Senior Case Report 5.8

Case Presentation by Dr. Katie Dobratz

CC: “I fell”

HPI: Patient is a 49 yo male who states he fell off a ladder about 3 feet. He believes he landed on his left side, mostly on the left elbow and left side of his body and back.  He states that his head hit last and he did not sustain any loss of consciousness and has no acute headache.  He is complaining of acute pain in the left elbow.  He states he looked at his back and noticed a swelling and is having pain there as well. He drove himself here to the hospital and currently is standing at the side of the bed complaining of pain in the left lower back, left elbow, and left flank pain.  The pain in the back has not radiated.  It stays on the left side near the swelling and is described as a sharp pinching movement that is deep inside.  He states movement makes it worse.  Nothing makes it better.  Rates it an 8/10.

ROS:

CONSTITUTIONAL:  No fevers, chills or weakness.

EYES:  No visual changes.

ENT:  No facial trauma.

CARDIOVASCULAR:  Some left-sided upper back, chest pain.

RESPIRATORY:  Some pain with deep breaths on the left.  No shortness of breath.

GI:  No abdominal pain.

GENITOURINARY:  No hematuria.  Positive left flank pain.

SKIN:  Positive laceration over the left elbow.

MUSCULOSKELETAL:  Left lower lumbar pain, left rib pain.  Left elbow pain.

NEUROLOGIC:  No loss of consciousness, numbness, tingling or weakness.

PAST MEDICAL HISTORY:  None.

PAST SURGICAL HISTORY:  Vasectomy

MEDICATIONS:  NONE

ALLERGIES:  None.

SOCIAL HISTORY:  Denies alcohol, tobacco, and illicit drug abuse.  The patient works as a UPS driver and deliveryman.

PHYSICAL EXAM:

VITAL SIGNS:  On arrival 161/89 with pulse 64, respirations 16, temperature 36.6 and pulse oximetry is 98% on room air, which is within normal limits.

GENERAL:  This is a 49-year-old, well-nourished, well-developed, well-hydrated male standing at the side of an ER cart in mild to moderate distress.

PSYCHIATRIC:  Awake, alert, and cooperative, with normal memory, mood and judgment.

HEAD:  Normocephalic, atraumatic.

EYES:  Reveal no conjunctiva injection.  No scleral icterus.

ENT:  His oropharynx is clear with moist mucous membranes.

NECK:  Trachea is midline, no tenderness in the cervical spine to palpation

CARDIOVASCULAR:  Heart has a regular rate and rhythm.  There is no S3, S4.

RESPIRATORY:  Normal respiratory effort. He has equal and clear breath sounds bilaterally.  No rales, rhonchi or wheezes.  No obvious splinting.     GI:  His abdomen is soft, nontender.  There is no rebound, rigidity or guarding.

SKIN:  Warm and dry. There is a laceration and abrasion over the left elbow.  There is a contusion over L1.  No other obvious sites of bruising or injury.  No further abrasions or lacerations.

MUSCULOSKELETAL:  He has some tenderness over the superior SI joint on the left and over the paraspinal musculature of the lumbar area.  He has contusion and swelling over L1 but no acute tenderness to palpation in this area.  He has some tenderness over the left posterior ribs profusely.  There is no point tenderness.  Extends from the midaxillary to the midscapular line.  He has no tenderness over the C-spine or T-spine.  Examination of the right upper extremity, left lower and right lower extremity shows no gross abnormalities or tenderness to palpation.  The pelvis is nontender.  The left upper extremity reveals a 2-cm laceration over the elbow.  However, he has full range of motion of the elbow.  No acute bony tenderness to palpation is noted up and down the left upper extremity.

Neruologically: A&O x 3, GCS of 15, no facial droop, normal speech, ambulates with a steady gait and has symmetrical strength upper and lower extremities

XRAY:

QUESTIONS:

1) What abnormality is seen in the radiologic study seen above?

2) Based on the radiologic study, what laboratory study must be ordered to rule out an important associated injury?

a) electrolytes

b) CPK

c) lactate

d) U/A

3) What other imaging study can be of use in further diagnosing this injury or associated injuries

a) Intravenous pyleogram

b) Angiography

c) Ultrasound

d) Computed tomogram

————————————————————

Answers and Discussion:

1)   Transverse process fracture of the lumbar spine

2)   Urinalysis

3)   Computed Tomography

1)   Transverse Process fractures put the patient at risk for ureteral injuries.  Ureteral injuries due to external trauma are rare. It composes less than 1% of all genitourinary injuries caused by external trauma.   The ureter is well protected by the bony pelvis, psoas muscle and vertebrae.  If the ureter is damaged, it is generally due to a significant trauma with associated injuries to other abdominal organs.  The presentation and management is generally dictated by the severity of associated injuries.  Penetrating trauma is more likely the cause of ureteral injury than blunt trauma accounting for 91%.  Ureteral injuries associated with blunt trauma generally occur at the pelviureter junction.  With blunt trauma the mechanism of injury is generally hyperextension with overstretching or compression of the ureter against the transverse process of the lumbar spine.  These injuries generally result from high speed MVCs, a fall from a significant height, or a direct blow to L2-L3 region   In this case, the transverse processes were actually fractured off the vertebral body, increasing the risk of penetrating ureteral injury.  Penetrating ureteral injuries generally occur in the upper portion greater than the distal portion, although this is generally due to penetrating trauma from a projectile or stab wound.  Ureteral injuries can range from a simple contusion to partial tear to full transection.

2)   In patients with external trauma a high level of suspicion must be maintained.  The diagnostic laboratory test of choice to assess for ureteral injury is a urinalysis.  This is to assess for microscopic hematuria or gross hematuria.  There is controversy related to the evaluation of ureteral injuries, by means of urinalysis.  Hematuria is found in 74% of cases (either gross or microscopic.) Failure to see hematuria may be due to complete transection of the ureter or partial transection of an adynamic segment. There have been studies that show absent hematuria in patients with penetrating trauma, but operatively found to have disruption of the ureter (Brandes et al.)  This has made the evaluation of ureteral trauma with urinalysis not completely reliable.

3)   CT is the most reliable means to diagnosis an ureteral injury in blunt trauma with a stable patient.  If the clinician has a high index of suspicion for ureteral injury, a CT scan should be performed with images in the excretory phase to visualize the opacified collecting system and ureters.  This means having delayed imaging of at least 10-15 minutes after contrast injection in order to see urine extravasation. The integrity of the ureter can be determined whether iodinated urine is present in the ureter below the level of the injury.  If it is this may be indicative of a partial disruption or contusion.  This type of injury, particularly a partial tear, may be repaired by ureteral stenting versus a laparotomy.  Intravenous pyleograms maybe considered if a patient is unstable and unable to be taken to the CT scanner.  IVP’s can be done in the operating room, but there have been documented cases where IVP has failed to diagnosis a ureteral injury, making this an unreliable test as well.  Findings that suggest an injury include delayed renal function or excretion, ureteral dilatation or deviation, extravasation of contrast or non-visualization of the ureter.

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