Orthopedics
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| C2: Axis has what features? | bifid spinous process & odontoid process
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| C7: Vertebra prominans has: | a large spinous process
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| Atlas (C1): ring structure with: | anterior & posterior arches; lateral masses separate A&P arches
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| Axis (C2): 1st vertebra with: | a heavy body
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| C2: superior projection of the body = | odontoid process (dens); articulates with the C1 anterior arch
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| What ligaments hold atlas to axis & keep it stable? | Alar ligaments
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| Light touch: Upper Neck: | C2
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| Light touch: Lower Neck: | C3
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| Anterior vert column: | vert bodies, disc spaces, A&P longitudinal ligaments, & annulus fibrosis
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| Posterior vert column: | pedicles, facet joints, laminar spinous processes, & posterior ligament complex
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| If one of the two vert columns is intact, then: | the injury is stable
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| If both columns are disrupted, then: | the injury is unstable
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| 2 major regions of C spine: | cranio-cervical junction (occiput to C2); lower cervical spine (C3 - C7)
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| Cranio-cervical jnct (occiput to C2) | 50% of motion; atl-occ jnt (Yes); atl-axial jnt (No)
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| Lower C spine (C3 - C7) | 50% of motion divided evenly between segments
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| Spine Forces: | flexion (forward & lateral), extension, axial compression, rotation, & distraction
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| Anterior Marginal Line | line drawn along the anterior vertebral bodies
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| Posterior Marginal Line | line drawn along the posterior vertebral bodies C2 - C7
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| Spinolaminal Line | line drawn along the bases of the spinous processes C1 - C7 (marks the posterior margin of the spinal canal)
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| Posterior Spinous Line | line drawn along the tips of the spinous processes C2 - C7
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| Radiology: Trauma: | order lateral, AP, & odontoid view; all 7 vertebrae must be seen
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| Radiology: Lateral: | 4 smooth lines
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| Radiology: AP: | spinous processes should be in a vertical row
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| Radiology: Odontoid: | open mouth: inspect odontoid, distance between axis & dens should be equal bilateral
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| Tx Jefferson fx: stable | Rigid collar (cervicothoracic) x 3 mo; regular f/u for radiographs
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| Tx Jefferson fx: unstable | Cranial traction; halo x 3 months; > 5mm C1-C2 subluxation = C1-C3 fusion
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| Odontoid fx types | type I (rare): avulsion fx of alar ligament; type II & III
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| Burst Jefferson fx stability: determined by: | transverse ligament
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| Burst Jefferson fx stability: neuro effects | Usually neuro intact (fragments burst away; wide breadth of C1 canal)
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| Burst Jefferson fx: 1/3 of fx assoc with: | an axis fx
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| Burst Jefferson fx: 50% chance that: | some other C spine injury is present
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| Odontoid fx MOA | Hyper-flexion or hyper-extension
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| Odontoid fx: Blood supply (watershed area): | neck
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| Odontoid fx: assoc with: | C1 neural arch fracture or Jefferson fx
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| Odontoid fx: 25% incidence of: | neurologic injury
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| Odontoid fx: non-displaced fx show: | callus at 2-3 weeks
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| Hangmans Fx = | Traumatic Spondylolisthesis of C2 (bilateral C2 pedicle fx)
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| Hangmans Fx MOA | hyperextension & sudden violent distraction; hyperextension & axial loading; or flexion & compression (usu combination of forces)
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| Hangmans Fx: Types | 4 types (I, II, IIA, III = worst)
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| Hangmans Fx: Immobilization: | rigid cervical orthosis or halo vest system
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| Hangmans Fx: Traction: | used generally for reductions (Gardner-Wells tongs or halo vest system)
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| C spine injury prevalence in football | 10-15% of football players
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| Sp cord injury overall incidence | 4/100,000 per year
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| Most recent sport SCI: | football, trampoline (gymnastic), diving
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| Highest % head injuries | football; then ice hockey
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| Acute Cervical Sprain = | Injury to restraining ligaments of cervical spine
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| Acute C- Sprain grade I (mild): | ligaments damaged but not lengthened
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| Acute C- Sprain grade II (mod): | some laxity but not total disrupt
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| Acute C- Sprain grade III (severe): | ligament completely disrupt
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| Acute C- Sprain can occur alone or with: | C-strain (mx), fx/ dislocation, instability
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| Isolated C-sprain: S/S | localized pain, decreased ROM, no neurologic deficits
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| Acute C- Sprain: if no fx/ sublux on films, then get: | flex/ext (assess for instability)
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| Acute C- Sprain: if sig mx spasm, then: | repeat flex/ext films after spasms subside (protect neck)
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| Acute C- Sprain: if poss subluxation: | pt should wear hard collar & flex/ext films repeated in 2-4 wks
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| Acute C- Sprain: if instability present, may need: | 6-12 wks immobilization in rigid orthosis and/or surgery
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| Acute C- Sprain: if xray w/u neg: | RTP only when painless full ROM & normal neck strength
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| Cervical Stenosis = | narrowing of sagittal diameter of cervical canal
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| C-stenosis often asymptomatic until: | acute hyperflexion/ extension or axial loading of C-spine produces neuro signs
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| C-stenosis: segments most commonly involved | C5 and C6 segments
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| Cervical Stenosis Types | Congenital; Developmental; Acquired
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| C-stenosis: Congenital = | short pedicles, funnel shape of cervical canal
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| C-stenosis: Developmental = | bone size due to stress in weight training
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| C-stenosis: Acquired = | spondylosis, spurs, disc bulge or space narrowing
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| Paresthesia with transient quadriplegia incidence: | 1.3/10,000
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| Fx & Dislocation: Injury MOA | axial load w/ slight neck flexion (spearing)
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| Downed Player: initial x-rays s/b obtained: | on spine board with helmet on
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| Cervical Spondylosis = | Chronic disc degeneration (arthritis)
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| Cervical Spondylosis: Represents: | nerve root compression
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| Cervical Spondylosis S/S: | neck pain, radicular pain radiating from neck to upper extremity
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| Cervical Spondylosis Rx: | supportive, facet injections, operative decompression
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| Brachial Plexus Neuropraxia include: | Burners, stingers, hot shots (football, wrestlers, hockey)
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| Brachial Plexus = | C5, C6, C7, C8, T1
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| Brachial Plexus Neuropraxia: Blow to head: | lateral flexion to contra side of shoulder being depressed results in traction on nerves
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| Brachial Plexus Neuropraxia S/S | Sudden burning pain, numbness in lateral arm, thumb, & index finger, lasts 1-2 min
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| Brachial Plexus Neuropraxia: if S/S persist/ repeated: | MRI is indicated
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| Brachial Plexus Neuropraxia RX: | ROM, strengthening, protection
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| Atlas: superior surface of lateral masses articulates with: | the occipital condyles forming the occipito-atlantal joints
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| Atlas: inf surface of lateral masses articulate with: | the superior articular facets of C2 forming the C1 - C2 apophyseal joints
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| R/O C Spine Fx | 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
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| C Spine injuries | 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)
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| Burst Jefferson fx MOA | Axial blow to head, force transmitted thru occ condyles; forces C1 lateral masses outward
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| Burst Jefferson fx Radiology: | C1 lat masses not line up vertly w/ C2 sup articular facets; distance btw dens & C1 lat masses is asymmetric
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| Odontoid fx: tx | Reduce fx & hold in halo immobilization (3 months); C1-C2 fusion if severely displaced or non-union; Few advocate acute ORIF dens
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| Hangmans Fx: alignment: | vert body of C2 is normally aligned w/ C1 & dens; post elements of C2 are normally aligned w/ C3
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| Hangmans Fx: Stability: | unstable; neuro deficit is surprisingly rare unless C2 - C3 subluxation is severe
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| Hangmans Fx: Tx | will usually stabilize with halo fixation; anterior fusion may be needed due to delayed instability
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| Hangmans Fx: Operative Tx: | occipitocervical fusion; atl-axial fusion; transarticular screw fixation; ant. screw fixation of dens; internal fixation w/ posterior plating of occiput to C2
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| Evaluation of cervical instability (White & Punjabi ) | Vert malalignment; >3.5mm translational displacement; 1.7 mm or greater disk widening
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| C-Cord Neurapraxia & Transient Quadriplegia: S&M recovery usu occurs in: | 10-15 minutes (up to 24-36h in some)
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| C-Cord Neurapraxia & Transient Quadriplegia may involve: | both legs, both arms, or ipsilateral arm & leg
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| C-Cord Neurapraxia & Transient Quadriplegia Initial evaluation: | routine c-spine films & poss CT scan (flex/ext films if routine films normal); consider MRI
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| Fx & Dislocation: forces transmitted: | 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
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| On Field Eval (Downed Player) | 1: Assess ABCs; 2: initial neuro; 3: turning the athlete; 4: immobilization; 5: evacuation
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| Downed Player: turning athlete | Doc at head grasp player shoulders & cradle head w/ forearms (if use hands alone, avoid flexing neck). Avoid cervical traction
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| Downed Player: immobilization | 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
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| Downed Player: immobilization: C-collar = | NOT an alternative to proper head immobilization on the board & may compromise the airway
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| C Spine injuries: Tx | Philadelphia collar immobilization (stable); Halo immobilization (stable); Occipito-cervical fusion (unstable)
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| Trapezial strain: | localized pain posterior C-Spine; Pain reproducible with palpation of trapezius; Wry neck or torticollis; Rx: Supportive
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| Stingers & Burners = | transient shooting/ burning pain or paresthesia in one arm related to neck or shoulder trauma
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| Stingers & Burners: due to: | stretch injury on brachial plexus or compression on nerve root (neural foramen)
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| Stingers & Burners: If S/S longer than 15 min: | consider w/u (if compression type injuries, image for foraminal stenosis or herniated disk)
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| Most common Spinous Process fx found in: | C-spine (Clay Shovelers fx)
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| Football player with burning pain, numbness, tingling from shoulder to hand which resolves | Brachial plexus neurapraxia, “stinger,” caused by stretching of brachial plexus
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| cervical impingement: common sites & MOA | C5-C7 most common; often d/t DDD or HNP; surg if persistent neuro sxs
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| Axial blow to the head with force transmitted through the occipital condyles; Forces the lateral masses of C1 outward | Jefferson fracture
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| bilateral C2 pedicle fractures (usually due to combo of forces; eg, hyperextension and sudden violent distraction) | Hangman's fracture
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| C1: Atlas has no: | spinous process
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| C spine inj prevalence in football | 10-15% of football players
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| Paresthesia with transient quadriplegia incidence: | 1.3/10,000
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| On Field Eval (Downed Player) | 1: Assess ABCs; 2: initial neuro; 3: turning the athlete; 4: immobilization; 5: evacuation
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| Downed Player: immobilization: C-collar is NOT: | an alternative to proper head immobilization on the board & may compromise the airway
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| C Spine injuries: Tx | Philadelphia collar immobilization (stable); Halo immobilization (stable); Occipito-cervical fusion (unstable)
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| Dec. cervical ROM, pain below elbow = | Cervical disc disease
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