Anatomy Objectives: Pelvis, Perineum, and Lower Limb
Male Pelvic Organs
The students should be able to:
1. Describe the anatomical relationships of the bladder, seminal vesicle, prostate and rectum.
 Bladder is in the most anterior part of the pelvic viscera – expands superiorly into the abdomen when full.
 The seminal vesicle is lateral to the base of the bladder and follows the course of the ductus deferens.
 The prostate surrounds the urethra and is immediately inferior to the bladder, posterior to pubic symphysis,
anterior to rectum
 The rectum is the most posterior structure in the pelvic cavity
2. Describe the reflections of the peritoneum on the bladder and rectum.
 In men, peritoneum drapes over the top of the bladder onto the seminal vesicles and reflects on to the
lateral & anterior surface of the rectum.
 A rectovesical pouch is formed between the bladder and the rectum.
3. Describe the course of the ureter from the posterior body wall to the bladder.
 The ureter begins at the pelvis of the kidney (constriction point #1) and enters the pelvic cavity through the
pelvic inlet where goes through the bifurcation of the common iliac artery (constriction point #2) and enters
the base of the bladder (constriction point #3).
 In the pelvis, the ureter is crossed by the ductus deferens (water under the bridge)
4. Describe the course of the ductus deferens from the anterior body wall to the ejaculatory duct.
 The ductus deferens is a long muscular duct that transports spermatozoa from the epididymis in the
scrotum to the ejaculatory duct.
 Starts at the scrotum as a part of the spermatic cord and passes through the inguinal canal. After passing
through the deep inguinal ring, it bends and crosses the external iliac artery and iliac vein to enter the pelvic


cavity. It descends medially and crosses the ureter posterior to the bladder. There it is joined by the seminal
vesicle to form the ejaculatory duct.
Simplified: Scrotum  deep inguinal ring  External iliac vessels  Posterior to bladder  Combines with
seminal vesical
See Picture of Question #1 for visual
5. Describe the anatomy of the prostate.
 The prostate surrounds the urethra in the pelvic cavity: Inferior to bladder, superior to levator ani.
Ejaculator ducts pass through the posterior part of the prostate to open into the prostatic urethra.
 The prostate is composed of 5 lobes: Anterior, 2 Lateral, Median, and posterior
6. Describe the innervation, blood supply, venous and lymphatic drainage of the organs in the male pelvic cavity.
Organ
Rectum
Innervation
PSNS: Pelvic
Splanchnic
Artery
Vein
Superior, Middle,
Superior & Middle
Inferior Rectal Art. Rectal veins
Lymphatics
Internal Iliac
Nodes
Anal
Canal
PSNS: Pelvic
Splanchnic
SNS: Pudendal Nerve
PSNS: Pelvic
Splanchnic
SNS: Pudendal Nerve
Prostatic Plexus
(Inferior Hypogastric
Plexus)
Perineal nerve
Inferior Rectal
Inferior Rectal
Superficial
Inguinal
Supr/Infr Vesical
Art.
Prostatic/Vesical
Plexus
Internal Iliac
Nodes
Inferior Vesical
Artery
Inferior Vesical Vein
Internal Iliac
Nodes
Perineal Art.
Deep dorsal vein of
penis
Superficial
Inguinal
Bladder
Prostate
Penis
7.
List the most common clinical signs produced by enlargement of the prostate gland. What are some of the
symptoms of this condition?
Enlargement of the prostate gland can be indicative of benign prostate enlargement (BPH) or prostate cancer
BPH – enlargement is usually found in the median and lateral lobes of the prostate. Enlargement of the prostate
can cause contraction of the urethra and also the bladder.
o Urethra compression  weak stream of urine
o Bladder compression  frequent urination
 Prostate cancer – carcinoma typically affects the posterior lobe.
o Prostate cancer can travel to the CNS via prostatic plexus  vertebral venous plexus (valveless system)
o Back pain – can be a sign that prostatic cancer has spread to the vertebral venous plexus (CNS).
A digital rectum exam can be one of the first tests to check for BPH or prostatic cancer.

8. Describe the consequences of benign prostate enlargement (“BPH”).
See Question #7
9. Describe the common complications of the procedure called TURP (TransUrethral Resection of the Prostate).
TURP is the excison of the prostate/parts of the prostate via the urethra. When taking out the prostate, it can
lead to problems of the urethra which can cause:

Retrograde ejaculation: Urethra is larger  sphincters cannot adequately close  ejaculate travels into
bladder.


Urine incontinence: Urethra is larger  sphincters cannot adequately close  Urine passes through
internal sphincter
Ejaculation problems: TURP may injury parts of the pudendal nerve which contribute to ejaculation
(sympathetic).
10. List the common complications of open prostatectomy (effects on sexual functioning and continence of urine).
See Question #9.
Complications are the same as TURP. Mechanism is also the same, affects the urethra and internal sphincters.
11. List some of the common sites of prostate cancer metastasis and explain how prostate cancer cells can travel to
the central nervous system.
See question #7
12. Describe the anatomical relationship of the bladder, uterus, uterine tubes, ovaries and rectum in the
pelvic cavity.
Bladder is in the most anterior position of the pelvis. The uterus lies posterior to the bladder and anterior to the
rectum while the uterine tubes extend from each side of the uterus to the lateral pelvic wall. The ovaries are on the
posterior side of the broad ligament so the uterine tubes pass superiorly and terminate laterally at the ovaries. The
rectum lies posteriorly.
13. Describe the reflections of the peritoneum on the bladder, uterus, uterine tube, ovary and the rectum.
The broad ligament is a fold of the peritoneum. It surrounds the uterine tube on the superior side. The
mesovarium is located on the anterior aspect of the ovary while the mesometrium is along the sides of the uterus.
The mesosalpinx is the part of the broad ligament between the mesovarium and the uterine tube. The peritoneum
descends over the posterior side of the uterus and cervix onto the vaginal wall. It then reflects to the anterior and
lateral walls of the rectum. The lower 1/3 of the rectum is not covered by the peritoneum. (This is common to both
males and females) (page 418 Grey’s).
14. Describe the course of the ureter from the posterior body wall to the bladder.
The ureters descend into the pelvic cavity via the pelvic inlet. They enter anterior to the bifurcation of the common
iliac artery. In women the ureter is crossed by the uterine artery (while in males it’s the ductus deferens) and then
continues until the base of the bladder. (Page 399 Greys).
15. Describe the anatomy of the uterus, uterine tube and ovary.
The uterus lies posterior to the bladder and the two uterine tubes extend from each side of the uterus until it
reaches the ovaries.
16. Describe the innervation, blood supply, venous and lymphatic drainage of the organs in the female
pelvic cavity.
Arterial supply to the uterus: Ovarian artery (a branch from the aorta), uterine artery, vaginal artery and internal
pudendal artery (all of which come from the internal iliac arter). (Page 5 of lecture 41)
Lymph drainage of the uterus: Fundus of uterus drains to lumbar nodes; body of uterus, cervix and upper vagina
drain into external and internal iliac nodes and the sacral nodes. The lower vagina, labia majora/minora drain into
the inguinal nodes. (Page 14 of lecture 41) Lymphatics from the ovaries empty into the aortic nodes. All end up
draining into the lumbar trunks and the thoracic duct (greys page 434)
Nerves: lower ¼ of vagina is innervated by pudendal nerve; upper ¾ of vagina is innervated by visceral afferents.
(page 14 of lecture 40)
Venous drainage: follows the branches of the internal iliac except for the umbilical artery. All these veins
contribute to the portal and caval systems which can give rise to hemorrhoids (especially in pregnant women).
There is a deep dorsal vein that drains the clitoris and this vein does not follow the branches of the internal
pudendal artery. Instead it goes directly into the pelvic cavity. The ovarian veins follow the corresponding arteries
(they join the left renal vein on the left side and on the right side, they join the IVC) (Page 431 greys)
17. Explain how/where the female ureter is at risk during ligation of ovarian vessels?
The ureter runs inferior to the ovarian vessels. Thus as the ureter crosses into the true pelvis, the ureters can be at
risk during the ligation of these vessels. (Case study example on page 463 of greys)
18. The importance of the relationship between the posterior fornix of the vagina and the rectouterine
pouch (of Douglas)?
The posterior fornix of the vagina is located between the posterior wall and the cervix. The two are very closely
related and the pouch of Douglas can be felt from this space.
19. Describe how a physician can determine if the uterine tubes are patent.
Contrast dye can be injected into the uterus. As it follows through the uterine tubes, if the contrast “spills” out into
the peritoneal cavity then the tubes are said to be patent.
20. Describe the clinical importance of the lymphatic drainage of uterus.
Lymph drainage of the uterus:
 Fundus/ovaries/fallopian tubes: drains into lumbar nodes
 Body of uterus/cervix/upper vagina: drain into external and internal iliac and sacral nodes
 Lower vagina, labia majora/minora: inguinal nodes
It can be seen how the different lymph drainage is important because it indicates its embryological origins. Also,
lymph nodes follow the arteries that supply that specific area so clinically we can see what arteries supply the
uterus.
21. Describe ectopic pregnancy. Where does it occur most commonly?
22. Describe uterine prolapsed.
Ectopic pregnancy occurs when implantation occurs outside the uterus. The most common site is the uterine
tubes. Uterine prolapsed occurs when the cardinal and/or uterosacral ligaments and the levator ani muscles no
longer provide support due to greater intraabdominal pressure.
23. List the most important ligaments supporting the uterus Describe a cystocele.



Cardinal/transverse ligament
Broad Ligament
Round Ligament
A cystocele is a fallen bladder. This can be caused by muscle strain (such as pregnancy).
24. Describe what trauma produces a cystocele?
A cystocele (prolapsed bladder) can be caused by excessive straining due to childbirth, constipation and heavy
lifting. It may also occur after menopause when estrogen levels decrease.
25. Discuss why urinary tract infections are more common in females than males?
Urinary tract infections (UTI) are more common in females than males because of the relatively short length of
the urethra. UTI presents with inflammation of the bladder (cystitis).
26. Explain the importance of the ligaments of the uterus and the pelvic diaphragm following parturition.
Ligaments that stabilize uterus in the pelvic cavity: pubocervical ligament (cervix to anterior pelvic wall),
transverse cervical/cardinal ligament (cervix to lateral pelvic wall), uterosacral ligament (cervix to posterior
pelvic wall). During parturition, these ligaments are relaxed. Following parturition, these ligaments help to
restore the normal size of the uterus and pelvic diaphragm.
27. Name the structure that has to be avoided when removing the uterus.
When removing the uterus, the ureter has to be avoided.
Pelvic Organs Common to Males and Females
28. Describe the urinary bladder and the urinary sphincters.
Urinary bladder:
- muscular organ that collects urine from the kidneys via ureters, urine exists via the urethra
-in males, the bladder is: between the rectum and pubic symphysis and superior to the prostate gland.
-in females, the bladder is: inferior to the uterus and anterior to the vagina.
- parts of the urinary bladder: apex, fundus, body & neck
- supported by pubovesical (females) or puboprostatic (females) ligaments (thickenings of endopelvic fascia)
- the trigone is an area in the bladder where the mucosa is attached to the serosa -> smooth appearance
-detrusor muscle is a layer of the urinary bladder wall made of smooth muscle fibers
-tonically relaxed by the sympathetic nervous system
-parasympathetic nervous system causes contraction during micturition
Urinary Sphincters:
-
-
internal urethral sphincter: located at the junction of the bladder with the urethra, made up of smooth
muscle, autonomic control: sympathetic nervous system closes/contracts, parasympathetic nervous system
opens/relaxes
external urethral sphincter (sphincter urethrae): located at the bladder's distal inferior end in females and
inferior to the prostate (at the level of the membranous urethra) in males, made up of skeletal muscle,
voluntary control: somatic innervation by the pudendal nerve.
29. Describe the anatomy of the rectum and anal canal.
Rectum:
-
begins at the end of the large intestines (sigmoid colon), found within the pelvis: begins at S3 and ends at
the tip of the coccyx.
contains superior, middle & inferior rectal folds
rectal ampulla: dilation of the rectum
Anal Canal:
-
located in the perineum, extends from the anorectal junction (at the level of the pelvic diaphragm) to the
anus.
Interior of anal canal contains longitudinal anal columns and anal sinuses.
The lower ends of the anal columns form the pectinate line
Ischioanal fossa is a fat filled space around the anal canal between the skin of the anal region and pelvic
diaphragm
Contains the internal and external anal sphincter
-internal anal sphincter: formed by the continuation of the inner circular smooth muscle layer from the GIT
(supplied by autonomics, parasympatheticsrelax, sympatheticscontract)
-external anal sphincter: made of striated, skeletal muscle (voluntary, supplied by inferior rectal n.)
30. Identify, in radiological images, major anatomical structures of the male and female pelvis.
refer to plate 355 in Netter’s
31. Explain an automatic reflex bladder resulting from an injury to the spinal cord.
An automatic reflex bladder occurs when you have a complete transection of the spinal cord above the sacral
levels S2-4. The bladder fills and empties reflexively, as there is a loss of micturition reflexes and bladder
sensation. Results in involuntary urination and urinary incontinence.
32. Explain an autonomous bladder from injury to the cauda equina or a peripheral nerve.
In an autonomous bladder, the reflex arc controlling the bladder is interrupted. This would result in both
voluntary and involuntary control of the bladder being lost. The bladder wall is flaccid, as the detrusor muscle
will not be able to contract and empty the bladder. Therefore, the bladder will fill to capacity and start to
overflow resulting in urinary dribbling.
33. Explain what approach might be taken to empty a distended bladder when the urethra is obstructed.
When the urethra is obstructed, a catheter can be inserted through the anterior abdomen in the suprapubic region
to empty a distended bladder. Only the superior aspect of the bladder is covered by peritoneum
(infraperitoneal/subperitoneal), therefore in a distended bladder, a catheter can pierce the suprapubic region to
enter and drain the bladder without puncturing the peritoneum.
34. List the sites that urine can be extravasated and explain why.
The sites of urine extravasation depends on if Buck’s fascia is ruptured or not.
If Buck’s fascia is intact:
-
extravastion of urine is limited to the penis (deep to Buck’s fascia)
If Buck’s fascia is torn:
-
extravasation of blood/urine in the superficial perineal space, “butterfly” extravasation into superficial
pouch
May pass into the scrotum, and penis (outer to Buck’s fascia)
Urine/blood may also pass into lower anterior abdominal wall since Colles’ fascia is continuous with
Scarpa’s fascia of anterior abdomen
- Extravastion stops at the anterior thigh due to fascia lata of thigh
35. Explain the importance of the relationships of the rectouterine pouch to its surrounding structures.
The rectouterine pouch (pouch of Douglas) is the deepest point of the peritoneal cavity, it is posterior to the
uterus and anterior to the rectum. It is also in close proximity to the posterior fornix, which can be punctured to
evacuate fluid build up in the pouch of Douglas. It can also be drained through the rectum. The rectouterine
pouch is a common site for the spread of pathologies such as ascites, pus, endometriosis, infections and
tumours.
36. Describe the normal branching pattern of the internal iliac artery in males and females.
Internal iliac artery has posterior & anterior trunks (branches).

Posterior
o iliolumbar a. – rises back up into iliac fossa (almost recurrent)
o lateral sacral aa. – go along sacrum & send branches into spinal formina
o superior gluteal a. (b/w lumbrosacral trunk[L4, 5] & S1) – going into gluteal region via greater
sciatic foramen

Anterior
o inferior gluteal a.
o internal pudendal a. - leaves via greater sciatic foramen, hooks around ischial spine & enters via
lesser sciatic foramen & into perineum (a. of the perineum)
o middle rectal (off of internal pudendal a.)
o vaginal a. (females) or inferior vesical a. (males)
o uterine a. – only in females
o obturator a. – goes through obturator canal along w/ obturator n.
o umbilical a.
 Distal portion of umbilical a. is obliterated (becomes medial umbilical ligament)
o superior vesical a. (off of umbilical a.) – supplies superior bladder
37. List the roots contributing to the sacral plexus and the terminal branches of the sacral plexus.
 Roots
o Ventral rami of S1 to S4 & lumbrosacral trunk (L4,5)
 Terminal Branches
o Sciatic tibial – L4 to S3
o Common fibular – L4 to S2
o Pudendal – S2, 3, 4
o Superior gluteal – L4 to S1
o Inferior gluteal – L5 to S2
o n. to obturator internus & superior gemellus – L5 to S2
o n. to quadratus femoris & inferior gemellus – L4 to S1
o posterior femoral cutaneous – S1to S3
o perforating cutaneous – S2, S3
o n. to piriformis S(1), S2
o nn. to levator ani, coccygeous, & ext. anal sphincter – S4
o pelvic splanchnic nn. – S2, 3, (4)
38. Describe the relationship of the sacral plexus and its branches to the piriformis muscle.
The sacral plexus is closely related to the anterior surface of the piriformis muscle. Most nerves originating
from the sacral plexus leave the pelvic cavity by passing through the greater sciatic foramen inferior to piriformis
muscle, and enter the gluteal region of the lower limb. The pudendal n. leaves the pelvis through the greater
sciatic foramen between the piriformis and the coccygeus muscles. It then hooks around the ischial spine and
sacrospinous ligament and enters the perineum through the lesser sciatic foramen. The superior gluteal n. arises
from the anterior rami of spinal nerves L4 to S1 and leaves the pelvis through the greater sciatic foramen, superior
to the piriformis. The inferior gluteal n. arises from the anterior rami of spinal nerves L5 to S2 and leaves the
pelvis through the greater sciatic foramen, inferior to the piriformis and superficial to the sciatic nerve.
39. List the nerve fibers found in the pelvic (inferior hypogastric) plexus and how they travel to reach this plexus.
The superior hypogastric plexus (mainly postgang. sympathetics) is a continuation of the aortic
(intermesenteric) plexus, which lies inferior to the bifurcation of the aorta. It divides into left and right hypogastric
nerves, which descend on the anterior surface of the sacrum, as it enters the pelvis. These nerves descend lateral to
the rectum within the hypogastric sheaths and then spread in a fan-like fashion as they merge with the pelvic
splanchnic nerves (pregang. parasympathetics) to form the right and left inferior hypogastric plexuses, which thus
consist of both sympathetic and parasympathetic fibers. Autonomic (sympathetic) fibers also enter the pelvis via
the sympathetic trunks and periarterial plexuses.
40. Describe the autonomic innervation of the urinary bladder and rectum/anal canal.
41. Describe the autonomic nerves and their roles in erection and ejaculation.
42. What vessels are specifically involved in the formation of internal and external hemorrhoids? What is the nature
of the pain associated with these?
43. List the areas anesthetized by a pudendal nerve block and describe the bony landmarks for determining the
position of the pudendal nerve during this procedure.
Perineum
1. Describe the boundaries of the anal and urogenital triangles of the perineum.
A transverse line joining the anterior ends of the ischial tuberosities divides the diamond-shaped perineum
into two triangles, the oblique planes of which intersect at the transverse line.


Anal triangle lies posterior to this line. The anal canal and its orifice, the anus, constitute the major deep
and superficial features of the triangle, lying centrally surrounded by ischioanal fat.
o contains anal canal, anus, & ischioanal fossa
Urogenital (UG) triangle is anterior to this line. In contrast to the open anal triangle, the UG triangle is
closed by a thin sheet of tough, deep fascia, the perineal membrane, which stretches between the two sides
of the pubic arch, covering the anterior part of the pelvic outlet.
o contains scrotum, root of penis or in females, only vulva
2. Describe the pectinate line in the anal canal and its importance in relation to embryological development,
innervation and lymphatic drainage
3. Describe the innervation of the internal and external sphincters of the anal canal.


Internal anal sphincter (smooth muscle – inner circular layer)
o Innervated by ANS (visceral) – painless
External anal sphincter (striated/skeletal muscle)
o Innervated by somatic, inferior rectal n. (branch of pudendal n.) – painful
4. Describe the boundaries and contents of the ischioanal fossa., including innervation, blood supply,
venous and lymphatic drainage.
a fat-filled space located lateral to the anal canal and inferior to the pelvic diaphragm; its boundaries are: The
ischioanal fossa lies lateral to the anal canal and inferior to the pelvic diaphragm. Its boundaries are as follows:




Superomedial: pelvic diaphragm (anterior recess extends superior or deep to the urogenital
diaphragm)
Medial: external anal sphincter muscle and anal canal
Lateral: obturator internus fascia and ischial tuberosity
Posterolateral: sacrotuberous ligament and gluteus maximus muscle (posterior recess extends
superior to the gluteus maximus muscle)
The contents include:
Fat! -- which allows the expansion of the anal canal and therefore the passage of stored feces.
Inside Alcock's canal, on the lateral wall
- internal pudendal artery
- internal pudendal vein
- pudendal nerve
Outside Alcock's canal, crossing the space transversely
-
inferior rectal artery
inferior rectal veins
inferior anal nerves
Innervation: Pudendal Nerve
Blood Supply: Inferior Rector Artery from Internal Pudendal Artery
Lymphatic Drainage: internal iliac nodes
5. Describe the male perineal structures, including innervation, blood supply, venous and lymphatic
drainage.
Nerves: Pudendal nerve (Inferior rectal nerve, perineal nerve, and dorsal nerve of penis). Parasympathetic
fibers stimulate erection which enter the inferior hypogastric plexus via pelvic splanchnic nerves from spinal
cord levels of S2 to S4.
Artery to the bulb of the penis, the urethral artery, the deep artery of the penis, and the dorsal artery of the
penis
Lymphatics: Deep parts of the perineum drain mainly into the internal iliac nodes of the pelvis. Superficial
tissues of the penis accompany the superficial external pudendal blood vessels and drain mainly into superficial
inguinal nodes, as do lymphatic channels from the scrotum. The glans penis drain into deep inguinal nodes and
external iliac nodes.
6. Describe the female perineal structures, including innervations, blood supply, venous and lymphatic
drainage.
Nerves: Pudendal nerve (Inferior rectal nerve, perineal nerve, and dorsal nerve of clitoris).
Arteries of the bulb of vestibule, deep arteries of the clitoris, dorsal arteries of the clitoris
Lymphatics: Deep parts of the perineum drain mainly into the internal iliac nodes of the pelvis. Superficial
tissues of the clitoris accompany the superficial external pudendal blood vessels and drain mainly into
superficial inguinal nodes, as do lymphatic channels from the labia majora. The glans clitoris, labia minora, and
terminal inferior end of the vagina drain into deep inguinal nodes and external iliac nodes.
Female Male
vestibular bulbs corpus spongiosum
greater vestibular glands bulbourethral glands
urethral and paraurethral glands prostate gland
glans clitoris glans penis
prepuce of clitoris prepuce of penis
corpus of clitoris corpus (shaft) of penis
labia minora penoscrotal raphe
labia majora scrotum
dorsal nerve of the clitoris dorsal nerve of the penis
7. List the types of anesthesia are used for childbirth.
Regional Anesthesia
Agents such as lidocaine and bupivacaine are used in obstetrics. Depending on where they are injected, they
cause varying amounts of pain relief. For example, a spinal or saddle block creates a rather large area of total
numbness. An injection of anesthetic is made in the lower part of the back, and the medicine enters the spinal
fluid. The anesthetic is heavy and stays low in the spine. You might become numb from your ribs down to your
toes (spinal block) or from your buttocks and lower part of the abdomen down your inner thighs (saddle block).
The amount of numbness is determined by how low the injection is given, how low in the spinal canal the
medicine remains, and what concentration of anesthetic solution is used. You can have a spinal headache after a
spinal anesthetic; this is very painful, can last for days, and usually requires you to lie down much of the time.
Local Anesthesia
Three types of local anesthesia may be used for childbirth: the paracervical block, the pudendal block, and local
infiltration of the perineum.
The paracervical block is given during the late first stage. Two injections of local anesthetic drugs are made into
the cervix and bring pain relief during contractions. Although this form of anesthesia rarely causes problems for
the mother, it frequently causes sudden drops in the fetal heart rate and noticeable effects on the baby's muscle
tone and reactivity after birth.
Although the amount of pain relief provided by a paracervical block is far less than with the regional blocks, a
significantly greater amount of the anesthetic agent is used -- thus, more serious side effects occur. So this form
of block has been discontinued in many areas of the country.
The pudendal block causes anesthesia in the birth canal and is given in the second stage. Local anesthetic agents
are injected into each side of the vaginal wall. Again, a larger amount of medication is used than for an epidural,
but the incidence of drops in fetal heart rate appears not as serious as with the paracervical block. A pudendal
block can be used for forceps delivery or pain in the second stage. Most doctors also give a pudendal block
before an episiotomy is performed.
Local infiltration of the perineum consists of several injections to numb the area of skin and muscle between the
vagina and the anus. It is most commonly used after natural childbirth if stitches are needed. It can also be given
in the second stage before an episiotomy is performed. Side effects of a local block appear to be slight.
General Anesthesia
General anesthesia means a loss of consciousness along with pain relief. In other words, a woman is put to sleep
and wakes up after the anesthetic has worn off. Nowadays, general anesthesia is uncommonly used-and is
generally reserved for emergency situations.
General anesthetics are usually gases, which are inhaled. They cause a total loss of awareness. Nitrous oxide,
Trilene (trichloroethylene), and Penthrane (methoxyflurane) are examples of such inhalation agents. Sometimes
these are used along with sedatives that cause drowsiness. The sedatives might be injected into your vein.
One reason general anesthetics are used less often today is that they have profound side effects. The mother's
breathing may slow down or stop; her blood pressure may drop and cause her heart rate to change. General
anesthetics may also stop contractions of the uterus and cause excessive bleeding after birth. The baby is also
affected. Babies often have breathing difficulties, sucking difficulties, and poor muscle tone after the use of
general anesthetics.
8. List the structures cut during an episiotomy and the clinical significance.
An episiotomy is a surgical incision through the perineum made to enlarge the vagina and assist childbirth. The
incision can be midline or at an angle from the posterior end of the vulva, is performed under local anaesthetic
(pudendal anesthesia) and is sutured closed after delivery.
The primary rationale behind an episiotomy is related to the nature rather than the size of the tear. An episiotomy
creates a primary intention wound which is easier and less painful to suture, causes less scarring and reduces the
risk of infection compared to natural wounds. This is because the natural wounds are typically secondary or
tertiary intentions which create poorly related wounds (ragged edges) and shearing between perineal layers
slowing healing and increasing the infection risk
Many physicians use episiotomies because they believe that it will lessen perineal trauma, minimize postpartum
pelvic floor dysfunction by reducing anal sphincter muscle damage, reduce the loss of blood at delivery, and
protect against neonatal trauma.
9. List the boundaries of the superficial perineal cleft. What is its potential clinical importance?
The fascia is divided into a superficial part (Campers) and a deep part (Scarpa’s). The superficial part extends
upward on the abdominal wall and downward over the penis, scrotum, perineum, thigh, and buttocks. The deep
part extends from the abdominal wall to the penis (Buck’s fascia), the scrotum (dartos), and the perineum (Colles’
fascia).
Usually two spaces are formed: the superficial perineal cleft and the superficial perineal pouch. The cleft is situated
between Colles’ fascia and the muscle fascia that covers the mucles of the superficial perineal pouch. The pouch is
defined by the perineal membrane, the external perineal fascia (Gallaudet), and the ischiopubic rami.
10. Explain where the urethra is particularly vulnerable to injury. Describe the results of injury to its
intrapelvic segment, in contrast to injury to its perineal portion.
Urethral injuries can be classified into 2 broad categories based on the anatomical site of the trauma. Posterior
urethral injuries are located in the membranous and prostatic urethra. These injuries are most commonly related
to major blunt trauma such as motor vehicle accidents and major falls. They are most commonly associated with
pelvic fractures. Injuries to the anterior urethra are located distal to the membranous urethra. Most anterior
urethral injuries come from blunt trauma to the perineum (straddle injuries), and many have delayed
manifestation, appearing years later as a stricture.
External penetrating trauma to the urethra is rare, but iatrogenic injuries are quite common in both segments of
the urethra. Most are related to difficult urethral catheterizations.
11. Explain why extravasated urine inthe superficial pouch will not pass into the thighs or the iscioanal
fossa.
Extravasation of urine with a torn Buck’s fascia results in urine accumulating in the superficial perineal space then
passing to the scrotum, penis, and lower abdominal wall. It is stopped at the ischiopubic ramus by the fascia of the
thigh.
12. Describe the events that might lead to an abscess in the ischioanal fossa, or to fistula-in-ano.
The anal mucosa is particularly vulnerable to injury and may be easily torn by hard feces. Occasionally, patients
develop inflammation and infection of the anal canal (sinuses or crypts), which can spread into the ischio-anal
fossae. The infection may spread between the sphincters, producing intersphincteric fistulas. The tracts may
spread superiorly into the pelvic cavity or laterally into ischio-anal fossae.
13. Describe a varicocele?
Varicocele is an abnormal enlargement of the [vein] that is in the scrotum draining the testicles. The testicular
blood vessels originate in the abdomen and course down through the inguinal canal as part of the spermatic cord
on their way to the testis. Up-ward flow of blood in the veins is ensured by small one-way valves that prevent
backflow. Defective valves, or compression of the vein by a nearby structure, can cause dilatation of the veins near
the testis, leading to the formation of a varicocele.
The term varicocele specifically refers to dilatation and tortuosity of the pampiniform plexus, which is the network
of veins that drain the testicle. This plexus travels along the posterior portion of the testicle with the epididymis
and vas deferens, and then into the spermatic cord. This network of veins coalesces into the gonadal, or testicular,
vein. The right gonadal vein drains into the inferior vena cava, while the left gonadal vein drains into the left renal
vein at right angle to the renal vein, which then drains into the inferior vena cava.
14. Describe testicular torsion
Testicular torsion is the twisting of the spermatic cord, which cuts off the blood supply to the testicle and
surrounding structures within the scrotum. Some men may be predisposed to testicular torsion as a result of
inadequate connective tissue within the scrotum. However, the condition can result from trauma to the scrotum.
The condition is more common during infancy (a) and during adolescence. Testicular maldescent (cryptorchidism)
results in a testis in an ectopic position (b) – they originally develop near the kidneys and 'descend' by relative
growth differentials of retroperitoneal tissues. This and a retractile testis may tort also, the latter commonest in
the inguinal canal. Occasionally, a small embryological remnant – the cyst of Morgagni – may mimic a testicular
torsion (c).
Acute scrotal swelling in young children may also be caused by idiopathic scrotal oedema, a self-limiting condition,
sometimes bilateral, which presents as an acute red and oedematous scrotum extending into the penis and
perineum. The critical feature which differentiates this from other causes of acute scrotal swelling is that it is
painless and not tender – the child is not distressed. Some cases have been associated with a haemolytic
streptococcus that can be isolated from a rectal swab.
15. Explain the developmental mechanism responsible for the formation of hypospadias and epispadias.
Hypospadias is a birth defect of the urethra in the male that involves an abnormally placed urinary meatus
(opening). Instead of opening at the tip of the glans of the penis, a hypospadic urethra opens anywhere along a line
(the urethral groove) running from the tip along the underside (ventral aspect) of the shaft to the junction of the
penis and scrotum or perineum.
Cause is due to failure of urethral folds to unite during development
An epispadias is a rare type of malformation of the penis in which the urethra ends in an opening on the upper
aspect (the dorsum) of the penis.
16. -Describe the obstetrical procedure called episiotomy and list the structures at risk when a midline episiotomy
extends posteriorly during head delivery
An episiotomy is a surgical incision through the perineum made to enlarge the vagina and assist childbirth. The
incision can be midline or at an angle from the posterior end of the vulva, is performed under local anaesthetic
(pudendal anesthesia) and is sutured closed after delivery.
The main structure at risk is the perineal body
The perineal body is essential for the integrity of the pelvic floor, particularly in females. Its rupture during
delivery leads to widening of the gap between the anterior free borders of levator ani muscle of both sides, thus
predisposing the woman to prolapse of the uterus, rectum, or even the urinary bladder.
At this point, the following muscles converge and are attached:
 External anal sphincter
 Bulbospongiosus
 Superficial transverse perineal muscle
 Anterior fibers of the levator ani
 fibers from external urinary sphincter
 Deep transverse perineal muscle
Therefore an incision through the perineal body may put any or all of these muscles at risk for dysfunction.
17. -Explain the localization of extravasated urine / blood in injuries of the male urethra, both when Buck’s fascia is
intact and when Buck’s fascia is torn.
Lower Limb
Overview
The students should be able to:
1. -Compare the upper and lower limbs relative to general development and function.
2. Describe the various stages of gait.
3. -Describe the line of weight in relative to the sacrum, hip, knee and ankle joints.
4. Identify, in radiological images, structures of the hip joint, femur, knee joint, tibia and fibula, ankle joint and
foot.
Gluteal Region
The students should be able to:
1. Describe the cutaneous innervation of the gluteal region. (next page)
2. List the muscles of the gluteal region, giving their attachments, innervation and actions.
Muscle
Origin
Insertion
Action
Nerve Supply
Gluteus
Maximus
outer surface of
iliotibial tract,
ilium, sacrum,
coccyx,
gluteal
tuberosity
sacrotuberous
ligament
Gluteus Medius
Outer surface of
ilium
of femur
extends and
laterally rotates
thigh at hip;
Inferior gluteal
nerve
through
iliotibial tract
it extends knee
joint
greater
trochanter of
femur
abducts thigh at
hip; tilts pelvis
superior gluteal
nerve
when walking
Gluteus
Minimus
Outer surface of
ilium
Greater
trochanter of
femur
abducts thigh at
hip; anterior
fibers medially
rotate
Superior gluteal
nerve
thigh
Tensor fasciae
latae
Iliac crest
Iliotibial treact
Assists gluteus
maximus in
extending the
knee joint
Superior gluteal
nerve
Piriformis
Anterior surface
of sacrum
Greater
trochanter of
the femur
Lateral rotator
of thigh
Sacral nerve S1
and S2
Superior
gamellus
Spine of ischium
Greater
trochanter of
femur
Lateral rotator
of thigh
Nerve to
obtruator
internis
Obturator
internus
Inner surface of
obturator
membrane
Greater
throchanter of
femur
Lateral rotator
of thigh
Nerve to
obtruator
internis
Inferior
gamellus
Ischial
tuberosity
Greater
trochanter of
femur
Lateral rotator
of thigh
Nerve to
quadratus
femoris
Obturator
externus
Outer surface of
obturator
membrane
Greater
trochanter of
femur
Lateral rotator
of thigh
Obturator nerve
Quadratus
femoris
Ischial
tuberosity
Quadrate
tubercle on
upper end of
femur
Lateral rotator
of thigh
Nerve to
quadratus
femoris
3. -Describe the arterial supply and venous drainage of the gluteal region.
Superior Gluteal Artery – Supplies Gluteus maximus muscle, piriformis muscle, tensor fascia latae: Drained by
Superior gluteal veins
Superior Gluteal Artery - is the largest branch of the internal iliac artery, and appears to be the continuation of
the posterior division of that vessel.
It is a short artery which runs backward between the lumbosacral trunk and the first sacral nerve, and, passing
out of the pelvis above the upper border of the Piriformis, immediately divides into a superficial and a deep
branch.
Within the pelvis it gives off a few branches to the Iliacus, Piriformis, and Obturator internus, and just previous
to quitting that cavity, a nutrient artery which enters the ilium.
Superficial Branch - enters the deep surface of the glutæus maximus, and divides into numerous branches,
some of which supply the muscle and anastomose with the inferior gluteal artery, while others perforate its
tendinous origin, and supply the integument covering the posterior surface of the sacrum, anastomosing with
the posterior branches of the lateral sacral arteries.
Deep Branch - lies under the Glutæus medius and almost immediately subdivides into two. Of these, the
superior division, continuing the original course of the vessel, passes along the upper border of the Glutæus
minimus to the anterior superior spine of the ilium, anastomosing with the deep iliac circumflex artery and the
ascending branch of the lateral femoral circumflex artery. The inferior division crosses the Glutæus minimus
obliquely to the greater trochanter, distributing branches to the Glutæi and anastomoses with the lateral
femoral circumflex artery. Some branches pierce the Glutæus minimus and supply the hip-joint.
Inferior Gluteal Artery – supplies gluteus maximus, piriformis, quadratus femoris muscle: Drained by inferior
gluteal veins
The inferior gluteal artery (sciatic artery), the larger of the two terminal branches of the anterior trunk of the
internal iliac artery, is distributed chiefly to the buttock and back of the thigh.
It passes down on the sacral plexus of nerves and the Piriformis, behind the internal pudendal artery, to the lower
part of the greater sciatic foramen, through which it escapes from the pelvis between the Piriformis and Coccygeus.
It then descends in the interval between the greater trochanter of the femur and tuberosity of the ischium,
accompanied by the sciatic and posterior femoral cutaneous nerves, and covered by the Glutæus maximus, and
is continued down the back of the thigh, supplying the skin, and anastomosing with branches of the perforating
arteries.
Internal pudendal artery – Supplies external genitalia and perineum: Drained by internal pucendal vein.
4. -Explain how the hip abductor muscles function during gait.
5. Describe and explain the safe and unsafe areas for gluteal intramuscular injections.
Safe zone = Upper lateral zone of the gluteal area.
Safest zone = To be even more safe, locate the tubercle near the Anterior Superior Iliac Spine. Safest zone
because it tries to avoid superior glueteal nerve.
Unsafe zone = Lower areas of the gluteus maximus are not safe due to the presence of the sciatic nerve.
6. Differentiate between a Trendelenburg Sign and a Trendelenburg Test.
 The Trendelenburg Test is to check the competency of the valves in the superficial and deep veins of the
leg.
o The leg is raised above the level of the heart. A tourniquet is then applied around the upper thigh to
compress the superficial veins. The leg is then lowered by asking the patient to stand. Normally the
superficial veins will fill from below within 35 seconds;
 If the superficial veins fill more rapidly with the tourniquet in place there is valvular
incompetence below the level of the tourniquet.
If the veins fill rapidly from above when the tourniquet is removed, the incompetence is at
the sapheno-femoral junction.
The Trendelenburg Sign is a test to check the abductor muscles of the hip – gluteus medius & gluteus
minimus
o The Trendelenburg sign is positive when a person is standing on one leg, the pelvis on the opposite
side drops. Therefore, the gluteus medius & minimus are weak/damaged on the opposite side of the
pelvic drop.


7. Explain a “waddling gait” and what anatomical problems may cause it.
Waddling gait can be caused by muscle dystrophy, spinal muscle atrophy, or congenital hip dislocation.
All of these disorders can cause a weakness to the gluteus medius/minimus which results in a waddling gait.
Thigh
The students should be able to:
1. Describe the fascia lata.
The outer layer of deep fascia in the lower limb forms a thick 'stocking-like' membrane, which covers the limb
and lies beneath the superficial fascia. This deep fascia is particularly thick in the thigh and gluteal region and is
termed the fascia lata.
2. Describe the cutaneous innervation of the anteromedial thigh, and explain the consequence of nerve
lesions that result in sensory loss.
Femoral nerve
The femoral nerve carries contributions from the anterior rami of L2 to L4 and leaves the abdomen by passing
through the gap between the inguinal ligament and superior margin of the pelvis to enter the femoral triangle on
the anteromedial aspect of the thigh. In the femoral triangle it is lateral to the femoral artery. The femoral nerve:



innervates all muscles in the anterior compartment of the thigh;
in the abdomen, gives rise to branches that innervate the iliacus and pectineus muscles;
innervates skin over the anterior aspect of the thigh, anteromedial side of the knee, the medial side of the
leg, and the medial side of the foot.
Obturator nerve
The obturator nerve, like the femoral nerve, originates from L2 to L4. It descends along the posterior abdominal
wall, passes through the pelvic cavity and enters the thigh by passing through the obturator canal. The obturator
nerve innervates:



3.
all muscles in the medial compartment of the thigh, except the part of adductor magnus muscle that
originates from the ischium and the pectineus muscle, which are innervated by the sciatic and the femoral
nerves, respectively;
the obturator externus muscle;
skin on the medial side of the upper thigh.
List the major anatomical features of the femur.
4. Describe the hip joint, listing the ligaments of the joint.
 Multiaxial ball and socket synovial joint
 Acetabular labrum- fibrocartillage rim that deepens the articular socket for the head of the femur and
consequently stabilizes the hip joint
 Fibrous capsul- encloses part of head and most of neck of femur, reinforced anteriorly by iliofemoral
ligament, posteriorly by ischiofemoral ligament, and inferiorly by pubofemoral ligament
 Ligaments
o Iliofemoral ligament: fibrous capsule ANTERIORLY; resists hyperextension and lateral rotation at
hipjoint during standing
o Ischiofemoral ligament: fibrous capsule POSTERIORLY; limits extension and medial rotation
o Pubofemoral ligament: fibrous capsule INFERIORLY; limits extension and abduction
o Ligamentum teres capitis femoris: provides pathway for artery of ligamentum capitis femoris from
obturator artery
o Transverse acetabular ligament: forms foramen through which nutrient vessels enter joint
5. List the muscles of the thigh, their general attachments, innervations and actions
Anterior Compartment:
Medial Compartment:
Posterior Compartment:
6. Describe the arterial supply and venous/lymphatic drainage of the thigh.
 Arteries
o Three arteries enter the thigh: the femoral artery, the obturator artery, and the inferior gluteal
artery. Of these, the femoral artery is the largest and supplies most of the lower limb. The three
arteries contribute to an anastomotic network of vessels around the hip joint.

Venous/Lymphatic drainage
- Veins in the thigh consist of superficial and deep veins. Deep veins generally follow the arteries and
have similar names. Superficial veins are in the superficial fascia, interconnect with deep veins, and
do not generally accompany arteries. The largest of the superficial veins in the thigh is the great
saphenous vein.
- The great saphenous vein originates from a venous arch on the dorsal aspect of the foot and
ascends along the medial side of the lower limb to the proximal thigh (see p. 498). Here it passes
through the saphenous ring in deep fascia covering the anterior thigh to connect with the femoral
vein in the femoral triangle (see p. 502).
- Deep lymphatic vessels of the gluteal region accompany the blood vessels into the pelvic cavity and
connect with internal iliac nodes.
- Superficial lymphatics drain into the superficial inguinal nodes on the anterior aspect of the thigh.
7. Describe the blood supply of the hip joint.
 Three arteries enter the thigh: the femoral artery, the obturator artery, and the inferior gluteal artery. Of
these, the femoral artery is the largest and supplies most of the lower limb. The three arteries contribute to
an anastomotic network of vessels around the hip joint.
 Cruciate anastomosis: lateral femoral circumflex artery, inferior gluteal artery, 1st perforating branch
artery, branch of medial femoral circumflex artery
8. Describe the clinical significance of an intracapsular versus and extracapsular fracture of the femoral neck.
 Intracapsular fracture: Most femoral neck fractures are intracapsular and disrupt the cervical vessels
formed from the subsynovial intra-articular ring. The femoral head may therefore necrose
- Intracapsular fractures are notorious for their high incidence of non union. This occurs due to the
disruption of blood supply to the femoral head, which leads to Avascular necrosis and finally non
union. Intracapsular fractures will unite well if anatomically reduced and internally fixed within 6
hours of the fracture.
 Extracapsular fracture: These fractures occur below the attachment of the fibrous capsule.
- They unite well in comparison to Intracapsular fractures.
- Extracapsular fractures are almost always treated by early internal fixation. If not reduced
adequately, will result in Malunion.
9) The blood supply of the femoral head are the Retinacular arteries (superior, Anterior, and Inferior) which
branch off of the Medial circumflex femoral artery (pg. 504 Netters)
10) The boundaries of the femoral triangle are:
a) The base- the inguinal ligaments
b) the medial border- the medial margin of the adductor longus muscle in the medial compartment of the thigh
c) The lateral margin- the medial margin of the Sartorius muscle in the anterior compartment of the thigh
d) The floor- formed medially by the pectineus and adductor longus muscles in the medial compartment of the
thigh and laterally by the iliopsoas muscle descending from the abdomen
- The apex of the femoral triangle points inferiorly and is continuous with a fascial canal (adductor canal), which
descends medially down the thigh and posteriorly through an aperture in the lower end of one of the largest of the
adductor muscles in the thigh (the adductor magnus mucle) to open into the popliteal fossa behind the knee.
(page 503 Gray’s)
11) The structures in the femoral sheath include: the Femoral Artery, the Femoral Vein, and the associated
lymphatic vessels.
The most medial compartment (the femoral canal) contains the lymphatic vessels and is conical in shape
The femoral nerve is lateral to and not contained within the femoral sheath
(page 504 Gray’s)
12) The superficial inguinal nodes are in the superficial fascia and parallel the course of the inguinal ligament in
the upper thigh.
- Receive lymph from the gluteal region, lower abdominal wall, perineum, and superficial regions of the
lower limb.
- The drain into the external iliac nodes.
- The deep inguinal nodes are medial to the femoral vein
- Receive lymph from deep lymphatics associated with the femoral vessels and from the glans penis/
clitoris in the perineum.
- Also drain into the external iliac nodes ( pass through the femoral canal)
(page 500 Gray’s)
13) A femoral hernia is located at the ‘neck’ below the inguinal ligament. Whereas an inguinal ligament, the
hernia neck is above the inguinal ligament (being either direct or indirect).
- Femoral hernias are most likely to incarcerate/strangulate due to narrow rigid femoral ring.
14) The lumbosacral plexus contains many important nerves of the lower limb. These include the femoral nerve,
obturator nerve, sciatic nerve, superior gluteal nerve, and inferior gluteal nerve. Nerves such as the lateral
cutaneous femoral nerve, nerve to obturator internus, nerve to quadrates femoris, posterior cutaneous nerve of
thigh, performing cutaneous nerve, and branches of the ilio-inguinal and genitor-femoral nerves supply skin or
muscles.
- Nerve lesion on the lumbosacral trunk can result is the lack of function of some or even all of these nerves and
their respective structures.
15) Enlarged inguinal lymph nodes in both males and females can be palpated in the groin region.
16) Meralgia paresthetica is numbness or pain in the outer thigh not caused by injury to the thigh, but by injury
to a nerve that extends from the thigh to the spinal column. This chronic neurological disorder involves a
single peripheral nerve, namely the Lateral cutaneous nerve of thigh.
Leg
1) The boundaries of the popliteal fossa are
a) The margins of the upper part of the diamond are formed medially by the distal ends of the semitendinous
and semimembranosus muscles and laterally by the distal end of the biceps femoris muscle
b) The margins of the smaller lower part of the space are formed medially by the medial head of the
gastrocnemius muscle and laterally by the plantaris muscle and the lateral head of the gastrocnemius muscles
c) The floor of the fossa is formed by the capsule of the knee joint and adjacent surfaces of the femur and tibia,
and by the popliteus muscle
d) The roof is formed by the deep fascia, which is continuous with the fascia lata of the thigh and below the deep
fascia of the leg.
2) The contents of the fossa are:
a) The popliteal artery- Continuation of the femoral artery and passes posteriorly through the adductor hiatus in
the adductor magnus muscle.
b) The popliteal vein – superficial to the popliteal artery and runs with it.
c) The tibial nerve (Descends vertically through fossa and exits deep to the margin of plantaris)
d) Common fibular nerves ( exits following the biceps femoris tendon and continues to the lateral side of the leg
where it swings around to the neck of the fibula and enters the lateral compartment of leg)
3) The crural fascia (deep fascia of the leg) forms a complete investment to the muscles, and is fused with the
periosteum over the subcutaneous surfaces of the bones.
- It is continuous above with the fascia lata, and is attached around the knee to the patella, the ligamentum patellæ,
the tuberosity and condyles of the tibia, and the head of the fibula.
4. Describe the cutaneous innervation of the leg, and explain the consequence of nerve lesions that result in
sensory loss.
- The cutaneous innervation of the leg is provided by three nerves namely: Saphenous Nerve,
sural Nerve and superficial peroneal nerve. The saphenous nerve accompanies the great
saphenous vein along the medial aspect of the leg and supplies skin on the medial side of the leg
and also the medial border of the foot as far as the ball of the great toe. The Sural nerve
accompanies the short saphenous vein and supplies cutaneous sensation to the lateral border of
the foot and little toe. The superficial fibular nerve enters the anterior compartment of the leg
on the anterior border of peroneus longus and supplies lateral skin of the leg and the dorsum of
the foot. It has two branches namely: medial and lateral branches.
5. List the major anatomical features of the tibia and fibula.
6. Describe the knee joint, listing the cartilages, synovial membrane and ligaments of the joint.
-
The knee is formed by the femur (the thigh bone), the tibia (the shin bone), and the patella (the
kneecap). Two ligaments on either side of the knee, called the medial and lateral collateral
ligaments, stabilize the knee from side-to-side. The anterior cruciate ligament (ACL) is one of a
pair of ligaments in the center of the knee joint that form a cross, and this is where the name
"cruciate" comes from. There is both an anterior cruciate ligament (ACL) and a posterior
cruciate ligament (PCL). Both of these ligaments function to stabilize the knee from front-toback during normal and athletic activities. The ligaments of the knee make sure that the weight
that is transmitted through the knee joint is centered within the joint minimizing the amount of
wear and tear on the cartilage inside the knee. The cartilages and the menisci serve as cushions
to reduce the force onto the articular surfaces of the lower knee joint.
7. Describe the blood supply of the knee joint.
-
The femoral artery and the popliteal artery help form the arterial network surrounding the
knee joint (articular rete). There are 6 main branches: Superior medial genicular artery,
Superior lateral genicular artery, Inferior medial genicular artery, Inferior lateral genicular
artery, Descending genicular artery, Recurrent branch of anterior tibial artery
8. List the muscles in the anterior compartment of the leg, their general attachment, innervation and actions.
-
The anterior compartment of the leg is supplied by the deep fibular nerve and anterior tibial
artery. It contains the dorsiflexors (tibialis anterior, extensor hallucis longus, extensor
digitorum longus, fibularis tertius).
9. List the muscles in the lateral compartment of the leg, their general attachment, innervation and actions.
-
The lateral compartment of the leg is supplied by the superficial peroneal nerve. Its proximal
and distal arterial supply consists of perforating branches of the anterior tibial artery and
fibular artery. It contains the evertors of the foot (fibularis longus, fibularis brevis).[2] These
muscles also are involved in plantarflexion.
10. List the muscles in the posterior compartment of the leg, their general attachment, innervation and actions.
- The posterior compartment of the leg is supplied by the tibial nerve. It contains the plantar
flexors:[1]

deep: popliteus, flexor hallucis longus, flexor digitorum longus, tibialis posterior

superficial/calf: gastrocnemius, soleus, plantaris
11. Describe the arterial supply and venous/lymphatic drainage of the leg.
Inguinal Lymph Nodes
1. Superficial:
a. Horizontal group (along inguinal ligament): body wall inferior to umbilicus, buttock, eternal
genitalia, lower part of anal canal, vagain, and lower uterus
b. Vertical group (along great saphenous vein): Superficial thigh, leg and foot (except for
lateral side of food and posterior aspect of leg)
2. Deep Group(In femoral canal): all deep areas of thigh, leg, and foot; receives tributaries from the
superficial groups and eventually drain into the external iliac nodes
3. Popliteal Lymph nodes- drain superficial areas of lateral side of foot up to the 5th toe, and superficial
aspect of posterior leg; These then drain into the Deep inguinal nodes.
12. Describe the calf pump mechanism for venous return.
- The calf muscle pump is recognized as an integral component of effective venous return from
the lower limbs. Calf contraction increases the venous return from lower limbs by compression
of the veins in the area to push the blood superiorly.
13. Describe the significance of the prepatellar and infrapatellar bursae.
Prepatellar bursae/bursitis, also known as housemaid's knee, is a common cause of swelling
and pain on top of the kneecap. Most common bursitis. The symptoms of prepatellar bursitis or
knee bursitis include: Swelling over the kneecap, Limited motion of the knee, Painful movement
of the knee
- Infrapatelar bursae- clergyman's knee as it may sometimes be known as is inflammation of the
infrapatellar bursa. Infrapatellar bursitis can be caused by friction between the skin and the
bursa and may sometimes happen in conjunction with Jumper's knee. Associated with pain at
the front of the knee, and inflammation at front of the knee.
14. Describe the function of the anterior and posterior cruciate ligament.
- There is both an anterior cruciate ligament (ACL) and a posterior cruciate ligament (PCL). Both
of these ligaments function to stabilize the knee from front-to-back during normal and athletic
activities. The ligaments of the knee make sure that the weight that is transmitted through the
knee joint is centered within the joint minimizing the amount of wear and tear on the cartilage
inside the knee.
-
15. Define the terms “anterior drawer sign” and “posterior drawer sign.”
 Anterior drawer test-a positive anterior drawer test is when the proximal head of a patient's tibia can be
pulled anteriorly on the femur. The patient lies supine on the couch. The knee is flexed to 90° and the heel
and sole of the foot are placed on the couch. The examiner sits gently on the patient's foot, which has been
placed in a neutral position. The index fingers are used to check that the hamstrings are relaxed while the
other fingers encircle the upper end of the tibia and push the tibia. If the tibia moves forward, the anterior
cruciate ligament is torn. Other peripheral structures, such as the medial meniscus or meniscotibial
ligaments, must also be damaged to elicit this sign.
 Posterior drawer test: same as anterior drawer test except the examiner pulls the tibia backward in order
to test if the posterior cruciate ligament is torn.
16. What isDescribe a “Baker’s Cyst”?
 Popliteal (Baker’s) cyst is a swelling behind the knee, caused by knee arthritis, meniscus injury, or
herniation or tear of the joint capsule. It impairs flexion and extension of the knee joint, and the pain
gets worse when the knee is fully extended, such as during prolonged standing or walking. It can be treated
by draining and decompressing the cyst.
 A popliteal cyst (Baker's cyst) is a synovial outpouching that arises from the posteromedial aspect of the
knee joint. The synovial membrane of the knee joint outpouches between the medial head of
gastrocnemius and the semimembranosus tendon to lie medially within the popliteal fossa. Occasionally it
tracks inferiorly to lie in and around the tendons that form the pes anserinus (sartorius, gracilis, and
semitendinosus).
17. List the nerves involved in the patellar tendon reflex?
 L2-L4 spinal(femoral) nerves
 Activating muscle spindle in the quadriceps; afferent impulses travel in the femoral nerve to the spinal
cord, and efferent impulses are transmitted to the quadriceps via motor fibers in the femoral nerve.
18. Describe the “unhappy triad” of the knee joint.
 May occur when a football player’s cleated shoe is planted firmly in the turf and the knee is struck from the
LATERAL side. It is indicated by a knee that is markedly swollen, particularly in the suprapatellar region,
and results in tenderness on application of pressure along the extent of the tibial collateral ligament. It is
characterized by:
o Rupture of the tibial collateral ligament, as a result of excessive abduction
o Tearing of the anterior cruciate ligament, as a result of forward displacement of the tibia
o Injury to the medial meniscus, as a result of the tibial collateral ligament attachment
o Varun is a douche
 Pneumonic: ATM
19. Describe the anterior and posterior drawer signs and the ligament they are testing.
 See question #15… I guess I got lucky
20. Explain the consequence of a lesion of the common fibular nerve at the neck of the fibula.
 Damage to the common peroneal(fibular) nerve: results in foot drop and loss of sensation on the dorsum
of the foot and lateral aspect of the leg and causes paralysis of all muscles in the anterior and lateral
compartments of the leg (dorsiflexor and evertor muscles of the foot)
 PK is an indecisive bastard
 Damage to the superficial peroneal (fibular) nerve: causes no foot drop but does cause loss of eversion of
the foot
 Damage to the deep peroneal(fibular) nerve: results in foot drop(loss of dorsiflexion) and hence a
characteristic high-stepping gait. When the person with foot drop walks, the foot slaps down onto the floor.
To accommodate the toe drop, the patient may use a characteristic tip-toe walk on the opposite leg, raising
the thigh excessively, as if walking upstairs, while letting the toe drop. This serves to raise the foot high
enough to prevent the toe from dragging, and prevents the slapping.
21. Explain the consequence of a lesion of the tibial nerve in the popliteal fossa.Describe the consequence of
“anterior compartment syndrome”.
 Tibial nerve lesion: causes loss of plantar flexion of the foot and impaired inversion resulting from
paralysis of the tibialis posterior and causes a difficulty in getting the heel off the ground and a shuffling of
the gait. It results in a characteristic clawing of the toes and secondary loss on the sole of the foot, affecting
posture and locomotion.
 Anterior compartment syndrome: is characterized by ischemic necrosis of the muscles of the anterior
compartment of the leg. It occurs, presumably, as a result of compression of arteries (anterior tibial artery
and its branches) by swollen muscles following excessive exertion. It is accompanied by extreme
tenderness and pain on the anterolateral aspect of the leg.
22. Describe the development of varicose veins.
 Veins have leaflet valves to prevent blood from flowing backwards (retrograde). Leg muscles pump the
veins to return blood to the heart. When veins become enlarged, the leaflets of the valves no longer
meet properly, and the valves don't work. The blood collects in the veins and they enlarge even more.
Varicose veins are common in the superficial veins of the legs, which are subject to high pressure when
standing.
Ankle and Foot
The students should be able to:
1. Describe the ankle joint, listing the major ligaments of the joint.
 Ankle joint: hinge-type synovial joint between the tibia and fibular superiorly and the trochlea of the talus
inferiorly, permitting dorsiflexion and plantar flexion.
 The articular cavity is enclosed by a synovial membrane, which attaches around the margins of the
articular surfaces, and by a fibrous membrane, which covers the synovial membrane and is also attached to
the adjacent bones.
 The ankle joint is stabilized by medial (deltoid) and lateral ligaments:
o Medial(deltoid) ligament:
 Has 4 parts
 Tibionavicular
 Tibiocalcaneal
 Anterior tibiotalar
 Posterior tibiotalar
 Prevents overeversion of the foot and helps maintain the medial longitudinal arch
o Lateral ligament
 Has 3 parts
 Anterior talofibular
 Posterior talofibular
 Calcaneofibular
 Resists inversion of the foot and may be torn during an ankle sprain (inversion
injury)…mehul obviously has a weak lateral ligament
2. List the bones of the foot and their relationships to one another.
 Tarsus (seven tarsal bones):
o Talus
 Transmits weight of body from tibia to the foot
 Head serves as keystone of the medial longitudinal arch of the foot
o Calcaneus
 Forms heel of the foot, articulates with the talus superiorly and the cuboid anteriorly.
 Has a shelf-like medial projection called the sustentaculum tail, which supports the head of
the talus and has a groove on its inferior surface for the flexor hallucis longus tendon
o Navicular bone
 Boat-shaped tarsal bone lying between the head of the talus and the three cuneiform bones
o Cuboid bone
 Has a groove for the peroneus longus muscle tendon
 Serves as the keystone of the lateral longitudinal arch of the foot
o Cuneiform bones (3)
 Three wedge-shaped bones that form a part of the medial longitudinal arch and proximal
transverse arches
 Articulate with the navicular bone posteriorly and with the three metatarsals anteriorly
 Metatarsus
o Consists of five metatarsals and has prominent medial and lateral sesamoid bones on the first
metatarsal
 Phalanges
o Consists of 14 bones (two in the first digit and three in each of the others)
3. Describe the cutaneous innervations of the foot, and explain the consequence of nerve lesions that result in
sensory loss.
DORSUM OF THE FOOT - SUP. PERONEAL
PINK DORSUM AND LATERAL SIDE – LAT . DORSAL/SURAL
INBETWEEN TOE BIG TOE AND 2ND TOE – DEEP PERONEAL
ANKLE – TIBIAL/ MEDAL
4. List the muscles in the sole of the foot, their general attachments, innervations and actions.
Muscle
origin
insertion
nerve
action
abductor
hallucis
medial tubercle of medial side, base of
calcaneum; flexor proximal phalanx of
retinaculum
big toe
medial plantar nerve
flexes, abducts big toe; supports
medial arch
flexor
digitorum
brevis
medial tubercle of middle phalanx of
calcaneum
four lateral toes
medial plantar nerve
flexes lateral four toes; supports
medial & lateral longitudinal
arches
lateral side base of
proximal phalanx 5th lateral plantar nerve
toe
flexes, abducts 5th toe; supports
lateral longitudinal arch
medial & lateral
abductor digiti
tubercles of
minimi
calcaneum
muscles of Sole of Foot (Second Layer)
flexor
accessorius
(quadratus
plantae)
medial and lateral tendons flexor
sides of calcaneum digitorum longus
flexor
digitorum
shaft of tibia
longus tendon
lumbricals
tendons of flexor
digitorum longus
flexor hallucis
shaft of fibula
longus
lateral plantar nerve
aids long flexor tendon to flex
lateral four toes
base of distal
phalanx of lateral
four toes
tibial nerve
flexes distal phalanges of lateral
four toes; plantar flexes foot;
supports longitudinal arch
dorsal extensor
expansion of lateral
four toes
1st lumbrical from
medial plantar;
extends toes at interphalangeal
remainder lumbricals
joints
from deep branch of
lateral plantar nerve
base of distal
phalanx of big toe
tibial nerve
flexes distal phalanx of big toe;
plantar flexes foot; supports
medial longitudinal arch
Muscles of Sole of Foot (Third Layer)
cuboid, lateral
flexor hallucis cuneiform bones;
brevis
tibialis posterior
insertion
medial & lateral
sides of base of
proximal phalanx of
big toe
adductor
bases of 2nd, 3rd
hallucis
& 4th metatarsal
(oblique head) bones
lateral side base of
deep branch of lateral flexes big toe, supports
proximal phalanx big
plantar
transverse arch
toe
adductor
medial plantar nerve
flexes metatarsophalangeal joint
of big toe; supports medial
longitudinal arch
plantar ligaments lateral side of base of deep branch of lateral flexes big toe; supports
hallucis
(transverse
head)
flexor digiti
minimi brevis
proximal phalanx big plantar nerve
toe
base of 5th
metatarsal bone
lateral side of base of
superior branch of
proximal phalanx of
lateral plantar nerve
big toe
transverse arch
flexes little toe
Muscles of Sole of Foot (Fourth Layer)
dorsal
interossei (4)
adjacent sides of
metatarsal bones
bases of phalanges
and dorsal expansion
lateral plantar nerve
of corresponding
toes
plantar
interossei (3)
3rd, 4th, and 5th
metatarsal bones
bases of phalanges &
dorsal expansion of lateral plantar nerve
corresponding toes
adduct toes with 2nd toe as
reference; flex
metatarsophalangeal joints;
extend interphalangeal joints
tendon of
peroneus
longus
see above
see above
see above
see above
tendon of
tibialis
posterior
see above
see above
see above
see above
5. List the tendons of leg muscles that are found in the foot.
flexor hallucis longus
flexor digitorum longus.
(think that’s all )
6. List the major ligaments of the foot.
LATERAL
1. Anterior talofibular
2. Posterior talofibular
3. Calcaneofibular
deltoid
1.anterior tibiotalar
2.posterior tibiotalar
3. Tibiocalcaneal
4.tibioavicular
7. Describe the blood supply and venous/lymphatic drainage of the foot.
greater sapheanous V
abduct toes with 2nd toe as the
reference; flex
metatarsophalangeal joints;
extend interphalangeal joint
- medial/lateral plantar A/N – branch of postieror tibial artery.
small sapheanous V ?
8. List the muscles that function during dorsiflexion, plantarflexion, inversion.
dorsi = anterior compartment
plantar flex = posterior compartment
9. List the two ligaments most commonly torn in “sprained ankle”.
medial/lateral ligaments
10. Explain the clinical picture of hallux valgus and hallux varus.
valgus – big toe bent away from middle of the foot.
varus big to bent towards middle of foot
11. What is clinical picture of clubfoot?
A clubfoot, Giles Smith syndrome [1] or talipes equinovarus (TEV), is a birth defect. TEV is classified into 2 groups:
Postural TEV or Structural TEV. Without treatment, persons afflicted often appear to walk on their ankles, or on
the sides of their feet. It is a common birth defect, occurring in about one in every 1,000 live births. Approximately
50% of cases of clubfoot are bilateral. In most cases it is an isolated dysmelia. This occurs in males more often than
in females by a ratio of 2:1.
There are different causes for clubfoot depending on what classification it is given. Structural TEV is caused
by: genetic factors, such as Edwards syndrome, a genetic defect with three copies of chromosome 18. Growth
arrests at roughly 9 weeks and compartment syndrome of the affect limb are also causes of Structural TEV. Genetic
influences increase dramatically with family history. It was previously assumed that postural TEV could be caused
by external influences in the final trimester such as intrauterine compression from oligohydramnios or
from amniotic band syndrome. However, this is countered by findings that TEV does not occur more frequently
than usual when the intrauterine space is restricted. [2] Breach Birth presentation is also another known cause. TEV
may be associated with other birth defects such as spina bifida cystica. Use of MDMA (Ecstasy)
and smoking [3] while pregnant has been linked with this congenital abnormality.[4]
12. Explain the anatomical mechanism responsible for tarsal tunnel syndrome.
tibial nerve is impinged and compressed as it travels through the tarsal tunnel. TTS is a compression syndrome of
the tibial nerve within the Tarsal Tunnel. This tunnel is found along the inner leg behind the medial malleolus
(bump on the inside of the ankle). The posterior tibial nerve, a major artery, veins, and tendons travel in a bundle
along this pathway, through the Tarsal Tunnel. In the tunnel, the nerve splits into three different paths. One nerve
(calcaneal) continues to the heel, the other two (medial and lateral plantar nerves) continue on to the bottom of
the foot. The Tarsal Tunnel is made up of bone on the inside and the flexor retinaculum on the outside.