Clinical Anatomy of the Lower Limb

Question 1

78 year old female

Tripped over her cat

Unable to weight bear, complaining her right leg is extremely sore

PMHx (past medical history): Hypertension, T2DM (Type 2 diabetes mellitus)

DHx (drug history): Not relevant

Leg is externally rotated and shortened

Answer 1

Neck of femur fracture

Iliopsoas - main flexor of the hip

If neck of femur fracture, then iliopsoas has unopposed action.

This causes the leg to become shortened and externally rotated.

Question 2

What happens if blood supply is cut off in an intra-capsular neck of femur fracture ?

Answer 2

Avascular necrosis of femoral head

Question 2

How to diagnose neck of femur fracture ?

Answer 2

X-ray

Looking at the hip joint

Question 2

Types of neck of femur fractures

Answer 2

Intracapsular
Extracapsular

Question 3

Treatment for extra-capsular hip fracture

Answer 3

Dynamic hip screw

Question 4

40 year old male

Attending child’s sports day
Took part in parent race

Started to sprint and heard a pop, felt like he’d been shot in the back of the leg

Struggled to walk after this

On examination weak plantar flexion, positive Thompson’s test

Answer 4

Calcaneal tendon rupture

Question 5

Features of calcaneal tendon rupture

Answer 5

Most common tendon rupture in the lower limb

Men more affected than women

30-40 peak incidence

Question 6

Risk fractures for calcaneal tendon rupture

Answer 6

Steroid injections
Fluoroquinolone antibiotics

Question 7

Thompson’s test

Answer 7

Squeeze the leg, causes plantar flexion

Question 8

What contributes to the calcaneal tendon ?

Answer 8

Medial and Lateral heads of gastrocnemius

Soleus

Plantaris

Question 9

Treatment of Achilles tendon rupture

Answer 9

Surgery V Non-Surgical management

Question 10

Surgical management of calcaneal tendon rupture

Answer 10

Try to remove the damaged part of the tendon.

Blood supply to the middle part of the calcaneal tendon is poor in comparison to the top and bottom aspects.

So you could potentially remove the damaged area and replace it with a tendon graft from elsewhere in the body.

Question 11

Non-surgical management of Calcaneal tendon rupture

Answer 11

Aquinas boot

• foot is placed in the boot, plantar flexed

Question 12

25 year old male presents after Road Traffic Accident

Unable to weight bear, swelling, bruising over right ankle

No other injuries

Currently - DVNI (distally neurovascularly intact)

Medial malleolus shifted, bruising

Answer 12

Fractured Fibula

Fractured Medial and Lateral Malleolus

Talar shift

Possible posterior tibial fracture (aka posterior malleolus)

TRI-MALLEOLAR FRACTURE

Question 13

RISK of not treating tri-malleolar fracture

Answer 13

Inability to use foot
Sore foot

Poor healing

Question 14

What is the dorsalis pedis artery a continuation of ?

Answer 14

Anterior tibial artery

Question 15

Patient has post-operative pain (severe) despite huge amounts of morphine

Patient reports leg feeling tight

ON examination, loss of sensation and pain of passive stretch of the foot

Answer 15

Compartment Syndrome

• swelling of muscles causing compression of nerves and vessels

Question 16

Symptoms of compartment syndrome

Answer 16

Pain upon passive stretch

Failure to control pain

Loss of sensation

Question 17

18 year old male

Clipped by a car on the outside of his right leg

No PMHx, DHx, no other injuries noted

Presented to ED as he had problems walking

On examination you note he has a high stepping GAIT on the right side & weakness in dorsiflexion.

Answer 17

Foot drop

Common peroneal nerve injury

Question 18

Causes of a High stepping GAIT and weakness in dorsiflexion

Answer 18

Common peroneal nerve injury

• this nerve goes lateral and wraps around the fibula
• this supplies the lateral and anterior compartments
• damage causes weakness in dorsiflexion and eversion

Question 19

Where does the sciatic nerve split and what does it split into ?

Answer 19

Splits at the popliteal fossa

Splits into:
- Common peroneal nerve
- Tibial nerve

Question 20

Symptoms of foot drop

Answer 20

Injury to common peroneal nerve

Tingling
Weakness
Numbness

Question 21

Treatment of foot drop - common peroneal nerve damage

Answer 21

Physiotherapy
Orthotics

Treatment depends on the cause