SPINAL TRAUMA/ INJURY: CASE PRESENTATION- WEAKNESS OF LIMBS FOLLOWING RTA .
Download as PPT, PDF21 likes10,518 views
The document describes the medical history and examination of a 40-year-old male patient. He was in a motor vehicle accident 2 months ago which resulted in a cervical spine injury at C4-C5 and fractures to his left tibia and fibula. On examination, he had generalized muscle wasting, weakness, and diminished sensory and motor function in his limbs. MRI findings confirmed a cervical spine injury at C4-C5 with disc protrusions and spinal stenosis. The provisional diagnosis was an incomplete cervical spine injury at C4-C5 (central cord syndrome) with fractures of the left tibia and fibula. His treatment plan involved cervical collar, catheterization, physiotherapy, and plaster immobilization of the
SPINAL TRAUMA/ INJURY: CASE PRESENTATION- WEAKNESS OF LIMBS FOLLOWING RTA .
- 3. Prepared By- Dr. Md Nazrul Islam MBBS, M . sc. (B M E).
- 9. HISTORY :
- 10. Appearance : Ill looking Body built : Average. Patient is concious, co-operative and well orientated. Decubitus: Sitting & Lying Anaemia : Absent Jaundice : Absent Cyanosis ; Absent Odema : Absent. Pulse : 85 b/m. Blood pressure : 130/70 mm Hg.
- 11. Respiratory rate : 16 per min. Temp : Normal. Koilonychia : Absent. Leukonychia : Absent Neck gland : Not palpable. Lymph node : Not palpable. J.V.P : Not raised . Thyroid gland : Not palpable. Skin pigmentation : Absent.
- 12. EXAMINATION OF THE NECK: Inspection : There is no swelling or deformity . Palpation : Tenderness present over cervical spine. Local temperature normal. There is no enlarged lymph node & thyroid gland. Movement : (movement of the Cervical Spine ) Flexion – painful & restricted Extension – painful & restricted Lat flexion – painful & restricted Rotation – painful & restricted.
- 13. COMOTOR SYSTEM : Gait : Patient cannot walk & stand. Inspection : There is a swelling & deformity in the anteromedal aspect of the left leg. Muscle wasting present in the lower limbs. Feel : Localized temperature slightly raised in the middle part of left leg. There is tenderness miled deep tenderness present in the left middle part of the left leg. All pheripheral pulses are normal. Measurement : Left lower limb is shorten by I & ½ cm. (Tibil component) Movement : All joint movement of both upper and lower limb Active movement – weak. Passive movement – Normal Patient cannot walk on left leg.
- 14. LOOK Swelling and deformity over the middle part of the left leg. Tenderness present. Abnormal mobility in deformed area. Skin condition over the deformed area is normal. No discharging sinus. No vascular deficiency. FEEL Tenderness present. Temperature slightly raised. Peripheral pulses intact.
- 15. Examination of the left lower limb: MOVEMENT Left knee – joint movement can not be elicited due to painful condition. Ankle joint- Planter flexion --- weak in active & normal in passive movement. Dorsi flexion --- weak in active & normal in passive movement. Hip Joint- Extension and Flexion Normal in passive week in active movement. Adduction --- normal Adduction --- normal
- 16. Systemic Examination : Higher psychic function --- normal All cranial function --- normal Motor function Generalized muscles wasting of both upper and lower limbs. Palpation – Bulk of muscle – wasted tone of the muscle – Increased Perianal Sensation – normal Anal tone – present. Cremasteric reflex – present.
- 17. Systemic Examination : Regarding muscle power Upper limb – Shoulder (left &Rt) – Flexion – 4 Extention – 5 Abduction - 5 Adduction - 5 ELBOW (left &Rt) – Flexion -5 Extention -4 WRIST (left & Rt.) – Flexion – 4 Extention – 4 Hand (left &Rt) Grip -Weak 4 Finger adduction & Abduction- 4
- 18. Systemic Examination : Sensory and Motor: Sensory function of upper limbs– Deminished. Jerks of upper limbs Biceps Jerks - exaggerated Tricep Jerks - Exaggerated Brachioradialis Jerks - exagerated Hoffmann’s sign test - Positive. Jerks of Lower Limbs – Knee Jerk - Exaggerated Ankle Jerk - Exgcerated Babushkas Sign - Positive.
- 19. Systemic Examination : Muscle power – (Rt & Lt- Lower limb) Hip – Flexion - 5 Extention – 5 Abduction – 5 Adduction – 5 Knee (Rt) - Flexion – 5 (Muscle power of the left knee can not be elected due to deformity. & swelling of left leg) Extention - 5 Ankle (Rt & Lt) - Planter Flexion – 5 Dorsiflexion – 5 Toe extensor and toe flexor (Rt. & Lt.) - 4+ Sensory funtionof lower limbs- diminished.
- 20. Systemic Examination : Alimentary System Inspection – No abnormality detected Palpation – not tneder Auscultation – Bowel sound present P/R – Anal tone – present. Respiratory System Inspection – Normal in size and shape of the cheast. Resp. rate – 16/mint. Palpation – Tachea – Centrally placed Normal cheast expansibility. Percussion – Resonance Auscultation – Bronchial breath sound with no added souund.
- 21. Systemic Examination : Cardio-Vascular System Pulse – 84/mint. B.P – 120/70 m. m of Hg J.V.P – Not raised Inspection – N.A.D Palpation – Apex beat at the 5th intercostal space. Percussion – Superficial cardiac dullness present over precordiuam Auscultantion- S1 and S2 audible. Genito – urinary systim The patient unable to pass urine normally and the patient is in Cathder.
- 22. Salient Features: Md. Kanu, Aged – 40yrs. Coming from adaber–10, Mohammadpur, Dhaka, admitted on 08.08.11 in S.S.M.C.H with the complains of - Weakness of the both Upper and lower limb and enability to move. Difficulty inn passes of urine and stool. Fracture of the left leg following RTA – 2 weeks back. At this stage he was unable to stand and walk. His upper limbs were so weak that he can not grip anything. He is on Catheter as he could not pass urine. His Facial injury at the chin was healed up. There is a swelling and deformity at the middle of lower leg which is immobilized with bamboo – sticks by kobiraj.
- 23. Salient Features: He had a RTA 2 months back and with fracture of the left leg bones which was Maltreated by Kabiraz. He had no history of loss of conciounoss, weight loss, anorexia & fever. On General examination the patient is ill looking non-diabatic, non-icteric normotensive, conscious, co-operative and well orientated. On Local Examination- Face: Scar mark over the left side of race near chin. Neck movement – Restricted and painful.
- 24. Salient Features: Active movement of the joint of the limbs are weak. There is Generalized muscle wasting and weakness of the Limbs. Sensory and Motor function of the limbs–Dimished. (M.R.C grade– 2). All Jerks are (The Jerks of the upper and lower limb) exaggerated Tone of the muscle – Increased Perianal sensation – Intact Anal tone – Intact.
- 25. Salient Features: Patient is on catheter. There is an diffuse swelling over the middle third of the left leg which is tender and abnormal mobility present. Peripheral Vascular status – Normal. Other systemic examination reveal no abnormality (Except Nervous, urinary & loco-motor system).
- 27. Provisional Diagnosis- Incomplete Cervical Spinal injury (At C4/C5) (Central cord Syndrome) with fracture Left tibia & fibula. fibula
- 28. Differential Diagnosis - • Anterior cord syndrome • Brown – Sequard Syndrome.
- 29. Investigations: E.C.G – within normal limit Blood – C.B.C (3.7.11) Hb – 10.5gm% E.S.R – 25mm in fast hour N – 64% L – 30% M – 02% E – 04% R.B.S – 6.8 mmol/L (28.7.11) Blood urea – 34mg/dl Blood Creatinine – 0.90mg/dl S. Electrolytes – (28.7.11) Na – 135mmol/L K – 3.8 mmol/L Cl – 100 mmol/L
- 30. Investigations: X-ray cheast – N.A.D X-ray Cervical Spine – Lose of lordosis C4/C5 – post. Listhesis (Grade -1) Degenerative change – in all Cervical Spine X-ray left leg – Comminuted fracture of the middle of the shaft of the left tibia and oblique fracture of the proximal fibula.
- 31. Investigations: MRI- M.R.I Cervical Spine - Degenerative disc & spine disease. Focal myelitis at C4 – C5 – level. C2 – C3, C3 – C4, c5 – C6, C6 – C7: Disc bulging with corresponding thecal sac indentation. C4 – C5: Central and both para- central disc protrusion with corresponding spinal canal stenosis & foraminal narrowing.
- 32. Confirmatory diagnosis- . Incomplete Cervical Spine injury at C4 –C5 level,with Quadriparesis (Central cord syndrome) and Closed comminuted fracture of left tibia and fibula.
- 33. For Spinal( Cervical) injury - conservative by Semi-rigid Cervical Collar. For retention – Catheterization and bladder exercise. physiotherapy (Active and passive exercise of the limbs) For Fracture tibia fibula – Close reduction and plaster immobilization in the form of long leg full plaster.
- 34. Final follow up – After 2 month. Gait – Patient can stand and walk with support. Muscle power (MRC Scale) – 4 Active movement of the4 joints of the limb – Almost Normal. Griping power of the hand increased so that he can eat himself. Bulk of the muscale – improved Jerks are still – exagrated Clonus – Absent For fracture tibia –fracture is uniting. But the patient is still unable to pass urine without catheter, but can pass stool voluntarily. 34