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Clinical review of

LOWER LIMB
Coxa valga & coxa vara: coxa is the angle of inclination b/w the head of femur & shaft of femur,when it in its increased its coxa valga,when decreased its coxa vara,normal angle is 160 in child n 125 in adult Fracture of femur: the most common fracture in femur is fracture of the neck,more chances in women because of Weakness due to osteoporosis,but intracapsular fracture,shaft fracture,greater trochanteric fracture n distal end fracture can also happen Tibial fracture: the frequently fractured portion is between middle n inferior third, Fibular facture: are usually associated with ankle dislocation & tibial fracture,it is usually below the lateral malleolus or can include facture of lat malleolus Fibula is most common source fo bone graft Ant tibia due to its subcutaneous position can b used in bone graft in children,& can b used in intramedullary infusion in shocked&dehydrated children Calcaneal fracture: usually is of comminuted type because it fractures calcaneal into several pieces fracture of talar neck: usually in severe dorsiflexion (as in hard break) the body dislocates posteriorly sometimes fracture of metatarsal: its of dancer s fracture type,when a dancer puts ita ll weight on metatarsal n lose its balance,and fatigue fracture in which stress is on metatarsal due to prolong walking When foot is suddenly inverted tuberosity of 5th metatarsal can be avulsed(torn away) by tendon of fibularis brevis Os trigum: talus secondary ossification Centre converts into lat tubercle,but if this does nott fuse wd bone anyhow,by defect in ossification or by forceful planter flexion fracture of sesamoid bone: the sesamoid in tendons of flexor hallucis longus may b facture by crushing injury

fracture of femoral neck: cause lat rotation of lower limb Dislocation of hip joint: inability to abduct thigh is sign of congenital dislocation,acquired dislocation is uncommon because articulation is so strong n stable,but if it happens then post dislocations r common Genu valgum &varum: angle b/w femur n tibia is Q angle 17 degree,typically greater in females due to wider pelvis,if angel is small deformity is varum (bow leg cause destruction of knee joint) if angle is large deformity is valgum (knock knee,patella can be dislocated latterly) Patellar dislocations: are common to lateral side due to push of vastus liberalist in genu valgum Runners knee/pateelofemoral syndrome: its resulting from microtrauma due to abnormal tracking of patella in relative patellar surface of femur(due to downhill running,weakness of vastus medialis) Knee joint injury:1. Pain in lateral rotation of knee indicates lat meniscus rupture or fibular collateral ligament 2. Pain in med rotation indicates rupture of medial mensci,tibial collateral ligament(TCL is fused wd medial mensci but FBL is not fused with lat mensci)(injury or blow from lat side cause 2 problem &injury from medial blow cause 1) 3.ant drawer sign:ant cruciate ligament ruptures by severed force applied directly & cause tibia to slide freely anteriorly under fixed femur 4.post drawer sign: post cruciate ligament rupture,when lands on tibial tuberosity knee flexed & cause tibia to slide freely posteriorly under fixed femur, 5.unhappy triad: ACL torn+TBL torn+Medial menisci torn ARTHROSCOPY: is endoscopic examination that allows interior visualization of knee joint Aspiration of knee joint: 3 bony points should be remembered: anterolateral tibial tubercle+lat epicondyle of femur+patella Housemaids knee: prepatellar bursitis by direct blow or from falling on knee flexed(in rug installers/working on hardwood floor) Clergymans knee: due to infra patellar bursitis (more commonly in roofers n floor tillers if they dont wear knee pads) Supra patellar bursitis:infection caused by bacteria entering bursa from skin torn Balers cyst/popliteal cyst: it may be a herniation of gastrocnemius or semimembranosus bursa,can b as far n large that can reach in mid-calf Ankle injury: sprained ankle is nearly always an inversion injury involving Planter flexed foot,lateral ligament is usually rupture because its weaker then medial ligament,ant talofibular lig(part of lat ligament)+calcanofiblar

ligament+lat malleolus may fracture Trimalleolar fracture:medial lig rupture+medial melolus fracture+lat malleolus fracture+distal end of tibia sheared off from talus Tarsal tunnel syndrome: tibial nerve entraps b/w medial melolus & calcaneus Hallux valgus:foot deformity,L means lateral deviation(of big toe),decrease in medial long arch.mostly in females,1st metatarsal shifts medially n sesamoid bone laterally Hallux rigidus: lateral deviation later then Hallux valgus osteoarthritic changes happens &metatarsopharangeal joint become painful n rigid Hammer toe:proximal n distal phalanx hyperextended n Middle phalanx planter flexed,weakens lumbricals n introssie muscles Pes cavus/Claw toe: hyperextension of metatarsophalangeal joint &flexion of distal interphalangeal joint,may b by poliomyelitic Pes planus/flat feet:ankle joint becomes stretched n weight forced down b/w calcaneum n navicular, 3 types r 1.flexible flatfoot present when weight bearing but normal arches when not bearing weight, present in childhood n disappear in adulthood 2.rigid flatfoot present in both conditions if bearing weight or not 3. Acquired flatfoot is secondary to dysfunction of Tibialis post,head of talus not supported by plantar ligaments and displaces inferomedialy Club foot/talipes equinavarus:more in boys,foot assumes horses foot appearance,involves subtalar joint,forefoot adducted,medially rotated Compartment syndrome:increase in pressure in any compartment by any cause like burns,hemorrhage,edema,trauma &compress nerves& small Ramesses of muscles & also cause hypothermia distal to compression+disappearance of pulsations of arteries Deep vein thrombosis: DVT is in deep veins,characterized by infection/inflammation+warmth+swelling and can cause pulmonary thromboembolism,its due to muscular inactivity/loose fascia/external pressure Varicose veins:Common in great saphenous vein and in posteromedial part of lower limb its due to dilatation because cusps of valves donot close properly saphenous vein can b use as graft gracilis can b used as muscle graft in extensors or flexors of digits or in external anal sphincter

tendon of plantaris or Palmaris longus from upper limb can be used as autograft in flexors of fingers sural nerve can b used as graft Great saphenous vein is used to insert cannula in low b.p Inguinal lymph nodes can be enlarged in problem of lower limb and also in uterus,umbilical,perineurium of female Charley horse: cramping of an individual thigh muscle because of ischemia,most common site of thigh hematoma is n quadriceps Psoas abscess: pus formation in pelvis,abdomen characteristically occurring in association with T.B,it can be palpated in inguinal region can be confused with femoral or inguinal hernia ,but obscured psoas sheath in x rays clears it Patellar fracture: in transverse fracture proximal fragment si pulled superiorly by quadriceps and distal fragment inferiorly by Patellar ligament Patellar tendon reflex: tests femoral nerve L2-L4,knee jerk in dangling leg causes it to extend leg Groin pull: tearing of the proximal attachment(in inguinal region/groin) of flexors n adductors Riders strain:injury to add longus,horse riding muscle To get blood sample+pressure measurements+angiography to right chamber of heart cannula is passed from femoral vein,but in aft heart case its passed from femoral artery saphenous varix: localized dilation in terminal part of saphenous vein,varix should be considered when varicose veins present in other parts of legs Femoral hernia: small loop of intestine appear as mass in inferolateral part of pubic tubercle in femoral triangle,causing compression of vessels n lymph nodes in femoral sheath,inguinal hernia are most liable to strangulation in femoral hernia due to sharp,rigid boundaries of femoral ring particularly the concave margin of lacunar ligament Replaced/accessory obturator artery (branch of inf epigastric artery) runs along femoral ring to enter obturator foramen,so this should be saved in operations of femoral/inguinal hernias Injury to sup gluteal nerve:paralyze gluteal medius+minimus Trendburg sign: if a person with sup gluteal nerve injured is asked to stand on

foot the pelvis on the unsupported side descends,indicating dat gluteus medius+minimus on the supported side is weak.its positive sign Anesthetic agent of sciatic nerve:Anesthetic agent is injected just few cm inferior to mid point of line joining post sup iliac spine to greater trochanter Common fibular nerve can be can be compressed via piriformis in the gateways of gluteal region greater sciatic forearm) inter muscular injection should be in superolateral part of gluteus max,sup to line joining post sup iliac spine with greater trochanter Popliteal aneurysm:abnormal dilation of all parts of popliteal artery,it can b distinguish by other masses by thrills,abnormal pulsations via stethoscope Post dislocation of knee joint cause injury of tibial nerve cause lose of planterflexion Inflammation in ant or post compartment of leg spread in distal direction & in post compartment can ascend proximally Shin splints: mild form of ant compartment syndrome due to injury of Tibialis anterior,happens wd non trained athletes who don't warm up Injury to common fibular nerve in the neck of fibula cause foot drop due to injury to both superficial n deep branch of it,dorsiflexion n eversion is lost 3 mechanism to compensate walking in too long limb case: 1. Waddling gate: leans to opposite side limb of too long limb, 2.swing out gate: long limb abducted latterly 3. High stepping steppage gate: extra flexion at hip n knee (2 is most commonly adopted) Ski boot syndrome:compression of deep fibular nerve by tight fitting ski boots, in any anatomical structure in its path Calcaneal tendinitis:microscopic tear of collagen fibers in tendocalcanium Ruptured calcaneal tendon: forceful planterflexion --> audible snap -->sudden calf pain sudden dorsiflexion of Planter flexed foot (muscles affected are gastrocnemius+soleus+plantaris Calcaneal tendon reflex: tricep surae reflex,testing S1,S2,not=mal result is planterflexion Tennis leg:medial belly of gastrocnemius strained by hyperextension+dorsiflexion Retroachilis bursitis: calcaneal bursitis due to long distance running,basket

ball,tennis cause pain in posterior to heel Plantar Fascistis: inflammation of plantar fascia on point medial tubercle of calcaneum & medial side of this bone Plantar reflex: L4,5,S1,2 begin to test at heel n end at big toe,flexion is normal Babinki s sign: in children 1-4 years nervous system is not well developed so planter flexion may give negative result Joggers foot: medial plantar nerve entrap and compress in flexor retinacula/flex abductor hallucis due to repetitive eversion Vastus medialis extends farther distally then vastus lateralis,vastus medialis is the first muscle to atrophy in knee injury and last to recover Rectus femoris can b ruptured in sudden violent extension of knee joint ligmentum patella can be rupture in sudden flexion There are 2 types of bursae ,1 is anatomically present, 2nd develops abnormally named as adventitial bursae as by bad fitting shoes develops in tendocalcanium

Bunion: its an adventitial bursae located over medial side of head of 1st metatarsal
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