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
bone

Send "MedCom" (without inverted commas) to 9900 and Receive All First Year
Stuff FREE on ur Mobile via SMS Daily...

Prepared By: For More Study Stuff....

Shaista Malik & Join Us @
Muhammad Kamran Facebook :
Admins http://facebook.com/MedCom.2011
@ Med-Com Pring:
http://pringit.com/MedCom
Twitter:
http://twitter.com/MedCom_2011
Website:
http://med-com.co.cc

All Right Reserved.