Review Exam 2 LEAI 2022 Fall PDF

Fun history: Chiropodists Up until the 20th century, many doctors who focused on feet, ankles, and legs were called chiropodists. Why? Chiropody first entered the English language in the 18th century, when a corn operator/cutter by the name of David Low wrote the definitive text on care of the feet…...

Fun history: Chiropodists Up until the 20th century, many doctors who focused on feet, ankles, and legs were called chiropodists. Why? Chiropody first entered the English language in the 18th century, when a corn operator/cutter by the name of David Low wrote the definitive text on care of the feet…which plagiarized L’Art de Soigner les Pieds (1781; image on right), a popular treatise on corn cutting, written by Nicholas Laurent Lafrost. The profession became more established by the 1800s. There are more recent historical references to podiatrists and those who used them, including the King of France and Napoleon, who both had a personal podiatrist. Abraham Lincoln also had a personal foot doctor to help care for his ingrown toenails and “troublesome corns”. Review Midterm Exam 2 LEA I THIS IS A REVIEW OF CONCEPTS AND NOT COMPREHENSIVE OF ALL POSSIBLE EXAM MATERIAL Lectures covered in MT 2 Medial thigh Development of long bones Posterior thigh Intro to the hip joint Popliteal fossa Cross sections of the thigh In this review, I am not going over content of them in any particular order Long Bones humerus Endochondral Ossification X-ray of foot of a newborn All long bones of the lower extremity are formed this way 1o ossification center Occurs in The diaphysis of a long bone Middle of a short bone Appears or starts to ossify End of the embryo stage 2o ossification centers Occur in Epiphyses of long bones Other areas Appear in newborn or after birth You will learn these for all the bones of the LE Growth plate = physis Cartilaginous growing area of bone Occurs in the metaphysis of a long bone Femur neck Longest, strongest bone in the body Proximal end: Rounded head Cylindrical neck Two boney prominences The greater and lesser trochanters (when do they fuse?) Distal end: Two large rounded smooth projections Medial and lateral femoral condyles Rough intercondylar fossa/notch Between the two condyles Proximal End of the Femur Pectineal (part of pectineus insertion) and spiral lines continue inferiorly to linea aspera Head Fovea capitis Greater trochanter Greater trochanter Neck neck Intertrochanteric line (HIP JOINT) Lesser trochanter Trochanteric crest Lesser trochanter Gluteal tuberosity Pectineal line Anterior view Spiral line Posterior Linea Aspera Linea aspera Prominent boney ridge posteriorly Medial lip Adductor muscles of the thigh (REVIEW THEIR ATTACHMENTS TO THE LINEA ASPERA) Left femur: Posterior view Ossification of the Femur 1o ossification center in diaphysis 2o ossification centers in the epiphyses Distal epiphysis is present at birth Last growth plate to fuse, age 16-20 Growing end of the bone Head of the femur Appears at 1 year Greater trochanter Appears at 4 years Lesser trochanter Appears at 12 years Arterial Supply of the Lower Extremities Internal iliac artery Gluteal arteries Exit greater sciatic foramen Internal pudendal artery GSF -> LSF -> Perineum Obturator artery Thru obturator canal to medial thigh Helps supply prox. medial thigh Artery of the lig. of head of femur External iliac artery Main blood supply to lower extremities Becomes the femoral artery when passes deep to inguinal ligament Arteries of the Thigh Femoral artery Femoral artery Muscular branches to anterior thigh Descending genicular artery Travels with saphenous nerve in adductor canal Profunda femoris artery 4th perforating artery Thru adductor canal and adductor hiatus -> popliteal artery Profunda femoris artery (deep femoral artery) Branch of femoral artery Muscular branches to medial thigh Medial circumflex femoral artery posterior to femur; ascending, transverse branches Lateral circumflex femoral artery Deep to rectus femoris Ascending, transverse, descending branches Terminates when becomes 4th perforating artery Perforating arteries Branches of profundal femoris artery Perforate adductor magnus Supply muscles of posterior thigh Right Lower Extremity Two Hip Arterial Anastomoses Trochanteric (greater trochanter) (1) superior gluteal and (2) inferior gluteal arteries Ascending branches of (3) medial and (4) lateral circumflex femoral arteries Cruciate (lesser trochanter) (2) inferior gluteal artery Transverse branches of 3 & 4. Ascending branch of (5) 1st perforator Rotation of the Lower Extremity Embryo, 7-8 wks Embryo, 4-5 wks Fetus Femoral nerve L2-L4 Posterior division of lumbar plexus Innervates ant. thigh Obturator nerve L2-L4 Anterior division of lumbar plexus Innervates medial thigh Tibial nerve L4-S3 Tibial N Obtur. N Femoral N O F T Cross section of Left Thigh Femoral N Obt. N Tibial N Anterior division of sacral plexus Innervates posterior thigh and leg; plantar foot Lumbosacral Plexus Motor Innervation Lumbar plexus T12-L4 Femoral nerve L2-L4 ; posterior division Obturator nerve Motor to anterior thigh Also pectineus, etc Femoral nerve Obturator nerve L2-L4 ; anterior division Motor to medial thigh Also obturator externus Sacral plexus L4- S4 - anterior to piriformis Pudendal nerve S2-S4 Supplies perineum, travels w/ internal pudendal artery Sciatic nerve – travels in posterior compartment Tibial nerve; anterior division Motor to posterior thigh, posterior leg, plantar foot Also hamstring portion adductor magnus Common peroneal nerve ; posterior division Motor to anterior & lateral leg, dorsal foot Also short head biceps femoris Sciatic nerve Lumbar Plexus – Sensory Innervation Anterior Division: Obturator nerve L2-L4 Hip joint* Skin medial thigh Posterior Division: Femoral nerve L2-L4 Hip joint* Intermediate branch of anterior cutaneous nerve partially provides sensory to medial thigh Distribution covered in first module Sensory Innervation Posterior femoral cutaneous nerve Sacral plexus Posterior femoral cutaneous nerve Posterior division Located medial to sciatic nerve as it enters gluteal region Inferior to piriformis Sacral Plexus Anterior division Pudendal nerve S2-S4 N. to quadratus femoris* and inferior gemellus N. to obturator internus and superior gemellus Posterior division Superior gluteal nerve* Supplies gluteus medius, gluteus minimus and tensor fascia latae Inferior gluteal nerve* * Supplies gluteus maximus Posterior femoral cutaneous Sensory posterior thigh * Sensory to hip joint Intermuscular Septa Thick sheets of deep fascia quads Form fascial compartments in the limbs Thigh has 3 compartments adductors hamstrings Cross section of thigh Anterior, posterior and medial Separated by 3 intermuscular septa Medial, lateral and posterior Alttachments Linea aspera Deep surface of the fascia latae Medial Compartment of Thigh Anterior view 3 layers of muscles Superficial pectineus (femoral n.) adductor longus Middle Know Origins and insertions adductor brevis Deep adductor magnus Hamstring portion (tibial n.) – ischial tuberosity Gracilis Long, medial, slender muscle – pes anserinus Origin: gracilis pubis; (magnus – ischium) Insertion: linea aspera, medial lip (Pectineal line; adductor tubercle) Action Adduct, flex thigh Innervation Obturator nerve (L2-L4) Anterior and posterior divisions -Adductor brevis separates them adductor hiatus adductor magnus Pes Anserinus Three muscle tendons insert on the medial aspect of the tibia Resembles a goose’s foot From anterior to posterior: Sartorius Anterior compartment Gracilis Medial compartment Semitendinosus Posterior compartment Overview of the Posterior Thigh Muscles Extensors of the hip/thigh Flexors of the knee/leg Antagonists to muscles of anterior thigh Hamstrings Biceps femoris Semimembranosus Semitendinosus Blood supply Perforating arteries from profunda femoris artery Innervation Tibial nerve (sciatic nerve) Except short head of biceps femoris Common peroneal nerve b.f. s.m. s.t. Superficial Deep Hamstrings Two superficial muscle bellies Have common site of origin: Superomedial quadrant of isch. tuberosity Semitendinosus Biceps femoris, long head Two deep muscle bellies Semimembranosus Thicker, wider, more membranous than semitend. O: superolat quadrant isch. tub Biceps femoris, short head O: linea aspera of femur Note adductor magnus Deep to semimembranosus Visible medially and laterally Hamstring portion O: inferolat quadr isch tub Know Origins and insertions Posterior view Ilium Ischium Hip joint ligaments Ischial tuberosity Large, rough boney projection Formed by the body and the ramus Inverted teardrop shape Where weight is distributed when sitting Inferior, medial portion Covered by a fibro-adipose pad Body Ischial tuberosity Attachment site Obturator foramen Several muscles i.e. hamstrings Ligaments Ramus Lateral view Sacrotuberous ligament Review: Ischial Tuberosity Resembles an inverted teardrop Transverse ridge divides it into superior and inferior parts Vertical ridges divide each into medial and lateral parts Left ischial tuberosity: Superolat. Superomedial quadrant Superomed. Transverse ridge Common site of origin of semitendinosus and biceps femoris, long head Both are in the superficial layer of hamstrings Superolateral quadrant Origin of semimembranosus Inferomedial quadrant Fibro-fat pad located here Where you sit Inferolat. Inferomed. Inferolateral quadrant Partial origin of adductor magnus Bones of the Knee to view attachments and the distal femur 1. femur 2. adductor tubercle I: Adductor magnus, hamstring portion 5. base of the patella Quadriceps tendon 18 17 6. apex of the patella 10. tibial tuberosity Patellar ligament 11. tibia 14. head of the fibula I: biceps femoris 15. neck of fibula 17. Pes anserinus insertion 18. Gerdy’s tubercle ITB Left knee, anterior view Popliteal Fossa Right leg Know the contents and order of contents Sciatic nerve Common peroneal nerve Lateral, deep to biceps femoris Tibial nerve Vertical course Mid-fossa Structures from superficial to deep Tibial N Popliteal vein Popliteal artery Know borders of Popliteal fossa Don’t forget the Veins Deep veins Venae commitantes (paired) of the deep arteries Superficial veins Great saphenous vein Lesser saphenous vein Drains to popliteal vein Recall perforating veins Connect superficial to deep vv. Continually shunt blood to deep v. Close when muscle contracts Deep veins Superficial veins Thrombus = blood clot DVT – deep vein thrombosis Popliteal Artery Continuation of the femoral artery Branches in popliteal fossa: 2 superior genicular arteries (M&L) 2 sural arteries End arteries to gastrocnemius m. Middle genicular a. Not part of genicular anastomosis 2 inferior genicular arteries (M&L) Trifurcation Anterior tibial (usually 1st branch) & then posterior tibial & fibular aa. Aneurysm = ballooning of an artery Hip Joint Articular surfaces (hyaline cartilage) Lunate surface Head of femur Intrinsic ligaments Ligament of the head of the femur Transverse acetabular ligament Fibrous capsule Intertrochanteric line; mid neck post. Iliofemoral ligament (cut) Ligament of the head of the femur (cut) Ischiofemoral ligament (cut) Blood Supply to the Head and Neck of femur Retinacular (capitate) arteries Primary source of blood supply to the femoral head Artery of the ligament of the head of the femur Branch of obturator artery Retinacular arteries Travels thru acetabular foramen Small contribution Fractures of neck of femur may lead to avascular necrosis of the femoral head The closer the fx is to the head, the greater the risk Lateral Circumflex Artery Right Hip Joint: Sensory innervation of the hip joint: (ligs, fibrous capsule & synovial membrane) 1. 2. 3. 4. 5. 6. Femoral n Obturator n Sup. Gluteal n Inf. Gluteal n Sciatic n N. to quadratus femoris Anterior Posterior Hilton’s Law A sensory nerve supplying a joint also supplies (innervates) Muscles moving the joint Skin overlying the insertions of these muscles Sensory nerves innervating the hip joint capsule Cross Section Midthigh Anterior Compartment 1. Vastus lateralis 2. Vastus intermedius 3. Rectus femoris 4. Vastus medialis 5. Adductor canal - - - 6.Saphenous nerve, nerve to vastus medialis 7. Sartorius 8. Femoral a./v. Subcutaneous 9. Great saphenous vein 2 3 4 Medial Compartment 5 1 6 7 8 20 9 21 Posterior Compartment 19 10 12 Fascia lata 10. Adductor longus 11. Gracilis 12. Adductor brevis 13. Profunda femoris a./v. 14. Adductor magnus 18 20. ITB 21. Lateral intermuscular septum 13 17 16 15 14 11 15. Semimembranosus 16. Semitendinosus 17. Sciatic nerve 18. Long head of biceps femoris 19. Short head of biceps femoris