1. Spine and extermity injury
Samrina Shrestha
Intern
MBBS 8th batch

2. Extremity injury

3. Fractures
- A fracture is any break in the continuity of the bone.
- Types:
• 1. Open fractures: The fractured bone communicates with the exterior
exposing bone at the fracture site.
• 2. Closed fractures: Higher chances of infection. No communication with
the exterior.
- Clinical features:
• Swelling or a gross deformity of limb
• Pain
• Decreased/ absent range of movement of joints
• DNVS (Distal Neurological Vascular Status) – intact/ not
• Associated wounds

4. -Investigations:
• CBC, RFT
• Blood grouping, cross matching
• X-ray of fractured limb:
• Involve one joint above and below the fractured site
• Order 2 views

5. - A systematic approach is always helpful:
• Examine the most obviously injured part.
• Test for artery and nerve damage.
• Look for associated injuries in the region.
• Look for associated injuries in distant parts.

6. Look- Feel- Move
1. Look :
- Swelling, bruising and deformity and if the skin is intact
- Note posture of distal extremity and the color of skin ( tell-tale signs
of nerve or vessel damage)
2. Feel:
- Gently palpation for localized tenderness
- Characteristic associated injuries should also be felt for. For example,
an isolated fracture of the proximal fibula should always alert to the
likelihood of an associated fracture or ligament injury of the ankle, and
in high-energy injuries always examine the spine and pelvis
- Vascular and peripheral nerve abnormalities should be tested for both
before and after treatment.

7. • Move:
- Crepitus and abnormal movement may be present, but why inflict pain
when x-rays are available. It is more important to ask if the patient can
move the joints distal to the injury

8. • Principles Of Treatment :
The four essentials are:
• Antibiotic prophylaxis.
• Urgent wound and fracture debridement.
• Stabilization of the fracture.
• Early definitive wound cover.

10. Compartment syndrome
- It is a condition where the circulation within a closed compartment is
compromised by an increase in pressure resulting in ischemia and necrosis of
muscle and nerves.
- Common site: leg, fore arm
- Causes
• Severe crush injuries
• Tight/constricting casts
• Compression injuries
• Closed fractures
• Infections
• Burns

11. •Clinical Features:
• Pain: out of proportion to expected and increased by passive
stretching
• Paresthesia
• Pallor
• Paralysis
• Pulselessness (late sign)

12. - Investigations:
• If available, measurement of compartment pressure (<30mmHg)
indicates compartment syndrome
• Routine blood tests
• CPK
• X-ray of affected limb

14. Traumatic amputation
- Traumatic amputation may cause a significant threat to life and the
survival of the residual limb.
- It can also cause life threatening hemorrhage.
- Clinical Features:
• Pain
• Severe bleeding
• Hypotension, tachycardia

15. - Management:
• Primary survey+ resuscitation: Maintain ABC
• Preservation of amputated part:
- Wash the part in normal saline thoroughly.
- Wrap it in sterile gauge (soak it with 100,000 units Penicillin in 50ml
NS)
- Wrap it further in a sterile moist towel.
- Place in a plastic bag, keep it in crusted ice but avoid freezing.
- Refer immediately for definitive care.
NOTE: only clean cut amputation can be salvaged.

16. Spinal injury

17. Introduction
• Spine injury refers to insult to the spine resulting in damage to its
osseoligamentous components with or without associated neurologic
impairment.
• It is a frequently-occuring event with devastating consequences. Early
recognition and treatment are central to achieving satisfactory
outcomes.

18. Anatomy of spine
• Vertebral column- Fibro-osseous
- 33 Vertebrae
- Soft tissues- IV discs, facet joint capsule, ligaments
• Spinal cord: Extends from foramen magnum to L1/L2 in adults (
below in children)
- Part of CNS
- Neural tissue+ coverings
- Blood supply- spinal arteries.

20. Three column stability of spine

21. Spinal stability is the ability of the spine to withstand physiological
loads with acceptable pain, avoiding progressive deformity and
neurological deficit.
The spinal column can be divided into three columns: anterior, middle
and posterior. If two or more columns of the spine are injured the spine
is considered as unstable.

22. Etiology
• RTA
• Significant falls (>12ft)
• Deceleration injuries
• Blunt trauma to head, neck or back.
• Sports injuries
• Assault- Firearm, stab injury
• Pathological fractures- osteoporosis, TB spine.

23. Mechanism of injury
• There are three basic mechanisms of injury: traction (avulsion), direct injury and
indirect injury.

24. • Traction injury: In the lumbar spine resisted muscle effort may avulse
transverse processes; in the cervical spine the seventh spinous process can
be avulsed (‘clayshoveller’s fracture’).
• Direct injury: Penetrating injuries to the spine, particularly from firearms
and knives, are becoming increasingly common.
• Indirect injury: This is the most common cause of significant spinal
damage; it occurs most typically in a fall from a height when the spinal
column collapses in its vertical axis, or else during violent free movements
of the neck or trunk. A variety of forces may be applied to the spine (often
simultaneously): axial compression, flexion, lateral compression, flexion-
rotation, shear, flexion-distraction and extension.

25. Pathopysiology of injury.
• Primary changes:
Physical injury may be limited to the vertebral column, including its soft-tissue components,
and varies from ligamentous strains to vertebral fractures and fracture-dislocations. The spinal
cord and/or nerve roots may be injured, either by the initial trauma or by ongoing structural
instability of a vertebral segment, causing direct compression, severe energy transfer, physical
disruption or damage to its blood supply.
• Secondary changes:
During the hours and days following a spinal injury biochemical changes may lead to more
gradual cellular disruption and extension of the initial neurological damage.

26. Emergency management
• ABCs
Airway
Secure airway and keep the airway patent.
Remove foreign body, secretions if any present.
In a case of suspected C-spine injury head tilt and chin lift must be avoided
as it may further aggravate the injury, only jaw thrust must be performed.
Breathing
Check for breathing pattern of patient, respiratory rate, visible chest
deformity and chest movement.
Provide oxygen support as per the patient requirement.
Circulation
Asses BP and pulse of the patient.
If the patient is in shock (SBP<90mmHg) provide circulatory support via
rapid infusion or vasopressors as per requirment of the patient.

27. Emergency management contd:
• Immobilization
The spine must be immobilized as soon as possible if spinal injury is
suspected by the use of cervical collar or spinal board as it helps to prevent
secondary injury to the spine.
• Insert NG and foley’s catheter.
• Complete imaging of spine and consult spine service if avilable.
• If cervical cord lesion watch for respiratory insufficency, as patient may require
intubation and mechanical ventilation.
• Warm blanket, Trendelenburg position.
• Call police in case of RTA or physical assault.

29. Management:
• Multidisciplinary approach.
• Initial resucitation.
• History taking:
• pain in neck or back, mechanism of injury, previous deficits, SAMPLE
• paralysis, paresthesia, bowel/ bladder incontinence.
• Physical examination:
- ABCs
- Abdominal: ecchymosis, tenderness.
- Neurological: complete examination, including mental staus.

30. • Spine examination:
- Maintain neutral position
- Assess for tenderness, muscle spasm, bony deformities
- Assess rectal tone.
- Check for capillary refil.
- Anal wink and bulbocavernosus reflex. DRE is mandotary.

31. Investigations:
• Imaging:
• Full C-spine X-ray series for trauma ( AP, lateral, odontoid)
• Thoracolumbar X-ray ( AP and lateral )
• X-ray pelvis ( AP view)
• Bloodwork:
• CBC
• Electrolytes
• Creatinine
• Coagulation profile
• Glucose
• Toxicology screening
• CT scan , MRI and Myelography can be done for confirmation or in case of
obscure diagnosis.

32. Definitive management
• Operative
• Indications
Unstable fracture with progressive neurological deficit.
Unstable injuries with neurologic impairment.
Patient’s choice
To agument spine stability achieve by non-operative means
Treatment of complications.
• Techniques
Plates
Rods and screws
Wires
Lag screws

34. Supportive care:
• Skin care
Wash, dry and powder skin
2- hourly turning
No creases or crumbs in sheets
• Bladder and bowel care
Intermittent, aseptic bladder drainage. Commence bladder training ASAP.
Bowel training with enemas.
• Thromboprophylaxis
Early physiotherapy
Drugs

35. Rehabilitation
• Should be started as soon as possible
• Physiotherapy
• Prompts neural recovery
• Prevents DVT/PE
• Prevents contractures
• Occupational therapy
• Psychotherapy

36. Complications:
• Early
• DVT
• Pressure sores
• Bladder/bowel dysfunction
• UTI
• Neurogenic shock
• Pulmonary complications- Pneumonia, atelectasis, ventilatory failure
• Late
• Contractures
• Chronic pain
• Autonomic dysreflexia
• Osteoporosis
• Depression
• Heterotopic ossification

37. Current trends
• ASSISTIVE ROBOTIC EXOSKELETONS
• STEM CELL TRANSPLANTATION.

38. CONCLUSION
• Spine injuries are a clear and present danger to our economic stability.
Apart from being quite costly to manage, outcomes are sometimes
discouraging depsite best care.
• Efforts geared toward prevention will certainly reduce the burden of
this problem on society as a whole.

40. References
• Apley’s system of orthopaedics and fractures.
• Tronto notes
• Textbook of orthopaedics, Maheshwori
• Standard treatment protocol.