Case of the week

1. A 13 year old boy riding a quad bike ran into a rope that had been
stretched across the track he was riding on. He was able to get up
and walk away from the crash. Other than a sore neck he is
complaining of no other injuries. He is conscious & alert with all
vital signs in the normal range.
•What structures are you concerned may have been injured in this
crash ?
•What specific examination features should be sought ?
•What investigations are indicated ?

3. Given the mechanism of injury the 3 big areas of concern in this lad are: airway,
cervical spine, and arterial (carotid & vertebral) injury. Of these cervical spine injury
is probably the least likely, as given the mechanism it would likely either be fatal or
present with gross neurological deficit. The airway can be involved through trauma
to the soft tissues, fractures of the laryngeal cartilages or recurrent laryngeal nerve
damage.
Airway injury may be suspected/detected clinically by the presence of stridor or
drooling in severe cases, or by dysphonia/haemoptysis in the less severe. Take any
change in the patients voice seriously. Specifically look for crepitus due to
subcutaneous emphysema in the neck or supraclavicular fossae, as it indicates
significant airway damage/perforation. The best form of examination for laryngeal
injury is direct or fibre-optic laryngoscopy which will need the involvement of an
ENT specialist.
Plain xrays, whilst moderately sensitive for cervical spine injury, are not adequate to
image laryngeal/airway trauma. If the patient is able to lie flat, and there are no acute
concerns for the airway, then the investigation of choice is CT & CT angiography.
This will accurately identify carotid/vertebral artery tears/dissection and is good at
finding laryngeal skeleton injuries. Airway concerns mandate direct laryngoscopy