MSK2 - Lower Limb Flashcards
What are the two superficial veins of the lower limb?
The great saphenous and small saphenous
Which superficial vein ascends anterior to the medial malleolus? and which to the posterior? Where does each vein drain?
Anterior - great saphenous
Posterior - small saphenous
Great drains into femoral vein
Small drains in popliteal
What are the significant groups of lymph nodes for the leg? Where does each area drain to?
Superficial inguinal
Deep inguinal
Popliteal
Vessels accompanying the great saphenous drain into the superficial inguinal
Those with the small saphenous enter the poplitael
Describe the dermatomal arrangement of the lower limb
Upper thigh - L2
Mid thigh/knee - L3
Medial calf - L4
Lateral side inferior to knee, travelling to hallux - L5
Dorso-lateral foot and sole (except around hallux) - S1
Back of thigh, postolateral calf - S2
What part of the acetubulum does the labrum cover?
Upper and lateral borders
(Transverse acetabular ligamenet below)
What are the three main ligaments of the hip? What is each’s function?
Ischiofemoral - reinforces posterior, prevents hyperextension
Iliofemoral - prevents hyperextension, strongest of the three
Pubofemoral - reinforces antero-inferiorly, prevents hyperabduction
Which muscle is the chief flexor of the hip?
Which is the chief extensor?
Flexor: Iliopsoas
Extensor: Gluteus Maximus
Which muscles flex and extend the hip?
Flexors: Rectus femoris, sartorius, pectineus
Extensors:
Gluteus maximus
Hamstrings: semimembranosus, semitendinosus, biceps femoris
Adductor magnus (posterior section)
Which muscles adduct and abduct the hip?
Adductors (medial compartment):
- Adductors longus, brevis and magnus
- gracilis
- obturator externus
- pectineus(?)
Abductors:
- Gluteus medium and minimus
- piriformis
- TFL
Damage to which group of muscles (or their nerve supply) will result in a dropped pelvis when walking? What is this termed?
Trendelenburg gait - drop on OPPOSITE to affected side (no longer able to stabilise pelvis)
- damage to the abductors causes this
Which muscles are responsible for medial and lateral rotation of the hip?
Medial:
- Anterior fibres of gluteus medius and minimus
- TFL
Lateral:
- Piriformis
- Obturators
- Gemelli
- Quadratus femoris
- Gluteus Maximus, and minimus(?)
What are the four muscles of the quadriceps? How are they innervated?
Rectus femoris
Vastus Lateralis
Vastus Medialis
Vastus Intermedius
Femoral nerve (L2-4)
Where does the patellar tendon attach?
A continuation of the quadriceps femoris tendon distal to the patella. It attaches to the tibial tuberosity.
What are the actions of sartorius?
Flexes
Abducts
Laterally rotates the thigh at hip
Also flexes the leg at knee
What are the medial thigh muscles? Which nerve innervates?
Adductor Longus
Adductor Brevis
Adductor Magnus
Gracilis
Obturator Externus
Obturator nerve innervates
What structures pass through the adductor hiatus?
Femoral artery/vein
What is the main artery of the thigh, and what is it a continuation of? Where does the name change?
Femoral artery, from external iliac
Changes under the inguinal ligament and enters the femoral triangle
The femoral artery enters the thigh midway between which 2 bony surface markings?
ASIS and Pubic Tubercle
Name the large branch of the femoral artery which passes posteriorly toward the hamstrings
Profunda femoris
The femoral vein is the continuation of which vein?
The popliteal
The femoral vein passes under the inguinal ligament to continue as which larger vein?
External iliac
Which two important veins drain into the femoral vein in the femoral triangle?
Profunda femoris
Great saphenous
Which muscles are supplied by the femoral nerve?
Sartorius
Pectineus
Iliacus
Quadriceps femoris
What are the medial and lateral borders of the femoral triangle? Which structure forms the base?
What are the three major contents of the femoral triangle?
Adductor longus medially
Sartorius laterally
Base is inguinal ligament
Contents:
- femoral nerve
- femoral artery
- femoral vein
What are the contents of each compartment of the femoral sheath?
Lateral: femoral artery
Intermediate: femoral vein
Medial: lymphatics (+ fat/loose connective tissue to make femoral canal)
Are females or males more likely to get a femoral hernia?
Females
What does the femoral artery become, and where?
Becomes popliteal artery at the adductor hiatus
What are the contents of the adductor canal?
Femoral artery
Femoral vein
Nerve to vastus medialis
Saphenous nerve (largest cutaneous branch of femoral nerve)
Which nerve roots contribute to the formation of the lumbar plexus?
T12-L4
What are the two main branches of the lumbar plexus, and what do they innervate?
What are the root values of these nerves?
Femoral nerve - anterior compartment
Obturator nerve - medial compartment
Both roots from L2-L4
Which sciatic foramen is the route for structres entering or leaving the pelvis, and which for the perineum?
Greater - pelvis
Lesser - perineum
What muscles make up the gluteal region?
Superficial:
- Gluteus Maximus
- Gluteus Medius
- Gluteus Minimus
- TFL
Deep:
- Piriformis
- Obturator Internus
- Superior and Inferior Gemelli
- Quadratus Femoris
Which part of the fascia lata is called the iliotibial tract? Which uscles attach to the IT tract?
From pelvis to knee
TFL and Glut Maximus attached
What are the actions of gluteus maximus and how is it innervated?
Extension and lateral rotation
Innervated by inferior gluteal nerve (L5-S2)
What is the action of gluteus medius, minimus and TFL?
Which nerve innervates them?
They are abductors and medial rotators
Superior gluteal innervation
What is the function of deep gluteal muscles?
Stabilise hip joint and lateral rotation
Where is the sacral plexus found? The union of which ventral rami form it?
Which two nerves are the main branches of the sacral plexus?
Anterior to piriformis
L4-S4
Sciatic and pudendal nerve
What roots form the lumbosacral trunk?
L4-5
What are the roots of the superior gluteal nerve, and which muscles does it supply?
L4-S1
Supplies
- gluteus medius
- gluteus minimus
- TFL
What are the roots of the inferior gluteal nerve and what muscle does it supply?
L5-S2
Supplies gluteus maximus
List all the branches of the sacral plexus
Superior Gluteal
Lumbosacral plexus
Inferior Gluteal
Posterior femoral cutaneous
Direct branches - nerve to piriformis, nerve to quadratus femoris, nerve to obturator internus, nerve to levator ani and coccygeus
Sciatic
Pudendal
(SLIP DSP)
Where does the sciatic nerve emerge in the gluteal region?
Inferior to Gluteus maximus
What are the four hamstrings? What is their action and innervation?
Long and short heads of biceps femoris
Semitendinosus
Semimembranosus
Extend the hip and flex the knee
Sciatic innervation
What type of joint is the knee? What are the articulating surfaces?
Synovial compound hinge
Medial and lateral condyles of femur with tibia and posterior surface of patella
Which muscle is most important for stabilising the knee?
Quadriceps - specifically vastus medialis and lateralis
What separates the lateral collateral ligament from the lateral meniscus?
Tendon of popliteus
What does the medial collateral ligament attach to? What makes this important clinically?
Medial epicondlye of femur to medial condyle of tibia
Also attached at midpoint to medial meniscus
- this means tearing of medial collateral ligament often also tears the meniscus
What is the function of the ACL and the PCL?
ACL prevents tibia coming forward relative to femur (preventing hyperextension)
PCL prevents tibia moving backward relative to femur
What are the knee menisci made of?
Fibrocartilage
What are the main functions of the knee menisci?
Deepen the articular surface of the tibia, thus increasing stability of the joint.
Act as shock absorbers by increasing surface area to further dissipate forces
What is the ‘unhappy triad’ and what is the mechanism of injury?
Lateral force on knee strains the medial collateral ligament. As it is attached to the medial meniscus it is also damaged. This then loads the ACL, which may also tear.
If all 3 > unhappy triad
Which muscles are responsible for flexion and extension of the knee?
Flexion:
- Hamstrings (biceps femoris, semitendinosus/membranosus)
- Gastrocnemius
- Gracilis, Sartorius, Popliteus
Extension:
- Quadriceps
What bursae surrounds the knee?
Suprapatella bursa - extension of joint cavity
Prepatella bursa
Infrapatella bursa (deep and subcutaneous)
Semimembranosus bursa
What are the four muscles in the anterior compartment of the leg?
What are their main actions?
Tibialis anterior
Extensor digitorum longus
Extensor hallucis longus
Fibularis tertius
Mainly dorsiflexors of ankle and extensors of toes
What are the significant branches of the common fibular nerve? Which muscles do the main and branches innervate?
Common fibular:
- short head of biceps femoris
Superficial:
- fibularis longus and brevis (lateral compartment)
Deep:
- tibialis anterior
- extensor digitorum longus
- extensor hallucis longus
(the anterior compartment)
What are the two divisions of the sciatic nerve?
Tibial and common fibular
Which terminal branch of the popliteal artery supplies the anterior leg?
The anterior tibial artery
Which artery runs midway between the malleoli?
Dorsalis pedis
What muscles are in the lateral compartment of the leg?
What is their action and how are the innervated?
Fibularis longus and brevis
Eveters and weak plantarflexors
Superficial fibular nerve
Injury to what nerve may cause footdrop? Why might this happen? What muscles are affected?
Common fibular nerve
Winds round fibular neck - vulnerable
Affects anterior and lateral compartments
What type of joint is the ankle? What are the articular surfaces?
Synovial hinge
Distal tibia and fibula articulate with superior part of talus
During what movements is the ankle most and least stable?
Strongest during dorsiflexion
Weakest during plantarflexion
Which ankle ligament is the weakest? Which is called the ‘deltoid ligament’?
The lateral ligament is weaker
Medial is the ‘deltoid’ ligament
What is the structure and function of the ankle ligaments?
Medial: four ligaments
- from the malleolus, attaching to the talus, calcaneus and navicular bones
- resist over-eversion
Lateral: three ligaments
- Anterior talofibular
- Posterior talofibular
- Calcaneofibular
- together resist over-inversion
Which muscles are responsible for plantar and dorsi flexion of the ankle?
Plantarflexors - Posterior Compartment:
- gastrocnemius
- soleus
- posterior tibialis
- plantaris (minorly)
- fibularis longus/brevis (minorly)
Dorsiflexors - Anterior Compartment:
- tibialis anterior
- extensor hallucis longus
- extensor digitorum longus
- fibularis tertius
What type of joint are the superior/proximal tibiofibular and inferior/distal tibiofibular joints?
Superior - Synovial plane
Inferior - Fibrous
What are the borders of the popliteal fossa?
Upper medial - semimembranosus
Upper lateral - biceps femoris
Lower - lateral and medial heads of gastrocnemius
What are the contents of the popliteal fossa?
Popliteal artery/vein and branches
Tibial and common fibular nerve
Fat
Termination of small saphenous vein
Posterior cutaneous nerve of thigh
Popliteal lymph nodes/vessels
What muscles make up the posterior leg? What are the innervations?
Superficial:
- Gastrocnemius
- Plantaris
- Soleus
Deep:
- Popliteus
Tibialis Posterior
- FDL
- FHL
All tibial nerve
What is the function of the plantaris muscle?
Knee flexion
Ankle plantarflexion
Role in proprioception?
The achilles/calcaneal tendon is the tendon of which muscles?
Gastrocnemius
Plantaris
Soleus
Which nerve innervates all the muscles of the posterior compartment of the leg?
Which branch of the popliteal artery supplies these muscles?
Tibial nerve
Posterior tibial artery
Which four muscles make up the deep posterior compartment?
What path do they take to the foot, and what is their action?
Popliteus
FDL
FHL
Tibialis posterior
Pass medially to enter posterior to the medial malleolus
Flex toes and plantarflex ankle
What is the role of popliteus?
Laterally rotates the femur on the tibia – ‘unlocking’ the knee joint so that flexion can occur.
Which nerve and vessel accompany the deep posterior muscle tendons posterior to the medial malleolus?
Tibial nerve and posterior tibial artery
What are the bones of the foot?
Talus
Calcaneus
Naviular
Cuboid
4x Cuneiforms
5x metatarsals
What joints allows inversion and eversion of the foot? What type of joints are they?
The subtalar joints
- talonavicular - ball and socket
- talocalcaneal - synovial plane
What are the plantar muscles of the foot, by layer? What are the innervations?
First:
- Abductor hallucis - Medial plantar nerve
- Flexor Digitorum Brevis - Medial plantar nerve
- Abductor Digiti Minimi - Lateral plantar nerve
Second:
- Quadratus Plantae - Lateral plantar nerve
- Lumbricals - 1x medial nerve, 3x lateral nerve
Third:
- Flexor Hallucis Brevis - Medial plantar nerve
- Adductor Hallucis - Lateral plantar nerve
- Flexor Digiti Minimi Brevis - Lateral plantar nerve
Fourth:
- Plantar and Dorsal Interossei - Lateral plantar nerve
What passive and dynamic factors maintain the arches of the feet?
Passive:
- shape of bones
- plantar calcaneonavicular ligament
- long plantar ligament
- short plantar ligament
Dynamic factors:
- intrinsic muscles
- long flexor tendons
- tendon of tibialis anterior and fibularis longus
