Case presentation: WEAKNESS OF LIMBS FOLLOWING RTA –

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Case presentation: WEAKNESS OF LIMBS FOLLOWING RTA –

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FROM- DEPARTMENT OF ORTHOPAEDIC AND TRAUMATOLOGY. DATED: 20 TH OCTOBER/2011. VENUE: HOSPITAL CONFERENCE ROOM, SHAHEED SUHRAWARDY MEDICAL COLLEGE HOSPITAL. WEAKNESS OF LIMBS FOLLOWING RTA – WEEkLY CASE PRESENTATION -

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Prepared By- Dr. Md. Nazrul Islam-MBBS, M.sc . (Biomedical Eng.). Supervised By- Associate Prof. Dr. Paritosh Chandra Debenath - MBBS, MS (Ortho). Head of the Department. & Associate Prof. Dr. Sheikh AbbasUddin Ahmed- MBBS, MS (Ortho), AO ( Basic & Spine ). FROM- Department of Orthopedics‘ & Traumatology , Shaheed Suhrawardy Medical College Hospital, Dhaka -1207, Bangladesh.

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DEPARTMENT OF ORTHOPAEDIC AND TRAUMATOLOGY. Dr.Md.Aminul Islam MBBS, D.Ortho. Assistant Registrar. Presenting By-

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Name : Mr. Kanu Age : 40 yrs Sex : Male Address : Adabar-10,Mohammadpur,Dhaka Occupation : Day Labourer Marital status : Married Religion : Islam Date of admission : 08.08.2011 Date of examination :08.08.2011 Particulars of the patient

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1. Weakness of the both upper & lower limbs – two weeks following RTA 2. Difficulty in passing urine & stool – two weeks 3. Painful swelling And deformity at left leg –two weeks Chief complaints :

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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 . History of present illness -

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History of present illness - In the next day – The patient was unable to pass urine , for this reason he attend the NITOR where he was releived by catheterization and was advised to continue the ongoing treatment. For his pain & swelling ( Fracture) of his left leg – he was maltreated with bamboo sticks by Kabiraj . There is no history of Genito -urinary & abdominal injury. But his weakness of limb and difficulty in defeacation was not improving and he could not walk or stand even with support. Now with this complaints he got himself admitted in Sh.S.M.C.H in medicine unit, where he was treated conservatively. Then he was transferred to Orthopedic Dept. for proper management leg bone fracture. .

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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 of past illness -

Family history : Nothing contributory. Personal history : nothing contributory. Socio-economic condition: Lower middle class. Immunization : He was immunized against tetanus and tuberculosis. Drug history : He has taken analgesic and antibiotic previously but there was no history of hypersensitivity to any drugs. :

Family history : Nothing contributory. Personal history : nothing contributory. Socio-economic condition: Lower middle class. Immunization : He was immunized against tetanus and tuberculosis. Drug history : He has taken analgesic and antibiotic previously but there was no history of hypersensitivity to any drugs. HISTORY :

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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. General examination :

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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 General examination :

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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 Local examination EXAMINATION OF THE NECK:

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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. LOCOMOTOR SYSTEM : Local examination

Examination of the left lower limb::

Examination of the left lower limb: 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. Local examination

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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 Local examination MOVEMENT Examination of the left lower limb:

Nervous System :

Nervous System 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 :

Nervous System :

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 Nervous System Systemic Examination :

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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 Sensory and Motor: Systemic Examination :

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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 funtion of lower limbs- diminished. Systemic Examination :

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Inspection – No abnormality detected Palpation – not tneder Auscultation – Bowel sound present P/R – Anal tone – present. 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 . Alimentary System Respiratory System Systemic Examination :

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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. The patient unable to pass urine normally and the patient is in Cathder. Cardio-Vascular System Genito – urinary systim Systemic Examination :

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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:

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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:

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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:

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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). Salient Features:

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Provisional Diagnosis- ??

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

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Anterior cord syndrome Brown – Sequard Syndrome Differential Diagnosis -

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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 E.C.G – within normal limit Investigations:

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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:

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MRI- 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. M.R.I Cervical Spine - Investigations:

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

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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. Treatment Plan : And Prognosis -

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Video Clip: Conversation with The Patient And Examination (Dated 19 th Oct. 2011).

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Associate Prof. Dr. P. C. Debenath Associate Prof. Dr. Sheikh AbbasUddin . Associate Prof. Dr. ZiaulHaq Associate Prof. Dr. ShamimulHaq Associate Prof. Dr. Monowarul Islam Associate Surgeon Dr. Md. AminurRahman Assistant Prof. Dr. KaziShamimuzzaman Assistant Prof. Dr. A T M BaharUddin & Special Thanks Are Due To- Dr. Md Nazrul Islam Resident Surgeon, Department of Orthopedic’s & Traumatology . Shaheed Suhrawardy Medical College Hospital

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From- Department Of Orthopedics’ & Traumatology , Shaheed Suhrawardy Medical College Hospital. Dhaka- 1207

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