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Back & Limbs Board Review Cases


1. Let's play "Where Does It Drain!" Your patient comes to you with lesions on various areas of skin and superficial fascia. In each case, decide to which group of lymph nodes the lesion will drain. Abdomen, superior to umbilicus; back; scrotum; buttocks; anal canal inferior to pectinate line

2. After recuperating from a gunshot wound to the buttocks resulting from a hunting accident, your patient exhibits a positive Trendelenburg's sign. Explain.

3. An elderly woman falls and breaks her hip. After reviewing the films, the surgeon opts for ORIF and inserts an IM nail through the femoral neck and into the femoral head. Although the operation is a success, the surgeon worries that he may still have to go back and do a hemiarthoplasty. Why?

4. You've been given the task of inserting the catheter for a patient scheduled for angioplasty. What anatomical landmarks are you looking for?

5. A defensive back making his cut to stay with the receiver gets clipped. He experiences knee pain and limps off the field. Upon examination in the locker room he is found to exhibit a positive anterior drawer sign. An MRI is ordered. What might have happened to the football player's knee?

6. A student crossing JPA to catch the bus gets hit by a car just distal to the knee. Although no bones are broken, the student subsequently exhibits "dropfoot." What structure in the leg was likely damaged?

7. A leadoff batter tries to beat out a slow roller to short. Just before he hits the bag he feels a sharp pain and he instinctively grabs the back of his thigh. He limps back to the dugout having been thrown out on yet another bad call by the umpire. What probably happened to the batter?

8. Your patient complains of leg pain while walking. You suspect his popliteal artery is at least partially blocked. You decide to take his pulse at the ankle. Where do you place your fingers?

9. You have to do a lumbar puncture. What landmarks do you use to insert the needle? What layers of tissue will the needle pass through to reach CSF?

10. A middle-aged, overweight couch potato feels a sharp pain when he bends over to pick up his 24-can case of Bud. Subsequently he feels low back pain and pain down the posterolateral side of his leg. What most likely happened?

11. A baby is born with spina bifida. Explain what happened or didn't happen developmentally? How might this defect have been prevented?

12. The patient comes to the emergency room in severe shock. The attending tells you to start the IV.
Which vein would you use at the elbow? forearm? leg?

13. Your patient who has recently had a mastectomy now exhibits "winged scapula." What's the most likely reason?

14. A football player falls heavily to the ground and feels something in his shoulder snap. He runs off the field supporting his medially rotated upper limb. There a big knot in the root of his neck. What happened?

15. You examine a young man who was thrown from his motorcycle. You diagnose Erb-Duchenne paralysis. What is the position of the upper limb and why?

16. You have to tie off the axillary artery to achieve a bloodless field in order to repair damage to the shoulder resulting from a gun shot wound. You ligate the axillary artery confident that the upper limb will continue to receive adequate arterial blood. What anatomical knowledge do you have that accounts for your confidence?

17. Sgt. Snorkle falls off a cliff and brakes his fall by grasping a convenient snag with his right hand. Pvt. Beetle Bailey eventually pulls him to safety and he is rushed to an aid station where you are fullfilling the terms of your military medical scholarship. Upon examination you find that Sgt Snorkle is holding his hand in a peculiar way and has lost sensation on the medial side of his arm and to a lesser extent on the medial forearm, hand and two ulnar fingers. What nerve (s) has been damaged and what is the position of Sgt. Snorkle's hand?

18. Your patient works for Wampler-Longacre Foods over in the Valley near Harrisonburg and for eight hours a day with few breaks, she cuts the wings off of chickens as they move down a conveyer belt. She is complaining of severe "pins and needles" in her cutting hand. She experiences difficulty in buttoning up her clothes when dressing. What anatomical structure was affected in this patient?

19. A patient involved in an MVA fractures his arm and subsequently experiences wristdrop. What happened?

20. A young boy fell from his bike on to the hard pavement. He feels pain and tenderness at the base of the thumb. You order a radiograph and use it to make the diagnosis. What happened.?

21. Your patient receives what appears to be a minor cut on the palm of his hand near the base of the thumb. Upon examination you discover that certain of his thumb movements are impaired. Which ones and why?

22. A recently retired man goes fly fishing every day. He notices that his shoulder hurts every time he casts. The pain gets so bad he comes to see you, his primary-care physician. What do you suspect is wrong with this man's shoulder?

 

Back & Limbs Board Review Answers


1. Lymph from the skin and superficial fascia of the trunk and limbs initially drains to either axillary or superficial inguinal lymph nodes. The back, chest and abdomen superior to the umbilicus drain to axillary nodes. Abdominal skin inferior the umbilicus, scrotum, buttocks, and anal canal inferior to the pectinate line drain first to superficial inguinal lymph nodes, then through the saphenous opening to deep inguinal nodes.

2. When gluteus minimus and medius are paralyzed due to injury to the superior gluteal nerve, the loss of isometric contraction of those muscles causes the pelvis to dip contralaterally when the contralateral limb is unsupported as in swing phase of the gait..

3. Fractures of the femoral neck often result in avascular necrosis of the femoral head and required replacement of the head with a prothesis.

4. Just inferior to the midinguinal point (midway between the ASIS and pubic tubercle) the femoral artery passes anterior to the femoral head.

5. Classic case of the “unhappy triad” consisting of a torn ACL, medial collateral ligament and medial meniscus.

6. Common fibular (peroneal) nerve.

7. Hamstring pull (strain).

8. There are two places to take a pulse at the ankle: 1) at the posterior tibial artery just posterior to the medial malleolus , 2) at the dorsalis pedis artery just distal to the ankle joint between the tendons of extensor hallucis and extensor digitorum longus.

9. The supracristal line, i.e., a line connecting the highest points on the iliac crest, passes through the spinous process of L4. The needle should pass either immediately superior or inferior to the L4 spinous process.

10. Herniated nucleus pulposus impinging on nerve root of L5 or S1 spinal nerve.

11. The vertebral lamina failed to fuse in the midline. Women of childbearing age can ingest folic acid supplements to prevent this defect.

12. Superficial veins are commonly used for intravenous infusions. At the elbow the median cubital vein is used.. In the distal forearm, the cephalic vein can be accessed just posterior to the radial styloid, and in the distal leg, the great saphenous vein can be cannulated just anterior to the medial malleolus.

13. The long thoracic nerve was injured during surgery.

14. The clavicle is the most commonly fractured bone in the body. The arm is held close to the body and medially rotated due to action of powerful adductors and medial rotators like pectoralis major. It must be supported due to the weight of the limb. The medial end of the fractured clavicle is elevated by sternocleidomastoid.

15. This is an upper brachial plexus injury involving C5 and C6 nerve roots and thus profoundly affecting the suprascapular, musculocutaneous and axillary nerves. The arm is adducted and medially rotated. The forearm is extended and pronated.

16. This is a classic example of collateral circulation so prevalent throughout much of the body. The axillary artery is ligated distal to the thyrocervical trunk and proximal to the subscapular artery. Blood passing into the posterior shoulder via the suprascapular and transverse cervical arteries can then course in a retrograde fashion through the circumflex scapular and then subscapular artery to reach the brachial and vascularize the upper extremity.

17. Sgt. Snorkle has experienced a lower brachial plexus injury also known as Klumpke palsy. It results in damage to the T1 and C8 nerve roots. Lower trunk nerves are non-functional. They are medial brachial and antebrachial cutaneous nerves, ulnar nerve and the part of the median nerve that supplies innervation to the hand. Thus Sgt. Snorkle exhibits a claw hand, hyperextended at the MP joints and flexed at the IP joints. His thumb would be flattened and abducted.

18. Tendosynovitis of the common flexor sheath (ulnar bursa) has compressed the median nerve against the flexor retinaculum resulting in the symptoms described in this problem. Damage to the median nerve affects the thenar muscles that are necessary to oppose the thumb as in buttoning a shirt.

19. The fractured humerus damaged the radial nerve as it coursed in the radial groove. The radial nerve innervates the muscles that extend the wrist.

20. The boy has fractured his scaphoid , a bone particularly susceptible to avascular necrosis.

21. The recurrent branch of the median nerve has been severed. Most noticeably, opposition of the thumb would be lost. To a lesser extent thumb flexion and abduction would be affected.

22. You suspect that repeated casting has caused a rotator cuff tear. Most frequently the tendon of supraspinatus is torn.

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