Emergency Medicine

ADDITIONAL ORTHOPAEDIC INJURIES IN MULTIPLE TRAUMA

Surgical Emergencies 245

Thoracic and lumbosacral spine injury

DIAGNOSIS

1 This type of injury is caused by blunt trauma from a fall, a direct blow or
following a traffic crash. A fractured sternum may accompany a hyperf lexion
wedge fracture of the upper thoracic spine.

2 Always examine the back in multi-trauma patients. Maintain spinal pre-
cautions and carefully log-roll all patients with a suspected spinal injury.

3 Look for bruising, deformity and evidence of penetrating injury.

4 Palpate for localized tenderness and swelling around the vertebral column
or for an abnormal gap between the spinous processes suggesting a fracture,
or overlying the renal areas suggesting a kidney injury (see p. 242).

5 Perform a careful neurological examination, assessing for sensory deficit and a
sensory level, loss of peri-anal sensation, and for motor and ref lex loss in the
legs (see p. 331 for the dermatomes, myotomes and ref lex roots in the legs).
(i) The spinal cord ends at the level of the first lumbar vertebra, so
any injury distal to this involves the cauda equina only, causing
lower motor neuron weakness.

6 Send blood for FBC, U&Es, blood sugar and G&S.

7 Request thoracolumbar spine X-rays in all the following high-risk patients:
(i) Fall from 3 m (10 ft).
(ii) High-speed motor vehicle crash at over 80 k.p.h. (50 m.p.h.).
(iii) Ejection from motor vehicle or motor cycle.
(iv) GCS score of ≤8.
(v) Neurological deficit.
(vi) Back pain or tenderness (may be absent).

8 X-rays may show vertebral body fractures, e.g. a distraction ‘Chance’ fracture
or a wedge fracture, transverse process fracture, or a dislocation (particu-
larly between T12/L1, and L4/L5).

9 Request a CT scan for all significant or potentially unstable fractures.

MANAGEMENT

1 Treat associated thoracic and abdominal injuries as a priority. Maintain
spinal precautions, log-roll the patient and minimize unnecessary
movements, as thoracolumbar fractures are commonly unstable.

2 Commence i.v. f luids if there is hypotension from local or retroperitoneal
bleeding, or from loss of sympathetic tone in a high thoracic cord injury.

3 Refer the patient to the orthopaedic team.
(i) Consider i.v. methylprednisolone for spinal cord damage within
8 h of injury, only after consultation with the regional Spinal
Injuries unit (see p. 228).