Lower limb Flashcards
what is the acetabulum?
deep hemispherical concavity covered in articular cartilage within pelvic bone
what is the acetabular labrum?
- fibrocartilaginous collar
- deeps depression at hip joint
what are the 5 ligaments of the hip joint?
- ligament of femoral head
- transverse acetabular ligament
- extracapsular ligaments (iliofemoral, pubofemoral, ischiofemoral)
which ligament limits the extension of the hip joint?
iliofemoral
which muscles initiate external rotation?
- obtruator internus
- obtruator externus
- superior gemellus
- inferior gemellus
- quadratus femoris
- piriformis
what muscle initiates internal rotation?
- gluteus medius
- gluteus minimus
what muscles initiate adduction?
- adductor longus
- adductor brevis
- adductor magnus
- pectinus
- gracilis
- quadratus femoris
what muscles initiate abduction?
- gluteus medius
- gluteus minimus
- piriformis
what muscles initiate extension of hip?
- tension fasciae latae
- rectus femoris
- gluteus medius
- iliopsoas
- sartorius
what muscles initiate flexion of hip?
- gluteus maximus
- gluteus medius
- gluteus minimus
- biceps femoris
- semimembranosus
what are the proximal and distal articulations of the femur?
Proximal - with acetabulum to form hip joint
Distal - with tibia and patella to form knee joint
what is the greater trochanter?
- large palpable projection
- insertion point for gluteus medius, gluteus minimus, piriformis, obtruator internus, superior gemellus, inferior gemellus and obtruator externus
what attaches to the lesser trochanter?
attachment site for iliopsoas and part of adductor magnus
what are the 3 roughened ridges that merge to form linea aspera?
- gluteal tuberosity (lateral ridge)
- pectineal line (intermediate ridge)
- intertrochanteric line (medial ridge)
what attaches to the gluteal tuberosity?
attachment site for deep, distal fibres of gluteus maximus
what attaches to the pectineal line?
pectineus
what is the interochanteric line the origin of?
vastus medialis muscles
what are menisci?
fibrocartilaginous pads
inc. joint stability and absorb shock by dissipating pressure amongst a greater surface area
what type of bone is the patella?
largest sesamoid bone in body
in quadriceps femoris tendon
what are the 4 bursae?
synovial-filled sacs
- suprapatellar
- prepatellar
- infrapatellar
- semimembranosus
what muscles cause flexion of the knee?
- hamstrings
- gracilis
- sartorius
- popliteus
what muscles cause extension of the knee?
- quadriceps femoris (inserts into tibial tuberosity)
what are all the articulations of the tibia?
- femur: at tibiofemoral articulation of knee
- fibula: superior and inferior tibiofibular joints
- talus: at talocrural joint of ankle (where it forms medial malleolus)
what does the fibula form at the talocrural joint?
lateral malleolus (bony projection felt laterally at ankle)
describe the talocrural joint
synovial hunge joint
formed between medial malleolus of tibia, lateral malleolus of fibula and talus bone
what does the talus bone articulate with?
calcaneus (another tarsus bone) to form talocalcaneal joint
what 2 joints form the ankle?
- inferior tibiofibular joint
- talocalcaneal joint
what movements does the talocrural joint allow?
dorsiflexion and plantarflexion of foot
what movements does the talocalcaneal joint allow?
small degree of foot inversion and eversion
what is the calcaneus? what is it attached to?
- largest bone in foot
- lies below talus to form heel of foot
- vital in taking weight of body
- attached to Achilles tendon
what bones are in the proximal row of tarsal bones?
talus
calcaneus
what bone makes up the intermediate row of tarsal bones?
navicular bone
what does navicular articulate with?
3 cuneiform bones
what is cuboid?
main bone of midfoor
sits in dital row of tarsals alongside cuneiforms
articulates with lateral 2 metatarsals distally and calcaneus proximally
what are the 3 arches of the foot? what are they important in?
- medial longitudinal arch
- lateral longitudinal arch
- transverse arch
- important in lower limb motility
what movements are permitted in metatarsophalangeal joitns?
- flexion
- extension
- abduction
- adduction
- circumduction
what are the 8 compartments of the muscles of the lower limb?
- superficial muscles of pelvic girdle
- deep muscles of pelvic girdle
- ant compartment of thigh
- medial compartment of thigh
- posterior compartment of thigh
- anterior compartment of thigh
- lateral compartment of thigh
what are the key muscles of interest that are the superficial muscles of the pelvic girdle?
- gluteus maximus
- gluteus medius
- gluteus minimus
- tensor fascia latae
what does the gluteus maximus do?
- main extensor of thigh
- assits in lateral rotation
where does the gluteus maximus originate?
- sacrum
- ilium
- thoracolumbar fascia
- sacrotuberous ligament
where does the gluteus maximus insert?
- gluteal tuberosity of femur and iliotibial tract
what are the functions of the gluteus medius and minimus?
abduct and medially rotate thigh
where does the gluteus medius originate?
gluteal surface of ilium
where does the gluteus medius insert?
lateral surface of greater trochanter
where does the gluteus minimus originate?
just inferiorly and deep to gluteus medius on ileum
where does the gluteus minimus insert?
anterior aspect of greater trochanter
what innervates both the gluteus minimus and medius?
superior gluteal nerve
how do you test the gluteus medius?
ask pt to abduct their thigh against resistance whilst lying on their side
what is the Trendelenburg sign?
result of weakness of the hip abductor muscles
specifically gluteus medius and minimus which work to stabilise pelvis during movement
due to damage to superior gluteal nerve
drooping of pelvic opposite to affected side
what does the tensor fascia latae do?
abduct and medially rotate thigh
assists gluteus maximus through stabilisng thigh when extended
where does the tensor fascia latae originate?
ASIS
where does the tensor fascia latae insert?
iliotibial tract
what innervates the tensor fascia latae?
superior gluteal nerve
what do the deep muscles of the pelvic girdle do?
laterally rotate and weakly abduct thigh
stabilise femoral head within acetabulum
what are the deep muscles of the pelvic girdle?
piriformis
obtruator internus
superior and inferior gamelli
quadratus femoris
what is the thigh divided up into?
anterior compartment
medial compartment
posterior compartment
what are the muscles in the anterior compartment?
- quadriceps femoris
- sartorius
- pectineus
- iliopsoas
what innervates all the muscles in the anterior compartment?
femoral nerve
what is the function of the iliopsoas?
assists in flexion and lateral rotation of thigh
where does iliopsoas attach?
forms tendon that attaches to lesser trochanter of femur
where does the sartorius originate?
ASIS
where does the sartorius attach?
medial surface of tibia
what is the function of the sartorius?
flexion, lateral rotation, weak abduction of thigh
assists medial rotation of leg when knee joint is flexes
where does the pectineus originiate?
anterior surface of pelvic bone
where does the pectineus attach?
pectineal line on posterior side of femur, just inferior to lesser trochanter
what does the pectineus do?
adduction and flexion of hip joint
what 4 individual muscles make up the quadriceps femoris?
- vastus medialis
- vastus intermedius
- vastus lateralis
- rectus femoris
what are the functions of the quadriceps femoris?
flexion at hip joint and extension at the knee joint
where does the vastus lateralis originate?
greater trochanter and lateral lip of linea aspera
where does the vastus intermedius originate?
anterior and lateral surfaces of femoral shaft
where does the vastus medialis originate?
intertrochanteric line and medial lip of linea aspera
where does the rectus femoris originate?
from supra-acetabular groove
what do these 4 muscles fuse to form?
quadriceps femoris tendon which becomes patellar ligament at patella
inserts into tuberosity of tibia
how do you assess the quadriceps?
ask pt to extend their leg whilst sitting on edge of bed
apply firm resistance to distal part of leg
palpate contraction of quadriceps at ant surface of thigh
what are the muscles in the medial compartment of the thigh?
- gracilis
- obtruator externus
- adductor brevis
- adductor longus
- adductor magnus
what are all the muscles in the medial compartment of the thigh innervated and supplied by?
obtruator nerve
obtruator artery
where does gracilis originate from and insert?
originate: inferior rami of pubis
Insert: medial surface of tibia
what is the gracilis involved in?
adduction of thigh
flexion of leg
where does obtruator externus originate and insert?
originate: membrane of obtruator foramen
insert: posterior aspect of greater trochanter
what muscle forms the medial border of the femoral triangle?
adductor longus
where does the adductor longus originate and insert?
originate: pubis
inserts: linea aspera of femur
where is the adductor brevis?
short muscle
lying underneath and adductor longus
where does the adductor brevis originate and insert?
originate: from body of pubis and inferior pubic rami
attaches: to linea aspera
where is the adductor magnus?
largest muscle in medial compartment
lies posteriorly to other adductor muscles
what is the function of the adductor magnus?
has 2 parts
function to adduct thigh
but can cause flexion or extension depending on which part of muscle is contracted
what are the 2 parts of the adductor magnus called?
- adductor part
- hamstring part
how do you assess the function of the hip adductors?
ask pt to adduct their thigh whilst pt is sitting on edge of bed
apply resistance to distal part of thigh
“can you bend your knees and bring your legs together?”
what are the muscles in the posterior compartment of the thigh?
- biceps femoris
- semitendinosus
- semimembranosus
where does the biceps femoris originate?
has 2 heads
long head: originates from ischial tuberosity
short head: linea aspera
where does the biceps femoris insert?
both heads unite to form biceps femoris tendon
to insert into head of fibula
what is the function of the biceps femoris?
- extension of thigh at hip joint
- lateral rotation of leg when knee is flexed
where does the semitendinosus originate?
from same tendon as long head of biceps femoris at ischial tuberosity
where does the semitendinosus insert?
medial surface of tibia
what does the semitendinosus do?
medial rotation of leg when knee joint is flexed alongside semimembranosus
where does the semimemranosus originate and insert?
originate: ischial tuberosity
insert: medial condyle of tibia
what is the function of the semimemranosus?
extend thigh and medially rotates leg when flexed at knee joint
what are the 3 main muscles in the anterior compartment of the leg?
- tibialis anterior
- extensor digitorum longus
- extensor hallucis longus
what is this compartment innervated and supplied by?
deep fibular nerve
anterior tibial artery
where does the tibialis anterior originate and insert?
originates from lateral surface of tibia
inserts into plantar side of medial cuneiform and base of first metatarsal
what is the function of the tibialis anterior?
strongest dorsiflexor of foot
inversion of foot
where does the EDL originate?
lateral tibial condyle and medial surface of fibula
where does the EDL insert?
it descends down to form 4 tendons which insert at intermediate and distal phalanges of 4 lateral digits
where does the EHL originate?
medial side of fibula and interosseous membrane
where does the tendon of the EHL insert?
distal phalanx of hallux
what does the EHL do?
causes extension of this digit
causes dorsiflexion of foot
what do muscles in the posterior compartment of the leg do? innervation?
plantar flexion of foot
tibial nerve
superficial and deep
what are the superficial muscles of the posterior compartment?
plantaris, gastrocnemius, soleus
combine together to form single tendon that inserts into calcaneus of foot –> Achilles tendon
where does the gastrocnemius originate?
medial and lateral head
lateral head originates from lateral femoral condyle
medial head originates from medial femoral condyle
where does plantaris arise? what about soleus?
plantaris - femur
soleus - from fibular head and medial aspect of tibia
what are the 4 deep muscles in the posterior compartment of the leg? What do each do?
Popliteus - rotates femur on tibia
tibialis posterior - inverts and plantarflexes foot
FHL - flexion of hallux
FDL - flexion of lateral 4 digits
what does the lateral compartment of the leg contain? innervation?
fibularis longus
fibularis brevis
both innervated by peroneal nerve
what do FL and FB do?
eversion of foot
FL also assists in plantarflexion
what nerve roots make up the sciatic nerve?
L4-S3
what is the course of the sciatic nerve?
leaves pelvic cavity through greater sciatic foramen
comes out deep to inferior border of piriformis
enters gluteal region midway b/ PSIS and ischial tuberosity
in OSPE how would you describe the course of sciatic nerve?
curve between midpoint of PSIS and ischial tuberosity and midpoint between greater trochanter and ischial tuberosity upon entry into gluteal region
where does the sciatic nerve terminate? what does it form?
travels deep to long head of biceps femoris
terminates at popliteal fossa
forms tibial and common fibular nerve
what does the sciatic nerve innervate?
innervates hamstrings and hamstring portion of adductor magnus
how do you test the sciatic nerve?
ask pt to flex their knee joint
must be done with resistance
what nerve roots make up the superior gluteal nerve?
L4, L5, S1
describe the path of the superior gluteal nerve?
enters gluteal region through sciatic foramen superior to piriformis
what does the superior gluteal nerve innervate?
gluteus medius,
gluteus minimus,
tensor fascia latae,
piriformis
what does damage to the superior gluteal nerve result in?
Trendelenburg gait
what nerve roots make up the inferior gluteal nerve? what does it innervate?
L5, S1, S2
gluteus maximus
how do you test the gluteal nerves?
ask pt to abduct thigh against resistance while sitting on end of bed
apply resistance
palpate gluteal region
what nerve roots make up the femoral nerve and what is its path?
L2,L3,L4
travels lateral to psoas major to enter femoral triangle
what does the femoral nerve divide into? innervation?
divides into superficial and deep branches
provides motor innervation to quadricep muscles
sensory innervation to anteromedial thigh
what nerve does the femoral nerve give off?
saphenous nerve - provides sensation to medial side of leg and medial side of foot
how do you test the femoral nerve?
pt sit on end of bed
extend their knee against resistance
what nerve roots make up the obtruator nerve?
L2,L3,L4
describe the path of the obtruator nerve
enters thigh through obtruator canal
divides into anterior and posterior branch
what does the anterior branch innervate?
adductor longus
adductor brevis
gracilis
gives off a cutaneous branch to provide sensory innervation to small area on medial thigh
what does the posterior branch innervate?
adductor magnus
obtruator externus
how do you test the obtruator nerve?
ask pt to sit on end of bed and adduct both thighs against resistance
what nerve roots make up the superficial and deep peroneal nerves?
L4,L5,S1
what does the superficial peroneal nerve arise from>
common fibular nerve (one of terminal branches of sciatic nerve)
what does the superficial peroneal nerve innervate?
motor innervation to fibularis longus and fibularis brevis (which function to evert foot)
provides sensory innervation to anterolateral leg and dorsum of foot
how do you test the superficial peroneal nerve?
evert foot against resistance
can you turn your ankle to that the soles of your feet are facing towards you?
what is the deep peroneal nerve the other terminal branch of?
common fibular nerve
what does the deep peroneal nerve innervate?
EDL EHL tibialis anterior all work in dorsiflexion of foot provides sensory innervation to a small region on dorsum of foot
how do you test the function of the deep peroneal nerve?
ask pt to dorsiflex their foot against Resistance
stabilise ankle joint
how do you assess the neurological integrity of skin sensation?
light touch
pin prick
proprioception
vibration
how do you carry out light touch sensation?
- use wisp of cotton wool to touch patients sternum –> establish central baseline sensation , ask them to confirm when can feel
- ask pt to close their eyes and say yes everytime they feel it
- remember to assess contralateral dermatome on other side of the body
what are the 2 important reflexes in lower limb?
patellar tendon
Achilles tendon
both are stretch reflexes
what is a stretch reflex?
- rapid physiological response by a muscle
- protective measure against over stretch
- to prevent tearing, muscle contracts as a result of an impulse that is sent along reflex arc
- also leads to an inhibition of antagonisitc muscles which leads to their relaxation
what is a brisk reflex? what is it indicative of?
- stronger than appropriate response from muscle as a result of tendon stretch
- indicative of UMN lesion
what is a diminished reflex?
- absent or weaker than appropriate response
- indicative of LMN lesion
how do you elicit the biceps tendon reflex?
- strike tendon directly
- pt with legs dangling over side of bed
- palpate the biceps femoris
how do you do the achilles tendon reflex?
- ask pt to completely relax
- hold pt foot and initiate dorsiflexion
what is Jendrassik manoeuvre?
- where pt clenches teeth and interlocks both sets of flexed fingers into hook like form
- leads to larger reponse
what forms the femoral artery? describe its path
once external iliac artery crosses under inguinal ligament becomes femoral artery
passes through femoral triangle where it gives off 5 branches
continues to descend down posterolaterally to form popliteal artery
where does the popliteal artery branch? into what?
shortly after crossing popliteal fossa it gives rise to anterior and posterior tibial arteries
where can you feel the popliteal pulse?
midline in inferior part of popliteal fossa while their knee is flexed to relax hamstring
what does the posterior tibial artery give rise to?
fibular artery
what does the posterior tibial artery supply?
blood to plantar side of foot
partial supply to digits
where can you feel the posterior tibial artery pulse?
can be palpated behind and below medial malleolus
hold ankle of patient while they are lying on bed
what is the dorsalis pedis and what does it supply?
continuation of anterior tibial artery
supplies dorsal side of foot
where can you palpate dorsalis pedis pulse?
palpable on dorsum of foot in first intermetatarsal space just lateral to extensor digitorum hallucis tendon
what forms the long saphenous vein? where does it drain?
formed by dorsal venous arch of foot and dorsal vein of hallux
drains into femoral vein at femoral triangle
describe the pathway of the long saphenous vein
vein ascends up the medial side of lower limb
passes anteriorly to medial malleolus at ankle
what forms the small saphenous vein?
also formed by dorsal venous arch of foot and dorsal vein of fifth digit
describe the pathway of the small saphenous vein
ascends on posterior side of leg
passes behind lateral malleolus and along lateral border of calaneal tendon
where does the small saphenous vein drain?
drains into popliteal vein in popliteal fossa
what causes varicose veins?
condition associated with incompetency of valves of superficial veins
blood flows back into superficial veins and causes inc. intra-luminal pressure
causes veins to dilate
what is the gluteal safe area used for?
certain intramuscular medications
what is the location of the gluteal safe area?
superior lateral region of gluteal space to minimise rusk to sciatic nerve
how do you demonstrate it on a patient?
- heel of positioning hand on greater trochanter of femur, fingers pointing superiorly
- second digit on ASIS
- lateral 3 fingers placed posteriorly on iliac crest
- forms a V shape with fingers
- injection administered in centre of V shape
what are the borders of the femoral triangle?
- superior (base): inguinal ligament
- lateral: sartorius
- medial: adductor longus
what does the femoral triangle contain?
- femoral nevre
- femoral artery
- femoral vein
- femoral canal
- lymphatic vessels
(NAVEL) e= empty space for canal
what is contained within femoral sheath?
femoral artery, femoral vein and femoral contain contained within a fascia
what are the superolateral and superomedial borders of the popliteal fossa?
Superolateral: biceps femoris
Superomedial: semimembranosus and semitendinosus muscles
what are the inferomedial and inferolateral border of the popliteal fossa?
inferomedial: medial head of gastrocnemius
inferolateral: lateral head of gastrocnemius and plantaris
what are the contents of the popliteal fossa?
common fibular nerve
tibial nerve
popliteal vein
popliteal artery
what is the relationhip between small saphenous vein and popliteal fossa?
SSV enter popliteal fossa by piercing popliteal fasica to drain into popliteal vein
what is the popliteal artery?
continuation of femoral artery
gives rise to 5 genicular arteries
anastomose anteriorly to knee joint
