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What are the 4 parts that make up the entire lower limb?
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How many bones are in the foot, and how are they divided (by groups of bones)?
- foot: 26 bones
- phalanges (toes): 14 bones
- metatarsals (instep): 5 bones
- tarsals (ankle): 7 bones
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Name the bones of the forefoot:
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Name the bones of the midfoot:
- 1st, 2nd, and 3rd cuneiforms
- navicular
- cuboid
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Name the bones of the hindfoot:
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Describe the location and main function of the longitudinal arch of the foot?
- extends from calcaneous to the head of the metatarsals
- functions as a shock absorber and allows smooth walking
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Describe the location of the transverse arch of the foot and what bones does it consist of?
- located primarily along the plantar surface of the distal tarsals and the tarsometatarsal joints
- 1st, 2nd, and 3rd cuneiforms and the cuboid
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Which part of the foot is referred to as the dorsal surface or the dorsum?
the top of the foot
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Which part of the foot is referred to as the plantar surface?
the bottom of the foot
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How are the digits of the foot numbered?
- great toe is #1
- index toe is #2
- middle toe is #3
- ring toe is #4
- pinky toe is #5
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How many phalanges and joints does the great toe have?
- 2 phalanges (proximal and distal)
- 1 joint (interphalangeal joint)
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How many phalanges and joints do digits 2-5 of the foot have?
- 3 phalanges (proximal, middle, and distal)
- 2 joints (proximal and distal interphalangeal joints)
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Which part of a metatarsal bone is closest to the point of attachment?
the base of the bone
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Which part of a metatarsal bone is distal to the point of attachment?
the head of the bone
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Which metatarsal bone is the shortest and thickest of the five?
the 1st metatarsal
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Which metatarsal bone is the longest of the five?
the 2nd metatarsal
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What is a noteworthy aspect of the 5th metatarsal bone?
It has a tuberosity on the proximal end close to the base of the bone (a common fracture site).
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What actually makes up the "ball" of the foot, or the "tippy-toes"?
the five heads of the metatarsals
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Name the 7 tarsal bones, primary and secondary names:
- Medial cuneiform/1st cuneiform
- Intermediate cuneiform/2nd cuneiform
- Lateral cuneiform/3rd cuneiform
- Cuboid
- Navicular/scaphoid
- Talus/astragalus
- Calcaneous/os calcis
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Which tarsal bone is the most superior and forms the ankle joint with the tibula/fibula?
talus/astragalus
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Label the bones of the foot by their primary names:
- A. phalanges
- B. metatarsals
- C. tarsals
- D. medial cuneiform
- E. intermediate cuneiform
- F. lateral coneiform
- G. navicular
- H. cuboid
- I. talus
- J. calcaneous
- K. distal interphalangeal joint (DIP), 2nd digit
- L. proximal interphalangeal joint (PIP), 3rd digit
- M. distal phalanx, 5th digit
- N. middle phalanx, 5 digit
- O. proximal phalanx, 5th digit
- P. metatarsophalangeal joint (MTP), 5th digit
- Q. tuberosity of 5th metatarsal
- R. sesamoid bones
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Label the bones of the foot by their primary names:
- A. tibia
- B. talus
- C. calcaneous
- D. navicular
- E. medial cuneiform
- F. first metatarsal
- G. sesamoid bone
- H. phalanges
- I. metatarsals
- J. tarsals
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What 4 bones does the cuboid articulate with?
- calcaneous (posteriously)
- 4th and 5th metatarsals (anteriorly)
- lateral cuneiform (medially)
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What 4 bones does the navicular articulate with?
- talus (posteriorly)
- 3 cuneiforms (anteriorly)
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What 4 bones does the medial cuneiform articulate with?
- 1st and 2nd metatarsals (anteriorly)
- navicular (posteriorly)
- intermediate cuneiform (laterally)
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What 4 bones does the intermediate cuneiform articulate with?
- navicular (posteriorly)
- second metatarsal (anteriorly)
- medial and lateral cuneiforms (medially/laterally)
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What 6 bones does the lateral cuneiform articulate with?
- navicular (posteriorly)
- 2nd, 3rd, and 4th metatarsals (anteriorly)
- intermediate coneiform (medially)
- cuboid (laterally)
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What 2 bones does the calcaneuous articulate with?
- cuboid (anteriorly)
- talus (superiorly)
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What 4 bones does the talus articulate with?
- tibia and fibula (superiorly)
- calcaneus (inferiorly)
- navicular (anteriorly)
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Which cuneiform is the largest of the three and which is the smallest?
- largest: medial cuneiform
- smallest: intermediate cuneiform
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What bone is 2nd in size and weight only to the femur?
the tibia
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What joints does the tibia participate in?
- the knee joint
- the ankle joint
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What joints does the fibula participate in?
only helps to stabilize the ankle joint
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What is the name of the condition where the tibial tuberosity can pull away from the bone?
Osgood-Schlatter Disease
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Name three parts of the proximal end of the fibula:
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What is another name for the intercondylar eminence?
tibial spine
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What is on the lateral side of the distal tibia?
fibular notch
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What is on the medial side of the distal tibia?
medial malleolus
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Where is the lateral malleolus located?
on the distal end of the fibula
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What makes the "shin"?
tibial crest
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What is the angle of the tibial plateau?
a posterior slant of 5-7°
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When both the lateral and medial malleolus break?
Potts Fracture
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Which leg bone has an anterior tubercle?
the tibia
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What makes up the tibial spine?
a medial and lateral intercondylar tubercle
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On the distal femur, which condyle is larger?
the medial condyle
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Give two alternate names for the patellar surface of the femur:
- intercondylar sulcus
- trochlear groove
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Name an aspect of the femur designed for strength:
it is slightly convex anteriorly
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What determines the angle of the femurs?
the width of the pelvis (wider pelvis = more angle of femurs)
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On the posterior surface of the femur, what is the area located just superiorly to the intercondylar fossa?
the popliteal surface
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What is the largest and most constant sesmoid bone in the body?
the patella (kneecap)
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Describe the patella:
- approx 2" in diameter
- base on top, apex on bottom
- posterior surface smooth and oval-shaped
- anterior surface convex and rough
- articulates with femur
- protects knee joint, not part of it
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What type of joints are the interphalangeal joints?
- hinge = flexion and extension
- synovial
- diarthrodial
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What type of joints are the metatarsophalangeal joints?
- synovial
- diarthrodial
- condyloid = flexion & extention, abduction & adduction
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What type of joints are the tarsometatarsal joints and the intermetatarsal joints?
- synovial
- gliding/plane types
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What type of joint is the ankle mortise joint?
- synovial
- hinge type = flexion and extension
- So our only two natural movements are dorsiflex and plantarflex
- abduction and adduction are stress movements
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What type of joint is the proximal tibiofibular joint?
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What type of joint is the distal tibiofibular joint?
- fibrous
- syndesmosis
- (only slightly movable)
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What type of joint is the knee joint?
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What is the purpose of the menisci of the knee joint?
serve as shock absorbers
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Name the four main ligaments of the knee joint:
- anterior cruciate ligament
- posterior cruciate ligament
- medial collateral ligament
- lateral collateral ligament
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Name an injury common to the knee:
ACL damage (anterior cruciate ligament)
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What technique is common to the AP (axial) projection of the toes?
50-60 kVp @ 2 mAs
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What degree of angulation is used for an AP projection of the toes?
15° posteriorly
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What will be different on the image of the toes if no angulation is used for the AP projection?
- the joint spaces will be closed (PIPs, DIPS, IPs)
- the phalanges will be foreshortened
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Where is the light centered for an AP or AP oblique projection of the toes?
3rd metararsophalangeal joint
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To what degree do you angle the part for an oblique projection of the toes?
- 30° for a medial rotation
- 45° for a lateral rotation
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What technique is generally used for the foot?
55-60 kVp @ 3.2-4 mAs
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What degree of angulation is used for an AP (axial) projection of the foot?
10° posteriorly
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What is seen on an AP axial projection of the foot?
- joint spaces open
- overlap of 1st cuneiform and navicular
- overlap of 3rd cuneiform and cuboid
- open articulation of calcaneus and cuboid
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Where is the light centered for the AP (axial), AP oblique, and lateral projections of the foot?
the base of the 3rd metatarsal
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How should the part be angled for the AP oblique projection of the foot?
30° medially
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What is seen on an AP oblique projection of the foot?
- cuboid and tuberosity in profile
- slight overlap of base of 1st and 2nd MTs (the rest open)
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What is the best projection to view the sinus tarsi?
- the AP Oblique of the foot
- medial/internal rotation
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What is seen on a lateral projection of the foot?
- no direct superimposition of tarsal bones
- see cuboid and tuberosity peeking from underside of foot
- see sesamoid bones just under head of 1st MT
- see ankle joint and 2" of tib/fib
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What is a term to describe where the talus articulates with the tibia?
talar dome
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Why are lateral weight bearing projections taken?
- for demonstrating the bones of the feet to show the condition of the longitudinal arches under the weight of the body
- show fallen arches
- arthritis
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Describe the aspects of taking an axial calcaneus projection:
- 40° angle posteriorly, 32" SID
- center to level of base of 3rd MT, light exits both malleolus
- foot dorsiflexed to be perpendicular to film
- approx. 70 kVp @ 5-6 mAs
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What is seen in an axial calcaneous projection?
- the subtalar joint should be open
- the trochlear process should be in profile, laterally
- the sustentaculum tali should be in profile, medial side
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Where should the light be centered for the lateral projection of the calcaneous?
- one inch distal to the medial malleolus
- 65 kVp @ 4 mAs
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What is seen in a lateral calcaneous projection?
- include ankle joint and 5th MT tuberosity
- talar dome directly superimposed, open ankle
- (fibula closes it off slightly)
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What technique is usual for an AP ankle projection?
60 kVp @ 6 mAs
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What is seen in an AP ankle projection?
- ankle mortise closed off on lateral side (lateral malleolus)
- distal tib/fib included
- mortise centered
- both malleoli in profile
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What is seen in a lateral projection of an ankle?
- talus and calcaneous in profile
- tibiotalar joint open
- foot dorsiflexed
- open subtalar joint
- see navicular
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What is seen in an AP medial oblique rotation of the ankle?
- fibula out to side (in profile)
- distal tibiofibular joint well seen
- (Potts fracture well visualized here)
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What is seen in an Ankle Mortise projection (15-20° rotation)?
ankle mortise is open all the way across
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Why are stress views of the ankle taken?
- they can demonstrate ligament tears by a widening of the affected joint space
- physician inverts and everts foot wearing lead gloves
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What is seen in an AP tib/fib projection?
- joint space in knee and ankle
- fibula posterior to tibia proximally and distally
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What is seen in a lateral tib/fib projection?
- joint spaces not as open
- slight overlap of tibia on fibular head
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When positioning for an AP knee, how should the CR be angled if the ASIS is 19-24cm to the tabletop?
perpendicular
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When positioning for an AP knee, how should the CR be angled if the ASIS is more than 24cm from the tabletop?
5° cephalic
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When positioning for an AP knee, how should the CR be angled if the ASIS is less than 19cm from the tabletop?
5° caudal
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Where should the CR be centered to for an AP knee?
1/2 inch below apex of patella
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What is seen in an AP knee projection?
- outline of the patella superimposed behind femur
- femur condyles in profile
- tibial spine in center
- head of tibia overlaps fibula slightly
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How should the CR be centered and angled for a lateral knee?
5-7° cephalic angle, 1" distal to medial epicondyle
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Name two types of fractures common to the patella:
- stellate fracture - star-shaped fracture
- longitudinal fracture - splits patella in half
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What is seen in a lateral knee projection?
- femoral condyles directly superimposed
- patella in profile with patellar space open
- rotational errors determined by placement of medial condyle
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Other than arthritis, what are two conditions that we take standing knee projections to study?
- volgus (bowlegged) knee joints
- varus (knock-kneed) knee joints
- note, this slide not spell-checked with text book yet****
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How should the central ray be angled for the oblique projections of the knee?
the same as the AP was angled, depending on the measurement of the distance from the ASIS to the tabletop.
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What is seen on an AP oblique knee, lateral rotation?
- tib/fib directly superimposed
- patella over lateral condyle
- open joint space
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What is seen on an AP oblique knee, medial rotation?
- no superimposition of tib/fib
- patella over medial condyle of femur
- open joint space
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What method is used for different versions of the PA axial projections of the knee?
- Holmblad Method
- also, Camp-Coventry
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for the PA axial projection of the knee using the Holmblad Method, how should the pt be positioned in relation to the IR?
- femur should make a 70° angle to the IR surface (in all three positions: on stool, at wall bucky, on table)
- no angle on tube (perpendicular)
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for the PA axial projection of the knee using the Camp Coventry Method, how should the pt be positioned in relation to the IR and how is the tube angled?
- pt prone with knee flexed 40-50° (40-50° angle to IR)
- tube angled 40-50° to match angle of knee (perpendicular entry)
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What method is used for the tangential projection of the knee known as the axial or sunrise/skyline projection?
Settegast Method
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for the Settegast Method (sunrise/skyline), how is the pt positioned and how is the tube angled?
- prone or supine, knee bent, knee shadow in crosshairs
- tube angled approx 15-20° (depends on how much pt could bend knee)
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What method is used for a tangential view of the patellar-femoral joint?
Houston Method
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What method is used to view both knees, both patellas?
Merchant Method
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Describe how to center for the AP projections of the femur (proximal and distal)
- proximal: top of light at ASIS
- distal: bottom of light 1-2" inferior to patellar apex
- for both: pt leg rotated 15° internally, collimate to MSP
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Describe how to position and center for proximal lateral projection of femur:
top of film at ASIS, pelvis rolled back 10-15°, unaffected leg back, knee of affected leg bent 45°
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Describe how to position and center for distal lateral projection of femur:
bottom of light 1-2" below medial condyle, unaffected leg forward, knee of affected leg bent 45°
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