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Skeletal System Shannon Carroll, MDSuresh Agarwal, MD

Skeletal System Common Skeletal System Pathology encountered in Critical Care Complications of Skeletal Injury

Skull www.pycomall.com/images/P/skull.jpg

Skull Fractures 4 Major Types Linear Depressed Diastatic Basilar

Linear Skull Fracture Most common type Over Lateral Convexities Over squamous area of temporal bone Damage to middle meningeal artery Epidural Hematoma www.hawaii.edu/medicine/pediatrics/pemxray/v5c09h2.jpg

Depressed Skull Fracture Displaced bone fragments pushed into the cranial vault From blunt force by object with small surface area Often damages underlying brain tissue Complex = dura mater torn Contamination/Infection Often require surgery anatpat.unicamp.br/minDsc35446+.jpg

Diastatic Skull Fracture Fracture causes widening of suture Most commonly seen in infants and small children Seen in adults along the lambdoid suture Pirouzmand F, Muhajarine N. Craniofac Surg. 2008 Jan;19(1):27-36. Definition of topographic organization of skull profile in normal population and its implications on the role of sutures in skull morphology. img.medscape.com/pi/emed/ckb/radiology/336139-343764-9928.jpg

Basilar Skull Fracture From blunt force to the forehead or occiput Usually anterior Often involves cribriform plate Disruption of olfactory nerves Posterior Through petrous bone and internal auditory canal Disruption of the vestibulocochlear nerve and facial nerves CSF otorrhea/rhinorrhea t0.gstatic.com/images?q=tbn:TuEw6pvP4iIG5M:http://img.medscape.com/pi/emed/ckb/neurosurgery/247017-248108-4155.jpg

Basilar Skull Fracture Raccoon Eyes Battle’s Sign image.absoluteastronomy.com/images/encyclopediaimages/b/bl/blackeye_pigmentation.jpg www.itim.nsw.gov.au/images/Battle_Sign_s.jpg

Vertebral Injuries Vertebral Column forms the Axial Skeleton Among All Trauma Patients 4.3% Cervical Spine Injury 6.3% Thoracolumbar Spine Injury 1.3% Spinal Cord Injury www.eorthopod.com/images/ContentImages/spine/spine_thoracic/anatomy/thoracic_spine_anatomy01.jpg

Vertebral Injuries 7 Mechanisms of Injury Flexion – compression Axial compression Flexion – distraction Hyperextension Rotation Shear Avulsion

Cervical Spine Injuries www.physiotherapy-treatment.com/images/human-lateral-cervical-spine.jpg

Cervical Spine Injuries 25% Occiput to C2 75% C3 to C7 Occipto-cervical subluxation Rare Usually fatal Fractures of the Atlas Pain Decreased mobility Atlanto-axial dislocation High risk of neurologic deficit www.springerlink.com/content/26ghau7p5nmpcjle/

Fractures of the Odontoid Apical ligament avulsion fracture Stable Minimal if any external support img.medscape.com/pi/emed/ckb/orthopedic_surgery/1230552-1267150-1299.jpg

Fractures of the Odontoid • Waist of the odontoid • Unstable • Requires reduction or translation and angulation • Requires stabilization • Surgical • Halo vest img.medscape.com/pi/emed/ckb/orthopedic_surgery/1230552-1267150-1299.jpg

Fractures of the Odontoid • Extends below the waist into the body of C2 • Best treated with a halo vest • 15% incidence of nonunion with other immobilization img.medscape.com/pi/emed/ckb/orthopedic_surgery/1230552-1267150-1299.jpg

Thoracolumbar Spine Injuries L1 fracture 16% Spondylolisthesis Subluxation or Slip of one vertebral body on another Most common in lumbar spine Treatment Conservative management Fusion www.webinique.com/images/lumbar_spondylolisthesis_grades.jpg

Spinal Instability Disruption of anatomic components, motion or supportive elements Excessive or abnormal spinal motion 3 Column Model In thoracolumbar spine Instability = Injury to 2 or 3 columns www.pgblazer.com/wp-content/uploads/2009/11/three-column-concept-2.jpg

Spinal Instability • 50% Loss of Vertebral Body Height • Angulation > 20% • Compression Fractures • Burst Fractures www.pgblazer.com/wp-content/uploads/2009/11/three-column-concept-2.jpg

Non-operative Management of Spinal Injuries Stable injuries No neurologic deficits Immobilization www.alsab.ca/images/collar2.jpg

Spinal Immobilization C– spine Head halter Tongs Halo images.allegrocentral.com/9E/75/J-Tongs-Traction-Tongs-557879-PRODUCT-MEDIUM_IMAGE.jpg www.ossur.com/lisalib/getfile.aspx?itemid=15083&proc=3

Spinal Immobilization • T– and L– spine • Bedrest • Log rolling • Rigid brace www.optecusa.com/sites/default/files/imagecache/product_list/products_01_B09.jpg

Operative Management of Spinal Injuries Spinal Fusion Pedicle screws and rods Vertebroplasty Kyphoplasty eldoradopainmanagement.net/mediac/450_0/media/Compression_Render_Final.jpg www.backpain-guide.com/Chapter_Fig_folders/Ch15_Carpentry_Folder/Ch15_Images/15_3_Pedicle_Screws.jpg www.vancouverspinedoctor.com/images/balloon_kyphoplasty.jpg

Cervical Spine Clearance The NEXUS Clinical Criteria 1. Tenderness at the posterior midline of the cervical spine 2. Focal neurologic deficit 3. Decreased level of alertness 4. Evidence of intoxication 5. Clinically apparent pain that might distract the patient from the pain of a cervical spine injury Any of the above -> increased risk for cervical spine injury -> requires radiographic evaluation Sensitivity: 99.6% NPV: 99.9% Specificity: 12.9% PPV: 2.7% Hoffman JR, Mower WR, Wolfson AB, et al. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-Radiography Utilization Study Group. N Engl J Med. 2000;343:94 –99.

Cervical Spine Clearance Algorithm Como JJ, Diaz JJ, Dunham CM, et al. EAST practice management guidelines for identifying cervical spine injuries following trauma. 2009.

Chest Wall www.chelseagoodchild.com/images/portfolio/traditional/Rib_cage.jpg

Rib Fractures Overall mortality = 12% High-Energy Injuries: 1st or 2nd rib fractures Multiple rib fractures Scapula Fracture Rib Fractures in the Elderly (>65) 2 – 5 x greater risk of morbidity/mortality 19% Increase in mortality per rib fx 27% Increase in pneumonia image.wetpaint.com/image/1/XOMgDfktBYZImgBWx3Xc2g171569/GW537H600

Rib Fractures Treatment = Analgesia PCA Rib Blocks Epidural Intercostal/ IntrapleuralCatheter www.learningradiology.com/caseofweek/caseoftheweekpix2009-340/cow353-1lg.jpg

Flail Chest 2 ribs fractured in 2 locations Significant morbidity from underlying pulmonary contusions “Pendelluft” Treatment: Supplemental O2 Analgesia Pulmonary Toilet ?Endotracheal Intubation ?Surgical Stabilization Paradoxical Motion upload.wikimedia.org/wikipedia/commons/3/39/Flail_chest_mechaincs.jpg

Surgical Stabilization Studies suggest Quickly restores normal chest wall mechanics Less pain Decreased mortality Decreased mechanical ventilation needs Shorter hospital stays Decreased long term morbidity Gasparri MG, Almassi GH, Haasler GB (2003) Surgical management of multiple rib fractures. Chest 124:295S www.acuteinnovations.com/files/ribloc-overview1.20090316-1712.jpg

Suggested Indication for Surgical Treatment of Rib Fractures Flail chest Reduction of pain and disability Chest wall deformity/defect Symptomatic rib fracture non-union Thoracotomy for other indications Raminder Nirula1, Jose J. Diaz Jr.2, Donald D. Trunkey3 and John C. Mayberry3. Rib Fracture Repair: Indications, Technical Issues, and Future Directions. World Journal of Surgery 2009; 33(1): 14-22

Sternal Fractures “Steering Wheel Syndrome” Possible Associated Injury = Blunt Cardiac Injury Most Common Associated Injuries: Rib fractures Long bone fractures Head injuries Treatment: Rest Analgesia Monitor for EKG changes radiographics.rsna.org/content/21/5/1257/F42.medium.gif

Scapula Fractures From high energy trauma Rarely occur as an isolated injury Management: Sling Pendulum exercises at 3 weeks Strengthening at 6 weeks www.eorthopod.com/sites/default/files/images/adult_shoulder_fx_type_scapular_blade.jpg

Indications for Surgical Repair of Scapula Fractures If it is one of multiple shoulder fractures Displaced fracture of the glenoid neck Displaced fracture of the glenoid fossa Significant disruption of superior shoulder suspensory complex www.ncbi.nlm.nih.gov/bookshelf/picrender.fcgi?book=physmedrehab&part=A3412&blobname=ch4f4-30.jpg

Clavicle Fracture Classification Proximal (rare) Central (80%) Distal Risk of Nonunion (highest in distal fractures) Treatment: Sling Pendulum exercises at 2 to 3 weeks Avoidance of heavy activity x 8 weeks www.drdavidduckworth.com.au/css/images/clavicle-side.jpg

Clavicle Fractures Indications for surgical fixation: Distal clavicle Middle clavicle with >2cm of shortening Open Symptomatic Nonunions Associated neurovascular injury Complex injuries of the shoulder Surgical Procedure Screw and Plate Fixation Intramedullary implants images.google.com/imgres?imgurl=http://assets.sbnation.com/assets/161691 assets.sbnation.com/assets/161691/clavicle_fracture_surgery_photo.gif images.google.com/imgres?imgurl=http://assets.sbnation.com/assets/161691

Pelvis www.exchange3d.com/cubecart/images/uploads/aff973/Pelvis///Pelvis_thumb01.jpg

Pelvic Fractures Most Common Etiologies Motorcycle collisions Pedestrian v. Motor vehicle Fall > 15 feet Motor vehicle collision Mortality 7-14% 30% w/ severe or open fractures Most deaths due to other traumatic causes Concomitant Injuries in >90% of patients with pelvic fractures Most deaths due to: Head Injury Non-pelvic hemorrhage Lung Injury Thromboembolic Events MSOF

Pelvic Fractures Mean transfusion requirement = 8 units of packed red blood cells Minimize blood loss from pelvic fractures Early re-approximation and stabilization Bed Sheet Splint Clamp External Fixation Angiography Pelvic arterial disruption is source of hemorrhage 3 – 20% t3.gstatic.com/images?q=tbn:oc6jX5VKvtYoDM:http://www.vygia.com.vn/image/C-Clamp_02.jpg publicsafety.com/article/photos/1129742911746_13.jpg

Pelvic Compression Fracture Vectors Lateral Compression Anterior-Posterior Compression Vertical Shear images.google.com/imgres?imgurl=http://www.aofoundation.org/AOFileServerSurgery/MyPortalFiles%3FFilePath%3D/Surgery/en/_img/surgery/01-Diagnosis/61/62-A1-xrays-

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