Clinical notes of Lower Limb TENDERNESS OF THE HEAD OF THE FEMUR AND ARTHRITIS OF THE HIP JOINT - Head

of the femur (the art that is not intra-acetabular) o can be palpated on the anterior aspect of the thigh just inferior to the inguinal ligament just lateral to the pulsating femoral artery - tenderness over the head of the femur usually indicates the presence of arthritis of the hip joint BLOOD SUPPLY TO THE FEMORAL HEAD & NECK FRACTURES Avascular necrosis of the head - can occur after fractures of the neck of the femur young children: small branch of the obturatory aa - supply the epiphysis of the head

medial femoral circumflex aa - a profuse blood supply to the upper part of the neck of the femur - these branches pierce the capsule and ascend the neck deep to the synovial membrane

Occurs in o fractures of the neck of the femur o slipping of the femoral epiphysis in this condition, abduction of the hip joint is limited

Shentons line o is a useful means of assessing the angle of the femoral neck on a radiograph of the hip region FRACTURES OF THE FEMUR Fractures of the neck of the femur - common - 2 types: o Subcapital fracture Occurs in the elderly Is usually produced by a minor trip or stumble Are particularly common in women after menopause because of the thinning of the cortical and trabecular bone caused by estrogen deficiency Common complication: avascular necrosis of the head If the fragments are not impacted, considerable displacement occurs Muscles that pull the distal fragment upward so that the leg is shortened: Rectuts femoris Adductor mm Hamstring mm Muscles that rotate the distal fragment laterally Gluteus maximus Piriformis Obturator internus Gemelli Quadratus femoris o Trochanteric fracture Commonly occur in the young and middle-aged as a result of direct trauma The fracture line is extracapsular Both fragments have a profuse blood supply If the bone fragments are not impacted, the pull of the strong mm will produce shortening and lateral rotation of the leg

*as long as the epiphyseal cartilage remains, no communication occurs between the 2 sources of blood * in adults, after the epiphyseal cartilage disappears, an anastomosis between the 2 sources of blood supply is established

FRACTURES OF THE FEMORAL NECK - interfere with or completely interrupt the blood supply from the root of the femoral neck to the femoral head THE NECK OF THE FEMUR AND COXA VALGA & COXA VARA Neck of the femur - inclined at an angle with the shaft o 160 in young child o 125 in adult Coxa valga - An increase in the angle - Occurs, for example, in cases of congenital dislocation of the hip - In this condition, adduction of the hip joint is limited Coxa vara - A decrease in the angle

Fractures of the shaft of the femur - Usually occur in young and healthy persons - Fractures of the upper 3rd of the shaft o The proximal fragment is flexed by the iliopsoas Abducted by Gluteus medius Gluteus mminimus Laterally rotated by Gluteus maximus Piriformis Obturator internus Gemelli Quadratus femoris o The lower fragment is Adducted by adductor mm Pulled upward by the Hamstrings Quadriceps Laterally rotated by Adductors Weight of the foot - Fractures of the middle 3rd of the shaft o the distal fragment is pulled upward by hamstrings quadriceps o this results to considerable shortening o the distal fragment is also rotated backward by the pull of the 2 heads of the gastrocnemius - Fractures of the distal 3rd of the shaft o The same displacement of the distal fragment occurs as seen in fractures of the middle third of the shaft o However, the distal fragment is Smaller Rotated backward by gastrocnemius mm to a greater degree and may exert pressure on the popliteal aa and interfere with the blood flow through the leg and foot GLUTEUS MEDIUS & MINIMUS AND POLIOMYELITIS Gluteus medius & minimus mm - May be paralyzed when poliomyelitis involves the lower lumbar and sacral segments of the spinal cord - Supplied by superior gluteal nerve (L4, L5, S1) - Paralysis of these mm seriously interferes with the ability of the patient to tilt the pelvis when walking

GLUTEUS MAXIMUS AND INTRAMUSCULAR INJECTIONS - To avoid injury to the underlying sciatic nerve, the injection should be given well forward on the upper outer quadrant of the buttock

VEINS OF THE LOWER LIMB 3 divisions: 1. Superficial veins o Consist of the great & small saphenous veins & their tributaries Are situated beneath the skin in the superficial fascia o Great saphenous vein Its constant position in front of the medial malleolus should be remembered for patients requiring emergency blood transfusion 2. Deep veins o Are the venae comitantes to the anterior and posterior tibial aa the popliteal vein the femoral vein and their tributaries 3. Perforating veins o Are communicating vessels that run between the superficial and deep veins o Many of these veins are found particularly in the region of the ankle

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and the medial side of the lower of the leg Possess valves that are arranged to prevent the flow of the blood from the deep to the superficial veins -

elevated intra-abdominal pressure as a result of multiple pregnancies or abdominal tumors o thrombophlebitis of the deep veins, which results in the superficial veins becoming the main venous pathway for lower limb during exercise: o high-pressure venous blood escapes from the deep veins into the superficial veins and produces a varicosity o it might be localized to begin with but becomes more extensive later o

VENOUS PUMP OF THE LOWER LIMB The thin-walled, valved venae comitantes are subjected to intermittent pressure at rest and during exercise - Pulsations of adjacent aa help move the blood up the limb - However, the contractions of the large mm within the compartments during exercise compress these deeply placed veins and force the blood up the limb - Superficial saphenous veins (Except near their termination) o lie within the superficial fascia o Are not subject to these compression forces o as the mm within the closed fascial compartments relax, venous blood is sucked from the superficial veins into the deep veins VARICOSE VEINS has larger diameter than normal elongated and tortuous commonly occurs in the superficial veins of the lower limb although not life threatening, is responsible for considerable discomfort and pain causes: o hereditary weakness of the vien walls o incompetent valves

GREAT SAPHENOUS VEIN CUTDOWN exposure of the GSV through a skin incision (a cutdown) is usually performed at the ankle o this site has the disadvantage at phlebitis (inflammation of the vein wall) is a potential complication - GSV also can be entered at the groin in the femoral triangle, where phlebitis is relatively rare - The large diameter of the vein at this site o permits the use of large-diameter catheters o the rapid infusion of large volume of fluids THE GREAT SAPHENOUS VEIN IN CORONARY BYPASS SURGERY

LYMPHATICS OF THE LOWER LIMB

QUADRICEPS FEMORIS AS A KNEE JOINT STABILIZER Quadriceps femoris - a most important extensor mm for the knee joint - its tone greatly strengthens the joint - therefore, this mm mass must be carefully examined when disease of the knee joint is suspected - examination: o both thighs must be examined

if reduced that is caused by mm atrophy can be tested by measuring the circumference of each thigh a fixed distance above the superior border of the patella o consistency o strength vastus medialis o extends farther distally than the vastus lateralis o is the first part of the quadriceps mm to atrophy in knee joint disease and the last to recover

size

RUPTURE OF THE RECTUS FEMORIS occurs during in a sudden violent extension movements of the knee joint - its mm belly retracts proximally, leaving a gap that may be palpable on the anterior surface of the thigh RUPTURE OF THE LIGAMENTUM PATELLAE - can occur when a sudden flexing force is applied to the knee joint when the quadriceps femoris mm is actively contracting FEMORAL SHEATH & FEMORAL HERNIA Hernia sac - descends through the femoral canal within the femoral sheath