Transcript Lower Limb Case 3 working title

The Case of the
Bad Stick
Meghan Kaumaya
Kenneth Koncilja
Aravind Reddy
Andrew Williams
Patient Presentation
• Post Operative patient
(major surgery)
• Receiving Intramuscular
Injections of Antibiotics
– Complained of more
pain than normal
during one shot
• Nurse noticed a limp
that was previously not
observed
• Vitals normal
• Systems review normal
• Neurologic exam normal
Musculoskeletal Exam
• Left hip drops every
time left foot raised
off floor.
• On right side pelvis
remains level when
right foot lifted.
• All else normal.
• No evidence of
sensory loss from
the skin.
Gross Anatomy
Superior Gluteal n.
Gluteus medius
Where does it originate?
Lumbro-Sacral Plexus!
Gluteus minimus
Piriformis
How does superior gluteal n.
get between the gluteus
medius and gluteus minimus?
Through the Greater
Sciatic Foramen
Even More Gross!
DON’T BE OVERWHELMED
Gluteus maximus
Superior gluteal a.
Inferior gluteal n.
Pudendal n.
Posterior cutaneous
n. of thigh
Semitendinosus
Semimembranosus
Popliteal a.
Gluteus medius
Gluteus minimus
Piriformis
Sciatic n.
Biceps femoris
(long head)
Trendelenburg’s Gait
• Weakness in the
abductor muscles,
gluteus medius and
minimus
– Weak abduction of the
hip
– Abnormal gait caused
by weakened muscles
allowing the pelvis to tilt
down on the opposite
side when walking
Figure 6. Trendelenburg himself
Trendelenburg’s Test
• Stand on one foot on the side suspected
of having weakened abductor muscle
– Positive test: patient must put foot down
immediately because weakened muscles
cannot keep pelvis level so pelvis drops on
opposite side
– Negative test: patient can stay balanced on
one foot
Abductors of the Thigh
How To Give a Shot
• Superolateral gluteal
region
– Relatively free of
nerves and large blood
vessels
1. Place your thumb on
the ASIS and make a
fist
2. Spread your hand to
point your thumb out
3. Injection site will be
inbetween digits 2 and
3.
What else could cause
symptoms?
•
•
•
•
•
•
•
•
•
Polio
Fracture of Greater Trochanter
Dislocation of hip joint
Paralysis of the nerve
Spinal Muscular Atrophy
Muscular Dystrophy
Lumbar Nerve Compression
Inflammatory Myopathy
Coxa vara
References
• Ropper AH, Samuels MA, "Chapter 7. Disorders of
Stance and Gait" (Chapter). Ropper AH, Samuels MA:
Adams and Victor's Principles of Neurology, 9e:
http://www.accessmedicine.com/content.aspx?aID=3630
849.
• Moore K.L., Dalley A.F., Agur A.M.R. Chapter 5 Lower
Limb.. In: Taylor C, Heise J, Montalbano J., editors.
Clinically Oriented Anatomy. Baltimore: Lippincott
Williams & Wilkins; 2010. p.572-583.
• Netter, F. H. Altas of Human Anatomy, 4e. Philadelphia:
Saunders Elsevier, 2006.
• Stranding, S., Ed. Gray’s Anatomy: The Anatomical
Basis of Clinical Practice, 40e. Madrid: Churchill
Livingston Elsevier, 2008.