Lower limb related Clinical

cases
17/5/2020
Ali mohammed abdullah
• Objectives
• Bones related clinical cases.
• Vessels related clinical cases.
• Nerves related clinical cases.
• Other notes
 Bones
• Pelvic fracture =
fracture of hip
bones.
Bones
• Pubic fracture ‘ inferior ramus”
 Bones
• Ilium fracture “ ala of ilium’
Bones
• Ischial fracture
“ ischial
tuberosity”
Bones
• Hip fracture = femoral fracture
Bones
• It is large and strong bone but its fracture are
common.
• More in old-age and osteoporotic females.
• Neck of femur is the most common site of hip
fracture “ because it is narrow and in angle
with the line of gravity “
Bones
• Femoral neck fracture due to stumbling by
something and occurs in old age.
Bones
• Femoral neck
fracture “
transcervical
fracture ‘
Bones
• Intertrochanteric
fracture
• Greater trochanter fracture.
Direct trauma
Bones
Greater
trochanter
fracture.
Bones
• Femoral shaft
fracture
Bones
• Lateral Femoral
condyle fracture
• Avulsion ➔ bone fracture due to muscle
action.
• Avulsion occurs at the muscles attachment “
ASIS, AIIS, ischial tuberosity and ischiopubic
rami”
Bones
• Avulsion : fracture due to muscle actions.
Bones
Bones
Ischial tuberosity
avulsion
Ischial tuberosity
avulsion
Avulsion of
medial condyle
ASIS avulsion “sartorius action”
• Coxa vara
• Decrease the angle of inclination.
• Shortening of the limb.
• Coxa valga
• Increase the angle of inclination.
• Lengthening of the limb.
Coxa valga
Coxa vara
Vessels
• Femoral artery
catheterization
• Give contrast and
take radiography
for vessels.
• Measure pressure
inside the left
ventricle of the
heart.
Vessels
• Femoral vein
catheterization
Vessels
• Femoral artery catheterization.
• Anatomy of the Procedure
• 1. The skin of the thigh below the inguinal ligament
is supplied by the genitofemoral nerve; this nerve is
blocked with a local anesthetic.
• 2. The femoral pulse is palpated midway between
the anterior superior iliac spine and the symphysis
pubis, and the femoral vein lies immediately medial
to it.
• 3. At a site about two fingerbreadths below the
inguinal ligament, the needle is inserted into the
femoral vein.
Vessels
 DVT
• Deep venous thrombosis
• Venous stasis.
• Vessels wall injury.
• Hypercoagulable status.
• Important and life-threatening “ ascends
through veins to the heart and lung “
• occurs more in immobile patient “ post
surgery and after bone fractures”.
Vessels
• Varicose veins
• Larger diameter.
• Elongated.
• Tortouos.
Vessels
• Varicose veins
• Usually superficial veins of the lower limb.
• Not life-threatening.
• Discomfort and pain.
• Causes:
• Hereditary weakness of the veins wall.
• Incompetent valves.
• Elevated intraabdominal pressure “ like in
pregnancy “.
• More Common in women than in men
Vessels
• Great saphenous
vein graft.
• Used for coronary
artery bypass
graft surgery.
• The vein must be
reversed “bcz of
valves”.
Vessels
• Aberrant obturator artery.
• From inferior epigastric artery “branch of
external iliac”.
• Descends medially over the lacunar ligament
medial to femoral ring.
• Should take care during femoral hernia
surgery.
Vessels
Vessels
Muscles
• To test the action of a muscle:
1) make it moves (actively) ➔ ‫هو يحرك نفسه مو‬
.‫انت تساعده‬
2) In appropriate position ➔ ‫نايم على بطنه لو ظهره‬
‫لو صفح لولو‬
3) Against resistance “‫وزن أو تجر بإيدك ➔ ”مقاومة‬
.‫عكس الحركة‬
Muscles
• Quadriceps test
Muscles
• Hamstrings test.
Muscles
• Adductor test.
Muscles
• A muscle strain is the stretching or tearing of
muscle fibers. Most muscle strains happen for
one of two reasons: either the muscle has
been stretched beyond its limits or it has been
forced to contract too strongly
Muscles
Riders strain
• Horseback riders.
• Adductor longus.
• Pain.
• May cause tendon ossification.
Muscles
• Gracilis used for muscle transplantation.
• It is not so important as adductor, so it is
used in more important region like hand.
• The muscle is transplanted with its nerve
and vessels supply.
Muscles
 Sciatica
• back pain caused by a problem with the sciatic
nerve.
• The pain extends through the hip and buttock
and down one leg.
• Most common cause of sciatica is
herniated disc.
• In rare cases, sciatica may result from tumors
growing inside or along the spinal cord or
sciatic nerve.
Piriformis syndrome
 Piriformis syndrome
• Neuromuscular disorder.
• Sciatic nerve is compressed by piriformis
muscle due to :
1) Anatomical variation.
2) Overuse and strain.
• Pain, tingling and numbness in the buttocks
and along the pathway of the nerve.
• Sciatic nerve is compressed by
piriformis muscle.
• Anatomical variations
• Wallet Can Trigger Piriformis
• keeping your wallet in a front pocket or jacket
pocket.
 Intragluteal injection
• The only safe quadrant is the superolateral
one.
• Injection in other sites may cause nerve injury
specially sciatic.
 Butt enhancement
(Gluteal augmentation)
• Butt graft
• Transport fat from abdomen to gluteal region.
• Butt implant
• Implanting silicon
 Calcaneal tendon reflex
• Other names = ankle jerk reflex & Triceps sure
reflex.
• S1,S2.
• Deep reflex.
Muscles
• To test the action of a muscle:
1) make it moves (actively) ➔ ‫هو يحرك نفسه مو‬
.‫انت تساعده‬
2) In appropriate position ➔ ‫نايم على بطنه لو ظهره‬
‫لو صفح لولو‬
3) Against resistance “‫وزن أو تجر بإيدك ➔ ”مقاومة‬
.‫عكس الحركة‬
Triceps surae testing.
Normal you can see and
palpate calcaneal tendon
and triceps surae.
• Tibialis anterior

• Stand on heel
• Normally you can see and palpate the tendon.
✓FDL

✓EDL

✓FHL

✓EHL
✓Normally you can see and palpate
the tendon
• Tibialis posterior
• Normally you can see and palpate the tendon
posterior to medial malleolus.
 posterior tibial pulse
• Can usually be palpated between the
posterior surface of the medial malleolus and
the medial border of the calcaneal tendon
• Because the posterior tibial artery passes
deep to the flexor retinaculum, it is important
when palpating this pulse to have the person
invert the foot to relax the retinaculum.
 Compartment syndrome
• Increase intra-compartment pressure due to
swelling like in trauma and fractures.
• Compression of the vessels and nerves.
• Paralysis, loss of sensation and necrosis.
• More in leg than in thigh and upper limb.
• More in the posterior deep compartment.
• Decompression by longitudinal incision in the
deep fascia is a must.
 Leg edema
• Shin is a perfect site to
check for edema.
Fibular neck
fracture
Common fibular nerve is the most
injured nerve in the lower limb.
Foot drop
✓The loss of dorsiflexion “anterior
compartment” of the ankle causes foot drop.
✓unopposed inversion of the foot due to loss of
eversion “ lateral compartment”
✓Too long limb.