Case 25- Falls and Anatomy Flashcards
Fall definition
A fall is an event which results in a person coming to rest inadvertently on the ground or floor or other lower level
The 3 types of balance
Static/ dynamic steady state- ie maintaining a steady position in sitting, standing)
Proactive- anticipation of predicted disturbance
Reactive- compensation with a disturbance
Walking needs all 3
Systems we need to stand and walk?
1) Afferent systems (sensory and pathways to CNS)- vision, hearing, vestibular system, proprioceptors, stretch receptors, afferents nerves
2) Spinal reflexes – spinal function and integrity of nerve pathways
3) Autonomic nervous system- vasovagal, autonomic stability
4) Cognitive Processing dementia, delirium , depression, Basal Ganglia, thalamus, cerebellar, cortical function (strokes, parkinsons, huntingtons, etc)
5) Optimal perfusion to the brain-cardiac output, arrhythmias, hypotension, autonomic instability
6) Efferent systems (motor pathways and effect on locomotor system) efferent pathways, joints, muscles, biomechanics, gait, sarcopenia
7) Other factors- bone strength, confidence (fear of falling). coping strategies, co-morbidity
Sarcopenia
Humans loose approx. 20-30% of their skeletal muscle mass between young adulthood and 80y . The loss isn’t equal- type 2 muscle fibres are predominantly lost which results in a greater decline in power compared to strength- muscle power is needed for quick postural reactions.
Things to do to reduce risk of falls
Visual correction is the most effective thing to do- fix cataracts, get new glasses etc
The second most effective thing is treating general balance and strength issues
Gait and falls
1) Visual difficulties- small hesitant uncertain steps
2) Vestibular- tend to veer to one side- often staggering to correct for this
3) Sensory- polyneuropathy means people cannot feel their feet – as a response to this and to maximise sensory input they tend to stamp their feet
4) Anxiety- hesitant, leaning slightly forwards looking at feet. Is a response to fear of falling but actually increases risk of fall as centre of gravity tilted forwards and less sensory input from eyes about surroundings.
5) Higher motor function- hemi-plegic gait from a stroke – unilat weakness
How does the Mid brain affect gait
Parkinsonian shuffling gait
Choreiform- uncontrolled writhing movement
Pathology which can cause gait changes
Cerebellar- ataxic “drunk” like wide based gait
Spinal lesions- diplegic gait- bilateral spasticity and weakness in muscles- scissoring gait
Myopathic gait- trendelenberg gait- waddling
Neuropathic gait- high stepping/ equine as cant dorsiflex foot so it would catch otherwise.
Pain- Antalgic gait
Conditions that may present as ‘falls’
Benign Paroxysmal positional vertigo Parkinson’s Disease Orthostatic hypotension Visual Impairment OA hips / knees/ ankles New diagnosis dementia Depression and anxiety Drug adverse effects Spinal stenosis Sarcopenia Peripheral neuropathy
Consequence of falls
1) Fear of falling
2) Impact on confidence/activity level/independence
3) Fractures and trauma- osteoporosis assement
History of falls
1) When does it happen? (posture/ position change/ situational/ precipitants?)
2) What happens? Detailed description of events, associated features, LOC, prodrome?, what happens afterwards?
3) Why do they think it happens?
4) What do they do when it happens or to stop it happening?
5) How is it affecting AODL?
A multifactorial assessment of a fall may include
1) Chronic conditions that affect mobility or balance (including arthritis, diabetes mellitus, stroke, Parkinson’s disease, and dementia).
2) Gait, balance, and mobility problems.
3) Osteoporosis risk.
4) Perceived impaired functional ability and fear relating to falling.
5) Visual impairment.
6) Cognitive, neurological, and cardiovascular problems.
7) Urinary incontinence.
8) Home hazards.
9) Polypharmacy (the use of multiple drugs) and the use of drugs that can increase the risk of falls, for example drugs that can cause postural hypotension (such as antihypertensive drugs) and psychoactive drugs (such as benzodiazepines and antidepressants).
Different meanings of dizziness
Light headedness (presyncope)- normally cardiovascular
Dysequilibrium/ Unsteadiness- experiment-normally due to poor vision or balance or peripheral neuropathy
Vertigo – the illusion of movement- normally to do with the vestibular system usually presents with nystagmus
Causes of abnormal gait
Antalgic gait (pain) Parkinsonian gait (extra pyramidal) Ataxic gait (cerebellar) High Stepping gait (neuropathic/ equine ) Cautious/ hesitant gait (anxiety/ fear of falling) Hemiplegic gait (unilateral weakness) Diplegic gait (bilateral weakness with spasticity) Waddling gait (Trendelenberg gait) – myopathic Stamping gait (peripheral sensory neuropathy)
What to test for in an examination of falls
Higher functions- Mood, Memory
Neurology- Vision, vestibular testing, cranial and peripheral, sensory, Rhomberg, Cerebellar signs (DANISH)
Cardiovascular- Heart sounds, Heart rhythm (ECG), Postural hypotension
MSK- Gait, joints, muscle strength, sit to stand, balance assessment, feet and footwear
Treatment/Interventions for falls
Adapt the treatment to the underlying cause
Safety
Reasonable adaptions
Goals of care
Falls- strength and balance training
Evidence based- improves physical, mental and functional performance.
3 of the most common modifiable risk factors for falls are- Muscle weakness, Balance deficits, Gait instability
Anatomy of the hip joint
- Femero-acetabular joint
- Ball and socket synovial
- Head of femur articulates with acetabulum (vinegar cup)
- Articular surfaces lined with hyaline cartilage, the non-articular surfaces are covered with synovial membrane. The Hyaline cartilage lines the acetabulum at the lunate surface in the fossa, The hyaline cartilage lines the head of the femur except the fovea
- Ilium, ischium and pubis form hip bone (innominate bone) and meet at acetabulum
Triradiate cartilage
Separates the Ilium, Ischium and the Pubis
Proximal femur- anterior view
Greater trochanter- on the lateral side, the lesser trochanter is on the medial side and inferior, they are connected by the Intertrochanteric line which forms the margin between the neck and shaft of the femur.
Proximal femur- anterior view
Greater trochanter- on the lateral side, the lesser trochanter is on the medial side and inferior, they are connected by the Intertrochanteric line which forms the margin between the neck and shaft of the femur.
Muscles which attach to the greater trochanter
- Gluteus medius
- Gluteus minimus
- Piriformis
- Superior gemellus
- Obturator internus
- Inferior gemellus
Proximal femur- posterior view
- Lesser trochanter- Iliopsoas attaches here
- Quadrate tubercle- Quadratus femoris attaches here
- Gluteal tuberosity -Gluteus maximus attaches here
- Pectineal line- Pectineus attaches here
- Linea aspera – where the Gluteal tuberosity and Pectineal line combine,
- Intertrochanteric crest- raised crest between the lesser and greater trochanter
What attaches at the Linea aspera
- Vastus lateralis and medialis
- Adductor brevis, longus, magnus
- Biceps femoris (short head)
- Intermuscular septa
Intrinsic ligaments of the hip- anterior
- Iliofemoral ligament- from the Ileum to the Femur, supports the anterior aspect of the joint
- Pubofemoral ligament- from the pubis to the Femur. Supports the anteromedial aspect of the joint
- Stabilises the hip joint so it can support the body weight and for its involvement in locomotion. Stronger then shoulder joint but has a narrower range of movement
- Joint is completely surrounded by the ligaments
Intrinsic ligaments of the hip- lateral
- Iliofemoral ligament
- Ischiofemoral ligament- from the ischium to the femur, supports the posterior aspect of the joint
- Pubofemoral ligament
Ligaments of the femero-acetabular joint
- Ligament of the head of the Femur- connects the fovea on the head of the femur to the acetabulum. Blood supply by the artery of ligament of head of femur
- Fibrous capsule of the acetabulofemoral joint- strong to support the joint
- Acetabular Labrum- Fibrous capsule which surrounds the joint making it deeper
- The artery to the Ligament head of Femur is also called the Acetabular branch of Obturator. Only functions in children and young adults, in adults it becomes a ligament. In adults the blood supply to the femur comes from the lateral and medial circumflex femoral artery
- Acetabular fossa- bony part of the Acetabulum
- Fat pad- cushioning of the joint
- Synovial folds- formed from the synovial membrane
- Only 50% of the femur at any one time articulates with the Acetabulum
- Orbicular zone- fibres of the joint capsule which condense together
Muscles responsible for hip movement
- Gluteal muscles (Abductors, extensors, rotators)
- Anterior thigh muscles (Flexors)
- Medial thigh muscles (Adductors)
- Posterior thigh muscles (Extensors)
Nerve supply to the thigh muscle
- Gluteal muscles: Superior (L4-S1) and inferior (L5-S2) gluteal nerves. Nerve to piriformis (S1-S2). Nerve to obturator internus (L5-S2). Nerve to quadratus femoris (L4-L5).
- Flexors: Femoral nerve L2-L4 (Posterior divisions of anterior rami of L2-L4)
- Adductors: Obturator nerve L2-L4 (Anterior divisions of anterior rami of L2-L4)
- Extensors (thigh): Sciatic nerve L4-S3 (Tibial division)
Nerve supply: Hilton’s law
- Nerves to muscles which move a joint also provide sensory innervation to the joint
- Gluteal and thigh muscles have actions on hip joint
- Same nerves supply muscles and joint itself (capsule, ligaments, synovial tissue).
Gluteal nerves
- Come from the Lumbrosacral plexus
- Superior gluteal nerve- comes through the greater Sciatic foramen, superior to the piriformis and supplies the Gluteus minimus, the Gluteus medius and the Tensor fascia lata
- Inferior gluteal nerve- exits the pelvis through the greater sciatic foramen, inferior to piriformis. Supplies the Gluteus maximus
- Nerve to piriformis
- Nerve to obturator internus- supplies the superior Gemellus and the obturator internus muscle
- Nerve to the quadratus femoris- supplies the inferior gemellus and the Quadratus femoris
- Obturator nerve- supplies the Gluteal region
Obturator and thigh nerve
Thigh nerves- Tibial division of the Sciatic nerve supplies the hamstring which act on the hip joint
Obturator nerve- supply the adductors in the medial compartment of the thigh. Goes through the obturator canal and the obturator foramen. The Adductor muscles= Adductor longus, Adductor brevis, Adductor magnus and Gracilis
Hip joint blood supply
- Primarily the blood supply comes from the Femoral artery which is a continuation of the external iliac as it comes down under the inguinal ligament
- As the Femoral artery enters the Femoral triangle it gives off a branch called the Deep (profunda Femoris) artery
- The Profunda Femoris gives off two branches= the Lateral and medial circumflex femoral arteries and the Perforating branch. The Lateral and medial circumflex femoral arteries go around the neck of the Femur
- The superior gluteal artery comes over piriformis and the inferior gluteal artery goes under piriformis. They anastomose with the lateral and medial circumflex femoral arteries and the first perforating branch.
Hip joint blood supply: Anastomoses
- Cruciate anastomoses- between the inferior gluteal artery, the lateral and medial circumflex artery and the 1st perforating branch
- Trochanteric anastomoses= Superior gluteal artery, Inferior gluteal artery, Lateral and medial circumflex artery
Issues when blood supply to the hip joint is disrupted
Fractures to the hip joint can disrupt the blood supply which can lead to avascular necrosis of the femur and the hip joint
Superior gluteal artery and profunda femoris
Superior gluteal artery- supplies gluteal muscles and the hip joint
Profunda femoris- branch of the femoral artery
Gluteus maximus
- Action- hip extension and lateral rotation
- Innervation- inferior gluteal nerve
- Originates on the Ileum and the Sacrum and inserts on the Gluteal tuberosity which is on the posterior femur superior to the linea aspera
Gluteus medius
- Action: Hip Abduction, medially rotate thigh
- Innervation: Superior gluteal nerve
- Deep to the Gluteus maximus. Originates on the Ileum and inserts on the greater trochanter of the femur
Gluteus medius
- Action: Hip Abduction, medially rotate thigh
- Innervation: Superior gluteal nerve
- Deep to the Gluteus maximus. Originates on the Ileum and inserts on the greater trochanter of the femur
Gluteus minimus
- Action- Hip Abduction, medially rotate thigh
- Innervation- Superior gluteal nerve
- Inferior to the Gluteus medius. Originates on the Ileum and inserts on the anterior aspect of the greater Trochanter of the femur
Rotator muscles of the hip
Piriformis, Superior gemellus, Obturator internus, Inferior gemellus and the Quadratus femoris (from superior to inferior). They act to laterally rotate the extended thigh, Abduct the flexed thigh and stabilise the femoral head in the acetabulum
Piriformis
• Action: Hip rotation
Innervation: Nerve to piriformis
Originates on the sacrum and inserts onto the greater trochanter, crossing the hip joint
• Goes through the greater sciatic foramen
• The greater sciatic nerve originates inferior to the piriformis
Obturator internus
- Action: Hip rotation, stabilises the femoral head
- Innervation: Nerve to obturator internus
- Originates from the obturator foramen, inserts on the greater trochanter
Gemelli
- Superior and Inferior gemellus
- Action: Hip rotation, abduction of the flexed thigh and stabilising the joint
- Innervation: Nerve to obturator internus (superior), nerve to quadratus femoris (inferior)
- The superior gemellus originates from the ischial spine and the inferior gemellus from the ischial tuberosity and they both insert on the greater trochanter
Quadratus femoris
- Action: Hip rotation, stabilises the hip joint
- Innervation: nerve to quadratus femoris
- Originates from the ischial tuberosity and inserts on the Quadrate tubercle which is a raised area of the intertrochanteric crest on the femur
Anterior thigh: Iliopsoas
- Action: hip flexion
- Innervation: Femoral (L2-L4)
- Combination of Iliacus and Psoas major. The Iliacus originates from the Ileum, the Psoas major originates from the vertebral column. Travel under the inguinal ligament and combine to form the Iliopsoas muscle. Then inserts on the lesser trochanter
Anterior thigh: Quadriceps
- Rectus femoris, Vastus lateralis, Vastus medialis, Vastus intermedius
- Action: Hip flexion (Rectus femoris only)
- The rectus femoris muscle is the only Quadricep to cross the hip joint
- Inserts on the Patella
- Innervation: Femoral (L2-L4)
Anterior thigh: Sartorius
- Action: Hip flexion, abduct thigh, laterally rotate thigh, flex leg at knee
- Innervation: Femoral (L2-L4)
- Originates on the Anterior Superior Iliac Spine and inserts on the medial aspect of the proximal end of the tibia (Pes anserine). Crosses from lateral to medial side
Posterior thigh: Hamstrings
- Action: Hip extension
- Innervation: Sciatic nerve (L4-S3) (Tibial division)
- Bicep femorosis, Semitendinosus and Semimembrinosus
- Goes from pelvis to tibia
Medial thigh: Adductors
- Action- hip adduction
- Innervation: Obturator (L2-L4)
- Hamstring (ischiocondylar) part of adductor magnus extends the hip and is innervated by the sciatic nerve (tibial division)
- Medial muscles- Pectineis, Adductor brevis, Adductor longus (also forms the boundary of the femoral triangle) and Gracilis (inserts on the pes anserine), Adductor magnus
- The Adductor magnus has two parts, it has an adductor part and a Hamstring part which extends the hip. The adductor part of the adductor magnus is supplied by the obturator nerve, the hamstring part is supplied by the tibial division of the Sciatic nerve
