Limbs, Spine, Neuro Flashcards

Question

injury to ulnar nerve slide 12/18 of UE and LE

Answer 1

medial C8-T1. Ulnar nerve injury usually occurs in one of four places: (1) posterior to the medial epicondyle of the humerus (most common), (2) in the cubital tunnel formed by the tendinous arch connecting the humeral and ulnar heads of the FCU, (3) at the wrist, and (4) in the hand. Ulnar nerve injury occurring at the elbow, wrist, or hand may result in extensive motor and sensory loss to the hand. An injury to the nerve in the distal part of the forearm denervates most intrinsic hand muscles. If proximal, then flexor carpi ulnaris and the medial half of flexor digitorum profundus can be compromised, making it difficult to flex the wrist or to flex the medial digits to make a fist, respectively. If ulnar nerve is damaged, both palmar and dorsal interosseus function is compromised. In addition, the medial two lumbricals do not work, so that the hand cannot flex the digit at the MCP, extend at the PIP, DIP, and so creating a claw hand (although this term is the classic term, it is a bit of a misnomer, as the median vs. ulnar nerve descriptive appearance depends on whether one is making a fist or not; the claw hand occurs when the person is trying to extend the fingers and the ulnar-innervated lumbricals are not functioning to allow them to straighten). If the damage is more distal, e.g., at the ulnar tunnel by pisiform and hamate carpal bones, then weakening of intrinsic hand muscle function, and the decrease/loss of sensation in the ulnar distribution can occur. Ulnar-if further up flexor carpi ulnaris, ulnar side flexor digitorum profundus Ulnar damaged in hand- Hyperthenar eminance, lumbricals out on pinky side, adductor policis, dorsal dabbers palmer adders The power of wrist adduction is impaired, and when an attempt is made to flex the wrist joint, the hand is drawn to the lateral side by the FCR in the absence of the “balance” provided by the FCU. After ulnar nerve injury, the person has difficulty making a fist because, in the absence of opposition, the metacarpophalangeal joints become hyperextended, and he or she cannot flex the 4th and 5th fingers at the distal interphalangeal joints when trying to make a fist. Furthermore, the person cannot extend the interphalangeal joints when trying to straighten the fingers. This characteristic appearance of the hand is known as a claw hand. This deformity results from atrophy of the interosseous muscles of the hand. The claw is produced by the unopposed action of the extensors and FDP. Compression of the ulnar nerve also may occur at the wrist where it passes between the pisiform and the hook of hamate. The depression between these bones is converted by the piso- hamate ligament into an osseofibrous ulnar tunnel (Guyon tunnel). Ulnar canal syndrome is manifest by hypoesthesia in the medial one and one half fingers and weak- ness of the intrinsic hand muscles. Clawing of the 4th and 5th fingers may occur, but in contrast to proximal ulnar nerve injury, their ability to flex is unaffected and there is no radial deviation of the hand. The ulnar tunnel exists at the wrist where the ulnar nerve and artery pass deep to the palmaris brevis muscle and palmar (volar) carpal ligament, just lateral to the pisiform bone. Within the tunnel, the nerve divides into the superficial sensory and deep motor branches. Injury may result from trauma, ulnar artery thrombosis, fractures (hook of the hamate), dislocations (ulnar head, pisiform), arthritis, and repetitive movements. Claw hand may be present if the motor components are injured. Cubital tunnel syndrome results from compression of the ulnar nerve as it passes beneath the ulnar collateral ligament and between the two heads of the flexor carpi ulnaris muscle. This syndrome is the second most common compression neuropathy after carpal tunnel syndrome. The tunnel space is significantly reduced with elbow flexion, which compresses and stretches the ulnar nerve. The nerve also may be injured by direct trauma to the subcutaneous portion as it passes around the medial epicondyle.

Answer 2

Erb (-Duchenne) palsy, where the superior brachial plexus (upper roots, e.g., C5-7) have been damaged by neck stretching, e.g., during childbirth. Nerves affected include: suprascapular (supraspinatus and infraspinatus function), musculocutaneous (biceps brachii), and axillary nerve (deltoid and teres minor function). The loss of function of these muscles leads to a waiter’s tip position of the upper limb. Injuries to superior parts of the brachial plexus (C5 and C6) usually result from an excessive increase in the angle between the neck and the shoulder. These injuries can occur in a person who is thrown from a motorcycle or a horse and lands on the shoulder in a way that widely separates the neck and shoulder . When thrown, the person’s shoulder often hits something (e.g., a tree or the ground) and stops, but the head and trunk continue to move. This stretches or ruptures superior parts of the brachial plexus or avulses (tears) the roots of the plexus from the spinal cord. Injury to the superior trunk is apparent by the characteristic position of the limb (“waiter’s tip position”) in which the limb hangs by the side in medial rotation. Upper brachial plexus injuries can also occur in a newborn when excessive stretching of the neck occurs during delivery. As a result of injuries to the superior parts of the brachial plexus (Erb-Duchenne palsy), paralysis of the muscles of the shoulder and arm supplied by C5–C6 occurs. The usual clinical ap- pearance is an upper limb with an adducted shoulder, medi- ally rotated arm, and extended elbow. The lateral aspect of the upper limb also experiences loss of sensation. Chronic microtrauma to the superior trunk of the brachial plexus from carrying a heavy backpack can produce motor and sensory deficits in the distribution of the musculocutaneous and radial nerves.

Answer 3

Injuries to inferior parts of the brachial plexus (Klumpke paralysis) are much less common. These injuries may occur when the upper limb is suddenly pulled superiorly—for ex- ample, when a person grasps something to break a fall or when a baby’s limb is pulled excessively during delivery. These events injure the inferior trunk of the plexus (C8 and T1) and may avulse the roots of the spinal nerves from the spinal cord. The short muscles of the hand are affected and a claw hand results..

Answer 4

The tendon of the long head of the biceps, enclosed by a synovial sheath, moves back and forth in the inter- tubercular sulcus (groove) of the humerus. Wear and tear of this mechanism can cause shoulder pain. Inflammation of the tendon (biceps tendinitis) usually is the result of repetitive microtrauma in sports involving throwing (e.g., baseball).

Answer 5

Rupture of the tendon of the long head of the biceps usually results from wear and tear of an inflamed tendon (biceps tendinitis). Normally, the tendon is torn from its attachment to the supraglenoid tubercle of the scapula. The rupture is commonly dramatic and is associated with a snap or pop. The detached muscle belly forms a ball near the center of the distal part of the anterior aspect of the arm (Popeye deformity). Rupture of the biceps brachii muscle may occur at the tendon (or rarely the muscle belly). It has a high rate of spontaneous rupture compared with most muscle tendons. Rupture is seen most often in patients older than 40, in association with rotator cuff injuries (as the tendon begins to undergo degenerative changes), and with repetitive lifting (e.g., weight lifters). Rupture of the long head of the biceps brachii tendon is most common and may occur in the following locations: Shoulder joint Intertubercular (bicipital) sulcus of the humerus Musculotendinous junction.The biceps brachii tendon can be ruptured in older males, particularly at the tendon of the long head. Subacromial trapping of biceps makes it easier to tear this muscle.

Answer 6

Elbow tendinitis (tennis elbow) is a painful muscu- loskeletal condition that may follow repetitive use of the superficial extensor muscles of the forearm. Pain is felt over the lateral epicondyle and radiates down the poste- rior surface of the forearm. People with elbow tendinitis often feel pain when they open a door or lift a glass. Repeated force- ful flexion and extension of the wrist strain the attachment of the common extensor tendon, producing inflammation of the periosteum of the lateral epicondyle (lateral epicondylitis). As- sociated tears of the common extensor tendon, which may be surgically repaired, are visible on magnetic resonance imaging (MRI). Extensor muscles originate from the lateral epicondyle and repeated use, as with a backhand stroke with a tennis racket, may cause a strain on the periosteum and tendinous muscle attachments. In particular, overuse of extensor carpi radialis brevis (ECRB) can lead to microtears in its tendon. One can exhibit a medial epicondylitis (golfer’s elbow) as well, with anterior compartment (flexor) overuse.

Answer 7

Sometimes a nontender cystic swelling appears on the hand, most commonly on the dorsum of the wrist. The thin-walled cyst contains clear mucinous fluid. Clinically, this type of swelling is called a “ganglion” (G. swelling or knot). These synovial cysts are close to and often communicate with the synovial sheaths. The distal attachment of the ECRB tendon is a common site for such a cyst. A cystic swelling of the common flexor syno- vial sheath on the anterior aspect of the wrist can enlarge enough to produce compression of the median nerve by nar- rowing the carpal tunnel (carpal tunnel syndrome). Generally speaking, they are thought to represent connective tissue degeneration of the tendon sheaths. They are not simple herniations, as there is no synovial lining to them local degeneration.These can either be followed by observation, lessened by splinting, aspirated, or surgically excised depending on symptoms and impact on function

Answer 8

Sudden severe tension on a long extensor tendon may avulse part of its attachment to the phalanx. The most common result of this injury is mallet or baseball finger. This deformity results from the distal inter- phalangeal joint suddenly being forced into extreme flexion (hyperflexion) when the tendon is attempting to extend the distal phalanx—for example, when a baseball is miscaught (hyperflexing it) or the finger is jammed into a base pad. These actions avulse the attachment of the tendon from the base of the distal phalanx. As a result, the person is un- able to extend the distal interphalangeal joint. A mallet finger at the DIP has damage to the distal extensor expansion, so that unopposed flexor digitorum profundus action can keep the distal phalanx in flexion. Lever to straighten fingers.

Answer 9

Various traumatic finger injuries may occur, causing fractures, disruption of the flexor and extensor tendons, and torn ligaments. Each element must be carefully examined for normal function, including muscle groups, capillary refill (Allen’s test), and two-point sensory discrimination. In de Quervain tenosynovitis the tendons of the abductor pollicis longus and extensor pollicis brevis muscles pass through the same tendinous sheath on the dorsum of the wrist (first compartment in the extensor retinaculum). Excessive and repetitive use of the hands in a power grip or a twisting-wringing action can cause friction and thickening of the sheath, leading to pain over the styloid process of the radius. This pain is mediated by the superficial radial nerve (sensory), and the pain can extend distally into the thumb and radiate up the lateral forearm. A jersey finger has damage to the flexor digitorum profundus tendon, leaves the distal phalanx in extension. A gamekeeper’s thumb (skier’s thumb) or ulnar collateral ligament injury of the thumb may lead to instability with the MCP joint of the thumb following a fall on an abducted thumb. Ulnar side of things torn medial collateral ligament. Metacarpal fractures often occur from blows, with a boxer’s fracture of the fifth metacarpal that can lead to a presentation of a depressed knuckle.

Answer 10

Dupuytren contracture is a disease of the palmar fascia resulting in progressive shortening, thicken- ing, and fibrosis of the palmar fascia and palmar aponeurosis. The fibrous degeneration of the longitudinal digital bands of the aponeurosis on the medial side of the hand pulls the 4th and 5th fingers into partial flexion at the metacarpophalangeal and proximal interphalangeal joints. The contracture is frequently bilateral. Treatment of the contracture usually involves surgical excision of the fibrotic parts of the palmar fascia to free the fingers. The palmar fascia contributes to a thick palmar aponeurosis and extend to fibrous digital sheaths that enclose tendons and synovial sheaths. This is particularly seen in males of Northern European background, suggesting a genetic basis for the fibroblast proliferation and excessive collagen deposition seen in this process. Cant extend fingers completely. Palmaris longus tense tissues in hand.

Answer 11

synovial tendon sheaths help to reduce friction for long tendons. Punctures into those and subsequent infection can lead to rapid functional impairment, and so deserve quick consultation with hand specialists. There are ligaments or thickenings of the fibrous sheath surrounding the synovial sheaths that help to support the tendons (preventing bowstringing), and can act as pulleys. These ligaments can be anular or cruciate. Thickenings of the tendons can lead to trigger finger (digital tenovaginitis stenosans), with the inability to extend the finger if the tendon nodule has difficulty fitting in under an anular pulley finger doesn’t want to flex or extend back out.

Answer 12

Injuries such as puncture of a digit by a rusty nail can cause infection of the digital synovial sheaths. When inflammation of the tendon and synovial sheath (tenosynovitis) occurs, the digit swells and movement becomes painful. Because the tendons of the 2nd through 4th digits nearly always have separate synovial sheaths, the infec- tion usually is confined to the infected digit. If the infection is untreated, however, the proximal ends of these sheaths may rupture, allowing the infection to spread to the midpalmar space. Because the synovial sheath of the little finger is usually continuous with the common flexor sheath, tenosynovitis in this digit may spread to the common sheath and thus through the carpal tunnel to the forearm. How far an infection spreads from the digits depends on variations in their connections with the common flexor sheath. The tendons of the APL and EPB are in the same ten- dinous sheath on the dorsum of the wrist. Excessive fric- tion of these tendons results in fibrous thickening of the sheath and stenosis of the osseofibrous tunnel, Quervain tenovaginitis stenosans. This condition causes pain in the wrist that radiates proximally to the forearm and distally to the thumb. If the tendons of the FDS and FDP enlarge (forming a nodule) proximal to the tunnel, the person is unable to extend the finger. When the finger is extended passively, a snap is au- dible. This condition is called digital tenovaginitis stenosans (trigger finger or snapping finger). The anatomical snuffbox of extensor pollicis longus, extensor pollicis brevis, and abductor pollicis longus was mentioned in context of scaphoid location. Inflammation of the last two (EPB and APL) within a common tendinous sheath over the radial styloid, as elicited by pain with ulnar deviation (Finkelstein test): de Quervain tenosynovitis.

Answer 13

There are several anatomical sites of compression for the upper limb nerves, with some, such as the cubital tunnel for the ulnar nerve or the carpal tunnel for median nerve. Median nerve compression in the carpal tunnelwithin the carpal tunnel formed by the carpal bones and the flexor retinaculum, the most common compression neuropathy, is often linked to occupational repetitive movements related to wrist flexion and extension, holding the wrist in an awkward position, or strong gripping of objects. Long-term compression often leads to thenar atrophy and weakness of the thumb and index fingers, reflecting the loss of innervation to the muscles distal to the median nerve damage.

Answer 14

Intermittent bilateral attacks of ischemia of the dig- its, marked by cyanosis and often accompanied by paresthesia and pain, are characteristically brought on by cold and emotional stimuli. The condition may result from an anatomical abnormality or an underlying disease. When the cause of the condition is idiopathic (unknown) or primary, it is called Raynaud syndrome (disease). On either side of the fibrous sheath are neurovascular bundles supplying the digits. The blood flow to these may be compromised with Raynaud syndrome, with vasospasm in response to cold or stress. NAV on either side of digits. This follows a classic pattern of: White (vasoconstriction) , Blue (cyanosis) , Red (hyperemia from refill) . The arteries of the upper limb are innervated by sym- pathetic nerves. Postsynaptic fibers from the sympathetic ganglia enter nerves that form the brachial plexus and are distributed to the digital arteries through branches arising from the plexus. When treating ischemia resulting from Rayn- aud syndrome, it may be necessary to perform a cervicodorsal presynaptic sympathectomy (excision of a segment of a sympa- thetic nerve) to dilate the digital arteries. The Allen’s test is used to test the vascular perfusion distal to the wrist. The physician lightly places the thumbs on the patient’s ulnar and radial arteries, and the patient makes a tight fist to “blanch” the palmar skin (squeeze the blood into the dorsal venous network). Then, while compressing the radial artery with the thumb, the physician releases the pressure on the ulnar artery and asks the patient to open the clenched fist. Normally the skin will turn pink immediately, indicating normal ulnar artery blood flow through the anastomotic palmar arches. The test is then repeated by occluding the ulnar artery to assess radial artery flow

Answer 15

ulnar collateral ligament reconstruction slide 31 of UE and LE

Answer 16

Although its extrinsic (coracoclavicular) ligament is strong, the AC joint itself is weak and easily injured by a direct blow. In contact sports such as football,soccer, and hockey, it is not uncommon for dislocation of the AC joint to result from a hard fall on the shoulder or on the out- stretched upper limb. Dislocation of the AC joint also can occur when a hockey player is, for example, driven violently into the boards. An AC dislocation, often called a “shoulder separation,” is severe when both the AC and the coracoclavicular ligaments are torn. When the coracoclavicu- lar ligament tears, the shoulder separates from the clavicle. and falls because of the weight of the upper limb. Dislocation of the AC joint makes the acromion more prominent, and the clavicle may move superior to the acromion. Directly landing on location or stress on limb hits axillary skeletal points.

Answer 17

Adhesive fibrosis and scarring between the in- flamed capsule of the glenohumeral joint, rotator cuff, subacromial bursa, and deltoid usually cause adhesive capsulitis (“frozen shoulder”). A person with this condition has difficulty abducting the arm but can obtain an apparent abduction of up to 45 degrees by elevating and rotating the scapula. Injuries that may initiate this condition include glenohumeral dislocations, calcific supraspinatus tendinitis, partial tearing of the rotator cuff, and bicipital tendinitis. Movement at the shoulder joint (or almost any joint) can lead to inflammation of the tendons surrounding that joint and secondary inflammation of the bursa that cushions the joint from the overlying muscle or tendon. A painful joint can result, possibly even with calcification within the degenerated tendon. The supraspinatus muscle tendon is especially vulnerable because it can become pinched by the greater tubercle of the humerus, the acromion, and the coracoacromial ligament. The acromion can impinge upon the supraspinatus tendon. This can be enhanced by abduction, where the greater tubercle of humerus can be “driven towards” acromion. This can lead to supraspinatus tendinitis. A bursa is a sac of synovial membrane with synovial fluid that reduces friction at points of use. Note the possible bursitis that can occur here. More generally, ongoing inflammation and fibrosis of the structures in this area can lead to adhesive capsulitis (frozen shoulder), with loss of abduction particularly noted.

Answer 18

The subcutaneous olecranon bursa is exposed to injury during falls on the elbow and to infection from abrasions of the skin covering the olecranon. Repeated excessive pressure and friction produces a friction subcutaneous olecranon bursitis (e.g., “student’s elbow”). Subtendinous olecranon bursitis results from excessive friction between the triceps tendon and the olecranon—for example, resulting from repeated flexion–extension of the forearm as occurs dur- ing certain assembly-line jobs. The pain is severe during flexion of the forearm because of pressure exerted on the inflamed subtendinous olecranon bursa by the triceps tendon. Radial head supination pronation at location if dislocate it goes posteriorly. Bursitis from chronic overuse between tendon bone and bone and skin.

Answer 19

The ulnar collateral ligament by the medial epicondyle is an important reinforcement of the elbow, and can be impacted by throwing activities. Rupture, tearing, and stretching of the ulnar collat- eral ligament (UCL) are increasingly common inju- ries related to athletic throwing (primarily baseball pitching, but also football passing, javelin throwing, and play- ing water polo). Reconstruction of the UCL, commonly known as a “Tommy John procedure” (named after the first pitcher to undergo the surgery), involves an autologous transplant of a long tendon from the contralateral forearm or leg (e.g., the palmaris longus or plantaris tendon). A 10- to 15-cm length of tendon is passed through holes drilled through the medial epicondyle of the humerus and the lateral aspect of the coro- noid process of the ulna. Note that the grafting of “spare tendons” such as from palmaris longus or plantaris can be used to reconstruct this support if the UCL is damaged.

Answer 20

Posterior dislocation of the elbow joint may occur when children fall on their hands with their elbows flexed. Dislocations of the elbow may result from hyperextension or a blow that drives the ulna posteriorly or posterolaterally. The distal end of the humerus is driven through the weak anterior part of the fibrous layer of the joint capsule as the radius and ulna dislocate posteriorly. Injury to the ulnar nerve may also occur. Elbow dislocations occur third in frequency after shoulder and finger dislocations. Dislocation often results from a fall on an outstretched hand and includes the following types: • Posterior (most common) • Lateral (uncommon) • Anterior (rare; may lacerate brachial artery) • Medial (rare) Dislocations may be accompanied by fractures of the humeral medial epicondyle, olecranon (ulna), radial head, or coronoid process of the ulna. Injury to the ulnar nerve (most common) or median nerve may accompany these dislocations.

Answer 21

The elbow is a hinge joint formed by humerus, radius, and ulna. These are combined in one joint capsule, with the support of collateral ligaments, as well as an anular ligament to hold the radial head against a corresponding ulnar notch. Preschool children, particularly girls, are vulnerable to transient subluxation (incomplete temporary dis- location) of the head of the radius (“pulled elbow”). The history of these cases is typical. The child is suddenly lifted (jerked) by the upper limb when the forearm is pronated. The child may cry out and refuse to use the limb, which is protected by holding it with the elbow flexed and the forearm pronated. The sudden pulling of the upper limb tears the distal attachment of the anular ligament, where it is loosely attached to the neck of the radius. The radial head then moves distally, partially out of the anular ligament. The proximal part of the torn ligament may become trapped between the head of the radius and the capitulum of the humerus. The source of pain is the pinched anular ligament. The treatment of sub- luxation consists of supination of the child’s forearm while the elbow is flexed. Supination with flexion, or more recently, hyperpronation while flexing, are popular reduction techniques get the radial head back into position.That the pronation approach is less painful and more effective than the classic supination approach. The tear in the anular ligament soon heals when the limb is placed in a sling for about 2 weeks.

Answer 22

see pictures p. 407-409, 420-421, 439, 462-464

Answer 23

see pictures , p. 482-484

Answer 24

used for weight bearing, locomotion, and maintenance of equilibrium. One can divide up the lower extremity to three main joints and three main regions:hip, between hip and knee. knee joint (crus) between knee and ankle . ankle foot- talocrural joint.

Answer 25

Fractures of the hip bone are “pelvic fractures.” Avulsion fractures of the hip bone may occur during sports that require sudden acceleration or deceleration. A small part of the bone with a piece of tendon or ligament attached is “avulsed” (torn away)—for example, the ante- rior superior iliac spine. In older patients, pelvic fractures often include at least two fractures of the ring of bone formed by the pubis, pubic rami, and the acetabulum. One cannot just break one side of a stiff ring. Note how the process of osteoarthritis may lead to erosion of the articular cartilage and triggering of pain with the exposed bony surfaces rubbing against each other. With the subsequent bone effects, osteophytes may be generated.

Answer 26

Congenital dislocation of the hip (hip dysplasia), where the femoral head is not firmly planted in the acetabulum, may be adjusted with bracing, especially for girls and is bilateral in approximately half the cases.. Shallow acetabulum in children clunking in ortolani and bartlow’s. If identified, most commonly, the Pavlik harness is used to keep the hips flexed and abducted to enhance the seating of the femoral head into the acetabulum. In contrast, traumatic dislocation of the hip should be rare if the femoral head is well-seated in the acetabulum, as with adults. Femoral neck fractures. Dislocation occurs when the femoral head is not properly located in the acetabulum. The affected limb appears (and functions as if) shorter because the dislocated femoral head is more superior than on the normal side, resulting in a positive Trendelenburg sign (hip appears to drop to one side during walking). Inability to abduct the thigh is characteristic of congenital dislocation. Acquired dislocation of the hip joint is uncommon because this joint is so strong and stable. Nevertheless, dislocation may occur during an automobile accident when the hip is flexed, adducted, and medially rotated, the usual position of the lower limb when a person is riding in a car. Posterior dislocations are most common. The fibrous layer of the joint capsule ruptures inferiorly and posteriorly, allowing the femoral head to pass through the tear in the capsule and over the posterior margin of the acetabulum onto the lateral surface of the ilium, shortening and medially rotating the affected limb. Because of the close relationship of the sciatic nerve to the hip joint, it may be injured (stretched and/or compressed) during posterior dislocation or fracture–dislocation of the hip joint. Most have normal hip function, firstborns, which may suggest that unstretched uterine and abdominal walls limit fetal movement, and breech delivery. Ortolani’s test of hip abduction confirms the diagnosis.

Answer 27

The term hip fracture is most commonly applied, unfortunately, to fractures of the femoral heads, neck, or trochanters. the femoral neck is under a lot of strain, and with osteoporosis, the weakened bone is likely to fracture. With the main blood supply to the femoral head being branches of the medial circumflex femoral artery that transverse the femoral neck, a fracture in the neck region can lead to risk of avascular necrosis for the head. Its retinacular arteries often are torn when the femoral neck is fractured or the hip joint is dislocated. In some cases, the blood supplied to the femoral head through the artery to the ligament of the femoral head may be the only remaining source of blood to the proximal fragment. This artery is frequently inadequate for maintaining the femoral head; consequently, the fragment may undergo avascular necrosis (AVN—also called osteonecrosis), the result of deficient blood supply. Femoral artery then splits into deep femoral to hamstrings (lateral (trochanter) and medial circumflex (femoral neck and head) femoral arteries). Like scaphoid runs risk of becoming vascularly sclerosed. Osteoarthritis- disease of articular cartilage leading to fibrillation and breakdown of cartilage changing weight bearing aspect or relationship of joints for bone on bone. The neck of the femur is most frequently fractured, especially in females secondary to osteoporosis. Fractures of the proximal femur can occur at sev- eral locations—for example, transcervical and intertrochanteric . The femoral shaft is large and strong; how- ever, a violent direct injury, such as may be sustained in an automobile accident, may fracture it, causing, for example, a spiral fracture. Fractures of the distal femur may be complicated by separation of the condyles, resulting in misalignment of the knee joint. Fracture of the neck of the femur often disrupts the blood supply to the head of the femur. It is not a surprise then that prostheses are typically used for femoral head or neck issues.

Answer 28

The tibial shaft is narrowest at the junction of its inferior and middle thirds, which is the most com- mon site of fracture. Because its anterior surface is subcutaneous, the tibial shaft is the most frequent site of an open fracture (compound fracture)—one in which the skin is perforated and blood vessels are torn—or a diagonal fracture. Fracture of the tibia through the nutrient canal predisposes to nonunion of the bone frag- ments resulting from damage to the nutrient artery. Tibial more weight bearing, fracture fibula fracture could have some weight bearing issues as it pulls on connecting sheath.

Answer 29

Fibular fractures commonly occur just proximal to the lateral mal- leolus and often are associated with fracture–dislocations of the ankle joint. When a person slips, forcing the foot into an excessively inverted position, the ankle ligaments tear, forcibly tilting the talus against the lateral malleolus and shearing it off. In particular, loss of deep fibular nerve function and, hence, loss of the dorsiflexors, leads to foot drop and a compensatory gait.

Answer 30

Calcaneal fractures occur in people who fall on their heels (e.g., from a ladder). Usually, the bone breaks into several fragments (comminuted fracture) that dis- rupt the subtalar joint, where the talus articulates with the cal- caneus . Fractures of the talar neck may occur during severe dorsiflexion of the ankle, for example, when a person is pressing extremely hard on the brake pedal of a car during a head-on collision .

Answer 31

Metatarsal and phalangeal frac- tures are a common injury in endurance athletes and may also occur when a heavy object falls on the foot. Metatarsal fractures are also common in dancers, especially female ballet dancers using the demi-pointe technique. The “dancer’s fracture” usually occurs when the dancer loses balance, putting the full body weight on the metatarsal and fracturing the bone. Injury to the tibial nerve is uncommon because of its protected position in the popliteal fossa; how- ever, the nerve may be injured by deep lacerations in the fossa. Posterior dislocation of the knee joint may also damage

Answer 32

The primary ossification center for the superior end of the tibia appears shortly after birth and joins the shaft of the tibia during adolescence (usually 16–18 years of age). Tibial frac- tures in children are more serious if they involve the epiphys- ial plates because continued normal growth of the bone may be jeopardized. All such fractures of the immature skeleton are routinely characterized by the Salter-Harris classifica- tion that describes the pattern of involvement. Salter-Harris fractures involving epiphyseal growth plates are probably best known in the wrist, but can happen in other long bones as well. Depending on the damage to the plate, the length of the limb can be affected. The tibial tuberosity usually forms by inferior bone growth from the superior epiphysial center at approximately 10 years of age, but a separate center for the tibial tuberosity may appear at approximately 12 years of age. Disruption of the epiphys- ial plate at the tibial tuberosity may cause inflammation of the tuberosity and chronic recurring pain during adoles- cence (Osgood-Schlatter disease), especially in young athletes. A smaller epiphyseal growth plate involves the tibial tuberosity, and with active adolescents, can lead to inflammation and avulsed fragments, particularly in active adolescents 10-15 years old becoming big swollen bump.

Answer 33

Increased pressure in a conf ined anatom- ical space adversely affects the circulation and threatens the function and viability of tissue within or distal to the space (compartment syndrome). The fascial compartments of the lower limbs are generally closed spaces, ending proximally and distally at the joints. Trauma to muscles and/or vessels in the compartments from burns, sustained intense use of muscles, or blunt trauma may produce hemorrhage, edema, and inflammation of the mus- cles in the compartment. Because the septa and deep fascia of the leg forming the boundaries of the leg compartments are strong, the increased volume consequent to any of these processes increases intracompartmental pressure. Increased pressure in a confined space adversely affects the circulation and threatens the function and viability of tissue within or distally (compartment syndrome). The pressure may reach levels high enough to compress structures significantly in the compartment(s) concerned. The small vessels of muscles and nerves (vasa nervorum) are particularly vulnerable to compres- sion. Structures distal to the compressed area may become isch- emic and permanently injured (e.g., muscles with compromised blood supply and/or innervation will not function). Loss of distal leg pulses is an obvious sign of arterial com- pression, as is lowering of the temperature of tissues distal to the compression. A fasciotomy (incision of overlying fascia or a septum) may be performed to relieve the pressure in the compartment(s) concerned. The fascial compartments of the lower limbs are generally closed spaces, ending proximally and distally at the joints. Because the septa and deep fascia of the leg forming the boundaries of the leg com- partments are strong, the increased volume consequent to infection with suppuration (formation of pus) increases intracompartmental pressure. Inflammation within the an- terior and posterior compartments of the leg spreads chiefly in a distal direction; however, a purulent (pus-forming) infec- tion in the lateral compartment of the leg can ascend proxi- mally into the popliteal fossa, presumably along the course of the common fibular nerve. Anterior (tibial) compartment syndrome (or anterior or lateral shin splints) occurs from excessive contraction of anterior compartment muscles; pain over these muscles radiates down the ankle and dorsum of the foot overlying the extensor tendons. Lateral compartment syndrome occurs in people with excessively mobile ankle joints in which hypereversion irritates the lateral compartment muscles. These conditions are usually chronic, and expansion of the compartment may lead to nerve and vessel compression. In the acute syndrome (rapid, unrelenting expansion), the compartment may have to be opened surgically (fasciotomy) to relieve pressure. Interosseus membrane w/ tight fascia around muscle makes it possible to develop. Neurovascular bundle underneath muscles near interosseus membrane w/ bruising or trauma space filling compromising it. Fasciotomy to prevent squeezing of nerves and vessels. Once above pressure of cappilaries worried about perfusion worry about necrosis above and below nerve compression. Foot supply of tibial nerve becoming plantar nerve foot may be in tact but localized spot of dorsalis pedis look for deep fibular nerve. The five Ps of acute anterior compartment syndrome are: • Pain • Pallor • Paresis (footdrop, caused by compression of deep fibular nerve) • Paresthesia • Pulselessness (variable) Athletically active individuals may report hip pain when the injury may actually be related to the lumbar spine (herniated disc), buttocks (bursitis or hamstring injury), or pelvic region (intrapelvic disorder).

Answer 34

Frequently, the great saphenous vein and other superficial veins its tributaries become varicose (dilated and/or tortuous so that the cusps of their valves do not close). Varicose veins are common in the posteromedial parts of the lower limb and may cause discomfort. In a healthy vein, the valves allow blood to flow toward the heart while preventing blood flow away from the heart. Valves also bear the weight of short columns of blood between two valves. Valves in varicose veins, incompetent due to dilation or rotation, no longer function properly. The resulting reverse flow and the weight of long, unbroken columns of blood, produces varicose veins. Deep venous thrombosis (DVT) of one or more of the deep veins of the lower limb is characterized by swelling, warmth, and erythema (inflammation) and infection. Venous stasis (stagnation) is an important cause of thrombus forma- tion. Venous stasis can be caused by • Incompetent, loose fascia that fails to resist muscle expansion, diminishing the effectiveness of the musculovenous pump • External pressure on the veins from bedding during pro- longed institutional stays or from a tight cast, bandages, or bands of stockings • Muscular inactivity (e.g., during an overseas flight) DVT with inflammation around the involved veins (thrombophlebitis) may develop. A large thrombus that breaks free from a lower limb vein may travel to a lung, forming a pulmonary thromboembolism (obstruction of a pulmonary artery). A large embolus may obstruct a main pulmonary artery and may cause death.Although deep venous (or deep vein) thrombosis (DVT) may occur anywhere in the body, veins of the lower limb are most often involved. Three cardinal events account for the pathogenesis and risk of DVT: stasis, venous wall injury, and hypercoagulability. • Clinical risk factors for DVT include the following: Postsurgical immobility • Infection • Malignancy • Pregnancy. Incompetent valves in superficial veins can lead to varicosities. The loss of a set of valves puts additional pressure on an inferior valves, leading to the propagation of the dilated veins. Great (medial side dive into femoral) and small saphenous (posteriorly dives into popliteal) vessels. Communicating veins between saphenous and tibia with some laxity in vlaves of communicating giving saphenous more flow than used to. Lose one of veins becoming swollen and distended incompetence leads to compounding affect downstream as each valve upstream becomes incompetent. In contrast to the varicosities of superficial veins, deep venous thrombosis puts the patient at risk for pulmonary embolism.

Answer 35

Sports broadcasters and trainers refer to a “hip pointer injury,” which is a contusion of the iliac crest, usually its anterior part. This is one of the most common injuries to the hip region, usually occurring in association with sports, such as football, ice hockey, and volleyball. Contusions cause bleeding from ruptured capillaries and infiltration of blood into the muscles, tendons, and other soft tissues. The term hip pointer injury may also refer to avulsion of the bony site of muscle attachments, for example, of the sartorius or rectus femoris to the anterior superior and inferior iliac spines respectively. However, these injuries should be called avulsion fractures. Another term commonly used is “charley horse,” which may refer either to the acute cramping of an individual thigh muscle because of ischemia, nocturnal leg cramps, or to contusion and rupture of blood vessels sufficient to form a hematoma (blood clot). The latter is usually the consequence of tearing of fibers of the rectus femoris; sometimes, the quadriceps tendon is also partially torn.

Answer 36

Ischial bursitis results from excessive friction between the ischial bursae and the ischial tuberosities (e.g., as from cycling). Because the tuberosities bear the body weight during sitting, these pressure points may lead to pressure sores in debilitated people, particularly paraplegic persons. Diffuse deep pain in the lateral thigh region, especially during stair climbing or rising from a seated position, may be caused by trochanteric bursitis. It is characterized by point tenderness over the greater trochanter; however, the pain often radiates along the iliotibial tract. A commonly overlooked diagnosis that clinically mimics trochanteric bursitis is a tear of the insertion of gluteus medius tendon on the trochanter.

Answer 37

A charley horse is associated with localized pain and/or muscle stiffness and commonly follows direct trauma or muscle fatigue. A number of structures in the hip region can generate pain, whether referred pain from back issues, to groin pulls from the adductor muscles and their localized origins from the pubis, to hamstring pulls and their attachment to the ischial tuberosities, or different bursitis issues. Piriformis syndorme- on top of sciatic nerve in foramen and can squeeze sciatic nerve and pain. Ischial bursitis- sit all day and inflame bursa. Hamstring strain- off of ischial tuberosity

Answer 38

Pain deep to the patella often results from excessive running, especially downhill; hence, this type of pain is often called “runner’s knee.” The pain results from repetitive microtrauma caused by abnormal tracking of the patella relative to the patellar surface of the femur, a condition known as the patellofemoral syndrome. This syndrome may also result from a direct blow to the patella and from osteoarthritis of the patellofemoral compartment (degenerative wear and tear of articular cartilages). In some cases, strengthening of the vastus medialis corrects patellofemoral dysfunction. This muscle tends to prevent lateral dislocation of the patella resulting from the Q-angle because the vastus medialis attaches to and pulls on the medial border of the patella. Hence, weakness of the vastus medialis predisposes the individual to patellofemoral dysfunction and patellar dislocation. liotibial tract syndrome is common in runners and presents as lateral knee pain, often in the midrange of flexion, between 20 and 70 degrees of knee flexion. The iliotibial tract, often referred to as “iliotibial band” by clinicians, rubs across the lateral femoral condyle, and this pain also may be associated with more proximal pain from greater trochanteric bursitis.Quadriceps tendon rupture occurs mostly in older individuals, from either minor trauma or age-related degenerative changes, including the following:

Answer 39

Subluxation of the patella, usually laterally, is a fairly common occurrence, especially in adolescent girls and young women. It often presents with tenderness along the medial patellar aspect and atrophy of the quadriceps tendon, especially the oblique portion medially derived from the vastus medialis. Patellar ligament rupture usually occurs just inferior to the patella as a result of direct trauma in younger people. Quadriceps tendon rupture occurs mostly in older individuals, from either minor trauma or age-related degenerative changes, including the following: Arthritism Arteriosclerosis, Chronic renal failure, Corticosteroid therapy, Diabetes, Hyperparathyroidism, Gout

Answer 40

Tapping the patellar ligament with a reflex hammer normally elicits the patellar reflex (“knee jerk”). This myotatic (deep tendon) reflex is routinely tested during a physical examination by having the person sit with the legs dangling. A firm strike on the ligament with a reflex hammer usually causes the leg to extend. If the reflex is normal, a hand on the person’s quadriceps should feel the muscle contract. This tendon reflex tests the integrity of the femoral nerve and the L2–L4 spinal cord segments. Diminution or absence of the patellar tendon reflex may result from any lesion that interrupts the innervation of the quadriceps (e.g., peripheral nerve disease). Cruciate (anterior posterior stability of the knee and translocation. Colatteral ligaments- posterior cruciate ligament larger than anterior. ACL can anteriorly translocate tibia. Disruption of the normal function of the cruciate ligaments can be tested by the drawer tests

Answer 41

Knee joint injuries are common because the knee is a low-placed, mobile, weight-bearing joint and its stability depends almost entirely on its associated ligaments and muscles. The most common knee injuries in contact sports are ligament sprains, which occur when the foot is fixed on the ground. If a force is applied against the knee when the foot cannot move, ligament injuries are likely to occur. The MCL and LCL are tightly stretched when the leg is extended, preventing disruption of the sides of the joint. The firm attachment of the MCL to the medial meniscus is of clinical significance because tearing of this ligament frequently results in concomitant tearing of the medial meniscus. The injury is frequently caused by a blow to the lateral side of the extended knee or excessive lateral twisting of the flexed knee, which disrupts the MCL and concomitantly tears and/ or detaches the medial meniscus from the joint capsule. This injury is common in athletes who twist their flexed knees while running (e.g., in football and soccer). The ACL, which serves as a pivot for rotatory movements of the knee, is taut during flexion and may also tear subsequent to the rupture of the MCL. ACL rupture, one of the most common knee injuries in skiing accidents, for example, causes the free tibia to slide anteriorly under the femur, a sign known as the anterior drawer sign. Although strong, PCL rupture may occur when a person lands on the tibial tuberosity when the knee is flexed. PCL ruptures usually occur in conjunction with tibial or fibular ligament tears. The posterior drawer sign, in which the free tibia slides posteriorly under the fixed femur, occurs as a result of PCL rupture. Degenerative joint disease is a catch-all term for osteoarthritis, degenerative arthritis, osteoarthrosis, or hypertrophic arthritis; it is characterized by progressive loss of articular cartilage and failure of repair. The anterior cruciate ligament limits anterior motion and rotation of the tibia. The unhappy triad (of O’Donoghue) can be generated from a strong valgus force, with damage to the ACL (pull tibia anterior compared to femur if one is fixed Acl taking most of brunt pop sound and rupture w/ bleeding), MCL, and medial meniscus attach each other. Despite the implications in this picture with direct trauma, ACL injuries can be generated by planting the foot and then cutting. The ACL is under tension when the knee is flexed, and a patient with an ACL tear will typically report an audible “pop” while planting the foot and pivoting at the knee. This is followed by knee instability and immediate swelling. ACL tears have a high incidence of associated meniscal tears, as indicated here. MRI is typically the imaging study of choice so as to examine soft tissue. ACL very common in women because of Q angle, LCL off to side, MCL with medial meniscus, Suggested factors why females tend to be at higher risk for ACL tears include: Greater Q angle, Narrower intercondylar notch, Use of quadriceps over hamstrings for deceleration.

Answer 42

The anterior cruciate ligament limits anterior motion and rotation of the tibia. The unhappy triad (of O’Donoghue) can be generated from a strong valgus force, with damage to the ACL (pull tibia anterior compared to femur if one is fixed Acl taking most of brunt pop sound and rupture w/ bleeding), MCL, and medial meniscus attach each other. Despite the implications in this picture with direct trauma, ACL injuries can be generated by planting the foot and then cutting. The ACL is under tension when the knee is flexed, and a patient with an ACL tear will typically report an audible “pop” while planting the foot and pivoting at the knee. This is followed by knee instability and immediate swelling. ACL tears have a high incidence of associated meniscal tears, as indicated here. MRI is typically the imaging study of choice so as to examine soft tissue. ACL very common in women because of Q angle, LCL off to side, MCL with medial meniscus, Suggested factors why females tend to be at higher risk for ACL tears include: Greater Q angle, Narrower intercondylar notch, Use of quadriceps over hamstrings for deceleration. Intracondylar tunnel, ACL narrower cavity than PCL with fixed foot and twist ACL stretching ACL similar to flat feet and over pronating feet. With valgus force

Answer 43

Housemaid’s knee or prepatellar bursitis demonstrates the presence of the subcutaneous prepatellar bursa following chronic irritation. Swollen knees because of brusa and knee patella and skin (prepateller) suprapatellar (below quadriceps) synovial membrane sacs. pes anserinus (foot goose), with its interactions of sartorius, gracilis, and semitendinosus tendons, is among other structures in the knee region with its own bursa.

Answer 44

The femoral ring is a weak area in the lower anterior abdominal wall medial delineation of a fascial femoral sheath surrounding femoral structures that is the site of a femoral hernia, a protrusion of abdominal viscera (often a loop of small intestine) through the femoral ring into the femoral canal. A femoral hernia is more common in women than in men (in whom inguinal hernias are more common), presumably given the difference in pelvic widths. The hernial sac displaces the contents of the femoral canal and distends its wall. Initially, the hernia is relatively small because it is contained within the femoral canal, but it can enlarge by passing through the saphenous opening into the subcutaneous tissue of the thigh. Strangulation of a femoral hernia may occur and interfere with the blood supply to the herniated intestine, and vascular impairment may result in death of the tissues, doesn’t slide back and forth line inguinal and become incarcerated

Answer 45

The pulse of the femoral artery is usually palpable just inferior to the midpoint of the inguinal ligament. Normally, the pulse is strong; however, if the common or external iliac arteries are partially occluded, the pulse may be diminished. The femoral artery may be manually compressed at the midpoint of the inguinal ligament to control arterial bleeding after lower limb trauma. The femoral artery may be cannulated just inferior to the midpoint of the inguinal ligament (e.g., for cardioangiography—radiography of the heart and great vessels after the introduction of contrast material). For left cardiac angiography, a long slender catheter is inserted percutaneously into the femoral artery and passed superiorly in the aorta to the openings of the coronary arteries.The femoral vessels inferior to the inguinal ligament may offer access to the left heart via the femoral artery or the right heart via the femoral vein. Femoral nav order. Femoral to external artery and vein empty space have lymphatic

Answer 46

Injury to the superior gluteal nerve can lead to a sagging pelvic tilt, with a waddling gluteal medius limp. Gluteus medius and minimus contract on other side if not will sag.

Answer 47

The femoral pulse is felt at about the midpoint of the inguinal ligament. The femoral artery at this point lies directly over or just medial to the femoral head, just lateral to the femoral vein and about a finger’s breadth medial to the femoral nerve . The femoral artery and vein may be used to gain access to major vessels of the limbs, abdominopelvic cavity, and thorax (e.g., catheter threaded through femoral artery and into aorta for coronary artery angiography and angioplasty). Similarly, access to the larger veins of the inferior vena cava and the right side of the heart and pulmonary veins may be obtained through the femoral vein. “Up and out” (the superolateral quadrant) is the preferred location for intragluteal injections, so as to avoid the sciatic nerve aim for medius and minimus not maximus.

Answer 48

Because the popliteal artery is deep in the popliteal fossa, it may be difficult to feel the popliteal pulse. To palpate this pulse, the person is placed in the prone position with the knee flexed to relax the popliteal fascia and hamstrings. The pulsations are best felt in the inferior part of the fossa. The posterior tibial pulse can usually be palpated between the posterior surface of the medial malleolus and the medial border of the calcaneal tendon. Because the posterior tibial artery passes deep to the flexor retinaculum, it is important when palpating this pulse to have the person relax the retinaculum by inverting the foot. Failure to do this may lead to the erroneous conclusion that the pulse is absent. can suggest the presence of peripheral vascular disease, particularly in the presence of symptoms of intermittent claudication. Weakening or loss of the popliteal pulse is a sign of femoral artery obstruction. The popliteal artery is vulnerable in knee dislocations; downstream pulses should be tested if dislocation has occurred. The dorsalis pedis pulse is evaluated during a physical examination of the peripheral vascular system. Dorsalis pedis pulses may be palpated with the feet slightly dorsiflexed. The pulses are usually easy to palpate because the dorsal arteries are subcutaneous and pass along a line from the extensor retinaculum to a point just lateral to the extensor hallucis longus tendons. A diminished or absent dorsalis pedis pulse usually suggests vascular insufficiency resulting from arterial disease. The five P signs of acute arterial occlusion are pain, pallor, paresthesia, paralysis, and pulselessness. Some healthy adults (and even children) have congenitally nonpalpable dorsalis pedis pulses; the variation is usually bilateral. In these cases, the dorsalis pedis artery is replaced by an extended perforating fibular artery of smaller caliber than the typical dorsalis pedis artery, but running in the same location. Especially important when injured look at pulses distally

Answer 49

Shin splints—edema and pain in the area of the distal two thirds of the tibia—result from repetitive microtrauma of the tibialis anterior (TA), common in athletes, which causes small tears in the periosteum covering the shaft of the tibia and/or of fleshy attachments to the overlying deep fascia of the leg. Shin splints are a mild form of the anterior compartment syndrome. Shin splints cause pain along the inner distal two thirds of the tibial shaft. The primary cause is repetitive pulling of the tibialis posterior tendon as one pushes off the foot during running. Stress on the muscle occurs at its attachment to the tibia and interosseous membrane. Shin splints commonly occur during traumatic injury or athletic overexertion of muscles in the anterior compartment, especially TA. Muscles in the anterior compartment swell from sudden overuse, and the edema and muscle–tendon inflammation reduce the blood flow to the muscles. The swollen muscles are painful and tender to pressure.Chronic conditions can produce periostitis and bone remodeling or can lead to stress fractures. Pain usually begins as soreness after running that worsens and then occurs while walking or climbing stairs. Similarly, an anterior “shin splint” may represent excessive use/force on tibialis anterior, e.g., imbalance with the large plantarflexors, where microtrauma at its attachment to the tibial periosteum and interosseus membrane can lead to pain in the muscle and possible compression of the neurovascular contents if the muscles swell enough, e.g., from high levels of exertion or trauma. Tension or work on tibialis posterior and anterior (internal) could pull on interosseus membrane causing shin splint, exertional compartment syndrome, microfracture of bones can also cause

Answer 50

Tendinitis of the calcaneal (Achilles) tendon is a painful inflammation that often occurs in runners who run on hills or uneven surfaces. Repetitive stress on the tendon occurs as the heel strikes the ground and when plantarflexion lifts the foot and toes. Tendon rupture is a serious injury, and the avascular tendon heals slowly. Retrocalcaneal bursitis, an inflammation of the subtendinous bursa between the overlying tendon and the calcaneus, presents as a tender area just anterior to the tendon attachment. Microscopic tears of collagen fibers in the tendon, particularly just superior to its attachment to the calcaneus, result in tendinitis, which causes pain during walking. Calcaneal tendon rupture is often sustained by people with a history of calcaneal tendinitis. After complete rupture of the tendon, passive dorsiflexion is excessive, and the per- son cannot plantarflex against resistance. Microtrauma of the calcaneal tendon can lead to tendinitis. Chronic tendinitis and the accompanying inflammation can lead to the risk of calcaneal tendon rupture and the loss of plantarflexion. Not really vascularized wont heal quickly.

Answer 51

plantar fascia Supprot for medial arch of foot. Straining and inflammation of the plantar aponeurosis at its insertion in the calcaneal tuberosity, a condition called plantar fasciitis (heel spur syndrome) , may result from running and high-impact aerobics, especially when inappropriate footwear is worn. It causes pain on the plantar surface of the heel and on the medial aspect of the foot. Point tenderness is located at the proximal attachment of the plantar aponeurosis to the medial tubercle of the calcaneus and on the medial surface of this bone. The pain increases with passive extension of the great toe and may be further exacerbated by dorsiflexion of the ankle and/or weight bearing. A calcaneal spur (abnormal bony process) protruding from the medial tubercle has long been associated with plantar fasciitis and pain on the medial side of the foot when walking, where the ongoing traction of the fascia and inflammation can lead to bone spur formation; however, many asymptomatic patients are found to have such spurs. Generally, it is more common in females and obese persons. A bony spur may develop with plantar fasciitis, but the inflammation causes most of the pain, mediated by the medial calcaneal branch of the tibial nerve. Most patients can be managed nonsurgically, but relief from the pain may take 6 to 12 months. Exercises and orthotic devices are usually recommended in the initial course of treatment. Most cases of plantar fasciitis are self-limiting and respond well to conservative treatment. Bone spur- traction on the foot to develop bone in locations indicative of chronic traction .

Answer 52

The femur is placed diagonally within the thigh, whereas the tibia is almost vertical within the leg, creating a Q-angle at the knee between the long axes of the bones. The Q-angle is assessed by drawing a line from the ASIS to the middle of the patella and extrapolating a second (vertical) line through the middle of the patella and tibial tuberosity. The Q-angle is typically greater in adult females owing to their wider pelves. A medial angulation of the leg in relation to the thigh, in which the femur is abnormally vertical and the Q-angle is small, is a deformity called genu varum (bowleg) that causes unequal weight distribution. Genu varum (bowleg) R sticking out and genu valgum (knocknee) alter the Q-angle and lead to unequal distribution of stress on the knee different stresses on meniscus, collateral ligaments, and epicondyle. Excess pressure is placed on the medial aspect of the knee joint, which results in arthrosis (destruction of knee cartilage). Excessive valgus angulation is called genu valgum, or knock-knee, and an excessive varus angulation is called genu varum, or bowleg. These deformities occur in growing children and are often related to rickets, skeletal dysplasia, or trauma. Most resolve without treatment.

Answer 53

A lateral angulation of the leg in relation to the thigh (exaggeration of knee angle) is genu valgum (knockknee). Consequently, in genu valgum, excess stress is placed on the lateral structures of the knee. The patella, normally pulled laterally by the tendon of the vastus lateralis, is pulled even farther laterally when the leg is extended in the presence of genu varum so that its articulation with the femur is abnormal. The knee of a standing patient should look symmetric and level. The tibia normally has a slight valgus angulation compared with the femur. Valgus is used to describe the bone distal to the examined joint; a valgus angulation refers to a slight lateral angle.

Answer 54

The ankle is the most frequently injured major joint in the body. Ankle sprains (torn fibers of ligaments) are most common. A sprained ankle is nearly always an inversion injury, involving twisting of the weight-bearing plantarflexed foot. The anterior talofibular ligament (part of the lateral ligament) is most commonly torn during ankle sprains, either partially or completely, resulting in instability of the ankle joint. The calcaneofibular ligament may also be torn Most ankle sprains involve an inversion injury when the foot is plantarflexed, placing stress on the components of the lateral collateral ligament. Often the severity of the injury occurs from anterior to posterior, involving first the anterior talofibular ligament, then the calcaneofibular ligament, and finally, if especially severe, the posterior talofibular ligament. The anterior drawer test, in which the tibia is held steady while the heel is pulled anteriorly with the foot in about 10 to 20 degrees of plantarflexion, will confirm the injury to the anterior talofibular ligament if the translation of the foot anteriorly is excessive compared with that of the uninjured contralateral ankle. sprain involve ligaments, strains involve muscles/tendons

Answer 55

A forcible eversion can lead to a Pott fracture (bimalleolar fracture), with the medial ligament causing an avulsion fracture of the medial malleolus, and then damaging the fibula. A Pott fracture–dislocation of the ankle occurs when the foot is forcibly everted. This action pulls on the extremely strong medial ligament, often tearing off the medial malleolus. The talus then moves laterally, shearing off the lateral malleolus or, more commonly, breaking the fibula superior to the tibiofibular syndesmosis. If the tibia is carried anteriorly, the posterior margin of the distal end of the tibia is also sheared off by the talus. Deltoid contribute to evulsion fracture rather than tear by itself. Ankle joint capsule not as defined as rest

Answer 56

Hallux valgus is a foot deformity caused by degenerative joint disease; it is characterized by lateral deviation of the great toe (L. hallux). In some people, the deviation is so great that the first toe overlaps the second toe. These individuals are unable to move their 1st digit away from their 2nd digit because the sesamoid bones under the head of the 1st metatarsal are displaced and lie in the space between the heads of the 1st and 2nd metatarsals. In addition, a subcutaneous bursa may form owing to pressure and friction against the shoe. The thickened bursa (often inflamed and tender) and/or reactive hyperostosis of the head of the 1st metatarsal results in a protuberance called a bunion Hallux valgus, with its striking lateral deviation of the hallux (big toe), can lead to rubbing and inflammation of the head of the first metatarsal to generate a bunion. Wieght bearing causing friction point. Callus- hyperkeratinized throughout. Corns- softer in non weight bearing areas between or on toes, indurated internal part, initial firm part in middle and little hard part can become warped in in diabetes. Are they feeling it?

Answer 57

Acquired flatfeet (“fallen arches”) are likely to be secondary to dysfunction of the tibialis posterior owing to trauma, degeneration with age, or denervation. In the absence of normal passive or dynamic support, the plantar calcaneonavicular ligament fails to support the head of the talus. Consequently, the talar head displaces inferomedially and becomes prominent. As a result, some flattening of the medial longitudinal arch occurs, along with lateral deviation of the forefoot. Flatfeet are common in older people, particularly if they undertake much unaccustomed standing or gain weight rapidly, adding stress on the muscles and increasing the strain on the ligaments supporting the arches.

Answer 58

see pictures p. 320-322

Answer 59

see pictures p. 394-395

Answer 60

narrowing of the angle between parts.

Answer 61

increase of the angle between parts.

Answer 62

depression referring to scapula. Protract vs. retract

Answer 63

referring to raising or lowering the toes. (evertvs. invert). ankle joint is a hinge joint between tibia/fibula and talus (talocrural articulation). The tibial-talar interaction is such that the trochlear surface of the talus is narrower posteriorly, and hence less surface contact and stability in plantarflexion compared to dorsiflexion.

Answer 64

move towards the midline (“adding to it”)

Answer 65

move away from the midline

Answer 66

the circular motion best done at ball and socket joints.

Answer 67

bone along its long axis; note the difference between lateral or external rotation vs. medial or internal rotation.

Answer 68

palm anterior with forearm rotation.

Answer 69

palm posterior with forearm rotation.

Answer 70

Many headaches have a dural component, given the innervation of the meninges with branches of trigeminal nerve. The dura is sensitive to pain, especially where it is related to the dural venous sinuses and meningeal arteries. Although the causes of headache are numerous, distention of the scalp or meningeal vessels (or both) is believed to be one cause of headache. Many headaches appear to be dural in origin, such as the headache occurring after a lumbar spinal puncture for removal of CSF. These headaches are thought to result from stimulation of sensory nerve endings in the dura. When CSF is removed, the brain sags slightly, pulling on the dura; this may cause pain and headache. For this reason, patients are asked to keep their heads down after lumbar puncture to minimize the pull on the dura, reducing the chances of headache. Brain tissue not wired for pain, meninges are. Facial nerve 5 for different meninges wiring seems to be covering around tentoreum (cerebelli between cerebral cortex and cerebellum on bottom) and temporal lobe (herpes encephalitis)

Answer 71

Head injuries can be associated with intracranial bleeding. Three major types of bleeds outside of intracerebral involvement: Sharp blow, localized skull fracture, deeper majorly concussing. Blood from torn branches of a middle meningeal artery collects between the external periosteal layer of the dura and the calvaria, usually after a hard blow to the head. Epidural hematomas result most often from motor vehicle crashes, falls, and sports injuries. The blood collects between the periosteal dura mater and bony cranium. The source of the bleeding is usually arterial (85%); common locations include the frontal, temporal (middle meningeal artery is very susceptible, especially where it lies deep to the pterion), and occipital regions. brief concussion with loss of consciousness patient wakes up fine but later, drowsiness and coma occur because of space filling it leads to herniation through foramen magnum causing blown pupil because no parasymapathetic tone through oculomotor nerve. Extradural or epidural hemorrhage is arterial in origin.. This results in the formation of an extradural or epidural hematoma. The brain is compressed as the blood mass increases, necessitating evacuation of the blood and occlusion of the bleeding vessels. .

Answer 72

Tearing of the bridging veins between brain and dural sinuses. A dural border hematoma classically is called a subdural hematoma; however, this term is a misnomer because there is no naturally occurring space at the dura–arachnoid junction. Hematomas at this junction are usually caused by extravasated blood that splits open the dural border cell layer. The blood does not collect within a preexisting space but rather creates a space at the dura–arachnoid junction. Dural border hemorrhage usually follows a blow to the head that jerks the brain inside the cranium and injures it. The precipitating trauma may be trivial or forgotten, but a hematoma may develop over many weeks from venous bleeding. Dural border hemorrhage is typically venous in origin and commonly results from tearing of a superior cerebral vein bridging in as it enters the superior sagittal sinus. compresing brain causing significant damage. Subdural hemorrhage leading to a subdural hematoma, is more common in elderly/alcoholic patients (those with some brain atrophy and hence more “gap” that veins must transverse), and is often the result of tearing in a superior cerebral vein as it feeds into the superior sagittal sinus. These can be more chronic than the epidural hematoma, and may present with fluctuating drowsiness.

Answer 73

Subarachnoid hemorrhage is an extravasation (escape) of blood, usually arterial, into the subarachnoid space results in the collection of blood between the arachnoid mater and pia mate. Most subarachnoid hemorrhages result from rupture of a saccular aneurysm (sac-like dilation on an artery) in the willis region. Some subarachnoid hemorrhages are associated with head trauma involving cranial fractures and cerebral lacerations. Bleeding into the subarachnoid space results in meningeal irritation, a severe headache, stiff neck, and often loss of consciousness (seepage of blood down to spinal cord). The most common cause of subarachnoid hemorrhage is the rupture of a saccular, or berry, aneurysm. leading to signs of meningeal irritation (severe headache, stiff neck, “the worst headache of my life”), with blood in the CSF.

Answer 74

Cerebral contusion (bruising) results from brain trauma in which the pia is stripped from the injured surface of the brain and may be torn, allowing blood to enter the subarachnoid space. The bruising results from the sudden impact of the moving brain against the stationary cranium or from the suddenly moving cranium against the stationary brain. Cerebral contusion may result in an extended loss of consciousness. Cerebral lacerations are often associated with depressed cranial fractures or gunshot wounds. Lacerations result in rupture of blood vessels and bleeding into the brain and subarachnoid space, causing increased intracranial pressure and cerebral compression. Cerebral compression may be produced by • Intracranial collections of blood • Obstruction of CSF circulation or absorption • Intracranial tumors or abscesses • Brain swelling caused by brain edema, an increase in brain volume resulting from an increase in water and sodium content Fractures in the floor of the middle cranial fossa may result in leakage of CSF from the external acoustic meatus (CSF otorrhea) if the meninges superior to the middle ear are torn and the tympanic membrane (eardrum) is ruptured. Fractures in the floor of the anterior cranial fossa may involve the cribriform plate of the ethmoid, resulting in leakage of CSF through the nose (CSF rhinorrhea). CSF otorrhea and CSF rhinorrhea may be primary indications of a cranial base fracture and increase the risk of meningitis because an infection could spread to the meninges from the ear or nose

Answer 75

choroid plexus is the site of cerebrospinal fluid synthesis, with arachnoid granulations projecting into the superior sagittal sinus the location of where the CSF drains back into the venous circulation. CSF made by little collection of ependymal cells in lateral and fourth ventricle in the choroid plexus w/ blood supplies from loops of capillaries below that help to supply it with proper nutrition for the brain. CSF floats around and back to dural sinus (largest superior sagittal sinus). Overproduction of CSF, obstruction of its flow, or interference with its absorption results in an excess of CSF in the subarachnoid space ventricles. When it occurs in infants and young children, the head enlarges, a condition known as hydrocephalus. Cerebral aqueduct stenosis most common in infants. TBI or infection (meningitis) arachnoid and pia if no longer driaining pressure not going on. Midbrain and cerebral aqueduct can get stenosed off, choroid plexus of lateral plexus can dilate especially if anteiror and posterior fontanelle never fused. Excess CSF dilates the ventricles; thinning the surrounding brain; and, in infants, separates the bones of the calvaria because the sutures and fontanelles are still open. Internal (obstructive) hydrocephalus: CSF building up in the ventricles, most commonly from congenital aqueductal stenosis, so more common in preossified infants. This will usually cause cerebral cortex to atrophy and cranial bones to thin if not treated by ventriculostomy (artificial opening into the floor of the third ventricle draining into cistern beneath to recirculate) or ventricular shunting ending in the abdomen, which can get clogged)

Answer 76

Glial cells- keeping area sterile or in repair having macrophage. Additional cells floating around astrocytes- supprotive helping to surround blood vessels w/ tight junctions of capillaries combination leading to a blood brain barrier making it harder for substances to cross over. The homunculus is a functional HAL (head-arm-leg) representation on the precentral and postcentral gyri from lateral  medial. Note that the Internal carotid artery- middle cerebral artery (MCA) supplies the lateral HA (head-arm) part of the homunculus, while the anterior cerebral artery (ACA) supplies the medial L (leg) part. Increased cortical space means increased sensory. Vertebral\> basilar artey\> posterior\> temporal artery visual area at end of visual pathway and its association

Answer 77

Stroke is classified into the following two types: • Ischemic (70-80%): infarction; thrombotic or embolic, resulting from atherosclerosis of the extracranial (usually carotid) and intracranial arteries or from underlying heart disease. An ischemic stroke denotes the sudden development of neurological deficits that are related to impaired cerebral blood flow. In acute ischemic stroke, ischemic brain injury begins with a central core of very low perfusion and often irreversible cell death. This core is surrounded by an ischemic penumbra of metabolically disturbed cells that are still potentially viable, depending on the restoration of blood flow and duration of ischemia. Because most irreversible damage occurs in the first 3–6 hrs after onset of symptoms, therapies targeted to the 3-hr window achieve the best outcomes, with recovery in up to 50% of patients in some studies. The most common causes of strokes are spontaneous cerebrovascular accidents such as cerebral embolism, cerebral thrombosis, cerebral hemorrhage, and subarachnoid hemorrhage. The cerebral arterial circle is an important means of collateral circulation in the event of gradual obstruction of one of the major arteries forming the circle. Sudden occlusion, even if only partial, results in neurological deficits. In elderly persons, the anastomoses are often inadequate when a large artery (e.g., internal carotid) is occluded, even if the occlusion is gradual (in which case function is impaired at least to some degree). upper motor neuron lesion if caused by cerebral hemisphere stroke develop decorticate posturing (flexion of wrist and elbow and extension (straightening of ankle and knee). midbrain strokes- elbow extendinded (decerebrate posturting)

Answer 78

Hemorrhagic: occurs when a cerebral vessel weakens and ruptures (subarachnoid or intracerebral hemorrhage), which causes intracranial bleeding, usually affecting a larger brain area. Hemorrhagic stroke follows the rupture of an artery or a saccular aneurysm, a sac-like dilation on a weak part of the arterial wall. The most common type of saccular aneurysm is a berry aneurysm, occurring in the vessels of or near the cerebral arterial circle and the medium arteries at the base of the brain. In time, especially in people with hypertension (high blood pressure), the weak part of the arterial wall expands and may rupture, allowing blood to enter the subarachnoid space. poorly controlled BP supplies basal ganglia creating hemmorhagic, phalamic basal ganglia, disurpting communication from lower body to brain subarachnoid space normally CSF all blood is irritating giving stiff neck

Answer 79

A transient ischemic attack is a temporary interruption of focal brain circulation that results in a neurologic deficit that lasts less than 24 hours, usually 15 minutes to 1 hour. The most common cause of TIA is embolic disease from the heart, carotid, or cerebral vessels, which may temporarily block a vessel. The onset of the deficit is abrupt, and recovery is gradual. The most common deficits include the following: • Hemiparesis • Hemisensory loss • Aphasia • Confusion • Hemianopia • Ataxia • Vertigo Cerebrovascular accident (CVA) or stroke is a localized brain injury caused by a vascular episode that lasts more than 24 hours, whereas a transient ischemic attack (TIA) is a focal ischemic episode lasting less than 24 hours.

Answer 80

Dementia is an acquired neurologic syndrome that presents with multiple cognitive deficits. By definition, dementia includes short-term memory impairment, behavioral disturbance, and/or difficulties with daily functioning and independence. Dementia can be classified as degenerative, vascular, alcoholic, or human immunodeficiency virus (HIV) related. Vascular dementias are caused by anoxic damage from small infarcts and account for about 15% to 20% of dementia cases. Multiinfarct dementia is associated with heart disease, diabetes mellitus, hypertension, and inflammatory diseases. Damage brain from stroke at internal capsule and transect, upper neuromotor neuron symptom helping to regulate. Increased motor tone Limbic system- behavior Temmporal lobe- behavior things going on in hippocampus w/ processing of episodic informaiton to long term when damaged w/ alzheimers new memories don’t form and gyri around it losing distant memories tied in with emotion aka amygdala emotional context helps you to remember. The Papez circuit indicates the integral role of the role of the hypothalamus as a liaison between the autonomic system and the emotional processing of the limbic system. The hippocampus is well known as a site for memory consolidation. For example, “HM”, well-known in general psychology classes with his bilateral surgical removal of hippocampi for intractable seizures, had a subsequent loss of ability to establish new long-term memories for decades. Cortisol receptors if so overwhelmed and stressed cant remember. Alzheimer disease targets the hippocampus and parahippocampal gyrus initially. The amygdala receives a variety of inputs in order to affect (pun intended) emotional responses to different sensory stimuli. Adrogen and test leading to exaggerated emotional response. Smell olfactory bulb limbic system- affecting the limbic system triggering emotions, disrupting behavior and memories. Mammilary bodies behind pituitary damaged w/ chronic thaimaine deficeincy ex. Memory retraction altered bizarre and specialized cortical deficit. Mammillary body damage is often involved in Wernicke-Korsakoff syndrome, caused by thiamine deficiency in patients, e.g., chronic ethanol abuse.

Answer 81

The cerebrum is found in the forebrain, and is the largest part of the brain. It is responsible for higher mental functions, which include memory and reason. It consists of paired lobes and two hemispheres. Left and right hemispheres are partially divided by a longitudinal cerebral fissure. Cerebral Cortex- detailed integrated functions. Convolutions are evident, with elevated gyri (s. gyrus) and grooves of sulci (s. - sulcus) that help to increase the gray matter area. Fissures (deep sulci) separate the cerebral hemispheres into lobes. Immediately in front of the central sulcus (seperating frontal from parietal) is the precentral gyrus (important motor region). Immediately behind the central sulcus is the postcentral gyrus (important sensory region).

Answer 82

functions include voluntary motor impulses for skeletal muscles, and dealing with responses relating to personality, reason, emotions, etc. Broca area: motor speech. Prefrontal lobe- behavioral. Motor activity precentral gyrus of frontal lobe, (prefrontal lobe, personality issues) and motor areas, such as Broca, for motor aspects of speech; precentral gyrus; for motor initiation, organized lateral to medial: HAL (head arm leg) conscious intellect.

Answer 83

functions in interpretation of texture and shapes. sensory integration, with postcentral gyrus, also organized in HAL fashion, to where the somatosensory spinal tracts end, then with somatosensory association area to integrate and interpret those sensations.

Answer 84

interprets auditory sensation from postcentral gyrus and understanding it, processes many memories, and is involved in the limbic system. Wernicke area (in superior temporal lobe): speech oral comprehension. Hippocampus and longer term memory. with memory processing in the hippocampus inside of it, with an auditory area; near the intersection with parietal lobe, Wernicke area for speech interpretation.

Answer 85

is the site of vision integration. Distal occipital pole w/ visual association area making sense of it. visual association area of occipital to understand what is being seen

Answer 86

has as many neurons as rest of brain because of its positional function and nature making lack of coordinated movment or ataxia happening ipsalaterally. coordination of voluntary motor activity. cerebella positional information most neruons out of brain giving context and coordinationt o motor commands so nice flowing movements. cerebellar dysfunction has awkwardness of intentional movement. - folia or folds with inner part arbor vitae

Answer 87

language, speech, math cortical integration of specialized activities can best find through speech having motor (frontal lobe- precentral gyrus or motor), receptive aphasia (unable to understand)- vernicke area for comprehension- left side behind postcentral gyrus sensory and near auditory or temporal lobe. Vulnerable spot lateral to communcaiton- posterior component of anteiror capsule, blood supply to internal capsule weakest blood supply throughout the system subcortical why strokes easily loose all half side of that location. language function is involved the disabilities are termed aphasias. Aphasia may be receptive (i.e., reading, listening) or motor (i.e., writing, talking). For aphasia to occur, the lesion must be in the dominant hemisphere, which is the left hemisphere in right handed people and in many (but not all) left handed people. Subdivisions of this area are logical. Lesions in the anterior part of this area, near the motor cortex, tend to result in expressive aphasia. Lesions more posterior, near the auditory and visual cortex, result in receptive aphasia. Lesions nearer the visual cortex result in inability to read (alexia). Lesions near the audi- tory cortex result in inability to understand speech.Following lesions in the more anterior regions of the aphasic zone, speech disturbances tend to be nonfluent; the patient omits nouns and connector words like but, or and and. In the more posterior regions his words are plentiful or even excessive, but he crams into his speech inappropriate word substitutes, circumlocutions and neologisms—a word salad.

Answer 88

Inferior to the cerebrum is the diencephalon, dominated by the thalamus. (at the level of the internal capsule, basal nuclei, thalamus). lateral ventricles are connected to the third ventricle near thalamus by narrow interventricular foramina (of Monro). Arachnoid granualtions in superior saggital sinus. internal capsule: collection of projection fibers of ascending/descending tracts, e.g., face, arm, leg equally involved if internal capsule compromised from lesions of branches of middle cerebral artery, generating a hemiplegia. check for resting tremors or other movements, e.g., if basal nucleus (ganglion) lesion. The hypothalamus forms the floor and (part of) the lateral walls of the third ventricle, functioning to maintain homeostasis via autonomic nervous, endocrine, and limbic systems. The pituitary gland (cerebral hypophysis) is inferior and attached to the hypothalamus via the infundibulum. The cerebral arterial circle (circle of Willis) surrounds the pituitary, and the optic chiasm crosses anterior to it. Definitive bulgia to help w/ muscle coordination. Posterior pituitary- ADH, antidiruihetic, oxytocin.

Answer 89

The corpus callosum (large tract of white matter) connects the two hemispheres, making sure that each side is aware of the other and can share memories myelinated axons connecting over. check for aphasia, cortical sensory or other specialized deficit(s), e.g., loss of Broca area and motor aphasia. axons that communicate between the two cerebral hemispheres. The cingulate gyrus of the limbic system surrounds that.

Answer 90

check for crossed hemiplegia, e.g, right hemiplegia from the crossed spinal tract, left-sided brainstem signs from cranial nerve involvement. check for cerebellar signs, e.g., intention tremors, ataxia, that will be ipsilateral. long pathways too and from spinal cord, cell bodies of cranial nerve with most of cranial nerves, can localized to have damage within brainstem area. thalamus internal capsule can be interrupted as it runs up and down have profound effects downstream.

Answer 91

contains nuclei associated with CN III - IV, and centers associated with auditory, visual, and pupil reflexes. Cranial nerve and spinal tract combines in this location. defined by the cerebral aqueduct, contains a number of structures, such as the substantia nigra implicated in Parkinson disease. Four lumps quadragemina-cerebral culliculus. four bodies crossover communication of direct and consensual reflex. Inferior calliculus- head sound tracking corporate quadremina

Answer 92

contains nuclei associated with CN V (the motor part; a large sensory component extends inferior through the medulla) – VII/VIII, and centers such as those associated with regulation of breathing (“smoothing out” inspiration and expiration”).

Answer 93

Contains nuclei associated with CN VIII - XII, and multiple involuntary centers (note that most of XI really comes from the cervical spinal cord). These cranial nerves may be grouped, e.g., the nucleus ambiguus of the motor aspects of glossopharyngeal and vagus nerves. The pyramids are large ventral structures of medulla that carry major motor ("pyramidal") pathways

Answer 94

sensory relay and integrative center "stop-off point" connecting with many areas of the brain including the cerebral cortex, (and motor for items such as basal ganglia) up to corticocentral gyrus, basal ganglia, hypothalamus and brain stem. It is capable of perceiving pain but not of accurate localization. The thalamus is paired, and makes up the walls of the third ventricle. The thalamus is a relay center for almost all sensory impulses to the cerebral cortex. At the thalamic level (in the diencephalon), there is the general quality of perception, but fine distinctions are made with a third synapse of sensory neurons carrying impulses via the internal capsule lateral to the thalamus into the sensory cortex of the brain, to the postcentral gyrus. If tumors may have thalmic pain, which is vague but not localized. Sensory fibers, ascending through the brain stem, synapse in the thalamus and are then relayed to the cerebral cortex via the internal capsule. Motor fibers descending from the cortex pass to the brain stem via the internal capsule without synapsing in the thalamus. Important thalamic nuclei include: the ventral posterolateral (VPL) nucleus, a synaptic region for ascending spinal sensory pathways; the ventral posteromedial (VPM) nucleus, the synaptic area for the trigeminal lemniscus; the anterior thalamic nucleus, which is a part of the Papez circuit; the ventral lateral (VL) nucleus, which receives input from the cer- ebellum.

Answer 95

face, language not involved, myelinated nerurons pull out into separate spinal cord tracts w/in spinal cord. can determine a level of dermatome involvement with sensation, motor involvement, e.g., biceps reflex C 5-6, abdominal reflexes T8-T12, depending where you are compared to umbilicus, knee reflex L2-4, ankle reflex S1. separation of senses and motor aspects, e.g., vibration and position intact (dorsal columns), but loss of pain and temperature (spinothalamic tract). Separate stimuli e.g., interpreted as touch, pain, and temperature are carried together. In contrast, in the central nervous system, the mixed nerve fibers are sorted out into different bundles or tracts. Tracts are found in white matter-inulating material with huge tracts, surrounding nerve cell bodies that predominate in gray matter (interneurons communicating) which include interneurons as well as motor neurons. Motor nerves ventral root hook up at intervertebral foramen getting dorsal and ventral ramus. Sensory neurons- dorsal root ganglion. Major motor- corticospinal and in between ventral horn where motor neurons are: Spinothalamic tract- pain and temperature, Dorsal columns- discriminatory sense, vibration etc. concious position. Separate spinal cerebellar to coordinate position covering white matter tract areas. Tracts bear compound names of where they begin to where they end, e.g., corticospinal tract. a) afferent (sensory) or ascending tracts, b) efferent (motor) or descending tracts.

Answer 96

involves the sensory/motor distribution of specific nerves (e.g., wrist drop with radial nerve injury). What are the classic motor/sensory associations with these? Peripheral nerves- motor and sensory component w/ large ventral rami. Gray matter, central neuron, motor neuron DTR

Answer 97

lesion is in the primary motor area wherein paralysis may result, a higher level of dysfunction may be found, e.g. trying to get his head into the sleeve or trying other inadequate orientations. Simple anesthesia may result from lesions between primary sensory cortex and body peripehry. Complex cerebral receptive disabilities are called agnosias. Complex cerebral motor disabilities are apraxias. Area 4 (the primary motor area). Lesions result in initial flaccid paralysis followed in several months by partial recovery of function and a possible Babinski reflex; spasticity and increased deep tendon reflexes may occur if area 6 (the supplemen- tal motor area) is included.Areas of the frontal cortex rostral to the motor areas are involved in complex behavioral activities. Lesions result in changes in judgment, abstract thinking, tactfulness and foresight. Symptoms may include irresponsibility in dealing with daily affairs, vulgar speech and clownish behavior. Lesions to area 8 (the frontal eye fields) result in difficulty in voluntarily mov- ing the eyes to the opposite side. Areas 44, 45 (Broca’s speech area). The patient with a lesion in this area expe- riences motor aphasia, but only when the dominant hemisphere is involved. The patient knows what he wants to say but speech is slow, deleting many prepositions and nouns. Areas 3, 1, 2 (primary somesthetic area). Lesions produce contralateral impair- ment of touch, pressure and proprioception. Pain sensation will be impaired if the lesion lies in the secondary somesthetic sensory area which receives pain information. Areas 41, 42 (auditory area). Unilateral lesions have little effect on hearing owing to the bilateral representation of the auditory pathways. Significant audi- tory defects generally involve either CN8 or its entry point in the brain stem, for bilateral representation begins beyond this point. Area 22 (Wernicke’s area). Lesions in the dominant hemisphere result in audi- tory aphasia. The patient hears but does not understand. He speaks but makes mistakes unknowingly owing to his inability to understand his own words. Area 40 (supramarginal gyrus). Lesions in the dominant hemisphere result in tactile and proprioceptive agnosia, and a variety of other problems, such as con- fusion in left-right discrimination, disturbances of body-image, and apraxia, by cutting off impulses to and from association tracts that interconnect this area with nearby regions. Area 39 (angular gyrus). Lesions in the dominant hemisphere may result in alexia and agraphia (inability to read and write). Areas 17, 18, 19. Total destruction causes blindness in the contralateral visual field. Lesions to areas 18 and 19 alone do not cause blindness but rather difficulty in recognizing and identifying objects (visual agnosia). The silent area is believed to function in memory storage of visual and audi- tory information and is implicated in hallucinations and dreams. Epileptic attacks originating in this region may be associated with amnesia, auditory hallucinations, and the deja vu phenomenon. The basal nucleus of Meynert lies in the base of the frontal lobe just lateral to the optic chiasm. Degeneration of this nucleus is associated with the dementia of Alzheimer’s disease. t spinal pathways to/from the cortex run through the internal capsule, making it a potentially vulnerable area for stroke. The blood vessels off of the middle cerebral artery to the region of the internal capsule are strikingly small.

Answer 98

Clinical signs and symptoms of brain tumors depend on the location and the degree to which intracranial pressure (ICP) is elevated. Slow-growing tumors in relatively silent areas (e.g., frontal lobes) may go undetected and can become quite large before symptoms occur. Small tumors in key brain areas can lead to seizures, hemiparesis, or aphasia. Increased ICP can initiate broader damage by compressing critical brain structures. Early symptoms of increased ICP include malaise, headache, nausea, papilledema, and less often abducens nerve palsy and Parinaud’s syndrome. Classic signs of hydrocephalus are loss of upward gaze, downward ocular deviation (“setting sun” syndrome), lid retraction, and light-near dissociation of pupils. Primary tumors include the following: • Gliomas: arise from astrocytes or oligodendrocytes; glioblastoma multiforme is the most malignant form (astrocytic series). • Meningiomas: arise from the arachnoid mater and can extend into the brain. • Pituitary tumors: can expand in the sella turcica and affect CN II, III, IV, V1, V2, and VI; about 15% of primary tumors. • Neuromas: acoustic neuroma, a benign tumor of CN VIII, is a common example; about 7% of primary tumors. Metastatic brain tumors are more common than primary brain tumors. Most spread via the bloodstream, with cells seeded between the white matter (fiber tract pathways) and gray matter (cortical neurons). Some tumors metastasize directly from head and neck cancers or through Batson’s vertebral venous plexus. Presentation often includes headache (50%), seizures (25%), and elevated intracranial pressure. In contrast to the rapid onset of strokes, brain tumors, e.g., meningiomas, may present as space-filling lesions that may raise intracranial pressure or present with a focal lesion, depending on their location and progression. Glioblastoma- fatal tumor, necrosis leading to impacting fatal results. Acoustic neruoma- scwann cell tumor of CN 8, tinnitus, deafness, cerebellum squeezed movement coordination

Answer 99

In contrast to the corticospinal and corticobulbar tracts, there are additional descending tracts. These extrapyramidal tracts that travel through the medulla outside of the pyramids, and innervate (often ipsilaterally, or some that cross) via the white matter between the ventral horns, helping with postural adjustments and involuntary movements. As an example, note the vestibulospinal tract coming from inner ear nuclei. One way of highlight the postural, “antigravity” aspect of the extrapyramidal tracts is to look at posturing following brain damage. The red nucleus of the midbrain is a structure whose damage can indicate a brainstem lesion. The rubrospinal tract enhances flexor movements in the contralateral upper extremity, a function that is usually hidden/overridden by the corticospinal tract. decorticate posturing: lesion rostral/superior to the red nuclei; presentation of flexed upper limbs, extended lower limbs.decerebrate posturing: red nucleus affected by the lesion; presentation of both upper and lower limbs extended, and extensor input via the extrapyramidal tracts are dominant.

Answer 100

The body must control what kinds and what amounts of movements. These are a concern of 1) the ventral/anterior horn cells, or what we can call the final common pathway and 2) higher motor pathways that impinge on those horn cells. corticospinal tract (lateral as the main one, compared to the anterior) carries voluntary control of skeletal muscles. The corticospinal tract passes through the internal capsule lateral to the thalamus before crossing over at pyramids; synapses in anterior horn before leaving spinal cord. This is a skilled movement pathway. Note: the anterior corticospinal tract (~10% of the tract) of nondescussating fibers that supply axial musclesthat do not cross over in the pyramids and descending, either descussating in the spinal cord or not. These supply trunk and proximal muscles, so that the general positioning of the torso and gross positioning of limbs will occur if lateral corticospinal tract is damaged. The distal muscles of the limbs will be supplied by the crossing-over fibers of the lateral corticospinal tract. Spinothalmic tract crosses over then goes up Pain and temperature consisting of smaller sensory neurons with unmyelinated or thinly myelin- ated axons. Discriminatory- dorsal columns spinal tract have larger neurons with heavily myelinated axons. Stereonosis- spinal tract and knowing what is in your hand parietal association as well. Examples of lesions: Unable to express- Frontal lobe: expressive aphasia (L hemisphere), prefrontal lobe syndrome (bilateral), Parietal lobe: neglect syndrome (R hemisphere) of the contralateral L side and surroundings more striking than left side, Temporal lobe: receptive aphasia (L hemisphere), Occipital lobe: contralateral homonymous hemianopia/hemianopsia (± macular sparing). Precentral gyrus last part of frontal lobe hitting bottom part of pyramids and crossing over down to ventral horn . The lateral corticospinal tract (lateral as the main one, compared to the anterior) carries voluntary control of skeletal muscles and passes through the internal capsule lateral to the thalamus before crossing over at pyramids; synapses in anterior horn before leaving spinal cord. This is a skilled movement pathway. Neuromuscular junction- damage neuron out to muscle become flacid w/ atrophy. Lower motor neuron w/ no innervation atrophy. UMN- cortex, internal capsule, spinal cord and capsule spasticity because upper motor neuron gives lower permission and regulatory control lMN still innervation but not controlled.

Answer 101

Sensation is initiated by sense receptors and an impulse generated by an afferent (sensory) nerve fiber in a peripheral nerve. The afferent (sensory) nerve fiber follows the posterior (dorsal) root. Once in the spinal cord, (for the most part) its impulses move along one of the following three tracts: spinothalamic tract (lateral is the major one) carries pain/temperature (some light touch), and crosses over in spinal cord before subsequent ascent to thalamus cross over right away; posterior (dorsal) columns (components of fasciculus gracilis and fasciculus cuneatus) carry conscious proprioception, stereognosis, vibration sense, light touch, and ascends ipsilaterally before crossing over at medullary nuclei postcentral gyrus. At the thalamic level (in the diencephalon), there is the general quality of perception, but fine distinctions are made with a third synapse of sensory neurons carrying impulses via the internal capsule lateral to the thalamus into the sensory cortex of the brain, to the postcentral gyrus. spinocerebellar tract (dorsal as the major one) carry unconscious proprioception, as the dorsal spinocerebellar tract ascends ipsilaterally, entering cerebellum via peduncles, to give the cerebellum information for movement coordination.

Answer 102

The corticobulbar tract is a component of the corticospinal tract that does not reach the spinal cord, but directs voluntary control of skeletal muscles controlled by cranial nerves. Typically, corticobulbar fibers from both sides influence CNs; an important exception is that LMNs of lower facial muscles are only contralaterally supplied. This is how one separates an internal capsule or cortical stroke triggering lower facial issues from a Bell palsy affecting CN VII as a whole, and why in your neurological exam you include examination of both upper and lower facial muscles. If upper face is working well something in corticobulbar tract on contralateral side. Bad day in pons- whole face

Answer 103

In a crossed palsy (crossed hemiplegia), a brainstem lesion affects a nearby cranial nerve nucleus ipsilaterally and the spinal tracts before they cross (decuss), hence creating contralateral hemiparesis. Three examples of crossed palsy of the (reasonably midline) corticospinal tract with the following three cranial nerve nuclei that are located midline and so could be likely affected at the same time: Spastic paralysis- UMN corticospinal tract, proprioception, abduct eye CN 6, CN7- bells palsy in pons crossed pasy. Right pons- knocked out descending cortiospinal tract. Arm, tongue- medulla, Spinal tract and brain- brainstem. CN III involvement indicates a midbrain lesion, CN VI: involvement indicates a pons lesion, CN XII:involvement indicates a medulla lesion. Precentral gyrus- at beginning, first neuron goes down and at end of pyramids cross over and go down handing off to hitting on neurons in ventral neuron of spinal cord for lateral portion of spinal tract vulnerable area on vulnerable side of thalamus for focal point, upper motor neuron down to spinal cord living at precentral gyrus, lower motor neuron going to ventral horn out to muscle w/ two phenomenologies and directly innervating muscle onto cell bodies flaccid weak cell bodies. Damage brain from stroke at internal capsule and transect, upper neuromotor neuron symptom helping to regulate. Increased motor tone.

Answer 104

any neuron or level of motor control before the synapse in the ventral horn.corticospinal pathway synapses in anterior horn (grey matter) motor neurons above this are upper and below is lower. ex. "spastic paralysis," no muscle atrophy, increased muscle tone, increased reflexes, fasciculations and fibrillations not present, Babinski reflex may be present. When upper motor neuron systems are dam- aged above their crossover in the medulla, motor impairment develops on the opposite or contralateral side. In damage below the crossover, motor impairment occurs on the same or ipsi- lateral side of the body. The affected limb becomes weak or paralyzed, and skilled, complicated, or delicate movements are performed poorly when compared with gross movements.

Answer 105

the "common pathway" of the motor neurons whose nuclei are in the ventral horn and whose axons extend peripherally. ex. "flaccid paralysis" of muscle weakness, atrophy, decreased reflexes, fasciculations and fibrillations present, Babinski reflex not present. lower motor neuron (LMN) lesion: "flaccid paralysis" of muscle weakness, fasciculations progressing to atrophy, decreased reflexes. Damage to the lower motor neuron systems causes ipsi- lateral weakness and paralysis, but in this case, muscle tone and reflexes are decreased or absent.

Answer 106

An example of limbic involvement can be seen in the temporal lobe targeting of herpes encephalitis. This also is a reminder of how trigeminal nerve branches innervate along the meninges, tentoreum and temporal lobe developing infection affecting behavior, giving lots of antibiotics. Subtle pattern of behavior altered from baseline looked at from neurologic exam may not know what lesion is but can narrow it down.

Answer 107

proprioception, stereognosis, vibration sense, light touch, and ascends ipsilaterally before crossing over at medullary nuclei junction between spinal cord and brain fasciculus- columns(nucleues cuntaneus- upper leve, gracilis- lower levels). Neurons enters then medualla, then postcentral gyrus only at medulla. Have both conscious and unconscious pathway (connecting w/ cerebellum)spinocerebellar tract (dorsal as the major one) carry unconscious proprioception, as the dorsal spinocerebellar tract ascends ipsilaterally, entering cerebellum via inferior peduncles, to give the cerebellum information for movement coordination. HANDED OFF DORSAL HORN STAYS AT CEREBELLUM, IPSALATERAL, cerebellum talkis to one and then crosses showing up ipsalaterally. A muscle stretch reflex (or myotactic reflex) can be monosynaptic, as generated by passive stretching and subsequent contraction of a muscle. This is useful for an antigravity (i.e., standing erect) response, but we know it best as reflex testing. Swift hammer strike stretches muscle spindle fiber from cerebellar function- how much, how fast, hard tension that stretches w/ sensation in and motor reflex interneurons going on, inhibitory as well up to dorsal columns further up as well. Relax w/ increased tension at base of belly and tendon. Tendon organs how much tension generated cerebellar coordination for further recruitment. Sensation carried by afferent neuron to three areas: collateral branches up sensory tract to let brain know that reflex occurred, synapse on motor neuron to trigger contraction of agonist muscle, synapse on inhibitory interneuron to inhibit antagonist muscle. In addition to the muscle spindle apparatus, a Golgi tendon organ within tendons are sensitive to muscle tension and will initiate an inhibitory relaxation to the muscle if tension is sufficiently high.

Answer 108

hypothalamus is master controller meaning lesions result not in localized but widespread organized actions. regulates glands, smooth muscle and cardiac muscle. consists of parasympathetic and sympathetic of The first synapse is cholinergic (containing acetylcholine).For the sympathetic system this synapse is either in the paravertebral chain of sympathetic ganglia or farther away in the prevertebral ganglion plexuses. Parasympathetic synapses typically lie very close to or within the viscera. The final synapse of the parasympathetic system contains acetylcholine, whereas the final syn- apse of the sympathetic system contains noradrenaline, with the exception of certain synapses, as for sweating, that contain acetylcholine (i.e., are cholinergic).

Answer 109

Singulate gyrus- anterior cerebral artery and part of limbic system of behavior

Answer 110

Klüver-Bucy syndrome, there are lesions of the amygdala, resulting in docile behavior, hypersexuality, compulsive attentiveness to detail, and, with injury to nearby areas, visual agnosia (inability to recognize objects visually). In Wernicke’s syndrome, which occurs in patients who are alcoholic and under- nourished, there is paralysis of eye movements, ataxic gait and disturbances in the state of consciousness associated with hemorrhages in the hypothalamus and other regions. Korsakoff’s syndrome also occurs in alcoholic patients and consists of memory loss, confusion and confabulation associated with lesions in the mammillary bod- ies and associated areas. 1. Riley-Day syndrome (familial dysautonomia), a disease associated with degenerative changes in the central nervous system and the peripheral autonomic system. Symptoms include decreased lacrimation, transient skin blotching, attacks of hypertension, episodes of hyperpyrexia and vomiting, impairment of taste discrimination, relative insensitivity to pain, and emotional instability.2. Adiposogenital syndrome, characterized by obesity and retarded develop- ment of secondary sexual characteristics, sometimes is associated with lesions in the hypothalamus.3. Precocious puberty may result from hypothalamic tumors. 4. The common cold. Temperature elevation is apparently the consequence of some influence on hypothalamic functioning. 5. Tumors of the pituitary may have a destructive effect on the pituitary gland and hypothalamus by direct extension, e.g. in chromophobe adenoma and cranio- pharyngioma which generally are nonsecretory tumors. If the tumor contains func- tioning glandular tissue e.g., acidophilic or basophilic adenoma, there may be the opposite effect of hypersecretion of pituitary hormones. 6. Diabetes insipidus. Vasopressin (antidiuretic hormone) enhances the reup- take of water in the kidney. Interference with its production, as by an invading tumor, leads to diabetes insipidus, characterized by excessive production of urine and excessive thirst (up to 20 liters imbibed daily). 7. Horner’s syndrome. Interruption of the cervical sympathetic nerves (or in some cases their central origins in the spinal cord and brain stem) leads to ptosis, miosis and decrease in sweating on the involved side of the face. Sometimes this is the result of a tumor of the apex of the lung (Pancoast tumor) that interrupts the fibers as they course from the superior cervical ganglion (the most rostral ganglion in the sympathetic chain) to the carotid artery on their way to the orbit. Surgical procedures are performed that interrupt the sympathetic innervation of the lower extremities, in order to increase circulation in cases of vascular insufficiency. 8. Hirschsprung’s megacolon—Congenital absence of parasympathetic gan- glion cells in the wall of the colon, resulting in poor colonic motility and a dilated colon. 9. Shy-Drager syndrome (Multiple System Atrophy; MSA) is a condition, usually in men over 60 years old, that resembles Parkinson’s disease (slowness, stiffness, mask-like facies, pill-rolling tremor) along with autonomic symptoms (fainting when standing up, loss of bowel/bladder control, impotence, decreased sweating, nausea and digestive problems).

Answer 111

amyotrophic lateral sclerosis: both upper and lower motor neuron symptoms, hyperreflexive even if there muscle is fasiculating Guillain-Barré sydrome: peripheral demyelinating disease, typically in an ascending pattern, with both motor and sensory deficits. Teriary syphilis- … Pernicious anemia- Polio- oral fecal virus trophic lower motor neuron Guilain-barre- mild illness or gastric upset infection triggering cross reaction of antibodies massive demyelinating disease

Answer 112

syringomyelia : a central fluid-filled cavity of the cervical spinal cord may affect the crossing spinothalamic tracts, and so lead to bilateral deficits of pain and temperature sensation in the upper extremities. With progression, the condition may involve the ventral horn LMN cell bodies as well. Enlarged central canal thinned down edges. Whole got big most tracts not affected, spinal cerebellar are fine w/ the spinothalamic that is corrsing over other side affected in neck hitting cervical to arm. Present w/ a deficit in C5-C8 loss of pain and temperature in hands

Answer 113

A final check of our understanding of the spinal cord: hemisection of the spinal cord creates a pattern of ispilateral UMN and dorsal column deficits and contralateral pain and temperature deficits in the Brown-Séquard syndrome. Wiping out half the spinal cord. Sensation comes up affecting dorsal column, spinocerebellar (difficult finding way around), pain and temeprature fine on that side crossing over spinal over w/ opposite side pain and temperature with upper motor neuron pattern in that leg. In this individual: left hemisection of spinal cord inferior to T10 (as umbilicus is not involved). Dorsal column: ascension blocked ipsilaterally. Spinocerebellar tract: ascension blocked ipsilaterally. Corticospinal tract: crossed at medullary pyramids, descent to L lower extremity blocked. Spinothalamic tract: crosses over in spinal cord within 1-2 dermatomes, so that the pain and temperature from the R lower extremity is blocked, and the pain and temperature from the L lower extremity crosses over and travels up the R spinothalamic tract

Answer 114

Ataxia—awkwardness of posture and gait; tendency to fall to the same side as the cerebellar lesion; poor coordination of movement; overshooting the goal in reaching toward an object (dysmetria); inability to perform rapid alternating movements (dysdiadochokinesia), such as finger tapping; scanning speech due to awkward use of speech muscles, resulting in irregularly spaced sounds. Decreased tendon reflexes on the affected side. Asthenia—muscles tire more easily than normal. Tremor—usually an intention tremor (evident during purposeful movements). Nystagmus. ipsalateral

Answer 115

Basal nuclei (ganglia): within central white matter surrounding the thalamus. In effect, the basal ganglia act as "brakes" for motor activity. Typically inappropriate amounts of movement (“resting tremors”) result from lesions in these areas. In a highly simplified schema: striatum and pallidum represent inputs and outputs, respectively, of the basal ganglia of basal nucleid Example of Huntington chorea with striatal damage. Chorea: rapid, involuntary, “dancing” movements. substantia nigra (in the midbrain): Dark because of melanin deposition. Neurons here contain dopamine that influence input balance between direct and indirect basal ganglia pathways. Example of Parkinson disease, with rigidity, tremor. Surrounding the thalamus are most components of the basal ganglia, which influence stereotyped motor activity of postural/reflexive nature. In effect, the basal ganglia act as "brakes" for motor activity. Disorders are characterized by meaningless unintenional movements occuring unexpected. 1. Parkinson’s disease—rigidity; slowness; resting tremor; mask-like facies; shuffling gait, associated with degeneration in the basal ganglia and substantia nigra of the midbrain. 2. Chorea—sudden jerky and purposeless movements (e.g. Sydenham’s cho- rea found in rheumatic fever; Huntington’s chorea, an inherited disorder). 3. Athetosis—slow writhing, snake-like movements, especially of the fingers and wrists. 4. Hemiballismus—a sudden wild flail-like movement of one arm. Summary of Parkinson disease and the location of substantia nigra in midbrain, along with the projection of dopaminergic neurons. Basal ganglia (context at movement)- tremor at rest, demending upon where you damage w/ hemibalismis if you interefere w/ subtahalmus. Most common- parkinsons midbrain cereberal aqueduct, substania nigra (without stop starting of activity), red nucleus.Dopamine- movmeent, addiction, behavioral ongoing severe parkinsons impacts on behavior such as dementia

Answer 116

Complex cerebral receptive disabilities are called agnosias. Complex cerebral motor disabilities are apraxia

Answer 117

olfactory-hears: the openings in the cribriformplate of the ethmoidbone. midbrain sensory nerves, extend under frontal lobes

Answer 118

optic- sees: the optic canal; midbrain sensory nerves. form an optic chiasm in front of the pituitary

Answer 119

oculomotor- moves eyeballs around constricts pupils and accomodates, pens eye superior orbital fissure near aqueduct; midbrain; motor. parasympathetic components. midline in midbrain pons and medulal means corticospinal tract damage at same time

Answer 120

trochlear- moves eyeballs around superior orbital fissure; midbrain; crosses over and passes over roof of brain stem; motor. is relatively midline, small CN IV a bit more lateral, out of the midbrain small wimpy to superior oblique muscle goes contralateral

Answer 121

ophthalmic division of trigeminal- superior orbital fissure; pons. lesion on one part of cerebral hemisphere would interfere w/ sensation on opposite side of body including face because it crosses over after brain stem. A lesion destroying one half of the brain stem (theo- retical) would interfere with conscious sensation below the head contralaterally by destroying the medial lemniscus and spinothalamic tracts. The same lesion would decrease both ipsilateral and contralateral facial sensation (affecting both the ipsilateral nucleus and tract of 5 and ipsilateral trigeminal lemniscus which had crossed over).

Answer 122

maxillary division of trigeminal: foramen rotundum; pons

Answer 123

mandibular division of trigeminal- chews and feels front of head: foramen ovale;

Answer 124

abducens- moves eyeballs around: superior orbital fissure; nucleus in pons near fourth ventricle ; motor. midline in midbrain pons and medulal means corticospinal tract damage at same time

Answer 125

facial- moves face (closes/blinks eye) , tastes, salivates, cries, internal acoustic meatus (bells palsy when pressing on one get other one); pons. parasympathetic components. severing CN7 entire side of face would be paralyzed \*forehead ironed, eye will not close, flattening of nasolabial fold). if lesion above nucleus of 7 only below eyes paralyzed. Hence, the typical stroke patient with an upper MN lesion rarely needs a tar- sorrhaphy (an operation to keep the eyelids closed) whereas the patient with Bell’s palsy (a spontaneous peripheral nerve 7 palsy of unknown etiology commonly in facial canal- IAM and stylohyoid) may, because of marked difficulty in closing the eye. if affecting lacrimal and salivary branches leading to hyperacusis, when returns tears when eating. If lesion problem w/ MI sound. near the pons/medulla border in the pons

Answer 126

vestibulocochlear- hears, regulates balance : internal acoustic meatus (bells palsy when pressing on one get other one); pons and medulla sensory nerves; CN 7 and CN8

Answer 127

glossopharyngeal- Tastes, salivates, swallows, monitors carotid body and sinus; jugular foramen;. MORE LATERAL IN THE medulla parasympathetic components.

Answer 128

vagus- Tastes, swallows, lifts palate, talks, communication to and from thoraco-abdominal viscera; jugular foramen; medulla. parasympathetic components reaching widespread areas of the body thorugh this nerve along unlike sympathetic trunk. lesion result in hoarseness problems w/ K sounds. coming off spinal cord then hands w/ other two, more lateral in the medulla

Answer 129

spinal accessory- Turns head, lifts shoulders; judular foramen; medulla; motor

Answer 130

hypoglossal- move tongue : hypoglossal canal; medulla; motor. if lesion problem w/ LA sound. midline in midbrain pons and medulal means corticospinal tract damage at same time . more midline next to the medullary pyramids, in which the main motor tract, the corticospinal tract, runs.

Answer 131

Through lower motor neuron. This exceedingly complex system includes motor pathways between the cerebral cortex, basal ganglia, brainstem, and spinal cord. It helps to maintain muscle tone and to control body movements, espe- cially gross automatic movements such as walking. Disease of the basal ganglia system or cerebellar system does not cause paralysis, but can be disabling. Damage to the basal ganglia system produces changes in muscle tone (most often an increase), disturbances in posture and gait, a slow- ness or lack of spontaneous and automatic movements termed bradykinesia, and various involuntary movements.

Answer 132

Through lower motor neuron. The cerebellum receives both sensory and motor input and coordinates motor activity, maintains equilibrium, and helps to control posture. Cerebellar damage impairs coordination, gait, and equilibrium, and decreases muscle tone.

Answer 133

see pictures p. 576-579"

Answer 134

cavernous sinus hold particular vulnerability, in that facial blood can drain into there, and there are a number of partitions in that dural sinus down to sigmoid sinus and internal jugular vein. Hence a boil from the nose or upper lip (i.e., mid-face), if squeezed, can “inject” the infection into that region and cause a potentially lethal infection. Headache in the V1 distribution, with signs of venous obstruction, such as periorbital edema, and/or loss of cranial nerve functions from CN III, IV, VI warrant prompt evaluation. Occlusion of cerebral veins and dural venous sinuses may result from thrombi (clots), thrombophlebitis (venous inflammation), or tumors. The facial veins are connected with the cavernous sinus through the superior ophthalmic veins. Blood from the medial angle of the eye, nose, and lips usually drains inferiorly into the facial vein. However, because the facial vein has no valves, blood may pass superiorly to the superior ophthalmic vein and enter the cavernous sinus. In people with thrombophlebitis of the facial vein, pieces of an infected thrombus may extend into the cavernous sinus, producing thrombophlebitis of the cavernous sinus. ex. With staph boil on face, hit on every nerve out to eyeball 3,4,6 and first part of 5 ptosis occular finding.

Answer 135

spinothalmic tract (lateral is the major one) carries pain/temperature (some light/crude touch), and crosses over in spinal cord right away before subsequent ascent to thalamus then cerebral cortex. Neurons in that nerve hand off right away in dorsal horn at level of spinal cord to thalamus and postcentral gyrus to get interpreted. Sharp vs. dull. if have lesion w/ lose pain-temperature sensation contralaterally to level of lesions. Cerebellar dysfunction with right sided ataxia, loss of pain-tempera- ture on the right face and left upper and lower extremities, hoarseness, dif- ficulty swallowing, loss of taste on the right, vertigo and nystagmus. his is the classical syndrome of the posterior inferior cerebellar artery (Fig. 41C) which may become thrombosed. Cerebellar dysfunction— right spinocerebellar tract; loss of right facial pain-temperature—injury to spinal tract and nucleus of right CN5. Loss of left upper and lower extremity pain-temperature—injury to right spinothalamic tract (remember, it crossed over); hoarseness and swallowing difficulty—right nucleus ambiguus; taste —right nucleus solitarius; nystagmus—irritation of the vestibular nuclei.

Answer 136

Through lower motor neuron. The corticospinal tracts mediate voluntary movement and integrate skilled, complicated, or delicate movements by stim- ulating selected muscular actions and inhibiting others. They also carry impulses that inhibit muscle tone, the slight tension maintained by normal muscle even when it is relaxed. The corticospinal tracts originate in the motor cortex of the brain. Motor fibers travel down into the lower medulla, where they form an anatomical structure resembling a pyramid. There, most of these fibers cross to the opposite or contralateral side of the medulla, continue downward, and synapse with anterior horn cells or with intermediate neurons. Tracts synapsing in the brainstem with motor nuclei of the CNs are termed corticobulbar. When the corticospinal tract is damaged or destroyed, its functions are reduced or lost below the level of injury.

Limbs, Spine, Neuro Flashcards

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