Block 3: Lower Limb, Gray's Text Flashcards
1
Q
Longest bone in the body
A
femur
2
Q
Describe the proximal end of the femur
A
head, neck, greater & lesser trochanter
3
Q
What does the femoral head articulate with?
A
acetabulum
4
Q
Describe the fovea
A
Non-articular pit on the medial surface of the head of the femur
For the attachment of the ligament of the head
5
Q
Significance of the orientation of the neck of the femur in relation to the shaft
A
orientation of the neck in relation to the shaft increases the range of movement for the hip joint
6
Q
Greater & Lesser Trochanter f(x)
A
attachment for muscles that move the hip joint
7
Q
Trochanteric Fossa f(x)
A
attachment for the obturator externus muscle
8
Q
Lesser trochanter attaches to
A
combined tendonds of psoas major and iliacus muscles
9
Q
What forms the posterior margin of the greater trochanter to the lesser trochanter
A
intertrochanteric crest
10
Q
Quadrate Tubercle f(x)
A
attachment fo the quadratus femoris muscle
11
Q
Attachment for the gluteus maximus muscle
A
gluteal tuberosity
12
Q
What is the clinical significance of femoral neck fractures?
A
the femoral head has a significant blood supply; fractures of the neck `can disrupt the supply and lead to necrosis of the femoral head
13
Q
What artery enhances blood supply to the femoral head and neck?
A
Artery of the Ligamentum Teres
14
Q
Describe an inter-trochanteric fracture
A
a break that runs b/w the greater and lesser trochanter; does not disrupt blood supply to the femoral neck, does not render femoral head ischemic
15
Q
Describe why femoral shaft fractures are significant
A
It takes a lot of energy to fracture the femoral shaft so this injury is usually accompanied by damage to the surrounding soft tissues, which includes muscle compartments & the structures they contain
16
Q
What type of joint is the hip joint?
A
A synovial articulation b/w head of femur and acetabulum, specifically a ball and socket joint
17
Q
What are the articular surfaces of the hip joint?
A
spherical head of the femur and the lunate surface of the acetabulum
18
Q
Significance of the Ligament of the Head of the Femur
A
carries a small branch of the obturator artery, which contributes to the blood supply of the head of the femur
19
Q
What 3 ligaments stabilize the hip joint?
A
iliofemoral
pubofemoral
ischiofemoral
20
Q
Describe how the ligaments of the hip joint work to stabilize the joint d
A
the fibers are spirally oriented so they become tight when the joint is extended; this stabilizes the joint and reduces the amount of energy needed to stand
21
Q
What comprises the vascular to the hip joint
A
branches of the obturator artery, medial & lateral circumflex femoral arteries, superior and inferior gluteal arteries, first perforating branch of the deep artery of the thigh
22
Q
What is the hip joint innervated by?
A
femoral, obturator, superior gluteal and nerve to quadratus femoris
23
Q
What are the gateways to the lower limb?
A
obturator canal
greater sciatic foramen
lesser sciatic foramen
gap b/w inguinal ligament & anterosuperior margin of the pelvis
24
Q
What runs through the obturator canal?
A
obturator nerve and vessels
25
What passes through the greater sciatic foramen above the piriformis?
superior gluteal nerve and vessels
26
What passes through the greater sciatic foramen below the piriformis?
sciatic nerve
inferior gluteal nerve & vessels
pudendal nerve, internal pudendal vessels
posterior cutaneous nerve of thigh
nerve to obturator internus & gemellus superior
nerve to quadratus femoris & gemellus inferior
27
Inguinal Ligament & Pelvic Bone Gap
major route of communication b/w abdomen & anteromedial aspect of thigh
28
What passes through the gap b/w the pelvic bone & inguinal ligament?
```
psoas major
iliacus
pectineus muscle
femoral artery & vein
lymphatics of the lower limb
```
29
What are the nerves that enter the lower limb from the abdomen and pelvis?
terminal branches of the lumbosacral plexus
30
Lumbar Plexus contents
anterior rami of L1-L3, part of L4
31
Lumbosacral Trunk
anterior rami of L4-L5
32
Sacral Plexus
anterior rami of S1 to S3 and part of S4
33
What are the major nerves that originate from the lumbosacral plexus and leave the abdomen and pelvis to enter the lower limb?
```
femoral nerve
obturator nerve
sciatic nerve
superior gluteal nerve
inferior glutealnerve
```
34
Femoral Nerve formed by
anterior rami of L2-L4
35
How does the femoral nerve leave the abdomen
passes through the gap b/w the inguinal ligament & superior margin of the pelvis to enter the femoral triangle
36
Femoral Nerve f(x) (3)
1. innervates muscles in anterior compartment of thigh
2. in abdomen, gives rise to branches that innervate iliacus and pectineus
3. innervates skin over anterior aspect of thigh, anteromedial side of knee, medial side of leg, medial side of foot
37
Obturator Nerve formed by
anterior rami of L2 to L4
38
Obturator Nerve f(x) (3)
1. innervates muscles in medial compartment of the thigh (except part of the adductor magnus muscle and the pectineus muscle)
2. obturator internus
39
Largest nerve in the body
sciatic nerve
40
Sciatic nerve formed by
L4 to S3
41
What are the 2 branches of the sciatic nerve?
common fibular nerve
| tibial nerve
42
Posterior vs Anterior divisions of sciatic nerve
Posterior divisions of L4 to S3 are carried in the common fibular part
Anterior divisions of L4 to S3 are carried in the tibial part
43
Sciatic nerve innervates
1. all muscles in posterior compartment of thigh
2. part of adductor magnus originating from ischium
3. muscles in leg and foot
4. skin on lateral side of leg and sole of foot
44
Superior gluteal nerve formed by
anterior rami of L4 to S1
45
Superior gluteal nerve innervates
gluteus medius & minimus
| tensor fasciae latae muscle
46
Inferior gluteal nerve formed by
contributions from L5 to S2
47
Inferior gluteal nerve innervates
gluteus maximus muscle
48
Ilioinguinal Nerve formed by
L1
49
Ilioinguinal Nerve f(x)
innervate skin on medial side of upper thigh & adjacent parts of perineum
50
Genitofemoral nerve formed by
L1, L2
51
genitofemoral nerve f(x)
innervate skin over upper central part of anterior thigh
52
Lateral Cutaneous nerve of thigh formed by
L2, L3
53
Lateral Cutaneous nerve of thigh f(x)
innervates skin on lateral side of thigh
54
Nerve to the Quadratus Femoris
formed by
f(x)
formed by: L4 to S1
| innervates: gemellus inferior and quadratus femoris muscles
55
Nerve to the Obturator Internus
formed by
f(x)
formed by: L5 to S2
| supplies: gemellus superior muscle, perineal surface of obturator internus muscle
56
Posterior cutaneous nerve of thigh
formed by
function
formed by: S1 to S3
f(x): innervates a band of skin over the posterior aspect of the thigh
skin over gluteal fold, upper medial part of thigh
57
Perforating Cutaneous Nerve
formed by
function
formed by: S2 and S3
innervation: sensory innervation for skin over medial aspect of gluteal fold
58
Major artery supplying the lower limb
femoral artery
59
Femoral artery is a continuation of
external iliac artery in the abdomen
60
When does the external iliac artery become the femoral artery?
when it passes under the inguinal ligament to enter the femoral triangle
61
Describe the anastamotic network in the upper thigh and gluteal region
branches of femoral, inferior gluteal, superior gluteal and obturator artery in addition to branches from internal pudendal artery
provides collateral circulation when one vessel is interrupted
62
Deep veins of the lower limb
follow the arteries (femoral, superior gluteal, inferior gluteal, obturator)
63
Relationship b/w deep and superficial veins of the lower limb
the superficial veins are in the subcutaneous tissue & drain into the deep veins
64
What are the main 2 superficial veins of the lower limb>
great saphenous vein
| small saphenous vein
65
Normal venous blood flow depends on
valves
66
What happens when venous valves become incompetent?
they place pressure on the distal valves, which may also become incompetent and this leads to dilated tortuous superficial veins (varicose veins) in the great and small saphenous venous systems
67
what are the typical sites for valvular incompetence?
junction b/w great saphenous vein and femoral vein
perforating veins in midthigh
junction b.w small saphenous vein & popliteal vein
68
What is the "classic triad" that precludes DVT?
venous stasis
injury to vessel wall
hypercoagulable states
69
Explain the significance of a dislodged DVT
DVT in the calf veins can propagate to the femoral veins, then break off and pass through the heart to enter pulmonary circulation, resulting in:
1. occlusion of the pulmonary artery
2. cardiopulmonary arrest, leading to
3. death
70
Where do most lymphatics of the lower limb drain to?
superficial and deep inguinal nodes
71
Superficial Inguinal Nodes receive lymph from
gluteal region
lower abdominal wall
perineum
superficial regions or lower limb
72
Superficial inguinal nodes drain into
external iliac nodes
73
Deep inguinal nodes receive lymph from
deep lymphatics, glans penis (or glans clitoris)
74
Deep inguinal nodes connect with _______, and drain into ______
superficial inguinal nodes; external iliac nodes
75
Popliteal nodes receive lymph from
superficial vessels accompanying the great saphenous vein & from deep areas of the leg and foot
76
Popliteal nodes drain into
deep and superficial inguinal nodes
77
Fascia Lata
"stocking like membrane that covers the lower limb & lies beneath the superficial fascia
78
Fascia Lata is continuous with
deep fascia of the leg
79
Describe the superior region of the Fascia Lata
splits anteriorly to enclose the tensor fasciae lata muscle & posteriorly to enclose gluteus maximus muscle
80
Iliotibial Tract
lateral, longitudinal thickening of the fascia lata
81
Function of tensor fasciae latae and gluteus maximus muscle (together)
hold the leg in extension once other muscles have extended the leg at the knee joint
82
saphenous opening
opening in the fascia lata that allows the great saphenous vein to pass from superficial fascia through the deep fascia to connect w/ femoral vein
83
Major structures in the femoral triangle
femoral nerve
femoral artery
femoral vein
lymphatic vessels
84
Femoral Sheath
funnel shaped sleeve of fascia within the femoral triangle surrounding the femoral vein, artery, & associated lymphatics
does not include the femoral nerve (lateral to the sheath)
85
Significance of the opening of the femoral canal
it's a potentially weak spot in the lower abdomen & is a site for femoral hernias
86
What provides vascular access to the lower limb?
femoral artery and vein
"femoral approach
87
What are the deep group of muscles for the gluteal region?
```
pififormis
obturator internus
gemellus superior
gemellus inferior
quadratus femoris
```
88
What are the superficial group of muscles for the gluteal region?
gluteus minimus
gluteus medius
gluteus maximus
89
Piriformis muscle f(x)
rotates and abducts the femur at the hip joint
90
Piriformis innervation
in the pelvis: nerve to the piriformis
91
How is the piriformis a landmark?
it divides the greater sciatic foramen into 2 regions: one above and one below the piriformis
92
Obturator Internus
f(x)
innervation
f(x): laterally rotates & abducts the femur @ the hip joint
innervation: nerve to the obturator internus
93
Gemellus Superior Innervation
nerve to the obturator internus
94
Gemellus Inferior Innervation
nerve to the quadratus femoris
95
Gemellus Muscles f(x)
laterally rotate & abduct the femur at the hip joint
96
Quadratus Femoris
f(x)
innervation
f(x): laterallt rotate the femur at the hip joint
| innervation: nerve to the quadratus femoris
97
Gluteus Medius & Minimis f(x)
1. abduct the lower limb @ the hip joint
| 2. securing the position of the pelvis on the stance limb
98
Trendelenburg's Sign
what is it?
occurs in?
typically found in?
what's usually associated w/ a positive sign?
what: when a patient stands on one limb, the pelvis severely drops over the swing limb
occurs in: people with weak or paralyzed abductor muscles (gluteus minimus and medius)
found in: patients w/ damage to superior gluteal nerve
positive sign associated w/: gait issues
99
Gluteus Maximus Muscle
f(x)
innervation
f(x): extend the flexed thigh at the hip joint; stabilizes the knee and hip joints
inneration: inferior gluteal nerve
100
Tensor Fasciae Latae f(x)
stabilizes the knee in extension
| (w/ gluteus maximus): stabilizes the hip joint by holding the head of the femur in the acetabulum
101
What is the only nerve that exits the greater sciatic foramen passing above the piriformis?
superior gluteal nerve
102
Nerve to Quadratus Femoris f(x)
supplies a small branch to gemellus inferior
103
Nerve to Obturator Internus Innervates
small branch to gemellus superior; innervates obturator internus muscle
104
Posterior Cutaneous Nerve to Thigh innervates
skin on the posterior of leg and thigh
105
Inferior gluteal nerve innervates
gluteus maximus
106
Perforating cutaneous nerve innervates
skin over the medial aspect of the gluteus maximus
107
Intramuscular Injections
typical site
safest place, why?
site: gluteal region
safest place: upper outer quadrant of either gluteal region to avoid hitting any part of the sciatic nerve or other nerves/vessels in the gluteal region
108
What are the compartments of the thigh
anterior
medial
posterior
109
Posterior compartment of thigh is innervated by
sciatic nerve
110
Anterior compartment of thigh is innervated by
femoral nere
111
Medial compartment of thigh is innervated by
(mostly) obturator nerve
| the sciatic nerve innervates some of the adductor magnus and the pectineus is innervated by the femoral nerve
112
Patalla
bone type
formed within
sesamoid bone (formed w/i tendon of quadriceps femoris)
113
Describe how patellar shape helps its attachments
apex: pointed inferiorly for attachment to patellar ligament
base: broad, thick for attachment of quadriceps femoris
posterior surface: articulates w/ femur
114
Skeletal support for the thigh is provided by
the femur
115
Tibial tuberosity
palpable, inverted triangle on the anterior aspect of the tibia
site of attachment for the patellar ligaments
116
Anterior compartment of the thigh contains what muscles?
sartorious
| 4 large quadriceps femoris muscle (rectus femoris, vastus lateralis, vastus medialis, vastus intermedius)
117
Medial compartment of the thigh contains what muscles?
```
gracilis
pectineus
adductor longus
adductor brevis
adductor magnus
obturator externus
```
118
Posterior compartment of the thigh contains what muscles?
3 large muscles termed the "hamstrings"
biceps femoris
semitendinosus
semimembranosus
119
Compartment Syndrome
what is it?
significance?
what: occurs when there's swelling w/i a fascial enclosed muscle compartment in the limbs
significance: pressure w/i compartment elevates, blood flow and tissue perfusion is compromised, can lead to neuromuscular damage
120
Why are the iliacus and psoas muscles grouped in the lower extremity?
they both insert by a common tendon onto the lesser trochanter of the femur
121
What makes up the quadriceps femoris muscle?
vastus medialis
vastus intermedius
vastus lateralis
rectus femoris muscle
122
Quadriceps femoris muscle innervation
femoral nerve
123
Explain tapping with a hammer on the patellar ligament
it tests reflex activity mainly at spinal cord levels L3 and L4 b/c the quadriceps femoris is innervated by the femoral nerve
124
Patellar Ligament
essentially a continuation of the quadriceps femoris tendon below the patella
125
Adductor Hiatus
allows the femoral artery and veins to pass b/w the adductor canal and the popliteal fossa
126
Muscle injuries in the lower limb
how do they happen?
where do they usually happen?
how: direct trauma or overuse syndrome
where: hamstring muscles
127
What arteries enter the thigh?
femoral artery
obturator artery
inferior gluteal artery
128
Femoral Artery Paplable: Where?
in the femoral triangle, inferior to the inguinal ligament midway b/w ASIS & pubic symphysis
129
What 4 branches arise from the femoral artery in the femoral triangle?
superficial epigastric
superficial circumflex iliac artery
superficial external pudendal artery
deep external pudendal artery
130
Largest branch of the femoral artery in the thigh?
deep artery of the thigh
131
What are the branches of the deep artery of the thigh?
lateral circumflex
medial circumflex
3 perforating branches
132
What are the branches of the deep artery of the thigh?
ascending branch
descending branch
transverse branch
133
Obturator Artery Branches
anterior branch
| posterior branch
134
Peripheral Vascular Disease
what is it?
cause?
what: reduced blood flow to the legs
cause: stenoses and/or occlusions in the lower aorta and iliac, femoral, tibial, and fibular vessels
135
Chronic Leg Ischemia
vessels have undergone atheromatous change, and there is luminal narrowing
136
Critical Limb Ischemia
what is it?
leads to ?
what: severe ischemia that leads to threatened viability of the limb
leads to: gangrene, ulceration, severe rest pain in the foot
137
Most common symptoms or chronic leg ischemia
intermittent claudication (pain in the calf muscles or buttocks that increases with walking)
138
Largest superficial vein of the thigh
great saphenous vein
139
Femoral Nerve Branches
anterior cutaneous branches
motor nerves
1 long, cutaneous nerve (saphenous nerve)
140
Tibial Nerve
innervate
innervates:
muscles in posterior compartment of leg
intrinsic muscles in sole of the food
skin on posterolateral side of the lower half of the leg & lateral side of foot, ankle, little toe
141
Mensici
fibrocartilaginous C shaped cartilages in the knee joint (one medial, one lateral)
142
What separates the synovial membrane from the patellar ligament?
infrapatellar fat pad
143
What are the ligaments associated w/ the knee joint?
patellar ligament
tibial (medial) and fibular (lateral) ligaments
anterior & posterior cruciate ligaments
144
Collateral Ligaments f(x)
stabilize the hinge like motion of the knee
145
Significance of anterior & posterior cruciate ligaments
anterior: prevents anterior displacement of the tibia
posterior: restricts posterior displacement
146
Describe the locking mechanism
when standing, the knee joint is locked into position reducing the amount of muscle work needed to maintain the standing position
147
What are the components of the locking mechanism?
1. change in the shape & size of the femoral surfaces that articulate with the tibia
2. medial rotation of the femur on the tibia during extension
148
Describe the vascular supply to the knee joint
descending and genicular branches from the femoral, popliteal, and lateral circumflex arteries in the thigh & circumflex fibular artery & recurring branches from anterior tibial artery in the leg
149
What types of issues are common at the knee joint? Examples?
type: soft tissue injuries
ex: anterior & posterior cruciate ligaments, meniscal tears, trauma to collateral ligaments
150
What happens in osteoarthritis?
degenerative joint disease where there is reduction of joint space, small bony outgrowths, and bony cyst formation
