Q1

Identify this bone and the significant bony features at the proximal end.

Q1_Q5 Hip & Thigh (Femur)

  • Femur, appropriate side/orientation
  • Head, fovea, neck, greater & lesser trochanters, intertrochanteric crest & line, quadrate tubercle, pectineal line, gluteal tuberosity.

Pass Criteria:

  • Bold structures to pass

What is the blood supply of the head and neck of the femur?

  • Medial and lateral circumflex femoral arteries
    • Usually branches of deep artery of thigh (profunda femoris)
    • Branch to form retinacular arteries (from medial > lateral), feed under post unattached capsule (medial) or through iliofemoral ligament (lateral).
  • Artery to head of femur – branch of obturator (less important)

Pass Criteria:

  • Bold to pass
  • Need to show understanding of dual supply and relative contributions (circumflex arteries > artery to head of femur)

You plan to do a femoral nerve block. What structures does the femoral nerve supply? (Supplementary question if time remaining)

  • Anterior thigh muscles (quadriceps)
  • Pectineus, Sartorius, iliacus
  • Articular branches to hip and knee joints
  • Cutaneous branches to anteromedial thigh
  • Terminal cutaneous branch is saphenous nerve to anteromedial knee, leg, foot

Pass Criteria:

  • 2/3 bold to pass

Q2

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Identify the structures in this photo of the posterior thigh.

PROMPT – bold if required

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  • Sciatic nerve (19)
  • Gluteus maximus (5)
  • Long head biceps (9)
  • Semitendinosus (22)
  • Semimembranosus (21)
  • Ischial tuberosity (8)
  • Gracilis (6)
  • Iliotibial tract (7)
  • Adductor magnus (1)
  • Popliteal artery and vein (16,17)
  • Quadratus femoris (18)

Pass Criteria:

  • Bold + any 4 others to pass

What are the clinical features of a severed sciatic nerve in the upper thigh?

PROMPT –  what does the sciatic nerve supply distal to this point?

  • Motor: Sciatic nerve supplies all posterior thigh muscles (depending on level of injury these may be affected), all leg and foot muscles
    • Loss of hip extension and flexion
    • All ankle (flexion/extension, inversion, eversion) and toe movements lost
  • Sensory: Skin of most leg and foot
    • Posterior and lateral leg
    • Sole of foot
    • Lateral and dorsum of foot

Pass Criteria:

  • Motor: 3 bold to pass
  • Sensory: 3 bold to pass

Q3

Demonstrate the boundaries of the femoral triangle.

Inguinal ligament, medial border of Sartorius and lateral border of adductor longus form the triangle

  • Pectineus (medial) and iliopsoas (lateral) form the floor

Pass Criteria:

  • 3/5 bold to pass

What are the contents of the femoral triangle?

femoral-triangle-content

 

  • Femoral vein, artery and nerve (medial to lateral)
  • Deep inguinal lymph nodes

Pass Criteria:

  • All content
  • 3/3 bold to pass

What surface markings help would you look for when trying to locate the femoral vein? Which veins drain into the common femoral vein?

  • Artery is found below inguinal ligament, midway between ASIS and pubic tubercle – vein is just medial to artery
  • Continuation of the femoral vein, popliteal vein, receives profunda femoris and great saphenous vein, ends posterior to the inguinal ligament where it becomes the external iliac vein. Also receives superficial epigastric vein, superficial circumflex iliac vein and superficial external pudendal vein

Pass Criteria:

  • Bold to pass

Q4

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This is a photograph of the gluteal region. Identify the labelled structures.

PROMPT – Point to piriformis if not identified.

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  •  Sciatic nerve – tibial part
    • common fibular part
  • Gluteus maximus
  • Gluteus medius
  • Gluteus minimus
  • Greater trochanter of femur
  • Inferior gamellus
  • Inferior gluteal artery
  • Inferior gluteal nerve
  • Internal pudendal artery
  • Ischial tuberosity
  • Nerve to obturator internus
  • Obturator externus
  • Obturator internus
  • Piriformis
  • Posterior femoral cutaneous nerve
  • Pudendal nerve
  • Quadratus femoris
  • Sacrotuberous ligament
  • Superior gamellus

Pass Criteria:

  • All three bolded to pass and at least two other named structures

Describe the actions of the gluteus maximus muscle.

  • Straightens the leg at the hip during walking, running, climbing.
  • Assists in raising from a sitting position.
  • Lower part acts as adductor and external rotator of lower limb
  • Tensor of the fascia lata and by its connection with the iliotibial band, steadies the femur on the tibia during standing when the extensor muscles are relaxed

Pass Criteria:

  • Bold to pass

Describe the course of the sciatic nerve in the gluteal region and leg.

  • Enters the gluteal region via the greater sciatic foramen inferior to piriformis and deep to gluteus maximus
  • Descends in midline of the posterior thigh deep to biceps femoris
  • Bifurcates into tibial and common fibula nerves at apex of popliteal fossa

Pass Criteria:

  • 2/3 bold to pass

Q5

Please demonstrate the main bony features of the proximal femur.

  • Femoral head
  • Fovea for ligament of head
  • Greater trochanter
  • Lesser trochanter
  • Neck
  • Intertrochanteric line (anterior)
  • Intertrochanteric crest (posterior)
  • Quadrate tubercle
  • Pectineal line
  • Gluteal tuberosity
  • Linea aspera with medial and lateral lips

Pass Criteria:

  • Bold + 3 others

Demonstrate on the model the muscular attachments to the greater trochanter.

  • Muscles originating
    • Vastus lateralis
  • Muscles inserting
    • Gluteus maximus (some fibres only, most to ileotibial tract)
    • Gluteus medius; To lateral surface
    • Gluteus minimus: To anterior surface
    • Piriformis; To superior border
    • Obturator internus; To medial surface (Trochanteric fossa)
    • Superior and ifnerior gemelli; To medial surface

Pass Criteria:

  • 4 of 7

The patient has a subcapital (intracapsular) fractured neck of femur. What is the most concerning complication of this type of fracture and why does this occur?

PROMPT  – What is the blood supply to the hip joint and how would this be disrupted?

  • Avascular necrosis of femoral head
  • Hip has dual supply
    • Medial and lateral circumflex femoral arteries, usually branches of deep aa of thigh (sometimes can arise direct from fem aa)
    • Arteries to head of femur, branch of obturator aa, traverses ligament of head (often small/inadequate)
  • Main supply is via retinacular aa, from branches of circumflex femoral (especially medial circumflex femoral, because these are able to pass freely under unattached posterior border of joint capsule.
  • Branches from lateral circumflex must penetrate thick iliofemoral ligament and are smaller and fewer.
  • Reticular arteries are torn or disrupted in intracapsular fracture

Pass Criteria:

  • Bold to pass

Q6

Describe the bony features of the middle and lower end of the femur.

  • Linea aspera
  • Medial supracondylar ridge/line – inferior continuation of the medial lip of the linea aspera, interrupted to allow passage of the femoral artery, ends in the adductor tubercle
  • Lateral supracondylar ridge/line – descends to the lateral epicondyle
  • Medial condyle
  • Lateral condyle
  • Intercondylar fossa
  • Adductor tubercle
  • Attachment of the medial ligament

Pass Criteria:

  • 5 of 8 to pass

Which muscles attach to the linea aspera?

  • Vastus medialis
  • Vastus lateralis
  • Adductor brevis
  • Adductor longus
  • Adductor magnus
  • Short head of the biceps femoris

Pass Criteria:

  • 3 of 6 to pass

Which artery is most likely to be damaged by a fracture of the midshaft of the femur?
Prompt: What is the course of the femoral artery through the thigh?

  • Profunda femoris
  • Course of femoral artery is supplemental question for better candidates

Pass Criteria:

  • Bold 

 

Q7

PHOTO: Femoral triangle boundaries and contents

Identify the boundaries and contents of the femoral triangle in this photo.

  • Triangle:
    • Inguinal ligament
    • Adductor longus
    • Sartorius
  • Floor:
    • Pectineus (medial)
    • Iliopsoas (lateral)
  • Contents (medial to lateral):
    • Femoral vein
    • Femoral artery
    • Femoral nerve

Pass Criteria:

  • 4 of 5 boundaries to pass
  • 3 of 3 contents to pass

Describe the branches and course of the femoral artery.

  • 4 Superficial branches in femoral triangle
    • Superficial epigastric
    • Superficial circumflex iliac
    • Superficial & deep pudendal
  • Profunda femoris (“deep artery of thigh”) branches off posterior-lateral in triangle to supply thigh, passes behind adductor longus, gives rise to medial and lateral external femoral arteries, medial circumflex femoral supplies neck of femur
  • Femoral artery continues down thigh deep to Sartorius and passes through adductor canal and becomes popliteal artery at adductor hiatus

Pass Criteria:

  • 3 general points to pass

Knee & Calf  Ankle & Foot