Anatomy- Lower Limb Flashcards

1
Q

What are the 3 main long bones in the lower limb?

A
  1. Femur (proximal).
  2. Fibula (distal and lateral).
  3. Tibia (distal and medial).
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2
Q

What nerve innervates the muscles in the anterior compartment of the thigh?

A

The femoral nerve, L2-4.

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3
Q

What is the action of the majority of the muscles in the anterior compartment of the thigh?

A

Extension of the leg at the knee.

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4
Q

What is the origin of psoas major?

A

Transverse processes of T12-L5 vertebrae.

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5
Q

What is the origin of iliacus?

A

The iliac fossa and the pelvis.

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6
Q

Where does iliopsoas insert?

A

The lesser trochanter of the femur.

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7
Q

What is the innervation to psoas major?

A

Anterior rami of L1-3.

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8
Q

What is the innervation to iliacus?

A

Femoral nerve L2-4.

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9
Q

What is the action if iliopsoas?

A

Flexes the lower limb at the hip.

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10
Q

What muscles make up quadriceps femoris?

A
  1. Vastus medialis.
  2. Vastus intermedius.
  3. Vastus lateralis.
  4. Rectus femoris.
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11
Q

What is the lower part of quadriceps femoris related to?

A

The suprapatellar bursa.

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12
Q

What attaches the patella to the tibia?

A

The patella ligament.

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13
Q

What is the action of the vasti muscles?

A

Extension at the knee.

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14
Q

What is the action of rectus femoris?

A

Extension at the knee and flexion at the hip.

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15
Q

What is the innervation of quadriceps femoris?

A

Femoral nerve, L2-4.

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16
Q

What is the origin of sartorious?

A

Anterior Superior Iliac Spine

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17
Q

What is the action of sartorious?

A

Flexion, abduction and lateral rotation at the hip. Flexion at the knee.

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18
Q

What is the innervation to sartorious?

A

Femoral nerve, L2-4.

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19
Q

How can you test the action of quadriceps femoris?

A

Ask the patient to extend their legs against resistance whilst lying in a supine position.

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20
Q

What nerve innervates the muscles in the medial compartment of the thigh?

A

Obturator, L2-4.

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21
Q

What is the action of the majority of the muscles in the medial compartment of the thigh?

A

Hip adductors.

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22
Q

Name the 5 muscles found in the medial compartment of the thigh.

A
  1. Gracilis.
  2. Obturator externus.
  3. Adductor brevis.
  4. Adductor longus.
  5. Adductor magnus.
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23
Q

Where do adductor brevis, adductor longus and adductor magnus originate and insert?

A

Origin: pubis.
Insertion: medial femur.

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24
Q

What is the action of adductor brevis, adductor longus and adductor magnus.

A

Adduction of the thigh.

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25
Q

What is the innervation of adductor brevis, adductor longus and adductor magnus.

A

Obtruator nerve, L2-4.

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26
Q

What forms the superior border of the femoral triangle?

A

The inguinal ligament.

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27
Q

What muscle forms the medial border of the femoral triangle?

A

Adductor longus.

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28
Q

What muscle forms the lateral border of the femoral triangle?

A

Sartorious.

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29
Q

What are the contents of the femoral triangle?

A

Femoral nerve, femoral artery, femoral vein and lymph nodes. NAV lateral to medial.

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30
Q

What is the femoral canal and what does it contain?

A

A potential space medial to the femoral vein. It contains lymph nodes.

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31
Q

Define hernia.

A

The protrusion of an organ through the wall of the cavity containing it.

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32
Q

What is a femoral hernia?

A

Protrusion of bowel into the femoral canal. This manifests as a bulge in the thigh.

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33
Q

What is the subsartorial canal?

A

A passageway for vessels extending from the femoral triangle to the popliteal fossa at the back of the knee.

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34
Q

What is the saphenous opening

A

An opening in the fascia lacta pierced by the great saphenous vein.

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35
Q

What is the surface marking for the saphenous opening?

A

4cm below and lateral to the pubic tubercle.

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36
Q

What are the contents of the femoral sheath?

A

Femoral artery, veins and lymphatics.

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37
Q

What is the surface marking for the femoral artery?

A

2cm below the mid-inguinal point.

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38
Q

Where is the femoral artery pulsation palpable?

A

Below the mid-inguinal point.

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39
Q

Name the arteries in between the aorta and the femoral artery?

A

Aorta -> common iliac arteries -> external iliac arteries -> femoral artery.

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40
Q

Name the 2 main branches of the femoral artery.

A
  1. Profunda femoris artery.

2. Superficial femoral artery.

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41
Q

Which veins join to become the common femoral vein?

A

The superficial femoral vein and the profunda femoris vein.

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42
Q

Name all the major veins blood flows through from the femoral vein to the heart?

A

Femoral vein -> external iliac vein -> common iliac vein -> IVC -> heart.

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43
Q

If you do a femoral puncture to take blood from the femoral vein, do you introduce the needle lateral or medial to the femoral arterial pulsation?

A

Medial. NAV therefore vein is medial to artery.

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44
Q

What is the motor supply of the femoral nerve?

A

Anterior thigh compartment muscles.

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45
Q

Which joints does the femoral nerve supply?

A

The hip and knee.

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46
Q

What are the problems produced by weak quadriceps?

A

Difficulty walking downstairs.

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47
Q

In what muscle is the obturator nerve formed?

A

Psoas major.

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48
Q

Define referred pain.

A

Pain arising from one area but it’s felt elsewhere.

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49
Q

Give an example of referred pain in the leg.

A

Medial thigh pain can be felt due to inflammation of the ovary irritating the obturator nerve.

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50
Q

What is the femoral artery a continuation of?

A

The external iliac artery.

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51
Q

When does the external iliac artery become the femoral artery?

A

When it crosses under the inguinal ligament into the femoral triangle.

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52
Q

What artery does the obturator arise from?

A

The internal iliac artery.

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53
Q

Name the 3 glutei muscles.

A
  1. Gluteus maximus.
  2. Gluteus medius.
  3. Gluteus minimus.
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54
Q

Where does gluteus maximus insert?

A

The iliotibial tract and the gluteal tuberosity of the femur.

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55
Q

What is the action of gluteus maximus?

A

Extension of the thigh.

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56
Q

What is the innervation of gluteus maximus?

A

Inferior gluteal nerve.

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57
Q

What is the action of gluteus medialis and minimus?

A

Abduction of the lower limb.

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58
Q

What is the innervation of gluteus medialis and minimus?

A

Superior gluteal nerve.

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59
Q

When do you abduct the hip joint?

A

When walking.

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60
Q

What is the usual function of the abductors of the hip joint?

A

They hold the pelvis level when you take one foot off the ground.

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61
Q

Where do gluteal vessels and nerves emerge from?

A

The greater sciatic foramen.

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62
Q

What are the nerve roots of the sciatic nerve?

A

L4-S3.

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63
Q

What does the sciatic nerve innervate?

A

The muscles of the posterior thigh and the hamstring part of adductor magnus.

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64
Q

What does the sciatic nerve bifurcate into?

A

The tibial and common peroneal (common fibular) nerves.

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65
Q

What 3 muscles make up the hamstrings?

A
  1. Biceps femoris (lateral).
  2. Semimembranous (medial).
  3. Semitendinous.
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66
Q

What is the action of the muscles in the posterior compartment of the thigh?

A

Extension at the hip and flexion at the knee.

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67
Q

When do the extensors of the hip joint act?

A

When climbing the stairs.

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68
Q

What is the innervation of the muscles in the posterior compartment of the thigh?

A

Sciatic nerve L4-S3.

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69
Q

Where does the biceps femoris tendon insert?

A

The head of the fibula.

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70
Q

What muscle forms the superiomedial border of the politeal fossa?

A

Semimembranosus muscle.

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71
Q

What muscle forms the superiolateral border of the politeal fossa?

A

Biceps femoris.

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72
Q

What muscle forms the inferiormedial border of the politeal fossa?

A

Medial head of the gastrocnemius.

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73
Q

What forms the roof of the popliteal fossa?

A

Fascia.

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74
Q

What are the contents of the popliteal fossa?

A
  1. Popliteal artery.
  2. Popliteal vein.
  3. Tibial nerve.
  4. Common peroneal nerve.
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75
Q

How are the arteries, veins and nerves arranged in the popliteal fossa?

A

Usually NAV from lateral to medial. The nerve is always most superficial and the artery is always deepest.

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76
Q

How can you examine the hamstrings in the living?

A

Active flexion of the knee.

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77
Q

Name 4 muscles that insert on to the medial condyle of the tibia.

A
  1. Semitendinosus.
  2. Semimembranosus.
  3. Sartorious.
  4. Gracilis.
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78
Q

How does the popliteal artery reach the popliteal fossa?

A

As the femoral artery through the adductor canal.

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79
Q

What superficial vein drains into the popliteal vein?

A

The great saphenous vein.

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80
Q

What is the surface marking of the sciatic nerve?

A

Lower medial quadrant of the buttock.

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81
Q

What is the effect of a complete transection of the sciatic nerve?

A

Loss of hamstring function and of muscles below the knee.

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82
Q

What is the origin of the long head of the biceps, semitendinosus and semimembranosus?

A

The ischial tuberosity.

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83
Q

What is the origin of the short head of the biceps?

A

Linea aspera.

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84
Q

Where does biceps femoris tendon insert?

A

The head of the fibula.

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85
Q

Which of the hamstrings muscles lies most lateral?

A

The biceps femoris.

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86
Q

How can you identify semitendinosus

A

It has a very long tendon attaching to the medial condyle of the tibia.

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87
Q

Define myotome.

A

A group of muscles supplied by the same spinal nerve root.

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88
Q

Name 3 muscles in the anterior compartment of the leg.

A
  1. Tibialis anterior.
  2. Extensor digitorum longus.
  3. Extensor hallucis longus.
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89
Q

What are the actions of the muscles in the anterior compartment of the leg?

A

Dorsiflexion and inversion. The extensors also extend the toes.

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90
Q

Describe dorsiflexion.

A

Flexing the ankle joint so that the toes are brought closer to the shin.

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91
Q

What is the innervation to the muscles in the anterior compartment of the leg?

A

Deep peroneal nerve (L4-5).

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92
Q

What is the deep peroneal nerve a branch of?

A

The common peroneal nerve, which is a branch of the sciatic nerve.

93
Q

What is the action of tibialis anterior?

A

Dorsiflexion and inversion of the foot.

94
Q

Describe inversion of the foot.

A

Turning the ankle so that the plantar surface of the foot faces medially.

95
Q

What is the action of extensor digitorum longus?

A

Dorsiflexion of the foot and extension of the toes.

96
Q

What is the action of extensor hallucis longus?

A

Dorsiflexion of the foot and extension of the toes.

97
Q

Where does extensor hallucis longus insert?

A

The great toe.

98
Q

What is the blood supply to the muscles in the anterior compartment of the leg?

A

Anterior tibial artery

99
Q

What is the origin of extensor digitorum longus

A

Lateral condyle of the tibia and medial fibula.

100
Q

What can cause foot drop?

A

Damage to the common peroneal nerve and so paralysis of the dorsiflexors.

101
Q

What is foot drop?

A

When the foot is permanently plantarflexed as the action of these muscles in unopposed due to paralysis of the dorsiflexors.

102
Q

Name 2 muscles in the lateral compartment of the leg.

A

Peroneal brevis and longu

103
Q

What are the actions of the muscles in the lateral compartment of the thigh?

A

Eversion and plantarflexion.

104
Q

What do the tendons of peroneal brevis and longus pass posteriorly to in the foot?

A

The lateral malleolus.

105
Q

What is the innervation to the muscles in the lateral compartment of the thigh?

A

Superficial peroneal nerve

106
Q

Name 2 superficial muscles in the posterior compartment of the leg

A

Soleus and gastrocnemius.

107
Q

How many heads does gastrocnemius have?

A

2 - medial and lateral. They form the inferior borders of the popliteal fossa.

108
Q

What is the origin of gastrocnemius?

A
  • Medial head: medial condyle of the femur.

- Lateral head: lateral condyle of the femur.

109
Q

What is the insertion of gastrocnemius?

A

It combines with soleus to form the calcaneal tendon which inserts onto the calcaneus.

110
Q

What are the 2 actions of gastrocnemius?

A

Plantarflexion at the ankle and flexion at the knee.

111
Q

What other muscle combines to form the calcaneal tendon with gastrocnemius?

A

Soleus.

112
Q

What is the action of soleus?

A

Plantarflexion.

113
Q

What is the innervation to the posterior compartment of the leg?

A

Tibial nerve.

114
Q

In what compartment of thelower limb are the hamstrings located?

A

The posterior thigh.

115
Q

Name 4 deep muscles in the posterior compartment of the leg.

A
  1. Popliteus.
  2. Flexor digitorum longus.
  3. Flexor hallucis longus.
  4. Tibialis posterior.
116
Q

How many tarsal bones are there?

A

7.

117
Q

Which nerve winds around the neck of the fibula?

A

The common peroneal nerve.

118
Q

Complete transection of the common peroneal nerve can cause what clinical sign?

A

Foot drop.

119
Q

The muscles that form the calcaneus tendon are all supplied by which nerve?

A

Tibial nerve.

120
Q

Does the long saphenous vein cross anterior or posterior to the medial malleolus?

A

Anterior.

121
Q

What veins drain the superficial leg?

A

Short and long saphenous veins. The short saphenous vein drains the posterior leg.

122
Q

How do the superficial and deep veins of the leg communicate?

A

Via perforators which pass through the deep fascia

123
Q

What area of the leg receives skin sensation from the superficial peroneal nerve?

A

Anterolateral inferior 1/3 of the leg.

124
Q

What area of the foot receives skin sensation from the deep peroneal nerve?

A

Dorsum of the first web space.

125
Q

What area of the leg receives skin sensation from the saphenous nerve?

A

Medial leg.

126
Q

What area of the leg receives skin sensation from the posterior cutaneous nerve of the thigh?

A

Popliteal fossa.

127
Q

What area of the foot receives skin sensation from the tibial nerve?

A

Medial sole of foot.

128
Q

Describe compartment syndrome.

A

Bleeding, oedema or infection increase the pressure in a compartment. The increased pressure means blood flow will cease which results in ischemia.

129
Q

How can you test tibialis anterior?

A

Dorsiflexion at the ankle.

130
Q

How can you test extensor digitorum longus?

A

Extension of the toes.

131
Q

How can you test extensor hallucis longus?

A

Extension of the great toe.

132
Q

Which muscle compartment is supplied by the deep peroneal nerve?

A

Anterior leg.

133
Q

Does the deep peroneal nerve innervate skin? If so, where?

A

Innervates the first dorsal web space.

134
Q

What is the anterior tibial artery a branch of?

A

The popliteal artery. (Popliteal artery is a branch of the femoral artery)

135
Q

Which artery is the dorsal pedis artery a branch of?

A

The anterior tibial artery.

136
Q

When might the pulsation of the dorsal pedis artery be absent?

A

If the anterior tibial artery is blocked.

137
Q

What are the actions of the peroneii muscles?

A

Eversion of the foot

138
Q

What muscles make up the peroneii muscles?

A
  • Peroneal longus.

- Peroneal brevis.

139
Q

What nerve innervates the peroneii muscles?

A

Superficial peroneal nerve.

140
Q

How can you test the peroneii muscles?

A

Eversion against resistance.

141
Q

Which nerve injury will lead to paralysis of the peroneii muscles?

A

Superificial peroneal nerve or common peroneal nerve.

142
Q

What muscles are paralysed by damage to the common peroneal nerve?

A
  1. Peroneal longus and brevis (lateral compartment).

2. Tibialis anterior, extensor longus digitorum and extensor longus hallucis (anterior compartment).

143
Q

Describe the gait of a patient who has had complete teansection of the common peroneal nerve.

A
  • Foot drop.

- High steps to avoid stubbing toes.

144
Q

Which leg bone has more muscle attached to it?

A

Fibula.

145
Q

Why is the blood supply to the shaft of the tibia relatively poor?

A

The tibia has few muscles attached it. Attached muscles are responsible for supplying the majority of blood to a bone.

146
Q

Why do fractures of the tibia take a long time to heal?

A

Poor blood supply.

147
Q

How do you test the gastrocnemius?

A

Ask the patient to stand on their tip toes.

148
Q

What is the fibular artery a branch of?

A

The posterior tibial artery.

149
Q

Describe the ankle jerk reflex.

A

Tapping the achilles/calcaneal tendon acutely stretches the gastrocnemius. This results in a reflex contraction of the muscle.

150
Q

Which segments of the spinal cord are you testing when you elicit the ankle jerk reflex?

A

S1,2.

151
Q

Which segments of the spinal cord are you testing when you elicit the knee jerk reflex?

A

L2,3,4.

152
Q

Which muscle compartment is supplied by the tibial nerve?

A

Posterior leg.

153
Q

What are the structures in the tarsal tunnel deep to the retinaculum?

A

Tibial nerve.

154
Q

What type of joint is the hip joint?

A

Ball and socket, synovial.

155
Q

What is the main function of the hip joint?

A

To bear weight - its range of movements is therefore limited.

156
Q

What bones articulate in the hip joint?

A

The femoral head articulates with the acetabulum of the pelvis.

157
Q

What is the intrascapular ligament of the hip joint?

A

The ligament of the head of the femur.

158
Q

Name the 3 extrascapular ligaments of the hip joint.

A
  • Iliofemoral.
  • Ischiofemoral.
  • Pubofemoral.
159
Q

Which extrascapular ligament of the hip joint is located most posteriorly?

A

Ischiofemoral.

160
Q

Give 2 features of the acetabulum which add stability to the hip joint.

A
  1. It is deep and encompasses nearly all of the head of the femur.
  2. It is surrounded by the acetabular labrum which increases its depth and provides a larger articular surface.
161
Q

What is the name of the fibrocartilage collar that surrounds the acetabulum?

A

The acetabular labrum.

162
Q

Give 2 functions of the acetabular labrum.

A
  1. Increases the depth of the acetabulum.

2. Provides a larger articulating surface.

163
Q

The circumflex femoral arteries supply the hip joint. What are they a branch of?

A

The profunda femoris artery.

164
Q

What nerves innervate the hip joint?

A

Sciatic, obturator and femoral.

Any nerve supplying a muscles which moves a joint also innervates the joint

165
Q

What type of joint is the knee joint?

A

Hinge, synovial.

166
Q

What are the 2 articulations of the knee joint?

A
  1. Tibiofemoral.

2. Patellofemoral.

167
Q

What is the function of the tibiofemoral articulation?

A

It is the weight bearing joint.

168
Q

What is the function of the patellofemoral articulation?

A

It aloows the quadriceps femoris tendon to be onserted over the knee.

169
Q

Give 3 functions of the medial and lateral menisci.

A
  1. Shock absorbers.
  2. Permit some rotation.
  3. Deepen the articulating surfaces and so increase stability.
170
Q

What are the medial and lateral menisci both attached to?

A

The intercondylar area of the tibia.

171
Q

What is the medial meniscus attached to?

A
  1. Intercondylar area of the tibia.
  2. Tibial (medial) collateral ligament.
  3. Joint capsule
172
Q

What is the lateral meniscus attached to?

A

The intercondylar area of the tibia.

173
Q

Which meniscus is more prone to injury?

A

Medial meniscus - its extra attachments to the medial collateral ligament and joint capsule mean it is less mobile and so more prone to damage.

174
Q

What is the patellar ligament a continuation of?

A

The quadriceps femoris tendon distal to the patella.

175
Q

What is the function of the collateral ligaments?

A

To stabilise the hinge motion of the knee.

176
Q

Name the 2 collateral ligaments of the knee.

A
  1. Tibial (medial) - more prone to injury.

2. Fibular (lateral) - thinner and rounder.

177
Q

What bones do the cruciate ligaments attach to?

A

The femur and the tibia.

178
Q

Where does the anterior cruciate ligament attach?

A

The anterior intercondylar region of the tibia and the posterior femur.

179
Q

Where does the posterior cruciate ligament attach?

A

The posterior intercondylar region of the tibia and the anterior femur.

180
Q

What is the function of the cruciate ligaments?

A

They stabilise the knee in the anterior and posterior direction. Prevent dislocation.

181
Q

Which ligament of the knee is extrascapular?

A

Lateral collateral.

182
Q

What parts of the knee are intrascapular?

A

Menisci, ACL and PCL.

183
Q

If a force is applied to the lateral aspect of a fixed knee which collateral ligament would be damaged?

A

This would stretch the medial aspect of the knee resulting in damage to the medial collateral ligaments.

184
Q

What type of joint is the ankle joint?

A

Hinge, synovial.

185
Q

What movements are permitted at the ankle joint?

A

Dorsiflexion and plantarflexion.

186
Q

Which muscles of the leg are responsible for dorsiflexion?

A

Tibialis anterior, extensor hallucis longus and extensor digitorum longus (anterior compartment).

187
Q

Which muscles of the leg are responsible for plantarflexion?

A

Gastrocnemius and soleus (posterior compartment).

188
Q

What 3 bones make up the ankle joint?

A

Tibia, fibula and talus.

189
Q

What binds the tibia and fibular?

A

Tibiofibular ligaments.

190
Q

What do the tibia and fibula form that the talus articulates with?

A

A mortise.

191
Q

What is the name of the ligament originating from the medial malleolus of the foot?

A

The deltoid ligament.

192
Q

What 3 ligaments are found on the lateral side of the ankle joint?

A
  1. Anterior talofibular.
  2. Posterior talofibular.
  3. Calcaneofibular.
193
Q

What type of joint is the superior tibiofibular joint?

A

Synovial.

194
Q

What type of joint is the inferior tibiofibular joint?

A

Fibrous.

195
Q

What movements occur at the subtalar joint?

A

Inversion and eversion.

196
Q

What 3 bones articulate in the subtalar joint?

A
  1. Talus.
  2. Calcaneus.
  3. Navicular bone.
197
Q

What ligament does the talus articulate with in the subtalar joint?

A

Spring ligament.

198
Q

What joint shares the same synovial cavity as the subtalar joint?

A

Midtarsal joint.

199
Q

What muscles are the predominant invertors?

A

Tibialis anterior and posterior.

200
Q

What muscles are the predominant evertors

A

Peroneus longus and brevis.

201
Q

What muscles support the pelvis when standing on one leg?

A

Gluteus medius and minimus.

202
Q

In posterior dislocations of the hip which nerve is liable to injury?

A

Sciatic.

203
Q

What accompanies the ligament of the head of the femur in children?

A

Blood vessels supplying the femoral head epiphyses.

204
Q

What is the usual cause of avascular necrosis of the head of the femur in adults?

A

Fractured neck of the femur.

205
Q

A child with a hip joint disease has pain in the knee joint. What is this due to?

A

The sciatic nerve supplies the hip and the knee and so this is likely to be referred pain.

206
Q

What is the action of popliteus?

A

Twists the tibia on the femur to unlock the knee.

207
Q

What are the functions of the quadriceps?

A

Extension at the knee and flexion at the hip.

208
Q

How might the ACL be injured?

A

Hyperextension, common in sports injuries.

209
Q

What are bakers cyst and housemaids knee?

A

Clinical presentations of patella bursae inflammation.

210
Q

What is the function of the patella?

A

Transfers force from the quadriceps over the knee to the tibia.

211
Q

What are the attachments of the patella?

A

Quadriceps femoris tendon superiorly and patellar ligament inferiorly.

212
Q

nversion and eversion take place mainly at which joint?

A

Subtalar.

213
Q

What 2 bones does the talus articulate with?

A

Navicular and calcaneus.

214
Q

Name 3 things that support the medial longitudinal arch of the foot.

A
  1. The plantar aponeurosis.
  2. The spring ligament.
  3. The flexor hallucis longus.
215
Q

Which muscle fibres stabilise the patella?

A

The vasti muscles of the quadriceps.

216
Q

What is the nerve supply of the stomach?

A

Parasympathetic nerve supply comes from the posterior and anterior vagal trunks, derived from the vagus nerve. Sympathetic from the celiac plexus.

217
Q

What is the blood supply to the anterior compartment of the leg?

A

Anterior tibial artery.

218
Q

What is the blood supply to the posterior compartment of the leg?

A

Posterior tibial artery.

219
Q

What is the blood supply to the lateral compartment of the leg?

A

Peroneal artery.

220
Q

What is the innervation to the anterior compartment of the leg?

A

Deep peroneal nerve.

221
Q

What is the innervation to the posterior compartment of the leg?

A

Tibial nerve.

222
Q

What is the innervation to the lateral compartment of the leg?

A

Superficial peroneal nerve.

223
Q

Which muscles extend the knee?

A

Quadriceps femoris - anterior thigh.

224
Q

Which muscles flex the knee?

A

Hamstrings - posterior thigh.

225
Q

If you damage the lateral collateral ligament of the knee would there be any blood?

A

No, the lateral collateral ligament is extrcapsular.

226
Q

What muscle is the medial arcuate ligament related to?

A

Psoas major.

227
Q

What structure is the median arcuate ligament related to?

A

The aorta.

228
Q

What muscle is the lateral arcuate ligament related to?

A

Quadratus lumborum.