Lower Extremity final quiz Flashcards
Lower Limb Specialization
Support Body Weight Locomote Maintain Equilibrium/Balance
Connections To Body
Connected by Pelvic girdle (the bony ring formed by the hip bones and the sacrum) to the trunk
Origin of muscles that act on the lower limb
some arise from the pelvic girdle, and some arise from the vertebral column (it is customary when describing the lower limbs to include regions that are transitional between the trunk and the lower limbs, such as the gluteal region)
4 Parts of the lower limb
Hip, Thigh, Leg, and Foot
Hip
lateral prominence of the pelvis from the illiac crest to the thigh containing the hip bone connects the skeleton of the lower limb to the vertebral column
Thigh
between the hip and knee contains the femur which connects the hip and knee Patella covers the anterior surface of the knee
Leg
Between the knee and ankle Contains the Tibia and Fibula Connects the Knee and Ankle
Foot
Distal part containing: Tarsus Metatarsus Phalanges
Bones of the Lower Limb
Pelvic Girdle, 2 hip bones joined at the pubic symphysis and the sacrum Pelvic girdle + sacrum = bony pelvis the skeleton of the free limb is attached to the pelvic girdle
Transfer of weight through lower limb part 1
Body weight is transferred from the vertebral column to the pelvic girdle –> through the hip –> femur Femur is directed inferomedially through the thigh toward the knee (distal end of femur articulates with patella and tibia of leg (fibula d/n articulate with femur)
Transfer of weight through lower limb part 2
Weight is transferred from the knee to the ankle by the Tibia Fibula is firmly bound to the tibia inferiorly (forms an important part of the ankle joint) the Tarsal and Metatarsal bones of the foot form a flexible but stable support for the body
ilium
largest part of the hip bone superior part of acetabulum
ala
(L. Wing) the ileum has a wing like posterolateral surface that provides attachment for the gluteal muscles laterally and the iliacus muscle medially
ASIS
Anteriorly the ilium has an anterior superior iliac spine
AIIS
Inferiorly, the ilium has an anterior inferior iliac spine.
iliac crest
asis to posterior superior iliac spine
Iliac Tubercle
5-6 cm posterior to ASIS
ischial tuberosity
the bone you sit on
anatomical position of hip bone
acetabulum faces laterally and slightly anteriorly Anterior Superior Iliac Spine and anterosuperior aspect of the pubis lie in the same vertical plane Ischial spine and superior end of the pubic symphysis are approximately in the same horizontal plane symphyseal surface is vertical and parallel to the median plane internal acpect of the body of the pubis faces superiorly forming a floor for the bladder Acetabulum faces inferolaterally acetabular notch directed inferiorly obturator foramen lies inferomedial to the acetabulum tip of coccyx is typically on a level with the superior half of the body of the pubis
AP Compression Injury
anteroposterior compression of the hip bones is a common way to fracture the pubic rami
lateral compression of pelvis
or falling from a roof and landing on your feet. Often results in a fracture of the acetabula.
Avulsion fracture of Hip Bone
may occur in adolescents and young adults during sports that require sudden acceleration or deceleration these fractures occur at apophyses (bony projections that lack secondary ossification centers) occur where muscles are attached anterior superior and inferior iliac spines, ischial tuberosities, ischiopubic rami
Femur head and neck angle
115-140 averaging 126 degrees. widest at birth. Less in women b/c wider pelvis.
femoral neck fractures
common in older people even just as a result of a slight stumble. due to a combination of great strain on femoral neck in all people and brittle bones.
Intertrochanteric Line
On the FRONT of the femur where the neck joins the body of the femur a roughened ridge running from the greater to the lesser trochanter
intertrochanteric Crest
on the BACK of the femur. similar to the intertrochanteric line, but smoother it joins the trochanters posteriorly
quadrate tubercle
rounded elevation on the intertrochanteric crest
slipped epiphysis of the femoral head
in older children/adolescents (10-17 y/o) the epiphysis of the femoral head may slip away from the femoral neck because of a weakened epiphyseal plate caused by acute trauma or repetitive microtraumas with increased shearing stress on the epiphysis, especially with abduction and lateral rotation of the thigh often slips slowly and results in a progressive coxavara initial symptom is hip discomfort that may be referred to the knee
Coxa Vara
angle of inclination (angle the long axis of the femoral neck makes with the femoral body) is DECREASED a mild shortening of the lower limb and limitations with respect to passive abduction of the hip
Coxa Valga
angle of inclination is increased. Makes the limb appear longer.
Femoral fractures in the Elderly
the neck is frequently fractured when a person over 60 stumbles
femoral fractures in women
more common than in men because of an increased risk of osteoperosis.
femoral neck fractures
most problematic of all fractures because of the instability of the fracture site the periosteum covering the femoral neck is very thin and has very limited powers of osteogenesis (bone formation) * the retinacular arteries arise from the medial circumflex femoral arteries and run parallel to the femoral neck on their way to supply the femoral head, so vulnerable to injury when the neck of the femur fractures. Could result in rupture or degeneration of the femoral head and bleeding into the hip joint often from indirect violence or slipping or tripping on something
intertrochanteric fractures
common in persons older than 60 fracture of the femur between the greater and lesser trochanter
pertrochanteric fracture
a fracture through the trochanters. common in people (esp women, over 60)
Fracture of Body of Femur
usually only with severe trauma sometimes a spiral fracture which may be comminuted with the fragments being displaced may take up to 20 weeks for firm union of the fragments, and union of this serious fracture could take up to a year.
TIbia Fracture (most common site)
the most common site of a tibial fracture is at the junction of the middle and inferior thirds where the tibia is narrowest. this is also the most common site for a compound fracture (skin perforated and blood vessels torn)
Fracture through nutrient canal of Tibia
possible damage to the nutrient artery which predisposes to nonunion of the bone fragments.
Transverse Stress (March) Fractures of the Tibia
common in the inferior 3rd of the tibia common in people who take long walks when they are not conditioned to do so the strain may fracture the anterior cortex of the tibia
Diagonal Fractures of TIbia
indirect violence applied to the tibial body when the bone turns with the foot fixed during a fall severe torsion during skiing may produce a diagonal fracture of the tibial body at the junction of the middle and inferior thirds, as well as a fracture of the fibula
“Boot-top” Fracture of Tibia
high-speed forward fall while skiing leg is angled over the rigid ski boot usually a comminuted fracture in which the tibia is broken into several pieces at the junction of its middle and distal thirds
“Bumper Fractures” of Tibia
when the bumper of a car strikes the leg the blow often tears the skin tibia lies subcutaneously, bone fragments protrude resulting in a compound fracture.
Tibial Body Fracture
tibial body is unprotected anteromedially relatively slender at the junction of the inferior and middle thirds MOST COMMON LONG BONE FRACTURE compound injuries are common POOR BLOOD SUPPLY even undisplaced stable fractures may take up to 6 months to heal
Epiphyseal Plates (Tibia)
the primary ossification center for the superior end of the Tibia appears shortly after birth joins the body of the tibia during adolescence (16-18) fractures here are serious and jeopardize normal growth
FIbular Fractures
common 2-6 cm proximal to the distal end of the lateral malleolus. often associated with fracture-dislocations of the ankle often combined with tibial fractures
Fracture of the Lateral Malleolus
when the foot slips, it is forced into an excessively inverted position. This tears the ankle ligaments, forcibly tilting the TALUS against the Lateral Malleolus, shearing it off. fractures of both the lateral and medial malleoli are common in soccer and basketball players.
Bone grafts from the Fibula
running and jumping can be normal even if a long portion of the fibula can is used for a bone graft (fibula is commonly used) bone grafts used to avoid amputation. (bone defects, trauma, excision of malignant bone tumor) remaining parts of the fibula usually do not regenerate.
What is removed with the bone used for grafting?
periosteum nutrient artery
What happens to the transplanted fibula?
secured in its new site restores the blood supply of the bone that it is now connected to healing proceeds as if the fibula were just fractured at both ends.
location of nutrient foramen in the fibula
important to know when performing free vascularized fibular transfers located in the middle 1/3 of the fibula in most cases (used for transplanting when the graft must have an endosteal and a periosteal blood supply.
Tarsus
7 bones Calcaneus, Talus, Cuboid, Navicular, 3 Cuneiforms
Which is the only Tarsal bone to articulate with the leg bones?
Talus
What is special about Calcaneus?
It is the largest and strongest bone in the foot.
Which is the longest metatarsal?
2nd
Surface anatomy of Iliac Crests
Hands on hips: resting on the curved superior boarders of the wings of the iliac (pleural of ilium) anterior 1/3 of crests is subQ and easily palpated posterior 2/3 usually covered with fat and difficult to palpate.
Supracrestal Plane
this is the highest level of the iliac crests passes through L4/L5 disc landmark for lumbar puncture.
Talus
narrow posteriorly has a groove for a tendon has a prominent laeral tubercle and a less prominent medial tubercle only tarsal bone with no muscular or tendinous attachments
Navicular tuberosity
medial surface of the navicular projects inferiorly. if it’s too prominent, it presses against the shoe causing foot pain.
Calcaneal Fractures
a hard fall from a ladder on the heal can fracture the calcaneus. produces a comminuted fracture usually results in a disability because the subtalar (talocalcaneal) joint is disrupted.
Fractures of the Talar Neck
Occur during severe dorsiflexion of the ankle in some cases, the body of the talus dislocates posteriorly
Fractures of the Metatarsals
heavy object falling on foot, or foot run over also common in dancers fatigue fractures from prolonged walking + repeated stress on the metatarsals usually transverses
Avulsion fractures of the 5th metatarsal
Foot is suddenly and violently inverted Tuberosity of the 5th metatarsal may be avulsed by the tendon of the fibularis brevis muscle part of the tuberosity is pulled off resulting in pain and edema common in basketball and tennis players
Fracture of the sesamoid bones of the great toe
Fracture of the sesamoids may result from a crushing injury.
facia lata attachments
Superior - inguinal ligament, pubic arch, body of pubis, pubic tubercle, membranous layer of subcutaneous tissue (Scarpa’s) of the lower abdominal wall. Laterally - iliac crest Posteriorly - iliac crest, sacrum, coccyx, sacrotuberous ligament, ischial tuberosity Distally - exposed parts of bones around the knee, continuous with crural fascia
Iliotibial Tract (Iliotibial Band - ITB)
The fascia lata is substantial, it encloses the large thigh muscles, especially laterally where it is thickened and strengthened with additional longitudinal fibers to form the iliotibial tract
Crural Fascia
is thin in the distal part of the leg, but is thicker where it forms the extensor retinacular anterior and posterior IM septa pass from the deep surface of the crural fascia and attach to the corresponding margins of the fibula.
3 thigh compartments
anterior, posterior, medial
3 leg compartments
anterior, posterior (superficial and deep), lateral
Venous drainage of the lower limb
superficial veins in subQ deep veins deep to the deep fascia (accompany all major arteries) more valves in the deep veins
in subQ
superficial veins, lymphatic vessels, cutaneous nerves
2 major superficial veins of the lower limb
great saphenous vein (medial) small saphenous vein (lateral and posterior)
Great Saphenous Vein
Dorsal venous arch + dorsal vein of great toe –> anterior to medial malleolus –> posterior to medial condyle of femur –> anastomoses with small saphenous vein –> traverses the saphenous opening in the fascia lata –> empties into femoral vein has 10-12 valves with more in the leg than thigh. (valves are just inferior to the perforating veins)
Accessory Saphenous Vein
if present this vein becomes the primary communication between the great and small saphenous veins
lateral and anterior cutaneous veins
large veins that arise from networks of veins in the inferior part of the thigh they enter the great saphenous vein superiorly just before entering the femoral vein
small saphenous vein
arises on lateral foot from the union of the dorsal vein of the small (little) toe with the dorsal venous arch. ascends posterior to lateral maleolus as a continuation of the lateral marginal vein –> along the lateral border of calcaneal tendon –> inclines to the midline of the fibula and penetrates the deep fascia –> ascends between the 2 heads of the gastrocnemius muscle –> empties into the popliteal vein in the popleteal fossa.
order of veins
Superficial –> Perforating –> Deep
perforating veins
only permit blood to flow from the superficial to the deep veins. Pass through the deep fascia at an oblique angle to prevent back flow.
musculovenous pump
enables muscular contractions to propel blood toward the heart against the pull of gravity
deep veins of the lower limb
accompany all the major arteries and their branches usually paired contained within the vascular sheath with the artery. Pulsations help to compress and move blood in the veins.
dorsal veins of the foot
receive tributaries from the plantar arch join to form common dorsal digital veins –> terminate in the dorsal venous arch
medial and lateral plantar veins
pass close to the arteries communicate with the great and small saphenouus veins from the posterior tibial veins posterior to the medial malleolus
Vericose Veins
cusps of the valves of the great saphenous vein do not close the incompetent valves within the great saphenous vein alow the blood flow to sucomb to the pull of gravity, a higher intraluminal pressure as a result, the superficial veins become tortuous and dilated.
Thrombosis
the veins of the lower limb are subject to venous thrombosis after: a bone fractures venous stasis (stagnation) Inflammation may develop around the vein (thrombophlebitis), so be on the lookout for that.
thrombophlebitis
inflammation around a vein that contains a clot
pulmonary thromboembolism
obstruction of a pulmonary artery occurs in a few cases when: a thrombus breaks free from a lower limb vein –> passes to the lungs –> a large embolus may obstruct a main pulmonary artery and cause death.
use of Great Saphenous Vein for coronary artery bypass
GSV used because readily accessible, usable lengths can be harvested due to long distances between the tributaries and perforating veins wall contains more muscle and elastic fibers than other superficial veins. also used to bypass obstructed blood vessels.
a saphenous cutdown
procedure used to insert a cannula for prolonged administration of blood, plasma expanders, electrolytes, or drugs
saphenous nerve injury
the saphenous nerve accompanies the great saphenous vein anterior to the medial malleolus. if cut by accident, patient may complain of pain along the medial border of the foot.
superficial lymphatic vessels of the lower limb
accompany the saphenous veins and their tributaries the lymphatic vessels accompanying the great saphenous vein end in the superficial inguinal lymph nodes most lymph in these nodes passes directly to the external iliac lymph nodes located along the external iliac vein
deep lymphatic vessels of the lower limb
lymph may also pass to the deep inguinal lymph nodes. from the leg, deep lymphatic vessels accompany deep veins and enter the popliteal lymph nodes. most lymph from these nodes ascends through deep lymphatic vessels to the deep inguinal lymph nodes. These nodes lie under the deep fascia on the medial aspect of the femoral vein. lymph from the deep nodes passes to the external iliac lymph nodes.
lymphatic vessels accompanying the small saphenous vein
enter the popliteal lymph nodes and surround the popliteal vein in the fat of the popliteal fossa
Enlarged inguinal lymph nodes
these nodes are in subQ tissue enlarged when diseased abraisions and minor sepsis may produce slight enlargement of the superficial inguinal lymph nodes (lymphadenopathy) in otherwise healthy people their entire field of drainage must be examined to determine the cause of their enlargement.
cutaneous innervation of lower limb
memorize dermatome chart fig 5.12
subcostal nerve (T12)
branches descend over the iliac crest toward the anterosuperior iliac spine (asis) and enter the superolateral part of the thigh and supply the skin of the thigh anterior to the greater trochanter of the femur (cutaneous)
iliohypogastric nerve (L1, occasionally T12)
divides into Lateral Cutaneous Branch - supplies the skin over the superolateral part of the buttock Anterior Cutaneous Branch - supplies skin superior to the pubis (cutaneous)
ilioinguinal nerve (L1, occasionally T12)
accompanies the spermatic cord or the round liigament of the uterus through the superficial inguinal ring to the scrotum or labium majus (cutaneous)
Branches of the ilioinguinal nerve
are distributed to the skin over the proximal and medial parts of the thigh and to the scrotum and labia majus through their anterior scrotal and labial branches respectively (cutaneous)
Genitofemoral Nerve (L2 and L3)
has genital and femoral branches that supply skin just inferior to the middle part of the inguinal ligament
Lateral Femoral Cutaneous Nerve (L2 and L3)
a direct branch of the lumbar plexus runs obliquely toward the anterior superior iliac spine (ASIS) passes deep to the inguinal ligaament into the thigh –> divides into anterior branches becoming superficial approximately 10 cm distal to the inguinal ligament –> supply skin on the lateral and anterior parts of the thigh.
Femoral Nerve (L2, L3, L4)
Arises from the 2nd 3rd and 4th lumbar nerves in the substance of the psoas major muscle Enters the thigh deep to the inguinal ligament and lateral to the femoral vessels sends branches to: thigh muscles anterior femoral cutaneous nerves to the skin on the anterior and medial thigh
Anterior Femoral Cutaneous Nerve
arises from the femoral nerve as a branch from the lumbar plexus. Arises in the femoral triangle pierces the fascia lata along the path of the sartorius muscle supplys the skin on the medial and anterior thigh
Posterior Femoral Cutaneous Nerve
A branch of the sacral plexus that supplies branches to the skin on the posterior aspect of the thigh and over the popliteal fossa
Sciatic Nerve
arises from the sacral plexus passes through the greater sciatic foramen in the inferior gluteal region –> posterior thigh –> at the apex of the popliteal fossa, the sciatic nerve divides into: common fibular nerve (peroneal) tibial nerves cutaneous branches
Abnormalities of Sensory Function
neighboring dermatomes may overlap pain sensation is tested by using a safety pin and asking the patient if the pinprick is felt if sensory loss to pain exists, the spinal cord segment involved can be determined.
what is the cheif flexor of the thigh?
Iliopsoas this is also a postural muscle that is active during standing as it prevents hyper extension of the hip joint.
psoas major attachments
T12-L5 vertebrae and discs –> Lesser Trochanter
Psoas minor attachments
T12 - L1 vertebrae and discs –> pectineal line, iliopectineal eminence via iliopectineal arch
Iliacus
Iliac crest, iliac fossa, ala of sacrum, anterior sacroiliac ligaments –> tendon of psoas major, lesser trochanter and femur distal to it
Innervation of Psoas major
ventral rami of lumbar nerves (L1, L2, L3)
Innervation of Psoas Minor
ventral rami of lumbar nerves (L1, L2)
Innervation of Iliacus
Femoral Nerve (L2, L3)
Iliopsoas arterial supply
lumbar branch of iliopsoas branch of internal iliac artery
Pectineus attachments
superior ramus of pubis –> pectineal line of femur (just inferior to lesser trochanter
Pectineus Action
Adducts and flexes the thigh, and assists with medial rotation of the thigh.
Pectineus Innervation
Femoral Nerve (L2, L3), may receive a branch from obturator nerve.
Pectineus Arterial supply
medial circumflex femoral branch of femoral artery and obturator artery.
Movement of Tensor Fascia lata
to produce flexion, it acts in concert with iliopsoas (when iliopsoas is paralyzed tfl hypertrophies in an attempt to compensate) works with gleuteus medius and minimus to medially rotate contracts during abduction, but is too far anterior to be a strong abductor (probably serves as a synergist or fixator) tenses the fascia lata and iliotibial tract, helping to support the femur on the tibia while standing NO DIRECT ACTION ON LEG!
Tensor Fascia Lata Attachments
Anterior Superior Iliac Spine and anterior crest –> IT band that attaches to lateral condyle of tibia
Tensor Fascia Lata Innervation
Superior Gluteal Nerve (L4, L5)
Sartorius actions
acts across 2 joints. flexes the hip and participates in knee flexion weak abductor of thigh lateral rotation of thigh the actions of both sartorius muscles bring the lower limbs into the cross-legged sitting position NONE OF THE ACTIONS ARE STRONG!
Sartorius attachments
Anterior Superior Iliac Spine and superior notch inferior to it –> superior part of medial surface of tibia
Sartorius innervation
Femoral Nerve (L2, L3)
Sartorius Blood Supply
Muscular branches of the femoral artery
What is the largest muscle in the body?
Quadriceps Femoris it is also one of the most powerful
Quadriceps facts
this is the great Extensor of the knee all 4 parts join to attach on tibia 3 vastus muscles are tough to separate.
Rectus Femoris Attachments
Anterior Inferior Iliac Spine (AIIS) and Ilium superior to acetabulum –> base of patella and tibial tuberosity by patellar ligament
Main action of Rectus Femoris
knee extension, helps iliopsoas flex the thigh, steadies hip
Rectus Femoris Innervation
Femoral Nerve (muscular branches L2, L3, L4)
Rectus femoris Blood Supply
Lateral circumflex femoral artery
Vastus Lateralis Attachments
Greater Trochanter and lateral lip of linea aspera of femur –> base of patella and tibial tuberosity by patellar ligament
Vastus Lateralis Actions
extend knee
Vastus Lateralis Innervation
Femoral Nerve Muscular branches (L2, L3, L4)
Vastus Lateralis Blood Supply
Lateral Circumflex Femoral Artery
Vastus Medialis Attachments
Intertrochanteric Line and medial lip of linea aspera –> base of patella and tibial tuberosity by patellar ligament
Vastus Medialis action
extend leg at knee joint
vastus medialis innervation
Femoral Nerve Muscular branches
Arterial supply of vastus medialis
femoral artery, profunda femoris artery, and superior medial genicular branch of popliteal artery
Vastus intermedius attachments
anterior and lateral surface of body of femur –> base of patella and by patellar ligament to tibial tuberosity
Vastus Intermedius action
extend the leg at knee
Vastus intermedius innervation
muscular branches of femoral nerve
Vastus intermedius arterial supply
lateral circumflex femoral artery
Vastus Medialis Oblique (VMO) Insufficiency
realigns the patella MEDIALLY VMO is the only dynamic medial stabilizer that is active through the whole ROM adductor magnus –> ? lateral circumflex artery
Articular muscle of knee
inferior part of anterior femur –> synovial membrane of knee joint and wall of the suprapatellar bursa Fxn - pulls the synovial capsule superiorly during extension of leg, preventing folds of the capsule from being compressed between the femur and the patella w/i the knee joint.
“hip pointer”
a contusion of the iliac crest usually the anterior part where the sartorious attaches to the asis. bleeding from ruptured capillaries results in an infiltration of the blood into the muscles, tendons, and other soft tissue.
contusion
can also refer to an avulsion of bony muscle attachments, although this is more accurately called an avulsion fracture
Charly Horse (“cricket thigh”)
cramping of an individual thigh muscle because of ischemia (inadequate circulation of blood) localized pain, muscle stiffness direct trauma is a possible cause
hematoma
when a contusion results in a tearing of muscle fibers severe enough to rupture enough blood vessels to cause a bruise most common site of thigh hematoma is quadriceps (sometimes the quadriceps tendon is also torn)
Genu Varum (Bow Leg)
a medial angulation deformity of the leg in relation to the thigh results in unequal weight distribution all pressure taken by inside of the knee joint arthrosis destruction of knee cartilage patella tends to move laterally when the leg is extended the movement is increased by vastus lateralis appears 1-2 years after they start walking.
