Lower limb Flashcards
(135 cards)
1
Q
Describe the course of the ilioinguinal nerve?
A
Lies between internal oblique and transversus abdominus (supplies their lower fibres). Then pierces the internal oblique and passes deep to external oblique to emerge through superficial inguinal ring.
Supplies root of penis, anterior 1/3 of scrotum and a small area of the thigh below inguinal ligament
2
Q
Origin and course of genitofemoral nerve
A
1st and 2nd lumbar nerves- only fibres from L1 pass into femoral branch. This branch is given off as it lies on psoas major. Runs with external iliac artery and passes beneath inguinal ligament into femoral sheath. Supplies skin over femoral triangle. Genital branch passes through deep ring with the spermatic cord
3
Q
Key differences between medial femoral cutaneous nerve and intermediate femoral cutaneous nerve?
A
Medial: pierces the fascia lata at mid thigh and suppies medial side of the thigh
Intermediate: pierces sartorius and pierces fascia lata above medial and supplies front of thigh down to the knee
Both L2, L3
4
Q
Course of lateral femoral cutaneous nerve
A
L2L3
Passes from lateral border of psoas major and lies behind the fascia iliaca, but then approaching the inguinal ligament it inclines forwards and is incorporated within iliac fascia. Pierces inguinal ligament a centimetre to the medial side of the ASIS.
Supplies posterolateral aspect of mid thigh
Can be compressed as passes through inguinal ligament causing meralgia parasthetica or through iliac fascia
5
Q
What are the four superficial branches of the femoral artery found beneath the inguinal ligament?
A
Superficial circumflex iliac- lateral to saphenous opening
Superficial epigastric- through saphenous opening
Superficial external pudenal- through saphenous opening in front of spermatic cord to scrotum and penis
Deep external pudendal-pierces fascia lata behind spermatic cord
6
Q
Course of long saphenous vein
A
Longest vein in body
Starts as medial marginal vein of the foot, passes up medially in front of medial malleolus and ends by passing through cribiform fascia covering saphenous opening (3cm below and lateral to pubic tubercle). Here it joins femoral vein.
Vein contains up to 20 valves.
7
Q
Describe the lymphatics of the genitals
A
external genitalia (including lower vagina but excluding the testes) go to superficial inguinal nodes.
Glans penis/ clitoris go to deep inguinal nodes
Testes go to para-aortic nodes
8
Q
Why can femoral hernias never grow very large?
A
Scarpas fascia from the abdomen fuses with fascia lata at the hip joint and extends laterally from the pubic tubercle below the inguinal ligament. Therefore a femoral hernia cannot get deep to scarpas fascia, it can only get into subcutaneous fat.
9
Q
Where is the saphenous opening?
A
The gap in the fascia lata, attached laterally to the falciform edge and medially to the fascia lata where it lies over adducter longus
Pierced by great saphenous vein, its tributaries and efferent lymphatics- looks like sieve (called cribriform fascia)
10
Q
Origin Insertion Action Nerve supply Special features Tensor fascia lata
A
External lip of iliac crest 5cm from ASIS to tubercle
Iliotibial band
Pull on iliotibial tract to assist GM in extending the knee and resists abduction in walking
Superior gluteal nerve (L4-5, S1)
Sup glut nerve ends in it
11
Q
What does the iliotibial tract do?
A
It maintains the knee hyperextended while quadriceps is relaxed and patella freely mobile.
Inserts on Gerdy’s tubercle
Three quarters of glut max is inserted onto it.
12
Q
What are the borders of the femoral triangle?
A
Lateral: sartorius
Medial: Adductor longus
Superior: inguinal ligament
13
Q
What lies in the femoral triangle?
A
Femoral nerve, artery and vein
Iliacus, psoas, pectineus and adductor longus lie in the floor
14
Q
Origin Insertion Action Nerve supply Special features Sartorius
A
Immediately below ASIS
Upper medial surface of the tibia, in front of gracilis and semitendinosis
Flexes, abducts and laterally rotates the thigh at the hip. Flexes, medially rotates leg at the knee
Ant division of the femoral nerve L2-L4
Longest muscle in the body, parallel fibres. Pierces by intermediate femoral cutaneous nerve. Bursa lies between tendon and MCL
15
Q
Origin Insertion Action Nerve supply Special features Iliacus
A
Iliac fossa
Lowermost surface of lesser trochanter of femur, in front of psoas tendon
Flexes the hip
Femoral nerve (L2-3)
Passes below inguinal ligament. Passes in front of the hip joint, may communicate with bursa in front of the hip joint
16
Q
Origin Insertion Action Nerve supply Special features Psoas major
A
Transverse process of L1-5, bodies of T12-L5 and intervertebral discs below body of T12-L4
Lesser trochanter of femur
Flexes the hip
Anterior primary rami of L1-3 (mainly L2)
Passes below inguinal ligament. Passes in front of the hip joint, may communicate with bursa in front of the hip joint
17
Q
Origin Insertion Action Nerve supply Special features Pectineus
A
Pectineal line of the pubis and superior pubic ramus below it
Vertical line behind and below lesser trochanter
Flexes and adducts the hip
Ant division of femoral nerve (L2-3) +/- obturator
18
Q
Which layer of abdominal fascia becomes the femoral sheath?
A
Transversalis
19
Q
Where does the femoral sheath fuse with the adventitia of the artery and vein?
A
3cm distal to inguinal ligament
20
Q
How is the femoral neurovascular bundle ordered from lateral to medial?
A
Femoral nerve (outside femoral sheath)
Artery
Vein
Femoral canal
21
Q
What are the four boundaries of the femoral ring?
A
Ant: medial part of inguinal ligament Med: lacunar ligament Post: pectineal ligament Lat: femoral vein Femoral canal contains 1 lymph node which drains directly from the clitoris
22
Q
Describe the course and branches of the femoral artery
A
Enters thigh midpoint between ASIS and pubic symphysis (on top of psoas major tendon).
Profunda femoris branch comes off just below the femoral sheath. Passes between pectineus and adductor longus.
Lateral circumflex artery comes off profunda femoris (sometimes femoral).Lies deep to rectus femoris and sartorius. Becomes ascending, transverse and descending branches.
Medial circumflex comes off profunda femoris
23
Q
Where does the ascending branch of the lateral circumflex artery run and why is it important?
A
Runs of the vastus lateralis, beneath sartorius and tensor fascia lata and passes on towards ASIS and anastomoses with the superficial and deep circumflex iliac (superior gluteal artery). Lies between between sartorius and tensor fasciae lata in the anterior approach to the hip
24
Q
When does the femoral vein become the external iliac vein?
A
Receives profunda femoris vein just below the femoral sheath and the great saphenous vein joins it anteriorly, then in the sheath, passes under inguinal ligament becoming external iliac vein
25
What is the difference in the origins of the obturator vs femoral nerves?
Femoral: Posterior divisions of L2, 3, 4
Obturator: Anterior divisions of L2, 3, 4
26
Describe the course of the femoral nerve
Supplies iliacus in abdomen
Enters thigh between psoas and iliacus beneath the inguinal ligament
Enters femoral triangle, gives off branch to pectineus.
2 nerves to sartorius, 2 nerves to rectus femoris.
Nerve to vastus medialis (largest branch)
Nerve to vastus lateralis
Saphenous nerve leaves femoral angle and passes in front of femoral artery to reach medial side, passes between sartorius and gracilis
27
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Origin
Insertion
Action
Nerve supply
Special features
Rectus femoris
```
Straight head: AIIS above ileofemoral ligament
Reflected head: ilium above acetabulum
Quadriceps tendon to patella
Extends leg at the knee at flexes the thigh at the hip
Deep branch of femoral nerve (L3-4)
Posterior surface covered by glistening aponeurosis separating it from vastus intermedius
28
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Origin
Insertion
Action
Nerve supply
Special features
Vastus lateralis
```
Upper intertochanteric line, base of the trochanter and lateral lip of lateral linea aspera, lateral supracondylar ridge and lateral IM septum
Quads tendon to patella
Extends knee
Deep branch of femoral nerve (L3,4)
Descending branch of of lateral circumflex artery and nerve to vastus lateralis lies in gutter between of VL and VI
29
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Origin
Insertion
Action
Nerve supply
Special features
Vastus intermedius
```
Ant and lateral upper 2/3 of shaft of femur
Quads tendon to patella
Extends knee
Deep branch of femoral nerve L3,4
30
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Origin
Insertion
Action
Nerve supply
Special features
Vastus medialis
```
Lower intertrochanteric line and the medial lip of linea aspera and from tendon of adductor magnus below haitus for femoral vessels
Quads tendon to patella
Extends knee
Deep branch of femoral nerve L3,4
Most important muscle in stabilising patella
31
Where is the articularis genu?
5th quadricep muscle Arises from the lower 1/3 of femur and inserts on suprapatellar bursa, deep to vastus intermedius
32
What are the boundaries of the adductor canal?
Lies between vastus medial and adductors
Roof: fascia and sartorius
Floor: adductors
Contains femoral artery, vein, saphenous vein and nerve to vastus medialis and subsartorial plexus (medial cutaneous nerve, saphenous nerve and ant division of obturator nerve)
33
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Origin
Insertion
Action
Nerve supply
Special features
Gracilis
```
Inferior ramus of pubis and ischial ramus
Upper medial shaft of tibia behind sartorius
Adducts hip, flexes knee and medially rotates flexed knee.
Anterior division of the obturator nerve L2-3
Blood supply is medial circumflex, profunda and femoral arteries
34
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Origin
Insertion
Action
Nerve supply
Special features
Adductor longus
```
Body of pubis inferior and medial to pubic tubercle
Lower 2/3rd medial linea aspera
Adducts the hip
Anterior division of the obturator L2-3
Most superficial adductor
35
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Origin
Insertion
Action
Nerve supply
Special features
Adductor brevis
```
Inferior ramus and body of pubis, deep to pectineus and adductor longus
Upper 1/3 of linea aspera
Adducts hip
Anterior division of obturator nerve L2-3
Anterior division of obturator nerve passes in front of muscle, posterior obturator nerve passes behind
36
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Origin
Insertion
Action
Nerve supply
Special features
Adductor magnus- adductor part
```
Ischiopubic ramus
Lower tuberosity and linea aspera
Adducts hip
Posterior division of the obturator L2-3
Horizontal upper border is edge to edge with quadratus femoris. Medial circumflex femoral artery runs between the two
37
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Origin
Insertion
Action
Nerve supply
Special features
Adductor magnus- hamstring part
```
Lower outer quadrant of posterior surface of the ischial tuberosity
Adductor tubercle of femur and medial supracondylar line
Extends hip
Tibial part of sciatic nerve L2-3
4 openings for profunda femoris alone linea aspera. Opening for adductor hiatus above medial supracondylar line.
38
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Origin
Insertion
Action
Nerve supply
Special features
Obturator externus
```
Obturator membrane and anterior border of obturator foramen
Trochanteric fossa on medial side of greater trochanter
Laterally rotates hip
Posterior division of the obturator L3-4
Part of the posterior capsule deficient where the tendon crosses the neck of femur. Muscle passes posterior lateral to NOF
39
How does the obturator artery supply the hip joint?
Obturator artery enters thigh through obturator foramen. Divides into anterior and posterior branches which then anastomose with medial circumflex artery. From posterior branch- articular twig to hip joint
40
What do the anterior and posterior branches of obturator nerve supply?
Anterior:Hip joint, adductor longus, gracilis and subsartorial plexus
Posterior: obturator externus, passes on adductor magnus and gives a terminal branch which runs with femoral artery through hiatus in muscle to supply capsule of knee joint
41
Describe the spinal origins of the sensation of skin of buttock
Central -coccygeal
Anus-S5/S4
S3 beyond anus
S2 central buttock and down medial posterior leg
S1 lateral buttock and posterior lateral leg and lateral foot
42
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Origin
Insertion
Action
Nerve supply
Special features
Gluteus maximus
```
Outer surface of ilium behind posterior gluteal line and posterior 1/3 of iliac crest, lumbar fascia, lateral mass of the sacrum and ST ligament
Deepest 1/4 into gluteal tuberosity of the femur. Remaining 3/4 into the IT tract.
Extends and laterally rotates hip, supports knee extension through ITT
Inferior gluteal nerve (L5, S1, 2) only muscle by this nerve
Largest muscle in the body- 3 bursae-ischial tuberosity, GT and ITT
43
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Origin
Insertion
Action
Nerve supply
Special features
Gluteus medius
```
Gluteal surface of the ilium between posterior and middle gluteal lines
Posterolateral surface of greater trochanter of femur
Abducts and medially rotates the hip. Tilts pelvis on walking.
Superior gluteal nerve above piriformis (L4-5, S1)
Bursa over lateral GT. Posterior 1/3 covered by gluteus maximus, anterior 2/3 by thick fascia
44
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Origin
Insertion
Action
Nerve supply
Special features
Gluteus minimus
```
Gluteal surface of ileum between posterior and anterior gluteal lines
Posterolateral surface of greater trochanter of femur
Abducts and medially rotates the hip. Tilts pelvis on walking.
Superior gluteal nerve (L4-5, S1)
Bursa over anterior GT
Superior gluteal nerve superficial. Opposite side contracts to prevent pelvis sagging to unsupported side
45
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Origin
Insertion
Action
Nerve supply
Special features
Piriformis
```
Arises 2,3,4 costotransverse bars of the anterior sacrum between sacral foramina
Anterior part of medial aspect of greater trochanter of femur
Laterally rotates and stabilises the hip
Anterior rami of S1, 2
Passes through greater sciatic foramen
Upper border: superior gluteal a/n
Lower border: inferior gluteal a/n, pudendal a/n, obturator int n, sciatic n, post femoral cutaneous n, quadratus femoris n
46
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Origin
Insertion
Action
Nerve supply
Special features
Obturator internus
```
Inner surface of obturator membrane and rim of pubis and ischium
Middle part of medial greater trochanter
Hip stabiliser, lateral rotator of extended thigh, abductor of flexed thigh
Nerve to obturator internus (ant divisions L5, S1-2)
Passes through lesser sciatic foramen. Bursa at lesser sciatic notch
47
Describe the borders of the lesser sciatic foramen and the contents
Superior: Sacrospinous ligament
Posterior: sacrotuberous ligament
Anterior: ischial spine, lesser sciatic notch and ischial tuberosity
Contains: pudendal nerve, tendon of obturator internus, internal pudenal artery and vein, nerve to obturator internus
48
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Origin
Insertion
Action
Nerve supply
Special features
Superior gemellus
```
Spine of ischium
Middle part of medial greater trochanter
Hip stabiliser, lateral rotator of extended thigh, abductor of flexed thigh
Nerve to obturator internus L5-S2
Sciatic nerve passes down posterior surface
49
```
Origin
Insertion
Action
Nerve supply
Special features
Inferior gemellus
```
Upper border of ischial tuberosity
Middle part of medial trochanter
Hip stabilisers, lateral rotation of hip in extension and abductor of flexed thigh
Nerve to quadratus femoris (ant divisions L4, 5 S1)
50
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Origin
Insertion
Action
Nerve supply
Special features
Quadratus femoris
```
Lateral border of sichial tuberosity
Quadrate tubercle of femur
Hip stabiliser, lateral rotation of the hip in extension, abductor of flexed thigh
Nerve to quadratus femoris (ant L4,5, S1)
Separated from NOF by tendon of obturator extensor, border of adductor magnus lies below
51
Which muscles do the gluteal nerves emerge in between?
Superior gluteal: emerges between piriformis and runs between gluteus minimus and medius
Inferior gluteal: emerges beneath piriformis and disappears into gluteus maximus
52
Which vessels form the trochanteric anastomosis?
Descending branch of superior gluteal artery
| Ascending branch of lateral and medial circumflex arteries (from profunda femoris)
53
Describe the course of the sciatic nerve (L4, 5, S1-3)
Emerges below piriformis (more laterally than inf gluteal and pudendal)
Lies on the ischium, in contact with bone at a point 1/3 of the way up from ischial tuberosity to the PSIS (the surface marking for entry into gluteal region).
Passes down posterior surface of obturator internus and quadratus femoris. Crossed posteriorly by long head of biceps femoris. Separates into tibial (L4, 5 S1-S3) and common peroneal (L4, 5 S1, 2) nerves at the popliteal fossa. Can occasionally separate early- in which case common peroneal pierces the piriformis and tibial emerges beneath piriformis
54
Why is the posterior femoral cutaneous nerve relevant to pelvic pain?
Distribution is S1-3. S2,3 segments supply pelvic parasympathetic nerves. Pain from pelvic disease may be referred to distribution of posterior femoral cutaneous nerve ( down posterior thigh and upper calf)
55
Which three parts of the pelvis form the acetabulum of the hip joint?
Ilium, ischium and pubis.
56
What are the three ligaments of the fibrous capsule of the hip?
Iliofemoral ligament; triangular, strongest
Pubofemoral ligament
Ischiofemoral ligament; weakest
57
Describe the anterior, posterior, medial, lateral, superior and inferior relations of the capsule of the femoral head?
Anterior: Psoas major divides the capsule from the femoral artery
Posterior: piriformis
Medial: Acetabular fossa and the ovary, separated by obturator internus
Lateral: Iliotibial tract
Superiorly: rectus femoris and gluteus minimus
Inferiorly: obturator externus
58
Which artery lies in the ligament in the head of the femur?
Acetabular branch of the obturator artery
| Becomes atrophied into ligamentum teres by age 7
59
What is the main blood supply to the femoral head?
Tronchanteric anastomosis mainly from acending branches of medial circumflex femoral artery and lateral circumflex artery , descending superior gluteal artery and inferior gluteal artery (at greater trochanter)
Cruciate anastomosis: transverse branches of medial and lateral circumflex, descending branch of inferior gluteal and ascending branch of first perforating artery (at lesser trochanter)
60
What is the nerve supply to the head of the femur?
Femoral nerve via the nerve to rectus femoris, the obturator nerve directly from the anterior division, the nerve to quadratus femoris and articular twigs from sciatic
61
In which position is the hip joint the least stable?
When flexed and adducted
62
What is the difference between the anterior and anteriolateral approach to the hip?
Anterior: Through the interval between sartorius and tensor fasca lata
Anterolateral: between tensor fascia lata and glut medius and performing an osteotomy of the greater trochanter
63
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Origin
Insertion
Action
Nerve supply
Special features
Semimembranous
```
Upper outer quadrant of the posterior surface of the ischial tuberosity
Medial condyle of tibia
Flexes knee, extends hip, medial rotation of hip when knee semiflexed
Tibial portion of sciatic (L5, S1)
Splits into 3 expansion; MCL, oblique popliteal lig. fascia overlying popliteus
64
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Origin
Insertion
Action
Nerve supply
Special features
Semitendinosus
```
Medial ischial tuberosity
Upper medial shaft of tibia (pes anserinus)
Flexes knee, extends hip, medially rotates hip when knee semiflexed
Tibial portion of sciatic (L5, S1)
Bursa between tendon and MCL
65
```
Origin
Insertion
Action
Nerve supply
Special features
Biceps femoris long head
```
Medial ischial tuberosity
Head of fibula, lateral collateral ligament and lateral tibial condyle
Flexes knee, lateral rotation of hip when kneee semiflexed, long head extends hip
Tibial portion of sciatic (L5, S1)
Crosses sciatic nerve on its posterior aspect. Bursa between tendon and LCL
66
```
Origin
Insertion
Action
Nerve supply
Special features
Biceps femoris short head
```
Whole length of linea aspera and upper part of lateral supracondylar line of femur
Head of fibula, lateral collateral ligament and lateral tibial condyle
Common peroneal portion of sciatic nerve (L5, S1)
In relation to LIMS, vastus lateralis in front, biceps femoris behind
67
What are the boundaries of the popliteal fossa?
Medial: semitendinosis
Lateral: biceps femoris
Roof: fascia lata
Floor:femur and capsule of the knee joint
68
What passes through the popliteal fossa?
Popliteal artery (deepest) and vein (always between artery and nerve)
Tibial nerve
Common peroneal nerve
Popliteal lymph nodes
69
What are the branches of the common peroneal nerve and what do they supply?
Sural communicating nerve: joins sural nerve below gastrocnemius
Lateral cutaneous nerve of the calf: supplies skin over peroneal and extensor part of the leg
Superior and inferior genicular nerves: travel with arteries and supply capsule of the knee
Recurrent genicular nerve: perforates tibialis anterior and supplies knee joint and tibfib joint
Common peroneal nerve ends by dividing into the deep and superficial peroneal nerves
70
How does the tibial nerve enter the calf and what does it supply there?
Enters below fibrous arch at origin of soleus
| Supplies motor branches to plantaris, gastrocnemius, soleus and popliteus
71
Describe the course of the sural nerve
Only cutaneous branch of tibial nerve
Runs vertically between 2 heads of gastroc
Pierces deep fascia halfway down calf where it replaces posterior cutaneous nerve of thigh.
Joins sural communicating nerve (from common peroneal)
Supplies lateral leg, lateral heel and lateral foot
72
What is the blood supply to the knee?
2 sural arteries
5 genicular arteries
Middle genicular artery supplies cruciate ligaments
73
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Origin
Insertion
Action
Nerve supply
Special features
Popliteus
```
Posterior surface of the tibia below tibial condyles
Lateral surface of the lateral condyle of the femur (posterior). Also attached to knee capsule and lateral meniscus.
Unlocks the extended knee by lateral rotation of the femur on tibia, also pulls back the lateral meniscus
Tibial nerve
Tendon passes into the knee capsule and attaches to lateral meniscus. Crossed superficially by arcuate popliteal ligament.
74
What is the largest synovial joint in the body?
Knee joint
75
What are the key differences between the tibial collateral ligament and the fibular collateral ligament?
Tibial collateral ligament: medial, attached to medial meniscus and capsule, crossed by pes anserinus
Fibular collateral ligament: lateral, NOT attached to lateral meniscus, a bursa lies between the ligament and the capsule, tendon of popliteus runs deep to the capsule here
76
Which muscles is the oblique popliteal ligament associated with?
Blends with tendon of semimembranosus
| Medial posterior edge of capsule
77
Where is the arcuate popliteal ligament?
Lateral posterior capsule
Lies over tendon of popliteus
Some popliteus muscle fibres attach to it
78
Where are the cruciate ligaments of the knee joint found?
Within the capsule of knee joint but not within synovial membrane
Anterior cruciate: attached to anterior tibial plateau between the menisci and attaches to lateral femoral condyle. Blends with lateral meniscus. Lies ANTEROLATERAL to posterior cruciate
Posterior cruciate: much stronger but shorter. Begins at tibial intercondylar area and ends at medial femoral condyle.
79
Describe the menisci
Thicker and convex peripherally
Thinner and concave proximally
Mainly avascular but capillaries around periphery
Horns are innervated but central parts have no sensory fibres
Medial: anterior horn is attached intracondylar area in front of anterior cruciate ligament. Posterior horn attached in front of posterior cruciate ligament.
Lateral: 4/5 of a circle. Anterior horn behind anterior cruciate ligament (blends). Posterior horn in front of posterior horn of medial meniscus
80
Which bursa communicate with the synovial knee joint?
```
Suprapatellar bursa
Superior tibulofibular joint
Bursa deep to medial head of gastrocnemius and often lateral head of gastrocnemius
Semimembranous bursa
Popliteus bursa
```
81
What is the nerve supply to the knee joint?
Femoral nerve
Tibial nerve
Obturator nerve
Local anaesthetic will numb skin but cruciate ligaments are supplied by tibial nerve and so remain sensitive
82
How does the movements of the bones in extension change depending on whether the foot is fixed?
When foot fixed; lateral condyle of femur rotates forwards and medial condyle glides backward. Lateral rotation of femur must proceed flexion. Done by popliteus
When foot free; passive rotation of tibia occurs. Popliteus medially rotates tibia.
83
How do the ligaments of the knee contribute to stability?
Forward displacement of the tibia on the femur if prevented by anterior cruciate.
Backwards displacement is prevented by posterior cruciate. ( important when walking downhill)
84
Which menisci and ligaments are more likely to be damaged?
Medial meniscus and medial ligament more likely to be injures
Anterior cruciate more likely to rupture than posterior.
85
Describe the cutaneous nerve distribution of the leg
Lateral leg from just above the knee to above half way down is lateral cutaneous nerve of the calf (common peroneal). Lateral beneath that and down to the foot is the sural nerve (tibial)
Medial leg down to medial malleolus is the saphenous nerve (femoral)
Heel skin is medial calcaneal branch of tibial nerve
Anterior lower leg and foot is superficial peroneal (common peroneal)
And 1st MTP webspace is deep peroneal (common peroneal)
86
Where does the great saphenous vein have most of its deep connections?
In the subcutaneous fat of the tibia
87
What are the muscles of the extensor compartment?
Tibialis anterior
Extensor hallicus longus
Extensor digitorum longus
Peroneus tertias
88
Which is the only muscular tendon of the extensor compartment with a synovial sheath beneath the superior extensor retinaculum?
Tibialis anterior (most medial tendon under the sheath)
89
Where are the anterior tibial vessels and deep peroneal nerves relative to the muscular tendons beneath the superior extensor retinaculum?
Between extensor hallicus longus tendon and extensor digitorum tendon
90
What is the order of flexor tendons as they pass posterior to the medial malleolus from anterior to posterior?
```
Tibialis posterior
flexor Digitorum longus
posterior tibial Artery
posterior tibial Vein
tibial Nerve
flexor Hallicus longus
```
91
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Origin
Insertion
Action
Nerve supply
Special features
Tibialis Anterior
```
Upper 2/3 of lateral tibia and IOM
Inferomedial aspect of medial cuneiform and base of first MT
Dorsiflex and inverts foot at the ankle, maintains medial longitudinal arch.
Deep peroneal and recurrent genicular nerve (L4)
Tendon has its own synovial sheath through sup and inf extensor retinaculum
Anterior tibial artery and deep peroneal nerve run beneath, anterior recurrent branch of ATa pierces
92
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Origin
Insertion
Action
Nerve supply
Special features
Extensor hallicus longus
```
Middle half of anterior shaft of fibular and IOM
Dorsal base of distal phalanx of the great toe
Dorsiflex/extends big toe and foot. Inverts foot and tightens subtalar joint.
Deep peroneal nerve (L5)
Deep to tib ant and EDL, emerging between the two. Crosses in front of anterior tibial artery and deep peroneal nerve from lateral to medial
93
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Origin
Insertion
Action
Nerve supply
Special features
Extensor digitorum longus
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Upper 3/4 of anterior shaft of fibular, IOM and lateral condyle of tibia.
Extensor expansion of lateral 4 toes. (middle slip goes to middle phalynx outer slips split then reunite to attach to distal phalynx
94
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Origin
Insertion
Action
Nerve supply
Special features
Peroneus tertius
```
Lower 1/3 of ant fibula
Dorsum of base of 5th metatarsal
Dorsiflex and evert foot
Deep peroneal nerve L5,S1
95
What is the blood supply to the extensor department of the leg?
Anterior tibial artery (runs on interosseus membrane)
| Gives off anterior recurrent branch which pierces tibialis anterior
96
What is the difference between the superior tibulofibular joint and the inferior tibulofibular joint?
Superior-synovial, communicates with knee joint
Inferior-fibrous
97
Where does the inferior extensor retinaculum sit?
Between the calcaneus and medial malleolus and plantar aponeurosis
98
```
Origin
Insertion
Action
Nerve supply
Special features
Extensor digitorum brevis/extensor hallicus brevis
```
Upper calcaneus and inferior extensor retinaculum
Attaches to proximal phalynx of medial 4 toes (extensor hallicus brevis muscle belly separates early and inserts onto great toe)
Extends toes when foot fully dorsiflexed
Deep peroneal nerve L5, S1
All tendons deep to EDL
Crosses on top of dorsalis pedis nerve and arterty. Runs on top of lateral tarsal artery and arcuate artery
99
```
Origin
Insertion
Action
Nerve supply
Special features
Peroneus longus
```
Upper 2/3 lateral shaft of fibula and IM septum.
Plantar side of 1st metatarsal and medial cuneiform
Plantarflexes (weakly)and everts the foot. Maintains the lateral longitudinal and transverse arches of the foot.
Superficial peroneal nerve L5, S1
Common peroneal nerve splits into deep and superior within PL.
Tendon lies next to cuboid bone where sesamoid fibrocartilage often ossifies.
100
```
Origin
Insertion
Action
Nerve supply
Special features
Peroneus brevis
```
Lower 2/3 shaft of lateral fibula
Base of 5th metatarsal
Plantarflexes (weakly) and everts the foot
Superior peroneal nerve L5, S1
Anterior to longus throughout. Tendon grooves lateral malleolus. Common tendon sheath splits at level of peroneal trochlea of calcaneus
101
```
Origin
Insertion
Action
Nerve supply
Special features
Gastrocnemius lateral head
```
Posterior surface of lateral condyle of femur (above popliteus).
Blends into aponeurosis with soleus to form tendo calcaneous which inserts on the middle 3rd of posterior calcaneus
Plantar flexes foot and flexes knee
Tibial nerve S1, S2
Tibial nerve passes between 2 heads. Main force for jumping. Lateral bursa may communicate with knee joint.
102
```
Origin
Insertion
Action
Nerve supply
Special features
Gastrocnemius medial head
```
Medial condyle of femur
Blends into aponeurosis with soleus forming tendo calcaneus which inserts onto middle 3rd of calcaneus
Plantar flexes foot and flexes knee
Tibial nerve S1, S2
Tibial nerve passes between 2 heads. Medial bursa usually communicates with knee joint.
103
```
Origin
Insertion
Action
Nerve supply
Special features
Plantaris
```
Lateral supracondylar ridge above lateral head of gastroc
Tendocalcaneus, medial side deep to gastroc tendon
Plantarflexes foot and flexes knee
Tibial nerve S1. S2
Absent in 10-20% of people
104
```
Origin
Insertion
Action
Nerve supply
Special features
Soleus
```
Soleal line and middle 3rd of posterior border of tibia and upper 1/4 of posterior shaft of fibula
Tendocalcaneous to middle 3rd of posterior calcaneus
Plantar flexes foot and aides venous return
Multipennate fibres, slow. Main propulsive force for walking and running
Tibial nerve and popliteal artery and nerve pass beneath its fibrous arch of origin. Receives 2 branches from tibial nerve.
105
What are the three deep muscles of the calf?
Flexor digitorum longus
Flexor hallicus longus
Tibialis posterior
106
```
Origin
Insertion
Action
Nerve supply
Special features
Flexor digitorum longus
```
Posterior shaft of tibial below soleal line
Base of distal phalanges of lateral 4 toes.
Flexes distal phalanges of lateral 4 toes and foot at the ankle. Supports longitudinal arch of the foot.
Tibial nerve S1, S2
Superficial to TP and EHL, crosses TP in calf medial to lateral, then FHL medial to lateral in sole. Medial 2 tendons receive slips from FHL and all 4 receive insertion of flexor acccessorius. Each tendon also gives the origin to a lumbrical.
107
```
Origin
Insertion
Action
Nerve supply
Special features
Flexor hallucis longus
```
Lower 2/3 of posterior fibula and IOM
Base of distal phalynx of big toe
Flexes big toe (last point the leave the ground in propulsion). Plantar flexes ankle joint and supports medial longitudinal arch.
Tibial nerve S1, S2
Peroneal artery runs deep to muscle on PT. Crosses the tendons of FDP in the sole
108
```
Origin
Insertion
Action
Nerve supply
Special features
Tibialia posterior
```
Upper 1/2 of of posterior tibia and fibula and IOM
Navicular bone, all tarsal bones, bases of metatarsals 2-4 and sustenaculum tali
Inverts and adducts the forefoot, it plantarflexes the ankle joint, supports medial longitudinal arch
Tibial nerve S1,2
Deepest muscle of posterior compartment. Posterior tibial artery runs on top
109
Which three muscles are in the first layer of the foot?
Flexor digitorum brevis
Abductor hallucis
Abductor digiti minimi
110
What is the segmental nerve to all of the foot muscles?
S2
111
```
Origin
Insertion
Action
Nerve supply
Special features
Flexor digitorum brevis
```
Medial process of the calcaneus, deep surface of central plantar aponeurosis
Middle phalanx of lateral 4 toes
Flexes toes in any position of the ankle
Medial plantar nerve
Central muscle
112
```
Origin
Insertion
Action
Nerve supply
Special features
Abductor hallucis
```
Medial process of calcaneus and flexor retinaculum
Medial side of proximal phalanx of great toe
Abducts great toe
Medial plantar nerve
Medial margin of the foot
113
```
Origin
Insertion
Action
Nerve supply
Special features
Abductor digiti minimi
```
Medial and lateral processes of calcaneus, deep to FDB
Base of proximal phalanx of 5th toe and tubercle of 5th MT
Abduct little toe
Lateral plantar nerve
Lateral margin
114
Which muscles make up the second layer of the foot?
Flexor hallicus longus tendon (crossed by FDL inferiorly, synovial sheath whole course)
Flexor digitorum longus tendon (receives insertion of flexor accessorius)
Flexor accessorius
Lumbricals
115
```
Origin
Insertion
Action
Nerve supply
Special features
Flexor accessorius/quadratus plantae
```
Medial head: medial calcaneus
Lateral head: lateral calcaneus
Tendon of Flexor digitorum longus as it subdivides into digits
Flexion of lateral 4 toes in any position of the ankle
Lateral plantar nerve
116
```
Origin
Insertion
Action
Nerve supply
Special features
Lumbricals (of the foot)
```
Tendons of flexor digitorum longus
Extensor expansions of lateral 4 toes
Maintains extension of digits and interphalyngeal joint while flexor digitorum longus is flexing the toes, so toes don't buckle under when running
1st lumbrical-medial plantar nerve- unicipital
Lateral 3 lumbricals- lateral plantar nerve-bicipital
Lie on the medial (toe) side of their metotarsalpharyngeal joints
117
Which muscles make up the third layer of the foot?
Flexor hallucis brevis
Adductor hallucis
Flexor digiti minimi brevis
118
```
Origin
Insertion
Action
Nerve supply
Special features
Flexor hallicus brevis
```
Cuboid, lateral cuneiform
Medial and lateral sides of proximal phalanx of great toe as 2 separate heads
Flex proximal phalynx of great toe
Medial plantar nerve
Medial insertion blends with abductor hallucis
Lateral insertion blends with adductor hallicus
119
```
Origin
Insertion
Action
Nerve supply
Special features
Adductor hallucis
```
Oblique head: long plantar ligament, base 2-4 MT
Transverse head: deep transverse ligament and plantar ligaments of lateral 4 MTPJ (no boney origin)
Lateral side of base of proximal phalanx of great toe (with lateral FHB)
Draws big toe in towards the axis of MT and maintains transverse arch
Deep branch of lateral plantar nerve
Long plantar ligament sits superficially to peroneus longus tendon
120
```
Origin
Insertion
Action
Nerve supply
Special features
Flexor digiti minimi brevis
```
Base of 5th MT
Base of 5th proximal phalanx medial to abductor digiti minimi
Flexes little toe
Superficial branch of lateral plantar nerve
121
What makes up the 4th layer of the foot?
Interosseus muscles
Tendon of peroneus longus
Tendon of tibialis posterior
122
```
Origin
Insertion
Action
Nerve supply
Special features
Plantar interossei
```
MT of own toe
Medial sides of 3rd- 5th base of proximal phalanges and dorsal extensor expansion
ADDUCT lateral 3 toes towards second toe
Extends IPJ and flexes MTPJ
Lateral plantar nerve- (4th superficial branch, all the others deep)
Only lateral 3 toes, great toe has adductor hallucis, none for 2nd toe as cant adduct towards itself
123
```
Origin
Insertion
Action
Nerve supply
Special features
Dorsal interossei
```
MT heads of both sides of intertarsal space
1st-big toe side of base of the 2nd toe and extensor expansion
2nd-4th: pinky toe side of their individual toes
ABDUCT away from lines of 2nd toe
Extend IPJ and flex MTPJ
Lateral plantar nerve (4th superficial, others deep)
2nd toe has on on each side. Great toe and 5th toe have their own abductors
124
```
Origin
Insertion
Action
Nerve supply
Special features
Dorsal interossei
```
MT heads of both sides of intertarsal space
1st-big toe side of base of the 2nd toe and extensor expansion
2nd-4th: pinky toe side of their individual toes
ABDUCT away from lines of 2nd toe
Extend IPJ and flex MTPJ
Lateral plantar nerve (4th superficial, others deep)
2nd toe has on on each side. Great toe and 5th toe have their own abductors
125
Describe the cutaneous innervation of the anterior thigh
From lateral to medial along inguinal ligament. subcostal (T12), femoral branch of genitofemoral (L1,2), iloinguinal (L1)
Lateral thigh is lateral femoral cutaneous (L2,3)
Middle thigh and knee is medial and intermediate femoral cutaneous (L2,3)
Most medial thigh is obturator (L2,3,4)
126
Describe the cutaneous innervation of the anterior thigh
From lateral to medial along inguinal ligament. subcostal (T12), femoral branch of genitofemoral (L1,2), iloinguinal (L1)
Lateral thigh is lateral femoral cutaneous (L2,3)
Middle thigh and knee is medial and intermediate femoral cutaneous (L2,3)
127
How does an injury of the femoral nerve present?
Absent knee extension, weakness of hip flexion, sensory loss over front of thigh
128
How does an injury of the femoral nerve present?
Absent knee extension, weakness of hip flexion, sensory loss over front of thigh
129
How does an injury of the sciatic nerve present?
Paralysis of hamstrings and all muscles of the leg and foot. Sensory loss below knee but not on the medial side of the leg or upper calf
130
How does an injury of the sciatic nerve present?
Paralysis of hamstrings and all muscles of the leg and foot. Sensory loss below knee but not on the medial side of the leg or upper calf
131
How does an injury of the common peroneal nerve present?
Foot drop
| Loss of dorsiflexion
132
At what age are the pelvic bones all fully ossified and fused?
25
133
What angle does the neck of femur sit at?
Approximately 125 degrees to the shaft and anteriorly 10-15 degrees
134
List the bones of the foot from proximal to distal and medial to lateral
```
Calcaneus
Talus
Navicular, cuboid
Cuneiform bones (medial intermediate lateral)
Metatarsal bones
Phalangeal bones
```
135
Which is the first long bone to ossify?
Clavicle, then femur
