Mss 07: Functional Anatomy Of The Lower Extremity

Front 1

What muscles are in the anterior compartment of the thigh? Innervation? Action?

Back 1

IPSquad: Iliacus, Pectineus, Sartorius, Quads
- Femoral n.
- Flex at hip and extend at knee

Front 2

What muscles are in the medial compartment of the thigh? Innervation? Action?

Back 2

POAAAG: Pectineus, Obturator Ext., 3 Adductors, Gracilis
- Obturator n.
- Adduct leg towards midline

Front 3

What muscles are in the posterior compartment of the thigh? Innervation? Action?

Back 3

BSASB: Biceps long, Semitendinosus, Adductor Magnus, Semimembranosus, Biceps short
- Sciatic n.
- Flexion at knee, extension at hip

Front 4

What muscles are in the posterior compartment of the lower leg? Innervation? Action?

Back 4

PGPS(TFF): Popliteus, Gastroc, Plantaris, Soleus, Tib post, FDL, FHL
- Tibial n.
- Flex at knee and plantarflex (stand on tip toes)

Front 5

What muscles are in the anterior compartment of the lower leg? Innervation? Action?

Back 5

TEEP(F)EE: Tib ant., EDL, EHL, Fib tertius, EDB, EHB
- Deep fibular nerve
- Dorsiflex (walk on heels)

Front 6

What muscles are in the lateral compartment of the lower leg? Innervation? Action?

Back 6

FF: Fibularis long and Fibularis brev
- Superficial fibular n.
- Evert ankle

Front 7

What muscles are intrinsic to the foot? Innervation?

Back 7

- Medial Plantar n.: Abductor hallucis, Flexor digitorum brevis, Flexor hallucis brevis, most medial Lumbrical
- Lateral Plantar n.: all others

Front 8

Slipped Capital Femoral Epiphysis (SCFE):
- History
- Etiology
- Presentation
- Treatment

Back 8

- History – classically an overweight early adolescent with history of groin or knee pain, which may be referred to anteromedial thigh. Often occurs bilaterally (but not simultaneously)
- Etiology – repetitive overload
- Presentation – Vague symptoms, worse with activity. Limitation of internal rotation.
- Treatments – plain x-rays, surgical fixation

Front 9

Transient Synovitis of the Hip:
- History
- Etiology
- Presentation
- Treatment

Back 9

- History: Ages 3-10
- Etiology - usually viral, post-vaccine or drug-induced
- Examination - usually hold hip slightly flexed & external rotation; resistance to abduction and internal rotation. Any motion at joint causes pain; child refuses to bear weight; otherwise looks okay
- Treatment - Sed rate 35-60mm/hr & CBC - mild leukocytosis; NSAIDs for 1-3 wks

Front 10

Septic Joint:
- History
- Etiology
- Presentation
- Treatment
- Complication

Back 10

- History / Presentation
a) Swollen, extremely painful joint
b) Passive & active ROM very painful
c) Red, hot joint
d) Usually has systemic signs, but may be absent in diabetic patient or immunosuppressed patient

- Etiology - Gonorrhea or skin flora
- Treatment - often requires surgical incision and drainage followed by IV antibiotics
- Complication - articular surface destruction

Front 11

13 yo soccer player complains of knee pain; denies any known injury; pain to palpation of tibial tubercle and pain w/ resisted knee extension.

What is the underlying pathology?

Back 11

- Relative weakness of immature skeleton compared to the mature skeleton
- Osgood-Schlatter Condition

Front 12

What is the cause of Osgood-Schlatter Condition?

Back 12

- Following an adolescent growth spurt, repeated stress from contraction of the quadriceps is transmitted through the patellar tendon to the immature tibial tuberosity.
- This can cause multiple partial avulsion fractures (pulling the tibial tuberosity away from tibia)
- Also, inflammation of the tendon can lead to excess bone growth in the tuberosity and producing a visible lump which can be very painful, especially when hit

Front 13

What is seen in this image?

Back 13

Osgood-Schlatter Disease (OSD) - tibial tuberosity elongated and fragmented, with overlying soft tissue swelling

Front 14

What happens in Apophysitis?

Back 14

- Pain and inflammation of ossification centers from repetitive tension
- E.g., Osgood-Schlatter Disease

Front 15

How should Apophysitis (e.g., Osgood-Schlatter disease) be treated?

Back 15

- Activity as tolerated
- Stretching
- Ice ± NSAIDs

Front 16

What are some common sites of Apophysitis?

Back 16

- Tibial tubercle (Osgood-Schlatter)
- Calcaneus (Sever's)
- Distal patellar pole (Sinding-Larsen-Johnson)
- Sartorius (ASIS)
- Rectus Femoris (AIIS)
- Medial Epicondyle (little leaguer's elbow)

Front 17

What is the term for excessive fluid in a joint?

Back 17

Effusion

Front 18

What is the term for a synovial lined sac that contains fluid and acts to reduce friction between structures? Examples?

Back 18

Bursa - Achilles, olecranon, subacromial, prepatellar, and other knee locations

Front 19

What is the term for fluid filled soft tissue mass filled with a collection of synovial or peritendinous fluid that arises from a joint or tendon sheath? Example?

Back 19

Ganglion
E.g., wrist

Front 20

What are the characteristics of an effusion?

Back 20

- Uniform and diffuse fluid around a joint
- Does not move independently (non-mobile) since it is "attached" to joint

Front 21

What are the characteristics of bursitis?

Back 21

- Localized, mobile
- Small or large
- Located throughout the body
- Usually feels "squishable"

Front 22

What are the characteristics of a ganglion?

Back 22

- Usually relatively small <2 cm
- Usually near joints
- Usually fairly tense
- Chronic non-painful swelling in wrist, gets larger and smaller, but never completely goes away

Front 23

58 yo mentally handicapped women is brought in because she is "walking slower and less often than normal" since a fall 4 months ago; she was seen in ER and diagnosed w/ a small fibular avulsion fracture; had been doing PT w/ improvement in ankle pain.

Exam: uneven gait, tends to lean toward R, favoring L leg; L leg is more externally rotated than R and 2 cm shorter; increased ER and decreased IR on L; normal strength, mild pain with abduction and flexion.

What do you suspect / what should you do?

Back 23

Femoral neck fracture

Front 24

What are femoral neck fractures associated with?

Back 24

- Young: trauma
- Elderly: osteoporosis + fall

Front 25

What are the four femoral neck fracture types?

Back 25

- I: impaction of superior portion of femoral neck (incomplete)
- II: non-displaced fracture (complete)
- III: partial displacement between femoral head and neck
- IV: complete displacement between femoral head and neck

Front 26

What is an "enthesopathy"?

Back 26

Disorder of muscular or tendinous bony attachment

Front 27

What is the difference between Tendinitis and Tendinosis?

Back 27

- Tendinitis - acute inflammation of tendon (trauma - blow or pull)
- Tendinosis - chronic degenerative condition of tendon (submaximal repetitive irritation)

Front 28

What happens in a strain? What is the cause? Symptoms?

Back 28

- Muscle fiber damage from overstretching
- Eccentric loading (muscle lengthening during firing)
- Sx: stiffness, bruising, swelling, soreness

Front 29

What happens in a sprain? What is the cause? Symptoms?

Back 29

- Ligamentous damage from overloading
- Sx: instability or laxity, swelling

Front 30

A football player gets hurt during a play causing his knee to bend backwards, what do you suspect? What are you most concerned about damage to?

Back 30

- Knee multi-ligament tears
- Most concerned about damage to vessels (without this, you will need an amputation)

Front 31

What would most patients with an ACL injury complain of?

Back 31

Buckling of the knee - no stability in knee (PCL alone is not enough to support sudden changes in direction)

Front 32

What are the three knee articulations?

Back 32

- Femoral condyles
- Tibial plateau
- Patella

Front 33

What are the ligaments of the knee?

Back 33

- Medial meniscus (c-shaped)
- Lateral meniscus (o-shaped)
- Cruciates: ACL and PCL
- Medial (tibial) collateral
- Lateral (fibular) collateral

Front 34

In what direction can the tibia move relative to the femur if the ACL is torn? PCL is torn?

Back 34

- ACL tear - move tibia anterior relative to femur
- PCL tear - move tibia posterior relative to femur

Front 35

What are the different degrees of sprains of the knee ligaments?

Back 35

- 1st degree: stretched ligament w/ little or no tearing
- 2nd degree: partial tearing of ligament w/ joint laxity
- 3rd degree: complete rupture of ligament, resulting in an unstable joint

Front 36

What happens in the "Unhappy Triad"?

Back 36

Force to lateral side of knee causes:
- Damage to ACL and MCL
- Also damage to lateral meniscus (compression injury)

Front 37

Anterior Cruciate Ligament Sprain:
- Etiology
- History
- Exam

Back 37

- Etiology - twisting non-contact, deceleration or hyperextension injury
- History
a) Acute - pop and rapid effusion
b) Chronic - instability
- Exam - (+) Lachmann – knee at 20-30° flexion; stabilize femur; check anterior translation & endpoint of tibia

Front 38

What can cause the menisci to tear?

Back 38

Twisting injuries to knee

Front 39

If a knee is "locking" what should you suspect?

Back 39

Meniscal tear because pieces of meniscus can get in the way of the condyles and lock up a joint

Front 40

Meniscal Tear:
- Etiology
- History
- Exam
- Treatment

Back 40

- Etiology - usually occur with twisting on a loaded (weight-bearing) knee in athletes; degenerative tears are common in older patients
- History - locking & effusion
- Exam - pain over joint line; pain with circumduction tests (McMurray is best known)
- Treatment
a) Locked - needs reduction; referral to orthopaedic surgeon
b) No locking - physical therapy and relative rest

Front 41

35 yo runner complains of foot drop when running sub-5 minute/mile pace and great toe "numbness". He has no problems at slower speeds or with ADLs. No recent change in exercise regimen.

What do you suspect / what should you do?

Back 41

- Exertional compartment syndrome of anterior calf
- When working harder, increases pressure in anterior compartment, leads to swelling
- At lower intensity the pressure is lower
- Cutting off circulation
- Foot drop (d/t compression of deep fibular nerve)

Front 42

Compartment Syndrome:
- Pathology
- Etiology
- Presentation

Back 42

- Pathology – elevation of pressures in a muscular compartment high enough to interfere with perfusion

- Etiology:
a) Acute – severe bleed – usually caused by fracture
b) Chronic exertional – from hypertrophied muscle in tight compartment with exercise (which increases muscle bulk up to 20%)
c) Common locations – leg>>forearm

- Presentation (6P’s): Pain, Paresthesia, Poikilothermia (coolness), Paralysis, Pallor, Pulselessness

Front 43

What are the 6 P's of Compartment Syndrome? Early or late signs?

Back 43

1. Pain out of proportion (early sign)
2. Paresthesia (early sign)
3. Poikilothermia (coolness)
4. Paralysis (late) - footdrop d/t compression of deep fibular nerve
5. Pallor (late)
6. Pulselessness (late & rare)

Front 44

What causes anterior tibial compartment syndrome? Lateral compartment system?

Back 44

- Anterior: excessive contraction of anterior compartment muscles
- Lateral: excessively mobile ankle joint in which hypereversion irritates the lateral compartment muscles

Front 45

What are the normal / elevated / compartment syndrome pressures?

Back 45

- Normal: 0-10 mm Hg
- Elevated, but not dangerous: 10-30 mm Hg
- Acute compartment syndrome (potentially dangerous): 30-40 mm Hg
- Usually dangerous, usually requires compartment release: 40-60 mm Hg
- Consistently dangerous, requires urgent release: >60 mm Hg

Front 46

24 yo male sustains a GSW to lateral aspect of left knee; exam reveals that the deep fibular nerve has been damaged. Which muscles will be affected?

Back 46

TEEP(F)EE:
- Tib ant.
- EDL
- EHL
- Fib tertius
- EDB
- EHB

Front 47

30 yo runner is struck on the side of the leg by a bicyclist. Exam reveals the inability to evert her foot and diminished sensation on the dorsum of her foot. Which muscles are affected?

Back 47

- Fibularis longus
- Fibularis brevis

Front 48

50 yo male was working with his chain saw when he slipped and sustained a laceration down to his bone on the posterior aspect of his medial malleolus. Nerve deficits could include which of the following?

Back 48

Medial plantar nerve

Front 49

Which compartment is least likely to get exertional compartment syndrome?

Back 49

Superificial posterior

Front 50

What compartment is most likely to get a compartment syndrome?

Back 50

- Anterior: 40-50%
- Deep posterior: 30%
- Lateral: 20%

Front 51

What happens in Deep Vein Thrombosis?

Back 51

- Clots, commonly in vein of lower limb
- Clot can break loose from leg and flow to lungs and cause PE

Front 52

What three events account for the pathogenesis and risk for a Deep Venous Thrombosis?

Back 52

- Stasis
- Venous wall injury
- Hypercoagulability

Front 53

What are the risk factors for a Deep Venous Thrombosis?

Back 53

- Postsurgical immobility
- Paralysis
- Vessel trauma
- Malignancy
- Infection
- Trauma

Front 54

How does a pressure ulcer (bedsore) occur?

Back 54

- Soft tissue compressed between bony eminence (e.g., greater trochanter) and bed or wheelchair
- Comatose, paraplegic, or debilitated patients cannot sense discomfort caused by pressure from prolonged contact

Front 55

What are the most common sites of pressure ulcers?

Back 55

- Pelvic girdle: sacrum, iliac crest, ischium, greater trochanter of femur
- Other bony prominences

Front 56

What are the four stages of pressure ulcers?

Back 56

- I: changes in skin temp, consistency, or sensation; persistent redness
- II: partial-thickness skin loss, similar to an abrasion w/ shallow crater or blister
- III: full-thickness skin loss w/ SUBCUTANEOUS tissue damage and a deep crater
- IV: full-thickness skin loss w/ necrosis or damage to MUSCLE, BONE, or adjacent structures

Front 57

Where can the pulse from the femoral artery be felt?

Back 57

Just inferior to the inguinal ligament as it is compressed against the femoral head; lateral to the femoral vein

Front 58

Where does the tibia most commonly get fractured?

Back 58

- Lateral tibial condyle most common site of tibial plateau fractures
- Tibial shaft (most common fracture of a long bone)

Front 59

What is a common patellar injury?

Back 59

Subluxation of patella / dislocation

Front 60

Patellar Dislocation
- Epidemiology
- History
- Exam
- Treatment

Back 60

- Epidemiology - usually lateral dislocation, more common in adolescent girls / young women
- History - cutting with active quadriceps contraction, immediate pain & swelling, tenderness along medial aspect
- Examination - ecchymosis, effusion; sometimes atrophy of quadriceps tendon; Positive apprehension test – feeling of instability with stressing of the joint
- Treatment – physical therapy. If recurrent may eventually need surgery

Front 61

What can happen to the patellar / quadriceps tendons?

Back 61

Rupture of patellar tendon (d/t direct trauma in younger person) or quadriceps tendon (d/t minor trauma or age-related degeneration in older adults)

Front 62

What changes can cause an older adult to be at increased risk for a quadriceps tendon rupture?

Back 62

- Arthritis
- Arteriosclerosis
- Chronic renal failure
- Corticosteroid therapy
- Diabetes
- Hyper-PTH
- Gout

Front 63

What are the common symptoms of Osteoarthritis in the knee?

Back 63

- Painful associated w/ activity
- Weather may precipitate painful episodes
- Stiffness after inactivity
- Decreased ROM
- Subluxation of knee may occur w/ a varus (bowleg) deformity

Front 64

What causes Shin Splints?

Back 64

- Repetitive pulling of tibialis posterior tendon as one pushes off the foot in running
- Stress on muscle occurs at attachment to tibia and interosseus membrane

Front 65

What are the symptoms of shin splints?

Back 65

- Pain along inner distal 2/3 of tibial shaft
- Chronic conditions can cause periostitis and bone remodeling or stress fractures

Front 66

What is the most common malignant bone tumor of mesenchymal origin?

Back 66

Osteosarcoma

Front 67

Who gets Osteosarcoma more commonly? Where?

Back 67

- Males
- Usually before 30 years
- Distal femur or proximal tibia (also proximal humerus, proximal femur, pelvis)
- Metaphysis of long bones at areas of greatest growth

Front 68

What is the normal orientation of the knee (varus vs valgus)? What do these terms mean?

Back 68

- Normal: slight valgus (knock knee)
- Genu Valgum - knock-knee (tall boy)
- Genu Varus - bowleg (short boy)

Front 69

What is the cause of genu valgum and genu varum? Treatment?

Back 69

Usually d/t Rickets, skeletal dysplasia, or trauma (most resolve w/o treatment)

Front 70

Who is most likely to get Achilles Tendinitis? Why?

Back 70

- Runners who run on hills or uneven surfaces
- Repetitive stress on tendon occurs as heel strikes ground and when plantarflexion lifts foot and toes

Front 71

Achilles tendon rupture:
- Epidemiology
- History
- Exam
- Treatment

Back 71

- Typical patient – middle aged male ruptures while playing basketball
- History – heard pop & felt like someone hit them in back of ankle with golf club. Difficulty walking
- Exam: Defect in Achilles and pain & weakness with plantar flexion
- Treatment – either acute immobilization (heals slowly) or surgery

Front 72

What happens in Retrocalcaneal Bursitis?

Back 72

- Inflammation of subtendinous bursa between the overlying tendon and the calcaneus
- Presents as a tender area just anterior to tendon attachment

Front 73

How do most ankle sprains occur? Which ligaments are injured?

Back 73

- INversion injury when foot is plantarflexed, placing stress on components of lateral collateral ligament
- Anterior to posterior (most commonly injured ligaments): first anterior talofibular ligament, then calcneofibular ligament, and finally, posterior talofibular ligament

Front 74

How do you examine a potential ankle sprain?

Back 74

- Anterior drawer test – tibia held steady while heel is pulled anteriorly w/ foot at 10-20 deg plantarflexion; abnormal is 3-5 mm more than uninjured side; may also fell softer end point on injured side (indicates anterior talofibular ligament)

- Squeeze test – squeeze the tibia & fibular together mid-shaft; pain at ankle suspicious for high ankle sprain; pain at knee suspicious for Maisonneuve fracture – fracture of the proximal fibula associated with ankle injury
- External rotation test (+) suspicious for high ankle sprains

Front 75

What are the stages of ankle fractures?

Back 75