Serious bicycle crash injury in chiropractic practice – a case report of delayed diagnosis
© The Author(s). 2016
Received: 5 April 2016
Accepted: 16 August 2016
Published: 1 November 2016
Bicyclists are vulnerable road users and are at risk of serious spinal injury if involved in traffic crashes. In Denmark approximately 25 bicyclists are killed each year and some 20.000 bicycle related casualties are registered in the National Patient Registry each year. In addition to these figures, a large number of casualties remain unregistered despite injury. Many of the casualties will consult chiropractors in primary practice with or without preceding evaluation in the established emergency care facilities. Therefore, chiropractors are expected to be able to proficiently evaluate these patients clinically and radiologically in order to ensure the best possible patient care.
This report involves a middle-aged female who consulted several physicians following a collision with a motor vehicle while riding a bike. Despite clinical symptoms and consequent examinations she suffered from inadequate diagnostic evaluation until a radiological examination was performed 18 days following the injurious crash identifying unstable cervical spine fractures.
The presented case is an example of the serious spinal injuries bicyclists may suffer when involved in high-energy traffic crashes despite wearing a bicycle helmet. The case report highlights the need for relevant clinical (including radiological) decision strategies when dealing with trauma patients in chiropractic practice. This involves the direct access to radiological procedures with no unnecessary delay when indicated as in most trauma cases. Furthermore, clearly defined and easy accessible referral schemes from primary care settings to emergency departments must be available to the chiropractic physician. Chiropractors are clinically competent to examine and diagnose, including radiologically evaluate, patients who have been injured in traffic crashes. Hence, chiropractors may contribute to the diagnosis, management and rehabilitation of spinal injured patients following many types of crashes and accident, including bicycle crashes.
KeywordsBicycle traffic crash Cervical spine fracture Delayed diagnosis Chiropractic practice
In Denmark, biking is extremely popular for recreational purposes, sports and commuting. However, bicyclists can be regarded as vulnerable road users and consequently at risk of personal injury when involved in a road traffic crash. These crashes may be “solo” crashes or involve other parties, e.g. cars, bicycles or pedestrians. The mechanism of trauma significantly influences the types of lesions sustained by the casualty. In the perspective of injury prevention measures the bicyclist has limited options. The most common protective device is a bicycle helmet which has a well-documented effect on preventing serious head injuries [1–5]. However, there is limited scientific information concerning the effect of wearing a bicycle helmet and the risk of neck injuries [1–3, 6].
According to the National Patient Registry (Landspatientregisteret) approximately 20.000 Danes are injured on bicycles each year causing them to consult an emergency departments (ED) . In comparison, only 10 % of these are registered in Denmark Statistics which is a national database based solely on police records when addressing traffic crashes . Hence, casualties who do not contact the emergency department or become registered by the police should be added to the reported numbers. Therefore, the number of injured bicyclists is probably much higher than the official numbers, and this is most likely a worldwide phenomenon . All fatalities are recorded which amounts to approximately 25 bicyclist each year equivalent to 15 % of all road traffic fatalities in Denmark [10, 11]. The Danish Traffic Safety Commission for 2013–2020 has defined bicycling as a focus area in order to improve our understanding of this underreported area of traffic injury and safety [9, 12, 13].
When injured, the bicyclist sustains injuries of a wide range of severities. For the majority of severely injured casualties immediate contact to the emergency department will take place. Rarely, these patients will contact a chiropractic physician directly. In some cases, presumably very few, a clinical evaluation at the emergency department will have been insufficient whereby clinically important conditions remain undisclosed. Some of these patients may consult a chiropractor in a primary care facility. Less severely affected individuals are more likely to contact a chiropractor directly.
This case report presents a middle-aged female who consulted several physicians following a bicycle crash before a radiological evaluation at a primary care chiropractic facility revealed serious cervical spine fractures. The purpose of this paper is to remind the clinicians of the challenges that primary care may face when consulted by newly injured bicyclist complaining of a variety of symptom severities.
This case report concerns a case from a chiropractic practice where a bicyclist presented with cervical spine fractures following a bicycle crash that had been undiagnosed for 18 days despite several medical and chiropractic consultations. Following diagnostic imaging evaluation she underwent stabilizing surgery with a moderate outcome.
Bicyclists are vulnerable road users and are likely to get injured when involved in crashes . When this happens the casualty most often suffers short-lived symptoms from minor contusions, lacerations and abrasions . In moderate severity injuries dislocations and distortions are seen, whereas severe injuries include fractures, spinal cord injuries, intracranial injuries and injuries to the thorax and abdomen [1, 5–7, 15]. The most common injury locations are the extremities, and when controlling for injury severity the head injuries are the most common potentially fatal (AIS4+) injuries [6, 15]. Cervical spine fractures are rare following bicycle crashes affecting less than 1 % of all bicycle crash victims [1, 6, 15], with a significantly increased prevalence when a head or brain injury is present . A recent meta-analysis found helmet use to increase the risk of cervical spine injury alone . However, there are some conflicting reports concerning the evidence of helmet use and the risk of cervical spine injury [1, 6, 15]. In the reported case the casualty, who wore a bicycle helmet, suffered serious cervical spine injuries but no head injuries. Hence, she clearly benefitted from the proven protective effects of the helmet as this was broken due to the impact sustained during the crash [1–5]. The cervical spine fractures were most likely the consequences of the high-energy impact transferred from the initial point of contact via the helmet to the cervical spine. The important role on safety and injury prevention of bicycle helmets is clear [1–5]. Consequently, many countries have implemented this knowledge into national laws and recommendations. However, mandatory use of helmets is only enacted in a few European countries and affects only children and young people .
When the spinal fractures were detected the patient had to be referred for hospital care. At the time of the reported case, no formal collaboration existed between the chiropractors in private practice and the hospitals with regard to referral of acute spinal injury. Therefore, the patient had to be referred by the GP. However, more recently, a direct referral option has been established in some regions of the country, e.g. Central Region Denmark, which enables the chiropractors to refer directly to the ED via the visitation procedures present at the local hospital. Treatment of acute cervical spine fractures follows relevant guidelines and do not involve the chiropractor except for the potential diagnostic role as in the presented case. However, following healing of fractures chiropractic treatment may become relevant in order to restore biomechanical function, improve physical loading capability and reduce pain. Hence, a previous serious spinal injury does not contraindicate future chiropractic care. On the contrary, chiropractors can contribute to the management and rehabilitation of patients with spinal injury following many types of crashes and accident, including bicycle crashes.
The presented case is an example of the serious spinal injuries bicyclists may suffer when involved in high-energy traffic crashes despite wearing a bicycle helmet. The casualty experienced delayed diagnosis of the injuries despite several medical and chiropractic consultations. Hence, this paper highlights the necessity for clinicians, including chiropractors, to be familiar with clinical guidelines involving diagnostic imaging, when managing trauma patients. In this context, it is imperative that chiropractors have immediate and direct access to radiological procedures with no unnecessary delay. Furthermore, clearly defined and easy accessible referral schemes from primary chiropractic care settings to emergency departments must be available. Chiropractors are clinically competent to examine and diagnose, including radiologically evaluate, patients who have been injured in traffic crashes. This is a prerequisite for optimal management and rehabilitation of spinal injured patients following many types of crashes and accident, including bicycle crashes.
Anterior-posterior lower cervical
Anterior-posterior open mouth
Canadian C-Spine rule
National Emergency X-Radiography Utilization Study
The permission to publish the diagnostic images from the Department of Neuroradiology, Aarhus University Hospital is greatly appreciated. The kind permission from the authors Stiell et al.  to reuse the illustration in Fig. 4 is greatly appreciated.
The author is solely responsible for the writing of this manuscript.
The author declares that he has no competing interests.
Consent for publication
Written informed consent for publication of her clinical details and radiological images was obtained from the patient. A copy of the consent form is available for review by the Editor of this journal.
Ethics approval and consent to participate
Ethics approval is not needed in this case. The patient has consented to publication.
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