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Ortho discuss-spine fx
- 1. Case discussion Extern วรินทรพลานุภาพ
- 2. History Patient Profile ผู้ป่วยหญิงไทยคู่อายุ 43ปี CC: ตกต้นไม้สูงประมาณ 4เมตร 2 ชั่วโมงก่อนมารพ
- 3. Primary survey A –Patent airway, no cervical midline tenderness, can flex/extend neck B – Equal breath sound, trachea in midline, no distant heart sound C – BP 120/69 mmHg, PR 80 bpm, no external bleeding, CR<2 sec D – E4V5M6, pupil 3 mmRTLBE
- 4. Secondary survey A –No allergy M – No current medication P – No underlying disease L – Last meal 5 hours PTA E – 2ชั่วโมงก่อนมารพ ผู้ป่วยตกต้นไม้สูงประมาณ 4เมตร เอาส้นเท้าลง ไม่มีศีรษะกระแทก ไม่สลบ จาเหตุการณ์ได้ตลอด ปวดกลางหลังบริเวณเอวทันที ลุกเดินไม่ได้ ลุกนั่งไม่ได้ งอยืดหลังไม่ได้ ยกแขนขาพอได้ ไม่ชา ไม่มีบาดแผล ภายนอก กลั้นปัสสาวะอุจจาระได้
- 5. Physical examination PE: Vitalsigns – BP 120/60mmHg,PR 80bpm, RR14/min, Temp 36.6◦C GA – A Thai woman, good consciousness, well co-operative HEENT – no pale conjunctiva, anicteric sclera, no subconjunctival hemorrhage Heart – pulse full, regular, normal S1S2, no murmur Lungs – good air entry, normal breath sound equal both lungs Abdomen – no distension, no ecchymosis, soft, no tenderness Extremities and Back – tender at posterior midline of lumbar region and Left calcaneus, cannot flex and extend back, no external wound
- 6. Physical examination • Motor:normal tone • DTR 2+, BBK absent • PR – good sphincter tone, bulbocarvernosus reflex +ve
- 7. Right Left Motor SensoryMotor Sensory C5 V intact V intact C6 V intact V intact C7 V intact V intact C8 V intact V intact T1 V intact V intact L2 V intact V intact L3 V intact V intact L4 V intact V intact L5 V intact V intact S1 V intact V intact
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- 13. Diagnosis: Burst fractureof L1 spine Management Surgery – Percutaneous pedicle screw fixation T12-L2
- 15. Thoracolumbar spinal Fracture anddislocation
- 16. Anatomy •Support the axialmusculature •Protect the spinal cord and nerve roots
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- 19. Denis classification system anteriorcolumn • anterior longitudinal ligament (ALL) • anterior 2/3 of vertebral body and annulus middle column • posterior longitudinal ligament (PLL) • posterior 1/3 of vertebral body and annulus
- 20. posterior column • pedicles •lamina • facets • ligamentum flavum • spinous process • posterior ligament complex (PLC) Posterior Ligamentous Complex critical predictor of spinal fracture stability consists of supraspinous ligament interspinous ligament ligamentum flavum facet capsule
- 21. Denis classification system Denisclassification system แบ่ง T-L fracture เป็น 4 กลุ่ม •1. Compression fracture •2. Burst fracture •3. Flexion distraction (seat belt-type) •4. Fracture dislocation
- 22. Compression fracture •Failure ofanterior column •The middle column is intact •Usually no Neurological deficits
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- 24. Burst fracture •Axial compressionresulting in Failure of anterior and middle column •If posterior column involved results in instability •Most common at T/L junction
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- 26. Flexion distraction (seatbelt-type) •Hyper-flexion and subsequent tension forces •Both posterior and middle columns fail •The anterior part of the anterior column may partially damaged ,but still functions like a hinge
- 27. Flexion distraction (seatbelt-type)
- 28. Fracture dislocation •failure ofall three columns under compression, tension, rotation, or shear. •similar to seat-belt-type injury. However, the anterior hinge is also disrupted and some degree of dislocation is present.
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- 32. Management •Nonoperative indications - compression, stableburst and chance fracture (PLC intact) with neurologically intact treat in orthosis for 6 to 12 weeks depending on degree of instability
- 34. Management •Operative indications for surgery -progressive neurologic deficits - gross spinal instability - posterior ligament complex stability compromised
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- 37. References •ตาราออร์โธปิดิกส์ ฉบับเรียบเรียงใหม่ ครั้งที่3, คณะแพทยศาสตร์ รพ. รามาธิบดี. •Rockwood and Green’s, Fracture in Adults, 3rd Edition. •Netter’s Concise Orthopaedic anatomy, 2nd Edition.