Humeral Fracture Treatment Guide

Humeral
fractures

Proximal humeral fracture
*Proximal humerus consists of:
-‐Humeral head -‐Lesser tuberosity -‐Greater tuberosity -‐Humeral shaft.
*Blood supply: anterior and posterior circumflex humeral vessels
Anatomy
*Displacement of fractured segments:

-‐Greater tuberosityà superiorly+ posteriorly: by supraspinatus muscle.
-‐Lesser tuberosityà medially: by subscapularis.
-‐Humeral shaftà adducted by pectoralis major.
-‐Proximal segmentà abducted by deltoid.
-‐ Young adult: MVA
MOI
-‐elderly: FOSH
-‐ Pain -‐Swelling -‐Tenderness over the shoulder -‐ Painful ROM
C/P
-‐ Injured extremity is supported by contralateral hand

Plain radiograph à Shoulder trauma series: AP, lateral scapula plane and axillary shoulder view
Radiology
CTà -‐Articular involvement -‐Degree of fracture displacement

-‐ impression fracture of the head -‐Glenoid rim fractures
Neer’s classification system

Classificat
Notes:
ion
Anatomical neck fracture: uncommon, high risk of avascular necrosis

Surgical neck fracture: common
Non displaced Two-‐part fractures Three-‐parts Four-‐parts Fracture

fractures fracture dislocation
1-‐Sling immobilization 1-‐Anatomical neck -‐Unstable -‐é risk of 2-‐partsà close
Treatment According to Neer’s
2-‐Follow-‐up with fracture: -‐Youngà ORIF avascular 3 or 4partsà

radiographs (look for loss of -‐Young: ORIF with plates with plates and necrosis ORIF or
fracture reduction) -‐Elderly: shoulder hemi-‐ screws -‐same as three-‐ Shoulder hemi-‐
3-‐Early active shoulder arthroplasty -‐Elderlyà part or we can arthroplasty
mobilization 2-‐Surgical neck: Shoulder hemi-‐ use K-‐wires in (elderly or
ORIF plates +screws or arthroplasty ORIF dislocation >40%
IMN of humeral head)
3-‐Greater tuberosity:
ORIF with screws &
consider rotator cuff
repair
Lesser tuberosity:
conservative unless
rotation is blocked
Stiffness & loss of movement
-‐ Esp. abduction and internal rotation
-‐ Causes: Malunion, persistence displaced greater tuberosity
Complication
-‐ Prevention: early mobilization and physical therapy

Nonunion/ Malunion:
-‐ If it causes pain or severe restricted movement à treat with internal fixation & bone grafting or arthroplasty
Osteonecrosis
Neurovascular injury:
-‐ Especially if the shaft displaced medially
-‐ Nerves: axillary, median, radial, ulnar.

Humeral shaft fractures
Anatomy Extends from the insertion of pectoralis major to supraconylar ridge
Spiral groove: radial nerve + brachial artery
Rich of blood supply
C/P Pain Swelling Deformity Shortening
Radiology AP Lateral
TTT Mostly conservative: 20° angulation + 3cm apposition
Options Indications
Hanging cast Displaced spiral or oblique fracture
Coaptation splint Minimal shortening
Conservative
Fracture prone to displacement with hanging cast

(short transverse, oblique)
Thoracobrachial Minimally displaced or Undisplaced + child/elderly
immobilization
Functional bracing 1-‐2 weeks after management with other methods
for 8 weeks à allow maintenance of alignment and
movement of adjacent joints
*Approaches Polytrauma
-‐Anterolateralà Inadequate close reduction
proximal 1/3 of Pathological fracture
humeral shaft Associated vascular injury
Operative
-‐Posterior à distal Floating elbow fracture

1/3 of shaft Segmental fracture
*ORIF with plates Intra-‐ articular extension
and screws Bilateral humeral fracture
Open fracture
Neurovascular loss and radial palsy

Distal humeral fractures
* Uncommon
* Most of them are peri-‐articular fractures: risk of NV injury

Anatomy Distal humerus à triangle shape: medial + lateral borders + base (trochlea and
capitellum) + corners ( condyles)
Trochlea articulates with ulna
Capitellum with radius
MOI Young: MVA Elderly: FOSH
C/P Pain Swelling Crepitus
Displacement Soft tissue damage
Radiology -‐AP
-‐Lateral
-‐Fat pad sign: presence of effusion or hemarthosis à displacement of the
adipose layer overlying the joint capsule: in Lateral radiograph à radiolucent
line.
CT à more details, pre-‐operative
Types
Most common
Comminution
Intercondylar
Displacement of fracture fragment

TTT:
*Mostly: ORIF with Dual plates and screws
*Osteoporosis or comminuted à locking plates.
*Conservative:
-‐Undisplaced, elderly, severe comorbidity
-‐ By cast, bag of bones technique or olecranon pin
Elderly: FOSH or force applied to flexed elbow
condylar
Trans-‐
TTT:
*Non-‐operative: an above elbow cast immobilization + ROM exercises
*ORIF + 1-‐2 plates à open fracture, displaced and unstable
*Fracture on the coronal plane parallel to anterior humerus
*FOSH
*Often associated with radial head fracture
Capitellum
*No soft tissue attachment: displacement + restriction of movement

* Prone to avascular necrosis of the fragment
TTT:
Non-‐operative: posterior splint immobilization for 3 weeks followed by elbow
motion exercises
ORIF with screws: displaced
Rare
Trochlear
TTT:
Non-‐displaced à non-‐operative: posterior splint immobilization for 3 weeks
followed by elbow motion exercises
Displaced àORIF with screws or K wires
Rare
Supraco
ndylar
Non-‐displaced (Mostly) à non-‐operative: posterior splint immobilization for 3

weeks followed by elbow motion exercises
ORIF if displaced or complications
Compartment syndrome
Complicati
NV injury: brachial A. ulnar, median N.

ons
Post traumatic arthritis

Failure of fixation
Iatrogenic NV injury or infection

Radius fractures

Distal radius fractures
Most common fracture of Upper extremity
More common in elderly female (osteoporosis)
Anatomy:
Metaphysis of radiusà mostly cancellous bone: one of primary sites for
osteoporosis
Articulates with à scaphoid and lunate.
Attachmentà palmar and dorsal radiocarpal ligaments: intact in distal radius
fractures à facilitate reduction.
Triangle fibrocartilage complexà thick ligament, connect radius with ulna,
frequently injured
Axial weight à 80%: distal radius. 20% ulna through TFCC
Mechanism of injury:
FOSH
Clinical presentation:
1. Pain
2. Swelling
3. Wrist deformity:
• Dorsal à colles or dorsal barton
• Volar à smith or volar barton
4. ±Carpal tunnel symptoms
• Numbness, tingling, weakness
• Cause: direct pressure from bone fragments, hematoma, increased
compartment pressure
5. ± Open injury: young patient + high energy trauma
Radiological evaluation:
Views: AP, lateral
Normal parameters:

Name Normal value What?
Radial inclination 22° Measured between the horizontal and the distal
radial articular surface
Radial length 11mm Between 2 horizontal lines drawn parallel to
each other at level of radial and ulnar ends
Palmar tilt 12° Lateral radiograph: between a perpendicular to
the radial axis and a line drawn along the
articular surface

Classifications
1. Frykmann:
Pattern of intra-‐articular involvement
8 classes
No ulnar fracture With ulnar fracture
Extra-‐articular 1 2
Intra-‐articular
Radiocarpal joint injury 3 4
Distal radioulnar joint injury 5 6
Both injured 7 8
2. Fernadez
Mechanism of injury
5 classes
1à bending 2à shearing 3à compression 4à avulsion 5à combination

Types

Name Joint MOI Deformity Notes
involvement Fall on:
Colles Extra-‐ -‐ Hyper-‐ Dinner fork: Most common
articular extended Dorsal angulation
wrist Dorsal
-‐ Radial displacement
deviation Radial shift
-‐ Pronation &shortening
Smith Extra-‐ -‐Flexed wrist
Garden spade: Mostly: unstable à
articular -‐Supination Volar angulation requiring ORIF with
Volar displacement plates and screws.
Barton Intra-‐ -‐Dorsiflexion Volar (more Unstable à ORIF
articular -‐Pronation commom)
-‐Shearing Dorsal
force

Treatment
Acceptable radiograph parameters
Radial inclination: <5° loss
Radial length: ±2-‐3mm of the contralateral wrist
Palmar tilt: at least 0 (no dorsal tilt is accepted)
Step-‐off: in intra-‐articular, <2mm.
Notes:
• No dorsal tilt is accepted because load will be transferred to the ulna and
TFCC+ scaphoid fossa à arthritis
• In all cases à try close reduction even if surgery is planned: reduce pain and
swelling
Option Indication Notes
Close reduction external Undisplaced fractures -‐1 week follow-‐up: check
fixation (cast Minimally displaced secondary displacement
immobilization) Stable after reduction -‐Left for 6 weeks
-‐Early shoulder, elbow
and finger mobilization is
important to prevent
stiffness.
Operation Secondary displacement Method depend on many
Instability factors
Articular comminution
Metaphysical
comminution
Bone loss
DRUJ incongruity
Methods
Close reduction internal Extra-‐articular fractures Using 2-‐3 K-‐wires (2-‐
fixation: 3Ws)
Percutaneous pinning + Cast (6Ws)

ORIF: buttress plate or Fracture with fragments,
locking plates Intra articular

Complications
3. Secondary displacement: caused by loose cast when swelling subsides.
4. Malunion: common with conservative management à deformity ± pain and
restricted movement
5. TFCC injury: chronic disabling wrist pain.
6. Peripheral nerve injury: commonly median nerve (carpal tunnel syndrome)
7. Injury of radial artery: with open fracture, rare.
8. Radiocarpal osteoarthritis
9. Complex regional pain:
• Old female + distal radius fracture + casting for 6 weeks
• Burning pain: out of proportion, of unknown origin, more at night
• Swelling, shiny redness, sweating
• Patchy demineralization in radiograph

Fractures of the shaft of the radius and ulna
Typical picture: young male, MVA, ± open fracture (second most common site after
tibial fracture)
Anatomy
• Ulna and radius: hold together by interosseous membrane, Distal RUJ and
proximal RUJ
• Ulna à straight, acts as an axisà rotation of radius around it.
• Attachment:
-‐ Proximally: biceps + supinators muscles
-‐ Distally: pronators
-‐ Attachments affect the position of the fracture fragments after
injuryàdisplacement

Types

Both ulnar and Ulnar fracture Ulnar fracture Radial fractures
radius fractures (Nightstick) (Monteggia) (Galeazzi)
Direct trauma à Ulnar fracture + Fracture of radial
Definition
isolated ulnar proximal radial diaphysis at the

shaft fracture head dislocation junction of the
middle and distal
1/3rd + disruption
of the distal RUJ
Pain Pain Elbow swelling, Pain
Swelling Swelling deformity Swelling
Deformity Abrasion Crepitus Tenderness
C/P
Loss of function Bruising Painful ROM of Wrist and mid
elbow esp. forearm pain
pronation &
supination
-‐AP -‐Lateral -‐AP -‐AP -‐Lateral
-‐Ipsilateral wrist -‐Lateral DRUJ disruption:
Radiology
and elbow: R/O Fracture of the

associated fracture ulnar styloid base
or dislocation Wide DRUJ
Subluxed ulna
Radial shortening
Non-‐displaced: Undisplacedà Pediatric: close Fracture of
rareà cast plaster reduction with necessity:
Treatment
Displaced: ORIF immobilization casting + regular ORIF with plates in

àcompression Displacedà follow-‐up all patients à
plates ±bone graft compression Adults: ORIF Compression
plates with plates. plates + volar
approach.
Malunion Malunion
Nonunion Nonunion
Post-‐traumatic NVI iatrogenic
synostosis: esp.
proximal one-‐
third, no
Complications
supination or
pronation
Compartment
syndrome: pain on
passive stretch of
fingers.
Iatrogenic: radial
artery injury,
radial and
interosseous
nerves injury
Careful -‐Careful
neurovascular neurovascular
Notes
exam is essential exam is essential

-‐Baddo
classification

Tibial and fibular fractures

Tibial plateau fractures
1% of all fractures
Bicondylar (10-‐30%), medial and lateral (70-‐90%)
Anatomy:

Varus or valgus forces with axial loading
• Young à High energy à split fractures with ligamentous disruption
• Elderly with osteopenic bone à simple fall à split depression fractures no
ligamentous disruption
6. Pain
7. Swelling
8. Knee Deformity:
• Haemarthrosis: Aspiration à marrow fat
9. ±Ligamentous injury: meniscal, collateral, cruciate
10. ± Open injury, laceration: careful assessment
11. ± Neurovascular injury
• Popliteal artery
• Peroneal nerve (Stretching à neuropraxia)
12. ± Compartment syndrome

Views:
• AP
• Lateral
• Oblique: 40o internal and external rotation (for lateral
and medical plateau visualization)
• 10 – 15o caudally tilted plateau view

Classification:
Schatzker classification

Type Description
Type I Lateral plateau, split fracture
Type II Lateral plateau, split depression fracture
Type III Lateral plateau, depression fracture
Type IV Medial plateau fracture
Type V Bicondylar plateau fracture
Type VI Plateau fracture with separation of the
metaphysis from the diaphysis

Treatment:
Non-‐surgical -‐ Low energy fractures that are • Active assisted and
• Hinged knee stable to varus and valgus stress passive range of
brace and • Undisplaced fractures motion exercises are
mobilization • Minimally displaced initiated immediately
• Above knee cast -‐ Non-‐ ambulatory patients • Weight bearing is
-‐ Patients unfit for surgery delayed for 8 -‐12
weeks
Surgical -‐ Articular depression >5mm • Soft tissue injuries
-‐ Instability more than 10o should be healed
-‐ High energy injuries involving before surgery
metaphyseal-‐diaphyseal junction • Fixation is according
or unstable bicondylar junction to the fracture pattern
-‐ Open fractures with CS and • Menisci should never
vascular injuries be excised
-‐ Floating knees injuries with lower • Identify ligamentous
femoral fractures injuries
• Post-‐op continuous
passive motion and
active range of motion
exercise
Methods
ORIF: Different -‐ Arthroscopy useful for • Biological plates and
techniques reduction of articular surfaces percutaneous screws
• Limited open -‐ Locked plates useful reduce soft tissue
reduction osteoporotic bone injury and wound
• Arthroscopy -‐ Type I: 2 transverse healing complications
• Augmented IF with cancellous screws (buttress • Dual plates increase
resorbable bone or locked plate if widening) risk of infection
cement - Type II: Bone grafting with • Locked plates
• Plate and screws cancellous screws of eliminates the need for
(dual, locked) metaphysis and buttress dual plates
plate of lateral cortex
-‐ Type III: Bone grafting and
buttress plate of the lateral
cortex
-‐ Type IV: Medical buttress
plate with cancellous screws
-‐ Type V: similar to type II.
Dual plating or lateral
buttress plate and medial
percutaneous screws
-‐ Type VI: Similar to type V, or
hybrid external fixation.
External fixation: -‐ Associated soft tissue

• Temporary injuries
spanning fixators -‐ Sometimes in Type VI
• Hybrid and/or fine fractures
wire fixation
Complications
10. Knee stiffness: caused by:
• Trauma from injury and surgical dissection
• Extensor retinacular injury
• Soft tissue scarring
• Prolonged immobility
11. Malunion, non union: common with Schatzker IV fractures: related to:
• Extend of comminution
• Unstable fixation
• Implant failure
• Infection
12. Post traumatic osteoarthritis: related to
• Articular incongruity
• Chondral damage
• Malalignment of the mechanical axis
13. Infection: more common with dual plating
Tibial spine fractures:
Anatomy:
-‐ Tibial spine (Tibial eminence): injury to the
intercondylar region of the tibial plateau
-‐ Tuberculum intercondylare mediale is the site of
insertion of ACL
-‐ No ligamentous insertion at the lateral eminence
Low energy fall onto an outstretched leg
-‐ ACL avulsion at insertionà functionally incompetent
-‐ Fracture may extend to thearticular surface of medical
tibial plateau
Classification:
-‐ Based on extent of displacement
Type Displacement
Type I Undisplaced fractures
Type II Partially displaced or hinged
Type III Completely displaced
Type IV Comminuted

Treatment:
Surgical intervention Type III and IV • Post-‐op active
• ORIF: Open surgical assisted range of
technique with motion
parapettelar arthrotomy immediately in a
and IF with lag screws hinged brace
• ORIF: Arthroscopically • Rehabilitation
assisted reduction and IF similar to ACL
with K wires followed by injury
cannulated screws
(preferred)

Fractures of the tibia and fibula:
The tibia is the most commonly fractured long bone
High incidence of open fractures
Anatomy
• Long tubular bone responsible for 85% of weight bearing
• Fibula transmits the remaining 25%
• Blood supply:
− Endosteal: Nutrient artery a branch from the posterior
tibial artery
− Periosteal: Anterior tibial artery
− Distal third: periosteal anastomosis around the ankle
− Junction of the middle and distal third: watershed area à
blood supply is reduced
• High energy direct injuries à transverse or comminuted
fractures with displacement, high incidence soft tissue
injury
• Indirect injuries
− Torsionà spiral, minimally displaced, little soft tissue injury
− Bending forces à short oblique fractures
− Crush injuries à Comminuted or segmental fractures, external soft tissue
injury
• Isolated fibular shaft à direct trauma to the lateral aspect of the leg
• Severe energy or violence à tibial fracture with segmental fibular fractures
Clinical evaluation:
Diagnosis is obvious
• Neurovascular evaluation
• Extent of soft tissue injury
− Fracture blisters: contraindicate open reduction
• Monitoring for Compartment syndrome (clinical signs + pressure
monitoring)
− Early: pain out of proportion, pain on dorsiflexion of the foot
− Late: Pale, pulseless, paralytic limb
− If pressure is higher than 30 mmHg: 4 compartment Fasciotomy
− Deep posterior compartment may be missed: claw toes
• Knee ligament injuries evaluation
X-‐ray:
• Views: AP/Lateral with visualization of the knee and ankle joints
Asses:
• Secondary fracture lines
• Osseous defects
• Gas in the soft tissue: secondary to open injuries, gas gangrene, necrotizing
fasciitis, other anaerobic infection
Ct or MRA:
• Indicated if an arterial injury is suspected

Classification:
• Descriptively based on location, pattern, extent of displacement, extent of
comminution and status of soft tissue envelope
• AO classification
Type Description
Type A Simple fracture that are spiral, oblique
or transverse
Type B High energy dissipation at the level of
injury and are classified as spiral,
bending or fragmented wedges
Type C Complex fractures with multiple spiral
fractures, segmental fractures or highly
comminuted fractures

Treatment:
Recommendation for accepted fracture reduction:
• Less than 5o varus-‐valgus angulation
• Less than 10o anteroposterior angulation
• Less than 10o rotation (external rotation better tolerated than internal
rotation)
• Less than 15mm of shortening
Guide to alignment of the spine:
• Anterior superior iliac spine, center of the patella, base of the 2nd proximal
phalanx should be in the same linear axis

Non-‐surgical Isolated fractures, closed fractures, • Partial weight bearing
• Long leg cast low energy fractures with minimal with crutches as
displacement and comminution tolerated.
• Full weight bearing by
the 2nd to 4th week
• After 4-‐8 weeks the
long leg cast is
exchanged by a patella
bearing cast or
fracture brace
• Union takes about 16
weeks
Surgical
Methods
Internal Fixation
• IM nailing -‐ Interlocking IM nails • Interlocking nails:
(interlocking nails (preferred) control alignment,
or flexible nails) à -‐ Flexible IM nails (Children translation and
reamed IM nails and adolescents) rotation
usually used

• Plates (ORIF) − Proximal tibial diaphysieal
fracture ± Tibial plateau
fracture
External fixation -‐ Temporary stabilization in • IF with IM nails after
open fractures 2-‐3 weeks
-‐ Closed fractures • High incidence of pin
complicates with CS tract infection and
-‐ Polytrauma poor patient tolerance

Special situations:
Fracture Notes
Tibial diaphysis with intact fibula • Not displaced: non-‐operative àfrequent
radiographs “varus deformity”
• Displaced: operative: IM nails
Proximal tibial fractures near the • IM nailing à difficult so use a blocking screw
metaphyseal-‐diaphyseal junction or percutaneous small reduction plate during
nail insertion “valgus deformity and apex
anterior angulation”
Distal tibial fractures • IM nailing leads to valgus angulation à small
distal fibular plate the usually coexisting
fibular fracture to prevent malalignment
Stress fractures • Common in military reqruits
• Mostly in the metaphyseal-‐ diaphyseal
junction
• Presence of sclerosis at the posteromedial
cortex
• Ballet dancers à middle third
• Occur because of overuses
• Radiographs: X-‐ray(delayed), CT, MRI,
Technetium bone scanning (Useful in early
diagnosis)
• Ttt: cessation of offending activity, short leg
walking cast (If acute symptoms present)
Isolated fibular shaft fractures • Non-‐operative treatment: short period of
immobilization à weight bearing as tolerated
Complications:
1. Compartment syndrome
2. Non-‐union: high velocity injuries and open fractures
3. Reflex sympathetic dystrophy: common in patients unable to bear weight
early and prolonged cast immobilization
4. Neurovascular injuries
5. Malunion, delayed union

Tibial plafond fracture
Intra-‐articular fractures of the distal tibia
Anatomy:

Variety of mechanisms:
1. Falls from heights à axial compression à articular impaction &
comminution
• Ankle Plantarflexion à posterior plafond injury
• Ankle Dorsiflexion à anterior plafond injury
2. Skiing accidents à torsion + varus or valgus stress à 2 or more fragments
and minimal articular comminution
3. Injuries that produce combined compression and shear forces à complex
fracture patterns
Clinical evaluation:
• Pain, swelling, deformity of the distal leg
• Open injures are common (tibia is subcutaneous in this region and there is
danger of displacement)
• Neurovascular examination
• Assessment of skin integrity (necrosis, blisters)
• Thorough assessment of soft tissue damage
• Most are associated with injuries to the calcaneus, tibial plateau, pelvis and
vertebra
Radiographic evaluation:
X-‐ray
• AP/Lateral/mortise
CT
• 3D reconstruction (evaluation of fracture pattern)
Classification:
Rüedi and Allgöwer classification system (based on severity of comminution and the
displacement of the articular surface)
Type I Non displaced cleavage fracture of
the ankle joint
Type II Displaced fracture with minimal
impaction or comminution
Type III Displaced fracture with significant
articular comminution and
metaphyseal impaction
•Prognosis depends on severity of injury (type I & II and AO type A à better
prognosis)
Treatment:
Non-‐surgical -‐ Undisplaced • Long leg cast is followed by bracing
• Long leg cast -‐ Severely debilitated patients and early range of motion exercise
(6 weeks) • Loss of reduction occurs commonly
Surgical -‐ Displaced • Surgery may be delayed in the
-‐ Comminuted presence of swelling, soft tissue
injury, or blisters (EF until surgery)
• Post operative immobilization in
dorsiflexion
• Non weight bearing exercise(6-‐12 w)
• Weight bearing exercise (after
radiographic evidence of fracture
healing)
Arthrodesis -‐ In case all other treatments • Best done after soft tissue has
have failed and post recovered and fracture comminution
traumatic arthritis ensued has consolidated
-‐ In selected severe open
fractures with extensive
articular comminution and
talar injury.
Methods
Internal Fixation
• Screws
• Plates (Preferred)
± Bone grafting
External fixation • Temporary stabilization • Disadvantages: pin tract infection,
• ± minimal • Joint spanning à patients Pin loosening and ankle stiffness
internal with soft tissue compromise
fixation or open fractures
• Joint • Definitive treatment in the
spanning EF presence severe soft tissue
• Non-‐ injury and adequate reduction
spanning EF is established
(e.g. hybrid
fixator)
Complications:
• Associated talar injury • Post operative wound infection
• Severe soft tissue injury • Non union/malunion
• Poor reduction of the articular • Infection à osteomyelitis
surface • Post traumatic arthritis
• Unstable fixation
Spinal fractures
Cervical spine fracture
Epidemiology
North America
150000 new cases yearly
M:F 4:1
Missed Dx :
22% C-‐spine
5% Thoracolumbar spine
20% Non-‐contagious multilevel fractures
causes of missed Dx:
Low level of suspicion
Failure to take proper radiographs
Polytrauma patients
Failure to interpret radiographs Decreased level of consciousness
Anatomy:
Occipital condyles: connect skull to cervical spine
C1: Atlas C2: Axis
Odontoid is part of Axis acting as the body of atlas and stabilized by transverse
ligament.
Occiptoatlas joint: flexion, extension, and lateral flexion
Atlantoaxial joint: rotation
Causes: MVA (50%), fall from height (25%), gunshot(15%), athletic injuries (10%)
Associated injuries:
Multiple injuries (80%)
Head and face injury
Major chest injury
Major abdominal injuries
Long bone/ pelvic fractures
Radiograph:
Plain radiographà
From occiput to T1
Viewsà
• Lateral cervical must show C1-‐T1à most important
• AP cervical
• Open mouth cervical
• Swimmer view in those with short neck to see the cervicothoracic juntion
• Stress radiograph shouldn’t be done in cases of unstability or neck pain bc
spasm can mask unstability. They are used to look for ligamountous injury
-‐Swimmer view à
1-‐ upper extremity proximal to the beam à abducted 80°
2-‐ contralateral extremity à axial traction
3-‐ beam directed 60° cauded
CTà high & moderate risk of spinal cord injury.
MRIà to look for paravertebral soft tissue like spinal cord, disc, ligmnents. used in
those with abnormal neuro findings to look at the roots but never done to look for
cervical fracture only.
Injury to the occiput-‐C1-‐C2 complex

1-‐ Occipital condyle fractures
Potential lethal trauma with 11% mortality
High rate of another spinal level injury
Mechanism: compression and lateral bending
Cause: compression fracture of the condyle bc its presses against the superior facet
of C1 -‐ avulsion of the alar ligaments when there’s an extreme atlanto-‐occipital
rotation
Classifications:
• Type 1: comminuted impaction condyle fractures caused by axial load -‐ stable
• Type 2: extension of basillar skull fracture into condyles. its stable.
• Type 3: most common -‐ unstable -‐ avulsion of the condyle fracture -‐ think of
occipitocervical dissociation
Clinical Presentation:
• CN palsies days to wks after the injury. Especially 9-‐10-‐11
Investigations:
• CT is the best for diagnosis
• Plain x-‐ray has sensitivity of 3%!

Treatment:
Type 1: nonop -‐ rigid cervical collar or halo for 8wks
Type 2: nonop -‐ rigid cervical collar or halo for 8wks
Type 3: first the fracture should be immobilized for 12wks in halo vest > then check
the stability > if still instabile > fusion of occipit to C2 is needed

2-‐ Occipitocervical Dislocation:
More common in children bc shallow condyles and large head
Its lethal and if the patient survives, they will have a wide range of neuro injuries
Mechanisms:
High-‐energy injury caused by hyperextension/distraction/rotation at the same time
Classifications:
• Anterior dislocation
• Longitudinal “distraction separation"
• Posterior dislocation
Investigations:
• Plain x-‐ray with measurement of the power ration BC: AC
If its greater than 1 > anterior dissociation
• MRI better than x-‐ray
• CT better than x-‐ray
Treatment:
1. Halo vest applied “close reduction"
2. NO NO NO NO traction
3. Early surgery by fusion of the occuptiocervical spine

3-‐Atlas fractures:
Usually doesn’t affect nerve function bc of large amount of space available
Half of the cases there will be other cervical fracture (odontoid and spondyliothesis
of axis)
Axial compression with hyperextension and asymmetrical loading of the condyles
1. Headache
2. Sub occipital pain
3. Limiting of movement
4. CN lesions of 6-‐12 -‐ neurapraxia of subocciptal and greater occipital nerves -‐
significant spinal cord injury causes immediate death but it’s rare
5. The vertebral artery could be affected causing basilar insufficiency (vertigo -‐
blurred vision -‐ nystagmus)
The stability depends of the integrity of the transverse ligament how to know? look
at the open mouth radiograph
Classifications:
1. Isolated posterior
2. Lateral mass fracture
3. Burst fracture also called Jefferson
Also other types could occur like transvers process fracture -‐ anterior arch fracture -‐
anterior tubercle fractures
Investigations:
• AP cervical
• Open mouth cervical: we can suspect transverse ligament disruption by viewing
the lateral mass, if its overhang by 7mm > disruption of the ligament
• Lateral cervical: measure the atlantodens interval to check for ligamental
disruption when its more than 3 mm
• CT shows avulsion of the transverse ligament
• MRI shows rupture of the transverse ligament
Common fracture sites: anterior arch (midline or just lateral to it) posterior
(narrowes point behind the lateral mass)
Treatment:
• Isolated anterior arch fracture: rigid cerivcal collar for 6-‐12wks
• Isolated posterior arch fracture: rigid cerivcal collar for 6-‐12wks
• Transverse process fracture: rigid cerivcal collar for 6-‐12wks
• Minimally displaced lateral mass: rigid cerivcal collar for 6-‐12wks
• Stable burst fracture: rigid cervical collar or halo vest
• Unstable burst fracture: halo traction for 3-‐6wks > halo vest for 6 wks OR can be
treated with posterior fusion of C1-‐C2

4-‐ Pure Transverse ligament injuries
Mechanism: Fall with a blow to the back of the head
Classification:
1. Mid-‐substance ruptures: likely to heal with early surgery where we will start by
skull traction to stabilize then posterior stabilization with fuse C1 and C2
2. Avulsions of the insertion of the ligament on the lateral masses of C1. treat with
halo vest first bc it can heal without surgery

5-‐ Atlantoaxial rotary subluxation and dislocation:
Normally two ligaments stabilize the joint: transverse (prevent excess anterior
displacement of the atlas on the axis) and alar (prevent excess rotation where the
right ligament prevent left rotation vise versa)
Mechanism: Flexion/extension with rotation component -‐ sometimes it occurs
spontaneously without trauma
Causes:
Adults: trauma
Children: tonsillitis -‐ following URTI -‐ minor head induction -‐ induction of GA bc
they have a larger head so greater pressure on the C1-‐2 joint
Neck pain
Torticollis (cock-‐robin poision)
Decreased neck movement
vertebrobasilar insufficiency
neuro involvement is uncommon

Investigations:
Open mouth radiograph: wink sign (overlap) -‐ unilateral facet joint narrowing
Gold standard is dynamic CT
Treatment:
• Conservative
• Immobilization
• Traction
• Manual reduction
• Surgery if the transverse ligament is torn or avulsed -‐ instable -‐ neural
involvement -‐ didn’t get better by conservative
Methods of surgery: C1-‐C2 fusion with C1-‐C2 transarticlar screw

6-‐ Fractures of the odontoid process:
Mechanisms:
MVA > young
Falls > old bc osteoporosis -‐ also children
There is an avulsion of the apex by the alar ligament OR lateral/oblique force that
cause the fracture through the body and base OR hyperextension that causes
posterior displaced fractures OR hyperflexion that causes anterior displaced
fracture
Pathology:
the neck of the odontoid is a watershed area that’s why it has a high rate of non-‐
union -‐ it also doesn’t have periosteum nor cancellous none (Type II)
the apex is supplied by basilar artery -‐ the base is supplied by the vertebral artery
Severe pain behind ears -‐ neck stiffness -‐ instability at base of skull -‐ present with
holding their head at both hands -‐ retropharyngeal swelling
Investigations:
Can be easily missed so look carefully!
CT fine section with open mouth view is good
Plain radiograph
Treatment:
1. Type I: immobilize with external orthosis for 2 months after excluding the
possibility of occuptocervical disacissiation
2. Type II: halo vest immobilization mostly done when its undisplaced -‐ anterior
odontoid screw -‐ posterior C1-‐2 fusion -‐ nonunion more commonly seen in
displaced fractures
3. Type III: rigid cast and halo vest

5-‐ Traumatic spondylolisthesis of C2 (hangman fracture):
Pathology:
bilat fracture of the pars interarticularis with disc disruption
There will be bilateral pedicle fracture and ligament disruption between C1-‐2
Mechanism: MVA -‐ falls with flexion -‐ extension with axial load
Most patient die
Clinical Presentation: tenderness local -‐ stiffness -‐ tenderness over the spinous
process of C2
Investigations:
AP x-‐ray
L x-‐ray: retropharyngeal space is widen
CT
Treatment:
Type I: its stable so just put rigid orthosis for 3 months
Type II: skull traction bc displaced where the neck will be in extension over a rolled
up towel for 3-‐6wks (do serial radiograph for confirmation) -‐ put a halo best for 3
months
Type IIA: halo vest with slight compression for 3 months -‐ or we can do anterior
interbody fusion and plating of the C2-‐3 -‐ bilateral C2 pars screw osteosythesis
Type IIIL first halo traction then do OR fusion we can do anterior C2-‐3 fusion or
posterior C1-‐3 fusion
NOTES:
neuro injury is more common in lower cervical fracture

Subaxial cervical spine injuries:
C3-‐C7
Denis classification (3 column system)
Radiograph: AP, lateral, oblique ( pedicle, foramen, facet joint)
Classification: compression,-‐flexion, destructive-‐flexion, compression-‐extension.
1-‐ Compression flexion:
-‐ Compressive failure of anterior half without disturbance of the posterior
body cortex and without retropulsion into the spinal canal.
-‐ Common sites: C4, C5, C6
2-‐ Vertical compression fracture (burst)
-‐ Compression failure of the vertebral body
-‐ Fracture extension through the posterior body cortex
-‐ Bone retropulsion
-‐ Commonly unstable à SCI
-‐ Common sites: C6, C7
3-‐ Distractive flexion
-‐ Bilateral facets dislocation à significant SCI
-‐ Unilateral facet dislocation à mono radiculopathy
-‐ à disc herniation
-‐ Management: consider possibility of disc herniation à
-‐ If patient is awake + alert à close reduction + serial neurological
examination
-‐ Development of neurological deficit à stop close reduction and do MRI to
check for disc herniation
3-‐ destructive-‐ extension
-‐ Elderly + ankylosing spondylitis + diffuse skeletal hyperostosis
Start as benign à if not treated à Neurological deficit

Neurological examinations
Upper extremity Lower extremity Other
C5-‐ Area over Deltoid L1-‐ anterior proximal Trunk
C6-‐ Thumb thigh T4-‐ Nipple
C7-‐Middlefinger L2-‐ anterior middle thigh T8-‐ xiphisternum
Dermatomes
C8-‐Littlefinger L3-‐ medial knee T10-‐ umbilicus

T1-‐Medialforearm L4-‐ medial malleolus T12-‐ symphysis pubis
+medial aspect of the leg
L5-‐ 1st web space
S1-‐ foot lateral border
S3-‐ Ischial tuberosity
S4-‐5 – perianal region
C5-‐ shoulder abduction L1-‐2-‐ hip flexion Muscle grading chart
C6-‐ elbow flexion and L3-‐4-‐ knee extension
wrist extension L4-‐5 ankle dorsiflexion Grade Muscle action
C7-‐ elbow extension and L5-‐ toe dorsiflexion 0 zero Total
wrist flexion S1-‐ toe plantar flexion paralysis
C8-‐ finger flexion and and hip extension 1 trace Visual or
thumb extension S1-‐2-‐ ankle plantar palpable
T1-‐ finger adduction and flexion contraction
thumb abduction S2-‐ knee flexion 2 poor Active
movement,
gravity
Myotomes
eliminated
3 fair Active
movement,
against
gravity
4 good Active
movement
against
resistant
5 Active
normal movement
against full

resistance
Superficial Deep tendon reflexes

Abdominal reflex: T7-‐T12 Biceps reflex àC5-‐6à Musculocutaneous
Reflexes
Plantar reflex: L5-‐S1 Triceps reflex à C6-‐7à Radial

Brachioradialis reflexà C5-‐6 à radial nerve
Knee reflex à L3-‐4à Femoral nerve
Ankle reflex à S1-‐2 à Tibial nerve

Anatomy of the spinal cord:
Ascending tracts:
Dorsal à vibration, deep touch, proprioception
Lateral à pain, temperature
Anterior à light touch
Decending tracts:
Anterior+ lateral à motor (upper extremity more central)
Autonomic nervous system:
Sympathetic à 22 ganglion (3 cervical, 11 thoracic, 4 lumbar, 4 sacral)
Parasympathetic à hypogastric plexes (S2-‐S4)
Blood supply:
Anterior spinal arteryà
More commonly injured + worse
Supplies the anterior 2/3 of the spinal cord including lateral aand anterior
corticospinal tract.
Posterior spinal artery à
Supplies the sensory spinal tract
Artery of adamiewicz
Originate from anterior segmental artery on the left side between T8-‐L1

Complete spinal cord injury
Tetraplegia
Paraplegia
Patient must be recovered from spinal shock (intact pulbocavernouus reflex)
ASIA A

Incomplete spinal cord injury
Spinal cord injury with some preservation of motor or sensory function below the
level of injury, any of the following indicate incomplete injury:
Sacral sparing
Perianal sensation
Visible muscle contraction

Mechanism Pathophysiology C/P Prognos
of trauma is
Central cord Minor Incomplete cervical UE > LE Good
injury extension. white matter injury. Flaccid paralysis in UE
* Most common Osteoarthritis à and spastic paralysis
Effects elderly osteophytesà in LE.
compression of spinal
cord between
osteophytes anteriorly
and ligamentum
flavum posteriorlyà
pre-‐existing of SC
compression + Central
SC edema.
Anterior cord Severe Direct osseous LE > UE Worst
injury Flexion compression à Motor paralysis
anterior spinal artery Variable sensory
damage. dysfunction ( pain
+temperature
effected)
Brown séquard Unilateral Complete cord hemi-‐ Ipsilateral: Excellen
syndrome laminar or transection Motor + t
pedicle proprioception +
fracture vibratory.
Penetrating Contralateral:
(mostly Pain + temperature
gunshot) or
rotational
injury à
subluxation
Cauda equine Injury to Bilateral radicular
lumbosacral pain
nerve roots Numbness
within Weakness
spinal canal Hyporeflexia or
areflexia in LE
Saddle anesthesia
Loss of voluntary
bowel & bladder
function.

Note:
Neurological level à most cauded segment with normal sensory and motor function
on both sides.
For example, if the last nerve shows normal function is C6 then you examined C7
and appeared abnormal, the level of injury is C6.

ASIA classification
For spinal cord injury
A—> complete, no sensory or motor function, no spinal shock.
B—> incomplete, sensory preserved.
C—> incomplete, muscle power distal to spinal injury <3.
D—> incomplete, muscle power >=3.
E—> normal

Spinal vs hypovolemic shock
Spinal Hypovolemic
Hypotension Hypotension
Bradycardia Tachycardia
Absent pulbocavernosus reflex Present Reflex
Flaccid paralysis -‐

Note:
-‐Spinal shock may mask hypovolemic shock:
Check urine output, if decreased —> associated hypovolemic shock:
Treat by resuscitation then treat spinal shock with vasopressors.
-‐ Spinal shock: Lower motor neuron injury neurological shock: upper motor injury

Approach to trauma of spine:
Should be suspected in:
-‐ All unconscious patients
-‐ Multiple injury
-‐ Evidence of neurological deficit
-‐ High energy trauma
Pre-‐hospital management
Aim:
-‐ Retrieve the patient from the site of injury safely and rapidly
-‐ Manage the Life threatening condition
-‐ Transfer to a suitable facility.
Steps:
1-‐ Proper extraction
2-‐ Immobilization (cervical collar, sand bag, hard board, tape)
3-‐ Manage life threatening conditions
4-‐ Transfer to suitable facility
Intra-‐hospital management
ATLA:
1-‐ ABCD
2-‐ History (patient, family, paramedics)
3-‐ Head-‐to-‐toe examination
4-‐ Spine exam (look, feel, But DON’T move)
5-‐ Neurological exam:
-‐ Dermatomes
-‐ Myotomes
-‐ Reflexes:
• Abdominal
• Cremasetric
• Bulbocavernosus: pulling penis or clitoris à contraction of anal sphincter
• Sacral sparing: anal muscle, big toe flexion, perianal sensation.
• DRE
6-‐ If there are signs of spinal cord injury:
-‐ Resuscitation
-‐ Start methyl prednisolone
-‐ DVT prophylaxis: LMWH, rotating bed, compression stocking.
-‐ If spinal shock without hypovolemic à vasopressors.
-‐ Investigations after stabilization (C-‐spine CT)
-‐ Catheterize to prevent bladder distention and to check urine
-‐ Gastroprotective agents to prevent hemorrhagic gastritis
Investigations:
X-‐ray
CT:
Injury is suspected on plain film à Better visualize fracture.
Better assessment and for classification
MRI:
Assessing cord and soft tissue.
Hemorrhage or edema of soft tissue and intra-‐substance hematoma
R/O associated disc herniation (facet joint dislocation)
Prognostic assessment of final motor function
Definitive management:
Based on TLICS
Score <4 à non-‐operative management
4 à doctor decision
score > 4 à operative
Principles:
-‐ Preserve neurological function
-‐ Relieve spinal compression
-‐ Restore spinal alignment
-‐ Stabilize the patient
-‐ Rehabilitate the patient
Non-‐operative:
Stable + no neurological deficit
Stable:
Operative:
Unstable + multiple injuries + progressive neurological deficit
Stabilization with or without decompression (if there is neurological deficit)
Could be posterior, anterior or both.

Complications of spinal cord injury:
1-‐ Bed sores à treat by prevention
2-‐ DVT
3-‐ Urosepsisà common cause of death, prevention: aseptic catheter, prevent
bladder over distention.
4-‐ Sinus bradycardia
5-‐ Orthostatic hypotension
6-‐ Major depressive disorder
7-‐ Autonomic dysreflexia:
-‐ Headache, agitation, hypertension, increased ICP.
-‐ Caused by visceral stimulation: bladder distention (mostly), bowel
distention, tight clothing
-‐ Potentially fatal
-‐ ttt:
• First change Foleys catheter,
• Semi setting position,
• remove tight clothing,
• Check fecal impaction
• Anti diuretics or anti hypertensive

Humeral Fracture Treatment Guide

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Humeral

*Displacement of fractured segments:

-­‐ Injured extremity is supported by contralateral hand

CTà -­‐Articular involvement -­‐Degree of fracture displacement

Neer’s classification system

Anatomical neck fracture: uncommon, high risk of avascular necrosis

Non displaced Two-­‐part fractures Three-­‐parts Four-­‐parts Fracture

2-­‐Follow-­‐up with fracture: -­‐Youngà ORIF avascular 3 or 4partsà

-­‐ Prevention: early mobilization and physical therapy

Fracture prone to displacement with hanging cast

-­‐Posterior à distal Floating elbow fracture

Displacement of fracture fragment

*No soft tissue attachment: displacement + restriction of movement

Non-­‐displaced (Mostly) à non-­‐operative: posterior splint immobilization for 3

NV injury: brachial A. ulnar, median N.

Post traumatic arthritis

isolated ulnar proximal radial diaphysis at the

and elbow: R/O Fracture of the

Displaced: ORIF immobilization casting + regular ORIF with plates in

exam is essential exam is essential

External fixation: -­‐ Associated soft tissue

C8-­‐Littlefinger L3-­‐ medial knee T10-­‐ umbilicus

Superficial Deep tendon reflexes

Plantar reflex: L5-­‐S1 Triceps reflex à C6-­‐7à Radial

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-‐ Injured extremity is supported by contralateral hand

CTà -‐Articular involvement -‐Degree of fracture displacement

Non displaced Two-‐part fractures Three-‐parts Four-‐parts Fracture

2-‐Follow-‐up with fracture: -‐Youngà ORIF avascular 3 or 4partsà

-‐ Prevention: early mobilization and physical therapy

-‐Posterior à distal Floating elbow fracture

Non-‐displaced (Mostly) à non-‐operative: posterior splint immobilization for 3

External fixation: -‐ Associated soft tissue

C8-‐Littlefinger L3-‐ medial knee T10-‐ umbilicus

Plantar reflex: L5-‐S1 Triceps reflex à C6-‐7à Radial