Exam 3 Flashcards
Primary functions of the lower extremity
- ) support the weight of the body
- ) to provide a stable foundation while standing
- ) to allow locomotion (ex: running and walking)
Innominate bone
The pelvic bone consists of a single bone on each side known as _________ _________ which articulates the sacrum, femur, and other bones like this
Ilium, ischium, and pubis.
These bones then fuse together to one single bone around 18-20 years old
What does each innominate bone consists of?
Acetabulum
A large depression on the lateral aspect of each innominate.
It receives the head of the femur to form the hip joint
Acetabular notch
The acetabular rim is the outside edge of the acetabulum, which is deficient inferiorly known as _________ ________.
Transverse acetabular ligament
Associated with the acetabulum which is a piece of connective tissue that bridges the acetabular I’m with the acetabular notch
Ilium
Larges and uppermost portion of the the pelvic bone.
- ) anterior gluteal lines
- ) posterior gluteal lines
- ) inferior gluteal lines
What are the three oblique lines of the ilium? They can be found on the external or lateral surface of the bone.
It indicates the bony origins and gluteal muscles
What do the three oblique lines of the ilium indicate?
Iliac fossa
What is the medial surface of the ilium?
Iliac tuberosity
Posterior to the iliac fossa which is the most superior is known as ______ ________. This is where ligaments attach
Auricular surface
Posterior to the iliac fossa and more inferior of these surfaces. This is where each innominate articulates with the sacrum
Accurate line
Just inferior of the iliac fossa is a curved line that marks the boundary between the major or false pelvis from the minor or true pelvis
Pelvic brim
The ilium arcuate line from each innominate forms known as ______ ______.
Iliac crest
The superior border of the ilium which terminates anteriorly as the anterior superior iliac spine and anterior inferior iliac spine
Iliac tubercle
A distinct bump that is found on the lateral most aspect of the iliac crest
Greater sciatic notch
Just inferior to the posterior inferior iliac spine is a deep notch known as __________ _________ ________.
Ischium
An “L” shaped bone which consists of body and Ramis
Ischial spine
A small projection of the body of the ischium
Lesser sciatic notch
A small notch just below the spine
Ischial tuberosity
Inferior to the lesser sciatic notch is large roughened area and it bears the weight of the body when sitting (the hamstring muscles originate from here)
Ramus
What is the most inferior portion of the ischium?
Pubis
Consists of a body and two rami
Symphyseal surface (pubic symphysis)
The medial body consists of ________ __________ which articulates with the pubis from the opposite innominate.
Pubic tubercle
The superior aspect of the body of the pubis
Pubic Crest
A line going from the pubic tubercle to the symphyseal surface
Pubic pecten
A prominent ridge of the superior ramus of the pubis
Obturator foramen
A large oval opening found at the inferior aspect of each innominate
Obturator groove
It’s an indentation found at the superior anterior border of the obturator foramen
Obturator membrane
The obturator foramen is closed by a piece of connective tissue called ________ _________.
False or major pelvis
Is bounded posteriorly by the lumbar vertebrae, laterally by the ilium and anterior by the abdominal wall; it helps to support and protect much of the abdominal viscera.
True or minor pelvis
Is bounded posteriorly by the sacrum and coccyx, laterally and anteriorly by the ilium, Ischium, and pubis; this portion of the pelvis surround the birth canal in females
Pelvic Bone
Functions:
- ) protects the pelvic viscera
- ) transmits body weight to the limbs and absorbs the stresses of muscular activity
- ) allows locomotion, by causing the pelvic bone to swing from side to side
- ) In females, provides the bony support for the birth canal
Android Pelvis
Typical male pelvis
Gynecoid pelvis
Typical female pelvis
Anthropoid pelvis
Exaggerated male pelvis
Platypelloid pelvis
Exaggerated female pelvis
- ) pubic rami
- ) acetabulum
- ) sacroiliac joint
- ) most lateral aspect of the ilium
What features of the pelvis are most prone to fracture?
High morbidity and mortality rate
With fractures of the pelvis is there a high or low morbidity rate?
Hip pointers
A common painful contusion injury of the soft tissue associated with the iliac crest.
It’s very common in contact sports and usually result in a painful hematoma
Ossification of the pelvic bone
Three primary centers
- ilium
- ischium
- pubis
Five secondary centers
- iliac crest
- anterior inferior iliac spine
- ischial tuberosity
- pubis symphysis
- acetabulum
Bone is completed between 20-22 years old
Femur
Longest, heaviest bone in the body
Hip joint
At the proximal end of the femur is found a rounded head, which articulates with the acetabulum forte pelvic bone to form the _____ _______.
Fovea capitis
On the head of the femur is a pit or depression, which is for the attachment fo the capitis femoris ligament
- spiral
- pectineal
- gluteal
What three lines come together to form the lines aspera?
Ossification of femur
Primary centers
-shaft
Secondary centers
- head
- greater trochanter
- lesser trochanter
- distal ends of condyles and epicondyles
Bone completes by 15 years in female and 17 1/2 years for males
Angle of inclination
The way the neck of the femur meets the shaft of the bone, an angle is formed is known as _____ __ _______.
Cox Valga
An increase in the angle of inclination, which can occur with the developmental dysphasia of the hip (congenital)
Coxa Vara
A decrease in the angle of inclination, which can occur in fractures to the proximal part of the femur and in the condition of rickets.
Age and sex related
What is a major factor in femur fractures?
Subcapital fractures
This a fracture through the neck of the femur and are what is commonly called as a broken hip.
Fairly common in older people who suffer from osteoporosis (Estrogen deficiency)
Avascular necrosis
Subcapital fractures often interrupt the blood supply to the femoral head, leading to a degeneration of the head.
Obturator artery
The head of the femur is supplied by the _______ ______.
Femoral artery (medial and lateral femoral circumflex arteries)
The neck of the femur receives a rich blood supply from branches of the _______ _______
Patella
This large sesmoid bone develops within the common tendon of insertion of the quadriceps
Gives additional leverage to the quadriceps during the last part of extension of the leg. This helps to increase the power of the extension movement
What is the main function of the patella?
Patella fracture
Due to direct trauma usually this bone becomes comminuted
Transverse fracture
When there is indirect trauma and it becomes displaced
- ) severe pain
- ) swelling and tenderness
- ) inability to carry out extension at the knee joint
Symptoms of a fracture patella
Patella Emarginata
A patella in which the superior lateral portion of the bone remains unossified
Bipartite or Tripartite Patella
A patella in which the superior lateral portion ossified independently
Occurs in 3% of the population
Can be confused with a fracture of the patella
Chondromalacia
A condition in which there is a softening and fissuring of the articular cartilage on the posterior aspect of the patella
Common in young adults
Complaint is dull pain and worsens with exercise
Fascia Lata
This is the connective tissue investment (deep fascia) of the thigh region
It provides the quadriceps from bulging during contractions of the muscle
Iliotibial Tract
Is a thickened lateral aspect of the fascia Lata which received insertions from eh tensor fascia Lata and gluteus Maximus
Iliotibial band syndrome (ITBS)
An overuse syndrome which occurs at the distal end of the iliotibial band where it repetitively rubs over the lateral condyle of the femur, thus irrational and inflaming the bursa located there.
Abduction of the femur
Lateral movement of the femur
Adduction of the femur
Medial movement of the femur
Lateral (outward) rotation
Is the rotation of the femur around its longitudinal axis, so that the knee is turned outward.
Medial (inward) rotation
Is the rotation of the femur around its longitudinal axis, so that the knee is turned inward.
Iliopsoas
What is the psoas major and the iliacus combine to be?
Weakness of the psoas major and iliacus
Weakness of the ________ ________ or _________ will result in marked disability in carrying out activities such as stair climbing, walking up inclines, getting up from a reclining position.
Psoas Minor
What is the muscle that is missing out of half of the population?
Psoas Minor
What is the muscle that often gets mistaken for a nerve (genitofemoral nerve)?
Quadriceps
The rectus femoris and the three vastus muscles make up the _____________
Sartorius
This is the longest muscle in the body
Articularis genu
A distinct bundle of muscle fibers separates from the deepest layer of the vastus inter Medius and become a separate muscles known as _________ _____. Also this attaches to the synovial membrane of the knee joint.
Atrophy of the quadriceps
Atrophy of ________ will have difficulty extending their leg against resistance and will usually press on the distal end of the femur during walking to prevent flexion from occurring at the knee joint.
Weakness of this muscle can also result in abnormal patellar movements and loss of joint mobility
The patient will have difficulty carrying out extension at the knee joint
Charley Horse
Used to indicate a cramping or spasm of the quadriceps
Also indicates trauma to the muscles, which can cause a tearing of muscle fibers and lead to painful hematomas and bruising
Jumper’s Knee (Patellar Tendonitis)
A painful overuse injury of the common tendon of insertion of the quadriceps and/or of the patellar ligament
Patellar Reflex
Carried out by tapping the patellar ligament and is used to test for the segmental innervation of L2, L3, and L4
Gracilis
What muscle crosses both the hip and knee joint?
Gracilis
What muscle can be removed without a noticeable loss of action?
Pectineus and Adductor Brevis
What muscles both have an insertion of the pectineal line?
Pulled groin (adductor strain)
A condition in which there is stretching of the origin of an adductor muscle beyond their tensile strength.
May consists of micro tears of the fibers (grade 1), Partial tears (grade 2), complete tears (grade 3)
Symptoms:
- pain and tenderness in the groin area
- stiffness in the area
- weakness of the muscle(s)
- possible bruising in the area
A strain of the iliopsoas is also classified as a pulled groin
Trochanteric bursae
Separates the superior part of the muscle from the greater trochanter
Ischial bursae
Separates the inferior part of the muscle from the ischial tuberosity
Weakness of the gluteus Maximus
A weakness of this muscle will cause patients to have difficulty getting from a sitting to standing position, straightening from a bending position, walking uphill or up stairs.
Trendelenburg Test
A simple test which is used if one suspects atrophy and weakness of the gluteus media’s and minimus muscles
The pelvis will drop on the unaffected side when the foot is raised off of the ground
Gluteal Gait/ Trendelenburg Gait
A type of abnormal locomotion due to atrophy and weakness of the Gluteus Medius and minimus
Postural deviations
Weakness of the gluteus media’s and minimus muscles can cause this _____ ______.
This results in the vertebral column deviating toward the side where the pelvis is low, giving rise to what is known as a “C” curve of the column
Piriformis Muscle syndrome
A common cause of pain in the gluteal region due to compression of the sciatic nerve by the Piriformis muscle (sciatica)
Lateral rotation
What type of rotation of the femur is important in the control of the body’s balance and posture?
Lateral; medial
The (lateral/medial) rotators are stronger than (lateral/medial) rotators of the femur
Goose’s foot
What name is given to describe the tendons of insertion of the semitendinosus, Gracilis, and Sartorius
Pulled hamstrings
Is also known as a hamstring strain and is a common sports injury
The strong muscular contractions required to excel in these sports may lead to a tearing of the muscles, which are classified as grade 1,2, and 3
Contributing factors:
- running style
- over developed quadriceps
- biomechanical factors
- inadequate warm ups and stretches
Avulsion of the ischial tuberosity
May result from forcible flexion of the hip when the knee is extended (ex: hurdler)
Weak or tight Hamstrings
With this condition the body may compensate by changing the position of the pelvic bone, which can place stress on other muscles in the are and may compress spinal nerves
Lumbar plexus
This plexus is found in the pelvic cavity, embedded for the most part in the psoas major muscle
Lumbrosacral Trunk
This term given to the nerve axons of L4 and L5 that allows communication between the lumbar plexus and the sacral plexus
L4
What is common to both lumbar and sacral plexuses?
Iliohypogastric Nerve
Segmental Innervation : L1 (sometimes T12)
Anterior division
Motor supply: internal oblique and transverse abdominal muscles
Cutaneous supply: lateral aspect of the buttocks
Ilioinguinal Nerve
Segmental innervation: L1
Anterior division
ONLY cutaneous supply: proximal medial aspect of the thigh
Lateral (femoral) cutaneous nerve of the thigh
Enters the thigh by passing beneath inguinal ligament
Segmental innervation: L2 and L3
Posterior division
ONLY cutaneous function: lateral aspect of the thigh (both anterior and posterior)
Meralgia Paresthesia (lateral femoral cutaneous nerve entrapment)
A compression neuropathy of the lateral femoral cutaneous nerve as it leaves the pelvic cavity beneath the inguinal ligament
Symptoms (Lateral aspect of the thigh)
- pain
- burning
- tingling sensation
Common causes:
- obesity
- wearing tight fitting clothing
- any activity which puts the femur in a flexed position
This condition is sometimes confused with trochanteric bursitis
Genitofemoral nerve
This nerve is only in males
Segmental innervation: L1 and L2
Anterior division
Motor supply: cremaster muscle
Cutaneous supply: genitalia and small area below the inguinal ligament
Femoral nerve
Largest branch of the lumbar plexus
Segmental innervation: L2, L3, and L4
Posterior division
Motor supply: iliacus, psoas major, Sartorius, quadriceps, and Pectineus
Cutaneous supply: medial and intermediate aspect of the anterior thigh and medial aspect of the leg and foot
Cutaneous branch of the nerve supplies the skiing covering the medial aspect of the leg and foot is known as the saphenous nerve
The nerve gives off articular branches to supply the hip and knee joints
Damage to the femoral nerve
Nerve can be injured by trauma
When the nerve is comprised the following will occur:
Motor- quadriceps are involved and the leg cannot be extended. Flexion
at the hip is diminished
Sensory: medial and intermediate aspect of the thigh. Medial aspect of
the leg and foot.
Test: assessing both flexion at hip and extension at the leg
Within the Adductor canal
Where does compression of the saphenous nerve happen?
Obturator nerve
Segmental innervation: L2, L3, and L4
Anterior division
Motor supply: Pectineus, Adductor magnus, adductor longus and brevis, Gracilis, and obturator externus
Cutaneous supply: medial aspect of the thigh
Articular supply: hip and knee joints
Accessory obturator nerve
Found in only 20% of the population
Segmental innervation: L3 and L4
When present supplies the Pectineus muscle and hip joint
Damage to obturator nerve
Nerve may be damaged during a difficult birth or by and anterior dislocation of the hip joint.
Test: adduction of the femur against resistance
Sacral plexus
Formed from L4 and L5 (lumbosacral trunk) and S1, S2, S3, S4
Sacral nerves enter the pelvis via anterior sacral foramina
Posterior femoral cutaneous nerve
Segmental innervation: S1, S2, and S3
Anterior and Posterior divisions** UNIQUE
Cutaneous supply: distal part of the buttocks, posterior thigh, and popliteal fossa
Superior gluteal nerve
Leaves pelvis via superior part of the greater sciatic notch
Segmental innervation: L4, L5, and S1
Posterior division
Motor supply: Gluteus Medius, gluteus minimus, and tensor fascia Lata
No Cutaneous supply
Inferior gluteal nerve
Leaves pelvis via inferior part of the greater sciatic notch
Segmental innervation: L5, S1, and S2
Posterior division
Motor supply: gluteus Maximus
No Cutaneous Supply
Pudendal nerve
Segmental innervation: S2, S3, and S4
Anterior division
Main sensory nerve to the external genitalia
Leaves pelvic cavity via greater sciatic notch
Sciatic Nerve
This nerve is also a continuation of the sacral plexus into the leg and foot
Nerve leaves the pelvis through the greater sciatic notch deep to the Piriformis muscle
Segmental innervation: L4, L5, S1, S2, and S3
Motor supply: adductor magnus, semitendinosus, semimembranosus, and biceps femoris
Also consists of 2 nerves: tibial nerve and common fibular
Tibial nerve
Formed from the anterior division and supplies the muscles and most of the skin fo the posterior leg and plantar surface of the foot
Common fibular nerve
Formed from the posterior division which wraps around the neck of the fibula and has two branches (deep fibular and superficial fibular); the branches supply the muscles and skin of the anterior leg, lateral leg, and dorsum of the foot
- fractures of the pelvis
- posterior dislocation of the hip joint
- penetrating wounds (badly placed intramuscular injections)
How can the sciatic nerve be injured?
Clinal features of an injured sciatic nerve
Motor:
- Hamstring muscles are atrophied but weak flexion of the leg is possible due to actions fo the Sartorius and Gracilis
- all muscles distal to the knee may be involved
- the foot due to gravity falls into the plantar flexed position (drop foot)
Sensory:
-loss of sensation below the knee EXCEPT for an area along the medial side of the leg and foot
Sciatica
A condition with pain along the sensory distribution of the sciatic nerve. Pain is typically experienced in the gluteal region, posterior thigh and leg.
Causes:
- compression, inflammation or subluxation of L4-S3 (herniation)
- compression neuropathy of the sciatic nerve in the gluteal area (Piriformis syndrome)
- intrapelvic tumor
L1
Proximal anterior thigh
L2
Middle anterior thigh
L3
Distal anterior thigh; posterior medial leg
L4
Distal lateral thigh; medial leg and foot; digit one
L5
Lateral leg; digits 2,3,4
S1
Posterior lateral thigh and leg; lateral aspect of the foot; digit 5
S2
Medial posterior thigh and leg
S3
Perineum
Valves
What do veins have in the lower extremity that help maintain blood flow in an upward direction?
Great saphenous vein
This vein arises from the medial aspect of the dorsal venous arch of the foot
- Passes superiorly in front of the medial malleolus
- Passes behind the knee and curves forward on to the medial aspect of the leg
- passes through saphenous opening of the fascia Lata where it receives three tributaries (superficial circumflex iliac vein, superficial epigastric vein, and superficial or external pudendal vein).
Terminates at the femoral vein
Lesser Saphenous Vein
Arises from the Lateral aspect of the dorsal venous arch.
Ascends behind the lateral malleolus as it passes the ankle joint. It’s accompanied by the sural nerve in the posterior aspect of the leg.
Terminates at the popliteal vein in the popliteal fossa
Termination has some variation and could joint the great saphenous or divide, sending one branch to popliteal vein and one to the great saphenous vein
Varicose Veins
A condition in which the veins become enlarged, twisted, and painful due to poorly functioning valves.
Causes of this condition:
- congenitally defective valves
- pregnancy
- overweight
- inflammation of the vein (sometimes with a blood clot)
The great saphenous vein
What vein is commonly used for coronary artery bypass surgery?
- readily accessible
- has enough length
- contains a higher percentage of muscular and elastic fibers than do other superficial veins of the body
What are the reasons why the great saphenous vein is used in coronary bypass surgery?
Femoral triangle
A very important surface landmark of the anterior thigh, which is seen as a depression below the inguinal ligament on the anterior surface of the proximal thigh
Clinically important:
- hernias are common here
- it is an arterial pressure point in the case of uncontrolled bleeding of the lower extremity
Contents:
- Femoral nerve
- femoral artery and vein (femoral sheath)
- inguinal lymph nodes (most medial aspect)
Superior: inguinal ligament
Lateral: Sartorius
Medial: adductor longus
What are the boundaries of the femoral triangle?
Femoral sheath
Consists of connective tissue which enclose the femoral blood vessels.
It’s a downward protrusion of the fascia covering the pelvic floor
Function: is to allow the femoral artery and vein to glide deep to the inguinal ligament during movements of the hip joint
3 compartments by vertical septa:
- Lateral compartment for the femoral artery
- intermediate compartment for the femoral vein
- medial compartment which is known as the femoral canal
Femoral canal
The most medial and smallest of the 3 compartments formed from the femoral sheath
The canal contains:
- adipose tissue
- lymphatic lymph nodes
Canal is WIDER in females in males
Femoral ring
This is an opening in the roof of the femoral canal and it is known as the _______ ________.
the femoral ring
What is the originating site for a femoral hernia?
Femoral hernia
This type of hernia is a protrusion of abdominal viscera through the femoral ring into the femoral canal.
Eventually it can push through the saphenous opening in into the subcutaneous area of the anterior thigh and cause problems
