Download 22-Leg12008-05

Prof. Saeed Abuel Makarem
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1- Lateral (A)
2- Extensors (B)
3- Flexors (E,G & H)
E-Tibialis posterior
D- Fibula.
C- Tibia.
Prof. Saeed Abuel Makarem
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The Leg is divided
Into 3
Compartments
By:
2 Intermuscular
Septae,
Deep Fascia, &
Interossus
Membrane:
Anterior
intermuscular
septum
1- Extensor.
2- Lateral.
3- Flexor.
Prof. Saeed Abuel Makarem
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• 1- Anterior
compartment
(Extensors)
• It contains:
Extensors
muscles.
Deep peroneal,
(Anterior tibial) nerve.
Anterior tibial
vessels.
Prof. Saeed Abuel Makarem
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2- Lateral compartment
(Peroneal)
It contains:
Peroneus Longus and brevis muscles.
Superficial peroneal, (musculocutaneous)
nerve.
Branches from peroneal artery.
Prof. Saeed Abuel Makarem
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3- Posterior compartment
(Flexors)
It contains:
Flexors muscles.
Posterior tibial vessels,
Posterior tibial nerve (tibial nerve).
Prof. Saeed Abuel Makarem
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Anterior Compartment
• 1-Tibialis anterior.
• 2- Extensor hallucis
longus.
• 3- Anterior tibial artery
• 4- Anterior tibia vein
• 5- Anterior tibial nerve.
• 6- Extensor Digitorum
longus.
• 7- Peroneus tertius.
• (Tom has a very nice
dog pig).
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Prof. Saeed Abuel Makarem
• Origin:
• Upper ½ or 2/3 of the lateral
surface of the tibia &
adjoining part of the
interosseous membrane.
• Insertion:
• Medial cuneiform &
adjoining base of the 1st
metatarsal bone.
Tibialis Anterior
• Nerve: Deep peroneal
( Anterior tibial) nerve
• Action:
• Dorsi flexion & inversion.
• Maintain the medial
longitudinal arch.
Prof. Saeed Abuel Makarem
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Insertion of tibialis anterior
Prof. Saeed Abuel Makarem
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• Origin:
• Middle 2/4th of anterior
surface of fibula & the
interosseous membrane.
• Insertion:
• Dorsum of terminal
phalanx of hallux (big toe)
• Nerve: Deep peroneal n.
• Action:
• Extension (dorsiflexion of
all joints of big toe.
It also assists in dorsi
flexion & inversion of the
foot.
Extensor Hallucis
Longus
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Insertion of extensor hallucis longus
Prof. Saeed Abuel Makarem
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Origin:
Upper 3/4th of the anterior
surface of the fibula &
interosseous membrane.
Insertion:
Extensor expansion of
lateral 4 toes.
Nerve: Deep peroneal nerve
Action: Extension of all
joints of lateral 4 toes.
Also, dorsi flexion of ankle
joint.
Extensor Digitorum
longus
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Prof. Saeed Abuel Makarem
• Origin:
• Lower ¼ of anterior
surface of fibula &
interosseous membrane.
• Insertion:
• Medial part of the base of
the 5th metatarsal bone.
• Nerve: Deep peroneal N.
• Action:
• Dorsi flexion & Eversion
the of foot
Peroneus tertius
Prof. Saeed Abuel Makarem
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Insertion of peroneus tertius
Medial side of dorsal aspect of
5th metatarsal bone.
Prof. Saeed Abuel Makarem
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peroneus
peroneus
Peroneus
NB.
Dorsi flexion & Planter flexion
occur in the ankle joint.
While Eversion & Inversion occur
in the subtalar & transverse
tarsal joints or (Tallo-calcenionavicular joints).
Prof. Saeed Abuel Makarem
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Extensor Retinacula
• These are thickened
bands of deep fascia.
• 1- Superior extensor
retinaculum
Attachment:
• To the distal ends of
the anterior borders of
both tibia & fibula.
• Near its medial end it
splits to enlose the
tendon of tibialis
anterior.
Prof. Saeed Abuel Makarem
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2-Inferior Extensor Retinaculum
• Y-shaped band of deep
fascia.
• Attachment:
• Stem: anterior part of the
upper suface of calcaneum
• Upper limb of the Y: To the
medial malleolus.
• Lower limb of the Y: Is
continuous with the planter
fascia.
• Extensor tendons split the
upper limb into sueficial and
deep layers.
Prof. Saeed Abuel Makarem
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Prof. Saeed Abuel Makarem
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• Peroneus Longus
• Origin: Upper 2/3 of lateral
surface of the fibula.
• Insertion: Medial
cuneiform & base of 1st
metatarsal bone.
Nerve: Superficial peroneal
(Musculocutaneous) N.
• Action: Eversion & planter
flexion of the foot.
It maintains the longitudinal,
transverse arches of the
foot.
Lateral
Compartment
Prof. Saeed Abuel Makarem
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Peroneus brevis
Lateral
Compartment
Origin: Lower 2/3 of lateral
surface of the fibula.
Insertion: Tuberosity in base
of 5th metatarsal bone.
Nerve: Superficial peroneal
(musculocutaneous) nerve.
Action: Eversion & planter
flexion of foot.
Prof. Saeed Abuel Makarem
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Prof. Saeed Abuel Makarem
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Prof. Saeed Abuel Makarem
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Superficial peroneal Nerve
(Musculocutaneous)
• One of the two terminal branches of the common
peroneal nerve.
• It arises at the lateral side of the neck of fibula.
• In upper 1/3rd of the leg it descends within the
Peroneus Longus
• In middle 1/3rd it runs between Peroneus Longus and
brevis.
• In lower 1/3rd it pierces deep fascia and runs in the
superficial fascia crossing superficial to superior and
inferior extensor retinaculae to the dorsum of the foot
Prof. Saeed Abuel Makarem
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• Branches:
• Muscular: for the peroneus Longus
& peroneus brevis).
• Cutaneous: Majority
Lower 1/3rd of lateral surface of the
leg.
Middle part of the dorsum of foot.
Dorsum of all toes
Except:
Lateral side of little toe (Sural
nerve).
Adjacent sides of big & second toes
( Anterior tibial nerve).
Prof. Saeed Abuel Makarem
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Common Peroneal Nerve Injury
The common peroneal
nerve is in an exposed
position as it leaves the
popliteal fossa and
winds around the neck
of the fibula to enter the
peroneus longus
muscle.
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The common peroneal nerve is commonly injured in:
• Fractures of the neck of the fibula
• Trauma to the neck of the fibula.
• Pressure from casts or splints.
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• The following clinical features are
present in Common Peroneal Nerve
Injury
Motor:
• The muscles of the anterior and
lateral compartments of the leg are
paralyzed,
• As a result, the opposing muscles,
the plantar flexors of the ankle joint
and the invertors of the subtalar
and transverse tarsal joints,
• cause the foot to be plantar flexed
(foot drop) and inverted, an attitude
referred to as equinovarus.
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Sensory:
• Loss of sensation occurs down the anterior
and lateral sides of the leg and dorsum of
the foot and toes, including the medial side
of the big toe.
• The lateral border of the foot and
the lateral side of the little toe are
virtually unaffected (sural nerve,
from tibial nerve).
• The medial border of the foot as
far as the ball of the big toe is
completely unaffected
(saphenous nerve, from the
femoral nerve).
Prof. Saeed Abuel Makarem
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Prof. Saeed Abuel Makarem
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• Cutaneous nerve supply
I- On the dorsum of foot:
Medial part: Saphenous nerve.
Intermediate part: Superficial peroneal nerve.
Lateral part: Sural nerve.
II- On the dorsum of toes:
Sural nerve, lateral side of little toe.
Deep peroneal nerve, Adjacent sides of the big
and 2nd toes.
Superficial peroneal, to all remaining toes.
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Prof. Saeed Abuel Makarem
• Feeling the Dorsalis
Pedis pulse.
• Just lateral to tendon
of extensor hallucis
Longus.
• Five (P) signs of acute
arterial occlusion:
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1- Pain.
2- Pallor.
3- Paresthesia.
4- Paralysis.
5- Pulselessness.
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Prof. Saeed Abuel Makarem
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• Extensor Digitorum brevis:
• The only muscle on the dorsum of the foot
Origin: anterior part of upper surface of calcaneus
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Insertion: Medial, medial, medial, 4 toes.
The medial slip is called extensor hallucis brevis.
It is inserted into proximal phalanx of big toe.
Each of the lateral 3 slips joins the extensor
expansion of the 2nd,3rd & 4th toes.
Nerve supply: anterior tibial nerve.
NB. No tendon of Extensor Digitorum brevis reaches
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the little toe.
Prof. Saeed Abuel Makarem
Prof. Saeed Abuel Makarem
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Prof. Saeed Abuel Makarem
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Femoral Nerve Injury
• The femoral nerve (L2,3,
and 4) enters the thigh from
behind the mid point of the
inguinal ligament.
•
it lies about a finger breadth
lateral to the femoral pulse.
• About 5 cm below the
inguinal ligament, the nerve
splits into its terminal
branches.
Prof. Saeed Abuel Makarem
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The following clinical features are present when the nerve is completely
divided:
• Motor: The quadriceps femoris muscle is paralyzed, and the knee cannot
be extended.
• Is walking possible?
- Yes. In walking, this is compensated for to some extent by use of the
adductor muscles.
Prof. Saeed Abuel Makarem
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Femoral Nerve Injury
Sensory:
Skin sensation is lost:
 over the anterior and medial
sides of the thigh,
 over the medial side of the leg.
 Along the medial border of the
foot as far as the ball of the big
toe; ( saphenous nerve).
Prof. Saeed Abuel Makarem
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Common Peroneal Nerve Injury
The common peroneal nerve
is in an exposed position as it
leaves the popliteal fossa and
winds around the neck of the
fibula to enter the peroneus
longus muscle.
Prof. Saeed Abuel Makarem
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Tibial Nerve Injury
• The tibial nerve leaves the
popliteal fossa by passing
deep to the gastrocnemius
and soleus muscles.
• Because of its deep and
protected position, it is rarely
injured.
Prof. Saeed Abuel Makarem
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• Complete division results in
the following clinical features:
Motor:
• All the muscles in the back of
the leg and the sole of the foot
are paralyzed.
• The opposing muscles
dorsiflex the foot at the ankle
joint and evert the foot at the
subtalar and transverse tarsal
joints, an attitude referred to
as calcaneovalgus.
Prof. Saeed Abuel Makarem
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