EM Forum Case #122 "The Older you Are, The Harder you Fall!"
by Charlene Babcock Irvin, MD, FACEP  

A 66 y/o male in good health presents after a snow mobile accident. He has a cottage on a lake up north, and the family meets there for weekends. Earlier today, they were all snowmobiling on the lake, and when he drove his snowmobile off the lake he didn’t hit the ramp straight on and he fell off to the side into a snow bank. He was on a fast snowmobile, but he slowed down considerably to exit the ice so he estimates he was only going about 30 MPH. He did not hit his head, got up immediately, and drove the snowmobile back to the cottage. He thinks he injured his left shoulder and left hip in the fall. He denies any loss of consciousness. As they were driving back to Detroit, he began to have increased pain in his left shoulder and left hip area, so his wife brought him to the ED.

She tells you he is not a complainer, and when he complains of pain, she always knows its real.

ROS: No headache, blurred vision, numbness or weakness, neck pain, chest pain, abdominal pain, vomiting, pain with urination or bowl movement. No blood in his urine.
PMH: Hypertension
SH: No smoking, social alcohol. No drugs.
Meds: BP pill
VS: BP 125/82, RR=20, HR=88, Afeb, Oxygen Sat-95%
PE: WDWN robust man in no acute distress appearing younger than 66 yrs old.
HEENT: Unremarkable. No pain with ROM of neck. No neck tenderness.
Heart: RRR, no murmurs.
Lungs: Equal breath sounds. He does complain of pain up near his axilla with deep breath. Palpation of the chest wall does not reveal any crepitance. Equal chest excursion. Some rib tenderness is noted at rib number 4 and 5. No bruising or swelling to the skin.
ABD: Soft, non-tender. No masses. He does note that when you palpate in the LUQ area, he has increased pain in his left lateral rib area.
Pelvis: Stable, non-tender on compression.
Ext: Pain at left Acromioclavicular joint. Full range of motion is noted, but increased pain with abduction of shoulder. The left hip is also tender. Range of motion is maintained, but pain with range of motion testing. He notes he can walk on it, but has considerable pain with walking (His wife chimes in that he has to limp when he walks).
Neurologic: Alert and oriented x 3. No motor, sensory or reflex deficit. Cranial nerves are normal. Finger to nose testing is normal.
Back: No thoracic or lumbar spine tenderness.
Rectal: No gross blood.


Questions:

1. Should you order a C-Spine X-Ray?

2. CXR reveals no pneumothorax or other abnormality identified. Hip x-ray is normal. C-spine x-ray is normal. Trauma labs are all normal. What is your disposition?

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