Burst fracture

IDENTITAS PASIEN
Nama : Didik Setyawan
JK/ Usia

: L/ 35 th 8 bln

No. RM /PG : 12483196

Diagnosa

: Burst Fracture VL1

frankel grade E

Ruangan

: Ruang Flamboyan F3

Rencan
Tx
immobilization

:body

jacket

Anamnesa
Jk : 14.00(21/2/16)
JD : 17.00
Jatuh terduduk dari ketinggian 4m. Setelah itu
pasien masih bs berjalan. Dibawa dan dirawat
ke RSI selama 2 hari, karena merasa lebih
enak, pasien minta PP. Sekarang pasien datang
kembali karena kesulitan duduk dan nyeri
pungung

Pemeriksaan Fisik
Primary Survey : Clear
Secondary Survey :
Pemeriksaan fisik
O : KU : cukup
Td:130/80 mmhg
36.0 c
GCS: 456

N: 86 x/mnt,

KL : a/i./c./d : Thoraks : sim, ret, C/P dbN

Abd : flat, supel, BU + N
Ext : a. HKM

Rr: 18x/mnt,

T:

Pemeriksaan fisik

Status lokalis :
Lumbal Spine
L : Deformitas -.
Swelling +, jejas
F : nyeri +, Step off
M : ROM terbatas nyeri

 Motorik

Statusneurologi

L25/5
L35/5
L45/5
L55/5
S15/5
Sensorik:Hipoesthesia()
Autonom:TSA(+)
BCR(+)

25/2 /2016

CT Scan 3D Rekonstruksi

HASIL LAB
( 25 February 2016)
HGB : 15.4 (P : 11,016,6 )
PLT : 232 ( 150 -450 )
WBC : 7.03( 3,37-10,0 )
SGOT : 26 ( 15 - 50 )
SGPT : 39 ( 12-78 )
Albumin : 4.04 ( 3,4
-5,0 )
HbsAg : non reaktif

HASIL LAB
(25 February 2016)

PPT
: 12.2 ( 11-14)
APTT: 26.5 ( 25-40)
: 9 ( 7-18)
BUN
: 0,85(0,6-1,3)
SK
Kalium : 3,8 (3,5-5,1)
Natrium : 148 (136-145)
Klorida : 103 (98-107)

Assessment
Burst Fr V. L I Denis type B, Fr E

Initial Management
INLINE IMMOBILISASI
LOG ROLL /2JAM
INJ :
TRAMADOL 3X100
DLM 100ml PZ
Diet bebas TKTP

Treatment
Body jacket immobilization

Ro Post Body jacket

L1
L1

Overview
Definition
Glimpse on Spine Anatomy
Etiology of vertebral fracture
Complications
Classifications of Thoracolumbar
Fractures
Examination and diagnosis
Treatment Options

Definition
Fracture is :

fracture is a break of continuity of bone tissue that is

generally caused by trauma

A burst fracture:
is a type of traumatic spinal injury in which a vertebra breaks
from a high-energy axial load ,

 The thoracolumbar region (T11 to L2) is the commonest

site of burst fractures :
the region forms a transition zone between the relatively
fixed, kyphotic thoracic spine above, and the relatively
mobile, lordotic lumbar spine below which causes
stress forces to concentrate upon the thoracolumbar
vertebral column.

Etiology
Direct trauma with hard objects
Fall from height with a

great deal of force vertically onto

the spine, a vertebra may be crushed.

Pathological conditions

COMPLICATIONS
Gastrointestinal:
regurgitation and aspiration, and hemorrhagic gastritis
are common early complications, occurring as early as
the second day after injury.

Urologic:
Urinary tract infections are recurrent problems in the
long-term management of paralyzed patients

 Pulmonary:
Acute quadriplegic patients are able to inspire only using their
diaphragm because
their abdominal and intercostal muscles are paralyzed.

Skin: Problems associated with pressure ulceration are

common in spinal cordinjured patients
owing to anesthesia of the skin.

Spinal Shock
Spinal shock is defined as spinal cord dysfunction based on
physiologic rather than structural disruption.
Resolution of spinal shock may be recognized when reflex
arcs caudal to the level of injury begin to function again,
usually within 24 hours of injury.

Spinal shock should be distinguished from neurogenic shock,

which refers to hypotension associated with loss of
peripheral vascular resistance in spinal cord injury.

Neurogenic Shock
Neurogenic shock refers to flaccid paralysis, a-reflexia,
and lack of sensation to physiologic spinal cord
shutdown in response to injury.

It is most common in cervical and upper thoracic injuries.

It almost always resolves within 24 to 48 hours
.
The bulbocavernosus reflex (S3S4) is the first to return.

 Initial tachycardia and hypertension immediately after injury

are followed by hypotension accompanied by bradycardia and
venous pooling.
Hypotension from neurogenic shock may be differentiated
from cardiogenic, septic, and hypovolemic shock by the
presence of associated bradycardia, as opposed to
tachycardia.

Treatment is based on administration of isotonic fluids, with

careful assessment of fluid status (beware of overhydration).

Recognizing neurogenic shock as distinct from hemorrhagic

shock is critical for safe initial resuscitation of a trauma
patient.

Treatment of neurogenic shock is pharmacologic intervention

to augment peripheral vascular tone. This vascular tone may
be essential for effective resuscitation.

Fluid overload from excessive fluid volume administration,

typical in treatment of hemorrhagic shock, can result in
pulmonary edema in the setting of neurogenic shock.

Frankel Classification

Grade A: Absent motor and sensory function

Grade B: Absent motor function; sensation present
Grade C: Motor function present but not useful (2/5 or 3/5);
sensation present
Grade D: Motor function present and useful (4/5);
sensation present
Grade E: Normal motor (5/5) and sensory function

Denis Classification of
spinal trauma
Denis divided the vertebral column into three vertical
parallel columns based on biomechanical studies
related to stability post traumatic injury. Instability
occurs when injuries affect two contiguous columns.

The three columns are:

Anterior column
Middle column
Posterior column

Denis Classification of spinal

trauma

BURST FRACTURE
The burst fracture results from failure under axial
load of both the anterior and the middle columns.
originating at the level of one or both end-plates
of the same vertebra.
Five different types of burst fractures can
be described (see the picture below).

 Type A: Fracture of both end-plates. The bone is

retropulsed into the canal.
Type B: Fracture of the superior end-plate. It is
common and occurs due to a combination of
axial load with flexion.
Type C: Fracture of the inferior end-plate.
Type D: Burst rotation. This fracture could be
misdiagnosed as a fracture-dislocation. The he
mechanism of this injury is a combination of axial
load and rotation.
Type E: Burst lateral flexion. This type of fracture
differs from the lateral compression fracture in
that it presents an increase of the interpediculate
distance on anteroposterior roentgenogram.

Subtypes of burst fractures according to

Denis.

Stability
Instability exists with disruption of any
two of the three columns.

Thoracolumbar stability usually

follows the middle column: If it is intact,
then the injury is usually stable.

 Three degrees of instability are recognized:

First degree (mechanical instability):
potential for late kyphosis
Severe compression fractures
Seat belttype injuries
Second degree (neurologic instability):
potential for late neurologic injury
Burst fractures without neurologic deficit
Third degree (mechanical and neurologic
instability):
Fracture-dislocations
Severe burst fractures with neurologic deficit

CLINICAL
EVALUATION
1.Patient assessment: This involves airway,
breathing, circulation, disability, and exposure
(ABCDE).
2 Initiate resuscitation: Address life-threatening
injuries. Maintain spine immobilization. Watch for
neurogenic shock (hypotension and bradycardia)
.
3 Evaluate the level of consciousness and
neurologic impairment: Glasgow Coma Scale

 4 Assess head, neck, chest, abdominal, pelvic, and

extremity injury.

5 Ascertain the history: Assess the mechanism

of injury, witnessed head trauma, movement of
extremities/level of consciousness immediately
following trauma, etc.

6 Physical examination
Back pain and tenderness
Lacerations, abrasions, and contusions on back
Abdominal and/or chest ecchymosis from seat belt injury
(also suggestive of liver, spleen, or other abdominal injury)
7 Neurologic examination
Cranial nerves
Complete sensory and motor examination
Upper and lower extremity reflexes
Rectal examination: perianal sensation, rectal tone
Bulbocavernosus reflex

Evaluasi motorik & sensorik

bulbocavernosus reflex
The bulbocavernosus reflex refers to contraction
of the anal sphincter in response to a squeeze on
the glans penis in a male, the clitoris or the mons
pubis in a female, or a pull on the urethral
catheter.
The absence of this reflex indicates spinal
shock.
The return of the bulbocavernosus reflex
heralds the end of spinal shock and generally
occurs
within 24 hours of the initial injury.
The presence of a complete lesion after spinal
shock has resolved portends a virtually
nonexistent
chance of neurologic recovery.
The bulbocavernosus reflex is not prognostic
for lesions involving the conus medullaris or the
cauda equina.

Dermatomes
Area of skin innervated by sensory axons
within a particular segmental nerve root
Knowledge is essential in determining
level of injury
Useful in assessing improvement or
deterioration

Downloaded from: Rosen's Emergency Medicine (on 29 April 2009 06:34 PM)
2007 Elsevier

Downloaded from: Rosen's Emergency Medicine (on 29 April 2009 06:34 PM)
2007 Elsevier

Myotomes :
Segmental nerve root innervating a muscle
Again important in determining level of injury
Upper limbs:
C5 - Deltoid
C 6 - Wrist extensors
C 7 - Elbow extensors
C 8 - Long finger flexors
T 1 - Small hand muscles

Myotomes :
Segmental nerve root innervating a muscle
Again important in determining level of injury
Upper limbs:
C5 - Deltoid
C 6 - Wrist extensors
C 7 - Elbow extensors
C 8 - Long finger flexors
T 1 - Small hand muscles

 Lower Limbs :
L2

- Hip flexors

L3,4 - Knee extensors

L4,5 S1 - Knee flexion
L5 - Ankle dorsiflexion
S1 - Ankle plantar flexion

Muscle Strength Grading:

5 Normal strength
4 Full range of motion, but less than
normal strength against resistance
3 Full range of motion against gravity
2 Movement with gravity eliminated
1 Flicker of movement
0 Total paralysis

MotorExam
Muscle Grading System (ASIA)

Total paralysis

Palpable or visible contraction

Active movement, full range of motion, gravity eliminated

Active movement, full range of motion, against gravity

Active movement, full range of motion, against gravity and provides some resistance

Active movement, full range of motion, against gravity and provides normal resistance

NT

Patient unable to reliably exert effort or muscle unavailable for testing due to factors such as immobilization, pain on effort
or contracture.

RADIOGRAPHIC EVALUATION

Anteroposterior (AP) and lateral views of the thoracic and

lumbar spine are obtained.
Chest and abdominal radiographs obtained during the initial
trauma survey are not adequate for assessing vertebral
column injury.
Computed tomography (CT) and/or magnetic resonance
imaging (MRI) of the injured area may be obtained to
characterize the fracture further, to assess for canal
compromise, and to evaluate the degree of neural
compression

TREATMENT
A stable burst fracture may be treated without surgery.
stable burst fracture is one in which there is no neurologic
injury.
in which the angulation of the spine is less than 20
degrees .
the amount of spinal canal compromise is less than 50
percent.
Types:
moulded turtle shell type brace (TLSO)
body cast .
This brace is usually worn for eight to twelve weeks in
order to ensure adequate healing.

 - consider NG tube if patient develops an ileus;

- total contact orthosis (w/ or w/o hyperextension) is worn for
4-6 months;
- leg extension must be added for fractures below L3;
- typically patients are allowed out of bed 3 to 14 days
after injury,unless there are other concomitant injuries such as
pelvic frx;
- whereas initial radiographs are taken supine, w/ long term
follow up, radiographsneed to be taken standing to evaluate for
kyphosis;
- middle column can be disrupted at L4 to L5, but if
posterior elementsare intact or have only longitudinal frx, injury
will be stable;
- wt bearing will be tolerated thru these posterior
elements ifpt is able to maintain normal lordosis;
- physiologic wt lordosis prevents excessive wt bearing &
collapsein the middle column;

 A fracture that was thought to be stable

and treated in a brace may begin to
angulate while in the brace.
This may necessitate a later decision to
perform surgery.
Generally All burst fractures require some
type of treatment.

 Surgical treatment if:

A burst fracture is considered unstable if
neurologic injury is present.
angulation of the spine is greater than 20
degrees
there is subluxation or dislocation of the spine.
there is greater than 50 percent spinal canal
compromise.
Unstable burst fractures usually do better with
early surgery
Surgery for burst fractures may be performed
from either an anterior (front) or posterior
(back) approach.

TERIMA KASIH