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MRCS B > Anatomy - Lower Limb > Flashcards

Anatomy - Lower Limb Flashcards

1
Q

Which nerves arise from Lumbar plexus?

A

6 Major Nerves
“I TWICE Get Laid On Fridays”
1) Iliohypogastric Nerve
Roots : L1
Motor: Internal oblique and transversus abdominis
Sensory: Innervates the posteriolateral gluteal skin
2) Ilioinguinal Nerve
Roots: L1
Motor: Internal oblique and transversus abdominis
Sensory: Skin on anteromedial thigh +
males – root of penis and anterior scrotum, females – skin over pubis and labia majora
3) Genitofemoral Nerve
Roots: L1,2
Motor : Cresmasteric muscle – Genital branch
Sensory:
Genital branch
• Skin of mons pubis and anterior scrotum in males, Labia majora in females.
Femoral branch
• Skin of upper anterior thigh

4) Lateral Cutaneous Nerve of the Thigh
Roots: L2, L3
Motor: None
Sensory: Anterior and lateral thigh down to knee
5) Obturator Nerve
Roots: L2, L3, L4
Motor: Innervates muscles of medial thigh
obturator externus, adductor longus, adductor brevis, adductor magnus and gracillis

6) Femoral Nerve
Roots: L2,L3,L4

Motor: Muscles of anterior thigh – Iliacus, Pectineus, Sartorius and Quadriceps Femoris
Sensory: Skin on the anterior Thigh and Medial leg
o Anteromedial thigh – Anterior cutaneous branches of the femoral nerve
o Saphenous nerve – Medial leg and foot

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2
Q

What Nerves arise from The Sacral Plexus?

A

“Some Irish Sailors Pester Polly”
1) Superior Gluteal Nerve (L4,L5,S1)
o Motor – Glut. Minimus, Glut. Medius and Tensor fascia lata
o Sensory – None
2) Inferior Gluteal Nerve (L5,S1,S2)
o Motor - Gluteal Maximus
o Sensory- None
3) Sciatic Nerve (L4,L5,S1,S2,S3)
o Tibial portion
• Motor – Muscles of posterior compartment of thigh (except biceps femoris)
• Sensory- Skin in posterolateral leg, lateral foot and sole of the foot
o Common Peroneal
• Motor – Short head of biceps femoris, all muscles in anterior and lateral leg + extensor digitorum brevis
• Sensory- Skin lateral leg and dorsum of foot
4) Posterior Femoral Cutaneous ( S1,2,3)
o Motor- None
o Sensory – Innervates skin on posterior surface of the thigh and leg + skin of perineum
5) Pudendal Nerve (S2,3,4)
o Motor – Skeletal muscles of perineum, EUS, EAS, Levator Ani
o Sensory – Penis, clitoris and most of skin of the perineum

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3
Q

What are extracapsular ligaments of the hip joint and their attachments?

A

Iliofemoral – Y shaped and twisted
• ASIS to intertrochanteric line
Pubofemoral
• Iliopubic junction inserts to medial aspect of capsule
Ischiofemoral
• Ischium and inserts into the base of the greater trochanter

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4
Q

What structures attach to GT/ LT

A
  • Gluteus medius
  • Glut. Minimus
  • Piriformis
  • Superior Gemili + Inferior Gemili
  • Obturator externus
  • Obturator internus

LT- Iliopsoas

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5
Q

Name the muscles that attach to Linea Aspera

A

Pectineus, Adductor magnus (Adductor portion) , Adductor longus, Adductor brevis

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6
Q

Name the structures that attach to ASIS and AIIS

A
  • ASIS: Tensor fasciae latae, Sartorius, Inguinal ligament

* AIIS: Iliofemoral ligament, Staight head of rectus femoris

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7
Q

Structures attaching to the IT band

A
  • Thickening of fascia latae
  • IT track blends to become band
  • Glut Maximus
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8
Q

Function of IT band

A

Stabilises knee on extension during the gait cycle

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9
Q

Blood supply to the hip joint

A

• Suppled by 2 important anastomoses – Cruciate and Trochanteric
• Cruciate anastomoses
- IGA, medial and lateral circumflex femoral, 1st perforating artery from Profunda Femoris and posterior branch of obturator artery

• Trochanteric anastomoses – Main blood supply to head of femur
- Superior gluteal artery and medial and lateral superior circumflex arteries

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10
Q

Blood Supply to the neck and head of femur

A

Retinacular arteries - Ascending cervical branches of lateral circumflex femoral artery contribute to sub synovial arterial ring and the medial circumflex artery supplies the weight bearing posterior superior aspect

Extracapsular ring of anastomosis - Ascending cervical vessels also contribute to the extracapsular ring of anastomosis at the bease of the femoral neck.

Artery of ligamentum teres - branch of obturator

Interossous blood supply
Perforating arteries of profunda femoris

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11
Q

What is the clinical relevance of the blood supply to neck and head of femur

A

Intracapsular fractures of the neck and femur disrupt retinacular vessels - Disrupt vascular supply, avascular necrosis

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12
Q

Structures passing through the greater sciatic foramen above the piriformis

A
  • Superior Gluteal Nerve

* Superior Gluteal Vessels

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13
Q

Structures passing through the greater sciatic foramen below the piriformis

A
  • Inferior gluteal nerve
  • Inferior gluteal vessels
  • Pudendal nerve
  • Sciatic nerve
  • Posterior femoral cutaneous nerve
  • Nerve to obturator internus
  • Nerve to quadratus femoris
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14
Q

Structures passing through lesser sciatic foramen

A
  • Pudendal nerve – (Leaves GSF to re-enters foramen via the lesser sciatic foramen)
  • Internal pudendal artery and vein
  • Obturator internus tendon
  • Nerve to obturator internus
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15
Q

Main flexors of the hip ?

A
  • Psoas and Iliacus muscles are main hip flexors

* Pectineus, Rectus femoris, adductor longus and sartorius contribute

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16
Q

Nerve Supply to the main flexor of the hip

A

• Psoas Major – L1,L2,L3 Ventral rami
• Ilacus, rectus femoris and sartorius – Femoral Nerve (L2,3,4)
Pectineus -Femoral (Accessory Obturator in 20% )

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17
Q

Name the external rotators of the hip

A
  • Piriformis
  • Superior and inferior gemilli
  • Obturator internus and externus
  • Quadratus femoris
  • Gluteus Maximus
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18
Q

Garden Classification

A
  • Garden 1 – Incomplete, No displacement
  • Garden 2 – Complete, undisplaced
  • Garden 3 – Complete, partially displaced
  • Garden 4 – Complete, completely displaced
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19
Q

Lateral approach to hip

A
  • Division of Tensor Fascia Latae, gluteus medius, and minimus to expose femoral neck
  • Gain further access by detaching Greater Tuberosity attachments
20
Q

Anterior approach to hip

A
  • Incision Anterior half of iliac crest towards direction of lateral patella
  • Head of Rectus femoris is divided and reflected
  • Gain further access by detaching GMed and GMin from ilium
21
Q

Posterior approach to hip

A
  • Curvilinear incision over PSIS to Greater trochanter

* Superior gluteal nerve and Sciatic nerve at risk

22
Q

Name the boundaries of the femoral triangle

A
  • Lateral border: Medial border of Sartorius
  • Medial border: Medial border of Adductor longus
  • Superior border: Inguinal Ligament
  • Floor: Pectinues, Iliacus, psoas major
  • Roof: Fascia lata, Subcutaeous tissue and Skin
23
Q

Name Contents of femoral triangle

A
  • From lateral to medial
  • Femoral nerve
  • Femoral Arteryguin
  • Femoral Vein
  • Femoral Canal and lymph nodes
24
Q

Contents of Femoral Sheath

A

• Femoral Artery, Femoral Vein, Femoral Canal

25
Q

Borders of Femoral Canal

A
  • Medial border – Lacunar ligament
  • Lateral- Femoral vein
  • Anterior- Inguinal ligament
  • Posterior- Pectineal ligament + muscle
26
Q

What is the femoral Ring?

A
  • Opening of femoral canal at the superiorly abdominal end

* Femoral hernias – inferolateral to pubic tubercle (FV laterally, Lacunar medially)

27
Q

Describe course of femoral artery

A
  • External iliac artery becomes the common femoral artery at the level of the inguinal ligament (mid-inguinal point)
  • Approx. 4cm into the femoral triangle, the common femoral artery divides into deep profunda femoris and superficial femoral
  • Profunda femoris give off medial and lateral circumflex femoral arteries
  • Superficial femoral runs to the apex of femoral triangle and enters the adductor canal and exits the adductor hiatus to form the popliteal artery.
28
Q

Name the muscles that make up the hamstrings and innervations

A

Biceps femoris
• Long head from ischial tuberosity, short head from linea aspera
• Inserts head of fibula
• Long head - Tibial part of sciatic nerve
• Short head – Common peroneal
• Main action is flexion at the knee. It also extends the thigh at the hip, and laterally rotates at the hip and knee.
• Semitendinosus – tendon like structure
• Ischial tuberosity
• Medial surface of the tibia
• Tibial part of sciatic nerve

Semimembranosus (Under semimembranosus)
• Ischial tuberosity
• Attaches to medial tibial condyle
• Flexion of the leg at the knee joint. Extension of thigh at the hip. Medially rotates the thigh at the hip joint and the leg at the knee joint.

29
Q

Name the adductor muscles of the thigh

A
  • Gracillis
  • Inferior rami+ body of pubis descends vertically down the leg, attaches to medial surface of the tibia - Pes Anserinus
  • Adductor longus
  • Broad fan structure originates from pubis attaches to linea aspera
  • Obturator (L2,3,4)
  • Adductor brevis
  • Lies in between anterior and posterior divisions of obturator nerve
  • Body of pubis + pubic rami and attaches to linea aspera on posterior surface of femur
  • Obturator
  • Adductor Magnus
  • Adductor part originates from inferior rami of the pubis and rami of ischium attaches to linea aspera – Obturator
  • Hamstring part originates from ischial tuberosity and attaches to adductor tubercle and medial supracondylar line of femur – Tibial compartment of Sciatic
30
Q

Name the muscles that make up the quadriceps

A

Rectus Femoris
• Orgin – AIIS, part of ilium superior to acetabulum Vastus Lateralis
• Greater trochanter and lateral lip of linea aspera Vastus medialis
• Intertrochanteric line and medial lip of the linea aspera
Vastus intermedius
• Anterior and lateral surfaces of femoral shaft

31
Q

Name the boundaries of the Hunter’s Canal

A
  • Lateral: Vastus Medialis
  • Posterior: Adductor longus and adductor magnus
  • Anterior: Sartorius
32
Q

Structures passing through Hunter’s canal

A
  • Superficial femoral artery
  • Femoral Vein
  • Saphenous nerve
  • Nerve to vastus medialis
  • Terminal division of the obturator nerve
  • Lymphatics
33
Q

Describe the characteristic features of the medial and lateral menisci

A
  • Medial meniscus
  • Elongated C shaped structure (as the tibial surface is larger on the medial side)
  • Attached to medial collateral ligament and joint capsule- less mobile – therefore more susceptible to injury as cannot accommodate for abnormal stresses
  • Lateral meniscus
  • Smaller and more circular
  • No attachment to the lateral collateral ligament or joint capsule therefore is more mobile
  • Popliteus tendon runs between the joint capsule and the lateral meniscus
34
Q

What structures are encountered during arthroscopic surgery to the knee – anterior approach?

A 
•	Transverse meniscal ligament
•	Anterior horn of medial meniscus
•	ACL
•	Anterior horn of lateral meniscus
•	Posterior horn of medial meniscus
•	PCL 
`
35
Q

Describe attachments of ACL and PCL

A
  • ACL – attaches to the anterior intercondylar area of the tibia (medial aspect) and runs up and posterior laterally to attach to medial surface of lateral femoral condyle
  • PCL – attaches to the posterior intercondylar area (lateral aspect) and runs up and superiomedially to attach to lateral surface of medial femoral condyle
36
Q

Describe the bursae around the knee joint

A
  • Suprapatellar Bursa: Lies between the inferoanterior surface of the femur and the deep surface of quadriceps
  • Prepatellar Bursa: Between Patella and the skin
  • Infrapatella bursae: superficial and deep
  • Semimembranosus bursa
37
Q

How are patellar fractures managed?

A
  • Conservative if non displaced/minimally displaced
  • Surgical if extensor lag or significant displacement
  • ORIF with Tension band wiring
38
Q

Boundaries of popliteal fossa?

A
  • Superomedial: Semimembranosus
  • Superolateral: Biceps femoris
  • Inferomedial: Medial head of Gastroc
  • Inferolateral: Lateral head of Gastroc
  • Floor: Popliteal surface of femur, capsule of knee joint and popliteus
39
Q

Contents of popliteal fossa?

A
  • Popliteal artery (Deepest) – commences at adductor hiatus
  • Popliteal Vein (Small saph vein drains)
  • Tibial Nerve
  • Common Peroneal Nerve
40
Q

Blood supply of the knee joint

A
  • Five Genicular branches of popliteal artery – genicular anastomoses
  • Descending genicular branch of femoral
  • Descending genicular branch of lateral femoral circumflex
  • Anterior recurrent branch of anterior tibial artery (Inferolaterally)
41
Q

Describe course of popliteal artery

A

• Popliteal artery descends down and gives off genicular branches and exits between gastrocnemius and popliteus
• At lower border of popliteus, popliteal arterial terminates and gives off
o Anterior tibial and Tibioperoneal
• Anterior tibial
o Passes anteriorly between extensor hallucis longus and tibialis anterior close to IO membrane
o Moves inferiorly down the leg can be palpated between two malleoli at the anterior aspect of the ankle lateral to the tendon of EHL
o Becomes dorsalis pedis at distal edge of the retinaculum – DP pulse between 1st and second metatarsals of the foot
• Tibioperoneal
o Posterior tibial – posterior compartment - enters foot with tibial nerve in tarsal tunnel
o Peroneal artery – Lateral compartment- travels posterior to fibula Perforating branches

42
Q

Name muscles of anterior compartment of lower leg

A
  • Tibialis Anterior
  • Extensor Digitorum longus
  • Extensor Hallucis longus
  • Fibularis tertius
43
Q

Name origins and insertion of the anterior compartment muscles

A
  • All supplied by deep fibular nerve- DORSIFLEXION AND INVERSION OF FOOT
  • Tibialis anterior
  • Origin: Lateral surface of tibia attaches to medial cuneiform and base of 1st Metatarsal
  • Strongest dorsiflexor of foot
  • Extensor Digitorum Longus
  • Origin: Lateral condyle of the tibia and the medial surface of the fibula, fibres converge and travel down to the foot where they split into four, each inserting onto a toe
  • Extension of lateral four toes, dorsiflexion of the foot
  • Extensor hallucis longus
  • Originates from the medial surface of the fibular shaft
  • Tendon crosses anterior to ankle joint and attaches to the base of distal phalanx of great toe
  • Extension of great toe and dorsiflexion of the foot
  • Fibularis Tertius
  • Originates with EDL on medial surface of the fibula, tendon descends with EDL but diverges and attaches to 5th Metatarsal
  • Eversion + Dorsiflexion of the foot
44
Q

Lateral compartment of leg – PLANTARFLEX AND INVERSION

A

Fibularis longus
o Origin: superior and lateral surface of fibula and lateral tibial condyle
o Tendon passes posterior to lateral malleolus – medial cuneiform and base of 1st metatarsal
o Superficial fibula (L4-S1)
Fibularis Brevis
o Inferolateral aspect of fibula, travels with longus and passes posterior to lateral malleolus and inserts on to 5th MT
o Superficial fibula (L4-S1)

45
Q

Posterior Compartment of leg

A

Gatrocnemius

  • Lateral head – lateral femoral condyle
  • Medial head – Medial femoral condyle
  • Converge together and insert onto calcaneus
    Plantaris
  • Lateral supracondylar line of the femur
  • Muscle descends medially between gastroc and soleus
    Soleus
  • Originates from soleal line of the tibia and proximal tibia
46
Q

Posterior Compartment of leg - deep muscles

A

Deep Muscles
Popliteus
- Forms base of popliteal fossa
- Originates from lateral condyle of the femur and the posterior horn of lateral meniscus
- Inserts above the origin of soleus muscle
Tibialis Posterior
- Originates from the interosseous membrane between the tibia and fibula, posterior surfaces of the two bones
- Tendon enters the foot posterior to the medial malleolus and attaches to medial tarsal bones
Flexor Digitorum Longus
- Originates from medial surface of the tibia, attaches to plantar surfaces of lateral four digits
Flexor Hallucis Longus
- Originates from posterior surface of the fibula, attaches to the plantar surface of great toe phalanx

47
Q

What is tarsal tunnel

A 
Borders
o	Floor – cancave surface formed by medial aspect of tibia, talus and calcaneus 
o	Roof – Flexor retinaculum 
        Contents
o	Tom Dick and Very Naughty Harry

MRCS B (2 decks)

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