Transcript Lecture Lower limb II 2010

Lower Limb, part II
Barbara Kraszpulska, Ph.D.
Neuroscience, Cell Biology,
and Physiology
Popliteal fossa
Semitendinosus m.
Semimembranosus m.
Gracilis m.
Popliteal artery and vein
Sartorius m.
Superior medial genicular a.
Biceps femoris
Tibial nerve
Common fibular nerve
Superior lateral genicular a.
Plantaris m.
Lateral sural cutaneous n.
Medial sural cutaneous
n.
Small saphenous vein
Gastrocnemius m.
Common fibular gives rise to
lateral sural
Tibial nerve gives rise to medial
sural cutaneous n.
Superior genicular artery (one on
lateral and one on medial side)
-Superior lateral genicular a.
- Superior medial genicular a.
Popliteal Fossa
The popliteal fossa is a space or shallow depression located
at the back of the knee joint.
The boundaries of the fossa are:
* superior and medial: the semimembranosus m., lateral to
which is the semitendinosus m.
* superior and lateral: the biceps femoris m.
* inferior and medial: the medial head of the gastrocnemius m.
* inferior and lateral: the lateral head of the gastrocnemius m.
The contents of the politeal fossa include the:
* termination of the small saphenous vein
* popliteal arteries and veins and their branches and tributaries
* tibial and common fibular nerves
Vein lies more anteriorly
Artery lies deeper in popliteal fossa
* popliteal lymph nodes and lymphatic vessels
Knee joint
This is condylar type of synovial joint (between two condyles of the femour
and tibia), in addition it includes a saddle joint between the femur and the patella!
Functionally this a hinge type of synovial joint – the main movement is flexion
and extension, but there is also rotation when the knee is flexed !
The fibula is NOT involved in the knee joint!!!!!!!!!!!
Extracapsular ligaments( external ligaments):
* patellar lig.
* tibial collateral lig.
* fibular collateral lig.
* oblique popliteal lig.
* popliteus tendon
Bursae – there are at least about 12
bursae around knee joint!
Intracapsular ligaments:
* anterior cruciate lig.
* posterior cruciate lig.
* medial meniscus
* lateral meniscus
Quadriceps tendon becomes the
patellar ligament
Tibial and fibular collateral
ligaments are like the ulnar and
radial collateral ligaments.
Right Knee – Cruciate and Collateral Ligaments
Anterior view
4
2
6
5
3
1
3
9
8
1 – medial condyle
2 – lateral condyle
3 – medial meniscus
4 – lateral meniscus
7
5
1
6
7
4
2
8
Posterior view
5 – anterior cruciate lig.
6 – posterior cruciate lig.
7 – tibial collateral lig.
8 –fibular collateral lig.
9 – tendon of popliteus m.
Function of the Cruciate ligaments
Anterior cruciate ligament
Prevents anterior displacement
of the tibia relative to the femur
Posterior cruciate ligament
Prevents posterior displacement
of the tibia relative to the femur
Menisci of the knee joint
Posterior cruciate lig.
Lateral meniscus
Infrapatellar fat pad
Medial meniscus
Anterior cruciate lig.
Which meniscus is more frequently torn in injures and why???
1.“Unhappy triad "
2. Bursitis in the knee region
a. Tibial collateral lig.
b. Medial meniscus
c. Anterior cruciate lig.
Genicular anastomoses around the knee
Four genicular branches
1 & 2. Superior medial and lateral loop over
respective femoral condyles
3. Inferior medial parallels superior edge of
popliteus
4. Inferior lateral crosses popliteus
4 branches of genicular arteries – which are
derived from the Popliteal artery:
-Superior lateral genicular arteries
- loops over lateral femoral condyle
- Superior medial genicular arteries
- loops over medial femoral condyle
- Inferior medial genicular artery
- parallels superior edge of popliteus
- Inferior lateral genicular artery
- crosses popliteus
Right knee
Vastus lateralis
Vastus medialis
Quadriceps femoris tendon
Iliotibial tract
Medial patellar retinaculum
Lateral patellar retinaculum
Semitendinosus
Gracilis
Sartorius
}
Patellar ligament
Pes
anserinus
Anterior (extensor) compartment
Action:
1. they all extend (dorsiflex) the foot
(ankle joint)
Tibialis
anterior M.
Tibia
2. Tibialis anterior- inverts the foot
3. Extensor. digit. long. – extend digits (toes),
everts foot
4. Extensor hallucis long. – extend great toe,
inverts foot
Innervation:
Deep fibular nerve (L5,S1)
Extensor digit.
longus m.
Extensor hallucis
longus m.
1
1
1. Sup. extensor
retinaculum
2. Inf. extensor
retinaculum
2
2
Blood supply:
Anterior tibial artery
(terminal branch of popliteal a.)
Actions of the anterior
extensor compartment:
-Tibialis anterior:
-Extend (dorsiflexion) of
foot at ankle joint
- inverts foot
- Extensor digitorum longus
-Extends the foot at the
ankle joint
-Everts foot
-extend digits
“Odd man out is ED”
• Extensor hallucis longus
•Extends the foot at
ankle joint
•Inverts foot
•Extend great toe
Innervation:
-Deep fibular nerve (L5, S1)
Blood supply:
-Anterior tibial artery
(Terminal branch of popliteal
a.)
Lateral (eversion) compartment
Action:
1. They both evert the foot
(elevate the lateral margin of the foot)
2. They weakly flex (plantarflex) the foot
(because they pass posterior to the
transverse axis of the ankle)
Fibularis
Longus (1)
Innervation:
Superficial fibular nerve (L5-S2)
Fibularis
Brevis (2)
(1)
Blood supply:
Perforating branches of
the anterior tibial
and fibular artery
(posterior tibial artery
Tendon of
fibularis longus
(1)
(2)
The lateral compartment is
supplied by both the anterior
and posterior tibial arteries (the
fibular artery, in this case).
However, they are perforating
branches.
Unlike the anterior
compartment (deep branch, L5S1), the lateral compartment is
innervated by the superficial
branch (L5-S2)
Fibularis longis (lateral
compartment, supplied by
perforating branches of anterior
tibial and fibular arteries) wraps
under the flexor digitorum
brevis
Common fibular N
Deep fibular N
Superficial fibular N
Lateral sural
cutaneous n.
Superficial
fibular n.
Deep fibular n.
Sural n.
(lat. dorsal cutaneous branch)
Deep fibular N
Injury to the common fibular nerve
Footdrop is due to weakness or paralysis of the muscles involved in lifting the
front part of your foot. This can cause inability to stand on heels and walk with a
foot slap. Footdrop isn't a disease but a sign of an underlying problem.
Causes include:
*Compressed nerve root, usually in the lower spine, due to a
ruptured lumbar disk
*Pressure or injury to the peroneal nerve in your lower leg, such
as from sitting with your legs crossed for long periods
*Peripheral nerve disorder (neuropathy)
*Muscle disorders (myopathies)
*Tumor or stroke affecting the areas of the brain that control
movement of the legs
*Disorders of the spinal cord such as tumors or multiple sclerosis
Depending on the cause, footdrop can be temporary or permanent. Treatment depends
on the underlying cause but may include a brace (orthotic) worn on the ankle and foot
to hold the foot in the normal position.
Footdrop is a sign of injury
to the common fibular
nerve (also known as the
peroneal nerve)
-Result of compression of
nerve root, injury to nerve
itself, peripheral nerve
disorder, muscle disorder,
tumor or stroke, disorder
of spinal cord
-(Basically, damage to
nerve, damage to brain,
damage to spinal cord or
muscle itself)
Superficial group:
Gastrocnemius
Soleus
flex the foot
plantaris
Deep group:
TOM
DICK
HARRY
Posterior (plantarflexion) compartment
Soleus
Flexor Digitorum longus
Tibialis posterior
Posterior tibial artery and vein
Lateral to medial:
Tom Dick VAN Halen
Tibial nerve
Calcaneal tendon is also known as
the Achilles tendon
Flexor Hallucis longus
Flexor retinaculum
Achilles tendon
(calcaneal tendon)
Tibialis posterior tendon
TOM –
Tibialis posterior
DICK- Fl.
Digitorum longus
HARRY- Fl.
Flexor digitorum longus
Posterior tibial A
and Tibial nerve
Flexor hallucis longus
Hallucis longus
Tarsal tunnel
Tarsal tunnel syndrome
Flexor retinaculum
The tarsal tunnel is a narrow space that lies on the inside of the ankle
next to the ankle bones.
Tarsal tunnel syndrome is a compression, or squeezing, on the posterior
tibial nerve that produces symptoms anywhere along the path of the
nerve. The posterior tibial nerve runs along the inside of the ankle into the
foot.
Tarsal tunnel
syndrome (TTS), also known
as posterior tibial neuralgia,
is a painful foot condition in
which the tibial nerve is
impinged and compressed as
it travels through the tarsal
tunnel.
Tibial nerve
Common fibular (peroneal)
nerve
Gastrocnemius muscle (cut)
Popliteus muscle
Flexor digitorum longus M.
Tibialis posterior M.
Flexor hallucis longus M.
Sural nerve
Soleus Muscle (cut)
Innervation:
Tibial nerve (L4-S3)
Blood supply:
Posterior tibial artery
and also fibular artery
(branch of posterior tibial a.)
Tibial nerve innervates the
posterior plantarflexion
compartment
Roots?
L4- S3
Muscles:
-Popliteal
- Gastrocnemius
- Soleus
- Tibial posterior
- Flexor digitorum longus
- Flexor hallucis longus
Tarsal bones
"Tall Cocky Navy Medical I
nterns Lay Cuties":
· In order (right foot,
superior to inferior, medial
to
lateral): Talus Calcanous N
avicular Medial
cuneiform Intermediate
cuneiform Lateral
cuneifrom Cuboid
Foot
Bones:
Tarsals (7): talus, calcaneus, navicular, cuboid, and cuneiforms (3)
Metatarsal – 5, Phalanges - 14
calcaneus
talus
Transverse
tarsal joint
cuboid
Ankle
joint
tibia
Subtalar
joint
navicular
cuneiform
bones
talus
calcaneus
Tarsometatarsal
joint
Function of the foot:
*Provide a stable platform
*Generate propulsion
*Absorb shock
Foot joints:
extension
1. Ankle joint – between the distal end of the tibia and
fibula and the superior part of talus. This is a hinge
type joint!
Movements: dorsiflexion ( extension) of the foot,
plantarflexion (flexion) of the foot.
Flexion
2. Subtalar joint
articulation between talus and calcaneus
3. Transverse tarsal joint
articulation between talus, navicular,
calcaneus and cuboid bones
Movements: inversion and eversion.
Eversion- elevation of the lateral
margin of the foot
Inversion – elevation of the medial
margin of the foot.
Lateral (collateral) ligament
Posterior talofibular ligament
Calcaneofibular ligament
Anterior talofibular ligament
(most commonly injured in
ankle sprains)
Fibularis longus tendon
Fibularis brevis tendon
Lateral collateral ligament
-Contains 3 parts
- torn under inversion
Inversion and eversion of the foot
Tibialis anterior AND tibialis
posterior control inversion of
the foot.
-What else controls it?
- Flexor hallucis longus
Fibular
Inversion injuryAnkle sprains!
Deltoid lig. stabilizes
the ankle joint during
eversion and prevents
sublocation of the
joint!
DELTOID (medial) ligament
1. Posterior tibiotalar part
1
2. Tibiocalcaneal part
2
3. TIbionavicular part
4. Anterior tibiotalar part
SPRING LIGAMENT
(Plantar calcaneonavicular)
3
4
Short
plantar
ligament
Long
plantar
ligament
Although the lateral side
(fibular side) is composed of
3 different ligaments, the
medial side is considered
one giant ligament.
This ligament is known as
the deltoid ligament.
-Its components are similar
to the lateral compartment,
with the addition of the
tibionavicular ligament.
-Function?
- Stabilizes the ankle
joint during eversion
and prevents
sublocation of the jiont.
-Also laterally, we have the
spring ligament (plantar
calcaneonvaciular
Ankle injuries
A Pott fracture–dislocation of the ankle
Sole of foot
Flexor digitorum
brevis
Medial plantar
nerve(S2, S3)
Plantar
aponeurosis
Lateral plantar
fascia
Medial plantar
fascia
Superficial dissection
Abductor digiti
minimi
Lateral plantar
nerve(S2, S3)
Abductor hallucis
Medial plantar
nerve(S2, S3)
First layer
Sole of foot
Adductor
hallucis
Lateral plantar
nerve(S2, S3)
Lumbrical
Lateral and
medial plantar
nerve(S2, S3)
Quadratus
plantae
Lateral plantar
nerve(S2, S3)
Second layer
Flexor digiti
minimi brevis
Lateral plantar
nerve(S2, S3)
Third layer
Flexor hallucis
brevis
Medial plantar
nerve(S2, S3)
First layer of the foot
• Flexor digitorum brevis
• Medial plantar nerve
(S2, S3)
• Abductor hallucis
• Medial plantar nerve
(S2, S3)
• Abductor digiti minimi
• Lateral plantar nerve
(S2, S3)
The lateral and medial
plantar nerves are branches
of the tibial nerve, which is
itself a branch of the sciatic
nerve
Sole of foot:
-First layer
- Flexor digitorum brevis
- Medial plantar n
- Abductor hallucis
- Medial plantar
- Abductor digiti minimi
- lateral plantar n.
-Second layer
- Quadratus plantae
- lateral plantar n.
- Lumbrical
- lateral and medial
plantar nerves
-Third layer
- Adductor hallucis
- lateral plantar
nerves
- Flexor digit minimi
brevis
-Lateral plantar
nerves
- flexor hallucis brevis
- medial plantar
nerves
Muscles of the foot
Plantar muscles function primarily as a group during the support phase of stance,
maintaining the arches of the foot.
The muscles of the foot are of a little importance individually because fine control
of the individual toe is not important for most people. Rather than producing
actual movement, they are most active in fixing the foot or in increasing
the pressure applied against the ground by various aspects of the sole or toes
to maintain balance.
Nerves of the foot:
Medial plantar nerve (S2, S3)
Lateral plantar nerve (S2, S3)
Both terminal branches of tibial nerve!
Deep fibular- dorsum of the foot
Arteries of the foot:
Dorsalis pedis artery- terminal branch
of the anterior tibial
Medial plantar and lateral plantarterminal branches of the posterior tibial
Arteries of the foot
Nerves of the Leg and Foot
Sciatic nerve (L4-S3)
Tibial nerve (L4-S3)
Common fibular nerve (L4-S2)
Medial plantar nerve
Lateral plantar nerve
Superficial branch
Deep branch
Superficial
fibular nerve
Deep fibular nerve
Medial branch
Lateral branch
Medial plantar nerve:
flexor digitorum brevis
abductor hallucis
flexor hallucis brevis
first lumbrical
Lateral plantar nerve:
abductor digiti minimi
quadratus plantae
lumbricals 2, 3 and 4
adductor hallucis
flexor digiti minimi brevis
dorsal and plantar interossei
Cutaneous nerves of Lower Extremity
Major ligaments of the foot (plantar aspect)
Spring ligament!!
1.Supports the head
of the talus
2. Transfers weight from
the talus
3. Supports the
longitudinal arch
Supports the
longitudinal arch
(Long plantar calcen
Calcaneocuboid lig.
Supports the
Longitudinal arch
Flexor hallucis longus
supports the..
Dynamic support-Major muscles that invert
foot
-Major muscles that evert
foot
-Intrinsic plantar muscles
Passive support
-On bottom of foot and
ligaments
- plantar aponeurosis
- plantar
calcaneonavicular lig
- long plantar lig
- short plantar lig
Arches of the foot
Medial longitudinal arch – higher and more important
Is composed of: calcaneus, talus, navicular, three cuneiforms, three medial
metatrasal bones.
This is arch is supported by:
tendon of the flexor hallucis longus muscle and spring ligament
Arches of the foot
Lateral longitudinal arch – much flatter.
Is composed of: calcaneus, cuboid and lateral two metatarsalas.
Supported by:
Fibular (peroneus) longus tendon and long and short plantar
ligaments.
Arches of the foot
Transverse arch of the foot – runs from side to side.
Is composed of: cuboid, cuneiforms and bases of the metatarsals.
Support by tendons of two muscles:
Fibularis longus (FL) and tibialis posterior (TP), crossing under the sole
of the foot.
FL
FL
TP
Factors involved in forming and maintaining the arches of the foot
Passive factors:
1. the shape of the united bones
2. plantar aponeurosis
3. long plantar ligament
4. short plantar ligament
5. spring plantar ligament
Dynamic factors:
1. Active action of the intrinsic muscles of foot
2. Active and tonic contraction of muscles with long tendons
extending into foot:
a. flexor hallucis longus and digitorum longus (longitudinal arch)
b. fibularis longus and tibialis posterior (transverse arch)
Questions of the day!
1. What are the primary muscles that control eversion of the foot?
1. fibularis longis and brevis
2. If a patient cannot stand on his heel, which nerve is not functioning?
1. Common fibular (more specifically, that means we cannot extend, meaning deep fibular
nerve… because extension is dorsiflexion
3. Nerves can frequently be compressed against bony structures in the lower limb. What nerve rests
against the head and neck of the fibula?
1. Common fibular
2. Foot drop is a result