Plate 544-Nerves and Veins of the Thigh and Leg

Plate 164-Dermatomes

·  Inguinal ligament is in L1

·  Patella is L5

Plate 544-nerves and veins of the thigh and leg

·  Great Saphenous vein runs on the medial thigh ascending toward the inguinal region.

o  Origin in the foot (therefore also called the long saphenous vein)

·  Bridge communication back and forth between the deep and superficial veins. Flow is usually from superficial to deep.

o  Valvular incompetence in the deep veins causes varicose veins

·  All these veins have valves.

·  There is hole in the fascia lata at the inguinal ligament called the saphenous opening. Through this flows the great saphenous, the superficial epigastric, the superficial circumflex, the external pudendal vessels

·  Cutaneous nerves—Most of the visible nerves over the fascia lata are terminal branches of the femoral nerve

o  The only one not a branch of the femoral is the lateral cutaneous nerve of the thigh.

Plate 546-Lymphatic

·  Lymphatics generally drain into the superficial inguinal lymph nodes.

o  Vertical follow saphenous

o  Transverse follow inguinal ligament

·  Perineum (except testicle), anterior abdominal wall below the umbilicus, the superficial areas of the lower limb including the buttocks all drain into the superficial inguinal nodes (HUGE drainage field

·  Deep inguinal nodes are deep to the fascia lata. The deep nodes collect from the superficial nodes through the saphenous opening.

Plate 492-Musculature

·  There is an Intramuscular septum between the compartments, but its subtle

·  Sartorius m—ASIS then crosses and attaches medially to the tibia

o  Flexion at the hip joint, flexion at the knee joint. Also is a lateral (External) rotator of the hip joint. Allow to touch heel to the opposite knee (allows for sitting Indian style)

·  Tensor fascia lata sits laterally. Lies antior to the plane of the hip joint. It puts tension on the fascia lata. Maintains extension of the knee after the quads have straightened the knee joint.

·  Deep to Sartorious are the quads

o  Rectus femorus m. Ilium (Anterior Interior Iliac Spine) then attaches to the tibial tuberosity (the patella is in this tendon). The only muscle in the quadriceps that cross the hip joint.

o  Vastus lateralis, vastus medialis, vastus intermedius

§  Intermedius is deep the rectus femorus. They unite (along with rectus femoris) and form a common tendon at the knee joint called the tendon of the quadriceps femoris. The patella is a sesamoid bone in the tendon of the quadriceps femoris. From the patella on it is called the patellar ligament (bone to bone is ligament)

·  Sartorious and quadriceps femoris are all innervated by the femoral nerve

Plate 492-Medial compartment—All adduct the thigh ( lateral to medial)

·  Iliopsoas—Combaination of the iliacus and the psoas which then unite and pass deep the inguinal ligament and attach to the lesser trochanter (the only one). It is the most powerful hip flexor.

o  Sit ups with bent knee causes active insufficiency of the iliopsoas.

·  Pectineus—medial and deep to the iliopsoas. Pretty much in same plane as adductor longus and gracilis

·  Adductor longus

·  Gracilis—Great for muscle transplant. A most common is for making an external anal sphincter. The only muscle in the adductor compartment that cross the knee.

·  All innervated by the obturator nerve. EXCEPT pectineus m. Pectineus m is innervated by the femoral nerve always (some will say dual innervation with femoral and obturator)

·  The muscles go from pubis to femur (therefore adduction)

·  Deep to pectineus is the obturator externus takes origin from external aspect of the obturator foramen and attaches to the greater trochanter.

·  If you cut adductor longus out of the way, you can see adductor brevis. Deep to those are the adductor magnus. Adductor magnus runs the entire shaft of the femur for insertion.

·  SIX EXTERNAL ROTATORS-The gemellus inferior and superior, the obturator internus externus, piriformis, quadratus femoris. Sartorious can but is not included in the group of 6 small muscles in the deep gluteal region

Plate 493

·  Adductor magnus m.

o  Most of the fibers attach to the linea aspera and the medial supracondylar ridge. There are small apertures that perforate adductor mangus that allow for passage of the Perforating arteries and are the blood supply for the hamstring.

o  There is a fairly large gap in the tendon of the adductor magnus m called the adductor hiatus. The femoral artery and vein will cross through this hiatus and emerge as the popiteal vessels on the posterior of the thigh and leg.

o  Dual nerve supply-obuturator and tibial nerve.

§  Part of the adductor magnus can sometimes be considered part of the hamstrings.

Plate 500

·  Femoral triangle

o  Adductor longus forms medial border

o  Sartorius forms lateral border

o  Inguinal ligament forms superior border

·  Neurovascular bundle is quite superficial-great pressure point for hemorrhage

o  Most lateral is the femoral nerve and most medial is femoral vein.

o  Femoral Nerve breaks apart in the femoral triangle and follow as nerves named by their target

·  If you remove Sartorius m, there are two nerves that follow with the femoral artery and vein

o  Nerve to vastus medials

o  Saphenous nerve—becomes cutaneous beyond the knee joint and supplies the skin along the course of the great saphenous vein.

o  These nerves and vessels follow in a canal called the sub Sartorius canal (Hunter’s Canal, Adductor Canal)

§  Contains for things, Femoral A and V, N to Vastus Medialis, Saphenous N.

o  Branching posteriorly from the femoral is the profunda femoris (deep femoral) artery.

§  The femoral vessels are invested in the femoral sheath for a short period of time, which is a continuation of the transversalis fascia (endopelvic fascia)

ú  The femoral nerve is NOT within the femoral sheath.

ú  Along the medial aspect of the femoral vein is a potential space called the femoral canal. It is the site of femoral herniation.

ú  Cloquet’s Lymph node is the only lymph node in the femoral sheath.

Plate 501-

·  Adductor muscles have a nice supply of blood

o  Profunda femoris

o  Obturator

Plate 504-Profunda femoris

·  Gives off medial and lateral circumflex femoral arteries.

o  They go around the hip joint.

§  Lateral is almost always the larger. It is the major artery for the quadriceps (especially the descending branch)

§  The femoral artery does not supply any blood, its just a conduit for blood to pass. The PROFUNDA FEMORIS supplies the major component of medial and anterior compartment

Nerve supply

·  Anterior—Femoral nerve only

·  Medial-Obturator with exception of the pectineus (femoral Nerve)

·  Posterior-Tibial with exception of the short head of the biceps femoris (common fibular)

Plate 495

·  Medial and Lateral Gastrocnemius muscle and the biceps femoris and semitendonous/membranous create a diamond called the popliteal region.

o  The popliteal region /fossa are the popliteal a and v, the sciatic nerve (which splits to form the tibial and common fibular nn.)

·  Genicular arteries are branches of the popliteal artery that supply the knee. Are very important for collateral circulation

Plate 513

·  The fibular component of the ankle joint is the lateral malleolus.

·  The tibial has a medial projection at the ankle joint is the medial malleolus

·  Posterior aspect of the tibia called the soleal line

Plate 514

·  There is an interosseus membrane between the tibia and fibula. There are intervals at the proximal and distal points of the bones.

Plate 522

·  No longer fascia lata…its called the crural fascia

·  The majority of the shaft of the tibia is subcutaneous.

·  Anterior compartment of the leg

·  Lateral compartment of the leg

·  Posterior compartment of the leg

o  Superficial and Deep

Plate 516

·  Short saphenous vein lies in the subcutaneous tissue and ends in the popliteal vein in the popliteal fossa

o  Sural nerve (from tibial and common fibular nn) is the companion nerve with the short saphenous

·  Upper half of the gastrocnemius is fleshy. Originates from just above the knee joint on the femurThe distal half is tendonus and attaches on the calcaneus. Action is plantar flexion

·  Movements of the foot

o  Plantar flexion-point toes

o  Dorsi flexion-toes to your nose

o  Inversion-sole of foot medial

o  Eversion-sole of foot lateral

·  Just deep to gastrocnemius is the soleus taking origin from the soleal line. The tendon will unite with the tendon of gastrocnemius to form a very strong tendon called the achilles tendon.

·  There is another muscle in the superficial posterior compartment called the planteris muscle. It attaches to the femur just above the knee joint and turns tendonous almost immediately after crossing the knee joint. The tendon never unites with the Achilles tendon and attaches to the calcaneus.

o  Great source for tendon graft.

o  Rupture will cause same symptoms as Achilles tendon rupture except the calves will look the same.

Plate 518—Remove Soleus and Gastrocnemius

·  Coming into the deep compartment is the tibial nerve. It passes deep to the origin of the soleus

·  4 muscles in the deep compartment

o  Three are parallel (extrinsic Foot Muscles)

§  Most lateral is the Flexor Hallicus Longus m and extends it tendon to the distal phalanx of the big toe. Tendon Crosses the ancle on the medial aspect of the calcaneus. Attaches to the fibula.

§  Most Medial is Flexor Digitorum Longus. Tendon crosses posterior to the medial malleolus and attach to the distal phalanges of the lateral toes. Proximal attachment is from the tibia.

§  Between Flexor Hallicus and Flexor Digitorum is Tibialis Posterior m. Crosses the ankle joint posterior to the medial malleolus. Mostly the IO membrane

o  One is the popliteal muscle and is the floor of the popliteal fossa. It is short and oblique. It inserts superior the solear line. There is a small amount of rotation of the knee joint when the knee is locked. Popliteal m unlocks the knee for rotation.

§  When the limb is bearing weight, the popliteal m move the femur a few degrees.

§  Blood supply from popliteal a.

·  ALL Muscles in the posterior Compartment (both superficial and Deep) are innervated by the Tibial nerve.

·  They are all Plantar Flexors

·  Deep compartment are also inverters.

·  Flexor digitorum longus and Flexor hallucis longus also act on the digits.

Plate I don’t have—Arteries (I guess you can use Plate 518)

·  Genicular Arteries provide collateral circulation around the knee joint.

·  When the popliteal a reaches the lower border of the popliteal m., it splits into the anterior and posterior tibial aa.

o  Posterior stays posterior and supplies the mm of the posterior compartment

o  Anterior leaves the posterior compartment through the proximal gap in the IO membrane and enters the anterior compartment.

·  Posterior Tibial a will commonly give of a branch laterally called the fibular branch. It will commonly run within the flexor hallucis longus. It supplies the lateral compartment and flexor hallucis longus.

·  Posterior tibial a is a major a for the foot. It passes posterior to the medial malleolus

·  For some reason, the posterior tibial a is prone to sclerotic disease. Intermittent claudication (pain) due to vascular insufficiency.

Order things pass posterior to the medial malleolus (medialàlateral)

TOM-Tibialis

DICK-digitorum

AND-Artery

HARRY-Hallucis

Plate 519-Anterior Compartment—Dorsi Flexion

·  Tibialis Anterior-Tibiaàattaches to the metatarsal of the big toe and a tarsal bone. Its primary focus is on the ankle joint. Will also Invert

·  Extensor Hallucis Longus—IO membraneàBig Toe

·  Extensor Digitorum Longus—Fibulaàlateral toes

Plate 520-Anterior Compartment-Extensor digitorum/ hallicus

·  Right on the neck of the fibula is the common fibular nerve. It will divide right there into the superficial and deep fibular nerves. Deep fibular nerve is for the anterior compartment. Superficial nerve is for the medial compartment

·  The anterior tibial nerve will join up and run with the deep fibular nerve.

o  Both pass the ankle joint and work on dorsum of the foot.

·  If there is edema in the anterior compartment

o  Tearing of the muscles from the bone in the anterior compartment is called Shin Splints

o  Tibial compartment syndrome is when the muscles are too tightly packed. It will compress the vessels and lead to necrosis due to lack of proper blood supply. The pain is due to lack of blood to the nerves.

Plate 521-Lateral compartment

·  Fibularis Longus—attaches to the first metatarsal (crosses the plantar foot all the way. For this reason..def an important muscle for eversion.

·  Fibularis Brevis (deep to fibularis longus)—attaches to the fifth metatarsal

·  Both Cross the ankle joint posterior to the lateral malleolus

·  Both Take origin from the fibula

·  Both are plantar flexors

·  Nerve supply to the lateral compartment-Superficial fibular nerve

·  Blood supply from unnamed arteries from the fibular artery. Fibular artery never enters the lateral compartment, it just gives off branches.

Damage to the common fibular nerve by trauma to the neck of the fibula will cause foot drop (plantar flexion). Diagnositc for common fibular nerve damate. They would also have weakened eversion. Common Fibular nerve only innervates ONE muscle—The shorthead of the biceps femoris.

Plate 542

The dorsum of the foot is the top of the foot.

The bottom of the foot is the sole of the foot.

Plate 523-Bones of the Dorsum of the foot

·  Tarsal Bones

o  Calcaneus

o  Talus—bone that participates in the ankle joint. The malleoli drape over the sides of the talus.

o  Navicular—looks like a boat

o  Cuboid-lateral to the navicular

o  Cuneiform bones

§  Lateral, Intermediate, medial

·  Metatarsal

·  Phalanges

Plate 542

·  Superficial fibular nerve becomes a sensory nerve and supplies most of the sensory information on the dorsum of the foot.

·  Deep fibular nerve crosses the ankle joint and become sensory of the adjacent sides of the first and second toe (the wedge between the big and pointer toe.

Plate 530

·  There are retinaculae that bind the tendons to the joint. There are superior and inferior extensor retenaculum