CHAPTER 6
Femoral triangle:
-
Base:
Inguinal ligament
Medial:
Adductor longus
Lateral:
Sartorius
Floor:
Pectineus and
Apex is adductor hiatus into popliteal fossa
o Medial VAN (vein artery nerve
Popliteal fossa:
-
Gastrocnemius
Semi-tendinous
Biceps femoris Long Head
o Tibial nerve (sciatic)
o Popliteal a. and v.
o Common fibular (
 Medial CNVA
Tarsal Tunnel: Tom Dick and Nervous Harry
-
Tendon of flexor halluces longus
Tibial Nerve
Post. Tibial a.
Tendon of Flex digitorum Longus
Tendon of Tibialis posterior
-Gap between pelvic bone and inguinal ligament is weak, and allows for femoral hernia (femoral canal
by lymphatics
Selected joint movements for myotome testing:
-
Flexion of hip Extension of kneeKnee flexion
Plantarflexion
Adduction of digits
L1 L2
L3/L4
L5 to S2
S1/S2
S2/S3
Basic innervation:
-
Gluteal:
superior and inferior gluteal
Ant. compartment of thigh femoral nerve (ex tensor fasica latte (sup gluteal)
Medial compartment
obturator (ex pectineus (femoral) and adductor mag (sciatic)
-
Posterior thigh, sole of foot:
fibular of sciatic)
Anterior and lateral components:
tibial sciatic (ex short head of biceps femoris (common
common fibular sciatic
Cutaneous
-
Femoral: skin of anterior thigh, medial leg, medial ankle
Tibital sciatic: lateral ankle and foot
Common fibular: lateral leg and dorsum of foot
Pelvic fractures:
-
Lots of bleeding, pelvic hematoma
o Type 1: no disruption of pelvic ring (iliac crest)
o Type 2: single break in pelvic ring (pubis)
o Type 3: double break in pelvic ring (bilateral frac of pubic rami)
o Type 4: acetabulum
Blood Supply to femoral head:
-
Extracapsular arterial ring around base of femoral neck
Supplied from gluteal arteries
Also from ligamentum teres which is from the obturator a.
Femoral neck fractures:
-
Intracapsular:
Interotrochanteric:
-
Femoral shaft: requires IMMENSE trauma, which should damage localized tissue at site
Lymphatics:
-
Superficial inguinal nodes: (10) follow tract of igunial ligament
o Lymph from gluteal region, abdominal wall and superficial regions of lower limb
External iliac nodes: accept drainage from superficial
Deep inguinal nodes: (3) medial to femoral vein
o Receive lymph from deep femora vessels and drain into external
Popliteal nodes: drain into deep inguinal
Varicose veins:
-
Blood flow requires compentent valves to prevent reflux
Valves become incompentent, they place pressure on distal valves
o
o
o
Dilated veins of short and long saphaenous
Caused by deep vein thrombosis or genetics
Sites:
 long saphaneous and femoral jnct.
 Small saphaneous and popliteal
Deep vein thrombosis
-
Virchow: venous stasis, injury to vessel wall, hypercoagulate states
Basically, clot forms and then breaks off  occlusion of pulmonary artery
o Surgical risk :
 Give anticoagulants
 Graduated stockings (prevent venous stasis and facilitate emptying of deep
veins
 Signs: Calf muscle tenderness, limb swelling, postoperative pyrexia (fever)
- access to femoral vein allows for placement of catheters into renal, gonadal veins, right atrium,
pulmonary artery. Superior vena cava is from the neck
Intramuscular injections:
-
-
Gluteal region (avoids neuroinjury)
Division by 2 lines
o Vertical:
dissecting iliac crest and head of femur
o Horizontal: dissects between highest part of iliac crest and horizontal plane of
ischial tuberosity
Anterior corner up upper lateral quadrant is best to avoid sciatic
Quadriceps femoris is innervated by femoral and L3 and L4
-
Tap with hammer on knee tests reflex action of L3 and L4
Muscle injury
-
Partial tear, fills with fluid
Usually hamstrings, soleus
- Femoral artery is palpable in femoral triangle just inferior to inguinal ligament between anterior iliac
spine and pubic symphysis
Peripheral vascular disease
-
Reduced blood flow to legs
o Chronic ischemia
 Atheromatous change and there is luminal narrowing
 PAD
o
o
o
Intermittent claudication
 Most common, history of pain in calf muscles (narrowing of femoral) or
buttocks (narrowing of aorto-iliac)
Clinical diagnoses utilizes comparison between tibial blood pressure and arm blood
pressure (systolic) (Ankle-brachial systolic pressure index – ABPI)
 Healthy: 1
 Intermittent claudation: 0.6
 Chronic ischemic: 0.3
Acute: blood clot or embolism from heart (mitral valve disease)
Knee injuries
Soft tissue:
-
Tears of ligaments
Degenerative joint disease (osteoarthritis)
-
Synovial joints (knee)
-
Examintion of knee
o
-
Lachmans test: ACL
 Patient on couch
 One hand on distal femur, one on tibia
 Flex knee at 20 deg angle
 Apply sudden forward force, will note no firm endpoint of sliding when ACL
is torn
o Anterior drawer
 Proximal head of tibia can be pulled anteriorly to femur
 Knee flexed to 90 in supine patient, heel and sole of foot on couch
 Sit on foot, index fingers used to check hamstrings
 Other fingers encircle tibia, pull on tibia
 Tibia forward = ACL
o Pivot Shift
 Patients foot wedged between examiners body and elbow
 One hand flat under tibia pushing it forward with knee in extension
 One hand on thigh pushing other way
 At 25 degrees pivot shift occurs, indicates ACL tear
Posterior:
o
Posterior Drawer
 Can push tibia posteriorly to femur
 Supine, knee flexed at 90
 Push tibia backwards  movement indicates PCL tear
Neurological Exam of legs
-
Look for muscle wasting
Test power in muscle groups
o Hip flexion – L1/2 iliopsoas
 straight leg raise
o Knee flex - L5-S2 hamstrings
 Patient tries to bend knee while examiner puts force to hold in extension
o Knee extension – L3/4 quad. Femoris
 Keep leg straight while examiner applies flexion force
o Ankle plantarflexion – S1/2
 Push foot down while examiner applies force to sole
o Ankle dorsoflexion - L4/5
 Foot up while examiner pushes down
o Tap patella tendon: L3/L4
o Tap calcaneal tendon: S1/S2
Fractures of the foot
-
-
Talus
o
Blood supply is vulnerable to damage
 Posterior tibial a. into tarsal canal
 Dorsalis pedis supplies superiorly
o Fracture of neck interrupts blood supply
Midfoot
o Uncommon, usually heavy weigh or vehicle
Ankle
o Fibro-osseus ring in coronal plane
 Upper ring: tibia and fibia
 Sides: ligaments that connect medial malleolus and lat. Malleolus to tarsals
 Bottom: subtalar joint
o Visualize action to predict damage
Bunions:
-
Medial aspect of first metatarsal
Protuberance of bone
As it progresses, toe moves aDductly
High heeled or pointy shoes
Dorsalis pedis artery
-
Continuation of anterior tibial
Crosses ankle joint
Medial anterior ankle to branching
Mortons Neuroma:
-
Enlarged plantar nerve in space between third and fourth toes
Pain in third interspace
During pushoff phase of walking, nerve is impinged