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).

26. Provisional
Diagnosis- ??

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

36. Incepta
Pharmaceutical,
Dhaka, Bangladesh.