Blocks of Nerves of the Sacral Plexus Supplying the Lower Extremities
Jean-Pierre Monnet, Yves Harmand in Pediatric Regional Anesthesia, 2019
The anesthetized area consists of the posterior aspect of the thigh and the lower part of the skin covering the gluteus maximus muscle. The sacral plexus lies on the anterior aspect of the piriformis muscle, behind the posterior wall of the pelvic cavity. Sciatic nerve blocks are recommended for operations on the foot, including ingrowing toenails, removal of foreign bodies and implants, dressing of wounds, osteotomies, and clubfoot repair. The sciatic nerve emerges from the pelvis through the greater sciatic foramen and runs towards the back of the thigh between the greater trochanter of the femur and the ischial tuberosity. Complete anesthesia of the area supplied by the sciatic nerve can be achieved with the same amounts of local anesthetics as those recommended for blocking the femoral nerve. Anterior approaches to the sciatic nerve may lead to penetration of femoral vessels, with subsequent, possibly compressive, hematomata.
The lower limb
Ffion Davies, Colin E. Bruce, Kate Taylor-Robinson in Emergency Care of Minor Trauma in Children, 2017
Children may sustain avulsion fractures following sudden movements, usually during sport. The five places this can occur are the ischial tuberosity, the greater and lesser trochanters of the femur and the anterior superior and anterior inferior iliac spine. Fractures may be transverse, spiral or supracondylar. Seventy percent occur in the middle third of the femur. Most acute knee injuries are sprains, sustained during sport or while falling over, usually with a history of twisting. Accurate assessment of acute knee injuries can be difficult because of pain. An effusion is the cardinal sign of an injury within the joint. Ligament injury is best assessed with the knee in a slightly flexed position. The extensor mechanism consists of the quadriceps muscle, the patella, the patella tendon and the tibial tuberosity. Injury can disrupt these components at their junctions with each other. The most common symptom of septic arthritis is the child not using the limb, or pain when it is handled.
Hip and knee
Ian Mann, Alastair Noyce in The Finalist’s Guide to Passing the OSCE, 2021
All joint examinations follow the same format. It is important to remember that when an individual complains of pain in a specific joint, this could be referred pain, or arise secondary to another joint. Gain verbal consent to examine the patient's hip/knee joint by explaining what will be involved. If the knee is being examined in isolation, a pair of shorts will suffice. Tenderness in specific areas may relate to an underlying pathology: greater trochanter, lesser trochanter and ischial tuberosity. The knee should be moved through extension and flexion, with both active and passive movement being assessed. The skin is warm to touch, with exquisite tenderness of the left hip on palpation. Inspection, palpation and movement are all normal in the right hip. Inspection, palpation and movement are all normal in the right hip.
The relationship between pressure offloading and ischial tissue health in individuals with spinal cord injury: An exploratory study
Published in The Journal of Spinal Cord Medicine, 2019
Sharon Gabison, Sunita Mathur, Ethne L. Nussbaum, Milos R. Popovic, Mary C. Verrier
Objectives: To compare thickness and texture measures of tissue overlying the ischial region in able-bodied (AB) individuals vs. individuals with spinal cord injury (SCI) and to determine if there is a relationship between pressure offloading of the ischial tuberosities (IT) and tissue health in individuals with SCI. Design: Exploratory cross-sectional study. Setting: University setting and rehabilitation hospital. Outcome Measures: Thickness and texture measurements from ultrasound images of tissues overlying the IT were obtained from AB individuals (n = 10) and individuals with complete or incomplete traumatic and non-traumatic SCI American Spinal Injury Association Impairment Scale (AIS) classification A–D (n = 15). Pressure offloading was measured in individuals with SCI and correlated with tissue health measurements. Results: The area overlying the IT occupied by the muscle was significantly greater in the SCI when compared with AB cohort. The area occupied by the muscle in individuals with SCI appeared to lose the striated appearance and was more echogenic than nearby skin and subcutaneous tissue (ST). There was no correlation between offloading times and thickness, echogenicity and contrast measurements of skin, ST and muscle in individuals with SCI. Conclusion: Changes in soft tissues overlying the ischial tuberosity occur following SCI corresponding to the loss of striated appearance of muscle and increased thickness of the area occupied by the muscle. Further studies using a larger sample size are recommended to establish if thickness and tissue texture differ between individuals with SCI who sustain pressure injuries vs. those who do not.
Diagnostic dilemma of sacral abscess presented with seizure and altered conscious level in a patient with spinal cord injury
Published in The Journal of Spinal Cord Medicine, 2017
Kelvin Cheng Chek Siang, Aishah Ahmad Fauzi, Nazirah Hasnan
Context: Infection and septicaemia may clinically presented with seizure and altered conscious level. In spinal cord injury (SCI) population, they are at risk of having pressure ulcer which can be complicated further with infection and septicaemia. Findings: A 40-year-old man with complete T4 SCI and multiple clean and non-healing pressure ulcers at sacral and bilateral ischial tuberosity regions was initially admitted for negative pressure wound therapy (NPWT) dressing. He had an episode of seizure and subsequently had fluctuating altered conscious level before the diagnosis of deep-seated sacral abscess was made and managed. Prior investigations to rule out common possible sources of infections and management did not resolve the fluctuating event of altered consciousness. Clinical relevance: We presented an unusual case presentation of septicemia in a patient with SCI with underlying chronic non-healing pressure ulcer. He presented with seizure and fluctuating altered conscious level. Even though a chronic non-healing ulcer appeared clinically clean, a high index of suspicion for deep seated abscess is warranted as one of the possible sources of infection, especially when treatment for other common sources of infections fails to result in clinical improvement.
Unilateral Hyperhidrosis From a Contralateral Source in an Individual With C4 Complete Tetraplegia
Published in The Journal of Spinal Cord Medicine, 2010
Setting: Outpatient clinic of a spinal cord injury rehabilitation center. Design: Case report. Participant: A 40-year-old man with a 20-year history of C4 complete tetraplegia complained of 5 years of excessive intermittent left-sided sweating. The sweating occurred only in the seated upright position. There was no associated headache, blurred vision, or blood pressure variability. Findings: When examined upright, the patient sweated excessively on the left face and body. When he was laid down, sweating ceased. Skin examination revealed intact ischial regions. Pressure applied to the right ischium for several minutes caused sweating to recur on the left forehead, but it then subsided with release of pressure. This phenomenon was repeatable. Local lidocaine injection in the subcutaneous tissues around the right ischium and subsequent use of lidocaine transdermal patches halted the contralateral sweating in the upright position. Pressure mapping analysis showed increased pressure in the region of the right ischial tuberosity. The patient's gel cushion was replaced with an air-filled cushion, providing significant ongoing relief from the hyperhidrosis. Conclusion/Clinical Relevance: Unilateral hyperhidrosis can be caused by a contralateral source of irritation. Use of techniques that interrupt the afferent arm of the autonomic pathway may be effective in the management of hyperhidrosis in individuals with spinal cord injury.
Related Knowledge Centers
- Ischium
- Sacrotuberous Ligament
- Superior Ramus of The Ischium
- Sitting
- Gluteus Maximus
- ADDuctor Magnus
- Semimembranosus