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Abstract: A 24-year-old female patient, who was not able to have a car accident trauma 1 hour ago, caused severe pressure pain in the sacrococcygeal region to the extent that she could not walk, so she came to our hospital and was clearly diagnosed with sacral fracture after examination. After 3 weeks of bed rest, she was given ibuprofen extended-release capsules, diclofenac sodium extended-release tablets and methylcobalamin tablets for 1 week, the pain symptoms were relieved, and she was discharged from the hospital for convalescence. 2 weeks after her discharge, she returned to the hospital for a review, and the fracture site was well aligned and the healing progress was good.
Basic information】Female, 24 years old
Disease Type】Sacral fracture
Hospital】The First Hospital of China Medical University
Date of consultation】May 2021
Treatment plan】Medication (ibuprofen extended-release capsules, diclofenac sodium extended-release tablets, methylcobalamin tablets)
Treatment period】Inpatient treatment for 1 week, return to the hospital for review at the 2nd week and 1 month after discharge
Treatment effect]: Symptom reduction, good alignment of fracture site, good healing progress
I. Initial interview
The patient was 24 years old, female. 1 hour ago, she suffered a traumatic injury in a car accident and injured her sacrococcygeal region, resulting in severe pressure pain in the sacrococcygeal region to the extent that she could not walk, so she came to the clinic. Outpatient examination showed sacrococcygeal pain, limited movement, bilateral lower limb muscle strength and sensation, no redness, swelling, heat and pain in the rest of the joints, free movement, normal abdominal wall reflex, biceps, triceps reflex, knee reflex and Achilles tendon reflex, negative meningeal stimulation sign and negative Babinski’s sign. He was ordered to undergo a CT scan of the pelvis, which revealed a sacral fracture and a small amount of fluid in the pelvis, and was admitted to the hospital with a sacral fracture. The patient had a normal diet since the trauma and had no urinary or fecal incontinence.
II. Treatment history
After the patient was admitted to the hospital, a CT scan of the lumbar spine was performed and no obvious traumatic changes were seen. Combining the patient’s clinical symptoms and relevant examination results, the patient was judged to have a mild fracture of the sacrum. The patient was told to rest in bed for 3 weeks, given ibuprofen extended-release capsules and diclofenac sodium extended-release tablets for analgesia and swelling, and mecobalamin tablets for repair of damaged nerves. On the second day after medication, the patient complained of nausea and discomfort, which was considered to be caused by analgesic drugs, and was advised to observe closely and discontinue the drugs if necessary. On the third day of admission, the patient’s lumbosacral pain was relieved, the movement of the limbs felt good, and the nausea disappeared, so he continued to take analgesic drugs. 1 week later, if the symptoms were relieved, he could be discharged from the hospital for convalescence, and returned to the hospital for review 2 weeks after discharge.
III. Treatment effect
Before the treatment, the patient had obvious pressure pain in the sacrococcygeal area and limited activity. After being admitted to hospital for bed rest and given ibuprofen extended-release capsules, diclofenac sodium extended-release tablets and methylcobalamin tablets for 1 week, the pain symptoms were relieved and discharge was approved for convalescence. The fracture site of sacral vertebra was well aligned, bone scab was formed and the healing progress was good.
IV. Precautions
After the patient’s condition improved, my mood was very happy. Before the patient was discharged, I did not forget to emphasize to the patient that the following points should be noted in life after treatment.
1, because the patient needs to rest in bed for 3 weeks, in order to avoid constipation, the diet should choose foods rich in vitamins and dietary fiber, such as celery, sweet potatoes, lettuce, soybeans, etc., while paying attention to supplemental water.
2.After the patient’s condition improves, exercise should be performed under the guidance of the doctor, and early bedtime activities should be performed in the company of family members to avoid falls and aggravation of the condition.
3.Patients should avoid riding bicycles and sitting for a long time before complete healing.
V. Personal insight
In this case, the patient’s fracture of the sacral spine caused by trauma in a car accident needs to be differentiated from the following diseases in its diagnosis.
1, pathological fracture: pathological fracture patients generally suffer from light violence or no obvious history of trauma, the X-ray film may be accompanied by skeletal pathological aggression manifestations, and this patient does not match.
2. Soft tissue injury combined with physiological skeletal variation: This type of injury may also have local pain and swelling, but the X-ray is usually distinct from a fresh fracture, so it can be excluded.