What is a Distracting Injury?

This is probably one of those posts where I point out that I am not your medical director, I don’t sign your paycheck, and I have nothing to do with whether you continue your employment or not.  So use your own best judgment and do what you think is right.  With that being said…

You are sent to the riverside bike path on the report of a bicycle crash.  Of course, it is like any call on a path away from road signs – it takes forever for the caller to figure out enough landmarks for you to find the call.  In any case, after your irritatingly long response time, you arrive to find a 50-year old male who was spending his morning riding several thousand dollars of carbon fiber.  For whatever reason, he was forced to swerve at speed off of the concrete path.  Off the path, he struck a bench and was thrown forward off of the suddenly stopped bicycle.

You find him awake and alert, but in obvious distress.  He is cradling his right arm and complaining of severe right shoulder pain.  Making a long story short (because you don’t want to spend all day reading this), he has a demolished right shoulder – probably a fractured clavicle, maybe dislocated, and maybe humeral or scapular fractures.  It is all a tender, swollen, discolored, and abraded mess.  His distal sensation and circulation are intact, but the shoulder is just wrong.  Interestingly, his helmet is rather abraded and cracked, as well.  The patient denies loss of consciousness, and additionally denies neck pain or tenderness. 

Do you immobilize him?

The spinal immobilization criteria in my system are pretty similar to the NEXUS criteria.  We don’t need to immobilize if there is no focal neuro deficit, no midline spinal tenderness, no altered consciousness or intoxication, and no distracting injury.  He has no neuro deficits, no spinal tenderness (or pain), and is not altered or intoxicated.  Does he have a distracting injury?

The NEXUS literature defines a distracting injury as “a condition thought by the clinician to be producing pain sufficient to distract the patient from a second (neck) injury.”¹  The Canadian C-spine rule describes distracting injuries as “injuries […] that are so severely painful that the neck examination is unreliable.”²  Common examples include long bone fractures, visceral injuries requiring surgical consultation, large lacerations, degloving injuries, crush injuries, large burns, and injuries producing acute functional impairment (whatever that is).  Okay, we got it – stuff that hurts.  Heffernan added any painful chest injury³ and Konstantinidis showed that the 4% of patients with painless neck fracture all had rib fractures and/or severe chest tenderness.  So add chest injury to the description of distracting injuries, I guess. 

Everything in this video would result in a distracting injury to me...

All of the listed injuries above vaguely irritate me.  The authors made a good faith attempt to objectively describe injuries that are likely to distract a patient.  And I think that they failed.  They failed because the task is impossible.  I get that a femur fracture (long bone fracture criteria) is probably a distractor.  But what about a distal tibia fracture?  I drove myself to the ED four hours after fracturing my distal tibia – I wasn’t distracted.  How severe does a burn have to be?  How much degloving do you need?  What is "severe chest tenderness"?  Are pelvic fractures (not being long bones) never distractors?  What the hell constitutes a “large” laceration?  Speaking of hell, what the hell is acute functional impairment – an injury that the patient doesn’t want to move?!?  

If you ask me, “any testicular injury” should be on the list of distractors.

Jackie, I thought you were better than that...

Everything is still subjective.  Sorry, but you still have to make a decision.  Is the patient distracted by his/her other injuries?  Answer the question.  A distracting injury is something so painful that the patient can't pay attention to other injuries.  They feel nothing but the distractor.  It has 100% of their attention.  So how do we decide where that line is?

I have an idea.  This is something that I have done for years.  It is not supported by literature, but see if it makes sense to you.

Check if the patient is distracted. 

Do this in blunt trauma, because who still immobilizes penetrating trauma?  So what you want to do is pinch one of the patient’s fingers without them being able to see the finger.  They have to feel the pinch.  Cover their hand with a blanket, cover their eyes, whatever makes sense to hide their fingers.  Squeeze a finger, about as hard as you do when you check capillary refill and hold it.  Ask the patient which finger you are squeezing.

If they get the answer correct, especially if you repeat the test with lighter and lighter touch, they can separate the pain from their other injury from their other neurologic inputs.  They are also likely to be able to recognize midline cervical tenderness when asked.  They are demonstrably not distracted.  Thus, if they can identify which finger your are touching, they probably don’t have a distracting injury. 

What do you think?  Does this make sense to you? 

The patient described in the beginning of this post passed the squeeze test.  He could even identify which finger was being lightly scratched with a fingernail.  I decided that even in the face of a destroyed shoulder and cracked helmet, I felt like I could trust his denial of spinal tenderness. We had a talk about immobilizing him, paralysis, and distracting injuries while I was starting an IV.  He agreed that immobilization was unnecessary.  So I didn’t immobilize him.  There are other patients who are in such pain that they can’t even pay attention to the fact that you are trying to test them, however.  Those patients have distracting injuries and get immobilized in my bus. 

If you are concerned that a distracting injury is present, check if the patient is distracted. 

1. Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI. Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt trauma. NEJM 2000;343:94-99.

2. Stiell IG, Wells GA, Vandemheen KL, Clement CM, et al. The Canadian C-spine rule for radiography in alert and stable trauma patients. JAMA 2001;286:1841-1848.

3. Heffernan DS, Schermer CR, Lu SW. What defines a distracting injury in cervical spine assessment? J Trauma 2005; 59: 1396-1399.