Test 3 Info Flashcards
what type of nerves are pelvic splanchnic nerves?
parasympathetic
what types of nerves are lumbar splanchnic nerves?
sympathetics
what type of and name of the muscle that makes up the wall of the bladder?
smooth muscle; detrusor muscle
peritoneum
fascial covering in the gut
is the urinary bladder mostly superior or inferior to the peritoneum?
inferior to (along with the kidneys)
apex of bladder
anterior aspect near pubic symphysis
fundus of bladder
base of bladder, formed by its posterior wall; opposite the apex
body of bladder
major portion of bladder between apex and fundus
neck of bladder
where fundus and inferolateral surfaces of bladder meet (close to exit point, near prostate in males)
trigone of bladder
area of bladder defined by smooth internal surface, formed by 2 ureters and internal urethral orifice
* sensitive to expansion/ stretch (highly innervated with sensory fibers– lets you know bladder is filling)
what prevents urine from retrograding when it is leaving the bladder?
flap valves at the point where ureters enter bladder, shut when bladder muscle contracts
referred visceral pain: heart
C8-T4 on left
referred visceral pain: lungs
T2-T5
referred visceral pain: esophagus
T4-T5
referred visceral pain: liver
T6-T9 on right
referred visceral pain: ovaries and Fallopian tubes
T11-L1
referred visceral pain: kidneys
T10-T11
referred visceral pain: ureters
T11-L2
referred visceral pain: colon
T8-L2
referred visceral pain: bladder
T11-L3
referred visceral pain: rectum, ovaries, prostate
S2-S5
4 parts of urethra in male
preprostatic
prostatic
membranous
spongy
preprostatic urethra characteristics
contains internal urethral sphincter
membranous urethra characteristics
passes through external urethral sphincter
spongy urethra characteristics
goes through the penis
internal urethral sphincter characteristics and function
involuntary sphincter of smooth muscle
prevents retrograde movement of SEMEN into bladder during ejaculation
what kind of neural control is the internal urethral sphincter under?
ANS control
what is the internal urethral orifice?
leads to urethra
what is the purpose of the ejaculatory duct and where is it found?
where sperm enters the semen, found in the prostatic urethra
what is the purpose of the prostate?
secretes fluid that provides nutrition for sperm
external urethral sphincter characteristics and function
consists of skeletal muscle – under VOLUNTARY control
makes up part of the UG diaphragm
provides a means of stopping the escape of urine from the body
function of urogenital diaphragm
supports contents of deep pelvis along with pelvic diaphragm
what is one reason why females are more prone to UTIs?
length of female urethra is shorter (bacteria has a shorter distance to go)
what is the micturition reflex?
visceral afferent fibers stimulated by bladder stretch (~350-400mls) causes the bladder to contract reflexively while the internal sphincter relaxes and urine flows into urethra
what is required in order to suppress the micturition reflex?
training and intact neural pathway from supra spinal centers (e.g., external urethral sphincter would remain contracted – voluntary control via pudendal n)
testes
male sex organs that lie within scrotum
produce sperm and testosterone
epididymis
portion of male genital tract where sperm maturation is partially accomplished (sperm stored here)
receives sperm from testes and continues as ductus deferens
ductus deferens
thick walled tubular structure running from each testis into ejaculatory duct
carry sperm from epididymis towards penis
seminal vesicles
produce semen (fluid that activates and protects sperm after it has left penis)
prostate
gland in male that surrounds portion of urethra
secretes alkaline liquid that neutralizes acid in urethra and stimulates motility of sperm
bulbourethral glands
two small, rounded, pea sized bodies posterolateral to membranous urethra
discharge component of seminal fluid into urethra
ejaculatory duct
begins at seminal vesicles, passes through prostate, and empties into urethra
during ejaculation, semen passes through EJ ducts
function of internal urethral sphincter in female
literature suggests no function or it does not exist, bc function is specific to male
what does parasympathetic innervation do in terms of B B SF?
generally vasodilatory (–> erection)
stimulate (motor) bladder contraction
inhibit internal urethral sphincter (so it relaxes and you can urinate)
modulates activity of lower colon (peristalsis)
what does sympathetic innervation do in terms of B B SF?
contraction of smooth muscle in internal urethral sphincter and internal anal sphincters (preventing urination and defecation)
cause smooth muscle contraction associated with reproductive tract and accessory glands
help move secretions from epididymis and associated glands into urethra to form semen during ejaculation
spastic bladder occurs with what type of injury?
SCI above S2-4 segments
what aspects of bladder control are intact with a spastic bladder?
micturition reflex is intact
bladder contracts and reflexively empties in response to certain level of filling pressure
what aspects of bladder control are lost with a spastic bladder?
lose sensation of bladder dissension and urge to urinate (supraspinal contral)
how does an SCI pt with a spastic bladder relieve themselves?
bladder training can be used – trigger stimulus to establish planned voiding (makes bladder reflexively contract)
- tapping
- pulling pubic hair
also. .. - pay attention to how much you drink
- try to plan ahead of time
flaccid bladder occurs with what type of injury?
SCI involving S2-4 levels or the sacral ventral/dorsal roots of S2-4
what aspects of bladder control are intact with a flaccid bladder?
not really anything
what aspects of bladder control are lost with a flaccid bladder?
no reflex action of detrusor muscle – micturition reflex destroyed
no supraspinal control (pathway between brain and SC interrupted)
- unable to establish reflex voiding
how does an SCI pt with a flaccid bladder relieve themselves?
usually intermittent catheterization is used
may use Val Salva maneuver along with manual compression (Crede Maneuver) of lower abdomen
*more apt to leakage
external anal sphincter
under voluntary control
skeletal muscle
supplied by S4 ventral ramus
internal anal sphincter
involuntary smooth muscle
supplied by sympathetic fibers (maintain tone)
supplied by parasympathetic fibers (inhibit tone)
spastic bowel occurs with what type of injury?
SCI above S2-4 region
what aspects of bowel control are intact with spastic bowel?
anal sphincters are intact
what aspects of bowel control are lost with spastic bowel?
no supraspinal control (pathway between brain and SC interrupted)
how does an SCI pt with a spastic bowel relieve themselves?
responds well to rectal/ anal stimulation and timed voiding
prognosis excellent for good bowel control – hydration, fluid monitoring with high fiber diet are essential
flaccid bowel occurs with what type of injury?
SCI at S2-4 region
what aspects of bowel control are intact with flaccid bowel?
not much of anything
what aspects of bowel control are lost with flaccid bowel?
anal sphincters are not intact
no supraspinal control (pathway between brain and SC interrupted)
arrival of stool in rectum results in incontinence
how does an SCI pt with a flaccid bowel relieve themselves?
bowel control possible with routine daily bowel evacuation (removes stool before it enters rectum– manual evacuation with straining via increased abdominal pressure)
hydration and fluid monitoring along with high fiber diet is key to success
what could happen if stool is impacted?
ANS is activated –> autonomic dysreflexia
what is an upper motor neuron (UMN)?
UMN is a neuron whose cell body originates in the cerebral cortex or brainstem and terminates within the brainstem or spinal cord
what is a lower motor neuron (LMN)?
cell body of a LMN lies within the ventral horn of the spinal cord or the brainstem motor nuclei of the cranial nerves which have motor modalities (in CNS). axon of a LMN exits the CNS and forms the somatic motor part of the peripheral nervous system (PNS).
example of LMN lesion
ventral rami lesion
example of LMN lesion
ventral rami lesion
is erectile function greater for male with a UMN or LMN lesion?
UMN lesion
reflexogenic erection
sensory stimulation of genitals or perineum
also can occur due to (day)dreams
requires intact reflex arc (S2-S4)
what is still intact in a female in terms of sexual function if there is an UMN lesion?
reflex arc still intact — vaginal lubrication, engorgement of labia and clitoral erection are still intact
aka motor process works but can’t feel the sensation through the genital region
another name for deep fascia of lower limb
fascia lata
fascia lata characteristics
non-elastic
especially strong – encircles limb like a stocking
prevents bulging of muscles during contraction, making it more efficient
fasciotomy
since fascia is not elastic, nerves start dying off if fascia is too tight
often done when person has compartment syndrome
what is a Trendelenburg sign and what does it indicate?
pelvic drop during gait – pelvis drops on uninvolved side when uninvolved side is lifted
indicates gluteus medius weakness
weakness in R gluteus medius - what would Trendelenburg sign show?
when walking and left foot is in the air, left hip would drop
piriformis muscle is a landmark for what?
superior gluteal n.a.v. exit above it
inferior gluteal n.a.v. exit below it
sciatic n TYPICALLY exits below it
what positioning can compress sciatic nerve and why?
passive hip IR
because piriformis is hip ER so it is stretched via IR – when muscle is elongated, it can compress on the sciatic n which typically exits below it
what is piriformis syndrome?
irritation of sciatic n caused by “compression” or irritation of n within buttock area by piriformis m
etiology of piriformis syndrome (5)
hypertrophy, inflammation or spasm (rare) of piriformis m
direct trauma resulting in hematoma and scarring
more common in females (6:1)
pseudoanuerysm of inferior gluteal a
anatomical abnormalities (like potentially split piriformis)
s/s of piriformis syndrome
pain in posterior buttock that may or may not radiate into posterior thigh
increased by contraction of piriformis muscle, prolonged sitting, or direct pressure applied to muscle
pain with active ER of hip
pain with passive IR of hip
differential diagnosis for piriformis syndrome
lumbar radiculopathy (nerve involvement) lumbar spine referred pain (joint involvement)
where can lumbar spine refer pain?
lower back, buttock, posterior thigh
where does nerve to obturator internus and superior gemellus exit?
exits below piriformis
where are the gemelli muscles?
form a “gemellus sandwich” with the obturator internus
superior gemellus - obturator internus - inferior gemellus
what are the 6 deep lateral rotators of the thigh?
piriformis obturator internus superior gemelli inferior gemelli quadratus femoris obturator externus
what is a common fracture site of femur
intertrochanteric line
the intertrochanteric line is ___
anterior
the intertrochanteric crest is __
posterior
what is the angle of inclination and what is the normal measure of the angle?
angle between long axis of neck/head and long axis of shaft
normal = ~126
coxa vara
angle of inclination is diminished
<126 deg
coxa valga
angle of inclination is increased
(>126 deg) – valGa is Greater
angle of anteversion is…
aka angle of femoral torsion
plane of femoral neck and head lies ANTERIOR to plane of femoral condyle
normal degree of angle of anteversion
~15 deg
~31 in infancy and decreases with WB
what is the most frequent cause of childhood in-toeing?
excessive femoral anteversion
excessive femoral anteversion characteristics
affected LE is IR
more common in females
most noticeable between ages 4-6
gait looks clumsy
in-toeing will often appear worse with running and when fatigued
will become worse over time with W-sitting
excessive femoral anteversion - braces, twister cables, special shoes, etc.
make no difference in outcome
compliance is problem
acetabular labrum
fibrocartilaginous ring, which deepens the cup and increases stability
transverse acetabular ligament
goes across acetabular notch to help create full “circle” around head of femur
what is the fovea and what is attached here?
pit in head of femur ligamentum teres (or ligament of the head of the femur) attaches here
what does the ligament of the head of the femur help with?
blood supply to region - contains a small artery to head of femur
what are the ligaments that support the hip?
iliofemoral ligament
pubofemoral ligament
ischiofemoral ligament
iliofemoral ligament attachments
from AIIS to intertrochanteric line
iliofemoral ligament characteristics
strongest ligament
located anteriorly
iliofemoral ligament becomes taut with what action of the hip?
hyperextension of the hip
pubofemoral ligament attachments
from superior ramus of pubis to intertrochanteric line
pubofemoral ligament characteristics
runs anterior and inferior
pubofemoral ligament becomes taut with what action of the hip?
hyperextension and abduction of hip joint
ischiofemoral ligament attachments
ischium to femoral neck
ischiofemoral ligament characteristics
arises posteriorly and spirals superolaterally
- only ligament on posterior aspect of hip
ischiofemoral ligament becomes taut with what action of the hip?
hyperextension of hip
what ligaments restrict hip extension?
iliofemoral ligament
pubofemoral ligament
ischiofemoral ligament
blood supply to femoral head and neck
- ligamentum teres acetabular branch of the obturator aa
- medial circumflex femoral artery
examples of intracapsular fractures of femur
subcapital neck fracture
transcervical neck fracture
examples of extracapsular fractures of femur
subtrochanteric fracture
fracture of greater trochanter
fracture of lesser trochanter
when would you use a pin vs ORIF?
both used for hip fractures
pin only is typically used for clean neck fracture, where ORIFs are used for big fractures that need more support
importance of hip ligamentous structures for our patients
paraplegic patients can “stand” or hang on iliofemoral ligaments for stability because they are so strong
what are bursae?
membranous sacs lined with synovial membrane, found between tendons and bony protuberances in areas subject to friction (like hip)
role: decrease friction
ischial bursa
separates gluteus maximus from ischial tuberosity
iliopsoas bursa
separates joint from muscle
trochanteric bursa
separates gluteus maximus from greater trochanter
gluteofemoral bursa
separates iliotibial band from superior portion of vests laterals
how do bursae become irritated and how is this irritation treated?
resting or leaning on something hard for a long time (i.e. falling asleep on concrete)
rest, relaxation, and injections can help
how to differentiate between semitendinosus and semimembranosus
semitendinosus tendon feels more tendinous and is more superficial (“Tom on Mary”)
semiMembranosus is more Medial
superior border of popliteal fossa
hamstrings
medially: semimembranosus and semitendinosus
laterally: biceps femoris
inferior border of popliteal fossa
2 heads of gastroncnemius (medial and lateral heads) and plantaris (laterally)
posterior border of popliteal fossa
skin and fascia
anterior border of popliteal fossa
popliteal surface of femur, oblique popliteal ligament, popliteal fascia over popliteus
where does the sciatic nerve split and what are the names of its branches?
just proximal to or right around popliteal fossa
splits into common fibular (peroneal) branch and tibial branch
what is sural n?
superior cutaneous nerve of lower leg that is formed by the medial and lateral sural nn coming together (which are branches off the common fibular/ peroneal branch and tibial branch of sciatic nerve)
what is the commonplace name of the plantaris tendon?
“fool’s nerve” or “freshman’s nerve”
contents of popliteal fossa
popliteal arteries and veins (deeper)
lesser saphenous vein (superficial)
tibial and common perineal nerves (med/lat sural nn, sural n)
posterior femoral cutaneous n
popliteal lymph nodes and lymphatic vessels
when the femoral artery passes through the ___, it changes its name to the popliteal artery
adductor hiatus
what does the femoral artery supply?
anterior and anteromedial surface of thigh
what does the profunda femoral artery supply?
posterior, lateral, and anterior aspect of thigh
what does the medial femoral circumflex artery supply?
primary blood supplier to head and neck of femur via posterior reticular arteries
what does the lateral femoral circumflex artery supply?
primarily supplies lateral hip muscles
ascends to gluteal region
transverses around femur
descends to knee
when does the external iliac artery change its name to the femoral artery?
after crossing the inguinal ligament
where does the profunda femoral artery arise from and what does it give rise to?
from femoral artery near inguinal ligament
gives rise to perforating branches thru adductor magnus muscles (4)
what does the medial femoral circumflex artery arise from and what does it give rise to?
usually from profunda femoral artery, but can arise from femoral artery
terminates by dividing into ascending/ transverse branches
** enters gluteal region below quadratus femoris and gives rise to posterior reticular aa **
** travels posteriorly between iliopsoas and pectineus**
what does the lateral femoral circumflex artery arise from?
usually from profundal femoral artery, but can arise from femoral artery
what are retinacular arteries?
arise from medial (and lateral) femoral circumflex arteries and are main supply to hip joint
what arteries does cruciate anastomosis include?
- transverse and ascending branch of lateral femoral circumflex a
- medial femoral circumflex a
- inferior gluteal a
- first perforating artery from profunda femoral a
the cruciate anastomosis of hip - which artery anastomoses with ascending branch of medial circumflex femoral a?
ascending branch of lateral femoral circumflex a
the cruciate anastomosis of hip - inferior gluteal a anastomoses with which artery?
ascending branch of medial femoral circumflex a
if the neck of the femur is fractured, what happens with the blood supply to the head of the femur?
all of the arteries of the cruciate anastomosis may be compromised, and the acetabular branch of the artery to the head of the femur (in ligamentum teres) is the only branch that is still intact
what is often the result of a femur neck fracture?
pt needs ORIF or hip replacement, depending on how much blood supply is compromised or if the bone is shattered
what is avascular necrosis?
condition that results from poor blood supply to an area of bone, causing bone death
what can cause avascular necrosis?
trauma and damage to blood vessels that supply oxygen to bone systemic steroids sickle cell anemia alcohol abuse radiation therapy
poor blood supply may lead to _________________________________, causing …
may lead to ischemia and necrosis of bone tissue, causing weakening of bone with eventual collapse
what is Legg-Calves Perthes disease?
child avascular necrosis with unknown origin
is Legg-Calves Perthes disease more common in boys or girls, and at what age is it most prevalent?
boys
4-7
how is Legg-Calves Perthes disease treated?
historically, with casting or bracing
now, evidence suggests that those who are casted or braced have no difference in outcomes to those who did not receive treatment
now, it is more important to treat specifically for pt’s condition – research done on joint-preserving surgery which is relatively successful
what is slipped capital femoral epiphysis (SCFE)?
epiphysis of femoral head make slip away from femoral neck due to weakened epiphyseal plate
causes of slipped capital femoral epiphysis (SCFE)
acute trauma (large force through hip like a fall)
repetitive micro trauma with shear stress
gradual slippage with associated hip pain that may refer to the knee
what s/s is often associated with a slipped capital femoral epiphysis (SCFE)
antalgic gait
hip pain that also may refer to the knee
slipped capital femoral epiphysis (SCFE) usually occurs in…
children between 10 and 16
overweight and short, or thin and tall adolescents
boys > girls
African Americans > caucasian
difference between stable and unstable slipped capital femoral epiphysis (SCFE)
if unstable, likely unable to weight bear and is often an emergent situation
common treatment for slipped capital femoral epiphysis (SCFE)
“in situ fixation”
bone held in place with single central screw, which keeps femur from slipping and closes growth plate
sometimes do prophylactic bilateral surgical intervention
great saphenous vein blood flow
ascends anterior to medial malleolus
passes posterior to medial condyle of femur
passes through saphenous opening/ fossa ovalis
empties into femoral vein
what is the popliteal artery a continuation of, and where does it end?
continuation of femoral artery
ends at superior border of popliteus muscle
what are the branches of the popliteal artery?
superomedial genicular superolateral genicular middle genicular inferomedail genicular inferolateral genicular
what do the genicular arteries supply?
articular capsule and ligaments of knee
what does the genicular anastomosis include?
all genicular arteries (x5)
descending genicular branch of femoral a (anteriorly)
descending branch of lateral femoral circumflex a
recurrent branch of anterior tibial a
the popliteal artery divides into….
anterior and posterior tibial arteries
when doing hip abductions in sidelying, if hip is placed into flexion, what primary muscle(s) is being used?
tensor fascia lata (TFL)
when doing hip abductions in sidelying, if hip is placed into extension/ neutral, what primary muscle(s) is being used?
gluteus medius and gluteus minimus
what is the femoral triangle?
triangular depress inferior to inguinal ligament
borders of femoral triangle
superior: inguinal ligament
medial: adductor longus m
lateral: sartorius m
floor: iliopsoas and pectineus mm
roof: (deep to superficial) fascia lata, cribriform fascia, subcutaneous tissue, skin
name of the opening of the femoral triangle
saphenous opening (or fossa ovalis)
what covers/ fills in saphenous opening?
cribriform fascia
what is the falciform margin?
the most lateral portion of the saphenous opening, very clear rounded border, very tough
drainage pattern of great saphenous vein
dorsal venous arch
anterior to medial malleolus
posterior to medial knee
up along medial thigh to saphenous opening
femoral triangle contents (from lateral to medial)
NAVEL
femoral nerve, artery, vein, empty space, and lymph
contents of femoral sheath (from lateral to medial)
femoral artery, vein, and canal
femoral n is NOT INCLUDED
purpose of femoral sheath
allows for femoral artery and vein to glide deep to inguinal ligament with hip motion (prevents compression during hip flexion)
what is femoral canal and what does it contain?
most medial compartment of sheath
contains loos CT, fat, and lymph vessels
purpose: allows room for blood vessels to expand
femoral ring is the proximal opening to the ____
femoral canal
clinical correlation of the femoral canal
femoral hernia
intestine protrudes through femoral ring
most common postpartum or in people with digestive problems (lots of bearing down)
clinical correlation of femoral triangle
palpating femoral a
trigger point dry needling – DO NOT want to go near femoral triangle
what is the patellar tendon reflex and what does it check?
tap patellar ligament, which pulls on quadricep tendon and on the muscles that attach to it
integrity check of L2-L4
quadriceps tendon vs patellar ligament
quadriceps tendon is PROXIMAL and connects muscle to bone (superior aspect of patella)
patellar ligament is DISTAL and connects bone to bone (apex of patella to tibial tuberosity)
medial and lateral patella retinaculi
tendinous expansions of vastus medialis and lateralis which attach to margins of the patella – meshes to help become the patellar ligament
if the patella dislocates laterally, the __ retinaculum could rupture
medial
if the patellar retinaculum ruptures, what could happen to the patella?
it could be prone to sublux more often
deep tendon reflex of patellar region tests integrity of…
L2, L3, L4*
deep tendon reflex of achilles tests integrity of…
S1*
deep tendon reflex of hamstrings tests integrity of…
L5*
what is the adductor canal and where is it found?
middle 1/3 of medial thigh
contains femoral a and v, saphenous n (sensory), and usually the n to vastus medialis
boundaries of adductor canal
lateral: vastus medialis
medially: adductor magnus and adductor longus
superficial: sartorius
adductor hiatus location and what goes through it
opening in aponeurotic distal attachment of adductor angus
distal end of adduct canal
femoral a and v, and saphenous n go through it to the popliteal fossa
n to vastus medialis exits and innervates VM before entering popliteal fossa
where is adductor brevis relative to adductor longus?
adductor brevis is deep to adductor longus
about what % of body weight does the tibia accept?
~90%
what does the tibia articulate with?
femoral condyles proximally
talus distally
fibula
tibia plateau
superior surface of tibia, within it you can find medial and lateral tibial condyles and intercondylar groove
what attaches to Gerdy’s tubercle and where is it found?
insertion of IT band
on anterior aspect of lateral condyle of tibia
what attaches to tibial tuberosity and where it is found?
distal attachment for patella tendon (ligament)
on anterior surface of tibia
distal articulating surface of tibia is…
plafond
normal tibial torsion at distal end:
externally rotated (toe-out when standing), usually 20-40 deg
where is soleal line?
on posterior aspect of tibia
where is the “third malleolus”?
posterior margin of articular surface of distal tibia
function of fibula
function for attachment of muscle provides lateral stability of ankle joint (talocrural joint), assists in stabilizing talus
head of fibula articulates with…
proximal/ lateral portion of tibia
apex of fibula
pointed end of head
body of fibula is __ shape… borders are ….
triangular with 3 borders
anterior
interosseous
posterior
where does the lateral malleolus end relative to medial malleolus
lateral malleolus is directed more posteriorly and ends 1cm more distal than medial malleolus
common characteristics of trimalleolar fracture (what occurs with injury, how it is treated)
dislocation with ligamentous injury
disruption and separation to tibial-fib syndesmosis
treatment: ORIF
can happen with extreme inversion injuries
proximal tibiofibular joint is __ shape and a __ joint
plane shaped
synovial joint
proximal tibiofibular joint is between the ___ and ___
slightly convex facet on head of fibula
slightly concave facet on lateral condyle of tibia
proximal tibiofibular joint: surrounded by joint capsule?
yes
proximal tibiofibular joint is supported by…
anterior and posterior ligaments to head of fibula
movements of proximal tibiofibular joint
small amounts of…
- superior and inferior sliding of fibular and fibular rotation - during DF/PF of ankle joint (respectively)
ER of fibula during DF
- IR of fibula during PF
distal tibiofibular joint is made up of __ joint between ….
syndesmosis (fibrous joint) between concave facet of tibia and convex facet of fibula
distal tibiofibular joint surrounded by joint capsule?
no
in distal tibiofibular joint, tibia and fibula are separated by…
fibroadipose tissue
distal tibiofibular joint is supported by…
**interosseous ligament (extension of interosseous membrane)
anterior tib-fib ligament
posterior tip-fib ligament
medial collateral (deltoid) ligament
ankle joint function is completely dependent on..
tib-fib mortise
purpose of ligaments at distal tibiofibular joint
restrict motion at distal tip-fib joints and assist in maintaining stable ankle mortise
mortise joint
comprised of distal tib-fib articulation
articulates with talus
two most common fractures in body
- radial head fracture
2. distal tib-fib fracture
distal tib-fib fracture usually results from…
sprained ankle avulsion fracture (fragment of bone tears away from main mass of bone) or from shear force on talus along surface of tibia and fibula
talus articulates with…
fibula
calcaneus
navicular
body of talus has __ articular surfaces:
3: large lateral facet, smaller medial facet, trochlear facet superiorly
body of talus characteristics
** wider anteriorly than posteriorly, wedge shape
trochlear surface of talus characteristics
large convexity, central groove at angle
talus muscular attachments
** NONE
talus rests medially on…
sustentaculum tali ** (part of calcaneus)
sustentaculum tali
on medial surface of calcaneus, juts out like a shelf for talus to rest on
talocrural joint is a __ shape and a __ joint, with __ DOF
hinge shaped synovial joint 1 DOF (PF/ DF)
talocrural joint is articulation between…
convex talus and concave distal tibia
convex talus and concave distal fibula
closed pack position of talocrural joint
full DF
closed pack position –> all tissues are elongated and can’t move as much
open pack position of talocrural joint
PF – can still move ankle well aka is MORE UNSTABLE
one reason why walking on toes or in heels is unstable
why does eversion have the end feel it does? (what is this end feel)
hard because of contact between lateral malleolus and calcaneus
what happens to the bones of the talocrural joint during DF?
**DF moves the wider anterior part of the trochlea (of talus) posteriorly, which spreads the tibia and fibula slightly apart
this is why DF is closed pack position
if the distal tib-fib joint is fused (i.e. with trimalleolar fracture), what movements are affected?
DF is compromised – tibia and fibula cannot spread
axis of rotation of talocrural joint
oblique line running med/lateral through fibular (lateral) malleolus, body of talus, and just distal to tibial malleolus
about 15 deg off coronal plane – “toe out” position
about 8 deg off horizontal
medial ligamentous support of ankle
medial collateral ligament (deltoid ligament) runs from medial malleolus to... - talus - calcaneus - navicular
deltoid ligament is comprised of…
- anterior and posterior tibiotalar ligaments
- tibiocalcaneal ligament
- tibionavicular ligament
lateral ligamentous support of ankle
lateral collateral ligaments:
- anterior talofibular (ATFL)
- calcaneofibular (CFL)
- posterior talofibular (PTFL)
anterior talofibular ligament (ATFL) goes from…
lateral malleolus of distal fibula to neck of talus
calcaneofibular ligament (CFL) goes from…
from tip of lateral malleolus to lateral calcaneus
posterior talofibular ligament (PTFL) goes from…
from malleolar fossa to lateral tubercle of talus
runs horizontal
calcaneus articulates with…
talus superiorly and cuboid anteriorly
characteristics of calcaneus
largest and strongest bone in foot
transmit most of weight of foot to ground
sustentaculum tali (medially)
peroneal (fibular) trochlea (laterally)
what would happen if there was a fracture of sustentaculum tali?
articulation between talus and calcaneus would be compromised
what ligament(s) are tested in anterior drawer test for ankle?
ATFL (anterior talofibular ligament) and CFL (calcaneofibular ligament)
performance of anterior drawer test for ankle
posterior to anterior translatory force
ankle remains in neutral position (no DF/ PF)
if positive, see puckering/ gapping in skin
if there was a fracture at the base of the 5th metatarsal, what motions would be limited?
DF and eversion (because peroneus tertius attaches there)
superior extensor retinaculum function
binds down muscles in anterior compartment, prevents them from bowstringing during DF
superior extensor retinaculum attachments
connects fibula to tibia, proximal to malleoli
inferior extensor retinaculum function
forms strong loop around tendons of peroneus tertius and EDL
inferior extensor retinaculum attachments
Y-shaped, attaches laterally to anterosuperior surface of calcaneus
compartment syndrome
- crural fascia around leg compresses structures in compartment (usually after trauma to leg that results in inflammation or hemorrhage)
- fasciotomy to reduce pressure
deep peroneal nerve entrapment: how it occurs and what is the result
occurs due to excessive use of muscles supplied by deep peroneal n
muscles swell in anterior compartment, and there is dorsal pain in 1st web space
shin splints, aka
anterior tibialis tendinopathy
anterior tibialis tenidonpathy
overuse injury that could lead to stress fracture
swelling and pain in distal 2/3 of tibia, resulting from repetitive micro trauma of tibia anterior and small tears of periosteum of tibia
peroneus longus position relative to brevis
share fascial compartment, longus is more superficial
common peroneal n location
near neck of fibula
common peroneal n injuries
- when fibular head fractures
- prolonged bedrest with LE externally rotated (puts pressure on nerve)
- “bar stool palsy” legs crossed for prolonged period of time
common peroneal n injury results in…
paralysis of muscle of anterior and lateral compartments
foot drop
region of common peroneal n where lesion would affect lateral sural n
closer to popliteal fossa = lost
near fibular head = intact
lateral sural n innervates…
lateral aspect of proximal 1/2 of shank
superficial peroneal n innervates…
lateral aspect of distal 1/2 of shank and dorsal aspect of foot (not 1st web space)
sural n innervates….
lateral aspect of dorsum of foot
deep peroneal n innervates…
1st web space on dorsal aspect of foot
saphenous n innervates…
anterior and medial aspect of shank
which is the largest compartment of the leg?
posterior compartment
what divides superficial and deep groups of calf muscles?
transverse intermuscular septum
what provides blood supply to posterior compartment of leg?
posterior tibial artery and vein
muscles in superficial group of posterior compartment of leg
- gastrocnemius
- soleus
- plantaris
muscles in deep group of posterior compartment of leg
- popliteus
- flexor digitorum longus
- flexor hallicis longus
- tibialis posterior
where is the small saphenous vein found? What region does it drain, and what does it drain into?
goes down center of bifurcation of gastrocnemius muscle
drains superficial foot
drains into popliteal vein
gastrocnemius and soleus combined is called…
triceps surae
which posterior leg compartment muscle is absent is 10-15% of the population? What is it commonly used for?
plantaris – commonly used for grafting during reconstructive surgery
plantaris and popliteus relative locations to each other
popliteus is more medial
clinical importance of popliteus
attaches to lateral meniscus — if lateral meniscus is torn and is surgically repaired, active or resisted knee flexion is deferred for a few weeks
where does the flexor hallucis longus tendon run and why is its location important?
tendon runs between 2 sesamoid bones in tendons of flexor hallucis brevis
sesamoid bones protect FHL tendon from pressure at first metatarsal
anterior tibial artery terminates as….
dorsalis pedis a
where to find pedal pulse
just distal to medial/ lateral malleoli, between 1st and 2nd metatarsals
deep fascia of plantar foot is called ___ and thick central part is ___
plantar fascia, central part is plantar aponeurosis
roles of plantar fascia
holds foot together
protects plantar surface from injury
supports longitudinal arches of foot
plantar aponeurosis attachments
from calcaneus
to 5 divided bands that become continuous with tendon sheath of each toe
function of intrinsic muscles of foot
instead of producing motion, primarily focus on isometrically working to maintain foot arches
layer 1 of intrinsic foot muscles
- abductor hallucis
- flexor digitorum brevis
- abductor digiti minimi
layer 2 of intrinsic foot muscles
- quadratus plantae
5. lumbricals (x4)
layer 3 of intrinsic foot muscles
- flexor hallucis brevis (2 heads – medial and lateral)
- adductor hallucis (2 heads – oblique and transverse)
- flexor digiti minimi brevis
layer 4 of intrinsic foot muscles
- plantar interossei (x3)
10. dorsal interossei (x4)
how many plantar interossei are there?
3
how many dorsal interossei are there?
4
characteristics of medial plantar n compared to lateral plantar n
medial plantar n larger and more anterior
border between medial and lateral plantar nn is…
along 4th metatarsal
which cutaneous n travels through the adductor canal?
saphenous n
bones in hindfoot
talus and calcaneus
bones in mid foot
navicular, cuboid, cuneiforms (medial, lateral and intermediate)
bones in forefoot
metatarsals, phalanges
subtalar joint is articulation between…
three separate inferior articulating surfaces on talus with 3 separate articulating surfaces on superior aspect of calcaneus
functions of subtalar joint
- translates motion of tibia to foot and vice versa
- dampens rotational forces while maintaining contact with ground
- allows for smooth walking over uneven surfaces, pivoting
ligaments supporting subtalar joint
- talocalcaneal ligaments
- medial collateral ligaments
- lateral collateral ligaments
the subtalar joint has __planar movement around a __ axis
triplanar movement
single oblique joint axis
subtalar axis is __ degrees up from horizontal plane and __ degrees in from sagittal plane
42 degrees up from horizontal
25 degrees in from sagittal plane
composite motions of subtalar joint
supination and pronation
supination is a combination of…
inversion
adduction
PF
pronation is a combination of…
eversion
abduction
DF
lateral subtalar joints
- lateral talocalcaneal ligament
- dorsal talonavicular ligament
- interosseous talocalcaneal ligament (at sinus tarsi canal)
cuboid bone articulates with….
calcaneus posteriorly
lateral two metatarsals anteriorly
navicular and lateral cuneiform medially
cuboid bone key characteristics
cuboid tuberosity on plantar surface
groove for peroneus longus tendon
navicular articulates with…
talus
cuboid
3 cuneiform bones
navicular key characteristics
flattened, boat shape navicular tuberosity (attachment of tibialis posterior m)
in ankle pronation, medial malleolus is ____ relative to lateral malleolus
higher
medial cuneiform articulates with….
1st MT bone
intermediate cuneiform articulates with…
2nd MT bone
lateral cuneiform articulates with…
3rd MT bone and cuboid bone
cuneiform ___ motion lends to….
planar motion (small amount) lends some flexibility to foot
high ankle sprain
separation between distal tibia-fibula joint
transverse tarsal joint is between….
calcaneus and talus proximally, and cuboid and navicular distally (divides hind foot and Midfoot)
what type of joint is transverse tarsal joint?
compound synovial joint
transverse tarsal joint major ligamentous support
plantar calcaneonavicular ligament (spring ligament)
long plantar ligament
short plantar ligament (plantar calcaneocuboid ligament)
long plantar ligament extends from…
calcaneus to 2-4 MT
function of plantar calcaneonavicular ligament (spring ligament)
helps maintain middle arch
purpose of arches of foot
adds to weight bearing capabilities and resiliency of foot
provides for shock absorption
arches become slightly flattened during WB, resume curve during NWB
integrity of arches maintained by…
shape of interlocking bones
strength of plantar ligaments
strength of plantar aponeurosis
lateral longitudinal arch is comprised of…
calcaneus, cuboid, and lateral 2 metatarsals
medial longitudinal arch
calcaneus, talus, navicular, 3 cuneiforms, and medial 3 metatarsals
if you fracture your talus, which arch(es) would be affected?
medial longitudinal arch
if you fracture your calcaneus, which arch(es) would be affected?
lateral and medial longitudinal arches
transverse arch is comprised of…
cuboid, cuneiforms, and bases of metatarsals (runs lateral to medial)
tarsometatarsal joint is a ___ joint
plane joint (gliding only), synovial
inter metatarsal joint is a ___ joint
plane joint (gliding motion only), synovial
metatarsophalangeal joints (MTP) are ___ joints with __ DOF
ovoid synovial joints with 2 DOF (flex/ext, abd/add)
interphalangeal joints are ___ joints
synovial hinge joints
