Lower Limb Flashcards
What are the key functions of the upper and lower limbs respectively
Upper: designed to place and use the hand in as many positions as possible so requires more mobility than stability at its joints
Lower: requires greater stability in order to bear weight
Give 4 major differences between upper and lower limbs
Rotation
Pelvic girdle is fixed whereas pectoral girdle is mobile
Tibia and fibula are fixed whereas radius and ulnar have movement between them
Hand has substantial independent digital movement (especially the thumb) whereas the foot is adapted to act as a segmented arched structure with limited independent movement of toes
5 roles of the vertebral column
Protect spinal cord and nerves
Support weight of body above pelvis
Provide a rigid and flexible axis for body and pivot for head
Posture and locomotion
Shock absorber
Describe the primary curves of the spine (2)
Found in embryonic life and are concave anteriorly (kyphosis)
Present in thoracic and sacral regions
Describe the secondary curves of the spine
Develop after birth and is concave posteriorly (lordosis)
Present in cervical region and lumbar region
Why do we have lordosis in the cervical spine ?
What kind of curve is this
To support the head and for binocular vision
Secondary
What is the point of the body and neural arch of a vertebral body
Body- weight bearing
Arch- protection
What is the neural arch made of
Pericles joining it to the body and lamina connecting the pedicles posteriorly
Where are the articular facets in the vertebral body
What kind of joint exists here
At the junction of the transverse processes: 2 superior and 2 inferior
Synovial
Where is the intervertebral foramen
Why do we have this
Formed between the pedicles of adjacent vertebrae
Where spinal nerves pass through
How are adjacent vertebrae connected
What kind of joint is this
By intervertebral discs and 2 ligaments connecting the vertebral bodies
Secondary cartilaginous
What is a vertebral disc composed of
A central nucleus pulposus which becomes more solid with age
This is surrounded by concentric rings of fibrocartiledge (the annulus fibrosis)
What is the nucleus pulposus a remnant of
What is it like at birth
The notochord
The nucleus pulposus is fluid at birth
What is the point of the annulus fibrosis
Resists torsion movements between vertebral bodies
What are the ligaments called that connect the vertebral bodies
Anterior and posterior longitudinal ligaments
What is a prolapsed disc and where does it usually occur
Degeneration and rupture if the annulus fibrosis, leading to protrusion of the nucleus pulposus which may press on a spinal nerve or the spinal cord
Most commonly happens in the lower lumbar region
Where are ligaments connected to the vertebrae to strength the facet joints
Give the name of each ligament
Spinous processes (supraspinous and infraspinous) Transverse processes (intertransverse) Laminae (ligamentum flavum)
Where is the human centre of gravity
~55% of the person’s height above the ground
Usually 3cm in front of the 2nd sacral vertebra
What are the movement tendencies for all lower limb joints
Extension
What are the tendencies of the cervical, thoracic and lumbar regions of the spine
Cervical- flexion
Thoracic- flexion
Lumbar - extension
What resists cervical tendency
Tendency is flexion
Erector spinae and ligamentum nuchae resist this
What resists thoracic tendency
Tendency is flexion
Resisted by erector spinae
What resists lumbar extension
There is little muscle action needed
What resists hip joint tendency
Tendency is extension
Resisted by tension in iliofemoral ligament
What resists knee tendency to fall
Locked knee position (most ligaments are taut) and tension in fascia lata (by glut max and tensor fascia lata)
What resists ankle tendency to fall
Soleus
What resists hip flexion
Glut max
What resists knee flexion
Quadriceps femoris
What is the name for muscles that resist a joints tendency
Postural/ antigravity muscles
All postural muscles are required during upright position. True or false?
False
They are all needed to attain this posture but not to maintain it
Which positions do people usually stand in
Why
Feet apart or one slightly in front of the other
These use minimum energy
How is the foot designed
How can this be seen
To adapt to uneven surfaces yet be converted into a rigid strut for walking
Tarsals are arranged in a bow forming both longitudinal and transverse arches
What are the passive elements holding the foot arches together
Fascia and ligaments
Eg plantar aponeurosis, spring ligament, and plantar interosseus ligament
What are the dynamic elements holding the foot arches together
Intrinsic foot muscles
Eg flexor digitorum brevis and adductor hallucis
Muscles with longitudinally running ligaments eg flexor hallucis longus
What are the suspensory elements supporting the foot arches
Tibialis anterior
Fibularis longus
How do the arches change when the foot is loaded
They give a little as muscles and ligaments tense
This reduces jarring and allows the foot to adapt to uneven surfaces
As the load on the foot increases what happens to the arches
What about when the foot is fully loaded
The arches become more resistant as ligaments become more taut
The foot is transformed into a rigid lever that acts in plantar flexion during locomotion
What is the benefit of the foot being adaptable
Can be flexible and absorb forces when unloaded yet can transmit forces when loaded
What happens when one leg is lifted
How do we do this
The centre of gravity shifts to the other leg
By lateral flexion of the spine and the action of the abductors of the hip (glut medius and minimus) at the side that is ground
What do the hip abductors do when lifting one leg
Prevent pelvis from tilting to the side off the ground but also tilt the hip upward and shift weight over the supporting limb
How is the ground foot stabilises when standing on one leg
Action of the inverters (tibialis anterior and posterior) and everters (fibularis longus and brevis)
What happens if the hip abduction is impaired
Pelvis tilts to side off the ground
Producing a waddling gait- Trendelenburg’s sign
How are arms used in walking
Weighted pendulums to increase impetus
Also swung as balancers
Where does the walking cycle go from
What are the 2 phases? Which phase is longer?
Toe off to toe off
Swing and stance (stance is longer in normal walking, but as speed increases swing time increases)
What are the 5 events of walking
Toe off, mid swing, heel contact, mid stance, heel off
There is a period when both feet are on the ground during normal walking. True or false?
True
The double stance phase
What is it called when both feet are off the ground when running
Double swing phase
Describe pelvic movement when walking
Why do we have this
Medial rotation at hip at the side in stance phase while there is lateral rotation at the side in swing phase
So one foot comes down in front of the other
Which muscles are used when rising up
Gluteus maximus (hip extension) and quadriceps femoris (knee extension)
Agnostic contraction must occur when sitting
What kind of walk might a patient get after a CVA (cerebrovascular accident)
Paralysis of one side or a shuffling gait in someone with Parkinson’s
What may lead to a waddling gait
Developmental dysplasia of the hip
Femur neck fracture
Muscle weakness following poliomyelitis
Which nerve is most frequently affected by trauma
What is the effect
What phase of walking is most affected
Common fibular
Weakness of dorsiflexion and in the fibularis muscles - drop foot
This has a key issue in dorsiflexion during swing phase
What connects the lower limb to the axial skeleton
The pelvic girdle
What forms the pelvic girdle
To hipbones and the sacrum
How does the bony pelvis transfer bodyweight to the lower limbs
Through the acetabula
What are the four ways for structures to pass from the pelvis to lower limb
The inguinal ligament,
through the obturator foramina,
and through the greater
and lesser sciatic foramina
How is the lower limb divided
Into four regions: the gluteal region, thigh, leg and foot
Name two important areas which convey structures between the regions of the lower limb
The femoral triangle
The popliteal fossa
Name the six bone groups of the lower limb
Hipbone, femur and patella, tibia and fibula, tarsus metatarsus phalanges
Give the nine joints of the lower limb
Sacroiliac joints and pubic symphysis Hip Knee Tibiofibular (superior, middle and inferior) Ankle (talocrural) Midtarsal Tarsometacarpal Metatarsophalangeal Interphalangeal
Describe the sacroiliac joints
They are synovial joints but very stable due to a regular interlocking ridges and strong interosseous ligaments
Describe the hip joint
Synovial ball and socket joint
With a deep acetabulum into which the head of the femur sits
In Which kind of patients are femoral neck fractures particularly common
Elderly people with osteoporosis
What kind of joint is the knee
What are the articulations of this joint
A complex synovial joint
Tibiofemoral and patellofemoral articulations
What are the principal functions of the medial and lateral menisci
Load transmission and shock absorption
What maintains stability in the knee
The strong collateral and cruciate ligaments and powerful muscles which also flex and extend the joint
What kind of joint is the superior tibiofibula joint
Synovial
Which joint is vital for ankle stability
Strong fibrous inferior tibiofibular joint
What kind of joint is the tibiofibular joint
Fibrous
What do the distal ends of the tibia and fibula form
A deep mortise into which the body of the talus fits, forming the ankle joint
Give the other name of the ankle joint
Talocrural joint
What are the midtarsal joints concerned with
Inversion and eversion of foot
What kind of joint are the tarsometatarsal joints
What do they permit
Synovial plane joints
Gliding movements
How is the thumb different from the big toe
The big toe has almost no mobility at its tarsometatarsal joint
What kind of joint are the metatarsophalangeal joints
Hinge joints with strong collateral ligaments
What kind of joint are the interphalangeal joints
Hinge joints with strong collateral ligaments
What are the three gluteal region muscle groups
What do these muscles do
Gluteal muscles
Tensor fasciae Latae
Short rotators of the hip
Move the thigh and control the movement of the pelvis relative to the weight-bearing limb in locomotion.
How did the lower limb rotate in embryological development? What has this resulted in?
Internally rotated
Has resulted in the extensor compartment being located anteriorly and flexor compartments being rotated posteriorly
Where is the thigh
Between the inguinal ligament and the knee
What’s supplies the quadriceps femoris
Femoral nerve
What is in the anterior compartment of the thigh
Quadriceps femoris
What muscle group can be found in the medial compartment of the thigh and which nerve supplies it
Adductors
Obturator nerve
Which muscle group is in the posterior compartment of the thigh? What is their action and what supply them?
Hamstrings
Extend the hip and flex the knee
Sciatic nerve
Where is the leg
Between the knee and the ankle
What are the compartments of the leg
Anterior lateral and posterior
Below the knee all muscles are supplied by which nerves
Tibial or common fibular nerves
The muscles in the leg produce which actions at the ankle joint
Doris flexion and plantar flexion
Also maintain the arches of the foot
What results in foot drop
The common fibular nerve winds around the neck of the fibula where it is superficial and thus liable to injury
What do the intrinsic muscles of the foot provide
Dynamic support in weight-bearing and locomotion
The lower limb is innervated by branches from which plexus
Lumbosacral
What does the lumbosacral plexus consist of
The lumbar plexus: formed by the anterior rami of L1-4
And
Sacral plexus: formed by branches from the anterior rami of L4 and 5 and S1-4
What does the femoral nerve pass under
The inguinal ligament
Which foramen does the obturator nerve pass through
The obturator foramen
Name two nerves passing out of the pelvis through the greater sciatic foramen
What do these supply
Superior and inferior gluteal nerves
3 gluteals and tensor fasciae latiae
Briefly describe the course of the femoral artery
The external iliac artery continues as the femoral artery below the inguinal ligament in the groin, and gives off the profound femoris artery to supply the muscles of the sign for husband.
The femoral artery continues down the thigh and passes through adductor hiatus to continue as the popliteal artery posterior to the knee
Describe the course of the popliteal artery as it leaves the popliteal fossa
Divides into the anterior and posterior tibial arteries supply the respective compartments of the leg
Where are the anterior and posterior tibial arteries palpable
At the ankle and in the foot
Which arteries supply the gluteal region
Superior and inferior gluteal arteries
What are the gluteal arteries branches of
The internal iliac artery
What is present in the valves of the lower limb to ensure one-way flow of blood from superficial and deep pains and then backed a heart
Valves
What are the superficial veins of the lower limb
Great saphenous Femoral Small saphenous Popliteal fossa Perforating veins
Describe the course of the great saphenous vein
Ascends anterior to the medial malleolus and along medial thigh to drain into the femoral vein in the groin
Describe the course of the small saphenous vein
Runs posterior to the lateral malleolus to drain into the popliteal vein in the popliteal fossa
What do the perforating veins of the lower limb do
Connect the superficial and deep venous systems along the medial side of the calf
The deep lymphatics of the lower limb drain to where?
With the arteries
The superficial lymphatics of the lower limb drain with which vessels?
With the veins
To wear to both groups of lymphatics in the lower limb drain to
Where else drains to here
Inguinal lymph nodes
Abdominal wall and perineum
What are the bony landmarks of the lower limb important for
They are important point of attachment of muscles and tendons and are important in diagnosis of many musculoskeletal disorders
What do the superficial veins of the lower limb arise from
The dorsovenous arch of the foot
Deep to the skin, the muscles and other structures are enveloped by what in the lower limb
A layer of deep fascia, the fascia lata
Where is the fascia lata particularly thick and well-developed
In the thigh where it forms the iliotibial tract on the lateral aspect
Describe the intermuscular septum of the lower limb
Extends from the deep Fasher dividing the thigh into anterior and posterior compartments
It divides the leg into anterior, posterior, and lateral compartment
What is the os innominatum
The hipbone
What is the pubis
The tubular set of bones which are located anteriorly in the hipbone
What kind of joint is the pubic symphysis
Secondary cartilagineous
What kind of joints on the sacroiliac joints
Synovial
What form is the superior border of the ilium
The iliac crest
Where does the iliac crease run from
From the anterior superior iliac spine to the posterior superior iliac spine
The iliac fossa gives attachment to which muscle
Iliacus
What does the ischial spine demarcate
The greater and lesser sciatic notches
What is the ischial tuberosity
What does it do
A thickening inferiorly
Supports weight when sitting
What does the pubic body bear
The pubic crest and pubic tubercle superiorly
What is the obturator foramen
An opening bounded by the ischium and the superior and inferior pubic rami
What forms the ischiopubic ramus
The fusion of the inferior pubic ramus with the ischial ramus
What is the largest bone in the body
The femur
How does the head of the femur extend from the neck into the acetabulum
Immediately, anteriorly and superiorly
Describe an interesting detail on the head of the femur
There is a central depression to which the ligamentum teres is attached
This is called the fovea
Discuss the neck of the femur
The next form is an angle of 125° (the angle of inclination) with the shaft
There is a 12° angle of anteversion of the femoral neck in relation to the femoral condyle is at the level of knee
Note something interesting about the shape of the femoral shaft
There is a forward convexity to the shaft
What are the greater and lesser trochanters
Thickenings on the proximal end of the femoral shaft
What marks the junction between the neck and the shaft of the femur
Anteriorly and posteriorly by the trochanteric line and the trochanteric crest respectively
What is the linea aspera
A line running longitudinally along the posterior aspect of the shaft, dividing into supracondylar lines distally
Where does the medial suprachondylar line end
At the adductor tubercle
Describe the surface between the supracondylar lines
The popliteal surface: it is smooth
What comprises the distal end of the femur
The medial and lateral femoral condyles
Which condyle is more prominent
What separates them
The lateral
The intercondylar notch posteriorly
What is the largest sesamoid bone in the body
Patella
What is the shape of the patella
Triangular with the base facing proximally and the apex distally
What is the posterior surface of the patella covered with
Articular cartilage for articulation with the intercondylar groove of the femur
What is the patella divided into
The larger lateral and smaller medial facets
What comprises the proximal end of the tibia
What is it called
The medial and lateral tibial condyles
Tibial plateau
What do the tibial condyles articulate with
The respective femoral condyles
What interrupts the tibial plateau
The intercondylar eminence (with 2 projections)
What are the 2 projections of the intercondylar eminence
The medial and lateral intercondylar tubercles
What is well marked in the intercondylar area
Facets for attachments of the horns of the menisci of the knee and the cruciate ligaments
What is on the Anterior aspect of the proximal end of the tibia
What insert here
The prominent tibial tuberosity
Patellar ligament
The inferior aspect of the lateral condyle has a small articular surface for articulation with what
What joint does this form
Head of fibula
The synovial superior tibiofibular joint
Describe the shaft of the tibia
A narrowing of the bone with a sharp anterior border.
The shaft is vertical in the standing position.
Proximal on his posterior surface surface is a rough and area, the soleal line, which extends obliquely to give attachment to the soleus muscle
Above the ankle the shaft Splays out to form the medial malleolus, and and articular surface on the lateral aspect for the inferior tibiofibular joint
What is the medial malleolus
A horizontal articular surface on the tibia which articulates with the talus
What gives the origin of the interosseous membrane between the tibia and fibula
The sharp lateral margin of the tibia
Where is the head of the fibula? what does it articulate with?
Proximal end
Forms a synovial joint with the inferior facet on the lateral tibial condyle
What forms the lateral malleolus
A slight splaying of the Fibula What’s the distal and which forms the lateral buttress of the ankle joint
What are the two distal medial facets of the fibula
Articulations with the tibia and with the talus
What are the seven bones of the tarsus
Calcaneus , talus, cuboid, navicula, three cuneiforms “(medial, intermediate and lateral)
What is the largest tarsal bone
The calcareous
What does the calcaneous articulate with
The talus superiorly and with the cuboid anteriorly to form the calcaneocuboid joint
A shelf projects from the upper border of the calcaneus on its medial surface. What is this called
The sustentaculum tali
What muscle is related to the sustentaculum
The tendon of flexor hallucis longus inferiorly
What does the calcaneus have a facet for anteriorly
Articulation with the cuboid
Describe the posterior surface of the calcaneus
Has a smooth upper part into which the calcaneal tendon (tendo Achilles) inserts with an intervening bursa
Describe the inferior surface of calcaneus
Inferior surface has 2 tubercles (large medial and smaller lateral)
They form the weight bearing part to which the plantar aponeurosis attaches
Which bone carries the weight of the whole body
The talus
Which bone forms the ankle joint
Talus
What does the talus do
Lies on the calcaneus and communicates thrust from the calcaneus to the tibia
Describe the talus
Has a body, neck and a rounded head, which articulates with the navicular
The other surface of the body articulated the tibia as part of the ankle joint and forms lateral and medial articular facet which articulate with the fibula and articular surface of the medial malleolus
True or false: the body of the talus is wider anteriorly than posteriorly
Why
True
So the dorsiflexed foot is locked
The inferior surface of the talus has what?
What does this allow
A large posterior facet that articulates with the superior surface of the calcaneus to form part of the subtalar joint
Inversion and eversion of the foot
What form is the midfoot
Articulations of the navicula, cuboid, and three cuneiform bones
What forms the tarsometatarsal joints
The cuboid and three cunieforms articulate with that metatarsals
How is the midfoot arched
Longitudinally and transversely
How is the Longitudinal arch of the foot maintained medially
By the plantar calcaneonavicular ligament
Which ligament is the spring ligament
The plantar calcaneonavicular ligament
How is the longitudinal arch of the foot maintained laterally
Supported by the long plantar ligament which is attached to the calcaneus and cuboid
Where does the long plantar ligament continue to
The bases of the 2nd and 4th metatarsals
What does the long plantar ligament form
The roof of the tunnel for the fibularis longus tendon
What is Deep to the long plantar ligament
The shorter, wider short plantar ligament
What does the short plantar ligament stretch between
Between the Calcaneus and cuboid
How is the transverse arch of the foot maintained during weight-bearing
By the wedge shaped cuneiforms and the tendon of fibularis longus
How many animals have feet with arches
Only humans
Other than bones/ muscles/ ligaments, what is indispensable for maintainence of the arches of the foot
The windlass mechanism
Describe The windlass mechanism
As the great toe is flexed the plantar aponeurosis is drawn tightly around the joint of the great tail. The increased tension within the plantar fascia packs all the joints of the foot tightly together, converting the foot to a rigid structure for the forward thrust of propulsion
How is the first metacarpal different to the first metatarsal
The first metatarsal is a thick bone lying parallel with the other metatarsals and with limited mobility at it tarsometatarsal joint
What is the first metatarsal important for
Transmitting thrust in propulsion
Which is the longest metatarsal
2nd
What does the base of the second metatarsal fit into
A mortise formed by the cuneiforms
Describe the base of the fifth metatarsal
Prominent and has a styloid process for the attachment of the tendon of fibularis brevis
How do the phalanges of the foot compare to those of the hand
They’re much smaller than the hand and movements are much more restricted
Unlike in the hand, abduction and addiction of the toes are movements away from and towards the second toe
Where does the great saphenous vein begin
How does it end
At the medial end of the dorsovenous arch when it is accompanied by the saphenous nerve
By piercing the cribriform fascia to open into the medial side of the femoral vein
How far behind the knee does the great saphenous vein run
A handbreadth
How many valves does the great saphenous vein contain
Over a dozen
Where does the small saphenous vein arise
What nerve accompanies it
From the lateral part of the dorsovenous arch where it ascends posterior to the lateral malleolus
Sural nerve
How does the small saphenous vein run after leaving the lateral malleolus
Upwards along the lateral border of the calcaneal tendon and pierces the deep Fascia in the lower part of the popliteal fossa to enter the popliteal vein
The great and small saphenous veins are analogous to which veins in the upper limb? However?
The cephalic and basilic veins respectively
However the great saphenous vein is medial while the cephalic vein is lateral in the upper limb. The same applies for the other two veins
How does Venus return to the heart differ between the arms and legs
Blood returned from the arm to the heart is largely via the superficial veins, while in the leg the perforating veins direct blood towards the deep veins, so the soleus muscle can act as a pump to return blood to the heart
What are the deep veins of the lower limbs enclosed within
What does this mean
Fascial Compartment and are subject to pressure at rest and during exercise
Professions of neighbouring arteries help move the blood up with a limb. During exercise, muscle contractions within the compartment compress the deep veins to force blood up the limb
What prevent back flow from the high-pressure deep veins to the low-pressure superficial veins in the legs
Valves
Name five musculoskeletal disorders that can be identified using the bony landmarks of the lower limb
Trochanteric bursitis Meniscal tears Tendinitis of the tibialis posterior muscle Ankle fracture Patella dislocation
How do varicose veins occur
They occur in superficial veins of the lower limb and may result from incompetent valves in the perforating beans or at the saphenofemoral junction
What is a “cut down”
Exposure of the great saphenous vein through the skin incision
How is a “cut down” performed
When is it done
Why is it feasible
Why must care be taken
Anterior to the medial malleolus in an emergency situation
When the patient is in clinical shock
As the position of the vein is constant
Not to damage the saphenous nerve
How much bodyweight does the fibula take
25% on heel strike during walking
How does the fibula move while walking
Therefore fractures of the fibula result in?
The fibula rotate axially to allow movement of the talus and therefore flexion and extension of the ankle
Result in problems with weight-bearing and ankle movement
What is an important anatomical landmark at the proximal end of the fibula
Where the common fibular nerve winds laterally across the neck of the fibula
As the nerve lies on the lateral aspect of the neck of the fibula, it is subcutaneous and therefore vulnerable to injury due to direct trauma or in fractures of the proximal fibula
What can injury to the common fibula nerve result in
Foot drop
How is the talus unique
It does not provide attachment for any muscle tendons and is held in place by ligamentous and bony elements
Describe the main blood supply to the talus
What does this mean for talus fractures
Diet the neck from the sinus tarsi, a fat filled the space between the Calcaneus and the neck of the Talus, and runs in a retrograde fashion to supply the body
Fractures can lead to avascular necrosis of the body of the talus
Where does the anterior compartment of the thigh extend from
From the hip to the knee
Name the three muscles that are contained within the anterior compartment of the thigh
Fascia lata
Quadriceps femoris
Sartorius
Which arteries, veins and nerves are contained within the anterior compartment of the thigh
Arteries: femoral and profunda femoris
Veins: femoral
Nerve: femoral
What muscles are contained within the medial compartment of the thigh
What nerve supplies all of these? What is the exception?
Obturator externus
Pectineus
Adductor Magnus, brevis and longus
Gracilis
Obturator nerve
The ischial head of adductor Magnus (supplied by sciatic nerve) and pectineus (femoral nerve)
How does the femoral nerve enter the thigh
Deep to the inguinal ligament, lateral to the femoral sheath and divides into muscular and cutaneous branches
Where does the femoral artery extend from
Which of its branches supply the thigh
From the inguinal ligament to the adductor hiatus where it becomes the popliteal artery
Profunda femoris
Describe the course of the obturator nerve
Runs deep in a canal in the upper part of the obturator foramen and divides into anterior and posterior branches, which supply the muscles in the medial compartment of the thigh and skin on the medial aspect of the thigh
What are the actions of the muscles of the anterior compartment of the Thigh
What are they supplied by
Dorsiflexors of the ankle and extensors of the toes
The deep branch of the common fibular nerve
What are the muscles of the lateral compartment of the leg
What are their actions
What are they innervated by
Fibularis longus and brevis
Eversion of the foot and weak plantar flexion of the ankle
The superficial branch of the common fibular nerve
Describe the fascia lata
The thick layer of deep fascia that encloses the thigh and send septa to divide the muscles into groups
Proximately it is attached to the iliac crest and inguinal ligament
Where is the saphenous opening
3 cm below and lateral to the pubic tubercle
What is the saphenous opening covered in
A loose connective tissue, the sieve like cribriform fascia
What pierces the cribriform fascia
The great saphenous vein as it drains into the femoral vein
What does the fascia lata attach to inferiorly
The inferior margins of the tibial condyles, the head of the fibula and the patella blending with the patellar retinacula
What does the fascia lata form laterally
Describe
The iliotibial tract
This receives insertions of tensor fasciae latae and gluteus maximus
It passes vertically down the posterolateral aspect of the thigh to insert onto the anterior aspect of the lateral tibial condyle. It has an important role in stabilising the extended knee
Fill in the blanks: three muscles of the quadriceps femoris arise from the a) blank and one from the b) blank
a) femur
b) hip bone
Where does the common tendon of quadriceps femoris converge
Via the patella and ligamentum patellae onto the tibial tuberosity
What is the action of quadriceps femoris
All muscles extend the knee with rectus femoris being a hip flexor as well
What nerve supplies quadriceps femoris
Femoral nerve
Describe rectus femoris
Originates from the anterior inferior iliac spine, with a reflected head arising from the upper acetabula margin and hip joint capsule. It attaches to the patella superiorly
Describe vastus medialis
Arises from the medial lip of the linea aspera, an area inferior to the lesser trochanter, and the intertrochanteric line. Its lowest fibres are inserted into the medial border of the patella and are important in maintaining patella stability
Describe vastus lateralis
Arises from the lateral lip of the linea aspera, extending up to the base of the greater trochanter. It attaches to the lateral aspect of the patella
Describe vastus intermedius
Lies deepest of the quadriceps femoris muscles.
Originates from the upper 2/3 of the shaft of the femur.
It is attached to the deepest surface of the extensor quadriceps mechanism
Describe how the patella moves during knee movement
The patellofemoral joint slides superiorly when the knee extends and inferiorly when the knee flexes. A slight amount of medial and lateral deviation, as well as tilting, takes place during normal movement.
How does the pull of rectus femoris and vastus lateralis affect the patella
The lateral and upwards pull on the patella and but his counteracted by the lowest fibres of vastus medialis and the prominent lateral femoral Condyle
From where does Sartorius arise.? Where does it insert?
Arises from the anterior Superior iliac spine and insert into the upper part the medial surface of the tibia
How does the Sartorius insertion relate to the insertions of gracilis and semitendinosus
Sartorius insert anterior to the insertions of gracilis and semitendinosus
Which nerve supply Sartorius
The femoral nerve
What is the action of Sartorius
A combination of flexion and lateral rotation of the hip, knee flexion, and medial rotation of the flex knee
What is Sartorius named after
Why
The Tailor – sartorial elegance
It’s action brings the lower limb to sit cross-legged
What are the boundaries of the femoral triangle
What forms its floor
Superiorly: inguinal ligament,
laterally: medial border of Sartorius,
medially: the medial border of adductor longus
Floor: iliacus, psoas Major, pectineus
What are the contents of the femoral triangle surrounded by
What is the exception
The femoral sheath
The femoral nerve lies lateral outside the sheath
Describe the femoral canal
Femoral canal lies medial to the femoral vein within the femoral sheath and transmits all the lymphatics from the lower limb. It provides space into which the femoral vein can expand and is the site of a femoral hernia
What are the six muscles of the medial compartment of the thigh
All except one perform the same action. What is this and what is the exception?
Obturator externus, pectineus, adductors longus, brevis, Magnus, and grisilis
They adduct the thigh, except obturator externus which is a lateral rotator of the hip
Generally why did the three adductor muscles of the leg arise from and insert
Arise from the pubic bone and ischio pubic ramus to descend to the linea aspera of the femur
What is the additional origin of adductor Magnus
What is its addition insertion
From the ischio tuberosity
It also sends a tendon distally to the adductor tubercle on the medial femoral condyle
How does the femoral artery pass with respect to adductor Magnus
The femoral artery passes lateral to adductor Magnus’ separate tendon to the adductor tubercle and then the artery runs from the anteromedial thigh to the popliteal fossa but it is situated deeply, next to the bone
Briefly discuss adductor brevis
Lies anterior to adductor Magnus and separates the two divisions of the obturator nerve
Which muscle separates the two divisions of the obturator nerve
Adductor brevis
Describe adductor longus in relation to the other adductors of the thigh
What other structure is it related to
It is longer and thinner. Life is more anteriorly and obliquely.
It’s medial border forms the medial boundary of the femoral triangle
Describe gracilis
Discuss its insertion
What is its action
A ribbon like muscle running down the medial thigh to insert into the other part of the tibial shaft
Inserts posterior to Sartorius and superior to semitendinosus
Flexes knee
Where does pectineus arise from
Where does it attach
What is its action
The pectineal line of the pubic bone
Attaches to the upper femur medial to the insertion of adductor brevis
Adducts and flexes the hip
What are the three compartment of the leg
Anterior
Lateral
Posterior
What does the anterior compartment of the leg lie between
Which compartment is this
The deep fascia and the interosseus membrane between the tibia and fibula
Extensor
What is the origin of tibialis anterior
Insertion?
Function?
Rises from the upper part of the lateral tibial surface and the interosseous membrane
Inserts into the medial cuneiform on the first metacarpal
both Dorsi flexion and inversion
Describe inversion of the foot
Which Joint does this occur at
The sole of the foot faces inwards and its inner border moves inwards and upwards. This action occurs at the subtalar joint
What Is the origin of extensor hallucis longus?
Insertion?
Describe function
Medial part of the anterior surface of the fibula and the interosseous membrane
into the base of the distal phalanx of the great toe
Its actions are extension of the great toe and the weak dorsiflexion of the ankle.
What is the hallux
Great toe
The origin of extensor digitorum longus?
Insertion?
Action?
Arises from the upper 2/3 of the anterior surface of the fibula and the interosseous membrane
Four tendons into the base of the middle and distal phalanges of the four lesser toes
Extension of the toes and weak dorsiflexion of the ankle
Describe fibularis tertius
Arises in continuity with extensor digitorum longus but insert into the dorsal surface of the base of the fifth metatarsal. As a result it dorsiflexes the ankle and everts the foot
Give the nerve supply of the following muscles: tibialis anterior, extensor hallucis longus, extensor digitorum longus, and fibularis tertius
The deep branch of the common fibular nerve
How are toe extensors and ankle Dorsiflexers useful when walking
What prevents bowstringing of these tendons
They help to keep the foot clear of the ground when walking
There are two extensor retinacula which span the bones
Which functional compartment is the lateral compartment of the leg
What are the boundaries of this compartment
Evertor
Anterior and posterior inter muscular septa
Describe eversion of the foot
The sole of the foot faces outwards, and the lateral border moves outwards and upwards.
Why can the lateral compartment of the leg also act as weak ankle flexors
Their tendons run behind the lateral malleolus and hence posterior to the axis of the ankle joint
Origin of fibularis longus
Describe the tendon’s course
Upper part of the lateral aspect of the fibula shaft
Passes behind the lateral malleolus, grooves the cuboid to cross the soul of the foot obliquely, and insert into the medial cuneiform and the base of the first metatarsal
Describe The function of fibularis longus
Antagonist to tibialis anterior.
Supports the lateral longitudinal and transverse arches of the foot
Origin of fibularis brevis
Insertion
Arises from the lower part of the lateral aspect of the fibula shaft, distal to the origin of fibularis longus.
Its tendon also runs behind the lateral malleolus, but lies closer to the bone and that of fibularis longus. It inserts into the tuberosity at the base of the fifth metatarsal
Which Nerve supplies the lateral compartment of the leg
Common Fibula nerve
How Could a femoral nerve injury occur and what does it result in
Penetrating trauma or during an operation on groin or hip
Can result in paralysis of the knee extensors and severe difficulty when walking or standing
Discuss a femoral artery occlusion
Inclusion of the femoral artery due to thrombosis or embolism can result in limb loss as a result of impaired blood supply to the lower limb
True or false:
swelling in the groin is a common presenting symptom
True
Give possible causes of a groin swelling
Inguinal or femoral hernia, a femoral artery aneurysm, a variscosity of the termination of the great saphenous vein and enlarged lymph nodes
What is a saphena varix
A variscosity of the great saphenous vein
What can inflammation of the iliotibial tract lead to?
Where does this occur
When might this occur
PainFul tendinitis
Either in the distal portion as it rubs against the lateral femoral condyle or (less commonly) approximately over the greater trochanter of the femur.
This is often an overuse injury with repetitive flexion and extension of the knee or hip
What does the stabilisation of the patella depend upon
The coordinated action of the vasti, rectus femoris, and the insertion of the patella ligament into the tibial tubercle
Why might the patella dislocate
If on equal eccentric forces are applied to the patella, usually due to the loss of vastus medialis, the patella may dislocate laterally over the lateral femoral condyle
When may compartment syndrome occur
When the pressure within the compartment rises as a result of bleeding or swelling after trauma. The raised pressure within the compartment leads to impaired blood supply to the muscles and nerve compression within the compartment, and muscle necrosis can occur
How do you treat acute compartment syndrome
Urgent fasciotomy to relieve pressure within the compartment
Where would the common fibular nerve often be injured
What can this result in
How does the patient present
As it winds around the neck of the fibula
Paralysis of the extensors and everters of the leg.
The patient presents with footdrop, and sensory loss of the anterolateral aspect of the leg and the dorsum of the foot.
Describe the gluteal region
The region of the products, a transitional area between the trunk and lower limb. On either side it is bounded superiorly by the iliac crest and inferiorly for the gluteal fold, with intergluteal cleft in the midline.
Where do the gluteal muscles arise from
The posterior aspect of the ala of the ilium
Gluteus maximus’ superficial fibres arise from the sacrotuberous ligament, the sacrum and the coccyx and the deep ones arise from the ala of the ilium
Where do the gluteals insert
Maximus: gluteal tuberosity of the femur (distal) and the iliotibial tract (proximal)
Medius and minimus: greater trochanter
Other Than the three gluteals, what are the other muscles of the gluteal region
What are they known as collectively
The piriformis, obturator internus,, the superior and inferior gemelli, quadratus femoris
The short lateral rotators of the hip
There is also tensor fasciae latae
Is the sciatic nerve in relation to the short lateral rotators of the hip
How does the sciatic nerve leave the region
It lies deep to piriformis but superficial to all others, exiting the gluteal region deep to the hamstring muscles
What Arteries from the trochanteric anastomosis
The superior and inferior gluteal arteries and their branches, along with the branches of the femoral and profunda femoris arteries
Which Nerves can be observed in the gluteal region
Superior and inferior gluteal nerves, sciatic nerve, posterior femoral cutaneous nerve, nerve to obturator internus, pudendal nerves
How does the pudendal nerve leave the pelvis? what accompanies it?
By passing out of the greater sciatic foramen and then winding round the sacrospinous ligament to enter the perineum through the lesser sciatic foramen
Accompanied by the internal pudendal vessels
What is the ala of the ilium
The wing of the ilium
Where is the origin of the deep fibres of gluteus maximus in relation to the gluteal line
Posterior to the posterior gluteal line on the ala of the ilium
Also posterior to the fascia of gluteus medius and the sacrotuberous ligament
Where can a bursa be found in the gluteal region
The bone and the insertion of gluteus maximus
Describe the relationship between gluteus maximus and the ischial tuberosity
In the upright position, the ischial tuberosity is covered by gluteus maximus. In sitting, and muscle moves laterally to expose the tuberosity
What Is the primary action of gluteus maximus
when is this important
A combination of extension and lateral rotation at the hip joint
When rising/straightening up from a bent position, and when climbing stairs and going off a slope as it prevents forward tilting of the pelvis on the upright legs
What does the contraction of gluteus maximus do through the iliotibial tract
Supports the extended knee
What is the gluteal fault and how does it relate to gluteus maximus
The gluteal fold is a transverse skin crease but does not correspond with the lower border of gluteus maximus which is oblique
Where does gluteus medius medius arise from the gluteal surface of the ala of the ilium
Between the anterior and posterior gluteal lines i.e. between the origins of gluteus minimus and maximus
What can the insertion of gluteus medius be compared to
It inserts onto the greater trochanter of the femur like a cap With a bursa lying underneath
DeScribe the shape of gluteus medius
Fan shaped
Describe the action of gluteus medius
Therefore when is it important
The whole muscle abducts the hip or, when the leg is on the ground, tilts the opposite side of the pelvis upwards by approximating the iliac crest to the greater trochanter
When walking as it supports the pelvis and prevent it from dropping on the unsupported side
What can the anterior fibres of gluteus medius do
Posterior fibres?
Medially rotate the hip
the posterior fibres can laterally rotate the hip
Where does gluteus minimus originate from on the wing of the ilium
Between the anterior and inferior gluteal lines and is inserted into the anterior part of the greater trochanter
Describe the function of gluteus minimus
It is a abductor and medial rotator of the hip, and assists gluteus medius in walking.
What is the origin of tensor fasciae latae?
Insertion?
The outer aspect of the ileum between the tubercle of the crest and the anterior Superior iliac spine
Iliotibial tract
What is the primary function of tensor fasciae latae
Innervation?
Act primarily on the iliotibial tract to provide stability to the hip and knee in the upright posture
Superior gluteal nerve
What about the position of the short lateral rotators of the hip makes them lateral rotators
The vertical axis of movement of the hip joint lies anterior to the line of these muscles
Origin of piriformis and its course
Insertion?
Anterior aspect of the middle three pieces of the sake room within the pelvis and exits through the greater sciatic foramen
Inserts into the posterior extremity of the upper margin of the greater trochanter
What supplies piriformis
Branches from L5, S1 and S2. It is the only short lateral rotator to lie superficial the sciatic nerve
Origin of obturator internus
From the obturator membrane and the bone surrounding the obturator foramen.
How does the tendon of obturator internus leave the pelvis
Where does it insert
What supplies it
Through the latter sciatic foramen, then turns at a right angle round the lesser sciatic notch where there is a bursa
Inserts into the greater trochanter above the trochanteric fossa
Nerve to obturator internus
Describe the Gemelli
The superior and inferior gemelli are two small muscles arising from the upper and lower margins of the lesser sciatic foramen
Run Alongside obturator internus And insert into its tendon
What supplies the Gemelli
Superior: nerve to obturator internus,
inferior:nerve to quadratus femoris
What is the shape of quadratus femoris?
Origin?
Square
Outer border of the ischial tuberosity
Describe the course of quadratus femoris
Nerve?
Its fibres run horizontally to insert into the quadrate tubercle on the upper aspect of the intertrochanteric crest of the femur
Nerve to quadratus femoris
What forms the sacral plexus
The lumbosacral trunk and the anterior rami of S1-4
What forms the lumbosacral truck
Describe its course
The anterior primary ramus of L5 with a branch from L4
Crosses the pelvic brim and joins the anterior Ramus of S1. On piriformis, they join the anterior rami of S2–4 to form the sacred plexus which gives a number of nerves which exit the greater sciatic foreman
True or false
superior gluteal nerve exits below piriformis
False
Exits above
What nerves exit below piriformis
Sciatic nerve, inferior gluteal nerve, nerve to obturator internus, nerve to quadratus femoris, posterior femoral cutaneous nerve
Which spinal roots are in the sciatic nerve
L4 – S3
Forms in the pelvis from L4-5 then joins lumbosacral trunk
How does the sciatic nerve run after joining the lumbosacral plexus
It emerges into the buttock through the greater sciatic notch, deep to piriformis then run superficial to the remaining short lateral rotators. After crossing the quadriceps femoris, it emerges from the gluteal region deep to the inferior border of gluteus maximus and the hamstrings
What accompanies the sciatic nerve
Inferior gluteal artery
What does the sciatic nerve divide into
Where
Tibial and common fibular nerves
Usually mid thigh
Which nerve is medial to the sciatic nerve (with spinal roots)
What does this supply
The posterior femoral cutaneous nerve (S2–3)
The skin of the buttock and posterior aspect of the thigh as far as the knee
(The pudendal nerve is also medial to the sciatic nerve and this passes out of the greater sciatic foramen with the internal pudendal vessels)
The superior and inferior gluteal arteries are both branches of which artery?
Internal iliac
Where do the superior and inferior gluteal arteries lie in relation to gluteus maximus medius and minimus
What do their branches contribute to
Superior: between gluteus medius and minimus
Inferior: deep to gluteus maximus
Branches of both arteries along with branches of the profunda femoris artery from the trochanteric and cruciate anastomoses.
Which quadrant of the button should be given injections to
Why
The upper outer quadrant
To avoid sciatic nerve damage
Do the gluteal muscles have any control over the anus
In the upright position the medial border of the gluteal muscles are close together. By clenching the buttocks when the gluteus maximus muscles are simultaneously contracted they have an accessory action on anal sphincter control.
Do the gluteal muscles join together in the midline
No
What is gluteal bursitis?
Presentation?
What is another name for this?
Inflammation of the bursa superficial to the greater trochanter of the femur.
Patients present with lateral hip pain but joint movements unaffected.
It is sometimes known as the greater trochanteric pain syndrome or trochanteric bursitis
How might you manage gluteal bursitis
Conservative management includes rest, anti-inflammatory medication, corticosteroid injections and physiotherapy. In recalcitrant cases, the use of minimally invasive endoscopic trochanteric bursectomy and iliotibial tract release has been shown to produce good outcomes
What can Paralysis of gluteus medius and minimus leads to?
Trendelenbug gait
A waddling gait
The drooping of the pelvis on the opposite side of the pelvis when the patient is asked to stand on one leg
Cause of Trendelenburg gait
Paralysis of gluteus medius and minimus due to lesion of the superior gluteal nerve
Previously polio involving the lower lumbar and secret segments of the spinal cord used to be an important cause
Why might the sciatic nerve be damaged in a dislocation of the hip
When might damage to this nerve be iatrogenic
The sciatic nerve runs posterior to the hip joint and is liable to injury during posterior dislocation of the hip
During hip replacements, particularly when posterior surgical approach is used
Where is the sciatic nerve liable to penetrating trauma
As it emerges from the buttock before lying deep to the hamstrings
How can ultrasound be used to trace the path of a sciatic nerve
An ultrasound probe maybe use to identify the greater trochanter and ischial tuberosity
Generally what does the posterior compartment of the lower limb contain
The hamstrings
Branches of the profunda femoris artery
Sciatic nerve with its tibial and common fibular components
What are the hamstrings
Semitendinosus
Semimembranosus
Biceps femoris
Where do the hamstrings originate and what are they supplied by
What is the exception
From the ischial tuberosity and supplied by the tibial nerve
The short head of Biceps femoris is the exception arising from the linea aspera and is supplied by common fibular nerve
What is the function of the hamstrings?with what exception?
The hamstrings extend the hip and flex the knee with the exception of the short head of biceps femoris
Where do me hamstrings insert
The two heads of biceps insert as a common tendon into the head of the fibula, while semitendinosus and semimembranosus insert onto the proximal tibial shaft and medial tibial condyle respectively
What at boundaries of the popliteal fossa
Proximately: the diverging hamstrings (semitendinosus and semimembranosus medially and biceps laterally)
distally: converging heads of gastrocnemius
Floor: popliteal surface of femur, knee joint capsule and popliteal fascia
Roof: fascia lata
What does the popliteal fossa contain (6)
Popliteal lymph nodes Popliteal artery and vein Tibial nerve Sural nerve Common fibular nerve
How are the muscles of the posterior compartment of the leg divided
Superficial:
Gastrocnemius
Soleus
Plantaris
Deep: popliteus Flexor hallucis longus Flexor digitorum longus Tibialis anterior
Which nerve supplies the bottom of the foot
The tibial nerve as it divides into the medial and lateral plantar nerves that supply the sole of the foot
How does semimembranosus arise
From the posterolateral aspect of the ischial tuberosity
It arises as a long flat tendon (membrane)
How does semimembranosus arise in relation to semitendinosus and biceps femoris’ long head
Deep to semitendinosus and the long head of biceps femoris
Where does semimembranosus insert
into a groove on the posterior aspect of the medial tibial condyle with expansion is that diverge obliquely across the capsule of the name and inferiorly over t popliteus to soleal line on the tibia
How does semitendinosus arise
How does it run
From the in the Faroe medial aspect of the ischio tuberosity
It decreases in size from above downwards so that midway down the thigh it is replaced by a cordlike tendon that lies in the gutter on semimembranosus.
It’s tendon passes behind the medial femoral condyle and curves forward to insert into the medial aspect of the upper tibial shaft posterior to Sartorius and inferior to grisilis
What is pes anserinus
Goose’s foot
The insertions of semitendinosus, Sartorius and gracilis on the medial upper tibial shaft
Semitendinosus insert posterior to Sartorius and inferior to gracilis
Which muscle does the long head of biceps femoris arise with
Semitendinosus
How does the long head of biceps femoris run
Arises from the medial aspect of the ischial tuberosity and passes across the semimembranosus tendon to join the short head from the linea aspera in the distal thigh
the heads form a common tendon which insert into the lateral aspect of the head of Fibula
Which tendon is easily palpable on the lateral aspect of the knee
Biceps femoris
What pierces the fascia lata in the roof of the popliteal fossa
The small saphenous vein and posterior femoral cutaneous nerve
What forms the calcaneal tendon
The joining of the superficial muscles of the posterior leg (gastrocnemius, plantaris and soleus )
Which tendon is tendo Achilles
The calcaneal tendon
What do you gastrocnemius and plantaris do
What are they supplied by
Flex the knee and plantarflex the ankle
Supplied by branches of the tibial nerve
How does gastrocnemius arise
By two heads from the distal end of the posterior aspect of the femur.
The medial head arises just proximal to the medial condyle of the lateral head arises from the lateral aspect of the lateral condyle itself
How does gastrocnemius run
The lateral and medial head converge to live side-by-side with a dense aponeurosis between them.
The fleshy part of the muscle extends to about the mid calf, where it forms the calcaneal tendon. A bursa separates the tendon from the bone
What is the function of gastrocnemius
Strong plantar flexion of the foot and weak flexion of the knee
Describe plantaris
A muscle with a short muscle belly and a very long tendon.
It arises from the distal end of the lateral supracondylar ridge of the femur.
Its tendon passes downwards and medially between soleus and gastrocnemius, blending with the medial part of the calcaneal tendon
Where does soleus arise
The upper quarter of the posterior aspect of the fibula, the soleal kind of the tibia, and middle third of the medial border of tibia
How does soleus run
Its fibres form a fibrous arch over the popliteal vessels. The muscle is flat and has a characteristic appearance with a dense aponeurosis on both sides
Where does soleus insert
Into the deeper aspect of the calcaneal tendon
True or false: Soleus is a uni pennate muscle
False
Is is a powerful multipennate muscle
What is the function of soleus
Flexes foot at the ankle
It is also important Venous pump
How does soleus act as a venous pump
perforating veins from the great saphenous vein enter into the soleus muscle and when the muscle contracts the veins are emptied, does aiding Venous return to the heart.
Which of the deep three muscles in the posterior compartment of the leg that insert into the foot is deepest
What does this muscle lie on
Tibialis posterior
Almost entirely on interosseus membrane
How do the three muscles from the deep group of the posterior leg insert into the foot
What supplies these 3
Under the flexor retinaculum
Tibial nerve
What are the two proximal attachment of popliteus
The lateral part attaches as a round tendon to the anterior end of the popliteal groove on the lateral femoral condyle, while the medial part attaches as a flat aponeurosis to the lateral meniscus and capsule of the knee joint
What is the distal attachment of popliteus
To the popliteal surface on the posterior tibia above the soleal line
What supplies popliteus
How does it reach the muscle
Tibial nerve
A branch curves around the distal border of the muscle to enter it’s deep surface
What is the action of popliteus
To stabilise and control the position of the lateral meniscus and to rotate the femur laterally on the tibia to unlock the knee
What is the origin of flexor hallucis longus
Where does its tendon lie? How does it travel?
The distal 3/4 of the fibula and the interosseus membrane
Very deep at the ankle, grooving the talus and inferior surface of the sustentaculum tali of the calcaneus
It runs forward in the sole to insert into the plantar surface at the base of the distal phalanx of the great toe (hallux)
What supplies flexor hallucis longus
What is the muscle’s action
Tibial nerve
To flex the great toe and maintain the medial longitudinal arch of the foot in running and walking
Where does flexor digitorum longus arise from
The medial part of the posterior surface of the tibia below the soleal line
How does the flexor digitorum longus travel after entering the sole of the foot
Crosses the flexor hallucis longus tendon and divides into four tendons, each inserting into the plantar surface of the respective bases of the four lateral toes and passing through a decussation of the tendons of the flexor digitorum brevis in a manner identical to that scene between flexor digitorum superficialis and profundus
What nerve supplies flexor digitorum longus and what is its action
Supplied by Tibial nerve and the muscle’s action is to flex the toes when walking and running.
Where does tibialis posterior arise from (3)
The lateral half of the posterior surface of the tibia below the soleal line,
the interosseous membrane,
the upper part of the medial surface of the fibula
Where does tibialis posterior insert
Primarily into the tuberosity of the navicula with slips going into the cuboid, cuneiforms and bases of the four medial metatarsals
What is the action of tibialis posterior
Innervation?
Flex and invert the foot and support the longitudinal arches
Tibial nerve
What is the secondary action of the following muscles and why:
Flexor hallucis longus
flexor digitorum longus
tibialis posterior
Plantar flexion of the foot at the ankle
The tendons of the muscles all pass behind the medial malleolus
Describe the flexor retinaculum of the foot
Extends from the medial malleolus of the tibia to the medial margin of the posterior part of the calcaneus.
In what order do the tendons and nerves and vessels pass beneath the flexor retinaculum of the foot
From medial to lateral, they are tibialis posterior, flexor digitorum longus, the posterior tibial artery with venae comitantates, the tibial nerve, and flexor hallucis longus
True or false: hamstring tears and athletes are usually midsubstance and heal spontaneously
True
Which injury to the hamstrings is common in waterskiers
Which age group does this tend to be
Treatment?
Avulsion of the hamstrings from the ischial tuberosity
Middle age
Acute surgical repair
In a knee ligament rupture what is used to augment the stability of the knee
The strong tendon of semitendinosus
for example can be used if there is a ruptured anterior cruciate ligament
Why might that aneurysm of the popliteal artery or a cyst in the popliteal fossa cause neurological symptoms
Compression of the adjacent tibial nerve
Where does a Baker’s cyst originate and what can happen
Within the knee joint
It can rupture into the popliteal fossa spreading fluid between the layers of muscles in the calf
What do the symptoms of a Baker’s cyst mimic
Give examples
A deep vein thrombosis.
There is a sudden onset of severe calf pain, with increased pain on forced extension of the ankle which puts tension in these muscles and raises the intracompartmental pressure
Why mate deep venous thrombosis happen
What happens
After prolonged inactivity e.g. immobilisation in bed or on long haul flights,
when blood pools in the lower limb due to interference with the action of the muscle pump in Venous return
Is deep venous thrombosis dangerous?
Yes this condition is potentially life-threatening, as part of the thrombus may break off passing through the right side the heart into the lungs and cause a pulmonary embolism
Which tendon in the leg is often ruptured
What will be the presentation
Why?
Tendo Achilles
A patient will present with an inability to initiate the gait(no spring in the step) having to depend on the toe flexors to weakly Flex the ankle when walking. There is usually a palpable gap in the tendon
This is because this is the common tendon of the ankle flexors
What is interesting about a ruptured tendo Achilles
The plantaris tendon almost never ruptures, suggesting that it remain separate until just before inserting into the calcaneus
When might the tibialis posterior tendon rupture
Due to age related degeneration, overuse, or chronic recurrent tenosynovitis
Spontaneous rupture may occur in overweight women
In children, the tibialis posterior tendon may be lacerated by glass fragments as they run barefoot on a sandy beach, producing an acute flat foot
What do people with a ruptured tibialis posterior tendon present with
Pain and swelling along the medial aspect of the foot and ankle, as well as a gross flat foot deformity
How does tarsal tunnel syndrome occur
The tibial nerve may be compressed as it passes through the tarsal tunnel posterior to the medial malleolus.
this is analogous to but much rarer than carpal tunnel syndrome
Why might tarsal tunnel syndrome occur
It tends to occur currently in athletes due to chronic sustained overuse of the infected foot
Swelling of the tendons in the tunnel may also give rise to
What gives the stability of the hip joint
Containment of the femoral head within the acetabulum however this also reduces movement
True or false: the ligament surrounding the hip joint capsule are weak and accessory
False they are thick and strong to assist stability
What do the ligaments of the knee control
Excessive collateral laxity and anteroposterior gliding, regardless of the angle of the flexion
True or false:
there is no movement at the superior and inferior tibiofibular joints
False there is little movement but there is no movement of the leg that it is analogous to super nation and pronation of the forum
How does the fibula rotate and why
The fibula rotates on its long access to allow the wedge shaped talus to remain stable within the ankle complex during flexion and extension of the ankle
Which joint is crucial to the stability of the ankle joint
The fibrous inferior tibiofibula joint
What kind of joint is the ankle
synovial hinge joint
The combined movements of which joints give the foot its versatility to function as a weight-bearing pod on all surfaces while maintaining an upright posture
The ankle and subtalar joints With rotation in the midtarsal joints
How is the function of the foot enhanced by the longitudinal arch
It acts as a spring with the aid of the plantar aponeurosis and ligaments
How does the long femoral neck assist mobility
It laterally offsets the femoral shaft from the pelvis. As the neck is also narrower than the diameter of the head, considerable movement in all directions is possible before the femoral neck impinges on the acetabular labrum
What shape is the articular surface of the acetabulum
Horse shoe shaped
Discuss the structures associated with the horseshoe shape of the articular surface of the acetabulum
The tips of the horseshoe are connected by a transverse ligament
the whole of the rim is augmented by a fibrocartilaginous labrum.
The centre of the horseshoe is occupied by a ligament connecting the femoral head to the acetabulum: the ligament of the head of the femur/ligamentum teres
How is the capsule of the hip joint attached
Proximally: Around the acetabular labrum and transverse ligament
Distally: To the neck of the femur
Anteriorly: to the inter trochanteric line
Posteriorly: attached halfway along the femoral neck, proximal to the trochanters
Describe in further detail the distal attachment of the hip capsule to the femur
From the distant attachment, several fibres are affected upwards as longitudinal bands (Retinacular fibres) along the femoral neck to the articular margins of the head.
These fibres support nutrient carrying arteries from the trochanteric anastomoses, which extends along the femoral neck before supplying the main part of the head of the femur
The capsule of the hip joint is strengthened by which three ligaments
Iliofemoral, ischiofemoral and pubofemoral ligaments
Describe the iliofemoral ligament
Shaped in the form of an inverted “Y” with the stem arising from the anterior inferior iliac spine and the acetabula room and the two limbs of the “Y” diverging to be attached to the upper and lower into trochanteric line
it prevents hyper extension
Which of the following ligaments is strongest
Iliofemoral,
ischiofemoral,
pubofemoral
Iliofemoral
What are the movements of the hip joint
Flexion and extension, abduction and adduction, medial and lateral rotation
Which muscles perform flexion at the hip joint
Psoas major and Iliacus
assisted by rectus femoris,
tensor fasciae latae,
Sartorius
and pectineus
What limits flexion at the hip joint
Limited by the thigh touching the abdomen or by tension in the hamstrings when the knee is extended
What performs extension at the hip joint
What limits extension?
Gluteus maximus and the hamstrings
The strong iliofemoral ligament
What produces addiction at the hip
Pectineus,
adductors longest, brevis, Magnus,
gracilis
What perform is abduction at the hip joint
Gluteus medius and minimus
What produces medial rotation at the hip joint
The anterior fibres of gluteus medius and minimus
What produces lateral rotation at the hip joint
Gluteus maximus with the other lateral rotators serving as stabilisers of the hip joint. These include the posterior fibres of gluteus medius and minimus, piriformis, obturator externus and internus , the Gemelli, and quadratus femoris
Discuss the blood supply to the femoral head
Primarily from arteries running along the neck in the retinacular fibres of the capsule
The ligament of the head contains a branch of the obturator artery in children but this blood supply is negligible and adults
What does the blood supply to the head of the femur mean for a femoral neck fracture
There is injury, which is common especially in elderly osteoporotic bones, may tear the retinacular vessels resulting in a vascular necrosis of the femoral head
What kind of joint is the knee
A synovial complex hinge joint
What movement is allowed at the knee joint
Flexion and extension with some rotation in flexion
Does the patella articulate with the tibia
Know the femoral condyles articulate with a tibial condyles and the patella articulates with the anterior surface of the distal femur
Do the bony contours of the knee joint confer stability
No stability depend on the strong medial and lateral collateral ligament and the two cruciate ligaments
The cruciate orientation provides what in the knee
Anteroposterior stability in all positions of flexion
How do the femoral condyles differ in shape from the tibial condyles
The femoral condyles are convex while the tibial condyles are flat
As the tibial condyles are flat, what makes them concave to fit into the femoral condyles
Fibrocartilaginous menisci (medial and lateral)
Which meniscus is popliteus attach to
Puppeteers is attached my fibres into the lateral meniscus and latterly by attendant passing through the capsule to the lateral femoral condyle
The capsule of the knee is deficient anteriorly. How is it completed?
By quadriceps tendon
How are the medial and lateral aspect of the knee capsule reinforced
By retinacular fibres originating by the vasti medialis and lateralis
How does the synovial membrane of the knee extend superiorly
As the suprapatellar bursa/Pouch
Describe the medial and lateral collateral ligaments of the knee.
extend from the femur to the tibia medially and to the head of the fibula laterally
The medial ligament is flat and attached to the capsule and medial meniscus. Its fibres run downwards and forwards
The lateral ligament is called like. It is quite free from the capsule and its fibres run downwards and backwards
Describe the anterior cruciate ligament
What is its function
It connects the anterior aspect of the intercondylar eminence of the tibia to the posteromedial aspect of the lateral femoral condyle.
To prevent backwards displacement of the femur on the tibia, or forward displacement of the tibia on the femur
Describe the posterior cruciate ligament
Functions?
Connects the posterior aspect of the intercondylar eminence to the anterolateral aspect of the medial femoral condyle
Prevent forward displacement of the femur on the tibia and is especially important when weight-bearing on a flex knee e.g. going downhill
What are the primary extensors and flexors of the knee
Extensor: quadriceps
Flexor: hamstrings
What produces medial rotation of the flexed knee
Mainly semimembranosus and semitendinosus
What produces lateral rotation of the knee
Biceps femoris
What does it mean to say the completely extended knee is physiologically locked?
It will maintain the body in an upright position without muscular effort
What will help maintain the knee in the extended position
The iliotibial tract into which tensor fasciae latae and gluteus maximus are inserted
How does the weight of the body pass in relation to the knee joint
What does this mean
The weight passes anterior to the centre of the knee and anterior to the medial and lateral ligaments
The collateral and cruciate ligaments can resist the weight and enable the muscles to relax
How do you initiate flexion of the knee
Popliteus rotates the femur laterally on the tibia, unlocking the knee
What kind of joint is the superior tibiofibular joint
Does it have a capsule
What is the movement
A small synovial joint between a facet on the lateral tibial condyle and a corresponding facet on the fibula
There is a capsule with anterior and posterior ligaments
Movement is limited to a small degree of axial rotation of the fibula
Describe the inferior tibiofibular joint
A fibrous joint (syndesmosis) with the opposing Ruffside surfaces of the bones connected by strong interosseous ligaments and augmented by anterior and posterior tibiofibula ligaments
Define syndesmosis
A slightly movable fibrous joint e.g. tibia and fibula
What do the ligaments of the inferior tibiofibular joint allow
Slight distraction of the tibia from the fibula during Dorsiflexion of the ankle when the wider anterior body of the talus comes between them
Describe the ankle joint
A synovial hinge joint with a deep mortise formed by the distal tibia and fibula to house the body of the talus
Which ligaments is the stability of the ankle joint dependent on
The ligaments that hold the tibia and fibula together as well as the collateral ligaments that keep the talus contained within the mortise
What does the talus articulate with
Upper aspect: with tibia
Medially: medial malleolus
Lateral surface of the body: with the medial articular surface of the distal fibula
What are the movements of the ankle joint
Plantarflexion and dorsiflexion
What do the malleoli prevent
Inversion or eversion occurring at the ankle joint
What are the main plantar flexors of the ankle joint
The posterior muscles whose tendons form the tendo Achilles (soleus, gastrocnemius, plantaris)
What is the main extensor of the ankle
Tibialis anterior
At which joint does inversion and eversion of the foot occur
Subtalar
Describe the subtalar joint
A composite of the posterior talocalcaneal and the talocalcaneonavicular joints which function as 1 joint
describe the talocalcaneonavicular joint
Consists of the convex head of the talus and a concave socket formed by calcaneus, navicular and ligaments
How is the foot inverted and everted
By approximate ball and socket movements around the head of the talus by the talocalcaneonavicular joint, with gliding movements in the posterior talocalcaneal joint
The hip joint is prone to which degenerative disease?
What happens in this disease?
Osteoarthritis
The movement of the hips are painful and restricted. The constrained nature of the joint and the presence of the osteophytes lead to reduce movement and makes walking difficult and running very difficult
What are osteophytes in osteoarthritis
protrusions of sharp bone on the edges of the femoral head
What can I help fracture of the femoral neck result in
External rotation and shortening of the affected limb due to the powerful action of Iliacus and psoas major on the lesser trochanter
Blood supply to the femoral head may be compromised
What must happen if the blood supply to the femoral head is compromised in a femoral neck fracture
A prosthetic replacement of the femoral head becomes necessary
Discuss developmental dysplasia of the hip
This term refers to a spectrum of pathology, ranging from mild acetabula dysplasia with a stable hip through to more severe forms of dysplasia, often associated with neonatal hip instability, to establish to hip dysplasia with or without later subluxation or dislocation
What did developmental dysplasia of the hip used to be known as
Congenital dislocation of the hip
What is the common knee injury
What does this result in
What is associated
It is common rupture the medial collateral ligament When a valgus strain is applied to the knee
This results in the knee giving way as a result of the lack of collateral stability
There is often an associated tear with the medial meniscus and a tear of the anterior cruciate ligament
What is the unhappy triad of O’Donoghue
A rupture of the medial collateral ligament, attack of the medial meniscus and a tear of the anterior cruciate ligament
What does a tear of the anterior cruciate ligament cause
Excessive anterior glide of the tibia on the femur
Which knee injury combination put an end to many a promising sports career
The unhappy triad of O’Donoghue
What do you twisted ankles commonly involve
What is a common result of this
A tear of the anterior talofibular band of the lateral ligament
Chronic pain and instability are often a result of these injuries as the nature and severity of the injury is frequently not appreciated
What do ankle fractures often affect
Bones and soft tissue
They often involve the medial and lateral collateral ligament as well as the distal tibiofibular ligament
One should only consider the bone injury in the ankle fracture
No! Simply dealing with a bony injury without consideration of the ligamentous injury will give a poor functional outcome
What is the Maisonneuve fracture
One kind of ankle fracture that involves rotation eversion forces on the ankle that causes a rupture of the medial ligament in association with a fracture of the proximal shaft of the fibula, together with a tear of the length of the interosseous membrane
Give the nerve roots of pudendal nerve
S234
Give the nerve root of the femoral nerve
Obturator?
L234 posterior divisions
L234 anterior divisions
