1. Finding Spine Fractures
Plenary 2 - Zebra’s or Horses
March 2, 2018
Sukhvinder Kalsi-Ryan BScPT, MSc, PhD
Co-Founder STN, Clinician Scientist - TRI

2. Finding Fractures - Outline
Prevalence
History Taking
What are the symptoms?
What are the signs?
What are the tests?
How should the conservative care practitioner treat?
When and how do you involve the specialists?

3. Facts about “non-displaced” fractures
70% of serious cervical injuries present with no neurological deficit at time of initial assessment – sometimes x-rays are not done
Up to 67% of cervical fractures are not seen on lateral x-rays
11-13% of cervical fractures are odontoid fractures
4% to 30% of cervical fractures are missed
Of the 1.5 million osteoporotic fractures in the US, 700,000 are vertebral compression fractures

4. History – Key Factor in Diagnosis
Cause of the discomfort/pain
Description of pain/neuropathic/dermatomal
Osteoporosis
Trauma
Ankylosing Spondylitis

5. Evaluation - Symptoms Pain when loading/movement Night pain
Neurological Deficit

6. Evaluation - Signs
Midline tenderness to palpation (directly on bone, not paraspinal muscles)
Reduced ROM
Bruising/bogginess
Step/gap deformities; spine deformity
Neurological deficits/changes
Dermatomal distributions
Numbness/tingling/burning
Weakness myotomal patterns
Bilateral complaints (shoulder pain)
Strange alterations (numb lips)

7. Neurological Exam: Spinal Cord
Spinal cord dysfunction (aka myelopathy):
Weakness
Numbness
Incoordination
Gait ataxia
Bowel/bladder dysfunction
Hyper-reflexia
Assess with ISNCSCI examination

8. Neurological Exam: Nerve Root
Nerve root dysfunction (aka radiculopathy):
Weakness
Numbness
Hypo-reflexia

9. Spine Injuries - Classification
Class Systems:
AO: bony morphology
Denis: 3 column model (structural)
TLICS/SLICS: rates stability and need for surgery

10. Typical Management if Fracture is Diagnosed at time of injury
Evaluate stability of fracture
No neurological deficit/stable – immobilize
Bracing
Movement precautions
Neurological deficit/risk of movement – stabilize
Surgery with fusion
Post-op bracing

11. Case Study 1 80 year old male
Sustained a standing height fall two weeks ago
When he fell his head bent all the way back
He was able to get up on his own and move around OK
He took a few Tylenol and some extra rest and did not seek medical help
His neck pain is excruciating now and has come to see you because he feels a little massage will help

12. Type I Odontoid Fracture
Case Study 1
Type I Odontoid Fracture

13. Case Study 2
25 year old female, involved in an MVA in Dominican while on vacation, was able to manage getting home on pain meds before seeking medical help
Her symptoms since the accident are and were a sore neck, difficulty turning the head, transient numbness of the right and left thumbs (not at same time), headaches when up for too long, feeling better when in bed
She has come to see you because she thinks she might have a minor whiplash and needs some exercises

14. Case Study 2 C5/C6 middle column fracture FINDINGS
Swelling in posterior area of neck
15% of ROM in all directions
Hyperreflexia in biceps
Positive hoffman’s
Burning sensations in C6 dermatome and wrist weakness
C5/C6
middle column fracture

15. Case Study 3
75 year old female, woke up one morning with pain in both sides at the level of the belly button
She has no history of trauma, her past medical history is positive for osteoporosis
The pain is terrible when she up or moving and almost goes away in supine
She has come to see you because she feels that she has pulled her side abdominal muscles and her husband thinks she needs to exercise

16. Case Study 3 T10 compression fracture FINDINGS Slight kyphosis
Not just pain, but burning at times
Altered sensation at T10 and T11
Strength normal
Previous spontaneous hip fracture
T10 compression fracture

17. What do you do?
We need to facilitate imaging to CONFIRM the diagnosis.
Family Doctor
Specialist if they have one (Osteoporosis)
Spine specialist (ortho or neuro)
Diagnosis is confirmed
Post Medical management
Re-intervene after medical clearance

18. Post Medical Management?
Case Study 1
Immobilized 3 to 6 months
Reduced cervical ROM, weakness, deconditioning
Case Study 2
Surgical (12 weeks post Sxz0
Reduced cervical ROM, weakness, pain, potential deficits in the limbs
Case Study 3 –
Immobilized 6 to 12 weeks
Reduced ROM, weakness, decline posture, deconditioning

19. Building Community
Familiarize with local specialists, family doctors and nurse practitioners
Emergency Room if necessary
Directing the patient back to the most resourceful health care provider

20. Finding Fractures
Provide context for the diagnosis, inform the person receiving the referral it is imminent
Ask for immediate attention is required to these cases particularly to have imaging completed and reviewed
Follow up with patient or to whom you referred