Trauma - Thoracic and chest injuries.pptx

injuries of the thoracic cavity

1. Kenya Medical training college Faculty of Clinical Sciences Department Of Orthopaedics and Trauma Medicine Year Two Semester Two Traumatology II By Gideon Sifirino Class: Diploma September 2021 1

2. Learning outcomes By the end of this lesson the learner should be able to; Discuss the anatomy of the thoracolumbar Discuss common injuries of thoracolumbar Discuss management thoracolumbar i njuries 2

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4. Whiplash Injury SYN: Acceleration injury, cervical sprain syndrome, soft tissue neck injury. 4

5. Definition It is an unconventional and inconsequential ligamentous injury of the cervical spine allegedly due to an extension injury following a rear-end collision in an RTA. 5

6. Incidence It is seen in about 25 percent of rear-end collision of RTAs. Seventy percent of those affected are women. It is common in the 3rd or 4 th decades 6

7. Clinical Features Upper neck pain that becomes worse With movement. Occipital headache. Neck stiffness. Rarely vertigo, auditory or visual disturbances, etc. 7

8. Cont'd Hoarseness of voice, (involvement of recurrent laryngeal nerve). Difficulty in swallowing, (stretching and contusion of esophagus). 8

9. Cont'd Pain in the back and the shoulder, (radiating pain). Pain and paresthesia (due to involvement of nerves). 9

10. Cont'd Decreased range of neck movements Neck muscle spasm 10

11. Cont'd Symptoms may develop as early as within 2 hours to as late as 8 days. 11

12. Investigations X-rays are usually normal. MRI helps to make a diagnosis 12

13. Treatment Drugs: NSAIDs, muscle relaxants. Collars: These are recommended for the first three days. Short arc active movements are slowly begun. Active ROM exercises are slowly commenced. 13

14. Cont'd After the pain subsides, isometric strengthening exercises are slowly commenced. Other modalities take ultrasound, traction, manipulation, massage, etc. also helps. 14

15. Clay Shoveller’s Fracture An avulsion of the tip of the C7 spinous process may occur due a sudden pull of the trapezius muscle . 15

16. Cont'd This historically happened when shovelling heavy unrelenting clay. The fracture is painful but stable and can be treated conservatively. 16

17. Fractures Of The Thoracic And Lumbar (Thoracolumbar) Spine Young patients; high-energy trauma Elderly; bony insufficiency 17

18. Risk Factors Rheumatoid arthritis Osteoporosis History of long-term steroid Skeletal metastases 18

19. Vulnerability The thoracolumbar transitional zone is particularly vulnerable, with 40–60% of all spinal fractures involving; T12 L1 L2 19

20. Classification A diagnostic algorithm for this classification is most easily approached in reverse order by exclusion of the most severe injuries. 20

21. C-type: displacement or dislocation injuries Rare severe spinal disruption with dissociation between cranial and caudal spinal segments Cord injury is common 21

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23. B-type: tension band injuries Anterior tension band failure in extension B3 Hyperextension 23

24. Cont'd Posterior tension band failure in flexion B2 Osseoligamentous disruption 24

25. Cont'd B1 Osseous disruption (Chance fractures) These are characterized by failure of the posterior bony elements (spinous process, lamina) in tension. 25

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27. A-type: compression injuries The anterior structures fail under compression 27

28. Cont'd A4 Burst fractures The entire vertebral body fails under compression. 28

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30. Cont'd Radiological Features Loss of vertebral height Loss of cortical integrity of the posterior vertebral body on the lateral radiograph Widened pedicles on the AP view. 30

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32. Cont'd On CT scan, retropulsion of fragments into the vertebral canal. This may result in spinal cord injury 32

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34. Cont'd A3 Incomplete burst fractures Involve the posterior bony wall but only one endplate. 34

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36. Cont'd A2 Pincer fractures Both endplates fail but both the posterior and anterior walls of the vertebral body. 36

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38. Cont'd A1 Simple wedge compression fractures Most commonly encountered spinal fractures. The posterior elements are intact but the anterior vertebral body fails in flexion and compression. Spinal cord injury is uncommon. 38

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40. Cont'd A0 Minor fractures (non-structural) Minor and not associated with instability (e.g. transverse process). 40

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42. Note that these fractures may be markers of other injuries, such as unstable pelvic fractures or renal injuries. 42

43. AO neurological score N0: neurologically intact N1: transient neurological deficit, which is no longer present N2: radicular symptoms N3: incomplete spinal cord injury or any degree of cauda equina injury 43

44. Cont'd N4: complete spinal cord injury NX: neurological status unknown due to sedation or head injury. 44

45. Assessing stability Morphology Neurological status Integrity of posterior elements 45

46. Thoracolumbar Injury Classification and Severity (TLICS) score Morphology Compression 1 Burst 2 Translation/rotation 3 Distraction 4 46

47. Cont'd Neurological status Intact 0 Nerve root 2 Complete cord injury 2 Incomplete cord injury 3 Cauda equina injury 3 47

48. Cont'd Integrity of posterior elements Intact 0 Indeterminate 2 Injured 3 48

49. Radiological features AP and lateral radiographs CT MRI 49

50. Cont'd AP view; coronal deformity or widening of the pedicles Middle column disruption 50

51. Cont'd The lateral view ;loss of normal Vertebral shape or loss of sagittal alignment (such as a kyphotic deformity). 51

52. Cont'd CT: This is indicated where a neurological deficit clinically or inadequate plain films. Axial imaging provides a particularly good indication of whether there is retropulsion of bone into the canal. 52

53. Cont'd MRI: spinal cord and soft tissues for signs of injury. Posterior ligament complex injury. 53

54. Orthopaedic management Non-operative Stable fractures For those patients admitted to the ward, the aim is to provide analgesia and bed rest initially, then progressive mobilization once trunk control returns. 54

55. Cont'd Patients are said to have trunk control once they can comfortably roll themselves around the bed, are able to tense their abdominal musculature and feel as if they can sit up. 55

56. Cont'd Bracing may help early mobilization, provide pain relief and prevention of fractures from deteriorating. 56

57. Operative Posterior surgical decompression and instrumented spinal fusion 57

58. Cont'd Decompression with laminectomy alone should be avoided, as it will further destabilize the spine by compromising the posterior supporting structures. 58

59. Cont'd Posterior fusion alone (no decompression) may be undertaken where there are no signs of neurological compromise. 59

60. Cont'd Anterior decompression and stabilization may also be considered and has the potential advantage of providing direct visualization of fracture fragments and therefore better canal clearance and better anterior column support. 60

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62. Questions??? 62

63. Assignment To be Provided… 63

64. References Ebnezer , J, (2012): Textbook of Orthopedics Fifth Edition:, Jaypee Brothers Medical Publishers (P) Ltd . Blom , A.W, Warwick, D and Whitehouse, M. R.: Apley and Solomon’s System of Orthopaedics and Trauma Tenth Edition: CRC Press Taylor & Francis Group. 64

65. The end Thank you 65