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Lower Limb MSK Zoulikha Zair 17 th May 2013. Ischium Pubic Ilium Iliac Crest * Acetabulum Point of union of 3 bones Pubic Tubercle * Ischial Tuberosity.

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Presentation on theme: "Lower Limb MSK Zoulikha Zair 17 th May 2013. Ischium Pubic Ilium Iliac Crest * Acetabulum Point of union of 3 bones Pubic Tubercle * Ischial Tuberosity."— Presentation transcript:

1 Lower Limb MSK Zoulikha Zair 17 th May 2013

2 Ischium Pubic Ilium Iliac Crest * Acetabulum Point of union of 3 bones Pubic Tubercle * Ischial Tuberosity * Anterior Superior Iliac Spine * Posterior Superior Iliac Spine * Ischial spine * Greater sciatic notch * = Palpable R G Tunstall 2013 What makes up the hip bone? 2

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 Sartorius Adductor longus Inguinal ligament Key notes: Access point for vascular structures Artery enters at midinguinal point ± 1.5cm Palpate for pulsation – vein sits ~1cm medial Nerve Artery Vein Lymph ASIS Pubic Tubercle Femoral triangle sits in the proximal anterior thigh R G Tunstall

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

7 Pink = anterior divisions Yellow = 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

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 Maximus Inferior gluteal nerve (L5-S1) Gluteus Medius & Minimus Superior 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

10 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

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 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 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

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 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

20 Popliteal Artery (deep) Popliteal Vein Tibial Nerve (superficial) Common fibular nerve Passes close to fibula head R G Tunstall 2013 Popliteal Fossa Borders 1.Semimembranosus Semitendinosus 2.Biceps femoris 3.Gastrocnemius medial head 4.Gastrocnemius lateral head What is the popliteal fossa? Name it’s borders? 20

21 Further down still…..

22 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?


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