Case Study - Acquired Brain Injury in Disasters and Conflicts
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Abstract[edit | edit source]
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Key Words [edit | edit source]
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Patient Characteristics[edit | edit source]
Background
The patient is a 32-year-ol d female who was pulled from the rubble of a collapsed building three
hours post-earthquake, ten days ago. She sustained an injury to the head and multiple fractures
(left humerus, left tibia/fibula, ribs 7, 8, 9 on the right-hand side) and some facial injuries. Her
sister, who was present when the patient was rescued, reports temporary loss of consciousness
on the way to the hospital and the patient was confused. She reports no vomiting or seizures.
The nurse accompanying the patient to the rehabilitation department reports the medical notes
are not available and she does not know the patient well.
Assessment
Observation: Patient is lying in bed, she appears tired, emotional and cries easily, but consents
to treatment. She is wearing a left, below-knee cast and her left arm is in a sling.
Active range of motion: unable to assess on left side due to fractures, but able to wriggle fingers
and toes. Asked the patient to do simple movements, bending her right knee and taking her
hand to her mouth. The patient is able to move her right leg, but not through its full range of
motion; no movement seen in right arm.
Passive ROM: tested in all joints (free from casting) on both sides with no problems noted.
Tone: Tested on the right side only, since left side is immobilised by cast and sling. The upper limb
felt very floppy during testing, but some resistance to dorsiflexion was noted at the right ankle.
Power: Tested using the Oxford MRC Scale, graded as 0/5 for all major muscle groups through
right upper limb and 2/5 in the right lower limb
Sensation: On testing, reduced sensation to light touch was noted in the right arm and leg,
proprioception was normal in all limbs.
Coordination: Not tested due to fractures on the left side and extensive weakness on the right.
Speech and comprehension: Patient seems to be communicating normally and following basic
commands in her own language.
Functional assessment
The patient is reluctant to roll due to pain, especially around her ribcage. Lying to sitting without
a full roll required the assistance of two people – one to support the lower limbs and one to
manage the trunk and arm. Once up, the patient does not report any dizziness and can sit
unsupported. The patient’s legs do not reach the floor, and so were supported on a block.
Sitting balance during movement was not tested due to lack of arm function and pain on trunk
movement. At this time, the patient requires full assistance with all basic tasks, such as eating
and drinking and personal care, and is being supported by family members. Transfers, standing
and walking were not assessed due to power of 2/5 in right leg. A non-weight-bearing status on
the left leg and arm is initially assumed, due to the lack of medical notes.
Clinical impression
Right-sided weakness and loss of sensation due to left-sided ABI, indicating likely parietal and
frontal lobe involvement. Rib pain is a limiting factor to assessment and a likely limitation for
treatment unless better controlled. Right upper limb is low-toned, lacking activity and at risk
of shoulder subluxation and development of shoulder pain. Increased tone in plantar flexors
on right-hand side and at risk of muscle shortening. Patient is currently fully dependent for
all transfers and daily activities. Noted that the patient was tearful and may need further
assessment due to recent psychological trauma and frontal lobe involvement.
Treatment goals (short-term): Get patient out of bed for sitting and clarify weight-bearing status
on the left leg and precautions for left upper limb.
Treatment approach: Build time in upright sitting for now and allow weight bearing in sitting
through the right foot while maintaining good ankle positioning. Patient to sit out in a chair regularly
but requires a lift transfer to the chair at present. Avoiding complications related to immobility by
regular position changes, advice to the patient to wriggle fingers and toes and maintain movement
in the left side as pain and fracture sites allow. Confirm weight-bearing status on left leg with
medical team. If the patient is non weight bearing, consider splint for right ankle to maintain
muscle length during rest. Start regular, repeated right leg exercises to improve activity and
power. Once right gluteal and quadriceps are 4/5 on the Oxford MRC Scale, the patient can single
leg stand on this leg with assistance. Begin sensory re-education of right side.
Education: Advise and teach the patient’s sister about the importance of and how to change
position regularly. Teach her sister to do safe, daily, passive range of motion exercises for right
arm, noting that abduction and forward flexion should remain below horizontal level. Inform her
about the risk of developing shoulder pain and how to care for the arm by supporting its weight
when upright and avoiding pulling on the arm. Inform her about the possibility of ongoing altered
or low mood. Use her sister to identify motivating/interesting stimuli for meaningful activities and
to monitor mood. Inform her about the possible development of shoulder pain and how to care
for the arm. Ensure her sister is aware of the patient’s need for assistance with daily activities.
Outcome: As the rib pain decreases, the patient can become more actively involved in bed
mobility. Once patient has enough power in her right lower limb to stand and/or fractures have
healed or weight-bearing status has changed to full weight bearing (whichever is first), she
should then be in a position to work on standing and stepping. At this time, it is not possible
to predict the outcome of her right arm function, but once the left arm fracture is healed, she
should be more independent in daily activities.
Examination Findings[edit | edit source]
References [edit | edit source]
