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Upper Extremity Trauma How do fractures heal? 2 Fracture healing Why do fractures unite? Because the bone is broken! 3 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 4 Healing cascade Late repair: Fibrous tissue replaced by cartilage Endochondral ossification Periosteal healing » membranous ossification 5 What is the difference between direct and indirect bone healing? 6 Indirect healing – healing by Callus Unstable Callus stabilises # Direct healing between cortices 7 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 8 What are the aims of fracture treatment? 9 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 10 What factors effect fracture healing? 11 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 12 Upper Extremity Trauma 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 14 Topics Clavicle Shoulder Dislocation Humerus Elbow Forearm Distal Radius Clavicle Fractures Clavicle Fractures Mechanism – Fall onto shoulder (87%) – Direct blow (7%) – Fall onto outstretched hand (6%) Trimodal distribution 80 70 60 50 40 Percent 30 20 10 0 Group I (13yrs) Group 2 (47yrs) Group 3 (59yrs) The clavicle is the last ossification center to complete (sternal end) at about 22-25yo. Clavicle Fractures Clinical Evaluation – Inspect and palpate for deformity/abnormal motion – Thorough distal neurovascular exam – Auscultate the chest for the possibility of lung injury or pneumothorax Radiographic Exam – AP chest radiographs. – Clavicular 45deg A/P oblique X-rays Clavicle Fractures Allman Classification of Clavicle Fractures – Type I Middle Third (80%) – Type II Distal Third (15%) Differentiate whether ligaments attached to lateral or medial fragment – Type III Medial Third (5%) Clavicle Fracture Closed Treatment – Sling immobilization for usually 3-4 weeks with early ROM encouraged Operative intervention – – – – – – Fractures with neurovascular injury Fractures with severe associated chest injuries Open fractures Group II, type II fractures Cosmetic reasons, uncontrolled deformity Nonunion Clavicle Fractures Associated Injuries – Brachial Plexus Injuries Contusions most common, penetrating (rare) – Vascular Injury – Rib Fractures – Scapula Fractures – Pneumothorax Shoulder Dislocations Shoulder Dislocations Epidemiology – Anterior: Most common – Posterior: Uncommon – Inferior (Luxatio Erecta), hyperabduction injury Shoulder Dislocations Clinical Evaluation – Examine axillary nerve (deltoid function, not sensation over lateral shoulder) – Examine biceps function and anterolateral forearm sensation Radiographic Evaluation – – – – True AP shoulder Axillary Lateral Scapular Y Stryker Notch View (Bony Bankart) Shoulder Dislocations Anterior Dislocation Recurrence Rate – Age 20: 80-92% – Age 30: 60% – > Age 40: 10-15% Look for Concomitant Injuries – Bony: Bankart, Hill-Sachs Lesion, Glenoid Fracture, Greater Tuberosity Fracture – Soft Tissue: Subscapularis Tear, RCT (older pts with dislocation) – Vascular: Axillary artery injury (older pts with atherosclerosis) – Nerve: Axillary nerve neuropraxia Shoulder Dislocations Anterior Dislocation – Traumatic – Atraumatic (Congenital Laxity) – Acquired (Repeated Microtrauma) Shoulder Dislocations Posterior Dislocation – Adduction/Flexion/IR at time of injury – Look for “lightbulb sign” and “vacant glenoid” sign – Reduce with traction and gentle anterior translation (Avoid ER arm Fx) Shoulder Dislocations Inferior Dislocations Luxatio Erecta – Hyperabduction injury – Arm presents in a flexed “asking a question” posture – High rate of nerve and vascular injury – Reduce with in-line traction and gentle adduction Shoulder Dislocation Treatment – Nonoperative treatment Closed reduction should be performed after adequate clinical evaluation and appropriate sedation – Reduction Techniques: Traction/countertraction- Generally used with a sheet wrapped around the patient and one wrapped around the reducer. Hippocratic technique- Effective for one person. One foot placed across the axillary folds and onto the chest wall then using gentle internal and external rotation with axial traction Stimson technique- Patient placed prone with the affected extremity allowed to hang free. Gentle traction may be used Milch Technique- Arm is abducted and externally rotated with thumb pressure applied to the humeral head Scapular manipulation Shoulder Dislocations Postreduction – Post reduction films are a must to confirm the position of the humeral head – Pain control – Immobilization for 7-10 days then begin progressive ROM Operative Indications – – – – Irreducible shoulder (soft tissue interposition) Displaced greater tuberosity fractures Glenoid rim fractures bigger than 5 mm Elective repair for younger patients Proximal Humerus Fractures Proximal Humerus Fractures Epidemiology – Most common fracture of the humerus – Higher incidence in the elderly, thought to be related to osteoporosis – Females 2:1 greater incidence than males Mechanism of Injury – Most commonly a fall onto an outstretched arm from standing height – Younger patient typically present after high energy trauma Proximal Humerus Fractures Clinical Evaluation – Patients typically present with arm held close to chest by contralateral hand. Pain and crepitus detected on palpation – Careful NV exam is essential, particularly with regards to the axillary nerve. Test sensation over the deltoid. Deltoid atony does not necessarily confirm an axillary nerve injury Proximal Humerus Fractures Neer Classification – Four parts Greater and lesser tuberosities, Humeral shaft Humeral head – A part is displaced if >1 cm displacement or >45 degrees of angulation is seen Proximal Humerus Fractures Treatment – Minimally displaced fractures- Sling immobilization, early motion – Two-part fractures Anatomic neck fractures likely require ORIF. High incidence of osteonecrosis Surgical neck fractures that are minimally displaced can be treated conservatively. Displacement usually requires ORIF – Three-part fractures Due to disruption of opposing muscle forces, these are unstable so closed treatment is difficult. Displacement requires ORIF. – Four-part fractures In general for displacement or unstable injuries ORIF in the young and hemiarthroplasty in the elderly and those with severe comminution. High rate of AVN (13-34%) Humeral Shaft Fractures Humeral Shaft Fractures Mechanism of Injury – Direct trauma is the most common especially MVA – Indirect trauma such as fall on an outstretched hand – Fracture pattern depends on stress applied Compressive- proximal or distal humerus Bending- transverse fracture of the shaft Torsional- spiral fracture of the shaft Torsion and bending- oblique fracture usually associated with a butterfly fragment Humeral Shaft Fractures Clinical evaluation – Thorough history and physical – Patients typically present with pain, swelling, and deformity of the upper arm – Careful NV exam important as the radial nerve is in close proximity to the humerus and can be injured Humeral Shaft Fractures Radiographic evaluation – AP and lateral views of the humerus – Traction radiographs may be indicated for hard to classify secondary to severe displacement or a lot of comminution Humeral Shaft Fractures Conservative Treatment – Goal of treatment is to establish union with acceptable alignment – >90% of humeral shaft fractures heal with nonsurgical management 20 degrees of anterior angulation, 30 degrees of varus angulation and up to 3 cm of shortening are acceptable Most treatment begins with application of a coaptation spint or a hanging arm cast followed by placement of a fracture brace Humeral Shaft Fractures Treatment – Operative Treatment Indications for operative treatment include inadequate reduction, nonunion, associated injuries, open fractures, segmental fractures, associated vascular or nerve injuries Most commonly treated with plates but also IM nails Humeral Shaft Fractures Holstein-Lewis Fractures – Distal 1/3 fractures – May entrap or lacerate radial nerve as the fracture passes through the intermuscular septum Elbow Fracture/Dislocations Elbow Dislocations Epidemiology – Accounts for 11-28% of injuries to the elbow – Posterior dislocations most common – Highest incidence in the young 10-20 years and usually sports injuries Mechanism of injury – Most commonly due to fall on outstretched hand or elbow resulting in force to unlock the olecranon from the trochlea – Posterior dislocation following hyperextension, valgus stress, arm abduction, and forearm supination – Anterior dislocation ensuing from direct force to the posterior forearm with elbow flexed Elbow Dislocations Clinical Evaluation – Patients typically present guarding the injured extremity – Usually has gross deformity and swelling – Careful NV exam in important and should be done prior to radiographs or manipulation – Repeat after reduction Radiographic Evaluation – AP and lateral elbow films should be obtained both pre and post reduction – Careful examination for associated fractures Elbow Fracture/Dislocations Treatment – Posterior Dislocation Closed reduction under sedation Reduction should be performed with the elbow flexed while providing distal traction Post reduction management includes a posterior splint with the elbow at 90 degrees Open reduciton for severe soft tissue injuries or bony entrapment – Anterior Dislocation Closed reduction under sedation Distal traction to the flexed forearm followed by dorsally direct pressure on the volar forearm with anterior pressure on the humerus Elbow Dislocations Associated injuries – Radial head fx (5-11%) – Treatment Type I- Conservative Type II/III- Attempt ORIF vs. radial head replacement Elbow Dislocations Associated injuries – Coronoid process fractures (5-10%) Elbow Dislocations Associated injuries – Medial or lateral epicondylar fx (12-34%) Elbow Dislocations Instability Scale – Type I Posterolateral rotary instability, lateral ulnar collateral ligament disrupted – Type II Perched condyles, varus instability, ant and post capsule disrupted – Type III A: posterior dislocation with valgus instability, medial collateral ligament disruption B: posterior dislocation, grossly unstable, lateral, medial, anterior, and posterior disruption Forearm Fractures Forearm Fractures Epidemiology – Highest ratio of open to closed than any other fracture except the tibia – More common in males than females, most likely secondary mva, contact sports, altercations, and falls Mechanism of Injury – Commonly associated with mva, direct trauma and falls Forearm Fractures Clinical Evaluation – Patients typically present with gross deformity of the forearm and with pain, swelling, and loss of function at the hand – Careful exam is essential, with specific assessment of radial, ulnar, and median nerves and radial and ulnar pulses – Tense compartments, unremitting pain, and pain with passive motion should raise suspicion for compartment syndrome Radiographic Evaluation – AP and lateral radiographs of the forearm – Don’t forget to examine and x-ray the elbow and wrist Forearm Fractures Ulna Fractures – These include nightstick and Monteggia fractures – Monteggia denotes a fracture of the proximal ulna with an associated radial head dislocation Monteggia fractures classification- Bado Type I- Anterior Dislocation of the radial head with fracture of ulna at any level- produced by forced pronation Type II- Posterior/posterolateral dislocation of the radial head- produced by axial loading with the forearm flexed Type III- Lateral/anterolateral dislocation of the radial head with fracture of the ulnar metaphysis- forced abduction of the elbow Type IV- anterior dislocation of the radial head with fracture of radius and ulna at the same level- forced pronation with radial shaft failure Monteggia fractures Forearm Fractures Radial Diaphysis Fractures – Fractures of the proximal two-thirds can be considered truly isolated – Galeazzi or Piedmont fractures refer to fracture of the radius with disruption of the distal radial ulnar joint Mechanism – Usually caused by direct or indirect trauma, such as fall onto outstretched hand – Galeazzi fractures may result from direct trauma to the wrist, typically on the dorsolateral aspect, or fall onto outstretched hand with pronation Galeazzi fracture Distal Radius Fractures Distal Radius Fractures Distal Radius Fractures Epidemiology – Most common fractures of the upper extremity – Common in older patients. Usually a result of direct trauma such as fall on out stretched hand – Increasing incidence due to aging population Mechanism of Injury – Most commonly a fall on an outstretched extremity with the wrist in dorsiflexion – High energy injuries may result in significantly displaced, highly unstable fractures Distal Radius Fractures A severe Colles fracture may assume a bayonet-like displacement. Distal Radius Fractures Clinical Evaluation – Patients typically present with gross deformity of the wrist with variable displacement of the hand in relation to the wrist. Typically swollen with painful ROM – Ipsilateral shoulder and elbow must be examined – NV exam including specifically median nerve for acute carpal tunnel compression syndrome Radiographic Evaluation 3 view of the wrist including AP, Lat, and Oblique – Normal Relationships 23 Deg 11 Deg 11 mm Distal Radius Fractures Eponyms – Colles Fracture Combination of intra and extra articular fractures of the distal radius with dorsal angulation (apex volar), dorsal displacement, radial shift, and radial shortenting Most common distal radius fracture caused by fall on outstretched hand – Smith Fracture (Reverse Colles) Fracture with volar angulation (apex dorsal) from a fall on a flexed wrist – Barton Fracture Fracture with dorsal or volar rim displaced with the hand and carpus – Radial Styloid Fracture (Chauffeur Fracture) Avulsion fracture with extrinsic ligaments attached to the fragment Mechanism of injury is compression of the scaphoid against the styloid Distal Radius Fractures Treatment – Displaced fractures require and attempt at reduction. Hematoma block-10ccs of lidocaine or a mix of lidocaine and marcaine in the fracture site Hang the wrist in fingertraps with a traction weight Reproduce the fracture mechanism and reduce the fracture Place in sugar tong splint – Operative Management For the treatment of intraarticular, unstable, malreduced fractures. As always, open fractures must go to the OR. Spinal Trauma Topics Introduction to Spinal Injuries Spinal Anatomy and Physiology Pathophysiology of Spinal Injury Assessment of the Spinal Injury Patient Management of the Spinal Injury Patient Introduction to Spinal Injuries Annually 15,000 permanent spinal cord injuries Commonly men 16–30 years old Mechanism of Injury – – – – Vehicle crashes: 48% Falls: 21% Penetrating trauma: 15% Sports injury: 14% 25% of all spinal cord injuries occur from improper handling of the spine and patient after injury. – ASSUME based upon MOI that patients have a spinal injury. – MANAGE ALL spinal injuries with immediate and continued care. Lifelong care for spinal cord injury victim exceeds $1 million. Best form of care is public safety and prevention programs. Spinal Anatomy and Physiology Vertebral Column 33 bones comprise the spine. Function: – Skeletal support structure – Major portion of axial skeleton – Protective container for spinal cord Vertebral Body: – Major weight-bearing component – Anterior to other vertebrae components Spinal Anatomy and Physiology Vertebral Column Spinal Anatomy and Physiology Vertebral Column Size of Vertebrae – C-1 and C-2: No vertebral body Support head Allow for turning of head – Vertebral body size increases the more inferior they become. Lumbar spine strongest and largest – Bear weight of the body – Sacral and coccyx vertebrae are fused. No vertebral body Spinal Anatomy and Physiology Vertebral Column Components of Vertebrae – Spinal Canal Opening in the vertebrae that the spinal cord passes through – Pedicles Thick, bony structures that connect the vertebral body to the spinous and transverse processes – Laminae Posterior bones of vertebrae that make up foramen – Transverse Process Bilateral projections from vertebrae Muscle attachment and articulation location with ribs Spinal Anatomy and Physiology Vertebral Column Components of Vertebrae – Spinous Process Posterior prominence on vertebrae – Intervertebral Disk Cartilaginous pad between vertebrae Serves as shock absorber Spinal Anatomy and Physiology Vertebral Column Vertebral Ligaments – Anterior Longitudinal Anterior surface of vertebral bodies Provides major stability of the spinal column Resists hyperextension – Posterior Longitudinal Posterior surface of vertebral bodies in spinal canal Prevents hyperflexion Spinal Anatomy and Physiology Vertebral Column Cervical Spine – 7 vertebrae – Sole support for head Head weighs 16–22 pounds – C-1 (Atlas) Supports head Securely affixed to the occiput Permits nodding – C-2 (Axis) Odontoid process (dens) – C-7 – Projects upward – Provides pivot point so head can rotate Prominent spinous process (vertebra prominens) Spinal Anatomy and Physiology Vertebral Column Thoracic Spine – 12 vertebrae – 1st rib articulates with T-1 Attaches to transverse process and vertebral body – Next nine ribs attach to the inferior and superior portion of adjacent vertebral bodies Limits rib movement and provides increased rigidity – Larger and stronger than cervical spine Larger muscles help to ensure that the body stays erect Supports movement of the thoracic cage during respirations Spinal Anatomy and Physiology Vertebral Column Lumbar Spine – 5 vertebrae – Bear forces of bending and lifting above the pelvis – Largest and thickest vertebral bodies and intervertebral disks Spinal Anatomy and Physiology Vertebral Column Sacral Spine – 5 fused vertebrae – Form posterior plate of pelvis – Help protect urinary and reproductive organs – Attach pelvis and lower extremities to axial skeleton Coccygeal Spine – 3–5 fused vertebrae – Residual elements of a tail Spinal Anatomy and Physiology Spinal Meninges Layers – Dura mater – Arachnoid – Pia mater Cover entire spinal cord and peripheral nerve roots that exit Cerebrospinal fluid bathes spinal cord by filling the subarachnoid space – Exchange of nutrients and waste products – Absorbs shocks of sudden movement Spinal Anatomy and Physiology Spinal Cord Function – Transmits sensory input from body to the brain – Conducts motor impulses from brain to muscles and organs – Reflex center Intercepts sensory signals and initiates a reflex signal Growth – Fetus Entire cord fills entire spinal foramen – Adult Base of brain to L-1 or L-2 level Peripheral nerve roots pulled into spinal foramen at the distal end (cauda equina) Spinal Anatomy and Physiology Spinal Cord Blood Supply – Paired spinal arteries Branch off the vertebral, cervical, thoracic, and lumbar arteries Travel through intervertebral foramina – Split into anterior and posterior arteries Spinal Anatomy and Physiology Spinal Cord General Cord Anatomy – Anterior Medial Fissure Deep crease along the ventral surface of the spinal cord that divides cord into left and right halves – Posterior Medial Fissure Shallow longitudinal groove along the dorsal surface – Gray Matter Area of the CNS dominated by nerve cell bodies Central portion of the spinal cord – White Matter Surrounds gray matter Comprised of axons Spinal Anatomy and Physiology Spinal Cord General Cord Anatomy – Axons Transmit signals upward to the brain and down to the body Ascending tracts – Axons that transmit signals to the brain – Sensory tracts Descending tracts – Axons that transmit signals to the body – Motor tracts Voluntary and fine muscle movement Spinal Anatomy and Physiology Spinal Nerves 31 pairs of nerves that originate along the spinal cord from anterior and posterior nerve roots – Sensory and motor functions – Travel through intervertebral foramina 1st pair exit between the skull and C-1 Remainder of pairs exit below the vertebrae Each pair has 2 dorsal and 2 ventral roots – Ventral roots: motor impulses from cord to body – Dorsal roots: sensory impulses from body to cord – C-1 and Co-1 do not have dorsal roots Spinal Anatomy and Physiology Spinal Nerves Plexus – Nerve roots that converge in a cluster of nerves Cervical plexus – 5 cervical nerve roots – Innervates the neck – Produces the phrenic nerve Peripheral nerve roots C-3 through C-5 Responsible for diaphragm control “C3, 4, and 5 keep the diaphragm alive” Spinal Anatomy and Physiology Spinal Nerves Brachial Plexus – C-5 through T-1 – Controls the upper extremity Lumbar and Sacral Plexuses – Innervation of the lower extremity Spinal Anatomy and Physiology Spinal Nerves Spinal Anatomy and Physiology Spinal Nerves Dermatomes – Topographical region of the body surface innervated by one nerve root – Key locations Collar region: C-3 Little finger: C-7 Nipple line: T-4 Umbilicus: T-10 Small toe: S-1 Spinal Anatomy and Physiology Spinal Nerves Spinal Anatomy and Physiology Spinal Nerves Myotomes – Muscle and tissue of the body innervated by spinal nerve roots – Key myotomes Arm extension: C-5 Elbow extension: C-7 Small finger abduction: T-1 Knee extension: L-3 Ankle flexion: S-1 Spinal Anatomy and Physiology Spinal Nerves Reflex Pathways – Function Speed body’s response to stressors Reduce seriousness of injury Body stabilization – Occur in special neurons Interneurons Example – Touch hot stove. – Severe pain sends intense impulse to brain. – Strong signal triggers interneuron in the spinal cord to direct a signal to the flexor muscle. – Limb withdraws without waiting for a signal from the brain. Spinal Anatomy and Physiology Spinal Nerves Spinal Anatomy and Physiology Spinal Nerves Subdivision of ANS – Parasympathetic, “Feed and Breed” Controls rest and regeneration Peripheral nerve roots from the sacral and cranial nerves Major Functions – Slows heart rate – Increases digestive system activity – Plays a role in sexual stimulation Spinal Anatomy and Physiology Spinal Nerves Subdivision of ANS – Sympathetic, “Fight or Flight” Increases metabolic rate Branches from nerves in the thoracic and lumbar regions Major Functions – Decreases organ and digestive system activity Vasoconstriction – Release of epinephrine and norepinephrine – Systemic vascular resistance Reduces venous blood volume Increases peripheral vascular resistance – Increases heart rate – Increases cardiac output Pathophysiology of Spinal Injury Mechanisms of Spinal Injury – Extremes of Motion Hyperextension Hyperflexion: “Kiss the Chest” Excessive rotation Lateral bending Pathophysiology of Spinal Injury Mechanisms of Spinal Injury – Axial Stress Axial loading – Compression common between T-12 and L-2 Distraction Combination – Distraction/rotation or compression/flexion – Other MOI Direct, blunt, or penetrating trauma Electrocution Pathophysiology of Spinal Injury Pathophysiology of Spinal Injury (4 of 14) Column Injury – Movement of vertebrae from normal position – Subluxation or dislocation – Fractures Spinous process and transverse process Pedicle and laminae Vertebral body – Ruptured intervertebral disks – Common sites of injury C-1/C-2: Delicate vertebrae C-7: Transition from flexible cervical spine to thorax T-12/L-1: Different flexibility between thoracic and lumbar regions Pathophysiology of Spinal Injury (5 of 14) Cord Injury – Concussion Similar to cerebral concussion Temporary and transient disruption of cord function – Contusion Bruising of the cord Tissue damage, vascular leakage, and swelling – Compression Secondary to: – – – – Displacement of the vertebrae Herniation of intervertebral disk Displacement of vertebral bone fragment Swelling from adjacent tissue Pathophysiology of Spinal Injury (6 of 14) Cord Injury – Laceration Causes – Bony fragments driven into the vertebral foramen – Cord may be stretched to the point of tearing Hemorrhage into cord tissue, swelling, and disruption of impulses – Hemorrhage Associated with contusion, laceration, or stretching Pathophysiology of Spinal Injury (7 of 14) Transection Cord Injury – Injury that partially or completely severs the spinal cord Complete – Cervical Spine Quadriplegia Incontinence Respiratory paralysis – Below T-1 Incontinence Paraplegia Incomplete Pathophysiology of Spinal Injury (8 of 14) Incomplete Transection Cord Injury – Anterior Cord Syndrome Anterior vascular disruption Loss of motor function and sensation of pain, light touch, and temperature below injury site Retain motor, positional, and vibration sensation – Central Cord Syndrome Hyperextension of cervical spine Motor weakness affecting upper extremities Bladder dysfunction – Brown-Sequard’s Syndrome Penetrating injury that affects one side of the cord Ipsilateral sensory and motor loss Contralateral pain and temperature sensation loss Pathophysiology of Spinal Injury (9 of 14) General Signs and Symptoms – – – – – – – – – Extremity paralysis Pain with and without movement Tenderness along spine Impaired breathing Spinal deformity Priapism Posturing Loss of bowel or bladder control Nerve impairment to extremities Pathophysiology of Spinal Injury (10 of 14) Spinal Shock – Temporary insult to the cord – Affects body below the level of injury – Affected area Flaccid Without feeling Loss of movement (flaccid paralysis) Frequent loss of bowel and bladder control Priapism Hypotension secondary to vasodilation Pathophysiology of Spinal Injury (11 of 14) Neurogenic Shock – Spinal-Vascular Shock – Occurs when injury to the spinal cord disrupts the brain’s ability to control the body Loss of sympathetic tone – Dilation of arteries and veins Expands vascular space Results in relative hypotension – Reduced cardiac preload – Reduction of the strength of contraction Frank-Starling reflex ANS loses sympathetic control over adrenal medulla – Unable to control release of epinephrine and norepinephrine Loss of positive inotropic and chronotropic effects Pathophysiology of Spinal Injury of 14) Neurogenic Shock – Signs and Symptoms Bradycardia Hypotension Cool, moist, and pale skin above the injury Warm, dry, and flushed skin below the injury Male: priapism (12 Pathophysiology of Spinal Injury (13 of 14) Autonomic Hyperreflexia Syndrome – Associated with the body’s resolution of the effects of spinal shock – Commonly associated with injuries at or above T-6 – Presentation Sudden hypertension Bradycardia Pounding headache Blurred vision Sweating and flushing of skin above the point of injury Pathophysiology of Spinal Injury of 14) Other Causes of Neurologic Dysfunction – Any injury that affects the nerve impulse’s path of travel Swelling Dislocation Fracture Compartment syndrome (14 Assessment of the Spinal Injury Patient (1 of 4) Scene Size-up – Evaluate MOI. – Consider spinal clearance protocol. – Determine type of spinal trauma. – Maintain suspicion with sports injuries. – If unclear about MOI, take spinal precautions. Assessment of the Spinal Injury Patient (2 of 4) Initial Assessment – Consider spinal clearance protocol. – Consider spinal precautions. Head injury Intoxicated patients Injuries above the shoulders Distracting injuries – Maintain manual stabilization. Vest style versus rapid extrication Maintain neutral alignment Increase of pain or resistance, restrict movement in position found Assessment of the Spinal Injury Patient (3 of 4) Initial Assessment – ABCs. – Suction. – Consider oral or digital intubation if required. Maintain in-line manual c-spine control. Assessment of the Spinal Injury Patient (4 of 4) Rapid Trauma Assessment – Focused versus rapid assessment – Rapid Assessment Suspected or likely spinal cord/column injury Multi-system trauma patient Evaluate for – Neck Deformity, pain, crepitus, warmth, tenderness – Bilateral extremities Finger abduction/adduction Push, pull, grips – Motor and sensory function – Dermatome and myotome evaluation – Babinski’s sign test – Hold-up position Babinski’s Sign Test Stroke lateral aspect of the bottom of the foot. Evaluate for movement of the toes. – Fanning and flexing (lifting) Positive sign – Injury along the pyramidal (descending spinal) tract Assessment of the Spinal Injury Patient Vital Signs – Body temperature Above and below site of injury – Pulse – Blood pressure – Respirations Ongoing Assessment – – – – Recheck Recheck Recheck Recheck elements of initial assessment. vital signs. interventions. any neurological deviations. Spinal Clearance Protocol Spinal Integrity Terminology Stabilize is a word commonly used to describe protecting the spinal cord from possible injury (or further injury) when vertebral column integrity is disrupted. Immobilize refers to the “splinting” of the head, neck, and torso to limit any transmission of motion to the spine. Spinal motion restriction (SMR) is now suggested as a more accurate description of modern spinal injury care. However, this phrase could be misunderstood to indicate a more limited “immobilization” of the spine than is currently practiced. Management of the Spinal Injury Patient (1 of 7) Spinal Alignment – Move patient to a neutral, in-line position. Position of function. – Hips and knees should be slightly flexed for maximum comfort and minimum stress on muscles, joints, and spine. Place a rolled blanket under the knees. – ALWAYS support the head and neck. – Contraindications to neutral position: Movement causes a noticeable increase in pain. Noticeable resistance met during procedure. Increase in neurological deficits occurs during movement. Gross deformity of spine. – LESS MOVEMENT IS BEST. Management of the Spinal Injury Patient (2 of 7) Manual Cervical Immobilization – Seated Patient Approach from front. Assign a caregiver to hold GENTLE manual traction. – Reduce axial loading. – Evaluate posterior cervical spine. Position patient’s head slowly to a neutral, in-line position. – Supine Patient Assign a caregiver to hold GENTLE manual traction. Adult – Lift head off ground 1–2”: neutral, in-line position. Child – Position head at ground level: avoid flexion. Management of the Spinal Injury Patient (3 of 7) Management of the Spinal Injury Patient (4 of 7) Cervical Collar Application – – – – – Apply the C-collar as soon as possible. Assess neck prior to placing. C-collar limits some movement and reduces axial loading. DOES NOT completely prevent movement of the neck. Size and Apply according to the manufacturer’s recommendation. Collar should fit snugly. Collar should NOT impede respirations. Head should continue to be in neutral position. SIZE IT, SIZE IT, SIZE IT!!! – DO NOT RELEASE manual control until the patient is fully secured in a spinal restriction device. Management of the Spinal Injury Patient (5 of 7) Standing Takedown – – – – – – – – – Minimum 3 rescuers. Have patient remain immobile. Rescuer provides manual stabilization from behind. Assess neck. Size and place c-collar. Position board behind patient. Grasp board under patient’s shoulders. Lower board to ground. Secure patient. COMMUNICATE WITH PARTNERS AND PATIENT. Management of the Spinal Injury Patient (6 of 7) Helmet Removal – When to remove: Helmet does not immobilize the patient’s head within. Cannot securely immobilize the helmet to the long spine board. Helmet prevents airway care. Helmet prevents assessment of anticipated injuries. Present or anticipated airway or breathing problems. Removal will not cause further injury. Management of the Spinal Injury Patient (7 of 7) Helmet Removal – Technique: 2 Rescuers. Have a plan. Remove face mask and chin strap. Immobilize head. – Slide one hand under back of neck and head. – Other hand supports anterior neck and jaw. Remove helmet. – Gently rock head to clear occiput. All actions should be slow and deliberate. – TRANSPORT HELMET with patient. – COMMUNICATION is the KEY. Movement of the Spinal Injury Patient (1 of 2) Any movement MUST be coordinated. Move patient as a unit. NO LATERAL PUSHING. – Move patient up and down to prevent lateral bending. Rescuer at the head “CALLS” all moves. ALL MOVES MUST be slowly executed and well coordinated. Consider the final positioning of the patient prior toet al.,beginning move. Bledsoe Paramedic Care Principles & Practice Volume 4: Trauma © 2006 by Pearson Education, Inc. Upper Saddle River, NJ Movement of the Spinal Injury Patient (2 of 2) Types of Moves – Log roll – Straddle slide – Rope-Sling slide – Orthopedic stretcher – Vest-type immobilization – Rapid extrication – Final patient positioning – Long spine board Bledsoe– et al., Paramedic Care vacuum mattress Full-body Principles & Practice Volume 4: Trauma Diving injury immobilization © 2006– by Pearson Education, Inc. Upper Saddle River, NJ Management of the Spinal Injury Patient (1 of 3) Medications and Spinal Cord Injury – Steroids if neuro-deficit is identified Reduce the body’s response to injury Reduce swelling and pressure on cord Administered within 1st 8 hours of injury Management of the Spinal Injury Patient (2 of 3) Medications and Neurogenic Shock – Fluid Challenge Isotonic solution: 20 mL/kg – 250 mL initially – Monitor response and repeat as needed – PASG Controversial – Research shows no positive outcome – Dopamine 2–20 mcg/kg/min titrated to blood pressure – Atropine 0.5–1.0 mg q 3–5 min (maximum of 2.0 mg) Management of the Spinal Injury Patient (3 of 3) Medications and the Combative Patient – Consider sedatives to reduce anxiety and calm patient. Prevents spinal injury aggravation – Medications: Meperidine (Demerol) Diazepam (Valium) Consider paralytics with airway control Summary Introduction to Spinal Injuries Spinal Anatomy and Physiology Pathophysiology of Spinal Injury Assessment of the Spinal Injury Patient Management of the Spinal Injury Patient The End