Scenario 19: Rosemary's Swollen Legs Flashcards
What is removed and replaced in development to allow the patella to articulate with the knee joint?
The anterior part of the joint capsule is removed and replaced with the tendinous fibres of the vasti muscles (retinacular bands)
How can we test for a torn menisci?
The McMurray test, the knee is flexed and then straightened and rotated which puts tension on the meniscus. If it torn there will be a clicking sound in the joint (CT or MRI to confirm)
What are the three lateral ligaments of the ankle?
Anterior and posterior talofibular ligaments and the calcaneofibular ligament
What bounds the lateral compartment of the leg?
Anterior and posterior intermuscular septums and fibula
What kind of movements are possible at the ankle joint?
A hinge joint with extension and flexion (called plantar and dorsiflexion)
What is the function of tibialis posterior?
Plantar flexion
What are the attachments of tibialis anterior?
Lateral surface of tibia and medial side of foot (medial cuneiform and base of 1st metacarpal)
When are the fibular and tibial collateral ligaments of the knee joint relaxed/taut?
Taut on full extension but relaxed during flexion
What is the function of flexor digitorum longus?
Plantar flexion
Which spinal roots control intrinsic muscles of the foot?
S2
Where does the tibia articulate with the femur?
The medial tibial condyle articulates with the medial and lateral femoral condyles
Where does the superior gluteal nerve arise?
L4-S1 and passes under the greater sciatic notch and upper border of piriformis
What attaches to the base and apex of the patella?
The quadriceps tendon attaches to the base above and the ligamentum patellae attaches to the apex below
Why is the ankle joint unstable when plantar flexed?
The trochlea of the talus is wider anteriorly than posteriorly so when the foot is dorsiflexed the narrowest part of the trochlea is in contact with the malleoli so a small amount a rotation is possible.
What bone may fracture following a forced inversion injury?
The lateral malleolus
Which bones comprise the medial longitudinal arch?
Talus, calcaneus, navicular, cuneiforms and medial three metatarsals
What is the nerve supply of the flexors of knee and plantar flexors of foot?
Tibial branch of sciatic (L4-S3)
What is the function of plantaris?
Plantar flexion
Why is the ankle joint so stable when dorsiflexed?
The trochlea of the talus is wider anteriorly than posteriorly so when the foot is dorsiflexed the widest part of the trochlea is in contact with the malleoli.
Where does the quadriceps pull the patella in flexion of the knee?
Along the mechanical axis of the femur in the direction of rectus femoris muscle fibres. The patella is pulled against the femoral condyles
Which spinal roots control flexion of the knee?
L5, 6
What is genu valgum?
Knock knee. Places strain on the medial collateral ligament and surrounding structures and pressure on the lateral cartilage and bone.
What are the bony features of the cuboid?
Groove for longus tendon and articulates with the 4th and 5th metacarpals in front
What is the nervous supply of the lateral compartment of the leg?
Superficial fibular nerve
What is the collateral support of the medial side of the knee joint?
Supported by the medial collateral ligament, pes anserinus muscles behind and retinacular band of vastus medialis in front
What may cause trochanteric bursitis?
Excessive extension of the hip leading to lateral hip pain
What is the major branch of the posterior tibial artery?
The fibular artery
What is the nerve supply of the intrinsic muscles of the foot?
S2 and S3 vis tibial nerve
What is the appearance of a torn tendocalcaneus?
A superior bulge and inferior hollow as muscles move up toward their proximal attachments. The normal contour of the back of the ankle is lost, reducing the power of plantar flexion
What do we use to test for anterior cruciate ligament injury?
The anterior draw test has been replaced with Lachman’s test. The patient lies on a couch with knee bent to 20/30 degrees, one hand is on the thigh, the other on the tibial tuberosity, The tibia is pulled forwards to check for absence on a firm ‘end point’
What is the function of flexor hallucis longus?
Plantar flexion
Where does flexor digitorum longus attach?
Tibia and inserts onto plantar surfaces of lateral four digits
Describe the superior tibio-fibular joint
Synovial joint, little movement, non-weight bearing
What is pes cavus?
Claw foot caused by muscles going into spasm or contracture of the foot
What is Perthe’s disease?
A common and unexplained abnormality where the femoral head fails to develop adequate blood supply and collapses with loss of hip joint function in children of 4-8, can be painful or painless limp
What is the nervous supply of the anterior compartment of the leg?
Deep fibular nerve
Where do the anterior and posterior horns of tibial menisci attach and what runs between them?
Have anterior and posterior horns attached to the sides of the tibial intercondylar eminence and have collagen strands which run between the two horns
How can we test for collateral ligament injury?
Straighten the limb to tighten the ligaments. To test the medial collateral, abduct the leg whilst holding the outside of the knee firm. For the lateral, support from the inside and push the knee inwards. Excessive movement indicates a torn ligament
What is inflamed in planat fasciitis?
Posterior part of plantar aponeurosis
What may cause iliopsoas bursitis?
Athletic activity
Which ligaments surround the knee joint?
Tibial and fibial collateral, anterior and posterior cruicate, meniscofemoral, oblique popliteal and arcuate
What is the course of the common fibular nerve?
Formed when sciatic nerve divides behind biceps femoris. Winds round neck of fibula and divides into superficial and deep branches.
Where do the cruciate ligaments get their rich blood supply?
From the synovial membrane of the knee joint which loops around them
What supports the foot on the lateral side?
Fibular tendons hold up the lateral bones with fibularis longus grooved under the cuboid bone
What are the attachments of soleus?
Soleal line of tibail and proximal fibular area then inserts onto calcaneus with the calcaneal tendon
What are the three joint surfaces of the knee joint?
The patella-femoral and the medial and lateral tibio-femoral condyles
Why is the femoral epiphysis prone to slipping?
The growth plate is a site of potential weakness and children of 10-16 are active in sporting activities which may put excessive stress on it, displacing the femoral head
What is the dorsalis pedis artery a continuation of?
It is a continuation of the anterior tibial artery and lies on the dorsum of the foot
Which ligament may the meniscofemoral ligament accompany?
The posterior cruciate
Why may there be swelling, discolouration and pain after a medial twisting of the knee when the foot is on the ground?
A tear of the highly vascular cruciate ligament causing haematoma
What is the appearance of a dislocated hip joint and why?
A shortened and medially rotated limb because once the femur is freed from the acetabular socket, iliopsoas and gluteal muscles will pull it upwards and rotate it medially
Which spinal roots control extension of the knee?
L3, 4
Where does the sural nerve supply?
Skin on the lateral margin of the foot
What is the nerve supply of dorsiflexors of foot?
Deep branch of the fibular nerve
What are the attachments of the deltoid ligament?
Medial collateral ligament of the ankle, attached at the apex to the medial malleolus, base attached to the talus, sustentaculum tail of the calcaneus and navicular bone
What is the innervation and blood supply of tibialis anterior?
Anterior tibial artery and deep fibular nerve
What is the blood supply and innervation of tibialis posterior?
Posterior tibial artery and tibial nerve
Where does the spring ligament run and what is it’s purpose?
Arises from calcaneus and runs on the sole of the foot to the navicular bone. Maintains foot arches and is important in propulsion
Where can we test for the L1 dermatome?
Line of the groin
What is the blood supply of the lateral compartment of the leg?
Fibular artery and anterior tibial indirectly from the popliteal
Where can we test for the S3 dermatome?
Buttocks
Where can we test for the L3 dermatome?
Medial inner thigh
What are the cutaneous nerves of the femoral nerve and where do they supply?
The anterior, intermediate and medial cutaneous nerves to the front and lower medial aspect of the thigh
What is the innervation a and blood supply of extensor digitorum longus?
Deep fibular nerve and anterior tibial artery
What are the important features of the fibula?
Head, neck, shaft, medial crest and lateral malleolus
Which bursa is inflamed in clergyman’s knee?
Lying either side of the patellar tendon, the infra-patellar bursa
What is the spinal root of the saphenous nerve?
L4
What are the symptoms of sciatica?
Lower back pain that radiates all the way down the back of the leg
What is the root of the sciatic nerve?
L4-S3
What does the anserine bursa protect?
The pes anserinus from the tibia
What is the blood supply and innervation of flexor hallucis longus?
Posterior tibial artery and tibial nerve
What supports the foot on the medial side?
Deep flexor tendons provide the required support. The medial longitudinal arch is supported by tibialis posterior and flexor hallucis longus tendonds.
What is the order of the tendons that pass through the tarsal tunnel?
Tibialis posterior, flexor Digitorium longus, Artery, Vein, Nerve, flexor Hallucis longus
Where does the inferior gluteal nerve arise?
L5-S2 and passes through the greater sciatic foramen and lower border of piriformis
Where does the common fibular nerve supply?
Anterolateral leg and dorsum of foot
What is the innervation and blood supply for extensor hallucis longus?
Deep fibular nerve and anterior tibial artery
What is developmental dysplasia of the hip?
A baby is born with excessively loose hips which easily dislocate. This may be repetitive so the femur slides in and out
What is the nerve supply of the plantar flexors of the lateral compartment of the foot?
Superficial branch of the fibular nerve
Describe the inferior tibio-fibular joint
Fibrous joint with strong ligaments (anterior and posterior tibo-fibular ligaments and interosseous ligaments)
What will a hamstring tendon tear or bone evulsion present as?
Visible dip at the top of the back of thigh with possible bruising from ruptured blood vessels
How can a broken tibia lead to a pulmonary embolism?
The bone marrow is full of fat so a fat embolism can occur
What are the bony features of the calcaneus?
Medial and lateral processes, anterior tubercle, sustentaculum tail which is a shelf of bone projecting from the calcaneus that supports the talus
What is the difference between femoral and inguinal hernias?
A femoral hernia is always lateral to and below the pubic tubercle. An inguinal hernia is always medial to and above the pubic tubercle
What can cause anterior hip dislocation?
A traumatic abduction and lateral rotation of the hip after a fall from a height
Where do the anterior and posterior cruciate ligaments arise from and insert onto?
Anterior cruciate arsies from the anterior intercondylar ridge of the tibia and inserts onto the medial surface of the lateral condyle of the femur. The posterior cruciate arises from the posterior intercondylar ridge of the tibia and inserts onto the lateral surface of the lateral condyle of the femur.
Where does the obturator nerve arise from?
L2-4 around the medial border of psoas major
What is the innervation and blood supply of fibularis longus?
Superficial fibular nerve, perforating arteries of fibular and anterior tibial artery
What is the nervous supply of the plantar surface of the foot?
Medial plantar nerve does the medial 3 and a half toes, the saphenous the medial border, the tibial nerve the heel, the lateral plantar nerve the lateral 1 and a half digits and the sural nerve the lateral border
What bounds the anterior compartment of the leg?
Crural fascia in front, tibia medially and fibula and interosseous membrane posteriorly
Which bursa is inflamed in housemaid’s knee?
The prepatellar bursa which sits between patella and skin
Where can we test for the S1 dermatome?
Pinky toe
Which cruciate ligament is more likely to tear?
The anterior one as it is thinner
What are the attachments of extensor hallucis longus?
Originates from the medial surface of the fibular shaft. The tendon crosses anterior to the ankle joint and attaches to the base of the distal phalanx of the great toe.
What is the treatment for anterior compartment syndrome?
Incise the crural fascia and open up the compartment to relive pressure and remove dead muscle before stitching it up again
Where does the femoral nerve arise from?
L2-4 around the lateral border of psoas major
Where does the tibial nerve supply?
Posterolateral leg and foot and sole of foot via calcaneal nerve
What are the usual branches of the lumbar plexus?
Iliohypogastric, ilioinguinal, genitofemoral, lateral femoral cutaneous, femoral, obtruratorm, branch to lumbosacral trunk and sacral plexus
What is the blood supply of the posterior compartment of the leg?
Posterior tibial artery from the popliteal artery
How can we test for developmental dysplasia of the hip?
Ortolani’s test. The baby’s hip is abducted whilst feeling the greater trochanters, a vibration and audible ‘clunk’ is a sign of DDH
What is the blood supply and innervation of flexor digitorum longus?
Posterior tibial artery and tibial nerve
What are the terminal branches of the posterior tibial artery?
The medial and lateral plantar arteries
What are the bony features of the tibia?
Medial and lateral condyles, intercondylar eminence, tibial tuberosity, shaft, anterior border, interosseous border, soleal line, medial malleolus
Which meniscus is more likely to tear?
The medial meniscus because it is attached to the deep part of the medial collateral ligament and is less free to move
What is pes planus?
Flat foot caused by the overstretching or tearing of plantar aponeurosis
Where can we test for the S2 dermatome?
Middle of the back of the thigh
What muscles are in the deep posterior compartment?
Flexor digitorum longus, flexor hallucis longus, tibialis posterior
What is the ‘unhappy triad’?
A torn anterior cruciate ligament is often associated with a partial tear of the medial collateral ligament and medial meniscus
Which bones comprise the lateral longitudinal arch? Which bone is the keystone?
Calcaneus, cuboid and 4th and 5th metatarsals. The keystone is the cuboid.
What is the spinal root of the sural nerve?
S1
What strengthens the knee joint medially and laterally?
Collateral ligaments
How are the anterior horns of tibial menisci attached to one another?
By the transverse genicular ligament which are thicker around the periphery and thinner medially
What is the function of tibialis anterior?
Dorsiflexors of the foot and inverter of the foot by elevating the medial side of the foot
What is a common cause of central dislocation of the hip bone?
Motorbike accidents where the head of the femur is driven through the acetabulum by direct trauma causing it to dislocate
Which ligaments of the knee are extra synovial but intracapsular?
The cruciate ligaments
What is the collateral support of the lateral side of the knee joint?
Supported by the lateral collateral ligament, biceps femoris and popliteus muscle behind, the retinacular band of vastus lateralis muscle and iliotibial muscle in front
What are the nerves in the sacral plexus?
Sciatic nerve, superior and inferior gluteal nerves
What is plantar flexion?
Lifting forefoot off the ground
What are the attachments of gastrocnemius?
Arising from the femur above the knee (lateral head from lateral condyle, medial from medial), it inserts onto calcaneus
What is likely to fracture in a forced eversion injury?
The medial malleolus and the talar tilt can cause a oblique fibular fracture
What strengthens the knee joint posteriorly?
Oblique popliteal ligament
What is the function of soleus?
Plantar flexion
What do the coronary ligaments of the knee attach to?
The capsular fibres around the margin of the menisci attached to the tibial condyles also attach to the menisci
Which spinal roots control inversion of the foot?
L4, 5
Which spinal roots control extension of the ankle?
L4, 5
What are the bony features of the navicular?
Tuberoisty
What are the shapes of the medial and lateral tibial menisci?
The medial meniscus is C shaped and the lateral one is O shaped
What are the three main bursae of the hip?
Trochanteric, ischial and iliopsoas bursae
Which spinal roots control extension of the hip?
L4, 5
What is the function of extensor digitorium longus?
Extends all joints from ankle to DIJ
Describe anterior compartment syndrome
Any inflammation can lead to compression of the neurovascular bundle. Venous compression leads to bruising around the ankle, arterial compression will cause tissue necrosis, nerve compression will lead to pain.
Why are the cruciate ligaments prone to injury during full extension?
The ligaments are taut and twisted due to medial rotation of the femur
What are the attachments of fibularis longus?
Upper part of lateral surface of the fibula inserting onto the medial cuneiform and base of 1st metatarsal after passing under the tarsal bones
What are the symptoms of a displaced femoral head fracture?
Lower limb shortening and lateral rotation on the affected side, any rotation is around the anatomical axis of the femur
What is the origin of the common fibular nerve?
L4-S2
Which nerve is most commonly injured in the lower limb and why?
Common fiblar nerve due to its superficial position on the neck of the fibula where it may easily compressed against bone
What is a bucket handle tear of meniscus and how can it be fixed?
A tear along the length of meniscus leaving a medial segment which is no longer tethered. There is no blood supply when the meniscus is torn so it must be removed or repaired surgically.
What is the nervous supply of the dorsum of the foot?
Superficial fibular nerve supplies the skin between the first two toes, sural nerve does the lateral margin and saphenous never the medial margin
What is a Baker’s cyst?
An enlarged semimembranous bursa
What is the function of extensor hallucis longus?
Extends all joints from ankle to DIJ and may aid inversion of foot
What are the attachments of plantaris?
Arises just above the knee joint at the lateral epicondyle of the femur and inserts just medial to tendocalcaneus
Where does the bifurcate ligament of the foot run?
On the dorsum of the foot from the calcaneus. It splits to attach to the navicular and cuboid bones
What is the innervation and blood supply of fibularis brevis?
Perforating arteries of fibular and anterior tibial arteries and superficial fibular nerve
What strengthens the knee joint anteriorly?
The patellar ligament (really a tendon)
What is the blood supply and innervation of plantaris?
Posterior tibial artery and tibial nerve
What are the muscles in the superficial posterior compartment of the leg?
Gastrocnemius, soleus, plantaris
What do we use to test for posterior cruciate ligament injury?
The posterior draw test, the patient has their knee bent 80 degrees and the hamstrings relaxed. A posterior displacement of the tibia suggests posterior cruciate damage.
What is the nerve supply of the knee joint?
Femoral, obturator, common fibular and tibial
Where does the lateral femoral cutaneous nerve arise from?
L2-3, under inguinal ligament near to ASIS
What are the bony features of the talus?
Head, neck, body, sulcus, tali and trochlear surface which articulatrs with the malleoli of tibia and fibula.
Where does the posterior aspect of the thigh get cutaneous contribution from?
(S1) S2, 3 of sacral plexus
Which tarsal bone is the keystone of the medial longitudinal arch and where is the weight directed?
The talus, directing weight anteriorly to the ball of the foot and posteriorly to the heel
Which spinal roots control flexion of the hip?
L2,3
What is the function of gastrocnemius?
Plantar flexion, inversion and eversion of foot
Which bursae of the knee joint don’t communicate with it?
Prepatellar, infra-patellear and anserine
Which bones comprise the transverse longitudinal arch? Which bone is the keystone?
Cuneiforms, cuboid and bases of all three metatarsal bones
What is the blood supply of the anterior compartment of the leg?
Anterior tibial artery from popliteal artery
Why does the lateral meniscus not attach to the lateral collateral ligament when the medial one does?
The popliteus tendon prevents this
Which spinal roots control eversion of the foot?
L5, S1
Where does flexor hallucis longus attach?
Fibula onto plantar surface of big toe
What are some possible diagnoses for swelling in the popliteal fossa?
A popliteal artery aneurysm, a thrombus of the popliteal vein, enlarged popliteal lymph nodes, neurofibroma, lipoma or a Baker’s cyst
Where does the lateral aspect of the thigh get cutaneous contribution from?
L2, 3 of lumbar plexus
What are the attachments of fibularis brevis?
Lower of lateral surface of fibular inserting onto the styloid process of the 5th metatarsal
How do varicose veins develop?
Valves in the perforating veins malfunction and the high pressure in the deep veins caused by muscle contraction forces blood into the superficial ones, enlarging them and causing varicose veins
Name the tarsal bones
Talus, calcaneus, navicular, cuneiforms (medial, intermediate, lateral) and cuboid
Where does the gatrocneumius bursa lie?
Separates the medial head of gastrocneumius and the tibia lying posteriorly
What are menisci?
The intra-synovial articular discs which support the joint surfaces of the knee joint. Deepen the concavity of joints at tibial femoral joint and ask as shock absorbers/lubricaters
What is fibularis tertius?
Only present in 85% population, inserts onto base of 5th metacarpal and aids eversion of the foot
What is the purpose of the infra patellar fat pad?
It sits anteriorly behind the ligamentum patellae with the synovium sitting on top. It prevents the synovium from dropping down
Where does tibialis posterior attach?
Interosseous membrane to bones on medial side of sole of foot
Which spinal roots control flexion of the ankle?
S1, 2
What are the attachments of extensor digitorum longus?
Originates from the lateral condyle of the tibia and the medial surface of the fibula. The fibres converge into a tendon, which travels to the dorsal surface of the foot. The tendon splits into four, each inserting onto a toe.
Why does the knee joint become ‘locked’ on full extension?
Near full extension of the knee, the lateral femoral condylar surface is used up by the tibial surfaces. The medial side continues in extension and the curved surface is used causing medial rotation of the femur on the tibia
When can the ACL be torn?
When there is over rotation at the joint, tehre will be an audible popping in the knee, with or without pain.
Where do vastus intermedius and lateralis pull the patella in extension of the knee?
Laterally along the anatomical axis of the femur, the anterior position of the lateral condyle prevents lateral dislocation as does the pull of vastus medialis
What is plantar flexion?
When we are on a tip toes
What is the nervous supply of the posterior compartment of the leg?
Tibial nerve
Which ligaments are most at risk of a forced inversion injury?
Anterior talofibular and calcaneofibular ligaments
Where do the oblique popliteal and arcuate ligament protect?
The back of the knee
Which direction are hip dislocations usually in and what causes these?
Posteriorly, MVA where the body is shunted forward with leg/knee against dashboard pushing the femur out of socket
Where is the axis for eversion and inversion of the foot?
Passes through the sub-talar joint complex
What is the blood supply and innervation of soleus?
Posterior tibial artery and tibial nerve
Where does the popliteus bursa lie?
Between popliteus and the lateral condyle of the tibia, protecting popliteus tendon
What is the blood supply of the knee joint?
The genicular arteries
Which bursae of the knee joint are directly continuous with it?
Suprapatellar, popliteus, gastrocnemius, semimembranosus
What are some risk factors for osteoarthritis of the hip?
Age over 60
In under 40s: obesity, previous joint trauma e.g. DDH, Perthe’s disease or dislocation
Where are the short and long plantar ligaments of the foot found?
On the lateral side of the plantar surface
Which muscles are in the lateral compartment of the leg?
Fibularis longus and fibularis brevis
Where can we test for the L4 dermatome?
Big toe
Which muscles are in the anterior compartment of the leg?
Tibialis anterior, extensor digitorum longus, extensor hallucis longus (fibularis tertius)
What is the function of fibularis longus and brevis?
Everters of the foot by elevation of the lateral margin of the foot. Important in maintaining foot arches and postural balance
What is genu varum?
Bow leg. Strain on the lateral collateral ligament and compression on the medial side of the knee which can lead to tearing of the meniscus and condyles of tibia and femur on that side
What is the blood supply and innervation of gastrocnemius?
Posterior tibial artery and tibial nerve
Why is the tendocalcaneus likely to rupture?
It has both heads of gastrocnemius and soleus which are used in running and are powerful. Sudden spasmodic contraction or wear and tear can tear this tendon
What is the anxiety test?
If the vastus medialis muscle has wasted the patella will be easily dislocated. If you go to manipulate the patella but don’t move it- watch for the anxiety on the patient’s face!
Why is the lateral femoral condyle more anteriorly projecting than the medial one?
This helps to prevent lateral dislocation
