Examination: Whiplash Injury

Casebank Combined
1

Where you are:
You are a foundation year 2 doctor in the emergency department.

Who the patient is:
Your next patient is Mr Williams, a 50-year old man who has come to the hospital with neck pain.

Other information you have about the patient:
None

What you must do:
Please take a history, perform a relevant examination and discuss management with the patient.

Patient information:

  • You are Mr. Williams, 50 years old. You are involved in a RTA.
  • You were stationery at the round about when another car hit you from behind.
  • You did not have any pain immediately after the accident.
  • You did not go to the hospital because there was no pain immediately after the accident.
  • You have no headache, no loss of consciousness, no vomiting, no seizure. Your neck pain is 8/10.
  • You did not hit your head to anything.
  • You are normally fit and well and not on any regular medications.

EMOTIONS AND ATTITUDE:

  • You are calm and normal emotions.

SET-UP:

  • 2 chairs for patient ,candidate and the examiner.

Questions:

  • What is wrong with me doctor?
  • Will you give me a neck collar?
  • If the doctor does not perform an X-ray,ask him “will you perform an X Ray or not?
  • EXAMINER’S PROMPT:
  • If the candidate says he would like to perform an X-Ray ,tell them the cervical spine X-Ray is normal.

On Examination:

  • When the doctor presses your bony prominences on your neck, you have severe pain. On C6 & C 7 spinal processus.
  • The rest of the examination is normal.

Examiner’s Prompt:

  • The candidate should mention they would like to apply a cervical collar and perform cervical X-ray.
  • Examiners should tell the candididates that Cervical X-ray has been done and it is normal.

Approach:

  • GRIPS, How can I help?
  • History of the neck pain
  • Is this the first time?
  • What do you think could have caused the pain?
  • Where is the pain?
  • Severity of the pain on a scale of 1-10
  • Trauma e.g. RTA
  • Previous incidents
  • Severity of the pain
  • Did he go to hospital after the accident?
  • History of the accident
  • Where and when
  • Driver/ passenger?
  • Nature of the accident
  • How many miles per hour?
  • Were you stationery or were you driving?
  • History of head injury
  • Loss of consciousness
  • Nausea and Vomiting
  • Seizure
  • Drowsiness
  • Discharge from the ear or nose

Examination:

  • Inspection (bruises or any wounds)
  • Palpation (Tenderness on spinal process and paraspinal)
  • Cervical spine X-Ray to rule out fracture (he/she overstretched the … Of the neck during the accident)
  • Examiner: “Doctor C-Spine X-Ray is normal”
  • Neurological:
    • Dermatomes: C 2=adams app, C 3 notch, Tip of the shoulder=C 4, Bicep= C5, Thumb c6, Middle finger C7, little finger C8
    • Power: (wrists, elbow and shoulder)
    • Nerves (Ulnar=grip fingers tightly, median=make a perfect sign and radial=make a thumb sign)
  • Check head movement

Explain diagnosis of Whiplash

MANAGEMENT:

  • Rest
  • Analgesia ( e.g Ibuprofen)
  • Physiotherapy
  • Neck collars are not advised as it increases neck stiffness and worsens the pain

Scenario A:
Patient has got pain on C 7 area
Neck movements are also very painful.

Scenario B:
The patient has got tenderness on the sides. Mainly its muscle tenderness but no cervical spine tenderness.
Neck movements are very painful.

NOTE: Candidates should not request an X-ray. Candidates who request an X-ray should fail this particular station.

2

What did you want to tell about X-ray at the end of this case?