MUSCULOSKELETAL LOWER LIMB

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MUSCULOSKELETAL LOWER LIMB

Spinal Cord Lumbar and Sacral Regions Spinal cord Dorsal root ganglion Conus medullaris Cauda equina Dorsal root ganglion of the fifth lumbar nerve End of subarachnoid space Lumbo-sacral plexus Sciatic nerve

Lumbar plexus Psoas major muscle Lateral femoral cutaneous nerve The anterior rami of L2, L3 and L4 contribute to the obturator nerve and the posterior rami of L2, L3 and L4 contribute to the femoral nerve Figure 5.20

Nerve Artery Vein MRCS OSCE Course SCHEMATIC REPRESENTATION OF SURFACE MARKINGS Inguinal Region ASIS PT Location of an inguinal hernia PS ASIS anterior superior iliac spine PT pubic tubercle Location of a femoral hernia PS pubic symphysis The mid-inguinal point is MEDIAL to the mid-point of the inguinal ligament Figure 5.5

Femoral Triangle Boundaries and contents IVC Aorta Psoas major Femoral nerve Iliacus Ilio psoas Inguinal ligament Great saphenous vein Femoral artery Femoral vein Pectineus Adductor longus Femoral sheath Sartorius

INTRODUCTION Femoral Triangle The femoral triangle is a wedge shaped depression formed in the upper thigh. ESSENTIAL ANATOMY Boundaries: Roof: Fascia lata Apex: Points inferiorly and continues with the adductor canal Superior: The inguinal ligament Medial: Medial border of adductor longus Lateral: Medial border of sartorius Floor (medial to lateral): Adductor longus, pectineus and iliopsoas Contents: (From medial to lateral VAN) Femoral vein Femoral artery Femoral nerve (The femoral artery can be palpated in the femoral triangle inferior to the inguinal ligament and midpoint between the ASIS and pubic symphysis). (Inguinal ligament extends from the ASIS to pubic tubercle)

Veins of the Lower Limb Great Saphenous Vein Common iliac vein Internal iliac vein External iliac vein Saphenous opening Femoral vein Popliteal vein Anterior and posterior tibial veins Small saphenous vein Great saphenous vein Superficial veins Dorsal venous arch

INTRODUCTION Knee Joint The Knee Joint is the largest synovial joint in the body. ESSENTIAL ANATOMY Ligaments 1. Collateral ligaments Fibular (lateral) collateral ligament: 2. Cruciate ligaments Anterior cruciate ligament: Posterior cruciate ligament: Tibial (medial) collateral ligament:

INTRODUCTION Knee Joint The patellar Ligament is the continuation of quadriceps femoris tendon inferior to the patella. ESSENTIAL ANATOMY 3. Menisci Medial and lateral menisci are C- shaped fibrocartilages Medial meniscus is larger than the lateral meniscus Medial meniscus is attached to the medial collateral ligament and joint capsule, and therefore less mobile Lateral meniscus is not attached to the lateral collateral ligament and thus more mobile Popliteus tendon runs between the joint capsule and the lateral meniscus Attachments: Superior: Apex of the patella Inferior: Tibial tuberosity 4. Patellar ligament Patellar ligament extends the knee joint The knee jerk is elicited on the patellar tendon (L3, 4)

Blood supply to the Knee Joint Anastomoses of Arteries Femoral artery Descending branch of lateral circumflex femoral artery Superior medial genicular artery Lateral superior genicular artery Lateral inferior genicular artery Inferior medial genicular artery Circumflex fibular artery Recurrent branch of anterior tibial artery

Popliteal Fossa Contents and boundaries Femoral artery Femoral vein Sciatic nerve Semimembranosus Semitendinousus Biceps femoris Adductor hiatus Tibial nerve Popliteal vein Popliteal artery Common fibular nerve Lateral head of gastrocnemius Medial head of gastrocnemius

INTRODUCTION Popliteal Fossa The popliteal fossa is a diamond shaped space located behind the knee joint. It is formed by the muscles in the posterior compartment of the thigh and the leg. ESSENTIAL ANATOMY Boundaries: Supero-medial: Semitendinosus and semimembranosus Supero-lateral: Biceps femoris Infero-medial: The medial head of the gastronemius Infero-lateral: The lateral head of the gastronemius Roof: Deep fascia Floor: Capsule of the knee joint and the popliteus muscle. Contents: The Popliteal Fossa contains: Popliteal artery Popliteal vein Tibial nerve Common fibular (peroneal) nerve Lymph nodes The roof contains: Small saphenous vein Posterior cutaneous nerve of thigh

Popliteal Artery Branches Lateral superior genicular artery Medial superior genicular artery Sural artery Medial inferior genicular artery Lateral inferior genicular artery Anterior tibial artery Peroneal (Fibular) artery Posterior tibial artery

Ankle Joint (Medial view) Tendons Tendon of flexor digitorum longus Tendon of tibialis posterior Posterior tibial artery Tibial nerve Tendon of flexor hallucis longus

Ankle Joint Extensor Retinaculum Tendon of extensor hallucis longus Superior extensor retinaculum Anterior tibial artery Tendon of tibialis anterior Inferior extensor retinaculum Tendon of peroneus tertius Dorsalis pedis artery Tendons of extensor digitorum longus First dorsal interosseous muscle

INTRODUCTION Ankle Joint The ankle Joint is a synovial joint. It is made up of three bones: the lower end of the tibia, the fibula and the talus. ESSENTIAL ANATOMY Tendons crossing the ankle joint (Anteriorly): From medial to lateral: (Tall Husbands Are Never Dear Persons) Tibialis Anterior Extensor Hallucis Longus tendon Anterior tibial artery Superficial peroneal Nerve Extensor Digitorum Longus Peroneus Tertius Tendons crossing the ankle joint (Medially): From anterior to posterior: (Tom, Dick, And a Very Naughty Harry) Tendon of Tibialis Posterior Tendon of Flexor Digitorum Longus Posterior Tibial Artery Vena commitantes Tibial nerve Tendon of Flexor Hallucis Longus

Tibial Nerve Course and Relations Gluteus medius Gluteus maximus Gluteus minimus Piriformis Sciatic nerve Iliotibial tract Biceps femoris Semitendinosus Semimembranosus Common peroneal / common fibular nerve Popliteus Flexor hallucis longus Sural nerve Tibial nerve Posterior tibial artery Flexor digitorum longus

Common Peroneal / Common Fibular Nerve Course and Relations Tibial tuberosity Neck of fibula Deep fibular (peroneal) nerve Superficial fibular (peroneal) nerve Tendon of fibularis (peroneus) longus Tendon of fibularis (peroneus) brevis

Dermatomes of Lower Limb SURFACE ANATOMY Dermatomes are areas of skin that are supplied by a single posterior spinal nerve root. There are eight cervical, twelve thoracic, five lumbar and five sacral nerves. Dermatomes are useful in neurological examination for finding the site of damage to the spine. L1- Below the inguinal ligament L2- Mid thigh L3- Around the knee L4- Medial side of the leg L5- Lateral aspect of the leg, medial side of the dorsum of the foot S1- Lateral aspect of the foot, the heel and most of the sole S2 - Posterior aspect of the thigh S3, S4, S5 concentric rings around the anus, the outermost of which is S3 Mnemonic: stand on S1, sleep on S2, sit on S3

Dermatomes Lower Limb S4 S3 L2 L3 L1 L2 L3 S2 L4 L5 L4 L5 Posterior view S1 L5 L4 S1 Anterior view

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