Posterior Element Fx & Fx Dislocation


Clay shoveler's fracture

  • Spinous process fracture of lower C-spine

Mechanism

  • Direct trauma, forceful hyperflexion

X-ray findings

  • Spinous process fracture
  • Usually C6 or C7

Physical Exam

  • Neurological deficit is rare
  • Stability
    • GENERALLY STABLE (unless lamina fractured)



Hyperextension & hyperflexion fracture/ dislocations

  • Dislocation of facet joints plus fracture

Mechanism

  • Flexion, distraction or other complex MOI's

X-ray findings

  • Bones may be intact
  • Soft tissue swelling may be only finding

Stability

  • VERY UNSTABLE

Pedicle / Lamina / Neural Arch Fractures

  • Rarely occur without other fractures or dislocations
  • Usually UNSTABLE injuries

 

 

 

 

Transverse Process Fractures

  • Common fracture
  • Injury forces
    • Usually associated with a direct blow
      • Contact sports
      • Other direct trauma
    • Attention should then be focused on underlying structures (kidneys, ureters)
      • Possible retroperitoneal bleeding
        • Especially if anticoagulated
    • Can be due to muscle force alone
  • Multiple transverse processes often fractured in trauma
  • High rate of nonunion
  • Usually STABLE injuries

X-Ray findings:

  • EASY to overlook
  • Usually vertical Fx line across base of transverse process
  • May see fragments
    • Minimally displaced
    • Markedly displaced
    • Often just tip of transverse process
  • May lose psoas muscle shadow




 

Spinous Process Fractures

  • Rarely found in thoracolumbar spine injuries

Injury forces

  • Forcible flexion and rotation
  • Direct blow
  • Generally STABLE if isolated

X-ray findings

  • Often see fragment avulsed from spinous process





 

TREATMENT

  1. Trauma ABCs
  2. Immobilization
    • Prehospital
      • Back board, c-collar
      • Head blocks or tape
    • ED
      • Keep patient supine and immobile
        • Unless low suspicion of injury
      • Cooperative patient - talk to them
      • Uncooperative patients
        • More aggressive measures
        • Sedation/ intubation
  3. If intubation required
    • RSI with inline stabilization
  4. Continue with primary survey
    • Stabilize patient
    • NEVER assume
      • Spinal shock
      • Neurogenic shock
      • Diagnosis of exclusion
  5. For spinal cord injury:
    • Start methylprednisolone
      • 30 mg/kg initially THEN
      • 5.4 mg/kg/hr for 24 hr
      • Discuss with Neurosurgery
    • MAY improve neurologic recovery if started w/in 8 hrs
  6. Other issues
    • Remove patient with a fractured spine from the backboard within 2 hr
    • Move to rotary bed (stryker) to avoid skin breakdown
  7. Reduction of fracture (Neurosurg / ortho)
    • Cervical or upper thoracic
      • Gardener-Well tongs
    • Thoracic or lumbar
      • Placement of pillows on stryker frame

 

DISPOSITION

  1. Admit
    • Essentially ALL spine fractures
      • Small compression fx's may be able to go home
        • Discuss with PMD / Ortho / Neurosurg first
    • Admit for
      • Observation
      • Assessment of stability
      • Pain control
      • Paralytic ileus frequently occurs
  2. Surgical intervention (reduction/ decompression/ fusion)
    • Emergent/ Urgent
      • Incomplete injury with worsening neuro exam
      • Incomplete deficits with an irreducible fracture
      • Severely unstable fracture with complete deficit
        • Allows earlier mobility
    • Non-emergent surgery
      • Usually done in 9-12 days
      • Mainly for stability and more rapid mobilization