Blue Boxes Anterior and Medial Thigh

Question 1

Hip and thigh contusions:

Hip pointer
Charley horse
Avulsion

Answer 1

“Hip Pointer” contusion of Iliac crest where sartorius ataches to ASIS. Most common injury to the hip usually occurs with collision sports. Contusions cause bleeded from capillaries and infiltration of blood into muscles tendons and soft tissues.

Avulsion fractures- avulsion of bony muscle attachments such as sartorius and rectus femoris to the ASIS and AIIS and hamstrings from ischium.

“Charley horse” cramping of muscle due to ischemia or contusion and rupture of blood vessels to form hematoma. usually due to tearing fibers of rectus femoris or partially quads tendon. Most common site of thigh hematoma is quads.

Question 2

Psoas Abscess:

Answer 2

A retroperitoneal pyogenic infection in abdomen or greater pelvis, associated with TB or Chron disease, can result in formation of psoas abscess. The abscess can pass btw psoas and its fascia to inguinal and proximal thigh resulting in referred pain to hip thigh or knee. Abscess should always be considred when edema occurs in proximal part of thigh. Can often be mistaken for indirect inguinal hernia or femoral hernia or enlargement of inguinial lymph nodes.

Question 3

Paralysis of Quads

Answer 3

Cannot extend leg against resistance. Walk with a forward lean pressing on distal end of thigh with hand as heel hist ground to prevent flexion of knee.

Weakness of vastus medialis or lateralis from arthritis or trauma can result in abnormal patellar movement and loss of stability

Question 4

Chondromalacia patellae

Answer 4

Softening of the articular cartilage of the patella (aka runners knee) Over stressing of knee can occur in running sports and results in soreness and aching around of deep to patella from quadriceps imbalance. Can also result from blow to patella or extreme flexion of knee

Question 5

Patellar fractures

Answer 5

direct blow can fracture it into two + pieces. Transverse patellar fractures result from blow to knee or sudden contraction of quads such as when you slip and try to prevent falling backwards. Proximal fragment is pulled with quads tendon and distal stays with patellar ligament.

Question 6

Abnormal ossification

Answer 6

Patella is cartilaginous at birth and ossifies around 3-6 years. There is frequently more than one ossification center but the bone should fuse together, sometimes they may remain separate giving rise to bipartite or tripartite patella. Ossification abnormalities are almost always bilateral

Question 7

Patellar tendon reflex

Answer 7

Tests femoral nerve (L2-4). Tapping the patellar ligament should activate muscle spindles in quadriceps. Afferent impulses from spindles travel to femoral nerve and efferent impulses go to quads resulting in extension of leg. A lesion that interrupts quads innervation can result in diminished reflex.

Question 8

Transplantation of gracilis

Answer 8

Weak member of adductors in the thigh, it can be removed without obvious loss. It is transplanted with its blood and nerve supply to replace damaged muscles in the hand. It produces digital flexion and extension once transplanted. It can also be used to replace external anal sphincter.

Question 9

Groin pull

Answer 9

Strain and most likely tearing of proximal attachments of anteromedial thigh muscles. Usually flexor and adductor thigh muscles. Proximal attachments are in inguinal region. Groin pulls usually happen in sports with sprinting or extreme stretching

Question 10

Adductor longus injury

Answer 10

Muscle strains occur in sports with fast acceleration, deceleration or changes in direction. Ice hockey, cricket, breast stroke, football and rugby. Also horseback riding (riders strain). Ossification of the tendons can occur in horseback riders as they adduct thighs to keep from falling. Wrongly called riders bones.

Question 11

Palpation compression and cannulation of femoral artery

Answer 11

The proximal part of the artery before branching into deep femoral, is superficial and is easily accessible.

When supine the femoral pulse can be found midway btw ASIS and pubic symphysis. Compression can be done by pressing directly posteriorly against superior pubic ramus, psoas major, and femoral head. Compression will reduce blood flow.

Can be cannulated inferior to the midpoint of the inguinal ligament. In cardiac angiography a catheter can be inserted and passed up to external iliac common iliac and aorta into the left vent of heart.

Question 12

Laceration of Femoral artery

Answer 12

Superficial position of artery in the femoral triangle makes it vulnerable to traumatic injury. Femoral artery and vein are injured as they are close. Sometimes and arteriovenous shunt occurs as result of communication btw injured vessels.

Cruciate anastamosis is meeting of medial and lateral circumflex femoral arteries with inferior gluteal artery and first perforating artery can supply leg with blood.

Question 13

Lethal Misnomer of femoral artery

Answer 13

Using the term “superficial femoral” when referring to the femoral artery or vein distal to deep femoral vessels is misleading as it is NOT superficial it is deep. This can lead to the mistreatment of what is actually an acute thrombosis as an acute clinical issue, not a life threatening issue. Most pulmonary emboli originate in the deep veins not superficial.

Question 14

Saphenous Varix

Answer 14

Localized dilation of terminal part of great saphenous vein. Can cause edema in the femoral triangle. Also can be confused with other groin swellings such as psoas abscess, but varix should be considered when varicose veins are present.

Question 15

Locating the femoral vein

Answer 15

Not palpable, but it can be located by finding the femoral artery inferior to the inguinal ligament, also lateral to the vein.

In thin people this vein can be mistaken for great saphenous vein. There are no tributaries at this level except for great saphenous vein ~3cm inferior to the inguinal ligament. This is important to know during varicose vein operations as to not tie off the femoral instead of the great saphenous vein.

Question 16

Cannulation of femoral vein

Answer 16

This is done to take pressure from chambers of right side of heart or pulmonary artery. Right cardiac angiography is done and passes catheter into the femoral vein, external and common iliac ceins, into IVC, and right atrium of heart. Femoral venous puncture can also be used to give fluids.

Question 17

Femoral Hernias

Answer 17

Femoral ring is weak in anterior abdominal wall. Usually is originating site of femoral hernia as well. A loop of intestine pushes through femoral ring into the femoral canal and appears as a mass in femoral triangle inferolateral to pubic tubercle.

Hernia is bounded by femoral vein laterally and lacunar ligament medially it compresses femoral canal contents and distends the wall of he canal. It can get larger if it passes through the saphenous opening.

Femoral hernias are more common in females due to wider pelvis and smaller inguinal canals and rings. Can also occur after multiple pregnancies, can cause hip or abdominal pain.

Strangulation of femoral hernia can occur bc of the sharp boundaries of femoral ring and results in death of that part of intestine.

Question 18

Replaced or accessory obturator artery

Answer 18

An enlarged pubic branch of the inferior epigastric artery can take the place of the obturator artery (called replaced) or it can join the obturator artery as an accessory artery. It runs close to or across the femoral ring and could be close to neck of femoral hernia and is involved in strangulated femoral hernia.