? Neuropraxia (24 year old)

[cafra23]

Hi,

I have just assessed a 24 year old male who has been discharged home from hospital following a fall from 30 feet in June 2009. He landed over a wall directly on his right hand side and sufferred a right traumatic pneumothorax and extensive bruising to his entire right chest wall, hip and leg as far as the ankle. Following discharge from ITU (5 days) he found that he had no sensation or power in his right leg. He has had various investigations including MRI and CT which were normal and more recently an EMG which showed that conduction was intact but 'sluggish'.

He is now able to mobiise with 1 stick by dragging his right leg. He has no sensation to touch, temperature or pain along the lateral aspect of his thigh and into his lateral foot.
He has an unsual swelling approximately 10cm in diameter and 5cm inferior to his greater trochanter. It is tender to touch and below this point there is no sensation.
He has minimal sensation along the medial boarder of his shin and into his great toe.
He has flickers of activity in all major muscle groups of the leg, but no active movement. If you passively take him in to dorsiflexion, his foot remains stuck and he is unable to release and repeated movement had no effect.
When observed on the stairs, he does seem to have around 5 degrees of active dorsiflexion but is unable to reproduce this when asked.

I have referred him for some hydro and we are working on improving the the little active movement he does have, but as present there is no clear diagnosis from his medical team and I was just wondering if anyone had any ideas about what I might be able to try to steer him in the right direction.

Thanks

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[gcoe]

Hi cafra23

This sounds a complex case. Anything you could do to lead to a better diagnosis would be helpful. Based on your description I am not really sure what to make of it. Here are some suggestions you could consider:

You have described the sensory loss in some detail but I wonder if it might be worth having another look - try to map out the sensory loss to differentiate 1) dermatomal distribution or 2) peripheral nerve distribution or 3) neither pattern.

To have such a widely distributed motor deficit suggests something fairly proximal. I am sure the CT/MRI included the spine and leg but did it include the brain? Have you checked for upper motor neurone signs, just in case? The neurologist might already have done this but it might be worth just checking.

How much detail do you know about the nerve conduction study? Is there a clear picture over which nerves are "sluggish"

Could he have a functional (hysterical) component (somatoform disorder) to the problem? He is obviously truly injured but perhaps there could be a functional component that may account for the profound muscle weakness. Clinically this is not that uncommon following trauma - for example the spinal units get quite a few cases. This could possibly explain the active dorsiflexion in stair climbing but not on instruction.

Has the swelling over the trochanter been imaged? - ultrasonography might be relevant. However sounds like a red herring in terms of his paralysis.

As for the problem with the passive dorsiflexion it would be interesting to try to differentiate if this could be a mechanical problem of the ankle joint due to trauma or if it could be part of a somatoform problem. If you could stick an EMG on the tib anterior muscle belly to see what is happening - I am wondering if it might be working hard but he can't "switch it off".

All the best with sorting this guy out. Keep us posted how you get on.