Lower limbs Pathology and Clinical Skills Flashcards
what is compartment syndrome?
This is a clinical syndrome where the pressure in the muscle compartment is so high that the venous drainage becomes blocked.
Pressure is very high that it can cause muscle ischaemia and death.
what are the causes of compartment syndrome
Infections
Fractures
Burns
Prolonge lower limb compression
what are the presentations of compartment syndrome
it commonly presents with pain, muscle tenderness and swelling. In later stages it presents with the 6 Ps:
- Pallor
- Pulselessness
- Paralysis
- Perishingly cold
- Pain
- Paresthesia
What would you find on examination for a pt with compartment syndrome
What other investigation can you do?
On examination:
- The limb is swollen
- Very painful on passive movement
Diagnosis is usually based on clinical suspicion however there are some devices which can measure intracompartmental pressure.
what are the treatment options for compartment syndrome
Treatment is with relieving pressure, all dressings, casts, splints should be removed.
Open fasciotomy - this is a surgical procedure where the skin and deep fascia are opened along the length of a muscle compartment to relieve the pressure
How many adjacent dermatomes are affected for a significant sensory loss to be detected? Why?
Atleast 3
This is because there is signifcant overlapping between between dermatomes
what spinal nerve dermatomes do not have overlap? what are they called?
Autonomous sensory zones.
e. g. L3, L4, L5 and S1
- useful clinically as pain and abnormal sensation can be attributed to a single spinal root
What sensory modalities can be tested?
- Light touch, localization of touch,
- Two point tactile discrimination,
- Pain, pressure, temperature, vibration,
- Sterognosis (3D)
- Passive joint movement,
- Postural sensibility.
There’s is a line where there’s no overlap of dermatomes. what line is this?
This IS NOT AUTONOMOUS SENSORY zones
Across the axial line
How do you test dermatomes of the lower limb
Same procedure as the hand but you have to put the specific point on the diagram
what tendon reflexes of the lower limb should you test and what spinal roots are responsible for them
Patella tendon (knee jerk): L2, L3, L4 via Femoral nerve
Achilles tendon (ankle jerk) reflex ( S1 and S2) via the tibia nerve
How can knee jerk myotactic reflex be facilitated
Jendrassik manoeuvre
Pt needs to voluntarily dorsiflex the same foot strongly whilst it is performed.
how do you preform/elicit the ankle jerk reflex
pt sit over edge of bed with knee 90 degree
Locate the achilles tendon and strike it with hammer
The foot should plantar flex
Contraction of gastroceniomus should be seen
what are the effects of Femoral nerve injury?
Motor:
- Quadriceps paralysis
- Weakness of knee
- Difficulty climbing up and down the stairs.
- Knee jerk reflex gone?
Sensory loss to:
- Anterior and medial thigh
- Medial side of the leg
- Medial border of the foot
What are the effects of Obturator nerve injury
Motor:
- Paralysis of all adductor muscles except hamstring part of adductor magnus and pectineus.
- Cross legging affected
Sensory loss:
- Insignificant loss to the medial side of the thigh.
- Pelvic disease, ovarian tumours may cause pain on the medial thigh
what are the effects of injury to the common fibular nerve
Motor:
- Foot extensor and evertors paralysed
- Foot drop seen (plantar flexed and inverted)
Sensory- loss to:
- Anterior and lateral side of the leg
- Dorsum of the foot
what are the effects of Tibial nerve injury
Motor:
- Paralysis of hamstrong and all muscles of posterior leg and sole of the foot
- On inspection, foot is dorsiflexed and in everted postion.
Sensory loss on sole of foot
What are the causes of sciatic nerve injury?
what are the effects of whole sciatic nerve injury.
CAUSES: pelvic fracture, hip joint dislocation/surgery, penetrating injuries.
Effects:
- Hamstrings and all muscles below knee are paralysed.
- Knee flexion affected
- Foot in plantar flexed position due to it’s wieght
Sensory loss below the knee EXCEPT a narrow areas on medial leg and foot (NOT BIG TOE) as this side is innervated by the saphenous nerve
what is sciatica and what are the causes?
what can it be mistaken for?
Cause: Herniated lumbar intervertebral disc (L4/L5) or (L5/S1) which compresses the L5-S1 part of the sciatic nerve.
Pelvic gridle pain in pregancy can be misdiagnosed as sciatica
where can you palpate the arteries of the lower limb
Femoral artery at mid inguinal point.
Popliteal artery: knee can be semi flexed or extended. Rest thumbs on tibai tuberosity and press with both hands to feel the artery just against the psoteirior surface of the tibia.
Posterior tibial artery: Between the medial Malleolus and Achilles
Dorsal pedalis: Mid dorsum of foot, lateral to the tendon of flexor hallucis longus
what are you investigating when palpating arteries
Pulse
Rhythm
Character and volume
Radial-femoral delay
Symmetry
what are the surgical/clincial usefulness of superficial veins of the lower limb
They can be harvested and used as vascular grafts especially for CABG
When they are readily visible they can be used for venous infusions
What is intermittent claudication?
This is a pain in the legs secondary to chronic arterial insufficiency, which is caused by peripheral arterial disease (PAD).
Its main feature is pain, which develops after movement, which disappears on rest.
The area of pain is dependant on the arteries that are diseased.
what is the claudication distance?
The claudication distance is the distance the patient can walk before they feel pain
what would you fins on examination for a patient with intermittent claudication?
Leg is cold and pale, with a loss of hair and muscle mass.
A thorough examination of the feet is also required to see if there are any ulcers.
Weak or absent pulses.
What are the consequences of the worsening PAD? and explain why
Night pain,- due to the loss of gravity and the reduction in cardiac output when sleeping.
Worsening PAD can also cause:
- Rest pain
- Tissue ulceration
- Gangrene,
PAD is so bad that the blood flow is not able to support the tissues.
what is the treatment for PAD?
Treatment depends on the severity of the disease.
Milder forms of the disease are treated with symptom control and antiplatelets,
If there is rest pain or non-healing ulcers, patients are assessed for revascularization.
