25.4, 26.4, 27.7

Question 1

The hip is composed of the ___, ___ (posterior) and ___ (anterior).

Answer 1

Ilium
Ischium
Pubis

Question 2

There are 2 parts of the acetabulum: the ___ surface which is weight bearing and where the head of the ___ articulates, and the acetabular ___ and ___ - a rough, deep part that is non-articular and non-weight bearing.

Answer 2

Lunate surface - weight bearing, head of femur articulates

Acetabular notch and fossa

Question 3

There is a Y shape in the acetabulum - this forms the ___ in the acetabulum and fuses by late ___/early ___.

Answer 3

Epiphysis

Fuses by late puberty/early adolescence

Question 4

There is a fat pad that is ___-articular but ___-synovial at the hip joint. It receives a nerve and blood supply that may be impinged resulting in pain or bleeding into the joint.

Answer 4

Intra-articular

Extra-synovial

Question 5

The neck of the femur projects down to the greater and lesser ___. These form sites for muscle attachments, therefore forming ___ epiphyses.

Answer 5

Trochanters

Traction epiphyses

Question 6

The capsule of the hip joint attaches to the ___ neck of the femur in utero, but after birth, the capsule migrates to the ___ line anteriorly, and less of the distance posteriorly (only some migration).

Answer 6

Anatomical
Intertrochanteric line anteriorly
But not as far posteriorly
(Intertrochanteric crest is posterior, capsule does not extend up to crest)

Question 7

The epiphysis of the greater trochanter fuses by mid-___.

Answer 7

Teens (later in males)

Question 8

The epiphysis of the head of the femur is a ___ epiphysis. It depends on adequate blood supply for normal growth. If there is interruption of blood supply to the epiphysis, growth of the head of the femur is affected. ___ disease is ___ ___ of the head of the femur due to interruption of blood supply.

Answer 8

Pressure epiphysis (also called the "capital epiphysis")
Perthes' disease - avascular necrosis of head of femur due to interruption of blood supply

Question 9

The head of the femur is directed ___, ___ and ___ to the acetabulum. Anteriorly, part of the head of the femur is out of the ___.

Answer 9

Upwards, medially and anteriorly

Anteriorly, part of head of femur out of acetabulum

Question 10

A bursa protects the head of the femur. The bursa is deep to a primary flexor of the hip - ___.

Answer 10

Iliopsoas (the psoas bursa)

Question 11

Trabeculae in the femur are organised to resist weight bearing forces. There are two main bundles: the ___ bundle and ___/___ bundle. A point ___ to the intersection of the two bundles is a site of weakness, esp. in people with ___.

Answer 11

Arcuate
Medial/vertical
Inferior
Osteoporosis

Question 12

There is an angulation between the ___ of the femur and the ___ of the femur.

Answer 12

Head/neck

Shaft

Question 13

Normal angulation is approx. 125 degrees. If >125 degrees = coxa ___. If

Answer 13

Coxa valga - >125 degrees
Pathological increase in angle (i.e. less acute)
Coxa vara -

Question 14

The priority for joints of the lower limb is ALWAYS to ___ the hip joint!

Answer 14

Stabilise

Question 15

In coxa vara in adolescence, the angle may result in the proximal epiphysis of the femur not being pushed on bone, but pushed down resulting in ___ ___ ___ epiphysis.

Answer 15

Slipped capital femoral epiphysis

Question 16

The line of gravity from the head passes ___ to the hip joint. Therefore, the joint is reinforced ___. When standing (i.e. extension/abduction/medial rotation), the joint is in its ___-packed position. When in flexion/adduction/lateral rotation, the joint is in its ___-packed position. In this position, it is vulnerable to injury e.g. trauma

Answer 16

Posterior
Reinforced anteriorly (in front)
Close packed - all articular surfaces are congruent and capsule/ligaments are tight
Loose packed - vulnerable to injury e.g. in trauma

Question 17

The main stabiliser of the hip joint is the ___ ligament. This ligament extends from the front of the ___ down to the ___ line. Posteriorly, the ___ and ___ ligaments project down but do not extend to the ___ crest. These ligaments are weaker.

Answer 17

Iliofemoral - main stabiliser because line of gravity is posterior to hip joint but ligament is anterior
Down front of acetabulum to intertrochanteric line
Pubofemoral and ischiofemoral ligaments - do not extend up to intertrochanteric crest

Question 18

On extension, the joint ___ rotates. This results in spiralling and tightening of the ___ ligament - this tightens on extension for maximum stability.

Answer 18

Medial rotation

Iliofemoral

Question 19

There are 2 intra-articular structures of the hip joint - the ___ (to increase depth of socket) and a ___ of the head of the femur, that attaches into the fovea of the femur.

Answer 19

Labrum - increases depth of socket for stability

Ligament of head of femur - inserts into fovea, no supporting role

Question 20

Dislocation of the hip joint usually occurs in the ___ direction (compared to dislocations of the shoulder, usually in the ___ direction). In dislocation, the ___ (intra-articular structure) is susceptible to injury.

Answer 20

Posterior
Shoulder - anteroinferior dislocations
Labrum

Question 21

A branch of the ___ artery is directed by the ___ of the head of the femur to to the femoral head for development. This regresses after puberty, but can bleed in hip replacement surgery.

Answer 21

Obturator artery

Ligament of head of femur

Question 22

Parts of the capsule around the hip joint project up the neck, called ___ fibres. Blood vessels penetrate the ___, called ___ vessels. These are susceptible to injury in fractures at the ___ of the femur.

Answer 22

Retinacular fibres
Retinaculum, called retinacular vessels
Neck of femur

Question 23

The primary hip flexor is ___ - from the ___ spine to the ___ trochanter of the femur.

Answer 23

Iliopsoas - from lumbar spine to lesser trochanter

Question 24

The primary hip extensor is ___ ___. Other hip extensors are ___ muscles.

Answer 24

Gluteus maximus

Hamstring muscles

Question 25

The hip abductors are ___ ___ and ___ ___.

Answer 25

Gluteus medius and gluteus minimus (deep to gluteus maximus)

Question 26

There is a cuff of “fixator” muscles around the ___ of the femur - these are lateral rotator muscles to stabilise the head of the femur in the acetabulum.

Answer 26

Neck

Question 27

Paralysis of gluteal muscles results in a ___ gait - the hip/pelvis falls to the unsupported side during the gait cycle.

Answer 27

Trendellenberg gait
Normally, gluteal muscles prevent hip from falling to unsupported side by contracting on weight bearing limb to pull hip bone down.

Question 28

Primary nerves to the hip joint are the ___ nerve, the ___ nerve (to supply adductor muscles) and the ___ nerves.

Answer 28

Femoral
Obturator - supplies adductor muscles
Gluteal

Question 29

There can be referred pain along the cutaneous branches of the ___ nerve to the medial thigh and knee.

Answer 29

Obturator

Question 30

Spinal segments for flexion at hip: L___/L___, and for extension at hip: L___/L___.

Answer 30

Flexion at hip - L2/L3

Extension at hip - L4/L5

Question 31

The major blood supply to the thigh is via the ___ ___ artery (a branch of the femoral artery) - supplies femur, muscles around femur, etc.
The two branches from this artery are the medial and lateral ___ ___ arteries. ___ vessels are branches of these arteries.

Answer 31

Profunda femoris
Medial and lateral femoral circumflex arteries
Retinacular

Question 32

The ___ nerve may be damaged due to traumatic posterior dislocation of the hip joint. What other structure may be damaged?

Answer 32

Sciatic as it passes posteriorly to the joint

The labrum may be damaged

Question 33

Dislocation of the hip joint may be congenital due to a shallow acetabulum (developmental dysplasia of acetabulum). You can test for congenital dislocation using the ___ test - flexion and abduction and listen for a click as the head of femur slips into the socket. How do you treat this condition?

Answer 33

Ortolani
Position child’s hip in abducted position so the head is relocated into the socket and normal repair mechanisms can occur

Question 34

The knee joint is most stable (close packed) in ___.

Answer 34

Extension - strong ligaments and muscles

Question 35

Injury to cruciate/collateral ligaments and menisci classically occur in some degree of ___ and ___!

Answer 35

Flexion and rotation

Question 36

Menisci are ___-capsular and ___-synovial. Cruciate ligaments are ___-capsular and ___-synovial.

Answer 36

Menisci - intracapsular and intrasynovial (but synovial membrane only lines margins of menisci, not the articular surfaces)
Cruciates - intracapsular and extrasynovial (during development, cruciate ligaments start posteriorly and move anteriorly - they push synovial membrane anteriorly so the anterior aspects of ACL and PCL are lined by synovial membrane)

Question 37

A tear of the ACL near its attachment to bone can result in a tear of the ___ membrane resulting in bleeding into the joint (i.e. ___).

Answer 37

Synovial

Haemarthrosis

Question 38

What is the order of insertions of pes anserinus tendons from superior to inferior?

Answer 38

Sartorius
Gracilis
(Bursa)
Semitendinosus
("Say grace before tea")

Question 39

Both ___ ligaments are stabilisers in the AP direction.

Answer 39

Cruciate

Question 40

When the knee joint moves into full extension, the joint rotates ___. If forces to the joint rotate it ___, the ACL is tight and commonly tears under weight bearing!

Answer 40

In extension, joint rotates medially

If forces rotate the joint laterally (i.e. opposite), ACL can tear

Question 41

The PCL is esp. susceptible to injury when the knee joint is in ___. Forces direcing the tibia posteriorly relative to the femur can tear the PCL.

Answer 41

Flexion

Question 42

The knee joint passively rotates to its locked position in extension by ___ rotation. To unlock the joint, ___ muscle initiates ___ rotation of the femur. Unlocking is an active process. Popliteus attaches to the lateral condyle of the femur from below.

Answer 42

Medial
Popliteus
Lateral

Question 43

The unhappy triad refers to the ___ ___ ligament, the ___ ___ and the ___ ___ ligament. These are commonly injured together.

Answer 43

Medial collateral ligament
Medial meniscus (MCL is attached)
Anterior cruciate ligament

Question 44

If menisci are removed, weight is directed to the centre of bone resulting in ___ change.

Answer 44

Osteoarthritic

Question 45

The medial meniscus is more commonly injured because it is longer in the ___ direction, there is a ___ distance between horns, and it is ___ mobile due to its attachment to deep fibres of the ___ ___ ___.

Answer 45

Longer in AP direction
Greater distance between horns
Less mobile - attachment to deep fibres of medial collateral ligament

Question 46

Tears of the meniscus can fold/flap up into the joint space resulting in ___ of the knee joint.

Answer 46

Locking

Question 47

The ___ or ___ bursa is anterior to the knee joint. These directly communicate with the joint cavity so fluid/blood/pus or infections can move from the bursa into the joint cavity. The ___ and ___ bursae are posterior to the knee joint. They commonly communicate with the joint. There are other bursae, usually where tendons or ligaments attach to bone, that do not communicate with the joint.

Answer 47

Suprapatellar or quadriceps

Semimembranosus and popliteus

Question 48

There is a large fat pad ___ to the patella and ___ to the tibia (and it is intracapsular but extrasynovial).

Answer 48

Inferior to patella, anterior to tibia

Question 49

The __ ossifies in two parts (i.e. bipartite), separated by a growth plate - it can be misinterpreted as a fracture.

Answer 49

Patella

Question 50

There is a tendency for the patella to be pulled in a ___ direction on flexion/extension due to angle of femur to knee joint. Therefore, there a mechanisms to prevent lateral displacement.

Answer 50

Lateral

Question 51

What are the 3 mechanisms for stabilisation of the patella in its groove?

Answer 51

High lip of lateral condyle of femur (passive): increases depth of groove to stop lateral displacement of patella
Medial patellar retinaculum (semi-passive): inextensible retinacular fibres on medial aspect of knee
Strong vastus medialis muscle (active): component of quadriceps on medial aspect of thigh

Question 52

The ___ or ___ angle is the angle between the tendon of quadriceps and the patellar tendon. In females, there is a natural tendency to pull the patella laterally due to the angle (also occurs in males but to a lesser extent because the angle is less acute).

Answer 52

Q or quadriceps angle

Question 53

The fibula is non-weight bearing and forms the attachment for many muscles (8 attach). Only 1 muscle inserts into the fibula - this is ___ ___, inserting into the head of the fibula.

Answer 53

Biceps femoris

Question 54

Fracture of the tibia is commonly associated with fracture of the ___.

Answer 54

Fibula
Because they are joined proximally and distally, forming a ring of bone
Note - there can be isolated fractures

Question 55

In the tibia, the junction of the ___ and ___ 1/3s are most susceptible to fracture because the bone is narrower and cylindrical, and the vessels from above and below anastomose so blood supply is poor.

Answer 55

Junction of middle and inferior 1/3s of tibia

Question 56

There is an ___ membrane between the tibia and fibula.

Answer 56

Interosseous

Question 57

The superior tibiofibular joint is a ___ joint, and the inferior tibiofibular joint is a ___ joint (or ___). In falls from a height, ___ tissue of the inferior joint can tear and the fibula and tibia can separate resulting in ___.

Answer 57

Superior - plane joint
Inferior - fibrous joint or syndesmosis
Fibrous tissue of inferior joint can tear resulting in diastasis

Question 58

The ___ metatarsal is narrow compared to the others and locked in the joint between the cuneiform bones and proximal aspect of adjacent metatarsals. It is esp. susceptible to weight bearing shock and ___ fractures.

Answer 58

Second

March

Question 59

There are many ___ bones (in tendons) in the foot, for example, there are 2 under the head of the first metatarsal. They can be confused as ___ fractures.

Answer 59

Sesamoid

Avulsion

Question 60

The ankle joint is a ___ joint. The body of the talus fits into a socket formed by the ___ of the tibia, and the fibular ___. The socket is deepened posteriorly by the ___ ___ ligament.

Answer 60

Hinge
Malleolus of the tibia (the medial malleolus)
Fibular malleolus (the lateral malleolus)
Deepened posteriorly by inferior transverse ligament

Question 61

The axis from the medial/tibial to the lateral/fibular malleoli is ___. Therefore, on dorsiflexion and plantarflexion there is also ___ and ___, and ___ and ___.

Answer 61

Oblique
Eversion and inversion
Abduction and adduction

Question 62

The ___ collateral ligaments of the ankle joint are very strong (radiate) and rarely injured.

Answer 62

Medial

Question 63

Most ankle injuries occur in the ___ and ___ position (e.g. stepping on a tennis ball with the medial aspect of foot). There is strain and injury to the lateral collateral ligament, esp. the ___ talofibular band. This can result in effusion or bleeding into the joint.

Answer 63

Plantarflexed and inverted position
LCL esp. the anterior talofibular band
(Remember - LCL is made of 3 bands (c.f. MCL, radiate and rarely injured) - anterior and posterior talofibular bands, and calcaneofibular ligaments)

Question 64

The subtalar joint is between the ___ and ___. Sinus tarsi is a groove between these two bones that divides the joint into anterior and posterior parts. ___ and ____ occur at the subtalar joint. There is a greater range of motion of ___. There is an interosseous talocalcaneal ligament in this groove that is very strong and limits ___ and ___ of the joints.

Answer 64

Talus and calcaneus
Inversion and eversion
Inversion (20 degrees from vertical, 10 degrees for eversion)
Inversion and eversion

Question 65

In locomotion, the foot strikes the ground in an ___ position, Weight is transferred across and the foot ___ into the next step. There is a total of approx. 30 degrees of movement.

Answer 65

Strike in inverted position

Leaves ground in everted position

Question 66

Abduction and eversion of the foot is ___. Adduction and inversion of the foot is ___.

Answer 66

Abduction + eversion = pronation

Adduction + inversion = supination

Question 67

MTP joints are ___ joints where ___/___ and ___/___ occur. IP joints are ___ joints where ___/___ occurs.

Answer 67

MTP - condyloid for flexion/extension and abduction/adduction
IP - hinge for flexion/extension

Question 68

The plantar ___ is a band of connective tissue between calcaneus and the heads of the ___. When the foot is placed on the ground, the band stretches. When on your toes, the band is tightened and forms a longitudinal arch of the foot.

Answer 68

Plantar aponeurosis - between calcaneus and heads of metatarsals

Question 69

There are 3 arches of the foot, a ___ and ___ longitudinal arch, and a ___ arch. Arches have ___ and ___ activities. What are they?

Answer 69

Medial and lateral longitudinal arch
Transverse arch
Static and dynamic
Static activity - ligamentous support
Dynamic activity - muscular support (intrinsic muscles and long muscles passing around esp. the medial aspect i.e. esp. flexor hallucis longus)