1 J hHkiO hdi S Cervical Spine Trauma Johns Hopkins Orthopaedic Surgery Review Course A. Jay Khanna, MD The Johns Hopkins Medical Institutions Department of Orthopaedic Surgery Baltimore, Maryland Disclosures Consultant/Teaching Zimmer SpineZimmer Spine Kyphon, Inc./Medtronic OrthoFix/Blackstone Medical Speaker Bureau AO S iNth AiAO Spine North America Equity New Era Orthopaedics, LLC 2 Key Points 1.Dermatome and Innervation Review 2.Importance of Transverse Ligament 3.Use of Powers Ratio in A-O Dislocation 4.Diagnosis and Tx of Jefferson Fracture 5.Type II Odontoid Fracture and When to Operate 6.Differentiate and Treat Type II and Type II A Hangman Fractures 7.Differentiate and Treat UFD and BFD OITE, 2006 3 OITE, 2003 Injury to the C7 nerve root results in weakness primarily of the 1- wrist flexors and finger flexors. 2- elbow flexors and wrist flexors. 3- elbow flexors and finger flexors. 4- elbow extensors and wrist flexors. 5- elbow extensors and wrist extensors. 4 What is the most significant factor leading to nonunion when a halo vest is used to treat a type II fracture at the base of the odontoid? 1- Diabetes 2- Osteoporosis 3- Extension injury 4- Age older than 65 years 5- Displacement more than 5 mm Which of the following is considered an appropriate surgical indication for management of acute type II odontoid fractures? 1-A fracture pattern with a frontal oblique orientation 2-A sagittal oblique fracture that may extend into the body of dens 3-A patient with osteoporosis 4-Displacement of 2 mm and any posterior angulation 5-An initial displacement of greater than 5 mm 5 Neural Anatomy 8ilt 8 cervical roots Each cervical root exits the c-spine above the pedicle of the matching vertebrae The remainder of the spine roots all exit the canal under the corresponding pedicle Physical Examination CTQ C6 Browner, Jupiter. Skeletal Trauma, 2nd Edition, 1998. 6 Physical Examination CTQ Browner, Jupiter. Skeletal Trauma, 2nd Edition, 1998. Physical Examination CTQ Browner, Jupiter. Skeletal Trauma, 2nd Edition, 1998. 7 Upper Cervical Spine Anatomy Browner, Jupiter. Skeletal Trauma, 2nd Edition, 1998. Ligaments Primary Restraint: Transverse (Atlantal) Ligament CTQ (Atlantal) Ligament 3-5mm ADI implies rupture of primary restraint Secondary Restraint: Alar & Apical Ligaments 5mm ADI implies rupture of primary and secondary restraints 8 Upper Cervical Spine Fractures 6.9 mm Treatment Controversial 1. Traction x 6-8 weeks f/b 6 weeks Halo 2. Halo Vest Only Flex-Ex after Halo Removed -Tx C1-C2 Instability ( 5 mm) with Fusion Tay, Eismont. OKU: Spine 2, 2002 Browner, Jupiter. Skeletal Trauma, 2nd Edition, 1998. CTQ C1 (Atlas) Fracture Browner, Jupiter. Skeletal Trauma, 2nd Edition, 1998. 12 C1-2 Subluxation (Atlantoaxial Instability) -occurs d/t transverse ligament ruptureoccurs d/t transverse ligament rupture -increased atlantodens interval 5 mm treated w/ C1-2 fusion -ligament injury w/o fx rare Miller, MD. Review of Orthopaedics, 3rd Edition, 2000. Browner, Jupiter. Skeletal Trauma, 2nd Edition, 1998. Odontoid Fracture Browner, Jupiter. Skeletal Trauma, 2nd Edition, 1998. 13 Odontoid Fracture -Most Common Mechanism: Flexion (80%)() -Type I (2-3%) -usually upper tip -usually stable if displacement 10 degrees -displacement 5 mm -age 60-65 years (OKU: 40 years) -smoking -nonunion rate reported as high as 88% (average 33%) -associated w/ C1 Fx in 16% Miller, MD. Review of Orthopaedics, 3rd Edition, 2000. An H. Principles & Techniques of Spine Surgery. 1998. Browner, Jupiter. Skeletal Trauma, 2nd Edition, 1998. Tay, Eismont. OKU: Spine 2, 2002 14 Odontoid Fracture Type II (60%)Type II (60%) -Treatment -Nondisplaced ( Halo x 8-12 weeks -Two or more risk factors: PSF of C1-2 Odontoid screwOdontoid screw Miller, MD. Review of Orthopaedics, 3rd Edition, 2000. Browner, Jupiter. Skeletal Trauma, 2nd Edition, 1998. Tay, Eismont. OKU: Spine 2, 2002 CTQ Odontoid Fracture Type III -high healing rate d/t greater cancellous bony overlap and rarity of fracture distraction -treated w/ closed reduction & halo x 8-12 weeks 13% Nonunion Rate-13% Nonunion Rate -15% Malunion Rate Miller, MD. Review of Orthopaedics, 3rd Edition, 2000. An H. Principles & Techniques of Spine Surgery. 1998. Browner, Jupiter. Skeletal Trauma, 2nd Edition, 1998. Tay, Eismont. OKU: Spine 2, 2002 15 C2 Isthmus (Hangmans) Fracture -Mechanism: Hyperextension + axial load + rebound flexion -Neuro injury uncommon -Often associated w/ other C-Spine injuries Type I -vertical fracture w/ no angulation -Tx: Rigid orthosis x 8-12 weeks Miller, MD. Review of Orthopaedics, 3rd Edition, 2000. Browner, Jupiter. Skeletal Trauma, 2nd Edition, 1998. C2 Isthmus (Hangmans) Fracture Type II-Type II 3mm translation 11oangulation -associated with wedge compression of anterior-inferior C2 VB Miller, MD. Review of Orthopaedics, 3rd Edition, 2000. Browner, Jupiter. Skeletal Trauma, 2nd Edition, 1998. Tay, Eismont. OKU: Spine 2, 2002 16 C2 Isthmus (Hangmans) Fr