Extremity Fracture and Neck Pain Case File

Extremity Fracture and Neck Pain Case File

Eugene C. Toy, MD, Barry C. Simon, MD, Terrence H. Liu, MD, MHP, Katrin Y. Takenaka, MD, Adam J. Rosh, MD, MS

Case 9

A 26-year-old waiter was serving food at a social function when he tripped and fell down a flight of stairs. He did not lose consciousness following the event but complains of severe neck pain and right wrist and hand pain. He was placed in a C-collar and transported by EMS to the emergency department (ED) with appropriate C-spine precautions. His vital signs and cardiopulmonary examinations are within normal limits, Glasgow coma scale (GCS) is 15, and he is able to move all extremities. Palpation of his neck reveals tenderness at the midline, and his right distal forearm/wrist/hand is swollen and exquisitely tender to touch.

⯈ What are the appropriate steps in the evaluation of his neck pain?

⯈ What are the important elements in the evaluation of his right upper extremity?

ANSWER TO CASE 9:

Extremity Fracture and Neck Pain

Summary: A young man tripped and fell down some stairs and now complains of neck and right upper extremity pain. His history and presentation are concerning for cervical spine and right upper extremity injuries.

• Evaluation of neck pain: Obtain computed tomography (CT) of the cervical spine. If the CT does not demonstrate any bony fractures or dislocation and his midline tenderness persists, then obtain flexion/extension x-rays or MRI of the C-spine to help differentiate ligamentous injury/spinal instability from soft tissue contusion.
• Evaluations of upper extremity: Given the soft tissue swelling and the location of pain, physical examination of the affect extremity should include detailed evaluation of the hand, wrist, and forearm, and this should include clinical assessments of tissue perfusion and functionality. Although, vascular injuries are uncommon with this patient’s injury mechanism, arterial inflow need to be evaluated based on capillary refill and presence or absence of pulses. If the perfusion status is in doubt, Doppler evaluation of pulse quality and pressures should be obtained. X-rays of the humerus, radius, ulna, wrist, and hand should be obtained to assess for possible bone injuries.

ANALYSIS

Objectives

1. Learn the common cervical spine injuries associated with the various injury mechanisms.
2. Learn the decision rules that guide the use of cervical spine radiography in trauma patients.
3. Learn the current role of corticosteroids in patients with spinal cord injuries.
4. Learn the emergency department management of elbow, forearm, wrist, and hand injuries.

Considerations

The neck pain associated with midline tenderness on palpation in this patient raises the concern for C-spine injury; therefore, radiographic evaluations must be obtained for further assessment. Either three views of the C-spine (AP, lateral, and odontoid views) or CT can be performed. CT is preferable over three views as the preferred diagnostic study in many centers because it is associated with much lower rates of false-negative examinations than plain radiography. CT would be especially helpful in this patient who exhibits concerning symptoms and physical findings. If the neck pain and midline C-spine tenderness persist despite negative CT, additional imaging to determine C-spine stability or to identify ligamentous injuries should be obtained. C-spine precautions should be maintained until the possibility of unstable injury can be eliminated based on imaging. Only when imaging studies indicate the absence of flexion/extension instability or the absence of ligamentous injuries can the patient be assumed to have neck pain related to soft tissue injuries only.

This patient also exhibit findings in the right distal forearm/wrist/hand that suggest the possibility of bony injuries. The initial evaluation should be directed toward evaluations of hand and digits functions; namely, motor/sensory functions and ligamentous integrity. Careful palpation of the hand, wrist, and forearm should also be performed to localize areas of concern for bony injuries. Two-view radiographs should be obtained to assess the bony integrity of the humerus, radius, ulna, carpal bones, and phalanges. When identified, fractures and dislocations should be reduced to minimize neurovascular compromises. Further assessments and management of all bony, ligamentous injuries and functional abnormalities should be discussed with an orthopedic or hand specialist.

Approach To:

Cervical Spine and Upper Extremity Orthopedic Injuries

DEFINITIONS

NEXUS LOW-RISK CRITERIA: This C-spine clearance approach was derived based on a 1998 publication by Hoffman et al (Ann Emerg Med 1998;32:461-469). The recommendations are that C-spine radiography is indicated for asymptomatic trauma patients unless they meet all of the following criteria: (1) No posterior midline cervical tenderness. (2) No evidence intoxication. (3) Normal level of alertness. (4) No focal neurologic deficits. (5) No painful distracting injuries. The major limitation of this approach is that no precise definition for painful distracting injuries was provided.

THE CANADIAN C-SPINE RULE (CCR): This is a guideline to determine the need for radiographic evaluations of alert and stable trauma patients. In comparison to the NEXUS criteria, the CCR has been shown to have slightly greater sensitivity and specificity for identification of patients who do not have C-spine injuries. (See Figure 9–1.)

PARTIAL CORD SYNDROMES: Compression or contusions to the spinal cord can develop with or without concomitant bony injuries. Compression of the anterior cord can produce complete motor paralysis, loss of pain and temperature perceptions. Posterior cord syndrome (Brown-Sequard) causes paralysis loss of vibratory sensation and proprioception ipsilaterally and loss of pain and temperature sensations contralaterally. Central cord syndrome is produced by injuries to the corticospinal tract, which produces great upper extremities weakness in comparison to the lower extremities.

Figure 9-1. Sample algorithm for assessing neck injury.

CLINICAL APPROACH

Millions of adults at risk for cervical spine injuries and/or upper extremity orthopedic injuries are evaluated in emergency departments throughout the United States and Canada every year. Among patients presenting with intact neurological status to the emergency department, the incidence of acute C-spine fracture or spinal injury is less than 1%. Even though spinal injury incidences are low, there are great consequences associated with mismanagement. Similarly, mismanagement of upper extremity injuries can lead to potential employment and functional compromises.

Clearing the C-spine in the Blunt Trauma Patient

The goal of C-spine clearance is to establish that injuries are not present, and based on statistics, probabilities for injuries are low. The approach to patients is based on patient classifications, where individuals are classified as asymptomatic, temporarily non-assessable, symptomatic, and obtunded. Asymptomatic patients can be approached using the CCR, which has been shown to lead to the reduction in unnecessary radiography and has been demonstrated to be superior in comparison to the NEXUS criteria. For temporarily non-assessable patients (either due to intoxication or distracting injuries), the approach is to assess the patient as an obtunded patient or reassess the individual after treatments of distracted injuries or return of normal mentation. Symptomatic patients are recognized by the presence of neck pain, midline tenderness, or neurologic signs and symptoms; symptomatic patients need to be initially evaluated with either 3-view C-spine x-rays or preferably CT; symptomatic patients with negative CT who are suspected of having ligamentous injuries need to be further evaluated with MRI of the C-spine, and if both CT and  MRI are negative, then the patients can be discharged with a collar for comfort; however, if the patient has persistent neck pain after 2 weeks, flexion/extension films are recommended to assess C-spine stability. All symptomatic patients should be evaluated by a spine specialist prior to discharge from the ED. For obtunded trauma patients (altered mental status or prolonged intubation or psychiatric disturbances or uncooperative), the initial evaluation is CT of the C-spine. If this is negative, there are two options; one option is to clear the C-spine, and the second option is to perform MRI to rule out ligamentous injuries. The major argument for option one is that isolated ligamentous injuries are rare, and the major argument for option two is that the negative predictive value of CT for ligamentous injuries is only 78%. It should be pointed out that the American College of Radiology recommends that CT and MRI are the most appropriate modalities for C-spine evaluation in the obtunded trauma patient. All obtunded trauma patients should be evaluated by trauma and/or spine specialists.

Emergency Department Management of C-spine Injuries

The initial management of any patient with C-spine injuries is to prioritize the ABCs, as most C-spine injuries do not occur as isolated injuries. Early definitive airways may be required for some patients who develop soft tissue swelling of the neck that lead to airway compromise. Similarly, definitive airway and mechanical ventilation may be required in patients with paralysis or muscle weakness associated with C-spine injuries. Definitive airway management in these patients is best accomplished by in-line C-spine stabilization and orotracheal intubations, following rapid-sequence induction. It is important to bear in mind that most of the respiratory accessory muscles receive their motor innervations from the thoracic level, and the diaphragm receives its innervations from C3-C5; therefore, patients with compromised ventilation secondary to C-spine injuries generally do not exhibit any external signs of respiratory distress, and the most reliable way to detect hypoventilation is by PaCO2 measurements on arterial blood gas. Estimation of neurologic deficits can be determined based on physical examinations and radiographic evidence of fracture and/or dislocation. From C1 to C7, nerve root exit above the level of the vertebrae, and from C8 and below, the nerve roots exit below the vertebrae.

If possible, it is always preferable to be able to perform a thorough motor-sensory examination prior to intubation. For patients with spinal cord injuries, it is always preferable to maintain a mean arterial pressure of 85 to 90 mm Hg to maximize spinal cord perfusion. If needed, patients with isolated spinal cord injuries may benefit from initiation of vassopressors such as dopamines or norepinephrine. Bradycardia associated with neurogenic shock can be addressed with atropine.

The priorities for any spinal cord injury patients are to address the life-threatening injuries first followed by management of the limb and quality-of-life threatening injuries.

Role of Corticosteroids for Spinal Cord Injuries

Corticosteroids had been a mainstay of therapy in the early management of spinal cord injury patients; however, more recent publications suggest that high-dose corticosteroids administration had only some benefits for individuals when the treatment was initiated within 3 hours of the injury. Unfortunately, the treatments with highdose corticosteroids are associated with increased rates of sepsis and other steroidassociated medical complications. In light of these published data, the application of corticosteroids for spinal cord injured patients have been dramatically reduced, and steroids should not be initiated for patients in the emergency department prior to discussions with the trauma and/or spine specialists who will ultimately manage the patient after ED discharge.

Management of Upper Extremity Injuries

Upper extremity injuries are commonly encountered in the ED. Inappropriate diagnosis and management in the ED can lead to chronic pain, and threat to recreational and vocational activities. Orthopedic injuries to the upper extremities are categorized by the bone, location (proximal, midshaft, or distal), presence or absence of joint involvement, degree of angulation, extent of comminution, and whether the fracture is open or closed.

Forearm fractures: Rotation of the forearm is crucial for hand function and activities of daily living. Normally, the radius rotate around the fixed ulna, and the ability of these bones to rotate around each other depends on the shape of the bones and their positions in relationship to each other. Initial evaluations of patients require careful determination of neurovascular status of the extremity followed by x-rays. Injuries that involve only one of the two bones are generally stable and are treated by closed manipulation, cast immobilization under conscious sedation or ultrasound- guided regional nerve blocks. Most displaced, fractures that involve both the ulna and radius are considered unstable fractures and are less amendable to closed fixations; therefore, many of these fractures are managed by open-reduction and internal fixations.

Distal radius fractures: This is one of the most common fractures encountered in children and adults. The bimodal distribution of this injury demonstrates a peak in late childhood (predominantly males) and after the sixth decade of life (predominantly females). The most common mechanism associated with this injury is a ground-level fall with outstretched hand. The Colles-Pouteau fracture is a fracture of the distal radial metaphysic with dorsal displacement of the distal fragment, and this represents the most commonly encountered distal radial fracture. In children, distal radius fractures are grouped as metaphyseal and physeal fractures, with the physeal fractures demonstrating involvement of the growth plate and can be further classified by the Salter-Harris classifications. Most of distal radius fractures in children are treated by closed reduction and cast fixation. The goals of a management in adults are to restore bone alignment and avoid shortening of the radius. The decision to treat patients by closed reduction and fixation versus operative reduction and fixation are determined by the degree of alignment, age, and functional status of the patients. Common complications associated with these injuries are malunion, nerve injury, tendon injury, stiffness, and chronic pain.

Carpal bone fractures: There are eight carpal bones in the hand. Carpal bones in general have limited blood supply and are susceptible to avascular necrosis following injuries. Often, details of fractures and/or dislocations of the carpal bones are difficult to visualize by plain radiography, therefore CTs or MRIs are sometimes used to determine the location and extent of injuries. Most displaced fractures are managed by operative reduction and fixation. Some of the stable, non-displaced carpal fractures can be initially approach with cast fixation. The management of any carpal injuries should be discussed with an orthopedic or hand specialist.

Metacarpal and phalangeal fractures: These fractures can be sometimes over-looked especially in a patient with multisystem injuries. The failure to identify and treat these injuries could lead to potential finger misalignement, pain, and functional loss. The goals of management of metacarpal fractures are to preserve bone length, rotational functions, and articular functions, which can be accomplished by either immobilization or internal fixation. The goals of managing phalangeal fractures are to minimize angulation and rotational deformities. Functional recoveries in most cases require patients’ participation in rehabilitation programs. Early involvement of a hand or orthopedic specialist is vital in the management of these patients.

COMPREHENSION QUESTIONS

9.1 A 78-year-old man is brought to the emergency center from an extended care facility. The patient reportedly was found to have fallen down in the bath room. He has contusions over his face and is confused. According to reports by his caretakers, this is his baseline mental status. How would you clear his C-spine?

A. Palpation of his C-spine for tenderness, if not tender than ask him to turn his head and if no pain is reported, the C-spine is cleared.

B. Keep him in C-spine precaution and reexamine him later when his mental status is improved.

C. Obtain CT, MRI, if these are negative, obtain flexion/extension films.

D. CT of the C-spine.

E. Remove the collar if he denies neck pain.

9.2 Which of the following approaches is most appropriate for the clearance of the C-spine in a 25-year-old man who the driver of a car struck from behind? He is hemodynamically stable, nonintoxicated, and has a GCS of 15.

A. NEXUS criteria

B. Canadian C-spine rule

C. CT of the C-spine

D. 3-view x-ray of the C-spine

E. Remove the collar because he does not have any pain

9.3 Which of the following is the most appropriate next step in the management of a 22-year-old man with C5 fracture and C5-C6 subluxation, absence of motor or sensory functions below the C4 level, heart rate of 45, and BP 100/60?

A. Maintain mean arterial pressure >85 to 90 mm Hg

B. Surgical airway

C. Orotracheal intubation with rapid sequence induction

D. Blind nasotracheal intubation

E. Administer atropine 1mg intravenously

9.4 Which of the following patient’s presentation is most compatible with the Brown-Sequard syndrome?

A. A 20-year-old man with absence of all motor/sensory functions in all extremities

B. A 20-year-old man with greater weakness in the upper extremities than the lower extremities

C. A 20-year-old man with complete motor paralysis, loss of vibratory sensation and proprioception on the ipsilateral side, and contralateral loss of pain and temperature sensation.

D. A 20-year-old man with fracture/dislocation of C5-C6 and intact motor/ sensory functions throughout

E. A 20-year-old man with normal CT of the C-spine and motor and sensory deficits below the C6 level

ANSWERS

9.1 D. For this patient with chronic altered mental status due to underlying medical conditions; therefore, the approach to clear his C-spine is one directed toward obtunded patients. His C-spine can be cleared based on a normal CT of the C-spine alone, which is sufficient to identify greater than 99% of all vertebral bony fractures/dislocations. An MRI can be added to identify the rare instances of isolated ligamentous injuries if the CT is normal. There is no consensus on whether MRI is indicated in this setting.

9.2 B. The Canadian C-spine rule (CCR) is an approach developed for the clearance of C-spines in asymptomatic patients following low mechanism events. The CCR has been compared to the NEXUS criteria and found to be more specific and sensitive in clearance of the C-spine.

9.3 C. This patient has signs consistent with neurogenic shock following a high spinal cord injury. The first concerns are his airway and ventilation. The airway appears to be clear but he needs a definitive airway to maintain optimal ventilation. Orotracheal intubation with rapid sequence induction and in-line C-spine stabilization is the optimal airway strategy for this patient. Maintenance of adequate pulse and blood pressure are important to maintain spinal cord perfusion, but these steps should be delayed until a secured airway is established.

9.4 C. The Brown-Sequard syndrome is caused by posterior spinal cord injury, characterized by paralysis, loss of vibratory sensation and proprioception on the ipsilateral side, and loss of pain and temperature sensation on the contralateral side. Patient described in A is compatible with complete cord injury. The patient described in B is compatible with central cord injury. The patient in D appears to have vertebral fractures/dislocation without neurologic compromises. The patient in E has a spinal cord injury without radiographic abnormality (SCIWORA); SCIWORAs occur more commonly in children than adults.

CLINICAL PEARLS

⯈ The Canadian C-spine rule is an effective evaluation system to clinically clear C-spines in asymptomatic patients.

⯈ Cervical spine injuries occur in 1% to 3% of all victims following blunt trauma.

⯈ Distal radius fractures have a bimodal pattern with peaks in late childhood and after the sixth decade of life.

References

Abraham MK, Scott S. The emergent evaluation and treatment of hand and wrist injuries. Emerg Med Clin N Am. 2010;28:789-809. 

Anderson PA, Gugala Z, Lindsey RW, et al. Clearing the cervical spine in the blunt trauma patient. J Am Acad Orthop Surg. 2010;18:149-159. 

Heggeness MH, Gannon FH, Weinberg J, et al. Orthopedic Surgery. In: Brunicardi FC, Andersen DK, Billiar TR, et al, eds. Schwartz’s Principles of Su rgery. 9th ed. New York, NY: McGraw-Hill; 2010:1557- 1608. 

Lifchez SD, Sen SK. Surgery of the hand and wrist. In: Brunicardi FC, Andersen DK, Billiar TR, et al, eds. Schwartz’s Principles of Surgery. 9th ed. New York, NY: McGraw-Hill; 2010:1609-1645. 

Pimentel L, Diegelmann L. Evaluation and management of acute cervical spine trauma. Emerg Med Clin N Am. 2010; 28:719-738.

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