thoracolumbar fracture: evaluation and management from er to rehab

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2011 Annual MeetingInstructional Course

Lecture Handout

Course Number:252

Course Title:Thoracolumbar Fracture: Evaluation and Management from ER to Rehab

Location:San Diego Convention Center, Room 4

Date & Start Time:16-Feb-2011 01:30 PM

INSTRUCTORS WHO CONTRIBUTED TO THIS HANDOUT:

Carlo Bellabarba, MD- 2 (Synthes);5 (Stryker; Synthes); Submitted on: 09/21/2010 and last confirmed asaccurate on 10/16/2010.

Marcel F Dvorak, MD- 1 (Medtronic Sofamor Danek);2 (Medtronic Sofamor Danek; Synthes);3B (MedtronicSofamor Danek);5 (Medtronic Sofamor Danek; DePuy, A Johnson & Johnson Company; Synthes; Arcus);6 (DePuy,A Johnson & Johnson Company; Medtronic Sofamor Danek; Synthes);7 (Thieme); Submitted on: 09/29/2010.

John C France, MD- 6 (Medtronic Sofamor Danek); Submitted on: 09/13/2010.

Mitchel B Harris, MD- (n) Submitted on: 05/25/2010 and last confirmed as accurate on 09/12/2010.

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The Academy does not view the existence of these disclosed interests or commitments implying bias or decreasing

the value of the authors participation in the meeting.

DISCLAIMER

The material presented at this course has been made available by the AAOS for educational purposes only.

The AAOS disclaims any and all liability for injury, loss or other damages resulting to any individual attending the

course and for all claims, which may arise from the use of techniques and strategies demonstrated therein. The

material is not intended to represent the only methods, procedures or strategies for the situations discussed. Rather,

the course is intended to present an array of approaches, views, statements and opinions which the faculty believe

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2011 AAOS Annual Meeting

ICL 252 - Thoracolumbar Fracture: Evaluation and Management from ER to

Rehab

Moderator: Mitchel B. Harris, MD

Order of Presentations:

Mitchel Harris, M.D. FACS

Emergency Room Evaluation of the Trauma Patient R/O Spinal Injury

Evaluation and Early Management of the Spin Injured Patient

Marcel Dvorak, MD, FRCSC

Non-operative Management of Thoracolumbar Injuries

John C. France M.D.

Thoracolumbar Fractures Anterior versus Posterior Surgical Options

Carlo Bellabarba, M.D

Sacral Fractures with Lumbosacral/Lumbopelvic Instability


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EMERGENCY ROOM EVALUATION OF THE TRAUMA PATIENT

R/O SPINAL INJURY

EVALUATION AND EARLY MANAGEMENT OF THE SPINE INJURED

PATIENT

Mitchel Harris, M.D. FACS

Partners Orthopaedic Trauma Service

Brigham and Womens Hospital

Associate Professor

Harvard Medical School

Dept. of Orthopaedic Surgery

I. ATLS: ADVANCED TRAUMA LIFE SUPPORT

Advanced Trauma Life Support teaches a systemic, concise approach to the earlycare of the trauma patient. The ATLS Program provides a safe, reliable method

for immediate management of the injured patient and the basic knowledgenecessary to address life then limb threatening injuries. All trauma patients are

presumed to have sustained a spinal column injuryuntil proven otherwise.

1. Primary Survey

A. Airway Management

1. Intubation: method to protect airway from obstruction after trauma

a. Bloodb. Tongue, teeth

c.

Laryngeal trauma

d. Facial trauma: 7-24% association with cervical spineinjuries (J Trauma 93; 34:549-553; J Trauma85; 90-93)

2. Tracheostomy: in line intubation; chin lift, jaw thrust

B. Breathing

1. Tension/Open Pneumothorax

2. Hemothorax

3. High energy chest trauma increases suspicion for thoracic spineinjury

a. Sternal fractures: Fourth column

b.

Floating/Flail chest4. Supplemental O2 administration in presence of SCI

C. Circulation

1.

Heart rate

2. Blood pressure, urine output

3. Hypotension rule out hemorrhage first; crystalloid resuscitation


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a. if unresponsive: early admin of O negative blood

b. Hypotension (90 mm Hg) + bradycardia ( 100 mm Hg.

D. Cervical Spine immobilization in the field

1. Adults: Field collar and backboard

2. Kids: pediatric trauma board with recessed head spot

a. Pediatric cranium disproportionately large compared totrunk neck forced into flexion.

b. Forehead taped to backboard with sandbags at sides

2. Secondary Survey

Complete clinical assessment from head to tail. Begins after hemodynamicstability is achieved or during active resuscitation. Principle Goal:

Identification of additional injuries that may require urgent/emergentintervention as well as lesser injuries.

A. Patients actively able to participate in evaluation

B. Patients able to participate but distracted from associated

injuries

C. Patients unable to actively participate in evaluation

1. Closed head injury

2.

Intubated and sedated

3. Alcohol, drugs, pharmaceuticals

3. Secondary Survey With Respect to the Spine

A. Credible Exam: findings determine necessity of radiographs

B. Compromised Exam: pharmacologically induced or other full

spine evaluation

1. Log-rolling not as safe as we believe( J Trauma 87; 27:525-31; J Trauma 2004; 57: 609-611)

2. Observe: abrasions, ecchymosis, open injuries

3. Palpate

a. Tendernessb.

Step-offs/Diastasis

c. Soft tissue bogginess

4. Full sensori-motor examination (see diagram)


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5. Peri-anal/perineal exam

6. Spinal shock = spinal cord concussiona. Bulbo cavernosus reflex

b. Conus injury

4. Steroids (Spine 2001; 26(24): S39-46)

A. Routine use of steroids in patients with acute SCIs is not

supported by the literature

B. Polytrauma patients may be more susceptible to complications

associated with the administration of high doses of steroids

1. Wound infections

2.

Pulmonary complications: pneumonia, emboli3. Sepsis

II. RADIOGRAPHIC EVALUATION OF THE SPINE IN THE EMERGENCY

ROOM

1. Isolated Spinal Injury

A. Plain films if low energy; region specific

B. MDCT with reconstructive views

C.

MRI

1. Neurological injury2. Unexplainable clinical exam after MDCT

3. Pre-op assessment of soft tissue component of injury:

ligaments, disc, spinal cord

2. Spine Injury in Presence of Polytrauma

A. CT scan of Head/C-spine/Chest/Abd/Pelvis

1. Recon views for initial spinal screening

2. Dedicated MDCT for spinal pathology if initial CT inadequate

for full assessment3. Dedicated MDCT for pre-op planning

B. MRI: Only if patient sufficiently stable

1.

Neurological injury

2. Unexplainable clinical exam


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3. Pre-op assessment of soft tissue component of injury:

ligaments, disc, spinal cord

III. SPINAL ASSESSMENT

1. Biomechanical Stability: Definition: subject to much debate

A. 2-column: Holdsworth

B. 3-column: Louis, Denis< McAfee

C. Mechanistic classification: Magerl/ AO

i. Flexion --- predominant compression ( anterior column) injuryspectrum

ii.

Distraction --- predominant extension ( posterior disruption)injury spectrum

iii. Multi-directional instabilityno residual stability

D. Posterior ligamentous complex (PLC) integrity of high

importance to stability theories ( Spine 94 James)

i. MRI assessment of PLC1. Spine 2000; 25: 2079-2084

2. Radiology 95; 194: 49-54 Black Stripe

3. Spine J 06; 6: 524-528

2. Neurology: #1 Driving factor to operative intervention

A. Intact neurology

i.

Regardless of canal compromise: You cant be better than

neurologically intactii. Rare occasion of subacute neurological deterioration

B. Incomplete SCI/ Conus Injury

i. Tendency to want to create an environment for neurological

improvement through decompressionii. Only animal studies document direct relationship between

length of time and severity of compression with respect to

neurological improvementiii. Isolated Conus lesion demonstrates better improvement with

anterior decompression.

C.

Complete SCI:

i. Biomechanical stability: no need for spinal procedure

ii. Unstable biomechanically: restore stability and avoid bracing

which can limit mobilization and lead to pressure sores in theinsensate.

3. Combined neurological and mechanical instability


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Non-operative Management of

Thoracolumbar Injuries

Marcel Dvorak, MD, FRCSC

Professor of OrthopaedicsUniversity of British Columbia

Vancouver General Hospital

Introduction:

Thoracolumbar burst fractures account for approximately fifteen percent of allthoracolumbar spine injuries. Burst fractures occur as a result of an axial load which

produces comminution of the involved vertebral body with associated retropulsion of

bone into the spinal canal, hence the term burst fracture. Despite being a commonfracture, there is significant variability in treatment recommendations bridging the

spectrum from anterior vertebrectomy and reconstruction to mobilization withoutexternal bracing. This controversy exists partly in response to ambiguity regarding the

definition of mechanical stability and the indications for operative treatment of thesefractures.

Stability of Thoraco-lumbar Fractures:

Generally, thoracolumbar burst fractures can be categorized as being clinically stable or

unstable from a mechanical or neurologic perspective. Denis proposed that injury tomiddle vertebral column in addition to the anterior column is the hallmark of vertebral

instability. Contrary to the assertions of Denis, James et al found that the posteriorcolumn is the most important contributor to spinal stability. They used staged

osteotomies to compromise the integrity of the anterior, then middle, and finally the

posterior columns of L1. The disruption of the anterior column alone, led to a significantincrease in angulation and translation of the T12-L2 motion segment when compared to

the intact spine. Further disruption of the middle column did not substantially change the

flexibility. Whereas, when the posterior ligaments were severed, there was a significant

increase in angulation over that observed when just the anterior and middle columns weredisrupted.

It is apparent from biomechanical studies, as well as clinical studies of Oner and others,that both the vertebral body injury and the posterior element injuries contribute in

different ways to the resultant degree of stability or stiffness of the injured spine segment.

The challenge is to somehow quantify the degree of disruption of these variousanatomical structures and thus express their relative contribution to the overall stability of

the injured spine.


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Stability as defined by Radiographs

Clinicians rely on radiographic parameters, such as kyphosis, vertebral comminution, and

loss of vertebral height, when determining fracture stability and the indications for non-

operative or surgical treatment. The loss of anterior unit height, which is the anteriorvertebral height plus the disc spaces above and below, has a strong correlation with

flexion-extension motion and axial stability. The deformation ratio; defined as the ratio

of the greatest sagittal vertebral diameter to the average of the anterior vertebral heightand posterior vertebral height correlates strongly with stability.

Neurologic Injury and Spinal Canal Occlusion

Neurologic deficit is associated with up to 50% of thoracolumbar burst fractures.

Dynamic canal encroachment at the moment of fracture differs from the staticencroachment measured after the injury has occurred. There is no significant correlation

between the occurrence or the extent of neurologic injury with the degree of spinal canalocclusion measured by axial CT.

Comparative Surgical vs. Non-Operative Studies

There are a number of comparative studies looking at surgery vs non-surgical care forthoracolumbar fractures without neurological deficit.

Wood, in a prospective trialfound a statistically significant difference in function and

disability favouring non-operative treatment; however, significant methodological issues

reduce the impact of this conclusion. Shen found that correction of kyphosis wasachieved better through surgery. However, the degree of kyphosis was found to progress

regardless of treatment and final kyphosis did not correlate with pain or function, a theme

consistent throughout the literature. Shen suggested an improved outcome in the surgicalpatients at 6 months but no difference at one year.

Siebenga, in a well designed and appropriately powered prospective study suggested that

surgery leads to improved outcomes, less pain and disability and improved return towork.

Neurological deterioration in this population is rare. Surgery exposes patients to a greaterrisk of both complication and possible future surgery.

Burst fractures of the thoracolumbar junction are common. There exists a wealth ofpublished studies concerning thoracolumbar burst fractures; however their

methodological quality is uniformly poor. At present, the available evidence to justify

the additional risks of surgery is minimal. Fisher has shown that use of a thoracolumbarorthosis does not improve outcome when compared to mobilization without an orthosis.


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It is possible that surgery is the treatment of choice for burst fractures at the

thoracolumbar junction without neurological deficit. Surgery theoretically may result inearlier mobilization, and hospital discharge, less initial pain and faster return to work, an

issue of considerable economic relevance.

Although final sagittal alignment is better maintained in patients who have undergonesurgery, vertebral alignment does not seem to correlate with HRQoL outcomes. Until

further evidence becomes available, the clinician should consider these facts when

making treatment decisions in cases of this common injury.

References:

1) Hashimoto T, Kaneda K, Abumi K. Relationship between traumatic spinal canalstenosis and neurologic deficits in thoracolumbar burst fractures. Spine 1988;

13(11):1268-1272.

2) Limb D, Shaw DL, Dickson RA. Neurological injury in thoracolumbar burst fractures.J Bone Joint Surg Br 1995;77(5):774-777.

3) Mehta JS, Reed MR, McVie JL, Sanderson PL. Weight-Bearing Radiographs in

Thoracolumbar Fractures : Do They Influence Management ? Spine 29(5) : 564-

567.4) Frankel HL, Hancock DO, Hyslop G, Melzak J, Michaelis LS, Ungar GH, Vernon JD,

Walsh JJ. The value of postural reduction in the initial management of closed injuries

of the spine with paraplegia and tetraplegia. Paraplegia 1969;7(3):179-192.5) Davies WE, Morris JH, Hill V : An analysis of conservative (non-surgical)

management of thoracolumbar fractures and fracture-dislocations with neural damage.

J Bone Joint Surg Am 1980;62:1324-1328.

6) Burke DC, Murray DD: The management of thoracic and thoracolumbar injuries ofthe spine with neurological involvement. J Bone Joint Surg Br 1976;58:72-78.

7)Kinoshita H, Nagata Y, Ueda H, Kishi K. Conservative treatment of burst fracturesof the thoracolumbar and lumbar spine. Paraplegia 1993;31(1):58-67.

8) Hartman MB, Chrin AM, Rechtine GR. Non-operative treatment of thoracolumbar

fractures. Paraplegia 1995;33(2):73-76.

9) Rivlin AS, Tator CH. Objective clinical assessment of motor function afterexperimental spinal cord injury in the rat. J Neurosurg 1977;47(4):577-581.

10) Rivlin AS, Tator CH. Effect of duration of acute spinal cord compression in a new

acute cord injury model in the rat. Surg Neurol 1978;10(1):38-43.11) Dolan EJ, Tator CH, Endrenyi L. The value of decompression for acute experimental

spinal cord compression injury. J Neurosurg 1980; 53(6):749-755.12) Delamarter RB, Sherman J, Carr JB : Pathophysiology of spinal cord injury :

Recovery after immediate and delayed compression. J Bone Joint Surg Am

1995 ;77 :1042-1049.

13) Carlson GD, Minato Y, Okada A, Gorden CD, Warden KE, Barbeau JM, Biro CL,Bahnuik E, Bohlman HH, Lamanna JC. Early time-dependent decompression for

spinal cord injury : vascular mechanisms of recovery. J Neurotrauma 1997;

14(12):951-962.


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14) Holdsworth F: Fractures, dislocations and fracture-dislocations of the spine. J Bone

Joint Surg Am 1970;52:1534-1551.15) James KS, Wenger KH, Schlegel JD, et al : Biomechanical evaluation fo the stability

of thoracolumbar burst fractures. Spine 1994;19:1731-1740.

16) Denis F: The three column spine and its significance in the classification of acute

thoracolumbar spinal injuries. Spine 1983;8:817-831.17) Panjabi MM, Goel VK, Takata K. Physiologic strains in the lumbar spinal ligaments. An in

vitro biomechanical study. 1981 Volvo Award in Biomechanics. Spine 1982;7(3):192-203.

18) Panjabi MM, Oxland TR, Lin RM, McGowen TW : Thoracolumbar burst fracture:A biomechanical investigation of its multidirectional flexibility. Spine 1994;19:578-

585.

19) Gertzbein SD: Scoliosis Research Society: Multicenter spine fracture study. Spine1992;17:528-540.

20) Weinstein JN, Collalto P, Lehmann TR: Thoracolumbar burst fractures treated

conservatively: A long-term follow-up. Spine 1988;13:33-38.21) Mumford J, Weinstein J, Spratt K, Goel V. Thoracolumbar burst fractures. The

Clinical efficacy and outcome of nonoperative management. Spine 1993; 18(8):955-970.

22) Chow GH, Nelson BJ, Gebhard JS, Brugman JL, Brown CW, Donaldson DH.Functional outcome of thoracolumbar burst fractures managed with hyperextension

casting or bracing and early mobilization. Spine 1996; 21(18):2170-2175.

23) Shen WJ, Shen YS: Non-surgical treatment of three-column thoracolumbar junctionburst fractures without neurologic deficit. Spine 1999;24:412-415.

24) Kraemer WJ, Schemitsch EH, Lever J, McBroom RJ, McKee MD, Waddell JP.

Functional outcome of thoracolumbar burst fractures without neurological deficit. JOrthop Trauma 1996 ; 10(8) :541-544.

25) Rechtine G, Cahill D, Chrin A. Treatment of thoracolumbar trauma : comparison ofcomplications of operative versus nonoperative treatment. J Spinal Disord

1999 ;12(5) :406-409.

26) Wood K, Butterman G, Mehbod A, Garvey T, Jhanjee R, Sechriest V: Operativecompared with nonoperative treatment of a thoracolumbar burst fracture without

neurological deficit. J Bone Joint Surg 2003;85-A:773-781.

27) Cantor JB, Lebwohl NH, Garvey T, Eismont FJ: Non-operative management of

stable thoracolumbar burst fractures with early ambulation and bracing. Spine1993;18:971-976.

28) Siebenga, J, Leferink V, Segers M, et al: Treatment of Traumatic Thoracolumbar

Spine Fractures: A Multicenter Prospective Randomized Study of Operative VersusNonsurgical Treatment. Spine. 31(25):2881-2890, December 1, 2006.


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Thoracolumbar Fractures

Anterior versus Posterior Surgical Options

John C France M.D.

Professor of Orthopaedic SurgeryWest Virginia University

Determining Factors1. Fracture Dependent

Ability to correct deformity (alignment) of fracture Need or & ability to decompress neural elements

Ability to control fracture (stabilize)

Fracture level (e.g. Low lumbar) Multiples levels

Fracture pattern Compression

Burst Flexion distraction

Extension

Fracture dislocation Ankylosing spondylitis

Determining Factors2. Surgeon/ Facility Dependent

Familiarity with approaches Ancillary support (ICU & vascular, thoracic, or trauma surgeons)

Available equipment

Better to do what you do best

Determining Factors3. Patient Dependent

Additional injuries Medical Comorbidities

Osteoporosis

Body habitus Desires of patient

Fracture PatternsGeneralities

Compression fracture

Stability & alignment only issues

Easily achieved posteriorly, short segment

Flexion distraction injuries


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DecompressionIf patient has deficit

LigamentotaxisLigamentotaxis with

posterolateral

decompression

Direct anterior

decompression

Posterior Posterior Anterior

Limits of Posterior Decompression

Rotated fragment, Create addition instability by bone removal

Diminish surface area for fusion

Bleeding Verification

DecompressionAnterior

Direct visualization

Reconstruct with anterior column support through defect

Posterior

Indirect, more difficult to verify complete

Add to instability and decrease surface area for fusion massBoth can be bloody

How much decompression necessary?

StabilityAxial load injuries

Burst or flexion-compression Anterior column support: Load sharing concept

McCormack T, Karaikovic E, Gaines RW

Spine 1994 19:1741-1744


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Special Circumstances

Osteoporosis Posterior

Include extra levels

Percutaneous Fixation Boney Chance

Multi-trauma

Summary

Spine trauma Surgeon should be familiar with both anterior & posteriorapproaches

Can usually use surgeon preferred direction

Some circumstances clearly favor one direction need to recognize these


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SACRAL FRACTURES Bellabarba

4. Classification

- Stable versus unstable- Three basic categories of pelvic region injuries:

- Pelvic ring fractures (Tile, Letournel, AO/ASIF)

- Lumbo-sacral junction disruption (Isler) Sacral fractures: Denis

- Roy-Camille sub-classification system for transverse Denis Zone III fractures.

Category A B C

Prevalent

Injury Zone

Pelvic Ring Lumbo

sacral

junction

Sacrum

Classifica-

tion system

TileLetournel

AO/ASIF

Isler DenisRoy-Camille

(Subclassificatio

n of Denis Zone

III)Descriptive

alphabet pattern

Pelvic ring injury Category B: Lumbo-sacral junction trauma:

- Dislocation versus fracture dislocation

- Unilateral versus bilateral

Classification of Isler differentiates location of a sacral fracture relative to L5 - S1 stability.

1. Fracture lateral to the L5 S1 facet joint: lumbo-sacral stability not impaired2. Injuries crossing through the L5- S1 facet joint

a)

extra-articular fractures of the lumbo-sacral junctionb) articular dislocations with various stages of displacement of the L5 and S1 articular

processes.3. Fractures crossing into the neural arch medial to the L5-S1 joint are usually complex

and inherently unstable in nature.

3


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- Brace or cast immobilization with unilateral or bilateral hip spica extensions

- Recumbent skeletal traction

- Duration: 8 to 12 weeks

Decompression Techniques

Posterior:central spinal canal or neuroforaminal decompressionIndication:reduction of the size of the first or second sacral foramen by 50 per cent in conjunction with

sciatica-type symptomsTechnique:midline exposure with hemilaminotomy/ laminectomy emanating from the L5/S1 laminar

interspace preferable to a parasagittal approach to avoid soft tissue compromise.

Bilateral parasagittal approaches , such as necessary for bilateral transiliac iliac platings, such be if at all

possible, avoided due to high soft tissue breakdown rate.

Anterior:ilioinguinal or low transperitoneal exposure

Indications:patients with lumbosacral plexopathy who require prealar neurolysis of decompression (rare)

Decompression techniques:

- Direct (fragment removal, laminectomy etc.)- Indirect (fracture reduction, ventral disimpaction, sacral kyphectomy)

Surgical Stabilization Techniques

- Assess anterior fixation needs first- Posterior pelvic ring stabilization

- Transiliac threaded compression rods (largely outdated)

- Iliac tension band plates (requires bilateral parasagittal approaches)- Sacral alar plating (small fragment plates inserted into ala lateral to posterior

neuroforamina) limited usefulness due to frequent comminution and limited

biomechanical stiffness- Open or percutaneous sacro-iliac screw fixation (for a wide variety of mildly and

moderately displaced sacral fractures)

- Galveston-type lumbo-iliac fixation techniques (for complex sacral H and U type

fractures); newer systems allow for segmental screw fixation to ileum instead of rod

placement.- Segmental lumbo-screw screw/rod fixation for lumbo-sacral dislocation

6. References:

1. Bellabarba C, Schildhauer TA, Vaccaro AR, Chapman JR: Complications associated withSurgical Stabilization of High-Grade Sacral Fracture-Dislocations with Spino-Pelvic

Instability. Spine 31(11S):S80-88, 2006.

2. Chapman JR, Schildhauer TA, Bellabarba C, Nork SE, Mirza SK: Treatment of SacralFractures with Neurologic Injuries. Top Spinal Cord Inj Rehabil, 8(2): 59-78, 2002.

3. Denis F, Davis S, Comfort T. Sacral fractures: An important problem. Retrospective analysis

of 236 cases. Clin Orthop 1988;227:67-81.

4. Isler B. Lumbosacral lesions associated with pelvic ring injuries.J Orthop Trauma1990;4:1-6.

5. Josten C, Schildhauer TA, Muhr G: Therapy of unstable sacrum fractures in pelvic ring.

Results of osteosynthesis with early mobilization] Chirurg. 1994 Nov;65(11):970-5. German.

5


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6. Nork SE, Jones CB, Harding SP et al. Percutaneous stabilization of U-shaped sacral

fractures using iliosacral screws: Technique and early results.J OrthopTrauma 2001;15:238-

46.

7. Oransky M, Gasparini G: Associated lumbosacral junction injuries (LSJIs) in pelvic

fractures. J Orthop Trauma. 1997 Oct;11(7):509-12.

8. Phelan ST, Jones DA, Bishay M. Conservative management of transverse fractures of the

sacrum with neurological features: A report of four cases.J BoneJoint Surg [Br] 1991;73:969-71.

9. Roy-Camille R, Saillant G, Gagna G, et al. Transverse fracture of the upper sacrum: Suicidal

jumpers fracture. Spine 1985;10:838-45.

10. Savolaine ER, Ebraheim NA, Rusin JJ, et al. Limitations of radiography and computed

tomography in the diagnosis of transverse sacral fracture from a high fall. A case report. Clin

Orthop 1991;272:122-126.

11. Schildhauer TA, Ledoux WR, Chapman JR, et al. Triangular osteosynthesis and iliosacralscrew fixation for unstable sacral fractures: A cadaveric and biomechanical evaluation under

cyclic loads.J Orthop Trauma 2003;17:22-31.

12. Schildhauer TA, McCulloch P, Chapman JR, et al. Anatomic and radiographicconsiderations for placement of transiliac screws in lumbopelvic fixations.JSpinal Disord

Tech 2002;15:199-205.

13. Schildhauer TA, Josten CH, Muhr G. Triangular osteosynthesis of vertically unstable

sacrum fractures: A new concept allowing early weight bearing.J OrthopTrauma

1998;12:307-14.

14. Schildhauer TA, Bellabarba C, Nork SE, Barei DP, Routt MLC, Chapman JR:

Decompression and Lumbopelvic Fixation for High Grade Sacral Fracture-Dislocations with

Spino-Pelvic Dissociation, J Orthop Trauma 20:447-457, 2006.

15. Strange-Vognsen HH, Lebech A. An unusual type of fracture in the upper sacrum.J

Orthop Trauma 1991;5:200-3.

16. Strange-Vognsen HH, Kiaer T, Tondevold E: The Cotrel-Dubousset instrumentation for

unstable sacral fractures. Report of 3 patients. Acta Orthop Scand. 1994 Apr;65(2):219-20.

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thoracolumbar fracture: evaluation and management from er to rehab

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