(1) etiology and classification
Violence is the main cause of thoracolumbar fractures.
① Classification of thoracolumbar fractures.
Simple wedge compression fracture: it is the result of anterior column injury of spine. This kind of fracture does not damage the column, but the spine remains stable.
Stable explosive fracture: it is the result of the injury of the front column and the middle column of the spine. The posterior column of the spine is not affected, so the stability of the spine is still maintained. However, the broken vertebral body and intervertebral disc can protrude in front of the spinal canal, damaging the spinal cord and causing symptoms.
Unstable explosive fracture: it is the result of simultaneous injuries to the front, middle and rear columns. Due to the instability of the spine, there will be post-traumatic hunchback and progressive neurological symptoms.
Chance fracture: horizontal laceration of vertebral body. This kind of fracture is also an unstable fracture, which is relatively rare in clinic.
Buckling-traction injury: the crankshaft buckled behind the anterior longitudinal ligament. The front column is damaged by compressive force, and the middle and rear columns are damaged by tensile force. The posterior longitudinal ligament was broken due to partial injury of the central column; The partial injury of posterior column is manifested as rupture of vertebral joint capsule, dislocation of articular process, subluxation or fracture. This injury is usually a potentially unstable fracture.
Spinal fracture-dislocation: also known as sports injury. The arrangement of spinal canal has been completely destroyed, and the spine has shifted along the transverse section at the injury plane. Usually all three pillars are destroyed by shear.
The injured plane usually passes through the intervertebral disc, so the degree of dislocation is heavier than that of fracture. When the articular process is completely dislocated, the inferior articular process moves in front of the superior articular process of the next vertebra and blocks each other, which is called articular process interlocking. This kind of injury is extremely serious, spinal cord injury is inevitable and the prognosis is poor.
② Classification of cervical fracture.
Buckling failure: it is the result of compression of the front column and tension of the rear column. Clinically common are:
Anterior subluxation (flexion injury) is the result of rupture of posterior column ligament of spine, which can be divided into two types: complete and incomplete. Bilateral intervertebral joint dislocation is caused by excessive flexion, which leads to the rupture of the ligament of the middle posterior column; Simple wedge-shaped (compression) fractures are more common, which are common in osteoporosis.
Damage caused by vertical compression.
Bilateral anterior and posterior arch fractures of the first cervical vertebra: also known as Jefferson fracture. It is difficult to find the fracture line on the X-ray film. CT examination can clearly show the fracture site, the number and displacement of fracture pieces, and MRI examination can show spinal cord injury. The treatment is mainly non-surgical treatment.
Burst fracture: It is a comminuted fracture of the lower cervical spine, which is more common in C5 and C6. Broken fracture pieces protrude into the spinal canal to varying degrees, so the incidence of paralysis is very high.
Hyperextension injury.
Hyperextension dislocation: common in high-speed cars. When braking suddenly or crashing, the head is overstretched due to inertia, and then excessively flexed, causing serious damage to the cervical spine. Fracture of anterior longitudinal ligament, horizontal fracture of intervertebral disc, avulsion fracture of anterior lower edge of upper vertebral body, fracture of posterior longitudinal ligament. The disease is characterized by signs of trauma on the forehead and face.
Injured vertebral arch fracture: the violence of this kind of injury comes from the forehead, which makes the cervical vertebra overstretched and forms a strong shear force in the second half of the axis, causing vertical fracture of the axis vertebral arch. It used to be more common in people who were hanged, so it was also called hanging fracture.
Fracture whose mechanism is not clear. Dentate fractures can be divided into three types. 1 type, odontoid process tip avulsion fracture; Type 2, transverse fracture at the base of odontoid process and above the vertebral body of axis; Type 3, fracture of the upper part of the axis vertebral body, involving the superior articular process of the axis, unilateral or bilateral.
L-type is stable, with few complications and good prognosis. Type 2 is more common, where the blood supply is poor and bone nonunion often occurs, requiring surgical treatment; Type 3 fracture has good stability, good blood supply and good prognosis.
③ According to the stability of fracture, it can be divided into stable type and unstable type. Simple compression fracture, the compression of vertebral body does not exceed the original height 1/3, and simple accessory fracture with waist above 4 ~ 5 is not easy to shift, which is a stable fracture. Simple compression fracture, crushing compression fracture, fracture and dislocation of cervical vertebra 1, anterior dislocation or subluxation, and fracture of lumbar lamina No.4-5 and articular process are easily displaced after reduction, which are unstable fractures.
(2) Clinical manifestations
(1) has a history of serious injuries, such as falling from high altitude, heavy objects hitting the head, neck, shoulders or back, diving injury, being buried by mud and ore in landslide accidents, etc.
② After thoracolumbar injury, the patient suffered from local pain, back muscle spasm, inability to stand, difficulty in turning over and waist weakness. Due to the stimulation of retroperitoneal hematoma to autonomic nerve, intestinal peristalsis slows down, and symptoms such as abdominal distension, abdominal pain and constipation often appear.
When the cervical vertebra is injured, the head and neck are painful, unable to move, and obviously tender. The wounded often put their heads in their hands. Spinal examination can find local swelling and obvious local tenderness in the midline. The swelling and kyphosis are not obvious when the cervical vertebra is injured, but there is obvious tenderness. Kyphosis often occurs in thoracolumbar injuries.
③ X-ray manifestations X-ray examination is of great significance in making a clear diagnosis, determining the location, type and displacement of the injury, and guiding the treatment.
Taking thoracolumbar fractures as an example, the X-ray manifestations are: on the lateral radiograph, there are wedge-shaped changes in the anterior upper part of the vertebral body, or the whole body is flattened. The continuity of the anterior edge of the vertebral body is interrupted, or there are bone fragments. When the fracture is compressed, the back of the vertebral body can protrude backward into an arc. When combined with dislocation, there is anterior and posterior dislocation between vertebral bodies, the relationship between articular processes has changed, or there is articular process fracture.
The anterograde radiograph shows that the vertebral body is flattened, or one side is wedge-shaped, and the continuity of bones on both sides is interrupted, or there is lateral displacement. There may also be fractures of lamina, articular process and transverse process.
(3) First-aid treatment ① Use wooden boards or door panels for handling.
(2) First straighten the wounded's two lower limbs, and straighten the two upper limbs to the side. The wooden board was placed on the wounded side, and 2 ~ 3 people helped a player's trunk roll into a whole and moved it to the wooden board. Be careful not to twist the trunk. Or three people at the same time hold the wounded with their hands and go straight to the board. It is forbidden to cuddle or lift the head and feet, because these methods will increase the curvature of the spine and aggravate the injury of vertebrae and spine.
(3) For the wounded with cervical spine injury, there should be a special person to hold the head and pull it slightly along the longitudinal axis to make the head and neck roll with the trunk. Or hold the head with the injured person's own hands and move slowly. It is forbidden to move your head by force at will. After sleeping on the board, put sand bags or folded clothes on both sides of the neck to fix it.
(4) Treatment of spinal fracture ① Treatment of thoracolumbar fracture.
Treatment of simple compression fracture: those whose vertebral compression does not exceed 1/5, or those who are old and weak and can't tolerate reduction and fixation, can lie on their back on a hard bed with a thick pillow at the fracture to overstretch the spine. After 3 days, they are required to start back muscle exercise. After 2 months, the fracture basically healed, and in the third month, he could go to the ground for a little activity. He still stayed in bed. After 3 months, gradually increase the time of outdoor activities.
Teenagers or middle-aged injured people whose vertebral compression height exceeds 1/5 can be reduced by two-table method. After reset, it should be fixed in this position with an overstretched plaster vest. During plaster fixation, patients are encouraged to go down to the ground and insist on functional exercise of back muscles every day. The fixed time is about 3 months.
Bicondylar suspension can also be used for reduction.
Treatment of explosive fracture: For explosive fracture without nervous system symptoms, if CT proves that no bone blocks are squeezed into the spinal canal, double condyle suspension reduction can be used. For those who have neurological symptoms and bone blocks squeeze into the spinal canal, it is not suitable for reduction. For this kind of fracture, it is advisable to take out the fracture block and intervertebral disc tissue in the spinal canal through the lateral anterior approach, and then carry out intervertebral bone grafting and fusion, and if necessary, insert it into the anterior fixation. Posterior column injury requires posterior internal fixation if necessary.
Chance fracture: patients with spinal flexion-traction injury and active fracture-dislocation need anterior and posterior reduction and internal fixation.
② Treatment of cervical fracture. For cases of cervical subluxation, it is often difficult to distinguish whether it is a complete tear or an incomplete tear in emergency. In order to prevent later complications, this kind of occult cervical injury should be fixed with plaster neck for 3 months. Anterior or posterior spinal fusion can be used for cases of late cervical instability and deformity.
For stable cervical fracture, patients with mild compression can be reduced by supine jaw pillow traction with a traction weight of 3kg. After reduction, plaster was applied to the neck and chest for 3 months. For patients with obvious compression and bilateral intervertebral joint dislocation, continuous skull traction reduction and plaster fixation of head, neck and chest can be used. The traction weight is 3 ~ 5 kg, which can be increased to 6 ~ 10 kg if necessary. After X-ray confirmed the reduction, the head, neck and chest plaster can be fixed by traction for 2 ~ 3 weeks and about 3 months. Patients with quadriplegia and traction failure need surgical reduction. If necessary, the articular process can be cut off to obtain good reduction, and internal fixation must be installed.
Patients with unilateral facet dislocation can have no neurological symptoms, especially those with large spinal canal. Continuous bone traction reduction can be applied first, and the traction weight increases gradually, starting from 1.5kg, and the longest traction time is about 8 hours. Manual reduction is not suitable for traction, so as not to aggravate neurological symptoms. Surgery is suitable for patients with difficulty in reduction. If necessary, the superior articular process can be removed and cervical fusion can be added.
In principle, patients with explosive fracture with nervous system symptoms should be treated by early surgery, usually by anterior surgery, bone fragment removal, decompression, bone graft fusion and internal fixation.
For hyperextension injury, non-surgical treatment is often used. In particular, a very small number of patients with traumatic pedicle fracture of axis accompanied by nervous system symptoms can be treated conservatively without displacement, and fixed in the head, neck and chest for 3 months after traction for 2 ~ 3 weeks; Patients with displacement should undergo anterior cervical interbody fusion.
Non-surgical treatment is generally used for patients with spinal cord injury around the central canal.
People with spinal canal stenosis or spinal cord compression usually undergo spinal canal decompression 2 ~ 3 weeks after injury.
For L-type, 3-type and 2-type odontoid fractures without displacement, non-surgical treatment is generally adopted, and plaster can be applied to the head, neck and chest for 3 months after traction with pillow belt or skull for 2 weeks.
Type 2 odontoid fracture, if the displacement exceeds 4mm, the healing rate is extremely low. Generally speaking, surgical treatment is advocated, and anterior L ~ 2 screw internal fixation or posterior Ct bone grafting and steel wire binding can be used.