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Increased atlanto-dental interval in a motor vehicle accident victim
Injury Extra (2008) 39, 1—3
www.elsevier.com/locate/inext
CASE REPORT
Increased atlanto-dental interval in a motor vehicle accident victim Hermione Race *, Damian Balmforth, Arjan B. Van As Imperial College London, Reynold’s Building St Dunstan’s Road, London W68RP, United Kingdom Accepted 2 April 2007
Introduction Cervical spine injury in trauma patients can lead to devastating neurological injury and therefore it is paramount that cervical spine injury is recognized and appropriately managed as quickly as possible.10 It can be extremely difficult to diagnose cervical spine injury in paediatric patients for several reasons: they may not be able to communicate where they have pain, they may be anxious or crying, they may have distracting injury and the anatomy of the cervical spine varies with age. These factors often result in clinicians taking multiple cervical spine radiographs to exclude pathology. The Red Cross Children’s Hospital in South Africa has a large paediatric trauma department which serves the whole Western Cape Province. For the past 2 years, it has been using a StatScan Lodox machine (Lodox Systems, (Pty) Ltd., Sandton, South Africa) to evaluate polytrauma patients.2,3 The benefits of the Lodox machine are three-fold: it is fast, has better resolution of the bronchi, trachea and cervical spine than conventional radiography and it emits a lower dose of ionizing radiation. Over half of the patients who are scanned at this unit are from motor vehicle accidents. We present the case of a 4-year-old child involved in a motor vehicle accident which illus* Corresponding author. Tel.: +44 7855822693. E-mail address: [email protected] (H. Race).
trates the suitability of using the StatScan machine for assessing cervical spine trauma.
Case summary A 4-year-old boy was involved as a pedestrian in a motor vehicle accident. He was hit from behind by a car and was subsequently admitted to the Red Cross Children’s Hospital Level 1 trauma unit. On arrival his airway was patent, he was breathing spontaneously and his pulse was 138 and regular. Cervical spine movement was painful in a soft collar. His Glasgow Coma Scale (GCS) was 15/15. It was noted that he had open wounds on his face and left thigh but good peripheral pulses. He also had a haematoma on the left frontal side of his head with no obvious focal signs. An anterior posterior full body and lateral cervical spine StatScan (Fig. 1) was performed in the trauma unit which showed: 1. An increase in the atlanto-dental interval (ADI) to 7.6 mm (Fig. 1). 2. A left proximal femur shaft fracture. 3. A left tibial distal metaphysis fracture. The ADI measures the distance between the dens and anterior arch of the atlas and can help to determine whether the transverse ligament between the dens and the spinal cord is still intact.
1572-3461/$ — see front matter # 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2007.04.006
2
Figure 1 Lateral cervical spine StatScan showing no widening of the prevertebral soft tissues but with wide atlanto-dense interval.
The maximum value consistent with an intact transverse ligament has been shown to be 4 mm when supine, and 5 mm when upright in children.8 The patient was prepared for theatre with cervical spine precautions. In theatre, the left femoral wound was washed out and debrided, and a suction dressing applied. A Denham pin was inserted from lateral to medial tibia and skeletal traction was applied to the femur. The distal tibia fracture was manipulated under anaesthetic and put into a cast. The increased ADI measurement was treated as a transverse ligament rupture with Halter traction in neck extension on a split mattress for 2 weeks. The patient was discharged home in traction, 12 days after the accident, into the care of his father.
H. Race et al. transverse ligament. Rupture of the transverse ligament can result in posterior displacement of the dens and compression of the spinal cord. Consequently, unstable fractures of this region need to be identified quickly and reliably. A recent study has illustrated that the StatScan can provide quicker and superior images compared to conventional radiography for assessment of the cervical spine.3 The StatScan provides a digital image on a computer in the trauma room and the ADI can be measured with the aid of a computer program.2 It therefore eliminates the need for magnification correction and direct measurement from printed radiographic films which lead to poor interobserver reliability between ADI measurements.3 In addition, the StatScan can provide a full body and cervical spine scan of a young child in just 10 s, it can be situated in the trauma room, does not require the patient to be transferred to another trolley to be scanned as it has an integrated docking resuscitation trolley and compared to conventional X-rays has an extremely low radiation dose.1,2,9 This is particularly important for paediatric patients who are very susceptible to the adverse effects of radiation with increased rates of thyroid, breast, leukaemias and other cancers being reported.6 This case illustrates that the StatScan is a highly efficient method for identifying increased ADI. The increase was noted on secondary survey within the trauma department by the orthopaedic registrar without the need for transferring the patient to radiology or a formal report immediately. This enabled cervical spine precautions and neurological observations to take place immediately and could have prevented a more serious spinal injury occurring.
Conclusion This case demonstrates many advantages of using digital radiographic measurement of ADI in the trauma situation. Primarily the result was fast and accurate, enabling appropriate management to be initiated immediately.
References Discussion In children, head injury is commonly associated with cervical spine injury and accounts for the majority of death and disability after trauma.4,5 The ADI is often used to assess trauma to the cervical spine as an increased value can indicate rupture of the
1. Beningfield S, Potgieter H, Nicol A, et al. Report on a new type of trauma full-body digital X-ray machine. Emerg Radiol 2003;10:23—9. 2. Boffard KD, Goosen J, Plani F, et al. The use of low dosage Xray (Lodox/Statscan) in major trauma: comparison between low dose X-ray and conventional x-ray techniques. J Trauma 2006;60:1175—81.
Increased atlanto-dental interval in a motor vehicle accident victim 3. Douglas TS, Sanders V, Machers S, et al. Digital radiographic measurement of the atlantodental interval in children. J Pediatr Orthop 2007;27:23—6. 4. Eleraky MA, Theodore N, Adams M, et al. Pediatric cervical spine injuries: report of 102 cases and review of the literature. J Neurosurg 2000;92:12—7. 5. Graham DI. Paediatric head injury. Brain 2001;124:1261—2. 6. Kleinerman RA. Cancer risks following diagnostic and therapeutic radiation exposure in children. Pediatr Radiol 2006;36:121—5.
3
8. Locke GR, Gardner JI, Van Epps EF. Atlas-dens interval (ADI) in children: a survey based on 200 normal cervical spines. Am J Roentgenol Radium Ther Nucl Med 1966;97:135—40. 9. Vernon DD, Furnival RA, Hansen KW, et al. Effect of a pediatric trauma response team on emergency department treatment time and mortality of pediatric trauma victims. Pediatrics 1999;103:20—4. 10. Viccellio P, Simon H, Pressman BD, et al. A prospective multicenter study of cervical spine injury in children. Pediatrics 2001;108:E20.
www.elsevier.com/locate/inext
CASE REPORT
Increased atlanto-dental interval in a motor vehicle accident victim Hermione Race *, Damian Balmforth, Arjan B. Van As Imperial College London, Reynold’s Building St Dunstan’s Road, London W68RP, United Kingdom Accepted 2 April 2007
Introduction Cervical spine injury in trauma patients can lead to devastating neurological injury and therefore it is paramount that cervical spine injury is recognized and appropriately managed as quickly as possible.10 It can be extremely difficult to diagnose cervical spine injury in paediatric patients for several reasons: they may not be able to communicate where they have pain, they may be anxious or crying, they may have distracting injury and the anatomy of the cervical spine varies with age. These factors often result in clinicians taking multiple cervical spine radiographs to exclude pathology. The Red Cross Children’s Hospital in South Africa has a large paediatric trauma department which serves the whole Western Cape Province. For the past 2 years, it has been using a StatScan Lodox machine (Lodox Systems, (Pty) Ltd., Sandton, South Africa) to evaluate polytrauma patients.2,3 The benefits of the Lodox machine are three-fold: it is fast, has better resolution of the bronchi, trachea and cervical spine than conventional radiography and it emits a lower dose of ionizing radiation. Over half of the patients who are scanned at this unit are from motor vehicle accidents. We present the case of a 4-year-old child involved in a motor vehicle accident which illus* Corresponding author. Tel.: +44 7855822693. E-mail address: [email protected] (H. Race).
trates the suitability of using the StatScan machine for assessing cervical spine trauma.
Case summary A 4-year-old boy was involved as a pedestrian in a motor vehicle accident. He was hit from behind by a car and was subsequently admitted to the Red Cross Children’s Hospital Level 1 trauma unit. On arrival his airway was patent, he was breathing spontaneously and his pulse was 138 and regular. Cervical spine movement was painful in a soft collar. His Glasgow Coma Scale (GCS) was 15/15. It was noted that he had open wounds on his face and left thigh but good peripheral pulses. He also had a haematoma on the left frontal side of his head with no obvious focal signs. An anterior posterior full body and lateral cervical spine StatScan (Fig. 1) was performed in the trauma unit which showed: 1. An increase in the atlanto-dental interval (ADI) to 7.6 mm (Fig. 1). 2. A left proximal femur shaft fracture. 3. A left tibial distal metaphysis fracture. The ADI measures the distance between the dens and anterior arch of the atlas and can help to determine whether the transverse ligament between the dens and the spinal cord is still intact.
1572-3461/$ — see front matter # 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2007.04.006
2
Figure 1 Lateral cervical spine StatScan showing no widening of the prevertebral soft tissues but with wide atlanto-dense interval.
The maximum value consistent with an intact transverse ligament has been shown to be 4 mm when supine, and 5 mm when upright in children.8 The patient was prepared for theatre with cervical spine precautions. In theatre, the left femoral wound was washed out and debrided, and a suction dressing applied. A Denham pin was inserted from lateral to medial tibia and skeletal traction was applied to the femur. The distal tibia fracture was manipulated under anaesthetic and put into a cast. The increased ADI measurement was treated as a transverse ligament rupture with Halter traction in neck extension on a split mattress for 2 weeks. The patient was discharged home in traction, 12 days after the accident, into the care of his father.
H. Race et al. transverse ligament. Rupture of the transverse ligament can result in posterior displacement of the dens and compression of the spinal cord. Consequently, unstable fractures of this region need to be identified quickly and reliably. A recent study has illustrated that the StatScan can provide quicker and superior images compared to conventional radiography for assessment of the cervical spine.3 The StatScan provides a digital image on a computer in the trauma room and the ADI can be measured with the aid of a computer program.2 It therefore eliminates the need for magnification correction and direct measurement from printed radiographic films which lead to poor interobserver reliability between ADI measurements.3 In addition, the StatScan can provide a full body and cervical spine scan of a young child in just 10 s, it can be situated in the trauma room, does not require the patient to be transferred to another trolley to be scanned as it has an integrated docking resuscitation trolley and compared to conventional X-rays has an extremely low radiation dose.1,2,9 This is particularly important for paediatric patients who are very susceptible to the adverse effects of radiation with increased rates of thyroid, breast, leukaemias and other cancers being reported.6 This case illustrates that the StatScan is a highly efficient method for identifying increased ADI. The increase was noted on secondary survey within the trauma department by the orthopaedic registrar without the need for transferring the patient to radiology or a formal report immediately. This enabled cervical spine precautions and neurological observations to take place immediately and could have prevented a more serious spinal injury occurring.
Conclusion This case demonstrates many advantages of using digital radiographic measurement of ADI in the trauma situation. Primarily the result was fast and accurate, enabling appropriate management to be initiated immediately.
References Discussion In children, head injury is commonly associated with cervical spine injury and accounts for the majority of death and disability after trauma.4,5 The ADI is often used to assess trauma to the cervical spine as an increased value can indicate rupture of the
1. Beningfield S, Potgieter H, Nicol A, et al. Report on a new type of trauma full-body digital X-ray machine. Emerg Radiol 2003;10:23—9. 2. Boffard KD, Goosen J, Plani F, et al. The use of low dosage Xray (Lodox/Statscan) in major trauma: comparison between low dose X-ray and conventional x-ray techniques. J Trauma 2006;60:1175—81.
Increased atlanto-dental interval in a motor vehicle accident victim 3. Douglas TS, Sanders V, Machers S, et al. Digital radiographic measurement of the atlantodental interval in children. J Pediatr Orthop 2007;27:23—6. 4. Eleraky MA, Theodore N, Adams M, et al. Pediatric cervical spine injuries: report of 102 cases and review of the literature. J Neurosurg 2000;92:12—7. 5. Graham DI. Paediatric head injury. Brain 2001;124:1261—2. 6. Kleinerman RA. Cancer risks following diagnostic and therapeutic radiation exposure in children. Pediatr Radiol 2006;36:121—5.
3
8. Locke GR, Gardner JI, Van Epps EF. Atlas-dens interval (ADI) in children: a survey based on 200 normal cervical spines. Am J Roentgenol Radium Ther Nucl Med 1966;97:135—40. 9. Vernon DD, Furnival RA, Hansen KW, et al. Effect of a pediatric trauma response team on emergency department treatment time and mortality of pediatric trauma victims. Pediatrics 1999;103:20—4. 10. Viccellio P, Simon H, Pressman BD, et al. A prospective multicenter study of cervical spine injury in children. Pediatrics 2001;108:E20.