Physical Therapists…Why We Need To Trust Our Instincts And Make The Appropriate Referrals

I recently evaluated a patient who suffered a traumatic fall and landed on the left side of his head. Soon after he went to see a physician specializing in internal medicine. The X-ray taken was negative for fracture or other bony pathology and he was referred to physical therapy. I initially saw him two weeks post fall in the clinic and at that time he had severe cervical range of motion deficits, exquisite tenderness to palpation and bruising behind the left mastoid process (commonly called a battle sign), and adjacent upper cervical muscle spasms. He also shifted his body to the right and felt the need to support his head with both hands, which gave him some sense of support. To make things more complicated he reported a chronic history of vestibular issues.

At this point without doing any tests what would be your hypothesis?

For me, two came to mind. One being an upper cervical fracture and the second an upper cervical ligamentous tear.

I wanted to be cautious so the initial exam was very light and hands-off. Primary focus was directed towards posture, symptom management strategies, and education regarding transfers & proper sleeping positions. At first follow-up appointment his symptoms had not changed and he was having difficulty performing the home exercise program due to pain. At that point I attempted an upper cervical acute scan consisting of upper cervical ligamentous stability tests (alar, transverse, anterior / posterior OA & AA, transverse), which were difficult to get an accurate feel due to muscle guarding. Vertebral artery was difficult due to insufficient cervical mobility; also compression & distraction were painful. No myotomal strength deficits, were noted, however upper cervical movements were weak and painful in all directions.

Going back to my initial hypothesis, I felt even more strongly about a fracture, however kept thinking the x-ray had ruled this out. As therapists we are taught to use the information presented and make an appropriate diagnosis, but also follow our gut. Mine was telling me fracture, fracture, fracture. So I offered the patient a soft-collar and informed him to call his doctor immediately.

The next day I received a message from the patient’s wife that the doctor took additional imaging and sure enough an upper cervical fracture was present. He was immediately placed in a Halo cervical brace and sent home. I will follow-up with him when appropriate.

For me, this experience reinforced the importance of following that little voice in the back of your brain telling you something is wrong, even when diagnostic imaging says otherwise. Luckily my patient was safe, but could have fell again or moved his head wrong, worsening his condition. He was placed in a halo cervical brace and is involved in rehabilitation.

Common subjective/objective signs & symptoms to rule in a fracture are as follows:

• Painful / weakness in all ranges of motion via strength testing
• Guarded active movements
• Painful compression / distraction
• Pain with vibration, via tuning fork
• Protective splinting with hands or feeling of looseness / instability

Thank you for reading.

– Saul