Anterior Column Fractures Wedge Fracture, stable fracture Causes: • Hyperflexion force • Axial force • Osteoporosis • Codfish spine appearance: biconcave appearance of vertebral end plates www.pgblazer.com/2009/11/ anterior-wedge-compr... Middle Column Fracture Burst fracture • Axial force Lower arrow points to intrusion into the spinal canal -more sci involvement radiographics.rsna.org/.../4/1009.figures-only Posterior Column Fractures All three columns have a fracture. This particular fracture is called a Chance fracture Notice the almost horizontal line through the spinous process and the compression fracture anteriorly Caused by a seat belt, Force is hyperflexion, distraction and impaction forces www.learningradiology.com/archives06/COW%2021... Stable or unstable fracture? Fractures Compression Fracture: wedge compression fracture of the vertebral body. MOI: flexion force or lateral flexion a. Posterior ligaments and posterior bone elements are intact b. Kyphotic angulation less than 10 degrees c. Loss of anterior vertebral body height is less than 40% d. Relatively stable injury Unstable Compression Fracture • Angulation is greater than 20 dg • Loss of 50% or more of anterior height • Creates pull on posterior ligaments of the spine – supraspinous, interspinous,ligamentum flavum or facet joint capsule Stable Burst Fracture: MOI: axial loading force (compression force) a. Anterior and middle columns are disrupted, posterior column is uninjured b. Kyphosis is limited to 15 degrees c. Loss of vertebral body height is less than 50% d. Neurologically intact Unstable Burst Fracture MOI: axial force (compression force) a. Anterior and middle columns are disrupted • Retropulsion of posterior column fragments into the vertebral canal occurs b. Pedicle widening on x-ray c. Neurological injury varies based on the level of injury rather than the canal compromised by bone fragments d. Fractures above L2 have greater neurological involvement anything below L2, have very mobile nerve roots so they can get out of the way or find away around the fracture. Flexion - Distraction injury MOI: seat belt injuries, lap belt injuries a. Failure of posterior elements in tension while the anterior and middle columns are compressed b. Widening of the spinous processes c. Vertebral body is wedged anteriorally d. Variable neurological involvement -Middle and Anterior Column. Chance Fracture MOI: hyperflexion injury over a secured lap belt (usually in back seat, flexion over the lap belt, fractures right into gut) Type of flexion distraction injury – involves more structures • Tension failure of all spinal bone elements and/or ligaments – anterior, middle and posterior columns • Bowel injuries occurs in 65% • No compromise of anterior elements occurs only when the injury is primarily ligamentous • Surgical candidate Compression Torsion/Translational injuries MOI: shear force or rotary force with compression a. Force will fracture or dislocate facet joints b. Neurological involvement occurs c. Surgical candidate RX for different fractures a. Stable fractures without neurological deficit: d. Unstable fractures with incomplete neurological deficit: • surgery is usually not needed • May or may not stabilize with internal fixation at first. b. Unstable fractures without neurological deficit: • External immobilization for 1216 weeks • Dependent upon improvement noted with a log rolling frame • Operate if neurological deficit becomes apparent e. Unstable fracture with complete neurological deficit: c. Unstable fractures with progressive neurological damage: Paraplegia • will operate within 48 hours for stabilization • Reduction of fracture and internal stabilization - with or without a fusion Indications for Immediate Surgery a . Advancing or progressive neurological deficits -get weaker, or can not move “big toe” -Reflexes check b. Paraplegia in absence of bony injury c. Severe nerve root pain -Usually a boney fragment. Rib Cage Fractures 1. Minor: simple rib fracture, in 1 spot, do not do much. 2. Major: fracture of 1 or more vertebrae resulting in a flail chest and/or a hemothorax or pneumothorax Copyright 2004 Nucleus Communications, Inc. All rights reserved. www.nucleusinc.com Rib Fracture SX: pain on inspiration Signs: palpable defect, tender to palpate, ecchymosis -Ask to breath in deep “if pain” then suspect a rib fracture. Or tap, vibrate to see if pain, symptoms increase. RX: simple fracture: can just bind the ribs to assist with pain management and coughing, will become stable within 1-2 weeks and heals by 6 weeks Flail Chest Definition: segment of the chest wall doesn't have continuity with the rest of the thoracic rib cage (two fractures of same rib-floating) Signs: Paradoxical motion occurs: moves in on inspiration and out on expiration splinting of chest wall muscles, decrease ventilation, decrease vital capacity, when breathing it will do the opposite of what ribs are suppose to do. Lab tests: x-ray and blood gases help to make a positive diagnosis http://www.cvmbs.colostate.edu/clinsci/wing/trauma/flail.htm Joint Dysfunctions Rib Cage Dysfunctions 1) Costochondritis: anterior chest wall syndrome • pain in the costochondral articulation without swelling, • affects T3,T4,T5 costochondral junction • Similar signs to MI so people may jump to conclusion COSTOCHONDRITIS Risk factors: women more than men, over 40 years old SX: pain and tenderness in the anterior chest wall, may radiate to the shoulder or arm, aggravated by sneezing, coughing, inspiration, bending, lying down or exertion Signs: pain with palpation over the costochondral joint, *also commonly a structural dysfunction, as something is irritating the cartiatlage Tietze's syndrome Tietze's syndrome is similar to costochondritis. SWELLING only Difference!!! The difference between the two is that there is swelling over the costal cartilage with Tietze's syndrome and not with costochondritis -some research says Tietze may be the “acute” form. Scoliosis Definitions: A lateral curve of the thoracic or lumbar spine or a combination of thoracic and lumbar curves Primary Curve: first curve or earliest curve to appear in the thoracic or lumbar spine Secondary Curve: curve above or below a major curve Major Curve: largest structural curve Minor Curve: smallest curve, more flexible Apical Vertebrae: vertebrae which is furthest from the vertical axis of the vertebrae End Vertebrae: The vertebrae are at the ends of the curve and are maximally inclined toward the concavity of the curve. a. cephal: most cephal vertebrae maximally inclined toward the concavity b. caudal: most caudal vertebrae maximally inclined toward the concavity Rib Hump: Rotation of the thoracic spine which is noted in a flexed position. As the patient flexes forward, the ribs push posterior on one side of a scoliotic curve. Rib Hump Apparent Deviation: Line from the sacrum (gluteal cleft) to the SP of C7. Deviation occurs when there is a linear distance between the vertebrae at C7 from the linear distance at the sacrum. Indicates curve compensation. -how much compensation. Etiology Idiopathic: unknown cause 1) infantile: onset less than 3 years of age. 80 90% will resolve 2) juvenile: 3-10 years of age brace if curve is greater than 30 dg and less than 45 dg surgery if curve is greater than 45 dg after bracing -checked in school 3) adolescent: onset is puberty ~ 10 years of age until skeletal maturity Paralytic scoliosis: muscle Neurofibromatosis Have “cafe au lait” spots, in ped populaiton. Adult Scoliosis Adult Scoliosis: spinal deformity may be more rigid Spinal stenosis, DDD, osteopenia are associated pathological conditions which may contribute to an increase in Cobb angle SX: pain on the convex side of the curve due to muscle fatigue Prevalence, Risk factors, Surgical Considerations a. 5 % of all scoliotic curves are greater than 10 dg, .04% exhibit curves greater than 20 dg b. greater the angulation and rotation of the spinal curve, the higher the possibility of curve progression. c. younger the child when diagnosed, the higher the possibility for curve progression Likeiness of Curve Progression d. Risser Score of skeletal maturity: score of 1 or less, higher possibility for curve progression -Gives skeletal “age” of a person by epiphyseal plates. e. A shorter curve progresses more f. the higher the curve in the spinal column, the more likely the curve is to progress -No stable base g. the stiffer the curve in an immature individual and the more flexible the curve in a mature individual, the more likely the curve is to progress Radiographic Assessment 1. Cobb Method: preferred method of curve measurement. Very consistent between examiners a. caudal and cephal end vertebrae are identified. b. parallel lines to the end plates are drawn into the concavity of the curve c. lines drawn at right angles to the parallel lines will intersect at an angle. d. angle is measured for the degree of curvature Cobb Method. Identify caudel and cephal end vertebrae Draw parallel line Draw perpendicular lines Measure angle of curve http://www.rad.washington.edu/mskbook/scoliosis.html 2. Risser Scale Indicates the ossification of the iliac epiphysis which begins at the ASIS and ends at the PSIS *Ossifies Anterior to Posterior a. Grades 0= 0% has closed,1= 25% or less has closed,2 are skeletally immature: 50% or less has yet to ossify b. Grade 3: progressing skeletal maturity: 75% or less has closed c. Grade 4: end of spinal growth, epiphyseal plate has closed but not fused =100% or less has closed d. Grade 5: epiphyseal plate has fused Greulich and Pyle Atlas 3. Bone age: radiograph of the left wrist and hand and compared to standards set forth by Greulich and Pyle Atlas -compare to a series 4. Moire Thermography: heat pictures, from the muscles Other Testing: 1. Pulmonary function tests: curves • greater than 70 dg have a decrease in vital capacity Management of Scoliosis 1. Goals of treatment: a. prevent progression and maintain balance b. maintain respiratory function c. reduce pain and preserve neurological status d. Cosmesis- important for the kid e. combo of bracing and physical therapy evidence says is best Non-operative treatment of scoliosis a. observation in curves less than 25 dg in skeletally immature patients and less than 50 dg in skeletally mature patients b. exercise in combination with bracing may be effective, without a brace has been proven ineffective in stopping the progression of a curve. c. Bracing occurs with any curve greater than 25 dg in a skeletally immature patient Milwaukee CTLSO Bracing Milwaukee brace (MWB) or cervical-thoracic-lumbarsacral orthosis (CTLSO) - curve has an apex at T8 or higher - provides pressure over the point of maximum convexity, traction between the occiput and the pelvis -Tries to stop curve at all parts, for T8 or higher, provides distraction http://milwaukee.brace.nu/Links2.html Boston TLSO Bracing Boston Bracing System or thoracolumbar-sacral orthosis (TLSO) - pads are applied laterally below the apex of the curve - no head piece - works best with apex of curve lower than T8 Goals Stop curve progression with either type of bracing. The physician will look for a 50% reduction of the curve with the brace on Brace is worn 23 hours a day until a Risser 4 is reached and, if female, two years after menarche Patient will be weaned off brace for 1 year Patient will be followed up with a physician visit every 6 months and repeat x-rays every 12 months Surgery Indications: progressive curve 40 - 50 dg in growing children failure to prevent progression of the curve with bracing or cannot get a 50% correction with the use of a brace progressive curves greater than 50 dg in adults. Goals: prevent progression of curve - spine and pelvic balance are more important than curve correction - prevent respiratory compromise - prevent back pain or decrease it - cosmesis Types of Surgery posterior fusion anterior fusion combination of anterior and posterior Instrumentation - Harrington Rod techniques - Drummond's technique using a combination of Harrington Rod's and Luque rods/wires - Luque rod with segmental sublaminar wires - Multiple hook systems Thoracic Spine Dysfunctions Scheuermann's Disease: juvenile kyphosis, vertebral epiphysitis Etiology: may be secondary to repetitive trauma, growth retardation or vascular disturbances are all hypothesis MOI: stress fracture of the anterior aspect of the vertebral endplates. Scheurmann’s Disease Vertebral wedging of at least 3 consecutive vertebra End plate deformities -box is shorter, angled Scheurmann’s Disease: Diagnostic Criteria Thoracic kyphosis > 45 deg (25 to 40 deg being normal); Wedging > 5 deg of three adjacent vertebrae Thoracolumbar kyphosis > 30 deg (thoracolumbar spine is normally straight); Scheurmann’s Disease DX: lateral radiograph shows decrease in disc height, vertebral end plate irregularities such as Schmorl's nodes may occur Risk factors: adolescents, males and females about equal, autosomal dominant Scheurmann’s Disease SX: back pain, worse with prolonged activity or standing for long periods of time, relieved by rest Signs: acute thoracic kyphosis and an increase in lumbar lordosis, local tenderness to palpation, limited extension & painful, sensory and motor exam is normal Conservative RX: •Pain •At least two more years of skeletal growth remaining •Brace •Active exercises concentrating on extension, can help prevent, Surgical Candidates: • Apical wedging severe deformity with disabling pain • Neurologically compromised • Continued progression despite conservative treatment Type of surgery: • Fusion if the curve is greater than 70 dg and rigid, severe DISH: Diffuse Idiopathic Skeletal Hyperostasis, Ankylosis hyperostosis Definition: common disorder, osteophytes develop into bony spurs that may join to form bridges to each other Can occur in thoracic, lumbar or cervical spine Type of Enthesopathy DISH Ossification of the anterior longitudinal ligament of the spine -there is no anterior space. At least four vertebral levels Preserved disk space *If not 4 then ankylosis DISH Risk factors: NIDDM (type II) diabetes, males 2:1 over females, middle aged or older Onset: insidious SX: back stiffness in the T or L spine, calcaneal pain common, the groups of ossified vertebrae will move as a group Signs: early on the examination is normal, as disease progresses, will see limitation is spinal movements Lab tests: normal or slightly elevated ESR Radiograph: calcification and ossification of the ALL in 4 continuous vertebrae, preservation of disc height, absence of facet ankylosis, SI sclerosis RX: symptomatic, treat similar to OA patients with exercise to maintain mobility especially in the peripheral joints T4 Syndrome Clinical pattern of pain and parasthesia in one or both UE’s. Head pain can also occur due to embroyonic involvement. May occur alone or in conjunction with other pathology in the T spine Area of Involvement: T2-T7, T4 almost always included Incidence and Prevelence: females > males 79% to 21%. Onset: variable SX: dull aching pain in head, one or both hands, forearms and shoulders can be affected • Symptoms are intermittent, variable during time most felt, better with movement T4 Syndrome Signs: •Positive palpation findings indicating some restriction of T spine movement •Deviation of SP from midline •Uneven spacing of SP Spondylolysis Definition: fracture of the pars interarticularis, unilateral or bilateral -Most common in Lumbar, but also can occur in thoracic and cervical MOI: stress fracture, non union -like hiking with backpack, or bending forward with gardening so muscle spasms. http://www.aurorahealthcare.org/you rhealth/healthgate/getcontent.asp?U RLhealthgate=%2211539.html%22 Spondylolysis a. Posterior elements have a reduced ability to stabilize the spinal unit b. Soft tissue undergoes plastic deformation Etiology: 5% in general population SX: •Related to activity •Aching pain in back •May radiate toward LE •Relieved by rest or decreasing activity •Stiffness noted Spondylolysis Signs: paravertebral muscle spasm, flattening of the normal lumbar lordosis, tight hamstrings, decrease in SLR motion Radiograph: collar on the Scotty Dog RX: modify activities, primary repair or fusion if patient has unrelenting pain, stabilization exercises Scottie Dog Scottie Dog Body part of Dog Anatomical Bone Segment Eye Pedicle Ear Superior articulating process, ipsilateral Nose Transverse process, ipsi Front Paw Inferior articulating process, ipsi Body Lamina Neck Pars Interarticularis Rear Paw Inferior articulating process, contra Tail Superior articulating process, contra Spondylolisthesis Definition: forward slippage of one vertebral body on another, longstanding segmental instability, spondylolysis associated with it Spondylolisthesis Five Types of Spondylolisthesis Type I is called dysplastic spondylolisthesis and is secondary to a congenital defect of either the superior sacral or inferior L5 facets or both with gradual slipping of the L5 vertebra. Type II: Isthmic (Skinny Island) Can be divided into three subcategories • Bone defect • Elongation of pars • Repeated micro fracture Stress spondylolisthesis • most likely caused by recurrent micro-fractures caused by hyperextension • It is also called a stress fracture of the pars interarticularii • much more common in males. • Usually a sport related injury: wrestling Five Types of Spondylolisthesis Type III, is a degenerative spondylolisthesis • Occurs as a result of the degeneration of the lumbar facet joints. • The alteration in these joints can allow forward or backward vertebral displacement. Five Types of Spondylolisthesis Type IV, traumatic spondylolisthesis, is associated with acute fracture of a posterior element (pedicle, lamina or facets) other than the pars interarticularis. Five Types of Spondylolisthesis Type V • pathologic spondylolisthesis • occurs because of a structural weakness of the bone secondary to a disease process such as a tumor or other bone diseases. Grading System Based on the percent displacement of the superior vertebral body on the inferior vertebral body Grade I: 0 - 25% length of vertebral body slide of superior on inferior Grade II: 25 - 50% may still not need surgery Grade III: 50 - 75% surgery more than likely Grade IV: 75-100% (surgery) *Higher the Grade the more Neurological Involvement, so Grade IV is the Worst! Spondylolisthesis SX: pain in the back, buttock or thigh. unilateral or bilateral aching, pulling, weakness, heaviness, numbness, burning Signs: pain with forward bending, muscle spasms or erector spinae muscles, decrease pain with flexed positions (such as supine with knees bent), increased with extension *Flexion in supine will decrease s(x), but flexion in standing will increase s(x). *Extension will not make it feel better, but if Spondylisis then extension will make it feel better Spondylolisthesis Radiographs: Collar on Scotty Dog - + pars interarticularis fracture, lateral flexion radiograph shows the slippage RX: conservative for 6 months, PT for pain management, lumbar stabilization, may brace in grades II and III Spondylolisthesis Surgery: if it is a grade III or more and conservative treatment has failed Goals of surgery: prevent further slippage, stabilize an unstable segment, prevention of neurological deficits, pain relief, cosmetic, posture and gait improvement Ankylosing Spondylitis Marie Strumpell disease, rheumatoid spondylitis Definition: chronic inflammatory arthritis which leads to deformity and fusion of the spine Ankylosing Spondylitis Risk Factors: •15-40 years of age, •males 3:1 over females •(fusion of entire spins in 20 years) Onset: •insidious •complaints are related to spinal movements or sacroilitis Ankylosing Spondylitis Medical Diagnosis: • back pain greater than 3 months • decrease in spinal motion • decrease in chest expansion • sacroilitis • peripheral joint problems Lab Tests: •95% have a +HLAB27 human leukocyte antigen Radiograph: Ankylosing Spondylitis • bamboo spine in advanced stages • SI fusion in one or both sides is earliest sign Should be line, rather solid mass Clinical Manifestations: Ankylosing Spondylitis Symptoms: • • spinal pain/stiffness worse in am or after resting pain/stiffness improves with exercise Signs: • normal neurological screen • SI tenderness • + FABER's test • decrease in lumbar lordosis • rib expansion less than 2 cm Ankylosing Spondylitis PT Interventions: pain relief, maintenance of mobility, swimming Surgical Interventions: peripheral joint disease - THR Fixed Flexion deformity Review: Disc Herniation Review Definitions Bulge Protrusion Extrusion Sequestration Herniation Review Signs and Symptoms of a Disc Herniation T1-2: 1) clinical symptoms 2) signs: Motor Sensory Reflexes T2 - T11: Specific to T and L spine Thoracic discs are very stable and herniations in this region are quite rare. Herniation of the uppermost thoracic discs can mimic cervical disc herniations, while herniation of the other discs can mimic lumbar herniations. Radiation of pain around the rib cage (dermatome pattern) can also occur T12 - L3: Reflexes: none MMT: iliopsoas, quadriceps, adductors Dermatome pattern: specific to each nerve root Lumbar Spine: Most common areas are L4-5 and L5-S1 L4 Reflex: Quadriceps MMT: tibialis anterior Sensation: medial aspect of foot to big toe L5: Reflex: Medial hamstring MMT: EHL Sensation: middle toes, dorsum of foot, big toe S1: Reflex: Achilles MMT: peroneus longus and brevis, gastroc soleus, gluteus maximus Sensation: little toe, outside of calf, lateral aspect and plantar surface of foot Spinal Surgeries Decompression Back Surgery •Small portion of the bone over the nerve root and/or disc material from under the nerve root is removed to give the nerve root more space and provide a better healing environment. Microdiscetomy Best for treating radiculopathies rather than back pain Open Decompression Laminectomy: • Indications: spinal stenosis, herniated disc • Remove lamina and facet joints are trimmed a bit to give nerve more room • Success rate: 70-80% improve function, decrease back/leg pain kyphoplasty http://www.spine-health.com/video/kyphoplasty-osteoporosis-fracturetreatment Spinal Fusion http://www.spine-health.com/video/spine-fusion-surgery-video Thoracic Spine: Radiographic Views Standard Views •AP View •Lateral View Special Views •Swimmers View •Oblique Views •Utilized for viewing the sternum •Coned Views of thoracolumbar region or other specialized areas Radiology Thoracic spine radiology 1. Anteroposterior view: 2. *Know by the heart on the left side visible. • • • • • • • • Thoracic vertebral bodies The intervertebral disc spaces Alignment of the pedicles Spinous processes Transverse processes Articular processes and the Costovertebral joints Posterior ribs. www.ceessentials.net/article32.html Keys to viewing Alignment: • In this view, pay attention to the position of the pedicles, they will indicate any rotation of the thoracic spine • Symmetry of the vertebral bodies: any change in symmetry or curve of the spine Bone Density: • In this view, check each vertebral body, does one or two or many of them appear to have a different radiolucency than the others? Cartilage Space and Disc Height Cartilage: •SC joints are easily seen due to overlay of vertebral spine •Costovertebral joints can be seen – better in upper thoracic than lower Disc Height •should appear similar as you move down the spine Soft Tissue Heart shadow should be on the patient’s left side Lungs should appear black due to the amount of air Diaphragm should be overshadowing the lower ribs and vertebral spine This view is often used to detect the presence of pneumonia as lungs won’t be as dark Pedicle Position: Rotation of the spine is determined by the position of the pedicles in relation to midline. The closer to the midline a pedicle is, the more rotation is occurring to that side. Distance between the pedicles represents the transverse diameter of the spinal canal (Nash CL, Moe JH. A study of vertebral rotation. J Bone Jt Surg Am 1969;51: 223-229.) Nash-Moe Method Grade Pedicle Displacement 0 = no rotation of the vertebral body 1 or + = minimal rotation of the vertebral body 2 or ++ = pedicles on the concave side of the spinal curve rest on or near the margin of the vertebral body 3 or +++ = only one pedicle is seen and it is nearing the midline 4 or ++++ = the only visible pedicle is seen beyond the midline of the vertebral column 2. Lateral view: Demonstrates the thoracic vertebral bodies, intervetebral disc space First 2-3 vertebrae are not easily seen because of the shoulder and scapula being interposed between the body and the film. *Swimmers view gets the arm up and out of the way www.ceessentials.net/article32.html Alignment 3 column classification system by McAfee This picture includes a little more of the posterior structures than the one in the book http://www.hawaii.edu/medicine/ pediatrics/pemxray/v6c13.html Swimmer's View A lateral view with arm closest to film is raised to see vertebrae C7-T1. *Therefore wrong view for Justin as his pain is T7. www.ceessentials.net/article15.html Computed Tomography Picks up problems with the posterior elements best Highly effective and accurate in diagnosis of fracture Evaluates spinal canal well 2-mm axial sections has a confidence level of 98% that a fracture will be seen (Nadalo, Moody, 2007) Axial CT’s may miss small compression fractures Magnetic Resonance Imaging Superior to CT scans in detecting herniated disk, ligamentous edema and spinal cord compression: see arrows Does not pick up bone fractures as well as CT Minimally displaced fractures are difficult to see http://www.neurology.org/cgi/content-nw/ full/69/24/E41/F117 Schmorl Nodes Herniation of the disc through the end plate of the vertebral body May or may not be symptomatic More schmorl nodes MRI T2 sagittal image of large schmorl node Axial CT radiopaedia.org/articles/schmorl_nodes Rib radiology Standard Views: •AP or PA •Above Diaphragm or below Diaphragm •Anterior Oblique •Posterior Oblique Anteroposterior (AP) or Posterioanterior (PA) AP: posterior ribs are closest to the film cassette PA: anterior ribs are closest to the film cassette -used to look at lungs for pneumonia Also, note views are taken as above the diaphragm or below the diaphragm Alignment: •Thoracic vertebrae •Pedicles •Ribs Density: Uniformity of bone appearance Rib Fractures http://emedicine.medscape.com/article/395172-media Standard AP view Oblique View These are the same patient, elderly female, minor fall Axial CT of Rib Cage and Lungs Black arrow – rib fracture White arrows – pneumothorax http://emedicine.medscape.com/article/395172-media Ultrasound and Rib Fractures Lumbar Spine Oblquies: Scooty Dogs -will have a lateral view -Also cone-in view for L5 and Sacrum -look for where heart is, and it should be listed on the X-ray.