Current ATLS protocols dictate that spinal precautions should be in place when a casualty has sustained trauma from a significant mechanism of injury likely to damage the cervical spine. In hostile environments, the application of these precautions can place pre-hospital medical teams at considerable personal risk. It may also prevent or delay the identification of airway problems. In today’s global threat from terrorism, this hostile environment is no longer restricted to conflict zones. The aim of this study was to ascertain the incidence of cervical spine injury following penetrating ballistic neck trauma in order to evaluate the need for pre-hospital cervical immobilisation in these casualties. We retrospectively reviewed hospital charts and autopsy reports of British military casualties of combat, from Iraq and Afghanistan presenting with a penetrating neck injury during the last 5.5 years. For each patient, the mechanism of injury, neurological state on admission, medical and surgical intervention and cause of death was recorded. During the study period, 90 casualties sustained a penetrating neck injury. The mechanism of injury was by explosion in 66 (73%) and from gunshot wounds in 24 (27%). Cervical spine injuries (either cervical spine fracture or cervical spinal cord injury) were present in 20 of the 90 (22%) casualties, but only 6 (7%) actually survived to reach hospital. Four subsequently died from injuries within 72 hours. Only 1 (1.8%) of the 56 survivors to reach a surgical facility sustained an unstable cervical spine injury that required surgical stabilisation, however this patient died as result of a co-existing head injury. Penetrating ballistic trauma to the neck is associated with a high mortality rate. Our data suggests that it is very unlikely that penetrating ballistic trauma to the neck will result in an unstable cervical spine in survivors. In a hazardous environment (e.g. shooting incidents or terrorist bombings), the risk/benefit ratio of mandatory spinal immobilisation is unfavourable and may place medical teams at prolonged risk. In addition cervical collars may hide potential life threatening conditions

Aims. Due to the recent rapid expansion of scooter sharing companies, there has been a dramatic increase in the number of electric scooter (e-scooter) injuries. Our purpose was to conduct a systematic review to characterize the demographic characteristics, most common injuries, and management of patients injured from electric scooters. Methods. We searched PubMed, EMBASE, Scopus, and Web of Science databases using variations of the term “electric scooter”. We excluded studies conducted prior to 2015, studies with a population of less than 50, case reports, and studies not focused on electric scooters. Data were analyzed using t-tests and p-values < 0.05 were considered significant. Results. We studied 5,705 patients from 34 studies. The mean age was 33.3 years (SD 3.5), and 58.3% (n = 3,325) were male. The leading mechanism of injury was falling (n = 3,595, 74.4%). Injured patients were more likely to not wear a helmet (n = 2,114; 68.1%; p < 0.001). The most common type of injury incurred was bony injuries (n = 2,761, 39.2%), of which upper limb fractures dominated (n = 1,236, 44.8%). Head and neck injuries composed 22.2% (n = 1,565) of the reported injuries, including traumatic brain injuries (n = 455; 2.5%), lacerations/abrasions/contusions (n = 500; 7.1%), intracerebral brain haemorrhages (n = 131; 1.9%), and concussions (n = 255; 3.2%). Standard radiographs comprised most images (n = 2,153; 57.7%). Most patients were treated and released without admission (n = 2,895; 54.5%), and 17.2% (n = 911) of injured patients required surgery. Qualitative analyses of the cost of injury revealed that any intoxication was associated with higher billing costs. Conclusion. The leading injuries from e-scooters are upper limb fractures. Falling was the leading mechanism of injury, and most patients did not wear a helmet. Future research should focus on injury characterization, treatment, and cost. Cite this article: Bone Jt Open 2022;3(9):674–683

Claims for personal injury after whiplash injury cost the economy of the United Kingdom more than £3 billion per year, yet only very few patients have radiologically demonstrable pathology. Those sustaining fractures of the cervical spine have been subjected to greater force and may reasonably be expected to have worse symptoms than those with whiplash injuries. Using the neck disability index as the outcome measure, we compared pain and functional disability in four groups of patients who had suffered injury to the cervical spine. After a mean follow-up of 3.5 years, patients who had sustained fractures of the cervical spine had significantly lower levels of pain and disability than those who had received whiplash injuries and were pursuing compensation (p < 0.01), but had similar levels to those whiplash sufferers who had settled litigation or had never sought compensation. Functional recovery after neck injury was unrelated to the physical insult. The increased morbidity in whiplash patients is likely to be psychological and is associated with litigation

Personal injury claims following whiplash injury currently cost the British economy more than £3 billion a year, yet only a minority of patients have radiologically demonstrable pathology. Patients sustaining fractures of the cervical spine have been subjected to greater force and might reasonably be expected to have worse symptoms than those with whiplash injuries. Using the Neck Disability Index, we compared pain and functional disability in four groups of patients who had suffered cervical spine injuries. The four groups were: patients with stable cervical fractures treated conservatively, patients with unstable cervical fractures treated by internal fixation, patients with whiplash injuries seeking compensation, and patients with whiplash injuries not involved in litigation. After a mean follow-up of 3½ years, patients who had sustained cervical spine fractures had significantly lower levels of pain and disability than those who suffered whiplash injuries and were pursuing compensation (p< 0.01), but had similar level to those whiplash sufferers who had settled litigation or had never sought compensation. Functional recovery following neck injury is unrelated to the physical insult. The increased morbidity in whiplash patients is likely to be psychological and is associated with litigation

Introduction. Catastrophic neck injury is rare in rugby, however the consequences are invariably devastating. Schoolboys have previously been identified as a group at risk. This study came about as a result of a recent increase in admissions of schoolboy rugby players to the National spinal injuries unit in Glasgow. Aim. To audit schoolboy rugby admissions to spinal injury units throughout the United Kingdom and Ireland, in doing so to appraise the current state of data collection. To obtain estimates of playing numbers from the Home unions. Method. Retrospective review of all 12 spinal injury units for records of cases subsequent to 1996. Representatives of each of the four home unions were contacted to confirm cases and establish playing numbers. Results. Records were available from 1996 in Scotland and Ireland and from 2000 in England and Wales. Two units collect prospective data, two had easily retrievable data. In the absence of any register data retrieval was challenging elsewhere. Of the 36 cases 24 would be classified as catastrophic 12 as near misses. The median age for injury was 17. 51% of injuries occurred in the tackle, 35% in the scrum. 92% of scrum injuries involved neurological damage, 61% with complete neurological loss at presentation, 8% with no neurological injury. Tackle injuries were associated with neurological damage in 42%, 26% with complete lesions and no neurological injury in 57%. Estimates for playing numbers (U18 inclusive) approximate to Scotland 19,000, Wales 30,000, Ireland 40,000 and England 1,200,00. Conclusion. •. A persistent number of schoolboys were injured through the study period. •. Recording of serious neck injuries is inconsistent through the United Kingdom and Ireland. •. The numbers injured in Scotland were disproportionate in view of the relative playing populations. •. Whilst less frequent, scrum injuries were more often associated with spinal cord injury

Injury of the neck may result when a motor vehicle is run into from behind; such injury is frequently the cause of prolonged disability and litigation. We report a series of 61 patients with these injuries. A classification, based upon the presenting symptoms and physical signs has been evolved. This classification is shown to be a reliable basis for formulating a prognosis. Factors which adversely affect prognosis include the presence of objective neurological signs, stiffness of the neck, muscle spasm, and pre-existing degenerative spondylosis.

Background. A cautious outlook towards neck injuries is the norm to avoid missing cervical spine injuries. Consequently there has been an increased use of cervical spine radiography. The Canadian Cervical Spine rule was proposed to reduce the unnecessary use of cervical spine radiography in alert and stable patients. Our aim was to see whether applying the Canadian Cervical Spine rule reduced the need for cervical spine radiography without missing significant cervical spine injuries. Methods. This was a retrospective study conducted in 2 hospitals. 114 alert and stable patients who had cervical spine radiographs done for suspected neck injuries were included in the study. Data on patient demographics, Canadian Cervical Spine rule, cervical spine radiography results and further visits after discharge were recorded. Results. 14 patients were included in the high risk category according to the Canadian Cervical Spine rule. 100 patients were assessed according to the low risk category. If the Canadian Cervical Spine rule was applied, there was a significant reduction in cervical spine radiographs (p<0.001) as 86/100 patients (86%) in the low risk category would not have needed cervical spine radiograph. 2/100 patients who had significant cervical spine injuries would have been identified when the Canadian Cervical Spine rule was applied. Conclusion. Applying the Canadian Cervical Spine rule for neck injuries in alert and stable patients reduced the use of cervical spine radiographs without missing out significant cervical spine injuries. This relates to reduction in radiation exposure to patients and cost benefits

Background: A cautious outlook towards neck injuries has been the norm to avoid missing cervical spine injuries. Consequently there has been an increased use of cervical spine radiography. The Canadian Cervical Spine rule was proposed to reduce the unnecessary use of cervical spine radiography in alert and stable patients. Our aim was to see whether applying the Canadian Cervical Spine rule reduced the need for cervical spine radiography without missing significant cervical spine injuries. Methods: This was a retrospective study conducted in 2 hospitals. 114 alert and stable patients who had cervical spine radiographs done for suspected neck injuries were included in the study. Data on patient demographics, Canadian Cervical Spine rule, cervical spine radiography results and further visits after discharge were recorded. Results: 14 patients were included in the high risk category according to the Canadian Cervical Spine rule. 100 patients were assessed according to the low risk category. If the Canadian Cervical Spine rule was applied, there was a significant reduction in cervical spine radiographs (p< 0.001) as 86/100 patients (86%) in the low risk category would not have needed cervical spine radiograph. 2/100 patients who had significant cervical spine injuries would have been identified when the Canadian Cervical Spine rule was applied. Conclusion: Applying the Canadian Cervical Spine rule for neck injuries in alert and stable patients reduced the use of cervical spine radiographs without missing out significant cervical spine injuries. This relates to reduction in radiation exposure to patients and cost benefits

Objectives. To evaluate the neck strength of school-aged rugby players, and to define the relationship with proxy physical measures with a view to predicting neck strength. Methods. Cross-sectional cohort study involving 382 rugby playing schoolchildren at three Scottish schools (all male, aged between 12 and 18 years). Outcome measures included maximal isometric neck extension, weight, height, grip strength, cervical range of movement and neck circumference. Results. Mean neck extension strength increased with age (p = 0.001), although a wide inter-age range variation was evident, with the result that some of the oldest children presented with the same neck strength as the mean of the youngest group. Grip strength explained the most variation in neck strength (R. 2. = 0.53), while cervical range of movement and neck girth demonstrated no relationship. Multivariable analysis demonstrated the independent effects of age, weight and grip strength, and the resultant model explained 62.1% of the variance in neck strength. This model predicted actual neck strength well for the majority of players, although there was a tendency towards overestimation at the lowest range and underestimation at the highest. Conclusion. A wide variation was evident in neck strength across the range of the schoolchild-playing population, with a surprisingly large number of senior players demonstrating the same mean strength as the 12-year-old mean value. This may suggest that current training regimes address limb strength but not neck strength, which may be significant for future neck injury prevention strategies. Age, weight and grip strength can predict around two thirds of the variation in neck strength, however specific assessment is required if precise data is sought

Abstract. Objectives. Catastrophic neck injuries in rugby tackling are rare (2 per 100,000 players per year) with 38% of these injuries occurring in the tackle. The aim of this study was to determine the primary mechanism of cervical spine injury during rugby tackling and to highlight the effect of tackling technique on intervertebral joint loads. Methods. In vivo and in vitro experimental data were integrated to generate realistic computer simulations representative of misdirected tackles. MRI images were used to inform the creation of a musculoskeletal model. In vivo kinematics and neck muscle excitations were collected during lab-based staged tackling of the player. Impact forces were collected in vitro using an instrumented anthropometric test device during experimental simulations of rugby collisions. Experimental kinematics and muscle excitations were prescribed to the model and impact forces applied to seven skull locations (three cranial and four lateral). To examine the effects of technique on intervertebral joint loads the model's neck angle was altered in steps of 5° about each rotational axis resulting in a total of 1,623 experimentally informed simulations of misdirected tackles. Results. Neck flexion angles and cranial impact locations had the largest effects on maximal compression, anterior shear and flexion moment loads. During posterior cranial impacts compression forces and flexion moments increased from 1500 to 3200 N and 30 to 60 Nm respectively between neck angles of 30° extension and 30° flexion. This was more evident at the C5-C6 and C6-C7 joints. Anterior shear loads remained stable throughout neck angle ranges however during anterior impacts they were directed posteriorly when the neck was flexed. Conclusions. The combination of estimated joint loads in the lower cervical spine support buckling as the primary injury mechanism of anterior bilateral facet dislocations observed in misdirected rugby tackles and highlights the importance of adopting a correct tackling technique. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Introduction A tertiary referral centre for spinal injuries will receive referrals from many different centres. The format and quality of imaging that accompanies these patients varies considerably. Methods Two cases are reported where initial imaging demonstrated unstable cervical spine injuries that were subsequently found to be normal. The cases and images are presented. Results A 19-year old female was transferred to our unit having fallen off a wall and sustaining a neck injury. The accompanying CT scan showed a C6 vertebral body fracture with bilateral fracture-subluxations of the facet joints. As there was a discrepancy with the clinical findings, a repeat fine cut CT scan was performed which was completely normal. The previous appearances were entirely due to artifact throughout the scan. A 46-year old male fell down stairs sustaining a neck injury and loss of consciousness. A CT scan of his cervical spine demonstrated an odontoid peg fracture (type II). Subsequent imaging showed the odontoid peg was completely normal. The initial CT appearances were entirely due to artifact caused by the patients’ tongue piercing!. Discussion CT scans are used with increasing frequency in the assessment of cervical spine injuries. In both these case the abnormalities present on the initial scans were entirely due to artifact that was reciprocated through the entire CT scans. Reporting these cases reinforces the importance of careful clinical examination and correlation with appropriate investigations. If there is a discrepancy between the clinical and radiological findings then it is essential that further imaging is performed

The April 2024 Foot & Ankle Roundup³⁶⁰ looks at: Safety of arthroscopy combined with radial extracorporeal shockwave therapy for osteochondritis of the talus; Bipolar allograft transplantation of the ankle; Identifying risk factors for osteonecrosis after talar fracture; Balancing act: immediate versus delayed weightbearing in ankle fracture recovery; Levelling the field: proximal supination osteotomy’s efficacy in severe and super-severe hallux valgus; Restoring balance: how adjusting the tibiotalar joint line influences movement after ankle surgery.

Introduction: Injuries to the urinary tract are a well known complication in patients with pelvic trauma. A severe urological injury frequently results in adverse long term outcome and prolonged disability. We present a review of the results of management of urological injury and the impact on final outcome in patients with pelvic fractures. Patients: Out of 554 patients admitted to our center with pelvic fracture, 39 with injury to the urinary tract were identified – 8 females and 31 males (study group). The mean age of the patients was 30.9 yrs (range 15 to 71 yrs) and the mean ISS was 12.9 (range 9 to 22). Two patients had a skin wound communicating with fracture hematoma. Seven (18 %) had upper tract injury, 6 (15.4 %) had extraperitoneal bladder rupture, 9 (23.1 %) had intraperitoneal rupture, 3 (7.6 %) had bladder neck injury and 14 (35.9 %) had urethral injury. The mechanism and type of injury, initial management, timing of urological intervention, orthopaedic procedure complications and long term result in terms of incontinence, stricture and sexual dysfunction were assessed. All patients were assessed based on Orthopaedic, urological and the Euroqol (EQ5D) generic health questionnaire and compared to age and sex matched control group of 47 patients with similar pelvic injuries and ISS but no urological injury. The mean follow up period was 2.3 years. Results: Upper urinary tract injuries: All were managed nonoperatively and had a uniformly good outcome except one patient who had a traumatic renal vein thrombosis and required nephrectomy. Three had acetabular fractures (one ant column and 2 both column fractures) and 4 had pelvic ring injuries (2 AP, 2 LC). Six were operated with av. time delay between injury and surgery being 7.1 days. We consider the urological injury related to the general trauma rather than the specific pelvic injury. Lower tract injuries: 14 out of 15 patients with bladder rupture had a repair of bladder within 24 hours of arrival at our center. One with a small extra-peritoneal tear was managed nonoperatively. Seven had LC injury, 6 had ARC and 2 had acetabular fractures (both column). One of the acetabulum fractures was managed by fixation and bladder repair on the day of arrival and the other had secondary congruence, which was not operated. Pelvic ring injuries were managed by internal and/or external fixation as appropriate. The average time delay between injury and surgery was 1.8 days. One patient with AP2 fracture died after 3 weeks due to severity of associated visceral injuries. Three patients reported failure of erection. All three patients with bladder neck injury had an APC fracture. Two were managed by immediate repair (day 1 and day 2) and had normal continence. One repair was delayed due to delay in transfer and was done on the 4th day. He developed faecal and urinary incontinence and loss of sexual function. Thirteen males had urethral injury – average age 37 yrs (range 19 to 70 years). Five had APC and five LC pelvic ring injuries, three had acetabular fractures. Three patients had a primary urethrostomy for a gap defect and two of these developed erectile dysfunction. Two were referred late to our center and were managed by continent urinary diversion. The rest had a catheter railroaded to maintain alignment of the two urethral ends and delayed repair was done for three patients. One patient in this group had sexual dysfunction while 5 developed a stricture. The only female patient with urethral injury had an open tilt fracture associated with urethral tear. The control group had 7 acetabular fractures, 19 AP compression, 17 lateral compression injuries and 4 vertical shear injuries. Four were managed nonoperatively. None of these had an open fracture. The average time delay between injury and surgery was 2.2 days. We found no significant difference between the study and the control group in the outcome on comparing patients with upper tract and bladder injuries but the urethral injury group had a poorer result in all 5 parameters of the EQ5D. Conclusions: Upper tract and bladder injuries in the context of pelvic trauma can be successfully managed as described, they do not add significant morbidity compared to the control group. In contrast urethral injuries significantly affected the outcome after pelvic fracture in terms of general health and return to normal function. Early management with primary alignment at the time of pelvic stabilisation and a delayed repair if required produced good results. A high index of suspicion and routine retrograde urethrograms would reduce risk of missed or iatrogenic injury. A team approach is required to achieve optimum results

We report a 30-year-old patient who was involved in a high-velocity road traffic accident and developed a left-sided hemiparesis, which was noted in the post-operative period following bilateral femoral intramedullary nailing. CT scanning of the brain revealed infarcts in the right frontal and parietal lobes in the distribution of the right middle cerebral artery. CT angiography showed occlusion of the right internal carotid artery consistent with internal carotid artery dissection. He was anticoagulated and nine months later was able to walk independently. An awareness of this injury is needed to diagnose blunt trauma to the internal carotid artery. Even in the absence of obvious neck trauma, carotid artery dissection should be suspected in patients with a neurological deficit in the peri-operative period

Serious neck injury in rugby football is becoming more common, especially in schoolboys. We report five who presented with spinal cord damage between 1977 and 1983, two in the 1982-83 season. The mechanisms of injury, the treatment, and the outcome are discussed. We suggest measures to reduce the incidence of this most serious injury and draw attention to the appropriate management in the critical phase directly after injury

Neck injury of the whiplash type may lead to the cranial symptoms of the Barre-Lieou syndrome. Forty patients with this syndrome and 40 without it were investigated by a variety of imaging techniques. There was a clear correlation between root sleeve defects at C3/4 shown by special oblique myelographic views and cranial symptoms. Good results were obtained by anterior cervical discectomy and fusion at C3/4 in 21 cases. It is suggested that the syndrome may result from irritation of the sympathetic nervous supply at this level

Traumatic atlanto-axial subluxation is a rare injury which may not be revealed on routine radiographs, especially when there is muscle spasm. We report on seven patients with atlanto-axial subluxation as a result of neck injury; only two of them had significant head injuries. Three patients presented with a neurological deficit attributable to the injury, one immediate and two with delayed onset. Traumatic atlanto-axial instability, occurring in an otherwise healthy patient, has a potential for neurological disaster; early consideration of operative treatment is indicated

1. Seventy-five injuries of the cervical spine are reported. Fifty-three were dislocations and fracture-dislocations involving the third to the seventh segments. 2. The importance of careful examination in all neck injuries is stressed. 3. The injuries are divided into stable and unstable types and the causation of the instability is discussed. 4. Plaster immobilisation for more than six months failed in some patients to prevent recurrence of dislocation. 5. Operative treatment was advised in all cases of dislocation, the spine being wired and grafted with iliac bone. This prevents recurrence and shortens the period of convalescence