1. Pelvic and Spinal Injuries
EM Teaching

2. Pelvic Injuries

3. Stable injuries - Pubic Rami #

4. Stable injuries – Iliac Wing #

5. Stable injuries – Acetabular #

6. Avulsion Injuries

7. Pelvic Injuries – Unstable fractures

8. Anteroposterior compression

9. Lateral compression

10. Vertical shear

11. Complex

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

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

14. Spinal Injuries

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

16. 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.

17. 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

18. Dermatomes

19. Mytomes

20. Spinal Tracts

21. 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”

22. 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

23. 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

24. 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)

25. 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

26. Spinal Fractues Many different classifications
Cervical Spine fractures
Spinal fracture principles

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

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

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

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

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

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. Questions?