Rehabilitation Program

of Traumatic Spine
Fractures

Rr. I. Lukitra Wardhani, dr Sp. KFR (K)

Lydia Arfianti,dr Sp.KFR (K)
Dyah Intania Sari,dr SpKFR
 Definisi Fraktur
• Terputusnya kontinuitas tulang, tulang rawan sendi
(intra artikular), dan lempeng pertumbuhan epifisis
• Terdapat kerusakan jaringan lunak sekitarnya

Salter, Robert B. 1999

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 INSIDEN FRAKTUR VERTEBRA

• Di Amerika, angka kejadian fraktur vertebra yaitu 10,7/1000 penduduk perempuan,

dan 5,7/1000 penduduk laki-laki (Issa et al, 2019)
• Di Jerman, angka kejadian fraktur vertebra (thoracal dan lumbal), mencapai 8000
kasus/tahun (Spiegl et al, 2018)

Berdasarkan penelitian yang dilakukan di sebuah rumah sakit militer di Chongqing,

Cina pada tahun 2001-2010 (Wang, Liu & Zhao, 2016).
• Pria memiliki risiko 1,9 kali > perempuan untuk cedera tulang belakang
• Mekanisme cedera: terjatuh ketinggian > 2 meter, dan kecelakaan lalu lintas
• Berdasarkan lokasi fraktur: 47,81% fraktur vertebra lumbal (terutama vertebra
lumbal 1), 30,49% fraktur vertebra toraks 20,45% fraktur cervical, dan 1,24%
mengalami fraktur vertebra sakral.

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INSIDEN DI
INDONESIA ??
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RS Dr. Soetomo Surabaya tahun 2013-2017 (Lukas Widhiyanto dkk, 2019).

• Laki-laki 3,3 kali > perempuan untuk cedera tulang belakang.

• Penyebab: jatuh dari ketinggian, diikuti dengan kecelakaan lalu lintas, d
an tertimpa beban.
Berdasarkan tingkat fraktur:
• Vertebra lumbal (34,6%),
• Vertebra toraks (33%),
• Setinggi C3-C7 (25,3%),
• Setinggi C1-C2 (4,9%),

Kompresi atau burst adalah jenis fraktur yang umumnya paling banyak terj
adi di semua segmen vertebral
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(Lukas Widhiyanto dkk, 2019).

 Klasifikasi Fraktur

I. Berdasarkan etiologi II. Berdasarkan gambaran klinis

ü Fraktur traumatis ü Fraktur tertutup (simple fracture)
ü Fraktur patologis ü Fraktur terbuka (compound fracture)
ü Fraktur stress ü Fraktur dengan komplikasi
(complicated fracture)

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III. BERDASARKAN GAMBARAN RADIOLOGIS
Lokasi

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Patofisiologi Fraktur

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DIAGNOSIS FRAKTUR

Anamnesa
Keluhan Utama
Nyeri lokal
Nyeri gerak
Penurunan fungsi anggota gerak
Krepitasi
Mekanisme trauma
Riwayat penyakit atau Operasi terdahulu
Riwayat pengobatan, Alergi.

Salter , Robert B, Textbook of dissorder and injuries of the musculosceletal system

3rd, WILLIAM and WILKINS , 1999

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 Pemeriksaan Fisik
Kondisi yang mengancam (ATLS)
Status generalis
Status lokalis
Look:
o Bengkak
o Memar, lecet atau luka
o Deformitas
Feel :
o Temperatur kulit
o Nyeri tekan
o Spasme otot
o Status Neurovaskular
Neurologis : motorik, sensorik, reflex
Vaskular : pulsasi distal, waktu pengisian kapiler
Salter , Robert B, Textbook of dissorder and injuries of the musculosceletal system 3rd,
WILLIAM and WILKINS , 1999

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 Move :
o Krepitasi
o Nyeri gerak
o Aktif and pasive ROM
o Pseudoarthrosis

Pencitraan diagnostik
Foto X-ray
o AP, Lateral and Oblique view
o Rule of “Two” ( two view, joints, limbs, occasion,
injuries).
CT scan
MRI
Salter , Robert B, Textbook of dissorder and injuries of the musculosceletal system
3rd, WILLIAM and WILKINS , 1999

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 ICF Vertebral Fracture
Diagnosis (ex: Burst Fracture VL 1)

Body Function
Decrease of touch function (b265)
Sensation of pain (b280)
Decrease of muscle power (b730)
Increase of muscle tone ( b735)
Motor reflex function (b750)
Involuntary movement reaction
function (b755)
Urinary excretory functions
(b610)
Defecation function (b525)
Body Structure
Activity Limitation Participation Limitation
Spinal cord and
d910 Community life
related structures Self care (d569)
Recreational activities
(s110) Structure of Transferring (d420)
Religious activities
lower extremity Walking and moving (d456)
(s750) Caring for body parts (d520)
Structure of trunk
(s760)

Personal Factors
Enviromental Factors Gender
health services and systems Age
Comorbid factors
Spine Healing and Fusion (Pilitsis et al., 2002)

1) Early inflammatory stage

• 2 minggu pertama pasca cedera
• Dimulai dengan perdarahan karena cedera vascular àInfiltrasi sel inflamasi dan fibroblast
• Terbentuk vaskularisari dan jaringan granulasi

2) Repair stage
• Pembentukan kalus: pertambahan vaskularisasi, sekresi osteoid, dan jaringan fibrokolagen
• Union awal muncul 4-6 minggu pasca cedera
• Osteoblast beraktivitas untuk menngantikan kartilago awal pada tulang cancellous

3) Remodeling stage
• Tulang cancellous diubah menjadi tulang kompak saat deposisi osteoid berlanjut.
• Proses terus berlangsung hingga kekuatan cukup terbentuk setelah 6 bulan
Soft tissue healing in spine fracture (Martinez-Perez et al., 2014)

Struktur yang dapat terlibat

• Vertebral joint capsules

• Vertebral arteries
• Ligamentous subfailure: anterior longitudinal ligaments, posterior longitudinal
ligaments, ligamentum flavum.
• Disc disruption
• Muscle sprain
• Spinal cord injury

• Timeline bervariasi tergantung struktur yg terlibat: weeks- months

Perbaikan Fungsi
Terapi non-operatif (Ataizi et al., 2018; Schouten et al., 2015; Stadhouder et al., 2009)

Mayoritas cedera tulang belakang thoracolumbar stabil dan tanpa defisit neurologis
ditangani tanpa operasi.

Penggunaan korset untuk imobilisasi setelah masa bedrest 1-3 minggu selama 3 bln
serta terapi rehabilitasi sampai 6 bulan.
Dengan penanganan konservatif studi menunjukkan:
• rata-rata 61% pasien mampu bebas dari rasa sakit 1 tahun pasca-cedera tanpa
restriksi aktivitas yang berarti.
• Nilai Oswestry Disability Index (ODI) pada pasien setelah 1 tahun: low disability
• 71% pasien yang dirawat secara konservatif dengan fraktur burst torakolumbalis
mampu return-to-work dalam waktu 6 bulan.
Perbaikan Fungsi
Penanganan surgical (Schouten et al., 2015)

Tindakan operatif diikuti rehabilitasi

• rata-rata 48% pasien mampu bebas dari rasa sakit 1 tahun
pasca-cedera dengan restriksi aktivitas yang minimal.
• 32% pasien akan mendapatkan kembali kemampuan
untuk berpartisipasi dalam olahraga low impact
• Dalam 6 bulan diperkirakan: 29% pasien dapat return-to-
work dalam 4-8 minggu dan 48% lainnya dalam waktu 9-
16 minggu.
• Rata-rata lama perawatan rawat inap 5 hari (kisaran 3-10
hari).
Rehabilitation of
Spine Fractures
 FRAKTUR VERTEBRA
1. C1 Fracture (Jefferson Fracture)
2. C2 Fracture (Hangman's Fracture)
3. Fractures of the Odontoid (Dens)
4. Cervical Spine Compression and Burst Fractures
5. Cervical Spine Unilateral and Bilateral Facet
Dislocation
6. Thoracolumbar Spine Fractures
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 CERVICAL FRACTURES
• Axial Loading dpt menyebabk compression,
burst, tear drop fractures
• Compression Fr : imobilisasi ekstrn 6- 12 mg.
Fusi dipertimbangkan u prev kifosis,t! b/
angulasi >11 or khilangan > 25% tinggi vertbr
o

• Menej Burst Fr ssuai deficit neurologis

• Tear Drop Fr : Orthosis Cervical 6 minggu

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Cl Fracture (Jefferson Fracture)
Treatment goals
Orthopaedic Objectives
1. Obtain and maintain spinal alignment and reduction of the fracture.
2. Provide spinal stability.
3. Prevent new neurologic deficits and attempt to improve and prevent the exacerbation of existing
neurologic deficits.
4. Prevent future spinal deformity.

Rehabilitation Objectives
1. ROM

2. MMT : Restore and maintain the strength of paracervical and cervical muscles, including the
trapezius and the upper extremity muscles
3. Functional Goals : Develop cervical spinal flexibility for functional independence.
Cl Fracture (Jefferson Fracture)
Expected Time and Methods of Treatment
Bone Healing
Eight to 16 weeks before fusion is solid or fracture healing is complete.

Rehabilitation
Three to 6 months.
**Most Jefferson fractures do not result in neurologic impairment because the spinal canal is generally
widened as a result of the fracture, and there is sufficient space to accommodate the spinal cord.

Orthosis
Hard collar (e.g., Philadelphia collar), stemal- occiput-mandibular immobilization (SOMI) brace,
cervicothoracic orthosis, four-poster brace, or halo vest
Open Reduction and Posterior Spinal Fusion
Surgery is rarely necessary for isolated fractures of the ring of C1.
Cl Fracture (Jefferson Fracture)
Prescription
Cl Fracture (Jefferson Fracture)
Prescription
LONG-TERM CONSIDERATIONS

Residual pain may require

temporary bracing and anti-
inflammatory medications.

Residual neurologic deficits

must be addressed and may
require extremity bracing,
therapy, or surgery for
contracture releases and
tendon transfers.
C2 Fracture (Hangman's Fracture)
Treatment
Orthosis
A fracture is treated with a hard collar, such as a Philadelphia collar or one of the other
non-halo devices such as the SOMI brace, or a cervicothoracic orthosis. The
Further immobilization is generally maintained for 8 to 12 weeks.
treatment and If the fracture shows further angulation with traction, it should be placed in a halo
rehabilitation vest from the outset.
follows the same
protocol as for Surgery
Jefferson Direct osteosynthesis of C2 pedicle fracture, open reduction of C2-C3 dislocation
fractures and posterior spinal fusion C2-C3. (Interspinous wiring or plating)

**31%of patient's with Hangman's fractures have associated injuries of the cervical spine,
94% of which involve the upper three cervical segments. Thus, a search for associated
cervical spine injuries other region is critical.
Fractures of the Odontoid (Dens)
Treatment goals
Orthopaedic Objectives
1. Obtain and maintain spinal alignment and reduction of the fracture.
2. Provide spinal stability.
3. Prevent new neurologic deficits and attempt to improve and prevent the
worsening of existing neurologic deficits.
4. Prevent future spinal deformity.

Rehabilitation Objectives
1. ROM

2. MMT : Restore and maintain the strength of paracervical and cervical muscles, including the
trapezius and the upper extremity muscles
3. Functional Goals : Develop cervical spinal flexibility for functional independence.
Fractures of the Odontoid (Dens)
Expected Time and Methods of Treatment
Bone Healing
12 to 16 weeks before fusion is solid or fracture healing is complete.

Rehabilitation
Three to 6 months.
** If progressive deformity occurs, surgery may be necessary. There may be permanent loss of range of motion.
The degree depends on number of segments arthrodesed and level and extent of the fracture.

Orthosis
Soft Collar, Hard Collar, or Halo Vest

Posterior Arthrodesis and Wiring of Cl-2

Anterior Odontoid Screw Fixation
Further treatment and rehabilitation
follows the same protocol as for
Jefferson fractures
Cervical Spine Compression and Burst Fractures

Treatment Goals

Orthopaedic Objectives
1. Obtain and maintain spinal alignment and reduction of the fracture.
2. Provide spinal stability.
3. Prevent new neurologic deficits and attempt to improve and prevent the
worsening of existing neurologic deficits.
4. Prevent future spinal deformity.

Rehabilitation Objectives
1. ROM: Restore range of motion in all planes without creating neurologic deficits
2. MMT : Restore and maintain the strength of paracervical and cervical muscles,
including the trapezius and the upper extremity muscles
3. Functional Goals : Develop cervical spinal flexibility for functional independence.
Cervical Spine Compression and Burst Fractures

Expected Time
Bone Healing
Six to 12 weeks for compression fracture and 8 to 12 weeks for a burst fracture.

Rehabilitation
Three to 6 months.
**Comminuted burst fractures frequently result in spinal cord injury. Treatment
varies according to the patient's neurologic status and the extent of the injury.

Orthosis
Hard Cervical Collar, Cervicothoracic Orthosis, Halo Vest)

Surgery
Anterior decompression with strut graft fusion with or without anterior plating or with
posterior wiring or plating; or posterior wiring or plating alone.
Cervical Spine Compression and Burst Fractures
Prescriptions
Cervical Spine Compression and Burst Fractures
Prescriptions

LONG-TERM CONSIDERATIONS

Residual pain may require temporary bracing and anti-inflammatory medications.

Residual neurologic deficits must be addressed and may require extremity bracing, therapy, or surgery for
contracture releases and tendon transfers.
Cervical Spine Unilateral
and Bilateral Facet Dislocation
Treatment goals
Orthopaedic Objectives
1. Obtain and maintain spinal alignment and reduction of the fracture or dislocation
2. Provide spinal stability.
3. Prevent new neurologic deficits and attempt to improve and prevent the exacerbation of existing
neurologic deficits.
4. Prevent future spinal deformity.

Rehabilitation Objectives
1. ROM

2. MMT : Restore and maintain the strength of paracervical and cervical muscles, including the
trapezius and the upper extremity muscles
3. Functional Goals : Develop cervical spinal flexibility for functional independence.
Cervical Spine Unilateral
and Bilateral Facet Dislocation
Expected Time and Methods of Treatment
Bone Healing
Eight to 16 weeks for pure facet dislocation. Soft tissue injury or an arthrodesis had been performed as a
definitive treatment, the expected time before arthrodesis or fracture healing is 12 to 16 weeks.

Rehabilitation
Three to 6 months.

Skeletal Traction (for Reduction) and Halo Vest

Innitial 10 pounds weight traction, additional weights are then applied, in 5- to 10-pound increments, at 15- to 30-
minute intervals. A unilateral facet dislocation that is successfully reduced by closed means
may be treated in a halo vest for 3 months.

Surgery
Posterior spinal fusion, anteroposterior spinal fusion, and a hard cervical collar.
Cervical Spine Unilateral
and Bilateral Facet Dislocation
Prescription
Cervical Spine Unilateral
and Bilateral Facet Dislocation
Prescription

LONG-TERM CONSIDERATIONS

Residual pain may require temporary bracing and anti-inflammatory medications.

Residual neurologic deficits must be addressed and may require extremity bracing, therapy, or surgery for
contracture releases and tendon transfers.
Thoracolumbar Spine Fractures
NON BEDAH >> & BEDAH

Indikasi Non Bedah :

Neurologis intak, sdt kifosis < 25º , lost t vertebr < 50% ,
pnyempitan kanal < 50%, kompl lig post intak
Menej : Orthosis v Casting Hiperekstensi 3 bln

Indikasi Bedah :
Defisit neurologis inkomplete, kompresi medl spin progresif ec
segmen yg retropulsi, Burst Fr tak stabil, termasuk kompleks lig post, fraktur
dengan rotasi signifikan
Thoracolumbar Spine Fractures
Treatment goals
Orthopaedic Objectives
1. Realign the spine in order to restore normal spinal contour and prevent future deformity.
2. Provide spinal stability.
3. Prevent new neurologic deficits and attempt to improve and prevent the exacerbation of existing
neurologic deficits.

Rehabilitation Objectives
1. ROM

2. MMT : Restore strength of the paraspinal muscles, latissimus dorsi, trapezius, and quadratus
lumborum. The gluteal muscles are involved if an autologous bone graft is harvested for arthrodesis.
3. Functional Goals : Allow for pain-free sitting, standing, and walking, and develop spinal flexibility for functional
independence.
Thoracolumbar Spine Fractures
Expected Time and Methods of Treatment
Bone Healing
Eight to 16 weeks before fusion is solid.
Rehabilitation
Three to 6 months.

Nonoperative Treatment: Orthosis/Body Cast

The thoracolumbar-sacral orthosis offers the most support in all planes. The Jewett brace is effective in
hyperextending and limiting the flexion of the spine.

Operative Treatment: Instrumentation/Arthrodesis

1. Posterior instrumentation and arthrodesis (pedicle screw devices, hook constructs)
2. Anterior strut graft and plate fixation
3. Anterior corpectomy, strut graft with/wout instrumentation, and posterior fusion with instrumentation
Thoracolumbar Spine Fractures
Prescription
Thoracolumbar Spine Fractures
Prescription
LONG-TERM CONSIDERATIONS

Posttraumatic deformity,
such as kyphosis and
lateral list, and
degenerative changes may
be seen.

If progressive deformity,
intractable pain, or
neurologic deficit occurs,
surgical stabilization and
decompression should be
considered.
Lumbosacral Fractures
Sebag besar Menejemen Non Bedah berupa Imob dng Orthosis 12 mg

Indikasi Bedah : Sindr. Cauda Equina, deficit neurol signifikan,

pnyempitan kanal yang berat
Postoperatively, or if surgery is not required, an orthosis is usually prescribed, and
maintained for approximately 3 months

Generally :
§ the occipito-C2 levels : Halo-vest may be used, although some surgeons will
utilize a head-cervical orthosis (HCO) ex: Miami J Collar
§ the C3-7 levels : an HCO is utilized
§ the T1-3 levels : a cervicothoracic orthosis is used (i.e., extended HCO or Yale
brace)
§ the T4 through L2: a thoracolumbar spinal orthotic (TLSO)
§ the L3 and below : a lumbosacral orthotic (LSO) with the incorporation of one
hip/thigh (spica attachment to a LSO or TLSO) will ensure satisfactory
immobilization of the low lumbar and sacral spine is required
Thank You