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AAOS Now

Published 7/1/2020
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Terry Stanton

What About Whiplash?

Upcoming course will cover diagnosis, treatment, and medicolegal considerations

The “whiplash” scenario may have presented itself to you as an orthopaedic surgeon: You cared for a patient with neck pain after a motor vehicle crash, and then were called to give a deposition during which lawyers implied that despite your training in biomechanics during residency, you were not “expert enough” to testify about whether the patient’s clinical presentation made medical sense given the facts of the crash.

A half-day virtual course scheduled for Nov. 5 offers orthopaedic surgeons the opportunity to advance their understanding of whiplash so they may treat patients with this injury confidently and speak with authority about it when called on to do so in a legal setting.

The session, which will precede the annual two-day Workers Compensation course—to be presented virtually in accommodation to the COVID-19 pandemic—will feature lectures and panel discussions on whiplash and associated disorders, covering topics such as how to assess impact severity and occupant kinematics and to conduct injury analysis, and report writing. Presentations by biomechanical engineers and orthopaedic surgeons will cover current best practices for establishing a diagnosis, determining treatment, developing a causation determination, and completing the report.

“We explain the science and how you apply the physics to the individual, and then take that information and write a report and render an opinion within a reasonable degree of medical probability that you may then testify to in court,” said course director J. Mark Melhorn, MD, FAAOS, an associate clinical professor at the University of Kansas School of Medicine–Wichita.

“We explain, through examples, how to make appropriate decisions. We help those who are new to the process become more comfortable with seeing these patients so there is less anxiety and more interest in being involved. Once you break down the process, it’s not as intimidating as it may seem if you don’t routinely engage in it,” he added.

Universal concept

The term whiplash, Dr. Melhorn explained, is a descriptive label for neck pain that may occur after a motor vehicle collision (MVC)—typically a rear-end collision—in which the head is reported to have been bent forward and then “snapped” back quickly. Whiplash is a “universal concept” that has been defined by many governmental and healthcare organizations, including AAOS, Australia Government, European Union, Quebec Task Force in Canada, and the United Kingdom Health Service.

“The important thing to understand is that whiplash is actually a descriptive label and not a specific pathoanatomic diagnosis,” Dr. Melhorn said. These possible soft-tissue “injuries” with associated pain are more difficult to diagnose and treat for most orthopaedists compared to an individual with identifiable pathology, such as a vertebral fracture where there is an obvious reason for the neck pain and a clearly indicated intervention.

Some orthopaedic surgeons, he said, are less than eager to treat patients with neck pain with no demonstrable condition after an MVC. But others, he said, “are interested in knowing about the science—how do you actually assess the presentation and determine if the MVC—the physics involved, the force involved—was sufficient to have caused a structural change to support the reason why the person still has that pain.”

Multiple factors are required, Dr. Melhorn said. “You need an appropriate history and physical examination. The clinician should have a good understanding of the biomedical, biomechanical, and physics issues that would be involved.” The primary factor is the force of the collision, which is correlated to delta V, the change in velocity of the target vehicle that occurs when the “bullet” vehicle strikes the “target” vehicle. This change happens in milliseconds.

The clinician needs to assess the mechanism of injury, the onset of the symptoms, the clinically consistent pattern of the symptoms and their appropriate response to treatment, and any supporting clinical studies such as radiographs and MRI that would support the signs and symptoms.

“If a patient says, ‘My neck hurts, I was involved in a car crash. I have whiplash,’ you may find they have a cervical strain or sprain, which is a true diagnosis,” Dr. Melhorn explained. “They could have a herniated disk or a vertebral body fracture that causes their neck pain and is linked to this whiplash injury. Or they may have no obvious objective clinical findings, clinical studies, or physical findings, but they say, ‘My neck hurts, and my neck did not hurt before I had this collision. And therefore, the other driver who caused this collision is responsible for my neck pain.’” Understanding the factors involved in whiplash “allows you to render an opinion that there is no objective, scientific basis for why this individual is having subjective pain complaints.”

Making the grade

A grading system does exist for whiplash. In 1995, the Quebec Task Force on Whiplash-associated Disorders published a paper proposing a five-level scale:

  • Grade 0: No complaints about the neck. No physical sign(s).
  • Grade I: Neck complaint of pain, stiffness or tenderness only. No physical sign(s).
  • Grade II: Neck complaint and musculoskeletal sign(s). Musculoskeletal signs include decreased range of motion and point tenderness.
  • Grade III: Neck complaint and neurological sign(s). Neurological signs include decreased or absent deep tendon reflexes, weakness, and sensory deficits.
  • Grade IV: Neck complaint and fracture or dislocation.
J. Mark Melhorn, MD, FAAOS

Otherwise, the literature does not provide much conclusive guidance on whiplash. One oft-cited study by Schrader et al., appearing in The Lancet in 1996, explored the association of patient-reported whiplash and expectation of compensation and found “a remarkable absence of whiplash syndrome” in countries without such financial expectation.

The authors of that study concluded: “Our results suggest that chronic symptoms were not usually caused by the car accident. Expectation of disability, a family history, and attribution of preexisting symptoms to the trauma may be more important determinants for the evolution of the late whiplash syndrome.”

Studies on the effect of headrests and airbags on the incidence of whiplash show no overall observed decrease, Dr. Melhorn said, although research does suggest that headrests have reduced the incidence of brain injuries for adults.

“Some conflicting information says airbags may increase brain injuries in children, because airbags are for large males,” Dr. Melhorn said. The injury may occur because the child is inappropriately seated.

Newer emergency department neck screening protocols have had a benefit in reducing some specific neck injuries, but “for whiplash itself, probably not,” Dr. Melhorn said. “The protocols do seem to be helping with fractures, but not with nonspecific complaint of pain.”

Dr. Melhorn noted that some orthopaedists are content to avoid whiplash cases and resultant interaction with the legal system, but involvement may be inevitable. “For some, it’s easier to say, ‘I’m not interested,’ and not develop that as part of their practice, but if you are a general orthopaedist in a smaller community, you will be pulled into that system whether you want to be or not,” he said. “You will see someone who originally has no attorney. Then at some point you will hear from an attorney who represents the individual or the insurance company or from both, and they need you to come to court. Even if you don’t want to be involved, you may still be sucked into the process.”

Of those who attend the whiplash course, Dr. Melhorn estimates that a third are repeat attendees. Another third are physicians thinking about transitioning from a surgical to nonsurgical practice. Roughly a sixth of participants are new and young individuals whose practice partners may have encouraged them to take the course, and another sixth are “regular orthopaedists” who want insight into whiplash and associated litigation. He said physicians and other healthcare providers attend the course.

Dr. Melhorn said that many of the topics covered in the half-day course are not taught in traditional surgeon training programs. Previous attendees have shared in their evaluations that this should be taught in residency and that their lives would be easier if they had taken it early in their careers, he said.

Terry Stanton is the senior medical writer for AAOS Now. He can be reached at tstanton@aaos.org.

References

  1. Schrader H, Obelieniene D, Bovim G, et al: Natural evolution of late whiplash syndrome outside the medicolegal context. Lancet 1996;347:1207-11.

Sign up now for November courses

The 22nd Annual AAOS Workers’ Compensation and Musculoskeletal Injuries Course will be offered as a virtual event, taking place Nov. 6–7. Featuring prerecorded content packaged with live-streamed lectures, this online course will provide fresh perspectives on causation, diagnosis, treatment options, and strategies  for handling medical and nonmedical issues associated with treating workers’ compensation patients.

Preceding the course on Nov. 5 will be the half-day course AAOS Whiplash Injury and Other Reported Injuries: The Science of Accident Reconstruction and Impact/Vehicular Biomechanics, also delivered online. This course will help attendees establish a diagnosis, formulate a treatment plan, determine causation, and write reports for whiplash-associated disorders.

Register for both courses and save $150 on combined fees. Both courses offer continuing medical education credit. For more information, visit www.aaos.org/3056A.