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Wedge Fracture, stable fracture Causes: Hyperflexion force Axial force Osteoporosis Codfish spine appearance: biconcave appearance of vertebral end plates.

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Presentation on theme: "Wedge Fracture, stable fracture Causes: Hyperflexion force Axial force Osteoporosis Codfish spine appearance: biconcave appearance of vertebral end plates."— Presentation transcript:


2 Wedge Fracture, stable fracture Causes: Hyperflexion force Axial force Osteoporosis Codfish spine appearance: biconcave appearance of vertebral end plates Anterior Column Fractures anterior-wedge-compr...

3 Burst fracture Axial force Lower arrow points to intrusion into the spinal canal -more sci involvement Middle Column Fracture

4 All three columns have a fracture. This particular fracture is called a Chance fracture Notice the almost horizontal line through the spinous process and the compression fracture anteriorly Caused by a seat belt, Force is hyperflexion, distraction and impaction forces Stable or unstable fracture? Posterior Column Fractures

5 Fractures Compression Fracture: wedge compression fracture of the vertebral body. MOI: flexion force or lateral flexion Hoppenfeld S. Treatment and Rehabilitation of Fractures

6 a. Posterior ligaments and posterior bone elements are intact b. Kyphotic angulation less than 10 degrees c. Loss of anterior vertebral body height is less than 40% d. Relatively stable injury

7 Angulation is greater than 20 dg Loss of 50% or more of anterior height Creates pull on posterior ligaments of the spine – supraspinous, interspinous,ligamentum flavum or facet joint capsule Unstable Compression Fracture

8 Stable Burst Fracture: MOI: axial loading force (compression force) a. Anterior and middle columns are disrupted, posterior column is uninjured b. Kyphosis is limited to 15 degrees c. Loss of vertebral body height is less than 50% d. Neurologically intact Hoppenfeld S. Treatment and Rehabilitation of Fractures

9 Unstable Burst Fracture MOI: axial force (compression force) a. Anterior and middle columns are disrupted Retropulsion of posterior column fragments into the vertebral canal occurs b. Pedicle widening on x-ray c. Neurological injury varies based on the level of injury rather than the canal compromised by bone fragments d. Fractures above L2 have greater neurological involvement anything below L2, have very mobile nerve roots so they can get out of the way or find away around the fracture.

10 Flexion - Distraction injury MOI: seat belt injuries, lap belt injuries a. Failure of posterior elements in tension while the anterior and middle columns are compressed b. Widening of the spinous processes c. Vertebral body is wedged anteriorally d. Variable neurological involvement -Middle and Anterior Column.

11 Chance Fracture MOI: hyperflexion injury over a secured lap belt (usually in back seat, flexion over the lap belt, fractures right into gut) Type of flexion distraction injury – involves more structures Tension failure of all spinal bone elements and/or ligaments – anterior, middle and posterior columns Bowel injuries occurs in 65% No compromise of anterior elements occurs only when the injury is primarily ligamentous Surgical candidate Hoppenfeld S. Treatment and Rehabilitation of Fractures

12 Compression Torsion/Translational injuries MOI: shear force or rotary force with compression a. Force will fracture or dislocate facet joints b. Neurological involvement occurs c. Surgical candidate

13 d. Unstable fractures with incomplete neurological deficit: May or may not stabilize with internal fixation at first. Dependent upon improvement noted with a log rolling frame e. Unstable fracture with complete neurological deficit: Paraplegia will operate within 48 hours for stabilization a. Stable fractures without neurological deficit: surgery is usually not needed b. Unstable fractures without neurological deficit: External immobilization for weeks Operate if neurological deficit becomes apparent c. Unstable fractures with progressive neurological damage: Reduction of fracture and internal stabilization - with or without a fusion RX for different fractures

14 a. Advancing or progressive neurological deficits -get weaker, or can not move “big toe” -Reflexes check b. Paraplegia in absence of bony injury c. Severe nerve root pain -Usually a boney fragment. Indications for Immediate Surgery

15 Rib Cage Fractures 1. Minor: simple rib fracture, in 1 spot, do not do much. 2. Major: fracture of 1 or more vertebrae resulting in a flail chest and/or a hemothorax or pneumothorax Copyright 2004 Nucleus Communications, Inc. All rights reserved.

16 SX: pain on inspiration Signs: palpable defect, tender to palpate, ecchymosis -Ask to breath in deep “if pain” then suspect a rib fracture. Or tap, vibrate to see if pain, symptoms increase. RX: simple fracture: can just bind the ribs to assist with pain management and coughing, will become stable within 1-2 weeks and heals by 6 weeks Rib Fracture

17 Definition: segment of the chest wall doesn't have continuity with the rest of the thoracic rib cage (two fractures of same rib-floating) Signs: Paradoxical motion occurs: moves in on inspiration and out on expiration splinting of chest wall muscles, decrease ventilation, decrease vital capacity, when breathing it will do the opposite of what ribs are suppose to do. Lab tests: x-ray and blood gases help to make a positive diagnosis Flail Chest

18 Rib Cage Dysfunctions 1)Costochondritis: anterior chest wall syndrome pain in the costochondral articulation without swelling, affects T3,T4,T5 costochondral junction Similar signs to MI so people may jump to conclusion Joint Dysfunctions

19 Risk factors: women more than men, over 40 years old SX: pain and tenderness in the anterior chest wall, may radiate to the shoulder or arm, aggravated by sneezing, coughing, inspiration, bending, lying down or exertion Signs: pain with palpation over the costochondral joint, *also commonly a structural dysfunction, as something is irritating the cartiatlage COSTOCHONDRITIS

20 Tietze's syndrome is similar to costochondritis. SWELLING only Difference!!! The difference between the two is that there is swelling over the costal cartilage with Tietze's syndrome and not with costochondritis -some research says Tietze may be the “acute” form. Tietze's syndrome

21 Definitions: A lateral curve of the thoracic or lumbar spine or a combination of thoracic and lumbar curves Primary Curve: first curve or earliest curve to appear in the thoracic or lumbar spine Secondary Curve: curve above or below a major curve Scoliosis

22 Major Curve: largest structural curve Minor Curve: smallest curve, more flexible Apical Vertebrae: vertebrae which is furthest from the vertical axis of the vertebrae

23 The vertebrae are at the ends of the curve and are maximally inclined toward the concavity of the curve. a. cephal: most cephal vertebrae maximally inclined toward the concavity b. caudal: most caudal vertebrae maximally inclined toward the concavity End Vertebrae:

24 Rib Hump: Rotation of the thoracic spine which is noted in a flexed position. As the patient flexes forward, the ribs push posterior on one side of a scoliotic curve.

25 Rib Hump

26 Apparent Deviation: Line from the sacrum (gluteal cleft) to the SP of C7. Deviation occurs when there is a linear distance between the vertebrae at C7 from the linear distance at the sacrum. Indicates curve compensation. -how much compensation.

27 Idiopathic: unknown cause 1) infantile: onset less than 3 years of age % will resolve 2) juvenile: 3-10 years of age brace if curve is greater than 30 dg and less than 45 dg surgery if curve is greater than 45 dg after bracing -checked in school 3) adolescent: onset is puberty ~ 10 years of age until skeletal maturity Etiology

28 Paralytic scoliosis: muscle

29 Have “cafe au lait” spots, in ped populaiton. Neurofibromatosis

30 Adult Scoliosis: spinal deformity may be more rigid Spinal stenosis, DDD, osteopenia are associated pathological conditions which may contribute to an increase in Cobb angle SX: pain on the convex side of the curve due to muscle fatigue Adult Scoliosis

31 a. 5 % of all scoliotic curves are greater than 10 dg,.04% exhibit curves greater than 20 dg b. greater the angulation and rotation of the spinal curve, the higher the possibility of curve progression. c. younger the child when diagnosed, the higher the possibility for curve progression Prevalence, Risk factors, Surgical Considerations

32 d. Risser Score of skeletal maturity: score of 1 or less, higher possibility for curve progression -Gives skeletal “age” of a person by epiphyseal plates. e. A shorter curve progresses more f. the higher the curve in the spinal column, the more likely the curve is to progress -No stable base g. the stiffer the curve in an immature individual and the more flexible the curve in a mature individual, the more likely the curve is to progress Likeiness of Curve Progression

33 1. Cobb Method: preferred method of curve measurement. Very consistent between examiners a. caudal and cephal end vertebrae are identified. b. parallel lines to the end plates are drawn into the concavity of the curve c. lines drawn at right angles to the parallel lines will intersect at an angle. d. angle is measured for the degree of curvature Radiographic Assessment

34 Cobb Method. Identify caudel and cephal end vertebrae Draw parallel line Draw perpendicular lines Measure angle of curve

35 Indicates the ossification of the iliac epiphysis which begins at the ASIS and ends at the PSIS *Ossifies Anterior to Posterior a. Grades 0= 0% has closed,1= 25% or less has closed,2 are skeletally immature: 50% or less has yet to ossify b. Grade 3: progressing skeletal maturity: 75% or less has closed c. Grade 4: end of spinal growth, epiphyseal plate has closed but not fused =100% or less has closed d. Grade 5: epiphyseal plate has fused 2. Risser Scale

36 3. Bone age: radiograph of the left wrist and hand and compared to standards set forth by Greulich and Pyle Atlas -compare to a series 4. Moire Thermography: heat pictures, from the muscles Greulich and Pyle Atlas

37 1. Pulmonary function tests: curves greater than 70 dg have a decrease in vital capacity Other Testing:

38 1. Goals of treatment: a. prevent progression and maintain balance b. maintain respiratory function c. reduce pain and preserve neurological status d. Cosmesis- important for the kid e. combo of bracing and physical therapy evidence says is best Management of Scoliosis

39 a. observation in curves less than 25 dg in skeletally immature patients and less than 50 dg in skeletally mature patients b. exercise in combination with bracing may be effective, without a brace has been proven ineffective in stopping the progression of a curve. c. Bracing occurs with any curve greater than 25 dg in a skeletally immature patient Non-operative treatment of scoliosis

40 Milwaukee CTLSO Bracing Milwaukee brace (MWB) or cervical-thoracic-lumbar- sacral orthosis (CTLSO) - curve has an apex at T8 or higher - provides pressure over the point of maximum convexity, traction between the occiput and the pelvis -Tries to stop curve at all parts, for T8 or higher, provides distraction

41 Boston TLSO Bracing Boston Bracing System or thoracolumbar-sacral orthosis (TLSO) - pads are applied laterally below the apex of the curve - no head piece - works best with apex of curve lower than T8

42 Stop curve progression with either type of bracing. The physician will look for a 50% reduction of the curve with the brace on Brace is worn 23 hours a day until a Risser 4 is reached and, if female, two years after menarche Patient will be weaned off brace for 1 year Patient will be followed up with a physician visit every 6 months and repeat x-rays every 12 months Goals

43 Goals: prevent progression of curve - spine and pelvic balance are more important than curve correction - prevent respiratory compromise - prevent back pain or decrease it - cosmesis Indications: progressive curve dg in growing children failure to prevent progression of the curve with bracing or cannot get a 50% correction with the use of a brace progressive curves greater than 50 dg in adults. Surgery

44 Types of Surgery posterior fusion anterior fusion combination of anterior and posterior

45 Instrumentation - Harrington Rod techniques - Drummond's technique using a combination of Harrington Rod's and Luque rods/wires - Luque rod with segmental sublaminar wires - Multiple hook systems

46 Scheuermann's Disease: juvenile kyphosis, vertebral epiphysitis Etiology: may be secondary to repetitive trauma, growth retardation or vascular disturbances are all hypothesis MOI: stress fracture of the anterior aspect of the vertebral endplates. Thoracic Spine Dysfunctions

47 Vertebral wedging of at least 3 consecutive vertebra End plate deformities -box is shorter, angled Scheurmann’s Disease

48 Thoracic kyphosis > 45 deg (25 to 40 deg being normal); Wedging > 5 deg of three adjacent vertebrae Thoracolumbar kyphosis > 30 deg (thoracolumbar spine is normally straight); Scheurmann’s Disease: Diagnostic Criteria

49 DX: lateral radiograph shows decrease in disc height, vertebral end plate irregularities such as Schmorl's nodes may occur Risk factors: adolescents, males and females about equal, autosomal dominant Scheurmann’s Disease

50 SX: back pain, worse with prolonged activity or standing for long periods of time, relieved by rest Signs: acute thoracic kyphosis and an increase in lumbar lordosis, local tenderness to palpation, limited extension & painful, sensory and motor exam is normal Scheurmann’s Disease

51 Conservative RX: Pain At least two more years of skeletal growth remaining Brace Active exercises concentrating on extension, can help prevent,

52 Apical wedging severe deformity with disabling pain Neurologically compromised Continued progression despite conservative treatment Type of surgery: Fusion if the curve is greater than 70 dg and rigid, severe Surgical Candidates:

53 Diffuse Idiopathic Skeletal Hyperostasis, Ankylosis hyperostosis Definition: common disorder, osteophytes develop into bony spurs that may join to form bridges to each other Can occur in thoracic, lumbar or cervical spine Type of Enthesopathy DISH:

54 Ossification of the anterior longitudinal ligament of the spine -there is no anterior space. At least four vertebral levels Preserved disk space *If not 4 then ankylosis DISH

55 Risk factors: NIDDM (type II) diabetes, males 2:1 over females, middle aged or older Onset: insidious SX: back stiffness in the T or L spine, calcaneal pain common, the groups of ossified vertebrae will move as a group Signs: early on the examination is normal, as disease progresses, will see limitation is spinal movements DISH

56 Lab tests: normal or slightly elevated ESR Radiograph: calcification and ossification of the ALL in 4 continuous vertebrae, preservation of disc height, absence of facet ankylosis, SI sclerosis RX: symptomatic, treat similar to OA patients with exercise to maintain mobility especially in the peripheral joints

57 Clinical pattern of pain and parasthesia in one or both UE’s. Head pain can also occur due to embroyonic involvement. May occur alone or in conjunction with other pathology in the T spine Area of Involvement: T2-T7, T4 almost always included Incidence and Prevelence: females > males 79% to 21%. Onset: variable SX: dull aching pain in head, one or both hands, forearms and shoulders can be affected Symptoms are intermittent, variable during time most felt, better with movement T4 Syndrome

58 Signs: Positive palpation findings indicating some restriction of T spine movement Deviation of SP from midline Uneven spacing of SP T4 Syndrome

59 Spondylolysis Definition: fracture of the pars interarticularis, unilateral or bilateral -Most common in Lumbar, but also can occur in thoracic and cervical MOI: stress fracture, non union -like hiking with backpack, or bending forward with gardening so muscle spasms. rhealth/healthgate/getcontent.asp?U RLhealthgate=% html%22

60 a. Posterior elements have a reduced ability to stabilize the spinal unit b. Soft tissue undergoes plastic deformation Etiology: 5% in general population Spondylolysis

61 SX: Related to activity Aching pain in back May radiate toward LE Relieved by rest or decreasing activity Stiffness noted

62 Signs: paravertebral muscle spasm, flattening of the normal lumbar lordosis, tight hamstrings, decrease in SLR motion Radiograph: collar on the Scotty Dog RX: modify activities, primary repair or fusion if patient has unrelenting pain, stabilization exercises Spondylolysis

63 Scottie Dog

64 Body part of DogAnatomical Bone Segment EyePedicle EarSuperior articulating process, ipsilateral NoseTransverse process, ipsi Front PawInferior articulating process, ipsi BodyLamina NeckPars Interarticularis Rear PawInferior articulating process, contra TailSuperior articulating process, contra Scottie Dog

65 Definition: forward slippage of one vertebral body on another, longstanding segmental instability, spondylolysis associated with it Spondylolisthesis

66 Spondylolisthesis

67 Five Types of Spondylolisthesis Type I is called dysplastic spondylolisthesis and is secondary to a congenital defect of either the superior sacral or inferior L5 facets or both with gradual slipping of the L5 vertebra.

68 Type II: Isthmic (Skinny Island) Can be divided into three subcategories Bone defect Elongation of pars Repeated micro fracture Stress spondylolisthesis most likely caused by recurrent micro-fractures caused by hyperextension It is also called a stress fracture of the pars interarticularii much more common in males. Usually a sport related injury: wrestling

69 Type III, is a degenerative spondylolisthesis Occurs as a result of the degeneration of the lumbar facet joints. The alteration in these joints can allow forward or backward vertebral displacement. Five Types of Spondylolisthesis

70 Type IV, traumatic spondylolisthesis, is associated with acute fracture of a posterior element (pedicle, lamina or facets) other than the pars interarticularis.

71 Five Types of Spondylolisthesis Type V pathologic spondylolisthesis occurs because of a structural weakness of the bone secondary to a disease process such as a tumor or other bone diseases.

72 Based on the percent displacement of the superior vertebral body on the inferior vertebral body Grade I: % length of vertebral body slide of superior on inferior Grade II: % may still not need surgery Grade III: % surgery more than likely Grade IV: % (surgery) *Higher the Grade the more Neurological Involvement, so Grade IV is the Worst! Grading System

73 SX: pain in the back, buttock or thigh. unilateral or bilateral aching, pulling, weakness, heaviness, numbness, burning Signs: pain with forward bending, muscle spasms or erector spinae muscles, decrease pain with flexed positions (such as supine with knees bent), increased with extension *Flexion in supine will decrease s(x), but flexion in standing will increase s(x). *Extension will not make it feel better, but if Spondylisis then extension will make it feel better Spondylolisthesis

74 Radiographs: Collar on Scotty Dog - + pars interarticularis fracture, lateral flexion radiograph shows the slippage RX: conservative for 6 months, PT for pain management, lumbar stabilization, may brace in grades II and III Spondylolisthesis

75 Surgery: if it is a grade III or more and conservative treatment has failed Goals of surgery: prevent further slippage, stabilize an unstable segment, prevention of neurological deficits, pain relief, cosmetic, posture and gait improvement Spondylolisthesis

76 Ankylosing Spondylitis Marie Strumpell disease, rheumatoid spondylitis Definition: chronic inflammatory arthritis which leads to deformity and fusion of the spine 76

77 Risk Factors: years of age, males 3:1 over females (fusion of entire spins in 20 years) Onset: insidious complaints are related to spinal movements or sacroilitis 77 Ankylosing Spondylitis

78 Lab Tests: 95% have a +HLA- B27 human leukocyte antigen Medical Diagnosis: back pain greater than 3 months decrease in spinal motion decrease in chest expansion sacroilitis peripheral joint problems Ankylosing Spondylitis 78

79 Radiograph: Ankylosing Spondylitis bamboo spine in advanced stages SI fusion in one or both sides is earliest sign 79 Should be line, rather solid mass

80 80 Clinical Manifestations: Ankylosing Spondylitis Symptoms: spinal pain/stiffness worse in am or after resting pain/stiffness improves with exercise Signs: normal neurological screen SI tenderness + FABER's test decrease in lumbar lordosis rib expansion less than 2 cm

81 81 Ankylosing Spondylitis PT Interventions: pain relief, maintenance of mobility, swimming Surgical Interventions: peripheral joint disease - THR Fixed Flexion deformity

82 Review: Disc Herniation Review Definitions Bulge Protrusion Extrusion Sequestration Herniation Review Signs and Symptoms of a Disc Herniation

83 83 T1-2: 1) clinical symptoms 2) signs: Motor Sensory Reflexes

84 T2 - T11: Specific to T and L spine Thoracic discs are very stable and herniations in this region are quite rare. Herniation of the uppermost thoracic discs can mimic cervical disc herniations, while herniation of the other discs can mimic lumbar herniations. Radiation of pain around the rib cage (dermatome pattern) can also occur 84

85 T12 - L3: Reflexes: none MMT: iliopsoas, quadriceps, adductors Dermatome pattern: specific to each nerve root Lumbar Spine: Most common areas are L4-5 and L5-S1 85


87 L4 Reflex: Quadriceps MMT: tibialis anterior Sensation: medial aspect of foot to big toe 87

88 L5: Reflex: Medial hamstring MMT: EHL Sensation: middle toes, dorsum of foot, big toe 88

89 S1: Reflex: Achilles MMT: peroneus longus and brevis, gastroc soleus, gluteus maximus Sensation: little toe, outside of calf, lateral aspect and plantar surface of foot 89

90 Decompression Back Surgery Small portion of the bone over the nerve root and/or disc material from under the nerve root is removed to give the nerve root more space and provide a better healing environment. Spinal Surgeries

91 Microdiscetomy Best for treating radiculopathies rather than back pain

92 Open Decompression Laminectomy: Indications: spinal stenosis, herniated disc Remove lamina and facet joints are trimmed a bit to give nerve more room Success rate: 70-80% improve function, decrease back/leg pain

93 treatment kyphoplasty

94 Spinal Fusion

95 Special Views Swimmers View Oblique Views Utilized for viewing the sternum Coned Views of thoracolumbar region or other specialized areas Standard Views AP View Lateral View Thoracic Spine: Radiographic Views

96 Radiology Thoracic spine radiology 1.Anteroposterior view: 2.*Know by the heart on the left side visible. Thoracic vertebral bodies The intervertebral disc spaces Alignment of the pedicles Spinous processes Transverse processes Articular processes and the Costovertebral joints Posterior ribs.

97 Bone Density: In this view, check each vertebral body, does one or two or many of them appear to have a different radiolucency than the others? Alignment: In this view, pay attention to the position of the pedicles, they will indicate any rotation of the thoracic spine Symmetry of the vertebral bodies: any change in symmetry or curve of the spine Keys to viewing

98 Disc Height should appear similar as you move down the spine Cartilage: SC joints are easily seen due to overlay of vertebral spine Costovertebral joints can be seen – better in upper thoracic than lower Cartilage Space and Disc Height

99 Lungs should appear black due to the amount of air This view is often used to detect the presence of pneumonia as lungs won’t be as dark Heart shadow should be on the patient’s left side Diaphragm should be overshadowing the lower ribs and vertebral spine Soft Tissue

100 Rotation of the spine is determined by the position of the pedicles in relation to midline. The closer to the midline a pedicle is, the more rotation is occurring to that side. Distance between the pedicles represents the transverse diameter of the spinal canal (Nash CL, Moe JH. A study of vertebral rotation. J Bone Jt Surg Am 1969;51: ) Pedicle Position:

101 Nash-Moe Method

102 0 = no rotation of the vertebral body 1 or + = minimal rotation of the vertebral body 2 or ++ = pedicles on the concave side of the spinal curve rest on or near the margin of the vertebral body 3 or +++ = only one pedicle is seen and it is nearing the midline 4 or ++++ = the only visible pedicle is seen beyond the midline of the vertebral column Grade Pedicle Displacement

103 2. Lateral view: Demonstrates the thoracic vertebral bodies, intervetebral disc space First 2-3 vertebrae are not easily seen because of the shoulder and scapula being interposed between the body and the film. *Swimmers view gets the arm up and out of the way

104 3 column classification system by McAfee This picture includes a little more of the posterior structures than the one in the book Alignment pediatrics/pemxray/v6c13.html

105 A lateral view with arm closest to film is raised to see vertebrae C7-T1. *Therefore wrong view for Justin as his pain is T7. Swimmer's View

106 Highly effective and accurate in diagnosis of fracture 2-mm axial sections has a confidence level of 98% that a fracture will be seen (Nadalo, Moody, 2007) Picks up problems with the posterior elements best Evaluates spinal canal well Axial CT’s may miss small compression fractures Computed Tomography

107 Superior to CT scans in detecting herniated disk, ligamentous edema and spinal cord compression: see arrows Does not pick up bone fractures as well as CT Minimally displaced fractures are difficult to see Magnetic Resonance Imaging full/69/24/E41/F117

108 Herniation of the disc through the end plate of the vertebral body May or may not be symptomatic Schmorl Nodes

109 MRI T2 sagittal image of large schmorl node Axial CT More schmorl nodes

110 Standard Views: AP or PA Above Diaphragm or below Diaphragm Anterior Oblique Posterior Oblique Rib radiology

111 AP: posterior ribs are closest to the film cassette PA: anterior ribs are closest to the film cassette -used to look at lungs for pneumonia Also, note views are taken as above the diaphragm or below the diaphragm Anteroposterior (AP) or Posterioanterior (PA)

112 Alignment: Thoracic vertebrae Pedicles Ribs Density: Uniformity of bone appearance

113 Standard AP viewOblique View Rib Fractures These are the same patient, elderly female, minor fall

114 Black arrow – rib fracture White arrows – pneumothorax Axial CT of Rib Cage and Lungs

115 Ultrasound and Rib Fractures

116 Oblquies: Scooty Dogs -will have a lateral view -Also cone-in view for L5 and Sacrum -look for where heart is, and it should be listed on the X-ray. Lumbar Spine

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