Physical Exam of the Lower Extremity

Landmarks - Surface Anatomy Palpable bony parts anteriorly   Anterior superior iliac spine

(ASIS)   Symphysis pubis   Pubic tubercles (PT)   Inguinal ligament Palpable bony parts at the buttocks   Posterior superior iliac spine

(PSIS)   Ischial tuberosity (IT)   Greater trochanter (GT

Surface Markings of the Lower Limb

  Patella   Condyles of the femur and

tibia   Head of the fibula   Joint line of the knee   Tibia   Fibula

Palpable Soft Tissues

  Rectus femoris   Vasti muscles, lateral

and medial.   Sartorius   Adductor longus

muscle   Pulsations of the

femoral artery   Posterior compartment

muscles   Terminal branches of

the sciatic nerve

Identify the boundaries of the femoral triangle.

Base - inguinal ligament. Lateral - medial border of sartorius. Medial - medial border of adductor

longus. Apex - where sartorius and adductor

longus overlap.

Identify the major muscles that form the floor of the femoral

triangle. Adductor longus.

Pectineus. Iliacus and psoas major.

From medial to lateral, the floor of the femoral triangle is formed by the adductor longus, a tiny

part of adductor brevis, pectineus, illiacus and psoas

major. This floor is curved, the femoral neurovascular bundle lies in the deepest part of this

curve running over psoas major.

VESSELS OF THE LOWER EXTREMITY

  Femoral artery   Popliteal artery   Dorsalis pedis   Posterior tibial

artery

Blood extraction from femoral artery or vein

Cardiac catheterization

  Where are the clinically relevant veins in the lower limb?

  What procedures require this knowledge?

Femoral vein cannulation

remember that vein is not only medial to artery but also may be posteriorly situated !

locate femoral artery ...

insert needle just medial to femoral pulse

femoral vein is medial ... femoral nerve lateral to artery

Saphenous vein cutdown   Long saphenous vein -

in front of the medial malleolus; no matter how collapsed, how obese, or how young and tiny the patient, the vein can be relied upon to be available at this site when urgently required for transfusion purposes.

Saphenous vein cutdown

  transverse incision made 1-2 cms in front of medial malleolus

  note the proximity of the saphenous nerve to the vein !

Varicose Veins

The following reasons are offered:

a. The great length of the veins in the lower limb.

b. The large column of blood their valves have to support.

c. The vertical position to which they are often placed.

d. The iliac veins, to which the blood they carry are eventually drained, tend to be compressed by related organs.

e. Their superficial location allows for the condition, to which is added the absence of muscular contraction of surrounding muscles which help in the venous circulation.

Venous Stasis Ulcer

Causes:   hereditary weakness of the vein walls   incompetent valves   elevated intraabdominal pressure

Treatment:   Ligation and division of the entire main

tributaries of the great or small saphenous;

  Ligation and division of all the perforating veins.

  "It is imperative to ascertain that the deep veins are patent".

Anterior compartment syndrome

What is the mechanism & effect of ‘anterior compartment syndrome’ (of the leg) ?

Deep Vein Thrombosis

Pitting Edema

Distal Pulses   Pulses are assessed to identify the presence of

arterial vascular disease. In general, the less prominent the pulses, the greater the chance that there is occlusive arterial disease. This is not a perfect correlation, however, as pulses may be palpable even when significant disease is present (e.g. may be affecting predominantly smaller, more distal blood vessels). A history of pain/cramps with activity suggestive of arterial insufficiency is also of great importance. The location of the blockage(s) will dictate the symptoms and findings. Aorto-iliac disease, for example, will cause symptoms in the hips/buttocks and a loss of the femoral pulse while disease affecting the more distal vessels will cause symptoms in the calves and feet.

Popliteal Area

Gangrene of toes Cellulitis

Neuropathic Ulcer in Patient with Diabetic Neuropathy

POPLITEAL AREA

  The popliteal fascia is part of the binding fascia lata, which tends to limit the progress of infection, hemorrhage, tumor and aneurysms in the region.

  However, the binding characteristic causes severe pain if these conditions develop.

  A swelling of the bursae - "Baker's Cyst".

BURSAE OF THE LOWER LIMB

 Weaver's bottom  Housemaid's knee  Clergyman's knee  Bursitis over the insertion of the

tendon of Achilles into the calcaneus