5.9E Ortho Fractures - Spine Em

Front 1

Regarding cervical spine fractures from flexion injuries- true or false
1. anterior wedge fractures are usually stable
2. a clay shoveller's fracture may be due to an avulsion or a direct blow, and is at the C3 -4 vertebrae
3. subluxation injuries are unstable as only the nuchal ligament remains intact
4. anterior teardrop fractures are nearly always unstable and frequently have neurological and ligamentous disruption
5. bilateral facet joint dislocations usually have an intact disc and disrupted anterior ligament, and are quite stable

Back 1

1. T
2. F classically C6-7, but through the spinous process of any of the lower cervical or upper thoracic vertebrae
3. F the ANTERIOR intervertebral ligament remains intact
4. T
5. F VERY unstable, annulus of the disc and anterior ligament also disrupted

Front 2

Regarding Odontoid fractures which is incorrect
1. airway obstruction is a rare complication
2. the ossification centre of the dens appears at 2 years and fuses by 12
3. normal dens variants include hypolasia, absence or separation from the body of the axis
4. a type II fracture occurs through the C2 body and is mechanically unstable

Back 2

1. T - extensive soft tissue swelling, displaced fractures and degenerative changes CAN rarely result in airway obstruction
2 T
3 T - separation from the body of the axis is called os odontoideum where is it a separate bone, can be asymptomatic or predispose to cervical instability
4 INCORRECT -

TI = uncommon, through tip above transverse ligament
TII = most common, junction body/dens, conservative or operative treatment depending on displacement
TIII = v unstable, through body of C2

Front 3

Regarding C-spine rotation injuries which is incorrect
1, in the absence of fracture, unilateral facet joint dislocations are stable
2 unilateral facet joint dislocations may be diagnosed by malaligned spinous processes on the lateral film
3 rotatory dislocation of C1-2 is rare, and diagnosed by odontoid lateral mass asymmetry
4 rotatory dislocation of C1-2 may present with pain, torticollis, but usually no neuro abnormality

Back 3

2 incorrect, AP film shows malalignment; lateral instead shows wide interspinous spaces

Front 4

Regarding normal dimensions of the adult retropharyngeal space on lateral C-spine XR which is incorrect
1 C1 <10mm
2 C2 <10 mm
3 C3/4 <7mm or 1/2 body
4 C6 <22mm (children <15mm)

Back 4

2 - INCORRECT C2 is <7mm

Front 5

Regarding spinal extension injuries which is incorrect
1. fractures of posterior arch may be confused with congenital absence of the posterior arch
2 Hangman's fracture usually cause cord injury
3 an extension teardrop fracture is usually mechanically unstable and central cord syndrome is common
4 a Hangman's fracture is a bilateral fracture of the pedicles of the axis

Back 5

1 T - may be mechanically unstable, usually due to compression between occiput and atlas
2 INCORRECT spinal canal at widest point here so cord injury may not occur; >90% fuse with nonoperative external immobilisation, mechanically unstable

Front 6

Regarding cervical vertical compression injuries which is incorrect
1 a burst fracture is mechanically unstable
2 a burst fracture may injure the cord
3 Jefferson fractures are fractures of anterior and posterior neural arches with disruption of transverse ligament
4 Jefferson fractures may be difficult to detect

Back 6

1 INCORRECT usually STABLE, comminuted fracture with ligaments intact
2 yes due to fracture fragments
4 yes if fragments not displaced; a mechanically unstable fracture, posterior spinal line may be intact, predental space may be widened, lateral masses C1 moved laterally

Front 7

Regarding thoracolumbar fractures which is incorrect
1 site most at risk is junction thoracic and lumbar spine
2 unstable fractures may be marked by disruption of two of the anterior, posterior and spinolaminar lines on lateral film
3 minor fractures include pars interarticularis, flexion distraction injuries and translational injuries
4 wedge or compression fractures - neural injury is rare

Back 7

1 T - 65% injuries T12 - L2, 90% T11 - L4
3 INCORRECT - flexion distraction injuries, translational injuries, burst, chance and wedge compression fractures are all MAJOR fractures/dislocations

Front 8

What are the three columns of the spine?

Back 8

The Three-Column Concept
When describing and diagnosing spinal fractures, spine surgeons divide the spinal column into 3 sections:
1. Anterior column - made up of the anterior longitudinal ligament and the anterior one-half of the vertebral body, disc, and annulus.
2. Middle column - made up of the posterior one-half of the vertebral body, disc, and annulus, and the posterior longitudinal ligament.
3. Posterior column - made up of the facet joints, ligamentum flavum, the posterior elements and the interconnecting ligaments.

Stable and Unstable Fractures
Generally, a fracture is considered stable if only the anterior column is involved, as in the case of most wedge fractures. When the anterior and middle columns are involved, the fracture may be considered more unstable. When all three columns are involved, the fracture is by definition considered unstable, because of the loss of the integrity of the posterior stabilizing ligaments.

Front 9

Regarding thoracolumbar injuries which is incorrect
1 Burst fractures may impinge on spinal cord
2 65% of Chance fractures have associated intestinal or mesenteric injuries
3 Chance fractures maintain laminae and pedicle integrity
4 Flexion distraction injuries disrupt the middle and posterior columns and split horizontally

Back 9

3 INCORRECT - Chance fractures completely disrupt (nearly everything!!) spinous process, laminae, transverse processes, pedicles, vertebral body. Due to flexion around axis anterior to anterior spinal longitudinal ligament e.g. lap seat belt
4 in contrast in flexion distraction injuries the axis is POSTERIOR to anterior spinal long lig and anterior column acts as hinge and is uninvolved or slightly compressed (think of it as a partial chance fracture??)

Front 10

Lumbar transverse process fractures - what are the associated injuries?

Back 10

A long list
- renal, adrenal or ureteric trauma
- splenic, hepatic, pancreatic injuries
- diaphragmmatic injury
- ipsilateral pelvic fractures - v common if L5 transverse process involved

Front 11

Imaging thoracolumbar injuries
1 plain radiography only 75% sensitive
2 80% with vertebral fracture will have 2nd spinal fracture
3 50% vertebral fracture will have associated other injuries - esp chest head and long bone
4 5 % unable to give hx will have thoracolumbar spine injury

Back 11

2. INCORRECT 20%