Humpty Dumpty

Author: Catalin-Iulian Efrimescu / Editor: Tajek B Hassan / Reviewer: Phil Delbridge / Codes: NeuC10, NeuP5, NeuP6, RP4, SLO4, TP2 / Published: 19/08/2021

A 70-year-old male is brought to the Emergency Department by ambulance complaining of dizziness and generalised weakness following a fall.

Earlier that day he was walking out of a garage when he tripped over a tractor axel falling forwards over a small wall. He sustained a hyperextension injury of the neck and a blunt trauma of the head. He lost consciousness for 15-20 minutes, and was unable to move for 4 hours. After he recovered consciousness he stated that he felt his body “floating, without being able to move”. He was found by his wife after 4 hours who alerted the EMS.

On arrival in the ED he is noted to have normal vital signs. There is a secondary survey revealed a 5 cm laceration above the right eyebrow and dried blood in his right nostril. He has diffuse midline tenderness along the cervical spine. There are no signs of penetrating trauma and no other injuries found on primary and secondary survey.

Neurological examination shows hypertonic quadriparesis. Power is 3/5 for the Right Upper Limb, 2/5 for the Left Upper Limb and 4/5 for the lower limbs. The motor deficit is more obvious with the flexors of the lower limbs and the extensors of the upper limbs. Reflexes are generally decreased (the upper limb reflexes are slightly more reduced than the lower limbs). There are no fasciculations. Pain, temperature and tactile sensation are slightly decreased with no specific localisation of the level of injury. The posterior columns, sacral reflexes and sphincters are intact. The rest of the examination is within normal limit.

MRI and plain X-ray images are shown below.