Delayed diagnosis of an unsuspected pelvic fracture in a patient with tetraplegia

Abstract

Study design: Case report.

Context: In patients with a complete spinal cord injury (SCI) above T6 level, autonomic dysreflexia (AD) can be the only alerting sign of complications below the level of injury. A case report is presented of a patient with tetraplegia who progressively developed an AD syndrome after falling from a wheelchair. Initially, he was treated for symptomatic urinary tract infection and only later an unstable pelvic fracture was detected.

Findings: A patient with chronic tetraplegia fell from his wheelchair while intoxicated. After the fall, he showed no signs of injury. Two days later, AD symptoms appeared while lying on his side or sitting. He presented to his community-based physician and received antibiotics for concomitant urinary tract infection. Because of persisting complaints, the patient was referred to the Spinal Cord Unit. Once the history of falling from the wheelchair was made known, symptoms of AD were suggestive of an internal injury. Radiography showed pelvic fracture and conservative treatment was administered. The fractures healed in 3 months, the therapeutic bed rest regimen was relaxed without trigerring AD symptoms.

Conclusion: AD symptoms can suggest complications below the SCI level. Awareness and recognition of these symptoms are of utmost importance. However, etiology may be misleading. The role of a community-based general physician is to recognize the right moment when the need of a specialized assessment in a Spinal Cord Unit arises. In addition, patients should also be well informed about the most common possible complications from specialized SCI centers.

Keywords: Autonomic dysreflexia; Osteporosis; Patients with tetraplegia; Pelvic fracture; Spinal cord injury.

Figures

Figure 1

Pelvic X-ray, anteroposterior view (A) showing left-sided pubic rami fractures, lateral view (B) showing sacral fracture.

Figure 2

Pelvic CT scan, anteroposterior view (A) showing tolerable pubic rami fragment's position and (B) verifying fracture of both lateral masses of sacrum.

Figure 3

Pelvic CT scan, anteroposterior view (A) showing displacement, with a 1.5-cm length shift in the area of pubic rami with good healing potential and (B) showing no change in the posterior pelvic complex.

Figure 4

Pelvic CT scan, anteroposterior view (A) and (B) showing healed fractures.