Lower limb

• The gluteal region extends from the gluteal fold to the iliac crest
• The neck of the femur extends from the head to the lesser and greater trochanter

  Ridge between the lesser and greater trochanter is the inter-trochanteric crest - where the capsule of the hip sits
• The medal and lateral condyles are at the distal end of the femur, above the knee
• The proximal tibia has medial and lateral condyles - between is the tibial tuberosity

  The distal tibia - medial malleolus
• The distal fibula has the lateral malleolus - bony prominence felt on the lateral ankle
• Hip stabilising factors:

  • anterior ligaments provide the most support to the hip joint - iliofemoral ligament is by far the strongest
  • Posterior ligament - shorter than anterior ligaments
  • Because the hip joint is much more supported anteriorly - more likely to dislocate posteriorly
• Blood supply to the neck of femur:

  • Supplied by the femoral artery
  • Femoral artery gives rise to medial and lateral circumflex arteries
  • Blood supply moves distal to proximal
  • Tiny arterial branch from pelvic artery supplies the very head of the femur
• Extracapsular / interochanteric fractures of neck of femur:

  • Fracture below the capsule and between the trochanters
  • blood supply to the head of the femur is not lost
  • Dynamic hip screw and aim to fully weight bare post op
• Intracapsular fracture:

  • Above the trochanteric line/crest
  • Blood supply to the head of the femur is interrupted
  • Ischaemia/avascular necrosis
  • Emergency surgery - hemi/total arthroplasty
• A fractured NOF will cause loss of shenton's line on an x-ray

  Should be a continuous line from the superior pubic ramus down to the lesser trochanter
• Typically a NOF presents with a shortened limb that is externally rotated
• Main flexor of the hip = iliopsoas muscle
• Main extensor of the hip = gluteus maximus
• Main abductors of the hip = gluteus medius and gluteus minimus
• The muscles of the medial thigh are the adductor muscles
• Compartments of the lower limb:

  • thigh - anterior compartment, medial compartment and posterior compartment
  • leg - anterior compartment, lateral compartment and posterior compartment
• Anterior compartment of the thigh:

  • quad muscles
  • Iliacus and psoas are main hip flexors
  • Quads extend the leg at the knee joint
  • Innervated by the femoral nerve
• Medial compartment of the thigh:

  • Adduction compartment
  • Innervated by the obturator nerve (pelvic nerve)
  • Arterial supply is by the obturator artery (pelvic artery)
• Posterior compartment of the thigh:

  • Flexes knee
  • Extends at the hip
  • Innervated by the sciatic nerve
• Gluteal muscles:

  • Gluteus maximus = power extensor
  • Gluteus medius and gluteus minimus = abductors
  • Piriformis = rotator
• The sciatic nerve passes underneath the piriformis muscle (rotator)
• Hip dislocation is more rare than shoulder - more stable ball and socket joint:

  • Posterior dislocation more likely
  • Trauma and prosthetic hips are the main risk factors
  • Blood supply to the head of femur and sciatic nerve will be stretched
  • Shortened, adducted and internally rotated limb
• Slipped upper femoral epiphysis:

  • Most common in adolescents - obesity is a major risk factor
  • Fracture through the growth plate - epiphysis
  • Head of femur remains in the socket and the femur below the growth plate shifts
  • Unstable and can lead to avascular necrosis
  • Treated with a screw to hold femur together
• Parthe's disease:

  • Childhood condition - boys aged 4-8 at most risk
  • Inadequate blood supply to the femoral head leading the avascular necrosis
  • 60% resolve with conservative management - no running, hip splints
• Contents of the popliteal fossa:

  • Tibial nerve
  • Popliteal vein
  • Popliteal artery
• The popliteal artery is a continuation of the femoral artery
• Genu varum = bowed leg

  • Commonly caused by osteoarthritis
  • Wearing of the medial knee joint
• Genu valgum = knock knee

  • Rheumatoid arthritis
  • Wearing of the lateral knee joint
• The patellar ligament attaches the tibial tuberosity to the patella
• Collateral ligaments of the knee:

  • Medial collateral ligament - attaches to the medial epicondyle of the femur and the medial condyle of the tibia - prevents valgum
  • Lateral collateral ligament - attaches to the lateral epicondyle of the femur and the lateral surface of the fibular head
  • The medial ligament is wider than the lateral ligament
• The cruciate ligaments of the knee:

  • Connect the femur and tibia
  • Anterior cruciate ligament (ACL)
  • Posterior cruciate ligament (PCL)
• Anterior cruciate ligament (ACL):

  • attaches to the anterior intercondylar region of the tibia where is ascends posteriorly to attach to the femur in the intercondylar fossa
  • Prevents anterior dislocation of the tibia onto the femur
  • Common MOI -medial rotation on a planted foot
  • ACL injury allows anterior displacement of tibia on a fixed femur - anterior draw test
• Posterior cruciate ligament (PCL):

  • attaches at the posterior intercondylar region of the tibia and ascends anteriorly to attach to the femoral condyle
  • Injury - direct blow to anterior tibia, hyperextension injury, dashboard injury
  • PCL injury allows posterior placement of tibia on fixed femur - posterior sag
• Menisci of the knee:

  • Medial and lateral menisci are C-shaped fibrocartilage rings located within the knee joint
  • The medial meniscus is also fixed to the medial collateral ligament and the joint capsule, therefore damage to the medial collateral ligament is often associated with a medial meniscus tear
• Unhappy triad of the knee with lateral side of the knee - medial collateral ligament, ACL and medial meniscus can all be injured
• The external iliac artery passes under the inguinal ligament and becomes the femoral artery
• The femoral artery along the thigh is anterior

  Passes through the adductor hiatus to become posterior - becomes the popliteal artery
• In the femoral triangle, the profunda femoris artery arises from the posterolateral aspect of the femoral artery – gives 3 main branches
• Posterior compartment of the leg:

  • Has a superficial and deep compartments
  • Tibial nerve
  • Posterior tibial artery
  • Plantar flexing- standing on tip toes
  • Inversion of the foot
• Lateral compartment of the leg:

  • Peroneal (fibula) nerve
  • Peroneal (fibula) artery
  • eversion of the foot