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4/12/2018
1
Care of Axis (C2) Fractures
IOANNIS KARAMPELAS, MDNEUROSCIENCE DEPARTMENT
ST CLOUD HOSPITAL, MNAPRIL 2018
10 days ago….
4/12/2018
2
But, it’s coming this weekend….
Topics:
C2 Fractures
Conservative vs Surgical Management
Halo Vest Treatment
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Anatomy
Axis2ND Cervical Vertebra
Αξων = Axon
(it’s all greek to me!)
something around which a structure revolves
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Odontoid Process
of 2ND Cervical Vertebra
Οδωντας = Tooth
(it’s all greek to me again!)
Two main types of Axis (C2) Fractures
Odontoid (Dens) Fracture
and
Traumatic Spondylolisthesis of C2(Hangman’s Fracture)
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Odontoid Fracture
15% of all cervical fractures
Usually due to hyperflexion with anterior displacement
Commonly associated with C1 fx
Neurologic deficit in 15-25% of cases
Odontoid fracture typesI II III
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Odontoid fracture types:Subtype II a
Comminuted fx that involves the base of the odontoid
Associated with severe Instability
Treatment of Odontoid FracturesFactors to consider
Fracture typeDegree of (initial)dens displacementExtent of angulation at the fracture sitePatient’s age and medical condition
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Non operative treatment ofC2 fractures
Cervical Hard Collar Traction Minerva Cast Halo vest jacket
Non operative means of therapy are primarily indicated for
Type I and Type II fractures (but not perhaps for Type IIa)
Why is it so hard to treat Type II fractures without surgery?
Because the dens is displaced and it is very difficult to immobilize the fracture fragments so they are aligned
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Operative Treatment of Odontoid Fractures
Primarily indicated for Type II and Type III fractures (so, Type II, which is the commonest variety,
can be treated either way)
Should be considered in cases of:- Dens displacement of 5 mm or more (non union rate 86% vs 18% )
- -dens fracture type Iia- Inability to achieve fracture reduction via conservative means/external immobilization
Surgical options (I)
Anterior dens screw fixation (Type II fractures especially, up to 89% fusion rate)
Anterior atlantoaxial screw fixation and fusion Posterior atlantoaxial fusion (Gallie or Brooks) Posterior atlantoaxial screw fixation and fusion Posterior atlas and axis screw-rod fixation and fusion
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Anterior dens screw fixation
Anterior atlantoaxial screw fixation and fusion
Anterior dens screw fixation
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Posterior atlantoaxial fusion
Gallie
or
Brooks
Posterior atlantoaxial screw fixation and fusion
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Posterior atlas and axis screw-rod fixation and fusion
Posterior atlas and axis screw-rod fixation and fusion
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Management of dens fractures in the elderly (> 60 yrs of age…)
Type II fxs treated with external immobilization: Fusion rate: 23%
Posterior C1-C2 surgery results in 86% fusion rate
Anterior odontoid screw or hard collar: fusion rate 20%
Halo vest is poorly tolerated in patients older than 75 yrs of age
Halo vest treatment has a 23x higher rate of fusion success in pts younger than 50 yrs of age in Type II fxs
Hangman’s fracture
Hyperextension injury
Common in MVAs, diving and falls
It is a fracture of the pedicles of the axis
It can result in spondylolisthesis of the axis
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Pedicle Fracture resulting in “spondylolisthesis” of the fracture segments
Hangman’s fracture Classification
Type 1 Type 2 Type 2a Type 365% 28% 7%
Treatment of Hangman’s Fracture
Mostly Nonsurgical- Cervical ImmobilizationHard C spine collar or Halo Vest treatmentMost fractures will heal with 12 weeks of immobilization
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Halo vest therapy A form of external
spinal orthosis Attached the skull to
provide traction and spinal stability
Indicated for Type I and Type III fractures
Pin site care
Check for pin migration:
Listen for patient complaint ofpain at pin site
Look for skin build up ontop of pin
Look for a pin track under the pin
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Pin site care
Check for pin site infection
Administer oral antibioticsuntil resolved.
If does not resolve inappropriate time:
1. Insert and torque a new, sterile,pin in an adjacent pin site.
2. Then, remove and discard old pin.
Skin care
Patients should be checked oftenfor signs of a developing problem.
Wash daily.
Neurologically compromisedpatients are at increased risk forskin complications.
Their skin should be examined daily.
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Halo vest therapy complications
• Pin loosening 36%• Pin infection 20%• Severe pin discomfort 18%• Pressure sores 11%• Severe scars 9%• Nerve injury 2%• Dysphagia 1%• Bleeding pin sites 1%• Dural puncture 1%
What is
THE NUMBER ONE QUESTION
when a patient comes to the floor on a halo vest??
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Where is the torque wrench?????????!!!!!!!!!!!!!!!!!!
Why?
You cannot do CPR on a patient with the halo on…
CentraCare takes CARE….Patient walks in to our clinic with this…