Fall At Nursing Home, Hit Chin

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altParamedics bring in an elderly female who fell at the nursing home.  By report, she slipped on something and fell forward, landing chin-first on the edge of a coffee table.  She complained immediately of neck pain and was immobilized by EMS.  Vitals are P 75, BP 180/105, RR 20, sat 95% RA.  She is alert and appropriate.  General exam reveals only a small contusion/laceration on the chin.  Her neurologic exam is intact.
Paramedics bring in an elderly female who fell at the nursing home.  By report, she slipped on something and fell forward, landing chin-first on the edge of a coffee table.  She complained immediately of neck pain and was immobilized by EMS.  Vitals are P 75, BP 180/105, RR 20, sat 95% RA.  She is alert and appropriate.  General exam reveals only a small contusion/laceration on the chin.  Her neurologic exam is intact.

You order a medical work-up (cause of fall), as well as the ubiquitous head and C-spine CT scanning.

About 30 minutes later, the CT tech calls you to review the scan.
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What does it show?
Dx: Hyperextension Injury of Cervical Spine
I just like this CT scan, which shows a classic disruption of the anterior longitudinal ligament (see arrow) of the cervical spine at a single level with a significant displacement.  The posterior longitudinal ligament (which forms the anterior portion of the spinal canal) appears to be intact, but might also be injured.  In the latter case, the injury would be much more unstable, with the spinal cord “core” exposed on one side. The non-flexible geriatric C-spine has appeared to have just “snapped” from hyperextension at the C6-C7 level.  There is crowding of the posterior elements at this level, which may not add much to this case but is noteworthy.  Also seen is an iso-dense hematoma/soft tissue swelling anterior to the ruptured segment (circle).

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The clinical history is classic for a hyperextension injury, and we were surprised there was no neurologic deficit.  The classic deficit with this mechanism would be a central cord syndrome.  Although the mechanism may not be entirely understood, hyperextention injury leads to injury to the centrally-located cord motor tracts, giving a primary deficit of upper extremity weakness greater than lower extremity weakness. This syndrome can be mistaken for a factitious neurologic defect.

Treatment initially consists of immobilization with a hard collar. This patient was referred to the trauma center to consider spinal stabilization surgery.  She remained without neurological deficit.  All things considered, a fortunate outcome


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ABOUT THE AUTHOR

John Dallara, MD, practices emergency medicine in Virginia and North Carolina and directs the EM PREP Course. www.emprepcourse.com

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