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A 36-year-old female is involved in a motor vehicle accident in which she is rear-ended in slow moving traffic at less than 5MPH. She presents to the ER complaining of localized neck pain and stiffness. On physical exam she has paraspinal tenderness in the cervical region. She has limited motion in all planes secondary to pain. Her motor, sensory, and reflex exam are normal in her upper and lower extremities. Radiographs are obtained and shown in Figure A, B, C, and D. A photo of the damage on her car was brought to the ER by EMT and is shown in Figure D. Which of the following is most appropriate in the treatment of this patient's injury?
Soft cervical orthosis with early physical therapy
Philadelphia collar with restricted motion
C2 pars screw osteosynthesis
C2 anterior screw osteosynthesis
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The patient's history and physical exam are consistent with a diagnosis of whiplash. Of the options listed, a soft cervical orthosis with early physical therapy is the most appropriate treatment.
Whiplash is a term describing a range of injuries to the neck caused by or related to a sudden distortion of the neck associated with extension. Whiplash is commonly associated with motor vehicle accidents, usually when the vehicle has been hit in the rear. The most appropriate treatment of this injury is placement of a soft cervical orthosis until symptoms improve. Early range of motion exercises of the neck have also been shown to be beneficial in addition to bracing.
Agabegi et al. completed a review article on spinal orthoses. They state that the soft collar has little effect on restricting motion in any region of the cervical spine, and that indications for this collar are whiplash injuries and neck pain without unstable bony or ligamentous injury. They also note that this collar is contraindicated for injuries with the potential for instability.
Schofferman et al. completed a review article on whiplash injuries. With regards to acute treatment, they state that patients who remain active despite pain generally have a more favorable outcome than do those who rest excessively or avoid activity. They also note that physical therapy with active exercise is superior to treatment with a soft collar.
Figure A and B show a normal cervical spine AP and lateral radiograph. Figure C shows a normal swimmers view radiograph which is obtained to visualize the C7-T1 segment - this is required when clearing a cervical spine radiographically. Figure D shows a normal odontoid view. Figure E shows a minor "fender bender" indicating a low energy accident. Illustration A shows the three primary anatomic lines used to access the cervical spine which include: 1) anterior vertebral body cortex line 2)
posterior vertebral body cortex line 3) spinolaminar junction line.
Answer 2: Philadelphia collars are typically used to treat stable bony or ligamentous injuries.
Answer 3: A Halo would not be indicated in the absence of cervical fracture or instability.
Answer 4: C2 pars screw osteosynthesis is used to treat Hangman's fractures.
Answer 5: C2 anterior screw osteosynthesis would be indicated in odontoid fractures.
Agabegi SS, Asghar FA, Herkowitz HN.
J Am Acad Orthop Surg. 2010 Nov;18(11):657-67. PMID: 21041800 (Link to Abstract)
Agabegi, JAAOS 2010
Schofferman J, Bogduk N, Slosar P
J Am Acad Orthop Surg. 2007 Oct;15(10):596-606. PMID: 17916783 (Link to Abstract)
Schofferman, JAAOS 2007
Harty JA, Lenehan B, O'Rourke SK
Emerg Med J. 2005 Sep;22(9):625-7. PMID: 16113180 (Link to Abstract)
Harty, EMJ 2005
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