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Dislocation between fifth & sixth cervical vertebrae
560
American
Journal
of Surgery
Krida-Dislocation
of Vertebrae
phine; he had hurt his knee, and by having the joint aspirated of about 6o C.C. of blood, he was entirely relieved. As to Dr. MiIch’s remarks about these fractures, I did not mean to imply that there if no such condition as osteochondritis dis-
SEPTEMBER. ,930
secans; it must be very rare; in exploring kneejoints I have never seen one that I could not attribute to traumatism. I have never seen ostcochondritis dissecans non-traumatic. These fractures correspond in appearance to Koenig’s description of osteochondritis dissecans.
DISLOCATION BETWEEN FIFTH @ SIXTH CERVICAL VERTEBRAE DELAYED
OPERATIVE ARTHUR
REDUCTION
KRIDA, M.D., F.A.C.S. NEW
T
HE
which
case
a
here
reported
successful
is
outcome
& FUSION*
one
YORK
in
was
obtained by open reduction and fusion of a gros.sIy unstabIe fifth and sixth cervical dislocation, eleven weeks after injury. The possible failure to obtain and the obvious failure to maintain reduction are outlined in the recital of events
prior to the date of operation.
being fastened to a single foot stirrup, and counter traction by a surcingle over the iliac crests reinforced by manual traction on the Iower extremities. After fairly considerable traction had been apphed, there was a coarse bony click. The traction on the head was then maintained manually and a pIaster of Paris dressing was applied including the chin and occiput and extending to below the nipple line. The patient was not again seen until admission to Hospital for Ruptured and Crippled five weeks later, and details of his stay at the country hospital include an x-ray picture taken through the plaster collar which was reported upon as indicating that the dislocation had been reduced. Without advice the collar was removed at the end of three weeks since there was no evidence of paralysis at this time and patient ahowcd to sit up and move his neck about. At this time an x-ray- was made which, much to the astonishment of the attending surgeon, showed that the dislocation has either recurred or in the initial instance not been reduced. November g, 1928. Hospital for Ruptured and Crippled. There was no pain, paralysis, or gross external deformity. The x-rav sholvcd a rcmarkabIc degree of dislocation at the junction of the fifth and sixth cervical vertebrae. The dislocation of the fifth body was of a degree where its posterior border impinged just behind the anterior upper border of the sixth. There was aIso an angulation at this point in which the upper part of the spine was angulated forward on the lower. There was no evi-
History: A. H., aged forty-two, laborer. Forty-eight hours previously he was struck on the back of the head by a bale of hay falling from a Ioft in the barn. It was stated that he was immediately disabled and that he had paralysis of the extensors of the wrists and fingers, and of the biceps humeri on both sides, together with a feeling of heaviness in both Iower extremities. I was asked to see the patient at the request of an insurance company in consuItation with his attending physician at a hospital in the country. He had at this time no paralysis, but weakness of the extensors of the wrist and fingers, and a very much increased knee-jerk on the right side. He was in great pain and his neck was rigid. The x-ray showed a nearly complete forward dislocation of the fifth upon the sixth cervical vertebra. I. Closed manipulation. The Operation patient was removed to the operating room. Traction apparatus was improvised, and the patient was anesthetized with cthcr. Traction was applied to the head with an improvised portable Hawley apparatus, the head straps * Case reported and .x-rays shown before the Set tion of Orthopedic Surgery, New York Academy of Rlcdicine, February,
1930.
FIG. I. Condition
five weeks after injury.
~__
__
-. .____
_
FIG. 3. Recurrence of deformity
in Calot jacket.
FIG. 4. Solid fusion with slight deformity after open operation. I[56111
six months
562
American Journal of Surgery
Krida-DisIocation
dence of gross crushing or of fracture of the laminae. He was pIaced on a convex stretcher frame and traction was appIied to the head. After one week an .x-ray showed a marked reduction in the deformity. After three weeks of traction a Calot pIaster of Paris jacket was appIied under suspension. Five days Iater an x-ray was made through the Calot jacket, which showed that the deformity had recurred to substantiaIIy the degree present on his admission to hospital. This indicated that there was no stabiIity in the operated area, and he was prepared for open operation. Operation 2. December II, 1928. Operation for disIocation of the cervica1 spine. A Iong median incision, the patient’s head resting in a special head rest so arranged with a traction band so that traction couId be made during the operation, the band being pIaced around the waist of an assistant. The spinous processes and Iaminae were exposed beginning at the first dorsa1 vertebra and working upward. It was found that at the junction of the fifth and sixth cervica1 vertebrae, the upper ones were dispIaced forward and flexed to a fairIy remarkabIe degree, the distance between the Iamina of the sixth and that of the fifth being fuIIy I in. and the forward displacement in this pIane being about $6 in. The Iaminae of
+EI3+
of Vertebrae
SEPTEMBER.
,930
the fifth, fourth and third were carefuIIy freed and exposed. Then by combination of grasping the Iamina of the fifth and Ievering on either side between the articuIar facets and by traction on the head, the fifth was graduaIIy mobiIized and drawn backwards on to the sixth. At the termination of the mobiIization and reduction and upon reIeasing the traction on the head there was a fair tendency for the bones to remain in pIace. Fusion between the fifth and sixth was then done by the Hibbs method, turning up bone from both Iaminae and erasing the joint, spIitting the spinous processes and utiIizing as re-enforcing materia1 the split spinous process of the seventh cervica1 vertebra. The incision was cIosed and the previousIy prepared pIaster of Paris CaIot coIIar was appIied. The postoperative x-ray showed that the disIocation had been reduced. The patient was discharged from the hospita1 at the end of six weeks, wearing a CaIot coIIar, for which a Ieather Thomas coIIar was substituted after one month. AI1 support was removed at the end of five months. August 31, 1929, eight and one haIf months after operation, the x-ray shows that the fused area is soIid, and that there is but slight deformity.
American
Journal
of Surgery
Krida-Dislocation
of Vertebrae
phine; he had hurt his knee, and by having the joint aspirated of about 6o C.C. of blood, he was entirely relieved. As to Dr. MiIch’s remarks about these fractures, I did not mean to imply that there if no such condition as osteochondritis dis-
SEPTEMBER. ,930
secans; it must be very rare; in exploring kneejoints I have never seen one that I could not attribute to traumatism. I have never seen ostcochondritis dissecans non-traumatic. These fractures correspond in appearance to Koenig’s description of osteochondritis dissecans.
DISLOCATION BETWEEN FIFTH @ SIXTH CERVICAL VERTEBRAE DELAYED
OPERATIVE ARTHUR
REDUCTION
KRIDA, M.D., F.A.C.S. NEW
T
HE
which
case
a
here
reported
successful
is
outcome
& FUSION*
one
YORK
in
was
obtained by open reduction and fusion of a gros.sIy unstabIe fifth and sixth cervical dislocation, eleven weeks after injury. The possible failure to obtain and the obvious failure to maintain reduction are outlined in the recital of events
prior to the date of operation.
being fastened to a single foot stirrup, and counter traction by a surcingle over the iliac crests reinforced by manual traction on the Iower extremities. After fairly considerable traction had been apphed, there was a coarse bony click. The traction on the head was then maintained manually and a pIaster of Paris dressing was applied including the chin and occiput and extending to below the nipple line. The patient was not again seen until admission to Hospital for Ruptured and Crippled five weeks later, and details of his stay at the country hospital include an x-ray picture taken through the plaster collar which was reported upon as indicating that the dislocation had been reduced. Without advice the collar was removed at the end of three weeks since there was no evidence of paralysis at this time and patient ahowcd to sit up and move his neck about. At this time an x-ray- was made which, much to the astonishment of the attending surgeon, showed that the dislocation has either recurred or in the initial instance not been reduced. November g, 1928. Hospital for Ruptured and Crippled. There was no pain, paralysis, or gross external deformity. The x-rav sholvcd a rcmarkabIc degree of dislocation at the junction of the fifth and sixth cervical vertebrae. The dislocation of the fifth body was of a degree where its posterior border impinged just behind the anterior upper border of the sixth. There was aIso an angulation at this point in which the upper part of the spine was angulated forward on the lower. There was no evi-
History: A. H., aged forty-two, laborer. Forty-eight hours previously he was struck on the back of the head by a bale of hay falling from a Ioft in the barn. It was stated that he was immediately disabled and that he had paralysis of the extensors of the wrists and fingers, and of the biceps humeri on both sides, together with a feeling of heaviness in both Iower extremities. I was asked to see the patient at the request of an insurance company in consuItation with his attending physician at a hospital in the country. He had at this time no paralysis, but weakness of the extensors of the wrist and fingers, and a very much increased knee-jerk on the right side. He was in great pain and his neck was rigid. The x-ray showed a nearly complete forward dislocation of the fifth upon the sixth cervical vertebra. I. Closed manipulation. The Operation patient was removed to the operating room. Traction apparatus was improvised, and the patient was anesthetized with cthcr. Traction was applied to the head with an improvised portable Hawley apparatus, the head straps * Case reported and .x-rays shown before the Set tion of Orthopedic Surgery, New York Academy of Rlcdicine, February,
1930.
FIG. I. Condition
five weeks after injury.
~__
__
-. .____
_
FIG. 3. Recurrence of deformity
in Calot jacket.
FIG. 4. Solid fusion with slight deformity after open operation. I[56111
six months
562
American Journal of Surgery
Krida-DisIocation
dence of gross crushing or of fracture of the laminae. He was pIaced on a convex stretcher frame and traction was appIied to the head. After one week an .x-ray showed a marked reduction in the deformity. After three weeks of traction a Calot pIaster of Paris jacket was appIied under suspension. Five days Iater an x-ray was made through the Calot jacket, which showed that the deformity had recurred to substantiaIIy the degree present on his admission to hospital. This indicated that there was no stabiIity in the operated area, and he was prepared for open operation. Operation 2. December II, 1928. Operation for disIocation of the cervica1 spine. A Iong median incision, the patient’s head resting in a special head rest so arranged with a traction band so that traction couId be made during the operation, the band being pIaced around the waist of an assistant. The spinous processes and Iaminae were exposed beginning at the first dorsa1 vertebra and working upward. It was found that at the junction of the fifth and sixth cervica1 vertebrae, the upper ones were dispIaced forward and flexed to a fairIy remarkabIe degree, the distance between the Iamina of the sixth and that of the fifth being fuIIy I in. and the forward displacement in this pIane being about $6 in. The Iaminae of
+EI3+
of Vertebrae
SEPTEMBER.
,930
the fifth, fourth and third were carefuIIy freed and exposed. Then by combination of grasping the Iamina of the fifth and Ievering on either side between the articuIar facets and by traction on the head, the fifth was graduaIIy mobiIized and drawn backwards on to the sixth. At the termination of the mobiIization and reduction and upon reIeasing the traction on the head there was a fair tendency for the bones to remain in pIace. Fusion between the fifth and sixth was then done by the Hibbs method, turning up bone from both Iaminae and erasing the joint, spIitting the spinous processes and utiIizing as re-enforcing materia1 the split spinous process of the seventh cervica1 vertebra. The incision was cIosed and the previousIy prepared pIaster of Paris CaIot coIIar was appIied. The postoperative x-ray showed that the disIocation had been reduced. The patient was discharged from the hospita1 at the end of six weeks, wearing a CaIot coIIar, for which a Ieather Thomas coIIar was substituted after one month. AI1 support was removed at the end of five months. August 31, 1929, eight and one haIf months after operation, the x-ray shows that the fused area is soIid, and that there is but slight deformity.