Subject: Anatomy First Semester A.Y.

2013-2014
Topic: 2.7 Clinical Correlations of the Deep Back and Lower Limbs
Lecturer: Dr. Borromeo UERM CLASS 2017B
Date: August 7, 2013

OUTLNE B. Lumbar/Lower Back

I. Introduction C. Muscle and Bone Injuries  Thoracic spine – posterior side where you auscultate for lung sounds
II. Back D. Knee Injuries  Lumbar spine – where the cauda equina exits
A. Dermatomes E. Clinical Tests for the Lower Limbs and
 SOURCES of LOWER BACK PAIN:
B. Lumbar/Lower back Ankle Injuries
o Ligaments/muscle inflammations
III. Lower Limbs F. Categories of Fractures
A. Hip muscles/fractures o Nerve impingement by disc herniation, spinal canal stenosis
B. Lower extremity muscles and (narrowing of the canal)
fractures o Fractures/injuries
o Joint arthropathies
I. INTRODUCTION o Spasm of erector spinae muscles, quadratus muscles
 Musculoskeletal system is designed for: o Inflammation of muscles and ligaments
o Basic body systems  Manifestation: painful bending, standing or sitting for long periods
o Performance of activities of daily living (ADL)
o Locomotion
 ADL functions are carried out by:
o Muscles and tendons
o Bones and ligaments
o Supported by: nerves and blood supply
 Diagnosis of musculoskeletal disorders
o Good correlation of history and physical exam with basic anatomy
and physiology allows recognition of:
 Changes in movement, gait, motor power and sensation
 Closer to a more accurate diagnosis
 Minimal laboratory and ancillary parameters
o Physical diagnosis requires a good knowledge of surface and deep
anatomy
Figure 2. Photo of an old spine with jagged edges called bone spurs, which
II. BACK can press on the discs/nerve roots – becomes source of pain
A. Dermatome
 With reference to the spine (bone) and the spinal cord (tail of brain)  HERNIATED DISC
 Dermatomes indicate the approximate level of injury of the spine or o History
spinal cord  Pain is reproduced by: straining, coughing, sneezing
 What area to be x-rayed; example:  Pain radiates posteriorly from the buttocks to the leg and foot
o T4 – numbness from the nipple line down o Positive list, trunk shifted to one side (positive Straight Leg Raise at
o T10 – umbilicus area down 45 degrees)
o L1 – inguinal level
o L4 to L5 – medial side of the thigh, leg, and toes
o S1 – lateral side of foot

Figure 3a and 3b. Fig. 3a (above) explains disk herniation; Fig. 3b (below)
Figure 1. Dermatome map of the body shows a schematic diagram of herniated disc

Trans Group: 15B Superio, Sy, Alyssa, Sy, Dale, Sy, Jan Raymond Page 1 of 7
Edited By:
 Sciatica
o Sciatic nerve compression
o Pain in 40% of points
o Caused by pressure from herniated disc (ballooning), stenosis,
vertebral abnormalities
o Pain in stenosis is precipitated by bending backwards and/or walking
more than 50-100 yards

Figure 4. Image showing nerve compression

III. LOWER LIMBS
A. Hip Muscles and Fractures/Dislocations
 Weakness of the gluteus maximus or gluteus medius will result in
abnormal gait.
 Gluteus Maximus Gait
o The gluteus maximus is the chief extensor and most powerful
lateral rotator of the thigh
o Compensatory backward motion of the trunk (gluteus maximus
lurch) at heel-strike on the weakened side
o This prevents the forward motion of the trunk as the hip will
collapse on a weak gluteus maximus
 Congenital Hip Dislocation
o The gluteus medius is an abductor and medial rotator of the thigh
o Weak gluteus medius results in a positive Trendelenburg’s test
 A patient is asked to stand on one leg at a time; pelvis
horizontality should be maintained in a normal hip joint.
 In hip dislocation, hip abductors are weakened, thus horizontality
is not maintained
 The gait is known as gluteus medius gait, gluteal gait or waddling
gait
Figure 6. Image showing dashboard injury and its effect on the hip joint
o Characterized by the following:
 Thigh in slight flexion (iliopsoas)
 Adducted to midline (adductors + iliopsoas)
 Internally rotated (Sartorius + iliopsoas)
NOTE
Iliopsoas – flexes and rotates thigh medially
Medial femoral muscles – a.k.a. adductor compartment,
the three adductors (longus, brevis, magnus) adducts
and laterally rotates thigh
Sartorius – Flexes thigh and leg
 Hip Joint Fractures
o Weight of the torso cannot be transmitted to the legs
o Common case: patient falls again when attempting to walk or stand
o Common in females due to osteoporosis
o Femoral head undergoes aseptic/avascular necrosis because it is
isolated from blood supply (medial and lateral circumflex arteries)
o Treatment is attempting to join the remaining pieces together, or
use of prosthetic replacement

Figure 5. Image A (left) shows normal gait, B (right) shows gluteus medius
gait

 Dashboard injury
o Common posterior hip dislocation, occurs in vehicular accidents
when knee is sharply hit by the dashboard of a car, femoral head is
pushed out of socket Figure 7. Diagram of fractures of the femur, note that the head of femur is
isolated from blood supply and will degrade over time (aseptic necrosis)

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 o Types:
B. Lower Extremity Muscles and Fractures  Transcervical-middle of neck
 Weakness of the tibialis anterior, gastrocnemius, quadriceps or  Intertrochanteric fracture
hamstring muscles will lead to abnormal gait  Intracapsular fracture- occurs within the joint
 Foot Drop
o Weak tibialis anterior muscle (inverts and dorsiflexes the foot) due
to femoral head hitting sciatic nerve
o Blow to the side of the knee may also damage the common peroneal
nerve
o Unable to dorsiflex the foot
 Gastrocnemius
o Plantarflexes (tiptoes) foot and flexes the knee
o Part of the triceps surae (other two muscles are also plantarflexors -
soleus and plantaris), which supports the knee during stance phase
of the gait cycle
o Weak gastrocnemius results in dropping of the pelvis on the affected
side during the last part of the stance phase in the gait cycle
o Cannot plantarflex the foot or tiptoe if gastrocnemius is weak

Figure 8. The gait cycle, weak gastrocnemius interferes with push off
Figure 9. Types of proximal femur fractures
 Type of Fractures
o Compound fracture  Fracture at the shaft of the femur
 result from direct trauma o Spiral fracture: due to activities such as skiing, motor vehicles
 damage through the nutrient canal results to nonunion of bone accidents
fragments o Main femoral artery is cushioned from bone by muscles (midshaft)
 examples: “bumper fracture” (car bumper hitting the leg) o Closed fracture is common
o Transverse Stress Fractures o Usually no external bleeding but swelling may be present since 2.0-
 “March “or “boot top” fracture 2.5 L of blood is stored in the midshaft
 common in people who takes hikes that were not conditioned
before the hike  Distal fracture of the femur
 strain fractures the anterior cortex of tibia o Posterior to it is the popliteal artery
o Diagonal Fracture o Popliteal artery injury is commonly observed because there is no
 Commonly obtained in skiing intervening muscle or bones
 Related to muscle shortening o Amputation is most likely to be done because the popliteal is the
 Lower 2/3 of tibia, fracture of fibula only blood supply of the leg

 Tibial Fractures C. Common Muscle and Bone Injuries

o Most frequent site of fracture: Tibia shaft  Hamstring injuries
o Is the narrowest at the junction of its middle and inferior thirds o Hamstring strains (pulled and/or torn hamstrings)
o Fibula is also affected o Common in individuals who kick and/or run hard
o Has the poorest blood supply o May be accompanied with contusion (bruise) and tearing of muscle
o Most common site for open fractures since no muscle is between fibers
the tibia and the skin (shin area) o May tear part of the proximal tendinous attachments of the
hamstrings to the ischial tuberosity
 Femur Fractures o Comprises of semitendinosus, semimembranosus and biceps
o Age and sex related type of fracture femoris working against the quadriceps
o Rare site for open fracture o Caused by inadequate warming up before the activity
o Frequent site of fracture: neck of femur
o Secondary to osteoporosis  Avulsion of ischial tuberosity
o caused by forcible flexion of the hip with the knee extended
 Types of Femur Fractures o occurs at the proximal attachment of the biceps femoris and
o Proximal Fracture of Femur semitendinosus
 Site: Neck of femur - weakest part

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 Quadriceps injuries NOTE
o Injury to the quadriceps femoris muscle or its tendons *The old 2016A trans mentions 3-5L of blood instead of
o Patella acts as the coordinator of the strength of the quadriceps 3-5 cc of synovial fluid. Please be advised.
o Without it you can't kick or jump or straighten the knee **The new triad includes the lateral meniscus instead
 Patellar tendon or the patella of medial meniscus see link:
o Injury transverse patellar fracture http://www.ncbi.nlm.nih.gov/pubmed/1962712
o Once quadriceps contract the proximal patellar fragment will be
pulled up
o Separates into 2 fragments E. Clinical Tests for the Lower Limbs and Common Ankle Injuries
o Quadriceps can't function well  Knee Ligament Injuries
o No knee extension  Tests
o Anterior Drawer’s Test
 Test to check if Anterior Cruciate (ACL) Ligament is ruptured
 examiner sits on the patient's feet and grasps the patient's tibia
and pulls it forward
 the tibia pulls forward more than normal, the test is considered
positive

Figure 10. Image showing an injured patella

D. Knee Injuries
o Knee has 3-5 cc of synovial fluid* Figure 12. Anterior Drawer’s Test
o Increased synovial swelling or blood in injured knees
o Common injury in basketball o Posterior Drawer’s Test
o Difficulty in bending the knee when swollen (limited flexion)
 Test to check If Posterior Cruciate Ligament (PCL) is ruptured
o Knee is unstable
o Blunt force at lateral side of the knee injuries the medial ligaments:  the tibia pushes backward more than normal, the test is
 Medial meniscus considered positive
 Medial collateral ligament deep layer  “I think this is a misnomer because a drawer cannot be pushed
 Medial collateral ligament superficial layer backwards; they can only be pulled outward” Dr. Borromeo
 Anterior cruciate ligament - usually injured ligament of the knee
 Posterior cruciate ligament
o Valgus injury (blow to the lateral aspect of knee) medial
displacement
o Varus injury (blow to the medial aspect of knee) lateral
displacement

Figure 13. Posterior Drawer’s Test

 Blood Supply of the Leg

 In patients with advanced Diabetes Mellitus (DM), the nerves and
vessels are damaged by the disease
o Neuropathy – nerve damage
 Decreased sensation
 Numbness, partially of the foot
Figure 11. Classic triad of O’Donaghue, also known as the “unhappy triad”, o Angiopathy – blood vessels are damaged
composed of anterior cruciate ligament, tibial (medial) collateral ligament  Decreased blood flow (especially to the legs)
and the medial meniscus**, often injured by athletes  Weak pulse of: Popliteal A., Dorsalis Pedis A., Posterior Tibial A.
o May lead to
 Unnoticed wounds
 Slow or poor healing
 Prone to infection

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 NOTE
External iliac artery -> femoral artery -> Popliteal artery
-> anterior and posterior tibial artery -> foot Anterior Talo-Fibular Ligament
This path is clinically significant because the anterior
and posterior tibial arteries contain palpable pulses
used in identifying patients with Diabetes Mellitus
–Dr. Borromeo

 Injured Ankle Deltoid

 Lateral ligaments Ligament
o occurs in sports in which running and jumping are common
(basketball, 70-80% of players have had at least one sprained ankle)
o lateral ligament is injured because it is much weaker than the medial Calcaneo-Fibular
ligament Ligament
o ligament that resists inversion at the talocrural joint
 Swelling
 Pain
 Hematoma
Figure 15. Ligaments of the Ankle
 Usually an Inversion Injury
o When you twist your ankle with an inward twisting  Stress Test
o Soles are facing inward  Anterior Drawer Test
o Anterior Talo-Fibular Ligament and Calcaneo-Fibular Ligament are
ruptured
NOTE
Inversion injuries are more common because of the
anatomy of the ankle (please refer to figure 14b below),
bone #5 is the fibula (lateral) which is longer than the
end of bone #7 (medial malleolus). Thus, the longer
fibula prevents the foot from everting during injuries and
makes inversion more common.
–Dr. Borromeo

Figure 16. Stress Test

 Injured Tendon
o Achilles Tendon
Figure 14a and 14b. Image of an inverted foot (14a, left), and a diagram of
 Complete tear – can’t tiptoe – no plantar flexion
the ankle (14b, right)
 Achilles Tendon Rupture – swollen, inability to tiptoe
*Sometimes when you sprain your ankle, you also fracture 5, 6, and 7
Types of Sprains
 Partial Tear
 Complete Tear

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 flex
o No plantar flexion = there is a cut in the connection between the
gastrocnemius and the ankle

Figure 17. Complete Tear of Achilles Tendon

Figure 18. Achilles Tendon Rupture

 In Relation to Gastrocnemius Figure 20a and 20b. Thompson’s Test

o As mentioned previously, one of the important functions: tip toe
o When part of the gastrocnemius is injured or the tendon or the
lower part, especially when you have an injured tendon of Achilles,
one cannot tip toe (take off) because the instruction of the
gastrocnemius is not transmitted to the foot.
o Painful Plantar Flexion (Tiptoe)
F. Categories of Fractures
 Open Fractures
 Type I – wound < 1cm long with no evidence of contamination
 Type II – wound > 1 cm long with no soft tissue stripped from bone
 Type III A – Large wound with adequate soft tissue coverage of bone
 Type III B – Large wound with periosteal stripping; bone exposed
 Type III C – large wound with significant arterial injury

 Less common configurations of fractures

o Avulsion

Figure 19. Gastrocnemius Muscle Injury

 Thompson’s Test o Impacted

o Squeeze the belly of the gastrocnemius and the ankle will plantar

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 o Compression

o Segmental

 Palpate
o Extremities

 Limb Girth
o Keep muscle relaxed
o From upper edge of bony landmark, successively measure limb girth
at 4, 6, 8, 10 and 12 inches

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