Anatomy - Lower Leg and Ankle

Question 1

What is intraosseous (IO) access ? When is it used?

Answer 1

An effective route for fluid resuscitation and drug delivery directly into bone when patient is very unwell (especially in children)

Question 2

What is found here? What attaches here?

Answer 2

Tibial tuberosity (with medial and lateral tibial condyles either side) - attachment site of quads via patella tendon

Question 3

What features of the tibia and fibula are present distally?

Answer 3

Elongated pieces of bone –> medial and lateral malleolus

Question 4

What is the lateral malleolus? What forms it?

Answer 4

The bony prominence on the lateral side of the ankle joint - It is formed by the inferior end of the fibula.

Question 5

What is the medial malleolus? What forms it?

Answer 5

The medial malleolus is the prominence on the inner side of the ankle, formed by the lower end of the tibia.

Question 6

What forms the articular surface for the ankle joint? What is this called?

Answer 6

Formed by the curved undersurface of the tibia, and the inner surfaces of the medial malleolus, and the lateral malleolus –> the ankle mortise

Question 7

What bone sits in the ankle mortise?

Answer 7

The talus (this forms the ankle joint)

Question 8

What movement is this?

Answer 8

Extension (dorsiflexion)

Question 9

What movement is this?

Answer 9

Flexion (plantarflexion)

Question 10

What muscles perform extension (dorsiflexion)?

Answer 10

Extensor muscles that lie on anterior aspect of leg

Question 11

Which muscles perform flexion (plantarflexion)?

Answer 11

Flexors lying in posterior compartment of leg

Question 12

Where do inversion and eversion movements of the foot happen?

Answer 12

At the subtalar joint

Question 13

What is the subtalar joint between?

Answer 13

The subtalar joint is an articulation between two of the tarsal bones in the foot – the talus and calcaneus

Question 14

What is being pointed to? Where is it found?

Answer 14

Soleal line - posterior aspect of tibia

Question 15

What attaches to the soleal line?

Answer 15

large muscle of leg - ‘soleus’ (calf muscle)

Question 16

How can you tell if a tibia is right or left?

Answer 16

• Look for medial malleolus (should be on same side as big toe i.e. face medially)
• Then look for anterior or posterior surface (sharp anterior or soleal line)

Question 17

What bone is being pointed to?

Answer 17

Talus

Question 18

What is the ‘heel’ bone?

Answer 18

Calcaneus

Question 19

What does the calcaneus articulate with?

Answer 19

The calcaneus connects with the talus and cuboid bones

Question 20

What bone is being pointed to?

Answer 20

Navicular (tarsal bone)

Question 21

What bone is being pointed to?

Answer 21

Cuboid (most laterally)

Question 22

What bone is being pointed to?

Answer 22

Medial cuneiform bone

There are three cuneiform bones: The medial cuneiform (also known as first cuneiform) is the largest of the cuneiforms. It is situated at the medial side of the foot, anterior to the navicular bone and posterior to the base of the first metatarsal. Lateral to it is the intermediate cuneiform.

Question 23

View of metatarsals and phalanges

Answer 23

Question 24

What joint is being pointed to?

Answer 24

Tarsometatarsal joint

Question 25

What joint is being pointed to?

Answer 25

Metatarsophalangeal joint

Question 26

What joint is being pointed to?

Answer 26

The hallux interphalangeal joint (big toe)

Question 27

Muscles of the anterior leg generally act on the ankle and toes as...?

Answer 27

Extensors

Question 28

Muscles of the lateral leg generally act on the ankle as...?

Answer 28

Everters (on subtalar joint)

Question 29

The nerve of the anterior leg is...?

Answer 29

The deep fibular (a branch of the common fibular)

Question 30

The nerve of the lateral leg is...?

Answer 30

The superficial fibular (branch of common fibular)

Question 31

What is being pointed to? Where are the muscles of the anterior compartment found in relation to this?

Answer 31

Sharp anterior border of tibia - muscles found lateral to this

Question 32

What bony projection is being pointed to?

Answer 32

Lateral malleolus

Question 33

How are the compartments of muscles of the leg separated?

Answer 33

The **deep fascia** of the leg sends **intermuscular septae** into leg to separate compartment

Question 34

What fibrous band is seen here? What does it cover?

Answer 34

Extensor retinaculum - covers and protects long tendons as they travel across the anterior part of ankle

Question 35

Innervation and arterial supply of muscles of anterior compartment of leg?

Answer 35

Deep fibular nerve (branch of common fibular) and anterior tibial artery

Question 36

What are the muscles of the anterior compartment of the leg?

Answer 36

* Tibialis anterior * Extensor digitorum longus * Extensor hallucis longus * (peroneus tertius muscle, also known as fibularis tertius) - not really mentioned as absent in some people, also considered as part of extensor digitorum longus

Question 37

What muscle is being pointed to?

Answer 37

Tendon of tibialis anterior (most anterior muscle) - trace distally to find muscle belly

Question 38

Insertion of tibialis anterior?

Answer 38

Medial and inferior aspects of the medial cuneiform and the 1st metatarsal

Question 39

Action of tibialis anterior?

Answer 39

Dorsiflexion of ankle, inversion of foot

Question 40

Tendon and insertion of tibialis anterior diagrams

Answer 40

Question 41

What tendons are being pointed to?

Answer 41

Tendons of extenstor digitorum longus

Question 42

Actions of extensor digitorum longus?

Answer 42

* 4 tendons - extend the 4 digits * Dorsiflexion of ankle

Question 43

Where does extensor hallucis longus lie?

Answer 43

Deep to other anterior muscles

Question 44

What tendon is being pointed to?

Answer 44

Tendon of extensor hallucis longus

Question 45

Insertion of extensor hallucis longus?

Answer 45

Distal phalanx of big toe

Question 46

Insertion of tendons of extensor digitorum longus?

Answer 46

Distal phalanges of toes 2-5

Question 47

Actions of extensor hallucis longus?

Answer 47

* Extends big toe * Dorsiflex ankle

Question 48

How can you identify the muscles of the anterior from the lateral compartment?

Answer 48

Look for tendons behind the lateral malleolus (these are tendons of lateral compartment) and trace proximally

Question 49

What are the muscles of the lateral compartment?

Answer 49

* Fibularis longus * Fibularis brevis

Question 50

What muscle is being pointed to?

Answer 50

Fibularis longus (brevis lies deeper)

Question 51

Where do fibularis longus and brevis travel?

Answer 51

Book hook behind lateral malleolus

Question 52

Innervation and arterial supply of lateral compartment of leg?

Answer 52

Superficial fibular nerve and fibular artery (branch from posterior tibial artery)

Question 53

Where does tendon of fibularis brevis attach?

Answer 53

Base of 5th metatarsal

Question 54

Where does fibularis longus attach?

Answer 54

Travels under foot and into sole of foot and inserts on the inferior aspect of the **medial cuneiform** and the **1st metatarsal**

Question 55

What sheet of fibrous tissue is being pointed to?

Answer 55

IOM - lying between tibia and fibula

Question 56

What tendon is being pointed to?

Answer 56

Tendon of tibialis anterior

Question 57

What vessel?

Answer 57

Anterior tibial artery

Question 58

What nerve?

Answer 58

Deep fibular nerve

Question 59

Where do the anterior tibial artery and deep fibular nerve pass after the leg?

Answer 59

Pass into the foot

Question 60

What tendon?

Answer 60

Tendon of fibularis longus

Question 61

What nerve?

Answer 61

Superifical fibular nerve

Question 62

What nerve winds round here?

Answer 62

Common fibular - winds around head and neck of fibula

Question 63

After winding round head and neck of fibula, what 2 branches does the common fibular nerve divide into?

Answer 63

Deep and superficial fibular branches

Question 64

What causes 'foot drop'?

Answer 64

Dropping of the forefoot happens due to weakness, irritation or damage to the **common fibular nerve** (deep muscles) --\> damage to **anterior compartment** muscles so can't **dorsiflex** foot (toes drag on ground)

Question 65

How do patients compensate for 'foot drop' during walking?

Answer 65

High stepping gait; flexing hip and knee more so whole leg clears the ground

Question 66

Muscles of the posterior leg generally act on the ankle and toes as...?

Answer 66

Flexors

Question 67

The nerve of the posterior leg is...?

Answer 67

Tibial nerve

Question 68

What bony protrusion?

Answer 68

Medial malleolus

Question 69

What nerve?

Answer 69

Tibial nerve

Question 70

What nerve?

Answer 70

Common fibular nerve - running along lateral aspect of popliteal fossa

Question 71

Actions of muscles of posterior compartment of leg?

Answer 71

* Plantarflex ankle * Flex toes

Question 72

Innervation and arterial supply of muscles of posterior compartment of leg?

Answer 72

Tibial nerve and posterior tibial artery

Question 73

What are muscles of posterior compartment of leg divided into?

Answer 73

Superifical and deep group

Question 74

What muscles make up the superficial group of the posterior compartment of the leg?

Answer 74

3 muscles: * Gastrocnemius * Plantaris * Soleus

Question 75

What muscles make up the deep group of the posterior compartment of the leg?

Answer 75

4: * Popliteus * Tibialis Posterior * Flexor Digitorum Longus * Flexor Hallucis Longus

Question 76

What muscle is being pointed to?

Answer 76

Gastrocnemius (has 2 heads - medial and lateral)

Question 77

What do the 2 heads of gastrocnemius form?

Answer 77

The inferior border of the popliteal fossa

Question 78

How do the 2 muscle bellies of gastrocnemius converge distally? What is this tendon called?

Answer 78

Converge distally onto posterior and superior aspect of calcaneum (achilles tendon)

Question 79

What movement normally causes rupture of achilles tendon?

Answer 79

Very sudden and forceful plantarflexion (e.g. running/jumping)

Question 80

Action of gastrocnemius?

Answer 80

Powerful plantarflexor of the ankle

Question 81

What tendon? (N.B. gastrocnemius has been reflected)

Answer 81

Tendon of plantaris

Question 82

What muscle?

Answer 82

Soleus - large flat muscle

Question 83

Where does soleus insert distally?

Answer 83

Achilles tendon (joins with gastrocnemius)

Question 84

Action of soleus?

Answer 84

Powerful plantarflexor of ankle

Question 85

How do calf muscles assist venous return?

Answer 85

Muscle pump --\> contract and sqeeze deep veins of leg, forcing blood back towards heart (venous return) Immobility can predispose you to DVT

Question 86

What 2 muscles of the posterior leg compartment can flex the toes?

Answer 86

* Flexor hallucis longus * Flexor digitorum longus

Question 87

Where does flexor hallucis longus insert?

Answer 87

Distal phalanx of big toe (N.B. can also plantarflex the ankle)

Question 88

Where does flexor digitorum longus insert?

Answer 88

Distal phalanges of digits 2-5 (N.B. can also plantarflex ankle)

Question 89

Where does the tibialis posterior insert?

Answer 89

Attachment centered around medial cuneiform and the navicular

Question 90

How do the tendons of posterior leg compartment enter the foot? Which artery and nerve accompanies them?

Answer 90

Travel behind medial malleolus - accompanied by posterior tibial artery and tibial nerve

Question 91

Which tendon?

Answer 91

Tibialis posterior

Question 92

What tendon?

Answer 92

Tendon of flexor digitorum longus

Question 93

What tendon?

Answer 93

Tendon of flexor hallucis longus

Question 94

Order of tendons entering the foot posteriorly (behind the medial malleolus)?

Answer 94

1. Tibialis posterior 2. Flexor digitorum longus 3. Flexor hallucis longus (most posterior) I.e. Tom Dick and Harry

Question 95

Between which tendons does the tibial nerve and posterior tibial artery lie?

Answer 95

Between tendon of flexor hallucis longus and tendon of flexor digitorum longus

Question 96

How can the deep muscles of the posterior leg compartment be identified?

Answer 96

Find tendons first then trace back

Question 97

Origin of tibialis posterior?

Answer 97

Originates from the interosseous membrane between the tibia and fibula, and posterior surfaces of the two bones.

Question 98

Origin of flexor hallucis longus?

Answer 98

Originates from the posterior surface of the fibula then travels laterally

Question 99

Origin of flexor digitorum longus?

Answer 99

It is located medially in the posterior leg and originates from the medial surface of the tibia

Question 100

What does the posterior tibial artery divide into when entering the foot?

Answer 100

Medial and lateral plantar arteries

Question 101

What does the tibial nerve divide into when entering the foot?

Answer 101

Medial and lateral plantar nerve

Question 102

What is the artery of the lateral compartment of the leg? What is this a branch of?

Answer 102

Fibular artery (branch from posterior tibial)

Question 103

Where does the great saphenous vein form?

Answer 103

Just anterior to medial malleolus

Question 104

What vessel?

Answer 104

Great saphenous vein

Question 105

What does the great saphenous vein drain into? Where?

Answer 105

Into the femoral vein in the femoral triangle

Question 106

Dorsal venous arch diagram

Answer 106

Question 107

Laterally, what does the dorsal venous arch drain into?

Answer 107

Small saphenous vein

Question 108

Where does the small saphenous vein drain into?

Answer 108

The popliteal vein in the popliteal fossa

Question 109

Medially, what does the dorsal venous arch drain into?

Answer 109

Great saphenous vein - travels **anterior to medial malleolus**