Lower Limb Flashcards
What are the most common lower leg injuries
Knee, leg and foot
How do most lower leg injuries occur
Acute trauma during contact sports such as hockey and foot ball and from overuse during endurance sports
Why are adolescents more vulnerable to sport related lower limb injuries
Demands of sports on their maturing MSK systems
The cartilaginous models of the bones in the developing lower limbs are transformed into bone by ___ ___
Endochondral ossification
When does endochondral ossification of lower limb complete
Early adulthood
Epiphyseal plates
Discs of hyaline cartilage between the metaphysics and epiphysis of a mature long bone that permit the bone to grow long
During a growth spurt, do muscles of bones grow faster
Bone
Osteochondrosis
Irritation and injury of epiphyseal plates and developing bones from combined stress on the epiphysesal plates resulting from physical activity and rapid growth
Pelvic fractures
Hip bone fracture
Hip fracture
Femoral Head, neck or trochanter
How may you get an avulsion fracture of the hip bone
Sports that require sudden acceleration or deceleration forces, such as sprinting or kicking a footblall, soccer, hurdle jumping, basketball and martial arts
What is an avulsion fracture
A small part of bone with a pierce of a tendon or ligament attached is avulsed away
Where do avulsion fractures typically occur
Apophyses
Coxa vara
When angle on inclination is decreased between the long axis of the femoral neck and the femoral shaft
Coxa Volga
When angle of inclination between long axis of femoral neck and femoral short is increased
Valga and virus describe what
Joint deformed
Coxa vara causes a mild ___ of the lower limb and limits passive abduction of the hip
Shortens
Why in older children and adolescents , may the epiphysis of the femoral head slip away fromt he femoral neck
Weak epiphyseal plate
What may cause dislocation of epiphysis of femoral head
Acute trauma or repetitive microtraumas that place increased shearing stress on the epiphysis, especially with abduction and lateral rotation of the thigh
The epiphysis often dislocates slowly resulting in a progressive __ ___
Coxa vara
Common initial symptom of dislocated epiphysis of femoral head
Hip discomfort that may be referred to the knee
How do you confirm a diagnosis of a dislocated epiphysis of the head of the femur
Radiographically examination of the superior end of the femur
Despite its large size and strength, the femur is commonly ___
Fractured
Why is the neck of the femur the most frequently fractured part
Narrowest and weakest and lies at a marked angle to the line of weight bearing (pull of gravity)
Femoral fractures are common in what population
Older females, secondary to osteoporosis
What are two examples of fractures of the proximal femur
Transcervical (middle of neck) and intertrochanteric
What may cause a proximal femur fracture
Indirect trauma (stumbling or stepping down hard, as off a curb or step)
Why are fractures of the proximal femur unstable, often resulting in impaction
The angle of inclination
What is impaction
Overriding of fragments resulting in foreshortening of the limb
What else may contribute to shortening of the limb with proximal femoral fractures
Muscle spasm
What is an intracapsular fracture of the femur
Within the hip joint capsule
What is a complication of an intracapsular fracture
Degeneration of the femoral head owing to vascular trauma
What may cause a fracture of the greater trochanterand femoral shaft
Direct trauma (direct blows sustained by the bone resulting from falls or being hit) DURING ACTIVE YEARS MVC, sports like skiing and climbing
Spiral fracture of the femoral shaft or grater trochanter
Results inforeshortening as the fragments override
Comminuted fracture of femur: greater trochanter and femoral shaft
Broken into several pieces
With fragments displaced in various directions as a result of muscle pull and depending on the level of the fracture
Fractures of the inferior or distal femur may be complicated by what
Separation of the condyles, resulting in misalignment of the articular surfaces of the knee joint or by hemorrhage from the large popliteal artery that runs directly on th posterior surface of the bone
Where does the popliteal artery run
Directly on the posterior surface of the femur
What is of concern if a fracture of the inferior or distal femur injures the popliteal artery
Comprises blood supply to the leg (always consider this occurrence with knee fractures or dislocations)
What should you always keep in mind with knee fractures or dislocations
The popliteal artery
Where is the tibial shaft narrowest
At the junction of its middle and inferior thirds
What is the most frequent site of fracture of the tibia
Where it is narrowest-the junction of its middle and inferior thirds
What area of the tibia has the poorest blood suppply
Where it is most common fractures and narrowest-the junction of its middle and inferior thirds
Bc its anterior surface is subcutaneous, the tibial shaft is the most common site of ____ fracture
Compound
What may cause a compound tibial fracture
Direct trauma (car bumper strikes leg)
Fracture of the tibia through the nutrient canal predisposes the patient to what
Nonunion of the bone fragments resulting from damage to nutrient artery
Who gets transverse march 9stress) fractures of the inferior third of thetibia
People who take long hikes before they are conditioned for them
The strain may fracture the anterior cortex of the tibia
How may someone fracture their tibial shaft
Indirect violence applied to the tibial shaft when the bone turns with the foot fixed (tackle in football)
What kind of tibial fracture may you get through severe torsion during skiing
Diagonal fracture of the tibial shaft at the junction of the middle and inferior thirds as well as fraction fo the fibula
What are diagonal fractures associated with
Limb shortening caused by overriding of the fractured ends
Boot top fracture
Frequently during skiing a fracture results from a high speed forward fall, which angles the leg over the rigid ski boot
When does the primary ossification center for the superior end of the tibia appear? When does it join the shaft?
Shortly after birth
During adolescence
Why are tibial fractures more serious in children if they involve the epiphyseal plates
Continued normal growth of the bone may be jeopardized
How does the tibial tuberosity form
Inferior bone growth from the superior epiphyseal center at 10 years of age
But a separate center for the tibial tuberosity may appear at age 12
Osgood-schlatter disease
Disruption of the epiphyseal plate at the tibial tuberosity may cause inflammation of te tuberosity and chronic recurring pain during adolescence , especially in young athletes
Most common spot for fibular fracture and what are they associated with
2-6 cm proximal to the distal end of the lateral malleolus
Associated with fracture-dislocation of the ankle joint , which are combined with tibial fractures
What happens when a person slips and the foot is forced into an excessively inverted position
Ankle ligaments tear forcibly tilting the talus against the lateral malleolus and may shear off
What group are lateral and medial malleolus fractures common in
Basketball players
Why are fibular fractures painful
Disrupted muscle attachments.
Why do fibular fractures compromise walking
Role in stability of the ankle
Radiographically sign of osgood schlatter disease
Prominence of tibial tuberosity elongated and fragmented with overlying tissue swelling
The __ is a common source of bone for grafting. Why
Fibula
Even after removing, running jumping and stuff is still normal
When a segment of fibula is taken out, why doesn’t it usually regenerate.
the periosteum and nutrientartery are generally removed with the piece of bone so that the graft will remain alive and grow when transplanted somewhere else
What does a fibular segment do at. A new site
Restores blood supply of the bone to which it is now attached. Healing proceeds as if a fracture had occurred at each of its ends
When performing free vascularized fibular transfers, why is it important to be aware of the location ofthe nutrient foramen in the fibula. Why
The segment of bone with the nutrient foramen is used for transplanting when the graft must include a blood supply to the medullary cavity as well as the compact bone of the surface
Where is the nutrient foramen of the fibula
Middle third of the fibula
Why may we use the subcutaneous anterior tibia
Grafting in kids
As a site of intraosseous infusion in dehydrated kids or kids with shock
Intraosseous infusion
Delivering hydration, blood, and medications directly into the medulary cavity of a bone when peripheral venous access is difficult or impossible
What causes do we primarily use intraosseous infusion
Traumatic shock
Children with circulatory collapse
What is the most common site for intraosseous infusion
Proximal tibia, due to thinness of the skin and existence of landmarks that aid int he correct insertion of the IO needle into the medullary cavity while avoiding the growth plate
What are some other sits for intraosseous infusion
Distal femur, tibia, fibula, proximal humerus, and manubrium
Describe intraosseous infusion of proximal tibia
Needle inserted into flat area of bone 2 cm distal and slightly medial fromt he tibial tuberosity
Why must interosseous infusion be replaced with peripheral venous or central line access within 24 hours
Risk of osteomyelitis
A hard fall onto the heel, may cause fracture in the ___ into several pieces. What is this type of fracture called
Calcaneous
Comminuted
Why is a calcanela fracture disabling
Disrupts the subtalar joint where the talus articulates with the calcaneous
Fractures of the Taler neck may occur with severe ___ of the ankl
Dorsiflexion
In some cases of fracture of Taler neck the body of the talus may dislocate ___-
Posteriorly
What often happens when a heavy object falls on the foot, or something runs over it or in female ballet dancers who use point shoes
Metatarsal fracture
Dancers fracture
Dancer loses balance , putting the full body weight on the metatarsal and fracturing the bone
Fatigue fractures of the metatarsals
From prolonged walking
Usually transverse, resulting from repeated stress on the metatarsals
What happens when the foot is suddenly and violently inverted
The tuberosity of the 5th metatarsal may be avulsed by the tendon of the fibular is brevis muscle
Who commonly gets avulsion fractures of the tuberosity of the 5th metatarsal
Basketball players and tennis players
Symptoms of avulsion fracture of the tuberosity of the 5th metatarsal
Pain and edema at the base of the 5th metatarsal and may be associated with a severe ankle sprain
Os trigonum
An accessory ossicle which occurs in 15-25% of adults , more commonly bilaterally, and is more prevelant among soccer players and ballet dancers
During ossification of the talus, the secondary ossification center, which becomes the lateral tubercle of the talus sometimes fails to unite with the body of the talus. What causes this failure
Applied stress (forceful plantarflexion) during early teens Or sometimes a partly or even fully ossified center may fracture and progress to nonunion
What does this result in
Do trigonum
The ___ bones of the great toe in the tendon of the flexor hallucinations longus near the weight of the body, especially when
Sesamoid
During the latter part of the stance phase of walking
When and how do the sesamoid bones develop
Develop before birth and begin to ossify during late childhood
Fracture of the sesamoid bones may result from a ___ injury
Crushing
Lateral external hip rotation
L5, S1
Medial internal hip rotation
L4, L5
Hip adduction
L2-4
Hip abduction
L5, S1
Subtalar inversion
L4, L5
Subtalar Everion
L5, S1
Hip extension
L4, L5
Hip flexion
L3 L4
Knee flexion
L5 S1
Knee extension
L3, L4
Dorsiflexion
L4, L5
Plantarflexion
S1 s2
Toe extension
L5 S1
Toe flexion
S2 S3
Subcostal nerve
From T21 anterior ramus
Courses along inferior border of the 12th rib. Lateral cutaneous branch descends over iliac crest
Lateral cutaneous branch supplies skin of hip region inferior to anterior part of iliac crest and anterior to greater trochanter
Iliohypogastric nerve
From lumbar plexus (l1, occasionally t12)
Parallels iliac crest and divides into lateral and anterior cutaneous branches
Lateral cutaneous branch supplies superolateral quadrant of buttocks
Origin of ilioinguinal nerve
Lumbar plexus (l1, occasionally T12)
Course of ilioinguinal nerve
Passes through inguinal canal; divides into femoral and scrotal or labial branches
Distribution of ilioinguinal nerve
Femoral branch supplies skin over medial femoral triangle
Origin of genitofemoral nerve
Lumbar plexus (l1-l2)
Course of genitofemoral nerve
Descends anterior surface of psoas major, divides into genital and femoral branches
Distribution of genitofemoral nerve
Femoral branch supplies skin over lateral part of femoral triangle,genital branch supplies anterior scrotum or labia majora
Lateral cutaneous nerve of thigh origin
Lumbar plexus (l2-l30
Lateral cutaneous nerve of the thigh course
Passes deep to inguinal ligament, 2-3 cm medial to anterior superior iliac spine
Distribution distribution of the lateral cutaneous nerve of thigh
Supplies skin on anterior and lateral aspects of thigh
Origin of anterior cutaneous branches
Lumbar plexus (l2-l4)
Course of anterior cutaneous branches
Arise in femoral triangle, pierce fascia lata along path of sartorius muscle
Distribution of anterior cutaneous branches
Supply skin of anterior and medial thigh
Origin of the cutaneous branch of obturator nerve
Lumbar plexus via obturator nerve , anterior branch (l2-l4)
Course of cutaneous branch of obturator
Following its descent between adductors longus and brevity, anterior division of obturator nerve pierces fascia lata to reach skin of thigh
Distribution of the cutaneous. Branch of obturator nerve
Skin of middle part of medial thigh
Origin of the posterior cutaneous nerve of thigh
Sacral plexus s1-s3
Course of posterior cutaneous nerve of the thigh
Enters the gluteal region via infrapiriform portion of greater sciatic foramen deep to gluteus Maximus and then descends deep to fascia lata
Distribution of posterior cutaneous nerve of thigh
Terminal branches pierce fascia lata to supply skin of posterior thigh and popliteal fossa
Origin of saphenous nerve
Lumbar plexus via femoral nerve (l3-l4)
Course of saphenous nerve
Transverse adductor canal but does not pass through adductor hiatus. Crossing medial side of knee deep to sartorius tendon
Distribution fo the saphenous nerve
Skin on medial side of leg and foot
Superficial fibular nerve origin
Common fibular nerve (L4-s1)
Course of superficial fibular nerve
Courses through lateral compartment of leg; after supplying fibular muscles, perforated deep fascia of leg
Superficial fibular nerve distribution
Skin of anterolateral leg and dorsomedial of foot, excluding web between great and 2nd toes
Deep fibular nerve origin
Common fibular nerve (l5)
Deep fibular nerve course
After supplying muscles on dorsomedial of foot, pierces deep fascia superior to heads of 1st and 2nd metatarsals
Distribution of deep fibular nerve
Skin of web between great and 2nd toes
Sural nerve origin
Tibial and common fibular nerves (s1-s2)
Course of sural nerve
Medial sural cutaneous branch of tibial nerve and lateral sural cutaneous branch of fibular nerve to merge at varying levels on posterior leg
Distribution of sural nerve
Skin of posterolateral leg and lateral margin of foot
Origin of medial plantar nerve
Tibial nerve (l4-L5)
Course of medial plantar nerve
Passes between first and second layers of plantar muscles and then between medial and middle muscles of first layer
Distribution of medial plantar nerve
Skin of medial side of sole and plantar aspect, sides and main beds of medial 3.5 toes
Lateral plantar nerve origin
Tibial nerve s1-s2
Lateral plantar nerve course
Passes between first and second layers of plantar muscles and then between middle ad lateral muscles of first layer
Distribution of lateral plantar nerve
Skin of lateral sole, and plantar aspect, sides, and nail beds of lateral1.5 toes
Calcaneal nerve origin
Tibial and sural nerves s1-s2
Calcaneal nerves course
Lateral and medial branches of tibial and sural nerves, respectively, over calcaneal tuberosity
Distribution of calcaneal nerves
Skin of heels
Superior clunial nerve origin
L1-L3 posterior rami
Course of superior clunial nerves
Penetrate thoracodorsal fascia; course laterally and inferiorly in subcutaneous tissues
Distribution of superior clunial nerves
Skin overlyingsuperior and central parts of buttocks
Medial clunial nerve origin
S1-s3 posterior rami
Medial clunial nerve course
Emerge from dorsal sacral foramina; directly enter overlying subcutaneoustissue
Distribution of medial clunial nerves
Skin of medial buttocks and intergluteal cleft
Inferior clunial nerve origin
Posterior cutaneous nerve of thigh (s2-s3)
Inferior clunial nerves course
Arise deep to gluteus Maximus; emerge from beneath inferior border of muscle
Distribution of inferior clunial nerves
Skin of inferior buttocks (overlying gluteal fold)
The fascial compartments of the lower limbs are generally ___ spaces, ending proximally and distally at the joints
Closed
Trauma to muscles and/or vessels in the compartments from burns , sustained intense use of muscles, or blunt trauma may produce what
Hemorrhage, edema, inflammation of muscles
Bc the septa and deep fascia of the leg forming the boundaries of the leg compartments are strong,the increased volume may increase ____ ___
Intracompartmental pressure
Compartment syndrome!!
Issues with increased intracompartmental pressure
Compress structures, like the small vessels and nerves (vasa nervorum)
Ischemia
Adversely effects circulation and threatens the function of tissue within or distal to the compartment syndromes
What is an obvious sign of arterial compression in compartment syndrome
Loss of distal leg pulses
Lowering temperature of tissue distal to compression
Fasciotomy
Incision of overlying fascia of a septum
Performed to relieve th pressure in the compartment
Frequently, the great saphenous vein and its tributaries become ___
Varicose
What are varicose veins
Dilated vines so that the cusps of the valves do not close
Where are varicose veins common
Posteromedial parts of lower limb and may cause discomfort
What is the function of normal vein valves
Valves allow blood flow to the heart while keeping blood from flowing away from the heart
Varicose vein valve
Incompetent due to dilation or rotateion
BLOOD FLOWS INFERIORLY IN THE VAINS PRODUCING VARIOSE
Dvt characterization
Swelling, warmth, and erythema
__ __ is an important cause of thrombus formation
Venous stasis (stagnation)
What can cause venous stasis
Incompetent loose fascia that fails to resist muscle expansion, diminishing the effectiveness of the musculovenous pump External pressure on the veins from bedding during a prolonged hospital stay of from a tight cast or bandage Muscular inactivity (flight)
Thrombophlebitis
Dvt with inflammation around the involved veins
A large thrombus that breaks free from a lower limb b=vein may travel to a ___, forming what
Lung Pulmonary thromboembolism (obstruction of a pulmonary artery)
A large embolus may obstruct a main pulmonary artery and cause ___
Death
Why is the great saphenous vein sometimes used for coronary bypasses
-readily accessible
Sufficient distance occurs between the tributaries and the perforating veins so that usable lengths can be harvested
Its wall contains a higher percentage of muscular and elastic fibers than superficial veins
Saphenous veins grafts are used for what
To bypass obstructions in blood vessels
When part of the great saphenous vein is removed for bypass why is the vein inverted
So valves do not obstruct blood flow in the venous graft
Does removal of great saphenous vein cause problems
Rarely bc so many other leg veins if deep veins are in tact
Removal of the great saphenous vein may facilitate the superficial to dee drainage pattern to take advantage of the ____ ___
Musculovenous pump
Who may the great saphenous vein not be visible in
Infants
Obese people
Patients in shock who have collapsed veins
How can the great saphenous vein always be located
Making a skin incision anterior to the medial malleolus
Saphenous cut down procedures
Skin incision anterior to the medial malleolus
Used to insert a cannula for prolonged administration of blood, plasma expanders , electrolytes or drugs
The saphenous nerve accompanies the great saphenous vein __ to the medial malleolus
Anterior
What happens is saphenous nerve cut during saphenous cutdown or ligated during closure of surgical wound
Pain or numbness along medial border of food
Can you palpate the superficial inguinal lymph nodes
No locked in subcutaneous tissue
Enlarged inguinal lymph nodes in female
Metasticisis of uterine cancer (drains uterine fundus) may flow along lymphatics accompanying the round ligament of the uterus through the inguinal canal to reach the superficial inguinal lymph nodes
How do we do a nerve block of lower limbs
Perineural injection of anesthetics close to the nerves whose conductivity is to be blocked
How can you block the femoral nerve
L2-l4
2cm inferior to the inguinal ligament , 1 finger breath lateral to the femoral artery
How would you know if the saphenous nerve is affected
Paresthesia radiates to the knee and over the medial side of the leg
Hip pointer
Contusion of the iliac crest that usually occurs at its anterior part (here the sartorius attaches to the ASIS)
How do people get contusion of the iliac crest
Collision sports, such as various forms of football, ice hockey, and volleyball
What does avulsion of the iliac crest cause
Bleeding from ruptured capillaries and infiltration fo blood into he muscles, tendons, and other soft tissue
What else may hip pointer refer to, although they should be called avulsion fractures
Avulsion of bony muscle attachments for example, of the sartorius or rectus femoris to the anterior superior and inferior=riot iliac spines, respectively, of the hamstrings from the ischium
Charley horse
Crampingof an individual thigh muscle because of ischemia or to contusion and rapture of blood vessels sufficient enough o form a hematoma
What causes charley horse
Tearing of fibers of the rectus femoris; sometimes, the quadriceps tendon too
What is the most common site of thigh hematoma
Quadriceps
A charley horse is associated with __ pain and/or muscle ____ and commonly follows direct trauma (hockey stick slash)
Localized
Stiffness
What does the psoas major arise from
IV discs, sides of T12-L5 vertebrate and their TP
The __ ___ ligament of the diaphragm arches obliquely over the proximal part of the psoas major
Medial arcuate
The ____ fascia on the internal abdominal wall os continuous with the psoas fascia, where it forms a fascial covering for the psoas major that accompanies the muscle into the anterior region of the thigh
Transversalis
There is a resurgence of __ in Africa, Asia, and elsewhere
TB
Causes of psoas abscess
TB -retroperitoneal pyogenic infection in the abdomen or greater pelvis, characteristically associated with TB in vertebral column
Secondary to regional enteritis of the ileum (crohns)
What happens when the abscess passes between the psoas and its fascia to the inguinal and proximal thigh regions,
Severe pain may be referred to the hip, thigh or knee joint
When should a psoas abscess always be considered
When ede,a occurs in the proximal part of the thigh
Can you observe or palpate a psoas abscess
Inguinal region just inferior or superior to the inguinal ligament
What may a psoas abscess be mistaken for
Indirect inguinal hernia , femoral hernia, enlargement of inguinal nodes, or saphenous varicose
The ___ border of the psoas is commonly visible in radiographs of the abdomen;an obscured psoas shadow may be an indication of abdominal pathology
Lateral
Paralyzed quadriceps muscles
Can’t extend the leg against resistance
How does someone with paralyzed quadriceps muscle walk
With a forward lean, pressing on the distal end of the thigh with their hand as the heel contacts the ground to prevent inadvertent flexion of the knee joint
What does weakness of the vastus medialis or vastus lateralis, resulting from arthritis or trauma to the knee joint cause
Abnormal patellar movement and loss of joint stability
Chondromalacia patellar or “runners knee”
Marathon runners, basketball
Softening of the articular cartilage of the patella
In chondromalacia patellae, the soreness and aching around or deep to the patella often result from ___ ___
Quadriceps imbalance
Chondromalacia patellae may also result from a blow to patella or extreme ____ of the knee (squatting or power lifting
Flexion
Direct blow to the patella
Fracture into two or more fragments!
Transverse patellar fractures, how get them
From a blow to knee or sudden contraction of quadriceps , like when one slips and tries to prevent a backwards fall
In a transverse patellar fracture, the proximal fragment is pulled superiorly with the ____ ____ and the distal fragment remains with the patellar ligament
Quadriceps tendon
The patella is cartilaginous at birth . It ossified when
Years 3-6, frequently from more than one ossification center
Bipartite or tripartite patella
Although ossification centers usually coalesce and form a single bone , they may remain separate on one or both sides
What may bipartite or tripartite be mistaken as
Patellar fracture
Are ossification abnormalities of the patella are unilateral or bilateral
Bilateral
How can you tell bipartite and tripartite from fracture of patella
Radiographically from looking at both patella
Bilateral are likely to be ossification abnormalities
Patellar tendon/myotactic DTR
Quadriceps should contract
L2-L4
Tapping the patellar ligament activates muscle spindles in the ___. Afferent imposes fromt he spindles trail in the ____ nerve to the l2-L4 segments of the spinal cord. From here , efferent impulsesare transmitted via motor fibers in the ___ nerve to the ____ muscles to cause __ of the leg
Quadriceps
Femoral femoral
Quadriceps
Extension
Why have diminution or abscence of the patellar tendon reflex
Lesion that interrupts the innervation of the quadriceps (peripheral nerve disease
Why’d an the gracilis be removed without noticeable effects
Weak member of adductors
Why would surgeons transplant gracilis
With its nerve and blood vessels to replace a damaged muscle in the hand
Once implanted it produced good digital flexion and extension
OR can be repositioned to create a replacement for a non function external anal sphincter
Pulled groin
Strain , stretching and maybe tearing of the proximal attachments of the anteromedial thigh muscles
What muscles are involved in pulled groin
Flexor and adductor thigh muscles
What are the proximal attachments of the flexor and adductor thigh muscles
Inguinal region(groin) and junction of the thigh and trunk
Groin pulls occur in what sports
That require quick starts or extreme stretching (gymnastics, baseball)
How get a muscle strain of the adductor longus
Sports that require fast acceleration , deceleration, or changes in direction
Hockey, cricket, breaststroke swimming, football, and rugby
Rides strain
Horseback riders
Muscle strains of the adductor longus
Why do riders get ossification in the tendons of the adductor longus
Actively adduct their thighs to keep from falling from their animals.
Why use the initial part of the femoral artery, proximal to the branching of the profunda femoris artery in procedures(the common femoral artery)
Superficial in position
With a person lying in the supine position , where may the femoral pulse be palpated
Midway between the asis and the pubic symphysis
How would you palpate it
Thumb on pubic tubercle, pinky on asis and can feel with midpalm on just inferior to the inguinal ligament by pressing firmly
Normally the pulse of the femoral artery is strong. Why would it be weak
Common or external iliac arteries are partially occluded
Compression of the femoral artery may also be accomplished at this site by pressing directly posteriorly against the ___ __ __, __ __ and __ __-
Superior pubic ramus
Psoas major
Femoral head
Why compress the femoral artery here
Reduce blood flow through the femoral artery and its branches such as the profunda femoris artery
The femoral artery may be cannulated just inferior to the midpoint of the inguinal ligament
Ok
Left cardinal angiography
Long slender catheter is inserted into the artery and passes up the external iliac artery, common iliac artery, and aorta to the left ventricle of the heart.
Coronary arteriography
Same approach
Blow may also be taken from the femoral artery for blood gas analysis
To determine oxygen and carbon dioxide concentration and pressures with the pH of the blood by laboratory tests
The ___ position of the femoral artery in the femoral triangle makes it vulnerable to traumatic injury, especially laceration
Superficial
What is commonly lacerated in anterior thigh wounds
Femoral artery and vein
What is a concern if lacerate the femoral artery and vein
Arteriovenous shunt
Ligate femoral artery. The ___ anastomoses helps
Cruciate
Describe the cruciate anastomses
Four way common meeting of the medial and lateral circumflex femoral arteries with the inferior gluteal artery superiorly and the first perforating artery inferiorly, posterior to the femur, occurring less often tha its frequent mention implies
Superficial femoral??
Its actually deep . Do not use this terminology
They are in the subcutaneous tissue
Most pulmonary emboli originate where
Deep veins, not superficial
Issue with calling femoral artery or vein superficial
Could overlook this spot for emboli
They are deep
Anticoagulants help
Saphenous varix
Localized dilation of the terminal part of the great saphenous vein
What may saphenous varix cause
Edema int he femoral triangle
What may a saphenous varix be confused with
Other groin swelling.
When should saphenous varix be considered
Varicose veins are present in other parts of th lower limbs
We cant palpate the femoral vein. But how can it be found
Inferior to the inguinal ligament by feeling the pulsation of the femoral artery which is immediately lateral to the vein
Don’t mistake the femoral vein for saphenous vein in thin people! How tell which is which
Femoral vein has no tributaries right under inguinal ligament , except for the great saphenous vein that joins it 3 cm inferior to the inguinal ligament
In varicose vein operation why identify the great saphenous vein
So tie it off and not tie off the femoral vein by mistake
Cannulation of femoral vein
To get blood samples and take pressure from right side of hear or pulmonary artery and to do right cardiac angiography, a long slender catheter is inserted into the femoral vein as it passes through the femoral triangle. It is passed superiorly through the external and common iliac veins into the inferior vena cava and right atrium of the heart
Femoral venous puncture
For the administration of fluids
What is the femoral ring
Weak area int he anterior abdominal wall that normally is the size sufficient to admit tip of little finger
Femoral hernia
A protrusion of abdominal viscera (intestine). Through the femoral ring into the femoral canal
How does a femoral hernia appear
A mass , often tender, in the femoral triangle, inferolateral tothe pubic tubercle
What is a femoral hernia bounded by laterally and medially
Laterally-femoral vein
Medially-lacunar ligament
The hernial sac compresses the contents of the femoral canal and distends the wall of the canal . What is in the femoral canal
Loose CT, fat, lymphatics
Initially a femoral hernia is small bc it is contained in the canal. How does it become large
Passing inferiorly through the saphenous opening into the subcutaneous tissue of the thigh
Are femoral hernias more common in males or females
Females
Why are femoral hernias more common in females
Wider pelvis and smaller inguinal canal and rings, multiple pregnancies due to enlargement of the femoral ring over time fromt he femoral canal
What kind of pain is associated with femoral hernia
Hip or abdominal
Strangulation of femoral hernia
Bc the sharp rigid boundaries of the femoral ring, particularly the concave margin of the lacunae ligament.
Concern of strangulation of a femoral hernia
Interferes with the blood supply to the herniated intestine
Necrosis
What happens to an enlarged pubic branch of the inferior epigastric artery
Either takes the place of the obturator artery or joins it as an accessory obturator artery in 20% of people
Where does the accessory or replaced obturator artery run
Close to or across the femoral ring to reach the obturator foramen and could be closely related to the neck of a femoral hernia
Does the accessory or replaced obturator artery ever get involved in strangulated femoral hernia
Yea
Surgeons placing staples during endoscopic repair of both inguinal and femoral hernias must also be vigilant concerning the possible preserve of this common arterial variant
Sure
Trochanteric bursitis
Inflammation of the trochanteric bursa
What may cause trochanteric bursitis
Repetitive actions such as climbing stairs while carrying heavy objects or running on a steeply elevated treadmill
What do these movements involve (running on a steep treadmill or climbing stairs)
Gluteus Maximus= and move the superior tendinous fibers repeatedly back and forth over the bursa of the greater trochanter.
Pain from trochanteric bursa
Deep diffuse pain in the lateral thigh region
Characterization of friction bursitis
Point tenderness over the great trochanter; however the pain radiates along iliotibial tract that extends form the iliac tubercle to the tibia
Thickening of the fascia lata receives tendinous reinforcements from what
Tensor fascia lata and gluteus Maximus muscles
Pain from an inflamed trochanteric bursa
Localized just posterior to the greater trochanter , is generally elicited by manually resisting abduction and lateral rotation of the thigh whole the person os lying on the unaffected side
What causes ischial bursitis
Recurrent microtrauma resulting from repeated stress may overwhelm the ability of the ischial bursa to dissipate applied stress
Ischial bursitis is a friction bursitis resulting from what
Excessive friction between the ischial bursa and the ischial tuberosities
With ischial tuberosity, localized pain occurs over the bursa and the pain increases with movement of the ___ ___
Gluteus Maximus
___ may occur in the bursa with chronic bursitis
Calcification
Bc the ischial tuberosities bear the bodies weight during sitting, these pressure points may lead to __ __ in debilitated people , particularly paraplegic persons with poor nursing care
Pressure sores
Hamstring strain; who gets them
Individuals who run and/or kick hard
The violent muscular exertion required to excel in these sports may ___ part of the proximaltendinous attachments of the hamstring to the ischial tuberosity
Avulse
Hamstring strains are _ as common as quadricep strains
Twice
Usually thigh strains are accompanied by contusion and tearing of muscle fibers, resulting in rupture of the bloodvessels supplying the msucles
The resultant hematoma is contained by the dense stocking like fascia lata
Tearing of the hamstring fibers is often so painful that when the athlete moves or stretches the leg that the person falls and writhes in pain
These injuries often result from inadequate warming up before practice or competition
Avulsion if the ischial tuberosity at the proximal attachment of the biceps femoris and semitendinosus may result from forcible flexion of the hip with the knee extended
Ok
Injury to the superior gluteal nerve results in what
Disabling gluteus mediums limp
Why do people with injury to the superior gluteal nerve cause a gluteus mediums limp
Compensate for the weaker abduction of the thigh by the gluteus mediums and minimus and or gluteal gait.
Describe gluteal gait
Compensation places the center of gravity over the supporting lower limb
Medial rotation fothe thigh is also severely impaired
What test tests gluteus mediums
Trendelenburg test
Which superior gluteal nerve is damaged if left hip drops when on right foot
Right
What could cause a positive trendelenberg test
Injury to superior gluteal nerve
Fracture of the greater trochanter
Dislocation of the hip joint
When the pelvis descends not he unsupported side, the lower limb becomes , in effect __ ___ and does not clear the grounf
Too long
How does one compensate
Waddling or gluteal gait
Steppage
Swing out
How do you compensate for foot drop
Same
How block sciatic nerve pain
Injections. Few cm inferior to the midpoint of the line joining the posterior superior iliac spine and the superior border of the greater trochanter
How does it anesthic of sciatic nerve present
Paresthesia radiates to the foot because of anesthesia of the plantar nerves, which are terminal branches of the tibial nerve derived from the sciatic nerve
Compression of the sciatic nerve by the piriformis results in what “piriformis syndrome”
Pain in buttocks
Whoa re likely to develop piriformis syndrome
Ice skaters, cyclists, rock climbers and women
In 50% of piriformis syndrome there has been trauma to
Buttocks associated with hypertrophy and spasm of the piriformis
Complete section fothe sciatic nerve
May involve inferior gluteal and or the posterior femoral cutaneous nerves. Recovery si slow and incomplete
What is the side of safety and side of danger
With respect to the sciatic nerve, the buttocks have a side of safety (lateral)and a side of danger (medial).
Wounds or surgery on the medial side of the buttocks may injure the sciatic nerve and its branches to the hamstrings on the posterior aspect of the thigh(semitendinosus, semimembranosus, biceps femoris)
Paralysis of these msucles results in impairment of the thigh extension and leg flexion
The gluteal region is a common site for intramuscular injection of drugs. Gluteal IM penetrate the skin, fascia, and muscles
Te gluteal region is a common injection site because the muscles are thick and large; consequently they provide a substantial volume for absorption of injection substance by IM veins. It is important to be aware of the extend of the gluteal region and the safe region for giving injections
Some people restrict the area of the buttocks to the most prominent part. This misunderstanding may be dangerous. Why
The sciatic nerve lies deep to this area .
Injections into the buttocks are safe only in what quadrant
Superolateral quadrant of the buttocks or superior to a line extending from the PSIS to the superior border of the greater trochanter(approximating the superior border of the gluteus Maximus)
IM injections can also be given safely into the anterolateral part of the thigh where the needle enters the gluteus medius or tensor fascia lata as it extends distally from the iliac crest and ASIS
The index finger is placed on the ASIS and the fingers are spread posteriorly along the iliac crest until the tubercle of the crest is felt by the middle finger
An IM injection can be made safely in the triangular area between the fingers because it is superior to the sciatic nerve
Complications of improper techniques include nerve injury, hematoma, and abscess formation
