Download Upper Extremity Fractures

Upper Extremity Trauma
How do fractures heal?
2
Fracture healing
Why do fractures unite?
Because the bone is broken!
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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
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Healing cascade
Late repair:

Fibrous tissue replaced by
cartilage

Endochondral ossification

Periosteal healing »
membranous ossification
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What is the difference between
direct and indirect bone healing?
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Indirect healing – healing by Callus
Unstable
 Callus stabilises #

Direct healing between
cortices
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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
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What are the aims of fracture
treatment?
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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
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What factors effect fracture
healing?
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FACTORS AFFECTING
FRACTURE HEALING

The energy transfer of the injury

The tissue response
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–

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
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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
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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
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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