WhiteCoat

What’s The Diagnosis #5

An intoxicated 68 year old male involved in a car accident is brought in by ambulance in full spinal immobilization. No complaints of pain, but since the patient is intoxicated you do trauma films, including this c-spine x-ray series.

What’s the diagnosis and the treatment? Scroll down after the three x-rays for the answer.

Xray-1

Xray-2

Xray-3

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Answer: C2 Odontoid Fracture – Type II
In addition to the lucency on the odontoid view, if you look close, you can also see that the ring of C2 on the lateral x-ray is disrupted.
Read about C2 fractures at Maitrise Orthopedics (best explanation), Wheeless’ Textbook of Orthopedics, LearningRadiology.com, Medscape

Xray-3-2CT-1

9 Responses to “What’s The Diagnosis #5”

  1. EMintern says:

    Why not a CT on this guy?

    • WhiteCoat says:

      Tough to do routine total body radiation on every MVA. Can’t just radiate every patient in a car accident with no vehicle damage and acute Allstate-itis of the neck. That’s where clinical judgment comes in. If this guy hadn’t reeked of alcohol, I probably wouldn’t have done any films. Presumably if he wasn’t intoxicated, he would have complained of neck pain to clue me in to an injury, but that’s another story.
      Sometimes when you’re checking orders, the Big Guy upstairs just gives you a nudge in the right direction.
      Welcome to emergency medicine.

  2. throckmorton says:

    This is a great pick up an an excellent case! For the non medical that follow your blog, I think that they will look at the xrays and even knowing the answer will not see the fracture until they look at the ct.

  3. JJ says:

    Why did you get any imaging? You said he had no complaints of neck pain, what a waste of resources. :)

    See prior discussions regarding reimbursement/CPT coding/chief compaints in the ED.

  4. Dr. Greenbbs says:

    most excellent set of films. I didn’t pick it up until i saw the open mouth odontoid view, then went back to the lateral and slapped myself in the head.

  5. ERP says:

    I agree with EMintern. A drunk trauma for me always gets a CT of head and C-spine in one shot. Still, good pick up.

  6. SeaSpray says:

    I have an older monitor and things appear darker than on others and so I can’t tell what I am supposed to see..not that I would know anyway …but …the CT is real clear.

    You all must’ve been ecstatic when more advanced radiological testing came on the scene.

    I wish CTs and pet scans and especially that one that can give an accurate, realistic view into your heart that Dr Oz showed on Oprah were safe (minimal rads)and cheap so that we could all get God’s view into our bodies. talk about saving lives! :)

  7. Sparky says:

    That’s a great case- just goes to show you the importance of looking at the alignment on the lateral in a systematic manner. On the open mouth plain film- I initially thought it was a type 3 because it looks pretty low on the dens- probably just because I am looking at it on a regular computer monitor- thoughts on that?

  8. Jess says:

    A good call on the films, I think anyone who is drunk in an accident or fall you can’t really take any chances just in case they have a serious injury that they aren’t complaining about due to being intoxicated.

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