Lecture 13: Lower Extremity pt 1

Question 1

List the 6 regions of the lower extremities (that exist for descriptive purposes)

Answer 1

1) Gluteal region (buttocks and hip) – transition zone
2) Hip joint
3) Femoral region (thigh)
4) Knee region (joint)
5) Leg or crural region
6) Ankle or talocrural region (joint)
7) Foot region

Question 2

What makes up mature hip bones?

Answer 2

Fusion of 3 primary bones

Question 3

1) Are the 3 bones that make up the hip bones still separated at puberty? Explain
2) When does cartilage disappear and begin to fuse?
3) When does fusion finish?

Answer 3

1) At puberty still separated by triradiate cartilage
2) Cartilage disappears and begin to fuse ~ 15-17 y/o
3) Fusion complete by age 20-25 y/o

Question 4

List the 3 bones of the hip bones and some features of each

Answer 4

1) Ilium: body, ala, iliac crest
2) Ischium: body, ramus
3) Pubis: body, superior & inferior rami, symphysis

Question 5

1) What is the acetabulum?
2) What is it made of?
3) What lines it?

Answer 5

1) Articular “socket” for femoral head
2) 3 bones
3) Labrum

Question 6

What are the two parts of the hip joint?

Answer 6

Femoral head and acetabulum

Question 7

Why are there usually multiple pelvic fractures?

Answer 7

Rings usually break in 2 or more places

Question 8

What bones make up the LE?

Answer 8

1) Hip bones – 3 bones, acetabulum
2) Femur
3) Patella (sesamoid)
4) Tibia
5) Fibula
6) Tarsus (7 bones)
7) Metatarsus (5)
8) Phalanges (14)

Question 9

1) What is the main part of the femur called?
2) What are the features of the proximal femur?
3) What are the features of the distal femur?
4) What rests on top of the distal femur?

Answer 9

1) Shaft
2) Head w articular cartilage, neck, and trochanters
3) Femoral epicondyles & condyles (articular cartilage)
4) Patella

Question 10

1) What are the trochanters of the proximal femur?
2) What is the head of the femur covered with? Where is it not covered?

Answer 10

1) Greater and lesser
2) Articular cartilage except for fovea

Question 11

What surface landmark is on the proximal femur?

Answer 11

Greater trochanter

Question 12

Explain the angle of inclination

Answer 12

1) When we’re born, the angle of inclination is abt 135 degrees
2) Reaches about 125 degrees in adulthood
3) As elderly people age, that angle decreases even more, can cause neck of femur to snap off

Question 13

Explain the torsion angle of the femur

Answer 13

At the axis of the femoral head and neck there’s about a 12 degree angle. If the angle is larger the toes will point inward; sometimes kids start with outward pointing toes.

Question 14

What does the angle of inclination + torsion angle allow for?

Answer 14

Rotatory movements of the femoral head within the obliquely placed acetabulum to convert into flexion and extension, abduction and adduction and rotational movement of the thigh.

Question 15

1) What does a decreased AI (angle of inclination) cause? In who is this common?
2) What causes in-toeing?

Answer 15

1) Increased stress on femoral neck; elderly
2) Increased torsion angle (anteversion)

Question 16

1) What is the most common rotational deformity seen in pediatric orthopedics?
2) What is the most frequent cause of in-toeing in children between the ages of 3-10 years?

Answer 16

1) In-toeing gait (pigeon-toed)
2) Femoral anteversion/torsion

Question 17

1) Each year over ____________ older (>65) people are hospitalized for”hip fractures”.
2) What percent of femoral neck fractures are caused by falling?

Answer 17

1) 300,000
2) > 95%

Question 18

1) ___[Wo/men]____ experience three-quarters of all hip fractures.
2) The average cost of a hip fracture is what according to the American Academy of Orthopedic Surgeons (Nov 5, 2015)?

Answer 18

1) Women
2) $26,912

Question 19

1) What does the colloquial term “hip fracture” usually refer to?
2) What do pelvic fractures convey?

Answer 19

1) “Hip fracture” commonly used to convey fracture of femoral neck
2) Convey fracture to pelvic girdle, usually causing two breaks in the “ring”

Question 20

What is a relatively easy type of femoral fracture to repair?

Answer 20

Femoral neck fracture

Question 21

What are the 4 surface landmarks of the distal femur?

Answer 21

1) Epicondyles (“above” the condyles)
2) Adductor tubercle (adductor m.)
3) Condyles (articular surface)
4) Patella (big sesamoid bone)

Question 22

1) What bone is also a surface anatomy landmark?
2) What type of bone is it?
3) What are its two surfaces?
4) Where are its apex and base?

Answer 22

1) Patella
2) Sesamoid
3) Medial & lateral articular surfaces
4) Apex usually inferior, base usually superior

Question 23

What are the two bones of the lower leg? Which is weight bearing?

Answer 23

1) Tibia (shin): Weight bearing
2) Fibula: Minimal weight bearing

Question 24

What are 3 tibial articulations?

Answer 24

1) Femur condyles superiorly
2) Talus inferiorly
3) Fibula at proximal and distal ends.

Question 25

Where does the distal end of the tibia rest? What does this form?

Answer 25

Medial malleolus; medial and posterior mortise of ankle joint

Question 26

What part of the tibia may be mistaken for a fracture?

Answer 26

Nutrient foramen and canal

Question 27

1) Where does the distal end of the fibula rest? What does this form? 2) What locks the fibula to tibia proximally and distally?

Answer 27

1) Lateral malleolus distally; lateral part of “mortise” of ankle joint 2) Interosseous membrane (with tibia)

Question 28

What are the surface landmarks of the tibia and fibula?

Answer 28

1) Pes anserine (SGT insert) 2) Patella 3) Quad tendon 4) Patella ligament 5) Joint line & condyles 6) Medial and lateral collateral ligs. 7) Tibial tuberosity 8) Gerdy’s tubercle (ITB insert G) 9) Adductor tubercle 10) Body 11) Anterior border 12) Medial surface 13) Med malleolus 14) Head of fibula 15) Lateral malleolus

Question 29

1) What ROMs of the knee joint should be tested? 2) What should you palpate?

Answer 29

1) Active and passive 2) Quad tendon, patella, and patella ligament @ origin & insertion at tibial tuberosity

Question 30

What should you palpate medially and laterally on the knee joint?

Answer 30

1) Medially: epicondyle with adductor tubercle, medial joint line, medial meniscus, MCL, tibial condyle, and pes anserine (tibia for insertion of SGT) 2) Laterally: epicondyle, lateral joint line, fibular head, LCL, tibial condyle and Gerdy tubercle (tibia for ITB)

Question 31

What are the 3 categories of special tests for the knee joint? What tests are within each?

Answer 31

1) Collateral ligament integrity: Valgus and Varus stress 2) ACL/PCL integrity: anterior/posterior draw, Lockman, Pivot shift 3) Meniscal integrity: McMurry

Question 32

What is the Mortise view (of the ankle)?

Answer 32

~20 deg. oblique

Question 33

Why are ankle injuries usually lateral?

Answer 33

Ankle inverts further than it does evert

Question 34

The direct weight bearing is between what two bones of the distal shin?

Answer 34

Tibia and talus (tibiotalar joint)

Question 35

A fracture of medial malleolus is probably from an _____[eversion/ inversion]____ injury

Answer 35

inversion

Question 36

1) What are the two bones of the hind foot? 2) What are the 3 bones of the mid foot? 3) What are the 2 bones of the fore foot?

Answer 36

1) Talus and calcaneus 2) Navicular, cuboid & cuneiforms 3) Metatarsus, phalanges

Question 37

What are the surface anatomy landmarks of the foot?

Answer 37

1) Talus 2) Calcaneus and Achilles tendon 3) Navicular 4) Cuboid 5) 3 cuneiforms 6) MT 7) 1st and 5th MTP 8) 1st MTP sesamoids 9) Base of 5th MT

Question 38

Surface anatomy: 1) What is at the base of 5th MT? 2) What is just distal to f. brevis insertion? 3) What are the features of the big toe (hallux)?

Answer 38

1) Fibularis brevis insertion 2) Fibularis tertius 3) 2 phalanges and 2 sesamoids planter surface of MT-P joint

Question 39

Surface anatomy: 1) Where do bunions typically occur? 2) Where are Taylors bunions? 3) How many tarsal bones are there and what do they provide?

Answer 39

1) Medial MTP joint 2) Lateral 5th MTP joint 3) 7; provide flexibility and shock absorption during weight bearing

Question 40

Surface anatomy: 1) What bone is weight bearing (and the only tarsal bone to articulate with the leg)? 2) What envelops the calcaneus? What does this continue as? 3) What does the navicular bone refer to?

Answer 40

1) Talus 2) Achilles tendon; continues as plantar aponeurosis 3) Tarsus and carpus (scaphoid)

Question 41

1) What is a Lisfranc injury/ Lisfranc fracture? 2) What usually causes it? 3) What's its main symptom?

Answer 41

1) An injury of the foot in which one or more of the metatarsal bones are displaced (dislocated) from the tarsus 2) Weight bearing and twisting injury (soccer or football cleats anchoring foot, cutting and twisting or upper body, etc) 3) Midfoot pain

Question 42

1) What is the transition between the glutes and thigh called? 2) What is the Fascia Lata? What does it do?

Answer 42

1) Gluteal fold 2) Deep fascia of the thigh; investing like a stocking, compression, support.

Question 43

1) What is the IT tract/ band/ ITB of the thigh? 2) Where does it insert?

Answer 43

1) Aponeurosis of tensor facia lata and gluteus maximus muscles 2) Iliac (GERDY) tubercle to anterolateral tibial tubercle

Question 44

1) What muscle is the saphenous opening/ hiatus in? 2) What vein goes through it? Where does it go? 3) Where is the saphenous opening in relation to the inguinal ligament?

Answer 44

1) Fascia lata 2) Greater saphenous v. (superficial) to femoral v. (deep) 3) Inferior

Question 45

What are the fascia of the thigh?

Answer 45

1) Superficial fascia (SQ) 2) Deep or investing fascia (continuous from Fascia Lata) -3 compartments

Question 46

What are the fascial components of the leg? Which is continuous from the Fascia Lata? Which is divided into 3 compartments?

Answer 46

1) Crural fascia (deep investing): continuous from Fascia Lata, septa divide into 3 compartments 2) Transverse intermuscular septum

Question 47

1) What makes up the superficial fascia/ SQ of the thigh? 2) What forms the thigh's deep or investing fascia (continuous from Fascia Lata)?

Answer 47

1) Fatty tissue and superficial veins 2) Fascia lata and 3 intermuscular septa

Question 48

What are the 3 compartments formed by the deep/ investing fascia (continuous from Fascia Lata) of the thigh?

Answer 48

1) Anterior: knee extend, hip flex 2) Medial: hip adductor 3) Posterior: hamstrings

Question 49

What are the 3 compartments formed by the Crural fascia (deep investing) of the leg?

Answer 49

1) Anterior: dorsiflexor compartment 2) Lateral: foot evertor compartment 3) Posterior: plantar flexor compartment

Question 50

1) What does the transverse intermuscular septum divide into two parts? 2) What are these two parts?

Answer 50

1) Posterior fascia compartment of lower leg into superficial and deep parts 2) Superficial = calf muscles (cross knee and ankle) Deep = foot plantar flexors (cross ankle)

Question 51

1) When does compartment syndrome usually occur? 2) What about exertional compartment syndrome?

Answer 51

1) Usually following trauma, blood clot or infection 2) Exercise

Question 52

1) What are the symptoms of compartment syndrome? 2) Are these symptoms present in the entire leg?

Answer 52

1) Pain, pallor (pale skin tone), paresthesia (numbness feeling), pulselessness (faint pulse) and paralysis (weakness with movements). 2) Numbness, tingling, or pain may be present in the entire lower leg and foot

Question 53

What are the two categories of veins in the lower extremities? Where are each?

Answer 53

1) Superficial: in SQ (great and small saphenous) 2) Deep veins: in deep fascia within compartments

Question 54

What are two superficial veins of the leg? Where are each and what forms them?

Answer 54

1) Great saphenous vein: Dorsum of foot and medial aspect of leg -Dorsal digital vein of the great toe and dorsal venous arch of the foot 2) Small saphenous vein: Lateral (and posterior) aspect of leg -Dorsal digital vein of 5th digit & dorsal venous arch

Question 55

1) What do the deep leg veins accompany? What do they travel within? 2) What do perforating veins do?

Answer 55

1) Major arteries, travel within vascular sheath with artery 2) Communicate between deep and superficial veins

Question 56

What type of veins have one-way valves and go superficial to deep (except foot – deep to superficial)?

Answer 56

Perforating veins

Question 57

What does the musculovenous pump do to blood in the vessels of the leg?

Answer 57

Move from: 1) Saphenous to femoral vein 2) Small saphenous to popliteal vein to femoral vein

Question 58

1) Where does the great saphenous vein run? 2) Where does it ascend?

Answer 58

1) Dorsomedial foot and leg to femoral vein 2) Anteromedially

Question 59

The great saphenous vein ascends anteromedially. While it does this, where is it in relation to?: 1) The medial malleolus 2) Medial condyle 3) Saphenous opening in fascia lata

Answer 59

1) Anterior to medial malleolus 2) Posterior to medial condyle (about hands breath posterior to medial margin of patella) 3) Traverses it into the femoral vein

Question 60

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Question 61

1) Where does the small saphenous vein run? 2) What does it empty into/ continue as?

Answer 61

1) Dorsolateral foot to posterior leg 2) Popliteal vein

Question 62

Where does the small saphenous vein ascend?

Answer 62

-Posterior to lateral malleolus -Inclines to midline to penetrate the deep fasci & ascends between heads of the gastrocnemius mm.

Question 63

1) What veins accompany major arteries in vascular sheath? 2) What 3 things aid in venous return superiorly to IVC?

Answer 63

1) Deep veins 2) Pulsation of artery + muscle contraction + venous valves

Question 64

1) What type of veins have similar anastomosis around the joints to the arteries? 2) What two venous arches are in the foot?

Answer 64

1) Deep veins 2) Dorsal and plantar arches in the foot

Question 65

List some deep veins

Answer 65

Fibular, anterior + posterior tibial, popliteal, femoral, profundis, ext. iliac veins

Question 66

1) Varicose veins from venous HTN cause what? 2) What is post DVT syndrome?

Answer 66

1) Venous reflux and damage to vein valves 2) Thrombophlebitis

Question 67

What are 3 treatments for thrombophlebitis/ post-dvt syndrome?

Answer 67

Tx: “the vein shop”: 1) Striping 2) Sclerosing 3) Endovascular therapy

Question 68

What are the two categories of lymphatics of the leg?

Answer 68

Superficial and deep

Question 69

Regarding superficial lymphatics of the LE: what two things do they follow? Where?

Answer 69

1) Greater saphenous v.; to superficial inguinal nodes to deep inguinal & iliac lymph nodes 2) Small saphenous v.; drain to popliteal nodes then accompany deep v. & lymphatics

Question 70

Describe deep lymphatics of the LE; what do they accompany? To where?

Answer 70

Deep veins; to popliteal nodes > deep inguinal nodes > iliac nodes

Question 71

1) What is the major artery to lower extremity? 2) What supplies the posterior and lateral aspects of the thigh with blood? 3) What is usually a branch of internal iliac artery that supplies the medial compartment of the thigh?

Answer 71

1) Femoral artery 2) Profunda femoris artery 3) Obturator artery

Question 72

What 2 things does the popliteal artery branch into? Describe the courses of each

Answer 72

Anterior and posterior tibial arteries (distal to popliteal fossa (leg)) 1) Anterior tibial a.: to anterior compartment of leg to ankle to become Dorsal Pedis a. 2) Posterior tibial a.: to posterior compartment of leg to become medial and lateral plantar aa.

Question 73

If you want to see if there's an occlusion in the aorta, would you look into the arteries or veins of the leg?

Answer 73

Arteries

Question 74

Where can pulses be palpated on the LE? (4 places)

Answer 74

1) Femoral artery 2) Popliteal artery 3) Posterior tibial artery 4) Dorsal pedis pulse

Question 75

1) Where does the femoral artery go through? 2) What arteries does it branch into?*

Answer 75

1) Adductor canal and hiatus 2) Profunda femoral artery and circumflex arteries

Question 76

1) What artery is found in the posterior popliteal fossa? 2) Which artery is at the knee?

Answer 76

1) Popliteal a. (from superficial femoral) 2) Geniculate arteries (from superficial femoral and popliteal)

Question 77

1) What artery is on the anterior foot? 2) What about the posterior foot?

Answer 77

1) Dorsal pedis a 2) Plantar aa.

Question 78

The sciatic, femoral, & obturator nerves have what two kinds of sensory branches?

Answer 78

Motor and cutaneous

Question 79

What dermatome is the anterior thigh compartment? What innervates it?

Answer 79

L2-4; femoral nerve

Question 80

1) What are the two motor functions of the femoral nerve? 2) What are the two sensory functions of the femoral nerve? What branches are these performed as?

Answer 80

1) Flexors of the hip + extensors of the knee 2) Anterior cutaneous n. for thigh and Saphenous n. for medial calf and foot

Question 81

1) When can saphenous nerve injury occur? 2) What can this cause and why?

Answer 81

1) During harvesting of saphenous vein for bypass grafting 2) Pain and/or paresthesia medial aspect of the calf & foot; no motor division

Question 82

What dermatome is the medial thigh compartment? What supplies it?

Answer 82

L2-4; obturator

Question 83

1) What is the motor function of the obturator nerve? What's the exception? 2) What is the sensory function of the obturator nerve?

Answer 83

1) Adductors of the thigh (L2-4) -*Except hamstring part of adductor magnus m. innervated by tibial nerve 2) Medial thigh sensation

Question 84

Where does the sciatic nerve come from? (dermatome and plexus) 1) What are its two major branches? 2) What does one of those branch into?

Answer 84

L4-S3; sacral plexus: 1) Tibial nerve (posterior thigh and leg) 2) Common fibular nerve: into superficial and deep fibular (peroneal) nerves (anterior and lateral leg)

Question 85

What motor and sensory functions is the sciatic nerve responsible for? Why?

Answer 85

1) Branches provide ALL motor below knee 2) Most sensory below knee -Saphenous nerve is from the femoral n. on medial aspect of leg and foot

Question 86

1) What is the tibial nerve a branch of? 2) Where does it come from? 3) What part of the thigh does it supply and what does it supply it with?

Answer 86

1) Sciatic nerve 2) L4-S3 3) Posterior thigh compartment; supplies motor to muscles

Question 87

1) What are the two motor functions of the tibial nerve? (branch of sciatic nerve) 2) What two branches does this nerve use to provide sensory innervation? What two areas are supplied?

Answer 87

1) Hamstrings: semi-T & semi-M (flex knee & extend hip) and hamstring pt of adductor m. 2) Medial sural n. and sural n.; calf region and heel of foot

Question 88

1) Where do the plantar nerves originate? 2) What spinal nerves do they come from? 3) What are the two types of plantar nerves?

Answer 88

1) Tibial nerve 2) S1-2 3) Lateral & medial

Question 89

1) Where does the plantar nerves supply motor innervation to? 2) What two places does the plantar nerves supply with sensory innervation?

Answer 89

1) Intrinsic muscle of foot 2) Plantar surface + other nerves

Question 90

1) What is the common fibular nerve a branch of? What spinal level does it come from? 2) What 2 parts of the leg does it supply?

Answer 90

1) Sciatic nerve; L4-S2 2) Anterior and lateral compartment

Question 91

1) What is the motor function of the common fibular nerve? 2) What does the common fibular nerve branch into to provide sensory innervation? Where to?

Answer 91

1) Dorsiflexion and Eversion of the foot 2) Lateral sural n.; lateral leg & foot, dorsum of foot