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2471 Cards in this Set
- Front
- Back
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What is pyrexia
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Raised temperature
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What is raised temperature called?
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Pyrexia
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What is enthesopathy?
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Enthesopathies are disorders of peripheral ligamentous or muscular attachments to the bone
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What is plantar digital neuritis?
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Morton's neuroma
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What is Morton's neuroma?
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Plantar digital neuritis
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What are one of the distinguishing features of gout?
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Nocturnal pain
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What can be a cause of nocturnal pain?
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Gout
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What can mask the inflammatory response to a fungal or skin infection and blur the distinctive border between infected and non-infected tissue?
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Using a corticosteroid cream
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What can using a corticosteroid cream do?
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It can mask the inflammatory response to a fungal or skin infection and blur the distinction between infection and non-infection
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What are the different rating scales for MRC muscle strength
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0 No movement
1 Palpable contraction but no visible movement 2 Movement but only with gravity eliminated 3 Movement against gravity 4 Movement against resistance but weaker than the other side 5 Normal power |
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What is the MRC grading for muscle strength useful for?
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It is suitable for patients with peripheral nerve damage causing muscle flaccidity. It is not a valid technique for patients with hypertonicity.
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What should a clinical measurement be?
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It should be accurate, precise, repeatable, reliable and valid
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What is intraobserver reliability?
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The same observer making measurements
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What is it called when the same observer is making the measurements
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Intraobserver reliability
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What is interobserver reliability?
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Different observers making the same measurement
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What is it called when different observers make the same measurement?
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Interobserver reliability
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What is sensitivity?
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The ability of a measurement or test to identify positive cases of the observation of interest
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What is it called when a test or measurement identifies the positive cases of the observation of interest?
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Sensitivity
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What is specificity?
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The ability of the measurement or test to exclude negative cases of the observation of interest
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What is it called when a test or measurement excludes negative cases of the observation of interest?
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Specificity
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What are the systematic errors when taking a measurement?
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1. Clinical environment
2. Procedure 3. Equipment 4. Practitioner 5. Patient |
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What can invalidate vibration testing?
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Consumption of caffeine about an hour previous to the test.
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What is cadence?
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Steps per minute
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What is the term for steps per minute?
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Cadence
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What is Morton's neuroma?
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Morton's neuroma is a painful condition of the forefoot caused by a benign enlargement of (usually) the third common digital branch of the medial plantar nerve, located between and often distal to the 3rd and 4th distal metatarsal heads. The syndrome is a mechanical entrapment neuropathy with degenerative changes resulting from stretch and compression forces.
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What are the symptoms of Morton's neuroma?
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Sharp, throbbing pain which may radiate into adjacent areas. It is exacerbated by exercise and relieved by rest and massage. The condition can be present from about 4-6 months before the patient sees about it.
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When can nail surgery be contra-indicated?
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On a patient with a prosthetic joint. It may produce bacteraemia which could infect and loosen the joint replacement.
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What is bacteraemia?
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Bacteraemia is the presence of bacteria in the blood.
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What is the presence of bacteria in the blood called?
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Bacteraemia
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What medication is contra-indicated when patients are asthmatic?
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Aspirin or NSAIDs
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What is a symptom of hepatitis?
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Jaundice
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What is jaundice a sign of?
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Hepatitis
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What are the signs that a patient could have deep vein thrombosis?
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1. Oedema
2. Cigarette smoking 3. Use of the contraceptive pill 4. Recent immobilisation |
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What are symptoms of psoriasis and eczema?
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Hypertrophy and anhidrosis of the skin
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What can cause hypertrophy and anhidrosis of the skin?
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Psoriasis and eczema
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What is a symptom of Parkinson's disease?
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Reduced facial expression
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What can cause reduced facial expression?
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Parkinson's disease or long-term use of psychotropic drugs eg pyschiatric medication
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What is a symptom of long-term use of psychotrophic drugs?
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Reduced facial expression
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What is a symptom of a thyrotoxic patient?
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Protruding eyes
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What can cause protruding eyes?
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Thyrotoxicosis
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What do patients exhibit when on long-term steroid therapy?
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A 'moon face'
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What can cause a 'moon face'?
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Long-term steroid therapy
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What are the symptoms of hypothyroidism?
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A loss of hair from the outer third of the eyebrows, baldness and coarse thickened facial skin
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What can cause a loss of hair from the outer third of the eyebrows?
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Hypothyroidism
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What can cause baldness?
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Hypothyroidism
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What can cause coarse thickened facial skin?
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Hypothyroidism
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What is acromegaly?
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Excess of growth hormone due to a disorder of the pituitary gland
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What can an excess growth of hormone due to a disorder of the pituitary gland cause?
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Acromegaly
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What is a symptom of acromegaly?
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A heavy 'lantern' jaw
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What can cause a heavy 'lantern' jaw?
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Acromegaly
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What is salbutamol?
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It is a beta-2 agonist used for the treatment of asthma
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What side effects does salbutamol have on the lower limb?
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Peripheral vasodilation
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What effect can the contraceptive pill have on the lower limb?
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Increased risk of DVT
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What is chloramphenicol?
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It is bacteriostatic antimicrobial
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What is chloramphenicol used for?
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It is used mainly for bacterial conjunctivitis
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What effect can chloramphenicol have on the lower limb?
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Peripheral neuritis
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What is neuritis?
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Inflammation of a nerve or group of nerves, characterized by pain, loss of reflexes, and atrophy of the affected muscles
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What is colchicine?
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It is used in the treatment of gout
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What is the effect of colchicine on the lower limb?
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It can cause sensorimotor neuropathy
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What is metronidazole?
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It is an antibiotic
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What is metronidazole's mechanism of action?
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It binds to DNA causing strand breakage
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What is metronidazole used for?
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It is used for the treatment of trichomonal infections, amoebic dysentry, giardiasis, gas gangrene, various abdominal infections, lung abcesses, dental sepsis and TB infection
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What is the effect of metronidazole on the lower limb?
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Sensorimotor neuropathy
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What is indomethacin?
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It is an NSAID
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What is indomethacin used for?
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It is used for acute attacks of gout and arthritis
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What effect does indomethacin have on the lower limb?
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Sensorimotor neuropathy
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What are 4-quinolones?
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The quinolones are a family of synthetic broad-spectrum antibiotics
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What are the names of a 4-quinolone?
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Ciprofloxacin, Clindomycin
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What are 4-quinolones used to treat?
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They are used in the treatment of pseudomonas, UTIs, chest, GU, GI infections and osteomyelitis
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How do 4-quinolones work?
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They inhibit DNA gyrase
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What effect do 4-quinolones have on the lower limb?
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They cause damage to epiphyseal cartilage and there is evidence to suggest they can also cause Achilles tendinopathy
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What are corticosteroids?
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Corticosteroids are a class of steroid hormones that are produced in the adrenal cortex
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What is the action of corticosteroids?
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They are anti-inflammatory by preventing phospholipid release, decreasing eosinophil action and a number of other mechanisms.
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What is the effect of corticosteroids on the lower limb?
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They can cause osteoporosis and skin atrophy. Inhaled corticosteroids have been implicated in achilles tendinopathy
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What is aspirin?
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It is an NSAID
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How does aspirin work?
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It acts by inhibition of cyclooxygenase, the enzyme that allows prostaglandin production
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What effect does aspirin have on the lower limb?
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It can cause purpura (bleeding into the skin)
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What is frusemide?
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It is a loop diuretic
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What is frusemide used for?
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Hypertension
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What effect does frusemide have on the lower limb?
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It can cause bullous eruptions
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What is nalidixic acid?
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Nalidixic acid is bacteriostatic and is the basis for the quinolones
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What is the mechanism of nalidixic acid's action
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It inhibits DNA gyrase
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What is nalidixic acid used for?
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Nalidixic acid is used mainly for urinary tract infections
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What effect does nalidixic acid have on the lower limb?
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Bullous eruptions
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What is prednisolone?
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Prednisolone is a steroidal anti-inflammatory
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What is prednisolone used for?
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Prednisolone is used in the treatment of RA
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What effects can prednisolone have on the lower limb?
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Prednisolone can reduce skin thickness and impair wound healing
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What is bendrofluazide?
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It is a thiazine diuretic
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What is bendrofluazide used for?
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It is used for hypertension
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What effect can bendrofluazide have on the lower limb?
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It can cause hyperuricaemia (high level of uric acid in the blood) which may result in gout
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What effect can overdosing on Vitamins A and D do?
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It can case ectopic calcification (pathologic deposition of calcium salts in tissues) in tendon, muscle and periarticular tissue
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What can cause ectopic calcification (pathologic deposition of calcium salts in tissues)?
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Overdosing on Vitamins A and D
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What are the symptoms of anaphylaxis?
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Hypotension, bronchiole constriction, laryngeal oedema, swelling of the tongue, urticaria, vomiting and diarrohea
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What can overdosing with a LA cause?
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Convulsions, hypotension and cardiovascular depression
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What effects do amphetamines have on the lower limb?
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They have a vasoconstrictive effect
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What effect does tobacco have on the lower limb?
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It can affect wound healing because of its vasoconstrictive effect and it can cause increased platelet adhesiveness and atherosclerosis
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What effect does heavy alcohol consumption have on the lower limb?
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It can effect peripheral sensation, immune response, postoperative wound healing and the metabolism of LAs as well as having implications for treatment compliance.
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What effect can a hysterectomy have on the lower limb?
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It can cause a hormone imbalance leading to osteoporosis
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What are examples of inherited neurological diseases that affect the lower limb?
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Friedrich's ataxia and Charcot-Marie-Tooth disease
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What is Friedrich's ataxia?
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Friedrich's ataxia is an inherited disease that causes progressive damage to the nervous system resulting in symptoms ranging from gait disturbance and speech problems to heart disease.
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What are the effects of spina bifida occulta on the lower limb?
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Impaired gait, pes cavus and plantar ulceration can happen in later life.
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Who does thalassaemia mainly affect?
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People of Mediterranean and South East Asian descent
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What is CRAGCEL?
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C Cardiovascular
R Respiratory A Alimentary G Genitourinary C Central nervous system E Endocrine L Locomotor system |
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What two clinical syndromes does ischaemic heart disease refer to?
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Angina pectoris and myocardial infarction
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What causes angina?
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Atherosclerosis of the arteries to the myocardium and often coexists with atherosclerois of the arteries to the lower limb
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What is a myocardial infarction?
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MI is a gross necrosis of the myocardium due to interruption of the blood supply to the area.
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What is hypertension a risk factor for?
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MI, renal failure and cerebral vascular accidents (strokes)
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What is congestive heart failure (CHF)?
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CHF results from the inability of the heart to sufficiently supply oxygenated blood to the tissues.
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What can cause congestive heart failure (CHF)?
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Causes can include valvular heart disease, myocardial disease and hypertension
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What is rheumatic fever?
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Rheumatic fever is a febrile disease (fever) occurring as a sequel to group A haemolytic streptococcal infections. It is characterised by inflammatory lesions of connective tissue structures especially of the heart and blood vessels and predisposes to bacterial endocarditis.
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What happens in congested heart failure (CHF)?
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There is an inadequacy in the supply of oxygenated blood. To compensate for this, first the heart rate and then the volume of blood filling the left ventricle increases. Because it takes longer to fill the left ventricle, the pressure in the whole cardiac pulmonary system 'backs up' causing pulmonary congestion, reduced blood gas exchange and eventually pulmonary oedema.
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What are the signs and symptoms of congestive heart failure (CHF)?
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Pulmonary oedema and shortness of breath.
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What causes right-sided heart failure?
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Right-sided heart failure is almost always associated with left-sided heart failure. The right side of the heart can no longer deal with the volume of venous blood returning to the heart for transportation to the lungs and a 'back up' of pressure occurs in the systemic circulation.
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What is a cause of peripheral oedema?
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Right-sided heart failure
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How does right-sided heart failure cause peripheral oedema?
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The 'back up' of pressure from the right side of the heart results in transudation of fluid into the peripheral connective tissue. Gravity will force most of the transudate to collect bilaterally in the feet and ankles. When the condition is chronic the odema will fibrose and the oedema is no longer relieved by elevating the legs.
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What are the signs and symptoms of peripheral vascular disease?
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1. get cramp at night
2. get muscle cramps while walking 3. suffer from chilblains 4. notice their feet change colour if it is particularly cold |
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What is a risk of sickle cell anaemia?
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Use of tourniquets. A tourniquet causes relative anoxia and this in turn causes occlusion in small vessels due to changes in the haemodynamic qualities of red blood cells which may lead to small vessel infarction and possibly digital gangrene.
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What is chronic bronchitis associated with?
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Smoking and peripheral atherosclerosis
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What drugs do gastric ulcers contra-indicate?
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NSAIDs and analgesic preparations
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What diseases are polyuria associated with?
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Diabetes, cardiac failure or cortisol deficiency
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What is a symptom of renal dysfunction?
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Ankle oedema
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What are the lower limb symptoms of Reiter's disease (reactive arthritis) (sexually transmitted infection)
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Asymmetric arthralglia of the hip, knee, ankle and MTPJ, 'sausage toe', keratoderma blenhorragica (skin lesions)
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What are the lower limb symptoms of HIV?
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Karposi's sarcoma - a widespread skin or mucous membrane lesion appearing as a pink or red macule or violaceous plaques and nodules on the face, trunk and limbs. May appear wart-like.
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What is the effect of gonococcal arthritis (sexually transmitted disease) on the lower limb?
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Acute joint pain, swelling and stiffness. Usually accompanied by urethritis, dysuria and haemorrhagic vesicular skin lesions. Serious joint damage may result if the condition is not treated properly.
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What is dysuria?
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Painful urination
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What are the 12 causes of peripheral neuropathy?
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1. Nerve root compression of the sciatic or femoral nerve
2. Distal nerve compression of the popliteal, common peroneal and anterior tibial nerve 3. Hereditary neurological diseases eg Friedrich's ataxia, Charcot-Marie-Tooth disease 4. Endocrine eg diabetes mellitus, hypothyroidism, hypocalcaemia 5. Chronic alcohol abuse 6. Nutritional disorders eg pernicious anaemia, thiamine or Vit B6 deficiencies 7. Renal failure 8. Systemic disorders eg RA, SLE, vasculitis, sarcoidosis, amyloidosis 9. Infections eg TB, AIDS, leprosy, syphilis 10. Tumour eg bronchogenic carcinoma, myeloma, lymphoma 11. Toxic agents eg carbon monoxide, solvents, industrial poisons, lead 12. Medication eg isoniazid, metronidazole, nitrofurantoin |
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What is isoniazid?
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Isoniazid is used in the treatment of mycobacterial infection
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What is nitrofurantoin?
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Nitrofurantoin is used to treat urinary tract infections
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What are the three most common symptoms of diabetes?
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Thirst, polyuria and weight loss
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What other conditions can have the symptoms of thirst, polyuria and weight loss?
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Diabetes insipidus, hypercalcaemia and renal failure
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What are the six causes of thirst and polyuria?
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1. Diabetes mellitus - osmotic diuretic effect of glucose
2. Diabetes insipidus - kidney disease prevents normal concentrating of urine or pituitary gland disorders cause a deficiency of antidiuretic hormone 3. Hypercalcaemia - result of hyperthyroidism where hypercalcaemia causes reversible impairment of renal concentrating mechanism 4. Hypocalcaemia - often a side effect of diuretic therapy it leads to impaired concentrating ability in the kidney 5. Excess salt intake - osmotic diuretic effect of increased sodium level 6. Renal failure - normal concentrating function of kidney lost |
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What are the 11 clinical features of hyperthyroidism?
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1. Weight loss with a normal appetite
2. Heat intolerance 3. Fatigue 4. Cardiac palpitations 5. Irritability 6. Hand tremors 7. Sleep disturbance 8. Bulging eyes 9. Goitre 10. Diarrohea 11. Generalised muscle weakness |
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What 2 effects does hyperthyroidism have on the lower limb?
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1. Infiltration of of non-pitting mucinous ground substance on the anterior surface of the tibia which causes intense itching and erythema. This so-called pretibial myxoedema (a confusing term since myxoedema suggests hypothyroidism) is more accurately described as an infiltrative dermopathy
2. Tarsal tunnel syndrome |
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What are the thyroid hormones called ?
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Triiodothyronine (T3) and
Thyroxine (T4) |
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What are the features of hypothyroidism?
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The facial expression is dull and the features puffy with swelling around the eye sockets due to infiltration of mucopolysaccharides. The eyelids will droop due to decreased adrenergic drive and the skin and hair will be coarse and dry. The tongue may be enlarged, the voice hoarse and speech slow. Tarsal and carpal tunnel syndrome, caused by infiltration of mucopolysaccharides are common clinical features.
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Why is hypo- or hyperthyroidism contraindicated for nail surgery?
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Because it reduces the patient's ability to deal with stress.
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What are the parts of the adrenal gland?
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The cortex and the medulla.
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What does the adrenal cortex produce?
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Glucocorticoids and mineralocorticoids
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What is adrenal undersecretion called?
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Addison's disease
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What is adrenal oversecretion called?
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Cushing's syndrome
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What are the clinical features of Addison's disease
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1. It is an autoimmune disease.
2. Reduction in the level of cortisol leading to reduced resistance to infection and trauma 3. Deficiency in mineralocorticoids and glucocorticoids |
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What are the clinical features of Cushing's syndrome?
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Overproduction of glucocorticoids. High production of cortisol increases carbohydrate production and leads to trunal obesity and development of a moon face. Purple striae or stretch marks will develop on the abdomen. An increased production of androgens may cause hirsutism. Thinning of the skin and increased risk of infection are important lower limb features. Osteoporosis may occur as a sequel to disruption of normal kidney function. Secondary diabetes may also occur as a sequel to Cushing's syndrome.
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What are the clinical issues of acromegaly?
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Excess growth hormone leads to glycogenesis c 30% of acromegalics develop diabetes mellitus. Hypertension due to inadequate renal clearance of phosphates affects 30% of acromegalics. The majority of acromegalics suffer from headaches and joint pains.
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Describe the atrium
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The atrium is the upper chamber and a receiving vessel with a thin muscle wall or myocardium
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Describe the ventricle
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The ventricle is the lower chamber and because it is a dispersing vessel has much thicker muscle walls to generate propulsive forces
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What are the two linings of the heart called?
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The heart is lined by endocardium and surrounded by a tough pericardium.
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What does endocardium do?
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It forms the cusps of one-way valves (tricuspid and bicuspid) and semilunar valves
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What forms the tricuspid, bicuspid and semilunar valves?
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Endocardium
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What do the tricuspid and bicuspid valves do?
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They are one-way valves which control the flow of blood through the heart.
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What do the semilunar valves do?
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They control the entry of blood into the vessels leaving the heart
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What valves are responsible for controlling the flow of blood through the heart?
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The bicuspid and tricuspid valves
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What valves control the entry of blood into the vessels leaving the heart?
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The semilunar valves.
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What does the right ventricle do?
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It serves the pulmonary or minor circulation and sends deoxygenated blood via the pulmonary arteries to the lungs
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What does the left ventricle do?
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The left ventricle supplies the systemic or major circulation with oxygenated blood through the aorta to the body
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What happens in the left atrium?
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Oxygenated blood is returned from the lungs via the right and left pulmonary veins into the left atrium
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What happens in the right atrium?
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Deoxygenated blood from the body flows through the superior and inferior vena cavae into the right atrium
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What are the layers of the arteries?
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Tunica intima (inside), tunica media (middle), tunica adventitia (outside)
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What lines the tunica intima?
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Vascular endothelium
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What does the vascular endothelium do?
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Its cells secrete a variety of substances essential for maintenance of vessel wall and circulatory function
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Where is the smooth muscle in an artery?
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Tunica media
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Which vessels have the greatest proportion of smooth muscle?
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Arterioles
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Why do arterioles have the greatest proportion of smooth muscle?
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Because they have to change diameter
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What do the arteries leaving the heart have the greatesst proportion of?
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Elastic tissue
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Why do arteries have a high proportion of elastic tissue?
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Because they act as secondary pumps
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How does blood reach the heart?
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Blood is drained from the tissue bed by venules which join to form larger vessels called veins
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What does vascular endothelium do in the veins?
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It forms semilunar valves in the veins and venules
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What do valves in veins prevent?
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Backflow of blood
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Where are veins found?
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They are found either in the superficial fascia or deep in the muscle
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What links the veins in the superficial fascia and deep in the muscle?
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Communicating veins
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What does a capillary do?
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It links arterioles and venules
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What links arterioles and venules?
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Capillaries
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What is a capillary made up of?
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Thin-walled endothelium
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What are metarterioles?
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They are smooth muscle sphincters situated at the entrances to the capillaries and regulate blood flow into the capillaries
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What regulates blood flow into the capillaries?
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Metarterioles
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What are A-V (arteriovenous) anastomases?
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They are vessels which form a direct link between arterioles and venules and can bypass capillaries
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What are A-V anastomases called when they form under the nail bed?
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Glomus bodies or Sucquet-Hoyer canals.
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What are glomus bodies?
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A-V anostomases under the nail bed
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What are Sucquet-Hoyer canals?
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They are A-V anostomases under the nail bed
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What is the microcirculation?
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The smaller diameter vessels
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What is the collection of smaller diameter vessels called?
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The microcirculation
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What are collaterals?
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These are anastomases that provide an alternative circulation route for blood flow
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What do lymphatic vessels do?
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They drain the tissues and transport lymph through various lymph nodes eventually rejoining the peripheral circulation through the thoracic duct
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What is tissue fluid?
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It continuously forms from blood at capillary and postcapillary venular sites
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How does tissue fluid move in and out of tissues?
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Through hydrostatic and oncotic pressures
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How does the body maintain the flow of blood around the body?
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By altering the rate and force of contraction of the myocardium and by varying the diameter throughout the peripheral circulation
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What are the two phases of the heart beat
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Systole or contraction phase and diastole the relaxation phase
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What is special about the myocardium and what is it called
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It can contract without nerve pulses and this is called myogenicity
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How does myogenicity work?
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It is due to the presence of specialised 'pacemaker' cells which generate spontaneous action potentials.
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Which is the most important action potential in the heart?
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The sino-atrial node situated in the right atrium
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|
|
What is the sino-atrial node?
|
It is the most important action potential in the heart and it is situated in the right atrium
|
|
|
Describe the route of an action potential in the heart
|
From the SA node to the AV node to the Bundle of His to the Purkinje fibres
|
|
|
How does the heart alter its activity according to the differing demands?
|
One way is through the autonomic system
|
|
|
How does the sympathetic nerve act on the heart?
|
Through beta 1 receptors
|
|
|
What are beta 1 receptors
|
They act on the heart through the sympathetic nerve
|
|
|
What is the beta 1 receptor's action on the heart?
|
Their action is to increase cardiac output by increasing stroke volume and heart rate
|
|
|
What is positive inotropy?
|
Increasing cardiac stroke volume
|
|
|
What is positive chronotrophy?
|
Increasing heart rate
|
|
|
How does the body increase cardiac output?
|
Through the beta 1 receptors, part of the sympathetic nerve
|
|
|
What two actions increase cardiac output?
|
Increasing stroke volume and heart rate
|
|
|
What is the parasympathetic nerve to the heart called?
|
The vagus
|
|
|
What is the vagus?
|
The parasympathetic nerve to the heart
|
|
|
What does the vagus do?
|
It causes slowing of the heart rate
|
|
|
What is slowing of the heart rate called?
|
Negative inotropy
|
|
|
What is negative inotropy?
|
Slowing of the heart rate
|
|
|
What does the vagus work on to cause slowing of the heart?
|
Cholinergic receptors
|
|
|
What do the sympathetic nerves do?
|
Speed things up
|
|
|
What do the parasympathetic nerves do?
|
Slow things down
|
|
|
What are cholinergic receptors?
|
They are acted on by the vagus to slow the heart down
|
|
|
What nerve from the ANS predominates at rest?
|
Parasympathetic nerve
|
|
|
What is the average resting heart rate?
|
72 beats per minute
|
|
|
Aside from activity, what cause a change in heart rate?
|
It is affected by posture, increasing on a change from supine to an upright position
|
|
|
What do baroreceptors do?
|
They regulate blood pressure
|
|
|
Where are baroreceptors situated?
|
In the arteries and veins
|
|
|
Where are the most important baroreceptors situated for controlling blood pressure?
|
In the aortic arch and carotid body
|
|
|
Where is the cardiovascular control centre?
|
The medulla oblongata in the brain stem
|
|
|
What muscle does the sympathetic nerve act upon in the arteries?
|
The smooth muscle in the tunica media
|
|
|
How do baroreceptors work in hypertension?
|
They rapidly adapt to a sustained change so that they are triggered by a higher than normal 'operating' range
|
|
|
What vessels respond to sympathetic tone?
|
All vessels except capillaries
|
|
|
What happens to the blood vessels when there is increased sympathetic tone?
|
Vasoconstriction
|
|
|
What is happening in the autonomic system when blood vessels constrict?
|
Increased sympathetic tone.
|
|
|
What happens to the blood vessels when there is decreased sympathetic tone?
|
Vasodilation
|
|
|
What is happening in the autonomic system when blood vessels dilate
|
Decreased sympathetic tone
|
|
|
Which vessels does the sympathetic nerve have the most effect on?
|
Arterioles
|
|
|
What has the greatest effect on arterioles?
|
The sympathetic nerves
|
|
|
Why do the sympathetic nerves have such a big effect on arterioles?
|
Because they have the highest proportion of smooth muscle in their walls
|
|
|
Which vessels have the highest proportion of smooth muscle in their walls?
|
Arterioles
|
|
|
What do arterioles have the most proportion of in their walls?
|
Smooth muscle
|
|
|
What are arterioles sometimes called?
|
The resistance vessels
|
|
|
What are the resistance vessels?
|
Arterioles
|
|
|
What vessels control homeostatic blood pressure and control distribution of the blood?
|
Arterioles
|
|
|
What do arterioles predominantly do?
|
Help control distribution of blood and homeostatic control of blood pressure
|
|
|
What organs help control blood volume?
|
Low pressure baroreceptors in the right atrium, kidneys as well as the CVS
|
|
|
What do kidneys assist with in the CVS?
|
They help control blood volume
|
|
|
What do the low pressure baroreceptors control?
|
They help control blood volume
|
|
|
Where are the baroreceptors that control blood volume?
|
In the right atrium
|
|
|
Which are the elastic arteries?
|
Aorta and pulmonary arteries
|
|
|
What do the aorta and pulmonary arteries have the highest percentage of in their walls?
|
Elastic tissue
|
|
|
How does the elastic tissue work in the aorta and pulmonary arteries?
|
They distend as the bolus of blood is received from the ventricles and act as a secondary pump during diastole when the elastic coil propels the blood forward
|
|
|
What are the only vessels not to deliver blood?
|
The capillaries
|
|
|
What does blood contain?
|
Dissolved nutrients, oxygen and hormones
|
|
|
What does blood take away?
|
Metabolic waste such as carbon dioxide and urea
|
|
|
What parts of the body is heat generated from?
|
Active muscles and the liver
|
|
|
What is the organ that controls heat loss?
|
The skin
|
|
|
What is a function of the skin?
|
Controlling heat loss
|
|
|
How does skin control heat loss?
|
It controls heat loss by superficial papillary loops and glomus bodies which can reroute blood towards or away from the skin surface
|
|
|
What is a function of a glomus body?
|
Glomus bodies can reroute blood towards or away from the skin surface
|
|
|
What is the function of the capillaries?
|
The exchange of the substances transported to the tissues by the blood
|
|
|
What happens to blood pressure when it enters the capillary beds?
|
There is a large drop in pressure
|
|
|
How is the blood pressure increased in veins and venules after leaving the capillary bed?
|
Semilunar valves, venoconstriction and the pumping action surrounding skeletal muscle on the deep veins as well as fluctuating negative pressures in the abdomen and thorax due to respiratory movements and the heart itself
|
|
|
Which part of the heart is venous blood drawn back into?
|
The atrial chambers
|
|
|
What is the blood returning to the heart called?
|
Venous return or preload
|
|
|
What is venous return?
|
Blood returning to the heart
|
|
|
What is preload?
|
Blood returning to the heart
|
|
|
What parts of the circulation should equal each other ?
|
Venous return should equal ventricular output
|
|
|
What is an intrinsic property of the myocardium?
|
Matching of venous return and cardiac output
|
|
|
Is the matching of venous return and cardiac output under nervous control?
|
No
|
|
|
What is Starling's law of the heart?
|
The matching of venous return to cardiac output
|
|
|
What is the matching of venous return to cardiac output called?
|
Starling's law of the heart
|
|
|
What are the consequences of unmatched venous return to cardiac output?
|
Congestive heart failure
|
|
|
How is congestive heart failure caused?
|
By unmatched venous return to cardiac output
|
|
|
What is the congestion due to in congestive heart failure?
|
It is due to a build up of blood throughout the venous tree due to a weak or damaged myocardium
|
|
|
In addition to returning blood to the heart, what else do veins do?
|
Because of their distensibility they act as capacitance vessels normally holding 3/5ths of the blood in the body
|
|
|
How much blood do the veins hold in the body?
|
They normally hold 3/5ths of the blood in the body
|
|
|
What is the purpose of the pulmonary circulation?
|
To deliver blood containing carbon dioxide to the lungs and exchange it for oxygen
|
|
|
What are the alveolar capillaries?
|
They exchange carbon dioxide for oxygen in the lungs
|
|
|
What is the interface between the lungs and the blood?
|
Alveolar capillaries
|
|
|
What is the advantage of having two separate circulations?
|
So they can act at different pressures
|
|
|
What are the two separate circulations?
|
The cardiac and pulmonary circulation
|
|
|
What do red blood cells contain?
|
Haemoglobin
|
|
|
What does haemoglobin do?
|
Picks up oxygen in the lungs in a stepwise manner and releases it in the tissues
|
|
|
What picks up oxygen in the lungs and releases it in the tissues?
|
Haemoglobin
|
|
|
What does the presence or absence of oxygen do to a haemoglobin molecule?
|
It changes its shape and changes its colour?
|
|
|
What colour is oxygenated blood?
|
What colour is deoxygenated blood?
|
|
|
Bright red
|
Bluish red
|
|
|
What causes blood to be bright red?
|
When it is oxygenated
|
|
|
What causes blood to be bluish red?
|
Deoxygenated blood
|
|
|
What are erythrocytes?
|
Red blood cells
|
|
|
What are red blood cells called?
|
Erythrocytes
|
|
|
Where are erythrocytes formed?
|
From stem cells in the red bone marrow
|
|
|
How do erythrocytes mature?
|
From the influence of hormones from the kidney called erythropoitins
|
|
|
What are erythropoitins?
|
They are hormones from the kidney
|
|
|
What do erythropoitins do?
|
They help mature erythrocytes
|
|
|
In addition to erythropoitins, what other factors are also needed for formation of the mature erythrocyte?
|
Iron, folic acid and Vitamin B12
|
|
|
How long does the erythrocyte circulate for?
|
120 days
|
|
|
What happens to the erythrocyte after it has circulated for 120 days?
|
It is broken down in the liver by phagocytic von Kupffer cells
|
|
|
What are von Kupffer cells?
|
They phagocytose erythrocytes in the liver
|
|
|
What is anaemia?
|
It is a reduction in the oxygen carrying capacity of the erythrocyte
|
|
|
What is a reduction in the oxygen carrying capacity of the erythrocyte called?
|
Anaemia
|
|
|
What causes aplastic anaemia?
|
Damage to the bone marrow by radiation can damage the stem cells or the young red blood cells
|
|
|
How does pernicious anaemia develop?
|
An autoimmune disease can destroy the parietal cells in the stomach leading to lack of Castle's intrinsic factor which causes an inability to absorb Vitamin B12
|
|
|
What vitamin is required for erythropoiesis and normal nerve function?
|
Vitamin B12
|
|
|
What does a deficiency of Vitamin B12 cause?
|
B12 is required for erythropoeisis and normal nerve function
|
|
|
What does the peripheral vascular system include?
|
Arteries, veins and lymphatics
|
|
|
What are the 7 cardiac conditions which may affect the lower limb?
|
1. Heart failure - left and/or right sided
2. Ischaemic heart disease - angina or myocardial infarction 3. Rheumatic fever 4. Myocarditis 5. Valve disorders - mitral stenosis, aortic stenosis, mitral regurgitation, tricuspid regurgitation 6. Infective endocarditis 7. Congenital heart disease - septal defects, valve defects, coarction of the aorta, Fallot's tetrology |
|
|
What is coarction of the aorta?
|
A congenital condition whereby the aorta narrows in the area where the ductus arteriosus (ligamentum arteriosum after regression) inserts.
|
|
|
What is Fallot's tetrology?
|
A congenital condition which involves four abnormalities of the heart and is the most common cause of blue baby syndrom
|
|
|
What is ischaemia?
|
A condition which deprives the tissue of not only oxygen but nutrients and prevents removal of waste products
|
|
|
What is the condition which deprives the tissue of oxygen and nutrients and prevents the removal of waste products?
|
Ischaemia
|
|
|
What is the most common cause of ischaemic heart disease (IHD)?
|
Atherosclerosis of coronary vessels
|
|
|
What does atherosclerosis of coronary vessels cause?
|
Ischaemic heart disease (IHD)
|
|
|
What is ischaemic heart disease also called?
|
Coronary arterial disease (CAD)
|
|
|
What is coronary arterial disease (CAD) also called?
|
Ischaemic heart disease (IHD)
|
|
|
How do angiotensin converting enzymes (ACE) inhibitors work?
|
They interfere with the production of angiotensin 2 which is a powerful vasoconstrictor and triggers release of the hormone aldosterone from the adrenal cortex. Aldosterone promotes water and salt reabsorption from the kidney and inhibiting this hormone will reduce preload and cardiac output
|
|
|
How do diuretics act to reduce blood pressure?
|
They act on various parts of the kidney nephron to reduce water and salt reabsorption reducing preload and cardiac output
|
|
|
How do beta-blockers work to reduce blood pressure?
|
They prevent stimulatory action of endogenous catechoamines on the heart reducing cardiac output and blood pressure
|
|
|
How do calcium antagonists work to reduce blood pressure?
|
They act by interfering with the process of vascular smooth muscle contraction, reducing peripheral resistance and reducing blood pressure
|
|
|
What does angiotensin 2 do?
|
It is a powerful vasoconstrictor
|
|
|
What does aldosterone do?
|
It promotes water and salt reabsorption from the kidney
|
|
|
What are examples of ACE inhibitors?
|
Ramipril, Captopril
|
|
|
What are Ramipril and Captopril?
|
ACE inhibitors
|
|
|
What are examples of diuretics?
|
Bendrofluazide - thiazide diuretic and furosemide - loop diuretic
|
|
|
What are bendrofluazide and furosemide?
|
Bendrofluazide is a thiazide diuretic and furosemide is a loop diuretic
|
|
|
What are examples of beta blockers?
|
Atenolol, metaprolol and propranolol
|
|
|
What are atenalol, metaprolol and propranolol?
|
Beta blockers
|
|
|
What are examples of calcium channel antagonists?
|
Amlodipine and verapimil
|
|
|
What are amlodipine and verapimil?
|
Calcium channel antagonists
|
|
|
How is angina usually relieved?
|
Sublingual nitroglycerine
|
|
|
What is orthopnea?
|
Difficulty in breathing when supine
|
|
|
What are the main symptoms associated with anaemia?
|
Lassitude
|
|
|
What is pernicious anaemia associated with?
|
Peripheral neuropathy
|
|
|
What is sickle cell anaemia associated with?
|
Leg ulcers
|
|
|
What can anaemia trigger or make worse?
|
Angina pectoris, claudication or dementia
|
|
|
What are local factors that cause oedema in the lower limbs?
|
Trauma or occluded drainage vessels
|
|
|
What are central factors that cause oedema in the lower limb?
|
Congestive heart failure
|
|
|
How does congestive heart failure cause oedema in the lower limb?
|
Failure of the left ventricle to produce an adequate cardiac output causes backward pressure through the CVS which causes right ventricular failure. Right ventricular failure causes bilateral peripheral oedema in the lower limb
|
|
|
What oedema does left ventricular heart failure cause?
|
Left ventricular failure causes oedema in the pulmonary circulation
|
|
|
What causes oedema in the pulmonary circulation?
|
Left ventricular failure
|
|
|
What causes bilateral peripheral oedema in the lower limb?
|
Right ventricular failure
|
|
|
What does right ventricular failure do in the lower limb?
|
Causes bilateral peripheral oedema
|
|
|
What is another factor that can contribute to oedema in the lower leg besides right ventricular failure?
|
The renin-angiotensin-aldosterone system which is triggered by the low cardiac output causing renal retention of salt and water leading to a greater load on a failing heart
|
|
|
How can the renin-angiotensin-aldosterone system contribute to oedema?
|
Low cardiac output causes causes renal retention of salt and water leading to a greater load on the heart
|
|
|
What is central cyanosis?
|
Bluish discolouration of the lips, tongue and mucous membranes
|
|
|
What causes bluish discolouration of the lips, tongue and mucous membranes?
|
It indicates that arterial blood is inadequately oxygenated
|
|
|
What causes central cyanosis?
|
It can be due to deficiencies in the pump such as a congenital hole in the heart or cardiac failure or deficiencies in ventilation such as chronic obstructive airways disease
|
|
|
What can cause peripheral cyanosis of the toes and feet?
|
Severe cardiac and respiratory failure
|
|
|
What is koilonychia?
|
Spoon-shaped nails
|
|
|
What are spoon-shaped nails called?
|
Koilonychia
|
|
|
What causes koilonychia (spoon-shaped nails)?
|
Lack of iron can cause koilonychia of the finger, nails and a smooth red tongue
|
|
|
What is clubbing of the nails called?
|
Hippocratic nails
|
|
|
What are hippocratic nails?
|
Clubbing of the nails
|
|
|
What are hippocratic (clubbing of the) nails due to?
|
Subacute infective endocarditis or congenital cyanotic heart disease
|
|
|
What other factors can cause clubbing of the nails (hippocratic)?
|
Respiratory causes as well as bronchial carcinoma
|
|
|
What is vasculitis?
|
Inflammation of small vessels
|
|
|
What is inflammation of small vessels called?
|
Vasculitis
|
|
|
What are splinter haemorrhages associated with?
|
Vasculitis
|
|
|
Where are splinter haemorrhages usually found?
|
They usually appear near the nail margins
|
|
|
What may cause splinter haemorrhages?
|
Local causes may be digital septic thrombus. Systemic causes may be RA and they can also be caused by subacute bacterial endocarditis
|
|
|
What are symptoms of vascular problems?
|
Angina and myocardial infarction, dyspnoea (breathlessness) and lassitude
|
|
|
What are signs of vascular problems?
|
Oedema, cyanosis, pallor, koilonychia, hippocratic nails, splinter haemorrhages
|
|
|
What are clinical tests for vascular assessment?
|
Heart rate and blood pressure
|
|
|
What heart rate is classified as bradycardia
|
Less than 60 beats per minute
|
|
|
What is less than 60 beats per minute classified as?
|
Bradycardia
|
|
|
How many beats per minute would be classed as tachycardia?
|
Over a 100 beats per minute
|
|
|
What is over a 100 beats per minute classified as?
|
Tachycardia
|
|
|
What is an example of a physiological bradycardia?
|
A trained athlete
|
|
|
What is an example of a pathological bradycardia?
|
A complete heart block in the atrioventricular septum
|
|
|
What is sinus arrythmia?
|
It is a physiological arrhythmia associated with respiration seen mainly in young people. There is tachycardia on inspiration and bradycardia on expiration. It is thought to be due to the parasympathetic output to the heart
|
|
|
What drugs cause bradycardia
|
Beta blockers such as atenolol
|
|
|
What can cause tachycardia?
|
Hyperthyroidism can induce tachycardia
|
|
|
What can cause irregular or abnormal pulses (arrythmias)?
|
Physiological arrhythmia can be caused by exertion, training, age, anxiety or an underlying systemic condition such as thyroid disorders or medication such as beta blockers
|
|
|
What can cause a bounding pulse?
|
A response to stress, pyrexia, thyrotoxicosis or in hypoglycaemia
|
|
|
What is hypertension a risk factor for?
|
MI, left ventricular failure, cerebrovascular accidents, aortic dissection and renal failure
|
|
|
When is pressure highest in the arteries?
|
At ventricular systole when the blood is being forced into the arteries
|
|
|
When is pressure lowest in the arteries?
|
When the heart is relaxed just before its next contraction
|
|
|
What is a healthy adult's blood pressure
|
120/80 mm/Hg
|
|
|
What is pulse pressure?
|
The difference between the systolic and diastolic pressures
|
|
|
What causes pulse and systolic pressure to rise?
|
Age
|
|
|
Why does age cause pulse and systolic pressure to rise?
|
Because age causes loss of compliance in the tunica media
|
|
|
Name 5 errors that can happen whilst taking blood pressure
|
1. The rubber tubing may be perished
2. The valve may be faulty 3. The cuff may be the wrong size for the diameter of the limb 4. The arm may not be at heart level 5. The practitioner may not read the values correctly |
|
|
What values are taken as being indicative of hypertension?
|
Over 160mm/Hg systolic, over 95mm/Hg diastolic
|
|
|
How many times should blood pressure be taken to decide whether the patient is hypertensive?
|
On three separate occasions
|
|
|
What are non-invasive hospital vascular assessments?
|
Electrocardiogram, chest x-ray, phonocardiography, echocardiography, electron beam tomogrophy
|
|
|
What does an electrocardiogram do?
|
The electrical activity of the heart is recorded using limb and chest leads attached to the skin. Many pathologies of the heart such as MI or ventricular enlargement in a failing heart will alter the normal PQRS waveform
|
|
|
What does an X-ray show in a vascular assessment?
|
Enlargement of the heart, calcification of coronary arteries or malignant masses
|
|
|
What does phonocardiography do?
|
It involves the application of a sensitive microphone to the chest wall to allow heart sounds and murmurs to be recorded. It is now being superceded by echocardiography
|
|
|
What does echocardiography do?
|
This uses ultrasound to visualise the heart and coronary arteries. It can visualise movement of ventricular walls, septum and heart valves
|
|
|
What does electron beam tomography do?
|
It is more sensitive in detecting patients at high risk of CAD than analysis of lipid or cholesterol levels
|
|
|
What are invasive hospital methods of vascular assessment?
|
Blood analysis, coronary angiography and myocardial perfusion scintigraphy
|
|
|
How can anaemia be diagnosed?
|
By a full blood count where the number and volume of the red blood cells is calculated as is the oxygen content
|
|
|
How can a blood test diagnose MI or angina?
|
During unstable angina or MI the ischaemic myocardial cells produce increased amounts of cardiac creatine kinase which peak 24 hours after the attack
|
|
|
What levels of LDL and HDL are considered to put a patient at risk of CAD?
|
LDL greater than 3.4mmol/l and HDL less than 0.9mmol/l are considered to have subclinical CAD
|
|
|
What is cardiac creatine kinase?
|
It is the enzymes produced by the ischaemic myocardium 24 hours after an angina attack or MI
|
|
|
What does coronary angiography do?
|
A diagnostic catheter is introduced through the femoral artery into the left ventricle and associated vessels. Pressures in the main chambers and vessels can be measured. Blood samples can be taken to measure oxygen content and ischaemic metabolites such as lactate and contrast cine-angiograms can be taken by injecting a radio-opaque dye at the site to be investigated
|
|
|
What is myocardial perfusion scintigraphy?
|
This is very sensitive imaging using radionuclides to detect CAD
|
|
|
What are the three causes of arterial insufficiency in the foot?
|
Acute, transient chronic
|
|
|
What are the acute causes of arterial insufficiency in the foot?
|
Extrinsic
1. Light clothing 2. Tourniquet 3. Plaster cast 4. Trauma 5. Frostbite 6. Immersion foot Intrinsic 1. Thrombosis 2. Embolus 3. Ruptured aneurysm 4. Oedema |
|
|
What are the transient causes of arterial insufficiency in the foot?
|
1. Raynaud's phenomenon
2. Chilblains 3. Hereditary cold fingers |
|
|
What are the chronic causes of arterial insufficiency in the foot?
|
1. Atherosclerosis
2. Vasculitis 3. Thromboangitis obliterans (Buerger's disease) 4. Arteriosclerosis? |
|
|
What is arteriosclerosis?
|
Arteriolosclerosis is any hardening (and loss of elasticity) of arterioles (small arteries).
|
|
|
What does peripheral arterial occlusive disease (PAOD) lead to?
|
Ischaemia and poor tissue viability
|
|
|
What is the most common cause of PVD?
|
Atherosclerosis
|
|
|
Describe the pathological process of atherosclerosis
|
This is a pathological process involving formation of a fatty plaque or atheroma in the intima of large and medium-sized arteries. The atheroma itself causes no obstruction to blood flow but its tendency to ulcerate promotes thrombus formation which causes narrowing (stenosis) or complete occlusion of the vessel. In addition the thrombus is likely to embolise and be swept away to cause obstruction further down the arterial tree.
|
|
|
Where does arteriosclerosis happen?
|
In retinal and renal vessels and do not have major complications in the foot
|
|
|
What are the less common causes of PVD?
|
Vasculitis, thromboangiitis obliterans and arterial emboli
|
|
|
What is thromboangiitis obliterans?
|
Thromboangiitis obliterans is a rare disease in which blood vessels of the hands and feet become obstructed. It mainly affects young males and has a very strong association with smoking. All signs and symptoms of arterial ischaemia and superficial phlebitis of the hands and feet may be present. Eventually distal necrosis occurs
|
|
|
What are some of the conditions associated with vasculitis?
|
RA, systemic lupus erythmatosus (SLE), polymyositis, dermatomyositis, systemic sclerosis, polyarteritis nodosa, giant-cell arteritis, erythema nodosum, Henoch-Schonlein syndrome
|
|
|
What is Henoch-Schonlein syndrome?
|
It is a systemic vasculitis characterized by deposition of immune complexes containing the antibody IgA in the skin and kidney. It occurs mainly in young children.
|
|
|
What is an arterial emboli?
|
Arterial emboli can be composed of any obstructive body that lodges in the smaller vessels of the arterial tree causing ischaemia distally
|
|
|
What is the most common embolus?
|
A fragmentation of a thrombus such as a mural thrombosis found on the endocardium especially around the heart valves or in the arteries mostly at sites of bifurcation where turbulence is most likely
|
|
|
What do emboli do?
|
They may occlude arterioles and capillaries causing isolated patches of digital necrosis
|
|
|
Where do emboli come from?
|
Septic thrombus from infection or deformed red blood cells as seen in sickle cell anaemia
|
|
|
What effects can cryovascular disorders such as Raynaud's and chilblains have on the lower limb?
|
Attacks of vasospasm may become chronic and cause painful digital ulceration
|
|
|
What does an inadequate blood supply lead to in the lower limb?
|
Pain
Pallor Pulselessness Paraesthesia Paralysis Perishing cold |
|
|
What is the Fontaine classification of PVD?
|
1. Occlusive arterial disease but no symptoms (due to collaterals)
2. Intermittent claudication 3. Ischaemic rest pain (usually worse at night, relieved by dependency) 4. Severe rest pain with ulceration/necrosis (gangrene) |
|
|
What is intermittent claudication an indication of?
|
An inadequate blood supply to the periphery
|
|
|
What makes intermittent claudication worse?
|
Exercise
|
|
|
What is the distance a patient can walk without ischaemic pain called?
|
Ischaemic or claudication distance
|
|
|
What can prevent intermittent claudication being felt?
|
Peripheral neuropathy
|
|
|
What alleviates night cramps?
|
Dangling the legs over the side of the bed or walking on a cool floor
|
|
|
How do night cramps happen?
|
The warmth of the bedclothes increases the metabolic rate of the tissues and increases the demand for oxygen which cannot be met and produces ischaemic pain. Using gravity to aid flow and cooling the limb helps to reduce metabolic activity
|
|
|
Which is the most severe condition of critical limb ischaemia?
|
Rest pain
|
|
|
How do peripheral tissues get blood during rest pain?
|
The legs must always lie below the level of the heart either by raising the head of the bed or by sleeping in a chair
|
|
|
How does the skin appear in PVD?
|
Thin, shiny and dry with absent hairs
|
|
|
What could be the cause of absent hairs on the leg other than PVD?
|
Friction from boots and depilatories
|
|
|
What does PVD do to muscles in the lower limb?
|
It can cause atrophy especially on the plantar surface of the foot
|
|
|
What are the characteristics of ischaemic ulcers?
|
1. They are caused by trauma
2. Very painful (unless there is neuropathy present) 3. Lack of granulation tissue 4. Low amounts of exudate 5. Slough is often present 6. Borders are well demarcated and they may have a punched out appearance 7. They often occur first under toenails, on the apices of the toes or around the border of the feet as a result of tight or ill-fitting footwear 8. Leg elevation can exacerbate the pain whereas lowering the leg into dependency can improve the blood supply and ease the pain 9. Ischaemic ulcers are unlikely to heal unless there is an improvement in blood supply |
|
|
What medication can stop ulcers from healing?
|
Betablockers because they reduce cardiac output
|
|
|
How does blood supply affect the nails?
|
They may be crumbly, discoloured or thickened. They are prone to fungal infection and pitting
|
|
|
What is the DDX of crumbly nails affected by arterial insufficiency?
|
Psoriasis
|
|
|
What does necrosis or dry gangrene look like?
|
The tissue will appear hard, black and mummified with a clear demarcation line between dead and living tissue
|
|
|
What is usually NOT a symptom of poor peripheral arterial supply?
|
Oedema
|
|
|
What is the cause of unilateral or localised oedema?
|
Infection, trauma, allergy or impaired venous or lymphatic drainage
|
|
|
What does a pink skin mean?
|
Healthy circulation
|
|
|
What does white/pale skin mean?
|
Cold, anaemia,chilblains, Raynaud's, cardiac failure
|
|
|
What does white skin below demarcation line mean?
|
Severe ischaemia
|
|
|
What does blue skin mean (peripheral cyanosis)?
|
Cold, chilblains, Raynaud's, venous stasis
|
|
|
What does blue skin seen with central cyanosis mean?
|
Cardiac/respiratory failure
|
|
|
What does hazy blue skin mean?
|
Infection, necrosis
|
|
|
What are the six reasons for red skin?
|
Heat, exercise, extreme cold (cold-induced vasodilation), inflammation, infection (cellulitis), chilblains, Raynaud's
|
|
|
What does brown skin mean?
|
Haemosiderosis, moist necrosis
|
|
|
What does black skin mean?
|
Bruise, shoe dye, necrosis
|
|
|
What are the clinical tests for PVD?
|
Temperature gradient, capillary filling time, Buerger's elevation/dependency test, Allen's test, pedal pulses, bruits, Doppler ultrasound, claudication distance, ABPI
|
|
|
What is the difference in temperature that should be investigated between two legs?
|
A 2 degree difference in temperature should be investigated
|
|
|
How is Buerger's test done?
|
The leg should be elevated until all the veins in the dorsal arch of the foot have emptied. The plantar surface of the foot will appear pale. A mild pallor should be seen within 1 minute. A severe, wide-spread pallor is indicative of arterial insufficiency. The limb should be lowered into dependency and the time taken for the plantar surface to return to the colour of the other leg or for the dorsal veins to refill should be noted. Return to normal should be within 15 seconds, 20 seconds or more suggests that blood supply is inadequate and 40 seconds or more suggests severe ischaemia. If the skin is dusky red on dependency this is a serious sign indicating a severely compromised blood supply
|
|
|
What is Allen's test for?
|
To detect occlusion distal to the ankle
|
|
|
How is Allen's test done?
|
One leg of the patient is elevated and the dorsalis pedis artery is compressed. Maintaining pressure on the artery the leg is lowered into dependency. If the tibialis posterior artery is patent the foot should return to normal quickly. The patency of the dorsalis pedis artery can be tested by compressing the posterior tibial artery
|
|
|
What does oedema look like in cardiac failure?
|
It is bilateral, transudate, pitting, acquired, post myocardial infarction
|
|
|
What does oedema look like in venous stasis?
|
It is unilateral, transudate, pitting, acquired, post immobilisation
|
|
|
What does oedema look like in primary lymphoedema
|
It is bilateral, exudate, non-pitting, congenital
|
|
|
What does oedema look like in secondary lymphoedema?
|
It is unilateral, exudate, non-pitting unless very long-standing, acquired, post-infection, radiotherapy, surgery, malignancy
|
|
|
What is a bruit?
|
Bruits are abnormal sounds which can be heard using a stethoscope in the arteries
|
|
|
What causes bruits?
|
Bruits are due to turbulence in arteries caused either by an increased velocity or an obstruction
|
|
|
What are the three sounds in a triphasic pulse?
|
The first sound is the ejection of the ventricular bolus during systole. The second and third sounds are the diastolic sounds due to the reversal of flow caused by the elastic distension in the arteries and a final forward flow as the arteries rebound
|
|
|
What will a clinician be more likely to hear with a Doppler with a patient with bradycardia?
|
A weak triphasic sound
|
|
|
What will a clinician be more likely to hear with a Doppler with a patient with tachycardia?
|
Only a biphasic sound as the heart is beating too rapidly for reverse flow to occur.
|
|
|
How is the ABPI determined?
|
The reading for the ankle is divided by the brachial systolic reading
|
|
|
What is the average values for healthy adults with the ABPI?
|
0.98-1.31
|
|
|
What can a value of greater than 1 mean with the ABPI?
|
Calcification of the arteries
|
|
|
What is Monckberg's sclerosis?
|
Calcification of the tunica media of the muscular arteries
|
|
|
What does a value of less than 0.8 in the ABPI suggest?
|
There could be some obstruction in the more proximal part of the artery to the lower limb
|
|
|
What does a value of 0.75 or less in the ABPI indicate?
|
Severe problems
|
|
|
What does a value of 0.5 in the ABPI indicate?
|
Healing is unlikely to take place as the leg is in a pre-necrotic state
|
|
|
What other test besides ABPI can be used if there are calcification of the arteries?
|
The pole test
|
|
|
What hospital tests are used for testing macrocirculation?
|
Duplex ultrasound, angiography, MRI and PET scanning
|
|
|
What hospital tests are used for testing microcirculation?
|
Capillaroscopy, transcutaneous oxygen tension, photoelectric plethysmography, isotope clearance and Laser Doppler fluximetry
|
|
|
Why are hospital tests used?
|
1. Suitability for reconstructive surgery
2. The prognosis for the healing of ulcers 3. The level at which amputations should be performed |
|
|
What does a duplex ultrasound do?
|
It gives an image of the artery and the flow within that artery and is non-invasive compared to contrast angiography
|
|
|
What does angiography do?
|
It is the gold standard for imaging the arterial supply of the lower limb. A needle is inserted into the femoral artery and a radio-opaque dye is injected just proximal to the occlusion. It can be used to:
1. locate occlusion and stenotic vessels 2. can determine whether a collateral circulation has been established 3. help determine the most appropriate revascularisation procedure 4. if a bypass procedure is to be performed it locates the site of the distal anastomasis 5. it is used to predict the prognosis for a limb salvage and graft patency 6. it can be used by the surgeon to have an accurate picture of distal run-off |
|
|
What does MRI and PET scanning do?
|
They can be used to visualise various parts of the circulation but they are expensive and there are doubts as to whether they improve patient outcomes
|
|
|
What does capillaroscopy do?
|
The capillaries of the pedal nail fold can be examine using an oil immersion microscope under a strong light. In a healthy person the nutritive capillaries are distinct and well filled with blood but as ischaemia progresses the capillaries become hazy and less distinct. Capillaroscopy can be used to predict those patients likely to develop critical limb ischaemia and the likelihood of healing of ischaemic patients
|
|
|
What does the transcutaneous oxygen tension test do?
|
The skin is heated and the oxygen which diffuses to the surface of the skin is measured. It can be used as a predictor of level of amputation and of the success of angioplasty
|
|
|
What is photoelectric plethysmography?
|
It is used to measure skin blood pressure
|
|
|
What is isotope clearance?
|
It is used to measure skin perfusion pressure (SPP) and skin vascular resistance (SVR) in order to ascertain the likelihood of the healing of ischaemic ulcers.
|
|
|
What does Laser-Doppler fluximetry do?
|
It measures the movement of red blood cells in cutaneous vessels which changes as ischaemia progresses and can be used to determine amputation level
|
|
|
What are the three main pathological processes affecting veins?
|
1. Absent or incompetent valves
2. Formation of a thrombus which may trigger inflammation of the vein wall (thrombophlebitis) 3. inflammation of the vein wall (phlebitis) with possible secondary formation of a thrombus (phlebo-thrombosis) |
|
|
What is phlebitis?
|
Inflammation of the vein wall
|
|
|
What is inflammation of the vein wall called?
|
Phlebitis
|
|
|
What is the formation of a thrombus which triggers inflammation of the vein wall?
|
Thrombophlebitis
|
|
|
What is thrombophlebitis?
|
Formation of a thrombus which triggers inflammation of the vein wall
|
|
|
What is inflammation of the vein wall with secondary formation of a thrombus?
|
Phlebo-thrombosis
|
|
|
What is phlebo-thrombosis?
|
Inflammation of a vein wall with a secondary formation of a thrombus?
|
|
|
Which veins do absent or incompetent valves affect?
|
Superficial or communicating veins
|
|
|
What are the causes of absent or incompetent valves?
|
1. Congenital
2. Increased pressure such pregnancy, abdominal tumour or ascites which causes venodilation and renders the valves incompetent |
|
|
What conditions cause swelling or dilation of veins?
|
Congenital conditions
|
|
|
How does swelling or dilation of the veins cause pathology?
|
The resulting back flow due to gravity leads to increased hydrostatic pressure in the lower limb veins giving rise to the knotty appearance of varicose veins
|
|
|
What veins do inflammation of the vein walls affect?
|
Superficial or deep veins
|
|
|
What does deep vein pathology cause?
|
Superficial varicosities
|
|
|
What veins does phlebitis (inflmmation of the vein wall) affect?
|
Superficial veins
|
|
|
What is usually the cause of inflammation of the vein walls (phlebitis)?
|
Trauma or infection
|
|
|
What are the causes of venous thrombi?
|
1. Stasis
2. Hypercoagulability 3. Injury to the endothelium |
|
|
What is Virchow's triad?
|
1. Stasis
2. Hypercoagulability 3. Injury to the endothelium |
|
|
What are causes of venous insufficiency in the superficial veins?
|
1. Varicose veins - primary (idiopathic), secondary (backflow from deep to superficial vein)
2. Thrombophlebitis 3. Phlebangioma (congenital swelling of the vein) 4. Phlebectasia (congenital dilation of the vein) |
|
|
What are causes of venous insufficiency in the deep veins?
|
1. Deep vein thrombosis due to - abnormalities affecting blood flow, abnormalities of clotting, abnormalities of endothelium
2. Idiopathic 3. Thrombophlebitis |
|
|
What is phlebangioma?
|
Congenital swelling of the vein
|
|
|
What is congenital swelling of the vein called?
|
Phlebangioma
|
|
|
What is phlebectasia?
|
Congenital dilation of the vein
|
|
|
What is congenital dilation of the vein called?
|
Phlebectasia
|
|
|
What is Factor V Leiden?
|
It is the genetic tendency for hypercoagulation
|
|
|
What is the genetic tendency for hypercoagulation called?
|
Factor V Leiden
|
|
|
What are the symptoms of phlebitis in superficial veins?
|
The vein and surrounding area will be tender with erythema or cellulitis
|
|
|
What are the symptoms of thrombophlebitis?
|
The vein will be palpable as a linear, indurated cord and is usually associated with tenderness, erythema and warmth
|
|
|
What sensation is associated with problematic deep veins?
|
A bursting or aching associated with ankle oedema
|
|
|
What alleviates the pain of venous insufficiency?
|
Elevation of the leg
|
|
|
What are the symptoms of DVT?
|
DVT can be asymptomatic or it can be associated with tenderness, severe pain or warmth in the calf
|
|
|
What is the DDX for deep vein thrombosis?
|
A ruptured popliteal cyst as sometimes seen in RA
|
|
|
What diagnostic test would you NOT use if you suspected DVT
|
Homan's sign
|
|
|
Why would you not use Homan's sign if you suspected DVT?
|
Homan's sign increases pressure on the calf and increases the risk of embolism
|
|
|
What is Homan's sign?
|
Homans' sign is a sign of deep vein thrombosis (DVT). A positive sign is seen when present when passive dorsiflexion of the ankle by the examiner elicits sharp pain in the subject's calf.
|
|
|
Describe the route of venous emboli
|
Venous flow is proximal and central so venous emboli will be swept through increasingly larger vessels and emptied into the heart. From the heart it will enter the pulmonary circulation which is where the vessels are small enough to stop the embolus. It will then occlude one of the main pulmonary vessels (pulmonary embolism) preventing any gaseous exchange often with fatal consequences
|
|
|
Why does wear tight hosiery help with venous insufficiency?
|
The extra compression provided by the stocking aids venous blood flow and reduces peripheral oedema
|
|
|
What is telangiectasia?
|
It is dilated microvasculature
|
|
|
What does telangiectasia signify?
|
Telangiectasia around the medial malleolus indicates poor drainage
|
|
|
What colour does the skin go when there is stagnation of the blood in the lower limb?
|
Mottled cyanosis
|
|
|
What does mottled cyanosis of the skin of the lower limb signify?
|
Stagnation of blood in the veins as a result of poor drainage
|
|
|
What is atrophie blanche?
|
White patches on the skin around the ankles due to strangled microcirculation leading to fibrotic and sclerotic changes in the skin
|
|
|
Why does haemosiderin form?
|
Because of increased hydrostatic pressure
|
|
|
What is capillary hydrostatic pressure?
|
This pressure drives fluid out of the capillary and is highest at the arteriolar end of the capillary and lowest at the venular end
|
|
|
What is interstitial hydrostatic pressure
|
This pressure is determined by the interstitial fluid volume
|
|
|
What is capillary oncotic pressure?
|
The osmotic (oncotic) pressure within the capillary is principally determined by plasma proteins
|
|
|
What is interstitial oncotic pressure?
|
The oncotic pressure of the interstitial fluid depends on the interstitial protein concentration. The more permeable the capillary barrier is to proteins, the higher the interstitial oncotic pressure.
|
|
|
What are the DDX for haemosiderosis?
|
Erythema ab igne and necrobiosis lipoidica diabeticorum
|
|
|
What is erythema ab igne?
|
Erythema ab igne (EAI) is a skin reaction caused by chronic exposure to infrared radiation in the form of heat. It was once a common condition seen in the elderly who stood or sat closely to open fires or electric space heaters
|
|
|
What is necrobiosis lipoidica diabeticorum?
|
This is a condition associated with diabetes where yellowish patches are seen on the shins and the skin appears very transparent so that transparent blood vessels can be seen
|
|
|
What is the skin temperature likely to be in venous insufficiency?
|
Warm
|
|
|
What are the causes of varicose veins?
|
It may be due to incompetent valves in the superficial or communicating veins or as a consequence of DVT
|
|
|
How are varicose veins formed?
|
Back pressure due to an obstruction in the deep veins will accumulate through the communicating veins to the superficial veins. This causes the superficial veins to become incompetent and forward flow of blood is deficient. These veins are very extensible with non-uniform areas of weakness and have little support in the superficial tissues so they bulge unevenly due to the pressure of blood giving the knotted appearance of varicose veins
|
|
|
What is the sequelae of varicose veins?
|
Poor tissue viability which may lead to cellulitis or superficial phlebitis where the vein will be cord-like and painful
|
|
|
What are the consequences of poor drainage in the lower limb?
|
Poor drainage results in the accumulation of waste products which affects tissue viability. The skin may eventually become indurated.
|
|
|
What is indurated skin?
|
Deep thickening of the skin
|
|
|
What is gravitational (venous) eczema?
|
Signs of discolouration and pigmentation, scaly and lichenified skin in the presence of oedema, haemosiderosis and atrophie blanche. the area can be very pruritic and may lead to development of ulcers
|
|
|
What is another name for gravitational eczema?
|
Venous eczema
|
|
|
What medications do people with gravitational (venous) eczema often become sensitive to?
|
Topical antibiotics and to preservatives in other topical medicaments and bandages
|
|
|
Where are venous ulcers found?
|
Around the malleoli, particularly the medial malleoli but can spread completely around the leg. They form scars when healed.
|
|
|
What are venous ulcers associated with?
|
Post-thrombotic syndrome including gravitational (venous) eczema. They are rarely associated with superficial varicosities.
|
|
|
What do venous ulcers look like?
|
They are usually shallow with irregular borders and have either a healthy or slightly sloughy base unless infected
|
|
|
What does NOT necessarily cause a venous ulcer?
|
Trauma
|
|
|
When are venous ulcers painful?
|
They are usually painful only when have become infected.
|
|
|
How can the pain of venous ulcers be alleviated?
|
By elevation
|
|
|
Do these ulcers heal quickly?
|
No, they can hang around for years
|
|
|
What can make a venous ulcer heal more quickly?
|
Adequate compression
|
|
|
What should a practitioner be looking for in a long-standing venous ulcer?
|
Malignant changes such as squamous cell carcinoma
|
|
|
What are the signs of malignant change in an ulcer?
|
Rolled edges and a hyperplastic base
|
|
|
What is a hyperplastic base?
|
It is where the there is proliferation of cells over what would be expected in the base of an ulcer
|
|
|
How does oedema result?
|
Increased hydrostatic pressure causes leakage of tissue fluid
|
|
|
What is post-thrombotic syndrome?
|
Post-thrombotic syndrome refers to the long-term effects that can occur after venous thrombosis. It is also referred to as post-phlebitic syndrome.
|
|
|
What are the symptoms of post-thrombotic syndrome?
|
It is characterized by chronic pain, swelling, heaviness and other signs in the affected limb and in severe cases, venous ulcers may develop. It is the most common complication of deep venous thrombosis. Other complications may include purpura, eczematoid reaction, dermatitis, pruritis and ulceration
|
|
|
How does non-pitting oedema form?
|
Where the tissue fluid is an exudate it contains fibrinogen which will become organised
|
|
|
What is the tissue fluid called in pitting oedema?
|
Transudate
|
|
|
Why does transudate not become organised?
|
Because it does not contain fibrinogen but it may organise if it is very long-standing
|
|
|
Is the pitting due to DVT pitting or non-pitting?
|
It usually demonstrates pitting
|
|
|
What can oedema also cause if it forms around the ankles?
|
Ischaemia and occlude arteries which can cause moist gangrene if the occlusion is very severe
|
|
|
What sort of legs do people with chronic venous ulceration have?
|
Champagne or inverted bottle legs
|
|
|
What are champagne or inverted bottle legs indicative of?
|
Chronic venous ulceration
|
|
|
How does a clinician detect pitting oedema?
|
Digital pressure is firmly applied to the area for a period of 3-5 seconds. If an imprint of the fingers remain the oedema is described as pitting
|
|
|
What are the clinical tests to detect venous insufficiency?
|
Pitting/non-pitting oedema, Perthes test and Doppler
|
|
|
What is Perthes test?
|
With the leg dependent, on occlusion cuff is inflated at mid-thigh level. The superficial veins will become prominent as they fill. The patient is then asked to walk for 5 minutes. If the veins are healthy, the prominence will reduce due to drainage into the deep veins. If the superficial veins are incompetent the prominence will remain and if this is accompanied by a dusky rubor it suggests that the deep veins are incompetent
|
|
|
What is Perthes test used for?
|
It can be used to test the competency of leg veins.
|
|
|
What sound do veins give when heard through a Doppler?
|
They give a non-pulsatile, continuous, low-pitched sound like wind sighing down a chimney
|
|
|
Why do veins give a non-pulsatile continuous low-pitched sound?
|
Because of the effects of respiration on the flow of venous blood in the thorax.
|
|
|
When would a vein give a pulsatile sound?
|
When there is excessive fluid in the lower limbs as in congestive heart failure
|
|
|
What would a vein sound like if there is excessive fluid in the lower limb such as in congestive failure?
|
A pulsatile sound
|
|
|
What can a Doppler be used for in venous insufficiency?
|
To test for valvular incompetence of the calf veins
|
|
|
How could a clinician test for valvular incompetence of the calf veins?
|
By a Doppler
|
|
|
How does a clinician test for valvular incompetence of the calf veins by a Doppler?
|
With the patient standing and knee slightly flexed, the Doppler probe should be positioned over the vein in the popliteal fossa. The clinician should squeeze and release the calf distal to the probe. Two sharp sounds should be heard. The first sound is flow forward towards the probe as the vein is squeezed and the second sound is reverse flow due to gravity on release of the pressure. If there is no sound on compression this indicates a blockage between the site of compression and the probe. If the second sound is not abrupt but continues and fades away it suggests leakage of blood through the valves.
|
|
|
When should testing of valvular incompetence by a Doppler NOT be used?
|
When there is a high index of suspicion that there is a DVT
|
|
|
What are the hospital tests used to detect venous insufficiency?
|
Plethysmography, venous angiography and duplex ultrasound
|
|
|
What is plethysmography?
|
This test can be used to diagnose thrombotic obstruction of major proximal veins of the extremities
|
|
|
What can plethysmography NOT detect?
|
It is not useful for detecting calf vein thrombosis
|
|
|
What is venous angiography?
|
A radio-opaque dye is injected into the affected vein to show valvular incompetence and the presence of an obstruction
|
|
|
What does Duplex ultrasound do?
|
It can be used to ascertain whether the long saphenous vein is suitable for femoral bypass grafting as well as determining the presence of a thrombus
|
|
|
What do the lymphatic vessels do?
|
They play an important part in draining tissue fluid back, via the thoracic duct to the heart
|
|
|
What is it called when the lymphatic drainage is adversely affected?
|
Lymphoedema
|
|
|
What is lymphoedema?
|
When the lymphatic drainage is adversely affected
|
|
|
What is primary lymphoedema?
|
Primary lymphoedema is congenital
|
|
|
What is secondary lymphoedema?
|
Secondary lymphoedema is acquired
|
|
|
What are the causes of primary (congenital) lymphoedema?
|
1. Milroy's disease
2. Idiopathic |
|
|
What are the causes of secondary (acquired) lymphoedema?
|
Intrinsic
1. Malignant neoplasia 2. Radiotherapy 3. Surgical excision of lymph nodes 4. Filariases 5. Infection 6. Pregnancy Extrinsic 1. Trauma 2. Plaster cast |
|
|
What is Milroy's disease?
|
Onset is either early in life or later in life at about the age of 35 years. It affects females more than males. Once it is organised it will not be alleviated by leg elevation
|
|
|
What is lymphoedema praecox?
|
Onset of lymphoedema early in life
|
|
|
What is lymphoedema tarda?
|
Onset of lymphoedema at the age of about 35 years
|
|
|
What are the signs of primary lymphoedema?
|
It begins as a soft, pitting form but becomes harder and non-pitting with time. It can be unilateral or bilateral
|
|
|
What are the signs of secondary lymphoedema?
|
Secondary lymphoedema is usually unilateral and considerable fibrosis may occur
|
|
|
How does lymphoedema affect tissue viability?
|
Tissue fluid stagnation will interfere with diffusion of gases and nutrients and removal of waste products which will affect tissue viability
|
|
|
What other pathologies are associated with lymphoedema?
|
Cellulitis and thickening and scaling of the skin leading to an "elephantiasis-like" appearance of the skin
|
|
|
What causes red streaks(lymphangitis) following the course of a vessel?
|
The presence of infection in the lymphatic vessels.
|
|
|
What are red streaks called following the course of the vessel?
|
Lymphangitis
|
|
|
What is lymphangitis?
|
Red streaks following the course of a vessel near infection
|
|
|
How would you find the popliteal vein with a Doppler?
|
Locate the popliteal artery and move the probe slightly sideways
|
|
|
What is lymphadenitis?
|
When infection reaches the lymph nodes/glands which will become tender and swollen
|
|
|
What is it called when infection in the lymph vessels reaches the lymph nodes/glands which become tender and swollen?
|
Lymphadenitis
|
|
|
What is it called when infection enters the bloodstream?
|
Bacteraemia
|
|
|
What sort of legs do people with chronic venous ulceration have?
|
Champagne or inverted bottle legs
|
|
|
What are champagne or inverted bottle legs indicative of?
|
Chronic venous ulceration
|
|
|
How does a clinician detect pitting oedema?
|
Digital pressure is firmly applied to the area for a period of 3-5 seconds. If an imprint of the fingers remain the oedema is described as pitting
|
|
|
What are the clinical tests to detect venous insufficiency?
|
Pitting/non-pitting oedema, Perthes test and Doppler
|
|
|
What is Perthes test?
|
With the leg dependent, on occlusion cuff is inflated at mid-thigh level. The superficial veins will become prominent as they fill. The patient is then asked to walk for 5 minutes. If the veins are healthy, the prominence will reduce due to drainage into the deep veins. If the superficial veins are incompetent the prominence will remain and if this is accompanied by a dusky rubor it suggests that the deep veins are incompetent
|
|
|
What is Perthes test used for?
|
It can be used to test the competency of leg veins.
|
|
|
What sound do veins give when heard through a Doppler?
|
They give a non-pulsatile, continuous, low-pitched sound like wind sighing down a chimney
|
|
|
Why do veins give a non-pulsatile continuous low-pitched sound?
|
Because of the effects of respiration on the flow of venous blood in the thorax.
|
|
|
When would a vein give a pulsatile sound?
|
When there is excessive fluid in the lower limbs as in congestive heart failure
|
|
|
What would a vein sound like if there is excessive fluid in the lower limb such as in congestive failure?
|
A pulsatile sound
|
|
|
How does lymphoedema affect tissue viability?
|
Tissue fluid stagnation interferes with diffusion of gases and nutrients and removal of waste products
|
|
|
What other pathologies are lymphoedema associated with?
|
Cellulitis and thickening and scaling of the skin which can lead to an "elephantiasis-like" appearance
|
|
|
What is lymphangitis?
|
The presence of infection in the lymphatic vessels.
|
|
|
What is presence of infection in the lymphatic vessels called?
|
Lymphangitis
|
|
|
What are the symptoms of lymphangitis?
|
Presence of red streaks following the course of the vessel.
|
|
|
What is lympadenitis?
|
Infection of the lymph nodes/glands
|
|
|
What is infection of the lymph nodes/glands called?
|
Lymphadenitis
|
|
|
What are the symptoms of lymphadenitis?
|
Swollen and tender lymph nodes
|
|
|
What is the condition called when infection enters the bloodstream?
|
Bacteraemia
|
|
|
What is bacteraemia?
|
When infection enters the bloodstream
|
|
|
What is septicaemia (blood poisoning)?
|
When bacteria enters the bloodstream causing systemic infection
|
|
|
What is the condition called when bacteria enters the bloodstream causing system infection?
|
Septicaemia or blood poisoning.
|
|
|
How would you find the popliteal vein with a Doppler?
|
Find the popliteal artery with the probe and move slightly sideways
|
|
|
What is yellow nail syndrome?
|
It is where the nail appears yellow, thickened but smooth and there is an increase in lateral curvature. There is also a reduced rate of growth.
|
|
|
What causes yellow nail syndrome?
|
The condition is associated with chronic lymphoedema
|
|
|
What can chronic lymphoedema cause in the nails?
|
Yellow nail syndrome
|
|
|
What are the hospital tests used for lymphoedema?
|
Lymphangiography and X-rays
|
|
|
What is lymphangiography?
|
It is the same technique as used for venous angiography
|
|
|
What do X-rays show in lymphoedema?
|
In primary lymphoedema they show hypoplasia of the lymphatic system and spidery and scanty lymphatic channels
|
|
|
What are the five most important signs that should alert the practitioner to further vascular assessment?
|
1. Absence of pedal pulses
2. ABPI of <0.9 3. Intermittent claudication 4. Oedema 5. A difference in temperature between the lower limbs of 2 degrees centigrade or more |
|
|
What is the purpose of a neurological assessment?
|
1. establish which, if any, part of the nervous system is functioning abnormally
2. Identify the extent of the dysfunction 3. Where possible, arrive at a specific diagnosis 4. Draw up a treatment plan which takes account of the above information |
|
|
What is a cerebral vascular accident (CVA)?
|
It is caused by haemorrhage, embolus or thrombus of the cerebral arteries
|
|
|
What is a stroke?
|
A cerebral vascular accident
|
|
|
What is an embolism?
|
An embolism occurs when an object (the embolus, plural emboli) migrates from one part of the body (through circulation) and causes a blockage (occlusion) of a blood vessel in another part of the body.
|
|
|
What is a thrombus?
|
A thrombus, or clot forms at the blockage point within a blood vessel
|
|
|
What is the difference between a thrombus and an embolism?
|
An embolism is carried to the site of occlusion whereas a thrombus forms at the site of occlusion
|
|
|
What is Parkinsonism?
|
A degeneration of dopaminergic receptors.
|
|
|
What can cause Parkinsonism?
|
It is usually idiopathic but can be drug induced
|
|
|
What is the condition called where there is haemorrhage, embolus or thrombosis of the cerebral arteries?
|
Cerebral vascular accident (CVA) or stroke
|
|
|
What is the condition called where there is a degeneration of dopaminergic receptors?
|
Parkinsonism
|
|
|
What is Friedrich's ataxia?
|
It is an inherited disorder affecting the cerebellum
|
|
|
When is the onset and what is the prognosis of Friedrich's ataxia?
|
Onset is in childhood and death is usually around 40 years
|
|
|
What is multiple sclerosis?
|
Patchy demyelination of the CNS which shows relapses and remissions
|
|
|
When is the onset of multiple sclerosis?
|
20+
|
|
|
What is the condition associated with patchy demyelination of the CNS which shows relapses and remissions?
|
Multiple sclerosis
|
|
|
What is poliomyelitis?
|
It is a virus that affects the (lower motor neurones) LMNs?
|
|
|
What is syringomyelia?
|
It is a progressive destruction of the spinal cord due to blockage of the central canal eg tumour
|
|
|
What is tabes dorsal?
|
It occurs with tertiary stage syphillis
|
|
|
What is spina bifida?
|
It is a defective closure of the vertebral column. It is congenital.
|
|
|
What is motor neurone disease?
|
It is degeneration of both upper motor neurones (UMNs) and lower motor neurones (LMNs). There is no sensory loss.
|
|
|
What age is the onset of motor neurone disease?
|
Between the ages of 40 and 60.
|
|
|
What causes motor neurone disease?
|
Idiopathic
|
|
|
What is generally the cause of death in motor neurone disease?
|
Death is usually due to respiratory infection
|
|
|
What is subacute combined degeneration of the spinal cord?
|
Due to lack of vitamin B12 and is usually seen in pernicious anaemia. It affects both sensory and motor tracts in the spinal cord. It is reversible if detected in time.
|
|
|
What is pernicious anaemia?
|
It is anaemia caused by a deficiency of vitamin B12. Vitamin B12 helps form red blood cells.
|
|
|
What is Charcot-Marie-Tooth disease?
|
It affects peroneal nerve and is predominantly motor with variable sensory deficit. It is the commonest inherited neuropathy and the onset is in teens and slowly worsens.
|
|
|
What are the other names for Charcot-Marie-Tooth disease?
|
Peroneal muscle atrophy or hereditary motor-sensory neuropathy
|
|
|
What is the name for the inherited disease that affects the peroneal nerve?
|
Charcot-Marie-Tooth disease
|
|
|
What is Guillain-Barre syndrome?
|
It is a post-viral autoimmune response. Predominantly motor effects with muscle weakness and paralysis but some sensory loss. 80% of patients show full recovery but there can be a chronic relapsing form. There is rapid onset and is potentially fatal due to respiratory failure
|
|
|
What is neurofibromatosis?
|
An inherited condition that leads to tumours of nerves and compression of the spinal cord
|
|
|
What pathologies can cause peripheral neuropathy?
|
Alcoholism, injury, diabetes mellitus
|
|
|
What is myasthenia gravis?
|
An inherited condition that affects the neuromuscular junction and leads to severe fatigue and weakness/paralysis
|
|
|
What are myopathies?
|
They are a range of relatively rare diseases affecting muscle only. They can be inherited or acquired. Symptoms are similar to LMN disease but no fasciculation
|
|
|
What is an ataxic gait?
|
An unco-ordinated gait
|
|
|
What is an unco-ordinated gait called?
|
An ataxic gait
|
|
|
What can cause an ataxic (unco-ordinated) gait?
|
It may be due to a disorder of the cerebellum or a lack of proprioceptive information
|
|
|
What are the initial clinical features of multiple sclerosis?
|
1. Double vision
2. Falling over 3. Tingling sensations 4. Loss of function |
|
|
If a patient complains of double vision, falling over, tingling sensations and loss of function what could the pathology be?
|
Multiple sclerosis
|
|
|
What lower limb pathology are Guillan-Barre sufferers prone to?
|
Ulcers
|
|
|
What are the two types of cell that make up the tissue of the nervous system?
|
Glial cells and neurones
|
|
|
What are the four types of glial cells?
|
1. Ependymal
2. Oligodendrocytes (brain) and Schwann cells (periphery) 3. Astrocytes 4. Microglial |
|
|
What types of cells are ependymal, oligodendrocytes (brain), Schwann cells (periphery), astrocytes and microglial?
|
They are glial cells.
|
|
|
What do ependymal cells do?
|
They are involved in the secretion and absorption of cerebrospinal fluid (CSF) which acts as an interstitial fluid bathing the cells of the brain and spinal cord
|
|
|
What are the cells called that are involved in the secretion and absorption of cerebrospinal fluid (CSF)?
|
Ependymal cells
|
|
|
What acts as the interstitial fluid of the brain and spinal cord called?
|
Cerebrospinal fluid (CSF)
|
|
|
What is cerebrospinal fluid (CSF)?
|
It acts as the interstitial fluid of the brain and spinal cord
|
|
|
What do oligodendrocytes in the brain and Schwann cells in the periphery do?
|
They are responsible for the manufacture of the myelin sheath around the axons of the neurones which improves the speed of nerve conduction. They also play a role in the development and repair of nervous tissue helping to guide the growing axons to their correct destination
|
|
|
What cells produce the myelin sheath around the axons of the neurones and help repair nervous tissue and guide the growing axons to their correct destination?
|
Oligodendrocytes in the brain and Schwann cells in the periphery
|
|
|
What are astrocytes and
what do they do? |
-Act as buffers in the CSF, keeping K+ concentration constant.
-Play a Nutritive role -Phagocytic -Take up certain neurotransmitters |
|
|
What are the cells called that keep K+ constant in the CSF, provide nutrients, are phagocytic and take up certain neurotransmitters?
|
Astrocytes
|
|
|
What do microglial cells do?
|
They are phagocytic and remove debris
|
|
|
What cells are phagocytic and remove debris?
|
Microglial cells
|
|
|
What is a function of glial cells?
|
Due to their sheer bulk they provide structural support as there is no connective tissue within the nervous tissue.
|
|
|
What cells provide structural support within the nervous tissue?
|
Glial cells
|
|
|
What happens when a neurone is damaged?
|
It cannot be replaced. Damage results in permanent changes.
|
|
|
How many parts does a neurone consist of and what are they?
|
1. Cell body
2. Dendrites 3. Axon 4. Presynaptic terminals |
|
|
What is the function of a cell body in a neurone?
|
It contains the nucleus and other organelles and is the site of synthesis of chemicals (neurotransmitters) for the transmission of impulses.
|
|
|
What is the function of dendrites in a neurone?
|
Dendrites are fine branches from the cell body which are the chief receptive area for impulses from other neurones or for the reception of other stimuli
|
|
|
What is the function of an axon in a neurone?
|
This is the conducting portion and can be up to 1m in length. It conducts electrical impulses and is also involved in the transport of various substances to and from the cell body. It may be myelinated but if less than a micrometre in diameter it will be unmyelinated
|
|
|
What is the function of presynaptic terminals in the neurone?
|
These are fine branches of the axon which are responsible for the release of neurotransmitters to enable the impulse to pass from one neurone to the next or on to a muscle or gland
|
|
|
What is the gap or synapse between one neurone and the next called?
|
It is an area of physical discontinuity
|
|
|
Where is an area of physical discontinuity called?
|
It is the gap or synapse between one neurone and the next.
|
|
|
What is the anatomical classification of the nervous system?
|
The central nervous system (CNS), the peripheral nervous system (PNS) and muscle
|
|
|
What is the functional classification of the central nervous system?
|
The somatic nervous system, and the autonomic nervous system (ANS)
|
|
|
What is contained in the central nervous system?
|
All the structures lying within the central axis of the body ie the brain and spinal cord and it consists of neurones and glial cells
|
|
|
What are the three areas of the brain?
|
1. Forebrain
2. Midbrain 3. Hindbrain |
|
|
What two structures are in the forebrain?
|
1. Cerebral cortex
2. Diencephalon |
|
|
What structure is in the midbrain?
|
Corpora quadrigemina
|
|
|
What three structures are in the hindbrain?
|
1. Pons
2. Cerebellum 3. Medulla oblongata |
|
|
What four structures are in the cerebral cortex?
|
1. Frontal lobe
2. Parietal lobe 3. Temporal lobe 4. Occipital lobe |
|
|
What four structures are in the diencephalon?
|
1. Thalamus
2. Hypothalamus 3. Limbic system 4. Basal ganglia |
|
|
What two structures are in the corpora quadrigemina?
|
1. Superior colliculi
2. Inferior colliculi |
|
|
What is the function of the pons?
|
Modification of respiration
|
|
|
Where in the brain is respiration modified?
|
In the pons
|
|
|
What is the function of the cerebellum?
|
Modification of movement
|
|
|
Where in the brain is movement modified?
|
In the cerebellum
|
|
|
What is the function of the medulla oblongata?
|
It is a vital control centre
|
|
|
Where is the vital control centre of the brain?
|
In the medulla oblongata
|
|
|
What is the function of the frontal lobe?
|
Abstract thought, conscious action and speech
|
|
|
Where is the centre for abstract thought, conscious action and speech located?
|
In the frontal lobe
|
|
|
What is the function of the parietal lobe?
|
General senses, verbal understanding
|
|
|
Where is the centre for general senses and verbal understanding located?
|
In the parietal lobe
|
|
|
What is the function of the temporal lobe?
|
Hearing, taste, smell, emotions
|
|
|
Where is the centre for hearing, taste, smell and emotions?
|
In the temporal lobe
|
|
|
What is the function of the occipital lobe?
|
Vision
|
|
|
Where is the centre for vision located?
|
In the occipital lobe
|
|
|
What is the function of the thalamus?
|
It is a sensory relay station
|
|
|
Where is the sensory relay station located in the brain?
|
In the thalamus
|
|
|
What is the function of the hypothalamus?
|
Emotions, endocrine system, autonomic nervous system (ANS)
|
|
|
What is the centre for emotions, the endocrine system and the autonomic nervous system (ANS)?
|
The hypothalamus
|
|
|
What is the function of the limbic system?
|
It is the centre for motivation and emotions
|
|
|
Where is the centre for motivation and emotions?
|
In the limbic system
|
|
|
What is the function of the basal ganglia?
|
Movement
|
|
|
Where is the centre of movement in the brain?
|
In the basal ganglia
|
|
|
What is the function of the superior colliculi?
|
Visual orientation
|
|
|
Where is the centre for visual orientation in the brain?
|
In the superior colliculi
|
|
|
What is the function of the inferior colliculi?
|
Auditory orientation
|
|
|
Where is the centre for auditory orientation in the brain?
|
In the inferior colliculi
|
|
|
Where is the medulla oblongata located?
|
In the hindbrain
|
|
|
Where is the cerebellum located?
|
In the hindbrain
|
|
|
Where is the pons located?
|
In the hindbrain?
|
|
|
Where is the inferior colliculi located?
|
In the corpora quadrigemina
|
|
|
Where is the superior colliculi located?
|
In the corpora quadrigemina
|
|
|
Where is the corpora quadrigemina located?
|
In the midbrain
|
|
|
Where is the basal ganglia located?
|
In the diencephalon
|
|
|
Where is the limbic system located?
|
In the diencephalon
|
|
|
Where is the hypothalamus located?
|
In the diencephalon
|
|
|
Where is the thalamus located?
|
In the diencephalon
|
|
|
Where is the diencephalon located?
|
In the forebrain
|
|
|
Where is the occipital lobe located?
|
In the cerebral cortex
|
|
|
Where is the temporal lobe located?
|
In the cerebral cortex
|
|
|
Where is the parietal lobe located?
|
In the cerebral cortex
|
|
|
Where is the frontal lobe located?
|
In the cerebral cortex
|
|
|
Where is the cerebral cortex located?
|
In the forebrain
|
|
|
How many vertebrae surround the spinal cord?
|
32
|
|
|
What is the grey matter in the CNS formed from?
|
The cell bodies of the neurones
|
|
|
What is the white matter in the CNS formed from?
|
The axons form the white matter due to the presence of myelin
|
|
|
Where can lumbar punctures be performed without damaging the spinal cord?
|
At the level of L3 or L4
|
|
|
What are the nerves in the lower limb?
|
Lumbar plexus 1-4, femoral nerve, sacral plexus L4, L5, S1-3,hamstring nerve, sciatic nerve, common peroneal nerve, superficial peroneal nerve, tibial nerve, saphenous nerve and the deep peroneal nerve
|
|
|
What does the peripheral nervous system consist of?
|
Those nerves that lie outside the spinal cord and brain
|
|
|
What is the peripheral nervous system (PNS) divided into?
|
Afferent nerve fibres and efferent nerve fibres
|
|
|
What is the function of afferent nerve fibres?
|
They carry impulses towards the CNS from receptors such as warmth receptors
|
|
|
What is the function of efferent nerve fibres?
|
They carry impulses away from the CNS to effectors such as the leg muscles or sweat glands
|
|
|
How many pairs of cranial nerves are there?
|
12 pairs originating from the brain stem
|
|
|
How many pairs of spinal nerves are there?
|
31 pairs
|
|
|
How many roots do the spinal nerve emerge from the spinal cord as?
|
2 roots
|
|
|
What are the two roots of the spinal nerves that emerge from the spinal column called?
|
1. Dorsal (posterior) root
2. Ventral (anterior) root |
|
|
What happens to the two roots of the spinal nerves after they have emerged from the spinal column?
|
They join to form the peripheral mixed spinal nerve which emerges between two adjacent vertebrae
|
|
|
What does the dorsal (posterior) root contain?
|
The cell bodies of afferent fibres
|
|
|
Where are the cell bodies of afferent fibres located in the dorsal (posterior) root?
|
They are located in a swelling called the dorsal root ganglion
|
|
|
What is a dorsal root ganglion?
|
It is a swelling in the dorsal root which contains the cell bodies of afferent fibres
|
|
|
Where does each afferent neurone travel into?
|
The dorsal horn
|
|
|
What is the dorsal horn?
|
The dorsal horn is where each afferent neurone travels into
|
|
|
What does the ventral (anterior) root contain?
|
Mainly efferent fibres
|
|
|
What is a dermatome?
|
it is defined as an area of skin supplied by a single nerve's dorsal root
|
|
|
What is the area of the skin supplied by a single nerve's dorsal root?
|
A dermatome
|
|
|
Where does S1 innervate?
|
The back of the foot up to just past the malleoli and the 4th and 5th toes and the skin superior to them up to the lateral malleolus
|
|
|
What dermatome innervates the back of the foot up to just past the malleoli and the 4th and 5th toes and the skin superior to them up to the lateral malleolus
|
S1
|
|
|
Where does L5 innervate?
|
The area from the 1st, 2nd and 3rd digits diagnonally across to the lateral malleolus to the lateral side just below the knee
|
|
|
What dermatome innervates the area from the 1st, 2nd and 3rd digits diagnonally across to the lateral malleolus to the lateral side just below the knee
|
L5
|
|
|
What does L4 innervate?
|
The medial side of the calf from below the knee to just below the medial malleolus
|
|
|
What dermatome innervates the medial side of the calf from below the knee to just below the medial malleolus
|
L4
|
|
|
What is the structure of skeletal muscle?
|
Elongated fibres, multi-nucleated syncytium with visible striations
|
|
|
What muscle has elongated fibres, multi-nucleated syncytium with visible striations
|
Skeletal muscle
|
|
|
What is a syncytium?
|
A multi-nucleate cell
|
|
|
What is the name for a multi-nucleate cell?
|
A syncytium
|
|
|
What innervates skeletal muscle?
|
Somatic nerves
|
|
|
What muscle do somatic nerves innervate?
|
Skeletal muscle
|
|
|
What is the function of skeletal muscle?
|
1. Moves bones
2. Functions as part of a motor unit 3. Cannot contract without a nerve impulse 4. Conscious control |
|
|
What is the structure of cardiac muscular tissue?
|
It has branched fibres, a single nucleus per cell and visible striations
|
|
|
What muscular tissue has branched fibres, a single nucleus per cell and visible striations?
|
Cardiac muscular tissue
|
|
|
What innervates cardiac muscular tissue?
|
Autonomic nerves
|
|
|
What muscular tissue do autonomic nerves innervate?
|
Cardiac and smooth muscular tissue
|
|
|
What is the function of cardiac muscular tissue
|
It pumps blood, forms a functional unit, has myogenicity and unconscious control
|
|
|
What muscular tissue pumps blood, forms a functional unit, has myogenicity and unconscious control?
|
Cardiac muscular tissue
|
|
|
What structure does smooth muscular tissue have?
|
It has spindle-shaped fibres, a single nucleus per cell and no visible striations
|
|
|
What innervates smooth muscular tissue?
|
Autonomic nerves
|
|
|
What is the function of smooth muscular tissue?
|
It moves vessels, organs and glands. It forms functional sheets. There is myogenicity in some smooth muscles and has unconscious control
|
|
|
What muscular tissue moves vessels, organs and glands. It forms functional sheets. There is myogenicity in some smooth muscles and has unconscious control?
|
Smooth muscular tissue
|
|
|
What do the three main types of muscles depend on to initiate contraction?
|
The binding of calcium ions to calcium-binding proteins
|
|
|
What are the three main types of muscle?
|
1. Skeletal
2. Cardiac 3. Smooth |
|
|
What happens when a muscle contracts?
|
Contraction or shortening involves the formation of crossbridges and sliding of actin and myosin myofilaments over one another
|
|
|
What is the somatic nervous system?
|
It includes all parts of the nervous system that deals with the conscious perception of stimuli and conscious action including the sensorimotor or conscious cortex
|
|
|
What is another name for afferent nerves?
|
Sensory nerves
|
|
|
What is another name for sensory nerves?
|
Afferent nerves
|
|
|
What is another name for efferent nerves?
|
Motor nerves
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What is another name for motor nerves?
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Efferent nerves
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What is the autonomic nervous system (ANS)?
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This is the part of the nervous system that deals with the internal organs
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What parts of the brain are involved with the autonomic system?
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The hypothalamus and the limbic system
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What is the parasympathetic nervous system?
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It is the efferent part of the autonomic nervous system which restores the 'status quo' and allows emptying actions
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What neurotransmitter is released in the parasympathetic nervous system?
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Acetylcholine
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What is the sympathetic nervous system?
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It is the efferent branch of the autonomic nervous system which prepares the body for action, the fight or flight response
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What neurotransmitter is mainly released in the sympathetic nervous system
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Noradrenaline or norepinephrine
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Where do parasympathetic nerves innervate?
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They do not innervate structures outside the central axis apart from blood vessels of the pelvic region
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What structures do the sympathetic nerves innervate?
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All peripheral structures including skin and blood vessels
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In the lower limb what does sympathetic activity cause? and what does reduction of sympathetic activity cause?
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Sympathetic activity causes peripheral vasoconstriction and a reduction in this activity or 'tone' causes vasodilation
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How does a nerve impulse or signal work?
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It is dependent upon the movement of ions across the cell membrane and through protein ion channels
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What is an action potential?
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It is used by the neurone to transmit an impulse over long distances
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What is a graded potential?
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A graded potential is the neurotransmitter crossing the synaptic gap to trigger an action potential in the next neurone. Graded potentials can only travel over very small distances and rapidly dissipate.
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What potentials are affected by parkinsonism and myasthenia gravis and why?
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They affect the graded potential because in parkinsonism there is loss of dopamine which is a neurotransmitter and with myasthenia gravis there is a loss of cholinergic receptors which affect the normal functioning of the graded potential
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What are the differences between an action potential and a graded potential?
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1. Action potentials have voltage-gated ion channels and graded potentials have chemically/mechanically/light-gated ion channels
2. A threshold must be reached before an action potential is generated. No threshold, all triggers will generate graded potentials 3. Action potentials are fixed magnitude (all or nothing). Graded potentials have magnitudes proportional to the size of the trigger 4. Action potentials have large potentials. Graded potentials have small potentials 5. Action potentials do not summate. Graded potentials do summate 6. Action potentials do not attenuate. Graded potentials rapidly attenuate 7. Action potentials are used for long-distance signalling. Graded potentials are used for local signals |
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What sense activates a mechanoreceptor?
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Touch, pressure
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Which receptor does touch, pressure activate?
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Mechanoreceptors
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What sort of nerve endings does a mechanoreceptor have?
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Encapsulated and free nerve endings
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What sense activates a thermoreceptor?
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Warmth, cold
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What receptor does warmth, cold activate?
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Thermoreceptors
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What nerve endings do thermoreceptors have?
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Free nerve endings
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What sense does a nociceptor pick up?
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Pain
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What receptor does pain activate?
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Nociceptors
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What sort of nerve endings do nociceptors have?
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Free nerve endings
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What is the function of a proprioceptor?
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It detects position
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What sort of nerve endings does a proprioceptor have?
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Encapsulated nerve endings
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What receptor detects position?
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Proprioceptor
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What are free nerve endings?
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Free nerve endings are the branched terminations of the axons
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What are encapsulated nerve endings?
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Encapsulated nerve endings consist of branched axons enclosed in a discrete connective tissue capsule
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What are baroreceptors?
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Baroreceptors monitor changes in blood pressure
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Where are baroreceptors located?
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In the aorta
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What are osmoreceptors?
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Osmoreceptors monitor the osmolarity of the extracellular fluid
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Where are osmoreceptors located?
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In the hypothalamus
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What receptors monitor changes in blood pressure?
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Baroreceptors
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What receptors monitor changes in osmolarity?
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Osmoreceptors
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What receptors register position sense, tension and degree of stretch?
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Proprioceptors
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What do proprioceptors register?
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Proprioceptors register position sense, tension and degree of stretch
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Where are proprioceptors located?
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In the muscles, tendons and joints
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Where do proprioceptors send their impulses to?
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To the cerebellum and the somatosensory cortex
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What is a sensory unit?
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A sensory unit is the afferent nerve, its branches and the attached receptors
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What is the area called that is served by a sensory unit?
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The receptive field
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What is a receptive field?
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The area served by a sensory unit
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What is somatotopic organisation?
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This is where discrete areas of the cortex receive the information from the various parts of the body
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What is the term for where discrete areas of the brain receive information from various parts of the body?
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Somatotopic organisation
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What are the two main ascending pathways?
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1. The rapid, highly organised oligo-(few) synaptic pathways
2. The less well organised multisynaptic pathways |
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What tract carries pain information?
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The lateral spinothalamic tract
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Where does the lateral spinothalamic tract run?
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It runs from the lateral region of the spinal cord up to the thalamus
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What information does the lateral spinothalamic tract carry?
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Pain information
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What tracts carry proprioceptive information?
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The spinocerebellar tract
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What information does the spinocerebellar tract carry?
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Proprioceptive information
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Where does the spinocerebellar tract run to?
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To the ipsilateral lobes of the cerebellum in the hindbrain
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How many tracts does the oligosynaptic pathway consist of?
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Two
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What are the tracts that make up the oliogosynaptic pathway?
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1. The dorsal (posterior) columns
2. The neospinothalamic tracts (part of the anterolateral tract) |
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What pathway does the dorsal (posterior) column and the neospinothalamic tract (part of the anterolateral tract) make up?
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The oligosynaptic pathway
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What is another name for the dorsal columns?
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The posterior columns
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What is another name for the posterior columns?
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The dorsal columns
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What is the neospinothalamic tract a part of?
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The anterolateral tract
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What is the anterolateral tract a part of?
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The neospinothalamic tract
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How many ascending tracts make up the multisynaptic pathway?
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Two
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What are the two tracts that make up the multisynaptic pathway?
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1. Fasciculi propii tract
2. Paleospinothalamic tract |
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What pathway do the fasciculi propii tract and paleospinothalamic tract make up?
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The multisynaptic pathway
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What tracts carry information about touch?
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The dorsal (posterior) column and the ventrospinothalamic tract
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Why does a CVA affecting a particular part of the sensory cortex produce numbness or paraesthesia in a specific part of the body on the opposite or contralateral side?
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Because the majority of ascending tracts cross over to the opposite side either in the spinal cord or in the brain stem.
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What does ipsilateral mean?
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Same side
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What are the neurones called that are responsible for initiating commands in the brain?
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Upper motor neurones (UMNs)
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What is the function of an upper motor neurone?
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UMNs are neurones responsible for initiating commands in the brain
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How do upper motor neurones work?
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They exert their influence via neurones in the ventral (anterior) horn of the spinal cord called lower motor neurones (LMNs)
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Do upper motor neurones send impulses directly to muscles?
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No
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What is the function of lower motor neurones (LMNs)?
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LMNs send impulses to the skeletal muscles via their axons.
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What neurones send impulses to the skeletal muscles via their axons?
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Lower motor neurones (LMNs)
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What pathways do the axons of LMNs form?
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They form the peripheral efferent pathways within the spinal nerves
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How many tracts form the descending pathways?
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Two tracts
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What are the tracts that form the descending pathways?
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1. The corticospinal tract
2. The multineuronal (brain stem) tract |
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What pathway does the corticospinal tract and the multineuronal (brain stem) tract form?
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The descending pathways
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What is the corticospinal tract responsible for?
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The skilled movements of small, distal limb muscles such as those used in scalpel work
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Where do most of the fibres of the corticospinal tract cross over?
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They mainly cross over in the brain stem
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What does the crossed over part of the corticospinal tract descend as?
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The lateral corticospinal tract
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What do the uncrossed fibres of the corticospinal tract descend as?
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The ventral (anterior) corticospinal tract
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Where do the upper motor neurones enter the spinal cord to synapse with the lower motor neurones?
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The ventral horn of the grey matter
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What is the corticospinal tract also known as?
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The pyramidal tract
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What is the pyramidal tract also known as?
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The corticospinal tract
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Why is the corticospinal tract known as the pyramidal tract?
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Because the corticospinal tract forms a rough pyramid shape as it passes through the brain stem
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Which of the descending tracts is the rapid pathway?
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The corticospinal tract or the pyramidal pathway
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Which of the descending tracts is the slower pathway?
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The multineuronal tract or extrapyramidal pathway
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What are multineuronal tracts also known as?
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Extra (outside)-pyramidal pathways
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Why are extra-pyramidal tracts so named?
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Because these tracts do not form part of the pyramids in the medulla
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What do extra-pyramidal (multineuronal) tracts influence?
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1. The large proximal limb muscles
2. The axial muscles of posture 3. They have a predominantly inhibitory effect on the ventral horn cells 4. They are responsible for the antigravity reflexes which keep our knees extended and head erect to maintain upright posture |
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What influences are LMNs subject to?
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They are subject to influences from neurones in the descending tracts and also spinal neurones
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What is the final common pathway?
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The peripheral pathway from LMN to skeletal muscle
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What is the peripheral pathway from the LMN to skeletal muscle called?
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The final common pathway
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What is the motor unit?
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The peripheral pathway from LMN to skeletal muscle, the neuromuscual junction and the skeletal muscle fibres innervated by the nerve.
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What is the peripheral pathway from LMN to skeletal muscle, the neuromuscual junction and the skeletal muscle fibres innervated by the nerve?
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The motor unit
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What are the actions of the cerebellum?
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The actions of the cerebellum are unconscious and are very important in postural reflexes
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What part of the brain acts on postural reflexes?
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The cerebellum
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What descending pathways go from the cerebellum to the spinal cord?
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No descending pathways go from the cerebellum to the spinal cord
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Instead of descending pathways how does the cerebellum communicate?
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By sending modifying influences to the sensori-motor cortex, the reticular formation and brain-stem nuclei
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What is the reticular formation?
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The reticular formation is a part of the brain (brain stem) which is involved in stereotypical actions, such as walking, sleeping, and lying down. It is absolutely essential for life.
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What could cause symptoms of cerebellar defects?
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Lesions in the
1. Ascending spinocerebellar tracts 2. Cerebellum itself 3. Efferent pathways going to other parts of the brain |
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What information does the cerebellum primarily receive?
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Information on position sense from the ears, proprioceptors and the cerebral cortex
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What are the functions of the basal ganglia?
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The functions are unknown but are thought to enable abstract thought to be converted into voluntary action
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Does the basal ganglia function at a conscious or unconscious level?
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Unconscious level
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What is the direct pathway from the basal ganglia to the LMNs?
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There is no direct pathway to the LMNs from the basal ganglia
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What areas of the brain does the basal ganglia influence?
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The sensorimotor cortex and the descending reticular formation
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What tract does the basal ganglia have the main influence on?
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The descending extra-pyramidal (multineuronal) tracts
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What are conditions called that affect the extrapyramidal system?
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Extrapyramidal syndromes
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What is an example of an extrapyramidal syndrome?
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Parkinsonism
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What syndrome is parkinsonism an example of?
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Extrapyramidal syndrome
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What are reflex actions?
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They are automatic responses to particular stimuli and form the basis of much of our behaviour from the knee jerk to driving a car
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What automatic responses are important in posture, balance and gait?
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Reflexes
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How do we get reflexes?
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They can be inborn or acquired
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What are examples of inborn reflexes?
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1. Eye blink
2. Pupil dilation/constriction 3. Change in heart rate 4. Knee jerk (stretch) reflex 5. Pain withdrawal 6. Sweat secretion |
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What are examples of acquired reflexes?
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1. Swimming
2. Walking 3. Driving 4. Debriding callus |
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What parts of the nervous system and effector organs can they involve?
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They can involve any subdivisions of the nervous system and any type of effector organ
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Which two systems are in close association in a reflex arc?
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The nervous system and the endocrine system
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What responses are produced in an inborn reflex?
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Stereotypic responses which are usually protective reflexes or those responses needed for posture and balance
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What does an acquired reflex involve?
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They involve the conscious cortex and many different effectors and can be more easily modified
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What is a reflex arc?
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The pathway between a detector and effector and always involves the CNS but not necessarily the brain
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What is the pathway between a detector and effector which involves the CNS but not always the brain?
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A reflex arc
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What are the three reflexes that are of particular importance to the functioning of the lower limb?
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1. Pain withdrawal reflex
2. Crossed extensor reflex 3. Stretch reflex |
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What are the essential elements of a reflex arc?
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1. A detector to detect the change (stimulus) in either the internal or external environment
2. Afferent neurones that send the information into the CNS along the afferent pathways. 3. An integrating centre to match the appropriate response to the stimulus. This will be in the brain or spinal cord. Different parts of the CNS communicate with one another via ascending and descending pathways 4. Efferent neurones that carry instructions from the CNS via efferent pathways to the effectors (skeletal, smooth or cardiac muscle or gland) 5. An effector to carry out the necessary response |
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Which two reflexes are often superimposed on each other?
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The pain withdrawal reflex and the crossed extensor reflex eg withdrawing an injured limb during the pain withdrawal reflex while the remaining limb bears weight during the crossed extensor reflex
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Besides being involved in the pain withdrawal reflex what else is the crossed extensor reflex involved in?
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It is involved in each step in walking when one limb is in the swing phase and the other is weightbearing
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What reflex is important in walking?
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Crossed extensor reflex
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What is a very important reflex in all motor activity especially when new actions are being learnt?
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The stretch reflex
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What is the stretch reflex particularly important for?
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All motor activity and learning new actions
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What reflex do the patellar and Achilles tendon reflexes demonstrate?
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The stretch reflex
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Where is the stretch reflex best demonstrated?
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The patellar and Achilles tendon reflexes
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What information does the stretch reflex supply?
|
It supplies the cerebellum with information about the state of contraction in muscle
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What are the receptors called in the stretch reflex?
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Stretch receptors
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What are stretch receptors?
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They are receptors in the stretch reflex
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Where are stretch receptors located?
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In specialised muscle fibres called intrafusal fibres
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What are intrafusal fibres?
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This is where stretch receptors are located
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Where do receptors lie within intrafusal fibres?
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They lie within swellings called muscle spindles within intrafusal fibres
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What are muscle spindles?
|
Muscle spindles are swelling within intrafusal fibres where stretch receptors are located
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What are extrafusal fibres?
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Theyare ordinary muscle fibres
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How does a stretch reflex work?
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1. Ordinary muscle fibres (extrafusal fibres) are stretched when patellar tendon is hit by a hammer.
2. Stretch receptors generate graded potentials 3. These graded potentials trigger action potentials 4. Action potentials travel into the spinal cord and synapse with an alpha LMN 5. Efferent impulses travel out to the extrafusal fibres causing contraction of the muscle |
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How many types of stretch receptors are there?
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Two
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What are the types of stretch receptors
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1. One conveys information about the degree of stretch (static)
2. The other conveys information about the rate of change of stretch (dynamic) |
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Which pathway does the information supplied by the stretch receptors go on?
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The spinocerebellar pathway
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What sites of the brain are involved in motor co-ordination?
How are these sites involved? |
1. Premotor cortex - plans actions
2. Sensorimotor cortex - initiates action 3. Basal ganglia - converts thought into action 4. Cerebellum - Modifies action, compares actual and intended action, smooths action 5. Brain stem - modifies action, (extrapyramidal) - corrects position, (pyramidal) - skilled work |
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How is the premotor cortex involved in motor coordination?
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It plans actions
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How is the sensorimotor cortex involved in motor coordination?
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It initiates action
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How is the basal ganglia involved in motor coordination?
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It converts thought into action
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How is the cerebellum involved in motor coordination?
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It modifies action, compares actual and intended action, smooths action
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What function does the brain stem have on motor co-ordination?
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It modifies action
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What function does the extrapyramidal tracts have on motor co-ordination?
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They correct position
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What function do the pyramidal tracts have on motor co-ordination?
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They are responsible for skilled actions
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What part of the brain plans action in motor coordination?
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The premotor cortex
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What part of the brain initiates action in motor coordination?
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The sensorimotor cortex
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What part of the brain converts thought into action in motor coordination?
|
The basal ganglia
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What part of the brain modifies action, compares actual and intended action and smooths action in motor coordination?
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The cerebellum
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What part of the brain just modifies action in motor coordination?
|
The brain stem
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What tracts correct position in motor coordination?
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The extrapyramidal tracts
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What tracts promote skilled action in motor coordination?
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The pyramidal tracts
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Which part of the brain is primarily responsible for posture and balance?
|
The cerebellum
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What is the cerebellum primarily responsible for?
|
Posture and balance
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What parts of the brain are responsible for gait?
|
1. Premotor cortex
2. Sensorimotor cortex 3. Basal ganglia 4. Brain stem 5. Extrapyramidal tracts 6. Pyramidal tracts 7. Cerebellum |
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What are the causes of neurological disorders?
|
1. Heredity
2. Developmental defects 3. Trauma 4. Ischaemia 5. Compression 6. Infection 7. Autoimmune 8. Nutritional/metabolic 9. Iatrogenic 10. Idiopathic |
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What are the hereditary causes of neurological disorders?
|
1. Huntington's chorea
2. Peroneal muscular atrophy 3. Friedrich's ataxia 4. Malignant hyperpyrexia |
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What is malignant hyperpyrexia?
|
It is an inherited rare life-threatening condition that is triggered by exposure to certain drugs used for general anesthesia
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What are the developmental defects that cause neurological disorders?
|
1. Spina bifida
2. Syringomyelia |
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What are the sorts of trauma that cause neurological disorders?
|
1. Severing of the spinal cord or a peripheral nerve
2. Concussion |
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What are the ischaemic causes of neurological disorders?
|
1. Stroke
2. Cerebral haemorrhage |
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What are the compression causes of neurological disorders?
|
1. Tumour of the cerebellum
2. Morton's neuroma 3. Common peroneal nerve palsy |
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What are the infective causes of neurological disorders?
|
1. HIV
2. Jakob-Creutzfeld disease 3. herpes zoster (shingles) 4. Guillain-Barre syndrome 5. lepromatous neuropathy |
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What are the autoimmune causes of neurological disorders?
|
1, Myasthenia gravis
2. Polymyositis 3. Possibly multiple sclerosis |
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What are the nutritional/metabolic causes of neurological disorders?
|
1. Korsakoff's psychosis
2. Sub-acute combined degeneration of the spinal cord 3. Diabetic neuropathy |
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What is Korsakoff's psychosis?
|
It is a brain disorder caused by the lack of thiamine (vitamin B1) in the brain
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What is sub-acute combined degeneration of the spinal cord?
|
Subacute combined degeneration of spinal cord, also known as Lichtheim's disease refers to degeneration of the posterior and lateral columns of the spinal cord as a result of vitamin B12 deficiency. It is usually associated with pernicious anemia.
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What are iatrogenic causes of neurological disorders?
|
1. Tight plaster cast causing nerve palsy
2. Drug-induced myopathies such as lithium and high-dose steroids |
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What are idiopathic causes of neurological disorders?
|
1. Parkinson's disease
2. Motor neurone disease 3. Non-familial Alzheimer's disease |
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What is mononeuropathy?
|
It is abnormality of a single nerve
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What is abnormality of a single nerve called?
|
Mononeuropathy
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What is mononeuritis multiplex?
|
It is assymetric abnormality of several individual nerves
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What is assymetric abnormality of several individual nerves?
|
Mononeuritis multiplex
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What is radiculopathy?
|
Abnormality of a nerve root
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What is abnormality of a nerve root?
|
Radiculopathy
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What is polyneuropathy?
|
Widespread, symmetrical abnormality of many nerves, usually characterised as sensory/motor/autonomic 'glove and stocking' distribution
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What is widespread, symmetrical abnormality of many nerves, usually characterised as sensory/motor/autonomic 'glove and stocking' distribution?
|
Polyneuropathy
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What may occlusion of the posterior cerebral artery cause?
|
It may cause visual disturbance
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What artery feeds the occipital lobe of the brain?
|
The posterior cerebral artery
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What vascular disturbance may cause visual disturbance?
|
Occlusion of the posterior cerebral artery
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What part of the brain does the posterior cerebral artery feed?
|
The occipital lobe
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What could cause ataxia?
|
Occlusion of the cerebellar artery
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What could occlusion of the cerebellar artery cause?
|
Ataxia
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What might occlusion to the vasa nervosum of a peripheral nerve cause?
|
'Glove and stocking' paraesthesia
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What could cause 'glove and stocking' paraesthesia?
|
Occlusion of the vasa nervosum of a peripheral nerve
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What is a vasa nervosum?
|
Blood vessels to the nerves
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What five things would assessment of neurological function include?
|
1. Levels of consciousness
2. Sensory function 3. Motor function (to include muscles) 4. Posture and coordination 5. Autonomic function |
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|
What nerve axons are most often affected in multiple sclerosis?
|
The optic nerves, the cerebellar nerves and the nerves of the lower spinal cord
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|
What are the symptoms of multiple sclerosis?
|
1. Blurring of vision (diplopia)
2. Unsteady gait 3. Weakness in the lower limbs 4. Lower limb sensory loss 5. Disturbances of micturition (urination) |
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What is diplopia?
|
Blurring of vision
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What is blurring of vision?
|
Diplopia
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What is micturition?
|
Urination
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What is another word for urination?
|
Micturition
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What are the three most common diseases to affect the CNS?
|
1. Stroke
2. Parkinson's disease 3. Multiple sclerosis |
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|
What is the onset of Guillain-Barre syndrome?
|
It has a sudden postviral onset
|
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|
What is paresis?
|
Weak, sluggish or paralysed
|
|
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What is the term for weak, sluggish, paralysed?
|
Paresis
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|
What would a slow progressive onset of muscular weakness suggest?
|
Muscular dystrophy
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|
What would an acute onset of muscular weakness suggest?
|
A demyelinating disease
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What would continuous pain, numbness, a sensation of heaviness or a 'pins and needles' sensation in the arm not associated with exercise suggest?
|
These symptoms could be due to compression of nerve roots in the spine eg cervical spondylosis
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|
|
What would spasmodic pain, numbness, a sensation of heaviness or a 'pins and needles' sensation in the arm associated with exercise suggest?
|
An attack of angina pectoris
|
|
|
What would a history of frequent falls with no loss of consciousness suggest?
|
A lesion in one of the areas of the brain dealing with balance and posture such as the cerebellum or basal ganglia eg Parkinson's disease or multiple sclerosis
|
|
|
What could the presence of a severe headache signify?
|
1. Migraine
2. Subarachnoid haemorrhage 3. Tumour |
|
|
What is smoking a risk factor for?
|
Atherosclerosis and therefore CVAs
|
|
|
What problems can chronic alcoholism cause?
|
1. Motor coordination
2. Memory (Korsakoff's psychosis) - alcohol induced thiamine deficiency which damages the limbic system |
|
|
What is progressive encephalopathy?
|
It is a an altered mental state which can be caused by the HIV virus
|
|
|
Which gender is affected more by myasthenia gravis?
|
Females
|
|
|
Which gender is affected more by Duchenne's muscular dystrophy?
|
Males
|
|
|
What neurological conditions are all associated with the over-60s?
|
1. Shingles (herpes zoster)
2. Parkinsonism 3. CVAs |
|
|
What is the most likely age of onset of shingles (herpes zoster)?
|
Over 60
|
|
|
What is the most likely age of onset of Parkinsonism?
|
Over 60
|
|
|
What is the most likely age of onset of CVAs?
|
Over 60
|
|
|
When is Charcot-Marie-Tooth likely to manifest itself?
|
When people are in their 20s
|
|
|
When is spina bifida likely to manifest itself?
|
From birth
|
|
|
How does spina bifida occulta affect the lower limb?
|
1. A cavoid type foot
2. Clawed toes |
|
|
Which are the two areas of the brain that are concerned with maintaining consciousness?
|
1. The cerebral cortex
2. Reticular formation |
|
|
What is syncope?
|
A simple faint
|
|
|
What is the term for a simple faint?
|
Syncope
|
|
|
What three conditions can cause syncope?
|
1. Benign causes - emotional shock causing vasovagal syncope
2. Autonomic neuropathy if the fainting episode is associated with a change to an upright posture 3. Serious causes such as haemorrhage or anaphylactic shock |
|
|
What would cause a physiological tremor?
|
Maintenance of posture is accompanied by a tremor (10Hz). This may be exacerbated by anxiety, fatigue or thyrotoxicosis
|
|
|
What would cause tremor in an older person?
|
With age the normal physiological tremor slows to 6-7 Hz. As a result the tremor becomes more noticeable especially when undertaking a slow motion such as picking up a cup to drink from
|
|
|
What is resting tremor caused by?
|
Tremor that is present during rest (4-5Hz) is seen in parkinsonism
|
|
|
What is intention tremor caused by?
|
Tremor that increases as the individual tries to undertake a coordinated movement as seen with cerebellar dysfunction
|
|
|
What causes an essential tremor?
|
Postural tremor similar to a physiological tremor but of much greater amplitude, usually hereditary
|
|
|
What drug can cause tremors?
|
Tremor similar to an essential tremor may occur in 40% of patients treated with barbiturates
|
|
|
What is a transient ischaemic attack (TIA)?
|
They are a temporary interruption in the vascular supply to the brain
|
|
|
What is the age when people have TIAs?
|
60+
|
|
|
What are the main causes of TIAs and strokes?
|
Thrombosis resulting from atheromatous plaques in cerebral vessels cause 80% of TIAs and strokes. Haemorrhage cause the remainder
|
|
|
How long do TIAs last?
|
From 1 to 30 minutes and always less than 24 hours
|
|
|
What disorders accompany TIAs?
|
1. Disorders of speech (dysphasia)
2. Disorders of vision 3. Disorders of movement (dyskinesia) 4. Disorders in swallowing (dysphagia) |
|
|
What is the prognosis for a TIA?
|
A full recovery is usual
|
|
|
What is a disorder of speech called?
|
Dysphasia
|
|
|
What is a disorder of movement called?
|
Dyskinesia
|
|
|
What is a disorder of swallowing called?
|
Dysphagia
|
|
|
What is dysphasia?
|
A disorder of speech
|
|
|
What is dyskinesia?
|
A disorder of movement
|
|
|
What is dysphagia?
|
A disorder of swallowing
|
|
|
What is a petit mal?
|
A brief loss of consciousness during an epileptic fit
|
|
|
What is a brief loss of consciousness during an epileptic fit called?
|
Petit mal
|
|
|
What is a grand mal?
|
A loss of conscious accompanied by tonic-clonic jerks during an epileptic fit
|
|
|
What is a loss of conscious accompanied by tonic-clonic jerks during an epileptic fit?
|
A grand mal
|
|
|
How would a patient show they were alert and wakeful?
|
They would be fully aware of the environment and self and responds to stimuli
|
|
|
How would you classify a patient as confused?
|
The patient shows lack of attentiveness, cannot concentrate and has impaired memory
|
|
|
How would you classify a patient as delirious?
|
The patient would be anxious, excited, agitated and may be hallucinating
|
|
|
How would you classify a patient as lethargic?
|
The patient is drowsy but responds to verbal stimuli
|
|
|
How would you classifiy a patient in a stupor?
|
The patient is unconscious but responds to pain
|
|
|
How would you classify a patient in a coma?
|
Patient cannot be roused
|
|
|
What are the hospital tests that may be undertaken if a patient shows an altered level of consciousness?
|
1. Occuloplethysmography
2. Duplex Doppler ultrasound 3. Angiography 4. Brain scans 5. Electroencephalogram (EEG) 6. Lumbar punctures 7. Myelography |
|
|
What is occuloplethysmography?
|
A non-invasive test to detect carotid lesions that cause a reduction in blood flow to the ipsilateral orbit compared to the opposite eye
|
|
|
What may a Duplex Doppler ultrasound reveal in vascular testing?
|
It may reveal a stenosis or occlusion of the carotid arteries and is often used prior to an angiogram
|
|
|
What is angiography used for in neurological disorders?
|
Injection of a radio-opaque dye into the suspected artery will show atherosclerotic plaques in cerebral vessels
|
|
|
What are brain scans?
|
They are computed tomography (CT) or MRI which can be used to confirm TIAs, full blown CVAs, neoplastic masses or epileptic foci
|
|
|
What does an EEG do?
|
It measures brain waves and are normally used to confirm a clinical diagnosis and locate the focus of epilepsy
|
|
|
What is a lumbar puncture?
|
A hollow needle is inserted into the spinal canal through the intervertebral space between L3 and L4 or L4-5 to withdraw cerebrospinal fluid
|
|
|
What does a lumbar puncture help diagnose?
|
1. Encephalitis
2. Meningitis 3. Guillain-Barre syndrome 4. Abscess 5. Tumour 6. Haemorrhage |
|
|
What is myelography?
|
A radio-opaque dye is introduced into the subarachnoid space via a lumbar puncture and the fluid is manoeuvred to the suspected area
|
|
|
What does myelography help diagnose?
|
1. Tumours of the spinal cord
2. Diseases of the invertebral disc space 3. Bony abnormalities 4. Spondylitic lesions of the vertebral column |
|
|
What are the sensory units that can be damaged and cause sensory deficits?
|
1. Parietal cortex
2. Ascending pathways 3. Receptors |
|
|
What are the causes of sensory deficits?
|
1. Diabetes mellitus
2. Subacute combined degeneration of the spinal cord (vitamin B12 deficiency) 3. Congenital absence of particular sensory neuones 4. Spina bifida 5. Syringomyelia 6. Tabes dorsalis 7. Nerve injuries 8. Guillain-Barre syndrome 9, Multiple sclerosis 10. Cord compression/lesion eg tumour (Brown-Sequard syndrome) 11. Chronic alcoholism |
|
|
What is Brown Sequard syndrome?
|
Damage to one side of the spinal cord results in ipsilateral loss of touch, position sense, two-point discrimination and vibration sense below the level of the lesion due to dorsal column injury and contralateral loss of pain and temperature sensation below the level of the lesion due to damage to the anterolateral tracts
|
|
|
What is neuropraxia?
|
Mild trauma or compression causing local demyelination and leading to temporary loss of function. Full recovery within days or weeks
|
|
|
What is axonotmesis?
|
Crush injuries causing degeneration of axon and myelin sheath (wallerian degeneration). Neurolemma sheaths intact and reinnervated
|
|
|
What is neurotmesis?
|
It is where a whole nerve axon is severed. Surgical repair is needed to ensure reinnervation of distal trunk
|
|
|
What is it where a whole nerve axon is severed and surgical repair is needed to ensure reinnervation of distal trunk
|
Neurotmesis
|
|
|
What is the term for the type of nerve damage where there is mild trauma or compression of a nerve caused by local demyelination and leading to temporary loss of function wth full recovery within days or weeks?
|
Neuropraxia
|
|
|
What is it called when a crush injury to a nerve causes degeneration of the axon and myelin sheath (wallerian degeneration) but the neurolemma sheathss are intact and reinnervated?
|
Axonotmesis
|
|
|
Where can referred pain be felt if there is damage to S1?
|
In the heel
|
|
|
If there is referred pain in the heel which is the likely nerve root to be affected?
|
S1
|
|
|
What can be used to test light touch?
|
Cotton wool/brush/monofilament
|
|
|
What is a monofilament used to test?
|
Light touch
|
|
|
What is the fibre type and pathway for light touch?
|
A-beta fibres and ipsilateral dorsal column
|
|
|
What can be used to test two point discrimination?
|
Dividers or two orange sticks
|
|
|
What would dividers or two orange sticks test?
|
Two point discrimination
|
|
|
What fibre type and what pathway in the spinal cord is two point discrimination?
|
A-beta fibres and ipsilateral dorsal column
|
|
|
What would be used to test vibration?
|
Tuning fork or neurothesiometer
|
|
|
What does the tuning fork or neurothesiometer test?
|
Vibration
|
|
|
What fibre type and what pathway in the spinal cord is vibration?
|
A-beta fibres and ipsilateral dorsal column
|
|
|
What would be used to test temperature?
|
Warm and cold test tubes
|
|
|
What would warm and cold test tubes test?
|
Temperature
|
|
|
What fibres and what pathway in the spinal cord is temperature?
|
A-delta and C fibres and contralateral (anterolateral columns)
|
|
|
With what would you test sharp pain/pinprick?
|
A neurotip
|
|
|
What would neurotips test?
|
Sharp pain/pinprick
|
|
|
What fibre type and what pathway in the spinal cord is sharp pain/pinprick?
|
A-delta and C fibres and contralateral anterolateral columns
|
|
|
What would test proprioception?
|
Dorsi/plantarflexion of the hallux
|
|
|
What does dorsi/plantarflexion of the hallux test?
|
Proprioception
|
|
|
What fibre type and pathway in the spinal cord is proprioception?
|
A-alpha fibres and ipsilateral dorsal columns
|
|
|
What do neurological tests test?
|
Neurological tests examine the integrity of the afferent pathways that involve the ipsilateral dorsal columns and the contralateral anterolateral columns
|
|
|
What non-pathological factors may cause neurological deficits?
|
Overlying callus and normal slowing of conduction rates associated with aging
|
|
|
What can be used to test light touch?
|
Cotton wool, a fine brush or a 10g monofilament
|
|
|
Are A-beta fibres large or small diameter
|
A-beta fibres are large diameter
|
|
|
What receptors are responsive to light touch?
|
Meissner's corpuscles
|
|
|
What are Meissner's corpuscles?
|
Receptors for light touch
|
|
|
Where are Meissner's corpuscles found?
|
They lie in the superficial dermis
|
|
|
What is used to test pressure?
|
The 10g monofilament
|
|
|
What was the first monofilament used for detecting neuropathy?
|
The Semmes-Weinstein monofilament
|
|
|
Who produced the Semmes Weinstein monofilament?
|
The Hansen's Disease Center, USA
|
|
|
How does a 10g monofilament work?
|
It buckles when a force of 10g is applied
|
|
|
What does inability to detect the 10g monofilament indicate?
|
It indicates neuropathy of large fibres
|
|
|
What can be used to test vibration?
|
The 128Hz tuning fork or a graduated Rydel-Seiffer tuning fork
|
|
|
What receptors are sensitive to pressure?
|
The pacinian corpuscles
|
|
|
Where are the pacinian corpuscles located?
|
Deep in the dermis
|
|
|
What are pacinian corpuscles?
|
The are receptors sensitive to pressure
|
|
|
Are A-delta fibres large diameter or narrow diameter?
|
They are narrow diameter
|
|
|
Are C fibres large diameter or narrow diameter?
|
They are narrow diameter
|
|
|
Which are the large diameter fibres?
|
A-beta fibres
|
|
|
Which are the narrow diameter fibres?
|
A-delta fibres and C fibres
|
|
|
What is Tinel's sign used for?
|
This helps in the diagnosis of nerve compression.
|
|
|
What can Tinel's sign be used for?
|
Tinel's sign can be used to assess for compression of the posterior tibial nerve (tarsal tunnel syndromes)
|
|
|
What is a sign of a suspected entrapment of the sciatic nerve?
|
When the affected leg is raised while the patient lies in a supine position
|
|
|
What hospital tests are used to test sensory function?
|
Nerve conduction tests and nerve biopsy tests
|
|
|
What is a nerve conduction test?
|
Sensory nerve conduction velocities are measured by placing stimulating electrodes on the skin over the nerve to be tested.
|
|
|
What four causes can cause slowing of conduction velocity in a nerve?
|
1. Ageing
2. Damage to the cell body as in herpes zoster or shingles 3. Nerve axon damage as in compression due to a spinal tumour, a slipped disc or tarsal tunnel syndrome 4. Demyelinisation as seen in Guillain-Barre syndrome |
|
|
What is a nerve biopsy?
|
This can be carried out on sensory, motor and autonomic nerves. A small sample of tissue is removed and examined.
|
|
|
What are the signs that a motor system is functioning normally?
|
Muscles should display
1. resting tone 2. good muscle power on active contraction 3. be able to move against resistance |
|
|
What are the graded reflex responses?
|
3+ = clonus
2+ = increased 1+ = normal +/- = obtainable with reinforcement 0 = absent |
|
|
What graded reflex response would suggest an UMN lesion?
|
Values of 2 or above
|
|
|
What would a value of 2 or above in the graded reflex response suggest?
|
There was an UMN lesion
|
|
|
What graded reflex response would suggest an LMN lesion, peripheral sensory nerve or muscle damage?
|
A value of below 1
|
|
|
What would a value of below 1 in the graded reflex response suggest?
|
It would suggest an LMN lesion, peripheral sensory nerve or muscle damage
|
|
|
What does the patellar reflex test?
|
It tests the integrity of the spinal reflex pathway L3 and L4 and demonstrates descending influences on the ventral horn
|
|
|
What would you do to relax the leg in preparation for a patellar reflex test?
|
The patient should clasp both hands around the other knee and pull.
|
|
|
What is a Jedrassik manoeuvre?
|
It is when the patient clasps both hands around the other knee and pulls.
|
|
|
How does the Jedrassik manoeuvre relax the leg?
|
It releases spinal influence.
|
|
|
What does the Achilles reflex test?
|
It tests the spinal pathway S1 and S2
|
|
|
What can cause lower limb motor dysfunction?
|
1. Damage to upper motor neurones
2. Damage to lower motor neurones 3. Damage to peripheral nerves or muscles |
|
|
Where can upper motor neurone lesions occur?
|
Anywhere between the cortex and L1 in the spinal cord
|
|
|
Where does the spinal cord end?
|
L1
|
|
|
What does damage to the multineuronal pathway cause?
|
It causes release of inhibition on the LMNs in the spinal cord, especially those which innervate the antigravity muscles producing the effect most commonly associated with UMN lesions, that of spasticity or stiffness in the limbs
|
|
|
What is the effect most commonly associated with UMN lesions?
|
Spasticity or stiffness in the limbs
|
|
|
How does a UMN lesion affect the gait?
|
The effect is extension at the hip and knee with plantarflexion and inversion of the foot
|
|
|
If a UMN lesion is unilateral what is the term used to describe the person?
|
Hemiplegic
|
|
|
What is hemiplegia?
|
It is where a UMN lesion is unilateral.
|
|
|
If a UMN lesion affects both sides what is the term used to describe the person?
|
Paraplegic
|
|
|
What is paraplegia?
|
It is where a UMN lesion affects both sides
|
|
|
What are the ten conditions associated with UMN signs?
|
1. Cerebral palsy due to anoxia at birth
2. Cerebral vascular accidents 3. Brain injury 4. Friedrich's ataxia 5. Spinal injury 6. Brain or spinal tumours 7. Amyotrophic lateral sclerosis (motor neurone disease) 8. Vitamin B12 deficiency 9. Multiple sclerosis 10. Later stages of syringomyelia |
|
|
What are the signs of an UMN lesion?
|
1. Exaggerated tendon reflexes
2. Extensor plantar response (+ve Babinski sign) 3. Loss of abdominal reflex 4. Normal electrical excitability of muscle 5. Some muscle wasting over a period of time due to lack of use 6. Increase in muscle tone (clonus) 7. Whole limb affected |
|
|
What is increased muscle tone called?
|
Clonus
|
|
|
What is clonus?
|
Increased muscle tone
|
|
|
What causes clasp knife spasticity in UMN lesions?
|
It is due to a length dependent inhibition of the stretch reflext
|
|
|
What causes brisk tendon reflexes in UMN lesions?
|
Due to the reduced inhibition by the multineuronal tracts the alpha LMNs responsible for the contraction of extrafusal fibres are hyperexcited which results in exaggerated patella and ankle tendon reflexes
|
|
|
What causes a Babinski sign?
|
It is due to the release of a spinal inhibitory reflex
|
|
|
What causes increased muscle tone in UMN lesions?
|
Due to the release of spinal inhibition in UMN conditions, the LMNs will be in a hyperexcited state and so will be firing more frequently which leads to greater muscle tone and the affected muscle will feel very firm and tense
|
|
|
Which side of the body will be affected if UMN lesion is in the cortex?
|
The effects will occur on the contralateral side
|
|
|
If the UMN lesion is in the spinal cord where will the effects be?
|
The effects will be ipsilateral below the level of the lesion
|
|
|
What is paresis?
|
Weakness
|
|
|
What is the medical term for weakness?
|
Paresis
|
|
|
What is the medical term for complete loss of function?
|
Paralysis
|
|
|
What is paralysis?
|
Complete loss of function
|
|
|
What are diseases affecting the muscles?
|
Myopathies
|
|
|
What are myopathies?
|
Disease affecting the muscles
|
|
|
What are the four classifications of myopathies?
|
1. Inherited
2. Biochemical defect 3. Acquired inflammatory 4. Non-inflammatory |
|
|
What are some of the inherited myopathies?
|
1. Muscular dystrophies
- Duchenne's - Becker's - Dystrophia myotonica 2. Facio-scapulo-humeral autosomal dominant condition 3. Limb girdle |
|
|
What are some of the biochemical defects that can cause myopathies?
|
1. McArdle's syndrome
2. Malignant hyperpyrexia |
|
|
What are acquired inflammatory conditions that can cause myopathies?
|
1. Polymyositis-autoimmune disease
2. Dermatomyositis |
|
|
What are non-inflammatory conditions that can cause myopathies?
|
Secondary to high-dose steroids and thyrotoxicosis
|
|
|
What are the symptoms of Duchennes muscular dystrophy?
|
1. Commonest and most serious of the inherited dystrophies
2. Affects males 3. Onset before 10 years 4. Weakness in proximal and girdle muscles of lower limb first, later upper limbs 5. Hypertrophy and later fatty infiltration of calf muscles 6. Cardiac muscles also affected 7. Elevated levels of serum phosphokinase 8. Death from respiratory failure usually between 20 and 30 years |
|
|
What are the symptoms of dystrophia myotonica?
|
1. Insidious onset, usually between 20 and 50 years but can be present earlier
2. Progressive weakening and wasting of distal as well as proximal limb muscles, facial and sternomastoids 3. Cardiomyopathy, cataracts and frontal baldness also common 4. Patient cannot open hand quickly after making a fist 5. Membrane hyperexcitability |
|
|
What is myotonia?
|
Failure of muscle to relax immediately after contraction
|
|
|
What is the term used when there is a failure of the muscle to relax immediately after contraction?
|
Myotonia
|
|
|
What is facio-scapulo-humeral-autosomal dominant condition?
|
1. Benign
2. Often asympomatic 3. Wasting and weakness of facial, scapular and humeral muscles 4. Patient has difficulty in whistling, heavy lifting 5. Scapula is in abnormal condition. |
|
|
What is McArdle's syndrome?
|
1. Abnormality of glycogen metabolism due to deficiency of muscle phosphorylase
2. Patient suffers from fatigue, cramps and muscle spasm |
|
|
What is malignant hyperpyrexia?
|
1. No muscle wastage or weakness
2. Symptoms occur during or immediately after administration of a general anaesthetic especially if halothane or suxemethonium 3. Prolonged muscle contraction leading to raised body temperature 4. Fatal in 50% of cases |
|
|
What is polymyositis-autoimmune disease?
|
1. Infiltration of monocytes and muscle necrosis
2. Weakness of proximal limb, trunk and neck muscles 3. Patient has difficulty raising hands above head, getting up out of low chairs and bath. 4. May be associated pain on muscular exertion |
|
|
What is dermatomyositis?
|
1. Infiltration of monocytes and muscle necrosis
2. Weakness of proximal limb, trunk and neck muscles 3. Patient has difficulty raising hands above head, getting up out of low chairs and bath. 4. May be associated pain on muscular exertion 5. Involvement of skin of face and hands with erythematous rash |
|
|
Where can an LMN lesion be found?
|
1. Since LMNs or their spinal nerves exit at all segments of the spinal cord, LMN symptoms can be seen as a result of damage to any segment from C1 to S5
2. Due to the anatomy of the spinal cord any damage to the cord from L2 will only result in an LMN lesion |
|
|
Where can the damage be if there is a combination of UMN and LMN symptoms?
|
C1 and L1
|
|
|
What are eight conditions associated with LMN lesions?
|
1. Poliomyelitis
2. Injury to lower motor neurone and/or peripheral nerve 3. Motor neurone disease 4. Syringomyelia 5. Vitamin B12 deficiency 6. Cord compression/lesion (Brown-Sequard syndrome) 7. Spina bifida 8. Charcot-Marie-Tooth disease |
|
|
What are the sites of damage for an LMN lesion?
|
1. Lower motor neurone eg polio
2. Peripheral axon eg diabetes 3. Neuromuscular junction eg destruction of cholinergic receptors of the skeletal muscle as in myasthenia gravis |
|
|
What is the site of neurological damage from the polio virus?
|
A lower motor neurone
|
|
|
What is the site of neurological damage from diabetes
|
Peripheral axon
|
|
|
What is the site of neurological damage from myasthenia gravis?
|
The neuromuscular junction
|
|
|
What would be the differential diagnosis for LMN lesions?
|
Myopathies
|
|
|
What does the anterior tibial muscle control?
|
Deceleration of dorsiflexion at the ankle in gait
|
|
|
What does damage to the tibialis anterior nerve cause?
|
It produces a characteristic slapping gait
|
|
|
What are essential to the health of a muscle?
|
Nerve impulses
|
|
|
What is denervation atrophy?
|
Where lack of nerve impulses to the muscle lead to atrophy
|
|
|
What is the term for muscular atrophy due to lack of nerve impulses?
|
Denervation atrophy
|
|
|
When a LMN lesion causes fasciculation, what causes the quivering?
|
A denervated muscle become highly sensitive to very small amounts of neurotransmitter (acetylcholine) possibly due to upregulation of receptors which results in a quivering of the muscle (fasciculation)
|
|
|
What is fasciculation?
|
Quivering of the muscle
|
|
|
What is the medical term for quivering of the muscle?
|
Fasciculation
|
|
|
What is the MRC grading for muscle power?
|
5 = normal power
4+ = submaximal movement against resistance 4 = moderate movement against resistance 4- = slight movement against resistance 3 = moves against gravity but not resistance 2 = moves with gravity eliminated 1 = flicker 0 = no movement |
|
|
What would a reduction or absence of all lower limb reflexes suggest?
|
1. Polyradiculopathy
2. Cauda equina lesion 3. Peripheral polyneuropathy 4. Myopathy |
|
|
What would a single reduced or absent reflex suggest?
|
1. Mononeuropathy
2. Radiculopathy |
|
|
What are the two chief pathological processes that occur in peripheral nerve disease?
|
1. Axonal degeneration
2. Segmental demyelination |
|
|
What are diseases associated with axonal degeneration?
|
1. Polyneuropathies of diabetes
2. Alcoholism 3. Toxicity due to heavy metals 4. Nerve entrapment 5. Friedrich's ataxia |
|
|
What are the symptoms of axonal degeneration?
|
1. Weakness, numbness and atrophy
2. Slowing of nerve conduction velocities and loss of large fibres 3. Reduction in action potential amplitude 4. More prominent distally than proximally (longest fibres affected first) 5. fibrillation (fasciculations) seen on electromyograph |
|
|
What are pathologies associated with segmental demyelination?
|
1. Vasculitis of RA
2. Guillain Barre syndrome 3. Charcot-Marie-Tooth/peroneal muscular atrophy/hereditary motor and sensory neuropathy |
|
|
What are the symptoms of axonal degeneration?
|
1. Electrophysiological changes seen first
2. Dramatic fall in nerve conduction velocities, maybe even total conduction block 3. Worsens proximally |
|
|
Is Charcot-Marie-Tooth disease an example of axonal degeneration or segmental myelination?
|
There are two subtypes. One shows segmental demyelination and the other shows axonal degeneration
|
|
|
What is electromyography?
|
A needle electrode is inserted into the muscle to show the electrical activity of the muscle.
|
|
|
What can electromyographies detect?
|
Dysfunction of motor nerves, neuromuscular junction lesions and myopathies
|
|
|
What is electromyography used for specifically?
|
It is the only means of testing for myopathies
1. If due to motor denervation such as polio 2. If due to changes at the neuromuscular junction such as myasthenia gravis 3. If due to muscle disease such as Duchennes muscular dystrophy |
|
|
What are the symptoms of lower motor neurone lesions?
|
1. Loss of tendon reflexes
2. Flexor plantar response (-ve Babinski sign) 3. Normal abdominal reflex 4. Fasciculation (fibrillation seen on EMG) 5. Marked muscle wasting occurs relatively quickly 6. Flaccid muscles (lack of tone) 7. Certain muscle groups affected depending on site of damage 8. Deformity due to contracture of antagonists |
|
|
What conditions that affect the cerebellum would cause poor coordination?
|
1. Tumour
2. Multiple sclerosis 3. Arnold-Chiari malformation 4. Friedrich's ataxia 5. Other hereditary spinocerebellar ataxias 6. Hypothyroidism 7. Repeated head trauma as in boxing |
|
|
What conditions that affect the basal ganglia would cause poor coordination?
|
1. Parkinsonism
2. Huntington's chorea 3. Wilson's disease 4. Sydenham's chorea |
|
|
What conditions that affect the ascending pathways would cause poor coordination?
|
1. Subacute combined degeneration of the spinal cord
2. Guillain Barre syndrome 3. Tabes dorsalis 4. Alcoholism |
|
|
What can a stamping gait be symptomatic of?
|
It may be due to loss of proprioception due to tabes dorsalis where the ascending columns degenerate. The patient is unaware of where his body is in space and lifts his legs much higher than necessary to clear the ground. The patient will be unaware of when his foot is about to make ground contact and stamps his foot down. This stimulates pressure receptors proximally as vibrations travel from the foot travel up the leg and provide much needed information to the brain
|
|
|
What causes tabes dorsalis to get worse?
|
The ascending tracts in the dorsal columns degenerate
|
|
|
What are indications that proprioception is lacking?
|
The patient will not know where his body is in space and lifts his legs much higher than necessary to clear the ground. The patient will also be unaware of when his foot is about to make ground contact and so stamps the foot down. This stimulates pressure receptors proximally as vibrations from the foot travel up the leg and so provide much needed information to the brain.
|
|
|
What is the problem with a high stepping gait following by stamping?
|
Lack of proprioception
|
|
|
What is dysarthria?
|
Inability to speak or form syllables
|
|
|
What is the term for inability to speak or form syllables?
|
Dysarthria
|
|
|
What causes dysarthria?
|
Cerebellar dysfunction affects the speech muscles and produces a scanning speech with inappropriate syllabic stress and volume
|
|
|
What is most likely to be affected if the speech is scanning with inappropriate syllabic stress and volume?
|
The cerebellum
|
|
|
What is dysdiachokinesia?
|
This is where actions are no longer smooth, continuous movements but are broken down into their component parts producing clumsy jerky actions
|
|
|
What is it when actions are no longer smooth, continuous movements but are broken down into their component parts producing clumsy jerky actions?
|
Dysdiachokinesia
|
|
|
What is an intention tremor?
|
It is where the tremor increases in amplitude as the person tries to carry out any tasks with the affected limb. The tremor disappears at rest.
|
|
|
What is it when a tremor increases in amplitude as the person tries to carry out any tasks with the affected limb. The tremor disappears at rest?
|
An intention tremor
|
|
|
What dysfunction is an intention tremor associated with?
|
It is a cerebellar defect
|
|
|
What causes an intention tremor?
|
Dysfunction of the stretch reflex
|
|
|
What is an ataxic gait?
|
The gait will be clumsy or staggering
|
|
|
What is the term used to describe a clumsy or staggering gait?
|
An ataxic gait
|
|
|
What does damage to the basal ganglia cause?
|
It produces either a poverty of movement (hypo/bradykinesia) of jerky, writhing movements (choreoathetosis)
|
|
|
What is hypokinesia?
|
Poverty of movement
|
|
|
What is bradykinesia?
|
Poverty of movement
|
|
|
What are the terms used to describe poverty of movement?
|
Hypokinesia or bradykinesia
|
|
|
What is choreoathetosis?
|
Jerky writhing movements
|
|
|
What are jerky writhing movements called?
|
Choreoathetosis
|
|
|
What pathologies are associated with hypo/bradykinesia?
|
Parkinson's disease
|
|
|
What pathologies are associated with choreoathetosis?
|
Huntington's chorea or Sydenham's chorea
|
|
|
What pathology is Sydenham's chorea associated with?
|
Rheumatic fever
|
|
|
Which pathology is associated with long-lasting choreoathetosis and which pathology is associated with a brief benign effect of choreoathetosis?
|
Huntingdon's chorea is associated with long-lasting choreoathetosis and Sydenham's chorea is associated with a brief benign bout of choreoathetosis
|
|
|
What does Romberg's sign detect?
|
It can be used to confirm proprioceptive disturbance in the dorsal columns or peripheral nerves
|
|
|
How is Romber's test carried out?
|
The patient is observed standing with feet together, eyes open and then closed.
|
|
|
What is the problem if a patient is unable to maintain balance if the eyes are open during Romberg's test?
|
It could be a cerebellar or vestibular defect and if the patient rocks backward and forward with eyes open a cerebellar defect could be the cause. If the eyes are open this is not a +ve Romberg's sign and cannot be performed
|
|
|
What does a positive Romberg's sign indicate?
|
1. Cord compression
2. Tabes dorsalis 3. Vitamin B12 deficiency 4. Degenerative spinal cord disease |
|
|
What is nystagmus?
|
Rapid eye movements
|
|
|
What causes nystagmus?
|
Vestibular dysfunction
|
|
|
What can elicit nystagmus?
|
A rapid head movement
|
|
|
What does the presence of nystagmus show?
|
Its presence indicates a cerebellar lesion
|
|
|
What tests are used to test cerebellar dysfunction?
|
1. Romberg's
2. Heel-shin test 3. Heel-toe test 4. Finger-nose test |
|
|
What other symptoms could be caused by a patient staggering around the midline when asked to perform the heel-toe test?
|
Old age or alcohol
|
|
|
What is the muscle tone like in cerebellar dysfunction?
|
It will be reduced in the affected limbs
|
|
|
What are tendon reflexes like in cerebellar dysfunction?
|
Tendon reflexes may be unusually sustained because of the oscillations of an abnormal stretch reflex but they should not be exaggerated
|
|
|
What is the most common extrapyramidal disease?
|
Parkinson's disease
|
|
|
What is hypermetria?
|
Over-reaching the intended object
|
|
|
What is the medical term for over-reaching an intended object?
|
Hypermetria
|
|
|
What is hypometria?
|
Underreaching an intended object
|
|
|
What is the medical term for underreaching an intended object?
|
Hypometria
|
|
|
What causes Parkinson's disease?
|
Parkinson's disease is due to a depletion of dopaminergic neurones in the substantia nigra which project to the caudate nucleus
|
|
|
What are the symptoms of Parkinson's disease?
|
1. Hypo/bradykinesia which results in the patient having great difficulty initiating or stopping movement
2. Rest tremor. If the hand is affected the tremor may cause the patient to move index finger and thumb in a 'pill-rolling' movement 3. Rigidity 4. The patient may show a mask-like face and speak in a soft voice 5. Small handwriting (micrographia) is also a characteristic 6. The antigravity muscles are affected producing a stooped posture with knees flexed so the patient's centre of gravity is no longer over the base of gait. This causes the patient to move more and more quickly to avoid falling forward 7. Gait also tends to be shuffling with poor heel-ground contact - 'marche a petit pas' 8. Tendon reflexes are unaffected 9. There is a general resistance to passive stretch described as lead pipe rigidity. It may show a superimposed intermittent release of the resistance, producing a series of jerks (the cogwheel effect) 10. There is no habituation with the glabellar tap reflex |
|
|
What is micrographia?
|
Small handwriting
|
|
|
What is the medical term used for small handwriting?
|
Micrographia
|
|
|
What is the shuffling of Parkinson's disease called?
|
Marche a petits pas
|
|
|
What is marche a petits pas?
|
The shuffling of Parkinson's disease
|
|
|
What is the glabellar tap reflex?
|
A practitioner gently, slowly and repeatedly taps the forehead of the patient between the eyes. In a healthy person the first tap or two will elicity the eye-blink reflex but this will rapidly habituate
|
|
|
What do the autonomic nerves do?
|
They innervate the viscera and internal structures such as blood vessels and enable the nervous system to maintain homeostais
|
|
|
What are two of the signs which would suggest autonomic neuropathy?
|
1. Abnormal sudomotor responses in the skin
2. Abnormal cardiovascular responses in the functioning of the heart and peripheral blood vessels |
|
|
What does sudomotor neuropathy lead to?
|
Absence of sweating and a dry skin although it may produce hyperhidrosis
|
|
|
What does the absence of sweating and a dry skin or hyperhidrosis indicate?
|
Sudomotor neuropathy
|
|
|
What does vasomotor neuropathy cause?
|
It usually produces a warm red skin and an absence of vasoconstriction in response to cold although it may produce a prolonged vasoconstriction. It may also lead to postural hypotension
|
|
|
What is postural hypotension?
|
It is loss of blood pressure when rising after lying or sitting down
|
|
|
What does neuropathy of nerves of cardiac pacemaker tissue lead to?
|
The heart fails to respond appropriately to the demands of the body eg an absence of tachycardia in response to exercise
|
|
|
What tests can measure autonomic function?
|
1. Heart rate supine and standing
2. Blood pressure supine and standing 3. Valsalve manoeuvre |
|
|
How many beats per second should a heart rate increase by in a healthy person between a supine position and an upright position?
|
The heart beat should increase by more than 11 beats per minute
|
|
|
If the heart rate does not increase by more than 11 beats per minute what would this suggest?
|
Parasympathetic abnormality
|
|
|
What should happen in a healthy person when blood pressure is taken supine and standing?
|
Systolic blood pressure should fall on standing by approximately 30mmHg and the diastolic pressure should fall by 15mmHg
|
|
|
What does it indicate when the systolic pressure doesn't drop by 30 mmHg on standing and diastolic pressure by 15mmHg on standing?
|
It suggests a sympathetic abnormality
|
|
|
What could happen if the cardiovascular system cannot compensate for postural effects?
|
Postural syncope
|
|
|
What is the Valsalva manoeuvre?
|
The patient is asked to take a deep breath and exhale against a closed glottis (or blowing up a balloon) for 10-15 seconds and then breathe normally. The pulse rate is taken during the Valsalva manoeuvre and on release. Heart rate should increase during manoeuvre and fall on release. No increase during the manoeuvre suggests sympathetic abnormality and no decrease on release suggests sympathetic abnormality
|
|
|
When should you not do the Valsalva manoeuvre?
|
If there is evidence of proliferative retinopathy
|
|
|
What should happen to a healthy person during the Valsalve manoeuvre?
|
Heart rate should increase during the manoeuvre and fall on release
|
|
|
What does it indicate if there is no increase in heart rate during the Valsalva manoeuvre?
|
It suggests sympathetic abnormality
|
|
|
What does it indicate if there is no decrease on release during the Valsalve manoeuvre?
|
It suggests parasympathetic abnormality
|
|
|
What is the Valsalva manoeuvre testing?
|
Abnormal responses to the baroreceptor reflex which implicates defects in innervation of the cardiac pacemaker tissue rather than peripheral autonomic neuropathy
|
|
|
What are the tests for peripheral autonomic neuropathy?
|
There are no clinical tests
|
|
|
What are the signs of peripheral autonomic sympathetic neuropathy?
|
1. A dry skn due to failure of sudomotor nerves
2. A warm foot due to lack of arterial vasoconstriction 3. Engorged dorsal veins due to lack of venous vasoconstriction |
|
|
What are signs of parasympathetic neuropathy?
|
Disorders of bowel and bladder function and impotence
|
|
|
What is the most common condition associated with autonomic neuropathy?
|
Diabetes mellitus
|
|
|
What other conditions besides diabetes mellitus are associated with autonomic neuropathy?
|
1. Guillain Barre syndrome
2. Amyloidosis 3. Congenital autonomic failure |
|
|
What is amyloidosis?
|
amyloidosis refers to a variety of conditions in which amyloid proteins are abnormally deposited in organs and/or tissues.
|
|
|
What other conditions can affect the cardiovascular system and may give a false/positive result when testing for autonomic neuropathy?
|
1. Infection
2. Anaemia 3. Beta blockers |
|
|
What parts of the nervous system are affected by diabetes mellitus?
|
1. Sensory
2. Motor (LMN) 3. Autonomic |
|
|
What parts of the nervous system are affected by motor neurone disease?
|
1. LMN
2. UMN |
|
|
What parts of the nervous system are affected by spina bifida?
|
1. LMN and sensory
|
|
|
What parts of the nervous system are affected by syringomyelia?
|
1. Sensory
2. LMN 3. UMN |
|
|
What is syringomyelia?
|
Syringomyelia is a generic term referring to a disorder in which a cyst or cavity forms within the spinal cord. This cyst, called a syrinx, can expand and elongate over time, destroying the spinal cord
|
|
|
What part of the nervous system does Vitamin B12 deficiency affect?
|
1. Sensory
2. LMN 3. UMN |
|
|
What part of the nervous system does multiple sclerosis affect?
|
1. Sensory
2. UMN |
|
|
What part of the nervous system does cord compression/lesion affect?
|
1. Sensory
2. LMN 3. UMN |
|
|
What part of the nervous system does Guillain-Barre syndrome affect?
|
1. Sensory
2. Autonomic 3. LMN |
|
|
What part of the nervous system does Charcot-Marie-Tooth disease affect?
|
Mainly LMN but possible sensory
|
|
|
What part of the nervous system do nerve injuries affect?
|
Depends upon site, may result in LMN, UMN, sensory or autonomic
|
|
|
If a patient exhibits apraxic gait, aphasia, speech defects and visual defects where would the site of the lesion be and what could the possible disease be?
|
1. UMN (hemisphere
2. Stroke 3. Hydrocephalus 4. Head injury |
|
|
If a patient exhibited progressive focal deficit epilepsy where would the site of the lesion be and what could the possible disease be?
|
1. UMN (head)
2. Tumour 3. Ischaemic stroke 4. Previous intracranial disease |
|
|
If a patient exhibited increased tone and reflexes, weak arm extensors and weak leg flexors where would the site of the lesion be and what could the possible disease be?
|
1. UMN (head/spinal cord)
2. Neck, cervical region 3. Stroke 4. Cerebral palsy 5. Neck injury 6. Multiple sclerosis |
|
|
If a patient exhibite hypo/bradykinesia, festinating gait, lead-pipe/cog-wheel rigidity, rest tremor where would the site of the lesion be and what would the cause be?
|
1. Basal ganglia
2. Parkinson's disease |
|
|
If a patient exhibited choreoathetotic movements where would the site of the lesion be and what would the cause be?
|
1. Basal ganglia
2. Huntington's chorea 3. Sydenham's chorea (rare) |
|
|
If the patient exhibited nystagmus, dysarthria and cranial nerve palsies where would the site of the lesion be and what would the cause be?
|
1. Brain stem
2. Multiple sclerosis 3. Syringomyelia |
|
|
If the patient exhibited nystagmus, dysarthria, scanning speech, diminished pendular reflexes, intention tremor, ataxic gait, dysdiadochokinesia where would the site of the lesion be and what would the cause be?
|
1. Cerebellum
2. Spinal cord 3. Friedrich's ataxia 4. Stroke 5. Tumour 6. Vitamin B12 deficiency 7. Syringomyelia 8. Spina bifida |
|
|
If a patient exhibited diminished tendon reflexes, paresis/paralysis, pain, paraesthesia/anaesthesia where would the site of the lesion be and what would the cause be?
|
1. LMN (spinal cord/nerve roots/axons)
2. Poliomyelitis 2. Diabetes mellitus 3. Chronic alcoholism 4. Guillain-barre syndrome 5. Rheumatoid arthritis 6. Charcot-Marie-Tooth disease 7. Vitamin deficiencies (B1, B6, B12) 8. Tumour 9. Disc protrusion 10. Trauma |
|
|
If a patient exhibited progressive fatiguability and weakness where would the site of the lesion be and what would the cause be?
|
1. Neuromuscular junction
2. Myasthenia gravis |
|
|
If a patient exhibited proximal limb muscle weakness and wasting but no sensory loss and no fasciculation where would the site of the lesion be and what would the cause be?
|
1. Muscle
2. Myopathies |
|
|
How many cardinal planes are there and what are they?
|
1. Sagittal
2. Frontal (coronal) 3. Transverse |
|
|
What do cardinal planes form the reference points for?
|
1. Position of a part of the body
2. Joint motion 3. Position of a joint 4. Deformity of a part of the body |
|
|
What plane does anterior and posterior describe
|
Anterior and posterior describe positions in the frontal plane eg the patella lies anterior to the knee joint
|
|
|
What terms describe positions in the frontal plane?
|
Anterior and posterior
|
|
|
What terms describe positions in the transverse plane?
|
Distal and proximal
|
|
|
What cardinal planes does distal and proximal describe the positions of?
|
The transverse plane
|
|
|
What terms describe positions in the sagittal plane?
|
Lateral and medial
|
|
|
What cardinal plane does lateral and medial describe the positions of?
|
The sagittal plane
|
|
|
What are the motions in the sagittal plane?
|
Dorsiflexion and plantarflexion
|
|
|
What cardinal plane does dorsiflexion and plantarflexion describe the motions of?
|
The sagittal plane
|
|
|
What are the motions in the frontal (coronal plane)?
|
Inversion and eversion
|
|
|
What cardinal plane does inversion and eversion describe the motions of?
|
Frontal (coronal) plane
|
|
|
What are the motions in the transverse plane?
|
Abduction and adduction
|
|
|
What cardinal plane does adduction and abduction describe the motions of?
|
The transverse plane
|
|
|
Why is adductor hallucis so named?
|
Adductor hallucis is inserted into the lateral side of the proximal phalanx of the hallux and is so named because it brings about adduction of the hallux - movement of the hallux towards the midline of the foot
|
|
|
What is triplanar motion?
|
If a joint axis is positioned at an angle of less than 90 degrees to all the cardinal body planes triplanar motion occurs
|
|
|
What are examples of triplanar motion?
|
Pronation and supination
|
|
|
What movements make up pronation?
|
Dorsiflexion, abduction and eversion
|
|
|
What are the collective movements of dorsiflexion, abduction and eversion called?
|
Pronation
|
|
|
What movements make up supination?
|
Plantarflexion, adduction, inversion
|
|
|
What are the collective movements of plantarflexion, adduction and inversion called?
|
Supination
|
|
|
Where in the foot do triplanar motions occur?
|
The subtalar joint and midtarsal joints
|
|
|
What suffix is used to describe the position of a joint?
|
-ed eg a foot is dorsiflexed or plantarflexed
|
|
|
Why is it important that a distinction be made between joint motion and joint position?
|
Because a joint moves in the opposite direction to the position it is in eg at heel strike the foot is slightly supinated (position) but as soon as the heel contacts the ground pronation (motion) occurs at the subtalar joint in order to absorb shock from ground contact
|
|
|
What position is the foot at heel strike?
|
Supinated
|
|
|
What motion occurs as soon as the heel contacts the ground?
|
Pronation of the subtalar joint
|
|
|
Why does the subtalar joint pronate when the heel contacts the ground?
|
To absorb shock from ground contact
|
|
|
What is the definition of deformity?
|
It is used to describe a fixed position adopted by a part of the body
|
|
|
What suffix is used to denote deformity?
|
-us eg equinus when the foot or part of the foot is plantarflexed
|
|
|
What is equinus?
|
When the foot or part of the foot is plantarflexed eg ankle equinus
|
|
|
What is extensus?
|
When the foot or part of the foot is dorsiflexed eg hallux extensus
|
|
|
What is hallux extensus?
|
When the hallux is dorsiflexed
|
|
|
What is Calcaneus when it is being described as a fixed deformity?
|
It is rarely seen but it is used to describe the calcaneus when it is in fixed dorsiflexion eg talipes calcaneovalgus
|
|
|
What are the deformities in the sagittal plane?
|
Equinus and extensus
|
|
|
What plane are equinus and extensus in?
|
The sagittal plane
|
|
|
What are the deformities in the frontal plane?
|
Varus and valgus
|
|
|
What plane are varus and valgus in?
|
The frontal plane
|
|
|
What are the deformities in the transverse plane called?
|
Adductus or abductus
|
|
|
What plane are adductus or abductus in?
|
The transverse plane
|
|
|
What is genu valgum?
|
Knock knees
|
|
|
What is the medical term for knock knees?
|
Genu valgum
|
|
|
What is genu varum?
|
Bow leg
|
|
|
What is the medical term for bow leg?
|
Genu varum
|
|
|
What plane are genu varum and genu valgum in?
|
Frontal plane
|
|
|
What are two frontal plane deformities?
|
Genu varum and genu valgum
|
|
|
Describe genu varum?
|
The knees are far apart and the medial malleoli are close together
|
|
|
What is the medical term for when the knees are far apart and the medial malleoli are close together?
|
Genu varum
|
|
|
Describe genu valgum
|
The knees are close together and the medial malleoli are far apart
|
|
|
What is the medical term for when the knees are close together and the medial malleoli are far apart?
|
Genu valgum
|
|
|
What are the factors that can affect normal function?
|
1. Hereditary/congenital problems eg Charcot-Marie-Tooth disease, talipes equinovarus, CDH ???
2. Acute/chronic injury causing pain eg slipped femoral epiphysis, ankle sprain 3. Abnormal alignment secondary to trauma eg femoral/tibial/epiphyseal fracture 4. Abnormal alignment (developmental) eg internal femoral torsion, genu valgum 5. Infections eg tuberculosis 6. Neurological disorders eg CVA 7. Muscle disorders eg Duchenne's muscular dystrophy 8. Neoplasia eg osteosarcoma 9. Systemic disease eg autoimmune (RA), bone disease (Paget's disease) 10. Degenerative processes eg osteoarthritis 11. Joint hypermobility eg Marfan's syndrome 12. Osteochondroses eg Perthe's disease 13. Psychological factors eg attention seeking 14. Footwear eg high-heeled shoes |
|
|
Describe what normal lower limb function should be?
|
Pain-free and energy efficient
|
|
|
What is the purpose of an orthopaedic lower limb assessment?
|
1. Establish the main complaint(s) eg pain, stiffness, tenderness, numbness, weakness or crepitus
2. Identify the site of the primary problem eg foot, leg, knee, hip and try to relate to underlying structures 3. Identify any secondary problems and relate them to the primary problem eg lesion patterns, pronation due to leg-length discrepancy 4. Identify the cause of the problem eg abnormal alignment 5. Establish how the problem evolved 6. Identify any movement/activity that produces/exacerbates symptoms 7. Identify movement/activity that relieves symptoms 8. Establish any differential diagnoses 9. Utilise the data from the assessment to produce an effective management plan 10. Utilise the data from the assessment to monitory the progress of the condition |
|
|
When assessing the lower limb what is it important to observe?
|
Weightbearing (dynamic and static) and non-weightbearing
|
|
|
What can a forefoot varus cause?
|
Abnormal pronation of the subtalar joint
|
|
|
What could a bouncy gait be an indication of?
|
Early heel lift
|
|
|
What sort of gait can early heel lift cause?
|
A bouncy gait
|
|
|
What is a cause of ankle equinus?
|
A short gastrocnemius muscle
|
|
|
What can an early heel lift be an indication of?
|
A short gastrocnemius muscle
|
|
|
What factors must be assessed when gaining a full and detailed picture of the function of the locomotor system?
|
1. Gait
2. Alignment and position of the lower limb 3. Joint motion 4. Muscle action |
|
|
What sequence should be adopted when assessing the locomotor system?
|
1. Gait analysis. This will focus on the position and alignment of the body and foot-ground contact
2. Non weight-bearing. This will focus on the assessment of joints and muscles 3. Static weightbearing. This will focus on the position and alignment of the body and the relationship of the foot to the ground during stance |
|
|
What is compensation?
|
It is a change in structure, position or function of one part in an attempt to adjust to an abnormal structure, position or function in another part eg scoliosis of the spine may lead to an apparent leg-length discrepancy which will affect foot function
|
|
|
What may scoliosis of the spine lead to?
|
An apparent leg-length discrepancy which will affect foot function
|
|
|
What may an uncompensated rearfoot varus lead to?
|
Discomfort and pain at the knee
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What is the process of musculoskeletal assessment?
|
1, General observation of the patient
2. Specific joint observation 3. Palpation 4. Examination of joint movement 5. Muscle assessment 6. Undertaking special tests 7. Arranging further investigation |
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What are clinical features associated with pathology of joints in the lower limb?
|
1. Oedema
2. Contusion 3. Erythema 4. Local muscle wasting 5. Alteration in shape or the presence of scars 6. Comparison of symmetry of contralateral parts 7. Abnormal posture 8. Evidence of limb shortening 9. Abnormal joint movement during gait |
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What clinical features may be evident from palpation of the limb segment?
|
1. Raised or lowered skin temperature
2. Swelling/effusion 3. Tenderness 4. Pain or abnormal lumps/nodules |
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What are features of an inflamed joint?
|
1. Redness
2. Heat 3. Pain 4. Swelling 5. Loss of function |
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What could inflammation of a joint be due to?
|
1. Trauma
2. Infection 3. Loose body (osteochondritis dissecans) |
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What is osteochondritis dissecans?
|
A loose body in the joint
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What is the medical term for a loose body in the joint?
|
Osteochondritis dissecans
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Before examining a joint what is it important to do?
|
Make sure the joint is warmed up (moved through its range of motion)
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What does warming up the joint do?
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It relaxes the ligaments and muscles and reduces the viscosity of the synovial fluid
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What is ROM?
|
Range of motion
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What is DOM?
|
Direction of motion
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What is QOM?
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Quality of motion
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What is SOM?
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Symmetry of motion
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What is ROM measured in?
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In degrees
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What is the expected norm of ROM at the 1st MTPJ?
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70 degrees
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What is the condition caused where there is limited ROM at the 1st MTPJ?
|
Hallux limitus
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What is hallux limitus?
|
Where is limited ROM at the 1st MTPJ
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What instruments can be used to measure ROM?
|
Protractors, tractographs and goniometers
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What is the normal total ROM of transverse plane rotation at the hip?
|
90 degrees
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What is dislocation?
|
Dislocation occurs where there is no contact between articulating surfaces of the joint
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What is the condition called where there is no contact between articulating surfaces of the joint?
|
Dislocation
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What is subluxation?
|
Where there is only partial contact between articulating surfaces of the joint.
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What is the condition called where there is only partial contact between articulating surfaces of the joint?
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Subluxation
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What is the test for articular damage in an MTPJ?
|
Compression of the metatarsal head against the proximal phalanx
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What is the test for capsular damage in an MTPJ?
|
Dorsiflexion/plantarflexion of a distracted proximal phalanx against the joint capsule dorsally/plantarly (pulling the joint slightly apart)
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What can cause joint stiffness?
|
Inflammatory or degenerative changes
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What can cause tightness or tension in a joint?
|
Swelling or protective muscle spasm
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What can cause popping in a joint?
|
A muscle tear or strain
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What can cause snapping in a joint?
|
A tendon slipping over a bony prominence
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What can cause clicking in a joint?
|
A meniscal tear or patella rubbing femoral condyles
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What can cause grating in a joint?
|
Osteoarthritis or osteochondritis
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What can cause crepitus in a tendon?
|
Inflammation of a tendon
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What can cause crepitus in a joint?
|
Articular damage or a loose body
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What can cause tearing in a joiont?
|
Muscle or ligament tear
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What can cause tingling in a joint?
|
Neural or circulatory pathology
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What can cause warmth in a joint?
|
Local inflammation or infection
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What can cause numbness or hypersensitivity in a joint?
|
Local nerve or nerve root compression
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What symptoms can inflammatory or degenerative changes cause in a joint?
|
Joint stiffness
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What symptoms can swelling or protective muscle spasm cause in a joint?
|
Tightness or tension
|
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What symptom can a muscle tear or strain cause in a joint?
|
Popping
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What symptom can tendon slipping over a bony prominence cause in a joint?
|
Snapping
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What symptom can a meniscal tear or patella rubbing femoral condyles cause in a joint?
|
Clicking
|
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What symptom can osteoarthritis or osteochonditis cause in a joint?
|
Grating
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What symptom can inflammation of a tendon cause?
|
Crepitus
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What symptom can articular damage or a loose body cause in the joint?
|
Crepitus
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What symptom can neural of circulatory pathology cause in a joint?
|
Tingling
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What symptom can local inflammation or infection cause in a joint?
|
Warmth
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What symptom can local nerve or nerve root compression cause in a joint?
|
Numbness or hypersensitivity
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What should muscles be tested for?
|
1. Strength
2. Tone 3. Spasm 4. Bulk |
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|
What grading system is used for muscle strength?
|
The Medical Research Council (MRC) system
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|
What is the MRC system for grading muscle strength?
|
0 = no contraction
1 = a flicker from muscle fasciculi 2 = slight movement with gravitational effect removed 3 = muscle can move part against gravity 4 = muscle can move part against gravity + resistance 5 = normal power |
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What is the term used when the patient moves the body part?
|
Active movement
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What would an active ROM mean?
|
The patient was moving the joint in ROM
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What is the term used when the practitioner moves the body part?
|
Passive movement
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What would a passive ROM be?
|
When the practitioner moves the body part in ROM
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|
Describe what muscle tone is?
|
That a muscle is in a state of partial contraction without full movement being necessary
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What is a useful measure of muscle tone?
|
Asking the patient to undertake isometric contraction of a muscle eg the tone of the quadriceps can be assessed by asking the patient to contract the muscle while the knee is in an extended position
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What should normal toned muscles feel like when contracting?
|
They should feel firm as well as appear taut
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What do muscles look and feel like when they lack tone?
|
Flaccid
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|
|
What could flaccid muscles be a sign of?
|
Lower motor neurone disorders
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|
What could absence of tone in young males indicate?
|
Duchenne's muscular dystrophy
|
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|
What can a spasm affect?
|
Joint motion
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|
|
How many types of muscle spasm are there and what are they?
|
1. Tonic
2. Clonic |
|
|
Why does a tonic spasm occur in a muscle?
|
It is usually an attempt by the muscles to stop movement at a painful joint
|
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|
What is a clonic spasm and what is it associated with?
|
It is associated with neurological (upper motor neurone) deficit and is involuntary
|
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What is atrophy of muscle and what can it be due to?
|
1. Lack of use
2. Lower motor neurone lesion |
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|
What causes hypertrophic muscles?
|
Exercise
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|
What does Lachman's test assess?
|
It assesses sagittal plane stability of the knee in an anterior direction and the integrity of the anterior cruciate ligament
|
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|
What does gait involve?
|
It involves complex neuromuscular coordination of the lumbar spine, pelvis, hips and those structures distal to them
|
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What are three dysfunctions that can influence gait?
|
1. Neurological
2. Systemic 3. Structural |
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|
What are the neurological dysfunctions that can influence gait?
|
1. Motor eg CVA
2. Sensory eg tabes dorsalis, blindness 3. Cerebellum eg Friedrich's ataxia 4. Basal ganglia eg Parkinson's disease |
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|
What are the systemic dysfunctions that can influence gait?
|
1. Joint disease eg RA, OA
2. Crystal arthropathies eg gout 3. Muscle disease eg Duchennes muscular dystrophy, dermatomyositis 4. Bone disease eg rickets, Paget's disease |
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|
What are the structural dysfunctions that can influence gait?
|
1. Limb-length inequality eg DDH???, polio, femoral/tibial fracture
2. Alignment disorders eg coxa valga/vara, genu valgum/varum/recurvatum, tibial /femoral torsion, rearfoot varus |
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|
What is gait divided into?
|
Swing phase and stance phase
|
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|
What happens in stance phase?
|
The period of the gait cycle when the foot is in contact with the ground
|
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|
What does swing phase relate to?
|
Swing phase is when the foot is not in contact with the ground
|
|
|
What does stance phase consist of?
|
1. Contact
2. Midstance 3. Propulsive stages |
|
|
When does contact phase start and end?
|
Contact phase starts when the heel makes ground contact and this is followed by the rest of the foot
|
|
|
What happens during contact phase?
|
The foot pronates in order to absorb shock from the effects of ground reaction
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|
When does the foot pronate in order to absorb shock from the effects of ground reaction?
|
During contact phase
|
|
|
When does midstance start and finish?
|
Midstance starts when all the foot is in ground contact and ends with heel lift
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|
What happens during midstance?
|
The foot starts to resupinate ready for propulsion
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|
|
What part of stance does the foot start to resupinate ready for propulsion?
|
During midstance
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|
When does propulsion start and finish?
|
Propulsion starts at heel lift and ends when the hallux leaves the ground
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|
What happens during propulsion?
|
The foot continues to supinate
|
|
|
When part of stance does the foot continue to supinate?
|
During propulsion
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|
During propulsion what part of the foot is the first to leave the ground and what part of the foot is the last to leave the ground?
|
The fifth metatarsal head is the first part of the foot to leave the ground and the hallux should be the last to leave the ground
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|
|
What are the anatomical and functional features to observe during gait?
|
1. Head position
2. Shoulder position 3. Arm swing 4. Trunk position/rotation 5. Pelvic tilt 6. Limb motion 7. Thigh segment 8. Patellar position (transverse plane) 9. Knee position (frontal/sagittal plane) 10. Tibial position 11. Ankle 12. Calcaneal position 13. Navicular position 14. Midtarsal joint (position/movement) 15. Metatarsals (anterior/lateral views) 16. Toe position 17. Foot position/shape 18. Muscle activity 19. Propulsion 20. Swing phase |
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|
What is torticollis?
|
Torticollis is where the head is twisted to one side due to muscle contracture
|
|
|
What is the term used to describe where the head is twisted to one side due to muscle contracture?
|
Torticollis
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|
Where will the head tilt due to cervical scoliosis?
|
The head will tilt down on the long limb side
|
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|
What could unilateral tilting of the shoulders be due to?
|
Limb length inequality or scoliosis
|
|
|
Where will shoulders tilt in children under 12 years with leg length inequality?
|
The shoulder will always tilt to down on the short limb
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|
Where will the shoulders tilt in adults with secondary scoliosis?
|
The shoulders will tilt on the long side
|
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|
What does arm swing denote?
|
Arm swing is a feature of normal forward progression. The arms should swing to even out leg movement
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|
What does a flexed position of arm or hand held close to the body suggest?
|
CVA
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|
|
What is the arm position in patients with LLI?
|
The arm on the shorter side will be held away from the body to help maintain balance and will hang lower than the contralateral arm
|
|
|
What is spinal kyphosis?
|
It is curvature of the upper (thoracic) spine
|
|
|
What is curvature of the thoracic spine called?
|
Spinal kyphosis
|
|
|
What is spinal lordosis?
|
An abnormal inward curve of the lumbar spine
|
|
|
What is an abnormal curve of the lumbar spine called?
|
Spinal lordosis
|
|
|
What is the smooth up and down motion of the pelvis called?
|
Sinusoidal motion
|
|
|
What is sinusoidal motion?
|
The smooth up and down motion of the pelvis
|
|
|
What are four causes of pelvic tilt?
|
1. Neurological problems
2. Spinal deformity 3. LLI (pelvis tilts down on side of short limb) 4. Injury |
|
|
What can weakness of the gluteus medius muscle cause?
|
Trendelenburg gait
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|
What sort of gait does a CVA patient have?
|
Exaggerated circumducted movement
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|
What would an exaggerated circumducted movement in gait indicate?
|
CVA
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|
What is excessive transverse plane rotation in the thigh called?
|
Internal and external rotation
|
|
|
Is the normal leg internally or externally rotated at heel strike?
|
Internal rotation
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|
|
If a normal leg is internally rotated where is the patella facing?
|
The patella should face inward
|
|
|
Is the normal leg internally or externally rotated during midstance and when propelling?
|
Externally rotated
|
|
|
If a normal leg is externally rotated where is the patella facing?
|
The patella is facing outward
|
|
|
Where does torque conversion take place in the leg?
|
The subtalar joint
|
|
|
What is internal rotation of the leg converted to in the foot?
|
Pronation
|
|
|
What is the function of pronation?
|
Shock absorption
|
|
|
What is external rotation of the leg converted to in the foot?
|
Supination
|
|
|
What is the function of supination?
|
It is required for stability of the foot during propulsion
|
|
|
What is excessive extension of the knee?
|
Genu recurvatum
|
|
|
What is genu recurvatum?
|
Excessive extension of the knee
|
|
|
What is valgum of the hip called?
|
Coxa
|
|
|
What can coxa valgum cause further down the leg?
|
Genu varum
|
|
|
What can coxa vara cause further down the leg?
|
Genu valgum
|
|
|
What could be indicated if a unilateral genu valgum or varum is present?
|
1. Injury
2. Infection 3. Growth disturbance at the epiphysis in earlier life 4. Tumour (rare) |
|
|
What is bowing of the tibia in the frontal plane called?
|
Tibia varus
|
|
|
What is tibia varus?
|
Bowing of the tibia in the frontal plane
|
|
|
What further up the leg can cause rearfoot varus?
|
Tibial varus
|
|
|
What is sagittal plane tibial bowing called?
|
Sabre tibia
|
|
|
What is sabre tibia?
|
Sagittal plane bowing of the tibia
|
|
|
What pathology is sabre tibia an indication of?
|
Paget's disease
|
|
|
What is the minimum degrees of dorsiflexion in the ankle required for normal gait?
|
10 degrees
|
|
|
Why is dorsiflexion required in gait?
|
To allow the leg to pass over the foot during midstance
|
|
|
What plane do unstable ankles have instability in?
|
Frontal plane
|
|
|
What is another term for the ankle joint?
|
Talocrural joint
|
|
|
What is the talocrural joint?
|
The subtalar joint
|
|
|
What plane does the ankle joint move in?
|
Sagittal plane
|
|
|
What planes does the subtalar joint move in?
|
Frontal and transverse plane
|
|
|
What is an arthrodesis?
|
Where the joint is fused
|
|
|
What is the position of the calcaneus as it contacts the ground?
|
Slightly inverted
|
|
|
What happens to the calcaneus as a result of ground contact?
|
It everts
|
|
|
What three reasons could there be for an early heel lift?
|
1. Neurological problem
2. Ankle equinus 3. Hamstring tightness |
|
|
What could rapid eversion of the calcaneus at heel contact be a compensation for?
|
A rearfoot deformity such as a fully compensated rearfoot varus
|
|
|
What is a fully compensated rearfoot varus sometimes called?
|
A heel strike pronator
|
|
|
What could a heel strike pronator be compensating for?
|
A fully compensated rearfoot varus
|
|
|
What happens to the navicular on pronation?
|
The talar head adducts
|
|
|
When the talar head adducts is the distance between the navicular and the ground reduced or increased?
|
Reduced
|
|
|
When the talar head adducts is the foot pronating or supinating?
|
Pronating
|
|
|
What happens to the navicular on supination
|
The talar head abducts
|
|
|
When the talar head abducts is the distance between the navicular and the ground reduced or increased?
|
Increased
|
|
|
When the talar head abducts is the foot pronating or supinating?
|
Supinating
|
|
|
When does the MTJ play its most important role?
|
During midstance and propulsion it maintains foot stability in order to withstand forces on the foot generated by uneven surfaces and during propulsion
|
|
|
What is an abductory twist?
|
Unlocking of the midtarsal joint during the last half of midstance if resupination fails to occur at the STJ. The MTJ unlocks and causes the forefoot to abduct on the rearfoot resulting in a less springy propulsive phase
|
|
|
What is the ideal number of degrees that the MTPJ should dorsiflex to for normal propulsion?
|
70 degrees
|
|
|
On ground contact are the toes dorsiflexed or plantarflexed?
|
Dorsiflexed
|
|
|
What muscles influence the position of the digits during the stance phase?
|
Lumbrical, interossei, long and short flexors and extensors
|
|
|
What is the role of the intrinsic muscles?
|
To provide transverse plane stability at the distal and proximal IPJs and prevent the toes from buckling under the effects of contraction of the extensors and/or flexors
|
|
|
What muscles provide transverse plane stability at the distal and proximal IPJs and prevent the toes from buckling under the effects of contraction of the extensors and/or flexors?
|
The intrinsic muscles
|
|
|
Why does clawing of toes occur?
|
When flexors have a mechanical advantage over the intrinsic and extensor muscles and when there is increased extensor muscle activity prior to heel lift
|
|
|
When flexors have a mechanical advantage over the intrinsic and extensor muscles and when there is increased extensor muscle activity prior to heel lift, what happens to the toes?
|
Clawing of the toes occur
|
|
|
What number of degrees abducted should a normal foot be in stance
|
About 13 degrees
|
|
|
Do cavoid feet have a high or low STJ axis?
|
A high STJ axis
|
|
|
Where and what are the likely problems caused by cavoid feet?
|
They produce a greater percentage of internal/external leg rotation which can result in proximal symptoms in the lower limb
|
|
|
Where and what are the likely problems caused by low-arched feet?
|
They produce increased frontal plane motion which causes symptoms in the feet
|
|
|
How does deceleration work?
|
The muscle resists joint movement by eccentric contraction
|
|
|
When the muscle resists joint movement by eccentric contraction, what is this called?
|
Deceleration
|
|
|
What are the extensor tendons of the foot doing on contact with the ground during gait?
|
They decelerate the foot
|
|
|
What does deceleration of the foot prevent?
|
Foot slap and allows the sole of the foot to contact the ground smoothly
|
|
|
What does paralysis of the anterior muscle group in leg cause?
|
It leads to a rapid collapse of the foot on the ground and an audible slap
|
|
|
What neuromuscular condition prevents the foot from clearing the ground during the swing phase?
|
Polio
|
|
|
What is the cause of an apropulsive gait?
|
When the hallux doesn't dorsiflex to 70 degrees and the hallux should be the last digit to leave the ground on propulsion
|
|
|
What are four causes of an apropulsive gait?
|
1. Hallux limitus/rigidus
2. Abnormal pronation 3. Unusual metatarsal formula 4. Excessive internal rotation of the leg |
|
|
What are the three compensations for a lack of propulsion?
|
1. Rolling off its medial border
2. Propelling from a hyperextended (dorsiflexed) 1st IPJ rather than the MTPJ 3. Abductory twist |
|
|
What can abnormal pronation be classified as?
|
Excessive pronation and/or pronation occurring when the foot should be supinating
|
|
|
What are five signs of abnormal pronation?
|
1. Excessive/prolonged internal rotation of the leg
2. Eversion of the calcaneus 3. Abduction at the midtarsal joint 4. Apropulsive gait 5. Abnormal phasic activity of the muscles |
|
|
What is toe walking?
|
When there is no heel contact
|
|
|
When should heel lift occur?
|
It should normally occur at the end of midstance prior to propulsion
|
|
|
What can cause a bouncy gait?
|
Early heel lift
|
|
|
What sort of gait can an early heel lift cause?
|
A bouncy gait
|
|
|
What is the most common cause of an early heel lift?
|
Ankle equinus
|
|
|
What does a Trendelenburg gait look like?
|
It is characterised by a lurching/waddling gait where the pelvis tilts to the affected side
|
|
|
What is a waddling/lurching gait where the pelvis tilts to the affected side called?
|
Trendelenburg gait
|
|
|
What can cause a Trendelenburg gait?
|
Hip osteoarthritis due to weak gluteus medius muscles, congenital dysplasia of the hip or Achilles tendon lengthening procedure
|
|
|
What are four causes of a painful hip joint?
|
1. Osteoarthritis
2. Perthe's disease 3. Slipped capital femoral epiphysis |
|
|
How is a painful hip joint held?
|
It is held in slight flexion, abduction and external rotation
|
|
|
What three conditions is a high knee lift produced during gait associated with?
|
1. Peroneal damage (Charcot-Marie-Tooth disease)
2. Weak tibialis anterior 3. Poliomyelitis |
|
|
What is a circumducted gait?
|
The person will rotate the leg in an arc and flex the elbow and hand towards the body
|
|
|
What condition is associated with a circumducted gait?
|
CVA
|
|
|
What is a scissoring gait?
|
It is when legs cross the line of progression during gait
|
|
|
What condition is associated with a scissoring gait?
|
Cerebral palsy
|
|
|
What is a dystrophic/atrophic gait?
|
An exaggerated alternation of lateral trunk movements with an exaggerated elevation of the hip suggestive of the gait of a duck or penguin
|
|
|
What condition is associated with a dystrophic/atrophic gait?
|
Duchenne's muscular dystrophy
|
|
|
What is a festinating gait?
|
Small accelerating shuffling steps often taken on tip-toe
|
|
|
What condition is a festinating gait associated with?
|
Parkinson's disease
|
|
|
What is an ataxic gait?
|
An unstable poorly coordinated wide base of gait pattern
|
|
|
What condition is associated with an ataxic gait?
|
It is primarily seen in patients with cerebellar pathology
|
|
|
What is a helicopod gait?
|
The feet describe half circles as they shuffle along during contact and early mid-stance phase.
|
|
|
What condition is associated with a helicopod gait?
|
This gait is seen frequently in hysterical disorder
|
|
|
What 9 areas are examined during a non-weight-bearing examination?
|
1. Hip
2. Knee 3. Ankle 4. Subtalar 5. Midtarsals 6. Metatarsals 7. MTPJs 8. Digits (proximal and distal IPJs) 9. Alignment of the lower limb |
|
|
What four structures make the hip stable?
|
1. Depth of the acetabulum
2. Strong capsule 3. Capsular ligaments 4. Surrounding muscles |
|
|
How many planes does the hip move in?
|
Three
|
|
|
What is coxodynia?
|
Hip pain
|
|
|
If pain is felt on the outside of the femur where is this pain likely to originate from?
|
It is usually referred pain from the spine
|
|
|
Ideally how many degrees of flexion and extension should there be in the hip?
|
120-140 degrees of flexion and 5-20 degrees of extension
|
|
|
How do you assess hip flexion?
|
The patient is placed supine on a firm flat couch. The practitioner holds the leg firmly and flexes the hip by pushing the leg towards the body until resistance is met.
|
|
|
How do you assess hip extension?
|
The patient is placed in the prone position. The practitioner places one hand on the posterior superior iliac crest to stabilise the pelvis while the other hand holds the opposite knee just above the anterior knee and moves the leg towards the body to the point of resistance
|
|
|
What plane is flexion and extension in the hip joint?
|
Sagittal plane
|
|
|
What three conditions could cause loss of sagittal plane motion in the hip joint?
|
1. Pain
2. Femoral nerve entrapment 3. Effusion in the hip joint as the anterior ligaments iliofemoral and pubofemoral)will be under greater tension |
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What are the anterior ligaments in the hip?
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Iliofemoral and pubofemoral
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What are the sagittal plane movements of the hip?
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Flexion and extension
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What plane is abduction and adduction in the hip joint?
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Frontal plane
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What are the frontal plane movements of the hip?
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Abduction and adduction
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How do you assess abduction and adduction at the hip?
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The patient lies supine and the practitioner holds the leg just below the anterior knee. The leg with the knee extended is moved across the opposite leg (adduction) and then brought back and abducted. The pelvis should be stabilised during this assessment by placing a hand on the opposite iliac crest
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In a normal person what should there be less of in the hip joint, abduction or adduction?
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There should be less adduction than abduction at the hip
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What sort of gait can tightness of the abductors lead to?
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A scissors type gait where one or both legs have a tendency to cross over during gait
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What are the transverse plane movements at the hip?
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Internal and external rotation
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What plane is external and internal rotation of the hip in?
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Transverse plane
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What should the total range of transverse plane motion be in a normal adult and how is this divided between internal rotation and external rotation?
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90 degrees, 45 degrees internal rotation and 45 degrees external rotation
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What gender tends to show more internal rotation?
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Females
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How can you assess transverse plane motion at the hip?
|
The patient lies in a supine position. The hips and knees are flexed and the leg is moved medially and laterally as one would the arms of a clock
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What could an internally rotated femur cause in the subtalar joint?
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Abnormal pronation
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What is the scouring/circumduction test?
|
This test is used to assess QOM and joint congruency in patients complaining of groin pain
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What test is used to assess QOM and joint congruency in patients complaining of groin pain?
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The scouring/circumduction test
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How is the scouring/circumduction test performed?
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The hip is flexed and adducted and the practitioner rotates the hip to test for any crepitations. If pain is provoked during this manoeuvre with the hip internally rotated a lesion of the acetabular labrum should be suspected
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What is Patrick's or faber's test?
|
Flexion abduction external rotation (faber)
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How do you do Patrick's or faber's test?
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The patient lays supine with one leg straight. The other knee and hip are flexed so that the heel is placed on the knee of the straight leg. The knee is then slowly lowered into abduction. Gentle pressure is applied to the flexed knee while the opposite hand stabilises the pelvis over the opposite anterior superior iliac spine. This test stresses the medial hip capsule by placing an anteromedial force on the hip, the integrity of the iliofemoral/pubofemoral ligaments and also assesses for sacroiliac discomfort
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What test assesses the medial hip capsule, the integrity of the iliofemoral/pubofemoral ligaments and assesses for sacroiliac discomfort?
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Patrick's or faber's test
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What does Patrick's or faber's test assess?
|
This test stresses the medial hip capsule by placing an anteromedial force on the hip, the integrity of the iliofemoral/pubofemoral ligaments and also assesses for sacroiliac discomfort
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How do you do the sacroiliac joint provocation test?
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The practitioner places her hands on the anterior superior iliac spines of the pelvis and presses down firmly and evenly to compress the joint and stress the sacroiliac ligaments. The test is positive if the patient experiences unilateral pain in the abdominal-groin, gluteal region or the leg
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What condition also elicits pain in the hip joint area?
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Pathology of the sacroiliac joint
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If somebody has pathology of the sacroiliac joint where could they feel pain?
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In the hip joint area
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What happens if the test is positive for a sacroiliac joint provocation test?
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The patient experiences unilateral pain in the abdominal-groin, gluteal region or the leg
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How many hip muscle tests are there and what are they?
|
There are 9 and they are:
1. Young's test 2. Thomas's test 3. Ely's test 4. Ober's test 5. Piriformis test 6. Adductor strength test 7. Abductor strength test 8. Trendelenburg's test (stork test) 9. Laseque's (straight-leg raise) test |
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What fascia on the lateral side of the leg causes the knee and hip to flex when it is taut?
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Tensor fascia latae
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What action does a taut tensor fascia latae cause?
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The knee and hip to flex
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How do you perform Young's test?
|
By abucting the lower limb, tension on the tensor fascia latae is reduced and any flexion deformity should disappear
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What is a possible cause of an apparent limb length discrepancy?
|
A tight tensor fascia latae
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What can a tight tensor fascia latae cause?
|
An apparent leg length discrepancy
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What does the iliopsoas group of muscles consist of?
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1. Psoas minor
2. Psoas major 3. Iliacus |
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What is the function of the iliopsoas group of muscles?
|
They are prime flexors of the hip
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What muscles are the prime flexors of the hip?
|
The iliopsoas group of muscles
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What does Thomas's test do?
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It rules out the presence of iliopsoas contracture
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How do you perform Thomas's test?
|
The patient is supine. Bring both knees to the chest. Maintain pelvic tilt. Patient should lower the leg until it is relaxed or the pelvic tilt is lost. A positive finding is where there is lack of hip extension with knee flexion of 45 degrees or greater is positive
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What group of muscles can irritate the femoral nerve?
|
The iliopsoas group
|
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What nerve can tight iliopsoas muscles irritate?
|
The femoral nerve
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What two problems can damage to the femoral nerve do in the upper leg?
|
1. Weakness of the quadriceps
2. Loss of sensation on the anterior and medial aspects of the leg |
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What nerve arises in the psoas major, crosses the hip joint and exits through the obturator foramen?
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The obturator nerve
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Describe where the obturator nerve goes
|
It rises in the psoas major and crosses the hip joint, exiting through the obturator foramen
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What condition can injure the obturator nerve?
|
A slipped capita femoris epiphysis
|
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What nerve can be injured due to a slipped capita femoris epiphysis?
|
The obturator nerve
|
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What is a slipped capita femoris epiphysis?
|
Displacement of the head relative to the femoral
shaft common in boys aged 10-15. Primarily prevalent in overweight people and in persons with Hispanic heritage |
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In Thomas's test what must the practitioner be looking for whilst performing this test?
|
While the patient flexes the hip, the practitioner must observe the opposite thigh for any sign of elevation. The lumbar spine must lie flat. If the iliapsoas muscles are tight, the contralateral hip will rise as the ipsilateral hip will force the lumbar spine against the couch.
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What is Ely's test?
|
This test is used to assess hip flexor (rectus femoris) tightness or contracture.
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What is a hip flexor?
|
Rectus femoris
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What action does rectus femoris have?
|
Hip flexion
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How do you perform Ely's test?
|
The patient lies prone and the knee is slowly flexed as far as possible until the heel comes close to the buttocks. Observe the buttock/hip during this manoeuvre. The point at which the buttock rises off the couch on the tested side indicates the degree of hip flexor tightness
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What is Ober's test?
|
This test is designed to assess for iliotibial band contraction or tightness
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How do you perform Ober's test?
|
The patient lies on his side with the inner knee flexed and the outer limb with the knee extended is moved anteriorly and adducted towards the couch. This stretches the lateral structures primarily the iliotibial band. A modified form of the test separately tests the short fibres of the knee which is achieved by flexing the knee and repeating the manoeuvre
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What does a modified form of Ober's test by flexing the knee test?
|
The short fibres of the knee
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What test could you use to test the short fibres of the knee?
|
A modified form of Ober's test by flexing the knee
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What test assesses the tightness of the tensor fascia latae?
|
Young's test
|
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What test assesses the tightness of the iliopsoas group of muscles?
|
Thomas's test
|
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What test is used to assess hip flexor tightness?
|
Ely's test
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What test is used to assess iliotibial band tightness?
|
Ober's test
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What test is used to assess tightness of the piriformis?
|
The piriformis test
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How do you perform piriformis test?
|
With the patient lying on his side, the hip and knee are flexed to 90 degrees. The examiner places one hand on the pelvis for stabilisation and with the other hand applies pressure at the knee pushing it towards the couch. This puts the piriformis muscle under tension. If tightness of the piriformis muscle is impinging on the sciatic nerve, pain may be produced in the buttock and also down the leg. Also in this position the strength of the external rotators of the hip can be tested by asking the patient to externally rotate the hip against resistance
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Where do the adductors have their insertion?
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On the medial side of the femur along the linea aspera
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What part of the gait are adductor muscles important for and how do they work during swing phase?
|
They are important during the swing phase, stabilising the contralateral side of the hip against the pelvis as the leg swings forward
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How can adductors be tested?
|
The patient lies supine with both both legs flexed at the hip and knee with the knees apart. The practitioner puts their hand on the medial side of the knee and asks the patient to push against the hand
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What is the function of gracilis?
|
It is a partial adductor and rotates the femur on the hip
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What are the group of adductor muscles?
|
adductor longus, adductor magnus, adductor brevis
are all adductors of the thigh. These muscles are supplemented by the pectineus. Gracilis is also an adductor |
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Where does gracilis lie?
|
This muscle crosses the knee and lies between sartorius and semitendinosus on the medial aspect of the knee
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What adductor is in action when the knee is extended?
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Gracilis
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What adductor muscle is not active when the knee is flexed?
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Gracilis
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What three muscles are the abductors of the hip?
|
1. Gluteus medius
2. Gluteus maximus 3. Tensor fascia latae They act through the iliotibial band |
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How do you test the strength of the abductors of the hip?
|
By having the patient lie on their side and raising the leg away from the couch against gravity and resistance
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What are you testing when the patient lies on their side and raises the leg away from the couch against gravity and resistance?
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The strength of the abductors
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What does Trendelenberg's test (stork test) assess?
|
It tests the stability of the hip and the ability of the hip abductors to stabilise the pelvis on the femur
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What tests the stability of the hip and the ability of the hip abductors to stabilise the pelvis on the femur?
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Trendelenberg (stork test) test
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How do you do the Trendelenberg test?
|
The patient stands on one leg with the other knee flexed. The pelvis should tilt upwards or stay level on the side of the lifted leg. A positive Trendelenberg sign occurs when the reverse happens; the pelvis tilts downwards indicating weak glutei
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What pathology can produce a positive Trendelenberg sign?
|
Osteoarthritis of the hip
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What does Laseque's (straight leg raise) test test?
|
This test will provoke pain in patients with hamstring muscle inflexibility, severe hip pathology and also tests mobility of nerve roots L4 to S2. Where no pathology is present the leg should make an angle of 70 degrees to the supporting surface
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How many degrees to the supporting surface should the leg be in a Laseque's (straight leg raise) test in a normal person?
|
70 degrees
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What other tests can be used to reproduce pain if the formal examination has not reproduced the patient's in the hip?
|
Functional tests such as single leg squats or step up or step down tests
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What functional test can be used to assess pelvic control?
|
Single leg squat
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What does a single leg squat test?
|
Pelvic control
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What is the largest joint in the body?
|
The knee joint
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What two joints comprise the knee joint?
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Patellofemoral joint and tibiofemoral joint
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What joint is comprised of the patellofemoral joint and the tibiofemoral joint?
|
The knee joint
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What muscles and ligaments provide stability to the knee?
|
The cruciate and collateral ligaments, the menisci, the iliotibial band and sartorius muscle
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What does the patella articulate with?
|
The anterior surface of the inferior end of the femur
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What bone articulates with the anterior surface of the inferior end of the femur
|
The patella
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What sort of bone is the patella?
|
A sesamoid
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What are the ten elements of assessment of the knee?
|
1. Observation
2. Palpation 3. Patellofemoral joint tests 4. Tibiofemoral joint motion 5. Tibiofemoral joint stability 6. Integrity of internal knee structure 7. Muscle testing 8. Q angle 9. Functional tests 10. Laboratory tests |
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|
When observing the knee joint what eight things should you be looking for?
|
1. Gross deformity (genu valgum/varum, enlarged or abnormal position of tibial tubercle)
2. Patella position ((squinting, fisheye or outward facing, patella alta, patella tilt or rotation) 3. Patella size (small patella unstable in femoral groove, susceptible to subluxation/dislocation) 4. Oedema - the presence and site of swelling in the knee should be noted 5. Tonic muscle spasm (hamstrings) secondary to intra-articular/extra-articular pain 6. Muscle wasting (quadriceps femoris, particularly vasus medialis) 7. Bruising (trauma) 8. Scars (site and evidence will provide evidence of type/extent of surgery |
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What is patella alta?
|
A high-riding patella
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What is a high-riding patella called?
|
Patella alta
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What 6 conditions can swelling of an extreme nature in the knee be associated with?
|
1. Bursitis
2. Acute synovitis 3. Tearing of the menisci 4. Rheumatoid arthritis 5. Osteoarthritis 6. Baker's cyst |
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|
What is a Baker's cyst?
|
It is also known as a popliteal cyst and is a benign swelling behind the knee joint
|
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What is haemarthrosis?
|
A bleeding into the joint
|
|
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What is bleeding into the joint called?
|
A haemarthrosis
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What is a benign swelling behind the knee joint called?
|
A Baker's cyst or popliteal cyst
|
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What three conditions can cause spontaneous swelling in the knee joint?
|
1. Cruciate injury
2. Meniscus injury 3. Haemarthrosis following trauma |
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|
What four conditions are muscle wasting around the knee joint associated with?
|
1. Anterior knee pain
2. Osteoarthritis 3. RA 4. Osgood Schlatter's disease |
|
|
What is Osgood Schlatter's disease?
|
The condition occurs in active boys and girls aged 11-15, coinciding with periods of growth spurts. The condition is usually self-limiting and is caused by stress on the patellar tendon that attaches the quadriceps muscle at the front of the thigh to the tibial tuberosity. Following an adolescent growth spurt, repeated stress from contraction of the quadriceps is transmitted through the patellar tendon to the immature tibial tuberosity. This can cause multiple subacute avulsion fractures along with inflammation of the tendon, leading to excess bone growth in the tuberosity and producing a visible lump.
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What is Osgood Schlatter's disease also known as?
|
A tibial tubercle apophyseal traction injury
|
|
|
What is a tibial tubercle apophyseal traction injury also known as?
|
Osgood Schlatter's disease
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|
What group of diseases does Osgood Schlatter's disease belong to?
|
Osteochondroses
|
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What ten areas of the knee should be palpated and state what you are palpating for.
|
1. Palpate for warmth (inflammatory joint disorder)
2. Palpate for oedema (generalised/localised) 3. Palpate joint line medially/laterally for joint, meniscal pathology and anteriorly for coronary ligament pathology 4. Palpate for tendons crossing the knee joint: medially (semitendinosus/semimembranosus); laterally (biceps femoris, iliotibial band); and anteriorly (patellar tendon) 5. Palpate patella - tenderness superior pole (rectus femoris tear or bipartite patella) - pain in body of patella (fracture following trauma) - pain inferior pole of patella (Sinding-Larsen-Johannson syndrome); infrapatella fat pad palpated for tenderness - this fat pad can become impinged between the patellar and femoral condyle following forced extension of the knee (Hoffa's syndrome); however, chronic fat pad impingement (aka infrapatella bursitis) occurs more frequently 6. Popliteal fossa (Baker's cyst, popliteus bursitis, fabella) 7. Tender, enlarged tubercle (Osgood Schlatter's disease) 8. Local oedema 9. Bursae 10. Soft tissue lumps such as lipoma can also be found around the knee |
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|
Where are the coronary ligaments of the knee?
|
Portions of the joint capsule which connect the inferior edges of the fibrocartilaginous menisci to the periphery of the tibial plateaus.
|
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|
What are the portions of the joint capsule which connect the inferior edges of the fibrocartilaginous mensici to the periphery of the tibial plateaus.
|
The coronary ligaments of the knee
|
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|
What tendons cross the joint medially?
|
Semitendinosus and semimembranosus
|
|
|
Where do semimembranosus and semitendinosus cross the joint, medially or laterally?
|
Medially
|
|
|
What tendons cross the knee joint laterally?
|
Biceps femoris and iliotibial band
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|
Where do biceps femoris and the iliotibial band cross the joint, medially or laterally?
|
Laterally
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|
Where does the patellar tendon cross the knee joint, anteriorly or laterally?
|
Anteriorly
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|
What tendon cross the knee joint anteriorly?
|
Patella tendon
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|
What is Sinding-Larsen-Johansson syndrome?
|
Sinding-Larsen-Johansson syndrome is inflammation of the kneecap (patella) at its lowest point. This is the site of origin of the patellar tendon. There is traction on the kneecap at this point due to action of the large, powerful thigh muscle (quadriceps), as well as with deep bending of the knee. The injury is due to repeated stress or vigorous exercise. It is a temporary condition of the patella that is uncommon after age 16. It is the children’s equivalent of patellar tendinitis (jumper’s knee).
|
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|
What could be the cause of pain in the lower part of the patella in an active adolescent?
|
Sinding-Larsen-Johansson syndrome
|
|
|
What is Hoffa's syndrome?
|
In the case of a forceful direct impact to the kneecap, the fat pad can become impinged (pinched) between the femoral condyle and the patella. As the fat pad is one of the most sensitive structures in the knee, this injury is known to be extremely painful. This condition is normally long-standing as it is aggravated by extension (straightening) of the knee joint. Hence the fat pad comes under constant irritation and may become significantly inflamed.
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What other name is Hoffa's syndrome also known as?
|
Fat pad impingement
|
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|
What is the infrapatellar fat pad also known as?
|
Hoffa's pad
|
|
|
Where is the infrapatellar fat pad (Hoffa's pad) situated?
|
It is soft tissue that lies beneath the patella (kneecap) separating it from the femoral condyle (end of the thigh bone).
|
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|
What is chronic fat pad impingement also known as?
|
Infrapatella bursitis
|
|
|
What is infrapatella bursitis also known as?
|
Chronic fat pad impingement
|
|
|
What is a fabella?
|
The fabella is a small sesamoid bone found embedded in the tendon of the lateral head of the gastrocnemius muscle behind the lateral condyle of the femur. It is a variant of normal anatomy and present in humans in 10% to 30% of individuals. Rarely, there are 2 or 3 of these bones (fabella bi- or tripartita). It can be mistaken for a loose body or osteophyte.
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What is a small sesamoid bone found embedded in the tendon of the lateral head of the gastrocnemius muscle behind the lateral condyle of the femur?
|
A fabella
|
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|
Where is the suprapatellar bursa?
|
Between the quadriceps tendon and femur
|
|
|
What bursa is between the quadriceps tendon and the femur?
|
The suprapatellar bursa
|
|
|
Where is the prepatellar bursa?
|
Between the front of the patellar and the skin
|
|
|
What bursa is between the front of the skin and the patellar?
|
The prepatellar bursa
|
|
|
Where is the infrapatellar bursa?
|
Between the patellar tendon and proximal tibia
|
|
|
What bursa is between the patellar tendon and the proximal tibia?
|
The infrapatellar bursa
|
|
|
Where is the pes anserine?
|
Under the tendinous insertion of gracilis, semitendinosus and gracilis muscles
|
|
|
What is the tendinous insertion under gracilis, semitendinosus and sartorius muscles?
|
The pes anserine
|
|
|
How many patellofemoral joint tests are there and what are they?
|
There are 5 and they are:
1. Ballottement test (patellar tap test) 2. Wipe test (fluid displacement test) 3. Apprehension test 4. 50:50 test 5. Clarke's test |
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|
What does the Ballottement test (patellar tap test) test for?
|
It is used to test for moderate intracapsular swelling
|
|
|
What test is used to test for moderate intracapsular swelling of the knee?
|
The Ballottement test (patellar tap test)
|
|
|
How do you perform the ballottement test (patellar tap test)?
|
Squeeze excess fluid out of the suprapatellar pouch, place tips of the thumb and three fingers on the patella and jerk it quickly downwards. A floating sensation of the patella over fluid or a click indicates the presence of an effusion
|
|
|
What does the wipe test (fluid displacement test) test for?
|
This is used to test for slight to moderate intracapsular swelling
|
|
|
What test is used to test for slight to moderate intracapsular swelling?
|
The wipe test (fluid displacement test)
|
|
|
How do you perform the wipe test (fluid displacement test)?
|
Evacuate the suprapatellar pouch of fluid then stroke the medial side of the patella. A wave of fluid will bulge on the lateral side of the joint. Stroke the lateral side and observe the medial side of the joint for fluid movement.
|
|
|
What is the apprehension test used for?
|
To test if the patella is manually displaced laterally
|
|
|
What indicates hypermobility of the patella?
|
If it can be displaced than 50% of its width both medially and laterally
|
|
|
What does displacement of the patella greater than 50% of its width both medially and laterally indicate?
|
Hypermobility
|
|
|
How do you perform Clarke's test?
|
With the patient supine the practitioner places one hand proximal to the superior pole of the patella and asks the patient to contract the quadriceps. This test is used to detect anterior knee pain or patello-femoral pain syndrome.
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|
|
What is Clarke's test used for?
|
To test for anterior knee pain
|
|
|
What test is used to test for anterior knee pain?
|
Clarke's test
|
|
|
What is chondromalacia patellae?
|
Chondromalacia patellae is a term for a large and disparate group of medical conditions that can cause pain in the front of the knee
|
|
|
Which plane does the main movement happen in the knee?
|
The sagittal plane
|
|
|
What number of degrees should the knee flex to in a healthy person?
|
About 135 degrees
|
|
|
How many degrees should the knee extend to in a healthy person?
|
From 0 degrees to 10 degrees
|
|
|
What is the condition known as when extension of the knee is greater than 10 degrees?
|
Genu recurvatum
|
|
|
What is genu recurvatum?
|
When the knee extends more than 10 degrees
|
|
|
Why is flexion of the knee important in gait?
|
For forward progression
|
|
|
What can genu recurvatum be indicative of?
|
Lower limb dysfunction or flexed trunk posture
|
|
|
What plane do the lateral and medial ligaments of the knee provide stability in?
|
The frontal plane
|
|
|
What ligaments provide stability to the knee in the frontal plane?
|
The frontal plane
|
|
|
Should there be frontal plane motion at the knee?
|
No
|
|
|
What patient group has frontal plane motion of the knee?
|
Frontal plane motion is only available to a child under 6 years
|
|
|
What does a lateral collateral ligament stress test (varus stress test) assess?
|
A lateral stress test is used to assess the lateral collateral ligaments
|
|
|
What test is used to test the lateral collateral ligaments in the knee?
|
The lateral collateral ligament stress test
|
|
|
How do you perform the lateral collateral ligament stress test (varus stress test)?
|
With the patient supine the knee is flexed to 30 degrees so the joint is unlocked during the test. The practitioner places one hand on the medial side of the lower end of the femur and the other on the lateral side of the upper end of the tibia. The practitioner then pushes with both hands in an attempt to 'break' the knee by stressing the lateral collateral ligament
|
|
|
Where is the lateral collateral ligament in relation to the biceps femoris tendon?
|
It is deep to the biceps femoris tendon
|
|
|
What position is it easiest to palpate the lateral collateral ligament in?
|
The figure-4 position where the patient is seated with the hip maximally externally rotated, the knee flexed to 90 degrees and the foot rested on the top of the distal thigh of the other leg
|
|
|
How is the medial collateral ligament stress test (valgus test) carried out?
|
By doing the lateral collateral ligament stress test and placing the hand in the opposite position
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What does motion at the knee indicate?
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Weak collaterals and poor knee stability
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Which collateral ligament in the knee is more commonly damaged?
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The medial collateral ligament
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Who is more likely to damage their collateral ligaments?
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Football and rugby players
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Who is likely to damage their lateral collateral ligaments?
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Ice hockey players
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What structures of the knee hold the knee stable in the sagittal plane and prevent the knee "opening up"?
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Anterior and posterior cruciate ligaments
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What is the function of anterior and posterior cruciate ligaments?
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To hold the knee stable in the sagittal plane and to prevent the knee "opening up"
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What is the drawer test?
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It tests the anterior and posterior cruciate ligaments
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What test would be used to test the anterior and posterior cruciate ligaments?
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The drawer test
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How do you do the drawer test for the anterior cruciate ligament?
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The patient lies supine with the knee flexed to 45 degrees and the foot flat on the couch. The practitioner sits on the foot and grasps the upper end of the tibia and pulls it forward to stress the anterior cruciate ligament. More than 2-3cm displacement of the tibia is considered abnormal and may be painful. Excessive movement suggests tearing of these structures.
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How do you do the drawer test for the posterior cruciate ligament?
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The patient lies supine with the knee flexed to 45 degrees and the foot flat on the couch. The practitioner sits on the foot and grasps the upper end of the tibia and pushes it backward to stress the posterior cruciate ligament. More than 2-3cm displacement of the tibia is considered abnormal and may be painful. Excessive movement suggests tearing of these structures.
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Why is the test known as a drawer test?
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Because the action is like opening and shutting a drawer
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What does Lachman's test test?
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The anterior cruciate ligament
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How do you perform Lachman's test?
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The knee is flexed to 25 degrees and the tibia is pulled forward while the knee is externally rotated. If there is displacement of the tibia this is indicative of a weak anterior cruciate ligament. A positive sign is indicated by a forward translation of the tibia with a mushy/soft end feel.
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How many tests are there for the anterior cruciate ligament and what are they?
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1. Drawer test
2. Lachman's test 3. The pivot shift test |
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What does the pivot shift test test?
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The anterior cruciate ligament
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How do you do the pivot shift test?
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With the knee in full extension and the tibia internally rotated, a valgus force is applied to the knee. In an anterior cruciate deficient knee, the condyles will be subluxed. The knee is then flexed, looking for a 'clunk' of reduction, rendering the pivot shift test positive.
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What does McMurray's test test?
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Meniscus tears or any loose bodies by detecting crepitations and clicking
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What test tests for meniscus tears or any loose bodies?
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McMurray's test
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Which meniscus is most likely to tear?
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The medial meniscus
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Why is the medical meniscus most likely to tear?
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Because it has less flexibility and it is attached to the capsule
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How do you perform McMurray's test?
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The patient lies supine with the knee and hip flexed to 90 degrees. The practitioner grasps the sole of the foot with one hand; the other should be placed around the knee so that the joint can be palpated. By moving the foot the tibia is externally rotated and a valgus stress is applied. A positive test will elicit a 'popping' or 'snapping' sound or sensation. The test is repeated with internal rotation and a varus stress for the lateral meniscus.
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How many tests are there to test for meniscal tears and what are they?
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1. McMurray's test
2. Apley's compression test |
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What does Apley's compression test test?
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Meniscus damage
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How is Apley's compression test performed?
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The patient lies prone and the knee is flexed and the foot grasped. The practitioner creates a compression at the knee joint while producing a rotation movement. A noisy and painful response suggests meniscus damage
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Wasting of which muscle occurs as a result of knee dysfunction?
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Medial vastus muscle
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Where should the circumference of both legs be measured when measuring the quadriceps?
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10cm above the superior pole of the patella
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What is the function of the rectus femoris muscle?
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It is a weak flexor of the hip but a powerful extensor of the knee
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What muscle group does rectus femoris belong to?
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The quadriceps
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How does rectus femoris function within the quadricep group of muscles?
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Rectus femoris is an important stabiliser of the knee, in conjunction with the vasti and is needed to swing the leg forward in gait
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Where does rectus femoris insert at?
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The anterior inferior iliac spine
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What muscle is a weak flexor of the hip and a powerful extensor of the knee?
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Rectus femoris
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How do you examine rectus femoris?
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The patient sits on the edge of the couch with the knees flexed. To assess the strength of this muscle the patient is asked to extend the knee while the practitioner attempts to resist this active motion
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How are the hamstrings tested?
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From an extended knee position the strength of the hamstrings is tested by asking the patient to flex their knee (push down) against resistance.
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What test is used to identify tightness and contracture of the hamstring muscle group?
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The 90:90 test
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What does the 90:90 test test?
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It identifies tightness and contracture of the hamstring muscle group
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What problems can tight hamstrings cause?
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Tight hamstrings may cause knee flexion, creating an inefficient antagonist action with the quadriceps and a functional equinus at the ankle joint
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How is the 90:90 test performed?
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The patient is supine. The knee and hip are flexed to 90 degrees. The practitioner holds the leg and extends the knee until resistance is met. If the knee can be fully straightened or to within 10 degrees, then the hamstrings are within normal limits. If the leg can only be partially extended it indicates tight hamstrings
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How do you assess whether biceps femoris is tight or whether it is semitendinosus?
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If the knee is extended as far as possible then medially rotated biceps femoris is being tested. Laterally rotating the extended leg will test semitendinosus.
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What is the Q angle?
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The Q angle is the position the patella adopts in relation to the direction of pull of the quadriceps tendon
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How is the Q angle measured?
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A line is drawn from the ASIS to a line bisecting the patella. If the angle of this line to the bisection of the patella is greater than 15 degrees the patient is said to have a high Q angle. This suggests medial displacement of the patella and is often associated with greater than normal internal rotation and anterior knee pain.
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If the Q angle is greater than 15 degrees what does this indicate?
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A high Q angle
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What does a high Q angle mean?
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It suggests medial displacement of the patella and is often associated with greater than normal internal rotation and anterior knee pain
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What 3 pathologies can X-rays show of the knee?
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1. Osteoarthritis
2. Loose bodies 3. A fragmented or bipartite patella |
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What 3 pathologies can MRI scans show?
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1. Thickening or swelling around the tendon
2. The presence of any tendon tears or degeneration 3. Meniscal damage |
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What could pus in the joint indicate?
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Infective arthritis
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What would bilateral swelling around the tibiofibular area indicate?
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A systemic cause rather than a local cause
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What could unilateral leg oedema in women over 40 years indicate?
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An intrapelvic neoplasm
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What 2 pathologies could local bone swelling indicate?
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1. An old fracture
2. Neoplasm eg osteoid osteoma |
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What is an osteoid osteoma?
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A benign bone tumour of the long bones
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What is diaphyseal aclasia?
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It is multiple or single exostoses that occur in the tibia
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What is the name of the condition where there is multiple or single exostoses that occur in the tibia?
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Diaphyseal aclasia
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What is thickening of the ends of the tibia indicative of?
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1. Osteoarthritis
2. Rickets |
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What is an enlarged and painful tibial tuberosity an indication of?
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Osgood Schlatter's disease
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What is Brodie's abscess or osteitis?
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A Brodie abscess is a subacute osteomyelitis, which may persist for years before converting to a frank osteomyelitis.
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What is a subacute osteomyelitis which has persisted for years before converting to frank osteomyelitis called?
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Brodie's abscess or osteitis
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What could be tenderness over the proximal lateral area of the tibia be indicative of?
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Brodie's abscess or osteitis
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What is another name for Brodie's abscess?
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Osteitis
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What is a symptom of Brodie's abscess or osteitis?
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Tenderness over the proximal lateral area of the tibia
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What could pain in the region of the head of the fibular be indicative of?
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Proximal tibiofibular joint osteoarthritis
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What is a symptom of proximal tibiofibular joint arthritis?
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Pain at the head of the fibular
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What is anterior tibial compartment syndrome?
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It is a buildup of pressure in the anterior tibial compartment
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What does the anterior tibial compartment have in it?
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1. Tibialis anterior
2. Extensor digitorum longus 3. Extensor hallucis longus 4. Peroneus tertius 5. Anterior tibial artery 6. Deep peroneal nerve |
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What is the compartment called which has these elements in it?
1. Tibialis anterior 2. Extensor digitorum longus 3. Extensor hallucis longus 4. Peroneus tertius 5. Anterior tibial artery 6. Deep peroneal nerve |
Anterior tibial compartment
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What could be indicative of pain over the anterior tibial border?
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Stress fracture
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What could pain over the medial border of the tibia be indicative of?
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Medial tibial stress syndrome
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What could pain over the inferior tibiofibular joint be associated with?
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Lateral ligament injury and may cause anterior ankle pain
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What could tenderness in the back of the calf be indicative of?
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Ruptured plantaris tendon syndrome
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What could pain over the tendocalcaneus be indicativ of?
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A partial or complete rupture of the Achilles tendon
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What test do you perform to test if there is Achilles tendon rupture?
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Thomson's test
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How do you perform Thomson's test?
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With the patient prone squeeze the calf. If no plantarflexion occurs a complete rupture of the Achilles tendon is indicated
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What is the test called that squeezes the calf to test for Achilles tendon rupture?
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Thomson's test
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When is Thomson's test contraindicated?
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When there is an index of suspicion that there might be a DVT
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What are the two frontal plane deformities in the tibia?
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Tibial varum and tibial valgum
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How do you test for tibial varum or tibial valgum?
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The patient is in the supine position by bringing the legs together and observing the relative distance between the knees and the malleoli. A greater distance between the knees is seen in tibial varum
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When testing for tibial varum or valgum what does a greater distance between the knees than the malleoli indicate?
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Tibial varum
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Which is more common, tibial varum or tibial valgum?
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Tibial varum
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What is tibial varum
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Where there is a greater distance between the knees than the malleoli
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What number of degrees is considered normal in tibial varum?
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About 6 degrees
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What is the factor that can cause lessening of the lower limb problems associated with tibial varum?
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The ability of the STJ to compensate
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What is the eight finger test?
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It estimates the degree of frontal plane bowing of the tibia (tibial varum)
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What test can be used to estimate the degree of frontal plane bowing of the tibia?
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The eight finger test
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How do you perform the eight finger test?
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All eight fingers are placed along the anterior border of the tibia and their alignment compared
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What does sagittal plane bowing (sabre tibia) and general tibial thickening indicative of?
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Paget's disease
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When is the onset of Paget's disease?
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60-70 years old
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What is Paget's disease (osteitis deformans)?
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Paget's disease, otherwise known as osteitis deformans, is a chronic disorder that typically results in enlarged and deformed bones.
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What is another name for Paget's disease?
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Osteitis deformans
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What is another name for osteitis deformans?
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Paget's disease
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What is sagittal plane bowing called?
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Sabre tibia
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What is sabre tibia?
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Sagittal plane bowing
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What are the transverse plane deformities of the tibia?
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Medial tibial torsion and lateral tibial torsion
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What plane is medial tibial torsion and lateral plane torsion in?
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The transverse plane
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What two problems are medial tibial torsion associated with?
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1. Flat feet
2. Intoeing deformities |
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What roblem is lateral torsion associated with?
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Pes cavus feet
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What test is used to test for the relative lengths of the tibiae?
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Skyline/Allis test
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What is the Skyline/Allis test?
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It tests the relative lengths of the tibiae
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How do you perform the Skyline/Allis test?
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With patient supine and knees flexed and the soles of the feet on the couch, the relative lengths of the tibiae can be assessed by comparing the heights of the knees or tibial tuberosities
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What comprises the ankle joint?
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The talocrural joint and the subtalar joint
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How many joints are there in the ankle?
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Two
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What is the inferior tibiofibular joint?
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It is a syndesmosis supported by the inferior tibiofibular ligament
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What are the two most common coalitions seen at the ankle joint?
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The talocalcaneal joint (medial and posterior facets) and the calcaneonavicular joint.
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What three types of tissue can be involved in coalitions?
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1. Fibrous coalition
2. Cartilaginous coalition 3. Osseous coalition |
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What movement and symptoms can be seen in a fibrous coalition?
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Some movement and few symptoms
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What movement and symptoms can be seen in a cartilaginous coalition?
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No movement but more symptoms
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What movement and symptoms can be seen in an osseous coalition (synostosis)?
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No movement but more symptoms
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What is a common symptom of tarsal coalitions?
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Tonic spasms of the peronei
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What could cause tonic spasm of the peronei?
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Tarsal coalitions
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How do you definitely diagnose an osseous tarsal coalition (synostosis)?
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By X-ray
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What is a synostosis?
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An osseous tarsal coalition
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What is another name for an osseous tarsal coalition?
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A synostosis
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What bones and articulations form the talocrural joint?
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The trochlear surface of the talus articulates with the inferior surface of the tibia to form the talocrural joint
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What is a function of the medial and lateral malleoli?
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They provide additional articulations and stability to the ankle joint
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What is the talocrural joint, biplanar or triplanar?
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Triplanar
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In which plane is the main motion of the ankle joint?
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Sagittal plane
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How many degrees of dorsiflexion should there be in the ankle?
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10 degrees
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Why do you need 10 degrees of dorsiflexion in the ankle?
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To allow the leg to move over the foot
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What three areas can the body compensate for a lack of dorsiflexion?
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1. Knee
2. Subtalar joint 3. Midtarsal joint |
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What can the knee do to compensate for lack of dorsiflexion at the ankle?
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The knee can hyperextend (genu recurvatum) to compensate for an ankle equinus
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What six things should be assessed for at the talocrural joint?
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1. Range of motion
2. Stability 3. Strength 4. Palpation for tenderness 5. Grading of ligamentous injury 6. Proprioception |
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How do you assess dorsiflexion range of motion non-weightbearing?
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The patient should lie prone or spine with the knee extended and the foot and ankle free of the end of the couch. The practitioner holds the foot in neutral with one hand, places the other hand on the sole of the foot and dorsiflexes the ankle. If subtalar joint pronation is allowed to occur during the examination a falsely elevated dorsiflexion value will result.
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What is the problem of testing dorsiflexion range of motion non-weightbearing?
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The force applied by the practitioner to TCJ dorsiflexion can vary
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What two things may prevent TCJ dorsiflexion?
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1. A tight soleus
2. A tight gastrocnemius |
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How do you differentiate between a tight gastrocnemius and a tight soleus?
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The amount of the dorsiflexion with the knee extended and flexed should be measured. With the knee flexed the tendons of gastrocnemius which cross the knee are released from tension so gastrocnemius affect TCJ dorsiflexion. If the amount of dorsiflexion is still reduced when the knee is flexed the cause is likely to be soleus. However a bony block (osteophytes on the distal/anterior tibia) can also limit TCJ dorsflexion with the knee flexed however the Achilles tendon in this case will feel slack.
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What other conditions can affect TCJ dorsiflexion with the knee flexed?
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A bony block (osteophytes on distal on the distal/anterior tibia) can also limit TCJ dorsflexion with the knee flexed however the Achilles tendon in this case will feel slack.
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Describe the two types of feeling you expect to get from TCJ end ROM when testing dorsiflexion
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1. Soft tissue limitation will result in a springy end-feel
2. Limitation resulting from a bony block will be abrupt |
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What is a more consistent way of testing TCJ dorsiflexion, weight-bearing or non-weight-bearing?
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Weight-bearing
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How do you test weight-bearing TCJ dorsiflexion?
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The patient stands facing a wall with a distance of approximately 0.5m between the patient and the wall. One leg, with the knee in a flexed position, is placed in front, approximately 30cm from the wall. The other leg is placed behind the forward foot with the knee extended and the foot held in a neutral position. The patient leans forward and places both hands on the wall and is asked to move his body towards the wall. In order to do this the patient must dorsiflex the ankle of the limb furthest from the wall.
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What are the lateral ligaments in the ankle.?
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Calcaneofibular and talofibular ligements
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What test tests the integrity of the anterior talofibular ligament?
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The ankle drawer test
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How do you do the ankle drawer test?
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The foot is flat on the couch and a forward and backward motion should be applied to the TCJ
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What does the ankle drawer test test?
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The integrity of the anterior talofibular ligament
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What does the talar tilt test assess?
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It assesses the integrity of the calcaneofibular ligament laterally and the deltoid ligament medially
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How do you perform the talar test?
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Wit the patient supine the calcaneus is grasped and moved medially and laterally. The medial and lateral movement of the talus and calcaneus is assessed in relation to the tibia and fibular
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What is TELOS?
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It is a stress X-ray using a German system which allows the ankles to be compared. The procedure is performed under LA using a common peroneal nerve block. It provides a reproducible method to determine ankle stability
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How many muscles are there in the gluteal region and what are they?
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There are 8
1. Gluteus maximus 2. Gluteus medius 3. Gluteus minimus 4. Piriformis 5. Quadratus femoris 6. Obturator internus 7. Gemellus superior and inferior 8. Obturator externus |
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What is the function of gluteus maximus?
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Extension and lateral rotation of the hip joint
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Where does gluteus maximus go from?
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Gluteus maximus goes from the posterior gluteal line of the hip bone, the dorsal surface of the lower part of the sacrum and the side of the coccyx, the sacrotuberous ligament and the fascia over the gluteus medius.
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Where does gluteus maximus go to?
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Gluteus maximus goes to the iliotibial tract with the deep fibres of the lower part attaching to the gluteal tuberosity of the femur
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What is the function of gluteus medius?
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Abduction and medial rotation of the hip joint and prevention of adduction
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Where does gluteus medius go from?
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Gluteus medius goes from the outer surface of the ilium between the posterior and anterior oblique lines
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Where does gluteus medius go to?
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Gluteus medius goes to the lateral surface of the greater trochanter of the femur
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What is the function of gluteus minimus?
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Abduction and medial rotation of the hip joint and prevention of adduction
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Where does gluteus minimus go from?
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Gluteus minimus goes from the outer surface of the ilium between the anterior and inferior gluteal lines
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Where does gluteus minimus go to?
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Gluteus minimus goes to the anterior part of the lateral surface of the greater trochanter of the femur
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What is the function of piriformis?
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Abduction, lateral rotation and stabilization of the hip joint
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Where does piriformis go from?
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Piriformis goes from the middle three pieces of the sacrum
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Where does piriformis go to?
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Piriformis goes to the upper border of the greater trochanter of the femur
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What is the function of quadratus femoris?
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Lateral rotation and stabilization of the hip joint
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Where does quadratus femoris go from?
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From the upper part of the outer border of the ischial tuberosity
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Where does quadratus femoris go to?
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To the quadrate tubercle of the intertrochanteric crest of the femur
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What is the function of obturator internus?
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Lateral rotation and stabilization of the hip
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Where does obturator internus go from?
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Obturator internus goes from the inner surface of the obturator membrane and the adjacent anterolateral pelvic wall
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Where does obturator internus go to?
|
Obturator internus goes to the greater trochanter of the femur above and in front of the intertrochanteric fossa
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What is the function of gemellus superior and inferior?
|
Assists obturator internus
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Where does gemellus superior go from?
|
Gemellus superior goes from the dorsal surface of the ischial spine.
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Where does gemellus superior go to?
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Gemellus superior goes to the superior borders of obturator internus
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Where does gemellus inferior go from?
|
Gemellus inferior goes from the upper part of the ischial tuberosity
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Where does gemellus inferior go to?
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Gemellus inferior goes to the inferior borders of obturator internus
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What is the function of obturator externus?
|
Lateral rotator of the thigh
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Where does obturator externus go from?
|
Obturator externus goes from the outer surface of the obturator membrane and the ischiopubic ramus
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Where does obturator externus go to?
|
Obturator externus goes to the trochanteric fossa of the femur
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How many muscles are there in the front of the thigh and what are they?
|
There are 9 muscles
1. Iliacus 2. Psoas major 3. Tensor fasciae latae 4. Sartorius 5. Rectus femoris 6. Vastus lateralis 7. Vastus medialis 8. Vastus intermedias 9. Articularis genus |
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What is the function of iliacus?
|
Flexor of the hip, assisting psoas major
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Where does iliacus go from?
|
Iliacus goes from the upper two-thirds of the iliac fossa in the lower abdomen
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Where does iliacus go to?
|
Iliacaus goes to the psoas tendon and the femur below and in front of the lesser trochanter
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What is the function of psoas major?
|
Flexor of the hip
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Where does psoas go from?
|
Psoas goes from the sides of the lumbar vertebrae and intervertebral discs
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Where does psoas go to?
|
Psoas goes to the lesser trochanter of the femur
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What is the function of tensor fasciae latae?
|
Extensor of the knee and lateral rotator of the leg
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Where does tensor fasciae latae go from?
|
Tensor fasciae latae goes from the anterior 5cm of the outer lip of the iliac crest
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Where does tensor fasciae latae go to?
|
Tensor fasciae latae goes to the iliotibial tract
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What is the function of sartorius?
|
Flexor, adductor and lateral rotator of the hip
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Where does sartorius go from?
|
Sartorius goes from the anterior superior iliac spine
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Where does sartorius go to?
|
Sartorius goes to the upper part of the medial surface of the shaft of the tibia in front of gracilis and semitendinosus
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What is the function of rectus femoris?
|
Flexor of the hip and extensor of the knee
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Where does rectus femoris go from?
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Rectus femoris goes from the anterior inferio iliac spine (straight head) and the ilium above the rim of the acetabulum (reflected head)
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Where does rectus femoris go to?
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Rectus femoris goes to the base of the patella
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What is the function of vastus lateralis?
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Extensor of the knee
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Where does vastus lateralis go from?
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Vastus lateralis goes from the upper part of the intertrochanteric line of the femur, anterior and inferior borders of the greater trochanter, lateral lip of the gluteal tuberosity and the upper part of the linea aspera
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Where does vastus lateralis go to?
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Vastus lateralis goes to the lateral border of the patella and the quadriceps tendon
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What is the function of vastus medialis?
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Extensor of the knee
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Where does vastus medialis go from?
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Vastus medialis goes from the lower part of the intertrochanteric line of the femur, the spiral line, the linea aspera, the upper part of the medial supracondylar line and the tendon of adductor magnus
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Where does vastus medialis go to?
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Vastus medialis goes to the medial border of the patella and the quadriceps tendon
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What is the function of vastus intermedius?
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Extension of the knee
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Where does vastus intermedius go from?
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Vastus intermedius goes from the anterior and lateral surfaces of the upper two-thirds of the shaft of the femur
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Where does vastus intermedius go to?
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Vastus intermedius goes to the deep part of the quadriceps tendon
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What is the function of the articularis genus?
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Retraction of the bursa as the knee extends
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Where does articular genus goes from?
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Articular genus goes from the anterior surface of the femur below vastus intermedius
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Where does articularis genus go to?
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Articularis genus goes to the apex of the suprapatellar bursa
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How many muscles are there in the medial thigh and what are they?
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There are 5 muscles
1. Pectineus 2. Gracilis 3. Adductor brevis 4. Adductor longus 5. Adductor magnus |
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What is the function of pectineus?
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Flexor, adductor and lateral rotator of the thigh
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Where does pectineus go from?
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The pectineus goes from the pectineal line of the pubis and bone in front of the line
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Where does pectineus go to?
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Pectineus goes to the femur on a line from the lesser trochanter to the linea aspera
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What is the function of gracilis?
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Flexor, adductor and medial rotator of the thigh
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Where does gracilis go from?
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Gracilis goes from the body of the pubis and ischiopubic ramus
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Where does gracilis go from?
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Gracilis goes from the body of the pubis and ischiopubic ramus
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Where does gracilis go to?
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Gracilis goes to the upper part of the medial surface of the shaft of the tibia between sartorius and semitendinosus
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What is the function of adductor brevis?
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Adductor of the thigh
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Where does adductor brevis go from?
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Adductor brevis goes from the body and inferior ramus of the pubis
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Where does adductor brevis go to?
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Adductor brevis goes to the shaft of the femur on a line from the lesser trochanter to the linea aspera and to the upper part of the linea
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What is the function of adductor longus?
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Adductor of the thigh
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Where does adductor longus go from?
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Adductor longus goes from the front of the pubis
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Where does adductor longus go to?
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Adductor longus goes to the middle part of the linea aspera
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What is the function of adductor magnus?
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Adductor and lateral rotator of the thigh
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Where does adductor magnus go from?
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Adductor magnus goes from the lower lateral part of the ischial tuberosity and the ischiopubic ramus
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Where does adductor magnus go to?
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Adductor magnus goes to the shaft of the femur from the gluteal tuberosity along the linea aspera to the medial supracondylar line and to the adductor tubercle
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How many muscles are there at the back of the thigh and what are they?
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There are three
1. Biceps femoris 2. Semitendinosus 3. Semimembranosus |
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What is the function of biceps femoris?
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Flexion and lateral rotation of the knee and extension of the hip
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Where does biceps femoris go from?
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Biceps femoris goes from the medial facet of the ischial tuberosity with semimembranosus (long head) and from the linea aspera and lateral supracondylar line of the femur (short head)
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Where does biceps femoris go to?
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Biceps femoris goes to the head of the fibula
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What is the function of semitendinosus?
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Flexion and medial rotation of th knee and extension of the hip
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Where does semitendinosus go from?
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Semitendinosus goes from the medial facet of the ischial tuberosity with the long head of biceps
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Where does semitendinosus go to?
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Semitendinosus goes to the upper part of the subcutaneous surface of the tibia behind gracilis
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What is the function of semimembranosus?
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Flexion and medial rotation of the knee and extension of the hip
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Where does semimembranosus go from?
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Semimembranosus goes from the lateral facet of the ischial tuberosity
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Where does semimembranosus go to?
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Semimembranosus goes to the groove on the back of the medial condyle of the tibia with expansions forming the oblique popliteal ligament and the fascia over popliteus
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How many muscles are there in the front of the leg and what are they?
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There are four muscles
1. Tibialis anterior 2. Extensor hallucis longus 3. Extensor digitorum longus 4. Peroneus tertius |
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What is the function of tibialis anterior?
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Dorsiflexion and inversion of the foot
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Where does tibialis anterior go from?
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The tibialis anterior goes from the upper two-thirds of the lateral surface of the tibia and adjoining part of the interosseous membrane
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Where does tibialis anterior go to?
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Tibialis anterior goes to the medial surface of the medial cuneiform and base of the first metatarsal
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What is the function of extensor hallucis longus?
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Extension of the great toe and dorsiflexion of the foot
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Where does extensor hallucis longus go from?
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Extensor hallucis longus goes from the middle third of the medial surface of the fibula
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Where does extensor hallucis longus go to?
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Extensor hallucis longus goes to the base of the distal phalanx of the great toe
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What is the function of extensor digitorum longus?
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Extension of the second to fifth toes and dorsiflexion of the foot
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Where does extensor digitorum longus go from?
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Extensor digitorum longus goes from the upper two-thirds of the medial surface of the fibula
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Where does extensor digitorum longus go to?
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Extensor digitorum longus goes to the four lateral toes by the dorsal digital expansions attached to the middle and distal phalanges
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What is the function of peroneus tertius?
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Dorsiflexion and eversion of the foot
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Where does peroneus tertius go from?
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Peroneus tertius goes from the lower third of the medial surface of the fibula, continuous with extensor digitorum longus
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Where does peroneus tertius go to?
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Peroneus tertius goes to the shaft of the fifth metatarsal
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What is the muscle on the dorsum of the foot?
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Extensor digitorum brevis
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Where does extensor digitorum brevis go from?
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Extensor digitorum brevis goes from the upper surface of the calcaneus
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Where does extensor digitorum brevis go to?
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Extensor digitorum brevis goes to the base of the proximal phalanx of the great toe (as extensor hallucis brevis) and the dorsal digital expansions of the second to fourth toes
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What is the function of extensor digitorum brevis?
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Extension of the first to fourth toes
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How many muscles are there on the lateral side of the leg and what are they?
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There are two muscles
1. Peroneus longus 2. Peroneus brevis |
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What is the function of peroneus longus?
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Plantarflexion and eversion of the foot
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Where does peroneus longus go from?
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Peroneus longus goes from the upper two-thirds of the fibula
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Where does peroneus longus go to?
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Peroneus longus goes to the lateral sides of the medial cuneiform and base of the first metatarsal
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What is the function of peroneus brevis?
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Plantarflexion and eversion of the foot
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Where does peroneus brevis go from?
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Peroneus brevis goes from the lower two thirds of the lateral surface of the fibula
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Where does peroneus brevis go to?
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Peroneus brevis goes to the tuberosity of the base of the fifth metatarsal
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How many muscles are there at the back of the leg and what are they?
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There are 7 muscles at the back of the leg
1. Gastrocnemius 2. Soleus 3. Plantaris 4. Popliteus 5. Tibialis posterior 6. Flexor hallucis longus 7. Flexor digitorum longus |
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What is the function of gastrocnemius?
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Plantarflexion of the foot and flexion of the knee
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Where does gastrocnemius go from?
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The medial head goes from the upper posterior part of the medial condyle of the femur. The lateral head goes from the lateral surface of the lateral condyle of the femur
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Where does gastrocnemius go to?
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Gastrocnemius goes to the middle of the posterior surface of the calcaneus by the tendo calcaneus in association with soleus
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What is the function of soleus?
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Plantarflexion of the foot
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Where does soleus go from?
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Soleus goes from the soleal line and upper part of the medial border of the tibia, a tendinous arch over the popliteal vessels and tibial nerve and the upper part of the posterior surface of the fibula
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Where does soleus go to?
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Soleus goes to the tendo calcaneus with gastrocnemius
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What is the function of plantaris?
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Plantarflexion of the foot and weak flexion of the knee
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Where does plantaris go from?
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Plantaris goes from the lateral supracondylar line of the femur
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Where does plantaris go to?
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Plantaris goes to the calcaneus on the medial side of the tendocalcaneus
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What is the function of popliteus?
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Lateral rotation of the femur on the fixed tibia (or medial rotation of the tibia on the fixed femur). Pulls lateral meniscus backward during flexion of the knee
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Where does popliteus go from?
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Popliteus goes from the back of the tibia above the soleal line
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Where does popliteus go to?
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Popliteus goes to the outer surface of the lateral epicondyle of the femur
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What is the function of tibialis posterior?
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Plantarflexion and inversion of the foot
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Where does posterior tibialis go from?
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Tibialis posterior goes from the posterior surface of the interosseous membrane and adjacent posterior surfaces of the tibia and fibula
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Where does posterior tibialis go to?
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Posterior tibialis goes to the tuberosity of the navicular with slips to other tarsal bones (except the talus) and the middle three metatarsals
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What is the function of flexor hallucis longus?
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Plantarflexion of the great toe and foot
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Where does flexor hallucis longus go from?
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Flexor hallucis longus goes from the lower two thirds of the posterior surface of the fibula
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Where does flexor hallucis longus go to?
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Flexor hallucis longus goes to the plantar surface of the base of the distal phalanx of the great toe
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What is the functioin of flexor digitorum longus?
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Plantarflexion of the four lateral toes and the foot
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Where does flexor digitorum longus go from?
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Flexor digitorum longus goes from the medial part of the posterior surface of the tibia below the soleal line
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Where does flexor digitorum longus go to?
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Flexor digitorum longus goes to the four lateral toes by a tendon to each, reaching the plantar surface of the base of the distal phalanx
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How many muscles are in the first layer of the foot and what are they?
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There are three muscles
1. Abductor hallucis 2. Flexor digitorum brevis 3. Abductor digiti minimi |
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What is the function of abductor hallucis?
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Abduction and plantarflexion of the great toe
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Where does abductor hallucis go from?
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Abductor hallucis goes from the medial process of the calcanean tuberosity and the plantar aponeurosis
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Where does abductor hallucis go to?
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Abductor hallucis goes to the medial side of the proximal phalanx of the great toe
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What is the function of flexor digitorum brevis?
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Plantarflexion of the four lateral toes
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Where does flexor digitorum brevis go from?
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Flexor digitorum brevis goes from the medial process of the calcanean tuberosity and the deep surface of the central part of the plantar aponeurosis
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Where does flexor digitorum brevis go to?
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Flexor digitorum brevis goes to the lateral four toes by a tendon to each. The tendon divides into two slips (to allow the flexor digitorum longus tendon to pass between them) which are attached to the sides of the middle phalanx
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What is the function of abductor digiti minimi?
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Abduction and plantarflexion of the fifth toe
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Where does the abductor digiti minimi go from?
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Abductor digiti minimi goes from the lateral and medial processes of the calcanean tuberosity and the plantar aponeurosis
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Where does abductor digiti minimi go to?
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Abductor digiti minimi goes to the lateral side of the base of the proximal phalanx of the fifth toe (with flexor digiti minimi brevis)
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How many muscles are in the second layer of the foot and what are they?
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There are two muscles
1. Quadratus plantae 2. Lumbricals |
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What is the function of quadratus plantae?
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Assistance with plantarflexion of the four lateral toes
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Where does the quadratus plantae go from?
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The quadratus plantae goes from the concave medial surface of the calcaneus and from the plantar surface of the calcaneus in front of the lateral process of the tuberosity
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Where does quadratus plantae go to?
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Quadratus plantae goes to the lateral border of flexor digitorum longus before the division into four tendons
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What is the function of the lumbricals?
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Plantarflexion at the four lateral MTPJs and extension at the interphalangeal joints
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Where does the first lumbrical go from?
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The first lumbrical goes from the medial border of the first tendon of flexor digitorum longus
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Where does the first lumbrical go to?
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The first lumbrical goes to the medial sides of the dorsal digital expansions of the tendons of extensor digitorum longus
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Where do the 2nd, 3rd and 4th lumbricals go from?
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The 2nd, 3rd and 4th lumbricals go from the four adjoining tendons of flexor digitorum longus
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Where do the 2nd, 3rd and 4th lumbricals go to?
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The 2nd, 3rd and 4th lumbricals go to the medial sides of the dorsal digital expansions of the tendons of extensor digitorum longus
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How many muscles are in the third layer of the foot and what are they?
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There are three muscles in the third layer of the foot
1. Flexor hallucis brevis 2. Adductor hallucis 3. Flexor digiti minimi brevis |
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What is the function of flexor hallucis brevis?
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Plantarflexion of the MTPJ of the great toe
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Where does flexor hallucis brevis go from?
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Flexor hallucis brevis goes from the plantar surface of the cuboid and lateral cuneiform
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Where does flexor hallucis brevis go to?
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Flexor hallucis brevis goes by a tendon to each side of the base of the proximal phalanx of the great toe, the medial tendon joining with that of abductor hallucis and the lateral with adductor hallucis. There is a sesamoid bone in each tendon
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What is the function of adductor hallucis?
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Adduction of the great toe
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Where does adductor hallucis go from?
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The oblique head goes from the bases of the second, third and fourth metatarsals and the transverse head from the plantar MTP ligaments of the third, fourth and fifth toes
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Where does adductor hallucis go to?
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Adductor hallucis goes to the lateral side of the base of the proximal phalanx of the great toe with part of flexor hallucis brevis
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What is the function of flexor digiti minimi brevis?
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Plantarflexion of the MTPJ of the 5th toe
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Where does flexor digiti minimi brevis go from?
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Flexor digiti minimi brevis goes from the plantar surface of the base of the 5th metatarsal
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Where does flexor digiti minimi brevis go to?
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Flexor digiti minimi brevis goes to the lateral side of the base of the proximal phalanx of the 5th toe with abductor digiti minimi
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How many muscles are there in the fourth layer of the foot and what are they?
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There are seven
1. Dorsal interossei (four) 2. Plantar interossei (three) |
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What is the function of the four dorsal interossei?
|
Plantarflexion of the MTPJs and extension of the IPJs of the 2nd, 3rd and 4th toes and abduction of the same toes
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Where do the four dorsal interossei go from?
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The four dorsal interossei go from the adjacent sides of the bodies of the metatarsals
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Where do the four dorsal interossei go to?
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The four dorsal interossei go to the bases of proximal phalanges and the dorsal digital expansions. 1st and 2nd to the medial and lateral sides of the 2nd toe; 3rd and 4th to the lateral sides of the 3rd and 4th toes
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What is the function of the three plantar interossei?
|
Plantarflexion of the MTPJs and extension of the IPJs of the 3rd, 4th and 5th toes and adduction of the same toes
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Where do the three plantar interossei go from?
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The three plantar interossei go from the bases and medial sides of the 3rd, 4th and 5th metatarsals
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Where do the three plantar interossei go to?
|
The three plantar interossei go to the medial sides of the bases of the proximal phalanges and dorsal digital expansions of the corresponding toes
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What nerves go down the front of the leg?
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1. Femoral nerve
2. Saphenous nerve 3. Common peroneal nerve 4. Superficial peroneal nerve 5. Deep peroneal nerve |
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What nerves go down the back of the leg?
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1. Sciatic nerve
2. Tibial nerve 3. Sural nerve 4. Medial plantar nerve 5. Lateral plantar nerve |
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What are the arteries in the leg?
|
1. External iliac artery
2. Femoral artery 3. Profunda femoris artery 4. Medial and lateral circumflex femoral arteries 5. Popliteal artery 6. Genicular arteries 7. Posterior tibial artery 8. Peroneal artery 9. Anterior tibial artery 10. Arcuate artery (dorsum) 11. Plantar arch 12. Dorsalis pedis artery |
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What are the deep and superficial veins of the lower limb?
|
1. External iliac vein
2. Femoral vein 3. Profunda femoris vein 4. Popliteal vein 5. Knee veins 6. Peroneal vein 7. Anterior tibial vein 8. Posterior tibial vein 9. Great saphenous vein 10. Small saphenous vein |
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What functional test would you use to test weightbearing dorsiflexion and anterior impingement syndromes?
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The lunge test
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What would the lunge test be used to tes?
|
Weightbearing dorsiflexion and anterior impingement syndromes
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What is used to test tibialis posterior dysfunction syndrome?
|
The single limb heel raise test
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What does the single limb heel raise test test?
|
Posterior tibialis dysfunction syndrome
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What is Stieda's process?
|
It is the posterior process of the talus
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What is the posterior process of the talus called?
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Stieda's process
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What order are the three parts of the lateral ligament usually damaged?
|
1. The anterior talofibule ligament
2. The calcaneofibular ligament 3. The posterior talofibular ligament |
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What are the three grades used to grade lateral ligament injuries?
|
1. Grade 1 = minor ATFL tear with pain but no laxity
2. Grade 2 = painful if stressing ligament with laxity but firm end-point 3. Grade 3 = gross laxity without discernible end-point |
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What Grade is a minor ATFL tear with pain but no laxity?
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Grade 1
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What Grade is a minor ATFL tear with pain but no laxity?
|
Grade 1
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What Grade is a painful ligament but when stressing is lax but has a firm end-point
|
Grade II
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What Grade is a gross laxity without discernible end-point lateral ligament?
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Grade 3
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Where is the interosseous talocalcaneal ligament situated?
|
In the sinus tarsi
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What ligament is situated in the sinus tarsi?
|
The interosseous talocalcaneal ligament situated
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What are the angles of the axes of the subtalar joint?
|
1. 42 degrees from the transverse plane
2. 45 degrees from the frontal plane 3. 16 degrees from the sagittal plane |
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If the distal fibular is tender what could this be indicative of?
|
Fracture
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If the lateral malleolus is tender what could this be indicative of?
|
Fracture
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If the lateral ligaments are tender what could this be indicative of?
|
Anterior talofibular ligament/calcaneofibular ligament (ATFL/CFL) sprain due to forced inversion/plantarflexion. Complete tear of ATFL, CFL and posterior talofibular ligament (PTFL) follows an ankle fracture
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If the lateral aspect of the talus is tender what could this be indicative of?
|
Fracture to lateral process of talus
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If the posterior aspect of talus is tender what could this be indicative of?
|
Fracture to posterior process of talus or os trigonum fracture
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If the peroneal tendon is tender what could this be indicative of?
|
Peroneal tendonitis due to excessive eversion, peroneal dislocation due to forced passive dorsiflexion and tearing of peroneal retinaculum or peroneal rupture
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If the base of the 5th metatarsal is tender what could this be indicative of?
|
Avulsion fracture due to inversion injury
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If the anterior joint line of the ankle is tender what could this be indicative of?
|
Articular damage (OA)
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If the dome of the talus is tender what could this be indicative of?
|
Osteochondral fracture associated with compressive component of inversion injury (landing from a jump)
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If the tibialis anterior is tender what could this be indicative of?
|
Tibialis anterior tendinitis due to overuse of ankle dorsiflexors secondary to restriction in joint range of motion
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If the posterior medial malleolus is tender what could this be indicative of?
|
Entrapment of posterior tibial nerve (tarsal tunnel syndrome) due to inversion injury or excessive pronation
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If the medial malleolus is tender what could this be indicative of?
|
Stress fracture
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If the medial (deltoid) ligament is tender what could this be indicative of?
|
Ligament sprain associated with fractured medial malleolus, talar dome
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If the tibialis posterior tendon is tender what could this be indicative of?
|
Tibialis posterior tendinitis (pain is exacerbated by excessive eversion)
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If the sustentaculum tali is tender what could this be indicative of?
|
Flexor hallucis longus tendinitis (pain aggravated by resisted flexion of hallux or full dorsiflexion of hallux)
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If the sinus tarsi is tender what could this be indicative of?
|
Excessive subtalar joint pronation or ankle sprain
|
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If the anterior inferior talofibular ligament is tender what could this be indicative of?
|
The anterior inferior talofibular ligament (AITFL) is damaged in more severe ankle injuries. Occasionally associated with malleolar fractures
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What is abnormal pronation?
|
Excessive STJ pronation during contact phase and/or STJ pronation occurring when the STJ should be supinating during midstance and propulsion.
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|
What abnormal plane motion in the foot affects the ankle and forefoot?
|
A large degree of frontal plane motion (inversion/eversion)
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What part of the lower limb does a large degree of frontal plane motion affect?
|
Inversion/eversion
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What abnormal plane motion in the tibia affects the knee and leg?
|
Transverse plane tibial rotation (tibial torsion)
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What part of the lower limb does a large degree of transverse plane tibial rotation affect?
|
It is thought to affect the leg and the knee
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|
What are the 7 indicators of abnormal pronation?
|
1. More than 6 degrees between the relaxed calcaneal stance position (RCSP) and the neutral calcaneal stance position (NCSP)
2. Medial bulging of the talar head or 'midtarsal break' - quantified using the navicular drift technique (Menz 1998) 3. lowering of the medial longitudinal arch - quantified using the navicular drift technique (Mueller et al 1993) 4. More than 4 degrees eversion of the calcaneus 5. Helbing's sign (medial bowing of the tendo Achilles) 6. Abduction of the foot at the MTJ (concavity of lateral border of foot) 7. apropulsive gait. Four or more of these indicates abnormal pronation |
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What are the 7 conditions which may lead to abnormal pronation?
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1. Internal or external torsion of the leg/thigh
2. Tibial (genu) valgum/varum 3. Coxa vara/valga 4. Ankle equinus 5. Rearfoot varus 6. Inverted forefoot 7. Everted forefoot |
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What is the action of the plantarflexors?
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The posterior group of muscles plantarflex the foot at the ankle but may also restrict the amount of dorsiflexion at the ankle
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What is the test to assess normal action of the Achilles tendon?
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The foot should plantarflex when the calf muscle is squeezed
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Is plantaris present in everyone?
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No
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What could be indicative of a painful medial swelling over the posterior aspect of the calcaneus at its insertion near the Achilles tendon?
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Rupture of plantaris
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What are the signs that plantaris has ruptured?
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A painful medial swelling over the posterior aspect of the calcaneus at its insertion near the Achilles tendon?
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What are the main invertors of the foot?
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Tibialis posterior and tibialis anterior
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What is the main action of tibialis posterior and tibialis anterior?
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They are the main invertors of the foot
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What role do tibialis posterior and tibialis anterior play during gait?
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They play an important role in resupinating the foot during midstance and propulsion
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What are the main dorsiflexors of the foot?
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The long extensors and tibialis anterior
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How should the dorsiflexors be tested?
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The patient should be asked to dorsiflex the ankle with the foot in inversion against resistance
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How much stronger are the plantarflexors than the dorsiflexors in the foot?
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About 4.5 times stronger
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What happens if the dorsiflexors of the foot are weak?
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The foot is held in a plantarflexed position as the plantarflexors have a mechanical advantage
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What are the everters of the foot?
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The peronei
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What is the action of the peronei?
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Eversion of the foot
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Which are the stronger, everters or inverters of the foot?
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The inverters of the foot
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What happens to the peroneals in tarsal coalition?
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They are in tonic spasm
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What can be done to differentiate between tarsal coalition and muscle spasm?
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An LA can be administered.
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What is the MTJ comprised of?
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The talonavicular joint and the calcaneocuboid joint
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What is the talonavicular joint and the calcaneocuboid joint called?
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The MTJ
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What is the MTJ also known as?
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The transtarsal or Chopart's joint
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What is the transtarsal joint or Chopart's joint known as?
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The MTJ
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What is the articulation between the forefoot and the rearfoot called?
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The MTJ
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What is the MTJ joining?
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The rearfoot and the midfoot
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How many axes does the MTJ have and what are they?
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Two, longitudinal and oblique axis
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What motion is provided by the longitudinal axis?
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Frontal plane motion
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How is frontal plane motion facilitated in the MTJ?
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It is facilitated by the ball and socket joint of the talonavicular articulaton
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What plane of motion is caused by the ball and socket joint of the talonavicular articulation?
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Frontal plane of motion
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What motion is provided by the oblique axis?
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It primarily produces transverse plane and sagittal plane motion
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How is transverse plane and sagittal plane motion facilitated in the MTJ?
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By involvement of both talonavicular and calcaneocuboid joints
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What plane of motion is caused by the involvement of both talonavicular and calcaneocuboid joints?
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Transverse plane of motion
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If there are limitations at the ankle, how could the foot compensate for this?
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The foot compensates at the oblique axis of the MTJ
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What axis does compensation occur in the MTJ if there are limitations at the ankle?
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At the oblique axis
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What are the three functions of the MTJ?
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1. Assists in reducing impact forces
2. Helps prepare the foot for propulsion 3. It accommodates walking on uneven terrain without affecting the rearfoot |
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What happens to the forefoot and rearfoot in a normally functioning MTJ?
|
The forefoot inverts while the heel remains vertical
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How is joint range of motion assessed at the MTJ?
|
The practitioner must stabilise the STJ and prevent any motion occurring at this joint by firmly holding the heel with one hand and holding the foot just distal to the MTJ with the other. The MTJ should then be moved in the sagittal, transverse and frontal planes. There should be most motion in the sagittal and transverse planes and minimal motion in the frontal plane
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Where should most of the motion be in the MTJ?
|
There should be most motion in the sagittal and transverse planes and minimal motion in the frontal plane.
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Which metatarsals have independent axes of motion and what planes are these ranges of motion?
|
The 1st and 5th metatarsals have independent axes of motion and produce triplanar motion
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Which metatarsal has the least motion and why?
|
The second metatarsal has the least motion because it is firmly anchored to the intermediate cuneiform
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Which metatarsal has the least amount of motion, the third or fourth?
|
The third metatarsal
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What planes of motion do the 2nd, 3rd and 4th metatarsals move in?
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The sagittal plane
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Why is it important that the first metatarsal should be able to plantarflex?
|
So that the medial side of the foot makes ground contact during gait and the 1st MTPJ can dorsiflex during propulsion
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What is the normal number of mm you would find when dorsiflexing and plantarflexing the first ray?
|
10mm in either direction
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What is the term used when there is lack of plantarflexion at the first ray?
|
Metatarsus primus elevatus
|
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What is metatarsus primus elevatus?
|
Lack of plantarflexion at the first ray
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What is a short first metatarsal associated with?
|
Development of hallux valgus
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What is a long metatarsal associated with?
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Hallux rigidus
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What 3 conditions does shortening of a lesser metatarsal cause?
|
1. Intractable plantar keratosis
2. Metatarsalgia 3. Hammer toe deformity |
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What happens to the 1st and 5th metatarsals in a normal position when they are moved?
|
They exhibit equal motion above and below the 2nd and 4th metatarsal of 10-20mm(5-10mm in each direction)
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What problems does metatarsus primus elevatus cause and what is its differential diagnosis
|
Reduces ability of first metatarsal to bear weight and overloads central (dorsiflexed 1st metatarsal) metatarsals. DDx is forefoot varus. Shows limited plantarflexion and cannot be reduced below level of 2nd metatarsal
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What is the differential diagnosis for metatarsus primus elevatus?
|
Forefoot varus
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What does a flexible plantarflexed first metatarsal look like?
|
The first metatarsal may appear pronounced on the plantar surface of the foot with a cleft between the 1st and 2nd metatarsal heads. Most of the movement is in the plantar direction. Loading the metatarsal head produces reduction of the position
|
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What does a rigid plantarflexed first metatarsal look like?
|
The first metatarsal cannot be reduced at all from its plantarflexed position. The forefoot tends to rotate in inversion during weightbearing and this affects rearfoot function
|
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Where are the MTPJs?
|
They are the joints between the metatarsals and the proximal phalanges
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What motion do the MTPJs produce?
|
Sagittal plane motion
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What must happen at the MTPJs to facilitate toe-off?
|
Dorsiflexion
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What degrees of dorsiflexion and plantarflexion should the first MTPJ have?
|
70-90 degrees dorsiflexion and 20 degrees plantarflexion
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What accounts for at least 15 degrees of dorsiflexion of the MTPJ at rest?
|
The declined angle of the first ray
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How many degrees dorsiflexion does the declined angle of the first ray give the 1st MTPJ at rest?
|
At least 15 degrees
|
|
|
What is another term for trigger toe?
|
Hallux extensus
|
|
|
What is another term for hallux extensus?
|
Trigger toe
|
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What sort of foot is hallux extensus (trigger toe) associated with?
|
Pes cavus
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What does a hallux extensis (trigger toe) look like?
|
It is where the proximal phalanx is abnormally dorsiflexed
|
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What is the term used where the proximal phalanx is abnormally dorsiflexed?
|
Hallux extensus or trigger toe
|
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What two pathologies can cause restriction of the movement of the MTPJs?
|
1. Osteophytes
2. Loose bodies or articular damage eg osteochondritis dissecans |
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|
What are two effects of Freiberg's disease?
|
1. Enlargement of the metatarsal head
2. Early osteoarthritis changes Usually affects the 2nd or 3rd metatarsal |
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What 7 features should be assessed when looking at the alignment of the leg and foot?
|
1. Presence of genu varum/valgum
2. Malleolar torsion 3. Rearfoot to forefoot alignment 4. Arch height 5. Metatarsal formula 6. Toe position 7. Foot length |
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How do you assess the presence of lower limb varus or valgus?
|
The patient lies supine with the knees extended. The practitioner takes hold of the ankles and brings the legs together. If there is a difference of more than 5cm between the knees genu varum is suspected. If it is impossible to bring the malleoli together a genu valgum is present. Obesity may prevent the knees and malleoli being brought together
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What two features can torsion of the leg affect?
|
1. In/out toeing
2. The position of the patellae |
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|
How can tibial torsion be tested?
|
By assessing the relationship of the tibia and fibula malleoli to each other.
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How is malleolar torsion assessed?
|
The patient lies supine with the legs extended on the couch. The femoral condyles should be parallel to the couch. The practitioner bends down until her eyes are level with the malleoli and observes the relationship of the malleoli to each other. Place the thumb of each hand anterior to the malleoli. The medial malleoli should be one thumb's thickness anterior to the lateral malleoli
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In a normal forefoot to rearfoot position what should happen?
|
The plantar plane of the forefoot should be parallel to the plantar plane of the rearfoot.
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What 4 conditions can an inverted forefoot be due to?
|
1. True forefoot varus
2. Forefoot supinatus 3. Dorsiflexed 1st ray (fixed/flexible) 4. Plantarflexed 5th ray (fixed/flexible) |
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|
What does the presence of a true forefoot varus lead to?
|
A very flat foot with no longitudinal arch
|
|
|
What is forefoot supinatus?
|
It is an acquired soft tissue deformity due to abnormal pronation of the rearfoot. The forefoot is held in an inverted position because of soft tissue contraction
|
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How can a forefoot supinatus and forefoot varus be differentiated?
|
Get the patient to stand. The foot is put into neutral. With both conditions the medial side of the foot should not be in ground contact. Pressure is applied to the dorsum of the first ray. With a supinatus there should be some give and the first ray should plantarflex. With forefoot varus any pressure on the dorsum of the first ray should cause the foot to tilt inwards and the fifth ray to leave ground contact
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|
What three conditions may a forefoot valgus be due to?
|
1. Forefoot valgus
2. Plantarflexed first ray (fixed/flexible) 3. Dorsiflexed 5th ray (fixed/flexible) |
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|
What is more common, plantarflexed 1st ray and metatarsus primus elevatus or forefoot varus or forefoot valgus?
|
Plantarflexed first ray and metatarsus primus elevatus
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What does the foot look like non weightbearing in metatarsus adductus?
|
The lateral border of the foot is banana-shaped
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Which is usually the longest and the shortest metatarsal?
|
The second metatarsal is the longest and the shortest is the 5th metatarsal
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|
What are two typical metatarsal formulae?
|
2>1>3>4>5 or 2>3>1>4>5
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Why is it important that the 1st metatarsal is shorter than the 2nd metatarsal?
|
To allow normal function during propulsion. When the 1st MTPJ dorsiflexes the first ray plantarflexes on to the sesamoids. If the first metatarsal is as long as the second this cannot occur and as a result the 1st MTPJ is not able to dorsiflex resulting in overloading of the other metatarsal heads commonly the second
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How much does foot length and width increase when weightbearing?
|
It can increase up to 1 and a half shoe size
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If a foot increases by 2-3 shoe sizes weight bearing what would this indicate?
|
It would indicate a mobile foot which excessively pronates during gait
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If a foot did not increase in size at all during weightbearing what would this indicate?
|
It would indicate a rigid foot
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|
What 9 features should be looked at during a static weightbearing examination of stance?
|
1. Head
2. Shoulder 3. Spine 4. Pelvis 5. Angle and base of gait 6. Relaxed and neutral calcaneal stance position 7. Longitudinal arch 8. Toes 9. Foot width and length |
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|
How can you tell the difference between a true scoliosis and a functional scoliosis?
|
Ask the patient to bend forward. If the spine is still deviated when the hips are flexed a true scoliosis exists. If vertebrae alignment improves it is likely to be a functional scoliosis.
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|
What is a normal angle and base of gait?
|
It is when the feet are slightly abducted (c 13 degrees from the midline of the body) and the distance between the malleoli is c 5cm
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|
What is frontal plane deformity of the legs?
|
Genu valgum or genu varum
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|
|
When will the gap between the malleoli greater, genu valgum or genu varum?
|
Genu valgum
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|
When will the gap between the malleoli be lesser, genu valgum or genu varum?
|
Genu varum
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|
|
What two conditions can excessive internal torsion lead to?
|
1. An adducted base of gait
2. Squinting patellae |
|
|
What condition can excessive external rotation lead to?
|
An abducted base of gait
|
|
|
What is an indicator of STJ motion when weightbearing?
|
Relaxed calcaneal position
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|
|
What does relaxed calcaneal position indicate?
|
STJ motion when weightbearing
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|
What are the normal limits seen between RCSP and NCSP?
|
0-4 degrees
|
|
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What does 0-4 degrees signify between RCSP and NCSP?
|
Normal limits
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|
|
What does 0-4 degrees signify between RCSP and NCSP?
|
Normal limits
|
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|
What does 4-7 degrees signify between RCSP and NCSP?
|
Moderate pronation requiring treatment if symptomatic or a cause for concern
|
|
|
What would 8 degrees or above between RCSP and NCSP signify?
|
Marked pronation
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|
|
What are four causes of an abnormal everted RCSP
|
1. Compensated forefoot varus
2. Compensated ankle equinus 3. Tibial valgum/varum 4. Internal/external torsion of the leg |
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|
If the calcaneus is not everted during RCSP what could this indicate?
|
If the calcaneus is not everted it does not mean that abnormal pronation is not occurring. Compensation for a rearfoot varus involves excessive STJ pronation in order to bring the medial tubercle of the heel into ground contact and provide shock absorption during contact phase of gait. A 10 degree rearfoot varus will require 10 degrees of pronation in order to bring the heel into a vertical position. Although excessive pronation has occurred, the RCSP will appear vertical and not everted.
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|
What could be five causes of an inverted RCSP?
|
1. Neurological problem
2. An uncompensated varus deformity affecting the rear or forefoot, 3. Subtalar joint damage 4. Tonic spasm of the inverters of the foot 5. Presence of a plantarflexed first ray |
|
|
What does NCSP and RCSP measure?
|
It only measures frontal plane motion (inversion/eversion)
|
|
|
What four factors affect the shape of the longitudinal arch?
|
1. The rearfoot/forefoot position
2. The declination angles of the metatarsals 3. The inclination angle of the calcaneus 4. The tone and activity of intrinsic and extrinsic muscles |
|
|
What is a good test of longitudinal arch height?
|
Asking the patient to stand on tiptoe and the position of the foot arch should be noted. With rigid flat feet the arch height does not increase when the patient stands on tip toe. With a flexible flat foot the arch height increases.
|
|
|
What two conditions can cause rigid flat feet?
|
1. Bony coalitions (synostoses)
2. Contractures due to muscle imbalance or neurological paralysis with subsequent soft tissue contractures |
|
|
What are the three main causes of lesser toe deformities (lesser hammer toe syndrome)?
|
1. Flexor stabilisation
2. Flexor substitution 3. Extensor substitution |
|
|
What does the foot look like when there is flexor stabilisation?
|
A contraction (hammering) of all the lesser toes with an associated adductovarus deformity of the 5th and sometimes 4 toes (quadratus plantae losing its mechanical advantage)
|
|
|
When does flexor stabilisation occur and what muscles in the foot are involved?
|
Flexor stabilisation can occur in an excessively pronated foot during late stance phase when flexor digitorum longus and/or flexor digitorum brevis have gained mechanical advantage over the interossei muscles.
|
|
|
Why does flexor stabilisation occur and what muscles are involved?
|
Pronation of the STJ allows unlocking of the midtarsal joint resulting in forefoot hypermobility. The flexors fire earlier and longer than normal in an attempt to stabilise the forefoot. These muscles are ineffective at stabilising the forefoot but effective in overpowering the small interosseous muscles causing hammering or clawing of the toes.
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|
|
What is flexor substitution?
|
A straight contraction of all the lesser toes with no adductovarus of the fourth and fifth toes.
|
|
|
When does flexor substitution occur and what muscles are involved?
|
This can occur in a supinated foot during late stance phase when the flexors have gained mechanical advantage over the interossei muscles.
|
|
|
Why does flexor substitution occur and what muscles are involved?
|
It occurs when the triceps surae muscle is weak and the deep posterior and lateral leg muscles try to substitute for the weak triceps.
|
|
|
Which is the least common of the 3 pathologies that create lesser toe deformities?
|
Flexor substitution
|
|
|
What is extensor substitution?
|
It describes the excessive dorsiflexion of the toes during swing phase of gait and at heel strike
|
|
|
What muscles are involved in extensor substitution?
|
Extensor digitorum longus gains mechanical advantage over the lumbricales. Without the stabilising effect of the lumbricales the MTPJs will be excessively dorsiflexed resulting in severe dorsal contraction of the toes. This deformity often begins as a flexible deformity that may reduce completely during weightbearing but becomes more rigid as accommodative contractures develop
|
|
|
What four factors can cause extensor substitution?
|
1. Anterior pes cavus
2. Ankle equinus 3. Pain 4. Spasticity of the extensor digitorum longus muscle or weakness of the lumbricales. |
|
|
How many degrees is considered normal for abduction of the hallux?
|
15 degrees
|
|
|
What is another term for tailor's bunion?
|
Digiti quinti varus
|
|
|
What is hallux abductus?
|
Hallux abducted more than 15 degrees from the midline of the body
|
|
|
What is the term for a hallux abducted more than 15 degrees from the midline of the body?
|
Hallux abductus
|
|
|
What is hallux abductovalgus?
|
Hallux abducted more than 15 degrees from the midline of the body and the hallux is also rotated so that the hallux nail faces towards the midline of the body
|
|
|
What is the term for Hallux abducted more than 15 degrees from the midline of the body and the hallux is also rotated so that the hallux nail faces towards the midline of the body?
|
Hallux abductovalgus
|
|
|
What is hallux abductus interphalangeus?
|
Distal hallucal phalanx abducted away from the midline of the body
|
|
|
What is the term for a distal hallucal phalanx abducted away from the midline of the body?
|
Hallux abductus interphalangeus
|
|
|
What is hallux varus?
|
Hallux adducted towards the midline of the body
|
|
|
What is the term for a hallux adducted towards the midline of the body?
|
Hallux varus
|
|
|
What is hallux limitus?
|
Reduced dorsiflexion at the 1st MTPJ
|
|
|
What is the term used for reduced dorsiflexion at the 1st MTPJ
|
Hallux limitus
|
|
|
What is hallux rigidus?
|
Complete lack of dorsiflexion at the 1st MTPJ
|
|
|
What is complete lack of dorsiflexion at the 1st MTPJ?
|
Hallux rigidus
|
|
|
What is hallux flexus
|
Plantarflexion of the hallux at the 1st MTPJ
|
|
|
What is the term for plantarflexion of the hallux at the 1st MTPJ?
|
Hallux flexus
|
|
|
What is hallux extensus?
|
Dorsiflexion of the hallux at the 1st MTPJ
|
|
|
What is the term for dorsiflexion of the hallux at the 1st MTPJ?
|
Hallux extensus
|
|
|
What is a hyperextended hallux?
|
Distal phalanx of the hallux dorsiflexed
|
|
|
What is the term for distal phalanx of the hallux dorsiflexed?
|
Hyperextended hallux
|
|
|
What is a hammer toe?
|
Dorsiflexion at the MTPJ, plantarflexion at the proximal IPJ and either normal position or dorsiflexion at the distal IPJ
|
|
|
What is the term for dorsiflexion at the MTPJ, plantarflexion at the proximal IPJ and either normal position or dorsiflexion at the distal IPJ?
|
Hammer toe
|
|
|
What is a claw toe?
|
Dorsiflexion at the MTPJ, plantarflexion at the proximal and distal IPJs
|
|
|
What is the term for dorsiflexion at the MTPJ, plantarflexion at the proximal and distal IPJs?
|
A claw toe
|
|
|
What is a retracted toe?
|
A claw toe where the apex of the toe is not in ground contact
|
|
|
What is a claw toe where the apex of the toe is not in ground contact?
|
A retracted toe
|
|
|
What is a mallet toe?
|
Plantarflexion at the distal IPJ
|
|
|
What is the term for plantarflexion at the distal IPJ?
|
A mallet toe
|
|
|
What is an adductovarus fifth?
|
Fifth toe rotated so that nail is facing away from the midline of the body and the toe is adducted (moved towards the midline of the body)
|
|
|
What is the term for a fifth toe rotated so that nail is facing away from the midline of the body and the toe is adducted (moved towards the midline of the body)?
|
Adductovarus fifth
|
|
|
What is it when toes are dorsally displaced?
|
One or more toes is in a dorsiflexed position in comparison to the other toes
|
|
|
What is the term for one or more toes is in a dorsiflexed position in comparison to the other toes?
|
Dorsally displaced
|
|
|
What is a real limb length discrepancy due to and what can cause a LLI?
|
It can be due to a difference in the length of the femurs or tibiae and is common after a hip replacement
|
|
|
What two factors can cause an apparent limb length discrepancy?
|
1. Osteoarthritis
2. Scoliosis |
|
|
What 7 factors can reveal the presence of a limb length discrepancy?
|
1. Shoulder tilt to one side
2. Unequal arm swing 3. Pelvic tilt 4. Foot supinated on the short side 5. Foot pronated on the long side 6. Knee flexed on the long side 7. Ankle plantarflexed on the short side |
|
|
How do you assess for the presence of a real limb length discrepancy?
|
The patient lies supine on a flat couch. The practitioner places her hands around the heels and asks the patient to push their buttocks off the couch and then replace them. The practitioner exerts a slight pull on the legs at the same time bringing the legs together so that the knees and malleoli are touching. The knees and malleoli should be level. A difference indicates an inequality at the femur or tibia. To identify which bone is affected the knees should be flexed and the heels pushed flush against the buttocks (Skyline/Allis test). If the tibiae are of unequal length, the knees or tibial tubercles will be at different levels. If one femur is longer than the other, the knee of the longer femur will be positioned further forward than the other knee.
|
|
|
What is the skyline/allis test?
|
It should show which bone is affected if there is a limb length discrepancy
|
|
|
How do you do a skyline/allis test?
|
The knees should be flexed and the heels pushed flush against the buttocks
|
|
|
When using a tape measure to measure limb length discrepancy where should it be placed?
|
At the anterior superior iliac spine (ASIS) to the medial malleolus
|
|
|
How can the distinction between a real or apparent LLI be achieved non-weightbearing?
|
The tape is placed at the xiphisternum and the distance from the xiphisternum to each malleolus is measured. If the values are the same then the LLI is likely to be apparent where the cause could be at the hip or pelvis where a fixed deformity makes the limbs appear unequal.
|
|
|
How can the distinction between a real or apparent LLI be achieved weightbearing?
|
1. The patient stands in the RCSP
2. The position of the ASISs is assessed to see if they are level 3. The feet are then placed in the NCSP 4. The position of the ASISs is assessed to see if they are level 5. If the ASISs are not level in either the RCSP and NCSP and the extent of the discrepancy remains the same in RCSP and NCSP a true LLI should be suspected. If the ASISs are on the same level in the NCSP but differ for the RCSP an apparent LLI should be suspected |
|
|
What is the name for the organ of skin?
|
The integument
|
|
|
What are the four ways that skin disorders affect individuals?
|
1. Discomfort ie itching and pain
2. Disability ie foot ulceration, hand eczema 3. Disfigurement ie scarring or rashes 4. Death ie skin cancers |
|
|
What two factors can cause clubbing of the nails?
|
1. Smoking
2. Lung disease |
|
|
What are the five most common disorders that affect the lower limb?
|
1. Fungal and other skin infections
2. Dermatitis/eczema 3. Psoriasis 4. Warts 5. Tumours (benign and malignant) |
|
|
How many layers are there in the skin and what are they?
|
1. Epithelium (epidermis)
2. Dermis (connective tissue matrix firmly bound together at the dermo-epidermal junction) 3. Subcutaneous (fat) layer |
|
|
What are the seven functions of the skin?
|
1. Physical barrier ie thermal/mechanical/radiation
2. Chemical barrier ie irritants/allergens/water loss 3. Microbiological barrier ie infections/infestations 4. Touch/vibration/pressure/temperature 5. Nociception 6. Thermoregulation and assistance in maintaining blood pressure 7. Vitamin D and cholesterol production |
|
|
What is the epidermis?
|
An avascular structure relying on the diffusion of materials across the dermo-epidermal junction for nutrients and waste disposal
|
|
|
What is the epidermis composed of?
|
It is principally composed of keratinocytes (corneocytes) which make up 80% of the cells as well as melanocytes, Merkel's discs and Langerhan's cells.
|
|
|
What are the three appendages in the epidermis?
|
1. Nails
2. Sweat glands 3. Sebaceous glands |
|
|
How thick is the epidermis?
|
From 0.4 to 1.5mm depending on the anatomiccal location
|
|
|
How many layers are there in the epidermis and what are they?
|
Four layers
1. Basal layer (stratum germinativum) 2. Prickle cell layer (stratum spinosum) 3. Granular layer (stratum granulosum) 4. Horny layer (stratum corneum) |
|
|
What are Merkel's discs?
|
Mechanoreceptors in the skin
|
|
|
What are mechanoreceptors in the skin called?
|
Merkel's discs
|
|
|
What are Langerhans cells?
|
They are dendritic cells which take up and process microbial antigens to become an antigen presenting cell when infection takes place in the skin
|
|
|
What does the basal layer (stratus germinativum) consist of?
|
The basal layer consists of a single undulating layer of cuboidal keratinocytes
|
|
|
What is the basal layer attached to?
|
The cells in this layer are attached to the dermo-epidermal junction (DEJ) by tonofilaments.
|
|
|
What is the function of cells in the basal layer?
|
They generate cells of the more superficial layers of the epidermis
|
|
|
Where are melanocytes located?
|
In the basal layer
|
|
|
What specialist cells are located in the basal layer?
|
Melanocytes
|
|
|
What is the ratio of melanocytes in the skin?
|
In sun-exposed skin they may have a ratio of 1 to 4 but in unexposed areas such as the surface of the foot they may decrease to 1 in 30
|
|
|
What are melanocytes?
|
They are dendritic cells which produce a pigment melanin in specialist organelles known as melanosomes
|
|
|
How does melanin work?
|
It forms a protective cap over the cell nucleus, its function being to limit the amount of harmful ultraviolet radiation reaching the DNA within the nucleus and it also may have a role in mopping up free radicals which arise as a result of inflammation within the skin
|
|
|
What is the function of Merkel's cells?
|
The perception of light touch
|
|
|
Where in the body are Merkel's cells predominantly found
|
They are numerous on the volar (pulp) surfaces of the fingers and toes, in the nail beds and the dorsum of the foot
|
|
|
Where do the new cells generated by the basal layer go to?
|
The prickle cell layer (stratum spinosum)
|
|
|
What do the cells look like in the prickle cell layer (stratum spinosum)?
|
They are more polyhedral and they have abundant spinous processes called desmosomes which bond adjacent cells together. They are an important component of the epidermis as they resist mechanical stress.
|
|
|
Which layer of the epidermis are Langerhans cells in?
|
The prickle cell layer (stratum spinosum)
|
|
|
What cells that are immunological in function are found in the prickle cell layer (stratum spinosum)?
|
Langerhans cells
|
|
|
What do cells look like when they have reached the granular layer (stratum granulosum)?
|
They are much more flattened and are packed with keratohyalin granules which are composed of proteins and various types of keratin
|
|
|
What is the primary function of the granular layer (stratum granulosum)?
|
At the junction of stratum corneum a watertight seal or hydrophobic barrier is formed along the junction of the granular layer (stratum granulosum) and stratum corneum. In eczematous plaques this process of a watertight barrier is often reduced leading to increased water loss through the epidermis and resultant fissuring.
|
|
|
What is thought to cause the water loss and resulting fissuring of eczematous plaques?
|
The lack of formation of a hydrophobic barrier between stratum corneum and stratum granulosum (granular layer)
|
|
|
What happens to the cell when it reaches the horny layer (stratum corneum)?
|
The cells lose a percentage of their water content and have a very flattened appearance with around 15-20 layers of keratinocytes. The remaining intracellular water accumulates and causes the cell to swell which improves the barrier seal to the epidermis and prevents fissuring of the skin under normal tensile forces.
|
|
|
How long does it take for a keratinocyte to ascend through the four layers?
|
28-70 days
|
|
|
How quickly does a cell ascend through the four layers when the patient has psoriasis?
|
As little as 5 days
|
|
|
What is the term for when the dermis meets the epidermis?
|
The dermo-epidermal juntion (DEJ)
|
|
|
What is the dermo-epidermal junction (DEJ)?
|
Where the dermis meets the epidermis
|
|
|
What are dermal papillae?
|
It is where the dermis makes regular finger-like folds into the overlying epidermis
|
|
|
What is the term for where the dermis makes regular finger-like folds into the overlying epidermis
|
Dermal papillae
|
|
|
How is the dermo-epidermal junction constructed and what is it made up of?
|
It is a basement membrane divided into a number of layers crossed by a complex of filaments, keratins and proteins that form an anchoring surface between the dermis and epidermis
|
|
|
What are the protrusions from the epidermis into the dermis called?
|
Rete pegs or epidermal ridges
|
|
|
What are rete pegs or epidermal ridges?
|
Protrusions from the epidermis into the dermis
|
|
|
What is a major dermatological feature of the plantar surface of the foot?
|
Dermal papillae and rete pegs or epidermal ridges where mechanical stresses are high
|
|
|
Is the DEJ (dermo-epidermal junction) prone to many pathologies and what are they?
|
The DEJ is the site of many pathologies and this can lead to loss of adhesion and the development of blistering diseases eg epidermolysis bullosa, dermatitis herpetiformis
|
|
|
What two pathologies are associated with the DEJ (dermo-epidermal junction)?
|
1. Epidermolysis bullosa
2. Dermatitis herpetiformis |
|
|
What lies below the DEJ (dermo-epidermal junction)?
|
The dermis
|
|
|
What does the dermis consist of?
|
Dense fibro-elastic connective tissues in a gel-like base (ground substance) which contains glycosaminoglycans.
|
|
|
What five appendages are found in the dermis?
|
1. Skin appendages eg hair follicles, sebaceous glands, sweat glands
2. Macrophages 3. Fibroblasts 4. Neurovascular network 5. T lymphocytes and mast cells |
|
|
How many layers are there in the dermis and what are they?
|
There are two
1. The thin upper layer or papillary dermis 2. The less vascular, deep reticular layer |
|
|
What does the thin upper layer of the dermis contain?
|
The blood and lymphatic vessels
|
|
|
What does the less vascular deep reticular layer of the dermis contain?
|
Collagen and elastic fibres
|
|
|
What is collagen's role within the dermis?
|
Collagen strands provide tensile strength with elasticity afforded by interwoven elastic fibres that make this a pliable tissue
|
|
|
What separates the dermis from the fascia?
|
The subcutaneous (fat) layer
|
|
|
Where is the subcutaneous (fat) layer found?
|
Between the dermis and the fascia
|
|
|
What is found in the subcutaneous (fat) layer?
|
It is a layer of fat cells rich in nerves, blood vessels and lymphatics
|
|
|
What is the function of the subcutaneous (fat) layer?
|
Its main function is to provide thermal insulation and physical protection
|
|
|
Which layer of skin provides thermal insulation and physical protection?
|
Subcutaneous (fat) layer
|
|
|
Where is the subcutaneous (fat) layer particularly well developed in the foot?
|
Across the metatarsal heads and heels where it may be up to 18mm thick
|
|
|
How is the plantar fat constructed under the fascia?
|
Plantar fat is divided into vertical chambers by dividing fibrous septae which act as an effective shock absorption system
|
|
|
Where does the main blood supply to the skin arise from?
|
A network (or plexus) of vessels located in the subcutaneous layer
|
|
|
What does the blood supply at the level of the subcutaneous layer?
|
Branches supply eccrine sweat glands located deep in the reticular dermis
|
|
|
Where are eccrine sweat glands located?
|
Deep in the reticular dermis
|
|
|
Where is the second network of vessels located after the subcutaneous layer?
|
In the mid-dermis
|
|
|
What do vessels supply in the mid-dermis?
|
Hair follicles
|
|
|
What part of the dermis are hair follicles found in?
|
In the mid-dermis
|
|
|
Where is the third network of blood vessels in the dermis?
|
In the papillary dermis
|
|
|
Where are the most densely organised network of capillaries found in the human body?
|
The plantar surface of the foot
|
|
|
What part of the skin are the lymph vessels found?
|
In the dermis
|
|
|
What is one of the functions of lymph vessels in the skin?
|
One of the functions is maintaining turgidity which is vital to retaining mechanical resilience in the skin requiring a fine balance between supply and drainage as dehydration and oedema can lead to a reduction in skin stiffness and deformation in the structure of collagen and elastic fibres
|
|
|
What two conditions leads to a reduction in skin stiffness and deformation in the structure of collagen and elastic fibres?
|
1. Dehydration
2. Oedema |
|
|
What problems can dehydration and oedema cause in skin?
|
Dehydration and oedema can lead to a reduction in skin stiffness and deformation in the structure of collagen and elastic fibres
|
|
|
Where are hair follicles not found?
|
The plantar surface of the foot
|
|
|
Where are few sebaceous glands found?
|
The plantar surface of the foot
|
|
|
What are the two types of sweat glands and where are they found?
|
1. Apocrine glands which are larger and exclusively associated with the hair follicle in the groin and axillae
2. The smaller eccrine gland is a smaller coiled structure located in the reticular dermis with an opening directly onto the epidermis |
|
|
What does the eccrine gland look like and where is it located?
|
It is a smal coiled structure located in the reticular dermis with an opening directly onto the epidermis
|
|
|
What stimulates sweat glands?
|
The sympathetic branch of the autonomic system
|
|
|
Where are sweat glands most numerous?
|
They are most numerous on the plantar surfaces of the feet
|
|
|
What are the two functions of sweating?
|
1. Thermoregulation
2. Aid gripping |
|
|
How is gripping further enhanced in the hands and soles of the feet?
|
By the presence of dermatoglyphics which are a result of the unique arrangement of collagen fibres in the dermis and are more prominent on the weightbearing surfaces of the foot (pulp of the toes, heel and metatarsal area)
|
|
|
What protects the integrity of the foot?
|
A dense and highly organised neural network in the underlying dermis which provides a rich tactile perception necessary to protect the integrity of the foot
|
|
|
What skin problems can stress make worse?
|
1. Psoriasis
2. Eczema 3. Lichen planus |
|
|
What external factor can make psoriasis, lichen planus and eczema worse?
|
Stress
|
|
|
What skin condition is improved by sunlight?
|
Psoriasis
|
|
|
What condition is made worse by sunlight?
|
Lupus erythematosus
|
|
|
What external factor improves psoriasis?
|
Sunlight
|
|
|
What external factor makes lupus erythematosus worse?
|
Sunlight
|
|
|
What medication can dramatically increase the spread of a fungal eruption?
|
A steroid cream
|
|
|
What is dermatitis herpetiformis?
|
A blistering disorder
|
|
|
What other condition is dermatitis herpetiformis also associated with?
|
Coeliac disease
|
|
|
What is coeliac disease?
|
A gluten intolerance affecting the gut
|
|
|
What condition is more associated with outdoor workers?
|
Skin cancer
|
|
|
What occupational group is skin cancer more associated with?
|
Outdoor workers
|
|
|
What external condition can make psoriasis worse?
|
Alcoholic consumption
|
|
|
Which racial group is more predisposed to melanoma?
|
Caucasians
|
|
|
What skin condition are Caucasians more likely to get?
|
Melanoma
|
|
|
What are the nine areas of the skin affected in aging?
|
1. It appears more translucent
2. Irregular pigmentation 3. Thinning of the skin occurs at all layers including the subcutaneous layer which may be evident on the plantar area of the foot 4. Natural turgidity and elasticity is lost 5. Pinching of the skin results in “tenting” as the skin fails to return to its natural shape 6. Decreased sweat and sebum production leading to the normal skin surface barrier becoming compromised so more prone to the effects of drying and irritation 7. A reduced immune response as the numbers of T and B lymphocytes along with Langerhans’ cells decrease leaving the skin more open to infection and malignant change 8. Any inflammation that does occur tends to be damped down so signs of inflammation appear less acute 9. Nails reduce their rate of growth, become thicker and slightly yellow in colour |
|
|
What skin condition can dandruff mimic?
|
Psoriasis
|
|
|
What skin condition can look like scalp psoriasis?
|
Dandruff
|
|
|
What surfaces of the arms and legs does eczema affect?
|
The flexor surfaces
|
|
|
What is the distribution pattern of atopic eczema?
|
Antecubital and popliteal fossa, face, neck and hands
|
|
|
What does antecubital mean?
|
The anterior part of the elbow
|
|
|
What is the term for the anterior part of the elbow?
|
Antecubital
|
|
|
What is the distribution pattern for contact dermatitis?
|
Hands, face and feet
|
|
|
What is the distribution pattern for psoriasis?
|
Extensor surfaces of knees and elbows, scalp, back, nails
|
|
|
What is the distribution pattern for lichen planus?
|
Flexor surfaces of wrist, ankles, oral cavity and genitalia
|
|
|
What is the distribution pattern of erythema nodosum?
|
The anterior surfaces of shins
|
|
|
What does annular mean when describing a skin condition?
|
Ring-like
|
|
|
What 3 skin conditions have annular (ring-like) lesions?
|
1. Psoriasis
2. Lichen planus 3. Granuloma annulare |
|
|
What sort of lesions do psoriasis, lichen planus and granuloma annulare have?
|
Annular (ring-like) lesions
|
|
|
What does nummular mean?
|
Round or coin-like
|
|
|
What skin condition has nummular (round or coin-like) conditions?
|
Nummular eczema
|
|
|
What sort of lesion does nummular eczema have?
|
Nummular (round or coin-like)
|
|
|
What 2 conditions have discoid lesions?
|
1. Eczema
2. Psoriasis |
|
|
What sort of lesions do eczema or psoriasis have?
|
Discoid lesions
|
|
|
What is a reticulate lesion?
|
A lesion that looks net-like
|
|
|
What sort of lesions does livedo reticularis have?
|
A reticular (net-like) lesion
|
|
|
What skin condition has a reticular (net-like) lesion?
|
Livedo reticularis
|
|
|
What is livedo reticularis?
|
Livedo reticularis refers to a condition in which dilation of capillary blood vessels and stagnation of blood within these vessels causes mottled discolouration of the skin. It is described as being reticular (net-like) cyanotic, cutaneous discolouration surrounding pale central areas. It occurs mostly on the legs, arms and trunk and is more pronounced in cold weather.
|
|
|
What does an arcuate lesion look like?
|
Curved
|
|
|
What skin condition presents with arcuate (curved) lesions?
|
Contact dermatitis
|
|
|
What sort of lesions does contact dermatitis present with?
|
Arcuate (curved) lesions
|
|
|
What 2 conditions present with grouped lesions?
|
1. Insect bites
2. Dermatitis herpetiformis |
|
|
What sort of lesions do insect bites and dermatitis herpetiformis present with?
|
Grouped lesions
|
|
|
What is Koebner’s phenomenon?
|
It is where skin lesions of a specific disease may appear at a site of trauma which was previously unaffected.
|
|
|
What are four examples of Koebner’s phenomena?
|
1. Warts
2. Psoriasis 3. Lichen planus 4. Molluscum contagiosum |
|
|
What is molluscum contagiosum?
|
It is a viral infection of the skin or occasionally of the mucous membranes
|
|
|
What is the DDX between fungal infections and psoriasis and eczema?
|
Psoriasis and fungal infections have much more marked, well-defined edges than eczema
|
|
|
How can you tell if a rash or lesion is due to blood?
|
the colour is pink, purple or red and if gentle pressure blanches the area
|
|
|
If the area of skin does not blanch what 2 conditions may this be due to?
|
Extravasation (loss of blood constituents into the skin) or pigmentation due to melanin
|
|
|
What is extravasation?
|
Loss of blood constituents into the skin
|
|
|
What three micro-organisms are malodorous?
|
1. Pseudomonas
2. Staphylococcus 3. Diphtheroids |
|
|
What is bromhidrosis?
|
Excessive sweating
|
|
|
What is the term for excessive sweating?
|
Bromhidrosis
|
|
|
How may skin lesions be classified and what do these classifications mean?
|
Primary and secondary. Primary lesions arise due to the initial effects of a condition. Secondary lesions evolve from or as a complication of primary lesions
|
|
|
What happens to psoriatic skin when it is scratched?
|
It demonstrates pinpoint bleeding and the scaling becomes more pronounced.
|
|
|
What is Auspitz sign?
|
Auspitz's sign is the appearance of punctate bleeding spots when psoriasis scales are scraped off
|
|
|
What is the medical term for psoriatic skin that gives the appearance of punctate bleeding spots when psoriasis scales are scraped off?
|
Auspitz sign
|
|
|
What are the three things that skin does when it is injured or infected?
|
1. It bleeds
2. Oozes serum 3. Discharges pus |
|
|
What is a common feature in eczema?
|
Crusting
|
|
|
What is erythema?
|
Redness, often due to inflammatory response
|
|
|
What is the term used for redness often due to inflammatory response?
|
Erythema
|
|
|
What is a macule?
|
It is flat, differently coloured eg freckles, vitiligo
|
|
|
What is vitiligo?
|
Vitiligo or leukoderma is a chronic skin disorder that causes loss of pigment, resulting in irregular pale patches of skin.
|
|
|
What is the medical description for flat, differently coloured patches of skin such as freckles or vitiligo?
|
Macules
|
|
|
What is a papule?
|
It is a palpable, solid bump in the skin eg lichen planus
|
|
|
What is lichen planus?
|
Lichen planus is a chronic mucocutaneous disease that affects the skin and the oral mucosa, and presents itself in the form of papules, lesions or rashes.
|
|
|
What is the medical term describing a palpable, solid bump in the skin as in lichen planus?
|
A papule
|
|
|
What is a nodule?
|
It is a palpable, deeper mass than a papule eg ganglion or rheumatoid nodule
|
|
|
What is the medical description for palpable, deeper mass than a papule such as seen in a ganglion or rheumatoid nodule?
|
A nodule
|
|
|
What is a plaque?
|
It is an elevated, disc-shaped area of skn over 1cm in diameter eg psoriasis
|
|
|
What is the medical term for an elevated, disc-shaped area of skin over 1cm in diameter as seen in psoriasis?
|
A plaque
|
|
|
What does a tumour look like?
|
It is a large mass over 2cm in diameter eg lipoma
|
|
|
What is the medical term describing a large mass over 2cm in diameter such as a lipoma
|
A tumour
|
|
|
What is a cyst?
|
It is a subdermal, fluid-filled fibrous swelling, loosely attached to deeper structures eg dermal cyst
|
|
|
What is the medical term describing a subdermal, fluid-filled fibrous swelling, loosely attached to deeper structures?
|
A cyst
|
|
|
What is a weal?
|
Large oedematous bump eg insect bite
|
|
|
What is the medical term describing a large oedematous bump such as seen in an insect bite?
|
A weal
|
|
|
What is a vesicle?
|
A tiny, pinprick-sized collection of fluid eg mycosis, pompholyx
|
|
|
What is the medical term describing a tiny, pinprick-sized collection of fluid such as seen in mycosis or pompholyx?
|
A vesicle
|
|
|
What is pompholyx?
|
Pompholyx is a common type of eczema affecting the hands and sometimes the feet (pedopompholyx). It is also known as dyshidrotic eczema or vesicular eczema of the hands and/or feet.
|
|
|
What is bulla?
|
It is serous fluid/blood-filled intraepidermal or dermoepidermal sac eg bullous pemphigoid
|
|
|
What is the medical term for a serous fluid/blood-filled intraepidermal or dermoepidermal sac?
|
Bulla
|
|
|
What is bullous pemphigoid?
|
Bullous pemphigoid is a blistering skin disease which usually affects middle aged or elderly persons. It is an immunobullous disease, i.e. the blisters are due an immune reaction within the skin.
|
|
|
What is a pustule?
|
It is a vesicle or bulla filled with pus eg acne, pustular psoriasis
|
|
|
What is the medical term for a vesicle or bulla filled with pus?
|
A pustule
|
|
|
What is a burrow?
|
A short, linear mark in skin visible with magnifying lens eg scabies
|
|
|
What is the medical term for a short, linear mark in skin visible with magnifying lens eg scabies?
|
A burrow
|
|
|
What is scabies?
|
Scabies is an itchy rash caused by a little mite that burrows in the skin surface
|
|
|
What is an itchy rash caused by a little mite that burrows in the skin surface?
|
Scabies
|
|
|
What is ecchymosis?
|
Large extravasation of blood into the tissues eg bruising
|
|
|
What is the medical terms for large extravasation of blood into the tissues?
|
Ecchymosis
|
|
|
What is petechia?
|
Pinhead-sized macule caused by blood seeping into the skin
|
|
|
What is the medical term for a pinhead-sized macule caused by blood seeping into the skin?
|
Petechia
|
|
|
What is telangiectasiae?
|
Permanently dilated small cutaneous blood vessels
|
|
|
What is the medical term for permanently dilated small cutaneous blood vessels?
|
Telangiectasiae
|
|
|
What happens to keratin when shedding fails?
|
It forms thickened areas
|
|
|
What is the medical term for warty?
|
Papillomatous
|
|
|
What does papillomatous mean?
|
Warty
|
|
|
What happens during lichenification?
|
It is a reaction of the skin to chronic rubbing or scratching and involves the whole epidermis
|
|
|
What is the medical term for the reaction of the skin to chronic rubbing or scratching and involves the whole epidermis?
|
Lichenification
|
|
|
What is a common feature of atopic eczema and where does it appear?
|
Lichenification and it appears on the flexures.
|
|
|
What are flexures?
|
The areas where the limbs bend, bringing together two surfaces, for example, the front of the elbows and the back of the knees
|
|
|
What is the medical term for the areas where the limbs bend, bringing together two surfaces, for example, the front of the elbows and the back of the knees?
|
Flexures
|
|
|
What does excoriation mean?
|
Scratch
|
|
|
What is the medical term for scratch?
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Excoriation
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What is an ulcer?
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It is an area of full thickness skin loss usually covered by exudate or crust
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What is an area of full thickness skin loss usually covered by exudate or crust?
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An ulcer
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What does atrophic skin look like?
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The skin is depressed and blood vessels are visible beneath. The skin is often pale and wrinkled.
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How would you describe skin that is depressed and blood vessels are visible beneath as well as being pale and wrinkled?
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Atrophic
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What are large pustules called?
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Abscesses
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How would you describe an abscess?
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As a large pustule
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What three other primary lesions can a scar look like?
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1. Macule
2. Papule 3. Plaque |
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What is the primary function of the toenail?
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The toenail is purely a protective plate overlying the deep structures and acting as a counter pressure to the volar tissues
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How are the toenails supplied with nutrients?
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Nails are provided with a rich neurovascular supply
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What are the names of the 15 primary skin lesions?
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1. Erythema
2. Macule 3. Papule 4. Nodule 5. Plaque 6. Tumour 7. Cyst 8. Weal 9. Vesicle 10. Bulla 11. Pustule 12. Burrow 13. Ecchymosis 14. Petechia 15. Telangiectasiae |
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What are the names of the 14 secondary skin lesions?
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1. Scale
2. Crust 3. Excoriation 4. Fissure 5. Necrosis 6. Ulcer 7. Scar 8. Keloid 9. Striae 10. Purpura 11. Urticuria 12. Lichenification 13. Haematoma 14. Sinus |
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What is a scale?
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A flake of skin eg mycosis, psoriasis
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What is the medical term for a flake of skin as seen in mycosis and psoriasis?
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A scale
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What is a crust?
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A scab, dried serous exudates eg acute eczema
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What is the medical term for a scab or dried serous exudates as seen in acute eczema?
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A crust
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What is excoriation?
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Scratch marks eg pruritis
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What is the medical term for scratch marks as seen in pruritis?
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Excoriation
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What is a fissure?
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It's a crack in dry or moist skin
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What is the medical term for a crack in dry or moist skin?
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A fissure
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What is necrosis?
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Non-viable tissue
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What is the medical term for non-viable tissue?
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Necrosis
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What is an ulcer?
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Loss of epidermis. It may extend through the dermis to deeper tissue eg venous ulcer
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What is the medical term for loss of epidermis. It may extend through the dermis to deeper tissue?
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An ulcer
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What is a scar?
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Fibrous tissue production post-healing
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What is the medical term for fibrous tissue production post-healing?
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A scar
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What is a keloid?
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Excessive production of fibrous tissue post-healing
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What is the medical term for excessive production of fibrous tissue post-healing?
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A keloid
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What are striae?
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Lines in skin that do not have normal skin tone eg striae tensae in pregnancy, Cushing's disease
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What is the medical term for lines in skin that do not have normal skin tone?
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Striae
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What is purpura?
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Purplish lesions which do not blanche under pressure eg Vitamin C deficiency
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What is the medical term for purplish lesions which do not blanche under pressure as seen in Vitamin C deficiency?
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Purpura
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What is urticuria
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Nettle rash eg drug eruption, allergy, heat
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What is the medical term for nettle rash as seen in drug eruption, allergy and heat?
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Urticuria
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What is lichenification?
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Patchy toughening of the skin eg chronic eczema
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What is the medical term for patchy toughening of the skin as seen in chronic eczema?
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Lichenification
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What is a haematoma?
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A blood-filled blister
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What is the medical term for a blood-filled blister?
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Haematoma
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What is a sinus?
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A channel that allows the escape of pus or fluid from tissues
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What is the medical term for a channel that allows the escape of pus or fluid from tissues?
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A sinus
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How many widths are there in the nail plate and what are they?
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1. Dorsal nail plate
2. Intermediate nail plate 3. Ventral nail plate |
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Where is the hyponychium?
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Under the nail just before the free edge
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What is the medical term for under the nail just before the free edge?
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Hyponychium
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Where is the eponychium?
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Distal to the proximal nail fold on the dorsum of the nail
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What is distal to the proximal nail fold on the dorsum of the nail?
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The eponychium
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How long does a toe nail take to grow out completely?
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12-18 months
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What is onychauxis?
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Thickening of the nail plate usually due to trauma
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What is the medical term for thickening of the nail plate due to trauma?
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Onychauxis
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What is onychogryphosis?
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Thickened nail with a distortion in the direction of growth
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What is the medical term for a thickened nail with a distortion in the direction of growth?
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Onychogryphosis
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What is onycholysis?
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Separation of the nail from the nail bed, distal to proximal
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What is the medical term for separation of the nail from the nail bed distally to proximally?
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Onycholysis
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What is onychomadesis?
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Separation of the nail from the nail bed, proximal to distal
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What is the medical term for separation of the nail from the nail bed proximally to distally?
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Onychomadesis
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What is onychocryptosis?
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Ingrowing toe nail
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What is the medical term for an ingrowing toe nail?
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Onychocryptosis
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What is involution?
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An inward curvature of the lateral or medial edges of the nail plate towards the nail bed
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What is the medical term for an inward curvature of the lateral or medial edges of the nail plate towards the nail bed?
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Involution
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What are splinter haemorrhages?
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Longitudinal, plum-coloured linear haemorrhage (around 2mm in length) under the nail plate
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What is the medical term for longitudinal plum-coloured linear haemorrhage (around 2mm in length) under the nail plate?
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Splinter haemorrhages
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What is paronychia?
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It is inflammation of the tissues surrounding the nails
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What is the medical term for inflammation of the tissues surrounding the nails?
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Paronychia
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What is onychomycosis?
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Fungal infection of the nail plate
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What is the medical term for fungal infection of the nail plate?
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Onychomycosis
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What is chromonychia?
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Abnormal colouration of the nail tissue
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What is the medical term for abnormal colouration of the nail tissue?
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Chromonychia
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What is koilonychia?
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Transverse and longitudinal concave nail dystrophy which gives a spoon-shaped appearance
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What is the medical term for transverse and longitudinal concave nail dystrophy which gives a spoon-shaped appearance?
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Koilonychia
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What is clubbing?
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Increased longitudinal curvature of the nail plate with enlargement of the pulp of the digit
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What is the medical term for increased longitudinal curvature of the nail plate with enlargement of the pulp of the digit?
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Clubbing
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What are Beau's lines?
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Transverse ridging of the nail plate seen as the result of a temporary cessation of nail growth
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What is the medical term for transverse ridging of the nail plate seen as the result of a temporary cessation of nail growth?
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Beau's lines
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What four factors can lead to an increase in the rate of growth of the nail?
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1. Psoriasis
2. Hyperthyroidism 3. Nail trauma 4. Drugs |
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What shape are toe nails?
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Quadrangular
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What is a pincer nail?
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Transverse over-curvature of the nail or involution
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What is another term for transverse over-curvature of the nail or involution?
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A pincer nail
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What two things happens if there is a subungual exostosis?
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1. Lifting of the distal nail plate
2. Pain |
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What four disorders can cause splinter haemorrhages in nails?
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1. Trauma
2. Rheumatoid disease 3. Vasculitis 4, Skin disease such as psoriasis or eczema |
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What causes splinter haemorrhages?
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Extravasation of blood between the nail bed and plate
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What fourteen factors can cause koilonychia (spooning)?
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1. Idiopathic
2. Hereditary 3. Iron deficiency anaemias 4. Insulin-dependent diabetes 5. Physiologically thin nails eg children 6. Psoriasis 7. Alopecia 8. Lichen planus 9. Raynaud's disease 10. Scleroderma/systemic sclerosis 11. Renal transplant 12. Thyroid disease 13. Acromegaly 14. Occupation (immersion in oils, acid and alkali) |
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What seven factors can cause clubbing of the nails?
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1. Idiopathic
2. Hereditary 3. Lung disease - bronchiectasis - lung cancers - abscess - lung infections - fibrotic lung disease - emphysema - asthma in childhood 4. Cardiovascular disease - congestive heart failure - subacute bacterial endocarditis - myxoid tumours - congenital heart disease 5. Alimentary disease - ulcerative colitis - Crohn's disease - gut cancers 6. Endocrine - active hepatitis - auto-immune thyroidits - acromegaly 7. Other - polycythaemia - cirrhosis - malnutrition |
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What is scleroderma?
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Scleroderma is a chronic autoimmune disease characterized by a hardening or sclerosis in the skin or other organs.
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What is the name of the disease that is a chronic autoimmune disease characterized by a hardening or sclerosis in the skin or other organs?
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Scleroderma
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What is a myxoid tumour?
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A tumour that arises from or occupies the myocardial or pericardial tissues
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What is the name of a tumour that arises from or occupies the myocardial or pericardial tissues?
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A myxoid tumour
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What is polycythaemia?
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It is a condition where there is a high red blood cell count
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What is the condition called where there is a high red blood cell count?
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Polycythaemia
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What 3 conditions accentuate longitudinal lines in nails?
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1. RA
2. PVD 3. Lichen planus |
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Define metatarsus adductus
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Metatarsus adductus is a transverse plane deformity arising at the tarsometatarsal (Lisfranc) joint
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What is the key fact to establish about a metatarsus adductus foot?
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Whether the deformity is flexible.
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What percentage of metatarsus adductus deformities spontaneously resolve?
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90%
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