MIAMI BEACH — The cervical injuries and vertebral insufficiency stress fractures that follow traumatic injury in elderly patients present special diagnostic challenges, Dr. Richard H. Daffner said at a symposium on emergency radiology sponsored by Baptist Health South Florida.
Decreased vision and hearing, diminished motor skills, slower reaction times, and multiple comorbidities disproportionately affect patients 65 years and older, he explained.
“What complicates this, particularly because falls are the biggest source of injury and trauma to the elderly, is fractures—which can contribute significantly to their ultimate demise,” said Dr. Daffner, director of musculoskeletal, trauma, and emergency radiology, Allegheny General Hospital, Pittsburgh.
Emergency physicians are most likely to encounter cervical fractures and vertebral insufficiency stress fractures in the elderly trauma patient. The majority of cervical fractures in the elderly tend to cluster at the C1 and C2 level, Dr. Daffner said. Hyperextension injury is the leading cause of a C2 fracture. “As you get older, your neck tends to be stiffer, but the C1-C2 region remains the most mobile,” he explained.
Dr. Daffner and his colleagues studied 231 elderly patients with a total of 274 cervical injuries. They found that 119 of these injuries (43%) were at C2. In contrast, among the 749 participants in the study who were younger than 65 years with a total of 870 cervical injuries, 221 injuries (25%) occurred at C2.
Dens fractures “can be quite subtle” on a radiograph, Dr. Daffner said. “You see it much better on computed tomography —a slight shift of bone forward around C2.”
A hyperextension injury is often devastating, Dr. Daffner said. “A wide vertebral disk space [on radiograph] is the hallmark sign, and it's never normal in the elderly population.” Patients with a wide disk space should undergo magnetic resonance imaging immediately to determine the extent of injury, he suggested. The injury can be associated with development of edema, osteophytes impinging on the spinal cord, and neurologic compromise.
Insufficiency stress fractures are common in the elderly and are very site-specific for a particular activity, Dr. Daffner said. The sacrum and pelvis are most commonly involved, but the fractures also occur at the femoral neck and tibial plateau. “The diagnosis is not often considered by the clinician—some of these seniors are very active.” Failure to identify these fractures early can lead to progressive disability, a longer healing time, and a fracture that becomes distracted.
An occult fracture can be detected with a bone scan if the injury is more than 24 hours old, Dr. Daffner said. On a bone scan, a butterfly pattern (which can also be described as resembling a Honda car logo) is highly suggestive of a sacral stress fracture.
Radiographs are less useful but sometimes show some osteopenia. Computed tomography is useful if there is an occult fracture in the spine. Computed tomography is also the procedure of choice for pelvic stress fractures.
However, magnetic resonance imaging is recommended for fractures in the peripheral skeleton. “A complete MR study is not needed—we often do coronal and axial images” in less than half an hour in most cases, he said. “MRI is very useful early on when a patient comes in right away complaining of pain.”
Many patients who have an insufficiency stress fracture have bone compromised by osteoporosis and/or a history of malignancy.
“One of the keys to differentiating a malignancy versus a stress fracture is a stress fracture tends to be linear and occurs in the vertical plane, up and down, whereas malignancies tend to be globular,” Dr. Daffner said.