Spinal trauma — MCQs

10 questions

A 44-year-old man is brought to the emergency department 25 minutes after falling off the roof of a house. He was cleaning the roof when he slipped and fell. He did not lose consciousness and does not have any nausea. On arrival, he is alert and oriented and has a cervical collar on his neck. His pulse is 96/min, respirations are 18/min, and blood pressure is 118/78 mm Hg. Examination shows multiple bruises over the forehead and right cheek. The pupils are equal and reactive to light. There is a 2-cm laceration below the right ear. Bilateral ear canals show no abnormalities. The right wrist is swollen and tender; range of motion is limited by pain. The lungs are clear to auscultation. There is no midline cervical spine tenderness. There is tenderness along the 2nd and 3rd ribs on the right side. The abdomen is soft and nontender. Neurologic examination shows no focal findings. Two peripheral venous catheters are placed. Which of the following is the most appropriate next step in management?

A 12-year-old boy presents to the emergency department after falling from his bike. He is holding his right arm tenderly and complains of pain in his right wrist. When asked, he says that he fell after his front tire hit a rock and landed hard on his right hand. Upon physical examination he is found to have tenderness on the dorsal aspect of his wrist in between the extensor pollicis longus and the extensor pollicis brevis. Given this presentation, which of the following is the most likely bone to have been fractured?

A 38-year-old man comes to the physician for a follow-up examination. He has quadriparesis as a result of a burst fracture of the cervical spine that occurred after a fall from his roof 1 month ago. He has urinary and bowel incontinence. He appears malnourished. His temperature is 37.1°C (98.8°F), pulse is 88/min, and blood pressure is 104/60 mm Hg. Examination shows spasticity in all extremities. Muscle strength is decreased in proximal and distal muscle groups bilaterally. Deep tendon reflexes are 4+ bilaterally. Plantar reflex shows extensor response bilaterally. Sensation to pinprick and temperature is absent below the neck. Sensation to vibration, position, and light touch is normal bilaterally. Rectal tone is decreased. There is a 1-cm area of erythema over the sacrum. Which of the following is the most likely cause of this patient's symptoms?

A patient with a known spinal cord ependymoma presents to his neurologist for a check up. He complains that he has had difficulty walking, which he attributes to left leg weakness. On exam, he is noted to have 1/5 strength in his left lower extremity, as well as decreased vibration and position sensation in the left lower extremity and decreased pain and temperature sensation in the right lower extremity. Which of the following spinal cord lesions is most consistent with his presentation?

A 47-year-old man comes to the emergency department because of urinary and fecal incontinence for 6 hours. Earlier in the day, he suffered a fall at a construction site and sustained injuries to his back and thighs but did not seek medical attention. He took ibuprofen for lower back pain. His temperature is 36.9°C (98.4°F), pulse is 80/min, and blood pressure is 132/84 mm Hg. Examination shows tenderness over the lumbar spine, bilateral lower extremity weakness, absent ankle jerk reflexes, and preserved patellar reflexes. There is decreased rectal tone. An ultrasound of the bladder shows a full bladder. Which of the following is the most likely diagnosis?

A 22-year-old man is brought to the emergency department 30 minutes after being involved in a high-speed motor vehicle collision in which he was the unrestrained driver. After extrication, he had severe neck pain and was unable to move his arms and legs. On arrival, he is lethargic and cannot provide a history. Hospital records show that eight months ago, he underwent an open reduction and internal fixation of the right humerus. His neck is immobilized in a cervical collar. Intravenous fluids are being administered. His pulse is 64/min, respirations are 8/min and irregular, and blood pressure is 104/64 mm Hg. Examination shows multiple bruises over the chest, abdomen, and extremities. There is flaccid paralysis and absent reflexes in all extremities. Sensory examination shows decreased sensation below the shoulders. Cardiopulmonary examination shows no abnormalities. The abdomen is soft. There is swelling of the right ankle and right knee. Squeezing of the glans penis does not produce anal sphincter contraction. A focused assessment with sonography for trauma shows no abnormalities. He is intubated and mechanically ventilated. Which of the following is the most appropriate next step in management?

A 22-year-old man is rushed to the emergency department after a motor vehicle accident. The patient states that he feels weakness and numbness in both of his legs. He also reports pain in his lower back. His airway, breathing, and circulation is intact, and he is conversational. Neurologic exam is significant for bilateral lower extremity flaccid paralysis and impaired pain and temperature sensation up to T10-T11 with normal vibration sense. A computerized tomography scan of the spine is performed which shows a vertebral burst fracture of the vertebral body at the level of T11. Which of the following findings is most likely present in this patient?

A 36-year-old male is taken to the emergency room after jumping from a building. Bilateral fractures to the femur were stabilized at the scene by emergency medical technicians. The patient is lucid upon questioning and his vitals are stable. Pain only at his hips was elicited. Cervical exam was not performed. What is the best imaging study for this patient?

A 56-year-old man is brought to the emergency department 25 minutes after he was involved in a high-speed motor vehicle collision where he was the unrestrained passenger. He has severe lower abdominal and pelvic pain. On arrival, he is alert and oriented. His pulse is 95/min, respirations are 22/min, and blood pressure is 106/62 mm Hg. Examination shows severe tenderness to palpation over the lower abdomen and over the left anterior superior iliac spine. There is no limb length discrepancy. Application of downward pressure over the pelvis shows no springy resistance or instability. Rectal examination is unremarkable. A focused assessment with sonography shows no free fluid in the abdomen. There is no blood at the urethral meatus. Placement of a Foley catheter shows gross hematuria. An x-ray of the pelvis shows a fracture of the left pelvic edge. Which of the following is the most appropriate next step in management?

Q10

A trauma 'huddle' is called. Morphine is administered for pain. Low-flow oxygen is begun. A traumatic diaphragmatic rupture is suspected. Infusion of 0.9% saline is begun. Which of the following is the most appropriate next step in management?

Spinal trauma US Medical PG Practice Questions and MCQs

Question 1: A 44-year-old man is brought to the emergency department 25 minutes after falling off the roof of a house. He was cleaning the roof when he slipped and fell. He did not lose consciousness and does not have any nausea. On arrival, he is alert and oriented and has a cervical collar on his neck. His pulse is 96/min, respirations are 18/min, and blood pressure is 118/78 mm Hg. Examination shows multiple bruises over the forehead and right cheek. The pupils are equal and reactive to light. There is a 2-cm laceration below the right ear. Bilateral ear canals show no abnormalities. The right wrist is swollen and tender; range of motion is limited by pain. The lungs are clear to auscultation. There is no midline cervical spine tenderness. There is tenderness along the 2nd and 3rd ribs on the right side. The abdomen is soft and nontender. Neurologic examination shows no focal findings. Two peripheral venous catheters are placed. Which of the following is the most appropriate next step in management?

A. CT scan of the cervical spine (Correct Answer)
B. Focused Assessment with Sonography in Trauma
C. X-ray of the neck
D. X-ray of the chest
E. X-ray of the right wrist

Explanation: ***CT scan of the cervical spine*** - This patient suffered a significant fall from a height, which is a **high-risk mechanism of injury** for cervical spine trauma, even without immediate neurologic deficits or midline tenderness. - Due to the high-energy trauma and the potential for severe consequences from an unstable cervical spine injury, a **CT scan** is the preferred imaging modality as it offers superior detail compared to plain X-rays, especially in complex anatomy. - The patient is **hemodynamically stable** with a benign abdominal exam, and the cervical collar is already in place, indicating that spinal precautions are the immediate priority before any further movement or transfers. *Focused Assessment with Sonography in Trauma (FAST)* - FAST exam is primarily used to detect **free fluid (hemorrhage)** in the pericardial, perihepatic, perisplenic, and pelvic spaces in trauma patients. - While important in trauma evaluation, this patient is **hemodynamically stable** (normal blood pressure, normal pulse) with a **soft, nontender abdomen**, making urgent FAST less critical than clearing the cervical spine. - The primary concern in a patient with a significant fall mechanism and cervical collar in place is ruling out **cervical spine instability** before further interventions or movement. *X-ray of the neck* - While an X-ray can assess the cervical spine, a **CT scan** is generally superior for detecting subtle fractures, ligamentous injuries, and malalignments, especially in patients with high-energy trauma. - Given the patient's mechanism of injury, an X-ray might miss critical injuries that a CT would identify, leading to potential delays in diagnosis and treatment. *X-ray of the chest* - A chest X-ray would be appropriate to assess the patient's **rib fractures** and potential associated injuries like pneumothorax or hemothorax. - However, the most immediate life-threatening injury in this context, after airway and breathing are secured, is an unstable cervical spine injury, which takes precedence in a stable patient with high-risk mechanism. *X-ray of the right wrist* - An X-ray of the right wrist is indicated to evaluate the **swollen and tender wrist** for a fracture or dislocation. - While important for comprehensive trauma management, it is not the most immediate or life-threatening concern compared to potential cervical spine injury from a high-impact fall.

Question 2: A 12-year-old boy presents to the emergency department after falling from his bike. He is holding his right arm tenderly and complains of pain in his right wrist. When asked, he says that he fell after his front tire hit a rock and landed hard on his right hand. Upon physical examination he is found to have tenderness on the dorsal aspect of his wrist in between the extensor pollicis longus and the extensor pollicis brevis. Given this presentation, which of the following is the most likely bone to have been fractured?

A. Pisiform
B. Scaphoid (Correct Answer)
C. Lunate
D. Capitate
E. Trapezoid

Explanation: ***Scaphoid*** - The mechanism of injury (**fall on an outstretched hand**) and the location of tenderness (**dorsal aspect of the wrist between the extensor pollicis longus and extensor pollicis brevis**, which corresponds to the **anatomical snuffbox**) are classic signs of a scaphoid fracture. - The **scaphoid** is the most commonly fractured carpal bone and its fracture can lead to **avascular necrosis** due to its retrograde blood supply if not properly managed. *Pisiform* - Fractures of the **pisiform** are rare and typically result from direct trauma to the hypothenar eminence, not from a fall on an outstretched hand. - Pain would be localized to the **ulnar side of the wrist**, distinct from the anatomical snuffbox. *Lunate* - A **lunate fracture** is rare and usually associated with high-energy trauma, often leading to **Kienbock's disease** (avascular necrosis of the lunate). - Tenderness would be more centrally located on the dorsal aspect of the wrist, not specifically within the anatomical snuffbox. *Capitate* - **Capitate fractures** are uncommon and often occur in conjunction with other carpal injuries due to its central and protected position. - Pain and tenderness would be more diffuse in the midcarpal region rather than localized to the anatomical snuffbox. *Trapezoid* - **Trapezoid fractures** are very rare and typically result from axial loading force through the second metacarpal. - Tenderness would be located more distally, at the base of the **second metacarpal**, not within the anatomical snuffbox.

Question 3: A 38-year-old man comes to the physician for a follow-up examination. He has quadriparesis as a result of a burst fracture of the cervical spine that occurred after a fall from his roof 1 month ago. He has urinary and bowel incontinence. He appears malnourished. His temperature is 37.1°C (98.8°F), pulse is 88/min, and blood pressure is 104/60 mm Hg. Examination shows spasticity in all extremities. Muscle strength is decreased in proximal and distal muscle groups bilaterally. Deep tendon reflexes are 4+ bilaterally. Plantar reflex shows extensor response bilaterally. Sensation to pinprick and temperature is absent below the neck. Sensation to vibration, position, and light touch is normal bilaterally. Rectal tone is decreased. There is a 1-cm area of erythema over the sacrum. Which of the following is the most likely cause of this patient's symptoms?

A. Hemi-transection of the spinal cord
B. Cavitation within the spinal cord
C. Injury to gray matter of the spinal cord
D. Occlusion of the posterior spinal artery
E. Damage to the anterior spinal artery (Correct Answer)

Explanation: ***Damage to the anterior spinal artery*** - This typically results in **anterior cord syndrome**, characterized by bilateral loss of pain and temperature sensation, motor function (quadriparesis), and autonomic dysfunction (bowel/bladder incontinence below the level of injury). - The **preservation of posterior column functions** (vibration, proprioception, light touch) is a hallmark of anterior spinal artery ischemia, as the posterior columns are supplied by the posterior spinal arteries. *Hemi-transection of the spinal cord* - This describes **Brown-Séquard syndrome**, which involves ipsilateral loss of motor function, vibration, and proprioception, and contralateral loss of pain and temperature sensation. - The patient's symptoms are inconsistent with Brown-Séquard syndrome due to the **bilateral presentation of motor and sensory deficits**. *Cavitation within the spinal cord* - This condition, known as **syringomyelia**, typically presents with a **cape-like distribution of pain and temperature loss** (due to central cord involvement affecting the decussating spinothalamic fibers). - It would usually spare motor function initially and would not explain the sudden, severe quadriparesis and complete sensory loss described. *Injury to gray matter of the spinal cord* - Isolated gray matter injury, often seen in conditions like **central cord syndrome**, primarily affects the pain and temperature pathways and may cause upper extremity weakness. - It would not explain the **complete loss of motor function and pain/temperature sensation below the neck** while preserving posterior column function. *Occlusion of the posterior spinal artery* - Occlusion of the posterior spinal artery would primarily affect the **dorsal columns**, leading to loss of vibration, proprioception, and light touch. - This patient, however, has **preserved sensation to vibration, position, and light touch**, making posterior spinal artery occlusion unlikely.

Question 4: A patient with a known spinal cord ependymoma presents to his neurologist for a check up. He complains that he has had difficulty walking, which he attributes to left leg weakness. On exam, he is noted to have 1/5 strength in his left lower extremity, as well as decreased vibration and position sensation in the left lower extremity and decreased pain and temperature sensation in the right lower extremity. Which of the following spinal cord lesions is most consistent with his presentation?

A. Anterior cord syndrome
B. Posterior cord syndrome
C. Syringomyelia
D. Right-sided Brown-Sequard (hemisection)
E. Left-sided Brown-Sequard (hemisection) (Correct Answer)

Explanation: ***Left-sided Brown-Sequard (hemisection)*** - This syndrome is characterized by **ipsilateral loss of motor function (weakness)** and **proprioception/vibration sensation** below the lesion, along with **contralateral loss of pain and temperature sensation**. - The patient's left leg weakness, decreased vibration/position sensation in the left lower extremity, and decreased pain/temperature sensation in the right lower extremity perfectly match a **left-sided hemisection of the spinal cord**. *Anterior cord syndrome* - This syndrome results in **bilateral motor paralysis** and bilateral loss of **pain and temperature sensation** below the level of the lesion. - However, **proprioception** and **vibration sense** are typically preserved, which contrasts with the patient's presentation of ipsilateral loss of these senses. *Posterior cord syndrome* - This rare syndrome primarily affects the **dorsal columns**, leading to bilateral loss of **vibration and proprioception** below the lesion. - **Motor function** and **pain/temperature sensation** are largely preserved, which is inconsistent with the patient's significant motor weakness and contralateral pain/temperature loss. *Syringomelia* - This condition involves a fluid-filled cavity (syrinx) within the spinal cord, often causing a **cape-like distribution of pain and temperature loss** (crossing the midline) due to damage to the **decussating spinothalamic fibers**. - While it can cause weakness, the distinct **ipsilateral proprioceptive loss** and **contralateral pain/temperature loss** seen in this patient are not typical for syringomyelia. *Right-sided Brown-Sequard (hemisection)* - A right-sided Brown-Sequard syndrome would present with **right-sided weakness** and **loss of proprioception/vibration sensation**, along with **left-sided loss of pain and temperature sensation**. - This is the **opposite of the patient's presentation** of left-sided weakness and ipsilateral proprioceptive loss.

Question 5: A 47-year-old man comes to the emergency department because of urinary and fecal incontinence for 6 hours. Earlier in the day, he suffered a fall at a construction site and sustained injuries to his back and thighs but did not seek medical attention. He took ibuprofen for lower back pain. His temperature is 36.9°C (98.4°F), pulse is 80/min, and blood pressure is 132/84 mm Hg. Examination shows tenderness over the lumbar spine, bilateral lower extremity weakness, absent ankle jerk reflexes, and preserved patellar reflexes. There is decreased rectal tone. An ultrasound of the bladder shows a full bladder. Which of the following is the most likely diagnosis?

A. Cerebellar stroke
B. Spinal epidural abscess
C. Anterior spinal cord syndrome
D. Conus medullaris syndrome (Correct Answer)
E. Brown-Sequard syndrome

Explanation: ***Conus medullaris syndrome*** - The combination of **bilateral lower extremity weakness**, **urinary and fecal incontinence**, **decreased rectal tone**, and a **full bladder** is characteristic of conus medullaris syndrome. This syndrome results from damage to the **conus medullaris** (the terminal part of the spinal cord), which typically involves the **S3-S5 nerve roots**. - **Absent ankle jerk reflexes** (S1-S2) with **preserved patellar reflexes** (L2-L4) further pinpoints the lesion to the lower lumbar/sacral spinal cord segments, consistent with conus medullaris involvement. The recent **fall with back injury** is a predisposing factor. *Cerebellar stroke* - **Cerebellar stroke** would primarily manifest with symptoms of **ataxia**, **dysarthria**, **nystagmus**, and **vertigo**, without direct involvement of bladder/bowel function or specific lower extremity reflex abnormalities as described. - While a stroke can cause weakness, it would typically be **unilateral** or involve specific cortical patterns, and not generally present with this constellation of lower spinal cord signs. *Spinal epidural abscess* - A **spinal epidural abscess** would typically present with **fever**, **severe localized back pain**, and progressive **neurological deficits**, often following an infection or recent spinal procedure. - While it can cause neurological deficits similar to the conus medullaris syndrome, the absence of **fever** and the acute onset following trauma makes an abscess less likely in this scenario. *Anterior spinal cord syndrome* - **Anterior spinal cord syndrome** primarily affects the **anterior two-thirds of the spinal cord**, leading to **motor paralysis** below the lesion and **loss of pain and temperature sensation**, while **proprioception** and **vibration sense are preserved**. - Although it can cause motor weakness and bladder dysfunction, the isolated loss of ankle jerk reflexes with preserved patellar reflexes and the specific pattern of incontinence are more indicative of conus medullaris involvement. *Brown-Sequard syndrome* - **Brown-Séquard syndrome** is characterized by **ipsilateral motor paralysis** and loss of **proprioception/vibration sensation**, along with **contralateral loss of pain and temperature sensation** below the level of the lesion, due to hemisection of the spinal cord. - This patient presents with **bilateral weakness** and specific bladder/bowel dysfunction, which is inconsistent with the typical lateralized deficits seen in Brown-Séquard syndrome.

Question 6: A 22-year-old man is brought to the emergency department 30 minutes after being involved in a high-speed motor vehicle collision in which he was the unrestrained driver. After extrication, he had severe neck pain and was unable to move his arms and legs. On arrival, he is lethargic and cannot provide a history. Hospital records show that eight months ago, he underwent an open reduction and internal fixation of the right humerus. His neck is immobilized in a cervical collar. Intravenous fluids are being administered. His pulse is 64/min, respirations are 8/min and irregular, and blood pressure is 104/64 mm Hg. Examination shows multiple bruises over the chest, abdomen, and extremities. There is flaccid paralysis and absent reflexes in all extremities. Sensory examination shows decreased sensation below the shoulders. Cardiopulmonary examination shows no abnormalities. The abdomen is soft. There is swelling of the right ankle and right knee. Squeezing of the glans penis does not produce anal sphincter contraction. A focused assessment with sonography for trauma shows no abnormalities. He is intubated and mechanically ventilated. Which of the following is the most appropriate next step in management?

A. Cervical x-ray
B. CT of the head
C. Intravenous dexamethasone therapy
D. MRI of the spine (Correct Answer)
E. Placement of Foley catheter

Explanation: **MRI of the spine** - The patient presents with clear signs of a **spinal cord injury** (flaccid paralysis, absent reflexes, decreased sensation below the shoulders, severe neck pain after trauma). **MRI** is the most sensitive and specific imaging modality to visualize soft tissue injuries, including the spinal cord, ligaments, and disc herniations, which are crucial for diagnosing and guiding treatment for a spinal cord injury. - Given the patient's **hemodynamic stability** after initial resuscitation and intubation, and the suspicion of spinal cord injury, a thorough evaluation with MRI is the next appropriate step to delineate the extent and location of the injury. *Cervical x-ray* - While cervical X-rays are often performed in trauma cases, they have **limited sensitivity** for detecting all spinal injuries, especially soft tissue damage, ligamentous injuries, or non-displaced fractures. - In a patient with clear neurological deficits suggesting spinal cord involvement, X-rays alone are **insufficient** for a definitive diagnosis and treatment planning. *CT of the head* - A CT scan of the head would be appropriate if there were signs of a **head injury**, such as focal neurological deficits suggestive of intracranial pathology, or a change in mental status not fully explained by other injuries. - In this case, the predominant neurological signs point to a **spinal cord injury** rather than a primary head injury, making head CT a lower priority at this stage. *Intravenous dexamethasone therapy* - The use of high-dose corticosteroids like dexamethasone for acute spinal cord injury is **controversial** and its routine use is **not recommended** by current guidelines due to a lack of clear benefit and potential for harm. - Imaging to characterize the injury is a more urgent and appropriate step before considering any pharmacological interventions for spinal cord protection. *Placement of Foley catheter* - While a **Foley catheter** will likely be needed for this patient to manage neurogenic bladder dysfunction that often accompanies spinal cord injury, it is a supportive measure. - It does not address the immediate diagnostic need to characterize the spinal cord injury, which is paramount for guiding surgical or medical management and preventing further damage.

Question 7: A 22-year-old man is rushed to the emergency department after a motor vehicle accident. The patient states that he feels weakness and numbness in both of his legs. He also reports pain in his lower back. His airway, breathing, and circulation is intact, and he is conversational. Neurologic exam is significant for bilateral lower extremity flaccid paralysis and impaired pain and temperature sensation up to T10-T11 with normal vibration sense. A computerized tomography scan of the spine is performed which shows a vertebral burst fracture of the vertebral body at the level of T11. Which of the following findings is most likely present in this patient?

A. Intact vibration sense
B. Bowel incontinence (Correct Answer)
C. Flaccid paralysis at the level of the lesion
D. Spasticity below the lesion
E. Impaired proprioception sense

Explanation: ***Bowel incontinence*** - The presented symptoms of acute **bilateral lower extremity flaccid paralysis**, **impaired pain and temperature sensation**, and a T11 **vertebral burst fracture** are highly indicative of **anterior cord syndrome**. - **Anterior cord syndrome** characteristically involves damage to the **anterior two-thirds of the spinal cord**, affecting the **corticospinal tracts** (motor control), **spinothalamic tracts** (pain and temperature sensation), and the **autonomic fibers** that control bladder and bowel function, leading to **bowel and bladder dysfunction**. *Intact vibration sense* - The sensation of **vibration** and **proprioception** is carried by the **dorsal columns** (posterior part of the spinal cord), which are typically **spared** in **anterior cord syndrome**. - Therefore, **intact vibration sense** is an expected finding, but the question asks for the **most likely finding** that represents a significant complication of the syndrome. *Flaccid paralysis at the level of the lesion* - While **flaccid paralysis** is present in the lower extremities, it occurs **below the level of the lesion** due to damage to the descending motor tracts (corticospinal tracts). - Flaccid paralysis *at* the level of the lesion would typically involve damage to the **lower motor neurons** at that specific segment, which is not the primary feature described for a burst fracture causing **anterior cord syndrome**. *Spasticity below the lesion* - **Spasticity** typically develops much **later** in spinal cord injuries, after the initial phase of **spinal shock** resolves (usually weeks to months). - In the acute phase following a significant spinal cord injury, **flaccid paralysis** is the more common finding below the lesion, reflecting spinal shock. *Impaired proprioception sense* - Similar to vibration sense, **proprioception** is primarily mediated by the **dorsal columns**, which are generally **spared** in **anterior cord syndrome**. - Therefore, **proprioception** would likely be **intact**, not impaired, in this specific type of spinal cord injury.

Question 8: A 36-year-old male is taken to the emergency room after jumping from a building. Bilateral fractures to the femur were stabilized at the scene by emergency medical technicians. The patient is lucid upon questioning and his vitals are stable. Pain only at his hips was elicited. Cervical exam was not performed. What is the best imaging study for this patient?

A. AP and lateral radiographs of hips
B. Lateral radiograph (x-ray) of hips
C. Magnetic resonance imaging (MRI) of hips, knees, lumbar, and cervical area
D. Anterior-posterior (AP) and lateral radiographs of hips, knees, lumbar, and cervical area
E. Computed tomography (CT) scan of cervical spine, hips, and lumbar area (Correct Answer)

Explanation: ***Computed tomography (CT) scan of cervical spine, hips, and lumbar area*** - In **high-energy trauma** (fall from height), a CT scan is the **gold standard** for evaluating the **spine and pelvis**, providing detailed cross-sectional images superior to plain radiographs. - Since the **cervical exam was not performed**, cervical spine imaging is **mandatory** per ATLS (Advanced Trauma Life Support) protocols. High-energy falls carry significant risk of **cervical spine injury** even without obvious neurological symptoms. - CT allows comprehensive assessment of **hip fractures, pelvic injuries, and the entire spine** (cervical, thoracic, lumbar), identifying both obvious and **subtle fractures** that may be missed on plain films. - This approach provides the most **efficient and thorough evaluation** in the acute trauma setting, allowing for appropriate surgical planning and ruling out life-threatening spinal instability. *AP and lateral radiographs of hips* - Plain radiographs provide **limited detail** and may **miss subtle fractures**, particularly in complex areas like the pelvis and acetabulum. - This option **fails to address cervical spine clearance**, which is essential in all high-energy trauma patients, especially when cervical exam has not been performed. - Radiographs are insufficient for **comprehensive trauma evaluation** after a fall from height. *Lateral radiograph (x-ray) of hips* - A single lateral view is **grossly insufficient** for evaluating hip and pelvic fractures, providing only a **two-dimensional perspective** that can miss significant injuries. - This option **completely neglects spinal evaluation**, which is dangerous in an uncleared trauma patient with a high-energy mechanism. *Magnetic resonance imaging (MRI) of hips, knees, lumbar, and cervical area* - While MRI excels at evaluating **soft tissues, ligaments, and bone marrow**, it is **not the initial imaging modality** for acute bony trauma due to longer scan times and lower sensitivity for acute fractures compared to CT. - MRI is **time-consuming and impractical** in the emergency setting for initial fracture assessment, potentially delaying definitive treatment. - CT is superior for evaluating **acute skeletal injuries** in the trauma bay. *Anterior-posterior (AP) and lateral radiographs of hips, knees, lumbar, and cervical area* - Multiple plain radiographs have **limited sensitivity** for complex or non-displaced fractures, particularly in the **spine and pelvis**, making them inadequate for high-energy trauma evaluation. - Obtaining multiple radiographic views requires **numerous patient repositionings**, which risks further injury if **spinal instability** is present. - Plain films provide significantly **less diagnostic information** than CT scanning for trauma assessment.

Question 9: A 56-year-old man is brought to the emergency department 25 minutes after he was involved in a high-speed motor vehicle collision where he was the unrestrained passenger. He has severe lower abdominal and pelvic pain. On arrival, he is alert and oriented. His pulse is 95/min, respirations are 22/min, and blood pressure is 106/62 mm Hg. Examination shows severe tenderness to palpation over the lower abdomen and over the left anterior superior iliac spine. There is no limb length discrepancy. Application of downward pressure over the pelvis shows no springy resistance or instability. Rectal examination is unremarkable. A focused assessment with sonography shows no free fluid in the abdomen. There is no blood at the urethral meatus. Placement of a Foley catheter shows gross hematuria. An x-ray of the pelvis shows a fracture of the left pelvic edge. Which of the following is the most appropriate next step in management?

A. Intravenous pyelography
B. External fixation of the pelvis
C. Cystoscopy
D. Retrograde urethrography
E. Retrograde cystography (Correct Answer)

Explanation: ***Retrograde cystography*** - The presence of **gross hematuria** in a patient with a **pelvic fracture** necessitates ruling out **bladder injury**. A retrograde cystography directly visualizes the bladder and can detect extravasation of contrast if a bladder rupture is present. - This imaging study specifically investigates the bladder using retrograde contrast filling, which is crucial for diagnosing **intraperitoneal** or **extraperitoneal bladder rupture**. *Intravenous pyelography* - This study evaluates the **kidneys** and **ureters** for injury, but the primary concern with gross hematuria and pelvic fracture is the bladder. - An IV pyelogram provides less detailed imaging of the bladder compared to a retrograde cystogram and is less effective for detecting bladder rupture. *External fixation of the pelvis* - While the patient has a pelvic fracture, the immediate priority in a hemodynamically stable patient with gross hematuria is to identify and manage potential **life-threatening urologic injuries** before definitive orthopedic repair. - **Pelvic external fixation** is primarily indicated for **unstable pelvic fractures** or those causing significant hemorrhage, neither of which is explicitly described as an immediate concern requiring intervention before urologic evaluation. *Cystoscopy* - **Cystoscopy** is an endoscopic procedure that allows direct visualization of the bladder's interior. While it can identify bladder injuries, it is generally considered after imaging studies like **retrograde cystography** to confirm findings or address specific issues like clot evacuation or stent placement. - The initial diagnostic step should focus on assessing for rupture via contrast study, which is often less invasive than a direct endoscopic procedure in the acute trauma setting. *Retrograde urethrography* - **Retrograde urethrography (RUG)** is used to evaluate for **urethral injury**, especially when there is blood at the urethral meatus, a high-riding prostate, or an inability to pass a Foley catheter. - The patient's Foley catheter was successfully placed, and there was **no blood at the urethral meatus**, making urethral injury less likely and thus RUG a lower priority as the initial step compared to assessing for bladder injury.

Question 10: A trauma 'huddle' is called. Morphine is administered for pain. Low-flow oxygen is begun. A traumatic diaphragmatic rupture is suspected. Infusion of 0.9% saline is begun. Which of the following is the most appropriate next step in management?

A. Chest fluoroscopy
B. Barium study
C. CT of the chest, abdomen, and pelvis (Correct Answer)
D. MRI chest and abdomen
E. ICU admission and observation

Explanation: ***CT of the chest, abdomen, and pelvis*** - A suspected **traumatic diaphragmatic rupture** requires a comprehensive imaging study to assess the diaphragm, surrounding organs, and potential associated injuries. - **CT scan** of the chest, abdomen, and pelvis provides detailed anatomical information, can identify herniated abdominal contents, and is essential for surgical planning in trauma settings. *Chest fluoroscopy* - While fluoroscopy can detect diaphragmatic motion, it is **less sensitive** for identifying tears or herniated contents in the **acute trauma setting**. - It does not provide the comprehensive view of surrounding organs and associated injuries often needed in trauma. *Barium study* - A barium study is primarily used to evaluate the **gastrointestinal tract**, but it is generally **not the initial imaging modality** for diaphragmatic rupture due to its limited ability to visualize the diaphragm itself or other solid organ injuries. - It would be performed after suspicion is increased or for very specific indications, not as a primary diagnostic tool. *MRI chest and abdomen* - While MRI offers excellent soft tissue contrast, its use in **acute trauma** is limited by **longer acquisition times**, potential contraindications with metallic implants (though less common in acute trauma), and lower availability compared to CT. - CT remains the **gold standard** for rapid, comprehensive imaging in unstable trauma patients. *ICU admission and observation* - While observation in the ICU is important for monitoring and supportive care, it is **not the next step for diagnosis** of a suspected diaphragmatic rupture. - Definitive diagnosis through imaging (CT) is crucial before determining specific management strategies, including potential surgical intervention.

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