Delayed hemorrhagic shock due to reverse chance thoracic vertebrae fracture complicated with hypoxemia caused by diaphragmatic eventration

Abstract

Deceleration injuries sometimes cause thoracolumbar spine burst fractures. These injuries can also occur in people with kyphosis, which is common in elderly societies. The type of fracture and initial treatment require greater consideration in elderly than in non-elderly cases. An 82-year-old woman with kyphosis was involved in a traffic accident and was admitted to our hospital with severe back pain, to treat reverse chance thoracic vertebrae burst fracture. The initial treatment involving rest in the spine position was unsuccessful. Continuous hemorrhage resulted in shock. She also developed respiratory insufficiency due to diaphragm elevation and diaphragmatic eventration. She required respiratory management with tracheal intubation and massive transfusion to treat her shock. Spine burst fractures in elderly patients with kyphosis could cause retroperitoneal hemorrhage and hemothorax. Initial treatment of the spine burst fracture, by placing the patient in a supine position, resulted in massive hemorrhage and shock. Learning objectives:•Practitioners should acknowledge the difficulty of treating spine burst fracture in elderly patients with kyphosis, particularly reverse chance fracture. Repositioning of the patient for treatment, unlike in non-elderly patients, may be required to prevent retroperitoneal hemorrhage and hemothorax.•Practitioners should recognize that placing the patient in the supine position, which is conventional initial treatment for spine burst fracture, may not be optimal in elderly patients with kyphosis, given the difficulty of stabilizing the fracture, which can cause hemorrhage. Lying in a supine position can cause diaphragm elevation in patients with diaphragmatic eventration, a common complication in elderly patients with kyphosis that could lead to respiratory insufficiency.

Keywords: Elderly driver; Hemorrhage shock; Respiratory insufficiency.

Fig. 1

Initial computed tomography and magnetic resonance imaging showing reverse burst fracture of the 12th thoracic vertebra with retrograde hematoma around the fractured spine.

Fig. 2

Re-examination of enhanced computed tomography images shows expansion of the retrograde hematoma around the thoracic vertebra reverse burst fracture.

Fig. 3

(a) Chest X-ray image obtained during respiratory insufficiency shows diaphragm elevation with a gastric bubble rising to the middle of the left thoracic. (b) Chest X-ray image after tracheal intubation with a respirator showing the gastric bubble was suppressed down to the left diaphragm line.