This document discusses evaluating cervical spine injuries. It begins by contrasting evaluating a knee injury versus a neck injury after a fall. For neck injuries, a focused physical exam and imaging are important to rule out fractures or ligament injuries. The preferred imaging is a multi-detector CT scan, which is highly sensitive and specific for fractures. If the CT is normal but the physical exam is painful, a collar should remain on until follow-up. If both the CT and physical exam are normal, the collar can be removed safely. An MRI may also be useful if the physical exam is difficult. The "2/3 rule" states that if two of three tests - CT, MRI, and physical exam - are normal, a
Periprosthetic fractures are the third most common reason for revision total hip arthroplasty. Surgical treatment of periprosthetic fractures belongs to the most difficult procedures due to the extensive surgery, elderly polymorbid patients and the high frequency of other complications. The aim of this study was to evaluate the results of operatively treated periprosthetic femoral fractures after total hip arthroplasty.
We evaluated 47 periprosthetic fractures in 40 patients (18 men and 22 women) operated on between January 2004 and December 2010. The mean follow-up period was 27 months (within a range of 12-45 months). For the clinical evaluation, we used modified Merle d'Aubigné scoring system.
In group of Vancouver A fractures, 3 patients were treated with a mean score of 15,7 points (good result). We recorded a mean score of 14,2 points (fair result) in 6 patients with Vancouver B1 fractures, 12,4 points (fair result) in 24 patients with Vancouver B2 fractures and 12,8 points (fair result) in 7 patients with Vancouver B3 fractures. In group of Vancouver C fractures, we found a mean score of 16,2 points (good result) in 7 patients.
Therapeutic algorithm based on the Vancouver classification system is, in our opinion, satisfactory. Accurate differentiation of B1 and B2 type of fractures is essential. Preoperative radiographic images may not be reliable and checking the stability of the prosthesis fixation during surgery should be performed.
Comparison Results between Patients with Developmental Hip Dysplasia Treated ...CrimsonPublishersOPROJ
Comparison Results between Patients with Developmental Hip Dysplasia Treated with Either Salter or Pemberton Osteotomy by Dello Russo Bibiana* in Orthopedic Research Online Journal
The IOSR Journal of Pharmacy (IOSRPHR) is an open access online & offline peer reviewed international journal, which publishes innovative research papers, reviews, mini-reviews, short communications and notes dealing with Pharmaceutical Sciences( Pharmaceutical Technology, Pharmaceutics, Biopharmaceutics, Pharmacokinetics, Pharmaceutical/Medicinal Chemistry, Computational Chemistry and Molecular Drug Design, Pharmacognosy & Phytochemistry, Pharmacology, Pharmaceutical Analysis, Pharmacy Practice, Clinical and Hospital Pharmacy, Cell Biology, Genomics and Proteomics, Pharmacogenomics, Bioinformatics and Biotechnology of Pharmaceutical Interest........more details on Aim & Scope).
All manuscripts are subject to rapid peer review. Those of high quality (not previously published and not under consideration for publication in another journal) will be published without delay.
Purpose: To evaluate the influence of age and severity of keratoconus in the clinical outcomes of implantation of Ferrara intrastromal corneal ring segments (ICRS).
Anatomical Glenoid Reconstruction for Recurrent Anterior Glenohumeral Instabi...Peter Millett MD
Eleven cases of traumatic recurrent anterior instability that required bony reconstruction for severe anterior glenoid bone loss were reviewed. In all cases, the length of the anterior glenoid defect exceeded the maximum anteroposterior radius of the glenoid based on preoperative assessment by 3-dimensional CT scan. Surgical reconstruction was performed using an intra-articular tricortical iliac crest bone graft contoured to reestablish the concavity and width of the glenoid. The graft was fixed with cannulated screws in combination with an anterior-inferior capsular repair. For more shoulder surgery and instability studies, visit Dr. Millett, The Steadman Clinic, Vail Colorado http://drmillett.com/shoulder-studies
Robotic spine surgery is on the cutting edge of medicine, allowing our surgeons to exercise an incredible level of precision, well beyond standard capabilities.
Patient Management with Greater Tuberosity Fracture and Rotator Cuff Tear | G...Peter Millett MD
Patients with hyperflexion/hyperabduction injury to the glenohumeral joint are at risk for isolated greater tuberosity fractures, which are often undiagnosed or misdiagnosed. In this case report, we describe the clinical decision-making process that led to the diagnosis of an isolated greater tuberosity fracture and subsequent rotator cuff tear.
For more shoulder surgery and rotator cuff studies, visit Dr. Millett, Greater Denver Area http://drmillett.com/shoulder-studies
Periprosthetic fractures are the third most common reason for revision total hip arthroplasty. Surgical treatment of periprosthetic fractures belongs to the most difficult procedures due to the extensive surgery, elderly polymorbid patients and the high frequency of other complications. The aim of this study was to evaluate the results of operatively treated periprosthetic femoral fractures after total hip arthroplasty.
We evaluated 47 periprosthetic fractures in 40 patients (18 men and 22 women) operated on between January 2004 and December 2010. The mean follow-up period was 27 months (within a range of 12-45 months). For the clinical evaluation, we used modified Merle d'Aubigné scoring system.
In group of Vancouver A fractures, 3 patients were treated with a mean score of 15,7 points (good result). We recorded a mean score of 14,2 points (fair result) in 6 patients with Vancouver B1 fractures, 12,4 points (fair result) in 24 patients with Vancouver B2 fractures and 12,8 points (fair result) in 7 patients with Vancouver B3 fractures. In group of Vancouver C fractures, we found a mean score of 16,2 points (good result) in 7 patients.
Therapeutic algorithm based on the Vancouver classification system is, in our opinion, satisfactory. Accurate differentiation of B1 and B2 type of fractures is essential. Preoperative radiographic images may not be reliable and checking the stability of the prosthesis fixation during surgery should be performed.
Comparison Results between Patients with Developmental Hip Dysplasia Treated ...CrimsonPublishersOPROJ
Comparison Results between Patients with Developmental Hip Dysplasia Treated with Either Salter or Pemberton Osteotomy by Dello Russo Bibiana* in Orthopedic Research Online Journal
The IOSR Journal of Pharmacy (IOSRPHR) is an open access online & offline peer reviewed international journal, which publishes innovative research papers, reviews, mini-reviews, short communications and notes dealing with Pharmaceutical Sciences( Pharmaceutical Technology, Pharmaceutics, Biopharmaceutics, Pharmacokinetics, Pharmaceutical/Medicinal Chemistry, Computational Chemistry and Molecular Drug Design, Pharmacognosy & Phytochemistry, Pharmacology, Pharmaceutical Analysis, Pharmacy Practice, Clinical and Hospital Pharmacy, Cell Biology, Genomics and Proteomics, Pharmacogenomics, Bioinformatics and Biotechnology of Pharmaceutical Interest........more details on Aim & Scope).
All manuscripts are subject to rapid peer review. Those of high quality (not previously published and not under consideration for publication in another journal) will be published without delay.
Purpose: To evaluate the influence of age and severity of keratoconus in the clinical outcomes of implantation of Ferrara intrastromal corneal ring segments (ICRS).
Anatomical Glenoid Reconstruction for Recurrent Anterior Glenohumeral Instabi...Peter Millett MD
Eleven cases of traumatic recurrent anterior instability that required bony reconstruction for severe anterior glenoid bone loss were reviewed. In all cases, the length of the anterior glenoid defect exceeded the maximum anteroposterior radius of the glenoid based on preoperative assessment by 3-dimensional CT scan. Surgical reconstruction was performed using an intra-articular tricortical iliac crest bone graft contoured to reestablish the concavity and width of the glenoid. The graft was fixed with cannulated screws in combination with an anterior-inferior capsular repair. For more shoulder surgery and instability studies, visit Dr. Millett, The Steadman Clinic, Vail Colorado http://drmillett.com/shoulder-studies
Robotic spine surgery is on the cutting edge of medicine, allowing our surgeons to exercise an incredible level of precision, well beyond standard capabilities.
Patient Management with Greater Tuberosity Fracture and Rotator Cuff Tear | G...Peter Millett MD
Patients with hyperflexion/hyperabduction injury to the glenohumeral joint are at risk for isolated greater tuberosity fractures, which are often undiagnosed or misdiagnosed. In this case report, we describe the clinical decision-making process that led to the diagnosis of an isolated greater tuberosity fracture and subsequent rotator cuff tear.
For more shoulder surgery and rotator cuff studies, visit Dr. Millett, Greater Denver Area http://drmillett.com/shoulder-studies
This is an old article circa 2002 that is an excellant overview of selective spinal immobilization. Since I am having trouble finding it online anymore, I put it here for all to read and enjoy. I did not write it nor do I came any copywrite for it.
40%-80% of auto accident claimants have overlooked diagnoses. The most commonly overlooked are thoracic outlet syndrome, cervical disc damage mistakenly called sprain or whiplash, post-concussion syndrome, slipping rib syndrome, Tietze syndrome and Tempro-mandibular joint syndrome. This article tells readers the clinical sign and symptoms of each and the correct medical tests to use, which are employed by doctors at Johns Hopkins Hospital. It also described an on-line questionnaire at www.DiagnoseThePains.com which gives diagnoses with a 96% correlation with diagnoses of Johns Hopkins Hospital doctors.
Missed Diagnoses association in Rear end collisions Nelson Hendler
There are a number of overlooked diagnoses which occur after a rear-end accident. This paper shows an attorney how to convert a misdiagnosed 'soft tissue injury case" into damaged cervical disc,TMJ, thoracic outlet syndrome,and post concussion syndrome using a diagnostic paradigm to get diagnoses with a 96% correlation with diagnoses of Johns Hopkins Hospital doctors. This improves patient care and increases recovery.
Background: Distal femur fractures make up 6 to 7% of all femur fractures. Various plating options for distal femur fracture are conventional buttress plates, fixed-angle devices, and locking plates. This study was planned to evaluate and explore locking compression plate fixation in distal end femur fractures which is expected to provide a stable fixation with minimum exposure, early mobilization, less complications and a better quality of life.
Methods: The study was conducted as prospective clinical study in 20 skeletally mature patients with x-ray evidence of distal femur fracture fulfilling inclusion and exclusion criteria, operated with distal femur LCP plating. Patients were assessed radiologically and classified according to distal femur fracture classification and outcome graded as excellent, good, fair and poor based on Lysholm Knee Score.
Results: Out of 15 excellent outcome cases, 3 cases were type A1 fracture, 1 case had type A3, 2 cases had type B1 and B2 each, 5 cases had type C2 and 2 cases had type C3 fracture. 1 case with good outcome was type C3. 1 case with fair outcome was type B2. While 3 cases with poor outcome were type A1, A2 and C3.
Conclusions: The DF-LCP is an ideal implant to use for fractures of the distal femur. However, accurate positioning and fixation are required to produce satisfactory results. We recommend use of this implant in Type A and C, osteoporotic and periprosthetic fractures.
Keywords: Distal femur, DF-LCP, Lysholm score, Periprosthetic fracture
Study of current pattern of Cervical Spondylotic Myelopathy and to evaluate t...iosrjce
IOSR Journal of Dental and Medical Sciences is one of the speciality Journal in Dental Science and Medical Science published by International Organization of Scientific Research (IOSR). The Journal publishes papers of the highest scientific merit and widest possible scope work in all areas related to medical and dental science. The Journal welcome review articles, leading medical and clinical research articles, technical notes, case reports and others.
Functional and radiological assessment of displaced midshaft clavicle fractures treated through open reduction and internal fixation surgery using pre-contoured locking compression plates
Slides from Prof Dan Pratt presented at the Teaching to Teach Workshop in Boston, MA, May 1-2, 2009;
Massachusetts General Hospital, Harvard Medical School.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Couples presenting to the infertility clinic- Do they really have infertility...
Trauma Rounds, 1:3; Evaluating The Cervical Spine
1. P A R T N E R S O R T H O P A E D I C
Trauma Rounds
Case Reports from the Mass General Hospital and Brigham &Women’s Hospital
A Quarterly Case Study Volume 1, Spring 2010
Evaluating the Cervical Spine
Mitchel Harris, MD
Imagine getting called to the Emergency De-
partment to evaluate a painful and swollen
knee after a skiing accident. The plain x-rays
are read as normal, with no evidence of acute
fracture and demonstrate evidence of degenera-
tive arthritis of the knee. If the patient is expe-
riencing too much pain to allow for an adequate exam, a knee
brace will be provided and the patient re-evaluated in the office
in 7-10 days. If there is significant ligamentous injury, the brace
will suffice for temporary stability and a follow-up MRI might
be required to fully define the extent of the injury.
Now consider another presentation. This time the mechanism
of injury is a fall from standing in an elderly woman and the
area of concern is her cervical spine. The patient has a black
eye, no history of loss of consciousness and complains of neck
pain while in the collar. There are no other associated injuries.
Plain x-rays of her cervical spine are read as normal, with no
evidence of acute fracture and demonstrate evidence of degen-
erative arthritis of the neck. The questions now are: what
should the next tests be, and can the patient be safely dis- Normal appearing Left and Right facets of the cervical spine
charged in a collar for a follow-up appointment in 1-2 weeks? from MD Computerized Tomography (MDCT) scan.
Evaluation of the cervical spine can be a difficult process, par- The presence of drugs or alcohol, an associated major skeletal
ticularly in a patient who has multiple injuries, is intubated, or or visceral injury, or a closed head injury all have the potential
who otherwise cannot reliably participate in the physical exam. to mask the presence of a cervical spine injury. However, a
However, in the patient who is alert, oriented and can partici- good clinical exam - even if the patient is intoxicated - can help
pate, a focused physical exam can greatly assist with the initial identify the presence of a fracture, and occasionally can provide
assessment. An unremarkable exam in association with a pain- sufficient evidence to direct the clinician towards a treatment
free, active range of motion after a low energy injury will often plan prior to obtaining films. Once the credibility of the clinical
allow the Emergency Department doctor, or the initial consult- exam becomes compromised the radiographic evaluation be-
ing physician to clear the cervical spine without obtaining screen- comes the primary assessment tool.
ing x-rays. The presence of a distracting injury can cloud this
When films are deemed necessary in the evaluation of the cer-
process and prompt the need for initial x-rays. A distracting
vical spine, the multi-detector CT (MDCT) scan is the most utili-
injury can range from a scalp laceration to a fracture of an ex-
tarian. It has consistently high sensitivity and specificity when
tremity, with patient-specific relevance.
identifying cervical fractures. In combination with its axial im-
See associated Bibliography online at: ages, the sagittal and coronal reconstructions are a valuable tool
AchesAndJoints.org/Trauma
Trauma Rounds, Volume 1, Spring 2010
1
2. P A R T N E R S O R T H O P A E D I C T R A U M A R O U N D S
to assess traumatic soft tissue injuries including
posterior ligamentous injuries and facet subluxa-
tion. So in the second example above, if films
are deemed necessary to assess for a cervical
spine injury, MDCT should be preferentially or-
dered over the traditional c-spine trauma series
consisting of an AP/ Lateral/ Open mouth dens
view.
Once the MDCT has been reviewed, the man-
agement controversy begins. In the setting of a
positive scan a spine consult should be obtained.
However, if the MDCT is read as normal with no
evidence of an acute fracture and demonstrates
evidence of degenerative arthritis of the neck,
can the collar be safely discontinued? At this
juncture, the safest management option is to
carefully perform (or repeat) a focused physical Left: Ligamentum falvum disruption observed in MRI - T2 image.
exam. It should start with the evaluation of the Right: C-Spine Evaluation Algorithm; Read about the 2/3 Rule in Text
midline structures, both bony and ligamentous. In the setting where the examination remains difficult to inter-
If there are no palpable defects and no appreciable tenderness pret or the patient is unable to provide feedback (intubated,
to palpation, the patient should be asked to laterally rotate his/ intoxicated, closed head injury, drugs, electrolyte imbalance,
her head from side-to-side. If this can be performed without post-seizure, etc.) an MRI will be valuable to safely allow for
pain the patient should be asked to lift his/her head off the bed removal of the collar. An MRI without evidence of an acute
and bring chin to chest. If this too can be performed without
injury and a negative MDCT should consistently provide the
pain, then in the presence of a negative MDCT the collar can be
greatest assurance that it is safe to remove the collar.
safely discontinued.
However, if there is pain with motion or tenderness with palpa- The key to navigating this often-difficult evaluation algorithm
tion despite the presence of a negative CT, the collar should stay is to remember the 2/3 Rule. If two of the three key evaluation
on until a follow-up visit with x-rays 10-14 days later. An up- studies (MDCT, MRI and credible physical exam) are negative,
right lateral x-ray in the collar should be carefully reviewed at a clinically relevant injury will not be missed.
this follow-up. If there is no sign of deformity, the focused
exam should be repeated with the collar off. If uncertainty still While a spine surgery consult is not often necessary after your
exists, active flexion-extension films would be helpful to further initial evaluation, it will be beneficial for you to have a comfort-
assess for an occult ligamentous injury. Flexion-extension films able relationship with your local spine surgeon. These surgeons
will be optimally useful if the patient is capable of actively often have defined protocols for this controversial area of man-
moving his/her neck through a full range of motion. agement and can help guide you toward the best practices.
Trauma Faculty David Ring, MD — 617-724-3953 Editor in Chief
MGH Hand & Upper Extremity Service
Mark Vrahas, MD — 617-726-2943 Mark Vrahas, MD
dring@partners.org
Partners Chief of Orthopaedic Trauma
mvrahas@partners.org George Dyer, MD — 617-732-6607 Program Director
Mitchel B Harris, MD — 617-732-5385 BWH Hand & Upper Extremity Service
Suzanne Morrison, MPH
Chief, BWH Orthopedic Trauma gdyer@partners.org
(617) 525-8876
mbharris@partners.org Please send correspondence to: smmorrison@partners.org
R Malcolm Smith, MD, FRCS — 617-726-2794 Mark Vrahas, MD / Trauma Rounds
Chief, MGH Orthopaedic Trauma
Yawkey Center for Outpatient Care, Suite 3C Editor, Publisher
55 Fruit Street, Boston, MA 02114 Arun Shanbhag, PhD, MBA
rmsmith1@partners.org
David Lhowe, MD — 617-724-2800
MGH Orthopaedic Trauma
Linda Honeycutt: May 5, 1944 - April 10, 2010
dlhowe@partners.org Thank you for all the years you took such good care of our patients
& staff. We miss your smile, wit and easy manner.
2
Trauma Rounds, Volume 1, Spring 2010