Lower Extremity Flashcards
What are the functions of the lower extremity?
Weight bearing, locomotion, maintenance of equilibrium
what is the appendicular skeleton of the lower extremity?
Lower extremity attaches to the axia skelton via the pevlic girdle
What makes up the pevlis?
Innomiate
Sacrum
coccyx
What are the sex differences with pevlic girdle?
subpubic angle (angle formed by pubic symphysis) in men is much smaller 70° than women, 90-100°
this makes the females have greater sacral width and great flare of iliac bones
What are implications of a female plevis?
brings proximal aspect of femur more laterally on body, knees more likely to be knock-kneed
What makes up the innominate?
ilium
ischium (inferior posterior)
pubic (inferior anterior)
What is number 9?
Iliac Crest
What is the iliac crest?
Att:
located superiorly, on the lateral side of the ilium.
Att: ilacus, latissiumus dorsi, tensor fasciae latae
Where is the anterior interior iliac spine?
Att:
just inferior to iliac crest on anterior side of ilium.
rectus femoris m and iliofemoral ligament
what is 1?
Att:
Posterior superior iliac spine
gluteus maximus
what is 3?
Function?
Greater sciatic notch
transmits piriformis m, superior and inferior gluteal A and V, internal pudendal a and v, sciatic, pudendal, and Sup and inf. gluteal n.
Where is the gluteal surface?
att:
body and lateral side of the ilium
att: gluteus maximum, medium, minimum
What is number 1?
attachments:
iliac fossa or wing of ilium
iliacus m.
What is number 6 and 7?
What does this include?
Sacropelvic surface
1) iliac tuberosity (7)
2) Articular surface (6)
What are the attachments of the illiac tuberosity?
dorsal sacroiliac, interossesous sacroiliac, iliolumbar lig, quadratus lumborum
What is 5 and anteriorly to 5?
Public crest and pubic tubercle
What attaches to public crest?
rectus abdominis
adductor longus m.
what attaches to pubic tubercle?
inguinal ligament
What is number 2?
What does it consist of?
Superior pubic ramus
1) pecten public (pectineal line)
2) obturator groove
3) iliopubic eminence
Superior pubic ramus attachments
pectineus, obturator internus, obturator externus, pubofemoral ligament
Pectineal line attachments
conjoined tendon, lacunar and pectineal ligaments
obturator groove location
Groove on superioer part of pubic bone in obturator foramen
Transmist obturator n, a, v
Iliopubic eminence location
att
loc: border between ilium and pubic
att: obturator internus m.
What is 4?
Function?
Lesser sciatic notch
transmists obturator internus tendon, pudendal n., interal pudendal a and v
What is number 5?
Att
Ischial Spine
at: supraspinous ligament, superior gemellus m.
Where is the ischial ramus?
located just posteriorly to the pubis on border of obturator foramen. Anerior connects with pubis
attachemnts of anterior ischial ramus surface
obturator externus
adductor magnus m.
attachments to posterior surface of ischial ramus
obturator internus m.
What is 6?
Attachments
Ischial tuberosity
sacrotuberous ligament, gamellus inferior, adductor magnus, semimembranosus, semitendinosus, biceps femoris, quadratus femoris m.
What is the hole in the inominate?
Func:
att:
Obturator foramen
function; transmists obturator n, a, v
att: obturator internus and externus m.
Development of inominate bone
Ischiopubic ramus fuses at 7-8 years
full fushion at 15-25 years
What is the bottom line represent?
sacrotuberous ligament
conncets posterior of superior iliac spine and lateral margin of sacrum to ischial tuberosity.
what does top line represent?
sacrospinous ligament
ischial spine to lateral margin of sacrum
What are the ligament stabalizers of the SI joint?
sacrospinous lig.
sacrotuberous lig.
What do the sacrospinous and sacrotuberous ligaments have in common?
both are stabalizers of SI joint of pelvis.
Both attach to lateral aspect of the sacrum
What boundaries make up the sciatic foramina?
Anterior sacroiliac lig.
sacrotuberous lig.
sacrospinous lig
greater sciatic notch
what boundaries make up lesser sciatic foramen?
spine of ischium
sacrotuberous lig.
tuberosity of ischium
What are the contents of the greater sciatic foramen?
piriformis, sciatic n., posterior femoral cutaneous nerve., superior gluteal vessels, inferior gluteal vessels, internal pudendal vessels, pudendal n.
What are the contents of the lesser sciatic foramina?
obturatory internus
internal pudendeal vessels
pudendal n.
Where does the head of the femur reside?
in the acetabulum
What is the acetabulum?
holds the head of the femur to make the hip joint.
projects lateral, anterior and inferior
Which direction does the head of the femur project?
medially, anteriorly, superiorly.
What does the acetabulum surface consist of?
lunate surface (incomplete) that is closed off by transver acetablar ligament
What is the sacroiliac joint?
class
movement
joint between articular surface of ilium and the articular surface of sacrum.
synovial place (gliding)
mv: slight contribution towards pelvid movement
What is pubic symphysis joint?
Class
joint connecting the two pubis together
symphysis joint
What is the joint at the hip?
Synovial ball and socket.
Mvmt: FE, Abduction, adduction, medial and lateral rotation, and circumduction
Flexion
What is this?
Extension
what is this?
Lateral ritation
What is this?
Medial rotation
What is this?
Abduction
What is this?
Adduction
What is circumduction?
combination of all movements FE, Rotation, AA
Genu Valgum
Medical tern for knock-knee
Genu varum
medical term for bow-legged
Normal angle of inclication for hip joint
What is angle of inclination?
125
formed between lines of by head and neck of femur with shaft of femur
Coxa Valga
Angle of inclination greater than 125°
leads to genu varum (blowed legs)
What are the consequences of coxa valga?
lengthens lower extremity
increases load on femoral head, decreases load on femoral neck.
Coxa vera
angle of inclination below 125°
leads to genu valgum knocked knees
Consequences of coxa vara
shortens lower extremity
reduces load on femoral head, increases load on femoral neck
risk of osteoarthritis on head, and risk of frature in neck
Q Angle men vs women
Quadriceps angle
angle between shaft of femur and tibia
men 12°
women 17°
Angle of torsion
angle of axis of femoral head in relation to the axis of femoral condyle at the knee. Normal is 8-15°
Anteversion
proximal aspect of femur is rotated more anteriorly in angle of torsion
retroversion
decreased angle of torsion of femur
Twisted posteriorly, all the way down to 0°
Anteversion
increased angle of torsion
pigeon toed
increased angle on femur, foot is not longer able to keep this rotation and keep good contact in acetabulum, therefore lower extremity must rotate.
Retroversion
decreased angle of torsion
duck feet
to increase maximal contact, lower extremity must rotate outward
HIp Joint
classification
movement
synovial ball and socket, wrapped in firbour joint capsule.
F/E, AA, medial and lateral rotation, circumduction
what is the fibrous joint capsule?
attaches from margin of acetabulum to the neck, intertrocahntic line and interochanteric crest of the femur
What is this?
attachments:
function:
iliofemoral ligament
anterior inferior iliac spine to interochanteric line of femur
limits extension of femur
What are the capsular ligaments?
pubofemoral
ischiofemoral
iliofemoral
What is the lower line pointing towards?
ischiofemoral ligament
from ischitium posterior to the greater trochanter and iliofemoral ligament
assist iliofemoral in limiting extension of femur
What is the lower line pointing towards?
Pubofemoral ligament
from iliopublic eminence and superior pubic ramus to the fibrous capsule
limits abduction of femur
what do the capsular ligaments do?
limit the extension of the hip
What is the ligament of the femoral head?
goes from fovea from femoral head to acetbular notch
not supporting role of joint capsule
aid in weight bearing
Hip Dislocation
posterior dislocation 9:1 anterior
interferes with ischiofemoral ligamen and ligamentum teres.
could impinge or break sciatic nerve
Fascia Lata
Deep fascia fo the thigh, wraps around entire circumference.
extension of the inguinal ligament outside the fascia lata
What are the subtypes of fascia lata?
Iliotubial tract
lateral intermuscular septum
medial intermuscular septum
What is the iliotibial tract?
fascia lata that extens from tesnor fascia lata and gluteus maximum to the proximal lateral tibia
what is the lateral intermuscular septum?
attaches to the linea aspera and separates the anterior and posterior compartmetns of the thigh
What is the left red line?
right red line?
lateral intermusclar seputm in the thigh
medial intermuscular septum
Femoral Sheath
distal continuation of ilacus fascia and trasversalis fascia inferior to inguinal ligament
contains femoral a,v, canal
gluteus maximum
attach
for erector spinae, sacrum, acrotuberous ligament and gluteal surface of ilium to gluteal tuberosity of the femur and iliotibial tract.
What are the actions of the gluteus maximum?
extends and laterally rotates thigh
tenses fascia lata
What is the innervation of gluteus maximus?
inferior gluteal nerve
Gluteus medius
lies anteriorly and superiorly to gluteus maximus
from external iliac surface to the lateral aspect of great trochanter
gluteus medius actions
abducts and medially rotates thigh
keeps pevlis upright when lifting one leg
innervation of gluteus medius
superior gluteal nerve
Gluteus minimus
deepest of the gluteus muscles
from the external iliac surface to the anterolateral aspect of the greater trochanter
gluteus minimus actions
abducts and medially rotates thigh
keeps pelvis upright with lifiing one leg
innervation of gluteus minimus
superior gluteal nerve
What are the major differences between gluteal maximus, minimus, and medius?
Max: most superficial, extends and laterally rorates thigh, inferior gluteal nerve
Med: intermediate; abducts and medially rotates thigh, super GN
Min: deep, abducts and medially rotates thigh, superior GN
Trendelenburg gait
weakened of ineffective gluteus medius or minimus
with small weakness, pelvis on other side (ipsilateral) sags.
in Duchenne’s limp, overcompesation by other pevlis and it tilts upwards
What are the lateral rotators muscles of the hip?
piriformis
super gemellus
obturator internus
inferior gemellus
quadratus femoris
quadratus femoris
Piriformis
attach
for the anterolateral sacrum to the greater trochanter of femur
Piriformis
action:
abducts and laterally rotates hip
innervation of piriformis
lumosacral plexus
superior gemellus
ischial spine to obturator internus tendon
Gemellus action
laterally rotates thigh
gemellus innervation
sacral plexus
Gemellus inferior
ischital tuberosity to obturator internus tendon
Obturator internus
inbetween gemellus superior and inferior
anterolateral wall of pelvis, obturator foramen and obturator membrane –> medial surface of great trochanter
which three muscles merge on obturator internus tendon?
gemellus superior, gemellus inferior, and obturator internus
Quadratus femoris
from ischial tuberosity to quadrate tubercle of the femur.
most inferior of the lateral rotators
quatratus femoris action
laterally rotates thigh
innervation of quadratus femoris?
sacral plexus
Obturator externus
most anterior lateral rotating muscle
from exteral aspect of rim of obturator foramen to trochanteric fossa.
inferior to gemallus
what is obturator externus innervated with?
obturator nerve
Where are the external rotator muscles located?
posteriorly
Where are the internal muscles located?
anteriorly
Anterior compartment of the thigh
innevated by femoral nerve
flexors of hip, extensors of knee
Posterior compartments of thigh
innervated by sciatic nerve
extensors of hip, flexors of knee
medial compartment of thigh
obturator nerve territory
adductors of thigh
Anterior compartment of thigh muscles
rectus femoris
vastus medialis
vastus lateralis
vastus intermedius
sartorius
action of anterior muscles of thigh
flex hip, extend knee
anterior of thigh innervation and blood supply
femoral nerve and artery
Medial compartment of thigh muscles
adductor longus
adductor brevis
adductor magnus
gracilis
action of medial compartment of thigh
adduct and medially rotate thigh
medial compartment innervation and blood supply
obturator n and a
Adductor Magnus
dual innervation
Adductor part innervated by obturator n
hamstring part innervated by sciatic (tibial) n
Posterior compartment of thigh
hamstring
biceps femoris, long and short heads
semimembranosus
semitendinosus
function of posterior compartment of thigh
extend hip and flex knee
innervation and blood supply of posterior compartment of thigh
tibial dividsion of sciatic n.
profunda femoris a.
Lateral aspect of thigh
Iliotibial tract (or band)
no lateral compartment
What is the iliotibial band?
thickening of fascia lata
gluteus maximum and tensor fasciae latae attach
Femoral Nerve Course
saphenous branch descends through femoral triangle, enter adductor canal
Deep to inguinal ligament
What vertebraes does the femoral nerve correspond to?
L2-4
Obturator nerve course
emergens inferior to pubic ramus
anterior branch is superior to adductor brevis, inferior to adductor longus
Posterior inferior to adductor brevis
where does obturator nerve originate?
L2-4
Sciatic nerve course
on posterior aspect of thigh, Between great trochanter and ischial tuberosity. Then it splits and common fibular innervates biceps short head, and tibial innervates long head
Femoral triangle border
inguinal ligament
adductor longus
sartorius
Contents of femoral triangle
Femoral n, a, v
Artery supply of femur for children for adults
Children: obturator a
adults: primarily becomes circumflex femoral a.
Avascular necrosis
reduced femoral blood supply due to disloaction or fracture
Joints of the knee
tibiofemoral
patellofemoral
superior (proximal) tibiofibular
Femoral condyle morphology
tiba externally and laterally rotates as knee reachs full extension due to larger medial femoryl condyle
incrase stability to knee
Knee joint
class
movement
synovial bi-condylar hinge (complex
E/F, medial lateral rotation
Superior tibiofibular joint
synovial plane (gliding)
Popliteus muscle
posteior to knee
from lateral femoral condyle to sleal line of the tibia
popliteus function/action
unlocks knee during flexion
Which is bigger lateral or medial facet on patella?
Lateral
Bursae
extension of the joint capsule at the knee
Fibrous capsule of knee
margins of femoral condyles to margins of tibial condyles
Cruciate ligamments in the knee
Anterior cruciate
posterior cruciate
Anterior cruciate ligament
in knee joint
medial part of anterior intercondylar tibia to posterior part of the intercondylar fossa of femur.
More lateral than PCL
Anterior to PCL
Posterior cruciate ligament
from posterior intercondylar area of tibia to lateral surface of the intercondylar fossa
posterior and medial to ACL
What are the functions of ACL and PCL?
ACL: prevents anterior displacement of tibia and posterior dispalcement of femur. prevents hyperextension
PCL: prevents posterior displacement of tibia; prevent anterior dispacement of femur
Tibial (medial) collateral
Knee ligament on medial side
connects medial epicondyle of femur to medial condyle and shaft of tibia.
Function: prevents abduction of tibia
injured by glow to outside of knee
Fibular (lateral) collateral
resists bow legged stress genu varus
ligament on lateral side connecting lateral epicondyle of femur to head of fibula
Injured by inside blow to the knee
in genu valgum, which is stressed MCL or LCL?
MCL
what is stressed in genu varum, MCL or LCL?
LCL
Menisci
fibrocarilaginous shock absorbers in the knee, decrease friction, increase contact area
medial and lateral
medial meniscus
attaches to anterior and posterior regions of intercondylar area of tibia and fibrous capsule at TCL
larger menisc
forms C
Lateral menisci
attaches anterior and posterior regions of intercondylar area of tibia
smaller, forms O
Meniscectomy
removal of mensicus, old procedure.
increased wear of articular cartilage
increased risk of degenerative joint disease
total knee replacemnt necessary
Mensici blood supply
greatest in peripheral 1/3 and least in central
crural interosseous membrane
spans margins of tibia and fibula
Ankle joint
talocrurcal
synovial hinge
allows for dorsiflexion/plantar flexion movement
joints of foot
talocalcaneal joint
tarsometatarsal joints
mentatarsophalangeal joint
interphalangeal joints
Characterisics of inter phalangeal joints
head of one phalanx to base of distal one
syovial hing
flexion and extension
Crural Fascia
continuous with fascia lata, but covers crural leg
also forms comparments
thickening forms retinacula
Talocrural fascia
superior extensor
inferior extensor
superior peroneal
inferior peroneal
what muscles provide knee support
sartorius, gracilis, semitendinosus
interphalangeal joint
head of on phalanx to base of distal one
hinge
flexion and extension
superior extensor retinacula
distal tibia to distal fibula
inferior extensor retinaculum
extens from calcaneus to the navicular and medial malleolus
superior peroneal retinaculum
lateral malleolus to calcaneus
inferior peroneal retinaculum
inferior extensor retinaculum to calcaneus
anterior crural intermuscular septum
anterior fibular border
separates anterior and lateral leg comparments
posterior crural inter muscular septum
attaches to posterior tibia border
separates lateral and posterior comparments
deep transverse fascia
separates superficial and deep posterior compartment of muscles
compartment syndrome
trauma, overuse, hemorrhage, infection produce edema or hemmorage within the comparments
can be anterior or posteior
increased pressure compresses nerves and vessles and compromises leg function
perform a fasciotomy
fasciotomy
incision in the skin, fascia removed, skin grafted
anterior vs. posterior compartment syndrome
ant: most common, weakness if dorsiflex or toe extension and parasthesia over the dorsum of the foot.
Deep posterior: weakness in two flexion and inversion, parastehsias in plantar aspects
superficial posterior: weakness in plantarflexion, dorsolateral hypoesthesia
common fibular nerve
deep to proximal fibularis longus
curves lateral to neck of fibula
splits deep to fibularis longus
superficial fibular nerve course
begins at bifrication of common fibular n.
supplies fibularis longus and brevis
emerges as cuteansous branch around ankle
Deep fibular n. course
approaches interosseus membrane
between tibials ant and extensor hallucis longus
descends with anterior tibial a.
tibial n. course
joins with popliteal a. and v.
continues on with the posterior tibial a.
gives off sural n.
splits into lateral and medial plantar nn in foot.
tarsal tunnel
posterior tibia a and v
tibial n.
tibialis posterior
flexor digitorum longus
flexor hallucis longus
tarsal tunnel syndrome
entrapment and compression of tibial nerve.
edema and tightness in ankle involveing synovial sheaths
pain, tingling, numbness in plantar aspect, weaknessof intrinsic foot muscles
Ankel inversion sprain
90% of these are sprains.
rolling plam of foot inward
ankle sprain grade 1
ligament stretch, macroscopic tearing
little swelling and tendernes
no ligamentous laxity
little to no loss of function
ankle sprain grade 2
partial tear of ligament
mod. pain and welling
mild to moderate ligamentous laxity
moderate loss of function
grade III ankle sprain
complete ligament rupture and/or failure of load carrying capacity
severe swelling, pain, and hemorrhage
considerable ligamentous laxity
total loss of function
supporting strucutres of medial longitudinal arch
plantar aponeurosis, plantar calcaneovicular lig.
support for transverse arch
fibularis longus
plantar ligaments
short plantar (plantar calcaneocuboid) deep to long plantar
plantar calcaneonavicular (spring)
where is the thickest skin on the body?
overlying the heep
plantar aponeurosis
the fibrous structure on bottomo fthe foot. from proximal calcaneous to each of the five toes
plantar fasciitis
2 million americans
10% experience it
inflammation caused by overstrech or overuse
pain with palpation of attachment
most affects men 40-70yo
no heel spurrs needed
superficial inguinal lymph nodes
cenetereda round pelvic area on surface fo skin
drain from superficial structures inferior to the umbilicus except for the anus and glans of the clitoris or penis
deep inguinal lymph nodes
deep in pelvis
drain deep tissue of the thigh, the popliteal notes, and the superficial inguinal nodes
popliteal lymph nodes
dreain the knee and deep deep tissues of the leg and foot.
condisdered deep nodes
lymph nodes of lower extremities
superifical inguinal
deep inguinal
popliteal
what do deep inguinal lyph nodes give rise to
lympthatic trunks
what doe lympathit trunks give rise to…
cisterna chyli
