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Hip, Thigh, and Knee

Leslie Reyes, MD
OS 203: Skin, Muscles, and Bones
EXAM # 3
11 September 2014





I. INTRODUCTION

A. Function
1. Weight bearing
2. Locomotion
-
Compare vs. upper extremities: hands have to
function well (finer movement for daily activities)



B. Development


Figure 1. Changes in Position of Limbs Before Birth




C. Parts and Regions


ANTERIOR PARTS OF THE LOWER LIMB (10)
1. Hip joint (Coxa)
2. Thigh (Femur)
3. Knee (Genu)
4. Leg (crus)
5. Ankle (thallus)
6. Foot (pes)
7. Big toe (hallux)
8. Toes (digiti)


Week # Changes
5 Appearance of upper and lower limbs as finlike
appendages pointing laterally and caudally
6 Anterior bending of limbs; elbow, knees point
laterally with thumbs facing up; palms, soles,
face trunk
7 90 (degree) torsion of appendages about their
long axes (upper and lower rotate in opposite
direction); elbows point caudally and cranially
8 Barber pole cutaneous innervation
arrangement of lower limbs
OUTLINE
I. Introduction
a. Function
b. Development
c. Parts and Regions

II. Superficial Structures
a. Bony Landmarks
b. Superficial Veins
c. Lymphatic Vessels
d. Cutaneous Nerves

III. Hip Joint and Femur
a. Configuration
b. Angulation
c. Ligaments

IV. Hip, Thigh and Gluteals
a. Anterior Hip and Thigh
b. Medial Hip and Thigh
c. Lateral Hip and Thigh
d. Gluteals
e. Posterior Thigh
f. Motor branches of Nerves

V. Knee
a. Patella, Knee Capsule, and Bursae
b. Static Stabilizers
c. Dynamic Stabilizers

VI. Moores Blue Boxes

From 2018 trans:

Ambulation (movement from one place to another)
Abduction of big toe
From 2016 trans:

When we assume the fetal position, the lower extremities will
adduct, go down and internally rotate and become plantigrade

Dermatomes: provide sensation in the skin; A localized area of
skin that has its sensation via a single nerve from a single
nerve root of the spinal cord

Dermatomal innervation (muscles, ligaments and
innervations) is spiral because it follows the anatomical
orientation of the fetus (where the big toe still points upward)

Barber pole presentation represents arteries and vein and is
spiral due to internal rotation in fetal development

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OS 203: Hip, Thigh, and Knee



Movements of the Knee
Genu varum bow-legged
Genu valgum knock-knee
Genu recurvatum
Genuflect flexion of the patella



Figure 2. Genu Varum, Genu Valgum and Genu
Recurvatum




Figure 3. Posterior structures at the lower limb.

POSTERIOR PARTS OF THE LOWER LIMB (5)
1. Gluteal region (nates, clunes [Moore])

2. Hamstrings
located at the posterior thigh
flexor of the knee
extensor of the thigh

3. Poples (popliteal area)
posterior portion of the knee
opposite the patella (anterior)

4. Calf (sura)
Three muscles (collectively called Triceps Surae):
o Soleus (1)
o Gastrocnemius (2) median and lateral
Tendon of Achilles joins muscles together
Sural nerve:
o median sural cutaneous nerve (from tibial nerve)
o lateral sural cutaneous nerve (from common
fibular [peroneal] nerve)

5. Heel (calx)




SUPERFICIAL STRUCTURES

A. Bony Landmarks


Figure 4. Parts of the Pelvic Bone


1. Anterior superior iliac spine (ASIS)
very prominent; palpable
attachment of muscles (subcutaneous)
landmark: true leg length (ASIS to medial malleolus)
o vs. apparent leg length measurement (umbilicus to
medial malleolus)
o important for determination of leg length
discrepancy

2. Iliac Crest
the rim of the fan: has a curve that follows contour of
the ala between the anterior and posterior superior
iliac spines
can be palpated even in obese people [2018 trans: may
be non-palpable in obese people]
marks level of the lumbar spine (lumbar tap)

3. Pubic tubercle
where inguinal ring is located
can be palpated (but not in public)

4. Greater trochanter
might be able to palpate laterally [not palpable with too
much cellulite]
landmark for hip surgery incision

5. Posterior superior iliac spine (PSIS)
Area over dimple of buttocks
Spinous process of S2

6. Ischial tuberosity
covered by gluteus maximus, not palpable when
standing
You are sitting on your ischial tuberosity.; felt during
knee flexion

7. Lesser trochanter
Not palpable - covered with muscle
Femoral head, posterior inferior iliac spine, and
anterior inferior iliac spine





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OS 203: Hip, Thigh, and Knee



B. Superficial Veins

Veins: traced from most distal (tributaries) to heart


Figure 5. Veins of the Lower Extremities

1. Greater saphenous vein
Formation: dorsal vein of hallux + venous arch of foot
Pathway
o foot (medial side)
o leg (antero-medial side)
o medial femoral condyle (posterior side)
o thigh (medial side)
o femoral vein
accessory saphenous vein also drains to greater
saphenous vein

2. Lesser saphenous vein
Pathway:
o foot (lateral side)
o ankle
o leg calf (posterior side)
o popliteal vein

3. Inguinal tributaries
Superficial circumflex iliac
Superficial epigastric
Superficial extensor pudendal




C. Lympathic Vessels


Figure 7. Lymphatic vessels of the lower limb


Figure 8. Image of a man suffering from filariasis (left).
Amniotic band syndrome (right).

Filariasis/Elephantiasis
Wuchereria bancrofti
Cause: blockage of worm of lymph nodes
o inflammation
o impairment of lymphatic drainage
Swelling of parts
o Chronic edema leading to elephantiasis

Amniotic Band Syndrome
congenital
lymphatic fluid build up due to constriction
o constriction can go as deep as the bone

D. Cutaneous Nerves

Figure 9. Anterior cutaneous nerves of the lower limb


Figure 6. Varicose Veins

Veins: with valves to prevent back flow of blood
Defective valves become chronically dilated
develops discoloration, venous ulcers
Cure: raise legs above the level of the heart to
assist in the return of blood + vein stripping

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OS 203: Hip, Thigh, and Knee


ANTERIOR CUTANEOUS NERVES
1. Lateral femoral cutaneous nerve
From: inguinal ligament
To: thigh (superficial lateral side)
Innervates lateral aspect of thigh (sensory)
prominent; tight belt can cause numbness of thigh

2. Genitofemoral nerve
synapse of sensory and motor nerve
innervates superomedial part of thigh
2 branches:
o sensory - anterior inguinal side
o motor - scrotum
! innervates cremastic muscles
! cremasteric reflex: stimulation of inguinal area
results to testicles going up

3. Anterior femoral cutaneous nerve
femoral nerve branch
innervates anterior part of thigh
skin nerves

4. Saphenous nerve
continuation of femoral nerve
innervates anteromedial side of leg (sensory)
injury would lead to numbness of medial part of leg

5. Cutaneous branch of obturator nerve
innervates medial side of thigh
above adductor brevis
passes through obturator foramen (stretched via
horseback riding)




Figure 10. Posterior cutaneous nerves of the lower limb

POSTERIOR CUTANEOUS NERVES
1. Cluneal Nerves
innervates gluteal area

Nerve Origin
Superior
Cluneal Nerve
Dorsal rami of the 1
st
3 lumbar
vertebra
Middle Cluneal
Nerve
Dorsal rami of the 1
st
3 sacral
vertebra
Inferior
Cluneal Nerve
Posterior femoral cutaneous
nerve (as branch)

2. Posterior femoral cutaneous nerve
Origin: sacral plexus
Innervation: posterior aspect of thigh, knee, and leg
beside sciatic nerve

3. Sural Nerve
Lateral sural cutaneous nerve
o Origin: branch of common perineal nerve
o Innervation: lateral side of leg (sensory)
Medial sural cutaneous nerve
o Origin: branch of tibial nerve
o Innervation: posterolateral side of leg (sensory)

Other parts mentioned during the lecture:
1. Lateral femoral cutaneous nerve
2. Genitofemoral nerve
3. Anterior femoral cutaenous nerve
4. Saphenous nerve
5. Cutaenous branch of obturator nerve
6. Cluneal nerves
7. Posterior femoral cutaenous nerve
8. Lateral sural cutaenous nerve
9. Medial sural cutaenous nerve
10. Sural nerve
11. Medial calcaneal nerve
12. Medial plantar nerve
13. Lateral plantar nerve
14. Lateral sural nerve
15. Superficial peroneal nerve
16. Deep peroneal nerve
Innervates the dorsum of the web of the big toe and 2nd
toe

III. HIP JOINT AND FEMUR

A. Configuration of the Hip Joint


Figure 11. Hip joint showing the Acetabulum

1. Acetabulum:
Composed of the lunate surface, acetabular fossa and
acetabular notch.
moon-shaped
Contributed to by the ilium, pubis and ischium. (make up
the socket
o Not complete cartilaginous; with presence of fat.
Triradiate cartilage: to be filled in later in adulthood;
children still has this gap in the acetabulum.
Fovea insertion of ligamentum teres capitis (round
ligament for the femoral head) loose from acetabular
fossa.
Ball-and-socket joint (Enarthrosis).
o Ball: head of the femur
o Socket: fusion of the ilium, pubis and ischium.
! designed for stability

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OS 203: Hip, Thigh, and Knee

! Most movable of all joints next to the
glenohumeral joint.
! Action: Circumduction, flexion, extension,
adduction, abduction, internal and external
rotation.

B. Configuration of the Femur


Figure 12. Femur Configuration

1. Femoral Head about 2/3 size of a golf ball.
2. Neck
3. Calcar posteroinferior part of the neck
Carries a lot of weight.
Toughest part of the medial side of the neck.
Used as landmark for hip surgeries.
4. Greater trochanter
5. Lesser trochanter
6. Intertrochantic line in front; anterior capsule.
7. Intertrochantic crest More prominent than #6.
8. Linea aspira Line of Hope., literally.
9. Adductor tubercle
10. Medial femoral epicondyle with prominence adductor
tubercle inside.
11. Lateral femoral epicondyle.
*Isthmus at the proximal third of the femur; considered
during surgery.

Osteomyelitis
Chronic infection of the long bone
Form dead bone inside.


Figure 13. Angulation of the Femur

Angle of inclination in adults:
1. Average value (125 degrees) Normal antiversion: head
and neck not lined with the medial epicondyle
2. Coxa Vara (<125 degrees)
3. Coxa Valga (>125 degrees)

Femoral torsion or piki, toeing in.: Internal rotation of
the femur.
Very antiverted; 90%natural recovery.
In infants or toddlers, lower extremities will adjust: thus,
child will look as if he is toeing in, but this will
spontaneously normalize or correct itself.

C. Ligaments (IPIs)
Iliofemoral Y ligament/Ligament of Bigelow; prevents hip
from hyperextending to the back.
Pubofemoral
Ischiofemoral posterior and spiraling.


IV. HIP, THIGH, AND GLUTEALS

A. Anterior Hip and Thigh

Table: HIP FLEXORS (ISTR Easter)
Muscle Nerve O I A
Iliopsoas *Psoas
Major +
Iliacus
Lesser
trochanter
Hip flexor;
external
rotator
Sartorius L2-3:
Femoral
Nerve.
ASIS Tibial Shaft
(superior
portion of
medial
surface)
THIGH
flexor,
abductor,
lateral
rotator at
hip joint.
LEG -
flexor at
knee joint.
PELVIS
balancing.
Tensor
fascia
latae
L4-5:
Superior
Gluteal
Nerve
Arises
from ASIS
and the
anterior
portion of
the iliac
crest
Iliotibial
Tract
(inserts of
the tibias
lateral
condyle)
THIGH
medially
rotates, hip
flexion and
abduction.
KNEE
stabilizer
Rectus
femoris
L2-4:
Femoral
Nerve
Straight
Head:
ASIS
Reflected
Head:
Ilium
Quadriceps
tendon
Hip flexor;
knee
extensor.

Knee Extensors

Quadriceps femoris
Prevents the knee from moving upward.
Innervation: L2-4 AND extends your leg at the knee joint.
Four (4) Structures:
1. Rectus femoris
Crosses at the hip joint.
Help iliopsoas flex thigh at the hip.
Also acts on the knee through patellar ligament
(continuation of quadriceps tendon)
2. Vastus medialis prevent patella from going upward.
3. Vastus lateralis
4. Vastus intermedius.

Articularis Genu
Retracts the bursa as the knees extend
Pulls suprapatellar bursa
Prevents impingement of synovial membrane between
patella and femur



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OS 203: Hip, Thigh, and Knee


Figure 14. Articularis Genu


Figure 15. Femoral Triangle (ISAng triangle)

Femoral Triangle
Bounded by the Inguinal ligament, Sartorius and Adductor
Longus (ASIS to pubic tubercle)
Floor of triangle: Iliopsoas
Contain the anterior femoral vessels, femoral sheath
(Around arteries; containing deep inguinal lymph nodes and
femoral vein and artery) and femoral nerve (not part of the
sheath)

Adductor Canal
Hunters Canal
Continuation of the femoral triangle (Sartorius inner wall,
adductor longus and vastus medialis; gap in the adductor
magnus); contain femoral vein, artery and nerve that will
continue down to become the saphemous nerve.


FEMORAL ARTERY BRANCHES

Figure 16. Superficial Branches of the Femoral Artery

Superficial Branches
1. Superficial iliac circumflex artery
2. Superficial epigastric artery
3. External pudental artery (superficial and deep)


Figure 17. Deep Branches of the Femoral Artery

Deep Branches
1. Medial femoral circumflex artery:
Main blood supply of femoral head.
Aseptic/avascular necrosis: Occurs when femoral
head is blocked.
2. Lateral femoral circumflex
3. Profunda memoris artery

B. Medial Hip and Thigh


Figure 18. Medial Hip and Thigh

Muscle Innervation Action
1. Pectineus L2-3, Femoral
Nerve (and a
branch of the
Obturator Nerve)
Thigh adductor and
flexor; assist medial
rotation of thigh
2. Adductor
longus
L2-4 (Obturator
Nerve)
Thigh adductor; assist
medial rotation of thigh
3. Adductor
brevis
L2-4 (Obturator
Nerve)
Thigh adductor and
flexor; assist medial
rotation of thigh
4. Adductor
magnus
L2-4 (Obturator
Nerve); hamstring
by sciatic nerve
Powerful thigh adductor
Superior portion: weak
flexor, medial rotator
Lower portion:
Extensor, lateral rotator

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OS 203: Hip, Thigh, and Knee

5. Gracilis
(most
SUPERFICIAL
& WEAKEST
medial muscle
L2-3 (Obturator
Nerve)
Thigh adductor and
flexor; medial rotator
when knee is flexed
6. Obturator
foramen
L3-4 (Obturator
Nerve)
Laterally rotates and
abducts hip; steadies
the head of the femur

C. Lateral Hip and Thigh
Tensor fasciae latae
Iliotibial tract

D. Gluteal Area


Figure 19. Gluteal Area

Gluteus maximus in the greater trochanter and iliotibial
tract; hip extensor
Gluteus medius most lateral; pulls the greater trochanter
to abduct he femur to the pelvis.
o Threndelenberg test tests the competency of the
valves of the veins in the legs.
Gluteus minimus hip abductor
Piriformis Landmark structure
Inferior border: inferior gluteal and sciatic nerve.
Superior border: superior gluteal vessels.
Obturator rotates hip rotator
Gemeli (Superior and Inferior)
Quadratis femoris

E. Posterior Thigh BiTe Me
1. Biceps femoris (short head and long head)
2. SemiTendinosus
3. SemiMembranosus

* Hamstrings long head of 1, #2, and #3

F. Motor Branches of Nerves
1. Femoral Nerve (PIQS)
Pectineus
Iliacus
Quadriceps femoris
Sartorius

2. Obturator Nerve (L2-4; from Obturator foramen)
Obturator externus
Adductor longus
Adductor brevis
Adductor magnus
Gracilis

3. Gluteal Area (PPISS)
Posterior femoral cutaneous nerve (L4-S2)
Pudental Nerve (S2-4)
Inferior gluteal nerve (L5-S2)
Superior gluteal nerve (Superior portion of pyriformis;
upward) (gluteus medius, gluteus maximus, tensor
fasciae latae) (L4-5, S1)
Sciatic Nerve (Tibial and Peroneal divisions)
Clinical Applications:
Hip dislocation with posterior acetabular slip is much more
prone in men than women because men sit down with their
legs open, unlike women who sit with their knees together.-
Vertical fracture: Line generally suggests poorer
prognosis.
Typical deformity: Injured limb adducted, internally
rotated, and flexed at hip and knee, with knee resting on
thigh.
Psoas Abscess: Infection in the hip.


V. THE KNEE



Figure 20. Right Knee

Knee: MODIFIED HINGE JOINT
- At the last few degrees of extension, it will rotate to lock
to the knee joint.
- Tibia: Weight-Bearing Bone (articulates with femur only)
- Fibula: Not Weight-Bearing (Gerdies Tubercle
insertion of Iliotibial Tract; lateral to tibial tubercle)
Structures are virtually palpable
Possess a continuous lining of synovial fluid; hinge type of
synovial joint.
Highly prone to injury.
Largest and most superficial joint.
Allow flexion and etension, and also combined gliding
and rolling and minimal rotation.
Articulation: provides mechanical weakness but is
reinforced by stabilizers.
- Lateral and femoral articulations
- Femoropatellar articulation

A. Patella, Knee Capsule, and Bursae

1. Patella
Sesamoid bone
Able to withstand compression placed on quads tendon
during kneeling and running.
Provide additional leverage for quads in placing the
tendon anteriorly.
Superior and inferior poles (more pointed)
Patellar stabilizers: Vastus medialis insertion, lateral
patellar condyle, joint facets/shape.

2. Joint and Capsule
External fibrous layer, wherein in thicks parts make up
the instrinsic ligaments.
Internal synovial membrane.
Secretes the synovial fluid for lubrication.

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Located along the periphery of the articular cartilage
covering the femoral and tibial condyles, posterior of the
patella and edges of the menisci.

3. Bursae


Figure 21. Bursae of the Knee

Provides lubrication
At least 12 present around knee joint.
Suprapatellar bursa
o Located superior to patella.
o Synovial lining continuous with capsules synovial
membrane.
o May be a site of infection that may spread
eventually to the joint cavity, which results in
bulging, and in turn, flexion.

Clinical Applications of the Knee:
1. Suprapatellar Bulge excess fluid accumulation in the
suprapatellar pouch
2. Bakers Cyst swelling of the semimembranosus or
synovial bursa behind the knee joint.
3. Synovitis treated via air aspiration to reduce swelling.

B. Static Stabilizers


Figure 22. Static Stabilizers of the Knee

1. Medial lateral collateral ligament/Tibular collateral
ligament (MCL/TCL)
Stabilizes medial area around the knee.
Broad flat bed close to the bone.
Against valgus force (directed medially) which can result
to genu valgum.
Attachments: medial femoral epicondyle superior
medial surface of tibia.

2. Lateral collateral ligament/Fibular collateral ligament
(LCL/FCL)
Fibrous band that is not as thick as the MCL.
Stabilizes lateral area of the knee.
Against varus force (directed laterally) which can result to
genu varus
Attachments: lateral femoral epicondyle > lateral surface
head of the fibula.

3. Anterior Cruciate Ligament (ACL)
Together with the PCL contribute to the anteroposterior
stability.
Weaker of the two cruciate ligaments.
Limit posterior rolling of femoral condyles on tibial plateau
during flexion.
Arises from interior condylal area of tibia > posterior
part.

" Posterior Meniscofemoral ligament of Wristberg: pulls on
posterior horn of lateral meniscus.

4. Posterior Cruciate Ligament (PCL)
Prevents posterior displacement
Arises from posterior intercondylar area of tibia -> anterior
part of the lateral surface of femoral medial condyle.

5. Menisci
Support gliding of femoral epicondyle.
Composed of fibrocartilage; condensed in shape.
Needed for shock absorption.
Space-filler (analogous to labrum) for the even
distribution of synovial fluid.
Thicker along external margins and taper to thin edges.
Medial meniscus: C-shaped; less mobile.
Lateral meniscus: early circular and smaller.


C. Dynamic Stabilizers


Figure 23. Dynamic Stabilizers of the Knee


Extensor mechanism
1. Patellar retinacula
o
reinforces joint capsule to and keeps patella aligned
to patellar surface of the femur; medial and lateral.
Helps in prevention of dislocation.

2.
Patellar tendon

3.
Quadriceps (4 muscles)

o
Rectus femoris.

o
Vastus lateralis.

o
Vastus medialis.

o
Vastus intermedius


Biceps femoris
o posteriolateral dynamic stabilizer; inserts to head of
fibula.




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Iliotibial tract
o anterolateral dynamic stabilizer; inserts into Gerdies
tubercle

Pes anserinus
o Anteromedial dynamic stabilizer.
o ACTION: Flexion of the leg and medial rotation.
o Composed of the Sartorius, Gracilis and
Semimembranosus

Oblique popliteal ligament (Semimembranosus part)

Popliteus
o originates as tendon
o Posterior dynamic stabilizer; causes snap in the knee.
o Weakly flexes knee.
o Unlocks femur by rotating by 5 -> on fixed tibia.
o Medially rotates tibia of unplanted limb.

Medial and lateral head of gastrocnemius
o Plantar flexes ankle when knee is extended. Raises the
heel during walking.


BIOMECHANICS
Femoral epicondyle flexes, extends and rolls in the
knee joint
Role of menisci prevent detachment of knee joint; fill
up the space for more gliding surface & shock absorber.
o Additional stability; contains synovial fluid to ease
motions.
Lateral femoral condyle directed more anteriorly and
prevents the patella from dislocating laterally.
Medial femoral condyle Curvy, extension locks and
provides stability. Quadriceps can now relax the medial
femoral condyle distally.
Patella acts as pulley for more efficiency in extension.
Quadriceps angle Wider pelvis = greater angle; Can
be caused by patellar dislocation.
o Chondromalaisial patella: lateral patellar pain, more
often complained by females.

Clinical Applications Terminology
Genu varum bow-legged, sakang
Genu valgum knocked knee, piki.
Genu recurvatum knees bent backward; concave
anteriorly.
Osteoarthritic knee
Ehlers-Danlos Syndrome joint hypermobility.
Osteoarthritis caused by the eroded menisci.
ACL most commonly injured.
Torn TCL patella drawing posteriorly; can be checked by
Drawers Test.
Lockmans Test distal femur and proximal tibia;
- Normal: Not movable.
- Positive: if with Torn ACL.

MOORES BLUE BOXES SUMMARIES ..

1. LOWER LIMB INJURIES
Most common: KNEE, LEG AND FOOT
HIP injuries: 3% only.
Caused by contact sports and overuse in endurance
sports.
Most vulnerable: Adolescents
The combination of stress on epiphyseal plates (from
sports) and rapid growth causes the irritation and injury of
the plates and developing bones (osteoarthritis).




2. HIP BONE INJURIES
Pelvic fractures: on the hip bone
Hip fractures: on the femoral head, neck or
trochanters.
AVULSION FRACTURES:
o May occur during sports that require rapid
acceleration or deceleration. (e.g. sprinting, kicking,
hurdle jumps, martial arts)
o Tears away small piece of the tendon or ligament.
o Occur at the apophyses and muscle attachments (
anterior, superior, inferior iliac spines, ischial
tuberosities, inschiopubic rami)

3. COXA VARA AND COXA VALGA
Angle of inclination between the long axis of the femoral
neck and the femoral shaft
VARA: DECREASED angle, with mild shortening of the
hip and limits its passive abduction.
VALGA: INCREASED angle.

4. DISLOCATED SLIPPED EPIPHYSIS OF FEMORAL
HEAD
Epiphysis slips from the femoral head from the femoral
neck by a weakened epiphyseal plate.
Caused by acute trauma or repetitive microtraumas,
leading to shearing stress on the epiphysis. (abduction
and lateral rotation of thigh)
Leads to progressive coxa vara.
INITIAL SYMPTOM: Hip discomfort that was referred to
the knee.
CONFIRMATION via radiograph of the superior end of
the knee.

5. FEMORAL FRACTURES

GIST: 3 Types of Fracture and Location of Occurrence:
o Transcervical Middle of the Neck
o Intertrochanteric Trochanter
o Spiral Middle of the Shaft

MOST COMMONLY FRACTURED: Neck of Femur.
o Narrowest, longest part of the body
o Lies at a marked angle to weight-bearing.
o Vulnerability increases with age; especially in females;
secondary to osteoporosis.

Fractures of the Proximal Femur: TRANSCERVICAL and
INTERTROCHANTERIC
o Caused by indirect trauma
o Inherently unstable and impaction occurs. (Overriding of
fragments resulting in the foreshortening of the limb)

INTRACAPSULAR FRACTURE:
o Occurs within the hip joint fracture
o Complicated by the degeneration of the femoral head
due to femoral trauma

Fracture of Greater Trochanter or Femoral Shaft.
o Due to direct trauma
o More common during active years
o SPIRAL FRACTURE leads to foreshortening because
of the fragments.
o COMMINUTED FRACTURE fracture broken into
several muscle pieces due to muscle pull and level of
fracture.
o Repair may take up to one year.








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OS 203: Hip, Thigh, and Knee


6. HIP AND THIGH CONTUSIONS
Hip Pointer contusion of the iliac crest at the anterior
portion.
o Most common injuries to the hip region.
o Cause bleeding from the ruptured capillaries and
infiltration of blood into the muscles, tendons and
other soft tissues.
o Avulsion of bony muscle attachments
Charley Horse
o Cramping of an individual muscle.
o Due to ischemia or contusion
o Due to the tearing of fibers in the rectus femoris.
o Quadriceps tendon is torn.
o Associated with localized pain or muscle stiffness.

7. PSOAS ABSCESS
Retriperitoneal pus-forming infection in the abdomen or
greater pelvis.
Occuring in association with TB of the vertebral column
or Crohns Disease (ileum enteritis)
May present as edema in the proximal part of thigh.
Can be mistaken for inguinal or femoral hernia,
saphenous varix (dilation in the terminal part of
saphenous vein)

8. PROBLEMS OF THE PATELLA
A. Chondromalacia patellae (Runners Knee)
o Overstressing of the knee: soreness of aching
around or deep in the patella.
o Results from quadriceps imbalance: results from a
blow to the patella, extreme flexion of the knee
(During squatting or powerlifting)
o May also have transverse patella fracture from the
blow to the knee (Proximal fragments are pulled
superiorly with the quads tendon)
B. PATELLAR ABNORMAL OSSIFICATION
o Patella cartilaginous at birth.
o Ossification during 3-6 years of age.
o Abnormalities usually are bilateral
C. PATELLAR TENDON REFLEX
o Knee Flex
o Tests the integrity of femoral nerve and L2-L4
spinal cord segments.

9. GRACILIS TRANSPLANT
Transplant gracilis to a damaged hand muscle since
gracilis is a member of the weak adductor muscles.
Used also for non-functional external sphincters.
Produces good digital extension and flexion.

10. GROIN PULL
Strain stretching and tearing of proximal attachments of
anteromedial thigh muscles.
Involves flexor and adductor thigh muscles:
Attachments to the inguinal region.

11. ADDUCTOR LONGUS INJURY
Riders Strain.
Ossification in the tendons of muscles because of active
thigh adduction.

12. PALPATION, CANNULATION AND COMPRESSION OF
THE FEMORAL ARTERY.
Vulnerable to traumatic injury due to its superficial
position in the femoral triangle.
Femoral pulse is palpated midway between the ASIS
and pubic symphysis.
Pulse can be diminished if common on external iliac
arteries are occluded.
Femoral Artery Compression: pressing directly
posteriorly against the superior pubic ramus, psoas
major and femoral head; reduction of blood flow in
femoral artery.

13. LOCATION OF FEMORAL VEINS
Located inferior to the inguinal ligament; feel the
pulsations of the femoral artery.
Maybe mistaken for the great saphenous vein in thin
people.

14. BURSITIS
A. Ischial Bursitis
Due to repetitive trauma resulting from repeated
stress that involve repetitive hip extension.
Friction bursitis: Friction between ischial bursae
and ischial tuberosities.
Increased pain with movement of gluteus
maximus.
May lead to pressure sores.
B. Trochanteric Bursitis
Inflamed trochanteric bursae
Results from repetitive actions e.g. climbing and
carrying heavy objects on an elevated hill.
Deep diffuse pain through lateral thigh region,
radiating along iliotibial tract.
Point tenderness over greater trochanter.
Pain elicited through the resisting abduction and
lateral rotation of thigh while lying on unaffected
side.

15. HAMSTRING INJURIES
Pulled or torn hamstrings resulting from hard running or
kicking.
Violent muscular exertion leads to tearing of proximal
tendinous attachments to the ischial tuberosity.
Accompanied by contusions and ruptures of blood
vessels leading to hematoma in fascia lata.
Result from inadequate warming up.
Hurdlers Injury. avulsion of the ischial tuberosity.

16. SUPERIOR GLUTEAL NERVE INJURY
Gluteal gait or disabling gluteus limp.
A. Compensated by the weakened thigh abduction
with the gluteus medius and minimus.
B. Trendelenburg Test (+) patient asked to stand
on one leg; then the pelvis uon the unsupported
side descends due to weak or non-functional
gluteus medius or minimus. Can also be caused
by fracture at the greater trochanter or dislocation
of hip joint.
C. Waddling or characteristic gluteal gait or
Steppage Gait swing-out gait.

17. SCIATIC NERVE INJURY
Pyriformis Syndrome compression of sciatic nerve by
the pyriformis muscle.
o Involved in the sports requiring excessive use of
gluteal muscles
o Trauma to the buttock associated with hypertrophy
and spasm of pyriformis.
Complete Section of Sciatic Nerve. Uncommon;
impaired extension of hip and flexion of leg; loss in
ankle and foot movement.
Incomplete Section of the Sciatic Nerve
o From stab wounds; involves inferior and/or posterior
cutaneous nerves.
Buttock Sides
o Sides of Safety: Lateral Side
o Sides of Danger: Medial Side

18. POPLITEAL NOTES
Popliteal Abscess
o Spreads due to the toughness of popliteal fascia.
Popliteal Pulse
o Best felt in the anterior part of the fossa where the
popliteal artery is related to the tibia. Weakening or
loss leads to femoral artery obstruction.


[GO, GO, GOLING] 11 of 11

OS 203: Hip, Thigh, and Knee

Popliteal Aneurysm
o Distinguished from other masses by thrills and
bruits.

19. COMMON FIBULAR NERVE AND FOOTDROP
Severance of common fibular nerve.
o Severed during the fracture of the fibular neck or
when knee joint is dislocated
o Results in flaccid paralysis in anterior and lateral
compartments.
o Loss of dorsiflexion FOOTDROP.
! Exacerbated by unopposed inversion of foot.
! Limb becomes too long.
3 Means of Compensation.
1. Waddling Gait leaning to the side opposite of the
long limb; hiking limp.
2. Swing-Out Gait long limb is swung out laterally to
allow the toes to clear the ground.
3. Steppage Gait High-stepping; extra flexion of the
hip and knee to keep the toes from hitting the
ground.
o More commonly employed in flaccid paralysis.

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END OF TRANSCRIPTION
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Awow.
-jggo