Clinical Correlations Flashcards
1
Q
What causes meralgia paresthetica?
A
Pressure on the Lateral Femoral Cutaneous N. (L2,3)
2
Q
What are the symptoms of meralgia paresthetica?
A
Variable temperature sensations in the thigh
3
Q
Describe the pathological progression of ischial/throchanteric bursitis
A
Friction bursitis pathologic progression: fluid filled spaces, friction rub, inflammation, fibrosis, ca++ deposits, rupture of bursa or associated tendon
4
Q
Describe creatine kinase
A
An enzyme (three isoforms, found in the heart, brain, lung & skeletal muscle) which catalyzes the conversion of phosphocreatine + ADP → ATP (it also does the reverse rxn). Increased serum CK is an indication of; MI, rhabdomyolysis, muscular dystrophy, myasthenia gravis, myositis, acute renal failure, and certain drug use (Acronym = “MRDRD)”.
5
Q
Carnitine Deficiency Syndrome
A
Several etiologies, and symptoms can be dynamic. Primary = defective carnitine transporter, so FA can’t get past the outer mitochondrial membrane. Secondary = Carnitine inaccessible because it cannot be removed from acyl group, (eg a problem with CPT-II). The result is a significant reduction of beta-oxidation
6
Q
Describe Fatty Acid Transport Defects
A
Several etiologies (eg deficiency in CPT I (on inside of outer membrane), CPT II (on inside of inner membrane), or a defect in carnitine/acylcarnitine translocase). Also results in a significant reduction of beta-oxidation.
7
Q
Defects of beta-oxidation (Mitochondrial) enzymes
A
Most present with myopathic symptoms or signs that are usually progressive, but dynamic symptoms may also be observed (Recall that long-chain FAs represent a major source of energy for prolonged, low-intensity exercise lasting more than 40-50 minutes.
8
Q
Describe AMP deaminase deficiency
A
The enzyme which converts 2 AMP → ATP + IMP + NH3. Deficiency of this enzyme is a common cause of exercise-induced myopathy, and probably the most common cause of metabolic myopathy in humans.
9
Q
+ EMG and - NCV indicates what?
A
Myopathy
10
Q
+ EMG and + NCV indicates
A
Neuropathy
11
Q
Describe myasthenia gravis
A
Immune mediated loss of Ach receptor → decreased ability to generate an end-plate potential → muscle weakness. Although nerve conduction is normal, motor response diminishes after repeated stimulation. 9
12
Q
What percentage of patients show opthalmological manifestations of myasthenia gravis? What are the manifestations?
A
90%
Ptosis, blurred vision and general weakness
13
Q
What worsens the symptoms of myastenia gravis?
A
Increased activity worsens fatigue and weakness
14
Q
What can be used to treat myasthenia gravis? How does it work?
A
Edrophonium/Tensilon (an acetylcholinesterase inhibitor), which inhibits the breakdown of Ach, thus allowing ACh to accumulate in the NMJ.
[Ach] ↑ at the muscle end plate -> increased muscle strength. Application of ice packs also slows AChE enzyme, so it provides similar (but short term) effects to patients presenting with ptosis.
15
Q
What is the mechanism behind Lambert–Eaton myasthenic syndrome (LEMS, a paraneoplastic syndrome)?
A
mmune mediated attack directed against voltage-gated calcium channels (VGCCs) on the presynaptic motor nerve terminal → loss of functional VGCCs → Ca-mediated exocytosis is greatly diminished.
16
Q
What is a noteable difference between myasthenia gravis and Lambert–Eaton myasthenic syndrome?
A
Unlike myasthenia gravis, repeated stimulation → enough Ca-influx via functioning channels to trigger synaptotagmin (T-snare) → exocytosis of ACh-containing vesicles.
17
Q
How do tetanus and botulinum toxins function? Symptoms?
A
hether Tetanus or Botulinum, these neurotoxin endoproteinases target the snare complex. Whether they target V-snares or T-snares, fusion of ACh-containing vesicles is blocked → dry mouth, double vision, difficulty swallowing and speaking, vomiting and diarrhea (Botox)
18
Q
Hyperkalemic Periodic Paralysis is an utosomal dominant trait which affects the skeletal muscle gene SCN4A, located on chromosome 17. What is the mechanism of action?
A
This mutation impairs fast-inactivation of voltage-gated Na+ channels → Small, persistent influx of Na+ → Depolarizes the membrane → hyperexcitability.
19
Q
What clinical symptoms are associated with hyperkalemic periodic paralysis?
A
Clinically, severe muscle myotonia, weakness and/or paralysis are observed during a period of rest AFTER exercise, stress, fasting, or ingestion of large amounts of K+ (eg bananas).
20
Q
Malignant Hyperthermia - a rare, autosomal dominant trait, which results in a defective __________.
A
RYR1 gene, impacting ryanodine on the sarcoplasmic reticulum membrane.
21
Q
Describe malignant hyperthermia
A
his disorder of Ca regulation in skeletal muscle → uncontrolled release of Ca2+ from the SR → rigidity, tachycardia, hyperventilation, and hyperthermia & acute hyper-metabolic state within muscle tissue (prolonged contraction). MH can be triggered by volatile anesthesia and muscle relaxers, resulting in a potentially fatal increase in body temperature.
22
Q
Describe Multiple Sclerosis
A
A T-cell mediated autoimmune disorder, in which myelin in CNS (produced by oligodendrocytes) is attacked by one’s own immune system.
23
Q
Trigger and age of onset of MS? What neurons are impacted? What is the lost myelin replaced with?
A
Trigger is unclear, middle age onset.
Both sensory and motor neurons impacted.
Scar tissue, substantially reducing conduction velocity
24
Q
What often worsens MS symptoms? Conversely, what often improves them?
A
Symptoms in patients with M.S. are often worsened with increased body temperature, which affects the gating kinetics of voltage-gated Na+ channels. Treatments include cooling temperature and K+ channel blockers (which slow the repolarization phase, and prolong the AP)
25
How do local anesthetics function?
Inhibits VG Na+ channels, thus conduction of APs in the axon
26
How does Tetrodotoxin (puffer fish poison) function?
Works essentially the same as local anesthetic, high doses → muscle paralysis (including paralysis of the diaphragm)
27
How do Acetylcholinesterase Inhibitors (Rx name is Edrophonium/Tensilon) work? What are some uses?
revents the recycling of Ach from the synapse.
Used to treat Myasthenia gravis, and sometimes dementia (Alzheimer's or Parkinson’s) but not as effective. Also used as a chemical weapons.
28
Describe Curare Alkaloids
A class of drugs which are neuromuscular blocking agents. Used for causing muscle paralysis during anesthesia. It is a competitive antagonists that targets the nACh receptor, and so DOES NOT allow depolarization → paralysis
29
How does Succinylcholine work?
Also a neuromuscular blocking agent, used for causing muscle paralysis during anesthesia. It is an agonist which targets the nACh receptor and so DOES allow depolarization. It’s first action is to initially bind & open the channel, but with subsequent APs → receptor is occupied by succinylcholine → paralysis.
30
What does dantrolene do? What is it used to treat?
Inhibits the RYR receptors on the SR membrane, thus blocking the release of Ca2+ from SR, so no muscle contraction. Used to treat malignant hyperthermia and spasticity associated with upper-motor neuron disorders.
31
Describe the cause and appearance of the Trendelenburg Gait
The abductor muscles (gluteus medius and minimus) are weak, and so allow pelvis to rock to the side, resulting in a “waddling” gait. The patient leans towards the side which has lost the ability to abduct. Most often is a problem with the superior gluteal nerve, but can also be a problem with the muscles themselves.
32
What is Gower's sign, and what causes it?
Due to a lack of hip and thigh muscle strength, the patient must use their hands and arms to “walk” up their own body from a squatting position.
33
Describe Rhabdomyolysis. What organ can be impacted by this?
he breakdown of muscle fibers → muscle fiber contents (myoglobin) released into the bloodstream. These globular proteins get caught in the glomerular heads of the kidney → Kidney failure
34
Duchenne Muscular Dystrophy - An x-linked recessive condition, though many cases are due to spontaneous mutations. Describe the pathology of this disease.
he costameres, which ties the muscle cell membrane to the filaments, and contains the protein dystrophin. When dystrophin function is lost, the result is an inability to transmit the force to the cell membrane, and thus the ECM. Increased Ca2+ influx, which leads to oxidative stress, and ultimately necrosis of the myofiber. myofibers are then replaced by CT and adipose. In short, you lose dystrophin function, and so can’t transmit force outside of the cell → muscular atrophy.
35
What causes ischial bursitis? When is this bursa weight bearing? What scenario is this often seen in clinically?
Caused by movement of the gluteus maximus across the bursa overlying the ischial tuberosity. Also note that this bursa is weight bearing while seated. Bursa may become calcified, and with prolonged bedrest → pressure sores and ulceration
36
What causes Trochanteric bursitis? Where does the pain radiate to? What muscles put pressure on the trochanteric bursa?
Caused by movement of the gluteus maximus across the bursa overlying the greater trochanter (eg climbing or inclined walking). Causes pain which radiates deeply inferiorward from posterior the bursa along the lateral thigh to the knee. Recall that both the gluteus maximus and the tensor fascia lata insert onto the IT band, so activity of either muscle (tensor fascia lata during flexion, and gluteus maximus during extension) put a constant pressure on the trochanteric bursa.
37
Other common sites of bursitis?
iliopectineal, infra-, supra-, and prepatellar bursitis, retinacular bursitis, and calcaneal bursitis
38
Describe Medial Plantar Nerve Compression
analogous to CTS, as this nerve also passes under a flexor retinaculum. Excessive running or eversion → irritation of this nerve → paresthesias on the medial side of the sole of the feet, with weakness of the intrinsic muscles of the great toe.
39
What is the cause of plantar fasciitis? How about the pathology? What can be the long term result? How does one test this?
Plantar aponeurosis becomes inflamed (eg overuse, running, high impact activities). Pain can be elicited by; direct pressure at the point of its attachment to the calcaneus, by dorsiflexion, or by extending the great toe. It is often accompanied by calcaneal bone spurs in the direction of the aponeurosis and the surae muscles.
40
Describe femoral hernias
Viscus contents (a portion of the gut) protrudes through the femoral ring into the femoral triangle. May even protrude through the saphenous opening, in which case venous return of the greater saphenous vein would be impeded. Occurs more often in females.
41
How does compartment syndrome arise? How does it present clinically? What is necessary to relieve the symptoms in extreme cases?
Pressure increases within a fascial compartment, which can reduce blood flow, impinge nerves (causing distal paresthesias or paralysis of muscles within that compartment). Severe cases require fasciotomy to relieve these compressive forces prior to the occurrence of tissue necrosis.
42
How do muscular strains and ruptures typically occur?
Most often occurs as a result of large muscles exerting force quickly to overcome large amounts of inertia. AS lower limbs are weight bearing, this may occur during sprints, rapid change in direction, etc → injury close of the site of attachment.
43
What muscles are involved in groin strains, and how does the damage occur?
Adductor group “pulls” usually during fast hip-flexion activities.
44
What is the usual cause of hamstring strains?
Hamstrings strain near the ischial tuberosity as a result of fast extension during the “push-off” phase of running.
45
Describe Ruptured Achilles Tendon injuries
Week-end warrior injury”, due to increased age and irregular bouts of exercise (eg tennis or basketball) where rapid push-offs with the feet are required.
46
What would be used to evaluate a ruptured achilles tendon?
Sagittal MRI
47
Describe the cause of psoas abcesses. What misdiagnoses are common with this?
s a result of a retroperitoneal abdominal or pelvic infection that descends within the psoas sheath, deep to the inguinal ligament → pain and swelling w/in the femoral triangle, which can put pressure on the femoral nerve. This is often misdiagnosed as a femoral hernia, indirect inguinal hernia, inflammation of the inguinal lymph nodes, or a saphenous varix.
48
Describe Tibialis Anterior Strain (“Shin Splints”)
Microtears in the periosteal attachment (sharpey’s fibers) of the distal ⅔ of the tibialis anterior muscle to the tibia → pain. Also, decreased vascular exchange → swelling and inflammation within the muscle → pain. Usually results from overuse, infrequent bouts of exercise preceded by not stretching or warming up first and/or running on hard surfaces after having trained on softer surfaces.
49
What is the cause of calcaneal tendinitis? What is the pathology behind it?
Micro tears in the attachment of the calcaneal tendon to the calcaneal tuberosity. Occurs as a result of overuse, poor footwear, poor training surfaces, or infrequency of activity.
50
How do avulsion fractures occur? Where do they occur on the pelvis?
Fractures which occur as a result of fragments being pulled away from bones by rapidly loaded tendons and ligaments.
Pelvis - Can occur on ischial tuberosity, ASIS, AIIS or ichiopubic rami.
51
How do fractures of the femur neck typically occur? What artery must one be concerned about in this scenario?
Increased compressive forces ( eg stepping off a curb or step) onto a limb already weakened by metabolic process (eg osteoporosis) → Fx. The Fx can occur just distal to the head/neck junction, or can occur along the intertrochanteric line. End result is a shortened limb, and internal fixation is required.
Must be concerned about damage to medial circumflex femoral artery.
52
What are the typical causes of Fx of the Greater Trochanteric Shaft?
Direct trauma (MVA's and falls)
53
Discuss distal femur fractures
All involve the epiphysis. Fx can occur on or between the femoral condyles (Salter-harris scale 1-6 used for classification). In any case, results in aberration of the articular surfaces of the knee joint, and may disrupt blood supply to the knee or leg.
54
Describe patella fractures
An avulsion-type Fx, which occurs due to a sudden forceful contraction of the quads. A direct blow will also do the trick (eg MVA or falling into a kneeling position)
55
Describe a bipartite or tripartite patella
Asymptomatic non-union of the ossification centers of the patella. Often is misinterpreted as a Fx.
56
What are the common fracture types associated with the tibia?
Compression Fx
fx along shaft
fx at nutrient foramen
fx of the medial malleolus
Disruption of the epiphyseal plate (osgood-schlatter disease)
57
What is this fx?
Stress Fx (March Fx)
58
How do Fxs of the Medial Malleolus occur?
Due to direct contact with the talus during excessive eversion
59
What is disconcerting about a Fx at the Fxs @ the Nutrient foramen
If fractures occur at the nutrient foramen (about the middle of the shaft) there is a risk of non-union (failure to heal)
60
Where do most tibial Fx occur?
As the tibia is narrowest and least vascularized near the junction of the middle and distal thirds, most Fxs occur here.
61
Describe Osgood-Schlatter Disease?
Not really a disease, rather is a disruption of the tibial tuberosity at its growth plate during youth due to excessive action of the quads tendon → pain & inflammation.
62
How Do most Fxs of the fibula occur?
Most Fxs here occur just proximal to the lateral malleolus, and are often associated with fracture-dislocations of the ankle, and distal tibial fractures. Can also be due to contact with talus during excessive inversion.
63
What is this image showing
Osgood-Schlatter Disease
64
What bone is commonly used for bone grafts?
Fibula
65
What is a plain A-P Xray used for when visualizing the fibula? How about a lateral oblique?
plain A-P X-ray is done to look at the ankle mortise for dislocations, but a lateral oblique lets you see the tib-fib articulation better.
66
How do fractures of the calcaneus occur?
Most often occurs as a result of hard falls directly to the heel, and disrupt the subtalar joint (this joint is active during eversion/inversion).
67
How do Fx of the Talus occur?
Fx occurs most often during forced dorsiflexion. Fx of the neck of the talus results in posterior dislocation of the talar body.
68
What is the normal Angulation of the Hip Joint
The angle between the head, neck and shaft of the femur varies due to developmental variation (CCD angle = caput (head)-collum (neck)-diaphyseal (shaft). Normal = 120°
69
How is CCD angle evaluated?
Plain film groin lateral X-ray
70
Describe Coxa Vara. What is the impact on the distal tibia?
Decrease in the CCD angle → slight decrease in the length of the affected limb → concomitant increase in Q-angle (distal femur lies more medial than normal), which opens medial knee joint space → **genu valga** (distal tibia is moved outward/lateral)→ increased occurrence of patellar dislocation.
71
Coxa Valga, Describe
Increase in CCD angle → increase in length of the affected limb → concomitant decrease in Q-angle (distal femur lies more medial than normal), opens lateral knee joint space → genu vara (distal tibia is moved inward/medial)
72
Describe Q-Angle
What is normal for men and women?
Comparison between two lines, the first is drawn from the center of the patella to the ASIS, and the second is drawn from the middle of the patella to the middle of the hip joint. Normal Q-angle = 14° (men) and 17° (women)
73
What's going on in these images? Describe the condition?
Slipped Capital Femoral Epiphysis
Due to trauma in the region of the proximal femoral epiphysis (usually occurs in adolescents prior to epiphyseal plate closure). Distal fragment dislocates posteriorly → coxa vara
74
Describe Avascular Necrosis of the Femoral Head
Due to disruption of the arteries that surround the femoral neck and provide branches to the femoral head (branches of the medial femoral circumflex artery are most often implicated).
75
How does hip dislocation occur?
Driving the femur posteriorly while the leg is flexed (recall the “screw-home” effect, and that the hip joint is loosest when the thigh is in flexion) → posterior dislocation of the head of the femur from the acetabulum (eg MVA while leg in on the dash)
76
Describe femoroacetabular Impingement Syndrome (FAIS)
occurs when the ball shaped femoral head rubs abnormally or does not permit a normal range of motion in the acetabular socket. Damage can occur to the articular cartilage, or labral cartilage (soft tissue bumper of the socket), or both.
77
What imaging technique is used to view FAIS?
Plain film Frog-leg view X-Ray is taken to evaluate for this
78
What is the cause of hip drop?
Paralysis of the gluteus medius & minimus due to problem with the superior gluteal nerve (L4-S1) → allows the unsupported hip to drop during the swing phase of locomotion (they lean to the affected side). Same as Trendelenburg Gait in Ketchum’s section above.
Note that according to Buck it is ALWAYS due to a problem with the nerve, but according to Montemayor it can also be a problem with the muscles themselves (section VII B-4 in B.B)
79
Describe injuries to the menisci!
Placing the leg into full flexion while under force can trap the menisci, thereby tearing them. Opening the medial angle of the joint stretches the ligament and tears the cartilage. The medial meniscus is more often torn, as its attachment to the MCL renders it less mobile.
80
How does one fix the following?
Small Tears
Large Tears
Longitudinal Tears (Bucket handle)
Small Tears - Can simply be trimmed
Large Tears - Tears that are in the periphery where a good blood supply exists - can be repaired
Longitudinal (“Bucket Handle”) Tears - tears through the substance of the meniscus. When the handle tears free, it must be removed. Removal does not affect mobility, but stability is decreased, and overtime articular cartilaginous erosion increases.
81
Discuss the injuries associated with the LCL
Most often occur when foot is in contact with the ground, and force is applied to either the lateral or medial side of the extended and/or rotated knee. Opening the medial angle of the knee stretches the MCL, while opening the lateral angle stretches the LCL. Note that injury of the MCL is often associated with tearing of the medial meniscus, and tearing of the ACL (“unholy triad”).
82
Describe the injuries to the ACL and PCL
These control anterior and posterior movement of the femur on the tibial plateau. The ACL is the more often injured, and this can be done by: hyperextension, force applied to the leg when the foot is fixed, or while the limb is slightly flexed and the femur medially rotated (eg running). Slow application of force → avulsion, while quick application of force → tearing of the ligament (this is the more frequent of the two).
83
How does one test for ACL Vs. PCL
84
What imaging technique is used to visualize the cruciates and menisci?
Coronal MRI of the knee is done to evaluate the cruciates and menisci.
85
Describe the Unholy triad
Tearing of the MCL, ACL and medial meniscus - most often due to forced hyperextension.
86
What's going on in these images? Describe the condition!!!!
Chronic knee joint effusion (fluid accumulation) in the joint moves into the bursae. Occurs most often posteriorly (in the gastrocnemius or semimembranosus bursa). May impede flexion or put pressure on structures in the popliteal fossa → pain
87
Discuss Patellar Dislocations
Most likely to dislocate laterally, and occurs more often in females due to increased Q-angle. , which causes increased lateral pull on the patella via the rectus femoris and vastus lateralis.
88
Discuss Patellofemoral syndrome
Wearing down, roughening, or softening of the cartilage under the kneecap → Pain or discomfort seemingly originating from the contact of the posterior surface of the patella with the femur.
89
What is the method of visualizing patellofemoral syndrome?
plain sunrise X-Ray view is taken to evaluate for this
90
What can patellofemoral syndrome result in? How would one treat this?
May result in chondromalacia of the patella due to chronic overuse (eg extensive running), a direct blow to the patella, or repeated extreme flexion (deep squats). Treated by doing leg extensions with emphasis on the last 30° in order to increase tension of inferior-most fibers of the vastus medialis to re-establish proper patellar tracking
91
WTF is an os trigonum?
Super advanced race of beings from star trek. Just kidding...
An accessory bone behind the talus, which results from failure of a secondary ossification center to unite with the talus during development. Occurs in 14-25% of adults, and associated with sports where athlete utilizes excessive plantarflexion (soccer, ballet, heels)
92
What ankle sprain is most common? How does it occur?
Inversion Sprain - More common than eversion sprains. Over-elevation of the medial border of the foot usually due to stepping on an uneven foot while weight bearing → Injury to the LCL of the ankle, and anterior talofibular ligament is most often torn (Remember ATF for Always Tears First)
93
Discuss Eversion Sprains
Occurs less often because the MCL of the ankle is very strong, but can occur when the lateral border of the foot is over-elevated.
94
Discuss a Pott's Fx
Bimalleolar Ankle Fx
Forced eversion → avulsion Fx of the medial malleolus via the deltoid ligament → shift in the position of the talus → Fx of the lateral malleolus. The end result is a total disruption of the mortise of the ankle joint. P
95
How would you visualize a Pott's Fx?
plain A-P X-ray is done to look at the ankle mortise, but a lateral oblique lets you see the tib-fib articulation better.
96
Discuss Compression of the femoral Artery
Pulse is normally felt in a supine patient midway between the ASIS and the pubic tubercle. A diminished pulse here is a sign of obstruction to either the common or external iliac arteries.
97
Discuss Compression of the femoral Artery
Pulse is normally palpated inferiorly win the fossa against the posterior tibia when the patient is prone and he leg is flexed. Diminished popliteal pulse is a sign of obstruction of the femoral artery.
98
Discuss compression of the popliteal Artery
Pulse is normally palpated inferiorly win the fossa against the posterior tibia when the patient is prone and he leg is flexed. Diminished popliteal pulse is a sign of obstruction of the femoral artery.
99
Compression of the Posterior Tibial Artery, talk about it yo
pulse is normally felt posterior to the calcaneal tendon and the medial malleolus (deep to the flexor retinaculum), with the patient inverting the foot (which relieves pressure exerted on the artery by the retinaculum). A diminished pulse here is a sign of occlusion of the popliteal artery. Narrowing of the tibial arteries → muscular ischemia → intermittent claudication (cramping during exercise)
100
Discuss **Diminished Dorsalis Pedis**
Pulse is normally felt by palpating inferior to the extensor retinaculum, and lateral to the tendon of the extensor hallucis longus. Diminished pulse here is a sign of obstruction of the anterior tibial artery. Note: The dorsalis pedis artery can be congenitally absent, in which case the arterial supply to the dorsum of the foot is done by the perforating branch of the fibular artery.
101
Discuss the musculovenous pump
Contraction of muscles w/in a limited fascial space places pressure on the deep veins contained there, and this “milking action” assists in venous return against gravity. Venous valves (when functional) prevent backflow during periods of alternating skeletal muscle contraction and relaxation.
102
Superficial Varicosities?
Superficial veins can weaken as they dilate under the pressure of the supported column of blood → incompetency of valves. Also, a degeneration of deep fascia reduces or eliminates the “milking action”, and so can also -\> varicosities.
103
Talk about Saphenous Vein Grafts
Greater saphenous vein can be harvested for use in coronary arterial bypass surgery, due to its increased muscular and elastic walls. Removal forces venous drainage to deeper veins, but this is not a bad thing. Harvested vein is installed as a by pass with valves reversed so that they do not impede flow.
104
Saphenous Cut-downs , what the are these? Eh?
As the greater saphenous vein lies anterior to the medial malleolus, it is relatively easy to access prn cannulation for the delivery of fluids, drugs, etc. Care however must be taken to not cut the accompanying saphenous nerve.
105
What is the saphenous Varix
Dilation of the terminal portion of the greater saphenous veins → swelling in the femoral triangle. Can be misdiagnosed as femoral hernia, psoas abscess, etc.
106
Talk about cannulation for the cardiac angiography
The L. femoral artery is done just distal to the inguinal ligament for a L cardiac angiography, whereas the deep femoral vein (located 1 finger-width medial to where the pulse for the femoral artery is felt) is cannulated for R.
107
What is thrombosis?
The formation of a clot within a vein.
108
What is a DVT?
Clot forms spontaneously (eg because of prolonged periods of reduced physical activity, or weakened muscular fascia) or due to trauma (eg Fx, deep contusion, etc) → vascular stagnation
109
Discuss thrombophlebitis and thromboembolism. How about strokes?
DVT - Clot forms spontaneously (eg because of prolonged periods of reduced physical activity, or weakened muscular fascia) or due to trauma (eg Fx, deep contusion, etc) → vascular stagnation
Thrombophlebitis - When the presence of a clot leads to local inflammation
Thromboembolism - A clot which has broken free from an upper limb vein → transverse to the heart → lodges in the pulmonary arterial branch
Stroke - If the patient has a foramen ovale (a hole between the atriums) the clot can go to brain
110
Lymphangitis, describe it. What does it lead to? Describe that shit too.
Inflammation of the lymph vessels, usually visible as red streaks.
Lymphadenopathy - Enlarged lymph nodes due to inflammation (in the lower limb, the lymph nodes we would be able to palpate are in the popliteal fossa and the femoral triangle). Note: Superficial inguinal lymph nodes (superficial to the triangle) receive lymph (which drains parallel the greater saphenous vein) from the superficial thigh, lower abdomen, round ligament of the uterus, and the perineum. The deep inguinal lymph nodes (within to the triangle) receive lymph from the superficial inguinal nodes, and the deep structures of the foot, leg & thigh.
111
Describe tendon reflex testing. Three examples!!!
Done to check the integrity of myotatic arc (both sensory and motor) at specific levels.
Patellar reflex = L4
Achilles Reflex = S1
Plantar (Babinski) Fanning of the toes when the bottom of the foot is stroked. This is normal for children \< 2 yrs, but abnormal for adults.
112
Injury to the Femoral N.
Very serious injury, but easy to diagnose. Loss of anterior femoral compartment → loss of leg extension and reduced flexion of the thigh, loss of patellar reflex (L4, sensory arc is intact, but motor component is gone), and anesthesia in the distribution of the saphenous vein.
113
Injury/Compression to the Obturator N.
Compression results in decreased/weakness in flexion, adduction and rotation of the thigh, and paresthesias of the medial thigh.
114
Injury to the Sciatic N.
s a bundle which contains both the tibial & common fibular nerve. Damage here → weakness of extension of the thigh, complete loss of inversion, eversion, plantar & dorsiflexion, also loss of Achilles reflex (S1, sensory intact, but motor gone). In summary - you are left with a functionless leg.
115
Piriformis Syndrome
n about 12% of people, the common fibular portion of the sciatic nerve goes through the piriformis muscle. Thus use, trauma to, or hypertrophy (eg in athletes) of the piriformis muscle → compression of the common fibular N. → loss of eversion & dorsiflexion, as well as numbness on the lateral anterior portion the leg and dorsum of the foot.
116
Gluteal Injections
Glut injections should be administered between the index finger (placed on the ASIS) and the the middle finger (placed on the tubercle of the crest of the ilium). Injections done inferior to this area could damage the Sciatic N.
117
Injury to the Superior Gluteal N.
Both injury to the nerve itself, or to the L4 intervertebral disc → inability of the gluteus medius and minimus to act on the pelvis, causing the unsupported limb to drop. See Hip Drop or Trendelenburg gait above
118
Injury to the Inferior Gluteal N.
Loss or weakness of gluteus maximus → decrease in hip extension, (especially evident when the patient tries to climb stairs.
119
Most likely to occur in the popliteal area. Loss of posterior superficial & deep compartments of the leg and ALL plantar foot muscles → inability to plantarflex w/ reduced inversion of the foot, decreased leg flexion and loss of calf contour → Foot held in dorsiflexion and eversion, loss of cutaneous sensation to the sole of the foot, and loss of Achille’s reflex (S1).
120
Injury to the Common Fibular Nerve
Loss of anterior & lateral compartments of the leg → loss of dorsiflexion and eversion of the foot → foot held in plantar flexion and inversion.
121
Injury to the Superficial Fibular N. -
Loss of musculature of the lateral compartment of the leg → loss of eversion w/ reduced plantar flexion → foot held in dorsiflexed and inverted.
122
Injury to the Deep Fibular N.
Loss of musculature in the of the anterior compartment of the leg → loss of dorsiflexion and reduced inversion → foot held plantar flexed w/ slight eversion.
123
L4/5 Neuropathy Foot Drop
L4 affects tibialis anterior & L5 affects extensor hallucis longus. Extensor hallucis longus is not working, so toes are allowed to drag while stepping forward. Loss of tibialis anterior allows foot drop suddenly and “slap” the ground as they finish their step.
