W4 lower leg Flashcards
• Regions of the lower limb
o Gluteal region o Anterior thigh o Posterior thigh o Leg o Foot
• Gluteal region
o Posterolateral and between iliac crest and gluteal fold of lower buttocks
o Bones are two pelvic bones each formed by ilium, ischium, and pubis
o These bones fuse during childhood
• Anterior thigh
o Between inguinal ligament and knee joint
o Bone of the thigh is femur
• Posterior thigh
o Between gluteal fold and knee
o Bone of the thigh is femur
• Leg
o Between knee and ankle joint
o Bones are tibia and fibula
• Foot
o Distal to ankle joint
o Bones are tarsals, metatarsals and phalanges
• Hip movements
o Flexion o Extension o Abduction o Adduction o Medial and lateral rotation o Circumduction (combination of other four motions)
• Abduction of hip
o Can be abduction of femur on fixed pelvis
o Abduction of pelvis on fixed femur
o In both, angle between pelvis and femur decreases
o When taking a step, the high of the leg that is grounded abducts
• Knee joint
o Hinge joint
o Flexion
o Extension
• Ankle joint
o Hinge joint o Dorsiflexion (toes toward shin) o Plantarflexion (toes away from shin)
• Hip joint
o Synovial joint
o Head of femur and acetabulum on lateral pelvic bone
o Multi-axial
o Stability and weight bearing
• Acetabular labrum
o Fibrocartilaginous collar on the rim of acetabulum
o Prevents head of femur from moving inferiorly and deepening acetabulum
o Common site of injury: pain on weightbearing, flexion, internal rotation
• Ligament of the head of the femur
o Connective tissue that attaches the head of the femur to the acetabular fossa
o Obturator artery runs with this ligament and supplies femoral head
o Synovial membrane attaches to the margins of the articular surfaces of femur and acetabulum
• Fibrous capsule or membrane
o Surrounds synovial head
o Holds femoral neck in acetabulum
o Three ligaments
Iliofemoral – anterior to the hip joint
Pubofemoral ligament – anteroinferior to hip joint
Ischiofemoral ligament – posteroinferiorly to the hip joint
• Knee joint
o Primarily hinge joint
o Biggest synovial joint in the body
Articulation between femur and tibia is weight bearing
Articulation between patella and femur pulls quadriceps femoris muscle over the knee to tibia without tendon wear
• Lateral and medial meniscus
o Fibrocartilaginous
o Cushion knee and accommodate changes in shape of articular surfaces during movement
o Femoral condyles are flat during flexion, round during extension
• Synovial membrane of the knee
o Attaches to the margins of the articular surfaces and menisci
o forms two pouches (suprapatellar bursa and subpopliteal recess
• Fibrous capsule or membrane
o Encloses articular cavity
o Partly formed and reinforced by muscle tendons
• Patellar ligament
o Continuation of quadriceps femoris tendon
o Connects the patella to the tibia
• Collateral ligaments
o Medial or tibial (MCL or TCL) and lateral or fibular (LCL or FCL)
o Stabilize the hinge like motion of knee
o Medial meniscus attaches to MCL
• ACL
o Anterior cruciate ligament
o Crosses with PCL in intercondylar region of knee
o Connect tibia and femur and restrict movement
o Keeps tibia from moving anteriorly on the fixed femur
o Extends from lateral femoral condyle to the anterior tibia
• PCL
o Posterior cruciate ligament
o Crosses with ACL in intercondylar region of knee
o Connect tibia and femur and restrict movement
o Keeps tibia from moving posteriorly on fixed femur
o Extends from medial femoral condyle to posterior tibia
• Unhappy triad
o ACL, MCL, and medial meniscus tear
o Caused by lateral force applied to planted leg
o Audible snap and immediate pain and swelling
• Movements of the gluteal region
o Abduct, extend, and laterally rotate the femur relative to pelvic bone
• Deep muscles of gluteal
o Lateral rotators of the femur o Piriformis o Obturator internus o The gemelli o Quadratus femoris
• Superficial muscles of the gluteal
o Abduct (Gluteus mimimus and maximus) o Extend hip (gluteus maximus)
• Tensor fasciae latae
o stabilizes knee in extension by acting on iliotibial tract
o IL tract is a band of deep fascia that passes down lateral side of thigh to attach to proximal end of tibia
• Iliotibial tract
o Band of deep fascia that passes down lateral side of thigh to attach to proximal end of tibia
• Nerves of gluteal
o Enter from pelvis through greater sciatic foramen
o Most are in between superficial and deep muscles
o Superior gluteal nerve passes superior to piriformis muscle
o Others pass inferior to piriformis muscle
• Superior gluteal nerve
o L4, L5, S1
o Innervates gluteus miminus and medius muscles and tensor fascia latae
• Nerve to quadratus femoris
o L5, S1
o Supplies gamellus inferior
• Nerve to obturator internus
o L5, S1
o Supplies gemellus superior
o Then passes through lesser sciatic foramen to innervate obturator internus
• Posterior cutaneous nerve of the thigh
o Innervates the skin of the gluteal region the posterior thigh and posterior leg
• Inferior gluteal nerve
o L5,S1,S2
o Supplies gluteus maximus muscle
• Piriformis muscle innervation
o Innervated by branches of S1,S2
• Pudendal nerve
o S2-S4
• Trendelenburg sign/gait
o Superior gluteal nerve injury (innervates hip abductors, gluteus minimus and medius
o Sign: when patient stands on affected limb, pelvis drops over swing limb and abduction of pelvis on fixed femur does not occur
o Gait: when pelvis tilts over the swing limb patient compensates by lurching trunk to affected side to maintain level of pelvis during gait
o Contraction of gluteus minimus and medius on stance side prevents excessive pelvic tilt during swing phase on opposite side
• Gluteal blood supply
o Superior and inferior gluteal arteries
o Originate in iliac artery (a terminal branch of the aorta)
• Anterior compartment of the thigh
o Femoral nerve
o Branches of femoral artery
o Extension of leg
o Quadriceps femoris
Rectus femoris flexes the thig at hip and extends leg
Vastus lateralis, vastus medialis, and vastus intermedius extend leg
o Sartorius muscle flexes thigh and flexes leg
o Psoas major and iliacus pass into upper part of anterior compartment from posterior abdominal wall and flex thigh
• Medial compartment
o Obturator nerve
o Branches of the deep femoral artery and obturator artery
o Adduction of the thigh (and medially rotate)
o Gracilis
o Pectineus
o Adductor longus and brevis
o Adductor magnus
o Obturator externus lateral rotates thigh
• Posterior compartment
o Tibial division of sciatic nerve (common fibular division of sciatic nerve to short head of biceps femoris)
o Perforating branches of deep femoral artery
o Flexion of leg, extension of thigh
o Can rotate hip and knee joint
o Biceps femoris, semitendinosus, and semimembranosus (hamstrings)
o All but biceps femoris cross both hip and knee joints
• Pes anserinus
o Goose’s foot
o Common insertion of tendons of sartorius, gracilis, and semitendious muscles on proximal tibia
• Femoral artery
o Continuation of external iliac artery
o begins as external iliac artery passes under inguinal ligament to enter femoral triangle on anterior aspect of upper thigh
o middle branch is deep artery of the thigh (profundal femoris)
• deep artery of thigh
o major blood supply to thigh
o branches into
medial and lateral circumflex femoral arteries – medial compartment
perforating branches – posterior compartment
• obturator artery
o branch of internal iliac artery
o branches anastomose with inferior gluteal and medial circumflex arteries
anterior or superficial branch
a posterior or deep branch – near head of femur
• valgus
o bowing of a shaft of bone
o distal part is more lateral
• valrus
o bowing of shaft of bone
distal part is more medial
• Lachman
o Test for ACL o Patient is supine with knee flexed at 30 degrees o Grasp and stabilize thigh o Move proximal leg anteriorly o Positive is excessive forward motion
• Anterior drawer
o Test for ACL
o Patient supine with knee flexed at 90 degrees
o Sit on dorsum of foot
o Place hands behind knee and move proximal leg anteriorly
o Positive test is excessive forward motion of tibia
o Less sensitive than Lachman’s test
• Posterior drawer
o Test for PCL
o Patient supine with knee flexed at 90 degrees
o Palms of hands push proximal leg posteriorly
• Valgus stress
o MCL test
o Patient supine with knee extended or flexed 30 degrees
o Stabilize lateral aspect of knee and push ankle laterally
o Estimate medial joint space
o Positive test is significant gap in medial joint space
• Varus stress
o LCL
o Patient supine with knee extended or flexed 30 degrees
o Stabilize medial aspect of knee
o Push ankle medially
o Estimate lateral joint space
o Positive test is significant gap in lateral joint space
• McMurray
o Examiner passively flexes the knee with rotation of tibia or foot
o Or have patient do a two-legged squat
o Pain or popping on external rotation is medial meniscus
o Pain or popping during internal rotation is lateral meniscus
o Joint line tenderness
• Patellar apprehension test
o Apply lateral directed force toward medial aspect of patella
o Positive is apprehension from patient that it will dislocate
• Patellofemoral grind
o Apply downward and inferior pressure on patella while patient contracts quadriceps on extended knee.
o Pain with movement or unable to complete test shows patellofemoral pathology
