CARPAL TUNNEL vs DUPUYTREN CONTRACTURE O.

LYMPHATIC DRAINAGE
CARPAL TUNNEL • Anterior / Pectoral LN
DUPUYTREN CONTRACTURE
SYNDROME
• Posterior / Scapular
• Burning pain / “Pins and • Localized thickening and • Lateral / Humeral LN
Needles” along the contracture of the palmar
• Central LN
distribution of Median nerve aponeurosis
• Apical LN – Thoracic / Right Lymphatic duct
• Thickening of the synovial • Starts – ring finger draws
• Superficial lymphatic vessels
sheaths of the Flexor tendons into the palm then little
from the thumb, index, and
or arthritic changes of the finger; flexion of PROXIMAL
lateral side of the hand
carpal bones interphalangeal joints
follow the cephalic vein to
infraclavicular lymph
nodes
• Superficial lymphatic vessels
from the medial side of the
hand follow the basilic vein
to supratrochlear lymph
nodes then to the lateral
group of axillary lymph
BENNETT FRACTURE nodes
• a fracture of the base of the first • Deep lymphatic vessels
metacarpal bone follow the arteries to the
• thumb is forcefully abducted lateral group of axillary
lymph nodes
BOXER’S FRACTURE
oblique fracture of the necks of the AXILLARY LYMPHATICS
fourth or fifth metacarpals; distal
segment displaced proximally –
shortening of the finger posteriorly
✔GUIDE QUESTIONS
A patient complains of sensory loss over the anterior and posterior
surfaces of the medial one- and one-half fingers. Which of the following
nerve is injured?
A. Radial B. Median
C. Musculocutaneous D. Ulnar
BUZZ WORDS
MEDIAN NERVE ULNAR NERVE
• Supracondylar fractures • Medial epicondyle fractures
• Hand of Benediction • wrist abduction during
• Carpal tunnel syndrome wrist flexion
• Medial “clawing”
MUST KNOW: MEDIAN VS. RADIAL VS. ULNAR © Topnotch Medical Board Prep

✔GUIDE QUESTIONS
What is the dermatome level at the medial aspect of the
Hypothenar eminence?
A. C 5
B. C 6
C. C 7
D. C 8

N. DERMATOMES (MUST-KNOW!!) XXXI. LOWER EXTREMITY

• Area of the skin supplied by the somatosensory fibers from a single
spinal nerve: useful in localizing the levels of lesions • Functions
C2 – back of head o Support weight to body
C5 – tip of shoulder o Stable foundation for standing, walking, running
C6 – thumb • Regions
C7 – middle finger o Gluteal o Thigh
C8 – small finger o Knee o Leg
T4 – T5 – nipple o Ankle o Foot
T10 – umbilicus
L1 – inguinal A. THIGH
L4 – knee; medial leg • Fascial Compartments - Thigh
L5 – lateral leg; big toe o Anterior compartment – flexors
S1 – small toe o Posterior compartment – extensors
S5 – perineum o Medial compartment – adductors
 ✔GUIDE QUESTIONS
Which of the following muscles is a Flexor of the Thigh?
A. Adductor longus
B. Iliopsoas
C. Gracilis
D. Obturator internus

ANTERIOR THIGH MUSCLES

• Flexors of the thigh
• Extensors of the leg
• Innervated by the Femoral nerve
• Consists of:
1. Iliopsoas – STRONGEST FLEXOR
2. Tensor fascia lata - Flexes and MEDIALLY ROTATES the thigh ANTERIOR THIGH MUSCLES
3. Sartorius – Flexes and LATERALLY ROTATES the thigh MUSCLE ACTION NERVE SUPPLY
4. Pectineus Flexes and laterally
Sartorius Femoral
5. Quadriceps femoris: Rectus femoris rotates the thigh
Vastus lateralis Tensor Flexes, abducts and
Vastus medialis Superior gluteal
fascia lata medially rotates the thigh
Vastus intermedius
QUADRICEPS FEMORIS
ORIGIN INSERTION ACTION NERVE SUPPLY
Anterior inferior Flexes the thigh at hip joint;
Rectus femoris
iliac spine Extends leg at knee joint
Patellar tendon to
Vastus lateralis Femoral
tibial tuberosity
Vastus medialis Shaft of femur Extends leg at knee joint
Vastus intermedius
REMEMBER
ASIS – origin of Sartorius and TFL
AIIS – origin of Rectus femoris
Lesser trochanter of femur – common insertion of Iliacus and
Psoas
Quadriceps / Patellar tendon – common insertion of
Quadriceps femoris
RECTUS FEMORIS
• CROSSES both Hip and Knee joints
• Flexes the Thigh and Extends the leg
• All together - QUADRICEPS FEMORIS
EXTEND LEG at KNEE JOINT
TAKE NOTE:
• ANTERIOR COMPARTMENT – FLEXES the THIGH at HIP JOINT
and EXTENDS the LEG at the KNEE JOINT
MEDIAL THIGH MUSCLES
• Adducts the thigh
• Innervated by the Obturator nerve
• Consists of:
1. Adductor longus
2. Adductor brevis
3. Adductor magnus
4. Gracilis MEDIAL THIGH MUSCLES
MUSCLE -MEDIAL NERVE
ACTION REMEMBER
COMPARTMENT SUPPLY
ADDUCTOR Adducts the thigh and • Linea aspera of femur – common insertion of adductor
LONGUS assists in lateral rotation muscles
ADDUCTOR Adducts the thigh and • Adductor tubercle of femur – insertion of hamstring part of
BREVIS assists in lateral rotation adductor magnus
OBTURATOR • GRACILIS – ADDUCTS THIGH and FLEXES LEG
ADDUCTOR Adducts the thigh and
MAGNUS assists in lateral rotation
Adducts the thigh and
GRACILIS
flexes leg at the knee joint
 POSTERIOR THIGH MUSCLES
• Extensors of the thigh at the hip joint
• Flexors of the Leg at the knee joint
• Innervated by the Sciatic Nerve
• Common origin – ischial tuberosity
• Consists of (HAMSTRING MUSCLES):
o All together – EXTEND the THIGH at the HIP JOINT and FLEX
the LEG at the KNEE JOINT
o Common Origin – Ischial tuberosity
o Hamstring part – Sciatic
o Adductor part – Obturator
1. Semitendinosus
2. Semimembranosus
3. Biceps femoris – long head – TIBIAL part
short head– COMMON PERONEAL
4. Adductor magnus – Dual innervation
(Hamstring – Sciatic; Adductor – obturator)

FEMORAL SHEATH
• a funnel shaped fascial tube formed by inferior prolongation of
iliopsoas and transversalis fascia of the abdomen
• Compartments:
o Lateral – femoral artery
o Intermediate- femoral vein
o Medial – femoral canal
REMEMBER:
The most lateral structure within the femoral SHEATH is the femoral
artery. The most lateral structure within the femoral TRIANGLE is the
femoral nerve.
- Dr. Ortiz

POSTERIOR THIGH MUSCLES

MUSCLE - CLINICAL CORRELATION: FEMORAL VEIN CATHETERIZATION
NERVE • Skin of the thigh below the inguinal ligament is supplied by the
POSTERIOR ACTION
SUPPLY Genitofemoral nerve – is blocked with a local anesthetic
COMPARTMENT
Extends the thigh and • Femoral pulse is palpated midway between ASIS and symphysis
SEMITENDINOSUS flexes and medially pubis; Femoral vein lies immediately MEDIAL to it
rotates the leg • At a site two fingerbreadths below the inguinal ligament, the
Extends the thigh and needle is inserted into the Femoral vein
SEMIMEMBRANOSUS flexes and medially
SCIATIC
rotates the leg CLINICAL CORRELATION: FEMORAL HERNIA
Extends the thigh and • Femoral ring is a weak area in the
BICEPS FEMORIS flexes and laterally anterior abdominal wall that normally
rotates the leg admits the tip of 5th digit
ADDUCTOR MAGNUS Extends the thigh • Femoral hernia: protrusion of
REMEMBER abdominal parietal peritoneum through
the femoral canal
• Ischial tuberosity – common origin of Hamstring muscles
• Appears as a mass, often tender, in the
• Short head of Biceps femoris – linea aspera and lateral
femoral triangle
supracondylar ridge of femur
• More common in women than men
• NECK OF HERNIAL SAC LIES BELOW and
B. FEMORAL TRIANGLE, SHEATH, LATERAL TO THE PUBIC TUBERCLE
& ADDUCTOR CANAL The neck of the hernial sac lies at the femoral ring and related anteriorly to the
FEMORAL TRIANGLE inguinal ligament, posteriorly to the pectineal ligament and medially to the
lacunar ligament
• Boundaries:
o Superior – Inguinal ligament SUMMARY OF INGUINAL HERNIAS
o Medially – Adductor longus
o Laterally – Sartorius • Follows path of descent
o Floor – Adductor longus, Pectineus and Iliopsoas of the testes (deep
Failure of
• Contents of Femoral Triangle
Indirect inguinal ring à
processus
o NAVEL inguinal superficial inguinal Infants
vaginalis to
o Femoral nerve and its branches hernia ring à scrotum)
close
o Femoral sheath and its contents • Lateral to inferior
o Femoral artery and its branches epigastric vessels
o Femoral vein and its tributaries • Protrudes through Acquired
Direct
Hesselbach triangle weakness in Older
inguinal
• Medial to inferior transversalis men
hernia
epigastric vessels; fascia
• Protrudes below Females
Femoral Weak
inguinal ligament (wider
hernia femoral ring
through femoral canal pelvis)
 • Common origin of Gluteal muscles – Outer surface of Ilium
• Common insertion: Greater trochanter of femur EXCEPT:
o gluteus maximus – gluteal tuberosity, iliotibial tract
o quadratus femoris – quadrate tubercle
ADDUCTOR CANAL (SUBSARTORIAL CANAL, HUNTER’S CANAL)
SUMMARY OF MUSCLES ACTING AT THE HIP JOINT
• a fascial tunnel in the thigh running from the apex of the femoral THIGH & GLUTEAL NERVE
ACTION
triangle to the ADDUCTOR HIATUS in the tendon of adductor MUSCLES SUPPLY
magnus muscle Anterior
Flexion Femoral
• Boundaries: compartment
o Anterior – Sartorius Medial compartment Adduction Obturator
o Lateral – Vastus medialis Posterior
Extension Sciatic
o Posterior & Medial - Adductor longus/ magnus compartment
• Contents: Extension and weak Inferior
Gluteus maximus
o Femoral artery / vein lateral rotation gluteal
o Saphenous nerve Gluteus medius and Abduction and medial Superior
o Nerve to vastus medialis minimus rotation gluteal
• Flexion – Anterior Thigh – Femoral N
• Extension – Posterior Thigh – Sciatic N and Gluteus maximus –
Inferior Gluteal N
• Adduction – Medial Thigh - Obturator
• Abduction – Gluteus medius and minimus – Superior Gluteal N
• Medial rotation – Gluteus medius and minimus
• Lateral rotation – Piriformis etc.

FEMORAL NERVE – L2 L3 L4
• Largest branch of the lumbar plexus; supplies the anterior
compartment of the thigh
• Emerges from the lateral border of the psoas major muscle within
the abdomen and passes downward between the psoas major and
iliacus
• Enters the thigh lateral to the femoral artery and femoral sheath
behind the inguinal ligament
• DOES NOT ENTER THE THIGH WITHIN THE FEMORAL SHEATH

C. GLUTEAL REGION
MUSCLES OF THE GLUTEAL REGION:
1. Superficial group – Gluteus maximus
o Extensor of thigh
o Supplied by Inferior Gluteal nerve
2. Intermediate group - Gluteus medius & Gluteus minimus
o Abductor and Medial rotator of thigh
o Supplied by Superior Gluteal nerve
3. Deep group - Piriformis, obturator internus superior & inferior
gemelli, quadratus femoris
o Lateral rotator of thigh
OBTURATOR NERVE – L2 L3 L4 ROOTS OF
NERVES INNERVATION
• Supplies the medial compartment of the thigh ORIGIN
• Emerges on the medial border of the psoas major muscle COMMON L4L5S1
within the abdomen PERONEAL S2
• Runs forward on the lateral wall of the pelvis to reach the Superficial LATERAL COMPARTMENT of the
L5S1S2
obturator foramen Peroneal LEG
Deep L4L5S1 ANTERIOR COMPARTMENT of
Peroneal S2 the LEG
GLUTEAL NERVES
• Leaves the pelvis through the upper part of the
greater sciatic foramen ABOVE the piriformis
Superior Gluteal
• Runs forward between the gluteus
nerve (L4L5S1)
medius and minimus and ends by
supplying the tensor fasciae lata
• Leaves the pelvis through the lower part
Inferior Gluteal of the greater sciatic foramen BELOW the
nerve (L5S1S2) piriformis
• Supplies the gluteus maximus

SCIATIC NERVE – L4 L5 S1 S2 S3
• largest nerve
• Emerges from the pelvis through the lower part of the greater
sciatic foramen
• Appears below the Piriformis muscle and curves downward and
GLUTEAL NERVES
laterally lying on the root of the ischial spine, superior gemellus,
HIP JOINT LIGAMENTS
obturator internus, inferior gemellus and quadratus femoris to
reach the back of the adductor magnus muscle • ILIOFEMORAL – strong, inverted Y shaped; base attaches to the
• Related posteriorly to the posterior cutaneous nerve of the thigh anteroinferior iliac spine above and the two limbs of the Y attach
and gluteus maximus to the upper/lower parts of the intertrochanteric line of femur;
• Leaves the buttock region by passing deep to the long head of the prevents OVEREXTENSION during standing
biceps femoris to enter the back of the thigh • PUBOFEMORAL – triangular; base attach to the superior ramus of
the pubis and apex attaches below to the lower part of the
intertrochanteric line; limits EXTENSION and ABDUCTION
• ISCHIOFEMORAL – spiral shaped; attached to the body of the
ischium near the acetabular margin; fibers pass upward and
laterally then attach to the greater trochanter; limits EXTENSION
• TRANSVERSE ACETABULAR LIGAMENT – formed by the
acetabular labrum; converts the notch into a tunnel through which
blood vessels and nerves enter the joint
• LIGAMENT OF THE HEAD OF FEMUR – flat and triangular; lies
within the joint covered by synovial membrane

• ILIOFEMORAL – inverted Y shaped – prevents OVEREXTENSION during

standing
• PUBOFEMORAL – triangular; limits EXTENSION and ABDUCTION
• ISCHIOFEMORAL – spiral shaped; limits EXTENSION
✔GUIDE QUESTION
A patient walks with a waddling gait that is characterized by the pelvis
falling toward one side at each step. What nerve is involved?
A. Superior Gluteal C. Obturator
B. Inferior Gluteal D. Femoral
Which ligament of the hip is Y-shaped and checks hyperextension
From Sciatic Nerve of the joint during standing?
ROOTS OF A. Iliofemoral C. Ischiofemoral
NERVES INNERVATION
ORIGIN B. Pubofemoral D. Annular
L4L5S1 POSTERIOR COMPARTMENT of
TIBIAL
S2S3 the LEG CLINICAL CORRELATION: LOWER EXTREMITY LESIONS
Skin medial 3 and half toes; What keeps the hips stable?
Medial Abductor Hallucis, Flexor Hip joint Stability
S2S3
Plantar digitorum brevis, Flexor hallucis üStability when a person stands on one leg with the foot of the opposite leg
brevis, First lumbrical raised above the ground depends on 3 factors
Lateral Skin lateral 1 and half toes; üGluteus medius and minimus must be functioning normally
S2S3 üHead of the femur must be located normally within the acetabulum
Plantar All intrinsic muscles
üNeck of femur must be intact and must have a normal angle with shaft of femur
SUPERIOR GLUTEAL NERVE INJURY FEMORAL NERVE LESIONS
• Results to weakened abduction of the thigh by gluteus medius • May be damaged in the abdomen by an abscess of the Psoas
• “Waddling” gait - pelvis sags on the side of unsupported limb major
• (+) Trendelenburg sign - pelvis tils (hip drops to one side) • Weakness in the ability to flex the thigh at the hip
because weight-bearing leg cannot maintain alignment of pelvis • Weakness in the ability to extend the leg at the knee
through hip abduction • Diminished Patellar tendon reflex
SAPHENOUS NERVE LESIONS
• May be lesioned during a surgical procedure of the leg to remove
part of the great saphenous vein or may be lacerated as it pierces
the wall of the adductor canal
• Pain and Paresthesia in the skin of the medial aspect of the leg
and foot
• No motor loss
OBTURATOR NERVE LESIONS
• Most commonly lesioned in the Pelvis
© Topnotch Medical Board Prep • Patients are unable to adduct the thigh at the hip
INFERIOR GLUTEAL NERVE LESIONS Paresthesia in the skin of the medial thigh
• Weakness in the ability to laterally rotate and extend the
Let’s not confuse the different gaits:
thigh at hip joint
Spastic gait Amyotrophic lateral sclerosis
• Difficulty extending the thigh at the hip from a flexed position, as Waddling gait Superior gluteal nerve injury
in climbing stairs or rising from a chair Duchenne muscular dystrophy
• Have a Gluteus maximus gait, in which patients thrust their torso Wide-based gait Cerebellar lesion
posteriorly in an attempt to counteract the weakness of the Steppage gait (foot drop) Common peroneal nerve injury
gluteus maximus Shuffling gait Parkinson disease
- Dr. Ortiz
SCIATIC NERVE LESIONS
• Susceptible to damage from an IM injection in the lower medial D. THIGH
quadrant of the gluteus maximus muscle or it may be FEMUR
compressed as a result of a posterior dislocation of the femur • Neck shaft angle changes:
• L5 and S1 roots are commonly compressed – pain that radiates o 160 degrees – young
into the L5 and S1 dermatomes of the leg and foot o 125 degrees - adults
INTRAGLUTEAL INJECTIONS • COXA VARA
• Common site for intramuscular injections o Decreased
• should be made on the superolateral part of the buttock to o fractures of the neck
avoid hitting nerves & vessel o ABDUCTION is limited
• COXA VALGA
o Increased
o congenital dislocation
o ADDUCTION is limited

✔GUIDE QUESTION
A 54 y/o man has just dislocated his right hip. The physician is
concerned about the integrity of the joint’s blood supply. Which artery
is the main blood supply to the hip joint?
A. Lateral circumflex femoral
B. Medial circumflex femoral
C. Superficial circumflex iliac
PIRIFORMIS SYNDROME D. Deep circumflex iliac
• piriformis muscle irritates and places pressure on the Sciatic
nerve causing pain in the buttocks and referring pain along the CLINICAL CORRELATION: FEMUR
course of Sciatic nerve • Majority of the blood supply to the head of the femur comes from:
• Patients usually with excessive use of gluteal muscles (ice o Medial (and lateral) circumflex femoral arteries - anastomose
skaters, cyclists, rock climbers) or with history of trauma to the to form a ring around the neck of the femur
buttocks which can cause hypertrophy and spasm of the o Foveal artery (artery of the ligamentum teres) – runs within
piriformis the ligamentum teres to supply the femoral head, comes from
the obturator artery
SCIATICA • Disruption of blood supply to proximal femur may cause
• Pain in the lower back and hip radiating down the back of the AVASCULAR NECROSIS OF FEMORAL HEAD
thigh and leg • Causes: femoral neck fracture, dislocation of femoral head from
• Usually caused by herniated lumbar intervertebral disc that acetabulum; chronic steroid use, excessive alcohol consumption
compresses L5 or Si of sciatic nerve
✔GUIDE QUESTION
A basketball player fell on his left knee resulting into swelling and pain.
A fracture of the patella will result in:
A. Difficulty in extending leg at the knee joint
B. Difficulty in flexing leg at the knee joint
C. Inability to extend the thigh at the hip joint
D. Inability to flex the thigh at the hip joint
 FASCIAL COMPARTMENTS OF THE LEG

FEMORAL NECK FRACTURE

• common injury to the proximal femur
• associated with increased risk of avascular necrosis
• Features:
o LEG IS SHORTENED WITH LATERAL ROTATION
o Due to pull upward by the Quadriceps femoris, adductors and
Hamstring muscles
• Treatment: open reduction and internal fixation versus
arthroplasty.

FEMORAL NECK FRACTURE

DISLOCATION OF THE HEAD OF THE FEMUR
• Most commonly occur in posterior direction
• Thigh is shortened and MEDIALLY ROTATED by the gluteus ✔GUIDE QUESTION
medius and minimus muscles Which of the following muscles dorsiflexes the foot at ankle joint?
• Sciatic nerve may be compressed, resulting in weakness of A. Peroneus longus C. Tibialis anterior
muscles in the posterior thigh, leg and foot B. Tibialis posterior D. Peroneus tertius
Paresthesia over the posterior and lateral parts of the leg and dorsal
and plantar surfaces of the foot ANTERIOR LEG MUSCLES - EXTENSORS
• Muscles:
E. LEG o Tibialis anterior
BONES OF THE LEG o Extensor digitorum longus
TIBIA FIBULA o Extensor hallucis longus
• Large, weight bearing; • Slender; lateral o Peroneus tertius
medial • No part in the articulation at • Nerve: deep peroneal nerve
• Articulates with the the knee joint but it • Action: dorsiflexion and extension
condyles of the femur and participates in the ankle
head of fibula above and joint MUSCLE –
NERVE
with the talus and distal end • No part in the transmission ANTERIOR ACTION
SUPPLY
of the fibula below of body weight COMPARTMENT
• Expanded upper end • Expanded upper end TIBIALIS Dorsiflexes the foot
• Smaller lower end • Shaft ANTERIOR at the ankle joint; inverts
• Shaft • Lower end EXT. DIGITORUM Dorsiflexes the foot
• Lateral and Medial condyles • Upper end/ Head with a LONGUS at the ankle joint
Deep
• Shaft – triangular Styloid process EXT. HALLUCIS Dorsiflexes the foot
peroneal
• Three borders • Shaft – long and slender with LONGUS at the ankle joint
o Anterior – prominent four borders and four Dorsiflexes the foot
PERONEUS
forms the SHIN surfaces (medial border – at the ankle joint;
TERTIUS
o Medial Interosseous) everts
o Lateral / Interosseous • Lower end forms the
• Medial malleolus on the triangular Lateral malleolus
lower end
 LATERAL LEG MUSCLES – EVERTORS CLINICAL CORRELATION: SYMPTOMS OF ACHILLES TENDON
• Muscles: RUPTURE
o Peroneus (fibularis) longus • Sudden acute pain at the back of the calf or ankle
o Peroneus (fibularis) brevis • A snap may be heard
• Nerve: Superficial peroneal nerve • Difficulty in walking and standing on TIPTOE
• Action: Eversion and weak plantarflexion • A gap may be felt in the tendon
MUSCLE – • Bruising and weakness of the ankle
NERVE • Severe swelling is present
LATERAL ACTION
SUPPLY
COMPARTMENT
PERONEUS
EVERTS THE FOOT and
LONGUS SUPERFICIAL
PLANTARFLEXES the
PERONEUS PERONEAL
FOOT at the ankle joint
BREVIS

SUMMARY: LEG MUSCLES

NERVE
LEG MUSCLES ACTION
SUPPLY
LATERAL LEG MUSCLES ANTERIOR DORSIFLEXION of the DEEP
COMPARTMENT FOOT at ANKLE JOINT PERONEAL
POSTERIOR LEG MUSCLES – FLEXORS LATERAL SUPERFICIAL
EVERSION
• Muscles COMPARTMENT PERONEAL
o Superficial group: o Deep group: POSTERIOR PLANTARFLEXION of the
TIBIAL
§ Gastrocnemius § Popliteus COMPARTMENT FOOT at ANKLE JOINT
§ Plantaris § Flexor digitorum longus ALL PERONEUS EVERSION --
§ Soleus § Flexor hallucis longus ALL TIBIALIS INVERSION --
§ Tibialis posterior
• Nerve: tibial nerve F. POPLITEUS AND POPLITEAL FOSSA
• Action: Plantar flexion and flexion
POPLITEUS
• NOTE: Popliteus – Unlocks the knee; NO ACTION on ankle joint
• Action – unlocks the knee
• Gastrocnemius and Soleus: collectively called TRICEPS SURAE
• Common Insertion: ACHILLES TENDON MUST KNOW
MUSCLE – PE-TI
NERVE Peroneus Muscles Tibialis Muscles
POSTERIOR ACTION
SUPPLY Evert foot Invert foot
COMPARTMENT
GASTROCNEMIUS Plantarflexes the Plantar flex Plantar flex
Superficial
group
SOLEUS foot TIBIAL
PLANTARIS at the ankle joint
FLEXES LEG AT
POPLITEUS THE KNEE JOINT
/ UNLOCKS
FLEXOR
DIGITORUM Plantarflexes the
Deep LONGUS foot
TIBIAL
group FLEXOR HALLUCIS at the ankle joint POPLITEAL FOSSA
LONGUS • Boundaries:
Plantarflexes the o Laterally: Biceps femoris above and lateral head of
TIBIALIS foot Gastrocnemius below
POSTERIOR at the ankle joint; o Medially: Semimembranosus and Semitendinosus above and
INVERTS medial head of Gastrocnemius below
• Contents:
o Popliteal vessels o Small saphenous vein
o Common Peroneal N o Tibial N
o Post. Cutaneous N o Genicular branch of Obturator N.
o LN’s
 ✔GUIDE QUESTION
Which spinal root mediates the Achilles tendon reflex?
A. L 4 C. S 1
B. L 5 D. S 2

MUST KNOW TENDON REFLEXES

1. Biceps brachii tendon reflex – C 5
2. Brachioradialis – C 6
3. Triceps brachii – C 7 FEMORAL ARTERY
4. Patellar tendon – L 4 • behind inguinal ligament midway between the ASIS and
5. Achilles tendon – S 1 symphysis pubis
POPLITEAL ARTERY
G. BLOOD VESSELS OF THE LOWER EXTREMITIES • popliteal space fully relaxed by passively flexing the knee joint
COMMON ILIAC POSTERIOR TIBIAL
1. Internal iliac behind medial malleolus and beneath flexor retinaculum; lies
2. External iliac between tendons of FDL and FHL / midway between medial
a. FEMORAL malleolus and heel
b. Popliteal VENA COMMITANTES
c. Ant / Post Tibial • Ant / Post Tibial • External iliac
d. Plantar arch • Popliteal • Internal iliac
EXTERNAL ILIAC • Femoral • Common iliac
• BRANCHES:
✔GUIDE QUESTION
o Inferior epigastric A dehydrated 3 y/o has only one prominent vein which is located in
o Deep Circumflex iliac the ankle in front of the medial malleolus. What vein is it?
o Femoral A. Anterior tibial C. Small saphenous
✔GUIDE QUESTION B. Posterior tibial D. Great saphenous
A 50 y/o male patient was noted to have cyanosis and decreased
sensation of the left foot. You decided to assess the dorsalis pedis SAPHENOUS
pulse. Where will you palpate for pulsation? • Great / Long Saphenous drains into Femoral vein – anterior to
A. Medially to the EHL tendon medial malleolus
B. Medially to the EDL tendon
• Small / Short Saphenous drains into Popliteal vein – posterior
C. In front of medial malleolus
D. Behind the medial malleolus
to lateral malleolus

CLINICAL CORRELATION: GREAT SAPHENOUS VEIN CUTDOWN

• Usually performed at the ANKLE
• The Saphenous nerve is blocked
with local anesthetic (sensory
nerve supply to the skin
immediately in front of the
medial malleolus of the tibia)
• A transverse incision is made
through the skin and
subcutaneous tissue across the
long axis of the vein just
ANTERIOR and SUPERIOR to the
medial malleolus
• The vein is easily identified and
the Saphenous nerve lies just
ANTERIOR to the vein

H. CUTANEOUS INNERVATIONS
1. Lateral Cutaneous Nerve: Branch of common peroneal n.
2. Superficial Peroneal Nerve: Branch of common peroneal n.
3. Saphenous Nerve: Branch of femoral n.

ARTERIES TO LEG

CLINICAL CORRELATION: ARTERIAL PALPATION – LOWER LIMB

DORSALIS PEDIS ARTERY/ “DORSALIS
PEDIS PULSE”
• Laterally: tendons of extensor
digitorum longus
• Medially: tendon of extensor hallucis
longus
• Landmark – between malleoli or 1st
intermetatarsal space
 SUPERFICIAL PERONEAL / FIBULAR NERVE LESIONS
• May be injured as the nerve emerges from the lateral
compartment of the leg
• Pain and Paresthesia in the dorsal aspect of the foot
SAPHENOUS NERVE • Weakness in EVERSION of foot
• runs down the medial side of the leg together with the Great
Saphenous vein; TIBIAL NERVE LESIONS
• passes IN FRONT of the medial malleolus and along the medial • In patients with Tibial nerve lesions in the gluteal region (hip
border of foot; fracture, dislocation of femur), weakness may be evident in the
• Supplies the skin on the anteromedial surface of the leg ability to flex the leg at the knee and plantarflex at the ankle
• CAN’T STAND ON TIPTOES
SURAL NERVE • Paresthesia on skin of posterior leg, sole and lateral foot
• branch of the Tibial nerve;
• accompanies the Small Saphenous vein BEHIND the Lateral I. THE KNEE JOINT
malleolus;
• Synovial joint
• Supplies the skin on the lower part of the posterolateral surface
of the leg • Stabilized laterally by Biceps and Gastrocnemius tendons,
Iliotibial tract and Fibular collateral ligaments
• Stabilized medially by Sartorius, Gracilis, Gastrocnemius,
SCIATIC NERVE Semitendinosus and Semimembranosus muscles and Tibial
Collateral ligament
1. Tibial
2. Common Peroneal
Strength of the Knee Joint
a. Superficial Peroneal
• Depends on:
b. Deep Peroneal
o TONE of the muscles acting on the knee joint; most important
– Quadriceps femoris
✔GUIDE QUESTION
The nerve commonly injured in “foot drop”?
o Strength of the ligaments
A. Common Peroneal
B. Deep Peroneal
C. Superficial Peroneal
D. Tibial

CLINICAL CORRELATION: LOWER EXTREMITY NERVE LESIONS

COMMON PERONEAL / FIBULAR NERVE LESIONS
• Most frequently injured nerve in the lower limb
• Compression at neck of fibula, Hip fracture, dislocation of femur
• FOOT DROP– which results from a loss of dorsiflexion at the ankle
and loss of eversion
• “STEPPAGE” gait – raise the affected leg high off the ground and the
foot slaps the ground when walking
• Pain and Paresthesia in the lateral leg and dorsum of the foot
EXTRA CAPSULAR INTRACAPSULAR
LIGAMENTS LIGAMENTS
• Ligamentum patellae • Cruciate ligaments
• Lateral collateral ligament o Anterior cruciate ligament
• Medial collateral ligament o Posterior cruciate ligament
• Oblique popliteal ligament

INTRACAPSULAR LIGAMENTS
ANTERIOR CRUCIATE POSTERIOR CRUCIATE
Prevents forward sliding of Prevents backward sliding of
the tibia on the femur the tibia on the femur
Posterior displacement of Anterior displacement of
the femur on tibia the femur on tibia
DEEP PERONEAL / FIBULAR NERVE LESIONS LAX during FLEXION LAX during EXTENSION
• May be compressed in the anterior compartment of the leg • ACL – “APEX” ligament – attaches to the Anterior aspect of Tibia
• May have Foot drop and paresthesia in skin of the webbed space and courses Posteriorly and EXternally to attach to the lateral
between the great toe and the second toe condyle of femur
• PCL – “PAIN” ligament – attaches to the Posterior aspect of tibia
and courses Anteriorly and INternally to attach to the medial
condyle of femur
 CLINICAL CORRELATION: KNEE INJURIES
• 3 most commonly injured structures are the Tibial collateral
ligament, Medial meniscus and ACL (THE TERRIBLE TRIAD)
• Blow to the lateral aspect of the knee – may injure the tibial
collateral ligament; the attached medial meniscus may also be torn
• Blow to the anterior aspect of the flexed knee may tear only the
ACL

Unhappy Triad of O’Donoghue

1. ACL
EXTRACAPSULAR LIGAMENTS 2. MCL
• Ligamentum Patellae – attaches above to the lower border of the 3. Medial meniscus
patella and below to the tuberosity of the tibia Signs and Symptoms
• LATERAL COLLATERAL LIGAMENT – attaches above to the • Popping sound at the
lateral condyle of the femur and below to the head of the fibula time of injury
• MEDIAL COLLATERAL LIGAMENT – attaches above to the medial • Severe swelling of the
condyle of the femur and below to the medial surface of the shaft knee
of tibia • Bruising on or around
• Oblique Popliteal ligament – tendinous expansion derived from the knee
the semimembranosus muscle • Pain that ranges from
mild to severe
MEDIAL COLLATERAL LATERAL COLLATERAL • The knee feels unstable or that it may give out
Forced ADDUCTION of the • Stiffness in the knee
Forced ABDUCTION of the
TIBIA on FEMUR • The knee feels like it is catching or locking
TIBIA on FEMUR
(Less common) • Unable to move the knee
Treatment
MENISCI • Usually requires surgery: Reconstruction of ACL (Patellar tendon
• A meniscus is a piece of cartilage found where two bones meet autograft, hamstring tendon autograft, quadriceps tendon
(joint space); protects and cushions the joint surface and bone autograft; allograft); Meniscectomy
ends • Physical therapy: strengthening muscle and increasing the knee's
• In the knee, the crescent shaped menisci are positioned between range of motion without damaging the new grafts
the ends of the femur and tibia • Knee brace
• LATERAL MENISCUS
• MEDIAL MENISCUS MENISCAL INJURY
• Medial meniscus is damaged more frequently than lateral
BURSA because of its strong attachment to the medial collateral ligament
• a fluid filled sac; countering friction at a joint which restricts its mobility; injury to the Lateral meniscus is less
common because it is NOT attached to the Lateral collateral
• ANTERIOR
ligament and its more mobile
o Suprapatellar
o Prepatellar
o Infrapatellar – superficial and deep
• POSTERIOR
o Popliteal
o Semimembranosus

ANTERIOR DRAWER SIGN

• forward sliding of the Tibia on the Femur due to rupture of the
ANTERIOR CRUCIATE LIGAMENT
POSTERIOR DRAWER SIGN LIGAMENTS
• backward sliding of the Tibia on the Femur caused by rupture of • MEDIAL or DELTOID • LATERAL Ligament
the POSTERIOR CRUCIATE LIGAMENT Ligament (weaker)
o Tibionavicular o Anterior Talofibular Lig
o Tibiocalcaneal o Calcaneofibular Lig.
o Anterior Tibiotalar o Posterior Talofibular Lig
o Posterior Tibiotalar

KNOCK KNEE BOWLEG

(GENU VALGUM) (GENU VARUM)
Tibia is bent or twisted
Tibia is bent medially
laterally
Collapse of the lateral Collapse of the medial
compartment of the knee and compartment of the knee and
rupture of the Medial / rupture of the Lateral /
Tibial collateral ligament Fibular collateral ligament

CLINICAL CORRELATION: ACUTE ANKLE SPRAINS

To remember which one is knock-knee and which one is bowleg, think of it this way: Acute Sprains on the Acute Sprains on the
• GENU VALGUM - there is gum between the knees, making them stick together LATERAL ANKLE MEDIAL ANKLE
(hence, knock-knee)
Excessive INVERSION of the
• GENU VARUM – there is a large bottle of rum between the knees, forcing
them apart (hence, bowleg)
foot with PLANTARFLEXION Excessive EVERSION
of the ankle
Children normally appear bowlegged for 1 – 2 years after starting to walk. Ant Talofibular and
Knock-knees are also frequently observed in 2 -4 years of age. Persistence in late
childhood beyond implies congenital deformities that may need correction.
Calcaneofibular ligaments are Medial or Deltoid ligament
- Dr. Uy partially torn
BURSITIS ✔GUIDE QUESTION
• Knee Bursitis – inflammation of the bursa at the knee joint Which joint is mainly responsible for the inversion and
• Housemaid’s knee is also known as Prepatellar bursitis eversion of the foot?
A. Subtalar
B. Talocalceneal
C. Talocrural
D. Ankle joint proper
Condition wherein a person has high longitudinal arches of the
foot:
A. Pes Planus C. Talipes equinovarus
B. Pes cavus D. Plantar fasciitis
TARSAL BONES
• Calcaneus – largest bone of the foot,, forms the prominence of the
heel; with SUSTENTACULUM TALI (assists in the support of talus)
• Talus – articulates above at the ankle joint with tibia and fibula, in
front with navicular and below with the calcaneus; NO MUSCLE
ATTACHMENTS
J. THE ANKLE JOINT • Navicular
• Diarthrodial synovial hinge joint • Cuboid
• Cuneiforms (3)
BONES
• Tibia
• Fibula
• Talus
TAKE NOTE ANKLE JOINTS

1. DORSIFLEXION and PLANTARFLEXION – occur at the ANKLE

JOINT PROPER or TALOCRURAL JOINT – formed by distal
ends of malleoli of fibula and tibia and trochlea of Talus bone
2. INVERSION and EVERSION at the SUBTALAR JOINT between
the Talus and Calcaneus
METATARSAL BONES AND PHALANGES
• Metatarsals (5)
o First – large and strong and plays a role in supporting the weight
of the body; Medial side
o Fifth – on the lateral which has a prominent tubercle on its base
• Phalanges – each toe has three phalanges except the big toe which
possesses only 2

FOOT ARCHES
• Medial longitudinal – consists of calcaneum, talus, navicular,
three cuneiforms and the first three metatarsal bones
• Lateral longitudinal – calcaneum, cuboid, 4th and 5th metatarsal
bones
• Transverse – bases of the metatarsal bones, cuboid and three
cuneiforms

SUPPORT OF THE STONE BRIDGE (Support the arches)

• Most effective way of supporting the arch is to make the stones
wedge shaped; occupies the center of the arch is referred as the
KEYSTONE
• Medial longitudinal – rounded head of the Talus is the keystone
• Lateral longitudinal – Cuboid is the keystone
• Transverse - Cuneiform
TAKE NOTE
PES PLANUS/ PES CAVUS/
FLAT FOOT CLAW FOOT
Medial longitudinal arch is
Medial longitudinal arch is
depressed or collapsed; foot is
unduly HIGH
displaced laterally and everted

K. LYMPHATIC DRAINAGE OF LOWER LIMB

• Superficial lymph vessels ascend with superficial veins
• Deep lymph vessels follow deep arteries and veins
• All ultimately drain into deep inguinal group of nodes situated
in the groin
Superficial inguinal lymph nodes
• Lies just distal to the inguinal ligament
Superior • Receive lymph vessels from anterior abdominal
group wall below umbilicus, gluteal region, perineal
region, external genital organs
• Lies vertical along the terminal great saphenous
v.
• Receives all superficial lymph vessels of lower
Inferior
limb, except for those from the posterolateral
group
part of calf
• Efferent vessels drain into the deep inguinal ln.
or external iliac ln.
• Embedded in the fatty connective tissue of
popliteal fossa
• Receive superficial lymphatic vessels from
Popliteal
posterolateral part of calf, and from deep
LN
lymphatic vessels accompanying anterior and
posterior tibial a.
• Efferents pass to the deep inguinal ln.