Pelvic and Spinal Injuries EM Teaching

Pelvic Injuries

Stable injuries - Pubic Rami #

Stable injuries – Iliac Wing #

Stable injuries – Acetabular #

Avulsion Injuries

Pelvic Injuries – Unstable fractures

Anteroposterior compression

Lateral compression

Vertical shear

Complex

Pelvic Fracture Management Resuscitate Minimize movement Apply pelvic binder DO NOT log roll

Hip Fractures Intracapsular Intertrochanteric Analgesia Fascia Iliaca Block Consider cause of fall Rx medical problems

Spinal Injuries

Spinal Injuries Assessing Suspect Spinal Injuries Who needs imaging? Spinal fractures Incomplete cord injury patterns Neurogenic shock

Assessment of Spinal Injuries Consider possibility of spinal injury in all injured patients. Consider mechanism of injury, new neurological symptoms, pre existing spinal disease. Commonest sites of spinal injury are the cervical spine and thoracolumbar junction.

Neurological Examination Carefully perform and document neurological exam Accuracy of baseline examination important Document muscle group strength Grade 0-5 Record most caudal location with intact motor & sensory function Know myotomes and dermatomes Exam perineum and perform PR – voluntary contraction and anal tome

Dermatomes

Mytomes

Spinal Tracts

Imaging – C-spine There are multiple validated decisions rules for clearing the c-spine Canadian C-Spine Rules (CCR) and the National Emergency X-Radiography Utilization Group (NEXUS) criteria The following is a summary of the RCEM guideline “Exclusion of significant cervical spine injury in alert, adult patients with potential blunt neck trauma in the Emergency Department”

Imaging – C-spine Patients with blunt trauma and mechanism that may have injured neck. GCS<15 in ED Paralysis/paraesthesia/focal neurological deficit Patients with abnormal vital signs Severe neck pain >7/10 Any High risk features Fall from >5m Axial load to head High speed/Roll over/Ejection/Motorcycle RTC Aged >65 or known vertebral disease Injured >48hrs ago/representing Patient with dangerous mechanism and any injury above the clavicles or painful thoracic injury

Imaging – C-spine If NO high risk features and any low risk feature Simple rear-end RTC Sitting position in ED Ambulatory at anytime since injury Delayed onset neck pain Absence midline cervical spine tenderness Remove collar and assess range of movement If can rotate to 45degrees to left and right without significant pain No need for imaging

CT Imaging CT indicated if GCS below 13 on initial assessment Intubated patients Inadequate plain film series Suspicion or certainty of abnormality on plain film series Patient’s being scanned for head injury or multi-region trauma Patient has dementia (or a chronic disability precluding accurate clinical assessment) Patient has new neurological signs or symptoms Patient has severe neck pain ( ≥7/10 severity) Patient has a significantly reduced range of neck movement Patients with known vertebral disease (eg ankylosing spondylitis, rheumatoid arthritis, spinal stenosis, or previous cervical surgery)

Imaging – Thoracic and Lumbar-spine There are no validated decisions rules for clearing the thoracic or lumbar spine Imaging is generally required if there are the following: Point tenderness Deformity or bony step Neurological findings consistent with a thoracic or lumbar injury High risk mechanism, especially in the presence of distracting injuries

Spinal Fractues Many different classifications Cervical Spine fractures Spinal fracture principles

Odontoid Peg fracture Odontoid Peg fracture occurs where there is a fracture through the odontoid process of C2.

Hangman fracture Hangman fracture is a fracture involves the pars interarticularis of C2 on both side

Jefferson fracture Jefferson fracture is the eponymous name given to a burst fracture of C1.

Flexion teardrop fractures Flexion teardrop fractures - severe fracture of the cervical spine, often causing anterior cervical cord syndrome and quadriplegia.

Clay-shoveler fractures Fractures of the spinous process of a lower cervical

Facet dislocation anterior displacement of one vertebral body on another subluxed facet joint perched facet joint locked facet joint Unilateral facet dislocation bilateral facet dislocation

Three column concept of thoracolumbar spinal fractures Instability occurs when injuries go across two contiguous columns anterior column middle column posterior column anterior column anterior longitudinal ligament anterior two-thirds of the vertebral body/intervertebral disc middle column posterior one-third of the vertebral body/intervertebral disc posterior longitudinal ligament posterior column facet joints and articular processes ligamentum flavum neural arch and interconnecting ligaments

Traumatic spinal injuries wedge compression  stable burst unstable burst wedge compression: isolated anterior column compression  stable burst: anterior and middle column compression but posterior column is normal unstable burst: anterior and middle column compression with disrupted posterior column flexion-distraction  anterior column compression middle and posterior column: tensile failure axis of flexion: posterior to anterior longitudinal ligament chance fractures pure bony injuries that extend all the way through the spinal column: from posterior to anterior through the spinous process, pedicles, and vertebral body, respectively axis of flexion: anterior to anterior longitudinal ligament translational fractures ​shear force to all the 3 columns

Traumatic spinal injuries flexion-distraction chance fractures translational fractures wedge compression: isolated anterior column compression  stable burst: anterior and middle column compression but posterior column is normal unstable burst: anterior and middle column compression with disrupted posterior column flexion-distraction  anterior column compression middle and posterior column: tensile failure axis of flexion: posterior to anterior longitudinal ligament chance fractures pure bony injuries that extend all the way through the spinal column: from posterior to anterior through the spinous process, pedicles, and vertebral body, respectively axis of flexion: anterior to anterior longitudinal ligament translational fractures ​shear force to all the 3 columns

Incomplete cord injury patterns Anterior Cord Syndrome Loss of power and pain below injury Preservation of touch and proprioception Posterior Cord Syndrome Loss of sensation, power preserved Brow-Sequard Syndrome Hemisection of cord Ipsilateral paralysis and sensory loss below injury Contralateral loss of pain and temperature Central Cervical Cord Syndrome Incomplete tetraparesis, affects upper limbs more than lower limbs Sensory deficits variable

Neurogenic Shock Neurogenic shock Spinal shock Classical triad hypotension, bradycardia and peripheral vasodilatation Loss of sympathetic vascular tone Occurs after a significant proportion of the sympathetic nervous system has been damaged – as may occur with lesions at the T6 level or higher Spinal shock not a true form of shock. flaccid areflexia that may occur after spinal cord injury, and may last hours to weeks. It may be thought of as ‘concussion’ of the spinal cord

Neurogenic Shock Airway maintenance with cervical spine immobilization lesions above C5 require intubation for mechanical ventilation maintain cervical spine precautions Breathing and ventilation monitor for respiratory insufficiency from thoracic or higher spinal lesions Circulation with haemorrhage control treat neurogenic shock with repeated fluid boluses (e.g. 250 mL crystalloid) +/- noradrenaline infusion to maintain organ perfusion be aware that vagal stimuli may exacerbate neurogenic shock Disability detailed neurological exam including motor and sensory levels bilaterally; check for priapism; check anal sphincter tone and bulbocavernosus reflex. Exposure and Environmental Control higher risk of hypothermia - use fluid warmer, warm blankets, and/or bair hugger to keep patient warm

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