Year 2004 Paper one: Questions supplied by Megan

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1 QUESTION 47 A 58yo man is noted to have a right foot drop three days following a right total hip replacement. On examination there is weakness of right ankle dorsiflexion and toe extension (grade 4/5). Other muscle groups are normal. The knee jerks are symmetrical with an absent right ankle jerk. Sensation is reduced on the sole and dorsum of the right foot. The most likely diagnosis is: A. Femoral neuropathy B. Sciatic neuropathy C. L5 radiculopathy D. Tibial neuropathy E. Peroneal neuropathy CAUSES OF FOOT DROP - Common peroneal nerve palsy - Sciatic nerve palsy - L4,L5 root lesion - Peripheral motor neuropathy - Distal myopathy - Motor neuron disease - Stroke NERVES OF THE LOWER LIMB

2 Femoral Nerve: - Largest of the lumbar plexus - L2, L3, L4 - Forms in the abdomen and runs through the pelvis and under the inguinal ligament - Runs lateral to the femoral vessels in the femoral triangle and outside the femoral sheath - Breaks up into several terminal es - Supplies the anterior femoral muscles - Sends articular es to the hip and knee joints - Gives several es to the skin on the anteromedial side of the lower limb - Saphenous nerve (L2, L3, L4) is a cutaneous of femoral nerve - It descends through femoral triangle lateral to the femoral sheath - Then accompanies the femoral artery in the adductor canal and passes anteriorly to supply the skin and fascia of the anterior and medial aspects of the knee, leg and foot - Knee reflex (L2, L3, L4) Sciatic Nerve: - L4, L5, S1, S2, S3 - Largest nerve in the body - Leaves the pelvis through the greater sciatic foramen - Runs deep to gluteus maximus but usually supplies no structures in gluteal region

3 - Supplies all the hamstring muscles (mainly via tibial division but short head of biceps via common peroneal division) - Tibial and common peroneal nerves usually separate in inferior part of thigh - Tibial nerve (L4, L5, S1, S2, S3) runs behind the knee in the popliteal fossa - Gives es to the knee - Supplies gastrocnemius, plantaris, popliteus and soleus muscles (posterior compartment muscles) - Divides into medial and lateral plantar nerves which supply the skin on the sole of the foot - Uncommonly injured but can occur with lacerations or posterior dislocations of the knee - Results in loss of plantarflexion and flexion of toes and loss of sensation over sole of foot - In the foot, all intrinsic muscles are supplied by es of the tibial nerve except for flexor extensor digitorum brevis which is supplies by the deep peroneal nerve - Ankle reflex S1, S2 - Tibial nerve gives the medial sural cutaneous nerve which usually joins the communicating of the peroneal nerve to form the sural nerve - Sural nerve (S1, S2) supplies the lateral aspect of the ankle and foot - Common peroneal nerve (L4, L5, S1, S2) runs down the medial border of the popliteal fossa - Gives es to the knee - Gives off lateral sural cutaneous nerve which supplies the skin on the lateral aspect of the leg (L5, S1, S2) - Also gives off the peroneal communicating which joins the medial sural cutaneous nerve to form the sural nerve - Winds around the neck of fibula and runs down behind the peroneus longus muscle - Divides into superficial and deep es - Deep peroneal nerve supplies the muscles of the anterior crural compartment, the ankle joint and the skin between the big and 2 nd toes (L4, L5) - The anterior compartment muscles are mainly involved in dorsiflexion of the foot and extension of the toes - Superficial peroneal nerve (L5, S1, S2) supplies the lateral crural compartment muscles - These muscles (peroneal muscles) plantarflex and evert the foot - Superficial peroneal nerve also supplies an area of skin over the anterior aspect of the ankle, the dorsum of the foot and most of the toes A. Injury to the femoral nerve would result in weakness of knee extension and reduced knee jerk. Would also lead to loss of sensation over anteromedial aspect of thigh and leg. B. Sciatic neuropathy would results in weakness of knee flexion and all movements of the ankle/foot. Also there would be loss of sensation of the posterior, lateral and medial areas of the leg and all of the foot (ie. all areas below the knee except for that supplied by the saphenous nerve). Note sciatic nerve is most likely to be injured with hip surgery. C. L5 radiculopathy would result in loss of sensation over the dorsum of the foot and the anterolateral portion of the leg. There may be some weakness of all the movements of the ankle as L5 is involved in the supply to all 3 compartments and also to the feet. D. Tibial neuropathy would lead to weakness of plantarflexion as it supplies the muscles of the posterior crural compartment. Also loss of flexion of the toes and loss of sensation over the sole of the foot. E. Peroneal neuropathy results in weakness of dorsiflexion and extension of the toes. Loss of sensation of the skin over dorsum of foot and toes and anterior aspect of lower leg. May also be weakness of eversion due to involvement of superficial peroneal nerve. This man has weakness of dorsiflexion and toe extension (deep peroneal nerve) but also has reduced sensation on the sole (tibial nerve) and dorsum (peroneal nerve) of the foot. Absent ankle jerk indicates

4 the tibial nerve or S1, S2. Only the sciatic nerve is involved in all these processes so there must be a partial lesion of this nerve. Answer: B Table Common Mononeuropathies (from Harrisons) Nerve Origin a Muscles Innervated UPPER EXTREMITY Suprascapular C5, C6 Supraspinatus Usual Site of Lesion Clinical Features Infraspinatus Suprascapular notch of scapula lateral rotation of the humerus Long thoracic C5 C7 Serratus anterior Variable Winging of scapula Axillary C5, C6 Deltoid, teres minor Radial C5 T1 Triceps, brachioradialis, wrist, finger, and thumb extensors Posterior C7, C8 Finger and thumb extensors Ulnar C8, T1 Ulnar flexor of the wrist, long flexors of 4th and 5th digits, and most intrinsic hand muscles Median C6 T1 Abductor pollicis brevis; more proximal muscles include forearm pronator, long finger and thumb flexors Anterior C7 T1 Long flexors of thumb and index Near shoulder joint Spiral groove of humerus Edge of supinator muscle below elbow Ulnar groove at the elbow shoulder abduction; atrophy of shoulder Wrist drop most obvious, also finger and thumb extensors paralyzed Finger drop; wrist relatively spared finger adduction and abduction and thumb adduction (see text); atrophy, clawhand Comments Sensory deficit similar to C5 dorsal root lesion (See Figs and 22-3) Saturday night palsy (acute compression) is frequent cause May be acute or insidious; sensory symptoms/signs are distinctive (Figs and 22-3); see also text Cubital tunnel Same as above Often pain over medial proximal forearm (cubital tunnel) Medial base of palm Carpal tunnel Anterior interosseus Intrinsic hand muscles only, atrophy Characteristic sensory symptoms and deficit and inability to make a circle with thumb and index finger pinch; pain in Sensory deficit as per Figs and 22-3 (see text); known as carpal tunnel syndrome

5 and middle fingers LOWER EXTREMITY Femoral L2 L4 Iliopsoas (hip flexor) and quadriceps femoris (knee Lateral femoral cutaneous below the elbow Proximal to inguinal ligament extensor) L2, L3 None Inguinal ligament Obturator L3, L4 Thigh adductors Intrapelvic or at pubis Sciatic L4 S3 Hamstring Near sciatic muscles, hip notch abductor, and all muscles below the knee Posterior tibial L5 S2 Calf muscles (proximally), toe flexors, and other intrinsic foot muscles Peroneal L4 S1 Dorsiflexors of toes and foot, evertors of foot a Spinal segments. Tarsal tunnel, near medial malleolus At neck of fibula volar forearm Knee buckling; absent knee jerk; weak anterior thigh muscles with atrophy Dysesthetic hyperpathia of lateral thigh hip adduction Severe lower leg and hamstring weakness; flail foot; severe disability Pain and numbness of sole, weak toe flexors Foot drop and weakness of foot eversion Association with diabetes mellitus; sensory disturbance as per Fig Known as meralgia paresthetica Sensory deficit on medial thigh Uncommon except from war wounds; sometimes after a misdirected injection Known as tarsal tunnel syndrome (see text) Sensory deficit is similar in distribution to L5, S1 sensory roots

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