Backpainslashshoulderinjury – what?

An interesting thing happened today while on shift. I saw a patient, who’s card told me this was a 60-something year old female, who had recently been seen around 2 weeks back in ED following a fall, resulting in a fractured humerus (upper end, basically a fracture of the shoulder) and had presented today with a few days history of lower back pain which was very severe. As I walked to the waiting area to call her in for my assessment, I began making a plan in my head of what I needed to rule out: was this new back pain unrelated to her prior fall, or was this a consequence of some missed injury from that fall? I called out her name and this lady wrapped in a huge jacket (loosely draped over her shoulders because of – presumably – the shoulder fracture) got up from one of the waiting area chairs and walked in behind me, slightly tilted towards the right, and walking at an angle, as if holding herself to avoid pain. We walked into a nearby cubicle to be examined; I introduced myself and asked her what had brought her to ED.

I noticed as she walked in and sat herself on the trolley, she required help with the jacket; she allowed me to help her out of it, which made her predicament apparent: She was not wearing a sling on her arm; it was dangling by her side (this was the arm that had the fracture in the upper part of the humerus, or upper arm bone forming the shoulder joint) – the hand appeared slightly swollen, as it would be from a long period of dangling, gravity would do the rest. I asked her where her sling was, and she mentioned that it had gotten dirty a few days back, and had been meaning to wash it but hadn’t gotten round to it. She told me the arm or shoulder wasn’t the problem, she was here today because her back hurt. I started asking her about the back pain (when did it begin – 5 days back; did you injure yourself during the prior fall – No; did you have another fall? No. The pain just began a few days ago and has just gradually worsened).

At this point she tried to shuffle backward in the trolley to get to a more comfortable position, and was unable to use her dangling arm. I couldn’t stand it any longer, so after I helped her get comfortable, I excused myself to go get her a new sling. I put her arm in the sling, and as she let the arm relax in the sling, her expression changed from one of long-standing pain and discomfort, to one of relief and comfort – ‘Doctor, you have somehow cured by back pain as well, I feel no pain in my back!’ I told her that very likely what had happened was that due to the painful left shoulder (which had been getting more painful because it was dangling beside her body as she walked around, rather than resting in a sling so her shoulder muscled could relax and allow the bones to heal) she was holding herself extremely taut in an uncomfortable abnormal posture, the only way to counteract or even avoid the pain of the shoulder – whether consciously or subconsciously – and that posture had caused her back to begin hurting as her back was being twisted into an abnormal position. The muscles of her back had been protesting, and now that she had put the shoulder to rest appropriately, it had caused her to relax in her posture – thereby causing her discomfort to disappear. She was raring to go home, but I still told her I had to examine her back, make sure we hadn’t missed anything else. There was no tenderness or bruising anywhere on her back, or any part of the bony prominences of her spine. I also assessed the neurovascular status of the limb that had been affected by the fracture – she was lucky there was still no distal neurovascular compromise.

Where she had required help to get comfortable into the trolley, she stood up on her own this time, without any support, bent over to pick up her bag from the floor with her good hand, thanked me for my time, and went home. I asked her if she required any pain relief, she waved the idea away as she walked off, saying ‘You’ve fixed me, Doc!’ She seemed like a completely changed woman; from the haggard, appears-to-be-in-pain-as-she-walked-into-the-exam-room old lady to the almost-bouncing-out-of-the-same-exam-room smiling chatting lady; the transformation was amazing to behold.

Just goes to show, always dot your ‘i’s and cross your ‘t’s, and never take anything for granted: you never know when the back pain that you think is something straightforward and expected turns out to be a not-so-straightforward posture issue resulting from an inadequately managed shoulder fracture.

The back pain that became a pain in the … back!

Mechanism. Never forget mechanism of injury when assessing a patient with any sort of trauma. We tend to get distracted by other people’s assessments, or their version of events, or their assessment of injuries – do NOT fall into that trap. Always start from scratch, when you are the one responsible ultimately. And always, ALWAYS take mechanism of injury into consideration, however minimal the injuries may seem to be.

Quite a while ago now, I had a patient in ED, middle-aged female who had a background of hypertension and had previously had some chronic respiratory illness, and a heart rhythm abnormality called atrial fibrillation, for which she was on warfarin – an anticoagulant. She had come in with the history of traumatic back pain. As the story went, she had been lifting some sort of semi-heavy load outside her house, and had turned around (or intended to turn around) and fallen over backwards on 2 very low steps, in the process also managing to hit her head against a brick wall. She did not lose consciousness, and her husband heard her scream, and came out of the house at once to help her. She was unable to get up on her own, but with help got to her feet and felt fine. Due to her hitting her head, her husband felt they should get a check up, so they came into the ED. Enter yours truly – their saviour in shining armour. Or not.

I assessed the patient, took a detailed history, and fully examined her. I had in the back of my mind right from the outset that she needed a scan of the head due to her head injury while being on warfarin. She denied any neck pain, and had no palpable tenderness of the bony bits in her c-spine, or neck. She also complained of mid to lower back pain, but not in the midline, rather on the right side. I specifically felt all the palpable bony aspects of her vertebral column from top to (literal) bottom, and it did not elicit any pain. There was no bruising (surprising, since she was on an anticoagulant, and had literally landed on her back on the stairs). She had full range of motion of her majors joints, and had walked in to the department to be assessed. For all intents and purposes, her major injury was the head wound, and for that I requested a CT scan of the head. It came back as normal. I found no reason to investigate anything else. Her back pain wasn’t too severe, but I still advised her to take regular analgesia, and to seek medical help if it was worsening, or not improving after a few days, or if she had any other concerns (a typical statement for me when I discharge any patient). I sent her home with some head injury advice, instructing her husband on the red flag signs to look out for, and if any concerns to come back to us. I documented the whole encounter, and went on to see my next patient.

I found out later that the patient had returned 2-3 days later, because her back pain had not improved, rather it had become much worse, and she found it difficult to mobilise out of bed. One of my other colleagues very kindly examined her this time, there was still no bony tenderness in her back, and her pain seemed to be localised to the right side of her lower back, and my colleague agreed that it seemed very much like a soft tissue injury. However, because this was the patient’s second visit to ED with the same complaint – and the situation had worsened to the point that her activities of daily living were being hampered (like getting out of bed!) – he requested an x-ray of her thoracolumbar spine, which revealed to my extreme embarrassment and shock a wedge fracture of one of the vertebral bodies. She was admitted under orthopaedics, and I crawled into a hole and died. No I didn’t.

I read up on traumatic back pain, and I gathered as much information as I could about it. I also gave a presentation to my other colleagues in the department, as a learning point. Here is what I learnt, and I utilise this information everyday: Whenever assessing traumatic back pain, the method that I have been taught and always employed was the one I have described. What is now advised, is to not just palpate the bony prominences of the vertebrae, but to place one hand on the bony prominence of the spine at any level – with the palm resting on the back; then make a fist out of your other hand, and lightly tap the fist onto the back of the hand that is flat on the back – if it elicits any pain anywhere on the back, investigate further (do x-rays) – and assess the whole vertebral column integrity in this fashion.

I have also learnt after discussing this at length with many of my colleagues of varying seniority and specialty, that even though clinically an x-ray may not have been warranted at the first presentation, yet purely based on mechanism if you looked at it, along with her age group (women middle-aged and above are more likely to begin to have osteoporotic fractures with moderate trauma), an x-ray would not have been completely out of the question.

To this day, I am terrified when I see ‘back pain – fall’ as my next patient’s presenting complaint. But I am more, much more cautious now, and I am sharing this experience to highlight how easy it is to miss something even if you are looking for it at the right place and at the right time, and I hope this post will serve to help/guide someone to not make the same mistake I did. Cheerio!