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An 80 year old lady presented to the Emergency Department with neck pain 3 days after a fall. The lady lived alone in a flat on the third floor and whilst walking down a spiral staircase fell forwards. She remembered reaching for the rail and ended up on her bottom. She denied any head injury, neck pain, loss of consciousness or any other injuries. There were no preceding headaches, chest pain or palpitations. The lady woke up the following day with restricted neck movements due to constant pain. She was unable to alleviate this with paracetamol so presented to the ED.
On arrival at the ED the patients vital signs were all within normal physiological parameters. GCS was 15/15 and Abbreviated Mental Test Score was 10/10. Examination revealed reduced range of neck movements, limited by pain. The lady was able to flex her head to touch her chest but had reduced lateral rotation, lateral flexion and extension to 10 degrees. There was no c-spine tenderness and no palpable deformity. She had mild tenderness localized to her left trapezius. There were no abnormal neurological signs and systemic examination revealed no other abnormalities.
It was decided that AP, Lateral and Peg views should be obtained in order to exclude a c-spine fracture.
The lady was immobilised in the x-ray department and went on to have a CT cervical spine:
The lady was transferred to the Orthopaedic unit and the fracture managed conservatively in a cervical collar.
Falls in older people are common, with the prevalence being reported as almost 35% by some studies. They are significantly more common in women and are associated with fractures in 12% of cases. With an increasing population over 65 in the UK it is important that we are aware of this group of people and consider the causes and consequences of falling . Cervical spine fractures are also common following trauma with C2 being fractured most frequently, 55% affect the odontoid peg .
According to ATLS principles cervical spine radiographs are indicated for all trauma patients who have midline neck pain, palpation tenderness, neurological deficits referable to cervical spine, an altered level of consciousness, or are expected of being intoxicated . More recently studies have suggested that clinical examination cannot be relied upon to rule out c-spine fracture . Even with plain radiograph more than half of clinically significant c-spine fractures fail to be identified, with multislice CT having a higher sensitivity for detecting fractures .
This case highlights the importance of the history and high index of suspicion of c-spine fracture older patients following falls.
- Siqueira FV, Facchini LA, Piccini RX, Tomasi E, Thume E, Silveira DS, Vieira V, Hallal PC : [Prevalence of falls and associated factors in the elderly]. [Portuguese] Prevalencia de quedas em idosos e fatores associados. Revista de Saude Publica, Oct 2007, vol./is. 41/5(749-56), 0034-8910
- Pratt H, Davies E, King L: Traumatic injuries of the c1/c2 complex: computed tomographic imaging appearances. Current Problems in Diagnostic Radiology, Jan 2008, vol./is. 37/1(26-38), 0363-0188
- Advanced Trauma Life Support for Doctors, Student Course Manual, 7th Edition, American College of Surgeons Committee on Trauma
- Duane TM, Dechert T, Wolfe LG, Aboutanos MB, Malhotra AK, Ivatury RR: Clinical examination and its reliability in identifying cervical spine fractures. Journal of Trauma-Injury Infection & Critical Care, Jun 2007, vol./is. 62/6(1405-8; discussion 1408-10), 1529-8809
- Mathen R, Inaba K, Munera F, Teixeira PG, Rivas L, McKenney M, Lopez P, Ledezma CJ: Prospective evaluation of multislice computed tomography versus plain radiographic cervical spine clearance in trauma patients. Journal of Trauma-Injury Infection & Critical Care, Jun 2007, vol./is. 62/6(1427-31), 1529-8809
Ben Hickey, Aigbokhai Ohiwerei