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Blood Vessels of LE
- Most of the arteries and veins travel together & take same path
Arteries:
- At L4 ascending aorta branches into right & left common iliac
- Femoral artery continues distally & then dives deep to sartorious & vastus
medialis
- Enters the adductor canal along side the femoral vein and saphenous nerve
- Femoral artery & vein then pass through the adductor hiatus
- Pass adductor hiatus emerge posteriorly in the popliteal fossa
- Once in fossa becomes femoral artery & vein become popliteal artery &
vein
Popliteal Artery (and vein)
- Gives off branches that anastomose around the knee to perfuse the knee:
the foot (wont know they nicked foot, decreased blood supply which
compromises healing, and bacteria feasts on blood sugar, making it more
difficult)
- Dives deep inferior to the sustentaculum tali (on calcaneous) & splits in the
foot:
- Medial plantar artery perfuse medial base of foot
Veins:
- Follow the same course as the arteries (except for two superficial veins)
- The dorsal venous network in foot will drain into the great & lesser
saphenous veins
Greater Saphenous Vein:
- Superficial drainage to the entire length of the lower extremity
- Drains directly into popliteal vein (then to femoral & external iliac)
Pubis:
-Symphyseal surface: has the pubic symphysis
-Medial condyle: longer than the lateral condyle of the femur (most
inferior)
-Medial epicondyle: superior to the medial condyle
-Lateral condyle: shorter than medial condyle (most inferior)
-Lateral epicondyle: superior to the lateral condyle
-Adductor tubercle: sits on top of medial epicondyle; adductor magnus
has fibers that attach to the adductor tubercle as well as linea aspera
-Popliteal surface: posterior surface (behind knee)
-Intercondylar notch/fossa: between the medial & lateral condyle;
anterior & posterior cruciate ligament here
Tibia:
- Medial (large bone of the leg)
-Tibial tuberosity: on superior & anterior aspect; common insertion
point for all four heads of quadriceps femoris
*Osgood Schlaters disease: skeletal system is growing too fast for the
muscles to keep up with increase force/tension placed on tibial
tuberosity & it becomes enlarged (Wolfs Law)
- Gerdys tubercle: lateral to tibial tuberosity, also called lateral
tubercle of tibia; insertion point for the ilio-tibial band (thickened
portion of the fascia latta)
(Origin point for the ilio-tiboal band is iliac tubercle)
-Pes anserinus: flattened area medial to tibial tuberosity aspect; (goose
foot) common insertion point for three muscles: Sartorius (most
anterior), gracillis (intermediately) & semitendinosous (most posterior)
remember: SGT*
-Medial malleolus: large projection of bone along the inferio-medial
aspect
-Fibular notch: fibula fits into the tibia here
Fibula:
- Lateral bone in leg
-Apex: most superior aspect of the fibula; pointed portion of the fibular
head
-Head, neck: narrow portion of the fibula, shaft
-Lateral malleolus: large projection of bone on the inferior aspect of the
fibula
*Equilateral triangle on the apex of fibula & right triangle on the
inferior aspect of the fibula; most distal point of the lateral malleolus is
more anterior & angulation will taper posteriorly
-Lateral articular facet for talus: articulate with superior aspect of talus
Talus:
Navicular:
- Navicular tubercle: on the apex of the medial longitudinal arch;
anterior to the talus, articulating with the head of the talus; insertion
point for calcaneo-navicular ligament/spring ligament
*Spring ligament maintains the medial longitudinal arch
*Flat foot: the spring ligament is elongated, & arch drops down (pes
planis)
Femoral Nerve
Emerges lateral to psoas major & travels to anterior thigh
Roots: L2, L3, L4
Dives deep to inguinal ligament alongside femoral artery & vein
Femoral nerve in entirety found superficial to the iliopsoas
muscle
This region where you find femoral nerve as a whole is femoral
triangle
Little branches innervate the muscles past Sartorius/femoral
triangle
Sartorius, quadriceps femoris, illiacus, & portion of pectineus
Innervates entire anterior thigh, all muscles except tensor fascia
lata
Remember:
Infrapiriform nerves:
- Sciatic Nerve, Posterior femoral cutaneous, Inferior Gluteal nerve,
Pudendal
Suprapiriform nerve:
- Superior gluteal nerve
3 compartments of thigh: anterior, medial, posterior (fascia closes off
these areas)
3 compartments of leg: posterior: anterior, lateral, posterior
Sural Nerve:
- Branches reconvene together, form sural nerve together
- Medial sural cutaneous nerve: comes off tibial nerve (medial aspect of
distal popliteal fossa)
- Lateral sural cutaneous nerve: comes off the common fibular nerve
(lateral aspect of distal popliteal fossa)
- Superficial & sensory, distal aspect of popliteal fossa
- Provides sensation to posterior aspect of leg
- Dives posterior to the lateral malleolus through the fibular tunnel
- Provides sensation to lateral foot
*Saphenous nerve provides medial innervation to foot
Tibial
-
nerve:
After popliteal fossa, to posterior compartment
Dives deep to gastrocnemius
Sits right on top of tibialis posterior along with posterior tibial
artery & vein
Innervates all muscles in posterior thigh
Travels posterior to medial malleolus through tarsal tunnel
(concavity in tarsal bones)
Tarsal tunnel syndrome: effects tibial nerve
Passes tarsal tunnel gives off calcaneous branches (numbness
on heel)
Passes sustentaculum tali splits forming lateral & medial
plantar nerves
Medial Plantar Nerve: medial plantar muscles & skin on plantar surface
Lateral Plantar Nerve: lateral plantar muscles & skin on plantar surface
Myotomes:
L2, L3 hip flexion
L3, L4 knee extension
L4, L5 ankle dorsiflexion or inversion
L5, S1 hip extension, knee flexion, or ankle eversion or
great toe extension
S1, S2 ankle plantar flexion
DTRs:
L2, L3, L4 knee jerk (quad tendon)
L5, S1 medial hamstring reflex
S1, S2 ankle jerk (achilles tendon/reflex)
- Nerve, artery & vein all emerge superior to piriformis (head to glut
med & min)
Inferior gluteal neurovascular bundle:
- Nerve, artery & vein all emerge inferior to piriformis (head to glut
max)
Sciatic nerve: splits (medial branch: tibial portion, lateral branch:
common fibular)
Posterior femoral cutaneous nerve: comes straight down & attaches to
skin
Pudendal neurovascular bundle
- Nerve artery & vein emerge inferior to piriformis & come back in
Medial thigh: think obturator nerve (found in b/w adductor longus &
brevis)
1. Gracilis:
- Most medial muscle, pubic symphysis pes anserinus
2. Adductor longus:
- Pubic tubercle linea aspera posteriorly. Action: hip adduction
3. Adductor brevis:
- Deep to longus, inferior pubic ramus pectineal line of femur
4. Adductor magnus
- Deep to adductor brevis, hip extension & adduction
- Knee flexion & IR of tibia, unlocks the knee (opposite of screw home
mechanism)
The Leg & Foot
The leg:
- The fascia of the leg is known as crural fascia (crural=leg)
- Fascia is dense (no give), invaginates into clearly defined
compartments
It separates the leg into compartments:
Anterior (deep fibular nerve & anterior tibial artery & vein)
Lateral (superficial fibular nerve, fibular artery & vein)
Superficial posterior
Deep Posterior
Compartment syndrome vs. shin splints:
- Shin splits: overuse injury, compartment overused begins to pull
periosteal irritation, force becomes so large you start to tare
away from the bone
- Compartment syndrome: pain in leg, depending on
compartment, fascia in leg is so dense & does not allow for
expansion, pressure increases in one of the compartments
(vascular component swelling)
- Acute compartment syndrome: trauma, swelling but do not tare
actually fascia, medical emergency because nerve & vasculature
compression (nerve: lose sensation & function distal to
compression) (vascular issue: avascular necrosis structures in
foot supplied by that vessel will die & need to be amputated)
- Chronic compartment syndrome: not a medical emergency,
increase in pressure in compartment due to activity (pumping
action of muscle), feel pain/weakness/numbness, as soon as they
stop pressure normalizes, can be controlled by stopping
activity
- To diagnosis compartment syndrome: probe in leg & run on
treadmill to track pressure
- Pes anserinus: antero-medial aspect of tibia, insertion point for
Sartorius, gracillis & semitendinous, pes anserinus bursa underneath.
Chronic overuse of tendons bursitis
- Gerdys tubercle: proximal lateral aspect of tibia, in between tibial
tuberosity & head of fibula, Insertion for IT band.
- Tibial tuberosity: patellar tendon attaches here (infrapatellar bursa
posteriorly & prepatellar bursa anteriorly & quadriceps tendon
superiorly, with suprapatellar bursa posteriorly to it (articularis genu
pulls on it)
3.
-
Dorsal Foot:
2 intrinsic muscles of the dorsal foot:
1. Extensor digitorum brevis
- Lateral aspect of calcaneous middle phalanges of
digits 2-5
2. Extensor hallucis brevis
- Lateral aspect of calcaneous proximal
phalange of 1st digit
*Both innervated by superficial & deep fibular nerve
- Dorsalis pedis artery: in between extensor hallucis longus tendon &
extensor digitorum longus tendon
- Superficial fibular nerve & Deep fibular nerve
- Sinus tarsi: concavity, ATFL ligament sits here, space in between
calcaneous & talus
Plantar Foot:
Plantar aponeurosis:
- Most superficial structure in plantar foot
- Medial calcaneal tubercle (majority) & lateral calcaneal tubercle
just distal to metatarsal heads at proximal phalanges
- Superficial transverse metatarsal ligament: holds plantar
aponeurosis down to metatarsal heads
- Extend toes stretch & pull foot
1st Layer
1. Abductor halluces
Most medially
Abduct great toe
Medial plantar nerve
2. Flexor digitorum brevis
In the middle
Flex digits
Inserts middle phalanges
Medial plantar nerve
3. Abductor digiti minimi
Most laterally
Abduct 5th digit
Lateral plantar nerve
2nd Layer
- 2 muscles attach to the tendons of flexor digitorum longus
1. Lumbricals (4)
- Tendons of FDL on medial side of each tendon proximal
phalanges
- Flexion at MTP
- Medial 3: medial plantar nerve, Last lumbrical: lateral plantar
nerve
2. Quadratus plantae
- calcaneous tendon of flexor digitorum longus
- Normalize line of pull of flexor digitorum longus (without it, toes
would flex medially)
- Lateral plantar nerve
3rd Layer
-
4th Layer
Dorsal interosseous (4)
- Abduction
- Lateral plantar nerve
Plantar interosseous (3)
- Adduction
- Lateral plantar nerve
Medial and lateral plantar nerve, artery, vein all found in plantar foot
Calcaneo-navicular ligament:
- Spring ligament
- sustecaculum tali navicular tubercle
Long plantar ligament:
- Calcaneous metatarsals
Short plantar ligament:
- Calcaneous cuboid
The Foot:
Medial longitudinal arch:
- Medial aspect of foot
- Sensation: saphenous nerve
- Navicular=apex
- Flexor hallicus longus runs along this arch
- Flexor digitorum longus & tibialis posterior sweep across
Lateral longitudinal arch:
- Not as distinct, lateral aspect of foot
Transverse arch:
- Arch along metatarsal heads