Blue Boxes I Flashcards
Varicose Veins
Dilation of veins (great saphenous and tributaries) preventing valve cusp closure.
(dilated vein with backflow, can lead to venous stasis)
Thrombophlebitis
DVT from loose venous fascia (resists muscular expansion that pumps blood up) or inactivity, combined with inflammation around affected veins.
Pulmonary thromboembolism
Thrombus breaks free –> travels to lung (pulmonary TE) to occlude a pulmonary artery
Saphenous vein graft
- Easily accessible, usable distance between perforating veins/tributaries, thicker muscular/elastic wall than other veins.
- Redundant function with deeper veins, and may facilitate superficial to deep venous drainage taking advantage of the musculovenous pump.
- Commonly harvested for coronary artery bypasses (vein inverted so valves don’t interfere with blood flow).
Saphenous Nerve Injury
- runs alongside great saphenous vein
- can be damaged during saphenous cutdown causing pain or numbness on the medial aspect of the foot
Enlarged inguinal lymph nodes
Abrasions and minor sepsis (via pathogenic microorganisms or their toxins in the blood or other tissues) –> may produce moderate enlargement of the superficial inguinal lymph nodes (lymphadenopathy)
Regional Nerve Blocks of Lower Limbs
interruptions of conduction of impulses in peripheral nerves
femoral nerve (L2–L4) can be blocked 2 cm inferior to the inguinal ligament, ~ finger’s breadth lateral to the femoral a.
Saphenous n. block –> Paresthesia (tingling, burning, tickling) radiates to the knee and over the medial side of the leg.
Palpation, Compression and Cannulation of the Femoral Artery
- Femoral Pulse: Palpated midway between ASIS and pubic symphysis (PT).
- Compression of superior pubic ramus, psoas major and femoral head will diminish flow through the artery.
- Cannulation: Inferior to the midpoint of the inguinal ligament; common for passing up to the left heart via the external iliac artery to the aorta.
Location of femoral vein
- Not palpable, located below inguinal ligament just medial to pulsating femoral artery.
- No tributaries at this level until the great saphenous about 3cm below inguinal ligament
(do not mistake for great saphenous vein if palpable!)
Patellar reflex
Tests the integrity of the femoral nerve and the L2–L4 spinal cord segments.
If the reflex is normal, a hand on the person’s quadriceps should feel the muscle contract.
Mech: activate muscle spindles in the quadriceps –> afferent impulses from the spindles travel in the femoral nerve to the L2–L4 segments of the spinal cord –> efferent impulses transmitted via motor fibers in the femoral n to the quadriceps –> contraction
Lumbar Spinal Nerve Root Compression
Lumbar spinal nerves inc in size inferiorly with dec. intervertebral foramina size.
(L5 = thickest nerve with narrowest foramen)
^Increased chance of nerve compression with bony spurs (osteophytes) or disc herniation
Lumbar spinal puncture
LP withdraws CSF from lumbar cistern below conus medullaris (retracted nerve cord at L1/L2) by inserting needle between L3/L4 or L4/L5 with spine flexed to open intervertebral space
Plane thru top of iliac crest marks line through L4
Spinal Epidural Block
Anesthetic injected into extradural (epidural) space as with LP, but w/o passing through the meninges
Spinal Cord Injuries
Cervical intervertebral disc dislocation or herniation –> spinal cord shock or paralysis inferior to lesion due to encroachment of the spinal canal
Also swelling of ligamenta flava, osteoarthritis of zygapophysial joints can pressure nerve roots of the cauda equina (in lumbar region) –> sensorimotor weakness in associated muscles
-Lumbar Spondylosis: Degenerative joint disease; causes localized pain/stiffness.
Spinal transection
Spinal Transection
C1-C3: No function below head; ventilator required.
C4-C5: Quadriplegia.
C6-C8: Low of lower limb function, variable hand/upper limb function.
T1-T9: Paraplegia; trunk control varies with lesion height.
T10-L1: Loss of lower leg muscle function; some thigh muscle fuction remains.
L2-L3: Most leg function retained, may require short leg braces.
Ischemia of Spinal cord
Fractures, dislocations, and fracture–dislocations, obstructive arterial disease –> may interfere with the blood supply to the spinal cord from the spinal and segmental medullary arteries
aorta can be purposely occluded during surgery, or with ruptured aneurysms –> loss of all sensation and voluntary movement inferior to the level of impaired blood supply to the spinal cord
Femoral hernia
Femoral ring –> medial to femoral triangle, a small, weak opening through which the abdominal viscera may pass to enter the femoral canal
results in a mass inferolateral to pubic tubercle and medial to femoral NAVL(H)
can pass out through saphenous opening, cause strangulation and necrosis of herniated intestine
Dif from inguinal hernia because NECK of the hernia is BELOW the inguinal ligament
women>men (wider pelvis)
Leg compartment infections
- Closed intraseptal/fascial compartments of leg suffer inc pressure with pus formation –> distal spread of infection in anterior/lateral compartments
- Posterior compart. infections may spread to popliteal fossa along fibular nerve, requiring fasciotomy to relieve pressure
Tibial Nerve Injury
Deep in popliteal fossa (rare injury) but deep lacerations may affect it (posterior dislocation of knee joint).
Causes paralysis of leg flexor muscles and intrinsic foot muscles.
Tibialis Anterior Strain
“Shin Splints”
- repetitive microtrauma to tibialis anterior along tibia periosteum
Common Fibular Nerve Injury
Most superficial nerve in lower limb (fibular neck). Splits into deep and superficial fib n.
Flaccid paralysis of anterior/lateral leg compartments (ankle dorsiflexors and foot evertors) causing footdrop (foot does not clear floor on swing phase (A)).
May present with (B) waddling gait, (C) swing-out gait or (D) steppage gait.
or loss of sensation to anterolateral leg and dorsum of foot.
Deep Fibular Nerve Entrapment
Excessive use of anterior leg muscles (tibialis anterior, extensor hallucis longus and extensor digitorum longus) –> EDEMA in anterior compartment compressing the nerve
Causes pain in dorsal of foot –> radiates to 1st webbed phase
Calcaneal Tendon
Rupture: Audible snap during push-off (plantarflexion with knee flexed) causing inability to plantarflex and excessive passive dorsiflexion (affects gastrocnemius, soleus, plantaris)
-Calcaneal Reflex: Tests S1/S2 nerve roots by tapping tendon, causing myotactic plantarflexion
Posterior Tibial Pulse
- Palpation between posterior surface of medial malleolus and medial border of calcaneal tendon
- Foot must be inverted to relax flexor retinaculum to allow palpation of the tibial artery deep to it
- Absence of pulse if age > 60: Sign of peripheral arterial disease, concomitant with intermittent claudication (pain during walking disappearing after rest.)
Dorsalis Pedis Pulse
- Palpated with feet dorsiflexed; feeling along extensor retinaculum lateral to EHL tendons
weak –> vascular insufficiency via arterial disease
- pain
- pallor
- paresthesia
- paralysis
- pulselessness
Compartment syndrome
Fracture causing increased pressure within a compartment also presents with 5P
- pain
- pallor
- paresthesia
- paralysis
- pulselessness
leg compartment syndrome can cause loss of DP pulse, ischemic loss of affected muscles. Treat with surgical decompression.
Femoral Neck Fractures
Closer the fracture through the neck (between greater trochanter and fem. head) is to the head, the greater the risk of damage to the blood supply (medial/lateral circumflex femoral arteries; retinacular branches) causing ischemic necrosis of the femoral head
Types of femoral neck fractures
Intracapsular fracture: Closer to femoral head, in joint capsule.
Extracapsular Fracture: Closer to greater trochanter, allows maintenance of blood supply.
Intertrochanteric fracture: between greater/lesser trochanters along intertrochanteric line
“Hip fracture”: shortened and externally rotated
Dislocation of Hip Joint
(Fem. Head from Acetabulum)
Loss of internal rotation common
Congenital Dislocation
No abduction, appears shortened, adducted, medially rotated, with positive Trendelenberg sign (hip drops toward affected side)
Posterior Dislocation
Common in car accidents (hip is flexed, adducted, medially rotated when seated), shifts femoral head posteriorly (superior to acetabulum)
-May compress/stretch sciatic nerve –> paralysis in hamstrings and tingling in posterolateral aspects of leg and much of foot
Anterior Dislocation
Force hip into extension, abduction, lateral rotation, pushing femoral head inferior to acetabulum
Q-angle
Angle between line from ASIS to middle of patella and line through middle of patella and tibial tuberosity.
Normally places weight on interchondylar region of knee
Genu Varum
Medially shifted weight bearing (causing athrosis of knee cartilage), decreased Q-angle. (medial knee)
BOWLEG
fibular collateral ligament is overstressed
Genu Valgum
Laterally shifted weight bearing (athrosis of LCL and lateral meniscus). (lateral knee)
KNOCK KNEES
Tibial nerve entrapment
- Tibial nerve passes deep to flexor retinaculum between medial malleolus and calcaneus.
- Edema/tightness in ankle from tendons of posterior leg compartment causing compression of tibial nerve by flexor retinaculum = heel pain. (tarsal tunnel syndrome)
Caudal Epidural Anesthesia
Inject local anesthetic through sacral hiatus (piercing sacrococcygeal ligament) into fatty tissue surrounding filum terminale.
- Bony Landmarks: -Inferior to S4 Spinous Process.
- Between Sacral Cornua.
- Anesthetic acts on S2-Co1 spinal nerves of cauda equina, spreads inferiorly.
Transsacral Epidural Anesthesia
Inject through posterior sacral foramina from S1-S5
Herniation of Nucleus Pulposis
Herniation extends posterolaterally (thin end of annulus fibrosis, no anterior/posterior longitudinal ligaments for support)
- Rapid hyperflexion or rotation (compression) of vertebral column can rupture IV disk, fracture vertebrae
- Can cause LBP (acute local pain; pressure on longitudinal ligaments and inflammation) and low limb pain (chronic; referred to dermatome supplied by damaged nerve; common in lumbar/sacral spine)
Thoracic/Lumbar protruding disk usually compresses…
…nerve root inferior to it (ex: L4-L5 protrusion = L5 damage; nerve roots exit inferiorly)
Cervical protruding disk usually compresses…
nerve root at same level, but nerve root exits superior, so numerically inferior root is damaged (ex: C5-C6 prot. = C6 damage)
Sciatica
Herniated L5 or S1: Low back + radiated hip, posterior thigh to leg pain.
Osteophytes around zygapophysial joints decrease IV foramina further.
Sciatic nerve stretch = pain (flex thigh with extended knee; straight leg-raising test).
Structures that receive innervation in the back and can be sources of pain
Periosteum, Ligaments,
Annuli Fibrosi of IV discs
Meninges covering spinal cord (rare)
Synovial Joints (Zygapophysial) –> aging, osteoarthritis
Intrinsic Back Muscles –> muscular pain, spasms –> ischemia, secondary to guarding
Spinal Nerves, nerve Roots (out IV foramina) –> com via herniated discs
Trochanteric Bursitis
Inflammation of trochanteric bursa (beneath iliotibial tract on lateral surface of greater trochanter), gmax rubbing with superior tendinous fibers against the bursa.
-Pain radiates from lateral thigh down IT tract to tibia.
Ischial Bursitis
Commonly caused by repetitive seated hip extension (cycling, etc) causing repetitive rubbing of the bursa between gmax and the ischial tuberosity
Hamstring Injuries
avulsion of proximal tendons attaching hamstrings to ischial tuberosity
often w/ sub-fascia late hematoma
avulsion of ischial tuberosity due to hip extension and knee flexion
Superior Gluteal Nerve Injury
Gluteus medius limp (compensation for weakened thigh abduction by g med/min)
Gluteal gait: compensatory tilt to weakened gluteal side
Severe impairment of medial rotation of lower limb and abduction
sags on UNSUPPORTED SIDE (trendelenberg sign)
Sciatic nerve injury
piriformis syndrome (compression of sciatic nerve by muscle)
Complete sciatic section (all hip rotation/ extension, leg flexion, ankle/foot movements lost)
Medial buttock–> danger side (vulnerable sciatic nerve branches to hamstrings)
Lateral buttock –> upper quadrant is safe for intragluteal injections
Popliteal pulse
Lay prone with flexed knee to relax popliteal fascia/hamstrings, felt in inferior part nearest tibia.
weak –> may be a sign of femoral artery obstruction
Popliteal Aneurysm
abnormal dilation of popliteal artery –> pain/edema in popliteal fossa showing thrills and bruits (pulsations and abnormal sounds)
-May compress tibial nerve laying superficial to it, causing referred pain to medial calf, ankle, or foot
Popliteal Hemorrhage
Fracture or dislocation of inferior femur or joint capsule –> may rupture popliteal artery, or cause arteriovenous fistula between popliteal artery/vein
With ligation to femoral artery, blood can bypass through geniculate anastomosis to the popliteal artery distal to the ligation
Patellar dislocation
usu laterally dislocated
Q-angle represents angle of pull of quadriceps relative to patella-tibial axis
counterbalanced by medial pull from vests medialis
Ligament sprains
foot fixed in ground w/ force on knee
damage to LCL/MCL and lateral/medial meniscus
caused by lateral blow to extended knee or lateral twisting of flexed knee
Unhappy triad
rupture of MCL (via excessive abduction - lateral blow)
tearing od ACL (via fwd tibial displacement, test w/ Lachman)
injury to medial meniscus (via tearing firmly attached MCL)
Prepatellar Bursitis
Inflammation and swelling of prepatellar bursa (from skin-patella friction or compressive force on flexed knee thus “housemaid’s knee”)
visible as swelling anterior to knee
Subcutaneous Infrapatellar Bursitis
Excessive friction between skin and tibial tuberosity, with swelling on proximal tibia end (near knee)
Popliteal Cysts (Baker’s Cysts)
Swelling behind knee due to escape of synovial fluid posteriorly (complication of knee effusion) from the joint preventing flexion and extension
Ankle Injuries
Usually inversion injury
anterior talofibular ligament (pt of lat ligament) is most comm. sprained
shearing injury (fracture lateral malleolus superior to anklee joint)
Pott-fracture
forced eversion –> deltoid ligament avulses medial malleolus –> talus moves laterally shearing off lateral malleolus
trimallaeolar fracture can occur (posterior margin of tibia is sheared off)
kyphosis
Inc thoracic curvature (humpback)
due to anterior osteoporosis (elderly)
osteoporosis –> damages horizontal trabeculae in vertebral bodies, causing compression fractures = short, wedge-shaped thoracic vertebrae and overall shortening.
Lordosis
Anterior tilting of pelvis (Nutation: sacral flexing/anteroinferior rotation.)
w/ abnormal increase in lumbar kyphosis.
Often caused by weak trunk musculature (abdominals) or obesity (due to inc abdominal weight)
scoliosis
Abnormal lateral spine curvature.
Abnormal vertebral rotation causing rib protrusion on side of inc convexity
structural scoliosis
congenital, poss due to failed vertebral development (hemivertebra)
Functional scoliosis
due to difference in length of lower limbs, causing compensatory pelvic tilt
Myopathic scoliosis
due to asymmetric weakness of intrinsic back muscles
habit scoliosis
due to habitual, improper postures
