MSK LE Best- slide 29 on (exam 2) Flashcards
T/F: the plantaris and popliteus cross two joints
FALSE. they do not cross two joints
List 3 muscles that are knee extensors
-vastus mediaris -vastus lateralis and vastus intermedius
Veins of the LE: -anatomic superficial veins are
Greater Saphenous vein Lesser Saphenous vein
Veins of the Lower Extremity: Anatomic deep veins are?
-Anterior Tibial veins -Posterior Tibial veins -Peroneal (Fibular) veins -Popliteal vein -Femoral vein -Deep Femoral vein -Common Femoral Vein -Pelvic veins
The deep and superficial veins of the LE are connected by _______ veins
perforating
DVT that become Pulmonary Emboli occur in the: (hint lots of areas)
Proximal portion of the Greater Saphenous vein in the Thigh -Deep veins of the Leg, Thigh, and Pelvis: -Anterior Tibial veins -Posterior Tibial veins -Peroneal (Fibular) veins -Popliteal vein -Femoral vein -Deep Femoral vein -Common Femoral Vein -Proximal Portion of the Greater Saphenous vein -Pelvic veins
Dermatomes: -L1= -L2= L3 L4 L5= S1= S2=
?
Myotomes: _____ _______ are used to test Myotomes
Joint Movements
Myotome levels: -Hip extensors= -Hip flexors=
Primary Nerve Segments used Hip Extensors: L5-S1 Hip Flexors: L1-2
Myotome levels: -knee extensors ? -Knee flexors ?
Knee Extensors: L3-4 Knee Flexors: L5-S2
Myotome Levels: -Foot Dorsiflexors? -Foot plantarflexors?
Foot Dorsiflexors: L4-5 Foot Plantarflexors: S1-2
Myotome Levels: -Toe Extensors ? Toe Flexors?
Toe Extensors: L5-S1 Toe Flexors: S2
When people can’t walk on their toes, what myotome level is this affecting?
S1-S2
How are myotomes tested?
myostatic (stretch) reflexes
Causes of abnormalities in stretch reflexes in the lower extremities include:
herniated nucleus pulposis, peripheral neuropathy, spinal stenosis, hypothyroidism, motor neuron disease
Patellar reflex=
Knee Jerk Reflex, Quadriceps Muscle Stretch Reflex) tests L2,3,4 cord segments
Ankle Jerk Reflex:
(Achilles Reflex) tests S1/S2
Foot drop= -what nerve level affected? -Causes?
can’t dorsiflex foot– causes include L5 injury (HNP), Sciatic, or Peroneal (Fibular) nerve injury, ALS, MS.
Pes Anserinus - SGT FOS: -attachments at the Pes Anserinus? -muscles? -nerves to these muscles?
-Attachments at the Pes Anserinus (aka Goose foot) —Clinical Significance– Pes Anserinus Bursitis > Chronic Knee pain -Sartorius -Gracilis -SemiTendinosus –Nerves to these muscles – SGT FOS FOS = Femoral, Obturator, Sciatic
Describe the Sartorius
Sartorius- crosses 2 joints (hip and knee joint) helps you flex the hip joint and flex knee joint and externally rotate the femur Sartorius is anterior– innervated by the femoral nerve
Describe the Gracillis
Gracilis- innervated by obturator nerve (ADDUCTOR muscle= medial compartment of the thigh) . Obturator nerve does adductor muscles
Describe the Semitendonosis
Semitendonosus– innervated by the sciatic nerve (hamstrings= back of thigh= sciatic nerve))
Describe Sciatica
Sciatica is a set of symptoms, not a diagnosis. —Pain caused by compression and/or irritation of one of the five nerve roots that are branches of the Sciatic Nerve, L4 to S3.
Sciatica–> The compression or irritation of the Sciatic nerve can be caused by:
-Spinal disk herniation -Degenerative disk disease -Spinal Stenosis -Spondylolisthesis: with or without Spondylolysis -Piriformis Syndrome: compression of nerve beneath muscle -Sacroiliac joint dysfunction: unhealthy posture -Pregnancy
Sciatica: -where is pain felt? -Pain can be accompanied by?
-pain is felt in the lower back, buttock, and/or parts of the leg and foot. -This pain can be accompanied by numbness and muscle weakness.
Sciatic nerve innervates:
Innervates the muscles of the posterior thigh (biceps femoris, semimembranosus and semitendinosus) and the hamstring portion of the adductor magnus (remaining portion of which is supplied by the obturator nerve). Indirectly innervates (via its terminal branches) all the muscles of the leg and foot.
Iliopsoas –level of maximal nerve respnse?
L2,L3
Adductor longus –level of maximal nerve respnse?
L2, L3, L4
Vastus medialis vastus lateralis –level of maximal nerve respnse?
L2 L3 lateralis also has L4
Tibialis anterior:
L4,L5
Peroneus Longus
L4,L5,S1
Extensor Hallicus Longus
L4,L5,S1
Flexor Hallucis Longus
L5,S1
Medial Gastrocnemius Lateral Gastrocnemius Gluteus Maximus Biceps Femoris
L5,S1
The L5 nerve root can be affected by:
**-central herniated nucleus pulposis at the L4-5 level **-lateral herniated nucleus pulposis at the L5-S1 level
Herniation to the L4/L5 nerve affects which nerve root
L5/S1 -GET AN MRI to find out what the issue is and where
Sx of L5 motor nerve root damage: -motor findings? weakness of which muscles?
-Motor findings include: Foot Drop on the same side as the lesion from weakness of the Tibialis anterior, Peroneus longus, Extensor hallucis longus muscles. -Motor findings can include Trendelenberg gait from weakness of the Gluteus medius and minimus.
The L 5 nerve root can be affected by a central herniated nucleus pulposis at the L4-5 level or a lateral herniated nucleus pulposis at the L5-S1 level: -sensory findings can include?
-pain on the dorsum of the foot -numbness on the lateral calf
Damage to L4 nerve root: -motor weakness= -Screening exam= -Reflexes=
-(inability) of extension of quadriceps -screening= inability to squat and rise -Knee jerk diminished
Damage to L5 nerve root: -motor weakness= -Screening exam=
-dorsiflexion of great toe and foot -Inability to heel walk
Damage to S1 nerve root: -motor weakness= -Screening exam= -Reflexes=
-plantar flexion of great toe and foot -Inability to toe walk (walk on toes) -Ankle jerk diminished
Spondylolysis=
condition where the vertebrae are separated, in most cases from a fracture (*=fracture)
spondylolisthesis=
means the vertebrae have separated and moved out of proper position (aka **slide)
Scotty dog=
pars interarticularis (refers to a small segment of bone that joins the facet joints in the back of the spine)
loss of the neck of the scotty dog=
spondylolysis (L4-L5)
Piriformis Syndrome=
a tight piriformis muscle is taut and presses against the sciatic nerve, irritating it. This causes pain to travel up and down the nerve. (“wallet syndrome” aka piriformis syndrome– a large wallet pinches on the piriformis muscle—>pinches the sciatic nerve–extremely painful
Innervation of the lower leg: -the sciatic nerve gives rise to which nerves?
sciatic nerve gives rise to the Common fibular (aka peroneal nerve) that goes lateral and anterior, and the tibial nerve (travels medial and posterior).
Tibial nerve goes:
**posterior and medial to plantar flex and invert the foot -Posterior nerves will plantar flex foot and flex toes -Medial nerves will invert the foot
Fibular (aka peroneal) nerves go:
anterior and lateral to dorsiflex and evert the foot
Common Fibular (aka Peroneal nerve)(anterior and lateral): -Divides into the _____
-Deep Fibular/Peroneal nerve and the Superficial Fibular/Peroneal nerve - Superficial peroneal nerve (lateral)motor fx= foot eversion -Deep peroneal nerve motor (anterior) fx= foot dorsiflexion (L5), toe extension
Describe the proximal lower leg:
-Again, note deep and superficial veins DVT in deep veins Greater/Long Saphenous Vein is superficial. Lesser/Small Saphenous Vein is superficial. Deep Veins where DVT occur: -Anterior Tibial v is just lateral to the Tibia -Popliteal v just posterior to the Tibia. The Popliteal Vein will bifurcate into the Posterior Tibial Vein and the Common Peroneal/Fibular vein.
Mid lower leg innervation:
peroneal (fibular) nerve
Mid lower leg: -anterior compartment consists of which arteries and veins?
Anterior Tibial Artery and Vein and Deep Peroneal nerve = anterior compartment
Mid lower leg: -Posterior compartment=
Posterior Tibial Artery and Vein, Peroneal/Fibular Artery and Vein, and the Tibial Nerve (are in Deep Posterior Compartment)
Mid Lower LegCompartments/Compartment Syndromes (describe): -when evaluating compartment syndrome–> what MUST you document?
In injuries to the leg, to evaluate for Compartment Syndrome make sure that you document the presence of pulses and sensory and motor function distal to the injury.
Anterior compartment (of the thigh)= contains ?
-vastus lateralis -vastus intermedius -Rectus femoris -vastus medialis -sartorius -Iliotibial band -Femoral artery and vein, saphenous vein, adductor canal
Adductor compartment (aka medial/anterior compartment of the thigh)=
-obturator externus -gracilis -adductor longus -adductor brevis -adductor magnus -Deep femoral artery and vein
Posterior compartment of the thigh=
-biceps femoris (short head and long head) -semitendonosis -semimembranosus -sciatic nerve
Anterior compartment of the lower leg= contains?
-deep peroneal nerve -tibialis anterior -extensor hallucis longus -extensor digitorum longus
Lateral compartment of the lower leg= contains?
-peroneus longis -peroneus brevis
Posterior compartment of the lower leg= contains?
-soleus -gastrocnemius (lateral and medial heads) -
Deep posterior compartment of the lower leg= contains?
-tibialis posterior -flexor digitorum longus -flexor hallucis longus -posterior tibial artery, vein, and posterior tibial nerve
Compartment Syndrome: -sx? -causes?
-pain out of proportion to exam findings -pain on muscle stretch -loss of sensation -6 P’s Causes: burns, exercise, trauma, revasc. procedures -leads to a decrease in capillary perfusion, decreased tissue viability with fast and irreversible muscle/nerve damage
T/F: one can develop compartment syndrome within the fascia
true. or if cast is too tight! (- 2/2 bleeding, edema, or whatever is going on beneath a fascial plane, or 2/2 tight bandage or cast )
Compartment syndrome: -outcomes?
-Good outcome if Early intervention (<8 hrs) and adequate fasciotomy -too late–> BAD–> >35 hrs, morbidity high
Tom, Dick and Nervous Harry
Note Anterior and Posterior Tibial vessels image
The articular surface of the talus articulates with the _____
tibia (distal end) -note: the articular surface of the talus is wide anteriorly, and narrow posteriorly)
which 2 structures does the interosseus ligament separate?
Tibia and fibula
Deltoid Ligament of the ankle: -Deep components? -Superficial components?
**deltoid ligament= MEDIAL ligament of the ankle joint (has several components) -Posterior tibiotalar part (right below it is the medial tubercle of the talus) -anterior tibiotalar part -tibiocalcaneal part -tibionavicular part -Plantar calcaneonavicular ligament (connects the tuberosity of the navicular bone to the sustentaculum tali of calcaneous bone)
Lateral ankle Ligaments=
-anterior talofibular ligament -Calcaneofibular ligament (note: lateral ligaments are NOT as strong) Posteriorly: just have the Posterior talofibular ligament
Plantar Ligaments and Plantar Aponeurosis (bottom of the foot)
-Fibularis longus tendon (comes in and crosses over the bottom of the foot from lateral to medial, & inserts on the first metatarsal. Helps support the foot) -Short plantar ligament (connects calcaneal tubercle to calcaneocuboid joint) -Plantar calcaneonavicular ligament (located medially, on bottom of foot) -more superficial bottom of the foot: -Long plantar ligament (goes over the short plantar ligament) -Plantar Aponeurosis**= inserts on medial process of calcaneal tuberosity and goes to all the digits
Tarsal tunnel syndrome=
The tarsal tunnel refers to the canal formed between the medial malleolus (part of the ankle bone, this is the bump on the inside of the ankle) and the flexor retinaculum (a band of ligaments that stretches across the foot). Inside the tarsal tunnel are the nerves, arteries, and tendons that provide movement and flexibility to the foot. The sensory nerve in the ankle, the tibial nerve, passes through the tarsal tunnel and can be compressed and irritated causing numbness and tingling of the foot and toes as this nerve provides sensation to the bottom of the foot. Tarsal tunnel syndrome has also been called posterior tibial neuralgia.
Tarsal tunnel- location?
-located b/w the talus and flexor retinaculum -it contains tendon of flexor hallacis longus, tibial nerve, Posterior tibial artery, Tendon of flexor digitorum longus, Tendon of tibialis posterior) AKA Tom dick and very nervous harry
List Tom Dick and very nervous harry
(contents of the tarsal tunnel:) Mnemonic: Tom, Dick, and Nervous Harry. -*Tibialis Posterior Tendon, -Flexor *Digitorum longus, -Posterior Tibial *Artery - Tibial Nerve -Flexor Hallicus longus tendon
Where do you palpate the posterior tibial pulse?
-midway between the heel and medial malleolus
Peroneus Brevus and Peroneus Longus Tendons are located laterally behind the ______
fibula
Pimenta’s Point=
=the point where you can eval. the posterior tibial artery –>Posterior Tibial artery is palpated halfway between tip on Medial Malleolus and insertion of the Achille’s tendon. (aka midway b/w the heel and medial maleolus)
Where do you palpate the Dorsalis Pedis Artery?
lateral to the extensor hallucis longus tendon (or medially to the extensor digitorum longus tendon) on the dorsal surface of the foot,
Dorsalis pedis artery is located:
-underneath the **inferior extensor retinaculum -it innervates the first dorsal interosseus muscle -lateral to it you have the tendons of the extensor digitorum longus and fibularis tertius
Tendons of the fibularis longus and brevis muscles innervate the ____
5th metatarsal digit
Describe inversion of the foot
sole of foot faces in, some **adduction of the forefoot
Describe eversion of the foot
more difficult, sole of foot out laterally, some abduction
Longitudinal axis=
inversion and eversion
Vertical axis=
adduction/abduction
Coronal axis=
dorsiflexion/plantarflexion
Ankle sprain=
**is where one or more of the ligaments of the ankle are partially or completely torn.
What is the MC mechanism of injury for ankle sprains?
-**Inversion, lateral ligament injuries are 85% of all ankle sprains. -*Most common lateral ligament injured is the anterior talofibular Ligament (ATFL).
On the medial side of the ankle, which ligaments are injured with pronation and rotation of the hindfoot?
(pronation=eversion) the strong Deltoid ligament complex [Posterior tibiotalar (PTTL), Tibiocalcaneal (TCL), Tibionavicular (TNL), and Anterior tibiotalar ligaments (ATTL)] is injured with pronation and rotation of the hindfoot.
Which ligaments of the foot are stabilizing, but can be sprained with **external rotation of the leg and dorsiflexion of the ankle?
Tibiofibular syndesmosis (Interosseus ligaments)
Describe the MOI for Lateral, Medial and High Ankle sprains. -describe ligaments involved
image
Passive inversion or plantar flexion with inversion should replicate symptoms for a ______ ________sprain.
lateral ligament
Passive eversion should replicate symptoms for a _____ _______ sprain.
medial ligament
high ankle sprain MOI=
-external rotation and dorsiflexion -ligaments involved: ant.inferior tibiofibularligament, posterior inferior tibiofibular ligament, transverse tibiofibular ligament, interosseus membrane, interossues ligament, inferior transverse ligament
Lateral ankle sprain MOI=
inversion/plantar flexion -anterior talofibular ligament, cancaneo-fibular ligament, posterior talofibular ligament
**Ottawa Ankle Clinical Predication Rules: -An ankle X-ray series is required if:
-there is PAIN in the malleolar zone and any of these findings: -A-bone tenderness at A (lateral malleolus) -B- bone tenderness at B (medial malleolus) -Inability to bear weight Ottowa ankle rules: Medial malleolus pain 6 cm (malleolar zone) Lateral malleolus pain-up to 6 cm Unable to weight bear
Ottawa Ankle Clinical Predication Rules: -A foot x-ray series is only required if:
there is pain in the **midfoot zone and any of these findings: -Bone tenderness at C (base of 5th metatarsal) -Bone tenderness at D (navicular bone) -Inability to bear weight
With ankle injuries what do you need to look for: **
Look for impingement, Tarsal Tunnel Syndrome, Sinus Tarsi Syndrome, Cartilage or osteochondral injuries, Peroneal tendinopathy or subluxation, or Posterior tibial tendon dysfunction
What are the 4 Major Injury mechanisms? (of ankle fractures)
-SA =Supination Adduction -SE =Supination External Rotation -PA =Pronation Abduction -PE= Pronation External Rotation Note how this classification works: -Initial position of the foot and hindfoot (pronation or supination) and -The direction of the injuring force acting through the Talus
Supination-lateral rotation injury=
Lateral rotation forces applied to a supinated foot initially result in rupture of the anterior tibiofibular ligament (stage I). As the forces continue, a short oblique fracture of the distal portion of the fibula occurs (stage II). Stage III involves a fracture of the posterior aspect of the tibia. Stage IV is a fracture of the medial malleolus.
Supination-adduction injury.
Adduction forces applied to a supinated foot initially result in a traction or avulsion fracture of the distal portion of the fibula or rupture of the lateral ligaments (stage I). As forces continue, fracture of the medial malleolus or rupture of the deltoid ligament occurs (stage II). The fibular fracture is typically transverse, and that of the medial malleolus is oblique or nearly vertical.
Pronation-lateral rotation injury
Forces of lateral rotation applied to a pronated foot initially result in rupture of the deltoid ligament or fracture of the medial malleolus (stage I). As forces continue, the anterior tibiofibular ligament is ruptured (stage II). A high fibular fracture (stage III) and fracture of the posterior tibial margin (stage IV) are the final stages in this mechanism of injury.
Pronation-abduction injury.
The first two stages of this injury are identical to those of the pronation-external rotation fracture complex. Stage III is a transverse supramalleolar fibular fracture that may be comminuted laterally.
Supination-adduction injuries: -associated fx’s? -how common are these injuries?
-Note associated avulsion fracture of the tip of the Lateral Malleolus and Oblique Fracture of the base of the Medial Malleolus Supination-adduction: -occurs in 20-25% of ankle fractures -foot is fixed on the ground in supination when and adduction force is applied to the talus -Stage 1: supination results in a tear of the lateral collateral ligament or an avulsion fx of the lateral malleolus below the level of the tibial plafond -stage 2: more talar tilt results in the medial malleolus being pushed off in a vertical or oblique way
Supination-External Rotation injury: -how common?
-MC type of ankle fx and occurs in about 60-70% of all ankle fractures -the foot is fixed on the ground in supination and an exorotation force is applied to the talus
Supination-External Rotation injury: -Describe stage 1-4
stage 1= rupture of anterior inferior tibiofibular ligament stage 2= oblique fx or spiral fx of the lateral malleolus stage 3= rupture of posterior tibiofibular ligament or fx of the posterior malleolus of tibia stage 4: transverse fx of tibial malleolus
Pronation Abduction (injury): -stage 1? -stage 2? -stage 3?
stage 1–> transverse medial malleolus fx distal to mortise stage 2–> posterior malleolus fx or posterior tibio-fibular ligament stage 3–> fibular fx, typically proximal to mortise, often w/ butterfly fragment medial injury= transverse to short oblique medial malleolar fx -lateral injury= comminuted impaction type distal lateral malleolar fx
Pronation External Rotation Injury= fx of ?
**fracture of the Medial Malleolus, Posterior Malleolus, high Fibular fracture, and widening of Tibiofibular Syndesmosis Note: interosseus tendon is torn –>Tibia-fibular syndesmosis is torn–> this is VERY unstable!!!
Pronation External Rotation: -continued exorotation of the talus will rupture the _____
anterior tibiofibular ligament
**Maisonneuve Fracture Complex=
When you see a significant widening of the tibiofibular space suggesting an injury to the tibiofibular syndesmosis consider a proximal fibular fracture **Maisonneuve fx complex= significant widening of the tibiofibular space
Flexor Hallucis Longus=
crosses the midline and goes medially (from fibula, crosses midline, and goes to medial malleolus, and then under the foot to the distal phalanx *Flexor Hallucis Longus Tendon going posterior to Tibia and under the Sustentaculum Tali
** Proximal Fifth Metatarsal Fracture=aka
**Bob Jones Fracture (Peroneus longus and brevis insert on the 5th metatarsal, 1 of the criteria for the ottowa (pain of the 5th metatarsal) this Pt gets an xray)
Tarsal-Metatarsal Joint aka
lisfranc joint (The tarsometatarsal joints (Lisfranc joints) are arthrodial joints in the foot. The tarsometatarsal joints involve the first, second and third cuneiform bones, the cuboid bone and the metatarsal bones.)
Lisfranc Fracture/dislocation=
Lisfranc fx= multiple extensive fx’s in the midfoot and metatarsal joints -witwer talks about “foot in the stirups” and the back part of the foot is moving around
