Lower Limb

Question 1

Plantar flexors

Answer 1

Both superficial and deep compartments are involved
Superficial. Gastrocnemius soles plantar is
Deep tibialis posterior FDL FHL (popliteus-is part of deep posterior comp but no role in plantar flexion)

Question 2

Ankle eversion muscles and nerve supplying the said muscles

Answer 2

Peroneus longus and brevis
Superficial peroneal nerve

Question 3

Ankle inversion and joint at which it occurs

Answer 3

Tibialis anterior and posterior contract together
Occurs at subtalar joint

Question 4

What motor and sensory function is lost with
damage to the superficial peroneal nerve?

Answer 4

Inability to evert the foot and loss of sensation over
the dorsum of the foot, apart from the first web
space, which is innervated by the deep peroneal
nerve

Question 5

Findings in nerve root compression L2

Answer 5

Dermatome anteromedial thigh
Myotome iliopsoas
Reflex none

Question 6

L3 myotome and dermatome

Answer 6

Quadriceps
Anterior thigh

Question 7

L4

Answer 7

Dermatome anteromedial leg
Myotome tibialis anterior
Reflex patellar

Question 8

L5

Answer 8

Dermatome Lateral leg and dorsum of foot/big toe
Myotome EHL and gluteus medius
Reflex medial hamstring

Question 9

S1

Answer 9

Dermatome posterior calf plantar foot
Myotome gastrosoleus and gluteus Maximus
Reflex Achilles tendon

Question 10

S2 3 4

Answer 10

Dermatome perianal
Myotome bowel bladder
Reflex cremasteric

Question 11

Where would you test sensation of…
L4
L5
S1
deep peroneal nerve
superficial peroneal nerve
Sural nerve

Answer 11

Medial malleolus
Dorsum of foot
lateral border of the foot and little toe.

1st webspace
Dorsum of foot other that first webspace
Lateral malleolus

Question 12

Movements of EHL and structures passing deep to it

Answer 12

Extends big toe foot dorsiflexion and aids inversion
Dorsalis pedis artery vein and deep peroneal nerve

Question 13

Dorsifelxion muscles and at what joint it occurs

Answer 13

EDL EHL tibialis anterior peroneus tertius

At the ankle joint between the tibia/fibula and the talus

Question 14

Knee and ankle reflex nerve root

Answer 14

L3/ L4 mainly L4

S1

Question 15

Arteries of the foot

Answer 15

Dorsalis pedis artery
• It is the continuation of the anterior tibial
artery and begins as the anterior tibial
artery crosses the ankle joint.
• It passes anteriorly over the dorsal aspect
of the talus, navicular, and intermediated
cuneiform bones, and then passes
inferiorly, as the deep planter artery,
between the two heads of the first dorsal
interosseous muscle to join the deep
planter arch in the sole of the foot.

Medial and lateral plantar arteries
• Arteries which supply the sole of the foot
• Branches of posterior tibial artery
• Run in the sole between the 1st and 2nd
layer of muscles
• Lateral plantar artery forms plantar arch
along with dorsalis pedis artery

Question 16

Structures passing deep to flexor retinaculum/ medial malleolus

Answer 16

• Tibialis posterior tendon
• Flexor Digitorum longus
• posterior tibial Vessels
• tibial Nerve
• Flexor Hallucis longus

Question 17

Structures deep to extensor retinaculum

Answer 17

Tom Has Very Nice Dogs & Pigs
• Tibialis anterior
• Extensor Hallucis longus
• Anterior tibial Vessels
• Deep peroneal Nerve
• Extensor Digitorum longus
• Peroneus tertius

Question 18

Muscles attached to 5th metatarsal

Answer 18

Base peroneus tertius
Tuberosity peroneus brevis

Question 19

What is ankle joint more stable in dorsiflexio

Answer 19

• The anterior portion of the talus is wider than the posterior portion.
• In dorsiflexion, the talus glides posteriorly and the wider portion becomes wedged into the ankle mortise.
• In planter flexion, the talus moves anteriorly and the ankle becomes a little bit wobbly.

Question 20

Attachments of deltoid ligament

Answer 20

deltoid ligament (medial collateral ligament of ankle) is broad, triangular, and has one proximal attachment and four distal attachments
• Proximal attachment: Apex of the medial malleolus.
• Distal attachments (four parts):
1. Anterior tibiotalar part → to talus (anterior).
2. Posterior tibiotalar part → to talus (posterior).
3. Tibiocalcaneal part → to sustentaculum tali of calcaneus.
4. Tibionavicular part → to navicular bone.

Question 21

Parts of deltoid ligament

Answer 21

Anterior tibiotalar ATT
posterior tibiotalar PTT
Tibiocalcaneal TC
Tibionavicular TN

Question 22

Components of medial arch

Answer 22

Bones: TCN 3 cuneiforms 3 medial metatarsals
Ligaments : long plantar short plantar spring and deltoid ligament plantar aponeurosis
Muscles : tibialis anterior and posterior FHL short muscles of big toe
In case of medial arch muscles are the strongest support

Question 23

Lateral arch

Answer 23

Bones: calcaneum cuboid 2 lateral metatarsals
Ligaments: short plantar ligament plantar aponeurosis
Muscles: 3 peroneus small muscles of little finger
Ligaments give the strongest support here

Question 24

Transverse arch

Answer 24

3 cuneiforms and cuboid and base of all metatarsals
Interosseus ligaments
Peroneus longus transverse head of adductor hallucis

Question 25

Muscles of deep posterior compartment

Answer 25

Tibialis posterior FDL FHL Popliteus

Question 26

What is femoral sheath

Answer 26

Its a fascial sleeve formed by the thick cribriform fascia of transversalis & iliacus. It 'ensheaths' the femoral artery, femoral vein & femoral canal

Question 27

Locking of knee

Answer 27

Locking of the knee occurs in the last 30° of extension due to medial rotation of the femur on tibia, making the joint stable. popliteus muscle laterally rotates femur to unlock it

Question 28

External rotators of hip name and OINA

Answer 28

Gluteus Maximus Origin. Dorsal ilium posterior to posterior gluteal line, dorsal sacrum and sacrotuberous ligament Iliotibial tract & gluteal tuberosity of the femur Inferior gluteal Piriformis Anterior sacrum/sciatic notch Proximal greater trochanter Obturator externus External surface of obturator membrane and bone around it Trochanteric fossa Obturator nerve Obturator internus Internal surface of obturator membrane and bone around it Medial greater trochanter Nerve to Obturator internus Superior gemellus Outer ischial spine Medial greater trochanter Nerve to Obturator internus Inferior gemellus Ischial tuberosity Medial greater trochanter Nerve to Quadratus femoris Quadratus femoris* Lateral border of the upper part of the Ischial tuberosity Quadrate line of femur Nerve to Quadratus femoris

Question 29

Abductors of hip

Answer 29

Gluteus medius Ilium between posterior and anterior gluteal lines Greater trochanter Superior gluteal nerve Gluteus minimus Ilium between anterior and inferior gluteal lines Anterior border of greater trochanter Superior gluteal nerve Tensor fasciae latae (tensor fasciae femoris) Anterior iliac crest Iliotibial band Superior gluteal nerve

Question 30

Where does the iliotibial tract attach? What muscles insert here? What is its clinical significance

Answer 30

Proximally to tubercle of iliac crest Lateral condyle of tibia distally Glut max Tensor fascia Lata Stabilises knee joint in extension and partial flexion important in running and walking

Question 31

What are the surface markings of the sciatic nerve?

Answer 31

The sciatic nerve (L4,5, S1,2,3) exits the pelvis via the greater sciatic foramen from below the piriformis muscle. The surface marking of the sciatic nerve is a curved line drawn from 2 points: halfway between the posterior superior iliac spine to the ischial tuberosity to halfway between the ischial tuberosity and the greater trochanter.

Question 32

Name all hamstring muscles? Q: Action of all together? each one separately?

Answer 32

Biceps femoris Semitendinosus Semimembranosus Action together extend hip and flex knee joint Biceps femoris lateral rotation of hip and knee Semitendinosus and membranosus medial rotation of hip and knee

Question 33

Hamstrings originally insertion nerve

Answer 33

Biceps femoris (long head) Medial ischial tuberosity Fibular head/lateral tibia Tibial Biceps (short head) Lateral linea aspera/lateral Lateral tibial condyle Peroneal Semitendinosus ischial tuberosity Proximal anteromedial tibia with pes anserinus Tibial Semimembranosus Ischial tuberosity Posterior part of medial condyle of tibia; also gives rise to oblique popliteal ligament (reinforces posterior capsule of knee) Tibial

Question 34

Blood supply to the head of femur

Answer 34

The majority of the blood supply to the head of the femur is from retinacular arteries, which arise as ascending cervical branches from the extracapsular arterial anastomosis. This is formed posteriorly by the medial femoral circumflex artery and anteriorly from branches of the lateral femoral circumflex artery with minor contributions from the superior and inferior gluteal arteries. There is also supply from the artery of the ligamentum teres, also known as the artery of the round ligament of the femoral head (a branch of the obturator artery). Where do these arteries originate? The medial and lateral circumflex femoral arteries originate from the profunda femoris The artery of the ligamentum teres originates from the obturator artery

Question 35

What muscles attach to the lesser trochanter of the femur?

Answer 35

Iliopsoas

Question 36

Iliopsoas oina

Answer 36

The deep part of psoas major originates from the transverse processes of L1-L4. The superficial part originates from the lateral surfaces of T12-L4 and the intervening vertebral discs. Insertion lesser trochanter What is the action of psoas major? Psoas major flexes and externally rotates the hip

Question 37

Structures in popliteal fossa

Answer 37

Common peroneal nerve • Tibial nerve • Popliteal vein • Popliteal artery • Lymph nodes • Small saphenous vein • Posterior cutaneous nerve of the thigh • Genicular branch of the obturator nerve Supracondylar fracture of femur Occurs in older patients, usually due to low energy trauma such as a fall (osteoporotic bone). Can occur in young patients due to a high energy trauma. Popliteal artery is at risk, check distal pulses, ABPI (consider CTA or arteriogram) The tibial nerve lies superior to the vessels in the inferior aspect of the popliteal fossa. In the upper part of the fossa the tibial nerve lies lateral to the vessels, it then passes superficial to them to lie medially. The popliteal artery is the deepest structure in the popliteal fossa.

Question 38

Differential diagnosis of lump from popliteal fossa?

Answer 38

• Backer's cyst • Popliteal artery aneurysm • Lipoma • Schwannoma • Popliteal vein varicosities

Question 39

Lymph drainage to popliteal lymph nodes

Answer 39

Superficial popliteal nodes Lie in superficial fat of popliteal fossa Drain lymph from: Superficial lymphatics of lateral side of foot & leg (following small saphenous vein) Deep popliteal nodes Lie along the popliteal vein Drain lymph from: Knee joint capsule Deep structures of leg (muscles, deep vessels) They receive lymph from superficial popliteal nodes

Question 40

Adductors oina

Answer 40

ADDUCTOR BREVIS Origin. Body and inferior pubic ramus Insertion: upper third of linea aspera of femur Obturator nerve Adducts thigh at hip, weak hip flexor ADDUCTORS LONGUS Origin: Body of pubis inferior to pubic crest Insertion: Middle third of linea aspera of femur Obturator nerve (anterior division) Adducts thigh at hip ADDUCTOR MAGNUS Origin: Inferior pubic ramus, ramus of ischium Hamstring part: ischial tuberosity Insertion: Gluteal tuberosity, linea aspera, medial supracondylar line Hamstring part: adductor tubercle of femur Nerve supply Adductor part: obturator nerve Hamstring part: sciatic nerve (tibial division) Action Adductor part: adducts and flexes thigh Hamstring part:extends thigh Gracilis Origin – Body and inferior ramus of pubis Insertion – Upper part of medial surface of tibia (with sartorius & semitendinosus → pes anserinus) Nerve supply – Obturator nerve (anterior division, L2, L3) Action – • Adducts thigh • Flexes leg at knee • Medially rotates leg when knee is flexed

Question 41

Extensors of knee

Answer 41

Quadriceps femoris Revise oina from notes

Question 42

Femoral triangle boundaries and contents

Answer 42

Superiorly Inguinal ligament Laterally Sartorius Medially Adductor longus Floor Iliopsoas, pectineus and adductor longus Roof • Fascia lata and Superficial fascia • Superficial inguinal lymph nodes (palpable below the inguinal ligament) • Long saphenous vein Contents • Femoral vein (medial to lateral) ! Common Femoral artery-pulse palpated at the mid inguinal point • Femoral nerve • Deep and superficial inguinal lymph nodes • Lateral cutaneous nerve • Great saphenous vein • Femoral branch of the genitofemoral nerve

Question 43

Adductor canal Def boundaries content surface marking

Answer 43

Hunter's canal, also known as the subsartorial or adductor canal, runs from the apex of the femoral triangle to the popliteal fossa. Laterally Vastus medialis muscle Posteriorly Adductor longus, adductor magnus Roof Sartorius What are the contents of Hunter's canal? Contents Saphenous nerve Superficial femoral artery Superficial femoral vein (posterior to the artery in the upper part then posterolateral) Nerve to vastus medialis What is the surface marking of the adductor hiatus? The adductor hiatus lies ⅔ along the line between the ASIS and the adductor tubercle of the femur.

Question 44

Sartorius

Answer 44

= ASIS → medial tibia (pes anserinus), femoral nerve, “tailor’s muscle” → flexion, abduction, lateral rotation of hip + knee flexion.

Question 45

Condition in which saphenus nerve injury?

Answer 45

- great saphenus vein harvesting for CABG - faciotomy

Question 46

Vascular lacuna?

Answer 46

It’s the compartment beneath the inguinal ligament which allows for passage of the femoral artery and vein and femoral canal The muscular lacuna is the lateral compartment of the thigh inferior to the inguinal ligament, it is separated by the iliopectineal arch from the vascular lacuna Lacuna vasorum (vascular lacuna) is medially, while lacuna musculorum (muscular lacuna) is laterally and allows for passage of iliopasoas and femoral nerve

Question 47

Contents of vascular and muscular lacuna

Answer 47

Contents of lacuna vasorum? (order from medial part) • Deep inguinal lymph nodes • Femoral vein, • Femoral artery • Femoral branch of the genitofemoral nerve Contents of lacuna musculorum? • Femoral nerve • Iliopsoas • Lateral femoral cutaneous nerve

Question 48

Types of joints talocrural or ankle joint, subtalar or talocalcaneal joint, inferior tibiofibular joint

Answer 48

Synovial hinge joint Synovial plane joint Syndesmosis

Question 49

Midtarsal joint (of “Chopart”)?

Answer 49

The transverse tarsal joint or midtarsal joint or Chopart’s joint is formed by the • Articulation of the calcaneus with the cuboid (calcaneocuboid joint) (saddle) • Articulation of the talus with the navicular (talocalcaneonavicular joint) (ball & socket)

Question 50

Associated injury in syndesmotic fracture?

Answer 50

Fracture of lateral malleolus

Question 51

Lateral collateral ligament

Answer 51

Anterior talofibular Lateral malleolus Transversely to talus anteriorly Posterior talofibular Lateral malleolus Transversely to talus posteriorly Calcaneofibular Lateral malleolus Obliquely to calcaneus posteriorly