Trauma to the leg
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8 Min Clinical Anatomy Lecture
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Trauma to the leg
- 1. Trauma to the Leg Gazi Rashid, M4 grashid@emory.edu Dec 12th 2018 ASP Clinical Anatomy
- 2. Objectives Use a common trauma injury case to… 1. Understand the basic pathophysiology of compartment syndrome 2. Focus on the neurovasculature of a single compartment 3. Walk through the treatment guided by anatomical landmarks
- 3. Compartments in the Lower Leg 1 2 3 4
- 4. A common trauma patient
- 5. ABCDE
- 7. Whew… • Went through ABCDEs • Arteries and veins intact • Broken tibia • Called Ortho
- 8. What now?
- 11. Compartments in the Lower Leg
- 14. Fasciotomy
- 19. Objectives Use a common trauma injury case to… 1. Understand the basic pathophysiology of compartment syndrome 2. Focus on the neurovasculature of the anterior compartment 3. Walk through the treatment guided by anatomical landmarks
- 20. Review the Qs 1. What’s the major artery passing through the anterior compartment that eventually becomes the dorsalid pedis? 2. The Common Peroneal nerve gives off what branch in the Lateral compartment and what branch in the Anterior compartment? 3. CS of the anterior compartment presents as numbness or tingling where? 4. Foot drop occurs with damage to the deep peroneal because which muscle is affected?
- 21. Links 1. Acute Compartment Syndrome of the Lower Leg: A Review: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4970751/ 2. Lower extremity compartment syndrome: https://tsaco.bmj.com/content/2/1/e000094 3. Two Incision Four Compartment Fasciotomy: https://www.youtube.com/watch?v=- 1NDJkFH1vM&ab_channel=operationgivingback
- 22. Things to Know • Vasculature • Anterior tibial artery is the blood supply for this compartment…terminal branch of popliteal artery…passes anteriorly through gap in superior part of interosseous membrane, at malleoli Becomes dorsal artery of foot • The posterior tibial artery and its biggest branch the fibular artery supply the posterior compartment. • Know nerves • Deep peroneal - Extends in to foot to supply extensor digitorum brevis and extensor hallicus brevis and skin b/ 1st and 2nd toes • Goes to tibialis anterior dorsiflexes foot drop
Notes de l'éditeur
- 4 well-named compartments Fascia around all of them Septa separating them
- 24 yo female presents to the Marcus Trauma for peds v. auto
- Picture credit: http://4.bp.blogspot.com/-r-_FpBBe0dA/UN5xCFqNGQI/AAAAAAAAAJU/DwAH4si57xk/s1600/slide0006_image001.jpg 2 pulse check points branches of descending artery: popliteal AT & PT, aptly named
- Diagnosis Diagnosis of ACS is based largely on physical examination and six cardinal clinical manifestations described as the six P's.1-3, 6, 8 The six P's include: (1) Pain, (2) Poikilothermia, (3) Paresthesia, (4) Paralysis, (5) Pulselessness, and (6) Pallor.1-3, 8
- Basic pathophys Many different causes and can occur in many different “compartments”
- Basic pathophys Many different causes and can occur in many different “compartments”
- Fascia is very tight and tough, surrounded by 2 bones Swollen, edemetaous tissue starts to compress vasculature
- Many, many, many causes of foot drop – very important to know for boards, NOT for anatomy Credit: https://slideplayer.com/slide/3433447/12/images/32/ANTERIOR+COMPARTMENT+FOOT+DROP%3A+DAMAGE+EITHER+1%29+COMMON+PERONEAL+NERVE.jpg
- Helpful mnemonic about presenting symptoms – important for later – 5 Ps – know early vs. late symptoms
- Left leg Full video: https://www.youtube.com/watch?v=-1NDJkFH1vM&ab_channel=operationgivingback
- CS = compartment syndrome Anterior tibial artery Deep peroneal (ant comp), Superficial Peroneal (lat comp) Cutaneous sensation at Space btwn 1st and 2nd toe innervated by deep peroneal, which is the nerve in the anterior compartment Tibialis major
- Damage from loss of common fibular nerve: (most commonly injured nerve in lower limb because of where it winds around fibular neck) 1. Motor: (both deep and superficial fibular nerves) a. Paralysis of all muscle of anterior (dorsiflexors/extensors) and lateral (everters) compartments b. Get foot-drop → Foot passively plantarflexes and inverts causing toes to drag on the floor when walking, so the person develops high stepping (“steppage”) gate to keep toes from hitting the ground. Also, the foot slaps down when the heel is planted, producing a distinctive “clop.” c. Loss of function of the extensor digitorum brevis and extensor hallicus brevis on foot, which are innervated by deep fibular nerve 2. Sensory: a. Loss of sensation of the skin on lateral portion of the leg via lateral sural cutaneous nerve. b. Loss of sensation of skin on lateral ankle (malleolus) and lateral aspect of foot including lateral heel via dorsal lateral cutaneous nerve of foot (termination of sural nerve, so has some tibial component) c. Loss of sensation of skin on dorsum of foot and all digits, except lateral side of 5th digit and adjoining sides of 1st and 2nd digits via superficial fibular nerve d. Loss of sensation of the skin on contiguous sides of 1st and 2nd digits via deep fibular nerve