Case 15: Fall on Stairs

A 35 year-old male slips and falls rushing down hardwood stairs wearing only socks (He should have read Think Twice: More Lessons from the ER). He is unable to walk because of right buttock pain that radiates up his back and down his leg when he tries to stand. At rest he only complains of buttock pain and is tender in the gluteal area. X-rays of the pelvis and hip are normal so you order spinal films. The lateral is normal. Here is the AP. Anything wrong? (Look carefully)

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ANSWER: There is a fracture of the right lateral spinal process or the first lumbar vertebra. Since there was no compression fracture and no gross hematuria, no further testing was indicated. The patient received crutches to aid in ambulation and a prescription for Percocet. On follow-up he was doing much better. He saw an orthopedist the following week who, like the hospital radiologist, initially missed the fracture.

THORACIC & LUMBAR FRACTURES From QUICK ESSENTIALS: EMERGENCY MEDICINE
UNSTABLE: 2 or the 3 spinal columns(anterior, mid, posterior) involved. Higher risk of neuro compromise. Kyphosis >20?, translation >2mm, shortening >50%, articular process fx, burst, chance, fx-dlc
Burst Fx: Can have retropulsion into spinal canal. Mid body
Chance Fx: Mechanism usually lap belt only MVA. Fx in horizontal plane. Neuro defecit rare.
STABLE: Neuro compromise unlikely. Can go home if pain controlled and consult done.
To go home: CT &/or Flexion-extension films, PVR & rectal tone all OK, no ileus, has f/u
Simple Fx: Can be associated with ligamentous and rarely nerve injury.
Do CT + Flex/ex to r/o other injury
Lateral Process Fracture: Do flexion/extension films. Associated with renal injury: check UA
Spinous Process Fracture: Do flexion/extension films. Be certain it is an ISOLATED injury
Wedge Fx: AKA Compression: anterior body <50% loss of height
Rx: Consult, narcotics, salmon calcitonin 200 IU IN qd

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