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Review of Lower Extremity

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Review of Lower Extremity REVIEW OF LOWER EXTREMITY I. OVERVIEW - UPPER AND LOWER EXTREMITY ROTATION, DERMATOME MAP, REFLEXES II. REGIONS - HIP, KNEE, ANKLE, FOOT DEVELOPMENT OF EXTREMITIES: ROTATION CLAPPING BABY'S HANDS upper AND FEET extremity THUMB rotates IS LATERAL laterally lower extremity BIG TOE IS MEDIAL rotates medially Arms and legs initially have same orientation, perpendicular to spinal column (think of a baby sitting - palms touch, soles of feet touch). Ankle and Foot MOVEMENTS OF LOWER LIMB Dorsiflexion Hip joint - ball and socket Flexion - Anterior Extension - Posterior FLEX Adduction - Medial HIP Abduction - Lateral Rotation - movement EXTEND about long axis of Plantar flexion femur Inversion - Eversion - Knee joint - condylar FLEX sole faces sole faces joint KNEE medially laterally Flexion - Posterior Extension - Anterior Rotation (small) - movement about long axis of leg (tibia) EXTEND DERMATOME MAP IN ADULT - REFLECT ROTATION Hand - higher spinal DERMATOMES levels lateral OF LOWER EXTREMIY C6 thumb lateral C8 little finger medial L1- inguinal Foot - higher spinal ligament levels medial L3, L4 - anterior knee (patella) L4 big toe medial L4 - medial side of foot, big toe S1 little toe lateral S1 - lateral side of foot Patient: Complete lack of sensation S1, S2 - posterior at big toe. Which spinal nerve side of leg and would be compressed? L4 thigh STRETCH (TENDON TAP) REFLEXES OF LOWER EXTREMITY monosynaptic connection KNEE JERK - QUADRICEPS MUSCLE muscle alpha L3, L4 spindle motor neuron ANKLE JERK - GASTROCNEMIUS MUSCLE TENDON TAP S1 (STRETCH OR DEEP TENDON) CLINICAL - Patient has numbness of skin overlying little REFLEXES - toe. Ankle jerk reflexes reduced. What spinal level TEST SPINAL affected? S1 LEVEL OVERVIEW OF ARTERIAL SUPPLY: COURSE REFLECTS ROTATION HIP (ANTERIOR VIEW) LEG AND FOOT External Iliac POST. VIEW ANT. VIEW POPLITEAL ARTERY Inguinal ligament ANTERIOR TIBIAL ARTERY FEMORAL POSTERIOR courses first TIBIAL anteriorly, ARTERY then TAKE posteriorly PULSE supplies Dorsalis foot Pedis Adductor hiatus med. side Artery POPLITEAL KNEE HIP: FEMORAL HERNIA Inguinal SAPHENOUS ligament OPENING FASCIA GREAT LATA SAPHENOUS VEIN Saphenous opening - allows for passage of FASCIA LATA- deep Great Saphenous vein; GREAT SAPHENOUS fascia of thigh is thick; located inferior to VEIN courses on medial superiorly attached to the inguinal ligament, side of leg (SMALL pelvis, Scarpa's fascia and anterior to Femoral SAPHENOUS VEIN is on the inguinal ligament. artery and vein post side of leg) FEMORAL TRIANGLE FEMORAL SHEATH LATERAL - SARTORIUS SUPERIOR - TRANS- INGUINAL VERSALIS LIGAMENT FASCIA FEMORAL SHEATH MEDIAL - ADDUCTOR LONGUS - SHEATH IS CONTINUATION OF CONTAINS - LATERAL TO MEDIAL TRANSVERSALIS FASCIA OF FEMORAL NERVE, ARTERY ABDOMEN VEIN, LYMPHATICS - - SURROUNDS ARTERY, VEIN, LYMPHATICS NOT NERVE REMEMBER NAVL FEMORAL CANAL FEMORAL HERNIA transversalis fascia FEMORAL CANAL - contains LYMPHATICS IN MEDIAL PART OF SHEATH Femoral Hernia - Femoral ring is point of potential weakness of abdomino/pelvic wall; loop Femoral Canal - is contained in of bowel can protrude into medial part of femoral sheath; Femoral Canal and become contains lymph vessels from lower strangulate; more common in limb that drain to external iliac nodes ; females (inguinal hernias more opening is called Femoral Ring. common in males). CLINICAL QUESTION: Differentiating Femoral and Inguinal Hernias - reference is INGUINAL LIGAMENT Mother of 4 children lifts heavy load and feels bulge Inguinal Femoral on anterior groin or thigh. hernia hernia Ant. Sup. CAUSES OF FEMORAL Iliac HERNIA: Inguinal Spine 1) carrying or pushing heavy ligament loads 2) more frequent in older Pubic females tubercle 3) more common in women who have had one or more pregnancies 4) overweight (obese) 5) cough 6) constipation thumb Inguinal Hernia - index Femoral Hernia on pubic neck of hernia is - neck of hernia finger tubercle on ABOVE inguinal is BELOW ASIS ligament. inguinal to locate - VEE ligament TECHNIQUE ANTERIOR THIGH: 'HIP POINTER' Clinical Note: Contusion of SARTORIUS - muscles at Anterior Origin - Ant. Sup. Iliac Spine Superior Iliac spine (origin Insert - Tibia of Sartorius and Tensor ANT. SUP. Fascia Lata ) is called a Hip ILIAC Pointer - Symptom - SPINE Bruise on Hip QUADRICEPS FEMORIS - Insert - to Patella to Tibia SOCCER INNERVATION: PLAYER FEMORAL NERVE FALL MUSCLES OF MEDIAL THIGH: PULLED GROIN Clinical: PULLED GROIN - Tear of Adductor Muscle group at PUBIS; PLAYING SPORTS, INTENSE PAIN IN GROIN, DIFFICULTY WALKING ADDUCTORS: ADDUCTOR LONGUS MAGNUS BREVIS GRACILIS ORIGIN: PUBIS, ORIGIN: ISCHIAL HIATUS - PUBIS TUBER- passage OSITY FEM. A. AND V. INNERVATION: OBTURATOR NERVE POSTERIOR THIGH - PULLED HAMSTRINGS PULLED HAMSTRINGS - ORIGIN ALL - Ischial Tuberosity TEAR MUSCLE OR AVULSE FROM ISCHIAL TUBEROSITY Semi- tendinosus long head from Ischial Tub. short head Semi- from membranosus Femur Biceps femoris both insert to Tibia both heads insert to Fibula Clinical - ex. Tear when running; sudden excruciating pain in Action - All Extend thigh and flex leg back of thigh except Biceps Short head only flex leg GLUTEAL MUSCLES ORIGIN - ILIUM Medius + Minimus Gluteus Gluteus Gluteus Maximus Medius Minimus I - Femur, I - Femur I - Femur IT tract (Greater (Greater Maximus - Trochanter) Trochanter) also Act - sacrum, coccyx Extend, Act - Act - sac.tub.lig Laterally Abduct, Abduct, Medially Medially Maximus rotate rotate rotate Inn - Inferior Inn both - Superior Gluteal N. Gluteal N. GLUTEAL GAIT Clinical - caused by injury to Superior Gluteal nerve or poliomyelitis (also congenital dislocation of hip joint). Paralyze Gluteus Medius and Minimus. In walking, pelvis tilts down on non-paralyzed side when lift foot of opposite, non-paralyzed leg. NORMAL SUPPORT MUSCLES WEIGHT PELVIS PULL WHEN TILTS LIFT DOWN OPPOSITE ON NON- LEG PARA- PARALYZE LYZED THIS SIDE SIDE Positive Trendelenburg sign - WHEN LIFT OPPOSITE LEG, PELVIS TILTS DOWN ON (NON-PARALYZED) OPPOSITE SIDE. FEMORAL ARTERY Profunda Femoris - largest branch of femoral; branches: a. Medial Femoral Circumflex - provides most of blood supply to head of femur. MEDIAL LATERAL FEMORAL b. Lateral Femoral Circumflex - FEMORAL CIRCUMFLEX supplies lateral side of thigh, CIRCUMFLEX neck of femur; has Descending PROFUNDA branch that is part of Genicular FEMORIS anastomosis at knee joint. FEMORAL Descending ARTERY branch of Lateral Descending Femoral Genicular Circumflex artery from Femoral CLINICAL: CRUCIATE ANASTOMOSIS POST. SIDE CROSS-SHAPED Inf. Glut. Inferior Med. Lat. INT. Gluteal Fem. Fem. ILIAC -from Circ. Circ. Int. Iliac CAN Lat. LIGATE Med. Femoral Femoral Circ. Circ. First PROFUNDA Perforating FEMORIS A. First Perforating Clinical - Stab wound or Artery - from bleeding in Femoral Artery Profunda Can: Ligate External Iliac or Femoral between 1) Internal Iliac 2) Profunda femoris FRACTURE OF NECK OF FEMUR Note: Fracture of neck of femur - common in the elderly; leg is rotated laterally due to action of gluteus maximus and short rotators of hip. post. view of hip Fracture of neck of Leg is laterally femur rotate rotated leaves femur laterally Greater Trochanter attached to femur SHORT LATERAL ROTATORS OF HIP FRACTURE CAN PRODUCE AVASCULAR NECROSIS OF HEAD OF FEMUR Obturator Artery HEAD OF FEMUR branches through Ligament of from Obturator head of femur artery FRACTURE NECK Note: Fracture of neck of femur - head and neck of femur receive blood from branches of Obturator artery (through ligament of head) and branches of Medial and lateral femoral circumflex; after fracture, supply from circumflex arteries is disrupted; if obturator supply is inadequate, avascular necrosis may occur requiring artificial replacement of head and neck of MEDIAL FEMORAL femur. CIRCUMFLEX ARTERY DISLOCATE HIP JOINT HIP JOINT - LIGAMENTS STRONG Note: Dislocation - traumatic dislocation is rare due to strength of intrinsic ILIO- ligaments; FEMORAL congenitally, upper LIG. lip of acetabulum may fail to form and head of femur may dislocate superiorly; leg is rotated medially (action gluteus medius and minimus); also appears to be shorter Leg is rotated PUBOFEMORAL LIGAMENT medially and appears to be shorter KNEE JOINT - Anterior femur abuts against cruciate Posterior ligament cruciate tibia; fibula not part of ligament joint Lateral Femur Medial (fibular) (tibial) collateral collateral ligament ligament Patellar ligament strengthens ACL - joint lateral to anteriorly medial; Fibula Tibia points forward ANTERIOR AND POSTERIOR CRUCIATE LIGAMENTS ALLOW FOR FREE FLEXION AND EXTENSION OF KNEE ACL x x PCL ACL - PCL - PREVENTS PREVENTS ANTERIOR POSTERIOR MOVEMENT MOVEMENT OF TIBIA OF TIBIA TESTS FOR TEARS IN CRUCIATE LIGAMENTS ANTERIOR Tear POSTERIOR Anterior DRAWER DRAWER Cruciate SIGN - pull SIGN tibia anteriorly Tear Posterior Cruciate Tear Anterior Cruciate Tear Posterior Cruciate Ligament - can draw tibia Ligament - can push tibia anteriorly. posteriorly TERRIBLE TRIAD OF KNEE JOINT Clinical Note: Terrible Triad of the Knee joint: Knee joint is stable in extension but ligaments are slackened by joint flexion; blow to lateral side of the knee when the leg is flexed (as can occur in football tackles) or rotate and force lateral movement of body; can tear Tibial (Medial) collateral ligament, Anterior cruciate ligament and Medial meniscus (because it is firmly fixed to the medial collateral ligament). BURSAE OF KNEE CAN BECOME INFLAMMED Prepatellar bursa in subcutaneous tissue between skin and patella; Inflammation of inflammation - Prepatellar bursa HOUSEMAID'S KNEE
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