Blue Boxes LE Flashcards
Why are adolescents more vulnerable to acute trauma injuries
due to the fact adolescents are still growing and still have cartilaginous models that are being transformed at the endochondral ossification
Epiphyseal plate
disc of hyaline cartilage between the metaphysis and the epiphysis of the mature long bone
these are susceptible to fracture due to the combined stress from physical activity and growth via the stretching of the muscles
(osteochondrosis)
Pelvic fracture
fractures of the “hip” bone
Hip fracture
more commonly applied to fractures of the femoral head, neck and trochanters
Avulsion fractures of the hip bone
may occur in sports from sudden acceleration and deceleration forces like sprinting or kicking in a ball
these occur at the apophyses which are bony projections that lack secondary ossification centers
common areas: anterior superior and inferior iliac spines, ischial tuberosities, and ischiopubic rami
Coxa vara
significantly decreased angle of inclination between the long axis of the femoral neck and the femoral shaft due to weakening the neck of the femur
the distal limb deviates toward midline
causes mild shortening of the lower limb and limits passive abduction of the hip
Coxa valga
increase in the angle of inclination between the long axis of the femoral neck and the shaft due to weakening of the femoral neck
the distal element deviates away from midline
Dislocated Epiphysis of femoral head
older children the epiphysis of the femoral head may slip away from the femoral neck due to a weakened epiphyseal plate
due to acute trauma or repetitive microtraumas especially with abduction and lateral rotation of the thigh
often need radiographic examination to find
What are the two main locations of fractures of the proximal femur
transcervical: middle of neck
intertrochanteric
these occur due to indirect trauma (stumbling or stepping down hard off a curb)
this is because of the angle of inclination making the fractures inherently unstable and impaction
Intracapsular fracture
occurs within the hip joint
complicated by degeneration of the femoral head leading to vasculature trauma
how do Fractures of the greater trochanter and femoral shaft occur
results from direct trauma
occur frequently during motor vehicle accidents and sports
Spiral fracture
occurs at the femoral shaft resulting in foreshortening as the fragments override or the bone is fractured into multiple pieces
can take up to a year to union
Fractures of the inferior or distal femur
may be complicated due to seperation of the condyles and misalignment of the articular surfaces of the knee joint
can cause hemorrhage from cutting the large popliteal artery that runs on the posterior surface of the bone
Compound fracture of the tibia
usually occurs in the middle and inferior third of the shaft since it is the narrowest part of the bone
due to direct trauma “bumper fracture” from hitting the bumper of a car
has poor blood supply since anterior part is subcutaneous
if the fracture hits the nutrient canal it predisposes the patient to nonunion of the bone fragments due to the damage of the nutrient artery
Transverse march stress fracture
inferior third of the tibia
occurs in people who take long hikes before they are conditioned
may fracture the anterior cortex of the tibia
can also be caused by indirect violence applied to the tibial shaft when the bone turns as the foot is fixed
Diagonal fracture
torsion during skiing produce a diagonal fracture of the tibial shaft at the junction ofthe middle and inferior thirds and will fracture the fibula as well
can lead to limb shortening due to the overriding as well
Boot top fracture
fracture at where a a skiboot sits due to highspeed forward fall which angles the leg over the rigid ski boot
osgood schlatter disease
prominance of tibial tuberosity elongated and fragmented due to disruption of the epiphysial plate causing inflammation of the tuberosity and chronic recurring pain
Fibial Fractures
usually occur 2-6 cm to the distal end of the lateral malleolus and are often associated with fracture-dislocations of the whole ankle joint
usually occurs when a person slips and are forced into an excessive inverted position
or can occur with eversion as well
Bone Grafts
replacement of affected segments by a bone transplant may avoid amputation
fibula is a common source of bone grafting since normal actions can still be kept even after removal of segments of the fibula
free vascularized fibular transfers
help restore skeletal integrity to upper and lower limbs in which congenial bone defects exist and to replace segments of bone after trauma
remaining fibula usually doesnt regenerate
nutrient artery is removed with the bone so that the graft will remain alive in the new site it is transplanted too
Interosseous infusion
method of delivering hydration, blood, and medications directly into the medullary cavity of a bone when peripheral venous access is difficult to impossible
used in children with traumatic shock or circulatory collapse
usually done in the proximal tibia, needles are inserted 2cm distal and slightly medial to tibial tuberosity
special needles are used to get through the bone
IO infusion must be replaced with peripheral venous or central line access within 24 hours due to risk of osteomyelitis
Calcaneal fracture
usually a hard fall on to the heel, fractureing the calcaneus into several pieces and producing a commiuted fracture
this fracture disables walking because it usually affects the subtalar joint where the talus articulates with the calcaneus
Fracture of the talar neck
may occur during dorsiflexion of the ankle (occurs when someone is pressing hard on the brake pedal when trying to stop on a head on collision
some cases the talus dislocates posteriorly
Dancers fracture
occurs when the dancer looses balance and puts full weight on the metatarsal fracturing the bone
Fatigue fractures of the metatarsals
usually occur from prolong walking, these typically are transverse due to repeated stress on the metatarsals
Avulsion fracture of the tuberosity of the 5th metatarsal
foot is suddenly and violently inverted and the tuberosity of the 5th metatarsal may be avulsed by the tendon of the fibularis brevis muscle
most commonly in basketball and tennis players
usually associated with ankle sprain
Os trigonum
the secondary ossification center which becomes the lateral tubercle of the talus occasionaly fails to unite with the body of the talus
maybe caused to forceful plantarflexion in early teens
may result in a bone known as a os trigonum
fracture of the sesamoid bone
the sesamoid bones of the great toe can be fractured in a car crash and make it difficult to walk since they are important on the stance phase of walking
varicose veins
when a vein becomes dilated so that the cusps of their valves do not close and actually face the wrong way
lead to blood flowing wrong way and actually can pool
Thrombophlebitis
DVT with inflammation around the involved veins
Venous stasis
venous stagnation
can be caused by:
incompetent, loose fasci that fails to resist muscle epansion, diminishing the effectiveness of the musculovenous pump
external pressure on the veins from bedding during a prolonged hospital stay or from a tight cast or bandage
muscular inactivity
Pulmonary thromboembolism
a large thrombus that breaks free from a lower limb vein that may travel to a lung which will obstruct the pulmonary artery
Saphenous Vein grafts
great saphenous vein is sometimes used for coronary arterial bypass because it is readily accessible, there is a sufficient distance occurs between the tributaries and the perforating veins so that usable lengths can be harvested, and the walls contain a higher percentage of muscular and elastic fibers than other superficial veins
the vein is inverted so that the valves do not obstruct blood flow.
Saphenous cutdown
if need to get blood, plasma expanders, electrolytes, or drugs quickly into the vein you can make a small incision anterior to the medial malleolus and find the great saphenous vein
however can cut the saphenous nerve because it runs with the great sapheonous vein
patient will complain of pain or numbness along the medial border of the foot
Nerve block of the femoral nerve
L2-L4
can be blocked 2 cm inferior the inguinal ligament, approximately a fingers breadth lateral to the femoral artery
Paresthesia will radiate to the knee and over the medial side of the leg if the saphenous nerve is affected
Enlarged inguinal lymph nodes
look for infection or even uteran cancer since some drainage comes from the perineum
Abnormalities of sensory function
to interpet abnormalities of the peripheral sensory function, peripheral nerve distribution of the major cutaneous nerves must be interpreted anatomically different from dermatome distribution of the spinal cord segments
Hip Pointer
contusion of the iliac crest that usually occurs on the anterior part (ASIS)
Charley horse
ischemia or contusion and rupture of blood vessels sufficient to form a hematoma usually consequence of tearing of fibers of the rectus femoris
caused by localized pain or muscle stiffness which follows direct trauma
Psoas abcess
pyogenic infection from chrons disease or TB that when getting into the lymph in the psoas region looks like a inguinal hernia and causes pain
Paralyzed quadriceps
person cant extend the leg against resistance
walk 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 of the knee joint
injury just to the vastus medialis or vastus lateralis lead to abnormal patella movement and loss of joint stability
Chondromalacia patellae
called runners knee
softening of the articular cartilage of the patella
occurs in marathon runners due to overstressing of the knee region
can occur from blow to the patella or extreme flexion of the knee
can be caused due to quadriceps imbalance
Transverse patellar fractures
may result from a blow to the knee or sudden contraction of the quadriceps
the proximal fragment is pulled superiorly with the quadriceps tendon and the distal fragment remains with the patellar ligament
Bipartite or tripartite patella
ossification abnormality to have multiple segments attached to a patella
diminution or absence of the patellar tendon reflex
result may be to lesion that interrupts the innervation of the quadriceps
Transplantation of the Gracilis
surgeons transplant the muscle to help replace damaged muscles of the hand i.e. digital flexion and extension
muscle has also been used to recreate a nonfunctional external anal sphincter
riders strain
muscle strain of the adductor longus due to fast accleration, also due to horseback riding from constant adduction to stay on their horse
vascular surgeon naming of femoral artery
common femoral artery and the continuation distally as the superficial femoral artery
Femoral pulse
place little finger on the ASIS and the tip of thumb on the pubic tubercle then the midpalm is just inferior to the inguinal ligament which is where you can palpate the pulse
coronary arteriography
insert a probe into the femoral artery at this location to visualize the heart also same thing done for the left cardial angiography
blood gas analysis
the determination of oxygen and carbon dioxide concentrations and pressures, this blood is taken from the femoral artery
Laceration of the femoral artery
can be easy due to the superficial position,
when ligating the femoral artery the cruciate anastomosis will still get blood still down to the leg due to the meeting of the medial and lateral femoral circumflex artaeries and the inferior gluteal artery and the first perforating artery inferiorly
Saphenous Varix
a localized dilation of the terminal part of the great saphenous vein that may cause an edema in the femoral triangle
this should be considered if varicose veins are present
Trochanteric bursitis
inflammation of the trochanteric bursa
caused by constant moving of the gluteus maximus (climbing stairs) over the bursa that can lead to friction bursitis
point tenderness over greater trochanter and the pain radiates along the iliotibial tract
Ischial bursitis
recurrent microtrauma resulting from repeated stress (biking or rowing, tasks involving repetitive hip extension while seated
affects the ischial bursa and causes inflammation
pressure sores
calcification of the ischial bursa leading to chronic bursitis can lead to pressure sores in debilitated people because these tuberosities bear the body weight of people sitting
Hamstring strains
happens in people who involve quick violent muscular exertion
tear part of the proximal tendinous attachments of the hamstrings to the ischial tuberosity (more common than quadricep strains)
usually accompanied by hematoma that is contained in the fascia lata (bruising)
can also lead to avulsion of the ischial tuberosity due to the forcible flexion with the knee extended
injury to superior gluteal nerve
gluteus medius limp or a gluteal gait
weakened abduction of the thigh due to the lost of medius and minimus
medial rotation is also severly impaired
body compensates by putting the center of gravity over the supporting lower limb
Trendelenburg test
person asked to stand on one leg and the pelvis on the unsupported side descends (gluteus medius and minimus affected)
other cases of this would be fracture of the greater trochanter and dislocation of the hip joint
gluteal gait
when the pelvis descends on the unsupported side, the lower limb becomes in effect, too long and does not clear the ground.
to compensate the individual leans away from the unsupported side raising the pelvis to allow adequate room for the foot to clear the ground as it swings forward
Steppage gait
to lift the foot higher as it is brought forward
used against foot drop and injury to common fibular nerve
Swing out gait
to swing the foot outward laterally while walking
used to counter footdrop that results from common fibular nerve paralysis
foot drop
results in common fibular nerve paralysis
popliteal abscesses
because of the deep popliteal fascia that is strong and limits expansion pain from a abscess or tumor is usually severe
Severance of the tibial Nerve
Paralysis of the flexor muscles of the leg and the intrinsic muscles in the sole of the foot
cant plantarflex the ankle or flex the toes
sensation is lost at the sole of the foot
can happen due to posterior dislocation of the knee joint
Spread of infection in the leg
because of the compartments the only spreading occurs in the lateral compartment the infection can ascend proximal into the popliteal fossa along the course of the fibular nerve
fasciotomy must be done to relieve pressure and remove the suppuration infection
uniqueness of the foot compared to higher primates
humans feet are everted more so that we walk on our heels more
this pronation leads too the medial migaration of the distal attachment of the fibularis longus across the foot and the development of the fibularis tertius
injury to the common fibular nerve
occurs often since the common fibular nerve wraps around the neck of the fibula
this can also get severed during fracture of the fibular neck or when the knee joint is dislocated
lose all muscles on the anterior and lateral compartments
lose dorsiflexion and evertors of the foot
leads to foot drop
Deep fibular nerve entrapment
excessive use of muscles supplied by the deep fibular nerve may result in muscle injury and edema in the anterior compartment which may compress and entrap the nerve
pain occurs i the dorsum of the foot and radiates to the web space between the 1st and 2nd toes
common in skiing so called the ski boot syndrome
Superficial fibular entrapment
caused by chronic ankle sprains may lead to stretching of the superficial fibular nerve
may lead to numbness and parasthesia
Calcaneal tendinitis
inflammation of the calcaneal tendon due to running injuries
microscopic tears of collagen fibers in the tendon just superior to the attachment on to the calcaneus
can be caused by poor footwear or take up running after prolonged inactivity
ruptured calcaneal tendon
occurs during plantarflextion with knee extended and hear a snap
happens in people of history of calcaneal tendinitis
gap is palpable and patient presents in dorsiflexion
Calcaneal tendon reflex
reflex tests S1 and S2 nerve root
Absence of plantarflexion
to walk people will rotate the foot as far laterally as possible during the stance phase to disable passive dorsiflexion to allow a more effective push off through hip and knee extension exerted at the midfoot
tennis leg
gastrocnemius strain
usually occurs in the partial tearing of the medial belly at the musclutendinous junction
seen in individuals older than 40 years age and is caused by overstretchig of the muscle by concomitant full extension of the knee and dorsiflextion of the ankle joint
Calcaneal bursitis
inflammation of the deep bursa of the calcaneal tendon between the calcaneal tendon and the superior part of the posterior surface of the calcaneus
caused by excessive running and leading to excessive friction
Venous return from the leg
the venous plexus deep to the triceps surae is involved in pushing the blood back through and acting as a musculovenous pump
Accessory soleus
an extra muscle belly that appears as a distal belly medial to the calcaneal tendon. thismuscle may be associated with pain and edema during prolonged exercise
3 percent of people have this muscle
Posterior Tibial pulse
can be found at the posterior surface of the medial malleolus and the medial border of the calcaneal tendon
Calcaneal spur
protrudes from the medial tubercle and the plantar fasciitis is likely to cause pain on the medial side of the foot when walking.
bursa usually develops under this
Contusion of extensor digitorum brevis
abnormal edema and cuntusion of extensor digitorum brevis and extensor hallucis brevis make it look like the paitent has a severely sprained ankle
Sural Nerve grafts
pieces of the sural nerve are used asnerve grafts and the sural nerve can easily be found since it runs with the small saphenous vein
Anesthetic block of superficial fibular nerve
occurs when the superficial nerve pierces the deep fascia to become a cutaneous nerve, to inject the anesthetic agent the patient will plantar flex their foot and the injection will be given
Plantar reflex
L4,L5,S1, and S2
deep tendon reflex tested during neurological examinations
lateral aspect of the sole of the foot is stroked with a blunt object, flextion of toes is a normal response
fanning of the lateral four toes and dorsiflexion of the great toe is a abnormal response (babinski sign) which means brain injury or cerebral disease this sign will be only be present in children until 4 years old
Medial plantar nerve entrapment
compression of the medial plantar nerve as it passes deep to the flexor retinaculum or curves deep to the abductor hallucis
this causes numbness and tingling to the medial side of the sole of the foot and region of the navicular tuberosity
may occur during repetitive eversion of the foot
sometimes called joggers foot
Dorsalis pedis artery pulse
palpated with the feet slightly dorsiflexed and they are subcutaneous that pass along a line from the extensor retinaculum to a point just lateral to the extensor hallucis longus tendons
Hemorrhaging wounds of sole of foot
puncture would of the sole of the foot involving the deep plantar arch and its branches usually result in severe bleeding
typically from both ends of the cut artery because of the abundant anastomoses
ligation is difficult due to the depth and structures around it
Lymphadenopathy
enlargement of the lymphnodes
medial side foot infection shows up in the inguinial lymph nodes
lateral side of foot infection shows up in the popliteal lymph nodes
Acetabulum
overlies the femoral head to add stability and is important for transferring weight to the femur
osteoprosis
femoral neck fractures common in woman over 60 years due to the degeneration of the bone tissue
the femoral neck fractures are often intracapsular and requires internal skeletal fixation
pain edema, limitation of motion, erosion of articular cartilage
Aseptic vascular necrosis
when fracturing of the neck of the femur can also lose blood supply from the medial circumflex femoral artery and the breaking of the retinacular arteries
the only artery that may still be intact is the artery to the ligament of the femoral head but isnt sufficient to supply the head
Necrosis of femoral head in children
dislocations of the hip joint can disrupt the artery to the head of the femur
or fractures that result in seperation of the superior femoral epiphysis can lead to inadequate blood supply
lead to avascular necrosis of the head of the femur
also lead to development issues in growth of the bone if it occurs at the epiphysis in children 3-9
Congenital dislocation of the hip joint
common occurring bilaterally in girls
the femoral head is not properly placed in the acetabulum
patient cant abduct the thigh and appears shorter than normal
Aquired dislocation of the hip joint
very uncommon since the hip joint is so strong and stable
usually occurs during an automoblie accident when the hip is flexed adducted and medially rotated
posterior dislocations of the hip joint are the most common (head on collision)
this may affect the sciatic nerve and paralysis of the hamstrings and distal to the knee
Anterior dislocation occurs from a violent injury that causes hip extension, abduction, and lateral rotation
Q angle
greater in woman due to the wider pelves
Genu varum
close to zero Q angle and the distal leg points inward
stretches the lateral collateral ligament
stress on the medial meniscus
Genu valgum
great Q angle and the leg points outward
greater than 17 degrees
stretches the medial collateral ligament
stress on the lateral meniscus
Patellar Dislocation
always dislocates laterally
more common in women due to greater Q angle
this is due to the pull of the quadracips which makes it pull laterally
also the lope of the lateral patellar facet and the more anterior projection of the lateral femoral condyle make it go laterally
Patellofemoral syndrome
runners knee which is pain deep to the patella
caused by repetitive microtrauma caused by abnormal tracking of the petella
can occur from osteoartheritis
weakness of the vastus medialis leaves people predisposed to this
ACL rupture
hyperextension and severe force directed anteriorly against the femur with the knee semiflexed
this allows for the tibia to slide anteriorly under the fixed femur
lachmann test, anterior drawer test
PCL rupture
occur when a player lands on the tibial tuberosity with the knee flexed
usually occur with fibular and tibial ligament tears
allow for the free tibia to slide posteriorly under the fixed femur
Meniscal tears
usually medial meniscus tears and will be indicated by pain on the medial rotation of the tibia
lateral menisus will show with pain on lateral rotation of tibia
Arthroscopy
endoscopic examination that allows for visualization of the interior of the knee joint cavity
goes through an incision called a portal
use equipment or probe to remove the damaged tissues like the menisci or the loose bodies of the joint
ligament repair can also be done by this
Aspiration of the knee joint
if the knee joint becomes infected maybe after a laceration or fracture, inflammation and the amount of synovial fluid may increase
occurs when the knee joint is approached laterally when it is flexed. use the three bony landmarks (anterolateral tibial tubercle, lateral epicondyle of the femur and the apex of the patella
Prepatellar bursitis
caused by excessive and repeated friction between the skin and the patella
can also occur via compression forces from a direct blow to the knee
if chronic, the bursa becomes distended with fluid and forms a swelling anterior to the knee
subcutaneous infrapatellar bursitis
excessive friction between the skin and the tibial tuberosity, edema occurs over the proximal end of the tibia
called clergymans knee
and occurs more commonly in tilers and roofers if they do not wear knee pads
can also get a deep infrapatellar bursitis
Total knee replacement arthroplasty
artificial knee is inserted if the knee is diseased resulting from osteoarthritis
Ankle sprains
usually an inversion injury, involving twisting of the weight bearing plantarflexed foot
Lateral ligament sprains
occurs in jumping sports and particularly basketball
occcurs fairly frequently because the lateral ligaments are much weaker than the medial ligaments
Anterior talofibular ligament is the most vulnerable
the calcaneofibular ligament can also be torn
if severe the lateral malleolus may be sheared or avulsion fractures could occur
Pott fracture dislocation
foot is forcibly everted, this action pulls on the extremely strong medial ligament which will shear off the medial malleoulus
talus will then move laterally shearing off the lateral malleolus or more cmmonly breaking the fibula superior to the tibiofibular syndesmosis
if the tibia is carried anteriorly, the posterior margin of the distal end of the tibia is also sheared off by the talus, producing a trimalleolar fracture
Tarsal tunnel syndrome
there is edema and tightness in the ankle involving the synovial sheaths of the tendons of the muscles in the posterior compartment
the area involved is from the medial malleolus to the calcaneus
these both lead to entrapment and compression of the tibial nerve
Hallux valgus
lateral deviation of the great toe
sometimes the great toe can overlap the 2nd toe
causes a decrease in the medial longitudinal arch
can cause a medial shift of the sesamoid bones
Bunion
inflammed bursa found at the 1st metatarsal and usually caused by hallux valgus
Hard corns
inflammed areas of thick skin that form over the proximal interphalangeal joint especially the little toe
Hammer toe
foot deformity when the proximal phalanx is permanently and markedly dorsiflexed (hyperextended) at the metatarsophalangeal joint and the middle phalanx is strongly plantarflexed at the proximal interphalangeal joint
the distal phalank of the digit is often hyperextended
claw toes
hyperextension of the metatarsophalangeal joints and flexion of the distal interphalangeal joints
usually involved with the lateral four toes
callosities or corns develop on the dorsal surfaces of the toes due to the pressure of the shoes
and callositiess can develop on the plantar surfaces of the metatarsal heads and the toe tips because they bear extra weight
Pes planus
flat feet
flat appearance before age 3 is normal
can be flexible or rigid
flexible flat feet result from degenerated intrinsic ligaments (inadequate passive arch support)
usually resolves with age
Rigid flat feet: result from a bone deformity like a fusion of the tarsal bones
acquired flat feet or fallen arches are likely secondary to dysfunction of the tibialis posterior (dynamic arch support)
the plantar calcaneonavicular ligament fails to support the head of the talus making it go inferomdially and become prominent
this then will cause flattening of the medial part of the longitudinal arch and lateral deviation of the forefoot
Talipes equinovarus
clubfoot
congenital due to the lack of limb rotation during development in the embryo
the foot is inverted, and the ankle is plantarflexed and the forefoot is adducted
looks like a horses hoof
