Bluebox: Anterior and medial regions of thigh

HIP & THIGH CONTUSIONS

“Hip pointer”1. Contusion of iliac crest

Usually occurs @ anterior part (@attachment of sartorius)

Due to collision sports (football, ice hockey, volleyball)

2. Avulsion of bony muscle attachments

Technically avulsion fractures E.g. avulsion of sartorius to anterior superior

iliac spine“Charley horse”

Cramping of individual thigh musclesOccurs because of:

1. Ischemia2. Contusion and rupture

of BV resulting in hematoma

Ischemia/hematoma due too Tearing of fibres of rectus femoriso Quadriceps tendon may be torn – most

common thigh hematoma = quads Symptoms

o Localised paino Muscle stiffnesso Follows direct trauma

PARALYSED QUADRICEPS

Patient cannot extend leg against resistance Usually presses on distal end of thigh during walking to prevent

inadvertent flexion of knee joint

Weakened vastus medialis/vastus lateralis resulting from arthritis or trauma to knee joint can result in abnormal patellar movement and loss of joint stability

PATELLAR FRACTURES

Cause ResultDirect blow to patella

- Blow to knee- Sudden contraction of

quadriceps (when one slips & attempts to prevent a backward fall)

Transverse patellar fractures- Proximal fragment is pulled

superiorly with quadriceps tendon

- Distal fragment remains with patellar ligament

GROIN PULL – aka “pulled groin”, “groin injury”Meaning Involved muscles Cause

A strain, stretching & possibly tearing of proximal attachments of anteromedial thigh muscles have occurred.

Flexor & adductor thigh muscles, where their origin are in inguinal (i.e. groin) region(junction of thigh & trunk)

Sports that require- Quick starts

(sprinting, base stealing)

- Extreme stretching (gym)

INJURY TO ADDUCTOR LONGUS – “Muscle sprains of adductor longus”

Cause ResultLong time on horseback, producing pain (i.e. Riders Strain)

Ossification in tendons of adductor longus – riders actively adduct thighs to keep from falling off animals – ossified tendons: Riders’ bones

LACERATION OF FEMORAL ARTERY

The problem- Femoral artery in femoral triangle is superficial – This makes it vulnerable

to traumatic injury such as lacerations ( laceration = deep cut)- Due to proximity, femoral artery AND vein can be lacerated in anterior

thigh woundsResulting problem

- Arteriovenous shunt due to communication between injured vesselso AV shunt: Abnormal connection/passageway between an artery and a vein

The solution- The body has it’s own solution: anastomosis of branches of femoral artery

with other arteries that cross the hip joint – These supply blood to lower limb

- Cruciate anastomosis: 4-way common meeting of medial and lateral circumflex femoral arteries with inferior gluteal artery superiorly, and the first perforating artery inferiorly, posterior to femur

FEMORAL HERNIA – A tender mass in the femoral triangle, inferolateral to pubic tubercle

The problem- Femoral ring is a weak area in the anterior abdominal wall (size of little

finger)- Femoral hernia originates here, as a protrusion of abdominal viscera (often

a loop of small intestine) through the femoral ring into the femoral canal

About the annoying hernia- Bounded by femoral vein laterally, and lacunar ligament medially- The hernial sac compresses the contents of the femoral canal (loose CT,

fat, lymphatics)- The sac distends the wall of the canal as well- The hernia can be initially small as it is contained in the canal. However, it

enlarges by passing inferiorly through the saphenous opening into the subcutaneous tissue of the thigh.

- Femoral hernias are more common in females, due to their wider pelves.

What happens to the hernia?- Femoral hernia can be strangled due to:

o Sharp, rigid boundaries of femoral ring (due to lacunar ligament)- Strangulated hernia (remember it’s actually a loop of small intestine) may

have lack of blood supply, resulting in NECROSIS

PSOAS ABSCESS – Abscess: Collection of pus that has built up within the tissue of the body

Background information – Psoas Major Orgin

o Intervertebral discs,o Sides of T12-L5 vertebrae & their transverse processes

Medial arcuate ligament of the diaphragm arches obliquely over the proximal part of psoas major

Transversalis fascia on internal abdominal wall is continuous with psoas fascia

o Forms a fascial covering for the psoas major that accompanies the muscle into the anterior region of the thigh

Tuberculosis & Crohn disease can cause psoas abscess Resurgence in Africa, Asia Psoas abscess occurs due to retroperitoneal pyogenic (pus-forming)

infection in the abdomen or greater pelvis o Characteristically occurs in association with TB of the vertebral

columno Can be secondary to regional enteritis of the ileum in Crohn disease

About the abscess Extreme pain can be referred to the hip, thigh or knee joint when the

psoas abscess passes between the psoas and its fascia to the inguinal and proximal thigh regions

Psoas abscess should be considered when oedema (swelling) occurs in the proximal part of the thigh

Abscess can be palpated/observed in inguinal region, inferior/superior to inguinal ligament – often mistaken for inguinal/femoral hernia, inguinal lymph node enlargement, or saphenous varix

In normal radiographs of abdomen, the lateral border of the psoas is commonly visible – An obscured psoas shadow can be an indication of abdominal pathology

CHONDROMALACIA PATELLAE – aka “Runner’s knee”, common marathon injury

About this funny word Occurs due to over-stressing of knee region. Common in basketball/other

running sports as well. Symptom: Soreness/aching around or deep to patella Cause

o Quadriceps imbalanceo Blow to patellao Extreme flexion of knee (squatting/power-lifting)

SAPHENOUS VARIX Localized dilation of terminal part of great saphenous vein, known as a

saphenous varix may cause oedema in femoral triangle. Saphenous varix may be confused with other groin swellings.

Varix should be considered when varicose veins are present in other parts of the lower limb

ABNORMAL OSSIFICATION OF PATELLA Patella cartilaginous at birth, ossifies during 3-6th year with >1 ossification

centre. Can remain separate on one or both sides, giving rise to bipartite or

tripartite patella. Not to be confused with patellar fracture Ossification abnormalities are often bilateral, thus scan both limbs

REPLACED OR ACCESSORY OBTURATOR ARTERY – 20% of people Replaced

o Enlarged pubic branch of interior epigastric artery takes the place of obturator artery

Accessoryo Branch joins it as an accessory

Inferior epigastric artery runs close to, or across the femoral ring to reach obturator foramen – Can be closely related to the neck of femoral hernia

o Can be involved in strangulated femoral hernia Surgeons must be vigilant of this artery during endoscopic repair of

inguinal and/or femoral hernias

PATELLAR TENDON REFLEX: Knee jerk reflex (Tapping patellar ligament with reflex hammer)

Myotatic (deep tendon) reflex Person sits with dangling legs, firm strike on ligaments Hand on person’s quadriceps should feel the muscle contract Purpose

o Test integrity of femoral nerveo L2-L4 spinal cord segments

Physiologyo Tapping ligament activates muscle spindles in quadricepso Afferent impulses from spindles travel in femoral nerve to L2-L4

segments of spinal cordo Efferent impulses are transmitted via motor fibres in the femoral

nerve to the quadriceps, resulting in jerk-like contraction & extension @ knee

Pathology: Diminution/absence of patellar tendon reflexo Due to lesion that interrupts innervation of quadricepso E.g. peripheral nerve disease

PALPATION, COMPRESSION, CANNULATION OF FEMORAL ARTERY Misnomer/not used terminology: Common femoral artery and superficial

femoral artery to describe initial part of femoral artery proximal to branching of profunda femoris artery.

Femoral pulseo With person lying supine, pulse is palpated midway between ASIS

and pubic symphysiso ASIS (little finger), pubic tubercle (thumb) – femoral pulse on

midpalm inferior to the midpoint of inguinal ligament by pressing firmly

o Usually strong, but can e diminished if arteries are partially occluded

Compression of femoral arteryo Done by pressing directly posteriorly against superior pubic ramus,

psoas major, and femoral head, reducing blood through femoral artery and its branches (e.g. profunda femoris artery)

Cannulation (Introduce a thin tube into vein/body cavity)o Femoral artery cannulated inferior to midpoint of inguinal ligamento Left cardial angiography

Long, slender catheter is inserted into the artery and passed up external iliac artery, common iliac artery, and aorta to the left ventricle of the heart.

For visualising coronary arteries in coronary arteriography Blood draw

o Taken for blood gas analysis (determination of O2 and Co2 conc and pressures with the pH of blood by lab tests)

POTENTIALLY LETHAL MISNOMER Some people refer to femoral vein before it is joined by accompanying

veins of the profunda femoris artery (profunda femoris vein) as “superficial femoral vein” – Superficial vein is actually a deep vein, old people.

Acute thrombosis of this vessel is life threatening

Pulmonary emboli Originate in deep veins, not in superficial ones Risk of embolism is reduced by anticoagulant treatment Use of imprecise language creates possibility that an acute thrombosis of

this truly deep vessel can be overlooked as an acute clinical issue, life threatening issue created

LOCATION OF FEMORAL VEIN Not usually palpable – Position can be located inferior to inguinal ligament

by feeing the pulsations of the femoral artery (lateral to vein) Mistaken to be great saphenous vein in thin people Femoral vein has no tributaries at this level, except great saphenous vein

that joins it ~3cm inferior to inguinal ligament

Varicose vein operations Identify the great saphenous vein correctly, do not tie off the femoral vein

by mistake

CANNULATION OF FEMORAL VEIN Purpose: To secure blood sample and take pressure recordings from

chambers of the right side of heart Also to perform right cardiac angiography Procedure

o Long, slender catheter is inserted into femoral vein as it passes through the femoral triangle under fluoroscopic control.

o Passed superiorly through external and common iliac veins into the inferior vena cava and right atrium of heart

Femoral venous puncture – also used for administration of fluids.