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Lower Limb! > Ch. 27: clinical correlation > Flashcards

Ch. 27: clinical correlation Flashcards

1
Q

What is the cause of Meralgia Parasthesia?

A
  • can be seen when people wear their belts too tightly or fluid overload
  • physical deformation of lateral femoral cutaneous n. (L2,3) within the abdomen as it passes deep to the inguinal ligament
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2
Q

what is frictional bursitis? what are two types of bursitis seen in the lower limb?

A
  • fluid filled space, friction rub, inflammation –> fibrosis –> calcium deposits –> rupture of bursa or associated tendon
    1. Ischial Bursitis: inflamation of the bursa b/w ischial tuberosity and gluteus maximus
  • ischial tuberosity is weight bearing upon sitting
  • mvmt. of gluteus maximus across inflamed bursa causes pain and bursa may become calicific
  • can also be caused with prolonged bed rest and pressure sores –> ulceration
  1. Trochanteric Bursitis: inflammation of bursa b/w greater trochanter and glteus maximus
  • caused by repetitive motion of gluteus maximus across bursa during climbing and inclined walking
  • pain radiates deeply inferiorward along the lateral thigh to the knee
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3
Q

What would result in medial plantar nerve compression? What does the medial plantar n. innervate?

A
  • bursitis/synovitis of tendons passing under the reginacula
  • excessive running or eversion resulting in irritation of the medial plantar n. as it passes deep to the flexor retinaculum result in in parestheisas (aching, burning, numbness and tingling) on the MEDIAL side of the SOLE of the foot with weakness of the i**ntrinsic muscles of the great toe **
  • medial plantar n. innervates 1st lumbrical, abductor hallucis, flexor hallucis brevis, flexor digitorum brevis
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4
Q

what is the cause of plantar fascitis?

A

–> pain upon dorsiflexion

  • inflammation of plantar aponeurosis caused by overuse (running, high impact activities, improper footwear)
  • pain can be caused by direct pressure at the point of attachment to the calcaneus, or by dorsiflexing the foot/extending the toe
  • often this is accompanied by calcaneal bone spurs in the direction of plantar aponeurosis and tight triceps surae
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5
Q

Femorial Hernia

A
  • protrusion of a viscus (portion of the gut) through the femoral ring into the femoral canal; occurs more often in females
  • protrudes in the femoral triangle inferolateral to the pubic tubercle

–> in some cases the femoral hernia might protrude through the saphenous opening and impede venous return of the greater saphenous v.

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6
Q

What is the cause of compartmental syndromes of the leg?

A
  1. caused by infection, inflammation or arterial hemorrhage within a fascial compartment of the leg. It can produce pressure increases high enough to:
  • reduce the blood supply to muscles within or distal to the compartment
  • the pressure from accumulated blood may impinge nerves - can have paresthesias distal to compressed area or paralysis occurs to muscles located within the compartment
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7
Q

What are three types of strains and how are they most oftenly incurred?

A
  • often occur as result of large muscles having to exert force very quickly in order to covercome large amounts of inertia (i.e start of sprints)
    1. Groin strains: adductor group pulls during fast hip flexion activities
    2. hamstring sprain: semimembranosus, semitendinosus and biceps femoris near the ischial tuberosity as a result of fast extension during the “push-off” phase of running.
    3. Ruptured AChilles tendon” “week-end” warrior injury due to increased age and irregular bouts of exercise where rapid push-offs with feet are required.
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8
Q

How does a psoas abscess occur?

A
  • due to retroperitoneal abdomial/pelvic infection that descends within the psoas fascia sheath. Goes deep to inguinal ligament causing pain and swelling within the femoral triangle. can hurt all the way to the foot.
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9
Q

How does Tibialis Anterior Strain occur?

A
  • aka shin splints
  • micro tears in the periosteal attachment of the distal 2/3 of the tibialis anterior to the tibia resulting in pain
  • swelling/inflamm. within the muscle decreases vascular exchange, leads to apin
  • often results from overuse/infrequent bouts of exercise without stretching or warming up; also due to running on hard surfaces
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10
Q

what is calcaneal tendinitis?

A

micro tears in the attachment of the calcaneal tendon as a result of over use, poor footwear, poor training surfaces or infrequency of activity

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11
Q

what are avulsion fractures?

A
  • due to stretching muscle too quickly; fractures which occur as a result of fragments being pulled away from bones by rapidly loaded tendons and ligaments
  • Pelvis: ischial tuberosity, ASIS, AIIS
  • Tibial tuberosity (Osgood Schlatter)
  • Ankle: lateral and medial malleoli
  • Foot: fifth metatarsal
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12
Q

Where are the different places that the femur can be fractured?

A
  1. Neck: fracture along neck/introtrochanteric line
  • occurs most often as a result of increased compressive forces (stepping from a curbon a limb already weakened by osteoporosis)
  • results in a shortened limb and could lead to necrosis of the femoral head!
  1. Greater trochanter/shaft:
    * occurs usually as a results of direct trauma due to falls/vehicular accidents
  2. Distal Femoral Fractures:
  • fracture of femoral condyles or between condyles
  • both result in aberration of the articular surfaces of the knee joint
  • may disrupt blood supply to knee or let
  • see Salter-Harris classification
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13
Q

Salter-Harris classification

A
  • classification of different types of distal femoral fractures

Type I – A transverse fracture through the growth plate

Type II – A fracture through the growth plate and the metaphysis, sparing the epiphysis

Type III – A fracture through growth plate and epiphysis, sparing the metaphysis

Type IV – A fracture through all three elements of the bone, the growth plate, metaphysis, and epiphysis:

Type V – A compression fracture of the growth plate (resulting in a decrease in the perceived space between the epiphysis and diaphysis on x-ray

NOTE: type III and IV cause the most instability in adults

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14
Q

Fracture of patella: what are the two types?

A
  1. transverse patellar fractures:
  • avulsion due to sudden forceful contraction of hte quads
  • direct blow (car bumper/dashboard, falling into kneeling position)
  1. Bipartite/Tripartite patella: non-union of ossification center resulting in a patella that has two or three components –> often misinterpreted as a fracture
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15
Q

Fracture of tibia: where do fractures occur most often? what are the three fracture types?

A
  • most often occur near junction of middle and distal third (narrowest portion and least vascularized)
  • if fraactures occur through nutrient foramen, can lead to non-union

fracture of medial malleolus due to contact with talus durin excessive eversion.

  • three fracture types:
  1. transverse: due to prolonged stress or with sudeen changes in direction
  2. diaganol: due to severse torsion (i.e. skiing above boot line fracture)
  3. disruption of epiphyseal plate: osgood-Schlatter disease= disruption of tibial tuberosity at its growth plate during youth due to excessive action of quadricpes tendon results in inflammation and pain
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16
Q

fracture of Fibula. where do fractures most often occur?

A
  • fractures most often occur proximal to the lateral malleolus: associated with fracture-dislocations of the ankle and distal tibial fractures
  • fracture could be du eto contact with talus during excessive inversion
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17
Q

how to calcaneal fractures occur?

A
  • most often fractures as a result of hard falls directlyy to the heel - disrupts subtalar joint (active during eversion and inversion)
  • eversion= tibial and fibular fracture at malleolus
  • inversion = fibular fracture at malleoloar
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18
Q

how do talus fractures occur?

A

most often during forced dorsiflexion

  • results in fracture of the neck of the talus with posterior dislocation of teh talar body
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19
Q

What is the normal CCD angle? what is the Q angle? what does it measure? what is coxa vara? coxa valga?

A

CCD=Caput-Collum-Diaphyseal = head, neck shaft

  • should be **120 degrees **

Q angle = angle drawn from center of the patella to the ASIS and a line drawn from the middle of patella in the middle of the hip joint

  • normal male = 14 degrees, normal female = 17 degrees
  • coxa vara = decrease in CCD angle (looks like femur slants in more) = inward
  • causes a slight decrease in length of the affected limb
  • increase in Q angle opens medial knee joint space resulting in Genu Valgum = “knock kneed”
  • leads to increased occurence of patellar dislocation
  • Coxa Valga: increase in CCD angle (greater than 120 degrees) = outward
  • causes slight increase in the length of the affected limb
  • decrease in Q-angle resulting in Genu Varum - opens lateral knee joint space
  • “bowlegged”
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20
Q

what does a slipped capital femoral epiphysis result in ?

A

distal fragment dislocates posteriorly leading to coxa vara

  • cause by trauma in the region of the proximal femoral epiphysis - usually occuring in adolescents prior to epihpyseal plate closure
21
Q

which branches are most often disrupted in avascular necrosis of the femoral head

A

branches of medial femoral circumflex a.

22
Q

how do hip dislocations occur?

A
  • occurs most often when the knee is flexed (like sitting in a car, and hitting knee against a dash in an accident)
  • the capsule of the hip joint is loosest when the thigh is in flexion
  • hitting the knee and driving the femur posterirly can dislocate the head of the femur from the acetabulum posteriorly
23
Q

what is the cause of hip drop?

A
  • paralysis of gluteus medius and minimus (due to superior gluteal n. L4,5-S1)

when paralyzed, the sunsupported hip drops during the swing phase of locomotion

24
Q

How do meniscal tears occur? what is torn more often?

A
  • placing the leg in full flexion under force can trap the menisci thereby tearing them
  • the medial meniscus is more often torn as it is less mobile due to its attachment to the medial collateral ligament; opning the medial angle of the joints stretches the ligament and tears the cartilage
  • bucket handle tear = longitudinal tear through substance of meniscus
25
Q

how do you tear the collateral ligaments of the knee?

A

blunt force applied on the medial side (lateral collateral ligament) or blunt force applied on the lateral side (MCL tear)

  • most often injured when foot is in contact with the ground and force is applied to side of the extendended and or rotated knee
  • opening medial angle - stretches LCL
  • opening lateral angle: stretches MCL
26
Q

Tearing cruciate ligaments

A

cruciate ligaments control anterior and posterior mvmt of the femur on the tibial plateu when the foot is fixed

  • ACL is more often injured: hyperextension injury or force applied to the lower limb when the foot is fixed, the limb is in slight flexion and femur placed in medial rotation as in running and cutting on one foot to the opposite side
  • if force applied slowly, ligament will avulse the tibial plateau; if applied quickly, ligament tears in mid-substance (most often)

ACL: prevents the femur from sliding posteriorly on the tibia and hyperextension of the knee and limits medial rotation of the femur when the foot is on the ground and the leg is flexed

PCL: preents the femur from sliding anteirorly on the tibia, particularly when the knee is flexed

drawer test: asseses CL compromise: Anterior drawer sign is pain due to ACL problem (extension of leg). posterior drawer sign, pain with flexion of leg (due to PCL problem)

27
Q

what is the unholy triad? how does it happen?

A

tearing of the ACL, MCL, medial meniscus simultaneously. often due to extreme force being applied laterally

28
Q

where is patella more likely to dislocate?

A
  • patella more likely to dislocate laterally
  • more often seen in females due to greater Q angle, resulting in increased lateral pull on the patella via the rectus femoris and vastus lateralis muscle
29
Q

Patellofemoral syndrom

A
  • pain caused by improper tracking of the patella relative to the patellar groove of the femur
  • can result in chondromalacia of the patella (softening of the articular cartilage o the patella due to chronic over use - extensive running, direct blow to patella or repeated extreme flexion)
  • results in quadricps imbalance and improper patellar tracking; patella rides more on the lateral femoral condyle

Rx: leg extension with emphasis on last 30 degrees to increase tension of vastus medialis obliquus and re-establish proper tracking

30
Q

What is a Baker’s cyst?

A
  • popliteal cyst
  • result of chronic knee joint effusion (extra fluid accumulation)
  • establishes continuity of fluid in joints space with bursae surrounding knee: often occurs posteriorly in the gastroc. and semimembranosus bursae
  • may impede flexion, put pressure on structures of the popliteal fossa and result in pain.
31
Q

what is os trigonum

A
  • it is an accesory bone of the talus
  • associated with sports where atheltes use excessive plantar flexion (soccer and ballet)
32
Q

Ankle Sprains: what is injured in inversion vs. eversion?

A

Inversion of ankle: over elevation of the medial border of the foot usually due to stepping on an uneven surface whil weight bearing

  • results in injurty to the lateral collateral ligament of the ankle
  • anterior talofibular ligament is most often torn component

Eversion of ankle: over elevation of the lateral border of the foot

  • results in injury of the medial collateral ligament of the ankle
    • occurs less often because this ligament is very strong
33
Q

Pott’s fracture

A

**“bimaellolar ankle fracture” **

  • where both fibular and tibial maleoli are fractured
  • due to forced eversion of the ankle
  • avulsion fracture of medial malleolus via the deltoid ligament
  • talus shifts resulting in fracture of th lateral malleolus

–> results in total disruption of the mortise of the ankle joint

34
Q

Where can you feel pulses? what does diminshed pulse in these areas result from?

A
  1. femoral a. - midway b/w asis and pubic tubercle
    * diminished pulse sign of common/external iliac aterial obstruction
  2. popliteal a.. inferiorly within the fossa against the posterior tibia with the pateient prone and leg flexed
    * diminished pulse - sign of femoral a. obstruction
  3. posterior tibial a. - located posteirorly b/w the calcaneal tendon and medial malleolus (deep to flexor retinaculum) with foot inverted
  • dimished pulse - sign of popliteal artery occlusion
  • intermittent claudication (cramping leg pain during exercise which disappears with rest) is a sign of muscular ischemia due to narrowing of tibial aa.
  1. dorsalis pedis a. - pulse palpated inferior to extensor retinaculum lateral to the tendon of the extensor hallucis longus
    * diminished pulse - sign of anterior tibial artery obstruction

NOTE: SOME PEOPLE ARE MISSING A DORSALIS PEDIS A. IN THESE CASES THE BLOOD FLOW IS PROVIDED BY THE PERFORATING BRANCH OF THE FIBIAL A.

35
Q

VARICOSITIES

A

result of weakened superificial veins which dilate under the pressure of the supported column of blood

  • venous valves are no longer competent because they no longer appose
    3. degernerated deep fascia reduces or eliminates the musculovenous pump
36
Q

what can the saphenous v. be used for?

A
  1. saphenous vein grafts - harvested for use in coronary arterial bypass surgery - works well b/c has increased muscular and elastic fibers of wall
  2. saphenous cut down - saphenous v. is large and easty to locate at medial malleolus - can be used for cannulation of fluids, drugs, etc.
  3. saphenous varix - dilation of terminal portion of G. Saphenous v. –> caues swelling in femoral triangle
37
Q

what is thrombosis/ DVT? thrombophlebitis? thromboembolism?

A

thrombosis/DVT = clot formation as a result of prior trauma, i.e. fracture, deep contuson. occur spontaneously as a result of:

  1. vascular stagnation due to reduced physical activity
  2. weakened muscular fascia resulting in diminished musculovenous pump

thrombophlebitis = clot within a vein leading to inflamation at the site of the clot

thromboembolism = a clot which has broken free from a lower limb vein and traverses the heart to become lodged in the lung (pulmonary arterial branch)

38
Q

What is lymphangitis? lymphadenopathy?

A
  • lymphangitis = inflammation of lymph vessels, usually visible as “red streaks”
  • lymphadenopathy = enlarged lymph nodes due to inflamation which, in the lower limb, resides in teh popliteal fossa and femoral triangle
  • superficial thigh nodes –> superficial inguinal nodes in the femoral triangle
  • deep structures of foot, leg and thigh drain to the femoral triangle at the deep inguinal nodes.
39
Q

where are the patellar and achilles tendon reflexes?

A

patellar = L4

Achilles = S1

40
Q

what would injury at the femoral nerve look like? what cord levels would it affect?

A

L2,3,4

  • loss of leg extension (no quadratus muscles), impaired hip flexion, no patellar reflex, anesthesia of the anterior thigh, medial leg and foot in the L4
  • provides innervation to iliacus, sartorius, rectus femoris, vastus lateralis/medialis/intermedius, articularis genu and pectineus
41
Q

What would loss of obturator nerve look like?

A
  • L2,3,4
  • the obturaot r nerve can become entrapped as it exits the obturator canal resulting in weakness upon ADDUNCTION, flexiona nd rotation of thigh and paresthesia of the medial thigh
  • innervates the: pectineus, adductor longus/brevis, proximal head of adductor magnus, gracilis and obturator externus.
42
Q

What would loss of sciatic nerve look like? what is a common syndrome that disrupts the sciatic n?

A

L4,5-S1,2,3

  • weakness of extension of the thigh, major loss of flexion of the leg, complete loss of inversion, eversion, plantar and dorsiflextion of foot
  • could be lost with improper gluteal injections
  • no sensation on lateral/anterior leg
43
Q

What is piriformis syndrome?

A
  • damage to common fibular branch: L4,5,S1,2
    1. Piriformis syndrome - tibial and common fibular components of sciatic nerve are split by a portion of the piriformis

direct trauma to the buttock or with athletic hypertrophy of the piriformis (running, cycling, skating, climbing) may cause compression of the common fibular component of the sciatic n. resulting in complete loss of eversion and dorsiflexion and numbness on the lateral anterior portion of the leg and dorsum of foot.

44
Q

What would damage to superior gluteal nerve look like?

A

L4,5 S1 **** L5**********

“dropped hip”

  • prevents the gluteus medius and minimus from acting on the pelvis of the supported limb during walking causing the unsupported limb to drop (positive Trendelenberg test)
45
Q

damage to inferior gluteal n.

A

***S1*******

L5-S1,2

  • weakness of gluteus maximus (extension and lateral rotation) - decrease in hip extension especially visible when an affected individ. tries to negotiate going up stairs or getting out of a chair
46
Q

damage to tibial n.

A

L4,5 - S1,2,3

  • injury if occured within the popliteal fossa and would result in complete loss of plantarflexion, flexion, adduction and abudution of the toes and anesthesia toa large portion of the sole of the foot.
  • loss of posterior superficial and deep compartments of the leg and ALL plantar foot muscles
  • foot held in dorsiflexion and eversion
  • loss of Achille’s reflex S1
47
Q

Common fibular N

A

L4,5 -S1,2

  • can be result of direct trauma to the common fibular n. as it courses around the neck of the fibula
  • loss of lateral and anterior compartments of hte leg
  • loss of dorsiflexion and eversion of the foot
  • numbness on the lateral anterior portion of the leg and dorsum of foot
  • foot held in plantar flexion and inversion
48
Q

Superficial fibular n.

A

L5-S1,2

  • direct trauma to the lateral crural region can lead to damage of this nerve
  • results in major loss of eversion, moderate loss of plantar flexion, weakness of support for the arches of the foot (fibularis longus) and aneshtesia on the lateral anterior portion of the leg and dorsum of foot
  • loss of musculature of the lateral compartment of leg
  • foot held dorsiflexed and inverted
49
Q

deep fibular n.

A

L4,5

  • loss results in “foot drop”

Loss of tibialis anterior L4
Loss of extensor hallucis longus L5

  • trauma to deep fibular n. may occur as a result of piercing trauma and compartment syndrom of the anterior crural compartment
  • loss of musculature of the anterior compartment of leg
  • loss of dorsiflexion of foot, extension of toes and reduced inversion of foot
  • anesthesia between the 1st/2nd toe
  • foot is held in plantar flexed with slight eversion - due to the tibialis anterior loss. dragging of great toe due to loss of the extensor hallucis longus.

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