Bluebox Anatomy B1M2 and Anatomy of the Lower Limb

Femoral Fracture in the femoral neck/trancervical hurts which nerve

medial femoral circumflex nerve

Fracture in the intertrochanteric region of the femur injures which nerve?

Medial Femoral Circumflex nerve

Fracture in the shaft called a spiral fracture injures which nerve?

Deep femoral or profunda femoris

Fracture in the distal/ supracondylar region of femor injures which nerve

popliteal nerve

Clinical signs of femoral neck fracture

Usually in women over the age of 60, shortened, abducted, and laterally (externally) rotated leg, inability to bear weight, possible osteonecrosis due to damage of the medial circumflex femoral artery

Cruciate Anastomoses

alternative blood flow pathway when constriction of femoral artery;

Linkage of internal illiac artey to popliteal artery

Causes of posterior dislocation of the hip joint

severe impact trauma like car accidents; joint capsule tears in posteriorly and inferiorly, femoral head moves posterior to acetabulum

Presentation of posterior dislocation of the hip joint

flexed, medial rotation, and adduction

what is associated with posterior dislocation of the hip

fracture of the acetabulum, tear of the acetabulum labrum, injury to the sciatic nerve which causes paralysis of hamstrings and all muscles below the knee

Anterior dislocation of the hip

Captain Morgan’s sign”
(thigh is abducted, flexed, and externally rotated)
• Associated injury to femoral n. and a.

Trendelenburg test

Tests for superior gluteal nerve injuries

Has drop of opposite hip of injury when the person stands on one foot

Hamstring strains

Common in sports with sudden acceleration and deceleration; running and quick-start sports (TENNIS)

Hurdler’s injuries

Biceps femoris and Semitendinosus, avulsion of the ischial tuberosity

Function of ACL

Prevents hyperextension at knee
• Prevents posterior displacement of femur on tibia
• Limits posterior “rolling” of femoral condyles on tibial plateau during flexion

Function of PCL

• Prevents hyperflexion at knee
• Prevents anterior displacement of femur on tibia
• Limits anterior “rolling” of femoral condyles on tibial plateau during extension

Signs of ACL injury

– Hyperextension
– Tests= tibia will slide anteriorly under fixed femur
• Anterior drawer sign: 90° flexion, Less specific for ACL injury
• Lachman’s test: 20° flexion, Positive result if movement ≥ 5 mm
• Pivot shift test (rarely done)

Signs of PCL injury

– Falling onto tibial tuberosity with knee flexed OR hyperextension injuries (step into hole)
– Usually also tears TCL or FCL
– Posterior drawer sign

Extracapsular ligaments

FCL/LCL (fibular collateral ligament), Patellar ligament, TCL/MCL (Tibial Collateral ligament), Oblique popliteal ligament (strengthens posterior join capsule and expansion of semimembranosus), Arcuate popliteal ligament

Intra-articular ligaments

Menisci which are fibrocartilage pads attached to the proximal tibia and joint capsule

Function of menisci

• Act to deepen articular surface of tibia
• Act as shock absorbers

Medial Meniscus

C shaped, less mobile and firmly attached to MCL/TCL

Lateral Meniscus

Smaller and circular and more mobile

Transverse ligament

– connects the menisci to each other along anterior edges.
– It plays an important role in the stability of the menisci during movement.
• It has a restricting effect on the anterior-posterior excursion of the anterior horn of the medial meniscus at lower degrees of knee flexion.

Posterior meniscofemoral ligament

– Joins lateral meniscus to PCL and medial femoral condyle
– 50-70% of population have this vs.10-25% of population having the anterior version of this ligament
– Function is to stabilize the lateral meniscus (and the PCL), especially after injuries to the PCL

Knee joint “unhappy triad”

– ACL, MCL, medial meniscus

-most often caused by sports injuries like football

Knee replacement

Usually common in people with a diseased joint
(osteoarthritis)
•Components
•Metal on plastic
•Good results in “low-demand” individuals

Common Fibular Nerve

• L4-S2 posterior division of lumbosacral plexus

Divides into two branches the superficial fibular nerve and deep fibular nerve

injury to this nerve causes foot drop

Superficial Fibular nerve supplies

Lateral compartment of the leg muscles

Entrapment causes foot drop

Deep Fibular nerve

Anterior compartment of the leg

entrapment causes “ski boot syndrome”

If the Common Fibular nerve is injured

All muscles below the knee and

• Dorsiflexion and eversion of foot are absent
• No sensation on entire dorsum of foot or inferior lateral leg

Superficial Fibular Nerve injury

Fibularis longus and fibularis brevis loss of sensation

• Majority of eversion is lost
• Minor deficit in plantarflexion
• No sensation on majority of dorsum of foot or inferior lateral leg
• Retain sensation between 1st and 2nd toe

Deep Fibular nerve injury

• Dorsiflexion of foot is absent
• Minor deficit in eversion
• No sensation at 1st /2nd toe interdigital space on dorsum

Compartment Syndrome

• Fascial septa form boundaries
• Trauma produces hemorrhage, edema, and inflammation due to pressure buildup
• Can occur in limbs
– Usually middle segment

treatment: fasciotomy

Ruptured Calcaneal Tendon

Symptoms
• “Snap, Gap, Collapse”
– Treatment
• Surgical vs. Non-surgical
– Prognosis
• 4-6 months
• 3 months for elite athletes

Calcaneal Fracture

fall on the heel, comminuted number, disabling, and disrupts subtalar joint

Dancer’s fracture

pointe technique, loss of balance and full
body wt. on metatarsal (different types
of fractures associated with 5th metatarsal)

Fatigue Fractures

prolonged walking, repeated stress

Avulsion fractures of 5th metatarsal tuberosity

sudden and violent inversion, fibularis brevis tendon

Tarsal Tunnel syndrome

Compression of the tibial nerve deep to the flexor retinaculum

-Sharp pain radiating into the arch of the foot, heel, and sometimes the toes

-Pins and needles or numbness

-May occur due to repetitive eversion of the foot like during running which can also cause entrapment of the medial plantar nerve called “joggers foot”

Lateral Ligaments of the ankle

• Anterior talofibular, Posterior talofibular, Calcaneofibular
– Clinical correlations
• Ankle sprains

Medial ligaments of the ankle

Deltoid ligament
• Tibionavicular
• Tibiocalcaneal
• Anterior tibiotalar
• Posterior tibiotalar

Function of medial ligaments of the ankle

– Stabilizes during eversion and prevents subluxation

“Pott fracture”-Dislocation of Ankle

Due to forcible eversion of foot
- Avulsion of medial malleolus
- Avulsion of lateral malleolus
OR
- Fracture of fibula above inferior syndesmosis (due to lateral displacement of talus)
- Rupture of anterior tibiofibular lig.

Iliopsoas Innervation

Anterior Rami of lumbar nerves

Iliopsoas Action

Flexes the hip

Pectineus Action

• Adducts the hip

• Flexes the hip

  • Assists in medial and lateral rotation of the hip

Pectineus and Sartorius Innervation

Femoral Nerve

Sartorius Action

• Flexes the hip

• Abducts the hip

• Laterally rotates the hip

• flexes the knee

Tensor Fascia Lata Action

Abducts the hip

Medially rotates the hip

Tensor Fascia Lata Innervation

Superior Gluteal Nerve

Quadriceps Innervation

Femoral Nerve

Quadriceps Muscles

Rectus femoris, Vastus Lateralis, Vastus Medialis, Vastus intermedius

Rectus Femoris Action

Extends the leg

Flexes the thigh

Steadies the hip joint

Vastus lateralis, medialis, and intermedius action

Extends the leg

Adductor Longus and Adductor Brevis Action

Adducts the hip

Adductor Longus and Adductor Brevis Innervation

Obturator Nerve

Adductor Magnus Action

Adductor part: Adducts the hip and flexes the hip

Hamstring part: Extends the hip

Adductor magnus Innervation

Adductor part: Obturator Nerve

Hamstring part: Tibial Nerve

Gracilis action

Adducts the hip

Flexes the knee

Medially rotates at the knee

Gracilis and Obturator externus Innervation

Obturator nerve

Gluteus Maximus Innervation

Inferior gluteal nerve

Gluteus maximus Action

• Extends the hip

• laterally rotates the hip

• rising from sitting position

Gluteus Medius and Gluteus Minimus Action

• Abducts the hip

• Medially rotates the hip

Gluteus Medius and Gluteus Minimus Innervation

Superior Gluteal nerve

Piriformis, superior and inferior gemellus action

• Laterally rotates the extended hip

• abducts the flexed hip

Piriformis Innervation

Nerve to piriformis

Superior gemellus Innervation

Nerve to obturator internus

Inferior Gemellus Innervation

Nerve to Quadratus Femoris

Gastrocnemius, Plantaris, Soleus, and popliteus innervation

Tibial Nerve

Muscles of the superficial posterior compartment of the leg

Gastrocnemius, Plantaris, Soleus, and popliteus

Gastrocnemius Action

Plantarflexes the ankle (when knee is extended) and flexes the knee

Plantaris Action

Plantarflexes the ankle

Soleus action

Weakly plantarflexes the ankle

Popliteus Action

Weakly Flexes the knee, Unlocks the knee (rotates femur on fixed tibia)

Deep posterior compartment muscles of the leg

Tibialis posterior, Flexor Digitorum Longus, Flexor hallucis longus

Tibialis posterior, Flexor Digitorum Longus, Flexor hallucis longus innervation

Tibial Nerve

Tibialis Posterior action

Plantarflexes the ankle, inverts the foot

Flexor Digitorum Longus action

Flexes the 2nd-5th digits, plantar flexes the ankle

Flexor Hallucis Longus

Flexes the 1st digit, Weakly plantar flexes the ankle

Muscles of the lateral compartment of the Leg

fibularis longus, Fibularis Brevis, Fibularis tertius

Fibularis Longus and Fibularis Brevis innervation

Superficial Fibular nerve

Fibularis Tertius Innervation

Deep Fibular nerve

Fibularis Longus and fibularius brevis Action

Everts the foot, Weakly plantarflexes the ankle

Fibularis Tertius Action

Dorsiflexes the ankle, everts the foot

Muscles of the anterior compartment of the leg

Tibialis anterior, Extensor Hallucis Longus, Extensor Digitorum Longus

Innervation of Tibialis anterior, Extensor Hallucis Longus, Extensor Digitorum Longus

Deep Fibular Nerve

Tibialis Anterior Action

Dorsiflexes the ankle, inverts the foot

Extensor Hallucis Longus Action

Extends the big toe, Dorsiflexes the ankle

Extensor Digitorum Longus Action

Extends the 2-5 digits, dorsiflexes the ankle

Dorsal Muscles of the Foot

Extensor Hallucis Brevis, Extensor Digitorum Brevis

Innervation of the Extensor Hallucis Brevis, Extensor Digitorum Brevis

Deep Fibular Nerve

Extensor Hallucis Brevis Action

Extends the great toe at the metatarsophalangeal joint

Extensor Digitorum Brevis Action

Extends the metatarsophalangeal joints and interphalangeal joints of 2-4 digits

Plantar Muscles 1st Layer

Flexor digitorum brevis, abductor digiti minimi, abductor hallucis

Innervation of the Flexor Digitorum brevis and abductor hallucis

Medial Plantar nerve

Abductor Digiti minimi Innervation

Lateral Plantar nerve

Flexor Digitorum Brevis Action

Flexes the proximal interphalangeal joints of 2-5 digits

Abductor Digiti Minimi Action

Abducts the 5th digit, Flexes the 5th Digit

Abductor Hallucis Action

Abducts the 1st digit, Flexes the 1st digit

Plantar Muscles 2nd layer

Lumbricals, Quadratus Plantae