Image of the Day 17: Unstable L1 Burst Fracture

The case that I want to share here is to stress up the importance of pain management in which I did it pretty bad.

A patient of mine is a teenage girl who was playing on the top of crane which about four meters when she suddenly slip, fall and landed on the foot first but due to imbalance, then fall on the buttock and back. Sustain a very bad lower back pain associated with numbness of bilateral limb. The pain is very severe but reduce by lying on left lateral position.

upon examination, patient still able to move the lower limb with intact flexion/extension of lower limb's joint. she only complaint of numbness.

In my mind, I was expecting some crack fracture of the lumbar spine and give IV Diclofenac 75 mg stat. The pain reducing in severity  but still patient unable to lie supine. Supposedly, I should make her lie flat and put on spinal board to immobilize her  but due to pain, I think it is ok to let her lie in left lateral position

After the radiological imaging. I was shocked to see that the injury is far more severe than I expect. Yes, I do anticipate fracture but not the unstable L1 burst fracture like this.

Then I decided to give IV Fentanyl 50 mcg stat dose and surprisingly that she can lie flat.

Well, that's the lesson that i learn. Always expect the worst injury in patient who fall with a significant high and provide a good analgesia so that you can put them on proper supine position on spinal board and proceed with radiological imaging.