Clinical correlates (Glut, Thigh, Leg & Foot dissectors)

Question 1

The highest point of the iliac crest lies at the level of which vertebra? It is is a useful landmark in performing a lumbar puncture to collect cerebrospinal fluid for analysis or to inject anesthetic (spinal block).

Answer 1

fourth lumbar vertebra

Question 2

The two ischial tuberosities may be avulsed by forceful contractions of the……….. muscles in skeletally immature individuals. Decubitus ulcers (pressure sores) may develop over them in as well.

Answer 2

hamstring

Question 3

A contusion of the bone of the iliac crest is known as a what?

Answer 3

“hip pointer”

Question 4

The ASIS is frequently avulsed in skeletally immature athletes by what muscle?

Answer 4

Sartorius

Question 5

The articular cartilage on the head of the femur is frequently worn away in elderly individuals with what?

Answer 5

osteoarthritis (degenerative joint disease)

Question 6

The neck of the femur joins the shaft at an angle, the angle of inclination, which changes during life but averages 126° in adults. A pathological decrease in the angle of inclination is…………… and an increase is…………..

Answer 6

coxa vara

coxa valga

Question 7

Why does a fracture of the femoral neck often result in hip replacement?

Answer 7

because retinacular branches of the medial femoral circumflex artery, the main blood supply to the femoral head in the adult, course along the femoral neck and are torn by the fracture.

Question 8

Hip fracture in older adults affects not only their quality of life but is associated with a ……….% increase in mortality within one year.

Answer 8

15-20

Question 9

The greater trochanter may be avulsed in skeletally imature individuals due to what muscles?

Answer 9

gluteus medius and minimus

Question 10

What may avulse the lesser trochanter?

Answer 10

The iliopsoas muslce.

(May also be avulsed following weakening by an infection or metastatic tumor)

Question 11

The tibial tuberosity may be quite large in individuals who suffered……………….. of the tibial tuberosity during adolescence.

Answer 11

traction apophysitis (Osgood-Schlatter disease)

Question 12

The tibial tuberosity may be avulsed by the……………… muscle in young athletes.

Answer 12

quadriceps femoris

Question 13

Repetitive movements that cause the gluteus maximus to move back and forth over the trochanteric bursa (ex: repeatedly walking up and down stairs. carrying a heavy load) result in a friction bursitis (…………….). This condition is characterized by tenderness over the greater trochanter and pain that may radiate a variable distance down the iliotibial tract.

Answer 13

trochanteric bursitis

Question 14

The……………………… also may be irritated by friction as it moves over the greater trochanter or lateral femoral condyle.

Answer 14

iliotibial band (iliotibial band syndrome).

Question 15

What is a positive Trendelenburg sign?

What causes a positive Trendelenburg sign?

Answer 15

* dropping of the unsupported side of the pelvis when the patient stands on one foot on the affected side.There is a characteristic gluteus medius gait in which the patient leans the trunk toward the affected side when bearing weight on it during the stance phase.

Causes:

* Weakness of the gluteus medius and minimus muscles or a superior gluteal nerve lesion

* Avulsion of the greater trochanter of the femur also may cause a positive Trendelenburg sign.

Question 16

What nerves may be damaged in harvesting bone from the ilium for grafting?

Answer 16

The clunial nerves

Question 17

A lesion of the……………… nerve results in weakness abducting the thigh and a positive Trendelenburg sign. The patient also has difficulty in medial rotation of the thigh.

Answer 17

superior gluteal nerve

Question 18

A lesion of the………… nerve results in weakness during resisted extension of the thigh, as in standing up from a seated position or walking up stairs, both of which are resited by gravity.

Answer 18

inferior gluteal

Question 19

A gluteal lesion has little or no effect on ordinary walking on level ground. Why?

Answer 19

because the hamstring muscles can extend the thigh during this motion.

Question 20

Branches of the sciatic nerve supply joints of the lower extremity (except the hip joint) and all of the muscles below the knee. Knowing this, what can injure the nerve and cause major functional deficits?

Answer 20

An improperly placed gluteal injection or a posterior dislocation of the hip joint.

Question 21

An intramuscular injection in the gluteal region can only be made safely in the……………. quadrant.

Answer 21

superior lateral

Question 22

The sciatic nerve is really two nerves, the tibial nerve and common fibular nerve, bound together by connective tissue epineurium. In about 12-15% of the population the two nerves emerge separately from the greater sciatic foramen with the common fibular division passing through the piriformis muscle or superior to it. The muscle may compress the nerve to produce pain in the…………………… (piriformis syndrome). Individuals in whom the common. fibular nerve pierces the piriformis muscle or passes above it are predisposed.

Answer 22

buttock and posterior thigh

Question 23

What can cause piriformis syndrome?

Answer 23

• Hypertrophy of the piriformis muscle, which is more likely in some sports (ex: skiers, tennis players).
• Blunt trauma followed by fibrosis may have the same result.
• Half of the cases of piriformis syndrome are idiopathic.

Question 24

what nerve may be a source of continuing perineal pain during childbirth, even when an anesthetic agent is injected to block the pudendal and ilioinguinal nerves?

Answer 24

perineal branch of the posterior femoral cutaneous nerve

Question 25

The inferior gluteal artery often anastomoses with what to form the cruciate anastomosis?

* When it is present, the cruciate anastomosis allows safe ligation of the femoral artery.

Answer 25

the medial and lateral femoral circumflex arteries and the first perforating artery (from the profunda femoris)

Question 26

The hamstrings contract………………… at the end of forceful flexion of the thigh (ex: when punting a football) to decelerate the extremity. They are especially susceptible to injury during these contractions when they are stretched over both the hip and knee joints.

Answer 26

eccentrically

Question 27

The common fibular nerve passes around……………………, where the nerve is vulnerable to injury.

Answer 27

the neck of the fibula

Question 28

If the femoral vein becomes occluded or needs to be ligated, is there an alternative route of venous return?

Answer 28

Yes, thanks to some of the tributaries of the internal and external iliac veins communicating.

Question 29

As with other superficial veins of the upper and lower extremities, perforating veins carry blood from the……………… vein through deep fascia to………….. veins. This enables muscle contractions to help push the blood toward the heart against the pull of gravity (musculovenous pump).

Answer 29

small saphenous

deep

Question 30

The popliteal artery lies against the distal femur where it may be injured by a fracture if the…………… muscle rotates the distal fragment of bone posteriorly.

Since the artery crosses the capsule of the knee joint posteriorly, dislocation of the knee joint also may damage the artery.

Answer 30

gastrocnemius

Question 31

What is more frequently seen in equestrians, and may result in fatal hemorrhage?

Answer 31

Rupture of a popliteal aneurysm

Question 32

Traumatic injury of the popliteal artery and the closely related popliteal vein may result in an………………………. This can lead to loss of the leg and foot, or more serious consequences, if not promptly recognized and treated

Answer 32

arteriovenous fistula

Question 33

What may provide a collateral route for blood to return to the heart if either the superior vena cava or the inferior vena cava is blocked?

Answer 33

The superficial epigastric vein may anastomose with the lateral thoracic vein to form a thoracoepigastric vein

Question 34

The terminal portion of the great saphenous vein may become dilated (Known as what?) and be confused with other groin swellings (ex: a femoral hernia or psoas abscess).

Answer 34

saphenous varix

Question 35

If the valves in perforating veins or in the great saphenous vein itself become incompetent, blood pools in the great saphenous vein and it becomes tortuous and dilated (varicose veins). Why is the presence of valves significant when transplanting the great saphenous vein for coronary artery bypass surgery?

Answer 35

a segment of the great saphenous vein that is transplanted in coronary artery bypass surgery must be reversed to allow blood to flow past the site of coronary artery obstruction!

Question 36

What does it indicate if there is unexplained enlargement in superficial inguinal lymph nodes (lymphadenopathy)?

Answer 36

Its an indication that we need to examine the entire field of drainage for possible cancer or infection.

Question 37

What is a point to keep in mind for men when it comes to lymphadenopathy of the inguinal lymph nodes?

What about in Women?

Answer 37

Men: scrotal cancer in males, but not testicular cancer, characteristically metastasizes to the superficial inguinal nodes

Women: uterine cancer in females occasionally metastasizes along the round ligament of the uterus to the labium majus to reach the superficial inguinal nodes?

Question 38

What prevents spread into the thigh of extravasated urine from a ruptured penile urethra or other fluids from the lower abdominal wall?

Answer 38

The membranous layer of superficial abdominal fascia (Scarpa’s fascia) fusing with the fascia lata just below the inguinal ligament.

FYI: The fascia of Scarpa is the deep membranous layer of the superficial fascia of the abdomen. It is a layer of the anterior abdominal wall. It is found deep to the Fascia of Camper and superficial to the external oblique muscle.

Question 39

What 2 muscles attach to the IT band?

Answer 39

Gluteus maximus and tensor fasciae latae

Question 40

Where will you feel pain if you have IT band syndrome?

Answer 40

pain at the hip or at the knee (due to inflammation from friction)

Question 41

A pyogenic retroperitoneal infection of the posterior abdominal cavity may result in a psoas abscess that spreads between the muscle and its fascia (psoas fascia). The abscess passes deep to the inguinal ligament and into the proximal thigh, where it may be mistaken for what?

Answer 41

femoral hernia, saphenous varix, or enlarged superficial inguinal lymph nodes.

Question 42

​Due to the iliopsoas muscle’s close relationships to the kidneys and ureters, pancreas, cecum and appendix within the abdomen, inflammation of any of these structures may cause pain when the patient does what?

Answer 42

extends the affected thigh against resistance (positive iliopsoas maneuver or psoas sign)

Question 43

Following paralysis of the iliopsoas, what may hypertrophy to help compensate for weakened hip flexion?

Answer 43

The tensor fasciae latae

Question 44

What can the rectus femoris avulse in immature athletes?

Answer 44

AIIS

Question 45

What nerve is responsible for referred pain from the hip to the knee, due to it innervating both of them?

Answer 45

The femoral nerve

Question 46

Both femoral circumflex arteries supply muscles, but the medial femoral circumflex is also the major blood supply to the head of the adult femur via what branches?

Answer 46

retinacular branches

Question 47

A femoral pulse is easily taken in a supine patient. Where exactly do you take the pulse?

Answer 47

just inferior to the inguinal ligament, midway between the ASIS and pubic tubercle.

Question 48

Femoral or popliteal laceration may cause rapid exsanguination. If both the femoral artery and vein are lacerated, what may form?

Answer 48

an arteriovenous shunt

Question 49

The femoral artery is readily accessible for………………………, for arterial blood sampling, and continuous blood pressure monitoring

Answer 49

cannulation for cardiac angiography

Question 50

What vein may be cannulated to access the right side of the heart or to administer intravenous fluids?

Answer 50

The femoral vein

Question 51

What is important to remember when performing femoral venipuncture?

Answer 51

If poor technique is used, the hip joint may be seeded with infection that may destroy the joint! (septic arthritis)

Question 52

Deep venous thrombosis is the most common source of pulmonary thromboemboli. Where is a common cause of deep venous thrombosis?

Answer 52

The femoral vein

(Remember, some clinicians unfortunately use the term “superficial femoral vein” to refer to the femoral vein. That makes it easy to forget that the femoral vein is a deep vein)

Question 53

In a femoral hernia, which is more common in females, a loop of intestine or other viscera protrudes through the femoral ring from the abdominal cavity. The hernia is covered by peritoneum and extraperitoneal connective tissue and may escape through the saphenous opening into superficial fascia of the thigh.

How are femoral hernias distinguished from inguinal hernias?

Answer 53

by the femoral hernia protrusion being inferior and lateral to the pubic tubercle rather than superior to it.

Question 54

Femoral hernias are in danger of incarceration and of strangulation by what two structures?

Answer 54

• the lacunar ligament at the femoral ring
• the sharp falciform margin at the saphenous opening.

Question 55

Because the suprapatellar bursa is continuous with the joint cavity, infection in either space easily spreads to the other.

The suprapatellar bursa also can accommodate a large amount of joint effusion during synovitis of the knee joint. Why is this important?

Answer 55

It may mask the swelling characteristic of inflammation unless the bursa is “milked” downward toward the joint cavity

Question 56

The deep fibers of the………….. collateral ligament firmly attach to the medial meniscus. Therefore, injury to this collateral ligament typically is accompanied by injury to the medial meniscus.

Answer 56

tibial

Question 57

What three things are often injured together as part of the unhappy triad of athletic knee injuries?

Answer 57

The anterior cruciate ligament is often injured together with the tibial collateral ligament and medial meniscus

(Note: some authors have attempted to change the definition of the unhappy triad to substitute the lateral meniscus for the medial meniscus, but the original definition will be used for testing purposes)

Question 58

The most common injuries to the knee joint are ligament sprains. A blow to the lateral side of the knee (ex: a tackle in football) produces a …………..stress, often tearing the tibial (Medial) collateral ligament.

Answer 58

valgus

Question 59

A blow to the medial side of the knee produces a less common………… stress that stretches and may tear the fibular collateral ligament. Since the ligament has no attachment to the lateral meniscus, the meniscus typically is not torn with it.

Answer 59

Varus

Question 60

The……….. nerve may be injured during a severe varus stress (medial blow to knee) and should be examined along with the fibular collateral ligament.

Answer 60

common fibular

Question 61

The ACL may be sprained by different mechanisms, but they often involve a rapid change of direction (rotation of the femur on the tibia) with the foot firmly planted and/or a blow to the knee. Acute extravasation of blood into the joint cavity, known as…………….., is common.

Answer 61

hemarthrosis

Question 62

Anterior drawer sign (when the flexed tibia can be pulled forward on the fixed femur) indicates what is torn?

Answer 62

ACL

Question 63

Posterior drawer sign Indicates a tear in what?

Answer 63

PCL

* Interesting note: The posterior cruciate may be injured when the upper tibia of an unrestrained front seat passenger strikes the dashboard of an auto during a collision.

Question 64

Meniscal tears usually involve the medial meniscus rather than the more mobile lateral meniscus. Symptoms include joint line pain, popping, catching, and…………

Answer 64

locking

Question 65

Can a meniscus heal?

Answer 65

Only the peripheral third of the adult meniscus has a vascular supply and, therefore, a capacity for healing.

* Note that efforts are made to spare (or transplant) a meniscus if possible because the concentrated weight on the femoral and tibial articular surfaces following meniscectomy predisposes to the early development of osteoarthritis.

Question 66

Injuries of the extensor mechanism of the knee include rupture of the quadriceps tendon, rupture of the patellar ligament, patellar fracture, and patellar dislocation. Rupture of the quadriceps tendon typically occurs over the age of 40 following a preexisting condition that weakens the tendon, such as tendinitis. How can you tell if there is a ruptured quadriceps?

Answer 66

inability to extend the knee, with a gap developing in the suprapatellar region during the attempt.

Question 67

Rupture of the patellar ligament (patellar tendon) usually occurs in individuals younger that 40. Active knee extension is lost and the patella rides high (known as………….) because it has lost its anchor to the tibial tuberosity.

Answer 67

patella alta

Question 68

What type of fracture of the patella often results from forceful contraction of the quadriceps femoris muscle against resistance?

Answer 68

Transverse fractures

* Fracture is typically near middle of the patella, and the proximal fragment is displaced upward by the pull of the quadriceps.

Question 69

What type of fractures of the patella result from direct trauma, with the fragments often remaining nondisplaced?

Answer 69

Comminuted fractures

Question 70

Fractures of the patella must be differentiated from normal variations in patellar structure, resulting from lack of fusion of secondary ossification centers, known as…………..

Answer 70

bipartite patella

Question 71

Patellar dislocation is almost always………………and occurs more frequently in females due to the larger Q angle.

Answer 71

lateral

* Other factors that predispose to lateral subluxation include a shorter anterior projection of the lateral femoral condyle and a weak vastus medialis obliquus.

Question 72

Self-reduction of the dislocated patella usually occurs, but the patient shows a……………….. sign if the examiner pushes the patella laterally with the knee of the supported extremity flexed to 30° or so.

Answer 72

positive patellar apprehension

Question 73

………….. infrapatellar bursitis may be confused with Osgood-Schlatter disease.

Answer 73

Superficial

Question 74

Anserine bursitis involving the pes anserinus bursa may be confused with what injury?

Answer 74

a tibial collateral ligament injury.

Question 75

On the posterior aspect of the knee, the……………..bursa between the medial head of the gastrocnemius and the semimembranosus tendon may become inflamed to form a Baker’s (popliteal) cyst.

Answer 75

semimembranosus

Question 76

What is frequently used for vascularized bone grafts?

Answer 76

The middle of the shaft of the fibula

Question 77

What location on the tibia is subcutaneous through most of its length, and is therefore vulnerable to traumatic injury?

Answer 77

The anterior border and the adjacent medial surface

* A fracture involving the subcutaneous portion of the tibia is likely to be a compound fracture (aka a fracture that tears the skin) with the associated danger of bone infection (osteomyelitis).

Question 78

The tibial tuberosity is located at the upper end of the anterior border, where it provides attachment for the patellar ligament. The tuberosity may be enlarged as a result of what disease occuring during adolescence?

Answer 78

Osgood-Schlatter disease

Question 79

Where is the tibial shaft thinnest, which makes it the most frequent site of fracture?

Answer 79

at the junction of the middle and distal thirds

Question 80

What is the most frequently sprained ligament at the ankle joint? When does this usually occur?

Answer 80

The anterior talofibular ligament

* This usually occurs when the plantarflexed foot is forced into inversion.

Question 81

The great saphenous arises from the medial end of the dorsal venous arch of the foot and ascends………………. to the medial malleolus. It is accompanied in the leg by the saphenous nerve, which is a branch of the femoral nerve descending from the adductor canal.

Why is this important clinically?

Answer 81

Anterior

The great saphenous vein can be accessed rapidly for intravenous access in an emergency by a skin incision anterior to the medial malleolus (saphenous cutdown). During this procedure the saphenous nerve may be injured to produce pain or numbness along the medial side of the foot.

Question 82

What is the most commonly injured nerve in the lower extremity, due to its position winiding around the neck of the fibula?

Answer 82

The common fibular nerve

* at risk in direct trauma or a fracture of the fibula, or via severe stretching during dislocation of the knee.

Question 83

A lesion of the common fibular nerve results in what condition, and what compensatory behavior?

Answer 83

Footdrop and steppage gait

* A lesion of the common fibular nerve or its deep fibular branch results in footdrop with inability to dorsiflex the foot. In order to prevent the toes from dragging on the ground during the swing phase of gait, the patient compensates by swinging the limb out laterally or flexing his hip and knee joints to raise the foot high off the ground (steppage gait).

Question 84

If the foot is forcefully inverted while the fibularis brevis is contracting, the muscle may avulse the tuberosity of which metatarsal?

Answer 84

fifth metatarsal

Question 85

Damage to what structures greatly weakens plantar flexion, making it impossible to stand on the toes and making ambulation difficult?

Answer 85

Paralysis of the triceps surae or rupture of the calcaneal tendon (third degree strain)

Note: The tendon is prone to rupture after a history of chronic tendinitis or use of fluoroquinolone antibiotics.

Question 86

The patient with a paralyzed gastrocsoleus develops a triceps surae gait, in which the pelvis drops on which side during the weight bearing/stance phase of walking?

Answer 86

the affected side! (opposite to gluteus medius gait)

Question 87

What muscle contributes little force during plantar flexion and is sometimes transplanted in reconstructive surgery of the forearm and hand?

Answer 87

The plantaris

Question 88

The pulse of what artery can be felt at the tarsal tunnel, in order to help assess the peripheral circulation?

Answer 88

Posterior tibial artery

Note: To do this the patient is asked to invert the foot to relax the flexor retinaculum.

Question 89

A space-occupying lesion (ex: edema due to inflammation or pregnancy) compresses the tibial nerve, leading to tarsal tunnel syndrome. This results in pain and paresthesia over which area?

Answer 89

the medial heel and the sole of the foot

Question 90

The perforating branch of the fibular artery may give rise to the dorsalis pedis artery if the anterior tibial artery is small and ends at the ankle. What is important to keep in mind in this instance?

Answer 90

a dorsalis pedis pulse is not palpable.

Question 91

ankle sprains are more likely to occur in what position?

Answer 91

The plantar flexed postion

* The anterior part of the trochlea is wider than the posterior part so that the ankle joint is more stable when the foot is rotated upward toward the leg (dorsiflexion) than downward toward the floor (plantar flexion).

Question 92

The neck of the talus may be fractured in a severe ……………..flexion injury (ex: during an automobile collision when the driver has his foot pressed firmly against the brake pedal at the moment of impact).

Answer 92

dorsiflexion

* A fracture of the talar neck is significant because the main blood supply enters the body of the talus from anteriorly, through the neck, and a fracture that interrupts it may result in avascular necrosis of the body of the talus

Question 93

If the……………… is too large, it may press against a shoe to produce foot pain.

Answer 93

navicular tuberosity

Question 94

The tuberosity of the fifth metatarsal may be avulsed by the fibularis brevis during what movement of the foot?

Answer 94

forced inversion

Question 95

If an arch isn’t present in the foot of an adolescent or adult, the patient is said to have flatfeet (pes planus). Flatfeet can be either flexible or rigid. What is interesting to note about flexible flat feet?

Answer 95

Flexible flatfeet appear flat when weight-bearing but have an arch when not weight-bearing

Question 96

Rigid flatfeet are flat even when the patient is non-weight-bearing and are symptomaticm. They are usually painful and may be associated with spasm and contracture of the fibularis muscles. The congenital form usually results from bone deformities, including the fusion of adjacent tarsal bones (tarsal coalition). This typically involves which bones?

Answer 96

Fusion of the calcaneus with either the talus or navicular.

Question 97

Acquired flatfeet may result from failure (stretching) of the plantar ligaments and dysfunction of what tendon?

Answer 97

tibialis posterior tendon

(ex: can occur from prolonged unaccustomed standing in an older person who has gained a lot of weight)

Question 98

Aquired flat feet can also occur if the………………… ligament fails. The head of the talus loses its support and slips inferomedially with flattening of the medial longitudinal arch.

Answer 98

plantar calcaneonavicular (aka spring ligament)

Question 99

Why is edema more prominent on the dorsum of the foot?

Answer 99

The superficial fascia there is loose!

Question 100

The dorsalis pedis artery descends just…………… to the extensor hallucis longus tendon, where it is palpated as part of a physical exam in individuals suspected of having peripheral vascular disease.

Answer 100

lateral

Question 101

Occasionally a dorsalis pedis pulse is congenitally absent due to the artery’s replacement by an enlarged perforating branch of which artery?

Answer 101

The fibular artery

Question 102

Plantar fasciitis causes pain when walking when first arising in the morning and after a period of non-weight bearing results in heel pain. Point tenderness may be present near the aponeurosis’ attachment to the medial tubercle of the calcaneus. What is of concern with plantar fasciitis?

Answer 102

The chronic inflammation may result in formation of a bone spur at the medial tubercle.

Question 103

Compartments of the great toe and small toe are important in directing the spread of infection within the plantar portion of the foot, meaning an infection usually spreads where?

Answer 103

usually spreads along deep fascia rather than eroding through it into adjacent compartments.

Question 104

An abundant arterial anastomoses means that wounds that sever the ………….arterial arch or its larger branches result in severe bleeding. Ligature of the arch is difficult because of its deep position and surrounding structures.

Answer 104

plantar

* The plantar arterial arch gives off four plantar metatarsal arteries, each of which divides into two plantar digital arteries to supply the adjacent sides of toes.Perforating branches connect the plantar metatarsal arteries with the dorsal metatarsal arteries.

Question 105

What test is determining cervical radicular pain?

Answer 105

Spurlings Test

Question 106

What tests for lateral epicondylitis?

Answer 106

Cozens test