S2 - Lower Limb (thigh) Flashcards
describe the arterial supply of the head of the femur and when could this be compromised?
- medial circumflex a. gives off ascending branches (retinacular branches)
- obturator artery runs thru ligamentum teres
- if NOF is fractured this could be damaged
describe the arterial supply of the thigh and gluteal region
NOT INCLUDED IN DIAGRAM: INTERNAL PUDENDAL a. branches off anterior division of internal iliac artery
describe the arterial supply of the gluteal region
- superior gluteal artery leaves greater sciatic foramen superior to piriformis, supplies superficial glutes maximus, medius, minimus and TFL
- inferior gluteal artery leaves greater sciatic foramen inferior to piriformis, supplies deep glutes maximus, long head of biceps femoris and deep gluteal muscles (piriformis, superior gemellus, obturator internus, inferior gemellus, quadratus femoris)
what does the obturator artery supply?
- medial compartment of thigh (adductors): adductor magnus, brevis, longus, obturator externus, gracilis
- head of femur and hip joint
what do the femoral and popliteal arteries supply?
- femoral: anterior thigh
- popliteal: knee joint
which nerve runs lateral to the femoral triangle? and what does it supply?
- lateral femoral cutaneous nerve
- sensory only: anterolateral thigh
main nerves that supply the thigh
- femoral: extensors/quads (anterior)
- obturator: adductors (medial)
- tibial: flexors/hamstrings (posterior) AND hamstring part of adductor magnus EXCEPT short head of biceps femoris (common peroneal)
femoral nerve:
- what roots is it made up of
- motor innervation
- sensory innervation
- where does it run anatomically
- roots: L2, L3, L4
- motor: iliacus, pectineus, sartorius, quadriceps
- sensory: anteromedial surface of thigh + medial surfaces of leg and foot (saphenous nerve)
- course: runs under the midpoint of inguinal ligament, lateral to femoral artery
- terminates and becomes saphenous nerve (sensory only) just inferior to the pelvis > runs medially down the entire leg
obturator nerve:
- what roots is it made up of
- motor innervation
- sensory innervation
- where does it run anatomically
- roots: L2, L3, L4
- motor: obturator externus, adductor magnus, adductor brevis, adductor longus, gracilis
- sensory: medial surface of thigh
- course: runs thru obturator foramen, splits into anterior and posterior div., continues medially down leg
sciatic nerve:
- what roots is it made up of
- motor innervation
- sensory innervation
- where does it run anatomically
- roots: L4-S3
- motor: none directly (branches supply posterior thigh and all of leg)
- sensory: none directly (the branches do tho)
- runs thru greater sciatic foramen inferior to piriformis, bifurcates into common fibular nerve (deep + superficial) and tibial nerve in popliteal fossa
what muscles does the superior and inferior gluteal nerve supply?
- superior: gluteus medius, gluteus minimus, tensor fascia latae
- inferior: gluteus maximus
how are the roots of the lumbosacral plexus named?
- how does a herniated disc damage the nerve?
- after the vertebra above it
- e.g. L5 root has the L5 vertebra above it
- a herniated disc will damage the nerve BELOW it
- e.g. a damaged L4-L5 disc will damage the root/s below it
how to determine whether sciatic nerve has been impinged @ piriformis or at the spinal cord?
- if @ spinal cord: compressed before the branching of the dorsal/ventral ramus > therefore you get referred pain and muscle spasms in the back muscles
- if @ piriformis: pain/weakness only occurs in the leg > not referred to the back
impacts of a damaged superior gluteal nerve
- weakness of gluteus medius, gluteus minimus, tensor fascia latae (abductors)
- downwards tilted pelvis = leaning towards other side to compensate = waddling appearance (Trendelenburg gait)
what is the component in green?
- what are its contents?
- obturator foramen
- filled by obturator membrane
- contains obturator a., v. and n.
name the deep gluteal muscles and how are they innervated?
- piriformis
- superior gemellus
- obturator internus
- inferior gemellus
- quadratus femoris
- GEM THIEF - each muscle gets their own nerve but the gemelli steal the nerve from the one below
what is A?
- what is its origin and insertion?
- what is its innervation?
- what movement can it do?
- piriformis (‘pear shaped)
- origin: inside of sacrum > passes thru greater sciatic foramen and divides it into 2 parts
- insertion: greater trochanter
- innervation: piriformis nerve
- movement: hip abduction + external rotation
what is B?
- what is its origin and insertion?
- what is its innervation?
- what movement can it do?
- obturator internus (deep to obturator externus)
- origin: inferior margin of superior pubic ramus
- insertion: greater trochanter
- innervation: obturatus internus nerve
- movement: abduction and external rotation
what is C?
- what is its origin and insertion?
- what is its innervation?
- what movement can it do?
- gemellus superior
- origin: ischium
- insertion: greater trochanter
- innervation: obturator internus nerve
- movement: hip abduction + external rotation
what is D?
- what is its origin and insertion?
- what is its innervation?
- what movement can it do?
- gemellus inferior
- origin: ischium
- insertion: greater trochanter
- innervation: quadratus femoris nerve
- movement: hip abduction + external rotation
what is E?
- what is its origin and insertion?
- what is its innervation?
- what movement can it do?
- quadratus femoris
- origin: ischial tuberosity
- insertion: intertrochanteric crest
- innervation: quadratus femoris nerve
- movement: hip external rotation and extension
name the superficial gluteal muscles
- tensor fascia latae
- gluteus medius
- gluteus maximus
- gluteus minimus
what is A?
- what is its origin and insertion?
- what is its innervation?
- what movement can it do?
- gluteus maximus
- origin: many
- insertion: gluteal tuberosity
- innervation: inferior gluteal nerve
- movement: hip extension, abduction and external rotation, also knee extension (via IT band)
what are B and C?
- what is its origin and insertion?
- what is its innervation?
- what movement can it do?
- B = gluteus medius, C= gluteus minimus
- origin: gluteal fossa and gluteal line
- insertion: greater trochanter
- innervation: superior gluteal nerve
- movement: hip abduction and internal rotation
what is D?
- what is its origin and insertion?
- what is its innervation?
- what is its function?
- tensor fasciae latae
- origin: anterior iliac crest
- insertion: iliotibial tract
- innervation: superior gluteal nerve
- function: hip flexion, abduction + internal rotation
name the muscles in the anterior thigh
- psoas major + minor
- iliacus
- sartorius
- quadriceps
- pectineus is medial even tho innervated by femoral n.
what is A?
- what is its origin and insertion?
- what is its innervation?
- what movement can it do?
- iliacus
- origin: iliac crest
- insertion: lesser trochanter
- innervation: femoral nerve
- movement: hip flexion
what is B?
- what is its origin and insertion?
- what is its innervation?
- what movement can it do?
- psoas minor
- origin: T12-L1
- insertion: iliopectineal eminence and pecten pubis
- innervation: anterior ramus of L1
- movement: hip flexion and lumbar stability
what is C?
- what is its origin and insertion?
- what is its innervation?
- what movement can it do?
- psoas major
- origin: lumbar vertebrae
- insertion: lesser trochanter
- innervation: femoral n.
- movement: hip flexion + external rotation
what is A?
- what is its origin and insertion?
- what is its innervation?
- what movements is it responsible for?
- sartorius
- origin: anterior superior iliac spine (ASIS)
- insertion: gooses foot (tibia)
- innervation: femoral nerve
- movement: hip flexion, abduction, external rotation, knee flexion (tailor’s muscle b/c tailors sit cross legged)
what is B?
- what is its origin and insertion?
- what is its innervation?
- what movements is it responsible for?
- pectineus (medial)
- origin: superior pubic ramus
- insertion: pectineal line (right below lesser trochanter)
- innervation: femoral nerve
- movement: hip adduction + flexion
- what is C?
- what is its origin and insertion?
- what is its innervation?
- what movements is it responsible for
- vastus intermedius (anterior)
- origin: femur
- insertion: tibia
- innervation: femoral nerve
- movements: hip flexion and knee extension
- what is B?
- what is its origin and insertion?
- what is its innervation?
- what movements is it responsible for
- vastus lateralis
- origin: lateral linea aspera
- insertion: tibia
- innervation: femoral nerve
- movements: hip flexion and knee extension
- what is A?
- what is its origin and insertion?
- what is its innervation?
- what movements is it responsible for
- rectus femoris
- origin: ilium (one head proximal to acetabulum and one head anterior inferior iliac spine)
- insertion: tibia
- innervation: femoral nerve
- movements: hip flexion and knee extension
- what is D?
- what is its origin and insertion?
- what is its innervation?
- what movements is it responsible for
- vastus medialis
- origin: medial linea aspera
- insertion: tibia
- innervation: femoral nerve
- movements: hip flexion and knee extension
name the muscles in the medial compartment of the thigh
- obturator externus
- adductor brevis + longus
- gracilis
- adductor magnus
- pectineus
what is the muscle in red?
- what is its origin and insertion?
- what is its innervation?
- what movement is it responsible for?
- obturator externus
- origin: ischiopubic ramus and obturator membrane
- insertion: greater trochanter (posterior to femur)
- innervation: obturator nerve
- movement: hip external rotation + adduction
what is A?
- what is its origin and insertion?
- what is its innervation?
- what movement can it do?
- adductor brevis (medial)
- origin: body pubis
- insertion: linea aspera
- innervation: anterior branch of obturator nerve
- movement: hip adduction
what is B?
- what is its origin and insertion?
- what is its innervation?
- what movement can it do?
- adductor longus (medial)
- origin: body of pubis (medial to brevis)
- insertion: linea aspera
- innervation: anterior branch of obturator nerve
- movement: hip adduction
what is C?
- what is its origin and insertion?
- what is its innervation?
- what movement can it do?
- gracilis (most medial)
- origin: pubis
- insertion: tibia
- innervation: anterior branch of obturator nerve
- movement: hip adduction and flexion + internal rotation of knee
what is D?
- what is its origin and insertion?
- what is its innervation?
- what movement can it do?
- adductor magnus (medial)
- origin: ischiopubic ramus
- insertion: gluteal tuberosity
- innervation: obturator nerve (adductor part) and tibial nerve (hamstring part)
- movement: hip adduction
adductor hiatus
- hole created by adductor magnus to allow blood vessels to travel from anterior thigh to posterior leg
- also contributed by adductor longus tendon therefore popliteal aneurysms can also affect this too
name the muscles in the posterior compartment of the thigh)
- hamstrings
- semimembranosus
- semitendinosus
- biceps femoris
what is A?
- what is its origin and insertion?
- what is its innervation?
- what movements is it responsible for
- semimembranosus (posterior)
- origin: ischial tuberosity
- insertion: medial knee (proximal to tendinosus)
- innervation: sciatic n. (tibial)
- movement: hip extension, knee flexion
what is B?
- what is its origin and insertion?
- what is its innervation?
- what movements is it responsible for
- semitendinosus (posterior)
- origin: ischial tuberosity
- insertion: medial knee (distal to membranosus)
- innervation: sciatic n. (tibial)
- movement: hip extension, knee flexion
what is C?
- what is its origin and insertion?
- what is its innervation?
- what movements is it responsible for
- biceps femoris (posterior)
- origin: ischial tuberosity + femur
- insertion: head of fibula
- innervation: long head = tibial n. (medial) and short head = common fibular n. (lateral)
- movement: hip extension, knee flexion
what are A, B, C, D?
- A = iliac crest
- B = anterior superior iliac spine (ASIS)
- C = superior pubic ramus (black line is the pectineal line)
- D = pubic tubercle
what are E, F, G, H?
- E = inferior pubic ramus
- F = inferior ischial (ischiopubic) ramus
- G = ischial ramus
- H = ischial tuberosity
what are I, J, K, L?
- I = lesser sciatic notch
- J = ischial spine
- K = greater sciatic notch
- L = posterior inferior iliac spine (PIIS)
what are M, N, O, P?
- M = anterior inferior iliac spine (AIIS)
- N = posterior superior iliac spine (PSIS)
- O = pubic body
- P = superior ischial ramus
what are A, B, C, D, E?
- A = greater trochanter
- B = inter-trochanteric line
- C = head of femur (contains a little dip in the middle called the fovea)
- D = lesser trochanter
- E = inter-trochanteric crest
what are F, G, H, I?
- F = gluteal tuberosity
- G = linea aspera (has a medial + lateral lip)
- H = anatomical neck of femur
- I = surgical neck of femur
what are 3 ligaments in the pelvis?
- what are their function?
- sacrotuberous ligament: from sacrum to ischial tuberosity (forms greater and lesser sciatic foramina)
- sacrospinous ligament: from sacrum to ischial spine
- inguinal ligament: ASIS to pubic tubercle
- fix sacrum in place
acetabular labrum
- thickened fibrocartilage which deepens the acetabulum
ligaments of the hip joint
EXTRACAPSULAR
- iliofemoral (looks like a Y - anterior)
- pubofemoral - anterior
- ischiofemoral - posterior
INTRACAPSULAR
- ligament of the head of the femur (ligamentum teres)
- transverse acetabular ligament
when is the hip joint at its most and least stable?
- most: extension, adduction and internal rotation (makes the ligaments tighter)
- least (posterior dislocation): shortened limb, adduction, internal rotation, knee flexion - imagine trying to hold your pee
why is the hip least stable in a flexed position?
- flexion laxes the iliofemoral and pubofemoral ligaments, leaving ischiofemoral ligament stretched to protect joint in an unstable position
- acetabular labrum is thinner posteriorly = flexed position is less stable
what position of the leg would show a NOF fracture?
- shortened, externally rotated, abducted
what are A, B, C, D, E?
- A = external iliac a.
- B = femoral a.
- C = profunda femoris a.
- D = medial circumflex a.
- E = lateral circumflex a.
describe the borders of the femoral triangle
- superior: inguinal ligament
- medial: adductor longus
- lateral: sartorius
- A = ASIS
- C = pubic tubercle
what is contained in the femoral triangle?
- FEMORAL SHEATH CONTAINS EVERYTHING EXCEPT FEMORAL N. (saphenous branch)
- lateral: femoral a.
- intermediate: femoral v. (great saphenous v.)
- medial: femoral canal (contains lymphatics and empty space which allows for expansion of the femoral v.)
- femoral n. is NOT in the femoral sheath
- NAVEL (nerve, artery, vein, empty space, lymphatics - from lateral to medial)
which muscles make the floor of the femoral triangle?
- iliopsoas
- pectineus
- adductor longus
important lines in a femur x-ray
- semicircle from lesser trochanter to pubic tubercle
- angle @ which NOF interacts w/ hip joint = approx 120-130˚
- straight vertical line from greater trochanter and horizontal line from top of greater trochanter to middle of humeral head = 90 degrees
primary vs secondary hip abductors
- primary: gluteus minimus, tensor fascia latae,
- secondary: gluteus maximus, sartorius, piriformis
major terminal branches of the lumbosacral plexus and their spinal roots
- femoral nerve: L2-L4
- obturator nerve: L2-L4
- superior gluteal: L4-S1
- inferior gluteal: L5-S2
- sciatic nerve: L4- S3
what is sciatica?
- impingement to sciatic nerve e.g. by herniated disc or piriformis syndrome
- Sx: pain, tingling, numbness radiating down the leg
- test: elevate an extended leg
piriformis syndrome
- when piriformis is split
- sciatic nerve runs thru the split parts and gets compressed > sciatica
which structures are in the adductor canal?
- femoral vein
- femoral artery
- saphenous nerve
how to tell the diff b/n medial and lateral circumflex femoral artery
- medial circumflex = posterior
- lateral circumflex = anterior
types of femoral neck fractures
INTRACAPSULAR - can cause avascular necrosis b/c bone can lose blood supply
- subcapital, cervical, basal
EXTRACAPSULAR
- intertrochanteric, subtrochanteric
what movement is limited in hip osteoarthritis
- limited internal rotation
Hilton’s law
- a muscle that causes movement of a particular joint will have its nerve innervate the joint and some skin over the joint
describe the significance of the piriformis
- runs thru greater sciatic foramen
- divides it into a supra and infra portion
- supra: superior gluteal a. and n.
- infra: pudendal a. and n., inferior gluteal a. and n., sciatic n.
walking cycle
STANCE PHASE (60%)
- heel strike (glutes, quads, anterior leg)
- support (quads, everters, inverters, glutes medius and minimus)
- toe-off (hamstrings, quads, posterior leg)
SWING PHASE (40%)
- leg lift (iliopsoas, rectus femoris, hamstrings, anterior leg)
- swing (iliopsoas, rectus femoris, quads, anterior leg)
in the gluteal region, where is the bursa located?
- overlies greater trochanter, between glutes medius and maximus
which nerves innervate the hip joint
- femoral
- sciatic
- obturator
- superior gluteal
femoral vs inguinal hernia
- femoral: protrusion of intestine into femoral triangle
- inguinal: protrusion of intestine into inguinal canal
what nerve provides sensation to the posterior thigh
- posterior cutaneous nerve of the thigh
where does the common fibular nerve run?
- lateral to neck of fibula
lower limb myotomes
- L2 lift your shoe: hip flexion
- L3 extends the knee: knee extension
- L4 stops the door: dorsiflexion
- L5 the toes divide: big toe extension
- S1 can lift a ton: plantar flexion
- S2 heel comes back to you: knee flexion
what are the hard bony bits you can feel in your bum when you sit down
- ischial tuberosity
how to tell whether a hamstring tear is in a muscle or tendon
- tendon is avascular = won’t bleed
- muscle will bleed
when giving a gluteal injection, which region should you aim for to avoid the sciatic nerve?
- superolateral
implications of posterior hip dislocation
- sciatic nerve damage > no ankle jerk reflex
which nerve innervates the skin between the first and 2nd toes? (sensory)
- deep fibular
