VIVA: Anatomy - Lower limb Flashcards

1
Q

What are the myotomes of the lower limb?

A

6/10 to pass:
- Hip flexion L2/3
- Hip extension L4/5
- Knee extension L3/4
- Knee flexion L5/S1
- Ankle flexion L4/5
- Ankle extension S1/2
- Inversion L4
- Eversion L5/S1
- Big toe flexion L5/S1
- Big toe extension S1/2

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2
Q

Using this diagram, demonstrate the cutaneous nerve supply of the leg

A

5 to pass:
- Lateral thigh: lateral cutaneous nerve of thigh
- Anterior and medial thigh: anterior cutaneous branch of femoral nerve, intermediate and medial femoral cutaneous nerves, obturator nerve
- Posterior thigh: posterior cutaneous nerve of thigh
- Lateral leg from knee to mid-calf: lateral cutaneous nerve of calf and leg
- Anterolateral leg from mid-calf: superficial peroneal (fibular) nerve
- Posterolateral leg from mid-calf: sural nerve
- Medial leg: saphenous nerve
- Dorsum of foot, except 1st web space: superficial peroneal (fibular) nerve
- Heel: medial calcaneal branch of tibial nerve
- Sole of foot except heel: medial and lateral plantar branches of tibial nerve

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3
Q

Describe the anatomy of the inguinal canal

A
  • Oblique, inferomedial passage, 4cm long, superior to the medial 1/2 of the inguinal ligament
  • Deep (internal) ring superior to middle of inguinal ligament* and lateral to inferior epigastric artery
  • Superficial (external) ring superolateral to pubic tubercle*, formed by split in external oblique aponeurosis
  • Anterior wall: external oblique aponeurosis
  • Posterior wall: transversalis fascia (+ conjoint tendon)
  • Roof: transversalis fascia, internal oblique and transversus abdominis
  • Floor: inguinal ligament

*needed to pass + basic concepts of walls, roof and floor

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4
Q

What is the difference between a direct and indirect inguinal hernia?

A

Direct (acquired):
- Weakness of anterior abdominal wall
- Traverses medial 1/3 of canal and exits at superficial ring lateral to cord
- Rarely enters scrotum

Indirect (congenital):
- Traverses entire canal within patent processus vaginalis
- Goes from deep to superficial ring
- Inside cord, so commonly enters scrotum or labia majora

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5
Q

A patient with a known inguinal hernia presents with a tender lump in the groin. What underlying structures may be involved in this lump?

A
  • Small bowel*
  • Large bowel
  • Mesentery/omentum
  • Other abdominal or pelvic viscera (e.g. bladder, ovaries, appendix)

*needed to pass + 1 other

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6
Q

Identify the bony landmarks of the pelvis

A

Bones:
- Ilium*
- Ischium*
- Pubis*

Surface:
- Iliac crest*
- ASIS*
- AIIS*
- Ischial tuberosity*
- Ischial spine
- PSIS
- PIIS
- Symphysis pubis*

Joints:
- SIJ*
- Acetabulum/femur*
- Symphysis pubis*

Other:
- Pubic rami* (4)
- Ala of ilium
- Greater and lesser sciatic notches
- Obturator foramen

*needed to pass

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7
Q

Identify on the model the ligaments of the hip joint and their attachments

A
  1. Iliofemoral *:
    - AIIS/acetabular rim to intertrochanteric line *
  2. Pubofemoral *:
    - Obturator crest to capsule and iliofemoral ligament *
  3. Ischiofemoral:
    - Acetabular rim to base of greater trochanter

*needed to pass

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8
Q

Where on this model might you find a pathological fracture?

A

1 to pass:
- Pubic rami
- Neck of femur
- Proximal shaft

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9
Q

Identify the boundaries of the femoral triangle on this photo

A

3 to pass:
- Superior: inguinal ligament (13)
- Medial: lateral border of adductor longus (1)
- Lateral: medial border of sartorius (19)
- Floor: iliopsoas (11) and pectineus (15)

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10
Q

Identify the contents of the femoral triangle on this photo

A
  • Femoral nerve* (7)
  • Femoral artery* (6)
  • Femoral vein* (8)
  • Deep inguinal lymph nodes
  • Lymphatics

*2/3 to pass

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11
Q

What are the origin and terminal branches of the femoral artery?

A

Origin of femoral artery = external iliac artery*
Terminal branches of femoral = profunda femoris* (deep to adductor longus) and superficial femoral artery*

*need origin + one terminal branch to pass

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12
Q

Which spinal roots is the femoral nerve derived from?

A

L2, L3, L4

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13
Q

What anterior thigh muscles does the femoral nerve innervate?

A

4/6 to pass:
- Sartorius
- Articularis genu
- Quadriceps including rectus femoris, vastus medialis, vastus lateralis and vastus intermedius

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14
Q

What does the femoral nerve supply?

A

Motor (L2, L3, L4):
- Iliopsoas (hip flexion)
- Quadriceps* (knee extension; deep division): rectus femoris, vastus medialis, vastus lateralis, vastus intermedius
- Sartorius (hip flexion and lateral rotation, hip abduction, knee flexion; superficial division)
- Pectineus (hip flexion and adduction; superficial division)

Sensory:
- Intermediate and medial cutaneous nerve of thigh* (superficial division)
- Cutaneous saphenous (skin of medial leg and foot; deep division)
- Proprioception of hip joint from nerve to rectus femoris
- Proprioception to knee from nerve to vastus medialis

*needed to pass

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15
Q

What surface markings would you look for when trying to locate the femoral vein?

A
  • Artery is located inferior to the inguinal ligament at the mid-inguinal point (midway between ASIS and pubic symphysis)*
  • Vein is just medial to artery*

*needed to pass

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16
Q

Which veins drain into the common femoral vein?

A
  • Continuation of the popliteal vein
  • Receives the profunda femoris* and great saphenous vein* (7)
  • Ends posterior to the inguinal ligament where it becomes the external iliac vein
  • Also receives superficial epigastric vein (27), superficial circumflex iliac vein (25), and superficial external pudendal vein (28)

*needed to pass

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17
Q

Identify the proximal landmarks of the femur on this XR

A
  • Head* with fovea for ligament of head
  • Neck*
  • Greater and lesser trochanters*
  • Shaft*
  • Intertrochanteric line (anterior) and crest (posterior)
  • Quadrate tubercle
  • Pectineal line
  • Gluteal tuberosity
  • Linea aspera with medial and lateral lips
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18
Q

Describe the blood supply to the head of the femur

A
  1. Medial and lateral circumflex femoral arteries *:
    - Usually branches of the deep artery of thigh (profunda femoris)
    - Branch to form retinacular arteries (medial > lateral)
    - Medial feeds under posterior unattached capsule, lateral through iliofemoral ligament
    - Posterior retinacular arteries from medial circumflex are most important, lateral circumflex contributes a little via cruciate anastomosis
    - Distal to proximal *
  2. Artery to head of femur (foveal artery; less important):
    - Branch of obturator artery

*needed to pass

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19
Q

Describe the bony features of the middle and lower end of the femur

A

5/8 to pass:
1. Linea aspera
2. Medial supracondylar ridge:
- Inferior continuation of the medial lip of the linea aspera
- Interrupted to allow passage of the femoral artery
- Ends in adductor tubercle
3. Lateral supracondylar ridge:
- Descends to lateral epicondyle
4. Medial condyle
5. Lateral condyle
6. Intercondylar fossa
7. Adductor tubercle
8. Attachment of the medial ligament (medial epicondyle)

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20
Q

Which muscles attach to the linea aspera?

A

3/6 to pass:
- Vastus medialis
- Vastus lateralis
- Adductor brevis
- Adductor longus
- Adductor magnus
- Short head of biceps femoris

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21
Q

Which artery is most likely to be damaged by a fracture of the midshaft of the femur?

A

Profunda femoris

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22
Q

What is the course of the femoral artery through the thigh?

A
  • Continuation of external iliac artery as it crosses under the inguinal ligament at the mid-inguinal point and enters the femoral triangle
  • Gives off profunda femoris and continues as superficial femoral artery
  • After exiting the femoral triangle, it enters the adductor canal and continues down the anterior thigh
  • Exits the adductor canal at the adductor hiatus (opening in the adductor magnus) and enters posterior compartment of the thigh just proximal to the knee, where it becomes the popliteal artery
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23
Q

Demonstrate on the model the muscular attachments to the greater trochanter

A

4/7 to pass:
- Vastus lateralis (originates; all others muscles insert)
- Gluteus maximus (some fibres only, most to iliotibial tract)
- Gluteus medius (lateral surface)
- Gluteus minimus (anterior surface)
- Piriformis (superior border)
- Obturator internus (medial surface at trochanteric fossa)
- Superior and inferior gemelli (medial surface)

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24
Q

The patient has a subcapital (intracapsular) fractured neck of femur. What is the most concerning complication of this type of fracture and why does this occur?

A

Avascular necrosis of femoral head *:
- Hip joint has dual supply * from medial and lateral circumflex arteries * (usually branches of profunda femoris, can arise directly from femoral artery), and artery to head of femur (branch of obturator artery, traverses ligament of head and is often small/inadequate)
- Main supply of femoral head is via retinacular artery from branches of the circumflex femoral * (particularly medial, because these pass freely under unattached posterior border of joint capsule while branches from lateral must penetrate thick iliofemoral ligament and are smaller and fewer)
- Retinacular arteries are torn or disrupted in intracapsular fracture *

*needed to pass

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25
Q

What is the clinical significance of the blood supply to the head of the femur?

A

Intracapsular fractures (subcapital, transcervical) may lead to avascular necrosis of the head of the femur, especially if displaced, due to disruption of retinacular arteries from medial circumflex femoral artery (and less important lateral circumflex femoral)

26
Q

Identify the structures in this photo of the posterior thigh

A
  • Sciatic nerve (19)*
  • Gluteus maximus (5)
  • Long head of biceps (9)
  • Semintendinosus (22)
  • Semimembranosus (21)
  • Ischial tuberosity (8)
  • Gracilis (6)
  • Iliotibial tract (7)
  • Adductor magnus (1)
  • Popliteal artery and vein (16, 17)
  • Quadratus femoris (18)
  • needed to pass + 4 others
27
Q

What are the clinical features of a severed sciatic nerve in the upper thigh?

A

Motor:
- Supplies all posterior thigh muscles (depending on level of injury these may or may not be affected), and all leg and foot muscles
- Loss of hip extension, knee flexion, and all ankle (flexion *, extension *, inversion *, eversion *) and toe movements *

Sensory:
- Skin of most of leg and foot
- Loss of sensation to posterior and lateral leg, sole of foot, and lateral and dorsal aspect of foot

*3/5 motor and 3/5 sensory to pass

28
Q

Identify the bony structures shown on this XR

A
  • Femur*
  • Medial and lateral femoral condyles
  • Medial and lateral femoral epicondyles
  • Adductor tubercle
  • Tibia*
  • Medial and lateral tibial condyles
  • Tibial plateau
  • Intercondylar eminence with intercondylar tubercles (medial and lateral)
  • Fibula*
  • Head of fibula with apex
  • Neck of fibula
  • Patella*

*needed to pass + 6 others

29
Q

What factors stabilise the knee joint?

A
  1. Strength and actions of surrounding muscles and their tendons *:
    - Most important is quadriceps femoris * (especially inferior fibres of vastus medialis and lateralis)
  2. Ligaments * connecting femur and tibia:
    - Most important are the anterior and posterior cruciates *, and medial and lateral collaterals *
    - Others include posterior oblique, arcuate and patellar ligaments

No bony contribution * (relatively mechanically weak joint due to incongruence of articular surfaces)

Most stable position is the erect extended knee, as the articular surfaces are most congruent and the cruciates and collaterals are taut, with the joint splinted by many tendons

*needed to pass

30
Q

Describe the attachments of the cruciate ligaments

A

ACL:
- Arises from anterior intercondylar tibial eminence
- Passes superiorly and posterolaterally
- Inserts to medial aspect of lateral femoral condyle

PCL:
- Arises from posterior intercondylar tibial eminence
- Passes superiorly and anteromedially
- Inserts to lateral aspect of medial femoral condyle

31
Q

Identify the ligaments of the knee joint and their attachments

A

3/6 to pass:
- Patellar ligament: apex of patella to tibial tuberosity
- Fibular collateral ligament: lateral femoral epicondyle to lateral fibula head
- Tibial collateral ligament: medial femoral epicondyle to medial and superior aspect of tibia
- Anterior cruciate ligament: anterior intercondylar tibial eminence to medial surface of lateral femoral condyle
- Posterior cruciate ligament: posterior intercondylar tibial eminence to lateral surface of medial femoral condyle
- Posterior meniscofemoral ligament
- Lateral meniscofemoral (not on model)

32
Q

Describe the main movements of the knee joint and the muscles involved

A
  1. Extension:
    - Quadriceps femoris
  2. Flexion:
    - Semitendinosis
    - Semimembranosus
    - Biceps femoris
  3. Medial rotation:
    - When flexed: semitendinosus, semimembranosus
    - When non-weight-bearing knee extended: popliteus
    - When knee extended and weight-bearing: knee passively locks due to medial rotation of femoral condyles on tibial plateua, and unlocks through contraction of popliteus rotating femur laterally on the tibial plateau allowing flexion
33
Q

Describe the actions of the anterior and posterior cruciate ligaments

A

ACL:
- Prevents posterior displacement of femur on tibia (or anterior movement of tibia on femur)
- Prevents hyperextension of knee
- Limits posterior rolling of femoral condyles on tibial plateau in flexion

PCL:
- Limits anterior rolling of femur on tibial plateau in extension
- Prevents anterior displacement of femur on tibia (or posterior movement of tibia on femur)
- Helps prevent hyperflexion of knee

34
Q

Describe the medial meniscus and its attachments

A

3/7 to pass:
- Crescenteric
- Fibrocartilage
- Thickens towards joint margins
- Anterior horn attached to anterior intercondylar area of tibia, anterior to ACL
- Posterior horn attached to posterior intercondylar area of tibia, anterior to PCL
- Firmly attached to medial collateral ligament
- Less mobile than lateral meniscus

35
Q

Identify the superficial boundaries and the contents of the popliteal fossa

A

Superiorly:
- Biceps femoris (1)
- Semitendinosus (12) and semimembranosus (11)

Inferiorly:
- Lateral (3) and medial (4) heads of gastrocnemius

Contents:
- Popliteal artery (8) and vein (10)
- Small saphenous vein (13)
- Tibial nerve (15)
- Common fibular nerve (2)
- Sural nerve (14)

36
Q

Identify the muscles of the posterior compartment of the leg

A

6/8 to pass:
Superficial:
- Gastrocnemius
- Soleus
- Plantaris

Deep:
- Popliteus
- Flexor digitorum longus
- Tibialis posterior
- Flexor hallucis longus

37
Q

Which muscles form the Achilles tendon?

A

Gastrocnemius*
Soleus*
+/- plantaris

*needed to pass

38
Q

Where does the Achilles tendon insert?

A

Superoposterior aspect of the calcaneus

39
Q

Can you identify the nerve supply of these muscles?

A

Tibial nerve

40
Q

Can you identify the structures posterior to the medial malleolus?

A

Anterior to posterior:
- Tibialis posterior*
- Flexor digitorum longus*
- Posterior tibial artery
- Tibial nerve
- Flexor hallucis longus*

*2/3 muscles and neurovascular bundle to pass

41
Q

What is the blood supply of the gastrocnemius and soleus?

A

Gastrocnemius: sural artery
Soleus: posterior tibial artery, peroneal artery

42
Q

Describe the dermatomes of the lower limb

A

L1-5 winding around leg *
S1 and S2 down back of leg
S1 becomes lateral foot, L5 medial foot
Axial line down posteromedial aspect of leg

*needed to pass

43
Q

Describe the superficial venous drainage of the lower limb

A

Great saphenous vein (GSV) *:
- Dorsal venous arch of foot drains to great saphenous vein
- GSV ascends anterior to medial malleolus *, then behind the medial femoral condyle * (hands-breadth posterior to patella) and up medial thigh
- GSV pierces the fascia lata in the saphenous opening * to drain into the femoral vein
- Has numerous valves and perforators to the deep venous system *, and anastamoses with the small saphenous vein

Small saphenous vein (SSV) *:
- SSV arises from dorsal venous arch laterally * and ascends behind lateral medial malleolus, lateral to Achilles tendon
- SSV penetrates the fascia at the midline between the heads of the gastrocnemius to join the popliteal vein

*needed to pass

44
Q

On this model, demonstrate the factors maintaining the stability of the hip joint

A

Bony:
- Acetabular socket * reinforced by labrum *

Ligaments:
- Capsule
- Iliofemoral
- Ischiofemoral
- Pubofemoral

Muscles:
- Short muscles, especially gluteus medius and minimus

*needed to pass + 3 ligaments

45
Q

How does the popliteal artery supply the leg and foot?

A
  • Divides into posterior and anterior tibial arteries * at lower border of popliteus
  • Posterior tibial artery runs in posterior compartment than palpable posterior to medial malleolus *, and divides into medial and lateral plantar arteries to sole of foot
  • Main branch is fibular artery to posterior and lateral compartments
  • Anterior tibial artery * runs in anterior compartment then crosses anteriorly over ankle to become dorsalis pedis *

*needed to pass

46
Q

What functional deficit results from injury to the common fibular nerve and why?

A
  • Foot drop and high-stepping gait: loss of innervation of extensor muscle function (tibialis anterior, EDL, fibularis tertius, EHL)
  • Inability to evert foot: fibularis longus and brevis lost (superficial fibular nerve)
  • Sensory loss over cleft of first toe (deep fibular), and lower lateral part of leg and dorsum of foot (superficial fibular)
47
Q

What is the least stable position of the hip?

A

Flexion and adduction

48
Q

Identify this bone and its main features

A

R tibia:
- Medial and lateral condyles *
- Medial and lateral tibial plateaus, separated by intercondylar tubercles of the intercondylar eminence
- Tibial tuberosity *
- Shaft *
- Medial border
- Anterior border
- Interosseous border
- Soleal line (posterior)
- Medial malleolus *
- Fibula notch

*needed to pass

49
Q

Identify the attachments of the proximal end of this bone

A
  • Anterior and posterior horns of the medial meniscus
  • Anterior and posterior horns of the lateral meniscus
  • Anterior and posterior cruciate ligaments *
  • Patellar ligament *
  • Semimembranosus, vastus medialis (medial)
  • Iliotibial tract, EDL, fibularis longus (lateral)

*needed to pass

50
Q

What bones can you identify in this model?

A
  • Fibula *
  • Tibia *
  • Talus *
  • Calcaneus *
  • Cuboid *
  • Navicular *
  • Cuneiforms * (medial, intermediate, lateral)
  • 1st to 5th metatarsals *
  • Phalanges *

*needed to pass

51
Q

What structures make up the ankle joint?

A

Distal ends of the tibia and fibula *, the talus * and the inferior transverse part of posterior tibiofibular ligament

*needed to pass

52
Q

What movements occur through the ankle joint?

A

Plantar flexion
Dorsiflexion

53
Q

In what position of the foot is the ankle joint most unstable and why?

A

Plantar flexion, as then the trochlea (superior surface of the talus, which is narrower posteriorly) lies relatively loosely within the mortise between the malleoli

54
Q

Demonstrate the joints through which eversion/inversion of the foot occur

A
  • Subtalar (talocalcaneal) joint
  • Transverse (or mid) tarsal joint, consisting of the calcaneocuboid and talonavicular joints
55
Q

Identify factors that provide stability to the ankle joint

A

2/3 to pass:
1. Bony *:
- Ankle mortise around talus (lateral/medial malleolus and distal tibial articular surface), held together by anterior and posterior tibiofibular ligament
2. Ligamentous:
- Deltoid (medial) ligament with 4 parts: anterior and posterior tibiotalar, tibiocalcaneal, tibionavicular
- Lateral ligament with 3 parts: anterior and posterior talofibular ligament, calcaneofibular
- Distal tibiofibular syndesmosis
- Interosseous membrane
3. Muscular

56
Q

Demonstrate the attachments of the medial collateral ligament (deltoid ligament)

A

2/4 to pass:
- Anterior tibio-talar
- Posterior tibio-talar (to medial tubercle of talus)
- Tibio-calcaneal (to calcaneal shelf = sustenaculum tali)
- Tibio-navicular (to tuberosity of navicular)

57
Q

Describe the structures running immediately posterior to the medial malleolus

A
  • Tibialis posterior tendon
  • FDL tendon
  • Posterior tibial artery * and vein
  • Posterior tibial nerve
  • FHL tendon

*needed to pass + 2 tendons

58
Q

Describe the anatomy of the dorsalis pedis artery

A
  • Direct continuation of anterior tibial artery
  • Lies between EHL and EDL, and gives off medial tarsal artery, lateral tarsal artery (which joints the arcuate artery)
  • At the 1st interosseous space, divides into the 1st dorsal metatarsal artery and deep plantar artery (deep plantar artery join the lateral plantar artery to form the deep plantar arch)
58
Q

Identify the structures lying deep to the extensor retinaculum of the ankle

A

Medial to lateral:
- Tibialis anterior *
- EHL *
- Dorsalis pedis *
- Deep fibular nerve *
- EDL *
- Fibularis tertius
- EDB

*4/5 to pass

59
Q

Describe the cutaneous nerve supply of the foot

A

Dorsum *:
- Deep fibular nerve: 1st webspace
- Superficial fibular nerve (becomes dorsal digital nerves): majority of dorsum of foot
- Dorsal lateral cutaneous nerve of foot (terminal branch of sural nerve): lateral foot
- Saphenous nerve: medial foot below medial malleolus

Plantar *:
- Medial and lateral plantar nerves (terminal branches of tibial nerve)
- Calcaneal branches (of tibia and sural nerves)

*3/4 dorsal and 2/3 plantar to pass