ORTHOPAEDIC SURGERY

1. Spinal injuries
DR.HAFIZ-UR- REHMAN
Assistant Professor orthopaedic surgery
Postal address
Orthopaedic Clinic APWA Medical Complex
Ground Floor (Opposite: I B A & Ankal Seria Hospital)
GARDEN ROAD, SADAR, KARACHI- PAKISTAN.
Cell no. 0092 331 3 50 30 55
Email: hafeez.ortho.pk@gmail.com,
hafeezortho@yahoo.com

2. ORTHO PAEDICS
Nicholas Andry a French physcian
in 1741 credited for coining the term,
orthopaedics from two words
Ortho = striaght
Paedics = child
.

3. INVESTIGATION
LOCAL EXAMINAION
SYSTEMIC EXAMINATION
GENERAL PHYSICAL
EXAMINATION
HISTORY ( His /Her + Story)
DIAGNOSIS
?
?

4. Spinal
injuries
Trauma is the study of medical problems associated with physical injury.
The injury is the adverse effect of a physical force upon a
person.
Important Structures
The important parts of the cervical spine include
bones
joints
nerves
connective tissues
muscles
& spinal segments .

5. VERTEBRAL COLUMN (Spine or Bck bone)
7 Cervical
12 Dorsal
5 Lumber
5 Sacral
4—5
Coccygeal

6. Bone is specialised connective
tissue, providing a rigid
skeleton,an important
shape,protecting vital
structures, mineral storage
house and muscles attachment
which move joints on their
actions.

7. Suprior surface of the Atlas . C1 Nerve divides into
anterior & posterior rami just behind the Atlanto
occipital joint, lies in the groove beneath the
Vertebral artery.

8. Anterior & Lateral views of the 2nd
Cervical Vertebrae AXIS.

9. Essential
characteristis of
cervical
thoracic
&
Lumber
vertebrae.

10. CERVICAL SPINAL VERTEBAE
The cervical spine is the most
mobile area of the spine, and as
such it is prone to the greatest
number of injuries.
Injuries to the cervical spine and
spinal cord are also potentially
the most devastating and life
altering of all injuries compatible
with life.

11. Spinal injuries
carry a double
threat: damage
to
the vertebral
column
and damage to
the neural
tissue.

12. INCIDENCE of spinal cord injury range from 27 to
47 cases per million population per year. In the
world.
Road traffic accident is leading cause of spinal
injuries.
Pre- hospital survival and life expectancy of spinal
cord injury victims have improved.
United States 10,000 spinal cord injuries occur each
year.
80% of the victims are younger than 40 years.
80% of all people who suffer from spinal column
injuries are male.
60% of injuries to the vertebral column in patients
older than 75 years are presented with h/o fall.

13. In younger patients,
45% of injuries result from motor vehicle accidents,
20% from falls,
15% from sports injuries,
15% from acts of violence,
and the remainder from other causes.
3.5
3
2.5
2
1.5
1
0.5
0

14. Pre- hospital survival and life expectancy of
spinal cord injury victims have improved.
Why ? How?
Patients with cervical spine injuries are dying
secondary to respiratory complications.
The approach in treating these patients is early
recognition of cervical spine injuries with rapid
immobilization to prevent neurologic
deterioration while the evaluation and
treatment of associated injuries are carried out.

15. After the patient is stabilized,
the goals are restoration and maintenance
of spinal alignment
to provide stable weight bearing and
facilitate rehabilitation.
A T L S-------------------ABCD

16. Mechanism of acute traumatic injuries
Mechanism of injury The spine is usually injured in one of two ways:
(a) a fall onto the head or the back of the neck; and (b) a blow on the
forehead, .
which forces the neck into hyperextension. Fractures may
occur with minimal force in osteoporotic or pathological bone.

17. Indirect injuries usually occur when the spinal
column collapses in its vertical axis, typically in
a fall from a height or when someone is
trapped under a cave in; the direction of force
at any level of the spine is determined by the
position of the vertebral column at the
moment of impact. The flexible cervical and
lumbar segments may also be injured by
violent free movements of the neck or trunk.
or a sudden jerk of the neck following a rear-end
collision (whip-lash injury

18. The important types of displacement are:
(1) hyperextension;
(2) flexion;
(3) axial compression;
(4) flexion and compression combined with
posterior distraction;
(5) flexion combined with rotation and
shear; and
(6) horizontal translation.

19. . However, there is
always the fear that
movement may cause or
aggravate the neural
lesion;
hence the importance
of defining these injuries
as stable or unstable.
Cervical Spinal
immobilisation
Spinal log roll.

20. Stable and unstable injuries
these terms have specific meanings: a
stable injury is one in which the vertebral
components will not be displaced by
normal movements so that an undamaged
cord is not in danger;
an unstable injury is one in which further
displacement may occur.
. The three elements are:
the posterior complex,
the middle component
and the anterior column.
This concept is particularly useful in
assessing the stability of lumbar injuries.
the posterior
complex
the
anterior
column
the
middle
compo-nent
Denis’ classification
of the structural
elements of the spine

21. In assessing spinal stability, three osseo ligamentous
complex consisting of the pedicles, facet joints, posterior
bony arch, and interspinous and supraspinous ligaments;
a middle component consisting of the posterior third of
the vertebral body, the posterior part of the
intervertebral disc and the posterior longitudinal
ligament;
and the anterior column made up of the anterior two-thrids
of the vertebral body, the anterior part of the
intervertebral disc and the anterior longitudinal ligament.
Denis has suggested that, for instability to occur, both
posterior and middle elements have to be disrupted; this
is true particularly of the thoracolumbar spine.
Fortunately, only 10% of spinal fractures are unstable and
less than 5% are associated with cord damage,

22. Diagnosis
Every patient who has suffered a major accident should be
fully examined
his clothes may have to be cut from his body
with the least possible disturbance of position.
With an unconscious patient, awareness is everything;
the force producing a serious head injury may also injure the
neck
Any complaint of pain or stiffness in the neck or back should
be taken seriously, even if the patient is walking- or moving
without apparent difficulty.

23. With the patient supine, the chest and abdomen can be
examined for associated injuries.
Next the limbs are quickly examined for evidence of
neurological damage.
To examine the back, the patient is turned onto one side with
extreme care using a log-rolling technique.
The spinous processes are carefully palpated.
Sometimes a gap can be felt where ligaments are torn; this, or
a haematoma over the spine, is a sinister feature.
The bones and soft tissues are gently tested for tenderness.
Movement of the spine can be dangerous
avoided until a diagnosis has been made.
A full neurological examination is carried out in every case; this
may have to be repeated several times during the first few days.

24. Initially, during the phase of spinal shock, there may
be complete paralysis and loss of sensation below the
level of injury.
This may last for 48 hours or longer and during this
period it is difficult to tell whether the neurological
lesion is complete or incomplete.
It is important to test for the primitive anal skin reflex
and for perianal sensation.
Once the primitive reflexes return, spinal shock has
ended;
if there is still loss of all motor and sensory function
the neurological lesion is complete.
Intact perianal sensation a suggests an incomplete
lesion, and further recovery may occur.

25. Imaging The x-ray examination is crucial.
It should be carried out with the least possible manipulation of the
neck or back, yet it must be complete enough to provide the
essential information.
Lateral views of the cervical spine must include all the vertebrae from
C1 to T1; unless the vertebrae are actually counted, a low injury may
be missed.
Anteroposterior views must include the odontoid process.
Oblique views also may be necessary and it should be remembered
that more than one area of the spine may be damaged.
CT Scan is invaluable for showing fractures of the vertebral body or
the neural arch, or encroachment on the spinal canal.
MRI is helpful in displaying the soft tissues (intervertebral discs and
ligamentum flavum) and lesions in the cord.