Clinical correlations of lower limb

Question 1

meralgia paresthetica

Answer 1

deformation of the lateral femoral cutaneous nerv 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)

feels like hot and cold, pins and needles, or numb

type of cutaneous irritation

Question 2

friction bursitis ischial

Answer 2

on the ishcial tuberosity the bursa sitting here between ishial tuberosity and gluteus maximus

movement of the gluteus maximus across inflamed bursa causes pain

bursa may become calcific

with prolonged bed rest can lead to pressure sores and ulceration

Question 3

friction bursitis trochanteric

Answer 3

inflammation of bursa between greater trochanter and gluteus maximus

repetitive motion of gluteus maximus across bursa during climbing and inclined walking

every time you go long periods of time in extension (standing) or lots of flexion and extension can irritate this

Question 4

medial plantar nerve compression

Answer 4

this is deep to the flexor retinaculum
compare to carpal tunnel syndrome

due to excessive running and eversion of foot
alot of pressure on the deltoid limit (which prevents excessive eversion)

results in paresthesias on the medial side of the sole of the foot with weakness of the intrinsic muscles of the great toe
(abductor hallucis, flexor hallucis brevis, flexor dig brevis, 1st lumbrical)

Question 5

problem with friction bursitis

Answer 5

can cause the bursa to rupture and the ligament that is crossing it to rupture

from repetitive motion or bed rest

Question 6

plantar fasciitis

Answer 6

inflammation of the plantar aponeurosis caused by overuse

(running, high impact activities, improper footwear)

pain elicited by direct pressure at the point of attachment to the calcaneus or by DORSIFLEXING the foot or extending the great toe

if this goes on long enough there can develop a calcaneal bone spur in the direction of the plantar aponeurosis

get tight in the foot

Question 7

Femoral hernia

Answer 7

protrusion of a viscus (portion of the gut) through the femoral ring into the femoral canal

occurs more often in females b/c of wider hips

forms a protrusion in the femoral triangle inferolateral to the pubic tubercle

may protrude through the saphenous opening and impede venous return of the greater saphenous v.

Question 8

compartmental syndromes of the leg

Answer 8

infection
inflammation
arterial hemorrhage within a fascial compartment of the leg can produce pressure increases within the compartment high enough to cause:

-reduced blood supply to muscles within or distal to the compartment

pressure can accumulate from blood and may impinge nerves to the point that paresthesias occur or paralysis occurs to the muscles located within the compartment

Question 9

what do severe compartment syndromes require?

Answer 9

fasciotomy to relieve these compressive forces prior to the occurence of tissue necrosis

cut the intermuscular septum ?

Question 10

why do muscular strains and ruptures occur

Answer 10

occur as a result of large muscles which must exert force very quickly to overcome large amounts of inertia

Question 11

groin strains

Answer 11

usually occur in fast repetitive flexion

adductor group pulls

Question 12

hamstring strains

Answer 12

get hurt in the “push off” phase

runners grab their butts

Question 13

ruptured achilles tendon

Answer 13

week-end warrior injury due to increase age and irregular bouts of exercise

tennis or basketball
where rapid push-offs with the feet are required

Question 14

psoas abscess

Answer 14

due to retroperitoneal abdominal or pelvic infection that descends within the psoas fascial sheat from the kidney?

FEMORAL NERVE
parasthesias all the way down to the foot and anterior part of leg

descends deep to inguinal ligament, resutling in pain and swelling within the femoral triangle

can be mistaken for femoral hernia, indirect inguinal hernia, inflammation of inguinal lymph nodes, saphenous varix

can be from inflammation of the kidney which inflames the psoas

so alot of pain near femoral triangle may need to check kidney function

Question 15

shin splints!

Answer 15

tibialis anterior strain

micro tears in the periosteal attachment of the distal 2/3 of the tibialis anterior to the tibia resulting in pain

swelling and inflammation within the muscle decreased 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

Question 16

calcaneal tendinitis

Answer 16

micro tears in the attachment of the calcaneal tendon to the calcaneal tuberosity as a result of over use, poor footwear, poor training surfaces, or infrequency of activity

Question 17

avulsion fractures?

Answer 17

occur as a result of fragments being pulled away from bones by rapidly loaded tendons and ligaments

Question 18

where are common sites of avulsion fractures?

Answer 18

pelvis
ischial tuberosity (hamstrings)
ASIS, AIIS
ishiopubic rami
tibilal tuberosity (osgood schlatter) 
ankle (lateral and medial malleoli)
medial malleoli--> b/c of eversion of the foot the deltoid ligament gets stretched causing avulsion of the medial malleolar 
foot 5th metatarsal- fibularis brevis attaches there

Question 19

osgood schlatter disease

Answer 19

tibial tuberosity is avulsed

continued traction on the tibial tuberosity

Question 20

femur fracture (neck)

Answer 20

occur most often as a result of increased compressive forces (stepping from the curb or step) on a limb already weakened by osteoporosis

result in shortened limb and require internal fixation

fracture just distal to the junction of the femoral head with the feomral neck or fracture along the intertrochanteric line

Question 21

greater trochanter and shaft fracture of femur

Answer 21

usually as a result of trauma due to falls or MVA

Question 22

distal femoral fracture

Answer 22

fracture of femoral condyles or between condyles

Salter-Harris classification

both result in aberration of the articular surfaces of the knee joint

may disrupt blood supply to knee or leg

Question 23

patella fracture

Answer 23

transverse patellar fracture

• avulsion type due to sudden forceful contraction of the quadriceps
• direct blow (car bumper or dashboard)

bipartite and tripartite patella (THIS IS NOT TRAUMA)
-but rather non union of ossification centers resulting in a patella that has two or three components
often misinterpreted as fractures

Question 24

tibia fracture

Answer 24

most often fracture near junction of middle and distal third (narrowest and least vascularization)

if fractures occur through nutrient foramen can lead to non-union

Question 25

tibia fracture types

Answer 25

transverse diagonal disruption of epiphyseal plate ***

Question 26

fibula fracture

Answer 26

pg 340 buck book

Question 27

calcaneus fracture

Answer 27

most often fractures as a result of hard falls directly on the heel disrupts subtalar joint (active during eversion and inversion)

Question 28

talus fracture

Answer 28

occurs during forced dorsiflexion pg 341

Question 29

Coxa vara (inward)

Answer 29

decrease in the CCD angle (less than 120 degrees) moves the femur medially and makes it shorter Q angle has increased ``` knock kneed (genu valgum-pushing ankle out) lateral knee is going to wear out first ```

Question 30

coxa valga (outward)

Answer 30

increase in the CCD angle moves the femur outward and makes the femur longer Q angle has decreased ``` genu varum (pushing ankle in) (bow leg) medial knee is going to wear out first ```

Question 31

what is the Q angle

Answer 31

angle between a line drawn from the center of the patella to the ASIS and a line drawn from the middle of the patella to the middle of the hip joint normal male Q angle is 14 degree normal female Q angle is 17 degrees the female has a larger Q angle

Question 32

slipped capital femoral epiphysis

Answer 32

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

Question 33

Avascular necrosis of the femoral head

Answer 33

disruption of the arteries that surround the femoral neck to provides branches to the femoral head can lead to femoral head necrosis branches of the medial femoral circumflex artery are most often implicated

Question 34

hip dislocation?

Answer 34

hip is most stable in standing hip joint is loosest when the thigh is in flexion so this can happen during a car accident easily -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)

Question 35

hip drop

Answer 35

paralysis of the gluteal medius and minimus (superior gluteal nerve) action of these muscles usually maintain the sacral base (keeps the unsupported side from dropping when paralyzed the unsupported hip drops during the swing phase of locomotion L4,5- S1

Question 36

menisci injuries?

Answer 36

(lateral and medial) medial is more injured b/c of its attachment to the medial collateral ligament most detrimental, putting full weight on these when you go into flexion small tears can be trimmed and large tears in the peripherally where a good blood supply exists can be repaired

Question 37

typical bucket handle tera in menisci

Answer 37

longitudinal tear through substance of meniscus when the handle tears free it must be removed

Question 38

test for meniscal injury?

Answer 38

if you put in lateral rotation and get pain (then have cartilage damage of lateral side) if you put some medial rotation and get pain then you probably have medial meniscus injury

Question 39

collateral ligament injury

Answer 39

Hit hard medial then the opposie side will open up and stretch the lateral collateral ligaments and opposite is true

Question 40

unhappy triad

Answer 40

anterior cruciate ligament tibial collateral ligament medial meniscus tearing of these at the same time

Question 41

cruciate ligament s injury

Answer 41

ACL and PCL these normally control anterior and posterior movement of the femur on the tibial plateau when the foot is fixed ACL more often injured

Question 42

if you push the femur forward what gets tight? femur backward?

Answer 42

posterior cruciate ligament backward--> anterior cruciate ligament

Question 43

drawer tests do what?

Answer 43

asses cruciate ligament compromise if the anterior c l is not intact then you can pull the tibia forward (in leg flexion) if the posteiror c l is not intact you can actually push the tibia back and the patella/femur comes forward

Question 44

patellar dislocation

Answer 44

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 vatus lateralis muscles

Question 45

patellofemoral syndrome?

Answer 45

pain caused by improper tracking of the patella relative to the patellar groove of the femur can result in chrondromalacia of the patella: results in quadriceps imbalance and improper patellar tracking patella rides more on the lateral femoral condyle the vastus medialis muscles should be worked ON!!! so that the patella is kept in track

Question 46

what is chondromalacia of the patella

Answer 46

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)

Question 47

baker's cysts

Answer 47

result of chronic knee effusion | p. 343

Question 48

os trigonum

Answer 48

bone accessory to talus represents secondary ossification center which fails to unite with talus occurs in 14-25 percent of adults associated with sports where athletes utilizes excessive plantar flexion (soccer players, ballet dancers)

Question 49

Inversion sprain

Answer 49

over elevation of the medial border of the foot usually due to stepping on uneven surfaces while weight bearing results in injury to the lateral collateral ligament of the ankle anterior talofibular ligament is most often a torn component

Question 50

eversion sprain

Answer 50

over elevated of the lateral border of the foot | pg 344

Question 51

Pott's fracture

Answer 51

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

Question 52

femoral artery compression?

Answer 52

decreased pulse in the femoral triangle p. 344

Question 53

popliteal artery

Answer 53

p. 345

Question 54

posterior tibial artery

Answer 54

p. 345

Question 55

dorsalis pedis artery

Answer 55

p. 345 should have equal pulses palpated inferior to the extensor retinaculum lateral to the tendon of the extensor hallucis longus NOTE-- some people have a condition where the dorsalis pedis artery is congenitally absent

Question 56

msculovenous pump

Answer 56

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

Question 57

varicosities

Answer 57

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 the musculovenous pump

Question 58

saphenous vein grafts (greater saphenous v.)

Answer 58

p 346

Question 59

saphenous cut downs (greater saphenous v. )

Answer 59

pg 346

Question 60

saphenous varix

Answer 60

p. 346 infrequent dilatation of the terminal portion of the greater saphenous vein causes a swelling in the femoral triangle can be misdiagnosed as other femoral hernia, psoas abscess

Question 61

what do you use for right cardiac angiography

Answer 61

femoral vein

Question 62

DVT

Answer 62

clot formation as a result of prior trauma vascular stagnation due to reduced physical activity for prolonged periods weakened muscular fascia resuliting in musculovenous pump

Question 63

lymphangitis and lymphandenopathy

Answer 63

pg 346

Question 64

thromboembolism and thrombophlebitis

Answer 64

p. 346

Question 65

what does a femoral nerve injury look like

Answer 65

Loss of Patellar Reflex: L4 loss of anterior femoral compartment musculature loss of leg extension (of the knee) with reduced flexion of the thigh no sensation along medial leg anteriorly and anterior thigh

Question 66

lose the obturator nerve?

Answer 66

Compression results in decreased/weakness in flexion, adduction and rotation of the thigh and paresthesias of the medial thigh skin patch on the interior thigh

Question 67

sciatic nerve piriformis syndrome

Answer 67

the tibial and common fibular components of the sciatic nerve are split by a portion of the piriformis if a person exercise their butt (extending and abducting) a lot it may cause compression on this nerve (the fibular component) this results in complete loss of eversion and dorsiflexion -numbness on the lateral anterior portion of the leg and dorsum of the foot

Question 68

what happens if you lose the sciatic nerve

Answer 68

lose the hamstrings and the gastrocnemius (knee flexors), everything going to the foot Weakness of extension of the thigh, major loss of flexion of the leg, complete loss of inversion, eversion, plantar and dorsiflexion of the foot Loss of Achille’s reflex (S1)

Question 69

gluteal injections ? where do you put it

Answer 69

go more towards the crest of the ilium

Question 70

what is the cause of hip drop

Answer 70

superior gluteal nerve damage gluteus medius

Question 71

inferior gluteal n damage

Answer 71

going up steps, getting off toilet, is hard weakness of the gluteus maximus p 348 Loss of gluteus maximus (note loss of gluteal contour) Difficulty going up stairs, especially on affected limb during push-off; difficulty getting up from a sitting position

Question 72

loss of tibial nerve

Answer 72

Loss of posterior superficial & deep compartments of the leg and ALL plantar foot muscles Inability to plantarflex reduced inversion of the foot; decreased leg flexion; loss of calf contour Foot held in dorsiflexion and eversion*** Loss of the majority of cutaneous sensation to the sole of the foot Loss of Achille’s reflex (S1)

Question 73

common fibular nerve damage

Answer 73

Loss of lateral & anterior compartments of the leg Loss of dorsiflexion and eversion of the foot Foot held in plantar flexion and inversion lose

Question 74

superficial fibular nerve damage

Answer 74

Loss of musculature of the lateral compartment of the leg Loss of eversion with reduced plantarflexion Foot held dorsiflexed and inverted

Question 75

deep fibular nerve

Answer 75

Loss of musculature of the anterior compartment of the leg Loss of dorsiflexion and reduced inversion of the foot Foot held plantar flexed with slight eversion

Question 76

foot drop

Answer 76

loss of tibialis anterior L4 tibialis anterior has eccentric and concentric contraction so helps a person walk quietly loss of extensor hallucis longus L5