Unstable Cervical Spine Injuries Research Articles

Current Challenges in the Use of Computed Tomography and MR Imaging in Suspected Cervical Spine Trauma.

There is controversy regarding the optimal imaging strategy in adult blunt trauma patients for suspected cervical spine trauma. Some investigators recommend negative computed tomography (CT) alone to clear the cervical spine in adult blunt trauma patients, while others insist that MR imaging is necessary, especially among obtunded adult blunt trauma patients. CT is an excellent imaging modality for bony cervical spine injury; however, there is a nonzero rate of clinically significant cervical spine injuries missed on CT. MR imaging has high sensitivity for soft tissue cervical spine injuries, but low specificity for the rare isolated unstable ligamentous cervical spine injury.

Outcomes of Unstable Subaxial Cervical Spine Fractures Managed by Posteroanterior Stabilization and Fusion

Study DesignRetrospective study.PurposeTo evaluate clinical and radiological outcomes of unstable subaxial cervical spine injuries managed by both posterior tension band column stabilization and anterior decompression, stabilization, and fusion.Overview of LiteratureUnstable subaxial cervical spine injuries often involve disruption of the anterior column and posterior tension band osteoligamentous complex. Such injuries need immediate surgical intervention. Different methods of reduction and surgical approaches have been published in the literature, with lack of consensus on a uniform or standardized method. Controversy still exists regarding stabilization of unstable cervical fractures by anterior or posterior approach alone or combined approaches.MethodsWe retrospectively evaluated 24 patients with post-traumatic unstable subaxial cervical spine injuries with their preoperative clinical details, X-ray, computed tomography, and magnetic resonance imaging of the cervical spine for fracture classification based on the mechanism of injury with status of disc herniation and posterior tension band disruption. All patients were managed by immediate reduction, posterior and anterior stabilization, and fusion in a single session of anesthesia. Data of all patients were analyzed with respect to pre- and postoperative neurological status based on American Spinal Injury Association grading, Visual Analog Scale score, the observation of bony fusion, and implant failure at 1, 3, 6, and 12 months. Data were analyzed using paired t-test.ResultsAll patients had solid fusion at the desired level with considerable neurological improvement at the 1-year follow-up.ConclusionsIn unstable cervical injuries, stabilization of disrupted posterior tension band increases the stability of anterior plating and fusion. This method of immediate reduction and circumferential stabilization is rapid, safe, and effective and has a low rate of complications.

A study on functional outcome following surgical fixation for subaxial cervical spine injuries

Background: Cervical instability due to trauma is usually from level c3 to c7 (i.e sub axial). Neurological deficit are common i.e root compression and cord compression with subluxation and dislocation. Unstable cervical spine injuries with or without neurological deficit require open reduction. Stabilization is done by using various implants and bone grafting. Implants provide immediate stability, whereas bone grafts provide long term stability by achieving intervertebral fusion. Hence to relive from the primary impact, persistent compression and alignment of stable anatomy of cervical spine, early surgical intervention is necessary to relieve persistent compression and stabilization of subaxial cervical spine injuries. Aim of the study: To study the functional outcome following surgical fixation for subaxial cervical spine injuries involving patients who all are admitted with subaxial cervical spine injuries & amenable to intervention in our department of orthopaedics & traumatology, govt rajaji hospital, madurai from September 2011 to September 2015 Results: All the cases are male with most of the patients are in the age group of 41-50 years, Fall from height is the most common of injury followed by road traffic accident, C5-C6 # dislocation is most common spinal injury pattern. Incomplete neurological deficit are more in this study. Most of the cases are flexion distraction type of violence. Most of the cases presented with in one week of injury. Only 4 cases of 40 cases operated by global fusion, both of them are presented late and found to have locked facets. 4 out of 6 cases are expired from complete neurological deficit. Mobilisation of neck started after 6 weeks. Totally 6 cases were expired. Two cases was due to acute respiratory distress syndrome. One case due to aspiration pneumonia is. Four patients developed bed sores in which one case developed bed sore preoperatively and other postoperative lay. One patient who had grade 6 sacral sore underwent flap cover with the help of plastic surgeon intervention. Other 6 patients managed conservatively. Conclusion: The ultimate goal of surgical intervention for subaxial cervical spine injuries is stabilization of spine, restoration of spinal anatomy, decompression of neural elements, thereby promoting the neurological recovery and early facilitation of rehabilitation. In our study, we achieved a good functional outcome following surgical intervention. To conclude that early surgical stabilization of subaxial cervical spine injuries has good functional outcome, provided detailed clinical and radiological assessment, proper preoperative planning, selection of surgical approaches, precision in surgical techniques and early rehabilitation program are needed in achieving good results and minimising complications.

The Use of Clinical Cervical Spine Clearance in Trauma Patients: A Literature Review

IntroductionFive million patients in America are placed in spinal immobilization annually, with only 1% to 2% of these patients suffering from an unstable cervical spine injury. Prehospital agencies are employing selective and limited immobilization practices, but there is concern that this practice misses cervical spine injuries and therefore possibly predisposes patients to worsening injuries. MethodsA systematic review was conducted that examined literature from the last 5 years that reviewed cervical spine immobilization application and/or clearance in alert trauma patients. ResultsPrehospital selective immobilization protocols and bedside clinical clearance examinations are becoming more commonplace, with few missed injuries or poor outcomes. Prehospital providers can evaluate patients in the field safely to assess who needs or does not need cervical collars; similar criteria can be used in the emergency department. Harm from cervical collars is increasingly documented, with concerns that risks exceed possible benefits. DiscussionThe literature suggests that alert trauma patients can be cleared from cervical spine immobilization safely through a structured algorithm in either the prehospital or ED setting. The evidence is primarily observational. Thus, many providers who fear missing cervical injuries may be reluctant to follow the recommendations despite few or no published cases of sudden deterioration from missed cervical spine injuries.Image 1

A service evaluation of surgical tracheostomies in the emergency theatre at University Hospital, Coventry: time for a dedicated tracheostomy team?

Introduction/aims: The routine practice of surgical tracheostomy has been challenged by bedside percutaneous dilatational tracheostomy (PDT). Whilst PDT is cost-effective and time-efficient, there is still a place for the open technique in patients with unfavourable anatomy, unstable cervical spine injuries and/or coagulopathies. Complication rates of the open technique are often lower, but booking such cases into busy emergency theatres may prove difficult.

Neurological outcome and postoperative stability after anterior cervical spine fixation by the use of cervical spine locking plate

Background: The fractures of cervical spine are divided into upper cervical spine (C1-C2) and lower cervical spine (C3-C7) also called sub axial cervical spine. Sub axial cervical injuries are common, ranging in severity from minor ligamentous strain or spinous process fracture to complete fracture dislocation with bone and ligament disruption, resulting in severe spinal cord injury. The objective of this study was to determine the neurological outcome and postoperative stability after anterior cervical spine fixation by the use of cervical spine locking plate (CSLP) attached with cancellous screws.Methods: This descriptive study was carried out in the Department of Neurosurgery, Nishtar Hospital, Multan, Pakistan. One hundred and fifteen patients fulfilled the inclusion criteria were selected. Patient of either gender more than 15 years of age and less than 60 years of age having unstable lower cervical spine injuries from C-3 to C 7 on X-ray underwent anterior cervical fixation.Results: Age range from 15 to 60 years with mean 32.34±standard deviation (SD) =12.06. The mean Frankel grading of the patients was 3.26±standard deviation (SD) =1.33. There were 97 (84.3%) male patients and 18 (15.7%) female patients. The neurological outcome was good in 107(89.6%) patients and poor in 12 (10.4%). The postoperative stability was YES in 109 (94.8%) patients and NO in 06 (5.2%). In the mode of injury there were 65 (56.5%) patients having road traffic accident, 41 (35.7%) patients having fall from tree/roof/stairs, 6 (65.2%) patients having fall of brick on the patient, 1 (0.9%) patient having Buffalo hit/animal contact, 2 (1.7%) patient having contact of head at floor of swimming pool after jumped in.Conclusions: It is concluded from this study that good results were achieved with the use of the CSLP. The use of anterior approach in treatment of the injured lower spine is safe and effective.

Cadaveric study of movement in the unstable upper cervical spine during emergency management: tracheal intubation and cervical spine immobilisation—a study protocol for a prospective randomised crossover trial

IntroductionEmergency management of upper cervical spine injuries often requires cervical spine immobilisation and some critical patients also require airway management. The movement of cervical spine created by tracheal intubation and...

Does the novel lateral trauma position cause more motion in an unstable cervical spine injury than the logroll maneuver?

ObjectivePrehospital personnel who lack advanced airway management training must rely on basic techniques when transporting unconscious trauma patients. The supine position is associated with a loss of airway patency when compared to lateral recumbent positions. Thus, an inherent conflict exists between securing an open airway using the recovery position and maintaining spinal immobilization in the supine position. The lateral trauma position is a novel technique that aims to combine airway management with spinal precautions. The objective of this study was to compare the spinal motion allowed by the novel lateral trauma position and the well-established log-roll maneuver. MethodsUsing a full-body cadaver model with an induced globally unstable cervical spine (C5-C6) lesion, we investigated the mean range of motion (ROM) produced at the site of the injury in six dimensions by performing the two maneuvers using an electromagnetic tracking device. ResultsCompared to the log-roll maneuver, the lateral trauma position caused similar mean ROM in five of the six dimensions. Only medial/lateral linear motion was significantly greater in the lateral trauma position (1.4mm (95% confidence interval [CI] 0.4, 2.4mm)). ConclusionsIn this cadaver study, the novel lateral trauma position and the well-established log-roll maneuver resulted in comparable amounts of motion in an unstable cervical spine injury model. We suggest that the lateral trauma position may be considered for unconscious non-intubated trauma patients.

Tracheal Malplacement of the King LT Airway May Be an Important Cause of Prehospital Device Failure

BackgroundThe King LT airway (King Systems, Noblesville, IN) is a popular extraglottic device that is widely used in the prehospital setting. We report a case of tracheal malplacement of the King airway with a severe kink in the distal tube. Case ReportA 51-year-old unhelmeted motorcyclist collided with a freeway median and was obtunded when paramedics arrived. After bag mask ventilation, a King airway was placed uneventfully and the patient was transported to the emergency department. Because of the concern for an unstable cervical spine injury, a lateral cervical spine radiograph was obtained on arrival. No cervical injury was seen, but the King airway was noted to be malplaced; the King airway passed through the laryngeal inlet and became lodged on the anterior trachea, creating an acute kink between the two balloons. After reviewing the radiograph, ventilations were reassessed and remained adequate. Both balloons were deflated, and the King airway was removed; the patient was orotracheally intubated without complication. Why Should An Emergency Physician Be Aware of This?The King airway is a valuable prehospital airway that can be placed quickly and blindly with high success rates by inexperienced providers; the King airway, however, is not without complication. Ventilation was not impaired in this patient, but tracheal malplacement may be an important cause of prehospital device failure. If a first placement attempt of a King airway device fails, it is reasonable to reattempt King airway placement with a new, unkinked device before abandoning King airway placement.

Heterogeneity in cervical spine assessment in paediatric trauma: A survey of physicians' knowledge and application at a paediatric major trauma centre.

Evidence-based decision-making tools are widely used to guide cervical spine assessment in adult trauma patients. Similar tools validated for use in injured children are lacking. A paediatric-specific approach is appropriate given important differences in cervical spine anatomy, mechanism of spinal injury and concerns over ionising radiation in children. The present study aims to survey physicians' knowledge and application of cervical spine assessment in injured children. A cross-sectional survey of physicians actively engaged in trauma care within a paediatric trauma centre was undertaken. Participation was voluntary and responses de-idenitified. The survey comprised 20 questions regarding initial assessment, imaging, immobilisation and perioperative management. Physicians' responses were compared with available current evidence. Sixty-seven physicians (28% registrars, 17% fellows and 55.2% consultants) participated. Physicians rated altered mental state, intoxication and distracting injury as the most important contraindications to cervical spine clearance in children. Fifty-four per cent considered adequate plain imaging to be 3-view cervical spine radiographs (anterior-posterior, lateral and odontoid), whereas 30% considered CT the most sensitive modality for detecting unstable cervical spine injuries. Physicians' responses reflected marked heterogeneity regarding semi-rigid cervical collars and what constitutes cervical spine 'clearance'. Greater consensus existed for perioperative precautions in this setting. Physicians actively engaged in paediatric trauma care demonstrate marked heterogeneity in their knowledge and application of cervical spine assessment. This is compounded by a lack of paediatric-specific evidence and definitions, involvement of multiple specialties and staff turnover within busy departments. A validated decision-making tool for cervical spine assessment will represent an important advance in paediatric trauma.

Maxillofacial trauma - Underestimation of cervical spine injury.

Undiagnosed cervical spine injury can have devastating results. The aim of this study was to analyse patients with primary maxillofacial trauma and a concomitant cervical spine injury. It is hypothetised that cervical spine injury is predictable in maxillofacial surgery. A monocentric clinical study was conducted over a 10-year period to analyse patients with primary maxillofacial and associated cervical spine injuries. Demographic data, mechanism of injury, specific trauma and treatments provided were reviewed. Additionally a search of relevant international literature was conducted in PubMed by terms "maxillofacial" AND "cervical spine" AND "injury". Of 3956 patients, n=3732 (94.3%) suffered from craniomaxillofacial injuries only, n=174 (4.4%) from cervical spine injuries only, and n=50 (1.3%) from both craniomaxillofacial and cervical spine injuries. In this study cohort the most prevalent craniofacial injuries were: n=41 (44%) midfacial and n=21 (22.6%) skull base fractures. Cervical spine injuries primarily affected the upper cervical spine column: n=39 (58.2%) vs. n=28 (41.8%). Only in 3 of 50 cases (6%), the cervical spine injury was diagnosed coincidentally, and the cervical spine column was under immobilised. The operative treatment rate for maxillofacial injuries was 36% (n=18), and for cervical spine injuries 20% (n=10). The overall mortality rate was 8% (n=4). The literature search yielded only 12 papers (11 retrospective and monocentric cohort studies) and is discussed before our own results. In cases of apparently isolated maxillofacial trauma, maxillofacial surgeons should be aware of a low but serious risk of underestimating an unstable cervical spine injury.

Cervical spine injuries in civilian victims of explosions: Should cervical collars be used?

Semirigid cervical collars (SRCCs) are routinely applied to victims of explosions as part of the prehospital trauma protocols. Previous studies have shown that the use of SRCC in penetrating injuries is not justified because of the scarcity of unstable cervical spine injuries and the risk of obscuring other neck injuries. Explosion can inflict injuries by fragments penetration, blast injury, blunt force, and burns. The purpose of the study was to determine the occurrence of cervical spine instability without irreversible neurologic deficit and other potentially life-threatening nonskeletal neck injuries among victims of explosions. The potential benefits and risks of SRCC application in explosion-related injuries were evaluated. This is a retrospective cohort study of all explosion civilian victims admitted to Israeli hospitals during the years 1998 to 2010. Data collection was based on the Israeli national trauma registry and the hospital records and included demographic, clinical, and radiologic details of all patients with documented cervical spine injuries. The cohort included 2,267 patients. All of them were secondary to terrorist attacks. SRCC was applied to all the patients at the scene. Nineteen patients (0.83%) had cervical spine fractures. Nine patients (0.088%) had unstable cervical spine injury. All but one had irreversible neurologic deficit on admission. A total of 151 patients (6.6%) had potentially life-threatening penetrating nonskeletal neck injuries. Unstable cervical spine injuries secondary to explosion are extremely rare. The majority of unstable cervical spine fractures were secondary to penetrating injuries, with irreversible neurologic deficits on admission. The application of SRCC did not seem to be of any benefit in these patients and might pose a risk of obscuring other neck injuries. We recommend that SRCC will not be used in the prehospital management of victims of explosions. Prognostic/epidemiologic study, level III.

Safety of the lateral trauma position in cervical spine injuries: a cadaver model study.

BackgroundEndotracheal intubation is not always an option for unconscious trauma patients. Prehospital personnel are then faced with the dilemma of maintaining an adequate airway without risking deleterious movement of a potentially unstable cervical spine. To address these two concerns various alternatives to the classical recovery position have been developed. This study aims to determine the amount of motion induced by the recovery position, two versions of the HAINES (High Arm IN Endangered Spine) position, and the novel lateral trauma position (LTP).MethodWe surgically created global cervical instability between the C5 and C6 vertebrae in five fresh cadavers. We measured the rotational and translational (linear) range of motion during the different maneuvers using an electromagnetic tracking device and compared the results using a general linear mixed model (GLMM) for regression.ResultsIn the recovery position, the range of motion for lateral bending was 11.9°. While both HAINES positions caused a similar range of motion, the motion caused by the LTP was 2.6° less (P = 0.037). The linear axial range of motion in the recovery position was 13.0 mm. In comparison, the HAINES 1 and 2 positions showed significantly less motion (−5.8 and −4.6 mm, respectively), while the LTP did not (−4.0 mm, P = 0.067).ConclusionOur results indicate that in unconscious trauma patients, the LTP or one of the two HAINES techniques is preferable to the standard recovery position in cases of an unstable cervical spine injury.

Acutely unstable cervical spine injury with normal CT scan findings: MRI detects ligamentous injury

MRI can detect ligamentous injury not detectable with CT scan. The authors present a trauma patient with normal CT imaging despite dislocation on standing radiograph. MRI detected disruption of the C5–C6 posterior ligamentous complex that requires surgery.

The Effect of Cricoid Pressure on the Unstable Cervical Spine

BackgroundIt has been proposed that cricoid pressure can exacerbate an unstable cervical injury and lead to neurologic deterioration. ObjectiveWe sought to examine the amount of motion cricoid pressure could cause at an unstable subaxial cervical spine injury, and whether posterior manual support is of any benefit. MethodsFive fresh, whole cadavers had complete segmental instability at C5–C6 surgically created by a fellowship-trained spine surgeon. Cricoid pressure was applied to the anterior cricoid by an attending anesthesiologist. In addition, the effect of posterior cervical support was tested during the trials. The amount of angular and linear motion between C5 and C6 was measured using a Fastrak, three-dimensional, electromagnetic motion analysis device (Polhemus Inc., Colchester, VT). ResultsWhen cricoid pressure is applied, the largest angular motion was 3 degrees and occurred in flexion-extension at C5–C6. The largest linear displacement was 1.36 mm and was in anterior-posterior displacement of C5–C6. When manual posterior cervical support was applied, the flexion-extension was improved to less than half this value (1.43 degrees), and this reached statistical significance (p = 0.001). No other differences were observed to be significant in the other planes of motion with the applications of support. ConclusionsBased on the evidence presented, we believe that the application of cricoid pressure to a patient with a globally unstable subaxial cervical spine injury causes small displacements. There may be some benefit to the use of manual posterior cervical spine support for reducing motion at such an injured segment.

Absence of clinical findings reliably excludes unstable cervical spine injuries in children 5 years or younger.

Increased accessibility and rapidity of computed tomography (CT) have led to increased use and radiation exposure to pediatric trauma patients. The thyroid is radiosensitive and therefore at risk for developing malignancy from radiation exposure during cervical spine CT. This analysis aimed to determine which preelementary trauma patients warrant cervical spine CT by defining incidence and clinical characteristics of preelementary cervical spine injury. This was a retrospective review of pre-elementary trauma patients from 1998 to 2010 with cervical spine injury admitted to a Level I trauma center. Patients were identified from the trauma registry using DRG International Classification of Diseases-9th Rev. codes and reviewed for demographics, mechanism of injury, clinical presentation, injury location, injury type, treatment, and outcome. A total of 2,972 preelementary trauma patients were identified. Twenty-two (0.74%) had confirmed cervical spine injuries. Eleven (50%) were boys, and the mean (SD) age was 3 (1.7) years. The most common mechanism of injury was motor vehicle collision (n = 16, 73%). The majority (59%) were in extremis, and 12 (55%) arrived intubated. The median Glasgow Coma Scale (GCS) score was 3 (interquartile range, 3-10); the median Injury Severity Score (ISS) was 33 (interquartile range, 17-56). Nineteen injuries (76%) were at the level of C4 level and higher. The mortality rate was 50%. All patients had clinical findings suggestive of or diagnostic for cervical spine injury; 18 (82%) had abnormal neurologic examination result, 2 (9%) had torticollis, and 2 (9%) had neck pain. The incidence of cervical spine injury in preelementary patients was consistent with previous reports. Missing a cervical spine injury in asymptomatic preelementary patients is extremely low. Reserving cervical spine CT to symptomatic preelementary patients would decrease unnecessary radiation exposure to the thyroid. Therapeutic study, level IV.

Assessment of ultrasound as a diagnostic modality for detecting potentially unstable cervical spine fractures in pediatric severe traumatic brain injury: A feasibility study.

Background:Early cervical spine clearance is extremely important in unconscious trauma patients and may be difficult to achieve in emergency setting.Objectives:The aim of this study was to assess the feasibility of standard portable ultrasound in detecting potentially unstable cervical spine injuries in severe traumatic brain injured (TBI) patients during initial resuscitation.Materials and Methods:This retro-prospective pilot study carried out over 1-month period (June–July 2013) after approval from the institutional ethics committee. Initially, the technique of cervical ultrasound was standardized by the authors and tested on ten admitted patients of cervical spine injury. To assess feasibility in the emergency setting, three hemodynamically stable pediatric patients (≦18 years) with isolated severe head injury (Glasgow coma scale ≤8) coming to emergency department underwent an ultrasound examination.Results:The best window for the cervical spine was through the anterior triangle using the linear array probe (6–13 MHz). In the ten patients with documented cervical spine injury, bilateral facet dislocation at C5–C6 was seen in 4 patients and at C6–C7 was seen in 3 patients. C5 burst fracture was present in one and cervical vertebra (C2) anterolisthesis was seen in one patient. Cervical ultrasound could easily detect fracture lines, canal compromise and ligamental injury in all cases. Ultrasound examination of the cervical spine was possible in the emergency setting, even in unstable patients and could be done without moving the neck.Conclusions:Cervical ultrasound may be a useful tool for detecting potentially unstable cervical spine injury in TBI patients, especially those who are hemodynamically unstable.

Learning from the dead: improving safety while placing unconscious trauma patients in various lateral positions

Background The unconscious trauma patient with a possible unstable spinal injury constitutes a clinical challenge. To protect the unintubated airway, some guidelines [1,2] recommend that the patient be turned into a lateral position, e.g. the Recovery Position (RP) [1] or the Lateral Trauma Position (LTP) [2]. Other lateral positions have also been proposed, as the HAINES position [3] and variations thereof. However, moving the patient may cause secondary neurological injury. The aim of this study was to explore how much motion lateral position techniques produce in an unstable cervical spine injury.

Cervical spine Injury clearance protocol in Polytrauma patients

It is very common in General Hospital that cervical spine injury is missed in Polytrauma patients at the time of admission. In case where there is no clear indication of cervical spine injury, however, patients still need to be evaluated for cervical spine injuries because an unstable cervical spine injury could to delayed & result in devastation neurological deterioration. So our purpose of study is to reduce the rate of missed cervical spine injury by proposing the clinical guideline for clearance of cervical spine injury.

Comparison of functional and neurological outcome of conservative and operative management in patients with cervical spine injury with complete quadriplegia

Background: Cervical spine injury leads to significant functional impairment, one of them is quadriplegia. Debate between surgical versus conservative management of trauma to cervical spine has been going on since early 19th century. Aims & Objective: This study has been conducted to compare functional and neurological outcome of conservative and operative management in patients with cervical spine injury with complete quadriplegia. Materials and Methods: This was a retrospective study. Case records of 30 patients were analyzed. Patients were divided into 2 groups according to treatment given, i.e. Surgical and conservative. These two groups were compared retrospectively in terms of age, sex, type of injury, Mechanism of injury, mode of injury, stability, hospital stay, complications, neurological involvement and outcome. All patients were evaluated based on four parameters work, Functional independence measure, stability and neurological impairment. These parameters were measured and graded with appropriate modified scale. Results: Mean age of patients in this study was 35 Yr. (Operative 31.88 Yr, Conservative 38.2 Yr.) With approximately 73 % belongs to 20 to 40 years group of young and active individual. Road traffic accident was the major culprit for cervical spine injury in this study. It accounts for 46.66% of total patients, followed by fall from height and fall of heavy object on patient. In operative group out of 15 patient 3 had stable cervical spine injury & 12 had unstable injury. In conservative group 5 had stable cervical spine injury and 10 had unstable cervical spine injury. Overall among 30 patient only 15 patient (50%) improve neurologically other remained same or worsened. Neurological improvement in conservative (46.66%) and operative (53.33%) group was found practically to be with negligible difference. Conclusion: The ultimate neurological and functional outcome of cervical injury was probably decided at time of injury itself rather than by chosen management. Improvement in neurological function was independent of factor like type of surgery, Mechanism of injury (flexion-extension), spinal deformity and type of management. Surgical stabilization result in batter alignment and stability, early rehabilitation and probably decrease in length of stay but has its own complication and great economic burden to patients.