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Fracture of the cervical spine complicating bilateral fractures of the mandible: A case report
British Journal of Oral and Maxillofacial Surgery (1985) 23, 279-283 of Oral and Maxillofacial Surgeons @ 1985 The British Association
FRACTURE
OF THE CERVICAL
FRACTURES
SPINE COMPLICATING
OF THE MANDIBLE:
BILATERAL
A CASE REPORT
K. W. HEMMINGS,B.D.S. Department of Dental and &al Surgery, Dudley Road Hospital, Birmingham
Summary. A case reported of a 21-year-old male who sustained a fracture of the body of the second cervical vertebra, a bilateral fracture of the mandible and a deep laceration on the left side of his neck. The importance of excluding cervical spine fractures in cases of severe trauma to the head and neck is emphasised, and the airway management problems are discussed.
Introduction
In a national survey in America of 46,000 injuries resulting from road traffic accidents, Huelke et al. (1983) found that 14,927 (32 per cent) of these injuries were to the face, and a further 4,606 (10 per cent) of the total involved the neck. A study of cervical spine injuries in Massachusetts General Hospital (Rogers et al., 1958) indicated that 36 per cent exhibited no neurological symptoms. McSweeney (1984) reviewed the diagnosis and management of spinal cord injuries and described symptoms ranging from mild sensory disturbance of the extremities to tetraplegia or death. The combination of facial injuries and fracture of the cervical spine may present difficulty in the treatment and management of the patient. Immobilisation of the cervical spine is of paramount importance and endo-tracheal intubation is contra-indicated. The patient’s airway may be further compromised by facial and jaw injuries. Case Report
A 21-year-old male Caucasian was admitted to the Accident and Emergency Department at Dudley Road Hospital following a road traffic accident. He had been a front seat passenger in a car which somersaulted and landed on its roof. He had been wearing a safety belt. He was unconscious when removed from the car, but on admission was found to be alert and orientated. His main complaints were of pain from the left side of his neck and face. Examination by the Casualty Officer revealed a Z-shaped laceration of the left side of the neck beneath the lower border of the mandible and this was associated with a seat belt friction burn (Fig. 1). There were swellings over the left angle and right body of the mandible and intra-orally there was a step deformity between7 and 4. Limited opening restricted a more detailed examination at this stage. Neurological, cardiovascular, respiratory and abdominal examination were all within normal limits. A provisional diagnosis of bilateral fracture of the mandible was made and the patient was sent for radiographic examination of the skull, facial bones and cervical (Received Address Devon.
for correspondence:
30 July
Department
1984; accepted 30 October of Oral Surgery,
279
Torbay
1984)
Hospital,
Lawes Bridge,
Torquay,
280
BRITISH
JOURNAL
OF
ORAL
Fig. Figul pe l-Anterior
view of the neck showing
&
MAXILLOFACIAL
SURGERY
1
sutured
neck laceration
and surrounding
friction
spine. An orthopantomogram and PA mandible radiograph confirmed the presence of a bilateral fracture of the mandible through the 431 area and the left angle (Fig. 2). In addition, a previously unsuspected fracture through the body of the second cervical vertebra was found on a lateral cervical spine radiograph (Fig. 3). The cervical spine fracture was immobilised by application of a Blackburn caliper, the neck laceration was sutured and the patient admitted to the Intensive Care Unit. Neurological and airway observations were instituted. Antibiotic therapy consisted of Ampicillin and Flucloxacillin intramuscularly. Chymotrypsin was given intramuscularly in an attempt to reduce the increasing swelling in the neck. Eight hours after admission the patient complained of dysphagia and dysarthria. However, there was no stridor and the airway was satisfactory. On the third day the neck swelling had subsided and a tracheostomy was carried out under local anaesthesia. The following day, under general anaesthesia the mandibular fracture was reduced and immobilised with upper and lower arch bars. Intermaxillary fixation was applied using elastic bands. Two days post-operatively the patient was transferred to an orthopaedic ward to be nursed on a rotatable Stryker bed. Five and a half weeks post-operatively the intermaxillary fixation was removed, followed by removal of the tracheostomy tube. A week later the patient was allowed to leave the Stryker bed and a chest plaster and halo fixation was applied. The halo was removed one month later and a neck collar worn for one further month. He failed to attend for final review.
FRACTURE
OF
CERVICAL
SPINE
281
Fig. 2 Figure 2-(A)
Orthopantomogram
(OPG) showing fracture 43 area and Farea. same patient.
(B) PA mandible of the
Discussion Any violent forces that flex, hyper-extend or rotate the neck are likely to cause cervical spine fracture. Road traffic accidents are particularly liable to produce such forces. If seat belts are worn the trunk is restrained, but the head and neck are free to move following impact, often in a whiplash-like manner. Such forced passive extensions, flexions or rotations of the neck predispose to cervical spine injury. The apparent result of forces directed anteriorly is to rupture the lateral ligaments which bind the axis and the atlas, and to fracture the odontoid process at its base as it is carried forward with the arch of the atlas. The spinal cord is larger in diameter in the upper cervical region than elsewhere along its length, and this may explain
282
BRITISH
JOURNAL
OF
ORAL
Fig. Figure 3-Lateral
cervical
&
MAXILLOFACIAL
SURGERY
3
spine radiograph showing fracture of the second cervical base of the odontoid process.
vertebra
through
the
why minimally displaced fractures are tolerated without neurological symptoms at this level. The possibility of cervical spine injury must be excluded in any serious maxillo-facial trauma. Neck tenderness and reduced mobility are cardinal signs of such injury. If doubt exists radiographic examination of the cervical spine should precede any other radiographs required of suspected injuries elsewhere. If a cervical spine fracture is found, the appropriate immobilisation can then be placed prior to any further examination. Radiography of the cervical spine can be complicated by the condition of the patient. Standard cervical spine radiographs include antero-posterior, and lateral radiographs, and trans-oral view of the dens. If there is no evidence of a fracture or dislocation, lateral radiographs in flexion and extension are taken and examined for any abnormal features; in particular widening of the interspinous space, vertebral compression fracture, intervertebral subluxation and loss of the normal lordotic curve or limitation of flexion. If the patient is unable to open the mouth or raise the chin, good views of the upper cervical spine may not be possible. Similarly, the shoulders can obscure the lower cervical spine and upper thoracic spine. Reflex muscle spasm can elevate the shoulder, which further obscures the lower cervical spine. Significant head injury may cause the patient to be unconscious or restless which also may hamper radiography. Even if good cervical spine radiographs are obtained subtle abnormalities may be overlooked. Webb et al. (1976) describe a series of cases where late vertebral deformities developed after flexion injuries, the severity of which was initially not appreciated.
FRACTURE
OF
CERVICAL
SPINE
283
The orthopantomogram is commonly used in the diagnosis of mandibular fracture. However, its use is potentially hazardousfor a patient with cervical spine fracture because the posture required demands a ‘chin-up’ hyper-extension of the neck. Fortunately, no complication ensued in this case, but accident and emergency and radiographic staff should be aware of this possibility. Serious consequences may occur in the anaesthetic room if the presence of cervical spine fracture has been overlooked. Reflex muscle spasm may splint the injury. This protection will be lost if a muscle relaxant is given, the results of which may be disastrous. Bertolami (1982) suggests that accident and emergency staff are generally aware of the possibility of cervical spine injury following serious head and neck trauma, but may overlook significant mandibular injury; this was a reversal of the reported case. Bertolami further proposes that there is a regular gradation of injury following trauma to the chin. A light blow to the chin may result in a laceration, with greater force a mandibular fracture may result, whereas sufficient force may result in a fracture of the cervical spine. The present case demonstrates all these features. The management of the fractured mandible proceeded along conventional lines (Killey 1974). However, for six weeks the patient had to convalesce from his head, jaw and neck injuries in the supine position. Intermaxillary fixation could have been applied under local anaesthesia, but this could have created airway difficulties on the event of vomiting. The alternative of direct bone plating of the mandibular fractures would not have compromised the airway, but would have required a general anaesthetic with endotracheal intubation but this was contra-indicated because of the cervical spine fracture. Therefore, to obviate the risks to the airway a tracheostomy under local anaesthesia was carried out which enabled intermaxillary fixation to be applied subsequently under general anaesthesia. Conclusion The possibility of cervical spine fracture following serious maxillofacial injury should be emphasised to all accident and emergency staff. Radiographic examination of the cervical spine should precede all other radiographs in such injuries. The advantages of early tracheostomy may be considered in all cases of combined maxillo-facial and cervical spine injuries. Acknowledgements
I should like to thank Mr R. H. McGowan, Locum Consultant Oral Surgeon, Dudley Road Hospital, for permission to report this case. I am grateful to the staff of the Medical Photography Department for their invaluable photographic assistance, and Miss S. Emmett for typing the manuscript. References Bertolami, C. N. & Kaban, L. B. (1982). Chin trauma: a clue to associated mandibular and cervical spine injury. Journal of Oral Surgery, 53, 122. Huelke, D. F. & Compton, C. P. (1983). Facial injuries in automobile crashes. Journal ofMaxillo Facial Injuries, 241. Killey, H. C. (1974). Fractures of the mandible. 2nd Edn. John Wright and Sons Ltd., Bristol, McSweeney, T. (1984). Injuries of the cervical spine. Annals of the Royal College of Surgeons of England, 66, 1. Rogers. W. A. (1958). Fractures and dislocations of the spine. In: Fractures and other injuries. Chicago Year Book Publishers Inc. Webb, J. K., Broughton, R. B. K., McSweeney, T. & Park, W. M. (1976). Hidden flexion injuries of the cervical spine. Journal of Bone and Joint Surgery, SSB, 322.
FRACTURE
OF THE CERVICAL
FRACTURES
SPINE COMPLICATING
OF THE MANDIBLE:
BILATERAL
A CASE REPORT
K. W. HEMMINGS,B.D.S. Department of Dental and &al Surgery, Dudley Road Hospital, Birmingham
Summary. A case reported of a 21-year-old male who sustained a fracture of the body of the second cervical vertebra, a bilateral fracture of the mandible and a deep laceration on the left side of his neck. The importance of excluding cervical spine fractures in cases of severe trauma to the head and neck is emphasised, and the airway management problems are discussed.
Introduction
In a national survey in America of 46,000 injuries resulting from road traffic accidents, Huelke et al. (1983) found that 14,927 (32 per cent) of these injuries were to the face, and a further 4,606 (10 per cent) of the total involved the neck. A study of cervical spine injuries in Massachusetts General Hospital (Rogers et al., 1958) indicated that 36 per cent exhibited no neurological symptoms. McSweeney (1984) reviewed the diagnosis and management of spinal cord injuries and described symptoms ranging from mild sensory disturbance of the extremities to tetraplegia or death. The combination of facial injuries and fracture of the cervical spine may present difficulty in the treatment and management of the patient. Immobilisation of the cervical spine is of paramount importance and endo-tracheal intubation is contra-indicated. The patient’s airway may be further compromised by facial and jaw injuries. Case Report
A 21-year-old male Caucasian was admitted to the Accident and Emergency Department at Dudley Road Hospital following a road traffic accident. He had been a front seat passenger in a car which somersaulted and landed on its roof. He had been wearing a safety belt. He was unconscious when removed from the car, but on admission was found to be alert and orientated. His main complaints were of pain from the left side of his neck and face. Examination by the Casualty Officer revealed a Z-shaped laceration of the left side of the neck beneath the lower border of the mandible and this was associated with a seat belt friction burn (Fig. 1). There were swellings over the left angle and right body of the mandible and intra-orally there was a step deformity between7 and 4. Limited opening restricted a more detailed examination at this stage. Neurological, cardiovascular, respiratory and abdominal examination were all within normal limits. A provisional diagnosis of bilateral fracture of the mandible was made and the patient was sent for radiographic examination of the skull, facial bones and cervical (Received Address Devon.
for correspondence:
30 July
Department
1984; accepted 30 October of Oral Surgery,
279
Torbay
1984)
Hospital,
Lawes Bridge,
Torquay,
280
BRITISH
JOURNAL
OF
ORAL
Fig. Figul pe l-Anterior
view of the neck showing
&
MAXILLOFACIAL
SURGERY
1
sutured
neck laceration
and surrounding
friction
spine. An orthopantomogram and PA mandible radiograph confirmed the presence of a bilateral fracture of the mandible through the 431 area and the left angle (Fig. 2). In addition, a previously unsuspected fracture through the body of the second cervical vertebra was found on a lateral cervical spine radiograph (Fig. 3). The cervical spine fracture was immobilised by application of a Blackburn caliper, the neck laceration was sutured and the patient admitted to the Intensive Care Unit. Neurological and airway observations were instituted. Antibiotic therapy consisted of Ampicillin and Flucloxacillin intramuscularly. Chymotrypsin was given intramuscularly in an attempt to reduce the increasing swelling in the neck. Eight hours after admission the patient complained of dysphagia and dysarthria. However, there was no stridor and the airway was satisfactory. On the third day the neck swelling had subsided and a tracheostomy was carried out under local anaesthesia. The following day, under general anaesthesia the mandibular fracture was reduced and immobilised with upper and lower arch bars. Intermaxillary fixation was applied using elastic bands. Two days post-operatively the patient was transferred to an orthopaedic ward to be nursed on a rotatable Stryker bed. Five and a half weeks post-operatively the intermaxillary fixation was removed, followed by removal of the tracheostomy tube. A week later the patient was allowed to leave the Stryker bed and a chest plaster and halo fixation was applied. The halo was removed one month later and a neck collar worn for one further month. He failed to attend for final review.
FRACTURE
OF
CERVICAL
SPINE
281
Fig. 2 Figure 2-(A)
Orthopantomogram
(OPG) showing fracture 43 area and Farea. same patient.
(B) PA mandible of the
Discussion Any violent forces that flex, hyper-extend or rotate the neck are likely to cause cervical spine fracture. Road traffic accidents are particularly liable to produce such forces. If seat belts are worn the trunk is restrained, but the head and neck are free to move following impact, often in a whiplash-like manner. Such forced passive extensions, flexions or rotations of the neck predispose to cervical spine injury. The apparent result of forces directed anteriorly is to rupture the lateral ligaments which bind the axis and the atlas, and to fracture the odontoid process at its base as it is carried forward with the arch of the atlas. The spinal cord is larger in diameter in the upper cervical region than elsewhere along its length, and this may explain
282
BRITISH
JOURNAL
OF
ORAL
Fig. Figure 3-Lateral
cervical
&
MAXILLOFACIAL
SURGERY
3
spine radiograph showing fracture of the second cervical base of the odontoid process.
vertebra
through
the
why minimally displaced fractures are tolerated without neurological symptoms at this level. The possibility of cervical spine injury must be excluded in any serious maxillo-facial trauma. Neck tenderness and reduced mobility are cardinal signs of such injury. If doubt exists radiographic examination of the cervical spine should precede any other radiographs required of suspected injuries elsewhere. If a cervical spine fracture is found, the appropriate immobilisation can then be placed prior to any further examination. Radiography of the cervical spine can be complicated by the condition of the patient. Standard cervical spine radiographs include antero-posterior, and lateral radiographs, and trans-oral view of the dens. If there is no evidence of a fracture or dislocation, lateral radiographs in flexion and extension are taken and examined for any abnormal features; in particular widening of the interspinous space, vertebral compression fracture, intervertebral subluxation and loss of the normal lordotic curve or limitation of flexion. If the patient is unable to open the mouth or raise the chin, good views of the upper cervical spine may not be possible. Similarly, the shoulders can obscure the lower cervical spine and upper thoracic spine. Reflex muscle spasm can elevate the shoulder, which further obscures the lower cervical spine. Significant head injury may cause the patient to be unconscious or restless which also may hamper radiography. Even if good cervical spine radiographs are obtained subtle abnormalities may be overlooked. Webb et al. (1976) describe a series of cases where late vertebral deformities developed after flexion injuries, the severity of which was initially not appreciated.
FRACTURE
OF
CERVICAL
SPINE
283
The orthopantomogram is commonly used in the diagnosis of mandibular fracture. However, its use is potentially hazardousfor a patient with cervical spine fracture because the posture required demands a ‘chin-up’ hyper-extension of the neck. Fortunately, no complication ensued in this case, but accident and emergency and radiographic staff should be aware of this possibility. Serious consequences may occur in the anaesthetic room if the presence of cervical spine fracture has been overlooked. Reflex muscle spasm may splint the injury. This protection will be lost if a muscle relaxant is given, the results of which may be disastrous. Bertolami (1982) suggests that accident and emergency staff are generally aware of the possibility of cervical spine injury following serious head and neck trauma, but may overlook significant mandibular injury; this was a reversal of the reported case. Bertolami further proposes that there is a regular gradation of injury following trauma to the chin. A light blow to the chin may result in a laceration, with greater force a mandibular fracture may result, whereas sufficient force may result in a fracture of the cervical spine. The present case demonstrates all these features. The management of the fractured mandible proceeded along conventional lines (Killey 1974). However, for six weeks the patient had to convalesce from his head, jaw and neck injuries in the supine position. Intermaxillary fixation could have been applied under local anaesthesia, but this could have created airway difficulties on the event of vomiting. The alternative of direct bone plating of the mandibular fractures would not have compromised the airway, but would have required a general anaesthetic with endotracheal intubation but this was contra-indicated because of the cervical spine fracture. Therefore, to obviate the risks to the airway a tracheostomy under local anaesthesia was carried out which enabled intermaxillary fixation to be applied subsequently under general anaesthesia. Conclusion The possibility of cervical spine fracture following serious maxillofacial injury should be emphasised to all accident and emergency staff. Radiographic examination of the cervical spine should precede all other radiographs in such injuries. The advantages of early tracheostomy may be considered in all cases of combined maxillo-facial and cervical spine injuries. Acknowledgements
I should like to thank Mr R. H. McGowan, Locum Consultant Oral Surgeon, Dudley Road Hospital, for permission to report this case. I am grateful to the staff of the Medical Photography Department for their invaluable photographic assistance, and Miss S. Emmett for typing the manuscript. References Bertolami, C. N. & Kaban, L. B. (1982). Chin trauma: a clue to associated mandibular and cervical spine injury. Journal of Oral Surgery, 53, 122. Huelke, D. F. & Compton, C. P. (1983). Facial injuries in automobile crashes. Journal ofMaxillo Facial Injuries, 241. Killey, H. C. (1974). Fractures of the mandible. 2nd Edn. John Wright and Sons Ltd., Bristol, McSweeney, T. (1984). Injuries of the cervical spine. Annals of the Royal College of Surgeons of England, 66, 1. Rogers. W. A. (1958). Fractures and dislocations of the spine. In: Fractures and other injuries. Chicago Year Book Publishers Inc. Webb, J. K., Broughton, R. B. K., McSweeney, T. & Park, W. M. (1976). Hidden flexion injuries of the cervical spine. Journal of Bone and Joint Surgery, SSB, 322.