Anterior Tibial Artery

Anterior Tibial Artery

The anterior tibial artery is a branch of the popliteal artery (posterior aspect of knee), which divides into the anterior tibial artery and the posterior tibial artery (posterior). The anterior tibial artery is a branch of the popliteal artery (posterior aspect of the knee), which divides into the anterior tibial artery and the posterior tibial artery (posterior). Sometimes the two divisions are called the anterior tibial artery and the tibio-fibular trunk. ^th area of the anterior fibula. Then the extensor hallucis longus muscle appears, so the anterior tibial artery lies between the tibialis anterior muscle and the extensor hallucis longus muscle. The extensor hallucis longus muscle arises from the middle 2/4^th area of the anterior fibula. The extensor hallucis longus then crosses the leg medially to take a position in the medial side. The big toe is definitely medial, so the extensor hallucis longus will go towards the big toe and become medial. The other toes are lateral, so the extensor digitorum longus will be inserted laterally and the anterior tibial artery will then be between these two muscles in the distal part of the leg and in front of the ankle. When the extensor hallucis longus tendon crosses the leg to go medially, it then crosses the anterior tibial artery. At this point, the anterior tibial artery is between the extensor hallucis longus and the extensor digitorum longus tendons. At the level of the ankle joint, this is how we remember the arrangement of the anterior ankle structures. Tom Has a Very Nice Dog: Tibialis anterior, extensor Hallucis longus, Vessels, Nerve, extensor Digitorum longus. This is only good to remember the structures in the distal portion of the tibia in front of the ankle. This does not work proximally, and this does not work for the structures in the middle third of the tibia. Extensor hallicus longus tendon is medial. Anterior tibial artery is lateral. After the anterior tibial artery passes underneath the extensor retinaculum, the artery is then called the dorsalis pedis, distally. The deep peroneal nerve pierces the intermuscular septum to enter the anterior compartment and goes through the substance of the extensor digitorum longus muscle.   of retractors in the posterior part of the proximal tibia to avoid damage to any of these branches of the popliteal artery since the bifurcation of the popliteal artery is in this area.

The relationship between the anterior tibial artery and the deep peroneal nerve changes according to the location. Proximally the nerve is lateral, then the nerve comes in front of the artery, finally the nerve stays lateral, distally. CTA around the knee can be done for dislocations or severe fractures around the knee area. At this level of the distal femur, you can see the popliteal artery. At the level of the proximal part of the leg, you can see the three branches of the popliteal artery: anterior tibial artery, posterior tibial artery, and peroneal artery. Be careful during placement. The anterior tibial artery arises just below the popliteus muscle. The anterior tibial artery pierces the interosseous membrane to enter into the extensor compartment or anterior compartment of the leg. The anterior tibial artery gives the anterior and posterior tibial recurrent arteries. The anterior tibial recurrent artery is the one that can be injured from tibial tubercle fracture in children, which can cause compartment syndrome of the leg. The artery then runs proximally between the tibialis anterior medially and the extensor digitorum longus laterally. The extensor digitorum longus arises from the upper 3/4

Acute Low Back Pain Lumbar Disc Herniation

Acute Low Back Pain Lumbar Disc Herniation

Low back pain is a common condition. 90% of patients with low back pain will improve without surgery. Usually they get better with spontaneous resolution of the symptoms within 12 weeks. We usually advise the patient for early return to activity and function as the symptoms and the pain permits. The risk factors for development of low back pain are numerous, some include: vibration exposure, poor physical fitness, smoking and obesity, anxiety and depression, job dissatisfaction, or repetitive bending or “stooping” on the job. In summary, if the patient has no red flags and has a normal neurological exam, there is no reason to get early radiological studies. Getting early x-rays and early MRIs leads to a better patient satisfaction but does not give a better patient outcome. If there is no specific pain pattern, then there is no need for further workup. MRIs are good studies, but they give false positives. There is degeneration or a bulge of a disc in 35% of all asymptomatic subjects between 25-39 years of age. In patients 60 years old or older, the majority of the patients will have changes in the MRI. MRI abnormalities are common and must be correlated with the age and the clinical signs and symptoms of the patient. An MRI is good for diagnosing the lumbar disc herniation, which is sometimes called a ruptured disc, a slipped disc, or a herniated disc. The most common location of a disc herniation is a posterolateral herniation involving one nerve root. A foramninal L4-L5 herniation occurs in about 8%-10% of the cases. It involves the exiting nerve. A central herniation involves multiple nerve roots. It predominantly causes low back pain more than leg pain. It may cause bladder and bowel symptoms. This type of disc herniation causes Cauda Equina Syndrome which needs urgent diagnosis and surgical treatment. Clinical evaluation for a herniated disc examines sensory and motor reflexes. The Straight Leg Raising Test is the most important finding. It can be done in either the sitting or supine position. The test is positive as indicated by pain in the leg when the patient’s leg is raised to flex the hip with the knee extended. A positive straight leg test means a tension sign, something is putting tension or stress on the sciatic nerve. When the test is positive, it indicates possible disc herniation.

Treatment is typically non-operative. First, reassure the patient. Let the patient take some rest (no more than a few days), give the patient anti-inflammatory medication, and instruct them to attend physical therapy. Indications for surgery include progressive neurological deficits, Cauda Equina Syndrome, the patient is not getting better with time and treatment or if the symptoms are not getting better with conservative treatment, or the patient has a positive tension sign with persistent sever pain. Patients with sciatica and positive tension signs or patients with positive neurological findings on clinical exam with positive MRI findings make ideal surgical candidates. Surgery results in relief of leg pain in the majority of patients. Back pain may persist in some patients. Surgery results in neurological improvement, 50 % motor and sensory and 25% reflexes. In patients with discogenic back pain, they may need fusion which is a major procedure.The worst pressure on the disc occurs with prolonged sitting and bending over. This is the position that produces the highest pressure on the disc. If a patient has back pain but no radiation, by the patient’s history or physical examination and there are no red flags, then there is no reason to get x-rays or MRI early in the treatment of the patient. Red flags include a history of trauma, a tumor, infection, or Cauda Equina Syndrome symptoms. To rule out a history of trauma you should rule out fractures with x-rays, MRI, or CT scans. Tumors are a risk if the patient is older than 50 years old, if the patient had weight loss, or if the patient has pain at rest or at night. An infection may be present if the patient has fever and chills, if the patient has a history of diabetes, or if the patient has a history of IV drug abuse. Cauda Equina Symptoms may be present if the patient has back pain more than leg pain or if the patient also has bladder and bowel symptoms. Cauda Equina Syndrome needs to be diagnosed and surgically treated early. An MRI needs to be ordered urgently in the course of treatment. The MRI should be ordered STAT. There may need to be a wet read; a wet read is an early preliminary read of the radiographs. A wet read needs to be communicated with the physician and can be done while the patient is still on the table of the MRI.

Femoral Neck Fracture Nonunion

Femoral Neck Fracture Nonunion

Femoral neck fracture nonunion has multiple facets and is important to understand all aspects of this important problem.

Example:

40 year old patient had a displaced femoral neck fracture, fixed with multiple cancellous screws about 9 months ago. The patient still has persistent groin pain. The patient cannot bear full weight on the hip. The patient has a painful limb, antalgic gait, and difficulty in walking. X-rays are not clear and show a possible nonunion. CT scan shows the nonunion with some Varus angulation. The treatment for this would be removal of the hardware and valgus osteotomy. The scenario can be more complicated by adding a healed femoral shaft fracture to the nonunion of the femoral neck. In this case, you will do removal of the hardware from the femur and removal of the screws from the femoral neck nonunion. You will do valgus osteotomy and fixation with a plate, preferably a blade plate, to treat the nonunion of the femoral neck.

Intracapsular fractures of the proximal part of the femur are not common in adults younger than 50 years old, but they are associated with a high incidence of avascular necrosis and nonunion. About 10-30 % of femoral neck fractures go to nonunion after ORIF. It is usually the vertical fracture pattern, such as Type III in Pauwels Classification. These fractures are more prone to nonunion due to shear stress, rather than compression forces across the fracture site. In Garden Classification fracture Type IV, where the fracture is completely displaced, the greater the displacement, the higher the incidence of nonunion and reoperation rate after fixation of the femoral neck. The inverted triangle pattern of fixation of femoral neck fractures is the one that is commonly used with the inferior screw posterior to the midline and adjacent to the calcar. Achieving and maintaining anatomic reduction is important for femoral neck fracture fixation and healing. The femoral neck fractures are intracapsular. There will be no abundant callus formation during the healing (healing is intraosseous only). Sometimes it is difficult to know if the fracture healed or not. There is no correlation between age, gender, and rate of nonunion. Varus malreduction correlates with failure of fixation after reduction and cannulated screw fixation. Posterior comminution of the fracture does not allow stable fixation and can lead to nonunion. The comminution of the femoral neck is usually posteriorly and inferiorly. Some recommend adding a fourth screw in this situation. High energy fractures have a worse prognosis for healing, especially in patients with metabolic bone disease and nutritional deficiency. When you see a femoral neck nonunion after fixation, you need to get blood work and rule out infection (get sedimentation rate and CRP).

For the high angle femoral neck fracture, follow the patient up closely with clinical exam and x-rays. There might be a Varus collapse on the x-rays. You may see a femoral neck nonunion or a failed internal fixation. The patient walks with a limp, the limb is shortened, and the patient may have rotational deformity of the extremity. In the young patient with a femoral neck nonunion, arthroplasty is not a desirable option. In a young patient with femoral neck fracture nonunion, valgus intertrochanteric osteotomy with plate fixation produces a good result in the majority of cases. Valgus intertrochanteric osteotomy with plate fixation produces approximately 80% union rate and the procedure makes a vertical fracture more horizontal, converting the shear forces into compressive forces. It is done in a healthy, young patient with no joint arthritis and when the femoral head is intact. This procedure also corrects the Varus malalignment. Basically, the procedure changes the vertical fracture orientation to a horizontal fracture to achieve compression. Other procedures done in the young patient include revision ORIF with or without bone graft, but this is rarely done. Other procedures done in the young patient also include free vascularized fibular graft which is done in some patients especially in the younger patient with a nonviable femoral head. Hemiarthroplasy is done in patients with low physical demands. The articular cartilage of the patient is preserved with no evidence of infection. Total hip arthroplasty is done in patients that are older, in patients that have hip arthritis, if the femoral head is not viable, or if the hardware is cut out. It can also be done in younger patients that are active, when the femoral head is not viable and the patient does not want a free vascularized fibular graft or if the patient had collapse of the femoral head with nonunion. The problem with total hip replacement in this situation is more dislocations of the hip postoperatively.

Cervical Radiculopathy

Cervical Radiculopathy

Cervical radiculopathy is caused by cervical nerve root compression. The patient will have pain and/or progressive neurological deficit that results from conditions such as disc herniation that irritates a nerve in the cervical spine. Cervical radiculopathy is an irritation of the cervical nerve root. Cervical spine and shoulder problems overlap. The condition is of cervical spine etiology if the patient’s symptoms are relieved by shoulder abduction, by placing the hand over the head. The relief of the symptoms occurs due to decreased tension on the nerve roots. In cervical disc problems, be aware of false positive MRIs especially if the patient is above the age of 40 years old. Nerve conduction studies are not useful; they have a high false negative rate. EMG and nerve studies may differentiate radiculopathy from peripheral nerve entrapment. Cervical disc problems usually affect the lower numbered nerve root.

When you see the middle finger numbness, then this is C7. When compression of the C7 nerve root, there will be middle finger numbness, triceps weakness, and the triceps reflex will be affected. The cervical nerve roots are horizontal in orientation. It does not matter if cervical disc herniation is central or foraminal, it will compress the same nerve root. C7 nerve root runs above the pedicle of the C7 vertebra. C5-C6 is the most commonly affected disc and that will compress the C6 nerve root. The patient will come to the doctor with unilateral arm pain that is relieved by arm elevation. The numbness and paresthesia will occur in specific dermatomes. The patient may also have upper trapezius pain or interscapular pain. The patient may complain of occipital headache. When you examine the patient, do provocative tests such as the spurling’s test and the shoulder abduction test. The Spurling’s test is done by extending and rotating the neck towards the involved side. It reproduces the symptoms by narrowing the neuroforamen. The Spurling’s test differentiates cervical radiculopathy from peripheral nerve entrapment. Lifting the arm above the head relieves the symptoms if the cervical nerve roots are irritated. The Shoulder Abduction test differentiates cervical pathology from other causes of painful shoulder etiology. Make sure that you do not have a double crush syndrome, one in the neck and one in the peripheral nerve. Make sure that you differentiate radiculopathy from myelopathy. Make sure that you exclude a coexisting myelopathy. Examine the patient for upper motor neuron signs or cervical

myelopathy. Test the patient for gait instability. Test the patient for Hoffman’s sign. Test the patient for Babinski reflex. Test the patient for ankle Clonus. Check to see if the patient has hyperflexia in the upper and lower extremities (triceps/quadriceps). Even if there is a bad cervical spine disc problem on the MRI, treat it conservatively for about 3 months. Give the patient therapy and nonsteroidal anti-inflammatory medication (NSAIDS). 75% of the patients will improve with nonoperative treatment. Cervical radiculopathy is generally treated nonoperatively, in contrast to cervical myelopathy. Do surgery when there is persistent, severe pain for 6-12 weeks and/or progressive neurological deficit such as weakness or numbness. The procedure to treat cervical radiculopathy surgically is usually done anteriorly with direct removal of the lesion that causes the radiculopathy such as a herniated disc or spurs. When you place the anterior bone graft or the allograft in the disc space, you open the nueroforamen, and that will indirectly relieve the nerve. Then you will add the anterior plate. Some surgeons prefer to do a posterior approach.