frcature spine and peripheral nerve pptx - د. هشام

Peripheral nerve lesion

Peripheral nerves are bundles of axons conducting efferent

(motor) impulses from cells in the anterior
horn of the spinal cord to the muscles, and afferent

(sensory) impulses from peripheral receptors via cells

in the posterior root ganglia to the cord.
They also
convey sudomotor and vasomotor fibers from ganglion
cells in the sympathetic chain.

Classifications

Seddon's classification

Neurapraxia

-- temporary paralysis of a nerve caused by lack of blood flow or by pressure on the affected nerve with no loss of structural continuity

Axonotmesis –

neural tube intact, but axons are disrupted.

nerves are likely to recover.

Neurotmesis –

the neural tube is severed.
Injuries are likely permanent without repair.

PATHOLOGY

Nerves can be injured by

1.ischaemia.
2.Compression.
3.Traction. 4.Laceration.
5.or burning.

Transient ischaemia

Acute nerve compression causes numbness and tingling within 15 minutes,

loss of pain sensibility after 30 minutes and
muscle weakness after 45 minutes.

Relief of compression is followed by

intense paraesthesiae lasting up to 5 minutes (the familiar ‘pins and needles’ after a limb ‘goes to sleep’); feeling is

restored within 30 seconds and full muscle power after about 10 minutes.

OBSTETRICAL BRACHIAL PLEXUS PALSY

caused by

excessive traction on the
brachial plexus during childbirth, e.g. by pulling the
bay’s head away from the shoulder or
by exerting traction with the baby’s arm in abduction.

Three patterns
are seen: (1) upper root injury (Erb’s palsy), typically in
overweight babies with shoulder dystocia at delivery;

(2) lower root injury (Klumpke’s palsy), usually after

breech delivery of smaller babies; and

(3) total plexus injury.

Clinical features

Erb’s palsy is caused by injury of C5, C6 and (sometimes) C7. The abductors and external rotators of the shoulder and the supinators are paralysed.

The arm is held to the side,

at birth: after a difficult delivery the baby has a floppy or flail arm.

internally rotated and

pronated.

There may also be loss of finger extension.

Sensation cannot be tested in a baby.

X-rays

should be obtained to exclude fractures of

the shoulder or clavicle (which are not uncommon
and which can be mistaken for obstetrical palsy).

Management

Over the next few weeks one of several things may
happen.
Paralysis may recover completely.
Paralysis may be partially resolve.
Paralysis may remain especially in the presence of a Horner’s syndrome

RADIAL NERVE

The radial nerve may be injured at the elbow.

in the upper arm

or in the axilla.

Clinical features

High and Low lesions are usually due to

fractures or dislocations
at mid shaft of humerus or at the elbow,

or to a local wound.

after operations on the proximal end of the radius.

The patient complains of clumsiness and, on testing,

cannot extend the metacarpophalangeal joints of the hand.

In the thumb there is also weakness of extension.

Treatment

Open injuries should be explored and the nerve repaired or grafted as soon as possible.

Closed injuries

In patients with fractures of the humerus it is important to examine for a radial nerve injury on admission,

before

treatment and again after manipulation or internal fixation.
If the palsy is present on admission, one can
afford to wait for 12 weeks to see if it starts to recover.
If it does not,
then EMG should be performed;

While recovery is awaited,

Physiotherapy

The wrist is splinted in extension. ‘

To over come fixed contractures

CARPAL TUNNEL SYNDROME

In the normal carpal tunnel there is barely room for all the tendons and the median nerve; consequently,
any swelling is likely to result in compression and ischaemia of the nerve.

the syndrome is, however, common

at the menopause.
in rheumatoid arthritis.
pregnancy.
and myxoedema.

Clinical features

The history is most helpful in making the diagnosis.

Pain and paraesthesia occur in the distribution of the
median nerve in the hand.

Night after night the

patient is woken with burning pain,

tingling and

numbness.

Hanging the arm over the side of the bed,

or shaking the arm, may relieve the symptoms.
In advanced cases there may be clumsiness and weakness

The condition is far more common in women than in men.

The usual age group is 40–50 years;

younger patients it is not uncommon to find related factors such as

pregnancy, rheumatoid disease, chronic
renal failure or gout.

Sensory symptoms can often be reproduced by percussing

over the median nerve
(Tinel’s sign) or by

Clinical sign

holding the wrist fully flexed for less than 60 seconds

(Phalen’s test).

In late cases

there is wasting of the thenar muscles.

weakness of thumb abduction and

sensory dulling in the median nerve territory.

Electrodiagnostic tests,

which show slowing of nerve conduction across the wrist

DD:

Radicular symptoms of cervical spondylosis may confuse the diagnosis and

may coincide with carpal tunnel syndrome.

Treatment

Light splints that prevent wrist flexion can help those

with night pain or with pregnancy-related symptoms.

Steroid injection into the carpal canal, likewise, provides temporary relief.

Open surgical division of the transverse carpal ligament usually provides a quick and simple cure.

Endoscopic carpal tunnel release.

SCIATIC NERVE

Division of the main sciatic nerve is rare except.
in
gunshot wounds.

Traction lesions may occur with

traumatic hip dislocations

and with pelvic fractures.

Intraneural haemorrhage in patients receiving anticoagulants

Clinical features

In a complete lesion the hamstrings and all muscles
below the knee are paralysed;

the ankle jerk is absent.

Sensation is lost below the knee, except on the medial
side of the leg which is supplied by the saphenous
branch of the femoral nerve.

The patient walks with a

drop foot and

a high-stepping gait to avoid dragging the insensitive foot on the ground

Treatment

suture
or nerve grafting should be attempted ,more than a year for leg muscles to be re-innervated.

While recovery is awaited,

a below-knee drop-foot splint is fitted.

Spine injuries

Cervical classifications
wedge compression fracture of vertebral body

burst fracture of vertebral body

extension subluxation

flexion subluxation

fracture of the atlas

fracture-dislocation of the atlanto-axial joint

intraspinal displacement of soft tissue

soft-tissue strain

('whiplash injury')

MECHANISM OF INJURY

Flexion

Flexion-rotation
Extension
Vertical compression.

injuries of the cervical spine are usually caused by indirect violence,

Such as falls on to the head or
other violent movements transmitted from the skull. i.e in any direction.
flexion,
tension, lateral flexion or
rotation-
or a vertical compression force acting on
a straight spine.

Flexion and flexion-rotation injuries

are common:

flexion alone tends to a wedge compression fracture .

whereas combined flexion and rotation cause subluxation ,

dislocation or fracture-disIocation.

A flexion or flexion-rotation force may also cause massive displacement of an intervertebral disc, without bone injury

A hyperextension

force may fracture the neural arch, especially of the atlas

Or fracture the dens (odontoid process) of the axis.

hyperextension may rupture the anterior longitudinal ligament and the

anulus fibrosus, forcing the vertebral bodies apart anteriorly (extension
subluxation) .

DIAGNOSISX RAY

Anterio posterior X ray radiograph.lateral radiographs with the head in flexion and extension may revealinstability that is not shown in the routine lateral film.

oblique views

at 45° are especially helpful

a special projection

through the open mouth.

Computed tomography (CT)

and magnetic resonance imaging (MRI).

Treatment

It is unnecessary to attempt reduction, and all that is required is to support the

neck for 2 months to relieve pain. This may be achieved by a rigid plastic Collar.

In addition to N S A I

SOFT-TISSUE STRAIN OF THE CERVICAL SPINE

Mechanism of injury and pathology

At the moment of impact, the head is first
suddenly jolted forwards followed by rebound flexion of the spine.
And a second by extension of the neck.

Clinical features

At impact, the patient may feel jolting or 'wrenching' of the neck or

painful one of the shoulder,

neck pain is usually accompanied

by severe headache, which
Examination shows restriction of the range of
movement of the cervical spine, usually in all directions

Treatment

In general, the

principle to provide support and rest for the neck at
First, in the form of a protective cervical collar.

But after 1or 2 weeks there

should be on the restoration of mobility by exercises within the limits
imposed by pain, preferably under the supervision of a physiotherapist.

Dorsal and lumbar spine

Wedge compression fracture of a vertebral body.

Burst fracture of a vertebral body.

Distraction fracture of a vertebral body.

Dislocation and

fracture-dislocation

Minor fractures of the spinal column
Fractures of transverse processes .
Fracture of the sacrum
Fracture of the coccyx

Fractures of the thoracic cage.

Fractures of the ribs
Fractures of the sternum

MECHANISM OF INJURY

by vertical force acting through the long axis of the spinal column.

This force.
may act from above, as when a coal miner is buried by a fall of roof.

or from

Below, as by a heavy fall on the feet or buttocks, in high speed motor vehicle
collisions

The thoracolumbar junction

one or more of the vertebral bodies collapses

anteriorly and becomes wedge-shaped, giving rise to a localized kyphosis.

WEDGE COMPRESSION FRACTURE

Diagnosis .

obvious symptoms and signs pointing
In cases of major fracture there will be only between the T11 and L2

Treatment

It has been shown that persistent wedging of a vertebral body is compatible. With virtually normal function.

so correction of the deformity is not essential.

The standard method of treatment may, therefore, be said to be conservative.

BURST FRACTURE OF A VERTEBRAL BODY

the compression force thus acts vertically in the line of the vertebral bodies.

The intervertebral disc is forced
In the affected vertebral body, causing a comminuted bursting fracture in which fragments are driven outwards in all directions.

Treatment

If there is no neurological impairment, it is permissible to employ

Conservative treatment as for wedge compression fracture, but a rather longer period of recumbency is advisable.