Fractures of the Spine, Upper Extremities and Thoracic Cage Lecture PDF

Fractures of the Spine, and Thoracic Cage Objective To know the different types of fracture of the spine and thoracic cage Spinal Trauma In spinal injury spinal stability must be assessed, and the patient immobilized until his spine is cleared. CT scan is more reliable in assessing s...

Fractures of the Spine, and Thoracic Cage Objective To know the different types of fracture of the spine and thoracic cage Spinal Trauma In spinal injury spinal stability must be assessed, and the patient immobilized until his spine is cleared. CT scan is more reliable in assessing spine injury than plain radiographs. When neurologic deficits are present a decompressive procedure may be indicated. In spinal cord compression, prompt decompression should be performed. Animal models of spinal cord injury suggest that prompt decompression can lead to objective improvement of recovery. Spinal cord injuries should be triaged to trauma centers since trauma center care is associated with reduced paralysis. Occipital Cervical Dislocation Motor vehicle accidents can cause dislocation of the occiput on the condyles of the atlas (C1). Most patients with this injury suffer cervical cord injury, and do not survive. Traction on the spine is contraindicated. Treatment consists of stabilization and fusion in situ using a screw plate from the mid cervical spine to the occiput. 1. Fractures of C1 (Jefferson Fracture) Fracture of the C1 ring was described by Jefferson in 1920. The thin anterior and posterior rings of the C1 vertebra fracture with axial loads. C1 fracture causes the e lateral masses of C1 to spread, which is visible on a through- the- mouth AP X-Ray image of the cervical spine. This injury is rarely associated with neurologic injury. 1. Bracing with a cervicothoracic orthosis or a halo ring and vest is the recommended treatment for a Jefferson fracture. Fractures of C2 (Odontoid Fracture) Half of normal cervical rotation occurs at the atlanto-axial joint. The odontoid (Dens) is a small bony process which arises from the body of C2, and articulates with the body of C1 (the Atlas). Odontoid fractures are most often type I fractures (an avulsion fracture off the tip of the dens).  Type I fractures occur when there is tension applied to the alar ligaments (which span from the tip of the odontoid to the skull bypassing the C1 vertebra). Type I fractures are stable and managed nonoperatively.  A type II fracture, at the base of the odontoid, results from lateral loading forces. Operative stabilization is the preferred treatment since immobilization in a halo vest results in non-union rates ranging from 20% to 80%. Transfixing the odontoid fracture with a screw maintains rotational movement. Posterior fusion of C1 on C2 with sublaminar wiring resulting in decreased range of motion is another option.  Type III fractures extend into the body of C2, below the origin of the odontoid process. Type III fractures are generally treated with halo brace. (Anderson and D’Alonzo) Hangman’s Fractures of C2 Hangman’s fractures result from sudden extension forces on the neck and occur between the superior and inferior facets (pars interarticularis) of C2. Treatment is simple immobilization in a halo vest. Higher energy injuries causing severe extension forces can dislocate the C2-3 facet complex and damage the C2-3 disc. Such fractures can compromise the spinal canal, and death can occur from compromise of respiration. Significantly displaced Hangman’s fractures are managed by internal fixation and bone grafting between C2 and C3. Compression Fracture of the Spine In C3 to C7 an axial load can cause fracture of the endplate while preserving the posterior cortex of the vertebral body. These fractures generally heal well, and are treated nonoperatively with analgesics and a cervical brace. Burst Fractures of the Spine Diving accidents are the classic cause of Burst fractures of the cervical spine. The axial load when an unrestrained passenger in an automobile accident strikes the windshield the posterior cortex of the vertebral body fractures leading to displacement of bony fragments into the canal injuring the spinal cord. Burst fractures are treated surgically by anterior debridement of the fracture and reconstruction using a bone graft strut stabilized with a plate and screws. Unilateral and Bilateral Facet Dislocation Another injury associated with motor vehicle accidents is facet dislocation. A restrained passenger can suffer forced flexion with distraction resulting in dislocation of the facets. The diagnosis can be made on lateral radiographs. Treatment consists of axial traction with cranial tongs, graduated application of weight, and periodic X-Rays. The patient is kept awake for safety concerns. When reduction is attained, patients are taken to surgery for posterior fusion with interspinous process wiring or a screw plate.  Clay-Shoveler’s Injury Clay-Shoveler’s injury can result from a motor vehicle accident or from shoveling soil or clay. The injury (of C6, C7, T1, and T2) is the result of avulsion fracture of the spinous process by the paraspinal muscle forces. The fracture is treated nonoperatively with analgesics and a soft collar. FRACTURES OF THE THORACIC AND LUMBAR SPINE Thoracic Lumbar Spine Injury The ribs stabilize fractures of the thoracic spine, making these fractures more stable than similar fractures of the lumbar spine. Neurologic injuries are more common in the thoracic and proximal lumbar spine because of the presence of the spinal cord, which ends at the L2 level. Compression Fracture Compression fractures result from osteoporosis and abnormal bone density as well as trauma. Compression fractures involve a fracture of the superior or inferior endplate without associated posterior cortex fracture. Thoracolumbar compression fractures are treated nonoperatively with braces and analgesics. Burst Fracture Burst fractures are caused by falls and high energy automobile accidents. One or both endplates and the anterior cortex of the vertebrae with an associated fracture of the posterior cortex. The posterior cortex fracture differentiates the burst fracture from a compression fracture and results in retropulsion of bone into the canal, which can cause nerve injury. A vertical lamina fracture may contain an invaginated segment of the dura mater with accompanying nerve roots, and posterior surgery can result in dural tear or nerve injury.  If nerve injury is noted, treatment is an anterior exposure and removal of the fractured anterior elements (corpectomy) and a strut graft is placed. A laterally placed plate and screws add stability to the construct. Seatbelt Injuries (Flexion Distraction Injuries) A seatbelt injury occurs when there is acute forward flexion of the trunk and anterior (i.e. seatbelt) restraint. The pelvis and upper torso move forward, and failure of the spine under tension begins with the posterior elements. Tearing of the dorsal fascia, the interspinous ligament, dislocation of the facets, and tearing of the discs occurs. The bone of the spinous process, the lamina, the pedicles, and the vertebral body fail in tension (“Chance Fracture”). In flexion distraction injuries through soft tissue, posterior internal fixation and bone graft is recommended. “Chance fractures” are treated with bracing. Fracture Dislocations of the Spine Fracture dislocations of the spine displace the bony elements by translation or rotation resulting in canal narrowing and nerve injury. Reduction of the displaced bones is the best way to improve the canal dimensions. Patients with fracture dislocations of the spine and partial nerve function can recover. Fracture dislocations are treated operatively with surgical stabilization. Disc Herniation Disc herniation, most common between ages of 20 and 50, can occur in the cervical, thoracic, or the lumbar spine, and consists of a tear of the annulus allowing the nucleus pulposus material to extrude through the annulus and enter the canal, pressing on the exiting nerve or the ‘traversing’ nerve roots. In the cervical spine, spinal cord compression can occur.  Symptoms of most disc herniations resolve within eight weeks as the nerve root accommodates and inflammation recedes. The bulk of the extruded nucleus pulposus resorbs over time. When symptoms persist beyond six to eight weeks, excision of the involved disc and decompression of the nerve roots may be indicated.  In cervical disc herniation an anterior approach to the spine is performed with dissection through a transverse incision on the neck. Dissection is carried between the trachea and the carotid sheath. The disc is then removed. The disc space may be bone grafted to fuse the vertebrae. A locking screw low profile titanium plate is then attached to the vertebrae.  Posterior decompression and laminectomy exposes the posterior elements of the spine. A portion of the lamina is removed to allow access to the canal to correct foraminal impingement or to remove lateral disc herniations. While the posterior approach does not require fusion with plates and screws, central disc herniation cannot be managed through a posterior approach since the spinal cord cannot be safely retracted. For lumbar disc herniation a midline incision is used and laminectomy allows visualization of the lateral recess. Retraction of the dura allows visualization of the traversing nerve roots as well as of the disc fragment. Spinal Stenosis A loss of hydration of the discs causes loss of disc height and bulging of annular tissue and the ligamentum flavum which effectively narrows the canal (spinal stenosis). Osteophyte formation on the facet joints can also cause nerve impingement.  Cervical stenosis can cause myelopathic symptoms (hyperreflexia, ataxia, balance problems, weakness, and pain). Lumbar stenosis causes neurogenic claudication (progressive pain, weakness, and numbness in the legs). The claudication symptoms result from standing and walking which increases lumbar lordosis. The symptoms resolve with sitting and bending forward (decreasing lumbar lordosis).  Spinal stenosis is treated with epidural steroid injections and physical therapy. Resistant cases may require surgical decompression and stabilization with plates and screws. Spinal stenosis usually occurs in patients over 50 years of age. With degenerative spondylolisthesis or scoliosis fusion procedures with instrumentation may be required to prevent progression of the deformity. Back Pain and Degenerative Disc Disease Back pain occurs in the majority of adults but is usually self limited resolving in one to two weeks. Chronic unremitting back pain suggests the possibility of infection, malignancy, or metastatic disease.  While radiographs are one option in the management of disabling low back pain, they are ineffective at ruling out malignancy, and radiographic findings correlate poorly with symptoms. Patients with severe degenerative symptoms may have no pain, while others with mild degenerative findings complain of severe pain. The potential for secondary gain and psychiatric problems and the unpredictable results of spine fusion add to the difficulty of diagnosis and choosing a treatment plan.  Intervertebral disc replacement prostheses are now used to treat degenerative disc disease. The potential for loosening, creation of wear debris, and bone loss complicating revision surgery are concerns, as are the proximity of the device to the spinal canal and the great vessels. Scoliosis Scoliosis is a lateral curvature of the spine. Lateral bending of the spine is always accompanied by rotational deformity (coupling).  In order to measure the severity of scoliosis lines are drawn along the endplates of the vertebral bodies at either end of the curve and the angle formed when these lines intersect is magnitude of the curve. Scoliotic curves are classified as congenital, degenerative, metabolic (mucopolysaccharidoses), neurogenic (cerebral palsy), and myogenic curves (muscular dystrophy). Idiopathic scoliosis is the most common form, and represents a spectrum of genetic disease.  Adults with scoliosis may present with axial pain and imbalance in posture. Treatment for scoliosis may include medications, therapy, and activity modification. In severe cases with objective deformity surgical correction of the deformity may be indicated. Idiopathic Scoliosis The majority of idiopathic scoliosis curves become apparent during adolescence and progress during skeletal growth. Initial management consists of observation. Rapidly progressing curves are treated with braces. Brace treatment is recommended for curves between 20 and 40 degrees. For patients with large curves, surgical intervention may be needed using rods with grafting and fusion. Neuromuscular Scoliosis Neurologic conditions such as polio and cerebral palsy can lead to ‘uncompensated’ scoliosis curves where the patient is unable to lean with his upper body to restore balance. Scoliosis correction surgery may be needed to facilitate sitting balance, and to avoid skin breakdown caused by pelvic obliquity. Upper Extremities Clavicle Fractures Fractures of the clavicle are one of the most common fractures in orthopedics. They typically occur following a fall onto the shoulder and the majority of clavicle fractures occur in the middle third of the clavicle. Since the bone is subcutaneous, the fracture is often evident on inspection. Most clavicle fractures can be treated nonoperatively with a sling, range of motion exercises, and gradual return to normal activities.  Fractures that are significantly displaced and shortened, or that penetrate the skin, are treated with open reduction internal fixation, typically with plate and screw fixation.  Distal clavicle fractures are less common and may occur along with coracoclavicular ligament ruptures. These injuries can be more troublesome and are at risk for nonunion if the bone ends are not in contact. If there is displacement of the fracture, surgical management is often recommended.  Acromioclavicular (AC) joint injuries occur from either a fall directly onto the shoulder or onto an outstretched hand and can result in tears of the acromioclavicular and coracoclavicular ligaments. A step-off, or separation, of the AC joint may be apparent on radiographs.  The majority of these injuries can be treated with a sling and gentle range of motion. Injuries resulting in severe displacement of the clavicle may require open reduction and surgical repair.  The sternoclavicular (SC) joint is the only articulation between the upper extremity and the axial skeleton, and injuries to this joint are rare.  Anterior dislocations occur more frequently and closed reduction can be attempted, followed by sling immobilization.  Posterior SC joint dislocations can be dangerous, resulting in pulmonary or neurovascular compromise, and closed reduction under general anesthesia is recommended with a vascular surgeon present in case of vascular injury. Scapula Fractures Fractures of the scapula often result from significant trauma and can be associated with injuries to the head, lungs, ribs, and spine. Most scapula fractures are treated nonoperatively with the exception of fractures to the glenoid. As with most intraarticular fractures, displacement of the articular surface of the glenoid is an indication for open reduction and internal fixation. Shoulder Dislocations The shoulder is one of the most commonly dislocated joints and most dislocations are anterior. They are often associated with injuries to the labrum (Bankart lesion), impression fractures of the humeral head (Hill-Sachs lesion), and rotator cuff tears. Posterior dislocations are associated with seizures or electric shock. Adequate radiographs are required to diagnose a shoulder dislocation, with the axillary view being the most critical. If proper X-rays are not performed then dislocations can be missed and can result in significant debilitation of the shoulder. Dislocation of the shoulders can be managed with closed reduction followed by a short period of sling immobilization. Proximal Humerus Fractures Proximal humerus fractures occur most frequently in elderly patients following a fall onto the shoulder, though they can also occur following high-energy trauma. Treatment is determined by the displacement of the fracture fragments, the amount of angulation of the fracture, and the amount of comminution (which means multiple fracture fragments).  They have historically been classified by the number of fracture fragments using the Neer classification, which divides the proximal humerus into 4 parts: the humeral head, greater and lesser tuberosities, and the humeral shaft.  If there is suspicion of an intra-articular fracture, a computerized tomography (CT) scan is often indicated. The majority of proximal humerus fractures is minimally displaced and can be treated with sling immobilization, followed by early shoulder motion and pendulum exercises. Displaced fractures and fractures involving the humeral head are at increased risk for osteonecrosis and therefore surgery is often recommended. If there is adequate bone stock and the fracture can be successfully reduced, open reduction internal fixation with plate and screw fixation is the treatment of choice. Older patients with osteoporotic bone and comminuted fractures are typically treated with a prosthetic replacement of the humeral head, or a hemiarthroplasty. Humeral Shaft Fractures Humeral shaft fractures occur from direct trauma to the arm or from a fall on an outstretched arm, especially in elderly patients. The radial nerve spirals around the humeral shaft and is at risk for injury, therefore a careful neurovascular exam is important.  Most radial nerve injuries are neuropraxias, or stretching of the nerve, and function typically returns in 3 to 4 months. The majority of humeral shaft fractures can heal with nonsurgical management if they are within an acceptable degree of angulation. They are treated with a coaptation splint or functional bracing, which consists of a plastic clamshell brace with Velcro straps.  Close follow-up with serial radiographs is important to verify healing of the fracture, and gentle motion exercises are begun within 1 to 2 weeks. Fractures with significant angulation are most commonly treated with open reduction and plate fixation, with care to protect the radial nerve as it often lies close to the fracture site. Intramedullary nailing can also be performed, though it carries the risk of shoulder pain from the nail insertion. Distal Humerus Fractures Fractures of the distal humerus result from falls onto the elbow or onto an outstretched arm. Supracondylar fractures are most common, occurring above the elbow joint and do not involve the articular surface. Those minimally displaced can be treated with a posterior long arm splint, with the elbow typically flexed to 90 degrees.  Fractures involving the articular surface are treated with plate fixation, and depending on the fracture pattern may require 2 plates, one placed medially and one posterolaterally. As with other intra-articular fractures, the goals of treatment are anatomic reduction of the joint surface with stable fixation, restoration of the anatomic alignment of the joint, and early range of motion.  Severely comminuted fractures, especially in the elderly, may be treated with a total elbow replacement, which involves replacing the joint surfaces of the distal humerus, proximal ulna, and radial head with prosthetic components. Fractures about the elbow are notorious for developing stiffness and therefore early motion of the elbow is paramount to a successful outcome. Range of motion should be started as soon as the patient can tolerate therapy. Elbow Dislocations Dislocations of the elbow are common and typically occur posteriorly after a fall on an outstretched hand. A dislocation results in injury to the joint capsule and rupture of the lateral collateral ligament, though the medial collateral ligament can also be involved. They may even be associated with a fracture of the radial head, coronoid, or the epicondyles of the humerus. Simple elbow dislocations should be urgently reduced with the patient under sedation and treated briefly in a posterior long arm splint. Stiffness of the elbow is a common complication following elbow dislocations and therefore short-term immobilization (about 7–10 days) and early range of motion is recommended.  Dislocations associated with fractures may be treated surgically if there is any instability of the elbow joint. A severe injury, known as the “Terrible Triad,” includes an elbow dislocation, a radial head fracture, and a coronoid fracture. These are unstable injuries and require repair of the torn lateral collateral ligament (LCL), fixation or replacement of the radial head, and possible fixation of the coronoid depending on the size of the fracture fragment. Radial Head Fractures Most fractures of the radial head can be treated nonoperatively, simply with a sling for 1 to 2 days followed by motion exercises However, if there is a displaced fracture or if the fracture blocks pronation or supination of the forearm, then surgery is recommended. If the fracture can be well reduced, it is fixed with 1 or 2 screws. If the radial head is fractured into multiple pieces, the treatment of choice is a radial head replacement with a metallic implant. Excision of the radial head can also be performed, but this is reserved for elderly patients with limited demands and may contribute to elbow instability or wrist symptoms over time. Olecranon Fractures Olecranon fractures occur following a fall directly onto a flexed elbow. Nondisplaced fractures are treated with a splint in 45 to 90 degrees of flexion for a short time followed by range of motion exercises to prevent stiffness.  Because the triceps inserts on the olecranon, the pull of the muscle often displaces the fracture, causing a loss of the ability to actively extend the elbow, and therefore should be fixed surgically. Simple transverse fractures can be fixed with a tension band construct, which consists of cerclage wiring passed through the ulna and wrapped in a figure-of-8 fashion around 2 pins placed proximally into the olecranon, creating a compressive force across the fracture to promote healing. Comminuted fractures are treated with plate and screw fixation. Because of the subcutaneous location of the olecranon, this hardware can be irritating to the patient and may need to be removed after the fracture has healed. Forearm Fractures Forearm fractures are common injuries that result from high energy trauma or from falls onto an outstretched arm. Both bone forearm fractures often require surgery with plate and screw fixation.  The radius has a bow and rotates around the straight ulna for proper pronation and supination of the forearm, and therefore this anatomic relationship needs to be restored to maintain function. An isolated fracture of the ulna shaft, or a “nightstick fracture,” occurs from a direct blow to the side of the forearm. These can usually be treated in a cast, though fractures that are angulated or displaced can be treated with open reduction and plate fixation.  A Monteggia fracture is an ulna shaft fracture along with a radial head dislocation. The radial head dislocation may be missed without radiographs of the elbow and therefore a fracture of the ulna should raise suspicion of this injury. These injuries require surgery to fix the ulna fracture with plate and screw fixation and to reduce radial head.  A Galeazzi fracture is a radial shaft fracture with disruption of the distal radioulnar joint (DRUJ ) at the wrist. After the radius is fixed with plate and screw fixation, the DRUJ is assessed for stability and may need wires placed across the joint temporarily. Fracture to the Thoracic Cage  A broken rib is a common injury that occurs when one of the bones in your rib cage breaks or cracks. The most common cause is chest trauma, such as from a fall, motor vehicle accident or impact during contact sports.  Many broken ribs are merely cracked. While still painful, cracked ribs aren't as potentially dangerous as ribs that have been broken into separate pieces. A jagged edge of broken bone can damage major blood vessels or internal organs, such as the lung. In most cases, broken ribs usually heal on their own in one or two months. Adequate pain control is important so that you can continue to breathe deeply and avoid lung complications, such as pneumonia. Flail Chest Spontaneous breathing relies on the ability to create negative pressure within the thorax. Flail chest injury is defined by fractures of 2 or more ribs in continuity, in 2 or more locations. This injury results in a segment of the chest wall that is no longer in continuity with the rest of the thoracic cage, causing disruption of its integrity. It may result in paradoxical chest movement where the flail segment moves inwards on inspiration and outwards on expiration. (This is known as a clinical flail, as opposed to a radiological flail which is defined on imaging). The work of breathing is increased significantly in patients with clinically evident flail chest injury, and they may quickly develop respiratory failure.  Flail chest injury is usually the result of a significant energy force applied to the thoracic cage. Flail injury is therefore usually associated with injury to the underlying lung as well as pain leading to hypoxemia, hypercarbia and decreased lung compliance. Patients with flail chest injury and pulmonary contusions are at particular risk for further complications such as atelectasis, respiratory failure and pneumonia. Immediately life threatening injuries Tension pneumothorax - injury to pleural parenchyma creates a one-way valve defect allowing air to enter the pleural space but not leave, resulting in increasing pressure within the pleural cavity.  Massive Haemothorax - accumulation of blood and fluid in the hemithorax prevents adequate ventilation and compresses the lung, especially when there is >1500mls or 1/3 the patients’ blood volume in the chest cavity.  Cardiac Tamponade – blood, fluid or air enters the pericardium, restricting cardiac activity and interfering with filling. Pericardiocentesis.  Open pneumothorax – air follow the path of least resistance, therefore if an opening in the chest wall is approximately 2/3rd of the diameter of the trachea or greater, air will pass through the chest wall defect with each respiratory effort, rather than down the trachea. Symptoms The pain associated with a broken rib usually occurs or worsens when you: Take a deep breath Press on the injured area Bend or twist your body Causes Broken ribs are most commonly caused by direct impacts — such as Motor vehicle accidents, Falls , Child abuse or Contact sports. Ribs also can be fractured by repetitive trauma from sports like golf and rowing Severe and prolonged coughing. Risk factors Osteoporosis. Having this disease in which your bones lose their density makes you more susceptible to a bone fracture. Sports participation. Playing contact sports, such as hockey or football, increases your risk of trauma to your chest. Cancerous lesion in a rib. A cancerous lesion can weaken the bone, making it more susceptible to breaks. Complications A broken rib can injure blood vessels and internal organs. The risk increases with the number of broken ribs. Complications vary depending on which ribs break. Possible complications include: Torn or punctured aorta. A sharp end of a break in one of the first three ribs at the top of your rib cage could rupture your aorta or another major blood vessel. Punctured lung. The jagged end of a broken middle rib can puncture a lung and cause it to collapse. Lacerated spleen, liver or kidneys. The bottom two ribs rarely fracture because they have more flexibility than do the upper and middle ribs, which are anchored to the breastbone. But if you break a lower rib, the broken ends can cause serious damage to your spleen, liver or a kidney. Reference Thompson: Netter's Concise Atlas of Orthopaedic Anatomy, 1st ed. Copyright © 2001 Saunders, An Imprint of Elsevier Schwartz’s Principles of Surgery Eleventh Edition Copyright © 2019