0.5x ANATOMY LOWER LIMBS

Compiled by: Png Wenxian
ANATOMY – LOWER LIMBS
3. Gluteus medius: attachments and action when walking.

Gluteus Maximus
 It is the largest musde in the body.
 It is responsible for the prominence of the buttock
Origin from 1. Ilial crest
2. post surface of sacrum & coccyx
3. sacrotuberous lig
Insertion into: 1. iliotibial tract
2. gluteal tuberosity of femur
Nerve Supply inf gluteal n (L5-S2)
Actions 1. extends
2. laterally rotates
3. supports knee jt via iliotibial tract
Gluteus Medius
Origin From posterior ilium between posterior and middle gluteal line.
Insertion into lat surface of greater trochanter of femur
Nerve Supply sup gluteal n (L4-S2)
Actions 1. abducts
2. medially rotates
3. supporls pelvis during walking & running
ie. prevents pelvis from dipping downwards on opposite side
Gluteus Minimus
Origin from posterior surface of ilium btw middle & inf gluteal lines
Insertion into ant surface of greater trochanter
Actions 1. abducts
2. medially rotates
3. supports pelvis during movement
- Quadratus femoris and attachments

It is a lateral rotator of the thigh.
It arises from the lateral edge of the ischial tuberosity and inserts into the intertrochanteric crest on
the back of the femur.
Supplied by nerve to quadrator femoris. (which supplies the inferior gamellius as well)
4. My friend who picked limbs as first choice had to tell examiner about all the ankle ligaments and
attachments.
Ligaments
med (deltoid)  attachments
lig apex  margins & tips of med malleolus (TIBIA)
base = post tibiotalar ligament  talus
= anterior tibiotalar ligament  talus
= tibiocalcanean part  calcaneus
tibionavicular part  navicular
 functions - attach med malleolus to talus

- strengthen ankle jt
- hold calcaneus & navicular bone to talus
lat lig  3 parts
1. ant talofibular lig = from lat malleolus to talus
2. calcaneofibular lig = from lat malleolus to calcaneus
3. post talofibular lig = from lat malleolus to post tubercle of
talus
 function: attach lat malleolus to talus & calcaneus
Deltoid ligament anatomy.Basically whole anatomy of lowerlimb below the knee.

Deltoid ligament: Triangular ligament at the medial side of the ankle.
Anterior tibiocalcaneal lig, posterior tibiocalcaneal lig, Tibiocalcaneal ligament.
6. Venous cutdown sites, 1st rib, pleural domes, cubital fossa - what struc might u injure when
inserting in median cubital vein (MBTR), saphenous vein (saph nerve and innervation)
Venous cutdown sites –

1. Greater saphenous vein 2 cm superior and anterior to medial malleolus (transverse incision,
blunt dissection of vein, 2 ties – distal to ligate, proximal to secure cannula),
2. Median cubital vein/basilar vein at antecubital fossa.
Saphenous vein – saphenous vein continues the medial side of the dorsal network of veins and
runs anterior to the medial malleolus with the saphenous nerve anterior to it (a cutaneous branch
of femoral nerve L2-4 that traverses the adductor canal with femoral artery/vein to supply the
skin of the medial side of the leg/ankle/foot/to great toe)
8. Limbs and spine:

Stem: Young boy fell.
Showed xray: supracondylar fracture
Upper limb: Bone anatomy. Prominence. Muscle attachements.
9. Lower limbs.
Anatomy of the plantar and dorsi flexors of the foot. Asked to identify the tendons with a metal
pointer. Muscles and attachments/ actions.
Plantar flexors of foot:

1. Gastrocnemius – Superficial posterior compartment. Two heads arise from emdial and lateral
epicondyles of femur. Inserts onto the tuberosity at the back of the calcaneus. Also flexus the knee.
2. Soleus – Deep to gastrocnemius. Still part of the superfical posterior compartment. Arises from
the back of the head of the fibula and soleal line of tibia. Fibres merge with the achilles tendon.
Only acts to plantar flex ankle.
3. Plantaris – Arises from posterior surface of lateral femoral condyle, inserts into calcaneal
tuberosity medial to achilles tendon. Only acts to plantarflex ankle.
4. Tibialis posterior – Part of the deep posterior compartment. Arises from lateral half of the upper
part of the tibia and medial side of the upper part of the fibula. Also inverts foot.
Runs underneath the medial malleolus and runs into the sole of the foot
Inserts principally into the navicular bone, but tendon fans out to insert also into the orhter tarsal
bones (except the talus).
5. Peroneus longus – Arises from lateral surface of proximal two thirds of fibula. Runs behind the
lateral malleolus, underneath the calcaneus and inserts into the base of first metatarsal.
Also everts the foot.
6. Peroneus brevis – Arises from distal two thirds of fibula. Runs behind the lateral malleolus
anterior to the teondon of the peroneus longus. Inserts into the base of the 5th metatarsal. Also everts
foot.
Dorsi flexors of the foot:

1. Tibialis anterior – Anterior compartment of the leg. Arise from lateral side of the proximal tibial
shaft. Crosses the front of the tibia and top of ankle, inserts into the base of the first metatarsal. Also
inverts the foot.
2. Peroneus tertius – Arises from distal fibula and inserts into the base of the 5th metatarsal.
Medial and lateral arch of foot.

Medial Longitudinal Arch & Lateral Longitudinal Arch
Medial Longitudinal Arch Lateral Longitudinal Arch
Bones 1. calcaneum 1. calcaneum
2. talus = keystone 2. cuboid
3. navicular 3. 4th & 5th metatarsals
4. 3 cuneiforms
5. first 3 metatarsals
Support &
Maintenance  sustentaculum tali  not very impt
1. Shape of Bones holds up the talus  minimal shaping
 rounded head of talus btw calcaneum &
fits into concavity of navicular cuboid
 navicular in turn cuboid = keystone
fits into med cuneiform
Talus = keystone
2. Intersegmental inf edges of bones are tied tog by inf edges of bines are tied
Ties 1. Spring lig: From tog by
(ligaments) sustentaculum tali of calcaneus 1. long & short plantar lig
to navicular bone. Short plantar:
2. insertions of tibialis post Calcaneus to cuboid.
(inserts into all tarsal bones Long plantar:
except talus, metatarsals) Calcaneus to 2,3,4
metatarsal, covers short
plantar.
3. Beams 1. plantar apo 1. plantar aponeurosis
connecting 2. Medial part of flexor dig 2. lat part of flexor dig
both ends of longus & brevis longus & brevis
arch 3. Medial part of flexor hallucis 3. abductor digiti minimi
(muscles) longus & brevis
4. abductor hallucis
5. Tibialis posterior
11. Anat: crushed limb- live person

point out extensor hallucis longus, extensor digitorum, Ant tib artery, post tib artery, dorsalis pedis
point out the levels of dermatome
where does saphenous and sural nerve supply?

Saphenous nerve comes from femoral nerve, supplies cutaneous supply to medial leg, ankle foot
and toe.
Sural nerve comes from tibial nerve, supplies posterior leg, lateral side of foot and 5th toe.
what action ant compartment do?

Dorsiflexion.
Tibialis anterior is a strong invertor. Peroneus tertius is an evertor.
post compartment?
Plantarflexion of foot by gastrocnemius, soleus, plantaris.
Tibialis posterior inverts foot. Peroneus longus and brevis everts foot.
lat compartment?
Peroneus longus and brevis everts foot.
how u test EHL?

Dorsiflexion of big toe. (Innervated by L5)
Innervation of the compartements (muscular)

Superficial and deep posterior: By tibial nerve (from sciatic)
Lateral compartment: By superficial peroneal nerve from common peroneal (from sciatic)
Anterior compartment: By deep peroneal nerve from common peroneal (from sciatic)
Cutaneous supply of the lower limb

Anterior lateral thigh: Lateral cutanous nerve of thigh (L2,3)
Anterior medial thigh: Medial cutanous nerve of thigh (from femoral nerve)
Posterior thigh: Posterior cutanous nerve of thigh (S1,2,3)
Anterior lateral leg: Superficial peroneal nerve (from common peroneal nerve)
Anterior medial leg: Saphenous nerve (from femoral nerve)
Posterior leg: Sural nerve (from tibial nerve)
13. Right leg

- which nerve supplies here?
Deep peroneal: Space between 1st and 2nd toes.
Superficial peroneal: Lateral leg.
Saphenous nerve: Medial leg.
Sural nerve: Posterior lateral calf (anterior lateral calf by superficial peroneal), Lateral foot and 5th
toe.
 Saphenous nerve accompanies?

Greater saphenous vein and passes anterior to medial malleolus.
- Sural nerve accompanies?

Lesser saphenous vein to pass posterior to lateral malleolus.

 Saphenous nerve is part of which nerve?
Femoral nerve
 Sural nerve is part of which nerve?

Tibial nerve.
 What are the branches of tibial nerve supply to?

1. Muscular branches to gastroc, soleus and popliteus (superifical posterior) and tibialis
posterior, flexor digitorum longus and flexor hallucis longus (deep posterior).
2. Cutaneos branches as the sural nerve to provide sensation to lateral foot and 5th toe.
3. Articular branch to supply the knee
4. In the foot the tibial nerve gives rise to medial plantar and lateral plantar branches:
Medial plantar branch: Supplies the intrinsic muscles of toes: Abductor hallucis, flexor
digitorum brevis, flexor hallucis brevis, 1st lumbrical.
Lateral plantar branch: Supplies adductor hallucis, interossei, 3 lumbricals, flexor and
abductor digiti minimi.
Lower limb anatomy 5 muscles in the posterior compartment

Action of muscles ant and posterior tibialis cause inversion, peroneal muscles cause eversion, soles
and gastrocs cause plantar flexion
1. Gastrocnemius – (Superficial posterior compartment). Two heads arise from emdial and lateral
epicondyles of femur. Inserts onto the tuberosity at the back of the calcaneus. Also flexus the knee.
2. Soleus – (Superficial posterior compartment). Deep to gastrocnemius. Arises from the back of
the head of the fibula and soleal line of tibia. Fibres merge with the achilles tendon. Only acts to
plantar flex ankle.
Plantaris – Arises from posterior surface of lateral femoral condyle, inserts into calcaneal tuberosity
medial to achilles tendon. Only acts to plantarflex ankle.
4. Tibialis posterior – (Deep posterior compartment) Arises from lateral half of the upper pat of the
back of the tibia and from the medial side of the upper part of the fibula. Inserts into the navicular
bone, tarsal bones except talus and bases of middle 3 metatarsals. Plantarflex and inverts the foot.
5. Flexor hallucis longus – (Deep posterior compartment) Arises from the lower 2/3 of the back of
fibula. Runs under the medial malleolus. Inserts inot the distal phalanx fo the big toe.
6. Flexor digitorum longs – (Deep posterior compartment) Arises from the back of the tibial shaft,
runs under medial malleolus, divides into 4 bands each inserting into the distal phalanx of the toes.
Anatomy
Boundaries of adductor canal, femoral triangle, femoral canal
Femoral Triangle
It is a triangular depressed area situated in upper part of med aspect of thigh, just below inguinal lig
Boundaries
base ing lig
med border adductor longus
lat border sartorius
Supeirior Inguinal ligament
floor lat = iliopsoas
middle = pectineus
med = adductor longus
roof skin & fascia
Boundaries of femoral canal

Anterior Inguinal ligament
Posterior Pectineus
Laterally Femoral vein
Medially Lacunar ligament
Adductor canal
Extends from inferior angle of femoral triangle to adductor hiatus
Boundaries
Medially Vastus medialis
Laterally Sartorius
Posteriorly Adductor magnus, adductor longus
Contents of the adductor canal:

1. Femoral artery
2. Femoral vein
3. Saphenous nerve
4. Nerve to vastus medialis
Dermatomes of upper thigh
Muscles supplied by femoral nerve

Anterior muscles of the thigh:
- Quadriceps femoris: Rectus femoris
Vastus medialis
Vastus lateralis
Vastus intermedius
- Sartorius
- Pectineus
Floor of femoral triangle

lat = iliopsoas
middle = pectineus
med = adductor longus
Lumbar roots of femoral nerve

L2, 3 & 4
Branches of deep femoral artery

Profunda femoris artery, gives the
1. lateral femoral circumflex artery
2. Medial femoral circumflex artery
3. Perforating branches to perforate the adductor magnus to supply the posterior and medial
compartments of the thigh
4.
anatomy skeleton
Identify greater troch:
Gluteus medius
Gluteus minimus
Obturator internus
Superior gamellus
inferior gamellus
piriformis
Vastus lateralis (in front)
lesser troch femur:

Iliopsoas
Lesser tubercle humerus:

Subscapularis
Teres major
Greater tubercle humerus:

Supraspinatus
Infraspinatus
teres minor
Pec major.
Rotator cuff muscles origin insertions
Supraspinatus:
- From supraspinous fossa
- Inserts into greater tubercle
- Runs underneath acromion
- Abducts arm
- Innervated by suprascapular nerve (C5,6)
Infraspinatus:
- From infraspinous fossa
- Inserts into greater tubercle
- Runs across back of shoulder joint, inserts into greater tubercle
- External rotation
- Supplied by suprascapular nerve
Teres minor:
- From dorsal surface of scapular
- Runs across back of shoulder joint, inserts into greater tubercle
- External rotation
- Supplied by axillary nerve
Subscapularis:
- From anterior surface of scapular
- Runs across front of shoulder joint, inserts into lesser tubercle
- Internal rotation
- Supplied by lateral subscapular nerve
ASIS muscle attach:
Sartorius, inguinal ligament.
What runs medial to it
lateral cutaneous nerve of thigh
What entrapment
meralgia parasthetica.
Numbness or pain in the outer thigh
The lateral cutaneous nerve of the thigh most often becomes injured by entrapment or compression
where it passes between the upper front hip bone (ilium) and the inguinal ligament near the
attachment at the anterior superior iliac spine (the upper point of the hip bone).
Spiral groove-nerve:
Radial nerve
Medial epicondyle:
Ulnar nerve
Why does radial nerve inj result in wrist grip weakness:
Unable to extend wrist. Grip is strong with wrist in extension.
Lower limb show me asis and pubic tubercle

What runs in between
Inguinal ligament
Point out where inguinal hernia arises from

From superficial ring, weakness in the external oblique aponeurosis.
Comes out above and medial to the pubic tubercle.
Show me where the femoral hernia comes out from

Comes from the femoral canal.
What muscles attach to asis

Sartorius, inguinal ligament.
where does gluteus attach

Gluteus Maximus
 It is the largest musde in the body.
 It is responsible for the prominence of the buttock
Origin from 1. Ilial crest
2. post surface of sacrum & coccyx
3. sacrotuberous lig
Insertion into: 1. iliotibial tract
2. gluteal tuberosity of femur
Nerve Supply inf gluteal n (L5-S2)
Actions 4. extends
5. laterally rotates
6. supports knee jt via iliotibial tract
Gluteus Medius
Origin From posterior ilium between posterior and middle gluteal line.
Insertion into lat surface of greater trochanter of femur
Actions 4. abducts
5. medially rotates
6. supporls pelvis during walking & running
ie. prevents pelvis from dipping downwards on opposite side
Gluteus Minimus
Origin from posterior surface of ilium btw middle & inf gluteal lines
Insertion into ant surface of greater trochanter
Actions 4. abducts
5. medially rotates
6. supports pelvis during movement
How abt quad femoris

It is a lateral rotator of the thigh.
It arises from the lateral edge of the ischial tuberosity and inserts into the intertrochanteric crest on
the back of the femur.
Supplied by nerve to quadrator femoris. (which supplies the inferior gamellius as well)
3.Inguinal ligament, adductor canal, Femoral triangle anatomy
Anatomy (Lower Limb)

Identify femoral triangle, femoral vein, what is medial to it (femoral canal, containing Cloquet’s
node and lymphatics)
Identify rectus femoris, function (flex hip, extend knee)
Identify ITB, muscles attached (gluteus maximus, tensor fascia lata), function (lock knee in
extension)
Identify gluteus medius, nerve supply (superior gluteal nerve), function while walking (pelvic tilt)
Identify biceps femoris (short/long head), nerve supply (short head innervated by common peroneal
branch, long head by tibial branch)
Identify semitendinosus semimembranosus, function (flex knee)
Identify common peroneal nerve, landmark (neck of fibula), muscle groups supplied (anterior by
deep peroneal nerve, lateral compartment by superficial peroneal nerve), sensory distribution
(posterior and lateral aspect of leg, dorsum of foot)
Identify gastrocnemius, nerve supply (tibial nerve)
FHL weakness plus dorsum numbness – suspect L5 nerve root.
HISTORY TAKING – LIMBS
1. Hisotry taking: Vascular claudication

patient was and actor
standar history: chornic smoker. no other medical problems. vascular vs neurogenic
claudications.
PRESENTING COMPLAIN
1. Claudication
- Which part of the lower limb does the pain occur in
- Nature of the pain
- Radiation
- Severity
- Aggravating factors – exertion
- Relieving factors – rest (just standing is sufficient)
- Associated symptoms e.g. impotence in LeRiche’s
- When did pain first start
- Progress since first noticed until currently (worsening pain, increasing areas of lower limb affected, pain
on less exertion, development of rest pain)
- Current claudication distance
- How has symptoms affected lifestyle e.g. impaired mobility
2. Any rest pain
- Site, nature, severity
- Aggravating factors – raising the limb
- Relieving factors – putting limb in a dependent position
- Able to relieve with normal analgesics? Or require opioid analgesia?
- How long has rest pain lasted for requiring opioid analgesia (if more than 2 weeks, considered a feature of
critical limb ischaemia)
3. Any ulcer or gangrene in the lower limb?
- Ask about onset of ulcer/gangrene
- Progress (stable, or increasing in size, getting worse)
- If ulcer, any preceding trauma? Ill-fitting shoes? Altered sensation in the foot? Does patient take care to
protect foot? Pain? Redness/swelling/warmth in surrounding skin? Purulent/foul-smelling discharge from
the ulcer?
- If gangrene, is it wet or dry? Redness/swelling/warmth in surrounding skin? Any feeling in the toe
involved? Any sensory changes in the other normal toes, foot, limb?
- Any systemic signs of infection – fever, chills, rigors, malaise
Management so far:
- Any self medication to ulcer?
- Tried conservative therapy like walking, stopping smoking, pentoxyphylline?
PAST MEDIAL HISTORY

4. Risk factors (“Arteropath”)
- Diabetes mellitus – take a full diabetic history including other complications
- Hyperlipidaemia
- Heart disease
- Stroke
- Smoking
- Family history
5. DRUG/MEDICATION HISTORY
SMOKING/ALCOHOLIC HISTORY
- Aspirin intake
- Any allergies to contrast (for angiography) and also renal function.
- Ergots
6. SOCIAL HISTORY/FAMILY HISTORY
- Premorbid function and current function
- Social support and home condition (need to climb stairs?)
3. Questions: Differentials.
Clinical examination. Bed side tests: ABPI. How to perform ABPI and interpret.
1. Ankle-brachial pressure index
- How the ankle-brachial pressure index is done
 Brachial pressure is measured with a blood pressure cuff around the arm and a Doppler probe at the
brachial artery – cuff is inflated until the arterial signal is obliterated, then slowly deflated until the
signal just starts being detected, at which the pressure is recorded
 Ankle pressures are measured in a similar manner, with the cuff around the calf and the Doppler at the
dorsalis pedis and posterior tibial arteries – one reading for each artery
 The ankle pressure to be used for each leg is the higher of the two taken
 This ankle pressure is then divided by the brachial pressure (the higher of the two brachial pressures
for both upper limbs) to get the ankle-brachial pressure index
- Interpreting the values
 Normal ABPI is greater than 0.9 (can be more than 1.0 as ankle pressures tend to be higher than
brachial; if >1.3, suggests non-compressible calcified vessel)
 ABPI between 0.5 to 0.9 – occlusion, often associated with claudication
 ABPI <0.5: Critical ischaemia
- Accuracy of the index
 ABPI below 0.9 has 95% sensitivity and 100% specificity for detecting angiogram-positive peripheral
arterial disease and is associated with >50% stenosis in one or more major vessels
- Exercise treadmill testing
 Measure ABPI before and after patient exercises on a treadmill
 If the ABPI falls by >0.2  claudication
Further investigations like Vascular study.

Duplex ultrasound
- Non-invasive test, good alternative to angiogram
- Duplex (means two modalities) = 2D ultrasound (like the normal kind) plus Doppler ultrasound (measures
flow and waveforms)
- Normal arterial flow waveform should be triphasic; biphasic and monophasic waves are abnormal
- Can define anatomy of occlusions and also look for relatively good arteries distally for “landing zone” of
bypass graft
-
Angiogram (arteriogram)
- Invasive and associated with risks of bleeding from arterial puncture, dissection/damage to artery with
worsening ischaemia
- Usually only done if planning intervention e.g. angioplasty, stenting
- Preparing for angiogram:
 Take informed consent from patient
 Ask about contrast allergy, asthma, renal disease, metformin
 Investigations: FBC (platelets impt), PT/PTT, creatinine
- Angiogram with digital subtraction – the images of the underlying bone are removed so as to better
visualise the arteries (if the bones are visible, then it is a normal angiogram, without digital subtraction)
Non medical, medical and surgical management.

Conservative
- Smoking cessation
- Exercise training
 Exercise at least half to one hour every day
 Walk until pain comes, rest 2-3 minutes, walk again
 Keep a walk diary recording daily claudication distance in paces
 Will stimulate collateral formation  symptoms get better
- Podiatrist to teach foot care
- Assessment of cardiovascular risk factors and treatment to optimise control – cardiologist
- Teach patient about symptoms of critical ischaemia, to return to ED if such symptoms arise
- Antiplatelets e.g. aspirin
- Statins for CVS risk factors


- ?Use of Vasteral (methoxyphylline): acts by decreasing viscosity of blood
- Monitor regularly with measurement of ABPI
Intervention (endovascular or surgical)

- At least 6 months of conservative treatment first
- Monitor claudication distance and ABPI – intervene if deteriorating despite conservative management
- If parameters improve but then plateau, discuss with patient about whether he can accept the level of symptoms,
and the risks of intervention  weigh risks against benefits
- Usually do angioplasty rather than bypass as it is less invasive, though may not be as effective in treating the
symptoms
1. Angioplasty
 Stenting usually not done for lower limbs except in aortoiliacs (since stent needs to be placed in a
vessel which is relatively fixed and won’t be kinked/bent by movement)
 Angioplasty only effective for focal stenotic lesions and better for large vessels
 Problem with angioplasty is that it is not long-lasting – restenosis can occur
 New method: subintimal angioplasty – if lumen is so occluded that guide wire cannot pass through,
the guidewire is threaded into the subintimal space to create a dissection around the occluded segment,
and this space is then angioplastied to create a channel parallel to the actual lumen for blood to flow
through
2. Bypass grafting
 Consider bypass when lesions cannot be treated by angioplasty i.e. lesion extends for long distance
through the vessel and/or no lumen for guide wire to pass through (complete occlusion)
 Needs a good “landing zone” for graft distally – if vessel is diffusely diseased, difficult to perform
bypass like in microangiopathy of diabetes.
TREATMENT OF CRITICAL LIMB ISCHAEMIA

Need to revascularise – see interventions above
Wet gangrene: amputate then revascularis.
Ulcer: VAC, maggot therapy, hyperbaric O2 therapy.
AMPUTATION
Indications (3 D’s)
1. Dead
 Necrotic tissue
2. Dangerous
 Gangrene, ascending sepsis

3. Damn nuisance
 Non-functional limb; bad smell; pain; constant need to dress wound
- Level of amputation depends on vascularity of the limb and the indication (e.g. if infected, need to amputate
above level of infection)
- As far as possible try to preserve function of the lower limb
- May require revascularisation interventions before amputation to ensure good healing, or to enable lower
amputation
- Do not simply amputate without ensuring good vascular supply to the surgical site, otherwise the wound will
not heal
History taking
Vascular claudication 6/12. Distinguish from neurogenic. Look for risk factors including family
history. Questions on distinguishing between vascular/neurogenic, clinical assessment (pulses,
ABPI, Doppler), if ABPI 0.8 what next (conservative mx – control risk factors, stop smoking,
exercise regime, aspirin). Do not say conservative vs surgical mx if it is mild. Got glared at for even
letting the words arterial duplex escape my mouth.
hx taking left knee pain

With night pain LOW
Prev medial meniscus repair 25 years aog
Summarise hx
Age
Drug allergies
Occupation
Presenting complain:
pain
-site: Medial/lateral (medial compartment OA, collateral ligament strain, meniscal tear),
anterior knee (quadriceps mechanism, OSD), back of knee (OA, RA)
Other joints affected?
- Onset: Chronic or acute onset
- Character: Mechanical VS non mechanical

Morning pain
Worse with activity or immobility
Relieved by rest?
-radiation
-constant or intermittent
-Associations: Swelling, stiffness, locking, deformity, numbness/weaknesship pain, back

pain.
Associated symptoms:
Stiffness – worse in morning or end of day, movement or immobility makes it worse
Swelling: diffuse, a/w tenderness? Erythema?, duration, relieving factors?
Deformity
Instability,
Locking: unable to straighten knee completely.
Numbness/weakness: Neurological involvement, back pain??
- Time
-(Exacerbating activity)
-(relieving activity)
- severity/pain score
Red flags: (atiology)

- Trauma: History of falls, osteoporosis
- Infection: Fever, night sweats, chills and rigors, insidious onset
- Malignancy: LOA, LOW
Functional disability
- Limp. Climbing up and down stairs. Dressing.
- Walking aids? Distance she can walk b4 pain is intolerable?
- Knee functional score: squatting (squatting toilet?), climbing stairs, getting up from seat?
- Community: marketing?
- Work?
- Recreational: activities patient enjoys? Can pt still do them now?
ADL:
- Does it disturb sleep?
Past medical history/treatment history:

- Gout/RA, other autoimmune disease
- DM, HTN, LIPIDS, Previous hospitalization
- NSAIDS
- Physiotherapy
- Injections: Steroids, synvisc.
- Surgery: Arthroscope, synovial tap, osteotomy, knee replacement
- Any plans for operation.
Social/family history
Current/previous job
Affected job?
Drug history
Smoking
Alcohol
TCM, steroids
What are the differential diagnosis?

Degenerative:
- OA
- CMP: Irritation and degeneration of the undersurgace of the patella
- OSD: Traction apophysitis at patella ligament insertion to tibial tuberosity
Traumatic:
- ACL tear: Traumatic with haemarthrosis
- Meniscal tear: Locking, swelling
- Collateral ligment injury
- Osteochondritis dessicans: Osteocartilaginous fragment of medial femoral condyle, usually aw
trauma.
Inflammatory
- Actue septic arthritis
- RA
- Gout/pseudogout
- Reactive arthritis: Urethral discharge, red eyes, diarrhea, affects other joints as well.
What investigations would you do:

Blood investigations
- FBC: increased WCC
- ESR CRP
- Blood cultures: If septicaemic
- Uric acid: Rule out gout
- RF: for RA
Aspiration
- Bacterial C/S
- Light microscopy for crystals
Imaging
- Xray: AP, lateral, weight bearing
Bone: lesion, fracture, deformity, osteoporosis
Joint, loss of joint space, osteophytes, subchondral sclerosis, subchondral cysts, destruction.
Soft tissue: Swelling, gas.
-MRI: To evaluate ligaments and menisci
What is the management of OA knees:

Management
Nonpharmacological
Physiotherapy Preservation and improvement of joint
mobility
Exercise Range of motion and muscle strengthening
exercises
Load Body weight reduction if obese
reduction Use of walking aids
Pharmacological
Paracetamol Should be first line drug; effective in a
proportion of patients
NSAIDs Must be used with special care in

 >60y
 previous history of GI bleed
 concurrent warfarin/ steroid medications
 renal dysfunction
Prescribe with PPI/H2RA in patients with

increased likelihood of GI bleeding
COX-2 Vioxx a/w increased risk of stroke and
inhibitors cardiac events.
Glucosamine Glucosamine has anti-inflammatory

with properties
chondroitin Chondroitin inhibits cartilage breakdown and
stimulate cartilage repair
Have been found to be at least as effective as
NSAIDS, with the added advantage of fewer
side effects
Tramadol Consider in patients with highly-resistant
pain
Intraarticular Consider is patients with highly resistant
injections of pain. It is recommended that no more than 4
corticosteroid glucocorticoid injections be administered to a
s single joint per year because of the concerns
with long-term damage to cartilage
Intraarticular Marketed as ‘joint replacement’ substances;
hyaluronic expensive
acid injections
(e.g. Synvisc)
Surgical
Minimally For early degenerative arthritis
invasive Alternative to osteotomy and total knee
(Arthroscopic replacement if the patient is reluctant to have
) more aggressive surgery
Techniques include
 Washout and debridement
 Cartilage regeneration procedures
o Chondrocyte transplant
o Microfracture of subchondral
bone
o Mosaicplasty
Arthroscopic surgery may defer definitive
operation by up to 5 years
High tibial Only in certain cases e.g. unicompartmental
osteotomy involvement. Osteotomy permits
redistribution of weight
Contraindications
 Inflammatory arthritis
 Severe flexion deformity >15o
 Varus/ valgus >15o
 >5mm loss of subchondral bone

 lateral thrust while walking
Knee When symptoms are severe
replacement Try to avoid doing in patients <60 as TKRs
usu last only ~10y
 can be
o Unicompartmental
o Total +/- preservation of
PCL; PCL preservation
preserves proprioception
function but  wear of
prosthesis
Complications
 Wear of polythene surfaces
 Loosening of prosthesis-bone junction
 Thromboembolism (DVT, PE, stroke)
 Vascular & nerve injuries
 Infection: Management: 2 stages
 Removal of implant, plus 6 weeks IV
antibiotics
 Reimplantation after Abx completed
Cartilage regeneration procedures

Chondrocyte Harvest condrocytes from non weight-bearing
transplant sites, e.g. patellofemoral surface, culture,
reimplant
Microfracture Subchondral penetration of bone, inducing
regrowth of fibrocartilage
Mosaicplasty Cylindrical cartilage taken from non-weight
bearing areas, implanted on knee joint surface
to form a new layer of cartilage, comprised of
the intact original cartilage and the transplanted
grafts
Post-surgical
Physiotherapy To maintain joint ROM &
Continuous Passive Movement (CPM) muscle power
PHYSICAL EXAMINATION – LIMBS
Physical examination
OA knee. Straightforward. Remember to walk patient, look for walking aids, check neurovascular
status at the end.
Standing
Inspect
1. Scars – front, back and side
2. Swelling
Popliteal cyst (Baker’s cyst) – Sign of OA

- Synovial cyst
- Cyst clears when the knee is flexed
Semimembranosus cyst – Also a synovial cyst
- Between semimembranosus and medial head of
gastronemius.
- Does not empty when knee is flexed.
3. Symmetry
4. Sinus
5. Erythema
6. Deformity:
Genu valgus and varus,
GAIT!!! Walk the patient.
Supine
Inspection
1. Muscle wasting (especially the vastus medialis)

2. Swelling – loss of the lateral hollows in the parapatellar fossas
3. Scars
4. Sinuses
5. Skin changes
6. Fixed flexion deformity
Palpation
1. Feel for warmth. (Use back of hand)

2. If muscle wasting detected: test circumference of quadriceps
3. Test for effusion (limits of the synovial cavity and suprapatellar pouch)
- Patella tap (50cc)
– Bulge test (10cc)
3. Patella:
Clarks Patella grind test- Test for patella femoral OA and chondromalacia patellae
4. Tenderness: (knee flexed) Normal:135

1. Up the tibia and palpate the tibial tubercle – Osgood Schlatter’s disease
- Avulsion injury due to patellar
ligament tear.
2. Patella ligament
3. Point of insertion of patella ligament to patella – Sinding Larsen Johansson
disease. “Jumper’s knee”.
4. Joint lines. Look for the hollows at the side of the patella ligament when the
knee is flexed. The joint lines are right underneath it. Localized tenderness
could indicate a meniscus injury or collateral ligament injury.
5. Quadriceps tendon insertion to patella.
5. Passive flexion and extension

6. Active flexion and extension (With palm on knee feeling for crepitus)
7. Extension lag and fixed flexion deformity

From a flexed position, ask the patient to lift and extend leg as much as possible.
Extension lag – Patient can only actively extend up to a certain point, but can be
fully extended passively. Indicates quads wasting and OA.
Fixed flexion deformity – Full flexion cannot be achieved both actively and
passively.
- Check for hyperextension (genu recurvatum) at the same time.

- Seen in girls associated with high patella (patella alta), recurrent dislocation of the
patella, tears of ACL, medial ligament, medial meniscus (O’ donogue sign)
Special tests
1. Cruciate ligaments
Put both legs together in a flexed position first
- Always look for a posterior sag sign (Galeazzi sign) that would indicate a PCL tear
first!!
- Anterior drawer test: ACL (Once PCL tear has been ruled out to omit any false
positives)
Lift up leg at 30degrees flexion.

- Lachman test: Knee flexed at about 15 to 30 degrees. 1 hand on calve 1 hand on
thigh.
2. Collateral ligaments
- Support the knee at abt 30 degrees. At this point the cruciate ligaments and
posterior capsule is relaxed. So you know you are testing the collaterals solely.
- Varus stress for lateral collateral ligament.
- Valgus stress for medial collateral ligament.
1. Mc Murray’s test (meniscus)

Medial meniscus – Flex leg fully, externally rotate foot, abduct the lower leg and extend the joint
smoothly.
Lateral meniscus – Flex leg fully, internally rotate foot, adduct lower leg and extend join smoothly.
Assess Vascular status!!
Dorsalis pedis
Posterior tibial
Popliteal
Femoral
Questions on diagnosis, severity, importance of NV status.

Mainly questions on why you do certain parts of the examination.
What extensor lag represents: Indicates quadriceps wasting or OA.
Why you measure circumference set distances above and below tibial tuberosity.
Examine patient’s right knee

- Scar over anterolateral aspect of right knee
- Normal gait
- Temp / power – normal
- Tender over lateral side of joint line
- Patella tap, ant drawer, Lachman’s test – positive
- Post drawer, varus/valgus test – negative
- McMurray’s medial and lateral – positive
Examine this patient’s right knee
- a longitudinal scar noted over lateral right thigh
- patient has antalgic gait
- there was posterior lag
- drawer’s test positive
- what is the diagnosis? Right PCL tear
- Rt knee effusion with ACL tear and likely medial/lateral meniscus injury
Hip exam - had bilateral hip OA with reduced int+ external rotation more on Right with antalgic gait. includes
discussion of findings + diagnosis and explanation of trendelenburg test.
hip exam-b/l THR

Gross ROM limitation with lateral scars trendenlenburg + no LLD
Ddx ix mx
Muscular or prosthetic problems
Female-hard to expose, do running commentary so examiner understands ur problem
IX-XR MRI (for muscles)
Mx-PTOT revision sx
2. Varicose veins – very enthusiastic gentleman (venous)

- Tap test
- Did tourniquet test at SFJ, SPJ, Perthes test – veins did not collapse
- Said incompetent at SFJ, SPJ and deep perforators
- What would they present with?
-Asymptomatic
-Discomfort
-Venous insufficiency -> hyperpigmentation, oedema, lipodermatosclerosis
- What treatment would you offer him?
-Duplex scan the deep veins are patent
-Offer him either endovascular vs surgical
-Surgical I would offer him ligation of SPF, SFJ, stripping of vein and stab avulsions of perforators
-Endovascular -> EVLT/RFA
(some friends say they got to Doppler the varicose veins)
3. Examination of the hips, post-THR on the left. discussion findings, investigation and explain how
to interpret the Trendelenburg's test (my 3rd choice specialty)
4. Limbs and spine: OA HIp

- Pt was not primed properly. Kept complaining of right hip pain when the stem was a left hip
pathology.
- Signs: Right lateral THR scar. Trendelenburg on right leg. Gluteal wasting on right. Decrease
ROM globally on right > left.
Question:
- Differentials. Explain the tredenlenburg test. Explain and demonstrate thomas test.
- Imaging: Standing pelvis AP and lateral hip xray.
- Management: Non medical, medical and surgical
5. Varicose veins bilateral. (venous)

7mins to do pulses / sensation / tourniquet test. Even had a bedside Doppler. Difficult
station. Had to do everything very fast. Quizzed on anatomy of venous system and to
correlate your signs with anatomy.
Asked about the principle behind tourniquet test.
6. Back pain with sciatica

- back examination + neurological examination
- Investigation
- Treatment
3. Patient with left external fixator over left tibial region

- examine this patient
- left foot drop
- what do you want to palpate for? Mentioned pulses
- show me how to palpate for popliteal pulse on the right leg
- describe how do you palpate for popliteal pulse. What structure are you pressing it against?
- what is the diagnosis? Left foot drop due to deep peroneal nerve injury
 what are the muscles supplied by the deep peroneal nerve?
3. Examine LL
o Draw guy
o Multiple angulations of lower limbs, V shaped tibia
o Diagnosis – osteogenesis imperfect
o Questions
 Inheritance?
 Underlying pathology?
VASCULAR
1. Examine Lt LL
- Venous ulcer
- Varicose veins
Questions
 Show course of long saphenous vein
 Show course of short saphenous vein
 Site of SFJ
 Tourniquet test (theory)
 Management
 Stripping ?site
2. Examine Lt LL
o Distal leg and dorsum foot ulcer
 Exposed tendon
 ?how to know it is tendon – asked pt to move toes
o Calf muscle wasting
o After describing the ulcer
 Was asked what other examination wished to do
 Palpation – temp, CRT, pulses
 Show and describe how to locate pulses
Vascular (arterial)
1. Patient with left dry gangrenous big toe with no other toes
- spot diagnosis? Left ischaemic leg
- examine this patient
- what type of amputation has this patient had for the 4 other toes?
- describe where do you locate the PTA and DPA pulse
- how do you want to investigate this patient?
- if this patient has a no left popliteal pulse, mediocre left femoral pulse, assuming you have
optimised the patient’s BP, sugar level, lifestyle modification, what are the options you can offer to
the patient?
- what is the name of the endovascular technique you mentioned?
 what bypass will you do for this patient? Femoral-popliteal bypass
2. Left venous ulcers over anterior tibial and lateral tibial (venous)
- examine this patient.
- mentioned about multiple stab avulsion surgical scar, a long surgical scar over left mid thigh and
sapheno-femoral junction region
- examiner wants to know the shape of the leg: Beer bottle
- why do you think this is a venous ulcer?
- what is the common location for a venous ulcer?
- what operation has this patient undergone?
- if this patient has these ulcers before the surgery, and she presents to the clinic to see you, how do
you manage?
 what type of dressing will you do?
 - what type of bandaging will you do?
- any drugs?
- How does Daflon works?
- How does Pentoxyfillin (Trental) works?
VIVAS
1. Anatomy 1. Shown skeleton, which bones make up hip joint, stabilising factors, why iliofemroal
ligament strongest? Muscles of walking and climbing stairs on cadaver. Chap in room, hit side on
whilst cycling, extensive question about knee joint. Menisci, collaterals, blood supply, point on
cadaver. What invx? Shown MRI of knee, but not asked to comment, just asked, what would u see?
What other injury, com peroneal, how to test (on pt)? Also about ankle ligaments.
2. Veins for iv cannulation in arm and legs, structures at risk in median cubital cannula
- In the arm, medialn cubital vein commonly used for venipuncture because it is superficial. It is the
most prominent superficial vein in the body. Strcutures at risk in the cubital fossa are the brachial
artery and the median nerve, however they are protected by the bicipital aponeurosis.
- Other veins for cannulation in the arm are the basilic vein and the cephalic vein.
3. (venous)Varicose veins, Doppler etc, Tourniquet test, asked about signs on inspection
management, and what is Doppler.
4. Hx from lady with 6/12 hx of sciatic back pain. Recent onset of urinary symptoms, (only when
asked), present to examiners, differentials further invx. MRI-how soon, ie. Concern about cauda
equina.
5. Anatomy - lower limb ( leg) - nerve & reflexes root values, muscles spotters and muscles for foot
movements.
1-unmanned stations with full body skeleton and marked areas such as humerus , femur etc and
there is a paper with around 13 questions if i remember well, not easy to finish on time and you
better check all pages so you know how
5.Posterior approach of hip joint

 2nd most common approach
 Angled incision from PSIS to greater trochanter, then dropping vertically downwards.
 Gluteus maximus is split along the line of its fibres and incised along its tendinous insertion
(gluteal tuberosity)
 Lateral rotators detached from their insertions to the greater trochanter. Repair is advisable.
 Retract the piriformis (superior gluteal artery above, inferior gluteal artery and sciatic nerve
below)
 Nerve at risk: Sciatic nerve.
Other structures passing through the greater sciatic foramen:

 Superior gluteal and inferior gluteal arteries
 Superior gluteal and inferior gluteal nerves
 Piriformis
 Posterior cutaneous nerve of thigh
 Nerve to obturator internus
 Nerve to quadratus femoris
 Pudental nerve
 Obturator nerve
 Internal pudendal artery and vein

6. Given a lumbar vertebra

- what is this?
- which level of vertebra is this?
- what is this parts? Transverse process, pedicle, lamina, spinous process
- what is on top of this structure? intervertebral disc
- tell me the structures of the intervertebral disc? Anulus fibrosis, nucleus pulposus
- if intervertebral disc is damaged, how will it protrude?

- which level is most common?
- what is the root of the sciatic nerve?

0.5x ANATOMY LOWER LIMBS

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0.5x ANATOMY LOWER LIMBS

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ANATOMY – LOWER LIMBS

3. Gluteus medius: attachments and action when walking.

- Quadratus femoris and attachments

 functions - attach med malleolus to talus

Deltoid ligament anatomy.Basically whole anatomy of lowerlimb below the knee.

Venous cutdown sites –

8. Limbs and spine:

Plantar flexors of foot:

Dorsi flexors of the foot:

Medial and lateral arch of foot.

11. Anat: crushed limb- live person

where does saphenous and sural nerve supply?

what action ant compartment do?

how u test EHL?

Innervation of the compartements (muscular)

Cutaneous supply of the lower limb

13. Right leg

 Saphenous nerve accompanies?

- Sural nerve accompanies?

 Sural nerve is part of which nerve?

 What are the branches of tibial nerve supply to?

Lower limb anatomy 5 muscles in the posterior compartment

Boundaries of femoral canal

Contents of the adductor canal:

Dermatomes of upper thigh

Muscles supplied by femoral nerve

Floor of femoral triangle

Lumbar roots of femoral nerve

Branches of deep femoral artery

lesser troch femur:

Lesser tubercle humerus:

Greater tubercle humerus:

Rotator cuff muscles origin insertions

Lower limb show me asis and pubic tubercle

Point out where inguinal hernia arises from

Show me where the femoral hernia comes out from

What muscles attach to asis

where does gluteus attach

How abt quad femoris

3.Inguinal ligament, adductor canal, Femoral triangle anatomy

Anatomy (Lower Limb)

HISTORY TAKING – LIMBS

1. Hisotry taking: Vascular claudication

PAST MEDIAL HISTORY

Further investigations like Vascular study.

Non medical, medical and surgical management.

- Statins for CVS risk factors

Intervention (endovascular or surgical)

TREATMENT OF CRITICAL LIMB ISCHAEMIA

 Gangrene, ascending sepsis

hx taking left knee pain

- Onset: Chronic or acute onset

- Character: Mechanical VS non mechanical

-Associations: Swelling, stiffness, locking, deformity, numbness/weaknesship pain, back

Red flags: (atiology)

Past medical history/treatment history:

What are the differential diagnosis?

What investigations would you do:

What is the management of OA knees:

NSAIDs Must be used with special care in

Prescribe with PPI/H2RA in patients with

Glucosamine Glucosamine has anti-inflammatory