18 OS203 Hip, Thigh, And Knee

7/27/2019 18 OS203 Hip, Thigh, And Knee

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Hip, Thigh, and KneeLeslie Reyes, MD

OS 203: Skin, Muscles, and BonesEXAM# 3

11 September 2014

I. INTRODUCTION

A. Function1. Weight bearing2. Locomotion

- Compare vs. upper extremities: hands have tofunction 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 finlikeappendages pointing laterally and caudally

6 Anteriorbending of limbs; elbow, knees pointlaterallywith thumbs facing up; palms, soles,face trunk

7 90 (degree) torsion of appendages about theirlong axes (upper and lower rotate in oppositedirection); elbows point caudally and cranially

8 Barber pole cutaneous innervationarrangement of lower limbs

OUTLINEI. Introduction

a. Function

b. Developmentc. Parts and Regions

II. Superficial Structuresa. Bony Landmarksb. Superficial Veinsc. Lymphatic Vesselsd. Cutaneous Nerves

III. Hip Joint and Femura. Configurationb. Angulationc. Ligaments

IV. Hip, Thigh and Glutealsa. Anterior Hip and Thighb. Medial Hip and Thighc. Lateral Hip and Thighd. Glutealse. Posterior Thighf. Motor branches of Nerves

V. Kneea. Patella, Knee Capsule, and Bursaeb. Static Stabilizersc. 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 willadduct, go down and internally rotate and become plantigrade

Dermatomes: provide sensation in the skin; A localized area ofskin that has its sensation via a single nerve from a singlenerve root of the spinal cord

Dermatomal innervation (muscles, ligaments andinnervations) is spiral because it follows the anatomicalorientation 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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OS 203: Hip, Thigh, and Knee

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 GenuRecurvatum

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 Achillesjoins 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 superioriliac spines

can be palpated even in obese people [2018 trans: maybe 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 duringknee flexion

7. Lesser trochanter

Not palpable - covered with muscle

Femoral head, posterior inferior iliac spine, andanterior 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 ankleo leg calf (posterior side)o popliteal vein

3. Inguinal tributaries Superficial circumflex iliac

Superficial epigastric Superficial extensor pudendal

C. Lympathic Vessels

Figure 7. Lymphatic vessels of the lower limb

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 inflammationo impairment of lymphatic drainage

Swelling of parts

o Chronic edema leading to elephantiasis

Amniotic Band Syndrome

congenital

lymphatic fluid build up due to constrictiono 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 NERVES1. 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 sideo motor - scrotum

! innervates cremastic muscles

! cremasteric reflex: stimulation of inguinal arearesults 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 viahorseback riding)

Figure 10. Posterior cutaneous nerves of the lower limb

POSTERIOR CUTANEOUS NERVES

1. Cluneal Nerves innervates gluteal area

Nerve Origin

SuperiorCluneal Nerve

Dorsal rami of the 1s3 lumbar

vertebra

Middle ClunealNerve

Dorsal rami of the 1s3 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 nerveo Origin: branch of common perineal nerveo Innervation: lateral side of leg (sensory)

Medial sural cutaneous nerve

o Origin: branch of tibial nerveo Innervation: posterolateral side of leg (sensory)

Other parts mentioned during the lecture:1. Lateral femoral cutaneous nerve

2. Genitofemoral nerve3. Anterior femoral cutaenous nerve4. Saphenous nerve5. Cutaenous branch of obturator nerve6. Cluneal nerves7. Posterior femoral cutaenous nerve

8. Lateral sural cutaenous nerve9. Medial sural cutaenous nerve

10. Sural nerve11. Medial calcaneal nerve12. Medial plantar nerve13. Lateral plantar nerve14. Lateral sural nerve15. Superficial peroneal nerve16. 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 andacetabular notch.

moon-shaped

Contributed to by the ilium, pubis and ischium. (make up

the socketo 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(roundligament for the femoral head) loose from acetabularfossa.

Ball-and-socket joint (Enarthrosis).o Ball: head of the femuro Socket: fusion of the ilium, pubis and ischium.

! designed for stability


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! Most movable of all joints next to theglenohumeral joint.

! Action: Circumduction, flexion, extension,adduction, abduction, internal and externalrotation.

B. Configuration of the Femur

Figure 12. Femur Configuration

1. Femoral Head about 2/3 size of a golf ball.2. Neck3. 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 trochanter5. Lesser trochanter6. Intertrochantic line in front; anterior capsule.7. Intertrochantic crest More prominent than #6.8. Linea aspira Line of Hope., literally.

9. Adductor tubercle10. Medial femoral epicondyle with prominence adductor

tubercle inside.11. Lateral femoral epicondyle.

*Isthmus at the proximal third of the femur; consideredduring 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 epicondyle2. Coxa Vara (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 willspontaneously 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 *PsoasMajor +Iliacus

Lessertrochanter Hip flexor;externalrotator

Sartorius L2-3:FemoralNerve.

ASIS Tibial Shaft(superiorportion ofmedialsurface)

THIGH flexor,abductor,lateralrotator athip joint.LEG -flexor at

knee joint.PELVIS balancing.

Tensorfascia

latae

L4-5:Superior

GlutealNerve

Arisesfrom ASIS

and theanteriorportion ofthe iliaccrest

IliotibialTract

(inserts ofthe tibiaslateralcondyle)

THIGH medially

rotates, hipflexion andabduction.KNEE stabilizer

Rectusfemoris

L2-4:FemoralNerve

StraightHead:ASISReflectedHead:Ilium

Quadricepstendon

Hip flexor;kneeextensor.

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 lateralis4. Vastus intermedius.

Articularis Genu

Retracts the bursa as the knees extend

Pulls suprapatellar bursa

Prevents impingement of synovial membrane betweenpatella 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 thesheath)

Adductor Canal

Hunters Canal

Continuation of the femoral triangle (Sartorius inner wall,adductor longus and vastus medialis; gap in the adductormagnus); 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

Superficial Branches1. Superficial iliac circumflex artery2. Superficial epigastric artery3. External pudental artery (superficial and deep)

Figure 17. Deep Branches of the Femoral Artery

Deep Branches1. Medial femoral circumflex artery:

Main blood supply of femoral head.

Aseptic/avascular necrosis: Occurs when femoralhead 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 abranch of theObturator Nerve)

Thigh adductor and

flexor; assist medialrotation of thigh

2. Adductor

longus

L2-4 (Obturator

Nerve)

Thigh adductor; assist

medial rotation of thigh3. Adductorbrevis

L2-4 (ObturatorNerve)

Thigh adductor andflexor; assist medial

rotation of thigh

4. Adductormagnus

L2-4 (ObturatorNerve); hamstringby sciatic nerve

Powerful thigh adductorSuperior portion: weakflexor, medial rotatorLower portion:Extensor, lateral rotator


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5. Gracilis(mostSUPERFICIAL& WEAKEST

medial muscle


Thigh adductor andflexor; medial rotatorwhen knee is flexed

6. Obturatorforamen


Laterally rotates andabducts 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 iliotibialtract; 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 Me1. Biceps femoris (short head and long head)

2. SemiTendinosus3. SemiMembranosus

* Hamstrings long head of 1, #2, and #3

F. Motor Branches of Nerves1. 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, tensorfasciae latae) (L4-5, S1)

Sciatic Nerve (Tibial and Peroneal divisions)

Clinical Applications:Hip dislocation with posterior acetabular slipis much moreprone in men than women because men sit down with theirlegs 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 onthigh.

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 glidingand rolling and minimal rotation.

Articulation: provides mechanical weakness but isreinforced 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 thetendon 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 thepatella and edges of the menisci.

3. Bursae

Figure 21. Bursaeof the Knee

Provides lubrication

At least 12 present around knee joint.

Suprapatellar bursao Located superior to patella.o Synovial lining continuous with capsules synovial

membrane.

o May be a site of infection that may spreadeventually 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 pouch2. 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 superiormedial 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 togenu 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 plateauduring flexion.

Arises from interior condylal area of tibia > posteriorpart.

"Posterior Meniscofemoral ligament of Wristberg: pulls onposterior horn of lateral meniscus.

4. Posterior Cruciate Ligament (PCL)

Prevents posterior displacement

Arises from posterior intercondylar area of tibia -> anteriorpart 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 evendistribution 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 mechanism1. Patellar retinacula

o reinforces joint capsule to and keeps patella alignedto patellar surface of the femur; medial and lateral.Helps in prevention of dislocation.

2. Patellar tendon3. Quadriceps (4 muscles)

o Rectus femoris.

oVastus lateralis.

o Vastus medialis.o Vastus intermedius

Biceps femoriso posteriolateral dynamic stabilizer; inserts to head of

fibula.


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Iliotibial tracto anterolateral dynamic stabilizer; inserts into Gerdies

tubercle

Pes anserinuso 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)

Popliteuso originates as tendono 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 theheel during walking.

BIOMECHANICS

Femoral epicondyle flexes, extends and rolls in theknee joint

Role of menisci prevent detachment of knee joint; fillup the space for more gliding surface & shock absorber.o Additional stability; contains synovial fluid to ease

motions.

Lateral femoral condyle directed more anteriorly andprevents the patella from dislocating laterally.

Medial femoral condyle Curvy, extension locks and

provides stability. Quadriceps can now relax the medialfemoral 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 byDrawers 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 (fromsports) and rapid growth causes the irritation and injury ofthe plates and developing bones (osteoarthritis).

2. HIP BONE INJURIES

Pelvic fractures: on the hip bone

Hip fractures: on the femoral head, neck ortrochanters.

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, ischialtuberosities, inschiopubic rami)

3. COXA VARA AND COXA VALGA

Angle of inclination between the long axis of the femoralneck 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 FEMORALHEAD

Epiphysis slips from the femoral head from the femoralneck by a weakened epiphyseal plate.

Caused by acute trauma or repetitive microtraumas,leading to shearing stress on the epiphysis. (abductionand 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 Necko Intertrochanteric Trochantero Spiral Middle of the Shaft

MOST COMMONLY FRACTURED: Neck of Femur.o Narrowest, longest part of the bodyo Lies at a marked angle to weight-bearing.o Vulnerability increases with age; especially in females;

secondary to osteoporosis.

Fractures of the Proximal Femur: TRANSCERVICALandINTERTROCHANTERIC

o Caused by indirect traumao Inherently unstable and impaction occurs. (Overriding of

fragments resulting in the foreshortening of the limb)

INTRACAPSULAR FRACTURE:o Occurs within the hip joint fractureo Complicated by the degeneration of the femoral head

due to femoral trauma

Fracture of Greater Trochanter or Femoral Shaft.o Due to direct traumao More common during active yearso 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 anteriorportion.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 Horseo Cramping of an individual muscle.o Due to ischemia or contusiono 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 columnor 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 ofsaphenous vein)

8. PROBLEMS OF THE PATELLAA.Chondromalacia patellae (Runners Knee)

o Overstressing of the knee: soreness of achingaround or deep in the patella.

o Results from quadriceps imbalance: results from ablow to the patella, extreme flexion of the knee(During squatting or powerlifting)

o May also have transverse patella fracture from theblow to the knee (Proximal fragments are pulled

superiorly with the quads tendon)

B.PATELLAR ABNORMAL OSSIFICATIONo Patella cartilaginous at birth.o Ossification during 3-6 years of age.o Abnormalities usually are bilateral

C.PATELLAR TENDON REFLEXo Knee Flexo 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 activethigh adduction.

12. PALPATION, CANNULATION AND COMPRESSION OFTHE 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, psoasmajor and femoral head; reduction of blood flow infemoral 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. BURSITISA. 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 gluteusmaximus.

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 andlateral rotation of thigh while lying on unaffectedside.

15. HAMSTRING INJURIES

Pulled or torn hamstrings resulting from hard running or

kicking.

Violent muscular exertion leads to tearing of proximaltendinous attachments to the ischial tuberosity.

Accompanied by contusions and ruptures of bloodvessels 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 abductionwith the gluteus medius and minimus.

B. Trendelenburg Test (+) patient asked to standon one leg; then the pelvis uon the unsupportedside descends due to weak or non-functionalgluteus medius or minimus. Can also be causedby fracture at the greater trochanter or dislocationof hip joint.

C. Waddling or characteristic gluteal gait orSteppage 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 muscleso 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 inankle and foot movement.

Incomplete Section of the Sciatic Nerve

o From stab wounds; involves inferior and/or posteriorcutaneous 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 thepopliteal artery is related to the tibia. Weakening orloss leads to femoral artery obstruction.


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Popliteal Aneurysm

o Distinguished from other masses by thrills andbruits.

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 dislocatedo 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 toallow the toes to clear the ground.

3. Steppage Gait High-stepping; extra flexion of thehip and knee to keep the toes from hitting theground.o More commonly employed in flaccid paralysis.

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Awow.-jggo

Documents

18 OS203 Hip, Thigh, And Knee