Blunt neck trauma: Difference between revisions
 
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==Background==
==Background==
*Suspect vascular damage to the cord if discrepancy between neuro deficit and level of spinal column injury
*Suspect vascular damage to cord, if discrepancy between [[Focal neurologic deficits|neuro deficit]] and level of spinal column injury
*Down syndome predisposes to atlanto-occipital dislocation; RA predisposes to C2 transverse ligament rupture
*[[Spinal cord injury]] is more likely if anterior (vertebral bodies) AND posterior (spinal canal) columns are disrupted
*Cord injury is more likely if anterior (vertebral bodies) AND posterior (spinal canal) columns are disrupted  
*If find injury consider CT C-spine, xray rest of spine


==Atlanto-occipital Disassociation==
==Clinical Features==
*Unstable
*Signs of life-threatening neck or upper thoracic injury (look for ''TWELVE''):
*Evaluate with the Powers ratio
:'''T'''racheal deviation'',
**Ratio of BC:OA > 1 suggests anterior subluxation
:'''W'''ounds,
**BC = distance between basion and midpoint of C2 post laminar line
:'''E'''xternal markings,
**OA = Distance between opisthion and ant arch of C2
:'''L'''aryngeal disruption,
:'''V'''enous distention,
:'''E'''mphysema (surgical)
*Features may include signs and symptoms of:
**[[Spinal cord injury]]
**[[Vertebral and Carotid Artery Dissection]]
**Laryngeal or [[tracheal injury]]


==C1 Fractures==
===Pediatrics===
===Burst (Jefferson)===
*In a small study of 42 patients with a cervical seatbelt sign there were no isolated  cerebrovascular injuries. For pediatric patients in a motor vehicle collision, the presence of an isolated seatbelt sign was not associated with any cases of cerebrovascular injury. <ref>Desai NK, et al. Screening CT angiography for pediatric blunt cerebrovascular injury with emphasis on the cervical “seat- belt sign.” AJNR Am J Neuroradiol. 2014 Sep;35(9):1836-40. PMID: 24722311.</ref>
*Unstable
*Axial loading transmitted through occipital condyles to the lateral masses
**Results in fx of the ant and post arches
**Stability is determined by whether or not the transverse ligament is disrupted
*Suspect disruption if:
**Lateral xray: Increase in the predental space between C1 and the dens
***Predental space greater than 3 mm in adults or 5 mm in children is abnormal
**Odontoid xray: Masses of C1 to lie lateral to the outer margins of the articular pillars of C2
**If either of the above findings on xray then obtain CT c-spine
===Anterior Arch===
*Stable


===Posterior Arch===
==Differential Diagnosis==
* Stable (b/c anterior arch and transverse ligament are unaffected)
{{Blunt neck trauma DDX}}
* Must ensure that you are not confusing this with a burst fx!
** Odontoid view must be normal
* Due to forced neck extension
* Vertical fx line through posterior arch seen on lateral xray


==C2 Fractures==
===Other===
===Odontoid (dens) Fracture===
*[[Head trauma]]
*Only stable if fx confined to avulsion of the tip (sup to transverse ligament)
*[[Thoracic trauma]]
*Frequently involves other cervical spine injuries
*25% a/w neurologic injury
===Traumatic Spondylolisthesis ("Hangman's Fx")===
*Unstable
*Fracture of both C2 pedicles leads to C2 displacing anteriorly on C3
*Seen in MVA and diving accidents (not in suicidal hangings)
**Forced extension of an already extended neck
*Spinal cord damage is often minimal (diameter of neural canal is greatest at C2)


==Cervical Fractures==
==Evaluation==
===Anterior Wedge Fracture===
===Workup===
* Only unstable if:
*Consider x-ray or non-contrast cervical CT to evaluate for bone/cord injury (see below)
** Loss of over half of vertebral height OR multiple adjacent wedge fractures
**May later consider cervical MRI to further evaluate for cord injury
*Consider CTA neck with contrast to evaluate for vascular injury (see below)


===Flexion Teardrop Fracture===
===General Approach===
*Unstable
[[File:Vertebral lines.png|thumb|Plain films lines]]
*Displacement of teardrop shaped fragment of antero-inferior portion of superior vertebra
*If concern for cervical spine injury, use a [[cervical spine clearance]] decision rule to determine need for imaging
**Severe flexion > vertebral body colliding with the one below
*Perform a neuro exam, to determine concern for [[spinal cord injury]]
*Associated with acute anterior cervical cord syndrome due to fx-induced kyphosis
*If concern for vascular injury, use the [[Denver screening criteria]]


===Extension Teardrop Fracture===
==Management==
*Unstable
*Prehospital
*Abrupt neck extension > anterior longitudinal ligament avulses anteroinferior corner
**See the [[EBQ:Prehospital Spine Immobilization|NAEMSP National Guidelines for Spinal Immobilization]]
**Avulsed fragment is greater in height than width (contrast with flexion teardrop)
*Hospital
*Often occurs at C5-C7 associated with diving accidents
**Secure ABCs
**Associated with central cord syndrome
**See [[cervical spine clearance]]
**See specific diagnosis


===Spinous Process Fracture (Clay Shoveler's)===
==Disposition==
* Stable
*Based on specific diagnosis
* Isolated fracture of one of the spinous processes of the lower cervical vertebrae


===Burst Fracture===
==See Also==
*Unstable
*[[Penetrating neck trauma]]
*Axial compression > nucleus pulposus forced into vertebral body
*[[Cervical spine clearance]]
*Posteriorly displaced fracture fragment may impinge on the cord
*[[Canadian cervical spine rule]]
* Imaging
*[[NEXUS cervical spine rule]]
** Lateral xray - Comminuted body and loss of vertebral height
*[[Strangulation]]
** AP xray - Vertical fracture of the body
*[[Vertebral and carotid artery dissection]]
 
==Facet Dislocations==
===Bilateral===
* Unstable
* Complete spinal cord injury most often results
* Disruption of annulus fibrosus and ant longitudinal ligament > ant displacement of spine
*Imaging
**Lateral xray: vertebral body will be displaced >50% of its width
 
===Unilateral===
*Stable
*Imaging
**Lateral xray: vertebral body will be displaced <50% of its width
**Anterior xray: affected spinous process points toward side that is dislocated
*Spinal cord injury rarely occurs


==See Also==
==External Links==
*[[Spinal Cord Trauma]]
*[https://coreem.net/podcast/episode-173-0-blunt-neck-trauma/ Blunt Neck Trauma from CoreEM]
*[[Cord Compression]]
*[[Spinal Cord Syndromes]]
*[[Neurogenic Shock]]


==Source==
==References==
*UpToDate
<references/>
*Tintinalli's


[[Category:Trauma]]
[[Category:Trauma]]
[[Category:Ortho]]
[[Category:Orthopedics]]

Latest revision as of 19:45, 9 October 2024

Background

  • Suspect vascular damage to cord, if discrepancy between neuro deficit and level of spinal column injury
  • Spinal cord injury is more likely if anterior (vertebral bodies) AND posterior (spinal canal) columns are disrupted

Clinical Features

  • Signs of life-threatening neck or upper thoracic injury (look for TWELVE):
Tracheal deviation,
Wounds,
External markings,
Laryngeal disruption,
Venous distention,
Emphysema (surgical)

Pediatrics

  • In a small study of 42 patients with a cervical seatbelt sign there were no isolated cerebrovascular injuries. For pediatric patients in a motor vehicle collision, the presence of an isolated seatbelt sign was not associated with any cases of cerebrovascular injury. [1]

Differential Diagnosis

Neck Trauma

Other

Evaluation

Workup

  • Consider x-ray or non-contrast cervical CT to evaluate for bone/cord injury (see below)
    • May later consider cervical MRI to further evaluate for cord injury
  • Consider CTA neck with contrast to evaluate for vascular injury (see below)

General Approach

Plain films lines

Management

Disposition

  • Based on specific diagnosis

See Also

External Links

References

  1. ↑ Desai NK, et al. Screening CT angiography for pediatric blunt cerebrovascular injury with emphasis on the cervical “seat- belt sign.” AJNR Am J Neuroradiol. 2014 Sep;35(9):1836-40. PMID: 24722311.
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