> So are you generally dismissive about "bony tenderness"? For
> example, do you not apply Ottawa Rules for Ankles which after
> all is mainly based on bony tenderness.
I don't actually fully agree with Adrian on this one. However, ankles and
necks are different. My own ankles have no bony tenderness other than the
standard spots at the Achilles tendon enthesis and the proximal diaphysis of
the fifth metatarsal. My neck does have midline tenderness (OK, former prop
forward so may be related to that, but I think- as Adrian says- that it's
pretty universal). Also the Ottawa foot and ankle rules are based on
presence of both swelling and tenderness- if you x-rayed everyone with
tenderness but no swelling you'd x-ray a lot more.
> Finally, we recommend clinicians use the decision instrument
> to guide their evaluations, and not as a absolute rule.
> Radiography may be wise in some patients who exhibit none of
> the criteria (particularly those with spine disorder -
> rheumatoid arthritis, ankylosing spondylitis, etc - and the
> very young). Similarly, it may be safe to omit radiography
> in some patients who have one of the criteria, although
> clinicians should be careful in making these selections."
Mildly worrying- x-ray departments will complain if you send patients who
don't fit the criteria. It might have been better if the original article
was clearer on the fact that you still x-ray based on your clinical
judgement rather than on the rules they lay down.
> What Robert is highlighting is the difficulty in out-ruling
> unstable ligamentous cervical spine injuries in patients with
> neck pain, significant mechanism of injury, and apparently
> normal standard c. spine x-rays.
> Early flexion/extension views may not be helpful due to
> muscle spasm limiting range of movement.
> So - should these patients be given a rigid collar and
> analgesia and be brought back later for flexion / extension
> views? Or does anyone have other suggestions?
It's a tricky one. If the neck is truly unstable, then a rigid collar won't
help. However, every patient I've seen with an unstable neck (other than
obtunded consciousness) has been holding their neck very stiffly or has had
neurological symptoms (other people I talk to have had the same experience).
Accepting numbers are limited, there will be some exceptions and it is
entirely possible that I've sent home patients with unstable necks and never
found out about it.
However, if you think the neck is unstable, you need to manage the patient
as an inpatient- the rigid collar will not be worn by the patient, won't
help anyway; and if you're thinking defensive medicine, how do you defend
sending home a patient who you thought had an unstable neck injury (and if
you didn't think that, why the rigid collar). No firm guidelines, though. In
general I wouldn't want to send home someone who'd been unable to move their
neck since the incident or had neurological symptoms just on the basis of
plain films.
Matt Dunn
Warwick
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