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MRCS Part B > Lower Limb > Flashcards

Lower Limb Flashcards

1
Q

What type of joint is the hip joint?

A

Ball in socket, synovial joint

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2
Q

What are the ligaments of the hip joint?

A

Intracapsular:
- Ligament of the head of the femur running from the acetabular fossa to the fovea of the femur.

Extracapsular:
- Ileo-femoral (Y shape): from ASIS to intertrochanteric line.
- Pubofemoral (Triangular shape): from superior pubic rami to intertrochanteric line.
- Ischiofemoral (spiral shape): from the ischial body to the greater trochanter

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3
Q

What is the vascular supply to the hip joint?

A

Small artery within the intracapsular ligament of the femoral head.
Medial and lateral circumflex arteries which are branches of the profunda femoris.

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4
Q

What attaches to the greater trochanter?

A

The ischiofemoral ligament.
Muscles:
- Piriformis
- Gluteus medius and minimus
- Vastus lateralis
- Gemelli
- Obturator internus

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5
Q

What muscle attaches to the lesser trochanter?

A

Iliopsoas

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6
Q

Where does the quadratus femoris attach to?

A

The intertrochanteric crest (on the posterior aspect of the proximal femur)

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7
Q

Where does the gluteus maximus muscle attach on the femur?

A

The gluteal tuberosity, proximal to the linea alba

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8
Q

Which condyle on the femur is more prominent and what is the clinical significance of this?

A

The lateral condyle is more prominent to prevent lateral subluxation of the patella.

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9
Q

What is the fascia lata?

A

This is a sheet of tough fibrous tissue in the hip area which lies deep to the skin.
It originates at the iliac crest, sacrum and coccyx, inguinal ligament and the ischial tuberosity.
It has a lateral thickening called the IT band which receives a tendon from the gluteus maximus.
It attaches to the femoral and tibial condyles, patella, head of fibula and tibial tuberosity and then becomes the deep fascia of the leg.

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10
Q

What is the opening in the fascia lata called?

A

This is the saphenous opening (where the saphenous vein enters)

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11
Q

What is the IT band and what are its function?

A

This is a longitudinal thickening of the fascia lata which is strengthened by additional fibres of the glut max.

Functions:
- Movement (extensor, abductor and lateral rotator)
- Compartmental division (due to the intermuscular septum)
- Forms a muscular sheath around the TFL.

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12
Q

What is the TFL? What is the innervation and insertions?

A

The tensor fascia lata is a muscles which acts as a flexor, abductor and internal rotator.
It is innervated by the superior gluteal nerve.
It originates at the iliac crest and inserts onto the IT band.
It acts to limit the outward expansion and reduces the force required to move the hip.

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13
Q

What are the origins/insertions, actions and innervations of the gluteus maximus?

A

Origin: Surface of the ileum, sacrum and coccyx.
Insertion: the gluteal tuberosity and some fibres into the IT band
Innervation: Inferior gluteal nerve
Action: hip extensor, assists in lateral rotation.

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14
Q

What are the origins/insertions, actions and innervations of gluteus medius?

A

Origin: surface of the ileum.
Insertion: Greater trochanter
Innervation: superior gluteal nerve
Action: abduct and medially rotate. A key pelvis stabiliser.

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15
Q

What are the origins/insertions, actions and innervations of gluteus minimus?

A

Origin: ileum
Insertion: greater trochanter
Innervation: superior gluteal nerve
Action: pelvic stabiliser, abductor and medial rotator.

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16
Q

What is the function of the superior gluteal nerve and what sign may you see if it is damaged?

A

Innervates the gluteus medius and minimus, which have a role in stabilising the pelvis during locomotion. If the nerve is damages then a Trendelenburgs sign develops.

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17
Q

What are the origins/insertions, actions and innervations of piriformis?

A

Origin: Anterior sacrum
(through greater sciactic foramen)
Insertion: Greater trochanter
Innervation: Nerve to piriformis.
Action: abducts and laterally rotates hip.

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18
Q

What are the origins/insertions, actions and innervations of obturator internus?

A

Origin: pubis and ischium at the obturator foramen.
Passes via the lesser sciatic foramen
Insertion: Greater trochanter
Innervation: Nerve to obturator
Action: Laterally rotates

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19
Q

What are the origins/insertions, actions and innervations of gemmeli?

A

Origin: The superior originates from the ischial spine and the inferior from the ischial tuberosity (either side of the obturator internus)
Insertion: Greater trochanter
Innervation: superior is the nerve to the obturator and inferior is the nerve to the quadratus femoris.
Action: Lateral rotation and abduction.

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20
Q

What are the origins/insertions, actions and innervations of quadratus femoris?

A

Origin: Ischial tuberosity.
Insertion: The intertrochanteric crest
Innervation: Nerve to quadratus femoris
Action: Acts to laterally rotate the hip.

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21
Q

What are the differences between the male and female pelvis?

A

Male:
- thicker and heavier
- deep false pelvis
- narrow
- heart shaped inlet
- small outlet
- suprapubic angle <70
- large acetabulum
- Oval obturator foramen
- large acetabulum
- narrow sciatic notch.

Female:
- thinner and lighter
- shallow false pelvis
- wide and oval shaped inlet
- large outlet
- suprapubic angle >80
- small acetabulum
- triangular obturator foramen

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22
Q

What structures pass through the greater sciatic foramen?

A

Nerves: superior gluteal, inferior gluteal, sciatic nerve, posterior cutaneous nerve of the thigh, pudendal nerve, nerve to quadratus femoris, nerve to obturator
Arteries: superior gluteal and inferior gluteal, internal pudendal
Muscles: piriformis

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23
Q

What are the boundaries of the greater sciatic foramen?

A

Superior - ASIS
Posteromedial - sacrotuberous ligament
Anterolateral - greater sciatic notch of the ileum
Inferior - sacrospinous ligament/ischial spine.

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24
Q

What are the boundaries of the lesser sciatic foramen?

A

Superior: The sacrospinous ligament and the ischial spine
Anterior: ischial spine, lesser sciatic notch and ischial tuberosity
Posterior: sacrotuberous ligament

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24
What are the contents of the lesser sciatic foramen?
Internal pudendal artery and vein Pudendal nerve Nerve to the obturator internus
25
Where does the lumbar plexus lie?
Within the psoas muscle?
26
Which nerve roots contribute to the lumbar plexus?
L1-L4
27
What are the branches of the lumbar plexus?
Iliohypogastric (L1): internal oblique and transversus abdominis, provides sensation to posterolateral gluteal skin Ilio-inguinal (L1): innervates internal oblique and transversus abdominus, and sensory to the penis root and scrotum Genitofemoral (L1-2): sensory to the scrotum/labia and upper thigh, motor to cremasteric muscle Lateral Cutaneous (L2-L3): sensory to the lateral thigh Obturator (L2-L4): motor and sensory to the medial thigh Femoral (L2-L4): motor to anterior thigh, sensory to anterior thigh and medial leg.
28
Which nerve roots form the sacral plexus?
L4-S4
29
Where is the sacral plexus located?
On the posterior pelvic wall, anterior to the piriformis. The branches either remain in the pelvis or exit via the greater sciatic foramen.
30
What are the branches of the sacral plexus?
Superior gluteal (L4-S1): glut med and min, TFL Inferior gluteal (L5-S2): glut max Sciatic (L4-S3): posterior thigh and leg muscles, lateral leg muscles, sensation to posterolateral leg and foot. Posterior Femoral cutaneous (S1-S3): sensation to posterior thigh and perineaum Pudendal (S2-4): skeletal muscles of the external urethral and anal sphincter and levator ani, and sensation to the clitoris, penis and perineum + nerve to piriformis, nerve to obturator internus and nerve to quadratus femoris.
31
What are the roots of the sciatic nerve?
L4-S3 (from the lumbosacral plexus)
32
What is the course of the sciatic nerve?
Leaves pelvis via the greater sciatic foramen (inferior to piriformis). Crosses the posterior surface of the gemelli, obturator internus and quadratus femoris and passes into the posterior thigh deep to the long head of the biceps. In the thigh gives off branches to innervate the hamstring and the hamstring portion of the adductor magnus. It terminates by branching into the tibial and common peroneal nerves.
33
What are the functions of the sciatic nerve?
Motor: Posterior compartment of the thigh, hamstring potion of the adductor magnus. Also innervates the lower leg via the tibial and common peroneal branches. Sensory: none directly but supplies the posterolateral leg and the foot via its terminal branches.
34
What are the boundaries of the femoral triangle?
Medial: adductor longus Lateral: sartorius Superior: inguinal ligament Floor: iliopsoas muscle, pectineus and adductor longus Roof: fascia lata
35
What are the contents of the femoral triangle?
Femoral Nerve, Artery, Vein and canal
36
What are the boundaries of the femoral canal?
Medial: lacunar ligament Lateral: Femoral vein Anterior: inguinal ligament Posterior: pectineal muscle/tendon
37
What are the contents of the femoral canal?
Lymphatic vessels and Cloquets lymph node. Loose connective tissue to allow for expansion of the femoral vein
38
What are the roots of the femoral nerve?
L2-L4 (from the lumbar plexus)
39
What is the course of the femoral nerve?
Arises from the lumbar plexus and travels through the psoas major muscle, passes beneath the inguinal ligament, via the femoral triangle and then 4cm below the inguinal ligament it divides into an anterior and posterior division. The anterior becomes the anterior cutaneous branch and the branches to the pectineus and the sartorius. The posterior becomes the saphenous nerve (passes into adductor canal) and the branch to the quadriceps.
40
What is the function of the femoral nerve?
Motor: anterior compartment of the thigh (hip flexors and knee extensors) Sensation to the anteromedial thigh and the medial aspect of the leg and foot.
41
What are the roots of the obturator nerv?
L2-L4
42
What is the function of the obturator nerve?
Motor and sensation to the medial compartment of the thigh
43
Describe the venous drainage of the lower limb?
DEEP: The dorsal venous arch mainly drains into the superficial veins, but some drains into the anterior tibial vein. The medial and lateral plantar arches combine to form the posterior tibial and peroneal vein. The 3 veins form the popliteal vein and this enters the adductor canal to become the femoral vein. SUPERFICIAL: The long saphenous vein is formed by the dorsal venous arch and the dorsal vein of the great toe. It ascends anterior to the medial malleolus, posterior to the medial condyle of the knee and then pierces the fascia lata to enter the femoral vein. The small saphenous vein is formed by the dorsal venous arch and the dorsal vein of the little toe and it ascends posterior to the medial malleolus to then drain into the popliteal vein.
44
What are the boundaries and contents of Hunters canal?
Hunters canal AKA adductor canal Anteromedial: Sartorius Lateral: Vastus medialis Posterior: Adductor longus/magnus Contents: Femoral artery and vein Saphenous nerve Nerve to the vastus
45
What are the muscles of the anterior compartment of the thigh? What nerve innervated them?
Innervated by the femoral nerve. Iliopsoas: arises from the lumbar vertebrae and the iliac fossa of the pelvis. Inserts onto the greater trochanter of the femur. Quadriceps femoris (4 muscles): - vastus lateralis - vastus intermedialis - vastus medialis - rectus femoris They all insert onto the patella via the quadriceps tendon. Sartorius: from the ASIS to the pes anserina (superomedial tibia). Pectineus: from the pectineal line of the pubis to the pectineal line on the posterior femur (just inferior to the lesser trochanter).
46
What are the muscles of the medial thigh? What are they innervated by?
Innervated by the obturator nerve. Adductor magnus: originates from the inferior pubic rami and ischial rami and inserts onto the linea aspera (the hamstring part originates from the ischial tuberosity and attaches to the adductor tubercle and medial supracondylar line). The adductor longus: pubic bone - linea aspera The adductor brevis (sits between the anterior and posterior division of the obturator nerve). Originates from the body of the pubis and attaches to the linea aspera Obturator externus: from obturator membrane to greater trochanter Gracilis: inferior pubic rami to medial tibia
47
What are the muscles of the posterior thigh? What nerve are they innervated by?
Innervated by the sciatic nerve. The biceps femoris: long head from ischial tuberosity, short head from linea aspera. Insert onto the fibula. (acts to extend hip, flex knee and laterally rotates). The semitendinsosus: originates from ischial tuberosity and attaches to the medial tibia. The semimembranosus: orginates from the ischial tuberosity and attaches to the medial tibial condyle.
48
What arteries supply the knee joint?
The genicular branches of the popliteal artery.
49
What are the menisci? What is their function?
These are cartilage plates that sit within the knee joint. They act to deepen the articular surface to increase stability and act as a shock absorber by dissipating force.
50
Describe the anatomy of the menisci.
They both attach to the intercondylar area of the tibia. The medial meniscus is fixed with the MCL and joint capsule. The lateral has no other attachments and is therefore more mobile.
51
What are the bursa of the knee?
Suprapatella (between the quadriceps tendon and the femur) Infrapatella (between the patella tendon and the tibia AND between patella tendon and skin) Prepatella (between patella bone and skin) Semimembranosus (between the semimembranosus and the medial head of the gastroc (on posterior aspect of the knee).
52
What is the function of a bursa?
Decrease the friction between tendons, bone and skin when movement occurs.
53
Which bursa cause housemaids and clergyman's knee?
Housemaids = prepatella Clergyman's = infrapatella
54
What are the ligaments of the knee?
Patella ligament: patella - tibial tuberosity Medial collateral: medial epicondyle of femur to medial condyle of tibia Lateral collateral: lateral epicondyle of the femur to the fibular head. ACL: anterior intercondylar region of the tibia to the lateral aspect of the posterior intercondylar fossa on the femur. PCL: the posterior intercondylar region of the tibia to the anteromedial femoral condyle.
55
What is the unhappy triad?
Lateral force in an extended knee resulting in injury to MCL, medial meniscus and ACL injury.
56
What type of bone is the patella?
Sesamoid bone
57
What is the function of the patella?
Enhance leg extension via quads to increase muscle efficiency Protects the anterior knee from trauma
58
What type of joints are the tibiofibular joints?
Proximal: plane type synovial joint allowing some movement. Lined with hyaline cartilage. Distal: fibrous joint
59
What are the boundaries of the popliteal fossa?
Superomedial: semimembranosus/ semitendinosus Superlateral: biceps femoris Inferior: two heads of the gastrocnemius Floor: Popliteus and knee joint capsule Roof: fascia
60
What are the contents of the popliteal fossa?
Popliteal artery Popliteal vein (and the short saphenous tributary) Tibial nerve Common peroneal nerve
61
What are the roots of the tibial nerve?
L4-S3
62
Describe the course of the tibial nerve?
Arises from the sciatic nerve at the apex of the popliteal fossa. It gives off the sural nerve. Continues down the posterior border of the tibia and then passes postero-inferior to the medial malleolus via the tarsal tunnel.
63
What are the functions of the tibial nerve?
Motor: Superficial and deep compartments of the posterior leg --> plantar flexion of foot and toes. Also supplies all the intrinsic muscles of the foot except for extensor digitorum brevis. Sensory: sural nerve (tibial and common peroneal combined) and innervates the posterolateral leg and the lateral foot. It also gives of the medial calcaneal, medial plantar and lateral plantar to supply the sole of the foot.
64
What are the roots of the common peroneal nerve?
L4-S2
65
Describe the path of the common peroneal nerve.
Arises at the apex of the popliteal fossa then continues along the medial border of the biceps femoris in an inferolateral direction over the head of the gastroc and around the neck of the fibula where it divides into superficial and deep branches.
66
What is the function of the superficial peroneal?
Lateral compartment of the lower leg and sensation to the anterolateral leg and dorsum of the foot (L5-S1 dermatomes)
67
What is the function of the deep peroneal?
Anterior leg muscles and the extensor digitorum brevis in the foot. Sensation to the first dorsal web space.
68
What are the muscles of the anterior compartment of the lower leg?
Tibialis anterior (lateral tibia to medial cuneiform and the base of metatarsal I). Acts to dorsiflex foot. Extensor digitorum longus (lateral tibial condyle and medial fibula to a tendon on the dorsal foot which splits into 4 to insert onto the digits). Extensor hallucis longus (medial fibular, crosses the angle joint and attaches to the distal phalanx of the hallux) Peroneus tertius (originates with extensor digitorum longus on the medial fibula and attaches to the 5th metatarsal
69
What muscles sit in the lateral compartment of the lower leg?
Peroneus Longus: Superolateral fibula, passes posterior to the lateral malleolus and inserts onto the medial cuneiform and base of 1st metatarsal (passes underneath the foot contributing to the lateral and transverse arches). Peroneus Brevis: from inferolateral fibular to the base of the 5th metatarsal
70
What muscles are in the superficial posterior compartment of the lower leg?
Gastocnemius: Medal head from medial femoral condyle Lateral head from lateral femoral condyle Distally converge with the soleus to form the calcaneal tendon. Soleus: Deep to the gastrocnemius. Originates on the soleal line of the tibia and proximal fibular to the calcaneal tendon. Plantaris: From lateral supracondylar line on the femur to the calcaneal tendon (sits between the gastroc and the soleus)
71
What muscles sit in the deep posterior compartment of the lower leg?
Popliteus: floor of the popliteal fossa (over the popliteal bursa). Originates from the lateral condyle of the femur and the lateral meniscus and inserts onto the proximal tibia just above the soleus muscle. Acts to laterally rotate the femur relative to the tibia. Flexor digitorum longus: medial tibia to the plantar surface of the 4 digits. Flexor hallucis longus: sits lateral to the FDL. Originates from the fibular and attaches to the great toe. Tibialis posterior: deepest muscle, arising from the posterior surface of the interosseous membrane, passes behind the medial malleolus and attaches to the medial tarsal bone.
72
What type of joint is the ankle?
Mortoise socket synovial
73
What are the ligaments of the ankle?
Medial/Deltoid ligament: this fans from the medial malleolus to the talus, calcaneus and the navicular bones. Lateral Ligaments (all originate from the lateral malleolus) - Anterior talofibular: lateral talus - Posterior talofibular: posterior talus - Calcaneofibular: calcaneal.
74
Which bones make up the hindfoot, midfoot and forefoot?
The hindfoot is the talus and calcaneus. The midfoot is the navicular, cuboid and cuneiform. The forefoot is the metatarsals and phalanges.
75
What muscles attach to the talus.
None - this bone is at risk of avascular necrosis because of this!
76
What are the borders of the tarsal tunnel?
Floor: concave surface formed by the medial tibia, talus and calcaneus. Roof: flexor retinaculum (running from medial malleolus to the medial tubercle of the calcaneus).
77
What are the contents of the tarsal tunnel?
Anterior to posterior: - Tibialis anterior - Flexor digitorum longus - Posterior Tibial artery - Posterior tibial vein - Tibial nerve - Flexor hallucis longus It has 4 compartments, the 1st contains the neurovascular structures and the other 3 have 1 tendon each.
78
Which intrinsic foot muscles are found on the dorsal aspect?
Extensor digitorum brevis: extends the toes, innervated by the deep peroneal nerve. Extensor hallucis brevis: innervated by the deep peroneal nerve.
79
What are the intrinsic foot muscles on the plantar aspect.
4 layers: 1. Abductor hallucis, flexor digitorum brevis, abductor digiti minimi 2. Quadratas plantae, lumbricals. 3. Flexor hallucis brevis, adductor hallucis, flexor digiti minimi brevis 4. 3x plantar interossei (medial) = adduction, 4x dorsal interossei (lateral) = abduction
80
What nerve innervates the intrinsic muscles of the foot?
The dorsal (extensor digitorum brevis and extensor hallucis brevis) are innervated by the deep peroneal. The plantar are innervated by terminal branches of the tibial nerve
81
What type of joint is the subtalar joint and what supports it?
This is a synovial joint, enclosed within a capsule. It is an articulation between the inferior talus and the superior calcaneus. It is supported by 3 ligaments and the interosseous calcaneal ligament in the sinus tarsi cavity. - Posterior talocalcaneal - Medial talocalcaneal - Lateral talocalcaneal
82
What are the foot arches?
These are arches that act to shock absorb and aid in flexibility to allow walking/running. The Medial longitudinal The lateral lingitudinal The anterior transverse
83
What forms the medial arch of the foot?
This is the higher arch, formed by the calcaneus, talus, navicular and 3x cuneiform and 1-3 metatarsal bones. It is supported by the tibialis anterior, posterior and the peroneus longus, FDL and FHL as well as intrinsic foot muscles.
84
What forms the lateral longitudinal arch of the foot?
The calcaneus, cuboid and 4-5th metatarsal bones. Supported by the peroneal longus, FDL and intrinsic foot muscles.W
85
What forms the transverse arch of the foot?
Formed by the coronal plane with the metatarsal bases, cuboid and 3x cuneiforms. Supported by the peroneus longus and tibialis posterior.
86
Where does the lymphatic drainage for the lower limb go?
The medial superficial follow the great saphenous vein and drain into the inguinal node. The lateral superficial follow the short saphenous and drain into the popliteal node. The deep follow all 3 deep veins and all drain into the popliteal.
87
How are the inguinal lymph nodes divided?
Superficial and deep as per their position in comparison to the GSV. Superficial: receive from penis, scrotum, perineum, buttock and abdo wall. Superficial sub-inguinal: from lower limb superficial Deep sub-inguinal: from deep lower limb
88
What is the function of the popliteus muscle?
Acts to initiate flexion of the knee from full extension. Also acts to internally rotate at the knee.

MRCS Part B (14 decks)

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