LOWER LIMB VIVAS

Sample vivaModel – knee: patella stability and quadricepsWhat factors are responsible for stability of the patella?The oblique placement of the femur and/or line of pull of the quadriceps femoris muscle relative to the axis of the patellar tendon and tibia, assessed clinically as the Q-angle, favors lateral displacement of the patella (line from the ASIS to the middle of the patella and extrapolating a second (vertical) line passing through the middle of the patella and tibial tuberosity. The Q-angle is typically greater in adult females, owing to their wider pelves.)The tendency toward lateral dislocation is normally counterbalanced by the medial, more horizontal pull of the powerful vastus medialis. In addition, the more anterior projection of the lateral femoral condyle and deeper slope for the larger lateral patellar facet provide a mechanical deterrent to lateral dislocation. An imbalance of the lateral pull and the mechanisms resisting it result in abnormal tracking of the patella within the patellar groove and chronic patellar pain, even if actual dislocation does not occur.

POINTS1 Primarily muscular, especially direction of pull of VM. Capsule / ligaments – minimal2 Bony – lat femoral condyle.3 Capsule / ligaments – minimal

Describe the components of the quadriceps.4 muscles origin of rectus femoris if doing well – both heads.

2011-2Model leg1. Identify the muscles of the anterior compartment of the leg, describe their attachments 2. Actions? 3. What nerves supply the muscles of the anterior compartment of the leg?

Muscle Proximal Attach Distal AttachInnervatio

n Action

Anter ior compartment

       

Tib ia l is anter ior

Lateral condyle and superior hal f of lateral sur face of t ibia and interosseous membrane

Medial and infer ior surfaces of medial cuneiform and base of 1st metatarsal

Deep f ibular nerve (L4 , L5)

Dorsi f lexes ankle and inver ts foot

Extensor digi torum longus

Lateral condyle of t ibia and super ior three quarters of medial surface of f ibula and interosseous membrane

Middle and dista l phalanges of lateral four digi ts

Extends lateral four digi ts and dorsi f lexes ankle

Extensor Middle par t of Dorsal aspect of Extends

hal lucis longus

anter ior surface of f ibula and interosseous membrane

base of d ista l phalanx of great toe (hal lux)

great toe and dorsi f lexes ankle

Fibular is tert ius

Infer ior th ird of anter ior surface of f ibula and interosseous membrane

Dorsum of base of 5th metatarsal

Dorsi f lexes ankle and aids in eversion of foot

2011-2Model: Leg1. Identify the fibularis muscles, describe their attachments? 2. Actions? 3. What nerves supply the fibularis muscles?

2011-2Model: Leg1. Identify the muscles of the posterior compartment of the leg (calf) 2. Describe the proximal attachments of the muscles of the superficial compartment 3. Describe the actions of the muscles of the deep compartment

SUPERFICIAL MUSCLES OF POSTERIOR COMPARTMENT OF LEG

Muscle Proximal AttachDistal Attach

Innervation Main Action

Gastrocnemius(over 2 jo ints)

Lateral head: lateral condyle Medial head: popl i teal sur face of femur, superior to medial condyle

Poster ior sur face of calcaneus via calcaneal tendon

Tibia l nerve (S1, S2)

Plantar f lexes when knee extended (ra ises heel dur ing walking) f lexes knee

Soleus(over 1 jo int)

Fibula: poster ior head, superior ¼ of post sur faceTibia: soleal l ine, middle 1/3 medial border of t ibiaTendinous arch between

Plantar f lexes ankle independent of posi t ion of knee; steadies leg on foot

Muscle Proximal Attach Distal AttachInnervatio

n Action

Anter ior compartment

       

Fibular is tert ius

Infer ior th ird of anter ior surface of f ibula and interosseous membrane

Dorsum of base of 5th metatarsal

Deep f ibular nerve (L4 , L5)

Dorsi f lexes ankle and aids in eversion of foot

Lateral compartment

       

Fibular is longus

Head and superior two thi rds of lateral sur face of f ibula

Base of 1st metatarsal and medial cuneiform

Superf ic ial f ibular nerve (L5, S1 , S2)

Everts foot and weakly plantarf lexes ankle

Fibular is brevis

Infer ior two thi rds of lateral sur face of f ibula

Dorsal surface of tuberosi ty on lateral s ide of base of 5th metatarsal

Everts foot and weakly plantarf lexes ankle

Plantar is Infer ior end of lateral supracondylar l ine of femur; obl ique popl i teal l igament

Weakly assists gastrocnemius in plantarf lexing ankle

MuscleProximal

Attach Distal AttachInnervatio

n Main Action

Popl i teus

Lateral condyle and lateral meniscus

Post t ibia, superior to soleal l ine

Tibia l nerve

Weakly f lexes knee, unlocks i t , medial ly rotates t ibia of unplanted l imb, pul ls lateral meniscus post, assists PCL

Flexor hal lucis longus

Infer ior 2/3 post f ibula; infer ior interosseous membrane

Base of d ista l phalanx of great toe (hal lux)

Flexes great toe at a l l jo ints; weakly p lantar f lexes ankle; supports medial longitudinal arch of foot

Flexor digi torum longus

Medial poster ior t ibia inf to soleal l ine; by a broad tendon to f ibula

Bases of d ista l phalanges of lateral four digi ts

Flexes lateral four d ig i ts; plantar f lexes ankle; supports longitudinal arches of foot

Tib ia l is poster ior

Interosseous mem; post t ibia inf to soleal l ine; post f ibula

Tuberosi ty of navicular, cuneiform, and cuboid; bases 2nd, 3rd, and 4th MTs

Plantar f lexes ankle; inver ts foot

DEEP MUSCLES OF POSTERIOR COMPARTMENT OF LEG

2011-1X-ray: Ankle1. Please demonstrate the ligamentous attachments of the ankle joint

The ankle joint is reinforced laterally by the lateral ligament of the ankle, a compound structure consisting of three completely separate ligaments:

1. Anterior talofibular ligament, a flat, weak band that extends anteromedially from the lateral malleolus to the neck of the talus,

2. Posterior talofibular ligament, a thick, fairly strong band that runs horizontally medially and slightly posteriorly from the malleolar fossa to the lateral tubercle of the talus.

3. Calcaneofibular ligament, a round cord that passes posteroinferiorly from the tip of the lateral malleolus to the lateral surface of the calcaneus.

The joint capsule is reinforced medially by the large, strong medial ligament of the ankle (deltoid ligament) that attaches proximally to the medial malleolus. The medial ligament fans out from the malleolus, attaching distally to the talus, calcaneus, and navicular via four adjacent and continuous parts: the tibionavicular part, the tibiocalcaneal part, and the anterior and posterior tibiotalar parts. The medial ligament stabilizes the ankle joint during eversion and prevents subluxation (partial dislocation) of the joint.

2. What is the most common injury of the ankle joint?

Sprain of lateral ligament (anterior talofibular)

2011-1Knee – Model: Movements and locking1. Identify the ligaments of the knee joint and their attachments that you can see in this

model.1. Patellar ligament – apex of patella to tibial tuberosity 2. Fibular collateral ligament (FCL or LCL) – lateral epicondyle of femur to lateral surface of

fibular head 3. Tibial collateral ligament (TCL or MCL) – medial epicondyle of femur to medial condyle and

superior aspect of medial surface of tibia 4. Anterior cruciate ligament (ACL) – anterior intercondylar area of tibia to posterior part of

medial side of lateral condyle of femur 5. Posterior cruciate ligament (PCL) – posterior intercondylar area of the tibia to anterior

aspect of lateral surface of medical condyle of femur 6. Posterior meniscofemoral ligament – joins lateral meniscus to the PCL and medial femoral

condyle

2. Describe the main movements of the knee joint and the muscles that are involved. Prompt: Are there rotational movements of the knee that you can describe?

1. Extension – quadriceps femoris (weakly: tensor of fascia lata)2. Flexion – (120 hip extended, 140 hip flexed and 160 passively) semitendinosus,

semimembranosus, long and short heads of biceps femoris3. Medial rotation – (10 deg, limited by collateral ligaments) When flexed - semitendinosus,

semimembranosus. When non-bearing knee extended (5 deg) - popliteus. 4. Lateral rotation – (30 deg) When flexed - biceps femoris

3. Describe the locking and unlocking process that occurs with the weight- bearing knee as we extend and flex the joint whilst walking.

When knee fully extended and weight bearing – knee passively locks due to medial rotation of femoral condyles on tibial plateau. Knee unlocks through contraction of popliteus – rotating femur laterally on tibial plateau to allow flexion.

2011-1Foot sensation1. Describe the peripheral nerves which supply sensation to the foot?

Dorsum of foot:- Lateral border-> sural nerve- Most of dorsum supplied by superficial fibular (peroneal) nerve- 1st web space by deep fibular (peroneal) nerve.- Medial side of ankle -> Saphenous n.

Sole of foot:Tibial nerve

- Heel -> medial calcaneal bra nches- Lateral sole -> lateral plantar nerve- Medial -> medial plantar nerve

2. Describe the dermatomes of the dorsum of the foot.

L4- medial border foot and heelDorsum:L5 from lateral leg to medial foot, medial 3 toesS1 lateral 2 toes and border of foot, Sole:S1 mostly, L5 the medial 3 toes and ball

2010-2Photo: Gluteal Area1. This is a photograph of the gluteal region. Identify the structures. Prompt if needed – what is this (Sciatic Nerve)15-Piriformis Sciatic N: 23-Tibialpart; 1-Common Fibular part 2-Gluteus maximus;16-Post Fem Cutaneous N 13-Obturator Externus 18-Quadratus femoris 7-Inferior gluteal art. 17-Pudental N;9-Internal Pudental art; 11-N to Obturator Internus 20-Superior Gamellus; 14-Obturator Internus 6-Inferior Gamellus 21-; 22-; 8-Inferior gluteal N 3-Gluteus medius; 4-Gluteus minimus 5-Greater Trochanter Femur 19-Sacrotuberous Ligt 10-Ischael Tuberosity

2. Describe the course of the Sciatic Nerve, and the muscles it supplies. Enters gluteal region via greater sciatic foramen inferior to piriformis and deep to gluteus maximus; decends in midline posterior thigh deep to biceps femoris; bifurcates into tibial and common fibula (perioneal) nerves at apex of popliteal fossaNo supply in gluteal region. Supplies all muscles of posterior compartment of thigh (common fibula short head biceps, tibial division all the rest)

2010-2Bone: Femur1. Identify the landmarks of this bone Head, fovea, neck Greater trochanter, lesser trochanter, Trochanteric fossa intertrochanteric line intertrochanteric crest pectineal line shaft and/or linea aspera medial / lateral supracondylar lines adductor tubercle medial / lateral epicondyles medial / lateral condyles intercondylar fossa

2. Demonstrate the attachments of the adductor muscles of the hip. Adductor longus -> Middle 1/3 linea aspera Adductor brevis -> Pectineal line and proximal linea aspera Adductor magnus -> Adductor part – linea aspera, medial supracondylar line

Hamstring part (not strictly in this Q) -> adductor tubercle [Gracilis] -> Not femur, Sup part of med surface of tibia w/ sartorius and semitend. Pes anserinusPectineus -> Pectineal line inferior to lesser trochanter Obturator Externus ->Trochanteric fossa

MUSCLE PROX ATTACH DIST ATTACH INNERVATION ACTIONAdductor longus Body of pubis inf

to pubic crestMiddle 1/3 linea aspera

Ant div of obturator L2, L3, L4

Adducts thigh

Adductor brevis Body and inf ramus of pubis

Pectineal line, prox linea aspera

Adduct thigh (some flexion)

Adductor magnus- adductor part Inf ramus of

pubis and ramus of ischium

Gluteal tuberosity, linea aspera, medial supracondylar line

Obturator n. L2, L3, L4

Adducts and flexes thigh

- hamstrings part(transitional)

Body and inf ramus of pubis

Adductor tubercle of femur

Tibial part of sciatic n. L4

Adducts and extends thigh

Gracilis Body and inf ramus or pubis

Sup part of med surface of tibia

Obturator L2, L3

Adducts thigh, flexes leg, helps med rot of leg

Obturator enternus Obturator foramen and membrane

Trochanteric fossa of femur

Obturator n.L3, L4

Lat rot of thigh, steadies head in acetablum

2010-2XR: Pelvis

1. Identify the bony features of this x-ray

Iliac crest, Ala of ilium Sacro iliac joint, Sacrum Lumber vertebrae Pelvic brimAnterior superior iliac spin Anterior inferior iliac spine Ischial spine Ischial turberosity Obturator foramen Acetabular fossa, Superior rami Inferior rami Symphysis pubis

2. Describe the anatomy of the iliopsoas muscle. Iliopsoas – consists of Iliacus & Psoas major

Psoas major- Superior attachment -> Transverse process of lumbar vertebrae, Sides of vertebral bodies

Intervertebral discs T12- L5- Inferior attachment - Single tendon to lesser trochanter of femur- Innervation - Anterior rami of L1, L2, L3

Iliacus- Superior attachment -> Superior 2/3 of iliac fossa, Ala of sacrum, Anterior sacro-iliac ligaments- Inferior attachment -> Lesser trochanter of femur and shaft inferior and Psoas major tendon- Innervation - Femoral nerve L2- L4

2010-2Model: Ankle1. Identify the ankle dorsiflexors on this model? 2. What is their nerve supply? 3. Identify the insertions?

Muscle Proximal Attach Distal AttachInnervatio

n Action

Anter ior compartment

       

Tib ia l is anter ior

Lateral condyle and superior hal f of lateral sur face of t ibia and interosseous membrane

Medial and infer ior surfaces of medial cuneiform and base of 1st metatarsal

Deep f ibular nerve (L4 , L5)

Dorsi f lexes ankle and inver ts foot

Extensor digi torum longus

Lateral condyle of t ibia and super ior three quarters of medial surface of f ibula and interosseous membrane

Middle and dista l phalanges of lateral four digi ts

Extends lateral four digi ts and dorsi f lexes ankle

Extensor hal lucis longus

Middle par t of anter ior surface of f ibula and interosseous membrane

Dorsal aspect of base of d ista l phalanx of great toe (hal lux)

Extends great toe and dorsi f lexes ankle

Fibular is tert ius

Infer ior th ird of anter ior surface of f ibula and interosseous membrane

Dorsum of base of 5th metatarsal

Dorsi f lexes ankle and aids in eversion of foot

Tim - Tib antHas - EHLA - Ant tib artery -> DPVery - VeinNasty - Deep fibular nerveDisease - EDLFever - Fibularis tertius

2010-2Bone: Ankle Joint1. Identify the bony landmarks of the ankle – what are the features of this bone (point at talus

or name if already named)Landmarks: lat malleolus, medial malleolus, talus, trochlea talus, head talus, neck talus, body talus, lateral tubercle talus, medial tubercle talus, groove for flexor hallucis longus

2. Name the structures passing behind the medial malleolus Tim - Tibialis posterior Doth - Flexor digitorum longus Vex - Posterior tibial veinAll - Posterior tibial arteryNervous - Tibial nerveHousemaids - Flexor hallucis longus

2010-1Pelvic bone1. What bones make up this structure, and what are their major features?

Ilium, Ischium, Pubis

Acetabulum (with acetabular notch)Obturator foramen (with obturator groove)IliumAlaIliac crestInferior, anterior and posterior gluteal linesAnterior superiorAnterior inferior, Posterior superiorPosterior inferior iliac spinesGreater sciatic notchIschiumIschial spineLesser sciatic notchIschial tuberosityIschiopubic ramusPubis Superior pubic ramusPubic symphysis

2. What are the lateral rotators of the femur, and where do they originate?

MuscleProximal

Attach Distal Attach Innervation Main Action

DEEP LAYER

Pir i formis

Ant sacrum, sacrotuberous l ig

Super ior border of greater t rochanter

Branches of anter ior rami of S1 , S2

Lateral ly rotate extended thigh and abduct f lexed thigh; steady femoral head in acetabulum

Obturator internus

Obturator membrane and surrounding bone

Medial surface of greater t rochanter ( t rochanter ic fossa) of femur

Nerve to obturator internus(L5, S1 )

Super ior and infer ior gemel l i

Super ior : ischial spine

Infer ior: ischial tuberosi ty

Nerve to quadratus femoris (L5, S1)

Quadratus femoris

Lateral border of ischia l tuberosi ty

Quadrate tubercle on intert rochanter ic crest of femur and area infer ior to i t

Lateral ly rotates thigh, steadies femoral head in acetabulum

SUPERFICIAL LAYER

Gluteus maximus

I l ium (post to post g lut l ine) , sacrum, coccyx, sacrotuberous l ig

I l io t ibia l t ract -> lat condyle and some -> gluteal tuberosi ty

Infer ior gluteal n. (L5, S1, S2 )

Extends (esp f rom f lexed), assists lat rot , steadies thigh and assists r is ing f rom si t t ing

2010-1Describe the superficial venous drainage of the lower limb - Long system, Great saphenous vein: Dorsal v arch of foot drains medially to GSV, ascends ant to MM, then behind med fem condyle (hand breadth post to patella), then up med thigh through fascia lata via the cribriform facia in saph opening into fem V (4cm inferolat to pubic tubercle). .

- Numerous valves, perforators to deep system (classically 3,6,9cm above MM for GSV) and anastomoses via accessory saphenous vein with SSV

- Short system: Laterally, Small SV arises from dorsal venous arch, ascends behind LM, lateral to Achilles, penetrates fascia at mid-line, between heads of gastroc to join popliteal vein

Pass criteria:Identify  MM, fem condyle and saph opening landmarks of GSVName SSV and general locationIdentify connection with deep system via perforators

2010-11. Outline the course of the common fibular nerve and its main branches 2. What does it supply? (Motor and sensory)

Common fibular nerve:Forms as sciatic bifurcates at apex of popliteal fossa and passes over posterior aspect of head of fibula and then winds around neck of fibula deep to fibularis longus, where it divides into deep and superficial fibular nerves

Supplies: skin on lateral part of posterior aspect of leg via its branch (lateral sural cutaneous nerve); also supplies knee joint via its articular branch

Superficial fibular nerve:Arises between fibularis longus and neck of fibula and descends in lateral compartment of leg; pierces deep fascia at distal third of leg to become subcutaneous

Supplies: fibularis longus and brevis (lateral compartment muscles) and skin on distal third of anterior surface of leg and dorsum of foot

Deep fibular nerve:Arises between fibularis longus and neck of fibula; passes through extensor digitorum longus and descends on interosseous membrane; crosses distal end of tibia and enters dorsum of foot

Supplies: anterior muscles of leg and dorsum of foot, and skin of first web space; sends articular branches to joints it crosses

2010-1Bone: FemurIdentify this bone and the significant boney landmarks of the proximal portionWhat is the blood supply of the neck and head of the femurHow does the capsule of the hip joint attach on this bone

2009-2

X-ray: Lateral Ankle1. Please identify the bones on this xray

2. What movements occur at the ankle joint? Type and Location- Hinge-type synovialMovements- Dorsiflexion – ant compartment m- Plantar flexion – posterior compartment m- Wobble in plantar flexion (abduction, adduction, inversion and eversion) due to the trochlea of the

talus being narrow posteriorly- Most unstable in plantar flexion because trochlea narrow posteriorly- Most injuries involve inversion during plantarflexion

2009-2Bone: Ankle/foot1. Identify the bones of the ankle and foot ID: lat/med malleoli, talus, calcaneus, navic, cub, cuneiforms, metat, phalanges (8 of 9)

2. What are the parts of the talus?

3. Demonstrate the attachments of the lateral ligament of the ankle

The ankle joint is reinforced laterally by the lateral ligament of the ankle, a compound structure consisting of three completely separate ligaments:

1. Anterior talofibular ligament, a flat, weak band that extends anteromedially from the lateral malleolus to the neck of the talus,

2. Posterior talofibular ligament, a thick, fairly strong band that runs horizontally medially and slightly posteriorly from the malleolar fossa to the lateral tubercle of the talus.

3. Calcaneofibular ligament, a round cord that passes posteroinferiorly from the tip of the lateral malleolus to the lateral surface of the calcaneus.

2009-2

TibiaFibulaCalcaneusTalusNavicularCuboidMetatarsal and cuneiforms (grouped)Lateral and medial malleoli

Model: Femoral triangle, muscles and contentsUsing the model Demonstrate the boundaries of the femoral triangle

Demonstrate the contents

What does the femoral nerve supply? Muscles: Anterior thigh muscles- Especially the quadriceps, also iliacus and

sartorius. Also supplies pectinieus, but dual supply from obturator

Joints: Hip and kneeCutaneous: Anterior thigh via the anterior cutaneous branches

2009-1Model: knee1. Indicate the major ligaments and their attachments

1. Patellar ligament – apex of patella to tibial tuberosity 2. Fibular collateral ligament (FCL or LCL) – lateral epicondyle of femur to lateral surface of

fibular head 3. Tibial collateral ligament (TCL or MCL) – medial epicondyle of femur to medial condyle and

superior aspect of medial surface of tibia 4. Anterior cruciate ligament (ACL) – anterior intercondylar area of tibia to posterior part of

medial side of lateral condyle of femur 5. Posterior cruciate ligament (PCL) – posterior intercondylar area of the tibia to anterior

aspect of lateral surface of medical condyle of femur 6. Posterior meniscofemoral ligament – joins lateral meniscus to the PCL and medial femoral

condyle

2. What are the actions of these Patella ligament: extensor mechanism, extends the lower leg through action of quadricepsCollateral ligaments: become taught in extension, especially with the hyperextended locked knee, check rotation of the lower legThe ACL and PCL: also check medial rotation (by winding taught)The ACL prevents anterior draw of the tibia and hyperextension. It is also important in physiologic locking of the knee as the femour will rotate internally on its axis.The PCL prevents posterior sag of the tibia and stabilizes the knee in flexion, eg when climbing down stairs or a hill.

3. What are the attachments of the menisci 1. Firmly at anterior ends to intercondylar area of the tibia with transverse ligament between them2. Coronary ligaments from artic margins of the femur and tibia except under popliteus tendon

and transverse ligament anteriorly to each other3. Medical meniscus: Firmly to the MCL, and posteriorly to the intercondylar area4. Lateral Meniscus: more movable, attached to popliteus posteriorly (drawn back in flexion), also

to the meniscofemoral ligament joinigin it to the PCL and medial condyle5. MAL,LMP: ant horn of MM, ACL, ant horn LM, post horn LM, post horn MM, PCL

2009-11. Name the bones of the foot – which of these constitute the medial longitudinal arch Arch Bones Boney support Ligamentous sup Muscular support

Longitudinal medial(high)

Calcaneus, talus,3 cuneiform, 3 MTs

Keystone talus Plantar aponeurosisLong plantar lig.Short plantar lig.(calcaneocubiod)Spring ligament(calcaneonavicular)

Intrinsic plantar m.

FHL, FDLLongitudinal lateral(low)

Calcaneous, cuboid, 2 MTs

Transverse (high)

Cuboid, cuneiforms Base of MTs

Wedge shapedcuneiforms

FL, TP

2. What are the major factors contributing to the stability of the boney arches of the foot

Of these factor the plantar aponeurosis and plantar ligaments bear the greatest stress and are most important

3. What is the function of the longitudinal arches of the foot - shock absorption- Distribution of weight over the pedal platform- Act as springboards when walking, running and jumping

2009-1Identify the fibularis musclesWhat nerves supply these musclesWhat are the actions of the fibularis musclesWhat joints are involved in inversion and eversion of the footSubtalar joint (talocalcaneal) and transverse tarsal joint (calcaneocuboid and talonavicular)

2008-2Bone: tibiaDescribe the features of the proximal end of this bonePrompt "Demonstrate the attachments of the menisci and cruciate ligaments."Meniscal attachments Anterior and posterior cruciate attachments Capsular margin Tibial tuberosity Median and lateral condyles Tibiofibular joint

2008-21. Describe the proximal Tibiofibular joint (Tibia and fibula put together for candidates)2. What structures can be damaged by direct trauma to the region of the proximal fibula?3. Describe the consequences of injury to the Common peroneal nerve

1. Identify proximal fibula and articular area of fibula and tibia Synovial joint, separate to knee joint, minimal movement possible2 & 3 Lateral collateral ligament Biceps femoris tendon Common peroneal nerveSuperficial fibular nerve – weakness of ankle eversion (and slight reduction in plantar flexion), sensory loss over lateral aspect of leg , reduced sensation over posterior aspect of leg and lateral aspect of foot ((Lateral) Sural nerve)Deep Fibular nerve (Anterior tibial) – weakness of ankle dorsiflexion (T.Anterior), sensory loss dorsum of foot and first interdigital cleft Injury to fibularis (peroneus) longus and brevis muscles– weakness of ankle eversion.

2008-2Describe the superficial boundaries of the popliteal fossaUsing this photo demonstrate the contents?What is the distribution and supply of the common fibular nerve/

Superiorly: biceps femoris 1, semitendinosus 14 and semimembranosus 13 Inferiorly : lat 5 and med 6 heads of gastrocnemius Popliteal vessels 10&11Small saphenous vein 15 Tibial 19 & common fibular 2 nerves Lymph nodes and lymphatics Superficial fibular nerve lateral compartmentAntero lat leg and foot Deep fibular nerve ant comp and dorsum footSkin b/w great &2nd toeSuperiorly: biceps femoris 1, semitendinosus 14 and semimembranosus 13 Inferiorly : lat 5 and med 6 heads of gastrocnemius Popliteal vessels 10&11Small saphenous vein 15 Tibial 19 & common fibular 2 nerves Lymph nodes and lymphatics Superficial fibular nerve lateral compartmentAntero lat leg and foot Deep fibular nerve ant comp and dorsum footSkin b/w great &2nd toe

2008-1Photo - femoral triangle boundaries and contentsIdentify the boundaries and contents of the femoral triangle in this photo Ing lig, add long and Sartorius form triangle, pectineus (med) and iliopsoas (lat) form floorfem vein, fem art and fem nerve (med to lat)

4 superficial branches in fem triangle (superf epig, superf cx iliac, superf and deep pudendal)

Profunda femoris (“deep artery of thigh”!) branches off post-lat in triangle to supply thigh, passes behind add longus. Gives med and lat cx fem arteries. Med cx fem supplies NOF

Fem artery continues down thigh deep to Sartorius and pass through adductor canal and becomes popliteal art at adductor hiatus

2008-1XR AP PelvisCOMMENTSOPENING QUESTIONDescribe the major bony features seen on this Xray1 Ilium – crest, ASIS, AIIS, acetabulum (pt), SI jt15 features to pass2 Ischium – body, ramus, tuberosity, spine,3 Pubis – symphisis, inf ramus, sup ramus, tubercle, pectineal line4 Sacrum – vertebral foramina, L5-S1 jt5 Coccyx6 Femur – head, neck, gter trochanter, lesser trochanter7 Acetabulum, obturator foramen,PROMPTSWhich bones can you see? Where do fractures usually occur?

Demonstrate the bony attachments of the main muscles which flex the hip

1 Flexors – Iliacus – iliac crest, fossa, ala sacrum, ant SI lig to psoas maj, Psoas maj – T12-L5 vert, discs, transv proc to lesser troch fem, Psoas min – T12 – L1 to pec line, iliopect eminence Rectus femoris – AIIS, ilium) Pectineus (superior ramus of pubis) Sartorius (ASIS)

2008-1Pelvis XR APDescribe the major bony features seen on this Xray

Ilium – crest, ASIS, AIIS, acetabulum (pt), SI jointIschium – body, ramus, tuberosity, spinePubis – symphisis, inf ramus, sup ramus, tubercle, pectineal line

Sacrum – vertebral foramina, L5-S1 jointCoccyxFemur – head, neck, gter trochanter, lesser trochanterAcetabulum, obturator foramen

Demonstrate the important ligament attachments of the hip jointIliofemoral lig – strong, ant sup ASIS, inf intertrochanteric linePubofemoral – med – obturator crest pubis inf-lat to merge with capsule deep to

iliofemoral ligIschiofemoral – post, weakest of 3, from ischial pt of acetabular rim superolat’ly to

femoral neck, med to base greater trochanterLig of head of femur – from acetabular notch to fovea for lig of head femur

2008-1Identify the bones of the tarsusCOMMENTSPOINTS REQUIRED1 Talus (head, neck, dome, groove for FHL post, groove for tibialis posterior on plantar surface, articular surfaces for calcaneum, navicular + ankle mortise)6 out of 7 correct to pass2 Calcaneum (shelf= sustentaculum, groove for FHL, site of insertion of tendo achilles, insertion of long plantar ligament on plantar surface, articular surfaces for talus + cuboid)(Extra marks for detail)3 Cuboid4 Navicular5 Medial, middle + lateral cuneiforms

Demonstrate the attachments of the medial collateral ligament ( = ‘ deltoid ligament’)2 of the 4 parts to passPOINTS REQUIRED1 Posterior tibio-talar (to medial tubercle of talus)2 Tibio-calcaneal (to calcaneal shelf =sustentaculum tali)3 Tibio-navicular (to tuberosity of navicular)4 Anterior tibio-talar

Describe the structures running immediately posterior to the medial malleolus2 to pass - correct order from superficial to deep neededPOINTS REQUIRED1 Tibialis posterior tendon2 Posterior tibial artery3 Posterior tibial nerve (lying deep to the artery)

2008-1XR AP Pelvis

Describe the major bony features seen on this XrayCOMMENTSPOINTS REQUIRED1 Ilium – crest, ASIS, AIIS, acetabulum (pt), SI jt15 features to pass2 Ischium – body, ramus, tuberosity, spine,3 Pubis – symphisis, inf ramus, sup ramus, tubercle, pectineal line4 Sacrum – vertebral foramina, L5-S1 jt5 Coccyx6 Femur – head, neck, gter trochanter, lesser trochanter7 Acetabulum, obturator foramen,PROMPTS

Which bones can you see? Where do fractures usually occur?SECOND QUESTION (if needed)Demonstrate the important ligament attachments of the hip joint2 out of 4 to passPOINTS REQUIRED1 Iliofemoral lig – strong, ant sup ASIS, inf intertrochanteric line2 Pubofemoral – med – obturator crest pubis inf-lat to merge with capsule deep to iliofemoral lig3 Ischiofemoral – post, weakest of 3, from ischial pt of acetabular rim superolat’ly to femoral neck, med to base gter troch4 Lig of head of femur – from acetabular notch to fovea for lig of head femur

2008-1 Knee joint: ligaments; stability ___________________ NUMBER: 11/4 - 4No prompts. COMMENTS Must pass questions 1 & 2 to pass overallOPENING QUESTIONDemonstrate the bony features on this x-ray.COMMENTSPOINTS REQUIRED1 Bones – femur; tibia; fibula8 = pass2 Patella (sesamoid)3 Tibia – intercondylar eminence (ICE); posterior intercondylar area; anterior intercondylar area4 Tibia - tuberosity5 Tibia –condyles (lateral; medial)6 Femur – condyles (lateral; medial)7 Femur – epicondyles (lateral; medial)8 Fibula – head of fibulaPROMPTSIndicate features and askSECOND QUESTIONUsing the x-ray as a guide, describe the cruciate ligaments.POINTS REQUIRED1 Cruciates – anterior (ACL) (anterior part ICE → postero- medial lat femoral condyle) and posterior (PCL) (stronger; posterior part ICE → ant-lat med femoral condyle)Both correct to pass2 Ligaments of fibrous capsule: ligamentum patellae (continuation of Quadriceps Femoris tendon → tib tuberosity); fibular collateral (lateral) ligament (lat epicondyle of femur → head of fib); tibial collateral (medial) ligament (med epicondyle of femur → medial surface of tibia); oblique popliteal ligament (expansion of tendon of Semimebranosis; strengthens capsule posteriorly); arcuate popliteal ligament also strengthens capsule posteriorly; post aspect of head of fib → ICE and post aspect of lat epicondyle of femur)Extra if doing well3 Others: menisci joined anteriorly by transverse ligament; medial cruciate joined to PCL by posterior menisco-femoral ligamentTHIRD QUESTION (if needed)What are the factors that contribute to stability of the knee joint?If doing well and sufficient timePOINTS REQUIRED1 Strength of surrounding muscles (most important): particularly Quadriceps femoris (especially lower fibres of Vastus medialis and Vastus lateralis)2 Strength of surrounding ligaments3 Bony structures (minor)

2007-2Bone: femur and acetabulum

Name this bone and describe its proximal featuresWhat factors contribute to stability of the hip joint

2007-2Demonstrate the attachments of the inferior extensor retinaculumIdentify the structure passing beneath the IERWhat is the funtion of the inferior extensor retinaculum

2007-2Demonstrate the structures passing behind the medial malleolusWhat is the cutaneous innervation of the tibial nerve

2007-1ciatic nerve ______________________________ NUMBER: __________6OPENING QUESTIONWhat structures are visible in this buttock dissection?COMMENTSPOINTS REQUIRED1 sciatic nerve (23)mandatory2 piriformis (15)mandatory3 gamelli sup (20) and inf (6)4 post cutaneous nerve of the thigh (16)5 gluteus medius (2)6 to pass6 any otherPROMPTSIdentify the sciatic nerve and piriformisSECOND QUESTION (if needed)Describe the course of the sciatic nerve in the thighPOINTS REQUIRED1 Leaves gluteal region at midpoint of greater trochanter and ischeal tuberosity2/4 to pass2 Passes deep to long head of biceps3 Lies on adductor Magnus4 Generally divides in lower third (12% common fibular branch passes thru piriformis), often divides earlyPROMPTSWhere does it divide and into whatTHIRD QUESTION (if needed)Describe its motor distribution in the thighPOINTS REQUIRED1 tibial branch – hamstrings and part of adductor Magnus

2007-1discussion – lower limb _____________________ NUMBER: __________COMMENTSOPENING QUESTIONDescribe the dermatomes of the lower limbCOMMENTSPOINTS REQUIRED1 indicate (?on self ) L1,2,3,4,5 winding around legneeded2 S1 S2 back of leg s1 becomes lateral foot, L5 medial foot

3 axial line down postero medial aspect of leg5PROMPTSSECOND QUESTION (if needed)Please describe the cutaneous nerves of the lower limb5 facts in total to passPOINTS REQUIRED1 lateral cutaneous nerve of thigh L2,3 anterior cutaneous branch of femoral nerve L2-4 Intermediate and medial femoral cut nerves Ilio-inguinal ObturatorPosterior cutaneous S1-3 Most of thigh2 saphenous nerve ( from femoral) L3,4 (antero medial leg)lateral sural cutaneous n and sural (postero lateral leg)3 fibula (peroneal) nerves anterolateral leg and dorsum of foot4 calcaneal branches of tibial and sural nerves lateral and medial plantar nerve from tibial (sole )5 deep fibular (deep peroneal) nerve L5 in first web space

2007-1Ankle ___________________________________ NUMBER: __________COMMENTSOPENING QUESTIONWhat bones can you identify in this ankle and foot?COMMENTSPOINTS REQUIRED1) Distal Tibia2) Distal Fibula3) Calcaneous4) Talus5) Metatarsals 1st and 5thPROMPTSSECOND QUESTION (if needed)What are the neurovascular relations of the medial malleolus?3 / 4 to passPOINTS REQUIRED1) Post tibial artery post2) Tibial nerve post3) Venae commitantes of the artery post4) Great saphenous nerve and vein anterior56PROMPTSWhat nerves and vessels run close to the medial mall?THIRD QUESTION (if needed)How much of the skin of the foot is blocked if you do a post tibial block behind the med. Mall.POINTS REQUIRED1) Medial plantar nerve..medial side of foot2) lateral plantar...lateral side of foot3)doesn’t block the lateral side of heel, foot..sural

2006-1Ankle x-ray - stability and ligamentsCOMMENTS

NUMBER:ThAMtfjLOPENING QUESTIONIdentify the bones on this x-ray

COMMENTSPOINTS REQUIRED1 fibular/lateral malleolus6 of8 to pass2 tibia/medial malleolus3 talus - head, neck, dome4 calcaneus5 navicular6 cuneiforms7 proximal 2/3 s of the metatarsals 8 cuboidPROMPTSCan you identify any specific parts of that boneSECOND QUESTION (if needed)What factors contribute to stability of the ankle joint3/3 ligs named to passPOINTS REQUIRED1 Bones - talus sandwiched between tib and fib2 Muscles - all muscles that cross the jt3 Ligaments - main factor: medial (deltoid), lateral (3 parts), and post tibiofibular4PROMPTSTHIRD QUESTION (if needed)Demonstrate the attachments of the lateral ligament on the x-ray2/3 to passPOINTS REQUIRED1 ant talofib- ant border of lat mal to neck of talus2 calcaneofibular - tip of lat mal down and back to latsurface of calc3 post talofib - post aspect of lat mal horizontally to lat tubercle of talus

2006-1Femoral triangle photo - position of femoral artery NUMBER: 3THRSIAH 4OPENING QUESTIONIdentify the Femoral Artery and related structuresCOMMENTSPOINTSREQUBRED1 Fern Art2 Fern Nerve and Vein (and canal)3 Medial muscles: Add longus, pectineus4 Lateral Mus: Iliacus, sartorius5 Inguinal ligament6 Deep is Psoas ligament7 Deeper is Hip capsulePROMPTS5 of 7 to passSECOND QUESTION(ifneeded)Describe the surface markings of the Fern Artery in the femoral trianglePOINTS REQUIRED

1 Mid Inguinal point2 mid way between Pub symphysis and ASISAll correct to pass3 exits distally under sartorius456PROMPTSTfflRD QUESTION (if needed)Describe the anastomoses associated with the femoral arteryPOINTS REQUIRED1 trochanteric (head of femur) via med and lat fern c-flex2 cruciate (lessr trochanter) as above with inf glut atr3 geniculate (popl fern and tibial arts)

2006-1Knee joint bones _ _COMMENTSNUMBER: Th PM Q2OPENING QUESTIONIdentify the bony features of the knee jointCOMMENTSPOINTS REQUIRED1 2 femoral condyles2 2 Epicondyles3 2 condylar surfaces4 1 intercondylar eminences with 2 tibial spines5 of7topassPROMPTSSECOND QUESTION(ifneeded)What are the major ligaments of the knee joints?POINTS REQUIRED1 Anterior cruciate2 Posterior cruciate3 Medical collateral superficial and deep4. Lateral collateral ligament4. Popliteal ligament5. Arcuate ligament6 Ligamentum patellae2 paired ligaments to passPROMPTSTIflRD QUESTION (if needed)Demonstrate their attachments on the tibia?POENTS REQUIRED1 Anterior cruciate2 Posterior cruciate3 Medical collateral superficial and deep4 Ligamentum patellae

2006-1photo of the posterior thigh - sciatic nerve NUMBER: Th Q4 P A

COMMENTStOPENING QUESTIONThis is a photograph of the back of the right thigh. This is the medial aspect. This is the lateral aspect. Could you name the numbered muscular structures?COMMENTSPOINTS REQUIRED1 Adductor gracilis (2)Possible2 Semitendinosus (3)Must know3 Semimembranosus (4)Must know4 Long head Biceps (5)Must know5 Short head biceps (14)Must Know6 Quadratus femoris (9)Possible7 Ilio-tibial band (13) 8. Gluteus maximus (10 9. Adductor magnus (19) )Possible Should know Possible 6 of9 to passPROMPTSPerhaps questions of orientation. Tell me what you can seeSECOND QUESTION (if needed)Can you identify the sciatic nerve and the What is the course of the sciatic nerve in the thigh?POINTS REQUIRED1 Appropriate identification of the sciatic nerveMust know2 Enters by passing deep to piriformis, usually.Could know3 Enters the upper thigh deep to the hamstringsCould know4 After biceps overarches the nerve the, nerve lies deeply between semimembranosus and bicepsShould know5 Divides into peroneal and tibial nerves about 5 cm above the knee jointShould know6 Giving off muscular branches to hamstrings

2006-1nee photo (or x-ray) - landmarks & capsular attachmentsNUMBER: Fri Q4 ^COMMENTSOPENING QUESTIONIndicate the bony features on this x-rayCOMMENTSPOINTS REQUIRED1 Femoral shaft2 Femoral condyles3 Tibial plateau4 Intercondylar eminence5 Patella6. Fibula head7 Fibula neck8. Fibula shaft6 of8 to passSECONDQUESTION

(if needed)POINTS REQUIREDDescribe the capsular attachments of the kneeCOMMENTS1 attached to the margins of the articular surfaces2 Femoral - posteriorly to prox margin of the condyles3 anteriorly - deficit allowing for suprapatellar bursa - blends with patella retinacula and ligament4 laterally - passage of popliteus tendon5 - attach to head of fibula6 medially -deep component of med collat lig. + Meniscus7 weak attachment to both menisci4/7 to passPROMPTSTHERD QUESTION (if needed)Which structures add stability to the joint

2006-1Femoral nerve and myotomeCOMMENTSsNUMBER: Fri5OPENING QUESTIONCould you outline the lower limb myotomes?COMMENTSPOINTS REQUIRED1 L2 & 3 Hip flexors & Adductors2 L3 & 4 Knee extensors & Hip Abductors3 L4 & 5 Hip extensors3 L5& SI Knee flexors4 L4 & 5 Ankle and long dorsi flexors5 SI &2 Plantar flexors6EversionL5 & SI7 Inversion L45 of 7 to passPROMPTSWhat is the innervation of the muscles of the etc?SECOND QUESTION(ifneeded)What is the motor distribution of the femoral nerve?POEVTS REQUIREDCourses through between the psoas and iliacus supplying both.Passes into the femoral canal and begins to divide into its muscular branches in the femoral triangle supplying quadriceps femoris and articularis genu

2006-2Demonstrate the attachments of the ligaments of the ankle

1. Med – deltoiddeep – med. mall. to side of talus below art. surfacesuperficial – triang –from borders of med mall to wide attachment from med tubercle

talus along susten tali, spring lig, to tuberosity of navicular2. Lat – 3 bandsant. talofib – ant border lat mall to neck of taluscalcaneofib – front of tip of lat mall down & back to lat surface calc

post talofib – horizontal, from malleolar fossa to lat tubercle of talus, strong

What factors contribute the stability of the ankle?Bone – med & lat malleoliLigamentsmed, latant & post tibiofibular

2006-2Bone: footDemonstrate the insertions of the muscles of the posterior compartment of the legDemonstrate the insertions of the mm of the lateral compartment of the leg

2006-2What factors are responsible for the stability of the patellaDescribe the components of the quadriceps

2006-1X-ray: ankleIdentify the bonesStability factorsAttachment of lateral ligament

2006-1Photo: femoral triangleIdentify the femoral artery and related structuresDescribe the surface markings of the femoral artery in the femoral triangleDescribe the anastomoses associated with the femoral artery

2006-1Bones: knee jointIdentify the boney features of the knee jointWhat are the major ligaments of the knee jointsDemonstrate their attachments on the tibia

2006-1Photo: posterior thighIdentify the muscular structuresCan you identify the sciatic nerve and what is the course in the thigh

2006-1Photo: knee or X-ray: kneeIndicate the boney featuresDescribe the capsular attachments of the kneeWhich structures add stability to the joint

2006-1Femoral nerve and myotomesCould you outline the lower limb myotomesWhat is the motor distribution of the femoral nerve

2005-2Discussion: Knee model NUMBER: 1.5OPENING QUESTIONHere is a model of a knee. Could you point out the main ligaments?COMMENTS * Essential

POINTS REQUTRED1 Tibial collateral lig (med lig)*2 Fibular collateral lig (lat lig)*3 Anterior cruciate lig*4 Post cruciate lig*5 Patellar*6 Posterior meniscofemoral ligamentPROMPTSWhat other ligaments help stabilise the knee joint?SECON D QUESTI ONWhat is the most important stabilising factor of the knee joint?POINTS REQUIREDCruciates* How do they act to stabilise the knee? Forward displacement of tibia on femur prevented by ant cruciate* Backward displacement of tibia on femur prevented by post cruciate.** essentialTETTRD QUESTIONDescribe the main anatomical features of the cruciate ligamentsPOINTS REQUntED1 Intracapsular but extrasynovial (covered by synovium on front and sides but not posteriorly)Cruciates cross each other like " X " with ant cruciate lying anterolateral to the post cruciate2 Ant cruciate; Anterior part of tibial plateau* between attachments of ant horns of med and lat menisci Ascends posteroiaterally twisting on itself Attaches to posteromedial aspect of lat fern condyle*Essential to demonstrate an understanding of attachments3 Post cruciate; Stronger shorter and less oblique Smooth impression on post part of tibial intercondylar area (which extends to the uppermost part of post surface of tibia Ascends anteromediallyAttaches to anterolateral aspect of med fem condyle

2005-2Model: Femoral Triangle NUMBER: 2.1COMMENTSOPENING QUESTIONIdentify the muscles that make up the femoral triangle and describe its contents.COMMENTSPOINTS REQUTREDSartorius* Adductor longus*lliacu Psoas Pectineus Adductor longussContents: (medial to lateral) Femoral canal Femoral vein* Femoral artery*Femoral nerve**essential to identify plus 2/3 of other muscles to passSECOND QUESTIONPlease describe the course of the femoral artery from the inguinal ligament to the popliteal fossaPOE\TS REQUTRED1 Art enters thigh at midinguinal point* (mid b/w ASIS & pubicsymp on psoas tendon overlying capsule of hip jt)*essential2 Runs deep to sartorius at lower end of triangle*3 Enters adductor canal*4 Anterior to femoral vein (post to saphenous nerve)

5 Passes into popliteal fossa through adductor hiatus* in adductor magnusPROMPTAt which point does it enter the thigh?PROMPTSPlease name the branches of femoral artery in the femoral triangle.Superficial cutaneous branches: Superficial circumflex iliac Superficial epigastric Superficial external pudendal Deep external pudendalProfunda femoris

2005-2Bone:Pelvis NUMBER 3.3COMMENTSOPENINGQUESTIONIdentify the main features of this bone?COMMENTSJPOEYTSFEQUERED3 bones**essentialAcetabulum*, greater and lesser sciatic notches, ischial tuberosity, ischial spine, pubic tubercle, ASIS, obturator foramen, iliac crest, pubic rami, SI joint7 to passPROMPTIdentify the bones that make up this structureSECOND QUESTIONDescribe the origin and course of the sciatic nerve.POINTS REQUIRED1L4,5,S1,2,3* from the triangular sacral plexus form from the ant divs of these nn to eventually be the tibial portion of the sciatic while the peroneal portion comes from post divs of L4,5, Sl,24/7 to pass2 They join in pelvis, and exit under piriformis* (line b/w PSIS & tip of coccyx) thru gtr sciatic notch*3 lies on ischium over post acetabulum*, next to bone b/w isch tuber &PSIS4 under glut max* in buttock b/w gtr troch & isch tuberosity5 vert down with hamstrings*6 upper popliteal fossa* > tibial & peroneal nn.

2005-2:Post. Compartment leg, Achilles attachments NUMBER: 3.5 _OPEMNG QUESTIONList the muscles in the posterior compartment of the leg/calfCOMMENTS * EssentialPOINTS REQUTREDSuperficial group Gastrocnemius (lateral and medial heads) Plantaris SoleusDeep group Flexor digitorum longus Flexor hallucis longus Tibialis posterior* 2 from each groupSECOND QUESTION (if needed)Describe the origin and attachments of gastrocnemius and soleusPOINTS REQUIREDGastrocnemius - Lat head from lat surface of lat fern condyle* (from smooth pit above that of popliteus). - Med head from back of med condyle* and popliteal surface of femoral shaftBroad bellies of mm insert into dense aponeurosis on their ant surfaces, bearing on soleus mmThis aponeurosis blends with that of soleus to form tendo calcaneusTendo calcaneus inserts into smooth transverse area on middle third of post surface of calcaneus*. Soleus

Upper quarter of back of fibula including head, fibrous arch* (over pop vessels and tibial nn) in continuity to soleal line of tibia and middle third of post border of tibia.Post, (superficial) lamella is continued at its lower end into tendo calcaneus. The mm fibres of soleus are received into deep surface of tendo calcaneus* down to within a short distance of calcaneus.* essentialBroad upper attachmentwith fibrous arch AND insertion into tendo calcaneus essentialTHIRD QUESTIONWhat is the nerve supply to this group of muscles ?Tibial nerve* (S 1,2)•essentialBONUS QUESTIONDescribe the course and branches of the tibial nerve in the legTibial nn is the continuation of the sciatic nn (after it divides into tibial and common peroneal)DE08a Anatomy Viva workshop.rtfDE08a Anatomy Viva workshop.rtfRuns vertically down middle of pop fossa Passes deeply between heads of gastrocnemius Runs with pop vessels beneath fibrous arch of origin of soleus. Enters calf below this fibrous arch Gives motor branches to all mm that arise in pop fossas Both heads of gastrocSoleus PopliteusBranch to popliteus hooks around lower border of popliteus to enter its deep (tibial) surface. Has only 1 cutaneous branch ; sural nn Runs vertically down between 2 heads of gastrocPierces deep fascia halfway down calf (replaces post cutaneous nn of thigh) In superficial fat it joins sural communicating nn and lies close to small saphenous w .Nerve is lateral to vein 3 articular branches ; genicular nerves which accompany sup,inf and medial genicular aa. Tibial n runs straight down middle of calf, deep to soleus Post tib aa is at first lat to it. The aa then passes ant to it and continues down on medial side of nnNerve ends under middle of flexor retinaculum by dividing into medial and lateral plantar nn Surface marking is middle of pop fossa to midway between med malleolus and tendo calcaneusGives branches to ; Those listed above Flex dig longusFlex hall longus Tib postMed calcaneal nns (pierce flex ret to supply skin of heel)

2005-1Femur NUMBER: 1-3OPENING QUESTIONIdentify the landmarks on the upper endCOMMENTSPOINTSREQUTRED1 Gt Trochanter6 of92 Lesser Trochanter3 Intertrochanteric line (ant), crest (post)4 Quadrate Tubercle5 Trochanteric Fossa6 Neck7 Head & FoveaPROMPTSPoint and ask smaller onesSECOND QUESTION (if needed)What is the Blood supply to the head?2 of3 to passPOINTS REQUIRED1 Mainly ascending cervical branches along femoral neck - tight to bone(from extracapsular arterial ring from

medial and lateral circumflex femoral artery)2 Secondary from artery of ligamentum teres (from obturator, inadequate on own)3 Intramedullary vessels456PROMPTSTHIRD QUESTION (if needed)What are the attachments of the capsule?All or nonePOINTS REQUTRED1 Intertrochanteric Line anteriorly2 Halfway along neck posteriorly (because of obturator externus)

2005-1Great Toe NUMBER: 2-4COMMENTSOPENING QUESTIONWhat nerves are responsible for sensation of the great toe?COMMENTSPOINTS REQUTRED1 Deep peroneal in the web3 to pass2 superficial peroneal on the dorsum3 medial plantar on the bottom4 sometimes some saphenous on medial side at the MTP567PROMPTSSECOND QUESTION (if needed)What roots?PassPOINTS REQUTRED1L5 -23456PROMPTSTHIRD QUESTION (if needed)What myotomes govern movement of great toe? 'Both to passPOINTS REQUIRED1 5,1 extension ••2 1,2 for plantar flexion

2005-1Ankle X-RayCOMMENTS. NUMBER: 3-1OPENING QUESTIONIdentify the major bony features visible on this xray.COMMENTSPOINTS REQUTRED

1 Tibia / Posterior malleolus / medial malleolus5 to pass2 Fibula / lateral malleolus3 dome of talus4 calcaneum5 navicular6 cuboid7 base of Vth MT + metatarsalsPROMPTSSECOND QUESTION (if needed)Describe the ligaments that stabilise the ankle jointLat, Med, 3 of 4 LatPOINTS REQUIRED1 Medial: (Deltoid ligament) -superficial2 -Deep(spring)3 Lat: Anterior talofibular4 Lat: Posterior talofibular5 Lat: calcaneofibular6 Lat: post Tibiofibular

2004-2Commencing with its origin in the foot, describe the course and relations of the long saphenous veinCOMMENTSPOINTS REQUIRED1 commences at medial side of dorsal venous archRequire course2 course upward in front of medial malleolus3 crosses to behind medial border of tibia and pass behind knee ( 1 handsbreath behind medial border patella)4 spirals forward across medial aspect thigh to pass through cribriform fascia and join femoral vein5 perforating veins connect LSV and deep system - below med malleolus, 10cm above med malleolus mid calf knee mid thigh6 LSV accompanied by saphenous nerveAccompanying nerve7 valves along course (optional)PROMPTSSECOND QUESTION (if needed)What functional deficit results from a tibial nerve injury at the knee and explain whyPOINTS REQUIRED1 Unable to stand on tiptoes (calf flexors lost) – soleus, TP, FDL, FHL2 Sensory loss – Medial Calcaneal, medial and lateral plantar nerves – loss of sensation over leg and sole of foot3 intrinsic muscles of foot lost – medial & lateral plantar nerves

2004-2Identify the bony features of the knee joint shown on this XrayCOMMENTSPOINTS REQUIRED1 Femoral Condyles x 24 of 6 to pass2 Tibial Condyles x 23 Intercondylar eminence and tubercles4 Patella567PROMPTSSECOND QUESTION (if needed)What are the features that contribute to stability of this joint?POINTS REQUIRED1 Primarily Ligaments – tib & fib collaterals, ant & post cruciates

3 of 4 ligs and muscles to pass2 Muscles – Quads, hamstrings3 Bones minimal contribution, eminence to prevent sideways movement

2004-2What are the borders & contents of the femoralCOMMENTSPOINTS REQUIRED1 Boundaries: Sartorius, Adductor Longus, Inguinal ligaments2 Floor: Iliacus, Psoas, Pectineus, Adductor Brevis3 Contents: Femoral Nerve, Artery, VeinsPROMPTSSECOND QUESTION (if needed)What are the branches of the femoral nerve?POINTS REQUIRED1 Nerve to sartorius2 Medial Femoral Cutaneous nerve3 Intermediate femoral cutaneous nerve4 Nerve to Rectus Femoris5 Nerve to vastus medius6 Nerve to Vastus Lateralis7 Nerve to vastus intermedius8 Saphenous nerve

2004-2Identify the muscles responsible for flexion and extension of the knee on this modelCOMMENTSPOINTS REQUIRED1 Semimembranosus – flexion2 Semitendinosus – flexion3 Biceps femoris – flexion4 Quadriceps – extension567PROMPTSSECOND QUESTION (if needed)What factors contribute to the stability of the patella?POINTS REQUIRED1 Bony – lateral condyle of femur2 Ligamentous – tension in medial patella retinaculum3 Muscular – vastus medialis

2004-2Describe the myotomes of the lower limbCOMMENTSPOINTS REQUIRED1. hip flexion L23, extension L45 2. knee extension L34 flexion L5 S1 3. ankle flexion L4 5 extension S 1 2 4.

inversion L4 eversion L5 S 1 5. bigtoeL5S1 extensionS12PROMPTSSECOND QUESTION (if needed)What functional deficit results from injury to the common femoral nerve and why?POINTS REQUIRED1. foot drop – loss of innervation of extensor muscle function ( tib Ant, ext dig long, peroneus tertius, EHL)2. high stepping gait3/42. inability to evert foot - peroneus longus and brevis lost ( sup peroneal nerve)1/23. sensory loss : cleft of first toesup peroneal N. lower lateral part leg & dorsum of footdeep peroneal – 1st web space

2003-2

TOPIC 2Hip Joint ModelQUESTIONS AND POINTS REQUIREDOn this model, demonstrate the factors maintaining stability of the hip joint:Bony: acetabular socket reinforced by labrumLigaments: capsule, iliofemoral, ischiofemoral, pubofemoral ligamentsMuscles: short muscles esp. gluteus medius and minimusAcetabulum and labrum, 3 ligaments to passDescribe the attachments of the iliofemoral ligament Anterior inferior iliac spine to intertrochanteric lineAttachments to passDemonstrate the least stable position of the hip Flexion and adduction

2003-2Ankle joint XrayCOMMENTS(Required to pass)QUESTIONS AND POINTS REQUIREDDemonstrate the bony features of the ankle joint:3 bones and malleoliDemonstrate the capsular attachments (AP view):Articular margins extending over neck of talusDemonstrate the ligamentous attachments (lateral):Deltoid with superficial and deep parts, Lateral with 3 parts, Posterior tibiofibular

2003-2On the model demonstrate the movements of the bony components of the knee joint in going from flexion to extension when the foot is on the ground.1. Lateral condyle completes its extension short of full extension, 2.lateral condyle rotates forwards around taught ACL, 3. medial condyle glides backwards as full extension approaches. 4.Result is 10 deg of hyperextension (First 2 to pass)Which muscles flex and extend the knee.Flex – Hamstrings, Sartorious, Gracilis, Gastrocnemius, Plantaris, Popliteus. (Hams and Pop – unlock and 1 other to pass)Extension – Quads and Tensor Fascia Latae (Quads to pass)

2003-2Demonstrate / describe the sensory innervation of the foot.Saphenous – medial dorsum to base of big toe, Superficial peroneal – dorsum, Deep peroneal – 1st web space, sural – lateral, Medial and lateral plantar nerves on the sole, Medial calcaneal – heel. 5/7 to pass.Demonstrate the dermatomes below the knee.4,5, S1, S2 First 3 correct to pass

2003-1Ankle ________________________________NUMBER: 4AM ___________COMMENTSOPENING QUESTIONUSING THIS MODEL, CAN YOU IDENTIFY THE MUSCLES INVOLVED IN PLANTAR FLEXION AT THE ANKLE?COMMENTSPOINTS REQUIREDSUPERFIC: GASTROCNEMIUS SOLEUSDEEP:PLANTARIS FL DIGITORUM LONGUS FL HALLUCIS LONGUS TIBIALISPOSTERIOR (PERONEUS LONGUS/BREVIS)3/7234567PROMPTSSECOND QUESTION (if needed)WHAT IS THE NERVE SUPPLY THESE MUSCLES?POINTS REQUIREDPOSTERIOR TIBIAL NERVE

2003-1X-RAY KNEE ___________________________ NUMBER: 1 ___________

COMMENTSOPENING QUESTIONCAN YOU IDENTIFY THE MAJOR FEATURES ON THIS X-RAYCOMMENTSPOINTS REQUIRED1 CONDYLES (PLATEAU): MEDIAL & LATERAL (TIBIA)4 BONES PLUS 4 OTHER THINGS TO PASS23 INTERCONDYLAR TUBERCULE X24 INTERCONDYLAR NOTCH /FOSSA (FEMUR)5 FEMORAL CONDYLES6 TIBIA/FEMUR/FIBULA HEAD/PATELLA7 ASSORTED SHAFTSPROMPTSSECOND QUESTION (if needed)1A: WHAT FACTORS CONTRIBUTE TO STABILTY OF PATELLA2/3 TO PASSPOINTS REQUIRED1 BONE – SHAPE OF LATERAL CONDYLE FEMUR2 LIGAMENT – MEDIAL PATELLA RETINACULUM3 FIBRES OF VASTUS MEDIALIS