Clinical correlations of lower limb Flashcards
meralgia paresthetica
deformation of the lateral femoral cutaneous nerv within the abdomen (tumor pregnancy)
or as it passes deep to the inguinal ligament near its attachment to the ASIS (fluid overload, overly tightened belt)
feels like hot and cold, pins and needles, or numb
type of cutaneous irritation
friction bursitis ischial
on the ishcial tuberosity the bursa sitting here between ishial tuberosity and gluteus maximus
movement of the gluteus maximus across inflamed bursa causes pain
bursa may become calcific
with prolonged bed rest can lead to pressure sores and ulceration
friction bursitis trochanteric
inflammation of bursa between greater trochanter and gluteus maximus
repetitive motion of gluteus maximus across bursa during climbing and inclined walking
every time you go long periods of time in extension (standing) or lots of flexion and extension can irritate this
medial plantar nerve compression
this is deep to the flexor retinaculum
compare to carpal tunnel syndrome
due to excessive running and eversion of foot
alot of pressure on the deltoid limit (which prevents excessive eversion)
results in paresthesias on the medial side of the sole of the foot with weakness of the intrinsic muscles of the great toe
(abductor hallucis, flexor hallucis brevis, flexor dig brevis, 1st lumbrical)
problem with friction bursitis
can cause the bursa to rupture and the ligament that is crossing it to rupture
from repetitive motion or bed rest
plantar fasciitis
inflammation of the plantar aponeurosis caused by overuse
(running, high impact activities, improper footwear)
pain elicited by direct pressure at the point of attachment to the calcaneus or by DORSIFLEXING the foot or extending the great toe
if this goes on long enough there can develop a calcaneal bone spur in the direction of the plantar aponeurosis
get tight in the foot
Femoral hernia
protrusion of a viscus (portion of the gut) through the femoral ring into the femoral canal
occurs more often in females b/c of wider hips
forms a protrusion in the femoral triangle inferolateral to the pubic tubercle
may protrude through the saphenous opening and impede venous return of the greater saphenous v.
compartmental syndromes of the leg
infection
inflammation
arterial hemorrhage within a fascial compartment of the leg can produce pressure increases within the compartment high enough to cause:
-reduced blood supply to muscles within or distal to the compartment
pressure can accumulate from blood and may impinge nerves to the point that paresthesias occur or paralysis occurs to the muscles located within the compartment
what do severe compartment syndromes require?
fasciotomy to relieve these compressive forces prior to the occurence of tissue necrosis
cut the intermuscular septum ?
why do muscular strains and ruptures occur
occur as a result of large muscles which must exert force very quickly to overcome large amounts of inertia
groin strains
usually occur in fast repetitive flexion
adductor group pulls
hamstring strains
get hurt in the “push off” phase
runners grab their butts
ruptured achilles tendon
week-end warrior injury due to increase age and irregular bouts of exercise
tennis or basketball
where rapid push-offs with the feet are required
psoas abscess
due to retroperitoneal abdominal or pelvic infection that descends within the psoas fascial sheat from the kidney?
FEMORAL NERVE
parasthesias all the way down to the foot and anterior part of leg
descends deep to inguinal ligament, resutling in pain and swelling within the femoral triangle
can be mistaken for femoral hernia, indirect inguinal hernia, inflammation of inguinal lymph nodes, saphenous varix
can be from inflammation of the kidney which inflames the psoas
so alot of pain near femoral triangle may need to check kidney function
shin splints!
tibialis anterior strain
micro tears in the periosteal attachment of the distal 2/3 of the tibialis anterior to the tibia resulting in pain
swelling and inflammation within the muscle decreased vascular exchange and leads to pain
usually results from overuse or infrequent bouts of exercise not preceded by stretching or warming up
running on hard surfaces after having trained on softer surfaces
calcaneal tendinitis
micro tears in the attachment of the calcaneal tendon to the calcaneal tuberosity as a result of over use, poor footwear, poor training surfaces, or infrequency of activity
avulsion fractures?
occur as a result of fragments being pulled away from bones by rapidly loaded tendons and ligaments
where are common sites of avulsion fractures?
pelvis ischial tuberosity (hamstrings) ASIS, AIIS ishiopubic rami tibilal tuberosity (osgood schlatter) ankle (lateral and medial malleoli) medial malleoli--> b/c of eversion of the foot the deltoid ligament gets stretched causing avulsion of the medial malleolar foot 5th metatarsal- fibularis brevis attaches there
osgood schlatter disease
tibial tuberosity is avulsed
continued traction on the tibial tuberosity
femur fracture (neck)
occur most often as a result of increased compressive forces (stepping from the curb or step) on a limb already weakened by osteoporosis
result in shortened limb and require internal fixation
fracture just distal to the junction of the femoral head with the feomral neck or fracture along the intertrochanteric line
greater trochanter and shaft fracture of femur
usually as a result of trauma due to falls or MVA
distal femoral fracture
fracture of femoral condyles or between condyles
Salter-Harris classification
both result in aberration of the articular surfaces of the knee joint
may disrupt blood supply to knee or leg
patella fracture
transverse patellar fracture
- avulsion type due to sudden forceful contraction of the quadriceps
- direct blow (car bumper or dashboard)
bipartite and tripartite patella (THIS IS NOT TRAUMA)
-but rather non union of ossification centers resulting in a patella that has two or three components
often misinterpreted as fractures
tibia fracture
most often fracture near junction of middle and distal third (narrowest and least vascularization)
if fractures occur through nutrient foramen can lead to non-union
tibia fracture types
transverse
diagonal
disruption of epiphyseal plate
***
fibula fracture
pg 340 buck book
calcaneus fracture
most often fractures as a result of hard falls directly on the heel
disrupts subtalar joint (active during eversion and inversion)
talus fracture
occurs during forced dorsiflexion
pg 341
Coxa vara (inward)
decrease in the CCD angle (less than 120 degrees)
moves the femur medially and makes it shorter
Q angle has increased
knock kneed (genu valgum-pushing ankle out) lateral knee is going to wear out first
coxa valga (outward)
increase in the CCD angle
moves the femur outward and makes the femur longer
Q angle has decreased
genu varum (pushing ankle in) (bow leg) medial knee is going to wear out first
what is the Q angle
angle between a line drawn from the center of the patella to the ASIS and a line drawn from the middle of the patella to the middle of the hip joint
normal male Q angle is 14 degree
normal female Q angle is 17 degrees
the female has a larger Q angle
slipped capital femoral epiphysis
trauma in the region of the proximal femoral epiphysis
usually occurs in adolescents prior to epiphyseal plate closure
distal fragment dislocates posteriorly leading to coxa vara
Avascular necrosis of the femoral head
disruption of the arteries that surround the femoral neck to provides branches to the femoral head can lead to femoral head necrosis
branches of the medial femoral circumflex artery are most often implicated
hip dislocation?
hip is most stable in standing
hip joint is loosest when the thigh is in flexion
so this can happen during a car accident easily
-hitting the knee and driving the femur posteriorly can dislocate the head of the femur from the acetabulum posteriorly (hitting the dashboard with the knee during a deceleration accident)
hip drop
paralysis of the gluteal medius and minimus (superior gluteal nerve)
action of these muscles usually maintain the sacral base (keeps the unsupported side from dropping
when paralyzed the unsupported hip drops during the swing phase of locomotion
L4,5- S1
menisci injuries?
(lateral and medial)
medial is more injured b/c of its attachment to the medial collateral ligament
most detrimental, putting full weight on these when you go into flexion
small tears can be trimmed and large tears in the peripherally where a good blood supply exists can be repaired
typical bucket handle tera in menisci
longitudinal tear through substance of meniscus
when the handle tears free it must be removed
test for meniscal injury?
if you put in lateral rotation and get pain (then have cartilage damage of lateral side)
if you put some medial rotation and get pain then you probably have medial meniscus injury
collateral ligament injury
Hit hard medial then the opposie side will open up and stretch the lateral collateral ligaments
and opposite is true
unhappy triad
anterior cruciate ligament
tibial collateral ligament
medial meniscus
tearing of these at the same time
cruciate ligament s injury
ACL and PCL
these normally control anterior and posterior movement of the femur on the tibial plateau when the foot is fixed
ACL more often injured
if you push the femur forward what gets tight? femur backward?
posterior cruciate ligament
backward–> anterior cruciate ligament
drawer tests do what?
asses cruciate ligament compromise
if the anterior c l is not intact then you can pull the tibia forward (in leg flexion)
if the posteiror c l is not intact you can actually push the tibia back and the patella/femur comes forward
patellar dislocation
the patella is more likely to dislocate laterally
more often dislocated in females due to greater Q angle
increased Q angle results in increased lateral pull on the patella via the rectus femoris and vatus lateralis muscles
patellofemoral syndrome?
pain caused by improper tracking of the patella relative to the patellar groove of the femur
can result in chrondromalacia of the patella:
results in quadriceps imbalance and improper patellar tracking
patella rides more on the lateral femoral condyle
the vastus medialis muscles should be worked ON!!! so that the patella is kept in track
what is chondromalacia of the patella
softening of the articular cartilage of the patella due to chronic over use (extensive running)
a direct blow to the patella
or repeated extreme flexion (deep squats)
baker’s cysts
result of chronic knee effusion
p. 343
os trigonum
bone accessory to talus
represents secondary ossification center which fails to unite with talus
occurs in 14-25 percent of adults
associated with sports where athletes utilizes excessive plantar flexion (soccer players, ballet dancers)
Inversion sprain
over elevation of the medial border of the foot usually due to stepping on uneven surfaces while weight bearing
results in injury to the lateral collateral ligament of the ankle
anterior talofibular ligament is most often a torn component
eversion sprain
over elevated of the lateral border of the foot
pg 344
Pott’s fracture
bimaleolar ankle fracture
forced eversion of the ankle
avulsion fracture of the medial malleolus (tibia) via the deltoid ligament
talus shifts resulting in fracture of the lateral malleolus (fibula)
results in total disruption of the mortise of the ankle joint
femoral artery compression?
decreased pulse in the femoral triangle
p. 344
popliteal artery
p. 345
posterior tibial artery
p. 345
dorsalis pedis artery
p. 345
should have equal pulses
palpated inferior to the extensor retinaculum lateral to the tendon of the extensor hallucis longus
NOTE– some people have a condition where the dorsalis pedis artery is congenitally absent
msculovenous pump
contraction of the muscles within a fascial limited space places pressure upon deep veins contained within the same muscular compartment and assists in venous return against gravity
venous valves prevent backflow during periods of alternating skeletal muscle contraction and relaxation
varicosities
weakened superficial veins which dilate under the pressure of the supported column of blood
venous valves are no longer competent because they no longer appose
degenerated deep fascia reduces or eliminates the musculovenous pump
saphenous vein grafts (greater saphenous v.)
p 346
saphenous cut downs (greater saphenous v. )
pg 346
saphenous varix
p. 346
infrequent dilatation of the terminal portion of the greater saphenous vein
causes a swelling in the femoral triangle
can be misdiagnosed as other femoral hernia, psoas abscess
what do you use for right cardiac angiography
femoral vein
DVT
clot formation as a result of prior trauma
vascular stagnation due to reduced physical activity for prolonged periods
weakened muscular fascia resuliting in musculovenous pump
lymphangitis and lymphandenopathy
pg 346
thromboembolism and thrombophlebitis
p. 346
what does a femoral nerve injury look like
Loss of Patellar Reflex: L4
loss of anterior femoral compartment musculature
loss of leg extension (of the knee) with reduced flexion of the thigh
no sensation along medial leg anteriorly and anterior thigh
lose the obturator nerve?
Compression results in decreased/weakness
in flexion,
adduction and rotation of the thigh
and paresthesias of the medial thigh
skin patch on the interior thigh
sciatic nerve piriformis syndrome
the tibial and common fibular components of the sciatic nerve are split by a portion of the piriformis
if a person exercise their butt (extending and abducting) a lot it may cause compression on this nerve (the fibular component)
this results in complete loss of eversion and dorsiflexion
-numbness on the lateral anterior portion of the leg and dorsum of the foot
what happens if you lose the sciatic nerve
lose the hamstrings and the gastrocnemius (knee flexors), everything going to the foot
Weakness of extension of the thigh,
major loss of flexion of the leg,
complete loss of inversion, eversion, plantar and dorsiflexion of the foot
Loss of Achille’s reflex (S1)
gluteal injections ? where do you put it
go more towards the crest of the ilium
what is the cause of hip drop
superior gluteal nerve damage
gluteus medius
inferior gluteal n damage
going up steps, getting off toilet, is hard
weakness of the gluteus maximus
p 348
Loss of gluteus maximus (note loss of gluteal contour)
Difficulty going up stairs, especially on affected limb during push-off; difficulty getting up from a sitting position
loss of tibial nerve
Loss of posterior superficial & deep compartments of the leg and ALL plantar foot muscles
Inability to plantarflex
reduced inversion of the foot;
decreased leg flexion;
loss of calf contour
Foot held in dorsiflexion and eversion***
Loss of the majority of cutaneous sensation to the sole of the foot
Loss of Achille’s reflex (S1)
common fibular nerve damage
Loss of lateral & anterior compartments of the leg
Loss of dorsiflexion and eversion of the foot
Foot held in plantar flexion and inversion
lose
superficial fibular nerve damage
Loss of musculature of the lateral compartment of the leg
Loss of eversion with reduced plantarflexion
Foot held dorsiflexed and inverted
deep fibular nerve
Loss of musculature of the anterior compartment of the leg
Loss of dorsiflexion and reduced inversion of the foot
Foot held plantar flexed with slight eversion
foot drop
loss of tibialis anterior L4
tibialis anterior has eccentric and concentric contraction so helps a person walk quietly
loss of extensor hallucis longus L5
