Clinical correlates (Glut, Thigh, Leg & Foot dissectors) Flashcards
(106 cards)
1
Q
The highest point of the iliac crest lies at the level of which vertebra? It is is a useful landmark in performing a lumbar puncture to collect cerebrospinal fluid for analysis or to inject anesthetic (spinal block).
A
fourth lumbar vertebra
2
Q
The two ischial tuberosities may be avulsed by forceful contractions of the……….. muscles in skeletally immature individuals. Decubitus ulcers (pressure sores) may develop over them in as well.
A
hamstring
3
Q
A contusion of the bone of the iliac crest is known as a what?
A
“hip pointer”
4
Q
The ASIS is frequently avulsed in skeletally immature athletes by what muscle?
A
Sartorius
5
Q
The articular cartilage on the head of the femur is frequently worn away in elderly individuals with what?
A
osteoarthritis (degenerative joint disease)
6
Q
The neck of the femur joins the shaft at an angle, the angle of inclination, which changes during life but averages 126° in adults. A pathological decrease in the angle of inclination is…………… and an increase is…………..
A
coxa vara
coxa valga
7
Q
Why does a fracture of the femoral neck often result in hip replacement?
A
because retinacular branches of the medial femoral circumflex artery, the main blood supply to the femoral head in the adult, course along the femoral neck and are torn by the fracture.
8
Q
Hip fracture in older adults affects not only their quality of life but is associated with a ……….% increase in mortality within one year.
A
15-20
9
Q
The greater trochanter may be avulsed in skeletally imature individuals due to what muscles?
A
gluteus medius and minimus
10
Q
What may avulse the lesser trochanter?
A
The iliopsoas muslce.
(May also be avulsed following weakening by an infection or metastatic tumor)
11
Q
The tibial tuberosity may be quite large in individuals who suffered……………….. of the tibial tuberosity during adolescence.
A
traction apophysitis (Osgood-Schlatter disease)
12
Q
The tibial tuberosity may be avulsed by the……………… muscle in young athletes.
A
quadriceps femoris
13
Q
Repetitive movements that cause the gluteus maximus to move back and forth over the trochanteric bursa (ex: repeatedly walking up and down stairs. carrying a heavy load) result in a friction bursitis (…………….). This condition is characterized by tenderness over the greater trochanter and pain that may radiate a variable distance down the iliotibial tract.
A
trochanteric bursitis
14
Q
The……………………… also may be irritated by friction as it moves over the greater trochanter or lateral femoral condyle.
A
iliotibial band (iliotibial band syndrome).
15
Q
What is a positive Trendelenburg sign?
What causes a positive Trendelenburg sign?
A
* dropping of the unsupported side of the pelvis when the patient stands on one foot on the affected side.There is a characteristic gluteus medius gait in which the patient leans the trunk toward the affected side when bearing weight on it during the stance phase.
Causes:
* Weakness of the gluteus medius and minimus muscles or a superior gluteal nerve lesion
* Avulsion of the greater trochanter of the femur also may cause a positive Trendelenburg sign.
16
Q
What nerves may be damaged in harvesting bone from the ilium for grafting?
A
The clunial nerves
17
Q
A lesion of the……………… nerve results in weakness abducting the thigh and a positive Trendelenburg sign. The patient also has difficulty in medial rotation of the thigh.
A
superior gluteal nerve
18
Q
A lesion of the………… nerve results in weakness during resisted extension of the thigh, as in standing up from a seated position or walking up stairs, both of which are resited by gravity.
A
inferior gluteal
19
Q
A gluteal lesion has little or no effect on ordinary walking on level ground. Why?
A
because the hamstring muscles can extend the thigh during this motion.
20
Q
Branches of the sciatic nerve supply joints of the lower extremity (except the hip joint) and all of the muscles below the knee. Knowing this, what can injure the nerve and cause major functional deficits?
A
An improperly placed gluteal injection or a posterior dislocation of the hip joint.
21
Q
An intramuscular injection in the gluteal region can only be made safely in the……………. quadrant.
A
superior lateral
22
Q
The sciatic nerve is really two nerves, the tibial nerve and common fibular nerve, bound together by connective tissue epineurium. In about 12-15% of the population the two nerves emerge separately from the greater sciatic foramen with the common fibular division passing through the piriformis muscle or superior to it. The muscle may compress the nerve to produce pain in the…………………… (piriformis syndrome). Individuals in whom the common. fibular nerve pierces the piriformis muscle or passes above it are predisposed.
A
buttock and posterior thigh
23
Q
What can cause piriformis syndrome?
A
- Hypertrophy of the piriformis muscle, which is more likely in some sports (ex: skiers, tennis players).
- Blunt trauma followed by fibrosis may have the same result.
- Half of the cases of piriformis syndrome are idiopathic.
24
Q
what nerve may be a source of continuing perineal pain during childbirth, even when an anesthetic agent is injected to block the pudendal and ilioinguinal nerves?
A
perineal branch of the posterior femoral cutaneous nerve
25
The **inferior gluteal artery** often anastomoses with what to form the _cruciate anastomosis_?
\* When it is present, the cruciate anastomosis allows safe ligation of the femoral artery.
the **medial and lateral femoral circumflex arteries** and the **first perforating artery** (from the profunda femoris)
26
The hamstrings contract..................... at the end of forceful flexion of the thigh (ex: when punting a football) to decelerate the extremity. They are especially susceptible to injury during these contractions when they are stretched over both the hip and knee joints.
**eccentrically**
27
The common fibular nerve passes around........................, where the nerve is vulnerable to injury.
the neck of the fibula
28
If the femoral vein becomes occluded or needs to be ligated, is there an alternative route of venous return?
Yes, thanks to some of the tributaries of the internal and external iliac veins communicating.
29
As with other superficial veins of the upper and lower extremities, **perforating veins** carry blood from the.................. vein through deep fascia to.............. veins. This enables muscle contractions to help push the blood toward the heart against the pull of gravity (**musculovenous pump**).
small saphenous
deep
30
The popliteal artery lies against the **distal femur** where it may be injured by a fracture if the............... muscle rotates the distal fragment of bone posteriorly.
Since the artery crosses the capsule of the knee joint posteriorly, dislocation of the knee joint also may damage the artery.
**gastrocnemius**
31
What is more frequently seen in equestrians, and may result in fatal hemorrhage?
Rupture of a popliteal aneurysm
32
Traumatic injury of the **popliteal artery** and the closely related **popliteal vein** may result in an............................ This can lead to loss of the leg and foot, or more serious consequences, if not promptly recognized and treated
**arteriovenous fistula**
33
What may provide a collateral route for blood to return to the heart if either the superior vena cava or the inferior vena cava is blocked?
The **superficial epigastric vein** may anastomose with the **lateral thoracic vein** to form a **thoracoepigastric vein**
34
The terminal portion of the great saphenous vein may become dilated (**Known as what?**) and be confused with other groin swellings (ex: a femoral hernia or psoas abscess).
**saphenous varix**
35
If the valves in perforating veins or in the great saphenous vein itself become incompetent, blood pools in the great saphenous vein and it becomes tortuous and dilated (**varicose veins**). Why is the presence of valves significant when transplanting the great saphenous vein for coronary artery bypass surgery?
a segment of the great saphenous vein that is transplanted in coronary artery bypass surgery must be reversed to allow blood to flow past the site of coronary artery obstruction!
36
What does it indicate if there is unexplained enlargement in superficial inguinal lymph nodes (lymphadenopathy)?
Its an indication that we need to examine the entire field of drainage for possible cancer or infection.
37
What is a point to keep in mind for _men_ when it comes to lymphadenopathy of the inguinal lymph nodes?
What about in _Women_?
Men: **scrotal cancer** in males, but _not testicular cancer_, characteristically metastasizes to the superficial inguinal nodes
Women: **uterine cancer** in females occasionally metastasizes along the **round ligament of the uterus** to the labium majus to reach the superficial inguinal nodes?
38
What prevents spread into the thigh of extravasated urine from a ruptured penile urethra or other fluids from the lower abdominal wall?
The membranous layer of superficial abdominal fascia (Scarpa’s fascia) fusing with the fascia lata just below the inguinal ligament.
FYI: The fascia of Scarpa is the deep membranous layer of the superficial fascia of the abdomen. It is a layer of the anterior abdominal wall. It is found deep to the Fascia of Camper and superficial to the external oblique muscle.
39
What 2 muscles attach to the IT band?
Gluteus maximus and tensor fasciae latae
40
Where will you feel pain if you have IT band syndrome?
pain at the hip or at the knee (due to inflammation from friction)
41
A pyogenic **retroperitoneal infection** of the posterior abdominal cavity may result in a **psoas abscess** that spreads between the muscle and its fascia (**psoas fascia**). The abscess passes deep to the inguinal ligament and into the proximal thigh, where it may be mistaken for what?
**femoral hernia, saphenous varix,** or **enlarged superficial inguinal lymph nodes.**
42
Due to the iliopsoas muscle’s close relationships to the kidneys and ureters, pancreas, cecum and appendix within the abdomen, inflammation of any of these structures may cause pain when the patient does what?
extends the affected thigh against resistance (**positive iliopsoas maneuver** or **psoas sign**)
43
Following paralysis of the iliopsoas, what may **hypertrophy** to help compensate for weakened hip flexion?
The tensor fasciae latae
44
What can the rectus femoris avulse in immature athletes?
AIIS
45
What nerve is responsible for referred pain from the hip to the knee, due to it innervating both of them?
The femoral nerve
46
Both femoral circumflex arteries supply muscles, but the _medial_ femoral circumflex is also the **major blood supply to the** **head of the adult femur** via what branches?
retinacular branches
47
A femoral pulse is easily taken in a supine patient. Where exactly do you take the pulse?
just inferior to the inguinal ligament, midway between the ASIS and pubic tubercle.
48
Femoral or popliteal laceration may cause rapid exsanguination. If both the femoral artery and vein are lacerated, what may form?
an **arteriovenous shunt**
49
The femoral artery is readily accessible for..........................., for arterial blood sampling, and continuous blood pressure monitoring
**cannulation for cardiac angiography**
50
What vein may be cannulated to access the right side of the heart or to administer intravenous fluids?
The femoral vein
51
What is important to remember when performing femoral venipuncture?
If poor technique is used, the hip joint may be seeded with infection that may destroy the joint! (septic arthritis)
52
**Deep venous thrombosis** is the most common source of pulmonary thromboemboli. Where is a common cause of deep venous thrombosis?
The femoral vein
(Remember, some clinicians unfortunately use the term “superficial femoral vein” to refer to the femoral vein. That makes it easy to forget that the femoral vein is a deep vein)
53
In a femoral hernia, which is more common in females, a loop of intestine or other viscera protrudes through the femoral ring from the abdominal cavity. The hernia is covered by peritoneum and extraperitoneal connective tissue and may escape through the **saphenous opening** into superficial fascia of the thigh.
How are femoral hernias distinguished from inguinal hernias?
by the femoral hernia protrusion being inferior and lateral to the pubic tubercle rather than superior to it.
54
Femoral hernias are in danger of incarceration and of strangulation by what two structures?
- the **lacunar ligament** at the femoral ring
- the sharp **falciform margin** at the saphenous opening.
55
Because the suprapatellar bursa is continuous with the joint cavity, _infection_ in either space easily spreads to the other.
The suprapatellar bursa also can accommodate a large amount of **joint effusion** during **synovitis of the knee joint**. Why is this important?
It may mask the swelling characteristic of inflammation unless the bursa is “milked” downward toward the joint cavity
56
The deep fibers of the.............. **collateral ligament** firmly attach to the **medial meniscus**. Therefore, injury to this collateral ligament typically is accompanied by injury to the medial meniscus.
**tibial**
57
What three things are often injured together as part of the _unhappy triad_ of athletic knee injuries?
The **anterior cruciate ligament** is often injured together with the **tibial collateral ligament** and **medial meniscus**
(Note: some authors have attempted to change the definition of the unhappy triad to substitute the lateral meniscus for the medial meniscus, but the original definition will be used for testing purposes)
58
The most common injuries to the knee joint are **ligament sprains**. A blow to the _lateral_ side of the knee (ex: a tackle in football) produces a **..............stress**, often tearing the tibial (Medial) collateral ligament.
**valgus**
59
A blow to the medial side of the knee produces a less common............ stress that stretches and may tear the fibular collateral ligament. Since the ligament has no attachment to the lateral meniscus, the meniscus typically is not torn with it.
**Varus**
60
The........... nerve may be injured during a severe varus stress (medial blow to knee) and should be examined along with the fibular collateral ligament.
common fibular
61
The **ACL** may be sprained by different mechanisms, but they often involve a rapid change of direction (rotation of the femur on the tibia) with the foot firmly planted and/or a blow to the knee. Acute extravasation of blood into the joint cavity, known as................., is common.
**hemarthrosis**
62
Anterior drawer sign (when the flexed tibia can be pulled forward on the fixed femur) indicates what is torn?
ACL
63
Posterior drawer sign Indicates a tear in what?
PCL
## Footnote
\* Interesting note: The posterior cruciate may be injured when the upper tibia of an unrestrained front seat passenger strikes the dashboard of an auto during a collision.
64
Meniscal tears usually involve the _medial meniscus_ rather than the more mobile lateral meniscus. Symptoms include joint line pain, popping, catching, and............
locking
65
Can a meniscus heal?
Only the peripheral third of the adult meniscus has a vascular supply and, therefore, a capacity for healing.
\* Note that efforts are made to spare (or transplant) a meniscus if possible because the concentrated weight on the femoral and tibial articular surfaces following meniscectomy predisposes to the early development of osteoarthritis.
66
Injuries of the **extensor mechanism of the knee** include rupture of the quadriceps tendon, rupture of the patellar ligament, patellar fracture, and patellar dislocation. Rupture of the quadriceps tendon typically occurs _over the age of 40_ following a preexisting condition that weakens the tendon, such as **tendinitis**. How can you tell if there is a ruptured quadriceps?
inability to extend the knee, with a gap developing in the suprapatellar region during the attempt.
67
Rupture of the patellar ligament (patellar tendon) usually occurs in individuals _younger that 40_. Active knee extension is lost and the patella rides high (**known as.............**) because it has lost its anchor to the tibial tuberosity.
**patella alta**
68
What type of fracture of the patella often results from forceful contraction of the quadriceps femoris muscle against resistance?
Transverse fractures
\* Fracture is typically near middle of the patella, and the proximal fragment is displaced upward by the pull of the quadriceps.
69
What type of fractures of the patella result from direct trauma, with the fragments often remaining nondisplaced?
Comminuted fractures
70
Fractures of the patella must be differentiated from normal variations in patellar structure, resulting from lack of fusion of secondary ossification centers, known as..............
bipartite patella
71
Patellar dislocation is almost always..................and occurs more frequently in females due to the larger **Q angle**.
lateral
## Footnote
\* Other factors that predispose to lateral subluxation include a shorter anterior projection of the lateral femoral condyle and a weak vastus medialis obliquus.
72
Self-reduction of the dislocated patella usually occurs, but the patient shows a.................... sign if the examiner pushes the patella laterally with the knee of the supported extremity flexed to 30° or so.
**positive patellar apprehension**
73
.............. infrapatellar bursitis may be confused with Osgood-Schlatter disease.
Superficial
74
Anserine bursitis involving the pes anserinus bursa may be confused with what injury?
a tibial collateral ligament injury.
75
On the posterior aspect of the knee, the**.................bursa** between the medial head of the gastrocnemius and the semimembranosus tendon may become inflamed to form a **Baker’s (popliteal) cyst**.
**semimembranosus**
76
What is frequently used for vascularized bone grafts?
The middle of the shaft of the fibula
77
What location on the tibia is subcutaneous through most of its length, and is therefore vulnerable to traumatic injury?
The anterior border and the adjacent medial surface
\* A fracture involving the subcutaneous portion of the tibia is likely to be a **compound fracture** (aka a fracture that tears the skin) with the associated danger of bone infection (**osteomyelitis**).
78
The **tibial tuberosity** is located at the upper end of the anterior border, where it provides attachment for the _patellar ligament_. The tuberosity may be enlarged as a result of what disease occuring during adolescence?
Osgood-Schlatter disease
79
Where is the tibial shaft thinnest, which makes it the most frequent site of fracture?
at the junction of the middle and distal thirds
80
What is the most frequently sprained ligament at the ankle joint? When does this usually occur?
The anterior talofibular ligament
## Footnote
\* This usually occurs when the plantarflexed foot is forced into **inversion.**
81
The great saphenous arises from the medial end of the dorsal venous arch of the foot and ascends................... to the medial malleolus. It is accompanied in the leg by the saphenous nerve, which is a branch of the femoral nerve descending from the adductor canal.
Why is this important clinically?
**Anterior**
The great saphenous vein can be accessed rapidly for intravenous access in an emergency by a skin incision anterior to the medial malleolus (**saphenous cutdown**). During this procedure the saphenous nerve may be injured to produce pain or numbness along the medial side of the foot.
82
What is the most commonly injured nerve in the lower extremity, due to its position winiding around the neck of the fibula?
The **common fibular nerve**
\* at risk in direct trauma or a fracture of the fibula, or via severe stretching during dislocation of the knee.
83
A lesion of the common fibular nerve results in what condition, and what compensatory behavior?
**Footdrop and steppage gait**
\* A lesion of the common fibular nerve or its deep fibular branch results in **footdrop** with inability to dorsiflex the foot. In order to prevent the toes from dragging on the ground during the swing phase of gait, the patient compensates by swinging the limb out laterally or flexing his hip and knee joints to raise the foot high off the ground (**steppage gait**).
84
If the foot is forcefully inverted while the fibularis brevis is contracting, the muscle may avulse the tuberosity of which metatarsal?
fifth metatarsal
85
Damage to what structures greatly weakens plantar flexion, making it impossible to stand on the toes and making ambulation difficult?
Paralysis of the **triceps surae** or rupture of the **calcaneal tendon** (third degree strain)
_Note:_ The tendon is prone to rupture after a history of chronic tendinitis or use of fluoroquinolone antibiotics.
86
The patient with a paralyzed gastrocsoleus develops a **triceps surae gait**, in which the pelvis drops on which side during the weight bearing/stance phase of walking?
the affected side! (opposite to gluteus medius gait)
87
What muscle contributes little force during plantar flexion and is sometimes transplanted in reconstructive surgery of the forearm and hand?
The plantaris
88
The pulse of what artery can be felt at the tarsal tunnel, in order to help assess the peripheral circulation?
**Posterior tibial artery**
## Footnote
_Note:_ To do this the patient is asked to invert the foot to relax the flexor retinaculum.
89
A space-occupying lesion (ex: edema due to inflammation or pregnancy) compresses the tibial nerve, leading to **tarsal tunnel syndrome**. This results in pain and paresthesia over which area?
the medial heel and the sole of the foot
90
The perforating branch of the fibular artery may give rise to the **dorsalis pedis artery** if the anterior tibial artery is small and ends at the ankle. What is important to keep in mind in this instance?
a dorsalis pedis pulse is not palpable.
91
ankle sprains are more likely to occur in what position?
The plantar flexed postion
\* The anterior part of the trochlea is wider than the posterior part so that the ankle joint is more stable when the foot is rotated upward toward the leg (**dorsiflexion**) than downward toward the floor (**plantar flexion**).
92
The neck of the talus may be fractured in a severe .................flexion injury (ex: during an automobile collision when the driver has his foot pressed firmly against the brake pedal at the moment of impact).
**dorsiflexion**
\* A fracture of the talar neck is significant because the main blood supply enters the body of the talus from anteriorly, through the neck, and a fracture that interrupts it may result in **avascular necrosis of the body of the talus**
93
If the.................. is too large, it may press against a shoe to produce foot pain.
navicular tuberosity
94
The tuberosity of the _fifth_ metatarsal may be avulsed by the _fibularis brevis_ during what movement of the foot?
**forced inversion**
95
If an arch isn’t present in the foot of an adolescent or adult, the patient is said to have **flatfeet** (**pes planus**). Flatfeet can be either flexible or rigid. What is interesting to note about flexible flat feet?
Flexible flatfeet appear flat when weight-bearing but have an arch when not weight-bearing
96
Rigid flatfeet are flat even when the patient is non-weight-bearing and are symptomaticm. They are usually painful and may be associated with spasm and contracture of the fibularis muscles. The **congenital form** usually results from bone deformities, including the fusion of adjacent tarsal bones (**tarsal coalition**). This typically involves which bones?
Fusion of the **calcaneus** with either the **talus** or **navicular.**
97
Acquired flatfeet may result from failure (stretching) of the plantar ligaments and dysfunction of what _tendon_?
**tibialis posterior tendon**
(ex: can occur from prolonged unaccustomed standing in an older person who has gained a lot of weight)
98
Aquired flat feet can also occur if the..................... _ligament_ fails. The head of the talus loses its support and slips inferomedially with flattening of the medial longitudinal arch.
plantar calcaneonavicular (aka spring ligament)
99
Why is edema more prominent on the **dorsum** of the foot?
The superficial fascia there is loose!
100
The dorsalis pedis artery descends just............... to the extensor hallucis longus tendon, where it is palpated as part of a physical exam in individuals suspected of having **peripheral vascular disease**.
lateral
101
Occasionally a dorsalis pedis pulse is congenitally absent due to the artery’s replacement by an enlarged perforating branch of which artery?
The fibular artery
102
P**lantar fasciitis** causes pain when walking when first arising in the morning and after a period of non-weight bearing results in **heel pain**. **Point tenderness** may be present near the aponeurosis’ attachment to the medial tubercle of the calcaneus. What is of concern with plantar fasciitis?
The chronic inflammation may result in formation of a **bone spur** at the medial tubercle.
103
Compartments of the great toe and small toe are important in directing the spread of infection within the plantar portion of the foot, meaning an infection usually spreads where?
usually spreads along deep fascia rather than eroding through it into adjacent compartments.
104
An abundant arterial anastomoses means that wounds that sever the **.............arterial arch** or its larger branches result in severe bleeding. Ligature of the arch is difficult because of its deep position and surrounding structures.
**plantar**
\* The plantar arterial arch gives off four plantar metatarsal arteries, each of which divides into two plantar digital arteries to supply the adjacent sides of toes.Perforating branches connect the plantar metatarsal arteries with the dorsal metatarsal arteries.
105
What test is determining cervical radicular pain?
Spurlings Test
106
What tests for lateral epicondylitis?
Cozens test
