"Knee, Leg, Ankle, Foot" Questions Flashcards
What are the bones of the lower limb?
Femur Patella Tibia Fibula Bones of the foot - tarsals, metatarsals, phalanges
Where are and what are the two trochanters of the femur?
Greater trochanter
Lesser trochanter
- greater is bigger and lateral to the head of the humerus while the lesser is smaller and medial to the femur head
What are the important landmarks at the proximal end of the femur?
Head (of the femur) Neck Greater trochanter Intertrochanteric crest Lesser trochanter Linea aspera (medial/lateral lip) on posterior surface
What are the important landmarks at the distal end of the femur?
Medial epicondyle Adductor tubercle (just superior and lateral) Medial condyle Lateral condyle Lateral epicondyle
Where is a common fracture point on the femur?
Femoral neck
What is the greater trochanter a common attachment point for?
The gluteal muscles
- abductor muscles of the thigh at the hip
Where do the two heads of the gastrocnemius insert in the distal femur?
Medial head - just behind the adductor tubercle
Lateral head - superior facet of the lateral epicondyle
How are the two condyles of the distal femur related?
Anteriorly they are connected
Posteriorly they are separated by the intercondylar fossa
Which walls of the proximal tibia do the posterior and anterior cruciate ligaments attach to?
PMAL
Posterior cruciate ligament attaches to the lateral surface of the Medial wall
Anterior cruciate ligament attaches to the medial surface of the Lateral wall
Why is the proximal end of the tibia more expanded than the distal end?
Designed for weight-bearing
What are the main features of the proximal shaft of the tibia?
Tibial tuberosity (anteriorly) (insertion of patellar ligament) Soleal line (posteriorly)
What are the main features of the distal end of the tibia?
Medial malleolus (bony protuberance on medial side) Groove for tibialis posterior tendon (posterior side of medial malleolus)
What kind of bone is a sesamoid bone and which bone in the leg is a sesamoid bone?
A bone formed within a muscle tendon
- patella, formed within the tendon of the quadriceps femoris muscle
What shape is the patella, which borders does it have, and how does it attach or articulate to the bones around it?
Triangular shaped
- base is the “flat” proximal end, attached to the quadriceps fem. tendon
- apex points down, attached to patellar ligament attaching it to the tibia
- has a lateral and medial border, both facing inferiorly
- posterior surface (back of it) articulates with the femur
What are the important landmarks of the proximal end of the fibula?
Articular facet for articulation with tibia
Small proximal head
Apex, head, neck of the fibula
Large impression for attachment of biceps femoris
What are the important landmarks of the distal end of the fibula?
- moving lateral to medial
Lateral malleolus
Groove for fibularis longus/brevis muscles
Malleolar fossa
(The medial surface of the lateral malleolus bears a facet of articulation with the talus and there is a triangular area superior to this which fits into the fibular notch on the tibia)
How many rows of tarsal (foot) bones are there and what are they?
- 3
Proximal, Intermediate, Distal
What are the bones of the proximal row of tarsal bones?
Talus (ankle bone)
Calcaneus (heel bone)
What bone is in the intermediate row of tarsal bones?
Navicular bone
What bones are in the distal row of tarsal bones?
Medial cuneiform
Intermediate cuneiform
Lateral cuneiform
Cuboid (most lateral)
Which bones does the Talus articulate with?
It is the most superior bone so articulates with
- tibia
- fibula
projects forward and articulates with
- navicular (intermediate bone on medial side of the foot)
- talus (inferiorly)
Which bones does the Calcaneus articulate with?
Articulates with talus and intermediate tarsal on lateral side (cuboid)
- Talus (superiorly)
- Cuboid (anteriorly)
What bones does the Navicular articulate with?
Talus (posteriorly)
Distal group of tarsals (anteriorly)
What bones does the Cuboid bone articulate with?
Calcaneus (posteriorly)
Lateral cuneiform (anteriorly)
Bases of the two lateral metatarsals
What bones do the three cuneiform bones articulate with?
Each other
Navicular
Medial three metatarsals
How are the bones in the foot divided after the tarsal bones?
5 metatarsals (all have distal head, shaft, proximal base) Each toe then has 3 phalanges (proximal, middle, distal) except for great toe (only 2 phalanges) Each phalanx also consists of a proximal base, shaft and distal head.
What are the additional features of the talus, calcaneus and navicular?
Talus - head/body/neck + trochlea (anterior extension)
Calcaneus - calcaneal tuberosity + sustentaculum tali (medial side)
Navicular - navicular tuberosity
What are the joints of the lower leg?
Knee joint
Proximal/distal tibio-fibular joints
Ankle joint
What are the joints of the foot?
Ankle joint Subtalar joint Midtarsal joint Intertarsal joints Metarso-phalangeal joints Interphalangeal joints
What kind of joints are the knee joint, tibio-fibular joints and the ankle joint?
Knee joint - hinge synovial
Proximal tibio-fibular - plane synovial (range of motion restricted by multitude of ligaments between the two bones)
Distal tibio-fibular - fibrous joint (just a ligament)
Ankle - hinge synovial
What are the two menisci of the knee called?
Medial and lateral menisci
What are the ligaments of the knee?
Medial/lateral (tibial/fibular) collateral ligaments
Anterior/posterior cruciate ligaments
What bones is the knee joint formed between?
Femur
Patella
Tibia
Where do the two cruciate ligaments attach and what do they do?
PMAL
Posterior CL attaches to medial wall of the intercondylar fossa of the femur + the posterior intercondylar plateau of the tibia
Anterior CL attaches to the lateral wall of the intercondylar fossa of the femur + the anterior intercondylar plateau of the tibia
Both work together to stabilise the knee
What is the function of the menisci and what are they connected by?
Allow for greater stability of the knee joint
Attach anteriorly and posteriorly to the intercondylar plateau of the tibia + connected directly by the transverse ligament of the knee
When is the knee most stable and why?
During knee extension
- the femoral condyles are shaped to conserve energy when locked, they have more rounded posterior surfaces (knee flexion) and flatter anterior surfaces (knee extension)
What happens that allows the knee to lock into place when extended and which muscle unlocks it?
There is a small medial rotation of the femur against the fixed tibia which locks the knee in place
- unlocked by the popliteus muscle, attaches to lateral epicondyle and causes lateral femur rotation when it contracts (thus unlocking knee)
What movements occur at the ankle joint?
Dorsiflexion (points upwards)
Plantarflexion (points downwards)
(NO EXTENSION)
What are the ligaments of the ankle?
Lateral ligament complex (anterior/posterior talofibular, calcaneofibular)
Medial (deltoid) ligament of the ankle (tibiocalcaneal)
What are the 3 joints that make up the subtalar joint?
Talo-calcaneal joint
Talo-navicular joint
Calcaneo-cuboid joint
What is the structure of the subtalar joint?
Synovial joint enclosed in a synovial membrane covered by a fibrous membrane
- 3 joints inside
What is the difference between the midtarsal joints and the intertarsal joints?
Mid-tarsal = joints between midtarsal bones and metatarsals
Intertarsal = joints between the tarsal bones (usually synovial except for cuboid-navicular joint which is usually fibrous)
What are the arches of the foot?
Medial longitudinal arch
Lateral longitudinal arch
Transverse metatarsal arch
Where are the arches of the foot found on the foot?
Medial longitudinal - medial side of the foot involving medial edge of navicular, medial cuneiform and 1st metatarsal
Lateral longitudinal - lateral side of the foot involving lateral edge of cuboid, lateral cuneiform and 5th metatarsal
Transverse metatarsal - distal surfaces of the cuboid and all 3 cuneiforms
What do flat-footed people often have and what are the arches of the foot required for?
Poorly developed calf muscles
- arches needed for good efficient movement and flat feet don’t spring off like normal feet
What are the 4 compartments of muscles in the lower leg?
Anterior
Posterior
Lateral
Foot
What are the muscles of the anterior compartment of the leg? (remember not the thigh)
Tibialis anterior (L4,5) Extensor hallucis longus (L5,S1) Extensor digitorum longus (L5,S1)
What are the main actions of the muscles of the anterior compartment of the leg and which nerve innervates them?
Dorsiflexion (ankle)
Great toe extension
Digit extension
- all innervated by the deep peroneal nerve (L4,L5,S1)
What are the muscles of the lateral compartment of the leg?
Peroneus longus
Peroneus brevis
(both also known as fibularis longus/brevis)
- both L5,S1, S2
What are the actions of the muscles of the lateral compartment of the leg and what nerve are they innervated by?
Ankle eversion (away from middle) Can contribute to dorsiflexion - both innervated by superficial peroneal nerve (L5, S1, S2)
Where and what shape are the two extensor retinacula of the foot?
Superior extensor retinaculum - straight band of tendon running laterally just above the two malleoli
Inferior extensor retinaculum - Y-shaped band of tendon starting straight from lateral side of foot and dividing into two attachments on the medial side
What are the muscles of the posterior compartment of the leg?
- superficial
Gastrocnemius
Soleus
Plantaris
- deep Popliteus Flexor digitorum longus Flexor hallicus longus Tibialis posterior
Which muscles come together to form another muscle whose distal tendon becomes the calcaneal tendon (Achilles)?
Gastrocnemius (2 heads) + Soleus (1 head) come together to form the Triceps Surae
- distal tendon of triceps surae becomes the tendocalcaneus (Achilles tendon)
Which muscle is sometimes not present in the human body and what is the percentage of people that don’t have it?
Plantaris muscle
- missing in 5-10% of people
What are “shin splints” and what are they caused by?
Pain along the inner distal 2/3rds of the tibial shaft
- primary cause is repetitive pulling of the tibialis posterior tendon as one pushes off the foot during running.
What are the actions of the muscles of the posterior compartment of the leg and which nerve innervates these muscles?
Ankle plantarflexion and inversion
Flexion of the toes
- innervated by the tibial nerve L4, L5, S1, S2, S3
What nerve are the muscles of the foot supplied by?
Tibial nerve
How many layers of muscles are there in the sole of the foot?
4 (first, second, third, fourth)
Which muscles are in the first layer of muscles in the sole of the foot?
Abductor hallucis longus
Flexor digitorum brevis
Abductor digiti minimi
Which muscles are in the second layer of muscles in the sole of the foot?
Quadratus plantae
Tendons of flexor hallucis longus/flexor digitorum longus
Lumbricals
Which muscles are in the third layer of muscles in the sole of the foot?
Flexor hallucis brevis
Adductor hallucis
Flexor digiti minimi brevis
Which muscles are in the fourth layer of muscles in the sole of the foot?
Plantar interossei
Dorsal interossei
What are the boundaries of the popliteal fossa?
Superolaterally - biceps femoris
Superomedially - semimembranosus
Inferolaterally - lateral head of gastrocnemius
Inferomedially - medial head of gastrocnemius
Posteriorly - skin + fascia
Anteriorly - femur
What does the popliteal fossa contain?
Popliteal artery and vein
Popliteal lymph nodes
Tibial nerve and common peroneal nerve
Short saphenous vein
Explain the path of the arteries of the whole leg.
External iliac artery
- femoral artery (midinguinal point)
- profunda femoris artery, circumflex arteries given off, femoral artery becomes superficial femoral artery
- superficial femoral artery runs through adductor hiatus and winds around to gain access to the back of the knee and becomes the popliteal artery
- genicular (knee) branches given off and popliteal artery continues into distal leg
- popliteal gives off anterior/posterior tibial artery + peroneal (aka fibular) artery
- dorsalis pedis artery and posterior tibial artery supply the dorsum and sole of the foot respectively
Which compartments of the leg do the three branches of the popliteal artery and the two main foot arteries supply?
Anterior tibial artery - supplies anterior compartment, passes over front of ankle and forms dorsalis pedis artery
Posterior tibial artery - supplies posterior compartment
Peroneal (fibular) artery - supplies lateral compartment
Dorsalis pedis artery - formed from anterior tibial artery, supplies dorsum (top of) the foot
Posterior tibial artery - passes behind the medial malleolus into sole of foot through tarsal tunnel, supplies the sole (bottom of) the foot
Where can you palpate the pulses of the dorsalis pedis and posterior tibial artery when they enter the foot?
Dorsalis pedis - palpate just lateral to extensor hallucis longus tendon
Posterior tibial artery - palpate just behind the medial malleolus
What are the superficial veins of the leg?
Dorsal venous arch (dorsum of foot)
Long saphenous vein
Short saphenous vein
Where does the long saphenous vein originate/end and how does it interact with the short saphenous vein and deep venous system?
Arises from medial aspect of dorsal venous arch of the foot.
Runs up the medial aspect of the leg, behind the knee, and empties into the femoral vein at the sapheno-femoral junction.
It anastamoses freely with the short saphenous vein and has connections with the deep system via the perforating veins at valved junctions.
Where does the short saphenous vein originate/end and how does it interact with the long saphenous vein and deep venous system?
Originates from the lateral aspect of the dorsal venous arch.
Runs posterior to lateral malleolus and up the back of the calf to join the deep venous system in the popliteal fossa by draining into the popliteal vein.
Connects freely with long saphenous vein and perforating veins via valved junctions.
What veins are in the deep venous system of the leg? (from foot to groin)
Dorsal digital veins Deep calf veins Posterior/Anterior tibial veins Popliteal vein Perforating veins (above AND below the knee, superficial to deep passing points for blood) Venae comitantes of the profound femoris artery Femoral vein External iliac vein
What are the 5 groups of lymph nodes in the lower limb?
Superficial popliteal nodes Deep popliteal nodes Superficial inguinal nodes Deep inguinal nodes External iliac nodes
Where is the lymphatic drainage in the lower limb?
Runs with the superficial and deep veins
Name the main nerves of the lower limb.
Femoral nerve
Obturator nerve
Sciatic nerve
- sciatic divides posteriorly into tibial nerve and common peroneal nerve
Tibial nerve
- divides into medial and lateral plantar nerves
Common peroneal nerve
- divides into deep and superficial peroneal nerves
Which muscle compartments are supplied by which nerves in the lower limb?
Femoral - anterior compartment of the thigh
Obturator - medial compartment of the thigh
Sciatic “proper” - posterior compartment of the thigh
Tibial - posterior compartment of the leg and intrinsic muscles of the foot (except extensor digitorum brevis - deep peroneal nerve)
Superficial peroneal (fibular) - lateral compartment of the leg
Deep peroneal (fibular) - anterior compartment of the leg
Where does the common peroneal (fibular) nerve run before its division and why is this clinically relevant?
Winds around the neck of the fibula
- can be easily damaged to loss of motor supply to anterior and lateral compartments of the leg
How is the motor segmental supply for the various movements of the lower limb organised?
Hip flexion - L2,3 Hip extension - L4,5 Knee extension - L3,4 Knee flexion - L5, S1 Ankle dorsiflexion - L4,5 Ankle plantarflexion - S1,2
How are the dermatomes of sensory supply distributed in the lower limb/where would you test them?
L2 upper anterior thigh L3 anterior lower thigh and knee L4 medial aspect of calf L5 lateral aspect of calf + great toe/medial foot S1 sole of foot + lateral foot S2 posterior thigh
What are the main nerves involved with peripheral sensory supply of the leg and foot?
Saphenous nerve - stretch of skin along inner border of leg + ankle (accompanies long saphenous vein)
Sural nerve - branch of tibial nerve in the popliteal fossa, supplies lateral aspect of the leg and foot (accompanies short saphenous vein)
Superficial peroneal nerve - most of the dorsum of the foot
Deep peroneal nerve - patch of skin on dorsum of foot at base of great/second toes
Medial/lateral plantar nerves - sole of the foot
How are the muscles of the anterior compartment of the leg tested?
Tibialis anterior - subject inverts foot while examiner grasps forefoot to provide resistance, grasps ankle to stabilise joint
Extensor hallucis longus - subject dorsiflexes the toes while the examiner places the palm of their hand across the toes (including great toe) to resist the movement
Extensor digitorum longus - same as EHL
How are the muscles of the lateral compartment of the leg tested?
Fibularis (peroneus) longus/brevis - subject everts foot while examiner grasps ankle and forefoot to resist movement
How can the superficial muscles of the posterior compartment of the leg be tested? (gastrocnemius + soleus + calcaneal tendon)
Test is the same for all
- Subject stands on toes and muscle bellies + calcaneal tendon can be seen and palpated in the calf area on the posterior side of the ankle
What are the 2 phases and 7 sub-phases of the Gait Cycle? (walking)
Stance phase and swing phase Stance phase - Heel strike (initial contact) - Loading response - Midstance - Terminal stance (heel off) - Preswing Swing phase - Initial and mid-swing - Terminal swing
During which parts of the gait cycle is the body double (both feet in contact with floor) and single supported?
Double supported in heel strike and preswing (start and end phases of stance phase)
Single supported in all other phases
Where is the “push-off” region in the gait cycle?
During terminal stance and preswing phase
- last two sub-phases of stance phase
Most of the leg muscles are not contracted for long in the gait cycle, which muscles are contracted for a while, when are they contracted and why?
Hip abductors (gluteus medius/minimus)
- remain contracted in the entire stance phase for BOTH limbs to maintain stability and line of the pelvis
- this is because the body shifts the weight to the stance leg to shift the centre of gravity and so needs supported while it is weight-bearing
