Lower Extremity Forum 2011 Describe the content of the subinguinal hiatus (space between the inguinal ligament and the pelvic rim) • Psoas major, iliacus, pectineus muscles • Femoral artery, vein, nerve – Femoral nerve not included in the femoral sheath – Parent branch of artery is external iliac artery • Lymphatics • Lateral cutaneous nerve of thigh (lateral femoral nerve of thigh) – Located near the ASIS Describe the borders and content of the femoral triangle • Base = inguinal ligament • Medial border is adductor longus • Lateral border is the medial part of the sartorius muscle • Floor is the pectineus, adductor longus – And some of the iliopsoas • Fascia latae forms the roof of the triangle • Continues with fascial canal all the way to the adductor canal • Contains the femoral artery, nerve, vein, and lymphatics Describe the walls and content of the adductor canal • Forms the apex of the femoral triangle • Covered by fascia, roof is sartorius vasculoductor membrane • Comprised of fascia – Contains femoral artery, femoral vein, saphenous nerve for some of time (from femoral), genicular artery • Descends medially down the thigh and shoots out posteriorly thorough the adductor canal – Goes through the adductor magnus muscle – Opens into the popliteal fossa; now popliteal artery/vein Describe the adductor hiatus • Opening at the end of the adductor canal – Deposits the femoral artery and vein into the posterior portion of the leg via the opening at the distal portion of the adductor magnus • Will now become the popliteal artery/vein Describe the borders and contents of the popliteal fossa • Superior Medial Border is the semitendonosus • Superior Lateral Border is biceps emoris • Inferior Medial Border is the medial head of the gastrocnemius • Inferior Lateral Border is the lateral head of the gastrocnemius • Plantaris muscle included on inferior lateral border • Popliteal artery, vein, and Tibial nerve (AVN- aviation up) – Common fibular included? NOT QUITE Describe the pathogenesis of the Baker’s cyst and the prepatellar bursitis • Buildup of synovial fluid behind the knee – Caused by knee arthritis, meniscus injury, herniation or tear of the joint capsule – In popliteal fossa; hurts more during extension – Impairs flexion and extension at the knee joint • Inflammation and swelling of the prepatellar bursa (lies right on top of patella) – Housemaid’s knee; inability to flex the knee – Repetitive kneeling will cause this Describe the pathogenesis of the foot drop • Results from a non-functional tibialis anterior – Common fibular nerve injury • Passes behind the head of the fibula – From head or neck fracture of the fibula – Loss of dorsiflexion – loss of sensation on the dorsum of the foot and lateral aspect of the leg – paralysis of all muscles in the anterior and lateral compartments Describe the unhappy triad and the Pott fracture • MCL (tibio-collateral ligament), ACL, and medial meniscus have been torn – Usually results from impact to lateral portion of leg • Fracture of distal fibula – Often goes with a fracture of the medial malleolus or rupture of the deltoid ligament • Avulsion fracture is when medial malleolus comes off with it – Torn anterior tibiofibular – Comes from forced eversion of foot Describe the cutaneous innervation of the lower limb • L2-L3 is from ass to knee, with L2-L4 coming from the obturator on the inner thigh • Page 346-347 Describe the borders of the femoral canal and the symptoms of the femoral hernia • Femoral canal borders: – Do not need to know for exam • Femoral hernias more common in women because they have a larger superior pubic ramus – Portion of abdominal cavity protrudes into femoral canal (usually portion of the small intestine) – Can be strangulated – Poor blood supply occurs with death of nearby tissues resulting (pinching femoral vein, artery perhaps) Describe the pes anserinus • Results from combinations of tendons of gracilis, sartorius, and semitendonosus – Found out at the medial border of the tuberosity of the tibia – Can be used to help repair a torn ACL – SGT FOS • Sart, grac, semitendinosus/femoral, obturator, sciatic Describe the course of the saphenus nerve and the descending genicular artery • Great saphenous nerve branches off from the femoral nerve and goes with it through the adductor canal – DOES NOT go through the adductor hiatus – Breaks medially to innervate medial side of leg • Breaks through fascia between sartorius and gracilis • Will supply skin on medial leg, knee, and foot • Des. Genicular Artery arises from femoral artery in adductor canal just before it passes adductor hiatus – anastomose around the knee joint with other genicular arteries (these come form the popliteal artery) – Also gives rise to a saphenous branch – Only genicular a. that comes off the femoral Describe the venous circulation of the lower limb • Great saphenous drains the medial leg and thigh anteriorly – Wraps posteriorly around knee very briefly, then comes back to the anteriomedial leg – Pierces the femoral canal fascia to enter the canal near the groin • Small saphenous vein drains the posterior medial leg and then enters into popliteal fossa – Now named popliteal vein; goes through adductor hiatus and becomes femoral vein • Dorsal venous arch of foot gets the top of foot Describe the anatomy of the lesser and greater sciatic foramina • Split in two by the Piriformis muscle – The main point of reference for gluteal region • Goes through the hole made by the ilium, sacrum, and sacrotuberous and sacrospinous ligaments • Part goes over the piriformis, another goes under piriformis – OVER= superior gluteal artery, nerve, vein – UNDER= sciatic nerve, inferior gluteal artery, vein, nerve, posterior femoral cutaneous nerve, nerve to obturator internus and gemellus superior, nerve to quadratus femoris/gemellus inferior • Lesser sciatic foramen goes under the ilium – Obturator internus muscle tendon, and pudendal artery and nerve also pass through this Describe the ligaments supporting the plantar arch • Medial and lateral plantar arches at deep level – Fall of medial arch results in flat foot • Spring ligament involved • Tibialis anterior and posterior/fibularis longus support the arch on the lateral and medial sides – Ligaments are the static support – Muscles are the dynamic support Describe the arterial supply of the femoral head and the possible fracture sites • The lateral circumflex femoral artery and the medial circumflex femoral artery (goes posterior) – Some blood from superior and inferior gluteal aa. – Artery of obturator internus also supplies some blood – Medial circumflex femoral artery supplies more; main supplier to head and neck of femur • If broken, femur dies • Possible fracture sites are the femoral neck, intertrochanteric fossa, femoral shaft – If neck not injured, blood supply could be safe