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anatomy > Gao Lectures 10-15 > Flashcards

Gao Lectures 10-15 Flashcards

1
Q

Compartment Syndromes in the Leg

A

Strong septa form the boundaries of the leg compartments Trauma can cause the muscles in the compartments to hemorrhaga, have edema or become inflammed arterial bleeds can increase pressure in the compartment and compress the structures therein AN EMERGENCY FASCIOTOMY (incision of a fascial septum) may be performed to relieve the pressure in the compartment

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2
Q

Anterior Tibialis Strain

A

aka shin splints edema and pain in the area of the distal 2/3 of the tibia from repetitive microtrauma of the tibialis anterior and small tears in the periosteum covering the body of the tibia a mild form of anterior compartment syndrome

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3
Q

Deep Fibular Nerve Entrapment

A

aka “ski boot syndrome” tight ski boots compress the deep fibular nerve where it passes deep to the inferior extensor retinaculum and the extensor hallucis brevis causes pain in the dorsum of the foot that radiates to the web space between the 1st and 2nd digits tight shoes create this problem in runners and soccer players

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4
Q

Boundaries of the lateral compartment of the leg

A
  • lateral surface of fibula
  • anterior intermuscular septa
  • posterior intermuscular septa
  • crural fascia
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5
Q

Muscles in the Lateral Compartment

A

Fibularis Longus and Fibularis Brevis Test: eversion of the foot against resistance should be strong and the tendons can be seen and palpated inferior to lateral malleolus

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6
Q

Fibularis (Peroneus) Longus (shape, location and attachments)

A

Head and superior 2/3 of lateral fibula –> Base of 1st metatarsal and medial cuneiform

Tendon can be palpated and seen proximal and posterior to lateral malleolus (lies on top of tendon for fibularis brevis and does not touch the lateral maleolus)

crosses the sole of the foot, running obliquely and distally to reach its distal attachment.

Narrow, longer, and more superficial than fibularis brevis

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7
Q

Fibularis Longus Action

A

Everts foot, and

Weakly plantarflexes ankle

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8
Q

Fibularis Longus Innervation

A

Superficial Fibular Nerve

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9
Q

Fibularis Longus Arterial Supply

A

Anterior Tibial and Fibular Arteries

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10
Q

Fibularis Brevis Attachments and general description

A

Inferior 2/3 of lateral fibula –> Dorsal surface of tuberosity on the lateral side of the base of 5th metatarsal

Shorter than and lies deep to fibularis longus

Its broad tendon grooves the posterior aspect of the lateral malleolus

the tendon can easily be traced to its distal attachment to the base of the 5th metatarsal

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11
Q

Fibularis Brevis Innervation

A

Superficial Fibular (peroneal) Nerve

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12
Q

Fibularis Tertius Attachments

A

Inferior 1/3 of anterior surface of fibula + interosseous membrane –> Dorsum of base of 5th metatarsal

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13
Q

Fibularis Terius Innervation

A

Deep Fibular (peroneal) Nerve

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14
Q

Fibularis Tertius Arterial Supply

A

Anterior Tibial Artery

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15
Q

Nerves in the Lateral Compartment

A

Superficial Fibular (peroneal) nerve

this is a branch of the Common fibular (peroneal) nerve that supplies the skin on the distal part of the anterior leg and nearly all the dorsum of the foot.

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16
Q

Injury to the Common Fibular Nerve (How it happens)

A

Common when neck of fibula is broken or when knee joint is injured or dislocated

MOST LIKELY NERVE INJURY OF LOWER EXTREMITY DUE TO SUPERFICIAL POSITION AROUND FIBULAR NECK

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17
Q

Injury to the Common Fibular Nerve (result)

A

Paralysis of all muscles in the

  • anterior compartments of the leg (dorsiflexors of the ankle)
  • lateral compartment of the leg (evertors of the foot)
  • results in foot drop
  • Stepping gate (impossible to make heel strike ground first
  • distinctive clop when person walks
  • variable loss of sensation on anterolateral leg and dorsum of foot
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18
Q

Artery in the Lateral Compartment

A

THERE IS NO ARTERY IN THE LATERAL COMPARTMENT

Muscles are supplied

  • Superiorly - by perforating branches of Anterior Tibial Artery
  • Inferiorly - by perforating branches of the fibular artery
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19
Q

Posterior Compartment of the Leg

A

Largest of the 3 leg compartments

Calf muscles in the posterior compartment are divided into 2 groups by the transverse IM septum:

  • superficial group
  • deep group
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20
Q

Tibial Nerve and Posterior Tibial Vessels

A
  • Supply the superficial + deep groups of the posterior compartment
  • Run between the superficial + deep groups of muscle just deep to the transverse IM septum
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21
Q

Superficial Muscle Group in the Posterior Compartment

A

3 muscles

  • gastrocnemius
  • soleus
  • plantaris

Forms a powerful muscle mass in the calf that PLANTAR FLEXES the foot

Large size of these muscles directly related to upright stance

these strong and heavy muscles (plantaris is the exception) support and move the weight of the body

Supplied by Tibial Nerve

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22
Q

Three-headed Triceps Surae

A

2-headed Gastrocnemius (medial and lateral heads) + soleus

SHARE A COMMON TENDON, THE ACHILLES TENDON (aka calcaneal tendon), which attaches to the calcaneus

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23
Q

Three-headed Tricep Surae (movements)

A
  • plantar flexes the ankle joint
  • raises heal against body weight (used in walking, dancing, and/or standing on toes)
  • Soleus - for strolling
  • Gastrocnemius - for power
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24
Q

Superficial Calcaneal Bursas

A

between the skin and calcaneal tendon

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25
Q

Deep Calcaneal Bursa (Retrocalcaneal Bursa)

A

between achilies (calcaneal) tendon and calcaneus

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26
Q

Gastrocnemius (location, shape and attachments generally)

A
  • most superficial in the posterior compartment
  • forms part of the prominence of the calf
  • medial head - slightly larger & extends more distally than lateral head
  • 2 JOINT MUSCLE - crosses the knee + ankle joints (cannot exert its power on both joints at the same time)
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27
Q

Gastrocnemius (attachments)

A
  • Medial Head - Popliteal surface of femur, superior to medial condyle –> Posterior surface of calcaneus via calcaneal tendon
  • Lateral Head - Lateral aspect of lateral condyle of femur –> posterior surface of calcaneus via calcaneal tendon
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28
Q

Gastrocnemius (Actions)

A
  • Plantarflexes ankle when knee is extended
  • raises heel during walking
  • flexes leg at knee joint
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29
Q

Gastrocnemius Innervation

A

Tibial Nerve (S1 + S2)

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30
Q

Gastrocnemius Arterial Supply

A

Each head is supplied by a sural branch of the popliteal artery

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31
Q

Soleus (generally)

A
  • Deep to gastrocnemius
  • Strong
  • Large-Flat muscle resembling a sole fish
  • fibers slope inferomedially
  • while standing on tiptoes, can be felt
  • does not act on the knee
  • an anti gravity muscle that contracts alternately with the extensor muscles of the leg to maintain balance
  • strong, but slow plantar flexor
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32
Q

Soleus (Attachments)

A

Posterior head of fibula, superior fourth of posterior surface of fibula, soleal line and medial border of tibia –> Posterior surface of calcaneus via calcaneal tendon

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33
Q

Soleus (Action)

A

Powerful plantarflexor of ankle

Independant of position of knee

Steadies leg on foot

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34
Q

Soleus (Innervation)

A

Tibial Nerve (S1+S2)

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35
Q

Soleus (Arterial Supply)

A
  • Posterior Tibial Artery
  • Fibular Artery
  • Sural Artery
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36
Q

Plantaris (General)

A
  • small vestigial muscle
  • short belly
  • long thin tendon
  • often absent
  • acts with gastrocnemius
  • has a high density of muscle spindles (receptors for proprioception) (proposed to be an organ of proprioception for the large plantar flexors
  • plantaris tendon often removed for grafting (no disability results)
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37
Q

Plantaris (Attachments)

A

Inferior end of lateral supracondylar line of femur and oblique popliteal ligament –> Posterior Surface of calcaneus via calcaneal tendon

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38
Q

Calcaneal (Achilles) Tendinitis

A
  • Inflammation of the achilles tendon constitutes 9-18% of running injuries
  • Microscopic tears of collagen fibers in the tendon
  • Pain durring walking, esp. when wearing rigid-soled shoes
  • often a result of repetitive activities esp. running after a long period of innactivity
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39
Q

Ruptured Calcaneal (Achilles) Tendon

A
  • often occurs in poorly conditioned 30-45 y/o people with a history of calcaneal (achilles) tendonitis
  • Sudden calf pain with an audible snap
  • usually caused by sudden dorsiflexion of a plantarflexed foot
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40
Q

Calcaneal Tendon Reflex

A
  • aka ankle reflex or ankle jerk
  • calcaneal tendon is struck briskly with a reflex hammer just proximal to the calcaneus
  • the normal response is plantarflexion of the ankle joint
  • Tests the S1 and S2 nerve roots
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41
Q

Calcaneal Bursitis (Retroachilles Bursitis)

A

Inflammation of the deep calcaneal bursa (located between the calcaneal tendon and the superior part of the posterior surface of the calcaneus)

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42
Q

Deep Muscle Group in the Posterior Compartment

A
  1. Popliteus - acts on the knee
  2. Flexor Digitorum Longus - acts on the ankle and foot joints
  3. Flexor Hallucis Longus - acts on the ankle and foot joints
  4. Tibialis Posterior - acts on the ankle and foot joints
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43
Q

Popliteus (General)

A
  • Thin
  • Triangular
  • Forms the inferior part of the floor of the popliteal fossa
  • tendon adheres to the articular capsule of the knee joint, lies between the fibrous capsule and the synovial membrane
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44
Q

Popliteus Movement

A
  • Weakly Flexes the knee and Unlocks it
  • knee partly flexed –>popliteus assists the PCL in preventing anterior displacement of the femur on the tibia in (closed chain) standing with knees “locked” in full extension –> the popliteus acts to rotate the femur laterally 5 degrees on the tibial plateaus (this unlocks the knee so flexion can occur)
  • In open chain, while starting flexion of the knee: the popliteus can rotate the tibia medially beneath the femoral condyles
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45
Q

Popliteus Bursa

A

Lies deep to the popliteus tendon

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46
Q

Popliteus Attachments

A

Lateral Surface of Lateral Condyle of Femur and Lateral Meniscus –> Posterior surface of tibia superior to soleal line

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47
Q

Popliteus Innervation

A

Tibial Nerve

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48
Q

Popliteal (arterial supply)

A
  • Medial Inferior Genicular Branch of Popliteal Artery +
  • Muscular Branch of Posterior Tibial Artery
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49
Q

Flexor Digitorum Longus (general)

A
  • Smaller than flexor hallucis longus
  • passes diagonally into the sole of the foot, superficial to the tendon of the flexor hallucis longus
  • divides into 4 tendons whihc pass to the distal phalanges of the lateral 4 digits
  • Test - distal phalanges of the lateral 4 toes are flexed against resistance (normal - tendons of the toes can be seen and palpated)
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50
Q

Flexor Digitorum Longus Attachments

A

Medial Posterior Surface of TIbia inferior to soleal line + by a broad tendon to the fibula –> Base of Distal Phalanges of lateral 4 digits

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51
Q

Flexor Digitorum Longus Action

A
  • Flexes lateral 4 digits
  • plantar flexes the ankle
  • supports longitudinal arches of foot
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52
Q

Flexor Digitorum Longus Innervation

A

Tibial Nerve (S3, S4)

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53
Q

Flexor Digitorum Longus Arterial Supply

A

Branch of Posterior Tibial Artery

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54
Q

Flexor Hallucis Longus

A
  • the Powerful pushoff muscle
  • provides spring to the step
  • tendon - passes posterior to the distal tibia, occupies a shallow groove on posterior talus which is continuous with the groove on the plantar surface of the sustentaculum tali –> then crosses deep to the tendon o the flexor digitorum longus in the sole of the foot –> runs between 2 sesamoid bones in the tendon of flexor hallucis brevis (protect the tendon from the pressure of the head of the 1st metatarsal bone
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55
Q

How to Test Flexor Hallucis Longus

A
  • terminal phalanx of the great toe is flexed against resistance
  • if it is acting normally, the tendon can be seen and palpated
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56
Q

Flexor Hallucis Longus Attachments

A

Inferior 2/3 of posterior surface of fibula and inferior part of interosseous membrane –> base of distal phalynx of great toe (hallux)

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57
Q

Flexor Hallucis Longus Actions

A
  • Flexes Great toe at all joints
  • weakly plantarflexes ankle
  • supports medial longitudinal arches of foot
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58
Q

Flexor Hallucis Longus Innervation

A

Tibial Nerve (S2 + S3)

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59
Q

Flexor Hallucis Longus Arterial Supply

A
  • muscular branch of fibular
  • posterior tibial
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60
Q

Tibialis Posterior (General)

A
  • Deepest of the posterior compartment muscles
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61
Q

Tibialis Posterior Attachments

A

Interosseous membrane, posterior surface of tibia inferior to soleal line, and posterior surface of fibula –> Tuberosity of navicular cuneiform, and cuboid and bases of 2nd, 3rd, and 4th metatarsals

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62
Q

Tibialis Posterior Action

A
  • Plantarflexes ankle
  • Inverts the foot
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63
Q

TIbialis Posterior Innervation

A

Tibial Nerve (L4, L5)

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64
Q

Tibialis Posterior Arterial Supply

A
  • Muscular branches of sural
  • Fibular Tibial Artery
  • Posterior Tibial Artery
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65
Q

Nerves in the Posterior Compartment

A

TIbial Nerve (L4, L5, S1, S2, S3)

  • At the ankle - lies between the tendons of flexor hallucis longus and flexor digitorum longus
  • Posteroinferior to the medial malleolus - divides into Medial Plantar Nerve and Lateral Plantar Nerve.

Medial Sural Cutaneous Nerve

  • a branch of the tibial nerve
  • usually unites with the communicating branch of the common fibular nerve to form the sural nerve
  • suplies skin of lateral and posterior 1/3 of leg
  • Supplies skin on lateral side of foot

Articular Branches of Tibial Nerve - supply knee joint

Medial Calcaneal Branches - Supply skin of heal

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66
Q

Arteries in the Posterior Compartment

A

Posterior Tibial Artery

  • Larger terminal branch of the popliteal artery
  • Fibular artery is the largest branch of Posterior TIbial Artery
  • after giving that off –> PTA passes inferomedially on the posterior surface of tibialis posterior accompanied by tibial nerve and tibial veins
  • deep to flexor retinaculum and the origin of the abductor hallucis, the posterior tibial artery divides into medial and lateral plantar arteries

Fibular artery

  • largest and most important branch of tibial artery
  • begins inferior to the distal border of the popliteus and the tendinous arch of the soleus –> descends obliquely toward the fibula and passes along its medial side –> usually w/i the flexor hallucis longus

Circumflex Fibular Artery

  • Arises from the origin of the anterior or posterior tibial artery at the knee
  • Passes laterally over the neck of the fibula to the anastomoses around the knee

Nutrient Artery of the TIbia

  • largest nutrient artery in the body
  • arises from the posterior tibial artery near its origin
  • pierces tibialis posterior –> supplies branches –> enters the nutrient foramen in the proximal 1/3 of the posterior tibia

Calcaneal Arteries - supply the heel

Malleolar Branch - joins the network of vessels on the medial malleolus

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67
Q

Posterior TIibial Pulse

A
  • can be palpated between the posterior surface of the medial malleolus and the medial border of the calcaneal tendon
  • essential for examining patients with occlusive peripheral artery disease
  • because the artery passes deep to the flexor retinaculum, it is important to relax the retinaculum by inverting the foot with palpation to get a reliable result
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68
Q

Hind Foot Bones

A
  • Talus
  • Calcaneus
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69
Q

Midfoot Bones

A
  • Navicular
  • Cuboid
  • Cuneiforms
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70
Q

Forefoot Bones

A
  • Metatarsals
  • Phalanges
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71
Q

Plantar Surface of the foot

A
  • sole of the foot
  • part of the foot facing the floor or ground
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72
Q

Dorsal Surface of Foot

A
  • Dorsum of foot
  • part facing superiorly
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73
Q

Heel of Foot

A

part of foot underlying the calcaneus

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74
Q

Ball of the Foot

A

Part of the sole underlyig the heads of the metatarsals

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75
Q

Hallux

A
  • 1st digit
  • great toe
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76
Q

Small Toe

A

5th digit

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77
Q

Dorsal Skin of Foot

A
  • thin
  • not very sensitive (compared to plantar surface)
  • subQ tissue is loose deep to the dorsal skin (as a result, edema is most marked here especially anterior to and around the medial malleolus)
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78
Q

Skin of the Sole of the Foot

A
  • covers major weight bearing areas
  • thick
  • heel
  • lateral margin of foot
  • ball of great toe
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79
Q

SubQ tissue in Sole

A

Fibrous Septa

  • divide this tissue into fat-filled areas making it a shock absorbing pad, especially over the heel
  • anchor the skin to the underlying plantar aponeurosis, improving the “grip” of the sole
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80
Q

Plantar Skin

A
  • Hairless
  • many sweat glands
  • entire sole of foot is ticklish
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81
Q

Deep Fascia of the Foot

A

Dorsum of the foot

  • thin
  • continuous with the inferior extensor retinaculum

Lateral and Posterior foot

  • continuous with plantar fascia
  • continuous with deep fascia of the sole
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82
Q

Plantar Aponeurosis

A
  • central part of Deep Fascia of the Foot forms the strong plantar aponeurosis
  • longitudinally arranged bands of dense fibrous CT
  • has a thick central part and weaker medial and lateral parts
  • arises posteriorly from the calcaneus
  • divides into 5 bands that split to enclose the digital tendons that attach to the margins of the fibrous digital sheaths and the sesamoid bones of the great toe

plantar fascia

  • holds part of the foot together
  • helps protect the plantar surface of the foot from injury
  • helps support the longitudinal arches of the foot
    *
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83
Q

3 Compartments of the Sole of the Foot

A

Fron the margins of the central part of the plantar aponeurosis, vertical septs extend deeply to form three compartments of the sole of the foot

Medial Compartment

  • abductor hallucis
  • flexor hallucis brevis
  • medial plantar nerve
  • medial plantar vessels

Central Compartment

  • Flexor Digitorum Brevis
  • Flexor Digitorum Longus
  • Quadrate Plantae
  • Lumbricals
  • Proximal Part fo the tendon of flexor hallucis longus
  • Lateral Plantar Nerve
  • Lateral Plantar Vessels

Lateral Compartment

  • Abductor Digiti Minimi Brevis
  • Flexor Digiti Minimi Brevis
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84
Q

Disection of the Sole

A

Muscles are disected more easily in layers than by compartments

85
Q

4 Muscular layers in the Sole of the Foot

A
  • help maintain the arches of the foot
  • enable standing on uneven ground
  • little importance individually because fine motor control of individual toes is not important to most people
86
Q

1st Layer of Plantar Muscles

A
  • Abductor Hallucis - Abductor of the Great toe
  • Flexor Digitorum Brevis - Flexor of the Lateral 4 Toes
  • Abductor Digiti Minimi - Abductor of the small toe
87
Q

2nd Layer of Plantar Muscles

A
  • Quadratus Plantae (flexor accessories) - flexor of the lateral 4 toes
  • Tendons of the Flexor Hallucis Longus - long flexor of the 1st toe
  • Tendons of the Flexor Digitorum Longus - long flexors of the toes
  • Lumbricals - flexors of the proximal phalanges; extensors of the middle and distal phalanges of the lateral 4 toes
88
Q

3rd Layer of Plantar Muscles

A
  • Flexor Hallucis Brevis - Flexor of the proximal phalynx of the great toe
  • Adductor Hallucis (transverse and oblique heads) - adductor of the great toe
  • Flexor Digiti Minimi Brevis - Flexor of the Proximal Phalynx of the Small Toe
89
Q

4th Layer of Plantar Muscles

A

3 Plantar interossei

  • adductors of the metatarsophalangeal joint of 3rd, 4th, and 5th digits
  • lexors of the metatarsophalangeal joint of 3rd, 4th, and 5th digits
  • Adduct and arise from a single metatarsal
  • remember PAD, or trying to hold water

4 Dorsal Interossei

  • abductors of the metatarsophalangeal joints of the 2nd, 3rd, and 4th digits
  • flexors of the metatarsophalangeal joints of the 2nd, 3rd and 4th digits
  • abduct and arise from 2 metatarsals
  • remember DAB, and trying to balance a ball on the back of the foot
90
Q

Function of muscles in the sole of the Foot

A

the Primary function of the intrinsic muscles of the sole of the foot (the 4 muscle layers) is to

  • resist flattening
  • maintain the longitudinal arch of the foot
91
Q

2 NeuroVascular Planes in the Foot

A

Superficial

  • lateral plantar artery and nerve - course laterally between the muscles of the 1st + 2nd layers of plantar muscles

Deep

  • their deep branches course medially between the muscles of the 3rd + 4th layers
92
Q

Extensor Digitorum Brevis and Extensor Hallucis Brevis

A
  • 2 closely connected muscles on the dorsum of the foot
  • thin broad muscles forma a fleshy mass on the lateral part of the dorsum of the foot, anterior to the lateral malleolus
  • help the long extensors extend the toes

Extensor Hallucis Brevis

  • Part of the extensor digitorum brevis
  • small fleshy belly may be felt when the toes are extended
  • Extends great toe

Extensor Digitorum Brevis

  • extends digits 2-4 at the metatarsophalangeal joints
93
Q

Contusion of Extensor Digitorum Brevis

A

knowing the location of the belly of the extensor digitorum brevis is important for distinguishing it from abnormal edema

94
Q

Nerves of the Foot

A

TIbial nerve, posterior to the medial malleolus divides into

  • medial plantar nerve (larger)
  • lateral plantar nerve (smaller)
  • Nerves supply the intrinsic muscles of the foot (except the Extensor Digitorum Brevis which is supplied by the Deep Fibular Nerve)

Cutaneous Innervation of the Foot Supplied By

  • Saphenous Nerve - Medial Side of Foot –> head of 1st metatarsal
  • Superficial and Deep Fibular Nerves - Dorsum of Foot
  • Medial and Lateral plantar nerves - sole of the foot
  • sural nerve - lateral aspect of the foot, including part of the heel
  • Calcaneal Branches of the tibial and sural nerves - Heel

Saphenous Nerve

  • largest cutaneous branch of the femoral nerve
  • supplys the skin and fascia on the anterior and medial leg
  • passes anterior to medial malleolus –> supplies skin along the medial foot –> proceeds to the head of the 1st metatarsal

Superficial Fibular Nerve

  • lies between the fibular muscles
  • leaves them around the junction of the middle 2/3 and the inferior 1/3 of the lateral leg
  • ends by supplying the skin on the dorsum of the foot

Deep Fibular Nerve

  • passes deep to the extensor retinaculum
  • supplies the skin on the contiguous sides of the 1st and 2nd toes

Medial Plantar Nerve

  • larger of 2 terminal branches of the tibial nerve
  • passes deep to abductor hallucis
  • runs anteriorly between abductor hallucis + Flexor Digitorum Brevis
  • on the lateral side of the medial plantar artery
  • terminates near the bases of the metatarsals by dividing into 3 sensory branches
  • Supplys - cutaneous branches to the medial 3 1/2 digits
  • Supplys - motor branches to: abductor hallucis, flexor digitorum brevis, flexor hallucis brevis, and the most medial lumbrical muscle (1st lumbrical muscle)

Lateral Plantar Nerve

  • the smaller of the 2 terminal branches of the tibial nerve
  • begins deep to flexor retinaculum + abductor hallucis
  • runs anterolaterally
  • medial to lateral plantar artery
  • between the 1st and 2nd layers of plantar muscles
  • terminates by dividing into superficial and deep branches
  • Superficial Branch - divides into 2 digital nerves that send cutaneous branches to the lateral 1 1/2 digits
  • Deep Branch - supplys motor branches to muscles of the sole that are not supplied by the medial plantar nerve

Sural Nerve

  • formed by union of branches from Tibial Nerve + Common Fibular Nerve
  • the level of the junction varies
  • sometimes these nerves d/n join, and no sural nerve forms (the skin normally innervated by the sural nerve is supplied by the tibial and fibular branches)
  • Accompanies the small saphenous vein –> enters the foot posterior to the lateral malleolus
  • supplys the skin along the lateral margin of the foot + the lateral side of the 5th digit
95
Q

Medial Plantar Nerve Entrapment

A
  • aka “Jogger’s Foot”
  • as this nerve passes deep to the flexor retinaculum or curves deep to the abductor hallucis, compression may cause paresthesia
  • Aching, Burning, Numbness, Tingling
  • on: medial sole, navicular tuberosity region
  • often due to repetitive eversion of the foot (gymnastics, running)
96
Q

Nerves of Foot Dermatomes

A
97
Q

Plantar Reflex

A
  • Deep Tendon Reflex
  • Tests L4, L5, S1, S2 nerve roots
  • routinely tested during neurological examinations
  • the lateral aspect of the sole of the foot is stroked with a blunt object, begining at the heel and crossing to the base of the great toe (firm & continuous motion that is neither painful nor ticklish)
  • Normal Response - Flexion of the Toes
  • Abnormal Response (babinski sign) - slight fanning of the lateral 4 toes and dorsiflexion of the great toe
  • brain injury or cerebral disease
  • d/n apply to newborns - 4y/o b/c the corticospinal tracts are not fully developed in newborns
98
Q

Arteries of the Foot

A

Dorsal artery

  • terminal Branches of Anterior Tibial Artery
  • direct continuation of the anterior tibial artery
  • begins midway between the malleoli
  • runs anteromedially
  • deep to the inferior extensor retinaculum between the tendons of extensor hallucis longus and extensor digitorum longus
  • dorsum of foot –> 1st interosseous space –> divides into a deep plantar artery that passes to the sole of the foot –> joins plantar arch and the 1st dorsal metatarsal artery

Plantar artery - terminal branches of posterior tibial artery

Lateral Tarsal Artery

  • a branch of the dorsal artery of the foot
  • runs laterally in an arched course beneath the extensor digitorum brevis
  • supplys: extensor digitorum brevis, underlying tarsals, underlyng joints
  • it then anastomoses with other branches such as the arcuate artery

Deep Plantar Artery

  • passes deeply through the 1st interosseous space
  • participates in the formation of the deep plantar arch by joining the lateral plantar artery

First Dorsal Metatarsal Artery

  • divides into branches that supply, both sides of the great toe + medial side of 2nd toe

Arcuate Artery

  • runs laterally across the bases of the lateral 4 metatarsals
  • deep to the extensor tendons
  • gives off the 2nd, 3rd, and 4th dorsal metatarsal arteries –> they run to the clefts of the toes –> each of them divides into 2 dorsal digital arteries for the sides of adjoining toes

the Metatarsal Arteries

  • dorsal metatarsal arteries are connected to the plantar arch and to the plantar metatarsal arteries by perforating arteries

Sole artery of the Foot

  • prolific blood supply
  • arteries derive from the posterior tibial artery
  • divides deep to the abductor hallucis to form the medial plantar artery and lateral plantar artery (they run parallel to the simalarly named nerves)

Medial Plantar Artery

  • Small
  • Supplies mainly the muscles of the great toe
  • most plantar digital arteries arise from this vessel
  • superficial branch - helps supply the skin on the medial side of the sole
  • digital branches - accompany digital branches of the medial plantar nerve and contribute little to the circulation of the toes

Lateral Plantar Artery

  • much larger
  • accompanies the nerve of the same name
  • runs laterally and anteriorly
  • first - runs deep to the abductor hallucis –> deep to the flexor digitorum brevis
  • arches medially –> crosses the foot –> forms the deep plantar arch with the deep branch of the lateral plantar nerve

Deep Plantar Arch

  • begins opposite the vase of the 5th metatarsal
  • completed medially by union with the deep plantar artery (a branch of the dorsal artery of the foot)
  • crosses the foot and gives off: 4 plantar metatarsal arteries, 3 perforating arteries, many branches to the sole of the foot (skin, fascia, muscles)
  • Join with the superficial branches of the medial plantar artery to form the plantar digital arteries which supply the adjacent digits
99
Q

Palpation of the Dorsalis Pedis Pulse

A
  • Evaluated during a physical exam of the peripheral vascular system
  • palpated with feet slightly dorsiflexed
  • usually easy to palpate b/c it is subQ and passes along a line from the extensor retinaculum to a point just lateral to the extensor hallucis longus tendon
  • some people are lacking this pulse as a result of a genetic anomaly (replaced by an enlarged perforating fibular artery
  • Vascular insufficiency resulting from arterial disease can result in a diminished or absent dorsal pedis pulse
100
Q

5 P signs of acute arterial occlusion

A

Relates to palpation of dorsalis pedis pulse (pulse of the Dorsal artery of the foot)

  • Pain
  • Pallor
  • Paresthesia
  • Paralysis
  • Pulselessness
101
Q

Puncture Wounds of the Sole of the Foot

A
  • involving the deep plantar arch and its branches –> severe bleeding
  • Because of its depth and the structures that surround it –> ligature of the arch is difficult
102
Q

Infections of the Foot

A
  • Common
  • Infected areas may be drained according to their location
  • the plantar fascial spaces are usually incised and drained on the medial side of the foot so that the person will not have a painful scar in a weight bearing area
103
Q

Venous Drainage of the Foot

A
  • dorsal digital veins run along the dorsum of each toe –> continuous with the dorsal metatarsal veins –> join to form the dorsal venous arch in subQ

Veins leave the Dorsal Venous Arch

  • Medailly - form the great saphenous vein
  • Laterally - form the small saphenous vein

Superficial veins of the sole unite to form a plantar venous network

  • efferent vessels pass to the medial marginal vein and the lateral marginal vein –> join with the great and small saphenous veins

Deep Veins of the Sole

  • Begin as plantar digital veins on plantar aspects of the digits –> communicate with the dorsal digital veins through perforating veins
  • most blood returns from the foot through deep veins that accompany the arteries
104
Q

Lymphatic Drainage of the Foot

A
  • begins in the subQ plexus
  • the collecting vessels consist of: superficial lymphatic vessels + deep lymphatic vessels
  • follow the veins

Superficial Lymphatic Vessels

  • most numerous in the sole
  • leave the medial foot along the great saphenous vein
  • leave the lateral foot along the small saphenous vein

Medial Superficial Lymphatic Vessels

  • larger
  • more numerous
  • Drain the medial side of the dorsum of the foot and the Sole
  • Converge on the great saphenous vein
  • Accompany it to the distal group of superficial inguinal lymph nodes located along the termination of the great saphenous vein

Superficial Inguinal Lymph Nodes

  • Drain mainly into the external iliac lymphnodes
  • some nodes drain into the deep inguinal nodes

Lateral Superficial Lymphatic Vessels

  • Drain the lateral side of the foot and sole
  • pass posterior to the lateral malleolus –> accompany the small saphenous vein to the popliteal fossa –> enter the popliteal lymphnodes

Deep lymphatic Vessels

  • follow the main blood vessels (anterior tibial vessel, posterior tibial vessel, fibular vessel, popliteal vessel, femoral vessel)
  • from the foot drain into the popliteal lymph nodes –> follow femoral vessels –> carrying lymph to the deep inguinal lymph nodes –> external iliac lymph nodes –> comon iliac nodes –> lateral aortic nodes
105
Q

Lymphadenopathy

A
  • enlargement of the lymphnodes
  • infections of the foot may spread proximally causing enlargement of popliteal and inguinal lymph nodes
  • inflammation of the popliteal nodes often results from lateral lesions of the heel
  • infections on the lateral side of th foot and sole initially produce enlargement of popliteal lymph nodes, later the inguinal lymph nodes may enlarge

Inguinal lymphadenopathy

  • can result from infection of skin on the leg and/or foot
  • also can result from an infection or tumor in: vulva, penis, scrotum, perineum, gluteal region, terminal parts of urethra, anal canal, or vagina
106
Q

Lymphangiography

A
  • Normally numerous large lymphatic vessels in the subQ tissue on the dorsum of the foot
  • contrast medium injectected into the foot and transported to these vessels to the inguinal lymphnodes and iliac lymph nodes
  • a radiograph shows the lymph nodes outlined by contrast medium so that their size and number can be studied to help determine thecause of the lymphadenopathy
  • gradually being replaced by other diagnostic imaging techniques such as CT and MRI which d/n require an injection of contrast media
107
Q

Hip Joint

A
  • Synovial Joint
  • designed for stability + a wide range of movement (2nd most movable joint)
108
Q

Head of Femur

A
  • covered with articular cartilage
  • except for the pit (fovea) for the ligament of the femoral head
109
Q

Depth of Acetabulum

A
  • Depth is increased by a fibrocartilaginous acetabular labrum
  • more than 1/2 of the head fits w/i the acetabulum
    *
110
Q

Articular capsule of the Hip Joint

A
  • Strong, loose fibrous capsule
  • permits free movement of the hip
  • ligaments (parts of the fibrous capsule are thicher than others
  • most capsular fibers take a spiral course from the hip bone to the intertrochanteric line
  • some deep fibers pass circularly around the neck forming the orbicular zone

Attaches distally to the neck of the femur

  • anteriorly - at intertrochanteric line + root of greater trochanter
  • posteriorly - the fibrous capsule crosses to the neck proximal to the intertrochanteric crest, but it’s not attached to it.
111
Q

Retinacula of the Hip Joint

A
  • some deep longitudinal fibers of the capsule reflect superiorly along the femoral neck as longitudinal bands that blend with the periosteum

the retinaculas contain:

  • retinacular blood vessels (branches of: medial femoral circumflex artery + lateral femoral circumflex artery which supply the head and neck of the femur)
112
Q

Iliofemoral Ligament

A
  • aka ligament of Bigelow
  • strong
  • anterior
  • Y-shaped

attaches to the:

  • AIIS
  • Proximally - acetabular rim
  • Distally - intertrochanteric line

PREVENTS HYPEREXTENSION OF THE HIP WHEN STANDING

  • by screwing the femoral head into the acetabulum
113
Q

Pubofemoral Ligament

A
  • arises from the obturator crest of the pubic bone
  • passes laterally and inferiorly to merge with the fibrous capsule of the hip
  • blends with the medial part of the iliofemural ligament
  • tightens during extension and abduction
  • prevents over abduction of the hip
114
Q

Ischiofemoral ligament

A
  • reinforces the fibrous capsule posteriorly
  • arises from the ischial part of the acetabular rim
  • spirals superolateraly to the neck of the femur
  • spirals medially to the base of the greater trochanter
  • tends to screw the femoral head medially into the acetabulum preventing hyperextension
115
Q

Ligament of the Head of the Femur

A
  • weak and of little importance in strengthening the hip joint
  • wide end attaches to the margins of the aceptabular notch and the transverse acetabular ligament
  • narrow end attaches to the pit in the head of the femur
  • usually the ligament contains a small artery to the head of the femur
116
Q

Fat Pad of Hip Joint

A
  • Covered with synovial membrane
  • fills the part of the acetabular fossa that is not occupied by the femoral head

the malleable nature of the fat pad permits it to:

  • change shape
  • accommodate the varying shape of the head during joint movements
117
Q

Movements at the Hip Joint

A
  • flexion-extension
  • abduction - adduction
  • medial - lateral rotation
  • circumduction
118
Q

Main muscles that Flex the Hip

A

Flexion:

  • iliopsoas (strongest flexor)
  • sartorius
  • tensor of fascia lata
  • rectus femoris
  • pectineus
  • adductor longus
  • adductor brevis
  • adductor magnus (anterior part)
  • gracilis
119
Q

Main muscles that Extend the Hip

A

Hamstrings

  • semitendinosus
  • semimembranosus
  • long head of biceps femoris

Adductor Magnus

  • posterior part

Gluteus Maximus

  • relatively inactive from the standing position to the fully extended position
  • only used if forceful extension is required
  • acts mostly from the fully flexed to the straight position (climbing stairs, rising from a sitting position)
120
Q

Main muscles that produce Abduction movements in the Hip

A
  • gluteus medius
  • gluteus minimus
  • tensor of fascia lata

(all of these also medially rotate)

121
Q

Main Muscles that produce Adduction in the Hip

A
  • Adductor Longus
  • Adductor Brevis
  • Adductor Magnus
  • Gracilis
  • Pectineus
  • Obturator Externus
122
Q

Main muscles that produce Medial Hip Rotation

A
  • Anterior fibers of gluteus medius
  • Gluteus Minimus
  • Tensor of Fascia Lata
123
Q

Main Muscles that Laterally Rotate the HIp

A
  • obturator externus
  • obturator internus
  • gemelli
  • piriformis
  • quadratus femoris
  • gluteus maximus
124
Q

Blood Supply of the Hip Joint

A
  • Medial and Lateral Circumflex femoral arteries
  • especially the medial circumflex femoral artery - usually branches of the deep artery of the thigh, occassionally arising as branches of the femoral artery
  • artery to the head of the femur - a branch of the obturator artery that enters through the ligament of the head
125
Q

Nerve Supply of the Hip

A

Anteriorly

  • Femoral Nerve or its Muscular branches
  • accessory obturator nerve if present

Inferiorly

  • Obturator Nerve anterior division

Superiorly

  • Superior gluteal Nerve

Posteriorly

  • Superior Gluteal Nerve
  • Nerve to quadratus femoris

(pain in the hip may be misleading b/c it can actually be referred pain from the vertebral column)

126
Q

Fractures of the Femoral Neck

A
  • the fractures are intracapsular
  • realignment of the neck fragments requires internal skeletal fixtaion (ORIF)
  • most troublesome of all fractures
  • common in persons over 60 esp. women b/c osteoperosis
  • may also fracture when traumatic force is applied to the foot and ankle
  • knee firmly braced and knee locked during a head-on collision –> if force is transmitted superiorly, produces a femoral neck fracture
  • often disrupts the blood supply to the head of the femur
  • the blood from the artery of the ligament of the head is in some cases the only blood that the proximal fragment of the femoral head receives
  • if the artery to the head of the femur is ruptured, the fragment may receive no blood and will undergo aseptic vascular necrosis

the medial circumflex artery is clinically important

  • supplies most of the blood to the head and neck of the femur
  • often torn when the femoral neck is fractured or hip is dislocated
127
Q

Surgical Hip Replacement

A
  • in cases of severe traumatic injury and degenerative disease
  • THR is the 1st joint for which the replacement prosthesis was developed
  • for osteoarthritis of the hip joint caracterized by pain, edema, limitation of motion, erosion of articular cartilage (common cause of disability)

During hip replacement

  • a metal prosthesis is anchored to the person’s femur by bone cement replaces the femoral head and neck
  • a plastic socket cemented to the hip bone replaces the acetabulum
128
Q

Dislocation of the Hip

A

Congenital Dislocation

  • common
  • occurring in appx. 1.5/1000 live births
  • bilateral in appx. 1/2 of the cases
  • girls 8x more likely than boys

Acquired Dislocation

  • uncommon b/c the articulation is strong and stable
  • may occur durring an auto accident when the hip is flexed, adductued, medially rotated (this is the position of the hip when riding in a car)

Posterior Dislocations

  • most common
  • head-on collision causes the knee to strike the dashboard and dislocate the hip when the femoral head is forced out of the acetabulum
  • the close relationship of the sciatic nerve to the hip means that it may get injured (stretched/compressed)
  • fracture doslocations of this type may result in paralysis of hamstrings, muscles distal to the knee, and muscles supplied by the sciatic nerve

Anterior Dislocations

  • a violent injury that forces the hip into extension, abduction and lateral rotation
  • the femoral head is inferior to the acetabulum
  • the acetabular margin often fractures producing a fracture-dislocation
  • usually carries with the acetabular bone fragment and acetabular labrum
129
Q

Tibial Plateaus

A
  • The articular area on the superior surface of each tibial condyle
  • coresponding with the femoral condyle
  • lateral tibial plateau
  • medial tibial plateau
  • separated by intercondylar eminence (lateral & medial intercondylar tubercles)
130
Q

Tibiofemoral Joint

A
  • the distal articulating surfaces - 2 shallow concave medial and lateral condyles at the proximal end of the Tibia
  • 2 bony spines - intercondylar tubercles - separate the medial condyle from the lateral condyle of the tibia
  • 2 joint discs - menisci - attached to the articulating surfaces on the tibial condyles
131
Q

Tibiofemoral Joint Rotation

A
  • Lateral rotation of the tibia occurs during the last 10-15 degrees of extension
  • to begin flexion - joint must be unlocked by the tibia as it rotates medially
  • this rotation is not under voluntary control and should not be confused with the voluntary rotation movement possible at the joint
  • the greatest range of voluntary knee rotation occurs at 90 degrees of flexion; at this point, about 40-45 degrees of lateral rotation and 15 degrees of medial rotation are possible
132
Q

Tibiofemoral Joint Rolling & Sliding

A

Arthokinematics

  • Incongruance - femoral articulating surfaces are bigger than the tibial articulating surfaces
  • when the femoral condyles are moving on the tibial condyles (in a weight-bearing situation), the femoral condyles must roll and slide to remain on the tibia
133
Q

Patellar Ligament

A
  • aka ligamentum patellae
  • a very strong, thick band
  • continuation of the tendon of the quadriceps femoris muscle
  • sesamoid bone in this tendon
  • continuous with the fibrous capsule of the knee joint
134
Q

Fibular Collateral Ligament

A
  • aka Lateral Collateral Ligament
  • round pencil-like cord
  • extends inferiorly from the lateral epicondyle of the femur to the lateral surface of the head of the fibula
  • tendon of the popliteus muscle passes deep to the fibular collateral ligament, separating it from the lateral meniscus - the fibular collateral ligament is not attached to the lateral meniscus
135
Q

Tibial Collateral Ligament

A
  • aka Medial Collateral Ligament
  • Strong flat band
  • extends from the medial condyle of the femur to the medial condyle and superior part of the medial surface of the tibia
  • thickening of the fibrous capsule of the knee, partially continuous with the tendon of the adductor magnus
  • Deep fibers are firmly attached to the medial meniscus and fibrous capsule of the knee
136
Q

Clinical Significance of the Tibial Collateral Ligament

A
  • firm attachment to the medial meniscus frequently resulting in simultaneous injury to MCL and Medial meniscus
  • most common type of football injury
  • the damage is frequently caused by a blow to the lateral side of the knee

Unhappy triad of the knee injuries

  • rupture tibial collateral ligament
  • tear medial meniscus
  • tear anterior cruciate ligament
137
Q

3 Cs for Considering Soft TIssue Injuries of the Knee

A

Indicate structures that might be damaged

  • collateral ligaments
  • cruciate ligaments
  • cartillages of menisci
138
Q

synovial capsule of knee

A
  • more extensive than the synovial capsule of any other joint
  • largest joint space in the body
139
Q

Bursae around the knee

A
  • several bursae around the knee b/c most tendons around it run parallel to the bones and pull lengthwise across the joint
  • 4 bursae communicate with the synovial cavity of the knee joint
140
Q

Suprapatellar Bursa

A
  • Large saccular extension of the synovial capsule passes superiorly between the femur and the tendon of the quadriceps femoris
  • extends appx. 8 cm (4 fingerbreadths) superior to the base of the patella
  • Communicates freely with the synovial cavity of the knee joint - regarded as a part of it
  • stab wounds proximal to the patella in the anterior part of the thigh may infect the knee joint via the suprapatellar bursa
  • may also be involved in fractures on the distal end of the femur resulting in hemarthrosis (blood in the joint)
141
Q

Popliteus Bursa

A
  • subpopliteal extension of the synovial cavity of the knee joint
  • lies between the tendon of the popliteus muscle and the lateral condyle of the tibia
  • opens into the lateral synovial cavity of the knee, inferior to the lateral meniscus
142
Q

Baker’s Cyst

A
  • aka Popliteal Cyst
  • occasionally synovial fluid escapes from the knee joint and accumulates in the popliteal fossa –> Becomes enclosed in a membranous sac –> known as a popliteal cyst
  • in cases of rheumatoid or degenerative joint disease where there is an escape of synovial fluid (synovial effusion) –> the popliteal cyst becomes distended by the effused fluid and may extend inferiorly as far as the middle calf
143
Q

Subcutaneous Prepatellar Bursa

A
  • Bursae do not normally communicate with the synovial cavity of the knee
  • usually related to the patella
  • lies between the skin and anterior surface of the patella
  • allows free movement of the skin over the patella during flexion and extension
  • may become inflammed after prolonged working on the hands and knees (scrubbing the floor)
144
Q

Prepatellar Bursitis

A
  • Friction bursitis caused by frictionbetween the skin and patella
  • if chronic –> the bursa become distended with fluid and forms a soft fluctuant swelling anterior to the knee
  • house maids, miners and other people who work on all fours
145
Q

Subcutaneous Infrapatellar Bursa

A
  • Lies between the skin and the tibial tuberosity
  • allows the skin to glide over the tibial tuberosity and withstand pressure when kneeling with the trunk upright
146
Q

Subcutaneous Infrapatellar Bursitis

A
  • From excessive friction between the skin and tibial tuberosity
  • swelling over the proximal tibia
  • “clergyman’s knee” often in roofers, floor tilters, and carpet layers who d/n wear knee pads
147
Q

Deep Infrapatellar Bursa

A
  • small bursa
  • lies between the ligamentum patellae and anterior surface of the tibia, superior to the tibial tuberosity
  • separated from the knee joint by the infrapatellar fat pad
148
Q

Deep Infrapatellar Bursitis

A
  • swelling between the patellar ligament and the tibia, superior to the tibial tuberosity
  • swelling is usually less pronounced than that associated with superficial prepatellar bursitis
  • enlargement of this bursa obliterates the dimples on each side of the patellar ligament when the leg is extended
149
Q

Cruciate Ligaments of the Knee

A
  • w/i the knee capsule there are 2 cruciate ligaments that attach the femur to the tibia
  • important - the cruciate ligaments are w/i the capsule, but outside the synovial cavity of the knee
  • located between the medial and lateral condyles
150
Q

Anterior Cruciate Ligament

A
  • weaker than PCL
  • arises from the anterior part of the intercondylar area of the tibia just posterior to the attachment of the medial meniscus
  • extends superiorly, posteriorly, and laterally to attach to the posterior part of the medial side of the lateral condyle of the femur
  • slack when the knee is flexed and taught when the knee is fully extended
  • prevents posterior displacement of the femur on the tibia and hyperextension of the knee joint
  • at a right angle, the tibia cannot be pulled anteriorly because it is held by the ACL
151
Q

Anterior Cruciate Ligament Injury

A

may be torn when:

  • tibia is driven anteriorly on the femur
  • femur is driven posteriorly on the tibia
  • knee joint is severely hyperextended

Anterior Drawer Sign:

  • knee joint becomes very unstable when ACL is torn
  • test its stability by pulling the tibia in an anterior direction
  • if there is anterior movement, an ACL tear is suggested
152
Q

Posterior Cruciate Ligament

A
  • Stronger than ACL
  • arises from the posterior part of the intercondylar area of the tibia –> passes superiorly, anteriorly on the medial side of ACL to attach to the anterior part of the lateral surface of the medial condyle of the femur
  • when the knee is opened posteriorly, the PCL is the 1st structure observed
  • tightens during flexion

prevents

  • anterior displacement of the femur on the tibia
  • posterior displacement of the tibia on the femur
  • hyperflexion
153
Q

Posterior Cruciate Ligament Injury

A

PCL may be injured when:

  • tibia is driven posteriorly on the femur; the superior part of the tibia is struck with the knee flexed (against a dashbosrd); may be accompanied by dislocation of the hip
  • Femur is driven anteriorly on the tibia
  • knee joint is severly hyperflexed
154
Q

Posterior Drawer Sign

A
  • the flexed knee is unstable when the posterior cruciate ligament is torn
  • to test its stability, the tibia is forced in a posterior direction
  • if there is posterior movement, tear of the posterior cruciate ligament is indicated
155
Q

Menisci of the Knee joint

A
  • medial and lateral menisci - semilunar cartilages
  • plates of fibrocartilage
  • lie on the articular surface of the tibia
  • shock absorbers
  • wedge-shaped in cross-section
  • firmly atached at their ends to the intercondylar area of the tibia
  • thick peripheral margins of the menisci are vascularized by genicular branches of the popliteal artery
  • thin unattached edges in the interior of the joint are avascular
156
Q

Blood Supply of the knee Joint

A
  • the articular arteries to the knee joint branches of the vessels that form the genicular anastomoses around the knee
  • middle genicular artery, a branch of the popliteal artery, penetrates the fibrous capsule and supplies the cruciate ligaments, synovial capsule, and margins of the menisci
157
Q

Nerve Supply of the Knee

A

Articular Nerves are Branches of

  • obturator nerve
  • femoral nerve
  • tibial nerve
  • common fibular nerve
158
Q

Blood Supply of the Superior TIbiofibular Joint

A

Derived from:

  • inferior lateral genicular arteries
  • anterior tibial recurrent arteries
159
Q

Injuries in Contact and Noncontact Sports

A
  • Mobility results in susceptibility to injuries in sports

Contact Sports

  • the most common knee injuries are ligament sprains
  • occur when the foot is fixed in the ground and force is applied against the knee
160
Q

Arthroscopy of the Knee Joint

A
  • the arthroscope is a useful diagnostic and surgical tool that allows visualization of the interior of the joint cavity
  • allows removal of torn menisci, loose bodies in the joint such as bone chips, and debridement (excision of devitalized articular cartilaginous material in advanced cases of arthritis)
  • general anesthesia is preferalbe and can be performed using local or regional anesthesia
161
Q

Patellofemoral Syndrome

A
  • Pain deep to the patella

Common causes:

  • excessive running, esp. down hill (“runner’s knee”)
  • repetitive microtrauma caused by abnormal tracking of the patella with the patellar surface of the femur
  • DIrect blow to patella
  • osteoarthritis of the patellofemoral compartment (degenerative wear and tear of articular cartilages)
162
Q

Patellofemoral Contact Area

A

0d - no contact

10d - 1st contact

20d - inferior margin across the medial and lateral facets, contact moves superiorly, increasing the area

90d - contact superior pole

10-90d - no contact at the medial margin until 135d

163
Q

Factors Affecting Patellar Allignment

A
  • Increased Q-Angle
  • Tight lateral structures
  • tightness of gastrocnemius and hamstrings
  • excessive pronation
  • Patella Alta
  • VMO insufficiency
164
Q

Reason for Increased Q-Angle

A
  • Femoral Neck Anteversion
  • External Tibial Torsion
  • Lateral Displacement of the tibial tubercle

Structures etc. involved

  • Quadriceps
  • Patellar Tendon
  • Vagus Vector

Q-angle

  • ASIS to mid-pole
  • mid-pole to tibial tubercle

Normal Q-Angle

  • males - 12d
  • females - 15d
165
Q

Patella Alta & Patella Baja

A

the ratio of:

  • patellar tendon length: the height of the patella should be 1:1 when the x-ray is measured at 45-50d, and sometimes 90d
166
Q

Patella Alta

A
  • Patella Alta tendon is 20% longer than the patella
  • more common in women
  • common finding in a congenitally subluxing patella
167
Q

Patella Baja

A
  • the tendon is 20% shorter than the patella
  • complication of anterior cruciate ligament reconstruction
  • an adaptive shortening of the patellar tendon
  • causes fat pad syndrome
168
Q

VMO Insufficiency

A
  • realigns the patella medially
  • the only dynamic medial stabilizer active through the whole ROM
  • arises from the adductor magnus tendon innervated from a branch of the femoral nerve
  • can be activated as a single motor unit
169
Q

Patellar Orientation

A

Static

  • Glide, Tilt, Rotation, Anteroposterior

Dynamic

  • Glide, Tilt, Rotation, Anteroposterior
170
Q

Knee Replacement

A
  • if knee is diseased, resulting from osteoarthritis etc. an artificial knee may be inserted (total knee replacement arthroplasty)
  • the artificial knee consists of plastic and metal components that are semented to the bone ends
171
Q

ACL Reconstruction

A
  • non-operative treatment is still poular and very common
  • however, if the patient’s goals involve stressful work or sports, they are candidates for a reconstructive proceedure
  • recent advances in instrumentation and graft fixation have facilitated more accurate graft placement and stronger graft fixation
  • arthroscopically assisted surgery has allowed earlier and more aggressive rehabilitation
172
Q

Ankle

A
  • Hinge, synovial joint
  • located between the distal ends of the tibia and fibula + superior talus
  • can be felt between the tendons on the anterior surface of the ankle - a slight depression, approximately 1cm proximal to the tip of the medial malleolus
173
Q

Articular Surfaces of the Ankle Joint

A
  • Distal ends of the tibia & fibula + inferior transverse part of the posterior tibiofibular ligament form a mortise (deep sacker) into which the pulley-shaped trochlea of the talus fits
  • the trochlea is the rounded superior articular surface of the talus
  • the medial surface of the lateral malleolus articulates with the lateral surface of the talus

the tibia articulates with the talus in 2 places

  • its inferior surface forms the roof of the mortise
  • its medial malleolus articulates with the medial surface of the tallus

the malleoli grip the talus tightly as it rocks anteriorly, and especially posteriorly in the mortise during movements of the joint

174
Q

During Dorsiflexion

A
  • Forces the wider, anterior part of the trochlea to move posteriorly, spreading the tibia and fibula apart slightly, the grip of the malleoli on the trochlea is strongest

this spreading is limited by the ligaments that unite the tibia and fibula

  • strong interosseous ligament
  • anterior tibiofibular ligaments
  • posterior tibiofibular ligaments
  • transverse tibiofibular ligaments
175
Q

During Plantarflexion

A
  • relatively unstable because the trochlea is narrower posteriorly so it lies relatively loosely w/i the mortise
  • most injuries of the ankle occur in this position (usually as a result of sudden, unexpected and therefore adequately resisted-inversion of the foot)
176
Q

Medial Malleolus

A

the prominence on the medial side of the ankle

  • sub-Q
  • easy to palpate
  • inferior end is blunt
  • d/n extend as far distally as the lateral malleolus
177
Q

Articular Capsule of the Ankle Joint

A
  • fibrous capsule is thin anteriorly and posteriorly
  • each side is supported by strong collateral ligaments
  • superiorly - attached to the boarders of the articular surfaces of the tibia and to the malleoli
  • Inferiorly - attached to the talus
178
Q

Lateral Ligaments of the Ankle Joint

A

Laterally, the fibrous capsule is reinforced by 3 discrete ligaments which are collectively referred to as the lateral ligament (weaker than the medial ligament), which consist of 3 parts:

  • anterior talofibular ligament - a weak, flat band that extends anteromedially from the lateral malleolus to the neck of the tallus
  • posterior talofibular ligament - a thick, fairly strong band that runs horzontally medially and slightly posteriorly from the malleolar fossa to the lateral tubercle of the talus
  • calcaneofibular ligament - a round cord that passes posteroinferiorly from the tip of the lateral malleolus to the lateral surface of calcaneus
179
Q

Medial Ligaments of the Ankle

A

medially, the fibrous capsule is reinforced by the large, strong medial ligament (deltoid ligament) that attaches proximally to the medial malleolus

they have fibers that fan out from the malleolus and attach distally to the talus, calcaneus, and navicular - forming the:

  • Tibionavicular ligament
  • anterior and posterior tibiltalar ligaments
  • tibiocalcaneal ligament

Stabilizes the ankle joint during eversion and prevents subluxation of the joint

180
Q

Synovial Membrane of Ankle

A
  • synovial membrane is loose and lines the fibrous capsule
  • the synoval cavity often extends superiorly between the tibia and fibula as far as the interosseous ligament of the distal tibiofibular joint
181
Q

Dorsiflexion of the Ankle

A
  • produced by the muscles in the anterior compartment of the leg

usually limited by:

  • passive resistance of the triceps surae to stretching
  • tension in the medial and lateral ligaments
182
Q

Plantarflexion of the Ankle

A
  • produced by the muscles in the posterior compartment of the leg
  • at this position, there is some rotation, abduction and adduction
  • in toe dancing by ballet dancers, the dorsum of the foot is in line with the anterior surface of the leg
183
Q

Blood Supply of the Ankle Joint

A

the arteries are derived from malleolar branches of the fibular and anterior and posterior tibial arteries

184
Q

Nerve Supply of the Ankle Joint

A

the nerves are derived from the tibial nerve and the deep fibular nerve, a division of the common fibular nerve

185
Q

Ankle Sprains

A

the ankle is the most frequently injured major joint

Ankle Sprains:

  • tearing fibers of ligaments - most common
  • nearly always an inversion injury involving twisting of the weight bearing foot (forcibly inverted)
186
Q

Lateral Ligament Sprains

A
  • Lateral ligament is MUCH WEAKER than the medial ligament
  • occurs in sports that involve running, jumpging, etc (in basketball 70-80% of players have had at least 1 sprain)
  • fibers of the anterior talofibular ligament which are part of the lateral ligament, are torn either partially or completely in ankle sprains
  • result is instability of the ankle joint
  • the calcaneofibular ligament may also be torn
  • in severe sprains, the lateral malleolus of the fibula may be fractured
  • shearing injuries fracture the lateral malleolus at or superior to the ankle joint
  • avulsion fractures break the malleolus inferior to the ankle joint, a fragment of bone is pulled off by the attached ligaments
187
Q

Pott’s Fracture - dislocation of ankle

A
  • occurs when the foot is forcibly everted
  • this action pulls on the extremely strong medial ligament, often tearing the medial malleolus
  • the talus then moves laterally, shearing off the lateral malleolus or, more commonly, breaking the fibula superior to the inferior tibiofibular joint
188
Q

Trimalleololar Fracture of the Ankle

A

if the tibia is carried anteriorly, the posterior margin of the distal end of the tibia is aldo sheared off by the talus producing a “trimalleolar fracture” (the distal end of the tibia is considered a malleolus)

189
Q

Tibial Nerve Entrapment

A
  • aka tarsal tunnel syndrome
  • the tibial nerve leaves the posterior compartment of the leg by passing deep to the flexor retinaculum in the interval between the medial malleolus and calcaneus
  • edema
  • tightness in the ankle involving the synovial sheaths of the tendins of muscles in the posterior compartment of the leg
  • entrapment and compression of the tibial nerve by the flexor retinaculum
  • pain from the medial malleolus to the calcaneus, and the heel
190
Q

Foot Joints

A

Many of the foot joints involve the:

  • tarsals
  • metatarsals
  • phalanges

the important tarsal joints are the:

  • transverse tarsal joint (calcaneocuboid and talonavicular joints)
  • subtalar joint

inversion and eversion of the foot are the main movements involving these joints

191
Q

Transverse Tarsal Joint

A

formed by the combined talonavicular part of the

  • talonavicular joint
  • cuboid joint

the 2 separate joints align transversely

transaction across the transverse tarsal joint is a standard method for surgical amputation of the foot

192
Q

Subtalar Joint

A
  • where the talus rests on andd articulates with the calcaneus
  • synovial - surrounded by an articular capsule, attached near the margins of the the articular facets

the fibrous capsule is weak but is supported by:

  • medial ligament
  • lateral ligament
  • posterior ligament
  • interosseous talocalcaneal ligament

orthopediac surgeons oftern use the term “subtalar” joint as a functional term where mast inversion and eversion movements occur (hinged door analogy)

193
Q

subtalar joint triplane motion

A

Pronation

  • Sagital - Dorsiflexion
  • Frontal - Eversion
  • Transvers - Abduction

Supination

  • Sagital - Plantarflexion
  • Frontal - Inversion
  • Transverse - Adduction
194
Q

Major Ligaments of the Foot

A

Plantar Calcaneonavicular Ligament (spring ligament)

  • extends from the sustentaculum tali to the posteroinferior surface of the navicular
  • plays an important role in maintaining the longitudinal arch of the foot

Long Plantar Ligament

  • passes from the plantar surface of the calcaneus to the groove on the cuboid
  • some of its fibers extend to the bases of the metatarsals, forming a tunnel for the tendon of fibularis longus
  • is important in maintaining the arches of the foot

Plantar Calcaneocuboid Ligament (short plantar ligament)

  • deep to the long plantar ligament
  • extends from the anterior aspect of the inferior surface of the calcaneus to the inferior surface of the cuboid
195
Q

Arches of the Foot

A
  • the tarsal and metatarsal bones are arranged in longitudinal and transverse arches which add to the weight bearing capabilities and resiliency
  • the resilient arches of the foot make it adaptable to surface and weight changes

act as shock absorbers for:

  • supporting the weight of the body
  • propelling the body during movement

the weight of the body istransmitted from the tibia to the talus:

  • posteroinferiorly to the calcaneus
  • anteroinferiorly to the heads of the 2nd - 5th metatarsals and the sesamoid bones of the 1st digit

between these weight bearing points are the relatively elastic arches

  • during standing, slightly flattened by body weight
  • when body weight is removed, resume their normal curvature

the integrity of the bony arches of the foot is maintained by the:

  • shape of the interlocking bones
  • strength of the plantar ligaments, especially the plantar calcaneonavicular (spring) ligament and the long and short plantar ligaments
  • plantar aponeurosis (central part of plantar fascia)
  • action of muscles through the bracing action of their tendons
196
Q

Longitudinal Arch of the foot

A
  • composed of medial and lateral parts
  • functionally, both parts act as a unit with the transverse arch spreading the weight in all directions
  • the medial longitudinal arch is higher and more important than the lateral longitudinal arch
197
Q

Medial Longitudinal Arch

A

composed of:

  • calcaneus, talus, navicular, 3 cuneiforms, 3 metatarsals
  • talar head is the keystone of the medial longitudinal arch
  • tibialis anterior, attaching to the 1st metatarsal and medial cuneiform, helps strengthen the medial longitudinal arch
  • the fibularis longus tendon passing from lateral to medial helps support this arch
198
Q

Lateral Longitudinal Arch

A
  • much flatter than the medial part of the arch
  • rests on the ground durring standing
  • composed of calcaneus, cuboid, and lateral 2 metatarsals
199
Q

Transverse Arch of the Foot

A
  • runs from side to side
  • formed by the cuboid, cuneiforms, and bases of the metatarsals
  • the medial and lateral parts of the longitudinal arch serve as pillars for the transverse arch
  • the tendon of the fibularis longus, crossing the sole of the foot obliquely, helps maintain the curvature of the transverse arch
200
Q

First Ray

A
  • a single foot segment consisting of the 1st metatarsal and 1st cuneiform

serves important purposes during the gait cycle:

  • provides shock absorption during the loading response
  • provides stability during the terminal stance and pushoff phases of the gait cycle
  • abnormal first ray position: plantar flexion + dorsiflexion
  • Abnormal Mobility: hypermobility, hypomobility, decreases the structure’s ability to function normally during gait
  • first ray abnormalities have been suggested as a causative factor for the development of metatarsalgia
  • experimentally, associations have been found between 1st ray abnormalities and Hallux Valgus
  • forefoot valgus, rheumatoid acquired flat foot, and plantar ulcerations
  • in addition, abnormal 1st ray mobility has also been highly correlated with excessive knee rotation and altered ground reaction forces during gait
201
Q

Hallux VaLgus

A

(Foot Deformity)

lateral deviation of the great toe, the L in valgus indicates Lateral deviation

202
Q

Hammer Toe

A

A deformity where the proximal phalanx is permanently flexed at the metatarsophalangeal joint and the middle phalynx is plantarflexed at the interphalangeal joint.

the distal phalynx is also flexed or extended, giving the digit (usually the 2nd) a hammer like appearance

203
Q

Claw Toes

A
  • Hyperextension of the metatarsophalangeal joints
  • flexion of the distal interphalangeal joints
  • usually all the lateral 4 toes are involved
204
Q

Pes Plantus

A

(Flat Feet)

  • the flat appearance of infants’ feet is normal and results from the thick subQ fat pads in the soles of their feet
  • pes planus or flat feet in adolescents and adults results from “fallen arches,” usually the medial parts of the longitudinal arches
205
Q

Clubfoot

A

(Talipes)

  • foot is twisted out of postion
  • several types, all are congenital (present at birth)
  • invloves the subtalar joint
  • boys are 2x more likely than girls
  • foot is inverted, ankle is plantarflexed, and forefoot is adducted

main abnormality is ahortness and tightness of:

  • muscles
  • tendons
  • ligaments
  • articular capsules

on the medial and posterior aspect of the foot and ankle

206
Q

Tibialis posterior Tendon

A
  • is the guide to the navicular
  • indicates the site for palpating the posterior tibial pulse (halfway between the medial malleolus and the calcaneal tendon)
207
Q

transverse tarsal joint (surface)

A

indicated by a line from the posterior aspect of the tuberosity of the the navicular to a point half way between the lateral malleolus and the tuberosity of the 5th metatarsal

208
Q

Talar Head

A
  • When the foot is inverted, it is palpable anteromedial to the proximal part of the lateral malleolus
  • when the foot is evened, the talar head is palpable anterior to the medial malleolus
  • occupies the space between the sustentaculum tali and the navicular tuberosity

anatomy (4 decks)

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