Lower Limb
A 78-year-old woman receives knee surgery because her lateral meniscus is torn. Before injury, the normal lateral meniscus of the knee joint:
Lies outside the synovial cavity
Choose the appropriate lettered site or structure in the following radiographs of the knee joint (see figure) to match the following descriptions. Fracture of this structure would most likely cause weakness in adduction, flexion, and extension of the thigh.
A
Choose the appropriate lettered site or structure in the radiograph of the hip and pelvis (see figure) to match the following descriptions. Which structure becomes necrotic after the medial femoral circumflex artery is severed?
A
A foot surgeon is about to perform a bunion surgery and needs to anesthetize the entire foot except the lateral border. Which of the following nerves would she not need to anesthetize?
Sural
A 20-year-old college student receives a severe blow on the inferolateral side of the left knee joint while playing football. Radiographic examination reveals a fracture of the head and neck of the fibula. If the lateral (fibular) collateral ligament is torn by this fracture, which of the following conditions may occur?
Abnormal passive adduction of the extended leg
Your 36-year-old patient is complaining of hip pain and a clicking sensation in his hip. An MR arthrogram of his hip is shown above. The red arrow points to a tear of which of the following?
Acetabular labrum
A 62-year-old woman slips and falls on the bathroom floor. As a result, she has a posterior dislocation of the hip joint and a fracture of the neck of the femur. If the acetabulum is fractured at its posterosuperior margin by dislocation of the hip joint, which of the following bones could be involved?
Ilium
A 48-year-old bartender complained to his physician about a globular swelling in his left groin. He said the swelling became smaller when he lay down but never completely disappeared. He also complained that the swelling occasionally became very large and formed a bulge under the skin on the anterior aspect of his thigh. When asked to pinpoint the location of the swelling, he put his fingers over the region of the femoral triangle. He later said he felt pain along the inside of his thigh. When the physician inserted his finger in the patient's superficial inguinal ring and asked him to cough, the physician did not feel a protruding mass. However he noted that the mass in his thigh increased in size. Which of the following statements best describes the most likely cause of the swelling in the man's thigh?
A hernial sac that descended through the femoral canal within the femoral sheath, causing a globular swelling in the thigh.
A 6-year-old boy playing barefooted in his backyard steps on a piece of broken glass and suffers a large transverse cut on his sole, at the level of the midfoot. In the emergency room, the examining physician determines the cut is to the depth of the first layer of the plantar muscles. Which of the following structures is most likely damaged in this injury?
Abductor hallucis muscle
Your 38-year-old patient has suffered a severe inversion ankle sprain. What structure is most commonly torn with this injury?
Anterior talofibular ligament
A 17-year-old boy was stabbed during a gang fight resulting in transection of the obturator nerve. Which of the following muscles is completely paralyzed?
Adductor longus
The obturator nerve and the sciatic (tibial portion) nerve of a 15-year-old boy are transected as a result of a motorcycle accident. This injury would result in complete paralysis of which of the following muscles?
Adductor magnus
You are evaluating your 60-year-old patient for peripheral artery disease. You cannot palpate a dorsalis pedis pulse in either foot. Although this likely supports a diagnosis of peripheral artery disease, this artery is sometimes replaced by which of the following?
An enlarged perforating fibular artery
A soccer player injures his left knee when he twists the flexed knee while trying to avoid another player. While performing a knee examination, his physician pulls the flexed knee toward her (the physician's) body, as shown in the illustration. This clinical test is a check for the integrity of which of the following ligaments?
Anterior cruciate ligament (ACL)
You are working in the ED and a patient is brought in with severe knee pain from an athletic injury. Upon testing the knee you discern excessive anterior movement of the tibia on the femur. You therefore suspect which of the following?
Anterior cruciate ligament tear
A 21-year-old female basketball player lands on her opponent's foot after jumping to rebound the basketball. Her foot is forcefully inverted, and when leaving the court, she tells her trainer that she twisted or sprained her ankle. After getting her ankle taped for support, she reenters the game. What ligament was most likely damaged?
Anterior talofibular ligament
A 20-year-old college student receives a severe blow on the inferolateral side of the left knee joint while playing football. Radiographic examination reveals a fracture of the head and neck of the fibula. Which of the following arteries could also be damaged by this fracture?
Anterior tibial
A basketball player was hit in the thigh by an opponent's knee. Which of the following arteries is likely to compress and cause ischemia because of the bruise and damage to the extensor muscles of the leg?
Anterior tibial
Your 46-year-old female patient felt a swelling in his upper thigh that you determine to be enlarged superficial inguinal lymph nodes. These nodes drain all of the following regions except:
Appendix
You suspect your 60-year-old patient has plantar fasciitis. If your suspicion is correct, where is point tenderness typically most acute?
At the proximal-medial attachment of the plantar aponeurosis
Your 45-year-old patient is about to have bone marrow removed from her pelvic bone for later autologous transplant. The patient has been advised that multiple needle punctures of the iliac crest are needed, with the iliac tubercles used as a "landmark". Where are these tubercles?
At the widest point of the iliac crest, 5-6 cm posterior to the anterior superior iliac spines
Your 22-year-old elite runner patient has severe pain in her right lower gluteal area and has difficulty walking and standing. Her hip radiograph is shown above with the black arrows pointing to the cause of her pain. What is your diagnosis?
Avulsion fracture of the ischial tuberosity
During a basketball game your 25 year-old-patient severely and violently inverted his foot and now has sharp pain along the lateral margin of his foot, slightly anterior to his cuboid bone. What do you suspect?
Avulsion fracture of the tuberosity of the 5th metatarsal
Choose the appropriate lettered site or structure in the following radiograph of the ankle and foot (see figure) to match the following descriptions. The peroneus longus muscle tendon is damaged in a groove of a tarsal bone by fracture. Which bone in the radiograph is most likely fractured?
B
Choose the appropriate lettered site or structure in the following radiographs of the knee joint (see figure) to match the following descriptions. A knife penetrating through this point would most likely cause muscle ischemia in the anterior compartment of the leg.
B
Choose the appropriate lettered site or structure in the radiograph of the hip and pelvis (see figure) to match the following descriptions. Fracture of which structure may destroy the site of insertion of the muscle that can rotate the thigh laterally and its tendon that passes through the lesser sciatic foramen?
B
A 38-year-old woman was walking barefoot around her swimming pool when she stepped on a sharp object that caused a deep cut in her left middle toe. She rushed to the house, cleansed the wound, and applied a bandage. After a few days, the toe was swollen and painful. She consulted her physician who observed that the toe was severely infected. Where would you expect lymph node swelling?
In the popliteal fossa
You are concerned about intermittent claudication in your 67-year- old female patient because of recurring leg pain. To determine if this condition exists, you want to test your patient's posterior tibial pulse. To do this where would you place your finger?
Between the medial malleolus and the Achilles (calcaneal) tendon
A 65-year-old man with a history of heavy smoking visits his physician complaining of intermittent pain in his feet, accompanied by pallor and coldness of his feet. The physician suspects vascular insufficiency and takes a pulse of the dorsalis pedis artery. That pulse is best palpated at which of the following locations?
Between the tendons of the extensor hallucis longus and extensor digitorum longus muscles
A 76-year-old woman who was involved in an automobile accident was carefully removed from the car. She complained of pain in her right hip region and was concerned about the swelling in her right thigh. An ambulance took her to the closest hospital. Radiographic examination of her right hip and thigh revealed a fracture of the neck of her right femur. Which of the following statements pertaining to femoral neck fractures is correct?
Bleeding from the blood vessels supplying the femoral head and neck after this fracture likely accumulates in the articular cavity of the hip joint.
Deep venous thrombosis is a common complication from sitting in one position for a prolonged duration, such as during a long car trip or a long plane flight. The first vascular channels likely to be obstructed or occluded by an embolus from the deep veins of a lower limb are the:
Branches of the pulmonary arteries.
Choose the appropriate lettered site or structure in the following radiographs of the knee joint (see figure) to match the following descriptions. Rupture of the tendon superior to this structure would most likely cause an inability to extend the knee joint.
C
Choose the appropriate lettered site or structure in the radiograph of the hip and pelvis (see figure) to match the following descriptions. Which fractured structure is likely to cause paralysis of the adductor magnus?
C
A "posterolateral corner" knee injury was treated surgically with successful repair of several torn structures including the fibular collateral ligament. However, the surgical repair of the popliteus tendon has failed. This would affect which motion of the knee most significantly?
Initiating flexion of his knee during terminal stance phase
A 76-year-old man recently had coronary bypass surgery in which the small saphenous vein was harvested to establish coronary blood flow. Following the procedure, he complained of numbness and paresthesia in the limb from which the vein was removed. The given photo highlights the cutaneous area affected in the patient. No motor loss was noted. What nerve was most likely damaged during harvesting of the vein for transplantation?
Sural nerve
Your 49-year-old patient had a bone graft taken from her posterior iliac crest and now has a sensory loss overlying the graft site. What nerve or branch of what nerve was presumably ligated?
Cluneal nerve
Your 23-year-old hockey player patient received a slicing injury to the lateral side of the upper part of his leg during a game. After the wound was closed, the patient walked with a foot drop on that side. What nerve was transected during the game?
Common fibular (peroneal)
A 32-year-old mixed martial arts fighter could not continue his fight after receiving a side leg kick to the neck of his left fibula. The fighter reported paresthesia and numbness on the entire dorsum of his left foot. During his physical examination, the patient often stumbled with his left toes dragging on the floor during the swing phase of his gait. Asymmetry in his normal foot position was also noted by the physician (see photo) as well as weakness in eversion of the foot at the ankle joint. What nerve was damaged?
Common fibular nerve
A 20-year-old college student receives a severe blow on the inferolateral side of the left knee joint while playing football. Radiographic examination reveals a fracture of the head and neck of the fibula. Which of the following nerves is damaged?
Common peroneal
A 12-year-old boy was playing soccer without protective shin pads. He was kicked very hard on the anterolateral surface of his right leg. He was helped to the sidelines complaining of pain in his leg. Later he was said that his foot was numb. Several hours later the pain was so severe that his parents took him to the hospital. On examination his right leg was tender, swollen, and hard. The dorsalis pedis pulse was absent. Radiographs of his leg revealed no bone fractures. He now complained that he could not dorsiflex the toes of his right foot. Which of the following statements completely describes the most likely cause of the swelling and pain in the boy's leg?
Compartment syndrome of the right leg
You are examining your 18-year-old patient's foot because of pain and you press your finger about a finger's breath distal (anterior) to the tip of the medial malleolus. What is the prominence you are feeling?
Sustentaculum tali
You are examining a 3-year-old girl who is walking awkwardly, dropping her right pelvis during the swing phase of her right limb. Further, she has very limited abduction of her right hip. What is your preliminary diagnosis?
Congenital right hip dislocation
As part of a physical examination to evaluate lower limb function, a physician places her hands on the dorsum of the patient's foot and asks the patient to dorsiflex the ankle joint against resistance, as shown. What nerve is the doctor testing?
Deep fibular nerve
Following surgery to repair a broken right tibia, a 22-year-old patient is placed in a short leg cast. Several hours later, she complains of extreme pain, numbness with a "pins and needles sensation," inflammation, and abnormal pressure on the anterior and lateral aspects of the affected lower leg. The cast is removed, and the physician notes weakness in dorsiflexion of the foot and toes, a weak dorsalis pedis arterial pulse, and sensory loss between the first and second toes. What nerve is most likely damaged?
Deep fibular nerve
A 72-year-old woman with Parkinson's disease fell down in the bathtub at her home and suffered a dislocation of the hip joint that may result in vascular necrosis of the femoral head and neck because of injuries to the arteries. Which of the following arteries might remain intact?
Deep iliac circumflex artery
A 47-year-old woman is unable to invert her foot after she stumbled on her driveway. Which of the following nerves are most likely injured?
Deep peroneal and tibial
A 58-year-old woman decided to do housecleaning to supplement her pension after her husband died. One of her duties was to clean the granite floors in a large kitchen and entrance hall. She decided to do this work on her knees. Although she found this uncomfortable, she refused to wear kneepads. After several weeks, she noticed swellings on the lower part of her knees. When these swellings became large, she consulted her family physician. On examination, she noted that the swellings were fluid-filled and tender and were anterior to the patella. The physician noted that the dimples on each side of the patellar ligament were present when the leg was extended. Which of the following statements best describes the cause of the swellings in her knees?
Friction bursitis of the subcutaneous prepatellar bursae
A 25-year-old woman is brought to the emergency room in severe pain due to an ankle injury. She tells the attending physician she was wearing high-heel shoes, stepped off the curb into the street, lost her balance and landed awkwardly, causing her foot to turn extremely outward (eversion). Which of the following ligaments is most likely damaged?
Deltoid ligament
A man interviewing for a new administrative position as hospital chief executive officer notices difficulty walking after sitting with his leg crossed for 2 hours. He was nervous during the interview but even more so now that he is attempting to stand to follow two board members for a tour of the hospital. Which of the following actions is most seriously affected by compression and temporary paralysis of the deep peroneal nerve?
Dorsiflexion of the foot
A 15-year-old girl is struck by a car while crossing the street. She suffers numerous pelvic injuries, including tearing of the sacrotuberous ligament. The damage to this ligament will most likely cause direct trauma to which of the following muscles?
Gluteus maximus
A 24-year-old woman complains of weakness when she extends her thigh and rotates it laterally. Which of the following muscles is paralyzed?
Gluteus maximus
A 72-year-old woman slips and falls on a wet floor, fracturing the neck of her right femur. Subsequent physical examination in the ER shows her right foot is laterally rotated, and the right lower extremity appears slightly shorter than the left. Which of the following muscles is mainly responsible for the rotated posture of the right limb?
Gluteus maximus
A 75-year-old female patient fell in a hospital and landed on her hip. The given AP X-ray reveals fragmentation of her proximal femur. Which of the following muscles is most likely detached in association with the fracture fragment?
Gluteus medius
A 62-year-old woman slips and falls on the bathroom floor. As a result, she has a posterior dislocation of the hip joint and a fracture of the neck of the femur. The woman experiences weakness when abducting and medially rotating the thigh after this accident. Which of the following muscles is most likely damaged?
Gluteus minimus
A 22-year-old soldier is injured from shrapnel from an improvised explosive device in the right upper thigh, below the midpoint of the inguinal ligament. Though he received field dressings from a medic, he arrives at the military hospital having lost copious amounts of blood. What sign and/or symptom would accompany this patient's presentation?
Tachycardia
A 32-year-old man was lifting a very heavy box into a van when it slipped out of his hands and hit his upper lateral right leg. He fell to the ground and complained of severe pain and loss of sensation on the entire dorsal surface of his foot. He was taken to a hospital where a physician examined him and noticed footdrop when he lifted his right foot off the ground. The physician knew that the patient had a peripheral nerve injury. Imaging revealed severe bruising to the proximal right fibula. Which of the following most likely explains the patient's complete condition?
Injury of the right common fibular (peroneal) nerve
A 36-year-old man arrives at the ER unconscious and with a suspected spinal cord injury after being involved in a motor vehicle accident. If the physician wants to localize the spinal cord lesion, what reflex would test the integrity of the L1-2 spinal cord segment?
Cremasteric reflex
A 21-year-old man falls from the attic and is brought to the emergency department. Examination and radiogram reveal that the lateral longitudinal arch of his foot is flattened. Which of the following bones is displaced?
Cuboid
Your 34-year-old patient was in an automobile accident and her clinically defined subtalar joint was dislocated. Which of the following bones or ligaments is not involved in this functional joint?
Cuboid
A 32-year-old carpenter fell from the roof. The lateral longitudinal arch of his foot was flattened from fracture and displacement of the keystone for the arch. Which of the following bones is damaged?
Cuboid bone
Choose the appropriate lettered site or structure in the following radiograph of the ankle and foot (see figure) to match the following descriptions. The medial longitudinal arch of the foot is flattened because the spring ligament is torn. Which bone in the radiograph is most likely fractured?
D
Choose the appropriate lettered site or structure in the radiograph of the hip and pelvis (see figure) to match the following descriptions. Which structure in this radiograph may be fractured, resulting in loss of the chief flexor of the thigh?
D
Following an appendectomy for surgical removal of a perforated appendix, a 21-year-old man was given a series of intragluteal injections of antibiotics. After several injections he complained of numbness and tingling (paresthesia) on the anterior and lateral sides of his left leg and dorsum of his foot. On examination, paresthesia was detected in the areas mentioned by the patient. The physician also observed that dorsiflexion of his left ankle was weaker than that of his right ankle. Which of the following statements best describes the most likely cause of the patient's signs and symptoms?
Injury to part of the sciatic nerve
An elderly woman comes to the emergency department with a non-displaced fracture of the superior part of her femoral neck in her right hip. Branches of which of the following arteries are most likely damaged in this injury?
Medial circumflex femoral artery
Choose the appropriate lettered site or structure in the following radiograph of the ankle and foot (see figure) to match the following descriptions. The tibialis anterior and peroneus longus muscles are weakened. Which bone in the radiograph is most likely fractured?
E
Choose the appropriate lettered site or structure in the following radiographs of the knee joint (see figure) to match the following descriptions. Fracture of this structure would most likely cause a lesion of the common peroneal nerve, resulting in paralysis of the muscles in the anterior and lateral compartments of the leg.
E
Your 76-year-old patient's first metatarsal-phalangeal joint is swollen and tender. You examine some aspirated synovial fluid from the joint and see uric acid crystals. Your diagnosis is most likely which of the following?
Gout
A construction worker falls feet first from a roof. He sustains a fracture of the groove on the undersurface of the sustentaculum tali of the calcaneus bone. Which of the following muscle tendons is most likely torn?
Flexor hallucis longus
You are examining a newborn male patient with talipes equinovarus. This is associated with all of the following except?
Foot eversion and ankle dorsiflexion
A 20-year-old college student receives a severe blow on the inferolateral side of the left knee joint while playing football. Radiographic examination reveals a fracture of the head and neck of the fibula. After injury to this nerve, which of the following muscles could be paralyzed?
Extensor hallucis longus
Two 11-year-old boys sneak up on their friend from behind. In surprising their friend, they shove him suddenly, which forcefully pushes his hips forward while he is standing relaxed talking to other friends. Which of the following ligaments best resists anterior dislocation of the head of the femur?
Iliofemoral ligament
A patient presents with a thrombosis in the popliteal vein. This thrombosis most likely causes reduction of blood flow in which of the following veins?
Femoral
Your 57-year-old patient requires pressure from his hand on his distal thigh during walking to prevent inadvertent flexion and collapse during walking. You suspect injury to which of the following nerves?
Femoral
A 63-year old woman goes to an emergency room with acute abdominal pain, nausea, and vomiting after moving heavy furniture in her house. On examination, the doctor discovers a painful, globular mass located below and lateral to the pubic tubercle. Given her presentation, what is the most likely diagnosis?
Femoral hernia
After spending 2 days moving heavy furniture out of her house, a 56-year-old woman goes to an emergency room in acute pain. The patient reports nausea, vomiting, and severe abdominal pain. On examination, the doctor discovers a painful, globular mass located inferior and lateral to the pubic tubercle. Given her presentation and history, what is the most likely diagnosis?
Femoral hernia
A physician tests the patellar tendon reflex as shown. A normal response of the involuntary contraction of the quadriceps femoris muscle is noted. This reflex confirms the integrity of what nerve?
Femoral nerve
Venous duplex sonography of your patient's lower limb shows a large thrombus in her popliteal vein. If this or a part of this thrombus breaks free, it would pass through which vein?
Femoral vein
A 25-year-old man suffers a gunshot wound to the calf that severs the posterior tibial artery at its origin. Which of the following vessels will not receive blood flow immediately following the injury?
Fibular (peroneal) artery
Your 48-year-old patient is having pain in his foot and upon examination during walking he shows an abnormally large loss of the transverse arch of his foot with each step. What is a major muscle (and tendon) that is responsible for supporting this arch?
Fibularis (peroneus) longus
A 47-year-old woman walks with difficulty into the ER and presents with pain, inflammation, and tenderness on the outside of her right foot. She reports she sprained her ankle, an inversion injury, while stepping off a sidewalk wearing 3-in. high heels. The given X-ray reveals an avulsion fracture on her lateral foot. The white arrow identifies the fracture fragment. What muscle is most likely injured, given the site of the fracture?
Fibularis brevis
Human feet are everted so that their soles lie fully on the ground during ambulation. What muscle is developmentally unique to humans, inserts into the base of the fifth metatarsal, and assists in eversion (or pronation)?
Fibularis tertius
A 55-year-old woman recently had pelvic surgery during which cancerous lymph nodes were removed from the lateral wall of her pelvis. During a postoperative examination, she says she has been having painful muscle spasms in her thigh. Which of the following muscles is most likely involved?
Gracilis
A 46-year-old woman with a history of coronary artery disease consulted her cardiologist when she experienced severe retrosternal pain as she rushed to catch a bus. The cardiologist examined her and arranged a graded exercise test (stress test). After review of this test he requested a coronary angiogram. This test revealed a 90% block of the circumflex branch of the left coronary artery (LCA) and an 80% block of the anterior interventricular branch of the LCA. Arrangements were made for a coronary artery bypass graft operation. Which of the following veins in the lower limb is commonly used in arterial bypasses?
Great saphenous vein
A 72-year-old woman complains of a cramp-like pain in her thigh and leg. She was diagnosed as having a severe intermittent claudication. Following surgery, an infection was found in the adductor canal, damaging the enclosed structures. Which of the following structures remains intact?
Great saphenous vein
A 36-year-old woman injured in an automobile accident tells the paramedics at the scene that her upper thigh hurts badly and she can barely flex her hip. A plain film of the hip joint reveals an avulsion fracture of the proximal femur, indicated by the open white arrow, and a fracture fragment identified by the solid white arrow. Which of the following muscles is most likely detached?
Iliopsoas
Your 20-year-old patient has anterior hip pain, and is keeping the hip mildly flexed. Hip extension not only increases the hip pain but it also causes back and abdominal pain. The patient reports that he generally only has back pain when walking downhill. You suspect pathology of the one muscle that flexes the spine and stabilizes it when walking downhill and is involved in hip flexion. What is that muscle?
Iliopsoas
A physician performs some simple muscle tests on a 35-year-old male patient when he complains of weakness in his lower limbs. In the physical test illustrated below, the patient is asked to touch his buttocks with his heel while working against resistance. What muscle group is being tested?
Hamstrings
Your patient is having difficulty walking and you suspect weakness in his gluteus medius and minumus. To test these muscles in the right limb, what would you do?
Have the patient lay on his left side and abduct his right limb against resistance
Your 61-year-old female patient has varicosities of her great saphenous vein. This is associated with all of the following except?
Hypertension
Your 45-year-old patient has sciatica that did not respond to initial medical treatment. MRI shows no disc herniation that would explain her symptoms. Careful clinical evaluation is now suggesting the presence of piriformis syndrome, which results from which of the following?
Hypertrophy of the muscle resulting in compression of the sciatic nerve or one of its components
A 22-year-old man stabbed himself in the thigh with a skinning knife, approximately four centimeters superior to the base (superior border) of the patella. To control the spurting of blood, he compressed the wound area with a handkerchief and the bleeding stopped in approximately 15 minutes. Later he covered the wound with a bandage. A few days later the inferior part of the anterior region of his thigh was swollen and painful and there was some swelling of his knee. He went to an ambulatory care clinic where he was examined and the wound was cleansed and bandaged. An oral antibiotic agent was prescribed. Which of the following statements best describes the most likely cause of the pain and swelling in the man's distal thigh and knee regions?
Infection of the suprapatellar bursa
Following a complicated hip replacement surgery, your 77-year-old patient is having difficulty walking up stairs although he can walk fairly normally on flat surfaces. You suspect the surgery likely injured which of the following nerves?
Inferior gluteal
A 70-year-old man reports an inability to climb stairs and stand up from a sitting position. Further examination also shows weakness when laterally rotating the thigh against resistance. What nerve is most likely compromised in this patient?
Inferior gluteal nerve
An 83-year-old woman reports an inability to stand up from a seated position and to climb stairs. Further examination also reveals weakness in lateral rotation at the hip joint. What nerve is most likely compromised in this patient?
Inferior gluteal nerve
An 80-year-old histologist complained to his physician about attacks of lameness and pain in his right leg, chiefly in the calf muscles. The physician noted that he had a slight limp when he entered his office. The man told his physician that these symptoms occurred when he walked a block or so and that he stopped when the intensity of the pain forced him to rest. After about 7 minutes, the pain disappeared, but it recurred when he walked another block. The physician also noted an absent right posterior tibial pulse. The patient had no other neurological signs (e.g., no paresthesia). Which of the following statements best describes the likely cause of the limp and pain in his right leg?
Intermittent claudication (ischemia) of the calf muscles
You are on the resuscitation team for an obese patient in profound shock. Attempts at peripheral and central venous access have failed. You decide to do a saphenous cutdown. This involves inserting a cannula where?
Into the great saphenous vein anterior to the medial malleolus
Your 45-year-old very athletic patient was playing soccer when she fell and was immediately in severe pain at the proximal attachment of her hamstring muscles. Imaging revealed avulsion of this attachment, which is?
Ischial tuberosity
Your 34-year-old patient has been diagnosed with inflammation of her iliotibial tract (band). Which of the following is not correct about this structure?
It forms part of the insertion of the rectus femoris
Your 61-year-old female patient with varicose lower limb veins is having surgery to remove her great saphenous veins. Which of the following is incorrect about this vein?
It has no tributaries above the mid-thigh
A 12-year-old girl suffers from a type of neural tube defect called tethered cord syndrome, a congenital anomaly that results from defective closure of the neural tube. This syndrome is characterized by an abnormally low conus medullaris, which is tethered by a short, thickened filum terminale, leading to progressive neurologic defects in the legs and feet. This girl has strong muscle function of the flexors of the thigh, but she has weakness of the extensors (hamstrings). A lesion has occurred at which of the following spinal cord levels?
L5
A patient with hereditary blood clotting problems presents with pain in the back of her knee. An arteriogram reveals a blood clot in the popliteal artery at its proximal end. Which of the following arteries will allow blood to reach the foot?
Lateral circumflex femoral
A 21-year-old tennis player comes to an emergency room and complains of pain in the knee joint. On examination, he has an infection inside the knee joint capsule but outside the synovial cavity. Which of the following structures is preserved from this infection?
Lateral collateral ligament
A 32-year-old woman, who has gained 50 pounds during her first 36 weeks of pregnancy while carrying twins, presents with numbness, tingling, and burning sensations in the lateral aspect of her right upper thigh. Her symptoms are exacerbated when her physician applies pressure near her right anterior superior iliac spine. What nerve is most likely affected?
Lateral femoral cutaneous nerve
A rising second-year medical student spends his summer hiking the Appalachian Trail with a 100-lb backpack in tow. After a month of hiking 30-mi/day (48-km/day), he notices numbness, tingling, and burning sensations in the lateral aspect of his right upper thigh. His symptoms are exacerbated by his backpack pressing on the area surrounding his right anterior superior iliac spine. What nerve is most likely affected?
Lateral femoral cutaneous nerve
As part of a physical examination to evaluate lower limb function, a physician asks a patient to abduct her second through fifth toes. What specific nerve is the doctor testing?
Lateral plantar nerve
A patient with a deep knife wound in the left buttock walks with a waddling gait that is characterized by the pelvis descending toward the right side at each step. Which of the following nerves is most likely damaged?
Left superior gluteal nerve
A knife wound penetrates the superficial vein that terminates in the popliteal vein. Bleeding occurs from which of the following vessels?
Lesser saphenous vein
A 17-year-old woman hurts her right knee after an opponent falls and impacts the lateral surface of her lower femur in her slightly bent leg during a soccer match. The impact causes forced abduction of the tibia on the femur. Her knee examination reveals exaggerated displacement when the physician abducts the tibia at the knee joint. Based upon the results of this clinical test, what knee ligament is most likely damaged?
Medial collateral ligament
Despite slamming on her brakes, a 23-year-old female driver crashes into the back of a car that stopped suddenly. During impact, her foot is severely dorsiflexed resulting in severe pain. At the ER, she explains to the attending physician that she thinks she has broken her foot. A lateral plain film of the foot reveals the fracture indicated by the white arrow. Which of the following bones is fractured in this patient?
Talus
An elderly man falls on an icy sidewalk outside his home and cannot get up. He tells the attending paramedics that he has a lot of pain in his right hip. Following inconclusive analysis of an AP X-ray, the given coronal MRI reveals a nondisplaced fracture of the right femoral neck, as noted by the black arrow. Branches of which of the following arteries are most likely to be damaged in this injury?
Medial circumflex femoral artery
Following a femoral neck fractures in a 76-year-old woman, her femoral head underwent avascular necrosis. This occurred because the fracture likely tore which of the following arteries?
Medial femoral circumflex
You are examining a 34-year-old patient with pronounced genu varum. You caution the patient that, because of this deformity, it is likely that he will develop osteoarthritis in which of the following joint regions?
Medial knee
Your 65-year-old patient has signs of lower limb deep venous thrombosis. Which of the following is the major clinical concern with this condition?
Pulmonary thromboembolism
While playing football, a 19-year-old college student receives a twisting injury to his knee when being tackled from the lateral side. Which of the following conditions most likely has occurred?
Tear of the medial meniscus
A 35-year-old male recreational basketball player heard a loud pop in his left knee while pivoting in a squatted position. He finished playing several more games, but 3 days later he went to an orthopedic surgeon reporting persistent pain, inflammation, and stiffness in his knee, and he admitted it felt like his knee was "going to give out" when he descended stairs. During a knee examination, the physician noted tenderness along the joint line and a clicking sound while placing a valgus stress on the lateral side of the flexed left knee. During a deep knee bend, the patient experienced pain in the bottom of the motion as shown in the figure. An MRI would confirm damage to what knee structure?
Meniscus
The fibula is often used for bone grafts because it is considered to be a non-weight bearing bone. When taking a bone graft from the fibula, one section that is not disturbed has a nerve running lateral to it. What is that part?
Neck
A 62-year-old woman slips and falls on the bathroom floor. As a result, she has a posterior dislocation of the hip joint and a fracture of the neck of the femur. Rupture of the ligamentum teres capitis femoris may lead to damage to a branch of which of the following arteries?
Obturator
During a basketball game, your 57-year-old patient heard an audible snap while jumping and developed acute calf pain and ankle dorsiflexion. Ambulation was only possible with the injured limb laterally rotated over the transversely placed foot, and he could not push off. What is your initial diagnosis?
Ruptured Achilles (calcaneal) tendon
Your 17-year-old male athletic patient is complaining of chronic recurring pain over his tibial tuberosity. What is your preliminary diagnosis?
Osgood-Schlatter disease
Your 56-year-old avid horse riding patient is feeling some firm but not painful "swellings" in his right anteromedial thigh. What is your diagnosis based on the above image?
Ossification of adductor muscle tendon
A 35-year-old male prisoner received a right gluteal intramuscular (IM) injection during a visit to the infirmary. Following the injection, the man experienced a painful, swollen right leg. Within a month, he complained that his right leg started to shrink. Examination revealed muscle wasting with fasciculations in the L4-S1 distribution and marked weakness in dorsiflexion, inversion, and eversion at the ankle joint. He also exhibited a typical high-steppage gait indicating right foot drop. What nerve was most likely damaged during the gluteal IM injection?
Sciatic nerve
A 41-year-old man was involved in a fight and felt weakness in extending the knee joint. On examination, he was diagnosed with a lesion of the femoral nerve. Which of the following symptoms would be a result of this nerve damage?
Paralysis of the vastus lateralis muscle
Which of the following muscles may be innervated by the femoral or the obturator nerves?
Pectineus
In a surgical procedure to remove a tumor from the semitendinosus muscle in the mid-thigh, the surgeon must identify which of the following arteries that could cause hemorrhage during surgery if lacerated?
Perforating
A patient with a deep knife wound in the buttock walks with a waddling gait that is characterized by the pelvis falling toward one side at each step. Which of the following nerves is damaged?
Superior gluteal nerve
An orthopedic surgeon ligates the posterior tibial artery at its origin. Which of the following arteries has no blood flow immediately after the ligation?
Peroneal
A 25-year-old gladiator sustains a penetrating injury that severs the superficial peroneal nerve. This will most likely cause paralysis of which of the following muscles?
Peroneus brevis
A motorcyclist falls from his bike in an accident and gets a deep gash that severs the superficial peroneal nerve near its origin. Which of the following muscles is paralyzed?
Peroneus longus
A 15-year-old girl, unaware that she is pregnant, borrows her friend's Accutane (retinoic acid; vitamin A) to combat an acne problem. She uses the Accutane for about 2 months, which corresponds to weeks 7 to 15 of the embryonic development of her fetus. Which of the following skeletal elements is most likely to be absent in the newborn infant?
Phalanges
During recruitment by the local representative for the Marines, a young college student presents with the condition known as flat foot. His foot is displaced laterally and everted, and the head of the talus is no longer supported. Which of the following ligaments probably is stretched?
Plantar calcaneonavicular (spring)
A veteran infantry soldier develops painful flat feet after several years of service including hundreds of miles of marches. The pain is particularly acute on the medial aspect of his sole. Which of the following structures is most likely strained in this condition?
Plantar calcaneonavicular (spring) ligament
A 40-year-old woman who runs marathons complains of plantar foot pain after first walking to the bathroom in the morning. The pain dissipates after 5 to 10 minutes of activity. She has not had any recent foot trauma. The patient has point tenderness on the medial surface of her calcaneus. You suspect:
Plantar fasciitis
Your 78-year-old patient presented with symptoms of left lower limb ischemia. During physical examination, you palpate a swelling in the left popliteal fossa associated with "thrills". A bruit can be detected when you listen with a stethoscope. What is your preliminary diagnosis?
Popliteal artery aneurysm
A patient is unable to prevent anterior displacement of the femur on the tibia when the knee is flexed. Which of the following ligaments is most likely damaged?
Posterior cruciate
During a sports medicine physical by a local family physician, a young woman is tested for stability of her joints before tryouts for the high school team. Which of the following ligaments is important in preventing forward displacement of the femur on the tibia when the weight-bearing knee is flexed?
Posterior cruciate ligament
A tall 17-year-old man is crammed into the front passenger seat of an automobile when the speeding car slides off a wet road and slams its front bumper into a road guardrail. The passenger's left shin slams against the dashboard with an impact just below the knee. He reports to the emergency room with considerable knee pain, tenderness, and a pronounced limp during walking. With the patient lying supine, his hips flexed at 45 degrees, knees flexed at 90 degrees, and feet flat on the table, the physician notes a widened space, or sag, in the sulcus between the tibia and the femur. When the physician pushes the left tibia posteriorly, as noted in the photo, a pronounced laxity is noted in the left knee when compared to the right. What structure is most likely damaged?
Posterior cruciate ligament (PCL)
A 19-year-old world-class female Alpine ski racer crashed during a downhill race and suffered the knee injury shown in the MRI above. The torn structure extends upwards and posterior from the anterior intercondylar area of the tibia. What is your diagnosis?
Posterior cruciate ligament tear
You are examining a 36-year-old patient in the ED who has a hip dislocation after a severe motor vehicle accident. Which direction of dislocation and associated nerve injury is most likely?
Posterior dislocation and sciatic nerve injury
A 45-year-old male patient has painful swelling over both of his patellae. You learn that he is often kneeling while at his job installing carpeting. The swelling is fluctuant, directly superficial to the patellae, and there does not appear to be a knee joint effusion. The rest of the physical exam is normal. What is your initial diagnosis?
Prepatellar bursitis
You are examining a young child who you suspect has a congenital dislocation of the hip. All of the following are typically found in such cases except:
Presence of genu valgum
A patient presents with extreme pain due to arterial insufficiency in the posterior femoral compartment. This compartment of the thigh receives its blood supply mainly from the perforating arteries. An arteriogram confirms partial occlusion of the artery that gives rise to these perforating arteries. What artery is occluded in the arteriogram?
Profunda femoris artery
Which of the following ligaments prevents over-abduction of the hip joint?
Pubofemoral
A 52-year-old woman slipped and fell and now complains of being unable to extend her leg at the knee joint. Which of the following muscles was paralyzed as a result of this accident?
Quadriceps femoris
A 24-year-old woman presents to her physician with weakness in flexing the hip joint and extending the knee joint. Which muscle is most likely involved in this scenario?
Rectus femoris
After a very strong kick while playing soccer your 35-year-old male patient complained of severe pain in his hip and points to the location of his anterior inferior iliac spine as the location of the most acute pain. You suspect which of the following caused an avulsion fracture?
Rectus femoris
A 34-year-old woman sustains a deep cut on the dorsum of the foot just distal to her ankle joint by a falling kitchen knife. A physician in the emergency department has ligated the dorsalis pedis artery proximal to the injured area. Which of the following conditions most likely occurs as a result of the injury?
Reduction of blood flow in the medial tarsal artery
As a 44-year-old man was walking to work, he stepped off the curb to cross the street, lost his balance, and fell in such a way that his foot was forced into an excessively inverted position. When he tried to stand up he realized that he had severely sprained his ankle. Before long his ankle was very painful on weight bearing and was swollen and discolored. His doctor examined his ankle and confirmed that it was severely sprained. Radiographs of the ankle did not reveal a fracture. His doctor applied an elastic bandage and fitted him with crutches. Which of the following statements best describes the most likely cause of his ankle sprain?
Tearing of fibers of the anterior talofibular ligament and possible rupture of the calcaneofibular ligament
While playing in a Super Bowl game, a 32-year-old professional football player is tackled, and his anterior cruciate ligament is torn. If not injured, the anterior cruciate ligament of the knee joint:
Resists posterior displacement of the femur on the tibia.
A 24-year-old football player was illegally blocked by a defensive back that drove his shoulder into the posterolateral aspect of the man's knee. The trainer who rushed to examine the player noted that his right leg was unstable but that there was no anterior or posterior tibial displacement. The injured player was carefully taken to the sidelines by the trainers and later was taken to a hospital. Radiographs and MRIs revealed a knee injury. Which of the following statements best describes the knee injury that most likely occurred?
Rupture of the tibial (medial) collateral ligament and tearing of the medial meniscus
Before knee surgery, a surgeon ligates arteries participating in the anastomosis around the knee joint. Which of the following arteries is most likely spared?
Saphenous branch of the descending genicular
A 62-year-old man recently had coronary bypass surgery in which the great saphenous vein was harvested for reestablishing coronary blood flow. Following the procedure, he complained of loss of sensation in the cutaneous area noted in the given photo in the limb from which the vein was harvested. Which of the following nerves was most likely damaged during the surgery?
Saphenous nerve
A patient has weakness when flexing both her thigh and leg. Which of the following muscles is most likely injured?
Sartorius
A 28-year-old basketball player falls while rebounding and is unable to run and jump. On physical examination, he has pain and weakness when extending his thigh and flexing his leg. Which muscle involved in both movements is most likely injured?
Semitendinosus
The above image is a radionuclide bone scan of a patient's tibia. The patient had taken a 20-mile hike after a long span of being sedentary. He is now complaining of severe anterior leg pain. Radiographs are normal. What is your preliminary diagnosis?
Shin splint
You are in the ED treating a patient with a severe anterior thigh wound. You completely compress the femoral artery in the femoral triangle and expect which of the following?
Some blood to reach the lower limb via the cruciate anastomosis
Your 56-year-old patient, who has had recurrent lateral ankle sprains, is now complaining of numbness and paresthesia along the lateral side of his leg and dorsum of his foot and ankle. What do you initially suspect?
Stretching of the superficial fibular (peroneal) nerve
A patient is involved in a motorcycle wreck that results in avulsion of the skin over the anterolateral leg and ankle. Which of the following structures is most likely destroyed with this type of injury?
Superficial peroneal nerve
A thoracic surgeon is going to collect a portion of the greater saphenous vein for coronary bypass surgery. He has observed that this vein runs:
Superficial to the fascia lata of the thigh.
Your 58-year-old female patient has a painful bunion. This is a friction bursitis of which of the following?
Superficial to the first metatarsal-phalangeal joint
A 62-year-old woman slips and falls on the bathroom floor. As a result, she has a posterior dislocation of the hip joint and a fracture of the neck of the femur. The woman undergoes hip surgery. If all of the arteries that are part of the cruciate anastomosis of the upper thigh are ligated, which of the following arteries maintains blood flow?
Superior gluteal
A 7-year-old boy has walked with an abnormal "dipping" gait since being born with a congenital dislocation of the right hip. When his physician asks him to stand on his right leg and lift his left leg off the ground, the left-side of his pelvis sinks below horizontal causing him to stumble to his left. Which of the following nerve was most likely damaged due to his congenital hip dislocation?
Superior gluteal nerve
A roofing installer falls off a high ladder and lands with the sole of his right foot hitting the ground first. He suffers a fracture and inferior displacement of the sustentaculum tali of the calcaneus. Which of the following structures is most likely torn?
Tendon of the flexor hallucis longus (FHL) muscle
Following major pelvic surgery your 59-year-old patient's right iliopsoas muscle was paralyzed. Which of the following muscles typically hypertrophies in these patients to compensate for the loss of the powerful hip flexor?
Tensor fascia latae
A 20-year-old patient cannot flex and medially rotate the thigh while running and climbing. Which of the following muscles is most likely damaged?
Tensor fasciae latae
Your 38-year-old skier patient has just suffered a "boot-top" fracture of his tibia. He is cautioned by an orthopedic surgeon about the possibility of non-union fracture of his tibia that involves the middle and inferior parts of the shaft of the bone. Why are you especially concerned about this?
The nutrient canal is likely disrupted
Your patient is very unstable when supporting weight on her left limb. One possible cause of this is weakness in the triceps coxae muscles. These consist of which of the following muscles?
The obturator internus and the superior and inferior gemelli
Upon recovering from a knife wound in his buttocks your patient walks with a waddling gait, shifting his body over the right limb while in right stance phase. You suspect that the injury involved which of the following?
The right superior gluteal nerve
Your 34-year-old male patient suffered a medial meniscus tear while playing basketball. The orthopaedic surgeon is recommending partial medial meniscectomy, depending upon findings during arthroscopy. Your patient asks you about the likelihood of adverse effects following such removal. What do you reply?
There is usually no loss of mobility
You are treating a 67-year-old woman with an intermittent swelling in her proximal anterior thigh. When she is standing and performing a valsalva maneuver, this swelling becomes most pronounced and is just below the inguinal ligament but appears to be a femoral hernia, rather than an inguinal hernia. Which of the following is not correct about femoral hernias?
They typically compress the femoral nerve and cause a loss of anterior thigh sensation
A 27-year-old patient exhibits a loss of skin sensation and paralysis of muscles on the plantar aspect of the medial side of the foot. Which of the following nerves is most likely damaged?
Tibial
Your 23-year-old patient is having heel pain subsequent to an eversion ankle injury. The medial side of her foot posterior and inferior to the medial malleolus is swollen and you suspect tarsal tunnel syndrome. This syndrome is associated with compression of which of the following nerves?
Tibial
A rugby player injures his left extended knee when hit from the lateral side by a defender trying to tackle him. While performing a knee examination, his physician applies pressure to his lateral thigh and medial leg (as shown in the illustration). This clinical test is a check for the integrity of which of the following ligaments?
Tibial (medial) collateral ligament (TCL)
A 21-year-old soccer player is tackled via a high-impact sweeping injury about the right knee, causing a posterior knee dislocation. Soon after, he is unable to plantar flex his right ankle or flex his toes. He also experiences loss of sensation on the sole of his right foot. Which of the following nerves is most likely injured?
Tibial nerve
A physician tests the calcaneal tendon (ankle jerk) reflex as shown. A normal response of plantar flexion of the ankle joint is noted. This myotatic (deep tendon) reflex confirms the integrity of what nerve?
Tibial nerve
As part of a physical examination to evaluate lower limb function, a physician asks a 10-year-old boy to stand on his tiptoes. What nerve is the doctor testing?
Tibial nerve
As part of a physical examination to evaluate lower limb function, a physician asks her patient to stand on his tiptoes, as shown. What nerve is the doctor testing?
Tibial nerve
A patient experiences weakness in dorsiflexing and inverting the foot. Which of the following muscles is damaged?
Tibialis anterior
Your 64-year-old patient is showing poor control of plantar flexion during walking immediately after heel strike, with abnormal lowering of the forefoot to the ground. You suspect a problem affecting which of the following muscles?
Tibialis anterior
A construction worker is hit on the leg with a concrete block and is subsequently unable to plantar flex and invert his foot. Which of the following muscles is most likely damaged?
Tibialis posterior
An injury to the leg of a golfer results in loss of the ability to invert the foot. Which of the following muscles is most likely paralyzed?
Tibialis posterior
Injury to muscles in the deep posterior compartment of the leg resulted in a compartment syndrome. What are the three muscles within this compartment that affect the ankle joint?
Tibialis posterior, flexor hallucis longus, flexor digitorum longus
An orthopedic surgeon is about to perform a femoral head replacement procedure. Regardless of which approach he takes, which of the following structures is the surgeon least likely to need to transect to perform this surgery?
Transverse acetabular ligament
Your 49-year-old patient has been using a highly inclined treadmill to train as preparation for climbing Mount Kilimanjaro. He denies any trauma but has deep diffuse pain over his lateral upper thigh. You examine him and increase his pain level by having him lay on his unaffected side and resisting abduction of the affected limb while laterally rotating it. What is your likely diagnosis?
Trochanteric bursitis
A 67-year-old patient has been given a course of antibiotics by gluteal intramuscular injections after a major abdominal surgery. To avoid damaging the sciatic nerve during an injection, the needle should be inserted into which of the following areas?
Upper lateral quadrant of the gluteal region
A patient experiences paralysis of the muscle that originates from the femur and contributes directly to the stability of the knee joint. Which of the following muscles is involved?
Vastus lateralis
An overweight woman participates in her first rugby match without proper training and conditioning. Upon catching the opening kickoff, she awkwardly twists her right knee, screams in pain, and falls to the ground. The team manager notes her patella is dislocated, residing on the lateral side of her knee. After straightening the woman's knee, the patellar dislocation is reduced (goes back into place). To prevent future dislocation of the patella, what specific muscle should be targeted during rehabilitation?
Vastus medialis
You are treating a 34-year-old elite runner with pain deep to her patella. You believe she is developing patellofemoral syndrome and recommend she perform exercises to strengthen which of the following muscles?
Vastus medialis
A 32-year-old male farmer cuts the medial aspect of his midthigh when climbing over a barbwire fence. Though he bandages the wound, he reports to the ER 5 days later with an infected wound, high fever (102.7°), and lymphadenitis (swollen lymph nodes). Given the location of the injury, which groups of nodes would be the first to receive drainage from the infected wound?
Vertical group of superficial inguinal
A 43-year old hunter suffers a cut on the medial side of his knee joint when climbing over a barbwire fence. Though he bandages the wound, he presents with an infected wound, high fever (102.5 degrees), and swollen lymph nodes at the emergency department four days later. Given the location of the injury, which groups of lymph nodes would be the first to receive drainage from the infected wound?
Vertical group of superficial inguinal
The lesser trochanter of the femur is an attachment for ______________.
psoas major.
Lesion of the inferior gluteal nerve will have the greatest affect on _____________.
thigh extension.