Lower Limb Flashcards
Three ligaments reinforce the hip capsule
• Iliofemoral (Y-shaped): from anterior inferior iliac spine, bifurcates, to each end of the trochanteric line (resists hyperextension)
- by the far the strongest!
- Pubofemoral: from iliopubic junction to blend with the medial aspect of the capsule (resists extension and abduction)
- Ischiofemoral: from the ischium and inserts into the base of the greater trochanter (limits extension)
Describe the blood supply to head of the femur.
- Extracapsular arterial ring at the base of the femoral neck - medial and lateral circumflex femoral arteries from Profunda Femoris with smaller contributions from superior and inferior gluteal arteries.
- Retinacular arteries arising from the ascending cervical branches. They give rise to the subsynovial intra articular ring.
- Artery of ligamentum teres - derived from obturator or medial circumflex femoral artery.
- Epiphyseal blood supply — arising primarily from medial and lateral epiphyseal arteries.
- Metaphyseal blood supply — arise from branches of ascending cervical arteries, & subsynovial intraarticular ring.
What are the principal hip flexors at the nerve supply?
Psoas Major - L1-3 Ventral Rami
(Tips of Transverse processes T12-L4)
Iliacus - Femoral Nerve - L2-4
Insert into the lesser trochanter
External Rotators
Gemellus S/I Obturator I (Joint tendon with above 2)/E Piriformis Quad Fem Gluteus Maximus
Hip Flexion
Flexion Femoral nerve (L2-L4)
Psoas major (- L1-3 Ventral Rami )
Iliacus
Rectus femoris
Sartorius
Hip Extension
Extension Inferior Gluteal Nerve (L5-S2)
Gluteus maximus
Hip Adduction
Adduction - Obturator nerve (L2-L4) Adductor longus Adductor magnus Adductor brevis Gracilis
Hip Abduction
Abduction Superior Gluteal Nerve (L4-51
Gluteus medius and minimus
Hip External Rotation
External rotation
Piriformis - NT Piriformis (S1-S2) Gemellus superior - Nt Ob Int (L5-S2) Obturator internus - Nt Ob Int (L5-S2) Gemellus inferior - Nt Qf Int (L4-S1) Quadratus femoris - Nt Qf Int (L4-S1) Obturator extemus - Post. Branch of Obturator Nerve L3-L4
Lateral to psoas major muscle
Subcostal nerve (L1) Iliohypcgastric nerve (L1) Ilinguinal nerve (L1)
Lateral femoral cutaneous nerve (L2, L3)
Femoral nerve (L2 — 4)
Anterior to psoas major muscle
Genitofemoral nerve (L1, L2)
Gen - Skin over scrotum
Fem - Skin over femoral triangle
Medial to psoas major muscle
Obturator nerve (L2 —4)
Through greater sciatic notch to enter gluteal region, inferior to piriformis muscle.
Sciatic nerve (L4 — S3)
Emerges from inferior border of gluteus maximus
Posterior femoral cutaneous nerve (S1, S2, S3)
posterior thigh and buttock
Femoral Triangle
- Roof: Fascia lata
- Apex: Points inferiorly and continues with the adductor canal
- Superior: The inguinal ligament
- Medial: Medial border of adductor longus • Lateral: Medial border of sartorius
- Floor (medial to lateral): Adductor longus, pectineus and iliopsoas
Contents of femoral sheath
femoral artery, femoral vein and femoral canal. NOT femoral nerve
femoral canal
femoral canal - medial compartment of the femoral sheath, opens superiorly into fem rm ring - contains fat, lymphatics and Cloquet’s node.
Cloquet’s node signficance
Cloquet’s node drains the lower limb, perineum and anterior abdominal inferior to the umbilicus. It may be enlarged in cases of carcinoma or infection at these sites.
Femoral Ring
Femoral ring is the superior opening of the femoral canal.
LMAP/FLIP
- L ateral: Fascia around femoral vein
- M edial: Lacunar ligament
- A nterior: Inguinal ligament
- P osterior: Pectineal ligament
Femoral hernias occur at the femoral ring.
Name the nerve roots of the sacral plexus.
The sacral plexus is formed from the anterior primary rami of L4-5, S1-4.
Note: Sacral nerves from anterior sacral foramina, unite in front of piriformis + joined by lumbosacral trunk (L4, 5)
Name the boundaries of the greater sciatic foramen.
- Anterolaterally: Greater sciatic notch of the ilium
- Posteromedially: Sacrotuberous ligament •Inferiorly: Sacrospinous ligament and the Ischial spine
- Superiorly: Anterior sacroiliac ligament
Name the structures passing through the greater sciatic foramen ABOVE pirifomis.
- Superior gluteal vessels
* Superior gluteal nerve
Name the structures passing through the greater sciatic foramen BELOW piriformis.
- Inferior gluteal nerve + vessels
- Internal pudendal vessels + nerve
- Sciatic nerve
- Posterior cutaneous nerve of the thigh •Nerve to quadratus femoris
- Nerve to obturator internus
Name the boundaries of the lesser sciatic foramen.
- Anterior: Tuberosity of the ischium
- Superior: Spine of the ischium and sacrospinous ligament
- Posterior: Sacrotuberous ligament
Name the structures passing through the lesser sciatic foramen.
- Tendon of obturator internus
- Nerve to obturator internus
- Internal pudendal vessels •Pudendal nerve
The Popliteal Fosse contains:
- Popliteal artery
- Popliteal vein
- Tibial nerve
- Common fibular (peroneal) nerve
- Lymph nodes
The roof contains:
• Small saphenous vein
• Posterior cutaneous nerve of thigh
Great saphenous vein:
Begins at the medial margin of dorsum venous arch of the foot - to femoral vein 3 cm. below inguinal ligament.
- It ascends in front of the medial malleolus and along medial side of the leg in relation with the saphenous nerve.
- It runs upward behind the medial condyles of the tibia and femur and to end in the femoral vein.
Small saphenous vein:
• Begins behind lateral malleolus a continuation of lat dorsal venous foot arch.
It first ascends along the lateral margin of the achilles tendon, and than crosses it to reach the middle of the back of the leg.
Running upward, it perforates the deep fascia in the lower part of the popliteal fossa, ending in popliteal vein, between the medial and the lateral heads of the gastrocnemius.
The small saphenous vein possesses nine to twelve valves, one of which is always found near its termination in the popliteal vein. In the lower third of the leg the small saphenous vein is in dose relation with the sural nerve which is vulnerable to damage during varicose vein surgery.
Tendons cross ankle anteriorly medial to lateral
(Tall Husbands Are Never Dear Persons) • Tiballs Anterior • Extensor Hallucis Longus tendon • Anterior tibial artery • Deep peroneal Nerve • Extensor Digitorum Longus • Peroneus Tertius
Tendons crossing the ankle Joint (Medially):
Tendons crossing the ankle Joint (Medially): From anterior to posterior: (Tom, Dick, And a Very Naughty Harry) • Tendon of Tibialis Posterior • Tendon of Flexor Digitorum Longus • Posterior Tibial Artery • Vena commitantes • Tibial Nerve • Tendon of Flexor Hallucis Longus
Name the three groups of ligaments of the ankle joint.
The three groups of ligaments which support the ankle joint are the:
•Deltoid ligament
•Lateral collateral ligamentous complex
•Syndesmosis
Deltoid ligament
•Deltoid ligament Consists of a
Deep pad (between medial malleolus + talus)
+
Superficial part - weaker and from medial malleolus + talus, calcaneus and navicular
Lateral collateral ligamentous complex
Consists of three bands:
Anterior and posterior talofibular ligaments and the
Calcaneoflibular ligaments
Syndesmosis
Syndesmosis
Consists of four parts and is the most important ligament in maintaining normal alignment of the ankle joint:
Anterior inferior talofibular ligament
Posterior inferior talofibular ligament
lnferior transverse talofibularligamemt lnterosseous ligament
Name the arches of the feet.
- Medial longitudinal arch
- Lateral longitudinal arch
- Transverse arch (each foot contributes half of the transverse arch)
Name the ligament which supplies the main support of the medial longitudinal arch of the foot?
The plantar calcaneonavicular ligament (spring ligament)
connects the sustentaculumtali with the plantar surface of the navicular bone.
It provides the main support for the medial longitudinal arch of the foot.
Dorsalis pedisis pulse
between the tendons of extensor hallucis longus and extensor digitorum on the dorsum of the foot
The Posterior tibial artery
a finger’s breadth below and behind the medial malleolus
Intrinsic muscle layers of the foot
1st Layer
1st Layer - Small side ABductors and the middle flexor
- Abductor hallucis
- Flexor digitorum brevis
- Abductor digitiminimi
Intrinsic muscle layers of the foot
2nd Layer
2nd Layer
- Quadratus plantae
- Lumbricals
Intrinsic muscle layers of the foot
3rd Layer
3rd Layer Small side flexors + AH Flexor halluicis brevis Adductor hallucis •Flexor digiti minimi brevis
Intrinsic muscle layers of the foot
4th Layer
- Plantar interossei
* Dorsal interossei
Lower limb dermatomes
- L1- Below the inguinal ligament
- L2- Mid thigh
- L3- Around the knee
- L4- Medial side of the leg
- L5- Lateral aspect of the leg, medial side of the dorsum of the foot
- S1.- Lateral aspect of the foot, the heel and most of the sole
- S2 - Posterior aspect of the thigh
- S3, S4, S5 concentric rings around the anus, the outermost of which is S3
Ovarian cyst - medial thigh pain
obturator nerve compression
Young heavy smoker leg cramps
Buergers disease
Superior and Inferior gluteal arteries from…
Sup Glut Artery from post trunk of internal iliac. IGA from anterior trunk
Trendelenburg gait: abduction loss
sup glut nerve + buttock wasting glut medius [min + TFL] without foot drop.
Trendelenburg gait + foot drop
L5 radiculopathy or polio
Lat cutaneous nerve of the thigh with respect to inguinal ligament
Lat cutaneous nerve of the thigh, lateral aspect of inguinal ligament
Heads of Adductor Magnus:
Adductor Magnus:
Posterior by Obturator +
Hamstring/ Ischiocondylar by Sciatic
Marks end of Hunter’s canal
Adductor Magnus marks end of Hunter’s canal
Biceps Femoris-…
Both heads insert into fibula head
o Long head – ischial tuberosity – sciatic nerve
o Short head – linea aspera – common peroneal nerve
Bone met in femur that is hypervascular –
renal primrary
Sartorius - Forms the Pes anserinus with
Sartorius - Forms the Pes anserinus with Gracilis + semitendinous
For intracapsular NOF, divide….
Divide transverse branch of lateral circumflex
Ankle eversion occurs at the
Ankle eversion at subtalar joint
Hunters canal:
Hunters canal: Saphenous Vein, superficial artery and vein
Osteolytic lesion? Psoas major can avulse
Osteolytic lesion? Psoas major can avulse lesser trochanter!
Young person with mid-thight mass
Young person with mid-thight mass – Ewing Sarcoma
Psoas major inserts into
lesser trochanter
Malunion – not typically in
NOFs
lies under SFJ, damaged during varicose surgery
Deep External pudendal artery – lies under SFJ, damaged during varicose surgery
Nerve to EHL
Extensor hallucis longus L5
Tibialis anterior nerve root
L5
McMurrays
McMurrays – flex the knee
– internal rotation = lat mesicus
extn = medial lemniscus
Delayed swelling and locking… diagnosis and management
torn meniscus - Arthroscopic menisectomy – no conservative management
female pain going downstairs, wasting of quads
Chondromalacial patalle
Upper part of the popliteal fossa - tibial nerve lies …and then passes…
Upper part of the popliteal fossa - tibial nerve lies laterally to vessels, it then passes superficial to them to lie medially.
(like the median nerve!)
Inferior aspect of the popliteal fossa - tibial nerve with respect to vessels
tibial nerve superior to vessels.
Deepest structure in popliteal fossa.
Popliteal artery - deepest structure in popliteal fossa.
Osgood-Schlatter
Patella tendon inflam at tibial tuberosity, overactivity – repeated growth plate stress
GrittiStrokes
through knee amputation, replace condyles with patella.
Pseudogout
Pseudogout: calcium pyrophosphate; positively birefringent; rhomboid-shaped
Gout
Gout: yellow monosodium urate; negatively birefringent; needle-shaped
Spontaneous haemoarthosis in
Spontaneous haemoarthosis in Haemophilia (not vW’s)
Posterior cruciate ligament separated from popliteal vessels by
Posterior cruciate ligament separated from popliteal vessels by oblique popliteal ligament.
Transverse ligament in the knee is located
Transverse ligament is located anteriorly. - connects the two meniscii
Sportsman – medial knee pain up stairs but not on flat –
Sportsman – medial knee pain up stairs but not on flat – pes anserius bursitis
Sartorius, gracilis and semitendinous tendons inserting into the anteromedial proximal tibia.
Knee flex and twist – crack and swelling –
Knee flex and twist – crack and swelling – ant cruciate ligament
Cuboid
Cuboid -
4th + 5th MT’s
Calcaneus
Medially - 3rd cuneiform + navicular.
Tibialis posterior attached to under surface.
Plantar Flexor weakness
Plantar Flexor weakness is S1
