Lower Limb MSK Zoulikha Zair 17th May 2013

What makes up the hip bone? Iliac Crest * Posterior Superior Iliac Spine * Anterior Superior Iliac Spine * Ilium Pubic Tubercle * Greater sciatic notch Pubic Ischial spine * Ischium Acetabulum Point of union of 3 bones Ischial Tuberosity * * = Palpable R G Tunstall 2013

Clinical Case 1 What does the x-ray show? So what???

What is the blood supply to the hip bone? Does the femoral artery come off the external or internal or common iliac artery???? Where is the ligamentum teres?? Why is this significant? In children who's epiphyseal line is still made of cartilage it helps to supply the head and neck of femur on its own WHERE DOES THE FEMORAL ARTERY SIT (LANDMARKS)?

Femoral triangle sits in the proximal anterior thigh ASIS Inguinal ligament Pubic Tubercle Sartorius Nerve Artery Vein Lymph Adductor longus Key notes: Access point for vascular structures Artery enters at midinguinal point ± 1.5cm Palpate for pulsation – vein sits ~1cm medial R G Tunstall 2013

Clinical Case 2 What does the x-ray show? What is the significance of this?

Sacral Plexus & Lower Limb Nerve Supply * Supplies lateral rotator muscles L4 L5 S1 S2 S3 S4 S5 C0 Pink = anterior divisions Yellow = posterior divisions *Lumbosacral trunk (L4, 5) *Superior gluteal nerve (L4, 5, S1) *Inferior gluteal nerve (L5, S1, S2) Nerves to levator ani Common fibular nerve Tibial nerve Pudendal nerve R G Tunstall 2013

Quiz What gluteal muscles are responsible for stair climbing, arising from chair and pelvic stabilisation during walking? Which nerves innervate these muscles? What clinical signs would you observe in patients with such nerve damage?

Gluteus Medius & Minimus Gluteal Region Gluteal muscles bring about powerful hip/trunk extension (stair climbing, arising from chair) and pelvic stabilisation during walking Gluteus Maximus Inferior gluteal nerve (L5-S1) Gluteus Medius & Minimus Superior gluteal nerve (L4-L5) Ilium, Sacrum & Ligaments Superior gluteal nerve (L4-L5) Inferior gluteal nerve (L5-S1) Femur & Iliotibial tract R G Tunstall 2013

Damage/paralysis can lead Trendelenburg sign & lurch when walking Gluteal Region Gluteus medius & minimus prevents pelvis tilting toward unsupported side Gluteus maximus prevents trunk from tipping forwards during walking Damage/paralysis can lead Trendelenburg sign & lurch when walking Damage/paralysis can lead to patient lurching backward when the weaker limb is on the floor during walking R G Tunstall 2013

Moving further down……

Case Soccer Star 16 y.o. female soccer player presents to clinic 1 week after injury. Reports she was coming down from header when she twisted on landing. Heard a pop in her knee and had pain. Taken from field and couldn’t return to game. Noticed that night knee was swollen. Now, 1 week later, almost normal gait. Knee feels much better. Slides taken from Rodney S. Gonzalez, MD

ACL Injury Case Soccer Star Physical exam Joint effusion present No joint line tenderness No LCL/MCL laxity Negative McMurray Positive Lachman ACL Injury Slides taken from Rodney S. Gonzalez, MD

Anterior Cruciate Ligament Injury Half occur with medial meniscal tear Can occur with MCL tear Rare with LCL or PCL tear Slides taken from Rodney S. Gonzalez, MD

X X Knee: Cruciate (Crossing) Ligaments Cruciate ligaments resist anterior-posterior translocation & rotation of the knee Posterior cruciate lig. (PCL) PCL prevents posterior tibial movement on femur X Anterior cruciate lig. (ACL) X ACL prevents anterior tibial movement on femur ACL injured by kick to back of flexed knee PCL injured by kick to front of load-bearing knee R G Tunstall 2013

Case Basketball Player Basketball player presents day after game for knee pain Remembers painful twist with planted foot during the game, but kept playing Swelled up overnight Now feels “locked” Slides taken from Rodney S. Gonzalez, MD

Case Basketball Player Physical exam Effusion Joint line tenderness Limited knee range of motion McMurray tests positive with painful click Meniscal Injury Slides taken from Rodney S. Gonzalez, MD

Meniscal Tear Anatomy Avascular inner 2/3, partly vascular outer 1/3 Minimal innervation Held in place by coronary ligaments, painful when torn (meniscotibial ligaments) Lateral meniscus less firmly attached, less prone to injury Slides taken from Rodney S. Gonzalez, MD

Knee: Collateral Ligaments Medial & lateral collateral ligaments resist valgus and varus forces at the knee MCL injured by lateral blow LCL injured by medial blow Medial (tibial) collateral ligament Attached to medial meniscus-both can be damaged together Lateral (fibula) collateral ligament Prevents tibial abduction (valgus) Prevents tibial adduction (varus) R G Tunstall 2013

What is the popliteal fossa? Name it’s borders? Popliteal Fossa Borders Semimembranosus Semitendinosus Biceps femoris Gastrocnemius medial head Gastrocnemius lateral head 2 1 Popliteal Artery (deep) Popliteal Vein Tibial Nerve (superficial) 3 4 Common fibular nerve Passes close to fibula head R G Tunstall 2013

Further down still…..

What are the contents of the tarsal tunnel? T - Tibialis posterior D – Flexor Digitorum A – Posterior Tibial Artery V - Vein N – Tibial Nerve H – Flexor Hallucis longus Posterior tibial artery pulsation examined between medial malleolus & calcaneus