Clinical Notes Of The Lower
Limb
:عبارة عن جهد مشترك بين كل من
Dr.Aoks
abdullah Z
د .ابو يسرا
ابـــــتـــــــســــــــــــم!!
نتمنى من اهلل العلي القدير ان تنال رضاكم واستحسانكم
…وأن تكون خالية من األخطاء … فنحن طالب مثلكم قد نخطئ
..تقبلوا فائق احترامنا وتقديرنا
Dr.Aoks : بواسطة
Blood Supply To The Femoral Head And Neck Fractures
o Anatomic knowledge of the blood supply to the femoral head explains why avascular
necrosis of the head can occur after fractures of the neck of the femur
o In the young, the epiphysis of the head is supplied by a small branch of the obturator artery,
which passes to the head along the ligament of the femoral head.
o The upper part of the neck of the femur receives a profuse blood supply from the medial
femoral circumflex artery.
These branches pierce the capsule and ascend the neck deep to the synovial membrane .
o As long as the epiphyseal cartilage remains no communication occurs between the two
sources of blood. In the adult , after the epiphyseal cartilage disappears, an anastmosis
between the two sources of blood supply is established .
o Fractures of the femoral neck interfere with or completely interrupt the blood supply from
the root of the femoral neck to the femoral head.
o The scant blood flow along the small artery that accompanies the round ligament may be
insufficient to sustain the viability of the femoral head, and ischemic necrosis gradually
takes place
The Neck Of The Femur And Coxa Valga And Coxa Vara
The neck of the femur is inclined at an angle with the shaft; the angle is about 160degree in the young
child and about 125degree in the adult. An increase in this angle is referred to as coax vagla , and it
occurs, for example, in cases of congenital dislocation of the hip. In this condition, adduction of the
hip joint is limited. A decrease in this angle is referred to as coax vara, and it occurs in fractures of the
neck of the femur and in slipping of the joint is limited. Shenton’s line is a useful means of assessing
the angle of the femoral neck on a radiograph of the hip region.
Gluteus Maximus And Intramuscular Injections
o The gluteus maximus is a large, thick muscle with coarse fasciculi that can be easily
separated without damage. The great thickness of this muscle makes it ideal for
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.
abdullah Z : بواسطة
Veins of the lower limb
llllllllllllllllllll((Skin))llllllllllllllllllll
0000000((Superficial Fascia))0000000
Superficial Veins
( Great saphenous & small Saphnous)
N.B “ great saphenous can be used to blood
transfusion near the medial Malleolus
Perforating Veins
Have valves to prevent flow of blood form
the deep to the superficial veins
Deep veins
( Venae comitants ) with:
A- posterior Tibial arteries
B- popliteal vein
C- femoral vein
Venous Pump of the lower limb
How is the blood pumped up the lower limb ?
Through the deep veins:
1. by the pulsatation of the adjacent arteries
2. the contraction of the muscles
why are there valves in the perforating vines ?
1. to prevent the blood from going to the superficial veins (low pressure )
…....from the deep veins ( high pressure ) during exercise
2. to allow the blood to go from the superficial veins to the deep during relaxation
Varicose Veins
o “ Varicose veins “ are larger than normal veins in diameter occurs in the veins (not life
treating ).
o Causes :
1. Heredity weakness of the veins walls
2. Incomplete valves ( due to increase intar-abdominal wall )
N.B : the successful operation treatment of the condition depends on ligation
and division of all main tributaries of the small and great saphnous veins
Great saphenous vein cut-Down
o Exposure of the G.saphenous vein through skin incision (( cut down)) is usually preformed
in the ankle
N.B the disadvantage is phlebitis (( inflammation of the veins wall ))
Anatomy of the ankle vein Cut-down
1. the sensory nerve supply to the skin is from the saphnous nerve branch which is blocked by
local anesthetic
2. a transverse incision is made through the SKIN> subcutaneous tissue
3. the saphenous vein lies behind the saphnous nerve (( check the figure ))
the great sahenous vein also can be entered @ the Groin in the femoral triangle (( here
Phlebitis is rare))
Anatomy of the Groin vein Cut-down
1. the area here is supplied by branches of the ilioinguinal the branches here are blocked by
local anesthetic
2. a transverse incision is made through the SKIN > subcutaneous tissue
3. remember its medially to femoral artery
THE G.saphenous vein in Coronary Bypass Surgery
o In patients with occlusive disease, the diseased arterial segment can be bypassed by
inserting a graft consisting of a portion of the G.saphnous . after reflecting it so the valves
will not stop blood flow
By that the venous blood on the lower limb will flow through the perforating vines
Femoral Sheath and Femoral Hernia
**For the first paragraph plz check D.Vohra Slides #401 page (3-4)
Femoral hernia :
o its more common in woman , in femoral canal
o the neck of the sac lies lateral to the pubic tubercle
o the neck of the sac is narrow and lies at the femoral ring
►Boundaries of the femoral ring:-
◘ Anterior :- Inguinal ligament
◘ Posterior :- Pectineal ligament& sup. pubic ramus
◘ Medial :- Edge of the lacunar ligament
◘ Lateral :- Femoral vein
o Because of the boundaries the neck is unable to expand
o If abdominal viscus has passed through the neck , may difficult to return it to abdominal
cavity ( irreducible hernia)
o It is a dangerous condition
o should always be treated surgically
N.B when considering the differential diagnosis of feumoral hernia it is important to
consider other diseases that may involve other anatomic structures close to inguinal
ligament
Inguinal canal : The swelling will lie above and medial to ligament
Superficial inguinal lymph nodes : Usually more than one lymph node/ never forget
mucous membrane for carcinoma
G.saphenous vein : hernia may be confused with saphenous varix
Psoas sheath : The swelling is above and below the inguinal ligment
Femoral artery : Swelling along the course of the femoral artery
Femoral artery Catheterization
o A catheter can be inserted into the Femoral artery as it descends through the femoral triangle
its guided under the fluoroscopic view along the external and common iliac artery into the
Aorta , the catheter then can be passed into the :
1. inferior mesenteric
2. superior mesenteric
3. Celiac artery
4. Renal artery
Pressure record can be also be taken by guiding the catheter through the aortic
valve to the left ventricle
Femoral Vein Catheterization
When is it used ?
o When rapid access to a large vein is needed but because to of the incidence of thrombosis
the catheter should be removed once the patient is stabilized
N.B we use local anesthetic to block the nerve supply to the area which is the Genitofemoral nerve
ابو يسرا. د: بواسطة
Referred pain from the hip joint
I. In the front & medial side of the thigh :
Because of : the intermediate & medial cutaneous nerves of the thigh that supply the skin of
front & medial side of the thigh are also supply hip joint.
II. In the knee joint :
Because of : the posterior division of the obturator nerve supply either hip & knee joints.
Congenital hip dislocation
The upper lip of the acetabulum fails to develop adequately .
The head of the femur :
Having no stable platform under which it can lodge , rides up out of the acetabulum
onto the gluteal surface of the ilium .
Trendelenburg's sign
The stability of hip joint when a person stands on one leg & rises other above the ground
depend on :
A. The Gluteus meduis must functioning normally.
B. The Gluteus minimus must functioning normally.
C. The head of femur must located normally within the acetabulum.
D. The neck of femur must be intact & have normal angle with the shaft of the femur.
if one of these is defective + ve Trendelenburgs sign.
The pelvis will sink downward on the opposite , unsupported side below the
horizontal plane .
In walking the patient will show the characteristic “dipping” gait.
N.B :In the patient with bilateral congenital dislocation of hip the gait is typically” waddling” in nature.
Ruptured tendo calcaneus
Common in middle age & tennis players.
Ruptured occurs at about 2 in above its insertion (posterior surface of the calceneum).
The gastrocnemius & soleus retract approximately , leaving a palpable gap in the tendon .
The problem is by impaired plantar flexion of the foot at the ankle joint & flexion of knee
joint .
Deep vein thrombosis in the leg
Cause : sitting for hours on long-distance flights without mobility .
Thrombosis of the veins of soleus muscle can cause mild pain or tightness in the calf &
calf muscle tenderness also may be asymptomic (with no sign or symptoms).
Thrombus can pass to heart & lungs causing pulmonary embolism.
Preventing :stretching of the legs every hour.
ابــتســـــم: !! بواسطة
PLANTAR FASCIITIS
o It occurs in individuals who do a great deal of standing or walking.
o Causes a pain and tenderness of the sole of the foot .
o It may cause by repeated minor trauma .
o The repeated attacks by this condition induce the ossification in the Posterior attachment of
the aponeurosis ,forming a calcaneal spur.
STRENGTH OF THE KNEE JOINT :
o The strength of the knee joint is depend on :
1. strength of ligament that bind the femur to tibia .
2. the tone of the muscles acting on the joint .
o And the most important muscles group is the quadriceps femoris.
It is capable to stabilizing the knee in the presence of torn ligament .
LIGAMENTOUS INJURY OF THE KNEE JOINT :
o 4 Ligaments
1. medial and lateral collateral ligaments.
2. anterior and post. Cruciate ligament.
All of them are commonly injured in the knee . even it sprints or tears it depending on
the force applied.
Medial collateral ligament (MCL):
o Forced abduction of the tibia on the femur can lead to partial tearing .
o The tearing of the menisci result in localized tenderness on the joint line .Whereas the sprain
of MCL result in tenderness over the femoral or tibial attachment of the ligament
Lateral collateral ligament (LCL:
o Forced adduction of the tibia on the femoral can lead to injury.
o It is less common than the MCL injury.
Cruciate ligament (CL) :
o Injury can occur when excessive force is applied on the Knee joint.
o Tears of ant. CL is common .
o Tears of post. CL is rare.
o The injury always accompanied by damage to other Knee structure.
o The injury lead to fill the cavity of joint with Blood so the cavity will swollen .
o Examination of patients with ruptured anterior cruciate ligament shows that the tibia can be
pulled excessively forward On the femur .
o But if there is arupture in the posterior cruciate ligament the tibia will move backward on
the femur .
o Because the stability of the knee depend on the tone of the quadriceps femoris and the
collateral ligament ,the operative repair of isolated torn cruciate ligament is not always
attempted.
o The knee is immobilized in slight flexion in a cast. And active physiotherapy on the
qadreiceps femoris is begun at once.
Meniscal injury of the knee joint
Injury to medial meniscus
o The medial meniscus is damaged much more frequently than the lateral meniscus
o Because of its strong attachment to medial collateral ligament of the knee joint , it is relatively
immobile .
Cause of injury :
Knee joint flexion + rotation of tibia or femur.
Then the tibia is abducted on the femur , the medial meniscus is pulled between the
femoral & tibial condyles.
Result:
a sudden movement between the condyles result in the meniscus being subjected to a
severe grinding force & splits along its length.
when the torn part of the meniscus becomes wedged between articular surfaces , further
movement is impossible , & the joint is said to lock.
Injury to lateral meniscus
o is less common
o because it is not attached to lateral collateral ligament , it is more mobile
o popliteus muscle is attached to lateral meniscus & can pull the meniscus into favorable
position during sudden movement of the knee joint
PES PLANUS – FLAT FOOT—
The cause of Flat Foot are both congenital and acquired .
It is a condition when the medial longitudinal arch is depressed or collapse .
- As a result the forefoot is displaced laterally & everted.
The head of the Talus is not supported, and the body weight forces it downward and medially
between the calcaneum and navicular bone.
When the deformity has existed for some time : the planter, clalcaneonavicular , and the medial
ligament of the ankle joint become permanently stretched and the bone change the shape And
the muscle and the tendons .
PES CAVUS (CLAW FOOT)
it is a condition in which the medial longitudinal arch is unduly High.
most cases are caused by muscle imbalance ,instances resulting from poliomyelitis.
