Suspected spinal fracture: recognizing back pain with leg radiation and a back hematoma to prioritize stabilization.

What injury should be suspected in a casualty presenting with lower back pain, pain radiating down their legs, and a hematoma on their back?

• A. Disc herniation
• B. Spinal fracture
• C. Muscle strain
• D. Pelvic fracture

Answer: (B)

In the scenario presented, where a casualty exhibits lower back pain, leg pain radiating from that area, and a hematoma on the back, a spinal fracture should be suspected due to the specific combination of symptoms. The presence of a hematoma suggests potential trauma to the spine, which is a critical indicator that a fracture may have occurred. Lower back pain can often indicate issues related to the spine, and when coupled with radiation of pain down the legs, it is suggestive of nerve involvement, which can happen when there is a fracture that compresses or irritates nearby nerves. In addition, the hematoma indicates localized bleeding, likely resulting from trauma, which often accompanies fractures. While disc herniation and muscle strain can also present with lower back pain and leg pain, they typically do not lead to the presence of a hematoma unless there’s significant trauma. A pelvic fracture could also lead to symptoms that overlap in some respects, but the specific combination of lower back pain with a hematoma is more closely aligned with a spinal fracture, which necessitates appropriate evaluation and management to prevent further injury. Thus, the characteristics provided clearly align with the presentation of a spinal fracture.

Title: When the Back Hurts and a Hematoma Appears: Why Spinal Fracture Should Be Top of Mind

Let’s picture the scene: a casualty complains of lower back pain, the pain radiates down the legs, and there’s a hematoma visible on the back. The question isn’t just academic trivia—it's a real-world signal that changes how you move, assess, and decide on transport. In this scenario, the best answer is spinal fracture. Let me explain why, how you spot it in the field, and what to do next so you don’t miss a critical injury.

What the clues are really telling you

Lower back pain is a common, gnarly symptom in the field. But add radiation down the legs and a hematoma on the back, and the picture shifts. Here’s how the pieces fit together.

• Pain that travels down a leg isn’t just “sciatica” in a casualty who’s been junking around in a rough environment. In a traumatic setting, that radicular sensation can point to nerve irritation or compression caused by a fracture. The spine houses the nerves that run to the legs, and a fracture can press on or irritate those nerve roots.

• A hematoma—visible bleeding into tissue—signals trauma that disrupted vessels. In the context of a back injury, this often accompanies a fracture or other serious spinal trauma. Hematoma isn’t a routine feature of a simple strain, and it rarely accompanies a disc herniation in a way that’s obvious on the back itself.

• Put bluntly, the trio of “back pain,” “leg pain radiating from the back,” and “a back hematoma” tilts the suspicion toward a fracture until proven otherwise.

How this differs from other possibilities

It’s useful to tease apart the common contenders, so you’re not chasing the wrong diagnosis in the heat of the moment.

• Disc herniation: Yes, you can get leg pain from a herniated disc, but you wouldn’t typically expect a hematoma on the back from a simple herniation. In the field, herniation rides on the side of radicular symptoms without the bleeding clue that trauma provides.

• Muscle strain: Strains can hurt in the lower back and sometimes radiate if the body tenses up, but hematomas aren’t a typical feature unless there’s another injury layered in. The key difference is the trauma fingerprint—discrete tissue damage with bleeding—paired with the back pain and leg symptoms.

• Pelvic fracture: Pelvic injuries are a serious, different code. They can cause leg pain and pain referred to the back, and they often come with pelvic instability, groin pain, or blood in the urine. The hematoma pattern on the back is less characteristic of a pelvic fracture as the primary injury, and the neurological pattern tends to be different.

The spine as a vulnerable line

Spinal fractures aren’t just “ouch, I broke a bone.” They can threaten the spinal cord or nerve roots, leading to loss of sensation, weakness, or even bowel and bladder changes if the injury is severe enough. In the field, the risk isn’t just about pain—it's about potential neurological compromise and the need to protect the spine during transport and care. That’s why this combination of symptoms demands careful handling and prompt escalation.

Immediate field assessment: what you do in the moment

In Tactical Combat Casualty Care, you prioritize life threats while keeping the spine as protected as possible. Here’s a practical flow you can rely on.

• Scene safety and initial checks: Ensure the casualty is stable enough for assessment. Control any external bleeding first if present, but don’t rush to move the person more than necessary.

• Primary survey with a spine tilt: Airway, breathing, circulation. If there are no obvious airway or breathing issues, you still treat circulation and protection of the spine as a parallel track.

• Protect the spine from the outset: If you have a cervical collar available, apply it unless it’s contraindicated by other injuries. Use rigid support to minimize movement. In the field, a backboard or a stiff trauma surface is your best friend for maintaining alignment.

• Immobilize with care: The goal is to keep the spine in a neutral position. Use straps to secure the torso, pelvis, and legs, but avoid forcing movement if you’re unsure about alignment. The log-roll technique can help you move a casualty to a firm surface while keeping the spine aligned—only if you’ve been trained to do it.

• Neurological checks, but keep them practical: Ask about numbness, tingling, or weakness in the legs. Look for foot or leg movement when you can safely check. If you notice any new weakness, numbness, or bowel/bladder changes, treat it as a red flag and escalate.

• Pain management that won’t tempt a risky re-movement: The aim is to keep the patient comfortable without compromising neurological status or masking symptoms. Follow your protocols for analgesia, but avoid anything that could cloud your assessment or delay transport.

• Monitor and reassess: Spinal injuries can show evolving symptoms. Reassess every few minutes, especially if the casualty is moving, changing position, or receiving care. Any deterioration? Escalate promptly.

Transport and escalation: getting to definitive care

Time matters when there’s a suspected spinal fracture. The longer the spine is moved or misaligned, the higher the risk of worsening injury. Prioritize rapid transport to a facility with imaging and surgical capability. If you’re working with a multiperson evacuation, coordinate so the spine remains immobilized throughout the move. Communicate clearly about the suspected injury to the receiving team—this speeds up imaging, stabilization, and potentially surgical intervention.

A quick differential check to keep your mind sharp

• A. Disc herniation — possible, but the hematoma on the back is not typical for a straightforward herniation, and the trauma pattern pushes you toward spine fracture.

• B. Spinal fracture — the correct choice given the symptom triad (back pain, radicular leg pain, back hematoma) and the trauma context.

• C. Muscle strain — plausible, but the hematoma and leg radiation from the back tilt away from a simple strain unless there’s a clearly observed muscle rupture in a dramatic wounding scenario.

• D. Pelvic fracture — a serious injury in its own right; consider it if pelvic instability or groin pain is present, but the back hematoma points you toward a spinal injury as the priority in this specific symptom cluster.

Why this matters in real life

Here’s the thing: it’s easy to underestimate back injuries in the field when adrenaline is high and the casualty is frightened or in pain. But a spinal fracture isn’t a “just-take-it-easy” injury. Improper handling can convert what might have been a manageable fracture into something that leaves the casualty with paralysis or long-term impairment. That’s why the emphasis on immobilization, careful movement, and rapid transport is baked into TCCC principles. The aim isn’t just to ease pain; it’s to prevent further harm.

Practical takeaways you can use

• Trust the pattern: A back hematoma with lower back pain and leg radiation in a trauma setting is a red flag for spinal injury. Treat it as such until proven otherwise.

• Immobilize early and well: A collar, a board, and secure strapping aren’t optional extras. They’re the backbone of preventing secondary injury.

• Keep movement to a minimum: Each movement can shift the spine. If you don’t have to move the casualty, don’t. If you do, move as a team with clear roles and a plan.

• Watch for neurological changes: New or worsening numbness, tingling, weakness, or changes in bladder or bowel function demand immediate escalation and documentation.

• Communicate with care: Tell the receiving team exactly what you found, what you did, and what you’re worried about. A clear handoff speeds imaging and definitive treatment.

A moment to reflect

Some might wonder, “Could a hematoma come from a less serious cause?” It can, but in this scenario with back pain plus radicular leg symptoms after trauma, the safer assumption is spinal fracture. It’s better to over-prepare than to miss a potentially devastating outcome. The goal is to stabilize, protect, and transport—now more than ever, precision matters.

Final takeaway: the correct answer, in plain terms

In a casualty presenting with lower back pain, pain radiating down the legs, and a hematoma on the back, spinal fracture is the most consistent and dangerous injury to suspect. The combination isn’t typical of simple muscle strain or disc herniation, and while pelvic fractures are serious, the back hematoma plus spine-focused symptoms raise the priority level for spinal injury. In the field, that means immobilize early, protect the spine, monitor neurologic status, and move fast to definitive care.

If you’re weaving these scenarios into your training, remember that clarity and control are your best tools. The human body doesn’t heal better when we rush or guess. In these moments, a steady plan—immobilize, assess, and evacuate—keeps the door open for the best possible outcome. And that, more than anything, is what trained responders strive for: a clear path from field to facility with the spine protected every step of the way.