Basic principles of treatment of breaks of he overhead extremities and spine.

1. Basic principles of treatment of breaks of he overhead extremities and spine. Tutor: Kostiv S. Ya.

2. SPINAL TRAUMA

3. C1 Fractures • The upper cervical spine is defined by the 2 most cephalad cervical vertebrae, C1 (the atlas) and C2 (the axis) • Jefferson originally described this type of C1 fracture in 1920. The principal treatment is with a halo and vest or cast, which remains an effective current treatment for many of these fractures. • Fractures of the atlas compromise 25% of atlantoaxial complex bony injuries, 10% of cervical spine injuries, and 2% of all spine injuries

4. Etiology • The Jefferson fracture most commonly occurs as the result of axial loading on the head through the occiput, leading to a burst-type fracture of C1. Diving is the most frequent cause of this fracture, when it results from striking the head on an obstacle in shallow water; hence, the national program "Feet first, first time" (North American Spine Society, 2005) provides a motto for diving in unknown waters or shallow collections of water and has been an effective deterrent. The next most frequent cause of this fracture is being thrown up against the roof of a motor vehicle, a car or bus, or even an aircraft, and the forces are distributed to the body through the neck. The third most frequent cause of these injuries is falls onto the head, except in toddlers, who are predisposed to injury from falls because of their disproportionate head size.

5. Clinical • Patients with a complete spinal cord injury and no neurologic function continue to have only sensation on the face and motor control of the facial muscles from the cranial nerves. A tracheostomy is essential because the patient requires respiratory assistance and a volume respirator. If the C3-5 area is intact, the phrenic nerve may often be stimulated to contract the diaphragm. If stimulation of the phrenic nerve does not contract the diaphragm, then the spinal cord is no longer functioning; the cell body is dead, and a phrenic electrical stimulator is not effective.

6. Imaging Studies • Cervical spine radiographs • Arteriography

7. Medical therapy • Patients with C1 fractures customarily have some form of trauma; thus, they need to be immediately stabilized at the scene, which requires the customary attention to the ABCs (airway, breathing, and circulation). If the airway is compromised or air exchange is inadequate, intubation without moving the head is crucial (C-spine protection). Careful evaluation and frequent reassessment is needed because the patient may have sustained a concussion with the impact to the head (the common injury that produces the C1 fracture) and, because of a clouded sensorium, may not be able to be fully evaluated or to report neck pain. Patients with a diminished alertness and orientation should carefully undergo imaging studies to exclude underlying pathology.

8. Surgical therapy • Treatment of the C1 fracture consists of stabilization or immobilization in a satisfactorily reduced position to allow reliable healing. This illustrates the necessity of identifying associated injuries; for example, if a Jefferson fracture is identified but an associated odontoid fracture, transverse ligament fracture, or other problem is present, then halo treatment may be modified or less successful. The transverse ligament is not necessarily expected to heal tightly or reliably, although a bony fracture would be expected to have mechanical integrity restored when healed

9. Fracture of the C1 ring may result in lateral displacement and subsequent overhang on the open mouth view in radiographs

10. Computed tomography scanning is often best to visualize C1 ring fractures

11. Computed tomography sagittal views can be used to evaluate the atlantodens interval or to visualize C1 fractures.

12. C2 Fractures • Cervical spine (C-spine) injuries are the most feared of all spinal injuries because of the potential for significant deleterious sequelae. Correlation is noted between the level of injury and morbidity/mortality (ie, the higher the level of the C-spine injury - the higher the morbidity and mortality). Craniocervical junction injuries are the deadliest. • As many as 10% of unconscious patients who present to the emergency department following a motor vehicle accident (MVA) have C-spine pathology. MVAs and falls are responsible for the bulk of C2 fractures. The clinical manifestations range from asymptomatic to frank paralysis. This article focuses on the uniqueness of and the most common types of traumatic C2 (axis) fractures.

13. Neurologic assessment of C2 fractures (C2 nerve root) • Motor: Muscles that have a contribution from the C2 nerve root include the sternocleidomastoid, trapezius, longus capitis, longus colli, rectus capitis anterior, splenius capitis, splenius cervicis, and semispinalis capitis. • Sensory: The posterior scalp, anterolateral neck, anteroinferior and posteroinferior external ear and C2 sensory innervation sites. • Reflexes: For the sternocleidomastoid (SCM) reflex, tap on the clavicular end and the muscle contracts.

14. Clinical examination includes the following: • Observe and palpate for deformities and step-offs • Muscle strength and tone of upper and lower extremities • Sensory testing of upper and lower extremities • Rectal examination • Shrugging the shoulders to test trapezius muscle • Observe for torticollis

15. Odontoid fractures • Type I fracture • A type I fracture (less than 5% of cases) is an oblique fracture through the upper part of the odontoid process. • This type of fracture occasionally is associated with gross instability due to traction forces applied to, and subsequent injury of, the apical and/or alar ligaments. • This is an avulsion injury to the tip of the odontoid and is usually stable. • Type II fracture: A type II fracture (more than 60% of cases) is a fracture occurring at the base of the odontoid as it attaches to the body of C2 (see Image 1). • Type III fracture • A type III fracture (30% of cases) occurs when the fracture line extends through the body of the axis. • The fracture line can extend laterally into the superior articular facet for the atlas. • Another type of odontoid process fracture is a vertical fracture through the odontoid process and body of the axis (less than 5% of cases). This type of fracture often is considered a variant of a traumatic spondylolisthesis of C2, which is discussed below.

16. C2 lateral mass fractures • C2 extension teardrop fractures

17. Traumatic spondylolisthesis of C2 (hangman fracture) • Type I fractures • Type I fractures (29%) are bilateral pedicle fractures with less than 3 mm of anterior C2 body displacement and no angulation. • The mechanism of this injury is hyperextension with concomitant axial loading and a force sufficient enough to cause the fracture but not enough to disrupt the anterior longitudinal ligament (ALL), posterior longitudinal ligament (PLL), nor the C2/C3 disk. • The integrity of the C2/C3 disk, ALL, and PLL determines the stability of the injury, and with these elements intact, the injury is considered stable. • Commonly associated concomitant injuries are C1 posterior arch fractures, C1 lateral mass fractures, and odontoid fractures. • Type II fractures • Type II fractures (56%) demonstrate significant displacement and angulation. • The mechanism of this injury is 2-fold; hyperextension with concomitant axial loading, followed by flexion with concomitant axial compression. • The resultant injury pattern is bilateral pedicle fractures with slight disruption of the ALL and significant disruption of the PLL and C2/C3 disk. This injury is considered unstable. • A wedge compression fracture of C3 is the most common associated injury. • Type IIA fractures • Type IIA fractures (6%) demonstrate no anterior displacement, but there is severe angulation. • The mechanism for this injury is flexion with concomitant distraction. The resultant injury pattern is bilateral pedicle fractures with C2/C3 disk disruption and some degree of insult to the PLL. This is an unstable fracture. • Radiographs taken while the patient is in cervical traction demonstrate an increase in the C2/C3 posterior disk space. • Type III fractures • Type III fractures (9%) demonstrate severe displacement and severe angulation. • The mechanism of this injury is flexion with concomitant axial compression. • The resultant injury pattern demonstrates not only bilateral pedicle fractures with C2/C3 disk disruption, but also concomitant unilateral or bilateral C2/C3 facet dislocations. • Varying degrees of injury occur to the ALL and PLL. This is an unstable fracture. • A relatively high incidence of mortality and morbidity is noted with this injury, particularly neurologic sequela.

18. Odontoid type II fracture

19. Atlantooccipital and atlantoaxial dissociation

20. Hangman fracture

21. Three types of C2 odontoid fractures: type I is an oblique fracture through the upper part of the odontoid process; type II is a fracture occurring at the base of the odontoid as it attaches to the body of C2; type III occurs when the fracture line extends through the body of the axis.