Acl Femoral Attachment

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Nerve Lesions

Nerve

Cause of Injury

Impairments

Clinical Features

Femcral

Obturator

Trauma at femoral triangle Pelvic fracture

Anterior hip dislocation Radical retropubic prostatectomy

Flexion of thigh is weakened

Extension of leg is lost Sensory loss on anterior thigh and medial leg

Adduction of thigh is lost Sensory loss on medial thigh

Loss of knee jerk reflex Anesthesia on anterior thigh

Superior gluteal

Surgery in area Posterior hip dislocation Poliomyelitis

Gluteus medius and minimus function is lost Ability to pull pelvis down and abduction of thigh are lost

Gluteus medius limp, or waddling gait

Positive Trendelenburg sign

Contralateral

Contralateral

Infericr gluteal

Surgery in area Posterior hip dislocation

Gluteus maximus function is lost Ability to rise from a seated position, climb stairs, or jump is lost

Leaning backward at heel strike

Common peroneal

Blow to lateral aspect of leg Fracture of neck of fibula

Eversion of foot is lost Dorsiflexion of foot is lost Extension of toes is lost Sensory loss on anterolateral leg and dorsum of the foot

Plantar flexion (foot drop) and inversion of foot Inability to stand on heels Walks with a foot slap

Tibial at popliteal fossa

Trauma at popliteal fossa

Inversion of foot is lost Plantar flexion of foot is los:

Flexion of toes is lost Sensory loss on sole of foot

Dorsiflexion and eversion of foot Inability to stand on toes

C. Superior gluteal nerve injury

1. The superior gluteal nerve may be injured during surgery, posterior dislocation of the hip, or poliomyelitis.

2. Paralysis of the gluteus medius and gluteus minimus muscles occurs so that the ability to pull the pelvis down and abduction of the thigh are lost.

3. Clinically, this condition is called "gluteus medius limp" or "waddling gait." The patient demonstrates a positive Trendelenburg sign, which is tested as follows. The patient stands with his or her back to the examiner and alternately raises each foot off the ground. If the superior gluteal nerve on the left side is injured, the right pelvis falls downward when the patient raises the right foot off the ground. Note that it is the side contralateral to the nerve injury that is affected. A Trendelenburg sign also can be observed in a patient with a hip dislocation or fracture of the neck of the femur.

D. Inferior gluteal nerve injury

1. The inferior gluteal nerve may be injured during surgery or posterior dislocation of the hip.

2. Paralysis of the gluteus maximus muscle occurs so that the ability to rise from a seated position, to climb stairs, or to jump is lost.

3. Clinically, the patient is able to walk. However, the patient leans the body trunk backward at heel strike to compensate for the loss of gluteus maximus function.

E. Common peroneal nerve injury

1. The common peroneal nerve may be injured as the result of a blow to the lateral aspect of the leg or fracture of the neck of the fibula. This is a very common type of injury.

2. Paralysis of the peroneus longus and peroneus brevis muscles (innervated by the superficial peroneal nerve) occurs so that eversión of the foot is lost.

3. Paralysis of the tibialis anterior muscle (innervated by the deep peroneal nerve) occurs so that dorsiflexion of the foot is lost.

4. Paralysis of the extensor digitorum longus and extensor hallucis longus muscles (innervated by the deep peroneal nerve) occurs so that extension of the toes is lost.

5. Sensory loss occurs on the anterolateral aspect of the leg and dorsum of the foot.

6. Clinically, the patient presents with the foot plantar flexed ("foot drop") and inverted. Because of the loss of dorsiflexion, the patient cannot stand on his or her heels. The patient has a high-stepping gait in which the foot is raised higher than normal so that the toes do not hit the ground. In addition, the foot is brought down suddenly, which produces a "slapping" sound (foot slap).

F. Tibial nerve injury at the popliteal fossa

1. The tibial nerve may be injured as a result of trauma at the popliteal fossa.

2. Paralysis of the tibialis posterior muscle occurs so that inversion of the foot is weakened.

3. Paralysis of the gastrocnemius, soleus, and plantaris muscles occurs so that plantar flexion of the foot is lost.

4. Paralysis of the flexor digitorum longus and flexor hallucis longus muscles occurs so that flexion of the toes is lost.

5. Sensory loss occurs on the sole of the foot.

6. Clinically, the patient presents with the foot dorsiflexed and everted. Because of the loss of plantar flexion, the patient cannot stand on his or her toes.

V. HIP AND GLUTEAL REGION (Figure 19-3). The piriformis muscle is the landmark of the gluteal region. The superior gluteal vessels and nerve emerge superior to the piriform muscle; the inferior gluteal vessels and nerve emerge inferior to it. Gluteal intramuscular injections can be safely made in the superolateral portion of the buttock.

A. The hip joint is the articulation of the head of the femur with the lunate surface of the acetabulum and the acetabular labrum. It is supported by the following ligaments:

1. The iliofemoral ligament (Y ligament of Bigelow) is the largest ligament and reinforces the hip joint anteriorly.

2. The pubofemoral ligament reinforces the hip joint inferiorly.

3. The ischiofemoral ligament is the thinnest ligament and reinforces the hip joint posteriorly.

4. The ligamentum teres plays a minor role in the stability of the hip joint, but carries the artery to the head of the femur.

B. The hip joint is related to the femoral triangle, which contains the following structures (listed medially > laterally):

1. The femoral canal (the most medial structure), which contains lymphatics and lymph nodes

2. The femoral vein. The great saphenous vein joins the femoral vein within the femoral triangle, just below and lateral to the pubic tubercle. A great saphenous vein cutdown can be performed at this site.

3. The femoral artery

4. The femoral nerve (the most lateral structure)

C. Clinical considerations

1. Femoral neck fracture most commonly occurs just distal to the femoral head (subcapital location) in elderly women who have osteoporosis. As a result, the lower limb is externally rotated and shorter than the uninjured limb. Avascular necrosis of the femoral head may occur if the medial and lateral circumflex arteries are compromised.

2. Posterior dislocation of the hip joint most commonly occurs due to severe trauma (e.g., car accident in which the flexed knee hits the dashboard). In a posterior dislocation, the head of the femur lies posterior to the iliofemoral ligament; the acetabulum may be fractured as well. As a result, the lower limb is internally rotated, adducted, and is shorter than the uninjured limb. Avascular necrosis of the femoral head may occur if the medial and lateral circumflex arteries are compromised. The sciatic nerve also may be damaged.

3. Anterior dislocation of the hip joint accounts for the remainder of hip dislocations. In an anterior dislocation, the head of the femur lies anterior to the iliofemoral ligament. As a result, the lower limb is externally rotated and abducted. The femoral artery may be damaged so that the lower limb may become cyanotic.

4. Legg-Perthes disease is characterized by idiopathic avascular necrosis of the head of the femur. This necrosis may occur when the medial and lateral circumflex arteries gradually replace the artery to the head of the femur as the main blood supply to this area. It most commonly affects Caucasian boys and causes unilateral hip pain,

Caucasus Left Femur

Figure 19-3. (A) Anteroposterior radiograph of the hip region. AF= acetabular fossa (curved dotted line): FH = femoral head; FN = femoral neck; GT= greater trochanter; IR = inferior ramus of the pubis; IT= ischial tuberosity; OB = obturator foramen; SL = Shenton line (a radiology term that describes a curved line drawn along the medial border of the femur and the superior border of the obturator foramen); SR = superior ramus of the pubis. (B) Anteroposterior radiograph of a femoral neck fracture (subcapital). In this type of fracture, seen most commonly in elderly women with osteoporosis, the lower limb is externally rotated and is shorter than the uninjured limb. A = oblique fracture line; FH = femoral head. (C) Anteroposterior radiograph of a posteriorly dislocated hip. This type of dislocation occurs most commonly in people who are involved in car accidents. The lower limb is internally rotated, adducted, and is shorter than the uninjured limb. AF = acetabular fossa; FH = dislocated femoral head. (D) Anteroposterior radiograph of an 8-year-old boy with Legg-Perthes disease. This patient had a limp and pain in the right hip. The femoral head on the right side (arrow) is almost completely absent, except for two bone fragments. The femoral head on the left side is normal. (A adapted with permission from Fleckenstein P, Tranum-Jensen J: Anatomy in Diagnostic Imaging. Philadelphia, WB Saunders, 1993, p 80; B and C adapted with permission from Levy RC, Hawkins H, Barsan WG: Radiology in Emergency Medicine. St. Louis, CV Mosby, 1986, pp 403, 405; D adapted with permission from Rosenbaum HD, Hildner JH: Basic Clinical Diagnostic Radiology. Baltimore, University Park Press, 1984, p 69.)

slight external rotation, and a limp. This disease has three major phases: initial, degenerative, and regenerative.

VI. KNEE REGION (Figure 19 4)

A. The knee (femorotibial) joint is the articulation of the medial and lateral condyles of the femur with the medial and lateral condyles of the tibia. It is supported by the following ligaments:

1. The patellar ligament, which is struck to elicit the knee-jerk reflex. This reflex is blocked by damage to the femoral nerve, which supplies the quadriceps muscle, or by damage to spinal cord segments L2—4.

2. The medial (tibial) collateral ligament extends from the medial epicondyle of the femur to the shaft of the tibia. This ligament prevents abduction at the knee joint; tearing causes abnormal passive abduction of the extended leg.

3. The lateral (fibular) collateral ligament extends from the lateral epicondyle of the femur to the head of the fibula. This ligament prevents adduction at the knee joint; tearing causes abnormal passive adduction of the extended leg.

4. The anterior cruciate ligament extends from the anterior aspect of the tibia to the lateral condyle of the femur. This ligament prevents anterior movement of the tibia in reference to the femur. A torn anterior cruciate ligament causes abnormal passive anterior displacement of the tibia (anterior drawer sign). Hyperextension injury at the knee joint stretches the anterior cruciate ligament.

5. The posterior cruciate ligament extends from the posterior aspect of the tibia to the medial condyle of the femur. This ligament prevents posterior movement of the tibia in reference to the femur. A torn posterior cruciate ligament causes abnormal passive posterior displacement of the tibia (posterior drawer sign). Hyperflexion injury at the knee joint stretches the posterior cruciate ligament.

B. The knee joint contains menisci, which include:

1. The medial meniscus, a C-shaped fibrocartilage that is attached to the medial collateral ligament. It is easily torn because it is not very mobile.

2. The lateral meniscus, an O-shaped fibrocartilage

C. The knee joint is related to the popliteal fossa, which contains the tibial nerve, common peroneal nerve, popliteal artery and vein, and small saphenous vein.

D. Clinical consideration. The terrible triad of O'Donoghue is caused by a violent blow on the lateral side of the knee (e.g., football "clipping") that causes abduction and lateral rotation. This injury causes tearing of the following structures:

1. Anterior cruciate ligament

2. Medial collateral ligament (because of excessive abduction of the knee joint)

3. Medial meniscus (as a result of its attachment to the medial collateral ligament)

Femur

Femur

Cruciate Ligament Attachment Femur
Violent blow

test for anterior cruciate ligament test for posterior cruciate ligament

Plantar Artery Small Saphenous Vein

Torn anterior cruciate ligament

Torn posterior cruciate ligament

VII. ANKLE AND FOOT REGION (Figure 19-5)

A. The ankle (talocrural) joint is the articulation of the inferior surface of the tibia with the trochlea of the talus. Dorsi flexion and plantar flexion of the foot occur at this joint. The ankle is supported by the following ligaments:

1. The medial (deltoid) ligament extends from the medial malleolus of the tibia to the talus, navicular, and calcaneus bones. It consists of the anterior tibiotalar, posterior tibiotalar, tibionavicular, and tibiocalcaneal ligaments.

2. The lateral ligament extei Js from the lateral malleolus of the fibula to the talus and calcaneus bones. This li jament consists of the anterior talofibular, posterior talofibular, and calcaneofibular ligaments.

B. The ankle (talocrural) joint contains the medial malleolus, which is related to the following structures:

1. The medial malleolus is related anteriorly to the saphenous nerve and great saphenous vein (an excellent location for a great saphenous vein cutdown).

2. The medial malleolus is related posteriorly to the flexor hallucis longus, flexor digitorum longus, and tibial posterior tendons; posterior tibial artery; and tibial nerve.

C. The subtalar joint is the articulation of the talus and the calcaneus. Inversion and eversión of the foot occur at this joint.

D. The transverse tarsal (Chopart) joint actually is two joints: the talonavicular joint and the calcaneocuboid joint. Inversion and eversión of the foot also occur at this joint.

E. The tarsometatarsal (Lisfranc) joint is the articulation of the tarsal bones with the metatarsals.

F. Clinical considerations (Figure 19-6)

1. Inversion injury is the most common ankle injury. It occurs when the foot is forcibly inverted and results in the following injuries:

a. Stretch or tear of the lateral ligament, most commonly the anterior talofibular ligament b. Fracture of the fibula c. Avulsion of the tuberosity of the fifth metatarsal (Jones fracture), where the peroneus brevis muscle attaches.

4 Figure 19-4. (A) Anteroposterior radiograph of the left knee. HF = head of fibula; IT = intercondylar tubercles; LFC = lateral femoral condyle; LTC = lateral tibial condyle; MFC = medial femoral condyle; MTC- medial tibial condyle; P= patella (dotted line indicates border). (B) "Terrible triad of O'Donoghue" injury to the left knee caused by a violent blow to the lateral side of the knee (e.g., football "clipping"). The curved arrows indicate the direction of movement at the knee joint (abduction and lateral rotation). The anterior cruciate ligament (ACL), medial meniscus (M), and medial collateral ligament (MCL) are torn. Other structures of the knee are uninjured. L = lateral meniscus; LCL = lateral collateral ligament; PCL = posterior cruciate ligament. (C) Clinical tests for a torn anterior cruciate ligament (anterior drawer sign) and a torn posterior cruciate ligament (posterior drawer sign). (A adapted with permission from Slaby F, Jacobs ER: Radiographic Anatomy. Media, PA, Harwal, 1990, p 53; C adapted with permission from Snell RS: Clinical Anatomy for Medical Students, 5th ed. Boston, Little, Brown, 1995, p 620.)

Torn Tibiocalcaneal Ligament Ankle

Transverse tarsal joint

(Chopart)

Transverse tarsal joint

(Chopart)

Tarsometatarsal joint

(Lisfranc)

Tarsometatarsal joint

(Lisfranc)

Talocrural Joint

Figure 19-5. (A) Anteroposterior radiograph of the left ankle. The dotted line indicates the talocrural joint, where dorsiflexion and plantar flexion (df/pf) occur. The diagrams show the components of the medial (deltoid) and lateral ligaments that provide support for the talocrural joint. ATF= anterior talofibular ligament (Indicates most commonly injured in an ankle sprain); ATT = anterior tibiotalar ligament; CF= calcaneofibular ligament; F= fibula; PTF= posterior talofibular ligament; P7T= posterior tibiotalar ligament; T= talus; TB = tibia; TC= tibiocalcaneal ligament; 77V = tibionavicular ligament. (B) Lateral radiograph of the left ankle shows the talocrural joint, where dorsiflexion and plantar flexion (df/pf) occur. The subtalar and transverse tarsal (Chopart) joints, where inversion and eversion (in/ev) occur, are shown. The tarsometatarsal (Lisfranc) joint is shown as well. C= calcaneus; CU= cuboid; F= fibula; N= navicular; T= talus; TB = tibia; 5th = fifth metatarsal (little toe). (A adapted with permission from Keats TE, Smith TH: An Atlas of Normal Developmental Roentgen Anatomy, 2nd ed. Chicago, Year Book Medical Publishers, 1988, p 572; B adapted with permission from Slaby F, Jacobs ER: Radiographic Anatomy Media, PA, Harwal, 1990, p 76.)

Figure 19-5. (A) Anteroposterior radiograph of the left ankle. The dotted line indicates the talocrural joint, where dorsiflexion and plantar flexion (df/pf) occur. The diagrams show the components of the medial (deltoid) and lateral ligaments that provide support for the talocrural joint. ATF= anterior talofibular ligament (Indicates most commonly injured in an ankle sprain); ATT = anterior tibiotalar ligament; CF= calcaneofibular ligament; F= fibula; PTF= posterior talofibular ligament; P7T= posterior tibiotalar ligament; T= talus; TB = tibia; TC= tibiocalcaneal ligament; 77V = tibionavicular ligament. (B) Lateral radiograph of the left ankle shows the talocrural joint, where dorsiflexion and plantar flexion (df/pf) occur. The subtalar and transverse tarsal (Chopart) joints, where inversion and eversion (in/ev) occur, are shown. The tarsometatarsal (Lisfranc) joint is shown as well. C= calcaneus; CU= cuboid; F= fibula; N= navicular; T= talus; TB = tibia; 5th = fifth metatarsal (little toe). (A adapted with permission from Keats TE, Smith TH: An Atlas of Normal Developmental Roentgen Anatomy, 2nd ed. Chicago, Year Book Medical Publishers, 1988, p 572; B adapted with permission from Slaby F, Jacobs ER: Radiographic Anatomy Media, PA, Harwal, 1990, p 76.)

Torn Anterior Talofibular Ligament

Torn anterior talofibular ligament

Avulsion of fifth metatarsal

Peroneus brevis muscle and tendon

Fractured fibula

Torn anterior talofibular ligament

Avulsion of fifth metatarsal

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