Eliot Lower Limb Questions

l. Which one of the five metatarsal bones is relatively short and sturdy?

1st metatarsal bone

k. Which one of the five metatarsal bones has a prominent styloid process on its base?

5th metatarsal bone

What is the important shared anatomical action of gluteus medius, gluteus minimus and tensor fasciae latae?

Abduction of the thigh at the hip

f. What is the principal shared action of the muscles that the superior gluteal nerve innervates?

Abduction of the thigh at the hip

f. Which of these ten tendons are from muscles that are invertors of the foot at the ankle?

Achilles tendon, tibialis anterior tendon, tibialis posterior tendon

e. Both sets of ligaments between the clavicle and scapula should be assessed to evaluate shoulder separation. Radiograph the patient while he or she is holding a weight to distract the upper limb inferiorly. If the ligaments are intact, the scapula will stay aligned with the clavicle. Where will shoulder separation be externally visible?

Acromioclavicular joint (acromion lower than clavicle)

b. What ligaments are there?

Acromioclavicular ligament is a thick part of the joint capsule, located superiorly

a. With what part of the scapula does the distal end of the clavicle articulate?

Acromion

d. Cerebral palsy is a result of brain injury, it causes uncontrolled hypertonicity of muscles; it often occurs to muscles that happen to be innervated by the obturator nerve. What is the position of the patient's lower limb?

Adducted, externally rotated thigh at the hip Sometimes the obturator nerve is surgically divided to paralyze these muscles.

c. What is the principal shared action of the muscles that the obturator nerve innervates?

Adduction of the thigh at the hip

e. What muscle is posterior to the adductor longus?

Adductor brevis

i. Where does the femoral artery become the popliteal artery, and where does the popliteal vein become the femoral vein?

Adductor hiatus (passing through the adductor magnus muscle)

a. What ligament holds the radial head in place against the radial notch of the proximal ulna?

Annular ligament of radius

c. Relative to the posterior cruciate ligament, where on the tibial plateau does the anterior cruciate ligament attach to the tibia?

Anterior

n. What compartment of the thigh has the muscles that the femoral nerve innervates?

Anterior compartment of the thigh

e. Which of the two cruciate ligaments is more obliquely oriented?

Anterior cruciate ligament

b. In general, what skin surfaces are innervated by cutaneous branches of the femoral nerve?

Anterior thigh and medial leg

b. Relative to the femur where is the iliofemoral ligament located?

Anterior to the femoral neck

c. Where is the great saphenous vein located in the foot (where does it cross the ankle)?

Anterior to the medial malleolus

f. Where along the length of the leg does the superficial fibular nerve achieve its vulnerable subcutaneous depth?

Approximately halfway between the head of the fibula and the lateral malleolus

f. What part of a foot bone is likely to fracture if an osteoporotic individual stumbles and impacts her heel with excessive force?

Calcaneal tuberosity

f. Who's radial head is much more easily deformed enough to slip distally away from the ligament that encircles it?

Child's

e. You will notice that the nerve to the short head of biceps femoris is on the lab study list for the "Gluteal region, posterior thigh, popliteal fossa and posterior leg" lab. From which part of the sciatic nerve does it branch?

Common fibular nerve

c. What nerves can be involved in piriformis syndrome?

Common fibular nerve especially, possibly tibial nerve

f. How is it that much tissue damage may have occurred in anterior compartment syndrome even though the right and left dorsalis pedis pulses of a patient appear symmetrical to palpation?

Compression and collapse of the veins occur at lower pressure than arterial pressure

d. What ligaments are between the coracoid process of the scapula and the clavicle?

Coracoclavicular ligaments

l. Inflammation of the plantar nerves in the tarsal tunnel causes tarsal tunnel syndrome. It is much less common than carpal tunnel syndrome. Is the anatomy of the tarsal tunnel more like that of the cubital tunnel or of the carpal tunnel?

Cubital tunnel. The nerve does not share the tunnel with tendons

h. The proximal bones of the midtarsal joint are the calcaneus and the talus; what are the two distal bones of the midtarsal joint?

Cuboid and navicular bone

g. What nerve innervates the tibialis anterior and the other muscles that share its principal anatomical action?

Deep fibular nerve

e. Between which two muscles does the lateral plantar neurovascular bundle pass to reach the more lateral parts of the foot?

Deep to flexor digitorum brevis muscle, superficial to quadratus plantae muscle

e. At what depth are the deep inguinal lymph nodes located?

Deep to investing layer of deep fascia

a. How deep is the tibial nerve in the leg?

Deep to the Soleus in the deep part of the posterior compartment

a. Where does the external iliac artery become the femoral artery, and where does the femoral vein become the external iliac vein?

Deep to the inguinal ligament

j. Is the head of a metatarsal bone at its proximal end or at its distal end?

Distal end

b. In health, how large is the space between the bones in that cavity?

Distracted or not weightbearing: less than a millimeter.

Flexion of the thigh at the hip and extension of the leg at the knee are tests designed to stretch lower lumbar nerve roots to detect the irritation that an intervertebral disc herniation causes. You can add a little more stretch to the nerves and fascia across the posterior side of the ankle. What movement of the foot will accomplish that last bit of stretch?

Dorsiflexion of the foot

m. What movement occurs to give the posterior leg muscles their "Eccentric" label?

Dorsiflexion of the foot at the ankle

h. Where does the deep fibular nerve become a relatively subcutaneous nerve?

Dorsum of the foot

j. From previous slides we know that the hamstrings have the actions of extending the thigh at the hip and flexing the leg at the knee. Taken alone, which of those two movements would be an eccentric contraction on slide 34?

Eccentric contraction during flexion of the thigh at the hip joint

Are fibularis longus and brevis functions examples of concentric contraction, or of eccentric contraction, or of both?

Eccentric contraction in mid-stance phase, the muscles are allowing dorsiflexion or inversion, but making it go gently or slowly. Maybe some concentric contraction at toe-off, especially if one has a "spring in one's step"

f. If one starts from a standing position, the back flexes. Is this concentric, isometric or eccentric "contraction" of the back muscles?

Eccentric. Relative to the upright starting position, is the movement of the back the same as the action of erector spinae that would be listed in a table in an anatomy book, opposite to that listed action, or is there no change in the muscle's length? Opposite

i. What action do they have that causes them to be stretched when one squats?

Extension of the leg at the knee

a. This question and the next follow up on question 42b. What is the principal shared action of the muscles that the femoral nerve innervates?

Extension of the leg at the knee tested by patellar tendon tap reflex

q. What two anatomical actions do the three true hamstring muscles share?

Extension of the thigh at the hip. Flexion of the leg at the knee

d. Almost all stretches involve more than one muscle, although many influence one muscle more than others. How far distally do you have to go to find a large movement of the lower limb that stretches only one major muscle without stretching any others?

Extension of the toes

g. Which of these ten tendons are from muscles that are evertors of the foot at the ankle?

Extensor digitorum longus, fibularis tertius tendon, fibularis longus tendon

c. Imagine injecting a pharmaceutical agent into the femoral vein. Through which vessels will it pass on its way to the heart?

External iliac vein, common iliac vein, inferior vena cava What chamber of the heart will it reach first? Right atrium What major organ will it reach next? Lungs

b. Severe trauma such as being trod upon by an angry or frightened horse can cause a fracture of the ala of the ilium. What major nerve (with muscular and cutaneous service) is found near the anterior superior iliac spine, and might be tested to evaluate the extent of such an injury?

Femoral nerve

m. Which one passes deep to the inguinal ligament to reach the femoral triangle?

Femoral nerve

d. What neurovascular bundle is anterior to this fascial plane (anterior to pectineus and iliopsoas)?

Femoral nerve, artery, and vein

a. Here we add detail to Objective 36. In the "N-A-V-L" mnemonic acronym, what does each letter stand for?

Femoral nerve, artery, vein, deep inguinal lymphatic nodes and channels

f. So which site would you prefer for a short term procedure such as injecting contrast medium for a vascular study?

Femoral vein

e. Actually, the significant differences between femoral and subclavian vascular access are in the surrounding tissues during the procedure itself. Which vessel presents no possibility of lacerating the lung and causing pneumothorax?

Femoral vein Which site is harder to monitor and keep sanitary? Femoral vein

f. In addition to blood and lymphatic vessels, there are two main components of the joint capsule of a synovial joint. Which of the two components provides sturdiness?

Fibrous capsule

q. What are the lateral compartment muscles?

Fibularis longus and fibularis brevis

d. In a typical case of hallux valgus, what joints of the first ray are most significantly malaligned?

First cuneometatarsal joint and first metatarsophalangeal joint

b. What bones are in the hallucal ray?

First metatarsal, first proximal (pedal) phalanx, first distal (pedal) phalanx

b. What bones are in the first pedal ray?

First metatarsal, first proximal phalanx, first distal phalanx

a. Which numbered ray of the foot is the hallucal ray?

First ray

c. If the hallucal ray of a foot has normal alignment, what is the principal anatomical action of the flexor hallucis longus muscle?

Flexion at the first interphalangeal joint and flexion at the first metatarsophalangeal joint

k. And, taken alone, which one would be a concentric contraction?

Flexion of the leg at the knee joint

d. What muscle of the lower limb is homologous to the flexor digitorum superficialis?

Flexor digitorum brevis

e. What muscle of the lower limb is homologous to the flexor digitorum profundus?

Flexor digitorum longus

h. What muscle attaches to the iliotibial band posteriorly?

Gluteus maximus

j. What muscle is separated from the greater trochanter by the trochanteric bursa?

Gluteus maximus muscle

s. What one muscle does the inferior gluteal nerve innervate?

Gluteus maximus muscle

q. What three muscles does the superior gluteal nerve innervate?

Gluteus medius, Gluteus minimus, and tensor fascia latae muscles

k. What muscles attach to the greater trochanter of the femur?

Gluteus medius, Piriformis, Gluteus minimus

m. Which is the deepest of the three gluteal muscles?

Gluteus minimus

f. Details of the capsular ligaments of the shoulder are beyond the scope of this part of the course. They are a weaker anteriorly, so anterior dislocation of the humerus is common (often occurs when the arm is fully abducted). In the physical examination of a patient with such a glenohumeral dislocation, what will the shoulder region look like?

Head of humerus visible anteriorly, arm held slightly abducted

b. What part of what bone sits at the top of the medial longitudinal arch?

Head of talus

e. What part of what bone articulates with the superior surface of the spring ligament?

Head of talus

p. What two joints do all of the three true hamstring muscles cross?

Hip joint, knee joint (tibiofemoral joint). Biceps femoris muscle also crosses the tibiofibular joint

c. All synovial joints have cartilage. What particular kind of cartilage do almost all of them have?

Hyaline cartilage

e. What tissue type is in the radial head of a young child?

Hyaline cartilage

d. What tissue types are in the adult radial head?

Hyaline cartilage, bone

i. Between what bone structure superiorly and what muscle edge inferolaterally and is the subcutaneous surface of the gluteus medius found?

Iliac crest, Gluteus maximus muscle

c. Which muscles are in contact with the iliofemoral ligament?

Iliopsoas

l. What muscle attaches to the lesser trochanter of the femur?

Iliopsoas

b. The gluteus maximus is a big, bullyish muscle that claims an entire nerve for itself. What is that nerve?

Inferior gluteal nerve

f. Where does the common fibular nerve divide?

Inferior to the head of the fibula. Just deep to the external investing layer of deep fascia. What are its two principal branches? Superficial fibular nerve and deep fibular nerve

a. What is the relationship of the superficial inguinal lymph nodes to the inguinal ligament?

Inferior to the ligament (in the thigh)

b. What is the relationship of the deep inguinal lymph nodes to the inguinal ligament?

Inferior to the ligament (in the thigh)

c. In fact, no ligament attaches to the head of the radius. What ligament attaches to the shaft of the radius?

Interosseous membrane of the forearm

c. Apply your knowledge of basic pathological processes and terminology. What is the most serious relatively immediate consequence of compartment syndrome?

Ischemia followed by necrosis

t. Between what two bony landmarks does the sciatic nerve pass as it leaves the gluteal region and enters the thigh?

Ischial tuberosity of the hip bone, Greater trochanter of the femur

l. If the two movements approximately cancel each other, what will be the result?

Isometric contraction

g. What effect do these malalignments of hallux valgus have on the action of the flexor hallucis longus muscle?

It becomes an abductor at the proximal joint and an adductor at the distal joint, compounding the malalignments

b. Which three ventral rami contribute to the obturator nerve?

L2, L3, L4

c. Which three ventral rami contribute to the femoral nerve?

L2, L3, L4

e. Which four ventral rami contribute to the common fibular part of the sciatic nerve?

L4, L5, S1, S2

d. Which five ventral rami contribute to the tibial part of the sciatic nerve?

L4, L5, S1, S2, S3

e. What dermatome (p. 539) matches the surface that is supplied by various cutaneous branches of the common fibular nerve (p. 537)?

L5

d. How is this similar to injecting into the subclavian vein?

Large vein in a limb that is close to the large veins of the trunk. How is it different? Femoral vein eventually leads to inferior vena cava, while subclavian vein leads to superior vena cava

n. The P-G-O-G-O-Q muscles (COA p. 564). The highest one is a weak abductor and the lowest one is a weak adductor. What anatomical action do they all share?

Lateral (external) rotation of the thigh at the hip

d. Which of the two femoral condyles is more prominent than the other anteriorly?

Lateral condyle

g. Where does the superficial fibular nerve enter the subcutaneous tissues?

Lateral side of the leg

b. Does this mnemonic go from medial to lateral or lateral to medial?

Lateral to medial ("N" on the lateral side)

b. Where around the circumference of the lower limb does the common fibular nerve cross the knee?

Lateral to the popliteal fossa

a. Where in the intercondylar fossa does the anterior cruciate ligament attach to the femur?

Laterally

g. How much blood and nerve supply does a meniscus get?

Little

a. Where around the circumference of the lower limb does the saphenous nerve cross the knee?

Medial

b. If you wish to access the femoral vein in the femoral triangle, will you insert the cannula (tube) medial to the arterial pulse you palpate, or lateral to the pulse?

Medial

c. The two nerves that innervate the two heads of the gastrocnemius muscle are among the more superficial branches of the tibial nerve. Where are they located?

Medial and lateral to the inferior part of the popliteal fossa

o. What compartment of the thigh has the muscles that the obturator nerve innervates?

Medial compartment of the thigh - Gracilis, adductor longus, adductor brevis, adductor magnus, pectineus muscle What muscle in this compartment is innervated by the femoral nerve? Pectineus muscle (femoral n. and obturator n.)

i. In what region of the lower limb is the saphenous nerve closely paired with the great saphenous vein?

Medial leg

a. Which is taller, the medial longitudinal arch or the lateral longitudinal arch?

Medial longitudinal arch

c. What are these two branches of the tibial nerve?

Medial plantar nerve, lateral plantar nerve

e. In general, what skin surfaces are innervated by cutaneous branches of the obturator nerve?

Medial thigh

j. In what region of the lower limb are the saphenous nerve and the great saphenous vein relatively separate from each other?

Medial thigh and adductor canal

e. Where and how large is the obturator nerve's cutaneous innervation in the leg?

Medial to the knee, small

b. Where in the intercondylar fossa does the posterior cruciate ligament attach?

Medially

g. What series of bones defines a ray of the foot skeleton?

Metatarsal and the two or three phalanges of a toe

c. Where around the circumference of the lower limb does the tibial nerve cross the knee?

Middle of the popliteal fossa

c. Between what two bones does that part of the bone rest?

Navicular bone and calcaneus

d. What bones are connected by the spring ligament?

Navicular bone and calcaneus

c. Is there a synovial joint between the coracoid process of the scapula and the clavicle?

No

j. Is the lateral meniscus securely attached to the knee joint capsule?

No

n. Is the lateral collateral ligament securely attached to the knee joint capsule?

No

g. The principal action of the anterolateral abdominal wall muscles (rectus abdominis, etc.) is flexion of the trunk. Are they needed for this movement in the behavior that is shown on Slide 19?

No. (maybe a little to initiate the movement)

n. Is there any need to label the anterior leg muscles?

No. Not needed because gravity is doing the work.

l. Compare the course of the femoral nerve and the obturator nerve. Which one passes across the pelvic brim and through the lesser pelvis?

Obturator nerve

b. What are the "five P's" for diagnosing compartment syndrome?

Pain, pallor, paresthesia, pulselessness, paralysis

a. What symptoms of femoral nerve injury will be evident below the knee?

Pain, paresthesia, or anesthesia in the distribution of the saphenous nerve

c. What bone articulates with the prominent surfaces on the anterior parts of the femoral condyles?

Patella

b. How would you distinguish saphenous nerve injury from injury of the whole femoral nerve?

Patellar tendon tap reflex

g. The deep femoral artery is in the medial compartment, but it is deep enough to supply most of the blood to the posterior compartment. What branches offer the blood supply of the superior part of the posterior thigh?

Perforating branches of profunda femoris artery

p. What structure separates the superior gluteal neurovascular bundle from the inferior gluteal neurovascular bundle?

Piriformis muscle

e. What movements are most extensive at the ankle joint proper?

Plantarflexion and dorsflexion (sagittal plane)

f. Consider the popliteal artery and popliteal vein. Which is closer to the bone and so might be more vulnerable to laceration if there is a fracture of the distal femoral metaphysis?

Popliteal artery Which is, in general, a more fragile tissue and might therefore be more vulnerable to laceration in such a fracture? Popliteal vein

d. Into which vein does the small saphenous vein drain to enter the deep venous circulation?

Popliteal vein

a. Which leg compartment is divided into superficial and deep parts?

Posterior compartment of the leg What is the principal functional difference between the muscles in one compartment and the other? Deep muscles go more anterior in the foot, and have direct actions distal to the midtarsal joint

d. Which of the two cruciate ligaments is more longitudinally oriented?

Posterior cruciate ligament

f. In what way does that more horizontal alignment limit movement of the tibia relative to the femur?

Prevents anterior glide of the tibia relative to the femur

i. Is the base of a metatarsal bone at its proximal end or at its distal end?

Proximal end

b. Why can't this ligament attach directly to the radius?

Radius has to be free to rotate in supination and pronation

k. What is the shape of the medial collateral ligament of the knee?

Relatively broad and flat

g. Slide 20 in the lower limb lecture concerns a different test for strength of these muscles (COA p. 568). Ask your patient to stand on his right leg, with his left foot off the ground. If his left iliac crest falls inferior to his right iliac crest, what muscles are weak or paralyzed?

Right gluteal muscles (Superior gluteal nerve could be injured)

m. What is the shape of the lateral collateral ligament of the knee?

Round and cord-like

g. What nerve emerges from the first (most superior) ventral sacral foramen?

S1

What cutaneous nerve (p. 537) supplies a surface that matches the L4 dermatome (p. 539)?

Saphenous nerve

i. The branch of the femoral nerve that reaches the foot is the longest nerve in the body, name it. Saphenous nerve What surface does it serve?

Saphenous nerve What surface does it serve? Medial side of the ankle Given the sources of the femoral nerve, what dermatome must this be? L4

What are the three muscles that form the Pes Anserine insertion on the medial aspect of the proximal tibia?

Sartorius, Gracilis, Semitendinosus

c. What bones are in the second pedal ray?

Second metatarsal, phalanges of the second digit

f. What ligament is stretched when weightbearing pushes all those bones toward the floor?

Spring ligament

b. What is the value of the word "heel" in the mnemonic "Tom, Dick and Harry; heel?

Start at the medial malleolus, end at the calcaneus

h. What is periarticular bone?

Subchondral bone with a surface inside the cavity of a synovial joint

Subclavian vs. Femoral vein: which would you prefer for long term administration of medication?

Subclavian vein

d. At what depth are the superficial inguinal lymph nodes located?

Superficial fascia

r. What is the innervation of fibularis longus and brevis?

Superficial fibular nerve

g. What two nerves should be tested to determine whether a fracture of the neck of fibula (two centimeters distal to the fibular head) is a relatively minor injury?

Superficial fibular nerve and deep fibular nerve

b. How deep is the tibial nerve as it branches near the ankle?

Superficial, covered only by deep fascia or the ligamentous tissue of the tarsal tunnel

b. Where is the adductor tubercle of the femur located, and what attaches there?

Superior surface of the medial epicondyle of the femur. Adductor magnus attaches to the adductor tubercle.

c. What is the relationship of the external iliac lymph nodes to the inguinal ligament?

Superior to the ligament (in the abdominopelvic cavity)

e. If the saphenous nerve is injured, what other peripheral nerves will overlap on its region of supply to minimize the area of total anesthesia?

Sural nerve

a. What fills the cavity between the bones of a synovial joint?

Synovial fluid

g. Which of the two components provides synovial fluid?

Synovial membrane

g. What muscle attaches to the iliotibial band anteriorly?

Tensor fascia latae

i. Most instances of hip joint dislocation in adults are accompanied by fracture of the hip bone or the femoral head. Why?

The acetabulum is deep and the femoral head sits deeply in it; relative to the cartilage, bone is brittle

j. What aspects of the anatomy of the hip bone of an infant allow dislocations to occur relatively easily, and without fracture?

The acetabulum is relatively shallow; relative to bone, cartilage is deformable

h. What part of the medial meniscus or lateral meniscus has the least blood supply and nerve supply?

The external edges of both menisci

b. Blue box, COA page 560. Although there are a deep femoral artery (profunda femoris a.) and a deep femoral vein, why should the femoral artery and vein themselves not be called the superficial femoral artery and vein?

The femoral artery is deep to the investing layer of deep fascia. Great saphenous vein is truly superficial

g. How does the alignment of fibrous tissue within the capsular ligaments of the hip aid in limiting this movement?

The fibers spiral so they tighten when the thigh extends. For example, the iliofemoral ligament runs from superior on the anterior side of the ilium to inferior on the femur, and the ischiofemoral ligament wraps over the superior surface of the femoral neck.

d. How would you distinguish saphenous nerve injury from a lesion of the dorsal root of the spinal nerve that contributes to the saphenous nerve?

There is very little difference in the lower limb. However, the spinal nerve also has a dorsal ramus that supplies some skin of the back and lateral abdominal wall.

g. The curved top of the talus that participates in the ankle joint is the dome of the talus, on your lab study list. What are the other two bones of the ankle joint?

Tibia and Fibula

d. Stand with your feet firmly on the ground. How does your tibia move relative to your femur if you rotate your thigh internally at your hip?

Tibia rotates externally

f. Which of the two divisions of the sciatic nerve innervates the adductor magnus?

Tibial nerve What other nerve innervates this large muscle that can be seen from the posterior side and the medial side of the thigh? Obturator nerve

u. What are the two branches of the sciatic nerve?

Tibial nerve and common fibular nerve

e. Which of these ten tendons are from muscles that dorsiflex the foot at the ankle?

Tibialis anterior, extensor hallucis longus, extensor digitorum longus, fibularis tertius

d. What tendons are closest to them?

Tibialis posterior and flexor digitorum longus tendons What blood vessels are also nearby? Medial and lateral plantar vessels branching from or draining into the posterior tibial vessels

d. Which ones of these ten tendons are from muscles that have at least some action of plantar flexion of the foot at the ankle?

Tibialis posterior, Flexor digitorum longus, flexor hallucis longus, achiles tendon, fibularis longus, fibularis brevis

h. If you accidentally inject a pharmaceutical agent that is intended for the femoral vein into the femoral artery, where will it go?

To the thighs and legs

e. We know that musculovenous pumping is a good way to deliver blood from the lower limb to the trunk. What intrinsic anatomical feature of lower limb veins makes this possible?

Valves

h. The muscles on the anterior side of the thigh are labeled "Eccentric." What muscles are we referring to?

Vastus muscles (medialis, intermedius, lateralis)

d. Does the obturator nerve innervate any muscles that cross the knee joint?

Yes

i. Is the medial meniscus securely attached to the knee joint capsule?

Yes

j. If the tibial nerve is injured three fingerbreadths superior to the medial malleolus, will the gastrocnemius and soleus muscles retain their innervation?

Yes

l. Is the medial collateral ligament securely attached to the knee joint capsule?

Yes

f. Do cutaneous nerves carry any efferent (motor) information?

Yes. Sympathetic to sweat glands and arrector pili muscles

t. Do all three muscles of Pes Anserine cross the hip joint?

Yes. Which muscle originates from the ilium? Sartorius. Which originates from the ischium (see p. 572 if necessary)? Semitendinosus. Is that muscle a hamstring muscle? Yes. Which one of the three muscles originates from the pubic bone? Gracilis muscle

d. What is the radiographic appearance of this cartilage?

approximately the same as water or surrounding soft tissues