Aims. No randomized comparative study has compared the extensile lateral approach (ELA) and sinus tarsi approach (STA) for Sanders type 2 calcaneal fractures. This randomized comparative study was conducted to confirm whether the STA was prone to fewer wound complications than the ELA. Methods. Between August 2013 and August 2018, 64 patients with Sanders type 2 calcaneus fractures were randomly assigned to receive surgical treatment by the ELA (32 patients) and STA (32 patients). The primary outcome was development of wound complications. The secondary outcomes were postoperative complications, pain scored of a visual analogue scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) score, 36-item Short Form health survey, operative duration, subtalar joint range of motion (ROM), Böhler’s angle and calcaneal width, and posterior facet reduction. Results. Although four patients (12.5%) in the ELA groups and none in the STA group experienced complications, the difference was not statistically significant (p = 0.113). VAS and AOFAS score were significantly better in the STA group than in the ELA group at six months (p = 0.017 and p = 0.021), but not at 12 months (p = 0.096 and p = 0.200) after surgery. The operation time was significantly shorter in the STA group than in the ELA group (p < 0.001). The subtalar joint ROM was significantly better in the STA group (p = 0.015). Assessment of the amount of postoperative reduction compared with the uninjured limb showed significant restoration of calcaneal width in the ELA group compared with that in the STA group (p < 0.001). Conclusion. The ELA group showed higher frequency of wound complications than the STA group for Sanders type 2 calcaneal fractures even though this was not statistically significant. Cite this article: Bone Joint J 2021;103-B(2):286–293

Aims

To determine the effectiveness of prone traction radiographs in predicting postoperative slip distance, slip angle, changes in disc height, and lordosis after surgery for degenerative spondylolisthesis of the lumbar spine.

Background. Sub-trochanteric fractures are challenging to treat due to various anatomical and biomechanical factors. High tensile forces contribute to the challenge of fracture reduction. Intramedullary nailing has become the treatment of choice. If anatomical reduction is not achieved, any mal-alignment will predispose to implant failure. Open reduction with cerclage wires can add to construct stability and improve the quality of reduction. There is no consensus or classification to guide surgeons on when to perform open reduction, which is often performed intra-operatively when closed reduction fails often with no planning. This can lead to intraoperative delays as theatre staff would not have prepared the correct equipment necessary for open reduction. Objectives. The purpose of this study was to assess outcomes of closed and open reduction of traumatic sub-trochanteric fractures treated with intramedullary nailing and to propose a new classification system to dictate management. Methods. After a review of current classification systems, a 3-tier classification was proposed (Type 1, 2 and 3). Type 1 indicated a transverse fracture, Type 2 was a spiral fracture with an intact posterior and medial wall and a Type 3 fracture were fractures with no posterior and/or medial walls. Over a two-year period (2013–2015), patients with sub trochanteric fractures were classified into Type 1, 2 or 3 injuries based on radiographic appearances by two senior clinicians. Patients with Type 3 injuries were divided into two groups based on whether they were treated with open or closed reduction. A clinical and radiographic review was performed. The primary outcome measure was the incidence of implant failure, whereas secondary outcome measures were related to fracture reduction. Statistical analysis was performed using GraphPad Prism Version 6 (GraphPad Software Inc. California, USA). Fisher's exact test was used for independent categorical data and Mann–U Whitney for continuous nonparametric data. Statistical significance was set at p<0.05. Results. 75 patients had intramedullary nailing for subtrochanteric fractures over the study period with a mean age of 82.6 years. There were 48 patients who had a Type 3 fracture pattern with a deficient medial and/or posterior wall. Reduction was achieved open with cerclage wires in 42% of patients (n=20 and closed in 58% (n=28). Overall there were a total of 18 (37.5%) major complications. In patients treated with closed reduction, 9 patients suffered mechanical complications (6 distal locking screw failures, 3 lag screw cut outs). There was a significantly increased risk of implant failure in patients treated with closed reduction compared to open reduction (p=0.006). No cases with cerclage wire had implant failure. Open reduction with cerclage wires improved the quality of reduction (p=0.0001) compared with closed reduction. There was no significant increase in operating time in patients treated with cerclage wires (p=0.4334). Conclusions. Open reduction with cerclage wires should be considered in patients with Type 3 sub-trochanteric fractures as it has shown to significantly reduce the risk of implant failure and improve the quality of reduction with no significant increase in operating time

Aims

We aimed to identify the pattern of nerve injury associated with paediatric supracondylar fractures of the humerus.

Objectives

Pedicle-lengthening osteotomy is a novel surgery for lumbar spinal stenosis (LSS), which achieves substantial enlargement of the spinal canal by expansion of the bilateral pedicle osteotomy sites. Few studies have evaluated the impact of this new surgery on spinal canal volume (SCV) and neural foramen dimension (NFD) in three different types of LSS patients.

This retrospective study was designed to evaluate the outcomes of re-dislocation of the radial head after corrective osteotomy for chronic dislocation. A total of 12 children with a mean age of 11 years (5 to 16), with further dislocation of the radial head after corrective osteotomy of the forearm, were followed for a mean of five years (2 to 10). Re-operations were performed for radial head re-dislocation in six children, while the other six did not undergo re-operation (‘non-re-operation group’). The active range of movement (ROM) of their elbows was evaluated before and after the first operation, and at the most recent follow-up.

In the re-operation group, there were significant decreases in extension, pronation, and supination when comparing the ROM following the corrective osteotomy and following re-operation (p < 0.05).

The children who had not undergone re-operation achieved a better ROM than those who had undergone re-operation.

There was a significant difference in mean pronation (76° vs 0°) between the non- re-operation and the re-operation group (p = 0.002), and a trend towards increases in mean flexion (133° vs 111°), extension (0° vs 23°), and supination (62° vs 29°). We did not find a clear benefit for re-operation in children with a re-dislocation following corrective osteotomy for chronic dislocation of the radial head.

Cite this article: Bone Joint J 2015;97-B:1582–7.

The December 2013 Spine Roundup³⁶⁰ looks at: Just how common is lumbar spinal stenosis?; How much will they bleed?; C5 palsy associated with stenosis; Atlanto-axial dislocations revisited; 3D predictors of progression in scoliosis; No difference in outcomes by surgical approach for fusion; Cervical balance changes after thoracolumbar surgery; and spinal surgeons first in space.

Purpose of study. Unstable pelvic ring injuries usually occur in polytrauma patients and are associated with high mortality and morbidity. Percutaneous screw fixation of sacro-iliac joint dislocations, fracture-dislocations and sacral fractures is a well-recognised technique first described by Routt and is increasingly gaining popularity. This method is biomechanically comparable to open reduction and internal fixation with plates and screws but offers the advantages of minimally invasive surgical techniques. It is however a technically demanding procedure with reported complications including hardware failure, misplacement of screws, nerve injury and poor posterior reduction. The purpose of the study is to report clinical results of patients treated with closed reduction and percutaneous ilio-sacral screw fixation for unstable pelvic ring fractures by a single surgeon. Methods. A review of prospectively collected data was performed on all patients who had percutaneous sacro-iliac fixation between 2009 and 2012. Thirty five percutaneus sacro-iliac screws were inserted in 30 patients with a mean age of 25.6 years (range 17–62). Fracture types included 10 AO type B, and 20 AO type C. The mean follow-up period was 11.6 months (range 3–38). The complications assessed were screw misplacement, neurovascular complications, hardware breakage and loss of reduction. Results. All patients had a satisfactory initial reduction. One patient (2.8%) had misplacement of a screw with resultant temporary neurological fallout. One patient (2.8%) had screw misplacement without neurological fallout. Both of these patients initially had two screws inserted and the misplaced screws were removed and not reinserted. One patient (2.8%) had screw cut-out with loss of reduction. This screw was removed, open reduction peformed and the screw was re-inserted. Conclusion. The use of percutaneous sacro-iliac screws provides a safe and effective technique for the management of unstable posterior pelvic ring injuries. Our combined complication rate is comparable to published literature. NO DISCLOSURES

The progressive kyphosis and pain in patients with acute thoracolumbar burst fractures treated conservatively so as the recurrent kyphosis after posterior reduction and fixation were associated to disc collapse rather than vertebral body compression. It depends on redistribution of the disc tissue in the changed morphology of the space after fractures of the endplate. The aim of this study is to evaluate the safety and the efficacy of balloon kyphoplasty with calcium phosphate, alone or associated to short posterior instrumentation, in the treatment of acute thoracolumbar burst fractures. Eleven fractures in ten consecutive patients with an average age of 48 years who sustained acute thoracolumbar traumatic burst fractures without neurological deficits were included in this study. The fractures were A1.2 (3), A3.1 (4) and A3.2 (4), according to AO classification. In 7 fractures (A1.2 and A3.1) the kyphopasty was performed alone in order to make the most of efficacy in fracture reduction, anterior and medium column stabilization and, as much as possible, segmental kyphosis correction. In the A3.2 fractures (4), that are unstable, the kyphoplasty was associated to a short posterior instrumentation. To avoid the PMMA long run complications in younger patients, we used a calcium phosphate cement. VAS, SF-36, Roland-Morris questionnaire (RMQ) and Oswestry low back pain disability questionnaire (ODQ) were used to evaluate pain, state of health, functional outcomes and spine disability. To the average follow-up time of 15.5 months (range 8–31) we did not observe statistically significant differences in 7 of 8 SF-36 domains in comparison to general healthy population of same sex and age. At the same follow-up, the spine disability questionnaire showed a functional restriction of 18% (ODQ) and 29,6% (RMQ) being 100% the maximum of disability. No bone cement leakage, no implant failure and no height correction loss were observed in any case. Our data confirm the safety and the efficacy of ballon kyphoplasty with calcium phosphate in the treatment of acute thoracolumbar burst fractures. In this way we can reduce the possible complications resulted from discal space collapse and obtain an early functional restoration. When performed alone, this mini invasive surgical technique offer the advantage of almost immediate return to daily activities. When associated to posterior instrumentation, it decreases the long run complications and allows to reduce the number of stabilized levels, maintaining, in part, the thoracolumbar junction movement

We present our early experience of arthroscopic reduction of the dislocated hip in very young infants with developmental dysplasia of the hip (DDH).

Eight dislocated hips, which had failed attempts at closed reduction, were treated by arthroscopy of the hip in five children with a mean age of 5.8 months (4 to 7). A two-portal technique was used, with a medial sub-adductor portal for a 2.7 mm cannulated system with a 70° arthroscope and an anterolateral portal for the instruments. Following evaluation of the key intra-articular structures, the hypertrophic ligamentum teres and acetabular pulvinar were resected, and a limited release of the capsule was performed prior to reduction of the hip. All hips were reduced by a single arthroscopic procedure, the reduction being confirmed on MRI scan. None of the hips had an inverted labrum. The greatest obstacle to reduction was a constriction of the capsule. At a mean follow-up of 13.2 months (9 to 24), all eight hips remained stable. Three developed avascular necrosis. The mean acetabular index decreased from 35.5° (30° to 40°) pre-operatively to 23.3° (17° to 28°).

This study demonstrates that arthroscopic reduction is feasible using two standardised portals. Longer follow-up studies are necessary to evaluate the functional results.

We present an illustrative case using a modification of the Gaines procedure for the surgical management of patients with spondyloptosis. It involves excision of the inferior half of the body of L5 anteriorly combined with posterior reduction and fusion

Post Traumatic Fixed Thoraco-Lumbar Spinal Deformity may result in pain, regional and or global spinal deformity and neural compromise. Treatment is demanding as osteotomy is required in either anterior alone or both anterior and posterior spinal columns with concomitant reconstruction. This paper reviews 15 years experience with these cases. A retrospective review of 21 patients operated on over 15 years was conducted. Patients were grouped based on original thoraco-lumbar injury pattern – Type A, B and C. Osteotomies and reconstruction were performed from both anterior and posterior approaches dependent upon the pathology. Clinical and radiological follow up for all patients was a minimum of one year. Analysis of outcomes was performed in relation to the clinical and radiological success. Complications were recorded. Sixteen patients had two-column involvement and five had only the anterior column affected. Initial injury patterns were – Type A–9, Type B–4, and Type C–8. Approaches were anterior in six (five in Type A injuries), posterior and anterior in 11 (five two-stage and six three-stage operations), and posterior only in four (one pedicle subtraction osteotomy, one vertebral column resection, one posterior reduction of a dislocation, and one case abandoned after the posterior procedure). Anterior reconstruction was performed with structural iliac crest (two), titanium mesh cages (14) and expanding corpectomy cages (three). All 14 cases requiring posterior stabilisation were treated with pedicle screw based systems. The global assessment of outcome was individualised to the original indication – mechanical pain, deformity, and or symptomatic spinal stenosis. Success (good or excellent outcome) was achieved in 16 cases. Failure (fair or poor outcome) occur red in three completed cases. These three cases had chronic pain (two major, one minor). Two patients had incomplete assessment – one dying of MI in recovery after a technically successful procedure – and one developing deep infection with abandonment of the later stages (see above). There was one non-union. There were no neurological complications. Delayed treatment of late posttraumatic deformity is challenging however good results are achievable with attention to the specific clinical and biomechanical requirements of each case. Technical failure occurred with inadequately radical intervention on one occasion. Major chronic thoracotomy pain occurred in one otherwise technically successful reconstruction

We have reviewed our experience in managing 11 patients who sustained an indirect sternal fracture in combination with an upper thoracic spinal injury between 2003 and 2006. These fractures have previously been described as ‘associated’ fractures, but since the upper thorax is an anatomical entity composed of the upper thoracic spine, ribs and sternum joined together, we feel that the term ‘fractures of the upper transthoracic cage’ is a better description. These injuries are a challenge because they are unusual and easily overlooked. They require a systematic clinical and radiological examination to identify both lesions. This high-energy trauma gives severe devastating concomitant injuries and CT with contrast and reconstruction is essential after resuscitation to confirm the presence of all the lesions. The injury level occurs principally at T4–T5 and at the manubriosternal joint. These unstable fractures need early posterior stabilisation and fusion or, if treated conservatively, a very close follow-up.

Introduction: Reversed oblique subtrochanteric fractures are unstable and pose a surgical challenge. Fixation with Dynamic Hip Screw is prone to collapse with medial displacement and high rate of non or mal union. The use of Proximal Femoral Nails may result in non anatomical reduction which delays union and impedes rehabilitation. PCCP is a percutaneous plate originally designed for fixation of intertrochanteric fractures. However, the plate supports the greater trochanter and can prevent collapse of subtrochanteric fractures and rigidly secure the femoral neck. This study summarized our experience in fixating reversed oblique subtrochanteric fracture with the PCCP technique. Patients and Methods: Between January 2005 and March 2006 26 patients who sustained reversed oblique subtrochanteric fractures (AO-31A3) were consecutively treated with PCCP. Two patients died and were excluded from this study. Patients’ age ranged between 58 and 93 (average 86, median 80). Follow-up was between 6 to 20 months (average 12). All patients were operated on a standard fracture table with the use of posterior reduction device. An attempt to reduce the fracture was done in each case prior to the surgical incision. In the majority of cases the shaft was displaced medially to the greater trochanter. The PCCP plate was introduced percutaneously and the medially displaced shaft was pulled to the plate using the reduction clamp. The rest of the procedure was done according to the regular technique of the PCCP. All patients were instructed to refrain from weight bearing for six weeks after the surgery and then resume full weigh bearing. Follow-up was in the out patient clinic 6 weeks, 3 months and one year after the surgery. Results: Time of surgery varied between 35 to 75 minutes. There were no patients who were planned to undergo this procedure and were diverted to a different modality of fixation. All the procedures were done percutaneously. Anatomic or near anatomic reduction was achieved in all cases. All patients resumed full weigh bearing six weeks after the surgery. All but one fracture united. The patient whose fracture did not unite was blind and fell a few times during rehabilitation and eventually suffered from pull-out of the plate from the femur with breakage of the shaft screws. She underwent revision surgery with bone graft and the fracture united. Follow-up radiograms showed that the reduction was maintained in all but three patients. Medial displacement of 8–15 mm occurred in 3 patients. There were no infections. Conclusions: While there is an ongoing debate among “nailers” vs. “platers” for the fixation of femoral neck fractures, PCCP combines the theoretical advantages of both percutaneous technique and absolute stability. In this study this biological system was found to be a reliable solution for the challenging fixation of reversed oblique (AO-31A3) subtrochanteric fractures, with high union rate, fast recovery and low complication rate

Scoliosis requires three dimensional correction at a global level (curve correction) and at a local one (apical axial derotation) as well as sagittal balance management. Except for in situ contouring, previously reported surgical techniques for scoliosis correction hardly deal with all these issues. The aim of the current study was to evaluate long term clinical and radiological outcomes after in situ contouring in 85 patients with severe scoliosis (Cobb= 40 to 110°). Age influence (adults versus adolescents) and surgical approaches (anterior release and posterior correction and fusion versus posterior correction and fusion only) were also assessed. The results of the study show that the in situ contouring is comparable to other surgical techniques in terms of surgery duration and blood loss. Anterior release proved useful in severe scoliosis correction. No difference in peroperative complications was found between age groups nor between approach groups. However, adolescents recover faster than adults. No difference of revision rates in double approach versus posterior approach populations was found. No statistically significant differences were found between the adolescent and adult populations. The mean overall frontal correction reached 68%. The mean loss of correction amounted 5%. No significant evolution was found in sagittal curvatures, emphasizing the difficulties in restoring physiological curvatures in patients with severe scoliosis. Our results suggest the in situ contouring technique is fully appropriate for severe scoliosis correction, regardless of the patient’s age and approach. Besides it will not result in higher morbidity for one specific population and warrants similar outcome when properly applied.

Purpose of the study: Surgical strategies for high-grade spondylolisthesis are controversial. The main subject of debate concerns the indications for reduction or in situ fusion. We present mid-term results obtained in a series of patients with high-grade spondylolisthesis treated by posterior reduction and fusion. Material and methods: Sixteen patient who had undergone surgery for spondylolisthesis of the superior isthmus > 50% were reviewed. Mean age was 12 years (range 9–16 years). Preoperatively, all patients were symptomatic with lumbalgia, truncated radicular pain, and gait anomalies. Surgical treatment consisted in a single posterior approach, L5 laminectomy, curettage of the L5-S1 disc combined with excision of the S1 dome, L4-S1 instrumented reduction, anterior L5-S1 and posterolateral L4S1 arthrodesis. Postoperative immobilization was achieved with a resin lumbar cast with crural stabilization for three months then a lumbar orthesis for three months. Clinical and radiographic outcome was assessed at 44 months on average (range 10–260 months). Results: Clinically, 14 patients were pain free and had resumed their former activities. One patient complained of intermittent pain. No improvement was observed in one patient. Radiographic results were: displacement 78% (range 52–100%) preoperatively and 30% (8–95%) at last follow-up. The L5S1 displacement angle was 14° kyphosis (range 8–30°) preoperatively and 9° lordosis (range 3–12°) at last follow-up excepting one case with complications. The pelvic incidence was 85° (range 65–100°) preoperatively and 74° (range 50–90°) at last follow-up. Complications: There was one early infection treated by wash-out debridement and antibiotics without removing implants. Disassembly of the implanted material in one patient with a poor clinical result led to complete recurrence and lumbosacral kyphosis. Sacral screw fracture was diagnosed in six patients on average one year after surgery but without any progression or recurrence of the displacement. There were no neurological complications. Discussion and conclusion: Posterior reduction enables restoration of a good sagittal balance. More than the reduction, it is particularly important to restore the lumbosacral junction in a lordosis position to guarantee long-term stability. This technique is a difficult surgical challenge and raises the risk of recurrence and potential neurological complications

Easier patient positioning and less extensive soft tissue dissection have spurred a trend for anterior instrumentation and fusion for C-spine fracture/ dislocations. We present group of forty-six patients treated over an eighteen month period with an anterior approach. There were no permanent approach related complications, infections, hardware failures or graft displacements. One patient had worsened post-operative neurological findings. One patient required additional posterior stabilization for a missed injury. Two patients were not reducible from the front and required posterior reduction and stabilization followed by anterior instrumentation and fusion. All grafts healed within four months of the operation. The purpose of this study was to assess the efficacy of anterior instrumentation and fusion for Cervical Spine fracture/ dislocations. Over an eighteen month period, forty-six out of fifty-two patients with C-spine injuries requiring surgical treatment were followed prospectively. All patients underwent anterior approaches to stabilize and fuse the unstable segments using tricortical bone grafting and application of an anterior plate (CSLP, Synthes). Thirty-eight patients had single level injuries treated with discectomy and fusion. Two patients had two level discecomies. Six patients underwent corpectomy and fusions for fractures of the vertebral bodies. There were no approach related complications such as recurrent laryngeal nerve injuries, oesophageal perforations, vascular injuries or strokes. One patient deteriorated neurologically. All other patients either improved neurologically or remained with their original findings. Two patients required oral antibiotics for superficial infections at the donor site. There were no spine infections, hardware loosening or graft extrusions. All bone grafts healed within four months both clinically and radiologically. Forty-one patients complained of minor or no pain after four months. Five patients continued to have moderate discomfort. One of these patients had a missed injury above his two-level fusion with gradual progression into kyphosis requiring posterior stabilization. Halo vest immobilization and posterior stabilization for C-spine fracture /dislocations have been the treatment of choice for many surgeons. The low complication and failure rate has spurred on a gradual change towards anterior instrumentation and fusion. Our study very strongly supports this trend. We see little indication for the more invasive posterior approach given our present results

Limited access surgery is thought to reduce post-operative morbidity and provide faster recovery of function. The percutaneous compression plate (PCCP) is a recently introduced device for the fixation of intertrochanteric fractures with minimal exposure. It has several potential mechanical advantages over the conventional compression hip screw (CHS). Our aim in this prospective, randomised, controlled study was to compare the outcome of patients operated on using these two devices.

We randomised 104 patients with intertrochanteric fractures (AO/OTA 31.A1–A2) to surgical treatment with either the PCCP or CHS and followed them for one year postoperatively.

The mean operating blood loss was 161.0 ml (8 to 450) in the PCCP group and 374.0 ml (11 to 980) in the CHS group (Student’s t-test, p < 0.0001). The pain score and ability to bear weight were significantly better in the PCCP group at six weeks post-operatively. Analysis of the radiographs in a proportion of the patients revealed a reduced amount of medial displacement in the PCCP group (two patients, 4%) compared with the CHS group (10 patients, 18.9%); Fisher’s exact test, p < 0.02.

The PCCP device was associated with reduced intra-operative blood loss, less postoperative pain and a reduced incidence of collapse of the fracture.

Injuries of the cervical spine can be classified into six categories according to a mechanistic system describing the biomechanical deficiencies incurred in a cervical spine injury. However high velocity flexion compression loads cause multiple contiguous and noncontiguous fractures due to multiple force vectors. A universal classification system cannot be applied. Instability exists if there is greater than 3.5 mm of translation or greater than 11 degrees of angulation as compared to other segments. The degree of ligamentous injury on MRI correlates with instability in patients with lateral mass facet fractures, with rupture of multiple ligaments including the anterior longitudinal, posterior longitudinal, interspinous, or facet capsule. Patients with less than 13 mm of narrowing of the sagittal canal are predisposed to neurologic injury. Vertical compression injuries cause canal occlusion and vertebral column shortening. The timing of surgery in cases of spinal cord injury is controversial. There is no difference in outcome between early (< 72 hours) and late (> 5 days) surgery. However, there remains at least a theoretical benefit to early surgery. Compression-flexion injuries result in loss of the anterior column by compression followed by the posterior column in distraction. The injury is considered unstable if there is a vertical cleavage fracture of the vertebral body or displacement. Treatment includes a cervical orthosis or halo for minor injuries, depending on the degree of kyphosis. Major injuries with displacement should be treated surgically by anterior corpectomy and plate or an anterior/posterior fusion, depending on the degree of posterior instability. The most common level of vertical-compression injuries is at the C6 or C7 level. Minimally displaced injuries can be treated with a collar or halo. Fragmentation and peripheral displacement of the bony fragments needs a halo followed by surgery and this may include an anterior corpectomy and plating. Distraction-flexion injuries may result in facet sub-luxation with less than 25% displacement, or dislocation of one (UFD) or both (BFD) facet joints. When there is 3 mm of translation (25%), the canal is occluded 20–25%. With 6mm of translation (50%), there is 40–50% canal occlusion. MRI can help analyse the soft tissue and ligamentous injuries. In UFD, all posterior ligamentous structures including joint capsule, and half the disc annulus are disrupted. Disruption of ALL and PLL is not necessary to create a UFD. In addition to the posterior structures, the ALL, the PLL and disc are disrupted in BFD. Rupture of the intervertebral disc may include posterior herniation or circumferential disruption. All distraction flexion injuries should be reduced closed. The necessity of a preoperative MRI is undetermined. Preoperative MRI is recommended if there is an unreliable exam due to the patient being uncooperative, if there is neurological worsening with, or failure of closed reduction. If the patient is neurologically intact and closed reduction successful, a posterior cervical fusion is advocated if there is no evidence of an extruded disc on the post reduction MRI. If the closed reduction failed, or MRI indicated, and there is no evidence of a herniated disc, an open posterior reduction followed by fusion is performed. Anterior discectomy with reduction, a graft and a plate is performed for a herniated disc. Compression-extension injuries fail by compression of the posterior elements followed by distraction of the anterior elements. There are unilateral or bilateral fractures of the laminae/neural arch with degrees of displacement. Undisplaced neural arch fractures can be treated with a cervical orthosis or halo. Displaced neural arch fractures are treated with a posterior cervical fusion. There are two stages in the distraction-extension injury group. The anterior longitudinal ligament is disrupted with possibly a transverse fracture of the body. With more major injuries, there is a significant displacement injuring the posterior column. Stage 1 injuries can be treated with a halo and Stage 2 with an anterior decompression and fusion with a plating device. There are two stages to lateral flexion injuries. Minor injuries include asymmetric centrum fracture and a unilateral arch fracture. In addition, there is displacement of the body with contralateral ligamentous failure in major injuries. The treatment for Stage 1 is usually a collar while treatment for Stage 2 is usually a posterior cervical fusion. Posterior stabilization procedures may be performed with wires and cables with or without rods. Posterior clamps usually are not recommended; while plates and screws are preferred. The plates and screws are biomechanically superior to wiring and avoid canal penetration. They are ideal when there is loss of the posterior elements. Pedicle fixation should be considered when operating on the C2 or C7 level. One in five patients may have complete disruption of vertebral artery blood flow. This occurs most commonly with flexion-distraction or flexion-compression injuries. Vertebral artery evaluation is recommended in patients with flexion injuries and symptoms consistent with vertebral artery insufficiency. It is important to understand the mechanism of injury; to understand which elements are compromised. We have to get the appropriate imaging studies, we have to be cognizant of the fact that the vertebral artery may be injured, or there may be an associated herniated disc. We have to understand the degree of instability, which dictates the appropriate treatment and we have to understand the risk benefit of the specific internal fixation systems that we use