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Clinical Anatomy of the Lower Limb carcher08@qub.ac.uk– • Describe the osteology of the lower limb & leg • Describe the arterial supply of the lower limb • Describe the musculature & innervation of Learning the lower limb, specifically the lumbar & sacral plexuses • Be aware of common clinical conditions objectives: affecting the lower limb, including their clinical features, investigations and appropriate management • Be able to apply knowledge to clinical scenariosOsteology of Lower • Connects the lower limbs to the axial skeleton •fusion of 3 bones: ilium, ischium & pubism the Limb: Pelvic • Major sites for muscle attachments GirdleHip Bone/Os coxae: Medial ViewAnterior Femur: PosteriorTibia & Fibula:Tarsals & MetatarsalsMuscles of the Gluteal RegionMuscle s of the ThighMuscles of the LegMuscles of (Plantar) FootLumbar PlexusSacral PlexusDermatomes of Lower Limb Muscles of the Gluteal Region Superficial - 3 glutei & tensor fascia lata. Abduct & extend the lower limb at the hip joint. Innervation: Gluteus maximus - inferior gluteal nerve (L5-S2). Remaining 3 - superior gluteal nerve (L4-S1). Deep - laterally rotate the lower limb & stabilise the hip joint. Innervation: Superior gemellus - nerve to obturator internus (L5-S2). Inferior gemellus – nerve to quadratus femoris (L4- S1). Hip Joint: • A multiaxial synovial ball & socket joint between the femoral head and the acetabulum • Deepened by acetabular labrum fibrocartilage • Stabilized by 5 ligaments: iliofemoral, pubofemoral, ischiofemoral, the transverse acetabular ligament & the ligament of the femoral head • Reinforced by a strong fibrous capsule attached to the acetabulum & the intertrochanteric line anteriorly & just superomedial to the intertrochanteric crest posteriorly • Ligament of femoral head transmits Transverse acetabular the artery of the head of femur, a ligament branch of the obturator arteryHip Joint: Arterial Supply of Hip Joint: Trochanteric & Cruciate Anastomosis: Superior & Inferior Gluteal arteries – branches of internal iliac aa., supply muscles of the gluteal region. Obturator artery – branch of internal iliac a., supplies adductors of the thigh. Medial & Lateral Circumflex Femoral arteries – arise from profunda femoris a., supply the femoral head, adductors of the hip, obturator externus muscle, hamstring muscles & sciatic lata & skin of anterolateral thighor fascia Musculature of the Hip & Thigh: Anterior Compartment: Innervated by Femoral Nerve Main flexor of Hip Quadriceps femoris Femoral Triangle: within the femoral triangle -ated most medial structure; contains lymphatic vessels, a deep lymph node i.e., lacunar node & empty space.Medial Compartment: Innervated by Obturator NervePosterior Compartment: Innervated by Sciatic Nerve Biceps femoris Semitendinosus SemimebranosusHip Fracture: • Hip fractures can be broadly classified as intracapsular or extracapsular • Intracapsular fractures can be of the femoral head or neck (most common) • Extracapsular fractures can be intertrochanteric or subtrochanteric • Signs & Symptoms – pain, inability to weight bear, bruising, swelling, shortened & externally rotated leg due to unopposed action of iliopsoas & hip abductors • Risk of avascular necrosis of femoral head if intracapsularHip Fracture: Garden ClassificationHip Fracture: Treatment Intracapsular: • Undisplaced – internal fixation. • Displaced – total hip replacement or hemiarthroplasty Total hip replacement indicated if patients: • can walk independently out of doors with no more than the use of a stick • are not cognitively impaired • are medically fit for anaesthesia and the procedure. Extracapsular: • Stable Intertrochanteric – Dynamic hip screw • Reverse oblique, transverse or subtrochanteric – intramedullary device Osteoarthritis: • Degeneration of the cartilage within a joint/s • Typical affects those over 50 years of age & becomes progressively more prevalent in subsequent increasing age groups • Characterized by loss of joint space, sclerosis, osteophyte formation & • Hip is a commonly affected joint • Causes = wear & tear, increasing age, excessive weight, repeated stress on the joint, genetics, sex (>female) • Signs & Symptoms – joint pain & stiffness, worsens as the day goes on & is relieved by rest, crepitus • Investigation = X-ray • joint replacementesia, physiotherapy, weight loss, Greater Trochanteric Pain Syndrome/Trochanteric Bursitis: • Commonly caused by minor trauma/ inflammation to soft tissue within the lateral hip & gluteal region. More common in women & risk higher in 40-60-year-olds • Damage to the tendons of the gluteus medius and/or minimus muscles +/- inflammation of the trochanteric bursa • Signs & Symptoms – pain at the lateral hip, thigh or glutes, intermittent in nature, exacerbated by weight bearing & lying on affected side, positive Trendelenburg gait, • Usually diagnosed clinically, investigations include USS/MRI • Treatment = conservative – rest, physiotherapy, weight loss if high BMI, analgesia, corticosteroid injection Perthes Disease: • Disruption of blood supply to the femoral head, leads to avascular osteonecrosis and subsequent loss of bone mass & weakening of the femoral head, eventually collateral blood vessels supply the femoral head but the femoral head may now be misshapen • Cause = idiopathic • Most commonly occurs in children between the ages of 4-8 • Signs & Symptoms: - Pain and/or stiffness in the hip/groin, radiates down thigh to knee - Exacerbated by activity; alleviated with rest - Limping - Restricted range of motion • Investigations = Arthrogram (X-ray), MRI • Tx = observation & physiotherapy, analgesia, crutches, surgery (femoral osteotomy) Knee Joint: • 2 articulations: tibiofemoral & patellofemoral • Stabilized by a number of ligaments, preventing dislocation • Presence of Menisci – rings of fibrocartilage which deepen the articular surface of the tibia & act as shock absorbersArterial Supply of Knee: Genicular Anastomosis Cruciate Ligament Injury: • ACL Injury: Occurs due to a sudden change in direction, deceleration, or landing from a jump with an extended, twisted, or hyperextended knee. Signs & Symptoms – acute onset of pain, “pop”/“snap” sensation, swelling, instability, reduced range of motion, joint tenderness, positive anterior drawer test & Lachman test Investigation – MRI Management: Conservative – RICE, NSAIDS, Physiotherapy, Bracing. Operative – ligament repair/reconstruction • PCL Injury: Most often occurs due to a bent knee hitting the dashboard during a car crash or an overextension injury. Signs & Symptoms – same as above except positive posterior drawer test. Investigation & Management same as above.Collateral Ligament Injury: MCL Injury - more common than LCL of the knee pushing it mediallyeral aspect aspect of the knee pushing it laterallyner • Symptoms – pain at site of the injured the knee jointling , instability, locking of • Investigation – MRI • Treatment – primarily conservative but ligament may be requiredent of the Inflammation Meniscal Injury: of Menisci Can be acute or degenerative Acute - occurs in a younger population due to a twisting injury on a flexed knee Degenerative – wear & tear with age • Signs & Symptoms – pain exacerbated on straightening the knee, instability, locking of the knee joint, joint tenderness • Investigation – MRI • Management – primarily conservative but surgical options can include meniscal repair, partial meniscectomy, & meniscal transplantationSeptic Arthritis: • Knee is most common site • Inflammatory condition resulting from a bacterial infection, most common causative organism = Staph. Aureus • Signs & Symptoms – red, hot swollen joint, fever, reduced range of movement • Investigations - Joint arthrocentesis for synovial fluid ESR, CRP & blood culturesnd culture, synovial fluid WCC, • Management – start empirical antibiotic therapy e.g., Flucloxacillin 2g QDS IV, & drain purulent fluid, IV antibiotics are continued for 2 weeks before switching to oral preparations in the subsequent month Popliteal Fossa: Popliteus Borders Contents Arterial Supply of the Leg: Branches of Popliteal Artery interosseus membrane between the tibia & fibula down to the foot, where it becomes the dorsalis pedis artery. Supplies the anterior compartment of the leg & dorsum of foot. Tibiofibular trunk – divides into the posterior tibial artery, which supplies the the foot, & the fibular artery, which gives perforating branches to supply the lateral compartment of the leg.Musculature of the Leg: Anterior Compartment: Innervated by Deep Fibular Nerve - Comprised of tibialis anterior, extensor digitorum longus & extensor hallucis longus - Fibularis tertius is an additional muscle found in approx. 40% of individuals - Act to dorsiflex & invert the foot, & extend the toes - Arterial supply via the anterior tibial artery Lateral Compartment: Innervated by superficial fibular nerve • Comprised of 2 muscles; fibularis longus & brevis • Fibularis longus – actions include eversion & plantarflexion; also acts to support the lateral & transverse arches of the foot • Fibularis brevis – acts to evert the foot.Posterior Compartment: Innervated by Tibial Nerve Superficial: Deep: popliteus, gastrocnemius, tibialis posterior, plantaris & soleus. All flexor digitorum insert onto the longus & flexor calcaneus & contribute hallucis longus. to plantarflexion at the Popliteus acts only on ankle joint & flexion at the knee joint while the knee joint - soleus the remaining 3 act acts only act the ankle on the ankle & foot joint Foot Drop: • Inability to dorsiflex the foot at the ankle joint due to weakness/paralysis of the muscles in the anterior compartment of the leg • Usually results from damage to the common fibular nerve • Common causes - fibular fracture, too tight a plaster cast, prolonged kneeling or leg crossing • Patient may adopt an “eversion flick” where they will flick the affected foot outwards when walking to avoid it dragging along the ground • Treatment may include braces/splints, physiotherapy, nerve stimulation or surgery Ankle Joint Synovial hinge joint; allows plantar- & dorsiflexion of the foot. Formed by the tibia, fibula & talus. The tibia and fibula are bound together by strong tibiofibular ligaments & form a bracket-shaped socket, covered in hyaline cartilage. Ankle Joint: Ligaments • Medial/Deltoid ligament - consists of four ligaments originating from the medial malleolus, attaching to the talus, calcaneus resist over-eversion of the foot.on is to lateral malleolus & consists of 3 distinct ligament: anterior & posterior talofibular ligaments, & the calcaneofibular ligament. Resists over-inversion of the foot.Ankle Sprain: • Partial or complete tears in the ligaments of the ankle due to excessive inversion of a plantarflexed foot while weight-bearing • The lateral ligament is most often affected due to being the weaker ligament & the fact that it resists over inversion of the foot • The structure of the lateral ligament most at risk of irreversible damage is the anterior talofibular ligament • Treatment = RICE, analgesia & physiotherapy exercisesAnkle Joint Fracture Dislocation: Pott’s Fracture • Caused by forced external rotation & excessive eversion of the foot; the talus is forcibly externally rotated against the lateral malleolus of the fibula • The torsion effect causes the lateral malleolus to fracture spirally • Continue rotation causes the talus to move laterally, this causes the medial ligament to become taut & pull off the tip of the medial malleolus • If the talus moves further, its rotatory movement results in contact between it & the posteroinferior margin of the tibia, which then shears offDorsum Foot Originate from the calcaneus & inferior extensor retinaculum. Extensor digitorum brevis - attaches onto the long extensor tendons of toes 2-4. Extensor hallucis brevis - attaches to the base of the proximal phalanx of the great toe. Act to extend the digits. Innervated by the deep fibular nerve.Plantar Foot Act to stabilise the arches of the foot and individually to control digits.t of the Innervated by the medial or lateral plantar nerves – nerve.es of the tibialPlantar FootPlantar Fasciitis • Inflammation of the plantar fascia - common cause of heel pain • Cause = unclear but repetitive stress/trauma is believed to be the underlying mechanism • Signs & Symptoms – pain near the heel, usually worst in the morning when first getting out of bed & also when standing for long time periods or getting up after sitting for a prolonged time, difficulty raising toes off the floor • Investigations – clinical diagnosis • Management – conservative i.e., rest, ice, physio, night splints, orthotics. If unresponsive, extracorporeal shock wave therapy or ultrasonic tissue repair may be consideredCrystal-induced Arthritis: Gout : • Elevated uric acid levels result in monosodium urate crystal deposition in joints, causing pain, inflammation & potential joint destruction. • Causes – genetics, overproduction/under-excretion of uric acid, consumption of red meat, seafood & alcohol, thiazides diuretics. • Most commonly affected joint = 1 metatarsophalangeal joint (podagra) • Signs & Symptoms – acutely inflamed, hot, swollen joint & presence of gouty tophi (masses of soft tissue swellings) • Investigations – Synovial fluid aspiration (negatively birefringent needle-shaped crystals), X-ray may show periarticular punched-out erosions • Treatment – NSAIDs, Colchicine, Steroids, Prophylaxis – allopurinolPseudogout: pyrophosphate crystal deposition, risk factors for the disease include diabetes, dehydration & hyperparathyroidism . Definitive investigation = joint aspiration (rhomboid-shaped positively birefringent crystals). Management is similar to that for gout.Clinical Scenarios: Q. An 18-year-old rugby player presents to ED following an injury sustained during a rugby match. She describes being tackled by another player and twisting her knee while it was bent. Which structure within the knee has most likely been damaged? 1. Anterior cruciate ligament 2. Medial collateral ligament 3. Meniscus 4. Posterior cruciate ligament 5. Lateral collateral ligament Q. An 18-year-old rugby player presents to ED following an injury sustained during a rugby match. She describes being tackled by another player and twisting her knee while it was bent. Which structure within the knee has most likely been damaged? 1. Anterior cruciate ligament 2. Medial collateral ligament 3. Meniscus 4. Posterior cruciate ligament 5. Lateral collateral ligamentQ. A 23-year-old footballer describes “going over” on his ankle during a football match, on clinical examination it is believed the patient has partially torn the lateral ligament in his ankle. Which structure within the lateral ligament is most at risk of irreversible damage? 1. Calcaneofibular ligament 2. Anterior talofibular ligament 3. Posterior inferior tibiofibular ligament 4. Deltoid ligament 5. Anterior inferior tibiofibular ligamentQ. A 23-year-old footballer describes “going over” on his ankle during a football match, on clinical examination it is believed the patient has partially torn the lateral ligament in his ankle. Which structure within the lateral ligament is most at risk of irreversible damage? 1. Calcaneofibular ligament 2. Anterior talofibular ligament 3. Posterior inferior tibiofibular ligament 4. Deltoid ligament 5. Anterior inferior tibiofibular ligamentQ. A 60-year-old man is suspected of having avascular necrosis of the hip. This condition results from a lack of blood supply to the femoral head leading to osteonecrosis. What is the main arterial supply to the femoral head? 1. Obturator artery 2. Superior gluteal artery 3. Profunda femoris artery 4. Circumflex femoral arteries 5. Internal iliac arteryQ. A 60-year-old man is suspected of having avascular necrosis of the hip. This condition results from a lack of blood supply to the femoral head leading to osteonecrosis. What is the main arterial supply to the femoral head? 1. Obturator artery 2. Superior gluteal artery 3. Profunda femoris artery 4. Circumflex femoral arteries 5. Internal iliac artery Q. A 73-year-old woman presents to ED with severe pain in her right hip & a decreased range of motion following a fall at home. Suspecting a hip fracture, an X-ray is taken and is displayed below. What is the most accurate description of this hip fracture? 1. Displaced intracapsular fracture 2. Garden stage 3 fracture 3. Comminuted intertrochanteric fracture 4. Extracapsular subtrochanteric fracture 5. Displaced complete fracture of neck of femur Q. A 73-year-old woman presents to ED with severe pain in her right hip & a decreased range of motion following a fall at home. Suspecting a hip fracture, an X-ray is taken and is displayed below. What is the most accurate description of this hip fracture? 1. Displaced intracapsular fracture 2. Garden stage 3 fracture 3. Comminuted intertrochanteric fracture 4. Extracapsular subtrochanteric fracture 5. Displaced complete fracture of neck of femurQ. A 50-year-old woman presents with pain over her right hip & gluteal region, she has no history of trauma & has a past medical history of diabetes, high BMI & lower back pain. She describes the pain as intermittent, worsening when she weight bears or tries climbing stairs. What is the most likely diagnosis? 1. Osteoarthritis of the hip 2. Hip fracture 3. Trochanteric bursitis 4. Nerve damage to superior & inferior gluteal nerves 5. Perthes diseaseQ. A 50-year-old woman presents with pain over her right hip & gluteal region, she has no history of trauma & has a past medical history of diabetes, high BMI & lower back pain. She describes the pain as intermittent, worsening when she weight bears or tries climbing stairs. What is the most likely diagnosis? 1. Osteoarthritis of the hip 2. Hip fracture 3. Trochanteric bursitis 4. Nerve damage to superior & inferior gluteal nerves 5. Perthes disease Q. A 25-year-old male presents with an acutely swollen red knee & a temperature of 38.7 degrees Celsius. Joint arthrocentesis & synovial fluid analysis & gram staining shows the presence of gram-negative diplococci, what is the causative organism of septic arthritis in this patient? 1. Clostridium difficile 2. Neisseria gonorrhoeae 3. Staphylococcus aureus 4. Escherichia coli 5. Chlamydia trachomatis Q. A 25-year-old male presents with an acutely swollen red knee & a temperature of 38.7 degrees Celsius. Joint arthrocentesis & synovial fluid analysis & gram staining shows the presence of gram-negative diplococci, what is the causative organism of septic arthritis in this patient? 1. Clostridium difficile 2. Neisseria gonorrhoeae 3. Staphylococcus aureus 4. Escherichia coli 5. Chlamydia trachomatisQ. A patient diagnosed with a fractured neck of femur - classified as Garden stage 2, is being considered for surgery, they are able to walk independently with no more than a stick and are medically fit for anaesthesia, what is the current recommended procedure in this case? 1. Hemiarthroplasty 2. Intramedullary nail 3. Total hip replacement 4. Internal fixationQ. A patient diagnosed with a fractured neck of femur - classified as Garden stage 2, is being considered for surgery, they are able to walk independently with no more than a stick and are medically fit for anaesthesia, what is the current recommended procedure in this case? 1. Hemiarthroplasty 2. Intramedullary nail 3. Total hip replacement 4. Internal fixation st Q. A 60-year-old male who presented with an inflamed 1 metatarsophalangeal joint undergoes synovial fluid aspiration which shows negatively birefringent needle-shaped crystals. What is the correct diagnosis for this patient & what may they take to prevent reoccurrence in the future? 1. Pseudogout & NSAIDS 2. Reactive arthritis & corticosteroids 3. Gout & Colchicine 4. Septic arthritis & flucloxacillin 5. Gout & allopurinol st Q. A 60-year-old male who presented with an inflamed 1 metatarsophalangeal joint undergoes synovial fluid aspiration which shows negatively birefringent needle-shaped crystals. What is the correct diagnosis for this patient & what may they take to prevent reoccurrence in the future? 1. Pseudogout & NSAIDS 2. Reactive arthritis & corticosteroids 3. Gout & Colchicine 4. Septic arthritis & flucloxacillin 5. Gout & allopurinolQuestions ?