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

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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?