Clinical Correlations of the lower limb Flashcards
1
Q
Avulsion Fractures of the Os Coxae
A
- Commonly occur during sports that require sudden deceleration or acceleration.
- Areas commonly affected:
ASIS
Ischial spine
Ischial tuberosity
2
Q
hip pointer
A
a contusion of the iliac crest; usually near the ASIS.
3
Q
Femoral fractures
A
- The Femoral neck is the most commonly fractured site because it is the weakest portion of the bone and often in postmenopausal women
4
Q
aseptic vascular necrosis of the femoral head
A
- Death of the femoral heal caused by a loss of blood supply.
- Common with femoral neck fx’s.
- The majority of blood to the head arises from the medial circumflex humeral artery which wraps around the femoral neck.
5
Q
Intertrochanteric femoral neck fractures
A
occur along line of the trochanters
6
Q
Fractures of the distal femur complication
A
- Hemorrhage
- due to the location of these types of fractures to the popliteal artery - instability of the knee
- due to misalignment of the articular surfaces.
7
Q
Tibial Fractures
A
- Most common site for tibial fractures is at the junction of the middle and distal thirds of bone (the weakest portion of the bone).
- These fractures are often compound due to the subcutaneous nature of the shaft of the femur.
8
Q
Diagonal fractures of the tibia
A
- Common in skiing injuries;
2. Can result in overriding of the fractured ends of the bone and shortening of limb.
9
Q
Stress fractures of the tibia
A
- Located commonly at the anterior portion of the tibial shaft
- Common in individuals who run or hike without adequate training
10
Q
Fibular Fractures
A
- Most common site for fibular fractures is at or near the lateral malleolus
- Often occur with hyperinversion or hypereverion injuries at ankle.
11
Q
Calcaneal Fractures
A
- Rare, but can occur with severe falls onto the calcaneus.
- Usually comminuted
- Disabling due to importance of the calcaneus in weight-bearing and in forming the subtalar joint.
12
Q
Talus Fractures
A
- With severe dorsiflexion of the foot, the talar neck can be fractured.
- The body in some of these instances can dislocate posteriorly.
13
Q
Os trigonum
A
An extra bone caused by failure of the talus to fuse during secondary ossification.
14
Q
Metatarsal Fractures
A
- These can occur when a heavy weight is dropped on the foot
- Dancer’s fracture is common in ballet dancers when the weight of the body is forced directly through the metatarsal.
- Tuberosity of the 5th metatarsal is also a common site for avulsion fractures.
15
Q
Patellar fractures
A
- Common with severe blows to the anterior knee
- Complete transverse fractures result in the superior portion of the bone being pulled superiorly with the quadriceps tendon.
16
Q
bipartite or tripartite patella.
A
Failure of the patella to completely fuse during ossification.
Usually bilateral
17
Q
Dislocations of the patella
A
- Almost always lateral due to the lateral pull of the quadriceps tendon.
- More common in females due to the increased q-angle.
18
Q
Patellofemoral syndrome
A
- Condition of pain, resulting from improper tracking of the patella on the femur
- Common in runners; referred to as runner’s knee
19
Q
chondromalacia patellae
A
- Inflammation on the deep surface of the patella, resulting in softening and degeneration of the cartilage.
- Treatment can include strengthening VMO portion of vastus medialis.
20
Q
slipped capital femoral epiphysis
A
Dislocation of the femoral epiphysis that occur in children and adolescents.
Can result in avascular necrosis of the femoral head.
21
Q
Osgood-Schlatter disease
A
- Condition of disruption of the epiphyseal plate at the tibial tuberosity.
- Results in inflammation at the tibial tuberosity
- Is a common cause of knee pain in adolescents, especially those involved in sports.
22
Q
Salter Harris Type 1 Classification
A
A complete physeal fx with or without displacement
23
Q
Salter Harris Type 2 Classification
A
A physeal fx that extends through the metaphysis producing a chip fracture of the metaphysis that may be very small
24
Q
Salter Harris Type 3 Classification
A
A physeal fx that extends through the epiphysis
25
Salter Harris Type 4 Classification
A physeal fx plus metaphysis and epiphyseal fx's
26
Salter Harris Type 5 Classification
A compression fx of the growth plate
27
Congenital hip dislocation
1. More common in females
2. Inability to abduct the hip
3. Affected leg will appear shorter and positive Trendelenburg sign may be present.
28
Acquired hip dislocation
1. Rare due to stability of joint
2. Posterior dislocations can occur with severe trauma; such as an automobile accident.
3. Posterior dislocations can sometimes result in sciatic nerve lesions.
29
Cause of tear to LCL (Lateral co-lateral ligament)
Force applied to the medial side of the knee
30
Cause of tear to MCL (Medial co-later ligament)
Force applied to the lateral side of the knee
31
ACL injuries (Anterior Cruciate Ligament)
1. Tearing of the ACL is common in sports related injuries (football, skiing).
2. Results in an anterior drawer sign (tibia slides anteriorly femur).
32
PCL Injuries
1. Tearing of the PCL is less common than ACL strains.
| 2. Results in a posterior drawer sign (tibia slides posteriorly femur).
33
Tear of the medial meniscus.
1. More common than lateral (due to the increased mobility of the lateral meniscus).
2. Pain on medial rotation of the tibia
34
Tear of the lateral meniscus.
Pain on lateral rotation of the tibia
35
Unholy or unhappy triad
1. Tearing of the medial collateral ligament + medial meniscus + anterior cruciate ligament.
2. Typically results from a blow to the lateral side of extended knee or excessive lateral twisting of flexed knee.
36
Coxa vara
1. Decrease in the angle of inclination of the femur (angle more acute)
37
Varus
the distal portion of anatomy deviating medially, toward midline.
38
Valgus
the distal portion of anatomy deviating laterally, away from midline
39
Coxa valga
1. Increase in the angle of inclination of the femur (angle more obtuse). >125
2. Affected limb will be lengthened
3. Because of the more obtuse angle of inclination of the femur, the distal end of the femur deviates away from midline.
40
angle of inclination of femur
Babies: about 150
| Adults 120-125. Larger in females
41
Q angle
Angle between a line passing from the ASIS to the patella (long axis of femur) and a line from the patella through the tibial tuberosity (long axis of knee).
Normally about 14° in males and 17° in females.
42
Genu Varum
Decrease in Q angle
Occurs concomitantly with coxa valgum, in which the femur is abnormally vertical (bow-legged)
The line of weight-bearing falls on medial side of knee; which results in abnormal wear and tear on the medial side of the knee (arthrosis of medial knee cartilages) and stretching of the fibular collateral ligament.
Affected limb is lengthened.
43
Genu valgum
Increase in the Q angle
Occurs concomitantly with coxa vara, in which the femur is abnormally inclined (knock-kneed).
The line of weight bearing falls on lateral side of the knee; which results in abnormal wear and tear on the lateral side of the knee (arthrosis of lateral knee cartilages) and stretching of the tibial collateral ligament.
Affected limb is shortened
44
Hyper-inversion injuries of the ankle
1. Typically, result in sprain of the anterior talofibular portion of the lateral ligament.
2. In severe strains, the lateral malleolus may also be fractured as the calcaneus is forcibly pushed laterally.
45
Hyper-eversion injuries
1. Often result in Pott fracture-dislocation
2. Medial malleolus is fractured as calcaneus is forcibly pushed medially.
3. Lateral malleolus or fibula is also fractured as the talus is forced laterally.
4. Sometimes the posterior portion of the distal tibia is also sheared off, resulting in a trimalleolar fracture.
46
Hallux valgus
AKA Bunion
1. Deformity of big toe, resulting from ill-fitting footwear or degenerative joint disease.
2. Results in a lateral deviation of toe
3. In some cases, the big toe will actually overlap the second toe.
4. Sometimes results in decrease in medial longitudinal arch of foot.
5. In addition, many people will develop a bursitis against the medial side of the big foot.
47
Hammer toe
1. Causes: arthritis/congenital deformity/sometimes from ill-fitting footwear
2. Proximal phalanx of toe is hyperextended
3. Middle phalanx is hyperflexed
4. Distal phalanx is over hyperextended
48
Claw toes
1. Proximal phalanx of toe is hyperextended
| 2. Middle and distal phalanges are hyperflexed
49
Pes Planus
Flat Feet. Can be flexible or rigid.
50
Flexible flatfeet
1. Normal looking foot at rest, arches fall when weight bearing.
2. Typically results from inadequate passive arch support, due to degeneration or weakness of intrinsic ligaments of the foot (especially the spring ligament).
51
Rigid flatfeet
1. Arches fallen at rest and when weight bearing
2. Congenital flatfeet is a bony deformity (fused tarsal bones).
3. Acquired flatfeet (fallen arches) – inadequate dynamic arch support.
52
Plantar Fasciitis
1. Inflammation of plantar aponeurosis
2. Most common pathology of the hindfoot; common in runners, especially with inappropriately fitting shoes.
3. Pain is most severe after periods of inactivity; especially in the morning.
4. Point tenderness exists near the calcaneus and is worsened during dorsiflexion and/or extension of the toes.
5. Pain is alleviated with use; likely due to stretching of tissue.
6. In some cases, a calcaneal bony spur can form (especially on the medial side of the foot).
53
Compartment Syndromes
1. Trauma within a compartment can result in hemorrhage, edema, and inflammation. The increased volume created by these processes causes increased pressure within a confined compartment.
2. The increased pressure can cause compression of the neurovascular bundle in of the compartment; resulting in nerve lesion and/or compression of arteries and veins.
3. Fasciotomy – surgical procedure involving incision of the deep fascia to relieve pressure within a compartment.
MOST COMMON in Anterior Compartment of leg.
54
Meralgia Parasthetica
The lateral femoral cutaneous nerve becomes impinged deep to the inguinal ligament near the ASIS.
Paresthesias and/or pain along the lateral thigh.
Occurs with pregnancy, obesity, edema, or from simply wearing clothing or a belt too tightly.
55
Femoral nerve lesion common causes
Trauma (penetrating wounds, hip fractures, abdominopelvic surgery),
Compression (ie. within psoas muscle),
Stretch (ie, during surgery),
Herniated discs compressing spinal nerves,
Ischemia
56
Femoral nerve lesion Motor Deficits
Weakness/loss of thigh flexion and leg extension
Weakness/loss of patellar tendon reflex
Difficulty with ambulation; the leg will often collapse as they go into the stance phase of gait.
Often, the patient will press their anterior thigh while walking to assist with leg extension and prevent flexion.
57
Femoral nerve lesion Sensory Deficits
1. To anterior thigh (involvement of anterior femoral cutaneous branches)
2. To medial knee, leg, and foot (involvement of saphenous nerve).
58
Obturator nerve lesion causes
Secondary to trauma (penetrating wounds, hip fractures, sacroiliac joint dislocation, abdominopelvic surgery),
Compression (ie. iliac aneurysm, pelvic lymph nodes),
Stretch (ie, during surgery),
Herniated discs compressing spinal nerves,
Ischemia
59
Obturator nerve lesion MOTOR deficits
Results in weakness/loss of thigh adduction
60
Obturator nerve lesion SENSORY deficits
To medial thigh
61
Superior gluteal nerve lesion causes
Trauma (intra-gluteal injections, hip fractures, abdominopelvic surgery),
Herniated discs compressing spinal nerves,
Ischemia
62
Superior gluteal nerve lesion deficits
1. Gluteus medius, gluteus minimus, and tfl weakness
| 2. Results in weakness/loss of thigh abduction and medial rotation
63
Clinical presentation of superior gluteal nerve lesion
Dropped hip (positive Trendelenburg sign) when contralateral limb is elevated (loss of support for the contralateral pelvis).
64
Compensatory Gaits of Superior Gluteal Nerve Lesion
Gluteal Gait
Swing Out Gait
Steppage Gait
65
Gluteal Gait
the patient will display a list toward the lesioned side, in order to elevate the contralateral hip.
66
Swing Out Gait
Help the limb clear the floor during the swing phase.
67
Steppage Gait
The patient excessively flexes the hip and knee to elevate the foot off the floor.
68
Inferior gluteal nerve lesion Causes
Trauma (intra-gluteal injections, hip fractures, abdominopelvic surgery),
Herniated discs compressing spinal nerves,
Ischemia
69
Inferior gluteal nerve lesion symptoms
1. Gluteus maximus weakness
2. Results in weakness of thigh extension and lateral rotation.
3. The weakness is most noted when attempting to lift up from a sitted position or climbing stairs.
4. Loss of contour of gluteal region; due to atrophy of gluteus maximus.
70
Piriformis syndrome
A hypertrophied piriformis muscle compresses the sciatic nerve.
In about 12% of the population, the common fibular component of the sciatic nerve courses through the piriformis; it is very common for these individuals to have a piriformis syndrome.
71
Sciatica
Compression of the L5 or S1 spinal nerve (i.e. herniated IV disc). The pain starts in the lower back and radiates down the posterior thigh and leg.
72
Sciatic nerve lesions
Complete lesion of the sciatic nerve is typically disabling.
Partial lesions will result in motor impairment or sensory impairment specific for the location of the lesion
73
Tibial nerve lesions- cause
May occur with trauma or compression in the popliteal fossa
74
Tibial Nerve Lesion- Motor Deficits
Posterior compartment of leg and all of plantar intrinsic foot muscles.
Results in weakness or loss of: plantarflexion and inversion of foot, flexion of toes.
Foot will often be held in a dorsiflexed and everted position when at rest.
Loss or weakness of calcaneal reflex
The intrinsic muscles of the plantar foot will also be weakened (these deficits can also be seen with specific medial and lateral plantar nerve lesions).
75
Tibial Nerve Lesion- Sensory Deficits
To posterolateral leg and lateral foot (sural nerve).
To plantar surface of foot (medial and lateral plantar nerves)
76
Tibial nerve entrapment syndrome (tarsal tunnel syndrome)
Edema within tarsal tunnel can cause compression of tibial nerve.
Can result in heel pain as well as paresthesia or loss of sensation on plantar foot; can also result in weakness of muscles of foot.
77
Common fibular nerve lesions Causes
Trauma
1. penetrating wounds, especially around lateral popliteal region;
2. fractures of head/neck of fibula.
78
Common fibular nerve lesions Motor Deficits
1. Weakness/loss of dorsiflexion, inversion of foot, extension of toes (Anterior Compartment)
2. Weakness/loss of eversion of foot. (Lateral Compartment)
3. Foot will be held in plantarflexed and inverted position at rest
79
Common fibular nerve lesions Sensory Deficits
1. Posterolateral leg and lateral foot (sural nerve)
| 2. Anterolateral leg and dorsum of foot (superficial and deep fibular nn).
80
Common fibular nerve lesions Clinical Presentation
Foot drop and toe slap (during gait cycle)
81
Common fibular nerve lesions compensatory gaits
1. “Steppage gait”
2. “Swing out” gait
3. “Waddling gait”
4. The patient will also typically kick the foot forward while it is being set-down in order to prevent the “foot slap”.
82
“Waddling gait” -
patient will lean to the side opposite the impaired limb to help elevate the foot off the ground (very similar to gluteal gait).
83
Deep fibular nerve lesions
| -Causes
1. Trauma
- penetrating wounds,
- fractures of head/neck of fibula
2. Compression
- with anterior compartment syndromes;
- compression by ski boot "ski boot syndrome"
3. ischemia.
84
Deep fibular nerve lesions
| -Motor Deficits
1. Loss of motor to:
- Anterior compartment of leg and dorsum of foot
- Weakness/loss of dorsiflexion, inversion of foot, extension of toes
85
Deep fibular nerve lesions
| Clinical Presentation
1. Foot will be held in plantarflexed and slightly everted position
2. Results in footdrop
86
Deep fibular nerve lesions
| -Sensory Deficits
Web of skin between 1st and 2nd toes
87
Superficial fibular nerve lesions
| -Causes
1. Trauma
- penetrating wounds,
- fractures of head/neck of fibula
2. compression
- with lateral compartment syndromes
88
Superficial fibular nerve lesions
| -Motor Deficits and clinical presentation
Loss of Motor to:
-Lateral compartment of leg: results in weakness/loss of eversion.
Foot will be held in an inverted position
89
Superficial fibular nerve lesions
| -Sensory Deficits
Anterolateral leg
| dorsum of foot (except web of skin between first and second toes)
90
Patellar tendon reflex
AKA Knee Jerk
1. Tests integrity of the femoral nerve.
2. Primarily tests the L4 spinal level
- though levels L2-L4 are likely involved
91
Calcaneal tendon reflex
1. Tests integrity of the tibial nerve.
2. Primarily tests the S1 spinal level
- though levels S1-S2 are likely involved
92
Psoas abscess
1. Infections within the pelvis that can dissect through the psoas fascia and result in a psoas abscess.
2. Can sometime be palpated just inferior to or superior to the inguinal ligament.
3. May extend into the femoral triangle, resulting in pain of the hip and thigh. Often mistaken for hernia's
93
Intragluteal injections
Should be given in the superolateral corner (superior to a line drawn from the PSIS to the greater trochanter) in order to avoid damaging the deeper nerves.
94
Anterolateral thigh injections
into the TFL muscle
-- The index finger is placed on the ASIS and the third finger is abducted to make a triangle; the injection is delivered in this triangle to avoid deeper structures.
95
pulled groin
A strain or stretching of the muscles of the medial (usually adductor group) or anterior compartment.
96
Hamstrings tears
Common in sprinters, jumpers, and basketball players.
Can cause an avulsion fracture at the ishial tuberosity.
97
Shin splints
Pain and edema in the anterior compartment of the leg caused by repeated microtrauma of the tibialis anterior.
Can cause tearing of the periosteum of the tibia or overlying deep fascia.
The edema can result in compartment syndrome (Anterior leg compartment)
98
Calcaneal tendon rupture
Can occur during rapid plantar flexion;
-especially if calcaneal tendinitis is already present.
The patient cannot plantarflex the foot against resistance and the foot will be held in a dorsiflexed position.
99
Femoral pulse palpation
Directly below the inguinal ligament about halfway between the ASIS and pubic tubercle
100
Popliteal pulse palpation
Difficult to palpate due to deep position in popliteal fossa. However, can be felt with deep palpation within the popliteal fossa of flexed knee.
101
Posterior tibial artery palpation
Posterior to the medial malleolus
- important to have the patient invert the foot in order to decrease the tension on the flexor retinaculum
102
Dorsalis pedis pulse palpation
Dorsum of the dorsiflexed foot just lateral to the Extensor Hallucis Longus tendon.
103
Occlusive peripheral artery disease
Absence or diminished pulses in individuals over 60 years of age is typically indicative
104
Popliteal artery aneurysms
Can cause compression of the popliteal vein and result in edema and pain in the fossa; these aneurysms can also cause compression of the tibial nerve
105
fractures of the distal femur or proximal tibia complications
Due to the proximity of the popliteal artery to the knee joint and capsule these fx's can result in laceration of the artery.
If left untreated, can result in an arteriovenous fistula and loss of blood supply to the leg and foot.
106
Deep vein thrombosis
1. Blood clots in a deep vein.
2. The veins of the lower limb are especially prone to DVT’s due to the fact that they have to work against gravity to return blood to the trunk.
107
Venous stasis
One of the most common causes of DVT’s.
| Also causes Varicose veins.
108
Venous stasis
1. Incompetent deep fascia or venous valves; diminished effectiveness of musculovenous pump.
2, Muscular inactivity (during bedrest; long airplane rides)
3. Pressure on veins from bandages or from bedding during bedrest.
109
Complications of DVT's
Pulmonary embolism
| -Clots can break off and move through venous system to the heart where they can enter the pulmonary system
110
Symptoms of DVT's
swelling, warmth, erythema of the lower limb
111
Saphenous vein cut-down
1. A skin incision is made anterior to the medial malleolus to insert a cannula into a vein
2. Care needs to be taken to not to disrupt saphenous n.
112
Saphenous vein graft
1. Used for coronary artery bypass surgery
| 2. The vein must be reversed in position so that the valves do not impede movement of the blood.
113
Saphenous varix
1. Dilation of saphenous vein in the distal portion of vein (where it passes through the saphenous opening).
2. May results in edema in the femoral triangle region.
114
Cannulation of the femoral vein
- Used for right cardiac angiography and other procedures.
- Localized in upper portion of femoral triangle by first locating the pulsations of the femoral artery and then moving about one fingers breadth medially.
115
Trochanteric bursitis
1. Caused by activities which cause repeated movement of the gluteus maximus over the greater trochanter.
2. Characterized by point tenderness over the greater trochanter which may radiate along the IT band.
116
Ischial bursitis
Typically occurs in activities like cycling and rowing (activities requiring “active sitting”).
117
Prepatellar bursitis
“housemaid’s knee”
occurs between skin and patella;
common in individuals who spend a lot of time on knees.
118
Lymphadenopathy of the superficial inguinal lymph nodes
Lower limb infections but also palpate other areas that drain to these nodes including:
1. Trunk inferior to umbilicus
2. Superficial structures of perineum
3. Fundus region of uterus
119
Calcaneal bursitis
typically occurs in sports like running, basketball, and tennis.
Results in pain localized posterior to the calcaneus
120
Popliteal cysts
"Baker’s cysts"
1. Abnormal synovial fluid-filled cysts that form in the popliteal fossa.
2. These result from chronic knee joint effusion.
121
Femoral hernia
Occurs through femoral ring
- Abdominal viscera will be found within the femoral canal and can compress structures within the femoral triangle.
- More common in females.
122
Femoral Shaft Fractures
Involve massive trauma, The femur is the strongest bone
