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Flashcards in Lower Limb Deck (65):

What is Coxa Vara and Coxa Valga?

Coxa Vara = Decreased angle of inclination (Riding a horse)
Coxa Valga = Increased angle of inclination (Nock knees)

*Angle of inclination = Angle between long axis of femoral neck and femoral shaft.


Dislocation of epiphysis of femoral head:
- What happens in this?
- Aetiology?
- Fast or slow occurance?
- Which deformity can occur?
- Presentation?

- Epiphysis of head of femur may slip away from the femoral neck
- Occurs with acute trauma or microstresses which put stress on epiphysis (eg. lateral rotation and abduction)
- Dislocation occurs slowly
- Results in progressive coxa vara
- Can present with hip discomfort which radiates to knees. Radiological examination is often needed for diagnosis.


Neck of femur fracture:
- Why is it so vulnerable?
- Who is most at risk of this?
- Complication?

- Thinnest and weakest part of the femur. Also, it lies at a marked angle to the line of weight bearing.
- Increasing aged women (due to increased risk of osteoporosis).
- Can be intracapsular and damage retinacular arteries (branches of the medial circumflex artery). Can lead to avascular necrosis of the head of the femur.


Proximal Femur Fracture:
- Give the 2 locations it could happen.
- Aetiology?
- Why are these fractures not stable?
- Presentation of fracture?

- Transcervical (middle of neck) or intertrochanteric.
- Often from indirect trauma (eg. stumbling off a curb)
- Not stable due to angle of inclination.
- Presents with external rotation + limb shortening.


Fractures of Greater Trochanter + Femoral Shaft:
- Aetiology?
- What type of fracture can occur here? Complication?

- Often occurs from direct trauma, during active years.
- Can have a spiral fracture - this leads to foreshortening as the fragments override (or as a fracture may be comminuted). Muscle pull can pull fragments in different directions.


Fracture of Distal Femur:
- What can complicate this fracture?
- What happens to the knee joint?
- Why can we get haemorrhage?

- If the condyles separate, we can get a complication.
- The knee joint articulation can be altered as there is misalignment of the articulation.
- Popliteal artery can be compromised - we can get haemorrhage. Blood supply to leg can be compromised.


Tibial Fractures:
- Where is the narrowest part of the tibia? Why is there slow healing here?
- Why is the tibia liable to open fractures/compound fractures?
- Which artery can be damaged, leading to non-union of bone fragments?

- Between the middle and inferior 1/3s of the tibia. Slow healing as there is a poor blood supply.
- This is due to its subcutaneous nature.
- Nutrient artery can be damaged, leading to non-union of bone fragments.


Transverse Stress Fracture:
- Where does this occur?
- Aetiology?

- Across inferior 1/3 of tibia
- Common in people taking hikes when they aren't conditioned for them. The strain may fracture the anterior cortex.


What type of fracture can result from severe torsion in skiing?

Diagonal fracture of tibial shaft. Especially at inferior-medial thirds junction (along with a fracture of the fibula).


How can a boot top fracture occur?

Skiing with high speed and a front fall - angles leg over rigid ski boot. Fracture tibia and fibula.


Fibular Fractures:
- Which region is most liable to fractures?
- How can excessive foot inversion cause fibular fracture?
- Why is walking disrupted?

- 2-6cm proximal to distal end of lateral malleolus
- With excessive inversion, ankle ligaments can rupture and talus can press against lateral malleolus - shearing it off.
- Walking is disrupted as muscle attachments are affected and the bone normally plays an important role in ankle stability.


Why is the fibula ideal for bone grafts? Which region do we generally take?

Ideal as it is superficial and some removal generally does not cause complications. Take from middle 1/3 as this is where the nutrient foramen is located (take this as it allows free vascularised fibular transfers - graft can grow).


When would we use an intramedullary infusion into the tibia?

In dehydrated or shocked children.


Calcaneal Fracture:
- Aetiology?
- Why is this fracture often distabling?

- Hard fall onto heel, causing comminuted fracture
- Fracture interrupts subtalar joint.


Fractures of Talar Neck:
- Aetiology
- Which direction can the body of talus be dislocated to?

- From severe dorsiflexion of ankle (eg. pressing hard on brake pedal in head on crash)
- Body of talus can be dislocated posteriorly


Fracture of metatarsals:
- Aetiology
- What is a Dancer's Fracture?
- What are fatigue fractures?
- What can occur if the foot is suddenly inverted violently?

- Crush injuries or in dancers
- Dance fractures are from when a dancer loses balance and puts full weight on metatarsals.
- Fatigue fractures of the metatarsals can occur with prolonged walking - transverse fracture from repeated stress on metatarsals.
- If suddenly, violently inverted, the tuberosity of the 5th metatarsal can be avulsed by peroneus brevis muscle. Associated with a severe sprain of the ankle + oedema at the base of the 5th metatarsal.


Os Trigonum:
- What is this?
- Bilateral or not?

- During talus ossification, 2ndary ossification centre may occasionally fail to unite with the body of the talus. This can be caused by forceful plantarflexion/stresses in early teens. OR a partly or fully ossified centre may fracture and become non-union. Both of these events lead to an os trigonum.
- Often bilateral.


Fracture of sesamoid bones:
- Where are the sesamoid bones in the foot?
- What are the function of these bones?
- Aetiology?

- Found in the flexor hallucis longus tendon of the great toe
- Function of weight bearing the body (especially in push-off phase of the gait cycle)
- Fracture from crush injury


Fractures involving epiphyseal growth plates:
- What can these jeopardise?
- What is osgood-schlatter disease?

- Can jeopardise normal bone growth
- Osgood-schlatter disease is when inferior bone growth from superior epiphyseal centre fails to form tibial tuberosity due to being disrupted. Leads to inflammation of the tuberosity and chronic recurring pain in adolescence.


Compartment Syndrome:
- What is it?
- What can be compressed?
- Presentation?
- Treatment?

- This is when haemorrhage, oedema, or inflammation occurs within a compartment surrounded by fascia - there is an increase in intracompartmental pressure.
- Small vessels of nerves + muscles can be most vulnerable to compression.
- Presents with cold to touch distal limb + lack of distal pulse
- Treatment can include a fasciotomy (slice the fascia).


Varicose Veins:
- Which vessel is most likely to develop these?
- What is it?

- Great saphenous veins + their tributaries frequently become varicose (dilated).
- Due to valves in veins becoming incompetent (eg. due to dilation or rotation) and no longer functioning properly. Blood can then back flow, causing varicose veins.


Deep Vein Thrombosis:
- Presentation?
- Venous stasis is an important cause of DVTs - what can cause stasis?
- What is the term used to described inflammation of veins, with associated thrombosis.
- What is a severe complication?

- Presents with swelling, warmth, erythema (superficial reddening of the skin).
- Loose/incompetent fascia (not resisting muscle expansion so musculovenous pump is less effective); Low muscular activity; External pressure on veins (eg. bedding, cast, bandages).
- Thromboplebitis
- Pulmonary Embolism


Saphenous Vein Graft:
- Which vein is often grafted for a coronary arterial bypass?
- Why is this vein ideal for the job?
- What do we have to do to the graft for it to be useful.

- Great saphenous vein
- Available in good lengths, easily accessible, has ideal muscular + elastic fibres in wall. Very little effect on circulation due to anastomosis.
- We need to invert the graft so that valves do not function.


Saphenous Cutdown:
- What is this?
- Where is the vein found?
- Which nerve is at risk of damage during this procedure?

- This is a procedure to insert a cannula for prolonged administration of blood, plasma expanders, drugs, electrolytes, etc. Insert into great saphenous vein.
- Anterior to medial malleolus
- Saphenous nerve (as it lies close)


Enlarged Inguinal Lymph Nodes:
- When do lymph nodes enlarge?
- Where else should we examine if a lymph node is enlarged?

- When they are diseased (Diseased lymph node = lymphadenopathy)
- Examine all nodes which drain into this one. In females, consider uterus cancer for enlarged inguinal lymph nodes. Also examine all other palpable lymph nodes.


Regional Nerve Blocks of Lower Limb:
- How do we interrupt peripheral nerve conduction?
- Where would we inject for femoral nerve block?

- We inject a perineural injection of anaesthesia
- We would inject 2cm inferior to the mid-point of the inguinal ligament (about a fingers width lateral to the femoral artery).


Hip + Thigh Contusions:
- Where does the blood come from and why?
- What is "Charley Horse"?

- Blood comes from ruptured capillaries following injury to the skin/tissue. You get bruising as the blood infiltrates muscles, tendons, and other soft tissues.
- Charley horse refers to cramping of a single thigh muscle due to ischaemia. Alternatively, it can refer to contusion + rupture of blood vessels, sufficient enough to form a haemotoma (commonly due to tearing of rectus femoris fibres).


Psoas Abcess:
- What is this?
- When should we suspect this?

- A retroperitoneal pyogenic infection in the abdomen or greater pelvis (characteristically from Crohn's Disease or TB of the vertebral column) can form an abscess. This can occur between the fascia + psoas muscle - this can lead to pain being referred to the hip, thigh, or knee.
- When there is oedema in the proximal thigh.


Paralysis of Quadriceps:
- What can sufferers not do?
- What may they need to do to assist walking?
- What can be the result of vastus medialis + vastus lateralis weakness?

- Cannot extend the leg against resistance.
- Tend to push on their distal thigh when walking (to prevent unwanted flexion of the knee)
- Can get abnormal patella movements and loss of joint stability.


Chondromalacia Patellae:
- Aetiology?
- Common name?
- What causes the soreness + aching around the patella?

- Tends to be found in sports which overstress the knee joint. Can also result from a direct blow to the knee, or extreme flexion of the knee.
- Runner's Knee
- This is due to an imbalance of quadriceps.


Patella Fractures:
- What can cause transverse patella fractures?
- What happens to the fragments?

- With a direct blow to the patella, or sudden forceful extension of the knee.
- Superior fragment is pulled superiorly by quadriceps tendon whilst inferior fragment is held inferiorly by patellar ligament.


Abnormal Ossification of Patella:
- Different types of ossification?
- Bilateral or not?

- Bipartite or Tripartite
- Tends to be bilateral. Helps us to distinguish this from a fracture on an X-ray.


Transplantation of Gracilis:
- Why is this muscle ideal?
- What can the graft be used for?

- Superficial + no loss of movement without it.
- Used to replace damaged hand muscles.


Groin Pull:
- Which thigh compartments does this tend to affect?
- What happens?

- Anterior and Medial thigh compartments
- Strain, stretching, and probably some tearing of proximal attachments of anteromedial thigh muscles.


Injury to adductor longus:
- What type of sport can particularly affect this muscle?
- What can happen to these people's tendons of adductor longus?

- Horse riders (as they use these muscles a lot)
- The tendons can become ossified.


Laceration of Femoral Artery:
- Why is the femoral artery vulnerable to laceration?
- What can we get due to the close lying nature of the femoral artery and femoral vein?

- Superficial in the femoral triangle
- Can get an arterio-venous shunt due to communication between the 2.


Saphenous Varix:
- What is this?
- What is the complication?
- When should we suspect this compared to other groin swellings?

- This is localised dilation of the terminal part of the great saphenous vein (called a saphenous varix).
- May get an oedema in the femoral triangle.
- Should consider this when you get groin swelling as well as varicose veins in other parts of the lower limb.


Femoral Hernias:
- What is this?
- What is the complication? What must happen for the herniation to increase in size?
- What may strangle the hernia? Consequences?

- Protrusion of abdominal viscera through the femoral ring and into the femoral canal.
- Complication is compression of femoral canal contents and distension of the wall of the canal. To increase in size, the herniation must pass through the saphenous opening.
- Sharp edges of lacunar ligament + other femoral ring boundaries can cause strangulation. This can lead to necrosis + altered blood supply to the herniation.


Replaced or Accessory Obturator Artery:
- Aetiology?
- What either replaces or accompanies the obturator artery?
- What could this contribute to if there is a femoral hernia?

- Natural variation
- An enlarged, inferior epigastric artery.
- Could contribute to strangulation (as it crosses/close to femoral ring in order to reach the obturator foramen).


Trochanteric Bursitis:
- Which bursa is affected?
- Why is the bursa inflammed?
- Presentation?
- How can we elicit pain from this injury?

- Trochanteric bursa
- Inflammed as superior tendinous fibres are rubbed repeatedly over the bursae of the greater trochanter.
- Presents with point tenderness (as it is a friction bursitis) over greater trochanter. Can radiate along iliotibial tract.
- Passive abduction + lateral rotation whilst patient lies on unaffected side.


Ischial Bursitis:
- Which bursa is affected?
- Why is the bursa inflammed?
- Presentation?
- How can we elicit pain from this injury?
- What can happen with chronic bursitis?

- Ischial bursa
- Friction bursitis sdue to friction between ischial bursae + ischial tiberosities.
- Localised pain over bursa.
- Pain worsens with movement of gluteus maximus.
- Calcification may occur with chronic bursitis. Eg. Can get pressure sores from sitting on ischaial tuberosities (especially in those who paraplegia + poor nursing care).


Hamstring Injuries:
- What can avulse with violent muscular exertion?
- What generally accompanies thigh strains?
- Hamstring fibre tearing can be very painful - vrai or faux?

- Ischial tuberosity (can occur from violent hip flexion + knee extension).
- Contusions + tearing of muscle fibres. May also get haemotoma (contained by the fascia) around some ruptured blood vessels.
- Vrai - very painful.


Injury to superior gluteal nerve:
- Which gaits could we see with this injury?
- Which movements are often impaired?
- Which test can we use?
- Which other conditions could give a positive result for the previous test?

- Gluteus medius limp, Gluteal gait, High steppage gait, or swing-out gait.
- Medial rotation + Abduction (a bit)
- Trendelenburg's Test
- Greater trochanter fracture + Dislocation of the hip


Anaesthetic Block of Sciatic Nerve:
- Where do we inject?
- Where does the loss of sensation radiate to?

- Few cm inferior to mid-point of PSIS to greater trochanter.
- Sensation lost to foot (as these are plantar branches of tibial nerve)


Injury to Sciatic Nerve:
- What is piriformis syndrome?
- What happens if common peroneal nerve passes through piriformis?

- This is when piriformis is so large that it compresses sciatic nerve. This is often with history of trauma to buttocks (associated with hypertrophy + piriformis spasm).
- You can get compression of the common peroneal nerve.


Complete Section of Sciatic Nerve:
- Which movements are lost with this?

- Hip extension, Knee Flexion, Dorsiflexion, Plantarflexion + all foot movements.


Incomplete Section of Sciatic Nerve:
- Aetiology?
- Which other nerves may be involved?
- Is recovery fast or slow?

- Eg. From a stab wound
- Posterior cutaneous nerve of thigh + Inferior gluteal nerve
- Recovery tends to be slow and incomplete.


Intragluteal Injections:
- Why is the buttocks ideal for injection?
- What must we be aware of?
- Give 3 locations where we could aim to inject.
- What can result from improper technique?

- Large muscle which is thick. Provides a substantial volume for absorption.
- Beware of sciatic nerve!
- 1. Inject into superolateral quadrant of buttock. 2. Superior to line between PSIS and greater trochanter. 3. Anterolateral part of thigh (between index finger on ASIS and middle finger over tubercle of the crest).
- Sciatic nerve injury, abscess, haemotoma


Popliteal Abscess + Tumour:
- Why is pain so high?
- Which directions does an abscess here tend to spread?

- Due to strong, deep popliteal fascia, the expansion is limited so pain is high.
- Due to the fascia, spread tends to be superior and inferior.


Popliteal Pulse:
- Where is this found?
- Best position to have the knee in?
- What is a weakening or lost popliteal pulse a sign of?

- Hard to find but it is quite deep in the popliteal fossa.
- Best to have the knee flexed in order to relax the fascia + hamstrings.
- Suggestive of a femoral artery occlusion.


Popliteal Aneurysm + Haemorrhage:
- What is a popliteal aneurysm?
- Presentation?
- How to distinguish aneurysm from other swellings?
- Complications of aneurysm?
- What type of fractures can cause haemorrhage from popliteal artery?
- Name of anastomosis around knee?

- Abnormal dilation of all or part of a popliteal fossa.
- Presents with oedema + pain in popliteal fossa
- Distinguishable as you get thrills + bruits with an aneurysm
- Aneurysm can stretch the nerve or compress the nerve's blood supply. Pain can refer to calf, ankle, or foot.
- Distal femur fractures
- Genicular anastomosis.


Injury to Tibial Nerve:
- Why is this uncommon?
- What can cause this injury?
- Presentation?

- Due to protected site of tibial nerve
- Deep laceration to the leg/popliteal fossa
- Patient has severely weakened plantarflexion of ankle and cannot flex their toes. Loss of sensation to sole of foot.


Osteoarthritis of hip joint:
- Presentation?
- What changes occur to the articular cartilage?
- What can be done to treat?

- Pain, oedema, limited motion
- Erosion of articular cartilage
- Hip replacement


Necrosis of Femoral Head in Children:
- What injuries can cause this?
- Presentation?

- Traumatic dislocations of the hip joint (disrupts artery to the head of the femur) + fracture separating the superior femoral epiphysis. Both can lead to post-traumatic avascular necrosis of the head.
- Presents with radiating hip pain to the knee and growth at epiphysis is slowed.


Dislocation of hip joint:
- What is it called when femoral head does not properly locate in the acetabulum, from birth?
- Which movement do sufferers struggle to perform?
- Appearance of lower limb lengths?
- Test?
- Long term complication?
- What is it called when the femoral head dislocates, not due to a congenital factor? Is this common?
- Which direction are hip dislocations most likely?
- Presentation of dislocated leg?
- Which nerve may be damaged?
- What forces are required for an anterior dislocation of the hip joint?
- What can the femoral head carry with it when it dislocates?

- Congenital dislocation of hip joint
- Abduction of thigh
- Affected side is generally shorter due to more superior femoral head.
- Gives a positive trendelenburg's test
- Can lead to arthritis.
- Acquired dislocation of hip joint. Not very common.
- Mostly in the posterior location (joint capsule ruptures inferiorly and posteriorly - femoral head can then exit acetabulum posteriorly).
- Shortened and medially rotated
- Sciatic nerve
- Force that pushes lower limb into extension, abduction, and lateral rotation. Causes femoral head to go inferior to acetabulum.
- Femoral head can carry acetabular bone fragment + acetabular labrum with it.


Patella Dislocation:
- Which direction does it nearly always go?
- Which gender is it most common in? Why?
- Which structures normally resist lateral dislocation?
- Complication of patella tracking in patellar groove?

- Lateral
- Women, due to larger Q angle
- Vastus medialis, anterior projection of lateral femoral condyle, deeper slope for larger lateral patellar facet.
- Chronic patellar pain (even if actual dislocation does not occur).


Patellofemoral Syndrome:
- Common name?
- What is this?
- Aetiology?
- Treatment?

- Runner's Knee
- This is abnormal tracking of patella in relative to patellar surface of the femur.
- Can occur from direct blow to patella, or from osteoarthritis of the patellofemoral compartment.
- Can resolve through strengthening of the vastus medialis.


Knee Joint Injuries:
- Common or rare?
- What is the unhappy triad?
- What does the anterior draw test test?
- What does the posterior draw test test?
- What does pain on tibial medial rotation suggest?
- What does pain on tibial lateral rotation suggest?
- You can have a meniscus removed in arthroscopic surgery - complication of this?

- Common as the knee is the fulcrum between 2 large levers and is fairly unstable.
- ACL + Medial meniscus + Medial collateral ligament all getting damaged together.
- Anterior cruciate ligament
- Posterior cruciate ligament
- Medial meniscus injury
- Lateral meniscus injury
- Can lead to decrease in stability (mobility is maintained). Complications is also that tibial plateaus can undergo inflammatory response.


Arthroscopy of knee joint:
- What can we use this for?

- To examine interior of knee. Can also use for operations.


Aspiration of knee joint:
- What is this?
- How can we get fluid build up in the joint?

- Procedure to remove excess fluid from knee joint. Can aspirate bursa or knee joint directly.
- Eg. In a fracture of distal femur + laceration of anterior thigh may involve suprapatellar bursa and result in infection of knee joint - you get an increased amount of synovial fluid produced. Joint effusions (leak of fluid from blood + lymphatic vessels can result in more fluid in joint cavity).

*Fullness of thigh near suprapatellar bursa suggests increased synovial fluid.


Housemaid's Knee:
- Which bursa is affected?
- Aetiology?

- Prepatellar bursitis
- Due to friction between skin and patella. May also be due to compressive forces from direct blow or falling on knee (when flexed). If chronic, bursa is distended with fluid and forms swelling anterior to the knee.


Clergyman's Knee:
- Which bursa is affected?
- Aetiology?

- Subcutaneous infrapatellar bursitis.
- Excess friction between tibial tuberosity and skin - oedema forms over proximal tibia.


Deep Infrapatellar Bursitis:
- Which bursa is affected?
- Presentation

- Deep infrapatellar bursa between patellar ligament and structures posterior to it (infrapatellar pad + tibia).
- Enlargement of infrapatellar bursa leads to dimples on either side of patellar ligament being lost when leg is extended.


Popliteal Cysts:
- Other name?
- What is it?
- What is it almost always a complication of?
- Effects in children?
- Effects in adults?

- Baker Cysts
- Abnormal fluid filled sacs of synovial membrane in the popliteal fossa. Alternatively, can be a herniation of gastrocnemius or semimembranosus bursae through fibrous joint capsule, into popliteal fossa.
- Fluid filled sacs of synovial membrane are almost always due to chronic knee joint effusion.
- Generally asymptomatic in children
- In adults, can spread to midcalf, restricting knee movements.


Knee Replacement:
- When would we do this?
- What type of person is it suitable for, and what type of person is it not ideal for?

- When an existing knee is diseased (eg. form osteoarthritis). Requires metal + plastic parts to be cemented to femur and tibia.
- Mimics smooth cartilage so it is good for low-demand activities but it is not ideal for high-demand activities as the components may loosen.