Download Plate 164-Dermatomes Inguinal ligament is in L1 Patella is L5 Plate

Medial and Anterior Thigh
1/26/2009 8:02:00 AM
Plate 164-Dermatomes
 Inguinal ligament is in L1
 Patella is L5
Plate 544-nerves and veins of the thigh and leg
 Great Saphenous vein runs on the medial thigh ascending toward
the inguinal region.
o Origin in the foot (therefore also called the long saphenous
vein)
 Bridge communication back and forth between the deep and
superficial veins. Flow is usually from superficial to deep.
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o Valvular incompetence in the deep veins causes varicose
veins
All these veins have valves.
There is hole in the fascia lata at the inguinal ligament called the
saphenous opening. Through this flows the great saphenous, the
superficial epigastric, the superficial circumflex, the external
pudendal vessels
Cutaneous nerves—Most of the visible nerves over the fascia lata
are terminal branches of the femoral nerve
o The only one not a branch of the femoral is the lateral
cutaneous nerve of the thigh.
Plate 546-Lymphatic
 Lymphatics generally drain into the superficial inguinal lymph
nodes.
o Vertical follow saphenous
o Transverse follow inguinal ligament
 Perineum (except testicle), anterior abdominal wall below the
umbilicus, the superficial areas of the lower limb including the
buttocks all drain into the superficial inguinal nodes (HUGE drainage
field
 Deep inguinal nodes are deep to the fascia lata. The deep nodes
collect from the superficial nodes through the saphenous opening.
Plate 492-Musculature
 There is an Intramuscular septum between the compartments, but
its subtle
 Sartorius m—ASIS then crosses and attaches medially to the tibia
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o Flexion at the hip joint, flexion at the knee joint. Also is a
lateral (External) rotator of the hip joint. Allow to touch heel
to the opposite knee (allows for sitting Indian style)
Tensor fascia lata sits laterally. Lies antior to the plane of the hip
joint. It puts tension on the fascia lata. Maintains extension of the
knee after the quads have straightened the knee joint.
Deep to Sartorious are the quads
o Rectus femorus m. Ilium (Anterior Interior Iliac Spine) then
attaches to the tibial tuberosity (the patella is in this tendon).
The only muscle in the quadriceps that cross the hip joint.
o Vastus lateralis, vastus medialis, vastus intermedius
 Intermedius is deep the rectus femorus. They unite
(along with rectus femoris) and form a common tendon
at the knee joint called the tendon of the quadriceps
femoris. The patella is a sesamoid bone in the tendon
of the quadriceps femoris. From the patella on it is
called the patellar ligament (bone to bone is ligament)
Sartorious and quadriceps femoris are all innervated by the femoral
nerve
Plate 492-Medial compartment—All adduct the thigh ( lateral to medial)
 Iliopsoas—Combaination of the iliacus and the psoas which then
unite and pass deep the inguinal ligament and attach to the lesser
trochanter (the only one). It is the most powerful hip flexor.
o Sit ups with bent knee causes active insufficiency of the
iliopsoas.
 Pectineus—medial and deep to the iliopsoas. Pretty much in same
plane as adductor longus and gracilis
 Adductor longus
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Gracilis—Great for muscle transplant. A most common is for
making an external anal sphincter. The only muscle in the adductor
compartment that cross the knee.
All innervated by the obturator nerve. EXCEPT pectineus m.
Pectineus m is innervated by the femoral nerve always (some will
say dual innervation with femoral and obturator)
The muscles go from pubis to femur (therefore adduction)
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Deep to pectineus is the obturator externus takes origin from
external aspect of the obturator foramen and attaches to the
greater trochanter.
If you cut adductor longus out of the way, you can see adductor
brevis. Deep to those are the adductor magnus. Adductor magnus
runs the entire shaft of the femur for insertion.
SIX EXTERNAL ROTATORS-The gemellus inferior and superior, the
obturator internus externus, piriformis, quadratus femoris.
Sartorious can but is not included in the group of 6 small muscles in
the deep gluteal region
Plate 493
 Adductor magnus m.
o Most of the fibers attach to the linea aspera and the medial
supracondylar ridge. There are small apertures that perforate
adductor mangus that allow for passage of the Perforating
arteries and are the blood supply for the hamstring.
o There is a fairly large gap in the tendon of the adductor
magnus m called the adductor hiatus. The femoral artery and
vein will cross through this hiatus and emerge as the popiteal
vessels on the posterior of the thigh and leg.
o Dual nerve supply-obuturator and tibial nerve.
 Part of the adductor magnus can sometimes be
considered part of the hamstrings.
Plate 500
 Femoral triangle
o Adductor longus forms medial border
o Sartorius forms lateral border
o Inguinal ligament forms superior border
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Neurovascular bundle is quite superficial-great pressure point for
hemorrhage
o Most lateral is the femoral nerve and most medial is femoral
vein.
o Femoral Nerve breaks apart in the femoral triangle and follow
as nerves named by their target
If you remove Sartorius m, there are two nerves that follow with
the femoral artery and vein
o Nerve to vastus medials
o Saphenous nerve—becomes cutaneous beyond the knee joint
and supplies the skin along the course of the great saphenous
vein.
o These nerves and vessels follow in a canal called the sub
Sartorius canal (Hunter’s Canal, Adductor Canal)
 Contains for things, Femoral A and V, N to Vastus
Medialis, Saphenous N.
o Branching posteriorly from the femoral is the profunda
femoris (deep femoral) artery.
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The femoral vessels are invested in the femoral sheath
for a short period of time, which is a continuation of the
transversalis fascia (endopelvic fascia)
 The femoral nerve is NOT within the femoral
sheath.
 Along the medial aspect of the femoral vein is a
potential space called the femoral canal. It is the
site of femoral herniation.
 Cloquet’s Lymph node is the only lymph node in
the femoral sheath.
Plate 501 Adductor muscles have a nice supply of blood
o Profunda femoris
o Obturator
Plate 504-Profunda femoris
 Gives off medial and lateral circumflex femoral arteries.
o They go around the hip joint.
 Lateral is almost always the larger. It is the major
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artery for the quadriceps (especially the descending
branch)
The femoral artery does not supply any blood, its just a
conduit for blood to pass. The PROFUNDA FEMORIS
supplies the major component of medial and anterior
compartment
Nerve supply
 Anterior—Femoral nerve only
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Medial-Obturator with exception of the pectineus (femoral Nerve)
Posterior-Tibial with exception of the short head of the biceps
femoris (common fibular)
Leg
1/26/2009 8:02:00 AM
Plate 495
 Medial and Lateral Gastrocnemius muscle and the biceps femoris
and semitendonous/membranous create a diamond called the
popliteal region.
o The popliteal region /fossa are the popliteal a and v, the
sciatic nerve (which splits to form the tibial and common
fibular nn.)
 Genicular arteries are branches of the popliteal artery that supply
the knee. Are very important for collateral circulation
Plate 513
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The fibular component of the ankle joint is the lateral malleolus.
The tibial has a medial projection at the ankle joint is the medial
malleolus
 Posterior aspect of the tibia called the soleal line
Plate 514
 There is an interosseus membrane between the tibia and fibula.
There are intervals at the proximal and distal points of the bones.
Plate 522
 No longer fascia lata…its called the crural fascia
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The majority of the shaft of the tibia is subcutaneous.
Anterior compartment of the leg
Lateral compartment of the leg
Posterior compartment of the leg
o Superficial and Deep
Plate 516
 Short saphenous vein lies in the subcutaneous tissue and ends in
the popliteal vein in the popliteal fossa
o Sural nerve (from tibial and common fibular nn) is the
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companion nerve with the short saphenous
Upper half of the gastrocnemius is fleshy. Originates from just
above the knee joint on the femurThe distal half is tendonus and
attaches on the calcaneus. Action is plantar flexion
Movements of the foot
o Plantar flexion-point toes
o Dorsi flexion-toes to your nose
o Inversion-sole of foot medial
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o Eversion-sole of foot lateral
Just deep to gastrocnemius is the soleus taking origin from the
soleal line. The tendon will unite with the tendon of gastrocnemius
to form a very strong tendon called the achilles tendon.
There is another muscle in the superficial posterior compartment
called the planteris muscle. It attaches to the femur just above the
knee joint and turns tendonous almost immediately after crossing
the knee joint. The tendon never unites with the Achilles tendon
and attaches to the calcaneus.
o Great source for tendon graft.
o Rupture will cause same symptoms as Achilles tendon rupture
except the calves will look the same.
Plate 518—Remove Soleus and Gastrocnemius
 Coming into the deep compartment is the tibial nerve. It passes
deep to the origin of the soleus
 4 muscles in the deep compartment
o Three are parallel (extrinsic Foot Muscles)
 Most lateral is the Flexor Hallicus Longus m and extends
it tendon to the distal phalanx of the big toe. Tendon
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Crosses the ancle on the medial aspect of the
calcaneus. Attaches to the fibula.
Most Medial is Flexor Digitorum Longus. Tendon crosses
posterior to the medial malleolus and attach to the
distal phalanges of the lateral toes. Proximal
attachment is from the tibia.
Between Flexor Hallicus and Flexor Digitorum is Tibialis
Posterior m. Crosses the ankle joint posterior to the
medial malleolus. Mostly the IO membrane
o One is the popliteal muscle and is the floor of the popliteal
fossa. It is short and oblique. It inserts superior the solear
line. There is a small amount of rotation of the knee joint
when the knee is locked. Popliteal m unlocks the knee for
rotation.
 When the limb is bearing weight, the popliteal m move
the femur a few degrees.
 Blood supply from popliteal a.
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ALL Muscles in the posterior Compartment (both superficial and
Deep) are innervated by the Tibial nerve.
 They are all Plantar Flexors
 Deep compartment are also inverters.
 Flexor digitorum longus and Flexor hallucis longus also act on the
digits.
Plate I don’t have—Arteries (I guess you can use Plate 518)
 Genicular Arteries provide collateral circulation around the knee
joint.
 When the popliteal a reaches the lower border of the popliteal m., it
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splits into the anterior and posterior tibial aa.
o Posterior stays posterior and supplies the mm of the posterior
compartment
o Anterior leaves the posterior compartment through the
proximal gap in the IO membrane and enters the anterior
compartment.
Posterior Tibial a will commonly give of a branch laterally called the
fibular branch. It will commonly run within the flexor hallucis
longus. It supplies the lateral compartment and flexor hallucis
longus.
 Posterior tibial a is a major a for the foot. It passes posterior to the
medial malleolus
 For some reason, the posterior tibial a is prone to sclerotic disease.
Intermittent claudication (pain) due to vascular insufficiency.
Order things pass posterior to the medial malleolus (mediallateral)
TOM-Tibialis
DICK-digitorum
AND-Artery
HARRY-Hallucis
Plate 519-Anterior Compartment—Dorsi Flexion
 Tibialis Anterior-Tibiaattaches to the metatarsal of the big toe and
a tarsal bone. Its primary focus is on the ankle joint. Will also
Invert
 Extensor Hallucis Longus—IO membraneBig Toe
 Extensor Digitorum Longus—Fibulalateral toes
Plate 520-Anterior Compartment-Extensor digitorum/ hallicus
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Right on the neck of the fibula is the common fibular nerve. It will
divide right there into the superficial and deep fibular nerves. Deep
fibular nerve is for the anterior compartment. Superficial nerve is
for the medial compartment
The anterior tibial nerve will join up and run with the deep fibular
nerve.
o Both pass the ankle joint and work on dorsum of the foot.
If there is edema in the anterior compartment
o Tearing of the muscles from the bone in the anterior
compartment is called Shin Splints
o Tibial compartment syndrome is when the muscles are too
tightly packed. It will compress the vessels and lead to
necrosis due to lack of proper blood supply. The pain is due
to lack of blood to the nerves.
Plate 521-Lateral compartment
 Fibularis Longus—attaches to the first metatarsal (crosses the
plantar foot all the way. For this reason..def an important muscle
for eversion.
 Fibularis Brevis (deep to fibularis longus)—attaches to the fifth
metatarsal
 Both Cross the ankle joint posterior to the lateral malleolus
 Both Take origin from the fibula
 Both are plantar flexors
 Nerve supply to the lateral compartment-Superficial fibular nerve
 Blood supply from unnamed arteries from the fibular artery. Fibular
artery never enters the lateral compartment, it just gives off
branches.
Damage to the common fibular nerve by trauma to the neck of the fibula will
cause foot drop (plantar flexion). Diagnositc for common fibular nerve
damate. They would also have weakened eversion. Common Fibular nerve
only innervates ONE muscle—The shorthead of the biceps femoris.
Plate 542
Foot
1/26/2009 8:02:00 AM
The dorsum of the foot is the top of the foot.
The bottom of the foot is the sole of the foot.
Plate 523-Bones of the Dorsum of the foot
 Tarsal Bones
o Calcaneus
o Talus—bone that participates in the ankle joint. The malleoli
drape over the sides of the talus.
o Navicular—looks like a boat
o Cuboid-lateral to the navicular
o Cuneiform bones
 Lateral, Intermediate, medial
 Metatarsal
 Phalanges
Plate 542
 Superficial fibular nerve becomes a sensory nerve and supplies
most of the sensory information on the dorsum of the foot.
 Deep fibular nerve crosses the ankle joint and become sensory of
the adjacent sides of the first and second toe (the wedge between
the big and pointer toe.
Plate 530
 There are retinaculae that bind the tendons to the joint. There are
superior and inferior extensor retenaculum
 Extensor Digitorum longus goes to the toes, but there is a random
tendon that attaches to the base of the fifth metacarpal called
fibularis tertius. Don’t try to find a muscle belly because is part of
the extensor digitorum.
 Extensor Digitorum brevis go to the four medial toes. There is no
contribution to the fifth toe. Those tendons blend in with the
tendons of the Extensor Longus mm.
Plate 531
 Deep fibular nerve innervates extensor digitorum brevis and then
splits to give sensory innervation to the adjacent sides of the first
and second toe
 The anterior tibial a becomes the dorsal artery of the foot.
Frequently will give off an arcuate artery which will then give off
metatarsal and digital branches.
o The dorsal a of the foot gives off a deep branch called the
deep plantar a. between the first and second metatarsals
 Medial Big Toe is L4
 Lateral Big Toe, and toes 2, 3 and 4 are L5
 Little toe is S1
Plate 523
 There is a shelf of bone from the calcaneus that supports the talus
called the sustantacular tali.
Plate 532
 Plantar aponeurosis divides the plantar foot into medial,
intermediate, and lateral compartments
 Plantar aponeurosis is a thick fascial layer. Some of the muscles of
the plantar foot use it as a tendon.
Plate 533—plantar aponeurosis removed!
 Layer 1 has three muscles
o Abductor Hallicus
o Abductor digiti minimi
o Flexor digitorum brevis
Plate 534-Second Layer
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Tendons of the extrinsic mm can be see here.
o Flexor digitroum
o Flexor Hallucis longus
 Muscles of the second layer
o Quadratus plantae inserts on the tendon of the flexor
digitorum and redirects the direction of the same muscle.
o Lumbricles flex the metatarsal joint and then blend to extend
the IP joint.
Plate 541
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The tibial nerve continues into the plantar foot and divides into
medial and lateral plantar nn.
 Medial plantar nerve gives sensory innervation to the medial 3.5
toes and the plantar give sensory innervation to the lateral 1.5
toes.
Plate 535-Third Layer of the sole of the foot.
 Deep to the flexor hallucis longus is the flexor hallucis brevis
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o Two head of the flexor hallucis brevis. Each of those heads
have a sesamoid bone. The tendon of the flexor hallucis
longus goes between the sesamoid bones. This helps divert
some of the weight from the flexor hallucis longus.
Flexor digiti minimi brevis
Adductor hallucis longus has two heads.
o Transverse Head and Oblique head
o They pull the bones together during weight bearing. Maintains
the integrity of the foot.
o Tranvserse has slips from all the metatarsals.
o Reference point for adduction and abduction is the second toe
in the foot. (middle finger in the hand)
Plate 536
 Posterior Tibial artery splits into a medial and lateral plantar
arteries.
o The lateral plantar artery has a branch the passes between
layers three and four and forms a plantar arch. It
anastomoses with the deep plantar artery from the dorsum of
the foot.
Plate 537-Interossei Muscles
 Dorsal and Plantar interossei musles.
 Dorsal Interossei are bipennate and abduct the toes (DAB)
o There is not distal attachment for the first and fifth digit.
 Plantar Interossei are unipennate and adduct the toes.
o There are no plantar interossie associated with the first and
second toe.
Medial Plantar Nerve
 Abductor Hallucis
 Flexor Hallucis brevis
 Flexor digitorum brevis
 Lumbical #1
Lateral Plantar Nerve—The rest of the muscles of the plantar foot.
Joints
1/26/2009 8:02:00 AM
Plate 487
 Between the two trochanters is the intertrochanteric line.
 There are fibers of the joint capsle along the intertrochanteric line.
 The joint capsule is reinforced by thickenings in the joint capsule
called the intrinsic ligaments.
o Anterior inferior iliac spineintertrochanteric line is the
iliofemoral ligament (Y ligament)
 It’s a check ligament for extension of the hip joint.
o Pubisintertrochanteric line is the pubofemoral ligament.
 It’s a check ligament for abduction of the hip joint.
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Iliopectineal bursa has a stalk that goes through the joint capsule
and communicates with the synovial membrane of the hip joint
 Posteriorly, IschiumFemur is the Ischiofemoral ligament
Open Joint, Same Plate
 There is an articular surface on the femur
o There is a pit on the femur called the fovea with a strand of
tissue that is called the ligament of the head of the femur and
attaches to the acetabulum. This ligament has a blood vessel
that is branch of the obturator Artery. There is very little
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communication between arteries in the neck of the femur and
the head of the femur. There fore any disruption to the
artery of the head of the femur from the obturator, there is
likelihood of necrosis
There is a lip of Fibrocartilage around the edges of the acetabulum
called the labrum. The labrum just deepens the joint.
The articular surface is over the labrum, but does not totally
circumnavigate the acetabulum.
There is a non articular surface in the floor of the acetabulum that
serves as the source of the ligament of the head of the femur.
Nerve supply to the hip joint is that of the same nerves that act on
that joint. (Hilton’s Law)
Plate 511
 There are accessory fibers that support the joint capsule (intrinsic
ligaments)
o Some of the fibers of semimembranosis reflect back up on to
the posterio region of the joint and are called the oblique
popliteal ligament.
o The arecuate popliteal ligament passes over the popliteal m.
The muscle fibers become intracapsular
o Medial/Tibial Collateral Ligament is extracapsular. It is broad
and intimate with the joint capsule
o Lateral/Fibular Collateral Ligament is cord like and not very
intimate with the joint capsule. The tendon of the popliteal m
is part of the capsule deep to the LCL.
Plate 509
 Fibular Collateral Ligament and Tibial Collateral ligament are intact.
The tendon of popliteus is between the LCL and the joint capsule.
 There are plates of cartilage between the condyles of the femur and
the tibia called the lateral and medial meniscus
o There is a small tendon that connect the lateral and medial
meniscus called the transverse ligament o the knee.
 There are some very strong ligaments midline that are intracapsular
o Anterior and posterior Cruciate ligament
 ACL is weaker of the two.
o Named for their attachment at the tibia.
 ACL is Lateral condyle (prevents hyperextension)
 PCL is medial condyle (prevents excessive flexion)
 Posteriorly there is the posterior meniscofemoral ligament going
from lateral meniscus to the medial condyle.
 The medial collateral ligament is invested in the medial meniscus
making it less mobile.
5 ligaments that are intrinsic
 Patellar ligament
 Arcuate popliteal
 Oblique popliteal
 Medial Collateral
 Lateral Collateral
The only structures that are intrasynovial are the two menicus.
Plate 508
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The menisces are concave toward to the interior. The most
outerlimb parts of the menisces are vascularized by the genicular
arteries. The inner third of the menisci are avascular and receive
nutrients from the synovial fluid.
Plate 511
 Appreciate the reflections of the synovium in red.
 There are lots of bursae
o The prepatellar bursa allows the skin to move freely.
 Subcutaneous
o Infrapatellar bursae
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Subcutaneous
Deep
Unhappy triad
 MCL
 Medial Menicus
 ACL
Plate 524
 Hindfoot-includes the calcaneus and talus
 Midfoot-includes the metatarsals
 Forefoot-includes metatarsals and phalanges
Plate 525
 The calcaneus has three contact points with the talus
Talus is the keystone bone. It is necessary for proper maintenance of the
arch. The ligaments of the foot are “staples) uniting the arches. the plantar
aponeurosis are “tie beams.” The suspesnsion cables are the extrinsic
muscles of the foot (like the tendon of the flexor hallucis longus, fibularis
longus, etc.)
Plate 528-Plantar Foot
 Fibularis longus comes across and attahces to the fifth metatarsal
and the lateral cuneiform bone.
 Tibialis posterior attaches to a large number of the bones on the
plantar surface of the foot.
 There is along plantar ligament that goes from the calcaneus to the
bases of the four lateral metatarsals
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The plantar calcaneonavicular ligament (spring ligament) is
superficial to the talus (talus is just deep to this ligament)
o The Spring ligament has quite a bit of elastic tissue and
supports the key stone of the foot.
Plate 527-Ankle
 Fibula is attached to the tarsal bone by two ligaments
o Anterior and posterior talofibular ligament
 Fibula is attaches to the calcaneus by the calcaneofibular ligament
 Lateral collateral ligaments are the anterior and posterior talofibular
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ligament an the calcaneofibular ligament
Tibia is attached to the talus by two ligaments
o Anterior and posterior tibiotalar ligaments
Tibia to navicular by the tibionavicular ligament
Tibia to calcaneus by the tibiocalcaneal ligament
The four ligaments from the tibia are called the deltoid ligament or
the medial colltateral ligaments