PMMH MSK Lower Limbs

33 Vertebrae of the Spine

7 cervical, 12 thoracic, 5 lumbar, 5 sacral, 4 coccygeal

Vertebrae composition (2)

1. Outer rim = annulus fibrosis, fibrous tissue and fibrocartilage

2. Central core = nucleus pulposus, elastic shock absorber

Dermatomes (4)

1. At each spinal nerve

2. Conducts impulses from specific areas of the skin

3. Acting as a map so brain knows where pain arrive from

4. E.g. C4 is ACJ, C5 is regimental badge sign over deltoid, C6,7,8 IS hand

Posture of the spine (2)

1. Kyphosis = increased convexity of the thoracic spine causing hunchback

2. Scoliosis = lateral curvature of the spine

Classification/Time-frames of Lower Back pain (3)

1. Acute < 6 weeks

2. Sub-acute is 6-12 weeks

3. Chronic > 12 weeks

Cauda Equina Syndrome (4)

1. Spinal cord ends near L1, forming conus medullaris

2. Bundle of nerve roots below L1 - S5 = cauda equina

3. Compressed from disc herniation, intradural tumours, haematomas

4. Saddle anaesthesia, bilateral leg weakness, sexual dysfunction, faecal incontinences, retention of urine

Why is the faecal incontinence in CES (3)

1. Complete loss of the anal sphincter control

2. Rectum is ONLY innervated from pelvic nerves

3. Other areas of bowel are innervated from thoracic or lumbar regions higher up

Why is there neurogenic retention of urine in CES (2)

1. Bladder is paralysed

2. Stretch receptors do not respond or send signals to brain

Sciatica (4)

1. Longest nerve running from lumbosacral area, down hips and buttocks, down each leg

2. Sits between the obturator internus and piriformis muscle

3. Compressed or irritated by disc herniation, muscle spasm spondylopathy

4. Unilateral shooting pain, originating at buttocks, radiating down legs

Herniated Disc (4)

1. Fibrous rim is thinner or less pliable from microtrauma

2. Nucleus core will bulge out under pressure

3. Fibrous rim pushes on nerve root

4. Burning, shock, unilateral pain below knee, numb

Spinal Stenosis (3)

1. Narrowing of passage where spinal cord runs

2. Pressure on nerves inside spinal canal

3. Pain when walking

Key Bony Landmarks of the Hip/Pelvis (5)

Ilium, ischium, pubis, acetabulum, obturator foramen

Key joints of hip and pelvis (2)

Sacroiliac joints and pubic symphysis

Trendelenburg Gait (3)

1. Wide swinging lower limb/pelvic tilt on unaffected side

2. Damage to superior gluteal nerve or associated vertebral level

3. = weakness of hip abductors (gluteus Medius and minimus)

Trendelenburg Test (2)

1. Stand on one leg

2. Observe a drop in the hip

Antalgic Gait (3)

1. Limping

2. Short stance phase and longer swing

3. Quickly unload weight off painful limb

Fractured Rami in Pregnancy (3)

1. Hormonal changes - secretion of relaxin causes ligament laxity

2. Compromises pelvic stability

3. Painful weight bearing and unstable vaginal delivery

Signs and Symptoms of Fractured Rami (3)

1. Groin or buttock pain

2. Local tenderness over pubic rami

3. Referred pain to tight (via involving the obturator foramen and irritating obturator nerve)

Greater Trochanter Bursitis (4)

1. Inflammation of bursa overlying greater trochanter and femur

2. MOI: repetitive friction, trauma on lateral hip, Trendelenburg gait, arthritis

3. Pain on lateral hip, worsens on prolonged walk, radiation down lateral thigh but not below knee

4. Check for heat, erythema, inflammation = ABx + steroids

Hamstring Tear (3)

1. Partial or complete tear of muscle at POSTERIOR thigh

2. MOI: sudden, forceful hip flexion + knee extension

3. Sudden sharp pain at posterior thigh, audible pop, bruising and swelling

Quadricep Tear (3)

1. Partial or complete tear of muscle at the ANTERIOR thigh, might rupture insertion at patella

2. MOI: sudden, forceful knee flexion against resistance

3. Sudden anterior thigh pain, swelling/bruising over anterior thigh, pain on knee extension

Bones of Knee (3)

Patella, tibia (lateral and medial condyles) and femur (lateral and medial condyles)

Anterior Cruciate Ligament (ACL) (3)

1. Extends from anterior tibial plateau to lateral femoral condyle

2. Rotational stability

3. Commonly torn in sudden pivoting/twisting motions

4. Audible pop sounds, swelling and hemarthrosis, knee instability

Lachman’s Test (4)

1. ACL injury test

2. patient lying supine + knee flexed at 20*

3. One hand on femur + one hand behind knee at the tibial tuberosity

4. Lower hand, draw the tibia forward

Posterior Cruciate Ligament (PCL) (3)

1. Extends from posterior tibial plateau to medial femoral condyle

2. Stronger than ACL - common in posterior force to tibia, or fall on flexed knee

3. Posterior knee pain/swelling, instability when walking downhill or descending stairs

Posterior Draw Test (3)

1. PCL injury test

2. Have the pt lying supine, and sit on the foot to stabilise the lower leg

3. Hands on upper tibia + thumbs on the joint line - push tibia backwards

Medial Collateral Ligament (MCL) (3)

1. Extends from the medial femoral condyle to the medial tibial condyle

2. Commonly injured when tackled to the lateral/outer side causing inward angulation (valgus stress)

3. Pain on medial side of knee, localised swelling or bruising, tenderness on palpation

Valgus Stress Test (3)

1. MCL injury test

2. Abduct hip so knee is hanging off the edge of the bed

3. Push upper leg in + lower leg out to create inward angulation on knee

Lateral Collateral Ligament (LCL) (3)

1. Extends from lateral femoral condyle to the head of fibula

2. Caused from outward angulation (varus injury)

3. Pain and tenderness on lateral side of knee

Varus Stress Test (3)

1. LCL injury test

2. Abduct hip so knee is hanging off the edge of the bed

3. Push upper leg out + lower leg in to create outward angulation on knee

Meniscus of Knee (4)

1. Fibrocartilaginous pads between femoral condyle and tibial plateau

2. Functions as shock absorbers

3. Medial meniscus = C-shaped, larger, firmly attached to MCL to shock-absorb load on medial compartment

4. Lateral meniscus = O-shaped, smaller, loosely attached, not attached to LCL

Meniscal Tear (3)

1. Tear to the fibrocartilaginous menisci

2. Common in twisting injury, with knee flexed and foot planted

3. Joint line pain/tenderness, swelling is delayed, locking or loss of full extension

McMurray’s Test (4)

1. Fully flex the knee and hip, support bottom of ankle

2. Medial Meniscus = rotate knee medially

3. Lateral Meniscus = rotate knee laterally

4. Support the patient by passively flexing and extending knee

Muscles of the thigh (4)

1. Quadricep femoris groups = anterior thigh, innervated by femoral nerve

2. Hamstring group = posterior thigh, innervated by tibial division of sciatic nerve

3. Rotators

4. Popliteus

Patella Fracture (2)

1. Break in patella, sesamoid bone embedded in quadricep tendon

2. MOI: direct fall onto flexed knee

Patella Apprehension Test (2)

1. Pt in supine position with knee in slight flexion

2. Apply lateral pressure to the patella

Fibular Head Fracture (3)

1. Fracture of upper proximal fibula, near articulation with tibia

2. Common fibular (peroneal) nerve winding around fibular neck

3. MOI: direct trauma to lateral knee, varus force, knee dislocation

Tibial Plateau Fracture (2)

1. Fracture of the proximal tibia

2. MOI: axial load + varus/valgus stress

Baker’s Cyst (4)

1. Palpable fluid-filled sac forming in popliteal fossa

2. Result of excess synovial fluid

3. MOI: joint pathology (e.g. meniscal tear, osteoarthritis), not traumatic

4. Visible lump present, tightness on full extension, posterior knee discomfort radiating down calf

Knee Bursitis (3)

1. Inflammation at anterior surface at knee

2. MOI: chronic repetitive stress, infection, systemic condition like rheumatoid arthritis or gout

3. Localised swelling over bursa, pain on extension, heat + erythema + fever = ABx

Ottawa Knee Rules (5)

1. Pt aged >55 y.o

2. Inability to immediately weight bare more than 4 steps

3. Inability to flex knee to 90*

4. Isolated tenderness of the patella

5. Isolated tenderness at fibular head

Pittsburgh Decision Rule (3)

1. Falls or blunt-trauma MOI

2. Age <12 or >50 y.o

3. Inability to walk 4 weight-baring steps

Calf and Calcaneal Tendon (4)

1. Superficial calf muscle with medial and lateral heads

2. Both heads join and merge with the soleus muscle

3. Extends to form the calcaneal or Achilles tendon

4. Which inserts at the posterior calcaneus

Tarsal bones

Talus, calcaneus, navicular, cuneiforms (medial, intermediate and lateral) and cuboid.

Ankle joint → calcaneus/heel → metatarsals → phalanges

Ligaments of ankle (4)

1. Anterior talofibular ligament (talus to fibula)

2. Posterior talofibular ligament (talus to posterior fibula)

3. Calcaneofibular ligament (calcaneus to fibula)

4. Deltoid/medial ligament complex (tibia to talus, navicular, calcaneus)

Steppage Gait (3)

1. Inability to flex ankle

2. Means lifting knee higher than normal when stepping

3. Avoid dragging toes

Ruptured Achilles Tendon (3)

1. Complete or partial tear of calcaneus tendon needed for plantarflexion

2. MOI: sudden forceful plantarflexion

3. Sudden sharp pain at back of ankle, audible pop, palpable gap above calcaneus

Simmonds Test (3)

1. Achilles Tendon Rupture test

2. Prone, lying position + feet hanging freely off edge of bed

3. Squeeze calf few times - observing slight plantarflexion

Lisfranc Injury (5)

1. Fracture-dislocation of tarsometatarsal joints

2. Specifically involves Lisfranc ligaments - connect medial cuneiform to the base of 2nd metatarsal

3. Crucial to stabilising midfoot arch

4. MOI: crush injury to foot

5. Midfoot pain over tarsometatarsal joints, plantar bruising, difficulty weight bearing

5th Metatarsal Fracture (5)

1. Can be avulsion fracture - inversion of ankle pulling bone fragment

2. Distal from blood supply, causing risk of non-union when healing

3. Jones fracture - twisting foot while weight baring

4. Stress fracture

5. Pain on lateral border of foot, swelling and bruising,

Ottawa Ankle Rules (5)

1. Bony tenderness 6cm above the lateral malleolus

2. Bony tenderness 6cm above the medial malleolus

3. Bony tenderness at the navicular

4. Bony tenderness at the base of the 5th metatarsal

5. Inability to weight bare immediately and in ED