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Fall from ladder
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Fall from ladder - February 22, 2005 10:28:00 PM
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Alex Brenner PT MPT OCS
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From: Kentucky
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20 year old male was helping his dad clean out gutters on the house. The ladder collapsed and he fell 15 feet. He landed feet-butt-head and was taken to the hospital. He complains of thoracic and rib pain. Thoracic films were taken.
What are the findings?
(all images obtained and used with permission)
[IMG]http://img.photobucket.com/albums/v85/brennerak/APT.jpg[/IMG]
[IMG]http://img.photobucket.com/albums/v85/brennerak/Latflex.jpg[/IMG]
[IMG]http://img.photobucket.com/albums/v85/brennerak/Lat.jpg[/IMG]
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Alex Brenner, PT, MPT, OCS
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Re: Fall from ladder - February 23, 2005 12:23:00 AM
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Jeep
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Army-
The images are really small- but my assessment is:
Rib fractures @ 5,6,(left), "stair stepping" @ multiple levels, indicating ligamentous injury(unable to determine levels per visualization).
Question: With complaints of rib pain, why was the AP collimated so tightly?
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Re: Fall from ladder - February 23, 2005 1:17:00 AM
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Alex Brenner PT MPT OCS
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Jeep,
Good question. The physician who ordered the films was more concerned about a spine injury than a rib injury at this point so only a t-spine series was ordered.
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Re: Fall from ladder - February 23, 2005 3:36:00 AM
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jma
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Looks like rib fracures on the left side @ 5/6. Are you sure the first radiograph was A/P? I think it was a P/A. I don't believe you can get a good look at the thoracic spine from an A/P view. The cardiac region would been seen more clearly than the thoracic spine. I think a rib series should be incorporated as well.
JMA
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Re: Fall from ladder - February 23, 2005 4:44:00 AM
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Dr.Wagner
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When the discussion is over...I will give my comments on how to approach this from an emergency medicine/trauma/EMS uniform approach as per current guidelines in the United States and EMTALA laws.
While there are no uniform national trauma guidelines, there are ATLS guidelines that need to be followed for a diagnostic approach.
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Re: Fall from ladder - February 23, 2005 7:29:00 AM
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UTDC
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To me, the ribs look fine, although maybe it's just the screen on my laptop. What I do see is a thoracolumbar compression fracture- maybe 2 levels, which would be consistent with the injury.
In any case, if the patient's presentation is consistent with rib fracture, it should be assumed. I believe that even a rib series is only about 50% sensitive. I would be more interested in getting a PA/lateral chest and evaluating his head injury than worrying about the rib fracture, although, I'm sure that Dr. Wagner could shed some light on this.
I don't see evidence of stair stepping.
The thoracic spine views should be a lateral and an AP (not a PA) which this appears to be.
Jeff
PS- Army, any heel pain?
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Re: Fall from ladder - February 23, 2005 9:32:00 AM
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chiroortho
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All I see is the 10% compression fx of L2 anteriorly (might be L1, can't count up from the bottom). Everything else looks fine.
Come on Wagner, take a chance. If you're wrong, you're fired. ;)
If the guy fell 15 feet he should certainly have had L-spine radiographs and rib films. I'd have ordered an L-spine CT to further characterize the comp fx (burst fx would require neurosurg consult due to inherent instability).
Hire a lawyer for the collapsing ladder, never work another day. :)
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Re: Fall from ladder - February 23, 2005 2:13:00 PM
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pablo w
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What is stair stepping?
I don't see any rib abnormalities. I can't see the lumbar spine very well.
I think there is something odd at T8. On the first film the spinous process is not as clear as the rest. On the second film, it looks like there may be some anterior wedging at T8.
Pablo
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Re: Fall from ladder - February 23, 2005 7:55:00 PM
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Alex Brenner PT MPT OCS
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I believe the "stair stepping" that Jeff is referring to is spondylolisthesis either anterior or retrolisthesis usually caused by a pars defect of the interarticularis portion of the vertebra.
Jeff, no heel pain but what I believe you are alluding to is the fact that with this type of mechanism calcaneal fractures need to be ruled out.
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Alex Brenner, PT, MPT, OCS
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Re: Fall from ladder - February 24, 2005 2:05:00 AM
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Jeep
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Listhesis- either anterior or posterior is not the same as stair-stepping.
Stair-stepping is usually seen in ligamentous injury or other circumstances of loss of ligamentous integrity.(eg. RA)
In this case, I was using "Stair-stepping" to describe the "stepping" of several thoracic segments along the posterior vertebral bodies(cannot ascertain levels on views submitted) . Usually a line drawn along the posterior vertebral bodies should be nicely even, one segment relative to the one above and below.(wish I had a pencil to draw here) When it does not,(or "steps"), loss of integrity of the posterior longitudinal ligament is a consideration. A bony defect is not necessary.
Hope this helps.
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Re: Fall from ladder - February 24, 2005 10:07:00 AM
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ehanso
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On the AP view I am seeing a deficit between T2-3 with what appears to be a rotation of T2 on T3 it also looks a little tilted. I can not see it on the lateral views. The 3rd, 4th, and 5th ribs appear abnormal as well. I think T11 looks a bit compressed too.
Thanks for the great forum. It is very educational to hear everyone's views (no pun intended).
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Re: Fall from ladder - February 24, 2005 3:37:00 PM
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Jon Newman
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I notice on the third film, if I follow each intervertebral foramen I eventually come upon one that seems obliterated. I can't really see the same effect on the second film.
jon
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Re: Fall from ladder - February 27, 2005 3:25:00 AM
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Pelfixer1
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A fall of the buttocks will elevate the pubis', which in turn flattens the lumbar spine, increases the thoracic kyphosis and forces the head into a FHP. The symptoms he is feeling is from the increased kyphosis posture fault. The pubes will need to be descended using a muscle energy technique, the spine extended starting at the LS joints using mobs, extension exercises etc. to balane the spine in the saggital plane.
If he also has a posteriorly rotated ilium, this will also put a rotational component in the spinal posture fault, so that shold be checked as well.
AP's of the pelvis may show this, but if the pubs are bilaterally elevated the pubs would appear to be normally aligned. The best way to evaluate pub malalignment is to check his extremity length.
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Re: Fall from ladder - February 27, 2005 6:03:00 AM
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steve
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Army,
This is a tough one, particularly with how small the images are on my little screen! It looks like there might be a mild compression fracture at T12.
Steve
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Re: Fall from ladder - March 4, 2005 10:02:00 AM
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chiroortho
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I'm a little worried about Army, we haven't heard from him in a week. Everything okay on the Western Front, Captain?
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Re: Fall from ladder - March 5, 2005 3:29:00 AM
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Alex Brenner PT MPT OCS
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Thanks for the concern. I just returned from another trip down south where I also have to see patients regularly.
We also have been getting slammed with snow so I have not been able to get to my images.
Here we go with the radiology report:
Thoracic spine flexion and extension
Compression fracture is noted at approximately T11. There is reduction approximately 25% in anterior vertebral body heights. No gross retropulsion is present however the patient is rotated. No evidence of subluxation identified.
As far as I can tell the ribs are ok from these images.
[IMG]http://img.photobucket.com/albums/v85/brennerak/Latflex2.jpg[/IMG]
My daughter is doing all she can to hold up this poorly planned ancient building. Anyone recognize it?
[IMG]http://img.photobucket.com/albums/v85/brennerak/Florence-Pisa049.jpg[/IMG]
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Alex Brenner, PT, MPT, OCS
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Re: Fall from ladder - March 5, 2005 4:14:00 AM
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jma
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Hello,
Thanks for the update. Was kind of thinking that something was occurring in that area but it was very hard to see it.
I believe the poorly designed building is the Leaning Tower of Pisa in Italy.
JMA
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Re: Fall from ladder - March 5, 2005 5:53:00 AM
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Synergy
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I cannot see that compression fracture for the life of me! Maybe it's my monitor, but I doubt it.
That picture is priceless Army! :)
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Chris Adams, PT, MPT
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Re: Fall from ladder - March 5, 2005 9:31:00 AM
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chiroortho
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Wow, and I thought it was L2 or L1. Hard to count vertebrae on lat thoracic views. Good case Army. Glad to hear all's well.
Comp fractures are very easy to miss, especially in lower T's because of superimposed diapragm. Just another good reason to look at films systematically, and to always take hx into consideration. To be perfectly honest, I might have missed this in the office if the films didn't look any clearer on the viewbox.
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Greg Priest, DC, DABCO
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Re: Fall from ladder - March 7, 2005 4:07:00 AM
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SJBird55
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Hey, Army... do they let you go in the tower yet? I was there 12 years ago and they were working on it because some engineer predicted when the thing would actually fall over. I thought their goal was to be open for tours, but I don't really remember. I'm not sure if the engineers fixed the lean that much though in comparing pictures - my picture has an old beautiful building with some cool architecture to the left of the tower (maybe a church?). Did they tear that down?
Have you been to Pompeii? When we were over there all I wanted to see was Rome and Pompeii... didn't get a chance to see Pompeii though.
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