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
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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 medius Gluteus maximus Gluteus minimus Superior gluteal a. Piriformis Inferior gluteal n. Sciatic n. Pudendal n. Posterior cutaneous n. of thigh Biceps femoris (long head) Semitendinosus Semimembranosus Popliteal a.
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
How To Give a Shot • Superolateral gluteal region • Relatively free of nerves and large blood vessels • Place your thumb on the ASIS and make a fist • Spread your hand to point your thumb out • 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=3630849. • 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.