Leslie Reyes, MD OS 203: Skin, Muscles, and Bones EXAM # 3 11 September 2014
I. INTRODUCTION
A. Function 1. Weight bearing 2. Locomotion - Compare vs. upper extremities: hands have to function well (finer movement for daily activities)
B. Development
Figure 1. Changes in Position of Limbs Before Birth
C. Parts and Regions
ANTERIOR PARTS OF THE LOWER LIMB (10) 1. Hip joint (Coxa) 2. Thigh (Femur) 3. Knee (Genu) 4. Leg (crus) 5. Ankle (thallus) 6. Foot (pes) 7. Big toe (hallux) 8. Toes (digiti)
Week # Changes 5 Appearance of upper and lower limbs as finlike appendages pointing laterally and caudally 6 Anterior bending of limbs; elbow, knees point laterally with thumbs facing up; palms, soles, face trunk 7 90 (degree) torsion of appendages about their long axes (upper and lower rotate in opposite direction); elbows point caudally and cranially 8 Barber pole cutaneous innervation arrangement of lower limbs OUTLINE I. Introduction a. Function b. Development c. Parts and Regions
II. Superficial Structures a. Bony Landmarks b. Superficial Veins c. Lymphatic Vessels d. Cutaneous Nerves
III. Hip Joint and Femur a. Configuration b. Angulation c. Ligaments
IV. Hip, Thigh and Gluteals a. Anterior Hip and Thigh b. Medial Hip and Thigh c. Lateral Hip and Thigh d. Gluteals e. Posterior Thigh f. Motor branches of Nerves
V. Knee a. Patella, Knee Capsule, and Bursae b. Static Stabilizers c. Dynamic Stabilizers
VI. Moores Blue Boxes
From 2018 trans:
Ambulation (movement from one place to another) Abduction of big toe From 2016 trans:
When we assume the fetal position, the lower extremities will adduct, go down and internally rotate and become plantigrade
Dermatomes: provide sensation in the skin; A localized area of skin that has its sensation via a single nerve from a single nerve root of the spinal cord
Dermatomal innervation (muscles, ligaments and innervations) is spiral because it follows the anatomical orientation of the fetus (where the big toe still points upward)
Barber pole presentation represents arteries and vein and is spiral due to internal rotation in fetal development
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Movements of the Knee Genu varum bow-legged Genu valgum knock-knee Genu recurvatum Genuflect flexion of the patella
Figure 2. Genu Varum, Genu Valgum and Genu Recurvatum
Figure 3. Posterior structures at the lower limb.
POSTERIOR PARTS OF THE LOWER LIMB (5) 1. Gluteal region (nates, clunes [Moore])
2. Hamstrings located at the posterior thigh flexor of the knee extensor of the thigh
3. Poples (popliteal area) posterior portion of the knee opposite the patella (anterior)
4. Calf (sura) Three muscles (collectively called Triceps Surae): o Soleus (1) o Gastrocnemius (2) median and lateral Tendon of Achilles joins muscles together Sural nerve: o median sural cutaneous nerve (from tibial nerve) o lateral sural cutaneous nerve (from common fibular [peroneal] nerve)
5. Heel (calx)
SUPERFICIAL STRUCTURES
A. Bony Landmarks
Figure 4. Parts of the Pelvic Bone
1. Anterior superior iliac spine (ASIS) very prominent; palpable attachment of muscles (subcutaneous) landmark: true leg length (ASIS to medial malleolus) o vs. apparent leg length measurement (umbilicus to medial malleolus) o important for determination of leg length discrepancy
2. Iliac Crest the rim of the fan: has a curve that follows contour of the ala between the anterior and posterior superior iliac spines can be palpated even in obese people [2018 trans: may be non-palpable in obese people] marks level of the lumbar spine (lumbar tap)
3. Pubic tubercle where inguinal ring is located can be palpated (but not in public)
4. Greater trochanter might be able to palpate laterally [not palpable with too much cellulite] landmark for hip surgery incision
5. Posterior superior iliac spine (PSIS) Area over dimple of buttocks Spinous process of S2
6. Ischial tuberosity covered by gluteus maximus, not palpable when standing You are sitting on your ischial tuberosity.; felt during knee flexion
7. Lesser trochanter Not palpable - covered with muscle Femoral head, posterior inferior iliac spine, and anterior inferior iliac spine
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B. Superficial Veins
Veins: traced from most distal (tributaries) to heart
Figure 5. Veins of the Lower Extremities
1. Greater saphenous vein Formation: dorsal vein of hallux + venous arch of foot Pathway o foot (medial side) o leg (antero-medial side) o medial femoral condyle (posterior side) o thigh (medial side) o femoral vein accessory saphenous vein also drains to greater saphenous vein
2. Lesser saphenous vein Pathway: o foot (lateral side) o ankle o leg calf (posterior side) o popliteal vein
Figure 8. Image of a man suffering from filariasis (left). Amniotic band syndrome (right).
Filariasis/Elephantiasis Wuchereria bancrofti Cause: blockage of worm of lymph nodes o inflammation o impairment of lymphatic drainage Swelling of parts o Chronic edema leading to elephantiasis
Amniotic Band Syndrome congenital lymphatic fluid build up due to constriction o constriction can go as deep as the bone
D. Cutaneous Nerves
Figure 9. Anterior cutaneous nerves of the lower limb
Figure 6. Varicose Veins
Veins: with valves to prevent back flow of blood Defective valves become chronically dilated develops discoloration, venous ulcers Cure: raise legs above the level of the heart to assist in the return of blood + vein stripping
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ANTERIOR CUTANEOUS NERVES 1. Lateral femoral cutaneous nerve From: inguinal ligament To: thigh (superficial lateral side) Innervates lateral aspect of thigh (sensory) prominent; tight belt can cause numbness of thigh
2. Genitofemoral nerve synapse of sensory and motor nerve innervates superomedial part of thigh 2 branches: o sensory - anterior inguinal side o motor - scrotum ! innervates cremastic muscles ! cremasteric reflex: stimulation of inguinal area results to testicles going up
3. Anterior femoral cutaneous nerve femoral nerve branch innervates anterior part of thigh skin nerves
4. Saphenous nerve continuation of femoral nerve innervates anteromedial side of leg (sensory) injury would lead to numbness of medial part of leg
5. Cutaneous branch of obturator nerve innervates medial side of thigh above adductor brevis passes through obturator foramen (stretched via horseback riding)
Figure 10. Posterior cutaneous nerves of the lower limb
POSTERIOR CUTANEOUS NERVES 1. Cluneal Nerves innervates gluteal area
Nerve Origin Superior Cluneal Nerve Dorsal rami of the 1 st 3 lumbar vertebra Middle Cluneal Nerve Dorsal rami of the 1 st 3 sacral vertebra Inferior Cluneal Nerve Posterior femoral cutaneous nerve (as branch)
2. Posterior femoral cutaneous nerve Origin: sacral plexus Innervation: posterior aspect of thigh, knee, and leg beside sciatic nerve
3. Sural Nerve Lateral sural cutaneous nerve o Origin: branch of common perineal nerve o Innervation: lateral side of leg (sensory) Medial sural cutaneous nerve o Origin: branch of tibial nerve o Innervation: posterolateral side of leg (sensory)
Other parts mentioned during the lecture: 1. Lateral femoral cutaneous nerve 2. Genitofemoral nerve 3. Anterior femoral cutaenous nerve 4. Saphenous nerve 5. Cutaenous branch of obturator nerve 6. Cluneal nerves 7. Posterior femoral cutaenous nerve 8. Lateral sural cutaenous nerve 9. Medial sural cutaenous nerve 10. Sural nerve 11. Medial calcaneal nerve 12. Medial plantar nerve 13. Lateral plantar nerve 14. Lateral sural nerve 15. Superficial peroneal nerve 16. Deep peroneal nerve Innervates the dorsum of the web of the big toe and 2nd toe
III. HIP JOINT AND FEMUR
A. Configuration of the Hip Joint
Figure 11. Hip joint showing the Acetabulum
1. Acetabulum: Composed of the lunate surface, acetabular fossa and acetabular notch. moon-shaped Contributed to by the ilium, pubis and ischium. (make up the socket o Not complete cartilaginous; with presence of fat. Triradiate cartilage: to be filled in later in adulthood; children still has this gap in the acetabulum. Fovea insertion of ligamentum teres capitis (round ligament for the femoral head) loose from acetabular fossa. Ball-and-socket joint (Enarthrosis). o Ball: head of the femur o Socket: fusion of the ilium, pubis and ischium. ! designed for stability
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! Most movable of all joints next to the glenohumeral joint. ! Action: Circumduction, flexion, extension, adduction, abduction, internal and external rotation.
B. Configuration of the Femur
Figure 12. Femur Configuration
1. Femoral Head about 2/3 size of a golf ball. 2. Neck 3. Calcar posteroinferior part of the neck Carries a lot of weight. Toughest part of the medial side of the neck. Used as landmark for hip surgeries. 4. Greater trochanter 5. Lesser trochanter 6. Intertrochantic line in front; anterior capsule. 7. Intertrochantic crest More prominent than #6. 8. Linea aspira Line of Hope., literally. 9. Adductor tubercle 10. Medial femoral epicondyle with prominence adductor tubercle inside. 11. Lateral femoral epicondyle. *Isthmus at the proximal third of the femur; considered during surgery.
Osteomyelitis Chronic infection of the long bone Form dead bone inside.
Figure 13. Angulation of the Femur
Angle of inclination in adults: 1. Average value (125 degrees) Normal antiversion: head and neck not lined with the medial epicondyle 2. Coxa Vara (<125 degrees) 3. Coxa Valga (>125 degrees)
Femoral torsion or piki, toeing in.: Internal rotation of the femur. Very antiverted; 90%natural recovery. In infants or toddlers, lower extremities will adjust: thus, child will look as if he is toeing in, but this will spontaneously normalize or correct itself.
C. Ligaments (IPIs) Iliofemoral Y ligament/Ligament of Bigelow; prevents hip from hyperextending to the back. Pubofemoral Ischiofemoral posterior and spiraling.
IV. HIP, THIGH, AND GLUTEALS
A. Anterior Hip and Thigh
Table: HIP FLEXORS (ISTR Easter) Muscle Nerve O I A Iliopsoas *Psoas Major + Iliacus Lesser trochanter Hip flexor; external rotator Sartorius L2-3: Femoral Nerve. ASIS Tibial Shaft (superior portion of medial surface) THIGH flexor, abductor, lateral rotator at hip joint. LEG - flexor at knee joint. PELVIS balancing. Tensor fascia latae L4-5: Superior Gluteal Nerve Arises from ASIS and the anterior portion of the iliac crest Iliotibial Tract (inserts of the tibias lateral condyle) THIGH medially rotates, hip flexion and abduction. KNEE stabilizer Rectus femoris L2-4: Femoral Nerve Straight Head: ASIS Reflected Head: Ilium Quadriceps tendon Hip flexor; knee extensor.
Knee Extensors
Quadriceps femoris Prevents the knee from moving upward. Innervation: L2-4 AND extends your leg at the knee joint. Four (4) Structures: 1. Rectus femoris Crosses at the hip joint. Help iliopsoas flex thigh at the hip. Also acts on the knee through patellar ligament (continuation of quadriceps tendon) 2. Vastus medialis prevent patella from going upward. 3. Vastus lateralis 4. Vastus intermedius.
Articularis Genu Retracts the bursa as the knees extend Pulls suprapatellar bursa Prevents impingement of synovial membrane between patella and femur
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Figure 14. Articularis Genu
Figure 15. Femoral Triangle (ISAng triangle)
Femoral Triangle Bounded by the Inguinal ligament, Sartorius and Adductor Longus (ASIS to pubic tubercle) Floor of triangle: Iliopsoas Contain the anterior femoral vessels, femoral sheath (Around arteries; containing deep inguinal lymph nodes and femoral vein and artery) and femoral nerve (not part of the sheath)
Adductor Canal Hunters Canal Continuation of the femoral triangle (Sartorius inner wall, adductor longus and vastus medialis; gap in the adductor magnus); contain femoral vein, artery and nerve that will continue down to become the saphemous nerve.
FEMORAL ARTERY BRANCHES
Figure 16. Superficial Branches of the Femoral Artery
Deep Branches 1. Medial femoral circumflex artery: Main blood supply of femoral head. Aseptic/avascular necrosis: Occurs when femoral head is blocked. 2. Lateral femoral circumflex 3. Profunda memoris artery
B. Medial Hip and Thigh
Figure 18. Medial Hip and Thigh
Muscle Innervation Action 1. Pectineus L2-3, Femoral Nerve (and a branch of the Obturator Nerve) Thigh adductor and flexor; assist medial rotation of thigh 2. Adductor longus L2-4 (Obturator Nerve) Thigh adductor; assist medial rotation of thigh 3. Adductor brevis L2-4 (Obturator Nerve) Thigh adductor and flexor; assist medial rotation of thigh 4. Adductor magnus L2-4 (Obturator Nerve); hamstring by sciatic nerve Powerful thigh adductor Superior portion: weak flexor, medial rotator Lower portion: Extensor, lateral rotator
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5. Gracilis (most SUPERFICIAL & WEAKEST medial muscle L2-3 (Obturator Nerve) Thigh adductor and flexor; medial rotator when knee is flexed 6. Obturator foramen L3-4 (Obturator Nerve) Laterally rotates and abducts hip; steadies the head of the femur
C. Lateral Hip and Thigh Tensor fasciae latae Iliotibial tract
D. Gluteal Area
Figure 19. Gluteal Area
Gluteus maximus in the greater trochanter and iliotibial tract; hip extensor Gluteus medius most lateral; pulls the greater trochanter to abduct he femur to the pelvis. o Threndelenberg test tests the competency of the valves of the veins in the legs. Gluteus minimus hip abductor Piriformis Landmark structure Inferior border: inferior gluteal and sciatic nerve. Superior border: superior gluteal vessels. Obturator rotates hip rotator Gemeli (Superior and Inferior) Quadratis femoris
E. Posterior Thigh BiTe Me 1. Biceps femoris (short head and long head) 2. SemiTendinosus 3. SemiMembranosus
* Hamstrings long head of 1, #2, and #3
F. Motor Branches of Nerves 1. Femoral Nerve (PIQS) Pectineus Iliacus Quadriceps femoris Sartorius
2. Obturator Nerve (L2-4; from Obturator foramen) Obturator externus Adductor longus Adductor brevis Adductor magnus Gracilis
3. Gluteal Area (PPISS) Posterior femoral cutaneous nerve (L4-S2) Pudental Nerve (S2-4) Inferior gluteal nerve (L5-S2) Superior gluteal nerve (Superior portion of pyriformis; upward) (gluteus medius, gluteus maximus, tensor fasciae latae) (L4-5, S1) Sciatic Nerve (Tibial and Peroneal divisions) Clinical Applications: Hip dislocation with posterior acetabular slip is much more prone in men than women because men sit down with their legs open, unlike women who sit with their knees together.- Vertical fracture: Line generally suggests poorer prognosis. Typical deformity: Injured limb adducted, internally rotated, and flexed at hip and knee, with knee resting on thigh. Psoas Abscess: Infection in the hip.
V. THE KNEE
Figure 20. Right Knee
Knee: MODIFIED HINGE JOINT - At the last few degrees of extension, it will rotate to lock to the knee joint. - Tibia: Weight-Bearing Bone (articulates with femur only) - Fibula: Not Weight-Bearing (Gerdies Tubercle insertion of Iliotibial Tract; lateral to tibial tubercle) Structures are virtually palpable Possess a continuous lining of synovial fluid; hinge type of synovial joint. Highly prone to injury. Largest and most superficial joint. Allow flexion and etension, and also combined gliding and rolling and minimal rotation. Articulation: provides mechanical weakness but is reinforced by stabilizers. - Lateral and femoral articulations - Femoropatellar articulation
A. Patella, Knee Capsule, and Bursae
1. Patella Sesamoid bone Able to withstand compression placed on quads tendon during kneeling and running. Provide additional leverage for quads in placing the tendon anteriorly. Superior and inferior poles (more pointed) Patellar stabilizers: Vastus medialis insertion, lateral patellar condyle, joint facets/shape.
2. Joint and Capsule External fibrous layer, wherein in thicks parts make up the instrinsic ligaments. Internal synovial membrane. Secretes the synovial fluid for lubrication.
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Located along the periphery of the articular cartilage covering the femoral and tibial condyles, posterior of the patella and edges of the menisci.
3. Bursae
Figure 21. Bursae of the Knee
Provides lubrication At least 12 present around knee joint. Suprapatellar bursa o Located superior to patella. o Synovial lining continuous with capsules synovial membrane. o May be a site of infection that may spread eventually to the joint cavity, which results in bulging, and in turn, flexion.
Clinical Applications of the Knee: 1. Suprapatellar Bulge excess fluid accumulation in the suprapatellar pouch 2. Bakers Cyst swelling of the semimembranosus or synovial bursa behind the knee joint. 3. Synovitis treated via air aspiration to reduce swelling.
B. Static Stabilizers
Figure 22. Static Stabilizers of the Knee
1. Medial lateral collateral ligament/Tibular collateral ligament (MCL/TCL) Stabilizes medial area around the knee. Broad flat bed close to the bone. Against valgus force (directed medially) which can result to genu valgum. Attachments: medial femoral epicondyle superior medial surface of tibia.
2. Lateral collateral ligament/Fibular collateral ligament (LCL/FCL) Fibrous band that is not as thick as the MCL. Stabilizes lateral area of the knee. Against varus force (directed laterally) which can result to genu varus Attachments: lateral femoral epicondyle > lateral surface head of the fibula.
3. Anterior Cruciate Ligament (ACL) Together with the PCL contribute to the anteroposterior stability. Weaker of the two cruciate ligaments. Limit posterior rolling of femoral condyles on tibial plateau during flexion. Arises from interior condylal area of tibia > posterior part.
" Posterior Meniscofemoral ligament of Wristberg: pulls on posterior horn of lateral meniscus.
4. Posterior Cruciate Ligament (PCL) Prevents posterior displacement Arises from posterior intercondylar area of tibia -> anterior part of the lateral surface of femoral medial condyle.
5. Menisci Support gliding of femoral epicondyle. Composed of fibrocartilage; condensed in shape. Needed for shock absorption. Space-filler (analogous to labrum) for the even distribution of synovial fluid. Thicker along external margins and taper to thin edges. Medial meniscus: C-shaped; less mobile. Lateral meniscus: early circular and smaller.
C. Dynamic Stabilizers
Figure 23. Dynamic Stabilizers of the Knee
Extensor mechanism 1. Patellar retinacula o reinforces joint capsule to and keeps patella aligned to patellar surface of the femur; medial and lateral. Helps in prevention of dislocation.
2. Patellar tendon
3. Quadriceps (4 muscles)
o Rectus femoris.
o Vastus lateralis.
o Vastus medialis.
o Vastus intermedius
Biceps femoris o posteriolateral dynamic stabilizer; inserts to head of fibula.
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Iliotibial tract o anterolateral dynamic stabilizer; inserts into Gerdies tubercle
Pes anserinus o Anteromedial dynamic stabilizer. o ACTION: Flexion of the leg and medial rotation. o Composed of the Sartorius, Gracilis and Semimembranosus
Oblique popliteal ligament (Semimembranosus part)
Popliteus o originates as tendon o Posterior dynamic stabilizer; causes snap in the knee. o Weakly flexes knee. o Unlocks femur by rotating by 5 -> on fixed tibia. o Medially rotates tibia of unplanted limb.
Medial and lateral head of gastrocnemius o Plantar flexes ankle when knee is extended. Raises the heel during walking.
BIOMECHANICS Femoral epicondyle flexes, extends and rolls in the knee joint Role of menisci prevent detachment of knee joint; fill up the space for more gliding surface & shock absorber. o Additional stability; contains synovial fluid to ease motions. Lateral femoral condyle directed more anteriorly and prevents the patella from dislocating laterally. Medial femoral condyle Curvy, extension locks and provides stability. Quadriceps can now relax the medial femoral condyle distally. Patella acts as pulley for more efficiency in extension. Quadriceps angle Wider pelvis = greater angle; Can be caused by patellar dislocation. o Chondromalaisial patella: lateral patellar pain, more often complained by females.
Clinical Applications Terminology Genu varum bow-legged, sakang Genu valgum knocked knee, piki. Genu recurvatum knees bent backward; concave anteriorly. Osteoarthritic knee Ehlers-Danlos Syndrome joint hypermobility. Osteoarthritis caused by the eroded menisci. ACL most commonly injured. Torn TCL patella drawing posteriorly; can be checked by Drawers Test. Lockmans Test distal femur and proximal tibia; - Normal: Not movable. - Positive: if with Torn ACL.
MOORES BLUE BOXES SUMMARIES ..
1. LOWER LIMB INJURIES Most common: KNEE, LEG AND FOOT HIP injuries: 3% only. Caused by contact sports and overuse in endurance sports. Most vulnerable: Adolescents The combination of stress on epiphyseal plates (from sports) and rapid growth causes the irritation and injury of the plates and developing bones (osteoarthritis).
2. HIP BONE INJURIES Pelvic fractures: on the hip bone Hip fractures: on the femoral head, neck or trochanters. AVULSION FRACTURES: o May occur during sports that require rapid acceleration or deceleration. (e.g. sprinting, kicking, hurdle jumps, martial arts) o Tears away small piece of the tendon or ligament. o Occur at the apophyses and muscle attachments ( anterior, superior, inferior iliac spines, ischial tuberosities, inschiopubic rami)
3. COXA VARA AND COXA VALGA Angle of inclination between the long axis of the femoral neck and the femoral shaft VARA: DECREASED angle, with mild shortening of the hip and limits its passive abduction. VALGA: INCREASED angle.
4. DISLOCATED SLIPPED EPIPHYSIS OF FEMORAL HEAD Epiphysis slips from the femoral head from the femoral neck by a weakened epiphyseal plate. Caused by acute trauma or repetitive microtraumas, leading to shearing stress on the epiphysis. (abduction and lateral rotation of thigh) Leads to progressive coxa vara. INITIAL SYMPTOM: Hip discomfort that was referred to the knee. CONFIRMATION via radiograph of the superior end of the knee.
5. FEMORAL FRACTURES
GIST: 3 Types of Fracture and Location of Occurrence: o Transcervical Middle of the Neck o Intertrochanteric Trochanter o Spiral Middle of the Shaft
MOST COMMONLY FRACTURED: Neck of Femur. o Narrowest, longest part of the body o Lies at a marked angle to weight-bearing. o Vulnerability increases with age; especially in females; secondary to osteoporosis.
Fractures of the Proximal Femur: TRANSCERVICAL and INTERTROCHANTERIC o Caused by indirect trauma o Inherently unstable and impaction occurs. (Overriding of fragments resulting in the foreshortening of the limb)
INTRACAPSULAR FRACTURE: o Occurs within the hip joint fracture o Complicated by the degeneration of the femoral head due to femoral trauma
Fracture of Greater Trochanter or Femoral Shaft. o Due to direct trauma o More common during active years o SPIRAL FRACTURE leads to foreshortening because of the fragments. o COMMINUTED FRACTURE fracture broken into several muscle pieces due to muscle pull and level of fracture. o Repair may take up to one year.
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6. HIP AND THIGH CONTUSIONS Hip Pointer contusion of the iliac crest at the anterior portion. o Most common injuries to the hip region. o Cause bleeding from the ruptured capillaries and infiltration of blood into the muscles, tendons and other soft tissues. o Avulsion of bony muscle attachments Charley Horse o Cramping of an individual muscle. o Due to ischemia or contusion o Due to the tearing of fibers in the rectus femoris. o Quadriceps tendon is torn. o Associated with localized pain or muscle stiffness.
7. PSOAS ABSCESS Retriperitoneal pus-forming infection in the abdomen or greater pelvis. Occuring in association with TB of the vertebral column or Crohns Disease (ileum enteritis) May present as edema in the proximal part of thigh. Can be mistaken for inguinal or femoral hernia, saphenous varix (dilation in the terminal part of saphenous vein)
8. PROBLEMS OF THE PATELLA A. Chondromalacia patellae (Runners Knee) o Overstressing of the knee: soreness of aching around or deep in the patella. o Results from quadriceps imbalance: results from a blow to the patella, extreme flexion of the knee (During squatting or powerlifting) o May also have transverse patella fracture from the blow to the knee (Proximal fragments are pulled superiorly with the quads tendon) B. PATELLAR ABNORMAL OSSIFICATION o Patella cartilaginous at birth. o Ossification during 3-6 years of age. o Abnormalities usually are bilateral C. PATELLAR TENDON REFLEX o Knee Flex o Tests the integrity of femoral nerve and L2-L4 spinal cord segments.
9. GRACILIS TRANSPLANT Transplant gracilis to a damaged hand muscle since gracilis is a member of the weak adductor muscles. Used also for non-functional external sphincters. Produces good digital extension and flexion.
10. GROIN PULL Strain stretching and tearing of proximal attachments of anteromedial thigh muscles. Involves flexor and adductor thigh muscles: Attachments to the inguinal region.
11. ADDUCTOR LONGUS INJURY Riders Strain. Ossification in the tendons of muscles because of active thigh adduction.
12. PALPATION, CANNULATION AND COMPRESSION OF THE FEMORAL ARTERY. Vulnerable to traumatic injury due to its superficial position in the femoral triangle. Femoral pulse is palpated midway between the ASIS and pubic symphysis. Pulse can be diminished if common on external iliac arteries are occluded. Femoral Artery Compression: pressing directly posteriorly against the superior pubic ramus, psoas major and femoral head; reduction of blood flow in femoral artery.
13. LOCATION OF FEMORAL VEINS Located inferior to the inguinal ligament; feel the pulsations of the femoral artery. Maybe mistaken for the great saphenous vein in thin people.
14. BURSITIS A. Ischial Bursitis Due to repetitive trauma resulting from repeated stress that involve repetitive hip extension. Friction bursitis: Friction between ischial bursae and ischial tuberosities. Increased pain with movement of gluteus maximus. May lead to pressure sores. B. Trochanteric Bursitis Inflamed trochanteric bursae Results from repetitive actions e.g. climbing and carrying heavy objects on an elevated hill. Deep diffuse pain through lateral thigh region, radiating along iliotibial tract. Point tenderness over greater trochanter. Pain elicited through the resisting abduction and lateral rotation of thigh while lying on unaffected side.
15. HAMSTRING INJURIES Pulled or torn hamstrings resulting from hard running or kicking. Violent muscular exertion leads to tearing of proximal tendinous attachments to the ischial tuberosity. Accompanied by contusions and ruptures of blood vessels leading to hematoma in fascia lata. Result from inadequate warming up. Hurdlers Injury. avulsion of the ischial tuberosity.
16. SUPERIOR GLUTEAL NERVE INJURY Gluteal gait or disabling gluteus limp. A. Compensated by the weakened thigh abduction with the gluteus medius and minimus. B. Trendelenburg Test (+) patient asked to stand on one leg; then the pelvis uon the unsupported side descends due to weak or non-functional gluteus medius or minimus. Can also be caused by fracture at the greater trochanter or dislocation of hip joint. C. Waddling or characteristic gluteal gait or Steppage Gait swing-out gait.
17. SCIATIC NERVE INJURY Pyriformis Syndrome compression of sciatic nerve by the pyriformis muscle. o Involved in the sports requiring excessive use of gluteal muscles o Trauma to the buttock associated with hypertrophy and spasm of pyriformis. Complete Section of Sciatic Nerve. Uncommon; impaired extension of hip and flexion of leg; loss in ankle and foot movement. Incomplete Section of the Sciatic Nerve o From stab wounds; involves inferior and/or posterior cutaneous nerves. Buttock Sides o Sides of Safety: Lateral Side o Sides of Danger: Medial Side
18. POPLITEAL NOTES Popliteal Abscess o Spreads due to the toughness of popliteal fascia. Popliteal Pulse o Best felt in the anterior part of the fossa where the popliteal artery is related to the tibia. Weakening or loss leads to femoral artery obstruction.
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Popliteal Aneurysm o Distinguished from other masses by thrills and bruits.
19. COMMON FIBULAR NERVE AND FOOTDROP Severance of common fibular nerve. o Severed during the fracture of the fibular neck or when knee joint is dislocated o Results in flaccid paralysis in anterior and lateral compartments. o Loss of dorsiflexion FOOTDROP. ! Exacerbated by unopposed inversion of foot. ! Limb becomes too long. 3 Means of Compensation. 1. Waddling Gait leaning to the side opposite of the long limb; hiking limp. 2. Swing-Out Gait long limb is swung out laterally to allow the toes to clear the ground. 3. Steppage Gait High-stepping; extra flexion of the hip and knee to keep the toes from hitting the ground. o More commonly employed in flaccid paralysis.
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