Transcript CASE PRESENTation ON SPINE FRACTURE

PRESENTED BY
SHERIN JOHN
PHYSICAL ASSESMENT
General Appearance
The patient is 25 yrs of age ,male .
He is conscious and oriented, with the following
vital signs;
BP
:110/70mm of Hg
PR
:92bpm
RR
:24cpm
Temp :36.80
SPO2 :96%
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



NAME
: Mr. M F A
AGE/ SEX : 25 years /Male
MR NO
:192406
DATE OF ADMISSION :18/12/2012
DIAGNOSIS :Fracture D7
SURGERY :Posterior Fixation Of D6 – D8
ON 18/12/2012
Skin
•Fair complexion
•Abrations present
Head
•Cut wound over scalp and swelling present
Consciousness and Orientation
•Awake and conscious and GCS is 15/15 on
admission.
•Oriented to persons(knows some of his
relatives)
•Place (he can tell where he is)
•Time(knows the day,date,and always asking
time.
Eyes
•Right eye is normal
•Left eye lid hematoma present
•Pupils equally round and reactive to light
•Conjunctiva,cornea and lens normal
Ears
•No discharges found
•Hearing normal
Nose
•Pink nasal mucosa
•No unusual nasal discharges
•No tenderness in sinuses
Mouth
•Pink and moist oral mucosa and free of swelling and
lesions
Neck and Throat
•No palpable lymph nodes
•No masses and lesions seen
Chest and Lungs
•Pain present in right lower chest and
breathing difficulty
•After investigations;ct chest and x-ray
chest shows haemopneumothorax with rib
fracture and right side ICD inserted
Cardio Vascular
•ECG reports shows clear and no changes
noted
Gastro Intestinal
•No Tender Ness of Abdomen and it is soft.
Genito Urinary
•With Foley catheter fr.18
Musculoskeletal
•Unable to move his left arm
•Has pain during Examination
•Cannot perform ADL
•Numbness over both lower limbs
Neurologic
•Patient is mentally alert and oriented with
circumstances.
•Able to follow Commands
•GCS is 15/15
•Right radial nurve injury.
PATIENT HISTORY
Past Medical History
•There is no history of surgeries done
Present Medical History
•Patient brought to ER by Red crescent c/o
difficulty in breathing and pain in the right
lower chest and back pain and numbness in
both lower limbs due to RTA on 18-12-12
and patient was admitted in icu and he
underwent posterior spine fixation of D6-D8
on the same day
VITAL SIGNS
•BP
:110/70mm of Hg
•PR
:92bpm
•RR
:24cpm
•Temp :36.80
•SPO2 : 96%
INVESTIGATIONS DONE FOR THE PATIENT
•CT scan Brain without contrast
•CT scan chest and abdomen with contrast
•CT scan cervical spine,thoracic spine and lumbar
spine.
•Blood Investigations
TREATMENT
Surgical Intervention: Posterior spine fixation of D6D8
Medications
Action
Side effects
Inj.Ceftriaxone
2gm iv bd
Inj.Amikacin
500mg iv bd
Antibiotics
Inj.flagyle 1000mg
bd
Antibiotics
Convulsive seizure,
head ache,fever
Inj.solumedrole
2gm iv bd
Corticosteroid
hormone
Heart burn
,sweating
Inj.risek40mg iv
od
Inj.perfelgan sos
Proton pump
inhibitor
Analgesic
Diarrhea,rashes,na
usea
Faster heart
rate,itching,redness
of skin
Antibiotics
Nausea,
diarrhea,headache
Seizure,diarrhea,
rashes
LAB REPORTS
TEST on 18/12/12
CBC
HB
HCT
RBC
PLT
sodium
pottassium
PT
APTT
INR
Rh typing
RESULT
REFERENCE
RANGE
11.6g/dl
33.8g/dl
3.71
13.7-17.5g/dl
40.1-51.0g\dl
4.63-6.08 *10^6/ul
268
140
4.0
13.4
29.2
1.3
163-337/ul
135-150 mmol/l
3.5-5.0mm0l/l
10.0-17.0sec
26.1-36.3sec
2.4theraputic
O+ve

The spinal column is one of the primary support
structures in the human skeleton. our spine is made up of
a column of vertically stacked bones, called vertebrae,
which surround and protect the spinal cord. There are 33
separate vertebrae that are divided into five segments:
cervical, thoracic, lumbar, sacral and coccyx. Each of the
vertebra lines up much like blocks on top of one other.
There are discs between each vertebra, which act as shock
absorbers between each bony vertebra. The vertebrae,
while interconnected, operate relatively independently,
which gives your back a degree of flexibility while enabling
it to provide a tremendous amount of support.
Running down the spine, and protected by the
vertebra, are some of the most important
components of the human body's nervous system. In
particular, the spinal cord is protected by an opening
in the back of the vertebrae called the foramen.
Other nerves extend from the spinal cord through
spaces between each vertebra.
The Disc
In between the vertebrae are the discs. The discs act
as a cushion between the vertebral bones. Each disc
consists of a soft jelly-like center and a tough outer
material that holds the disc's shape and position in
the spine.
On the back of the vertebrae are two sets of
facets; one set at the top of the vertebra (called
the "superior facets") and one set at the bottom
(called the "inferior facets"). The superior facets
face up and make contact with the downward
facing inferior facets on the next vertebra forming
the facet joint. The facet joints are the points at
which two vertebrae contact each other. The facet
joints act as a hinge on which two vertebrae move
when bending forward and backward.
The Ligaments, Tendons and Muscles
A variety of soft tissue holds the entire spinal column in
place and allows it to flex. Ligaments and tendons are
fibrous bands of tissue that attach to bone. Ligaments
connect two or more vertebrae and help stabilize the spine.
Tendons attach muscle to bone allowing the spine to move
when the muscles contract and relax.
Spinal Blood Supply
The function of the vascular system is to nourish each cell
in the body. This includes the vertebral column, spinal cord,
neural elements, muscles, and other related structures.
Blood and Its Importance
Blood contains plasma (fluid), red blood cells
(erythrocytes), white bloods cells, and platelets.
Vascular system
of the spine
Red = Artery
Blue = Vein
1 Carotid Artery
2 Aortic Arch
3 Thoracic Aorta
4 Abdominal Aorta
5 Iliac Artery
6 Internal Jugular
Vein
7 Superior Vena
Cava
8 Inferior Vena Cava
9 Iliac Vein
Arteries Supplying Spinal Column
Arteries
Region
Vertebral
Cervical (Head)
Basilar
Basilar Cervical (Head)
Carotid
Cervical/Thoracic
Thoracic Aorta
Thoracic cavity
Intercostal
Thoracic wall
Spinal Branch
Thoracic/Lumbar
Anterior Spinal
Thoracic/Lumbar
Abdominal Aorta
Thoracic/Lumbar cavities
Posterior Branch
Thoracic to Sacrum
Lumbar Segmental
Lumbar
Left Common Iliac
Lumbar/pelvic organs, legs
Right Common Iliac
Lumbar/pelvic organs, legs
Segmental
Lumbar to Sacrum
Middle Sacral
Lumbosacral
Iliolumbar
Lumbosacral
Internal Iliac
Lumbosacral
Veins Supplying Spinal Column
Veins
Internal Jugular
External Jugular
Superior Vena Cava
Thoracic Segmental
Inferior Vena Cava
Azygous
Hemiazygous
Lumbar Segmental
Left Common Iliac
Right Common Iliac
Batson’s Plexus
Common Iliac
Region/Comment
Cervical – returns blood from the head
Cervical – returns blood from the head
Cervical/Upper Thoracic Returns blood
from upper body to heart
Thoracic
Thoracic/Lumbosacral Returns blood
from lower body to heart
Lumbar – Returns blood from lower
body when inferior vena cava obstructed
Lumbar
Lumbar
Lumbar
Lumbar
Lumbar – Valveless vein, provides
alternate route for blood return to heart
Lumbosacral
Spinal Cord and Nerve Roots
The spinal cord originates in the brain, exiting through a hole at the skull base
called the foramen magnum and coursing through the spinal canal of the
cervical, thoracic and upper lumbar spine before ending most commonly
between the first and second lumbar vertebrae.
Nerve roots exiting from the lower end of the spinal cord continue as a
structure called the cauda equina, or horse's tail, to provide nerves to the lower
trunk, legs, bowels, bladder and sexual organs.
Spinal Cord and Nerve Roots
The spinal cord originates in the brain, exiting through a
hole at the skull base called the foramen magnum and
coursing through the spinal canal of the cervical,
thoracic and upper lumbar spine before ending most
commonly between the first and second lumbar
vertebrae.
Nerve roots exiting from the lower end of the spinal cord
continue as a structure called the cauda equina, or
horse's tail, to provide nerves to the lower trunk, legs,
bowels, bladder and sexual organs. Damage to the
nerves can cause pain, tingling, numbness or
weakness in the area where the nerve travels.
Damage to the spinal cord at any level can cause
many symptoms, from paralysis to numbness.
Functions of the Spine
The three main functions of the spine are to:
•Protect the spinal cord, nerve roots and several of the body’s
internal organs.
•Provide structural support and balance to maintain an upright
posture.
•Enable flexible motion.
Regions of the Spine
Typically, the spine is divided into four main regions: cervical,
thoracic, lumbar and sacral. Each region has specific
characteristics and functions.
Cervical Spine
The neck region of the spine is known as the Cervical Spine. This
region consists of seven vertebrae, which are abbreviated C1
through C7 (top to bottom). These vertebrae protect the brain
stem and the spinal cord, support the skull, and allow for a wide
range of head movement.
The first cervical vertebra (C1) is called the Atlas. The Atlas is ringshaped and it supports the skull. C2 is called the Axis. It is circular in
shape with a blunt peg-like structure (called the Odontoid Process or
“dens”) that projects upward into the ring of the Atlas. Together, the
Atlas and Axis enable the head to rotate and turn. The other cervical
vertebrae (C3 through C7) are shaped like boxes with small spinous
processes (finger-like projections) that extend from the back of the
vertebrae.
Thoracic Spine
Beneath the last cervical vertebra are the 12 vertebrae of the Thoracic
Spine. These are abbreviated T1 through T12 (top to bottom). T1 is
the smallest and T12 is the largest thoracic vertebra. The thoracic
vertebrae are larger than the cervical bones and have longer spinous
processes. In addition to longer spinous processes, rib attachments add
to the thoracic spine’s strength. These structures make the thoracic
spine more stable than the cervical or lumbar regions. In addition, the
rib cage and ligament systems limit the thoracic spine’s range of
motion and protect many vital organs.
Lumbar Spine
The Lumbar Spine has 5 vertebrae abbreviated L1 through L5
(largest). The size and shape of each lumbar vertebra is designed to
carry most of the body’s weight. Each structural element of a
lumbar vertebra is bigger, wider and broader than similar
components in the cervical and thoracic regions.
The lumbar spine has more range of motion than the thoracic spine,
but less than the cervical spine. The lumbar facet joints allow for
significant flexion and extension movement but limit rotation.
Sacral Spine
The Sacrum is located behind the pelvis. Five bones (abbreviated S1
through S5) fused into a triangular shape, form the sacrum. The
sacrum fits between the two hipbones connecting the spine to the
pelvis. The last lumbar vertebra (L5) articulates (moves) with the
sacrum.
Immediately below the sacrum are five additional bones, fused
together to form the Coccyx (tailbone).
The Pelvis and the Skull
Although not typically viewed as part of the spine, the pelvis and the
skull are anatomic structures that closely inter-relate with the spine,
and have a significant impact on the patient’s balance.
Spinal Curves
When viewed from the front (Coronal Plane) the healthy spine is
straight. (A sideways curve in the spine is known as scoliosis.) When
viewed from the side (Sagittal Plane) the mature spine has four
distinct curves. These curves are described as being either kyphotic or
lordotic.
A kyphotic curve is a convex curve in the spine (i.e. convexity towards
the back of the spine). The curves in the thoracic and sacral spine are
kyphotic.
A lordotic curve is concave (i.e. concavity towards the back of the
spine), and is found in the cervical and lumbar levels of the spine.
Vertebral Structures
All vertebrae consist of the same basic elements,
with the exception of the first two cervical
vertebrae.
The outer shell of a vertebra is made of cortical
bone. This type of bone is dense, solid and strong.
Inside each vertebra is cancellous bone, which is
weaker than cortical bone and consists of loosely
knit structures that look somewhat like a
honeycomb. Bone marrow, which forms red blood
cells and some types of white blood cells, is found
within the cavities of cancellous bone.
Vertebrae consist of the following common elements:
Veterbral Body
The largest part of a vertebra. If looked at from above it generally
has a somewhat oval shape. When looked at from the side, the
vertebral body is shaped like an hourglass, being thicker at the
ends and thinner in the middle. The body is covered with strong
cortical bone, with cancellous bone within.
Pedicles
These are two short processes, made of strong cortical bone, that protrude
from the back of the vertebral body.
Laminae
Two relatively flat plates of bone that extend from the pedicles on either side
and join in the midline.
Processes
There are three types of processes: articular, transverse and spinous. The
processes serve as connection points for ligaments and tendons.
Endplates
The top (superior) and bottom (inferior) of each
vertebral body is “coated” with an endplate.
Endplates are complex structures that “blend” into
the intervertebral disc and help support the disc.
Intervertebral Foramen
The pedicles have a small notch on their upper
surface and a deep notch on their bottom surface.
When the vertebrae are stacked on top of each
other the pedicle notches form an area called the
intervertebral foramen. This area is of critical
importance as the nerve roots exit from the spinal
cord through this area to the rest of the body.
Facet Joints
The joints in the spinal column are located posterior to the
vertebral body (on the backside). These joints help the spine to
bend, twist, and extend in different directions. Although these
joints enable movement, they also restrict excessive movement such
as hyperextension and hyper-flexion (i.e. whiplash).
Each vertebra has two facet joints. The superior articular facet faces upward
and works like a hinge with the inferior articular facet (below).
Like other joints in the body, each facet joint is surrounded by a capsule of
connective tissue and produces synovial fluid to nourish and lubricate the
joint. The surfaces of the joint are coated with cartilage that helps each joint
to move (articulate) smoothly.
Intervertebral Discs
Between each vertebral body is a "cushion" called an intervertebral disc. Each
disc absorbs the stress and shock the body incurs during movement and
prevents the vertebrae from grinding against one another. The intervertebral
discs are the largest structures in the body without a vascular supply.
Through osmosis, each disc absorbs needed nutrients.
Each disc is made up of two parts: the annulus fibrosis and the nucleus
pulposus.
Annulus Fibrosus
The annulus is a sturdy tire-like structure that encases a gel-like
center, the nucleus pulposus. The annulus enhances the spine’s
rotational stability and helps to resist compressive stress.
The annulus consists of water and layers of sturdy elastic
collagen fibers. The fibers are oriented at different angles
horizontally similar to the construction of a radial tire. Collagen
gains its strength from strong fibrous bundles of protein that are
linked together.
Nucleus Pulposus
The center portion of each intervertebral disc is a filled with a
gel-like elastic substance. Together with the annulus fibrosus, the
nucleus pulposus transmits stress and weight from vertebra to
vertebra.
Like the annulus fibrosus, the nucleus pulposus consists of water,
collagen and proteoglycans. However, the proportion of these
substances in the nucleus pulposus is different. The nucleus
contains more water than the annulus.
A compression fracture of the lumbar (lower) spine.
There are different types of spinal fractures. Doctors
classify fractures of the thoracic and lumbar spine
based upon pattern of injury and whether there is a
spinal cord injury. Classifying the fracture patterns
can help to determine the proper treatment. The three
major types of spine fracture patterns are flexion,
extension, and rotation.
Flexion Fracture Pattern
Compression fracture. While the front (anterior) of the
vertebra breaks and loses height, the back (posterior)
part of it does not. This type of fracture is usually
stable and rarely associated with neurologic problems.
Axial burst fracture. The vertebra loses height on both
the front and back sides. It is often caused by a fall
from a height and landing on the feet.
Extension Fracture Pattern
Flexion/distraction (Chance) fracture. The vertebra is
literally pulled apart (distraction). This can happen in
accidents such as a head-on car crash, in which the
upper body is thrown forward while the pelvis is
stabilized by a lap seat belt.
Rotation Fracture Pattern
Transverse process fracture. This fracture is uncommon
and results from rotation or extreme sideways (lateral)
bending, and usually does not affect stability.
A SIDE-VIEW OF A FRACTUREDISLOCATION OF A THORACIC
VERTEBRA.
A MAGNETIC RESONANCE IMAGING (MRI)
SCAN OF A FRACTURE-DISLOCATION IN
THE THORACIC SPINE. NOTE THE
DISRUPTION OF THE SPINAL CORD.
Surgical treatment for thoracic spine fracture-dislocation without
neurological deficit. The surgical treatment depends on the type of spinal
injury and the level .
•Posterior spine fixation with screw and rods and bone grafting
•Posterior spine fixation with screw ,rod and cage and bone grafting
•Posterior and anterior decompression and stabilization with implants
The transitional anatomy of the thoracolumbar spine
makes it vulnerable to injury from high-energy
vehicular crashes and falls. The definitive management
of patients with thoracolumbar spinal fractures is
dependent on the presence and extent of neurologic
injury, the presence and magnitude of acute deformity,
and an estimate concerning spinal stability. It is well
established that neurologic deficits generally improve
without surgery. Nonsurgical treatment leads to
decreased pain and improved function. Although there
is a dearth of high-quality studies comparing surgical
with nonsurgical treatment, the natural course of
thoracolumbar fractures usually is benign, and
nonsurgical methods should be the standard treatment
with few exceptions.
Complications of spine fracture
•The most serious complication of vertebral fracture is
spinal cord injury which can result in paralysis.
•Infection
•Nerve damage in displaced fracture.
•Faulty alignment of heald vertibre(malunion)
•Gastro intestinal disease
•Chronic pain
Complications of spine surgery
•Ophthalmic complication associated with prone
positioning in spine surgery
•Post operative spinal wound infections
•Various thromboembolism in spine surgery
•Impaired physical mobility related to neuro
muscular impairment and vertebral body
fracture.
•Anxiety related to perceived effects of injury
on life style and unknown fracture.
•Bowel incontinence: reflexes related to lack of
voluntary sphincter control secondary to
spinal cord injury.
•Encourage early ambulation.
•Encourage him to perform passive and active excercises.
•Instruct patient in methods of safe ambulation----brace and wheel chair
etc.
•Discuss prevention of recurrent fractures.
•Teach symptoms needing attention such as numbness,decreased
function,increased pain,elevated temperature.
•Teach the importance of follow up care.
•Encourage follow up medical supervision to monitor for union problems.
•Encourage adequate balanced diet to promote bone and soft tissue healing.
Conclusion
•A case of RTA patient with fracture of D7 and partially able to move his
both lower extremity.
•Surgical treatment posterior fixation of D6-D8done.
•Patient is able to move his legs slowly
•Health education given on physiotherapy and bowel training
ASSESSMENT
PLANNING
Cues/evidences
Nursing Dx
Goals and desired
outcomes
Nursing Action
Rationale for Action
Evaluation
SUBJECTIVE
Impaired
physical
mobility
related to
neuromuscu
lar
impairment
and
vertebral
body
fracture.
After 8 hours of
nursing
interventions the
patient will
demonstrate
technique or
behaviors that
enable resumption
of activity.
1.Assist in range of
motion exercises on all
extremities and joints,
using slow, smooth
movements such as
starting with log roll
exercises.
1. To assess the
presence of
complications. Early
mobility reduces
complications of bed
rest
After 8 hours
of nursing
interventions
we met the
goal and the
patient was
able to
demonstrate
technique or
behaviors that
enable
resumption of
activity
“I Cannot move
and I have pain
during motion”
as verbalized by
the patient.
OBJECTIVE



Limited
range of
motion.
Inability to
perform
action as
instructed
Decreased
muscle
strength and
control.
IMPLEMENTATION
2. To maintain
2. Reposition periodically position and function
even when sitting in
and reduce risk of
chair. Teach patient how pressure ulcers.
to use weight sitting
3. Promote well being
technique.
and maximize and
3. Inspect the skin daily. energy production….
Observe for pressure
areas, and provide
meticulous skin care
4. Encourage adequate
intake of fluids.
EVALUATION