Academy of Chiropractic Personal Injury & Primary Spine Care Program
Quickie Consult 193
“Clinical Review: Missed Fractures”
I accepted a patient for care with a fresh accident this week, my first in years because she is a very close friend and a surgeon in the community. My involvement will be limited to managing the case and making the referrals. She was T-boned at 80-90 mph on the passenger side with the "bullet" car not touching the brakes based upon the lack of skid marks. It appears the driver was being "pleasured" by his girlfriend and was not paying attention to cars in the intersection. This was not a happy ending!
The accident happened on 11-12-2010 and upon impact, the airbag deployed with a pure side impact where the bullet car hit the right front of her car flush, bounced off and the hit the right rear as the momentum was still carrying the car forward. The occupant (driver) first experienced exquisite pain and then couldn't breathe. This lasted a minute or so and then she lost the will to breathe. At the time, she went on to explain, she felt euphoric and experienced blissful peace with no pain. That last for a second, minute, hour, year, she has no recollection of, but then she was able to breathe and the exquisite pain re-engaged. Basically, she died and then re-emerged with no external support. A short while later the ambulance took her to the emergency room where they performed a c-spine and chest CAT scan and released her. The CAT Scan findings were atelectasis which, according to the Mayo Clinic:
Atelectasis (at-uh-LEK-tuh-sis) — a complete or partial collapse of a lung — is a possible complication of many respiratory problems. Mucus in the airways after surgery, cystic fibrosis, inhaled foreign objects, severe asthma and chest injuries are among the common causes of atelectasis.
Unlike pneumothorax, which is air between the chest wall and lung, atelectasis develops when the tiny air sacs (alveoli) within the lung become deflated.
The amount of lung tissue involved in atelectasis is variable, depending on the cause. Signs and symptoms of atelectasis also vary with the underlying cause and the extent of lung involvement. Atelectasis can be serious because it impairs the exchange of oxygen and carbon dioxide in your lungs. Treatment depends on the cause and severity of the collapse.
Depending on the severity of the atelectasis, there may be no obvious signs or symptoms. If you do experience signs and symptoms, they may include:
- Difficulty breathing (dyspnea)
- Rapid, shallow breathing
- Low-grade fever (in a child)
She was discharged from the hospital and told to see a pulmonologist. As a note, she is a staff surgeon at the same hospital. She consulted her family doctor about her lungs and he said to simply rest as there was no treatment. She contacted me 4 days post trauma to ask what she should do as she was in persistent exquisite pain; 10/10 in the chest, thoracics and right shoulder.
Upon evaluation in my living room at home, my new office, I determined there was possibly a thoracic myelopathy, based upon the negative chest CAT scan that ruled out any fractures. She had significant cognitive issues, headaches and large gaps in memory, both long and short term, radicular pain in the right side with right shoulder pain and was still unable to breathe without pain. She had paraspinal pain and spasms in her entire spine.
I consulted with a neurologist, one of my team members, and ordered immediate MRI's of her brain, cervical and thoracic spine and a right shoulder MRI. I also ordered x-rays of her full spine, a trauma series. The brain, cervical and thoracic MRI's were negative. Her x-rays were negative for fracture and only showed aberrant curves.
I consulted another member of my team, a neuroradiologist, about ordering a bone scan to see if fracture was present vs. taking another CAT scan of her chest vs. going back to the hospital that originally took the CAT scan to see if they had a good machine and could reformat the views. The sequence agreed upon was to consult with the original radiologist who read the CAT scan and see if she could reformat the views and see anything. If that was negative, then a bone scan should be performed and based upon the results, we'd make a determination.
I spoke to the hospital and asked for the reading doctor and was told she wasn't in. Another radiologist pulled the images and I asked him to reformat the CAT scan and look at the coronal views. Upon review, he informed me that he found 2 fractures, 1 in the sternum and the other at the costo-sternal junction. I asked for the report and 10 hours later, nothing had been sent.
I went to the hospital in the early evening only to be told there were no radiologists present, but they called the reading radiologist on her cell phone and I spoke with her. Upon informing her of the history, she said that no one in the ER department indicated that the patient had chest pain, so she didn't look carefully at the sternum or ribs. She confirmed the fractures and sent me the amended report. I professionally chastised both her and the ER physician for missing the obvious. She concurred.
Upon getting the MRI results of the patient's shoulder, it was determined that there was a fracture there as well and the patient was sent off to the orthopedic surgeon for fracture care. She had unnecessary MRI's in the cervical and thoracic spine because of the missed read of the radiologist and the work of the emergency department. I would have deferred the MRI's because the exquisite pain would have been explained with no concern of myelopathy in the presence of mild to moderate clinical extremity neurological deficits.
Now that the patient has a definitive diagnosis, no further tests are indicated at this time. She will see the neurologist in a few weeks for an EEG, but that isn't urgent. This case underscores the necessity to understand trauma and the use of x-ray, bone scan and CAT scans and have them clinically correlated to your examination.