Brief Case Review: 14yoM presenting to an academic center with 2 gunshot wounds to the back, with persistent pain despite escalating pain medication, found to have normal X-rays.

Link to case with answers

Discussion: A large part of the discussion focused on the apparent conflict between exam (seemingly superficial wounds) and normal x-rays and the patient’s report of pain. The in person discussion dovetailed nicely with the posted comments in stating that further investigations (namely imaging) are needed to rule out additional injury. Importantly, premature closure (assuming the patient had a low ‘pain tolerance’) would be inappropriate. The biggest injuries that need to be investigated are a possible expanding hematoma vs bone fracture vs bullet fragment lodged against spine.

The group was split in their choices of imaging, though all agreed that on modality (CT). Some suggested CT ab/pelvis with spine recon, some said CT T/L spine, and others stated that you could specify to radiology which aspects of the spine were needed (rather than doing the whole spine).

Denouement: Given escalating pain, decision was made to obtain CT of the thoracic and lumbar spine, which showed a single spinous transverse process fracture. He was admitted to trauma surgery for further monitoring.