Analisa X-ray Fraktur

pada Tulang Belakang

Trauma pada Tulang Belakang

 Trauma vertebra cervical

 Trauma vertebra thoracolumbal
Trauma vertebra cervical

 Mekanisme cedera yg sering:

 Hiperfleksi: KLL, mobil yg tiba2 berhenti
 Hiperekstensi: KLL, mobil yg ditabrak dari belakang
 Kompresi: terjun ke air yg dangkal dengan posisi kepala dibawah
Kriteria NEXUS

 Neurologic deficit
 Spinal midline tenderness
 Altered mental status
 Intoxication
 Distraction injury

 Jika ada, indikasi untuk pemeriksaan radiologis

Xray vertebra cervical

 AP
 Lateral
 Posisi lateral dgn traksi kedua lengan
 Swimmers view
 Open mouth (odontoid) view
Struktur Anatomis

 C1 (atlas) dan C2(aksis) berbeda dengan vertebra cervical yg lain

 Atlas:
 no body
 main structures are the lateral masses
 Aksis:
 Terdapat odontoid process
 Atlantodentalis interval (ADI) :
 < 3 mm pada orang dewasa
 4 mm pada anak <8 tahun
 Vertebrae C3-7 menunjukan struktur anatomis yg relative indentik dan
seragam:
 Korpus vertebra
 posterior neural arch : pedicle dan lamina

Greenspan, Adam.Orthopedic Imaging: A Practical Approach, 4th Edition

Greenspan, Adam.Orthopedic Imaging: A Practical Approach, 4th Edition
X-ray lines, landmarks, and
measurements using a
lateral cervical spine film.
The spinolaminar line (A)
posterior vertebral body line
(B)
anterior vertebral body line
(C)
On a perfect lateral view,
The facet joints should appear
as stacked parallelograms (D).
The prevertebral soft tissue
shadow is measured at the
C2&3 and C6&7 disc
spaces. More than 7 mm at the
C2&3 or 21 mm at the C6&7
disc is strongly suggestive of an
underlying spinal injury.
Kyphosis more than 11 degrees as measured by the end plate
method is strongly suggestive of posterior ligamentous injury
and potential instability Rockwood & Green's Fractures in Adults, 6th
Edition
The posterior vertebral body tangent
method of measuring cervical
kyphosis. A line is drawn along the
posterior aspect of the adjacent
vertebral bodies. The angle
subtended between the two is then
measured.

Rockwood & Green's Fractures in Adults, 6th

Edition
•Sagittal translation is measured at the
level of the inferior aspect of the
superior vertebral body.
•>3,5 mm is unstable

Rockwood & Green's Fractures in Adults, 6th

Edition
 •Vertebral body height
loss can be expressed as
a percentage. This is
best assessed by
measuring both anterior
and posterior height of
the injured and
adjacent uninjured
vertebral bodies.
•> 25% loss is unstable

Rockwood & Green's Fractures in Adults, 6th

Edition
The Chamberlain line.
This line is drawn from the
posterior margin of the
foramen magnum
(opisthion) to the dorsal
(posterior) margin of the
hard palate. The odontoid
process should not project
above this line more than 3
mm; a projection of 6.6
mm (±2 SD) above this line
strongly indicates cranial
settling.

Greenspan, Adam.Orthopedic Imaging: A Practical Approach, 4th Edition

The McRae line.
This line defines the
opening of the foramen
magnum and connects the
anterior margin (basion)
with posterior margin
(opisthion) of the foramen
magnum. The odontoid
process should be just
below this line or the line
may intersect only at the
tip of the odontoid process.
In addition, a perpendicular
line drawn from the apex
of the odontoid to this line
should intersect it in its
ventral quarter
Greenspan, Adam.Orthopedic Imaging: A Practical Approach, 4th Edition
Ranawat method.
Determining the extent of the
superior margin of the odontoid
process. The coronal axis of C-1 is
determined by connecting the center
of the anterior arch of the first
cervical vertebra with its posterior
ring. The center of
the sclerotic ring in C-2, representing
the pedicles, is marked. The line is
drawn along the axis of the odontoid
process to the first line. The normal
distance between C-1 and C-2 in men
averages 17 mm (±2 mm SD), and in
women, 15 mm (± 2 mm SD). A
decrease in this distance indicates
cephalad migration of C-2

Greenspan, Adam.Orthopedic Imaging: A Practical Approach, 4th Edition

Oblique View

 The film in this projection is effective primarily for demonstrating the

intervertebral neural foramina.
 Visualize obscure fractures of the neural arch and abnormalities of the neural
foramina and apophyseal joints.

Greenspan, Adam.Orthopedic Imaging: A Practical Approach, 4th Edition

 Oblique view.
An oblique view of the cervical
spine may be obtained in the
anteroposterior (as shown here) or
posteroanterior projection. The
patient may be erect or
recumbent, but the erect position
(seated or standing) is more
comfortable.
The patient is rotated 45° to one
side—to the left, as shown here, to
demonstrate the right-sided neural
foramina and to the right to
demonstrate the left-sided neural
foramina. The central beam is
directed to the C-4 vertebra with
15° to 20° cephalad angulation.
Greenspan, Adam.Orthopedic Imaging: A Practical Approach, 4th Edition
Greenspan, Adam.Orthopedic Imaging: A Practical Approach, 4th Edition
Flexion Extension View

 In patients with cervical tenderness and normal plain x-rays, flexion-

extension views can identify occult cervical ligamentous injury.
 Flexion-extension views in the acute setting can be nondiagnostic or even
dangerous.
 Unsupervised or forceful flexion in a patient with an occult ligamentous injury
may precipitate a neurologic injury.
 When necessary, flexion-extension x-rays should be performed in alert
patients, under supervision, and with voluntary unassisted positioning by the
patient.

Rockwood & Green's Fractures in Adults, 6th

Edition
Open Mouth View

 Provides effective visualization of the structures of the first two cervical

vertebrae.
 The body of C-2 is clearly imaged, as are the atlantoaxial joints, the odontoid
process, and the lateral spaces between the odontoid process and the
articular pillars of C-1.
 The head is straight, in the neutral position. With the patient's mouth open as
widely as possible, the central beam is directed perpendicular to the
midpoint of the open mouth.
 During the exposure, the patient should softly phonate “ah” to affix the
tongue to the floor of the mouth so that its shadow is not projected over C-1
and C-2.

Greenspan, Adam.Orthopedic Imaging: A Practical Approach, 4th Edition

Greenspan, Adam.Orthopedic Imaging: A Practical Approach, 4th Edition
Greenspan, Adam.Orthopedic Imaging: A Practical Approach, 4th Edition
Swimmer View

 Better demonstration of the C-7, T-1, and T-2 vertebrae, which on the
standard lateral or oblique projection are obscured by the overlapping
clavicle and soft tissues of the shoulder girdle.
 The patient is placed prone on the table with the left arm abducted 180° and
the right arm by the side, as if swimming the crawl.
 The central beam is directed horizontally toward the left axilla. The
radiographic cassette is against the right side of the neck, as for the standard
cross-table lateral view.

Greenspan, Adam.Orthopedic Imaging: A Practical Approach, 4th Edition

Greenspan, Adam.Orthopedic Imaging: A Practical Approach, 4th Edition
Notes

 Plain x-rays, if they show complete lateral visualization of the cervical spine
and include an open mouth view, are fairly sensitive in identifying cervical
spine fractures.
 Interpretation of x-rays has limitations. Knowledge of anatomy and clinical
experience are important for accurate interpretation of x-rays.
 Landmarks for measurements can be difficult to identify.
 A systematic approach to reading cervical x-rays can help reduce the chances
of missing an important injury.

Rockwood & Green's Fractures in Adults, 6th

Edition
Atlanto-occipital dislocation

 Typically massive retropharyngeal soft tissue swelling.

 The Power’s ratio (distance from the basion to the posterior arch of the atlas
divided by the distance from the opisthion to anterior arch of atlas ) is >1.0 in
all cases of AOD. (<0.9 is normal, 0.9 -1.0 are borderline )

T. Jackson, D. Blades / Atlas Oral Maxillofacial Surg Clin N Am 10 (2002) 167–187

T. Jackson, D. Blades / Atlas Oral Maxillofacial Surg Clin N Am 10 (2002) 167–187
Atlantoaxial rotatory
subluxation/dislocation
 On open-mouth odontoid view, there is typically asymmetry of the
atlantoaxial joint (the C1 lateral mass that is rotated forward appears larger
and closer to the midline).
 The spinous process of the axis is tilted in one direction and rotated in the
opposite direction.

T. Jackson, D. Blades / Atlas Oral Maxillofacial Surg Clin N Am 10 (2002) 167–187

Anteroposterior radiograph
demonstrating ‘‘cock robin’’ head
position described in atlantoaxial
rotatory subluxation

Lateral radiograph demonstrating rotation

of C1 on C2
Dens fracture
 There are three types of dens fractures
 type I fractures occur through the tip of the dens (very rare)
 type II fractures occur through the base of the neck of the dens (most common
type of dens fracture)
 type III fractures occur through the body of C2.

T. Jackson, D. Blades / Atlas Oral Maxillofacial Surg Clin N Am 10 (2002) 167–187

T. Jackson, D. Blades / Atlas Oral Maxillofacial Surg Clin N Am 10 (2002) 167–187
Jefferson fracture

 Open-mouth odontoid view shows outward displacement of the lateral most

edges of the C1 lateral mass relative to those of C2 .
 Significant retropharyngeal soft tissue swelling.

T. Jackson, D. Blades / Atlas Oral Maxillofacial Surg Clin N Am 10 (2002) 167–187

The classic Jefferson fracture,
seen here schematically on the
anteroposterior (A) and axial (B)
views, exhibits a characteristic symmetric
overhang of the lateral masses of C-1 over
those of C-2. Lateral displacement of the
articular pillars results in disruption of the
transverse ligaments.
(C) On occasion, only unilateral lateral
displacement of an
articular pillar may be present.

Greenspan, Adam.Orthopedic Imaging: A Practical Approach, 4th Edition

(A) Open-mouth anteroposterior view of the cervical spine shows lateral
displacement of the lateral masses of the atlas, suggesting a ring fracture of C-
1. (B) Lateralview demonstrates fracture lines of the posterior and anterior
arch
of C-1.
Hangman's Fracture (traumatic
spondylolisthesis of the axis)
 Anteriorsubluxation of C2 on C3 is frequently
seen on the plain radiographs.
 Lessoften, there may be an avulsion fracture
from the anterior inferior corner of the body
of C2, if this chip is seen, one must presume
there is an associated hangman’s fracture,
until the CT scan proves otherwise.

T. Jackson, D. Blades / Atlas Oral Maxillofacial Surg Clin N Am 10 (2002) 167–187

T. Jackson, D. Blades / Atlas Oral Maxillofacial Surg Clin N Am 10 (2002) 167–187
Burst fracture

 Typically, there is loss of body height and increased interpedicular distance

seen on plain radiographs.
 Retropulsion of bony fragments is typically seen on plain radiographs.

T. Jackson, D. Blades / Atlas Oral Maxillofacial Surg Clin N Am 10 (2002) 167–187

T. Jackson, D. Blades / Atlas Oral Maxillofacial Surg Clin N Am 10 (2002) 167–187
Compression/wedge fracture

 Loss of vertebral body height anteriorly with preservation of the posterior

vertebral body height (wedge-shaped vertebral body).

T. Jackson, D. Blades / Atlas Oral Maxillofacial Surg Clin N Am 10 (2002) 167–187

T. Jackson, D. Blades / Atlas Oral Maxillofacial Surg Clin N Am 10 (2002) 167–187
Subluxation facet fracture/lock

 With unilateral facet fracture-dislocation,

there is subluxation of approximately 25% of
the superior vertebral body relative to the
inferior vertebral body. Typically there is also
evidence of rotation.
 With bilateral facet fracture-dislocation, there
is approximately 50% or greater subluxation
without evidence of rotation.
T. Jackson, D. Blades / Atlas Oral Maxillofacial Surg Clin N Am 10 (2002) 167–187
 Lateral radiograph of
unilateral facet and
associated subluxation
of C4 on C5 of
approximately 5%of the
width of the vertebral
body.

T. Jackson, D. Blades / Atlas Oral Maxillofacial Surg Clin N Am 10 (2002) 167–187

 Lateral radiograph of
bilateral locked facets
with subluxation of
approximately 50% of the
width of the vertebral
body

T. Jackson, D. Blades / Atlas Oral Maxillofacial Surg Clin N Am 10 (2002) 167–187

Teardrop fracture

 A triangular piece of bone is typically seen at the anterior inferior

edge of the fractured vertebral body (the ‘‘teardrop’’).
 Frequently, there is an associated sagittal fracture of the vertebral
body.
 The fractured vertebral body is usually displaced posteriorly
relative to the vertebral body below.
 Kyphosis is frequently seen at the site of the fracture, and there
may be evidence of facet disruption.
 The subjacent disc space is often narrowed.
 There may be significant soft tissue swelling.

T. Jackson, D. Blades / Atlas Oral Maxillofacial Surg Clin N Am 10 (2002) 167–187

T. Jackson, D. Blades / Atlas Oral Maxillofacial Surg Clin N Am 10 (2002) 167–187
Clay shoveler’s fracture

 There is fracture of spinous process of C7, C6, or T1

T. Jackson, D. Blades / Atlas Oral Maxillofacial Surg Clin N Am 10 (2002) 167–187

Greenspan, Adam.Orthopedic Imaging: A Practical Approach, 4th Edition
Trauma vertebra thoracolumbal
Terima Kasih