Case discussionExtern วรนทร พลานภาพ

HistoryPatient Profile ผปวยหญงไทยค อาย 43ปCC: ตกตนไมสงประมาณ 4เมตร 2 ชวโมงกอนมารพ

Primary surveyA – Patent airway, no cervical

midline tenderness, can flex/extend neck

B – Equal breath sound, trachea in midline, no distant heart sound

C – BP 120/69 mmHg, PR 80 bpm, no external bleeding, CR<2 sec

D – E4V5M6, pupil 3 mmRTLBE

Secondary surveyA – No allergyM – No current medicationP – No underlying diseaseL – Last meal 5 hours PTAE – 2ชวโมงกอนมารพ ผปวยตกตนไมสงประมาณ

4เมตร เอาสนเทาลง ไมมศรษะกระแทก ไมสลบ จำาเหตการณไดตลอด ปวดกลางหลงบรเวณเอวทนท ลกเดนไมได ลกนงไมได งอยดหลงไมได ยกแขนขาพอได ไมชา ไมมบาดแผลภายนอก กลนปสสาวะอจจาระได

Physical examinationPE: Vital signs – BP 120/60mmHg,PR 80bpm, RR14/min, Temp 36.6◦CGA – A Thai woman, good consciousness, well co-operativeHEENT – no pale conjunctiva, anicteric sclera, no subconjunctival hemorrhageHeart – pulse full, regular, normal S1S2, no murmurLungs – good air entry, normal breath sound equal both lungsAbdomen – no distension, no ecchymosis, soft, no tendernessExtremities and Back – tender at posterior midline of lumbar region and Left calcaneus, cannot flex and extend back, no external wound

Physical examination•Motor: normal tone•DTR 2+, BBK absent•PR – good sphincter tone, bulbocarvernosus reflex +ve

  Right Left  Motor Sensory Motor SensoryC5 V intact V intactC6 V intact V intactC7 V intact V intactC8 V intact V intactT1 V intact V intactL2 V intact V intactL3 V intact V intactL4 V intact V intactL5 V intact V intactS1 V intact V intact

Film•TL spine AP

Film•TL spine lateral

Film•Left calcaneus axial view

•CT spine (L1)

Diagnosis: Burst fracture of L1 spine

ManagementSurgery – Percutaneous pedicle screw fixation T12-L2

Thoracolumbar spinal Fracture and dislocation

Anatomy•Support the axial musculature•Protect the spinal cord and nerve roots

Classification

Denis classification systemanterior column • anterior longitudinal ligament (ALL)• anterior 2/3 of vertebral body and annulusmiddle column • posterior longitudinal ligament (PLL)• posterior 1/3 of vertebral body and annulus

posterior column • pedicles• lamina• facets• ligamentum flavum• spinous process• posterior ligament complex (PLC)

Posterior Ligamentous Complex critical predictor of spinal fracture stability consists of supraspinous ligament interspinous ligament ligamentum flavum facet capsule

Denis classification system Denis classification system แบง T-L fracture เปน 4 กลม•1. Compression fracture•2. Burst fracture•3. Flexion distraction (seat belt-type)•4. Fracture dislocation

Compression fracture•Failure of anterior column •The middle column is intact•Usually no Neurological deficits

Compression fracture

Burst fracture•Axial compression resulting in Failure of anterior and middle column• If posterior column involved results in instability •Most common at T/L junction

Burst fracture

Flexion distraction (seat belt-type)•Hyper-flexion and subsequent tension forces•Both posterior and middle columns fail•The anterior part of the anterior column may partially damaged ,but still functions like a hinge

Flexion distraction (seat belt-type)

Fracture dislocation•failure of all three columns under compression, tension, rotation, or shear. •similar to seat-belt-type injury. However, the anterior hinge is also disrupted and some degree of dislocation is present.

Fracture dislocation

TLIC score

Management•Nonoperative

indications - compression, stable burst and

chance fracture (PLC intact) with neurologically intact

treat in orthosis for 6 to 12 weeks depending on degree of instability

Management•Operative

indications for surgery- progressive neurologic deficits- gross spinal instability- posterior ligament complex

stability compromised

Complication

References•ตำาราออรโธปดกส ฉบบเรยบเรยงใหม ครงท 3, คณะแพทยศาสตร รพ.รามาธบด.•Rockwood and Green’s, Fracture in Adults, 3rd Edition.•Netter’s Concise Orthopaedic anatomy, 2nd Edition.

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