SPINAL-TRAUMA-INJURY-CASE-PRESENTATION-WEAKNESS-OF-LIMBS-FOLLOWING-RTA-At-Shaheed-Suhrawardy-Medical-College-Hospital-Dhaka-Bangladesh.pptx

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SPINAL-TRAUMA-INJURY-CASE-PRESENTATION-WEAKNESS-OF-LIMBS-FOLLOWING-RTA-At-Shaheed-Suhrawardy-Medical-College-Hospital-Dhaka-Bangladesh.pptx Powered By Docstoc
					From -
Prepared By-
Dr. Md Nazrul Islam
MBBS, M . sc. (B M E).
   According to the statement of the patient, he had been a
    victim of RTA and severely injured over multiple sites
    particularly in the left side of face and left leg .
   But he was conscious after that injury and he noticed
    that he was unable to move his limbs. With this
    condition he was taken to D.M.C.H where his soft
    tissue injuries in his face were managed by surgical
    toileting and stitches. The patient was then advised to
    continue this treatment at home .
   Patient gave another history of R.T.A about 5
    months back followed by multiple injuries to
    the different parts of the body with fracture of
    the left tibia where he was managed
    immediately in Madaripur hospital.
   According to him he had a fracture at his left
    tibia which was ultimately maltreated by
    Kabiraj.
HISTORY :
   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.
   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
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
         Gait : Patient cannot walk & stand.
             Inspection : There is a swelling & deformity in the
LOCOMOTOR SYSTEM :
             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.
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.
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
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.
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
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
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.
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.
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 5 th 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.
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.
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.
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.
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).
Provisional
Diagnosis- ??
Provisional Diagnosis-

Incomplete Cervical Spinal
     injury (At C4/C5)
         (Central cord
         Syndrome)
    with fracture Left tibia
          & fibula .
   Differential
   Diagnosis -

Anterior cord syndrome
 Brown – Sequard Syndrome
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
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.
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.
.

    Confirmatory diagnosis-
    Incomplete Cervical Spine injury
    at C4 –C5 level,
    with
    Quadriparesis (Central cord
     syndrome)
    and
    Closed comminuted fracture of left
     tibia and fibula.
  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.
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.

				
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Description: SPINAL-TRAUMA-INJURY- CASE-PRESENTATION-WEAKNESS-OF-LIMBS-FOLLOWING-RTA-At-Shaheed-Suhrawardy-Medical-College-Hospital-Dhaka-Bangladesh.pptx