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Anatomy for MRCS > Lower limb > Flashcards

Lower limb Flashcards

1
Q

What attaches to where on the ischial tuberosity?

A

Upper:

Medial = Semitendinosus + long head of biceps femoris
Lateral = Semimembranosus

Lower:
Lateral = adductor magnus
Medial = fascia and connective tissue

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2
Q

What attaches to ischiopubic ramus?

A

Muscles of medial thigh = adductors

Adductor longus, brevis and magnus
Pectineus
Gracillis

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3
Q

What forms the greater sciatic foramen?

A

Greater sciatic notch
Ischial spine
Sacrotuberous and sacrospinous ligament

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4
Q

Contents of greater sciatic foramen?

A

Nerves = sciatic, pudendal, inferior and superior gluteal, nerve to obturator internus, quadratus femoris and gemellus and posterior femoral cutaneous nerve

Vessels = inferior and superior gluteal nerves, internal pudendal vessels

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5
Q

Of the contents of the greater sciatic foramen, which pass above the piriformis?

A

Superior gluteal vessels and nerve

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6
Q

Which structures pass through both lesser and greater sciatic foramen?

A

Internal pudendal vessels and nerves

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7
Q

Contents of lesser sciatic foramen?

A

Nerve to obturator internus
Internal pudendal vessels and nerve
Tendon of obturator internus

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8
Q

Contents of lesser sciatic foramen medial to lateral?

A

PIN

Pudendal nerve
Internal pudendal vessels
Nerve to obturator internus
+ tendon to obturator internus

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9
Q

What passes through the gap between the inguinal ligament and the pelvic bone?

A

Muscles = pectineus, psoas major and illiacus

Femoral nerve, artery and vein

Femoral branch of GF
Lateral cutaneous nerve of thigh
Lymphatics

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10
Q

How do we divide the gluteal region muscles?

A

Superficial larger group = gluteals

Deep lateral hip rotators = Piriformis, gemellus, obturator internus, quadratus femoris

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11
Q

Attachment of the three gluteal muscles?

A 
Maximus = gluteal tuberosity of femur and IT tract
Medius = lateral greater trochanter
Minimus = anterior greater trochanter
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12
Q

deep muscles of the gluteal region?

A

All their action is laterally rotate hip and abduct flexed hip

Piriformis
Origin = anterior sacrum
Insertion = Greater trochanter
Nerve = S1, S2

Obturator internus
Origin = obturator foramen
Insertion = Medial greater trochanter / trochanteric fossa
Nerve to obturator internus

Gemellus superior
Origin = ischial spine
Insertion = superior surface of obturator tendon, medial greater trochanter
Nerve to obturator internus

Gemellus inferior
Origin = ischial tuberosity
Insertion = inferior obturator tendon + medial greater trochanter
Nerve to quadratus femoris

Quadratus femoris
Origin = Anterior to ischial tuberosity
Insertion = Quadrate tubercle on intertrochanteric crest
Nerve to quadratus femoris

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13
Q

Superficial muscles of the gluteal region?

A

Gluteus minimus = abducts femur, prevents pelvic drop
Origin = external ilium between inferior and anterior gluteal lines
Insertion = anterior greater trochanter
Superior gluteal nerve

Gluteus medius = as above
Origin = external ilium, between anterior and posterior lines
Insertion = lateral greater trochanter
Superior gluteal nerve

gluteus maximus = Powerful extensor of flexed hip
Origin = Fascia covering gluteus minimus + external ilium behind posterior gluteal line
Insertion = IT band and gluteal tuberosity of proximal femur
Inferior gluteal nerve

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14
Q

Superior nerve vs gluteal nerve supply?

A

Superior = medius, minimus and tensor fascia latae

Inferior = Maximus

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15
Q

Which hip replacement approach injures which nerve?

A

Posterior approach = sciatic nerve

Anterolateral approach = superior gluteal = trendelenberg gait due to loss of adductors

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16
Q

Which arteries do the superior gluteal and inferior gluteal arise from?

A

Inferior gluteal = anterior trunk of internal iliac

Superior gluteal = posterior trunk of internal iliac

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17
Q

Where does the ligament of head of femur run, what does it contain and significance in children?

A

Also called ligament of Teres

Attaches at one end to the fovea of femur, other end attaches too acetabular fossa

Contains branch of obturator artery

In children = contains arterial supply to femoral head

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18
Q

3 extracapsular ligament of the hip joint?

A

Iliofemoral = anterior hip joint
- runs from ilium to intertrochanteric line of femur

Pubofemoral = runs from iliopubic eminence to blend with deep surface of iliofemoral

Ischiofemoral = posterior hip joint
- runs from medial ischium to greater trochanter, deep to iliofemoral

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19
Q

Where does the fascia lata have its one opening and what passes through?

A

Saphenous opening for great saphenous vein

Opening is just inferior to medial inguinal ligament

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20
Q

What bone does the femur articulate with inferiorly?

A

Tibia

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21
Q

What angle does the NOF meet the head?

A

125

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22
Q

What is the site of attachment for iliofemoral ligament?

What else inserts here?

A

Intertrochanteric crest medially

Quadratus femoris (on quadrate tubercle)

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23
Q

Which muscles attach to greater trochanter?

A

Gluteus medius and minimus + vastus lateralis

POGO:
Piriformis
Obturator internus
Gemellus
Obturator externus
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24
Q

What muscles attach to lesser trochanter?

A

Psoas major and illiacus

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25
Q

What muscles attach to upper middle part of linea aspera?

A

Thigh adductors and vastus muscles

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26
Q

Where do the two heads of the gastrocnemius insert?

Popliteus?

A

Medial head = roughened area above medial epicondyle on femur

Lateral head = facet above lateral epicondyle
Popliteus is just below this

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27
Q

Blood supply to femoral heaD?

A

Ring formed by medial and lateral femoral circumflex arteries = branch of profounda femoris

Also some small branches from inferior and superior gluteal arteries

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28
Q

In what position does the patellofemoral provide stability?

A

Full extension

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29
Q

4 ligaments of the knee joint?

A

MCL = from medial femoral epicondyle to medial tibial epicondyle
- prevents valgus instability

LCL = lateral femoral epicondyle to fibula head = prevents vagus instability

ACL = anterior tibia to lateral intercondylar notch of the femur = prevents tibia sliding anteriorly

PCL = posterior tibia to medial intercondylar notch of femur = Prevents tibia sliding posteriorly

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30
Q

Which ligament does the medial and lateral menisci attach to?

A

Medial attaches to tibial collateral ligament

Lateral attaches to loose fibres at edge of joint space > doesn’t actually attach to fibular collateral ligament

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31
Q

What ligament interconnects the menisci ?

A

Anteriorly it is the transverse ligament

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32
Q

Describe the superior surface of tibia?

A

2 condyles

Separated by intercondylar region = facets for attachment of ACL PCL and menisci

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33
Q

Semimembranosus origin and insertion?

A

Ischial tuberosity to medial condyle of tibia

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34
Q

What is the continuation of the quadriceps tendon, where does it attach?

A

Quadriceps tendon continues as patellar tendon

This inserts onto the tibial tuberosity

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35
Q

What attaches to the roughened area below tibial tuberosity?

A

Combined muscles of gracilis, sartorius and semitendinosus = pes anserinus

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36
Q

ACL injury - mechanism, symptoms and Mx?

A

High twisting force on bent knee

Loud crack, pain + immediate swelling

Mx = intense physio + surgery

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37
Q

PCL injury - mechanism?

A

Hyperextension injury

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38
Q

MCL injury - mechanism?

A

Leg forced into valgus

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39
Q

Meniscal tear - symptoms and mechanism?

A

Rotational injury

DELAYED knee swelling, joint locking, recurrent effusions and pain

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40
Q

Chondromalacia patellae - mechanism and symptoms?

A

teenage girls following a knee injury

Pain going down stairs, tenderness + quads wasting

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41
Q

Patellar dislocation - Mechanism, RF’s, imaging?

A

traumatic primary event.

RF’s = Genu valgum, tibial torsion, high riding patella

needs skyline radiographs

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42
Q

Boundaries of the popliteal fossa?

A

Lateral = biceps femoris above, plantaris and lateral head of gastrocnemius below

Medial = Semimembranosus/tendinosus above, medial head of gastrocnemius below

Roof = superficial fascia

Floor = Popliteal muscle. and popliteal surface of femur, posterior ligament of knee joint,

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43
Q

Contents medial to lateral of popliteal fossa?

A

Popliteal artery
Popliteal vein
Small saphenous vein
Tibial and common peroneal nerve
- tibial exits medially deep to margin of plantaris
- common peroneal exits following biceps femoris tendon where it wraps around neck of fibula.

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44
Q

Popliteal fossa - deepest and most superficial structure

A

Deepest = popliteal artery

Most superficial = tibial and common peroneal nerve

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45
Q

Where does femoral artery become popliteal?

A

When it passes through adductor hiatus in adductor magnus

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46
Q

What divides up the compartments of the leg?

A

Interosseous membrane, two inter muscular septa between fibula and deep fascia + direct attachment of deep fascia to periosteum of tibia

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47
Q

What are the different compartments of the lower leg?

A

Anterior = dorsiflexes, extends toe, inverts foot
Posterior compartment = plantar flexes, flexes toe, inverts foot
Lateral compartment = everts foot

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48
Q

Facets and fossa on lateral malleolus?

A

Facet for articulation with talus
Posteroinferior to this = fossa for attachment of talofibular ligament
Groove posteriorly for tendons of fibularis longus and brevis

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49
Q

How many apertures does the interosseous membrane have?

A

2 - one at top one at bottom.
Upper has anterior tibial artery
Lower has anterior peroneal artery

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50
Q

Femoral nerve - root, innervation and course

A

L2/3/4

Penetrates psoas major - supplies branches to pectineus and iliacus in its abdominal part.

Enters thigh by passing below inguinal ligament and enters femoral triangle.

Branches immediately into anterior and posterior division
Posterior = sartorius and medial/intermediate cutaneous branches
Anterior = quadriceps femoris and saphenous nerve.
Terminal cutaneous branch is saphenous nerve which travels in adductor canal.

Supply:
(don't) MIS VQ Scan for PE
Medial cutaneous nerve
Intermediate cutaneous nerve 
Saphenous nerve 
Quadriceps femoris
Sartorius 
Pectineus
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51
Q

Does the saphenous nerve exit the adductor hiatus with femoral nerve?

A

NO

It pierces directly through connective tissue at the end of the canal

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52
Q

Lateral cutaneous nerve - root and course?

A

L2/L3

Exits lateral part of psoas major anterior to iliac crest, passes under inguinal ligament at lateral part of it just medial to ASIS
Pierces fascia lata just below ASIS to give 2 branches

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53
Q

What are the 2 branches of the lateral cutaneous nerve and what do they supply?

A

Anterior branch = skin and fascia of anterolateral knee

Smaller posterior branch = skin from greater trochanter to distal thigh

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54
Q

Pudendal nerve - roots and path and action?

A

S234

Passes through greater sciatic foramen, then enters perineum passing via lesser sciatic foramen
Passes between piriformis and coccygeal.
Medial to sciatic nerve

Innervates anal sphincter and external urethral sphincter
Cutaneous = surrounding anus and vulva

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55
Q

Pudendal nerve clinically - anaesthesia and late pregnancy affects?

A

Can be blocked in episiotomy

In late pregnancy foetus can compress = pudendal neuropathy= faecal incontinence

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56
Q

3 branches of the pudendal nerve?

A

rectal, perineal and dorsal nerve of penis/clitoris

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57
Q

Genitofemoral nerve - roots, course and supply?

A

L2/3

Passes obliquely through psoas, emerges at medial border and travels on its anterior surface
Divides into genital and femoral branches
Genital travels in inguinal canal within spermatic cord.
Femoral inters thigh posterior to inguinal ligament

Genital = skin of scrota and fascia
Femoral = skin over femoral triangle
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58
Q

How can the genitofemoral nerve be injured?

A

Abdominal surgery / inguinal hernia repair

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59
Q

Obturator nerve - roots and path?

A

L2/3/4

Travels inferiorly in posterior of psoas major, before exiting at medial part
Passes anterior to sacroiliac joint
Descends on obturator internus into obturator groove
In lesser pelvis lies lateral to internal iliacs and ureter
Enters thigh to give anterior and posterior branches

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60
Q

Obturator nerve - what the two branches supply?

A

Anterior branch - it is anterior to adductor brevis, and behind pectineus and longus
supplies = Adductor longus, brevis and gracilis

Posterior branch = descends behind adductor brevis
Supplies = obturator externes, adductor brevis and the upper part of adductor magnus

61
Q

What organ is obturator nerve closely related to?

A

Bladder - can get twitching of thigh in transurethral resection of bladder tumour

62
Q

Sciatic nerve - roots, path and supply?

A

L4-S3

Roots converge at inferior border of piriformis, travels through greater sciatic foramen
Then runs inferolaterally under cover of gluteus maximus
Travels in posterior compartment of thigh superficial to adductor magnus
Travels downwards and at top of popliteal fossa gives tibial and common peroneal

Supply:
Motor: Semimembranosus/tendinosus, biceps femoris and. lower part of adductor magnus
Cutaneous = posterior thigh, gluteal region

63
Q

Tibial nerve - Route and innervation?

A

Branch of sciatic
Descends through popliteal fossa and continues in the posterior compartment of the leg on surface of tibialis posterior into sole of foot
Passes into foot via tarsal tunnel posterior to medial malleolus.

Innervates all muscles of posterior compartment EXCEPT SHORT HEAD BICEPS FEMORIS
Innervates all intrinsic muscles of the foot except 1st 2 dorsal interossei (deep peroneal)

64
Q

two cutaneous branches of tibial nerve?

A

Medial calcaneal nerve = originates from tibial nerve in lower leg near ankle and descends on medial side of heel
Supply = medial foot / heel

Sural nerve = originates in high leg between two heads of gastrocnemius. Passes down the leg around lateral malleolus
Supply = lower posterior leg and lateral ankle / foot + little toe

65
Q

Common peroneal nerve - route and innervation?

A

Branch of sciatic
Passes inferolaterally in popliteal fossa under the cover of the biceps femoris and tendon
Follows the medial margin of this, and passes over lateral head of gastrocnemius
Once it has passed around fibular head it divides into deep and superficial peroneal where it wraps around neck.

Innervation = short head of biceps femoris, lateral cutaneous nerve of calf, superficial and deep peroneal

66
Q

How can common peroneal be injured?

A

In legs in Lloyd Davies position = foot drop

If only superficial is injured then no foot drop as deep peroneal also has dorsiflexion innervation

67
Q

Deep branch of peroneal - route and innervation?

A

Pierces anterior inter muscular septum to enter anterior compartment of leg
Travels deep to extensor digitorum longus
Passes anteriorly down the ankle joint

Muscles = TEEP (which sounds like deep)
Tibialis anterior
Extensor hallucis longus
Extensor digitorum brevis and longus
Peroneus tertius

Cutaneous = web space between 1st and second toe

68
Q

In anterior compartment syndrome what nerve can be at risk?

A

Deep peroneal nerve - needs immediate decompression

69
Q

Superficial peroneal nerve - Route and innervation?

A

Descends in LATERAL compartment
Passes between peroneus longus and brevis
Just distal to fibula it bifurcates intermediate and dorsal cutaneous nerves

Lateral compartment = peroneus longus and brevis
sensation = dorsum of foot except the deep peroneals web

70
Q

What is the femoral artery a continuation of?

A

External iliac

71
Q

What are the four small branches of the femoral artery?

A

Superficial epigastric
Superficial circumflex iliac
Superficial external pudendal
Deep external pudendal

All occur in femoral triangle

72
Q

What is the biggest branch of the femoral and its route?

what are its branches?

A

Profunda femoris

Passes posteriorly between pectineus and adductor longus
Then between adductor longus and brevis
Eventually penetrates adductor magnus to connect with popliteal branches

Lateral and medial circumflex, + 3 perforating arteries

73
Q

What is the route of the lateral circumflex branch of the profunda femoris ?

A

Lateral circumflex:

Ascending branch = deep to fascia tensor lata, joins medial circumflex to form circle around NOF

Descending branch = deep to rectus femoris, pierces vastus lateralis and connects with popliteal branches

Transverse branch = passes laterally to pierce vastus lateralis, then circles shaft of femur to form CRUCIATE ANASTOMOSES around hip.

74
Q

What is the route of the medial circumflex branch of profunda femoris?

A

Passes medial around shaft of femur
Passes between pectineus and Iliopsoas
Then passes between obturator externus and adductor brevis

One branch ascends to trochanteric fossa
One passes lateral to form anastomoses around hip

75
Q

Route of perforating arteries of profunda femoris?

A

Pass anterior to adductor brevis

All the branches penetrate adductor magnus

76
Q

Obturator artery - what is it a continuation of, what is its route?

A

Continuation of internal iliac

Enters medial compartment of thigh via obturator canal
Passes through canal and bifurcates into posterior and anterior branch

77
Q

Popliteal artery - route?

A

Continuation of femoral artery.
Passes into posterior compartment of leg between two heads of gastrocnemius and popliteus
Continues inferiorly underneath tendinous arch and between two heads of soles muscle and enters deep compartment

In deep compartment branches to form anterior tibial and tibioperoneal trunk

78
Q

Posterior tibial artery - course and branches + supply?

A

Supplies posterior and lateral compartments

Descends in the deep posterior compartment, on superficial surface of tibialis posterior and FDL
Passes via tarsal tunnel behind medial malleolus into sole of foot

2 major branches:

  1. Circumflex fibular = passes laterally through soleus and back round fibular neck
  2. Fibular artery = passes along lateral posterior compartment
  3. has perforating branch through infeiror aperture of interosseous membrane = anastomoses with branch of anterior tibial.
  4. Terminates by forming network over calcaneus = medial and lateral planter arteries
79
Q

What nerve is in close proximity to the posterior tibial artery?

A

Tibial nerve
Crosses the posteiror tibial artery 2.5cm from the origin.
Initially lies medial then crosses to the lateral side of the artery

80
Q

Anterior tibial artery - course, how it terminates and what it supplies?

A

Supply = ANTERIOR COMPARTMENT OF THE LEG

Course:
Descends on anterior interosseous membrane
Passes between tendons of extensor digitorum and extensor hallucis longus
Terminates in front of ankle as dorsals pedis

81
Q

Anterior tibial artery in relation to deep peroneal nerve?

A

Nerve is lateral proximally
Crosses over anteriorly in the middle third
nerve is then medial to artery in lower third

82
Q

What is the dorsals pedis a continuation of?

A

Anterior tibial artery, which itself is a branch of popliteal. Which itself comes from femoral, which is a continuation of external iliac.

83
Q

Dorsalis pedis - course?

A

Runs to proximal end of first metatarsal space
Continues forward as first dorsal metatarsal artery
Gives off arcuate artery

Passes under inferior extensor retinaculum
Crossed by extensor hallucis brevis

84
Q

What veins form the long saphenous vein?
Near its origin what vessel runs near it?

what nerve is it associated with?

A

Dorsal vein merges with dorsal venous arch

Deep external pudendal artery runs under it - can be injured in surgery

Saphenous nerve

85
Q

Route of long saphenous vein?

A

Originates at first digit
Formed by margin of dorsal vein and dorsal venous arch
Passes ANTERIOR to medial malleolus, runs up medial leg
At knee runs over posterior medial epicondyle
then passes laterally in anterior thigh, through saphenous opening of fascia lata
Joins with femoral vein

86
Q

Tributaries of long saphenous vein?

A

Medial marginal
Superficial epigastric
Superficial iliac circumflex
Superficial external pudendal veins

87
Q

what nerve is associated with short saphenous vein?

A

Sural nerve

88
Q

Route of short saphenous vein?

A

Formed at 5th digit with dorsal vein merging with dorsal venous arch
Passes POSTERIOR and inferior to lateral malleolus
Passes between 2 heads of gastrocnemius and drain into popliteal vein
This becomes femoral vein

89
Q

What nerve supplies anterior compartment of thigh?

Which muscles are in the anterior compartment?

A

Femoral

Quads and vastus
Psoas major and iliacus
Sartorius

90
Q

Muscles of the anterior thigh - origin, insertion and action?

A

Psoas major = hip flexor
Origin = T12-L5 transverse processes + post. abdominal wall
Insertion = Lesser trochanter of femur

Iliacus = hip flexor
Origin = Posterior abdominal wall
Insertion = lesser trochanter 
Sartorius = flex hip, extend knee
Origin = ASIS
Insertion = inferomedial to tibial tuberosity (anterior to gracilis and semi-tendinosus)

Rectus femoris = flexes thigh and extends knee
Origin = Straight head from ASIS, reflected head from ilium above acetabulum

Vastus medialis
Origin = Medial part of intertrochanteric line, linea aspera and pectineal line

Vastus intermedius
Origin = upper 2/3rds of anterolateral femur

Vastus lateralis
Origin = lateral 2/3rds of IT line, pectineal line and linea aspera

All vasti insert into quadriceps tendon and extend knee

91
Q

Which nerve specifically supplies sartorius, and what does the middle third of sartorius form?

A

Superficial femoral

Roof of adductor canal
- contains femoral vessels, saphenous nerve + nerve to vastus medialis

92
Q

Muscles of posterior compartment of thigh - origin, insertion and innervation?

A

Biceps femoris short head:
Origin = Lateral lip of linea aspera
Insertion = fibular head
Common peroneal

Biceps femoris long head
Origin = ischial tuberosity
Insertion = fibular head
Tibial

Semitendinosus
Origin = Ischial tuberosity
Insertion = medial surface of proximal tibia
Sciatic

Semimembranosus
Origin = Ischial tuberosity
Insertion = medial condyle tibia
Sciatic

93
Q

Which muscles sit in the medial compartment of the thigh?

A

Adductor longus, magnus and brevis
Obturator externus
Gracilis + pectineus

94
Q

Muscles of medial compartment - origin, insertion and innervation

A

Gracilis = adducts thigh + flexes knee
Origin = Line on body of pubis, inferior pubic rami, ramus of ischium
Insertion = Medial surface of proximal tibia > between tendon of sartorius and semimembranosus
Obturator

Pectineus = adducts and flexes hip
Origin = Pectineal line of pubis
Insertion = Oblique line from lesser trochanter to linea aspera
Femoral nerve

Obturator externus = Laterally rotates hip
Origin = external obturator membrane and adjacent bone
Origin = Trochanteric fossa
Obturator nerve

Adductor brevis
Origin = Inferior pubic ramus
Insertion = upper third of linea aspera
Obturator nerve

Adductor longus
origin = anterior body of pubis
Insertion = middle third of linea aspera
Anterior division of obturator

Adductor magnus:
*Adductor part:
Origin = ischiopubic ramus
insertion = posterior femur and linea aspera 
Obturator nerve

*Hamstring part:
origin = Ischial tuberosity
Insertion = adductor tubercle and supracondylar line
Tibial nerve from sciatic

95
Q

Boundaries of adductor canal and contents?

A 
Laterally = vastus medialis 
Posteriorly = adductor Magnus and longus
Roof = sartorius

Contents = Femoral vessels, saphenous nerve and nerve to vastus medialis

96
Q

What muscles are in the anterior compartment of the leg and what innervates them all?

A 
PETE
Peroneus tertius
Extensor digitorum longus
Tibialis anterior
Extensor hallucis longus

Deep peroneal nerve

97
Q

muscles of anterior compartment of the leg - section, origin and insertion?

A

Peroneus tertius = dorsiflex and evert
Origin = medial fibula distally
Insertion = base of 1st metatarsal

Extensor digitorum longus = dorsiflex foot and extend lateral 4 toes
Origin = proximal half of medial fibula and lateral tibial condyle
Insertion = distal and middle phalanges of lateral 4 toes

Tibialis anterior = dorsiflexes and invert foot
Origin = lateral surface of tibia and associated interosseous
Insertion = medial and inferior cuneiform + adjacent base of 1st metatarsal

Extensor hallucis longus = dorsiflex and extend big toe
Origin = middle half of medial fibula and associated interosseous membrane
Insertion = base of distal phalanx of great toe

98
Q

What nerve innervates the lateral compartment of leg?

A

Superficial peroneal nerve

99
Q

Muscles of lateral compartment of lower leg - action, origin and insertion?

A

Peroneus longus = plantarflex and evert
Origin = upper lateral fibula and fibular head
Insertion = underside of cuneiform and base of first metatarsal

Peroneus brevis = eversion only
Origin = lower lateral fibula
Insertion = lateral tubercle at base of 5th metatarsal

100
Q

Which nerve innervates the superficial posterior compartment of leg?

A

Tibial nerve

101
Q

Muscles of the superficial posterior compartment of the leg - action, origin and insertion?

A

all three insert via the calcaneal tendon into the posterior calcaneus

GPS

Gastrocnemius = plantarflex foot and flex knee
Medial head = femur above medial condyle
Lateral head = lateral condyle of femur

Plantaris = plantarflex foot and flex knee
Origin = inferior part of lateral supracondylar line of femur
Soleus = plantarflex
Origin = soleal line and medial tibia
102
Q

Which nerve innervates all the deep posterior compartment muscles of the leg?

A

Tibial nerve

103
Q

Muscles of the posterior deep compartment of the leg - origin, insertion and action?

A

PFFT
Popliteus, flexor hallucis longus, flexor digitorum longus, tibialis posterior

Popliteus = stabilises and unlocks knee joint
Origin = lateral femoral condyle
Insertion = posterior proximal tibia

Flexor hallucis longus = flexes great toe
Origin = posterior surface of fibula
Insertion = plantar surface of distal phalanx of big toe

Flexor digitorum longus = flexes lateral four toes
Origin = medial side of posterior tibia
Insertion = plantar surface of base of distal phalanges

Tibialis posterior = inversion and plantar flexion
Origin = posterior interosseous membrane
Insertion = navicular tuberosity

104
Q

Medial ligaments of the ankle joint?

A

Deltoid ligament = 4 subdivisions, all from tibia to something

  1. tibionavicular - navicular tuberosity
  2. tibiocalcaneal - to sustenaculum of calcaneum
  3. anterior tibiotalar = attaches to medial talus (deep to the above 2)
  4. Posterior tibiotalar = medial tubercle of talus
105
Q

Lateral ligaments of the ankle joint?

A

From anterior to posterior…

Anterior talofibular = anterior lateral malleolus to adjacent talus

Calcaneofibular = lateral malleolus to tubercle on calcaneus

Posterior talofibular ligament = medial lateral malleolus to posteiror talus

106
Q

Syndesmosis ligaments?

A

Anterior inferior, posterior inferior and inferior transverse TIBIOFIBULAR
Interosseous membrane

107
Q

Structures passing behind medial malleolus?

A

3 tendons, x1 artery, vein and nerve

From anterior to posterior…..

Tibialis posteiror tendon 
FDL tendon 
Posterior tibial vein
Posterior tibial artery 
Tibial nerve 
FHL tendon
108
Q

Structures passing behind lateral malleolus?

A

Deep to superior peroneal retinaculum = peroneus brevis and longus tendon

Superficial to superior peroneal retinaculum = sural nerve and short saphenous vein

109
Q

What makes up the two longitudinal arches of the foot?

A

Lateral arch = Calcaneum, talus, cuboid bone and lateral 2 metatarsals

Medial arch = Calcaneum, talus, Navicular bone, three cuneiforms and medial three metatarsals head of talus

110
Q

What makes up the transverse arch of the foot?

A

three cuneiforms, cuboid, 5 bases metatarsals

111
Q

Which is the most superior tarsal bone?

A

Talus

112
Q

What does the talus articulate with?

A

Medially = medial malleolus of tibia
Laterally = lateral malleolus of fibula
Superior surface articulates with inferior tibia

Projects forward to articulate with navicular bone

Posteriorly articulates with calcaneus and has groove for FHL.

113
Q

Where does calcaneal tendon attach distally?

A

MIDDLE part of calcaneus = tuberosity

114
Q

What is on the lower part of the calcaneus and what attaches here?

A

Calcaneal tubercle

Short plantar ligament

115
Q

Articulations of the calcaneus?

A

Projects forward to articulate with cuboid
Superiorly articulates with talus

Medial surface has fibular trochlea = tendons of peroneus longus and brevis run here and at this point diverge
Just superior and posterior to this is roughening = attachment of calcaneofibular ligament.

Medially has groove for flexor hallucis longus

116
Q

What is superior to fibular trochlear on calcaneus and what attaches here?

A

Raised area for attachment of calcaneofibular ligament

117
Q

What does the navicular bone articulate with and what tendon attaches?

A

Articulates posteriorly with talus, anteriorly with cuneiforms

Has prominent tuberosity for attachment of tibialis posterior tendon

118
Q

What is the set up of the distal tarsal bones and what do they articulate with?

A

Cuboid laterally then three cuneiforms moving medially

Cuboid articulates with calcaneus posteriorly, anteriorly lateral 2 metatarsals and medially with lateral cuneiform + navicular

Cuneiforms articulate posteriorly with navicular and anteriorly with the three medial metatarsal bases

119
Q

What three ligaments support the talocalcaneonavicular joint?

A 
Inferiorly = plantar calcaneonavicular
Superiorly = talonavicular 
Posteriorly = interosseous talocalcaneal ligament
120
Q

What forms the tarsal tunnel?

A

Its on posteromedial ankle

Depression on medial malleolus of tibia
Posterior and medial talus

Medial calcaneus and inferior sustenaculum tali

Overlying flexor retinaculum

121
Q

Where does flexor retinaculum attach?

A

Superiorly to medial malleolus

Inferiorly behind medial margins of calcaneus

122
Q

What runs through the tarsal tunnel?

A

Medial to lateral… (all posterior to medial malleolus)

Tendon of tibialis posterior
Tendon of flexor digitorum longus 
Posterior tibial artery + vein
Tibial nerve 
Tendon of FHL
123
Q

attachment of the extensor retinaculum?

A

Superior one is thickening of deep fascia = attached to anterior surface of tibia and fibula

Lower one attaches to upper part of calcaneus
Then two arms move medially - one attaches to medial malleolus, one attaches to medial plantar aponeurosis

124
Q

Content of extensor retinaculum?

A

Medial to lateral…

Tendon of tibialis anterior
Tendon of EHL
Dorsalis pedis artery
Peroneus tertius tendon
EDL tendons
125
Q

Fibular retinacula - attachments and contents?

A

superior one attaches between lateral malleolus and calcaneus

Inferior one attaches to lateral calcaneus (fibular trochlea) and blends with inferior extensor retinaculum

Binds the tendons of the peroneus longus and brevis

126
Q

What is the plantar aponeurosis, what is it attached to and how does it finish?

A

Thickening of deep fascia of foot

Attaches to calcaneal tuberosity, extends anteriorly as thick band of tissue.
Then diverges into Digital bands

distal to the MTP joints these bands are joined by superficial transverse metatarsal ligaments

127
Q

What forms the fibrous sheaths of the toes?

A

Fibrous arches and cruciate ligaments

128
Q

What runs within the fibrous arches of toes?

A

tendons of FHL, FDL, FDB - they enter on the palmar aspect

FDB is inferior to FDL

129
Q

What runs in extensor hoods?

A

Tendons of EDL, EDB, EHL

130
Q

Which muscles are innervated by medial plantar nerve?

A

Abductor hallucis
Flexor hallucis brevis
FDB

131
Q

Muscles innervated by medial plantar nerve - action, origin, and insertion?

A

Abductor hallucis = abducts big toe
origin = medial calcaneus, flexor retinaculum
insertion = base of proximal phalanx

FDB = flexes all joints of the toe except DIP J's
Origin = medial calcaneus
Insertion = via 4 tendons into middle phalanges of lateral 4 toes

FHB = flexes MTP of big toe
Origin = medial cuboid bone and adjacent lateral cuneiform
Insertion = proximal phalanx of big toe
(tendon contains sesamoid bone)

132
Q

Which muscles are innervated by the lateral plantar nerve?

A 
Flexor digiti minimi brevis
Abductor digiti minimi
Adductor hallucis
Quadratus plantae 
Palmar and dorsal interossei
133
Q

Muscles innervated by lateral plantar - action, origin and insertion?

A

Flexor digiti minimi brevis - flexes little toe at MTP
Origin = base of metatarsal 5
Insertion = lateral side of base of proximal phalanx

Abductor digiti minimi - abducts little toe at MTP
Origin = tubercle of calcaneus
Insertion = lateral proximal phalanx

Adductor hallucis = adducts towards 2nd toe
Origin = oblique head from peroneus longus tendon, transverse head from plantar surface of lateral 4 MTPJ’s
Insertion = Lateral proximal phalanx of great toe

Quadratus plantae = assists FDL tendon in flexing toes 2-5
Origin = medial calcaneus and lateral calcaneal tuberosity
Insertion = lateral side of tendon of FDL

Dorsal interossei = abduct toes 2-4 at MTPJ (second toe abducts both ways)
Origin = side of adjacent metatarsals
Insertion = extensor hoods and bases of proximal phalanges 2-5
1st and second ones are innervated by deep peroneal too!

Palmar interossei = adduct toes 3-5
Origin = medial metatarsals
Insertion = extensor hoods and base of proximal phalanx 3-5

134
Q

Which muscles are innervated by deep peroneal?

Origin, insertion and action

A

Extensor digitorum brevis

Action = Extends MTPJ’s of medial four toes
But cannot extend IP’s without lumbricals

Origin = dorsal foot, calcaneus
Insertion = four thin tendons running forward and insert into medial four toes
135
Q

What innervates the lumbricals in the foot?

A

1st lumbrical is medial plantar nerve

2-4th lumbrical = lateral plantar nerve

136
Q

Lumbricals - origin, insertion and action?

A

Origin:
1st lumbrical is medial to FDL tendon of 2nd toe
The rest then fill in the adjacent gaps between tendons of FDL

Insertion = medial free margin of extensor hoods

Flexes MTPJ’s, extends IPJ’s

137
Q

Route of the posterior tibial artery?

A

enters sole via tarsal tunnel

As it passes under flexor retinaculum it branch into medial and lateral plantar arteries

138
Q

Medial plantar artery vs lateral plantar artery route?

A

Medial passes deep to abductor hallucis
Passes forward between abductor hallucis and FDB
ends by joining digital branch of deep plantar arch

Lateral artery passes deep to abductor hallucis
Then passes forward between quadratus and FDB
Joins with terminal end of dorsals pedis to form deep plantar arch

139
Q

What is the course of the dorsalis pedis

What are its branches?

A

Direct continuation of anterior tibial
Forms as anterior tibial crosses ankle joint
Passes anterior over talus, navicular and intermediate cuneiform

Branches = tarsal, arcuate, first dorsal metatarsal + deep plantar

140
Q

Great and short saphenous vein - medial or lateral, anterior or posterior to malleolus?

A

Great saphenous vein = medial = anterior to medial malleolus

Short = lateral = posterior to lateral malleolus

141
Q

How does tibial nerve split and into what?

Course of the two nerves?

A

Tibial nerve passes through tarsal tunnel and midway between medial malleolus and heel splits into medial and lateral plantar nerves

Medial plantar:
Passes forward under cover of flexor retinaculum
Lateral to the medial plantar artery

Lateral plantar:
Deep to proximal attachment of abductor hallucis
Passes anterolaterally towards base of 5th metatarsal between FDB and quadratus
Medial to lateral plantar artery
At base of 5th metatarsal it splits into superficial and deep plantar branches

142
Q

What pathology do we see at superficial plantar nerve?

A

The common plantar digital branch of this is often the site of Mortons neuroma
= pain in third interspace

143
Q

Deep peroneal nerve - relation to dorsalis pedis, sensory innervation and motor?

A

Lateral to dorsalis pedis
web between 1st and second toe
Motor = extensor digitorum brevis

144
Q

Superficial peroneal = how it enters foot and sensory supply?

A

Enters via dorsal superficial fascia

Sensory to most of dorsum of the foot, except web suppled by deep peroneal

145
Q

Sural nerve - branch of, how it enters foot and sensory supply?

A

Cutaneous branch of tibial nerve

Enters in superficial fascia posterior to lateral malleolus

Supplies thin strip on lateral foot

146
Q

Saphenous nerve - sensory innervation?

A

Medial ankle

147
Q

Draw the sensory innervation of foot?

A

Good luck

148
Q

What nerve supplies the deep posterior compartment of the leg?

Where do 3 of these muscles all travel?

A

Tibial nerve

3 of them - Tom, Dick and Harry - all pass posterior to medial malleolus:
Tibialis posterior
FDL
FHL

Anatomy for MRCS (7 decks)

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