Clinical Correlations of the Lower Limb Flashcards
femoral hernia
protrusion of viscus through femoral ring into femoral canal
more common in females
protrusion in femoral triangle inferolateral to pubic tubercle
-may protrude through the saphenous opening and impede venous return of greater saphenous vein**
unique location to palpate a bump
compartment syndrome of leg
infection, inflammation, or arterial hemorrhage within a fascial compartment of leg can produce pressure increases within compartment high enough to:
reduce blood supply to muscles impinge nerves (paresthesias and paralysis)
severe cases require fasciotomy to relieve these compressive forces prior to occurence of tissue necrosis
groin strain
adductor group pulls up usually during fast hip flexion
hamstring strain
strains of semimembranosus, semitendinosus, biceps femoris usually near the ischial tuberosity as a result of fast extension (push off in running)
ruptured achilles tendon
weekend warrior
-increased age and irregular exercise (rapid push offs of feet are required)
psoas abscess
due to retroperitoneal abdominal or pelvic infection that descends within psoas fascial sheath
descends deep to ingunial ligament resulting in pain and swelling within femoral triangle
can be mistaken for:
-femoral hernia, indirect inguinal hernia, inflammation of inguinal lymph nodes, saphenous varix
**inflammation of kidney - close to psoas
tibialis anterior strain
aka shin splints
microtears in periosteal attachments of distal 2/3 of tibialis anterior to tibia (sharpeys fibers)
resulting in pain
also swelling and inflammation within muscle decreases vascular exchange and leads to pain
usually from overuse or infequent bouts of exercise not preceded by stretching or warming up
running on hard surfaces after having trained on softer surface
calcaneal tendonitis
microtears in attachment of calcaneal tendon to calcaneal tuberosity as result of overuse, poor footwear or train surfaces
avulsion fractures
fragment being pulled away from bones by rapidly loading tendons
pelvis, tibial tuberosity, ankle, foot
pelvic avulsion fractures?
ischial tuberosity
ASIS
AIIS
ischiopubic rami
tibial tuberosity avulsion fractures?
osgood shlatter**
ankle avulsion fracture
lateral and medial malleloli
foot avulsion fracture
5th foot metatarsal
osgood schlatter
tibial tubercle apophyseal traction injury
avulsion of patellar ligament from tibial tuberosity
malleolar avulsion fraction
occurs during eversion
avulsed by deltoid ligament
avulsion of 5th metatarsal
fibularis brevis attachments pulls bone off
fracture of femur neck
increased compressive forces on an osteoporotic leg
shortened limb and require internal fixation
greater trochanter and shaft femur fracture
direct trauma to falls or vehicular accidents
distal femoral fractures
fractures of femoral condyles or between condyles
**salter harris classification
both result in aberration of articular surfaces of knee joint
may disrupt blood supply to knee or leg
patella fracture
transverse
- avulsion type due to sudden forceful contraction of quadriceps
- direct blow
salter harris classification
3 and 4 - give you instability
-dividing lateral and medial compartments
all threat to growth of bone if with epiphysis
bipartite or tripartite patella?
growth centers that didn’t fuse correctly
often misinterpreted as fractures
most often fracture of tibia?
near junction of middle and distal third
-narrow and least vascularized
tibia fractures
subQ location - prone to compound fracture
fracture of tibia through nutrient foramen
can lead to non-union
fracture of medial malleolus?
excessive eversion
fibula fracture?
most common just proximal to lateral malleolus
often associated with fracture dislocations of ankle and distal tibial fractures
fracture of lateral malleolus due to contact with talus during excessive inversion
what is most likely for bone graft procedures
fibula (not weight bearing)
calcaneus fracture
most often fractures as a result of hard falls directly on heel
talus fractures
mot often fractures during forced dorsiflexion
normal male Q angle
14 degrees
normal female Q angle
17 degrees
CCD angle?
caput - collum - diaphyseal angle
normal 120 degrees
coxa vara
decreased CCD angle (less than 120)
slight decrease in length of affected limb
with increased Q angle, opens medial knee joint space resulting in genu valgum - increased likelihood of patellar dislocation
Q angle
angle between line drawn from center of patella to ASIS and line between middle patella and hip joint
coxa valga
increased CCD angle (greater 120)
slight increase in length of affected limb
with decreased Q angle opens lateral knee joint space resulting in genu varum
genu valgum
decreased CCD, increased Q angle
opens medial knee joint
increased occurence of patellar dislocation
genu varum
increased CCD, decreased Q angle
opens lateral knee joint
wide knees
coxa valga
wears out medial meniscus
knock kneed
coxa vara
wears out lateral meniscus
slipped capital femoral epiphysis
trauma in region of proximal femoral epiphysis
usually occurs in adolescent prior to epiphyseal plate closure
distal fragment dislocates posteriorly leading to coxa vara
avascular necrosis of femoral head
disruption of arteries that surround femoral neck to provide branches to femoral head can lead to femoral head necrosis
branches of medial femoral circumflex most often implicated
hip dislocation
capsule loosest when thigh in flexion
hitting dashboard with knee - posterior dislocation
hip drop
paralysis of gluteus medius and minimus (superior gluteal nerve L4,5 - S1)
these muscles keen hip on unsupported side from dropping
paralysis causes hip drop during swing phase
menisci tear?
knee in full flexion can cause tears
what menisci more often torn?
medial meniscus
less mobile due to attachment to medial collateral
opening medial angle of joint stretches the ligament and tears cartilage
bucket handle tear
longitudinal tear through substance of meniscus
when handle tears free it must be removed
opening medial angle of knee?
stretch medial collateral
opening lateral angle of know?
stretch lateral collateral
injury of medial collateral?
associated with tear or medial meniscus and tearing of ACL
cruciate ligaments
control anterior and posterior movement of femur on tibial plateau when foot fixed
unholy triad
tearing of ACL, MCL, and medial meniscus simultaneously
patellar dislocation?
more likely laterally
more often in females (larger Q angle)
drawers test
assess cruciate ligament compromise
anterior drawer sign
ACL tear
tibia moves anterior
posteiror drawer sign
PCL tear
tibia moves posterior
reduction of torn ACL?
patellar tendon graft
patellofemoral syndrome
chondromalacia patella
softening of cartilage due to imbalance of quads
so the tracking is off
patella rides more on lateral femoral condyle
bakers cyst
chronic knee joint effusion (fluid accumulation)
continuity of fluid in joint space with bursae surrounding knee
occurs most often posteriorly
may impede flexion, put pressure on structures of popliteal fossa and result in pain
os trigonum
bone accessory of talus
represents secondary ossification center that doesn’t fuse
occurs in 14-25 % of adults
associated with sports where athletes use excessive plantarflexion
sprain
Ligaments
strain
Muscles
inversion sprain
over elevation of medial border of foot
injures lateral collateral ligament
torn - anterior talofibular ligament
eversion sprain
over elevation of lateral border of foot
injury to medial collateral ligament
occurs less often
pott’s fracture
bimaleolar of ankle
due to forced eversion
talus shifts resulting in fracture of lateral malleolus (fibula)
results in total disruption of mortise of ankle joint
femoral pulse
patient supine
palpate midway ASIS and pubic tubercle
femoral artery compression?
can be compressed against structures which compose floor of femoral triangle as well as pelvic brim (superior pubic ramus)
cannulation of femoral artery?
for purposes of left cardiac angiography takes place just inferior to inguinal ligament
popliteal pulse?
pulse can be palpated where??
diminished popliteal pulse??
Femoral artery obstruction
posterior tibial artery pulse??
Posteriorly between calcaneus tendon and medial malleolus. Deep to flexor retinaculum
diminished pulse of posterior tibial?
Popliteal artery obstruction
intermittent claudication
cramping leg pain during exercise
sign of muscular ischemia due to narrow tibial arteries
dorsalis pedis pulse?
Inferior to extensor retinaculum lateral to tendon of extensor Hallucis longus
diminished dorsalis pedis pulse?
Anterior tibial artery obstruction
absent dorsalis pedis?
Dorsum of foot provided by perforating branch of fibular artery
when checking pulse?
check BOTH SIDES
musculovenous pump
contraction of muscles within fascial space - pressure on deep veins that assists in venous return against gravity
varicosities
superficial veins weak and dilate under presure
valves no longer competent
degenerated deep fascia reduces or eliminates the musculovenous pump
saphenous vein grafts
greater saphenous vein
use in coronart artery bypass surgery
good candidate due to increased muscular and elastic fibers of wall
removeal forces drainage to deeper veins (not bad)
vein installed as bypass with valves reversed so they don’t impede flow
saphenous cut down
greater saphenous vein
large vein, easy to locate at medial malleolus where it lies very superficial
access port for cannulation for delivery of fluid drugs etc
care should be taken not to cut, ligate
saphenous varix
infrequent dilation of terminal portion of greater saphenous vein
causes swelling of femoral triangle
can be misdiagnosed as other entity:
femoral hernia, psoas abscess
DVT
deep vein thrombosis
clot formation
thrombophlebitis
clot within a vein leading to inflammation at site of clot
thromboembolism
clot which has broken free from lower limb vein and traverses to heart - gets lodged in lung (pulmonary arterial branch)
lymphangitis
inflammation of lymph vessels - red streaks
lymphadenopathy
enlarged lymph nodes due to inflammation
resnde in popliteal fossa and femoral triangle
drainage of lymph?
Superficial inguinal nodes- subQ connective tissue superficial to femoral triangle, receive drainage from superficial thigh, abdomen inferior to the navel, round ligament of the uterus and from perineum
Deep inguinal nodes- located within the femoral triangle receive drainage from the superficial inguinal nodes and from deep structures of foot leg and thigh
femoral nerve damage
all knee extension
reduced flexion of thigh
lose patellar reflex L4
lose anterior femoral compartment muscles
patellar reflex?
L4
achilles reflex?
S1
plantar reflex?
babinski - fanning
normal children less than 2
abnormal in adults
anesthesia of femoral nerve?
anterior thigh, medial leg and foot
L4 dermatome
obturator nerve damage?
strong flexors, adductors, and rotators
- loss causes weakness in flexion
- all adduction gone
skin patch on the medial side of thigh
obturator nerve?
L 2,3,4
femoral nerve?
L 2,3,4
sciatic neve
L 45 S 123
from greater sciatic foramen
piriformis syndrome
tibial and common fibular components of sciatic nerve split by portion of piriformis
hypertrophy of piriformis may cause compression of common fibular component
- lose eversion and dorsiflexion
- paresthesia on lateral anterior portion of leg and dorsum of foot
loss of sciatic nerve?
loss of achilles reflex S1
weakness of extension fo thigh
loss of flexion of leg
complete loss of inversion, eversion, plantar and dorsiflexion of foot
anesthesia posteiror thigh and lateral leg and posterior foot
gluteal injection
palpate ASIS with index finger
spreading fingers and palpate tubercle of crest of ilium with middle finger
injection made between index and middle finger
superior gluteal nerve loss?
L45 S1
hip drop!
inferior gluteal nerve loss?
L5 S12
weak gluteus maximus with decreased hip extension
especially visible when affected individual tries to negotiate going up stairs
tibial nerve loss?
L45 S123
within poplitela fossa
result in complete loss of plantarflexion, flexion, adduction, abduction of toes and anesthesia to large portion of sole of foot
common fibular nerve loss?
L45 S12
direct trauma when courses around neck of fibula and results in complete loss of eversion and dorsiflexion and numbness of lateral anterior portion of leg and dorsum of foot
superficial fibular nerve
L5 S12
direct trauma to lateral crural region can lead to damage of superficial fibular nerve
resulting in major loss of eversion, moderate loss of plantar flexion, and weakness of support for arches of foot (fibularis longus) and anesthesia on lateral anteiror portion of leg and dorsum of foot
deep fibular nerve
L45
foot drop
trauma to deep fibular nerve may occur as result of piercing trauma and compartment syndrome of anterior crural compartment would reult in complete loss of dorsiflexion and extension of toes and anesthesia between 1st and 2nd toes
above losses would result in dropping of foot as a result of tibialis anterior and dragging of great toe due to loss of extensor hallucis longus
slap the floor
tibialis anterior nerve level?
L4
extensor hallucis longus nerve level?
L5
