Lower Limb Flashcards
What Roots Make up the Lumbar Plexus?
How many major peripheral nerves does it give off?
And where is it located?
T12-L4
Gives off 6 major peripheral nerves -
iliohypogastric,
ilioinguinal,
genitofemoral,
lateral cutaneous nerve of the thigh,
obturator nerve,
femoral nerve
Located within the psoas major muscle and anterior to the transvers processes of the lumbar vertebrae
What roots does the iliohypogastric nerve contain?
What is its course?
and what is its motor and sensory function?
Roots: T12, L1
Path: Runs to the iliac crest, across the quadratus lumborum muscle of the posterior abdominal wall then perforates transferse abdominis and divides into terminal branches
Motor:
Innervates internal oblique and transverse abdominis
Sensory: innervates posterolateral gluteal skin in the pubic region
What root does the ilioinguinal nerve contain?
What is its course?
and what is its motor and sensory function?
L1
Path is same as iliohypogastric nerve. In anterior abdominal wall, lies between internal oblique and transversus abdominis. Peirves internal oblique and passes under external oblique through the superficial inguinal ring
Motor Function:
Innervates internal oblique and transversus abdominis (Same as iliohypogastric n.)
Sensation:
Innervates upper middle thigh,
Males: the root of penis and anterior 1/3 scrotum
Females - mons pubis and labia majora
What roots does the genitofemoral nerve contain?
What is its course?
and what is its motor and sensory function?
Roots: L1,L2
Path: After leaving the psoas major muscle, it divides into:
i) genital branch - enters spermatic cord, doesnt go to skin
ii) femoral branch (L1 only) - runs down external iliac artery. Passes beneath the inguinal ligament into the femoral sheath and passes anteriorly through it to supply the femoral triangle skin
Motor:
Genital Branch enters spermatic cords and inervats cremasteric reflex and doesnt reach skin
Sensory:
Femoral branch innervates the skin on the upper anterior thigh
What roots does the Lateral Cutaneous Nerve of the Thigh contain?
What is its course?
and what is its motor and sensory function?
Roots: L2,3
Path: Lateral border of the psoas, incorporated within iliac fascia, lites in a firbous tunned a cm medial to the ASIS. Enters thigh at lateral aspect of the inguinal ligament, where it provides cutaneous innervation to the skin. Enters thigh deep to fascia lata and divides into anterior (L3) and posterior (L2) branches.
No motor function
Sensation: innervates the anterior and lateral thigh down to the level of the knee
What roots does the Obturator Nerve contain?
What is its course?
and what is its motor and sensory function?
Roots: Anterior divisions of anterior rami L2,3,4
Path: Emerges at medial border of psoas, runs posterior to iliac arteries and laterally to the obturator foramen. It then enters the thigh through the obturator canal and splits into anterior and posterior divisions
Anterior division descends between adductor longus and brevis then pierces the fascia latal to become the cutaneous branch of the obturator nerve
The postrior division descends through the obturator externis muscle before passing anteriorly to adductor magnus and the capsule of the knee joint
Motor:
Innervates the obturator externus, pectineus, adductor longus, adductor brevis, adductor magnus, gracilis
Sensory:
Innervates the skin over the medial thigh
What roots does the femoral nerve contain?
What is its course?
and what is its motor and sensory function?
Roots: L2,3,4
Path:
Descends through psoas major muscle. Lies in the fossa between the psoas and illiacus. The nerve then travels underneath the inguinal ligament into the thigh to the femoral triangle where it is lateral to the femoral vessels.
4cm below the inguinal ligament it divides into anterior and posterior divisions:
- Anterior
Medial femoral cutaneous nerve L2,3 (supply medial thigh)
Intermediate femoral cutaneous nerve L2,3 (Supply anterior thigh)
branch to sartorius, branch to pectineus
- Posterior
(Saphenous nerve, branches to quadriceps femoris).
The terminal branch is the saphenous nerve which continues, with the femoral atery and vein
Motor:
Anterior thigh muscles - iliacus, pectineus, sartorius, rectus femoris, vastus lateralis, vastus medialis, vastus intermedius
Sensory:
Skin of the anterior thigh (anterior cutaneous branch) and medial leg (saphenous nerve)
What forms the patellar plexus
Network of nerves near the patellar
Formed by the terminal branches of the medial and intermediate femoral cutaneous nerves of the femoral nerve, the lateral femoral cutaneous nerve and the infrapatellar branch of the saphenous nerve
What nerve roots form the sacral plexus?
What nerves arise from it?
Roots: L4,L5, S1-S4
Located on the surface of the posterior pelvic wall, anterior to the piriformis muscle. The nerve roots have one of two destinations:
i) Remain in the pelvis
ii) Leave pelvis via the greater sciatic foramen
Gives rise to:
- Superior Gluteal Nerve
- Inferior gluteal nerve
- Sciatic Nerve
- Posterior femoral nerve
- Pudendal nerve
Sacral plexus:
What roots does the Superior gluteal nerve contain?
What is its course?
and what is its motor and sensory function?
L4,L5,S1
Path:
Leaves pelvis via greater sciatic foramen, entering gluteal region superiorly to the piriformis muscle (accompanied by the superior gluteal artery and vein)
Motor function:
innervates gluteus minimus, gluteus medias and tensor fascia lata
No sensory function
Sacral plexus:
What roots does the Inferior gluteal nerve contain?
What is its course?
and what is its motor and sensory function?
L5,S1,S2
Path: Leaves pelvis via greater sciatic foramen, intering gluteal region inferiorly to piriformis (accompanies inferior gluteal artery and vein)
Motor: Gluteus maximus
No sensory function
Sacral plexus:
What roots does the Sciatic nerve contain?
What is its course?
and what is its motor and sensory function?
L4,L5, S1, S2,S3
Path: Leaves pelvis via greater sciatic foramen into gluteal region. Emerges inferiorly to the piriformis muscle. Crosses posterior to obturator internus. Enters posterior thigh by passing deep to long head of bicep femoris.
Motor:
Innervates muscles of posterior compartment of thigh + hamstring component of adductor magnus (apart from short head of biceps femoris)
*Nerve gives off tibial and common fibular nerve
The tibial nerve.
What is its course?
and what is its motor and sensory function?
Path:
Tibial nerve is a branch of the sciatic nerve, and arises at the apex of the popliteal fossa
Travels posterior leg, between heads of gastrocnemius, deep to soleus, supplying posterior leg muscles and sural nerve (sensory lateral post. leg)
At foot it passes posteriorly and inferiorly to the medial malleoulus through the tarsal tunnel
Terminates by dividing into 3 sensory branches (Medial calcaneal, medial plantal and lateral plantar nerve)
Motor:
- Posterior compartment of leg and muscles in the sole of the foot
- Deep (Popliteus, flexor hallucis longus, flexor digitorum longus, tibialis posterior)
- Superficial (Plantaris, Soleus, gastrocnemius)
Sensory:
- Posterolateral leg (sural nerve) and posterolateral + medial surfaces of the foot and sole of foot (medial calcaneal branch, lateral and medial plantar nerve)
The common peroneal nerve
What is its course?
and what is its motor and sensory function?
Path:
From sciatic nerve. Begins at apex of popliteal fossa, where sciatic nerve bifurcates
Follows medial border of biceps femoris, running in a lateral, inferior direction over lateral head of gastrocnemius and fibular origin of soleus
Here it gives of two cutaneous branches
i) Peroneal communicating nerve (combines with sural nerve from tibial n.)
ii) lateral cutaneous nerve
iii) Superior and inferior genicular nerves
iv) recurrent genicular nerve
The nerve wraps around the neck of the fibula, passing between the attachments of the fibularis longus muscle.
Here the nerve terminates into a superfiical peroneal and deep peroneal nerve
i) superficial peroneal nerve - innervates muscles of the lateral compartment of leg (acting to evert the foot) and dorsal foot, anterolateral leg
ii) Deep fibular nerve - innervates the muscles of the anterior compartment of the leg (acting to dorsiflex the foot, extend digits) and dorsal foot
Summary:
Motor - All muscles in anterior and lateral compartments
Sensory - skin on anterolateral surface of the leg and dorsal aspect of the foot
Sacral plexus:
What roots does the Posterior Femoral Cutaneous Nerve contain?
What is its course?
and what is its motor and sensory function?
Roots: S1,2,3
Path:
Leaves pelvis via greater sciatic foramen, entering gluteal region inferiorly to piriformis muscle
Descends deep to gluteus maximus and runs down back of thigh to knee
No Motor Function
Sensory: Innervates skin of the posterior surface of the thigh and perineum
What roots does the Pudendal nerve contain?
What is its course?
and what is its motor and sensory function?
Roots S2,3,4
Leaves pelvis via greater sciatic foramen then re-enters via the lesser sciatic foramen
Moves anteriosuperiorly along the lateral wall of the ischiorectal fossa, and terminates dividing into several branches
(Nerve to piriformis, obturator internus, quadratus femoris)
Motor:
Innervates skeletal muscles in peroneum, external urethral sphincter, external anal sphincter, levator ani
Sensory:
Penis/ clitoris
Describe the femoral artery, its course and branches
FEMORAL ARTERY
External iliac artery becomes the femoral artery when it crosses under the inguinal ligament at the mid-point between the ASIS and pubic symphysis
On top of the psoas muscle
Emerges from femoral sheath and continues down anterior surface of thigh under sartorius, via adductor canal (which ends at the opening of adductor magnus - called the adductor hiatus). Femoral a. moves through this opening and enters the posterior thigh. Proximal to entering the posterior knee it becomes the POPLITEAL ARTERY,
Branches:
Gives off profunda femoris in femoral triangle
It gives off 3 main superficial arteries just below the inguinal ligament
1 Superficial iliac circumflex aryery
2 Extenral pudendal artery
3 profunda femoris
PROFUNDA FEMORIS
Given off in In the femoral triangle 4cm below inguinal ligament. Then spirals deep to adductor longus. The profunda femoris artery arises from the posterolateral aspect of the femoral artery. This gives off 3 branches:
i) Medial femoral circumflex artery (post. femur, suppyling neck and head. It can be easily damaged ina NOF)
ii) Lateral femoral circumflex artery
a) Ascending branch (runs up vastus lateralis - gives branch to trochanteric anastaomosis then goes to ASIS and anastomoses with circumflex iliac arteries) Must be careful in anterior approach to THR going between sartorius and tensor fascia lata not to hit this.
b) Transverse branch - winds around femur
c) Descending branch
iii) Perforating branches –> muscles in posterior/ medial thigh
Describe the internal iliac arteries supply of the leg and its branches
Internal iliac arterty gives off:
1) Gluteal region supplied by superior and inferior gluteal arteries (passes under and over piriformis with corresponding nerve)
2) Obturator artery - which breaks into a posterior and anterior branch
i) anterior - pectineus, obturator externus, adductor muscles, gracilis
ii) posterior - deep gluteal muscles
Describe the Popliteal artery course and its branches
Popliteal artery descends posterior thigh, through popliteal fossa, exits between gastrocnemius and popliteus muscles.
Gives off the sural arteries that supply heads of gastrocnemius and the genicular arteries which supply the knee.
At the border of the popliteus it divides into anterior and posterior tibial arteries
i) Anterior tibial artery which travels through the interosseous membrane of tibia and fibula then becomes dorsalis pedis artery
ii) Posterior tibial artery is accompanied by tibial nerve, deep to the soleus, and enters sole of foot via the tarsal tunnel. Gives off a fibular artey branch in the leg that supplies the lateral compartment of the leg.
Describe the arterial system in the foot
Posterior tibial artery enters through tarsal tunnel and splits into lateral and medial plantar arteries which suply plantar foot
Anterior tibial artery becomes the dorsalis pedis (felt between extensor hallus longus and brevis) which anastamoses with the lateral plantar artery to form the deep plantar arch
Dorsalis pedis also gives off branches of dorsum off foot - namely lateral tarsal a. and arcuate a.
Describe the deep veins of the leg
Deep veins accompany major arteries
Dorsal venous arch –> anterior tibial vein
Medial and lateral plantar veins –> posterior tibial and fibular veins
anterior tibial, posterior tibial and fibular veins units to form popliteal vein
popliteal vein –> enters thigh via adductor cannal –> femoral vein
The Profunda femoris vein joins the femoral vein, which then leaves the thigh under the inguinal ligament, at which point it is the external iliac vein
What are the superficial veins of the leg
Superficial veins found in the subcutaneous tissue
i) Great saphenous vein
- Formed by dorsal venous arch of foot and dorsal vein of great toe.
- Ascends medial side of leg, passing anterior to medial malleoulus of ankle and posterior of medial condyle of knee
- drains into femoral vein immediately inferior to inguinal ligament
- contains 20 valves, mainly below knee
ii) Small saphenous vein
- Formes by dorsal venous arch
- Moves up posterior side of leg, passing poasteriorly to lateral malleolus, along lateral border of calcaneal tendon
- Moves through two heads of gastrocnemius and empties into popliteal vein in the popliteal fossa
Superficial arteries of the thigh (4 cutaneous branches of the femoral)
4 branches just below the inguinal ligament
i) superficial circumflex iliac artery (anastamoses near ASIS)
ii) superficial epigastric artery (lower abdo wall)
iii) superficial external pudendal artery (scrotum)
iv) deep external pudendal artery (scotum)
Lymph Nodes of lower limb
Lymph atcs accompany the great saphenous vein
Superficial inguinal nodes (In the subcutanous fat of femoral triangle - has 3 groups
i) vertical - deep fascia and everything superficial of lower limb
ii) Lateral- buttock, flank, back below waist
ii) medial - below umbilicus and medial to ASIS
The efferent lymphatics from these groups pass through the cribriform fascia to enter the deep inguinal nodes
What is the fascia lata
What two muscles does it enclose fully?
Fascia lata is the deep fascia that encloses the thigh
Imaging a stocking - form the top it attaches from ASIS, around external lip of iliac crest (as far back as the posterior gluteal line, where it splits to enclose the gluteus maximus and attaches on the origin on the ilium and sacrum that the gluteus maximus has. It then traces around the ischial tuberosity, ischiopubic ramus and body of the pubic bone
The fascia lata is attached below to the patella and inferior margins of the tibial condyles and head of fibula
The fascia lata encloses two muscles - the gluteus maximus and the tensor fasciae lata
What is the saphenous opening and what structures go through the saphenous opening
Saphenous opening is an opening in the fascia lata
it occurs approx 3.5cm inferior/lateral to the pubic tubercle
The lymphatic vessels and greater saphenous vein go through the opening
it is overlied by cribriform fascia
Iliotibial tract
Origin:
Thickening of the fascia lata that commences at the level of the greater trochanter where 3/4 of the gluteus maximus and tensor fasciae lata are inserted into it
Insertion:
Anterior surface of lateral condyle of tibia
Function:
When the knee is straight the tract passes in fron of the axis of flexion thus maintains the knee in hyperextended position (Not an extensor of the flexed knee)
Important in walking with a minimally flexed knee and extending knee when standing up
Also similar to gluteus medius and minimus - abducting and medially rotating hip
Note the lateral intermuscular septum attaches to the tract which in turn connects it to the linea aspera of the femur
Surface Anatomy:
The bulge of vastus lateralis is seen anterior to the iliotibial tract
Tensor Fascia Lata
- Origin
- Attachment
- Innervation
- Function
Origin:
- External lip of iliac creast between the ASIS and tubercle of the crest
Insertion: iliotibial tract
Innervation: Superior gluteal nerve (L4,5,S1)
Action: Pull upon iliotibial tract which by extending knee joint, stablisation
Femoral Triangle
- Borders
- Contents
Borders:
Superior - Inguinal Ligament
- Lateral - Sartorius
- Medial - Adductor Longus
- Roof - Fascia Lata
- Floor - Pectineus, iliopsoas
Contents (Lateral to medial)
- Femoral nerve
- Femoral artery
- Femoral Vein
- Femoral canal (Contains deep lymph nodes and vessels)
*The femoral artery, vein and canal are in a femoral sheath
What is the femoral sheath and its contents?
And what is crifriform fascia?
Prolongation of the extraperitoneak fascia derived from the transversalis fascia and psoas fascia
Contains the femoral artery and vein
There is a small space medial to the vein in the sheath - called the femoral canal which transmits lymphatic vessels and allows the femoral vein to expand
The canal contains the lymph node of Cloquet which drains the clitoris/ penis
The anterior wall is peirced by the femoral branch of the genitofemoral nerve
In regards to pectineus muscle. How to the following structures relate to it:
Adductor brevis
Obturator nerve
Femoral Vein
Femoral Canal
Deep to pectineus: Adductor brevis, Obturator nerve inbetween adductor brevis and behind pectineus
Superficial: Femoral canal and vein
What is the femoral ring and whats a femoral hernia
The femoral ring is the opening of the femoral canal at its abdominal end
4 boundaries:
Anterior - Medial inguinal ligament
Medial - Crescenteric edge of lacunar ligament
Posterior - pectineal ligament and pectineus
Lateral - femoral vein
it is usually closed by the femoral septum (fusion of iliopectineal fascia and transversalis fascia), however…
Significance: a femoral hernia enters the canal through this ring
(the lacunar ligament may have to be incised to release a stangulated hernia)
It then inters the groing and passes through the saphenous opening… thus the hernia is covered in fascia of the femoral seeptum and cribiform fascia and fat (which can make cough impulse test less obvious)
Potential Complications of femoral artery cannulation
Retroperitoneal haemorrhage
Perforation of gut
Arteriovenous fistula (with the femoral and external iliac vein)
Anterior Thigh Muscles
- Origin
- Attachment
- Innervation
- Function
Adductor cannal
- Border
- Contents
Borders
- Anterior - Sartorius
- Lateral - Vastus medialis
- Medial - Adductor longus (above) and magnus (below)
Contents:
- Saphenous Nerve
- Nerve to vastus medialis
- Femoral Artery and vein (as they leave the canal they become the popliteal vein and artery)
*Skin overlying is supplied by the subsartorial plexus (Fibres from intermediate cutaneous nerve of thigh, saphenous nerve, anterior division of obturator nerve)
What is the medial and lateral intermuscular septum of the thigh
The medial intermuscular septum divides the Medial and anterior compartment of the thigh
The medial intermuscular septum of thigh is a fold of deep fascia in the thigh. It is between the vastus medialis, and the adductors and pectineus.
It is thinner than the lateral septum
Medial (Adductor) compartment of thigh
- origins
- attachment
- innervation
- function
Cutaneous nervve supply to gluteal regions
cluneal nerve - derived from posterior rami of L1-3 and S1-5
Then the anterior rami of
Also iliohypogastric nerve on lateral side
and lateral femoral cutaneous nerve
Superficial gluteal muscles
- origin
- attachment
- innervation
- function
What is the greater sciatic foramen?
An opening in the posterior pelvis.
It is formed by the sacrotuberous (Sacrum –> ischial tuberosity) and Sacrospinous (Sacrum –> Ischial spine) Ligaments
The piriformin muscle passes through and occupies most its volume
What passes through it?
i) Passing over the piriformis is the superior gluteal nerve and vessels
ii) Passing below the piriformis is:
a) he inferior gluteal nerve and vessels
b) the pudendal nerve and vessels
c) the nerve to obturator internus
d) and the sciatic nerve with the posterior femoral cutaneous nerve on its surface and the nerve to quadratus femoris deep to it
Whats the lesser sciaitic foramen
between the sacrospinous and sacrotuberous ligaments, and below the greater sciatic foraemen
the obturator internus passes through this as it wraps aorund to insert on the greater trochanter
Deep muscles in gluteal region
- origin
- attachment
- innervation
- function
Hip Joint
- Ligaments
- Neurovasc
Synoial joint between femur and acetabulum (deepened by acetabular labrum made of fibrocartilage then continues as transverse ligament)
Capsule is attached circumfrentially around labrum and transverse ligament, attaching to neck of femur
Ligaments:
Intracapsular - ligament of head of femur (Acetabular fossa to fovea of femur, enclosing a branch of the obturator artery)
Extracapsular
i) Iliofemoral (AIIS - tranchanteric line of femur)
ii) Pubofemoral (Superior pubic fami - intertrochanteric line of femur)
iii) Ischiofemoral (Ischium - greater trochanter)
Vasc:
- Mainly Medial and some lateral circumflex femoral arteries (Fromprofunda femoris)
- Inferior/superior gluteal arteries + obturator artery through ligament of head of femur (usually closes age 7) provide some additional supply
Neves (hiltons law)
- femoral, sciatic, obturator
Muscles involved in flexion at the hip
Mainly:
Psoas
Illiacus
Assistance from
- rectus femoris, tensor fasciae lata, sartorius, pectineus
Muscles involved in extention of the hip
Gluteus maximus (at extremities)
Hamstrings (immediate stage)
Muscles involved in adduction of leg
Gracilis
Adductor brevis, longus, magnus
Pectineus
Muscles involved in abduction of the hip
Gluteus medius, minimis
piriformis
What causes lateral and medial rotation of hip
Lateral (muscles that attach behind hip)
- piriformis, obturator interus, gemelli, quatratus femoris, obturator externus, glut maximus
Medial rotation:
- gluteus medius, minimus
- assisted by adductors and tensor fascaie lata
Posterior componant of thigh
- origin
- attachment
- innervation
- action
Popliteal fossa
- border
- contents
Borders
- Superiomedial - Semimembranous and semitendinous
- Superiolateral - Biceps femoris
- Inframedial and lateral - heads of the gastrocnemius
- roof - fascia lata (peirced by small saphenous vein and posterior femoral cutaneous nerve)
- Floor - popliteal surface of femur and capsule of knee joint and popliteus
Contents
- Popliteal artery (deepest structure)
- Popliteal vein (small saphenous vein empties in here)
- Tibial nerve
- Common fibular nerve (follows biceps femoris tendon, running lateral margin of fossa)
- popliteal lymph nodes
What two structures enter the posterior joint capsule of the knee?
Middle genicular artery –> supplies cruciate ligaments
genicular branch of obturator nerve
What are the two main gaps in the knee capsule
one allowing popliteus tendon to enter, the other communicating with the
suprapatellar bursa
Describe the ligamenture of the knee
Extracapsular Ligaments
1) Patellar retinacula (patella to lower condyles on tibia, fibrous extention of quad tendon)
a) Medial patella retinaculm
b) Lateral patella retinaculum
2) Collateral Ligaments
a) Lateral collateral ligament (Lateral epicondyle femur - lateral surface of fibular head. Lies free from capsule and lateral meniscus, seperated by popliteus)
b) Medial collateral ligament (medial epicondyle femur - medial surface tibia. Attaches to medial meniscus)
3) Oblique Poplital Ligament
4) Arcuate Poplital Ligament
5) lateral and medial patellofemoral ligament
Intra-articular ligaments:
1) Anterior Cruciate Ligament (Anterior tibial plateau -> smooth impression on posterior lateral condyle of femur in the intercondylar notch)
2) Posterior Cruciate Ligament (posterior tibia between condyles –> passes forward onto a smooth impreeion on the medial epicondyle, well forward of intercondylar notch)
3) Medial and Lateral Menisci (blood supply from periphery)
4) Transverse Ligament (between anterior horns of both menisci)
5) Meniscofemoral ligament (anterior and posterior, associated with lateral meniscus)
6) Lateral and Medial meniscotibial ligaments
important Bursae of the knee
1) Suprapatellar bursa (extension of synvial cavity, located between quadriceps femoris and femur)
2) Prepatella burrsa (apex of patella and skin)
3) Infrapatella bursa - between tibia and patella ligament
4) Semimembranous bursa (between semimembranous and medial gastrocnemisu)
blood and nerve supply to knee
blood - genicular arteries
nerve - femoral, common peroneal, tibial, obturator nerve (Hiltons law)
(Cruciate ligements - tibial nerve sensation)
What three nerves supply the skin of the (lower) leg?
Lateral half –> Common perineal nerve (lateral surcral cutaneous nerve)
Medial half –> Femoral nerve (Saphenous nerve)
Posterior –> Tibial nerve (Medial cutaneous nerve)
What nerves supply the foots skin?
Dorsal aspect:
- Superficial finular nerve (mainly)
- Deep fibular nerve (2nd toe)
Plantas aspect:
- Tibial branches: Calcaneal, medial plantar and lateral plantar nerves
Over the lateral malleolus:
- Sural nerve (Combination of the medial sural cutaneous nerve of tibial n. and lateral cutaneous nerve of common peroneal n.)
What nerves supply the skin to the thigh
Anterior: Femoral nerve (anterior cutaneous branch)
Lateral: Lateral femoral cutaneous nerve
Medial: Obturator nerve
Posterior: Posterior femoral cutaneous nerve
Groin:
Genitofemoral nerve (Femoral and genital branch)
Ilioinguinal
Penis: Pudendal nerve
Muscles of the anterior compartment of the leg
- origin
- attachment
- innervation
- function
Muscles of dorsum of foot
- origin
- attachment
- innervation
- function
Muscles of lateral compartment of leg
- origin
- attachment
- innervation
- function
Superficial muscles of posterior leg compartment
- Origin
- Attachment
- Innervation
- function
Deep muscles of the posterior leg
What is the tarsal tunnel, what are its borders and contents?
Borders:
- Floor - concave surface formed by medial aspect of tibia, talus and calcaneus
- covered by flexor retinaculum (which spans obliquely between the medial malleolus and medial tubercle of calcaneus)
Contents (Tom, Dick and A Very Nervous Harry)
[anterior to posterior]
- Tibialis posterior tendon
- Flexor digitorum longus tendon
- Posterior tibial Artery and Vein
- Tibial nerve
- Flexor Hallucis longus tendon
Describe the plantar aponeurosis
they originate from the medial and lateral tubercles of the calcaneus and from the back of that bone below the insertion of the tendo calcaneus. It fans out over the sole and is inserted by five slips, into each of the five toes. The digital slips bifurcate for the passage of the flexor tendons and are inserted around the edges of the fibrous flexor sheaths and into the transverse ligaments that bind together the metatarsal heads.
First Layer of Muscles on Sole of foot
- Origin, attachment, insertion,
Second Layer of muscles on sole of foot
Bones of the foot
Third layer of the foot muscles
- origin
- attachments
- innervation
- function
Fourth Layer of foot muscles
PAD and DAB
The ankle joint ligaments
Two sets of ligaments, originating from each malleolus
Medial malleolus:
Medial (deltoid) ligament (Consists of 4 ligaments), which fan out from malleolus attaching to talus, calcaneus and navicular bone. and attach to spring ligament.
Its Purpose is to resist over-eversion of the foot
Lateral malleolus
- Anterior talofibular
- Posterior talofibular
- Calcaneofibular
Ankle joint movements, blood and nerve supply
Movements:
- Plantarflexion – produced by muscles in the posterior compartment of the leg; gastrocnemius, soleus, plantaris and posterior tibialis
- Dorsiflexion – produced by the muscles in the anterior compartment of the leg; tibialis anterior, extensor hallucis longus and extensor digitorum longus
*Inversion, eversion at subtalar joint
Blood: posterior and anterior tibial arteries
Innervation: deep peroneal and tibial nerves
Talocalcaneonavicular joint and its ligaments, movements, blood supply and innervation
Stability
The subtalar joint is enclosed by a joint capsule, which is lined internally by synovial membrane and strengthened externally by a fibrous layer.
3 ligaments of talocalcaneal (subtalar)part:
- Posterior talocalcaneal ligament
- Medial talocalcaneal ligament
- Lateral talocalcaneal ligament
The interosseous talocalcaneal ligament acts to bind the talus and the calcaneus together, it lies within the sinus tarsi.
3 ligaments of talocalcaneonavicular part:
- Plantar calcaneonaviculr ligament (spring ligament)
- tibionavicular ligament
- half the bifurgate ligament
Movements
- Eversion and inversion movements produced by the muscles of the lateral compartment of the leg and the tibialis anterior muscle respectively
Neurovascular supply
- Arterial supply comes from the posterior tibial and fibular arteries
- Innervation of plantar aspect supplied by the medial or lateral plantar nerve, the dorsal aspect is supplied by the deep fibular nerve
Which joint does inversion/ eversion of the ankle take place? and what muscles perform these actions?
Talocalcaneonavicular joint
Inverts:
- Tibialis anterior (1)
- Tibialis posterior (3)
Everts:
- Peroneus tertius (2)
- Peroneus longus (4)
hese four combine in groups of two to produce their common movement and cancel out their opposing movements. Thus result dorsiflexion (1 and 2), inver sion (1 and 3), eversion (2 and 4) and plantarflexion (3 and 4) of the foot as a whole
What are the three arches of the foot
- transverse arch
- medial longitudinal arch
- lateral longitudinal arch
What are the muscles and ligaments involved in the medial arch of the foot
*if muscles paralysed, ligaments alone cant maintain arch
Muscles:
Flexor hallucis longus
Abductor hallucis
Medial half of flexor digitorum brevis
Tibialis anterior and posterior
Fibularis longus
Ligaments:
Plantar aponeurosis most important
Spring ligament second most important
Plantar ligaments (in particular the long plantar, short plantar and plantar calcaneonavicular ligaments)
What are the muscles and ligaments involved in the lateral arch
Muscles
- fibularis longus
- lateral flexor digitorum brevis , flexor digitorum longus
- abductor digiti minimi
Ligaments
- long plantar, short plantar
- plantar calcaneonavicular
- plantar aponeurosis
Transverse arch of foot what forms this
Bones: Cueiform bones
Ligaments: plantar ligaments and deep transverse metatarsal ligament, plantar aponeurosis
Muscles: peroneus longus and tibialis posteior
adductor hallucis muscle
Femoral nerve injury presentation
Nerve breaks into branches as soon as it enters thigh so usually subject to damage by penetrating injuries to lower abdomen
In a complete lesion
- Extension of quadriceps lost
- Weakness in hip flexion
- Anaesthesia over front of thigh, with lesions that cause pain in the nerve extending potentially to medial side of foot (saphenous branch)
how does damage to the lateral femoral cutaneous nerve damage present
No motor function
Produces parasthesia (meralgia paraesthetica) to upper lateral thigh
How would damage to the obturator nerve present
very rare due to deep position
Motor:
Loss of adduction. This cannot be noticed when walking, but when sitting the affected limb cant cross over the other
Sensation:
Parasthesia over medial thigh
How does damage to the sciatic nerve present?
commonest cause is by misplaced gluteal injections, then trauma/ hip dislocations
Motor
There is paralysis of hamstrings and all the muscles of the leg (supplied by tibial and common peroneal nerve)
*Hamstring power can be difficult to assess, but footdrop is obvious
Sensory:
Parasthesia below knee (but not on medial side of leg as supplied by saphenous nerve)
How does damage to the common peroneal nerve present?
Caused by direct trauma or pressure by plaster casts at neck of fibula
Motor:
- Foot drop (Due to paralysis of extensor muscles by deep peroneal branch). This results in a high step gait
- Peroneus longus and brevis also effected (superficial peroneal branch)
Sensory:
Anaesthesia over lower lateral part of lef and dorsum of foot (But may be little sensory loss)
How does damage to the tibial nerve present?
Uncommon
Motor:
Paralysis of calf muscles (unable to plantarflex). Cant tip toe walk.
Sensory:
anaesthesia sole of foot
Is the acetabulum pointed horizontally?
No, it is directed downwards and slightly backwards
Ossification of the hip
The bone develops in cartilage. Three primary centres appear, one for each bone, near the acetabulum. The centre for the weight-bearing ilium appears first, at the second month, followed by the ischium at the third and pubis at the fourth month of fetal life. At birth the acetabulum is wholly cartilage, and while the ilium is a broad blade of bone the ischium and pubis are no more than tiny bars of bone buried in the cartilage. Growth of these three bones causes them later to approximate each other in a Y-shaped cartilage in the acetabulum. The ischial and pubic rami fuse with each other at about 7 years. Around the whole bone there remain strips of hyaline cartilage as follows; the whole length of the iliac crest, anterior inferior iliac spine, body of pubis at the symphysis, ischial tuberosity and sometimes ischial spine. The Y-shaped cartilage begins to ossify at about 12 years, with the appearance within it of two or three small centres of ossification (ossa acetabuli) which enlarge to fuse with each other and the surrounding bones to close the acetabulum soon after puberty (say 15 years). At the same time bony centres appear in the peripheral strips of cartilage. These fuse with the main bone when growth of the whole body ceases (say 25 years).
Ossification of femur
The whole femur ossifies in cartilage. A centre in the shaft appears at the eighth week of fetal life. A centre for the lower end appears at the end of the ninth fetal month (at birth) and its presence is accept able medicolegal evidence of maturity. This is the growing end of the bone, and the epiphysis, which bisects the adductor tubercle (Fig. 3.56) unites with the shaft after 20 years. A centre appears in the head at 1 year of age, greater trochanter at 3 and lesser trochanter at 12 years. These upper epiphyses fuse with the shaft at about 18 years of age. Note that the neck of the femur is the upper end of the shaft and ossifies as part of it, not from an epiphysis.
ossification of tibia
The shaft ossifies in cartilage from a primary centre that appears in the 8th week of fetal life. The upper epiphysis (the growing end) shows a centre immediately after birth. This joins the shaft at 20 years along the epiphyseal line already noted. A secondary centre for the tuberosity may appear about puberty. The lower epiphysis ossifies at the second year and joins the shaft at 18 years. The epiphyseal line passes a centimetre above the distal end of the shaft and includes the medial malleolus; it is extracapsular.
ossification of fibula
The fibula ossifies in cartilage by a centre in* the shaft which appears in the eighth week. There is an epiphysis at each extremity. The head, the growing end, is exceptional in ossifying later (fourth year) than the lower end (second year). The upper epiphysis fuses with the shaft at 20 years, the lower before this (say 18 years).
Whats the simple rule of lymph drainage in the limbs
In each limb the rule applies that superficial lymphatics follow veins, while deep lymphatics follow arteries. The lymph is taken to lymph nodes lying in groin and axilla.
What muscles laterally rotate the hip
piriformis
obturator internus
obturator externus
Gemeli (superior and inferior)
Quadratus femoris
Sartorius
What muscles adduct the hip
Adductor brevis, longus, magnus
Pectineus
Gracillis
what muscles abduct the hip
gluteus minimus
gluteus medius
tensor fascia late
what muscles flex the hip
Powerful flexors:
psoas and iliacus
weaker flexors;
rectus femoris
sartorius
pectineus
What muscles cause hip extension
Gluteus maximus
Biceps femoris (long head)
semitendinous
semimembranous
what muscles extend the knee
vastus lateralis, medius, intermedius
Rectus femoris
what muscles can rotate the knee
Medial rotation
- Semitendinous
- Semimembranous
Lateral rotation
- biceps femoris
what are the ligaments that comprise of the distal tibiofibular syndesmosis
anterior- inferior tibiofibular ligament
posterior-inferior tibiofubilar ligament
interosseous membrane
inferior transverse ligament
interossoues ligement
What is Scarpa’s fascia?
And why can a femoral hernia not through Scarpa’s fascia
The membranous layer of the superficial fascia of the anterior abdominal wall (Scarpa’s fascia, p. 241) extends into the upper part of the thigh just below the inguinal ligament.
The attachment extends laterally from the pubic tubercle but below the inguinal ligament. It should be noted that the saphenous opening lies below this line, so that a femoral hernia, emerging from the saphenous opening, can never come to lie in the space beneath Scarpa’s fascia. The hernia emerges into ordinary subcutaneous fat and can therefore never become very large.
Lower limb dermatomes
Femeral Hernia Epidemiology:
- More common in which gender?
- More common in females (femoral ring and canal wider in females)
- Much less common than inguinal hernias
*For most hernias a truss is not reliable
Myotomes of lower limbg
(Start with the forward movement)
Hip
- Flexion: L2,3
- Extension: L4,5
Knee
- Extension: L3,4
- Flexion L5,1
Ankle:
- Dorsiflexion: L4,5
- Plantarflexion: S1,2
Inversion L4; Eversion L5, S1
Big Toe:
Extension: L5,S1
Flexion: S1,S2
What is the cruciate anastomosis?
*Cruciate means cross
The transverse branch of the medial circumflex femoral artery meets the transverse branch of the lateral circumflex artery at the lower border of the quadratus femoris. They are joined by an ascending branch of the first perforating artery and the descending branch of the inferior gluteal artery
Whats the trochanteric anastamosis ?
Provides main source of blood supply to femoral head
Formed by descending branch of superior gluteal arterywith the ascending branches of both lateral and medial circumflex femoral arteries. (inferior gluteal artery usually joints the anastamosis)
Branches from the anastamosis are called the retinacular arteries.
The synovial membrane of the knee relation to the cruciate ligaments and bursa
- communication with the suprapatellar bursa has already been noted.
- A hernia ion of synovial membrane beneath the rounded tendon of popliteus produces the banana-shaped popliteus bursa lying in the gutter between the tibia and the head of the fibula (Fig. 3.32). (Popliteus bursae communicates with the knee)
- The bursa beneath the medial head of gastrocnemius always and that beneath the lateral head usually, communicate with the joint. The bursa under the medial head of gastrocnemius usually communicates also with the semimembranosus bursa
The synovial membrane passes infront of the cruciate ligaments.
ossification of patella
the bone forms in hyaline cartilage by a centre that appears at 3 years; there is sometimes more than one centre. Ossification is complete soon after puberty.
Function of ACL
The anterior cruciate ligament prevents backward displacement of the femur on the tibial plateau, but this is unlikely to happen. The anterior cruciate ligament has a much more important role, that of limiting exten sion of the lateral condyle of the femur and of then causing medial rotation of the femur in the ‘screw- home’ position of full extension.
Extension is performed by the quadriceps and is limited by the tension of the anterior cruciate ligament, the oblique popliteal ligament and the collat eral ligaments, but these four ligaments do not tighten simultaneously. As the knee moves into full extension the anterior cruciate ligament is the first to become taut. Extension of the lateral condyle of the femur is thus termi nated. Further extension of the medial condyle is made possible by passive rotation forwards of the lateral condyle around the radius of the taut anterior cruciate ligament. This forces the medial condyle to glide backwards into its own full extension. The medial condyle has a longer and more curved articular surface than the lateral condyle for this very reason
What ventral rami are the tibial and common peroneal divisions of the sciatic nerve derived from?
Tibial nerve - L4,5; S1,2,3
ommon Peroneal - L4,5; S1,2
