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SE book revision > Lower limb anatomy > Flashcards

Lower limb anatomy Flashcards

1
Q

How many vertebrae make up vertebral column?

A

33

-7 cervical
-12 Thoracic
-5 lumbar
-5 sacral
-4 coccyx

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2
Q

Name three distinguishing characteristics of vertebrae from thoracic region

A

-Heart shaped vertebral body with costal facets for articulating with head of ribs
-T1-10 thoracic vertebrae have 2 demifacets on body for articulating with head. Superior demifacet correspondds with rib at same level and inferior one corresponds with the one below
-Small circular vertebral foramen
-Long transverse processes have facets for articulation with tubercle of ribs
-Long inferiorly projecting spinous process

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3
Q

Which vertebrae have a transverse foramen?

A

Cervical vertebrae

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4
Q

Name the structure which passes through the transverse foramen

A

-Vertebral artery, vein and sympathetic plexus through C1-C6
-C7 transmits vertebral vein but not the artery

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5
Q

What are the intervertebral discs composed of?

A

-Outer ring of concentric layers of fibrous cartilage: ‘annulus fibrosus’
-Gelatinous core ‘nucleus pulposus’

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6
Q

Describe the characteristic features of each vertebra

A

Cervical
-Small vertebral bodies
-Transverse foramen (to transmit vertebral arteries)
-Short bifid spinous process (apart from C1/7)
-Large triangular vertebral foramina

Thoracic
-Heart shaped vertebral body with costal facets for articulating with head of ribs
-T1-10 thoracic vertebrae have 2 demifacets on head. Superior demifacet correspondds with rib at same level and inferior one corresponds with the one below
-Small circular vertebral foramen
-Long transverse processes have facets for articulation with tubercle of ribs
-Long inferiorly sloping spinous process

Lumbar:
-Large kidney shaped vertebral body
-Triangular vertebral foramina
-Long, thin transverse process
-Large square spinous processes

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7
Q

Describe the function of the intervertebral discs

A

-lie between vertebral bodies of adjacent vertebrae forming secondary cartilaginous joints
-absorb compressive forces

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8
Q

Which ligament prevents hyperflexion of the vertebral column?

A

-Posterior longitudinal ligament
-Is attached to posterior aspect of vertebral column

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9
Q

What is the clinical significance of the attachment of the posterior longitudinal ligament to the discs?

A

-Function of posterior longitudinal ligament is to reinforce the annulus fibrosus
-However, ligament is weaker laterally; therefore most disc herniations occur laterally

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10
Q

What is the ligamentum flavum?

A

-Unites adjacent laminae
-Limits flexion of vertebral column, assists in extending spine after flexion and helps preserve curvatures of vertebral column

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11
Q

Name two tumours which commonly metastasize to the vertebrae

A

-Lung
-Prostate
-Breast

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12
Q

What type of joint is the hip joint?

A

-Synovial joint
-Formed by articulation of round head of femur and cup-like acetabulum of pelvis

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13
Q

Identify the points on the image (hip bone- in hip)

A

A: iliac crest
B: Posterior superior iliac spine
C: posterior inferior iliac spine
D: Greater sciatic notch
E: Lesser sciatic notch
F: Ischial tuberosity
L: ramus of ischium
K: inferior pubic ramus
J: obturator foramen
I: superior pubic ramus
H: Anterior inferior iliac spine
G: Anterior superior iliac spine

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14
Q

Name the extracapusular ligaments of the hip and their attachments

A

Iliofemoral:
–> Y shaped and twisted. Originates from anterior inferior iliac spine, bifurcates and inserts either side of intertrochanteric line (resists hyperextension)

Pubofemoral
–> Originates from superior pubic ramus, inserts into intertrochanteric line (resists extension and abduction)

Ischiofemoral:
–> originates from body of ischium
–> inserts into GT of femur
(limits extension

All 3 strengthen capsule and prevent exessive ROM at hip joint. Iliofemoral is the strongest.

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15
Q

Name the muscles which attach to the greater trochanter of the femur

A

Superior: piriformis

Lateral: gluteus medius

Anterior: gluteus minimus

Medial: obturator internus, gemelli superior and inferior

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16
Q

Describe blood supply to hip joint

A

-Majority of blood supply to the head of femur is from retinacular arteries
-These arise as acending cervical branches from extracapsular arterial anastamosis
-Formed posteriorly by medial circumflex artery and anteriorly from branches of lateral circumflex femoral
-Minor contributions from superior and inferior gluteal arteries
-Small supply from artery of ligamentum teres (branch of obturator

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17
Q

What is the clinical relevance of the blood supply to the head and neck of the femur?

A

-Intracapsular fractures of NOF disrupt retinacular vessels and compromise blood supply to femoral head
-Rupture of these vessels caused by a fracture can result in avascular necrosis of femoral head as blood supply through artery to ligamentum teres is usually inadequate

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18
Q

Name the main flexor muscles of the hip?

A

Psoas and iliacus are main flexors

Additional hip flexion comes from:
-Sartorius
-Rectus femoris
-Pectineus
-Adductor longus

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19
Q

What is the innervation of the hip joint?

A

The hip joint is supplied by sciatic, obturator and femoral nerves

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20
Q

What is the nerve supply to the main flexor muscles of the hip?

A

Psoas: L1-L3 ventral rami
Iliacus, sartorius, rectus femoris and pectineus: Femoral nerve L2-L4

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21
Q

Name the external rotators of the hip

A

Piriformis
Obturator internus and externus
Gemelli superior and inferior
Quadratus femoris
Gluteus maximus

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22
Q

What are the different approaches for surgical exposure of the hip joint?

A

Posterior
Lateral
Anterior

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23
Q

Muscle groups involved in moving hip

A

Flexion
–> iliopsoas
–> additional from pectineus, sartorius, rectus femoris,adductor longus

Extension
–> hamstrings
–> Gluteus maximus

Abduction
–> Gluteus medius and minimus
–> tensor fascia lata

Adduction
–> Adductor longus/magnus/brevis
–> Gracillis

Internal rotation
–> Tensor fascia lata, gluteus minimus and medius

External rotation:
–> POGQ
-Gluteus maximus

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24
Q

Briefly describe the different surgical approaches to the hip joint

A

Lateral:
-Divide fibres tensor fascia lata, gluteus medius and minimus to expose femoral neck.
-Further access is gained by detaching greater trochanter from its gluteal insertions

Posterior:
-10-15cm incision 1 inch posterior to posterior edge of greater trochanter
-Incise tensor fascia lata
-Split fibres of gluteus maximus
-Detach short external rotators
-Incise capsule

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25
Q

Name the structures at risk of injury during the posterior approach?

A

Sciatic nerve
superior gluteal nerve

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26
Q

Name the boundaries of the femoral triangle

A

-Medial: medial border of adductor longus
-Lateral: medial border of sartorius
-Superior: inguinal ligament
-Floor: iliacus, psoas major, pectineus
-Roof: skin, subcut fat, fascia lata

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27
Q

Name the contents of the femoral triangle

A

Lateral to medial:
-Femoral nerve
-Femoral artery
-Femoral vein
-Femoral canal

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28
Q

Name the points on the image (femoral triangle):

A

-A: femoral nerve
-Lymph nodes
-C: Femoral vein
-D: Pectineus
-E: Iliopsoas
-F: Inguinal ligament
-G: Femoral artery
-H: great saphenous vein
-I: Adductor longus
-J: sartorius

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29
Q

What are the origins and insertions of the iliacus and psoas muscles?

A

-Psoas major originates along lateral surfaces of vertebral bodies of T12 and L1-L5 and their associated vertebral discs
-Iliacus originates in iliac fossa of pelvis
-Psoas major unites with iliacus at level of inguinal ligament and crosses hip joint to insert on lesser trochanter of femur

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30
Q

What is the action of iliopsoas muscle?

A

Flexion and lateral rotation of the hip

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31
Q

Where is the mid-inguinal point and what is the clinical significance?

A

-The mid-inguinal point is half way between the ASIS and the pubic symphysis
-The femoral artery can be palpated here

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32
Q

What is the femoral sheath?

A

-Fascial tube
-Extends 3-4 cm inferior to inguinal ligaments
-Encloses proximal parts of femoral vessels and femoral canal
-Is continuation of transversalis fascia anteriorly, iliopsoas fascia posteriorly
-Allows femoral vessels to glide deep to inguinal ligament during movement of hip

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33
Q

Name the contents of the femoral sheath

A

Proximal parts of:
-Femoral artery
-Femoral vein
-Femoral canal

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34
Q

What is the femoral canal?

A

-Femoral sheath is subdivided into three compartments (lateral, intermediate and medial) by vertical septa
-Femoral canal is medial compartment of femoral sheath
-It provides a potential space for the femoral vein to expand, during increased venous return from lower limb

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35
Q

What are the contents of the femoral canal?

A

-Fat
-Lymphatics
-Cloquet’s node

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36
Q

What is the clinical significance of cloquet’s node?

A

-Cloquet’s node receives drainage from lower limb, perineum and anterior abdominal wall inferior to umbilicus. -Tumour or infection in this area can lead to its enlargement

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37
Q

What is the femoral ring?

A

The femoral ring is the entrance to the femoral canal

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38
Q

What are the boundaries of the femoral ring?

A

-Medial: lacunar ligament
-Posterior: pectineal ligament overlying superior pubic ramus
-Anterior: inguinal ligament
-Lateral: Femoral vein

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39
Q

What is the clinical significance of femoral ring?

A

-Femoral hernias can enter thigh through femoral ring
-Presents as tender mass in femoral triangle, infero-lateral to pubic tubercle
-Hernia is bounded by femoral vein laterally, lacunar ligament medially

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40
Q

Describe the course of the femoral artery

A

-External iliac artery becomes femoral artery once it crosses the inguinal ligament
-Enters femoral triangle and gives off profunda femoris artery ~ 4cm into femoral triangle
-Profunda femoris gives off three branches
–> perforating branches
–> medial circumflex femoral
–> lateral circumflex femoral

-Continues as superficial femoral artery in adductor canal
-Becomes popliteal artery after exiting adductor hiatus
-Gives off 5 geniculate branches in popliteal fossa
-Divides into anterior tibial artery and tibio-peroneal trunk
-Tibio-peroneal trunk divides into posterior tibial and peroneal

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41
Q

What is the function of the gluteal muscles?

A

Gluteus medius and minimus
–> Abduction
–> internal rotation
–> Stabilises unsupported side of pelvis to prevent it tilting during walking

Gluteus maximus
–> Hip extension
–> External rotation
–> supports extended knee via iliotibial tract e.g. standing from sitting, walking up stairs

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42
Q

What is the innervation of the gluteal muscles?

A

Gluteus medius: superior gluteal nerve (L5, S1)

Gluteus maximus: inferior gluteal nerve (S1, S2)

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43
Q

Other than gluteal muscles, what other group of muscles help stabilise the hip and where are they located?

A

-Deeper group of smaller muscles: short external rotators
-Covered by inferior half of gluteus maximus
-Laterally rotate thigh and help stabilise hip

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44
Q

Describe trendelenburg’s test

A

-Tests function of superior gluteal nerve
-Pt is supported and asked to stand on one leg
-Pelvis on supported side should raise. If it tilts/falls, this indicates weakness of abductors on weight bearing side: a +ve ‘trendelenburg test’

Rationale for test
-Superiro gluteal nerve supplies gluteus medius and minimus
-These muscles are important abductors of the hip and normally contract on contralateral side to leg being raised to stabilise hip during walking
-This allows non-weight bearing leg to swing forwards
-Dysfunction of these hip abductors results in pelvis falling/tilting when contralateral leg is raised off ground during walking

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45
Q

What are the origins of the superior and inferior gluteal arteries?

A

-Superior gluteal: Internal iliac posterior division: largest branch and continuation of this vessel

-Inferior gluteal: one of two terminal branches anterior division internal iliac (the other is internal pudendal)

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46
Q

Identify the points on the image (gluteal region)

A

A: gluteus maximus
B: superior gluteal nerve
C: inferior gluteal nerve
D: Pudendal nerve
E: Obturator internus
F: Obturator externus
G: sciatic nerve
H: semitendinosus
I: Gluteus medius
J: Gluteus minimus
K: Piriformis
L: Superior gemellus
M: Inferior gemellus
N: Quadratus femoris
O: biceps femoris (short head)
P: semimembranosu

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47
Q

What is the surface markings of piriformis?

A

-Line joining skin dimple of posterior superior iliac spine to superior border greater trochanter

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48
Q

Name the nerve roots of the sacral plexus and lumbosacral trunk

A

-Sacral plexus: S1-S4
-joined by nerve roots L4-L5 to form lumbosacral trunk

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49
Q

Name the boundaries of the greater sciatic foramen

A

Posterior: sacrotuberous ligament
Superior: anteiror sacroiliac ligament
Anterior: Greater sciatic notch of ilium
Inferior: sacrospinous ligament, ischial spine

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50
Q

Name the structures passing through the greater sciatic foramen above the piriformis:

A

-Superior gluteal nerve
-Superior gluteal vessels

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51
Q

Name the structures passing through the greater sciatic foramen below the piriformis

A

-Sciatic nerve
-Inferior gluteal nerve
-Inferior gluteal vessels
-Internal puendal vessels
-Pudendal nerve
-Posteiror cutaneous nerve of thigh
-Nerve to quadratus femoris
-Nerve to obturator internus

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52
Q

Name the boundaries of lesser sciatic foramen

A

Anterior: tuberosity of ischium
Superior: spine of ischium, sacrospinous ligament
Posterior: sacrotuberous ligament

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53
Q

Name structures passing through lesser sciatic foramen

A

PINTO

Pudendal nerve
Internal pudendal vessels
Nerve to obturator internus
Tendon of obturator internus

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54
Q

What is the innervation of the deeper group of gluteal muscles?

A

Piriformis: ventral rami S1-2
Superior gemellus: nerve to obturator internus L5-S1
Obturator internus: nerve to obturator internus L5-S1
Inferior gemellus: nerve to quadratus femoris L5-S1
Obturator externus: obturator nerve L3-l4
Quadratus femoris: nerve to quadratus femoris L5-S1

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55
Q

What are the surface markings of the sciatic nerve?

A

-Identify posterior superior iliac spine, greater trochanter and ischial tuberosity
-Draw curved line connecting following 3 points:
–> 2.5cm lateral to midpoint of line from PSIS to ischial tuberosity
–> midpoint between ischial tuberosity and greater trochanter
–> junction between upper 2/3rd and lower 1/3rd thigh in midline

-Nerve most commonly divides 5-7cm above posterior knee joint line

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56
Q

Describe the safe area for intramuscular gluteal injection

A

-Upper outer quadrant of buttock
-Avoids iatrogenic damage to sciatic nerve

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57
Q

Describe the anatomical variations of the relsationship of the sciatic nerve to the piriformis

A

Passes underneath piriformis in 85-90% of population

other variations:
-Piriformis divided into two parts: peroneal division passes between two parts piriformis (tibial division passes underneath as normal)
-Peroneal division of sciatic nerve passes over piriformis, tibial division passes underneath undivided muscle
-Entire nerve passes through divided piriformis

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58
Q

Identify the labels on the image (femur)

A

A: Head of femur
B: greater trochanter
C: neck of femur
D: intertrochanteric crest
E: Lesser trochanter
F: Gluteal tuberosity
G: Linea aspera
H: Adductor tubercle
I: lateral epicondyle
J: Medial epicondyle
K: lateral condyle
L: Intercondylar fossa
M: Medial condyle

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59
Q

What are the stages of ossificaiton of the proximal femur?

A

-Femoral shaft: undergoes ossification after 6 weeks in utero
-Femoral capital epiphyses: ossification 2-4 months in utero
-Femoral head: 6 months of age
-Greater trochanter: 2-4 years of age
-Lesser trochanter: puberty

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60
Q

Briefly describe ‘cox vara’ and ‘cox valga’

A

-The angle of inclination that the femoral head makes with the shaft can vary with age, sex, gender and pathological processes that can weaken neck of femur such as ricketts
-Increase in angle: coxa valga
-Decrease in angle: coxa vara

Coxa vara: results in shortening of lower limb, can limit passive abduction of the hip

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61
Q

How can fractures of the femoral neck be classified, and why is their management different?

A

Intracapsular:
-displaced vs non displaced

Extracapsular
-Intertrochanteric
-Subtrochanteric
-Reverse oblique

Intracapsular: greater risk of avascular necrosis, smaller surface area for bony union

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62
Q

Describe the Garden classification of intracapsular fractures of the femoral neck

A

1: Incomplete or impacted fracture, undisplaced
2: complete fracture, undisplaced
3. complete fracture, partially displaced
4. complete fracture, fully displaced

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63
Q

Describe how you would manage an intracapsular fracture of the hip

A

-Garden 1+2: fixing with cannulated screws or conservative if not fit for surgery
-If displaced: THR vs hemi

THR if:
-AMTS 7 or above
-Mobilises with 1 stick or better
-Fit for the operation

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64
Q

Describe management of extracapsular fracture of hip

A

DHS: oblique intertrochanteric
Reverse oblique: IM nail
Subtrochanteric nail: IM nail

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65
Q

Name the muscles that make up the ‘true hamstrings’ and their innervations. What is the origin of the muscles?

A

–> True hamstrings cross hip and knee joint, and extend thigh and flex knee
–> arise from ischial tuberosity

Semitendinosus
Semimembranosus
Biceps femoris: long head only

Innervated all by tibial division sciatic nerve

short head biceps femoris:
–> peroneal division sciatic nerve
–> arise from linea aspera of femur

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66
Q

Describe function of hamstring mucles

A

Extend thigh and flex knee

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67
Q

How would you clinically test the function of the hamstring muscles?

A

Flex knee against resistance, palpate tendons on either side of popliteal fossa

68
Q

Name adductor muscles of thigh

A

-Adductor longus
-Adductor magnus
-Adductor brevis
-Gracillis

69
Q

Name the nerve supply to the medial (adductor) compartment of the thigh:

A

Obturator nerve except: hamstring part adductor magnus
–> tibial division sciatic nerve

70
Q

Name the muscles which make up the quadriceps

A

Rectus femoris
Vastus intermedius
Vastus lateralis
Vastus medialis

71
Q

What is the innervation of the quadriceps femoris?

A

Femoral nerve L2-L4

72
Q

What is hunter’s canal?

A

-Aponeurotic sheath located in middle 1/3rd of the antero-medial thigh
-Extends from apex of femoral triangle to adductor hiatus (defect in adductor magnus)
Provides passage for femoral vessels to reach the popliteal fossa

73
Q

Name the boundaries of hunter’s canal:

A

Lateral: vastus medialis
Anterior: sartorius
Posterior: adductor longus and adductor magnus

74
Q

Name the contents of hunter’s canal. What is the fate of the nerves?

A

-Superficial femoral artery
-Femoral vein

-saphenous nerve
-Nerve to vastus medialis
-Terminal division of obturator nerve
-Lymphatics

Nerves do not exc

75
Q

Where is the intertrochanteric crest vs line

A

-Line: between trochanters anteriorly
-Crest: between trochanters posteriorly

76
Q

What type of joint is the knee joint?

A

Modified hinge joint. Largest synovial joint in body

77
Q

What is the arrangement of structures you would encounter during an arthroscopy of the knee in an anterior approach?

A

-Transverse meniscal ligament (stretches accross anterior horns of medial and lateral menisci)
-Anterior horn medial meniscus
-ACL
-Anterior horn lateral meniscus
-Posterior horn lateral meniscus
-PCL
-Posteiror horn meidal meniscus

78
Q

Name the articular surfaces of the knee joint

A

Knee has three articular surfaces:
-Medial and lateral articulations between femoral and tibial condyles
-Intermediate articulation between patellar and femur

79
Q

Name the attachments of the patellar ligament

A

Superior: apex of patellar

Inferior: tibial tuberosity

80
Q

What is the function of the patellar ligament?

A

-Extends the knee joint

81
Q

How would you test the patellar ligament?

A

-Patellar jerk (L3-L4)

82
Q

Name the intra and extra-articular ligaments of the knee joint

A

Intra-articular:
-ACL and PCL
-posterior meniscofemoral ligament
-Popliteus tendon (intra-articular during some of its course)

Extra-articular
-Medial and lateral collaterals

83
Q

What are the attachments of the anteiror cruciate ligament of the knee joint?

A

-Anterior intercondylar area of tibia
-Lateral femoral condyle

84
Q

What are the attachments of the posterior cruciate ligament of the knee joint?

A

-posterior intercondylar area of tibia
-Medial femoral condyle

85
Q

Describe the actions of the cruciate ligaments

A

Function is to prevent anterior/posterior displacement of the tibia relative to the femur

86
Q

How would you test the cruciate ligaments?

A

Anterior and posterior draw test

87
Q

What are the menisci?

A

-Crescent shaped fibrocartilages that fill that gap between the femur and the tibia
-Inner edges move freely as they aren’t attached tot he bone: menisci change shape as joint moves
-Front of meniscus is anterior horn, posterior part is posterior horn, middle is body
-Outer margins are thick and well vascularised from capsule, whilst inner surfaces are thein
-Poor blood supply to inner 1/3rd of meniscus makes it difficult for tears in this part of the meniscus to heal

88
Q

Describe injuries to the cruciate ligaments

A

ACL:
-When knee stops suddenly and tibia continues to move forward relative to femur
-skiing, rugby

PCL
-Less common as it is stronger
-Direct blow to flexed knee e.g. dashboard of car, or falling hard onto knee

If injury suspected
–> MRI

89
Q

What are the salient differences between medial and lateral menisci of the knee joint?

A

Medial:
-Less mobile (attached to medial collateral and joint capsule)
-larger and c shaped

Lateral
-More mobile (no attachment to medial collateral)
-Smaller and circular
-Popliteus tendon runs between joint capsule and lateral mensicus

90
Q

Why is injury to medial meniscus more common than to the lateral?

A

-Medial meniscus has strong attachment to the medial collateral ligmaent so is much less mobile than the lateral meniscus and therefore can’t accomodate abnormal stresses as easily

91
Q

What are the functions of the menisci of the knee?

A

-Shock absorbers
-Help to distribute the load by increasing the congruity of the articulation
-Contribute to joint stability
-Assist in proprioception
-Lubricate the knee joint

92
Q

Describe the bursae aroiund the knee joint

A

-Suprapatellar bursa: lies between infero-anteiror surface of femur and deep surface quadriceps femoris
-Pre-patellar bursa: between patella and the skin
-Superficial and deep infrapatellar bursa: lie between the patellar ligament and skin and tibia and patellar ligament

93
Q

What are the radiological featrues of osteoarthritis of the knee?

A

-Loss of joint space
-Osteophytes
-Subchondral cysts
-Subchondral sclerosis

94
Q

What is the popliteal fossa?

A

Diamond shaped intermuscular region on the posterior aspect of the knee

95
Q

Indentify the points on this image (popliteal fossa):

A

A1: semimembranousus
A2: semitendinosus
B: Popliteal artery
C: Medial head of gastrocnemius
D: biceps femoris
E: tibial division of sciatic nerve
F: popliteal vein
G: common peroneal nerve
H: lateral head gastrocnemius

96
Q

Name the boundaries of the popliteal fossa:

A

Superomedial: semimembranosus and semitendoinosus
Superolateral: biceps femoris
Inferomedial: medial head gastrocnemius
Inferolateral: lateral head gastrocnemius
Roof: skin, subcut tissue, popliteal fascia
Floor: Popliteal surface of femur, capsule of knee joint, popliteus

97
Q

Name the contents of the popliteal fossa

A

Superficial to deep:
-Common peroneal nerve
-Tibial nerve
-popliteal vein
-popliteal artery
-joint capsule
-tendon of popliteus laterally

Also contains:
-Termination of small saphenous vein as it drains into popliteal vein
-Sural nerve (arising from tibial nerve)
-Five genicular branches of popliteal artery
-Lymph nodes
-Fat

Medial to lateral
-Popliteal artery
-Popliteal vein
-Tibial division sciatic nerve
-Common peroneal division sciatic nerve

98
Q

What is the clinical significance of the anatomy of the popliteal fossa when performing a peroneal nerve block

A

In peroneal nerve blocks, the common peroneal nerve is located most superficial of all the structures, followed by the popliteal vein, then the popliteal artery which is the deepest structure from the needle

99
Q

Where does the popliteal artery commence?

A

When the femoral artery leaves the adductor hiatus

100
Q

Describe the blood supply to the knee joint

A

-5 Genicular branches of popliteal artery supply anterior capsule and ligaments
-Arteries are lateral superior, medial superior, middle, lateral inferior and medial inferior
-Form genicular anastamosis, network of vessels around knee joint
-Other vessels contribute to anastomosis:
–> descending genicular branch femoral artery
–> decending branch of lateral femoral circumflex artery

101
Q

What is the clinical significance of anatomy of popliteal artery?

A

-Relation of politeal artery to lower end of femur makes it vulnerable in supracondylar fractures

102
Q

Describe the course of the popliteal artery as it exits the popliteal fossa

A

-Bifurcates when it leaves popliteal fossa: Forms anterior tibial and tibio-peroneal trunk–> peroneal and posterior tibial arteries

Branches of popliteal artery:
-Genicular branches
-Sural arteries (supply gastroc/soleus/plantaris)
-Anterior tibial and tibio-peroneal trunk

103
Q

Describe the clinical course of the common peroneal nerve

A

Passes posterior to head of fibular, wraps around neck of fibula. Divides into superficial and deep peroneal branches

104
Q

What does the superficial peroneal nerve supply?

A

lateral compartment
Skin over dorsum of foot including 2nd-4th webspace

105
Q

Describe why the common peroneal nerve is vulnerable to injury

A

Because it runs superficial as it wraps around the neck of the fibular: vulnerable to too tight POP cast, direct blow

106
Q

What is the clinical significance of injury to the common peroneal nerve?

A

It supplies the anterior and lateral compartment, and also sensation to dorsum of foot: injury results in foot drop and loss of sensation over the dorsum of foot

107
Q

What is the differential diagnosis of a swelling in the popliteal fossa?

A

Popliteal artery aneurysm
Abscess
DVT
Sarcoma
Lipoma
Lymphadenopathy
Baker’s cyst

108
Q

Which cutaneous dermatome supplies sensation over the anterior and posterior aspects of the knee?

A

Anterior: L3 dermatome
Posterior: S1,S2

109
Q

Describe the venous drainage of the lower leg

A

-Lower leg has superficial veins within the subcutaneous tissue, and deep veins beneath the deep fascia which run within the muscle with named arteries
-Both superficial and deep veins have valves
-Superficial veins include long and short saphenous veins
-Perforating veins drain superficial veins to deep veins within the muscle which are subject to compression as muscles contract deep to the fascia

110
Q

Describe the anatomical course of the great saphenous vein

A

-Arises from dorsal venous arch
-Ascends 2cm anterior to medial malleolus, runs up medial aspect of tibia
-Passes posterior to medial femoral condyle at the knee, runs along medial thigh
-Empties into the sapheno-femoral junction 4cm below and lateral to the pubic tubercle

111
Q

Describe the course of the short saphenous vein

A

-Arises from dorsal venous arch
-Ascends posteriorly to lateral malleolus, passes along lateral border of achilles tendon
-Empties into popliteal vein in popliteal fossa
-Sural nerve accompanies popliteal vein from popliteal fossa to lateral malleolus

112
Q

Why is an understanding of this venous anatomy clinically significant?

A

Relevant for surgeons performing:
-Sapheno-venous cut-down
-varicose vein surgery
-Saphenous vein harvest for graft

113
Q

What is the function of the valves in the perforating veins?

A

-prevents flow from deep veins through perforating veins into superficial system
-If they become incompetent, blood flows into superficial venous system and as a result, they become tortuous and dilated
-They then present as varicose veins

114
Q

Why is the saphenous vein considered to be suitable graft for cardiac bypass surgery?

A

-Lies in superfiical fascia
-Has consistent anatomical course
-Walls have high content of muscular and elastin fibres
-Sufficient length can be harvested due to distance between tributaries and perforating veins

115
Q

Which structure may be at risk during saphenous venous cut down?

A

Saphenous nerve

116
Q

how does an injury to the saphenous nerve present?

A

-Sensory deficit medial lower leg, foot and ankle
-No motor deficit

117
Q

How can you differentiate the long saphenous vein from the femoral vein at the saphenofemoral junction?

A

-Femoral artery lies lateral to femoral vein in femoral triangle
-Long saphenous vein receives several tributaries in region of saphenous opening, femoral vein receives only saphenous vein
-Long saphenous vein is more superficial than femoral vein

118
Q

Describe the lymphatic drainage of the lower limb

A

-Lower limb drained by superfiical and deep lymphatic vessels
-Superfiical lymphatics accompany the saphenous veins and their tributaries
-Those accompanying long saphenous veins –> superficial inguinal lymph nodes –> external iliac lymph nodes

Short saphenous vein –> popliteal lymph nodes

Deep vessels from leg –> popliteal nodes –> deep inguinal nodes –> external iliac nodes

119
Q

Name some common causes of regional inguinal lymphadenopathy

A

Infection of lower limb/perineum/external genitalia
Dermatitis
Syphilis
Malignancy (SCC/melanoma) lower limb and perineum

120
Q

Name some complications following regional inguinal lymphadenectomy

A

Seroma
bleeding/haematoma
infection
scar
lymphoedema

121
Q

How many compartments are there in the lower leg?

A

4

122
Q

Name the compartments in the lower leg

A

Anterior (extensor)
Superficial posterior (flexor)
Deep posterior (flexor)
Lateral (peroneal)

123
Q

Name the muscles in the anterior compartment

A

Tibialis anterior
Extensor digitorum longus
Extensor hallucis longus
Peroneus tertius

124
Q

Which artery supplies the anterior compartment?

A

Anterior tibial artery

125
Q

Describe the course of anterior tibial artery

A

Popliteal artery bifurcates at inferior popliteal fossa to tibioperoneal trunk and anterior tibial artery

Anterior artery continues in anterior compartment between extensor hallucis longus and tibialis anterior

Becomes dorsalis pedis after running beneath extensor retinaculum

Can be palpated at ankle in midpoint between two malleoli, lateral to tendon of EHL

Deep peroneal nerve accompanies anterior tibial artery throughout its course and lies lateral to artery at the ankle

126
Q

What is the innervation of the anterior compartment?

A

Deep peroneal nerve

127
Q

What is the main action of the muscles in the anterior compartment?

A

Dorsiflexion of ankle, extension of toes

Tibialis anterior helps with inversion at subtalar joint

Peroneus tertius helps with eversion at subtalar joint

128
Q

Name the muscles of the lateral (peroneal) compartment

A

Peroneus longus
Peroneus brevis

129
Q

Which artery supplies the lateral (peroneal) compartment?

A

Perforating branches from anteiror tibial artery superiorly, perforating branches from peroneal artery middle and inferiorly

Peroneal artery lies within deep posterior compartment, not peroneal compartment

130
Q

What is the innervation of the lateral compartment?

A

Superficial peroneal nerve

131
Q

Describe the action of the muscles in the lateral compartment

A

Plantarflexion at ankle joint
Eversion at subtalar joint

132
Q

Name the muscles of the posterior compartment of the leg

A

Superficial

Gastrocneius
Soleus
Plantaris

Deep

Tibialis posterior
Flexor hallucis longus
Flexor digitorum longus

133
Q

What is the arterial and nerve supply of the flexor compartment of the lower leg?

A

Artery: posterior tibial artery

Nerve: tibial nerve

134
Q

Define compartment sydrome and describe its pathophysiology

A

-Compartment syndrome is a rise in interstitial fluid pressure in an osseo-fascial compartment of sufficient magnitude to induce myo-neural necrosis
-Intercompartmental septae are tough and resistant to stretch, therefore only a small rise in pressure can compress muscles and nerves resulting in microvascular injury
-Prompt diagnosis and treatment is required to avoid significant morbidity and irrerversible damage to the limb

135
Q

What are the key signs and symptoms of compartment syndrome?

A

-Key sign is: pain out of proportion to the injury which fails to improve the expected time course, and is aggravated by passive muscle stretch
-Sensory loss in distribution of nerves travelling in affected compartment is also useful early sign

Other signs:
-Pulselessness
-Paraesthesia
-Paralysis
-perishing cold
-Pallor

136
Q

Name some common causes of compartment syndrome

A

-Fracture
-Trauma
-Burns
-Toxins
-Too tigh POP cast

137
Q

How would you manage compartment syndrome?

A

-Elevate limb
-Analgesia
-Split POP cast
-Reassess

If non resolving: fasciotomies

Anterior and lateral compartment:
-15cm incision 2cm lateral to lateral border of tibia

Posterior compartment
-15cm incision 2cm posterior to medial border of tibia (releases superficial and deep compartments)

138
Q

What would be the threshold for intracompartmental pressure monitoring?

A

Difference of 30mmhg or less between intracompartmental pressure and diastolic blood pressure

139
Q

Describe the lumbosacral plexus

A

-Network of nerves arising from ventral rami of L1-L5, S1-S4 nerve roots
-Nerves of lumbar plexus emerge from within psoas major and are describe in relation to this muscle
-Certain nerves arise from lumbar plexus only, others from sacral plexus only, and some from both
-Lumbosacral trunk: L4+L5 join S1-S4

140
Q

Describe the nerves arising from the lumbar plexus and their innervation, and where they emerge from

A

I, I get leftovers on fridays

Iliohypogastric (L1) (H comes before I)
–> internal oblique, transversus abdominis, skin of mons pubis

Ilioinguinal (L1)
–> Skin of upper medial thigh

Genitofemoral (L1, L2)
–> Skin of external genitalia (genital branch)
–> Skin of external genitalia (femoral branch)

Lateral cutaneous nerve (L2, L3)
-SKin of lateral thigh

Obturator nerve (L2-L4)
-Adductor compartment of thigh (except hamstring part adductor magnus)

Femoral nerve (L2-L4)
-Quadriceps and sartorius
-Hip and knee joint

Where they emerge from:
-All lateral to psoas major except: genitofemoral (anterior to psoas major), Obturator (medial to psoas major)

141
Q

Describe the nerves arising from the lumbosacral trunk and their innervation

A

Sciatic nerve (L4-S3)
–> Skin back of thigh, hamstring muscles, divides into tibial and common peroneal nerves

Superior gluteal nerve (L5-S1)
–> Innervation of gluteus medius and minimus and tensor fascia lata

Inferior gluteal nerve (S1-S2)
–> Innervation of gluteus maximus

Emerge from:
–> Superior gluteal nerve: greater sciatic foramen above piriformis
–> Inferior gluteal and sciatic nerve: greater sciatic foramen below piriformis

142
Q

Describe the nerves arrising purely from the sacral plexus and their innervation

A

Posterior femoral cutaneous nerve (S1-3)
–> skin to posterior buttock and thigh

Pudendal nerve (S2-S4)
–> main nerve of perineum
–> cutaneous innervation of perineum and external genitalia
–> muscles of pelvic floor/perineum, external and internal urethral and anal sphincters

emerge from:
–> posteiror femoral cutaneous nerve: inferior border of gluteus maximus
–> Pudendal nerve: exits pelvis through greater sciatic foramen below piriformis, re-enters through lesser sciatic foramen

143
Q

What are the terminal branches of the sciatic nerve?

A

Tibial
Common peroneal nerve

144
Q

Describe the clinical deficit following sciatic nerve palsy

A

Loss of sensation to posterior thigh and lower leg below knee
Weak hip extension
Loss of all movement below the knee with foot drop

145
Q

What is the root value of the tibial nerve?

A

-L4-S3
-Tibial nerve is largest terminal branch sciatic nerve

146
Q

Name the muscles innervated by the tibial nerve

A

Muscles in superficial and deep posterior compartment lower leg

Gastrocnemius
Soleus
Plantaris
Popliteus

Tibialis posterior
Flexor hallucis longus
Flexor digitorum

All muscles in sole of foot via medial and lateral plantar nerves

147
Q

What is the nerve root value of the common peroneal nerve?

A

L4-S2

148
Q

Name the muscle and nerve root tested during the ankle reflex

A

Gastrocnemius
S1, S2 (via sciatic nerve: tibial branhc

149
Q

How would you clinically test the L5 nerve root?

A

Motor: Extension of the big toe (extensor hallucis longus)

Cutaneous sensation over 1st-4th web spaces

150
Q

Describe the blood supply to the foot

A

Blood supply is from two vessels: Dorsalis pedis, posterior tibial

Dorsalis pedis –> anterior tibial artery. Anastamoses with lateral plantar artery to form deep plantar arch

Posterior tibial–> splits into medial and lateral plantar arteries

Dorsalis pedis begins as anterior tibial artery enters foot. Passes over dorsal aspect of tarsal bones, then moves inferiorly towards sole of foot. Anastomoses with lateral plantar artery to form deep plantar arch. Supplies tarsal bones and dorsal aspect of metatarsals. Contributes to supply of toes via deep plantar arch.

POsterior tibial enters sole of foot via tarsal tunnel. Then splits into medial and lateral plantar arteries. These supply plantar aspect of foot and contribute to supply of toes via lateral plantar arch

151
Q

Name the structures which pass behind the medial malleolus

A

Tom, Dick And Very Naughty Harry

(anterior to posterior)

Tibialis posterior
Flexor digitorum longus
Posterior tibial artery
Posterior tibial vein
Posterior tibial nerve
Flexor halluclis longus

152
Q

Name the tarsal bones

A

Proximal: talus and calcaneum
Intermediate: Navicular bone
Distal: cuboid and cuneiforms

153
Q

Name the three groups of ligaments of the ankle joint

A

Deltoid ligament
Syndesmosis
Lateral collateral ligamentous complex

Deltoid ligament: deep and superficial part
–> Deep: Anterior tibiotalar ligament
–> Superficial: posterior tibiotalar ligament, tibionavicular ligament, tibiocalcaneal ligament

Lateral collateral ligamentous complex:
–> Anterior and posterior talofibular ligament
–> calcaneofibular ligament

154
Q

Name the arches of the foot

A

Medial longitudinal arch
Lateral longitudinal arch
Transverse arch (each foot contributes half of transverse arch)

155
Q

Which ligament supplies the main support of the medial longitudinal arch of the foot?

A

-Plantar calcaneonavicular ligament (spring ligament) connects sustenaculum tali with plantar surface of navicular bone. Provides main support for medial longitudinal arch of foot

156
Q

Describe the landmarks where you could palpate pulses in the foot and ankle

A

-Landmarks for palpation DP are: between tendons EHL + extensor digitorum on dorsum of foot, lateral to base of first metatarsal

POsterior tibial: Half way between medial malleolus and achilles tendon

157
Q

How many intrinsic layers of muscles are there on the plantar aspect of the foot?

A

4

158
Q

Name the muscles that make up the first layer of the plantar aspect of the foot

A

-abductor hallucis
-flexor digitorum brevis
-Abductor digiti minimi

159
Q

Describe function of dorsal and plantar interossei of the foot

A

-Plantar interossei adduct digits
-Dorsal interossei abduct the digits. Together with the lumbricals they also flex the MTPJs and extend the PIPJs and DIPJs

160
Q

Name the nerve which innervates the dorsal and plantar interossei

A

Lateral plantar nerve

161
Q

Name the cutaneous innervation of the medial aspect of the foot

A

Saphenous nerve
Sural nerve supplies lateral foot

162
Q

How are ankle fractures classified?

A

Weber classification

Weber A: below level of syndesmosis
Weber B: at the level of the syndesmosis
Weber C: above the level of the syndesmosis

163
Q

What is the clinical relevance of the weber classification

A

Weber A: usually stable fracture, can be managed conservatively
Weber B and C: more likely to be unstable and need fixation

164
Q

What is a stress fracture?

A

Incomplete fractreu caused by repeated stress, occurs most frequently to metatarsals 2, 3 and 4. Occurs most commonly in soldiers and athletes

165
Q

What is tarsal tunnel syndrome?What are its causes?

A

Causative factors: pes planus (arches of feet collapse, flat foot), obesity, repetative strain, compressive lesion

entrapment of tibial nerve at level of medial malleolus below the flexor retinaculum resulting in pain and paraesthesia of sole of foot

166
Q

How would you diagnose tarsal tunnel syndrome

A

-Palpating along clinical course of nerve in tarsal tunnel or percussion of nerve (tinel’s test) to elicit discomfort locally or distally
-Ultrasound or MRI may help diagnose causative pathology

167
Q

What is the management of tarsal tunnel syndrome?

A

Conservative management: Rest, elevation, NSAIDs, analgesia, supportive footwear, orthoses

Minimally invasive: local anaesthetic, corticosteroid

Surgical: excision of any compressive lesion/tarsal tunnel release

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