Orthopedics 4

Alar ligaments

C2

C3

vert bodies, disc spaces, A&P longitudinal ligaments, & annulus fibrosis

pedicles, facet joints, laminar spinous processes, & posterior ligament complex

the injury is stable

the injury is unstable

cranio-cervical junction (occiput to C2); lower cervical spine (C3 - C7)

50% of motion; atl-occ jnt (Yes); atl-axial jnt (No)

50% of motion divided evenly between segments

flexion (forward & lateral), extension, axial compression, rotation, & distraction

line drawn along the anterior vertebral bodies

line drawn along the posterior vertebral bodies C2 - C7

line drawn along the bases of the spinous processes C1 - C7 (marks the posterior margin of the spinal canal)

line drawn along the tips of the spinous processes C2 - C7

order lateral, AP, & odontoid view; all 7 vertebrae must be seen

4 smooth lines

spinous processes should be in a vertical row

open mouth: inspect odontoid, distance between axis & dens should be equal bilateral

Rigid collar (cervicothoracic) x 3 mo; regular f/u for radiographs

Cranial traction; halo x 3 months; > 5mm C1-C2 subluxation = C1-C3 fusion

type I (rare): avulsion fx of alar ligament; type II & III

transverse ligament

Usually neuro intact (fragments burst away; wide breadth of C1 canal)

an axis fx

some other C spine injury is present

Hyper-flexion or hyper-extension

Neck

C1 neural arch fracture or Jefferson fx

neurologic injury

callus at 2-3 weeks

Traumatic Spondylolisthesis of C2 (bilateral C2 pedicle fx)

hyperextension & sudden violent distraction; hyperextension & axial loading; or flexion & compression (usu combination of forces)

4 types (I, II, IIA, III = worst)

rigid cervical orthosis or halo vest system

used generally for reductions (Gardner-Wells tongs or halo vest system)

10-15% of football players

4/100,000 per year

football, trampoline (gymnastic), diving

football; then ice hockey

Injury to restraining ligaments of cervical spine

ligaments damaged but not lengthened

some laxity but not total disrupt

ligament completely disrupt

C-strain (mx), fx/ dislocation, instability

• localized pain, decreased ROM, no neurologic deficits
• Acute C- Sprain: if no fx/ sublux on films, then get:
• flex/ext (assess for instability)

repeat flex/ext films after spasms subside (protect neck)

pt should wear hard collar & flex/ext films repeated in 2-4 wks

6-12 wks immobilization in rigid orthosis and/or surgery

RTP only when painless full ROM & normal neck strength

narrowing of sagittal diameter of cervical canal

acute hyperflexion/ extension or axial loading of C-spine produces neuro signs

C5 and C6 segments

Congenital; Developmental; Acquired

short pedicles, funnel shape of cervical canal

bone size due to stress in weight training

spondylosis, spurs, disc bulge or space narrowing

axial load w/ slight neck flexion (spearing)

on spine board with helmet on

Chronic disc degeneration (arthritis)

nerve root compression

neck pain, radicular pain radiating from neck to upper extremity

supportive, facet injections, operative decompression

Burners, stingers, hot shots (football, wrestlers, hockey)

C5, C6, C7, C8, T1

lateral flexion to contra side of shoulder being depressed results in traction on nerves

Sudden burning pain, numbness in lateral arm, thumb, & index finger, lasts 1-2 min

MRI is indicated

• ROM, strengthening, protection
• Atlas: superior surface of lateral masses articulates with:
• the occipital condyles forming the occipito-atlantal joints

the superior articular facets of C2 forming the C1 - C2 apophyseal joints

Pt not c/o neck pain; no neck tenderness on palp; no hx LOC; no mental status changes fr trauma, etc; no S/S referable to neck inj (paralysis, sensory changes); no other distracting inj

Occ- atl Dislocn; Occ Condyle Fx; Atlas fx (C1); Odontoid fx; Atl-Axl (C1-C2) instability; C2 Lateral Mass fx; traumatic Spondylolisthesis of C2 (Hangmans fx)

Axial blow to head, force transmitted thru occ condyles; forces C1 lateral masses outward

C1 lat masses not line up vertly w/ C2 sup articular facets; distance btw dens & C1 lat masses is asymmetric

Reduce fx & hold in halo immobilization (3 months); C1-C2 fusion if severely displaced or non-union; Few advocate acute ORIF dens

vert body of C2 is normally aligned w/ C1 & dens; post elements of C2 are normally aligned w/ C3

unstable; neuro deficit is surprisingly rare unless C2 - C3 subluxation is severe

will usually stabilize with halo fixation; anterior fusion may be needed due to delayed instability

occipitocervical fusion; atl-axial fusion; transarticular screw fixation; ant. screw fixation of dens; internal fixation w/ posterior plating of occiput to C2

Vert malalignment; >3.5mm translational displacement; 1.7 mm or greater disk widening

10-15 minutes (up to 24-36h in some)

both legs, both arms, or ipsilateral arm & leg

routine c-spine films & poss CT scan (flex/ext films if routine films normal); consider MRI

directly to spinal structures; energy first absorbed by discs with compressive deformation; continued energy: angular deformation & buckling w/ failure of discs, lig structures & bony elements

• 1: Assess ABCs;
• 2: initial neuro;
• 3: turning the athlete;
• 4: immobilization;
• 5: evacuation

Doc at head grasp player shoulders & cradle head w/ forearms (if use hands alone, avoid flexing neck). Avoid cervical traction

Leave helmet & shoulder pads on; fasten torso to spine board w/ straps; sandbags/ blankets on either side of head and taped with helmet to board

NOT an alternative to proper head immobilization on the board & may compromise the airway

Philadelphia collar immobilization (stable); Halo immobilization (stable); Occipito-cervical fusion (unstable)

localized pain posterior C-Spine; Pain reproducible with palpation of trapezius; Wry neck or torticollis; Rx: Supportive

transient shooting/ burning pain or paresthesia in one arm related to neck or shoulder trauma

stretch injury on brachial plexus or compression on nerve root (neural foramen)

consider w/u (if compression type injuries, image for foraminal stenosis or herniated disk)

SC, AC, GH, Scapulothoracic

Flat, smooth acromion at clavicular joint; normal subacromial space

Hooked acromion; subacromial space mildly decreased

Hooked acromion with spur; subacromial space significantly decreased

hand dominance; Night pain; Clunks, pops; Neck pathology

rotator cuff injury

Serratus or Trapezius dysfxn

Posterior dislocation

RCT or suprascapular n. palsy

Cervical disc disease

Instability

Labral tear

Impingement, Frozen

Multidirectional instability

Asymmetry; Atrophy; Apley scratch test

Neer; Hawkins (both passive)

crossover (passive)

Speeds; Yergason (both active)

Sulcus; apprehension & relocation (both passive)

Obrien; anterior slide; crank

Adson; Allen; Roos

AP and axillary

suspected dislocation or scapular fx (trauma)

bony bankhart, Hill-Sachs (uncommonly), or spur; tumor or fx; elevated humeral head (RCT); AC separation or DJD

CT arthrogram good, but MRI is better (invasive)

bone abnormality; tumors

95% sensitivity & specificity in detecting RCT

RCT; SLAP lesions (Arthrogram); Soft tissue

Non-invasive; Cost; Portable

Quality; User dependent

Depo medrol w/ lidocaine & bupivacaine HCl (total of 10 mL); 25 gauge 1.25-1.5 needle

Depo Medrol, Celestone; Dexamethasone; Kenalog

shorter acting, less irritating

Medium (duration)

Long acting, slightly more painful initially; mix with lidocaine & Marcaine

Clavicle Fx

FOOSH, onto shoulder, direct trauma

AP, 45 degree cephalic tilt

6 different grades

Usually direct blow to shoulder

step deformity, TTP AC joint, (+) crossover sign

AP, Zanca (100 cephalic tilt), axillary

Refer for poss surgical fixation, otherwise conservative care (sling)

pain-free with abduction, crossover

Anterior usually MVA

TTP SC joint, deformity

AP, 40 degree cephalic view

Usually conservative; Sling, ROM

Usually fall on flexed and adducted shoulder

Can be life-threatening; immediate referral and CT

Closed reduction or surgical reduction

Anterior Shoulder Dislocations

ext. rotation and abduction

limited external rotation

AP and axillary or Y

Acute: reduction (Stimpson or Kocher)

recurrent dislocations, bony injury (Hill Sachs, or Bankhart), RCT , NV injury, arthropathy (later)

once reduced, sling w/ mobilization in 2 wks

usually > 40 y.o. unless traumatic

Insidious onset, worse w/ overhead activity, night pain

ROM, RC strength, Hawkins/Neer, Jobe

Injections contraindicated if there is a partial tear

NSAIDs, ice, avoid painful activity, PT, injections

arthroscopy vs open

other pathology (RCT, SLAP tear); may rupture if RCT worsens

TTP Bicipital groove, Speeds, Yergasons

NSAIDs, corticosteroid injection, PT

Usually > 50 yrs old

long head of biceps (short head rupture rare)

pop, ecchymosis

Contraction of capsule (Frozen Shoulder )

immobilization after injury

ROM (usually lose external rotation first)

PT, NSAIDs, injections; may need surgical lysis of adhesions

Painful; Adhesive; Recovery

Superior Labral Anterior Posterior

Painful shoulder with clicks, pops with motion

Pos clunk test, crank test, OBriens, sometimes instability or biceps tendonitis; MRI

Conservative tx (NSAIDs, PT, rest); arthroscopy vs open repair

Pt supine, elbow flexed 90, arm abducted to 90; push postly, pos test = pt apprehension & laxity

Posterior will have limited external rotation cf to anterior dislocations

middle third (followed by distal third); most common place at jnct btw middle & distal 1/3

edema & pt tenderness over fx site; assess ROM of neck, shoulder; motor strength, sensation; SC dislocations

Sling; Figure of 8 (sig displacement, use of arms for ADLs); Periodic ROM; No contact sports for 6 wks

NV compromise; open fx; symptomatic non-union at 12 wk; Cosmesis; Distal third (? physeal injury, AC injury); Proximal third (SC joint dislocation)

Instability; SLAP; Bursitis; Referred pain ; Calcific tendonitis; Thoracic outlet syndrome; Adhesive capsulitis

Thermal capsular shift (subluxations); arthroscopy vs open repair

Conservative: Proximal (most); MRI if dx uncertain; Tenodesis within 3-4 wks prn (Distal)

assoc w/ other illnesses (DM, thyroid, recent chemo/ rad); F >> M (increased estrogen receptors around shoulders)

(0-3 months); pain w/ movement; genl ache; mx spasm; inc noc/ rest pain

(3-6 months); Less pain; inc stiffness & restricted movement; less noc pain; pain at extreme ranges of movement

(>6 months); dec pain; restrictn w/ slow, gradual inc ROM; recovery spontaneous, often incomplete

numbness, paresthesia, thenar wasting

Men 5 degrees, women 10-15 degrees

AP, lateral, oblique

Cortical defects; Radiocapitellar line; Ant. humeral line; fat pad sign

Usually normal (Sail sign)

Always pathologic

radial head fx

supracondylar fx