2. Lower Limb Flashcards
6 lower limbs regions
Gluteal region
• Buttocks and hip
femoral
knee
leg
Ankle
Foot
Gluteal region
Is the transitional region between the trunk (torso) and free lower limbs
• 2 parts:
- posterior: Buttocks (L. nates) start at L5
- lateral: Hip region (L. region coxae),
- which overlies - the hip joint - greater trochanter of the femur
3 bones of the pelvis
○ Illium, pubis, ischium
○ Connected via tri radiate cartillage ○ Begins to fuse at 15-17 years Fusion complete by 20-25 years
Saccrum
○ Sacroiliac joint, connect to vertebrae though L1-s5 joint
Pelvis and hip joint - parts
Head of femur
neck of femur
Greater trochanter
Lesser trochanter
Sacroilliac joint – connects sacrum to illium
3 parts of iliac crest
Outer lip
Intermediate zone
Inner lip
Osteology of hip
Outer lip Intermediate zone Inner lip Anterior superior illiac spine Anterior inferior illiac spine Obtrurator foramen Ischial tuberosity Lesser sciatic notch Greater sciatic notch Posterior superior illiac spine Posterior inferior illiac spine
Osteology of femur
head
neck
shaft
Greater trochanter
Lesser trochanter
Lateral and medial epicondyle
Lateral and medial condyles
Angle of femur
Angle = 150 degrees, allows movement of head and hip joint
Hip joint
• Acetabulum is socket
• Head of femur is the ball
• forms the connection between lower limb and the pelvic girdle - strong and stable
• Ligament carries some blood supply to head of femur
• Transverese ligament close the socket ??
○ Surgery of hip displasia cut transverse ligament
○ Increase depth of ligament
What strengths stability of hip joint
• Labrum
Fibro cartiliaginous ring round joint, strengthens
* Joint capsule * Ligaments * Muscles
Acetabulum:
- Socket of joint, where hip bones converge
- Margin of acetabulum is incomplete inferiorly - acetabular notch
Labrum
- fibrocartilaginous rim attached to the margin of acetabulum
Capsule
- Capsular fibres take a spiral course
- In extension capsule helps pull femoral head into acetabulum
Hip joint 3 ligaments
Illofemoral
Pubofemoral
Ischiofemoral
Illofemoral ligament
(‘Y’- ligament) y shaped:
- the strongest ligament in the human body
- prevents hip hyperextension ( not > 15 degrees)
Illium and femur
Pubofemoral ligament
ligament prevents hip hyperabduction and is on the side
Ischiofemoral ligament
• Ischiofemoral ligament prevents hip hyperflexion on the back
2 extracapsular ligaments pelvis
- sacrotuberous
* Sacrospinsous
Function of extracapsular ligaments
- converts the greater and lesser Sciatic notches (that allow nerves to pass into pelvi area) into foramina and
- in standing upright (erect position):
- limit rotation of the inferior part of the sacrum during transmission of the weight of the body down the vertebral column
4 hip joint muscles
Gluteus maximus
Gluteus medius - under gluteus maximus
Gluteus minimus - under gluteus minimus
Piriformis muscle
• Disease or swelling in this area and muscle and compress sciatic nerve
3 steps of Clinical examination of joints
• Look at the joint (surface anatomy) ○ Swelling, scars, redness ?? • feel ○ Hotness, tenderness ○ Feel for structures • Move ○ Range of the join ○ Active = ask patient to move joint ○ Passive movements – examiner move joint
6 Hip joints movements
- Flexion
- Extension
- Adduction
- External (lateral) rotation
- Internal (medial) rotation
- Abduction
3 hip flexor muscle
• Muscles that cross in front of hp joint casue flexions
○ Sartorius muscle
○ iliopsoas
○ Rectus femoris
• Those 3 muscle casue around 140 degrees flexion of hip joint
3 Extensors of the thigh
Hamstring muscles :
- biceps femoris
- semitendinosus
- semimembranosus
SemiMembranous is on the Medial Side of the thigh
SemiTendinous is on Top of it
Pulled hornstring
A pulled hamstring tends to occur in sudden muscular exertion that results in stretching of the posterior tight muscles (e.g. footballers)
5 hip adductors
Adductors
Adductor magnus
Adductor brevis
Adductor Longus
Pectineus
Gracilis
• Pull the hip into a more medial way – toward middle – 20-30 degrees to mid line
7 Hip rotators external
- Gluteus maximus
- Piriformis- key muscle of gluteal region
And small rotators
- Gemellus superior
- Obturator internus
- Gemellus inferior
- Obturator externus
- Quadratus femoris
Hip rotation – external
- Around 40 degrees
- The muscles of the Gluteal Region are all external (lateral) rotators
(Gluteus Maximus, Piriformis, Obturator internus, Obturator externus, Quadratus femoris, Superior and Inferior Gemelli)
Hip rotation – internal
Gluteus medius
- Gluteus minimus
- Tensor fasciae latae
Functions of gluteus medius and minimus
- Help us to walk properly
2. Hold hip stable acting as abductors in the supporting eg
Glutus maximus muscle
3 functions
- Help us to run upstairs:
- extends the thigh from the flexed position and causes lateral rotation of the thigh - It is important in running:
- when a powerful thrust off trailing foot is required - It help to steady the femur on the tibia during standing by supporting the knee joint in extension: - fibers from gluteus maximus insert into the iliotibial tract (condensation of the fascia lata)
Blood supply for hip joint, buttock and thigh
- From abdominal arota
- Internal iliac artery and external iliac artery
External illiac artery
Femoral artery
• Divides into 2 branches supplying head of femur
• Perforating arteries
Blood supply to head of femur
- Major source ( profunda femoral artery): Medial circumflex femoral artery, Lateral circumflex femoral artery
- Minor source (adult): Obturator artery (via ligament of head of femur)
- Blood supply from ligament of the head of femur is often not adequate
- If you get a femoral neck # you can tear Retinacula arteries.
Result can be AVN avescular necrosis of femoral head – death of femur he
Thigh innervation by compartment
‘Map of sciatic’:
- Medial compartment: supplied by Obturator nerve
- Anterior compartment: supplied by Femoral nerve
- Posterior compartment: supplied by Sciatic nerve• Obturator and femoral nerve com from lumbar plexu L1,2,3,
Sciatic comes from sacral plexus
Medial compartment
Obtrurator nerve
Anterior compartment
Femoral nerve
Posterior compartment
Sciatic nerve
Major branches of sacral plexus
S Superior gluteal (L4,L5,S1)
I Inferior gluteal (L5,S1,S2)
S Sciatic (L4,L5,S1,S2,S3)
P Posterior femoral (S1,S2,S3) = sensory nerve for skin
P Pudendal (S2,S3,S4) = pass from greater sciatic notch
Osteoarthritis - definition
-> Degenerative disease of synovial joints that causes progressive loss of articular cartilage
Function of articular Hyaline cartilage
• decreases friction and distributes loads
Composition of articular Hyaline cartilage
- extracellular matrix (water, collagen, proteoglycans)
- Collagen – for stress
- 90% type II collagen cells (chondrocytes)
Pathophysiology
Of osteoarthritis
With age: Articular cartilage: increased water content causes
• Alterations in proteoglycans
• Collagen abnormalities
• Binding of proteoglycans to hyaluronic acid
• Inflammation of synovium/capsule
Early degenerative changes osteoarthritis
Early disruption of matrix
• Protoglycans and collagen
• Increased water content
Decreased joint space
Roughness of articular surfacce
Advanced degernative changes osteoarthritis
- Fissure presentation of subchondral bone
- Narrowing of joint
- Osteophytes – new bone formed aroudn edges of bone due to inflammation
End stage
• Almost no cartilage
• Subchondral cysts
Primary idiopathic OA
- No underlying cause Secondary OA
* Wear and tear of joint
Secondary OA
• Secondary to specific conditions that cause accelerated erosion of the articular cartilage
- Developmental Dysplasia of Hip (DDH)
- Traumatic
- Inflammatory disease eg. RA
- Septic/infection
- Metabolic, endocrine and hematological disorders
Modifiable risk factors -Osteoarthritis
Modifiable – we can change • Articular trauma • Muscle weakness • OBESITY • Heavy physical stress • High impact sports
Non Modifiable risk factors -Osteoarthritis
- Gender
- Increased age
- Genetics
- Developmental or acquired deformities (hip dysplasia, other)
Management of primary oa
- 80% over 75y symptomatic OAin one or morejoints
- Hands, spine, knee and hip
- Pain, limited range of movement (ROM), impaired function
- Night pain/pain at rest
Treatment of primary oa
Depends on if conservative treatment works
• Conservative treatment: changes in activities, rest, strengthening exercises, NSAID, local infiltration (drugs to decrease inflammation and pain)
• Surgical treatment: reconstructive procedures ○ Realignment surgery (osteotomy) ○ Joint replacement surgery (total hip replacement)
Osteoarthritis
Grading system
0 – joint space maintained normal hip
1- early sclerosis, bone
2- subchondral cysts
Narrow joint space
3 – advanced arthritis
Less joint space
Bone on bone
Osteoarthritis - radiological changes
Osteophyte –extra bone, increase narrowing
Scan shows
• No joint space
• osteophhyte
• Cysts
Osteoarthritis - surgical management
Total hip replacement
Joint replacement
Fractured neck of femur
- causes and stats
85,000/year inUK
• women > men women more affected weaker bone
• low energy falls in elderly
• high energetic trauma in young patients
• 6-9% associated femoral shaft fracture
Clinical signs – fracture neck of femur
• Leg is rotated laterally and shortened due to less connection between leg and femur
Fractured neck of femur – 2 types of classification
- Intracapsular (Garden classification) =
* Extracapsular (intertrochanteric/subtrochanteric) = blood supply maintained and can heal
2 types of intracapsular fracture
- Displaced: shortened, external rotation and abduction
* Undisplaced/impacted: pain, no deformity
Fractured neck of femur – management
- risk of AVN in intracapsular fractures
- hemiarthroplasty
- open reduction and internal fixation (ORIF)
Hip dislocation
—> dislocation = displacement of joint
• Joint is out of the socket
2 causes of Hip dislocation
• traumatic
• developmental/progressive over time due to underlying disease
Or paralysis as nothing keeps hip in p
Traumatic dislocation
—> patient is internallt located
- high energy injury
- young patients (16-40y)
- 90% posterior : 10% anterior
- painful ++
- associated sciatic nerve injury • risk ofAV
Examples of High energy injury
- e.g. dashboard injury in car
- Pushes hip out of socket
- dislocation
Management of traumatic dislocation
- closed reduction under GA
- open reduction
- traction
Long term follow-up to rule out avascular necrosis
1. Asses any other injuries, chest or brain 2. Try to relocate hip inside under general aesthetics 3. Open reduction – if something is blocking hip fitting socket – open it up and remove it
Major branches of lumbar plexus
IIlioinguinal(L1) GGenitofemoral(L1, L2) LLateral femoral cutaneous(L2, L3) OObturator(L2, L3, L4) FFemoral(L2, L3, L4)
Ilioinguinal(L1)
Internal oblique and transverse abdominus
Genitofemoral(L1, L2)
Genital branch , cremasteric muscle
Lateral femoral cutaneous(L2, L3)
Anterior and lateral thigh down to knee
Obturator(L2, L3, L4)
Medial thigh muscles - adductors and gracilis
Femoral(L2, L3, L4)
Anterior thigh muscles
Branches of sacral plexus
SSuperior gluteal(L4, L5, S1) IInferior gluteal(L5, S1, S2) SSciatic(L4, L5, S1, S2, S3) PPosterior femoral(S1, S2, S3) PPudendal(S2, S3, S4)
Superior gluteal(L4, L5, S1)
Gluteus mininous, medius and tensor fascia
Inferior gluteal(L5, S1, S2)
Gluteus maximus
Sciatic(L4, L5, S1, S2, S3)
Posterior thigh and leg, sole of foot
Posterior femoral(S1, S2, S3)
Skin on posterior thigh and leg
Pudendal(S2, S3, S4)
Muscles in perineum, external urethral sphinder
Right sided positive trendelenburg test
Pelvis droops on left side of body
When hip abductor muscles are very weak
