1. Lower Limb MSK
Zoulikha Zair
17th May 2013

2. 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

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

4. 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)?

5. 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

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

7. 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

8. 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?

9. 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

10. 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

11. Moving further down……

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. Further down still…..

22. 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