +/- decompression of the spinal cord.

23
Q

Outline the ‘3 columns of spinal stability’

A

• ANTERIOR COLUMN
– anterior 1/3 of vert. body & disc + anterior longitudinal ligament

• MIDDLE COLUMN
– posterior 1/3 of vert. body & disc + posterior longitudinal ligament

• POSTERIOR COLUMN
– “Posterior elements” i.e. rest of vertebra & ligaments

NB/ ALL fractures of middle column and one other column are unstable.

24
Q

Outline C-spine stability.

A

• Remember the role of ligaments in
maintaining cervical bony alignment & stability e.g. anterior & posterior longitudinal ligaments, at facet
joints, & transverse ligament around odontoid peg

25
Q

Describe a Jefferson fracture.

A

JEFFERSON FRACTURE (C1):

Compression fracture of the bony ring of C1

  • lateral masses splitting
  • transverse ligament tear
26
Q

Outline odontoid (C2) fractures.

A

Type 1: Avulsion off tip (by alar
ligament)
Usually stable:
Treat in orthotic brace

Type 2: fracture at junction of dens 
(peg) with the C2 body.
Most unstable:
Consider halo brace or surgery if 
medically suitable, or orthosis if 
unsuitable for surgery
Type 3: 
fracture in body of C2 (primarily 
cancellous bone).
Usually stable:
Treat in orthotic brace
27
Q

Outline ‘Hangman’s fracture’ - traumatic spondylolisthesis of C2.

A
  • 25% of C2 injuries
  • Motor vehicle accidents
  • Usually due to hyperextension-axial compression forces (windshield strike)
    • Neurological injury seen in only 5-10 % (acutely decompresses canal)
    • Traditional treatment has been Halo-vest
    • Collar adequate if < 6 mm displaced

Fractures (14 decks)

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