Lower Limb Flashcards
which compartment of the thigh is sartorius in?
anterior (most superficial)
Origin of sartorius?
ASIS
Insertion of sartorius?
Medial surface of the of the body of the tibia (upper part). It inserts anterior to gracilis and semitendinosus
Nerve supply of sartorius?
Femoral nerve (L2,3 -root values for sartorius)
Action of sartorius?
Flexor of the hip and knee, slight abducts the thigh and rotates it laterally
It assists with medial rotation of the tibia on the femur. For example it would play a pivotal role in placing the right heel onto the left knee ( and vice versa)
Boundaries of the femoral triangle?
superior: inguinal ligament
lateral: sartorius
medial: adductor longus
floor: Iliopsoas, adductor longus and pectineus
roof:Fascia lata and Superficial fascia
Superficial inguinal lymph nodes (palpable below the inguinal ligament)
Long saphenous vein
Contents of the femoral triangle?
Femoral vein (medial to lateral)
Femoral artery-pulse palpated at the mid inguinal point
Femoral nerve
Deep and superficial inguinal lymph nodes
Lateral cutaneous nerve
Great saphenous vein
Femoral branch of the genitofemoral nerve
Muscular innervation of the deep peroneal nerve?
Tibialis anterior
Extensor hallucis longus
Extensor digitorum longus
Peroneus tertius
Extensor digitorum brevis
Cutaneous innervation of the deep peroneal nerve?
Web space of the first and second toes
Actions of deep peroneal nerve?
Dorsiflexion of ankle joint
Extension of all toes (extensor hallucis longus and extensor digitorum longus)
Eversion of the foot
Nerve roots of deep peroneal nerve?
L4, L5, S1, S2
What nerves pass through the greater sciatic foramen?
Sciatic Nerve
Superior and Inferior Gluteal Nerves
Pudendal Nerve
Posterior Femoral Cutaneous Nerve
Nerve to Quadratus Femoris
Nerve to Obturator internus
which vessels pass through the greater sciatic foramen?
Superior Gluteal Artery and vein
Inferior Gluteal Artery and vein
Internal Pudendal Artery and vein
why is piriformis useful?
The piriformis is a landmark for identifying structures passing out of the sciatic notch
what is above piriformis?
Above piriformis: Superior gluteal vessels
what is below piriformis?
Below piriformis: Inferior gluteal vessels, sciatic nerve (10% pass through it, <1% above it), posterior cutaneous nerve of the thigh
Structures passing through the greater and lesser sciatic foramen?
Pudendal nerve
Internal pudendal artery
Nerve to obturator internus
Structures passing through the lesser sciatic foramen?
Tendon of the obturator internus
Pudendal nerve
Internal pudendal artery and vein
Nerve to the obturator internus
Superior and inferior borders of the greater sciatic foramen?
Superior: Anterior sacroiliac ligament
Inferior: Sacrospinous ligament and the ischial spine
Muscles of the anterior compartment of the lower leg?
Tibialis anterior
Extensor digitorum longus
Peroneus tertius
Extensor hallucis longus
Anterior tibial artery
Muscles of the peroneal compartment of the lower leg?
peroneus longus
peroneus brevis
Muscles of the superficial posterior compartment of the lower leg?
Gastrocnemius
Soleus
Muscles of the deep posterior compartment of the lower leg?
Flexor digitorum longus
Flexor hallucis longus
Tibialis posterior
Popliteus
Which nerve supplies the posterior compartment of the lower leg?
Tibial
Which nerve supplies the peroneal compartment of the lower leg?
Superficial peroneal nerve
Which nerve supplies the anterior compartment of the lower leg?
Deep peroneal nerve
Contents of the popliteal fossa?
Popliteal artery and vein
Small saphenous vein
Common peroneal nerve
Tibial nerve
Posterior cutaneous nerve of the thigh
Genicular branch of the obturator nerve
Lymph nodes
Lateral boundary of the popliteal fossa?
Biceps femoris above, lateral head of gastrocnemius and plantaris below
Medial boundary of the popliteal fossa?
Semimembranosus and semitendinosus above, medial head of gastrocnemius below
Floor of the popliteal fossa?
Popliteal surface of the femur, posterior ligament of knee joint and popliteus muscle
Roof of the popliteal fossa?
Superficial and deep fascia
Which structures pass through the greater and lesser sciatic foramina?
Structures passing through the lesser and greater sciatic foramina (medial to lateral): PIN
Pudendal nerve
Internal pudendal artery
Nerve to obturator internus
Origin of long head of biceps femoris?
ischial tuberosity
Insertion of the long head of biceps femoris?
Fibular head
Innervation of long head of biceps femoris?
Tibial division of sciatic nerve (L5, S1, S2)
Arterial supply of long head of biceps femoris?
Profunda femoris artery, inferior gluteal artery, and the superior muscular branches of popliteal artery
Origin of short head of biceps femoris?
Lateral lip of linea aspera, lateral supracondylar ridge of femur
Insertion of short head biceps femoris?
Fibular head
Innervation of short head of biceps femoris?
Common peroneal division of sciatic nerve (L5, S1, S2)
Arterial supply of short head of biceps femoris?
Profunda femoris artery, inferior gluteal artery, and the superior muscular branches of popliteal artery
What separates the popliteal vessels from the PCL?
Oblique popliteal ligament
What does the superior mesenteric vein drain into?
the portal vein
What are the contents of the adductor canal?
saphenous nerve
superficial femoral artery
superficial femoral vein
Which structures pass posteriorly to the medial malleolus?
Tom Dick And Nervous Harry
T ibialis posterior tendon
flexor Digitorum longus
A artery (posterior tibial)
N erve (tibial)
H allucis longus
Ligaments of ankle joint?
Deltoid ligament (medially)
Lateral collateral ligament
Talofibular ligaments (both anteriorly and posteriorly)
The calcaneofibular ligament is separate from the fibrous capsule of the joint. The two talofibular ligaments are fused with it.
components of tib/fib syndesmosis?
Antero-inferior tibiofibular ligament
Postero-inferior tibiofibular ligament
Inferior transverse tibiofibular ligament
Interosseous ligament
Features associated with L3 nerve root compression?
Sensory loss over anterior thigh/knee
Weak quadriceps
Reduced knee reflex
Positive femoral stretch test
Features associated with L5 nerve root compression?
Sensory loss dorsum of foot
Weakness in foot and big toe dorsiflexion
Reflexes intact
Positive sciatic nerve stretch test
Features associated with S1 nerve root compression?
Sensory loss posterolateral aspect of leg and lateral aspect of foot
Weakness in plantar flexion of foot
Reduced ankle reflex
Positive sciatic nerve stretch test
What innervates TFL?
Superior gluteal nerve
What supplies the hamstring component of adductor magnus?
sciatic
What forms the lumbar plexus?
The lumbar plexus is formed by the ventral rami of L1-4
What forms the sacral plexus?
The sacral plexus is formed by the
Lumbosacral trunk (L4,5)
This is a branch of the lumbar plexus
Ventral rami of S1-S4
What does the lumbar plexus supply?
gluteal, anterior and adductor compartments:
Femoral Nerve (L2,3,4)
-Derived from the posterior divisions
Obturator Nerve (L2,3,4)
-Derived from the anterior divisions
What does the lumbosacral trunk form?
L4,5 -> sacral plexus
Nerves to the abdomen and perineum only from lumbar plexus?
Iliohypogastric (L1)
Nerves to abdomen and perineum, also with cutaneous branches to the lower limb?
lioinguinal nerves (L1)
Genitofemoral nerve (L1, L2)
Cutenaous nerve to the lower limb?
Lateral femoral cutaneous (L2, L3)
What is the sciatic nerve a combination of?
Peroneal (fibular) nerve
Tibial nerve
What are the roots of the sciatic?
Sciatic nerve (L4-S3)
Nerves that supply the gluteal compartment? (sacral plexus)
The nerve to piriformis (S1,2)
The nerve to nerve to obturator internus (L5 + S1,2)
The superior gluteal nerve (L4,5 + S1)
The inferior gluteal nerve (L5 + S1,2)
Other nerves of sacral plexus?
The posterior cutaneous nerve of the thigh (S1-3)
The pelvic splanchnic nerves (S2-4) – parasympathetic*
The pudendal nerve (S2-4)*
What does the femoral nerve innervate?
Innervates all muscles in anterior compartment of thigh
Also innervates the pectineus of the adductor compartment
Sensory cutaneous branches of femoral nerve?
Medial femoral cutaneous nerve: Medial part of anterior thigh*
Intermediate femoral cutaneous nerve: Middle part of anterior thigh*
Saphenous nerve: anteromedial knee, medial leg and foot
What are the anterior and posterior branches of the obturator nerve relative to?
adductor longus
What does obturator innervate?
Innervates all of the muscles in the adductor compartment except?
The hamstring half of the adductor magnus
Pectineus
what does the sciatic nerve innervate?
Tibial nerve (almost all)
Semitendinosus
Semimembranosus
Long head of biceps femoris
Hamstring component of adductor magnus
Common peroneal:
Short head of biceps femoris
What does the superior gluteal nerve innervate?
Gluteus medius, minimus and tensor fascia lata
What does the inferior gluteal nerve innervate?
Gluteus maximus
What does the nerve to obturator internus innervate?
Obturator internus and gamellus superior (L5-S2)
What does the nerve to quadrates femoris innervate?
(L4-S1
Quadratus femoris and gamellus inferior
What does the saphenous nerve innervate?
cutaneous anteromedial knee, medial leg and foot
Contents of lesser sciatic foramen?
Pudendal Nerve and Pudendal Vessels (going into the perineum)
Tendon of obturator internus
Where is the tarsal tunnel?
posteromedial to the ankle
structures pass toPlantar Aspect
what structures pass through the tarsal tunnel?
Tom, Dick And Very Naught Harry
Tibialis Posterior, Flexor Digitorum Longus, Posterior Tibial Artery, Posterior Tibial Vein, Tibial Nerve, Flexor Hallucis Longus
What structure forms the tarsal tunnel?
Formed by Flexor Retinaculum on posteromedial side of ankle (behind Medial Malleolus
which muscles make up triceps surae?
Gastrocnemius + Soleus
Actions of gastrocnemius?
Plantarflexion, Knee Flexion
Proximal and distal attachments of gastrocnemius?
Medial Head – Superior to medial femoral condyle
Lateral Head - Superior to lateral femoral condyle
Distal: calcaneus
Proximal and distal attachments of plantari?
Proximal:
Inferior part of lateral supracondylar line of femur
Distal:
Calcaneal tendon
Actions of soleus?
Plantarflexion
Origin and insertion of soleus?
Proximal:
Soleal line and medial border of tibia
Posterior fibular head
Distal:
Calcaneal tendon
Action of popliteus?
Stabilises knee joint and limits lateral rotation of tibio-femoral joint
“Unlocks” the knee joint
Origin and insertion of popliteus?
Proximal:
Lateral femoral condyle
Distal:
Posterior surface of tibia
Attachments of ACL?
Superior: Lateral Wall of Femoral Intercondylar Fossa
Inferior: Anterior Tibial Intercondylar region
Attachments of PCL?
Superior: Medial Wall of Femoral Intercondylar Fossa
Inferior: Posterior Tibial Intercondylar region
What are the 7 tarsal bones?
Proximal: talus/calcaneus
Intermediate: navicular
Distal:3x cuneiforms
Which tendon are the sesamoid bones within?
Flexor Hallucis Brevis
Flexor Hallucis Longus traverses through these
medial ankle ligaments?
Tibiocalcaneal
Tibionavicular
Anterior tibiotalar
Posterior tibiotalar
lateral ankle ligaments?
Anterior talofibular
Posterior talofibular
Calcaneofibular
What makes up the achilles tendon?
Gastrocnemius
Soleus
Plantaris
Proximal attachments of tibialis posterior?
Posterior interosseous membrane
Tibia/Fibula
Distal attachments of tibias posterior?
Navicular Tuberosity
Medial Cuneiform
Actions of tibilialis posterior?
Plantarflexion, Foot Inversion
Also support of Medial Arch
Proximal attachment of flexor hallucis longus?
Posterior interosseous membrane
Fibula
Distal attachment of flexor hallucis longus?
Plantar surface of Base of Distal Phalanx of Great Toe
Proximal attachment of flexor digitorum longus?
Medial Tibia
Distal attachment of flexor digitorum longus?
Plantar surfaces of Base of Distal Phalanx of Lateral 4 Toes
Which muscles are found in the lateral compartment of the leg and what is their nerve supply?
Fibularis longus
Fibularis brevis
Superficial peroneal nerve (branch of common)
Action of lateral compartment muscles of leg?
foot eversion
plantarflexion
Proximal attachment of fibularis longus?
Upper lateral surface/Head of fibula
Distal attachment of fibularis brevis?
Base of 1st Metatarsal
Medial cuneiform
action of fibulas brevis?
foot eversion
Proximal attachment of fibularis brevis?
Lower 2/3 of lateral surface of fibula
Distal attachment of fibularis brevis?
Base of 5th Metatarsal
Which muscles are in the anterior compartment of the leg?
and nerve supply?
Tibialis Anterior
Extensor Hallucis Longus
Extensor Digitorum Longus
Peroneus Tertius
Deep peroneal nerve
What movements does the anterior leg allow?
Dorsiflexion
Toes extension
Foot inversion
Actions of tibialis anterior?
Dorsiflexion, Foot Inversion, Support of medial arch of foot
Proximal attachments of tibialis anterior?
Lateral Tibia
Anterior interosseous membrane
Distal attachments of tibialis anterior?
Medial Cuneiform
Base of 1st Metatarsal
Actions of extensor hallucis longus?
Extension of Great Toe, Dorsiflexion
Proximal and Distal attachments of extensor hallucis longus?
Proximal:
Medial Fibula
Anterior Interosseous Membrane
Distal:
Dorsal surface of Base of Distal Phalanx of Great Toe
Actions of extensor digitorum longus?
Extension of Lateral 4 Toes, Dorsiflexion
Proximal and distal attachments of extensor digitorum longus?
Proximal:
Medial Fibula
Lateral Tibial Condyle
Distal:
Dorsal surface of Bases of Distal & Middle Phalanges of Lateral 4 Toes
via Dorsal Digital Expansions
Actions of fibularis tertius?
Dorsiflexion, Eversion of Foot
Proximal and distal attachment of fibularis tertius?
Proximal:
Distal, Medial Fibula
Distal:
Dorsal surface of Base of 5th Metatarsal
what are the 4 layers of muslces in the feet (superficial to deep)?
1st Layer:
Abductor hallucis, Abductor digiti minimi, FDB
2nd Layer:
Quadratus plantae, Lumbrical, FHB, FDMB
3rd Layer:
Adductor halluces,
4th Layer:
4 Dorsal / 3 Plantar interossei
Action and innervation of abductor hallucis?
abduct big toe at MTPJ and can flex toe
medial plantar nerve (s2/3)
What are the muscles in first layer of the foot?
Abductor hallucis, Abductor digiti minimi, FDB
origin and insertion of abductor hallucis?
prox:medial process of calcaneal tuberosity/flexor retinaculum/aponeurosis
distal: medial aspect of base of proximal phalanx big toe
What are the muscles in second layer of the foot?
Quadratus plantae, Lumbrical, flexor digiti minimi brevis, flexor hallucis brevis
what are the muscles in the third layer of the foot?
Adductor hallucis
What are the muscles in the fourth layer of the foot?
plantar and dorsal interossei
Main anastomotic vessels of the knee?
superior medial genicular artery
superior lateral genicular artery
inferior lateral genicular artery
inferior medial genicular artery
What does the popliteal artery branch into?
Posterior Tibial Artery - supplies deep post compt
Enters Sole of Foot (via Tarsal Tunnel posterior to Medial Malleolus)
Anterior tibial artery -supplies ant compt
What does the posterior tibial artery branch into?
peroneal artery (posterior and lateral compartment)
dorsalis pedis
superficial veins of the leg?
Great/Small Saphenous Veins
In subcutaneous connective tissue
Interconnect with deep system using perforating veins
Great saphenous-origin, ascent and drainage?
Origin: Medial Side of Dorsal Venous Arch
Ascent: Anterior to Medial Malleolus
Medial side of leg, knee and thigh
Drainage:
Femoral vein inferior to inguinal ligament
Sapheno-femoral junction
Small saphenous vein origin, ascent and drainage?
Origin:Lateral Side of Dorsal Venous Arch
Ascent: Posterior surface of leg
Drainage into:
Penetrates deep fascia Popliteal Vein
Popliteal vein proximal to knee become femoral vein
Which foot muscles does the tibial nerve supply?
All Intrinsic Foot Muscles (except extensor digitorum brevis)
What does the tibial nerve divide into in the foot?
Medial plantar nerve
Lateral plantar nerve
Which nerve supplies extensor digitorum brevis?
deep peroneal nerve
How is the sural nerve formed and what does it originate from?
Formed from branch of Tibial Nerve + Common Peroneal
originates between the two heads of gastrocnemius
what does the sural nerve supply?
Supplies skin on:
Lower Posterolateral Leg
Lateral Foot/Little Toe
Commonly harvested for nerve repair
Motor segmental nerve supply for hip flexion?
L2, L3
Motor segmental nerve supply for hip extension?
L4, L5
Motor segmental nerve supply for knee extension?
L3, L4
Motor segmental nerve supply for knee flexion?
L5,S1
Motor segmental nerve supply for ankle dorsiflexion?
L4, L5
Motor segmental nerve supply for ankle plantar flexion??
S1, S2
Which nerve supplies the medial leg?
Femoral nerve (Saphenous Branch/saphenous nerve)
which nerve supplies the Calf region (posterior leg) and lateral foot?
Sural nerve
Which nerve supplies the Anterio-lateral leg and dorsal foot?
Superficial peroneal
Which nerve supplies the first toe web?
First toe web
Which nerve supplies the sole of foot?
Tibial nerve
What are the two reflex arcs in the lower limb?
Ankle (S1,S2) – Tap Calcaneal Tendon:
-Efferent Muscles – Posterior compartment of leg
-Gastrocnemeus
-Soleus
-Plantaris
Knee (L3,4) – Tap Patellar Tendon:
Efferent Muscles – Anterior compartment of thigh
Quadriceps femoris
Symptoms with damage to common peroneal nerve?
Sensory: Loss to the dorsum of the foot (supplied by superficial and deep peroneal nerves)
Motor: Foot drop
Reflex:No loss of reflex
Autonomic: Decreased sweating in cutaneous region of peroneal nerve
Trophic: Damage to sole of foot due to the pressure as a result of foot drop
Which adductor compartment muscle does the femoral nerve supply?
pectineus
Important cutaneous branches of femoral nerve?
Medial femoral cutaneous nerve: Medial part of anterior thigh*
Intermediate femoral cutaneous nerve: Middle part of anterior thigh*
Saphenous Nerve: anteromedial knee, medial leg and foot
Which adductor muscles does the obturator nerve NOT supply?
The hamstring half of the adductor magnus
Pectineus
What muscle do the anterior and posterior parts of the obturator nerve split around?
Adductor brevis
What do the posterior parts of the obturator nerve supply?
Obturator externus
Adductor portion of adductor magnus
Which intrinsic muscle in the foot does the deep peroneal nerve innervate?
Extensor digitorum brevis
What is meralgia paraesthetica?
Compression of lateral cutaenous nerve of the thigh as it passes under inguinal ligament (2cm medical to ASIS)
What does injury to the superior gluteal nerve cause and how is it commonly injured?
trendelenberg gait
during hip replacement; nerve lies 5cm proximal to the tip of the greater trochanter
Femoral triangle contents within the femoral sheath and otuside ?
Within the femoral sheath;
Femoral artery
Femoral vein
Lymphatics
Outside of the femoral sheath:
Femoral nerve
Psoas major tendon*
Pectineus*
Lateral femoral cutaneous nerve
Branches of the femoral artery within the femoral triangle?
Profunda femoris
the superficial circumflex iliac artery*
the superficial epigastric artery*
the superficial external pudendal artery*
the deep external pudendal artery*
What does the femoral artery become after giving off profunda femoris (and before becoming the popliteal?)
superficial femoral artery
What two important branches does the profunda femoris give off?
Lateral and medial circumflex arteries (and perforators)
What is a great saphenous vein cut down?
Emergency procedure, where venous cannulation is not possible
For example, in a shocked patient
Incision made 2cm anterior and proximal to the medial malleolus to gain direct access to the great saphenous vein under direct vision
Cannula inserted into vein to resuscitate patient
What is a great saphenous vein cut down?
Emergency procedure, where venous cannulation is not possible
For example, in a shocked patient
Incision made 2cm anterior and proximal to the medial malleolus to gain direct access to the great saphenous vein under direct vision
Cannula inserted into vein to resuscitate patient
Which structure is most liable to damage after dissection at the saphenofemoral junction?
deep external pudendal artery
What is adductor canal compression syndrome?
compression of the femoral artery by the musculotendinous band from adductor magnus muscle
(commonly young men)
Surface marking for femoral artery vs surface marking for deep inguinal ri
Mid inguinal point= surface marking for femoral artery
Mid point of the inguinal ligament = surface marking for deep inguinal ring.
