Lower limb anatomy Flashcards
13,18,11,15,10
Medial aspect
13 - Calcaneum
18 - Sustentaculum tali
11 - Talus
15 - Navicular
10 - medial cuneiform
Lateral aspect
17, 2, 6, 5, 10
17 - calcaneus
2 - cuboid
6 - lateral cuneiform
5 - intermediate cuneiform
10 - medial cuneiform
Which metatarsal does the cuboid articulate with
Lateral 2 metatarsals - only tarsal bone which articulates with 2
How many arches are there in the foot
3
Medial longitudinal arch
Lateral longitudinal arch
Transverse arch
What are the contents of the medial longitudinal arch
Bones: (9)
Calcaneus
Talus
Navicular
Medial, intermediate and lateral cuneiforms
1-3 metatarsals
Ligaments: (3)
Spring ligament (calcaneonavicular ligament)
Short and long plantar ligaments
Muscles: (4)
Tibialis anterior and posterior
Flexor hallucis longus
Peroneus longus
Plantar fascia
Contents of lateral longitudinal arch
Bones: (4)
Calcaneus
Cuboid
4&5 Metatarsals
Ligaments: (2)
Short and long plantar ligaments
Muscles: (3)
Peroneus longus and brevis
Short plantar muscles
Plantar fascia
Contents of transverse arch
Bones:
Base of all 5 metatarsals
Muscle:
Peroneus longus
Which muscle is in all 3 foot arches
Peroneus longus
Medial ankle
6,15,7,18,26
6 - deltoid ligament
15 - medial malleolus
7 - sustentaculum tali
18 - spring ligament
26 - navicular tuberosity
Attachments of deltoid ligament
Medial malleolus
Sustentaculum tali
Spring ligament
Neck and body of talus
Navicular tuberosity
Lateral view ankle - 3,13,1
3 - calcaneofibular ligament
13 - lateral malleolus
1 - Anterior talofibular ligament
Identify 19, 8, 10
19 - Posterior talofibular ligament
8 - lateral malleolus
10 - talus
Subtalar joint - type, movements, articulating surfaces
Articulating surfaces
Inferior surface of body of talus
Superior surface of calcaneus
Type - plane synovial
Movements - inversion and eversion of foot
Talocalcaneonavicular joint -type, movements, articulating surfaces
Articulating surface - head of talus with the calcaneus and navicular
Type - Synovial joint
Talonavicular part is ball and socket
Movements - Gliding and rotatory movements
Calcaneocuboid joint - type, movements, articulating surfaces
Anterior surface of calcaneum with posterior surface of cuboid
Type - plane synovial
Movement - inversion, eversion, circumduction
Midtarsal joint
compound joint - talonavicular joint and calcaneocuboid joint
Talonavicular - ball and socket
Calcaneocuboid - plane synovial
Ankle joint - articulating surface, type, movements
Articulating surfaces - lower end of tibia and fibula and trochlear surface of talus
Type - synovial hinge joint
Movements - Plantar flexion and dorsiflexion
In which position is the ankle joint most stable and why
Most stable in dorsiflexion
Because the talus glides posteriorly and the wider anterior portion of the talus becomes wedged in the ankle mortise
What type of joint is the inferior tibiofibular joint
Syndesmosis
What is the associated injury in syndesmotic injury
Lateral malleolus fracture
What structures pass posterior to medial malleolus
Tendons
Tibialis posterior tendon
Flexor digitorum longus tendon
Flexor hallucis longus tendon
Posterior tibial nerve
Posterior tibial vessels
Demonstrate the dorsalis pedis pulse
Between the 1st two metatarsal bones - lateral to the extensor hallucis longus tendon
Demonstrate the posterior tibial artery
Halfway between the posterior border of the medial malleolus and achilles tendon
What is the course of dorsals pedis artery
Originates from anterior tibial as it crosses the ankle joint
Passes over the dorsal aspect of the talus, navicular and
Passes between the 2 heads of the 1st dorsal interosseous muscle
Then joins the deep plantar arch
What are the arteries of the sole of the foot
Medial plantar and lateral plantar artery
Where do the arteries of the sole of the foot travel
Between the two layers of muscles of the sole of the foot
What muscles make the achilles tendon
Gastrocnemius
Plantaris
Soleus
Identify 7,6,5,2,12,17,15
7 - Extensor hallucis longus tendon
6 - Extensor hallucis brevis tendon
5 - Extensor digitorum longus tendon
4- Extensor digitorum brevis tendon
12 - peroneus Tertius tendon
17 - tibialis anterior tendon
15 - cuboid bone
How many compartments are there in the leg and what are they
4
Anterior
Lateral
Superficial posterior
Deep posterior
What separates the anterior and posterior compartments
Interosseous membrane
What separates anterior and lateral compartment
Anterior intermuscular septum
What separates lateral and posterior compartments
Posterior intermuscular septum
What separates superficial and deep posterior compartment
Transverse intermuscular septum
Components of anterior compartment of leg and actions
Muscles (tom has dog and pig)
Tibialis anterior
EHL
EDL
Peroneus Tertius
Nerves
Deep perineal nerve
Vessels
Anterior tibial vessels
Dorsiflexion of ankle and toes
Inversion at subtalar joint - tibialis anterior
Components of lateral compartments of leg and actions
Muscles
Peroneus longus
Peroneus brevis
Nerve
Superficial peroneal nerve
Vessels
none
Action
Eversion of subtalar joint
Contents of posterior compartment and actions
Muscles
Superficial
Gastrocnemius
Plantaris
Soleus
Deep
Popliteus
Tibialis posterior
FHL
FDL
Nerves
Tibial nerve and posterior tibial nerve
Vessels
Posterior tibial vessels
Peroneal vessels
Action
Plantarflexion at ankle and toes
Inversion at subtalar joint - tibialis posterior
4, 14
4 - Impression of the iliotibial tract - Gerdy’s tubercle
14 - tibial tuberosity
12 - soleal line
How to orientate the tibia
Head is superior
Lateral condyle is more prominent
Tibial tuberosity is anterior
Soleal line is posterior
6,9,11
11 - medial malleolus
9 - lateral malleolus
6 - inferior tibiofibular joint
How to articulate tibia and fibula
Fibular head articulates with lateral tibial condyle
Course of superficial peroneal nerve
Arises between peroneus longus and neck of fibula
Descends in lateral compartment of leg
Pierces deep fascia at distal 1/3 of leg to become subcutaneous
Course of deep peroneal nerve
Arises between peroneus longus and neck of fibula
Passes through extensor digitorum longus and descends on interosseous membrane
Crosses distal end of tibia and enters dorsal of foot
Where does the common peroneal nerve divide
Just inferior to the neck of the fibula
What occurs in injury of common peroneal nerve
Foot drop and foot inversion
Foot inversion because of unopposed action of tibialis posterior
Foot drop because of paralysis of dorsiflexors
Sensory loss over whole dorsum of foot and lower 1/3 of anterior leg
Sensory distribution of superficial peroneal nerve
Skin over dorsal of foot
Lower 1/3 of anterior surface of leg
Except skin of 1st dorsal web space
Sensory distribution of deep peroneal nerve
Skin of 1st dorsal web space
What nerve is the tibial and common peroneal nerve derived from
Sciatic nerve
Course of tibial nerve
Descends through popliteal fossa and its on popliteus muscle
Runs inferiorly on tibialis posterior with the posterior tibial vessels
Terminates between flexor retinaculum dividing into medial and lateral plantar nerves
What is the supply of the tibial nerve
Plantar flexor muscles of posterior compartment of leg and knee joint
Course of common peroneal nerve
Originates from sciatic bifurcation at apex of popliteal fossa
Follows medial border of biceps femoris
Passes over posterior aspect of neck of fibula
Winds around neck of fibula deep to peroneus longus
Then bifurcates
Course of sural nerve and distribution
Formed by union of cutaneous branches of tibial and common peroneal nerve
Supplies skin on posterior and lateral aspects of leg and lateral foot
Saphenous nerve origin and distribution
Originates from femoral
Supplies skin on medial side of leg and foot
Demonstrate the dermatomal supply of lower limb
L1 - below the inguinal ligament
L2 -Lateral aspect of anterior thigh
L3 - medial aspect of anterior thigh
L4 - Medial aspect of leg and hallux
L5 - lateral aspect of leg and toes 2-4
S1 - 5th toe and lateral border of foot
Why is the anterior tibial artery at a right angle
It passes through the interosseous membrane
What is the origin of the popliteal artery
Continuation of the femoral artery at the adductor hiatus in adductor Magnus
Demonstrate the knee and ankle reflexes
Knee - foot is unsupported, relaxed and off the ground. The thigh is fully exposed
The patellar tendon is tapped with the tendon hammer. Look for contraction of quadriceps muscle
Ankle reflex - the foot is pointing laterally, flexed and relaxed. The leg is fully exposed
Tap the achilles tendon. Look for contraction of calf muscles
Root values of knee and ankle reflex
Knee - L3/4
Ankle - S1
How would you recognise compartment syndrome in the lower leg
Pain out of proportion to the injury
In particular on passive stretching of the ankle
Swelling of the leg
Late stage - paraesthesia, pulselessness and paralysis
How to orientate the femur
Femoral head is medial and superior
Anterior femur
2-6
3 - femoral head
6 - neck of femur
2 - greater trochanter
5 - lesser trochanter
4 - intertrochanteric line
Posterior femur
2,5,9,12
5 - Intertrochanteric crest
12 - quadrate tubercle
2 - gluteal tuberosity
9 - linea aspera
9 - medial femoral epicondyle
8 - medial femoral condyle
5 - lateral condyle
6 - lateral epicondyle
1 - adductor tubercle
Describe the blood supply to the head of the femur
Profunda femoris artery gives lateral and medial circumflex femoral arteries
Lateral circumflex gives ascending branch, transverse and descending
Ascending branch anastomoses with branches of medial circumflex femoral artery to form extra capsular femoral anastomosis
Anastomosis gives reticular arteries which give main blood supply to femoral head
These enter femoral head through retinacular ligament
Obturator artery gives acetabular branch which goes through the ligamentum teres to the head of the femur
Why does avascular necrosis of the femoral head occur in nof fracture
The head of the femur will depend only on the acetabular artery as the anastomosis at the femoral neck will be disrupted
Compartments of the thigh
Anterior
Medial
Posterior
Anterior compartment of thigh - Muscles, nerves
Sartorius
Quadriceps femoris - rectus femoris, vastus medialis, intermedius and lateralis
Femoral nerve
Action of sartorius
Flexion of hip joint
Action of quadriceps femoris
Extension of knee and flexion of hip
Medial compartment muscles and nerves
Pectineus
Gracilis
Adductor longus, brevis, magnus
Obturator nerve except pectineus (femoral) and lateral 1/2 of adductor magnus (sciatic)
Posterior compartment muscles and nerves
Hamstring muscles - biceps femoris, semiteninosus and semimebranosus
Nerve - sciatic
Rectus femoris origin
Anterior inferior iliac spine and ilium superior to acetabulum
Vastus muscles origins
Lateralis - greater trochanter and lateral lip of linea aspera
Medialis - intertrochanteric line and medial lip of linea aspera
Intermedius - anterior and lateral surfaces of shaft of femur
Insertion of quadriceps tendon
Base of patella
Indirectly via the patellar ligament to the tibial tuberosity
Origin and insertion of semitendinosus and semimembranosus
Origin - ischial tuberosity
Insertion:
Semitendinosus - medial surface of superior part of tibia
Semimembranosus - posterior part of medial condyle of tibia
Origin and insertion of biceps femoris
Long head - ischial tuberosity
Short head - linea aspera and lateral supracondylar line of femur
Insertion - lateral side of head of fibula
Nerve supply of hamstrings
Semitendinosus, semimembranosus and long head of biceps - tibial division of sciatic nerve (L5, S1, S2)
Short head of biceps - common peroneal division of sciatic nerve
Iliopsoas origin and insertion
Psoas
Origin - sides of T12-L5 vertebrae and intervertebral discs, transverse processes of all lumbar vertebrae
Iliac
Origin - iliac breast, iliac fossa, ala of sacrum, anterior sacroiliac ligament
Attachment - lesser trochanter of femur
Innervation of iliopsoas
Psoas - anterior rami of lumbar nerves L1- L3
Iliacus - femoral nerve L2,3
Action of iliospsoas
Flexion and stabilisation of hip
Femoral triangle boundaries
Base - inguinal ligament
Medial border - lateral border of adductor longus
Lateral border - medial border of sartorius muscle
Floor - pectineus, adductor longus (medialy), iliopsoas (laterally)
Contents of femoral triangle
Femoral nerve, artery, vein, lymphatics and canal
surface marking of femoral artery
Mid inguinal point - midway between ASIS and pubic symphysis
What is the femoral sheath
Funnel shaped fascial tube 3-4cm in length
Passes deep to the inguinal ligament
Encloses femoral vessels and canal
Formed by inferior prolongation of transversals fascia and the iliopsoas fascia
Terminates as it becomes continuous with the adventitia of the femoral vessles
What is the femoral canal
Most medial structure in the femoral sheath
Lies between the medial wall of the femoral sheath and the femoral vein
Extends distally to the proximal edge of the saphenous opening
Function - allows the femoral vein to expand when venous return of lower leg is increased
Contains loose connective tissue, lymphatics and lymph node of cloquet
Femoral ring boundaries
Laterally - septum which divides femoral canal from femoral vein
Posteriorly - pectineal ligament
Medially - lacunar ligament
Anteriorly - inguinal ligament
What is the adductor canal
Canal running from the apex of the femoral triangle to the popliteal fossa at the adductor hiatus (opening in adductor Magnus muscle)
Boundaries of adductor canal
Anterolateral - vastus medialis
Anteromedial/roof - sartorius
Posterior - adductor longus and adductor magnus
Contents of adductor canal
Femoral artery and vein
Saphenous nerve
Nerve to vastus medialis
What is the surface marking of adductor hiatus
2/3 along the line between the ASIS and the adductor tubercle of the femur
Popliteal fossa boundaries
Superlateral - biceps femoris
Superomedial - semimembranosus and semitendonosus
Inferior - medial and lateral heads of gastrocnemius
Contents of popliteal fossa superficial to deep
Common peroneal nerve
Tibial nerve
Popliteal vein
Popliteal artery
Popliteal lymph nodes
What drains to the popliteal lymphatics
Small area of skin above heel and deep structures of calf
What is Ddx of lump in popliteal fossa
Baker’s cyst
Aneurysm
Popliteal vein varicosity
Schwanoma
Lipoma
Where does common femoral artery divide
Apex of femoral canal
What are the branches of the common femoral artery
Superficial femoral artery
Profunda femoris artery
2,3,6,7
2 - common femoral artery
6 - profunda femoris
7 - superficial femoral artery
3 - lateral circumflex femoral
What is the iliotibial tract
A tract formed by the continuation of the fascia lata on the lateral aspect of the thigh
Where does the iliotibial tract attach
Superior - tubercle of iliac crest
Inferior - Gerdy’s tubercle at the lateral tibial condyle
What inserts into the ilotibial tract
Gluteus maximus
Tensor fascia lata
3,4,5,10,12,14,15,22,23,24,28
10 - iliac crest
28 - tubercle of iliac crest
5 - anterior superior iliac spine
4 - anterior inferior iliac spine
23- posterior superior iliac spine
22 - posterior inferior iliac spine
21 - posterior gluteal line
3 - anterior gluteal line
12 - inferior gluteal line
14 - ischial spine
15 - ischial tuberosity
24 - pubic tubercle
How to orientate the hip bone
Acetabulum is lateral
Pubic tubercle is anterior
Ischial tuberosity is posterior
Quadratus femoris origin and insertion and nerve supply
Origin - ischial tuberosity
Insertion - quadrate tubercle on the intertrochanteric crest of the femur
Nerve to quadrates femoris - L5 and S1
Gluteus maximus origin and insertion and nerve supply
Action
Origin - area posterior to the posterior gluteal line
Insertion - iliotibial tract and gluteal tubercle on the posterior shaft of the femur
Nerve - inferior gluteal nerve L5, S1, S2
Hip extension and lateral rotation
Gluteus medius origin, insertion, nerve supply and action
Origin - between the anterior and posterior gluteal line
Insertion - greater trochanter
Nerve - superior gluteal nerve L4,5,S1
Hip abduction
Keeps pelvis level when opposite leg is elevated
prevents sagging of contralateral hemipelvis
Gluteus minimus origin, insertion, nerve supply and action
Origin - area between anterior and inferior gluteal line
Insertion - greater trochanter
Nerve - superior gluteal nerve L4,5,S1
Hip abduction
Keeps pelvis level when opposite leg is elevated - prevents sagging of contralateral hemipelvis
What is the trendelenberg test
Tests the integrity of gluteus medius and minimus and their nerve supply
Ask the patient to elevate one leg off ground
Observe the pelvis on the side elevated
If hip is level then the contralateral gluteus muscles are intact
If the hip is drooping or sagging the test is positive
“The sound side sags”
Causes of positive trendelenberg signs
Damage to superior gluteal nerve - pelvis fracture, space occupying lesions, post hip surgery due to disruption and subsequent atrophy of the gluteus medius and minimus tendons
Sciatic nerve surface marking
Curved line drawn between 2 points
1 - midway between posterior superior iliac spine and ischial tuberosity
2 - midway between greater trochanter and ischial tuberosity
What is the course of the sciatic nerve
Runs inferolaterally under the gluteal maximus midway between greater trochanter and ischial tuberosity
It then travels in posterior thigh, posterior to adductor magnus
Anterior to long head of biceps tendon in the inferior thigh
What are the anatomical variations in the exiting of the sciatic nerve through the pelvis
- Normally - exits from greater sciatic foramen on the anterior boundary of piriformis with both branches in same common connective sheath
- Common peroneal and tibial exit the piriformis separately with common peroneal piercing the piriformis muscle
- Common peroneal nerve exits above piriformis and tibial nerve below piriformis
