Download - Lower Limb MSK
Lower Limb MSK
Zoulikha Zair17th May 2013
Ischium
Pubic
Ilium
Iliac Crest *
AcetabulumPoint of union of 3 bones
Pubic Tubercle *
Ischial Tuberosity *
Anterior Superior Iliac Spine *
Posterior Superior Iliac Spine *
Ischial spine *
Greater sciatic notch
* = PalpableR G Tunstall 2013
What makes up the hip bone?
2
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)?
Sartorius
Addu
ctor
lo
ngus
Inguinal ligament
Key notes:• Access point for vascular structures• Artery enters at midinguinal point ± 1.5cm• Palpate for pulsation – vein sits ~1cm medial
NerveArteryVeinLymph
ASIS
Pubic Tubercle
Femoral triangle sits in the proximal anterior thigh
R G Tunstall 2013
5
Clinical Case 2
What does the x-ray show?
What is the significance of this?
Pink = anterior divisionsYellow = posterior divisions
L4
L5
S1
S2
S3
S4
S5
C0
*Superior gluteal nerve(L4, 5, S1)
Common fibular nerve
Tibial nerve Pudendal nerve
Nerves to levator ani
*Lumbosacral trunk(L4, 5)
Sacral Plexus & Lower Limb Nerve Supply
R G Tunstall 2013
*Inferior gluteal nerve(L5, S1, S2)
7
* Supplies lateral rotator muscles
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 MaximusInferior gluteal nerve (L5-S1)
Gluteus Medius & MinimusSuperior gluteal nerve (L4-L5)
Gluteal Region
Ilium, Sacrum & Ligaments
Femur &Iliotibial tract
Gluteal muscles bring about powerful hip/trunk extension (stair climbing, arising from chair) and pelvic stabilisation during walking
Inferior gluteal nerve (L5-S1)
Superior gluteal nerve (L4-L5)
R G Tunstall 2013
9
Gluteus medius & minimus prevents pelvis tilting toward
unsupported side
Damage/paralysis can lead Trendelenburg sign & lurch
when walking
Gluteal Region
Gluteus maximus prevents trunk from tipping forwards during walking
Damage/paralysis can lead to patient lurching
backward when the weaker limb is on the floor during
walking
R G Tunstall 2013
10
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
Case Soccer StarPhysical 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
ACL prevents anterior tibial movement on femur
Anterior cruciate lig.
(ACL)
Posterior cruciate lig.
(PCL)
X
X
Knee: Cruciate (Crossing) Ligaments
ACL injured by kick to back of flexed knee PCL injured by kick to front of load-bearing knee
R G Tunstall 2013
Cruciate ligaments resist anterior-posterior translocation & rotation of the knee
PCL prevents posterior tibial movement on femur
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 InjurySlides taken from Rodney S. Gonzalez, MD
Meniscal TearAnatomy• 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
Lateral (fibula) collateral ligament
Medial (tibial) collateral ligament
Attached to medial meniscus-both can be
damaged together
Prevents tibial adduction
(varus)
Prevents tibial abduction
(valgus)
Knee: Collateral Ligaments
MCL injured by lateral blow
LCL injured by medial blow
R G Tunstall 2013
Medial & lateral collateral ligaments resist valgus and varus forces at the knee
Popliteal Artery (deep)Popliteal VeinTibial Nerve (superficial)
Common fibular nervePasses close to fibula head
R G Tunstall 2013
Popliteal Fossa Borders1. Semimembranosus
Semitendinosus2. Biceps femoris3. Gastrocnemius medial head 4. Gastrocnemius lateral head
1 2
43
What is the popliteal fossa? Name it’s borders?
20
Further down still…..
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
What are the contents of the tarsal tunnel?