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An orthopaedic overview Review of anatomy Cervical Spine ◦ Review of conditions/ management Thoracic spine ◦ Review of condition/ management Lumbar Spine ◦ Review of conditions/ management Degenerative Disc Disease Traumatic Conditions ◦ ◦ ◦ ◦ ◦ Nerve root - burners Whiplash Muscle strains Torticollis Ligament instability/ segmental instability Atlanto-axial, other ◦ Neck fractures Type 1, 2, 3, hangman ◦ Prolapse of disc Degenerative Disc Disease ◦ Gradual onset of wear and tear on disc from loads ◦ Decreased height of disc due to loss of water content ◦ Tearing of outer fibrotic layers of disc (annulus) ◦ Increases likelihood of nucleus tracking into the outer layers and creating bulges ◦ Symptoms include chronic neck pain, possible neurological features from nerve root pressure ◦ Associated osteophyte formation b/w vertebrae especially at facet joints Xray findings- loss of intervertebral spacing, osteophyte formation b/w vertebrae and at facet joints Treatment: symptomatic, short or long-term analgesia, physiotherapy for ROM, mobilization, strengthening, avoid aggravating activities: loading spine etc. MOI: A distraction or stretch injury causing a momentary stretch injury to the upper cords of the brachial plexus. The extended C-spine is compressed and rotated toward the painful arm. Injury occurs because the cervical nerves are tethered by fibrous tissue between the vertebral arteries and the distal foramina at each cervical level. These dentate ligament attachments become taut and stretch the cervical nerve roots as they leave the spine. Arm weakness and burning sensation from 2 minutes to 24 hours Self-limiting Symptoms reproduced by Spurling test Forceful abrupt movement of neck Hyper-extension, flexion, lateral Headache, neck pain stiffness, paraesthesia, radiating pain to shoulders, dizziness Quebec severity classification of Whiplash Associated Disorders (WAD) Assess for C/S fracture, instability (on scene and imaging) refer to Canadian C-Spine Rules Rest/ ice, NSAIDs, restricted activity, physiotherapy to progress and mobilize Refers to flexion and rotation of neck due to muscle contraction: often due to acute neck injury Spasmotic Torticollis: refers to chronic neurological disorder causing involuntary movements of the neck/head (dystonia) Predominately idiopathic, some secondary causes Onset b/w 30-50 yrs, strong family history Evaluation: neurological assessment, review of meds, ROS, Referral for specialist assessment and imaging Treatment: multi-faceted, targeted at involved muscles, underlying conditions Atlanto-axial (C1/C2) (>3mm spacing) Traumatic vs. degenerative (RA), congenital (connective tissue disease) Instability can cause cord compression Symptoms: coordination, gait, neck pain, sensory changes, upper motor neuron sign Assess symptoms, immobilize and image if acute onset post trauma. (Canadian C-Spine rules) Requires emergency and surgical evaluation if confirmed instability Simple wedge fracture o Fracture of the anterosuperior end plate of the vertebral body o Associated with posterior ligament disruption, which makes the injury unstable o Differs from a burst fracture because no vertical element to the fracture is present Anterior teardrop fracture o Teardrop fracture with an anteroinferior vertebral body fragment o Unstable fracture associated with complete disruption of ligaments o Associated with anterior cord syndrome Clay shoveller's fracture o Avulsion of spinous process of the lower cervical vertebrae, usually C7 o Stable fracture Atlantooccipital and atlantoaxial dislocation with fracture o High instability o High mortality Bilateral facet dislocation with fracture Anterior arch of the atlas (avulsion fracture) – Unstable fracture Posterior arch of the atlas fracture o Compression between the axis and occiput o High association with other fractures Hangman's fracture o C2 pedicles with anterior displacement o Common in diving accidents o NOTE: The patient may be without neurologic deficit, but this is an unstable fracture Laminar fracture o Subtle fracture associated with spinous process fractures o Stable fracture Extension teardrop fracture o Anteroinferior vertebral body fracture from an avulsion by the anterior longitudinal ligament o Most common at C2 o Unstable fracture Pillar fracture o Vertical or oblique fracture of the articular mass o Stable fracture Pediculolaminar fracture o Variety of severities o Associated ligamentous injuries Jefferson fracture o The occipital condyles are driven into C1, forcing the lateral masses apart. o Often associated with rupture of the transverse ligament o Unstable fracture Burst fracture o Axial lode causes the vertebral body to burst. o Involves both end plates and may intrude into the spinal canal o Unstable fracture Spear tackler's spine o Associated with use of the head as the initial contact in football o Over time, athletes develop cervical stenosis, posttraumatic changes, and loss of cervical lordosis. o Traumatic axial compression can cause compression of the anterior column, followed by flexion, resulting in a fracture. o o o Type I – At the tip superiorly. The transverse ligament remains intact, and the fracture is stable. Type II – At the junction of the odontoid and the body. This is the most common type of odontoid fracture. Type III – Through the superior portion of C2 at the base of the odontoid Approach with suspicion. Consider ABCs from the beginning. Obtain the history (i.e. MOI) before the physical examination or movement of the patient. Determine location and quality of any pain. Ask if the pain radiates distally or to the extremities. Paresthesias or weakness. Other distracting injuries, HI, or drugs. Palpate the neck, and specifically feel for midline bony pain, muscle spasm, step-off, and crepitus. Determine if extremity sensation is intact. Have athlete move all extremities without deficits. Determine if the athlete can perform range of motion (ROM) in all directions without pain or symptoms. NOTE: Do not perform passive ROM of the neck. Determine if head compression elicits pain or symptoms. Refers to disruption of annulus of intervertebral disc with extrusion of nucleus pulposus material Traumatic rupture with forced neck movement May result in compression of nerve roots Full C/S and upper extremity exam including neurological exam: Myotomes, Dermatomes, Reflexes May immobilize to reduce pain and muscle spasm Evaluation by physician, surgical team if hard neurological findings Alert (GCS 15) and stable trauma pts High Risk factor: age>65, numbness in ext, dangerous mech (fall>3 ft, axial load, >100km/hr MVC, rollover, ejection ◦ Yes= immobilize and image Low Risk factors (allow exam): simple rearend, sitting in ED, Ambulatory, Delayed onset neck pain, absent midline tenderness ◦ Yes=voluntary ROM to 45 L and R (regardless of pain) Yes/Able= no immobilization, No=immobilize ◦ Not low risk (no ROM exam) = immobilize *Simple excludes pushed into traffic, hit by bus/truck/high speed vehicle, or rollover Fractures of ribs/ sternum Fractures of vertebrae Costochondritis Direct trauma, consider force and impact on underlying lung tissue (contusion/ hemothorax) vs. pathological fracture Single vs. multiple ( flail etc) Assess vitals acutely and in repeated follow up Clinical exam and Xray for underlying lung injury Treatment: splinting, analgesia, restrictions Expect 4-6 wks healing Blunt anterior chest trauma Symptoms: local pain, dyspnea, palpitations Assess for unstable patients (vitals) Examine for associated and underlying injury Treatment: oxygen, IV access, analgesic, evacuation for additional testing (xray, ecg, fixation) Most do not require fixation 4 types 1. Compression: anterior aspect of body, stable 2. Burst: whole body +/- unstable 3. Flexion/distraction: spinous process, pedicle and vertebral body 4. Fracture/dislocation: high force in various directions (flex/ ext, rotation, shear) Chest wall pain arising from costochondral joints Idiopathic abrupt onset , often 2nd or 3rd rib involved Ages 20-40 Aggravated by chest wall movement/ respiration Pain may radiate to shoulders Exam: swelling of joint with overlying erythema, painful to palpation Treat with NSAIDS, ice, rest from activity that loads/stresses the joint Degenerative Disc Disease (DDD) ◦ Loss of vertebral disc height with aging and accelerated by increased loads ◦ Bulging and tearing of annulus fibrosis ◦ Change in alignment of facet joints ◦ Osteophyte formation Clinical: lower back pain, poorly localized, dull to sharp pain, acute exacerbations of chronic symptoms with associated with activity Exam: decreased AROM, no local tenderness, +/- muscle spasm Treatment: conservative, rest, modified activity, NSAIDS, muscle relaxant prn, physiotherapy, core strengthening Rarely surgical decompression +/- fusion Acute onset following repeated flexion loading or single heavy flexion load Tear in annulus fibrosis allows protrusion of nucleus pulposus causing disc herniation Most common levels: L5-S1 >L4-L5 >L3-L4 Lateral herniation produces predominately leg symptoms (sciatica) Central herniation produces predominately back pain: large may produce Cauda Equina syndrome- immediate surgical evaluation for decompression +/- muscle spasm Neurological testing: decreased power, sensation, reflex in affected nerve root distribution, Saddle Symptoms +ve SLR, femoral nerve stretch Treatment: Rest, NSAIDS, Physiotherapy, Consider MRI and surgical consult if “hard” neurological findings Defect in the pars interarticularis of the vertebral arch Most occur at L5; may be one or both sides Often asymptomatic in screening studies Axial LBP with radiation into legs, sudden or gradual, worsen with activity Hyperlordosis and tight hamstrings One legged hyperextension maneuver is probably less specific and sensitive than once thought Dx with X-ray Conservative, but long, treatment Defect in the pars interarticularis of the vertebral arch on both sides allows body of vertebra to slip Grade 1: 1- 25% slippage Grade 2: 26-50% slippage Grade 3: 51-75% slippage Grade 4: 76-100% slippage Grade 5: Greater than 100% slippage Back pain not due to prolapsed disc or other defined pathology Aggravated by activity No neurological findings Treatment: symptomatic, restricted activities, physiotherapy Causes: mechanical, disc prolapse, traumafracture, exacerbation of chronic condition. Rule out pathological process: neoplasm, inflammatory, infectious referred- abdominal aortic aneurysm Identify and treat underlying condition Let’s take a break.
