2What makes up the hip bone? Iliac Crest *Posterior Superior Iliac Spine *Anterior Superior Iliac Spine *IliumPubic Tubercle *Greater sciatic notchPubicIschial spine *IschiumAcetabulumPoint of union of 3 bonesIschial Tuberosity ** = PalpableR G Tunstall 2013
3Clinical Case 1What does the x-ray show?So what???
4What 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 ownWHERE DOES THE FEMORAL ARTERY SIT (LANDMARKS)?
5Femoral triangle sits in the proximal anterior thigh ASISInguinal ligamentPubic TubercleSartoriusNerveArteryVeinLymphAdductor longusKey notes:Access point for vascular structuresArtery enters at midinguinal point ± 1.5cmPalpate for pulsation – vein sits ~1cm medialR G Tunstall 2013
6Clinical Case 2 What does the x-ray show? What is the significance of this?
8QuizWhat 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?
9Gluteus Medius & Minimus Gluteal RegionGluteal muscles bring about powerful hip/trunk extension (stair climbing, arising from chair) and pelvic stabilisation during walkingGluteus MaximusInferior gluteal nerve (L5-S1)Gluteus Medius & MinimusSuperior gluteal nerve (L4-L5)Ilium, Sacrum& LigamentsSuperior gluteal nerve (L4-L5)Inferior gluteal nerve (L5-S1)Femur &Iliotibial tractR G Tunstall 2013
10Damage/paralysis can lead Trendelenburg sign & lurch when walking Gluteal RegionGluteus medius & minimus prevents pelvis tilting toward unsupported sideGluteus maximus prevents trunk from tipping forwards during walkingDamage/paralysis can lead Trendelenburg sign & lurch when walkingDamage/paralysis can lead to patient lurching backward when the weaker limb is on the floor during walkingR G Tunstall 2013
12Case Soccer Star16 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
13ACL Injury Case Soccer Star Physical exam Joint effusion present No joint line tendernessNo LCL/MCL laxityNegative McMurrayPositive LachmanACL InjurySlides taken from Rodney S. Gonzalez, MD
14Anterior Cruciate Ligament Injury Half occur with medial meniscal tearCan occur with MCL tearRare with LCL or PCL tearSlides taken from Rodney S. Gonzalez, MD
15X X Knee: Cruciate (Crossing) Ligaments Cruciate ligaments resist anterior-posterior translocation & rotation of the kneePosterior cruciate lig. (PCL)PCL prevents posterior tibial movement on femurXAnterior cruciate lig. (ACL)XACL prevents anterior tibial movement on femurACL injured by kick to back of flexed kneePCL injured by kick to front of load-bearing kneeR G Tunstall 2013
16Case Basketball Player Basketball player presents day after game for knee painRemembers painful twist with planted foot during the game, but kept playingSwelled up overnightNow feels “locked”Slides taken from Rodney S. Gonzalez, MD
17Case Basketball Player Physical examEffusionJoint line tendernessLimited knee range of motionMcMurray tests positive with painful clickMeniscal InjurySlides taken from Rodney S. Gonzalez, MD
18Meniscal Tear Anatomy Avascular inner 2/3, partly vascular outer 1/3 Minimal innervationHeld in place by coronary ligaments, painful when torn (meniscotibial ligaments)Lateral meniscus less firmly attached, less prone to injurySlides taken from Rodney S. Gonzalez, MD
19Knee: Collateral Ligaments Medial & lateral collateral ligaments resist valgus and varus forces at the kneeMCL injured by lateral blowLCL injured by medial blowMedial (tibial) collateral ligamentAttached to medial meniscus-both can be damaged togetherLateral (fibula) collateral ligamentPrevents tibial abduction (valgus)Prevents tibial adduction (varus)R G Tunstall 2013
20What is the popliteal fossa? Name it’s borders? Popliteal Fossa BordersSemimembranosus SemitendinosusBiceps femorisGastrocnemius medial headGastrocnemius lateral head21Popliteal Artery (deep)Popliteal VeinTibial Nerve (superficial)34Common fibular nervePasses close to fibula headR G Tunstall 2013