On the blog thread, each participant should add one item. Choose from the following. Symptom she would be potentially having, a fact about the injury she has incurred, what is normal or abnormal about the images shown.
Wednesday, April 6, 2016
This should be an easy image to start with. 16 year old female with neck pain following MVA.
On the blog thread, each participant should add one item. Choose from the following. Symptom she would be potentially having, a fact about the injury she has incurred, what is normal or abnormal about the images shown.
On the blog thread, each participant should add one item. Choose from the following. Symptom she would be potentially having, a fact about the injury she has incurred, what is normal or abnormal about the images shown.
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ReplyDeleteThis CT scan shows a clear fracture of the odontoid process with anterior slippage. While common mechanism of injury for young adults is an MVA, an elderly person can suffer this injury from a simple fall.
ReplyDeleteGoing along with the comments above, she has a fracture of the dens. She will present with pain and difficulty actively moving her head/neck. As well as a feeling of instability on the neck, potentially using her hands to hold her head for greater stability.
ReplyDeleteThe CT scan of the cervical spine above displays an anterior slippage of C1 creating a fracture of the odontoid process. Halo immobilization has been considered to be the standard of care. Alternative options include anterior odontoid screw fixation or a posterior atlantoaxial fusion. All procedures have their own advantages and disadvantages.
ReplyDeleteThis is a sagittal CT of the c-spine with a fracture of the odontoid process. This patient will present with cervical spine instability due to the trauma disrupting ligamentous support in addition to the fracture. This injury could lead to quadriplegia if the pt isn't immobilized or has surgery to stabilize the c-spine. - Amanda Rudd
ReplyDeleteThis patient could present with the following signs and symptoms cervical pain, swelling around the neck, and cervical instability. She may also demonstrate difficulty breathing, tingling or loss of sensation in upper extremities and/or lower extremities, and a change in bowel and bladder function. - Elissa Westbrook
ReplyDeleteAgreeing with the comments above, the CT shows a fracture of the odontoid process and anterior slippage of C1. There are three types of odontoid fractures; Type I is an oblique fracture through the upper part of the odontoid process, Type II is a fracture occurring at the base of the odontoid as it attaches to the body of C2, and Type III occurs when the fracture line extends through the body of the axis. This fracture appears to be a Type II.
ReplyDeleteIt looks as though the patient received a type II fracture of the dens which is located at the junction between the dens and the body of C2. As stated in the textbook, this type of injury is extremely common in motor vehicle accidents in younger individuals. The CT sagittal view was likely chosen for this type of injury because of the ability for it to detect subtle or complex fractures at a much greater sensitivity than conventional radiographs. Typical radiographs such as using the AP open mouth view makes identifying a dens fracture difficult with the arches of the atlas or teeth getting in the way. -Madison Bertrand
ReplyDeleteAn interesting fact about a fractured odontoid (type II) is that there are actually several subdivisions of type 2 fractures. "A type 2A fracture is minimally displaced and is treated with external immobilisation. A type 2B is displaced and is generally treated with anterior screw fixation. A type 2C is a fracture that extends from antero-inferior to postero-superior and is treated with instrumental fusion of C1 – C2".
ReplyDeleteThere are 4 common treatment options and in order to determine which treatment option is appropriate it is important to complete a thorough neurological evaluation as well as screen for co-morbitities. The two surgery options are anterior screw fixation and posterior C1-C2 fusion. The two conservative options are the Halo vest and the rigid cervical collar. The two surgical options are as follows: "Anterior odontoid screw fixation: one or 2 screws are inserted via the anterior-inferior corner of the C2-endplate to stabilize the fracture. Reports say that the Type IIB fracture (anterior-superior to posterior-inferior) have the most ideal geometry for this technique. Posterior C1-C2 fusion: different techniques are reported. Gallie wiring technique, Magerl C1-C2 transarticular screw fixation and Harms posterior C1 lateral mass and C2 pars screws." The two conservative treatment options are : "The use of a semi-rigid cervical collar is said to be the treatment of choice in elderly (and younger patients with stable fractures), considering the problems related to Halo vest immobilization and the surgical risks of operative treatment. There’s a big challenge in the fact that non-operative management with external immobilization correlates with high rates of morbidity (complications) and mortality in elderly, especially with the Halo vest". Overall the treatment option depends on the severity of injury, age, and existing co-morbitites in addition to any other health concerns so it is ultimately patient dependent. Jennifer Cox
(http://www.physio-pedia.com/Odontoid_fractures#cite_note-Elgaffy-9)
Apparently, everyone agrees this is a type II fracture of the dens... While halo does provide high rates of union, an alternative approach is an anterior odontoid single screw fixation. If the fracture is less than 4 weeks old and the patient does not have large body habitus, this is a good option due to the fact that it has been proven to preserve rotation between C1/C2, has low rates of non union and other complications, and the patient doesn't have to wear the halo.
ReplyDeleteKevin Hall
I also agree with everyone above with their comments that the CT shows a fracture of the odontoid process and anterior slippage of C1. There are three types of odontoid fractures and this fracture looks like a Type II is a fracture occurring at the base of the odontoid as it attaches to the body of C2. This type of injury is extremely common in motor vehicle accidents in younger individuals. The patient will have symptoms that worsen with movement, and myelopathy could occur but very rare due how big the spinal cord is at this section. -Amber Buckles
ReplyDeleteI'm going to go ahead and agree with everyone that this CT scan shows an odontoid process fracture and anterior slippage of C1. There are subdivisions of the type 2 odontoid fractures. A type 2A fracture is minimally displaced and usually treated with external immobilization. A type 2B is displaced and is generally treated with anterior screw fixation. A type 2C is a fracture that extends from antero-inferior to postero-superior and is treated with instrumental fusion of C1 – C2. Non-operative management of stable Type II fractures has shown to have positive long-term functional outcomes in a younger population. Elderly (>65years) showed poor long-term functional outcomes with higher rates of non-union. Several factors have been related to non-union rates of conservatively treated Type II odontoid fractures including bad vascularization of the axis, gapping due the apical ligaments’ traction and age > 65 years.
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DeleteThe type 2 fracture of the dens is the most common and occurs through the base of odontoid process & may be caused by either hyper-flexion or hyper-extension forces. Blood supply is often compromised in this type of fracture. When dens displacement occurs, the C-1-dens-transverse ligament complex usually remains intact; ligamentous disruption may involve thick atlantoaxial capsular ligament. Patients with acute dens fractures usually present with upper cervical pain and restriction of neck movements. They may have a tendency to support their head with their hands while moving from an upright to a supine position. In case of cord compression by the displaced fracture segments, cervical myelopathy may occur. In a study, 82% patients of type II fractures presented with intact neurological status; 8% had minimal sensory disturbances over the scalp or limb; and 10% had significant neurological deficits.
Deletehttp://medind.nic.in/icf/t05/i1/icft05i1p3.pdf
Erin Osterthun
A CT coronal reconstruction reveals a fracture of the dens. The fracture appears to be a Type II fracture, which involves fracture at the junction of the dens to the body. Type II fractures of the dens are the most common and also the most difficult to heal. The most common mechanism for injury in young adults is a MVA.
ReplyDeleteMaKayla McPhail
This sagittal CT scan clearly reveals a fracture of the dens displacing C1 anteriorly on C2. Odontoid fractures make up roughly 9-15% of all adult cervical fractures, with type II being the most common. "Fortunately, the prevalence of associated neurologic injury is low, ranging from 2 to 27%. Neurologic injury, if present, usually results in catastrophic or fatal consequences due to the high level of spinal cord involved." High energy trauma such as MVA accounts for the younger population (17-30) and low energy trauma such as falls accounts for the older population (>70).
ReplyDelete"The long-term functional outcome of type II odontoid fractures managed non-operatively"
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2989219/
This appears to be a CT scan of the cervical spine with an anterior slippage of C1 on C2 causing a fracture of the dens, type 2 is most common with fracture of the junction of the dense to the body and is the most difficult to heal as well. She could have a wide range of neurological symptoms such brown sequard, hemiplegia, or paraplegia.
ReplyDeleteAdam Goltra
Her signs and symptoms might include pain (obviously given her MVA)typically in suboccipital region, headaches, transverse ligament instability, possibly dysphagia, and signs and symptoms of spinal cord compression including UE/LE weakness or paresthesia's depending on the severity. Stephanie Salisbury
ReplyDeleteThe image above shows an odontoid process fracture. There are two different classification systems to describe this type of fracture. The most commonly used system is the Anderson and D'Alonzo system which classifies the fracture based on the fracture line. Anderson D'Alonzo classification include three types. Type I - rare fracture of the upper part of the odontoid and is usually considered stable. Type II - most common and unstable fracture at the base of the odontoid with a high risk of non-union. Type III - fracture is through the odontoid and into the lateral masses of C2 and has the best prognosis for healing. The less commonly used classification system is the Roy-Camille classification which has been shown to better correlate with prognosis. This classification describes the plane of the fracture and the displacement. "Type I: oblique linear fracture in which its line slopes forward, with dens displacement in an anterior direction. Type II: oblique linear fracture in which its line slopes backward, with dens displacement in a posterior direction. Type III: horizontal fracture line and the dens displacement can be either anterior or posterior."
ReplyDelete(http://radiopaedia.org/articles/odontoid-process-fracture-roy-camille-classification)
Chricket Short Niehues
As mentioned above this is a CT scan of the cervical spine that shows a fractured odontoid process and anterior slippage of C1 on C2 (Type II). Besides the common neck pain she would be having she would also have cervical instability and possible neurological s/s as well. These symtpoms can be extremely variable depending on the amount of trauma to the spinal cord and swelling present following her MVA.
ReplyDeleteJake Snodgrass
This CT scan shows a patient that has suffered a slippage of the C1/C2 vertebrae secondary to an odontoid fracture. This is likely a result of a severe trauma such as a MVA. Symptoms that may be seen are neurological signs of cord compression, severe head and neck pain, and extremely guarded cervical spine movement. -Ashley Kelsey
ReplyDeleteAs mentioned above, the CT scan reveals a type II fracture of the dens sustained from a high energy trauma MVA more common in the younger population (17-30 years). The elderly population (>70 years) are most likely to receive these injuries in low energy trauma such as a fall from standing height. Possible physical symptoms the patient could present with range from pain, numbness, clumsiness, weakness or tingling in upper extremities. - Amber Padgett
ReplyDeletehttp://www.ncbi.nlm.nih.gov/pmc/articles/PMC2989219/
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ReplyDeleteWell, looks like I am late to the party! I agree as well that this appears to be a type II fracture of the dens. According to the following study, "Operative treatment (posterior C1-2 fixation or anterior screw fixation) provides a better fusion rate than external immobilization for acute odontoid Type II fractures, although in certain situations, such as anterior displacement of the fracture and for younger (< 45-55 years of age) patients, conservative management (halo vest or collar immobilization) can be as effective as surgery. Operative management is recommended in older patients, in cases of posterior displacement of the fracture, and when there is displacement of > 4-6 mm."
ReplyDeletehttp://www.ncbi.nlm.nih.gov/pubmed/19951016
Jacob Stucky
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ReplyDeleteThis comment has been removed by the author.
ReplyDeleteThis comment has been removed by the author.
DeleteNICK JOHANSEN
ReplyDeleteThis saggital view CT shows a type II fracture of the odontoid process. In the systematic review referenced below, it was identified that patients older than 60 with these types of fractures had decreased risk of short and long term mortality and better outcomes when the fracture was internally (surgically) stabilized vs external stabilization with a cervical collar. Also, the rate of nonunion of the dens fractures were more common in the groups who did not undergo operative treatment.
Schroeder GD, Kepler CK, Kurd MF, et al. A systematic review of the treatment of geriatric type II odontoid fractures. Neurosurgery. 2015;77: S6 - S14.
A pt suffering from a fracture of the odontoid process may present with symptoms of significant neck pain and limited motion with pain that may radiate into the scalp. This pt may or may not have SC involvement.
ReplyDeleteI would agree that this is a CT of a cervical spine, demonstrating fracture of the odontoid process with anterior displacement of C1. Physical therapy would be postponed until the fracture was stabilized, preferably by internal fixation.
ReplyDeleteChi YL, Wang XY, Xu HZ, et al. Management of odontoid fractures with percutaneous anterior odontoid screw fixation. Eur Spine J. 2007;16(8):1157-64.
This article describes a less invasive surgery than an open fixation, with ideal results.
Initial PT evaluation post-operatively would likely be in the acute care setting and should include examination for neurological symptoms, such as sensation changes in the head and neck, strength changes in upper traps (also bilateral SCM, and deep neck flexors, however pt would likely be in a hard cervical collar).
This sagittal CT scan reveals a fracture of the dens as you can see the displacement of C2. This fracture is not surprising as the patient's mechanism of injury was MVA. This patient would present with persistent pain that was especially worse with neck movements. Treatment would include stabilization with rigid cervical orthosis, halo traction, screw fixation, or late fusion for stability. It is also important to address any neurological deficits that may be present, as this is a cervical injury and neurological involvement is always possible.
ReplyDeleteRachelle Fisher
The CT scan reveals a fracture of the odontoid process of C2 that is unstable due to the anterior slippage of the C1 vertebrae and apex of the dens. According to this article, “fractures of the odontoid process of the axis account for 10-20% of acute cervical fractures.” This fracture is of the neck of the odontoid process thus deeming it a type II fracture. The fracture would be classified as an anterior oblique as the fracture slopes upwardly from the posterior portion to the anterior. The article continues to suggest “That mortality at the time of injury from a dens fracture ranges from 25-40% deeming it a serious pathology.” “25% of victims of an odontoid process fracture have neurological deficits.” Lastly the article continues to report that patients who undergo an anterior odontoid screw fixation have high rates of fusion and high rates of return of motion.
ReplyDeletehttp://www.bioline.org.br/pdf?ni05145
Kerby Rice
This is a type II ondontoid fracture, that is more common is the older population; however can occur in the younger population typically due to an MVA or impact type injury. The patient could have a wide variety of symptoms. Most common would be neck pain associated with swelling around and cervical instability. She may demonstrate dysphagia, double vision or loss of feeling in upper/lower extremities. Numbness, pain or tingling at the base of the skull that may be increased with movement may also occur. --Bri Fisher
ReplyDeleteThis image is displaying a type II fracture of the dens. The patient might display neurological changes in regards to decreased strength and/or sensation. Pt could also display signs of VAI including dizziness, diplopia, dysphagia, drop attacks, dysarthria, numbness, nausea, nystagmus, and ataxia.
ReplyDeleteOne retrospective study including 101 patients with C2 fractures showed that 18% had confirmed Vertebral Artery Injury (VAI) with no correlation between type of fracture and incidence of VAI.
http://jdc.jefferson.edu/cgi/viewcontent.cgi?article=1025&context=orthofp
Dava Logsdon
Like the above comments. The CT scan shows a fracture of the dens. This is common in MVA. Patient would present with pain, cervical instability, dysphagia, etc. Patient's cervical spine would need to be stabilized, one example would be a rigid cervical orthosis.
ReplyDelete-Kirsten Lyon
I would agree with the previous comments; this image is a CT scan of a patient who sustained a Type II fracture of the dens. The textbook states this type of fracture is "most common and most difficult to heal". The text also states that "dens fractures can be difficult to visualize on the AP open-mouth view because the arches of the atlas, or the teeth, may be superimposed".
ReplyDeleteDue to the recent instability of the atlanto-axial joint, C1 may displace on C2 and compress the spinal cord. The patient may present with signs and symptoms consistent with vertebral artery insufficiency (drop attacks, dizziness, diplopia, dysarthria, dysphagia, nystagmus, nausea, vomiting) or cervical myelopathy (hand paresthesias, extremity weakness, gait disturbances, (+) Lhermitte sign, increased tone, hyperreflexia, (+) UMN reflexes).
Chelsey Claassen
This sagittal image clearly depicts the fracture through the dens with the vertebral body being unaffected. A coronal CT would more clearly depict the body of C2 is not affected or fractured. The radiodensities of the remaining vertebra and occiput look appropriate and no other fractures are apparent. Teresa Kirby
ReplyDeleteSince everyone agrees that this is an odontoid fracture, a fact about an odontoid fracture is that there are three types of odontoid fractures. An odontoid fracture can be “through the tip of the dens (type I), through its base (type II), or involving the odontoid but extending into the vertebra body (type III) (1–3).” Another fact about odontoid fractures is that they “represent 7–15% of all cervical spine fractures.”
ReplyDeleteEgidijus, Kontautas,, Vytautas Ambrozaitis Kazys, Špakauskas Bronius, and Jonas Kalesinskas Romas. "The Treatment of Odontoid Fractures with a Significant Displacement." ResearchGate. Medicina (Kaunas), 15 Oct. 2004. Web. 10 Apr. 2016.
Zach White
This image is of a type II fracture of the dens. "Off all the cases of cervical trauma, about one out of five involves the axis. The most common type of the axis injury is an odontoid fracture at the junction of the dens and the body (type II odontoid fracture)1."
ReplyDelete1. Anderson LD, D’Alonzo RT. Fractures of the odontoid process of the axis.
J Bone Joint Surg (Am). 1974; 56: 1663-74.
http://medind.nic.in/icf/t05/i1/icft05i1p3.pdf
As everyone has already discovered this is an odontoid fracture. Due to it being a type II (described by being fractured through the waist) this young patient has a high change of nonunion due to blood supply interruption. She will likely be experiencing neck pain that is worse with motion, some dysphagia if there is a hematoma present. She likely will not be presenting with myelopathy due to the enlargement of the spinal canal at this level. The CT scan was likely ordered to assess the stability of the fracture and if vertebral artery integrity was questionable a CT angiogram could have been performed.
ReplyDeletehttp://www.orthobullets.com/spine/2016/odontoid-fracture-adult-and-pediatric
Becca A.
Rebecca Montgomery's Post:
ReplyDelete"The current role of external
immobilization in case of type II dens fractures is where
patients are unfit for general anesthesia or they have
sustained severe concurrent injury that precludes primary
surgical intervention for the fractured odontoid. Apfelbaum
et al17 have found a lower rate of bony fusion in patients
with anterior oblique fractures when compared to patients
in whom posterior oblique or horizontal fractures were
demonstrated."
http://medind.nic.in/icf/t05/i1/icft05i1p3.pdf
This sagittal view of a CT scan reveals anterior slippage of C1 and fractured odontoid process of C2. An article I found regarding the cost-effectiveness of operative vs non-operative treatment of Type II odontoid fractures in elderly patients divided the results into two groups. It was concluded that operative treatment was more cost-effective in patients age 65-84 "when using $100,000/quality-adjusted life years as a benchmark" but less effective and more expensive than non-operative treatment in patients older than 84 years of age. - John Babb
ReplyDeletehttp://www.ncbi.nlm.nih.gov/pubmed/27018900
As mentioned above, it appears to be a CT scan showing a anterior C1 slippage causing the dense to fracture. We are taught in PT school, this is a very serious injury and have always been under the notion that it will require surgery. However, that is not always the case, research shows that in the younger population conservative management using immobilization from either a halo or collar is just as effective as surgery http://www.ncbi.nlm.nih.gov/pubmed/19951016
ReplyDeleteHowever, in my experience with MVA, even after the fracture heals the patient nervous system will still be hypersensitive and producing pain. This is where PT comes in and use Adriaan Louw's take on pain science to get the nervous system calmed down and signify to the brain that the body is no longer in danger, therefore, the perception of pain is no longer necessary. CODY KELLY
Hyperflexion is the most common cause of dens fracture, causing anterior displacement of C1 on C2 as seen on the imaging above. Extension is a less common mechanism of injury for a dens fracture and could cause posterior displacement of C1 on C2. Danielle Shearrer
ReplyDelete