Lower Limb Flashcards
Identify on a skeleton: femur, patella, tibia/fibula, the tarsal bones, metatarsals, phalanges.
Important bony features: greater trochanter of femur, proximal head of fibula, lat. and med. malleoli at
ankle, sesamoid bones at the 1st MPJ. General organisation of the foot arches.
Netters
Lateral longitudinal arch - talus, calcaneus, cuboid bone, 5th metatarsal
Medial longitudinal arch - Talus, calcaneus, navicualr bone, medial cuneiform bone, 1st metatarsal
Transverse arch - metatarsals
Test movements of the hip joint
Flexion – flex against resistance
Extension – extend against resistance
Abduction – abduct against resistance
Adduction – adduct against resistance
Circumduction – circumduction against resistance
Test movements of the knee joint
Flexion – Flex against resistance
Extension – Extend against resistance
Limited rotation – Rotate (somewhat) against resistance
Test the movements of the ankle joint
Dorsiflexion – dorsiflex against resistance
Plantar flexion - plantarflex against resistance
Test the movements of the talo-calcaneo-navicular joints
- Talo-calcaneo-navicular joint + subtalar joint movement –> foot inversion + eversion (eversion = away from median plane and vice versa).
- Ask patient to move joint being tested, then repeat against resistance
Test the movements of the digits
Abduct, adduct, flex, extend against resistant
Test the gluteal muscles
Gluteal muscles = hip EXTENSORS, abductors and external rotators Gluteus medius - Patient lies on side with lower limbs fully extended. Ask patient to abduct limb at hip joint while applying resistance at distal end of thigh. Palpate gluteus medius contraction just inferior to iliac crest - superior gluteal nerve (L5/S1)
Tensor fascia lata - patient lies slightly supine and abduct the thigh
Gluteus maximus - subject lies prone with knees flexed. As to extend the thigh while resisting the distal end (inferior gluteal nerve)
Trendelenberg test
Done to evaluate motor loss of the hip abductors (gluteus medius + minimus). “Waddle” when walking seen in positive test.
- Patient stands on both legs - right and left sides of pelvis should be at same level
- Examiner stands in front patient and feels pelvis – pt.’s hands on your shoulders
- Ask patient to raise one leg off ground - pelvis should remain horizontal. Positive result = pelvis drops downward on side of raised leg. The weakness is on the side that the patient is standing on.
Test the thigh muscles
Quadriceps (Anterior compartment):
Subject sits on couch with knees at 90° over edge. Examiner applies pressure to distal part of leg, subject tries to extend. Contraction of quads can be palpated on anterior thigh – femoral nerve
Hamstrings (Posterior compartment):
Patient lies prone with knees flexed to 30°. Subject should try to flex knee further whilst examiner applies force at posterior ankle surface. Hamstring tendons should be seen - Sciatic nerve
Adductors (Medial compartment):
Subject asked to adduct thigh forcefully, examiner opposes force - with other hand palpate medial aspect of thigh for contraction of adductors - obturator nerve
Test the leg muscles
Tibialis anterior (Anterior compartment): Examiner grasps forefoot and subject asked to turn foot inward and upward - tendon becomes prominent and palpable antero-inferiorly to the medial malleolus - Deep fibular (peroneal) nerve
Fibular (Lateral compartment):
Examiner grasps forefoot and subject asked to turn foot outward and downward - tendon becomes prominent and palpable inferior to the lateral malleolus - Superficial fibular nerve
Calf muscles (Posterior compartment): Subject asked to stand on toes. muscle bellies at calcaneal tendon visible and palpable - Tibial nerve
Demonstrate palpation of arterial pulses in the lower limb and describe rate – femoral (will not be asked in the OSPE), popliteal, dorsalis pedis and tibialis posterior pulse.
The bones against which these pulse palpations occur should be recognised.
- Femoral: Palpated at midpoint between ASIS and pubic symphysis. Against the pubis. Vein is medial to this.
- Popliteal: Subject lies prone with knees flexed. Pulse palpated in inferior fossa in relation to the tibia. Against tibia.
- Dorsalis pedis: Palpate just lateral to EHL tendon. Against 1st metatarsal
- Tibialis posterior: Palpate just behind medial malleolus. Tibia
Veins - surface mark long saphenous and short saphenous, particularly their relationship to the
malleoli.
Long saphenous: Runs upwards 2cm in front of the medial malleolus, along medial side of leg, a hand’s width along the medial side of the patella, along medial side of thigh to saphenous opening in inguinal region
Short saphenous: Runs posterior to lateral malleolus and up back of calf to join deep venous system in popliteal fossa and drain into popliteal vein
Map and test the dermatomes of the lower limb
“L3 to the knee, L4 to the floor”
L1 = inguinal region
L2 = Upper lateral thigh
L3 = Lower lateral thigh
L4 = Medial leg + great toe
L5 = Lateral leg, dorsum of foot
S1 = sole of foot and little toe
S2 = Posterior thigh and penis
Test deep tendon reflexes - patellar tendon and ankle jerk using tendon hammers and recall
nerve roots
Patellar tendon (L4): Ask subject to sit on couch with legs dangling; must be relaxed. Palpate patellar tendon. Examiner strikes patellar tendon with tendon hammer.
Ankle jerk (S1): = Calcaneal (Achilles) tendon reflex - Ask subject to sit on edge of couch with legs dangling; must be relaxed. Palpate calcaneal tendon. Examiner strikes calcaneal tendon with tendon hammer whilst holding foot slightly dorsiflexed.
Surface mark sciatic nerve
- Leaves greater sciatic notch
- Enters gluteal region at midpoint between PSIS and ischial tuberosity.
- Curves downward and enters thigh at midpoint between greater trochanter and ischial tuberosity before reaching the popliteal fossa.
Test motor component of the sciatic nerve
Risk of damage during IM injection. Testing motor function of hamstrings (Flex knee)
