Download Muscles of the Gluteal Region

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