Anatomy Exam III

sustentaculum tali

"shelf " of bone protruding from the medial, superior surface of the calcaneus The middle facet of the subtalar joint is located on the upper surface of this feature

Metatarsophalangeal joints

(MTP) are condyloid joints and thus allow mostly flexion/extension as well as some abduction and adduction

What muscle group is responsible fore groin pulls?

Adductor muscles A groin pull usually refers to a strain of an adductor m. since the proximal attachment of most of these muscles is in the inguinal region (ie. groin).

Anterior Compartment of the leg (Arterial Supply, Innervation, Function)

Artery = Anterior tibial artery Innervation = Deep fibular nerve (S1,S2) Function = All Dorsiflex foot (may evert or invert)

Lateral Compartment of the leg (Arterial Supply, Innervation, Function)

Artery = Perforating branches of Anterior tibial artery and Fibular artery Innervation = Superficial fibular nerve (S1,S2) Function = Plantar flex foot, Evert foot

Posterior Compartment of the leg (Arterial Supply, Innervation, Function)

Artery = Posterior tibial artery Innervation = Tibial nerve (S1,S2) Function = Plantarflex and Invert foot Muscles divided into superficial and deep groups by the transverse intermuscular septum. The arterial and nerve supply are located within the deeper subcompartment.

flexor retinaculum

At the medial malleolus, a thickening of the transverse intermuscular septum retains the long flexor tendons of the leg as they course into the foot

What septa does the fascia lata create? What does this divide upper thigh into?

Intermuscular septa Lateral intermuscular septae (anterior and posterior) further divide the leg into anterior, posterior and lateral compartments

Femoral nerve

Largest branch of the lumbar plexus. Most lateral structure in femoral triangle. Divides into muscular and sensory branches to supply the anterior thigh. Two terminal branches = 1. nerve to vastus medialis (motor) 2. saphenous nerve (sensory) Note: The lateral femoral cutaneous nerve is not a branch of the femoral nerve. Purely sensory branch derived from lumbar plexus: (L2,L3)

Muscular Lacuna

Lateral Compartment = iliopsoas tendon and femoral n.

Vascular Lacuna

Medial compartment = vascular structures entering the femoral triangle (artery, vein, lymphatics)

Vein drainage starting from foot

Medial side of dorsal venous arch --> great saphenous vein --> femoral vein --> external iliac vein --> common iliac vein --> IVC Lateral side of dorsal venous arch --> small saphenous vein --> popliteal vein posterior to knee --> femoral vein --> external iliac vein --> common iliac vein --> IVC

Is Psoas Minor a muscle of the lower limb?

No. It originates, inserts and exerts its action on the trunk. O: T12-L1 vertebrae I: Pectin pubis; iliopubic ramus iliac fascia Innervation: ventral rami L1,L2 ● Not present in 40% of subjects

Sartorius

O: Anterior superior iliac spine I: Pes anserine of tibia "Pes anserine" means "goose foot"and describes the "three toed" appearance of three tendons that attach to the medial side of the tibia. The sartorius is one of those tendons. Innervation: Femoral n. (L2,3) Actions: ● Longest muscle in the body. ● Name means "tailor" and describes the actions of the sartorius. ● Flexes, abducts and laterally rotates thigh at the hip. ● Flexes leg at the knee.

Gracilis

O: Body and inferior ramus of pubis I: Medial tibia with what other muscles? Action: adduction of thigh Innervation: obturator n. (L2-L4)

Adductor Brevis

O: Body and inferior ramus of pubis I: Pectineal line and linea aspera of femur Actions: Adduction of thigh, Secondary flexors of thigh

Adductor Longus

O: Body of pubis I: Linea aspera of femur Actions: Adduction of thigh, Secondary flexors of thigh

Plantaris

O: Lateral supracondylar line of femur; oblique popliteal ligament I: Calcaneus via achilles tendon Action: weak knee flexion and plantarflexion

Condyloid joint

Oval, not perfectly round. Movement: flexion, extension, hyperextension, adduction, abduction, circumduction. NO ROTATION EX: knuckles between metacarpals and phalanges.

crural fascia

The deep fascia of the leg is called the crural fascia. This fascia attaches firmly to the anterior and medial tibial borders and like most deep fascia is continuous with the periosteum

extensor retinaculum

The deep fascia of the leg is thickened anteriorly at the ankle to form extensor retinaculum (superior and inferior) of the leg. The extensor retinacula prevent bowstringing of the extensor tendons as they pass over the ankle. The superior retinaculum isbroad and runs between the distal tibia and fibula. The y-shaped inferior extensor retinculum forms a strong loop laterally around the tendons of extensor digitorum longus and fibularis tertius.

On what bone is the pes anserine located? Anterior or posterior? What attaches there?

Tibia posterior Pes anserinus ("goose foot") refers to the conjoined tendons of three muscles that insert onto the anteromedial (front and inside) surface of the proximal extremity of the tibia. The muscles are the sartorius, gracilis and semitendinosus.

Articularis genu

derivative of vastus intermedius m. attaches to subpatellar bursa and pulls it upward during extension of the knee so it doesn't become entrapped between femur and patella

transverse intermuscular septum

divides muscles in the posterior compartment into superficial and deep parts

Dorsal compartment of the foot contains...

extensor hallucis brevis and extensor digitorum brevis as well as the terminal branches of the deep tibial nerve and dorsalis pedis artery (green)

Central compartment of the foot contains...

flexor digitorum brevis, the tendons of the flexor hallucis longus and flexor digitorum longus, quadratus plantae, lumbricals, adductor hallucis and the lateral plantar nerve and artery. (yellow)

Foot drop

is weakness of muscles in the feet and ankles that cause problems with the ability to felx the ankles and walk normally. Dorsiflexion of the ankle is a necessary component of smooth walking. Injury to the deep fibular nerve results in foot drop, foot slap in gait and/or a steppage gait. Foot drop can also be caused by CNS damage (i.e. stroke) or spinal nerve lesions (i.e. degenerative disc at L4,L5)

Femoral sheath

lines the vascular lacuna and encloses the femoral vessels i.e. femoral vein, artery, lymphatics

Calcaneal bursae

located between the skin and calcaneal tendon as well as between the calcaneal tendon and the calcaneus. Irritation of these bursal sacs may cause "pump bumps"

Tom, Dick, ANd Harry

mnemonic to ID tendons and vessels (anterior to posterior) posterior to the medial malleolus

Where does the sciatic nerve bifurcate and what are the products?

popliteal fossa common fibular nerve and tibial nerve *Within the popliteal fossa, the larger tibial nerve innervates the posterior compartment of the leg. The smaller common fibular nerve passes laterally toward the head of the fibula. Here, the common fibular nerve divides into two terminal branches, superficial and deep

The fibular artery is a branch of the (popliteal artery/femoral artery/anterior tibular artery/posterior tibular artery). It is located in the (medial/lateral/posterior) compartment and supplies the (medial/lateral/posterior) compartment.

posterior tibular artery posterior compartmet lateral compartment

Talus

receives body weight via its articulation with the itibia at the ankle joint (Talocrural joint)

Femoral canal

the femoral canal is the most medial compartment within the femoral sheath. It contains loose connective tissues and lymphatics. The space provided by this canal allows for expansion of the femoral vein medially

All the quadriceps muscles share what common distal attachment?

the patella through the quadriceps tendon Quadriceps tendon (muscle to bone) ↓ Patella ↓ Patellar ligament (bone to bone) ↓ Tibial tuberosity

Boundaries of Femoral Triangle

1. Superior border - inguinal ligament 2. Medial border - adductor longus 3. Lateral border - sartorius 4. Floor - iliopsoas laterally; pectineus medially. 5. Roof - superficial and deep fascia of thigh.

Why doesn't the femoral sheath enclose the femoral nerve?

1. The femoral sheath only encloses the femoral vessels 2. The femoral sheath is located in the vascular lacuna while the femoral nerve is located in the muscular lacuna along with the iliopsoas tendon, which attaches on the lesser trochanter

To assess anterior compartment syndrome one would evaluate

1. dorsiflexion strength 2. dorsalis pedis pulse 3. sensation between the first and second toes.

The deep fibular nerve may be injured

1. within the compartment: compartment syndrome 2. external to the compartment: trauma to the fibular head

What muscles make up your Quadriceps?

4 muscles Innervation: Femoral n. (L2,3,4) Proximal attachments: 1. Rectus Femoris P: Anterior inferior iliac spine (AIIS) + reflected head 2. Vastus Medialis P: Intertrochanteric line; medial lip of linea aspera 3. Vastus Lateralis P: Greater trochanter; lateral lip of linea aspera 4. Vastus Intermedius P: Anterolateral aspect of femoral shaft

Subtalar Joint

A joint in the ankle found between the talus and calcaneus Responsible for inversion and eversion of the foot The talar body transmits body weight to the calcaneus at the subtalar joint. The head of the talus forms additional articulations with the calcaneus as well as the navicular (talocalcaneonavicular joint). The talonavicular part of this joint maximizes the movements at the subtalar joint

Lateral Femoral Cutaneous Nerve

A purely sensory branch derived from the lumbar plexus (L2,L3)

Which compartments (anterior, medial, posterior) do the perforating branches of the deep femoral artery supply?

ALL OF THEM

Borders of Popliteal fossa

Biceps femoris, semimembranous, semitendinosus, L/M head of gastrocnemius

Navicular

Boat-shaped navicular is the most medial tarsal bone. Located between the talar head and the three cuneiforms.

saphenous nerve

Branch of the femoral nerve. Sensory innervation to the medial aspect of the foot and medial lower leg

Which structures pass through the adductor canal?

Femoral artery, femoral vein, saphenous nerve, and nerve to vastus medialus

What is the largest branch of the Lumbar Plexus?

Femoral nerve It divides into muscular and sensory branches to supply the anterior thigh

Popliteal artery

Five genicular arteries originate from the popliteal artery and participate in anastomoses around the knee within the popliteal fossa. These geniculate arteries provide collateral circulation to the leg when popliteal blood supply is limited during extended periods of knee flexion. The popliteal artery passes into the posterior compartment of the leg between the gastrocnemius and popliteus muscles. As it continues inferiorly it passes under the tendinous arch formed between the fibular and tibial heads of the soleus muscle and enters the deep region of the posterior compartment of the leg where it immediately divides into an anterior tibial artery and a posterior tibial artery (Dr. jones says the biforcation occurs at inferior border of popliteus)

Genicular arteries

Five genicular arteries originate from the popliteal artery and participate in anastomoses around the knee within the popliteal fossa. These geniculate arteries provide collateral circulation to the leg when popliteal blood supply is limited during extended periods of knee flexion.

plantar aponeurosis

Formed from the deep fascia of the foot. Supports the plantar surface of the foot. Extends between the phalanges of the toes and the calcaneus. Also encloses the plant muscles of the foot.

What type of joint is the ankle joint

Hinge joint Allows flexion/extension between the distal tibia/fibular mortise and the talus

Obturator externus

O: Obturator membrane and foramen I: Trochanteric fossa of femur Actions: Lateral rotation and weak adduction ● Obturator externus fills the external ventral surface of the obturator foramen and lies deep to pectineus. ● The tendon courses posteriorly and inserts at the trochanteric fossa of the femur deep to quadratus femoris. ● Thus, you will see the muscle belly of obturator externus on the anterior surface and it's tendon on the posterior surface in the gluteal region.

Soleus

O: Soleal line of tibia and superior ¼ fibula I: Calcaneus via achilles tendon Action: weak knee flexion and plantarflexion

Psoas Major

O: T12-L4 vertebral bodies and discs I: Iliopsoas on the lesser trochanter Actions: (refer to iliospoas) Innervation: L1-L3

Gastrocnemius

O: Two heads to lateral and medial femoral condyles I: Calcaneus via achilles tendon Action: includes knee flexion and plantarflexion

Fibularis Tertius

O: distal fibula I: base of metatarsal V. Innervation: Deep Fibular nerve (L5,S1) Artery: Anterior Tibial a. Actions: dorsiflex foot at the talocrural joint (ankle) and eversion at subtalar joint

Fibularis Longus

O: head, superior 2/3 fibula I: base of 1st metatarsal medial cuneiform on plantar surface. Actions: Strongly evert the foot at the subtalar joint. Fibularis longus is also able to plantarflex the foot

Fibularis Brevis

O: inferior 1/3 fibula and interosseous membrane I: tuberosity of metatarsal V Actions: Strongly evert the foot at the subtalar joint

Flexor Hallucis Longus

O: inferior 2/3 of fibula and interosseous membrane I: base of distal phalanx of hallucis Innervation: Tibial nerve (S4,S5) Artery: Posterior Tibial artery Actions: Inversion and plantar flexion @ ankle (talocrural jt) and flexion of distal phalanges

Tibialis Anterior

O: lateral condyle and superior lateral aspect of tibia I: medial cuneiform and base of metatarsal #1 Innervation: Deep Fibular nerve (L4,L5) Artery: Anterior Tibial a. Actions: dorsiflex foot at the talocrural joint (ankle) and inversion at subtalar joint *Tibialis anterior is the strongest dorsiflexor. Shin splints result from repetitive microtrauma of tibialis anterior. Pain results from small tears to the periosteum of the tibial shaft or the muscle's deep fascial attachments.

Extensor Digitorum Longus

O: lateral condyle of tibia; medial fibula and interosseous membrane I: dorsal surface middle and distal phalanges II-IV Innervation: Deep Fibular nerve (L5,S1) Artery: Anterior Tibial a. Actions: dorsiflex foot at the talocrural joint (ankle) and eversion at subtalar joint

Extensor Hallucis Longus

O: medial fibula; interosseous membrane I: dorsal distal phalanx (hallucis) Innervation: Deep Fibular nerve (L5,S1) Artery: Anterior Tibial a. Actions: dorsiflex foot at the talocrural joint (ankle) and inversion at subtalar joint *Extensor hallucis longus lies between tibialis anterior and extensor digitorum longus.

Pectineus

O: pectin pubis I: Pectineal line of femur Actions: Adduction of thigh, Secondary flexors of thigh *Pectineus is composed of two layers. Often one layer is innervated by the femoral nerve and the other by the oburator nerve.

Extensor hallucis brevis and Extensor digitorum brevis

O: superior surface of the calcaneus (tarsal shelf) I: EDB attaches distally to the long extensor tendons of digits 2-5 and EHB attaches distally to the proximal phalanx of digit 1 Innervation: Deep fibular nerve (L5,S1) Artery: Dorsal Pedis artery

Flexor Digitorum Longus

O: tibia inferior to soleal line I: base of distal phalanges II-V Innervation: Tibial nerve (S2,S3) Artery: Posterior Tibial artery Actions: Inversion and plantar flexion @ ankle (talocrural jt) and flexion of distal phalanges

Tibialis Posterior

O: tibia inferior to soleal line and interosseus membrane I: navicular tuberosity; cuneiform, cuboid, talar shelf of calcaneus and metatarsal heads (II-IV) Innervation: Tibial nerve (L4,L5) Artery: Posterior tibial artery Actions: Inversion and plantar flexion @ ankle

Which muscles in in the medial compartment are not innervate by obturator internus?

Pectineus and 1/2 of adductor magnus

Muscles of the Medial compartment

Pectineus, adductor longus, adductor brevis, adductor magnus (contains adductor haitus), Obturator externus, gracilis

plantar fasciitis

Plantar fasciitis is a painful condition caused by inflammation and shortening of the plantar aponeurosis. The pain is most severe upon initial standing after one arises from a sleeping or sitting position. Point tenderness is located at the proximal attachment of the plantar aponeurosis to the calcaneal tuberosity.

Deep contents of Popliteal fossa

Popliteal artery and vein as continuation of the femoral artery and vein following exit from adductor hiatus. Tibial/Common Fibular nerves Popliteal lymph nodes/lymphatic vessels.

Common fibular nerve

Posterior division of the sciatic nerve which wraps around the neck of the fibular and has two branches (deep fibular and superficial fibular). The branches supply the muscles and skin of the anterior leg, lateral leg, and dorsum of the foot L4-S2

What structure(s) travel anterior to the medial malleolus?

Saphenous nerve and Great Saphenous vein

Adductor Magnus

Superficial adductor part adducts/flexes thigh. Innervation: Obturator n. (L2,L3,L4) Deep hamstring part adducts/extends thigh. Innervation: Tibial portion of sciatic n. (L4,L5,S1,S2,S3) Adductor Part: O: ramus of ischium and pubis I: gluteal tuberosity, linea aspera medial supracondylar ridge of femur Hamstring Part: O: ischial tuberosity I: adductor tubercle of medial condyle of femur *Note: adductor hiatus formed by distal attachments of adductor magnus

What structure(s) travel anterior to lateral malleolus

Superficial fibular nerve

What structure(s) travel posterior to the lateral malleolus?

Sural nerve and Small saphenous vein

Tarsal Bones

Talus Calcaneus Cuboid Navicular 3 Cuneiforms

Superficial contents of Popliteal fossa

Terminal branches of posterior femoral cutaneous n. Small saphenous vein terminating in the popliteal vein within the fossa Sural cutaneous nerves

Patellar reflex

Tests L2-L4, femoral nerve, Quadriceps

Deep Tendon Reflex

The Achilles tendon reflex is used to assess the integrity of the S1,S2 spinal segments as well as the tibial nerve itself. A reflex hammer is used to tap the tendon just proximal to the calcaneus. A normal result is an ankle jerk into plantarflexion *This makes sense because the tendon that is being hit is the achilles tendon which is the tendon of the muscles in the superficial posterior compartment which are all innervated by the tibial nerve. The tibial nerve gets contributions from S1,S2 spinal segments

Adductur canal

The adductor canal is formed by deep fascia. The roof is formed by sartorius. The femoral artery and vein leave the adductor canal through a gap between the adductor and hamstring parts of the adductor magnus (adductor hiatus). The hiatus allows these femoral vessels to exit the anteromedial thigh and reach the popliteal fossa posterior to the knee

Compartment Syndrome in anterior compartment of the leg

The anterior compartment is confined to a small area bounded by the tibia, fibula and an interosseous membrane. Further, the deep fascia of the leg overlying the anterior compartment is especially dense. Inflammation and compression of structures within a tight fascial compartment is called compartment syndrome. A fasciotomy may be required to release pressure on these structures.

Anterior tibial recurrent

The anterior tibial recurrent artery is a small artery in the leg. It arises from the anterior tibial artery, as soon as that vessel has passed through the interosseous space. It ascends in the tibialis anterior muscle, ramifies on the front and sides of the knee-joint, and assists in the formation of the patellar plexus by anastomosing with the genicular branches of the popliteal, and with the highest genicular artery.

Cuboid

The cuboid is the most lateral tarsal bone. The cuboid and navicular feature important tuberosities for muscle attachment

Deep fibular nerve and Anterior fibular artery pathway

The deep fibular nerve exits the anterior compartment crossing the ankle to supply two intrinsic muscles of the foot and a small area of skin between the 1st and 2nd toe. The anterior tibial artery exits the anterior compartment at the ankle joint, changing names to the dorsalis pedis artery. The dorsalis pedis artery can be palpated midway between the medial and lateral malleoli.

Descending branch of lateral circumflex femoral artery

The descending branch of lateral circumflex femoral artery runs downward, BEHIND the rectus femoris, upon the vastus lateralis, to which it gives offsets; one long branch descends in the muscle as far as the knee, and anastomoses with the SUPERIOR LATERAL GENICULAR artery. It is accompanied by the branch of the femoral nerve to the vastus lateralis muscle.

What nerve innervates most of the anterior compartment of the thigh? What plexus does it arise from? What ventral rami contribute to it

The femoral nerve Lumbar Plexus L2-L4

What is the name of the proximal opening to the femoral triangle?

The femoral ring

Division of the Obturator nerve

The obturator nerve (L 2,L3,L4) descends along the medial border of the psoas major and enters the thigh through the obturator foramen. It divides into anterior and posterior branches which pass anterior and posterior to adductor brevis. Anterior branch supplies: adductor longus, adductor brevis, gracilis and pectineus. Posterior branch supplies: obturator externus and adductor magnus (adductor part). The obturator nerve supplies an area of skin on the medial side of the thigh

Ankle Mortise

The three bones of the ankle form a deep socket into which the talus fits. The socket is called the ANKLE MORTISE

femoral hernia

The proximal opening of the femoral canal (femoral ring) is a weak area in the anterior abdominal wall. It is a common site for a femoral hernia. The hernia can enlarge passing into the femoral canal and emerge from the saphenous opening in the fascia lata of the thigh. Femoral hernias are more common in females.

Where can you feel the femoral artery pulse?

The pulse of the femoral artery is palpable midway between the ASIS and pubic symphysis. Control of bleeding of the femoral a. may be accomplished at this location.

Sural nerve

The sural nerve travels with the small (lesser) saphenous vein down the leg to the lateral side of the ankle to pass posterior to the lateral malleolus A small branch of the tibial nerve (i.e., the medial sural cutaneous n.) combines with a communicating branch of the common fibular n. to form a larger sural nerve. The sural nerve supplies the cutaneous innervation of the lateral and posterior distal leg as well as the lateral side of the foot.

What is a sesamoid bone?

a sesamoid bone is a bone embedded within a tendon the patella is an example of one

Lateral compartment of the foot contains...

abductor digiti minimi and flexor digiti minimi brevis. (blue)

Medial compartment of the foot contains...

abductor hallucis, flexor hallucis brevis, tendon of flexor hallucis longus, and the medial plantar nerve and artery. (red)

patellar alta vs patellar baja

abnormally high lying patella vs. abnormally low lying patella

Descending genicular artery

arises from the FEMORAL artery just before it passes through the adductor hiatus. It immediately divides into: Saphenous branch of descending genicular artery Articular branches of descending genicular artery

Interphalangeal joints

hinge joints that allow only flexion and extension