Term
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Definition
flexion, extension, and rotation Compromise between weight transfer and mobility
[image]
rim of fibrocartilage called acetabular labrum deepens the acetabulum. ball and socket = wide range of movements but bc of the shape less than the shallow shoulder joing |
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Term
| ligaments reinforcing the hip joint |
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Definition
[image]
-surround the joint and strengthn it forming the fibrous capsule of the joint |
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Term
| ligaments and anatomy of the knee |
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Definition
[image]
-classic hinge joint that allows a small amnt of rotation
-can flex and extend and do a small amount of rotation
-strengthened by acl, pcl, fibular lateral collateral ligament and medial collateral ligament
-femoral condyles sit on the tibia (libial plateau)
-fibula not involved directly in articulation but is involved in stabilizing the knee w the fibular collateral ligament |
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Term
| function of menisci, and patella |
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Definition
deepen and stabilize the joint
-crescent-shaped fibrocartilages that deepen the socket
-provide cushioning to the joint
-patella is also involved w the joint, it's where the quadriceps muscle crosses the knee to attach |
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Term
| cruciate ligaments and attachements |
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Definition
[image]
-anterior cruciate attaches to the anterior part of the tibial plateau
-posterior cruciate attaches more posteriorly |
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Term
| Medial meniscus is attached to |
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Definition
the joint capsule (medial collateral)
[image]
-patellar tendon |
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Term
| How You Test the Cruciates |
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Definition
[image]
-pull forward on the tibia to test the ACL, push backwards on the tibia to test the PCL
-normally presence of an injured ACL is suspected on physical exam and confirmed in MRI |
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Term
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Definition
is also a hinge joint. The tibiotalar joint bears the weight. The fibulotalar joint stabilizes
[image]
-distal end of the tibia sits on the talus
-allows flexion and extension
-most movmnt occurs at tibiotalar joint
-the medial and lateral malleolus constrict the movement |
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Term
| Inversion and eversion occur at the |
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Definition
subtalar joint
[image]
-inversion and eversion
-calcaneus, calcaneal tendon, the force on the calcaneous causes movement at the tibiotalar joint |
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Term
| T/F The cruciate ligaments are named for their tibial attachments. |
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Definition
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Term
| T/F The cruciate ligaments are tested by placing lateral and medial stress on the knee. |
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Definition
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Term
| T/F Ankle dorsiflexion and plantarflexion and foot inversion and eversion take place at the tibiotalar joint. |
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Definition
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Term
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Definition
anterior cruciate lig- C
Lateral meniscus- E
Tibial plateau- B
Medical meniscus- A
Posterior cruciate lig- D |
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Term
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Definition
Anterior cruciate ligament- D
Medial collateral ligament- B
Medical meniscus- A
Lateral meniscus- E
Posterior cruciate ligament- C |
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Term
| superficial veins of the foot and ankle |
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Definition
[image]
To begin with, there are a series of superficial veins that begin on the dorsum of the foot, and these veins on the great toe side of the foot, we see the great saphenous vein, and on the lateral side of the foot, we see the small saphenous veins.
These are cutaneous veins which begin on the dorsum of the foot, and travel superficially here. |
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Term
| venous pathways of the lower limb |
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Definition
Limb has two venous pathways
Deep drainage with the arteries
A subcutaneous system without accompanying arteries (saphenous system)
[image]
We show the superficial vein draining here superficially all the way up to the groin, and it's this saphenous which is harvested for coronary bypass surgery.
There is also a deep venous drainage system, which runs within the muscular compartments, and they drain finally, eventually, into the iliac system.
So it's these deep veins, in this case the femoral vein, which is the veins, which are the large veins responsible for DVTs, deep vein thrombosis, and these large veins travel with the arteries. So the femoral artery and femoral vein travel together. The saphenous system is a cutaneous system, and these are veins, which are unaccompanied by arteries. |
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Term
| external iliac in the hip |
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Definition
External iliac becomes the femoral as it crosses the inguinal ligament
[image]
So if we take the arterial circulation here, this is one of the many places in the body where structures will change their name depending on where they are. So we see the aorta dividing into right and left common iliacs. And then shortly after the common iliac, we divide into internal iliac, which supplies the pelvis and the gluteal region, and the external iliac, which is destined for the lower limb.
And as the external iliac crosses the inguinal ligament, it becomes the femoral artery. So it's the same vessel, just simply changed its name because of its location. |
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Term
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Definition
Femoral artery runs deep to the sartorius
The femoral artery has a deep femoral branch that supplies most of the thigh
[image]
And the femoral artery then runs down the thigh here. We've removed one of the muscles, the sartorius to show its course along the thigh. We'll return to this area right here called the femoral triangle, just as it passes underneath the inguinal ligament is a pulse point. So we'll return to that briefly.
So then the artery runs from lateral to medial in the anterior thigh supplying the anterior thigh, and then giving off a branch, the deep femoral artery, which supplies most of the rest of the thigh |
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Term
| femoral artery anterior view |
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Definition
Femoral passes through the adductor hiatus to go posterior to the knee
Becomes the popliteal artery
Popliteal divides into
anterior and posterior tibial vessels
[image]
Then as it approaches the knee, the femoral artery passes behind the knee through a gap in the adductor magnus tendon, a gap called adductor hiatus. And from there it passes posterior to the knee, and now becomes the popliteal artery.
So it's gone from an anterior position, it's coursed behind the knee to become the popliteal artery. And what this artist has drawn here, he's drawn an extensive set of anastomosis around the knee, and this is done to emphasize the fact that wherever we have a joint, we have multiple ways around the joint should a vessel be temporarily constricted by movement.
So we can see blood can bypass the proximal part of the popliteal artery by simply following one of these anastomosis. And in fact, in an otherwise healthy person, it's possible to ligate the popliteal artery here, and preserve blood flow to the limb through these collateral pathways. So surgeons for centuries have taken advantage of this.
So then, posterior to the knee, the popliteal artery divides into anterior and posterior tibial arteries. The posterior tibial artery continues down in the posterior compartment of the leg, and the anterior tibial, as its name implies, pops back through the leg to supply the anterior leg as it descends. |
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Term
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Definition
Posterior tibial artery supplies the posterior and lateral compartments of the leg and the sole of the foot.
[image]
So the posterior tibial artery then supplies the posterior and lateral compartments of the leg and the sole of the foot. So this is a posterior view. So the calf muscles have been removed here to show the tibial artery descending. And then it goes posterior here the medial malleolus to supply the sole of the foot. So as such, this location right here is going to be important to us, because it's one of the pulse points. |
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Term
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Definition
Anterior tibial supplies the anterior compartment and the dorsum of the foot
[image]
The anterior tibial artery continues down, supplies the anterior compartment, and then becomes accessible to us again on the dorsum of the foot as the dorsalas pedis, or in anglicized as dorsal artery of the foot, and this is another pulse point, which is going to become important to us. So as we review the pulse points here, an important area here is the femoral triangle. |
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Term
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Definition
[image]
So the femoral triangle is here. It's the inguinal ligament. We recall this is where the external iliac becomes the femoral artery. So we can feel a pulse here, and there is a bit of important anatomy here, because right adjacent to the femoral artery, we have the femoral vein. And just lateral to it, we have the femoral nerve.
So there's often a mnemonic, NAVAL, nerve, artery, vein, and lymphatic, there's a little lymph node there. And this location is one in which the central access for both arterial procedures and venous procedures can be initiated. So angiograms are most often done by placing a catheter in the femoral artery, and right heart can be accessed through the femoral vein here. |
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Term
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Definition
[image]
So besides being a pulse point, this is an important region for the central access to the vascular system. Here, posterior to the knee, we see the popliteal artery and vein. And we can feel a pulse here, although it requires considerable pressure to feel a pulse, because the artery is quite deep. |
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Term
| posterior tibial pulse point |
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Definition
[image]
And then, at the ankle here, this is the medial malleolus, and this region here is called the tarsal tunnel. And right through the tarsal tunnel, we can see the posterior tibial artery. So this is a pulse point right here. |
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Term
| dorsal artery of foot pulse point |
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Definition
[image]
And then on the dorsum of the foot, between the tendon of the extensor hallucis longus, and the extensor digitorum in this interval right here, we can feel the dorsalis pedis pulse. So one thing I hope you've taken away from this is that we're very interested in joints, in vessels, and nerves as well, where they cross joints. I've sort of glossed over how these vessels get from hip to knee to ankle, and it's not as if it's not important to us, but in terms of normal clinical care, we like to know about these vessels when they cross the joints. |
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Term
| T/F The saphenous vein is accompanied by the saphenous artery. |
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Definition
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Term
| T/F The distal to the origin of the deep femoral artery, the femoral artery has most of its distribution in the leg and foot. |
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Definition
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Term
| The posterior tibial pulse is palpated posterior to the |
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Definition
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Term
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Definition
are hip flexors, cross the hip joint
[image] |
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Term
| gluteus maximus and gluteus medius |
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Definition
Gluteus maximus—hip extension (rising from seated position, most active when hip is flexed returning it to an extended position)
Gluteus medius—hip abduction (stabilize the hip during walking, When one lifts your right foot off the ground, the left gluteus medius keeps your hip from collapsing on that side)
[image] |
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Term
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Definition
a landmark
[image]
And so here we've taken the gluteus, we've removed the gluteus maximus and the gluteus medius. We see our little gluteus minimus, which we don't care about. But we highlight another muscle here, the piriformis muscle. The piriformis muscle is not particularly functionally important, but it helps us organize the gluteal region. We see right inferior to the piriformis is where the sciatic nerve comes down. And right superior to piriformis is where the superior gluteal nerves come out to supply the gluteus medius and gluteus minimus. So even though it doesn't do very much, it's going to be important to us when we start thinking about the neuromuscular organization of the gluteal region. |
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Term
| anterior medial and posterior compartments of LE |
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Definition
Anterior compartment: quads, etc. —femoral nerve
Medial compartment: adductors—obturator nerve
Posterior compartment: hamstrings—sciatic nerve
[image]
So if we think about the compartments of the thigh, they have different functions. The anterior muscles flex the knee. The medial muscles adduct the hip. The posterior muscles extend the hip and flex the knee. They have different functions, and they have different nerves. And this helps us think about the way that the lower limb is organized. |
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Term
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Definition
extend the hip and flex the knee.
[image]
So here now we look at-- so this is a posterior view. We're looking at the hamstrings. And because they go posterior to the hip joint here, when they contract, they extend the hip joint. But they go posterior to the knee and pull the-- so these muscles extend the hip and flex the knee. And these are the hamstrings, the semimembranosus, the semitendinosis, and the long and short heads of the biceps femoris. |
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Term
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Definition
plantarflex the ankle
[image]
Then if we look now at the posterior leg, we see the gastrocnemius and soleus muscles supplied by the tibial nerve. And their main job is to-- they attach to the calcaneus. And their main job is to plantar flex the ankle. We show a lateral view here showing our calcaneal or Achilles tendon coming down to the calcaneus. And when it contracts, it points the toe.
So the gastric and soleus, which we treat as a group, are important to us because we can see them, because they have an important function, and moreover, they have a tendon, calcaneal tendon, that we can tap to examine reflexes |
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Term
| Gastrocnemius and soleus removed to show the deep muscles that insert on the sole |
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Definition
[image]
If we remove the soleus and the gastrocnemius, deep to them we see a series of smaller muscles which course onto the sole of the foot and have various functions there, notably the flexion of the digits and eversion of the ankle. |
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Term
| Lateral compartment of lower extremity |
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Definition
evertors of the ankle
[image]
The lateral compartment here of the leg here is supplied by the superficial branch of the perineal nerve. The fibularis longus and brevis are everters. So just as we saw on the previous slide, the inverters passing around the medial border of the ankle, the everters pass around the lateral border. And these are supplied, again, by the superficial branch of the fibular or perineal artery. |
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Term
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Definition
dorsiflexes the ankle Clinically very important
[image]
The anterior compartment here has numerous muscles, but the one that we care about the most is the tibialis anterior muscle. Tibialis anterior muscle dorsiflexes the ankle. And if we can't properly dorsiflex the ankle, when we lift our foot off the ground, the foot drops down and we drag our feet and trip. So damage to the tibias anterior produces an important clinical condition called foot drop. And so it's this tibialis anterior then is important to us because it's functionally important, and furthermore, we can test its function clinically. |
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Term
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Definition
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Term
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Definition
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Term
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Definition
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Term
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Definition
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Term
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Definition
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Definition
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Definition
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Term
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Definition
[image]
So this is an artist's diagram here of the lumbar and sacroplexus. And we can identify a number of significant nerves that leave from here. We see a superior and inferior gluteal nerve. We see the femoral nerve, the obturator nerve, and the very large sciatic nerve |
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Term
| femoral nerve root level and target |
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Definition
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Term
| obturator nerve root level and target |
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Definition
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Term
| sciatic nerve root level and target |
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Definition
| L4-S3, posterior thigh and leg and foot |
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Term
| superior gluteal nerve root level and target |
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Definition
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Term
| inferior gluteal nerve root level and target |
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Definition
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Term
| Sciatic nerve relation to piriformis |
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Definition
[image]
So a bit about returning to the gluteal region and the importance of the piriformis muscle, again, we see our piriformis muscle here. And then, leaving superior to the piriformis muscle, coming from the pelvis out into the gluteal region, we see our superior gluteal nerve supplying the gluteus medius and gluteus minimus. And then, inferior to the piriformis, we see our large sciatic nerve leaving. And we also see our smaller inferior gluteal nerve which supplies the gluteus maximus. So all of these are organized up around the piriformis muscle, leaving the pelvis to reach their target. |
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Term
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Definition
anterior thigh
[image]
So again, the femoral nerve supplies the anterior thigh, so supplies the quadriceps, the quadriceps muscle, also the psoas and iliac. So damage to femoral nerve, we'd expect to see weakness in hip flexion and weakness in knee extension. The sciatic nerve supplies the posterior thigh. And once it gets to the knee, it splits into the tibial and common fibular. |
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Term
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Definition
Sciatic nerve supplies posterior thigh; splits into tibial and common fibular at the knee
Tibial supplies posterior leg and sole
Common fibular supplies anterior and lateral leg
[image]
So the sciatic nerve then supplies the hamstrings. So damage to the sciatic nerve up here, we'd expect to produce a defect in knee extension, hip extension, and knee flexion. Damage at the knee here, we'd expect to see deficits in the leg and in the foot. Again, we see the sciatic dividing into a tibial branch and a common fibular branch. |
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Term
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Definition
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Term
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Definition
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Term
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Definition
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Term
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Definition
| dorsiflexion of the ankle |
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Term
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Definition
| plantarflexion of the ankle |
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Term
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Definition
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Term
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Definition
[image]
So this is a plain film of the hip. We notice a number of features here. We see the hip socket, the acetabulum here. We see the femoral head sitting in the acetabulum. We see the neck of the femur.
And we see the greater trochanter here. And out of view down there is a lesser trochanter. And these regions, the neck and the trochanters, are important when you start examining patients who've had hip fractures, because fractures of the femoral neck and injured trochanteric fractures are common.
And then we can see the pubic symphysis here in the midline. We can see the obturator foramen, see the iliac crests up here. And then in the midline, we can see the sacrum, and we can see this outline here of the sacroiliac joint. And we can see lumbar vertebrae in this region here. So there's a lot to see on this image. We're concentrating principally on the hip joint. |
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Term
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Definition
[image]
Now this is an MRI. We can tell with some effort that it's a coronal MRI. And we know it's an MRI because it shows a lot of detail. And we also see other clues here, is we see subcutaneous fat, which is bright on MRI. We see the bone marrow here of the femur. We see the shaft of the femur, the neck of the femur, the greater trochanter, and the head of the femur here sitting in the acetabulum. And medial to the heads of the femur-- this'll become important to you when we do pelvic imaging-- just medial to the head of the femur there is the bladder. |
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Term
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Definition
[image]
Now, this is a view here of arthritis. If we look here on the right, we can see a nice, normal joint space. We see the outline here of the femoral head, and then adjacent to it, the outline of the acetabulum. Here the joint space is narrowed and thickened because of arthritic spurs that have developed in the hip joints, probably causing considerable pain and reducing movement. |
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Term
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Definition
| This is a total hip replacement. We see the prosthesis here in the shaft of the femur. We see the neck of the prosthesis. And we see the head of the femur. And we see the replacement of the acetabulum. We can see the screws that put it into place. And you'll encounter many patients who've had this procedure done to them. |
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Term
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Definition
[image]
We look at the knee joint here. And this highlights the importance of having two views. We see the femur here. We see the femoral condyles. We see the tibial plateau. We see the tibia here. And we know this is lateral, because we see the fibula. So we see the tibiofibular joint, and recall that the fibula's not directly involved in the joint.
And we can see the faint outline here of the patella, which becomes more evident when we look at the lateral film where the X-rays have had to penetrate to a larger distance through the bone. So looking at the knee, it's very important to get two views.
We recognize this as an MRI because of the appearance of the bone and the fat. We see the bright signal inside the bone marrow and the fat anterior to the knee joint. With some effort, we can tell this is a sagittal or parasagittal plane, because we can see the patella anteriorly, we can see the femur, and we can see the tibia. And we're through the center of the joint, so we're not lateral enough to see the fibula.
And we can see some very interesting anatomy. We can see the ACL here, going from anterior on the tibia to posterior on the femur. We can see the PCL attaching posterior on the tibia and moving anteriorly to the femur. This is the view that the radiologist would need to determine whether an ACL or a PCL was torn. And in addition, you also see the dense patellar ligament. |
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Term
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Definition
| This shows a total knee replacement. This is anterior. This is posterior. We see the prosthetic femoral replacement and small patellar replacement here and then the tibial head. So this is how the anatomy of a total knee replacement works. We replace the femoral component, the patellar component, and the tibial component. |
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Term
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Definition
[image]
This is now two views of the ankle. We see the tibia here. We see the talus. We see the fibula. This anterior view here shows our nice joint space, shows how the media malleolus and lateral malleolus are formed in order to produce a hinge joint. This is a lateral film here. Again, because it's lateral, our fibula and our tibia are superimposed on each other. We see the joint, the tibiotalar joint space from a lateral point of view. We see the talus and the calcaneus, and the forefoot here is out of view. |
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Term
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Definition
[image]
This next image here shows a lateral view of the foot itself. We can see the calcaneus here. We can see the navicular bone. We can see the talus and then numerous tarsals and metatarsals and phalanges, which comprise the rest of the foot. |
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Term
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Definition
| And an ankle replacement can also be done. We see here a person with a badly arthritic ankle. We see the tibial component and the talar component have been replaced in order to allow this person to continue to function. |
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Term
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Definition
[image]
So here is an angiogram here. This is a femoral angiogram. And what we can see here, right here is where the catheter has been placed in the left femoral artery and has been pushed up probably as-- well, at least as far as the bifurcation of the aorta, because we see filling of the femoral arteries on both sides. What we can see is we can see the femoral artery here dividing into femoral artery and deep femoral. And what these images show to some extent is that the main artery of the thigh is, in fact, the deep femoral artery and that although the femoral artery itself has branches in the thigh, its main target is going to be the leg and the foot. |
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Term
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Definition
[image]
More distally here, we can see the femoral artery coming down. This is the patella here. So posterior to the knee, it's becoming a popliteal artery. And then the popliteal artery then divides into anterior and posterior tibial arteries. And in this image, it's difficult to determine which one is which. We need a more distal image to be able to see the course that they'd take across the ankle joint. |
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Term
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Definition
[image]
This is a venogram. So you see here these large veins here, the posterior and anterior tibial veins and then the popliteal veins. These are these large veins that run with the popliteal and tibial arteries. And they are quite large. And it's these veins that are responsible for DVT.
And another interesting factor is that typically arteries are accompanied by two veins. So the first time I looked at this, I thought, well, wait. This is a double exposure. But, in fact, it isn't. There are two veins with each artery, and we can see that very beautifully on this venogram. |
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Term
Why is it important (to begin with) to test passive range of motion?
In how many compartments is there a deficit?
Where do you think the problem is localized? |
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Definition
1. to assess structural problems
2. 4
5. L5- weakness of left hip abductor, left hip extensor, left ankle dorsiflexor, left great toe extensor |
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Term
What do you think the reason for the high steppage gait is?
What do you make of her “foot drop”? |
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Definition
So she's compensating for her foot drop. So that's a loss of dorsiflexion of her foot. So she'd have to raise her leg a little bit higher because her foot's pointing down. if not paying attention toes might drag across the ground
So since we have a deficit in the anterior compartment supplied by the deep perineal, and in the lateral compartment supplied by the superficial perineal, that makes us suggest, makes us think that it's an injury-- an injury to the common perineal. And a common place for this to happen is as it hooks around the neck of the fibula where it can be compressed by normal-- just by normal wear and tear, or by a knee brace, or by an impact that might occur. |
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Term
| diabetic with weak left hip flexor and left knee extensor |
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Definition
So hip flexion would be the iliopsoas innervated by the femoral nerve.
And knee extension?
Wouldn't that be the quadriceps muscles?
Also supplied by?
The femoral.
Femoral nerves. So this is a localized-- a localized problem here involving a single muscle group-- the anterior thigh and hip flexor-- all supplied by the same-- by the same nerve. The remaining-- the other muscles have full strength. And if this is a diabetic neuropathy, why has it affected the femoral nerve, instead of any-- instead of another nerve? Tim, do you have an idea?- we don't know |
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