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Cervical Spine Trauma for Orthopaedic Exams
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Cervical Spine Trauma for Orthopaedic Exams
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Language: EN.
Segment:0 .
FRCS teaching webinar, the topic tonight is about cervical trauma. This is presented by ataa Siddiqui, who is a spinal senior fellow from London, and he's one of the senior mentors in this group.
I'm curious about I'll be moderating the session for you. And we have Kashif on also one of the senior mentors here to support us. If anyone has any question or you'd like to take part in the Viva practice session, that's after the presentation. Please raise your hand symbol or send a message through the chat option. Yeah, and just a reminder that everyone who attends is eligible for a CPD certificate is contact me through the telegram group or Facebook.
If you want to request one, and as you all know, that presentation will be recorded and edited and then afterwards published on the YouTube channel orthopedic fellowship preparation course for you to revise over to you at ulnar nerve, please. OK, guys, good evening. So today's topic would be cervical spine trauma or cervical spine curriculum. The curriculum is exhaustive, so I wouldn't be able to cover everything.
However, I will try and cover all the questions that has been previously asked. It's only subtopic of a spine topic, and it's unlikely that you get asked it very often. However, one spine question or two spine questions do pop up in the exam and whether it comes in your path, whether it comes in your trauma, whether or whether it comes in your short case, long case, long case, it's unlikely. The only known case that comes with that involves cervical spine is actually a reumatoide or spine a spinal cord technology.
However, we will. Today's topic is cervical spine trauma, so we start. So basically as a part of cervical spine trauma, all patients with all trauma patients have got cervical spine, cervical spine trauma, cervical spine trauma. Unless proven otherwise, cervical spine trauma has to be cleared both ideologically and physically. Physical examination involves obviously verification, look, feel, move and special test as of any other orthopedic examination up in a trauma setting in an Atlas setting where there is OA breathing, circulation and circulation gums or breathing comes with cervical spine, cervical spine immobilization and in line traction.
So basically, at that stage, you just press around the cervical spine, make sure you cannot find any gaps, any, any, any point of tenderness or any steps. Other clinical evaluation involves evaluation of any neurology that can present in terms of radiotherapy, mono, lateral, bilateral or signs of complete cord damage.
In terms of x-rays, cervical spine, lateral x-rays used to be part of the curriculum initially whittles. It used to be part of jaitley's as well and some hospitals it get done and it's a very favorite example where they ask you where they show you a lateral cervical spine x-rays. They ask you things about there are a few questions about this lateral cervical spine x-rays one whether the spine X-ray is adequate or inadequate and you have to see the superior border of the T1 for you to say that it's adequate x-rays.
Also, you need to comment on the four lines, which has been mentioned there. The intervertebral line will see a vertebral line, spinal Lemonnier line and spine. All these lines are self-explanatory. If the vertebral anatomy and any disruptions in those particular lines will give you an idea as to what is going on. So syrinx is defined as confirmation of the absence of the cervical spine injury.
We have talked about a physical examination in radiographs. Previous previous. Slide only Kessler. We have talked about physical examinations and radiographs, and we just wanted to make sure as to why it is important. One high rate of cervical spine injuries is there due to inadequate. Imaging of affected level, a loss of consciousness and will this multi-system trauma means there are distraction injuries.
Also, when one spinal injury is present, there is a reported, as you all know, that there is a 10% to 15% chance of patients having injury. In other parts of the spinal column as well. Now, a removal of cervical collar without radiographic studies is another paramount of your rattles. And as you attend the trauma, you need to take that and there are strict indications for that.
The indications are patients should be awake, alert and not intoxicated, has no neck pain, tenderness or neurological deficit, and has no other distracting injuries that is causing that. OK, now we come to the core topics now, the first topic is the occipital condyles fractures. The occipital condyles fracture, also called as C not fracture is fracture of new cervical junction.
It is 1, 2, 3 types, as you can see in this video. On the slides, sorry, not in the video on the slides. Type one is compression, type 2 is direct glue and type III is rotational. The reason why this we, we need to know about this malfunction is because of its high mortality rate. If you see an occipital condyles fracture, there's more than 10% chance that are roughly around 11% chance that you can die because of where it is, obviously.
All the ligaments in stability should be assessed at that stage and the radiograph of choice. Our imaging of choice would be CT scan, MRI scan and further evaluation as appropriate. Now most of these injuries are treated with the rigid colon or semi traject color like Miami colleagues. However, very unstable injuries will be treated with just type III type of injuries where you see the display segment behind the bag.
These these sort of injuries. You can create with claw palsy three posterior traditions. The only thing what you need to know is there are three types it's compression be a direct blow or rotational type. Type 3 is the one which is the most unstable one unstable one. And if it comes to the treatment, it requires some sort of fixation, mainly posterior. The reason why we are discussing it because of its high mortality if.
If we fracture it, OK, now we come on to the other side, please category. If you go on to the other side. I think I have either. So, yes, so orthopedic manifestations that can be is because why is it important to go back to the other side so it's manifestations that can come here to you?
The other orthopedic manifestation that can be here will be either cervical spinal cord injury or trauma. Medical manifestations can come as well because it's a. It's a direct blow to the head, a head in form of intracranial bleed, brain stem vascular lesions or elevated intracranial pressure. OK, we go on to the instability for the next slide. So the next a next slide would be for Atlanta axilo instability.
This is again a part of a fascist curriculum, and it can come in any question. For all practical purposes, you will see Atlanta axilo stability and rheumatoid patient. It can be a part of your long case where they are once you are done everything and you have come up to the level where you are discussing instability. Is it important in rheumatoid patients to have lateral spine x-rays as a part of preoperative planning?
Is Atlanta ADA and space available for code so that you can plan ahead? Your and ethicists have that information. Your interest is to have this information on hand, and you can talk about either fiber optic, awake intubation or any intubation that doesn't require hyperextension or hyperflexion of the is Down syndrome again in young, patient or in pediatric causes where you can have juvenile rheumatoid arthritis or the Atlanta axilo subluxation.
So remember these epicondyle Allen ligament complex. There are they're called transverse ligament, a vital ligament and Allen ligament. Remember that transverse ligament are the most important stabilizer and we would know about it in the homolateral fracture later on in the presentation by Allen ligament is a midline structure and Allen ligament repair surgical ligament, and they are responsible for instability.
Anterior posterior instability. If fracture. Remember that oral died have got multiple ossification centers and these are the ossification centers that there are guys may have this MSK or the Kyokushin in your. In in your part one. However, these questions can come in your part, too as well. So remember the ossification centers remember about the also known point, which is which you should know as well, because you can get easily caught by mistaking also employed as a type to put great fracture.
I also remember important stuff about these fractures, just remember important stuff, the more the first important structure is, it actually is in bimodal fashion. Yes it occurs in bimodal fashion. Like it, it can happen in a lonely hour, it can happen in young patients. Why can it happen in young patients? Because their necks are very mobile and then it hinges on the ulnar claw?
The other important, as I said to you about also, I didn't just remember it because it can look like a type Ii old and quite fractured on x-rays, on a lateral x-rays. So someone just ask how to differentiate between also the ahead and type 2. It's very hard. Ct scan can tell you type 1 is an oblique building fracture of the tip of rheumatoid due to a vision of a ligament.
Type 2 is a fracture to the waist. This is this is tough and always, always remember that type 2 is the one where you can think about high non-union, high non union rate, and it is due to the disruption of the blood supply type III fracture extend into the cancerous body, and it involves variable portion of the 72 to. It's actually a good thing because if it involves a more joint, if it involves more surface means it is going to, it is going to.
It is going to heal quicker, even in a rigid color of this 0.08 fracture. Like everything else, 1 to 3 normal period of treatment, non operative treatment should be for type 1 and type III. And in patients who are obviously very old and unlikely to. Unlikely to sustain or an aesthetically fit for such an extensive surgery.
The second treatment is either halo bracing or rigid color. And the third treatment is surgery. Always remember you. You're not going into the nitty gritty of what surgery you would like to perform. Always start small and then build up on it. The smallest thing to say here is surgical fixation. Then they will go, they will say, what surgery? Now you are getting into the gold.
Gold marks. So what Suzy means either anterior or posterior stabilization. What do you mean by anterior stabilization and stabilization is to the same anterior approach where you put one screw. However, fracture pattern is quite important in this type of surgery as to which side the fracture is going. And so if it's andeer superior and posterior inferior, the screw can go in from the front without displacing the fracture.
However, if it's a reverse fracture where interior is inferior and posterior superior, you try to put the screw in from the front. The fracture will displaced more so these things. These are small points, which they ask, and that's why this fracture treatment is important. The other thing to say here is the posterior fixation. What is the problem with fixation? This is common FR situation.
So the posterior fixation is because you are operating. So close to vertebral artery and you have to have preoperative CT angiogram or CT for your planning of. Of your bas status instrumentation, so remember these two points and then and then you will be OK. So we move on to traumatic next slide, which is traumatic on pieces of access and because of its because of where it is and because of what?
Catastrophic injury, it it can cause injury to your spinal cord, it can cause injury to your medulla, and it can be really, really unstable because both sides of arcing circularity is fractured. And if and if it's flexion type, it has torn your PLL, which is a PLL posterior longitudinal ligament, which is again a very important stabilizer when it comes to. You know, when it comes to cervical spine and stability of the cervical spine, why do you why you should not miss it?
Because because this has got 30% concomitant cervical spine fracture injuries as well associated. And you need to screen the whole of the spine or the cervical spine if you see similar sort of displacement. Treatment wise, again, with cervical spine, if you don't know, everything's a normal, pretty rigid color, a close election, halo mobilization or surgical stabilization.
If you say these three words, you're going to pass the exam. Everyone knows the lines which we discuss the phone lines which we discuss here. You should talk about how much of subluxation of C4 over C5 and hence do not commit yourself to unilateral or bilateral. Just say it is most likely to be unilateral, taking the 25% subluxation on the way into consideration.
Yes the other clinical features you will find with unilateral subluxation is. Unilateral subluxation, as it's on one side, it is associated with more radical petty means one sided whatever side you have dislocation that sided arm pain, bilateral well associated with significant spinal cord injury, either spinal show or bilateral distribution of signs of cord compression most frequently involves our superior facet, whether it's bilateral or unilateral.
And the reason why a superior facility is involved in facial fracture because of its anatomical. Decomposition composition or because how it is in acne. Now you can give the. The descriptions on the x-rays and for exam purposes, because remember, exam happens as exam happens, it happens in the most ideal hospital in the world where you can get everything.
So needless to for as far as imaging is concerned, if you see something wrong in imaging, you know, it's not going to be a negative mark. So just make sure you say if you see physician, you get MRI and you get a CT scan. However, there are people saying curriculum. There are specific indications for MRI scan, but in your real life, if you see a face a joint dislocation, you are definitely going to do an MRI scan.
So say the same in exam. Most likely you see it and see five, 606 or seven spinal cord. We have discussed that as well. If we have a picture in your mind and and you need to have this treatment algorithm for facial dislocations if the patient is alert and so there's no getting MRI scan, the answer is yes, you assess neurovascular deficit.
Is there a neurovascular deficit? A pain is not a neurological deficit in a single nerve root distribution. If the answer is no, you can. You are getting an MRI scan. If the answer is yes, you are taking patients straight into the theaters for emergent clause reduction. Again, if at all, someone is going to ask you anything about spinal reduction, it's going to be if it's a joint dislocation reduction.
Because it has been asked repeatedly in the past, and there are few controversial controversies here of when to get an MRI scan, whether to reduce open or closed. And what are the indications of anterior first possible second possible first and second stabilization. So have a clear picture in your mind as to how you are going to portray yourself in the exam and what are you going to say?
So if I were you, if I'm going for the exam and if I see facial dislocation with ridiculous Betty all or bilateral involvement. I would always say I'm going to get a CT scan and I'm going to get an MRI scan. And depending on the MRI findings, I will take the patient. I will discuss it with the National spinal injury unit. However, if I'm the regional spinal injury unit, the principal for emerging close election would be adequate anesthesia, sedation, supervision of the respiratory function indicators and serial cross stable lateral X-rays.
Remember also when you are reducing it, say some sort of reduction tool, whatever you have in your hospital. We use garden tongs. They are readily available supraorbital two points on one side of our little one pin on one side. When you are putting the pins on the patient to close the AIIS so that he doesn't have any problems. And then gradually increase axilo traction on the weight, there is a strict protocol about the weight, as well as to how much weight you can use per face a joint dislocation, but it has to do with body weight.
So no one can remember it. I'm not going to tell it. You just say it has. It has to do with body weight. I will be guided by the spinal surgeons or the regional trauma unit, whatever they say. If you find an interior disk on an MRI scan, you cannot do a close election. So it has to be patient, has to be blighted to the original spinal injury unit, have an interior cervical vasectomy decompression and then subsequent posterior reduction and stabilize that again, because that was very important what you said, the sort of absolute indication for patient transfer to a spinal unit.
Yeah so the absolute indication for patient transfer to spinal unit, if you see an MRI, if you see a disk, pressing the cord on an MRI scan means you cannot do it in your primary hospital, irrespective of whatever neurology patients have. Because what is the first Hippocratic oath that GMC ask us to take? Do no harm to the patient? By doing a procedure which you are not trained on, you will do more damage than any good to the patient.
So to be a safe doctor. However, if you don't have the facility, if don't get tricked into this thing or deny the other national spinal injury unit is two hours away, would you not keep the patient, maybe do the anterior approach to the disc? To me, no, is the answer. If there is a disk patient need to be transferred across and have the operation because it will be an interior.
Yes, I think he's asking whether we get an MRI scan in all cases. The answer to that from if I were you, I will say yes, because if you say no, then you are stepping into their trap and then they start asking you about the indication of them to get an MRI scan. When not to get an MRI scan, you see, I'm aware of an algorithm which you really discussed.
So we move on to the next slide, but always go to the slide again, taking the closed reduction requirements and technique into consideration. Make sure that the patient is awake. Make sure there is adequate anesthesia. Make sure you have an anesthetic colleague in there. So who is going to assist you in case you give too much sedation, a component of cervical flexion also facilitates reduction.
Does it facilitate reduction so that you can lodge the superior facet behind the inferior result? And that is taking into new this attractive spine and acmi into consideration and abort if there is new neurological neurologic appears and get immediate MRI scan, irrespective of whether you got an MRI scan before or not, so that you are looking at any changes within the skull fracture situation.
Now, why is it important. This lateral mass fractures? Why is it important? It is important because it affects two motion segment and as the superior facet and the inferior facet on either side or fractures. Garden Wilton is the name of the tong's got important because it affects two level location, mostly at around C6, followed by C5 seven, 4 and D1.
Always remember that there are associated conditions or associated conditions with inferior translation of fractured vertebra, superior adjacent vertebral microfracture or inferior vertebral fracture. They are very unstable, and you need to know as to what are the parameters of instability in the next slide, you will see. And that is as much as you know, in this particular, the instability parameters are if you have more than 3.5 millimeter displacement on either side or accompanying a combine of 7 millimeter displacement.
If you have kyphosis of 10 degrees or if you have rotation compared to adjacent vertebra of 10 degrees, so it's a three dimensional thing. Again, like everything else, get a CT and an MRI scan. Don't stay confused. I like to get a CT line to get a ct, because over here you will see about 50% to 60% There is disruption of the and both posterior ligament. Which is very important stabilizer as far as fine is cancer treatment as of everything else, as I said to you in the beginning of the talk as well.
If you say normal curative treatment, semi-major Cola and cervical stabilization, that is as much you say. I want to say that it is, but I think it should suffice. The only details in treatment, what you should know, it's about the old and quite bad connection. As far as the fracture, tenotomy is concerned when you are planning a fixation and when you're planning for severe fixation, the vocabulary and the other treatment is.
They face a joint dislocation where you're either taking patients to cater for close production or if you're taking action to or if the National spinal injury unit or local spinal injury unit is taking patients rotator. For her for interior stabilization, you need to know about the desk, and maybe if you're doing very good, they will ask about the interior approach, which is the Smith Peterson approach to the cervical spine. So that approach, you need to know if you don't know the approach, don't go to the exam, either.
So these are small things and the adequacy of the examiners. You are a safe surgeon. You're not going to miss functional problems. So what you serve, guys, please always say that sentence, checking the adequacy of the X-rays and again with the facet, joint dislocations, and maybe I could. Clarify this or confirm or not. There are a lot of issues, is it universite by facet dislocation?
We keep, you know, arguing, discussing, discussing this issue, but us think as far as the exam is concerned, we don't need to worry too much. I think first investigation is first dislocation. Don't commit yourself to uni or by far settle dislocations still need to manage it more or less in a similar manner. Is that correct? Yeah, exactly. So, you know, 25% is it 30 percent?
Is it? Don't it? It it matters. It doesn't matter at all. Just everything. So someone asked, treating to say, please repeat the three things. So there are, so I will add on to it. There are two things and three things.
The thing is, how do you investigate it? You investigate it. CTM tries to delineate body and Armie Hammer. I will give you a ligament instability and all the rest of it, any court issues, any disk issues, any edema around the court. CTE, as I said, will show you the bony anatomy. Plus, if it's CT with angiogram, it will show you about the vertebral artery anatomy as well, which is important in terms of floating point.
The other thing someone asked about the three things the three things are observation observation alone to see whether the patient works with software. The second thing is semi rigid or semi rigid color or hard color, or halo halo racing following reduction. And the third thing is surgical stabilization. So in spine or in cervical spine, for that matter, if you stay as vague as possible, start small and then you can build on it, make them ask questions.
So if you say surgical stabilization, then you say, OK, what surgical stabilization options available? So you say there are two surgical in case of fracture. There are two surgical stabilization options available depending on the fracture anatomy, which is a axilo synthesis or posterior antero-supero-lateral synthesis. Then they'll say, what are the advantages and disadvantages of each?
And tenodesis synthesis is through to a very well recognized anterior approach. And if and if the anatomy allows where you can put screws from front to back without spacing the fracture, it is the favorable way of treating it because there are. Less morbidity associated with it. However, if the fracture is transfers or if it's anterior inferior and posterior superior, and if you put screws from the front, it will displace the fracture.
Then you go from the back. However, a detailed anatomy of vertebral artery placement should know, and you should mark your screw screw placement beforehand so that you're not going very close to the screw, very close to the vertebral artery. I have seen it done 5 times one of the time someone hit the vertebral artery, and it was a thank you for explaining. Thank you. And I think just to clarify again, that's a joint dislocation.
We're getting MRI scan. This is a standard exam, and I don't think we should put any controversies here. First, a dislocation and left this unless there is life threatening other after injuries. We're getting MRI scan, please. OK, so I know Miller and other things. Other books can confuse matters with this issue, but for example, if our yes, please.
My advice to you is you request an MRI. OK, so any further comment Kashif to add. No, I think I tried very well. And as you correctly mentioned, MRI because I was asked this question as well in my exams and I mentioned MRI and there was no controversy after that. Yes, if you don't see MRI, you're stepping into. Yes yeah, you're getting a difficult conversation, then you have to justify where to do MRI, where not to do MRI and all this stuff.
So I think don't go into that controversy, just say MRI and then get out of that. And as I said, also one other hot topic in the exam with regards to the cervical spine is the anterior approach. Please it carefully, and as I say, I agree with them. If you if you don't know it, don't go for the exam. This is the approach and the spine they ask about if you're going for the left side approach and only have to do spine.
Segment:0 .
FRCS teaching webinar, the topic tonight is about cervical trauma. This is presented by ataa Siddiqui, who is a spinal senior fellow from London, and he's one of the senior mentors in this group.
I'm curious about I'll be moderating the session for you. And we have Kashif on also one of the senior mentors here to support us. If anyone has any question or you'd like to take part in the Viva practice session, that's after the presentation. Please raise your hand symbol or send a message through the chat option. Yeah, and just a reminder that everyone who attends is eligible for a CPD certificate is contact me through the telegram group or Facebook.
If you want to request one, and as you all know, that presentation will be recorded and edited and then afterwards published on the YouTube channel orthopedic fellowship preparation course for you to revise over to you at ulnar nerve, please. OK, guys, good evening. So today's topic would be cervical spine trauma or cervical spine curriculum. The curriculum is exhaustive, so I wouldn't be able to cover everything.
However, I will try and cover all the questions that has been previously asked. It's only subtopic of a spine topic, and it's unlikely that you get asked it very often. However, one spine question or two spine questions do pop up in the exam and whether it comes in your path, whether it comes in your trauma, whether or whether it comes in your short case, long case, long case, it's unlikely. The only known case that comes with that involves cervical spine is actually a reumatoide or spine a spinal cord technology.
However, we will. Today's topic is cervical spine trauma, so we start. So basically as a part of cervical spine trauma, all patients with all trauma patients have got cervical spine, cervical spine trauma, cervical spine trauma. Unless proven otherwise, cervical spine trauma has to be cleared both ideologically and physically. Physical examination involves obviously verification, look, feel, move and special test as of any other orthopedic examination up in a trauma setting in an Atlas setting where there is OA breathing, circulation and circulation gums or breathing comes with cervical spine, cervical spine immobilization and in line traction.
So basically, at that stage, you just press around the cervical spine, make sure you cannot find any gaps, any, any, any point of tenderness or any steps. Other clinical evaluation involves evaluation of any neurology that can present in terms of radiotherapy, mono, lateral, bilateral or signs of complete cord damage.
In terms of x-rays, cervical spine, lateral x-rays used to be part of the curriculum initially whittles. It used to be part of jaitley's as well and some hospitals it get done and it's a very favorite example where they ask you where they show you a lateral cervical spine x-rays. They ask you things about there are a few questions about this lateral cervical spine x-rays one whether the spine X-ray is adequate or inadequate and you have to see the superior border of the T1 for you to say that it's adequate x-rays.
Also, you need to comment on the four lines, which has been mentioned there. The intervertebral line will see a vertebral line, spinal Lemonnier line and spine. All these lines are self-explanatory. If the vertebral anatomy and any disruptions in those particular lines will give you an idea as to what is going on. So syrinx is defined as confirmation of the absence of the cervical spine injury.
We have talked about a physical examination in radiographs. Previous previous. Slide only Kessler. We have talked about physical examinations and radiographs, and we just wanted to make sure as to why it is important. One high rate of cervical spine injuries is there due to inadequate. Imaging of affected level, a loss of consciousness and will this multi-system trauma means there are distraction injuries.
Also, when one spinal injury is present, there is a reported, as you all know, that there is a 10% to 15% chance of patients having injury. In other parts of the spinal column as well. Now, a removal of cervical collar without radiographic studies is another paramount of your rattles. And as you attend the trauma, you need to take that and there are strict indications for that.
The indications are patients should be awake, alert and not intoxicated, has no neck pain, tenderness or neurological deficit, and has no other distracting injuries that is causing that. OK, now we come to the core topics now, the first topic is the occipital condyles fractures. The occipital condyles fracture, also called as C not fracture is fracture of new cervical junction.
It is 1, 2, 3 types, as you can see in this video. On the slides, sorry, not in the video on the slides. Type one is compression, type 2 is direct glue and type III is rotational. The reason why this we, we need to know about this malfunction is because of its high mortality rate. If you see an occipital condyles fracture, there's more than 10% chance that are roughly around 11% chance that you can die because of where it is, obviously.
All the ligaments in stability should be assessed at that stage and the radiograph of choice. Our imaging of choice would be CT scan, MRI scan and further evaluation as appropriate. Now most of these injuries are treated with the rigid colon or semi traject color like Miami colleagues. However, very unstable injuries will be treated with just type III type of injuries where you see the display segment behind the bag.
These these sort of injuries. You can create with claw palsy three posterior traditions. The only thing what you need to know is there are three types it's compression be a direct blow or rotational type. Type 3 is the one which is the most unstable one unstable one. And if it comes to the treatment, it requires some sort of fixation, mainly posterior. The reason why we are discussing it because of its high mortality if.
If we fracture it, OK, now we come on to the other side, please category. If you go on to the other side. I think I have either. So, yes, so orthopedic manifestations that can be is because why is it important to go back to the other side so it's manifestations that can come here to you?
The other orthopedic manifestation that can be here will be either cervical spinal cord injury or trauma. Medical manifestations can come as well because it's a. It's a direct blow to the head, a head in form of intracranial bleed, brain stem vascular lesions or elevated intracranial pressure. OK, we go on to the instability for the next slide. So the next a next slide would be for Atlanta axilo instability.
This is again a part of a fascist curriculum, and it can come in any question. For all practical purposes, you will see Atlanta axilo stability and rheumatoid patient. It can be a part of your long case where they are once you are done everything and you have come up to the level where you are discussing instability. Is it important in rheumatoid patients to have lateral spine x-rays as a part of preoperative planning?
Is Atlanta ADA and space available for code so that you can plan ahead? Your and ethicists have that information. Your interest is to have this information on hand, and you can talk about either fiber optic, awake intubation or any intubation that doesn't require hyperextension or hyperflexion of the is Down syndrome again in young, patient or in pediatric causes where you can have juvenile rheumatoid arthritis or the Atlanta axilo subluxation.
So remember these epicondyle Allen ligament complex. There are they're called transverse ligament, a vital ligament and Allen ligament. Remember that transverse ligament are the most important stabilizer and we would know about it in the homolateral fracture later on in the presentation by Allen ligament is a midline structure and Allen ligament repair surgical ligament, and they are responsible for instability.
Anterior posterior instability. If fracture. Remember that oral died have got multiple ossification centers and these are the ossification centers that there are guys may have this MSK or the Kyokushin in your. In in your part one. However, these questions can come in your part, too as well. So remember the ossification centers remember about the also known point, which is which you should know as well, because you can get easily caught by mistaking also employed as a type to put great fracture.
I also remember important stuff about these fractures, just remember important stuff, the more the first important structure is, it actually is in bimodal fashion. Yes it occurs in bimodal fashion. Like it, it can happen in a lonely hour, it can happen in young patients. Why can it happen in young patients? Because their necks are very mobile and then it hinges on the ulnar claw?
The other important, as I said to you about also, I didn't just remember it because it can look like a type Ii old and quite fractured on x-rays, on a lateral x-rays. So someone just ask how to differentiate between also the ahead and type 2. It's very hard. Ct scan can tell you type 1 is an oblique building fracture of the tip of rheumatoid due to a vision of a ligament.
Type 2 is a fracture to the waist. This is this is tough and always, always remember that type 2 is the one where you can think about high non-union, high non union rate, and it is due to the disruption of the blood supply type III fracture extend into the cancerous body, and it involves variable portion of the 72 to. It's actually a good thing because if it involves a more joint, if it involves more surface means it is going to, it is going to.
It is going to heal quicker, even in a rigid color of this 0.08 fracture. Like everything else, 1 to 3 normal period of treatment, non operative treatment should be for type 1 and type III. And in patients who are obviously very old and unlikely to. Unlikely to sustain or an aesthetically fit for such an extensive surgery.
The second treatment is either halo bracing or rigid color. And the third treatment is surgery. Always remember you. You're not going into the nitty gritty of what surgery you would like to perform. Always start small and then build up on it. The smallest thing to say here is surgical fixation. Then they will go, they will say, what surgery? Now you are getting into the gold.
Gold marks. So what Suzy means either anterior or posterior stabilization. What do you mean by anterior stabilization and stabilization is to the same anterior approach where you put one screw. However, fracture pattern is quite important in this type of surgery as to which side the fracture is going. And so if it's andeer superior and posterior inferior, the screw can go in from the front without displacing the fracture.
However, if it's a reverse fracture where interior is inferior and posterior superior, you try to put the screw in from the front. The fracture will displaced more so these things. These are small points, which they ask, and that's why this fracture treatment is important. The other thing to say here is the posterior fixation. What is the problem with fixation? This is common FR situation.
So the posterior fixation is because you are operating. So close to vertebral artery and you have to have preoperative CT angiogram or CT for your planning of. Of your bas status instrumentation, so remember these two points and then and then you will be OK. So we move on to traumatic next slide, which is traumatic on pieces of access and because of its because of where it is and because of what?
Catastrophic injury, it it can cause injury to your spinal cord, it can cause injury to your medulla, and it can be really, really unstable because both sides of arcing circularity is fractured. And if and if it's flexion type, it has torn your PLL, which is a PLL posterior longitudinal ligament, which is again a very important stabilizer when it comes to. You know, when it comes to cervical spine and stability of the cervical spine, why do you why you should not miss it?
Because because this has got 30% concomitant cervical spine fracture injuries as well associated. And you need to screen the whole of the spine or the cervical spine if you see similar sort of displacement. Treatment wise, again, with cervical spine, if you don't know, everything's a normal, pretty rigid color, a close election, halo mobilization or surgical stabilization.
If you say these three words, you're going to pass the exam. Everyone knows the lines which we discuss the phone lines which we discuss here. You should talk about how much of subluxation of C4 over C5 and hence do not commit yourself to unilateral or bilateral. Just say it is most likely to be unilateral, taking the 25% subluxation on the way into consideration.
Yes the other clinical features you will find with unilateral subluxation is. Unilateral subluxation, as it's on one side, it is associated with more radical petty means one sided whatever side you have dislocation that sided arm pain, bilateral well associated with significant spinal cord injury, either spinal show or bilateral distribution of signs of cord compression most frequently involves our superior facet, whether it's bilateral or unilateral.
And the reason why a superior facility is involved in facial fracture because of its anatomical. Decomposition composition or because how it is in acne. Now you can give the. The descriptions on the x-rays and for exam purposes, because remember, exam happens as exam happens, it happens in the most ideal hospital in the world where you can get everything.
So needless to for as far as imaging is concerned, if you see something wrong in imaging, you know, it's not going to be a negative mark. So just make sure you say if you see physician, you get MRI and you get a CT scan. However, there are people saying curriculum. There are specific indications for MRI scan, but in your real life, if you see a face a joint dislocation, you are definitely going to do an MRI scan.
So say the same in exam. Most likely you see it and see five, 606 or seven spinal cord. We have discussed that as well. If we have a picture in your mind and and you need to have this treatment algorithm for facial dislocations if the patient is alert and so there's no getting MRI scan, the answer is yes, you assess neurovascular deficit.
Is there a neurovascular deficit? A pain is not a neurological deficit in a single nerve root distribution. If the answer is no, you can. You are getting an MRI scan. If the answer is yes, you are taking patients straight into the theaters for emergent clause reduction. Again, if at all, someone is going to ask you anything about spinal reduction, it's going to be if it's a joint dislocation reduction.
Because it has been asked repeatedly in the past, and there are few controversial controversies here of when to get an MRI scan, whether to reduce open or closed. And what are the indications of anterior first possible second possible first and second stabilization. So have a clear picture in your mind as to how you are going to portray yourself in the exam and what are you going to say?
So if I were you, if I'm going for the exam and if I see facial dislocation with ridiculous Betty all or bilateral involvement. I would always say I'm going to get a CT scan and I'm going to get an MRI scan. And depending on the MRI findings, I will take the patient. I will discuss it with the National spinal injury unit. However, if I'm the regional spinal injury unit, the principal for emerging close election would be adequate anesthesia, sedation, supervision of the respiratory function indicators and serial cross stable lateral X-rays.
Remember also when you are reducing it, say some sort of reduction tool, whatever you have in your hospital. We use garden tongs. They are readily available supraorbital two points on one side of our little one pin on one side. When you are putting the pins on the patient to close the AIIS so that he doesn't have any problems. And then gradually increase axilo traction on the weight, there is a strict protocol about the weight, as well as to how much weight you can use per face a joint dislocation, but it has to do with body weight.
So no one can remember it. I'm not going to tell it. You just say it has. It has to do with body weight. I will be guided by the spinal surgeons or the regional trauma unit, whatever they say. If you find an interior disk on an MRI scan, you cannot do a close election. So it has to be patient, has to be blighted to the original spinal injury unit, have an interior cervical vasectomy decompression and then subsequent posterior reduction and stabilize that again, because that was very important what you said, the sort of absolute indication for patient transfer to a spinal unit.
Yeah so the absolute indication for patient transfer to spinal unit, if you see an MRI, if you see a disk, pressing the cord on an MRI scan means you cannot do it in your primary hospital, irrespective of whatever neurology patients have. Because what is the first Hippocratic oath that GMC ask us to take? Do no harm to the patient? By doing a procedure which you are not trained on, you will do more damage than any good to the patient.
So to be a safe doctor. However, if you don't have the facility, if don't get tricked into this thing or deny the other national spinal injury unit is two hours away, would you not keep the patient, maybe do the anterior approach to the disc? To me, no, is the answer. If there is a disk patient need to be transferred across and have the operation because it will be an interior.
Yes, I think he's asking whether we get an MRI scan in all cases. The answer to that from if I were you, I will say yes, because if you say no, then you are stepping into their trap and then they start asking you about the indication of them to get an MRI scan. When not to get an MRI scan, you see, I'm aware of an algorithm which you really discussed.
So we move on to the next slide, but always go to the slide again, taking the closed reduction requirements and technique into consideration. Make sure that the patient is awake. Make sure there is adequate anesthesia. Make sure you have an anesthetic colleague in there. So who is going to assist you in case you give too much sedation, a component of cervical flexion also facilitates reduction.
Does it facilitate reduction so that you can lodge the superior facet behind the inferior result? And that is taking into new this attractive spine and acmi into consideration and abort if there is new neurological neurologic appears and get immediate MRI scan, irrespective of whether you got an MRI scan before or not, so that you are looking at any changes within the skull fracture situation.
Now, why is it important. This lateral mass fractures? Why is it important? It is important because it affects two motion segment and as the superior facet and the inferior facet on either side or fractures. Garden Wilton is the name of the tong's got important because it affects two level location, mostly at around C6, followed by C5 seven, 4 and D1.
Always remember that there are associated conditions or associated conditions with inferior translation of fractured vertebra, superior adjacent vertebral microfracture or inferior vertebral fracture. They are very unstable, and you need to know as to what are the parameters of instability in the next slide, you will see. And that is as much as you know, in this particular, the instability parameters are if you have more than 3.5 millimeter displacement on either side or accompanying a combine of 7 millimeter displacement.
If you have kyphosis of 10 degrees or if you have rotation compared to adjacent vertebra of 10 degrees, so it's a three dimensional thing. Again, like everything else, get a CT and an MRI scan. Don't stay confused. I like to get a CT line to get a ct, because over here you will see about 50% to 60% There is disruption of the and both posterior ligament. Which is very important stabilizer as far as fine is cancer treatment as of everything else, as I said to you in the beginning of the talk as well.
If you say normal curative treatment, semi-major Cola and cervical stabilization, that is as much you say. I want to say that it is, but I think it should suffice. The only details in treatment, what you should know, it's about the old and quite bad connection. As far as the fracture, tenotomy is concerned when you are planning a fixation and when you're planning for severe fixation, the vocabulary and the other treatment is.
They face a joint dislocation where you're either taking patients to cater for close production or if you're taking action to or if the National spinal injury unit or local spinal injury unit is taking patients rotator. For her for interior stabilization, you need to know about the desk, and maybe if you're doing very good, they will ask about the interior approach, which is the Smith Peterson approach to the cervical spine. So that approach, you need to know if you don't know the approach, don't go to the exam, either.
So these are small things and the adequacy of the examiners. You are a safe surgeon. You're not going to miss functional problems. So what you serve, guys, please always say that sentence, checking the adequacy of the X-rays and again with the facet, joint dislocations, and maybe I could. Clarify this or confirm or not. There are a lot of issues, is it universite by facet dislocation?
We keep, you know, arguing, discussing, discussing this issue, but us think as far as the exam is concerned, we don't need to worry too much. I think first investigation is first dislocation. Don't commit yourself to uni or by far settle dislocations still need to manage it more or less in a similar manner. Is that correct? Yeah, exactly. So, you know, 25% is it 30 percent?
Is it? Don't it? It it matters. It doesn't matter at all. Just everything. So someone asked, treating to say, please repeat the three things. So there are, so I will add on to it. There are two things and three things.
The thing is, how do you investigate it? You investigate it. CTM tries to delineate body and Armie Hammer. I will give you a ligament instability and all the rest of it, any court issues, any disk issues, any edema around the court. CTE, as I said, will show you the bony anatomy. Plus, if it's CT with angiogram, it will show you about the vertebral artery anatomy as well, which is important in terms of floating point.
The other thing someone asked about the three things the three things are observation observation alone to see whether the patient works with software. The second thing is semi rigid or semi rigid color or hard color, or halo halo racing following reduction. And the third thing is surgical stabilization. So in spine or in cervical spine, for that matter, if you stay as vague as possible, start small and then you can build on it, make them ask questions.
So if you say surgical stabilization, then you say, OK, what surgical stabilization options available? So you say there are two surgical in case of fracture. There are two surgical stabilization options available depending on the fracture anatomy, which is a axilo synthesis or posterior antero-supero-lateral synthesis. Then they'll say, what are the advantages and disadvantages of each?
And tenodesis synthesis is through to a very well recognized anterior approach. And if and if the anatomy allows where you can put screws from front to back without spacing the fracture, it is the favorable way of treating it because there are. Less morbidity associated with it. However, if the fracture is transfers or if it's anterior inferior and posterior superior, and if you put screws from the front, it will displace the fracture.
Then you go from the back. However, a detailed anatomy of vertebral artery placement should know, and you should mark your screw screw placement beforehand so that you're not going very close to the screw, very close to the vertebral artery. I have seen it done 5 times one of the time someone hit the vertebral artery, and it was a thank you for explaining. Thank you. And I think just to clarify again, that's a joint dislocation.
We're getting MRI scan. This is a standard exam, and I don't think we should put any controversies here. First, a dislocation and left this unless there is life threatening other after injuries. We're getting MRI scan, please. OK, so I know Miller and other things. Other books can confuse matters with this issue, but for example, if our yes, please.
My advice to you is you request an MRI. OK, so any further comment Kashif to add. No, I think I tried very well. And as you correctly mentioned, MRI because I was asked this question as well in my exams and I mentioned MRI and there was no controversy after that. Yes, if you don't see MRI, you're stepping into. Yes yeah, you're getting a difficult conversation, then you have to justify where to do MRI, where not to do MRI and all this stuff.
So I think don't go into that controversy, just say MRI and then get out of that. And as I said, also one other hot topic in the exam with regards to the cervical spine is the anterior approach. Please it carefully, and as I say, I agree with them. If you if you don't know it, don't go for the exam. This is the approach and the spine they ask about if you're going for the left side approach and only have to do spine.
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