I felt a ball‑shaped lump in my lower back after a fall—should I seek urgent evaluation and what management is recommended?

Urgent Evaluation for a Palpable Lump in the Lower Back After a Fall

You should seek urgent medical evaluation immediately—a palpable "ball-shaped" lump in the lower back following trauma raises concern for hematoma, soft tissue injury, or occult fracture that requires prompt assessment. 1, 2

Why Immediate Evaluation Is Critical

A new palpable mass after fall-related trauma is not a typical finding in simple mechanical back pain and warrants investigation for:

• Hematoma formation from soft tissue or muscle injury that may expand or indicate deeper structural damage 1
• Occult vertebral fracture with associated soft tissue swelling, which plain radiographs may miss in up to 20-30% of cases 3
• Paraspinal muscle injury or herniation through fascial defects 2
• Underlying bone pathology (though less likely in acute trauma without pre-existing risk factors) 4

The presence of a palpable abnormality after trauma constitutes a "red flag" that moves this beyond simple mechanical back pain. 5, 6

Immediate Assessment Required

History Elements to Document

• Exact mechanism of fall: height fallen from, surface landed on, and body position on impact 4, 1
• Time spent on the ground after the fall, as prolonged downtime indicates severity 1
• Timing of lump appearance: immediate versus delayed onset 1
• Associated symptoms: loss of consciousness, neurological changes, bowel/bladder dysfunction, or saddle anesthesia 5, 6
• Pain characteristics: constant pain, night pain, or radicular symptoms lasting >4 weeks are concerning 4, 6

Physical Examination Priorities

A complete head-to-toe examination is mandatory—failure to perform this can miss occult injuries including fractures and internal bleeding. 1, 2

Specific findings to assess:

• Characteristics of the palpable mass: size, consistency, mobility, tenderness, and whether it is fluctuant (suggesting fluid collection) or firm (suggesting hematoma or bony abnormality) 1
• Neurological examination: motor strength, sensory deficits, reflexes, and signs of spinal cord compression 4, 2
• Spinal palpation: point tenderness over spinous processes suggests fracture 2, 6
• Gait assessment and "Get Up and Go" test: inability to ambulate safely requires admission 1

Imaging Strategy

Initial Imaging

Plain radiographs (AP and lateral views) of the affected spinal region are the appropriate first step for most patients, as they are readily available and can identify vertebral alignment abnormalities, fractures, and primary bone lesions. 4, 2

However, radiographs have limited sensitivity for acute fractures and cannot visualize soft tissue masses or hematomas. 4, 3

When to Proceed Directly to Advanced Imaging

CT without contrast should be obtained if:

• High-energy trauma mechanism (fall from height) 2
• Strong clinical suspicion for fracture despite normal radiographs 2, 3
• Elderly patient or those with osteoporosis risk 2
• Palpable mass suggests significant soft tissue injury requiring surgical evaluation 2

MRI without contrast is indicated if:

• Neurological deficits are present (motor weakness, sensory loss, reflex changes) 2
• Suspected spinal cord injury or nerve root compression 2
• Concern for epidural hematoma causing mass effect 2
• Radiographs and CT are negative but clinical suspicion remains high 4, 2

Critical Caveat

A case report documents a 29-year-old with normal radiographs after a fall who was found on CT to have multilevel compression fractures with bone fragment retropulsion—this underscores that radiographs alone may be insufficient when clinical findings are concerning. 3

Laboratory Testing

Maintain a low threshold for:

• Complete blood count: to assess for anemia from occult bleeding 1
• Coagulation studies: if patient is anticoagulated or has bleeding risk 1

Red Flags Requiring Immediate Specialist Referral

Any of the following mandate urgent imaging and specialist consultation:

• Progressive motor or sensory deficits 5, 6
• New-onset bowel or bladder incontinence, urinary retention, or saddle anesthesia (cauda equina syndrome) 2, 5, 6
• Loss of anal sphincter tone 5
• Expanding or pulsatile mass (concern for vascular injury) 1
• Severe uncontrolled pain despite initial management 1

Management Approach

If Imaging Reveals Fracture or Significant Hematoma

• Spine surgery consultation for unstable fractures or neurological compromise 2
• Observation for expanding hematoma with serial examinations 1
• Pain management with acetaminophen or NSAIDs as first-line agents 5, 7
• Avoid bed rest—encourage activity as tolerated unless fracture requires immobilization 5, 7

If Imaging Is Negative

• Conservative management with activity modification, NSAIDs, and reassurance 5, 7
• Close follow-up within 1-2 weeks to reassess the palpable finding 1
• Re-imaging if symptoms worsen or the mass enlarges 2

Common Pitfalls to Avoid

• Discharging a patient with a palpable post-traumatic mass without imaging risks missing fractures or significant soft tissue injury 1, 2, 3
• Relying solely on plain radiographs when clinical suspicion is high—CT or MRI may be necessary 2, 3
• Failing to perform a complete neurological examination can miss early signs of spinal cord or nerve root compression 1, 2
• Attributing the finding to "just a bruise" without documentation of mass characteristics and follow-up plan 1

Disposition Decision

Admission is warranted if:

• Patient cannot ambulate safely or fails the "Get Up and Go" test 1
• Neurological deficits are present 2
• Uncontrolled pain despite initial management 1
• Concern for expanding hematoma requiring monitoring 1

Discharge is appropriate only if:

• Imaging excludes fracture and significant hematoma 2
• Neurological examination is normal 1, 2
• Patient can ambulate safely 1
• Reliable follow-up within 1-2 weeks is arranged 1