Case 17 Flashcards by Ffion Haf

What are the boundaries of the femoral triangle?

Superior: inguinal ligament (base)
Medial: adductor longus
Lateral: sartorius
(apex is where adductor longus and sartorius cross)

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What’s inside the femoral triangle?

Femoral vein, artery, nerve (VAN - medial to lateral)

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Which fascial extension surrounds the femoral vessels?

Femoral sheath (fascial extension of abdomen)

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What is screening?

Finding apparently healthy people who may be at increase risk of a disease/ condition
Can then be offered info, further tests, treatment to reduce risks/ complications of disease

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What does sensitivity detect?

Correctly identifies those with the condition

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What does specificity detect?

Correctly identifies those without the condition

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Use these phrases to create formulae for sensitivity and specificity;
true positive 
false positive
false negative 
true negative

Sensitivity = true positives/ (true + false positives)

Specificity = false negatives/ (false + true negatives)

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What does positive predictive value mean?

Probability that someone with a positive screen result has the condition

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What does negative predictive value mean?

Probability that someone with a negative screen result does not has the condition

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What have studies shown people with less power, status and money to blame their illnesses on?

External factors

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What are health differences between genders or ethnic groups mostly due to?

Social structures

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What is the largest ethnic minority group?

South Asian ethnic origin

Indian, Pakistani, Bangladeshi descent

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What is ethnicity?

Refers to a person’s identification with a social group – on the basis of shared values, beliefs, customs, traditions, language, and lifestyles

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Does UK mortality data include information on ethnic group?

No only country of origin recorded on death certificate

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What is the principle within in NHS in regards to self reported identity?

Person should self-assign their ethnic group

Individual’s own identity takes priority

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What are the 7 explanations for the ethnic patterning of health & disease? (Davey Smith et al)

Artefact 
Biological 
Socio-economic 
Culture beliefs and behaviour 
Effects of migration 
Racism (social stress/ institutional racism)
Health service and access use

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What does an artefact explanation draw attention to?

The processes involved in data collection and measurement

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What does research suggest are the reasons why south asians have high rates of CHD?
How is this racialization of culture?

Cultural practice of cooking with ghee (butter made from the milk of a buffalo/ cow), not exercising or not making best use of medical facilities
Victim blaming
Assumes all south asians are culturally similar in diet and lifestyle
Ignored socio-economic impacts

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What’s the largest ethnic minority group in the UK?

South Asian Indian

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What has research found about ageing and ethnicity?

Ethnic inequalities in health are most pronounced at older ages

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What is social cohesion?

Implies feeling part of a society/ social group

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What’s inside the femoral canal?

Loose connective tissue
Fat
Lymphatic vessels
Sometimes a deep inguinal lymph node - cloquet node

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What are the compartments of the femoral sheath and what to they contain?

Lateral compartment - femoral artery
Intermediate compartment - femoral vein
Medial compartment - femoral canal

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How can direct inguinal and femoral hernias be told apart?

Direct inguinal hernia - medial and superior to pubic tubercle, rare to compress femoral vein

Femoral hernia - lateral and inferior to pubic tubercle, can compress femoral vein, firmer than inguinal hernia, more prone to strangulation (narrow neck of femoral ring)

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Which nerve is affected in meralgia paraesthetica?

Lateral cutaneous nerve of thigh

What is meralgia paraesthetica?

Trapping or compression of lateral cutaneous nerve of thigh beneath the inguinal ligament Causing altered sensation/ sensory symtoms in upper outer thigh (L2)

Which cutaneous nerve supplies the inner lower leg including the medial malleolus?

Which cutaneous nerve supplies the outer lower leg?

Which cutaneous nerve supplies the lateral side of foot and lateral malleolus?

What's the cutaneous innervation of the medial lower leg?

Saphenous nerve

What's the cutaneous innervation of the lateral lower leg?

Lateral sural cutaneous nerve

What's the cutaneous innervation of most of the dorsal surface of the foot?

Superficial fibular nerve becoming dorsal digital nerves

What's the cutaneous innervation between the big toe and 2nd toe?

Deep fibular nerve

What's the cutaneous innervation of the dorsal side of the lateral foot?

Lateral dorsal cutaneous nerve of foot

What's the cutaneous innervation of most of the anterior thigh?

Anterior cutaneous branches of femoral nerve

What's the cutaneous innervation of the upper, outer thigh?

Lateral cutaneous nerve of thigh

What's the cutaneous innervation of the upper, inner thigh?

Cutaneous branch of obturator nerve

What's the cutaneous innervation of the heel?

Medial calcaneal branches of tibial nerve

What's the cutaneous innervation of plantar surface of the lateral foot?

Lateral plantar nerve

What's the cutaneous innervation of the majority of the plantar surface of the foot?

Medial plantar nerve

What's the cutaneous innervation of the middle of the posterior lower leg including the lateral malleolus?

Sural nerve

What's the cutaneous innervation of the majority of the posterior thigh?

Inferior clunial nerve of thigh

What's the cutaneous innervation just inferior to posterior knee?

Posterior cutaneous nerve of thigh

What's the blood and nerve supply of the anterior compartment of the lower leg?

Blood: Anterior tibial artery Nerve: Deep fibular nerve

What's the blood and nerve supply of the lateral compartment of the lower leg?

Blood: Branches of fibula artery Nerve: Superficial fibular nerve

What's the blood and nerve supply of the posterior (deep and superficial) compartment of the lower leg?

Blood: Posterior tibial artery Nerve: Tibial nerve

What is compartment syndrome and how can it be treated?

Haemorrhage, inflammation of muscles or oedema in the compartment leads to an increase in intracompartmental pressure Compression Structures distal to compression become ischaemic Fasciotomy (incision of fascia/ septum) performed to relieve pressure

What clinical signs may confirm compartment syndrome?

Arterial compression - loss of distal leg pulses, lower temperature distal to compression

What are the 3 muscles of the superficial posterior compartment of lower leg?

Gastrocnemius Soleus Plantaris

What are the 4 muscles of the deep posterior compartment of lower leg?

Popliteus Flexor hallucis longus Flexor digitorum longus Tibialis posterior

What structures pass posterior to the medial malleolus on their way to the foot?

Flexor hallucis longus, Flexor digitorum longus, Tibialis posterior tendons (from deep posterior compartment of leg) Posterior tibial artery Tibial nerve

In which order do the tendons pass through the osteofascial tunnel posterior to the medial malleolus?

``` Tom, Dick and Harry (anterior to posterior) Tibialis posterior (anterior - closest to malleolus) flexor Digitorum longus flexor Hallucis longus (posterior - furthest from malleolus) ```

The structures passing posterior to the medial malleolus on their way to the foot, run beneath what?

Flexor retinaculum

What do the tibial nerve and posterior tibial artery divide into before entering the foot?

Medial and lateral plantar arteries/ nerves

What happens to the valves in varicose veins?

Valves dilate/ rotate/ do not function | Blood flows inferiorly

Which vessel is commonly become varicose?

Small saphenous vein

What does the great saphenous vein drain into?

Femoral vein

What does the small saphenous vein drain into?

Popliteal vein

Which vessels drain the foot?

Dorsal venous arch | Plantar arch

Which vessels are likely to be damaged from intracapsular femur fracture?

Retinacular arteries from mainly medial circumflex artery

Do extracapsular femur fractures usually compromise blood supply to the femoral head?

In an intracapsular femur fracture damaging the medial circumflex artery, what may be the only remaining blood supply to the head of the femur?

Artery to the head of femur (branch of obturator artery) - traverses ligament of the head

What would point tenderness at proximal attachment of plantar aponeurosis to medial tubercle of calcaneus suggest?

Plantar fascitis (straining and inflammation)

What gives rise to the dorsalis pedis artery?

Popliteal artery becomes anterior tibial artery becomes dorsalis pedis artery

Which 2 muscles make the lateral compartment of the lower leg?

Fibularis longus | Fibularis brevis

Which artery at the ankle is used for the ankle-brachial pressure index (ABI)?

Posterior tibial artery

What is the ankle-brachial pressure index (ABI)?

Ratio of systolic blood pressure at ankle compared to brachial artery Used to determine competency of arterial vessels in the lower limb and to diagnose probable peripheral artery disease

What is normal ABI?

Ankle pressure greater than elbow (normal) | 1 - 1.4

What ABI is suggestive of peripheral artery disease?

Less than 0.9 Less than 0.8 - moderate PAD Less than 0.5 - severe PAD (moderate to severe refer to vascular specialist)

Where can the femoral pulse be found?

Just inferior to mid-inguinal point

Where can the popliteal pulse be found?

Midline of popliteal fossa - easier if knee is flexed as it relaxes the popliteal fascia

Where can the posterior tibial artery be found?

Behind medial malleolus | Between flexor hallucis and digitorum longus

Where can the dorsalis pedis pulse be found?

Lateral to extensor hallucis longus tendon