Practical clas №2
TRAUMATIC DISLOCATION.
TRAUMATIC DISLOCATION. INJURIES AROUND SHOULDERS AND HUMERUS
RELEVANT ANATOMY
It is important to first understand the factors responsible for stability of a joint in order to understand why a particular joints dislocates. Joint held in a position because of:
The shape of a joint: The shape of the articulating surfaces: The shape in hemselves may provide great security against e.g. the hip joint with the deep socket (the acetabulum) and an almost spherical (i.e. the femoral head) isa good design from the stability view point. On the other hand the shoulder joint with its shallow socket (the glenoid) and a large ball (the humeral head) is a poor design.
The ligaments: These prevent any abnormal mobility of a joint and are called static stabilisers.
The Muscles: A strong muscle cover around a joint gives it stability.
Dynamic Stabilisers of a joint.
DEFINITIONS
Dislocation: - A joint is dislocated when its articular surfaces are wholly displaced, one from the other. So that all the opposition between them is lost.
Subluxation: - A joint is subluxated when its articular surfaces are partly displaced and retain some contact between them.
CLASSIFICATION
Dislocation and Subluxation may be classified on the basis of etiology into congenital or acquired.
Congenital dislocation: It is a condition where a joint is dislocated at
birth e.g. congenital dislocation of the hip.
Acquired Dislocation: It may occur at any stage. It may be traumatic or
pathological.
TRAUMATIC DISLOCATION
Injury is the commonest cause of dislocation and subluxation and produces dislocation at almost all joints. The force required to dislocate a particular joint varies from joint to joint. The following are different types of traumatic dislocation seen in the clinical practice:
Acute Traumatic dislocation: This is an episode
of dislocation where
the injury force is the main contributing factor e.g. shoulder dislocation,
Old Unreduced dislocation: A traumatic
dislocation, not reduced may
present as an old unreduced dislocation e.g. old posterior dislocations of
the hip.
Recurrent dislocations: In some joints, proper
healing does not occur
after the first dislocation. This results in weakness of the supporting
structures of the joint so that the joint dislocates recurrently, often with
trivial trauma. Recurrent dislocation of the shoulder and patella are common.
d) Fracture dislocation: When a dislocation is associated with a fracture of one or both of the articulating bones, it is called fracture - dislocation. Pathological Dislocation: The articulating surfaces forming a joint may be destroyed by an infective or a neoplastic process, or the ligaments may be damaged due to some diseases. This results in dislocation or subluxation of joints without any trauma e.g. dislocation of the hip in septic arthritis.
Diagnosis Clinical Examination: Some of the salient clinical features in case of dislocation are as follows:
1) Pain: Dislocations are very painful.
2) Deformity: In most dislocations the limb attains a classic attitude.
3) Swelling: It is obvious in the dislocation of a superficial joint, but
may not be so in a deeply located joint.
4) Loss of Movement because of severe pain and muscle spasm and loss
of articulation,
5) Shortening of the limb occurs in most dislocations except in anterior
dislocation of the hip where lengthening occur.
Radiological examination: In doubtful cases the diagnosis must depend finally on adequate x-ray examination. The following principles should be remembered:
1) X- ray should always be taken in two planes at right angles to each other, because a dislocation may not be apparent on single projections.
2) If in doubt, x-rays of the opposite limb may be taken for comparison,
3) An associated fracture or an osteochondrol fragment must always be
looked for.
Complications: As with a fractures, complications following a dislocation can be immediate early or late.
1) Immediate complication is an injury to the neuro-vascular bundle of the limb.
2) Early complications are a) recurrence b) myositis ossiflcans c) persistent instability d) joint stiffness.
3) Late Complications are a) recurrence b) osteoarthritis c) vascular necrosis.
TREATMENT
Treatment of a dislocation or subluxation depends upon its type, as discussed below:
Acute Traumatic Dislocation: Urgent reduction of the dislocation.
Conservative method: A dislocation may be reduced
by closed ma
nipulative manoeuvres, an instant pain-relief. Prolonged traction
may be required for reducing some dislocations.
Operative method's: Operative reduction may be
required in some
cases.
Failure of closed reduction because the dislocation is defected
late.
Fracture dislocation, if the fracture has produced significant in
congruity of the joint surfaces, or a loose piece of bone is lying
within the joint or the dislocation is difficult to maintain by
closed treatment.
Old unreduced dislocation: This often needs operative reduction. In some cases, if the function of the dislocated joint is good, nothing needs to be done.
Recurrent dislocation: An individual episode is treated like a traumatic dislocation; but for prevention of recurrences, reconstructive procedure is required.
|
Posterior dislocation |
|
Anterior dislocation |
|
Axillar dislocation (lower |
ANTERIOR DISLOCATION
Mechanism: A fall on the outstretched hand with the arm in the abducted and externally rotated positions causes the head of the humerous to slip anteriorly. Occasionally a direct violence on the back of the shoulder dislocates the shoulder forward.
Traumatic Pathology: In young adults at the time of injury the anterior capsule with the labrum glenoidale is slipped off the anterior margin of the bone glenoid. The head of the humerous slips forward and lies under the sub-scapularies muscle.
Clinical Features: The patient is usually a young adult. The C/F of the dislocation depend on:
The absence of the head in its normal position leaving the glenoid va
cant.
The presence of the head in an abnormal position.
The effects of the abnormal position.
On inspection the patients arm is found to be kept away from the body and the elbow and forearm and supported by the patients other hand. There is a flattening of the deltoid outline. On palpation, the emptiness of the glenoid is obvious with the normal bony resistance under the deltoid being absent.
Due to the dislocation it will not be possible for the patient to bring the elbow close to the body and put the hand on his opposite shoulder (DUGAS SIGN). One should always look for the complication of circumflex nerve paralysis.
Treatment: The anterior dislocation is easily reduced when it is a fresh one. The usual method is called Kocher's monocurve. The arm is strapped to the body with a pad in the axilla and a short cuff and collar is applied. Check radiograph is taken. This position of internal rotation should be maintained for 3 weeks to allow the torn capsule to heal completely.
RECURRENT DISLOCTION SHOULDER
The patient is usually a young male. Usually there is history that after the first acute dislocation was reduced, the shoulder was not immobilised sufficiently. The subsequent dislocations of the joint are caused when the patient does ordinary external rotation and abduction movements of the shoulder while dressing or playing. The subsequent dislocation is easily reduced often by the patient himself. During the examination the patient resists any attempted movement of adduction and external rotation due to fear or apprehension that it may get dislocated. This is the "Apprehension Sign".
Treatment: The-treatment of this condition depends upon the age, sex and occupation. The patient is advised to avoid extreme abduction and external rotation and instructed to do internal rotation exercises to strengthen the internal rotation muscles.
Surgical Treatment: Bankart Operation: - In this operation, Bankart lesions is repaired by fixing the detached labrum and capsule back to the anterior margin of the bony glenoid.
Injures to the humerus and injures about the elbow.
THE ELBOW
Elbow injuries are of great importance for the following reasons
They are very common in children.
Complications either due to the injury itself or due to bad treatment
lead to crippling deformities like Volksmann's ischaemic contracting
and myositis ossificans.
The injuries in the elbow region will be described under the following heads:
Fracture of the distal end of the humerus.
Dislocation of the elbow
Fractures of the proximal ends of the radius and ulna.
Features of the distal end of the Humerus:
Supracondylar fracture
Inter Condylar fracture of the humerus.
Fracture of the lateral Condyle.
Fracture of the medial epicondyle.
Fracture of the Capitulum.
SUPRACONDYLAR FRACTURE
This fracture occurs most commonly in children between the years 5-15. It is caused by a fall on the outstretched hand. Types of Fractures:
a) Extension Type: The vast
majority (80 %) is of this type where in the
distal fragment is displaced backward.
b) Flexion
Type: In this rare type the distal fragment is displaced forward.
Clinical Features:
The patient complains of severe pain in the elbow and holds it in the flexed position. The swelling is tense, filling up the hollows around the elbow and obscuring the bony points. Careful palpation will elicit Types of Supracondylar Fractures.
The fracture occurs just above the level of the Condyles and the distal fragment is displaced backwards upwards and laterally. Movements of the elbow are very painful and restricted.
This should be differentiated from posterior dislocation of the Elbow. As the whole distal end of the humerus carrying the elbow joint is displaced backwards in Supracondylar fracture, the normal triangular relationship between medial Condyle, lateral Condyle and the olecranon is not disturbed. In the case of posterior dislocation, the relationship is not disturbed and the three points may lie in a line.
In this injury one should always feel the radial pulse to see if there is any pressure on the brachial artery. A weaker radial pulse compared to that on the opposite side demands emergency attention to save the circulation of the forearm. One must also examine for evidence of injury to the median nerve.
Radiological Features:
In the A-P view, the fracture line runs transversely just above the condyles of the humerus. The distal fragment is displaced and rotated laterally. The line runs upwards and backwards in the lateral view. The lower fragment is displaced backwards and upwards and tilted posteriorly.
SUPRACONDYLAR FRACTURE SUPRACONDYLAR FRACTURE
Flexion Type Extension Type
Treatment:
Crack fracture without displacement needs only a posterior slab for about 2-3 weeks. Displaced fractures need reduction inder general anesthesia with traction. Counter traction and local pressures. V posterior plaster slab is applied with good padding.
Post-reduction management:
A check radiograph is taken to confirm .atisfactory reduction. Active movements of the fingers are insisted upon to p-event edema of the hand. The plaster is removed after 3-4 weeks and gentle ac ive movement started.
Complications:
EARLY: They occur at the time of
injury or immediate after.
Injury to median nerve.
Injury to brachial artery (FOLKMANN'S ISCHAEMIA)
This needs emergency management.
LATE: 1) Cubitus varus deformity.
2) Myositis Ossificans.
When cubitus varus is marked it is corrected by Supracondylar osteotomy of the humerus.
FRACTURE OF LATERAL CONDYLE OF HUMERUS
This is a common fracture in children.
Patho-Anatomy. The fracture line may take the shape of T or Y. The fracture is generally badly comminuted and displaced. When displaced, the two condyles fall apart and are rotated along their horizontal axis.
Diagnosis. There is generally severe pain, swelling, echymosis and crepi-tus around the elbow. The diagnosis is confirmed on X-Rays.
Treatment. It depends upon the displacement. An undisplaced fracture need support in an above elbow plaster slab for 3-4 weeks, followed by exercises. A displaced fracture is treated generally byopen reduction and internal fixation.
Complications:
Stiffness of the elbow
Mai-Union
Osteoarthritis.
FRACTURE OF MEDIAL EPICONDYLE OF HUMERUS
It is more commonly injured than the lateral epicondyle, because the epiphysis of the medial epicondyle appears 'arly and fuses late with the main epiphysis of the lower humerus. Its displacements varies from minimal to displacement of the whole fragment into the elbow joint. This fracture is commonly associated with posterior dislocation of the elbow. There may be an associated ulnar nerve injury.
Treatment: It's generally conservative, by immobilisations in an above-elbow slab. If displaced into the joint, it may require open reduction and internal fixation.
The Gunter”s triangle
DISLOCATION OF THE ELBOW JOINT
This is a common injury of young adults and is caused by a fall on the out stretched hand. There are two common types of dislocations.
Posterior dislocations: In this type, the proximal end of the ulna and
radius are displaced posteriorly.
Posterior-Lateral dislocation: In this type, which is commoner, in ad
dition to the posterior displacement, the radius and the ulna are dis
placed laterally. This is often
associated with rupture of the medial
ligament of the elbow, or avulsion of the medial epicondyle of the hu-
merus and stretching and paralysis of the ulnar nerve.
Clinical Features:
The elbow is swollen but one can detect the prominence of the olecranon posteriorly with a depression just above it due to the forward displacement of distal end of the humerus. One must always look for vascular and nerve injuries in all these cases. This injury is to be differential from Supracondylar fracture. In dislocation, the relative positions of the two epicondyle of the humerus and the tip of the olecrenon are altered whereas in the Supracondylar fracture relative positions are not altered.
Radiological features: A-P and lateral views of the elbow must be taken
confirm the type of dislocation. It also shows whether there are any associated
fractures of the epicondyle or head of the radius or coronoid process.
Posterior kind.
Anterior kind.
Treatment: Reduction is done under general anesthesia. After reduction a padded posterior from behind plaster slab is applied with the elbow in a safe degree of flexion.
Complications: Immediate complication could be injury to brachial artery or median and ulnar nerves. There could also be fractures of medial epicondyle or coronoid process. Latter complications could be myositis and joint stiffness.
PULLED ELBOW
This is a traumatic subluxation of the radial head in children between the ages of 2 and 6 years. The injury is produced by a jerk on the forearm when the child is lifted while at play by the parents or relatives.
The child complains with pain in elbow and inability to use the whole upper limb and tenderness proximal end of radius. Radiograph will not reveal any fracture and awareness of this condition enables the diagnosis.
Treatment is by simple manipulation of the forearm into supination with the elbow stabilised. There is a palpable click, pain disappears and the normal movement is restored immediately.
FRACTURE OF THE OLECRANONS:
This is usually seen in adults. It results from a direct injury as in a fall on the flexed elbow. The olecranons are fractured usually near the base.
Patho-Anatomy: The proximal fragment may be pulled proximally be the attached triceps muscle, thus creating a gap at the fracture site. The fracture may be one of three types:
Type I - Crack without displacement of fragments
Type II - Clean break separation of fragments
Type III - Comminuted fracture
Diagnosis: Pain, swelling and tenderness is present at the point of the elbow. A crepitus or a gap between the fragments may be present. Active extension of the elbow is not possible in fractures with a gap the diagnosis is confirmed on an X-ray.
Treatment: It depends upon the type of fracture:
Type I: A crack fracture without displacement is treated by immobilising the elbow in an above - elbow plaster slab in 30 deg of flexion. After 3 weeks the plaster is removed and elbow exercises began.
Type II: clean break with separation of the fragments is treated by open reduction and internal fixations using the technique of Tension band wiring. It is not possible to keep the fragments together in the plaster alone because of the constant pull exerted by the plaster.
Type III: A comminuted fracture if not separated is treated in a plaster slabs as in type I, but if the fragments are separated, tension-band wiring or excision of the fragments may be required.
Complications:
1) Non-Union
2) Elbow Stiffness
3) Osteoarthritis
FRACTURE OF HEAD OF THE RADIUS:
This is seen in adults, in contrast to fractures of the neck of the radius, which occurs in children. It is a valgus injury.
Patho-Anatomy:
The head is deformed because of scattering of fragments; sometimes a fragment of bone becomes loose and lies inside the elbow joint. The fracture may be of the following three types.
A crack only
A fragment of the head is broken off
Comminuted fracture (the commonest type)
Diagnosis:
This fracture is often missed because of minimal symptoms. There is mild pain and swelling over the total aspect of the elbow. A localised tenderness over the head of the radius located immediately distal to the lateral epicondyle in a semi-flexed elbow, and painful forearm rotation is useful signs.
Treatment: It depends upon the type of fracture as discussed below:
A crack only: The fracture is treated by immobilisation in an above -
elbow plaster slab for two weeks with the elbow at 90 deg with the
flexion and the forearm in pronation
A fragment of the head broken off: If the fragment is lees than 1/3 the
size of the head. It can be treated as above. If more than 1/3 in size, or
if it is lying loose inside the joint, it needs excision.
Comminuted fracture with displacement: This is treated by excision of
the head.
Complications:
Joint Stiffness
Osteoarthritis
FRACTURE OF NECK OF THE RADIUS
This fracture occurs in children. It is a valgus injury of the elbow. Displacements are usually mild, and immobilisation of such fractures in and above plaster slab for two to three weeks is generally sufficient. In some cases with severe angulation (usually more than 60 deg) it may possible to achieve acceptable reduction by closed manipulation. Sometimes, open reduction and fixation with K-wire is required. Cubitus valgus deformity may occur in a malunited fracture.
FRACTURE CAPITULUM
This is an uncommon fracture, seen in adults. The chipped off Capitulum may get displaced into the joints. Due to overlap of bones, the fracture fragment may go unnoticed on X-rays, if the fragment is small or comminuted excision is carried out. If it is a big fragment, open reduction and internal fixation is performed.
The Forearm:
In this group the following are included:
Fracture of the radius and ulna.
Fracture of the radius alone.
Fracture of the ulna alone.
Fracture of proximal third of ulna with dislocation of the head of the ra
dius. (MONTEGGIA FRACTURE DISLOCATION).
Fracture of the distal third of radius with dislocation of inferior radio-
ulnar joint (GALEAZZIFRACTURE DISLOCATION)
HUMERUS
Fracture of the Proximal end of Humerus: The following types of features occur at the proximal end of humerus:
Fracture of the greater tuberosity.
Fracture neck ofhumerus.
Fracture of the Grater Tuberosity:
This is of two types:
Confusion crack fracture due to direct injury: This
needs only a cuff
and collar sling for two weeks and active movements of the shoulder,
Avulsion fracture: Here the insertion of the
supraspinatus avulses the
greater tuberosity. This may sometime occur in association with dislo
cation of the shoulder. With the reduction of the shoulder, the avulsed
fragment usually falls into position. The arm is kept strapped to the
body for 2-3 weeks.
Fracture neck of humerus
Classification:
Articular segment of the head
The greater tuberosity
Lesser tuberosity
The surgical neck.
Depending on the number of parts displaced they are named as two part, three part and four part fracture.
Clinical Feature: The patient presents with pain, swelling and echymosis in the proximal end of humerous. In impacted fractures, the patient may be able to move the shoulder because of impaction and the fracture is likely to be missed. In displaced fractures abnormal mobility is present. In the older patient the possibility of a pathological fracture through a secondary malignant deposit must be kept in mind.
Radiograph: Most commonly radiology reveal an undisplaced fracture at the neck of humerus in a bone that is osteoporolic. Displaced fractures may be two parts, three parts or four-part fracture.
Treatment: Long periods of immobilisation in impacted fracture in the elderly will result in total stiffness of the shoulder. Cuff and Collar rest for 2 or 3 weeks till pain subsides and active pendular exercises to restore movements give good results.
In severely displaced fractures the upper end of the broken shaft gets displaced and lies under the head with no contact with the proximal fragment. Such a type is manipulated under anesthesia and the fragments are hitched. The shoulder is immobilised in a padded 'U1 plaster slab for 3-4 weeks and early.
In the younger are groups, three or four part Comminuted fractures may need surgical reduction and internal fixation. Severely Comminuted and displaced fracture may need replacement asthroplasty with prosthesis.
Fracture Dislocation
In some cases, the shoulder gets dislocated antero-inferiorly and the neck also breaks. This is a very serious type of injury and is difficult to treat. Open reduction and informal fixation is done.
Fracture of the shaft of the humerus:
Mechanism: This fracture is usually due to direct violence and is often Comminuted. Types of Fracture:
Transverse fracture
Oblique and Spinal fracture
Comminuted fracture
Clinical Features: The usual signs of fracture, viz. local bony tenderness and deformity are present. Abnormal mobility at the middle of the arm will make it obvious. The most important complications to look for in this fracture is an injury to the radial nerve as it winds round the spiral groove, producing wrist drop.
Radiological Features: Radiographs will show the type of fracture and the displacement of the fragments.
Treatment: The reduction of this fracture is easy. Without anesthesia the patient is kept in the sitting posture. The fracture is reduced and U shaped plaster slab is applied and cuff and collar given.
Functional cart bracing is a useful method in the management of fracture shaft of humerus.
The U slab is discarded when the fracture is sticky in about 2 to 3 weeks and a functional cart is applied to the shaft allowing movements in the elbow and shoulder.
Complications:
Nerve Injury: The radial nerve is commonly in a fracture of the hu
meral shaft. The injury to the nerve is generally a neurapraxia only. It may be
sustained at the time of fracture. The radial nerve injury results in paralysis
of
the wrist finger and thumb extensors (wrist drop), brachioradialis and supina-
tor. There is a sensory change in a small area on the radial side of the back
of
the hand. The nerve is explored and appropriate surgery is done.
Delayed and non-union: Fractures of the shaft of the humerus, espe
cially transverse fracture of the mid shaft, often go into delayed or
non-union.
The cause of non-union is generally inadequate immobilisaiton, or destruction
at the fracture site because of the effect of gravity.
Treatment: Open reduction, internal fixation with a plate and bone grafting is usually performed.
FRACTUR BOTH BONES FOREARM
The radius and ulnar are fractured either by fall on the outstretch hand or by direct injury. In children the green stick type of fracture is very common.
In the forearm, when one of the bones is fractured and displaced the other also is usually fractured. If only one bone shows a fracture with displacement and the other shaft is intact, one must expect displacement either at the superior or inferior radio-ulnar joint.
The axis of rotation of the forearm is the line joining the superior and the inferior radio-ulnar joints. The restoration of the inferroseous space by proper correction of overriding, angulation and rotation is very important in the management of this fracture. If this is not done there will be restriction of pronation and supination.
Anatomical factors:
It is important to remember certain anatomical factors, which produce the displacement of the fragments in fractures of the forearm bones. The biceps and the supinator muscles are inserted in the proximal third of the radius. The pronator terse is inserted in the middle of the radius and pronator quadratus in the distal third of the radius. In fractures above the insertion of the pronator terse, the proximal fragment goes into supination. After reduction, forearm should be held in full supination to bring the distal fragment in stable alignment with the proximal fragment. In fracture the middle third of the radius and ulna, the proximal is held in the mid prone position due to the balance action of the supinator and pronator. After reduction the forearm should be kept in the mid position to keep the distil fragment in stable alignment with the proximal fragment.
Clinical Features:
This is common in young adults due to a fall on the hand. The diagnosis is obvious by the deformity, swelling and abnormal mobility. In forearm injuries always palpate the superior and inferior radio ulnar joint for evidence of injury. On should always look for evidence of vascular injury to the nerves. In case of grovs angulation, one fragment of the ulna often penetrates the skin causing a punctured wound making it an open feature.
Radiological Features:
A-P and lateral views of the whole forearm including the elbow and wrist joints must be taken. Radiograph will show the level of the fractures, the amount of overriding and rotation of the fragments.
Treatment:
Closed reduction and plaster immobilisation:
Displaced fractures of the radius and ulna need manipulative reduction.
With this information the following points should be noted:
Do not accept a fracture of the radius or ulna as being an isolated injury until you have excluded a fracture or dislocation at either end of the other bone.
As a rule displaced fractures of the forearm bones are best treated in children by manipulation, and in adults by open reduction and internal fixation.
Reduction and fixation of the ulnar fracture is the key to the treatment of Monteggia fracture-dislocation.
The Montage fracture
Galeazzi fracture-dislocations are best treated in the adult by plating of the radius.
The Colles’ fracture is the most common of all fractures.
Greenstick fractures of the radius are sometimes difficult to detect in the radiographs and are not infrequently overlooked.
Sudeck’s atrophy (relax sympathetic dystrophy) may follow any injury about the wrist (even when the soft tissues alone are involved), but it is comparatively common after Colles’ fractures.
If possible, the integrity of the articular surface of the distal end of the radius must be maintained.
Fractures of the scaphoid may be difficult to detect, and special X-ray projections must be taken.
If the initial radiographs are negative, further radiographs should be taken after 10–14 days if where is continuing local tenderness.
Unstable fractures of the scaphoid should be treated by internal fixation.
Avascular necrosis is a serious complication of both scaphoid fractures and dislocations of the lunate.
Dislocationof the lunate may be accompanied by median nerve palsy requiring prompt treatment.
Always assess the deformity and stability of a metacarpal fracture, and always look for any associated soft tissue injury.
Metacarpophalangeal dislocations of the thumb may require open reduction.
Dupuytren’s disease has a genetic predisposition and is 10 times more common in men than women.
Surgical intervention is only necessary when contractures occur and function of the hand is impaired.
FRACTURE OF THE OLECRANONS:
This is usually seen in adults. It results from a direct injury as in a fall on the flexed elbow. The olecranons are fractured usually near the base.
Patho-Anatomy: The proximal fragment may be pulled proximally be the attached triceps muscle, thus creating a gap at the fracture site. The fracture may be one of three types:
Type I - Crack without displacement of fragments
Type II - Clean break separation o^ fragments
Type III - Comminuted fracture
Diagnosis: Pain, swelling and tenderness is present at the point of the elbow. A crepitus or a gap between the fragments may be present. Active extension of the elbow is not possible in fractures with a gap the diagnosis is confirmed on an X-ray.
Treatment: It depends upon the type of fracture:
Type I: A crack fracture without displacement is treated by immobilising the elbow in an above - elbow plaster slab in 30 deg of flexion. After 3 weeks the plaster is removed and elbow exercises began.
Type II: clean break with separation of the fragments is treated by open reduction and internal fixations using the technique of Tension band wiring. It is not possible to keep the fragments together in the plaster alone because of the constant pull exerted by the plaster.
Type III: A comminuted fracture if not separated is treated in a plaster slabs as in type I, but if the fragments are separated, tension-band wiring or excision of the fragments may be required.
Complications:
1) Non-Union
2) Elbow Stiffness
3) Osteoarthritis
FRACTURE OF HEAD OF THE RADIUS:
This is seen in adults, in contrast to fractures of the neck of the radius, which occurs in children. It is a valgus injury.
Patho-Anatomy:
The head is deformed because of scattering of fragments; sometimes a fragment of bone becomes loose and lies inside the elbow joint. The fracture may be of the following three types.
A crack only
A fragment of the head is broken off
Comminuted fracture (the commonest type)
Diagnosis:
This fracture is often missed because of minimal symptoms. There is mild pain and swelling over the total aspect of the elbow. A localised tenderness over the head of the radius located immediately distal to the lateral epicondyle in a semi-flexed elbow, and painful forearm rotation is useful signs.
Treatment: It depends upon the type of fracture as discussed below:
A crack only: The fracture is treated by immobilisation in an above -
elbow plaster slab for two weeks with the elbow at 90 deg with the
flexion and the forearm in pronation
A fragment of the head broken off: If the fragment is lees than 1/3 the
size of the head. It can be treated as above. If more than 1/3 in size, or
if it is lying loose inside the joint, it needs excision.
Comminuted fracture with displacement: This is treated by excision of
the head.
Complications:
Joint Stiffness
Osteoarthritis
FRACTURE OF NECK OF THE RADIUS
This fracture occurs in children. It is a valgus injury of the elbow. Displacements are usually mild, and immobilisation of such fractures in and above plaster slab for two to three weeks is generally sufficient. In some cases with severe angulation (usually more than 60 deg) it may possible to achieve acceptable reduction by closed manipulation. Sometimes, open reduction and fixation with K-wire is required. Cubitus valgus deformity may occur in a malunited fracture.
FRACTURE CAPITULUM
This is an uncommon fracture, seen in adults. The chipped off Capitulum may get displaced into the joints. Due to overlap of bones, the fracture fragment may go unnoticed on X-rays, if the fragment is small or comminuted excision is carried out. If it is a big fragment, open reduction and internal fixation is performed.
The Forearm:
In this group the following are included:
Fracture of the radius and ulna.
Fracture of the radius alone.
Fracture of the ulna alone.
Fracture of proximal third of ulna with dislocation of the head of the ra
dius. (MONTEGGIA FRACTURE DISLOCATION).
Fracture of the distal third of radius with dislocation of inferior radio-
ulnar joint (GALEAZZIFRACTURE DISLOCATION)
INJURIES OF WRIST AND HAND TENDON INJURIES
THE WRIST
It is important to recognise the following injuries around the wrist joint, all of which occur due to fall on the outstretched hand.
1) Fracture of the lower endofthe radius:
Colless fracture
Fracture separation of lower radial epiphysis
Smith's fracture (Reverse Collets fracture)
Barton's fracture
Fracture of the scaphoid bone.
Dislocation of the lunate bone.
COLLE'S FRACTURE
There is a fracture at the distal end of the
radius often associated with a fracture of the Ulnar styloid process, (about
The following are the displacement seen in Colless fracture.
Impaction of fragments
Dorsal displacement
Dorsal tilt
Lateral displacement
Lateral tilt
Supination
Fracture of the styloid process of the Ulna.
Rupture of the" Ulnar collateral ligament
Rupture of the triangular cartilage of the Ulna
■ Rupture
of the interosseous radio-ulnar ligament, producing radio-ulnar
subluxation
Diagnosis
Clinical Features: The patient presents himself with pain, swelling and deformity of the wrist. On examination, tenderness and irregularity of the lower end of the radius is found. There may be a classic "dinner - fork deformity". The radial styloid process comes to lie at the same level or a little higher than the Ulnar styloid process.
Radiological Features
A-P lateral radiographs are taken. In the lateral view, the fracture line runs upwards and backwards from the anterior surface about an inch above the articular end. The lower fragment is displaced and tilted dorsally and laterally with some impaction. The articular surface of the radius faces dorsally according to the degree of the dorsal tilt. Normally, it faces about 15 deg palmar-wards. The lower fragment is sometimes comminuted and the fracture line may run into the articular surface.
Treatment
The fracture is reduced by manipulation under general anaesthesia. It is immobilised by a below elbow plaster slab with the forearm pronated, the wrist in slight palmer (30 deg) flexion and ulnar deviation. A check radiograph is taken to confirm satisfactory reduction. The fingers, elbow and shoulder are actively exercised to prevent stiffness.
Complications
Stiffhess of joints
Mai-Unions
Subluxation of the inferior radio-ulnar joint
Larpor tunnel syndrome
Sudeck's osteodystrophy
Rupture of the extensor pollicies longus tendon
SMITH'S FRACTURE (Reverse of Colless fracture)
This uncommon fracture is seen in adults and in old people. Its importance lies in differentiating it from the commoner Colless fracture, which occurs at the same site. It differs from Colless fracture in that the distal fragment displaces ventrally and tilts ventrally.
Treatment
After reduction, the wrist is immobilised in a 30 deg dorsiflexion position with the forearm supinated in an above elbow plaster.
BARTON'S FRACTURE
This fracture extends from the distal surface of the radius to either its anterior or posterior cortices. The small distal fragment carries with it the carpesl. Accordingly there is a volar Barton's fracture (anterior marginal type), and a dorsal Barton's fracture (Posterior Marginal Type).
Treatment
Closed manipulation and plaster cart. Open reduction and internal fixation is required in those cases where closed reduction fails.
SCAPHOID FRACTURE
A scaphoid fracture is more common in young adults. It is rare in children and in elderly people.
Commonly, the fracture occurs through the waist the scaphoid. Rarely, it occurs through the tuberosity. It may be either a crack fracture or adisplaced fracture. Diagnosis
Clinical Features: Pain and swelling over the radial aspect of the wrist following a fall on the out-stretch hands in an adult should make one suspect strongly the possibility of a scaphoid fracture. On examination, one may be able to elicit tenderness in the scaphoid fossa (Anatomical snuff- box) A force transmitted along the axis of second metacarpal may produce pain in the region of the scaphoid bone.
Radiological Features
Whenever suspected, an oblique view of the wrist in addition to the A-P and lateral is essential. Sometimes, it is merely a crack fracture and is not visible on initial x-rays. If a fracture is strongly suspected, the x-rays should be repeated after 2 weeks.
1-2 the fractures of body;
3 – the fractures of tuber.
Treatment
The conservative treatment – application of plaster bandage for 3,5 month.
Usually there is no displacement. Hence the wrist is immobilised in a close fitting scaphoid plaster cart. The fraction of the distal pole heals easily in 2 to 3 weeks, where the fractures of the waist and proximal pole needs 8 to 12 weeks immobilisation.
Complications:
A vascular necrosis
Delayed and non-union
Wrist Osteoarthritis
Open reposition
DISLOCATION OF THE LUNATE BONE
The lunate is the commonest carpal to be dislocated. This occurs due to a hyperextension violence to the wrist and the bone gets dislocated palmarwards into the carpal tunnel.
Clinical Features
There is pain and swelling around the wrist. The lunate bone may be palpable under the transverse carpal ligament of the wrist with its concave articular surface facing palmawards. One should look for signs of median nerve pressure like paresthesia in the thumb index and middle fingers due to compression of the nerve by the dislocated lunate bone inside the carpal tunnel.
Radiograph
Lateral view of the wrist will show the lunate lying anteriorly and the capi-tatel not articulating with the lunate.
Treatment
Manipulative reduction is done under general anaesthesia and the wrist is immobilised in plaster if cleared reduction fails, open reduction is indicated.
Complication
Carpal tunnel syndrome is the main late complication of old unreduced lunate. The lunate is exercised to reduce the symptoms.
INJURIES OF THE HAND
The hand is an important functional unit of the upper limb, without which the whole of the upper limb becomes almost useless. This calls for adequate treatment of all hand injuries however minor they may appear. The following discussion includes only the important hand injuries.
Classification
I. CLOSED INJURIES
Fracture of the Metacarpal bones
Fracture of the phalanges
Dislocation of the Metacarpal phalangeal joints
Bennett's Fracture dislocation
II. OPEN INJURIES
Cuts and Lacerations
Crush injuries of the hand
Traumatic amputation
CLOSED INJURIES
Fracture of the Metacarpal bones. Fracture of the metacarpal shaft is common at all-ages. The common causes are a fall on the hand, a blow on the knuckles (as in boxing) and crushing of the hand under a heavy object. Fracture of one or more metacarpals may occur. The fracture may be classified, accordingly to the site as follows:
Fracture through the base of the metacarpal, usually
transverse and
Undisplaced.
Fracture through the shaft transverse or oblique.
c) Fracture through the neck of the metacarpal commonly affects the neck of the metacarpal.
Undisplaced Fracture
Treatment:
If there is gross swelling of the hand it should be splinted in a dorsal plaster slab, till the edema subsides. After about a week the plaster is removed and a strapping applied to the hand across the palms and dorsum leaving the fingers and thumb free to move. Early movement should be encouraged. These lenite in a few weeks. More harm is done by over immobilisation and over treatment of these fractures.
Displaced Fracture
Transverse fracture of metacarpal shaft may show displacement of the fragment with overriding. Such fracture is reduced by manipulation under anaesthesia and subsequent treatment is the same as above.
Indication for Surgery:
Multiple shaft fracture with displacement will need open reduction and internal fixation. Fracture of the shaft with gross angulation or fracture neck of metacarpal bone with marked displacement also will need surgical reduction and internal fixation.
FRACTURES OF THE PHALANGES
These are common factors, generally sustained by fall of a heavy object on the finger or crushing of fingers. The fractures can have various patterns, and may be displaced or undisplaced.
Crack fractures of the phalanges
These may be either oblique or transverse and are stable. Strapping the injured finger to the adjacent finger treats them. Active movements of all other finger are encouraged.
Displaced Transverse Fracture
These need manipulation reduction under anaesthesia. The fragments are hitched in stable position and the finger is immobilised in flexion's by strapping it over a roll of bandage, so that the lip points towards the base of its corresponding metacarpal bone, but towards the base of the metacarpal of the thumb. After two weeks in this position the finger is released and strapped to the neighbouring fingers and joint movements encouraged.
DISLOCATION OF THE METACARPO PHALANGEAL JOINT
The metacarpo phalangeal joint of the index finger and the thumb are the commonest joint to be dislocated. This is due to hyperextension injury to the finger and the proximal phalanx gets displaced dorsally. Clinically the head of the metacarpal bone is felt as a prominence in the palmer aspect. This is easily reduced if it is fresh, by manipulation under anaestnesia. After reduction, the finger is flexed and immobilised over a roll of bandage for 2 weeks till the capsule heals.
Occasionally, reduction is not possible due to the head of the metacarpal bone button holing the volar capsule of the joint. In such cases, operation is necessary to reduce the dislocation.
BENNETT'S FRACTURE DISLOCATION
It is an oblique intra-articular fracture of the base of the 1st Metacarpal with subluxation or dislocation of the metacarpal. It is sustained as a result of a longitudinal force applied to the thumb.
Treatment
Accurate reduction and restoration of the smooth joint surface is very important because this, being an intra-articular fracture, if not reduced accurately will lead to incongruity of the articular surface and would increase the chance of Osteoarthritis. It is often possible to achieve reduction by manipulation under anaesthesia but redisplacement is common. The following methods of treatment are reduced:
The close reposition
Closed manipulation and plaster cart.
Closed reduction andprecutaneous fixation.
Open reduction and internal fixation with K-wire or a screw may be
necessary in some cases.
Complications:
Osteoarthritis
ROLANDO'S FRACTURE
This is an extra-articular fracture across the base of the 1st metacarpal. Perfect reduction is not as important as in Bennett's fracture dislocation. Treatment
is by reduction and immobilisation in a thumb – spica for 3 weeks.
OPEN INJURIES
Open injuries have to be dealt with as surgical fracture fracture emergencies.
Tidy Wounds:
These are clean wounds caused by cutters, knives and choppers. Most of the domestic injuries and some of the industrial injuries fall into this group. These should be surgically cleaned and sutured following the general principals laid down and they heal easily.
Traumatic amputation and Reimplantation
More recently it has been possible to surgical reimplant clearly severed fingers or even the whole hand in special centers with facilities for microvas-cular surgery. Clean cut injuries with traumatic amputation of a digit, can be reattached. if taken in a clean condition with the patient to hand surgery centers within 6 hours.
Untidy Injuries:
These are classified as follows:
Crush injuries without skin loss
Crush injuries with skin loss
I Crush injury without skin loss
Such crush injuries need careful surgical cleaning, trimming of the cut skin edges and attempt at primary closure by turning suitable flaps. With modem antibiotics, hand wounds can be made fit for primary closure even up to 24 hrs after injury. Fractures and dislocations must be reduced and even internally fixed but no repairs of tendons or nerves should be attempted closure with nonviable skin and closure over nonviable tissues will both lead to failure of primary wound healing. Tendon injuries are dealt when the skin healing is satisfactory and when the fracture had united.
a) Single finger; In cases of
crush injuries of the finger, every attempt
must be made to save the finger. Primary amputation at the site of elec
tion should not be performed as a routine, in the hand. It may be neces
sary to sacrifice that fingers instead of prolonged conservative treat
ment, which may end up in stiffness of all the fingers. In case of the
thumb, every bit if it must be saved as even a stiff remnant of a thumb
will be most useful to function as a stump with any remaining finger in
the hand.
Primary tendon or nerve repair in fingers should be done only under the following condition by special trained surgeons.
Injury caused by clean sharp instruments.
No skin loss.
Preferably within 6-8 hrs of injury
Non bone damage.
b) Whole hand: Such case need
thorough surgical cleaning followed by
primary skin cover. When infection is controlled and the edema has
subsided, reconstructive procedures are undertaken.
TENDON INJURIES
Tendon injuries in the hand are most disabling and hence need all the care in the primary treatment as well as the secondary reconstructive management.
FLEXOR TENDON INJURIES
Anatomical Factors: Anatomically the important factor influencing the result of the repair of cut tendons is the fibrous flexor sheath in the palmer aspect of the fingers. These sheaths extend from the level of the distal palmer crease to the base of the distal phalanx. Inside the fibrous sheath the tendons are covered by a double layer of synovial membrane, which facilitates smooth gliding of tendon during flexion of the fingers.
The palmer aspect of hand is divided into 5 zones for purpose of treatment of cut flexor tendons.
Zone I: From the base of the distal phalanx to the middle of the middle phalanx. Contains only one tendon F.D.P.
Zone II: From the middle of the middle phalanx to the distal palmer crease, contains two tendons F.D.P. andF.D.S.
Zone III: From the distal palmer crease to the distal margin of the flexor retinaculum.
Zone IV: Flexor retinaculum — carpal tunnel.
Zone V: Distal Forearm - proximal to the -wrist crease. Diagnosis: Tendon injuries are commonly caused by cuts by sharp instruments or broken glass. Clinically when a patient presents with a cut in the flexor aspect of the finger, simple tests must be done to identify the tendon injury. Active flexion's at the DIP joint and MCP joint are tested to identify the cut tendons and their level.
Treatment of flexor Tendon injuries
Initial treatment should be confined to thorough cleaning of the wound clean dressing with pressure bandage and splinting and transfer to major hospital. Tidy wounds by sharp weapons in Zone I, III and V seen within 6 to 12 hours with no skin loss are treated by primary suture. Injury of FDS alone does not require repair. When both tendons are cut repair of FDP alone is done, because repairing both tendons with the flexor tendon sheath leads to adhesion and loss of movements. In injuries in Zone II occasionally both the tendons are exercised only the flexor digitorium profoundus, extending from the distal crease of the palm to the base of the distal phalanx.
EXTENSOR TENDOR INJURIES
Anatomical Factor: The extensor expansion of the extensor digitorium tendon is broad over the proximal phalanx and divides into three slips at the level of the proximal inter phalangeal joint. The central slip is inserted into the base of the middle phalanx and is the main extensor of the proximal interpha-langeal joint. The collateral slips unite distally and get inserted into the base of the distal phalanx.
INJURIES OF THE SPINE
Fracture and dislocations of the spine are serious injuries because they may be associated with damage to the spinal cord or cauda equina. The thoraco-lumbar segment is the commonest site of injury: the lower cervical being the next common.
About 20 % of all spinal injuries result in a neurological deficit in the form of paraplegia in the thoraco-lumbar spine injuries, or quadriplegia in the cervical spine injuries. Often the patient does not recover from the deficit.
RELEVANT ANATOMY
Structure: The vertebral column consists of 33 vertebrae (7 cervical, 12 thoracic, 5 lumbar, 5 sacral, 4 coccygeal) joined together by ligaments and muscles. Each vertebra consists of an anterior body and posterior neural arch. Each vertebra body has a central part of cancellous bone and a peripheral body cortex of compact bone. The margins of the upper and the lower surface of the vertebral body are thickened to form vertebral rings. The neural arch is constituted by pedicles, laminae, spinous process and articulating facets.
Between any two vertebrae is a strong "cushion" the intervertebral disc. It consists of two positions, a central nucleus pulpous and a peripheral annulus fibrosts. The nucleus pulpous is a remnant of the notochord and is made up of muco-gelatinous material. The annulus fibrosis is made up of fibrous tissue and surrounds the nucleus pulpous.
Articulation: In the CERVICAL REGION the postero lateral joint is formed by an inferior articular facet, which is flat and ova!, facing downwards and forwards articulating with the superior facets of the lower vertebrae which faces upwards and backwards. Such a disposition of the articular facets makes the cervical spine very mobile but less stable. If the ligaments and capsule are torn, the facets of the upper vertebra can very easily slip forward causing a dislocation.
In the thoracic Spine the inferior articular facets face backwards and the superior facets face forwards. This alignment together with the posterior liga-mentous complex and ribs make the thoracic spine very stable and hence dislocations are rare.
In the lumbar region the facets are large and strong. The lower facets of the vertebrae face laterally and are embraced by the upper facets of the lower vertebra, which face medially. This makes it more stable than the cervical spine.
BIOMECHANICS OF INJURY
Mode of Injury: A fall from height e.g. a fall from a tree is the commonest mode of sustaining a spinal injury in developing countries. In developed countries road traffic accident account for the maximum number.
Other modes are the fall of a heavy object on the back e.g. the fall of a rock onto the back of a minor, sports injuries etc.
Stable and Unstable injuries: Stable injury is one where farther displacement between two vertebral bodies does not occur because of the intact "mechanical linkage".
An unstable injury is one where further displacement can occur because of serious disruption of the structures responsible for statritity.
Classification
Spinal injuries are best classified on the basis of mechanism of injury into the following types:
Flexion injury
Flexion - rotation injury
Vertical compression injury
Extension injury
Flexion distraction injury
Direct injury
Indirect injury due to violent muscle contraction
Classification
Injuries of the spine will be considered under the following heads:
I. Injuries of the THORACIC and LUMBAR spine
1) Stable injuries without paraplegia
2) Unstable injuries (Fracture dislocation) with paraplegia
II. Injuries of the Cervical Spine
1) Stable injuries without quadriplegia
2) Unstable injuries (fracture dislocation) with quadriplegia
3) Whiplash injuries
FRACTURES OF THE THORACO-LUMBAR SPINE
Mechanism and types of injuries:
The spine may be subjected to 4 types of violence:
1) Flexion violence
2) Flexion Rotation violence
3) Vertical compression
4) Extension violence
A STABLE FRACTURES WITHOUT PARAPLEGIA
Clinical Features: This is the common type of fracture spine. There is usually a history of a fall from a height or a weight falling on the back. On examination, there may be local bruises in the back and a localised point of tenderness in the spine. An angular gibbous is sometimes seen or felt at the site of fracture.
A general examination must be made for evidence of shock and injuries to he head, chest and abdomen. The legs must be examined for preliminary assessment of motor paralysis and sensory loss, and their extent is estimated. One must also look for distension of the bladder, due to paralysis of the bladder function. In cases of falls from height, examine the heels for fracture cal-caneum.
Anteroposterior and lateral radiographs of the spine must be taken to confirm the presence and type of fracture.
Treatment
First Aid: Any patient with an injured spine must be carefully shifted in the face down position, so that further flexion of the spine and injury to the spinal cord are avoided.
WEDGE COMPRESSION FRACTURE
In those cases, the posterior ligaments are intact. These are called stable fractures, and hence prolonged immobilisation is not necessary. These patients are kept in bed for 2 to 3 weeks. As soon as there is healing of the soft tissue injury and the pain subsides, the patient is made to do active spinal extension exercises, when the muscle strength is developed the patient is allowed to get up and is advised to continue strengthening exercises to the back. It is not necessary to attempt restoration of the shape of the vertebrae. The aim of treatment is to restore a painless, strong and mobile back. He should be fit for duty in about 4-6 weeks.
COMMINUTED FRACTURES (BURST FRACTURE)
These are severe injuries. The fracture in the vertebral body is comminuted. These are treated by immobilisation in a plaster jacket in slight extension. The anterior -longitudinal ligament acts as a splint for the injured vertebra. The plaster jacket extends from the suprastemal notch to the symphysis pubis anteriorly and C7 spinous process to the top of the gluteal fold posteriorly.
The patient is allowed up in about 2-3 weeks. Extension exercises to the muscles are started. The plaster jacket must be kept for about three months. The exercise therapy is continued even after removal of the plaster. The patient may return to work with a spinal brace.
FRACTURE DISLOCATION WITH PARAPLEGIA
This injury is caused by very severe flexion rotation violence and is complicated in most cases by injuries to the cord or cauda equina resulting in paraplegia. In uncomplicated cases the treatment in the same as for the comminuted fracture.
These are always unstable injuries. These are difficult problems and are best treated in special centers for spinal injury. The treatment and rehabilitation of these cripples need a team of specialist including the orthopedic surgeon, neurosurgeon, plastic surgeon, urologist and good physiotherapy and rehabilitation facilities. Many die of infected bed sores and urinary infections. With modem advances in surgical techniques and rehabilitation it is possible to save the lives of most of these people and rehabilitate them to lead independent and useful lives. The prognosis in these cases depends on the degree of damage to the spinal cord or cauda equina.
Pathology: In the fracture dislocation, the cord or the cauda equina gets damaged by being compressed by the lamina of the upper vertebra against the postero superior margin of the vertebral body below. It may suffer the following types of injuries.
A. Cord Injuries
Confusion and edema
Laceration and transection of the tract fibers incomplete or complete.
Degeneration and liquefaction of the damaged cord substance follow
this.
3) Hemorrhage into or around the cord substance.
B. Cauda Equina Injuries
Partial injury: Crushing injury to the nerves of the Cauda equina.
Complete transection
Clinical Features: The patient is brought with a history of fall, severe pain in the back and instability to move the legs. On examination there is a gibbous with tenderness at the level of the vertebral damage. A general examination must be done to exclude injuries to abdomen, chest and the head. One should then determine the level of the cord injury. There will be motor paralysis of both lower limbs.
The level of SENSORY LOSS will depend on the level of vertebral damage. It will vary at the upper, middle and lower third due to the varying obliquity of the nerve roots inside the spinal canal. The sensory loss will be one segment below the vertebral body. In the middle third, the level of sensory loss will be 2 segments below and in the distal third it will be 3 segments below the level of body injury.
The clinical picture will depend on the stage (Spinal shock, stage of Reflex activity) at which the patient is brought. On first examination it will be difficult to diagnose the exact nature of the cord injury. Concussion, partial and complete transection of the cord, will all present a similar picture of spinal shock with flaccid paraplegia. The level and displacement of the fracture may partly inform the nature of the lesion.
Stage of spinal shock; This stage shows complete flaccid paralysis and loss of all functions, below the level of the injury. In case of confusions this stage is only a physiological transection of the cord and in the course of a few days or weeks shows complete recovery of function.
Stage of reflex activity: In case of partial disruption of the cord fibers, the stage of spinal shock is followed by the stage of paraplegia in extension and the return of reflex activity of the bladder. Depending on the degree of damage there will be partial recovery of motor and sensory functions.
In case of total anatomical disruption of the cord fibers, the stage of spinal shock is followed by a spastic paraplegia inflexion with mass reflex below the level of injury. No recovery could be expected in such cases.
Stage of failure of reflex functions: This occurs in cases where urinary sepsis and septicemia becomes overwhelming and there is loss of even whatever functional recovery that had occurred earlier. This is really a terminal stage and the paraplegia becomes flaccid again.
Radiological Features: AP and lateral view will show the level and type of lesion, CT Scan will be useful to accurately locate displaced fragments into the spinal cord.
Management of the Fracture: Shifting of the patient from the reception (casualty) to the radiology department or the ward would be done with extreme care to prevent jerking or flexion which will cause cord damage after arrival in the hospital. This is called the "Second Accident".
Conservative Treatment: The patient is positioned to lie supine in a split bed with a pillow under the gibbous to produce postural reduction. The fracture dislocation may get reduced. The patient is turned every 4 hrs to prevent pressure sores. When the paraplegia begins to recover a complete plaster jacket is applied. The plaster jacket is kept for 2-3 months. The patient is allowed to get up as soon as the muscle is good.
Role of Surgery: Open reduction and internal fixation to stabilise the spine can be done by the use of rods on either side of the spinous processes like Harrington Straight rod or Leeque's L Shaped rods.
Management of Paraplegia: The exact diagnosis of the traumatic pathology will become obvious anytime, between three days to three weeks. A concussion will recover completely. A patient with incomplete cord laceration will develop paraplegia in extension and the complete lesion will produce paraplegia in flexion.
The aim of the early treatment is to prevent bedsores and urinary sepsis, as they are the commonest causes of death. The next step is the rehabilitation of the paraplegia to enable him to lead an independent life.
The management of an acute traumatic paraplegia should include the following:
General care
Psychological care
Skin care
Bladder care
Bowel care
0 Rehabilitation
General Care: The general care treatment is important as these patients develop negative Nitrogen balance and anemia. A high protein diet and anti anemic treatment will increase the patient's resistance.
BED SORES (Pressure Sores)
Bedsores (pressure sores) or decubitus ulcers are localised areas of cellular necrosis resulting from prolonged exercise stress on soft tissue. Areas over bony prominence with compromised sensation are more susceptible to breakdown into decubitus ulcers. It is common over pressure areas like sacrum, back of the heels and greater trochanters.
They are graded into grade I, II, and III depending upon the area and depth of the ulcers.
Pathogenesis: The sore starts as a hyperemic area over pressure points like sacral, trochanteric, and heel areas (grade I). If neglected it leads to breakdown of the skin and ends up as deep ulcer due to sloughing of necrotic muscle exposing the underlying bone (grade III). In an already debilitated patient, pressure sore is the commonest cause of progressive deterioration and death.
This must be prevented by careful attention of pressure points like sacral, trochantric and heel areas. During the acute stage, the patient is nursed in a spinal turning frame and turned every four hours. The use of spinal turning
frames, airbeds and waterbeds for the paraplegic patients, will certainly minimise the incidence of bedsores.
Treatment consists of daily dressing, excision of necrotic tissue and slough and control of infection when the sore area shows clean granulation tissue skin grafting is done. Grade III sores with exposed bone will need plastic surgical reconstruction with fascia cutaneous or myocutaneous skin flaps.
BLADDER CARE
Stage of Spinal Shock: During the stage of spinal shock, there is retention of urine and as the paralysed bladder distends, there is overflow of urine from the distend bladder. The bladder acts as denervated organ and is unable to empty.
The further behaviour of the bladder depends on the type of disruption of the reflex pathways, which are controlling the bladder functions. The reflex centre for the bladder is at S2-S3 level in the cord and this is controlled by the inhibiting influence of the higher centre in the cerebral cortex.
AUTOMATIC NEUROGENIC BLADDER (Upper Motor Neuron Bladder)
This is the type of neurogenic bladder occurring after complete transection of the cord above S2 level. The reflex centres takes over the control of the bladder.
The reflex runs from the bladder to the sacral cord, Synapses and back to the bladder. The bladder becomes an organ controlled by a simple reflex activity. When the bladder is distended with urine the patient involuntarily empties the bladder by the reflex activity. The stimulus is either intrinsic from the bladder wall or extrinsic stimuli that provokes mass movement. The patients have no real sensation of visical filling but the increasing size of the bladder as the urine accumulates, produces sensation in the abdomen that they may interpret as fullness of the bladder. Urination occurs without warnings as soon as the reflex are closed by summation of afferent stimuli.
There will be minimal residual urine. This is called cord or automatic bladder. This may take 2-6 weeks to develop
AUTONOMOUS NEUROGENIC BLADDER (Lower Motor Neuron Bladder)
This occurs in injuries at the S2 level or below i.e. at the conus and cauda equina. This destroys the reflex centre with the afferent and efferent in the nerve roots. This isolates the bladder which then depends on the intrinsic plexus in the musculature of the bladder wall i.e. detrussor ganglion. This bladder, which resumes some function, is called autonomous bladder or atonic bladder. The emptying can be assisted by manual pressure or by trained contraction of the abdominal musculature. Due to spasm of the internal sphincter, the residual urine is large (300-400 cc)
Treatment: The aims of bladder management include:
Avoidance of bladder overdistension
Prevention of urinary infection
3) Restoration of continence, by bladder training depending on the type of bladder.
During the 1st 24 hrs of retention, there is no urgency to interfere. When the patient complains of discomfort, avoiding over distension is essential. This is accomplished by intermittent urethral catheterisation or indwelling catheter passed under strict aseptic precautions.
When drainage is established the following other measures are undertaken to prevent ascending urinary infection and avoid calculi formation.
A liberal fluid intake of 2-
Prophylactic antibiotics
Daily bladder wash
CERVICAL SPINE
The common type of cervical spine injury is the hyperflexion injury caused by a heavy weight falling on the head or by landing on the head while diving in shallow swimming pools. It is usually a dislocation at the lower cervical level, the commonest being at C5, C6 and C7. Dislocation at this level cause severe injuries to the spinal cord resulting in quadriplegia.
Lower Cervical Spine Injuries
First Aid: These patients must be handled with extreme care. Sandbags must steady the head and neck, pillows or cervical spine boards and no flexion movement must be allowed even momentarily during transport or radiography.
Clinical Features: After a general, assessment of the injury to the patient other injuries including head injuries must be excluded and general resuscia-tion done. There will be extreme pain and muscle spasm in the neck and tenderness at the site of dislocation. A neurological examination is done to assess the extent of paralysis. This will show evidence of nerve irritation at the segment just above the level of cord damage, causing muscle spasm and hyperes-thesia and typical pastures of the arms.
If the cord damage is a C6 level, there will be evidence of irritation at the C5 segment. There will be spasm of deltoid, flexions of the elbow and the su-pinator. The patient will lie with the arms abducted, externally rotated and the forearm supinated. If the injury is at C7 level, C6 segment shows irritation with spasm of adductors of the shoulder and pronators of the forearm lying pronated over the body. Both lower limbs will be paralysed. In injuries at C4 and C5 there will be respiratory distress due to diaphragmatic paralysis.
Radiological Features: Radiological examinations will show the level of damage and the type of injury and displacement. In cases of upper cervical injuries, always take radiographs of the skull. The use of Magnetic Resonance Imaging (MRI) can demonstrate the structural damage to the spinal cord at the level of injury.
Treatment: The aim of treatment is to reduce the dislocation and maintain it till stability is achieved. The best method of treatment is to apply skull traction with Gardener Wells tongs. The patient is treated in a spinal turning frame.
Glisson Sling Healter Traction
Where facilities for skull traction are not available, traction to the neck is applied with a sling. The sling exerts traction through the chain and the oceiput and hence is not comfortable to the patients and cannot be kept too long.
Surgical Treatment: Sometimes even heavy prolonged traction fails to reduce the dislocation due to the locking of articular processes. In such cases, operative reduction is carried out.
Upper Cervical Spine Injuries
Injuries of Ci C2 level are very serious as any displacement can cause fatal neurological complication.
Fracture Atlas (C1)
Fracture of the Atlas is due to vertical compression violence. The fracture occurs at the anterior or posterior arch causing separation of the lateral masses. The cord escapes injury.
Fracture Axis (C2)
The important fractures are:
Fracture adontoid: This can occur at the tip or the base. The fracture
can result in atlanto axial dislocation. This is treated by skull traction
followed by plaster.
Hangman's fracture dislocation: This is a traumatic spondylolisthesis
at C2, C3 level. It is treated by reduction by skull traction and immobi
lisation in plaster.
Atlano-Axial Dislocation
Pure atlanto axial dislocation without fracture of the adontoid process causes sudden cords compression and is fatal.
A pure dislocation of Cj, C2 is dangerous as it results in compression of the spinal cord. If there is a fracture at the base of adontoid also, it moves along with the atlas and cord escapes injury.