Lower limb problems III Flashcards
1
Q
What does the extensor mechanism of the knee consist of
A
Tibial tuberosity
Patellar tendon
Patella
Quadriceps tendon
Quadriceps muscles
2
Q
What are the muscles in the anterior compartment of the thigh
A
Pectineus
Iliopsoas (Iliac, psoas major)
Sartorius
Quadricep femoris (rectus femoris, vastus lateralis, vastus intermedius, vastus medialis)
3
Q
Iliopsoas =
A
Iliacus + psoas major
4
Q
What are the quadricep muscles
A
Rectus femoris
Vastus lateralis
Vastus intermedius (deep to rectus femoris)
Vastus medialis
5
Q
Name the flexors of the thigh
A
Pectineus
Iliopsoas
Sartorius
6
Q
Function of the quadriceps femoris
A
Extension of the leg
Rectus femoris weakly assists with flexion at hip
7
Q
Attachment of iliacus
A
Origin: Iliac fossa
Attachment: Lesser trochanter of femur
8
Q
Attachment of psoas major
A
Origin: Lumbar vertebrae T12-L4
Attachment: Lesser trochanter of femur
9
Q
Function of iliopsoas
A
Flexion of the thigh at hip joint
10
Q
Innervation of iliacus
A
Femoral nerve (L2-L4)
11
Q
Innervation of psoas major
A
Anterior rami of L1-L3
12
Q
Attachment of sartorius
A
Origin: ASIS
Attachment: Superior medial surface of tibia via pes anserinus bursa
13
Q
Function of sartorius
A
Flexion, abduction, lateral rotation of the hip joint
Flexion at the knee joint
14
Q
Innervation of sartorius
A
Femoral nerve (L2-L4)
15
Q
Origin of rectus femoris
A
AIIS (anterior inferior iliac spine)
16
Q
All muscles of the quadricep femoris attach to
A
Patella via quadriceps tendon then to tibial tuberosity via patella tendon
17
Q
Function of quadriceps femoris
A
Extension of the leg at knee
Rectus femoris assists with flexion of the hip
18
Q
Innervation of quadriceps femoris
A
Femoral nerve
19
Q
Name A-I
A
A- Psoas major
B- Pectineus
C- Tensor fascia lata
D- Sartorius
E- Vastus medialis
F- Quadriceps tendon
G- Patellar tendon
H- Rectus femoris
I- Vastus lateralis
20
Q
Extensor mechanism rupture commonly occurs in
A
Middle aged who does running / jumping sports
21
Q
Extensor mechanism rupture =
A
Patellar tendon / quadriceps tendon rupture
22
Q
Patellar tendon rupture commonly occurs in
A
Younger patients <40
23
Q
Quadriceps tendon rupture commonly occurs in
A
Older patients >40
24
Q
Risk factors of extensor mechanism rupture
A
Previous tendonitis
Steroids (body builders)
Chronic renal failure
Ciprofloxacin / quinolone antibiotics (can cause tendonitis)
Diabetes
RA
25
Symptoms of extensor mechanism rupture
Knee pain and weakness
Positive straight leg raise test
26
Clinical signs of extensor mechanism rupture
Positive straight leg raise test
Palpable gap in extensor mechanism
27
Describe the straight leg raise test for extensor mechanism rupture
1. Patient supine, knee fully extended
2. Raise the patient's leg by holding their ankle and one hand stabilising the knee to prevent flexion
Positive = pain
28
A positive straight leg raise test can also indicate
Lumbar nerve root compression pain
29
Investigations for extensor mechanism rupture
Xray
US
MRI
Straight leg raise test
Palpable gap
30
What may xray show in extensor mechanism rupture
High or low lying patella, depending on the rupture
31
Low lying patella suggests _____ rupture
High lying patella suggests _____ rupture
Low lying patella = quadricep tendon rupture
High lying patella = Patellar tendon rupture
32
Palpable gap in extensor mechanism may not be present / obvious in _____. What is the solution
Obese patients
Use US to determine the extent of injury
33
Management of extensor mechanism rupture
Urgent surgical repair
Physio
34
What should be avoided in extensor mechanism rupture
Steroid injection for tendonitis of the extensor mechanism
35
What is patellofemoral dysfunction
Disorders of the patellofemoral articulation causing anterior knee pain
36
Risk factors of patellofemoral dysfunction
Females
Adolescents
Joint hyper mobility
Valgus knee
37
Cause of patellofemoral dysfunction
Excessive lateral pull of patella due to quadriceps muscles, causing the lateral facet of patella to be compressed against the lateral wall of distal femoral trochlea
38
Why are females more at risk of patellofemoral dysfunction
Due to wider hips hence more lateral pull of the patella from the quadriceps
39
Why are adolescents more at risk of patellofemoral dysfunction
Due to ligamentous laxity
40
Symptoms of patellofemoral dysfunction
Anterior knee pain
Pain worse going downhill
Grinding / clicking sensation
Stiffness after prolonged sitting -> pseudolocking
41
investigations for patellofemoral dysfunction
Clinical
42
Management of patellofemoral dysfunction
Physiotherapy
Taping around anterior knee
43
What are the muscles in the medial compartment of the thigh
Adductor Magnus
Adductor longus
Adductor brevis
Obturator externus
Gracialis
44
Adductor Magnus can be divided into 2 parts. Which two?
Adductor part
Ischiocondylar part
45
Attachment of adductor part of adductor Magnus
Origin: Inferior pubic rami
Attachment: Linea aspera, Medial supracondylar line
46
Attachment of ischiocondylar part of adductor Magnus
Origin: Ischial tuberosity
Attachment: Adductor tubercle of femur
47
Function of adductor part of adductor Magnus
Adduct the thigh
Flexes the thigh
48
Function of hamstring part of adductor Magnus
Adduct the thigh
Extends the thigh
49
Innervation of adductor Magnus
Adductor part - tibial component of sciatic nerve
Ischiocondylar part - obturator nerve
50
Function of medial compartment of the thigh
All adduct the thigh
(some has other functions)
51
Innervation of medial compartment of thigh
Obturator nerve except adductor part of adductor Magnus
52
Function of obturator externs
Adduct the thigh
Lateral rotation of the thigh
53
Function of gracilis
Adduct the thigh
Weak flexion of leg at knee
54
Position of adductor brevis in relation to pectineus, adductor Magnus and adductor longus
Adductor brevis is
- deep to Pectineus
- superior and partially deep to adductor longus
- anterior to adductor Magnus
55
Name A-F
A- Pectineus
B- Adductor brevis
C- Adductor longus
D- Adductor Magnus
E- Adductor brevis
F- Openings for perforating arteries
56
Name A-G (D= muscle in green)
A- Tensor fascia lata
B- Pectineus
C- Adductor longus
D- Adductor Magnus
E- Vastus lateralis
F- Vastus medialis
G- Gracialis
57
Name A-G
A- Adductor tubercle
B- Medial epicondyle
C- Intercondylar fossa of femur
D- Medial intercondylar tubercle
E- Intercondylar eminence of tibia
F- Lateral intercondylar tubercle
G- Tibial tuberosity
58
What are the features of tibia shaft
Anterior - tibial tuberosity, Gerdy's tubercle
Posterior - soleal line , groove for tendon of tibialis posterior
Lateral- Attachment to interosseous membrane that binds with fibula
59
What attaches to Gerdy's tubercle
Iliotibial band
60
What attaches to the soleal line
Soleus muscle of the posterior compartment of leg
61
Name A-C
A- Tibial tuberosity (where the patellar tendon attaches)
B- Soleal line
C- Medial malleolus
62
At the posterior distal tibial surface, there is a groove for
A groove for tendon of Tibialis posterior
63
Name A-E
A- Soleal line
B- Groove for tendon of tibialis posterior
C- Medial malleolus
D- Articular facet of medial malleolus
E- Lateral malleolus
64
Which nerve winds around the neck of fibula
Common fibular nerve
65
Describe the articulations of the ankle joint
Tibia and fibula are bound together by tibiogibular ligaments which allows them to form a socket called mortise
The body of talus fits into the mortise = ankle joint
66
What type of joint is the ankle joint
Hinge type synovial joint
67
What are the movements of the ankle joint
Dorsiflexion of the foot
Plantarflexion of the foot
68
Which compartment of the leg produces dorsiflexion of the foot
Anterior compartment
69
Which compartment of the leg produces plantar flexion of the foot
Posterior compartment
70
Ankle can invert and evert as well. Which joint does these movements occur at?
Subtalar joint
71
Which bones articulate at the subtalar joint
Talus and calcaneus
72
What type of joint is the subtalar joint
Synovial joint
73
The body of the talus moves to allow movement. Describe the movement of the talus during dorsi/plantar flexion
Dorsiflexion - anterior part of body of talus in the mortise
Plantarflexion - posterior part of body of talus in the mortise
74
During which movement of the ankle joint is the joint less stable
Plantarflexion - posterior body of talus in mortise
75
Name A-F
A- anterior inferior tibiofibular ligament
B- Lateral malleolus
C- Posterior inferior tibiofibular ligament
D- Mortise
E- Medial malleolus
F- Talus
76
What are the 2 sets of ligaments of the ankle and where do they originate from
Medial ligament - from medial malleolus
Lateral ligament - from lateral malleolus
77
How many ligaments does the medial set consist of
4 ligaments
78
Function of medial ligament
Resist over-eversion of foot
79
What are the lateral ligaments of the ankle
Anterior talofibular
Posterior talofibular
Calcaneofibular
80
Name A-D
A- Deltoid ligament (medial ligament)
B- Posterior talofibular ligament
C- Anterior talofibular ligament
D- Calcaneofibular ligament
81
Function of lateral ligaments of the ankle
Resist over-inversion of the foot
82
Describe the arterial supply to the ankle joint
Malleolar branches of anterior tibial, posterior tibial and fibular arteries
83
Name A-F
A- fibular (peroneal) artery
B- Anterior tibial artery
C- Anterior medial malleolar artery
D- Anterior lateral malleolar artery
E- Posterior tibial artery
F- Posterior medial malleolar artery
84
Name A-G
A- Medial tarsal artery
B- Dorsalis pedis artery
C- Anterior medial malleolar artery
D- Anterior tibial artery
E- Arcutate artery
F- Lateral tarsal artery
G- Anterior lateral malleolar artery
85
Articulations of the midtarsal joint
Calcaneocuboid and talocalcaneonavicular
86
What type of joint is mid tarsal joint
Synovial joint
87
Midtarsal joint allows which movements
Inversion and eversion
88
Name A-L
A- Lateral malleolus
B- Calcaneus
C- Cuboid
D- Proximal phalanx
E- Middle phalanx
F- Medial malleolus
G- Talus
H- Navicular
I- Lateral cuneiform
J- Middle cuneiform
K- Medial cuneiform
L- Proximal phalanx of big toe
89
What is the tarsometatarsal joint
Synovial joint between the cuneiforms / cuboid and the metatarsals
90
What are the metatarsophalangeal joints (MTP)
Synovial joints between the metatarsals and the proximal phalanx
91
What movements do the MTP joints allow
Flexion, Extension, Abduction, Adduction, Circumduction of the toes
92
What are the interphalangeal joints (IP)
Synovial hinge joints between the phalanx
For 2nd - 5th toes - PIP and DIP
For big toe - IP
93
What movements do the IP joints allow
Flexion and extension of the toes
94
What are the arches of the foot
Medial longitudinal arch
Lateral longitudinal arch
Transverse arch
95
Function of the arches of the foot
Shock absorption
Allow you to push off
Increase weight bearing capacity
96
What structures support the arches of the foot
Plantar aponeurosis
Plantar ligaments
Tendons of the muscles of the leg
97
What structures support the medial longitudinal arch
Tendon of flexor hallucis longus
Tendon of tibialis anterior
Tendon of tibialis posterior
Tendon of fibularis longus
Plantar ligaments
Plantar aponeurosis
98
Which compartment is tibialis anterior muscle in
Anterior compartment of the leg
99
Which compartment is fibularis longus in
Posterior compartment of the leg
100
Which compartment is flexor hallicus longus in
Posterior compartment of the leg
101
Name A-E
A- Tendon of tibialis anterior
B- Tendon of fibularis longus
C- Tendon of flexor hallicus longus
D- Plantar aponeurosis
E- Tendon of tibialis posterior
102
Which arch of the foot is more important
Medial longitudinal arch
103
What structures support the transverse arch
Tendon of fibularis longus
Tendon of tibialis posterior
Plantar aponeurosis
Plantar ligaments
104
What is pes cavus
Unusually high medial longitudinal arch
105
Symptoms of pes cavus
Pain
Pain transmitted up to lower limb
Claw toes
106
Why does pain in pes cavus transmit up to the lower limb
Because of the higher arch, there is an increased stress placed on the heel of the foot during walking
107
Causes of pes cavus
Idiopathic
Hereditary
Secondary to neuromuscular damage
108
Management of pes cavus
Special shoes or sole
Weight loss can reduce stress placed on foot
Physiotherapy
Surgery if severe symptoms
109
What are claw toes
Hyperextension at MTP joint
Flexion at PIP DIP joints
110
What are hammer toes
Flexion at PIP joint
Extension at DIP joint
Neutral MTP joint
111
Which condition can cause hammer toes
Rheumatoid arthritis
112
What feet deformities can RA cause
Hallux valgus
Hammer toes
MTP subluxation
113
What is hallux valgus
Medial deviation of the 1st metatarsal
Lateral deviation of the toe
114
Which conditions can cause hallux valgus
RA
Cerebral palsy
Multiple sclerosis
115
Symptoms of hallux valgus
Bilateral
Bunion
May be painful
May be unable to wear closed shoes
Toes rubbing causing ulcers / skin breakdowns
116
Management of hallux valgus
Wear wider and deeper shoes
Use spacer in first web space to stop rubbing of the toes
Osteotomy if indicated
117
When is osteotomy indicated in hallux valgus
Failure of conservative management
Lesser toe deformities
Lifestyle/functional limitation
118
What is hallux rigidus
OA of the 1st MTP joint
119
Symptoms of hallux rigidus
Pain at 1st MTP
Stiffness
Pain worse with activity / wearing shoes
Dorsal bone spurs
IP joint hyperextension
120
Management of hallux rigidus
Weight loss if needed
Analgesia
NSAID
Wear stiff soled shoes to limit motion at MTP joint
Surgery
121
What are the surgical options for hallux rigidus
Arthrodesis
Removal of osteophytes
MTP joint replacement (controversial)
122
How does ankle fractures usually occur
Inversion injury with twisting forces
Fall from height
123
Ankle fracture often has one / more than one fracture sites
More than one fracture sites - lateral/medial/posterior malleolus (back of tibia)
124
What classification is used to assess ankle fractures
Weber classification
125
What is Weber's classification
Classification of lateral malleolar fractures, relating to the level of the fracture in relation to the ankle and tibiofibular syndesmosis (where tibiofibular ligament is)
126
Describe Weber A ankle fracture
Lateral malleolar fracture below the level of syndesmosis
May have fracture of medial malleolus
Stable fracture
Can be treated conservatively
127
Describe Weber B ankle fracture
Lateral malleolar fracture at the level of syndesmosis
Syndesmosis still intact
May be stable / unstable
May be treated conservatively if there is no talar shift
128
Describe Weber C ankle fracture
Lateral malleolar fracture above the level of syndesmosis
Syndesmosis disrupted
Medial malleolus often fractured
Unstable
Requires open reduction and internal fixation
129
Investigations for ankle fractures
Xray - AP and lateral
CT - esp for Pilon fractures
US / MRI for soft tissue injuries
130
What are Pilon fractures
High energy fractures at the bottom of tibia and involving the ankle joint
131
Management of ankle fractures
Cast / moon boot - Weber A and B
ORIF - Weber C
132
Which tarsal bone is the most frequently fractured
Calcaneus
133
Injury mechanism of calcaneus fracture
Axial compression - falling from height onto heel
134
Symptoms of calcaneus fracture
Pain
Unable to bear weight
Significant ankle swelling
135
Investigations for calcaneus fracture
Xray
CT
136
What may be seen on xray for calcaneus fracture
Loss of central peak - measured by Bohler's angle
Increase in bone density
137
Management of calcaneus fracture
Cast
Non-weight bearing for 6-12 weeks
138
Injury mechanism of talus fractures
Forced dorsiflexion
Rapid deceleration
139
Displaced talus fractures can cause
AVN of talus
140
What arteries supply the talus
Anterior tibial
Posterior tibial
Perforating peroneal artery
141
What is Lisfranc injury
Dislocation of tarsometatarsal joint between the articulation of medial cuneiform and base of second metatarsal
142
Symptoms of Lisfranc injury
Severe midfoot pain
Inability to bear weight
143
Investigations for Lisfranc injury
Xray- AP and oblique
CT - identify ligamentous avulsion fractures
144
Management of Lisfranc injury
ORIF
145
Most common type of ankle sprain
Lateral ankle sprain
146
Injury mechanism of lateral ankle sprain
Forced inversion of plantar-flexed foot
147
Which lateral ligament is the most likely to be injured in an ankle sprain
Anterior talofibular ligament
148
Symptoms of ankle sprain
Tenderness
Swelling
Bruising
Pain on weight bearing
Instability
149
Investigations of ankle sprain
Xray
150
Management for ankle sprain
RICE- rest, ice, compression, elevation
Physiotherapy
Reconstruction if needed
