Classification of spinal fracture by Dr. B. Borthakur

1. CLASSIFICATION, EVALUATION AND
MANAGEMENT OF SPINE FRACTURE
DR. B. BORTHAKUR (PROF.)
DEPT. OF ORTHOPAEDICS, SMCH

2. introduction
• There are so many classification for spine fracture.
• The classification of spine injuries is still evolving.
• None of the classification satisfy all aspect (prognosis,
treatment modality etc)

3. Cervical spine
• Injuries mainly divided into two parts
• Supra-axial injury
• Injury to occiput-C1-C2 complex
• They are mostly ligamentous.
• Sub-axial injury
• Injury to C3-C7 vertebrae

4. Cervical spine
• Injuries to the Occiput-C1-C2 complex
• Occipital condyle fractures
• Three types:
– Type I: Impaction of condyle(usually stable)
– Type II : Shear injury associated with basilar or Skull fracture
(potentially unstable)
– Type III : Condyle avulsion (unstable)
• Treatment
• Stable fracture - Rigid cervical collar immobilization
• Unstable fracture – halo immobilization or Occipital –
cervical fusion

5. Occipitoatlantal dislocation
• Almost always fatal
• Resulting from a combination of Hyperextension,
distraction and rotation at craniocervical junction
• Based on the position of occiput in relation to C1
• Type I: Occiput condyles anterior to the atlas
• Type II: Condyle longitudinally dissociated from atlas
• Type III: Occiput condyles posterior to the atlas

6. Cervical spine
• HARBORVIEW CLASSIFICATION
• For quantification of stability of craniocervical junction
– Type I: Stable with displacement <2 mm
– Type II: Unstable with displacement < 2 mm
– Type III: Gross instability with Displacement >2 mm
• Treatment :
• Halo vest application with strict avoidance of traction

7. Atlas fracture
• Levine classification
1. Isolated bony apophysis fracture
2. Isolated posterior arch fracture
3. Isolated anterior arch fracture
4. Comminuted lateral arch fracture
5. Burst fracture or Jefferson fracture
• Treatment
– Stable fracture – Rigid cervical orthosis
– Less stable fracture – Prolonged halo immobilization

8. Fracture of Odontoid process(DENS)
• Anderson and D‘Alonzo classification
– Type I: Oblique avulsion of apex
– Type II: Fracture at the junction of the body and neck
– Type III: Fracture extending into the cancellous body of C2

9. hangman’s fracture
• Levine and Edward classification
• Type I: Nondisplaced ,no angulation
• Translation <3 mm(stable)
• Type IA:Atypical unstable lateral bending Fracture that are
obliquely displaced .
Usually involves one parsinterarticularis, Extending anterior
to the pars and into the Body on contralateral side
• Type II: Significant angulation at C2-C3
• Translation >3 mm(unstable)
• Type IIA: Avulsion of entire C2-C3 intervertebral disc in flexion with injury to posterior
longitudinal ligament
• Type III: Rare,
• Severe angulation and translation with unilateral or bilateral facet dislocation of
• C2- C3 (unstable)

10. Injuries to C3-c7(sub-axial)
• Allen – Ferguson classification
• 1) compressive flexion(tear drop fracture)
– Stage I: Blunting of anterior body
– Stage II: “Beaking” of anterior body
– Loss of anterior vertebral height
– Stage III: Fracture lien passing from anterior body
through the inferior subchondral plate
– Stage IV: Inferior margin displaced <3 mm into neural canal
– Stage V: “Tear drop” fracture

11. • Allen-Ferguson classification
• 2) Vertical compression (Burst fracture)
– Stage I : Fracture through superior or inferior endplate (no
displacement)
– Stage II: Fracture through both endplates (minimal displacement)
– Stage III: Burst fracture
3) Distractive flexion (Dislocation)
• Stage I : Failure of posterior ligament facet subluxation
• Stage II: Unilateral facet dislocation
• Stage III: Bilateral facet dislocation
• Stage IV: Bilateral facet dislocation with 100% translation

12. Allen-Ferguson classification
4) Compressive extension
– Stage I: Unilateral vertebral arch fracture
– Stage II: Bilateral laminar fracture
– Stage III, IV: Theoretic continuum between stage II and V
– Stage V: Bilateral vertebral arch fracture with full vertebral
body displacement anteriorly,

13. • 5)Distractive extension
– Stage I: Failure of anterior Ligamentous complex
or transverse fracture of the body
– Widening of disc space
– No posterior displacement
– Stage II: Failure of posterior ligamentous complex and
superior displacement of the body into the canal
• 6) Lateral flexion
– Stage I: Asymmetric, Unilateral compression fracture of
vertebral body
– Stage II: Displacement of the arch on AP view or failure of the
ligaments on the contralateral side with articular
process separation

15. Miscellaneous cervical spine fracture
• Clay shoveler’s fracture
– Avulsion of Spinous process of lower cervical or upper thoracic
vertebrae
– Treatment- Restriction of movement and symptomatic treatment
• Sentinal fracture
– occurs through lamina on either side of Spinous process
– Treatment – Symptomatic

16. Thoracolumbar spine
Classification:
McAfee et al.
Based on the failure mode of the middle osteoligamentous complex
1) Axial compression
2) Axial distraction
3) Translation within the transverse plane

17. • McCormack et al
• This is a Load sharing classification
• Thoracolumber Injury Classification System(TICS)
• Done for-
– Grade and predict acute spine stability
– Risk of future deformity
– Progressive neurologic compromise

18. Denis
• Minor Spinal Injuries
– Articular process fracture
– Transverse process fracture
– Spinous process fracture
– Pars interarticularis fracture
• Major Spinal Injuries
– Compression fracture
– Burst fracture
– Fractures- dislocation
– Sealt belt- type injuries

19. Compression fracture
• Can be anterior or lateral
• There are 4 subtypes based on endplate involvement
– TypeA : Fracture of both endplate
– TypeB: Fracture of superior endplate
– TypeC: Fracture of inferior endplate
– Type D: Both endplates are intact
• Treatment :
• Stable fracture : Extension orthosis with early ambulation
• Unstable fracture : Open reduction and internal fixation

20. Burst fracture
• Due to compression failure of the anterior and middle
columns under an axial load.
• There is loss of Posterior vertebral body height and
splaying of pedicle
• There are 5 Subtypes
– Type A: Fracture of both endplates
– Type B: Fracture of superior endplate
– Type C: Fracture of inferior endplate
– Type D: Burst rotation
– Type E: Burst lateral flexion

21. Treatment : Burst fracture
• No neurological deficit : Hyperextension casting or
bracing
• Early stabilization required in case of
– Neurological deficit
– Loss of vertebral body height >50%
– Angulation >20 to 30 degrees
– Canal compromise of >50%
– Scoliosis >10 degrees

22. Fracture dislocation
• All three columns fail under compression, tension, rotation, or shear, with
transnational deformity
• Three types
– Type A: Flexion-rotation:
• Posterior and middle column fail in tension and rotation
• Anterior column fails in compression
• 75% with neurological deficit
Type B: Shear:
• Failure of all three columns
• Complete neurologic deficit
– Type C: Flexion-distraction:
• Tension failure of posterior and middle columns, anterior tear of annulus
fibrosus and stripping of the anterior longitudinal ligament
• 75% with neurologic deficit

23. Treatment : Fracture dislocation
• These are highly unstable, require surgical stabilization
• Patients whose fracture are stabilized within 3 days of
injury have a lowwr incidence of pneumonia and a
shorter hospital stay than those with fracture stabilized
more than 3 days after injury

24. Flexion-distraction injuries
• Chance fracture, seat belt-type injuries
• Patients are neurologically intact
• Four types:
– Type A: One level bony injury
– Type B: One level Ligamentous injury
– Type C: Two level injury through bony middle column
– Type D: Teo level injury through Ligamentous middle column
• Treatment
– Hyperextension casting for type A injuries
– Posterior spinal fusion with compression for Type B, C and D

26. Denis three- column model
• Denis three- column model for spinal stability as follows
• Instability exists with disruption of any two of the three columns.
• 1) Anterior column: contains
– Anterior longitudinal ligament
– Anterior half of the vertebral body
– Anterior anulus
• 2) Middle column: contains
– Posterior half of the vertebral body
– Posterior annulus
– Posterior longitudinal ligament
• 3) posterior column: contains
– Posterior neural arch( pedicles, facets and laminae)
– Posterior ligamentous complex(supraspinous ligament, interspinous
ligament, ligamentum flavum and facet capsules)

27. sacrum
• Denis classification
• Zone 1:
– Fracture lateral to foramina
– Most common
• Zone 2:
– Fracture through foramina
• Zone 3:
– Fracture medial to foramina into spinal canal
• U type sacral fracture
• Results from axial loading

28. INITIAL MANAGEMENT
TRANSPORT
– TOTAL SPINE IMMOBILAISATION
• HARD CERVICAL COLLAR
• SPINE BOARD
• 2-3cm OCCIPITAL PAD USED TO AVOID RELATIVE EXTENSION
• IN CHILDREN- OCCIPITAL RECESS USED TO AVOID RELATIVE FLEXION

30. INITIAL ASSESMENT
• ADVANCED TRAUMA LIFE SUPPORT
– AIRWAY
– BREATHING
– CIRCULATION

31. • SPINE ASSESMENT
– MECHANISM OF INJURY
– PRE-INJURY FUNCTIONAL LEVEL
– WEAKNESS OR SENSORY CHANGES
– SIGNS OF BLUNT HEAD TRAUMA
– SPINA TENDERNESS
– SPINE STEP OFF
– INTERSPINOUS WIDENEING
– FLACCIDITY IN THE EXTREMITIES
– INCONTINENCE
– PENILE ERECTION

32. • NEUROLOGICAL EXAMINATION RECORDED ON ASIA CHART

33. • NATIONAL EMERGENCY X-RADIOGRAPHY UTILISATION STUDY
(NEXUS) CRITERIA
N – NEURODEFICIT
S – SPINE TENDERNESS
A – ALERTNESS
I – INTOXICATION
D – DISTRACTING INJURY
• USED IN ASYMPTOMATIC PATIENTS
• FOR CLINICALLY CLEARING CERVICAL SPINE

34. DIAGNOSTIC IMAGING
• CERVICAL SPINE
– AP VIEW
– LATERAL WITH B/L SHOULDER PULLED DOWN OR SWIMMER’S VIEW
– ODONTOID VIEW
• DORSO-LUMBAR SPINE
– AP VIEW
– LATERAL VIEW
• LUMBO-SACRAL SPINE
– AP VIEW
– LATERAL VIEW
• CT SCAN & MRI – MAY BE REQUIRED FOR FURTHER EVALUATION

35. TREATMENT
• CERVICAL SPINE
1. NON OPERATIVE-
a) SOFT COLLAR
b) 2 PIECE RIGID COLLAR
c) STERNAL OCCIPITAL MANDIBULAR IMMOBILISATION (SOMI)
d) MINERVA
e) HALO VEST

36. 2. OPERATIVE
a) OCCIPITOCERVICAL FUSION USING MODULAR PLATE & ROD
CONSTRUCT/WIRE & BONE GRAFT
b) SEGMENTAL FIXATION WITH OCCIPITRAL PLATING
c) C1 LATERAL MASS SCREW
d) C2 ISTHMIC SCREW
e) LATERAL MASS FIXATION
f) POST. C1-C2 FUSION USING ROD & SCREW CONSTRUCT WITH C1
LATERAL MASS SCREW/MOD. GALLIE POST. WIRING TECHNIQUE
g) ANTERIOR ODONTOID SCREW FIXATION
h) POSTERIOR C1-C2 TRANSARTICULAR SCREW/TRANSLAMINAR
SCREW

37. TREATMENT
THORACOLUMBAR INJURIES
• COMPRESSION #
– EXTENSION ORTHOSIS – STABLE #
– HYPEREXTENSION CASTING/ORIF – UNSTABLE #
• BURST #
– HYPEREXTENSION CASTING/BRACING – NO NEURODEFICIT &
STABLE#
– SURGICAL DECOMPRESSION – UNSTABLE # & NEURODEFICIT

38. • FLEXION DISTRACTION INJURIES
– HYPEREXTENSION CASTING – FOR TYPE A
– POST. SPINAL FUSION WITH COMPRESSION – TYPE B, C & D
• FRACTURE DISLOCATION
– SURGICAL STABILISATION AS UNSTABLE

39. • SACRAL FRACTURES
– NON OPERATIVE – UNDISPLACED WITH STABLE PELVIS
– OPERATIVE – DISPLACED, UNSTABLE WITH PELVIC/SPINAL INSTABILTY

40. THANK YOU