Undetected hangman's fracture in a patient referred for physical therapy for the treatment of neck pain following trauma

BACKGROUND AND PURPOSE: This case report describes a patient referred for physical therapy treatment of neck pain who had an underlying hangman's fracture that precluded physical therapy intervention. CASE DESCRIPTION: This case involved a 61-year-old man who had a sudden onset of neck pain after a motor vehicle accident 8 weeks before his initial physical therapy visit. Conventional radiographs of his cervical spine taken on the day of the accident did not reveal any abnormalities. Based on the findings at his initial physical therapy visit, the physical therapist ordered conventional radiographs of the cervical spine to rule out the possibility of an undetected fracture. OUTCOMES: The radiographs revealed bilateral C2 pars interarticularis defects consistent with a hangman's fracture. The patient was referred to a neurosurgeon for immediate review. Based on a normal neurological examination, a relatively low level of pain, and the results of radiographic flexion and extension views of the cervical spine (which revealed no evidence of instability), the neurosurgeon recommended that the patient continue with nonsurgical management. DISCUSSION: In patients with neck pain caused by trauma, physical therapists should be alert for the presence of cervical spine fractures. Even if the initial radiographs are negative for a fracture, additional diagnostic imaging may be necessary for a small number of patients, because they may have undetected injuries that would necessitate medical referral and preclude physical therapy intervention.     

Dialysis-related spondyloarthropathy

OBJECTIVE: To discuss a case of dialysis-related spondyloarthropathy due to beta-2 microglobulin amyloid deposition. An emphasis is placed on the imaging findings. CLINICAL FEATURES: A 67-year-old man sought treatment for low back pain. His history revealed coronary artery bypass surgery, diabetes with bilateral foot neuropathy, gout, and bilateral renal failure that had been treated with dialysis for 2 years before left renal transplantation; the renal transplant had been performed 6 years earlier. Radiography, computed tomography, and magnetic resonance imaging revealed changes characteristic of dialysis-related spondyloarthropathy. INTERVETION AND OUTCOME: The patient was initially treated with physiotherapy. He was then admitted to the hospital and treated for renal infection and medicated for low back pain. Two weeks later he returned to the chiropractor, who began a treatment plan that included spinal manipulation, physiotherapy, manual distractive traction, and a gradual increase in activities of daily living. The patient was released from care after 2 months with significantly decreased pain. CONCLUSIONS: Dialysis-related spondyloarthropathy is a relatively uncommon complication of renal dialysis. It should be suspected in those patients who present with a correlative medical history and characteristic radiographic appearance. Chiropractic treatment can be effective as an adjunct to medical care in cases of chronic renal failure and associated complications.     

Missed cervical spine fracture: chiropractic implications

OBJECTIVE: To discuss the case of a patient with an anterior compression fracture of the cervical spine, which had been overlooked on initial examination. CLINICAL FEATURES: A 36-year-old man was seen at a chiropractic clinic 1 month after diving into the ocean and hitting his head on the ocean floor. He chipped a tooth but denied loss of consciousness. Initial medical examination in the emergency department did not include radiography, but an anti-inflammatory medication was prescribed. Radiographs taken at the chiropractic clinic 1 month later revealed an anterior compression fracture of the C7 vertebra, with migration of the fragment noted on flexion and extension views. INTERVENTION AND OUTCOME: The patient was referred back to his medical doctor for further evaluation and management.He was instructed to wear a Philadelphia collar for 4 weeks. During this time period, he reported "shooting" pain and tingling from his neck into his arms. The patient reported resolution of his neck and arm symptoms at 2.5 months after injury. Follow-up radiographs at 6 months after injury revealed fusion of the fracture fragment with mild residual deformity. At that time, the patient began a course of chiropractic treatment. CONCLUSION: After head trauma, it is essential to obtain a radiograph of the cervical spine to rule out fracture. Chiropractors should proceed with caution, regardless of any prior medical or ancillary evaluation, before commencing cervical spine manipulation after head and neck trauma.     

Sonographic detection of an isolated cuboid bone fracture not visualized on plain radiographs

We report the case of an isolated cuboid bone fracture in a child that was missed on radiography but was diagnosed on sonography. Plain radiographs of the patient's right foot showed no fracture, whereas sonograms demonstrated a fracture of the cuboid bone that appeared as a steplike discontinuity in the cortical bone. The diagnosis was confirmed on MRI. The fracture was treated with cast immobilization and no weight bearing for 4 weeks. In 8 weeks, the patient had no symptoms and good motor and sensory function of her right foot. Other imaging modalities are usually advocated for diagnosing fractures that are missed by radiography. Over the last decade, sonography has been increasingly used for diagnosing occult fractures. Although its use in such cases is not yet fully established, we believe that in the future, the sonographic detection of an injury that corresponds to the site of the reported pain will be adequate for initiating treatment of many types of fractures.     

Cervical spine fracture following a motor vehicle accident

We present the case of a 50-year-old man who visited our emergency department 12 h after an alcohol-related motor vehicle accident complaining of shoulder pain and neck stiffness. Cervical spine radiographs were obtained and interpreted as normal, and the patient was discharged. Subsequent review by a radiologist raised the question of a second cervical vertebra (C-2) abnormality, and the patient was recalled. Cervical computed tomography (CT) scan revealed an unstable oblique fracture of C-2 and a congenital nonfusion of the arch of C-1. The patient was placed in halo traction, and subsequent radiographs revealed a fracture of the transverse process of C-7. The patient made an uneventful recovery. The limitations of routine cervical radiographs are well-documented, but no feasible alternative exists as a screening procedure. Thus, a certain level of uncertainty must be accepted. Both physician and patient must recognize the limitations inherent in all medical practice and that follow-up examination and treatment are essential.     

Fracture of lateral process of the talus presenting as ankle pain

The case is presented of a 27 year old woman with lateral ankle pain after an inversion injury sustained while dancing. Although initial radiographs failed to identify the fracture, radiographs of the ankle at six weeks showed an unsuspected fracture of the lateral process of the talus. The fracture was treated with cast immobilisation for six weeks and the patient is currently undergoing aggressive physiotherapy. A literature review revealed that fractures of the lateral process of the talus are frequently overlooked and should be considered in the differential diagnosis of patients with acute and chronic ankle pain as an early diagnosis and treatment prevent long term complications.     

Injury to the upper cervical spine: fracture versus congenital anomaly

As skull and cervical spinal radiographs are being obtained routinely on head and neck injuries, more incidental anomalies of the neck region are being detected. The differentiation of congenital anomaly from fracture can be difficult. The importance of this, however, cannot be underestimated because of the dire consequences of a missed cervical fracture. A case of such an anomaly and its presentation following injury is presented.     

Mediale Schenkelhalsfraktur nach arthroskopischer Offsetkorrektur

Background

Hip arthroscopy has been established over the past decade as a safe treatment of many hip diseases. Complications such as fractures of the femoral neck are very rare.

Case report

We report the case of a 54-year-old woman who developed a stress fracture of the femoral neck 5 weeks after arthroscopic femoral neck osteochondroplasty. To our knowledge this is the first reported case of a female patient.

Conclusions

Postoperative groin pain after load increase should the surgeon aware of a possible femoral neck stress fracture. For further diagnosis, physicians should not hesitate to ask for an MRI or a CT scan because conventional radiographs can be normal. Stable stress fractures can be treated conservatively with restricted weight bearing on 2 crutches for 6 weeks.

     

Missed lumbar transverse process fractures in a high school football player

OBJECTIVE: To discuss the case of a football player who had suffered a transverse process fracture of the lumbar spine that was overlooked on initial chiropractic and medical examination. CLINICAL FEATURES: A 17-year-old male football player had been speared in the back by another player. He reported severe initial pain that caused him to fall to the ground, and there was a moderate degree of pain at the time of his chiropractic examination 1 week after injury. INTERVENTION AND OUTCOME: Initial chiropractic treatment consisted of spinal manipulation to the lumbar spine. Follow-up care consisted of lumbar spine radiographs that showed evidence of a lumbar transverse process fracture at 2 levels. The boy was referred to his medical doctor, who was not convinced of the presence of a fracture and returned him to play. A computed tomography scan was subsequently performed; this confirmed fractures of the transverse processes of L2 and L3. The patient was precluded from contact sports for 4 weeks. Chiropractic care 3 weeks after injury included physiotherapy and drop table mobilization to the sacroiliac joints. The patient returned to play 4 weeks after the injury. CONCLUSION: Transverse process fractures commonly occur secondary to blunt trauma in contact sports such as football. With high-force direct trauma, radiographs should be performed to rule out fracture before returning the athlete to play or commencing spinal manipulation.     

Occult ankle fracture detected by an ankle effusion on plain radiography: A case report

Subtle ankle fractures may escape detection on plain radiography. These occult fractures can cause prolonged disability and pain. We present a case of blunt ankle trauma where plain radiography failed to reveal any bony abnormalities. The recognition of an ankle effusion on plain radiographs prompted us to perform a computed tomography (CT) scan of the ankle. The CT scan demonstrated an anterior plafond fracture of the distal tibia, which required surgical fixation. Had the fracture not been identified, our patient would have been treated inappropriately for a ligament sprain. An occult fracture should be suspected if an ankle is grossly swollen after blunt trauma, and plain radiography demonstrates an effusion. In this circumstance, performance of further imaging studies, such as conventional or CT, are advised to rule out an occult ankle fracture.     

Long-standing axis odontoid fracture in patient presenting with acute low back pain

Objective:To present the case of a patient affending for chiropractic care with acute low back pain. Incidentally, a previously unknown long-standing axis odontoid fracture was diagnosed, which resulted in a referral for neurosurgical management.Clinical features:A 63-year-old man presented for chiropractic care with a chief complaint of severe acute low back pain. His examination revealed evidence of lumbar and upper cervical subluxations. Subsequent X-rays revealed a double rotatory lumbar scoliosis and an axis odontoid fracture at its base. A cervical flexion X-ray revealed instability and a later computed tomography confirmed the fracture.Intervention and outcome:Due to poor patient compliance, a neurosurgical consultation and subsequent upper cervical arthrodesis did not take place until over 4 months after the initial diagnosis. A Brooks C1-C2 posterior fusion using Songer cables and an iliac crest bone graft resulted in a successful outcome. Prior to surgery, the patient's low back pain was managed by the chiropractor with a successful outcome.Conclusion:This case presents a rare, yet precarious situation with the chiropractic management of a patient with a potentially catastrophic condition. This clinical example also stresses the importance of careful clinical assessment and imaging procedures for patients before providing spinal adjustments in order to avoid a potential iatrogenic incident. This case report also demonstrates the successful outcome of specific chiropractic care in the amelioration of acute low back pain.     

Application of clinical criteria for ordering radiographs to detect cervical spine fractures

OBJECTIVE: The aim of the study was to determine if spinal-immobilized patients met clinical criteria for x-rays and which clinical criteria were associated with cervical fractures. METHODS: This was a prospective, observational analysis of clinical findings and radiograph results for patients transported to the emergency department in spinal immobilization by emergency medical services. The presence of altered mentation, distracting injury, cervical spine tenderness, neck pain, neurologic deficit, and palpable deformity was recorded for each subject. RESULTS: Of the 2044 subjects enrolled in the study, 1367 subjects received radiographs and 50 had cervical spine fractures. Sixty percent of subjects met some clinical criteria for radiograph ordering. Cervical spine tenderness and neurologic deficit were the only clinical criteria statistically associated with fractures. All subjects with fractures met 1 or more of the clinical criteria for radiographs. CONCLUSION: Cervical spine radiographs were ordered for a significant number of patients who did not meet the clinical criteria. However, omission of any one of the criterion other than palpable deformity would have potentially resulted in a missed fracture. Strictly following the criteria would have significantly reduced the number of cervical spine radiographs taken.     

不典型主动脉夹层误诊的几点思考

目的分析临床表现不典型主动脉夹层（aortic dissection,AD）的误诊原因,并提出防范误诊的对策。方法对我院收治的2例临床表现不典型AD的临床资料进行回顾性分析。结果本组1例表现为腹腰痛在外院误诊为急性胰腺炎、急性胆囊炎等,1例因突发胸闷伴视物模糊入院误诊为冠心病,均经胸腹部CT确诊为AD,转上级医院治疗,1例病情好转出院,1例失访。结论 AD临床表现复杂多变缺乏特异性,首诊易误诊、漏诊,疑诊AD时仔细问诊和查体,及时选择相应的实验室和影像学检查,有利于提高早期诊断率,改善患者预后。     

髌骨纵行骨折的误诊原因及防范对策

目的 分析髌骨纵行骨折的临床特点及误诊原因,总结防范误诊措施.方法 对2018年1月—2020年5月收治的16例髌骨纵行骨折中曾误诊5例的临床资料进行回顾性分析.结果 本组误诊率为31.25％,4例因单侧膝关节肿痛伴稍许伸屈活动受限入院,1例因车祸致左膝关节肿痛、活动受限入院.误诊为膝关节软组织损伤2例,股骨髁间骨...     

Missed slipped capital femoral epiphysis: Illustrative cases and a review

Slipped capital femoral epiphysis (SCFE) is a fairly common condition affecting older children and adolescents, and has the potential for long-term, crippling sequelae. Early recognition is the single most important controllable factor, but the diagnosis is often missed or delayed, resulting in progression of the slip. A SCFE should be suspected and promptly evaluated in any older child or adolescent presenting with a limp or complaints of hip, groin, thigh, or knee pain, especially if the patient is overweight. The diagnosis is usually made by anteroposterior and frog-leg lateral radiographs of the hips. Common errors at initial presentation include: not obtaining hip radiographs (due to either no hip pain or the lack of an impressive history and physical findings); misreading hip radiographs (the findings can be subtle); and lack of timely referral. Early involvement of and treatment by an orthopedic surgeon can greatly reduce the potential complications. We present three cases of SCFE that highlight common errors made at initial presentation, and a discussion that includes the differential diagnosis of an older child or adolescent with a painful limp.     

Sonographic diagnosis of a radiographically occult displaced fracture of a costal cartilage

We report the case of a 22‐year‐old athlete who sustained a blunt thoracic trauma to the right chest causing a costal cartilage fracture. Plain radiographs revealed no abnormalities while sonographic (US) examination performed a week later because of persistent pain led to the diagnosis of a displaced fracture of the right tenth costal cartilage. A follow‐up US examination confirmed the healing of the fracture and allowed the patient to return to competitive sport activity. We recommend the use of US in patients with persisting pain after thoracic trauma with negative plain radiographs of the ribs to rule out radiographically occult costal cartilage fractures. © 2017 Wiley Periodicals, Inc. J Clin Ultrasound 45 :605–607, 2017     

Pelvic stress fracture: assessment and risk factors

OBJECTIVE: To discuss the case of a patient with a pelvic stress fracture and the differential considerations among patients presenting with hip and/or groin pain. FEATURES: A 42-year-old woman had hip pain after running. Initial radiograph of the pelvis was negative. Subsequent films showed a right inferior pubic ramus stress fracture. Stress fractures of the pelvis are relatively uncommon, accounting for only 1% to 2% of all stress fractures. INTERVENTION AND OUTCOME: Treatment included high-velocity, low-amplitude chiropractic manipulation, ultrasound, and stretching of the psoas and piriformis muscles. After 8 weeks, care was discontinued because the patient's hip pain had resolved. The pelvic fracture was left to heal with time. After 1 year, the patient still had delayed union of the fracture. CONCLUSION: When predisposing factors are present, such as osteoporosis and rheumatoid arthritis, pelvic stress fracture should be suspected in patients with groin or hip-area pain. However, because pelvic stress fractures are relatively rare, radiographic studies are often postponed, making diagnosis difficult.     

急性肺栓塞的影像诊断与介入治疗分析

目的:对影像诊断急性肺栓塞的应用价值以及介入治疗的效果展开研究。方法:从2017年5月-2019年5月我院收治的患者中随机拣选17例怀疑为急性肺栓塞的患者,所有患者均采取CT诊断,并接受介入治疗,观察CT诊断的准确率以及漏诊和误诊率,此外对比治疗前后的治疗效果。结果:肺动脉造影检查后准确率为100%,CT诊断后准确率94.8%,差异不显著,P>0.05。介入治疗后患者的疼痛评分明显降低,呼吸频率恢复正常,治疗前后差异显著,P<0.05。结论:急性肺栓塞疾病采取CT影响诊断后具有较高的诊断准确率,漏诊率以及误诊率较低,并且在介入治疗后能够有效改善疼痛反应以及各项临床指标,治疗价值较高。     

股骨干骨折合并同侧股骨颈骨折的诊断与手术治疗

[目的]探讨同侧股骨干、股骨颈骨折的临床特点、漏诊原因及治疗方法和疗效.[方法]回顾性分析2000年3月至2007年9月本院11例股骨干骨折合并同侧股骨颈骨折的临床资料,男8例,女3例;平均年龄32（25～57）岁.受伤原因：交通伤7例,高处坠落伤4例.术前诊断5例,术中诊断3例,术后诊断3例,其中2例采用股骨重建髓内钉同时固定股骨干和股骨颈,2例采用动力髋（DHS）固定,1例采用空心钉固定股骨颈骨折,再行闭合复位逆行带锁髓内钉固定股骨干骨折,2例采用顺行带锁髓内钉（UFN）结合空心钉或克氏针固定,1例合并髁上骨折,采用股骨髁解剖板固定股骨干和股骨髁上骨折,空心钉固定股骨颈,3例采用动力加压钢板（LC-DCP）固定3～35 d后发现股骨颈骨折,再行空心钉或克氏针固定.[结果] 同侧股骨干、股骨颈骨折常难以做出正确诊断,股骨颈骨折漏诊率较高,本组病人漏诊率27.3%,股骨干骨折多为粉碎性骨折,股骨颈骨折多为无移位骨折,术后随访2～5年,平均3.3年,内固定治疗效果满意,骨折均达骨性愈合,无股骨头坏死,关节功能恢复好,Harris评分平均92分.[结论] 对高能量损伤引起的股骨干骨折,要分析其受伤机制,仔细进行体格检查,常规拍摄髋关节X线平片,必要时行CT或MRI检查,骨折均应早期内固定手术治疗.