Upper Extremity Trauma. 2 How do fractures heal?

$Page 1: Upper Extremity Trauma. 2 How do fractures heal?$
Upper Extremity Upper Extremity TraumaTrauma

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How do fractures heal?

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Fracture healing

Why do fractures unite?

Because the bone is broken!

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Healing cascade: indirect healing Inflammation 0 – 5 days

– Haematoma– Necrotic material – Phagocytosis

Repair: 5 – 42 days– Granulation tissue– Acid environment– Periosteum – osteogenic

cells– Cortical osteoclasis

Remodelling– years

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Healing cascade

Late repair:

Fibrous tissue replaced by

cartilage

Endochondral ossification

Periosteal healing »

membranous ossification

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What is the difference between direct and indirect

bone healing?

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Indirect healing – healing by Callus

Unstable Callus stabilises #

Direct healing between cortices

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Direct bone healing – the response to rigid fixation Only occurs in

absolute stability of the fracture

Does not involve callus formation

Requires good blood supply

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What are the aims of fracture treatment?

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AIMS OF FRACTURE TREATMENT

Restore the patient to optimal functional state

Prevent fracture and soft-tissue complications

Get the fracture to heal, and in a position which will produce optimal functional recovery

Rehabilitate the patient as early as possible

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What factors effect fracture healing?

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FACTORS AFFECTING FRACTURE HEALING

The energy transfer of the injury

The tissue response– Two bone ends in opposition or compressed– Micro-movement or no movement– Blood Supply (scaphoid, talus, femoral and humeral

head)– Nerve Supply– No infection

The patient– smoking

The method of treatment

Upper Extremity Trauma

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DIAGNOSING THE BONE INJURY

Clinical assessment

– History - Co-morbidities

– Exposure/systematic examination

“First-aid” reduction

Splintage and analgesia

Radiographs– Two planes including joints above and below area

of injury

TopicsTopics

ClavicleClavicle Shoulder DislocationShoulder Dislocation HumerusHumerus ElbowElbow ForearmForearm Distal RadiusDistal Radius

Clavicle FracturesClavicle Fractures


MechanismMechanism– Fall onto shoulder Fall onto shoulder

(87%)(87%)– Direct blow (7%)Direct blow (7%)– Fall onto outstretched Fall onto outstretched

hand (6%)hand (6%) Trimodal distributionTrimodal distribution

0

10

20

30

40

50

60

70

80

Group I(13yrs)

Group 2(47yrs)

Group 3(59yrs)

Percent

The clavicle is the last ossification

center to complete (sternal end) at about 22-25yo.


Clinical EvaluationClinical Evaluation– Inspect and palpate for Inspect and palpate for

deformity/abnormal motiondeformity/abnormal motion– Thorough distal neurovascular examThorough distal neurovascular exam– Auscultate the chest for the possibility Auscultate the chest for the possibility

of lung injury or pneumothoraxof lung injury or pneumothorax Radiographic ExamRadiographic Exam

– AP chest radiographs.AP chest radiographs.– Clavicular 45deg A/P oblique X-raysClavicular 45deg A/P oblique X-rays

Clavicle FracturesClavicle Fractures Allman Classification of Clavicle FracturesAllman Classification of Clavicle Fractures

– Type IType I Middle Third (80%)Middle Third (80%)– Type IIType II Distal Third (15%)Distal Third (15%)

Differentiate whether ligaments Differentiate whether ligaments attached to lateral or medial fragmentattached to lateral or medial fragment

– Type IIIType III Medial Third (5%)Medial Third (5%)

Clavicle FractureClavicle Fracture

Closed TreatmentClosed Treatment– Sling immobilization for usually 3-4 weeks with Sling immobilization for usually 3-4 weeks with

early ROM encouragedearly ROM encouraged Operative interventionOperative intervention

– Fractures with neurovascular injuryFractures with neurovascular injury– Fractures with severe associated chest injuriesFractures with severe associated chest injuries– Open fracturesOpen fractures– Group II, type II fracturesGroup II, type II fractures– Cosmetic reasons, uncontrolled deformityCosmetic reasons, uncontrolled deformity– NonunionNonunion

Associated InjuriesAssociated Injuries– Brachial Plexus InjuriesBrachial Plexus Injuries

Contusions most common, penetrating Contusions most common, penetrating (rare)(rare)

– Vascular InjuryVascular Injury– Rib Fractures Rib Fractures – Scapula FracturesScapula Fractures– PneumothoraxPneumothorax


Shoulder DislocationsShoulder Dislocations


EpidemiologyEpidemiology– Anterior: Most commonAnterior: Most common– Posterior: UncommonPosterior: Uncommon– Inferior (Luxatio Erecta), hyperabduction injuryInferior (Luxatio Erecta), hyperabduction injury


Clinical EvaluationClinical Evaluation– Examine axillary nerve (deltoid function, not Examine axillary nerve (deltoid function, not

sensation over lateral shoulder)sensation over lateral shoulder)– Examine biceps function and anterolateral Examine biceps function and anterolateral

forearm sensationforearm sensation Radiographic EvaluationRadiographic Evaluation

– True AP shoulderTrue AP shoulder– Axillary LateralAxillary Lateral– Scapular YScapular Y– Stryker Notch View (Bony Bankart)Stryker Notch View (Bony Bankart)


Anterior Dislocation Recurrence RateAnterior Dislocation Recurrence Rate– Age 20: 80-92%Age 20: 80-92%– Age 30: 60%Age 30: 60%– > Age 40: 10-15%> Age 40: 10-15%

Look for Concomitant InjuriesLook for Concomitant Injuries– Bony:Bony: Bankart, Hill-Sachs Lesion, Glenoid Bankart, Hill-Sachs Lesion, Glenoid

Fracture, Greater Tuberosity FractureFracture, Greater Tuberosity Fracture– Soft Tissue: Soft Tissue: Subscapularis Tear, RCT (older Subscapularis Tear, RCT (older

pts with dislocation)pts with dislocation)– Vascular:Vascular: Axillary artery injury (older pts with Axillary artery injury (older pts with

atherosclerosis)atherosclerosis)– Nerve:Nerve: Axillary nerve neuropraxia Axillary nerve neuropraxia

Anterior DislocationAnterior Dislocation– TraumaticTraumatic– Atraumatic Atraumatic

(Congenital Laxity)(Congenital Laxity)– Acquired Acquired

(Repeated (Repeated Microtrauma)Microtrauma)


Posterior DislocationPosterior Dislocation– Adduction/Flexion/IR at time of Adduction/Flexion/IR at time of

injuryinjury– Look for “lightbulb sign” and Look for “lightbulb sign” and

“vacant glenoid” sign“vacant glenoid” sign– Reduce with traction and gentle Reduce with traction and gentle

anterior translation (Avoid ER anterior translation (Avoid ER arm arm Fx) Fx)


Inferior DislocationsInferior DislocationsLuxatio ErectaLuxatio Erecta– Hyperabduction injuryHyperabduction injury– Arm presents in a flexed Arm presents in a flexed

“asking a question” posture“asking a question” posture– High rate of nerve and High rate of nerve and

vascular injuryvascular injury– Reduce with in-line traction Reduce with in-line traction

and gentle adductionand gentle adduction


Shoulder DislocationShoulder Dislocation TreatmentTreatment

– Nonoperative treatmentNonoperative treatment Closed reduction should be performed after adequate Closed reduction should be performed after adequate

clinical evaluation and appropriate sedationclinical evaluation and appropriate sedation

– Reduction Techniques:Reduction Techniques: Traction/countertraction- Generally used with a sheet Traction/countertraction- Generally used with a sheet

wrapped around the patient and one wrapped around the wrapped around the patient and one wrapped around the reducer.reducer.

Hippocratic technique- Effective for one person. One foot Hippocratic technique- Effective for one person. One foot placed across the axillary folds and onto the chest wall placed across the axillary folds and onto the chest wall then using gentle internal and external rotation with axial then using gentle internal and external rotation with axial tractiontraction

Stimson technique- Patient placed prone with the affected Stimson technique- Patient placed prone with the affected extremity allowed to hang free. Gentle traction may be extremity allowed to hang free. Gentle traction may be usedused

Milch Technique- Arm is abducted and externally rotated Milch Technique- Arm is abducted and externally rotated with thumb pressure applied to the humeral headwith thumb pressure applied to the humeral head

Scapular manipulationScapular manipulation


PostreductionPostreduction– Post reduction films are a must to confirm the Post reduction films are a must to confirm the

position of the humeral headposition of the humeral head– Pain controlPain control– Immobilization for 7-10 days then begin Immobilization for 7-10 days then begin

progressive ROMprogressive ROM Operative IndicationsOperative Indications

– Irreducible shoulder (soft tissue interposition)Irreducible shoulder (soft tissue interposition)– Displaced greater tuberosity fracturesDisplaced greater tuberosity fractures– Glenoid rim fractures bigger than 5 mmGlenoid rim fractures bigger than 5 mm– Elective repair for younger patientsElective repair for younger patients

Proximal Humerus FracturesProximal Humerus Fractures



EpidemiologyEpidemiology– Most common fracture of the humerusMost common fracture of the humerus– Higher incidence in the elderly, thought to be Higher incidence in the elderly, thought to be

related to osteoporosisrelated to osteoporosis– Females 2:1 greater incidence than malesFemales 2:1 greater incidence than males

Mechanism of InjuryMechanism of Injury– Most commonly a fall onto an outstretched arm Most commonly a fall onto an outstretched arm

from standing heightfrom standing height– Younger patient typically present after high Younger patient typically present after high

energy trauma energy trauma


Clinical EvaluationClinical Evaluation– Patients typically present with arm Patients typically present with arm

held close to chest by contralateral held close to chest by contralateral hand. Pain and crepitus detected on hand. Pain and crepitus detected on palpationpalpation

– Careful NV exam is essential, Careful NV exam is essential, particularly with regards to the axillary particularly with regards to the axillary nerve. Test sensation over the deltoid. nerve. Test sensation over the deltoid. Deltoid atony does not necessarily Deltoid atony does not necessarily confirm an axillary nerve injuryconfirm an axillary nerve injury


Neer ClassificationNeer Classification– Four partsFour parts

Greater and lesser Greater and lesser tuberosities, tuberosities,

Humeral shaftHumeral shaft Humeral headHumeral head

– A part is displaced if A part is displaced if >1 cm displacement >1 cm displacement or >45 degrees of or >45 degrees of angulation is seenangulation is seen

Proximal Humerus FracturesProximal Humerus Fractures TreatmentTreatment

– Minimally displaced fractures- Sling immobilization, early Minimally displaced fractures- Sling immobilization, early motionmotion

– Two-part fractures- Two-part fractures- Anatomic neck fractures likely require ORIF. High incidence Anatomic neck fractures likely require ORIF. High incidence

of osteonecrosisof osteonecrosis Surgical neck fractures that are minimally displaced can be Surgical neck fractures that are minimally displaced can be

treated conservatively. Displacement usually requires ORIFtreated conservatively. Displacement usually requires ORIF– Three-part fracturesThree-part fractures

Due to disruption of opposing muscle forces, these are Due to disruption of opposing muscle forces, these are unstable so closed treatment is difficult. Displacement unstable so closed treatment is difficult. Displacement requires ORIF. requires ORIF.

– Four-part fracturesFour-part fractures In general for displacement or unstable injuries ORIF in the In general for displacement or unstable injuries ORIF in the

young and hemiarthroplasty in the elderly and those with young and hemiarthroplasty in the elderly and those with severe comminution. High rate of AVN (13-34%)severe comminution. High rate of AVN (13-34%)

Humeral Shaft FracturesHumeral Shaft Fractures


Mechanism of InjuryMechanism of Injury– Direct trauma is the most common especially Direct trauma is the most common especially

MVAMVA– Indirect trauma such as fall on an outstretched Indirect trauma such as fall on an outstretched

handhand– Fracture pattern depends on stress appliedFracture pattern depends on stress applied

Compressive- proximal or distal humerusCompressive- proximal or distal humerus Bending- transverse fracture of the shaftBending- transverse fracture of the shaft Torsional- spiral fracture of the shaftTorsional- spiral fracture of the shaft Torsion and bending- oblique fracture usually Torsion and bending- oblique fracture usually

associated with a butterfly fragmentassociated with a butterfly fragment


Clinical evaluationClinical evaluation– Thorough history and Thorough history and

physicalphysical– Patients typically Patients typically

present with pain, present with pain, swelling, and deformity swelling, and deformity of the upper armof the upper arm

– Careful NV exam Careful NV exam important as the radial important as the radial nerve is in close nerve is in close proximity to the proximity to the humerus and can be humerus and can be injuredinjured


Radiographic evaluationRadiographic evaluation– AP and lateral views of the humerus AP and lateral views of the humerus – Traction radiographs may be indicated Traction radiographs may be indicated

for hard to classify secondary to severe for hard to classify secondary to severe displacement or a lot of comminutiondisplacement or a lot of comminution

Humeral Shaft FracturesHumeral Shaft Fractures Conservative TreatmentConservative Treatment

– Goal of treatment is to Goal of treatment is to establish union with establish union with acceptable alignmentacceptable alignment

– >90% of humeral shaft >90% of humeral shaft fractures heal with fractures heal with nonsurgical managementnonsurgical management 20 degrees of anterior 20 degrees of anterior

angulation, 30 degrees of varus angulation, 30 degrees of varus angulation and up to 3 cm of angulation and up to 3 cm of shortening are acceptableshortening are acceptable

Most treatment begins with Most treatment begins with application of a coaptation spint application of a coaptation spint or a hanging arm cast followed or a hanging arm cast followed by placement of a fracture brace by placement of a fracture brace


TreatmentTreatment– Operative TreatmentOperative Treatment

Indications for operative treatment Indications for operative treatment include inadequate reduction, include inadequate reduction, nonunion, associated injuries, open nonunion, associated injuries, open fractures, segmental fractures, fractures, segmental fractures, associated vascular or nerve injuriesassociated vascular or nerve injuries

Most commonly treated with plates Most commonly treated with plates but also IM nailsbut also IM nails


Holstein-Lewis FracturesHolstein-Lewis Fractures– Distal 1/3 fracturesDistal 1/3 fractures– May entrap or lacerate radial nerve as the May entrap or lacerate radial nerve as the

fracture passes through the intermuscular fracture passes through the intermuscular septumseptum

Elbow Fracture/DislocationsElbow Fracture/Dislocations

Elbow DislocationsElbow Dislocations EpidemiologyEpidemiology

– Accounts for 11-28% of injuries to the elbowAccounts for 11-28% of injuries to the elbow– Posterior dislocations most commonPosterior dislocations most common– Highest incidence in the young 10-20 years and Highest incidence in the young 10-20 years and

usually sports injuriesusually sports injuries Mechanism of injuryMechanism of injury

– Most commonly due to fall on outstretched hand Most commonly due to fall on outstretched hand or elbow resulting in force to unlock the or elbow resulting in force to unlock the olecranon from the trochleaolecranon from the trochlea

– Posterior dislocation following hyperextension, Posterior dislocation following hyperextension, valgus stress, arm abduction, and forearm valgus stress, arm abduction, and forearm supinationsupination

– Anterior dislocation ensuing from direct force to Anterior dislocation ensuing from direct force to the posterior forearm with elbow flexedthe posterior forearm with elbow flexed

Elbow DislocationsElbow Dislocations

Clinical EvaluationClinical Evaluation– Patients typically present guarding the injured Patients typically present guarding the injured

extremityextremity– Usually has gross deformity and swellingUsually has gross deformity and swelling– Careful NV exam in important and should be Careful NV exam in important and should be

done prior to radiographs or manipulationdone prior to radiographs or manipulation– Repeat after reductionRepeat after reduction

Radiographic EvaluationRadiographic Evaluation– AP and lateral elbow films should be obtained AP and lateral elbow films should be obtained

both pre and post reductionboth pre and post reduction– Careful examination for associated fracturesCareful examination for associated fractures

Elbow Fracture/DislocationsElbow Fracture/Dislocations TreatmentTreatment

– Posterior DislocationPosterior Dislocation Closed reduction under sedationClosed reduction under sedation Reduction should be performed with the elbow flexed Reduction should be performed with the elbow flexed

while providing distal tractionwhile providing distal traction Post reduction management includes a posterior Post reduction management includes a posterior

splint with the elbow at 90 degreessplint with the elbow at 90 degrees Open reduciton for severe soft tissue injuries or bony Open reduciton for severe soft tissue injuries or bony

entrapmententrapment– Anterior DislocationAnterior Dislocation

Closed reduction under sedationClosed reduction under sedation Distal traction to the flexed forearm followed by Distal traction to the flexed forearm followed by

dorsally direct pressure on the volar forearm with dorsally direct pressure on the volar forearm with anterior pressure on the humerusanterior pressure on the humerus


Associated injuriesAssociated injuries– Radial head fx (5-Radial head fx (5-

11%)11%)– TreatmentTreatment

Type I- ConservativeType I- Conservative Type II/III- Attempt Type II/III- Attempt

ORIF vs. radial head ORIF vs. radial head replacementreplacement


Associated Associated injuriesinjuries– Coronoid process Coronoid process

fractures (5-10%)fractures (5-10%)


Associated injuriesAssociated injuries– Medial or lateral epicondylar fx (12-Medial or lateral epicondylar fx (12-

34%)34%)

Elbow DislocationsElbow Dislocations Instability ScaleInstability Scale

– Type IType I Posterolateral rotary Posterolateral rotary

instability, lateral ulnar instability, lateral ulnar collateral ligament disruptedcollateral ligament disrupted

– Type IIType II Perched condyles, varus Perched condyles, varus

instability, ant and post instability, ant and post capsule disruptedcapsule disrupted

– Type IIIType III A: posterior dislocation with A: posterior dislocation with

valgus instability, medial valgus instability, medial collateral ligament disruptioncollateral ligament disruption

B: posterior dislocation, B: posterior dislocation, grossly unstable, lateral, grossly unstable, lateral, medial, anterior, and medial, anterior, and posterior disruptionposterior disruption

Forearm FracturesForearm Fractures

Forearm FracturesForearm Fractures

EpidemiologyEpidemiology– Highest ratio of open to closed than any Highest ratio of open to closed than any

other fracture except the tibiaother fracture except the tibia– More common in males than females, More common in males than females,

most likely secondary mva, contact most likely secondary mva, contact sports, altercations, and fallssports, altercations, and falls

Mechanism of InjuryMechanism of Injury– Commonly associated with mva, direct Commonly associated with mva, direct

trauma and fallstrauma and falls

Forearm FracturesForearm Fractures Clinical EvaluationClinical Evaluation

– Patients typically present with gross deformity of Patients typically present with gross deformity of the forearm and with pain, swelling, and loss of the forearm and with pain, swelling, and loss of function at the handfunction at the hand

– Careful exam is essential, with specific Careful exam is essential, with specific assessment of radial, ulnar, and median nerves assessment of radial, ulnar, and median nerves and radial and ulnar pulsesand radial and ulnar pulses

– Tense compartments, unremitting pain, and pain Tense compartments, unremitting pain, and pain with passive motion should raise suspicion for with passive motion should raise suspicion for compartment syndromecompartment syndrome

Radiographic EvaluationRadiographic Evaluation– AP and lateral radiographs of the forearmAP and lateral radiographs of the forearm– Don’t forget to examine and x-ray the elbow and Don’t forget to examine and x-ray the elbow and

wristwrist

Forearm FracturesForearm Fractures Ulna FracturesUlna Fractures

– These include nightstick and Monteggia fracturesThese include nightstick and Monteggia fractures– Monteggia denotes a fracture of the proximal Monteggia denotes a fracture of the proximal

ulna with an associated radial head dislocationulna with an associated radial head dislocation Monteggia fractures classification- BadoMonteggia fractures classification- Bado Type I- Anterior Dislocation of the radial head with Type I- Anterior Dislocation of the radial head with

fracture of ulna at any level- produced by forced fracture of ulna at any level- produced by forced pronationpronation

Type II- Posterior/posterolateral dislocation of the radial Type II- Posterior/posterolateral dislocation of the radial head- produced by axial loading with the forearm flexedhead- produced by axial loading with the forearm flexed

Type III- Lateral/anterolateral dislocation of the radial Type III- Lateral/anterolateral dislocation of the radial head with fracture of the ulnar metaphysis- forced head with fracture of the ulnar metaphysis- forced abduction of the elbowabduction of the elbow

Type IV- anterior dislocation of the radial head with Type IV- anterior dislocation of the radial head with fracture of radius and ulna at the same level- forced fracture of radius and ulna at the same level- forced pronation with radial shaft failurepronation with radial shaft failure

Monteggia fractures Monteggia fractures

Forearm FracturesForearm Fractures Radial Diaphysis FracturesRadial Diaphysis Fractures

– Fractures of the proximal two-thirds can be Fractures of the proximal two-thirds can be considered truly isolatedconsidered truly isolated

– Galeazzi or Piedmont fractures refer to fracture Galeazzi or Piedmont fractures refer to fracture of the radius with disruption of the distal radial of the radius with disruption of the distal radial ulnar jointulnar joint

MechanismMechanism– Usually caused by direct or indirect trauma, Usually caused by direct or indirect trauma,

such as fall onto outstretched handsuch as fall onto outstretched hand– Galeazzi fractures may result from direct trauma Galeazzi fractures may result from direct trauma

to the wrist, typically on the dorsolateral aspect, to the wrist, typically on the dorsolateral aspect, or fall onto outstretched hand with pronationor fall onto outstretched hand with pronation

Galeazzi fractureGaleazzi fracture

Distal Radius FracturesDistal Radius Fractures



EpidemiologyEpidemiology– Most common fractures of the upper extremityMost common fractures of the upper extremity– Common in older patients. Usually a result of Common in older patients. Usually a result of

direct trauma such as fall on out stretched handdirect trauma such as fall on out stretched hand– Increasing incidence due to aging populationIncreasing incidence due to aging population

Mechanism of InjuryMechanism of Injury– Most commonly a fall on an outstretched Most commonly a fall on an outstretched

extremity with the wrist in dorsiflexionextremity with the wrist in dorsiflexion– High energy injuries may result in significantly High energy injuries may result in significantly

displaced, highly unstable fracturesdisplaced, highly unstable fractures


A severe Colles fracture may assume a bayonet-like displacement.


Clinical EvaluationClinical Evaluation– Patients typically present with gross Patients typically present with gross

deformity of the wrist with variable deformity of the wrist with variable displacement of the hand in relation to the displacement of the hand in relation to the wrist. Typically swollen with painful ROMwrist. Typically swollen with painful ROM

– Ipsilateral shoulder and elbow must be Ipsilateral shoulder and elbow must be examinedexamined

– NV exam including specifically median NV exam including specifically median nerve for acute carpal tunnel compression nerve for acute carpal tunnel compression syndromesyndrome

Radiographic EvaluationRadiographic Evaluation

3 view of the wrist including AP, Lat, 3 view of the wrist including AP, Lat, and Obliqueand Oblique– Normal RelationshipsNormal Relationships

23 Deg

11 mm

11 Deg

Distal Radius FracturesDistal Radius Fractures EponymsEponyms

– Colles FractureColles Fracture Combination of intra and extra articular fractures of the distal Combination of intra and extra articular fractures of the distal

radius with dorsal angulation (apex volar), dorsal radius with dorsal angulation (apex volar), dorsal displacement, radial shift, and radial shortentingdisplacement, radial shift, and radial shortenting

Most common distal radius fracture caused by fall on Most common distal radius fracture caused by fall on outstretched handoutstretched hand

– Smith Fracture (Reverse Colles)Smith Fracture (Reverse Colles) Fracture with volar angulation (apex dorsal) from a fall on a Fracture with volar angulation (apex dorsal) from a fall on a

flexed wristflexed wrist– Barton FractureBarton Fracture

Fracture with dorsal or volar rim displaced with the hand and Fracture with dorsal or volar rim displaced with the hand and carpuscarpus

– Radial Styloid Fracture (Chauffeur Fracture)Radial Styloid Fracture (Chauffeur Fracture) Avulsion fracture with extrinsic ligaments attached to the Avulsion fracture with extrinsic ligaments attached to the

fragmentfragment Mechanism of injury is compression of the scaphoid against Mechanism of injury is compression of the scaphoid against

the styloidthe styloid


TreatmentTreatment– Displaced fractures require and attempt at Displaced fractures require and attempt at

reduction.reduction. Hematoma block-10ccs of lidocaine or a mix of lidocaine Hematoma block-10ccs of lidocaine or a mix of lidocaine

and marcaine in the fracture siteand marcaine in the fracture site Hang the wrist in fingertraps with a traction weightHang the wrist in fingertraps with a traction weight Reproduce the fracture mechanism and reduce the Reproduce the fracture mechanism and reduce the

fracturefracture Place in sugar tong splintPlace in sugar tong splint

– Operative ManagementOperative Management For the treatment of intraarticular, unstable, malreduced For the treatment of intraarticular, unstable, malreduced

fractures.fractures. As always, open fractures must go to the OR.As always, open fractures must go to the OR.


Spinal TraumaSpinal Trauma

TopicsTopics

Introduction to Spinal InjuriesIntroduction to Spinal Injuries Spinal Anatomy and PhysiologySpinal Anatomy and Physiology Pathophysiology of Spinal InjuryPathophysiology of Spinal Injury Assessment of the Spinal Injury Assessment of the Spinal Injury

PatientPatient Management of the Spinal Injury Management of the Spinal Injury

PatientPatient

Introduction to Spinal Introduction to Spinal InjuriesInjuries

Annually 15,000 permanent spinal cord injuriesAnnually 15,000 permanent spinal cord injuries Commonly men 16Commonly men 16––30 years old30 years old Mechanism of InjuryMechanism of Injury

– Vehicle crashes: 48%Vehicle crashes: 48%– Falls: 21%Falls: 21%– Penetrating trauma: 15%Penetrating trauma: 15%– Sports injury: 14%Sports injury: 14%

25% of all spinal cord injuries occur from improper handling 25% of all spinal cord injuries occur from improper handling of the spine and patient after injury.of the spine and patient after injury.– ASSUME based upon MOI that patients have a spinal injury.ASSUME based upon MOI that patients have a spinal injury.– MANAGE ALL spinal injuries with immediate and continued MANAGE ALL spinal injuries with immediate and continued

care.care. Lifelong care for spinal cord injury victim exceeds $1 Lifelong care for spinal cord injury victim exceeds $1

million.million. Best form of care is public safety and prevention programs.Best form of care is public safety and prevention programs.

Spinal Anatomy and PhysiologySpinal Anatomy and PhysiologyVertebral Column Vertebral Column

33 bones comprise the spine.33 bones comprise the spine. Function:Function:

– Skeletal support structureSkeletal support structure– Major portion of axial skeletonMajor portion of axial skeleton– Protective container for spinal cordProtective container for spinal cord

Vertebral Body:Vertebral Body:– Major weight-bearing componentMajor weight-bearing component– Anterior to other vertebrae componentsAnterior to other vertebrae components

Spinal Anatomy and Spinal Anatomy and PhysiologyPhysiology

Vertebral Column Vertebral Column


Size of VertebraeSize of Vertebrae– C-1 and C-2:C-1 and C-2:

No vertebral bodyNo vertebral body Support headSupport head Allow for turning of headAllow for turning of head

– Vertebral body size increases the more inferior Vertebral body size increases the more inferior they become.they become. Lumbar spine strongest and largestLumbar spine strongest and largest

– Bear weight of the bodyBear weight of the body

– Sacral and coccyx vertebrae are fused.Sacral and coccyx vertebrae are fused. No vertebral bodyNo vertebral body


Components of VertebraeComponents of Vertebrae– Spinal CanalSpinal Canal

Opening in the vertebrae that the spinal cord passes Opening in the vertebrae that the spinal cord passes throughthrough

– PediclesPedicles Thick, bony structures that connect the vertebral body Thick, bony structures that connect the vertebral body

to the spinous and transverse processesto the spinous and transverse processes

– LaminaeLaminae Posterior bones of vertebrae that make up foramenPosterior bones of vertebrae that make up foramen

– Transverse ProcessTransverse Process Bilateral projections from vertebraeBilateral projections from vertebrae Muscle attachment and articulation location with ribsMuscle attachment and articulation location with ribs

Spinal Anatomy and PhysiologySpinal Anatomy and PhysiologyVertebral ColumnVertebral Column

Components of VertebraeComponents of Vertebrae– Spinous ProcessSpinous Process

Posterior prominence on vertebraePosterior prominence on vertebrae

– Intervertebral DiskIntervertebral Disk Cartilaginous pad between vertebraeCartilaginous pad between vertebrae Serves as shock absorberServes as shock absorber


Vertebral LigamentsVertebral Ligaments– Anterior LongitudinalAnterior Longitudinal

Anterior surface of vertebral bodiesAnterior surface of vertebral bodies Provides major stability of the spinal columnProvides major stability of the spinal column Resists hyperextensionResists hyperextension

– Posterior LongitudinalPosterior Longitudinal Posterior surface of vertebral bodies in Posterior surface of vertebral bodies in

spinal canalspinal canal Prevents hyperflexionPrevents hyperflexion


Cervical SpineCervical Spine– 7 vertebrae7 vertebrae– Sole support for headSole support for head

Head weighs 16Head weighs 16––22 pounds22 pounds– C-1 (Atlas)C-1 (Atlas)

Supports headSupports head Securely affixed to the occiputSecurely affixed to the occiput Permits noddingPermits nodding

– C-2 (Axis)C-2 (Axis) Odontoid process (dens)Odontoid process (dens)

– Projects upwardProjects upward– Provides pivot point so head can rotateProvides pivot point so head can rotate

– C-7C-7 Prominent spinous process (vertebra prominens)Prominent spinous process (vertebra prominens)


Thoracic SpineThoracic Spine– 12 vertebrae12 vertebrae– 1st rib articulates with T-11st rib articulates with T-1

Attaches to transverse process and vertebral bodyAttaches to transverse process and vertebral body

– Next nine ribs attach to the inferior and superior Next nine ribs attach to the inferior and superior portion of adjacent vertebral bodiesportion of adjacent vertebral bodies Limits rib movement and provides increased rigidityLimits rib movement and provides increased rigidity

– Larger and stronger than cervical spineLarger and stronger than cervical spine Larger muscles help to ensure that the body stays Larger muscles help to ensure that the body stays

erecterect Supports movement of the thoracic cage during Supports movement of the thoracic cage during

respirationsrespirations


Lumbar SpineLumbar Spine– 5 vertebrae5 vertebrae– Bear forces of bending and lifting above Bear forces of bending and lifting above

the pelvisthe pelvis– Largest and thickest vertebral bodies Largest and thickest vertebral bodies

and intervertebral disksand intervertebral disks


Sacral SpineSacral Spine– 5 fused vertebrae5 fused vertebrae– Form posterior plate of pelvisForm posterior plate of pelvis– Help protect urinary and reproductive Help protect urinary and reproductive

organsorgans– Attach pelvis and lower extremities to Attach pelvis and lower extremities to

axial skeletonaxial skeleton Coccygeal SpineCoccygeal Spine

– 33––5 fused vertebrae5 fused vertebrae– Residual elements of a tailResidual elements of a tail

Spinal Anatomy and PhysiologySpinal Anatomy and PhysiologySpinal MeningesSpinal Meninges

LayersLayers– Dura materDura mater– ArachnoidArachnoid– Pia materPia mater

Cover entire spinal cord and peripheral Cover entire spinal cord and peripheral nerve roots that exitnerve roots that exit

Cerebrospinal fluid bathes spinal cord by Cerebrospinal fluid bathes spinal cord by filling the subarachnoid spacefilling the subarachnoid space– Exchange of nutrients and waste productsExchange of nutrients and waste products– Absorbs shocks of sudden movementAbsorbs shocks of sudden movement

Spinal Anatomy and PhysiologySpinal Anatomy and PhysiologySpinal Cord Spinal Cord

FunctionFunction– Transmits sensory input from body to the brainTransmits sensory input from body to the brain– Conducts motor impulses from brain to muscles Conducts motor impulses from brain to muscles

and organsand organs– Reflex centerReflex center

Intercepts sensory signals and initiates a reflex signalIntercepts sensory signals and initiates a reflex signal

GrowthGrowth– FetusFetus

Entire cord fills entire spinal foramenEntire cord fills entire spinal foramen

– AdultAdult Base of brain to L-1 or L-2 levelBase of brain to L-1 or L-2 level Peripheral nerve roots pulled into spinal foramen at the Peripheral nerve roots pulled into spinal foramen at the

distal end (cauda equina)distal end (cauda equina)


Blood SupplyBlood Supply– Paired spinal arteriesPaired spinal arteries

Branch off the vertebral, cervical, thoracic, Branch off the vertebral, cervical, thoracic, and lumbar arteriesand lumbar arteries

Travel through intervertebral foraminaTravel through intervertebral foramina– Split into anterior and posterior arteriesSplit into anterior and posterior arteries


General Cord AnatomyGeneral Cord Anatomy– Anterior Medial FissureAnterior Medial Fissure

Deep crease along the ventral surface of the spinal Deep crease along the ventral surface of the spinal cord that divides cord into left and right halvescord that divides cord into left and right halves

– Posterior Medial FissurePosterior Medial Fissure Shallow longitudinal groove along the dorsal surfaceShallow longitudinal groove along the dorsal surface

– Gray MatterGray Matter Area of the CNS dominated by nerve cell bodiesArea of the CNS dominated by nerve cell bodies Central portion of the spinal cordCentral portion of the spinal cord

– White MatterWhite Matter Surrounds gray matterSurrounds gray matter Comprised of axonsComprised of axons


General Cord AnatomyGeneral Cord Anatomy– AxonsAxons

Transmit signals upward to the brain and Transmit signals upward to the brain and down to the bodydown to the body

Ascending tractsAscending tracts– Axons that transmit signals to the brainAxons that transmit signals to the brain– Sensory tractsSensory tracts

Descending tractsDescending tracts– Axons that transmit signals to the bodyAxons that transmit signals to the body– Motor tractsMotor tracts

Voluntary and fine muscle movementVoluntary and fine muscle movement


Spinal Anatomy and PhysiologySpinal Anatomy and PhysiologySpinal NervesSpinal Nerves

31 pairs of nerves that originate along the 31 pairs of nerves that originate along the spinal cord from anterior and posterior nerve spinal cord from anterior and posterior nerve rootsroots– Sensory and motor functionsSensory and motor functions– Travel through intervertebral foraminaTravel through intervertebral foramina

1st pair exit between the skull and C-11st pair exit between the skull and C-1 Remainder of pairs exit below the vertebraeRemainder of pairs exit below the vertebrae Each pair has 2 dorsal and 2 ventral rootsEach pair has 2 dorsal and 2 ventral roots

– Ventral roots: motor impulses from cord to bodyVentral roots: motor impulses from cord to body– Dorsal roots: sensory impulses from body to cordDorsal roots: sensory impulses from body to cord– C-1 and Co-1 do not have dorsal rootsC-1 and Co-1 do not have dorsal roots

Spinal Anatomy and PhysiologySpinal Anatomy and PhysiologySpinal Nerves Spinal Nerves

PlexusPlexus– Nerve roots that converge in a cluster of Nerve roots that converge in a cluster of

nervesnerves Cervical plexusCervical plexus

– 5 cervical nerve roots5 cervical nerve roots– Innervates the neckInnervates the neck– Produces the phrenic nerveProduces the phrenic nerve

Peripheral nerve roots C-3 through C-5Peripheral nerve roots C-3 through C-5 Responsible for diaphragm controlResponsible for diaphragm control ““C3, 4, and 5 keep the diaphragm alive”C3, 4, and 5 keep the diaphragm alive”


Brachial PlexusBrachial Plexus– C-5 through T-1C-5 through T-1– Controls the upper extremityControls the upper extremity

Lumbar and Sacral PlexusesLumbar and Sacral Plexuses– Innervation of the lower extremityInnervation of the lower extremity



DermatomesDermatomes– Topographical region of the body Topographical region of the body

surface innervated by one nerve rootsurface innervated by one nerve root– Key locationsKey locations

Collar region: C-3Collar region: C-3 Little finger: C-7Little finger: C-7 Nipple line: T-4Nipple line: T-4 Umbilicus: T-10Umbilicus: T-10 Small toe: S-1Small toe: S-1



MyotomesMyotomes– Muscle and tissue of the body Muscle and tissue of the body

innervated by spinal nerve rootsinnervated by spinal nerve roots– Key myotomesKey myotomes

Arm extension: C-5Arm extension: C-5 Elbow extension: C-7Elbow extension: C-7 Small finger abduction: T-1Small finger abduction: T-1 Knee extension: L-3Knee extension: L-3 Ankle flexion: S-1Ankle flexion: S-1


Reflex PathwaysReflex Pathways– FunctionFunction

Speed body’s response to stressorsSpeed body’s response to stressors Reduce seriousness of injuryReduce seriousness of injury Body stabilizationBody stabilization

– Occur in special neuronsOccur in special neurons InterneuronsInterneurons ExampleExample

– Touch hot stove.Touch hot stove.– Severe pain sends intense impulse to brain.Severe pain sends intense impulse to brain.– Strong signal triggers interneuron in the spinal cord to Strong signal triggers interneuron in the spinal cord to

direct a signal to the flexor muscle.direct a signal to the flexor muscle.– Limb withdraws without waiting for a signal from the Limb withdraws without waiting for a signal from the

brain.brain.

Spinal Anatomy and Spinal Anatomy and PhysiologyPhysiology

Spinal Nerves Spinal Nerves


Subdivision of ANSSubdivision of ANS– Parasympathetic, “Feed and Breed”Parasympathetic, “Feed and Breed”

Controls rest and regenerationControls rest and regeneration Peripheral nerve roots from the sacral and Peripheral nerve roots from the sacral and

cranial nervescranial nerves Major FunctionsMajor Functions

– Slows heart rateSlows heart rate– Increases digestive system activityIncreases digestive system activity– Plays a role in sexual stimulationPlays a role in sexual stimulation


Subdivision of ANS Subdivision of ANS – Sympathetic, “Fight or Flight”Sympathetic, “Fight or Flight”

Increases metabolic rateIncreases metabolic rate Branches from nerves in the thoracic and lumbar Branches from nerves in the thoracic and lumbar

regionsregions Major FunctionsMajor Functions

– Decreases organ and digestive system activityDecreases organ and digestive system activity VasoconstrictionVasoconstriction

– Release of epinephrine and norepinephrineRelease of epinephrine and norepinephrine– Systemic vascular resistanceSystemic vascular resistance

Reduces venous blood volumeReduces venous blood volume Increases peripheral vascular resistanceIncreases peripheral vascular resistance

– Increases heart rateIncreases heart rate– Increases cardiac outputIncreases cardiac output

Pathophysiology of Spinal Pathophysiology of Spinal Injury Injury

Mechanisms of Spinal InjuryMechanisms of Spinal Injury

– Extremes of MotionExtremes of Motion HyperextensionHyperextension Hyperflexion: “Kiss the Chest”Hyperflexion: “Kiss the Chest” Excessive rotationExcessive rotation Lateral bendingLateral bending

Pathophysiology of Spinal Pathophysiology of Spinal InjuryInjury

Mechanisms of Spinal InjuryMechanisms of Spinal Injury

– Axial StressAxial Stress Axial loadingAxial loading

– Compression common between T-12 and L-2Compression common between T-12 and L-2

DistractionDistraction CombinationCombination

– Distraction/rotation or compression/flexionDistraction/rotation or compression/flexion

– Other MOIOther MOI Direct, blunt, or penetrating traumaDirect, blunt, or penetrating trauma ElectrocutionElectrocution









(4 of 14)(4 of 14) Column InjuryColumn Injury

– Movement of vertebrae from normal positionMovement of vertebrae from normal position– Subluxation or dislocationSubluxation or dislocation– FracturesFractures

Spinous process and transverse processSpinous process and transverse process Pedicle and laminaePedicle and laminae Vertebral bodyVertebral body

– Ruptured intervertebral disksRuptured intervertebral disks– Common sites of injuryCommon sites of injury

C-1/C-2: Delicate vertebraeC-1/C-2: Delicate vertebrae C-7: Transition from flexible cervical spine to thoraxC-7: Transition from flexible cervical spine to thorax T-12/L-1: Different flexibility between thoracic and T-12/L-1: Different flexibility between thoracic and

lumbar regionslumbar regions


(5 of 14)(5 of 14) Cord InjuryCord Injury– ConcussionConcussion

Similar to cerebral concussionSimilar to cerebral concussion Temporary and transient disruption of cord Temporary and transient disruption of cord

functionfunction– ContusionContusion

Bruising of the cordBruising of the cord Tissue damage, vascular leakage, and swellingTissue damage, vascular leakage, and swelling

– CompressionCompression Secondary to:Secondary to:

– Displacement of the vertebraeDisplacement of the vertebrae– Herniation of intervertebral diskHerniation of intervertebral disk– Displacement of vertebral bone fragmentDisplacement of vertebral bone fragment– Swelling from adjacent tissueSwelling from adjacent tissue


(6 of 14)(6 of 14) Cord InjuryCord Injury

– LacerationLaceration CausesCauses

– Bony fragments driven into the vertebral foramenBony fragments driven into the vertebral foramen– Cord may be stretched to the point of tearingCord may be stretched to the point of tearing

Hemorrhage into cord tissue, swelling, and Hemorrhage into cord tissue, swelling, and disruption of impulsesdisruption of impulses

– HemorrhageHemorrhage Associated with contusion, laceration, or Associated with contusion, laceration, or

stretchingstretching


(7 of 14)(7 of 14) Transection Cord InjuryTransection Cord Injury

– Injury that partially or completely severs Injury that partially or completely severs the spinal cordthe spinal cord CompleteComplete

– Cervical SpineCervical Spine QuadriplegiaQuadriplegia IncontinenceIncontinence Respiratory paralysisRespiratory paralysis

– Below T-1Below T-1 IncontinenceIncontinence ParaplegiaParaplegia

IncompleteIncomplete


(8 of 14)(8 of 14) Incomplete Transection Cord InjuryIncomplete Transection Cord Injury– Anterior Cord SyndromeAnterior Cord Syndrome

Anterior vascular disruptionAnterior vascular disruption Loss of motor function and sensation of pain, light Loss of motor function and sensation of pain, light

touch, and temperature below injury sitetouch, and temperature below injury site Retain motor, positional, and vibration sensationRetain motor, positional, and vibration sensation

– Central Cord SyndromeCentral Cord Syndrome Hyperextension of cervical spineHyperextension of cervical spine Motor weakness affecting upper extremitiesMotor weakness affecting upper extremities Bladder dysfunctionBladder dysfunction

– Brown-Sequard’s SyndromeBrown-Sequard’s Syndrome Penetrating injury that affects one side of the cordPenetrating injury that affects one side of the cord Ipsilateral sensory and motor lossIpsilateral sensory and motor loss Contralateral pain and temperature sensation lossContralateral pain and temperature sensation loss


(9 of 14)(9 of 14) General Signs and SymptomsGeneral Signs and Symptoms

– Extremity paralysisExtremity paralysis– Pain with and without movementPain with and without movement– Tenderness along spineTenderness along spine– Impaired breathingImpaired breathing– Spinal deformitySpinal deformity– PriapismPriapism– PosturingPosturing– Loss of bowel or bladder controlLoss of bowel or bladder control– Nerve impairment to extremitiesNerve impairment to extremities

Pathophysiology of Spinal Pathophysiology of Spinal Injury Injury (10 of 14)(10 of 14)

Spinal ShockSpinal Shock– Temporary insult to the cordTemporary insult to the cord– Affects body below the level of injuryAffects body below the level of injury– Affected areaAffected area

FlaccidFlaccid Without feelingWithout feeling Loss of movement (flaccid paralysis)Loss of movement (flaccid paralysis) Frequent loss of bowel and bladder controlFrequent loss of bowel and bladder control PriapismPriapism Hypotension secondary to vasodilationHypotension secondary to vasodilation

Pathophysiology of Spinal Pathophysiology of Spinal Injury Injury (11 of 14)(11 of 14) Neurogenic ShockNeurogenic Shock

– Spinal-Vascular ShockSpinal-Vascular Shock– Occurs when injury to the spinal cord disrupts Occurs when injury to the spinal cord disrupts

the brain’s ability to control the bodythe brain’s ability to control the body Loss of sympathetic toneLoss of sympathetic tone

– Dilation of arteries and veinsDilation of arteries and veins Expands vascular spaceExpands vascular space Results in relative hypotensionResults in relative hypotension

– Reduced cardiac preloadReduced cardiac preload– Reduction of the strength of contractionReduction of the strength of contraction

Frank-Starling reflexFrank-Starling reflex ANS loses sympathetic control over adrenal medullaANS loses sympathetic control over adrenal medulla

– Unable to control release of epinephrine and Unable to control release of epinephrine and norepinephrinenorepinephrine

Loss of positive inotropic and chronotropic effectsLoss of positive inotropic and chronotropic effects


Neurogenic ShockNeurogenic Shock– Signs and SymptomsSigns and Symptoms

BradycardiaBradycardia HypotensionHypotension Cool, moist, and pale skin above the injuryCool, moist, and pale skin above the injury Warm, dry, and flushed skin below the injuryWarm, dry, and flushed skin below the injury Male: priapismMale: priapism


Autonomic Hyperreflexia SyndromeAutonomic Hyperreflexia Syndrome– Associated with the body’s resolution of the Associated with the body’s resolution of the

effects of spinal shockeffects of spinal shock– Commonly associated with injuries at or above Commonly associated with injuries at or above

T-6T-6– PresentationPresentation

Sudden hypertensionSudden hypertension BradycardiaBradycardia Pounding headachePounding headache Blurred visionBlurred vision Sweating and flushing of skin above the point of injurySweating and flushing of skin above the point of injury


Other Causes of Neurologic Other Causes of Neurologic DysfunctionDysfunction– Any injury that affects the nerve Any injury that affects the nerve

impulse’s path of travelimpulse’s path of travel SwellingSwelling DislocationDislocation FractureFracture Compartment syndromeCompartment syndrome

Assessment of the Spinal Injury Assessment of the Spinal Injury Patient Patient (1 of 4)(1 of 4)

Scene Size-upScene Size-up– Evaluate MOI.Evaluate MOI.– Consider spinal clearance protocol.Consider spinal clearance protocol.– Determine type of spinal trauma.Determine type of spinal trauma.– Maintain suspicion with sports injuries.Maintain suspicion with sports injuries.– If unclear about MOI, take spinal If unclear about MOI, take spinal

precautions.precautions.


Initial AssessmentInitial Assessment– Consider spinal clearance protocol.Consider spinal clearance protocol.– Consider spinal precautions.Consider spinal precautions.

Head injuryHead injury Intoxicated patientsIntoxicated patients Injuries above the shouldersInjuries above the shoulders Distracting injuriesDistracting injuries

– Maintain manual stabilization.Maintain manual stabilization. Vest style versus rapid extricationVest style versus rapid extrication Maintain neutral alignmentMaintain neutral alignment Increase of pain or resistance, restrict movement in Increase of pain or resistance, restrict movement in

position foundposition found


Initial AssessmentInitial Assessment– ABCs.ABCs.– Suction.Suction.– Consider oral or digital intubation if Consider oral or digital intubation if

required.required. Maintain in-line manual c-spine control.Maintain in-line manual c-spine control.


Rapid Trauma AssessmentRapid Trauma Assessment– Focused versus rapid assessmentFocused versus rapid assessment– Rapid AssessmentRapid Assessment

Suspected or likely spinal cord/column injurySuspected or likely spinal cord/column injury Multi-system trauma patientMulti-system trauma patient Evaluate forEvaluate for

– NeckNeck Deformity, pain, crepitus, warmth, tendernessDeformity, pain, crepitus, warmth, tenderness

– Bilateral extremitiesBilateral extremities Finger abduction/adductionFinger abduction/adduction Push, pull, gripsPush, pull, grips

– Motor and sensory functionMotor and sensory function– Dermatome and myotome evaluationDermatome and myotome evaluation– Babinski’s sign testBabinski’s sign test– Hold-up positionHold-up position

Babinski’s Sign TestBabinski’s Sign Test

Stroke lateral aspect of the bottom of Stroke lateral aspect of the bottom of the foot.the foot.

Evaluate for movement of the toes.Evaluate for movement of the toes.– Fanning and flexing (lifting)Fanning and flexing (lifting)

Positive signPositive sign– Injury along the pyramidal (descending spinal) Injury along the pyramidal (descending spinal)

tracttract

Assessment of the Assessment of the Spinal Injury PatientSpinal Injury Patient

Vital SignsVital Signs– Body temperatureBody temperature

Above and below site of injuryAbove and below site of injury

– PulsePulse– Blood pressureBlood pressure– RespirationsRespirations

Ongoing AssessmentOngoing Assessment– Recheck elements of initial assessment.Recheck elements of initial assessment.– Recheck vital signs.Recheck vital signs.– Recheck interventions.Recheck interventions.– Recheck any neurological deviations.Recheck any neurological deviations.

Spinal Clearance ProtocolSpinal Clearance Protocol

Spinal Integrity TerminologySpinal Integrity Terminology StabilizeStabilize is a word commonly used to describe is a word commonly used to describe

protecting the spinal cord from possible injury (or protecting the spinal cord from possible injury (or further injury) when vertebral column integrity is further injury) when vertebral column integrity is disrupted. disrupted.

ImmobilizeImmobilize refers to the “splinting” of the head, refers to the “splinting” of the head, neck, and torso to limit any transmission of neck, and torso to limit any transmission of motion to the spine. motion to the spine.

SpinalSpinal motion restrictionmotion restriction (SMR) is now (SMR) is now suggested as a more accurate description of suggested as a more accurate description of modern spinal injury care. However, this phrase modern spinal injury care. However, this phrase could be misunderstood to indicate a more could be misunderstood to indicate a more limited “immobilization” of the spine than is limited “immobilization” of the spine than is currently practiced. currently practiced.

Management of the Management of the Spinal Injury Patient Spinal Injury Patient (1 of 7)(1 of 7)

Spinal AlignmentSpinal Alignment– Move patient to a neutral, in-line position.Move patient to a neutral, in-line position.

Position of function.Position of function.– Hips and knees should be slightly flexed for maximum Hips and knees should be slightly flexed for maximum

comfort and minimum stress on muscles, joints, and comfort and minimum stress on muscles, joints, and spine.spine. Place a rolled blanket under the knees.Place a rolled blanket under the knees.

– ALWAYS support the head and neck.ALWAYS support the head and neck.– Contraindications to neutral position:Contraindications to neutral position:

Movement causes a noticeable increase in pain.Movement causes a noticeable increase in pain. Noticeable resistance met during procedure.Noticeable resistance met during procedure. Increase in neurological deficits occurs during movement.Increase in neurological deficits occurs during movement. Gross deformity of spine.Gross deformity of spine.

– LESS MOVEMENT IS BEST.LESS MOVEMENT IS BEST.


Manual Cervical ImmobilizationManual Cervical Immobilization– Seated PatientSeated Patient

Approach from front.Approach from front. Assign a caregiver to hold GENTLE manual traction.Assign a caregiver to hold GENTLE manual traction.

– Reduce axial loading.Reduce axial loading.– Evaluate posterior cervical spine.Evaluate posterior cervical spine.

Position patient’s head slowly to a neutral, in-line Position patient’s head slowly to a neutral, in-line position.position.

– Supine PatientSupine Patient Assign a caregiver to hold GENTLE manual traction.Assign a caregiver to hold GENTLE manual traction. AdultAdult

– Lift head off ground 1–2”: neutral, in-line position.Lift head off ground 1–2”: neutral, in-line position. ChildChild

– Position head at ground level: avoid flexion.Position head at ground level: avoid flexion.



Cervical Collar ApplicationCervical Collar Application– Apply the C-collar as soon as possible.Apply the C-collar as soon as possible.– Assess neck prior to placing.Assess neck prior to placing.– C-collar limits some movement and reduces axial loading.C-collar limits some movement and reduces axial loading.– DOES NOT completely prevent movement of the neck.DOES NOT completely prevent movement of the neck.– Size and Apply according to the manufacturer’s Size and Apply according to the manufacturer’s

recommendation.recommendation. Collar should fit snugly.Collar should fit snugly. Collar should NOT impede respirations.Collar should NOT impede respirations. Head should continue to be in neutral position.Head should continue to be in neutral position. SIZE IT, SIZE IT, SIZE IT!!!SIZE IT, SIZE IT, SIZE IT!!!

– DO NOT RELEASE manual control until the patient is fully DO NOT RELEASE manual control until the patient is fully secured in a spinal restriction device.secured in a spinal restriction device.


Standing TakedownStanding Takedown– Minimum 3 rescuers.Minimum 3 rescuers.– Have patient remain immobile.Have patient remain immobile.– Rescuer provides manual stabilization from behind.Rescuer provides manual stabilization from behind.– Assess neck.Assess neck.– Size and place c-collar.Size and place c-collar.– Position board behind patient.Position board behind patient.– Grasp board under patient’s shoulders.Grasp board under patient’s shoulders.– Lower board to ground.Lower board to ground.– Secure patient.Secure patient.

COMMUNICATE WITH PARTNERS AND PATIENT.COMMUNICATE WITH PARTNERS AND PATIENT.


Helmet RemovalHelmet Removal– When to remove:When to remove:

Helmet does not immobilize the patient’s head Helmet does not immobilize the patient’s head within.within.

Cannot securely immobilize the helmet to the long Cannot securely immobilize the helmet to the long spine board.spine board.

Helmet prevents airway care.Helmet prevents airway care. Helmet prevents assessment of anticipated injuries.Helmet prevents assessment of anticipated injuries. Present or anticipated airway or breathing problems.Present or anticipated airway or breathing problems. Removal will not cause further injury.Removal will not cause further injury.


Helmet RemovalHelmet Removal– Technique:Technique:

2 Rescuers.2 Rescuers. Have a plan.Have a plan. Remove face mask and chin strap.Remove face mask and chin strap. Immobilize head.Immobilize head.

– Slide one hand under back of neck and head.Slide one hand under back of neck and head.– Other hand supports anterior neck and jaw.Other hand supports anterior neck and jaw.

Remove helmet.Remove helmet.– Gently rock head to clear occiput.Gently rock head to clear occiput.

All actions should be slow and deliberate.All actions should be slow and deliberate.

– TRANSPORT HELMET with patient.TRANSPORT HELMET with patient.– COMMUNICATION is the KEY.COMMUNICATION is the KEY.

Bledsoe et al., Bledsoe et al., Paramedic Care Paramedic Care Principles & Practice Volume Principles & Practice Volume 4: Trauma4: Trauma© 2006 by Pearson Education, © 2006 by Pearson Education, Inc. Upper Saddle River, NJInc. Upper Saddle River, NJ

Movement of the Movement of the Spinal Injury Patient Spinal Injury Patient (1 of 2)(1 of 2)

Any movement MUST be coordinated.Any movement MUST be coordinated. Move patient as a unit.Move patient as a unit. NO LATERAL PUSHING.NO LATERAL PUSHING.

– Move patient up and down to prevent lateral Move patient up and down to prevent lateral bending.bending.

Rescuer at the head “CALLS” all moves.Rescuer at the head “CALLS” all moves. ALL MOVES MUST be slowly executed and ALL MOVES MUST be slowly executed and

well coordinated.well coordinated. Consider the final positioning of the patient Consider the final positioning of the patient

prior to beginning move.prior to beginning move.

Bledsoe et al., Bledsoe et al., Paramedic Care Paramedic Care Principles & Practice Volume Principles & Practice Volume 4: Trauma4: Trauma© 2006 by Pearson Education, © 2006 by Pearson Education, Inc. Upper Saddle River, NJInc. Upper Saddle River, NJ

Movement of the Movement of the Spinal Injury Patient Spinal Injury Patient (2 of 2)(2 of 2)

Types of MovesTypes of Moves– Log rollLog roll– Straddle slideStraddle slide– Rope-Sling slideRope-Sling slide– Orthopedic stretcherOrthopedic stretcher– Vest-type immobilizationVest-type immobilization– Rapid extricationRapid extrication– Final patient positioningFinal patient positioning– Long spine boardLong spine board– Full-body vacuum mattressFull-body vacuum mattress– Diving injury immobilizationDiving injury immobilization


Medications and Spinal Cord InjuryMedications and Spinal Cord Injury– Steroids if neuro-deficit is identifiedSteroids if neuro-deficit is identified

Reduce the body’s response to injuryReduce the body’s response to injury Reduce swelling and pressure on cordReduce swelling and pressure on cord Administered within 1st 8 hours of injuryAdministered within 1st 8 hours of injury


Medications and Neurogenic ShockMedications and Neurogenic Shock– Fluid ChallengeFluid Challenge

Isotonic solution: 20 mL/kgIsotonic solution: 20 mL/kg– 250 mL initially250 mL initially– Monitor response and repeat as neededMonitor response and repeat as needed

– PASGPASG ControversialControversial

– Research shows no positive outcomeResearch shows no positive outcome

– DopamineDopamine 22––20 mcg/kg/min titrated to blood pressure20 mcg/kg/min titrated to blood pressure

– AtropineAtropine 0.50.5––1.0 mg q 31.0 mg q 3––5 min (maximum of 2.0 mg)5 min (maximum of 2.0 mg)


Medications and the Combative Medications and the Combative PatientPatient– Consider sedatives to reduce anxiety Consider sedatives to reduce anxiety

and calm patient.and calm patient. Prevents spinal injury aggravationPrevents spinal injury aggravation

– Medications:Medications: Meperidine (Demerol)Meperidine (Demerol) Diazepam (Valium)Diazepam (Valium) Consider paralytics with airway controlConsider paralytics with airway control

SummarySummary

Introduction to Spinal InjuriesIntroduction to Spinal Injuries Spinal Anatomy and PhysiologySpinal Anatomy and Physiology Pathophysiology of Spinal InjuryPathophysiology of Spinal Injury Assessment of the Spinal Injury Assessment of the Spinal Injury

PatientPatient Management of the Spinal Injury Management of the Spinal Injury

PatientPatient

The End

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