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S&F 1 > Anatomical Correlates of the lower limb- Wilson > Flashcards

Anatomical Correlates of the lower limb- Wilson Flashcards

1
Q

The lower limb can act as the upper limb. How so?

A

It is capable of doing many other things as the anatomy is there to do so

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2
Q

Given the range of anatomical durability, how do you know what normal muscle strength and sensory sensitivity is?

A

you look for symmetry in the patient

Patient serves as his/her own control.
-structure
-sensory innervation
muscular strength

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3
Q

What symptoms can you get with peripheral nerve lesions?

A

peripheral nerve lesions are damages to a part of the neurons

can results in sensory and/or motor symptoms

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4
Q

What are examples of sensory symptoms?

A
  • Anesthesia (no sensation)
  • Hypothesia (reduced sensation)
  • Parathesia (abnormal sensation - eg, burning, tingling, and/or pens & needles)
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5
Q

What are examples of motor symptoms?

A
  • flaccid paralysis: LOWER motor neuron injury; no muscle tone
  • paresis: partial paralysis or muscle weakness; relative strength of muscle has been reduced
  • muscle atrophy (Wasting of muscle)
  • fasciulations
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6
Q

What are fasciculations?

A

during nerve damage before atrophy sets in, you get spontaneous twitches

its just individual motor units that are twitching which you can observe under the skin

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7
Q

What muscles can mask paralysis of the trapezius?

A

levator scapulae

test muscle action if you suspect partial loss of the innervation; and test against resistance to unmask weakness, as well using the patient as his/her own control ; the bulk of the muscle should be palpated

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8
Q

What is the point of reflexes?

A

testing fundamental circuits of the NS

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9
Q

What does each reflex test?

  • patellar reflex
  • achilles reflex
  • plantar response
A

Patellar reflex: testing femoral nerve (L2-4); stretching the muscle spindle and getting brisk contraction of quadriceps

achilles reflex: testing S1 and S2 for the soleus and gastrocnemius

plantar response: testing CUTANEOUS innervations (L4-S2); can have Babinski sign (dorsiflexion of hallux) which is acquired as an adult due to cortex suppressing the primitive (infant) response plantar flexion of hallux; with cortex lesion you lose this suppression

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10
Q

In what steps of the reflex arc can the reflex be modulated?

A

at the place of integration the reflex can be easily modulated

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11
Q

Lesions in which steps of the reflex arc will change the reflex?

A

AT ANY STEP OF THE REFLEX will change the reflex

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12
Q

What is the cremaster reflex?

A
  • test L1-2
  • there is skeletal muscle that rubs against the testes
  • pulls the testes up towards the body when you stroke against the inner thigh (testes are vulnerable in their position so may be used to protect it)
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13
Q

How can peripheral nerves be lesioned?

A

A. compression which can occur through:

  • joint fracture: sciatic nerve (posterior dislocation of the hip)
  • vessel aneurism: thin walls can balloon out due to high pressure which can compress the nerve nearby
  • fractures
  • herniated discs
  • entrapment syndromes: muscle compressed as it goes through muscle muscle hypertrophy

B. Cutting and tearing
-stab, bullet, shrapnel, fractures

C. Evulsion/Avulsion: nerves literally pulled out of the SC

D. Repetitive motion

E. Bacterial or viral infections (polio and leprosy)

F. Demyelination (MS, Guillain-barre)

G. Neuropathy (DM: the very fat large axons are susceptible DM and you start to lose sensation from these large axons)

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14
Q

Where are exogenous substances taken up in the NS?

A

synapses is where exogenous substance can be taken up from the synaptic cleft and transported through retrograde axonal transport

  • retrograde transport shuttles molecules away from axon termini toward the cell body
  • exogenous substances such as herpesvirus, poliovirus, rabies, and tetanus toxin affect neuron as a result of retrograde axonal transport

ex. Polio and Rabies

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15
Q

What is another name for Guillian-barre disease and what can it be caused by? What are its characteristics in terms of levels of protein and leukocytes?

A

acute idiopathic polyneuritis

  • caused by viral infection of respirator or GI tract
  • can be triggered by HIV and getting flu-innoculation
  • affects motor (usually distal motor fibers) more than sensory nerves
  • PROTEIN levels in CSF is pretty HIGH!!
  • leukocytes is NORMAL
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16
Q

What is Spinal Poliomyelitis – 79%?

A

a result of polio virus where there is muscle atrophy because muscles have lost their innervation

retrograde transport

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17
Q

How is polio different from AIDP?

A
  • NORMAL protein level in CSF
  • high level of leukocytes

AIDP (Guillian-Barre) has albuminocytologic dissociation without pleocytosis

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18
Q

Shingles (herpes zoster)

A

virus distributed by a dermatome of a single spinal nerve and are in the cell body and go out through ANTEROGRADE to synapse and be released to the skin

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19
Q

What is sciatica?

A

compression of roots of the sciatic nerve that produces radicular pain

-radicular pain is pain that radiates or extends along the course of the sciatic nerve

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20
Q

Describe herniations of intervertebral disc, that will compress cord and roots.

If you know the muscles and dermatome of each spinal nerve, you can localize the injury.

A

nucleus pulposus (NP) are remnants of the notocord in the adult: a gelatinous type of substance; acts as a shock absorber; overtime the annulus fibrosus can be come weakened allowing NP to herniate out and usually DORSOLATERALLY

depending on what level you get a herniation, that herniation can put stress directly on the spinal nerve as they exit the intervertebral foramen and it can also cause displacement of the SC at higher levels or levels above L2; but at lower levels the pressure is going to be directly on the nerve

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21
Q

Is it necessary for a herniated disc to come in contact with the nerve to cause compression?

A

No
herniation can evoke an inflammatory response and the edema and inflammation in the intervertebral foramen can compress the axons, causing sciatica in the lumbosacral region

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22
Q

Usually when you have a herniated disc in the lower lumbar region, what nerve is affected?c

A

the nerve that will be affected is the nerve exiting at a lower level, not the nerve in between

-the nerve in between that runs across the herniation

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23
Q

Cauda equina are nerves going to the lower limb exiting the genitalia or pelvic structure.
What is Cauda Equina Syndrome?

A

-can present as a number of symptoms: LOW BACK PAIN, sciatica, lower limb paresis (gait disturbances), SADDLE ANESTHESIA (part of saddle is innervated by sacral spinal nerve), LOSS OF SPHINCTER CONTROL, LOSS OF SEXUAL FUNCTION

Affect S2-S4, pudendal nerve

BOLDED ONES are the hallmark symptoms of cauda equina syndrome

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24
Q

What are causes of Cauda Equina Syndrome?

A
  • spinal stenosis: bone spurs form
  • trauma
  • fractures (burst fractures)
  • inflammation and scarring
  • spondylolisthesis (posterior side of vertebra body displaced anteriorly)

anything that changes size of canal or produces scarring is a cause of cauda equina syndrome

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25
Q

What is the relationship of the piriformis and the sciatic nerve?

A
  • Generally, the common fibular nerve passes inferior to the piriformis.
  • Occasionally, the common fibular nerve passes through the piriformis.

This muscle is most likely to cause entrapment of the sciatic nerve.

professional bike riders use this muscle very often which can produce spasms of piriformis and cause compression of the sciatic nerve producing sciatica

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26
Q

How can we verify a herniated disc is the cause of the sciatica?

A

contralateral SLR from 35 to about 75 degrees

normally you should be able to raise the leg up to 75 degrees without any pain

if pain is present, there is a herniated disc

-contralateral SLR= CROSSED SLR

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27
Q

How do you distinguish symptoms of the sciatica and symptoms of the hip (tight hamstrings, ischial bursitis, or arthritis of hip)?

A

take the leg up to 75 degrees and DORSIFLEX the foot (tibial nerve goes all the way to the foot to produce medial and lateral plantar nerve); stretching them will let you know if the pain in hip is coming from sciatic nerve (pain will be present)

-inflammed roots of sciatic nerve: as you raise the leg, the tension in the sciatic nerve is increased; you are stretching the sciatic nerve (putting traction on the sciatic nerve); however you’re also moving the tendons of the hamstrings so above is the way to differentiate

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28
Q

What is the difference between ipsilateral and contralateral SLR?

A

This is a passive test

Contralateral SLR will tell you if there is a herniated disc:

  • flexing the hip on opposite side of pain from 35 degrees to 70 degrees pulls the cauda equina and meninges
  • if pain is felt contralaterally then there is a herniated disc

Ipsilateral SLR (same side of pain) and dorsiflexion will tell you if the sciatic nerve is affected

raising the unaffected limb should not have an effect on the opposite limb unless if you have inflammed roots of the opposite limb, putting traction of the SC meninges and cauda equina bilaterally

Pain - tension in sciatic nerve is increasing

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29
Q

Herniation of disc L3-L4 irritates what rootlets?

A

rootlets of L4

30
Q

Person with sciatica due to a herniated disc will have what distinct problems?

A
  • have problems taking care of bodily needs (defecation, urination, pregnancy)
  • because every time they try to do the Valsalva maneuver to go to the bathroom, they are stretching the inflamed roots of the sciatic nerve produce intense pain (it hurts too much to go to the bathroom)

-pain of sciatica may be increased by raising intra-abdominal pressure and pregnancy because of pressure on the sacral plexus

31
Q

What is the clinical correlate of ovarian cancer?

A

ovaries sit right next to the obturator nerve; as you develop cancer of the ovaries it puts pressure on the obturator nerve

-one of the symptoms of the ovarian cancer is anesthesia or paresthesia (tingling) of the medial thigh

32
Q

What is the Trendelenburg sign?

A
  • main action of gluteus medius and gluteus minimus is ABDUCTION of hip
  • contralateral hip abduct at thigh causing pelvis to lift on opposite side (NORMAL)
  • paralysis of gluteus medius and gluteus minimus will cause abduction of pelvis/hip if you cannot abduct the thigh
  • pelvis is not being supported by two limbs ; the limb in swing phase has gravity pulling down the pelvis (positive Trendelenburg sign)
33
Q

What is characteristic of closed chain movements?

A

origin and insertion are reversed

34
Q

A positive Trendelenburg sign indicates what? What other muscles tilt the pelvis during walking?

A
  • paralysis of the the gluteus medius and/or minimus
  • dislocation of the hip

-contralateral muscle that is involved in upward tilting of the hip is the tensor fascia lata and ipsilaterally, the iliocostalis

35
Q

What occurs during gluteus maximus paralysis?

A

lose extension of hip

  • patient acquires abnormal posture during gait
  • backward lean to compensate for paralysis of the gluteus maximus
36
Q

What is a bursa?

A

fluid filled sac
sac that is like a synovial membrane that separates muscle/tendon and bone allowing for free movement (allow muscle and tendon to slide over bone without damage)

37
Q

What is Bursitis? What are examples?

A

fluid filled sac can become torn or damaged and any movement of the bursa will produce sharp pain

  • inflammation from repeated stress!!
  • ischial bursitis, trochanteric bursitis, olecranon bursitis, prepatellar bursitis (house made bursitis) , achillobursitis
38
Q

What is ischial bursitis?

A

sit bone is squished between ischial tuberosity and a hard bench AKA
“weaver bursitis”

Ischial bursitis, sometimes called ischiogluteal bursitis, is an inflammation of the fluid-filled sac, or bursa, that lies between the ischial tuberosity (the lower part of the V-shaped bone that helps form the pelvis) and the tendon that attaches the hamstring muscle to the bone

39
Q

Which bursas are affected in the Clergyman knee and the Housemaid knee?

A

Clergyman knee : infrapatella bursa (between ligament and bone)
Housemaid knee: prepatellar bursa (between patella and skin)

  • both are superficial
  • inflammed deep infrapatella bursa through MRI confirms subcutaneous infrapatellar bursa is also affected
40
Q

What is foot drop due to?

A

damage of the common fibular nerve which can occur through fracture of the neck of the fibula where the common fibular nerve passes next to

41
Q

To clear the foot from the ground and to prevent stumbling, the foot is normally dorseflexed during the swing phase of walking. What happens during foot drop?

A

foot hangs down or point down during the swing phase of walking resulting in stumbling

42
Q

What are clinical signs of someone with foot drop?

A
  • patient has to take a high stepping gait to compensate for foot drop
  • loud plopping sound when walking
43
Q

How do you differentiate between common fibular nerve, superficial fibular nerve, and deep fibular nerve damage?

A
  • lose sensation between the first and second toes –> deep fibular nerve is affected
  • loss of sensation of the lateral side of leg and dorsum of foot–> superficial fibular nerve is affected
  • loss of sensation in ALL of these areas–> common fibular nerve
44
Q

What forms the tarsal tunnel through which the tibial nerves
passes to the foot?

A

flexor retinaculum

-tibial nerve is between flexor digitorum longus and flexor hallucis longus at the levlel of the foot

45
Q

Rupture of the Insertion of the Triceps Surae (2 heads of gastrocnemius and soleus) AKA achilles tendons causes what and why?

A
  • bulking up of CALF muscle!!! (not the thigh like in the picture, he couldn’t find a good picture)
  • the muscles contract and there’s no way to pull it out into a relaxed position
  • Achilles is largely AVASCULAR.
46
Q

How do you test for a rupture of the achilles tension or Insertion of the Triceps Surae?

A

Thompson test

  • patient is supine
  • dorsiflex the foot
  • squeeze on the triceps surae (trying to shorten the achilles tendon)
  • if it is attached you get plantar flexion
47
Q

What is plantar fasciitis?

A

An inflammation of a thick band of tissue (fascia) that connects the heel bone (calcaneus) to the toes.

  • important for maintaining arches of the foot
  • walking can be a challenge
  • -pain is most severe where the fascia attaches to the medial tubercle of the calcaneus
48
Q

What is the difference between low and high ankle sprain?

A

High ankle sprain:
tear ant. inf. tibiofibular ligament which can tear interossesous membrane= high ankle sprain. Foot rotates outward. leg rotates inward

Low ankle sprain:
tear ant. talofibular ligament and calcaneofibular ligament= forced inversion of foot= OR eversion and subsequent tear of deltoid ligament= low ankle sprain

≈

49
Q

What goes through femoral triangle?

A

NAVL

femoral nerve (N)
femoral artery (A) 
femoral vein (V)
lymphatics (L)

vein and artery run in the sheath and the femoral canal runs medial to the sheath.

50
Q

What are the common reasons for swelling in the femoral triangle?

A
  • femoral hernia: piece of gut herniating into the femoral triangle through the femoral ring
  • psoas abscess
  • enlarged inguinal lymph node
  • saphenous varix (a dilation of the saphenous vein at its junction with the femoral vein in the groin.)
51
Q

Why is the septa that divides the femoral sheath important?

A

medially where you have lymph vessels you have the femoral canal which goes from the abdominal cavity into the femoral cavity
-it is a potential space where pieces of gut can herniate into this space which will produce a femoral hernia (abnormal bulb in femoral triangle)

52
Q

How do you differentiate between inguinal and femoral hernia?

A

inguinal hernia:

  • above inguinal ligament
  • the herniated neck pass superior and medial to pubic tubercle
  • common in male

femoral hernia:

  • inferior to inguinal ligament
  • the herniated neck passed inferior and lateral to the pubic tubercle
  • more common in females
53
Q

Why is deep fascia (fascial planes) important clincally?

A
  • excellent place to perform bloodless surgery
  • however prone to infection - infections may rapidly track along fascial planes

Fascial clefts are potential spaces between fascial layers

54
Q

What is psoas abscess?

A
  • like all muscles, it is surrounded by a fascial sheath which provides a potential conduit through which infections may spread
  • Tuberculosis can form an abscess in the lumbar vertebral column. If this infection spreads to the psoas major, it can track along its fascia and point at the femoral triangle.
55
Q

Infection of big toe can be traced up to leg or even elbow region. How so?

A

Infections follow these facial sheaths from the digits to the elbow/knee.

56
Q

What drains into the superficial inguinal lymph nodes?

A 
-lower limb 
umbilicus (belly button) and below 
-extenral genitalia and lower vagina
-uterus (via round ligament) 
-gluteal and perianal regions (below pectinate line)
57
Q

What is deep vein thrombosis?

A

occurs when a blood clot (thrombus) forms in one or more of the deep veins in your body, usually in your legs.

thrombosis: clot in BV

embolism (plug): obstruction of BV due to transported clot, mass of bacteria or foreign object

58
Q

What are predisposing factors for pulmonary embolism?

A
  • sitting in plane for long period of time
  • no calf pumping (venous stasis) -
  • prolonged bed rest
  • Venous stasis
  • varicose veins
  • taking birth control (hypercoagulability)
  • vessel wall damage
59
Q

What is one of the major reasons for massive embolism in lungs?

A

thrombosis that was initially in the leg that traveled to the heart

  • arteries get smaller the farther they are from the heart
  • veins get bigger the closer they are to the heart
  • thrombus forming in the lower limb can break free and go through the vessel until it reach the point in which the vessel size is the size of the thrombus
  • the thrombus will travel into the lungs and form an embolism
60
Q

What is anterior compartment syndrome commonly caused by?

A

increasing fluid in compartment -> pressure greater than perfusion -> vessel collapse and tissues become ischemic

  • tibial fracture is the #1 cause of compartment syndrome.
  • tibia is very near to the skin

Overuse of muscle can also cause compartment syndrome

61
Q

What is the purpose of a fascia ectomy?

A

cut through fascia to relieve pressure in the compartment so blood flow can be restored

62
Q

What vessels are first to collapse?

A

veins are the first to collapse as they are low pressure and venous return is the first to be compromised.

63
Q

The tibia is the bone most frequently involved in compound fractures.

A

Remember Kevin Ware (basketball player)

64
Q

How do you perform a McMurray Test for a torn lateral meninsus?

A
  • rotate leg externally and varus pressure
  • listening for clicking sound

Put one hand on the knee and one hand on the foot

diagnose torn lateral meniscus

65
Q

How do you perform a McMurray Test for a torn medial meninsus?

A
  • rotate leg internally and valgus pressure
  • listening for clicking sound
  • diagnosis for medial meniscus tear
66
Q

1st metatasophalangeal joint is usually the joint affected what type of arthritis?

A

gout

due to hyperuricemia, high fructose corn syrup, septic /infectious arthritis, or even damage to the joint itself

67
Q

How do you differentiate for gout?

A
  • lifestyle (meat, alcohol)
  • check for uric acid in the blood
  • extract synovial fluid and look for uric acid crystals
68
Q

fascia is also known as what?

A

Periosteum

69
Q

What is is Virchows’s triad?

A
  1. Venous stasis
  2. Hypercoagulability (birth control)
  3. Vessel wall damage
70
Q

Fascia of the lower limbs are known as?

A

Fascia late - thigh (thick and allows little expansion

Crual fascia - leg

71
Q

Compound fracture

A

Fracture that cause a break in the skin. Once it is exposed it is susceptible to infection

S&F 1 (25 decks)

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