Odontoid fracture

[drsutter]

I have recently seen this patient, a 25 years old male sitting in a chair watching t.v., then fell asleep and head hit the edge of table. Large hematoma on the side of the head, complain of head pain from the bruise. No neck tenderness, no other neurological symptoms. I CT him because he strongly requested it, negative. Sent him home with pain medication. 1 week later, he was diagnosed odontoid fracture at another ED facility. What am i missing here? Should we start scanning people head and c-spine with any minor trauma?

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[Hayduke]

I have recently seen this patient, a 25 years old male sitting in a chair watching t.v., then fell asleep and head hit the edge of table. Large hematoma on the side of the head, complain of head pain from the bruise. No neck tenderness, no other neurological symptoms. I CT him because he strongly requested it, negative. Sent him home with pain medication. 1 week later, he was diagnosed odontoid fracture at another ED facility. What am i missing here? Should we start scanning people head and c-spine with any minor trauma?

Here's the trauma.org ct guidelines.
http://www.trauma.org/neuro/neuroradiology.html
From your description, it sounds like this was an agressive workup for patient consideration.
The site states C2 is included in a standard, post-trauma scan. Could you see C2 on your films?
Re: your pt.
"fell asleep and head hit the edge of table" Now that's some heavy snoozing. Was this slumber augmented? In plain language-was he drinking/stoned? If this is a lifestyle selection for this patient he runs a pretty high risk of repeated head injury.
He may in fact have had an intact odontoid at the time of your assessment. What happened during the week in between?

 

[BKN]

I have recently seen this patient, a 25 years old male sitting in a chair watching t.v., then fell asleep and head hit the edge of table. Large hematoma on the side of the head, complain of head pain from the bruise. No neck tenderness, no other neurological symptoms. I CT him because he strongly requested it, negative. Sent him home with pain medication. 1 week later, he was diagnosed odontoid fracture at another ED facility. What am i missing here? Should we start scanning people head and c-spine with any minor trauma?

Did he have one of the conditions associated with loosening of the ligaments that hold odontoid, C1 and occiput together? (ex. JRA, Down's)

 

[Apollyon]

I have recently seen this patient, a 25 years old male sitting in a chair watching t.v., then fell asleep and head hit the edge of table. Large hematoma on the side of the head, complain of head pain from the bruise. No neck tenderness, no other neurological symptoms. I CT him because he strongly requested it, negative. Sent him home with pain medication. 1 week later, he was diagnosed odontoid fracture at another ED facility. What am i missing here? Should we start scanning people head and c-spine with any minor trauma?

Wait a minute - if you are EM/IM trained (5 years), and 3 years out of residency, don't you know the answer to this already?

 

[docB]

This isn't a bad ?. Would everyone here scan the neck or get CSP films on this patient? I agree the story is likely bogus, just like every other story I hear every day (Doc, I was hanging a lamp, naked and I fell off the ladder. Next thing you know...). But let's say the story is an unvarnished 20s yo M fell down while drunk. +LOC, event was 12 hours ago. Pt now is sober and rules out by NEXUS. Would anyone have gone looking for the odontoid fx?

 

[WilcoWorld]

If he had a large hematoma that was causing significant pain, could that be considered a distracting injury & thus no Nexus?

 

[BKN]

If he had a large hematoma that was causing significant pain, could that be considered a distracting injury & thus no Nexus?

The distracting injury thing is the toughest part of nexus. It's subjective, but I think most people would say a hematoma isn't distracting.

BTW all clinical decison rules have failures. The pubished sensitivity for NEXUS is 99%. The issue of importance is has a clinical decision rule been tested against clinical judgment and is it more reliable. I don't know that NEXUS has been, but I suspect that it is.

If that doesn't make you happy, you just have to xray anyone with mechanism.

 

[ERMudPhud]

I say the mechanism is totally bogus. More than once over the years I managed to fall asleep in class and wack my head on the desk so hard the entire lecture came to a screeching stop I never even once got a tiny bruise from this, much less a large hematoma.

On a side note many head CT protocals include the odontoid. Was it visuallized on the head CT?

We did have a drunk sustain an odontoid fracture and pith himself falling off a barstool a few years ago. The pithing may have happened when the medics arm and legged him out to the rig

 

[DropkickMurphy]

The pithing

Nicely put.....

 

[Apollyon]

Back when I was prelim, we had a woman on service that was about 95 years old; she had lived with her son (who was about 75), who had dropped her on her head while moving her (they were Polish, from Greenpoint - Poles are culturally very private, and this son refused to put his mother in a nursing home). He had lifted her, and was pivoting her, and she slipped, and her forehead goes BANG! - right flat onto the bed frame. She then twisted and cut her scalp. The odontoid fx was picked up in the ED, even though this lady wasn't per se tender (she was globally tender/not tender - you know the type). Neuro intact - not pithed.

She suffered an odontoid fracture (I don't recall which type), and all neurosurg said was a Philly collar for 3 months. However, less than a week later, she coded in the night and expired.

 

[drsutter]

This patient was sober, not on drug, appeared to be a legit patient. The hematoma on the scalp was large (but i will not consider that as a distracting injury. In other words, it's painful, but not that painful) Based solely on NEXUS criteria, i would not x-ray this guy, but i missed an C-2 fx. Beside, even for the sake of argument, if this guy's story was bogus, would you still x-ray or CT his c-spine when he is young and healthy, no midline cervical tenderness, no neurological deficit, and the mechanism of injury is minor? What would you do in real life setting?

 

[drsutter]

Just for clarification, are most of you EM residents or attendings?

 

[Apollyon]

Just for clarification, are most of you EM residents or attendings?

With several of us just having graduated, I think it's leaning towards attendings.

Let's see how many I can name - me, mikeCWRU, Quinn, Roja, DocB, bartleby, spyderdoc, ERMudPhud, EMRaiden, scrubbs, BKN - right off the top of my head.

There's several whom I'm not sure what their status is.

 

[edinOH]

I'm a newly minted attending myself. I don't know what else to tell you based upon the history you provided. Did you CT the cspine or just the head? If I'm getting a CT of the head in this case I'm probably gettting cspine films as well.

Can't really blame you for missing this though. I think it is very low probability to begin with. I'm curious what grade of odontoid fx he had.

 

[BKN]

I'm a newly minted attending myself. I don't know what else to tell you based upon the history you provided. Did you CT the cspine or just the head? If I'm getting a CT of the head in this case I'm probably gettting cspine films as well.

Can't really blame you for missing this though. I think it is very low probability to begin with. I'm curious what grade of odontoid fx he had.

I believe I've seen 3 patients who passed the nexus criteria who subsequently were found to have a fracture. 2 were >65 and thus would not have passed the canadian criteria. All 3 fractures were stable and thus finding them didn't change their management much except for pain measures.

 

[Annette]

Please forgive the IMer asking a ?stupid question, but can you have a non-healing odontoid fracture?

The medicine team had a patient in with some weird physical findings and lab values. (I don't remember what they were.) The care manager called up her home state to confirm medicaid status, and she was told that we were the 15th hospital that this patient had presented to. Kind of a Munchausen's with not-self inflicted pathology.

I know, I know, everyone can have real pathology to go with the psychopathology, and ya gotta sort them out.

 

[BKN]

Please forgive the IMer asking a ?stupid question, but can you have a non-healing odontoid fracture?

.

Sure, nonunion is possible with almost any fracture.

 

[DrQuinn]

This poses an interesting hypothetical question.

Let's say you see this guy the next DAY, i.e. he had the trauma the day before. You scan his head, sure. But do you scan his c-spine as well?

I had a patient referred to the ED today from Kaiser, minor MVA the day before, restrained. Moderate rear end collision. No LOC. Ambulatory on scene. Mild headache. Work up the next day with bilateral trapezius pain, and had two episodes of emesis. Referred to us for CT. On exam, everything is benign except she does indeed have posterior midline tenderness, C6-C7. I scanned her head, and c-spine, but... I did not put her in a collar for the scan. She ends up having loss of cervical lordosis, possible ligamentous injury (per rads read). I put her in an Aspen and send her for f/u MRI/neurosurg eval.

So, let's say you DO decide to xray/CT this guy's c-spine (some of you said you would). Do you put him in a collar before you do so?!

I tell ya, if I do scan these patients (and I document as best I can why I am NOT), I tend to not ct their c-spine unless they have positive findings on exam or on history....
Q

 

[bartleby]

So, let's say you DO decide to xray/CT this guy's c-spine (some of you said you would). Do you put him in a collar before you do so?!

This is the problem I see with in patients with dementia in particular. If they present uncollared do you leave them that way and risking finding a potentially unstable injury in someone non-immobilized ("Hi Mrs Smith. The results of your mom's CT are back, and I just wanted to come put this collar on so her head doesn't tip off the top of her spinal column while we're talking"), or you do go for the collar and risk getting a 90 y/o stirred up enough to need a sedative ("HEY DOC WAIT!"). Sometimes the "right" answer and the best thing to do for the patient are two different things.