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Y1 TP2 Musculoskeletal System > 2. Lower Limb > Flashcards

2. Lower Limb Flashcards

1
Q

6 lower limbs regions

A

Gluteal region
• Buttocks and hip

femoral

knee

leg

Ankle

Foot

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2
Q

Gluteal region

A

Is the transitional region between the trunk (torso) and free lower limbs

• 2 parts:

  1. posterior: Buttocks (L. nates) start at L5
  2. lateral: Hip region (L. region coxae),
    - which overlies - the hip joint - greater trochanter of the femur
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3
Q

3 bones of the pelvis

A

○ Illium, pubis, ischium

	○ Connected via tri radiate cartillage 
	○ Begins to fuse at 15-17 years Fusion complete by 20-25 years
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4
Q

Saccrum

A

○ Sacroiliac joint, connect to vertebrae though L1-s5 joint

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5
Q

Pelvis and hip joint - parts

A

Head of femur
neck of femur
Greater trochanter
Lesser trochanter

Sacroilliac joint – connects sacrum to illium

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6
Q

3 parts of iliac crest

A

Outer lip
Intermediate zone
Inner lip

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7
Q

Osteology of hip

A 
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
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8
Q

Osteology of femur

A

head
neck
shaft

Greater trochanter
Lesser trochanter
Lateral and medial epicondyle
Lateral and medial condyles

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9
Q

Angle of femur

A

Angle = 150 degrees, allows movement of head and hip joint

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10
Q

Hip joint

A

• 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

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11
Q

What strengths stability of hip joint

A

• Labrum
Fibro cartiliaginous ring round joint, strengthens

* Joint capsule 
* Ligaments 
* Muscles
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12
Q

Acetabulum:

A
  • Socket of joint, where hip bones converge

- Margin of acetabulum is incomplete inferiorly - acetabular notch

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13
Q

Labrum

A
  • fibrocartilaginous rim attached to the margin of acetabulum
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14
Q

Capsule

A
  • Capsular fibres take a spiral course

- In extension capsule helps pull femoral head into acetabulum

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15
Q

Hip joint 3 ligaments

A

Illofemoral
Pubofemoral
Ischiofemoral

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16
Q

Illofemoral ligament

A

(‘Y’- ligament) y shaped:
- the strongest ligament in the human body
- prevents hip hyperextension ( not > 15 degrees)
Illium and femur

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17
Q

Pubofemoral ligament

A

ligament prevents hip hyperabduction and is on the side

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18
Q

Ischiofemoral ligament

A

• Ischiofemoral ligament prevents hip hyperflexion on the back

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19
Q

2 extracapsular ligaments pelvis

A
  • sacrotuberous

* Sacrospinsous

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20
Q

Function of extracapsular ligaments

A
  1. converts the greater and lesser Sciatic notches (that allow nerves to pass into pelvi area) into foramina and
  2. 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
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21
Q

4 hip joint muscles

A

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
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22
Q

3 steps of Clinical examination of joints

A 
• 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
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23
Q

6 Hip joints movements

A
  1. Flexion
  2. Extension
  3. Adduction
  4. External (lateral) rotation
  5. Internal (medial) rotation
  6. Abduction
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24
Q

3 hip flexor muscle

A

• 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

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25
Q

3 Extensors of the thigh

A

Hamstring muscles :

  • biceps femoris
  • semitendinosus
  • semimembranosus

SemiMembranous is on the Medial Side of the thigh
SemiTendinous is on Top of it

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26
Q

Pulled hornstring

A

A pulled hamstring tends to occur in sudden muscular exertion that results in stretching of the posterior tight muscles (e.g. footballers)

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27
Q

5 hip adductors

A

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
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28
Q

7 Hip rotators external

A
  1. Gluteus maximus
  2. Piriformis- key muscle of gluteal region

And small rotators

  1. Gemellus superior
  2. Obturator internus
  3. Gemellus inferior
  4. Obturator externus
  5. Quadratus femoris
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29
Q

Hip rotation – external

A
  • 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)

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30
Q

Hip rotation – internal

A

Gluteus medius

  • Gluteus minimus
  • Tensor fasciae latae
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31
Q

Functions of gluteus medius and minimus

A
  1. Help us to walk properly

2. Hold hip stable acting as abductors in the supporting eg

32
Q

Glutus maximus muscle

3 functions

A
  1. Help us to run upstairs:
    - extends the thigh from the flexed position and causes lateral rotation of the thigh
  2. It is important in running:
    - when a powerful thrust off trailing foot is required
  3. 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)
33
Q

Blood supply for hip joint, buttock and thigh

A
  • 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

34
Q

Blood supply to head of femur

A
  • 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

35
Q

Thigh innervation by compartment

A

‘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
36
Q

Medial compartment

A

Obtrurator nerve

37
Q

Anterior compartment

A

Femoral nerve

38
Q

Posterior compartment

A

Sciatic nerve

39
Q

Major branches of sacral plexus

A

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

40
Q

Osteoarthritis - definition

A

-> Degenerative disease of synovial joints that causes progressive loss of articular cartilage

41
Q

Function of articular Hyaline cartilage

A

• decreases friction and distributes loads

42
Q

Composition of articular Hyaline cartilage

A
  • extracellular matrix (water, collagen, proteoglycans)
    • Collagen – for stress
    • 90% type II collagen cells (chondrocytes)
43
Q

Pathophysiology

Of osteoarthritis

A

With age: Articular cartilage: increased water content causes
• Alterations in proteoglycans
• Collagen abnormalities
• Binding of proteoglycans to hyaluronic acid
• Inflammation of synovium/capsule

44
Q

Early degenerative changes osteoarthritis

A

Early disruption of matrix
• Protoglycans and collagen
• Increased water content

Decreased joint space
Roughness of articular surfacce

45
Q

Advanced degernative changes osteoarthritis

A
  • 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

46
Q

Primary idiopathic OA

A
  • No underlying cause Secondary OA

* Wear and tear of joint

47
Q

Secondary OA

A

• 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
48
Q

Modifiable risk factors -Osteoarthritis

A 
Modifiable – we can change
• Articular trauma 
• Muscle weakness
 • OBESITY 
• Heavy physical stress 
• High impact sports
49
Q

Non Modifiable risk factors -Osteoarthritis

A
  • Gender
  • Increased age
  • Genetics
  • Developmental or acquired deformities (hip dysplasia, other)
50
Q

Management of primary oa

A
  • 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
51
Q

Treatment of primary oa

A

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)
52
Q

Osteoarthritis

Grading system

A

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

53
Q

Osteoarthritis - radiological changes

A

Osteophyte –extra bone, increase narrowing

Scan shows
• No joint space
• osteophhyte
• Cysts

54
Q

Osteoarthritis - surgical management

A

Total hip replacement

Joint replacement

55
Q

Fractured neck of femur

  • causes and stats
A

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

56
Q

Clinical signs – fracture neck of femur

A

• Leg is rotated laterally and shortened due to less connection between leg and femur

57
Q

Fractured neck of femur – 2 types of classification

A
  • Intracapsular (Garden classification) =

* Extracapsular (intertrochanteric/subtrochanteric) = blood supply maintained and can heal

58
Q

2 types of intracapsular fracture

A
  • Displaced: shortened, external rotation and abduction

* Undisplaced/impacted: pain, no deformity

59
Q

Fractured neck of femur – management

A
  • risk of AVN in intracapsular fractures
  • hemiarthroplasty
  • open reduction and internal fixation (ORIF)
60
Q

Hip dislocation

A

—> dislocation = displacement of joint

• Joint is out of the socket

61
Q

2 causes of Hip dislocation

A

• traumatic
• developmental/progressive over time due to underlying disease
Or paralysis as nothing keeps hip in p

62
Q

Traumatic dislocation

A

—> patient is internallt located

  • high energy injury
  • young patients (16-40y)
  • 90% posterior : 10% anterior
  • painful ++
  • associated sciatic nerve injury • risk ofAV
63
Q

Examples of High energy injury

A
  • e.g. dashboard injury in car
    • Pushes hip out of socket
    • dislocation
64
Q

Management of traumatic dislocation

A
  • 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
65
Q

Major branches of lumbar plexus

A 
I​Ilioinguinal​​​(L1)
G​Genitofemoral​​(L1, L2)
L​Lateral femoral cutaneous​(L2, L3)
O​Obturator​​​(L2, L3, L4)
F​Femoral​​​(L2, L3, L4)
66
Q

Ilioinguinal​​​(L1)

A

Internal oblique and transverse abdominus

67
Q

Genitofemoral​​(L1, L2)

A

Genital branch , cremasteric muscle

68
Q

Lateral femoral cutaneous​(L2, L3)

A

Anterior and lateral thigh down to knee

69
Q

Obturator​​​(L2, L3, L4)

A

Medial thigh muscles - adductors and gracilis

70
Q

Femoral​​​(L2, L3, L4)

A

Anterior thigh muscles

71
Q

Branches of sacral plexus

A 
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)
P​Pudendal​​​(S2, S3, S4)
72
Q

Superior gluteal​​(L4, L5, S1)

A

Gluteus mininous, medius and tensor fascia

73
Q

Inferior gluteal​​(L5, S1, S2)

A

Gluteus maximus

74
Q

Sciatic​​​​(L4, L5, S1, S2, S3)

A

Posterior thigh and leg, sole of foot

75
Q

Posterior femoral​​(S1, S2, S3)

A

Skin on posterior thigh and leg

76
Q

Pudendal​​​(S2, S3, S4)

A

Muscles in perineum, external urethral sphinder

77
Q

Right sided positive trendelenburg test

A

Pelvis droops on left side of body

When hip abductor muscles are very weak

Y1 TP2 Musculoskeletal System (10 decks)

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