Snakes and ladders

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Last month I had an interesting Room9 for visual purposes. The story per EMS was jumbled, as it can be from time to time. All we knew was that the patient was a middle aged man who either fell off a roof or jumped off a ladder into a foot and half of water. …agreed. Details were otherwise unavailable. We manage repercussions of injuries, not the causes.

The patent came in intubated, wet, hemodynamically stable. The patient had ketamine en route but was still active with GCS 6T. He required more than your typical sedation to be amenable for the CT scanner. The physical exam showed no motor activity in lower extremities, including to painful stimuli. We noted no step-offs or abrasions. The patient had no signs of trauma other than the motor weakness.He moved his upper extremities and needed restraints due to lack of response to sedation. CT images are below. Most of these images mirror almost exact images from Dr. Ferguson’s lecture on spine fractures, thus I thought it would be good to go over.

As you can see the patient had significant fractures of his cervical spine. Talking with Neurosurgery, the burst fracture is more common in lower thoracic and upper lumbar spine and only is seen in cervical spines to this degree under severe axial load injuries, such as going head first from a significant height (especially when the posterior column has a vertical fracture as seen above).

I’ve always wondered the significance of doing spinal check during the physical exam prior to CT, when they are already getting “manned”. I often feel that if there is real pathology (ie. unstable fractures), won’t palpating (and deep palpation on obese patients) worsen the fracture and theoretically cause neurological issues. I haven’t found much to substantiate that, but it seems to make intuitive sense; I am open to any other opinions / suggestions.

Does anyone want to comment on the type of fractures noted, stable vs unstable (refer to Ferguson’s lecture)?

Are teardrop fractures stable?

Is there any significant retropulsion?

Could you hypothesize flexion vs extension injury?

Answer: Unstable teardrop fracture as well as a burst fracture, and borderline chance fracture (not typical for this cervical spine location).

 

For further spine related information please look at the links below or Dr. Ferguson’s spine lecture. Ferguson’s is a great source covering the importance of stable and unstable fractures, and a great lecture for interns to go over, especially early on in the year.

Here is a good podcast from Scott W. on less traumatic c-spine injuries:

EMCrit 63 – A Pain in the Neck – C-Spine Imaging and Clearance

And some other good sources:

http://www.aafp.org/afp/1999/0115/p331.html

http://www.paems.org/pdfs/online-ce/Evaluation-and-management-of-acute-cervical-spine-trauma.pdf

327 thoughts on “Snakes and ladders”

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