discs of hyaline cartilage b/w metaphysis and epiphysis of mature long bone that permits bone to grow longer

Term for fractures to femoral head, neck or trochanters

Occur @ apophyses (bony projection that lacks secondary ossification center)

Avulsion factures

Angle of Inclination b/w long axis of femoral neck and shaft is DECREASED, >15 degrees

knock kneed

Increased angle of inclination

Knock-kneed

In older children and adolescence

Epyphysis of femoral head may slip away from femoral neck because of weakened ephiphysial plate

Slowly results in progressive coxa vara

Neck most frequently fractured (lies at angle to pull of gravity)

Proximal femoral fractures = direct trauma

Inferior/distal femur = result in missalignment of knee joint, comproise blood supply to leg, can hemmorage popliteal artery

Tibial shaft narrowest @ middle and inf 1/3 junction (area has poorest blood supply)

Because bone is subcutaneous, site common for compound fracture

Transverse march fracture = stress fracture, common in people who take long hikes before being conditioned

continued normal growth of bone compromised

may cause inflammation of tibial tuberosity and chronic recurring pain

OSGOOD-SCHLATTER disease

occur 2-6 cm proximal to distal end of lateral malleolus

associated w/ fracture-dislocations of ankle joint

foot forced into excessive inverted position, ankel ligs tear forcibly tilting talus against lateral malleolus and may shear it off

Fibula is common source (neutrient artery and periosteum are generally removed with piece of bone so graft can grow)

remaining fib does not regenerate

Anterior tib is subcutaneous so it is accessible for obtaining bone for grafting in children

often comminuted fracture

disabeling because it disrupts subtalar joint

occur from crushing

common in dancers

fatigue fractures can happen from prolonged walking

foot suddenly and violently inverted, tuberosity of 5th MT may be avulsed by fibularis brevis

during ossification of talus, secondary ossification center (which becomes lateral tubercle of talus) fails to unite w/ body of talus

fully ossified center may fracture and progress to non-union

occurs in 14- 25% of adults

"hip pointer" = contusion of iliac crest that occurs @ ASIS, can also mean avulsion of bony m. attachments

contusions cause bleeding from ruptured cappilaries and infiltration of blood into m. tend, and soft tissue

"charley horse" : cramping of thigh muscle because of ischemia or contusion forms hematoma -- most common site of thigh hematoma is in quadriceps

abscess passes b/w psoas and its fascia to inguinal and prox thigh regions, severe pain is refered to hip, thigh or knee

edema occurs in proximal part of thigh

common for runners

soreness and aching around or deep to patella from quadriceps imbalance

patella is cartilagenous @ birth

ossifies during 3rd - 6th years

more than one ossification center, if they do not join you can have a bipartite or tripartite patella

ossification abnormalities are almost always bi lateral

Tendon's reflex tests the integrity of the femoral n. and the L2 - L4 spinal cord segments

Dimunition or abscence of patellar tendon reflex may result from leision that interrupts innervation of quadriceps

Gracillis is relativly weak and can be removed w/o noticable loss of action on leg

can be transplanted to replace damabed muscle (often in hand)

can also be relocated and repositioned to replace nonfunctional external anal sphincter

femoral pulse can be palpated w /person in supine b/w ASIS and pubic symphysis

normal pulse is strong

if common or external iliac arteries are partially occluded, pulse may be diminished

anastomosis of branches of femoral a. w/ other a.s that cross hip joint may supply blood to lower limb

cruciate anastomosis is 4 way common meeting of medial and lateral circumflex femoral a. w/ inf gluteal artery and 1st perforating artery

localized dialation of terminal part of great saphenous vein

may cause edema in femoral triangle

should be considered w/ other varicsoe veins present in lower limb

"femoral ring" is usual originating site for femoral hernia

initally small because it is contained in fascia but it can travel posteriorly to saphenous opening

more common in females because of wider pelvis

 enlarged pubic branch of inferior epigastric artery takes place of obturator artery (replaced)

or

joins obturator a. as accessory obturator artery

in 20 % of people

inflammation of trochanteric bursa

results from repetitive actions

movements involve glut max and move over superior tendinous fibers repeatedly back and forth over bursae of greater trochanter

causes deep diffuse pain in lat thigh

fricition bursitis resulting from excessive friction b/w ischial bursae and ischial tuberosities

pain over bursae, and increasing pain w/ mvmnt of glut max

CALCIFICATION can occur with chronic bursitis

commin in runners and kickers

tears proximal tendinous attachments of hamstrings to ischial tuberosity

2x as common as quad strains

avulsion fractures can occur @ prox attach of semi tendinosus and biceps femoris

in standing on one leg, pelvis drops on opp side (positive Trendelenburg test

results in characteristic motor loss resulting in disabling glut med limp to compensate for weakened abd of thigh

or

gluteal gait: compensatory list of body to weakened sd

medial rotation is also impaired

gluteal gait (waddling)

steppage gait

swing-out gait (compinsate for foot drop)

caused by

paralysis of superior gluteal n.

fracture of greater trochanter

dislocation of hip

"hip drop when standing on one leg"

Injury to Sciatic N

"piriformis syndrome" compression of siatic by piriformis

women are more likely to have p syn

complete section of sciatic n in uncommon but if it happens, leg is useless - ext of hip impaired, flexion of leg impaired, all ankel and foot mvmnts lost

m. are thick, lg, and provide substantial volume for absorption of injected substances by intramuscular veins

safe only in superior lateral quadrant of butt or on anterolateral part of thigh into tensor fascia latae

deep pop fascia is strong and limits expansion of abscess or tumor

pain is severe

spreads superiorly and inferiorly because of toughness of poplitieal fascia

causes edema in popliteal fossa

ID'd with stethoscope

pain refered to skin overlying medial aspect of calf, ankle or foot

can be caused by fractures of femur and joint capsule

"arteriovenous fistula" communication b/w artery and vein

uncommon because it is deep

injured by deep lascerations to popliteal fossa or posterior dislocation of knee joint

unable to plantarflex ankle or flex toes

loss of sensation on sole of foot

suppuration: "formation of pus" increases intracompatmental pressure

spread in didstal direction

purulent (pus forming) infection in lateral compartment of leg can ascend proximally into pop fossa

fasciotomy may be necessary to relieve pressure and debride

result from repeated microtrauma of ant tib

causes small tears in periosteum

mild form of the anterior compartment syndrome

common fib n is most often injured in lower limb

results in flacid paralysis of all m in ant and lat compartments of leg

causes foot drop

waddling gait (hip hiking), swing-out gait (swung laterally to clear toes), high-steppage gait (hip and knee raise)

can be caused by tight shoes

pain in dorsum of foot and radiates to web space in b/w 1st and 2nd toes

chronic ankle sprains may produce recurrent streching of s.f.n.

pain along lat sd of leg and the dorsum of ankle and foot

numbness and parasthesia present and increases w/ activity

"fabella" sesamoid bone close to lat head of gastroc prox attachment.

fabella articulates w/ lateral femoral condyle

found in 3-5% of people

Inflammation of calcaneal tendon

foud in 9 - 18% of running injuries

gap is palpable

most severe acute m. problem of leg

individuals cannot plantarflex against resistance, can't raise onto heel and balance

passive dorsiflexion is excessive!! (normally only 20 degrees)

Walking only possible when limb is laterally rotated

tests S1 and S2 n. roots

if S1 nerve root is injured or ompressed, ankle reflex is virtually absent

present in approx 3% of people

appears as distal belly medial to calcaneal tendon

associated w/ pain and swelling during prolonged exercise

palpated b/w post surface of medial malleolus and medial border of calcaneal tendon

helps find "occlusive peripheral arterial disease"

inflammation of plantar fascia caused by an overuse mech

most common hindfoot problem in runners

Pain

Pallar

Parasthesia

Paralysis

Pulselessness

hip joint most stable when bearing weight

angle of wiberg - decreases in degree to which ilium overlies femoral head - may indicate joint instability

rarely is more than 40% of available articular surface of femoral head in contact with acetablulum

uncommon in people less than 40, only result from high-energy impact

most common in people over 60, mostly women

often intracapsular and realighnment of neck fragments require internal fixation

cause lateral rotation of lower limb and often dissrupt blood supply to head of femur

Trauma to hip - dislocaations - disrupt artery to head of femur

inadequate blood supply to femoral head

results in incongruency of joint surfaces and growth at epiphysis is slowed

most common in children 3-9 y.o.

common in neonates, occurs bilaterally, 8 x more in girls than boys

effected limp acts and appears shorter

results in positive trendelenbergs test

uncommon

may occur durring automobile accident when hip is flexed, abducted and medially rotated (riding in car)

MOST COMMON

may effect sciatic nerve which can result in paralysis of hamstrings and m.'s distal to knee supplied by sciatic n.

results from violent injury that forces hip into ext, abd and lat rotation (catching ski tip when skiing)

acatabular margin often fractures producing a fracture - dislocation of the hip joint

Valgum = knees together, tibial collateral lig overstreched, beight hearing falls lateral to center of knee, excess stress on lateral condyles, patella pulled even further laterall

Varum = femur abnormally vertical, q angle is small, bowleged, weighbearing in medial knee, fibular collateral lig is overstreched

nearly always dislocates laterally

more common in woman due to Greater Q angle (represents pull of quadriceps)

repetitive microtrauma caused by abnormal tracking of patella relative to patellar surface of femur or direct blow or osteoarthritis

Corrected by strengthening of Vastus Medialis

weakness of vastus med predisposes individual to patellofemoral dysfunction and patellar dislocation

Most common knee injury

occurs when foot is fixed on ground

tearing of TCL also results in tearing of medial meniscus

Can also tear the ACL

hyperextension and severe force directed anteriorly against femur w/ knee semiflexed may tear ACL

causes free tibia to slide anteriorly under fixed femur "anterior drawer sign" - lachman test

tears comm in midportion of ligament

occur when player lands on tibial tuberosity w/ knee flexed

occur in conjunction w/ tib or fib lig tears

PCL ruptures allow free tibia to slide posteriorly under fixed femur (posterior drawer syndrome)

usually on medial meniscus (laerial is more mobile, less tears)

pain on lateral rotation = lateral meniscus tear

pain on medial rotation = medial meniscus tear

most occur w/ ACT or TCL tears

can be repaired or heal w/ good blood supply, but w/out they are removed

Prepatellar bursitis (friction b/w skin and patella)

Subcutaneous infrapatellar bursitis (skin and tibial tuberosity)

Deep intrapatellar bursitis (patellar ligament and tibia)

Suprapatellar bursitis (infection caused by bacteria entering suprapatellar bursa from torn skin)

fluid filled sac of synovial membrane in region of popliteal fossa

almost always complication of chronic knee joint effusion

can be large, extending as far as mid calf

may interfere w/ knee movements

ANKLE IS MOST COMMONLY INJURED MAJOR JOINT IN BODY

ankle sprains are the most common

Almost always INVERSION injury

Lateral Ligament sprains, lat lig is much weaker

anterior talofibular ligament is most vulnerable and most commonly torn during ankle sprains

Calcaneofibular ligament may also be torn

in severe sparins, lateral malleolus can be fractured

avulsion fractures can happen

less common

Pott fracture dislocation: foot is forcibly everted

pulls on extreemly strong medial ligament

often causes tri-malleolar fracture

occurs w/ edema and tightness in ankle involving synovial sheaths of tendons of m.s in post compartment

TARSAL TUNEL SYNDROME

occurs b/w medial malleolus to calcaneus

caused by pressure from footwear and degenerative joint disease

characterized by lateral deviation of great toe (can overlap 2nd toe)

Decreases medial longitudinal arch

inflamed bursae called BUNION

CORNS: inflamed thick skinalso form over interphalengeal jts, pinki

prox phalanx permanetly dorsiflexed@ MTP joint

middle phalanx strongly plantar flexed @ PIPJ

Distal phalanx often hyperextended

may resuslt from weakness of lumbercal and interosseous m. which flex MTP jts and extend IP joints

hyperextension of mtp joints

flexion @ distal IP joints

Lateral 4 toes

flat foot normal @ age 3

flexible (normal whn not WB) or rigid (flat when not WB)

flexible = more common - results from loose or degeneraged intrinsic ligaments

rigid = bone deformity

"aquired flatfeet" (fallen arches) secondary to dysfunctiono of tibialis posterior

Common in old folks w/ a lot of standing or wgt gain