lower extremity Gao notes - Quiz 1
most frequent site of tibia fx
* narrowest at jx of middle and inferior thirds (like clavicle; away from center) * most common site for a compound fx * fx through nutrient canal --> damage to nutrient artery, predisposes nonunion of bone fragments/extra healing time
most common femoral fx
* neck fx most problemmatic: instability of fx site, thin periosteum covering area = extremely limited powers of osteogenesis * retinacular arteries (arising from medial circumflex femoral arteries) run parallel to neck on way to supply femoral head; vulnerable to injury in this fx, leading to head necrosis and bleeding into hip jt * often results from indirect violence, slipping on icy surgace/tripping over rug
fibula fx
* often 2-6 cm proximal to distal end of lateral malleolus * often associated with ankle jt fx/dislocation * many combined with tibial fx
most common long bone to fx
* tibia (body is unprotected anteromedially) * poor blood supply, even simple fx may take up to SIX MONTHS to heal!
# phalanges
14
primary hip bones begin to fuse when?
15-17 y/o
hip bone fusion complete when?
20-25 y/o
thigh's fascial intermuscular septa
3 septa; lateral is strong (extending from ITB to lateral lip of linea aspera and lateral supracondylar line of femur), other two are weak
# metatarsal bones
5
surface anatomy landmarks: iliac tubercle
5 to 6 cm posterior to ASIS, widest pt of iliac crest
intertrochanteric line
anterior
femur length
approx 1/4 a person's height, associated with a striding gait
hip fx for adolescents/young adults, in sports requiring jerk motion?
avulsion fx where muscles attach (ischial tuberosity, ASIS and AIIS, ischiopubic rami); occur at apophyses (bony projections that lack secondary ossification centers)
fx sesamoid bones of great toe
crushing injury (eg. Heavy object falling on toe)
diagonal tibial fx
eg. when tackled in football game, torsion in skiing accident
lateral malleolus of fibula
extends approx 1 cm more distally; more prominent and post. than medial malleolus; articulates with lateral surface of talus
anatomical position: internal aspect of body of pubis
faces almost directly superiorly (forms floor on which urinary bladder rests)
anatomical position: acetabulum
faces inferolaterally, with inferior acetabular notch
heaviest bone in body
femur
longest bone in body
femur
common source of bone for grafting
fibula (middle third is best, b/c w/blood supply); if long piece is removed --> walking, running, jumping all can be normal!
calcaneus lateral tubercle
first to strike floor (where shoe wears down!)
sciatic nerve
from sacral plexus, thru greater sciatic foramen (inf. glute region) into post. thigh; at apex of popliteal fossa, divides into: 1) common fibular (peroneal) and 2) tibial nerves
two major superficial veins in lower limb
great and small saphenous
vein graft candidate?
great saphenous v. often used for coronary arterial bypass; readily accessible, long, rich in elastic and muscular fibers; good coverage by other leg veins
saphenous opening of fascia lata
great saphenous vein
metatarsal fx
heavy object falling on foot/run over by wheel; common in dancers; fatigue fx from prolonged walking
avulsion fx 5th MT tuberosity
if foot's suddently inverted, may be avulsed by fibularis brevis tendon; common in bball and tennis players
chief flexor of thigh
ilipsoas; also a postural muscle --> active during standing by preventing hip hyperextension
tibia's vascular groove
immediately distal to soleal line; obliquely directed groove, leads to large nutrient foramen
what margin of acetabulum is deficient?
inferior: acetabulum notch (looks like cup with bottom piece of its lip missing), room for vessels
anatomical position: obturator foramen
inferomedial to acetabulum
other femoral fx common to older women who fall down
intertrochanteric (btn trochanters) and pertrochanteric (through the trochanters)
thinnest part of tibia
jx of middle and distal thirds
genu valgum
knock-knee, more knee jt issues than varum --> articular cartilage wear and tear
base of 5th MT
large tuberosity, projects over lateral margin of cuboid
angle of inclination
largest at birth (almost straight) and gradually diminishes (becomes more acute) until adult angle is reached (115-140 degrees, ave. 126 degrees); angle is less in females (breadth of pelvis, and greater obliquity of body of femur)
plantar surface of head of 1st MT
medial and lateral sesamoid bones (w/o, too much pressure on flexor tendon)
body of talus
narrow posteriorly, with groove for a tendon
what part of the femur has the most strain?
neck, due to head and neck being at an angle (which allows for hip joint mobility); fx here in elderly due to slight stumble even! THIS is what's injured in elderly person's "broken hip"
fibula articulates w/femur?
no
TFL
no direct action on leg; a thigh flexor, but doesn't act independently (is in concert with iliopsoas)
hip fx common?
no, even in contact sports (except high-energy severe trama, eg car accident; also skiing and ice dancing)
SI joint smooth?
no, really ugly! Has to match perfectly
fibula weight bearing?
no; mainly serves for muscle attachment, and lateral malleolus helps hold talus in socket
talar neck fx
ocurs during severe dorsiflexion of ankle (eg, slamming on break while driving); body of talus sometimes dislocates posteriorly
transverse stress (march) fx of tibia
of inferior third; common in people who take long walks when they're not conditioned
middle and distal phalanges of 5th digit
often fused due to disuse (esp. in elderly); NO jt mobilization!
tibial tuberosity
on ant. border/crest; DA for patellar ligament
pectineal line
on femur, prominent ridge from central part of linea aspera to base of lesser trochanter
anatomical position: tip of coccyx
on level with the superior half of body of pubis
intertrochanteric crest
posterior
head of tibia
proximal end
AP compression of hip bone, fx?
pubic rami fx
VMO
realigns patella medially; the ONLY dynamic medial stabilizer (active through whole ROM), arises from adductor magnus tendon; can be activated as a single motor unit
boot-top tibial fx
results from high-speed fwd fall in ski boots; usually comminuted fx
longest muscle in body
sartorius (but none of its actions are strong, other thigh muscles produce same mvmts)
foot pain areas
sustentaculum tali (superior border of medial calcaneus), navicular tuberosity (medial surface projects inferiorly), base of 5th MT
only tarsal bone with no muscular or tendinous attachments?
talus
which tarsus bone articulates with leg?
talus (the only one that does!)
surface anatomy landmarks: pubic tubercle
thumb's width from pubic symphysis; guide to superficial inguinal ring; important landmark in diagnosis/repair of inguinal femoral hernias
most common site for a compound fx (skin broken, BVs torn)
tibia's narrowest at jx of middle and inferior thirds
body of tibia
triangular: medial, lateral (interosseous), and posterior surfaces
anatomical position: symphyseal surface of pubis
vertical
thigh contusions
"charley horse," cramping of an individual muscle, due to ischemia, or contusion/tearing of muscle fibers --> hematoma (quads is most common site of thigh hematoma, from direct trauma)
hip contusions
"hip pointers," contusion of ASIS usually; bleeding from ruptured capillaries infiltrates muscles, tendons, other soft tissues
adductor longus injuries
"rider's strain," muscle strain of adductor longus; "rider's bones," ossification of tendons of these muscles
chondromalacia patellae
"runner's knee," common issue; due to quad imbalance, stemming from overstressing knee, a blow to patella, or extreme flexion
slipped epiphysis of femoral head
* 10-17 y/o, due to acute trauma or repetitive microtraumas (esp. abduction/lat. rotation of thigh), --> progressive coxavara * initial symptoms: hip discomfort, may refer to knee
cuneiform bones
* 1st (medial) is largest * 2nd (middle) is smallest * 3rd (lateral) * each articulates with 1) navicular, 2) base of its metatarsal (1st 3 MTs), and lateral 3rd cuneiform articulates with cuboid
coxa vara
* angle of inclination is decreased --> mild shortening of lower limb, limits hip abduction * leads to genu valgum (knock-knees)
coxa valga
* angle of inclination is increased --> mild lengthening of lower limb, limits hip adduction * caused by a slipped epiphysis of the femoral head * often combined with genu varum (bow-leggedness)
deep fascia of thigh
* fascia lata (L. lata = broad) * superior attachment: inguinal ligament, pubic arch, body of pubis, pubic tubercle, SC tissue (Scarpa's fascia) of lower abdominal wall * lateral attachment: iliac crest * post: iliac crest, sacrum, coccyx, sacrotuberous ligament, ischial tuberosity * dist: exposed parts of bones around knee, continuous with crural fascia
gluteal fold vs. sulcus/line
* fold = containing fat, coincides with inf. border of glute max * line = skin crease inf. to gluteal fold, indicates separation of butt from thigh
calcaneal fx
* hard fall from ladder on heal --> comminuted * usually disabling b/c disrupts subtalar (talocalcaneal) jt
femoral body fx
* may break or spiral due to violent injury * in cases of comminuted spiral fx, may take up to 20 weeks to firm union of fragments
cuboid
* most lateral bone in distal row of tarsus * groove for fibularis (peroneus ) longus muscle is anterior to cuboid tuberosity on lateral and inferior surfaces
# tarsal bones
7
adductor canal boundaries
AKA subsartorial or hunter's canal; 15cm-long fascial tunnel in middle third of thigh. Vastus medialis (lateral and anterior), sartorius (medial), adductors longus and magnus (post). Runs from apex femoral triangle to adductor hiatus; overlying sartorius muscle turns it into a canal.
BV injury in femoral neck fx/hip jt dislocation?
Medial circumflex femoral art.
Iliopsoas paralyzed?
TFL hypertrophies to try and compensate
lateral compression pelvis/falls on feet (eg, from roof), fx?
acetabula fx
ITB
additional longitudinal fibers within fascia lata
muscles of medial thigh: adductors
adductor longus, brevis, magnus, gracilis, obturator externus, pectineus --> all supplied by obturator n. (L2-L4) except pectineus (femoral, L2-L4) and HS part of adductor magnus (tibial part of sciatic n., L4)
largest muscle in adductor group
adductor magnus; adductor and HS parts, double nerve inn.!
nerve supply to adductor group
all supplied by obturator n (L2-L4) except pectineus (femoral, L2-L4) and HS part of adductor magnus (tibial part of sciatic n., L4)
genu varum
bowleg; all pressure on inside of knee joint, patella moves laterally to weight-bearing line --> arthrosis of knee cartilages (but children commonly appear bowlegged for 1-2 years after starting to walk)
circumflex femoral arteries
branches of deep art. of thigh, or directly from femoral art. Encircles thigh to supply its muscles and proximal end of femur. Medial circumflex is especially important --> supplies most blood to femur head and neck, often torn in femoral neck fx/hip jt dislocation
linea aspera
broad rough line on posterior of femur
navicular
btn. talar head and 3 cuneiform bones; tuberosity projects medioinferiorly
largest and strongest foot bone?
calcaneus (articulates with talus superiorly, cuboid anteriorly)
femoral artery palpation and compression
can palpate pulse (midway btn ASIS and pubic symphysis, just inferior to inguinal ligament); can compress at this site in emergency to stop bloodflow through femoral artery and it's branches (eg. deep art. of thigh)
bumper tibial fx
caused when bar bumper strikes leg; often tears skin, bone fragment protruding --> compound fx
fx of lateral and medial melleoli
common in soccer/basketball players
deep fascia of leg
crural fascia (L. crus = leg)
chief artery of thigh
deep artery of the thigh
varicose veins, thrombosis, and thrombophlebitis
dilation of the great saphenous vein and its tributaries; pulmonary thromboembolism occurs in a few cases when a thrombus breaks free in a lower limb vein (check: painful calf? Longterm bedrest? Red flags!)
surface anatomy landmarks: PSIS
dimple (skin and underlying fascia attach to PSIS)
patellar fractures
direct blow, sudden quad contraction (proximal fragment pulled up with quad, distal remains with patellar ligament); fx in 2+ fragments
head of fibula
distal end
adductor canal contents
femoral artery and vein, saphenous n., nerve to VMO/vastus medialis
femoral hernia
femoral ring in ant. abdominal wall is usual originating site; often s. intestine loop. Hernial sac compresses contents of femoral canal (loose connective tissue, fat, lymphatics). Strangulation of hernia may occur (sharp rigid boundaries of femoral ring) --> death of tissues.
femoral triangle contents
from lat. to med.: NAVE (femoral NERVE; femoral sheath with femoral ARTERY and VEIN, and EMPTY space = femoral canal with femoral ring), plus branches of nerve, artery, and veign's proximal tributaries (eg. great saphenous and deep femoral); femoral artery and vein leave and enter adductor canal at apex
femoral vein location
inferior to inguinal ligament (by feeling femoral art.), NO tributaries at this level except for great saphenous vein 3 cm inferior --> varicose v. operations, important to ID great saphenous v. and not tie off femoral v. by mistake!
femoral triangle boundaries
inguinal ligament (sup., base of triangle), adductor longus (medially; NOT magnus), sartorius (laterally); apex = where medial border sartorius crosses lateral border adductor longus; roof = fascia lata, cribriform fascia, subcutaneous tissue, skin
superficial femoral vein
is NOT superficial, potentially lethal misnomer! Thrombosis of this vessel is potentially life-threatening. "Superficial" should not be used.
which femur epicondyle is larger?
medial
patellar dislocation
nearly always lateral dislocation, and more often in women (wider pelvis; and esp. ages 16-18)
gracilis
of adductor group: weakest, most superficial, only one that crosses knee jt
tibia's soleal line
on post/proximal part of tibial body; rough diagonal ridge line, runs inferomedially, approx. 1/3 of way down body
adductor tubercle
on superior border of medial epicondyle of femur
Rectus femoris
only muscle of quad that crosses 2 jts, to help iliopsoas flex hip
calcaneus medial tubercle
only one that rests on ground during standing
adductor hiatus
opening in aponeurotic distal attachment of adductor magnus; femoral art
surface anatomy landmarks: supracrestal plane (highest level of iliac crests)
passes thru L4/L5 intervertebral disc
muscles of anterior thigh/hip flexors
pectineus, ilipsoas, sartorius, TFL --> mainly femoral n. (L2-4), lumbar n. for psoas maj and min (L1-3), sup. gluteal n. (L4, L5)
perforating veins of thigh and leg
penetrate deep fascia at an oblique angle; superficial >> perforating >> deep. Are compressed by muscle contractions.
muscles of anterior thigh/knee extensors
quadriceps femoris (rectus femoris; vastus medialis, lateralis, intermedius), femoral n. (L2-4)
patellectomy
removal of patella for a comminuted fx --> quads need to exert more force to completely extend leg (recent techiques for patellar tendon repair to help minimize weakness of knee extension)
terminal cutaneous branch of femoral n
saphenous nerve
groin pull
strain/stretching/possibly some tearing of PAs of anteromedial thigh muscles (flexor and adductor group); sports involving quick starts
knee jerk
tests L2-L4; if reflex is normal, hand on patient's quad should feel contraction
talus articulates with....?
tibia, fibula, calcaneus, navicular
femoral nerve
L2, L3, L4; in the substance of psoas major muscle; enters deep to inguinal ligament, lateral to femoral vessels; sends branches to thigh muscles, and ant. femoral cutaneous n. to skin (ant. and especially medial thigh)
surface anatomy landmark: post. hip dimples
PSIS, line connecting is at S2 spinous process, passes thru center of SI jt