Thursday, September 16, 2010

Compound Comminuted Depressed Frontoorbital Fracture

14yo Malay Boy
No known medical illness

Alleged MVA around 2am early morning
Claimed was MB vs MB (MB loss control & hit the fence, pt was not wearing helmet)
No LOC, noted bleeding from laceration wound over the scalp
No ENT bleed/ othorrhoea/ rhinorrhoea
No vomiting
No seizure
No limb weakness
No SOB/ chest pain/ abdominal pain

o/e:
Alert, conscious
GCS 15/15
Pupils 3/3 ++

Noted laceration wound (T+S done in HTAR) - about 5cm
Another laceration wound Rt temporal region (T+S done in HTAR) - 4cm

Chest/ pelvic spring done : -ve
No neck tenderness

Noted left UL- on immobilizer

BP 116/68
HR 76
Afebrile

Lungs: clear
CVS: DRNM
P/a: soft, nontender

Power Rt UL/ bilateral LL: 5/5
Sensation intact

CT brain:



CT brain:
Rt frontal depresses skull fracture -involving double table extending to superior orbital wall
No obvious ICB/ EDH/ SDH/ SAH seen
BC intact

Emergency elevation of depressed skull fracture

Frontal bone osteotomy done by neuro team with depressed fracture fragment (Lateral portion of the supraorbital rim) attached on the Rt
Depressed fragment elevated and held in place with 4 hole plate and 3 X 5mm screws

Frotal bone segment replaced and secured with horizontal long 16 hole plate across the R supraorbital rim with 5 X 5mm and 1X 4mm screws

All plates and screws from 1.5mm Walter lawrence system - straight reg.

Handed over to neuro team for closure

Post op CT scan:


Friday, August 13, 2010

Traumatic Intracerebral Hemorrhage

44 years old Malay gentle man

Alleged MVA today at Rawang
he was riding a MB before he hit a nearby old tyre by the roadside and skidded
he's wearing a fastened helmet

found unconscious and was brought alone by ambulance

Upon arrival to ED GCS was 5/15 ( E1V1M3)
pupil- rt 6mm lt 2mm fixed

patient was intubated-->noted loss of blood in the oral cavity
ryles tube inserted-->no blood/fluids come out

Pt is intubated and sedated
vital sign
BP 163/57 not on inotrops
pr 55
RR 15 on ventilator
swollen right supra-orbital with hematoma
pupil Rt cannot be asscess, Lt 2mm, non reactive

No oozing of blood from ear and nose
Noted dry blood over the nose and left ear Emergency CT scan brain:
ICB at Left frontal 5x4 cm over 4 cut with midline shift 0.6cm
no hydrochepalus, brain appears tight
Urgent craniectomy and evacuation of blood clot was performed.



Subsequently percutaneous tracheostomy was performed and weaned off ventilator
Currently CGS E4VTM5

Wednesday, July 14, 2010

Traumatic C2 dens fracture (Type II)

16 years old Chinese gentlemen, with no known medical illness

He was alleged MVA on 24/4/10 at 11 am in Klang.
He was a back seat passenger of a car with another 3 friends, while on the way to work.
The car was collided with a lorry.
LOC with unknown exact duration.

He was brought to HTAR with an ambulance. All other three victims died at the scene.

Upon arrival at HTAR, GCS was 7/15 then improved to 12/15 on the same day
Able to move all limbs and had 2 episodes of vomiting upon arrival

On arrival at Neurosurgical Centre;
He was on cervical collar
conscious, alert
GCS: E3V4M6
pupils:3/3 reactive ( left periorbiotal hematoma, cornea looks clear but conjunctiva hemorrhage seen)

L/W over the left frontal region --> T&S done in HTAR
multiple abrasion wound over the face

BP: 120/87
HR: 94
temp:37
SPO2: 100% on air
CT scan brain : Bifrontal contusion with comminuted frontal bone fracture with the involvement of frontal air sinuses (anterior and posterior wall) and thin left frontal EDH






Cervical X-ray shows C2 odontoid fracture




MRI cervical shows anterior displacement of dens with normal cervical cord



CT cervical shows type II odontoid fracture.





He was subjected to odontoid screw placement. Intra-operatively, reduction of displacement was done guided by the image intensifier. Post-operatively, he was extubated with no neurological deficit.

Post-op Cervical X-rays show the position of the screw.


Friday, February 26, 2010

Metastatic Squamous Cell Carcinoma

53 Years old Gentleman
Chronic smoker with underlying COAD
Developed progressive left sided limbs weakness for 2 months, associated with headache.
No other symptoms on systemic review
GCS full, PEARL
Higher mental function intact

No cranial nerves deficit noted
Left hemiparesis 4/5 with no sensory impairment
No cerebellar sign
Other examinations - Normal

MRI showed homogenous enhancing lesion at right motor cortex, left insular and left cerebellum


Tumour markers done – within normal value
CXR - NAD
CT thorax and abdomen - NAD

Right parietal craniotomy and excision of tumour done under IGS transsulcus approach

Frozen section sent- Metastatic tumour

Post-operatively, his weakness remain same.
On follow-up 2 weeks after surgery his weakness improved
HPE = Metastatic squamous cell carcinoma