Treatment.—Reduction should be attempted at once, before the vertebræ become fixed in their abnormal position. Under anæsthesia gentle extension is made on the head by an assistant, and the abnormal attitude is first slightly exaggerated to relax the ligaments and to restore mobility to the locked articular processes. The head is then forcibly flexed towards the opposite side, after which it can be rotated into its normal attitude (Kocher). Haphazard movements to effect reduction are attended with risk of damaging the cord. After reduction has been effected, the treatment is the same as that of a sprain.
Isolated Fractures of the Arches, Spinous and Transverse Processes.—Fractures of the arches and spinous processes usually result from direct violence, such as a blow or a bullet wound, and are accompanied by bruising of the overlying soft parts, irregularity in the line of the spines, and by the ordinary signs of fracture. Skiagrams are useful in showing the exact nature of the lesion. These fractures are most common in the lower cervical and in the thoracic regions, where the spines are most prominent and therefore most exposed to injury.
Fig. 207.—Compression Fracture of Bodies of Third and Fourth Lumbar Vertebræ. Woman, æt. 28, who fell three storeys and landed on the buttocks.
In many cases there are no symptoms of damage to the cord or spinal nerves, but when both laminæ give way the posterior part of the arch may be driven in and cause direct pressure on the cord, or blood may be effused between the bone and the dura. In such cases immediate operation is indicated. When there are no cord symptoms, the treatment consists in securing rest, with the aid of extension, if necessary, for several weeks until the bones are reunited.
The use of the X-rays has shown that one or more of the transverse processes of the lumbar vertebræ may be chipped off by direct violence. The symptoms are pain and tenderness in the region of the fracture, and marked restriction of movement, especially in the direction of flexion. This lesion may explain some of the cases of persistent pain in the back following injuries in workmen. It is important to remember, however, that in a radiogram an un-united epiphysis may simulate a fracture.
Isolated Fracture of the Bodies—“Compression Fracture.”—The “compression fracture” consists in a crushing from above downwards of the bodies—and the bodies only—of one or more vertebræ. It is due to the patient falling from a height and landing on the head, buttocks, or feet in such a way that the force is transmitted along the bodies of the vertebræ while the spine is flexed.
If the patient lands on his head, the compression fracture usually involves the lower cervical or upper thoracic vertebræ. When he lands on his buttocks or feet it is usually the lumbar or the lower thoracic vertebræ that are fractured ([Fig. 207]).
As a rule, there are no external signs of injury over the spine. The sternum, however, is often fractured, and irregularity and discoloration may be detected on examining the front of the chest. The recognition of a fracture of the sternum should always raise the suspicion of a fracture of the spine. On examination of the back a more or less marked projection of the spinous processes of the damaged vertebræ may be recognised. In the cervical and lumbar regions this projection may merely obliterate the normal concavity. The spinous process which forms the apex of the projection belongs to the vertebra above the one that is crushed. The cord usually escapes, but the nerves emerging in relation to the damaged vertebræ may be bruised, and this gives rise to girdle-pain.