A 66 y/o male in good health presents after a snow mobile accident. He has a cottage on a lake up north, and the family meets there for weekends. Earlier today, they were all snowmobiling on the lake, and when he drove his snowmobile off the lake he didn’t hit the ramp straight on and he fell off to the side into a snow bank. He was on a fast snowmobile, but he slowed down considerably to exit the ice so he estimates he was only going about 30 MPH. He did not hit his head, got up immediately, and drove the snowmobile back to the cottage. He thinks he injured his left shoulder and left hip in the fall. He denies any loss of consciousness. As they were driving back to Detroit, he began to have increased pain in his left shoulder and left hip area, so his wife brought him to the ED. She tells you he is not a complainer, and when he complains of pain, she always knows its real.
ROS: No headache, blurred vision, numbness or weakness, neck pain, chest pain, abdominal pain, vomiting, pain with urination or bowl movement. No blood in his urine.
SH: No smoking, social alcohol. No drugs.
Meds: BP pill
VS: BP 125/82, RR=20, HR=88, Afeb, Oxygen Sat-95%
PE: WDWN robust man in no acute distress appearing younger than 66 yrs old.
HEENT: Unremarkable. No pain with ROM of neck. No neck tenderness.
Heart: RRR, no murmurs.
Lungs: Equal breath sounds. He does complain of pain up near his axilla with deep breath. Palpation of the chest wall does not reveal any crepitance. Equal chest excursion. Some rib tenderness is noted at rib number 4 and 5. No bruising or swelling to the skin.
ABD: Soft, non-tender. No masses. He does note that when you palpate in the LUQ area, he has increased pain in his left lateral rib area.
Pelvis: Stable, non-tender on compression.
Ext: Pain at left Acromioclavicular joint. Full range of motion is noted, but increased pain with abduction of shoulder. The left hip is also tender. Range of motion is maintained, but pain with range of motion testing. He notes he can walk on it, but has considerable pain with walking (His wife chimes in that he has to limp when he walks).
Neurologic: Alert and oriented x 3. No motor, sensory or reflex deficit. Cranial nerves are normal. Finger to nose testing is normal.
Back: No thoracic or lumbar spine tenderness.
Rectal: No gross blood.
1. Should you order a C-Spine X-Ray?
According to the Canadian C-spine rules, just based on age (>65yrs) and trauma, he would be considered for C-spine imaging. (1). If you consider the Nexus rules, then you would need to determine if you felt any of his pain areas (lateral ribs, shoulder or hip pain) constituted a distracting injury. According to the Nexus rules, the distracting injury footnote states:
“No precise definition of a painful distracting injury is possible. This category includes any condition thought by the clinician to be producing pain sufficient to distract the patient from a second (neck) injury. Such injuries may include, but are not limited to, any long-bone fracture; a visceral injury requiring surgical consultation; a large laceration, degloving injury, or crush injury; large burns; or any other injury causing acute functional impairment. Physicians may also classify any injury as distracting if it is thought to have the potential to impair the patient’s ability to appreciate other injuries.” (1)
After you determine if you plan to image his neck, the next question raised is should you order a CT or plain radiographs? Clearly most of us have seen a substantial shift from plain cervical spine radiographs to CT of the neck in trauma patients at risk for c-spine injury. I personally consider 2 things when deciding whether to scan or just x-ray the neck. If the person has a high pre-test probability for a c-spine injury (significant trauma, or unconscious and unable to examine) I always go for the CT. The other time I consider a CT over plain x-rays is when the patient is older. All of the spurs, DJD, and disk disease, along with osteoporosis, make a challenge to pick up subtle fractures. In one meta-analysis, authors suggest that CT should be done when the patient is a high risk for a fracture or unconscious. (2) However, the authors found ‘insufficient evidence’ to suggest that CT replace radiographs as the initial screening test for fractures in patients with low risk for c-spine injury. (2).
In this patient, because of his age and his potentially distracting injuries, I probably would have ordered a CT. This is actually not my case, but a colleague. He ordered plain C-spine X-rays, which were negative.
2. CXR reveals no pneumothorax or other abnormality identified. Hip x-ray is normal. C-spine x-ray is normal. Trauma labs are all normal. What is your disposition?
There are several things to consider in making this disposition.
a. Hip pain after trauma with significant pain on ambulation. An X-ray negative for hip fracture will not rule out a fracture. If the patient has significant pain on ambulation, even if the x-ray is negative, additional imaging is needed (such as MRI). In one study of 73 patients with negative radiographs who were referred for additional testing with MRI, 46% had fractures identified. (3) The reason why it’s so important to pick up these ‘subtle’ fractures is treatment when they are not displaced are much easier (conservative non-weight bearing or even percutaneous management). Once they are displaced, they will likely need an open procedure.
So, simply based on the potential for a non-displaced hip fracture, I would not discharge him.
II. Lateral rib pain. If a patient has point boney tenderness on rib palpation, and a mechanism consistent with possible rib fracture, then I always assume they have rib fractures. Unfortunately, rib fractures can often be missed on CXR. This is more likely in anterior rib fractures. Additionally, one study found patients >65yrs with rib fractures had twice the mortality compared to younger trauma patients. (4) So based on his exam, I would conclude he had occult rib fractures at T-4 and 5 (where he was tender). I don’t always admit older patients with single rib fractures, especially if they are isolated and have adequate follow-up. However, I always get them an incentive Spiro meter, and have a discussion regarding risk of pneumonia and need for close follow-up. When older patients have more than one rib fracture, I begin to get more concerned. In one study, for each additional rib fracture in the elderly, mortality increased by 19% and the risk of pneumonia by 27%. (4)
I should point out that if you really want to know if a patient has a rib fracture, and the CXR is negative, ultrasound is a great way to pick it up. The Hennepin Country Medical Center has a great u-tube (lasts 2.26 min) describing this technique. See it at: http://www.youtube.com/watch?v=r1-HV5lnJUo
III. Age. Numerous studies discuss the increased mortality in elderly patients suffering trauma. In this case, with mechanism of trauma significant (fall going 30 MPH) and clinical evidence of potential hip and rib fractures, with his elderly age, I would have opted to admit or at minimum observe him.
Patient was evaluated by surgery for admission. Additional CT of chest and Abdomen revealed 3 rib fractures on the left, and a splenic rupture (grade 2) without hemoperitoneum. Patient was admitted to the ICU. This is one of my colleague’s cases, and he was very surprised by the missed splenic rupture. That’s my reason for presenting this case; as the spleen lies posteriorly in the abdomen behind the stomach and is relatively ‘hidden’ by the ribs (unless it is enlarged), the patient may not have severe tenderness on palpation in the LUQ. I’ve seen enough ‘surprise splenic ruptures’ that I’m very conservative with patients who have left lateral rib fractures, or significant trauma on the left side. Early in my career I missed one (my one and only ‘surprise splenic rupture’). But I’ve learned my lesson and have picked up numerous ‘surprise splenic ruptures’ since that time, most recently last weekend in a patient who fell 3 days earlier while doing cocaine (she was 58). The resident wasn’t impressed with her exam, but she did have point tenderness to the ribs consistent with possible clinical rib fractures (CXR normal), and was tachycardic at 120 (resident attributed it to cocaine—which it may have been related to). To my exam, she had mild LUQ tenderness. CT revealed grade II splenic rupture. So the point of this case is: The older they are the harder they fall (i.e. more likely to suffer significant injuries and higher mortality if older), and beware of ‘surprise splenic ruptures’.
1. Stiell IG, Clement CM, McKnight D, Brison R, et al. The Canadian C-spine Rule versus the Nexus Low-Risk Criteria in Patients with Trauma. NEJM Dec25, 2003; (349):2510-2518. Entire manuscript available for free at: http://content.nejm.org/cgi/content/full/349/26/2510
2. Holmes JF, Akkinepalli R. Computed tomography versus plain radiography to screen for cervical spine injury: a meta-analysis. J Trauma 2005 May; 58(5):902-5. Abstract accessed at: http://www.ncbi.nlm.nih.gov/pubmed/15920400?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_SingleItemSupl.Pubmed_Discovery_RA&linkpos=4&log$=relatedreviews&logdbfrom=pubmed
3. Oka M, Monu JUV. Prevalence and Patterns of Occult Hip Fractures and Mimics Revealed by MRI. AJR 2004; 182:283-288. Abstract accessed at: http://www.ajronline.org/cgi/content/full/182/2/283
4. Bulger EM, Arneson MA, Mock CN, Jurkovich GJ. Rib fractures in the elderly. J trauma 2000 Jun; 48(6):1040-6. Abstract available at: http://www.ncbi.nlm.nih.gov/pubmed/10866248?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_SingleItemSupl.Pubmed_Discovery_RA&linkpos=3&log$=relatedarticles&logdbfrom=pubmed