Confirmation of cervical stability in multiple trauma patients is often difficult. Prolonged collar immobilization of these patients is often required. Missed injuries can be catastrophic. Since January 2000, the senior author has regularly applied a modification of the classical White &
Panjabi stretch test in the operating room as a method of assessing cervical stability in qualifying trauma patients. Review of the first thirty cases finds two cases of stable ligamentous injury identified which would have otherwise been missed, a mean of almost two weeks’ collar immobilization eliminated and no missed instabilities, with no complications or assessment failures to date. The purpose of this study was to present the protocol and preliminary results of a modified White &
Panjabi cervical stretch test in the assessment of cervical instability in multiple trauma patients. Multiple trauma patients having no radiographic evidence of cervical instability on static imaging are routinely protected in hard collars until able to cooperate with clinical assessment and/or undergo flexion/extension radiographs for concern to possible discoligame-nous instability in the neck. Beginning in January 2000, such patients who were going to the operating room were routinely assessed with a stress test incorporating fluoroscopically-controlled axial distraction to tensile limit of the neck followed by maximum passive flexion and extension stressing. In the absence of intersegmental hypermobility, cervical precautions and immobilization were considered unnecessary and discarded. Chart documentation was reviewed for outcome and complications after discharge from the hospital. To date thirty-two tests have been performed and twenty-six cases had complete chart documentation available for review. No complications of the procedure and no missed instabilities have been identified. An average of thirteen days’ collar immobilization were eliminated by this protocol. Two cases of ligamentous hypermobility without instability were identified, one at O/C1 and the other at C5/6; both patients were treated observationally and have done well. One case of an undisplaced C2 pedicle fracture in a massively traumatized geriatric case was confirmed as stable on the day of injury, eliminating the need for collar support until the patient died of multiple organ failure twenty-one days later. Two patients went on to have neck pain complaints on regaining consciousness, but could be reassured that there was no instability. The operating-room cervical stress test is a practical and safe maneuver that can eliminate the requirement for collar immobilization in obtunded trauma patients, safely identify subtle ligamentous injuries without frank instability, and confirm stability in cases of undisplaced fracture. The operating-room cervical stress test is an effective tool in screening trauma patients for such injuries. It does not require access to MRI technology and can be used in any hospital with an operating room. Prolonged cervical collar immobilization and missed discoligamentous injuries of the neck in multiple trauma patients can be eliminated with the application of this test.
In this biomechanical study of isolated porcine C2 vertebrae, antero-posterior forces were applied to potted specimens. Bipedicular fractures were generated in 25.4% of fifty-nine specimens (others fractured mostly through laminae). Bipedicular fractures were subsequently fixed under direct vision with trans-pedicular lag screws. These fixed specimens were then tested again. The mean ultimate tensile strength of the construct was 27.1% compared to the native bone’s fracture strength in the same specimen. This is a good model for hangman’s fracture, and is relevant to newer constructs that utilize C2 pedicle screws as part of a larger instrumentation procedure. Hangman’s fracture rarely needs internal fixation. However, if fixation is indicated the fracture can sometimes be directly fixed with trans-pedicular screws rather than fusing C1-C2 and committing to a great loss of neck range of motion. To our knowledge, the actual pullout strength of pedicle screws in C2 is previously unreported. Hence, we developed a laboratory model of hangman’s fracture by applying antero-posterior tensile force in fifty-nine porcine specimens that were stripped of soft tissues. The failure strength of the bone averaged approximately 3200 N, and subsequent fixation averaged to 27.1% of this value. Regardless of pre-hoc expectations, these values indicate that the screw purchase is strong enough to consider continued use of the procedure in repair of hangman’s fracture, fixation to C2 of multi-level constructs, and so forth. Multiple anterior and posterior screw procedures have been tested in the past, but to our knowledge the pullout strength of C2 pedicle screws has not been examined. Because the usage of C2 pedicle screws is growing in popularity, this biomechanical information is pertinent to work in traumatic, degenerative, and reconstructive procedures. Some limitations of the present study are that the specimens were porcine rather than human, and that only fixation to single vertebrae was examined.
Retrograde nailing of femoral shaft fractures has been a routine trauma practice option for approximately five years and may be technically advantaged in many situations. Earlier review of our antegrade experience revealed that 30% of standard nails are recognized to frequently cause pain (30%) and/or heterotopic ossification at the hip; knee pain of unclear etiology was found frequently as well (13%). This review of our preliminary experience with retrograde nails found a 30% frequency of nonspecific knee pain complaints at a mean of thirty-four months. No ectopic ossification was seen and no nails had been removed. The purpose of this study was to review the experience of patients who have undergone retrograde femoral nailing with regard to possible knee pain complaints. Chart and imaging records were reviewed retrospectively. Patients were contacted and interviewed by telephone to determine late pain complaints. From January 2000 through February 2002, eighteen patients were treated for twenty-two femoral shaft fractures. The group included ten males and and eight females of mean age 54.5 years (range, nineteen to ninety years). Treatment was with Synthes retrograde femoral nails, reamed and statically locked, inserted under fluoroscopic control on a radiolucent table using a Tenet™ leg holder. At thirty-four months, all fractures had healed primarily with no appreciable malalignment, no infections and no nonunions. No intraarticular free bodies or ectopic ossification were seen. Eleven patients were asymptomatic with regard to the index injured extremity. Five had mild to moderate pain, generally localized anteriorly, without associated articular symptoms and not requiring any analgesia. Two had severe symptoms of diffuse knee pain with radiographic degenerative changes noted, but these were cases with associated complex tibial plateau fractures to account for it. Even eliminating these two patients, fully five of sixteen patients (30%) without associated periarticular trauma at the knee had mild to moderate nondisabling anterior knee pain complaints after retrograde femoral nailing. The frequency of anterior knee pain complaints after retrograde femoral nailing is significant. Previous authors have found knee pain complaints in 27–29% of cases. We found no evidence of articular derangement in our patients undergoing retrograde femoral nailing in the absence of associated periarticular trauma at the knee, we confirm a 30% frequency of nonspecific knee pain complaints persisting at almost three years after injury. Patients should be made aware that, at intermediate-term follow-up, mild to moderate knee pain may be a result of this fracture treatment.
