Orthopaedic Department,

Hospital Pakar Sultanah Fatimah,

84000 Muar,
Johor.

Medical Officer/Specialist Rehab,

Hospital Melaka,
Jalan Mufti Haji Khalil,
75400 Melaka. 22nd February 2021

Dear Dr,

Thank you for seeing this patient.

Name: Hairul Azmi Bin Norhisam

I.C No: 030510141143

Diagnosis :

1. Spinal shock, L1 chance fracture, L2 compression fracture

2. Laceration wound over left foot with EDT cut
3. STI over anterior chest

This is a 17 years old Malay gentleman, no known medical illness, no known drug & food allergy.
Patient had alleged motor vehicle accident (car skidded) at 5/2/2021 around 11.30pm. Patient was a
passenger over front seat, car skidded into ‘parit’ after hit on a pillar and unsure of mechanism
injury. Post trauma, patient unable to move bilateral lower limb and had pain over back. Otherwise
no loss of consciousness, no nausea, no vomiting, no chest discomfort, no shortness of breath, no
fitting episode.

Upon arrival at ED, GCS was E4V5M5, BP noted 138/74, PR 98, Temp 36.7

On examination:

Head: no scalp swelling/hematoma, abrasion wound over left cheek

Chest spring negative

Pelvic spring negative

Spine: tender over lower lumbar

Neurological assessment:

Upper limbs : Lower Limbs :

Power : C5 –T1- 5/5 (bilateral) Power : L2-S1 0/5 (bilateral)

Sensation : C5 -T1 2/2 (bilateral) Sensation : L2 – S1 0/5 (bilateral)

Reflexes : Normal Reflexes : Equivocal

Bulbocavernosus reflex: absent

Anal tone: lax

Investigations:

Blood investigations as per attached

Imaging as per attached

CT lumbosacral urgent shows transverse fracture of the L1 vertebral body with involvement
both lamina, left transverse process and spinous process. Anterior wedging of L1 vertebral body
noted. There is retropulsion of the posterior wall of L1 vertebral body causing spinal canal stenosis
with AP diameter measuring 0.5cm. T12/L1 facet joint is widened. Fracture of L2 spinous process
and left transverse process. Reduce of the T12/L1 and L1/L2 intervertebral disc spaces. Bilateral lung
contusion(CT report as attached)

Neurological progression/recovery during admission:

Day 3 (7/2/21):

Power Sensation
Right Left Right Left
L2 0 0 0 0
L3 0 0 0 0
L4 0 0 0 0
L5 0 0 0 0
S1 0 0 0 0

Day 8 (12/2/21):
Power Sensation
Right Left Right Left
L2 2 1 2 1
L3 2 0 0 0
L4 0 0 0 0
L5 0 0 0 0
S1 0 0 0 0

Done wound debridement, toilet and suturing of left foot for laceration wound left foot with
extensor digitorum tendon cut on 05/02/2021. Intraop findings as per attached.
Done posterior instrumentation T11-L2 for L1 chance fracture with L2 compression fracture
on 15/02/2021. Intraop findings as per attached.

Day 14 post operative assessment (18/2/21):

Power Sensation
Right Left Right Left
L2 2 1 1 1
L3 3 1 1 1
L4 0 0 0 0
L5 0 0 0 0
S1 0 0 0 0
 Upon discharge, patient is alert, conscious, GCS full, not tachypneic, pink, good pulse
volume, regular rhythm, vital signs of blood pressure 125/73, heart rate 65 beats per minute,
respiratory rate 18 per minute, temperature 36.8 and saturation 99% under room air. Lungs
transmitted sound, CVS dual rhythm no murmur, abdomen soft and non-tender. Sacral sore grade II
on hydrocolloid patch. BCR absent, anal tone lax. Patient is on CBD, and ambulate using wheel chair.

We are referring to your centre for spine rehabilitation as per patient and family request in
view of logistic issue.

Case referred by Dr Atiqah, MO Orthopedics HPSF to Dr Hema, MO rehab Hospital Melaka.

Please kindly do the needful.

Thank you.

Yours truthfully, Yours truthfully,

House Officer, Medical officer,

Orthopaedics Department, Orthopedics department,
Hospital Pakar Sultanah Fatimah, Hospital Pakar Sultanah Fatimah,
Muar, Johor, Malaysia. Muar, Johor.