Gross Lecture Exam 3 Flashcards
The three primary functions of the lower extremity
support weight of body
provide stable foundation while standing
allow locomotion
Modifications to lower extremities to accommodate its functions. (compared to upper extremities)
Bones are heavier and stronger
Joints are stronger and more stable
Muscles are more powerful and less capable of delicate movement
Blood Vessels are larger
Pelvic Bone (Os Coxae or Pelvis) consists of what two things? What do these two things articulate with?
Two innominate bones
They articulate with the sacrum, femur and each other
Three bones that make up the innominate
ilium ischium and pubis
what makes up the hip joint
acetabulum and head of femur
what is the name for the horshoe shaped surface of the acetabulum
lunar surface
name for the rough non articular surface of the acetabulum
acetabular fossa
outside edge of acetabulum (name it) which is deficient inferiorly is the___ that is bridged by connective tissue knowns as….
acetabular rim
acetabular notch
transverse acetabular ligament
What are the three lines on the external or lateral surface of the ilium
anterior posterior and inferior gluteal lines
posterior to the iliac fossa what are the two disticnt areas?
more superior one has ligaments attach and more inferior one is where the innominate articulates with sacrum
Iliac tuberosity
auricular surface
what marks the boundry between major or false pelvis from minor or true pelvis
arcuate line
Know ASIS, AIIS, PSIS, PIIS
oik
what is found on the most lateral aspect of the iliac crest?
iliac tubercle
just inferior to the PIIS is a deep notch
Greater Sciatic Notch
What two things make up the L shaped Ischium?
Which portion enters into the formation of the acetabulum?
Body and Ramus
the body
What is the name for the small projection of the body of the ischium? The small notch below it?
Ischial spine
Lesser sciatic notch
Inferior to the lesser sciatic notch is a large roughened area
ischial tuberosity
What three things make up the pubis?
Body and 2 rami
What is the other name for the pubis symphysis?
Symphyseal surface
The name for the superior rams of the pubis as it terminates
iliopubic eminence
prominent ridge on the superior ramus of the pubis
pubic pecten (pectineal line)
What extends posterior and inferior from the body of the pubis to join the ramus of the ischium?
inferior ramus of the pubis
name for the indentation found at the superior anterior border of the obturator foramen? name for the piece of connective tissue over the hole?
obturator groove
obturator membrane
What is the False Pelvis (Major) bode by posteriorly? Laterallly? anteriorly?
lumbar vertebrae
ilium
abdominal wall
what is the true pelvis bounded by posteriorly? laterally? anteriorly?
sacrum and coccyx
ilium, ischium, and pubis
What re the 4 functions of the pelvic bone?
Protect pelvic viscera
Transmit bodyweight to limbs
Allow locomotion
Provide bony support for birth canal
Pelvic inlet male and female?
Male heart shaped
female rounded or oval
Pelvic outlet
Male narrow
female wide
ASIS
male closer together
female farther apart
Greater Sciatic Notch
Male narrow
female wider
Obturator Foramen
Male Round
Female Triangle
Acetabulum direction
male face laterally
female face anteriorly
Symphysis pubis
Male longer
Female Shorter
Pelvic Arch
Male acute
Female Obtuse
What is an android pelvis?
gynecoid?
Anthropoid?
Platylpelloid?
Typical male
Typical female
exaggerated male
exaggerated female
Which pelvic areas are most prone to fractures? 4
Pubic rami
acetabulum
SI joint region
most lateral aspect of ilium
Fractures often occur in two places cuz pelvis is solid bone ring. Where do they occur?
Initial force site and 180 degrees opposite to it
What is usually assumed with pelvic fractures?
internal damage
Name for a common painful contusion of soft tissue around iliac crest?
Hip Pointer
What are the three primary centers of ossification of the pelvis?
Ilium Ischium and Pubis
5 secondary ossification centers of the pelvis?
iliac crest
anterior inferior iliac spine
ischial tuberosity
pubis symphysis
center of acetabulum
When does the ossification of the pelvis end?
between 20 and 22 years of age
What is the longest, heaviest, and strongest bone in the body?
Femur
What is the name for the pit or small depression on the head of the femur?
Fovea capitis (attachment site for capitis femoris ligament)
Deep pit between neck of femur and greater trochanter?
Trochanteric fossa
What joins the trochanters posteriorly? Anteriorly?
Intertrochanteric Crest
Intertrochanteric Line
What is located on the Intertrochanteric crest? its a prominent bump
quadrate tubercle
Which three lines make up the linea aspera? where are they located?
Spiral - posterior aspect of shaft
pectineal - just inferior to lesser trochanter
gluteal (tuberosity) - just inferior to greater trochanter
Added projection on the medial epicondyle
adductor tubercle
most superior part of the intercondylar fossa
intercondylar line
What are the ossification centers for the femur
Primary : shaft
Secondary : head, both trochanters, distal end (condyles and epicondyles)
When is ossicification of femur done?
by 15 years in male 17.5 female
What is an increase of angle of inclination which can occur with developmental dysphasia of hip?
Coxa Valga
Decrease of angle of inclination which occurs in fractures of proximal femur and rickets. causes mild shortening
Coxa Vara
Femur fractures describe
Common - esp osteoporosis
avascular necrosis if obturator artery, femoral artery, or lateral/medial femoral circumflex arteries are damaged
Main functions of the patella?
give more leverage to quadriceps during last part of leg extension. increases power
Ossification centers of the Patella. When does it start and stop?
ONE single center that appears in the 3rd year of life. fully developed at 10 years male 13 female
Describe direct trauma fracture of patella
indirect trauma
broken into many small fragments but not displaced
quads contract to cause transverse fracture. displaced or not displaced
symptoms of patella fracture
severe pain
swelling tenderness
cant extend
What are the two developmental anomalies of the patella?
Patella Emarginata - superior lateral portion unossified
Bipartite or tripartite patella - superior lateral portion ossified independently.
what is the softening and fissuring of the articular cartilage on the posterior aspect of the patella?
Caused by?
Symptoms
Chondromalacia
trauma, overuse, muscle weakness
pain under patella worse with exercise and flexion to extension
What are the functions of the fascia lata?
provide dense envelope for thigh to prevent bulging out of thigh muscles
enhances thigh muscle effectiveness
What is the thickened lateral aspect of the fascia lata?
Iliotibal Tract
Opening found in the proximal anterior aspect of the fascia lata? what goes through there?
Saphenous opening
Great saphenous vein and femoral vein
What is iliotibial band syndrome (ITBS)
Symptoms?
Cause?
overuse syndrome when distal end of IT band rubs over lateral condyle of femur and inflames a bursae there.
stinging pain on lateral knee
worse when runnin up down hill
Overuse of Glute Max which pulls on IT band
What are the three muscles of the anterior hip region?
Iliacus
Psoas Major
Psoas Minor
Iliacus OIAN
O: iliac fossa and sacrum
I: Lesser trochanter of femur
A: Flex femur @ hip, assist flexion/ vertebral column, help maintain posture
N: Femoral Nerve
Psoas Major OIAN
O: bodies&transverse processes of lumbars
I: Lesser trochanter of femur
A: Flex femur @ hip, assist flexion/ vertebral column, help maintain posture
N: Femoral Nerve
Psoas Minor OIAN
O: Bodies of lumbars
I: Iliopubic eminence of pubis
A: flex pelvic bone (upward movment)
N: L1 (sometimes L2)
Describe weakness of the Psoas major
difficulty stair climbing, walking up incline, getting up from reclining position and bringing trunk forward in sitting position before rising from chair.
Describe a Psoas Abscess
Distal fascia covering of Psoas major is loose, if infection gets in there it may produce an abcess which can “travel” down the muscle and end up as a painful “bag” of pus in the proximal anterior thigh
What are the 5 anterior thigh muscles?
Sartorius Rectus Femoris Vastus Lateralis Vastus Medialis Vastus Intermedius
What is the innervation for all of the anterior thigh muscles?
Femoral Nerve
Sartorius OIAN
O: anterior superior iliac spine
I: superior medial shaft of tibia
A: abducts & laterally rotates femur, medially rotates leg, assists flexion of hip and knee when both carried out
N: Femoral
What are the Quadriceps Femoris muscles and what are their common insertion?
Rectus Femoris, three Vastuses
base of patella. Portion of tendon which runs from apex of patella to the tibia is the patellar ligament
Rectus Femoris OIAN
O: anterior inferior iliac spine
I: base of patella
A: extends leg @ knee, flexion @ hip, tonus of muscles play role in knee strength
N: Femoral
Vastus Lateralis OIAN
O: Greater trochanter and Linea aspera of Femur
I: Base of patella
A: Extend leg @ knee, tonus play role in knee strength
N: Femoral
Vastus Medialis OAIN
O: linea aspera of femur
I: Base of patella
A: extends leg @ knee, tonus of muscles play role in knee strengthening
N: Femoral nerve
Vastus Intermedius OAIN
O: anterior-lateral aspect and linea aspera of femur
I: base of patella
A: extends leg @ knee, tonus of muscles play role in knee strengthening
N: Femoral
Occasionally a distinct bundle of fibers separate from deepest layers of vastus intermedius and become what new muscle attached to the synovial membrane of the knee joint? What are its actions?
Articularis Genu
Retracts synovial membrane of knee joint and helps stabalize knee
Describe paralysis of the quadriceps
difficulty extending leg against resistance and usually press on distal femur during walking to prevent flexion
knee may “give out” when getting out of bed
potential abnormal patellar movments
Quadriceps paralysis test procedure
lying or sitting patient extends knee against resistance. quads should be easily palpated here.
Describe a Charley Horse
cramp or spasm of Quadriceps
also used to indicate trauma to the muscles leading to hematoma or bruising
Describe Jumper’s Knee (Patellar Tendonitis)
overuse injury of common insertion tendon of quadriceps and/or patellar ligament. Continuous jumping sports.
Complain of soreness in area of area and hurts with activity
What does the patellar reflex test for? (segmental intervation)
L2, L3, and L4
What are the 5 muscles of the medial thigh
Gracilis Pectineus Adductor Longus Adductor Brevis Adductor Magnus
Gracilis OIAN
O: Ramus of Ischium and inferior ramus of pubus
I: superior medial shaft of tibia
A: flexes the leg and adducts the femur
N: Obturator nerve (L2,L3, L4)
Which is the only muscle of the medial thigh that crosses both the hip and knee joint?
Gracilis
Is gracilis a really necessary muscle?
it can be removed without noticable loss of action. Often used for muscle grafts
Pectineus OIAN
O: superior ramus (pubis pectin) of pubis
I: Pectineal line of femur
A: adducts femur, flexes femur at hip joint
N: Femoral and Obturator (L2,L3,L4 both)
Adductor Longus OIAN
O: superior ramus of pubis
I: linea aspera of femur
A: adducts femur
N: Obturator nerve
Adductor Brevis OIAN
O: inferior ramus of pubis
I: pectineal line of femur and line aspera of femur
A: adducts the femur
N: obturator nerve
Adductor Magnus OIAN
O: rami of ischium and pubis
I: linea aspera and adductor tubercle of femur
A: adducts femur and extends femur at hip
N: Obturator (L2,L3,L4) and Sciatic (L4-S3)
what is the name for the slit like opening of the tendon of insertion for the adductor magnus? what goes through there?
Hiatus tendinous (adductor hiatus)
femoral vessels become popliteal vessels
Describe a pulled groin
stretching of the origin of an adductor muscle beyond tensile strength.
micro, partial, or complete tears.
pain and tender, stiff, weakness, maybe bruise
Strain if iliopsoas also counts
What are the 10 muscles of the posterior hip?
Tensor Fascia Lata Gluteus Maximus, Medius, and Minimus Piriformis Superior and Inferior Gemellus Obturator Internus and Externus Quadratus Femoris
Tensor Fascia Lata OIAN
O: Crest of ilium
I: iliotibial tract
A: flex, abduct, and medially rotates femur. helps stabilize knee joint.
N: Superior Gluteal (L4,L5,S1)
Gluteus Maximus OIAN
O: Posterior gluteal line of ileum, sacrum&coccyx, posterior ligaments of SI joint
I: Gluteal tuberosity of femur, iliotibial tract
A: extend & laterally rotate femur, helps stabilize pelvic bone, stabilize knee joint
N: inferior gluteal (L5,S1,S2)
What are the names of the two gluteal bursae?
Trochanteric burase separates superior glut max from greater trochanter
Ischial bursae separates inferior glut max from ischial tuberosity
Describe weakness of gluteus maximus
difficulty sitting to standing, straightening from bent over, walking uphill, atrophy doesnt affect seriously when walking on level ground
Gluteus Medius OIAN
O: external surface of ileum
I: greater trochanter of femur
A: Abducts and medially rotates femur, helps steady pelvic bone when opposite foot raised
N: Superior Gluteal n. (L4,L5,S1)
Gluteus Minimus OIAN
O: External surface of ilium
I: greater trochanter of femur
A: Abducts and medially rotates femur, helps steady pelvic bone when opposite foot raised
N: Superior Gluteal (L4,L5,S1)
What is the Trendelenburg Test?
When glute med and min are weak then pelvis will drop on the unaffected side when the foot is raised off the ground.
the pelvis and buttock fold will fall on side that the foot is raised indicates a positive test
What is gluteal gait or trendleburg gate?
Trendelenburg test in motion
What happens to the spine if the gluteus medius and miniimus becomes weak?
postural deviations and potential “C” curve
weakness of right glute med and min will give rise to a left C curve of vertebral colum with opening of C toward the side where muscle is weak
Piriformis OIAN
O: anterior surface of sacrum
I: greater trochanter of femur
A: laterally rotate femur
N: S1 and S2
Describe Piriformis Muscle Syndrome
compression of sciatic nerve by piriformis muscle
deep pain in buttocks
common in sports requiring lateral rotation of femur
no test, diagnosed based on symptoms
Superior Gemellus OIAN
O: spine of ischium
I Greater Trochanter of the femur
A: laterally rotates femur
N: L4,L5,S1,S2
Obturator Internus OIAN
O: internal surface of the obturator membrane
I: greater trochanter of femur
A: laterally rotates femur
N: L4,L5,S1,S2
Inferior Gemellus OIAN
O: ischial tuberosity
I: greater trochanter of femur
A: laterally rotates femur
N: L4,L5,S1,S2
Obturator Externus OIAN
O: external surface of obturator membrane
I: trochanteric fossa of femur
A: laterally rotates femur
N: Obturator (L2,L3,L4)
Quadratus Femoris OIAN
O: tuberosity of ischium
I: quadrate tubercle of femur
A: laterally rotates femur
N: L4,L5,S1,S2
Which are stronger lateral rotator muscles of the femur or medial ones?
Lateral, thats why feet point out slightly when standing
Posterior Thigh Muscles name the three of them
Semitendinosus
Semimembranosus
Biceps Femoris
Semitendinosus OIAN
O: Ischial tuberosity
I: medial condyle and proximal posterior shaft of tibia
A: Flex leg @ knee, stabilize hip, extend femur, medially rotate leg
N: Sciatic Nerve
What is the name given to describe the tenons of insertion for the semitendonosis, gracilis, and sartorial? there is a bursa which separates the tendons from skin
Pes Anserinus
Semimembranosus OIAN
O: ischial tuberosity
I: medial condyle of tibia
A: Flex leg @ knee, stabilize hip, extend femur, medially rotate leg
N: Sciatic nerve
Biceps Femoris OIAN
O: long head - ischial tuberosity
Short head - Linea aspera
I: Head of fibula and lateral condyle of tibia
A: Flex leg @ knee, stabilize hip, extend femur, laterally rotate leg (Long)….Short does first and last
N: Sciatic Nerve
Describe a pulled hamstring
twice as common as quadriceps strain
athletes who run very hard with quick starts
Grade 1, 2, and 3
can lead to painful hematomas
sometimes is chronic for people
contributing factors are running style, overdeveloped quads, biomechanical factors, and not warming up or stretching
Describe an avulsion of the ischial tuberosity
may result from forcible flexion of the hip when knee is extended
LEARN LUMBAR PLEXUS
OKAY
Which nerves ventral nerve rami form the Lumbar Plexus?
Which nerve may contributes to plexus?
L1-L4
T12
What is the term given to the nerve axons of L4 and L5 that allow communication between lumbar plexus and sacral plexus?
Which level is common to both lumbar and sacral plexus?
Lumbosacral Trunk
L4
What are the 6 major nerves of the lumbar plexus from top to bottom?
Iliohypogastric Nerve
Illiolinguinal Nerve
Genitofemoral Nerve
Lateral Femoral Cutaneous Nerve
Femoral Nerve
Obturator Nerve
(lumbosacral Trunk)
Iliohypogastric nerve segmental innervation
division
motor supply
cutaneous supply
location?
L1 (sometimes T12)
Anterior
internal oblique and transverse abdominis
proximal lateral aspect of buttock
lateral to psoas major
Ilioinguinal segmental innervation
division
motor supply
cutaneous supply
L1
anterior
none
proximal medial aspect of thigh
Lateral Femoral cutaneous nerve of the thigh segmental innervation
division
motor supply
cutaneous supply
location
L2 and L3
posterior
none
lateral aspect of the anterior and posterior thigh
enters thigh by passing beneath inguinal ligaments, medial to ASIS
What is the name for a compression neuropathy of the lateral femoral cutaneous nerve as it leaves the pelvic cavity beneath the inguinal ligament?
Meralgia Paresthesia (Lateral Femoral Cutaneous Nerve Entrapment)
What are the symptoms of Meralgia Paresthesia
causes
often confused with?
pain burning and tingling along lateral thigh
obesity and tight fitting clothing or flexed femur for long time.
hip disorders, like trochanteric bursitis
Genitofemoral segmental innervation
division
motor supply
cutaneous supply
location
L1 L2
anterior
cremaster muscle
skin of genitalia and small area of skin below inguinal ligament
pierces psoas major and runs down on anterior side, breaks off into femoral and genital branches
Femoral nerve segmental innervation
division
motor supply
cutaneous supply
articular supply
L2 L3 and L4
posterior
iliacus, psoas major, sartorius, quadriceps, pectineus
medial and intermediate aspect of anterior thigh, medial aspect of leg and foot (saphenous branch)
Hip and knee
Describe damage to the Femoral nerve motor and sensory.
May be injured by trauma, but complete damage rare
Motor - weak quads, lex no extend. Flexion at hips is diminished (iliopsoas)
Sensory - medial and intermediate anterior thigh, medial aspect of leg and foot
Where does compression of the saphenous nerve occur in athletes often?
causes what pain?
adductor canal or where it exits the fascia to supply medial leg.
Knee
Obturator nerve Segmental innervation
division
motor supply
cutaneous supply
articular supply
L2, L3 and L4
anterior
pectineus, adductor magnus, adductor longus & brevis, gracilis, obturator externus
distal medial aspect of thigh
hip and knee
passes through obturator foramen membrane hole
Accessory Obturator Nerve found in 20% population
segmental
motor
articular
L3 and L4
Pectineus
Hip joint
What is a common way to damage obturator nerve? how do you test?
Child birth, anterior dislocation of hip joint
test adduction of femur agains resistance
Sacral Plexus major 6 nerves from top to bottom
(lumbosacral trunk)
Superior Gluteal Nerve
Inferior Gluteal Nerve
Posterior Femoral Cutaneous Nerve
Common Fibular Nerve Sciatic Nerve
Tibial Nerve
Pudendal Nerve
Posterior Femoral Cutaneous Nerve seg inn
division
cutaneous supply
S1, S2, S3
anterior AND posterior
lower part of buttocks, posterior thigh and popliteal
Superior Gluteal Nerve seg. inn.
division
motor supply
location
L4, L5, S1
posterior
gluteus medius, minimus, and tensor fascia lata
passes through greater sciatic notch superior to piriformis
Inferior Gluteal Nerve seg. inn.
division
motor supply
location
L5, S1, and S2
posterior
gluteus maximus
leaves the pelvis through greater sciatic notch, inferior to piriformis
Pudendal nerve seg inn.
division
location
S2, S3 S4
anterior
leaves pelvic cavity via greater sciatic notch
main nerve of perineum and chief sensory nerve for external genitalia
WHat is the largest nerve in the body that leaves pelvic cavity through greater sciatic notch deep to piriformis? its segmental innervaiton? What does it divide into?
Sciatic Nerve (L4-S3)
Tibial Nerve
Common Fibular
Describe Tibial Nerve
Common Fibular Nerve
Anterior division, supplys muscles and skin of posterior leg and plantar foot
posterior division, wraps around fibula head and has two branches that supply muscles and skin of anterior and lateral leg and dorsal foot
Deep fibular and Superficial fibular
Tibial and Common Fibular nerve seg inn.
divisions
motor supply
L4, L5, S1, S2, S3
anterior AND posterior
adductor magnus, semitendinosus, semimembranosus, biceps femoris
How is the Sciatic nerve usually injured?
Fracture of pelvis
Posterior dislocation of hip joint
Penetrating wounds (poor placed butt injections)
What are some clinical features when Sciatic nerve is damaged? Sensory and Motor
Motor - hamstring muscles atrophied but still weak flexion of leg possible due to sartorius and gracilis
foot drop due to gravity , falls in plantar flexion
Sensory - loss of sensation below the knee except for an area along the medial side of leg and foot
Describe Sciatica
patient complains of pain along sensory distrubition of sciatic nerve. butt posterior thigh and leg
Causes of Sciatica
compression, inflammation or subluxation of L4-S3
(prolapse of an intervertebral disc/hernaition
compression neuropathy of sciatic nerve in gluteal region (piriforimus sindrum or wallet problem)
intrapelvic tumor
Dermatome L1 and L2 locations
Proximal anterior thigh
middle anterior thigh
Dermatome L3 and L4 locations
distal anterior thigh, posterior medial leg
distal lateral thigh, medial leg and foot, digit 1
Dermatome L5 location
lateral leg, digits two, three, and four
Dermatome S1 and S2 locations
posterior lateral thigh and leg, lateral foot, digit 5
medial posterior thigh and leg
S 3 dermatome location
perineum
What are the four important superficial (cutaneous) veins?
Great Saphenous Vein
Lesser Saphenous Vein
Anterior and Posterior Tibial (perforating veins)
Great Saphenous Vein Describe
arises from medial part of Dorsal Venous Arch
passes superior in front of medial mallelous
passes behind knee curves to medial thigh
pass through saphenous opening of fascia lata
recieves three tributaries and terminates as Femoral Vein
Lesser Saphenous Vein Describe
arises from lateral dorsal venous arch
ascends behind the lateral mallelous
runs up posterior leg
terminates in popliteal vein
What is varicose veins and what causes it
incompetent veins so they dilate not constrict which causes pooling
congenitally defective valves
pregnancy
overweight
inflammation of vein sometimes with clot
