Lower Extremity final quiz Flashcards
(372 cards)
1
Q
Lower Limb Specialization
A
Support Body Weight Locomote Maintain Equilibrium/Balance
2
Q
Connections To Body
A
Connected by Pelvic girdle (the bony ring formed by the hip bones and the sacrum) to the trunk
3
Q
Origin of muscles that act on the lower limb
A
some arise from the pelvic girdle, and some arise from the vertebral column (it is customary when describing the lower limbs to include regions that are transitional between the trunk and the lower limbs, such as the gluteal region)
4
Q
4 Parts of the lower limb
A
Hip, Thigh, Leg, and Foot
5
Q
Hip
A
lateral prominence of the pelvis from the illiac crest to the thigh containing the hip bone connects the skeleton of the lower limb to the vertebral column
6
Q
Thigh
A
between the hip and knee contains the femur which connects the hip and knee Patella covers the anterior surface of the knee
7
Q
Leg
A
Between the knee and ankle Contains the Tibia and Fibula Connects the Knee and Ankle
8
Q
Foot
A
Distal part containing: Tarsus Metatarsus Phalanges
9
Q
Bones of the Lower Limb
A
Pelvic Girdle, 2 hip bones joined at the pubic symphysis and the sacrum Pelvic girdle + sacrum = bony pelvis the skeleton of the free limb is attached to the pelvic girdle
10
Q
Transfer of weight through lower limb part 1
A
Body weight is transferred from the vertebral column to the pelvic girdle –> through the hip –> femur Femur is directed inferomedially through the thigh toward the knee (distal end of femur articulates with patella and tibia of leg (fibula d/n articulate with femur)
11
Q
Transfer of weight through lower limb part 2
A
Weight is transferred from the knee to the ankle by the Tibia Fibula is firmly bound to the tibia inferiorly (forms an important part of the ankle joint) the Tarsal and Metatarsal bones of the foot form a flexible but stable support for the body
12
Q
ilium
A
largest part of the hip bone superior part of acetabulum
13
Q
ala
A
(L. Wing) the ileum has a wing like posterolateral surface that provides attachment for the gluteal muscles laterally and the iliacus muscle medially
14
Q
ASIS
A
Anteriorly the ilium has an anterior superior iliac spine
15
Q
AIIS
A
Inferiorly, the ilium has an anterior inferior iliac spine.
16
Q
iliac crest
A
asis to posterior superior iliac spine
17
Q
Iliac Tubercle
A
5-6 cm posterior to ASIS
18
Q
ischial tuberosity
A
the bone you sit on
19
Q
anatomical position of hip bone
A
acetabulum faces laterally and slightly anteriorly Anterior Superior Iliac Spine and anterosuperior aspect of the pubis lie in the same vertical plane Ischial spine and superior end of the pubic symphysis are approximately in the same horizontal plane symphyseal surface is vertical and parallel to the median plane internal acpect of the body of the pubis faces superiorly forming a floor for the bladder Acetabulum faces inferolaterally acetabular notch directed inferiorly obturator foramen lies inferomedial to the acetabulum tip of coccyx is typically on a level with the superior half of the body of the pubis
20
Q
AP Compression Injury
A
anteroposterior compression of the hip bones is a common way to fracture the pubic rami
21
Q
lateral compression of pelvis
A
or falling from a roof and landing on your feet. Often results in a fracture of the acetabula.
22
Q
Avulsion fracture of Hip Bone
A
may occur in adolescents and young adults during sports that require sudden acceleration or deceleration these fractures occur at apophyses (bony projections that lack secondary ossification centers) occur where muscles are attached anterior superior and inferior iliac spines, ischial tuberosities, ischiopubic rami
23
Q
Femur head and neck angle
A
115-140 averaging 126 degrees. widest at birth. Less in women b/c wider pelvis.
24
Q
femoral neck fractures
A
common in older people even just as a result of a slight stumble. due to a combination of great strain on femoral neck in all people and brittle bones.
25
Intertrochanteric Line
On the FRONT of the femur where the neck joins the body of the femur a roughened ridge running from the greater to the lesser trochanter
26
intertrochanteric Crest
on the BACK of the femur. similar to the intertrochanteric line, but smoother it joins the trochanters posteriorly
27
quadrate tubercle
rounded elevation on the intertrochanteric crest
28
slipped epiphysis of the femoral head
in older children/adolescents (10-17 y/o) the epiphysis of the femoral head may slip away from the femoral neck because of a weakened epiphyseal plate caused by acute trauma or repetitive microtraumas with increased shearing stress on the epiphysis, especially with abduction and lateral rotation of the thigh often slips slowly and results in a progressive coxavara initial symptom is hip discomfort that may be referred to the knee
29
Coxa Vara
angle of inclination (angle the long axis of the femoral neck makes with the femoral body) is DECREASED a mild shortening of the lower limb and limitations with respect to passive abduction of the hip
30
Coxa Valga
angle of inclination is increased. Makes the limb appear longer.
31
Femoral fractures in the Elderly
the neck is frequently fractured when a person over 60 stumbles
32
femoral fractures in women
more common than in men because of an increased risk of osteoperosis.
33
femoral neck fractures
most problematic of all fractures because of the instability of the fracture site the periosteum covering the femoral neck is very thin and has very limited powers of osteogenesis (bone formation) \* the retinacular arteries arise from the medial circumflex femoral arteries and run parallel to the femoral neck on their way to supply the femoral head, so vulnerable to injury when the neck of the femur fractures. Could result in rupture or degeneration of the femoral head and bleeding into the hip joint often from indirect violence or slipping or tripping on something
34
intertrochanteric fractures
common in persons older than 60 fracture of the femur between the greater and lesser trochanter
35
pertrochanteric fracture
a fracture through the trochanters. common in people (esp women, over 60)
36
Fracture of Body of Femur
usually only with severe trauma sometimes a spiral fracture which may be comminuted with the fragments being displaced may take up to 20 weeks for firm union of the fragments, and union of this serious fracture could take up to a year.
37
TIbia Fracture (most common site)
the most common site of a tibial fracture is at the junction of the middle and inferior thirds where the tibia is narrowest. this is also the most common site for a compound fracture (skin perforated and blood vessels torn)
38
Fracture through nutrient canal of Tibia
possible damage to the nutrient artery which predisposes to nonunion of the bone fragments.
39
Transverse Stress (March) Fractures of the Tibia
common in the inferior 3rd of the tibia common in people who take long walks when they are not conditioned to do so the strain may fracture the anterior cortex of the tibia
40
Diagonal Fractures of TIbia
indirect violence applied to the tibial body when the bone turns with the foot fixed during a fall severe torsion during skiing may produce a diagonal fracture of the tibial body at the junction of the middle and inferior thirds, as well as a fracture of the fibula
41
"Boot-top" Fracture of Tibia
high-speed forward fall while skiing leg is angled over the rigid ski boot usually a comminuted fracture in which the tibia is broken into several pieces at the junction of its middle and distal thirds
42
"Bumper Fractures" of Tibia
when the bumper of a car strikes the leg the blow often tears the skin tibia lies subcutaneously, bone fragments protrude resulting in a compound fracture.
43
Tibial Body Fracture
tibial body is unprotected anteromedially relatively slender at the junction of the inferior and middle thirds MOST COMMON LONG BONE FRACTURE compound injuries are common POOR BLOOD SUPPLY even undisplaced stable fractures may take up to 6 months to heal
44
Epiphyseal Plates (Tibia)
the primary ossification center for the superior end of the Tibia appears shortly after birth joins the body of the tibia during adolescence (16-18) fractures here are serious and jeopardize normal growth
45
FIbular Fractures
common 2-6 cm proximal to the distal end of the lateral malleolus. often associated with fracture-dislocations of the ankle often combined with tibial fractures
46
Fracture of the Lateral Malleolus
when the foot slips, it is forced into an excessively inverted position. This tears the ankle ligaments, forcibly tilting the TALUS against the Lateral Malleolus, shearing it off. fractures of both the lateral and medial malleoli are common in soccer and basketball players.
47
Bone grafts from the Fibula
running and jumping can be normal even if a long portion of the fibula can is used for a bone graft (fibula is commonly used) bone grafts used to avoid amputation. (bone defects, trauma, excision of malignant bone tumor) remaining parts of the fibula usually do not regenerate.
48
What is removed with the bone used for grafting?
periosteum nutrient artery
49
What happens to the transplanted fibula?
secured in its new site restores the blood supply of the bone that it is now connected to healing proceeds as if the fibula were just fractured at both ends.
50
location of nutrient foramen in the fibula
important to know when performing free vascularized fibular transfers located in the middle 1/3 of the fibula in most cases (used for transplanting when the graft must have an endosteal and a periosteal blood supply.
51
Tarsus
7 bones Calcaneus, Talus, Cuboid, Navicular, 3 Cuneiforms
52
Which is the only Tarsal bone to articulate with the leg bones?
Talus
53
What is special about Calcaneus?
It is the largest and strongest bone in the foot.
54
Which is the longest metatarsal?
2nd
55
Surface anatomy of Iliac Crests
Hands on hips: resting on the curved superior boarders of the wings of the iliac (pleural of ilium) anterior 1/3 of crests is subQ and easily palpated posterior 2/3 usually covered with fat and difficult to palpate.
56
Supracrestal Plane
this is the highest level of the iliac crests passes through L4/L5 disc landmark for lumbar puncture.
57
Talus
narrow posteriorly has a groove for a tendon has a prominent laeral tubercle and a less prominent medial tubercle only tarsal bone with no muscular or tendinous attachments
58
Navicular tuberosity
medial surface of the navicular projects inferiorly. if it's too prominent, it presses against the shoe causing foot pain.
59
Calcaneal Fractures
a hard fall from a ladder on the heal can fracture the calcaneus. produces a comminuted fracture usually results in a disability because the subtalar (talocalcaneal) joint is disrupted.
60
Fractures of the Talar Neck
Occur during severe dorsiflexion of the ankle in some cases, the body of the talus dislocates posteriorly
61
Fractures of the Metatarsals
heavy object falling on foot, or foot run over also common in dancers fatigue fractures from prolonged walking + repeated stress on the metatarsals usually transverses
62
Avulsion fractures of the 5th metatarsal
Foot is suddenly and violently inverted Tuberosity of the 5th metatarsal may be avulsed by the tendon of the fibularis brevis muscle part of the tuberosity is pulled off resulting in pain and edema common in basketball and tennis players
63
Fracture of the sesamoid bones of the great toe
Fracture of the sesamoids may result from a crushing injury.
64
facia lata attachments
Superior - inguinal ligament, pubic arch, body of pubis, pubic tubercle, membranous layer of subcutaneous tissue (Scarpa's) of the lower abdominal wall. Laterally - iliac crest Posteriorly - iliac crest, sacrum, coccyx, sacrotuberous ligament, ischial tuberosity Distally - exposed parts of bones around the knee, continuous with crural fascia
65
Iliotibial Tract (Iliotibial Band - ITB)
The fascia lata is substantial, it encloses the large thigh muscles, especially laterally where it is thickened and strengthened with additional longitudinal fibers to form the iliotibial tract
66
Crural Fascia
is thin in the distal part of the leg, but is thicker where it forms the extensor retinacular anterior and posterior IM septa pass from the deep surface of the crural fascia and attach to the corresponding margins of the fibula.
67
3 thigh compartments
anterior, posterior, medial
68
3 leg compartments
anterior, posterior (superficial and deep), lateral
69
Venous drainage of the lower limb
superficial veins in subQ deep veins deep to the deep fascia (accompany all major arteries) more valves in the deep veins
70
in subQ
superficial veins, lymphatic vessels, cutaneous nerves
71
2 major superficial veins of the lower limb
great saphenous vein (medial) small saphenous vein (lateral and posterior)
72
Great Saphenous Vein
Dorsal venous arch + dorsal vein of great toe --\> anterior to medial malleolus --\> posterior to medial condyle of femur --\> anastomoses with small saphenous vein --\> traverses the saphenous opening in the fascia lata --\> empties into femoral vein has 10-12 valves with more in the leg than thigh. (valves are just inferior to the perforating veins)
73
Accessory Saphenous Vein
if present this vein becomes the primary communication between the great and small saphenous veins
74
lateral and anterior cutaneous veins
large veins that arise from networks of veins in the inferior part of the thigh they enter the great saphenous vein superiorly just before entering the femoral vein
75
small saphenous vein
arises on lateral foot from the union of the dorsal vein of the small (little) toe with the dorsal venous arch. ascends posterior to lateral maleolus as a continuation of the lateral marginal vein --\> along the lateral border of calcaneal tendon --\> inclines to the midline of the fibula and penetrates the deep fascia --\> ascends between the 2 heads of the gastrocnemius muscle --\> empties into the popliteal vein in the popleteal fossa.
76
order of veins
Superficial --\> Perforating --\> Deep
77
perforating veins
only permit blood to flow from the superficial to the deep veins. Pass through the deep fascia at an oblique angle to prevent back flow.
78
musculovenous pump
enables muscular contractions to propel blood toward the heart against the pull of gravity
79
deep veins of the lower limb
accompany all the major arteries and their branches usually paired contained within the vascular sheath with the artery. Pulsations help to compress and move blood in the veins.
80
dorsal veins of the foot
receive tributaries from the plantar arch join to form common dorsal digital veins --\> terminate in the dorsal venous arch
81
medial and lateral plantar veins
pass close to the arteries communicate with the great and small saphenouus veins from the posterior tibial veins posterior to the medial malleolus
82
Vericose Veins
cusps of the valves of the great saphenous vein do not close the incompetent valves within the great saphenous vein alow the blood flow to sucomb to the pull of gravity, a higher intraluminal pressure as a result, the superficial veins become tortuous and dilated.
83
Thrombosis
the veins of the lower limb are subject to venous thrombosis after: a bone fractures venous stasis (stagnation) Inflammation may develop around the vein (thrombophlebitis), so be on the lookout for that.
84
thrombophlebitis
inflammation around a vein that contains a clot
85
pulmonary thromboembolism
obstruction of a pulmonary artery occurs in a few cases when: a thrombus breaks free from a lower limb vein --\> passes to the lungs --\> a large embolus may obstruct a main pulmonary artery and cause death.
86
use of Great Saphenous Vein for coronary artery bypass
GSV used because readily accessible, usable lengths can be harvested due to long distances between the tributaries and perforating veins wall contains more muscle and elastic fibers than other superficial veins. also used to bypass obstructed blood vessels.
87
a saphenous cutdown
procedure used to insert a cannula for prolonged administration of blood, plasma expanders, electrolytes, or drugs
88
saphenous nerve injury
the saphenous nerve accompanies the great saphenous vein anterior to the medial malleolus. if cut by accident, patient may complain of pain along the medial border of the foot.
89
superficial lymphatic vessels of the lower limb
accompany the saphenous veins and their tributaries the lymphatic vessels accompanying the great saphenous vein end in the superficial inguinal lymph nodes most lymph in these nodes passes directly to the external iliac lymph nodes located along the external iliac vein
90
deep lymphatic vessels of the lower limb
lymph may also pass to the deep inguinal lymph nodes. from the leg, deep lymphatic vessels accompany deep veins and enter the popliteal lymph nodes. most lymph from these nodes ascends through deep lymphatic vessels to the deep inguinal lymph nodes. These nodes lie under the deep fascia on the medial aspect of the femoral vein. lymph from the deep nodes passes to the external iliac lymph nodes.
91
lymphatic vessels accompanying the small saphenous vein
enter the popliteal lymph nodes and surround the popliteal vein in the fat of the popliteal fossa
92
Enlarged inguinal lymph nodes
these nodes are in subQ tissue enlarged when diseased abraisions and minor sepsis may produce slight enlargement of the superficial inguinal lymph nodes (lymphadenopathy) in otherwise healthy people their entire field of drainage must be examined to determine the cause of their enlargement.
93
cutaneous innervation of lower limb
memorize dermatome chart fig 5.12
94
subcostal nerve (T12)
branches descend over the iliac crest toward the anterosuperior iliac spine (asis) and enter the superolateral part of the thigh and supply the skin of the thigh anterior to the greater trochanter of the femur (cutaneous)
95
iliohypogastric nerve (L1, occasionally T12)
divides into Lateral Cutaneous Branch - supplies the skin over the superolateral part of the buttock Anterior Cutaneous Branch - supplies skin superior to the pubis (cutaneous)
96
ilioinguinal nerve (L1, occasionally T12)
accompanies the spermatic cord or the round liigament of the uterus through the superficial inguinal ring to the scrotum or labium majus (cutaneous)
97
Branches of the ilioinguinal nerve
are distributed to the skin over the proximal and medial parts of the thigh and to the scrotum and labia majus through their anterior scrotal and labial branches respectively (cutaneous)
98
Genitofemoral Nerve (L2 and L3)
has genital and femoral branches that supply skin just inferior to the middle part of the inguinal ligament
99
Lateral Femoral Cutaneous Nerve (L2 and L3)
a direct branch of the lumbar plexus runs obliquely toward the anterior superior iliac spine (ASIS) passes deep to the inguinal ligaament into the thigh --\> divides into anterior branches becoming superficial approximately 10 cm distal to the inguinal ligament --\> supply skin on the lateral and anterior parts of the thigh.
100
Femoral Nerve (L2, L3, L4)
Arises from the 2nd 3rd and 4th lumbar nerves in the substance of the psoas major muscle Enters the thigh deep to the inguinal ligament and lateral to the femoral vessels sends branches to: thigh muscles anterior femoral cutaneous nerves to the skin on the anterior and medial thigh
101
Anterior Femoral Cutaneous Nerve
arises from the femoral nerve as a branch from the lumbar plexus. Arises in the femoral triangle pierces the fascia lata along the path of the sartorius muscle supplys the skin on the medial and anterior thigh
102
Posterior Femoral Cutaneous Nerve
A branch of the sacral plexus that supplies branches to the skin on the posterior aspect of the thigh and over the popliteal fossa
103
Sciatic Nerve
arises from the sacral plexus passes through the greater sciatic foramen in the inferior gluteal region --\> posterior thigh --\> at the apex of the popliteal fossa, the sciatic nerve divides into: common fibular nerve (peroneal) tibial nerves cutaneous branches
104
Abnormalities of Sensory Function
neighboring dermatomes may overlap pain sensation is tested by using a safety pin and asking the patient if the pinprick is felt if sensory loss to pain exists, the spinal cord segment involved can be determined.
105
what is the cheif flexor of the thigh?
Iliopsoas this is also a postural muscle that is active during standing as it prevents hyper extension of the hip joint.
106
psoas major attachments
T12-L5 vertebrae and discs --\> Lesser Trochanter
107
Psoas minor attachments
T12 - L1 vertebrae and discs --\> pectineal line, iliopectineal eminence via iliopectineal arch
108
Iliacus
Iliac crest, iliac fossa, ala of sacrum, anterior sacroiliac ligaments --\> tendon of psoas major, lesser trochanter and femur distal to it
109
Innervation of Psoas major
ventral rami of lumbar nerves (L1, L2, L3)
110
Innervation of Psoas Minor
ventral rami of lumbar nerves (L1, L2)
111
Innervation of Iliacus
Femoral Nerve (L2, L3)
112
Iliopsoas arterial supply
lumbar branch of iliopsoas branch of internal iliac artery
113
Pectineus attachments
superior ramus of pubis --\> pectineal line of femur (just inferior to lesser trochanter
114
Pectineus Action
Adducts and flexes the thigh, and assists with medial rotation of the thigh.
115
Pectineus Innervation
Femoral Nerve (L2, L3), may receive a branch from obturator nerve.
116
Pectineus Arterial supply
medial circumflex femoral branch of femoral artery and obturator artery.
117
Movement of Tensor Fascia lata
to produce flexion, it acts in concert with iliopsoas (when iliopsoas is paralyzed tfl hypertrophies in an attempt to compensate) works with gleuteus medius and minimus to medially rotate contracts during abduction, but is too far anterior to be a strong abductor (probably serves as a synergist or fixator) tenses the fascia lata and iliotibial tract, helping to support the femur on the tibia while standing NO DIRECT ACTION ON LEG!
118
Tensor Fascia Lata Attachments
Anterior Superior Iliac Spine and anterior crest --\> IT band that attaches to lateral condyle of tibia
119
Tensor Fascia Lata Innervation
Superior Gluteal Nerve (L4, L5)
120
Sartorius actions
acts across 2 joints. flexes the hip and participates in knee flexion weak abductor of thigh lateral rotation of thigh the actions of both sartorius muscles bring the lower limbs into the cross-legged sitting position NONE OF THE ACTIONS ARE STRONG!
121
Sartorius attachments
Anterior Superior Iliac Spine and superior notch inferior to it --\> superior part of medial surface of tibia
122
Sartorius innervation
Femoral Nerve (L2, L3)
123
Sartorius Blood Supply
Muscular branches of the femoral artery
124
What is the largest muscle in the body?
Quadriceps Femoris it is also one of the most powerful
125
Quadriceps facts
this is the great Extensor of the knee all 4 parts join to attach on tibia 3 vastus muscles are tough to separate.
126
Rectus Femoris Attachments
Anterior Inferior Iliac Spine (AIIS) and Ilium superior to acetabulum --\> base of patella and tibial tuberosity by patellar ligament
127
Main action of Rectus Femoris
knee extension, helps iliopsoas flex the thigh, steadies hip
128
Rectus Femoris Innervation
Femoral Nerve (muscular branches L2, L3, L4)
129
Rectus femoris Blood Supply
Lateral circumflex femoral artery
130
Vastus Lateralis Attachments
Greater Trochanter and lateral lip of linea aspera of femur --\> base of patella and tibial tuberosity by patellar ligament
131
Vastus Lateralis Actions
extend knee
132
Vastus Lateralis Innervation
Femoral Nerve Muscular branches (L2, L3, L4)
133
Vastus Lateralis Blood Supply
Lateral Circumflex Femoral Artery
134
Vastus Medialis Attachments
Intertrochanteric Line and medial lip of linea aspera --\> base of patella and tibial tuberosity by patellar ligament
135
Vastus Medialis action
extend leg at knee joint
136
vastus medialis innervation
Femoral Nerve Muscular branches
137
Arterial supply of vastus medialis
femoral artery, profunda femoris artery, and superior medial genicular branch of popliteal artery
138
Vastus intermedius attachments
anterior and lateral surface of body of femur --\> base of patella and by patellar ligament to tibial tuberosity
139
Vastus Intermedius action
extend the leg at knee
140
Vastus intermedius innervation
muscular branches of femoral nerve
141
Vastus intermedius arterial supply
lateral circumflex femoral artery
142
Vastus Medialis Oblique (VMO) Insufficiency
realigns the patella MEDIALLY VMO is the only dynamic medial stabilizer that is active through the whole ROM adductor magnus --\> ? lateral circumflex artery
143
Articular muscle of knee
inferior part of anterior femur --\> synovial membrane of knee joint and wall of the suprapatellar bursa Fxn - pulls the synovial capsule superiorly during extension of leg, preventing folds of the capsule from being compressed between the femur and the patella w/i the knee joint.
144
"hip pointer"
a contusion of the iliac crest usually the anterior part where the sartorious attaches to the asis. bleeding from ruptured capillaries results in an infiltration of the blood into the muscles, tendons, and other soft tissue.
145
contusion
can also refer to an avulsion of bony muscle attachments, although this is more accurately called an avulsion fracture
146
Charly Horse ("cricket thigh")
cramping of an individual thigh muscle because of ischemia (inadequate circulation of blood) localized pain, muscle stiffness direct trauma is a possible cause
147
hematoma
when a contusion results in a tearing of muscle fibers severe enough to rupture enough blood vessels to cause a bruise most common site of thigh hematoma is quadriceps (sometimes the quadriceps tendon is also torn)
148
Genu Varum (Bow Leg)
a medial angulation deformity of the leg in relation to the thigh results in unequal weight distribution all pressure taken by inside of the knee joint arthrosis destruction of knee cartilage patella tends to move laterally when the leg is extended the movement is increased by vastus lateralis appears 1-2 years after they start walking.
149
Genu Valgum (knock knee)
a lateral angulation of the leg in relation to the thigh (exaggeration of the knee angle) common in children 2-4 persistence of these abnormal knee angles in late childhood results in deformities that require correction. any irregularity of a joint eventually leads to wear and tear of the articular cartillages
150
Paralysis of the Quadriceps femoris
Can't extend the leg against resistance Presses on the distal end of the thigh during walking to prevent inadvertent flexion of the knee joint weakness of the vastus medialis or vastus lateralis resulting from arthritis or trauma to the knee can result in abnormal patellar movement and loss of joint stability.
151
chondromalacia patellae "runner's knee"
quadriceps imbalance soreness and aching around or deep to the patella may result from running sports blow to patella extreme knee flexion (during squating while power lifting)
152
Patellar Dislocation
almost always a lateral dislocation more common in women the lateral dislocation is counterbalanced by the medial, more horizontal pull of the powerful vastus medialis, esp. the VMO Lateral Femoral Condyle has: a more anterior projection a deeper slope for the larger lateral patellar facet (a mechanical deterrent to lateral dislocation exists)
153
Patellar Fractures
Direct blow to the patella creating 2 or more fragments transverse patellar fractures from: blow to knee sudden contraction of the quads (when slipping and preventing a fall backward) proximal fragment - pulled superiorly with quadricep tendon distal fragment - remains with patellar ligament
154
Patellectomy
removal of the patella for a comminuted fracture requires more force by the quadriceps to extend the leg completely recently developed surgical techniques can repair the patellar tendon after patellectomy minimizing the weakness of knee extension.
155
Patellar Tendon Reflex (knee jerk)
strike of the patellar ligament with the reflex hammer causing the leg to extend if normal you should feel the patients quadriceps contract (muscle spindles activated) Afferent impulses travel to spinal cord through L2-4 Efferent impulses transmitted via motor fibers in the femoral nerve to quads tests L2-L3 nerves
156
Adductor Longus Attachments etc.
(MOST ANTERIOR OF ADDUCTOR GROUP) Strong tendon from body of pubis inferior pubic crest --\> Middle 1/3 of linea aspera
157
Adductor Longus Main Action
Adducts Thigh
158
Adductor Longus Innervation
obturator nerve, branch of anterior division (L2, L3, L4)
159
Adductor Longus Arterial Supply
Obturator artery and medial circumflex femoral artery
160
Adductor Brevis Attachments
body and inferior ramus of pubis --\> pectineal line and proximal part of linea aspera of femur
161
Adductor Brevis Action
Adducts thigh Flexes to some extent as well
162
Adductor Brevis innervation
Obturator Nerve (L2, L3, L4), branch of anterior division
163
Arterial Supply of Adductor Brevis
Obturator Artery and Medial Circumflex Femoral Artery
164
Adductor Magnus attachments
Adductor Part: inferior ramus of pubis, ramus of ischium --\> Gluteal Tuberosity, linea aspera, medial supracondylar line Hamstrings Part: Ischial Tuberosity --\> Adductor of Femur
165
Adductor Magnus Actions
Both parts adduct the thigh. Adductor part - flexes the thigh Hamstrings part - extends the thigh
166
Adductor Magnus Innervation
Adductor Part: obturator nerve (L2, L3, L4) branches of posterior division Hamstrings Part: Tibial Part of sciatic nerve (L4)
167
Adductor Magnus Blood Supply
Medial Circumflex artery, inferior gluteal artery, 1st - 4th perforating arteries, obturator artery, and some superior muscular branches of popliteal artery
168
Gracilis attachments
body and inferior ramus of pubis --\> superior part of medial tibia
169
Gracilis Action
adducts thigh, flexes the leg, and assists in medial rotation. All actions are weak. muscle can be removed with no noticeable loss of its actions on the leg.
170
Gracilis Innervation
Obturator nerve (L2, L3)
171
Gracilis Arterial Supply
obturator artery, medial circumflex femoral artery, and muscular branches of profunda femoris
172
Obturator Externus Attachments
margins of obturator foramen and obturator membrane --\> trochanteric fossa of femur
173
Obturator Externus Actions
Laterally Rotates Thigh, and steadies the head of the femur in the acetabulum
174
Obturator Externus Innervation
Obturator Nerve L3, L4
175
Obturator Arterial Supply
Obturator and medial circumflex femoral arteries
176
Groin Pull
a strain, and probably some tearing of the proximal attachments of the anteromedial thigh muscles. usually involves the flexor and adductor thigh muscles the proximal attachments of these muscles are in the inguinal region (groin) at the junction of the thigh and the trunk occur in sports that require quick starts
177
Injury to Adductor Longus
muscles strains of adductor longus may occur in horseback riders "rider's strain"
178
"Rider's Bones"
ossification sometimes occurs in the tendons of the adductor longus muscle because the horseback riders actively adduct their thighs to keep from falling off the horses.
179
Femoral Triangle
a junctional region between the trunk and lower limb a triangular fascial space in the superoanterior 1/3 of the thigh appears as a triangular depression inferior to the inguinal ligament when the thigh is: flexed, abducted, and laterally rotated
180
What are the boundaries of the Femoral Triangle?
Superiorly - Inguinal Ligament Medially - adductor longus (medial boarder) Laterally - Sartorius (medial boarder)
181
Where is the Apex of the Femoral Triangle?
where the lateral boarder of sartorius crosses the medial boarder of the adductor longus
182
what muscles are in the floor of the femoral triangle?
Iliopsoas and pectineus
183
What forms the roof of the femoral triangle
fascia lata, cribriform fascia, subQ tissue, skin
184
Femoral Nerve
largest branch of the lumbar plexus forms w/i psoas major --\> posterolateral path towards inguinal ligament --\> passes deep to IL --\> enters femoral triangle lateral too the femoral vessels --\> divides into several branches to the anterior thigh muscles --\> sends articular branches to the hip and knee joints --\> provides several cutaneous branches to anteromedial thigh --\> Saphenouus nerve which is the terminal cutaneous branch of the femoral nerve
185
Saphenous Nerve
Accompanies the femoral artery and vein through the adductor canal --\> becomes superficial passing through sartorius and gracilis when the femoral vessels traverse the adductor hiatus at the distal end of the canal --\> runs anteroinferiorly to supply the skin and fascia on the anteromedial knee, leg and foot.
186
Femoral Sheath
funnel-shaped fascial tube 3-4 cm inferior to the inguinal ligament encloses parts of the femoral vessels and the femoral canal formed by an inferior prolongation of the transversalis and iliopsoas fascia from the abdomen MEDIAL wall is pierced by the great saphenous vein and lymph vessels allows the femoral artery and vein to glide deep to the inguinal ligament during movements of the hip joint
187
Femoral Canal (medial compartment of femoral sheath)
smallest of the 3 femoral sheath compartments (lateral, intermediate, medial) lies between the medial edge of the femoral sheath and the femoral vein extends distally from the femoral ring to the level of the proximal edge of the saphenous opening allows the femoral vein to expand when venous return from the lower limb is increased contains loose CT, fat, a few lymphatic vessels, and sometimes a deep inguinal lymphnode (cloquet's node)
188
Femoral Ring
at base of femoral canal (its abdominal end) (actually oval shaped) 1cm wide
189
Femoral Artery
cheif artery to lower limb continuation of the external iliac artery begins at inguinal ligament --\> between asis and the pubic symphysis --\> enters femoral triangle deep to midpoint of inguinal ligament bisects the femoral triangle at its apex and enters the adductor canal deep to sartorius --\> exits the adductor canal by passing through the adductor hiatus and becoming the popliteal artery.
190
Deep artery of the thigh
largest branch of femoral artery CHEIF ARTERY OF THE THIGH arises in the femoral triangle from the lateral side of the femoral artery, 1-5 cm inferior to the inguinal ligament --\> passes deep into thigh --\> posterior to femoral artery and vein on medial femur --\> exits femoral triangle between pectineus and adductor longus --\> posterior to adductor longus --\>gives off perforating arteries that supply adductor magnus and hamstrings
191
circumflex femoral arteries
usually branches of the deep artery of the thigh may arise directly from the femoral artery encircle the thigh, anastomose with each other and with other arteries supply the thigh muscles and the proximal end of the femur
192
medial circumflex artery
is especially important because it supplies most of the blood to the head and neck of femur often torn when femoral neck is fractured or hip joint is dislocated passes deeply between the iliopsoas and pectineus reaches the posterior thigh
193
lateral circumflex femoral artery
passes laterally deep to sartorius and rectus femoris --\> between the branches of the femoral nerve --\> divides into branches that supply the head of the femur and muscles on the lateral side of the thigh
194
Obturator artery
helps the deep artery supply the adductor muscles of the thigh arises either from the internal illiac artery or as an accessory obturator artery from the inferior epigastric artery passes through the obturator foramen --\> thigh --\> divides into anterior branch --\> forms anastomoses posterior branch --\> forms anastomose & gives off an acetabular branch --\> supplies the head of the femur
195
How to palpate the femoral pulse
person lying supine femoral artery begins at the inguinal ligament --\> runs midway between ASIS and Pubic Symphesis Pulse can be felt JUST INFERIOR to the midpoint of the inguinal ligament by pressing firmly. normal = strong pulse diminished = might mean that the lumina of the common or external iliac arteries are partially occluded
196
Compression of the femoral artery
may be accomplished by pressing directly posteriorly against the: superior pubic ramus psoas major femoral head will stop bloodflow through the femoral artery and its branches such as the deep artery of the thigh.
197
Cannulation of the Femoral Artery
the femoral artery is easily exposed anc cannulated at the base of the femoral triangle just inferior to the modpoint of the inguinal ligament for left cardiac angiography, a long slender catheter is inserted percutaneously into the artery --\> passed up the external illiac artery --\> common iliac artery --\> aorta --\> to the left ventricle of the heart the coronary arteries can also be visualized by coronary arteriography
198
laceration of the femoral artery
superficial position in the femoral triangle vulnerable to punctures structures anterior to the femoral artery are: skin, subQ, superficial inguinal lymph nodes, superficial circumflex iliac artery, superficial layer of facia lata, anterior femoral sheath often the femoral vein is also lacerated b/c they are so close
199
Arteriovenous shunt
occurs as a result of communication between the injured vessels it is necessary to ligate the femoral artery the cruciate anastomosis supplies blood to the lower limb
200
Femoral Vein
the continuation of the popliteal vein proximal to the adductor hiatus through adductor canal --\> enters femoral sheath lateral to the femoral canal --\> ends posterior to the inguinal ligament --\> becomes the external iliac vein
201
What is received by the femoral vein?
the femoral vein receives the deep vein of the thigh which is formed by the union of 3 or 4 perforating veins --\> enters the femoral vein appx. 8cm inferior to the termination of the great saphenous vein the femoral vein also receives the great saphenous vein and other tributaries in the inferior femoral triangle.
202
What is the Potentially Leathal Misnomer?
Femoral Vein is NOT the Superficial Femoral Vein the SFV is a DEEP vein acute thrombosis of this vein is potentially life threatening. some labs and even dr.s screw this up. DONT USE THE ADJ "SUPERFICIAL"
203
Saphenous Varix
a localized dilation of the terminal part of the great saphenous vein
204
junction of femoral vein and great saphenous vein
appx. 3 cm inferior to the inguinal ligament (this is the only tributary to the femoral vein in this region.) in varicose vein opperations, it is important to identify the great saphenous vein correctly and not tie off the femoral vein by mistake!
205
Cannulation of the Femoral Vein
to secure blood samples take pressure recordings from : the chambers of the right side of the heart and the pulmonary artery for right cardiac angiography a long slender catheter is inserted into the femoral vein --\> passes through the femoral triangle. small cutaneous incision made inferior to the inguinal ligament medial to the femoral artery.
206
How is the Femoral Vein accessed for cannulation?
Access for venous puncture, administration of fluids, catheters Under fluoroscopic control, the catheter is passed superiorly through the external iliac vein, common iliac vein, inferior vena cava, right atrium of the heart.
207
Femoral Hernias and the Femoral Ring
in the anterior abdominal wall, the femoral ring is a weak area and is the usual originating site of a femoral hernia normally admits the tip of the 5th digit.
208
What is a femoral hernia?
a protrusion of abdominal viscera, often a loop of small intestine that protrudes through the femoral ring into the femoral canal. appears as a mass often tenderness in the femoral triangle inferolateral to the pubic tubercle. the hernia is bounded by laterally - femoral vein medially - the reflected part of the inguinal ligament and the lacunar ligament
209
hernial sac
compresses the contents of the femoral canal (loose CT, fat, lymphatics) Distends the wall of the canal initially the hernia is small and contained w/i the femoral canal. it can enlarge by passing inferiorly through the saphenous opening into the subQ tissue of the thigh
210
Where does a femoral hernia appear?
inferior to the inguinal ligament inferolateral to the pubic tubercle (more common in women)
211
Indirect Inguinal hernia
superior to the inguinal ligament may enter the scrotum inguinal hernias occur more commonly in males
212
Strangulation of a femoral hernia
may occur b/c of the sharp rigid boundaries of the femoral ring, particularly the concave margin of the lacunar ligament. interferes with the blood supply to the herniated intestine vascular impairment may result in tissue death.
213
Adductor Canal
appx. 15cm long apex of femoral triangle (where sartorius crosses adductor longus) --\> adductor hiatus inn tendon of adductor magnus deep to middle 1/3 of sartorius provides IM passage through which the femoral vessels pass to reach the popliteal fossa and become the popliteal vessels
214
what are the contents of the adductor canal?
femoral artery and vein, saphenous nerve (terminal branch of femoral nerve), Nerve to vastus medialis (esp. VMO)
215
The adductor canal is bounded by what?
Laterally - Vastus Medialis Medially - Sartorius Anteriorly - Vastus Medialis Posteriorly - Adductor Longus and Magnus
216
Gluteal Region
lies posterior to the pelvis between the level of the iliac crests and the inferior borders of the gleuteus maximus the gluteal muscles: maximus, medius, minimus, form the bulk of the buttock
217
Intergluteal (natal) cleft
separates the buttocks from each other
218
Gluteal Sulcus
lies inferior to the gluteal fold demarcates the: inferior boundary of the buttock superior boundary of the thigh
219
sacrotuberous and sacrospinous ligaments
convert the sciatic notches in the hip bones into the greater and lesser sciatic foramina.
220
greater sciatic foramen
the passageway for structures entering or leaving the pelvis (e.g. sciatic nerve)
221
lessser sciatic foramen
passageway for structures entering or leaving the perineum (e.g. pudendal nerve)
222
Gluteal Muscles
3 large gluteal extensors and abductors of the thigh maximus, medius, minimus and a deeper group of smaller muscles that stabilize the hip joint by steadying the femoral head in the acetabulum: piriformis, obturator internus, externus gemelli, quadratus femoris
223
Gluteus Maximus MISC
most superficial, largest and heaviest gluteal muscle. forms a pad over the ischial tuberosity when standing inserts into the IT tract some deep fibers of the inferior part of the muscle attach to the gluteal tuberosity of femur.
224
Gluteus Maximus Attachments
Ilium posterior to posterior gluteal line, dorsal surface of sacrum and coccyx, and sacrotuberous ligament --\> most fibers end in ITB, but some insert on gluteal tuberosity of femur
225
Gluteus Maximus Action
Extends thigh (especially from flexed position) and assists in its lateral rotation. also steadies the thigh and assists in rising from a seated postion. extends the trunk on the lower limb acts when force is necessary used little during casual walking and motionless standing. assists in making the knee stable b/c the iliotibial tract crosses the knee and attaches to the tibia.
226
Gluteus Maximus Innervation
inferior gluteal nerve (L5, S1, S2) enters the deep surface of the gluteus maximus at its center
227
Gluteus Maximus Arterial Supply
Inferior and Superior gluteal arteries and the 1st perforating branch of the profunda femoris artery.
228
Gluteal Bursa
Membranous sacs located in areas subject to friction (e.g. where the iliotibial tract crosses the greater trochanter) to reduce friction and permit free movement. 3 types of bursa associated with the gluteus maximus
229
Trochanteric Bursae
separate the superior fibers of the Gluteus Maximus from the greater trochanter these are large
230
Ischcial Bursa
separates the inferior part of the gluteus maximus from the ischial tuberosity (not always present)
231
Gluteofemoral bursa
separates the ITB from the superior part of the proximal attachment of the vastus lateralis
232
Gluteus Medius and Minimus
fibers pass in the same direction and have the same actions and nerve supply supplied by the same blood vessel, the superior gluteal artery both abduct the hip and rotate it medially largely responsible for preventing sagging of the unsupported side of the pelvis during walking gluteus medius can be palpated inferior to the iliac crest posterior to the tensor fascia lata which is also contracting during abduction of the hip.
233
Gluteus Minimus Attachments
external surface of ilium between anterior and inferior gluteal lines --\> anterior surface of greater trochanter of femur
234
Gluteus Minimus Action
abducts and medially rotates the thigh; keeps pelvis level when opposite leg is raised
235
Gluteus Minimus Innervation
Superior Gluteal Nerve (L5, S1)
236
Gluteus Minimus Arterial Supply
Superior Gluteal Artery
237
Gluteus Medius Attachments
External surface of ilium between anterior and posterior gluteal lines --\> Lateral surface of greater trochanter of femur
238
Gluteus Medius Action
abducts and medially rotates the thigh; keeps the pelvis level when opposite leg is raised
239
Gluteus Medius Innervation
Superior Gluteal Nerve (L5, S1)
240
Gluteus Medius Arterial Supply
Superior Gluteal Artery
241
Piriformis Misc.
Narrow and pear shaped determines the names of the blood vessels and nerves: superior vs. inferior vessels and nerves the surface of the superior border of the piriformis makes a line that connects the skin dimple formed by the posterior superior iliac spine and the superior border of the greater trochanter
242
Piriformis attachments
anterior surface of sacrum and sacro tuberous ligament --\> superior boarder of greater trochanter of femur
243
Piriformis actions
laterally rotates and extends the thigh abducts the flexed thigh steadies femoral head in acetabulum
244
Piriformis Innervation
Piriformis Nerve (branches of ventral rami of S1, S2)
245
Piriformis Blood Supply
superior and inferior gluteal and internal pudendal arteries
246
Tricipital (3 headed) muscle
Obturator internus Superior Gemelli Inferior Gemelli
247
Obturator Internus Attachments
Pelvic surface of obturator membrane and surrounding bones --\> medial surface of greater trochanter
248
Obturator Internus Action
laterally rotate extended thigh and abduct flexed thigh steadies femoral head in acetabulum
249
Obturator Internus Innervation
nerve to the obturator internus (L5 and S1)
250
Obturator Internus Arterial Supply
internal pudental and superior and inferior gluteal arteries
251
Superior Gemellus Attachments
Ischial Spine --\> Medial surface of greater trochanter (trochanteric fossa) (gemelli muscles blend with the tendon of obturator internus muscle as it attaches to the greater trochanter of femur
252
superior gemellus actions
laterally rotate extended thigh abduct flexed thigh steadies femoral head
253
Superior Gemellus Innervation
nerve to the obturator internus (L5, S1)
254
Superior Gemellus Arterial Supply
Inferior gluteal artery
255
Inferior Gemellus Attachments
Ischial tuberosity --\> Medial surface of greater trochanter (tochanteric fossa) of femur
256
Inferior Gemellus Actions
laterally rotates and extends the thigh abducts flexed thigh steadies femoral head in acetabulum
257
Inferior Gemellus Innervation
nerve to obturator internus and inferior gemellus - a branch of the sacral plexus (L5, S1)
258
Inferior gemellus arterial supply
inferior gluteal artery
259
Quadratus Femoris Misc.
short flat quadrangular/rectangular located inferior to: obturator internus and gemelli STRONG LATERAL ROTATOR OF THE THIGH
260
Quadratus Femoris Attachments
lateral boarder of ischial tuberosity --\> quatrate tubercle on intertrochanteric crest of femur + the area inferior to it
261
Quadratus Femoris Action
laterally rotates thigh (strong) steadies femoral head
262
6 lateral rotators of the thigh
piriformis, obturator internus, gemelli (superior and inferior), quadratus femoris, and obturator externus all of these muscles also stabilize the hip
263
Quadratus Femoris innervation
nerve to quadratus femoris (L5, S1)
264
Quadratus Femoris arterial supply
medial circumflex artery (possible problem here if hip is fractured)
265
Obturator Externus Misc.
Tendon passes deep to the quadratus femoris
266
Obturator Externus Attachments
margins of obturator foramen and obturator membrane --\> trochanteric fossa of femur
267
Obturator Externus Actions
laterally rotates thigh steadies femoral head
268
Obturator Externus Innervation
obturator nerve (L3, L4)
269
Obturator Externus Arterial Supply
obturator and medial circumflex arteries
270
Gluteal Nerves
arise from the sacral plexus Superior and inferior gluteal nerves
271
Superficial Gluteal Nerves Posterior Cutaneous Nerves of the Thigh
Superior Clunial Nerve Middle Clunial Nerve Inferior Clunial Nerve Perforating cutaneous nerve
272
Superior Clunial Nerve
richly innervates the skin of the gluteal region lateral cutaneous branches of the dorsal rami of L1, L2, and L3 supplies the skin of the gluteal region as far as the greater trochanter
273
Middle Clunial Nerve
lateral branches of the dorsal rami of S1-S3 supply skin and SubQ over the sacrum and adjacent area of the buttock
274
inferior clunial nerve
gluteal branches of the posterior cutaneous nerve of thigh a derivative of the sacral plexus (ventral rami of S1 - S3) supplys the inferior half of the buttock
275
perforating cutaneous nerve (s2 and s3)
passes through the sacrotuberous ligament and the inferior gluteus maximus supplys the skin over the inferior 1/2 buttock and the medial part of the gluteal fold
276
Deep Gluteal Nerves
sciatic nerve posterior cutaneous nerve of thigh superior gluteal nerve inferior gluteal nerve nerve to quadratus femoris pudential nerve nerve to obturator internus all are branches of the sacral plexus all leave the pubis through the greater sciatic foramen and emerge inferior to the piriformis (except the superior gluteal nerve)
277
Sciatic Nerve
largest nerve in the body forms the greatest part of the sacral plexus arises from ventral rami of L4 - S3 passes through the inferior part of the greater sciatic foramen most lateral structure emerging inferior to the piriformis (medial are: inferior gluteal nerve and vessels, internal pudendal vessels, pudendal nerve) RUNS BETWEEN GREATER TROCHANTER AND ISCHIAL TUBEROSITY receives its own blood supply from the inferior gluteal artery
278
What does the Sciatic Nerve innervate?
no structures in the gluteal region skin of foot most of the leg posterior thigh muscles all leg and foot muscles articular branches to all joints of the lower limb
279
Sciatic nerve is really 2 nerves
Tibial Nerve Common Fibular Nerve loosely bound together in the same CT sheath the separation of these 2 nerves occurs 1/2 way or more down the thigh (although in 12% they separate as they leave the pelvis; in these cases, the tibial nerve passes inferior to the piriformis and the common fibular nerve pierces the piriformis or passes superior to it)
280
What does the tibial nerve supply?
Flexor muscles
281
What does the Common Fibular Nerve Supply?
extensor and abductor muscles
282
Posterior Cutaneous Nerve of the Thigh
Arises from the sacral plexus (S1-S3) Leaves the pelvis with the: Inferior gluteal nerve and vessels and the sciatic nerve Passes through the greater sciatic foramen, inferior to piriformis descends deep to the gluteus maximus SUPPLIES MORE SKIN THAN ANY OTHER CUTANEOUS NERVE
283
Posterior Cutaneous Nerve of Thigh: what parts innervate what?
Skin of inferior buttocks - posterior divisions of S1 and S2 Skin over Perineum - anterior divisions skin of posterior thigh and proximal leg - other more inferior branches
284
Superior Gluteal Nerve
Arises from posterior divisions of the ventral rami of L4 - S1 Leaves the Pelvis through the Greater Sciatic Foramen Superior to Piriformis Runs laterally between the gluteus medius and minimus Runs with the deep branch of the superior gluteal artery
285
What are the divisions of the Superior Gluteal Nerve?
Superior Branch - supplies gluteus medius Inferior branch - passes between the gleuteus medius and minimus
286
what does the superior gluteal nerve supply?
gluteus medius gluteus minimus tensor facia lata
287
Inferior Gluteal Nerve
Arises from posterior divisions of the ventral rami of L5 through S2 Leaves the Pelvis through the greater sciatic foramen Inferior to piriformis Superficial to Sciatic nerve Divides into several branches to supply the overlying gluteus maximus
288
Nerve to Quadratus Femoris
Arises from anterior divisions of the ventral rami of L4, L5, S1 Leaves the pelvis anterior to: sciatic nerve and obturator internus passes over the posterior surface of the hip joint
289
What does the nerve to Quadratus Femoris Supply?
an articular branch to the hip joint inferior gemellis quadratus femoris
290
Pudendal Nerve
Arises from the anterior divisions of the ventral rami of S2 through S4 nerves Supplies structures in the perineum supplies no structures in the gluteal region
291
nerve to obturator internus
Arises from the anterior divisions of the ventral rami of L5 through S2 supplies obturator internus
292
Injury to the Superior Gluteal Nerve
results in a charachteristic muscle loss to the gluteus medius weakened abduction a disabling gluteus medius limp a gluteal gait a compensatory list of the body to the weakened gluteal side (to shift the center of gravity over the supporting lower limb) medial rotation of the hip is also severely impaired
293
Without injury to Superior Gluteal Nerve
normally: while standing on one leg, the gluteus medius contracts as soon as the contralateral foot leaves the floor this prevents tipping of the pelvis on the unsupported side
294
Trendelenburg Test/sign
occurs with injury to the superior gluteal nerve other causes include fracture of the greater trochanter (the distal attachment of the gluteus medius) pelvis descends on the unsupported side, lower limb becomes "too long" d/n clear the ground on the swing through phase.
295
Trendelenburg test/sign "Waddling Gait"
the individual leans away from the unsupported side raises the pelvis to allow adequate room for the foot to come forward
296
Trendelenburg test/sign "steppage gait"
lifts the foot higher as it is brought forward this is the same gait adopted in the presence of "foot-drop" from common fibular nerve paralysis
297
Injury to Sciatic Nerve
Piriformis Syndrome pain in the buttock results from compression of the sciatic nerve by the piriformis persons involved in sports that require excessive use of the gluteal muscles and women are more likely to have this (skating, cycling, climbing)
298
50% of injuries to Sciatic Nerve
trauma to the buttock associated with hypertrophy and spasm of piriformis
299
12% of people with injuries to Sciatic Nerve
common fibular division of the sciatic nerve passes through the piriformis and may result in a compressed nerve.
300
Intragluteal Injections
safe only in the superolateral part of the buttock other areas are dangerous because many nerves and vessels are present
301
Gluteal Arteries
arise directly or indirectly from the internal iliac arteries. the major gluteal branches of the internal iliac artery are: superior gluteal artery internal pudendal artery inferior gluteal artery
302
Superior Gluteal Artery
largest branch of the internal iliac artery leaves the pelvis through the greater sciatic foramen and superior to piriformis
303
What are the divisions of the Superior Gluteal Artery?
Superficial Branch - to gluteus maximus and the skin over its proximal attachment Deep Branch - Gluteus Medius, Gluteus Minimus, tensor fascia lata anastomoses with the inferior gluteal artery and the medial circumflex femoral artery
304
Inferior Gluteal Artery
Arises from the internal iliac artery leaves the pelvis through the greater sciatic foramen and inferior to piriformis enters the gluteal region deep to gluteus maximus and descends medial to the sciatic nerve
305
What does the inferior gluteal artery supply?
gluteus maximus obturator internus quadratus femoris superior parts of the hamstrings anastomoses with the superior gluteal artery participates in the cruciate anastomosis of the thigh.
306
Gluteal Veins
tributaries on the internal iliac veins drain blood from the gluteal region they accompany the corresponding arteries through the greater sciatic foramen superior gluteal vein - superior to piriformis inferior gluteal vein - inferior to piriformis communicate with tributaries of the femoral vein providing alternate routes for the return of blood from the lower limb if the femoral vein is occluded or has to be ligated.
307
Lymphatic Drainage of the deep tissue of the Buttocks
follows the gluteal vessels to the superior gluteal lymph node and inferior gluteal lymph node --\> internal, external, common iliac lymph nodes --\> lateral aortic lymph nodes
308
Lymphatic Drainage of the superficial tissue of the Buttocks
Lymph from the superficial tissues of gluteal region enters the superficial inguinal lymph nodes + receives lymph from the thigh all the superficial inguinal nodes send efferent lymphatic vessels to the external iliac lymph nodes.
309
Posterior Thigh muscles that span the hip and knee + arise from the ischial tuberosity
Semitendinosus Semimembranosus Biceps Femoris (long head) extensors of the hip and flexors of the knee
310
hamstrings
Semitendinosus, semimembranosus, biceps femoris when standing at ease, the hamstrings are the active hip extensors a person with paralyzed hamstrings, tends to fall FORWARD because the gluteus maximus muscles cannot maintain the necessary muscle tone to stand straight.
311
Semitendinosus Attachmetnts
Ischial Tuberosity --\> medial part of superior Tibia
312
Semitendinosus Actions
Extends Thigh flexes leg rotates medially when knee is flexed extends trunk when thigh and leg are flexed
313
Semitendinosus innervation
Tibial division of sciatic nerve (L5, S1, S2)
314
Semitendinosus Arterial Supply
perforating branches of profunda femoris artery, inferior gluteal artery, and superior muscular branches of popliteal artery
315
Semimembranosus Attachments
Ischial tuberosity --\> posterior part of medial condyle of tibia; reflected attachment forms oblique popliteal ligament (to lateral femoral condyle)
316
Semimembranosus Action
extends thigh flexes leg rotates leg medially when thigh and leg are flexed can extend the trunk
317
Semimembranosus innervation
Tibial division of Sciatic Nerve (L5, S1, S2)
318
Semimembranosus Arterial Supply
Perforating Branches of profunda femoris artery, inferior gluteal artery, and superior muscular branches of popliteal artery
319
Biceps Femoris Long Head Attachments
Ischial Tuberosity --\> lateral side of head of fibula, tendon is split at this site by fibular collateral ligament of knee
320
Biceps Femoris Short Head Attachments
Linea Aspera and lateral supracondylar line of femur --\> lateral side of head of fibula; tendonn is split at this site by the fibular collateral ligament of knee
321
Biceps Femoris action
Long head extends the hip joint flexes the knee rotates the tibia laterally Short Head: flexes knee rotates tibia laterally
322
Biceps Femoris Innervation
Long Head - tibial division of sciatic nerve (L5, S1, S2) Short Head - common fibular division of sciatic nerve
323
Biceps Femoris Arterial Supply
perforating branches of profunda femoris artery, inferior gluteal artery, and superior muscular branches of popliteal artery
324
Injury to nerve supply of Biceps Femoris
innervation to the 2 heads is different, so an injury could affect one and not the other.
325
Variations in the Length of the Hamstrings in Some People
the Hamstrings are not long enough to allow them to touch their toes makes it difficult to make a high kick in others, the hamstrings are long allowing easy high kicks
326
hamstring strains
not enough warming up of muscles violent muscular exertion may tear part of the proximal tendinous attachments of the hamstrings to the ischial tuberosity HAMSTRING STRAINS ARE 2X AS COMMON AS QUADRICEP STRAINS usually thigh strains are accompanied by: contusion, tearing of muscle fibers, rupture of the blood vessels supplying the muscles, hematoma is contained by the dense stockinglike fascia lata very painful when the leg is moved or stretched
327
"Hurdler's Injury"
avulsion of the ischial tuberosity at the proximal attachment of the biceps femoris, or semitendinosus results from: forcible flexion of the hip with the knee extended, e.g. kicking a football)
328
Nealton's Line
a line drawn from the ASIS --\> ischial tuberosity passes over the lateral hip region normally passes over or near the top of the greater trochanter a dislocated hip or fractured femoral neck results in the trochanter being felt superior to this line
329
Nerve locations
Tibial Nerve - Bisects the popliteal fossa Common Fibular nerve - travels under the biceps femoris Sciatic Nerve - stretches when hip is flexed and when the knee is extended; relaxes when hip is extended and knee is flexed.
330
Infrapatellar Fat Pads
scan be palpated as the loose fatty tissue on both sides of the patellar ligament
331
Leg length Discrepancy
Measurements of the Lower Limb can detect shortening after a femoral fracture compare the limbs to each other.
332
True leg length discrepancy
real limb shortening is detected by comparing measurements of ASIS --\> distal tip of the medial malleolus Thigh measurement: ASIS --\> distal edge of lateral fomoral condyle a difference of 1.25 cm on one side or the other may be normal and not indicate a problem.
333
Boarders of the Popliteal Fossa
Superolaterally - biceps femoris Superomedially - semimembranosus + semitendonosus (lateral to semimembranosus) Inferolaterally - lateral head of gastrocnemius Inferomedially - medial head of gastrocnemius Posteriory - skin, fascia (roof) Anteriorly - popliteal surface of femur, oblique popliteal ligament, popliteal fascia over the popliteus (floor of fossa)
334
Contents of the Popliteal Fossa
Small Saphenous Vein Popliteal arteries and Veins Tibial and Common Fibular Nerves Posterior Cutaneous Nerve of Thigh Popliteal Lymph nodes and Lymphatic Vessels
335
Popliteal Artery
deepest structure in the fossa continuation of femoral artery begins when this artery passes through the adductor hiatus ends at the inferior border of the popliteus dividing into: anterior tibial artery, and posterior tibial artery
336
Genicular Branches of popliteal artery
5 genicular branches: lateral superior genicular artery medial superior genicular artery middle genicular artery lateral inferior genicular artery medial inferior genicular artery they supply the articular capsule of the knee joint and the ligaments of the knee joint.
337
genicular anastomosis
a network of vessels around the knee contributing vessels: genicular branches of popliteal artery decending genicular branch of the femoral artery (superomedially) descending branch of the lateral femoral circumflex artery (superolaterally) anterior recurrent branch of anterior tibial arterry
338
Muscular branches of Popliteal artery
supply the hamstring, gastrocnemius, soleus, plantaris the superior muscular branches of the popliteal artery have clinically important anastommoses with the terminal part of the deep femoral artery and gluteal artery
339
Popliteal Vein
formed at the DISTAL BOARDER of the popliteus close to the popliteal artery lies superficial to and in the same fibrous sheath as the artery has several valves ends at the adductor hiatus where it becomes the femoral vein
340
Small Saphenous Vein
passes from the posterior aspect of the lateral malleolus to the popliteal fossa --\> pierces the deep popliteal fascia --\> enters the popliteal vein
341
Common Fibular Nerve
Laterally located in Pop. Fossa smaller terminal branch of Sciatic Nerve Begins at the superior angle of the popliteal fossa leaves the fossa by passing superficial to the lateral head of gastrocnemius --\> over the posterior aspect of the head of the fibula --\> winds around fibular neck (susceptible to innjury) --\> divides into terminal branches
342
Posterior Cutaneous Nerve of the Thigh
Arises from posterior divisions of ventral rami of S1 and S2 nerves + the anterior divisions of S2 and S3 Supplies more skin than any other Cutaneous Nerve Leaves the pelvis with: inferior gluteal nerve inferior gluteal vessels sciatic nerve
343
Popliteal Aneurysm
Dilation of the Popliteal artery usually causes edema and pain in the popliteal fossa if the femoral artery has to be ligated, blood can bypass the occlusion through the genicular anastomoses and reach the popliteal artery distal to the ligation
344
Superficial Popliteal Lymph Nodes
usually small lie in the popliteal fat a lymph node lies at the termination of the small saphenous vein and receives lymph from the lymphatic vessels that accompany this vein
345
Deep Popliteal Lymphnodes
Receive lymph from the knee joint lymphatic vessels accompany the arteries of the leg
346
Popliteal Lymph Vessels
go from the popliteal lymphnodes --\> follow the femoral vessels to the deep inguinal lymph nodes
347
Superior Extensor Retinaculum
A strong, broad band of deep fascia passing from the fibula to the tibia proximal to the malleoli it binds down the tendons of muscles in the anterior compartment preventing them from bowstringing anteriorly during dorsiflexion of the ankle
348
Inferior Extensor Retinaculum
a Y shaped band of deep fascia that attaches laterally to the anterosuperior surface of calcaneous forms a strong loop around the tendons of the fibularis tertius and the extensor digitorum longus
349
Tibialis Anterior Misc
Tendon appears in the lower 1/3 of the leg on the anterior tibial surface and interosseous membrane tendon passes w/i its own synovial sheath deep to: superior + inferior extensor retinaculums + to its attachment on the medial side of the foot STRONGEST DORSIFLEXOR AND INVERTOR OF THE FOOT (Tibialis posterior also inverts the foot)
350
Tibialis Anterior Attachments
Lateral condyle and superior 1/2 of lateral surface of tibia and interosseous membrane --\> Medial and inferior surfaces of medial cuneiform and base of 1st metatarsal
351
Tibialis anterior Actions
strongest inverter and dorsiflexor of the foot
352
Tibialis Anterior Innervation
Deep Fibular Nerve (Peroneal) (L4, L5)
353
Tibialis Anterior arterial supply
Anterior Tibial Artery
354
Extensor Digitorum Longus Misc.
most lateral anterior leg muscle becomes tendinous superior to the ankle 4 tendons attach to the phalanges of the lateral 4 toes a common synovial sheath surrounds the 4 tendons of the extensor digitorum longus as they diverge on the dorsum of the foot and pass to their distal attachments each tendon forms a membranous extensor expansion (dorsal aponeurosis) over the dorsum of the proximal phalynx of the toe
355
Divisions of the membranous extensor expansions.
One central slip inserts into the base of the middle phalynx two lateral slips converge to insert into the base of the distal phalynx
356
Extensor Digitorum Longus Attachments
lateral condyle of tibia and superior 3/4 of medial surface of the fibula of interosseous membrane --\> middle and distal phalanges of lateral 4 digits
357
Extensor Digitorum Longus Actions
Extends lateral 4 digits and Dorsiflexes Ankle
358
Extensor Digitorum Longus Innervation
Deep FIbular Nerve (L5, S1)
359
Extensor Digitorum Longus Arterial Supply
Anterior Tibial Artery
360
Extensor Hallucis Longus Misc.
thin at its superior attachments, lies deep to fibula and interosseous membrane rises to the surface between the tibialis anterior and extensor digitorum longus
361
Extensor Hallucis Longus Attachments
middle part of anterior surface of fibula and interosseous membrane --\> dorsal aspect of base of distal phalynx of great toe (hallux)
362
Extensor Hallucis Longus Action
Extends and Dorsiflexes the Great Toe
363
Extensor Hallucis Longus Innervation
Deep Fibular Nerve (L5, S1)
364
Extensor Hallucis Longus Blood Supply
Anterior tibial Artery
365
Fibularis Tertius
a separated part of the extensor digitorum longus + shares its synovial sheath extensor digitorum longus and fibularis tertius are fused at their proximal attachments NOT ALWAYS PRESENT
366
Fibularis Tertius Attachments
inferior 1/3 of anterior fibula + interosseous membrane --\> dorsum of base of 5th metatarsal
367
Fibularis Tertius Action
Dorsiflexes ankle and aids in eversion of foot
368
Fibularis Tertius Innervation
Deep Fibular nerve (L5, S1)
369
Fibularis Tertius Arterial Supply
Anterior Tibial Artery
370
Deep Fibular Nerve
Nerve of the anterior compartment one of the 2 terminal branches of the Common Fibular Nerve Arises between Fibularis Longus and the neck of the fibula
371
Anterior Tibial Artery
supplies structures in the anterior compartment smaller terminal branch of the popliteal artery begins at the inferior boarder of the popliteus passes anteriorly through a gap in the superior part of the interosseous membrane then descends on the anterior surface of this membrane between the tibialis anterior and extensor digitorum longus ends at the ankle joint midway between the malleoli and becomes the dorsalis pedis artery (dorsal artery of the foot)
372
Navicular Tuberosity
the medial surface of the navicular projects inferiorly if it is too prominent it will press against the medial part of the shoe creating foot pain.
