Thigh and knee Flashcards
1
Q
What is the anteversion of the femoral neck?
A
15-20 degrees
2
Q
What is the articularis genu?
A
Small muscle on the anterior aspect of the distal femur deep to vastus intermedius
O: anterior surface of distal femur, deep to vastus intermedius
I: synovial membrane of knee
I: femoral nerve
A: pulls the suprapatellar bursa superiorly during knee extension, preventing impingement of the bursa between patellar and femur
3
Q
What innervates adductor Magnus?
A
Obturator (posterior branch) & sciatic (tibial portion)
4
Q
What are the origins and insertions of biceps femoris?
A
O:
Long head: ischial tubeosity (with semitendinosus)
Short head: lateral linea aspera, lateral supracondylar ridge
I: fibular head, LCL, lateral tibial condyle
5
Q
What comprises the conjoint tendon of the thigh?
A
Long head of biceps femoris & semitendinosus
6
Q
Name the insertion sites of semimimbranosus:
A
Posterior medial tibial condyle
posterior capsule and posterior horn of medial meniscus
oblique popiteal ligament
posterior oblique ligament
popliteus aponeurosis
7
Q
What are the borders of the adductor canal? Its contents?
A
Lateral: vastus medialis
Medial: sartorius
Floor: adductor longus/Magnus
Contents:
Femoral artery and vein
saphenous nerve
nerve to vastus medialis
***Note that the picture below has the vessels passing through the adductor hiatus of adductor magnus with a large portion of the muscle medially and a smaller portion laterally
8
Q
What vessels are included in the Cruciate anastamosis? Where is it located?
A
1st perforating branch of the profunda femoris (main)
Medial femoral circumflex artery
Lateral femoral circumflex artery
Inferior gluteal artery
Located at the inferior margin of quadratus femoris
9
Q
What degree is the tibial slope?
A
8-10 degrees posterior
10
Q
What is the average thickness of the largest sesamoid bone in the body?
A
23-25mm Note: in TKA, it should not be cut to a thickness of less than 12-15mm as this increases the risk of patellar fracture
11
Q
Describe the anatomic axis of the femur and tibia?
A
A line that runs down the intramedullary canal of the femur and tibia, respectively
12
Q
How do you measure Q-angle? What are normal values in men and women?
What are 4 ways to increase Q-angles in TKA? (this is bad and should be avoided!)
A
Angle between a line from ASIS to the patellar centre and another extending proximally from tibial tubercle through patellar centre Normal: Men: 14 degrees Women: 17 degrees
In TKA you must ensure you dont:
- internally rotate the femoral component
- internally rotate the tibial component
- medialize the femoral component
- lateralize the patellar component
13
Q
Name the 12 ligaments of the knee:
A
there are more than 12:
ACL
PCL
LCL
MCL
MPFL
Arcuate ligament
Oblique popliteal ligament
Retinacular ligament
Coronary ligament
Wrisberg ligament
Humphrey ligament
Transverse ligament
posterior oblique ligament
popliteofibular ligament
(ligamentum mucosum is not a ligament - misnomer - it is a plica)
14
Q
Which ligaments of the knee contribute to the fibrous capsule of the knee posteriorly?
A
Medially:
- Oblique popliteal ligament: semimimbranosus to posterior wall of capsule
Laterally:
- Arcuate ligament: Y-shaped fibres from fibular head
- popliteal muscle to the posterior capsule
- LCL contributes to joint capsule
15
Q
Which ligaments of the knee have attachments to the menisci (5)?
A
- MCL
- Coronary ligament: peripheral menisci to capsule/tibia
- Transverse: aka anterior intermeniscal ligament
- Wrisberg: behind PCL from posterior lateral meniscus to medial femoral condyle
- Humphrey: in front of PCL from posterior lateral meniscus to medial femoral condyle
16
Q
Which parts of the ACL and PCL are tight in flexion? Extension?
A
- PCL
- AL
- PM
- **Remeber PAL (PCL has AL bundle)
- ACL
- AM
- PL
Tight in flexion: PCL: anterolateral ACL: anteromedial
Tight in extension: PCL: posteromedial ACL: posterolateral
17
Q
When is the ACL tightest?
A
In extension
18
Q
Name the layers of the medial aspect of the knee and each layer’s contents:
A
What are the medial layers of the knee:
Layer 1
- Sartorius
- fascia
- patellar retinaculum
**gracilis, semitendinosis, and saphenous nerve run between layer 1 and 2
Layer 2
- superficial MCL
- posterior oblique ligament
- semimembranosis
- MPFL
Layer 3
- deep MCL
- capsule
- coronary ligament
19
Q
What are the layers of the lateral aspect of the knee and their contents?
A
What are the lateral layers of the knee (according to Orthobullets)
Layer 1:
- - IT tract
- - biceps femoris
Common Peroneal nerve lies between layers 1 and 2
Layer 2:
- - Patellar retinaculum
Layer 3:
Superficial:
- LCL
- fabellofibular ligament
- ALL
****Lateral geniculate artery runs between deep and superficial layers
Deep:
- popliteus tendon
- Arcuate ligament
- popliteofibular ligament
- coronary ligament
- capsule
20
Q
What part of the tibial plateau is concave and convex?
A
Medial is concave
Lateral is convex
21
Q
What is the insertion of the IT band?
A
Gerdys tubercle
22
Q
What is the insertion of the patellar tendon
A
tibial tubercle
23
Q
What is the usual deformity of a proximal one third tibia fracture
A
valgus and procurvatum
(from Pes and extensor mechanism)
24
Q
What attaches at the fibular head?
A
LCL
Biceps femoris tendon
25
What structure wraps around the neck of the fibula
Common peroneal nerve
26
What surface of the distal fibula is flat and accommodates plating
Posterolateral surface
27
What type of joint is the proximal tibiofibular joint and what ligaments strengthen it
(Arthrodial) Plane gliding joint
Stabilized by:
Anterior Superior Tib-fib ligament
Posterior Superior Tib-fib ligament
28
Name the four compartments of the leg
Anterior
Lateral
Superficial posterior
Deep posterior
29
Name the Contents of the anterior compartment of the leg
Anterior tibial artery and vein
Deep peroneal nerve
Muscles:
Tibialis anterior
EHL
EDL
Sometimes peroneus tertius (not in lateral compartment)
30
What is the innervation and blood supply to the anterior compartment of the leg?
Deep peroneal nerve
Anterior tibial artery
31
Where does the NV bundle run in the anterior compartment of the leg
Runs along the interosseous membrane, deep to the muscles - Its always surrounded by fat
32
With respect to the neurovascular bundle of the anterior compartment of the leg, describe its course at and below the ankle:
Above: between tibialis anterior and EHL (medial to EHL)
At the ankle: Crosses UNDER EHL
Below: Runs lateral to EHL
33
What are the contents of the lateral compartment of the leg
Peroneus longus - Superficial and very tendinous Peroneus brevis -superficial peroneal nerve
\*SPN runs in anterior compartment ~25% of the time
34
What is the innervation of the lateral compartment of the leg
Superficial Peroneal Nerve
35
What is the orientation of the peroneal tendons above the ankle and once they dive behind the fibula
Above the distal fibula: - Longus is superficial to brevis Behind the fibula: - Longus is posterior to brevis in the groove
Longus then passes under the brevis and dives deep to insertions in the midfoot
36
Describe the tendon sheath of the peroneal tendons
They run in a common sheath until they are past the distal fibula, then they divide into individual tendon sheaths
37
Name the retinaculae that covers the peroneal tendons
Superior peroneal retinaculum
Inferior peroneal retinaculum
38
Name the contents of the deep posterior compartment of the leg
Posterior tibial artery
Peroneal artery
Tibial nerve
Muscles: - Tibialis posterior - FHL - FDL
Remember the orientation in the mid tibia is not the same at the ankle.
At ankle - Tom, Dick Harry
At the mid tibia - Dick, tom, harry
The FDL crosses over TP to lie lateral.
Remember that FDL also crosses UNDER the FHL at the knot of henry.
39
What is the arrangement of the muscles on the posterior compartment of the leg proximal to the ankle and at the ankle
Proximal to the ankle: - Medial to lateral: (opposite of what you'd think) - FDL - tibialis posterior - FHL
At the level of the ankle: - All structures pass posterior to the medial malleolus - Tom Dick And a Very Nervous Harry - This is A to P, M to L
NOTE: FHL is fleshy all the way down so its the fleshy one when you cut there
40
What is the innervation of the posterior compartment of the leg
Tibial nerve
41
Name the contents of the Superfical posterior compartment of the leg
Gastrocnemius
Soleus
Plantaris
Strictly speaking, no nerves or vessels run in this compartment - they are either superficial or deep
42
What is the innervation of peroneus tertius?
Deep peroneal nerve (NOT superficial) - It runs in the anterior compartment, not the lateral
43
What compartment does perneus tertius run in?
Anterior compartment
44
What is the action of peroneus longus?
Everts, plantarflexes
(Brevis is an everter and WEAK plantarflexor)
45
What are the muscles (2) of the lower leg that cross 2 joints?
What are the muscles (7) of the upper leg that cross 2 joints?
Lower leg:
* Gastrocnemius - Medial and lateral femoral condyle to Achilles
* Plantaris - Lateral femoral condyle to calcaneus (NOT via Achilles) - Runs medial to Achilles tendon
Upper leg:
* Sartorius
* TFL
* Rectus femoris
* (Gracilis)
* SemiT, SemiMem, Biceps femoris
46
On which side of the Achilles tendon does plantaris run?
Medially, see image
47
What portion of the popliteus muscle is tendinous. What is its action?
What is it's origin and insertion?
- Proximal part is tendinous
- its origin is distal to its insertion
- Action is to unlock the knee from extension, initiating flexion - Remember, last few degrees of extension, the tibia ERs the leg to lock it into extension
Origin: Posterior surface of tibia - above soleal line
Insertion: Lateral condyle of femur just inferior to LCL origin, Also gives slips to fibular head and the posterior horn of lateral meniscus
Innervation: Tibial Nerve
48
Describe the course of the tibial nerve
Larger terminal branch of the sciatic nerve
- Popliteal fossa
- Medial sural cutaneous nerve branches here
- Crosses on top of plantaris, popliteus
- Dives deep to soleus through soleal arch and enters deep compartment
- Travels down deep posterior compartment of the leg
- Just deep to transverse intermuscular septum
- Runs with posterior tibial artery and vein, between FDL & FHL
- Supplies all muscles in superficial and deep posterior compartments
- Passes posterior to medial malleolus, through tarsal tunnel
- Divides into: medial and lateral plantar nerves
49
What nerve does the medial sural cutaneous nerve branch from?
tibial nerve, comes off in the popliteal fossa
50
What nerve does the lateral sural cutaneous nerve branch off from?
Common peroneal nerve. Joins the Med Sural cutaneous nerve (tibial nerve gives this off in the pop fossa) to form the sural nerve proper
51
What forms the sural nerve? What does it run with?
Medial and lateral sural cutaneous nerves, aka the tibial and common peroneal nerves - Runs with the small saphenous vein - The nerve is lateral to the vein
52
What is the terminal branch of the sural nerve?
Lateral dorsal cutaneous nerve - Innervates the lateral side of the foot and lateral 5th toe
53
Describe the course of the common peroneal nerve.
Small terminal branch of the sciatic nerve
terminal branch of the sciatic nerve
bifurcates in the popliteal fossa
runs medial and just anterior to biceps femoris
runs over the lateral head of gastric
- comes from out behind the biceps once it is passed the knee joint and curves anterolaterally to come around the head of the fibula 3-4 cm distal to the tip. It then pierces the POSTERIOR intermuscular septum to come into the lateral compartment where it BIFURCATES. The deep peroneal nerve then continues through the anterior intramuscular septum to the anterior compartment where innervates TA, EDL, EHL, and PT
54
Describe the course of the deep peroneal nerve
* Branch of the common peroneal nerve
* Makes a sharp turn and enters the anterior compartment through anterior septum
* Travels along anterior surface of IoM with anterior tibial artery
* Supplies all the muscles in the anterior compartment
* Passes deep to the extensor retinaculum - Supplies EDB
55
Describe the course of the superficial peroneal nerve:
* Branch of the common peroneal nerve
* Runs in the lateral compartment
* Proximal one third runs on the lateral surface of the fibula
* Then runs under peroneus longus and on top of brevis (between them)
* It then heads anterior and runs between brevis and EDL between the lateral and anterior compartments
* Pierces fascia 10-12cm above the lateral malleolus to run subcutaneously
* Runs in fat, above fascia, down to the ankle
* Runs just anterior to fibula
* Bifurcates into the medial dorsal cutaneous nerve and intermediate dorsal cutaneous nerve
56
The saphenous nerve is a branch of which nerve?
Terminal branch of the femoral nerve
57
Describe the course of the saphenous nerve
Terminal branch of femoral nerveTravels in adductor canal
- Starts lateral to vessels, on top of the artery on the underside of sartorious
- Emerges medial side of the vessels from the canal Pierces fascia at the medial knee between **gracilis and Sartorius**
- Becomes subcutaneous
- Gives off infrapatellar branch and medial crural branches
- Continues on medial side of leg just posterior to tibia
- Runs with great saphenous vein
- Divides at the ankle
- Smaller branch follows medial tibial border at level of ankle
- Larger branch passes anterior to medial malleolus
- Innervates skin on medial side of dorsal foot
58
Describe the course of the great saphenous vein
Dorsal vein of first digit merges with dorsal venous arch - Passes anterior to medial malleolus - Travels up medial side of the leg with saphenous nerve - A the knee, its posterior to the medial epicondyle of the femur - Goes up medial side of thigh - Passes through fossa ovalis (aka saphenous opening) - This is a defect through the fascia lata - Drains into the femoral vein
59
Describe the course of the popliteal artery
Continuation of the superficial femoral artery
- Enters the popliteal fossa between biceps femoris and semimembranosus
- Runs with (lateral to medial)
* tibial n
* popliteal vein
* popliteal artery
- Artery is always medial
- Artery lies behind the **posterior horn** of the lateral meniscus, **9mm posterior to the posterior aspect of the tibial plateau in 90 deg of flexion**
- Passes superficial to popliteus
- Deep to gastrocsésoleus and tibial nerve under a fibrous arch
- Bifurcates at the distal aspect of the popliteus muscle - Anterior tibial artery and tibioperoneal trunk
- Tibioperoneal trunk runs superficial to tib post
**- Divides into posterior tibial artery and peroneal artery, 2.5cm distal to popliteal fossa**
60
How do you landmark the popliteal artery with respect to the tibial plateau
Behind the posterior horn of the lateral meniscus
9mm posterior to the posterior aspect of the tibial plateau with the knee in 90 deg of flexion
61
Where does the tibioperoneal trunk divide and what does it divide into?
Divides 2.5cm below the popliteal fossa into the posterior tibial artery and the peroneal artery
62
Describe the course of the anterior tibial artery
From the popliteal artery Passes between 2 heads of tib post Through superior IoM into the anterior compartment Gives off 1st branch: anterior tibial recurrent artery Runs down with: - Deep peroneal nerve (nerve is lateral) - Runs on anterior surface of IoM between EHL and tib ant Passes deep to superior and inferior extensor retinacula - NV bundle - Above ankle: between TA and EHL - At ankle: Crosses under EHL - Runs down lateral to EHL Continues down as dorsalis pedis artery
63
Describe the course of the posterior tibial artery
From the tibioperoneal trunk Continues in deep posterior compartment Runs with: - Tibial nerve - Superrficial to tib post and gives off large nutrient artery to tibia At the ankle: - Posterior to medial malleolus, deep to flexor retinaculum - Terminates as medial and lateral plantar arteries
64
Describe the course of the peroneal artery
From the tibioperoneal trunk Largest branch of the posterior tibial artery Runs in the deep posterior compartment - (NOT the lateral compartment) Runs deep to FHL Terminates as - Anterior perforating artery - Passes from posterior to anterior through distal IoM - Lateral calcaneal branch
65
What is the average neck shaft angle of the hip?
127o
66
Name the structures
Answers:
68
Name the muscles of the Anterior, medial and posterior compartments of the thigh
Anterior:
Recturs femoris
Vastus lateralis
Vastus intermedius
Vastus medialis
Sartorious
Medial:
Adductor brevis
Adductor longus
Adductor magnus
Gracilis
Posterior:
Biceps (long head)
Biceps (Short head)
Semimembranosus
Semitendinosus
69
What are the borders and contents of the femoral triangle?
Boundaries:
Superior: Inguinal ligament
Lateral: Sartorius
Medial: Adductor longus
Floor: iliopsoas, pectineus, adductor longus
Contents:
NAVEL towards the navel
nerve, artery (Deep profunda branch), vein (great saphenous vein), empty, lymphatics
70
Specifically what artery and vein are located in the femoral triangle?
artery: common femoral and its main branches (superficial femoral, profunda)
vein: femoral vein and its branches (deep femoral and long saphenous)
71
Which artery in the Cruciate anastomosis provides the most blood supply?
1st perforating artery
72
What is the average angle between the anatomic and mechanical axes of the knee?
5-7o valgus
anatomic and mech axis of tibia are the same
so the question is the difference between anatomic and mech axis of femur, which is about 6 deg and valgus at knee (distal femur articular surface)
73
What percentages of the load do the menisci in the knee take?
Lateral: 70% of the load of the lateral compartment
Medial: 50% of the load of the medial compartment
They both take more load in flexion
74
Name the attachments of the pes anserinus:
Sartorius (most proximal)
Gracilis
Semitendinosus (most distal)
"Say Grace before T"
75
Which ligament's deep fibers are attached to the meniscus, LCL or MCL?
MCL
LCL deep fibers ARE NOT attached to the menisci
76
what muscle is intra-articular at the knee?
popliteus
(long head of biceps brachii is the only other intra-articular tendon, at the shoulder)
77
What muscle acting on the knee has its origins distal to its insertion?
Popliteus
78
Name the bursa around the knee (4):
1. Suprapatellar: extension of synovium under tendon of quadriceps femoris
2. Prepatellar (housemaids knee)
3. Infrapatellar: x2
1. Superficial: clergyman's knee
2. - Deep (to patellar ligament)
79
Name the borders and contents of the popliteal fossa:
Borders: Diamond shaped region behind the knee:
Semimembranosus
Biceps femoris
Medial heads of gastrocs
Lateral heads of gastrocs/plantaris
Contents:
Popliteal vessels
Tibial and common peroneal nerves (from sciatic)
Superficial to it: short/small saphenous veins draining into popliteal vein
80
How does the intramedullary reaming of the femur alter the blood supply to cortical bone?
Decreases inner 2/3, increases outer 1/3
81
Reaming of a femoral fracture does what to the cortical blood supply?
Increased by 30%
82
Which muscle is solely innervated by the obturator nerve?
Gracilis
Adductor magnus
Semitendinosis
Sartorius?
Gracilis
83
Which of the following is a landmark to the posterior appraoch to the knee?
Long head of biceps tendon
Medial sural cutaneous nerve
Popliteal artery
Medial aspect of the lateral gastrocs origin
Semitendinosis tendon
Medial sural cutaneous nerve
84
Which structure is most at risk posteriorly with suturing of the medial meniscus?
Tibial nerve
Saphenous nerve
Popliteal artery
Middle geniculate artery
Saphenous nerve
85
In a lateral approach to the knee, the most endangered structure is:
Lateral superior geniculate artery
Lateral inferior geniculate vein
Lateral inferior genicular artery
Lateral superior geniculate vein
Lateral collateral artery
Lateral Superior geniculate artery
86
What is the only innervation of the peroneal nerve proximal to the knee?
Short head of biceps
87
A patient has disruption of the superficial branch of the peroneal nerve. Which of the following is most correct with regards to findings?
Decreased sensation in the first web space
Decreased sensation in the second web space
Weakness of the first dorsal interosseous
Weakness of the extensor digitorum brevis
Decreased sensation in the lateral aspect of the foot
Decreased sensation in the second webspace
88
A patient presents after trauma to the lower leg and has pain on passive extension of the toes. Which compartment is most likely involved?
Deep posterior
89
All are true of the meniscus of the knee except:
Transmits 50% of the load
helps synovial flow
Protects articular cartilage from shear forces
There is a vascular frnge at the periphery of the meniscus but the vessels do not penetrate into the substance of the meniscus
There is good vascular supply to the meniscus near the popliteal tendon
There is good vascular supply to the meniscus near the popliteal tendon (this is false)
90
Where does the MPFL insert on the patella?
What about the femur?
* Patella - Superior medial aspect
* Femur -Schottle’s Point – isometric point for insertion of MPFL
* A reproducible anatomical and radiographic point:
* 1 mm anterior to the posterior cortex extension line
* 2.5 mm distal to the posterior origin of the medial femoral condyle, and proximal to the level of the posterior point of the Blumensaat line
* on a lateral radiograph with both posterior condyles projected in the same plane, shows the mean femoral medial patellofemoral ligament center.
91
What are the pertinent findings of the dial test?
Increased ER at 30o: Isolated PLC injury
Increased ER at 30/90o: PCL/PLC injury
Significance is 10-15o difference side to side
92
A 25 yo M injured his knee in an MVC. Abnormal findings include:
10o increased external tibial rotation at 30/90o of knee flexion.
WHat other abnormal finding would you expect to find?
Increased opening to valgus stress at 30o of knee flexion
Increased varus opening at 0o knee flexion
Positive patellar apprehension
Positive pivot shift
Medial tibial plateau rests 10mm anterior to the medial femoral condyle
Increased varus opening at 0o of knee flexion
(another test for injury to the PLC)
93
A soccer player sustains a knee injury and is noted to have a significant increase in tibial passive external rotation both at 30 and 90 degrees of knee flexion. His MRI would most likely show which of the following?
1. A popliteus tendon tear
2. A lateral collateral ligament tear
3. A posterior cruciate ligament tear
4. Answers 1 & 2
5. Answers 1, 2 & 3
5: Answers 1, 2, 3
popliteus tendon tear
LCL tear
PCL tear
94
A 17 year old quarterback sustained a left knee injury after being tackled five days ago. You suspect a posterolateral corner injury. What is the most accurate physical examination test to confirm your diagnosis?
1. Increased posterior tibial translation at 90 degrees of knee flexion
2. Positive pivot shift test
3. Asymmetrical tibial external rotation at 30 degrees of knee flexion
4. Asymmetrical tibial internal rotation at 30 degrees of knee flexion
5. Excessive valgus laxity at 30 degrees of knee flexion
3. Asymmetrical tibial external rotation at 30 degrees of knee flexion
95
What is the OINA of Sartorius?
O: ASIS
I: Pes anserinus
N: Femoral
A: Flexes and laterally rotates hip joint
Flexes the knee
96
Name the OINA for Rectus femoris
O:
Straight head: AIIS
Reflected head: Groove just above acetabulum
I: Base of patella to form central portion of quadriceps femoris tendon
N: Femoral
A: Extends the knee
97
What is the OINA of Vastus lateralis
O:
Intertrochanteric line (peel when doing lateral hip approach)
Ant and inferior borders of GT
Superior border of lateral lip of linea aspera
Lateral aspect of gluteal tuberosity
I:
Lateral base and border of patella
Also forms lateral patellar retinaculum and lateral side of quadriceps femoris tendon
N: Femoral
A: Extends the knee
98
Name the OINA of vastus medialis
O:
Intertrochanteric line
Medial lip of linea aspera
Medial supracondylar ridge
Medial intermuscular septum
I:
Medial base and border of patella
Also forms medial patellar retinaculum and medial side of quadriceps femoris tendon
N: Femoral
A: Extends knee
99
OINA of vastus intermedialis
O:
Superior 2/3 of anterior and lateral surfaces of femur
Lateral intermuscular septum of thigh
I:
Lateral border of patella
Also forms deep portion of quadriceps tendon
N: Femoral
A:
Extends knee
Overall its more lateral than medial
100
OINA of articular genu
O: anterior surface of distal femur, deep to vastus intermedialis
I:
Synovial membrane of knee joint
N: Femoral
A:
Pulls suprapatellar bursa superiorly during extension to prevent impingment of the synovial membrane between patellar and femur
101
OINA of adductor brevis
O:
Anterior inferior pubic ramus, inferior to origin of adductor longus
I: Pectineal line and superior part of medial lip of linea aspera
N: Obturator
A: adducts and flexes thigh
Helps to laterally rotate thigh
102
OINA of Adductor Longus
O:
Anterior surface of body or pubis, just lateral to pubic ramus
I:
Middle 1/3 of linea aspera, between adductor magnus/brevis (more medial) & origin of vastus medialis (more lateral)
N: Anterior division of obturator
A: adducts and flexes thigh
Helps laterally rotate thigh
103
OINA of adductor magnus
O:
Inferior pubic ramus
ischial ramus
Iferolateral area of ischial tuberosity
I:
Gluteal ruberosity of femur
medial lip of linea aspera
medial supracondylar ridge
adductor tubercle
N: **_Dual innervation:_**
Posterior division of obturator nerve
Tibial portion of sciatic (innervates hamstring portion)
A:
Powerful thigh adductor
also thigh flexion
104
OINA of Pectineus
O; Pecten pubis and pectineal surface of pubis
I: Pectineal line of femur
**_N: (Sometimes dual Innervated)_**
Femoral and (sometimes) obturator nerve
A: adducts thigh and flexes hip joint
\*\* If obturator nerve KO'ed, can still adduct thigh b/c of pectineus (femoral innervated)
105
OINA of Gracilis
O: Inferior margin of pubic symphysis
Inferior ramus of pubis
Adjacent ramis of ischium
I:
Medial surface of tibial shaft (pes anserinus), just posterior to sartorius
N: Anterior division of obturator nerve
A: Flexes the knee
adducts the thigh
medially rotates tibia on femur
106
OINA of biceps femoris
O:
Long head: ischial tuberosity: common/conjoint tendon with semitendinosus
Short head: Lateral lip of linea aspera, lateral supracondylar ridge of femur, lateral intermuscular septum of thigh
I:
Fibular head & LCL and lateral tibial condyle
N:
Long head: tibial nerve
Short head: common peroneal nerve (Short head is the only innervation of the peroneal nerve proximal to the knee)
A: flexes knee
Rotates tibia laterally
Long head helps extend the hip
107
OINA Semitendinosus
O: Common/conjoint tendon with long head of biceps femoris from superior medial quadrant of posterior portion of ischial tuberosity
I: Pes anserinus
N: Tibial branch of sciatic nerve
A: extends thigh and flexes the knee
Also rotates tibia, especially when knee is flexed
108
OINA of Semimembranosus
O: Superior lateral quadrant of the ischial tuberosity
I: Posterior surfae of the medial tibial condyle (5 insertion sites)
N: Tibial portion of sciatic nerve
A: Extends thigh, flexes knee, rotates tibia medially especially when knee is flexed
109
Name the insertion sites of semimembranosus
5 insertion sites:
Posterior medial tibial condyle (beneath MCL)
Oblique popliteal ligament
Posterior capsule and posterior horn of medial meniscus
Insertion on posterior oblique ligament (thickening of medial capsular ligament)
Expansion to aponeurosis of popliteal muscle
110
OINA of Gluteus medius
O: Dorsal ilium inferior to iliac crest
I: Lateral and superior surfaces of GT
N: Superior gluteal nerve
A: Major abductor ot thigh
Superior fibers help rotate thigh medially
Posterior fibers help rotate thigh laterally
111
OINA of Gluteus Maximus
O:
Posterior aspect of dorsal ilium, posterior to posterior gluteal line
PSIS
Posterior inferior aspect of sacrum and coccyx
Sacrotuberous ligament
I: Primarily in fascia lata at the IT band
Also: gluteal tuberosity on posterior femoral surface
N: Inferior gluteal nerve
A:
Major extensor of hip joint
Assists in laterally rotating thigh
Upper and middle sections of the muscles are abductors
113
OINA of Tensor fascia lata
O:
ASIS
Outer lip of anterior iliac crest and fascia lata
I: IT Band
N: Superior gluteal nerve
A: Stabilizes hip and knee joints by putting tension on the IT band of fascia
114
OINA of gluteus minimus
O:
dorsal ilium between inferior and anterior gluteal lines
Edge of greater sciatic notch
I: Anterior surface of GT
N: Superior gluteal nerve
A: Abducts and medially rotates hip joint
115
OINA of Iliacus
O:
Upper 2/3 of iliac fossa of ilium
Internal lip of iliac crest
Lateral aspect of sacrum
Ventral SI ligament
Lower portion of iliolumbar ligament
I: LT
N: femoral
A: Hip flexor
(flexes the torso and thigh with respect to each other)
117
What are the muscles that originate from the ASIS?
Sartorius
Tensor fascia lata
118
What is the danger of the lateral approach to the femur?
Perforating branches of the profunda femoris artery
119
What is the interval and dangers of the posterolateral approach to the distal femur?
Plane:
Vastus lateralis (femoral) and lateral intermuscular septum to linea aspera (covers hamstrings: sciatic)
Dangers:
Perforating branches of the profunda femoris. These pierce lateral intermuscular septums to supply v. lateralis
120
Name the plane and dangers to the anteromedial approach to the distal femur:
Plane:
V. medialis (femoral) & rectus femoris (femoral), both innervated proxially
Dangers:
Medial superior geniculate artery
Detachment of vastus medialis needs to be reattached to patella
121
What is the plane and dangers of the medial approach to the distal femur?
Plane:
Adductor magnus (post div of obturator/sciatic) & posterior border of vastus medialis
Dangers:
Saphenous nerve: identified over adductor tendon (crosses anterior to posterior at distal femur)
Femoral artery:
Crosses anterior to posterior 13 cm joint through the adductor hiatus
122
Where does the femoral artery cross above the knee joint?
13cm above knee joint on the medial side
123
What is the plane and the dangers of the posterior approach to the thigh?
Plane:
Proximally: Between lateral intermuscular septum (covering v. lateralis - femoral nerve) & biceps femoris (sciatic nerve)
Distally: reflecting short head of biceps from lateral lip of linea aspera medially (to protect sciatic nerve)
Dangers:
Posterior femoral cutaneous nerve
Sciatic nerve: medial to biceps femoris proximally, identified and protected distally when biceps moved laterally
Nerve to biceps femoris: branch of sciatic and inserts medailly high in the leg
124
Convex or concave: Medial tibial plateau?
Concave
125
Convex or convace, lateral tibial plateau?
Convex
126
Notch sign: medial or lateral femoral condyle?
Lateral
The (deep) lateral femoral notch sign describes a depression on the lateral femoral condyle at the terminal sulcus, a junction between the weight bearing tibial articular surface and the patellar articular surface of the femoral condyle.
An abnormally large notch or an asymmetrical/irregular notch can be an indirect sign of an ACL injury as evidence of a pivot shift mechanism and rotatory subluxation.
127
What are the components of the Posterolateral corner?
**Static structures (Ligaments/capsule)**
1. lateral capsule
2. LCL
3. popliteofibular ligament
4. Arcuate ligament
5. +/- Fabellofibular ligament
**Dynamic structures (MUSCLES):**
1. biceps femoris
2. IT band
3. Lateral head
4. Popliteus
\*\*The **Arcuate ligament (**variable) is a Y shaped thickening of the posterolateral capsule which arises from the fibular styloid and divides into 2 limbs:
1. medial limb - curves over popliteus to join with the oblique popliteal ligament
2. lateral limb - ascends to blend with the capsule near the lateral gastrocnemius muscle
128
What are the branches of the femoral artery?
1. superficial circumflex iliac artery
2. superficial epigastric artery
3. superficial external pudendal artery
4. deep external pudendal artery
5. profunda femoris artery
1. **Lateral circumflex femoral artery**
**Medial circumflex femoral artery**
**Perforating arteries - perforate the adductor magnus muscle to the posterior and medial compartments of the thigh.**
6. descending genicular artery
Details:
1. The **superficial circumflex iliac artery** is a small branch that runs up to the region of the anterior superior iliac spine.
2. The **superficial epigastric artery** is a small branch that crosses the inguinal ligament and runs to the region of the umbilicus.
3. The **superficial external pudendal artery** is a small branch that runs medially to supply the skin of the scrotum (or labium majus).
4. The **deep external pudendal artery** runs medially and supplies the skin of the scrotum (or labium majus).
5. The **profunda femoris artery** is a large and important branch that arises from the lateral side of the femoral artery about 1.5 in. (4 cm) below the inguinal ligament. It passes medially behind the femoral vessels and enters the medial fascial compartment of the thigh. It ends by becoming the fourth perforating artery. At its origin, it gives off the medial and lateral femoral circumflex arteries, and during its course it gives off three perforating arteries.
6. The **descending genicular artery** is a small branch that arises from the femoral artery near its termination within the adductor canal. It assists in supplying the knee joint.
