The Case of the Bad Stick

Meghan KaumayaKenneth Koncilja

Aravind ReddyAndrew Williams

Patient Presentation• Post Operative patient

(major surgery)• Receiving Intramuscular

Injections of Antibiotics– Complained of more

pain than normal during one shot

• Nurse noticed a limp that was previously not observed

• Vitals normal• Systems review normal• Neurologic exam normal

Musculoskeletal Exam

• Left hip drops every time left foot raised off floor.

• On right side pelvis remains level when right foot lifted.

• All else normal.• No evidence of

sensory loss from the skin.

Gross Anatomy

Gluteus minimus

Piriformis

Superior Gluteal n.Gluteus medius Where does it originate?

Lumbro-Sacral Plexus!

How does superior gluteal n. get between the gluteus medius and gluteus minimus?

Through the Greater Sciatic Foramen

Even More Gross!

Popliteal a.Semimembranosus

Semitendinosus

Pudendal n.

Inferior gluteal n.Superior gluteal a.

Gluteus maximusGluteus medius

Gluteus minimus

Piriformis

Sciatic n.

Biceps femoris(long head)

Posterior cutaneous n. of thigh

DON’T BE OVERWHELMED

Trendelenburg’s Gait• Weakness in the

abductor muscles, gluteus medius and minimus

– Weak abduction of the hip

– Abnormal gait caused by weakened muscles allowing the pelvis to tilt down on the opposite side when walking

Figure 6. Trendelenburg himself

Trendelenburg’s Test

• Stand on one foot on the side suspected of having weakened abductor muscle– Positive test: patient must put foot down

immediately because weakened muscles cannot keep pelvis level so pelvis drops on opposite side

– Negative test: patient can stay balanced on one foot

Abductors of the Thigh

How To Give a Shot• Superolateral gluteal region

– Relatively free of nerves and large blood vessels

1. Place your thumb on the ASIS and make a fist

2. Spread your hand to point your thumb out

3. Injection site will be inbetween digits 2 and 3.

What else could cause symptoms?

• Polio• Fracture of Greater Trochanter• Dislocation of hip joint• Paralysis of the nerve• Spinal Muscular Atrophy• Muscular Dystrophy• Lumbar Nerve Compression• Inflammatory Myopathy• Coxa vara

References

• Ropper AH, Samuels MA, "Chapter 7. Disorders of Stance and Gait" (Chapter). Ropper AH, Samuels MA: Adams and Victor's Principles of Neurology, 9e: http://www.accessmedicine.com/content.aspx?aID=3630849.

• Moore K.L., Dalley A.F., Agur A.M.R. Chapter 5 Lower Limb.. In: Taylor C, Heise J, Montalbano J., editors. Clinically Oriented Anatomy. Baltimore: Lippincott Williams & Wilkins; 2010. p.572-583.

• Netter, F. H. Altas of Human Anatomy, 4e. Philadelphia: Saunders Elsevier, 2006.

• Stranding, S., Ed. Gray’s Anatomy: The Anatomical Basis of Clinical Practice, 40e. Madrid: Churchill Livingston Elsevier, 2008.