Weak Topics Flashcards
What does the quadriceps tendon do?
attaches all four parts of the quadriceps femoris muscle to the patella
Where does the patella ligament run?
patella to tibial tuberosity
Patient presents with numbness, tingling, and burning sensations in the lateral aspect of right upper thigh, exacerbated by pressure to ASIS. What nerve is affected? What is the condition called? What conditions/factors aggravate the situation?
- meralgia paresthetica
- entrapment of the lateral femoral cutaneous nerve as it passes under the inguinal ligament in proximity to the ASIS
- Weight gain (ex: pregnancy) and nerve entrapment from tight undergarments or belts
Pt presents with painful swelling over bilateral patella after kneeling regularly for his job. Swelling is fluctuant, directly superficial to the patellae, and there does not appear to be a knee joint effusion. What is the diagnosis?
prepatellar bursitis
What muscle may be innervated by the femoral or the obturator nerves?
Pectineus
-Owing to its location, straddling the anterior and medial compartments of the thigh, the pectineus may be innervated by either the femoral or obturator or both nerves.
What muscle should be targeted to prevent lateral femoral dislocation?
vastus medialis m
- inserts into the patella and the tibial tuberosity through the common quadriceps tendon and patellar ligament
- extend the leg at the knee joint, but it also maintains a medial pull on the patella, reducing the lateral, dislocating force
- patella is stabilized by the vastus medialis muscle and the prominent femoral condyles, which usually prevent lateral dislocation during flexing of the leg at the knee joint
- stabilize the patella within the patellar groove to control the tracking of the patella when the knee is bent and straightened
What are the 4 components of the Cruciate Anastomosis?
- 1st Perforating Branch of deep femoral a.
- Medial circumflex femoral a.
- Lateral circumflex femoral a.
- Inferior gluteal a.
What are the 5 components of the Genicular Anastomosis?
- Lateral femoral circumflex a, descending branch
- Descending genicular a.
- Superior and inferior lateral genicular a
- Superior and inferior medial genicular a
- Middle genicular a.
What can happen to long time horseback riders?
firm but not painful “swellings” in his right anteromedial thigh due to ossification of adductor muscle tendon because of constant contraction
Where are the iliac tubercles located?
At the widest point of the iliac crest, 5-6 cm posterior to the anterior superior iliac spines
What are the components of the femoral triangle?
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What are the components of the adductor canal?
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What goes through the greater sciatic foramen?
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What goes through the lesser sciatic foramen?
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What 3 muscles attach to the ASIS?
- Tensor Fascia Lata m.
- Sartorius m.
- Rectus Femoris, straight head
What is the presentation for a hip dislocation?
instability and limited ABduction of joint and leg shortening with asymmetry of gluteal folds
Flexor hallucis longus is important for what action? Where is it’s pulley system?
Normal gait
-on talus: groove for flexor hallucis longus and sestentaculum tali on calcaneus also assists (holds up talus)
What 3 bones does the navicular bone articulate with?
- talus head (posterior)
- 3 cuneiforms (anterior)
- cuboid (lateral)
What 5 muscles provide dynamic support for foot?
- Tibialis posterior
- Tibialis anterior
- Flexor hallucis longus
- Fibularis longus
- Intrinsic plantar muscles
What 4 things do structures in the same structural compartment share?
- general function
- nerve
- artery
- vein
What does the anterior thigh compartment contain?
- femoral n
2. extensors @ knee
what compartments does the anterior septum separate?
anterior and lateral thigh
what compartments does the interosseous membrane separate?
anterior and deep posterior thigh
what compartments does the transverse septum separate?
deep and superficial posterior
what compartments does the posterior septum separate?
lateral and superficial posterior
What does the medial thigh compartment contain?
- muscles that adduct hip
2. obturator n.
What does the superficial posterior thigh compartment contain?
- gastrocnemius (triceps surae)
- soleus (triceps surae)
- plantaris m.
- sciatic n.
What does the deep posterior thigh compartment contain?
- popliteus
- flexor hallucis longus
- flexor digitorum longus
- tibialis posterior
- tibial and posterior tibial n.
Pes anserinus muscles
- sartorius
- gracilis
- semitendinosus
What is the adductor hiatus?
opening b/t aponeurotic distal attachment of adductor part of adductor Magnus and distal attachment of hamstring part
What does the adductor transmit?
femoral a and v from adductor canal in thigh to popliteal fossa
What is the base of the femoral triangle?
inguinal ligament
How can you palpate the femoral triangle in alive patients?
inferior to inguinal ligament when thigh is flexed, abducted, and laterally rotated
what makes up the medial and lateral borders of the femoral triangle?
medial: adductor longus
lateral: sartorius
what makes up the muscular floor of the femoral triangle?
iliopsoas laterally and pectinous medially
what forms the roof of the femoral triangle?
fascia lata, cribriform fascia, sub cut tissue, skin
Compression at which point will reduce blood flow through the femoral artery and branches?
pressing posterior against superior pubic ramus, posoas major, and femoral head
What would be a concern for anterior thigh wounds?
femoral a and v laceration, artery lies superficial in femoral triangle
Differential for lump in femoral triangle
- femoral hernia
- Saphenous varies
- Psoas abscess
What sites are common for an avulsion fracture of hip?
ASIS, AIIS, Ischial tuberosity, ischiopubic ramus
Why is the femoral neck most commonly fractures?
narrowest, weakest, and angle to line of weight bearing (pull of gravity)
What location is most concerning with a femur fracture?
inferior/distal location because it separates condyles and opportunity to misalign so compromises blood supply to leg
What types of femur fractures result from indirect (ex:stumbling on curb) trauma?
proximal fractures: transvervical (middle neck) or intertrochanteric
What type of femoral fractures typically result from direct trauma?
greater trochanter and femoral shaft
What tibial site is most common for compound fractures?
shaft
What tibial site is most common for general fracture
middle and inferior thirds b/c its the narrowest (also has poorest vascularization so poor healing)
What types of fractures are common in people who take long hikes before they are conditioned?
transverse march stress fractures of tibia
Osgood Schlatter
fracture that disrupts epiphyseal plate at tibial tuberosity
A skiing incident where one falls forward at high speeds is most likely producing what type of fracture?
“boot top fracture”
diagonal fracture of tibial shaft from eversion, which can also result in fibular fracture (presents as shortened leg)
What type of fracture is common with excessive inversion
fibular fx: ankle ligament tears and tilt talus against lateral malleolus and can sheer off fibia
What type of fracture is common after a hard fall on heel? What joint would this disrupt?
- calcaneus fracture resulting in shattering to several pieces (comminuted fracture)
- Subtalar (talocalcaneal) joint
What type of fracture is common with severe dorsiflexion (person presses really hard on brake during crash)?
talar neck fracture- commonly dislocates posteriorly
What type of fracture is common when a heavy object falls on foot?
metatarsal fracture
Dancer fx
dancer loses balance and outs full weight on metatarsal = metatarsal fx
What type of fracture could happen with prolonged walking?
transverse fracture of metatarsals
What type of fracture is common with basketball and tennis players who sprain their ankle? (sudden inversion)
avulsion fx of 5th metatarsal from tendon of fibularis braves m
What might present between talus and calcaneus if there is failure in secondary ossification centers? What type of people is this common in?
Os trigonum
-Dancers and soccer players
What type of injury can result in a crushing injury and is associated with the tendon of the flexor hallucis longus m?
sesamoid bone (head of 1st metatarsal)
What type of injury is common in muscle overuse, blunt trauma, and secondary to burn injury? What would be the symptoms?
Compartment syndrome- inflammation, edema, hemorrhage
What can happen to sites distal to compartment syndrome and what are the signs to look out for?
distal structures can become ischemic or permanently injured - loss of pulse, decreased tissue temp
What happens with blood flow in varicose veins
great saphenous becomes dilated or rotated so cusps of valves don’t correctly close = result is inferior blood flow
Which veins commonly become varicose?
great saphenous v and tributaries
Causes of venous stasis?
- incompetent fascia (fails to resist muscle expansion)
- external pressure on veins such as during hospital stay
- muscular inactivity
thrombophlebitis
inflammation around involved veins (such as during DVT)
What cardiac procedure are great saphenous veins commonly used for? How does this work?
coronary arterial bypass, vein is inverted so valves open same way as arteries
Why are great saphenous veins commonly used for coronary arterial bypasses?
- accessible
- decent harvest length b/c distance b/t tributaries and perforating branches
- walls have more elastic and muscular fibers
- circulation complications are more rare
Where can the great saphenous vein be found in a saphenous cutdown?
skin incision anterior to medial malleolus
What clinical scenario would saphenous cutdown be useful in?
insert cannula for prolonged administration of drugs, blood, plasma, and electrolytes
What is a complication of saphenous cutdown and what would be the presentation?
ligation of saphenous n. - pain or numbness to medial border of foot
Pt presents with lymphedema of the superficial inguinal lymph nodes, what are possible areas of infection? What is an extra concern in female patients?
perineum and entire lower limb b/c they drain entire trunk inferior to umbilicus
-metastatic uterine cancer b/c uterine fungus drains lymph into inguinal lymph nodes
If you are trying to block the femoral nerve, where would you insert to lidocaine? What nerve roots would this affect? What would be the effect if done correctly?
- L2-4
- block 2 cm inferior to inguinal ligament, “finger breadth lateral to femoral a”
- tingling, burning, and numbness (paresthesia) radiating down knee over medial side (if saphenous n. is affected)
What is a hip pointer? What is its typically mechanism?
Contusion of iliac crest and avulsion of bony muscles attaching to iliac crest
What muscles are commonly injured/affected in a hip pointer injury
- Sartorius (attaches to ASIS)
- Rectus Femoris (attach to AIIS)
- Hamstring muscles (semitendinosus, semimembranosus, biceps femoris b/c they attach to ischium)
What is the most common site for a charley horse (thigh hematoma)?
quadriceps (usually tendon of rectus femoris m.)
What fascias combine to make up fascia covering of psoas major m?
transversalis fascia (internal abd wall) and psoas fascia
What should be your differential for edema occurring in proximal, medial thigh?
- lymphedema indicating infection
- indirect or direct hernia
- saphenous varix
- psoas abscess from pyrogenic infection migrating via fascia from internal abd wall
What would weakness to vastus medialis and vastus lateralis cause?
abnormal patellar movement and loss of joint stability
Injury of femoral n cause? Describe their gait.
- paralysis of quadriceps so inability to extend leg
- Common gait: forward lean, pressing on the distal end of the thigh with their hand as the heel contacts the ground to prevent inadvertent flexion of the knee joint
What is softening of the patellar cartilage called and common mechanism? (include specific population)
Chrondromalacia patella
- marathon runners from over stressing knee (also basketball)
- blow to the patella or extreme flexion of the knee
What is a bipartite or tripartite patella?
different ossification centers fail to fuse patella into a single bone, so can sometimes be confused with fracture but THIS HAPPENS BILATERALLY
What reflex can check the integrity of the femoral n? What would an abnormal patella reflex potentially indicate?
Patella tendon reflex
-lesion interrupting innervation of quad (peripheral VD)
What are gracilis transplants commonly used for?
muscle in hand or external anal sphincter but you have to transplant nerve and blood vessels
A patient presents with an injury after playing hockey and now has pain to the medial anterior thigh, what are your concerns?
injury to adductor longus m. because injury is common in fast accelerating, decelerating, and sports that frequently change direction
Ossification of what tendon is commonly referred to as “riders bone”?
Adductor longus
How would one palpate the femoral pulse?
between ASIS and pubic symphysis
Where can one compress the femoral a via palpation/direct pressure?
pressing posteriorly against superior pubic ramus, posts major, and femoral head
What clinical procedures is the femoral artery commonly used for?
LEFT cardiac angiography, coronary arteriography, and blood gas analysis
Describe the process of cannulation?
happens inferior to inguinal ligament where catheter is inserted into LEFT femoral artery where it reaches the aorta to left ventricle for LEFT CARDIOANGIOGRAPHIES
Patient presents with a laceration to anterior thigh and is bleeding profusely, what artery are you concern was cut?
femoral artery because it lies superficial
What is a Saphenous Varix and what is its clinical presentation?
localized dilation of terminal great saphenous v which can cause edema in femoral triangle
What vascular source is used for a right cardiac angiology?
Femoral being - catheter inserted and passes superiorly to IVC into right atrium
4 areas that the deep fibular N supplies?
- anterior compartment muscles
- ankle and metacarpal phalangeal joints
- dorsal intrinsic foot muscles
- skin b/t digits 1 & 2
What landmarks demarcates division of tibial N to anterior and posterior arteries?
tibial tuberosity
What fascia does the lateral compartment lie between?
anterior and posterior crural septa
What is contained in the lateral leg compartment?
- fibularis brevis m.
- superficial fibular n
- Fibularis longus m.
* only compartment without distinct arterial branch accompanying nerve (fibular artery = largest branch of posterior tibial a.)
Where does the superficial fibular n. begin? Where’s its path?
between fibularis longus and fibula
-extends b/t fibular muscles and lateral to EDL
What areas does the superficial fibular n supply?
- anteroinferior leg
- nearly entire dorsal foot
- most dorsal aspect of digits
Injury to what could result in paralysis of all anterior and lateral crural muscles, commonly known as “foot drop”?
Common fibular n (L4-S2)- winds around fibular head so most commonly injured lower extremity nerve
Patient presents with high-stepping, waddling or “swinging-out” gait, what muscles movements do they have difficulty with and what nerve is affected?
- dorsiflexion and eversion
- common fibular N (L4-S2)
You are walking and hear the person next to you walking with a loud “clop”, you see that they have difficultly achieving a heel strike and swing their leg forward. What is causing this?
injury to common fibular N (L4-S2), so they have difficulty with dorsiflexion and eversion
Injury to the cutaneous branch of the common fibular n. would present with loss of sensation where?
anterolateral leg and dorsum of foot
Patient presents with pain and serious disability after a kick to the side of his knee. PE revealed a dark bruise just distal to head of fibula. What muscle(s) are likely injured?
tibialis anterior and extensor digitorum longus ms
Pt fell from bike and X-ray shows tibial and fibula fx. PE reveals pt has a foot drop, but normal eversion. What nerve is most likely injured?
deep fibular n.
What is the fascia covering the dorsalis pedis a. and deep fibular n. on the dorsum of the foot?
inferior extensor retinaculum - continuous with extensor retinaculum
What is the fascia covering the structures of the medial malleolus?
flexor retinaculum
What fascia supports the longitudinal arch of the foot which is divided into 5 bands that enclose distal tendons?
plantar aponeurosis
Nerve root of Femoral N
L2-4
Nerve root of Obturator N
L2-L4
Nerve root of Sciatic N
L4-S3
Nerve root of Tibial N
L4-S3
Nerve root of Common Fibular N
L4-S2
Nerve root of Lateral Femoral Cutaneous N
L2-3
Nerve root of Posterior Femoral Cutaneous N
S1-3
Tibial N supplies what compartment? What would a lesion to this nerve cause? How would you test this nerve?
- posterior leg
- loss of plantar flexion and weakened inversion
- achilles tendon reflex
What muscle tendons run under the superior flexor retinaculum?
Fibularis longus tendon and fibularis brevis tendon
Sensory innervation of the Tibial N.
sole of foot
Motor innervation of Tibial N
- biceps Femoris, long head
- triceps surae: gastrocnemius and soleus
- plantaris
- popliteus
- flexor muscles of the foot
What could cause injury to the tibial n?
- knee trauma
- baker cyst (proximal lesion)
- tarsal tunnel syndrome (distal lesion)
Presentation of tibial n injury?
TIP: Tibia Inverts & Plantarflexes
- cant stand on tip toes
- Inability to curl toes
- loss of sensation on sole of foot
- foot everted @ rest b/c can’t invert or plantar flex
Presentation of inferior gluteal n injury
- difficulty climbing stairs, rising from seated position
- loss of hip extension
Presentation of femoral n injury
decreased leg extension & decrease patellar reflex
Presentation of Obturator N injury
decreased thigh sensation (medial) and adduction
presentation of lateral femoral cutaneous N injury (also the inferior clunial n)
decreased thigh sensation: anterior and lateral
Presentation of genitofemoral n injury
- decreased upper medial thigh and anterior thigh sensation beneath inguinal l (lateral femoral triangle)
- absent cremaster reflex
Presentation of iliohypogastric n injury
burning or tingling paining surgical incision site radiating to inguinal and suprapubic region
Most Important (aka high yield for boards) specialty knee exams (5)
- anterior drawer sign
- posterior drawer sign
- abnormal passive abduction
- abnormal passive adduction
- McMurray test
Ligament in low ankle sprain (most common)
Always Tear First:
Anterior TaloFibular l. - due to overinversion/supination of foot
Ligament most common in high ankle sprain
Anterior inferior tibiofibular l.
What happens if AChE is inhibited for a prolonged period of time?
- ACh will stay in longer and eventually disperse, so choline will never get recycled = could result in Each depletion in membrane.
- Hypercontraction due to constant stimulus, eventually leading to paralysis due to increase threshold of adjacent tissue to stimulation b/c of depolarization (closing of Na activation gate)
What would happen if Ryanodine receptors could not close?
Continuous Ca+ release = continual contraction and this uses ATP continuously so increase in muscle cell metabolism = increased body temp = hyperthermia
-could also happen if DHP receptors could not close
What does activation of DHP receptors cause?
conformational change of RyRs on SR = Ca+ release into sarcolemma
What is in charge of sequestering the Ca+2 in the sarcolemma?
Ca+2/ATPase pump
What are the two factors that determine force of muscle contraction?
- starting length of sarcomere (distance b/t myosin and acting & most efficient overlap)
- how rapidly the fiber is stimulated by the nerve
3 ways to increase contractile force
- increase number of innervate muscle fibers
- more glycolytic fibers will generate greater force, but increased fatigue
- activate more motor neurons/units = recruitment
What is an absent patellar reflex called?
Westphal’s sign
Pes anserine bursitis
- inflammation of anserine bursa b/t pes anserinus and MCL (overuse/trauma)
- constant, aching pain aggregated by activity (climbing stairs), specifically flexion and IR knee
3 disadvantages of CT
- ionizing radiation
- renal function 1st evaluated
- allergies to iodine contrast
5 advantages of CT
- quick
- motion less of issue
- gray scale manipulation
- excellent resolution
- wide availability & cheaper than MRI
3 Advantages of MRI
- no ionizing radiation
- better soft tissue contrast than CT
- versatile
Contrast agents used in MRI
IV gadolinium and Oral agents (juice, H2O)
Disadvantages of MRI
- longer & more expensive
- can’t be manipulated after like CT
- bad if claustrophobic
- no metal in body
- Gadolinium can’t be used in pregnant women
- Pple with poor renal function have increased risk of NSF (nephrogenic systemic fibrosis)
- loud
