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Muscles of the Gluteal -gluteus maximus, medius minimus Region -obturator internus, externus -piriformis -gemelli -quadratus femoris Piriformis -above piriformis – superior gluteal structures -below – inferior gluteal structures -sciatic nerve – 80% below piriformis, rest are above or within Iliotbial tract (band) -thickening of the fasciae latae on the upper lateral aspect -proximally, attached to the greater trochanter -distally, attached to the anterior surface of the lateral condyle of the tibia Gluteal Intramuscular -upper outer quadrant is common site – avoid damage injection -NB – buttock defined as iliac crest to gluteal fold to sciatic N -needle – pass through gluteal fascia into gluteus medius, or straight into glut. Max, dep. on exact position Tredenlenburg sign -normal gait – left foot off ground, pelvis prevented from sagging to left by contraction of right glut. medius and minimus, so vertebral column can remain in near vertical position -when medius and minimus injured on one side, gait affected. -positive Tredenlenburg sign – left foot off ground and right glut med and minimis damage – pelvis tilts/sags to left -to compensate, vert. column tilts to left Greater and lesser -lie in the gluteal region Sciatic foramen -made by attachments of bony points and two Sacrotuberous ligament -attached to: posterior iliac spine ligaments (sacrotuberous and sacrospinous) -lower sacrum -coccyx -ischial tuberosity -forms the medial border of both foramina Sacrospinous ligament -attached to: - sacrum -coccyx -ischial spine -separates the two foramen Superior Gluteal Nerve -L4, L5, S1 -above piriformis -usually accompanied by superior gluteal vessels -branches off into: -superior branch (supplies gluteus mdius, minimus and tensor fascia lata) -inferior branch (supplies the hip joint) Inferior Gluteal Nerve -L5, S1, S2 -below piriformis -accompanied by inferior gluteal vessels (inferior gluteal artery = sciatic artery) -supplies gluteus maximus -inferior pudental N travels with for short distance Sciatic Nerve --L4, L5, S1, S2, S3 -largest spinal nerve -posterior to: lateral rotators of hip -sup. and inf. gemelli -obturator internus -quadratus femoris -the inferior gluteal A travels with the sciatic N for short distance until it supplies the gluteus maximus -branches into the tibial and fibular Ns Sciatic Nerve Damage -may occur secondarily to posterior dislocation of the hip or by wrong side intramuscular injection to the buttock Pudendal Nerve --S2, S3, S4 - passes through the greater sciatic foramen below the piriformis then (re)enters the pelvis through the lesser sciatic foramen -runs with the internal pudendal artery and vein -gives blood supply to the perimeum (pelvic notes) Clunial Nerves -cutaneous neres to the gluteal region -arise from different segments of the spinal cord (L1S3) Motor Nerves -Nerve to obturator internus -Nerve to quadratus -come directly off sacral plexus Superior Gluteal Artery -off internal ilia artery -pases through the greater sciatic foramen -acompanied by superior gluteal Nerve and Vein -Branches into: -superficial branch (to gluteus max) -deep branch (to gluteus med and min) Inferior Gluteal artery -off internal iliac artery -supplies gluteus max -joined by inferior gluteal N -gives a nutritive branch to sheath of the sciatic N Internal Pudendal artery -off internal iliac artery -accompanies pudendal nerve -passes through greater sciatic foramen (below piriformis m) -re-enters the pelvis through the lesser sciatic foramen -supplies the perineum (has no gluteal supply) Trochanteric anastomosis -lies near the trochanteric fossa and it’s the main source for the head of the femur -formed by: - branch off superior gluteal A -branch off both lat and med circumflex femoral As -branch off inferior gluteal A Interruption of blood -blood flow through delicate artery of ligamentum supply to femoral head -When femoral head undergoes necrosis caused by teres, arising from fovea capitis. interruption of blood supply(avascular necrosis) in a child, the femoral head can be compressed and flattene, leading to slippage of the femoral head along the epiphyseal plate which connects the neck and head of the femur. -most freq. in 3-9 y.o., commonly presenting with pain over hip joint, radiating down thigh as far as knee Cruciate Anastomosis -lies in the middle of the lesser trochanter -formed by: -branch off both lat and med circumflex fermoral arteries -branch off inferior gluteal artery -branch off first perforating artery Gluteal veins -hematoma of the buttock due to vein injury (not A) -names of veins are same as arteries -tributaries of the internal iliac vein Hematoma of the -usually results from a hard fall Buttock severe trauma often results in formation of large -large gluteal veins between glut max and med -> hematoma that results in ecchymosis (purplish patch caused by extravasation of blood into the subcutaneous tissue and skin) -blood for hematoma may be evacuated by aspiration or by incision and drainage Lymphatic Drainage -superficial gluteal tissue (skin and superficial fascia)drained into superficial inguinal LN -deep gluteal tissue (muscles and deeper) – drained into gluteal LN then into iliac LN (when visceral structures of pelvis drain) Ligaments of the Gluteal -sacrotuberous ligament Region -Function: stabilize the sacrum and prevent its Fascia of the Thigh -Superficial -sacrospinous ligament rotation at the sacroiliac joint -Deep (fascia lata) -continuation of Camper’s (fatty superficial fascia of abdomen) and Scarpa’s (fibrous superficial fascia of abdomen) -Fibrous septa – fascial septa that attaches to the inner aspect of the deep fascia of the thigh and the linea aspera of the femur -it divides the thigh into anterior, medial and posterior compartments Muscles of the Posterior Thigh -Hamstrings -semitendinosis -semimembranosis -biceps femoris (all arise from the ischial tuberosisty, are supplied by sciatic N) -small part of adductor magnus muscle Hamstring Injury -forceful contraction of the long muscles in the posteror thigh (the hamstring) can lead to small tears within the muscles and subsequent hemorrhage. -This causes sting pain and inability to use the muscles in the normal fashion. -Like many other muscle injuries, repair is confounded by the fact that continued use of the muscle causes pain and limits function -the large size of the vessels in this region leads to rapid formation of hematomas following trauma Profunda femoris artery - (deep femoral artery, main supplier of thigh) - off the femoral artery within the femoral triangle -Branches: -medial and lateral circumflex arteries -perforating branches (to posterior thigh ms) -anterior branches (to anterior thigh ms) -The circumflex vessels provide the “crossbar” (is. Clinical significance of Cruciate anastomois) which refers to the collateral circulation that refills the femoral A after injury to the -circumflex vessels common femoral A. The main source of this -lower limb muscle circumflex vessels. energy demands (large appetites), vascular surgeons spend much time collateral supply is the inferior gluteal A and -Large muscles of the lower limb doing heavy work dealing with ischemic cramping malfunction of the lower limb muscles, and warding off necrosis of the same muscles Innervation of Posterior -Cutaneous nerves – posterior cutaneous nerve of thigh the thigh (post femoral cutaneous N) Surface markings of -palapate PSIS, ischial tuberosisty an dgreater Sciatic Nerve -line connecting PSIS and ischial tuberosisty – -Sciatic N trochanter junction between lower and middle 1/3 of this line is point of entry of the sciatic N into the gluteal region. -Join this to mid-point between greater trochanter and ischial tuberosity and extend it vertically down to the lower 1/3 of thigh – this marks the whole course of the sciatic N in the thigh Referred Pain -Referred pain – may sometimes be felt in pelvic inflammation along the back of the thigh and leg because of common root value Sciatica -Sciatica – condition characterized by low back pain radiating down the buttock and below the knee -suggests herniated disc causing sciatic nerve root irritation which should be confirmed by physical examination and imaging techniques Sciatic Nerve injury -secondary to wrongly placed gluteal intramuscular injection or facture/dislocation of the hip joints or penetrating wound in the gluteal region -Hamstring ms will be paralyzed (-> weakness of knee flexion) -all ms below knee paralyzed -> foot drop -loss of sensation blow knee except for (posterior calf??) Venous Drainage of -Superficial Veins – small veins around the postero- Posterior Thigh saphenous vein, then to the femoral V medial and pertero-lateral thigh drain into the great -Deep Veins – veins accompanied by the profunda femoris artry drain into the profunda femoris vein then to the femoral V -NB clinically -> DVT Lymphatic Drainage of -skin and superficial fascia lymphatics drain into the Posterior Thigh -deep structures drain into the deep inguinal LN superficial inguinal lymph nodes (along the femoral V) Hip Joint -Articular surface -the acetabulum and the head of the femur -the head of the femur is covered by articular cartilage, except at the pit (attachment point for the ligament of the femoral head – ligamentum teres) -contains blood vessels (inside ligament) -the central and inferior part of the acetabulum, the acetabular fossa, is thin and non-articular Hip Joint -Capsule -very highly innervated -strong fibrous tissue that permits a wide range of movement -attached proximally to acetabulum and distally to femoral neck -forms ligaments Hip Joint -Ligaments -intrinsic ligaments (fibrous capsule) -iliofemoral, ishciofemoral, pubofemoral (there is no sharp boundary between these 3 ligaments -ligament of the head of the femur attaches to the fovea -the is an artery running through this ligament Important Relations in the Hip Joint -Anteriorly - iliopsoas, pectineus, rectus femoris muscles - femoral VAN -Posteriorly – obturator internus, the two gemelli, quadratus femorus ms -sciatic N -Superiorly – prirformis and gluteus minimus ms -Inferiorly – obturator externus m Traumatic Fractures of -neck of femur prone to fracture, even when force the hip -foot firmly planted, knee locked-> traumatic force of applied to feet and ankle and not hip itself blow is transmitted superiorly -> fracture of the femoral neck (with incr. age and osteoporosis, femoral neck more vulnerable to fracture) -events have tendency to recur, commonplace for entire upper end, head of femur to be replaced with a metal or plastic prosthesis (degenerative arthritis (decr. Capacity for hip mvmt)– also cause for hip replacement) Hip dislocation -hip most easily dislocated -congenital – femoral head dislocated upward into iliac fossa –lessens full mobility of jt, may be detected on PE as shortening of limb on that side (also, makes glut med, min ms unable to contract effectively (b’se they are shortened) – impairs posture, gait -acquired – hip flexed and medially rotated (sitting in car -forceful impact of knee on dashboard); force applied to thigh -> dislocation of hip upward, adj to the outer surface of ilium Surgical replacement of the hip -traumatic/arthritic destruction of interior of hip joint – movement reduced to minimum, or pain of standing/walking unbearable -upper end of femur and ecetabular socket may be relaced with Teflon or other inert materials and patient’s provided with vastly improved degree of mobility and relief of pain -Hip Joint Fluid -Aspiration of joint fluid usually performed by Aspiration by entering the skin 1 to 2 cm inf. to the inguinal lig. -Femoral Vessels VAN) Cannulation care must be exercised not to puncture the hip joint inserting a needle through the anterior joint capsule (nearby structures that must be avoided – femoral -If femoral vessels cannulation is being attempted, capsule and produce hip joint arthritis/osteomylitis Muscles of the Anterior -Quadriceps, iliacus, psoas (iliopsoas), sartorius -Tensor fascia lata Thigh Athletic injury to the -Hip pointer: bruise or hematoma along the iliac crest, Antero-medial thigh -Charly-horse: les specific term, referring to a esp in the region where the sartorius originates hematoma within a muscle; usually as a result of a forceful impact commonly occurring in the quadriceps Psoas Abscess -psoas major originates in upper post abdominal wall, inserts inferiorly to lesser trochanter -in abdomen, fascial covering is the medial arcuate ligament, which externds inferiorly as a loose fascial covering of the muscle as it travels into the thigh. Infectious material may work its way into the space btw the muscle and its fascia; may track all the way down into the upper thigh and present in the patient as a painful swelling in the groin or upper thigh -TB is a common pathogen for psoas abcess Muscles of the Medial -Pectineus, adductor longus, adductor brevis, gracilis, Thigh -all supplied by obturator N (L2-4), except hamstring adductor magnus, obturator externus part of add. magnus (supplied by sciatic N) Femoral Sheath -covers the femoral A & V -anteriorly – continuation of transversalis fascia -posteriorly – continuation of iliacus fascia -Contents: -femoral canal (med) -femoral vein (intermediate) -femoral artery (lat) -NOT femoral N! Femoral Canal -Lg in females; lies medial to the vemoral V; if femoral Femoral Ring -Boundaries: -inguinal ligament (anteriorly) V incr. in volume, will compress the femoral canal -pectineal ligament (posteriorly) (thickened periosteum along pectineal border of sup. pubic ramus and cont. med. w/ the pectineal part of the inguinal lig.) -Contents: -plug of fat -LN or femoral canal or Cloquet’s gland Femoral Triangle Boundaries: -Sup: inguinal lig -Let: med aspect of Sartorius -Med: lat side of adductor longus -Floor: psoas tendon, iliacus, pectineus, ad longus ms -Roof: skin, superficial fascia (contains sup. inguinal LN, great saphenous V), fascia latae Contents: -femoral VAN -deep inguinal LN -femoral sheath with femoral canal Femoral and Inguinal Herias -Herniation of intestinal contents can occur through the femoral canal, which is among the more freq. causes of intestinal herniation in women, wheras inguinal hernias predominate in men -When femoral herniation of intestinal contents occurs, hemorrhage or inflammatory exudate also may tract downward into the thigh along the path of the femoral sheath Femoral Nerve -L2-4 -travels within the psoas major m in the abdomen -at the femoral triangle, lies lateral to the femoral A -Motor: quadriceps, pectineus, Sartorius, iliacus -Branches: -articular br to the hip and knee jts -cutaneous branches: a. saphenous N b. medial cutaneous N of the thigh c. intermediate cutaneous N of the thigh Femoral Vein -at the femoral triangle, enclosed by femoral sheath and lies med. to femoral A -ends post to inguinal lig. by becoming the ext. iliac V -receives: -deep femoral V (profunda) -great saphenous V -other veins (a lot of variation) Femoral Artery -post. To the inguinal lif, it starts as a continuation of the ext. iliac A -at the femoral triangle, enclosed by femoral sheath and lies lat to femoral V and med to femoral N -at adductor canal, lies post to Sartorius m -beomes the popliteal A (at the pop. fossa) -at all levels in thihg, the femoral A lies btw the femoral and saphenous Ns Femoral Cannulation -femoral A second only to radial A as site for placement of arterial line -its superficial position below inguinal lig makes it easily accessible -commonest complications: retroperitoneal hemorrhage and perforation of the gut (by entering the abdominal cavity) and arterio-venous fistula (with femoral or ext. iliac vein) Adductor Canal -aka subsartorial/Hunter cana -gutter shaped groove btw vasus medialis and adductor ms (below apex of femoral triangle) Boundaries: -post: adductor longus and magnus ms -anterolaterally: vastus medialis -anteromedially: Sartorius m w/in fascial sheath -contents: femoral VA, saphenous N, N to vastus medialis (in upper part) Saphenous Nerve -off femoral N -becomes cuaneous at the knee by passing btw Sartorius and gracilis ms -Branches: -a cutaneous innervation to ant and med of knee, leg and foot -infra-patellar branch, which joins the patellar plexus Great Saphenous Vein -aka long saphenous V -formed by venous plexus at ankle -runs anteriorly to the medial maleollus Receives: -commnication from short saphenous V -lateral accessory V (within the thigh) -superficial epigastric V -superficial circumflex iliac V -superficial external pudendal V Small Saphenous Vein -aka short saphenous V -runs a short distance -starts at the ankle behind the lat. malleolus -runs superficially along post. leg -terminates deeply as popliteal V -great and small saphenous Vs communicate with each other Coronary Bypass Grafts -the great saphenous vein is often used as a source for graft, esp. for coronary bypass surgery. -usually numerous valves in GSV -may be some risk of varicose veins with absence of GSV in some indiv’s -operating on varicose veins – NB that all tributaries of groin ligated as well as main saphenous trunk -if one escapes, it in turn becomes dilated and produces recurrence of the varices Fracture involving the -any childhood fracture of the tibia, fibula or other Epiphyseal Plate epiphyseal plate long bone are dangerous if they involve the -the continued normal growth of the bone may be jeopardized if the epiphysis is involved, whereas the diaphysis fractures will almost always heal with realignment and splinting or casting Greenstick Fractures -special types of traumatic fractures occurring in children -bones less brittle than adults’ -> trauma can produce a fracture but without disrupting the continuity of the outer cortex of the bone (sim. to what happens when you break a tender branch from a sapling – hence “greenstick”) Severe Fracture of the -fracture of the lower end of the leg that involves both Leg and is likely to result in dislocation of the talus from the lateral and medial malleolus is a Pott’s fracture the ankle mortise -isolated lateral (more common) or medial malleolar fracture is less likely to destabilize the ankle jt Shin Splint -small tears in the periosteal membrance covering the tibia -can be the location of considerable swelling and pain -generally produced by traumatic injury or by excessive exercise involving repeated forceful landing on the ground Leg Fascia -aka crural fascia -continuation of fascia lata -three intermuscular sptae, which separate the leg into: -Anterior (dorsiflexion) -Anterolateral (eversion) -Posterior (plantar flexion) Extensor Retinacula -covers the ant m tendons and their synovial sheath -covers the deep peroneal N and ant tibial A -Superior extensor retinaculum -thick CT band that attaches to ant border of both tibia and fibula -Inferior extensor retinaculum-Y-shaped thick CT band ;covers same tendons as sup. ext. retinaculum -Peroneal retinacula – CT band that contain the tendons of the lat compartment (incl. sup and inf peroneal retinacula) Compartment -fascia enclosures of the 3 compartments are v strong Syndromes one or more compartments can cause pressure to -> hemorrhage, major tissue injury and edema w/in build up and block blood flow -structures distal to the injury may become ischemic and permanently injured -when leg has been injured, pressures w/in the compartments should be closely monitored and fasciotomy (incision of fascia) performed to relieve pressure (if indicated) Anterior, Lateral Anterior (dorsiflexion) Muscular Compartments digitorum, peroneus tertius -tibialis anterior, externsor hallucis longus, extensor -all supplied by deep peroneal N Lateral (eversion) -peroneus (fibularis) longus and peroneus (fibularis) bervis -both supplied by superficial peroneal N Common Peroneal Nerve -L4 – S1 -off the sciatic N, midway down the post aspect of the thigh (along with the tibial N) -courses med to tendon of the biceps femoris m -passes superficially around the neck of the fibula (where it is palpable and vulnerable to injury) Branches: -deep peroneal N -superficial peroneal N -lateral sural cutaneous N -articular br to the knee jt (recurrent) Deep Peroneal Nerve -L4-S1 -runs with the ant tibial A -close to the knee jt -> btw tibialis ant and EDL -further down -> btw tibialis ant and EHL Branches: -motor to all ms of the ant compartment -cutaneous to the dorsum of the foot (cleft btw the first and second toes) Superficial Peroneal -L5-S2 Nerves peroneus longus m and then runs btw the peroneus -passes in the lateral compartment by passing though longus and preoneus brevis ms Branches: -motor to all ms of the lat. compartment -cutaneous to the lat. leg and lat. foot Nerve Entrapments -Lateral femoral cutaneous N: compresed by tight clothing at inguinal ligament -Common peroneal N: pressure at neck of fibula (eg. Cast applied to tightly) -Deep peroneal N: excess exercise leading to muscle injury and edema in ant compartment of leg -Tibial N: compressed in vicinity of med malleolus (tarsal tunnel syndrome). Occurs when swelling of synovial sheath and/or deltoid lig, extending from med. malleolus to calcaneous (fascial strs surround Ns and Vs of post Peroneal (fibular) Artery compartment of leg as pass behind med. malleolus). -off post tibial A; lies on inteross. membrane (post’ly) -its terminal br (lat malleolar As) found behind the lat malleolus -supplies post and lat compartments Branches: -nutrient br to fibula -muscular br to posterior ms -perforating br to lateral ms -communicating br to post. tibial A Anterior Tibial -off popliteal A, on post surface of popliteus m (interosseous) Artery -terminates into dorsalis pedis A at the ankle -liess of inteross. membrane (anteriorly) Branches: -muscular br to ant. compartment ms -post. tibial recurrent br (inconsistent) -anterior tibial recurrent br -med. and lat. anterior malleolar br -dorsalis pedis A Vascular Grafts -arterial bypass surgery in the leg and thigh – necessary by prevalence of obstructve vascular dzs in lower limb -relief obtained when grafted segment of vessels is put in place to allow blood to get past the obstruction in the native artery -common places for such bypasses are the femoral, popliteal and anterior tibial arteries Thrombophlebitis -legs common sites for clots to become infected (thrombophlebitis) and pose a risk of systemic infection -immobilized patients and those who suffered traumatic lower limb injury are at high risk -clots themselves are always a danger in that they may break loose, drift upward and cause a pulmonary embolism Externsor Hallucis Brevis -Origin: dorsal surface of calcaneous -Insertion: joins the EHL tendon -Innervation: deep peroneal N -Action: extends big toe Externsor Digitorum -Origin: dorsal surface of the calcaneous Brevis second, third and fourth toes -Insertion: joins the extensor tendon of the EDL to -Innervation: deep peroneal N -Action: extends the toes Blood Supply to Dorsum of Foot -Dorsalis pedis artery: usually of the anterior tibial A, but occasionally from peroneal br of peroneal A -NB pulse in lower limb -Venous drainage: -dorsal venous arch w/in the subcutaneous tissue over the heads of the metatarsal bones -on the medial side, drains to the great saphenous V and on the lateral to small saphenous veins (end in popliteal V) Dorsalis Pedis Pulse -palpation is essential esp in suspected cases of intermittent claudication (cramps in calf brough on by exercise and relieved by rest) -usually palpable on dorsum of foot, where the A passes over the navicular and cuneiform tarsal bone, just lat to the extensor hallucis tendon (may also be felt distal to this at prox ed of the 1st inteross. space) -diminished/absent dorsalis pedis pulse suggests arterial insufficiency (not always indicative of arteriosclerosis dz as 14% of people, dorsalis pedis is absent, too small to Innervation of Dorsum of Foot Knee Joint palpate or not in usual position). -Medially: saphenous N -Middle: superficial and deep peroneal Ns -Laterally: sural N -Type: synovial hinge joint -Articulation: condyles of femur, tibia and patella -Capsule: -thin, weak and incomplete -deficient posteriorly and inferiorly – penetrated by the tendon of the popliteus m -reinforced medially by tibial collateral lig -reinforced posteriorly by oblique popliteal lig, which is an upward extension of semimembranous tendon -Movement: flexion, extension Knee Joint Bursae Suprapetellar B -lg’est; lies btw the lower end of the femur and quadriceps m and tendon -upward extension of the synovial cavity -most NB clinically – infection from bursitis can spread to knee jt Prepatellar B - btw the superficial patella and skin Infrapetellar B – subsutaneous b (btw skin and tibial tuberosity); deep b (btw patellar lig and tibia, sup to T. tuberosity) Anserine B – ass w/ the attch’t of popliteus, semitendinous, biceps femoris, 2 heads of gastrocnemius Knee Joint Ligaments -Intrinsic ligaments: -patellar, fibular collateral, tibial collateral, oblique popliteal, arcuate popliteal, meniscofemoral -Extrinsic ligaments: -anterior and posterior cruciate ligaments Knee Menisci -Lateral: more mobile; not tied to fibular collateral lig -Medial: tied to tibial collateral ligament -v. little mvmt Knee Injuries -traumatic low to lat side of knee/leg esp dangerous -direct blow + twisting motion -> damage to menisci -removal of menisci – not loss of mvmt, but articular surfaces of tibia and femur -> inflammatory rxns, permanent destructive injury -medial meniscus injures > lateral – reason not clear, but tears associated w/ tibial collateral lig tears (miniscal tears can’t heal unless near outer margin – only earea w/ enough blood supply; in majority of injuries, injured part of meniscus must be removed) Knee Injuries : injury to -violent abduction and twisting (as w/ planted foot) collateral ligaments, meniscus and the ant. cruciate ligament cruciate ligaments medio-lateral plan often injures the medial collateral lig, the medial -injuries to collateral ligs -> abnormal mobility in leg in -rupture of cruciate lig allows leg to slide forward or backward to an abnormal degree w/rt. femur (the drawer sign) Knee Injuries: Bursal - most bursal sacs cont. with the synovial space w/in the jt Sacs friction may cause inflammation -provide cushioning for knee jt, esp where str moves and -immediately after knee injury, swelling/bleeding into knee jt (producing an effusion) may make determination of normal/abnormal mobility impossible -swelling+effusion in prepatellar bursa -> housemaid knee -herniation of part of synovial memb. through the joint capsule into popliteal fossa creates firm swelling -> popliteal cyst (Baker’s cyst), causing serious pain and Arthroscopy of the Knee limited mobility -fiberoptic arthroscope – most direct way to examine patient’s knee joint -arthroscopy is increasingly common, allows surgical repair of many injuries without the need for the general anesthesia and long hospitalization Valgus and Varus -Varus deformity – distal component of jt is deviated Deformities -Valgus deformity – distal component of joint toward the midline deviated away from the midline (knock-kneed) -when applied to deformity of hip area, describe abnomalities in the angle btw the femoral shaft and the neck -valgus deformity of the knee often acc. By varus deformity of the hip (maintains centre of gravity over Osgood-Schlatter Disease the foot) -involves disruption of the epiphyseal plate found at the tibial tuberosity, where the patellar tendon inserts into the tibia -source of chronic recurrent pain, especially in young athletes Popliteal Fossa - - common site of arterial vascular dz Boundaries semitendinosis ms (superior); medial head of Boundaries: -Medially: semimembranosis and gastrocnemius ms (inferior) -Laterally: biceps femoris m (above); plantaris and lat. head of gastocnemius (inferior) -Floor: popliteal surface of femur, capsule of knee jt, fascia covering the popliteus m -Roof: skin, superficial and deep fascia of thigh (medial and lateral borders readily palpable) Popliteal Fossa Contents -small saphenous veins and branches of post. cutaneous N of the thigh -tibial and common peroneal Ns (superficial) -popliteal V along with popliteal LNs (intermediate) -popliteal A (deep) Popliteal Artery Injury -may be damaged by an aneurysm or in the supracondylar fracture of the femur, esp if there is displacement of lower fragment by the pull of the gastrocnemius m -to feel popliteal A pulsation, the knee should be partially flexed, to relax the deep fascia and the fingertips insered deply into the centre of the popliteal fossa Fetal Viabilty and Femur -distal end of femur undergoes ossification just Ossification -visibility of theis centre of ossification in radiographs before birth is commonly used a smedicolegal evidence that a newborn infant found dead was near full term and viable Muscles of the Posterior -Superficial muscles: -lateral and medial gastrocnemius, soleus, Leg plantaris Deep Muscles: -Popliteus, tibialis posterior, flexor digitorum longus and flexor hallucis longus Flexor Retinaculum -thickened CT band that extends between the medial malleolus, calcaneous and the deep plantar fascia -tibial N and posterior tibial A pass deep to flex. retinaculum -covers tendons of TDH muscles Tibial Nerve -descends behind the knee jt in the popliteal fossa (superficial to popliteal vessels) -in leg, lies deep to the gastrocnemius and soleus ms -runs w/ posterior tibial A behind medial malleolus -can be found btw the FHL and FDL and deep to flexor retinaculum Branches: -medial and lateral plantar Ns -medial sural N -medial calcaneal N Injury to the Tibial Nerve -uncommon; result of compression or penetrating wound behind the knee -usually results in loss of plantar flexion (tested by standing on tiptoes) Calcaneal Tendon Injury -inflammation – 9-18% of running injuries -tendinitis results from microscopic tears of collagen fibers in the tendon, particularly just superior to its attmt to the calcaneus -> pain during walking -calcaneal tendon rupture – most severe acute muscular problem of leg -complete rupture to tendon -> passive dorsiflexion is excessive, can’t plantarflex against resistance Ankle Reflex -elicited by striking the calcaneal tendon briskly with reflex hammer while person’s legs dangling over side of table -tests the S1 and S2 never roots -if S1 nerve root compressed/cut, ankle reflex virtually absent Calcaneal Bursitis -results from inflammations of bursa of calcaneal tendon, located btw the calcaneal tendon and superior part of posterior surface of calcaneus -causes pain posterior to the heel and occurs commonly during long distance running, basketball and tennis -caused by excessive friction on bursa as the calcaneal tendon continuously slides over it Arterial Supply to Posterior Leg Peroneal Artery Posterior Tibial Artery - off the popliteal A -arises at the lower border of popliteus m; runs w/ tibial N on post. surface of tibialis posterior; lies deep to flexor retinaculum and posterior to medial malleolus -Branches: -peroneal A -nutrient to tibia -circumflex fibular A (for peroneal ms and genicular anastomoses) -medial calcaneal A -medial posterior malleolar branch Complications of -the foot is subject to ulceration secondary to marginal blood perfusion exacerbated in small vessels Decreased Circulation diseases such as diabetes mellitus (NB to measure Proximal Tibiofibular Type: plane synovial joint Joint Ligaments: anterior and posterior ligaments Distal Tibiofibular Joint Type: fibrous (syndesmosis) joint pulse everywhere, especially lower limb) Articulaton : head of fibula and tibial condyles Movement: slight mvmt during dorsi/plantarflexion Articulation: inferior end of fibula and tibia Ligaments: supported by interosseous ligament, ant and post inferior TF ligaments, transverse tibiofibular lig (deep part o the post inf TF lig) Movement: slight mvmt during dorsiflexion of foot Deep Fascia of the Foot -also called plantar fascia -thin on the dorsum where it continues with the extensor retinaculum -thick on the plantar surface where it forms the plantar aponeurosis Plantar Aponeurosis -central thickening of the deep fascia -proximally, attached to the calcaneal tuberosity -distally, attached to 5 digital tendon sheaths -protects the underlying plantar neurovascular structures Muscles of the Foot (and -Layer one: abductor hallucis, flexor digitorum brevis, neurovascular bundles) -Layer two: quadratus plantae, lumbricals abductor digiti minimi -Layer three: flexor hallucis brevis, adductor hallucis, flexor digiti minimi brevis -Layer Four: plantar and dorsal interossei Neurovascular bundles: -between layers 1 and 2 (superficial) -between layers 3 and 4 (deep) Innervation of the Foot -medial and lateral plantar nerves -sural nerves -saphenous nevers Venous Supply to the Foot -Arterial supply – dorsalis pedis on dorsum of foot -medial and lateral plantar arteries -> plantar arterial arch -Venous drainage – dorsal venous arch -> great and small saphenous veins Lymphangiography -when concern about malignancy in LN of groin or pelvic region, dye may be injected into dorsum of foot -> lymphatic transport to region of question -on x-ray, LN outlined by dye and size and number can be studied -method now being replaced by axial imaging (CT, MRI) which doesn’t require dye injection Vericose Vein -when vein becomes distended (abnormal diameter) and tortuous, it is called varicose -condition commonly seen in superficial veins of the lower limb (other sites for varicosity – esophageal and rectal – commonly associated with hemorrhoids) Great Saphenous Vein -a cut down of the GSV (ie exposre through a skin Cut Down -site has disadvantage that phlebitis (inflamm’n of vein incision) is usu performed at the ankle wall) is potential complication -can be entered at femoral triangle where phlebitis is rare -both cut downs can be used for giving a lg and rapid infusion of fluids into the body -at ankle, GSV found constantly just ant and sup. to the medial malleolus where saphenous N branches lie anterior to the vein Talocrural Joint -hinge jt btw talus and malleoli of distal tibia and fibula -Ligaments -medial (deltoid) ligament – group of ligaments running from medial malleolus to navicular, calcaneous and talus (eg. tibionavicular, tibiotalar, tibiocalcaneal) -lateral ligament – group of ligaments running from fibular malleolus to talus and calcaneous (eg talofibular, calcaneo-fibular) Foot Joint Subtalar joint: consists of taloclcaneal joint Transverse tarsal joint – consists of talocalcaneonavicular and calcaneocuboidal joint Ligaments – plantar calcaneonavicular (spring) ligament Foot Arches -longitudinal and transverse arches -maintained by bon shapes, ligaments, tendons and plantar fascia Segmental Innervation of Hip flexion – L2, L3 the Lower Limb Ankle Dorsiflexion – L4, L5 Knee flexion – L5, S1 Foot Inversion – L4, L5 Hip Extension – L5, S1 Knee Extension – L3, L4 Ankle Plantar Flexion – S1, S2 Foot Eversion – L5, S1 Common Foot Deformities -Hallux Vagus -Pes Planus -Pes Cavus -Clubfoot Hallux Vagus (bunion) – progressively worsening medial deviation of the great toe; deformation at the metatarsophalangeal joint Pes Planus (flat foot) – common, resulting from laxity of ligaments and fasciae on sole of the foot (commonly the medial longitudinal arch is depressed/collapsed). Forefoot displaced laterally and everted Pes Cavus (claw foot) – medial longitudinal arch unduly high; most due to muscle imbalance resulting from poliomyelitis Clubfoot (talipes equinovarus) – foot inverted, ankle flexed and forefoot adducted. Involves subtalar jt, affects 1/1000 live births (male 75%) Acute Sprain of the -usually caused by excessive inversion of the foot Lateral Ankle -anterior talofibular and calcaneofibular ligaments are Acute Sprain of the -less common injury to medial or deltoid ligaments as Medial Ankle -great strength of medial ligament usually results in with planter flexion of the ankle partially torn, giving rise to pain and local swelling result of excessive eversion ligament pulling off the tip of the medial malleolus