1. Katrina Ducis Emily Gaare Mousumi Sircar Sarah Wall
Lower Limb Case 3
Katrina Ducis
Emily Gaare
Mousumi Sircar
Sarah Wall

2. History of Present Illness
Our patient was on a course of antibiotics delivered via intramuscular injection in the buttocks following a major surgery.
Following an injection, the patient complained of more pain than usual in the injection region.
Later that day, a nurse noted that the patient was walking with a limb that had not been present before.

3. Physical Exam
The patient had normal vital signs and a normal neurological exam.
A brief examination of the patient’s stride revealed that his left hip dropped every time he lifted his left foot off of the ground, as opposed to the right side where his pelvis remained level when his right foot was lifted.
Further inspection and muscle testing of the lower limb showed normal function and there was no loss of sensory sensation from the skin.

4. Which muscle(s) are affected in this patient?

5. What is the primary action of these muscles?
Gluteus Medius
Gluteus Minimus
What is the primary action of these muscles?
What is its application to normal locomotion?

6. If these muscles are affected, which nerve must be damaged
If these muscles are affected, which nerve must be damaged? And where is this nerve located?

7. Where does the superior gluteal nerve originate?

8. Where does the superior gluteal nerve originate and what is its path?
Sacral Plexus
Greater Sciatic Foramen
Relationship to Piriformis muscle?
Runs between Gluteus Medius and Minimus
What is the lateral limit of the superior gluteal nerve?
Tensor Fascia Lata
Ask about relationship to piriformis muscle through greater sciatic foramen

9. On which side of the body was the intramuscular injection in question given?

11. What other structures in this region might be damaged by an inappropriately administered intramuscular injection or other penetrating injury?

12. Structures that could be damaged
“Sciatic Nerve” – Common Fibular and Tibial
Gluteus Maximus – Inferior Gluteal Nerve
With a very poorly place injection:
Pudendal Nerve
Posterior Cutaneous Nerve of the Thigh

13. Where is the best location for giving intramuscular injections in the gluteal region? Why?

15. Technique for finding best location
1. Place thumb on ASIS 2. Make a fist 3. Rotate fist laterally 4. Inject in region where fist lands

16. Why is this the best location?

17. There are no major nerves in this region!
The region is easily accessed!
The region is easily located!

18. Trendelenburg’s Sign Gait Video Test Video
What is the clinical name given to the symptoms exhibited by our patient?
Trendelenburg’s Sign Gait Video Test Video

19. Other Conditions that can cause a positive Trendelenburg Test
Progressive Muscular Dystrophy
Chronic forms of Spinal Muscular Atrophy
Inflammatory Myopathies
Lumbar Nerve Root Compression
Congenital Dislocation of Hips
Femoral Nail for Proximal Femur Fracture