Ch 27

Saphenous cut downs (greater saphenous vein)

-Large vein easy to locate at medial malleolus where it lies very superficial. - serves as an access port for cannulation for the delivery of fluids, drugs, etc. - care should be taken not to cut or ligate the accompanying saphenous nerve.

Eversion sprain

-Results in injury to the medial collateral ligament of the ankle -Occurs less often because this sigament is extremely strong.

Thrombosis (deep venous thrombosis; DVT)

-Clot formation as a result of prior trauma, i.e. fracture, deep contusion, or can occur spontaneously as a result of: Vascular stagnation due to reduced physical activity for prolonged periods. Or, weakened muscular fascia resulting in diminished musculovenous pump.

Cruciate ligaments (ACL, PCL)

-Control anterior and posterior movement of the femur on the tibial plateau when the foot is fixed.

PCL injury

-Can occur in violent hyperextension injuries where ALL ligaments of the knee are ruptured. -More often occur in the approximate 90 degrees flexed leg when undue force is applied to the tibial tuberosity driving the leg posteriorly, ie., hitting the dashboard during a car collision, hitting the floor/ground in the kneeling position, or being hit low while running. -Results in a positive posterior drawer test.

Pre-patellar bursitis

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Ruptured Achilles' tendon

"week-end" warrior injury due to increased age and irregular bouts of exercise, i.e., tennis or basketball, where rapid push-offs with the feet are required.

Lymphangitis

inflammation of lymph vessels, usualy visible as "red streaks."

Femoral Hernia

-Abdominal event, the effects of which are seen in the thigh. -Protrusion of a viscus (portion of the gut) through the femoral ring into the femoral canal; occurs more often in females. -Forms of protrusion in the femoral triangle inferolateral to the pubic tubercle. -May protrude through the saphenous opening and impede venous return of the greater saphenous vein. 1 is femoral hernia 3 is femoral nerve. 4 is external iliac artery. 5 is pubic tubercle. 6 is femoral hernia.

Q-angle

-Angle between a line drawn from the center of the patella to the ASIS and a perpendicular line passing through the tibial tuberosity and the center of the patella. -Normal male Q-angle = 14 degrees; normal female Q-angle = 17 degrees (due to increased width of pelvis).

Transverse patellar fractures

-Avulsion type due to sudden forceful contraction of the quadriceps. -Direct blow (car bumper or dashboard; falling into a kneeling position)

Os trigonum

-Bone accessory to talus -Represents secondary ossification center which fails to unite with talus -Occurs in 14-25% of adults; associated with sports where athlete utilizes excessive plantar flexion (soccer players, ballet dancers)

Medial plantar nerve compression

-Deep to flexor retinaculum (compare to carpal tunnel syndrome) -Excessive running or eversion, resulting in irritation of the medial plantar nerve as it passes deep to the flexor retinaculum resulting in paresthesias (aching, burning, numbness, and tingling) on the medial side of the sole of the foot with weakness of the intrinsic muscles of the great toe.

Avascular necrosis of the femoral head

-Disruption of the arteries that surround the femoral neck to provide branches to the femoral head can lead to femoral head necrosis. -Branches of the medial femoral circumflex artery are most often implicated.

Psoas abscess

-Due to retroperitoneal abdominal or pelvic infection that descends within the psoas fascial sheath - Descends deep to inguinal ligament resulting in pain and swelling within the femoral triangle. - Can be mistaken for: femoral hernia, indirect inguinal hernia, inflammation of inguinal lymph nodes, saphenous varix.

Pott's fracture (bimaleolar ankle fracture)

-Forced eversion of the ankle -Avulsion fracture of the medial malleolus (tibia) via the deltoid ligament. -Talus shifts resulting in fracture of the lateral malleolus (fibula). -Results in total disruption of the mortise of the ankle joint.

Femur neck fracture

-Fracture junt distal to the unction of the femoral head with the femoral neck, or fracture along the intertrochanteric line. -Occur most often as a result of increased compressive forces (stepping from the curb or step) on a limb already weakened by metabolic processes, i.e., osteoporosis. -Result in a shortened limb and require internal fixation.

Distal femoral fractures

-Fracture of distal femoral physis (epiphyseal plate) involving metaphysis and epiphysis; see Salter-Harris classification. - May result in aberration of the articular surfaces of the knee joint. - May disrupt blood supply to knee or leg due to proximity of genicular anastomosis.

Avulsion fractures

-Fractures which occur as a result of fragments being pulled away from bones by rapidly loaded tendons and ligaments. --Pelvis: ischial tuberosity, ASIS, AIIS, ischiopubic rami --Tibial tuberosity - *Osgood-Schlatter disease:* disruption of tibial tuberosity at its growth plate during youth due to excessive action of quadriceps tendon resulting in inflammation and pain. --Ankle: Lateral and medial malleoli --Foot: 5th metatarsal

Saphenous vein grafts (greater saphenous veiin)

-Harvested for used in coronary arterial bypass surgery. - good candidate due to increased muscular and elastic fibers of wall. - remove forces drainage to deeper veins (not a bad thing). - vein installed as bypass with valves reversed so that they do not impede flow.

Coxa valga

-Increase in the angle of inclination (greater than 130 degrees). -Causes a slight increase in the length of the affected limb; concomitant decrease in Q-angle opens lateral knee joint space resulting in *genu-varum.* ("bow legged")

Compartmental syndromes of the leg

-Infection, inflammation, or arterial hemorrhage within a fascial compartment of the leg can produce pressure increases within the compartment high enough to: -Reduce the blood supply to muscles within or distal to the compartment. -pressure from accumulated blood may impinge nerves to the point where: --paresthesias occur distal to the compressed area. --paralysis occurs to muscles located within the compartment. -severe cases require fasciotomy to relieve these compressive forces prior to the occurrence of tissue necrosis.

Plantar fasciitis/calcaneal bone spurs

-Inflammation of the plantar aponeurosis caused by overuse. (running, high impact activities, improper footwear) -Pain can be elicited by direct pressure at the point of attachment to the calcaneus, or by dorsiflexing the foot, or extending the great toe. -Often accompanied by calcaneal bone spurs in the direction of plantar aponeurosis (late sequelae) and tight triceps surae (gastrocnemius and soleus) -Test it by passively dorsiflexing the foot and it will hurt them at the heel.

Saphenous varix

-Infrequent dilation of the terminal portion of the greater saphenous vein. - causes a swelling in the femoral triangle. - can be misdiagnosed as other entities: femoral hernia, psoas abscess.

Tibialis Anterior Strain (Shin Splints)

-Micro tears in the periosteum attachment of the distal 2/3 of the tibialis anterior to the tibia resulting in pain. - Also, swelling and inflammation within the muscle decreases vascular exchange and leads to pain. - Usually results from overuse, or infrequent bouts of exercise not preceded by stretching or warming up; running on hard surfaces after having trained on softer surfaces.

ACL injury

-More often injured that PCL. -*Contact injury* - hyperextension or hyperflexion injury when force is applied to the anterior lower limb when the foot is fixed. -*Non-contact injury* - The foot is fixed, the limb is in slight flexion and femur placed in medial rotation as in running and cutting on one foot to the opposite side. -Note: If force is applied slowly, the ligament will avulse the tibial plateau; if applied quickly, the ligament tears in mid-substance (most often). -Results in a *positive anterior drawer test.* -Note: *"Unhappy Triad":* Tearing of the ACL, MCL and medial meniscus simultaneously. As previously mentioned, the medial meniscus is attached to the MCL and the ACL often attaches through the anterior horn of the medial meniscus to reach the tibial plateau.

Talus fractures

-Most often fracture occurs during *forced dorsiflexion.* -Results in fracture of the neck of the talus with posterior dislocation of the talar body.

Calcaneus fractures

-Most often fractures as a result of hard falls directly to the heel. -Disrupts subtalar joint (talocalcaneal joint) (active during eversion and inversion).

Fibula fractures

-Most often fractures just proximal to the lateral malleolus. - fracture of lateral malleolus can occur during excessive inversion where contact with the talus can fracture the lateral malleolus. -Because the fibula is *NOT* a weight bearing bone, it is the candidate of choice for use in bone graft procedures. -Note: Fractures of the medial and lateral malleolus are often associated with fracture-dislocations of the ankle caused by either hyperinversion or hypereversion of the foot.

Tibial fractures general

-Most often fractures near junction of middle and distal third (narrowest portion and least vascularized) - also, due to subcutaneous location, prone to compound fracture. - if fractures occur through nutrient foramen, can lead to non-union. -Note: Tibial fractures can also be caused by forward momentum applying force above the rigid ski boot edge (boot top fracture).

Collateral ligaments (MCL, LCL)

-Most often injured when the foot is in contact with the ground and force is applied to either the lateral or medial side of the extended and/or rotated knee. -Opening the medial angle of the knee stretches the medial collateral ligament; opening the lateral angle stretches the lateral collateral ligament. -*Injury of the medial collateral ligament* is often associated with *tearing of the medial meniscus* and *tearing of the anterior cruciate ligament.* Called the "unholy triad"

Bipartite & Tripartite patella

-Non-union of ossification centers resulting in a patella that has 2 or 3 component parts -Often misinterpreted as fractures.

Patellofemoral syndrome

-Pain caused by improper tracking of the patella relative to the patellar groove of the femur. -Can result in *chondromalacia of the patella:* softening of the articular cartilage of the patella due to chronic over use (extensive running), a direct blow to the patella, or repeated extreme flexion (deep squats) -Results in quadriceps imbalance and improper patellar tracking; *patella rides more on the lateral femoral condyle.* -Rx: Leg extension with emphasis on the last 30 degrees to increase tension of vastus medialis obliquus (inferior-most fibers) to re-establish proper tracking.

Knee Menisci

-Placing the leg in full flexion under force can trap the menisci thereby tearing them. - Medial meniscus is more often torn as it is less mobile than the lateral meniscus due to its attachment to the medial collateral ligament; *opening the medial angle of the joint stretches the ligament and tears the cartilage.* - Small tears can be trimmed; large tears in the periphery where a good blood supply exists can be repaired. -Typical *"bucket handle"* tear: longitudinal tear through substance of meniscus. When the "handle" tears free, it must be removed. -Meniscus removal: Mobility remains the same with decreased stability and increased articular cartilaginous erosion over time.

Pulses/compression sites/cannulation: Popliteal artery

-Pulse can be palpated inferiorly within the fossa against the posterior tibia with the patient prone and the leg flexed. -Diminished popliteal pulse is a sign of femoral arterial obstruction.

Pulses/compression sites/cannulation: Dorsalis Pedis

-Pulse palpated inferior to extensor retinaculum lateral to the tendon of the extensor hallucis longus. - diminished dorsalis pedis arterial pulse is a sign of anterior tibial arterial obstruction. -Note: A condition exists where the dorsalis pedis artery is congenitally absent. In these cases, the dorsum of the foot is provided arterial circulation by the perforating branch of the fibular artery.

Pulses/compression sites/cannulation: Posterior tibial artery

-Pulse palpated posteriorly between the calcaneal tendon and the medial malleolus ( deep to the flexor retinaculum) -Patient must invert foot to relieve pressure of flexor retinaculum on artery to achieve accurate reading. -Diminished posterior tibial arterial pulse is a sign of popliteal arterial occlusion. -Intermittent claudication (cramping leg pain during exercise which disappears with rest) is a sign of muscular ischemia due to narrowing of tibial arteries.

Popliteal ("Baker's") cysts

-Result of chronic knee joint effusion (extra fluid accumulation). -Establishes continuity of fluid in joint space with bursae surrounding knee. -Occur most often posteriorly (gastrocnemius or semimembranosus bursae). -May impede flexion, put pressure on structures of the popliteal fossa and result in pain.

Inversion sprain

-Results in injury to the lateral collateral ligament of the ankle. -*Anterior talofibular ligament* is the most often torn component.

Pulses/compression sites/cannulation: Femoral artery

-The femoral pulse can be located in the supine patient by palpating midway between the ASIS and the pubic tubercle; diminished pulls is sign of common, or external iliac artery obstruction. -The femoral artery can be compressed against the structures which compose the floor of the femoral triangle, as well as the pelvic brim (sup. Pubic ramus) -Cannulation of the left femoral artery for purposes of left cardiac angiography takes place just inferior to the inguinal ligament. -*If there's a lack of a pulse at some point, that always indicates a problem going on more up stream.*

Slipped capital femoral epiphysis

-Trauma in the region of the proximal femoral epiphysis -Usually occurs in adolescents prior to epiphyseal plate closure. -Distal fragment "dislocates" posteriorly leading to coxa vara.

Deep femoral vein

-can be used for right cardiac angiography -Locate femoral arterial pulse, then go one finger breadth medially to locate the vein.

Musculovenous pump

Contraction of muscles within a fascial limited space, places pressure upon deep veins contained within the same muscular compartment and assists in venous return agaist gravity. Venous valves prevent backflow during periods of alternating okeletal muscle contraction and relaxation.

Thromboembolism

A clot which has broken free from a lower limb vein, and traverses the heart to become lodged in the lung (pulmonary arterial branch)

Thrombophlebitis

Clot within a vein leading to inflammation at the site of the clot.

Hip Joint Varus

Distal end of bone under consideration deviates *TOWARD* the midline.

Hip Joint Valgus

Distal end of the bone under consideration deviates *AWAY* from the midline.

Coxa vara

Decrease in the angle of inclination (less than 120 degrees) -Causes of slight *decrease* in the length of the affected limb; concomitant increase in Q-angle opens medial knee joint space resulting in *genu valgum* ("knock kneed"); leads to increased occurrence of patellar dislocation.

Lymphadenopathy

Enlarged lymph nodes due to inflammation which, in the lower limb, reside in the popliteal fossa and femoral triangle.

Coxa vara and coxa valga

Developmental variation in the angle between the head neck and shaft of the femur (CCD angle: *C*aput - *C*ollum - *D*iaphyseal = *angle of inclination) -Normal: 120 - 130 degrees -Changes with age Children = 140 degrees Adults = 125 degrees -Old age = 115 degrees

Piriformis Syndrome

In about 12% of people, the tibial and common fibular components of the sciatic nerve are split by a portion of the piriformis. -Direct trauma to the buttock or with athletic hypertrophy of the piriformis may cause compression of the *common fibular component* of the sciatic nerve, resulting in complete loss of eversion and dorsiflexion and numbness on the lateral anterior portion of the leg and dorsum of the foot.

Note about lymphatics

Knowledge of the drainage pattern of the inguinal nodes is extremely important. Superficial inguinal nodes, located in the subcutaneous connective tissue superficial to the femoral triangle, receive drainage from the superficial thigh, abdomen inferior to the navel, round ligament of the uterus and from the perineum. Deep inguinal nodes, located within the femoral triangle receive drainage from the superficial inguinal nodes, and from the deep structures of the foot, legs, and thigh.

Calcaneal Tendinitis

Micro tears in the attachment of the calcaneal tendon to the calcaneal tuberosity as a result of overuse, poor footwear, poor training surfaces, or infrequency of activity.

Muscular strains and ruptures

Occur as a result of large muscles which must exert force very quickly to overcome large amounts of inertia. Since the lower limb bears the weight of the rest of the body, starts during sprints, or changes in direction, which are made very rapidly, usually result in injury occurring close to an attached site.

Greater trochanter and shaft fracture

Occur usually as a result of direct trauma due to falls or vehicular accidents.

Meralgia paresthetica

Physical deformation of the lateral femoral cutaneous nerve (L2,3) within the abdomen (tumor, pregnancy) or as it passes deep to the inguinal ligament near its attachment to the ASIS (fluid overload, overly tightened belt).

Hamstring strains

Strains of the semimembranous, semitendinosus, and biceps femoris usually occur in the belly or musculotendinous junction as a result of fast extension during the "push-off" phase of running.

Hip dislocation

The *capsule of the hip joint is loosest when the thigh is in flexion.* -Hitting the knee and driving the femur posteriorly can dislocate the head of the femur from the acetabulum posteriorly (hitting the dashboard with the knee during a deceleration accident).

Patellar dislocation

The patella is more likely to dislocate laterally. -More often dislocated in females due to greater Q-angle; increased Q-angle results in increased lateral pull on the patella via the rectus femoris and vastus lateralis muscles.

Varicosities

Weakened superficial veins which dilate under the pressure of the supported column of blood. -Venous valves are no longer competent because they no longer appose. -Degenerated deep fascia reduces or eliminates tho musculovenous pump.

Friction bursitis pathologic progression

a fluid filled space - rubbed constantly - gets inflammed - causes fibrosis - gets calcium deposits - ruptures (of bursa of associated tendon) -*Ischial* = inflame bursa between ischial tuberosity and gluteus maximus. Ischial tuberosity is weight bearing upon sitting. Movement of gluteus maximu across inflamed bprsa causes pain. Bursa can become calcific. With prolonged bed rest, can lead to pressure soreo and ulceration -*Trochanteric* = Inflame bursa between greater trochanter and gluteus maximus. Caused by repetitive motion of gluteu maximus across bursa during climbing and inclined walking. *Remember the gluteus maximus and the tensor fascia latae utilize the iliotibial tract as their distal tendon of attachment. Therefore, there is constant presure placed on the trochanteric bursa during flexion (tensor fascia latae) and extension (gluteus maximus)*. The pain is the point tenderness at greater trochanter; it radiates from tubercle of the crest of the ilium inferiorly along the ITT to the knee. -You test for this in patients by manually resisting abduction and lateral rotation of the thigh.

Groin strains

adductor group "pulls" usually during fast hip flexion activities

Lower limb bursitis also can occur...

deep to the psoas (iliopectineal bursitis); infra, supra, and pre-patellar bursitis; retinacular bursitis; calcaneal bursitis.

Tibial Transverse fracture

due to prolonged stress or with sudden changes in direction.

Tibial Diagonal fracture

due to severe torsion, i.e., skiing; can lead to shortening.

Varus and valgus

terms which refer to the DISTAL end of a bone.