Fracture of the anterior arch of the atlas, accompanied by posterior atlantoaxial dislocation, typically presents on CT imaging as the odontoid process penetrating through and causing a high-energy shear fracture of the anterior arch. This injury may occur with or without retained fracture fragments. Its characteristic appearance resembles that of a plough traversing the earth, and it has historically been termed the plough fracture. Published case reports documenting this specific fracture pattern remain extremely rare in the literature. In our research group's earlier study on traumatic posterior atlantoaxial dislocation (TPAD), this fracture pattern was categorized as anterior arch fracture type TPAD (TPAD-AOT Type III). It was further subclassified based on transverse ligament integrity into: (1) Anterior arch fracture type TPAD with intact transverse ligament, and (2) Anterior arch fracture type TPAD with transverse ligament injury, reflecting a progressive increase in instability severity across these subtypes. Hyperflexion and hyperextension injury mechanisms play significant roles in the pathogenesis of this fracture pattern, with definitive diagnosis typically established via CT imaging. The integrity of the transverse ligament is critical for atlantoaxial stability. For patients with an intact transverse ligament, rigid external fixation or internal fixation may be indicated based on fracture displacement and reducibility. However, in cases with transverse ligament injury, posterior C1-C2 fusion typically achieves favourable functional outcomes.

This multisite case series examines the role of point-of-care ultrasound (POCUS) in diagnosing isolated sternal fractures in pediatric patients following indirect trauma. While traditionally linked to high-impact injuries and major trauma, these fractures can also occur in children participating in leisure activities like trampoline jumping. We aim to highlight POCUS as a rapid, radiation-free alternative to traditional imaging. We included pediatric patients presenting with acute chest pain after indirect trauma at three clinical sites in Switzerland. POCUS was performed by trained physicians to detect cortical discontinuity, confirming sternal fractures. Patients were managed conservatively and followed up by phone. Eleven children (median age: 11years) were diagnosed with isolated sternal fractures, with the majority involving hyperflexion injuries. None had external signs of trauma. POCUS swiftly identified fractures, enabling immediate diagnosis without additional imaging. All patients recovered fully with conservative management, and no repeat visits or complications were reported. POCUS could be an effective, non-invasive tool for diagnosing pediatric sternal fractures following indirect trauma. It may facilitate rapid evaluation, avoid unnecessary imaging, and may streamline management, making it a valuable first-line diagnostic modality in pediatric emergency care.

Traumatic posterior atlantoaxial dislocation (TPAD) is uncommon, and related research is very limited. By analyzing the imaging characteristics of the anterior arch-odontoid process-transverse ligament complex in patients, the authors classify the outcomes of TPAD and elucidate its mechanisms of injury. This is a retrospective review of CT and MRI data on patients with TPAD treated at two clinical centers from June 2014 to March 2024. Through analysis and statistics on injuries to the anterior arch, odontoid process, and transverse ligament complex, the authors proposed a new classification method based on different injuries to these structures on imaging. Additionally, they discuss the role of hyperflexion and hyperextension injuries in the formation of TPAD. The different injuries to the anterior arch-odontoid process-transverse ligament complex on imaging were classified into four types of TPAD: fracture-free TPAD (type I), odontoid process fracture TPAD (type II), anterior arch fracture TPAD (type III), and compound fracture TPAD (type IV); the latter three types are referred to as "fracture-associated TPAD." Considering the significant role of the transverse ligament in injuries, these four fracture types were further divided into two subtypes based on transverse ligament integrity (i.e., intact or injured). Among the 41 patients included in the study, there were 2 cases of fracture-free TPAD (i.e., 1 type Ia case and 1 type Ib case) and 39 cases of fracture-associated TPAD (i.e., 31 cases of odontoid process fracture TPAD, including 18 type IIa cases and 3 type IIb cases; 5 cases of anterior arch fracture TPAD, including 3 type IIIa cases and 2 type IIIb cases; and 3 cases of compound fracture TPAD, including 2 type IVa cases and 1 type IVb case). Based on the imaging classification method for different injuries to the anterior arch-odontoid process-transverse ligament complex, TPAD injuries demonstrate a higher degree of alignment, facilitating a comprehensive understanding of these injuries. Hyperflexion and hyperextension are the primary mechanisms in TPAD injuries, with the integrity of the transverse ligament playing a crucial role and guiding treatment principles.

The authors present a case of a 6-year-old boy who was treated nonoperatively for an unstable C2-3 hyperflexion injury with posterior cervical ligamentous disruption 8 years ago. The patient was managed with cervical collar immobilization for 2.5 years with long-term follow-up demonstrating complete healing of posterior element disruption, normal sagittal vertebral alignment on dynamic imaging, and full return to activities of daily living and sports. Pediatric spine injuries up to the C2-3 level with posterior ligamentous disruption alone without neurological deficit may be successfully treated nonoperatively with careful long-term immobilization and close follow-up.

A right-handed 52-year-old man complained of sudden deformity over his right ring finger following a hyperflexion injury. He accidentally hyperflexed the distal interphalangeal joint (DIPJ) of his right ring finger while showering. Since then, he noticed that he had a flexion deformity and could not actively extend his ring finger at the DIPJ.

When can an enhanced critical care team add value to equestrian related incidents? A retrospective observational study

We describe the case of a 28-year-old male professional football player experiencing right knee pain after noncontact, hyperflexion injury during a regular professional football league match. Infrapatellar fat pad injury was confirmed using magnetic resonance imaging. The athlete was fully recovered with conservative treatment and could return to sports at 6 weeks after injury.

To review and analyze the clinical significance of positive acute traumatic findings seen on MRI of the cervical spine (MRCS) following a negative CT of the cervical spine (CTCS) for trauma. We performed a sub-cohort analysis of 54 patients with negative CTCS and a positive MRCS after spine trauma from the previous multicenter study of the Research Consortium of New England Centers for Trauma (ReCONECT). Both CTCS and MRCS were independently reviewed by two emergency radiologists and two spine surgeons. The surgeons also commented on the clinical significance of the traumatic findings seen on MRCS and grouped them into unstable, potentially unstable, and stable injuries. Among 35 unevaluable patients, MRCS showed one unstable (hyperextension) and two potentially unstable (hyperflexion) injuries. Subtle findings were seen on CTCS in 2 of 3 patients upon careful retrospective review that would have suggested these injuries. Of 19 patients presenting with cervicalgia, 2/5 (40%) patients with neurological deficit demonstrated clinically significant findings on MRCS with predisposing factors seen on CT. None of the 14 patients with isolated cervicalgia and no neurological deficit had clinically significant findings on their MRCS. While CTCS is adequate for clearing the cervical spine in patients with isolated cervicalgia, MRCS can play a critical role in patients with neurological deficits and normal CTCS. Clinically significant traumatic findings were seen in 8.5% of unevaluable patients on MRCS, though these injuries in fact could be identified on the CT in 2 of 3 patients upon careful retrospective review.

Due to the inherent bony instability of the cervical spine, there is an over-reliance on ligamentous structures for stability, making this segment of the vertebral column most prone to traumatic injuries. The frequently occurring mechanisms of injury include axial compression, hyper-flexion, hyper-extension, and rotational type injuries. Good pre-hospital care and a thorough assessment in the emergency department of patients suspected to have a cervical spine injury (CSI) leads to improved clinical outcomes. The objective of the initial evaluation of a patient with a suspected CSI is to identify the presence of injuries through thorough clinical and radiologic assessments as missed injuries are potentially catastrophic. The treatment of cervical spine injuries can be conservative, pharmacological, or surgical, and aims to halt SCI progression, stabilize the spine, and to allow rehabilitation of the patient.

Background:Sports-related cervical spine injuries (CSI) are devastating traumas with the potential for permanent disability. There is a paucity of literature on operative CSI sustained in youth athletes.Hypothesis/Purpose:The aims of this study aims were to review injury characteristics, surgical treatment, and outcomes of severe pediatric CSI encountered in youth sports.Methods:We reviewed children less than 18 years old with operative sports-related CSI at a pediatric Level 1 pediatric trauma center between 2004−2019. All cases underwent modern cervical spine instrumentation and fusion. SCI were stratified according to the American Spinal Injury Association Impairment Scale (ASIA). Clinical, radiographic, and surgical characteristics were compared between groups of patients with and without spinal cord injury (SCI).Results:Three thousand two hundred and thirty-one children (mean, 11.3y±4.6y) were evaluated for CSI at our institution during the 16-year period. The majority of traumas resulted from sports/recreational activities and were seen in 1365 cases (42.3%). Of these, 171/1365 patients (12.5%) were admitted and 29/1365 patients (2.1%) required surgical intervention (mean age, 14.5y±2.88y; range, 6.4y–17.8y). Sports included: eight football (28%), seven wrestling (24%), five gymnastics (17%), four diving (14%), two trampoline (7%), one hockey (3%), one snowboarding (3%), and one biking injury (3%). Mechanisms were 19 hyperflexion (65%), eight axial loading (28%), and two hyperextension injuries (7%). The majority of operative CSI were fractures (79%) and/or subaxial defects (72%). Seven patients (30%) sustained SCI and three patients (10%) spinal cord contusion or myelomalacia without neurologic deficits. The risk of SCI increased with age (15.8y vs. 14.4y; p=0.03) and axial loading mechanism (71% vs. 14%; p=0.003).Postoperatively, two SCI patients (29%) improved 1 ASIA Grade and one (14%) improved 2 ASIA Grades. Increased complications developed in SCI than patients without SCI (mean, 2.0 vs 0.1 complications; p=0.02). Clinical and radiographic fusion occurred in 24/26 patients (92%) with adequate follow-up (median, 32 months). Ten patients returned to their previous activity and nine to sports with a lower level of activity.Conclusion:The overall incidence of sports-related operative CSI is low. Age- and gender discrepancies exist, with male adolescent athletes most commonly requiring surgery. Hyperflexion injuries had a good prognosis; however, older males with axial loading CSI sustained in contact sports were at greatest risk of SCI, complications, and permanent disability.Figure 1.1:Etiology of all cervical spine injuries between 2004-2019

Orthopaedic Nursing: January/February 2021 - Volume 40 - Issue 1 - p 49-50 doi: 10.1097/NOR.0000000000000737

Sternal fractures have often been associated with high-impact thoracic trauma. In children, this is not always the case. X-ray and even computed tomography can miss subtle sternal fractures. Point-of-care ultrasound has been shown to be more sensitive and specific for detecting subtle sternal fractures as compared with plain X-ray. The following 2 cases describe sternal fractures that were missed by traditional imaging modalities, including a fracture missed by chest computed tomography. They also highlight other potential causative mechanisms for sternal fractures in children, including hyperflexion injuries and low-mechanism motor vehicle accidents.

Objective: To analyze the prevalence of non-contiguous injury of spinal cord using MRI with a focus on cervical spinal injury patients. Methods: 60 cervical spinal injury patients were reviewed using the NIMIS (National Integrated Medical Imaging System) system. The MR imaging and imaging reports for cervical spinal injury were reviewed in a University Teaching Hospital in West Ireland (45 male and 15 female). The mean age of patients in this population group was 42. They were divided into three groups based on the mechanism of injury; hyperflexion, hyperextension and axial injury as per ASIA guidelines. The presence or absence of non-contiguous spinal injury was confirmed as to whether there was marrow contusion, herniation, or fracture at any area along the spine. During evaluation of spinal injury the cervical spine is often prioritized, however the importance of surveying the entire spine is essential. It has been emphasized that the whole cervical spine including the cervicothoracic junction (CTJ) Results: A total of 9 cases (15%) showed CTJ or upper thoracic spinal injuries defined as C7-L1 injury. 2 of 21 cases revealed obvious fractures in the CTJs or upper thoracic spines. Ligamentous injury in these regions was found in only one case, Traumatic disc herniation in four cases and spinal cord injury in five cases. Nerve impingement was observed in two cases. The incidence of non-contiguous spinal injuries was higher in the axial compression injury group (25%) than in the hyperflexion injury group (21%) or the hyperextension (20%) injury group, highlighting the importance of injury mechanism. Conclusion: Cervical spinal MR showed non-contiguous CTJ or upper thoracic spinal injuries in 28% of the patients with cervical spinal injury. The mechanism of cervical spinal injury did not significantly affect the incidence of the noncontiguous CTJ or upper thoracic spinal injury. Physicians in Ireland should consider imaging other areas of the spine when a cervical spinal injury is suspected.

Background: Wallenberg’s syndrome (WS), or lateral medullary syndrome is rare in pediatrics, but is not uncommon in adults. It is characterized by neurological deficits due to an ischemic lesion in the lateral medulla. Methods: Case report Results: We describe a 17-year-old boy who developed WS in the context of hyperflexion injury to the neck while diving in shallow water with vertebral dissection as a presumed etiology. He had ‘crossed’ neurological deficits above and below the neck. His MRA showed intra and extracranial left vertebral artery occlusion and his MRI showed T2W/FLAIR signal abnormality involving the left lateral medulla and inferomedial aspect of the cerebellum in keeping with infarcts secondary to the left vertebral artery thrombosis and occlusion of the left posterior inferior cerebellar artery. He was started on anti-coagulation after spinal surgery. On discharge, he had persistent dysphagia which prompt a gastrostomy tube placement prior to transfer to a rehabilitation center. Conclusions: Our case demonstrates that WS can occur post flexion injury in the pediatric population. The presence of crossed neurological findings above and below the neck in the context of neck injury is an important diagnostic clue that should prompt imaging study focusing on the brain stem and the posterior fossa vascular structures.

On the relative importance of bending and compression in cervical spine bilateral facet dislocation

Isolated dorsoradial capsule injuries of the thumb metacarpophalangeal joint are different from those associated with collateral ligament disruption. Early suspicion of this rare injury is important because, if overlooked, ulnarward subluxation of extensor pollicis longus tendon can develop. Functionally, active thumb extension becomes impaired, and over the long term, a thumb Boutonniere's deformity becomes established. Joint hypermobility/instability may predispose to this injury. The 2 cases presented illustrate this through anatomic differences. At the time of acute injury, 3 presenting clinical features should raise suspicion of dorsoradial capsular rupture: a history of isolated hyperflexion injury to the thumb, stable collateral ligaments on examination, and x-ray evidence of palmar subluxation of the proximal phalanx on the metacarpal. Ulnarward subluxation of the extensor pollicis longus is a delayed sign. Diagnostic imaging, beyond x-ray studies, may not be helpful in defining the injury. Early exploration and repair of this injury give the best long-term outcome. Postrepair, metacarpophalangeal joint range of motion may not be fully restored, but stability and a preinjury level of hand function can usually be reestablished.

BackgroundCervical spine fracture-dislocations in neurologically intact patients represent a surgical challenge due to the risk of inflicting iatrogenic spinal cord compression by closed reduction maneuvers. The use of MRI for early advanced imaging in these injuries remains controversially debated.Case presentationA 54-year old man sustained a fall over the handlebars of his racing bicycle. The helmeted patient sustained a fall on his head which resulted in a hyperflexion injury of the neck. He was neurologically intact on presentation. Initial CT imaging revealed a complex multisegmental cervical spine injury with a left-sided C6/C7 perched facet, a right sided C7/T1 fracture-dislocation, and a right-sided C6 and C7 traumatic laminotomy. The initial management consisted of temporary external Halo fixator application without closed reduction maneuver, to mitigate the risk of a delayed spinal cord injury. Subsequent advanced imaging by MRI revealed an acute traumatic C7/T1 disc herniation, with the intervertebral disc completely extruded into the spinal canal. Definitive surgical management was then accomplished by employing a three-stage anterior-posterior-anterior spinal decompression, realignment, fixation and fusion C4-T2 in one operative session. The patient recovered well and retained full neurological function. He resumed bicycle street racing within 10 months of the injury following successful spinal reconstruction.ConclusionsThe diagnostic evaluation of cervical fracture-dislocations should include advanced imaging by MRI in order to fully understand the injury pattern prior to proceeding with spinal reduction maneuvers which may impose the imminent threat of a devastating iatrogenic injury to the spinal cord. The presented staged management by initial Halo fixation without attempts for spinal reduction, followed by a surgical decompression and multilevel fusion, appears to represent a feasible and safe strategy for patients at risk of a delayed neurological injury.

Distal intersection syndrome is the tenosynovitis of the second compartment and the third compartment, at their cross point, in the dorsal wrist. It is a rare disorder presenting with pain, swelling, and tenderness in Lister’s tubercle area of the wrist. One of the causes may be the pulley effect of Lister’s tubercle on the third compartment, where the resultant tenosynovitis can spread to the second compartment through their communication foramen. This case of distal intersection syndrome is induced by hyperflexion and abduction injury of the thumb, which may have caused tenosynovitis of the third compartment by overstretching over Lister’s tubercle. It is unique that in addition to the typical presentation of the syndrome with tenosynovitis of the second and third compartments, the fourth compartment also displayed tenosynovitis. This extra presentation may result from the possible communication between the third and fourth compartments.

HISTORY: A 16 year old male football player presents with recurrent episodes of bilateral arm paresthesias. This first occurred six weeks prior to presentation after he was tackled with his neck axially loaded in a flexed position, and was associated with mild subjective weakness. This lasted a few minutes and resolved spontaneously. This happened four more times with each episode lasting longer in duration. He denied any lower extremity symptoms. One week prior to presentation, he was blocking an opposing player and had a hyperflexion injury which precipitated paresthesias which lasted for hours. He denied any bowel/bladder incontinence or saddle anesthesia. PHYSICAL EXAMINATION: No malalignment or rotational deformity of the neck. No bony tenderness or cervical paraspinal tenderness. Full cervical range of motion in all planes without pain. Spurling test is negative bilaterally. Full motor power in the bilateral upper and lower extremities except for slight weakness in right shoulder abduction and right hand finger abduction. No Hoffman sign present. Sensation intact to light touch bilaterally DIFFERENTIAL DIAGNOSIS: Cervical cord neurapraxia Spinal stenosis Cervical radiculopathy Stinger/Burner Brachial plexopathy Parsonage Turner Syndrome TEST AND RESULTS: Cervical cord neurapraxia without cord contusion in the setting of congenital stenosis of the cervical spine FINAL WORKING DIAGNOSIS: X-rays of the cervical spine showed normal lordosis, proper alignment, preserved intervertebral disc height, and no acute osseous abnormalities. An MRI showed significant central canal stenosis at C3-4, C5-6, and C6-7 with loss of surrounding CSF fluid signal at these levels. Smallest canal diameter is 8mm at C5-6. There was no cord edema noted. TREATMENT AND OUTCOMES: Though a validated risk stratification mechanism or return to play criteria does not presently exist in the literature, the results of the MRI and the progressively increasing duration of symptoms suggest an increased risk of future spinal cord injury with continued participation in contact sports. He does score in the “Moderate risk” category based on the Cervical Spine Injury Rating Scale proposed by Watkins, et al in 1990. He was held from participation and referred to spine surgery to discuss additional treatment options and return to play prognosis.

This study examined the cervical spine range of motion (ROM) resulting from whiplash-type hyperextension and hyperflexion type ligamentous injuries, and sought to improve the accuracy of specific diagnosis of these injuries. The study was accomplished by measurement of ROM throughout axial rotation, lateral bending, and flexion and extension, using a validated finite element model of the cervical spine that was modified to simulate hyperextension and/or hyperflexion injuries. It was found that the kinematic difference between hyperextension and hyperflexion injuries was minimal throughout the combined flexion and extension ROM measurement that is commonly used for clinical diagnosis of cervical ligamentous injury. However, the two injuries demonstrated substantially different ROM under axial rotation and lateral bending. It is recommended that other bending axes beyond flexion and extension are incorporated into clinical diagnosis of cervical ligamentous injury.