Inertial Injuries. Eric Toder, D.O. Assistant Professor Touro University Nevada Department of Osteopathic Manipulative Medicine

Transcription

1 Inertial Injuries Eric Toder, D.O. Assistant Professor Touro University Nevada Department of Osteopathic Manipulative Medicine

2 Objectives Recognize the physics involved in inertial injuries Identify the areas of the body that are most often injured Assess the types of injuries that can occur in each region of the body Determine the best osteopathic treatment for the patient

3 Inertial Injuries Definition: accidents which cause the body to be thrust forward and then backwards (or side to side) in quick succession. During the movements the tissue surrounding the spine becomes stretched and may be damaged. Commonly seen in car accidents where there is a transfer of acceleration and deceleration forces.

4 Occurrences Number of MVAs in the USA in the year ,296,000 Number of deaths 200,000 Number of injuries 2.35 million Number of Traumatic brain injuries 1.7 million and 60-67% are caused by rear end MVAs

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7 Pathophysiology 1. Movement of the head backward then forward (such as in a rear end collision) produces extension dysfunction of the thoracic spine. 2. Splinting of the anterior cervical muscles produces increased disc pressure, bulging and nerve irritation esp. C Cervical nociceptive input to the upper thoracic region produces palpable findings.

8 Pathophysiology continued 4. The sudden lift of the sacrum caused by the spinal dural tube, then its forceful downward recoil between the ilia disturbs the involuntary respiratory motion of the craniosacral mechanism that is responsible for the fluctuation of the cerebrospinal fluid and nourishment of the CNS.

9 Pathophysiology continued 5. Due to this sudden journey, as well as the ligamentous and membranous strain resulting from continuity of fascia, disturbances can concentrate on muscles such as the scalenes, anterior cervical, trapezius, levator scapula, erector spinae, abdominal diaphragm, latissimus dorsi, iliopsoas, hamstrings, ect.

10 Pathophysiology continued 6. The inertial forces can also affect the brain and central nervous system resulting in coupe contra coupe injuries, dural membrane strains, CSF flow disruptions etc.

11 Pathophysiology continued 7. Whiplash is a mechanism of injury not a type or extent of injury. It not only effects the head and neck, but also the sacrum and ilia and the whole body.

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13 Cervical Spine Anatomy Ligaments continued Thieme Atlas of Anatomy; General Anatomy and Musculoskeletal System, 1st ed, 2010

14 Cervical Spine Anatomy Ligaments continued Thieme Atlas of Anatomy; General Anatomy and Musculoskeletal System, 1st ed, 2010

15 Cervical Spine Anatomy MRI

16 Cervical Spine Anatomy Anterior Muscles

17 Cervical Spine Anatomy Posterior Muscles

18 Cervical Spine Anatomy Posterior Muscles

19 Cervical Spine Anatomy Posterior Muscles

20 Intrinsic muscles of the back

21 Core Link Dural Tube Look how the motion of the occiput is mirrored in the motion of the sacrum

22 Pelvis Anatomy Definitions Pelvis: Right and left innominates (hip bones), the sacrum and coccyx. Innominate (Hip Bone): Made up of: ilium, ischium and pubis, which meet at the acetabulum. Hip Joint: Articulation of the femoral head with the acetabular socket of the innominate. Thieme Atlas of Anatomy; General Anatomy and Musculoskeletal System, 1st ed, 2010

23 Pelvis Anatomy Bones and Ligaments The sacrum is suspended between the innominate bones by three true and three accessory ligaments. True Pelvic Ligaments Accessory Pelvic Ligaments Anterior Sacroiliac (AS) Posterior Sacroiliac (PS) Interosseous SI Sacrotuberous (ST) Sacrospinous (SS) Iliolumbar Ligaments (ILL) ILL ILL AS PS SS ST Thieme Atlas of Anatomy; General Anatomy and Musculoskeletal System, 1st ed, 2010

24 Pelvis Anatomy Bones and Ligaments The Sacroiliac Joints have been described as L shaped with a shorter upper arm and an longer lower arm, with the junction occurring at S2. The shape and size of both articular surfaces show considerable individual variation, more so than any other joint. S2 Thieme Atlas of Anatomy; General Anatomy and Musculoskeletal System, 1st ed, 2010

25 Pelvis Anatomy Muscle Attachments Muscles do not directly move the sacrum between the ilia. Instead, sacral movement is the result of gravitational, inertial, and elastic forces resulting from spinal movements, which are indeed the result of muscular activity. Thieme Atlas of Anatomy; General Anatomy and Musculoskeletal System, 1st ed, 2010

26 Pelvic and Sacral fracture

27 Traumatic Brain Injury

28 The Unfixed Brain

29 Definition of traumatic brain injury Non-degenerative, non-congenital insult to the brain from an external mechanical force, possibly leading to permanent or temporary impairment of cognitive, physical, and psychosocial functions, with an associated diminished or altered state of consciousness Traumatically induced physiologic disruption of the brain

30 The brain: relevant neuroanatomy Cerebral gray matter- cell bodies, dendrites and synapses Cerebral white matter- myelinated axons Cerebellum Dura Sympathetic s Parasympathetic s Lymphatic s

31 The brain: cerebral gray matter Cerebral cortex Frontal Prefrontal cortex/ orbital frontal cortex Limbic Parietal Temporal Occipital Nuclei

32 The brain: cerebral gray matter

33 The brain: cerebral white matter Myelinated fibers(nerve and oligodendrocytes) Components Transverse( commissural) Connect two cerebral hemispheres Projections Connect the cerebral cortex with lower structures or spinal cord Association Connect portions of a cerebral hemisphere

34 The brain: cerebral white matter

35 The brain: cerebral white matter

36 The brain: cerebral white matter

37 Force: Etiologies Falls 35.2% MVA 17.3% Sports 16.5% Blasts 21% Assaults 10%

38 The insult Primary injury Direct result of trauma Little intervention is available Secondary injury Changes that occur because of the primary injury Most acute treatment is aimed at decreasing this

39 The insult: primary injury Skull fractures/breach Hematomas/hemorrhage/contusion Destruction of neurons/connections Cellular damage(partially secondary)

40 The insult: primary injury

41 The insult: secondary effects Loss of hemostasis(decreased blood pressure, decreased O2, increased intra cerebral pressure, decreased cerebral blood flow) Biochemical changes Autonomic deregulation Pathophysiology Fixed intracranial volume Impaired cerebral blood flow

42 Diffuse axonal injury(dai)

43 Diffuse axonal injury(dai)

44 Tau protein tangles

45 Traumatic brain injuries symptoms Cognitive impairment Depression Tinnitus Cervical strain Post concussive syndrome Memory problems Vertigo and balance problems Syncope Dizziness Posttraumatic headache PTSD TMJ dysfunction

46 Grading scales for concussion Grading Scales for Concussions: Grade I Grade II Grade III Cantu I. Post-traumatic amnesia <30 minutes, no loss of consciousness II. Loss of consciousness <5 minutes or amnesia lasting 30 minutes 24 hours III. Loss of consciousness >5 minutes or amnesia >24 hours Colorado Medical Society I. Confusion, no loss of consciousness II. Confusion, post-traumatic amnesia, no loss of consciousness III. Any loss of consciousness American Academy of Neurology I. Confusion, symptoms last <15 minutes, no loss of consciousness II. Symptoms last >15 minutes, no loss of consciousness III. Loss of consciousness (IIIa, coma lasts seconds, IIIb for minutes)

47 Traumatic brain injuries symptoms

48 Dural Partitions

49 The Glymphatic System

50 Why sleep is important

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55 Dural Partitions

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58 Lab Psoas treatment Sacral treatment Cervical spine OA V spread for ocipitomastoid suture

59 Principles of BLT In balanced ligamentous tension (BLT) techniques, since strained ligaments are maintaining the somatic dysfunction, they will be used for correction. The articulation is carried in the direction of the ease, exaggerating the lesion position as far as is necessary to cause the tension of the weakened ligaments to be equal to, the tension of those that were not strained. This is the point of balanced tension. Note: Of greatest importance, however, is the mental equipment of the osteopathic physician and the ability to visualize the structures concerned in the dysfunction with keen tactile sense. This Strained Joint is Sidebent Right Lippincott HA, The Osteopathic Technique of W.. G. Sutherland, DO

60 Psoas

61 Sacrum

62 Hand placement for sacrum Supine 2 Hands - Knees Extended

63 Hand placement for sacrum Supine 2 Hands Knees Flexed

64 Hand placement for sacrum Showing finger locations

65 Cervical Spine Anatomy - Muscles Suboccipital Triangle 2008 Thieme Publishers, Illustrator: Karl Wesker

66 OA BLT 1. Make an accurate OA diagnosis (ex. OA FR R S L ) 2. With the patient supine, cradle the occiput with the posterior hand while the anterior hand contacts the frontal bone, near the glabella. Both middle fingers should be oriented midline.

67 OA BLT 3. Place the tip of the middle finger of the posterior hand against the posterior tubercle of C1. (between the occiput and the spinous process of C2) 4. Ask the patient to slightly tip, or nod his head forward, while avoiding flexion of the cervical spine. If the patient cannot slightly nod his head, the physician s anterior hand can accomplish the same with a slight inferior pressure. C1

68 OA BLT 5. As the occiput rocks into the posterior hand, the tubercle of C1 will be carried posteriorly into the tip of the middle finger This finger creates an anterior vector stabilizing C1 to create a disengagement While holding C1 anteriorly, make fine adjustments to create a point of balance (BLT) while keeping the head nodded forward You may need to adjust the position of the posterior hand to allow for a comfortable treatment for both the patient and the physician 6. Hold the position (fulcrum) until there is a release between the occipital condyles and C1 which is frequently felt by both the patient and the physician To the physician the release often feels as if the occiput is coming back into your hand 7. Reassess the original diagnosis C1

69 OA BLT Tipping the head animation

70 AA BLT 1. Make an accurate AA diagnosis (ex. AA Rotated Left) 2. With the patient supine, cradle the occiput with the cephlad hand while using its middle finger to contact the posterior tubercle of C1 3. The caudad hand contacts the spinous process of C2 using one finger pad Optional hold is holding the thumb and index finger on each articular pillar of C2 Optional C2 Hold C2 C1

71 AA BLT 4. The joint is disengaged then a point of balance (BLT) is established through rotation of C2 (lower segment), while stabilizing C1 (upper segment) 5. Hold the position (fulcrum) until there is a release between the C1 and C2 6. Reassess the original diagnosis C2 C1

72 C2-C7 BLT 1. Make an accurate segmental diagnosis (ex. C4 ER L S L ) 2. With the patient supine, cradle the neck between the hands, placing the pads of the index or middle fingers along the articular pillars of the typical cervical vertebrae C5 C4

73 C2-C7 BLT 3. To treat C4 ER L S L as depicted below, the right middle finger applies a gentle anterior pressure to the posterior aspect of the right articular pillar of C4 This causes left rotation of C4, in the direction of ease 4. The left middle finger applies a similar anterior force to the left articular pillar of C5 This stabilizes C5 so that a point of balance (BLT) can be achieved 5. Hold the position (fulcrum) until there is a release between C4 and C5 6. Reassess the original diagnosis C5 C4

74 Anterior cervical fascia release The anterior hand contacts the sternal notch and manubrium while the posterior hands contacts mastoid process and spinous process of C2 BLT is used to balance the anterior cervical fascia to release the superior cervical ganglia

75 V-Spread Technique

76 V-Spread Technique The V-spread is a very simple and safe technique for releasing any peripheral suture such as frontonasal, nasomaxillary, or occipitomastoid. 1. Place index and middle fingers of the ipsilateral hand on either side of the restricted suture. 2. Cluster the fingers of the other hand on the patient s head at the other end of the longest diameter of the head from the suture.

77 V-Spread Technique 3. Direct a fluid wave slowly from the clustered fingers to the restricted suture, while applying gentle separation force across the restricted suture with the ipsilateral fingers. 4. As long as the suture is restricted, the fluid sensation will bounce back. 5. Redirect the fluid wave back towards the restricted suture until there is a release. When it releases, you will feel a gentle, easy motion between your hands.