DEPARTMENT OF ORTHOPAEDICS,

TRAUMATOLOGY AND REHABILITATION

KULLIYYAH OF MEDICINE
YEAR 4 BLOCK 3 SESSION 2017/2018

2nd CASE WRITE UP

Chance fracture of L4.

Burst fracture of T12 with incomplete spinal cord injury.
Grade II splenic injury.

NAME : NUR SHAHIRAH BINTI RAMLI

MATRIC NO : 1415052
GROUP : A2
SUPERVISOR : Asst. Prof. Dr. Ed Simor Khan Mor Japar Khan
IDENTIFICATION DATA

Name Haryati A/P Hamzah

Age 14 year old
Marital Status Married (Adat Marriage)
Race Orang Asli
Registration Number (RN) 1044564
Occupation Housewife
Address Kg Lebak, 28700 Bentong, Pahang
Date of Admission 21/9/2017
Date of Clerking 23/9/2017
Date of Discharge -

Ward Teratai 2A

1
HISTORY

CHIEF COMPLAINT
Mdm Haryati, a 14 year old Orang Asli, with no underlying medical illness, was presented to
A&E of HTAA by ambulance with complaint of lower back pain and unable to move both lower
limbs following an incident of tree falling on her back.

HISTORY OF PRESENTING COMPLAINT

The patient was apparently well and ambulating well until when a tree of unsure height and
weight fall on to her back while she was fishing with her husband. Her husband able to avoid the
tree and does not sustained any injury. She was trapped under the tree bark for about 30 minutes
before her husband able to ask for help from around 4 people to lift the tree.

Following the incident patient had middle back pain, neck pain and abdominal pain. The pain at
her back described as throbbing in nature, intermittent pain throughout the back but more
prominent on middle back. The pain however does not radiate to other side of the body. Pain
score given was 6/10. She also unable to move both lower limb except toes after the incident and
only lies flat. She can’t sit by herself and experience pain when supported by her husband. She
complaint that the pain worsen by movement and relived by lying still. However, no loss of
sensation reported and she does not notice any bony deformity on her back or extremities and she
able to move her upper limb.

Other than that, she sustained abdominal pain in which she described as dull and crushing pain
throughout the abdomen and more prominent on left upper quadrant. The pain does not radiating
elsewhere and does not associated with vomiting or nausea. It was a continous pain with pain
score of 6/10.

Otherwise, no loss of consciousness, retrograde amnesia, trauma on head or other part of body,
shortness of breath, chest pain and bleeding from ear, nose and throat reported. She was then
brought by her father to Hospital Bentong and several investigations were done before she was
referred to our centre. She does not have bowel output till the day of clerking (3rd day post

2
trauma) and she able to move her lower limb with limited range of movement on 2nd day of
admission.

SYSTEMIC REVIEW

General health Good hydration and nutritional status. She had no fever and not
lethargy. She had no loss of appetite and no loss of weight.
Cardiovascular system No palpitation, chest pain, or syncope.
Respiratory system She had no shortness of breath, coughs,haemoptysis, or chest pain.
Gastrointestinal system There was abdominal pain but no nausea & vomiting,
hematemesis, dysphagia, diarrhoea, and melena. She have no
bowel output for 3 days. Her usal bowel ouput is once per day.
Genitourinary system There were no history of polyuria, nocturia, and flank pain. No
episodes of urinary frequency and urinary urgency.
Central nervous system She was fully conscious; there were no visual and hearing
disturbances.
Musculoskeletal system No arthralgia, myalgia, or muscle cramps.
Endocrine system No profuse sweating, polydipsia, or symptoms of hot or cold
intolerance.
Haematological system No bleeding tendencies.

PAST MEDICAL HISTORY

No known medical or surgical history. This is her first hospitalization.

DRUG HISTORY

She does not taking any medication. She has no known drug or food allergy.

FAMILY HISTORY

She is the 2nd of 4 siblings. Both her parents are still alive and healthy.

3
SOCIAL HISTORY

She is married to a 19 year old man by adat marriage and currently live with her husband family
at Chamang. She is a housewife. Their house is complete with basic aminities and household
income is around RM 900-1000.

PHYSICAL EXAMINATION
(on Day 3 of admission)

GENERAL EXAMINATION

She is lying flat in supine position with no pillow and on hard cervical collar. She is conscious,
alert, and cooperative. She was comfortable and not in pain. She is pale but no cyanosis. She is a
medium built lady, with good hydrational and nutritional status. There is branula at the dorsum
of his left hand with infusion of normal saline and no signs of thromboplebitis. There is a urine
bag at the right side of his bed with normal coloured urine.

VITAL SIGNS

Blood pressure: 130/90 mmHg (normotensive)

Pulse rate : 59 beat per minute, regular rhythm and good volume (normal)
Temperature : 37°C (afebrile)
Breathing rate : 16 breaths per minute (normal)

EXAMINATION OF THE NECK

On inspection, he is on cervical collar. There was no apparent deformity, bruises,

hematoma or any wound seen. No step deformity noted. There is cervical tenderness but
movement of the neck is not done.

4
EXAMINATION OF THE SPINE

There is no deformity such as scoliosis, hump or mass seen on any level of the spine.
There was also no bleeding, hematoma, bruises or wound noted. There was tenderness at the
level of T12 to L5 vertebra. However, there was no increase or decrease gap between the
vertebrae.

NEUROLOGICAL SYSTEM EXAMINATION

Upper limb examination:

For the left upper limb, the tone, power and reflexes are normal. No fasciculation or muscle
wasting. Sensations are intact.

3rd day of admission Motor Sensory

Spine level Right Left Right Left
C5 (elbow flexors) 5/5 5/5 2/2 2/2
C6 (wrist extensors) 5/5 5/5 2/2 2/2
C7 (elbow extensors) 5/5 5/5 2/2 2/2
C8 (finger flexors) 5/5 5/5 2/2 2/2
T1 (finger abductors) 5/5 5/5 2/2 2/2
On day of admission Motor Sensory
Spine level Right Left Right Left
C5 (elbow flexors) 4/5 4/5 2/2 2/2
C6 (wrist extensors) 4/5 4/5 2/2 2/2
C7 (elbow extensors) 4/5 4/5 2/2 2/2
C8 (finger flexors) 4/5 4/5 2/2 2/2
T1 (finger abductors) 4/5 4/5 2/2 2/2

Lower limb examination:

Both lower limbs are of normal attitude with no muscle wasting or fasciculation noted. The tone,
power and reflex is normal. Sensation also intact. Babinski and clonus are absent.

3rd day of admission Motor Sensory

Spine level Right Left Right Left

5
 L2 (hip flexors) 5/5 5/5 2/2 2/2
L3 (knee extensors) 5/5 5/5 2/2 2/2
L4 (ankle dorsiflexors) 5/5 5/5 2/2 2/2
L5 (big toe extensors) 5/5 5/5 2/2 2/2
S1 (ankle plantarflexors) 5/5 5/5 2/2 2/2
On day of admission Motor Sensory
Spine level Right Left Right Left
L2 (hip flexors) 5/5 5/5 2/2 2/2
L3 (knee extensors) 5/5 5/5 2/2 2/2
L4 (ankle dorsiflexors) 5/5 5/5 2/2 2/2
L5 (big toe extensors) 5/5 5/5 2/2 2/2
S1 (ankle plantarflexors) 5/5 5/5 2/2 2/2

Per rectal examination: (done by doctor)

Perianal sensation and voluntary anal contraction are present. The bulbocavernous reflex is also
present.

EXAMINATION OF ABDOMEN

On inspection, the abdomen was flat and not distended. There was no scar, no dilated veins, and
no obvious skin changes noted. On palpation, the abdomen tender on left hypochondriac region.
There was no mass palpable. There was no hepatosplenomegaly. The kidneys were not
ballotable. On, auscultation, normal bowel sound were heard. On per rectal examination, the anal
tone was present. There was no per rectal bleed and no melena.

Examinations of other systems revealed normal findings.

CASE SUMMARY

A 14 year old lady, with no known medical illness, presented with abdominal pain, back pain
and lower limb weakness. On examination, there is tenderness at the level of T12 to L5 vertebra
with no neurological deficit.

6
PROVISIONAL DIAGNOSIS

Burst fracture of T12-L5 vertebra

Supportive points Points against

 Low back pain  No step deformity
 Unstable fracture causing bilateral lower
limb paralysis and anaesthesia
 History of trauma

7
INVESTIGATIONS
FULL BLOOD COUNT
(Taken on day of admission)

Indications:
The test is performed as baseline assessment for health status of the patient, in case the
patient is subjected for operative intervention. And it is to assess the haemoglobin and platelet
level.
Findings:

RESULT UNIT REFERENCE

RANGE

Haemoglobin 6.2 L g/dL 12.0-15.0

Total red blood cell 5.24 H 10^12/L 3.80-4.80

MCV 61.8 L fL 83.0-100.0

MCH 18.7 L PG 27.0-32.0

MCHC 30.2 L g/dL 31.5-34.5

Platelets 253 10^9/L 150-400

Total white blood 16.62 H 10^9/L 4.0-10.0

cell

Comments: Patient is having a hypochromic microcytic anaemia and the platelet count is normal.
The white cell count increased proving ongoing infection or inflammatory process.

8
IRON STUDY

Result Unit Reference Range

TIBC 64.8 umol/L 21.5 - 85.9

Iron 2.7 L umol/L 9.0 – 30.4

UIBC 62.1 H umol/L 12.5 – 55.5

Comment: patient have normal total iron binding capacity but low iron level proving the
hypochromic microcytic anaemia due to bleeding.

RENAL PROFILE

Indications: This test is used to assess the hydration status of the patient as well as the
electrolyte balance of the patient. It is used as a standard baseline assessment to assess the health
status of the patient pre-operatively.

Findings:
Observation Value Unit Ref. Range
Urea 2.8 L mmol/L 3.2-7.4
Sodium 137 mmol/L 136-145
Potassium 3.3 L mmol/L 3.5-5.1
Chloride 109 H mmol/L 98-107
Creatinine 48 L mmol/L 64-111
Comments: patient is not dehydrated but have acute kidney injury due to the trauma.

9
UFEME

Value Unit Reference Range

Specific Gravity 1.011 H 1.015 – 1.025

pH 6.0 4.8 – 7.4

Leukocytes 500.0 H Cell / ul <10

Nitrite Positive

Protein Negative <0.10

Glucose Normal <0.84

Ketones 15.0 H mmol/L <0.5

Urobilinogen Normal <16.9

Bilirubin Negative <3.4

Erythrocytes / blood 10.0 H Cells/ul <5

Color Yellow

Comment: there is sign of urinary tract infection by presence of high leukocytes and positive
nitrite.

LIVER FUNCTION TEST

Indications: This test is used to test for the liver function of the patient as the baseline health
status of the patient.
Findings:
Observation Value Unit Ref. Range
Total bilirubin 6.6 µmol/L 3.4-20.5
Total protein 62.0 g/L 60.0-78.0
AG ratio 1.30 1.0-2.2
ALP 75 U/L 40-150
Comments: All the values are within the reference range.

10
X-RAY
1. Thoracolumbar X ray.
I accidentally deleted it from my phone and couldn’t retake the picture as the case not
already sent to record department.

Findings base on the case note: unstable burst fracture of T12 including anterior and middle
column

CT Scan Of The Spine

11
Comment: There is multiple spinous vertebral fractures at T11, T12, L3 and L4. There is also
chance fracture at L4 compromising AP diameter of spinal cord. Atlanto-axial dislocation.

FAST SCAN : No Free Fluid

12
CT SCAN OF ABDOMEN

Comment: Grade I – II splenic injury. Minimal left haemo and pneumothorax. No

pneumoperitoneum. Minimal free fluid.

Chest X-Ray
Finding: no pneumothorax, air under diaphragm or rib fracture.

FINAL DIAGNOSIS
1. Multiple spinous process fracture at level of T11, T12, L3 and L4.
2. Chance fracture of L4.
3. Burst fracture of T12 incomplete spinal cord injury.
4. Atlanto-axial dislocation.
5. Grade II splenic injury.

13
MANAGEMENT AND PROGRESS IN WARD

Management of Spinal Fracture

Upon admission to the ward, the patient was instructed for complete resting in bed. ASIA
chart was monitored daily. She was put on catheterized bladder drainage to avoid bladder
distention and to allow complete bed rest. She was then subjected for urgent CT scan of the spine
to assist in the diagnosis and for better planning of further management.
The patient was then put on extension body cast with single thigh extension on day 4 of
admission due to financial problem. Patient was explained regarding surgical procedure one
allowed.
Management of Grade II spinal injury
Patient was treated conservatively with intravenous solution 2 pins of normal saline and 2
pins of dextrose.she also prescribed with T. Hematinics OD. She was then transfused with 2 pack
cells on second day of admission.
Supportive management
For pain management, the patient was prescribed with IV Tramal 30mg TDS, T.
paracetamol 1gm TDS and T. Parexocib 40mg BD. The vital sign is monitored. And patient was
allow orally on day 4 of admission. On second day of admission, she was prescribed with IV
Cefoperazone and Metronidazole.

DISCUSSION

Spinal injury may double the threat to the patient: damage to the vertebral column and
neural tissue. All spinal injury can be classified into stable and unstable injury but the patient
must be handle as unstable injury patient until proven otherwise by examination and imaging.
Stable injury is when the vertebral column will not be displaced by normal movement and thus
less risk of damage to neural elements. While unstable injury is the one with high risk of
displacement and thus can cause damage to neural tissues.

The degree of stability in spinal injuries depends on the column involvement. The 3-column
model of the spine as introduced by Denis in 1983 divides the structural elements of the spine
into 3 columns:
14
  Anterior column: Anterior half of the vertebral body, anterior part of the intervertebral
disc and the anterior longitudinal ligament.
 Middle column: posterior half of the vertebral body, the posterior part of the
intervertebral disc and the posterior longitudinal ligament.
 Posterior column: those structures posterior to the PLL which includes the pedicles, facet
joints, posterior bony arch, interspinous and supraspinous ligaments.

An unstable injury is the one that involves the middle column and at least one other
column. There are three basic mechanism of injury which are traction, direct and indirect injury
in which indirect injury being the most common one. Various forces can be applied to spine in
this type of injury: axial compression, flexion, lateral compression, flexion-rotation, shear,
flexion-distraction and extension.

Most injuries of the thoracolumbar spine occur in transition area T11 to L2. Three
pathogenic mechanisms are low-energy insufficiency fractures, minor fractures of vertebral
process and high energy fractures. This patient experience a high energy unstable fracture. This
will be explain further. Axial compression is a failure of middle and anterior column causing a
‘burst’ fracture which is unstable. The anteroposterior x-ray may show spreading of vertebral
body with increase of interpedicle distance. There may be minimal anterior wedging. All this
findings can be clearly seen in CT scan of the patient. As we can see at T12, there is anterior
wedging, widening of the interpedicle distance and fracture can be seen on anterior and middle
column.

While flexion-distraction also known as ‘jack-knife’ injury causing failure of posterior

and middle columns and sometimes the anterior column. Combined flexion and posterior

15
distraction is the cause of this injury. The tear passes transversely through the bones or the
ligament structure or both. Chance in 1948, describe the injury as fracture that split runs through
the spinous process, transverse process, pedicles and vertebral body. In this patient CT scan, we
can clearly see a fracture line that transverse through all 3 columns of L4. There is also anterior
wedging and increase intervetebral space in which it should be reduce in chance fracture.
Neurological damage is uncommon even though the injury is unstable by definition.

When patient came, several physical examinations should be done. The patient is first put
in soft collar before it is being removed after doctors have confirmed no injury involving
cervical. The patient has tender on palpation around thoracolumbar which is a clue for spine
injury. Three types of shock may be encountered: hypovolemic shock, neurological shock and
spinal shock. In patient with clinical presentation of neurological deficit, determining whether
the cord lesion is complete or incomplete is important as it determines the management as well
as the prognosis of the patient. At initial presentation, the patient may experience spinal shock in
which all functions of the spinal cord is failed temporarily. The end of spinal shock is determined
by the presence of the bulbocavernous reflex which is a primitive reflex. When the patient first
presented on Emergency department, she had paraplegia and loss of anal reflex. Daily Asia Chart
was done and the patient can start to move all limbs and anal reflex return on second day of
admission. Thus, we can safely conclude that the patient has an incomplete neurological deficit
due to the trauma.

Management of spinal injury can be either conservative or operative management. The

objectives of the management are to preserve the neurological function, minimize neurological
compression, stabilize the spine and to rehabilitate the patient. In this case where the fracture is
unstable burst fractyre, but there is no neurological deficit. Surgery may prevent further damage
to the spinal cord. But this patient only had moderate wedging with no neurological damage.
This patient can be kept in bed until the acute symptoms settle (less than one week) and then is
mobilized in thoracolumbar brace or body cast for 12 weeks. A study shows that, there is no
difference in long term results in conservative or surgically managed patient. But complications
are more frequent in the surgical group. The Chance fracture heals rapidly and requires 3 months
in a body cast. Thus this patient is decided to be put on conservative management which is
extension body cast with single thigh extension. However, she was observed for new symptoms

16
like tingling, weakness or alterations of bladder or bowel function because further imaging
should be done and an anterior decompression and stabilization may then be needed.

Splenic trauma can occur after blunt or penetrating trauma or secondary to medical
intervention. The spleen is most frequently injures organ after blunt trauma. Patients may present
with left upper quadrant pain, left shoulder tip pain (referred pain from diaphragmatic irritation)
and signs of hypotension or shock. This patient also came with complaint of left hypochondriac
pain and her vital sign is stable on ED. However, her haemoglobin is low suggesting
intraabdominal injury. FAST scanning may be performed to determine the presence of free fluid.
Absence of free fluid does not rule our splenic injury. CT is the modality of choice for assessing
splenic trauma. The 1994 revision of the American Association for the Surgery of Trauma
(AAST) splenic injury scale is the most widely used grading system for splenic trauma at the
time of writing (late 2016).

 grade I
o subcapsular haematoma <10% of surface area
o capsular laceration <1 cm depth
 grade II
o subcapsular haematoma 10-50% of surface area
o intraparenchymal haematoma <5 cm in diameter
o laceration 1-3 cm in depth not involving trabecular vessels
 grade III
o subcapsular haematoma >50% of surface area or expanding
o intraparenchymal haematoma >5 cm or expanding
o laceration >3 cm in depth or involving trabecular vessels
o ruptured subcapsular or parenchymal haematoma
 grade IV
o laceration involving segmental or hilar vessels with major devascularisation (>25% of
spleen)
 grade V
o shattered spleen
o hilar vascular injury with splenic devascularisation

17
This patient had grade 2 splenic injury based on CT scan. The trend in management of splenic
injury continues to favor nonoperative or conservative management. This varies from
institution to institution but usually includes patients with stable hemodynamic signs, stable
hemoglobin levels over 12-48 hours, minimal transfusion requirements (2 U or less), CT scan
injury scale grade of 1 or 2 without a blush, and patients younger than 55 years. This patient
was managed conservatively by intravenous fluid and was transfused with 2 packed red cell.

REFERENCES

1. Solomon, Warwick, and Nayagam: Apley’s System of Orthopaedics and Fractures (9th
Edition), 2010, Hodder Arnold
2. https://radiopaedia.org/articles/splenic-trauma

18