Lower limb anatomy deck Flashcards
Structures that pass behind the medial malleolus
Tom, dick and very naughty harry
Tibial nerve, posterior tibial artery and vein, tibialis posterior tendon, tendon of flexor hallucis longus, flexor digitorum tendon
What is the nerve dermatomes in the lower limb
Look at photo on the internet and study
Where to inversion and eversion of the foot occour. What joint?
This occurs at the subtalar joint
Where does foot plantar and dorsiflexion occur
This occurs at the talus and tibio-fibular joint
What is the innervation to the first webspace of the foot
deep peroneal nerve
What is the garden classification of hip fractures
1: undisplaced and incomplete fracture
2: undisplaced and complete fracture
3: Discplased and incomplete fracture
4: Displaced and complete fracture
1,2 screw and 3,4 hemi
Subtrochanteric fractures are often managed with intramedullary nailing
What is the blood supply to the hip joint
Medial and lateral circumflex arteries that originate from the profunda as well as the artery to the femoral head in the ligamentum teres that originates from the obturator artery, this is negligible in adults
The blood supply is retrograde
Where does the psoas major originate and what is the action
L1-L4 and inserts into the lesser trochanter, causing flexion of the hip joint
Where does the iliotibial tract arise
Anterolateral iliac tubercle to the to the lateral condyle
What muscles insert onto the liotibial tract and what is the clinical significance
Glute max and tensor fascia lata, stabilises the knee in extension and partial flexion, it is important in running and walking
Where does the gluteus maximus muscle attach
Gluteal tuberosity of the femur, it is supplied by the inferior gluteal nerve and the nerve roots are L5,S1,S2
What nerve supplies the tensor fascia lata
Superior gluteal nerve L4,L5 and S1
Gluteus medias function
While standing, it is a hip abductor, while walking, supports the body with the minimus so that the hip does not fall to one side
What is the surface marking of the sciatic nerve
2 points
Halfway between PSIS and ischial tuberosity and halfway between the ischial tuberosity and the greater trochanter
What are the variations of the sciatic nerve exiting the pelvis
Normally goes from below the piriformis, but can also go through it or it may divide high with one division going through or around the piriformis
What is the blood supply to the knee joint
femoral, popliteal and crural arteries anastomose to form the blood supply to the knee
Medial and lateral superior genicular arteries: Supply the femoral condyles
Medial and lateral inferior genicular arteries: Supply the tibial condyles
Middle genicular artery: Supplies the ACL and PCL
How would one differentiate between the semimembranosus and the semitendinosus
The tendon one has a large tendon and the membrane one fans into an attachment
What are the possible causes for swelling in the back of the knee
Seb cyst, popliteal cyst (Bakers), abscess, DVT, varicose veins
What forms the pes anserius
Semitenndanosus, sartorius and gracilis
What is the iliotibial band
Longitudinal thickening of the tensor fascia lata extending from the iliac tubercle to the lateral tibial condyle. It is a dynamic stabilizer of the knee joint
How many arches does the foot have
Medial, lateral and transverse
What are the components of the medial longitudinal arch
Bones: Calcaneus, talus, navicular and all 3 cuniform bones and medial 3 metatarsals
Ligaments: Interosseous and spring ligament
Muscles: Flex hal long, flex dig long and brev, tib ant and post
What are the components of the lateral longitudinal arch
Bones: Calcaneus, cuboid and lateral 2 met
Ligaments: long and short plantar ligaments
Muscles: per long, flex dig long and brev
What are the components of the transverse arch
Bones: Bases of all 5 met
Ligaments: interosseous
Muscle: Peroneus longus
Which muscles form the inversion and eversion of the foot
Eversion: Per long and brev
Inversion: Tib ant and post along with some help from the extensors as well as flex hal long
What are the fascial compartments of the lower limb and their contents
Name the points of insertion of the extracapsular ligaments of the hip joint.
iliofemoral: Y shaped and arises from the anterior inferior iliac spine. Inserts into the trochanteric line. (resists hyperextension). One of the strongest in the body
Pubofemoral: Arises from the pubofemoral juntion and blends with the medial aspect of the capsule (resists extension and abduction)
Ischiofemoral: Ischium to the greater trochanter. Limits extension.
Blood supply to the hip joint and the head of the femur
Cruciate anastomoses: Inferior gluteal artery, the lateral and medial circumflex arteries, the first perforating artery of the profunda and the posterior branch of the obtruator artery
Trochanteric anastomosis: Superior gluteal artery and the medial and lateral superior circumflex artery.
Artery of ligamentum teres: branch of the obtruator artery.
What is the innervation of the hip joint
Sciatic, femoral and obtruator
What innervates the main flexors of the hip joint
Psoas major is ventral rami of L1, L2
Femoral nerve for the rest
What are the boundaries of the femoral triangle
Roof – fascia lata.
Floor – pectineus, iliopsoas, and adductor longus muscles.
Superior border – inguinal ligament (a ligament that runs from the anterior superior iliac spine to the pubic tubercle).
Lateral border – medial border of the sartorius muscle.
Medial border – medial border of the adductor longus muscle. The rest of this muscle forms part of the floor of the triangle.
What are the iliac and psoas major insertions and origins
Psoas originates T12 to L1-L5 and iliacus originates in the iliac fossa to lesser trochanter
What is the femoral sheath and what does it entail
The femoral sheath is a fascial tube that is the continuation of the transversalis fascia. It contains the femoral vessels and the canal but it DOES NOT contain the femoral nerve
What does the femoral canal contain
Fat, lymphatics and cloquets nodes. cloquets nodes drain the LL, perineum as well as the anterior abdominal wall. It may be enlarged in case of carcinoma
What is the femoral ring and what are the boundaries and significance
It is the superior aspect of the canal.
Ant: Inguinal lig
post: Pectineal ligament
medial: lacunar
lateral: femoral nerve
Femoral hernias enter the femoral triangle through the femoral ring
What is the action of the gluteal nerves
Gluteus medius and minimus abduct and medially rotate the thigh. Maximus extends and externally rotates
Describe the Trendelenberg test
It is a superior gluteal nerve test. a hip drop indicates weakness in the weight-bearing side
What are the surface markings of the piriformis?
The surface marking of the superior border of the piriformis is indicated by a line drawn from the posterior superior iliac spine to the superior border of the greater trochanter
What nerves form the sacral plexus
L4-S4
Name the boundaries of the greater sciatic foramen
Superiorly: Anterior sacroiliac ligament
Inf: Sacrospinous ligament
Posterior medially: Sacrotuberous ligament
Anterior laterally: Greater sciatic notch of ilium
Boundaries of the lesser sciatic foramen
The ischial body anteriorly, the ischial spine and the sacrospinous ligament superiorly and the sacrotuberous ligament posteriorly.
The landmarks for the sciatic nerve`
The anatomical course of the sciatic nerve must be considered when administering intramuscular injections into the gluteal region. The region can be divided into quadrants using 2 lines, marked by bony landmarks:
One line descends vertically from the highest point on the iliac crest.
The other horizontal line passes through the vertical line half way between the highest point on the iliac crest and ischial tuberosity.
The sciatic nerve passes through the lower medial quadrant. To avoid damaging the sciatic nerve therefore, intramuscular injections are given only in the upper lateral quadrant of the gluteal region.
Describe the anatomical landmarks of the femoral bone
Describe the stages of ossification of the femoral bone
Coxa valga vs Coxa Vara
Femoral neck angle increased in Valga and decreased in vara
Classification of femoral neck fractures
Intracapsular and extracapsular (sub, per and intertrochanteric )
Garden classification of intracapsular fractures
Type 1: incomplete and undisplaced
Type 2: Complete and undisplaced
Types 3: Complete and partially displaced
Type 4: Complete and fully displaced
Management of intra and extracapsular fractures
Intracapsular
Type 1 and 2 can be internal fixation with cannulated hip screws
Type 3 and 4 usually require hemi or total (hemi in old and total in young)
extra: DHS, below subtrochanteric line require intramedullary nailing
What are the boundaries of the adductor canal
Anteromedial – Sartorius.
Lateral – Vastus medialis.
Posterior – Adductor longus and adductor magnus.
What are the structures that would would encounter during arthroscopic surgery anterior approach
Tranverse meniscal ligament
Anterior horn of medial miniscus
ACL
Anterior horn of lateral miniscus
posterior horn of lateral miniscus
PCL
What are the articular surfaces of the knee joint
Lateral and medial is with femoral and tibial condyles
Intermediate is with the patella and femus
What are the salient differences between the medial and lateral meniscus
The medial meniscus is C shaped and the lateral is more circular
Medial meniscus is attached to the medial collateral lig but lateral is attached to nothing and is hence more mobile
Popliteus tendon runs between the joint capsule and the lateral meniscus
Why is injury to the medial meniscus more common than the lateral
Attachment to the medial collateral ligament means that it is not as mobile and can tear in abnormal stress
What is the role of meniscus
Shock absorber, joint stability and lubrication
Describe the bursae of the knee
Suprapatellar: Lies between the inferior anterior surface of the femur and the deep surface of the quads
Pre-patella: Between patella and skin
Superficial and deep infrapatellar: Lies between patellar ligament and the skin and the tibia and the patellar ligament
Describe the blood supply of the knee
Genicular arteries. There are 5 genicular branches of the popliteal artery
What is the cutaneous innervation to the knee
L3 anteriorly and S1 and S2 posteriorly
FACT
Sural nerve accompanies short saphenous vein and saphenous nerve accompanies the long saphenous vein
Why is a saphenous vein considered suitable for a coronary artery graft
Superficial and therefore can easily be accessed
Has a consistent anatomical course
Walls have a higher muscle content
Sufficient length
Describe the lymphatics of the lower limbs
Superficial and deep
Superficial follow saphenous and they end at superficial inguinal, then external iliac and the short saphenous and these drain into the popliteal.
Deep ones follow the deep veins and goes into the deep inguinal.
What is the course of the anterior tibial artery
From tibioperoneal trunk to between extensor hallucis longs and tib ant and close to the interosseous membrane
In the ankle it can be palpated between the 2 malleoli just lateral to the tendon of EHL.
Deep peroneal nerve accompanies it and lies just lateral to the artery at the ankle
Runs beneath the extensor ret and then becomes DP and the distal edge of the retinaculum. This can be palpated between the 1st and 2nd mets
Root values of the tibial nerve
L4-S3
Root value of the common peroneal nerve
L4-S2
How would you test the L5 nerve
Sensory would be the webspaces of 1st toth toes and motor would be testing the extension of the flexor hallucis longus
What are the ligaments of the ankle joint
The deltoid ligament: tibio-calcaneo-talar ligament, deep posterior tibiotalar, superficial post tibtal and anterior tib tal lig
Laterally: Anterior and posterior talofibular ligaments
Calcaneofibular ligaments
Plantar muscles
Intrinsic muscle layers of the foot
1st layer:
Abductor hallucis
Flex dig brev
abductor digiti minimi
2nd layer
Quadratus plantae
Lumbricals
3rd layer
Flex hal brev
Adductor hallucis
Flex dig mini brev
4th layer
Plantar interossei
dorsal interossei
Which nerve innervates the dorsal and plantar interossei
Lateral plantar nerve
What is the talofibular joint also called
The syndesmosis
What is tarsal tunnel syndrome and what are the different kinds of tarsal tunnel syndromes
Pain and paresthesia due to entrapment of the contents of the tarsal tunnel. Commonly caused by compression of the tibial nerve or any of its branches. It is uncommon
Anterior: Deep peroneal nerve is affected
Posterior: Posterior tibial nerve is affected leading to pain and paraesthesia at the sole of the foot
Diagnose: Tinnels, US and/or MRI
Treatment:
Conservative: Rest, elevation, NSAIDS, analgesia
Medical: INjection of LA or steroid
Surgical: Excision of compression lesion
Lumbar plexus
Lumbosacral plexus
Sacral plexus
What is the dermatome distribution of the lateral cutaneous nerve
L2 and L3
The surface marking of this vessel is 1-2 cm below and medial to the ACIS as it passes below the inguinal ligament
What is the femoral sheath formed by
Transversalis fascia anteriorly and the iliopsoas fascia posteriorly
What sort of a bone is the patella
Sesamoid bone
What is the function of the patella
To attach the quadriceps muscles to the tibial tuberosity via the patellar ligament and to increase its leverage and hence, power
Which of the cruciate ligaments is stronger
PCL
What is the unhappy triad of knee injury
Injury to ACL, MCL and Medial meniscus. Caused by a direct blow form the lateral aspect of the knee
At what level does the popliteal artery bifurcate
Lower border of the popliteus muscle
What is a baker cyst
Baker’s cyst is a fluid filled sack originating from the semimembranosus bursae. This is not a true cyst as there is usually some communication with the synovial sac
What is the sustantaculum tali
Shelf-like projection of the talus that gives support to the calcaneous
What arises from the linea aspera
The adductor muscles, Short head of biceps femoris. Vastus medialis and lateralis and the lateral and medial intermuscular septi
What muscles attach to the medial cuneiform
Tib ant and post as well as per long
What are the contents of the inguinal canal
- Spermatic cord (biological males only)
- Round ligament (biological females only) – originates from the uterine horn and travels through the inguinal canal to attach at the labia majora.
- Ilioinguinal nerve – contributes towards the sensory innervation of the genitalia
o Note: only travels through part of the inguinal canal, exiting via the superficial inguinal ring (it does not pass through the deep inguinal ring)
o This is the nerve most at risk of damage during an inguinal hernia repair. - Genital branch of the genitofemoral nerve – supplies the cremaster muscle and anterior scrotal skin in males, and the skin of the mons pubis and labia majora in females.
What are the contents of the inguinal canal
- Spermatic cord (biological males only)
- Round ligament (biological females only) – originates from the uterine horn and travels through the inguinal canal to attach at the labia majora.
- Ilioinguinal nerve – contributes towards the sensory innervation of the genitalia
o Note: only travels through part of the inguinal canal, exiting via the superficial inguinal ring (it does not pass through the deep inguinal ring)
o This is the nerve most at risk of damage during an inguinal hernia repair. - Genital branch of the genitofemoral nerve – supplies the cremaster muscle and anterior scrotal skin in males, and the skin of the mons pubis and labia majora in females.
How is the GOJ a physiological sphincter
The sphincter is classified as a physiological (or functional) sphincter, as it does not have any specific sphincteric muscle. Instead, the sphincter is maintained by four factors:
* Oesophagus enters the stomach at an acute angle.
* Walls of the intra-abdominal section of the oesophagus are compressed when there is a positive intra-abdominal pressure.
* Prominent mucosal folds at the gastro-oesophageal junction aid in occluding the lumen.
* Right crus of the diaphragm has a “pinch-cock” effect.
What are the tributaries of the splenic vein
- Short gastric veins – drain the fundus of the stomach.
- Left gastro-omental vein – drains the greater curvature of the stomach.
- Pancreatic veins – drain the pancreas.
- Inferior mesenteric vein – drains the colon.
What is the pressure needed to diagnose portal HT
Portal pressure greater than 20 mmHg is described as portal hypertension
