Lower limb Flashcards
What are the movements of the hip joint?
1) Flexion/Extension
2) Abduction/Adduction
3) Medial/lateral rotation
Owing to the ________________________________ during development, the original dorsal/extensor surface of the lower limbs becomes _____________, while the ventral/flexor surface becomes ______________.
Medial rotation of lower limb through 180° →
i) dorsal/extensor → anterior
ii) ventral/flexor → posterior
How is the body weight transferred to the lower limbs?
From vertebral column → sacroiliac joints → pelvic girdle
→ hip joints → femurs
→ knee joint → tibia
→ ankle joint → talus → tarsals + metatarsals
What are the 3 bones that form each hip bone?
1) Ilium → socket/articulation with femoral head
2) Ischium → posteroinferior part of the acetabulum
3) Pubis → anterior part of acetabulum & anteromedial part of hip bone
Which of the constituent hip bones contributes the cup-like cavity/socket on the superolateral aspects of the hip bone for articulation with the head of the femur?
Ilium
What are 4 components/features of the proximal end of the femur?
1) Head
2) Neck
3) Greater and lesser trochanters
4) Articular cartilage covering head except fovea for ligament of head
How do the cause of pathological lateral rotation and medial of a lower limb differ?
Lateral rotation (foot pointing lateral) → Femoral/Hip fracture
Medial rotation (foot pointing medial) → posterior dislocation of the hip
Which is more common, anterior/posterior dislocation of the hip?
Posterior
The _____________ surface of the neck of the femur is completely intracapsular whereas the only the __________ of the _________ surface is intracapsular.
The anterior surface of the neck of the femur is completely intracapsular whereas the only the medial half of the surface posterior is intracapsular.
Most of the femoral shaft is smoothly rounded, except for ___________________________ which diverges inferiorly.
a prominent double-edge ridge on its posterior aspect: the linea aspera
The distal end of the femur ends in _____________________.
two spirally curved femoral condyles (medial and lateral)
On the femur, the _____________ may be felt at the superior part of the medial femoral condyle.
adductor tubercle, a small prominence of bone
What are the bone components to form the knee joint?
The femoral condyles articulate with the tibial condyles to form the knee joint
What is the function of the angle of inclination of the femur?
Allows greater mobility of the femur at the hip joint because it places the head and neck more perpendicular to the acetabulum.
This is advantageous for bipedal walking; however, it imposes considerable strain on the neck of the femur.
What type of joint is the hip joint?
a strong and stable multiaxial ball and socket joint
The cup-shaped acetabulum is deepened by the ________________ which is made of ______________.
Deepened by acetabular labrum (made up of fibrocartilage)
How would a pes anserine bursitis of the knee be differentiated from OA?
Palpable joint line
→ if tender → intra-articular → OA
→ if not tender → extra-articular → bursitis
What are the 3 points of attachment of the hip joint capsule?
1) Acetabular lumen (medial)
2) Intertrochanteric line
3) Posterior aspect of the neck of the femur (lateral)
What are the 2 layers of the hip joint capsule?
1) Outer longitudinal (retinacular)
2) Inner circular fibres
What are 4 ligaments of the hip and their functions?
1) Ligamentum teres → carrier for the foveal artery
2) Iliofemoral → prevent hyper extension (strongest)
3) Pubofemoral → prevent overabduction of hip joint
4) Ischiofemoral → prevent hyperextension + limit medial rotation
What are 4 factors that contribute to the stability of the hip joint?
1) Depth of acetabulum
2) Three ligaments (iliofemoral, pubofemoral, ischiofemoral)
3) Strength of the surrounding muscles
4) Length and obliquity of the neck of femur
What is the cure for a flat foot?
Strengthening of posterior tibialis
Which muscles are involved in hip flexion?
1) Psoas major
2) Iliacus
3) Sartorius
4) Rectus femoris
5) Pectineus
Which muscles are involved in hip extension?
1) Gluteus maximus
2) Hamstrings
Which muscles are involved in hip abduction?
1) Gluteus medius
2) Gluteus minimus
3) Tensor fascia latae
4) Sartorius
Which muscles are involved in hip adduction?
1) Adductor longus
2) Adductor brevis
3) Adductor magnus
4) Pectineus
5) Gracilis
Which muscles are involved in hip medial rotation?
1) Anterior fibres of gluteus minus
2) Anterior fibres of gluteus medius
3) Tensor fascia lata
Which muscles are involved in hip lateral rotation?
1) Piriformis
2) Obturator internus
3) Obturator externus
4) Superior gemelli
5) Inferior gemelli
6) Quadratus femoris
Describe the innervation for the movements of the hip?
L2/3:
i) Flexion
ii) Adduction
iii) Medial rotation
L4/5:
i) Extension
ii) Abduction
iii) Lateral rotation
What are 5 arteries that supply the hip joint?
1) Obturatory artery (artery → head)
2-3) Superior and inferior gluteal arteries (trochanteric & cruciate anastomosis)
Branches from profunda femoris:
4-5) Medial and lateral circumflex femoral artery (head + neck)
What are 3 types of femoral neck fractures?
1) Intracapsular
Extracapsular:
2) Trochanteric
3) Sub-trochanteric
What is a common cause of aseptic vascular necrosis of the hip joint?
Fracture of femoral neck
→ impingement/disruption of medial circumflex femoral artery
→ retinacular arteries torn
→ inadequate perfusion of femoral head
→ aseptic vascular necrosis
The most common demographic for femoral neck fractures?
Women > 60y
- osteoporosis
What is a common cause and complication of posterior hip dislocation?
Car accident → femoral head forced out of acetabulum posteriorly
→ compression/stretching of sciatic nerve
→ paralysis of hamstrings and muscles distal to knee joint
Where does the ligamentum patella attach to?
Tibial tuberosity
Where does the deltoid ligament attach to?
Medial malleolus
The medial malleolus is (higher/lower) than the lateral malleolus.
The medial malleolus is higher than the lateral malleolus.
What muscles of the leg are attached to the fibula?
All of the leg except Tibialis anterior, Gastrocnemius, and Plantaris
True or False: With the Tibia, the fibula transmits half the body’s weight to the foot.
False.
Fibula does not take part is transmission of body weight.
The patella is the largest ______ bone found in the tendon of ____________.
Sesamoid bone in quadriceps femoris
The apex of the patella faces (upwards/downwards) while the base faces (upwards/downwards).
Patella:
Apex downwards
base upwards
What are the 2 articular surfaces of the posterior aspect of the patella and which articulates with the lateral femoral condyle?
Medial and lateral
Large lateral surface articulates with lateral femoral condyle
Which direction does the patella dislocate in most commonly?
Laterally
- due to upwards and lateral pull by Quadriceps
What are 3 factors that prevent patellar lateral dislocation?
1) Most forward projection of lateral femoral condyle
2) More prolonged insertion of Vastus medialis to medial border than of Vastus lateralis to lateral border of Patella
3) medial pull exerted by medial patellar retinaculum
What type of joint is the knee joint?
Modified hinge joint
1) Condylar
- articulation of lateral and medial femorotibial condyles
2) Saddle
- Femoropatellar articulation
What nerves innervate the knee joint?
1) Femoral
2) Tibial
3) Common peroneal
4) Obturator
What are the factors maintaining the stability of the knee joint?
1) Strength and actions of the surrounding muscles and tendons
2) Medial and lateral collateral ligaments maintain side to side stability
3) Cruciate ligaments maintain anteroposterior stability
4) Iliotibial tract helps in stabilising a partially flexed knee
What are 4 factors that make the knee joint structurally weak?
1) Incongruence of its articular surfaces
2) Tibial condyles are small and shallow to hold the large convex femoral condyles
3) Shallow articular surfaces of femur and patella
4) Outward angulation between the long axes of femur and tibia
What are the 3 bursae formed by the outpocketing of the synovial membrane of the knee joint?
1) Suprapatellar
2) Semimembranous
3) Popliteal
What are the extracapsular ligaments of the knee?
1) Ligamentum patellae
2) Lateral/Fibular collateral ligament
3) Medial/Tibial collateral ligament
4) Oblique popliteal ligament
What are the intra-articular ligaments of the knee joint?
1) Anterior cruciate ligament
2) Posterior cruciate ligament
3) Meniscus
True or false: Only in a fully extended position, both cruciate ligaments of the knee are relaxed.
False.
Because of their oblique orientation, in every position one cruciate ligament, or parts of one or both ligaments, is tense
Which of the 2 cruciate ligaments of the knee is weaker?
ACL
What is the function of the ACL?
1) Prevent posterior displacement of femur on tibia
2) Prevent hyperextension of knee joint
The ACL, which has a relatively poor blood supply, arises from _______________ and extends to _________________.
Anterior intercondylar area of tibia (posterior to medial meniscus attachment)
→
posterior part of medial surface of medial condyle of femur
What is the main stabilising factor of the femur when the knee is flexed and weight-bearing (eg. walking downhill)?
PCL
What is the function of the PCL?
1) Prevents anterior displacement of the femur on the tibia (with tibia on ground)/ posterior displacement of tibia on femur (within tibia off ground)
2) Prevent hyperflexion of the knee joint
The PCL arises from _____________ to the _________________.
Posterior intercondylar area of tibia
→
Anterior part of lateral surface of the medial condyle of the femur
What are the menisci of the knee joint and how are they orientated?
Lateral and menisci are crescenteric plates of fibrocartilage on articulating surfaces of the tibia
- thicker at external margins (attached to fibrous capsule of knee joint), thinner unattached edges interiorly
How are the movements of the 2 menisci coupled in knee movement?
Transverse ligament joins anterior edges of menisci, allowing them to move together during knee movements
What are the functions of the menisci of the knee joint?
1) Deepen articular surface of tibia
2) Shock absorption
How are the medial and lateral menisci of the knee differentiated?
Medial:
- C-shaped
- broader posteriorly than anteriorly
Lateral:
- nearly circular
- smaller
- more freely movable
In the knee, what separates the lateral meniscus from the fibular/lateral collateral ligament?
Tendon of popliteus
What are the 3 attachments of the medial meniscus of the knee joint?
Anterior/horn:
- anterior intercondylar area of tibia (anterior to ACL attachment)
Posterior:
- posterior intercondylar area (anterior to PCL attachment)
Medial:
- Deep surface of tibial collateral ligament
Which of the menisci of the knee are more prone to injury and why?
Medial > later
because of its firm fixity to the tibial collateral ligament,and greater excursion during the rotatory movements. (eg. Twisting strain as in kicking a football with a slightly flexed knee)
How does the popliteus muscle protect the lateral meniscus?
medial fibres of popliteal pull the posterior horn of meniscus backward so that it is not crushed between the articular surfaces
Which of the cruciate ligaments of the knee is taut during flexion?
ACL
What is the sign associated with an ACL injury?
Anterior drawer sign
- ACL rupture → free tibia can slide anteriorly under femur
What is the most common cause of a PCL injury?
Landing on tibial tuberosity when knee is flexed
What sign is associated with a PCL injury?
Posterior drawer sign
- PCL rupture → free tibia slides posteriorly under fixed femur
Which other ligaments usually rupture in conjunction with the PCL?
1) Tibial ligament
2) Fibular ligament
Describe how the knee “locks” and “unlocks”.
Fully extended leg w foot on ground → medial rotation of femur on tibia → “locking”
Popliteus contract → lateral rotation of femur on tibia plateau → “unlock” → allow flexion
What is the benefit of “locking” the knee?
1) Makes lower limb a solid column → more adapted for weight bearing
2) Thigh and leg muscles can relax briefly without making knee joint too unstable
Which muscles allow knee flexion?
Hamstrings
Which muscles allow knee extension?
Quadriceps femoris
Which muscles allow knee medial rotation?
1) Semitendinous
2) Semimembranosus
3) Popliteus
Which muscles allow knee lateral rotation?
Biceps femoris
What are the 3 points of articulation between the tibia and fibula?
1) Superior:
- plane synovial joint
- btwn head of fibula and lateral condyle of tibia
2) Middle
- fibrous joint
- interosseus membrane + ligament
3) Inferior
- syndesmosis fibrous joint
- strongest of all 3 joints
What are the movements at the ankle joint?
Dorsi/plantarflexion
What are the type and articulations of the ankle joint?
Hinge joint
Above: Lower end of the tibia and 2 malleoli
Below: Body of tallus
What nerves supply the ankle joint?
1) Deep peroneal
2) Tibial
Which of the muscles allow dorsiflexion at the ankle?
Mainly Tibialis anterior
Which of the muscles allow plantarflexion at the ankle?
Mainly
1) Gastrocnemius
2) Soleus
In which movement is the ankle joint more stable, dorsiflexion or plantarflexion?
Dorsiflexion
What are 4 factors maintaining stability of the ankle joint?
1) Close interlocking of its articular surfaces (tibiofibular mortise gripping the wedge shaped body of the talus
2) Strong medial and lateral collateral ligaments
3) Inferior transverse tibiofibular ligament (syndesmosis)
4) Tendons crossing in front and behind the ankle joint
What is the most common form of ankle sprain when a plantarflexed foot is excessively inverted?
Anterior talofibular ligament
What are the 3 ligaments of the ankle joint?
1) Anterior talofibular ligament
2) Posterior talofibular ligament
3) Calcaneofibular ligament
What is a “march” fracture?
Metatarsal fracture
Which toe does the line of axis of the foot pass through?
Second toe
What is the type and articulations of the subtalar joint?
Synovial
- talus rests on articulates with the calcaneus
What are the ligaments of the subtalar joint?
1) Medial
2) Lateral
3) Posterior
4) Interosseus
Talocalcaneal ligaments
What are the movements at the subtalar joint?
Inversion/eversion
What is the type and articulations of the transverse tarsal joint?
Compound joint:
- talocalcaneonavicular joint
- calcaneocuboid joint
- both joined transversely
Where does surgical amputation of the foot occur?
Transection across the transverse tarsal joint
What are the arches of foot?
1) Medial
2) Lateral
3) Transverse
What are 3 differences between the medial and lateral arch of the foot?
Medial
- > pliant (due to talocalcaneonavicular and subtalar joints)
- higher
- > involved in propulsion
What is the transverse arch of the foot formed by?
1) Cuboid
2) 3 Cuneiforms
3) Bases of metatarsals
- medial and lateral arches serves as pillars for transverse arch
What are 4 factors maintaining the medial arch of the foot?
1) Keystone
- Talus
2) Intersegmental ties
- Spring ligament
- Interosseus ligaments
- Interosseous talocalcaneal ligament
3) Tie beams
- plantar aponeurosis (medial part)
- abductor hallucis
- flexor hallucis brevis
4) Slings
- tibialis posterior
- flexor hallucis longus
- tibialis anterior tendons
5) Plantar calcaneonavicular ligament
What are 4 factors maintaining the lateral arch of the foot?
1) Keystone
- cuboid
2) Intersegmental ties
- long and short plantar ligaments
3) Tie beams
- plantar aponeurosis (lateral part)
- intrinsic muscles of little toe
4) Slings
- fibularis brevis
- tertius tendons
What are 4 functions of the arches of the foot?
1) Distribute the body weight to the weight bearing points of the sole
2) Shock absorber while jumping
3) Medial longitudinal arch provides a propulsive force during locomotion
4)Lateral longitudinal arch functions as a static support and helps in weight transmission
5) The concavity of arches protects the nerves and vessels of the sole
What is a pes cavus?
High arched foot
What is a pes planus?
Flat foot
What are the boundaries of the facia lata?
Superior:
- front of thigh → anterior superior iliac spine
- inguinal ligament
- pubic tubercle
Inferiorly:
- front and sides of knee + capsule
Posterior:
- sacrum
- coccyx
- sacrotuberous ligament
Medial
- pubis
- pubic arch
- ischial tuberosity
What are the components of the compartments of the thigh?
Posterior: (lateral and posterior septum)
i) Semimembranosus
ii) Semitendinosus
iii) Biceps femoris (long & short head)
iv) Sciatic nerve
Medial: (posterior and medial septum)
i) Adductor longus
ii) Adductor brevis
iii) Gracillis
iv) Adductor magnus
v) Obturator nerve
Anterior: (medial and lateral septum)
i) Vastus lateralis
ii) Vastus intermedius
iii) Vastus medialis
iv) Rectus femoris
v) Sartorius
vi) Femoral nerve
What is the most common cause of a flat foot/pes planus?
Weakness of posterior tibialis
What is the Iliotibial band and its function?
Thick band of fascia formed proximally at the hip by the fascia of the gluteus maximus, gluteus medius and tensor fasciae latae muscles
Stabilises knee (in both extension and partial flexion)
What is the saphenous opening?
Oval opening in the upper mid part of the fascia lata of the thigh
- covered by cribiform fascia
- exit route for femoral hernia
Which of the gluteal muscles are responsible for extension?
Gluteus maximus
Which of the gluteal muscles are responsible for abduction?
1) Gluteus medius
2) Gluteus minimus
Which of the gluteal muscles are responsible for rotation?
1) Piriformis
2) Obturator internus
3) Gemelli
4) Quadratus femoris
Gluteus maximus:
Function:
Origin:
Insertion:
Innervation:
Gluteus maximus:
Function: extensor of hip joint/thigh
Origin:
1) Ilium (dorsal segment outer slope + posterior surface)
2) Sacrum (dorsal surface)
3) Coccyx side
4) Sacrotuberous ligament
Insertion:
1) Iliotibial tract (superficial fibres)
2) Gluteal tuberosity of femur (deep fibres)
Innervation:
Inferior gluteal nerve
Gluteus medius:
Function:
Origin:
Insertion:
Innervation:
Gluteus medius:
Function:
Abduct hip joint/thigh
Origin:
Outer surface of ilium between anterior and posterior gluteal lines
Insertion:
Oblique ridge on lateral surface of greater trochanter
Innervation:
Superior gluteal nerve
Gluteus minimus:
Function:
Origin:
Insertion:
Innervation:
Gluteus minimus:
Function:
Abduct hip joint/thigh
Origin:
Outer surface of ilium between anterior and inferior gluteal lines
Insertion:
Ridge on the anterior surface of greater trochanter
Innervation:
Superior gluteal nerve
Where is the trochanteric bursa located?
Between Gluteus medius and minimus and greater trochanter of femur
Piriformis:
Function:
Origin:
Insertion:
Innervation:
Piriformis:
Function:
lateral rotation of hip/thigh
Origin:
Pelvic surfaces of middle 3 sacrum pieces
Insertion:
Apex of greater trochanter
Innervation:
Ventral rami of S1,2
Gemellus:
Function:
Origin:
Insertion:
Innervation:
Gemellus superior:
Function:
Lateral rotation of thigh/hip
Origin:
i) Superior: posterior surface of ischial spine
ii) Inferior: upper part of ischial tuberosity + lower part of lesser sciatic notch
Insertion:
Medial surface of greater trochanter
Innervation:
i) Superior: Nerves to obturator internus (L5, S1-2)
ii) Inferior: Nerves to quadratus femoris (L4-5, S1)
Obturator internus:
Function:
Origin:
Insertion:
Innervation:
Obturator internus:
Function:
Lateral rotation of thigh/hip
Origin:
Pelvic surface of obturator membrane and surrounding bones
Insertion:
Medial surface of greater trochanter
Innervation:
Nerve to obturator internus (L5, S1)
Quadratus femoris:
Function:
Origin:
Insertion:
Innervation:
Quadratus femoris:
Function:
Lateral rotation of hip/thigh
Origin:
Lateral border of ischial tuberosity
Insertion:
Quadrate tubercle on intertrochanteric crest and area below
Innervation:
Nerve to quadratus femoris (L5, S1)
Which muscles prevents excessive tilt during swing phase on opposite side?
Contraction of gluteus minimus and medius on stance side
Tensor fascia lata:
Function:
Origin:
Insertion:
Innervation:
Tensor fascia lata:
Function:
i) Abduct hip joint/thigh
ii) maintain extension of knee joint through Iliotibial tract
Origin:
Outer lip of iliac crest
Insertion:
Iliotibial tract
Innervation:
Superior gluteal nerve
What is trendenlenburg’s sign?
Sagging of pelvis on healthy side when 1 foot is off the ground (paralysis of gluteus medius and minimus)
What is the most common side of IM injections?
Gluteal region
What is a common associated of sciatic injuries?
Foot drop
What are the hamstring muscles?
Posterior compartment of thigh:
1) Semitendinosus
2) Semimembranosus
3) Biceps femoris
4) Adductor magnus (Ischial head)
Hamstring muscles:
Function:
Origin:
Attachment:
Innervation:
Hamstring muscles:
Function:
i) Flex knee
ii) Extend hip joint
Origin:
All ischial tuberosity
Attachment:
All into 1 of the bones of the leg
Innervation: Sciatic nerve
- all tibial part except short head of biceps (common peroneal part)
What are 3 main actions of the hamstring muscles?
1) Chief flexors of knee joint
2) Hip extensors during walking on flat ground
3) Action restricts range of hip flexion when knee is extended (eg. toe touching)
What are the muscles in the anterior compartment of the thigh?
Flexors of the hip:
1) Psoas major
2) Iliacus
Extensors of the knee: Quadriceps femoris
3) Rectus femoris
4) Vastus lateralis
5) Vastus medialis
6) Vastus intermedius
Adductor group:
7) Pectineus
8) Adductor longus
9) Adductor brevis
10) Adductor magnus
What are 2 flexors of the hip joint?
1) Psoas major
2) Iliacus
Psoas major:
Function:
Origin:
Attachment:
Innervation:
Psoas major:
Function:
Flex hip joint
Origin:
Lumbar vertebrae
Attachment:
Lessor trochanter of femur
Innervation:
L1-4 ventral rami
Iliacus:
Function:
Origin:
Attachment:
Innervation:
Iliacus:
Function:
Flex hip joint
Origin:
i) Upper 2/3 of floor of iliac fossa
ii) Inner lip of iliac crest
iii) Upper surface of lateral part of sacrum
Attachment:
Less trochanter of femur
Innervation:
Femoral nerve
Pectineus:
Function:
Origin:
Attachment:
Innervation:
Pectineus:
Function:
Adduct thigh @ hip
Origin:
i) pecten pubis
ii) upper 1/2 of pectineal surface of superior ramus of pubis
iii) pectineus fascia
Attachment:
Lesser trochanter to linea aspera
Innervation:
i) femoral nerve
ii) anterior division of obturator nerve
Adductor longus:
Function:
Origin:
Attachment:
Innervation:
Adductor longus:
Function:
i) Adduct thigh
ii) Medially rotate thigh
Origin:
Body of pubis between crest & symphysis
Attachment:
Middle 1/3 of linea aspera
Innervation:
Anterior division of obturator nerve
Adductor brevis:
Function:
Origin:
Attachment:
Innervation:
Adductor brevis:
Function:
Adduct thigh
Origin:
i) Anterior body of pubis
ii) Outer inferior ramus of pubis between gracillis and obturator externus
Attachment:
i) Lesser trochanter to linea aspera
ii) Upper part of linea aspera lateral to pectineus
Innervation:
Obturator nerve (both anterior and posterior division)
Adductor magnus:
Function:
Origin:
Attachment:
Innervation:
Adductor magnus:
Function:
i) Adduct thigh
ii) Medially rotate thigh
iii) Extend hip joint
Origin:
i) Hamstring: inferolateral ischial tuberosity
ii) Adductor: outer ischiopubic ramus
Attachment:
i) medial margin of gluteal tuberosity
ii) linea aspera
iii) medial supracondylar line
iv) adductor tubercle
Innervation:
i) Hamstring: Sciatic nerve (tibial part)
ii) Adductor: obturator (posterior division)
Where does the obturator nerve arise from and pass through to arrive at the tissues it innervates?
L2-4
through obturator canal
What are the structures supplied by the obturator nerve?
Anterior division:
1) Hip joint
2) Pectineus
3) Adductor brevis
4) Adductor longus
5) Gracillis
6) Cutaneous branch to medial aspect of thigh
Posterior division:
7) Obturator externus
8) Adductor magnus
9) Knee joint (through adductor hiatus)
Sartorius:
Function:
Origin:
Attachment:
Innervation:
Sartorius:
Function:
i) Flex hip
ii) Flex knee
iii) Abduct thigh laterally → sitting position
Origin:
Anterior superior iliac spine
Attachment:
Upper part of medial surface of tibial shaft
Innervation:
Femoral nerve
Gracillis:
Function:
Origin:
Attachment:
Innervation:
Gracillis:
Function:
Origin:
Attachment:
Innervation:
Obturator nerve
What are the 4 adductors of the thigh/hip?
1) Pectineus
2) Adductor longus
3) Adductor brevis
4) Adductor magnus
What the 4 components of the quadriceps femoris/extensors of the knee?
1) Rectus femoris
2) Vastus lateralis
3) Vastus medialis
4) Vastus intermedius
Which nerve supplies the quadriceps femoris?
Femoral
Rectus femoris:
Function:
Origin:
Attachment:
Innervation:
Rectus femoris:
Function:
i) Flex hip
ii) Extend knee
Origin:
i) Straight head: upper half of anterior inferior iliac spine
ii) Reflected head: groove above acetabulum
Attachment:
Base of patella
Innervation:
Femoral nerve
Vastus lateralis:
Function:
Origin:
Attachment:
Innervation:
Vastus lateralis:
Function:
Extend knee
Origin:
i) upper intertrochanteric line
ii) anterior and inferior borders of greater trochanter
iii) lateral lip of gluteal tuberosity
iv) upper 1/2 of lateral lip of linea aspera
Attachment:
i) Base and upper 1/3 of lateral border of patella
ii) Knee joint capsule and iliotibial tract
Innervation:
Femoral nerve
Vastus medialis:
Function:
Origin:
Attachment:
Innervation:
Vastus medialis:
Function:
Extend knee
Origin:
i) Lower intertrochanteric line
ii) Spiral line
iii) Medial lip of linea aspera
iv) Upper 2/3 of medial supracondylar line
Attachment:
i) base and upper 2/3 of medial border of patella
ii) knee joint capsule
Innervation:
Femoral nerve
Vastus intermedius:
Function:
Origin:
Attachment:
Innervation:
Vastus intermedius:
Function:
Extend knee
Origin:
Upper 3/4 of anterior & lateral surfaces of femoral shaft
Attachment:
base of patella
Innervation:
Femoral nerve
What spinal segments does the femoral nerve arise from?
L2-4
What tissues does the femoral nerve supply?
1) Iliacus
2) Hip joint
3) Pectineus
Anterior division:
4) Sartorius
5) Medial cutaneous nerve of thigh
6) Intermediate cutaneous nerve of thigh
7) Saphenous nerve
Posterior division:
8) Rectus femoris
9) Vastus lateralis
10) Vastus medialis
11) Vastus intermedialis
12) Articularis genu
13) Knee joint
What structure(s) separates the lateral and posterior compartments of the leg?
1) Posterior intermuscular septum
2) Fibula
What structure(s) separates the lateral and anterior compartments of the leg?
Anterior intermuscular septum
What structure(s) separates the anterior and posterior compartments of the leg?
1) Interosseous membrane
2) Tibia
What are the structures in the lateral compartment of the leg?
Foot evertors:
1) Peroneal longus
2) Peroneal brevis
3) Superficial peroneal nerve
What are the structures in the anterior compartment of the leg?
1) Tibialis anterior
2) Extensor hallucis longus
3) Extensor digitorum longus
4) Deep peroneal nerve
5) Anterior tibial vessels
What are the structures of the posterior compartment of the leg?
Deep:
1) Tibialis posterior
2) Flexor digitorum longus
3) Flexor hallucis longus
4) Peroneal vessels
5) Tibial nerve
6) Posterior tibial vessels
Superficial:
7) Soleus
8) Plantaris tendon
9) Gastrocnemius
10) Median cutaneous nerve
What nerve innervates the anterior compartment of the leg?
Deep fibular nerve
What is the function of the muscles within the anterior compartment of the leg?
1) Dorsiflexion
2) Extension
Tibialis anterior:
Function:
Origin:
Attachment:
Innervation:
Tibialis anterior:
Function:
i) Dorsiflex foot @ ankle
ii) Invert foot @ subtalar
Origin:
i) Upper 2/3 of lateral surface of tibia
ii) Adjoining part of interosseus membrane
iii) Distal part of lateral condyle of tibia
Attachment:
i) Medial cuneiform
ii) Adjoining part of 1st metacarpal
Innervation:
Deep fibular nerve
Extensor digitorum longus:
Function:
Origin:
Attachment:
Innervation:
Extensor digitorum longus:
Function:
i) Dorsiflex foot
ii) Extend lateral 4 toes @ MTPJ, PIPJ, DIPJ
Origin:
i) Lateral condyle of tibia
ii) Upper 2/3 of medial surface of fibula
Attachment:
Bases of middle and distal phalanges of lateral 4 toes
Innervation:
Deep fibular nerve
Where are the sesamoid bones of the foot found?
On plantar surface of 1st toe/metatarsal
Peroneus tertius:
Function:
Origin:
Attachment:
Innervation:
Peroneus tertius:
Function:
i) Dorsiflex foot
ii) Evert foot
Origin:
i) Lower 1/4 of medial surface of fibula
ii) Adjacent part of interosseus membrane
Attachment:
Medial part of 5th metatarsal bone
Innervation:
Deep fibular nerve
Extensor hallucis longus:
Function:
Origin:
Attachment:
Innervation:
Extensor hallucis longus:
Function:
i) Dorsiflex foot
ii) Extend great toe
Origin:
i) middle 1/2 of medial surface of fibular shaft
ii) adjoining part of interosseous membrane
Attachment:
Base of distal phalanx of great toe
Innervation:
Deep fibular nerve
Extensor digitorum brevis:
Function:
Origin:
Attachment:
Innervation:
Extensor digitorum brevis:
Function:
i) Extend great toe @ MTPJ
ii) Extend 2-4th toe @ MTPJ and PIPJ
Origin:
Anterior part of superior surface of calcaneus
Attachment:
i) base of the proximal phalanx of the 1st toe
ii) middle phalanx of the three medial digits joining with the extensor digitorum longus tendon
Innervation:
Deep fibular nerve
What nerve innervates the lateral compartment of the leg?
Superficial fibular nerve
What are the functions of the muscles of the lateral compartment of the leg?
1) Evert foot
2) Plantarflex (weak)
3) Support lateral longitudinal arch of foot
Peroneus longus:
Function:
Origin:
Attachment:
Innervation:
Peroneus longus:
Function:
i) Evert foot
ii) Plantarflex (weak)
iii) Support lateral longitudinal arch of foot
Origin:
i) Fibular head
ii) Upper 2/3 of lateral surface of fibular shaft
Attachment:
i) Medial cuneiform
ii) Base of 1st metatarsal
Innervation:
Superficial fibular nerve
Peroneus brevis:
Function:
Origin:
Attachment:
Innervation:
Peroneus brevis:
Function:
i) Evert foot
ii) Plantarflex (weak)
iii) Support lateral longitudinal arch of foot
Origin:
Lower 2/3 of lateral surface of fibular shaft
Attachment:
Lateral side of base of 5th metatarsal
Innervation:
Superficial fibular nerve
What are the muscles of the posterior compartment of the leg?
Superficial:
1) Gastrocnemius
2) Soleus
3) Plantaris
Deep:
4) Plantaris
5) Flexor digitorum longus
6) Flexor hallucis longus
7) Tibialis posterior
What is the posterior compartment of the leg innervated by?
Tibial nerve
How is the contracture of the gastrocnemius differentiated from that of the soleus?
Gastrocnemius cannot do plantarflexion when knee is flexed (unlike soleus)
Gastrocnemius:
Function:
Origin:
Attachment:
Innervation:
Gastrocnemius:
Function:
i) Chief plantarflexor of foot when knee is extended
ii) flex knee
Origin:
a) Medial head:
i) Posterosuperior surface of medial femoral condyle behind adductor tubercle
ii) Adjoining part of popliteal surface of femur
b) Lateral head:
Lateral surface of lateral femoral condyle
Attachment:
Middle 1/3 of posterior surface of calcaneum
Innervation:
Tibial nerve
Soleus:
Function:
Origin:
Attachment:
Innervation:
Soleus:
Function:
Plantarflexion when knee is flexed
Origin:
i) Posterior aspect of fibular head
ii) Upper 1/4 of posterior surface of fibular shaft
iii) Tendinous arch connecting tibia and fibula
iv) Soleal line and middle 1/3 of medial border of tibia
Attachment:
Middle 1/3 of posterior surface of calcaneum
Innervation:
Tibial nerve
What is the tendocalcaneus/tendoachilles?
Conjoint tendon of:
1) Gastrocnemius
2) Soleus
3) Plantaris
Why is the soleus muscle referred to as the “peripheral heart”?
Pumps venous blood back into the heart from the periphery
Plantaris:
Function:
Origin:
Attachment:
Innervation:
Plantaris:
Function:
just assists other muscles @ knee and ankle
Origin:
Lower part of lateral supracondylar line of femur
Attachment:
Middle 1/3 of posterior surface of calcaneum medial to tendocalcaneus
Innervation:
Tibial nerve
What is the ankle jerk reflex and where is tapped?
Tests S1-2 tibial nerve
- tap calcaneal tendon → plantar flexion → normal
Popliteus:
Function:
Origin:
Attachment:
Innervation:
Popliteus:
Function:
i) unlock knee (lateral rotation of femur during initial knee flexion)
ii) prevent crushing of tibia and femoral condyles (pull lateral meniscus backwards)
Origin:
i) Popliteal groove on lateral surface of lateral femoral condyle
ii) Lateral meniscus (outer margin)
iii) Arcuate popliteal ligament
Attachment:
Medial 2/3 of triangular area above soleal line
Innervation:
Tibial nerve
Flexor digitorum longus:
Function:
Origin:
Attachment:
Innervation:
Flexor digitorum longus:
Function:
i) plantarflex lateral 4 toes
ii) plantarflex ankles
iii) maintains longitudinal arches of foot
Origin:
Upper 2/3 of medial part of posterior surface of tibia below soleal line
Attachment:
Base of plantar surface of distal phalanges of lateral 4 toes
Innervation:
Tibial nerve
Flexor hallucis longus:
Function:
Origin:
Attachment:
Innervation:
Flexor hallucis longus:
Function:
i) plantarflex great toe
ii) plantarflex ankle
iii) maintains medial longitudinal arch of foot
Origin:
i) Lower 3/4 of posterior surface of fibula behind medial crest
ii) Adjoining part of interosseus membrane
Attachment:
Base of plantar surface of distal phalanx of great toe
Innervation:
Tibial nerve
Tibialis posterior:
Function:
Origin:
Attachment:
Innervation:
Tibialis posterior:
Function:
i) Plantarflex ankle
ii) Invert foot
Origin:
i) Upper 2/3 of lateral part of posterior surface of tibia
ii) Posterior surface of fibula in front of medial crest
iii) Upper 2/3 of posterior surface of interosseus membrane
Attachment:
i) All tarsal bones except talus
ii) 2-4 metatarsals
Innervation:
What are the bounds of the tarsal tunnel?
Anterior: Medial malleolus
Posterior: Achilles tendon
Roof: Flexor retinaculum
What are the contents of the tarsal tunnel?
Tom Dick And Very Nervous Harry
1) Tibialis posterior tendon
2) Flexor digitorum longus tendon
3) Posterior tibial artery
4) Posterior tibial vein
5) Tibial nerve
6) Flexor hallucis longus tendon
What are the layers of the sole of the foot?
1) Thick, hairless skin
2) Superficial fascia
3) Deep fascia
- central, medial, lateral
4) Plantar aponeurosis
- thickened part of deep fascia
What are 4 structures within the dorsum of the foot?
1) Extensor digitorum brevis
2) Fibularis tertius
3) Dorsal venous arch
4) Dorsalis pedis artery
What are the muscles of the foot (in layers)?
1st:
1) Abductor digiti minimi
2) Flexor digitorum brevis
3) Abductor hallucis
2nd:
1) Flexor digitorum accessorius/Quadratus plantae
2) Lumbricals
3rd:
1) Flexor digiti minimi brevis
2) Adductor hallucis
3) Flexor hallucis brevis
Where are the trunks of the medial and plantar nerves and arteries of the foot located?
Between 1st and 2nd layer
- below lumbricals and quadratus plantae
Where is the plantar arch of the foot located?
Between third and fourth layer of foot
- above flexor digiti minimi, flexor hallucis brevis and adductor hallucis
The dorsal interossei muscles facilitate (abduction/adduction) while the plantar interossei muscles facilitate (abduction/adduction).
Dorsal → Abduct (DAB)
Plantar → Adduct (PAD)
What provides blood supply to the lower limb in case of ligation/disruption of the femoral artery?
Cruciate anastomosis
- union of:
i) medial circumflex
ii) lateral circumflex
iii) inferior gluteal artery
iv) first perforating artery
What are the vessels that form the trochanteric anastomosis?
All common iliac:
1) Superior gluteal artery
2) Inferior gluteal artery
3) Lateral circumflex femoral artery
What are the bounds of the femoral triangle?
Superior: inguinal ligament
Medial: Adductor longus
Lateral: Sartorius
What are the contents of the femoral triangle?
Lateral to medial:
1) Femoral nerve
2) Femoral artery
3) Femoral vein
What is the adductor canal?
Space between vastus medius and adductor longus
(Sartorius overlying)
What are the contents of the popliteal fossa?
1) Tibial nerve
2) Popliteal vein
3) Popliteal artery
4) Lymph nodes
What are the bounds of the popliteal fossa?
Superomedial:
- Semimembranosus
- Semitendinosus
Superolateral:
- Biceps femoris
Inferomedial and lateral:
- medial and lateral heads of gastrocnemius
Roof:
- popliteal fascia
Floor:
- popliteal surface of femur
- knee joint capsule
- popliteal ligament
- popliteal fascia
Where is the posterior tibial pulse palpated?
Between posterior aspect of medial malleolus and medial border of calcaneal tendon
Where is the dorsalis pedis palpated?
Between tendons of extensor hallucis longus and extensor digitorum at ankle joint
What are the veins of the lower limb?
1) Superficial (SQ)
i/ii) great and small saphenous vein
2) Deep (deep to deep fascia)
- accompany all major arteries
- venae comitantes
3) Perforating veins
- blood flow from superficial → deep
Describe the course of the great saphenous vein?
Medial marginal vein of foot dorsum
→ ascend anterior to medial malleolus
→ posteromedial to knee
→ ascend medially in thigh to perforating the muscular fascia
→ join common femoral vein @ saphenofemoral junction (few cm distal to inguinal ligament)
Describe the course of the short saphenous vein.
Dorsal venous arch
→ ascend posterolaterally from behind lateral malleolus
→ ascend along middle of calf
→ ends in popliteal vein in posterior knee
What is a saphenous cutdown used for?
Invasive method for emergency venous access
Describe the physiological methods that prevent of venous backflow in the lower limb.
Superficial → perforating → deep veins
i) perforating contains valves to prevent backflow
ii) In deep vein, blood propelled by skeletal muscular contraction to femoral vein
ii) In deep vein, arterial pulsation helps blood to move
What are varicose veins?
Pathologically enlarged superficial veins due to valvular incompetency that allows blood flow from deep veins → perforating → superficial
What are the nerves that innervate the lower limb?
1) Femoral nerve
2) Obturator nerve
3) Sciatic nerve (tibial and common fibular divisions)
4) Ventral rami → lumbar plexus (L1-L4) + Sacral plexus (L4-S4)
What is a patellar tendon reflex and what does it assess?
Tap patellar ligament → leg extend → L2-4 ok
(controlled by muscle spindle in the quadriceps femoris)
What is the most common cause of sciatica?
Bulging/herniated disc
- also piriformis syndrome
How does the myotome of the superficial and deep peroneal nerve differ?
Superficial: lateral compartment of leg (everters)
Deep: anterior muscles of leg (dorsiflexors of ankle, extensors of toes)
What is the most common sign of a common fibular nerve/peroneal nerve injury?
Foot drop
eg. fracture of fibula
a) paralysis of dorsiflexors of ankle and evertors of foot (foot drop)
b) loss of sensation on anteromedial leg and dorsum of foot
What is equinovarus?
Foot abnormality:
- foot drop & everted
What is calcaneovalgus?
Foot abnormality:
- dorsiflexed and everted
How can a radiculopathy be diagnosed?
1) MRI
good for looking at soft tissues
2) CT scan
visualise, helps to rule out kidney stones (one of the dy dx diagnosis)
3) EMG electromyography
evaluates function of skeletal muscles & nerves that control these muscles, dorm of electrodiagnostic testing
How is hip joint pain referred to the knee?
Both within the L3 dermatome
What is the pathognonomic physical examination finding of a deep vein thrombosis
Medial joint line of the knee draw one line down 10cm measure calf circumference >2cm diff between both sides
Best clinical feature to identify DVT
