Physical Exam of the Lower Extremity
Landmarks - Surface Anatomy Palpable bony parts anteriorly Anterior superior iliac spine
(ASIS) Symphysis pubis Pubic tubercles (PT) Inguinal ligament Palpable bony parts at the buttocks Posterior superior iliac spine
(PSIS) Ischial tuberosity (IT) Greater trochanter (GT
Surface Markings of the Lower Limb
Patella Condyles of the femur and
tibia Head of the fibula Joint line of the knee Tibia Fibula
Palpable Soft Tissues
Rectus femoris Vasti muscles, lateral
and medial. Sartorius Adductor longus
muscle Pulsations of the
femoral artery Posterior compartment
muscles Terminal branches of
the sciatic nerve
Identify the boundaries of the femoral triangle.
Base - inguinal ligament. Lateral - medial border of sartorius. Medial - medial border of adductor
longus. Apex - where sartorius and adductor
longus overlap.
Identify the major muscles that form the floor of the femoral
triangle. Adductor longus.
Pectineus. Iliacus and psoas major.
From medial to lateral, the floor of the femoral triangle is formed by the adductor longus, a tiny
part of adductor brevis, pectineus, illiacus and psoas
major. This floor is curved, the femoral neurovascular bundle lies in the deepest part of this
curve running over psoas major.
VESSELS OF THE LOWER EXTREMITY
Femoral artery Popliteal artery Dorsalis pedis Posterior tibial
artery
Blood extraction from femoral artery or vein
Cardiac catheterization
Where are the clinically relevant veins in the lower limb?
What procedures require this knowledge?
Femoral vein cannulation
remember that vein is not only medial to artery but also may be posteriorly situated !
locate femoral artery ...
insert needle just medial to femoral pulse
femoral vein is medial ... femoral nerve lateral to artery
Saphenous vein cutdown Long saphenous vein -
in front of the medial malleolus; no matter how collapsed, how obese, or how young and tiny the patient, the vein can be relied upon to be available at this site when urgently required for transfusion purposes.
Saphenous vein cutdown
transverse incision made 1-2 cms in front of medial malleolus
note the proximity of the saphenous nerve to the vein !
Varicose Veins
The following reasons are offered:
a. The great length of the veins in the lower limb.
b. The large column of blood their valves have to support.
c. The vertical position to which they are often placed.
d. The iliac veins, to which the blood they carry are eventually drained, tend to be compressed by related organs.
e. Their superficial location allows for the condition, to which is added the absence of muscular contraction of surrounding muscles which help in the venous circulation.
Venous Stasis Ulcer
Causes: hereditary weakness of the vein walls incompetent valves elevated intraabdominal pressure
Treatment: Ligation and division of the entire main
tributaries of the great or small saphenous;
Ligation and division of all the perforating veins.
"It is imperative to ascertain that the deep veins are patent".
Anterior compartment syndrome
What is the mechanism & effect of ‘anterior compartment syndrome’ (of the leg) ?
Deep Vein Thrombosis
Pitting Edema
Distal Pulses Pulses are assessed to identify the presence of
arterial vascular disease. In general, the less prominent the pulses, the greater the chance that there is occlusive arterial disease. This is not a perfect correlation, however, as pulses may be palpable even when significant disease is present (e.g. may be affecting predominantly smaller, more distal blood vessels). A history of pain/cramps with activity suggestive of arterial insufficiency is also of great importance. The location of the blockage(s) will dictate the symptoms and findings. Aorto-iliac disease, for example, will cause symptoms in the hips/buttocks and a loss of the femoral pulse while disease affecting the more distal vessels will cause symptoms in the calves and feet.
Popliteal Area
Gangrene of toes Cellulitis
Neuropathic Ulcer in Patient with Diabetic Neuropathy
POPLITEAL AREA
The popliteal fascia is part of the binding fascia lata, which tends to limit the progress of infection, hemorrhage, tumor and aneurysms in the region.
However, the binding characteristic causes severe pain if these conditions develop.
A swelling of the bursae - "Baker's Cyst".
BURSAE OF THE LOWER LIMB
Weaver's bottom Housemaid's knee Clergyman's knee Bursitis over the insertion of the
tendon of Achilles into the calcaneus