Lower Limb Flashcards
Femoral triangle borders
Medial - medial border of adductor longus
Lateral - sartorius
Superior - inguinal ligament
Roof - fascia lata
Floor - AL, pect, posts, iliacus (M to L)
Origin of the hamstrings (M to L)
Ischial tuberosity
ST, SM, BF (long head)
Insertion of the short rotators (S to I)
Piriformis
Superior gemellus
Obturator internus
Inferior gemellus
Obturator externus
Quadratus femoris
Anastomoses of hip
Trochanteric
- Superior gluteal A
- Inferior gluteal A
- Medial Cx Fem A
- Lateral Cx Fem A
Cruciate
- Inferior gluteal A
- Medial Cx Fem A
- Lateral Cx Fem A
- Ascending 1st Perf
Relations of N + A to Psoas
Medial - ext iliac A + V
Deep / Medial - obt N
Lateral - femoral N
Root values of gluteal muscles
- Superior gluteal N = L4, L5, S1
- Inferior gluteal N = L5, S1, S2
- N to obturator internus = L5, S1, S2
- N to quadratus femoris = L4, L5, S1
1 + 4 / 2 + 3 = same
Closely assoc. structures to iliopsoas muscle
Medially @ the pelvic brim -> iliac vessels
@ insertion site -> medial femoral Cx A
Ligaments of the hip
- Iliofemoral (strong, anterior)
- Ischiofemoral (weak, posterior)
- Pubofemoral (small, posteroinferior)
Innervation of anterior thigh / hip flexors
- Psoas (L1, 2, 3)
- Iliacus (L2, 3, 4 - femoral N)
- Pectineus (L2, 3, 4 - femoral N, remember pectinous = watershed)
- Rectus femoris (L2, 3, 4 - femoral N)
- Sartorius (L2, 3, 4 - femoral N)
- VM, VI, VL (L2, 3, 4 - femoral N)
Pes anserine insertion
Common insertion site for (Say Grace Before Tea, Mum):
- Sartorius
- Gracilis
- Semitendinosus
- Semimembranosus
Surgical approach to pes anserine
Harvest semitendinosus / gracilis
Terminal branch of saphenous N @ risk as it runs between sartorius + gracilis
Additional structures within the femoral triangle (NOT NAVI)
Lateral cutaneous N of thigh crosses the lateral corner of the triangle
Femoral br of genitofemoral N (L1 / L2)
Structure related to sartorius in lower thigh
Saphenous N lies posterior to sartorius as it exits out of Hunters canal
Surgical considerations assoc. w/ vastus lateralis
Perforators from profound femurs runs deep to VL + need to be identified + ligated to prevent excessive bleeding
Obturator N supply
Ant division:
- Pectineus (watershed)
- Add B
- Add L
- Gracilis
- Sensory
Post division:
- Obt E
- Add M
Landmark for division of anterior / posterior Obturator N
Add B
Landmark for division of anterior / posterior Obturator N
Add B
Add Magnus rule of 2s
Origin
- Pubic
- Ischial
Insertion
- P - glut tub / linea aspera / supracondylar ridge
- I - adductor tubercle
N supply
- P - post division of Obt N
- I - tib portion of Sciatic N
A supply
- Proximal = obt A
- Distal = profunda femoris perforators
Function
- P - true adduction
- I - hip extension
Unique feature of gracilis
Only adductor that DOES NOT insert into the linea aspera
Piriformis as a landmark (structures above + below)
Above:
1. Superior gluteal A + N
Below:
- Sciatic N
- Inferior gluteal A + N
- Perf cut N
- Post Fem cut N
- N to QF
- N to obt Int
- Pudendal N
- Pudendal A + V
Structures via the lesser sciatic foramen
- Tendon of obt int
- N to obt int
- Internal pudendal A + V
- Pudendal N
Vessel @ risk with posterior hip approach
MCFA - deep branch crosses the tendon of obt ext (behind QF) -> travels superiorly posterior to the conjoint tendon (SG / OI / IG) to perforate into the capsule
Relation fo sciatic N to the short rotator muscles
Anterior to piriformis but posterior to obturator internus
Innervation of the gemelli muscles
Sup G - N to obt int
Inf G - N to QF
Landmarks for MFCA
Space between the inferior edge of inf G + superior edge of QF (lying on OR posterior to obt ext)
Surgical considerations for superior gluteal N
SGN is 5cm proximal / above the tip of the GT
@ risk w/ lateral (Hardinge) hip approach when splitting the glut med muscle
Order of structures inserting onto fibular head
From A to P
- LCL
- Popliteofibular lig
- Rectus femoris
Common Fib N relation to fibular
Passes posterior to the tendon of biceps femoris as it inserts into the fibula
Passes around the neck of the fibula
Gerdy’s tubercle
Lateral condyle of the tibia
Insertion point for the ITB
Attachments of the fascia lata
Proximal - inguinal ligament, ASIS, iliac crest, PSIS, ischiopubic ramus
Distal - patella, inferior portion of tibial condyles, head of fibular
Is continuous posteriorly w/ the popliteal fossa (where transverse fibres strengthen it) + then the deep fascia of the calf
Muscles enclosed by fascia lata
- Glut max
2. TFL
Femoral ring borders
A = inguinal ligament
P = pectineal lig + pectineus (covering superior pubic ramus)
M = lacunar ligament
L = femoral vein
Cloquet’s node
LN located in the femoral canal
Drains the clitoris in F + the glans penis in M
Genitofemoral N course in fem sheath
Fem br (L1) of GF N
Runs on the anterior surface of ext iliac A
Pierces the anterior wall of the fem sheath
Fem A br in the fem triangle
x4 superficial:
- Superficial Cx iliac A
- Superficial epigastric A
- Superficial external pudendal A
- Deep external pudendal A
x1 deep:
1. Profunda femoris
Cx of cannulating fem A
- Retroperitoneal haemorrhage
- Gut perforation
- AV fistula
Superficial epigastric A
Emerges from saphenous opening
Supplies the skin / subcut as it passes toward the umbilicus
Superficial external pudendal A
Emerges medially from saphenous opening
Passes anterior to spermatic cord / round lig to supply scrotal skin / subcut
Deep external pudendal A
Emerges more medially from saphenous opening than the SEPA
Passes posterior to spermatic cord / round big to supply scrotal skin / subcut
Superficial Cx Iliac A
Pierces FL lateral to saphenous opening
Passes superolaterally toward ASIS where it forms anastomosis w/ other vessels
Course of medial Cx fem A
Passes posteriorly between psoas + pectineus into the adductor compartment
Passess posteriorly between obt ext + add b into the posterior compartment
Visible between inf gemellus + QF as it divides
@ risk w/ posterior approach to the hip
Course of lat Cx fem A
Lies under sartorius
Ask br @ risk w/ anterior approach to the hip (lies between sartorius + TFL)
Fem vein course
Enters fem triangle posterior to fem A
In the fem sheath it comes to lie medial to fem A
Just below the fem sheath the greater saphenous vein joins its anteromedial side through the cribriform fascia
Gluteal IM inj
Upper outer quadrant of the gluteal region
Gluteal region = extends from the iliac crest to the gluteal fold
Stability of the hip joint
Result of the adaptation of the articulating surfaces of acetabulum + femoral head to each other
Mobility of the hip joint
Results from the femur having a neck that is much narrower than the equatorial diameter of the head
Haversian fat pad
Occupies the central non-articular portion of the acetabulum
Hip capsule attachment
Anteriorly extends to the intertroch line
Posteriorly it extends for only 1/2 this distance to 1/2 along the femoral neck
Capsule is loose but extremely strong
Clinical implications of iliofemoral lig
Limits extension @ the hip J
Forms the fulcrum or axis around which the neck of the femur rotates in dislocation of the hip joint
Weakest hip lig
Ischiofemoral lig
Bursae of the hip
- Under glut med / min @ GT
- Under glut max (over isch tub, GT + upper part of VL)
- Iliac bursa - extends upwards beneath iliacus
Structures that separate the fem A + V + N from the hip joint
Fem A - psoas
Fem V - pectineus
Fem N - iliacus
Structure that separates sciatic N from the hip joint
Obt internus + gemelli
Ant approach to hip (Smith Peterson)
Between sartorius + TFL (identifying LCFA)
Detaching TFL, RF + ant glut med + iliacus
Ant/Lat approach to hip (Watson Jones)
Between TFL + glut med (identifying LCFA)
Exposes the capsule under the ant fibres of glut med / min
Post approach to hip (Moore)
Splitting middle of glut max in line of its fibres
Divide piriformis, obt int + gemelli @ femoral attachments
Sciatic nerve is protected by reflecting obt int / gemelli medially
Inj into hip
Anterior - 5cm below ASIS, directed upwards / backwards / medially
Lateral - in front of GT + parallel w/ fem neck
Borders of pop fossa
Superomedial - ST / SM
Superolateral - BF
Inferomedial - med gastroc
Inferolateral - lat gastroc
Floor + roof of pop fossa
Roof = fascia lata w/ strengthening transverse fibres
Floor (sup to inf)
- Femur
- Knee capsule
- Popliteus fascia
Contents of pop fossa
Deep to Sup
- Popliteal A
- Popliteal V
- Popliteal LNs
- Sciatic N OR tibial / common fibular
Course of fem V relative to fem A
Lateral @ add hiatus
Posterior in fem triangle
Medial in femoral sheath
Borders of add canal
M - add longus superiorly, add magnus inferiorly
L - vastus med
Roof - sartorius fascia w/ sub sartorial plexus
Contents of add canal
- Fem A
- Fem V
- Saphenous N
- N to vast m
Relation of fem NV bundle
@ all times the fem A lies between fem V + saphenous N
Course of pop A relative to N
Medial + deep to sciatic N @ add hiatus
Lateral to tib N as it enters the solar arch
Relation of pop NV bundle
@ all times the pop V lies between pop A + tibial N
LCL vs MCL
LCL:
- Round, cord-like lig
- NOT attached to lateral meniscus
- Taut w/ ext + ‘screw home’ movement
MCL:
- Broad, flat, strong lig
- Attached to medial meniscus
- Limits ext + ‘screw home’ movement
Oblique pop lig
Thick rounded band, strong ++
Formed from lat expansion from insertion of SM -> slopes to popliteal surface of femur (obliquely)
Limits ext + rotation during screw home movement
Screw home mechanism
IR of tibia 15 degrees relative to femur
Occurs from 20 degrees flex to O degrees ext
MCL / LCL / OPL - tightens + prevent further IR
ACL - tightens + prevent further ext
Slightly hyperextended position
ER must occur to “unlock” knee before flex can occur
(ER movement - BF, SM ST)
Function of the menisci
- Shock absorbers
- Spread synovial fluid
- Obscure role in rotation @ the knee
- Slightly deepens the articular surface - ?stability
Anatomy of meniscal tears
MM torn much more commonly (x2) because of its attachment to MCL + therefore is less mobile
LM is attached to popliteus + meniscofemoral lig so can be pulled out of the way when there is a rotational force @ the knee
Meniscofemoral lig
Arises from the posterior horn of LM + attaches to the lateral aspect of medial femoral condyle
Splits into ant / post divisions around the PCL
Order of structures @ ext retinaculum
Timothy Has A Very Nasty Diseased Foot
- TA
- EHL
- Dorsal pedis A
- Deep fibular N
- Dorsal pedis V
- EDL
- FT
Order of structures @ flex retinaculum
Tom Dick And Very Naughty Harry
- TP
- FDL
- Posterior tibial A
- Posterior tibial V
- Posterior tibial N
- FHL
Baker’s cyst
One way valve defect in the posterior capsule of the hip
Forms due to fluid accumulation in out-pouching between the tendon of SM + the medial head of gastroc
ACL / PCL blood supply
Middle genicular A
Medial + lateral meniscus blood supply
75% of the meniscus is avascular =.white zone
25% is vascular = red zone
Med / Lat inferior genicular A w/ small contribution from middle genicular A to posterior horn
Deltoid lig
Medial collateral lig of the ankle - x2 layers
Main stabiliser w/ stance phase of gait
- Deep - narrow extending from tib mal -> medial side of the talus (rectangular)
- Superficial - triangular shaped, continuous across several attachments
Individual components of the deltoid lig
- Posterior tibiotalar lig
- Tibiocalcaneal lig (sustentaculum tali)
- Tibionavicular lig
- Anterior tibiotala lig
Lateral collateral lig of the ankle
- ATFL (weakest) - flat
- Calcaneofibular - rounded, cord-like
- PTFL (Strongest)
NV plane of the plantar aspect of the foot
Between 1st - 2nd muscular layers
Muscular layers of the foot
- Superficial - FDB, AbH, AbDM
NV plane
- Intermediate superficial - FHL, FDL (lumbricals on tendons of FDL), QP
- Intermediate deep - FHB, AdH, FDM
- Deep - IO muscles + deep tendons of FL + TP
