Case-based MCQ

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Correct Answer Is E A herniation of the disc between the L5 and S1 vertebrae will impinge on the S1 spinal nerve, which exits between the S1 and S2 vertebrae.In L5-S1 disc prolapse, ankle reflex is lost. A brief description of signs and symptoms of nerve root involvement at each level in the lumbar region is given below. 1.T12-L1-Pain in inguinal region and medial thigh. 2.L1-2- Pain in anterior and medial aspect of upper thigh- slight weakness in quadriceps 3.L2-3-Pain in anterolateral thigh and weakness of quadriceps leading to weak of knee reflex. 4.L3-4-Pain in the posterolateral thigh and anterior tibial area with diminished knee reflex. 5.L4-5-Pain dorsum of the foot with weak dorsiflexion of big toe and foot. 6.L5-S1-Pain in the lateral aspect of the foot with absent ankle jerk.

A 45-year-old male presented with sharp,burning, stabbing pain in the lateral aspect of the right foot.You suspect L5-S1 radiculopathy. Which of the following is lost in L5-S1 disc prolapse? A. Knee jerk B. Dorsiflexion of big toe and foot C. Inversion of foot D. Eversion of foot E. Ankle jerk

Correct Answer Is C The clinical presentation is suggestive of right anterior interosseous nerve injury {AIN). AIN is a purely motor branch of the median nerve that innervates all deep muscles of the anterior compartment of forearm except the ulnar part of the muscle flexor digitorum profundus. AIN branches from median nerve 4cm distal to medial epicondyle and runs along the front of the interosseous membrane of the forearm in the space between the flexor pollicis longus and flexor digitorum profundus. AIN ends distally In the pronator quadratus and wrist joint. Muscles innervated by AIN Include: Flexor pollicis longus (the long flexor of thumb) The radial part of flexor digitorum profundus (flexor of the index and (sometimes)middle fingers) Pronator quadratus (forearm pronation resulting in palm of the hand facing down) Radial nerve supplies thumb and fingers extensors and forearm supinator muscles. Radial nerve injuries or neuropathies do not cause weakness of fingers flexion or forearm pronation. Median nerve injuries distal to where AIN branches off cause weakness of thenar muscles including flexor pollicis brevis, abductor pollicis brevis and opponens pollicis. With compensatory action of flexor pollicis longus (supplied by the AIN) and abductor pollicis longus(supplied by the radial nerve) flexion and abduction remain almost unaffected; however, thumb opposition becomes impaired. Median nerve injuries proximal to AIN origin result in dysfunction of all median-innervated muscles in the forearm and hand. Posterior interosseous nerve innervates the common and deep extensors of the fingers. It branches off from the radian nerve at the radiohumeral joint line and travels down in the posterior compartment of the forearm. Injuries or neuropathies of this nerve do not result in the presentation in the case scenario. With ulnar nerve involvement, there would be weak flexion of the 4th and 5th fingers, weak flexion of wrist, and sensory disturbances in the territory of the ulnar nerve

After a left elbow injury, a 55-year-old man develops weakness of the long flexors of the right thumb and index finger. He is also unable to do forearm pronation on the same side. Which one of the nerves is involved? A. Radial nerve B. Median nerve C. Anterior interosseous nerve D. Posterior interosseous nerve E. Ulnar nerve

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Correct Answer Is B Sciatic nerve palsies have been reported in patients undergoing CABG (coronary artery bypass graft) due to prolonged nerve pressure compounded by low arterial pressure provided by cardiopulmonary bypass. The sciatic nerve is formed by the ventral rami of L4-S3. The sciatic nerve also indirectly innervates many other muscles, via its two terminal branches: 1-Tibial Nerve -the muscles of the posterior leg and some of the intrinsic muscles of the foot. 2-Common Fibular Nerve- the muscles of the anterior leg, lateral leg, and the remaining intrinsic foot muscles. The sciatic nerve continues down the posterior thigh, giving rise to motor branches for the hamstring muscles. When the sciatic nerve reaches the apex of the popliteal fossa, it terminates by bifurcating into the tibial and common fibular nerves. The sciatic nerve provides motor innervation to the muscles of the posterior compartment of the thigh, the hamstring part of Adductor Magnus and all muscles of the leg and foot. The sciatic nerve provides sensory innervation to the skin of the lateral aspect of the leg (anterolateral and posterolateral), and almost all of the foot (exception is the medial part of the foot that is innervated by saphenous nerve). Signs of L4 nerve root injury include weak quadriceps extension, positive squat and rise test, and diminished knee-jerk reflex. L5 nerve root injury is suggested by foot drop with the weakness of the anterior tibial, posterior tibial, and peroneal muscles. There is a sensory loss over the shin and dorsal foot. Injury to S1 nerve root is suggested by impaired ankle plantar flexion and loss of ankle jerk. There is a sensory loss over lateral calf and foot. This patient has a combination of signs and symptoms suggestive of sciatic nerve injury.

A 60-year-old male undergoes CABG for acute coronary artery disease. On second-day post procedure, he is found to have absent right ankle jerk with the inability to perform dorsiflexion and plantar flexion. Inversion and eversion of the foot are also lost. What is the most likely diagnosis? A. Injury of common peroneal nerve B. Injury of sciatic nerve C. Injury tibial nerve D. Injury of L5 E. Spinal cord compression

Correct Answer Is E Primary care physicians frequently encounter patients with foot and ankle pain. Common causes of pain in the proximal foot include ankle sprains, plantar fasciitis, and tarsal tunnel syndrome. Ankle sprains result from trauma with stretching of the lateral ankle ligaments. Swelling and bruising distal to the lateral malleolus are common. Evidence-based guidelines (Ottawa rules) suggests that the only patients who need x-rays of the ankle are those who cannot bear weight immediately after the injury or in the emergency department and those with point tenderness over the medial or lateral malleolus. Plantar fasciitis typically causes heel pain that is worse for the first few steps in the morning or after sitting. This is a common condition of runners after an increase in exercise intensity. The tarsal tunnel is a pathway along the medial malleolus between bone and the flexor retinaculum. The posterior tibial nerve runs through this path. Inflammation in this area can result in nerve irritation which causes pain in the ankle and heel and numbness of the sole of the foot at night. This condition is referred to as tarsal tunnel syndrome. Common causes of pain in the distal part of the foot include podagra (acute gout of the first metatarsal phalangeal joint, which comes on abruptly and is associated with swelling and redness), metatarsal stress fracture (which comes on abruptly, is made worse by weight-bearing, is associated with point tenderness, and may be associated with normal x-rays), hallux valgus (which is bunion formation as a result of lateral deviation of the great toe at the metatarsal joint) and Morton neuroma (which typically causes pain and numbness on the ball of the foot, and is made better by taking off shoes). Charcot joint is collapse of the arch of the associated with severe peripheral neuropathy.

A 54-year-old woman complains of pain and burning over the bottom of the forefoot; her symptoms are relieved by going barefoot. What is the appropriate disease? A. Plantar Fasciitis B. Metatarsal stress fracture C. Tarsal tunnel syndrome D. Hallux Valgus E. Morton neuroma

Correct Answer Is D During examination, patient was unable to plantar flex his left foot against resistance. Loss of the left ankle jerk was noted. This is supported by the radiological finding which showed a prolapse L5/S1 disc, subsequently causing left S1 nerve root impingement. Bladder function is mediated by autonomic outflow of lower sacral nerves. Foot drop is caused by weakness of the tibialis anterior, ankle and toe extensors which are supplied from the L5 nerve root through the common peroneal nerve, often associated with high-stepping gait. Quadriceps are innervated by the femoral nerve (L2-4). Knee jerk is controlled by quadriceps, hence the same nerve roots.

A 24-year-old man presented to the orthopaedic clinic with minimal back discomfort and complained of difficulty walking for the past two days. One month earlier, he developed a severe lower back pain while lifting a heavy load. MRI lumbosacral joint was ordered. Which one of the neurological findings would be consistent with this imaging? A. Loss of bladder function B. Weakness of left quadriceps C. Loss of left knee jerk D. Loss of left ankle jerk E. Left foot drop

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Correct Answer Is A This patient has symptoms of L4 radiculopathy. In L5 radiculopathy,pain usually is referred to posterolateral buttock,posterior thigh and lateral leg. In S1 radiculopathy,pain radiates through posterior buttocks,posterior calf and lateral foot.Ankle jerk is diminished as well in S1 radiculopathy. L5-S1 radiculopathy is mixture of both lesions. Sciatica is involvement of sciatic nerve causing shooting radiating pain through posterior thigh and posterior leg to little toe.

Mr John,a 48 year-old man with known history of chronic back pain comes to your clinic complaining of pain radiating to the hip,anterior thigh,medial aspect of knee and calf. On examination,sensory impairment is noted over medial calf.Knee jerk is also diminished. Which of the following is most likely diagnosis?   A. L4 radiculopathy B. L5 radiculopathy C. S1 radicuolpathy D. L5-S1 radiculopathy E. Sciatica

Correct Answer Is A This patient has developed clinical features of anterior cruciate ligament (ACL) injury while playing football. The clinical features of ACL injury include: – A ‘pop’ classically occurs at the time of knee injury with immediate severe pain. – An effusion develops within the first hour, and it indicates hemarthrosis. – Any attempt to continue activity results in episodes of an instability of the knee, especially when changing direction. – A knee that functions well in the anterior-posterior axis but gives way to rotational movements (often painlessly) suggests ACL deficiency. The examination of the knee involves assessment of following: – Weight bearing status. – Inspection and palpation for tenderness and effusion. – Assessment of the range of movements and muscle strength. There are specific tests which need to be performed to assess for particular area of knee injury: – ACL (anterior cruciate ligaments) rupture-Lachman and pivot shift tests. – PCL (posterior cruciate ligament) injury-posterior draw test and posterior sag. – Meniscal injury-McMurray test. – Collateral ligament injury – varus and valgus stress tests. – Patella dislocation – patellar apprehension test. The initial treatment of ACL injury includes rest, ice, compression and elevation (RICE). However, the ACL injury almost always needs reconstructive surgery and 9–12 months of intensive rehabilitation before they can return to competitive sport.

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