Anatomy (The Lower Limb) Flashcards
Location of symphyseal joints
In midline
define two important exits from the pelvis:
• the greater sciatic foramen, formed by the sacrospinous ligament and the greater sciatic notch
• the lesser sciatic foramen, formed by the sacrotuberous ligament and the lesser sciatic notch.
Nerve of flap maximus
Inferior gluteal nerve (L5, S1, 2).
small nerve supply and therefore not capable of fine or precise movements.
Gluteal lines
Inferior, anterior, posterior
Nerve of black medius and minimus
Superior gluteal (L4, 5, S1)
Rotation of thigh by gluteus
Maximus lateral
Minimus medial
lateral rotators of thigh
The gluteus maximus is the most powerful muscle involved in lateral rotation, but other muscles also contribute, including the piriformis, obturator internus and externus, the gemelli, and quadratus femoris.
Medial rotation of the thigh
Medial rotation of the thigh or hip brings the knee and foot medially. Muscles: gluteus medius and minimus, and the adductors (longus, brevis, magnus).
Nerve Supply of Gemelli
• Superior by nerve to obturator internus.
• Inferior by nerve to quadratus femoris.
Root of hip nerves
• Superior gluteal (L4, 5, S1).
• Inferior gluteal nerve (L5, S1, 2).
• Nerve to obturator internus (L5, S1, 2).
• Nerve to quadratus femoris (L4, 5, S1).
Difference between obturator internas and externas
Internas from internal> between course is
Externas from external> body of ischium
Both run POSTERIOLATERALLY
BEHIND neck of femur
*External lies deep to Internas from behind *So externas inserting anterior to internas onto medial surface of greater trochanter.
#The internus abducts the flexed hip,
& the externus adducts the flexed hip.
Because the obturator internus runs obliquely to the femoral axis, while the obturator externus runs orthogonal (right angle) to the femoral axis when the hip is FLEXED.
Direction of tibiofibular interosseous membrane
Up-Lateral
Or
Down -Medial
Bone of both proximal and distal row of tarsal
Cuboid
Plane of inversion and eversion of foot
occurs at the SUBTALAR joints
Unique attachment of talus
• There are no muscular or tendinous attachments to the talus but a number of ligaments are attached to it (see arches of the foot).
Which bone has the groove for the tendon of flexor hallucis longus.
The talus
weightbearing part of the heel.
medial tubercle on undersurface of calcaneum
Which bone has groove for the tendon of peroneus longus
Cuboid on its undersurface
Articulation of navicular bone
• Articulates with the head of the talus behind, with the three cuneiforms in front
and with cuboid LATERALLY
Insertion point of tibialis posterior
Navicular bone on a a tuberosity
Attachment of spring ligament
from the sustentaculum tali of the calcaneum to the tuberosity of the navicular.
Function of 3 cuneiforms
• Cuneus means wedge. The wedge-shaped bones help maintain the TRANSVERSE arch of the foot.
Which muscle has 2 sesamoid bones
•Flexor hallucis BREVIS.
•That’s why the first metatarsal has two depressions lined with articular cartilage for these two sesamoid bones in the tendon
Bone involved in March fracture
• The second metatarsal
•It is the longest and thinnest and in the event of FATIGUE is liable to break.
Insertion of peroneus BREVIS
•The fifth metatarsal
•It has a tuberosity on its base for
insertion .
Location of head of metatarsal
•DISTAL end
•In the standing position the metatarsal heads are in contact with the ground.
Contribution of adductor longus in formation of femoral triangle
•medial border by its medial border
•floor by its anterior surface
Basis of compartment syndrome
Fascia is a relaxed, wavy connective tissue that can support surrounding tissues, reduce friction, and transmit mechanical tension. When damaged by inflammation or local trauma, fascia can tighten and restrict underlying tissue movement, which can lead to pain and decreased blood flow.
What forms compartment of thigh
The fascia lata’s deep layer creates three intermuscular septa that attach to the femur’s center, forming the thigh’s anterior, posterior, and medial compartments. The medial and lateral septum are the names of these septa.
Location of the tensor fasciae latae (TFL) MUSCLE
between superficial and deep layers of iliotibial TRACT and superficial and deep layers of fascia LATA
•Sits between the superficial and deep layers of the iliotibial (IT) band in the proximal anterolateral thigh.
•The TFL is about 15 cm long and attaches to both the deep and superficial fascia of the IT band.
•The fascia lata itself has two layers at the top that enclose the TFL and gluteus maximus muscles. Lower down, the two layers merge into a single, thickened sheet called the gluteal aponeurosis that the two muscles share.
Why fascia at saphenous opening is called cribriform
Because it is pierced by numerous small holes. These are-
•Great saphenous vein
•3 superficial branches of Femoral artery :
9 o’clock. Superficial external pudendal
11 o’clock Superficial epigastric
2 o’clock Superficial circumflex iliac
•Lymphatics
•Smaller unnamed veins
It is part of fascia LATAs superficial part
what forms femoral ring?
The femoral ring is made up of several structures, including:
Inguinal ligament: The anterior border of the femoral ring
Lacunar ligament: The medial border of the femoral ring
Pectineal ligament: The posterior border of the femoral ring
Femoral vein: The lateral border of the femoral ring
Septum: The lateral border of the femoral ring, separating it from the intermediate compartment of the femoral sheath
Pectineus muscle: The posterior border of the femoral ring
Inferior epigastric vessels: Located at the junction of the anterior and lateral walls of the femoral ring
What is The femoral ring
The femoral ring is the superior opening OF the femoral CANAL, which is the medial compartment of the femoral sheath. The femoral canal allows the femoral vein to expand when venous return increases
What is Femoral sheath
The femoral sheath (also called the crural sheath) is a funnel-shaped downward extension of ABDOMINAL FASCIA (transversalis anteriorly and fascia over iliacus posteriorly) within which the femoral artery and femoral vein pass between the abdomen and the thigh.
Topographically, the femoral sheath is contained WITHIN the femoral triangle.
Compartments of femoral seath
The femoral sheath is subdivided by two vertical partitions to form three compartments (medial, intermediate, and lateral); the medial compartment is known as the femoral canal and contains lymphatic vessels and a lymph node, whereas the intermediate canal and the lateral canal accommodate the femoral vein and the femoral artery (respectively).
Location of femoral canal and contents
the MEDIAL compartment of The femoral SHEATH
The DEEP inguinal lymph nodes are located here .
The most proximal node in the deep inguinal lymph nodes is known as the node of Cloquet or Rosenmüller node also a sentinel node, which is located just inferior to the inguinal ligament.
Sentinel node of inguinal region
The node of Cloquet is also a sentinel node for patients whose superficial inguinal lymph nodes drain through it to the iliac/obturator nodes. The tumor status of the node of Cloquet can indicate the tumor status of the iliac/obturator nodes.
The node of Cloquet is often removed during pelvic lymph node dissection (PLND) for prostate cancer.
Rosenmuller’s node, is the superior-most inguinal lymph node and is considered to be the inferior-most external iliac lymph node.The external iliac lymph nodes are the primary drainage for the inguinal lymph nodes.
Area of drainage of deep inguinal lymph nodes
The deep inguinal lymph nodes receive drainage from the glans, clitoris, deep leg structures, and superficial inguinal nodes.
Demarcation between superficial and deep inguinal lymph nodes
Deep nodes are separated from the superficial nodes by the fascia lata.
Lymphatic drainage of lower half of anal canal
Inguinal
Other names of adductor canal , its extension, contents
•Subsartorial Canal, Hunter’s Canal
•This passes from the apex of the femoral triangle to the popliteal fossa.
• Contents:
• femoral artery
• femoral vein (behind the artery)
• SAPHENOUS nerve.
Which fascia is pierced by small saphenous vein
Deep popliteal fascia
Draining area of popliteal nodes
the lateral side of foot and heel
where does the sural nerve originate from and area of innervation
The sural nerve originates in the DISTAL THIRD of the calf from the joining of the medial sural cutaneous nerve and the lateral sural cutaneous nerve. The medial sural cutaneous nerve comes from the TIBIAL nerve, while the lateral sural cutaneous nerve comes from the common PERONEAL nerve.
#The sural nerve travels down the back of the leg, LATERALLY curves at the ankle, and ends before the toes. It supplies the lateral aspect of the lower leg and the lateral border of the foot, including the fifth toe.
Branches of popliteal artery
Tibiofibular trunk+anterior tibial artery (anterior tibial artery passes through an oval superior opening in the interosseous membrane)
Then
Trunk>posterior tibial artery+fibular artery
Point of taking arterial blood for blood gas analysis from femoral artery
midinguinal point—halfway between the anterior superior iliac spine and the pubic symphysis.
Which artery is vulnerable in supracondylar fracture of femur
Popliteal
Effect of popliteal artery aneurysm
DVT (pressure on vein)
Nerve palsies and pain (pressure on common peroneal nerve)
Which nerve accompany the great SAPHENOUS vein
Saphenous nerve
That’s why this nerve is one of the contents of adductor canal
Point of SAPHENOUS opening
4 cm inferolateral to pubic tubercle
Importance of great SAPHENOUS vein
• The relationship of the great saphenous vein to the medial malleolus is CONSTANT. It may therefore be used for life-saving cannulation.
• The saphenous nerve is immediately adjacent to the vein and may be caught in a ligature while doing a cutdown or during varicose vein surgery.
• The tributaries of the great saphenous vein at the saphenofemoral junction are important when carrying out a high tie during varicose vein surgery. Failure to ligate all tributaries may result in recurrence. Patterns of these veins are variable.
Smallest muscle of medial compartment of thigh
obturator externus
Similarity and difference of PES ANSERINUS
They converge as a group of tendons that attach to the medial side of the knee. The term translates to “goose’s foot” in Latin.
#difference is
Sartorius in Anterior compartment
Gracilis in Medial compartment
Semitendinosus in Posterior compartment
Peroneus Tertius is in which compartment of leg
Anterior
Nerve of artery of anterior compartment of leg
Nerve of artery of anterior compartment of leg
N-deep peroneal
A-anterior tibial
Nerve of artery of posterior compartment of leg
N-tibial
A-posterior tibial
Root of nerves of lumbar plexus
Femoral L2–4.
Obturator L2–4.
Genitofemoral L1, 2
What is Meralgia paresthetica
Meralgia paresthetica is a neurological disorder that causes a numb or painful area on the thigh. It’s also known as Bernhardt-Roth syndrome or lateral femoral cutaneous nerve (LFCN) neuralgia.
Occasionally it pierces the inguinal ligament. May be trapped by inguinal ligament.
from the Greek words meros (thigh) and algos (pain).
What is Meralgia paresthetica
Meralgia paresthetica is a neurological disorder that causes a numb or painful area on the thigh. It’s also known as Bernhardt-Roth syndrome or lateral femoral cutaneous nerve (LFCN) neuralgia.
Occasionally it pierces the inguinal ligament. May be trapped by inguinal ligament.
from the Greek words meros (thigh) and algos (pain).
Muscles supplied by sacral plexus
• Piriformis.
• Obturator internus.
• Quadratus femoris.
• Gemelli.
Roots of sacral plexus
Superior Gluteal L4, 5, S1.
Inferior Gluteal L5, S1, 2.
Pudendal S2, 3, 4.
Sciatic L4, 5, S1, 2, 3.(Tibial L45,S123 ; Common Peroneal L45.S12)
What malleolus is related to TIBIAL nerve
• Passes behind medial malleolus.
Nerve of intrinsic muscles of foot
Tibial nerve
What nerve gives off planter nerves
Tibial nerve
What nerve supplies skin of the web space between first and second toes.(FIRST WEB SPACE)
Deep Peroneal Nerve
Why does pain from hip disease therefore may be referred to the knee.
• Nerve supply to the hip joint and knee joint involves the same nerves (femoral, obturator, sciatic).
Intestinal obstruction associated with pain in the cutaneous distribution of the obturator nerve may indicate what?
obturator hernia.
Importance of the relationship of the pudendal nerve to the ischial spine
In obstetrics. The ischial spine can
be palpated per vaginam and a needle directed to the nerve to deliver local anaesthetic.
Effect of Bilateral block of the pudendal nerve
Bilateral block of the pudendal nerve leads to loss of anal reflex, relaxation of muscles of pelvic floor and loss of sensation to vulva and Lower third of vagina.
What bleeding may occur in sciatic nerve cutting
• An artery accompanies the sciatic nerve running in its substance (arteria comitans nervi ischiadici). Bleeding can be troublesome when the nerve is divided in an above-knee amputation.
So
. It must be carefully teased out and ligated in isolation to avoid ligation of nerve fibres with subsequent pain and neuroma formation.
Mechanism of inquiry of common PERONEAL nerve
Car-bumper injuries
below-knee plasters
Lloyd–Davies position
(for abdominoperineal resection of the rectum)
Area supplied by the saphenous nerve (branch of femoral)
over medial malleolus and medial border of foot to great toe.
Components of foot drop
• failure of dorsiflexion owing to paralysis of ANTERIOR compartment muscles (deep peroneal nerve)
• failure of eversion owing to paralysis of LATERAL compartment muscles (superficial peroneal nerve)
• patient exaggerates flexion of hip and knee when walking to lift foot well clear of ground to prevent SCUFFING (scrape or brush the surface of a shoe or other object against something).
• loss of sensation over lower lateral leg, dorsum of foot except medial aspect (saphenous nerve) and lateral aspect (sural nerve).
Ligaments of hip joint
• Iliofemoral: from anterior inferior iliac spine, bifurcating to attach at each end of the trochanteric line (inverted Y—STRONGEST of the three ligaments).
• Pubofemoral: from iliopubic junction to blend with medial aspect of the capsule.
• Ischiofemoral: from ischium to attach to base of greater trochanter.
Abductors and Medial rotators of hip
Abductors:
gluteus medius, gluteus minimus, tensor
fasciae latae.
Medial rotators:
anterior fibres of gluteus medius and gluteus minimus in flexed hip.
And tensor fasciae latae
Lateral rotators of hip
gluteus maximus (chiefly), obturator
internus, obturator externus, gemelli, quadratus femoris.
Which muscle is inferiorly related to hip joint
Obturator externus
Relation of meniscus with synovial membrane of knee joint
• In adult, menisci are not covered by synovial memb
What muscle is called “key to unlock the knee”.
popliteus muscle
by initiating the flexion of the fully extended (“locked”) knee.
So plays an important role in the gait cycle
Also when the knee is flexed, medial rotation.
What is Hilton’s law? With some implications
Hilton’s law is a well-known axiom in clinical anatomy that states that the nerves that supply a joint’s muscles also supply the joint and the skin above the muscles.
some implications
#REFLEX MUSCULAR SPASM
Irritation of the articular nerves that supply a joint can cause a reflex muscular spasm that positions the joint FOR COMFORT.
#REFERRED PAIN
The nerves that supply the joint also supply the skin above the muscles, which can cause referred pain from the joint to the SKIN.
#LOCAL REFLEX ARCS
The nerves that supply the antagonist muscles also supply the articular capsule segment that tightens when the muscles contract. This relationship creates local reflex arcs that STABILIZE the joint.
Attachment of PES ANSERINUS at joint level
Sartorius, gracilis, semitendinosus
From medial to lateral
location of spring ligament:
• sustentaculum tali of calcaneum to tuberosity of navicular.
location of Long plantar ligament:
• from calcaneum to base of second, third and fourth metatarsals
• covers short plantar ligament
• forms a tunnel for the tendon of peroneus longus with the cuboid bone.
location of Short plantar ligament:
• from plantar surface of calcaneum to cuboid.
SUPPORT of Transverse Arch
.
Muscular:
• peroneus longus.
Ligaments:
• interosseous
