1. Spinal fractures

2. -Spinal injuries are due either to direct force (eg : penetrating wounds ) or more likely due to indirect force (eg : falling from a height –when spinal column collapses on its vertical axis or during violent free
movements )-
-spinal injury is a double threat as it affects both vertebrae and the neural tissue . -

3. Types :
(depending on integrity of vertebral bodies and the ligaments linking them together ) :- 1)stable injury : .Vertebral components will not be displaced by normal movements 2)Unstable : Is the one where there’s a significant risk of displacement and consequent damage to the neural tissues . And It accounts only for 10% of the cases . Spinal injuries heal slowly. Non-union is rare but malunion is common and may lead to progressive deformity of the spine.

4. Imaging:
X-ray examination is mandatory for all accident victims complaining of pain or stiffness in the neck or back, all patients with head injuries or severe facial injuries (cervical spine), patients with rib
fractures or severe seat-belt bruising (thoracic
spine), and those with severe pelvic or abdominal
injuries (thoracolumbar spine).
-Accident victims who are unconscious should have spine x-rays .
-In cervical spine, anteroposterior and lateral views
(all 7 cervical + half of T1 should be visible )and open-mouth
views are needed. ‘
-Difficult’ areas, such as the
lower cervical and upper thoracic segments, whichare often obscured by shoulder and rib images  CT .
-for displaying the intervertebral
discs, ligamentum flavum and neural structures,MRI is the method of choice..

5. Treatment :
*The objectives of treatment are: 1. to preserve neurological function; 2. to relieve any reversible neural compression; 3. to restore alignment of the spine. 4. to stabilize the spine; 5. to rehabilitate the patient . 1)Stable : Treatment is by supporting the spine with a collar or lumbar brace until pain and spasm subsides . :2)Unstable In case of cervical fractures bed traction using tongs or halo vests until it’s stabalized , thoraco-lumbar might need internal fixation

6. 2)Cervical spine injury :
-When to think about it ? History of falling from height , motor vehicle accidents , diving athletes , unconscious patient with head injury . -how to asses pathology on X-ray ?

7. Jefferson’s fracture (c1)
mechanism : sudden severe load on the top of the head causing the atlas ring to burst , risk factors include :- car accident. A driver or passenger who hits the top of the car , divers landing on the back of their heads ,osteoporosis . diagnosis : Most clearly seen by open mouth XR (lateral masses displaces laterally away from the dense so c1 is over –hanging c2 )-or by CT scan .

8. Cont: Treatment: If the fracture is undisplaced, the injury is stable
and the patient needs only a rigid collar until the
fracture unites. If there is sideways spreading of the
lateral masses, the injury is unstable and should be
treated either by skull traction or by the
application of a halo-body orthosis for 6 weeks,
followed by another 6 weeks in a semi-rigid collar.
*NOTE : 50% of patients presenting with jefferson’s fracture may have other injuries elsewhere ( eg : hangman’s or odontoid ) so they should be excluded.

9. Hangman’s fracture(C2):-
Mechanism: Varying degrees of hyper-extention , compression and flexion . Risk factors include : motor vehicle accidents where the patients forehead strikes the dashboard . The hyper-extention causes the pedicles of vertebrae to fracture where as the flexion causes disc and posterior ligament injury. classification : 1) Typical : displaces vertebral body anteriorly and its poterior elements posteriorly , increasing the space for spinal cord so it’s not accompanied with neural injury .

10. 2)Atypical : Line of fracture leaves the canal circumferentially intact , which puts the spinal cord at risk of injury in case of displacement .

11. Hangman’s fracture – fracture of the pedicle or lateral pillar of C2

12. Treatment : Undisplaced fractures are treated in a semi-rigid
collar or halo-vest until united. Displaced fractures
may need reduction before immobilization in a
halo-vest for 12 weeks

13. :FRACTURE OF THE ODONTOID PROCESS
Mechanism: Odontoid fractures are uncommon. They usually occur as flexion injuries in young adults due to high-velocity accidents or severe falls; Less often they occur in elderly, osteoporotic people as a result of low-energy trauma in which the neck is forced into hyperextension, e.g. a fall onto the face or forehead . *NOTE : ¼ of these patiens will experience neurological deficits .

14. Types :
-type I : avulsion of the tip . Treated only by using a rigid collar until discomfort subsides .
-type II : fracture through the junction btw the odontoid and the body of C2 . If stable : treated by using a halo-vest . If displaced : reduced by traction until it’s stable then held by operative screw fixation or halo-vest .
-type III : fracture through the body of C2 . If undisplaced it’s treated by halo-vest for 8-12 W . If it’s displaced it’s reduced by traction then immobilized by halo-vest for 8-12 W .

15. WEDGE-COMPRESSION FRACTURE
Mechanism : This usually occurs in the mid-cervical and lower cervical segments. A pure flexion injury causes compression of the anterior part of the vertebral body. Mostly caused by a trauma , osteoporotic patients are at risk Diagnosis : It is a single column fracture Which means it only affects the a anterior part of the body (notice the loss in vertebral Body height ). Treatment : The injury is stable; all that is needed is a comfortable collar for 6–8 w .

16. BURST FRACTURE
Mechanism : Axial loading injury in which the disk above is pushed into the vertebral body below , leading to a comminuted fracture of the body . Risk factors include : motor vehicle accident , falling from a height and landing on feet , diving . (similar to jefferson’s fracture) NOTE : retropulsion of fractured bony fragments into the spinal canal in case of unstable fracture will cause neurological deficit .  Diagnosis: Plain x-rays show a comminuted fracture of the vertebral body. CT or MRI should be performed to look for retropulsion of large fragments into the spinal canal  Treatment : injury is treated by immobilization in a halo-vest if no neurological deficit is found . Neurological deficit calls for urgent anterior decompression followed by immobilization for 6-8 w .

17. 2)Thoraco-lumbar injury
-Why is it prone to injury ?
because it represents a transition zone between the relatively fixed thoracic spine and the relatively mobile lumbar spine.
In most cases the injury is sustained in a fall from a height; one can imagine a combination of forces due to axial compression and flexion. .

18. Cont :
 Stable / unstable :- We determine stability by taking a lateral x-ray and dividing the image into 3 columns. 1)Anterior column : composed of the anterior half of the vertebral body, the anterior part of the intervertebral disc and the anterior longitudinal ligament 2)Middle column :posterior part of vertebral body ,the posterior part of the intervertebral disc and the posterior longitudinal ligament . 3)Posterior column : pedicles, facet joints, posterior bony arch, interspinous and supraspinous ligaments .

19. Wedge compression injury
-The most common type of vertebral fracture . Mechanism : pure flexion , mostly in osteoporotic patients due to a minimal trauma . very painful stable : only the anterior column is damaged (posterior ligaments are intact ). neurological damage is rare . Treatment : a)minimal wedging : the pt is kept in bed for a week or 2 until pain subsides + muscle strengthening exercises . B) marked wedging (ant vertebral height reduces by 20-50%) needs a thoraco-umbar brace for 3 months . If vertebral compression is even more severe posterior fusion may be needed .

21. Burst injury
Severe axial compression may ‘explode’ the vertebral body, shattering the posterior part and extruding fragments of bone into the spinal canal. The injury is usually unstable. Diagnosis The x-ray appearance may superficially resemble the wedge compression fracture but the posterior border of the vertebral body is damaged; this is seen most clearly on CT scans. Treatment If there is minimal retropulsion of bone, no neurological damage and minimal anterior wedging, the patient is kept in bed until the acute symptoms settle and is then mobilized in a thoracolumbar brace, which is discarded at about 12 weeks. Surgery is needed only if there is progressive neurological deterioration.

23. Fracture-dislocation
-Mechanism Segmental displacement may occur with various combinations of flexion, compression, rotation  Injury is unstable . these are the most dangerous injuries , and are often assosiated with neurological injury . -Diagnosis  X-rays may show fractures through the vertebral body, pedicles, articular processes and laminae; there may be varying degrees of subluxation or even bilateral facet dislocation. CT is helpful in demonstrating the degree of spinal canal occlusion -treatment  Most fracture–dislocations will benefit from early surgery. -Open reduction and internal fixation.

25. Thank you
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