Lower Limb: Distal Neurovasculature Flashcards by Rosie Ellis

Label the superficial veins of the foot on the diagram

Which nerves travel alongside these?

Short saphenous vein travels posterior to the lateral malleolus alongside the sural nerve.

Long saphenous vein travels anterior to the medial malleolus with the saphenous nerve

Superficial veins sit superficial to the deep fascia

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Describe the route of the long saphenous vein

What can be formed as it joins the deeper veins?

Passes anterior to the medial malleolus and up the medial aspect of the leg, posterior to the patella and up the medial aspect of thigh

Enters the femoral triangle through the saphenous opening to join the femoral vein

Saphena varix can form here

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Which structure should be avoided when harvesting the long saphenous vein?

What fibres does this nerve carry?

Saphenous nerve

Somatic sensory

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Describe the route of the short saphenous vein

Which nerve does it travel alongside?

Passes from lateral foot posterior to lateral malleolus, up posterior leg to the popliteal fossa via the crural fascia.

Joins the popliteal vein in the popliteal fossa.

Travels alongside sural nerve (cutaneous)

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What may be a consequence of damage to the sural nerve?

Paraesthesia/pain to the lateral foot and lateral half of 5h metatarsal.

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Label the veins on the image

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What conditions could cause increased risk of DVT?

Hypercoagulability:

Factor V Leiden thrombophilia

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Label the nerves on the dissection photo

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Which nerve of the leg is particularly vulnerable to damage?

Common fibular nerve

Sits superficially around the neck of the fibula
Often damaged in RTAs as pedestrians often hit at this level.

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What does the deep fibular nerve innervate?

What could be the result of damage?

Muscles of anterior compartment of the leg

Muscles of dorsal foot

Skin between digits 1 & 2

Proximal damage results in foot drop

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What does the superficial fibular nerve innervate?

What could damage lead to?

Lateral compartment muscles

Skin over dorsal foot

Damage could lead to inability to prevent foot inversion

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Describe the route of the anterior tibial artery

How would you locate it on a patient?

Which nerve does it travel alongside?

Passes down anterior compartment of the leg into the dorsal foot where it becomes the dorsalis pedis artery

Sits between the tendons of extensor hallucis longus and extensor digitorum longus

Can be found lateral to extensor hallucis longus tendon (ask patient to extend big toe)

Travels alongside the deep fibular nerve.

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Describe the routes of each artery on the map

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What would be the consequences of a blockage of the femoral artery?

Lower limb would feel cold

Muscle pain worse on movement

Intermittent claudication

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Label the arteries on the image

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Describe the route of the dorsalis pedis artery

Why is this necessary?

Travels lateral to the tendon of extensor hallucis longus towards the 1st web space where it runs deep to join the arterial arch of the sole of the foot.

This anastamotic supply is necessary to accommodate the occlusion of arteries when walking/standing.

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Label the arteries on the diagram

Describe their route/locations where they are palpable

Describe the location of the tarsal tunnel

Between the medial malleolus (posterior to) and the calcaneus.

Deep to the flexor retinaculum

Where is the pulsation of the tibial artery palpable?

¹/₃ of the way back along the line between the medial malleolus and calcaneus

Label the contents of the tarsal tunnel on the diagram

Contains:

Tibialis posterior Tom
Flexor Digitorum Longus Dick
Posterior tibial Artery And
Vein Very
Tibial Nerve Nervous
Flexor Hallucis longus Harry

What can cause rupture of the tendons within the tarsal tunnel?

What could be a consquence of this?

Excessive wear against the medial malleolus can cause rupture or tear.

This can lead to collapse of the arches of the feet and a loss of function.

What movements does the ankle joint permit?

What bones is the ankle joint formed from?

When is it least stable?

Flexion and extension (dorsiflexion and plantarflexion)

Tibia
Fibula
Tarsal bone

Least stable during plantarflexion

What ligaments support the ankle?

What is their role?

How can they be damaged?

How are they named?

Medial collateral group (x4)

Prevent excess eversion of the foot
Damaged by exess eversion of the foot
Named tibio-x

Lateral collateral group (x3)

Prevent excess inversion of the foot
Damaged by excess inversion of the foot
Named X-fibular
Anterior talo-fibula ligament most commonly damaged (by excess inversion & planterflexion)

What test can be used to determine if the anterior talo-fibular ligament is damaged?

Anterior draw test:

Ankle will move forwards if ligament damaged
Will be painful on movement and palpation

Which fractures are the malleoli vulnerable to? What are the symptoms of a malleolus fracture? What should also be checked if a malleolus fracture is found?

Avulsion fractures: * From excess in/eversion Symptoms: * Pain * Swelling * Inability to weight bear * Pain on direct palpation If a malleolus fracture is discovered, proximal bones must also be checked.

What is a maisonneuve fracture, what is it caused by?

Spiral fracture of the distal fibula caused by excess eversion of the foot

What are the Ottowa ankle rules?

An X-RAY of the ankle is only required if: * Bone tenderness at the posterior edge or tip of the lateral malleolus (A) OR * Bone tenderness at the posterior edge or tip of the medial malleolus (B) OR * An inability to bear weight both immediately and in the emergency department for four steps

Label the bones of the feet on the diagram

What are the roles of the feet? What should be checked in the event of a calcaneal fracture?

Shock loading Store and release of energy Balance If the calcaneus is fractured, the vertebral column should also be checked for fractures.

What is this? What else must be checked? What else is commonly fractured alongside this?

Multiple convoluted fracture of the calcaneus Vertebral column must be checked Thoracic vertbrae commonly fractured in calcaneal fractures.

Label the tendons on the diagram and their innervation

What is the role of the synovial sheaths in the foot? What do they contain? What is the clinical significance of them?

Surround the tendons as they pass under the retinaculi Filled with synovia fluid for lubrication Can become inflamed from overuse. Can also provide a route for infection spread. * Synovitis: inflammation of the synovial sheath * Tenosynovitis: inflammation of the synovial sheath and tendon

Where can anaesthetic be injected into the nails? What is paronychia?

Proximal and lateral eponychium (nail folds) Paronychia= infection of the nail fold space

Label the sensory innervation to the dorsal and plantar foot

What can occur from lack of sensation to the feet?

Small injuries are not detected and can lead to infection

What are the 3 arches of the feet? What are their roles? Label them on the diagram

Medial arch Transverse arch Lateral arch * Formed by bones and soft tissues of the feet * Shock absorption * Weight distribution * Storage and release of forces during walking

What is pes planus?

No foot arches (flat feet) * Primary (born with) * Secondary (acquired)

What ligaments support the arches of the feet? What else supports the arches? Label them on the diagram

Long and short plantar ligaments Also: * Tendons of leg muscles (tibialis anterior supports arch from above) * Intrinsic foot muscles

What are the intrinsic muscles of the feet? Which nerves supply them? What are their roles?

* **Interossei** * **Abductor digiti minimi (AbDM)** * **Flexor digitorum (FDM)** * **Abductor hallucis brevis (AHB)** Posterior tibial nerve * Lateral branch * Medial branch Actions: * Support digits during 'push off' phase of walking * Store and release energy (act as dynamic ligaments) * Support the arches of the feet (weakness can lead to arch collapse)

What are the main arterial and nerves supplying the plantar surface of the foot? Where do the arteries anastamose with one from the dorsal surface?

Posterior tibial artery: * Lateral branch * Medial Branch Lateral and medial plantar nerves Between the 1st and 2nd digits the dorsalis pedis artery travels deep to join the plantar arterial arch fn the plantar foot

What is a morton's neuroma?

Growth on a digital nerve , usually the one passing between digits 3 and 4

What is plantar fasciitis?

Caused by overuse of the feet which causes tearing of the part of the plantar aponeurosis that attaches to the calcaneus. (commonly occurs in medial aspect of calcaneus)