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LL1 (NM4

)

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Describe the origin and course of the great saphenous vein. What is its relationship to the medial malleolus, the patella and the pubic tubercle? Originates from medial of dorsal venous arch of the foot. Goes anterior to medial malleolus. Goes hand’s breadth behind the patella. Below and lateral to pubic tubercle. Goes into saphenous opening to join femoral vein at the saphenofemoral junction.

2

What are the tributaries of the long saphenous vein? Near its termination, before it passes through the saphenous opening in the deep fascia, it receives veins from the anal skin, external genitalia and lower abdominal and upper thigh skin (external pudendals, superficial circumflex iliacs etc).

3

Does the great saphenous vein have valves? Yes.

4

What is a saphena varix? A varicosity (dilatation) at the termination of the great saphenous vein.

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What does saphenous mean? Visible (Greek).

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Do the long (great) and short saphenous veins communicate? Yes.

7

How does venous blood drain from the foot against gravity? Valves in the veins Soleal muscle pump – deep veins in the muscle are squeezed when the muscle contracts Elasticity of venous walls Diaphragm acts as a piston that sucks blood up

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Find about varicose veins and ulcers. What is a deep venous thrombosis? Deep venous thrombosis is a condition in which a blood clot forms in a vein that is deep inside the body.

LL2 (NM5)

1

Examine the surface anatomy of the lower limb. Identify and palpate bony landmarks, on yourself or a willing partner, and on the skeleton.

2

What is the midinguinal point? What can be palpated here? The midinguinal point is half way between ASIS and pubic symphysis. More important is the midpoint of inguinal ligament, which (as the name implies) is half way between ASIS and pubic tubercle. Femoral artery pulse can be palpated just below the midpoint of inguinal ligament.

3

What is the relationship of the nerves and vessels passing beneath the inguinal ligament? Femoral artery at midpoint, vein medial to artery, canal medial to vein, lacunar ligament forming medial border of canal. The nerve is lateral to the artery.

4

What are the medial, lateral, anterior and posterior relations of the femoral canal? Medial: lacunar ligament. Posterior: pectineal ligament. Lateral: femoral vein. Anterior: inguinal ligament. These would be the relations of the neck of a femoral hernia. What constitutes the sac and what are the likely contents of a femoral hernia? The sac would be a projection of peritoneum, possibly containing gut.

5

What are the normal contents of the femoral canal? Lymphatics and fat.

6

What gives rise to an abnormal obturator artery and why is it significant in femoral hernia repairs? It is a branch of either the femoral, external iliac or inferior epigastric. It may run over the lacunar ligament (which may need to be cut in femoral hernia reduction). It may exist with, or instead of, a normal obturator artery.

7

From which areas of the body does lymph drain to superficial inguinal nodes? Superficial skin of lower limb, external genitalia, lower part of anal canal and vagina.

8

What are the branches of the common femoral artery? Profunda femoris and continuation of the artery.

9

What is the course of the profunda femoris artery? What is the function of the profunda femoris artery? Make sure you study arteriograms and radiographs. The profunda (deep) femoris artery supplies the muscles of the thigh and gives branches to the hip joint (very important) and knee joint.

10

Understand the course and attachments of the obturator muscles. Study the transverse sections through the gluteal region which show these. Not important.

11

What passes through the obturator canal? Obturator nerve and vessels.

12

What is the relationship between the obturator nerve and adductor brevis muscle? Once the nerve has entered the thigh, it splits into anterior and posterior branches, on either aspect of adductor brevis.

13

What is the adductor hiatus and what structures pass through it?

LL3 (NM8)

1 2

Examine the sciatic foramina and bones and ligaments of pelvis. Define the surface markings of the sciatic nerve in the gluteal region. How is this clinically important with reference to injections and to road accidents? A quadrant from half way between the ischial tuberosity and the PIIS to half way between the greater trochanter and the PIIS. It may be damaged in posterior hip dislocations, or injections into the buttock. Such injections should always be done into the upper, outer quadrant in order to avoid the sciatic nerve.

3

Study the external surface of the hip bone noting the adaptations for weight bearing. Trace weight transmission from the sacrum to the head of the femur. Note regions of the muscular and ligamentous attachments and the places where nerves and vessels enter the gluteal region.

4

You must know the role of the gluteal muscles in walking, running, jumping. Medius and minimus are hip abductors - or, to put it the other way round, when the leg is weightbearing and the foot on the ground, they lift the pelvis so that the other foot may be raised from the ground. The use in walking will be obvious. Maximus is not used much in normal walking. Its principal role is as a powerful hip extensor such as might be used in squatting, in explosive extension (athletics), in climbing stairs, or getting up from the seated position.

5

What is Trendelenberg’s sign? What would be the effect on walking of a lesion of the right superior gluteal nerve? See 4 above. If medius and minimus are paralysed or weak (eg superior gluteal nerve lesion), then when the non weightbearing foot is raised, the pelvis will tilt down on that side because medius and minimus on the weightbearing side are weak. This is Trendelenberg’s sign or gait (not to be confused with Trendelenberg’s test for varicose veins).

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In what movements does gluteus maximus play a major role? Read about the attachments of the capsule of the hip joint (which you will study later) to the femur. Ask about the consequences of this as far as infections of the femur are concerned. Anteriorly it is attached to the intertrochanteric line, posteriorly it is attached to about half way up the neck.

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How is the pelvis supported when one foot is off the ground? What are the borders of the greater sciatic foramen and what passes through it? Sciatic nerve, superior and inferior gluteal vessels and nerves, pudendal nerve and vessels, piriformis.

10

What are the borders of the lesser sciatic foramen and what passes through it? Pudendal nerve and vessels only.

LL4 (NM10)

1

List the muscle groups of the thigh and give their nerve supply. Define the movements which are possible at the hip joint and the muscles involved. Anterior, knee extension, femoral L2,3,4. Medial, adductor, obturator, L2,3,4. Posterior, hip extensor and knee flexor, tibial (mainly) L5, S1.

2

Learn the segmental levels of movements of the hip joint: flexion, abduction, adduction, and extension. Flexion, adduction – L2,3 Extension, abduction – L4,5,S1

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Define on the skeleton the capsular attachments at the hip joint. By what mechanisms can the hip joint be fixed during standing without muscular action? Standing puts the hip into extension and this is limited by the iliofemoral ligament which takes the strain. This is because in this posture the weight is transmitted behind the axis of the joint, so this puts it into extension.

5

What is Hilton’s law? Nerves that supply the muscles that move a joint also supplies the joint itself.

6

What is the arterial supply of the head and neck of the femur (a) in the infant and (b) in the adult? Find the vessels contributing to the trochanteric and cruciate anastomoses. Both anastomoses are posterior to the joint. They receive vessels from profunda femoris and its branches, and from gluteals. In the adult the head and neck are supplied by retinacular vessels that enter at the capsular attachment and by branches of the nutrient artery of the shaft which passes up the marrow cavity. In the child, these last vessels do not reach the head because of the epiphyseal plate of hyaline cartilage (blood vessels never cross epiphyseal plates). In both the adult and the child there is also the small artery of the round ligament of the head of the femur, but this is not important in either adult or child. The general message is that the head of the femur in the child is, relatively speaking, not as well supplied as in the adult.

7

What is congenital dislocation of the hip? It is what it says. What is Shenton’s line? Shenton's line is an imaginary line drawn along the inferior border of the superior pubic ramus (superior border of the obturator foramen) and along the inferomedial border of the neck of femur.

This line should be continuous and smooth. A disrupted Shenton’s line is a radiological sign of hip dislocation. 8 How would the leg appear in a fracture of the neck of the femur? Shorter and foot laterally rotated, because the shaft is now free to rotate and psoas (which should normally flex the hip) will now laterally rotate the detached femoral shaft. 9 Where is the insertion of semitendinosus? Proximal tibia – pes anserinus. Say grace before tea. 10 What is the insertion of semimembranosus? Proximal tibia, deep to that of semitendinosus. 11 Which hamstring muscle passes laterally? Biceps. Where does it attach distally? Head of fibula. What is related to it at this point? Common peroneal nerve (= common fibular nerve). 12 Where does the sciatic nerve normally separate into its two components? Top of popliteal fossa. How may this vary? Higher or lower. Do the tibial and common peroneal nerves always maintain a separate identity, even in the gluteal region? No, they may be separate from the beginning, or anything between this and the normal point of separation. They may even pass separately through the greater sciatic notch: common peroneal (posterior divisions) above piriformis and tibial (anterior divisions) below. 13 What are the boundaries of the popliteal fossa? What are its contents? Above: semis (medial) and biceps (lateral). Below: two heads of gastrocnemius.

Roof: deep fascia of thigh Floor: (from superior to inferior) popliteal surface of femur, capsule of knee joint, popliteus muscle Main contents are tibial and common peroneal nerves, popliteal vessels. 14 Which structure in the popliteal fossa is nearest the femur? Remember, in the popliteal fossa, deep = anterior. The popliteal artery. Most anterior = deepest = nearest to the femur. Supracondylar femoral fractures may damage the artery because of this proximity. 15 16 Define the limits of the popliteal fossa and the length of the popliteal artery. What might happen to the popliteal artery if the knee is dislocated? Torn. 17 What might happen to the popliteal artery if there was a supracondylar (what does this mean?) fracture of the femur? Supracondylar = above a condyle.

LL5 (NM13)

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Revise the anatomy of the popliteal fossa. Which nerves send branches to the knee joint? Revise Hilton’s Law. So the knee is supplied by all the main nerves of the lower limb. The obturator does as well and is important. Knee pain can be referred to the hip and vice versa.

3

Name the muscles of the thigh which are innervated by more than one nerve. This is a bit of a so-what question. But anyway, piriformis (femoral and obturator), adductor magnus (obturator and tibial), and biceps (short head: common peroneal; long head: tibial).

4

Which region of the lower limb is drained by the popliteal lymph nodes? Lateral side of foot (equivalent of the medial side of the hand draining to epitrochlear nodes).

5

Feel the popliteal, posterior tibial and dorsalis pedis pulses on yourself and a friend. Work out landmarks for these so that you could identify them with ease on a patient. You may need help to find the popliteal pulse - ask for it!

6

How would blood reach the leg following occlusion of the popliteal artery? Profuse genicular anastomosis, the details of which you do not need to know.

7

Which muscles are contracted when standing in the upright position? The point is that few are.

8

Which nerves are responsible for the ankle jerk reflex? How many synapses are there in this pathway? Tibial nerve. S1,2. 1 (monosynaptic).

9 10

Study the osteology of the tibia, fibula, tarsus. Identify the great saphenous vein and note its origin on the dorsum of the foot. Note whether the short saphenous vein terminates in the popliteal vein or in the great saphenous vein on your cadaver.

11

At what site is the common peroneal nerve in danger of injury from trauma? Head of fibula. Describe the areas of sensory and motor loss following such injury. Would the gait be affected? Skin affected would be anterior and lateral leg and anterior (dorsum) of foot. Ankle dorsiflexors and evertors would be affected, leading to foot drop.

12

List the spinal segments which provide the cutaneous innervation to the following regions: femoral triangle; anterior and posterior surfaces of the knee; medial aspect of the leg; sole and dorsum of the foot. Femoral triangle – L1,2

Anterior surface of the knee – L3 Posterior surface of the knee – S2 Medial aspect of the leg – L4 Sole and dorsum of the foot – L5,S1 13 List the muscles producing dorsiflexion and plantarflexion of the ankle. Which spinal segments are involved? Dorsiflexion: anterior compartment, deep peroneal nerve, L4,5. Plantarflexion: posterior compartment, tibial nerve, S1,2. 14 Draw a diagram showing the relations of tendons, vessels and nerves at the ankle joint. How many of these structures can you palpate? 15 What is a retinaculum? A band of fibrous tissue keeping things in place. What other anatomical arrangements exist for transmitting force round corners? These include: joints, synovial sheaths, bursas, sesamoid bones. 16 Determine the relationship between the flexor and extensor retinacula and the nerves and vessels at the ankle. What relevance are these relationships in physical examination? Palpating the posterior tibial pulse: it lies about 1 cm behind the medial malleolus, separated from it by the tendons of tibialis posterior and flexor digitorum longus. 17 What is the difference in action between gastrocnemius and soleus? What is the obvious difference in their attachments that has a bearing on this? 18 Where would you palpate the anterior tibial pulse? Midway between two malleoli. 19 Where would you palpate the dorsalis pedis pulse? A bit further down. 20 Why is a kick in the medial aspect of the shin so painful? Because the blow lands upon periosteum - richly innervated. 21 Why do fractures of the tibia tend to heal slowly? Because there are no muscle attachments to this surface, there are fewer periosteal blood vessels entering the bone, so the vascular perfusion is poorer, so healing is slower. 22 What is a retinaculum? What is a synovial sheath? What is a bursa? What is a sesamoid bone? What do they all have in common? 23 What is bursitis? What is synovitis? What is tenosynovitis?

LL6 (NM14)

1

Which movements occur at the knee joint? List the muscles which are prime movers during these movements. Extension: quads, femoral nerve, L3,4. Flexion: hamstrings, tibial nerve, L5, S1. Some degree of rotation (locking) at the end of extension - unlocking by popliteus, tibial nerve, S1.

2

Define on the skeleton the capsular attachments at the knee joint. Which regions of the joint are not covered with synovial membrane? The posterior intercondylar surface of the tibia is not. This is where the cruciate ligaments are attached - they are intracapsular but are extrasynovial.

3

Which muscles by their insertion contribute to the stability of the knee joint? Vasti: by their expansions. Vastus medialis keeps the patella stable. Iliotibial tract stabilises the slightly flexed knee. This matters because people who might get proximal muscle wasting (e.g. in diabetes or neurological conditions) would have knee trouble as a result of these failures.

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Which structures are intracapsular but extrasynovial? By what mechanisms can the knee joint be fixed during standing without muscular action? Locking. At the end of extension, the femur medially rotates on the tibia, locking it in position.

6

What are the functions of the cruciate ligaments and the menisci of the knee joint? The cruciates keep the bones together; the menisci facilitate rotation (probably) and act as shock absorbers.

7

How would a torn anterior cruciate ligament be detected by physical examination? Torn posterior cruciate? Torn collateral ligaments? This is common sense. If you can move the tibia back more than usual on the femur, then the posterior cruciate is torn. If you can pull the tibia forwards more than usual on the femur, then the anterior cruciate is torn. If you can bend sideways more than usual the tibia on the femur, then the collateral of whichever side is torn.

8

List the structures attached to (a) the medial meniscus (b) the lateral meniscus of the knee.

(a) the medial collateral ligament (b) nothing that matters This is relevant to twisting injuries - the medial meniscus, being attached to the medial collateral, is less mobile so is not able to get out of the way of trouble like the lateral meniscus is. Medial meniscus injuries are more common than lateral meniscus injuries. 9 10 Palpate the joint space at the knee. What is the role of popliteus in knee movements? To unlock the knee at the beginning of flexion. See question 5 above. 11 Note the main bursas around the knee joint. Which of these communicate with the joint space? What is bursitis? Anterior: suprapatellar communicates; prepatellar and infrapatellars do not. Posterior: popliteus bursa communicates; there are bursas under the medial and lateral heads of gastrocnemius, both communicating with the knee joint, and the semimembranosus bursa communicates with the medial gastrocnemius bursa. 12 What is a sesamoid bone? A (small, flat) bone developed/embedded in a tendon. Example: patella (knee cap) 13 In what position is the ankle joint most stable? Least stable? Why? Most stable in dorsiflexion because the widest part of the talus fits snugly into the mortise of the tibia and fibula. Least stable in plantarflexion because the narrow part of the talus in the mortise and so the whole thing is wobbly. 14 Which ligament is most often torn in an ankle sprain? What are its attachments? Lateral. There are three bands: anterior talofibular, calcaneofibular, posterior talofibular. The anterior talofibular is usually the one. 15 What type of joint is the superior tibiofibular joint? The inferior? Superior – synovial Inferior – fibrous 16 Is the inferior tibiofibular joint easily dislocated? No.

LL7 (NM16)

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Study the osteology of the foot, particularly the joints between the tarsal bones. Name the bones which make up the different arches of the foot. This is not important. Medial arch: calcaneus, head of talus, navicular, medial cuneiform, first metatarsal. Lateral arch: calcaneus, cuboid, fifth metatarsal.

3

List the features which contribute to the maintenance of these arches under bony, ligamentous, and muscular headings. This is not important.

4

What is the normal weight distribution on the plantar surface of the foot in standing? How much may it vary and what factors may vary it? Look at a footprint in the sand, or a wet footprint on the carpet.

5

Which leg muscles make an appreciable contribution in (a) walking and (b) in standing? Which foot muscles do? All of them.

6

Which movements occur at (a) the ankle, (b) the subtalar, and (c) the transverse tarsal joints? Name the muscles which are prime movers during these movements. What is their value in walking?

7

What covers the superior surface of the spring ligament? Articular cartilage for the TCN joint. What are the ‘proper’ names of the spring and short plantar ligaments? Spring = plantar calcaneonavicular. Short plantar = plantar calcaneocuboid.

8

What are sesamoid bones? Bones that developed in a tendon.