Lower limb Flashcards
What attaches to where on the ischial tuberosity?
Upper:
Medial = Semitendinosus + long head of biceps femoris Lateral = Semimembranosus
Lower:
Lateral = adductor magnus
Medial = fascia and connective tissue
What attaches to ischiopubic ramus?
Muscles of medial thigh = adductors
Adductor longus, brevis and magnus
Pectineus
Gracillis
What forms the greater sciatic foramen?
Greater sciatic notch
Ischial spine
Sacrotuberous and sacrospinous ligament
Contents of greater sciatic foramen?
Nerves = sciatic, pudendal, inferior and superior gluteal, nerve to obturator internus, quadratus femoris and gemellus and posterior femoral cutaneous nerve
Vessels = inferior and superior gluteal nerves, internal pudendal vessels
Of the contents of the greater sciatic foramen, which pass above the piriformis?
Superior gluteal vessels and nerve
Which structures pass through both lesser and greater sciatic foramen?
Internal pudendal vessels and nerves
Contents of lesser sciatic foramen?
Nerve to obturator internus
Internal pudendal vessels and nerve
Tendon of obturator internus
Contents of lesser sciatic foramen medial to lateral?
PIN
Pudendal nerve
Internal pudendal vessels
Nerve to obturator internus
+ tendon to obturator internus
What passes through the gap between the inguinal ligament and the pelvic bone?
Muscles = pectineus, psoas major and illiacus
Femoral nerve, artery and vein
Femoral branch of GF
Lateral cutaneous nerve of thigh
Lymphatics
How do we divide the gluteal region muscles?
Superficial larger group = gluteals
Deep lateral hip rotators = Piriformis, gemellus, obturator internus, quadratus femoris
Attachment of the three gluteal muscles?
Maximus = gluteal tuberosity of femur and IT tract Medius = lateral greater trochanter Minimus = anterior greater trochanter
deep muscles of the gluteal region?
All their action is laterally rotate hip and abduct flexed hip
Piriformis
Origin = anterior sacrum
Insertion = Greater trochanter
Nerve = S1, S2
Obturator internus
Origin = obturator foramen
Insertion = Medial greater trochanter / trochanteric fossa
Nerve to obturator internus
Gemellus superior
Origin = ischial spine
Insertion = superior surface of obturator tendon, medial greater trochanter
Nerve to obturator internus
Gemellus inferior
Origin = ischial tuberosity
Insertion = inferior obturator tendon + medial greater trochanter
Nerve to quadratus femoris
Quadratus femoris
Origin = Anterior to ischial tuberosity
Insertion = Quadrate tubercle on intertrochanteric crest
Nerve to quadratus femoris
Superficial muscles of the gluteal region?
Gluteus minimus = abducts femur, prevents pelvic drop
Origin = external ilium between inferior and anterior gluteal lines
Insertion = anterior greater trochanter
Superior gluteal nerve
Gluteus medius = as above
Origin = external ilium, between anterior and posterior lines
Insertion = lateral greater trochanter
Superior gluteal nerve
gluteus maximus = Powerful extensor of flexed hip
Origin = Fascia covering gluteus minimus + external ilium behind posterior gluteal line
Insertion = IT band and gluteal tuberosity of proximal femur
Inferior gluteal nerve
Superior nerve vs gluteal nerve supply?
Superior = medius, minimus and tensor fascia latae
Inferior = Maximus
Which hip replacement approach injures which nerve?
Posterior approach = sciatic nerve
Anterolateral approach = superior gluteal = trendelenberg gait due to loss of adductors
Which arteries do the superior gluteal and inferior gluteal arise from?
Inferior gluteal = anterior trunk of internal iliac
Superior gluteal = posterior trunk of internal iliac
Where does the ligament of head of femur run, what does it contain and significance in children?
Also called ligament of Teres
Attaches at one end to the fovea of femur, other end attaches too acetabular fossa
Contains branch of obturator artery
In children = contains arterial supply to femoral head
3 extracapsular ligament of the hip joint?
Iliofemoral = anterior hip joint
- runs from ilium to intertrochanteric line of femur
Pubofemoral = runs from iliopubic eminence to blend with deep surface of iliofemoral
Ischiofemoral = posterior hip joint
- runs from medial ischium to greater trochanter, deep to iliofemoral
Where does the fascia lata have its one opening and what passes through?
Saphenous opening for great saphenous vein
Opening is just inferior to medial inguinal ligament
What bone does the femur articulate with inferiorly?
Tibia
What angle does the NOF meet the head?
125
What is the site of attachment for iliofemoral ligament?
What else inserts here?
Intertrochanteric crest medially
Quadratus femoris (on quadrate tubercle)
Which muscles attach to greater trochanter?
Gluteus medius and minimus + vastus lateralis
POGO: Piriformis Obturator internus Gemellus Obturator externus
What muscles attach to lesser trochanter?
Psoas major and illiacus
What muscles attach to upper middle part of linea aspera?
Thigh adductors and vastus muscles
Where do the two heads of the gastrocnemius insert?
Popliteus?
Medial head = roughened area above medial epicondyle on femur
Lateral head = facet above lateral epicondyle
Popliteus is just below this
Blood supply to femoral heaD?
Ring formed by medial and lateral femoral circumflex arteries = branch of profounda femoris
Also some small branches from inferior and superior gluteal arteries
In what position does the patellofemoral provide stability?
Full extension
4 ligaments of the knee joint?
MCL = from medial femoral epicondyle to medial tibial epicondyle
- prevents valgus instability
LCL = lateral femoral epicondyle to fibula head = prevents vagus instability
ACL = anterior tibia to lateral intercondylar notch of the femur = prevents tibia sliding anteriorly
PCL = posterior tibia to medial intercondylar notch of femur = Prevents tibia sliding posteriorly
Which ligament does the medial and lateral menisci attach to?
Medial attaches to tibial collateral ligament
Lateral attaches to loose fibres at edge of joint space > doesn’t actually attach to fibular collateral ligament
What ligament interconnects the menisci ?
Anteriorly it is the transverse ligament
Describe the superior surface of tibia?
2 condyles
Separated by intercondylar region = facets for attachment of ACL PCL and menisci
Semimembranosus origin and insertion?
Ischial tuberosity to medial condyle of tibia
What is the continuation of the quadriceps tendon, where does it attach?
Quadriceps tendon continues as patellar tendon
This inserts onto the tibial tuberosity
What attaches to the roughened area below tibial tuberosity?
Combined muscles of gracilis, sartorius and semitendinosus = pes anserinus
ACL injury - mechanism, symptoms and Mx?
High twisting force on bent knee
Loud crack, pain + immediate swelling
Mx = intense physio + surgery
PCL injury - mechanism?
Hyperextension injury
MCL injury - mechanism?
Leg forced into valgus
Meniscal tear - symptoms and mechanism?
Rotational injury
DELAYED knee swelling, joint locking, recurrent effusions and pain
Chondromalacia patellae - mechanism and symptoms?
teenage girls following a knee injury
Pain going down stairs, tenderness + quads wasting
Patellar dislocation - Mechanism, RF’s, imaging?
traumatic primary event.
RF’s = Genu valgum, tibial torsion, high riding patella
needs skyline radiographs
Boundaries of the popliteal fossa?
Lateral = biceps femoris above, plantaris and lateral head of gastrocnemius below
Medial = Semimembranosus/tendinosus above, medial head of gastrocnemius below
Roof = superficial fascia
Floor = Popliteal muscle. and popliteal surface of femur, posterior ligament of knee joint,
Contents medial to lateral of popliteal fossa?
Popliteal artery
Popliteal vein
Small saphenous vein
Tibial and common peroneal nerve
- tibial exits medially deep to margin of plantaris
- common peroneal exits following biceps femoris tendon where it wraps around neck of fibula.
Popliteal fossa - deepest and most superficial structure
Deepest = popliteal artery
Most superficial = tibial and common peroneal nerve
Where does femoral artery become popliteal?
When it passes through adductor hiatus in adductor magnus
What divides up the compartments of the leg?
Interosseous membrane, two inter muscular septa between fibula and deep fascia + direct attachment of deep fascia to periosteum of tibia
What are the different compartments of the lower leg?
Anterior = dorsiflexes, extends toe, inverts foot
Posterior compartment = plantar flexes, flexes toe, inverts foot
Lateral compartment = everts foot
Facets and fossa on lateral malleolus?
Facet for articulation with talus
Posteroinferior to this = fossa for attachment of talofibular ligament
Groove posteriorly for tendons of fibularis longus and brevis
How many apertures does the interosseous membrane have?
2 - one at top one at bottom.
Upper has anterior tibial artery
Lower has anterior peroneal artery
Femoral nerve - root, innervation and course
L2/3/4
Penetrates psoas major - supplies branches to pectineus and iliacus in its abdominal part.
Enters thigh by passing below inguinal ligament and enters femoral triangle.
Branches immediately into anterior and posterior division
Posterior = sartorius and medial/intermediate cutaneous branches
Anterior = quadriceps femoris and saphenous nerve.
Terminal cutaneous branch is saphenous nerve which travels in adductor canal.
Supply: (don't) MIS VQ Scan for PE Medial cutaneous nerve Intermediate cutaneous nerve Saphenous nerve Quadriceps femoris Sartorius Pectineus
Does the saphenous nerve exit the adductor hiatus with femoral nerve?
NO
It pierces directly through connective tissue at the end of the canal
Lateral cutaneous nerve - root and course?
L2/L3
Exits lateral part of psoas major anterior to iliac crest, passes under inguinal ligament at lateral part of it just medial to ASIS
Pierces fascia lata just below ASIS to give 2 branches
What are the 2 branches of the lateral cutaneous nerve and what do they supply?
Anterior branch = skin and fascia of anterolateral knee
Smaller posterior branch = skin from greater trochanter to distal thigh
Pudendal nerve - roots and path and action?
S234
Passes through greater sciatic foramen, then enters perineum passing via lesser sciatic foramen
Passes between piriformis and coccygeal.
Medial to sciatic nerve
Innervates anal sphincter and external urethral sphincter
Cutaneous = surrounding anus and vulva
Pudendal nerve clinically - anaesthesia and late pregnancy affects?
Can be blocked in episiotomy
In late pregnancy foetus can compress = pudendal neuropathy= faecal incontinence
3 branches of the pudendal nerve?
rectal, perineal and dorsal nerve of penis/clitoris
Genitofemoral nerve - roots, course and supply?
L2/3
Passes obliquely through psoas, emerges at medial border and travels on its anterior surface
Divides into genital and femoral branches
Genital travels in inguinal canal within spermatic cord.
Femoral inters thigh posterior to inguinal ligament
Genital = skin of scrota and fascia Femoral = skin over femoral triangle
How can the genitofemoral nerve be injured?
Abdominal surgery / inguinal hernia repair
Obturator nerve - roots and path?
L2/3/4
Travels inferiorly in posterior of psoas major, before exiting at medial part
Passes anterior to sacroiliac joint
Descends on obturator internus into obturator groove
In lesser pelvis lies lateral to internal iliacs and ureter
Enters thigh to give anterior and posterior branches
Obturator nerve - what the two branches supply?
Anterior branch - it is anterior to adductor brevis, and behind pectineus and longus
supplies = Adductor longus, brevis and gracilis
Posterior branch = descends behind adductor brevis
Supplies = obturator externes, adductor brevis and the upper part of adductor magnus
What organ is obturator nerve closely related to?
Bladder - can get twitching of thigh in transurethral resection of bladder tumour
Sciatic nerve - roots, path and supply?
L4-S3
Roots converge at inferior border of piriformis, travels through greater sciatic foramen
Then runs inferolaterally under cover of gluteus maximus
Travels in posterior compartment of thigh superficial to adductor magnus
Travels downwards and at top of popliteal fossa gives tibial and common peroneal
Supply:
Motor: Semimembranosus/tendinosus, biceps femoris and. lower part of adductor magnus
Cutaneous = posterior thigh, gluteal region
Tibial nerve - Route and innervation?
Branch of sciatic
Descends through popliteal fossa and continues in the posterior compartment of the leg on surface of tibialis posterior into sole of foot
Passes into foot via tarsal tunnel posterior to medial malleolus.
Innervates all muscles of posterior compartment EXCEPT SHORT HEAD BICEPS FEMORIS
Innervates all intrinsic muscles of the foot except 1st 2 dorsal interossei (deep peroneal)
two cutaneous branches of tibial nerve?
Medial calcaneal nerve = originates from tibial nerve in lower leg near ankle and descends on medial side of heel
Supply = medial foot / heel
Sural nerve = originates in high leg between two heads of gastrocnemius. Passes down the leg around lateral malleolus
Supply = lower posterior leg and lateral ankle / foot + little toe
Common peroneal nerve - route and innervation?
Branch of sciatic
Passes inferolaterally in popliteal fossa under the cover of the biceps femoris and tendon
Follows the medial margin of this, and passes over lateral head of gastrocnemius
Once it has passed around fibular head it divides into deep and superficial peroneal where it wraps around neck.
Innervation = short head of biceps femoris, lateral cutaneous nerve of calf, superficial and deep peroneal
How can common peroneal be injured?
In legs in Lloyd Davies position = foot drop
If only superficial is injured then no foot drop as deep peroneal also has dorsiflexion innervation
Deep branch of peroneal - route and innervation?
Pierces anterior inter muscular septum to enter anterior compartment of leg
Travels deep to extensor digitorum longus
Passes anteriorly down the ankle joint
Muscles = TEEP (which sounds like deep) Tibialis anterior Extensor hallucis longus Extensor digitorum brevis and longus Peroneus tertius
Cutaneous = web space between 1st and second toe
In anterior compartment syndrome what nerve can be at risk?
Deep peroneal nerve - needs immediate decompression
Superficial peroneal nerve - Route and innervation?
Descends in LATERAL compartment
Passes between peroneus longus and brevis
Just distal to fibula it bifurcates intermediate and dorsal cutaneous nerves
Lateral compartment = peroneus longus and brevis
sensation = dorsum of foot except the deep peroneals web
What is the femoral artery a continuation of?
External iliac
What are the four small branches of the femoral artery?
Superficial epigastric
Superficial circumflex iliac
Superficial external pudendal
Deep external pudendal
All occur in femoral triangle
What is the biggest branch of the femoral and its route?
what are its branches?
Profunda femoris
Passes posteriorly between pectineus and adductor longus
Then between adductor longus and brevis
Eventually penetrates adductor magnus to connect with popliteal branches
Lateral and medial circumflex, + 3 perforating arteries
What is the route of the lateral circumflex branch of the profunda femoris ?
Lateral circumflex:
Ascending branch = deep to fascia tensor lata, joins medial circumflex to form circle around NOF
Descending branch = deep to rectus femoris, pierces vastus lateralis and connects with popliteal branches
Transverse branch = passes laterally to pierce vastus lateralis, then circles shaft of femur to form CRUCIATE ANASTOMOSES around hip.
What is the route of the medial circumflex branch of profunda femoris?
Passes medial around shaft of femur
Passes between pectineus and Iliopsoas
Then passes between obturator externus and adductor brevis
One branch ascends to trochanteric fossa
One passes lateral to form anastomoses around hip
Route of perforating arteries of profunda femoris?
Pass anterior to adductor brevis
All the branches penetrate adductor magnus
Obturator artery - what is it a continuation of, what is its route?
Continuation of internal iliac
Enters medial compartment of thigh via obturator canal
Passes through canal and bifurcates into posterior and anterior branch
Popliteal artery - route?
Continuation of femoral artery.
Passes into posterior compartment of leg between two heads of gastrocnemius and popliteus
Continues inferiorly underneath tendinous arch and between two heads of soles muscle and enters deep compartment
In deep compartment branches to form anterior tibial and tibioperoneal trunk
Posterior tibial artery - course and branches + supply?
Supplies posterior and lateral compartments
Descends in the deep posterior compartment, on superficial surface of tibialis posterior and FDL
Passes via tarsal tunnel behind medial malleolus into sole of foot
2 major branches:
- Circumflex fibular = passes laterally through soleus and back round fibular neck
- Fibular artery = passes along lateral posterior compartment
- has perforating branch through infeiror aperture of interosseous membrane = anastomoses with branch of anterior tibial.
- Terminates by forming network over calcaneus = medial and lateral planter arteries
What nerve is in close proximity to the posterior tibial artery?
Tibial nerve
Crosses the posteiror tibial artery 2.5cm from the origin.
Initially lies medial then crosses to the lateral side of the artery
Anterior tibial artery - course, how it terminates and what it supplies?
Supply = ANTERIOR COMPARTMENT OF THE LEG
Course:
Descends on anterior interosseous membrane
Passes between tendons of extensor digitorum and extensor hallucis longus
Terminates in front of ankle as dorsals pedis
Anterior tibial artery in relation to deep peroneal nerve?
Nerve is lateral proximally
Crosses over anteriorly in the middle third
nerve is then medial to artery in lower third
What is the dorsals pedis a continuation of?
Anterior tibial artery, which itself is a branch of popliteal. Which itself comes from femoral, which is a continuation of external iliac.
Dorsalis pedis - course?
Runs to proximal end of first metatarsal space
Continues forward as first dorsal metatarsal artery
Gives off arcuate artery
Passes under inferior extensor retinaculum
Crossed by extensor hallucis brevis
What veins form the long saphenous vein?
Near its origin what vessel runs near it?
what nerve is it associated with?
Dorsal vein merges with dorsal venous arch
Deep external pudendal artery runs under it - can be injured in surgery
Saphenous nerve
Route of long saphenous vein?
Originates at first digit
Formed by margin of dorsal vein and dorsal venous arch
Passes ANTERIOR to medial malleolus, runs up medial leg
At knee runs over posterior medial epicondyle
then passes laterally in anterior thigh, through saphenous opening of fascia lata
Joins with femoral vein
Tributaries of long saphenous vein?
Medial marginal
Superficial epigastric
Superficial iliac circumflex
Superficial external pudendal veins
what nerve is associated with short saphenous vein?
Sural nerve
Route of short saphenous vein?
Formed at 5th digit with dorsal vein merging with dorsal venous arch
Passes POSTERIOR and inferior to lateral malleolus
Passes between 2 heads of gastrocnemius and drain into popliteal vein
This becomes femoral vein
What nerve supplies anterior compartment of thigh?
Which muscles are in the anterior compartment?
Femoral
Quads and vastus
Psoas major and iliacus
Sartorius
Muscles of the anterior thigh - origin, insertion and action?
Psoas major = hip flexor
Origin = T12-L5 transverse processes + post. abdominal wall
Insertion = Lesser trochanter of femur
Iliacus = hip flexor Origin = Posterior abdominal wall Insertion = lesser trochanter
Sartorius = flex hip, extend knee Origin = ASIS Insertion = inferomedial to tibial tuberosity (anterior to gracilis and semi-tendinosus)
Rectus femoris = flexes thigh and extends knee
Origin = Straight head from ASIS, reflected head from ilium above acetabulum
Vastus medialis
Origin = Medial part of intertrochanteric line, linea aspera and pectineal line
Vastus intermedius
Origin = upper 2/3rds of anterolateral femur
Vastus lateralis
Origin = lateral 2/3rds of IT line, pectineal line and linea aspera
All vasti insert into quadriceps tendon and extend knee
Which nerve specifically supplies sartorius, and what does the middle third of sartorius form?
Superficial femoral
Roof of adductor canal
- contains femoral vessels, saphenous nerve + nerve to vastus medialis
Muscles of posterior compartment of thigh - origin, insertion and innervation?
Biceps femoris short head:
Origin = Lateral lip of linea aspera
Insertion = fibular head
Common peroneal
Biceps femoris long head
Origin = ischial tuberosity
Insertion = fibular head
Tibial
Semitendinosus
Origin = Ischial tuberosity
Insertion = medial surface of proximal tibia
Sciatic
Semimembranosus
Origin = Ischial tuberosity
Insertion = medial condyle tibia
Sciatic
Which muscles sit in the medial compartment of the thigh?
Adductor longus, magnus and brevis
Obturator externus
Gracilis + pectineus
Muscles of medial compartment - origin, insertion and innervation
Gracilis = adducts thigh + flexes knee
Origin = Line on body of pubis, inferior pubic rami, ramus of ischium
Insertion = Medial surface of proximal tibia > between tendon of sartorius and semimembranosus
Obturator
Pectineus = adducts and flexes hip
Origin = Pectineal line of pubis
Insertion = Oblique line from lesser trochanter to linea aspera
Femoral nerve
Obturator externus = Laterally rotates hip
Origin = external obturator membrane and adjacent bone
Origin = Trochanteric fossa
Obturator nerve
Adductor brevis
Origin = Inferior pubic ramus
Insertion = upper third of linea aspera
Obturator nerve
Adductor longus
origin = anterior body of pubis
Insertion = middle third of linea aspera
Anterior division of obturator
Adductor magnus: *Adductor part: Origin = ischiopubic ramus insertion = posterior femur and linea aspera Obturator nerve
*Hamstring part:
origin = Ischial tuberosity
Insertion = adductor tubercle and supracondylar line
Tibial nerve from sciatic
Boundaries of adductor canal and contents?
Laterally = vastus medialis Posteriorly = adductor Magnus and longus Roof = sartorius
Contents = Femoral vessels, saphenous nerve and nerve to vastus medialis
What muscles are in the anterior compartment of the leg and what innervates them all?
PETE Peroneus tertius Extensor digitorum longus Tibialis anterior Extensor hallucis longus
Deep peroneal nerve
muscles of anterior compartment of the leg - section, origin and insertion?
Peroneus tertius = dorsiflex and evert
Origin = medial fibula distally
Insertion = base of 1st metatarsal
Extensor digitorum longus = dorsiflex foot and extend lateral 4 toes
Origin = proximal half of medial fibula and lateral tibial condyle
Insertion = distal and middle phalanges of lateral 4 toes
Tibialis anterior = dorsiflexes and invert foot
Origin = lateral surface of tibia and associated interosseous
Insertion = medial and inferior cuneiform + adjacent base of 1st metatarsal
Extensor hallucis longus = dorsiflex and extend big toe
Origin = middle half of medial fibula and associated interosseous membrane
Insertion = base of distal phalanx of great toe
What nerve innervates the lateral compartment of leg?
Superficial peroneal nerve
Muscles of lateral compartment of lower leg - action, origin and insertion?
Peroneus longus = plantarflex and evert
Origin = upper lateral fibula and fibular head
Insertion = underside of cuneiform and base of first metatarsal
Peroneus brevis = eversion only
Origin = lower lateral fibula
Insertion = lateral tubercle at base of 5th metatarsal
Which nerve innervates the superficial posterior compartment of leg?
Tibial nerve
Muscles of the superficial posterior compartment of the leg - action, origin and insertion?
all three insert via the calcaneal tendon into the posterior calcaneus
GPS
Gastrocnemius = plantarflex foot and flex knee
Medial head = femur above medial condyle
Lateral head = lateral condyle of femur
Plantaris = plantarflex foot and flex knee Origin = inferior part of lateral supracondylar line of femur
Soleus = plantarflex Origin = soleal line and medial tibia
Which nerve innervates all the deep posterior compartment muscles of the leg?
Tibial nerve
Muscles of the posterior deep compartment of the leg - origin, insertion and action?
PFFT
Popliteus, flexor hallucis longus, flexor digitorum longus, tibialis posterior
Popliteus = stabilises and unlocks knee joint Origin = lateral femoral condyle Insertion = posterior proximal tibia
Flexor hallucis longus = flexes great toe
Origin = posterior surface of fibula
Insertion = plantar surface of distal phalanx of big toe
Flexor digitorum longus = flexes lateral four toes
Origin = medial side of posterior tibia
Insertion = plantar surface of base of distal phalanges
Tibialis posterior = inversion and plantar flexion
Origin = posterior interosseous membrane
Insertion = navicular tuberosity
Medial ligaments of the ankle joint?
Deltoid ligament = 4 subdivisions, all from tibia to something
- tibionavicular - navicular tuberosity
- tibiocalcaneal - to sustenaculum of calcaneum
- anterior tibiotalar = attaches to medial talus (deep to the above 2)
- Posterior tibiotalar = medial tubercle of talus
Lateral ligaments of the ankle joint?
From anterior to posterior…
Anterior talofibular = anterior lateral malleolus to adjacent talus
Calcaneofibular = lateral malleolus to tubercle on calcaneus
Posterior talofibular ligament = medial lateral malleolus to posteiror talus
Syndesmosis ligaments?
Anterior inferior, posterior inferior and inferior transverse TIBIOFIBULAR
Interosseous membrane
Structures passing behind medial malleolus?
3 tendons, x1 artery, vein and nerve
From anterior to posterior…..
Tibialis posteiror tendon FDL tendon Posterior tibial vein Posterior tibial artery Tibial nerve FHL tendon
Structures passing behind lateral malleolus?
Deep to superior peroneal retinaculum = peroneus brevis and longus tendon
Superficial to superior peroneal retinaculum = sural nerve and short saphenous vein
What makes up the two longitudinal arches of the foot?
Lateral arch = Calcaneum, talus, cuboid bone and lateral 2 metatarsals
Medial arch = Calcaneum, talus, Navicular bone, three cuneiforms and medial three metatarsals head of talus
What makes up the transverse arch of the foot?
three cuneiforms, cuboid, 5 bases metatarsals
Which is the most superior tarsal bone?
Talus
What does the talus articulate with?
Medially = medial malleolus of tibia
Laterally = lateral malleolus of fibula
Superior surface articulates with inferior tibia
Projects forward to articulate with navicular bone
Posteriorly articulates with calcaneus and has groove for FHL.
Where does calcaneal tendon attach distally?
MIDDLE part of calcaneus = tuberosity
What is on the lower part of the calcaneus and what attaches here?
Calcaneal tubercle
Short plantar ligament
Articulations of the calcaneus?
Projects forward to articulate with cuboid
Superiorly articulates with talus
Medial surface has fibular trochlea = tendons of peroneus longus and brevis run here and at this point diverge
Just superior and posterior to this is roughening = attachment of calcaneofibular ligament.
Medially has groove for flexor hallucis longus
What is superior to fibular trochlear on calcaneus and what attaches here?
Raised area for attachment of calcaneofibular ligament
What does the navicular bone articulate with and what tendon attaches?
Articulates posteriorly with talus, anteriorly with cuneiforms
Has prominent tuberosity for attachment of tibialis posterior tendon
What is the set up of the distal tarsal bones and what do they articulate with?
Cuboid laterally then three cuneiforms moving medially
Cuboid articulates with calcaneus posteriorly, anteriorly lateral 2 metatarsals and medially with lateral cuneiform + navicular
Cuneiforms articulate posteriorly with navicular and anteriorly with the three medial metatarsal bases
What three ligaments support the talocalcaneonavicular joint?
Inferiorly = plantar calcaneonavicular Superiorly = talonavicular Posteriorly = interosseous talocalcaneal ligament
What forms the tarsal tunnel?
Its on posteromedial ankle
Depression on medial malleolus of tibia
Posterior and medial talus
Medial calcaneus and inferior sustenaculum tali
Overlying flexor retinaculum
Where does flexor retinaculum attach?
Superiorly to medial malleolus
Inferiorly behind medial margins of calcaneus
What runs through the tarsal tunnel?
Medial to lateral… (all posterior to medial malleolus)
Tendon of tibialis posterior Tendon of flexor digitorum longus Posterior tibial artery + vein Tibial nerve Tendon of FHL
attachment of the extensor retinaculum?
Superior one is thickening of deep fascia = attached to anterior surface of tibia and fibula
Lower one attaches to upper part of calcaneus
Then two arms move medially - one attaches to medial malleolus, one attaches to medial plantar aponeurosis
Content of extensor retinaculum?
Medial to lateral…
Tendon of tibialis anterior Tendon of EHL Dorsalis pedis artery Peroneus tertius tendon EDL tendons
Fibular retinacula - attachments and contents?
superior one attaches between lateral malleolus and calcaneus
Inferior one attaches to lateral calcaneus (fibular trochlea) and blends with inferior extensor retinaculum
Binds the tendons of the peroneus longus and brevis
What is the plantar aponeurosis, what is it attached to and how does it finish?
Thickening of deep fascia of foot
Attaches to calcaneal tuberosity, extends anteriorly as thick band of tissue.
Then diverges into Digital bands
distal to the MTP joints these bands are joined by superficial transverse metatarsal ligaments
What forms the fibrous sheaths of the toes?
Fibrous arches and cruciate ligaments
What runs within the fibrous arches of toes?
tendons of FHL, FDL, FDB - they enter on the palmar aspect
FDB is inferior to FDL
What runs in extensor hoods?
Tendons of EDL, EDB, EHL
Which muscles are innervated by medial plantar nerve?
Abductor hallucis
Flexor hallucis brevis
FDB
Muscles innervated by medial plantar nerve - action, origin, and insertion?
Abductor hallucis = abducts big toe
origin = medial calcaneus, flexor retinaculum
insertion = base of proximal phalanx
FDB = flexes all joints of the toe except DIP J's Origin = medial calcaneus Insertion = via 4 tendons into middle phalanges of lateral 4 toes
FHB = flexes MTP of big toe
Origin = medial cuboid bone and adjacent lateral cuneiform
Insertion = proximal phalanx of big toe
(tendon contains sesamoid bone)
Which muscles are innervated by the lateral plantar nerve?
Flexor digiti minimi brevis Abductor digiti minimi Adductor hallucis Quadratus plantae Palmar and dorsal interossei
Muscles innervated by lateral plantar - action, origin and insertion?
Flexor digiti minimi brevis - flexes little toe at MTP
Origin = base of metatarsal 5
Insertion = lateral side of base of proximal phalanx
Abductor digiti minimi - abducts little toe at MTP
Origin = tubercle of calcaneus
Insertion = lateral proximal phalanx
Adductor hallucis = adducts towards 2nd toe
Origin = oblique head from peroneus longus tendon, transverse head from plantar surface of lateral 4 MTPJ’s
Insertion = Lateral proximal phalanx of great toe
Quadratus plantae = assists FDL tendon in flexing toes 2-5
Origin = medial calcaneus and lateral calcaneal tuberosity
Insertion = lateral side of tendon of FDL
Dorsal interossei = abduct toes 2-4 at MTPJ (second toe abducts both ways)
Origin = side of adjacent metatarsals
Insertion = extensor hoods and bases of proximal phalanges 2-5
1st and second ones are innervated by deep peroneal too!
Palmar interossei = adduct toes 3-5
Origin = medial metatarsals
Insertion = extensor hoods and base of proximal phalanx 3-5
Which muscles are innervated by deep peroneal?
Origin, insertion and action
Extensor digitorum brevis
Action = Extends MTPJ’s of medial four toes
But cannot extend IP’s without lumbricals
Origin = dorsal foot, calcaneus Insertion = four thin tendons running forward and insert into medial four toes
What innervates the lumbricals in the foot?
1st lumbrical is medial plantar nerve
2-4th lumbrical = lateral plantar nerve
Lumbricals - origin, insertion and action?
Origin:
1st lumbrical is medial to FDL tendon of 2nd toe
The rest then fill in the adjacent gaps between tendons of FDL
Insertion = medial free margin of extensor hoods
Flexes MTPJ’s, extends IPJ’s
Route of the posterior tibial artery?
enters sole via tarsal tunnel
As it passes under flexor retinaculum it branch into medial and lateral plantar arteries
Medial plantar artery vs lateral plantar artery route?
Medial passes deep to abductor hallucis
Passes forward between abductor hallucis and FDB
ends by joining digital branch of deep plantar arch
Lateral artery passes deep to abductor hallucis
Then passes forward between quadratus and FDB
Joins with terminal end of dorsals pedis to form deep plantar arch
What is the course of the dorsalis pedis
What are its branches?
Direct continuation of anterior tibial
Forms as anterior tibial crosses ankle joint
Passes anterior over talus, navicular and intermediate cuneiform
Branches = tarsal, arcuate, first dorsal metatarsal + deep plantar
Great and short saphenous vein - medial or lateral, anterior or posterior to malleolus?
Great saphenous vein = medial = anterior to medial malleolus
Short = lateral = posterior to lateral malleolus
How does tibial nerve split and into what?
Course of the two nerves?
Tibial nerve passes through tarsal tunnel and midway between medial malleolus and heel splits into medial and lateral plantar nerves
Medial plantar:
Passes forward under cover of flexor retinaculum
Lateral to the medial plantar artery
Lateral plantar:
Deep to proximal attachment of abductor hallucis
Passes anterolaterally towards base of 5th metatarsal between FDB and quadratus
Medial to lateral plantar artery
At base of 5th metatarsal it splits into superficial and deep plantar branches
What pathology do we see at superficial plantar nerve?
The common plantar digital branch of this is often the site of Mortons neuroma
= pain in third interspace
Deep peroneal nerve - relation to dorsalis pedis, sensory innervation and motor?
Lateral to dorsalis pedis
web between 1st and second toe
Motor = extensor digitorum brevis
Superficial peroneal = how it enters foot and sensory supply?
Enters via dorsal superficial fascia
Sensory to most of dorsum of the foot, except web suppled by deep peroneal
Sural nerve - branch of, how it enters foot and sensory supply?
Cutaneous branch of tibial nerve
Enters in superficial fascia posterior to lateral malleolus
Supplies thin strip on lateral foot
Saphenous nerve - sensory innervation?
Medial ankle
Draw the sensory innervation of foot?
Good luck
What nerve supplies the deep posterior compartment of the leg?
Where do 3 of these muscles all travel?
Tibial nerve
3 of them - Tom, Dick and Harry - all pass posterior to medial malleolus:
Tibialis posterior
FDL
FHL
