These slides contains information regarding fractures and dislocations of spine, various classifications of fracture spine, approach to fractures of spine, criteria for surgical or conservative management of patient, various named fractures involving cervical spine and brief description of spine fracture dislocation.

1. Fractures &
Dislocation of
Spine
Dr. R.K. Arya
MS Orthopaedics (BHU)

2. INDEX
• Anatomy
• Mechanism of injury
• Assesment & Principle of initial management
• Diagnosis & Classifications
• Principle of definitive management
• Cervical injuries
• Fracture dislocation injuries

3. Spine Anatomy

5. Introduction
• Most common site – Thoracolumbar junction ( D11 to L2 )
• Bimodal age of distribution with young males and elderly females
• In young patients, due to high energy trauma while in elderly
patients, low energy mechanism
• Most common type – in elderly , ( Compression fractures )
• Elderly patients suffer more SCI during thoracolumbar fractures and
have poor outcomes

7. Assesment & Principles of initial management
• Diagnosis and management should go hand in hand
• Follow resuscitation protocol- ATLS
• Keep in mind about spinal injuries during resuscitation and primary survey
• Spine must be immobilized during resuscitation and treatment of other life
threatening injuries, if there is slightest possibility of spine injury

8. Principles of initial management
• Methods of temporary
immobilization
1. In line immobilization
2. Quadruple immobilization
3. Scoop stretcher
4. Spinal board
5. Logrolling technique- turned over
‘in one piece’

9. Diagnosis
• History
• Examination
• Neck
• Back, after log-rolling
• General examination- shock
• Shock- hypovolumic, neurogenic, spinal shock
• Neurological examination
• Imaging

10. Diagnosis
• Clinical examination
• Motor strength
• Sensory
• Rectal examinaton (sensory, tone,contraction)
• Bulbocavernosus (always to rule out spinal shock)

11. ASIA Scoring

12. ASIA Impairment Scale

13. Radiological assesment
• Plain Radiograph
• CT Scan
• MRI

14. Imaging
• X-rays are mandatory for
• all polytrauma patients
• Unconscious, accident victims
• Elderly patients
• Patients with known vertebral pathology (e.g. AS)
• X-rays should be obtained with minimal manipulation
• Special views
• Open mouth AP view neck- for atlus and axis fractures
• Swimmer’s view neck- for cervicodorsal spine
• Difficult areas of spine could not be assessed in X-rays, needs CT-scan
evaluation

15. Radiograph
• Anteroposterior and lateral views
• Look for Alignment, Interpedicle widening, Increased Interspinous process distance, loss of vertebral body height
• Anterior and Posterior vertebral lines are helpful in finding translations in saggital plane

17. Computed tomography
• Aids in diagnosis better than X rays alone
• Aids in finding size and location of
retropulsed fragments
• Saggital to transverse diameter ratio is
helpful in predicting neurological function
• Best modality for identifying fractures of
posterior elements

18. MRI
• Gold standard for
diagnosis of associated
soft tissue injury, like
epidural hematoma, SCI,
disc herniation, PLC status
• Non invasive investigation
(less radiation exposure)

19. Classifications
• Based on Imaging studies
• Helpful in planning treatment modalities
DENIS 3 column classifications- 4 Principal groups
AO (Magerl)- 3 groups ( A, B, C )
McAfee Classification – 6 types
Thoracolumbar Injury Classification and Severity Score

20. DENIS 3 COLUMN CLASSIFICATION
• Anterior, Middle and Posterior column
• 4 main groups i.e,
Compression
Burst
Chance
Fracture-dislocations

21. AO (Magerl)

22. McAfee Classification
• 6 types of fracture patterns
Wedge- Compression
Stable Burst
Unstable Burst
Chance fracture
Flexion Distraction
Translation

23. Thoraco Lumber Injury Classification And Severity
(TLICS) Score

24. MANAGEMENT

25. Management Principles
• Preserve neurological fucntion
• To minimize deformity progression
• Decrease pain
• Restore function

26. How do we achive these goals?
• Ensure that PLC is intact (Xrays, MRI)
• Bracing is done in hyperextension by using
(TLSO Brace, Taylor’s brace)
• Analgesics
• Progressive mobilistation (Immobilisation is
usually done at 12 weeks)

27. Operative Management
• Provides immediate spine stability, deformity correction, optimise neurological
improvement directly or indirectly
• Surgery is planned looking at the Morphology of fracture, neurological status, PLC
status
INDICATIONS
Unstable fractures
Worsening neurological deficit
Intersegmental translation
Radiologic evidence of severe PLC injury
Incomplete spinal cord injury with persistent spinal canal compromise
Bellabarba et, al. demonstrated improved results with early treatment (<72hours) of thoracic fractures in terms of days on a ventilator, days in the intensive care unit
and improved respiratory health although a similar analysis of lumbar fractures only demonstrated shortened overall hospital stay.

29. • Initially hooks and screws were used
• Pedicle screws with rods are now
used most commonly ( monoaxial,
polyaxial)
• Cervical plates

30. • Position –
• Prone on Jackson spinal table
• lateral

31. Cervical spine injuries
1. Occipital condyle fractures
2. Occipito-cervical dislocation
3. C-1 ring fracture (Jefferson’s fracture)
4. C-2 pars fracture (Hangman’s fracture)
5. C-2 odontoid fracture
6. Tear drop fractures
7. Fracture dislocations
8. Hyperextension injury
9. Clay shoveller’s fracture
10. Whiplash injury

33. Occipital condyle fracture
1. High energy trauma
2. Missed in xrays, so CT scan is
essential
3. Undisplaced and impacted-
conservative on Halo vest for
12weeks
4. Displaced- needs fixation

34. Occipito-cervical dislocation
1. High energy trauma
2. Usually fatal injury
3. Diagnosed by lateral X-rays
4. CT more reliable
5. Unstable injury
6. So need immediate reduction and
immobilization

35. Jefferson’s fracture
1. Usually not fatal
2. Even without neurological deficit
3. X-rays open mouth view
4. Usually stable injury
5. Both stable and unstable need
conservative treatment first on Halo
Vest

36. Hangman’s fracture
• B/L pars fracture of C2
• Also when forehead strikes the
dashboard in RTA
• Neurological loss unusual
• But fracture is unstable
• Conservative on halo vest

37. Odontoid fractures
• Uncommon injury
• Displaced fracture is fracture
dislocation of Atlantoaxial joint
• Anderson- D’alonzo 3 types
• Surgical treatment is reserved
for displaced, unstable, type 2
fracture

38. Clay shoveller’s fracture
• Avulsion fracture of spinous
process of lower cervical
vertbrae
• Painful but harmless
• No treatment needed
• Encourage for physiotherpy,
when pain permits

39. Tear drop fracture
• A severe type of wedge compression fracture in
lateral view of X-ray
• Posterior part of body displaces posteriorly
• So Traction must be applied immediately followed
by X-ray and CT
• Anterior decompression is warranted in case of
instability and neurological deficit

40. Fracture-Dislocations
• High energy injuries
• Highest rate of SCI of all spinal
fractures
• Thoracic fracture dislocations-
worst prognosis
• Urgent operative management
• Highly unstable

41. • Posterior/Anterior construct provide stability after realignment
• Very less chance of neurological recovery

42. Thank you