Introduction: A 72-year-old man is attended by a rural physician four days after a fall outside their croft house in the Outer Hebrides. The patient presented with a background of alcohol excess and a vague feeling in unease since the fall.
Presentation: A thorough examination of the central and peripheral nervous systems revealed a small neurological deficit, in the form of a patch of paraesthesia on the jaw. Subsequent imaging revealed a fracture to the odontoid peg. While this was managed appropriately, the patient unfortunately died some months later.
Conclusion: This case highlights the need for extra vigilance and a thorough examination in cases of trauma in the elderly population and highlights the challenges of recognizing significant injuries in Silver Trauma.
A 72-year-old man living in the Outer Hebrides (Scotland) was attended by a rural physician due to concerns raised by a neighbor. The patient had told his neighbor that he had fallen four days previously and hadn’t felt himself since. The patient was found sitting in his living room with a laceration and contaminated abrasions to the top of his head, which he stated happened when he fell forwards and hit his head on the ground outside his house.
- Complexities of Geriatric Trauma Patients
- Specialized EMS for the Elderly
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He described how he lost his balance because he had been drinking alcohol, but that otherwise he was unharmed and wasn’t knocked out by the fall nor head injury. He was complaining of no other pain and his vital signs were normal. He described an alcohol intake of 2-3 litres of whiskey a week, which he has consumed for the last decade. He was a non-smoker, and was prescribed amlodipine and a statin with poor concordance. The patient described that since the fall he has felt “awful” and “just not right” and as a result had not been out his house at all.
On examination, the patient had a mild scalp laceration. He had normal power and sensation in all four limbs. His cranial nerve examination was unremarkable aside from a small patch of paraesthesia on the angle of the mandible on the left side. He had no pain in this neck or back, nor deformity in these areas. He had full range of motion in his cervical spine. His breathing was unlabored and he was cognitively intact.
The patient was keen to remain at home, living as he did very rurally. Due to the isolated abnormal neurological finding however, the patient was advised to attend the nearest rural general hospital for imaging of his neck to rule out a fracture. In the hospital, a computerized tomography (CT) scan of the neck and head was requested. This scan revealed a fracture at the base of the odontoid process of the C2 vertebra (Figure 1), which extended into the left lateral transverse process and superior articular surface, associated with displacement of the odontoid peg. There was no evidence of intrusion into the spinal canal nor involvement of the cord.
This patient unfortunately had a complex journey after this injury, and despite receiving appropriate care, he deteriorated a number of months later and died from pneumonia and sepsis.
In this case, no delay in diagnosis occurred due to the initial attribution of his neurological deficit to a central lesion, however if his initial on-scene assessment had not included a thorough neurological examination, this injury may have been missed and the patient left at home. It is likely that the facial paraesthesia identified on examination was a result of compression to the C2 nerve root as it exited intervertebral foramina. The area of altered sensation likely represented the area of innervation of the Greater Auricular nerve, which is formed from branches of the C2 and C3 cervical nerve roots. This nerve supplies the angle of the mandible, while the more rostral part of the mandible is innervated by the mandibular division of the Trigeminal nerve (Cranial Nerve V).
In this case although the mechanism described was one of low energy transfer and was some time ago, this does not rule out major trauma.1 While we know that many patients who fall aren’t conveyed to hospital,2 the increasing recognition of the Silver Trauma paradigm, and that low energy transfer major trauma is a significant cause for morbidity and mortality should heighten EMS providers suspicions in such cases.1, 3, 4
This case highlights the benefits of a thorough neurological examination. It also serves to demonstrate that a detailed knowledge of anatomy facilitates early recognition of injuries from their presenting signs or symptoms. There is still work to be done to improve the care we give to elderly victims of trauma and constant vigilance is required in this patient group.
- A thorough examination of the central and peripheral nervous systems is required for patients who present with minor head injuries.
- Significant injuries may only result in minor abnormal findings on examination.
Competing interests: None to declare
Authors’ contributions: Dr. T. E. Mallinson
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