Diagnosis of a C-2 fracture during physiatric consultation: a case report

Consultation in the acute care setting allows physiatrists to make significant contributions. In our case, a 90-year-old woman presented to the emergency room after falling down five stairs. Six view C-spine films taken at that time revealed no fracture. She was sent home on anti-inflammatory medication and was later admitted for gastritis. A repeat six-view C-spine series again revealed no fracture. Physiatry was then consulted to prescribe modalities and therapies for "cervical strain." On examination, the patient demonstrated severely decreased neck range of motion limited by pain, with pain radiating down her right arm. Physiatry recommended obtaining a C-spine magnetic resonance image to rule out occult fracture or herniated disc before proceeding with therapies. The magnetic resonance image revealed a complex C-2 fracture consisting of a Type III odontoid component. Computed tomographic scan was then performed to obtain a high-resolution assessment of the bony architecture. The computed tomographic scan revealed a high degree of comminution, including bilateral pedicle fractures and a fracture through the left transverse foramen of C-2. The patient was placed in a hard cervical collar and seen by a neurosurgeon. Had therapies been initiated before physiatric consultation, the patient could have experienced significant neurologic complications, including the possibility of becoming tetraplegic. This case demonstrates that physiatrists play a crucial role in the evaluation of acute care patients before the initiation of therapies. The authors will review pertinent history and the results of physical and diagnostic tests.