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| ==Background== | | ==Background== |
| [[File:Three-column-concept-2.jpg|thumb|Three column concept of spinal fracture stability]]
| | *Suspect vascular damage to cord, if discrepancy between [[Focal neurologic deficits|neuro deficit]] and level of spinal column injury |
| *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 |
| *Down syndome predisposes to atlanto-occipital dislocation | |
| *RA predisposes to C2 transverse ligament rupture
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| *Cord injury is more likely if ant (vertebral bodies) AND post (spinal canal) columns are disrupted
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| *If find injury consider CT C-spine, x-ray rest of spine
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| *Penetrating injury rarely results in unstable fx
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| ==Prehospital Immobilization== | | ==Clinical Features== |
| Please see the [[EBQ:Prehospital Spine Immobilization|NAEMSP National Guidelines for Spinal Immobilization]]
| | *Signs of life-threatening neck or upper thoracic injury (look for ''TWELVE''): |
| | :Tracheal deviation'', |
| | :Wounds, |
| | :External markings, |
| | :Laryngeal disruption, |
| | :Venous distention, |
| | :Emphysema (surgical) |
| | *Features may include signs and symptoms of: |
| | **[[Spinal cord injury]] |
| | **[[Vertebral and Carotid Artery Dissection]] |
| | **Laryngeal or [[tracheal injury]] |
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| ==Atlanto-occipital Dissociation== | | ===Pediatrics=== |
| [[File:Atlanto-occipital Dissociation.jpeg|thumbnail|Atlanto-occipital Dissociation]]
| | *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
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| *Often associated w/ brain injury
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| *Evaluate with the Powers ratio
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| **Ratio of BC:OA > 1 suggests anterior subluxation
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| **BC = distance between basion and midpoint of C2 post laminar line
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| **OA = Distance between opisthion and ant arch of C2
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| ==C1 Fractures== | | ==Differential Diagnosis== |
| ===Burst (Jefferson)===
| | {{Blunt neck trauma DDX}} |
| *Unstable
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| *Fx of the ant AND post arches
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| **Due to axial loading transmitted through occipital condyles to the lateral masses
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| *Degree of instability determined by whether or not the transverse ligament is disrupted
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| *Suspect disruption if:
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| **Lateral x-ray: Increase in the predental space between C1 and dens (>3mm in adults, >5mm in children)
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| **Odontoid x-ray: Masses of C1 lie lateral to outer margins of articular pillars of C2
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| **If either of the above findings on x-ray obtain CT C-spine
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| ===Anterior Arch (Isolated)=== | | ===Other=== |
| *Stable | | *[[Head trauma]] |
| ===Posterior Arch (Isolated)===
| | *[[Thoracic trauma]] |
| *Stable
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| **Anterior arch and transverse ligament are unaffected
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| *Must ensure that you are not confusing this with a burst fx
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| **Odontoid view must be normal
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| *Due to forced neck extension
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| *Vertical fx line through posterior arch seen on lateral xray | |
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| ==C2 (Axis) Fractures== | | ==Evaluation== |
| ===Odontoid (Dens) Fracture=== | | ===Workup=== |
| *Only stable if fx confined to avulsion of the tip (superior to transverse ligament) | | *Consider x-ray or non-contrast cervical CT to evaluate for bone/cord injury (see below) |
| *Frequently involves other cervical spine injuries | | **May later consider cervical MRI to further evaluate for cord injury |
| *25% assoc w/ neurologic injury
| | *Consider CTA neck with contrast to evaluate for vascular injury (see below) |
| *consult ortho/nsg/trauma | |
| *Types
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| **Type I: Oblique avulsion fx of tip of odontoid; alar ligament avulsion
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| ***Stable
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| ***atlanto-occipital instability should be ruled out with flexion and extension films
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| **Type II: Fx at base of odontoid process where it attaches to C2; Fx through waist
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| ***Unstable
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| ***high nonunion rate due to interruption of blood supply
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| ****Young: Halo if no risk factors for nonunion, Surgery if risk factors for nonunion
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| ****Elderly: Collar if not surgical candidates, Surgery if surgical candidates
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| **Type III: Extension of the fx through upper portion of body of C2
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| ***Unstable
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| *Imaging
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| **Xray: AP, lateral, open-mouth odontoid view of cervical spine
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| **CT for further assessment if fracture identified
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| ===Traumatic Spondylolisthesis ("Hangman's Fracture")=== | | ===General Approach=== |
| [[File:Hangman fracture.png|thumb|Hangman's Fracture]] | | [[File:Vertebral lines.png|thumb|Plain films lines]] |
| *Unstable | | *If concern for cervical spine injury, use a [[cervical spine clearance]] decision rule to determine need for imaging |
| *Bilateral C2 pedicle fracture (leads to C2 displacing anteriorly on C3) | | *Perform a neuro exam, to determine concern for [[spinal cord injury]] |
| *Seen in MVA and diving accidents (not in suicidal hangings) | | *If concern for vascular injury, use the [[Denver screening criteria]] |
| **Forced extension of an already extended neck
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| *Spinal cord damage is often minimal (diameter of neural canal is greatest at C2)
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| ==C3-C7 Fractures== | | ==Management== |
| ===Anterior Wedge Fracture===
| | *Prehospital |
| *Only unstable if lose over half of vertebral height OR multiple adjacent wedge fractures | | **See the [[EBQ:Prehospital Spine Immobilization|NAEMSP National Guidelines for Spinal Immobilization]] |
| | *Hospital |
| | **Secure ABCs |
| | **See [[cervical spine clearance]] |
| | **See specific diagnosis |
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| ===Flexion Teardrop Fracture=== | | ==Disposition== |
| *Unstable
| | *Based on specific diagnosis |
| *Severe flexion > vertebral body colliding with the one below (shallow water diving injury, MVC deceleration)
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| *Most commonly at C5-C6
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| **Displacement of teardrop shaped fragment of antero-inferior portion of superior vertebra
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| **Leads to posterior displacement of vertebral body and disruption of posterior longitudinal ligament
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| *Associated with acute anterior cervical cord syndrome | |
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| ===Extension Teardrop Fracture=== | | ==See Also== |
| *Unstable | | *[[Penetrating neck trauma]] |
| *Abrupt neck extension > anterior longitudinal ligament avulses anteroinferior corner | | *[[Cervical spine clearance]] |
| **Avulsed fragment is greater in height than width (contrast with flexion teardrop) | | *[[Canadian cervical spine rule]] |
| *Often occurs at C5-C7 associated with diving accidents | | *[[NEXUS cervical spine rule]] |
| **Associated with central cord syndrome | | *[[Strangulation]] |
| | *[[Vertebral and carotid artery dissection]] |
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| ===Spinous Process Fracture (Clay Shoveler's)=== | | ==External Links== |
| *Stable | | *[https://coreem.net/podcast/episode-173-0-blunt-neck-trauma/ Blunt Neck Trauma from CoreEM] |
| *C7>C6>T1 avulsion fx; ; caused by extreme muscle flexion where spinous process is ‘pulled off’
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| *Isolated fracture of the spinous processes of the lower cervical vertebrae
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| *Management
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| **nonop
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| **collar for 10 days with ortho f/u
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| **r/o lamina and facet fx, r/o jumped facet
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| ===Burst Fracture===
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| *Unstable if:
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| **Associated neurologic deficits
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| **Loss of >50% of vertebral body height
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| **>20 degrees of spinal angulation
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| **Compromise of >50% of spinal canal
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| **Axial compression > nucleus pulposus forced into vertebral body
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| *Imaging
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| **Lateral x-ray - Comminuted body and loss of vertebral height
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| **AP x-ray - Vertical fracture of the body
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| ==Facet Dislocations==
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| *determine if more than 1 spinal column affected
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| ** 1 column = generally stable
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| ** 2 or more columns = unstable
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| *generally superior facet fx
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| *abnormal xray? -> get CT
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| ===Bilateral===
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| *Unstable as whole column can sublux
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| *high risk for significant spinal cord injury
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| *Disruption of annulus fibrosus and ant longitudinal ligament > ant displacement of spine
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| *Imaging
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| **Lateral xray: vertebral body will be displaced ~50% of its width
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| *Management
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| **spinal precautions
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| **operative management: nsg vs ortho
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| ===Unilateral===
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| *Relatively Stable
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| *Presentation
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| **C5/C6: C6 radiculopathy with weakness to wrist extension numbness and tingling in the thumb
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| **C6/C7: C7 radiculopathy with weakness to triceps and wrist flexion and numbness in index and middle finger
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| *Imaging
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| **Lateral x-ray: vertebral body will be displaced ~25% of its width
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| **Anterior x-ray: affected spinous process points toward side that is dislocated
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| *Spinal cord injury rarely occurs
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| == Vascular Injuries ==
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| *Carotid and vertebral artery injuries can occur with blunt c-spine trauma
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| **Half of patients present with initially normal neuro exam
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| **OR for carotid/vertebral artery injury of 8.6 with c-spine fracture
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| **OR for vertebral artery injury of 30.6 with transverse process fracture
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| **Vertebral angiography for transverse process fractures extending into transverse foramen or evidence of vertebral-basilar insufficiency(90% show dissection or occlusion of vertebral artery)
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| *Indications for screening (CTA or MRA) for vascular injury
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| **Unexplained neuro deficit with hyperflexion or extension injury
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| **Blunt trauma to neck or seatbelt injury
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| **C-spine or skull base fractures involving vascular foramina
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| **Le Fort II or III facial fractures
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| ==See Also==
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| *[[Spinal Cord Trauma]]
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| *[[Spinal Cord Compression (Non-Traumatic)]]
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| *[[Neurogenic Shock]]
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| *[[C-spine (NEXUS)]]
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| *[[C-Spine X-Ray]]
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| *[[Fractures (Main)]]
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| *[[Unstable spine fractures]]
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| ==Source== | | ==References== |
| *National Spinal Cord Injury Statistical Center (NSCISC). Spinal Cord Injury. Facts and Figures at a Glance. Birmingham, Ala: NSCISC; July 1996
| | <references/> |
| *Ivy ME, Cohn SM. Addressing the myths of cervical spine injury management. Am J Emerg Med. Oct 1997;15(6):591-5
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| *Woodring JH, Lee C, Duncan V. Transverse process fractures of the cervical vertebrae: are they insignificant? J Trauma. June 1993; 34(6):797-802.
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| *Tintinalli's
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| [[Category:Trauma]] | | [[Category:Trauma]] |
| [[Category:Ortho]] | | [[Category:Orthopedics]] |
