FAL and concepts Exam 2

hip fracture presents with:

-distal end is placed posteriorly so it's shortened, and lateral rotators pull externally so the leg is shortened and externally rotated.

A 23 year old is referred to an orthopaedic specialist with pain in the front of her right knee. The patient first noticed the pain about a year ago as a dull ache during strenuous activities, such as running, playing basketball, or perform squatting exercises at her gym, and she attributed this to "overdoing it". Over the past few months, however, the pain has intensified during these activities, and is also present during less strenuous activities, such as getting out of her seat and walking down stairs. The doctor orders plain film X-rays and MRI scans, which come back negative for fractures. The physician did, however, observe that she had an exaggerated Q-angle. Ober's test was performed... What was responsible for this condition?

.Tight iliotibial band

Fractures of the Taylor knocker most common fractures associated with this tarsal bone. Neck fracture with dislocation may be especially problematic because of which of the following complications? A. avascular necrosis of the talar body B. deep vein thrombosis C. disruption of tibialis posterior insertion D. rupture of the calcaneal tendon rupture of the spring ligament

A blood supply to the talus usually occurs through the Taylor neck. Fracture of the neck accompanied by subluxation or dislocation can lead to a vascular necrosis of the remainder of the tarsal

What specific muscles were torn in a hamstring injury? A.Biceps femoris (long head) B.Biceps femoris (short head) C.Semimembranosus D.semitendinosus

A.Biceps femoris (long head) C.Semimembranosus D.semitendinosus

Deep posterior compartment syndrome would result in (select all that apply)... A.Complete loss of digital flexion B.Complete loss of plantar flexion C.Partial loss of digital flexion D.Partial loss of plantar flexion

A.Complete loss of digital flexion D.Partial loss of plantar flexion

A 73-year-old morbidly obese female presents to a clinic complaining of a "heaviness and a pressure or pulling in her pelvis". Her history reveals that she has given birth to four children via vaginal delivery with one of the children weighing close to 9 lbs at birth. Recent patient history is unremarkable for acute fever, malaise or any sudden weight. She does state that she has experienced frequent urinations and occasional constipation. A pelvic exam is performed... what is your diagnosis A.Decent of the bladder into the vaginal canal B.Decent of the rectum into the vaginal canal C.Decent of uterus into the vaginal canal D.Infection of the external urethra orifice E.Infection of the vaginal orifice

A.Decent of uterus into the vaginal canal

A 17-year old high school track and field athlete presents to the ER with pain along the lateral aspect of her foot. The patient had been practicing for the 100 meter hurdle event when, as she stepped down after clearing the 4th hurdle, she felt a snap in the left side of her foot followed by immediate pain. She was help off the track and assessed by the athletic trainer, who noted significant point tenderness along the lateral aspect. The physician asked her to rate the pain, and she describe it as a 10 out of 10. The patient presents with a pronounced limp and unwillingness to put weight on the affected foot. Active and passive ROM are very painful, particularly when the doctor exerts a varus stress to the ankle or asks the patient to evert the ankle. A plain film radiograph is ordered (base of 5th metatarsal shows damage)... What soft tissue structure is directly involved in the patient's injury? A.Fibularis Brevis m. B.Fibularis Longus m. C.Flexor Hallucis Longus m. D.Latral Collateral Ligament of the Ankle E.Medial Collateral Ligament of the Ankle

A.Fibularis Brevis m. •aka pseudo-Jones fracture / avulsion fracture

Prepatellar Bursitis -presentation, diagnosis, treatment

AKA housemaid's knee •Inflammation of bursa between skin and patella Presentation •Pain, swelling, redness in knee, difficulty moving •History of repetitive motion, chronic kneeling, fall •Fluctuant edema over lower pole of the patella Dx •Physical inspection •Rule out ligament, meniscal injuries •Aspirate fluid for lab analysis (infection) Tx •PRICE •OT assessment in cases of chronic bursitis

Name the mm.'s in the 1st plantar layer in the foot & their action

Abductor Hallucis · Abductor, flexor of 1st digit Flexor Digitorum Brevis o Comparable to FDS of forearm · Flexes digits 2 to 5 up to proximal interphalangeal joint Abductor Digiti Minimi · Abductor, flexor of 5th digit

what happens with popliteal artery aneurisms

Aneurisms cause palpable pulsations, referred pain due to pressure on close lying tibial nerve

Which of the following muscle is cut during a mediolateral episiotomy? A.Anal sphincter B.Bulbospongiosus muscle C.Ishchiocavernosus D.Transverse perineal muscles E.Urethral sphincter

B.Bulbospongiosus muscle D.Transverse perineal muscles

A 20-year-old cross-country athlete reports to the athletic therapist prior to training for advice in dealing with shin splints, that typically start bothering her 15 minutes into her training routine. He does an examination and finds nothing of significance, but asks her to return after her training. She reports back with pain and tightness after training and showering up, and remembers to mention that she's been tripping herself up a lot late into her training sessions. Active and resistive ROM are painful but normal. Passive ROM is limited due to pain. Capillary refill test appears normal. A sensory test reveals an area of numbness in the webbing between the first 2 toes. What is the main medical condition? A.ACL/MCL/meniscus tears B.Common fibular nerve lesion C.Excessive pressure in anterior compartment D.Excessive pressure in lateral compartment

C.Excessive pressure in anterior compartment

6 weeks following a knee scope and meniscal repair, a 25 year old high school teacher gets back on his bike for the first time. During the ride, he takes a corner too sharply. His bike comes out from underneath him and he comes down hard on the affected knee. The knee swells almost immediate following the impact. Fearing that he's reinjured the meniscus, he goes to the ER. The physician performs a series of assessments for the various ligaments and menisci, which all seem negative. Joint ROM is also normal. There is point tenderness to the patella and dramatic swelling to the front of the knee. The physician orders an X-ray for the patella. What is your diagnosis? A.Achilles' tendon rupture B.Calcaneal stress fracture C.Inflamed bursa D.Meniscal tear E.Plantar fascia inflammation F.Popliteus tendinitis

C.Inflamed bursa

a 16-year-old high school cross country athlete makes an appointment with his family physician. He has been training on the indoor track of his high school gym during the winter months to maintain his cardio. Over the past few weeks, he has been noticing a dull aching pain at the front of his leg. The pain is greatest after a training session and seems to be alleviated with rest. The doctor refers the patient for an x-ray. What soft tissue structure is directly involved in the patient's injury? A.Flexor Hallucis Longus m. B.Tibialis Anterior m. C.Tibialis Posterior Muscle m. D.Fibularis Brevis m. E.Fibularis Longus m. F.Medial Collateral Ligament of the Ankle Flexor DigitorumLongus m

C.Tibialis Posterior Muscle m. shin splints

PCL Tear

Cause •Posterior force on knee in flexed position •MVA - dashboard; knee on turf Dx •Presentation •Acute - minimal pain, joint effusion; normal ROM •Physical exam - +ve posterior sag •MRI gold standard Tx •Operative vs. non-operative

Osteoarthritis vs. Avascular Necrosis

Characteristics of OA •Loss of joint space •Osteophyte formation around articular surface •Deformation of femoral head Characteristics of avascular necrosis •More subtle with plain film •Better observed with MRI •"double line" sign of degenerative border

Achilles Tendon Rupture

Complete tearing of the triceps surae tendon Presentation •c/o sudden snap with acute pain (shot, kicked, stabbed) •Inability to stand on affected side Treatment •Sugical vs. conservative •~ 6 mo rehab to normal

A 19 year old college student is involved in a rear end collision as a passenger in a car that struck a second car sitting at a red light. She is assessed at the hospital, and released with minor bruises across her chest and pelvis. She experiences pain and stiffness that is treated with over the counter NSAIDS. Several weeks later, she consults her family doctor about unresolved pain in the skin over her left lateral thigh. She describes it as an intermittent throbbing that does not seem to improve or worsen with sitting, standing, or lying down. Active/passive/resistive ROM are all normal and do not exacerbate the symptoms. Her family physician requests copies of plain film radiographs taken immediately following the accident. What is causing her pain?

Compression/lesion of lateral femoral cutaneous nerve

A 57 year old man is referred to an orthopedist with an acute knee injury. He reports stumbling while carrying an air conditioner down a flight of stairs and stepped hard on his right leg. He noticed immediate swelling. After a week of icing and NSAIDS, the swelling subsided. However the patient frequently feels a "buckling" sensation during pivoting motions and occasionally joint pain deep in the cavity when trying to fully extend the knee, even in a seated position. During physical examination, there is pain with palpation along the medial tibial plateau. The anterior drawer test is normal when compared to the uninjured side. The physician orders an MRI... (see image/bucket handle tear) Whats your diagnosis: A.ACL/MCL/meniscal tear B.Hamstring pull C.Excessive wear on lateral patellar surface D.Isolated meniscal tear E.Isolated ACL tear F.Isolated PCL tear

D.Isolated meniscal tear

Deep Muscular Compartment of posterior hip- where do they insert / what do they do? What about the superficial compartment-

Deep Muscle Layer · Collection of small muscles primarily originating off internal surface of pelvis · Insert on/around intertrochanteric fossa · Principally involved in lateral rotation, stabilization of hip joint Superficial Muscle Layer · Originate off external surface of sacrum, ilium · Produce extension, abduction, medial rotation

A 43 year old man is brought to the ER following a motor vehicle accident. Radiographs indicate a pelvic fracture. The man is taken to the OR and the fracture is reduced with surgical plates. During post-op recovery, the charge nurse reports that urine output is low. The physician performs two separate urethrogram tests; one where contrast medium is injected at the external urethral orifice (retrograde urethrogram) and a second where contrast medium is injected directly into the bladder (voiding cystourethrogram) Whats your diagnosis? A.Chronic contracture of the bulbospongiosus muscle B.Chronic contracture of the external urethral sphincter C.Chronic contracture of the internal urethral sphincter D.Post-surgical dehydration E.Post-surgical prostate enlargement F.Rupture of the urethra

F. Rupture of the urethra

A 32 year old female presents with point tenderness along the medial surface of the knee joint capsule. An avid runner, she originally noticed the pain during activity, especially downhill running. The pain has worsened to the point that she can no longer run. While assessing gait, the physician notices that the patient does not fully extend her knee at the end of swing phase. The patient explains that keeping her knee slightly bent seems to prevent her pain, which is worst when the affected leg pushes off from the ground. Upon physical examination, resisting against forced knee extension exacerbates the symptoms. What is the principle mechanism for the pain? A.Achilles' tendon rupture B.Calcaneal stress fracture C.Inflamed bursa D.Meniscal tear E.Plantar fascia inflammation F.Popliteus tendinitis

F.Popliteus tendinitis

Name the mm.'s in the 3rd plantar layer in the foot & their action

Flexor Hallucis Brevis · Flexor of great toe up to MTP joint Adductor Hallucis · Adductor of great toe; assists in maintaining transverse arch Flexor Digiti Minimi Brevis · Flexor of 5th digit up to proximal IP joint

name the actions of the superficial posterior lower leg : -gastrocnemius -soleus -plantaris

Gastrocnemius · More active in forceful contractions (sprinting, jumping) Soleus · The "workhorse" of plantar flexion o Continuous activity during standing, walking Plantaris · Thought to be more important as proprioceptor than as plantar flexor

A 15-year-old junior varsity football offensive tackle feels a sudden twinge in his hip while stepping awkwardly during a practice drill, followed by a dull pain in his hip and groin area. He initially tries to walk it off, but the pain persists and forces him to leave practice early. Over the next several days the athlete uses PRICE principles to help recover from the injury, but after 2 weeks, there is no noticeable improvement. His parents decide to consult with their family physician, and are referred to an orthopedic specialist, who orders a plain film radiograph... What is your diagnosis (see image) A.Avascular necrosis B.Greater trochanter avulsion fracture C.Groin pull D.Growth plate injury E.Hip dislocation F.Hip fracture G.Inguinal hernia H.Lesser trochanter avulsion fracture I.Osteoarthritis of the hip J.Snapping hip syndrome

Growth plate injury

A 20 year old undergraduate student consults student health about tightness and tenderness in the upper region of his anterior thigh, just lateral to his groin. Discomfort is greatest when he is standing and alleviated when he is in a seated or lying position. The patient is physically active and in overall good health. Active/passive/resistive ROM are all normal and asymptomatic in the sitting position. The physician notices a large gauze pad on the student's anterolateral leg. The student reports "scraping up" his shin when sliding into second base during a baseball game a few days prior. The student did not recall any pain to the hip during the time of the slide and played out the rest of the game. What is causing the pain? A.Avascular necrosis B.Compression/lesion of lateral femoral cutaneous nerve C.Compression/lesion of femoral nerve D.Disc herniation E.Femoral neck fracture F.Femoral triangle compression syndrome G.Groin pull H.Non-specific infection I.Osteoarthritis of the hip J.Osteoarthritis of the knee

H.Non-specific infection

What muscle(s) did Mike Smith most likely Injure during a groin pull? I. Adductor magnus II. Rectus femoris III. Gracilis IV. Biceps femoris

I. Adductor magnus III. Gracilis

Lymphatic drainage - explain the drainage for the lateral leg, the medial leg/thigh group, then the pelvis/perineum

Lateral leg •Follow small saphenous v. •Drain into popliteal lymphatics, up to deep inguinal lymph nodes Medial leg, thigh group •Follow great saphenous v. •Drain into superficial subinguinal nodes inferior to saphenous opening, through saphenous opening into deep inguinal lymph nodes Pelvis, perineum •Drain into superficial inguinal nodes superior to saphenous opening, through saphenous opening into deep inguinal lymph nodes

list muscles of medial compartment of the thigh / what they do and their innervation

Muscles of the Medial Compartment · All muscles innervated by obturator nerve · All muscles generate hip adduction adductor longus/brevis/magnus, gracilis, obturator externus

A hockey player has the puck and is going fast on the ice towards the goal. He slips and falls with his knee flexed and runs into the goal post. There is a posterior force on knee in flexed position, what is your diagnosis?

PCL Tear

What is the most important support for the medial arch?

Plantar calcaneal navicular spring ligament

Name the mm.'s in the 4th plantar layer in the foot & their action

Plantar interossei · Adductors of digits o Comparable to palmer interossei (3 PAD) Dorsal Interossei 4 DAB abduct

list the muscles in the deep compartment of the posterior lower leg and their functions: Popliteus Tibialis Posterior Flexor digitorum longus Flexor Hallucis Longus

Popliteus · Plays critical role in "unlocking" knee from full extension by medially rotating the tibia on the fibula Tibialis Posterior · Produces plantar flexion, inversion (in conjunction with tibialis anterior) · Thought to play major role in maintaining longitudinal arch of foot during standing, stance phase of walking, running Flexor digitorum longus · Flexor of distal phalanges 2-5 · Produces inversion with tibialis anterior and posterior Flexor Hallucis Longus o Contraction thought to produce "lift" to sustentaculum tali o Results in additional thrust with foot lift-off during walking, running o Great toe last in contact with ground prior to lift off from ground

Name the mm.'s in the 2nd plantar layer in the foot & their action

Quadratus Plantae · Realigns pull of FDL more posteriorly o Paralysis of quadratus plantae one of the causes of pigeon-toe gate Lumbricals o Comparable to lumbricals in hand · Contract to flex metatarsophalangeal (MTP), extend IP joints 4 DAB 3 PAD

sartorius action iliopsoas action pectineus action quadriceps action The ______ nerve innervates the sartorius, pectineus, and quadriceps femoris, and iliacus muscle of the iliopsoas. -What is unique about pectineus?

Sartorius o Flexes, abducts, laterally rotates the hip o Flexes the knee Iliopsoas principle flexor of the thigh Pectineus · Adducts, flexes, medially rotates hip Quadriceps knee extension The femoral nerve innervates the sartorius, pectineus, and quadriceps femoris, and iliacus muscle of the iliopsoas. Pectineus is Unique because: · "Hybrid" of anterior, medial compartment muscles o Dual innervation from both compartments (femora and obturator n.s)

What is the section of tendon commonly used in ACL autograft reconstructions?

Semitendinosus

What are the superficial muscle layers of posterior hip region? What are the deep muscle layers of posterior hip region?

Superficial -gluteal muscles (max/med/min) -tensor fascia lata Deep -piriformis -obturator internus -superior/inferior gemellis -quadratus femoris

What neuropathy can cause Trendelenburg sign?

Superior gluteal nerve neuropathy

T/F fibula does not contribute to knee joint

TRUE!

The "unhappy triad":

Term to describe tearing of MCL, ACL, meniscus with excessive valgus stressor -Traditionally believed to be medial meniscus that was torn · Due to connection with MCL -Studies show lateral meniscus more commonly torn (6 out of 10 cases) Due to compressive force of femur with valgus stressors

Pelvic Organ Prolapse

Treatment •Kegel exercises to strengthen pelvic diaphragm •Weight loss •Avoid constipation by increasing fiber intake, staying hydrated •Avoid heavy lifting •Control coughing •Vaginal pessary

What branch runs in the ligament of the femur, supplies the head of the femur, and is the branch of the _____ artery?

acetabular branch comes off the obturator artery to supply the head of the femur

Upon physical assessment in the locker room, the quarterback presented in great pain and with an inability to fully weight bear. The player's right thigh appeared adducted, flexed, and internally rotated. The team trainer also noted a mild leg length discrepancy, with the right leg appearing shorter. The player was transferred to the local hospital, where X-rays were ordered...

acetabular fracture

Injury to the proximal region of the femoral artery can result in :

extensive blood loss , death within minutes; artery can be compressed by landmarking mid-region of femoral triangle cutaneously and applying pressure

With a hip fracture, the affected side appears

externally rotated, shortened

what is the common site for intramuscular injections; "safe region" found laterally, void of neurovascular structures?

gluteus maximus

longest continuous vein in the body:

great saphenous

what action does the hamstring muscles perform? -what is not part of the hamstring muscles and what is its action?

hip extension, knee flexion biceps femoris short head- knee flexion

In the accompanying video, Jaylon Smith suffered a tear to both his ACL and MCL during a hyperextension injury. Coming off the field, he noticed difficulty lifting his toes as he was heading off the field. Sideline assessment identified numbness along the lateral aspect of his left leg and dorsum of his left foot. What nerve was most likely damaged in the hyperextension injury? A.Common fibular n. B.Deep fibular n. C.Saphenous n. D.Superficial fibular n.

hyperextension injury? A.Common fibular n.

obers test

identifies tightness of tensor fascia latae and/or iliotibial band tightness

A 19 year old varsity soccer player arranges an appointment with the team trainer to discuss an issue with her hip. For the past 2 seasons she has been dealing with pain in her anterior hip that tended to appear towards the end of matches late in the season. Both years she assumed that the off season would allow it to heal, but this year the pain was noticeable early in the playing season, started earlier in the games, and is now accompanied by knee pain. She has also recently noticed that cutting motions on the field result in a popping sound in her hip and a feeling that her hip has popped in and out of her joint, which has her concerned. She is referred for plain film radiographs, which show no dislocation or abnormalities in the articulating surfaces. In a follow up visit with the team physician, the patient is asked to lie flat on a table and draw the unaffected leg towards her chest. When she does this, the affected leg also rises off the table, despite giving the patient instructions to keep it flat on the table (figure A). When the patient draws the affected leg towards her chest, the unaffected leg remains flat on the table (figure B). What is your diagnosis?

iliopsoas bursitis

What is the most important extensor of hip

long head of biceps femoris

medial plantar nerve innervates: lateral plantar nerve innervates: which one is more muscular and which one is more cutaneous?

medial plantar · Enters plantar surface by passing deep to abductor hallucis, passing superior to flexor hallucis brevis, supplying both muscles · Additional muscular branches to flexor digitorum brevis, and 1st lumbrical lateral plantar o Deep branch supplies muscles not innervated by medial plantar nerve o Superficial branch supplies skin over lateral 1.5 digits · Greater muscular innervation, less cutaneous distribution than medial branch

tibial nerve damage would lead to..

o Injury uncommon, but would produce loss of plantar flexion; patient shows highly modified gait (extreme lateral rotation of hip to avoid unwanted dorsiflexion during stance phase

name the borders for femoral triangle -floor formed by:

o Superior - inguinal canal o Medial - adductor longus m. o Lateral - Sartorius m. · Floor formed by pectineus, iliopsoas muscles

name the 4 borders of popliteal fossa:

o Superomedial - semimembranosus o Superolateral - biceps femoris o Inferomedial - medial head gastrocnemius o Inferolateral - lateral head gastrocnemius (& plantaris, if present)

kendell/thomas test

performed to identify iliopsoas / hip flexor tightness

What artery is most likely damaged in a knee injury? A.Decending branch of lateral femoral circumflex B.Femoral C.Perforating branches D.Popliteal E.Profunda femoris

popliteal

On a return flight from Paris to Chicago, a 57-year-old man starts to notice painful swelling in his left calf and foot. He tries to massage his leg, which does nothing to help with the swelling, but intensifies the pain. Coming off the plane and into the airport, he finds it difficult to walk, as the pain intensifies with each step. Concerned, he stops in at an urgent care facility near his home. The physician notes the swelling, as well as redness throughout his lower leg. He also notices that the skin behind the back of his knee is relatively warm to the touch compared to the back of the thigh, just above the knee. The man is rushed to the emergency room, where a radiograph with contrast media is ordered... What anatomical structure is affected in the present situation?

popliteal vein (DVT is a risk)

theatre sign

prolonged sitting

longest continuous muscle in the body

sartorius

list the muscles in the superficial compartment of posterior lower leg list the muscles in the deep compartment of posterior lower leg

superficial- gastrocnemius, soleus, plantaris (o Generate >90% of plantar flexion force o Muscles insert on calcaneal tendon; thickest, strongest tendon in body) deep- tibialis posterior, flexor digitorum longus, flexor hallucis longus, popliteus (· Houses 4 muscles, 3 of which contribute to plantar/digital flexion)

Trendelenburg sign

swing hip sags low during gait, suggesting problems with the contralateral gluteal region o Abduction of particular importance during the stance phase of walking; abduction prevents sagging of contralateral side during swing phase; straight leg is the side affected

what is a sight of great bone strain?

the hip- common site for fractures, particularly in elderly individuals with osteoporosis with sudden hard impact (e.g. missing a step on the stairs); commonly called a broken hip, though it is distal to the hip joint; often impacted, due to orientation of bones, pull of muscles

what muscles produce inversion of the ankle?

tibialis anterior, tibialis posterior, flexor digitorum longus

A patient presents to her family physician with what she describes as pain in her right buttocks that radiates down her right leg. The pain is most noticeable during prolonged periods of either sitting or walking, as well as with bowel movements. Lying down for prolonged periods seems to help, but the pain is noticeable when getting up after a night's sleep. The patient has also felt pain radiate into her genital region, which has her particularly concerned. The physician performs a physical examination, and is able to reproduce symptoms when the right leg is horizontally flexed and internally rotated. What is your diagnosis?

tight piriformis

Piriformis syndrome -

tight piriformis muscle (resulting from repetitive contraction of gluteal muscles in sports such as skating, cycling) may impinge on sciatic nerve; more common in anomalies where sciatic nerve penetrates piriformis muscle

Explain Menisci / injuries

§ Accept axial load from femur § Anchored to joint capsule through numerous ligamentous attachments Medial meniscus · Most commonly injured from shearing forces of femur, particularly in ACL deficient knee · "bucket handle" tear - describes appearance of torn central flap hanging loose May also tear with medial collateral ligament tears, due to close association Lateral meniscus · Most commonly torn from compression forces of femur during valgus stressor · Less commonly torn with rotational movements o Less anchored, more mobile

Ligament sprains -Explain the 2 Collateral ligaments sprains

§ Taught in extended position § Resist lateral rotation of tibia Medial collateral ligament · Susceptible to tearing during pivoting, or from valgus stressor (blow to lateral aspect of knee) Lateral collateral ligament · Not as commonly injured (excessive varus stressors uncommon)

Ligament sprains -Explain the 2 Cruciate ligament sprains

§ Taught throughout joint angles § Resist medial rotation of tibia on femur Anterior cruciate ligament · Susceptible to hyperextension injury (isolated ACL sprains) · May also tear along with MCL with valgus stressor Posterior cruciate ligament · Infrequently torn when falling on flexed knee (pushes tibia backward)

anterior lower leg vs. lateral lower leg

· Anterior compartment o Houses the dorsiflexors (ankle extensors), digital extensors (· All muscles assist with dorsiflexion) o Vascular supply by anterior tibial a. o Innervated by the deep fibular nerve -tibialis anterior, extensor digitorum, extensor hallucis longus, fibularis tertius · Lateral compartment o Houses the everters of the ankle o Vascular supply by fibular a. o Innervated by the superficial fibular nerve -fibularis longus and brevis *don't get confused, fibularis tertius is a weak dorsiflexor but still an evertor, still innervated with the mm. of the anterior compartment

Name the lower limb cutaneous nerves

· Anterior nerves of the thigh o Branches off the femoral nerve supplying the anterior thigh · Lateral femoral cutaneous nerve o Direct branch from the lumbar plexus supplying the lateral thigh · Posterior femoral cutaneous nerve o Direct branch from the sacral plexus supplying the posterior thigh · Superior/inferior clunial nerves o Branches of varying origin supplying the gluteal region · Superficial fibular nerve o Branches off the common fibular nerve to supply the anterior leg, dorsum of foot · Saphenous nerve o Distinct branch off femoral nerve o Emerges proximal with the knee to run with the saphenous vein o Supplies the medial aspect of the leg · Sural nerve o Supplies the lateral/posterior aspect of the leg o Typically a fusion of lateral and medial sural cutaneous nerves, both of which branch from the sciatic nerve

Explain the 2 Subcutaneous Perineal Fascia

· Subcutaneous fatty tissue o Continuation of Camper's fascia from abdominal wall o Continues into anal triangle as ischioanal fat pad o Variable thickness proportional to abdominal fat content o In females, forms the mons pubis, portion of the labia majora o In males, subcutaneous fat disappears in scrotal sac to facilitate evaporative cooling of testes · Perineal fascia (a.k.a Colle's fascia) o The "deeper" part of the "superficial" fascia o Membranous layer of connective tissue just deep to the subcutaneous fat tissue o Continuation of fibrous Scarpa's fascial from abdomen, fascia lata from thigh o Forms a superficial covering for the urogenital triangle § Anchored to posterior margin of urogenital triangle; does not extend into anal triangle

Name the Superficial Perineal Muscles and their actions

· Superficial transverse perineal muscle · Tonically contracted to support pelvic floor in standing/sitting positions · Ischiocavernosus muscle o Contraction compresses erectile tissue, limiting blood flow back to caval circulation to assisting in producing/maintaining an erection · Similar function in both males & females, but more developed in males · Bulbospongiosus muscle § Similar to ischiocavernosus, contracts to limit venous blood return, assisting in producing/maintaining an erection § Also contracts to assist in expulsion of urine, seminal fluid

Legg-Calvé-Perthes disease (LCPD)

•Avascular necrosis in adolescence (4 - 10 years old) •Idiopathic or 20 to epiphysis damage (slipped capital femoral epiphysis), trauma •Dx - Presents with intermittent limp after activity, referred pain to thigh, knee; radiographic findings of avascular necrosis •Tx - protection, minimal WB; surgical osteotomy

"Snapping Hip" Syndrome

•Condition resulting in an audible snapping or clicking sound with specific movements •External - gluteus maximum, tight ITB •Internal - iliopsoas tendon •Can be related to hip joint pathologies, but much less common

Iliopsoas Tendinitis/Bursitis -What test is conducted to confirm?

•Conditions go hand-on-hand •Presents with pain during activity •Audible sound, as tendon catches on pectineal line •May alter biomechanics, resulting in secondary syndromes (eg. Knee) •Kendall/Thomas tests •When unaffected leg is pulled towards chest, causes superior pelvic tilt •With tight iliopsoas, affected leg is also pulled towards chest •Can distinguish between tight iliopsoas and tight rectus femoris based on movements at knee

Meralgia Paresthetica- cause/diagnosis/treatment

•Focal entrapment/lesion of LFCN •Causes - MVA, sudden increased weight (e.g. pregnancy), diabetes, "skinny pants syndrome", idiopathic •Dx with patient history, physical exam •Hip extension, soft tissue palpation at ASIS may reproduce Sx •Tx with rest (loose clothing), focal nerve block

Chronic Exertional Anterior Compartment Syndrome

•Gradual and progressive buildup of compartmental pressure •Etiology unclear (ischemia 20 to prolonged tissue edema) •Common in competitive athletes (e.g. long distance runners) •Most common in lower legs (often confused with shin splints) •Presentation •exercise-induced pain; relieved by rest •May be asymptomatic at rest •Pt reports pain, tightness, cramping, dull ache, "fullness" •Possible loss of dorsiflexion strength, decreased dorsalis pedis pulse, capillary refill, numbness in webbing between great & second toe •Dx •Gold standard - compartment pressure readings (rest and exercise) •Tx •PRICE, PT (conservative, poor success rate) •Fasciotomy (~85% success rate) followed by PRICE & cross training

Slipped Capital Femoral Epiphysis

•Important pediatric/adolescent hip disorder •Salter-Harris fracture to the epiphyseal growth plate •Results in shifting of the femoral head relative to the shaft •Most common in overweight adolescent boys •Requires accurate diagnosis to prevent further complications

Popliteus Tendinitis -presentation, diagnosis, treatment

•Inflammation of the popliteal attachment, most commonly to tibia •Presentation •History of previous joint injuries, downhill running (assists PCL) •Knee flexion pain from full extension, running downhill •Dx •Probably underdiagnosed •History and physical examination (muscle testing) •Rule out MCL, PCL tears •Tx •Acute phase - PRICE with stretching •Progress to deep transverse frictional massage, gradual increase in activity

Osteoarthritis

•Joint inflammation most commonly associated with excessive "wear and tear" •Characterized by osteophyte formation around joint •Results in increased signal, clouding of joint space

How does osteoarthritis of the hip present?

•Loss of joint space •Osteophyte formation around articular surface •Deformation of femoral head

Deep Vein Thrombosis

•Manifestation of venous thromboembolism •Due to clotting of stagnant blood in deep veins •Prolonged sedentary position •Long flights •Prolonged bedrest •Common in hospital settings!!! •Venous clots may break off and reach the lungs, resulting in potentially life-threatening pulmonary embolisms

Common Fibular (Peroneal) Mononeuropathy

•Nerve lesion, typically 20 to direct trauma (compression/stretch injury) •3rd most common monoeuropathy, next to median, ulnar nerves •Presentation •Frequent tripping, possible "foot drop" gait •Pain at site of compression •Parasthesia in lateral leg, foot •Dx •Physical assessment - APR ROM, nerve tapping test •Gold standard - electrodiagnostics (needle EMG) •Tx •Mostly conservative (rest, ankle-foot orthoses, PT for recovery of function)

cellulitis

•Non-necretizing inflammation of subcutaneous tissue •May result in lymphedema •Dx through patient Hx, physical examination •Inflammation at site of injury •Blood culture may be warrented •Tx - NSAIDS, antibiotics if warranted; carful monitoring of inflammation spread

Shin Splints

•Pain along the anterior aspect of the leg •Results from microtearing along tibialis posterior attachment to interosseous membrane •Due to repetitive stresses (running on hard surfaces) •Presentation •Dull aching pain to front of leg •Treatment •Price methods

Prepatellar vs. Infrapatellar Bursitis

•Prepatellar bursitis •"Housemaid's knee" Infrapatellar bursitis "Clergyman's knee"

piriformis syndrome: presentation, diagnosis, treatment

•Presentation •~5-10% of sciatica cases •Woman > Men (~6x) •20 to blunt trauma to gluteal region; idiopathic (sciatic nerve variants) •Pain in gluteal region; referred to groin, leg; intolerance to sitting •Dx •Physical assessment •Pain with passive, resisted flexion, abduction, internal rotation •Tx •PRICE; rehab •PT - stretch with muscle energy; soft tissue massage •OT - seating assessment

Meniscal Tear -what is it / diagnosis / treatment

•Tearing in the fibrocartilagenous pad, typically the result of shearing forces between femur and tibia •Presentation •Joint-line pain, joint effusion, joint locking at ~30±100 of full extension Dx •Numerous assessments (grind tests) •MRI is gold standard Treatment •Repair vs. partial/full menisectomy •Dependent on site/extent of tear •Preserve as much tissue as possible •Rehab focus in ROM early, strength later

groin pull

•Tearing of the hip adductors •Typically at the point of origin off the ischiopubic ramus, but can occur anywhere along the path of the muscle •Typically the result of excessive abduction, forceful adduction (eccentric contractions)

Iliotibial Band/Patellofemoral Syndrome

•Tightness of the ITB leading in rubbing of the band at the hip and/or knee •Can be exacerbated with excessive Q-angles •Tight ITB confirmed by Ober's test •Also results in lateral pull on patella, resulting in friction between patella and lateral femoral condyle, leading to pain and inflammation •Can be exacerbated with prolonged periods of knee flexion ("theater sign" - prolonged sitting) •Treated by stretching ITB, strengthening VMO

Avulsion Fracture

•aka pseudo-Jones fracture •Forceful contractions from fibularis brevis cause break in base of 5th metatarsal •Presentation •Antalgic gait •Avoid push-off phase •Point tenderness at base of 5th metatarsal •Helps with DDX of ankle sprain •Diagnosis •Physical presentation •Radiograph is gold standard •Treatment •Heals well with conservative treatment •Compression dressing, crutches (WBAT)