A 36-year-old woman is brought to the emergency department to be evaluated for right knee pain and swelling. The patient participated in a soccer match when she jumped and landed on her right foot with her right knee partially flexed. She subsequently heard a “pop” and developed swelling around her knee. Past medical history is significant for recent urinary tract infections treated with ciprofloxacin. She does not use tobacco, alcohol, or other recreational drugs. Vitals are within normal limits. Physical examination shows a large effusion over the right knee. The patient is unable to bear weight or extend the knee. X-ray of the knee shows a large effusion with a low-lying patella. Which of the following additional findings will likely be seen on physical examination?

And we hope you won't even break a sweat learning these conditions, let alone a leg. Let's start with femoral neck fractures often simply called hip fractures.

Hip fractures0:26–4:59

They can be classified as intracapsular or extracapsular fractures based on their anatomic location. Intracapsular fractures occur in the region of the femoral head and neck within the joint capsule of the hip.

While extracapsular fractures occur outside the fibrous joint capsule. Anywhere in the intertrochanteric or subtrochanteric area of the femur hip fractures are typically caused by mechanical falls or a trauma such as a car crash.

And while they can affect anyone, they are more likely to occur in the elderly because of associated conditions such as osteoporosis or Vitamin D and calcium deficiency.

The classic presentation of a hip fracture is an individual who presents after a fall and has an acutely shortened, externally rotated leg on physical examination compared to the contralateral side this is due to the attachment points and pull of the iliopsoas and gluteus muscles.

Other clinical features of a hip fracture include hip or back pain, joint deformity and inability to bear weight. Intracapsular fractures are at risk of avascular necrosis and displacement of the femoral head.

Whereas extracapsular fractures are less likely to undergo avascular necrosis. See with an intracapsular hip fracture.

The retinacular arteries branching mainly from the medial circumflex, femoral arteries are disrupted, resulting in potential avascular necrosis to the femoral head.

As the artery within the ligament to the head of the femur isn't able to ensure adequate blood supply on its own. Conversely with extracapsular femoral neck fractures, these arteries are not disrupted and maintain their function.

Confirming the diagnosis of a hip fracture usually relies on anterior posterior and lateral hip x-rays. But if x-rays are inconclusive in the context of strong clinical suspicion.

A CT scan can be done on imaging intracapsular fractures can be identified by a loss of shen's line. A line drawn from the inferior border of the superior pubic rami along the inferomedial border of the neck of the femur.

Other features of an intracapsular fracture include a prominent lesser trochanter due to external rotation of the femur compared to the contralateral side and shortening or angulation of the femoral neck extracapsular fractures.

On the other hand, are typically intertrochanteric fractures extending between the greater and lesser trochanter or subtrochanteric fractures found distal to the trochanters in the subtrochanteric region management of intracapsular and extracapsular hip fractures is typically surgical.

And the choice depends on the surgeon. It can be done using open reduction and internal fixation or O ri F for short, which is a type of open surgery where the fractured bone is put back together using screws, plates, intramedullary rods or a combination of these arthroplasty can also be done.

And that's when the femoral and acetabular components of the hip joint are either totally or partially replaced. Finally, a rare complication of hip fractures is sciatic nerve damage.

See, the sciatic nerve runs close to the posterior aspect of the hip joint and fracture at this site can injure the sciatic nerve and result in paresthesia of the sciatic nerve dermatomal distribution as well as weakness in knee flexion, ankle dorsiflexion and ankle plantar flexion.

Other complications of hip fracture include chronic pain, nonunion. Future arthritic changes of the associated hip joint and dislocation.

Speaking of which, let's talk about hip dislocation, which occurs when the femoral head is forced out of the acetabular socket, either anteriorly or posteriorly.

Hip dislocation4:59–6:55

Hip dislocations are typically caused by a traumatic injury such as a head on motor vehicle collision. Posterior dislocations are the most common amounting to 90% of dislocations.

An example of this is a dashboard injury due to a high velocity car accident where the hip is forced into flexion adduction and internal rotation due to the dashboard of the car as it pushes back on the flexed hips during a head on collision.

On the other hand, hyper abduction with extension will produce anterior dislocation especially in motorcycle crashes where the legs are hyper abducted while riding individuals with hip replacements are at an increased risk of hip dislocations as well as with a higher chance of posterior dislocation.

Individuals suffering a hip dislocation may also hear an audible pop or clunk as the femur comes out of its socket. In addition to pain and inability to bear weight.

On examination of a posterior dislocation, there can be shortening and internal rotation of the affected limb. Whereas an anterior dislocation presents with shortening and external rotation diagnosis is confirmed by X ray.

Hip dislocations especially posteriorly can also damage the sciatic nerve. And other complications include labral tears, which is when the ring of fibrocartilage surrounding the hip joint gets torn and associated hip fracture, hip, hip hooray, let's take a quick break and remember the most common complications of hip fractures.

Quiz6:55–7:11

Trochanteric bursitis7:11–8:04

Now, another issue in the hip area can be trochanteric bursitis or greater trochanteric pain syndrome, which is when the small bursa that covers the greater trochanter becomes inflamed.

Trochanteric bursitis is usually the result of repetitive actions such as climbing stairs because repetitive movements cause the tendons from the gluteus medius and minimus to compress the trochanteric bursa against the greater trochanter resulting in inflammation.

Diagnosis is based on clinical symptoms such as chronic pain in the lateral thigh and point, tenderness over the greater trochanter pain can also be elicited by manually resisting abduction of the thigh while the person is lying on the unaffected side.

Femoral pulse8:04–10:13

Now, let's switch gears and talk about the femoral artery pulse. You can locate the femoral artery as it enters the femoral triangle by palpating distal to the inguinal ligament at the mid inguinal point, which is halfway between the pubic symphysis and the anterior superior iliac spine.

It's a good idea to remember this because feeling the femoral pulse can give us a good idea of blood flow to the limb in case of peripheral artery disease.

And also because it's a significant place for catheterization during therapeutic and diagnostic procedures. For example, the femoral artery can be used for cardiac catheterization for both diagnostic angiography and for therapies like stent placement.

Speaking of cardiac catheterization, one complication to be aware of is retroperitoneal hemorrhage. This can occur if the posterior wall of the common femoral artery is punctured, allowing blood to track into the retroperitoneal space.

Additionally, before crossing distal to the inguinal ligament, the common femoral artery is a continuation of the external iliac artery.

If arterial puncture is done above the inguinal ligament, there is a higher risk of retroperitoneal hemorrhage as this area is directly inferior to the peritoneum retroperitoneal hemorrhage is a potentially deadly condition because external compression can't be applied on the retroperitoneal space.

So, without surgery, the affected individuals can bleed to death. Clinical signs to recognize include hemodynamic instability such as hypotension and power pain on the affected flank and a significant drop in hemoglobin.

The femoral artery is also prone to injury due to its anatomical location, close to the femur as proximal femur fractures or hip surgery can result in femoral artery injury.

Additionally, due to its superficial position within the femoral triangle, the artery can also be easily lacerated during traumatic events.

Varicose veins10:13–11:43

Now let's move on to varicose veins which can develop because of venous insufficiency with venous insufficiency, blood begins to pool in the veins of the leg rather than return to the heart.

And in time the veins become varicose or dilated. This can cause complications such as painful thrombosis edema as well as cosmetic issues.

One test that helps diagnose and characterize venous insufficiency is the trendelenburg test or the tourniquet test. When performing this, the individual lies on their back and the affected leg is then raised above their head where the veins of the leg are massaged or milked down towards the groin.

After the veins of the leg have been drained manually with the legs still elevated. A tourniquet is placed around the thigh at the saphenous opening and the individual is asked to stand up as the examiner is observing the limb for any signs of the varicose veins reappearing if the varicose veins do not reappear when the tourniquet is at the saphenous opening.

This indicates the incompetence resulting in the venous insufficiency is at the safi Nofal valve and the tourniquet is acting as a valve if the varicose veins pop up again, this indicates the problem is distal to the level of the tourniquet as the veins are filling again.

Therefore, the incompetent valve is lower down. One common condition associated with varicose veins is Safina varix, which is a dilation of the saphenous vein at its junction with the femoral vein in the groin.

Saphena varix11:43–12:24

Clinically, individuals can present with a groin swelling, the size of a golf ball, which enlarges with increased intraabdominal pressure like when coughing.

However, bear in mind that a femoral hernia also becomes apparent when asking a patient to cough. So a Sophina varix is commonly mistaken for an inguinal hernia.

Characteristic features for a Sophina varix include a bluish tinge and typically disappears when lying down. Speaking of the saphenous veins, it's also worth mentioning that they're also the main venous graft sites for things such as coronary bypass surgery.

Venous graft sites12:24–13:21

In coronary artery disease. Both the great and the small saphenous vein can be used with the great saphenous vein being the more popular choice because it's superficial and easy to access.

It's long enough to take a piece from it without affecting the blood flow to the area. And it has a wall rich in muscular and elastic fibers.

One complication during great saphenous vein harvesting is saphenous nerve injury. As the saphenous nerve accompanies the great saphenous vein as they travel distally.

So it can be accidentally cut during the procedure. Injury of the saphenous nerve can cause pain or numbness along the medial border of the lower leg and foot.

Now, let's take a quick break and see if you can recall the clinical findings with a Safina varix. Ok.

Quiz13:21–13:33

Now, let's discuss intramuscular injections. See the lower limb is one of the preferred sites for intramuscular administration of medication because of large muscles that have numerous blood vessels, making absorption faster than subcutaneous injections.

Intragluteal injections13:33–14:59

One of the most popular intramuscular injection sites is the gluteal region. Specifically, the superolateral quadrant of the buttock.

The superolateral quadrant of the buttock is used for large volume and more viscous injections. The superolateral area is located above the line extending from the posterior superior iliac spine to the superior border of the greater trochanter to mark this area.

The index finger is placed on the anterior superior iliac spine with the finger spreading posteriorly along the iliac crest until the tubercle of the crest is felt by the middle finger.

The injection can then be given safely in the triangle between the fingers just anterior to the proximal joint of the middle finger to avoid injuring the sciatic nerve.

Also note that the supramedial quadrant of the buttock should always be avoided as you are at risk of injuring the sciatic nerve and the major blood vessels that pass through the area.

Trendelenberg gait14:59–16:18

Another nerve that can be damaged in the supra, medial quadrant is the superior gluteal nerve, which is important as the superior gluteal nerve innervates the gluteus medius, gluteus minimus and tensor fascia lata, which all function to stabilize the pelvis and abduct the thigh injury to the superior gluteal nerve results in the presentation of a Trendelenburg gait.

Not to be confused with the Trendelenburg venous insufficiency test. Trendelenburg gait is characterized by tilting of the pelvis towards the unaffected side when the patient stands on the affected leg, as the abductors of the affected hip cannot keep the contralateral hip up indicating a positive Trendelenburg sign with Trendelenburg gait.

The patient leans towards the side of the affected superior gluteal nerve in order to compensate and maintain balance. Other causes of a Trendelenburg gait include gluteus, medius and gluteus minimus weakness resulting from things such as osteonecrosis of the hip leg calve Perthes disease, developmental dysplasia of the hip, nonunion of femoral neck fractures and hip surgery.

Other nerve injuries of the lower limb include meralgia, paraesthetica which is a condition caused by entrapment of the lateral femoral cutaneous nerve as it passes distal to the inguinal ligament.

Meralgia paresthetica16:18–16:58

This nerve supplies sensory innervation to the skin of the anterolateral and lateral aspects of the thigh and can become impinged in those who are pregnant, obese or wear tight clothing.

It can also be affected in conditions like diabetes, mellitus or hip replacement surgery. Symptoms include pain, burning numbness and coldness over the anterolateral aspect of the thigh, especially when using the affected limb or sitting.

Next. Piriformis syndrome refers to Piriformis muscle injury or hypertrophy resulting in sciatica like symptoms.

Piriformis syndrome16:58–17:43

This occurs because the sciatic nerve runs inferior to the piriformis muscle and can become compressed. Piriformis syndrome is characterized by pain, tingling and numbness in the buttocks and sciatic nerve distribution.

Piriformis syndrome can develop following trauma to the buttocks or Piriformis muscle strain leading to scarring and fibrosis around the nerve.

The wallet sign is often associated with Piriformis Syndrome and it's when an individual can no longer sit on their wallet without it causing symptoms.

Now that we have talked about vessels and nerves, let's move on to muscles. One of the more common injuries we encounter are muscular strains and tears.

Hamstring strains17:43–18:46

First, hamstring strains typically occur because of overuse. So they're common in active individuals such as professional athletes.

They can also occur because of inadequate warm up before activity. Muscle fatigue and trauma.

These types of injuries can occur when there is forced flexion of the hip when the hip and knee are extended. For example, when kicking a football hamstring strains can be mild, causing only minimal clinical consequences like pain and swelling with little functional loss.

However, complete tears of the muscle can cause severe pain, significant loss of knee flexion and associated large muscle hematomas.

Very severe hamstring injuries can even tear or cause an avulsion fracture of the ischial tuberosity where the proximal tendons attach.

And lastly let's go over quadriceps tendon tears which can occur during sudden forceful contraction of the quadriceps muscle during a deceleration from a fall or athletic activities.

Quadriceps tendon tears18:46–19:51

Quadriceps, tendon injuries can be classified in relation to the patella as either proximal or distal to the patella injury can occur approximately at the quadriceps, tendon causing a palpable defect proximal to the patella, which may potentially cause the patella to be pulled down or injury can occur distal to the patella within the patellar ligament where the palpable defect is below the patella and the patella may be pulled upwards.

Clinical findings include pain, inability to bear weight and loss of knee extension, rapid knee effusion, and a loud pop as the injury occurs.

Risk factors for tendon tears include anabolic steroid abuse, hypoparathyroidism and chronic kidney disease. We made it to the end before the recap.

Quiz19:51–20:04

Can you recall the main site in the lower limb where intramuscular injections can be administered? All right.

Review20:04–23:29

As a quick recap, hip fractures can be intracapsular or extracapsular and the latter can be either intertrochanteric or subtrochanteric diagnosis should always be confirmed by hip x-rays or ct hip dislocation is when the ball of the hip joint is pushed out of the socket, either anteriorly or posteriorly, which is more common and may be complicated by fracture or sciatic nerve injury.

Trochanteric bursitis presents with deep diffuse pain in the lateral thigh region and point tenderness over the greater trochanter.

The femoral pulse is best palpated distal to the inguinal ligament at the mid inguinal point. The femoral artery can also be injured during catheterization.

Proximal femur fractures, hip surgery or lacerated during traumatic events. Complications of femoral artery catheterization include retroperitoneal hemorrhage with a greater risk if the artery is punctured, proximal to the inguinal ligament, varicose veins can be diagnosed using the Trendelenburg test.

Aafia varix is a dilation of the Great Sahan vein at its junction with the femoral vein in the groin, with saphenous vein grafting the great saphenous vein is usually used because its easy to access long and because its wall is rich in muscular and elastic fibers.

Intragluteal injections can be administered in the supra lateral quadrant of the buttock. Trendelenburg gait refers to aberrant hip abduction and a drooping of the pelvis on the contralateral side.

While weight bearing on the affected side, this can be due to weakness of the gluteus medius and minimus muscles. After damage to the superior gluteal nerve meralgia, paraesthetica or impingement of the lateral femoral cutaneous nerve causes symptoms such as pain, burning numbness and coldness.

Over the anterolateral aspect of the thigh. Piriformis syndrome causes gradual pain located around the buttocks that increases with sitting and can present with sciatica like symptoms, hamstring strains as well as quadriceps, tendon tears can frequently occur in highly active individuals usually due to overuse inadequate warm up fatigue trauma or poor

Anatomy clinical correlates: Hip, gluteal region and thigh

Transcript

Introduction0:00–0:26