Case: Steel Worker
A Case of the Injured Steel Worker
Case: A 45-year-old white male steel worker presented to the Urgent Care Clinic three days after an accident at work. He received a crush injury from a bucket at the end of a boom, which continued to move forward—eventually pinning him between a steel beam and the side of the bucket. An observer below saw the accident, stopped the boom and brought him to ground level. He was unconscious at the time. Bystanders called 911 and the patient aroused spontaneously within a few minutes.
Emergency department (ED) evaluation with CT of the head, neck, chest, and abdomen noted. A series of four right lateral spinous process fractures from T10 to L1 and two right rib fractures #9 and #10. The remainder of the studies were reported as normal. CBC and metabolic profile were normal and a 12-panel drug screen was negative.
Physical examination: Patient ambulated into the clinic alert and oriented x3. He complained of much back pain, as well as difficulties breathing and moving. Records from the ED were obtained and reviewed. Chest X-ray noted consolidation at right base, believed to be a small pulmonary contusion. O2 saturation was 98%. The patient was advised of the findings and was given prescriptions for an antibiotic and pain medication. Pulmonary toilet discussed and cigarette cessation was encouraged.
A few weeks following the initiation of physical therapy, he continued to complain of right back pain and upper left chest pain. A follow-up chest X-ray revealed a displaced left 4th rib fracture not noted on prior studies. Patient was very motivated to get well. Pain management was ongoing with Oxycontin twice daily, low dose oxycodone for breakthrough pain and Valium for sleep.
Eight weeks later, the patient complained of difficulty with both physical therapy and his work-hardening program. He still required an opiate at least once daily for pain control. He did not feel strong, was somewhat depressed, and was having a recurrence of right back muscle spasms.
How would you proceed?
Thomas A. Malone, MD
Published on August 2, 2011
Updated on August 9, 2011
Discussion
Because long-term opiate therapy can suppress testosterone, a serum total testosterone was drawn and noted to be low at 221. Following hormone replacement therapy with testosterone gel, the patient reported improvement in his rate of recovery and his overall well-being.
Plan: Testosterone will be tapered slowly over a month once recovery is completed, opiate pain management ends, and the patient is back to work. He is expected to return to a eugonadal state once he is no longer taking narcotics for pain.
re-ct him
MRI