Unit 3 Clinical Boxes

Injury to Sciatic Nerve

-A pain in the buttock may result from compression of this nerve by the piriformis muscle (piriformis syndrome). Incomplete section of this nerve (i.e. from a stab wound) may also involve the interior gluteal and/or the posterior femoral cutaneous nerves. Recovery from a lesion is slow and usually incomplete. -With respect to the nerve, the buttock has a side of safety (its lateral side) and a side of danger (its medial side). Wounds or surgery on the medial side may injure the nerve and its branches to the hamstrings. Paralysis of these muscles result in impairment of thigh extension and leg flexion.

Chondromalacia Patellae

-AKA softening of the cartilage or runner's knee -common knee injury for marathon runners, but can also occur in running sports like tennis or basketball. The aching around or deep to the patella results from quadriceps imbalance. This condition can also result from a blow to the patella or extreme flexion of the knee.

Pelvic Fractures

-Avulsion fractures of the hip may occur during sports that require sudden acceleration or deceleration. A small part of bone with a piece of tendon/ligament attached is "avulsed" (torn away) -Older patients: this injury often includes at least two fractures of the ring of bone formed by pubis, pubic rami, and acetabulum.

Injury to Common Fibular Nerve

-Because of its superficial and lateral position, this nerve is the nerve most often injured in the lower limb. It winds subcutaneously around the fibular neck, leaving it vulnerable to direct trauma. This nerve may also be severed during fracture of the fibular neck or severely stretched when the knee joint is injured or dislocated.

Transplantation of Gracilis

-Because this is a relatively weak member of the adductor group of muscles, it can be removed without noticeable loss of its actions on the leg. -Surgeons often transplant this muscle, or part of it, with its nerve and blood vessels to replace a damaged muscle in the forearm or to create a replacement for a nonfunctional external anal sphincter, for example.

Fractures of Foot Bones

-Calcaneal fractures occur in people who fall on their heels (e.g. from a ladder). It usually breaks into several pieces (comminuted fracture) that disrupt the subtalar joint. -Fractures of talar neck may occur with severe dorsiflexion of the ankle, i.e. when someone is pressing very hard on the brake pedal during a head-on collision. -Metatarsal and Phalangeal fractures are common in endurance athletes and may also happen when a heavy object falls on the foot. -Metatarsal fractures are also common in dancers. "Dancers fracture" usually occurs when the dancer loses balance, putting the full body weight on the metatarsal.

Fibular Fractures

-Commonly occur just proximal to the lateral malleolus and are often associated with fracture-dislocations of the ankle joint. -When a person slips, forcing the foot into an excessively inverted position, the ankle ligaments tear, forcibly tilting the talus against the lateral malleolus and shearing it off.

Coxa Vara

-Decreased angle of inclination. Causes a mild passive abduction of the hip. -Angle of inclination varies with age, sex and development of the femur, as well as any pathological process that weakens the femur neck.

Tibialis Anterior Strain (Shin Splints)

-Edema and pain in the area of the distal two thirds of the tibia result from repetitive microtrauma of the tibialis anterior (TA), which causes small tears in the periosteum covering the shaft of the tibia and/or of fleshy attachments to the overlying deep fascia of the leg. This is a mild form of the anterior compartment syndrome. -This commonly occurs during traumatic injury or athletic overexertion of muscles in the anterior compartment, especially tibialis anterior. Muscles in the anterior compartment swell from sudden overuse, and the edema and muscle-tendon inflammation reduce the blood flow to the muscles. The swollen muscles are painful and tender to pressure.

Deep Fibular Nerve Entrapment

-Excessive use of muscles supplied by this nerve (i.e. during skiing, running and dancing) may result in muscle injury and edema in the anterior compartment. This may entrap (cause compression of) this nerve or its vasa nervorum and result in pain in the anterior compartment. -Compression of the nerve by tight-fitting ski boots, for example, may occur where the nerve passes deep to the inferior extensor retinaculum and the extensor hallucis brevis. Pain occurs in the dorsum of the foot and usually radiates to the web space between the first and second toes. Because ski boots are a common cause, this condition has been called the "ski boot syndrome"; however, the syndrome also occurs in soccer players and runners and can also result from tight shoes.

Bone Grafts

-Fibula is a common source for this, because even after its shaft has been removed, walking, running and jumping can be normal. -Free vascularized fibulas have been used to restore bone integrity in limbs with congenital bone defects and to replace segments after trauma or excision of a tumor. The transplanted piece of fibula, secured in its new site, eventually restores the blood supply of the site where it has been attached.

Coxa Valga

-Increased angle of inclination -Angle of inclination varies with age, sex and development of the femur, as well as any pathological process that weakens the femur neck.

Patellofemoral Syndrome

-Pain deep to the patella often results from excessive running, especially downhill; this type of pain is often called "runner's knee." The pain results from repetitive microtrauma caused by abnoral tracking of the patella relative to the patellar surface of the femur. May also result from a direct blow to the patella and from osteoarthritis of the patellofemoral compartment. -In some cases, strengthening of the vastus medialis corrects this dysfunction. Weakness of the vastus medialis predisposes the individual to this dysfunction and to patellar dislocation.

Footdrop

-Severance of the common fibular nerve results in flaccid paralysis of all muscles in the anterior and lateral compartments of the leg (dorsiflexors or ankle and evertors of foot). The loss of dorsiflexion of the ankle causes __________________, which is exacerbated by unopposed inversion of the foot. This has the effect of making the limb "too long." The toes do not clear the ground during the swing phase of walking.

Hip & Thigh Contusions

-Sports broadcasters & trainers refer to a "hip pointer injury" which is on the iliac crest, usually the anterior part. One of the most common hip injuries, especially with sports. -_________cause bleeding from ruptured capillaries and infiltration of blood into the muscles, tendons and other soft tissues. -Another term commonly used is "charley horse" which may refer to acute cramping of an individual this muscle because of ischemia, nocturnal leg cramps, or formation of a hematoma (blood clot).

Patellar Tendon Reflex

-Tapping this area with a reflex hammer normally elicits the "knee jerk" reflex. This myotatic (deep tendon) reflex is routinely tested during a physical examination by having the person sit with the legs dangling. A firm strike on the ligament with a reflex hammer usually causes the leg to extend. -If the reflex is normal, a hand on the person's quadriceps should feel the muscle contract. This tendon reflex tests the integrity of the femoral nerve and the L2-L4 spinal cord segments. Diminution or absence of this reflex may result from any lesion that interrupts the innervation of the quadriceps (ie peripheral nerve disease)

Cannulation of Femoral Artery

-The femoral artery may be cannulated just inferior to the midpoint of the inguinal ligament (eg for cardioangiography- radiography of the heart & great vessels after the introduction of contrast material). For left cardiac angiography, a long slender catheter is insert percutaneously into the femoral artery and passed superiorly in the aorta to the openings of the coronary arteries.

Femoral Hernia

-The femoral ring is a weak area in the lower anterior abdominal wall that is the site of a protrusion of abdominal viscera (often a loop of small intestine) through the femoral ring into the femoral canal. This issue is more common in women than in men (in whom inguinal hernias are more common). -The hernial sac displaces the contents of the femoral canal and distends its wall. Initially, the hernia is relatively mall because it is contained within the femoral canal, but it can enlarge by passing through the saphenous opening into the subcutaneous tissue or the thigh. Strangulation of a femoral hernia may occur and interfere with the blood supply to the herniated intestine, and vascular impairment may result in death of the tissues.

Femoral Fractures

-The neck is most often fractured, especially in females with osteoporosis. -Fractures can occur at several locations like transcervical and intertrochanteric. A violent direct injury like a car accident may cause a spiral fracture. -Distal fractures can be complicated by separation of the condyles, resulting in misalignment of the knee

Femoral Pulse

-The pulse is usually palpable just inferior to the midpoint of the inguinal ligament. Normally the pulse is strong; however, if the common or external iliac arteries are partially occluded, the pulse may be diminished. The artery may be manually compressed at the midpoint of the inguinal ligament to control arterial bleeding after lower limb trauma.

Tibial Fractures

-The shaft is narrowest at the junction of its inferior and middle thirds, which is most common site of fracture. -Anterior surface is subcutaneous so this is the most frequent site of an open fracture (compound fracture) where the skin is open and blood vessels are torn.

Injury to Superior Gluteal Nerve

-This injury, for example during hip replacement surgery depending on the surgical approach, results in a disabling gluteus medius limp to compensate for weakened abduction of the thigh by the gluteus medius and minimus. Also, a gluteal gait, a compensatory list of the body to the weakened side, may be present.Medial rotation of the thigh is also severely impaired. -When a person is asked to stand on one leg, the gluteus medius and minimus normally contract as son as the contralateral foot leaves the floor, preventing tipping of the pelvis to the unsupported side, indicating that the gluteus medius on the contralateral side is weak or nonfunctional. This is referred to as a positive Trandelenburg test. -When the pelvis descends on the unsupported side, the lower limb becomes, in effect, too long and does not clear the ground when the foot is brought forward in the swing phase of walking. To compensate, the individual leans away from the unsupported side, raising the pelvis to allow adequate room for the foot to clear the ground as it swings forward. This results in a characteristic "waddling" or gluteal gait. Other ways to compensate are to lift the foot higher as it is brought forward to to swing the foot outward.

Palpation of Dorsalis Pedis Pulse

-This is evaluated during a physical exam of the peripheral vascular system. It may be palpated with the feet slightly dorsiflexed. Usually easy to palpate because the dorsal arteries are subcutaneous and pass along a line from the extensor retinaculum to a point just lateral to the extensor hallucis longus tendons. -A diminished or absent pulse usually suggests vascular insufficiency resulting from arterial disease. The five P signs of acute arterial occlusion are pain, pallor, paresthesia, paralysis, and pulselessness. -Some healthy adults (and even children) have congenitally nonpalpable pulses in this area; the variation is usually bilateral. In these cases, the artery is replaced by an extended perforating fibular artery of smaller caliber than the typical artery, but running in the same location.

Steppage Gait

A high-stepping gait in which extra flexion is employed at the hip and knee to raise the foot as high as necessary to keep the toes from hitting the ground. Commonly employed in the case of flaccid paralysis (dropped foot). Sometimes, an extra "kick" is added as the free limb swings forward in an attempt to flip the forefoot upward just before setting the foot down.

Genu Valgum

A lateral angulation of the knee in relation to the thigh (exaggeration of knee angle) is also called knock-knee. Consequently, excess stress is placed on the lateral structures of the knee. The patella, normally pulled laterally by the tendon of the vastus lateralis, is pulled even farther laterally when the leg is extended in the presence of genu varum so that its articulation with the femur is abnormal.

Genu Varum

A medial angulation of the leg in relation to the thigh, in which the femur is abnormally vertical and the Q-angle is small, a deformity also known as bowleg that causes unequal weight distribution. Excess pressure is placed on the medial aspect of the knee joint, which results in arthrosis.

Paralysis of Quadriceps

A person with this issue cannot extend the leg against resistance and usually presses on the distal end of the thigh during walking to prevent inadvertent flexion of the knee joint. Weakness of the vastus medialis or vastus lateralis, resulting from arthritis or trauma to the knee joint, can result in abnormal patellar movement and loss of joint stability.

Pes Planus (Flatfeet)

AKA "fallen arches." This is likely to be secondary to dysfunction of the tibialis posterior owing to trauma, degeneration with age, or denervation. In the absence of normal passive or dynamic support, the plantar calcaneonavicular ligament fails to support the head of the talus. Consequently, the talar head displaces inferomedially and becomes prominent. As a result, some flattening of the medial part of the longitudinal arch occurs, along with lateral deviation of the forefoot (Fig. B5.19). Flatfeet are common in older people, particularly if they undertake much unaccustomed standing or gain weight rapidly, adding stress on the muscles and increasing the strain on the ligaments supporting the arches

Bursitis in Knee Region

AKA "housemaid's knee" is usually a friction bursitis caused by friction between the skin and the patella. If the inflammation is chronic, the bursa becomes distended with fluid and forms a swelling anterior to the knee. -Subcutaneous infrapatellar bursitis results from excessive friction between the skin and the tibial tuberosity. -Deep infrapatellar bursitis results in edema between the patellar ligament and the tibia, superior to the tibial tuberosity.

Calcaneal Bursitis

AKA Achilles bursitis Results from inflammation of the bursa of the calcaneal tendon located between the calcaneal tendon and the superior part of the posterior surface of the calcaneal tuberosity. Calcaneal bursitis causes pain posterior to the heel and occurs commonly during long-distance running, basketball and tennis. The bursitis is caused by excessive friction on the bursa as the calcaneal tendon continuously slides across it.

Popliteal Cysts

AKA Baker cysts. Abnormal fluid-filled sacs of synovial membrane in the region of the popliteal fossa. Almost always a complication of chronic knee joint effusion. The cyst may be a herniation of the gastrocnemius or semimembranosus bursa through the fibrous layer of the joint capsule into the popliteal fossa, communicating with the synovial cavity of the knee joint by a narrow stalk. Synovial fluid may also escape from the knee joint (synovial effusion) or a bursa around the knee and collect in the popliteal fossa. Here it forms a new synovial-lined sac, or popliteal cyst. Popliteal cysts are common in children but seldom cause symptoms. In adults, popliteal cysts can be large, extending as far as the midcalf, and may interfere with knee movements.

Gastrocnemius Strain

AKA Tennis leg A painful calf injury resulting from partial tearing of the medial belly of this muscle at or near its musculotendinous junction. It is caused by overstretching the muscle by concomitant full extension of the knee and dorsiflexion of the ankle joint.

Replaced or Accessory Obturator Artery

An enlarged pubic branch of the inferior epigastric artery either takes the place of the obturator artery (replaced obturator artery) or joins it as an accessory obturator artery in approximately 20% of people. This artery runs close to or across the femoral ring to reach the obturator foramen and could be closely related to a femoral hernia. Consequently, this artery could be involved in a strangulated femoral hernia. Surgeons placing staples during endoscopic repair of both inguinal and femoral hernias are vigilant concerning the possible presence of this common arterial variant.

Arthroscopy of Knee Joint

Arthroscopy is an endoscopic examination that allows visualization of the interior of the knee joint cavity with minimal disruption of tissue. The arthroscope and one (or more) additional cannula(e) are inserted through tiny incisions known as portals. The second cannula is for passage of specialized tools (e.g., manipulative probes or forceps) or equipment for trimming, shaping, or removing damaged tissue. This technique allows removal of torn menisci and loose bodies in the joint such as bone chips, and débridement (the excision of devitalized articular cartilaginous material in advanced cases of arthritis). Ligament repair or replacement may also be performed using an arthroscope.

Superficial Fibular Nerve Entrapment

Chronic ankle sprains may produce recurrent stretching of this nerve, which may cause pain along the lateral side of the leg and the dorsum of the ankle and foot. Numbness and parasthesia (pain, numbness or tingling) may be present and increase with activity.

Contusion of Extensor Digitorum Brevis

Clinically, knowing the location of the belly of the this muscle is important for distinguishing this muscle from abnormal edema. Contusion and tearing of the muscle fibers and associated blood vessels result in a hematoma, producing edema anteromedial to the lateral malleolus. Most people who have not seen this inflamed muscle assume they have a severely sprained ankle.

Medial Plantar Nerve Entrapment

Compressive irritation of the medial plantar nerve as it passes deep to the flexor retinaculum or curves deep to the abductor hallucis may cause aching, burning, numbness, and tingling (paresthesia) on the medial side of the sole and in the region of the navicular tuberosity. Medial plantar nerve compression may occur during repetitive eversion of the foot (e.g., during gymnastics and running). Because of its frequency in runners, these symptoms have been called "jogger's foot."

Trochanteric Bursitis

Diffuse deep pain in the lateral thigh region, especially during stair climbing or rising from a seated position, may be caused by this condition. It is characterized by point tenderness over the greater trochanter; however, the pain often radiates along the iliotibial tract. A commonly overlooked diagnosis that clinically mimics this one is a tear of the insertion of gluteus medius tendon on the trochanter.

Tibial Nerve Entrapment

Entrapment and compression of the tibial nerve (tarsal tunnel syndrome) occurs when there is edema and tightness in the ankle involving the synovial sheaths of the tendons of muscles in the posterior compartment of the leg. The area involved is from the medial malleolus to the calcaneus. The heel pain results from compression of the tibial nerve by the flexor retinaculum.

Hemorrhaging Wounds of Sole of Foot

Puncture wounds of the sole of the foot involving the deep plantar arch and its branches usually result in severe bleeding. Ligature of the arch is difficult because of its depth and the structures surrounding it.

Knee Replacement

If a person's knee is diseased (from osteoarthritis, for example), an artificial knee joint may be inserted (total knee replacement arthroplasty). The artificial knee joint consists of plastic and metal components that are cemented to the femoral and tibial bone ends after removal of the defective areas

Fractures of Femoral Neck (Hip Fractures)

Fracture of this area often disrupts the blood supply to the head of the femur. The medial circumflex femoral artery supplies most of the blood to the head and neck of the femur. Its retinacular arteries often are torn when this area is fractured or the hip joint is dislocated. In some cases, the blood supplied to the femoral head through the artery to the ligament of the femoral head may be the only remaining source of blood to the proximal fragment. This artery is frequently inadequate for maintaining the femoral head; consequently, the fragment may undergo aseptic vascular necrosis, the result of deficient blood supply. These fractures are especially common in individuals older than 60 years, especially in women because their femoral necks are often weak and brittle as a result of osteoporosis.

Absence of Plantarflexion

If the muscles of the calf are paralyzed, the calcaneal tendon is ruptured, or normal push-off is painful, a much less effective and efficient push-off (from the midfoot) can still be accomplished by the actions of the gluteus maximus and hamstrings in extending the thigh at the hip joint and the quadriceps in extending the knee. Because push-off from the forefoot is not possible (in fact, the ankle will be passively dorsiflexed as the body's weight moves anterior to the foot), those attempting to walk in the absence of plantarflexion often rotate the foot as far laterally (externally) as possible during the stance phase to disable passive dorsiflexion and allow a more effective push-off through hip and knee extension exerted at the midfoot.

Waddling Gait

Individual leans to the side opposite the long limb, "hiking" the hip

Inflammation of calcaneal tendon

Inflammation of the this tendon constitutes 9% to 18% of running injuries. Microscopic tears of collagen fibers in the tendon, particularly just superior to its attachment to the calcaneus, result in tendinitis, which causes pain during walking.

Injury to Tibial Nerve

Injury to this nerve is uncommon because of its protected position in the popliteal fossa; however, the nerve may be injured by deep lacerations in the fossa. Posterior dislocation of the knee joint may also damage this nerve. Severance of the nerve produces paralysis of the flexor muscles in the leg and the intrinsiv muscles in the sole of the foot. People with an injury to this nerve are unable to plantarflex their ankle or flex their toes. Loss of sensation also occurs on the sole of the foot.

Sural Nerve Grafts

Pieces of this nerve are often used for nerve grafts in procedures such as repairing nerve defects resulting from wounds. The surgeon is usually able to locate this nerve in relation to the small saphenous vein.

Groin Pull

Sports broadcasters refer to a "pulled groin" or "groin injury." These terms refer to a strain, stretching, and probably some tearing of the proximal attachments of the flexor and adductor thigh muscles. The proximal attachments of these muscles are in the inguinal region (groin). Groin pulls usually occur in sports that require quick starts (e.g., sprinting or soccer) or extreme stretching (e.g., gymnastics)

Plantar Fasciitis

Straining and inflammation of the plantar aponeurosis may result from running and high-impact aerobics, especially when inappropriate footwear is worn. It causes pain on the plantar surface of the heel and on the medial aspect of the foot. Point tenderness is located at the proximal attachment of the planter aponeurosis to the medial tubercle of the calcaneus and on the medial surface of this bone. The pain increases with passive extension of the great toe and may be further exacerbated by dorsiflexion of the ankle and/or weight bearing. A calcaneal spur (abnormal bony process) protruding from the medial tubercle has long been associated with plantar fasciitis and pain on the medial side of the foot when walking; however, many asymptomatic patients are found to have such spurs.

Hamstring Injuries

Strains to this muscles (Pulls and/or tears) are common in people who run and/or kick hard (i.e. sprinting, baseball and soccer). The muscular exertion required to excel in these sports may tear part of the proximal attachment of this muscle to the ischial tuberosity.

Fractures Involving Epiphysial Plates

The primary ossification center for the superior end of tibia appears shortly after birth and joins the shaft of the tibia during adolescence. Tibial fractures in children are more serious if they involve this area because continued normal growth of the bone may be jeopardized.

Calcaneal Tendon Reflex

The ankle (jerk) reflex is elicited by striking the calcaneal tendon briskly with a reflex hammer while the person's legs are dangling over the side of the examining table. This tendon reflex tests the S1 and S2 nerve roots. If the S1 nerve root is cut or compressed, the ankle reflex is virtually absent.

Ankle Sprains

The ankle is the most frequently injured major joint in the body. Torn fibers of ligaments are most common. This is nearly always an inversion injury, involving twisting of the weight-bearing plantarflexed foot. The anterior talofibular ligament (part of the lateral ligament) is most commonly torn during ankle sprains, either partially or completely, resulting in instability of the ankle joint. The calcaneofibular ligament may also be torn.

Containment and Spread of Compartmental Infections in Leg

The fascial compartments of the lower limbs are generally closed spaces, ending proximally and distally at the joints. Because the septa and deep fascia of the leg forming the boundaries of the leg compartments are strong, the increased volume consequent to infection with suppuration (formation of pus) increases intracompartmental pressure. Inflammation within the anterior and posterior compartments of the leg spreads chiefly in a distal direction; however, a purulent (pus-forming) infection in the lateral compartment of the leg can ascend proximally into the popliteal fossa, presumably along the course of the common fibular nerve. Fasciotomy may be necessary to relieve compartmental pressure and debride (remove by scraping) pockets of infection.

Cannulation of Femoral Vein

The femoral vein usually is not palpable, but its position can be located by feeling the pulsations of the femoral artery, which lies just lateral to it. In thin people, the femoral vein may be close to the surface and may be mistaken for the great saphenous vein. It is thus important to know that the femoral vein has no tributaries at this level, except for the great saphenous vein that joins it approximately 3 cm inferior to the inguinal ligament. To secure blood samples and take pressure recordings from the chambers of the right side of the heart and/or from the pulmonary artery and to perform right cardiac angiography, a long slender catheter is inserted into the femoral vein as it passes through the femoral triangle. Under fluoroscopic control, the catheter is passed superiorly through the external and common iliac veins into the inferior vena cava and right atrium of the heart

Intragluteal Injections

The gluteal region is a common site for intramuscular injection of drugs because the gluteal muscles are thick and large, providing a large area for venous absorption of drugs. Injections into the buttock area are safe only in the superolateral quadrant of the buttock. Complications of improper technique include nerve injury, hematoma, and abscess formation.

Surgical Hip Replacement

The hip joint is subject to severe traumatic injury and degenerative disease. Osteoarthritis of the hip joint, characterized by pain, edema, limitation of motion, and erosion of articular cartilage, is a common cause of disability. During hip replacement, a metal prosthesis anchored to the person's femur by bone cement replaces the femoral head and neck and the acetabulum is often lined with a metal/plastic socket.

Swing-Out Gait

The long limb is swung out laterally (abducted) to allow the toes to clear the ground

Knee Joint Injuries

These injuries are common because the knee is a low-placed, mobile, weight-bearing joint and its stability depends almost entirely on its associated ligaments and muscles. The most common knee injuries in contact sports are ligament sprains, which occur when the foot is fixed on the ground. If a force is applied against the knee when the foot cannot move, ligament injuries are likely to occur. The tibial (TCL) and fibular (FCL) collateral ligaments are tightly stretched when the leg is extended, preventing disruption of the sides of the joint. The firm attachment of the TCL to the medial meniscus is of clinical significance because tearing of this ligament frequently results in concomitant tearing of the medial meniscus. The injury is frequently caused by a blow to the lateral side of the extended knee or excessive lateral twisting of the flexed knee, which disrupts the TCL and concomitantly tears and/or detaches the medial meniscus from the joint capsule. This injury is common in athletes who twist their flexed knees while running (e.g., in football and soccer). The anterior cruciate ligament (ACL), which serves as a pivot for rotatory movements of the knee, is taut during flexion and may also tear subsequent to the rupture of the TCL, creating an "unhappy triad" of injuries (Fig. B5.16A). ACL rupture, one of the most common knee injuries in skiing accidents, for example, causes the free tibia to slide anteriorly under the femur, a sign known as the anterior drawer sign (Fig. 5.16B). Although strong, posterior cruciate ligament (PCL) rupture may occur when a person lands on the tibial tuberosity when the knee is flexed. PCL ruptures usually occur in conjunction with tibial or fibular ligament tears. The posterior drawer sign, in which the free tibia slides posteriorly under the fixed femur, occurs as a result of PCL rupture.

Ischial Bursitis

This condition results from excessive friction between the ischial bursae and the ischial tuberosities (e.g., from cycling). Because the tuberosities bear the body weight during sitting, these pressure points ma lead to pressure sores in debilitated people, particularly paraplegic persons.

Pott Fracture- Dislocation of Ankle

This injury occurs when the foot is forcibly everted. This action pulls on the extremely strong medial ligament, often tearing off the medial malleolus. The talus then moves laterally, shearing off the lateral malleolus or, more commonly, breaking the fibula superior to the tibiofibular syndesmosis. If the tibia is carried anteriorly, the posterior margin of the distal end of the tibia is also sheared off by the talus.

Hallux Valgus

This is a foot deformity caused by degenerative joint disease; it is characterized by lateral deviation of the great toe. In some people, the deviation is so great that the first toe overlaps the second toe. These individuals are unable to move their 1st digit away from their 2nd digit because the sesamoid bones under the head of the 1st metatarsal are displaced and lie in the space between the heads of the 1st and 2nd metatarsals. In addition, a subcutaneous bursa may form owing to pressure and friction against the shoe. The thickened bursa (often inflamed and tender) and/or reactive hyperostosis of the head of the 1st metatarsal results in a protuberance called a bunion.

Posterior Tibial Pulse

This pulse can usually be palpated between the posterior surface of the medial malleolus and the medial border of the calcaneal tendon. Because the artery passes deep to the flexor retinaculum, it is important when palpating this pulse to have the person relax the retinaculum by inverting the foot. Failure to do this may lead to the erroneous conclusion that the pulse is absent.

Plantar Reflex

This reflex (L4, L5, S1, and S2 nerve roots) is a myotatic (deep tendon) reflex. The lateral aspect of the sole is stroked with a blunt object, such as a tongue depressor, beginning at the heel and crossing to the base of the great toe. Flexion of the toes is a normal response. Slight fanning of the lateral four toes and dorsiflexion of the great toe is an abnormal response (Babinski sign), indicating brain injury or cerebral disease, except in infants. Because the corticospinal tracts (motor function) are not fully developed in newborns, a Babinski sign is usually elicited and may be present until children are 4 years of age.

Patellar Dislocation

When the patella is dislocated, it nearly always dislocates laterally. This issue is more common in women, presumably because of their greater Q-angle, which, in addition to representing the oblique placement of the femur relative to the tibia, represents the angle of pull of the quadriceps relative to the axis of the patella and tibia (the term Q-angle was actually coined in reference to the angle of pull of the quadriceps). The tendency toward lateral dislocation is normally counterbalanced by the medial, more horizontal pull of the powerful vastus medialis. In addition, the more anterior projection of the lateral femoral condyle and deeper slope for the larger lateral patellar facet provide a mechanical deterrent to lateral dislocation. An imbalance of the lateral pull and the mechanisms resisting it results in abnormal tracking of the patella within the patellar groove and chronic patellar pain, even if actual dislocation does not occur.

Rupture of Calcaneal Tendon

____________ tendon rupture is often sustained by people with a history of calcaneal tendinitis. After complete rupture of the tendon, passive dorsiflexion is excessive, and the person cannot plantarflex against resistance.