Archive | February, 2016

C1-C2 Fractures (quick review)

23 Feb

Submitted by Christina Brown, M.D.

C1-C2 FRACTURES/DISRUPTION

Occipital Condyle Fracture  – Neurologic impairment such as lower cranial nerve deficits and/or limb weakness.  It’s rarely visible on plain films.

Occipito-atlantal Disassociation –Skull displaced anteriorly/posteriorly or distracted from cervical spine.  It frequently results in death.  “Basion-dental interval” – Distance between basion and superior cortex of dens.  Normally distance is less than 8.5mm on CT. (1)

C1 (ATLAS) Fractures

 Jefferson Fx.  – Due to axial loading resulting in outward displacement of lateral masses of C1.  If displacement is >7mm in total, rupture of the transverse ligament and likely unstable.  (1)

Transverse Ligament Disruption – TV ligament is crucial to stability of C1 and C2. 

  • On lateral radiograph, the predental space should be less than 3mm in adults vs <2mm on CT. 
  • A predental space >3mm on lateral radiograph implies damage to TV ligament. 
  • >5mm indicates rupture. 

Avulsion Fx of Anterior or Posterior Arch of Atlas – Hyperextension injury.  Lateral XR.  An isolated avulsion of anterior tubercle is considered a stable fracture. 

 

C2 (AXIS) Fractures

Odontoid Fx – Frequently involve other injuries to cervical spine and multisystem trauma.  Clinical signs – Severe, high cervical pain w/ muscle spasm worsened by movement.  Neurologic injury in 18-25% odontoid fractures ranging from paresthesias to quadriplegia.  (1)

Type I – Avulsion of tip.  Stable, good prognosis. 

Type II – Junction of odontoid w/ body of C2, unstable. 

Type III – Through body of C2.  Unstable.  (1)

 

 

Hangman’s Fx – C2 (Axis) pedicle fractures.  Unstable injury d/t hyperextension following abrupt deceleration. 

Initial Management

Spinal Immobilization – There is no high quality evidence stating that it prevents spinal injury or improves outcome (2).  It’s recommended to remove patient from the backboard as soon as possible. 

Definitive Management – If a spinal column injury is deemed unstable, hospital admission and spine surgery consultation is mandatory.

Conservative Management – Closed reduction under fluoroscopy and halo-vest immobilization. The halo vest = graphite or metal and is secured to the frontal and parietal areas of the skull with metal pins.  The halo is the most common device applied for treatment of unstable cervical fractures.  (4)

 

Common Pitfalls

  • No spine immobilization
  • Low suspicion of spinal injury in multi trauma patient
  • Accepting radiographs that are inadequate to appropriately evaluate for spinal column injury
  • Failure to appreciate the high false negative rate of plain radiographs in diagnosing unstable burst fractures; failure to obtain a CT scan in such cases (2)
  • Failure to radiograph the entire spine when a fracture at one spinal level is demonstrated

 

 

References:

  1. Baron BJ, McSherry KJ, Larson JL, Jr., Scalea TM. Baron B.J., McSherry K.J., Larson J.L., Jr., Scalea T.M. Baron, Bonny J., et al.Chapter 255. Spine and Spinal Cord Trauma. In: Tintinalli JE, Stapczynski J, Ma O, Cline DM, Cydulka RK, Meckler GD, T. Tintinalli J.E., Stapczynski J, Ma O, Cline D.M., Cydulka R.K., Meckler G.D., T Judith E. Tintinalli, et al.eds.Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7e. New York, NY: McGraw-Hill; 2011. http://accessmedicine.mhmedical.com/content.aspx?bookid=348&Sectionid=40381743
  2. http://www.uptodate.com/contents/evaluation-and-acute-management-of-cervical-spinal-column-injuries-in-adults?source=search_result&search=cervical+fracture&selectedTitle=2~30
  3. http://www.uptodate.com/contents/spinal-column-injuries-in-adults-definitions-mechanisms-and-radiographs?source=search_result&search=cervical+fracture&selectedTitle=1~30
  4. Botte MJ, Byrne TP, Abrams RA, Garfin SR. Halo Skeletal Fixation: Techniques of Application and Prevention of Complications. J Am Acad Orthop Surg 1996; 4:44.
  1. Images +: https://www.med-ed.virginia.edu/courses/rad/cspine/index.html
  2. Odontoid types image: http://accessemergencymedicine.mhmedical.com/data/Books/schw1/schw1_c042f012.gif 

 

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strength in numbers: Pyelonephritis

3 Feb

some interesting stats, via a recent emdocs overview of pyelonephritis:

Clinical:

  • fever – present in up to 77% of patients
  • flank pain or CVA tenderness – 86%
  • elderly patients with NO fever – up to 33% (just to make our jobs difficult)

 

Urinalysis:

  • needs 10,000 colony forming units (CFU) per mm3 to confirm diagnosis
  • leukocyte esterase (LE):
    • sensitivity: 72% to 97%
    • specificity: 41% to 86%
  • nitrites:
    • sensitivity: 19% to 48%
    • specificity: 92% to 100%
  • Urine cultures positive in 90%

urine-analysis-28-638

Patient with symptoms, but negative dipstick: what now?

“urine dipstick showed sensitivities as low as 75%, which is not acceptable if the patient has symptoms.”

also beware of pyelo mimics (e.g. pneumonia, PE, AAA, chronic pyelonephritis, PID, pelvic pain syndrome, prostatitis, diverticulitis, appendicitis, ovarian/testicular torsion, HZV, epidural abscess, and ectopic pregnancy)

 

Food for thought.

 

References: emdocs article; picture