Lower Extremity Forum 2011

Psoas major, iliacus, pectineus muscles Femoral artery, vein, nerve Describe the content of the subinguinal hiatus (space between the inguinal ligament and the pelvic rim) Psoas major, iliacus, pectineus muscles Femoral artery, vein, nerve Femoral nerve not included in the femoral sheath Parent branch of artery is external iliac artery Lymphatics Lateral cutaneous nerve of thigh (lateral femoral nerve of thigh) Located near the ASIS

Describe the borders and content of the femoral triangle Base = inguinal ligament Medial border is adductor longus Lateral border is the medial part of the sartorius muscle Floor is the pectineus, adductor longus And some of the iliopsoas Fascia latae forms the roof of the triangle Continues with fascial canal all the way to the adductor canal Contains the femoral artery, nerve, vein, and lymphatics

Describe the walls and content of the adductor canal Forms the apex of the femoral triangle Covered by fascia, roof is sartorius vasculoductor membrane Comprised of fascia Contains femoral artery, femoral vein, saphenous nerve for some of time (from femoral), genicular artery Descends medially down the thigh and shoots out posteriorly thorough the adductor canal Goes through the adductor magnus muscle Opens into the popliteal fossa; now popliteal artery/vein

Describe the adductor hiatus Opening at the end of the adductor canal Deposits the femoral artery and vein into the posterior portion of the leg via the opening at the distal portion of the adductor magnus Will now become the popliteal artery/vein

Describe the borders and contents of the popliteal fossa Superior Medial Border is the semitendonosus Superior Lateral Border is biceps emoris Inferior Medial Border is the medial head of the gastrocnemius Inferior Lateral Border is the lateral head of the gastrocnemius Plantaris muscle included on inferior lateral border Popliteal artery, vein, and Tibial nerve (AVN- aviation up) Common fibular included? NOT QUITE

Buildup of synovial fluid behind the knee Describe the pathogenesis of the Baker’s cyst and the prepatellar bursitis Buildup of synovial fluid behind the knee Caused by knee arthritis, meniscus injury, herniation or tear of the joint capsule In popliteal fossa; hurts more during extension Impairs flexion and extension at the knee joint Inflammation and swelling of the prepatellar bursa (lies right on top of patella) Housemaid’s knee; inability to flex the knee Repetitive kneeling will cause this

Describe the pathogenesis of the foot drop Results from a non-functional tibialis anterior Common fibular nerve injury Passes behind the head of the fibula From head or neck fracture of the fibula Loss of dorsiflexion loss of sensation on the dorsum of the foot and lateral aspect of the leg paralysis of all muscles in the anterior and lateral compartments

Describe the unhappy triad and the Pott fracture MCL (tibio-collateral ligament), ACL, and medial meniscus have been torn Usually results from impact to lateral portion of leg Fracture of distal fibula Often goes with a fracture of the medial malleolus or rupture of the deltoid ligament Avulsion fracture is when medial malleolus comes off with it Torn anterior tibiofibular Comes from forced eversion of foot

Describe the cutaneous innervation of the lower limb L2-L3 is from ass to knee, with L2-L4 coming from the obturator on the inner thigh Page 346-347

Describe the borders of the femoral canal and the symptoms of the femoral hernia Femoral canal borders: Do not need to know for exam Femoral hernias more common in women because they have a larger superior pubic ramus Portion of abdominal cavity protrudes into femoral canal (usually portion of the small intestine) Can be strangulated Poor blood supply occurs with death of nearby tissues resulting (pinching femoral vein, artery perhaps)

Describe the pes anserinus Results from combinations of tendons of gracilis, sartorius, and semitendonosus Found out at the medial border of the tuberosity of the tibia Can be used to help repair a torn ACL SGT FOS Sart, grac, semitendinosus/femoral, obturator, sciatic

Describe the course of the saphenus nerve and the descending genicular artery Great saphenous nerve branches off from the femoral nerve and goes with it through the adductor canal DOES NOT go through the adductor hiatus Breaks medially to innervate medial side of leg Breaks through fascia between sartorius and gracilis Will supply skin on medial leg, knee, and foot Des. Genicular Artery arises from femoral artery in adductor canal just before it passes adductor hiatus anastomose around the knee joint with other genicular arteries (these come form the popliteal artery) Also gives rise to a saphenous branch Only genicular a. that comes off the femoral

Describe the venous circulation of the lower limb Great saphenous drains the medial leg and thigh anteriorly Wraps posteriorly around knee very briefly, then comes back to the anteriomedial leg Pierces the femoral canal fascia to enter the canal near the groin Small saphenous vein drains the posterior medial leg and then enters into popliteal fossa Now named popliteal vein; goes through adductor hiatus and becomes femoral vein Dorsal venous arch of foot gets the top of foot

Describe the anatomy of the lesser and greater sciatic foramina Split in two by the Piriformis muscle The main point of reference for gluteal region Goes through the hole made by the ilium, sacrum, and sacrotuberous and sacrospinous ligaments Part goes over the piriformis, another goes under piriformis OVER= superior gluteal artery, nerve, vein UNDER= sciatic nerve, inferior gluteal artery, vein, nerve, posterior femoral cutaneous nerve, nerve to obturator internus and gemellus superior, nerve to quadratus femoris/gemellus inferior Lesser sciatic foramen goes under the ilium Obturator internus muscle tendon, and pudendal artery and nerve also pass through this

Describe the ligaments supporting the plantar arch Medial and lateral plantar arches at deep level Fall of medial arch results in flat foot Spring ligament involved Tibialis anterior and posterior/fibularis longus support the arch on the lateral and medial sides Ligaments are the static support Muscles are the dynamic support

Describe the arterial supply of the femoral head and the possible fracture sites The lateral circumflex femoral artery and the medial circumflex femoral artery (goes posterior) Some blood from superior and inferior gluteal aa. Artery of obturator internus also supplies some blood Medial circumflex femoral artery supplies more; main supplier to head and neck of femur If broken, femur dies Possible fracture sites are the femoral neck, intertrochanteric fossa, femoral shaft If neck not injured, blood supply could be safe