Cervical Fractue dislocation Dr Nazim.pptx

Sjjsjs

1. WELCOME TO THE MORNING SESSION CASE PRESENTATION Dr. Anayetullah Nazim MS Resident Phase-B Violet-II

2. Particulars of the patient Name – Mr Ismail Age – 48 years Sex – Male Address– Vuapur , Tangail Ward/Bed-NB-873 Date of admission –27.04.23 Date of examination-02.05.23

3. Presenting complaints Pain in the cervical region for 23 days following fall of a heavy object on neck Difficulty to move left upper limb for same duration.

4. History of present illness According to the statement of the patient he was reasonably well 23 days back . Then he felt pain in cervical region following fall of a heavy object on his neck. He was unable to move left upper limb for same duration. For this reason he got admitted to NITOR for better management.

5. General Examination Appearance : Ill looking Body built : Average Cooperation : Co-operative Decubitus : Supine position Anaemia : Absent Jaundice : Absent Clubbing : Absent

6. Dehydration : Absent Lymph node : Not enlarged Pulse : 76 / min BP : 1 30 / 7 0 mm Hg Temp : Normal R/R : 18 / min Catheter in situ Systemic Examinations . All systemic examination reveals normal.

7. LOCAL EXAMINATIONS: Lower limbs and spine: Loco-regional Examination Look : Patient is on Tong traction There is no swelling or echymosis . Visible muscle wasting absent. Feel : . Temperature: Normal Tenderness : present. Paraspinal muscle spasm: present. Move : ROM of cervical spine not done

8. Neurological examinations : Sensory intact Muscle power ( MRC grade ) : 4/5 in in left upprt limb and all group of muscles in both upper and lower limbs are normal Biceps jerk : Normal Brachio-radialis : Normal Triceps jerks : Normal Knee and ankle jerks : Normal Planter response – Flexion Bulbocavernous reflex – Present Anal wink – Present

9. X-ray Cervical Spine

10. X-ray after Tong traction

11. MRI FILM

12. MRI Film

13. Diagnosis: 23 days old post traumatic fracture dislocation C4 over C5 with incomplete spinal cord injury (ASIA impairment scale-C) in a 48 years old male patient.

14. Unit Plan: Anterior cervical discectomy and fusion by autogenous cancellous bone graft and stabilization by plate and screw

15. Thank You