Friday, July 11, 2008

Undetected hangman's fracture in a patient referred for physical therapy for the treatment of neck pain following trauma- Be careful Blogs!!

The following are 2 case reports by Ross MD et al published journal of physical therapy & journal of orthopedic and sports physical therapy. (Evidence: diagnosis level 4)
These 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. Read the following minutely so that you can pick up clues for your own practice.
Case study 1: 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.
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.
Case Study 2: This case involved a 73-year-old woman who had a sudden onset of neck and left upper extremity pain after a fall 15 days prior to her initial physical therapy visit. Conventional cervical spine radiographs completed 1 day prior to her initial physical therapy visit were negative for a fracture. However, several components of this patient's history and physical examination were consistent with a condition for which physical therapy intervention would not be indicated until more definitive cervical spine diagnostic imaging had been completed; more specifically, the physical therapist was primarily concerned about the possibility of an undetected fracture. The referring physician was contacted and immediate magnetic resonance imaging was requested, which revealed a type II fracture of the odontoid. Thirty-four days after her fall, the patient underwent a C1-C2 fusion.
1. 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.
2. When evaluating patients with neck pain who have a history of cervical spine trauma, it is important that physical therapists understand the clinical findings associated with cervical spine fractures, as these findings provide guidance for the use of cervical spine diagnostic imaging and medical referral prior to implementing physical therapy interventions.

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