Blue Boxes/Clinicals

Question 1

Groin Pull

Answer 1

Strain, overstretching and perhaps some tearing to the proximal attachment of the anteromedial (Flexor and Adductor attachment points) — proximal attachment are in the inguinal region -Common in sports that require 1) quick start or 2) extreme stretching

Question 2

Osgood-Schlatter

Answer 2

Inflammation in the area distal to the knee where the tendon from the kneecap (patellar tendon) attaches to the shinbone (tibia)

Question 3

Meralgia Paresthetica

Answer 3

-aka “Gun Belt Palsy” -Impingement of LATERAL FEMORAL CUTANEOUS N. -Tingling numbness in the lateral thigh -Cause by those who wear a heavy belt that impinges the inguinal region

Question 4

Injury to Adductor Longus M.

Answer 4

-Muscle strains of Adductor Longus often occurs in sports that require fast acceleration, deceleration and change of direction (ice hockey, swimming, football, rugby). -Occurs in horseback riders and causes pain (Rider’s Strain) -Ossification can occur in the tendon of the muscles from repeatedly using adductor longs resulting in the misnomer Rider’s Bones

Question 5

Transplantation of Gracilis M.

Answer 5

-Because it is a weak muscle of the adductors, it is often removed and used elsewhere without any noticeable loss of action on the leg. -Transplantation sites include the hand for replacement of damaged muscle and as a replacement for a nonfunctional external anal sphincter

Question 6

Patellar Tendon Reflex

Answer 6

-Tests the integrity of the femoral nerve and the L2-L4 spinal cord -Tapping patellar L. with hammer elicits a “knee jerk” -Myotatic (deep tendon) reflex -Quad muscles will contract if all is normal

Question 7

Abnormal Ossification of Patella

Answer 7

-Patella is cartilage at birth and ossifies during the 3rd-6th year and has more than one ossification center -Ossifications centers usually form but when they don’t, they can remain separate and form a bipartite or tripartite patella which appears like a Patellar Fracture on radiograph or CT -Ossification abnormalities are nearly always bilateral, so X-rays should be examined from both sides

Question 8

Patellar Fractures (Transverse Patellar Fracture)

Answer 8

-Direct blow may fracture into two or more fragments -Transverse Patellar Fractures result from blow to knee OR sudden contraction of the quadriceps (i.e. slipping and attempting to precent a fall) — proximal fragment pulled superiorly and distal fragment remains on the patellar L.

Question 9

Chondromalacia Patellae

Answer 9

-aka Runner’s Knee -Softening of the articular cartilage of the Patella due to over stress, common in marathon runners and other running sports -Can also occur from blow to patella or extreme flexion of the knee

Question 10

Quadricep Paralysis

Answer 10

-Results in inability to extend the leg against resistance, thus the person walks with a forward lean, pressing on the distal end of the thigh with their hand as the heel contacts the ground to prevent inadvertent flexion Weakness of vastus medialis or vastus lateralis, from arthritis of trauma to the knee, can result in abnormal patellar movement and loss of joint stability

Question 11

Hip and Thigh Contusions (Hip Pointer and Charley Horse)

Answer 11

Contusion = when an injured blood vessel leaks into the surrounding area

Hip Pointer = contusion of the iliac crest —- most common injuries to the hip region and associated with collision sports like football and ice hockey

Charley Horse — cramping of an individual thigh muscle due to ischemia (not enough O2) or contusion that forms a HEMATOMA. Usually caused by tearing fibers of rectus femoris so it typically follows direct trauma

Question 12

Psoas Abcess

Answer 12

Psoas Major originates at the T12-L5 vertebrae and has a fascial covering over it (transversalis fascia) A retroperitoneal pyogenic infection (pus forming) in the abdomen or greater pelvis (associated with TB) may result in a PSAOS ABCESS. When the access moves from psoas and its facia into the inguinal and proximal thigh regions, severe pain in hip, thigh or knee occurs. May appear as a hernia but it ain’t

Question 13

Paralysis of quadriceps

Answer 13

Person cannot extend the leg and presents with a 1) forward lean 2) hand on distal end of thigh as heel contact ground to prevent inadvertent flexion of knee joint Weakness to vastus medialis or laterals can result in abnormal patellar movement and joint instability

Question 14

Cluneal nerve impingements

Answer 14

nerve impingement in the lumbar spine (L3, etc.) can result in pain over the distribution of superior and medial cluneal nerves

Question 15

Injury to Sciatic Nerve

Answer 15

• Pain in butt may be due to compression of the sciatic nerve due to Piriformis Syndrome (tightness, spasm resulting from a pathology)
• Common in sports that use glut muscles frequently (ice skaters, cyclists, rock climbers.
• More common in women

Complete Section of S. Nerve

-Lose all ankle and foot movements and impaired hip and leg

Incomplete Section of S. Nerve

• Inferior gluteal and Posterior femoral cutaneous nerves impacted
• Recovery slow

Safe side = lateral Danger side = medial

Question 16

Injury to Superior Gluteal Nerve

Answer 16

ID’d by Positive Trendelenburg Test -Lesion to nerve = drop of hip away from lesion when standing on one leg -Leg on that side can’t clear when walking and this is occurs for two reasons: 1) Thigh can no longer medially rotate leg and “lock” joint into place when placing weight 2) Abductor muscles can’t contract and prevent hip from falling (WEAKNESS OF GLUT MEDIUS and MINIMUS) Result in a waddle where the leg doesn’t clear (GLUTEAL GAIT) and the patient compensates by leaning

Question 17

Intragluteal Injections

Answer 17

-Butt is common site for injections since muscles are thick and large, providing ample volume for absorption -Injection in the Superolateral quadrant of the glut is the best spot because it is AWAY FROM THE SCIANTIC N.

Question 18

Anesthetic Block of Sciatic N.

Answer 18

Sensation carried by Sciatic N. can be blocked by injecting: -A few centimeters inferior to the midpoint of the PSIS and Greater Trochanter junction

Question 19

Trochanteric Bursitis

Answer 19

-Inflammation of the trochanteric bursa (type of friction bursitis) -Due to repetitive movements such as climbing stairs while carrying heavy weight or running on a steeply elevated treadmill -Deep, diffuse pain in lateral thigh results with it being point tenderness of the greater trochanter that radiates down the Iliotibial Tract -Pain occurs during lateral rotation and ABduction

Question 20

Ischial Bursitis

Answer 20

-Repeated microtrauma from stress (i.e cycling and hip extension activities) may lead to inflammation of the ischial bursa —- excessive friction between the bursa and ischial tuberosities Pain occurs over the bursa and will increase during gluteus maximus movement In severe, chronic cases, calcification of the bursa may occur Siting can cause pain due to ischial area providing support

Question 21

Hamstring Injuries

Answer 21

Strains/pulls of hamstring muscles are common in running/kicking sports and violent enough movement may avulse the proximal tendinous attachments to the ischial tuberosity (more common than quadricep strains) — Forcible flexion of hip with leg extended (i.e. kicking) Hamstring fiber tearing VERY PAINFUL, person can’t stand and will writhe in pain

Question 22

Lower Limb Injuries (Bones)

Answer 22

-knee, leg, foot injuries are the most common lower limb injuries -Common from contact sports -Because adolescents have not completed ossifying the lower limbs from cartilage via endochonral ossification, they are particularly susceptible -Epiphyseal plates = discs of hyaline cartilage that permits bones to grow longer Bones grow faster than muscle during growth spurts so there may be irritation and injury to the plates when stress from physical activity is involved

Question 23

Injuries of Hip Bone (Bone)

Answer 23

Fractures of hip bone = pelvic fracture Fracture of proximal femur = hip fracture Avulsion fracture of the hip bone occurs during sports with accelerating/decelerating forces Bone where tendon or ligament attaches rips away small piece of bone, which is why this usually happens at “apophyses” (bony projections without secondary ossification centers) Common sites are ASIS, AIIS, ischial tuberosities and ischiopubic rami

Question 24

Compartment Syndromes and Fasciotomy

Answer 24

Because fascial compartments are closed spaces and fascia is strong, an increase in volume (from swelling, etc.) can compress structures and cause impingement, ischemia (for arteries), etc. Loss of distal leg pulse is a sign of this FASCIOTOMY (incision in overlying fascia) can be performed to relive symptoms

Damage can be permanent

Question 25

Varicose Veins, Thrombosis and Thrombophlebitis

Answer 25

Varicose Veins: Great saphenous veins becomes varicose (dilated so the cusps of valves don’t close. Blood thus flows backwards (inferiorly) in the vein, producing swelling veins, causing discomfort and a bulging appearance in leg Deep Venous Thrombosis (DVT): -Swelling, warmth, inflammation from embolus in vein -Venous stasis important cause of thrombus formation -THROMBOPHLEBITIS may develop (inflammation around veins involved with DVT) Thrombus may break free and travel to lungs or heart, resulting in death if the artery is blocked

Question 26

Saphenous Vein Grafts

Answer 26

Used for coronary arterial bypass because 1) it is accessible 2) usable lengths can be harvested without issue 3) high percentage of muscular and elastic fibers compared to other veins Can also use for bypass in other parts of body —- vein is INVERTED to prevent valves from impacting venous graft blood flow

Question 27

Saphenous Cutdown and Saphenous Nerve Injury

Answer 27

Cutdown – incision at medial malleolus to locate Great S. Vein and insert cannula for administration of blood, plasma, drugs, etc. If saphenous nerve, which runs with the vein, is cut, numbness to medial foot may occur

Question 28

Enlarged Inguinal Lymph Nodes

Answer 28

-Lymph nodes become enlarged when diseased -Entire daring area should be examined to ID the cause of the enlargement -All palpable lymph nodes should also be examined In females, the possibility of metastatic of cancer from the uterus should be considered

Question 29

Regional Nerve Blocks of Lower Limbs

Answer 29

Perineural Injections of Anestetics near a nerve = blocked conduction of peripheral nerve impulse Ex. Femoral N. (L2-L4) blocked 2cm inferior to inguinal L. Ex. Paresthesia occurs in knee and medial side of the leg when saphenous n. is blocked

Question 30

Abnormalities of Sensory Function

Answer 30

Peripheral nerve sensitizing an area is multiple segments of spinal cord. Pain sensation if tested by using sharp object, asking if patient felt and then determine what segment(s) of spine are involved

Question 31

**Containment and spread of Compartmental Infections in Leg

Answer 31

Because the compartments of the leg are separated by strong septa, increase in volume is bad. This volume increase can come from infection with suppuration (formation of pus). Though It would typically move caudally, pus-forming infection in the lateral compartment may ascend to the popliteal fossa, along course of FIBULAR N. — fasciotomy may be necessary

Question 32

**Tibialis Anterior Strain

Answer 32

aka shin splints -edema and pain in the distal 2/3 of the tibia from microtrauma of tibias anterior, which CAUSES small tears in the periosteum covering the shaft of the tibia. Common in athletes and those who live sedentary lives that begin moving/participating in athletics for long periods/go on a very long walk untrained or did not warm up properly.

FORM OF COMPARTMENTAL SYNDROME!!!

Question 33

**Injury to Common Fibular N.

Answer 33

-INJURY to lower leg (FRACTURE) -Paralysis of anterior leg muscles and lateral leg compartment -Loss of dorsiflexion = FOOT DROP Compensate 1) waddling gait: individual leans to side opposite of leg affected 2) swing out gait: affected side swung out laterally to allow toe clearance 3) steppage gait: extra flexion employed at hip and knee to raise foot off ground

Question 34

Posterior Tibial Pulse (also why is it used?)

Answer 34

Palpated between: -Posterior surface of medial malleolus and the medial border of the Achilles Tendon -Patient should inverse foot in order to relax the Flexor Retinaculum or pulse may not be felt

Used to examine patients with:

occlusive peripheral artery disease –condition cause by ischemia from narrowing arteries — leg cramps and pain during walking that disappears after rest

Question 35

What is the importance of the Plantaris M. in a clinical context?

Answer 35

Because it has a long tendon (the freshman nerve), the tendon can be harvested and used in reconstructive hand surgery since it (typically) does not impact movement of the ankle or knee ———- HOWEVER:

-Violent ankle movements can lead to rupture of the tendon! (basketball players, ballet dancers, sprinters

Question 36

What is the the Fabella?

Answer 36

-Fabella means “bean” in Latin

Lateral head of gastrocnemius may have sesamoid bone close to its proximal attachment (3-5% of people)

MAY provide leverage for the lateral head but PAINFUL fabella stress fracture may accompany total knee replacement

Question 37

**Plantar Fasciitis

Answer 37

Cause: Running, High-impact activity, worn-out shoes, obesity

• Most common in hindfoot of runners
• Inflammation at proximal attachment of plantar aponeurosis
• Pain worse getting up in the morning/when you just start walkiing
• Can lead to the formation of a calcaneal spur which will also become irritated

Question 38

Hallux Valgus, Bunion and Corns

Answer 38

Halgus valgus - lateral deviation of Big Toe

Caused by 1) pressure from footwear and 2) degenerative joint disease

Tissue surrounding the deviated area swells and, as a result, there is an increase in friction over that area. Over time, the friction can cause a bursa to form which also becomes inflammed and is then a BUNION

Corns are associated wiht the above conditions and is an inflammed area w/ thickened skin over the proximal interphalangeal joints

Question 39

Toe Deformities (Claw Toe, Hammer Toe, Mallet Toe, Trigger Toe)

Answer 39

Thought to be due to SHORTENED FLEXORS

Claw Toe - Hyper-Extension at MP joint, flexion at PIP and DIP

Hammer Toe - Extension at MP joint, flexion at PIP (usually in 2nd digit) – may result from weakness in lumbricals or one of the interossei muscles

Mallet Toe - Flexion at DIP

Trigger Toe - Extension of the MP and flexion of IP at GREAT TOE