This is a case report of a young patient that sustained a compression fracture that was missed at the hospital. I hope that it will be useful and instructive to those of us that elect to treat trauma victims.

A 28 year old female presented herself to our office shortly after a head-on collision with another vehicle. She was the seat-belted driver, traveling at an estimated 40 mph at impact; the velocity of the other vehicle was uncertain. Her car did not have an airbag. Upon impact, she struck her legs on the dashboard but did not strike her head, nor did she lose consciousness. She declined transportation to the hospital as she didn’t have too much pain initially, although she was somewhat dazed and disoriented. However, within an hour or two she began to have intensifying pain in her chest and midback, so she went to a local hospital where she underwent xrays, was prescribed medication and released. Her pain continued to intensify, and she developed additional neck and lower back pain as well as tingling in both hands and feet, so she presented to our office six days after the accident for further evaluation.

On presentation, she was experiencing neck, midback and lower back pain as well as tingling in both hands and feet that did not appear to follow any clear dermatomal distribution. Her chest wall pain had improved, although she was still sore. She denied palpitations, chest pressure, shortness of breath or radiating pain to the jaw or arms. She had no history of cardiovascular disease. Her past pertinent medical history was significant only for a prior MVA ten years earlier in which she sustained a fractured pelvis while ten weeks pregnant which resolved without incident. In addition, she had a chronic history of migraine headaches for which she had undergone treatment with a neurologist. Her family history was unremarkable for significant neurologic or musculoskeletal disorders.

Examination showed her to be cooperative, alert and in no acute distress. Her gait and stance were normal, without overt limp or antalgia. She was right hand dominant, normotensive and afebrile. Pertinent clinical findings included global limitation of active cervical and lumbar ranging. Battle and raccoon signs were absent. Upper and lower extremity motor, sensory and reflex function was intact. There was no clonus at the ankles. Palpation showed cervical, thoracic and lumbar paraspinal spasm and tenderness, with tenderness also noted in the suboccipital region, over the midcervical posterior facetal articulations, over the midthoracic costotransverse articulations and over the lumbosacral junction. There was restriction in the midthoracic and lumbosacral regions to motion-augmented palpation.There was no bruising noted over the anterior or posterior thorax. There was minimal bruising noted over the right medial knee and left lateral leg that appeared to be resolving. There was no overt ligamentous instability at the knees, nor was there appreciable joint line tenderness. Straight leg raising did not produce radiculopathic symptoms.

She completed a General Pain Disability Index questionnaire at intake and her score was consistent with a debilitating level of disability relative to her activities of daily living. Her responses were consistent and appropriate throughout the course of her consultation, without overt evidence of symptom magnification.

Her xray reports were received via fax from the hospital and included chest and thoracic spine studies, both of which were interpreted by the radiologist as "normal." Imaging in our office included a seven-view cervical spine series and a three-view lumbosacral spine series. The cervical study revealed relative hypomobility at C5-C7 on the extension view and at C6/7 on the flexion view, without overt evidence of posterior ligamentous instability. There was a loss of the normal cervical curvature. The lumbosacral study was unremarkable. No acute bony abnormalities were identified.

Her course of care in our facility consisted of manipulative therapy to the C5/6 region as well as to the midthoracic and lumbosacral regions, in addition to various physiotherapeutic modalites. Over the next four weeks her midback and lower back pain resolved, as did her bilateral foot tingling, but her neck pain and bilateral hand tingling continued. Due to the persistence of her pain in these areas a cervical spine MRI was obtained, which revealed the presence of a compression fracture of the T2 vertebral body with mild retropulsion of the posterior aspect of the T2 body, although no direct neurologic compromise was noted. A marked Chiari I malformation was also noted. As the patient had been under concurrent care with a neurologist, further evaluation of her Chiari malformation was deferred. Ultimately, the patient completed her course of chiropractic care uneventfully and she was released to PRN followup, although her neck pain and hand tingling had not completely resolved. She continued under neurologic care subsequently for her hand tingling and for monitoring of her Chiari malformation. Upper extremity electrodiagnostic testing was normal.

DISCUSSION: Due to space limitations, this report has been significantly abbreviated, but it is very important to emphasize the need for diligent investigation in case of the patient that does not respond satisfactorily to conservative care over a reasonable period of time. This also serves to highlight two important points: first, it can be difficult to image the cervicothoracic region with radiographs, no matter how diligent one might be; second, one must never assume that a fracture cannot be present even if a board certified radiologist says that xrays of the area are normal. If you are not happy with the patient’s progress, investigate further until you are satisfied. Missed fractures are common, especially in certain hard-to-image areas of the spine, and it is incumbent upon all of us to keep this fact at the forefront of our minds in cases such as this. To do less is not good medicine, and can ultimately redound to the detriment of the patients that we are privileged to serve.

If you have any comments or questions, you may direct them to me at drpriest@cfl.rr.com.

Respectfully submitted,

Gregory C. Priest, DC, FACO
Board Certified by the American Board of Chiropractic Orthopedists
Fellow of the Academy of Chiropractic Orthopedists
www.drpriest.com