Third slide deck- the Leg Flashcards
Observable features of leg..
slide 2
Observable features of leg..
Gastrocnemius
Soleus
Great saphenous vein
Calcaneal tendon
Both the ___ and ___ muscles insert on the calcaneus via the calcaneal (Achilles) tendon
Gastrocnemius
Soleus
The ___ ___is the large bony projection on the medial side of the ankle
medial malleolus
The greater saphenous vein is the ____ of the two saphenous veins
Medial
The greater sephenous vein travels anterior to the medial malleolus, and ascends on the medial leg and thigh to terminate in the ___
femoral vein
The ___ ___ is the large bony projection on the lateral side of the ankle
lateral malleolus
The ___ ___ vein is the lateral of the two saphenous veins
lesser saphenous
The lesser saphenous travels posterior to the lateral malleolus, and ascends on the posterior leg to terminate in the ___ ___
Popliteal vein
More observable pictures of the leg…
slide 6
which compartment is responsible for: Dorsiflexion at the ankle Inversion of the foot (supination is a combination of inversion, plantarflexion and adduction.) Extension of the toes Innervation: deep fibular nerve
Anterior compartment
Which compartment is responsible for:
Weak plantarflexion
Eversion of the foot (pronation is a combination of eversion, dorsiflexion and abduction)
Innervation: superficial fibular nerve
Lateral compartment
Which compartment is responsible for:
Plantarflexion of the ankle
Flexion of the toes
Innervation: tibial nerve
Posterior Compartment
Compartments of the leg as seen from above:
slide 8
Compartments of the leg cross section:
slide 9
Anterior compartment consists of muscles that dorsiflex the foot:
- Tibialis anterior
- Extensor hallucis longus
- Extensor digitorum longus
- Fibularis (peroneus) tertius
Innervation of the anterior compartment muscles of the leg:
Innervation: deep fibular (peroneal) nerve
review some ant. compartment muscles of the leg:
slide 11
Tendons of the muscles of the anterior compartment are held firmly to the ankle by thickenings of deep fascia: the superior extensor retinaculum (AKA __ ___of the ankle) and inferior extensor retinaculum (AKA ___ ___ of the ankle)
Transverse ligament
Cruciate ligament
Origin: tibia, and interosseous membrane
Insertion: first cuneiform and first metatarsal
Tibialis Anterior
Action: dorsiflexes foot at the ankle and inverts foot
Innervation: deep fibular (peroneal) nerve
Tibalis Anterior
Origin: fibula, and interosseous membrane
Insertion: distal phalanx of great toe (dorsal surface)
Extensor Hallucis Longus
Action: extends great toe and dorsiflexes foot at ankle
Innervation: deep fibular (peroneal) nerve
Extensor Hallucis Longus
Origin: tibia, fibula, and interosseous membrane
Insertion: toes 2 – 5 (dorsal surface of middle and distal phalanges)
Extensor Digitorum Longus
Action: extend toes 2 - 5 and dorsiflexes foot at ankle
Innervation: deep fibular (peroneal) nerve
Extensor Digitorum Longus
Origin: fibula, and interosseous membrane
Insertion: base of fifth metatarsal
Fibularis (Peroneus) Tertius
Action: dorsiflexes and everts the foot (in conjunction with extensor digitorum longus)
Innervation: deep fibular (peroneal) nerve
Fibularis (Peroneus_ Tertius
Lateral compartment consists of muscles that ___ __ and evert the foot
Plantar flex
Lateral compartment consists of muscles that plantar flex and evert the foot
Fibularis (peroneus) longus
Fibularis (peroneus) brevis
Fibularis (peroneus) longus
Fibularis (peroneus) brevis
Innervation: ??
superficial fibular (peroneal) nerve
Lateral compartment muscle review:
slide 18
Origin: fibula
Insertion: first metatarsal and first cuneiform (medial, plantar foot)
Fibularis (Peroneus) Longus
Action: everts foot and plantar flexes foot at ankle (also helps to support the transverse arch of the foot)
Innervation: superficial fibular (peroneal) nerve
Fibularis (Peroneus) Longus
___ ___ inserts on the base of the 1st metatarsal and the medial cuneiform
Fibularis Longus
Tendon of fibularis longus crosses the ___ of the foot
Sole
Origin: fibula
Insertion: base of fifth metatarsal (lateral, plantar foot)
Fibularis (Peroneus) Brevis
Action: Everts foot and plantar flexes foot at ankle
Innervation: superficial fibular (peroneal) nerve
Fibularis (Peroneus) Brevis
Fibularis brevis inserts on the tuberosity of the ___ metatarsal
5th
Recall that tibialis anterior inserts dorsally at the base of the first metatarsal and first cuneiform bones, and ___ the foot.
Dorsiflexes
Fibularis longus inserts on the plantar aspect of the base of the first metatarsal and first cuneiform bones, and ___ __ the foot
Plantar flexes
Tibialis anterior and fibularis longus are therefore ____ muscles at the base of the first metatarsal and first cuneiform.
antagonistic
Posterior compartment consists of muscles in superficial and deep groups
The superficial muscles share a common tendon of insertion, the ___ ___ tendon
calcaneal (Achilles) tendon
Posterior compartment consists of muscles in superficial and deep groups
The deep muscles are deeper and (do/do not)? share a common tendon (either among themselves or with the superficial group)
Do not
Superficial posterior compartment pictures:
slide 25
Origin: lateral and medial femoral condyles
Insertion: the two heads unite into a broad aponeurosis which eventually unites with the deep tendon of the soleus to form the calcaneal (Achilles) tendon, inserting on the posterior calcaneal surface
Gastrocnemius
Action: plantar flexes foot at ankle, and flexes leg at knee
Innervation: tibial nerve
Gastrocnemius
Origin: tibia and fibula
Insertion: unites with the gastrocnemius aponeurosis to form the calcaneal (Achilles) tendon, inserting on the posterior calcaneal surface
Soleus
Action: plantar flexes foot at the ankle
Innervation: tibial nerve
Soleus
__ __ is a term sometimes applied to the combination of the gastrocnemius and soleus muscles, since both insert into the calcaneus, and together form the major part of the muscle of the posterior portion of the leg (the calf, L. sura).
Triceps surae
Origin: femur
Insertion: calcaneus
Plantaris
Action: plantar flexes foot at ankle, and flexes leg at knee
Innervation: tibial nerve
Plantaris
Deep posterior compartment leg
Pic page 30
Origin: femur
Insertion: tibia (just superior to the popliteal line)
Popliteus
Action: rotates knee medially and flexes the leg on the thigh
Innervation: tibial nerve
Popliteus
Origin: tibia, fibula, and interosseous membrane
Insertion: plantar tarsals and metatarsals of foot (second, third, and fourth metatarsals; navicular; cuneiforms; cuboid)
Tibialis Posterior
Action: plantar flexes foot at ankle, and inverts foot
Innervation: tibial nerve
Tibialis Posterior
Origin: tibia
Insertion: distal phalanges of toes 2 – 5
Flexor Digitorum Longus
Action: flexes toes 2 – 5, and plantar flexes foot
Innervation: tibial nerve
Flexor Digitorum Longus
Origin: fibula
Insertion: plantar surface of the distal phalanx of the great toe
Flexor Hallucis Longus
Action: flexes great toe, and plantar flexes foot at ankle (weakly)
Innervation: tibial nerve
Flexor Hallucis Longus
___ artery divides into the anterior and posterior tibial arteries at the inferior border of popliteus
Popliteal
Gives off the fibular artery (perforating branches to the lateral compartment)
Will supply most of the foot as plantar arteries (after dividing into medial and lateral plantar arteries)
Has paired deep veins (venae comitantes)
Posterior Tibial
Runs anterior to the interosseus membrane and supplies anterior compartment
Has paired deep veins (venae comitantes)
Anterior tibial artery
Arterial distribution
veinous drainage
charted on slide 36-40
Sciatic…
and nerves of the leg
slide 41/42/43
The __ __ __ winds around the fibular neck before dividing into the deep fibular (deep peroneal) and superficial fibular (superficial peroneal) nerves.
It is likely to be injured simultaneously with injury at or near the head of the fibula.
Common fibular nerve
Superficial fibular to the two lateral compartment muscles
Deep fibular to the four anterior compartment muscles
COMMON FIBULAR components to short head of biceps, anterior and lateral compartments of the leg, dorsum of the foot
Slide 44 all together
Because of the superficial position of the ___ __ __ as it winds around the fibular neck, it is the nerve most injured in the lower limb
It may be severed during fracture of the fibular neck, or severely stretched when the knee joint is injured or dislocated
Common fibular nerve
Severance of the common fibular nerve results in paralysis of all muscles in the anterior and lateral compartments of the leg (dorsiflexors of the ankle and evertors of the foot), causing __ __ The condition makes it impossible to make the heel strike the ground first—the foot drops and the toes drag on the floor when walking
Foot drop
The patient compensates by adopting a high stepping (“steppage”) gait, raising the foot as high as necessary to keep the toes from hitting the ground.
A distinctive clop is produced as the foot comes down (or, rather, is slung down)
There will also be a variable loss of sensation on the ____ aspect of the leg and the ___ of the foot due to loss of cutaneous sensation provided by the fibular nerve
Anterolateral - leg
Dorsum - foot
Deep fibular nerve AKA deep peroneal nerve
Travels in the front of the ankle and enters the top of the foot by passing under the __ __
Extensor retinaculum
Deep fibular nerve:
Continues on to supply
the extensor hallucis brevis muscle
extensor digitorum brevis muscle(s)
cutaneous sensation to an area between the
1st and 2nd Toes
Deep fibular neuritis is an entrapment neuropathy
Symptoms include pain, 1st / 2nd toe numbness and tingling, and weakness of big toe dorsiflexion
Deep fibular nerve may be injured after direct ankle trauma, or by tightly fitting lace up shoes
Deep peroneal neuritis
Common fibular nerve cutaneous innervation
slide 52/53
The ankle joint is a __-__ ___ joint between the distal ends of the tibia and fibula, and the superior part of the talus
hinge type synovial
A __ __ is formed by the distal ends of the tibia and fibula, into which the trochlea of the talus fits
malleolar mortise
The joint capsule is thin anteriorly and posteriorly, but is supported on each side by strong ___ __
collateral ligaments
movements of ankle
slide 56
movement:
Tibialis anterior, Extensor digitorum longus, and extensor hallucis longus
Dorsiflexion
Movement:
all muscles of the posterior compartment which cross the joint, and muscles of the lateral compartment (their action is weaker)
Plantarflexion
Movement: Tibialis anterior (supination is an outward roll of the foot during normal motion, and is an inversion-type movement)
Inversion
Movement:
lateral compartment, and fibularis tertius (pronation is an inward roll of the foot during normal motion; it is an eversion-type movement, and may be associated with flat foot and/or knock knees (genu valgum))
Eversion
Hinge-type synovial joint
Tibia/ talus & fibula/ talus
The tibia transfers weight to the joint, the ___ ___
Fibula stabilizes
A mortise is formed by the distal ends of the tibia and fibula, into which the trochlea of the talus fits
Superior surface of the talus is wider anteriorly than posteriorly (plantarflexion is less stable). The ankle joint is most stable when it is fully ____
dorsiflexed
Ankle articular capsule:
Fibrous capsule is rather ___, but is supported and stabilized on each side by strong collateral ligaments
thin
Ankle, medial ligment AKA..
Deltoid ligament
Comprises four discrete parts, collectively called the ___ ___
Anchors the medial malleolus to the talus
Stabilizes the ankle joint during eversion, and resists extreme eversion
Medial Ligament
Medial ligament:
Stabilizes the ankle joint during ___, and resists extreme ___
Eversion
Three discrete ligaments, collectively called the lateral ligament
The weaker of the two collateral ligaments
Lateral ligament (ankle)
Naming ligaments of the ankle joint:
Named after the bones the ligaments connect, plus a modifier (anterior, posterior) if necessary
slide 60
did you identify the “Spring” ligament
more ligament pics
slide 61
The most commonly injured ligament in the ankle is the ___ ___ ligament
anterior talofibular
It is rare for the ___ ligament to be sprained because the fibula tends to prevent the ankle from moving far enough to stretch the ligament. When the ___ ligament is injured, the event is often associated with a fracture of the fibula
Deltoid (medial)
The foot has ## bones and 55 articulations. It acts as a platform and shock absorber to support the weight of the body, and is also a powerful lever to propel the body
26 bones
foot has 3 distinct regions:
Forefoot, comprising the toes and metatarsals
Midfoot, consisting of the cuneiforms, cuboid, and navicular bones
Hindfoot, comprising the calcaneus and talus
what region:
most common site of foot complaints. Most problems are caused by poor shoe selection, foot deformities, or degenerative changes. Some conditions are bunions, stress fractures, fifth metarsal fractures
Forefoot
complaints are relatively uncommon, but include ___ sprain, tarsal fractures, and posterior tibialis dysfunction
Midfoot
Most problems (in this region?) are caused by overuse or excessive weight. Common complaints are plantar fasciitis, Achilles tendinosis, and bursitis
Hindfoot
Observable features of foot
slide 66
The two large bony projections on the sides of the ankle are the ___ and the ___
Medial malleolus
lateral malleolus
Which extensor tendons are observable on the foot?
Tendon of the extensor hallucis longus
Tendons of the extensor digitorum longus muscle
Which vessel is observable on the foot
Dorsal venous arch
Right foot, dorsal view
slide 70
right foot, anterolateral view
slide 71/72
Tom, Dick, and Harry
slide 73
Note the grooves for the tendon of flexor hallucis longus in the talus, and for the tendon of tibialis posterior in the tibia
slide 74
origin of foot surface features
slide 75
is a foot deformity caused by pressure from footwear, and degenerative joint disease.
Characterized by lateral deviation of the great toe (the “L” in valgus indicates lateral deviation).
In some persons, the deviation is so large that the great toe overlaps the second toe, and the first digit can not be moved away from the second digit because the sesamoids under the head of the first metatarsal are displaced and lie in the space between the heads of the first and second metatarsals.
Hallux valgus
A ___ is an enlargement of bone or tissue, or a tender and inflamed subcutaneous bursa that has formed around the metatarsophalangeal joint at the base of the big toe in hallux valgus.
The term usually is used to refer to the pathological bump on the side of the great toe joint. The bump is the swollen bursal sac and/or an osseous (bony) deformity that has grown on the mesophalangeal joint (where the first metatarsal bone and hallux meet).
Bunion
Flatfoot, AKA…
Pes Planus
A condition in which the longitudinal arch or instep of the foot collapses and comes in contact with the ground
Traditional home diagnosis is by means of the “wet footprint” test
Flatfoot
aka Pes planus
Flat appearance of the foot before age 3 is normal, resulting from the thick subcutaneous fat-pad (“baby fat”) in the sole, which is lost with age wherein a normal medial longitudinal arch becomes visible
Some people never develop arches, which is a normal variation in foot type
____ may or may not cause problems
Flatfoot
Contraction of the flexor muscles of the foot that is not balanced by the other foot muscles, or which is abnormal due to disease, flatfoot, or improper footwear can result in ___ or hammertoe
Clawfoot (clawtoe)
attaches to the middle phalanges of the toes
Flexor digitorum brevis
attaches to the distal phalanges of the toes
Flexor digitorum longus
contraction overpowers the other muscles, the middle phalanx is pulled downward due to the mechanical action of the muscle, resulting in clawfoot (clawtoe)
Flexor digitorum brevis
contraction overpowers the other muscles, the mechanical result of its pulling action is bending the toe at the middle joint, so that the tip of the toe is bent downward while the middle of the toe is cocked upward resembling a hammer
Flexor digitorum longus
AKA Claw foot, claw toe.
Claw toe is a deformity of the foot in which the toes (usually the lateral four toes) are pointed down and the arch is high, making the foot appear claw-like
see pic on slide 82
The metatarsophalangeal joints are hyperextended, and the distal interphalangeal joints are flexed.
___ can be a condition from birth or develop as a consequence from other disorders, such as in diabetics whose neurological lesions lead to atrophy of muscles of the foot
Claw toe
____ is a deformity of the proximal interphalangeal joint causing it to be permanently bent. The base of the toe points upward and the end of the toe points down.
Hammertoe
____ can involve the second, third, or fourth toe, although it usually exists in only one of those toes (unlike clawfoot, which occurs in multiple toes simultaneously)
In the earlier stages, ___ are flexible and can often be managed with noninvasive measures. If left untreated, ____can become more rigid and will not respond to non-surgical treatment.
Hammertoes
Improperly fitting shoes is a common cause of ____. Poorly-fitting shoes can hold the toes in an abnormal position and result in tightening of the muscles required to maintain that position. In particular, shoes that have high heels and are narrow at front tend to push the toes into an abnormal, bent position
Less commonly, diseases of the nerves, muscles, or joints (such as arthritis) can result in ____ deformity
Hammertoe
Congenital deformity in which the foot is twisted inferiorly and medially, and the angle of the arch is increased.
Clubfoot
Clubfoot AKA..
AKA talipes or talipes equinovarus
Without treatment, persons appear to walk on the sides of their feet or on their ankles
Treatment consists of manipulating the arch to a normal curvature by casts or adhesive tape, usually soon after birth (Ponseti method). Corrective shoes or surgery may also be required
Clubfoot
Some instances are caused by genetic factors, such as Edward’s syndrome (trisomy 18)
Other instances are due to external influences in the third trimester, such as intrauterine compression
Clubfoot
Straining and inflammation of the plantar aponeurosis may result from running and high-impact aerobics.
___ __ causes pain on the plantar surface of the heel and on the medial aspect of the foot. It is most severe after sitting, and when first walking in the morning.
Plantar Fasciitis
If a calcaneal spur protrudes from the medial calcaneal tubercle, the plantar fasciitis may produce the “\_\_\_\_ .”
Heel spur syndrome
Heel spur syndrome:
A ___ develops at the end of the spur, and that may also become inflamed and tender
Bursa
Cutaneous innervation of foot
slide 93
Arterial supply:
Dorsalis pedis at the ankle joint -> arcuate artery & deep plantar artery
Deep plantar artery joins the lateral plantar artery to form the plantar arch
slide 94
Posterior tibial divides into medial and lateral plantar arteries behind the __ __
medial malleolus
foot artery:
Medial plantar artery (smaller)
Lateral plantar artery joins the deep plantar artery to form the __ __
Plantar arch
foot artery:
The arch gives off plantar metatarsal arteries -> ____
common digital arteries
