Weakness of limbs following RTA

Prepared ByDr. Md Nazrul Islam MBBS, M . sc. (B M E).

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.

LOCOMOTOR 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 & 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 JointExtension 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 Hoffmanns 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 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.

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 ExaminationFace: 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 limbsDimished. (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 DiagnosisIncomplete 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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Incepta Pharmaceutical, Dhaka, Bangladesh.