Lower limb problems I Flashcards
Name A-G
A- ilium
B- ischium
C- pubis
D- acetabulum
E- obturator foramen
F- Ischial tuberosity
G- Ischial spine
Name A-G
A- posterior superior iliac spine
B- iliac crest
C- sacroiliac joint
D- pubic tubercle
E- pubic symphysis
F- anterior superior iliac spine
G- acetabulum
Name A-E
A- greater sciatic foramen
B- lesser sciatic foramen
C- piriformis muscle
D- sacrospinous ligament
E- sacrotuberous ligament
Function of greater sciatic foramen
Allows structures into the pelvis
Function of lesser sciatic foramen
Allows structures into the perineum
The lesser and greater sciatic foramen are formed by
Sacrospinous ligament and sacrotuberous ligament
The greater sciatic foramen can be divided into suprapiriform and infrapiriform fossa by
piriformis muscle
Energy of injury that can cause pelvic fracture
High energy for young people
Low energy for older, osteoporotic bone
The pelvis forms a bony ring. This means that a pelvic fracture will
Cause fractures in more than 1 site - at bones/symphysis/joints
What classification is used to classify pelvic ring fractures
Young-Burgess classification
Symptoms of pelvic fracture
Pain
Unable to bear weight
Investigations for high energy pelvic fracture
Xray if the pelvis is the only site of injury
CT if polytraumatic
Investigations for low energy pelvic fracture
Xray
CT
MRI (most sensitive)
Management of pelvic fracture
Rest
Pelvic binder
Analgesia
Surgery if severe - ORIF / external fixation
Complications of pelvic fractures
Haemodynamically unstable since pelvic fracture is usually associated with other injuries
Rectal tear
Bladder and urethral injuries
Causes of pelvic soft tissue injury
Sports - muscle tear / tendon avulsion
Chronic overuse
Secondary to pelvic fracture
Investigations for pelvic soft tissue injury
US
MRI - treatment of choice since it looks at soft tissue and bones
Management of pelvic soft tissue injury
RICE
Rest
Ice
Compression
Elevation
Hip joint is a type of
Ball and socket synovial joint
Extracapsular ligaments of the hip joint are formed by
Thickened part of joint capsule
What are the extracapsular ligaments of the hip joint
Iliofemoral
Pubofemoral
Ischiofemoral (seen in posterior aspect)
What is the intracapsular ligament of the hip joint
Ligamentum teres - ligament to head of femur
Name A and B
A- acetabular labrum
B- ligamentum teres
The ligamentum teres encloses a
branch of obturator artery which is an artery supplying the head of femur
Function of acetabular labrum
Increases the depth of acetabulum to increase stability of the joint
Blood supply to the hip joint
Medial and lateral circumflex arteries from deep femoral artery
Branch of obturator artery travels in ligamentum teres to head of femur
Medial and lateral circumflex arteries are branches of
Deep femoral artery
Medial / Lateral circumflex femoral artery is responsible for the majority of arterial supply
Medial
Branch of obturator artery to head of femur is more important in adults / children
Children, because it usually disappears in adults
Which part of femur is the most commonly fractured and why
Neck of femur because it is the narrowest part of femur and lies at an angle to the direction of weight bearing (weaker)
Pain from hip joint can radiate to the knee as sole knee pain. Why is that
HIp joint is innervated by sciatic, femoral and obturator nerves which also innervate the knee
Name A-D
A- Neck
B- Greater trochanter
C- Intertrochanteric line
D- lesser trochanter
Name A-D (posterior femur)
A- trochanteric crest
B- Pectineal line
C- Linea aspera
D- Gluteal tuberosity
What is trochanteric crest
Ridge on posterior aspect of femur, a posterior point of attachment for the joint capsule of the hip
What is the linea aspera
Roughed edges of bone on the posterior surface of femoral shaft then splits into medial and lateral supracondylar line
The proximal medial border of linea aspera becomes
Pectineal line
The proximal lateral border of linea aspera becomes
Glutea tuberosity
Gluteal tuberosity is the attachment point for
Gluteus maximus
The medial supracondylar line ends at
Adductor tubercle
Adductor tubercle is an attachment point for
Adductor magnus
Name A-E
A- lateral epicondyle
B- Lateral condyle
C- Medial condyle
D- Medial epicondyle
E- Adductor tubercle
Name A-E
A- Medial epicondyle
B- Medial condyle
C- Intercondylar fossa
D- Lateral condyle
E- Lateral epicondyle
injury mechanism of hip dislocation
Road traffic accidents
Contact sports with hip flexed
Most common type of hip dislocation
Posterior hip dislocation
Associated lesions with hip dislocation
Acetabular rim fracture
Posterior acetabular wall fracture
Femoral fracture
Clinical presentation of posterior hip dislocation
Hip is
- Flexed
- Internally rotated
- Adducted
- Shortened
Clinical presentation of anterior hip dislocation
Hip is
- extended
- externally rotated
- abducted
Investigations for hip dislocation
Neurovascular assessment - sciatic nerve
Xray
CT after reduction if acetabular fracture suspected
Management for hip dislocation
Urgent reduction
Fixation of other injuries/associated pelvic fractures
Complications of hip dislocation
AVN of femoral head
Sciatic nerve palsy
Secondary OA of hip
Mechanism of injury for hip fracture
Low impact fall in elderly (main)
High energy in young adults
Risk factors for hip fracture
Elderly
Female
Osteoporosis
Smoking
Malnutrition
Co-morbidities that increases risk of falling
Low BMI
Examples of co-morbidities that increases risk of falling
postural hypotension
cardiac arrhythmias
impaired vision
cerebrovascular insufficiency
Existence of co-morbidities does not only increase the risk of falling, it also increases the risk of
Complications during surgery - MI/ renal failure/ resp failure/ infections
Types of hip fractures
Intracapsular
Extracapsular
Intracapsular hip fracture =
Occur proximal to intertrochanteric line -> femoral head and neck
Subtypes of Intracapsular hip fracture
Subcapital = at the junction between head and neck
Transcervical = mid portion of femur neck
Complications of intracapsular hip fractures
Femoral head AVN
Non union
Intracapsular fractures are classified by
Garden classification = predicts union and risk of AVN
What is extracapsular hip fracture
Hip fracture occurring distal to intertrochanteric line
Subtypes of extra capsular hip fracture
Intertrochanteric = at intertrochanteric line
Subtrochanteric = below intertrochanteric line
Does extracapsular hip fracture cause AVN or non-union
No, blood supply is rarely disrupted
Apart from assessing neruovascular status of lower limb in a patient with hip fracture, what else should be assessed
Assess for dehydration - patient may have been on the floor for a long time
Assess for cognitive impairment due to fall
Investigations for hip fractures
Xray - most are easy to see
MRI
Management for extra capsular hip fracture at intertrochanteric line
DHS screw
Management for subtrochanteric extra capsular hip fracture
IM nail
Management for intracapsular hip fracture in high function patient
If displaced -> Total hip replacement
If not displaced -> Cannulated hip screw (CHS)
Management for intracapsular hip fracture in Low function patient
Hemi-arthroplasty
Management for intracapsular hip fracture in Low function patient
Hemi-arthroplasty
Post-sugery management for hip fractures
Early mobilisation
Local nerve blocks (analgesia)
Superficial muscles of the gluteal region
Gluteus maximus
Gluteus medius
Gluteus minimus
Name A-C
A- Gluteus medius
B- Gluteus maximus
C- Gluteus minimus
Function of gluteus Maximus
Most powerful extensor of the hip
Innervation of the gluteus Maximus
Inferior gluteal nerve L5-S2
Function of gluteus medius
Abduct and medially rotate the thigh at hip joint
Innervation of gluteus medius
Superior gluteal nerve L4-S1
Function of gluteus minimus
Abduct and medially rotate the thigh at hip
Innervation of gluteus minimus
Superior gluteal nerve L4-S1
What are the deep muscles of the gluteal region
Piriformis
Superior and inferior gemelli
Obturator internus
Obturator femoris (quadratura femoris)
Name A-G
A- Tensor fascia latae
B- Gluteus maximus
C- Gluteus medius
D- Piriformis
E- Superior and inferior gemelli
F- Quadratus femoris
G- Obturator internus
Function of piriformis
Laterally rotate the extended thigh
Abduct the flexed thigh
Function of piriformis in anatomy
Divides the greater sciatic foramen into suprapiriform and infrapiriform foramina
Innervation of piriformis
Anterior (ventral) ramus of S1 S2
Function of superior and inferior gemelli
Laterally rotate the extended thigh
Abduct the flexed thigh
Innervation of superior and inferior gemelli
Superior - nerve to obturator internus L5-S2
Inferior - nerve to quadratus femoris L4-S1
Function of obturator internus
Laterally rotate the extended thigh
Abduct the flexed thigh
Innervation of obturator internus
Nerve to obturator internus L5-S2
Function of quadratus femoris
Laterally rotate the thigh
Innervation of quadratus femoris
Nerve to quadratus femoris L4-S1
What is the neurovascular bundle deep to gluteal Maximus
Inferior gluteal neurovascular bundle
- inferior gluteal nerve (L5-S2)
- inferior gluteal artery and vein
What is the neurovascular bundle deep to gluteal medius
Superior gluteal neurovascular bundle
- superior gluteal nerve (L4-S1)
- superior gluteal artery and vein
Name A-F
A- Inferior gluteal nerve
B- Pudendal nerve
C- Nerve to obturator internus
D- Superior gluteal nerve
E- Sciatic nerve
F- Tibial nerve
Damage to gluteus medius / minimus can cause which clinical sign
Trendelenburg’s gait
Left gluteal medius / minimus muscle weakness causes
Right side of pelvis to drop when standing on left leg
Gluteal medius / minimus muscle weakness can be caused by
Superior gluteal nerve damage
Sacral plexus origins
L4-S4
Main branches of sacral plexus
Pudendal nerve
Superior gluteal
Inferior gluteal
Nerve to obturator internus
Nerve to quadratus femoris
Sciatic nerve
Pudendal nerve roots
S2-S4
Motor functions of the pudendal nerve
External urethral sphincter
External anal sphincter
Sensory innervation of pudendal nerve
Perineum
external genitalia
Skin around the anus and anal canal
Sciatic nerve innervates
All posterior compartment of the thigh
All of the leg (through its branches)
Nerve roots of sciatic nerve
L4-S3
Main branches of sciatic nerve
Tibial nerve
Common fibular nerve
Where does the sciatic nerve branch off into tibial and common fibular nerves
Anywhere between gluteal region and popliteal fossa
Most commonly inferior 1/3 of thigh
Anatomical course of sciatic nerve
- from sacral plexus
- exits greater sciatic foramen
- inferior to piriformis
- travels down the thigh and branch off into common fibular and tibial nerves at inferior 1/3 of thigh
Does the sciatic nerve innervate the gluteal region
No, it supplies nothing in gluteal region
Tibial nerve anatomical course
Descends vertically through popliteal fossa
Tibial nerve motor innervation
All muscles in the posterior compartment of the leg
Common fibular nerve anatomical course
- Descends along the lateral border of the popliteal fossa
- Deep to biceps femoris tendon
- Then leaves the popliteal fossa to reach the fibular neck
- Winds around the fibular neck
- Then divides into deep and superficial fibular branches
Common fibular nerve motor innervation
Superficial fibular nerve - lateral compartment of the leg
Deep fibular nerve - anterior compartment of the leg
Common fibular nerve sensory innervation
Superficial fibular nerve - anterolateral aspect of distal leg + dorsal of foot
Deep fibular nerve - skin of webbing between 1st and 2nd toes
Sural - posterolateral aspect of distal third of the leg, ankle, foot and heel
Lateral sural - upper lateral aspect of leg
What injuries can damage the common fibular nerve?
Compression injury against neck of fibula
E.g. tight plaster cast
Fractures of fibular neck
What is sciatica
Compression / irritation of sciatic nerve causing pain that travels along the path of sciatic nerve (from lower back to leg)
Causes of sciatica
Lumbar slipped discs
Nerve root compression due to malignant metastases
Hypertrophy of piriformis muscle - bc sciatic nerve is behind piriformis hence hypertrophy can compress it
When administering IM injections in gluteal region, what should be considered
Position of sciatic nerve - avoid sciatic nerve
How do you avoid damaging the sciatic nerve when giving IM injections
Only inject it in upper lateral quadrant
the lumbar plexus is formed by _______ rami of L_ -L_
Formed by the anterior rami of L1-L4 spinal nerves
Main branches of the lumbar plexus
Lateral cutaneous
Obturator nerve
Femoral nerve
Origin of lateral cutaneous nerve
L2, L3
Function of lateral cutaneous nerve
Sensory - lateral thigh down to the level of the knee
No motor innervation
Origin of obturator nerve
L2-L4
Function of obturator nerve
Motor - muscles of the medial thigh
Sensory - skin over the medial thigh
Anatomical course of obturator nerve
Exits the pelvis by passing through the obturator foramen at ischium
Enters the medial compartment of thigh
Branches off into anterior and posterior branches at adductor brevis
Origin of femoral nerve
L2-L4
Function of femoral nerve
Motor - anterior thigh muscles
Sensory - skin of anterior thigh (via anterior cutaneous branch)
and medial leg and foot (via saphenous)
Anatomical course of femoral nerve
Enters the thigh by passing under the inguinal ligament
Enters the femoral triangle of the thigh
Then divides into anterior and posterior branches
What are the main branches of femoral nerve that supplies sensory innervation
Saphenous nerve (posterior branch)
Anterior cutaneous branch
Anterior cutaneous branch of femoral nerve supplies
Sensory innervation to anterior thigh
Saphenous nerve (branch of femoral nerve) supplies
Sensory innervation to medial leg and foot
What is the fascia lata
Fascial plane that surrounds the deep tissues of the thigh
What is the iliotibial tract
Thickening of the fascia lata at the lateral side of the thigh
What is tensor fascia lata
The muscle that inserts onto the anterior aspect of iliotibial tract
Function of iliotibial tract
Protects the knee
Function of tensor fascia lata
Tightens the iliotibial band and strengthen the knee joint
Name A-C
A- gluteus maximus
B- Iliotibial band
C- Tensor fascia lata
Innervation of tensor fascia lata
Superior gluteal nerve
What is trochanteric bursitis
inflammation of the bursa overlying the greater trochanter of the femur.
Which muscles attach to the greater trochanter of the femur
Gluteus medius
Gluteus minimus
Risk factors for trochanteric bursitis
Female
Young and older patients
Hiking
Excessive running
fall onto the hip
Symptoms of trochanteric bursitis
Pain on the lateral aspect of the hip
Pain worse at night
Clinical signs of trochanteric bursitis
- Pain on palpation of the greater trochanter
- Pain on restricted abduction
- Trendelenburg’s gait or difficulty walking due to pain
Investigations for trochanteric bursitis
Clinical
Xray doesn’t show anything significant
Management for trochanteric bursitis
Analgesia
Steroid injections
Physiotherapy
