Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Lower Limb, part II Barbara Kraszpulska, Ph.D. Neuroscience, Cell Biology, and Physiology Popliteal fossa Semitendinosus m. Semimembranosus m. Gracilis m. Popliteal artery and vein Sartorius m. Superior medial genicular a. Biceps femoris Tibial nerve Common fibular nerve Superior lateral genicular a. Plantaris m. Lateral sural cutaneous n. Medial sural cutaneous n. Small saphenous vein Gastrocnemius m. Common fibular gives rise to lateral sural Tibial nerve gives rise to medial sural cutaneous n. Superior genicular artery (one on lateral and one on medial side) -Superior lateral genicular a. - Superior medial genicular a. Popliteal Fossa The popliteal fossa is a space or shallow depression located at the back of the knee joint. The boundaries of the fossa are: * superior and medial: the semimembranosus m., lateral to which is the semitendinosus m. * superior and lateral: the biceps femoris m. * inferior and medial: the medial head of the gastrocnemius m. * inferior and lateral: the lateral head of the gastrocnemius m. The contents of the politeal fossa include the: * termination of the small saphenous vein * popliteal arteries and veins and their branches and tributaries * tibial and common fibular nerves Vein lies more anteriorly Artery lies deeper in popliteal fossa * popliteal lymph nodes and lymphatic vessels Knee joint This is condylar type of synovial joint (between two condyles of the femour and tibia), in addition it includes a saddle joint between the femur and the patella! Functionally this a hinge type of synovial joint – the main movement is flexion and extension, but there is also rotation when the knee is flexed ! The fibula is NOT involved in the knee joint!!!!!!!!!!! Extracapsular ligaments( external ligaments): * patellar lig. * tibial collateral lig. * fibular collateral lig. * oblique popliteal lig. * popliteus tendon Bursae – there are at least about 12 bursae around knee joint! Intracapsular ligaments: * anterior cruciate lig. * posterior cruciate lig. * medial meniscus * lateral meniscus Quadriceps tendon becomes the patellar ligament Tibial and fibular collateral ligaments are like the ulnar and radial collateral ligaments. Right Knee – Cruciate and Collateral Ligaments Anterior view 4 2 6 5 3 1 3 9 8 1 – medial condyle 2 – lateral condyle 3 – medial meniscus 4 – lateral meniscus 7 5 1 6 7 4 2 8 Posterior view 5 – anterior cruciate lig. 6 – posterior cruciate lig. 7 – tibial collateral lig. 8 –fibular collateral lig. 9 – tendon of popliteus m. Function of the Cruciate ligaments Anterior cruciate ligament Prevents anterior displacement of the tibia relative to the femur Posterior cruciate ligament Prevents posterior displacement of the tibia relative to the femur Menisci of the knee joint Posterior cruciate lig. Lateral meniscus Infrapatellar fat pad Medial meniscus Anterior cruciate lig. Which meniscus is more frequently torn in injures and why??? 1.“Unhappy triad " 2. Bursitis in the knee region a. Tibial collateral lig. b. Medial meniscus c. Anterior cruciate lig. Genicular anastomoses around the knee Four genicular branches 1 & 2. Superior medial and lateral loop over respective femoral condyles 3. Inferior medial parallels superior edge of popliteus 4. Inferior lateral crosses popliteus 4 branches of genicular arteries – which are derived from the Popliteal artery: -Superior lateral genicular arteries - loops over lateral femoral condyle - Superior medial genicular arteries - loops over medial femoral condyle - Inferior medial genicular artery - parallels superior edge of popliteus - Inferior lateral genicular artery - crosses popliteus Right knee Vastus lateralis Vastus medialis Quadriceps femoris tendon Iliotibial tract Medial patellar retinaculum Lateral patellar retinaculum Semitendinosus Gracilis Sartorius } Patellar ligament Pes anserinus Anterior (extensor) compartment Action: 1. they all extend (dorsiflex) the foot (ankle joint) Tibialis anterior M. Tibia 2. Tibialis anterior- inverts the foot 3. Extensor. digit. long. – extend digits (toes), everts foot 4. Extensor hallucis long. – extend great toe, inverts foot Innervation: Deep fibular nerve (L5,S1) Extensor digit. longus m. Extensor hallucis longus m. 1 1 1. Sup. extensor retinaculum 2. Inf. extensor retinaculum 2 2 Blood supply: Anterior tibial artery (terminal branch of popliteal a.) Actions of the anterior extensor compartment: -Tibialis anterior: -Extend (dorsiflexion) of foot at ankle joint - inverts foot - Extensor digitorum longus -Extends the foot at the ankle joint -Everts foot -extend digits “Odd man out is ED” • Extensor hallucis longus •Extends the foot at ankle joint •Inverts foot •Extend great toe Innervation: -Deep fibular nerve (L5, S1) Blood supply: -Anterior tibial artery (Terminal branch of popliteal a.) Lateral (eversion) compartment Action: 1. They both evert the foot (elevate the lateral margin of the foot) 2. They weakly flex (plantarflex) the foot (because they pass posterior to the transverse axis of the ankle) Fibularis Longus (1) Innervation: Superficial fibular nerve (L5-S2) Fibularis Brevis (2) (1) Blood supply: Perforating branches of the anterior tibial and fibular artery (posterior tibial artery Tendon of fibularis longus (1) (2) The lateral compartment is supplied by both the anterior and posterior tibial arteries (the fibular artery, in this case). However, they are perforating branches. Unlike the anterior compartment (deep branch, L5S1), the lateral compartment is innervated by the superficial branch (L5-S2) Fibularis longis (lateral compartment, supplied by perforating branches of anterior tibial and fibular arteries) wraps under the flexor digitorum brevis Common fibular N Deep fibular N Superficial fibular N Lateral sural cutaneous n. Superficial fibular n. Deep fibular n. Sural n. (lat. dorsal cutaneous branch) Deep fibular N Injury to the common fibular nerve Footdrop is due to weakness or paralysis of the muscles involved in lifting the front part of your foot. This can cause inability to stand on heels and walk with a foot slap. Footdrop isn't a disease but a sign of an underlying problem. Causes include: *Compressed nerve root, usually in the lower spine, due to a ruptured lumbar disk *Pressure or injury to the peroneal nerve in your lower leg, such as from sitting with your legs crossed for long periods *Peripheral nerve disorder (neuropathy) *Muscle disorders (myopathies) *Tumor or stroke affecting the areas of the brain that control movement of the legs *Disorders of the spinal cord such as tumors or multiple sclerosis Depending on the cause, footdrop can be temporary or permanent. Treatment depends on the underlying cause but may include a brace (orthotic) worn on the ankle and foot to hold the foot in the normal position. Footdrop is a sign of injury to the common fibular nerve (also known as the peroneal nerve) -Result of compression of nerve root, injury to nerve itself, peripheral nerve disorder, muscle disorder, tumor or stroke, disorder of spinal cord -(Basically, damage to nerve, damage to brain, damage to spinal cord or muscle itself) Superficial group: Gastrocnemius Soleus flex the foot plantaris Deep group: TOM DICK HARRY Posterior (plantarflexion) compartment Soleus Flexor Digitorum longus Tibialis posterior Posterior tibial artery and vein Lateral to medial: Tom Dick VAN Halen Tibial nerve Calcaneal tendon is also known as the Achilles tendon Flexor Hallucis longus Flexor retinaculum Achilles tendon (calcaneal tendon) Tibialis posterior tendon TOM – Tibialis posterior DICK- Fl. Digitorum longus HARRY- Fl. Flexor digitorum longus Posterior tibial A and Tibial nerve Flexor hallucis longus Hallucis longus Tarsal tunnel Tarsal tunnel syndrome Flexor retinaculum The tarsal tunnel is a narrow space that lies on the inside of the ankle next to the ankle bones. Tarsal tunnel syndrome is a compression, or squeezing, on the posterior tibial nerve that produces symptoms anywhere along the path of the nerve. The posterior tibial nerve runs along the inside of the ankle into the foot. Tarsal tunnel syndrome (TTS), also known as posterior tibial neuralgia, is a painful foot condition in which the tibial nerve is impinged and compressed as it travels through the tarsal tunnel. Tibial nerve Common fibular (peroneal) nerve Gastrocnemius muscle (cut) Popliteus muscle Flexor digitorum longus M. Tibialis posterior M. Flexor hallucis longus M. Sural nerve Soleus Muscle (cut) Innervation: Tibial nerve (L4-S3) Blood supply: Posterior tibial artery and also fibular artery (branch of posterior tibial a.) Tibial nerve innervates the posterior plantarflexion compartment Roots? L4- S3 Muscles: -Popliteal - Gastrocnemius - Soleus - Tibial posterior - Flexor digitorum longus - Flexor hallucis longus Tarsal bones "Tall Cocky Navy Medical I nterns Lay Cuties": · In order (right foot, superior to inferior, medial to lateral): Talus Calcanous N avicular Medial cuneiform Intermediate cuneiform Lateral cuneifrom Cuboid Foot Bones: Tarsals (7): talus, calcaneus, navicular, cuboid, and cuneiforms (3) Metatarsal – 5, Phalanges - 14 calcaneus talus Transverse tarsal joint cuboid Ankle joint tibia Subtalar joint navicular cuneiform bones talus calcaneus Tarsometatarsal joint Function of the foot: *Provide a stable platform *Generate propulsion *Absorb shock Foot joints: extension 1. Ankle joint – between the distal end of the tibia and fibula and the superior part of talus. This is a hinge type joint! Movements: dorsiflexion ( extension) of the foot, plantarflexion (flexion) of the foot. Flexion 2. Subtalar joint articulation between talus and calcaneus 3. Transverse tarsal joint articulation between talus, navicular, calcaneus and cuboid bones Movements: inversion and eversion. Eversion- elevation of the lateral margin of the foot Inversion – elevation of the medial margin of the foot. Lateral (collateral) ligament Posterior talofibular ligament Calcaneofibular ligament Anterior talofibular ligament (most commonly injured in ankle sprains) Fibularis longus tendon Fibularis brevis tendon Lateral collateral ligament -Contains 3 parts - torn under inversion Inversion and eversion of the foot Tibialis anterior AND tibialis posterior control inversion of the foot. -What else controls it? - Flexor hallucis longus Fibular Inversion injuryAnkle sprains! Deltoid lig. stabilizes the ankle joint during eversion and prevents sublocation of the joint! DELTOID (medial) ligament 1. Posterior tibiotalar part 1 2. Tibiocalcaneal part 2 3. TIbionavicular part 4. Anterior tibiotalar part SPRING LIGAMENT (Plantar calcaneonavicular) 3 4 Short plantar ligament Long plantar ligament Although the lateral side (fibular side) is composed of 3 different ligaments, the medial side is considered one giant ligament. This ligament is known as the deltoid ligament. -Its components are similar to the lateral compartment, with the addition of the tibionavicular ligament. -Function? - Stabilizes the ankle joint during eversion and prevents sublocation of the jiont. -Also laterally, we have the spring ligament (plantar calcaneonvaciular Ankle injuries A Pott fracture–dislocation of the ankle Sole of foot Flexor digitorum brevis Medial plantar nerve(S2, S3) Plantar aponeurosis Lateral plantar fascia Medial plantar fascia Superficial dissection Abductor digiti minimi Lateral plantar nerve(S2, S3) Abductor hallucis Medial plantar nerve(S2, S3) First layer Sole of foot Adductor hallucis Lateral plantar nerve(S2, S3) Lumbrical Lateral and medial plantar nerve(S2, S3) Quadratus plantae Lateral plantar nerve(S2, S3) Second layer Flexor digiti minimi brevis Lateral plantar nerve(S2, S3) Third layer Flexor hallucis brevis Medial plantar nerve(S2, S3) First layer of the foot • Flexor digitorum brevis • Medial plantar nerve (S2, S3) • Abductor hallucis • Medial plantar nerve (S2, S3) • Abductor digiti minimi • Lateral plantar nerve (S2, S3) The lateral and medial plantar nerves are branches of the tibial nerve, which is itself a branch of the sciatic nerve Sole of foot: -First layer - Flexor digitorum brevis - Medial plantar n - Abductor hallucis - Medial plantar - Abductor digiti minimi - lateral plantar n. -Second layer - Quadratus plantae - lateral plantar n. - Lumbrical - lateral and medial plantar nerves -Third layer - Adductor hallucis - lateral plantar nerves - Flexor digit minimi brevis -Lateral plantar nerves - flexor hallucis brevis - medial plantar nerves Muscles of the foot Plantar muscles function primarily as a group during the support phase of stance, maintaining the arches of the foot. The muscles of the foot are of a little importance individually because fine control of the individual toe is not important for most people. Rather than producing actual movement, they are most active in fixing the foot or in increasing the pressure applied against the ground by various aspects of the sole or toes to maintain balance. Nerves of the foot: Medial plantar nerve (S2, S3) Lateral plantar nerve (S2, S3) Both terminal branches of tibial nerve! Deep fibular- dorsum of the foot Arteries of the foot: Dorsalis pedis artery- terminal branch of the anterior tibial Medial plantar and lateral plantarterminal branches of the posterior tibial Arteries of the foot Nerves of the Leg and Foot Sciatic nerve (L4-S3) Tibial nerve (L4-S3) Common fibular nerve (L4-S2) Medial plantar nerve Lateral plantar nerve Superficial branch Deep branch Superficial fibular nerve Deep fibular nerve Medial branch Lateral branch Medial plantar nerve: flexor digitorum brevis abductor hallucis flexor hallucis brevis first lumbrical Lateral plantar nerve: abductor digiti minimi quadratus plantae lumbricals 2, 3 and 4 adductor hallucis flexor digiti minimi brevis dorsal and plantar interossei Cutaneous nerves of Lower Extremity Major ligaments of the foot (plantar aspect) Spring ligament!! 1.Supports the head of the talus 2. Transfers weight from the talus 3. Supports the longitudinal arch Supports the longitudinal arch (Long plantar calcen Calcaneocuboid lig. Supports the Longitudinal arch Flexor hallucis longus supports the.. Dynamic support-Major muscles that invert foot -Major muscles that evert foot -Intrinsic plantar muscles Passive support -On bottom of foot and ligaments - plantar aponeurosis - plantar calcaneonavicular lig - long plantar lig - short plantar lig Arches of the foot Medial longitudinal arch – higher and more important Is composed of: calcaneus, talus, navicular, three cuneiforms, three medial metatrasal bones. This is arch is supported by: tendon of the flexor hallucis longus muscle and spring ligament Arches of the foot Lateral longitudinal arch – much flatter. Is composed of: calcaneus, cuboid and lateral two metatarsalas. Supported by: Fibular (peroneus) longus tendon and long and short plantar ligaments. Arches of the foot Transverse arch of the foot – runs from side to side. Is composed of: cuboid, cuneiforms and bases of the metatarsals. Support by tendons of two muscles: Fibularis longus (FL) and tibialis posterior (TP), crossing under the sole of the foot. FL FL TP Factors involved in forming and maintaining the arches of the foot Passive factors: 1. the shape of the united bones 2. plantar aponeurosis 3. long plantar ligament 4. short plantar ligament 5. spring plantar ligament Dynamic factors: 1. Active action of the intrinsic muscles of foot 2. Active and tonic contraction of muscles with long tendons extending into foot: a. flexor hallucis longus and digitorum longus (longitudinal arch) b. fibularis longus and tibialis posterior (transverse arch) Questions of the day! 1. What are the primary muscles that control eversion of the foot? 1. fibularis longis and brevis 2. If a patient cannot stand on his heel, which nerve is not functioning? 1. Common fibular (more specifically, that means we cannot extend, meaning deep fibular nerve… because extension is dorsiflexion 3. Nerves can frequently be compressed against bony structures in the lower limb. What nerve rests against the head and neck of the fibula? 1. Common fibular 2. Foot drop is a result