Limbs Flashcards
What are the veins of the lower limbs and where are they situated?
In the superficial fascia; greater (long) saphenous vein, lesser (short) saphenous vein
What are the fascia of the lower limbs?
Fascia lata, popliteal fascia, crural fascia, plantar fascia
What are the six main nerves of the lower limb?
- Superior gluteal
- Inferior gluteal
- Femoral
- Obturator
Sciatic: - Tibial
- Common fibular (common peroneal): superficial fibular and deep fibular
What does the saphenous vein empty into?
Femoral vein, in deep fascia of the groin (cribriform opening)
What are the 5 longitudinal bundles of the foot connected by?
transverse metatarsal ligaments
How do the intramuscular septa divide the thigh?
Anterior compartment: knee extensors (quadriceps femoris, femoral nerve (L2-L4)
Adductor/medial compartment: obturator nerve (L2-L4)
Posterior compartment: flexors of the knee, but mainly extend the hip joint (hamstrings), sciatic nerve
Which muscles are responsible for inversion of the foot?
Tibialis anterior (anterior compartment) and tibialis posterior (posterior compartment)
Which muscles are responsible for eversion of the foot?
Lateral compartment muscles + extra anterior muscle
How is the lower leg divided?
Anterior compartment: deep fibular (peroneal) nerve
Lateral compartment: superficial fibular (peroneal) nerve
Posterior compartment: tibial nerve (6 muscle: 3 deep (flexion of the digits) and 3 superficial (plantar flexion)
What is the biggest nerve in the body?
Tibial nerve
What is the main arterial supply of the hip joint?
Profunda femoris (from femoral artery which comes from external iliac)
What is the arterial supply to the lower leg?
Popliteal artery divides into: anterior tibial (–> dorsal pedis –> arcuate arteries), posterior tibial and peroneal (fibular) artery
What is the osteology of the hip joint?
Acetabulum: lunate surface + acetabular fossa + acetabular notch + acetabular labrum + transverse acetabular ligament (forms acetabular foramen)
Head of the femur contains fovea –> non-articular
What is the importance of the inter-trochanteric line and the trochanteric fossa?
Inter-trochanteric line: where capsule of hip joint attaches (posteriorly 2/3 down the neck)
Trochanteric fossa: attachment of lateral rotators
Along which axis does rotation of the femur occur?
Mechanical axis (3 degrees off vertical axis); extra: anatomical axis (6 degrees off vertical axis)
What are the angles of declination and inclination?
Declination: angle at which neck extends from the shaft: head is more in front compared to shaft
Inclination: when young start with coxa valga, problematic for support, women have lower angle of inclination –> osteoporosis –> higher risk of neck fracture
What is the blood supply to the head of the femur?
60% from lateral (mostly) and medial femoral circumflex arteries from profunda femoris, obturator artery also gives rise to artery in ligament of head of the femur
What is the difference between intertrochanteric line and crest?
Line: anterior
Crest: posterior
What are the capsular ligaments of the hip joint?
Iliofemoral ligament: strongest
Pubofemoral ligament: from iliopubic eminence
Ischiofemoral ligament: runs posteriorly to attach to greater trochanter
What is the zona orbicularis?
Band that goes around capsule of hip joint
How do patients with cerebral palsy or loss of motor tone tend to arch?
Backwards
What happens in neck fracture of the hip?
Limb is shortened, femur is drawn upwards, medial rotators are weakened because attachment is closer –> lateral rotation, 8/10 in females
Where does the iliopsoas tendon attach?
Lesser trochanter
How do intertrochanteric and cervical fractures of the hip differ in severity?
intertrochanteric: not a problem for arterial supply
Cervical: leaves only obturator artery –> not strong enough –> avascular necrosis of the head of the femur
What happens in hip dislocation?
Shortening of the limb and internal rotation; medial rotators are attached to the ileum and greater trochanter –> go into spasm and stretch; lateral rotators are shortened –> weak; shente’s line is disrupted
What are the gluteal lines on the ileum?
Posterior: gluteus maximus
Anterior: gluteus medius
Inferior: gluteus minimus
What are the ligaments that connect the sacrum to the hip pelvic bones?
Sacrotuberous ligament, sacrospinous ligament (these two form lesser sciatic foramen in between
Where does the gluteus maximus attach and how is it innervated?
gluteal tuberosity (minor) + iliotibial tract (thickening of fascia lata important in extension of the knee; inferior gluteal nerve (L5,S1,S2)
What are the functions of the gluteus medius and minimus, where do they attach and what is their innervation?
Hip abductors; prevent from falling (anti-gravity muscles); attach to greater trochanter; superior gluteal nerve (L4,L5,S1)
Where do the lateral rotators attach to?
Trochanteric fossa; piriformis (exits from greater sciatic notch), superior and inferior gemelli, obturator internus and quadratus femoris
What is trendelenburg’s sign?
Drop of pelvis when lifting the leg opposite to weak gluteus medius
What are the muscles of the anterior compartment of the thigh?
Vastus lateralis, rectus femoris, vastus medialis and sartorius
What are the muscles of the medial compartment of the thigh?
Gracilis, adductor magnus, adductor longus, adductor brevis, pectineus, obturatur externus
What are the muscles of the posterior compartment of the thigh?
Semimembranous, semitendinous, biceps femoris (long head and short head –> only one that allows lateral rotation)
What are the boundaries of the femoral triangle?
Inguinal ligament, sartorius and adductor longus
What are the structures within the femoral triangle?
Y: lymphatics
V: femoral vein
A: femoral artery
N: femoral nerve
What are the boundaries of the popliteal fossa and what does it contain?
Semimembranous, biceps femoris, medial and lateral head of gastrocnemius + plantaris; contains popliteal vessels, tibial nerve + common peroneal nerve on the side + popliteal nodes
What is baker’s cyst?
cyst in the popliteal fossa
What is the structure of the knee joint?
Capsule: absent anteriorly
Synovium and bursae (many)
Ligaments: collateral (tibial and fibular), cruciate (anterior and posterior –> inside capsule but extrasynovial), meniscofemoral, oblique popliteal, arcuate
Nerve supply: femoral, obturator, common peroneal, tibial
Blood supply: genicular arteries
What are the tendons below and above the patella?
Above: quadriceps tendon
Below: patellar tendon to tibial tuberosity
What does anterior dislocation of the tibia mean?
Ruptured anterior cruciate ligament
Where does the patella sit and how do its medial and lateral articulations differ?
Sits in intercondolar groove/notch; medial articulation is smaller than lateral
In which direction does patello-femoral dislocation occur?
Laterally; vastus medialis opposes action of vastus lateralis and vastus intermediate + medial condyle projects less
What is the Q angle and how is it increased?
Angle between quadriceps tendon and patellar tendon at full extension of the knee; increases in: genu valgum, increased femoral anteversion, external tibial torsion, laterally positioned tibial tuberosity, tight lateral retinaculum; female have wider hips and therefore larger Q angle
How do the medial and lateral menisci differ?
Medial is larger than lateral
What is the coronary ligament?
Attaches the meniscus to the outside
Why does the lateral meniscus allow more movement?
Not attached to lateral to lateral collateral ligament, more ball shaped, less likely to be torn
What is a parrot beak tear?
Tear of the horn of the meniscus
Is a meniscus injury likely to be repaired?
No; it is avascular
What is the importance of the popliteus muscle?
Unlocks the knee, attaches to the lateral epicondyle of the femur, goes through the capsule of the knee joint at the back
Which muscles form the pes anserinous and where is it situated?
Gracilis, sartorius, semitendinous; antero-medial surface of the tibia
Where does the biceps femoris attach?
Head of the fibula
Where does the iliotibial tract attach?
lateral side of the tibia
Where does the lateral collateral ligament attach?
Head of the fibula
What is the vastus retinaculum?
tendon of vastus medialis
What is the difference between genu varum and valgum?
Genu varum (bow leg), genu valgum (knock-knee: lateral angulation of leg in relation to thigh)
What are the differences between the anterior and posterior cruciate ligaments?
ACL: taut in extension, most likely to rupture
PCL: 3x the thickness of the anterior one, taut in flexion, runs medially
What is the name of the test that checks ACL and PCL rupture?
Lackman test
What is the unhappy triad?
ACL, medial meniscus tear, medial collateral ligament tear
How do the cruciate ligaments avoid being in the synovial compartment?
Infrapatellar fat pad prevents synovium from going down but not up, synovial membrane wraps around cruciate ligaments; tear –> bleeding –> can be repaired because vascularised unlike menisci
What are the bursae of the knee?
Suprapatellar bursa, popliteus bursa, gastrocnemius bursa –> communicate with the joint
anserine bursa: separates pes anserinus from tibia
What are the two types of knee bursitis?
Pre-patellar burstis: housemaid’s knee
Infra-patellar bursitis: superficial and deep, clergymen’s knee
What can fracture to the tibia lead to?
Fat gets into the blood vessels –> pulmonary embolism
What are the muscles of the anterior compartment of the lower leg and what is its nerve and blood supply?
extensors of the ankle —> dorsiflexion, extensor digitorum, extensor hallucis longus and tibialis anterior + (fibularis tertius); nerve supply: deep fibular nerve, artery: anterior tibial artery
What are the muscles of the lateral compartment of the lower leg and what is its nerve supply?
Fibularis longus and brevis (plantar flexors), nerve supply: superficial fibular nerve
What are the muscles of the posterior compartment of the lower leg and what is its nerve supply?
deep transverse septum divides in two, tibial nerve, posterior tibial artery + fibular artery —> perforating branches for lateral group
superficial muscles act as plantar flexors: lateral and medial gastrocnemius (arises from epicondyles of the femur) + soleus (arises below knee joint) + plantarus (often absent) —> Achille’s tendon (calcaneus)
Deep muscles act as flexors of the digits: flexor digitorum longus, flexor hallucis longus, posterior tibial
How do the superior and inferior tibio-fibular joints differ?
Superior: synovial (not many clinical problems)
Inferior: syndesmosis (stabilise joint)
What are the bones of the foot?
Lateral and medial malleoli, talus, calcaneus, navicular, coneiforms (3 in front of navicular), cuboid (interacts with calcaneus, flat joint), metatarsals, phalanges
Which are the midtarsal joints?
Calcaneo-cuboid and talo-navicular
Where does the fibularis brevis attach in the foot?
Styloid process on metatarsal of little toe
Which toe only has proximal and distal phalanges?
Big toe
What is the function of the sustentaculum tali?
It’s a feature of the calcaneus which allows the interaction with the talus
What are the retinaculae of the foot?
Anteriorly: superior extensor retinaculum and inferior extensor retinaculum (y-shaped)
Laterally: superior and inferior fibular retinaculum
Medially: flexor retinaculum
Where does fibularis longus attach?
Sole of the foot (base of first metatarsal and cuneiform)
What is the order of structures passing through the tarsal tunnel?
Tom: posterior tibial
Dick: flexor digitorum longus
Bloody: posterior tibial artery + tibial nerve
Harry: flexor hallucis longus
How does the stability of the trochlea change in dorsi vs plantar flexion?
Trochlear surface of talus is wider in front –> more stable in dorsiflexion
What are the ligaments of the ankle joint?
Posterior and anterior talofibular ligament (most commonly damaged, calcaneofibular ligament, deltoid ligament (medial)
What are the differences in forced inversion vs eversion injury?
Forced inversion: more common, oblique fracture of the fibula
Forced eversion: less common, neck fracture of the fibular and medial malleoli
Which ligament supports the medial longitudinal arch?
Spring ligament (between talus and navicular bone)
Which one is the most likely dorsal ligament to tear?
Bifurcate ligament
What is the lateral longitudinal arch supported by?
Long and short plantar ligaments
What is the transverse plantar arch supported by?
Fibularis longus tendon
Where do the tibialis anterior and posterior attach?
Anterior: 1st metatarsal and cuneiform on dorsal side
Posterior: navicular tuberosity (sole of the foot)
Which are the cutaneous nerves of the foot?
Dorsal side: sural nerve (via tibial nerve, S1), superficial fibular nerve (majority) + deep fibular nerve (supplies web of 1st and 2nd digits), saphenous nerve (from femoral nerve, L4, supplies medial part of the foot)
Plantar side: sural nerve, lateral and medial plantar, saphenous nerve, tibial nerve (sole of the foot)
What are the lower limb myotomes?
Hip: flexion (L2,3), extension (L4,5)
Knee: extension (L3,4), flexion (L5,S1)
Ankle: extension (L4,5), flexion (S1,2)
Foot: inversion (L4,5), eversion (L5,S1), intrinsic (S2)
Which spinal nerves form the lateral cutaneous nerve of the thigh?
L2,3
What happens if lateral cutaneous femoral nerve gets obstructed?
Miralgia paraesthetica
What is the sciatic nerve composed of?
Common peroneal (L4-S2) + tibial (L4-S3)
Which muscle plays a role in inflamed sciatic nerve?
Piriformis muscle
What are the bones of the pectoral gridle?
Manubrium sterni, clavicle and scapula
What is the structure of the clavicle?
Acromial end: acromial facet, trapezoid line, conoid tubercle
Posteriorly: subclavian groove (attachment for subclavius)
Sternal end: sternal facet
Long bone, no medullary cavity, trabecular (spongy) bone surrounded by compact shell
First bone to begin ossification but last one to finish
What is the sterno-clavicular joint and its ligaments?
Synovial, anatomically a saddle, functionally a ball and socket; anterior sterno-clavicular ligament + costo-clavicular ligament + interclavicular ligament
What is cleidocranial dysostosis?
absent or underdeveloped clavicle
What is the structure of the scapula?
Superior (suprascapular notch –> important conduit for suprascapular nerve), lateral and medial border
Posteriorly: supraspinous fossa, spine (leads to acromion), infraspinous fossa
Anteriorly: subscapular fossa, coracoid process
Laterally: glenoid cavity
What is the structure of the acromio-clavicular joint?
Acromio-clavicular ligament
Coraco-clavicular ligament: trapezoid ligament + conoid ligament
Incomplete articular disc, no muscles connect the articulating bones
What is the function of the trapezius on the scapula?
elevates, retracts and depresses scapula
What is the function of the latissimus dorsi on the humerus?
extends, adducts and medially rotates the humerus
What is the function of the serratus anterior?
protracts and rotates the scapula, holds it against thoracic wall, assists in respiration, paralysis –> winged scapula
What is the function of the pectoralis major?
Adducts, flexes and medially rotates the humerus
Where does the pectoralis minor attach?
Coracoid process of the scapula
What are the ligaments in the gleno-humeral joint?
Coraco-acromial ligament, coraco-humeral ligament, gleno-humeral ligaments (superior, middle and inferior)
What is the function of the deltoid and what are its origins and insertion?
Spinal (posterior) part: extends and laterally rotates the arm
Acromial (middle) part: abducts the arm
Clavicular (anterior) part: flexes and medially rotates the arm
Insertion: deltoid tuberosity on the humerus
Which are the posterior scapula muscles that take part in the GH joint?
supraspinatus: initiates abduction of the arm
infraspinatus: laterally rotates the arm
teres major: medially rotates the arm
teres minor: laterally rotates the arm
Which are the anterior scapula muscles that take part in the GH joint?
Subscapularis: medially rotates the arm
What are the rotator cuff muscles and the coraco-acromial arch?
Rotator cuff muscles: teres minor, infraspinatus, supraspinatus, subscapularis
Coraco-acromial arch: acromion, coraco-acromial ligament, coracoid process
Is the biceps tendon within the capsule and the synovium and why?
intracapsular but extrasynovial; escapes the inside of the joint through the rotator cuff interval between the supraspinatus and subscapularis tendons
Where does the biceps tendon arise from?
supra-glenoid tubercle
Which one is the only bursa that communicates with the GH joint?
Subscapular bursa
Which are the muscles of the arm?
Anterior compartment: biceps brachii, brachialis and coracobrachialis
Posterior compartment: triceps brachii
What is the structure of the humerus?
Anteriorly: greater and lesser tubercles, intertubercular sulcus (bicipital groove), deltoid tuberosity, lateral supra-epicondylar ridge, radial fossa, coronoid fossa, capitulum (lateral), trochlea, medial epicondyle
Posteriorly: greater tubercle, radial groove, medial supra-epicondylar ridge, olecranon fossa, medial and lateral epicondyles, trochlea
Where do the rotator cuff muscles attach?
Greater tubercle: teres minor, infraspinatus, supraspinatus
Lesser tubercle: subscapularis
What are the functions of the radial fossa, coronoid fossa, capitulum and trochlea?
Capitulum and radial fossa: attach to radius
Trochlea and coronoid fossa: attachment to ulna and allow space for coronoid process on ulna
What are the joints of the elbow joint?
Radio-capitular: most forces go through here
Humero-ulnar joint
Superior radio-ulnar joint
What are the ligaments of the elbow joint?
Anular ligament: wraps around the head of the radius, attaches to either side of the ulna; supports superior radio-ulnar joint (at radial notch of ulna)
Radial collateral ligament: blends into the anular ligament, doesn’t attach to radius –> allows for movement
Ulnar collateral ligament: three ligaments together, arise from medial epicondyle of the humerus, anterior and transverse attach just underneath the coranoid process, posterior to base of olecranon
What are the origin, insertion and functions of the biceps brachii?
Long head: supraglenoid tubercle
Short head: coracoid process
Insertion: radial tuberosity, bicipital aponeurosis
Functions: supination, flexion, shoulder stabilisation
What is the function of the coracobrachialis?
adducts, flexes, stabilises shoulder
What is the function of the brachialis?
Main flexor of the forearm
What is the innervation to the anterior compartment of the arm?
Musculocutaneous nerve (C5-C7) –> becomes lateral cutaneous nerve of the forearm
What are the origin, insertion and functions of the triceps brachii?
Long head: infraglenoid tubercle of the scapula
Medial head: medial surface of the shaft of the humerus, medial to spiral groove
Lateral head: lateral to spiral groove
Insertion: olecranon process of ulna
Function: main extensor of the forearm, long head: extension and adduction of the arm
What are the bursae of the elbow?
Subtendinous bursa, infratendinous bursa, olecranon bursa
What is the innervation of the posterior compartment of the arm?
Radial nerve (C5-8, T1): innervates posterior extensor compartment of the arm (C7-C8) and forearm
Which humeral dislocation is most common?
Anterio-inferior: pec major and subscapularis medially rotate and bring down
What are the four main humeral fractures?
Surgical neck fracture: potential damage to axillary nerve and posterior circumflex humeral artery
Midshaft fracture: potential damage to radial nerve and profunda brachii artery
Supracondylar: potential damage to brachial artery and median nerve
Medial epicondyle: potential damage to ulnar nerve and ulnar collateral artery
What is the anconeus muscle?
Lateral epicondyle to olecranon; assists triceps in forearm extension
Which muscles perform pronation?
Pronator qaudratus and pronator teres, extra help from flexor carpi radialis and palmaris longus
Which muscles perform supination?
supinator (lateral epicondyle, wraps around radius) and biceps brachii (attaches to radial tuberosity)
What is the distal radio-ulnar joint?
head of ulna sits in ulnar notch of radius + supporting articular disc
What are the contents of the cubital fossa?
Median nerve, brachial artery and vein, biceps tendon; outline: median cubital and cephalic vein
Which are the most clinically significant bursae of the elbow joint?
Olecranon bursae
Which tendon most commonly inflames to produce the tennis elbow?
extensor carpi radialis brevis
What are the characteristics of the posterior forearm compartment?
extensor-supinator muscles, common insertion on lateral epicondyle of humerus, superficial + deep layer muscles, key muscles that extend the hand and digits, muscle innervation from radial nerve, posterior interosseous artery supplies superficial and deep extensors
What are the superficial muscles of the posterior extensor compartment of the forearm?
- Extensor digitorum
- Extensor digiti minimi
- Extensor carpi ulnaris
What are the deep muscles of the posterior extensor compartment of the forearm?
- Supinator
- Abductor pollicis longus
- Extensor pollicis brevis
- Extensor pollicis longus
- Extensor indicis
What is the importance of the anatomical snuff box?
Passage of radial artery and superficial branch of radial nerve
What are the muscles in the mobile wad?
- Brachoradialis
- Extensor carpi radialis longus
- Extensor carpi radialis brevis
What are the arteries of the forearm anterior compartment?
Radial and ulnar artery + anterior interosseous artery
What is the innervation to the anterior compartment of the forearm?
Median nerve + some ulnar nerve
Which are the forearm flexors?
Superficial layer 1. Pronator teres 2. Flexor carpi radialis 3. Palmaris longus 4. Flexor carpi ulnaris 5. Flexor digitorum superficialis Deep layer 1. Flexor digitorum profundus 2. Flexor pollicis longus 3. Pronator quadratus
Where does the median nerve lie?
between flexor carpi radialis and palmaris longus
What are the carpal tunnel and guyon canal?
Carpal tunnel: bounded by carpal bones and flexor retinaculum, contains median nerve, flexor digitorum profundus and superficialis
Guyon canal: between pisiform and hook of hamate, contains the ulnar nerve
What is the structure of the wrist joint?
Doesn’t involve the ulna, radio-carpal joint; can extend and adduct more (abduction is limited by radial styloid process); scaphoid, lunate and triquetrum form articular surface
Which muscles function in extension adduction, abduction, flexion adduction, abduction?
Extension adduction: extensor carpi ulnaris
Extension abduction: extensor carpi radialis brevis and longus
Flexion adduction: flexor carpi ulnaris
Flexion abduction: flexor carpi radialis
What are the common fractures of the wrist?
Distal end of radius (Colle’s fracture –> dinner fork deformity), fracture of ulnar styloid, fracture of the scaphoid (radial artery might be ruptured)
What are the 8 carpal bones?
schaphoid, lunate, triquetrum, pisiform, hamate, capitate, trapezoid, trapezium
What are the five compartments for the intrinsic muscles of the hand?
Thenar, adductor, central, hypothenar and interosseous
What are the thenar muscles?
Opponens pollicis, abductor pollicis brevis, flexor pollicis brevis
What are the hypothenar muscles?
Abductor digiti minimi, flexor digiti minimi brevis, opponens digiti minimi
What forms the thenar eminence?
extensor pollicis brevis + 3 short thenar muscles; innervated by recurrent branch of median nerve
What is the innervation to the adductor pollicis?
ulnar nerve
What is the function of the lumbricals?
1st-4th: flex the digits at MCP and extend at IP joints –> writing position
What is the function of the dorsal and palmar interossei?
Dorsal: 1-4, abducts digits 2-4
Palmar: 1-3, adducts 2,4,5 digits
How does the radial nerve innervate the intrinsic muscles?
Sensory nerves to the dorsal aspect
What is the hand vasculature?
ulnar and radial arteries –> superficial and deep palmar arches through anastomoses
What is skier’s thumb?
injury to the ulnar collateral ligament of the metacarpophalangeal joint of the thumb
What is mallet finger?
tear of the tendon that straightens the end joint of the finger
What is trigger finger?
finger or thumb clicks or locks as it is bent towards the palm (increased risk in type II diabetes)
What is Dupuytren’s contracture?
disease of palmar fascia —> shortening, thickening and fibrosis
What are the myotomes of the upper limbs?
humeral abduction: C5 elbow flexion: C5/6 elbox extension: C6-8 finger flexion: C7/8 finger adduction and abduction: T1
Where does the brachial plexus pass?
Cervico-axillary canal, into axillary fossa, under pec minor and on top of subscapularis
What does the dorsal scapular nerve innervate?
C4, C5; rhomboids + levator scapulae sometimes
What does the long thoracic nerve innervate?
C5,6,7; serratus anterior; damage –> winged scapula
What does the suprascapular nerve innervate?
C4,5,6; supra and infra-spinatus and GH joint
What does the lateral pectoral nerve innervate?
C5,6,7; pec major and pec minor via communicating branches to medial pectoral
What does the medial pectoral nerve innervate?
C8,T1; innervates pec minor and major
What does the axillary nerve innervate?
C5,6: innervates teres minor, deltoid, GH, skin over inferior deltoid
What does the musculocutaneous nerve innervate?
C5-7; anterior compartment of arm, continues as lateral cutaneous nerve
What does the median nerve innervate?
C6,7,8, T1: muscles of anterior forearm, first two lumbricals and thenar eminence sensory to medial palm and first 3 digits
What does the ulnar nerve innervate?
C8, T1: flexor carpi ulnaris and flexor digitorum profundis + multiples muscles of the hand, sensory to lateral palm
What does the radial nerve innervate?
C5-8, T1: posterior extensor compartment of the arm and forearm
What happens if there’s damage of the radial nerve?
Saturday night palsy (honeymoon palsy), wrist drop, wartenberg syndrome
