The Lower Extremity Page 1 of 12 THE LOWER EXTREMITY Musculoskeletal Development Veins, Nerves, Miscellan Hip an!

p an! T"i#" $nee an! Le# %nkle an! &oot

M'()'LO($ELET%L DEVELO*MENT MESENCHYME: Not the same thing as mesoderm. t means loosely organized connective tissue that is pluripotential. t is often deri!ed from mesoderm "#t may a$so "e deri!ed from E%toderm Ne#ra$ Crest& as in 'Con#s area of heart& "ran%hia$ ar%hes& area aro#nd eyes(. MES)*E+M: The midd$e germ,$ayer. S)M TES: They are on the dorsa$ '"a%-( s#rfa%e of the em"ryo. (c"lerotome+ Media$ .art& "e%omes the "one. /t this stage it is .$#ri.otentia$. Dermam otome+ Latera$,P$ate Mesoderm ,, $atera$ .art& di!ides into dermatome and myotome to "e%ome s-in and m#s%$e.

0)NE *E1EL)PMENT: 2rom the .$#ri.otentia$ s%$erotome. Osteo,lasts+ 2orm "one. Osteoclasts+ 0rea- down and resha.e "one. Osteoc tes+ They are osteo"$asts& on%e %a$%ifi%ation has a$ready formed aro#nd the "one.

NT+/MEM0+/N)3S )SS 2 C/T )N: 2orming "one dire%t$y from mesen%hyma$ %e$$s& as they differentiate to osteo"$asts with no %arti$age intermediate. This ha..ens with f$at "ones $i-e the s-#$$. EN*)CH)N*+/L )SS 2 C/T )N: 2orming "ones with a Carti$age intermediate. The entry of a periosteal ,u! into the %arti$age is the -ey stage ,, this is what a$$ows the a!as%#$ar %arti$age to form !as%#$ar "one. n%rease in "one: o 4 *TH, NC+E/SES N 0)NE: )%%#rs "y $atera$ "one,de.osition& dire%t$y #nder the %o$$ar. The name of this de.osited "one is periosteal ,one. o LEN5TH, NC+E/SES N 0)NE: )%%#rs "y growth at the Meta.hysea$ P$ate& "y .ro$iferation of %hondro%ytes. )ssifi%ation %enters: o *RIM%RY O((I&I)%TION )ENTER+ Periostea$ "one de!e$o.ment o%%#rs at the .rimary %enter .renata$$y. This is in the midd$e of a $ang "one ,, the !iap" sis. o (E)OND%RY O((I&I)%TION )ENTER+ *e!e$o.s at or after "irth. These are $o%ated in the epip" sis& or near the ends of the "ones. Pretty m#%h a$$ of the "ones are .resent in a fet#s a$ready at 16,17 wee-s& ex%e.t for the sesamoid "ones ,, the tarsa$s and %ar.a$s.

/8 /L S9ELET)N: S.ine& s-#$$& stern#m& ri"s /PPEN* C3L/+ S9ELET)N: Extremities& .e%tora$ gird$e 's%a.#$a(& .e$!i% gird$e S9ELET/L * S)+*E+S (*IN% -I&ID%+

The Lower Extremity Page 2 of 12 (pina -i.i!a Occulta+ The !erte"ra$ ar%h doesn:t form f#$$y. t is inno%#o#s as $ong as it is $o%a$i;ed on$y to one !erte"rae. o (pina -i.i!a Occulta+ More serio#s. /s we$$ as ha!ing no %$os#re of the !erte"ra$ ar%h& yo# ha!e a %yst. f it is <#st a $itt$e sa% of meninges& it is %a$$ed a menin#ocele and may not "e a .ro"$em. Menin#om eloceles has "oth meninges and a .ie%e of s.ina$ %hord in the %yst. This is a .ro"$em. MYELO()HI(I( ,, worst %ase s%enario. The ne#ra$ t#"e ne!er %$oses. %)HONDRO*L%(I%: 5enera$ fai$#re in endo%hondra$ ossifi%ation& res#$ting in short "ones and short .erson= Has a strong inherited %om.onent. )on#enital Dislocation o. t"e Hip+ /$so has an inherited %om.onent& as we$$ as a"o#t 2>? en!ironmenta$ %om.onent& or so it seems. Osteo#enesis Imper.ecta+ +e.eated fra%t#res of the $ong "ones. nherited %om.onent with a defe%t in ty.e Co$$agen. Talipes E/uinovarus+ Ha!e a f$exion and in!ersion of the feet. Ta$i.es refers to Ta$#s. /gain& seems to "e "oth en!ironmenta$ and inherited %om.onents. o

M3SCLE *E1EL)PMENT: Myotomes di!ide into two di!isions: o Epa0ial 1Epimeric2 Division+ nner!ated "y dorsal primary rami. These are the m#s%$es of the ne%-& "a%-& and s.ine. o H pa0ial 1H pomeric2 Division+ Innervation by ventral primary rami. n%$#des most of the tr#n- and a$$ of the extremities.

L M0 +)T/T )N: nitia$$y& the $im"s extend %a#da$$y& then $ater they extend "a%- !entra$$y. 0#t initia$$y they are "oth fa%ing the same dire%tion '"ent and fa%ing forward(. Then rotation o%%#rs& s#%h that the knees point cranially and the elbows point caudally. THE ROTATIO I! I O""O!ITE #IRE$TIO !. This %reates the .etal position. o T"e upper lim,s rotate 34 laterall , so t"at t"e el,o5s point !o5n6 o T"e lo5er lim,s rotate 34 me!iall , so t"at t"e knees point up6 This rotation ex.$ains the twisted dermatoma$ arrangement in the $im"s ,, d#e to the rotation of the $im"s.

5ENE+/L *E+M/T)M/L P/TTE+N )2 3PPE+ L M0: Yo# mo!e down the $atera$ s#rfa%e and "a%- #. the media$ s#rfa%e& as yo# go from C7 to T2. 5ENE+/L *E+M/T)M/L P/TTE+N )2 THE L)4E+ L M0: More or $ess& yo# mo!e down the anterior s#rfa%e and "a%#. the .osterior s#rfa%e& as yo# go from L2 to S7. Verni0 )aseosa+ The en%omi#m of the fet#s as it is "orn& made of peri!ermal tissue that is s$o#ghed off of the fet#s: e%toderm .renata$$y.

VEIN(, NERVE(, MI()ELL%NY S3PE+2 C /L 1E NS )2 L)4E+ L M0 'N>12& N>16( 7reat (ap"enous Vein o )n the anterior thigh& it tra!e$s thro#gh the &ossa Ovalis& after whi%h it merges with the 2emora$ 1ein. o /s yo# go down the $eg& it wra.s media$$y aro#nd to the .osterior as.e%t of the -nee. o Then it %omes "a%- anterior$y to the media$ ma$$eo$#s of the an-$e& where it anastomoses with the Lesser Sa.heno#s 1ein. Lesser (ap"enous Vein+ +#ns #. the .osterior $eg. o t anastomoses with the 5reat Sa.heno#s 1ein aro#nd the an-$e.

*EEP 1E NS )2 L)4E+ L M0: 2or the most .art& the dee. !eins r#n with the dee. arteries.

The Lower Extremity Page 6 of 12 1N89:2 *opliteal Vein+ /ro#nd the "a%- of the -nee& this !ein is !ery im.ortant %$ini%a$$y. o 0L))* CL)T in P)PL TE/L 1E N ,,,,,,@ %emoral &ein ''''''( E)ternal Iliac ''''''( I&$ ''''''( Right Heart ''''''( *ungs ,,,,,,@ "ulmonary Embolism+ '' not good. o The Lesser Sa.heno#s 1ein feeds into the Po.$itea$ 1ein aro#nd the .osterior as.e%t of the thigh. o The Po.$itea$ 1ein feeds into the 2emora$ 1ein.

()I%TI) NERVE an! -ranc"es 1N:492+ Largest .eri.hera$ ner!e in "ody. nner!ates the .osterior thigh. *i!ides into two .rin%i.$e "ran%hes at the "opliteal %ossa usually, but may occur a -oot pro)imal to it. )ommon *eroneal Nerve& whi%h di!ides into o Deep *eroneal Nerve ,, Motor to media$ $eg o (uper.icial *eroneal Nerve ,, Motor to $atera$ $eg o Lateral (ural )utaneous ,, C#taneo#s inner!ation to $atera$ $eg. Ti,ial Nerve 'N>AB( ,, Posterior $eg t may arise a"o!e& thro#gh& or "e$ow the Piriformis m#s%$e in the hi..

&EMOR%L NERVE an! -ranc"es+ %nterior )utaneous -ranc"es ,, /nterior C#taneo#s inner!ation of thigh (ap"enous Nerve ,, /nteromedia$ inner!ation of $eg

L'M-%R *LEX'( 1N8;92+ L2& L6& L7 .rimari$y. Latera$ 2emora$ C#taneo#s Ner!e 2emora$ Ner!e )"t#rator Ner!e

(%)R%L *LEX'( 1N8;32+ L7& L>& S1& S2& S6 .rimari$y. S#.erior and nferior 5$#tea$ Ner!es S%iati% Ner!e o Ti"ia$ o Common Peronea$ Ner!e to the Piriformis

M3LT PLE SP N/L LE1ELS: 5enera$$y we sho#$d -now that di--erent movements o- the same limb utilize di--erent spinal levels. 5enera$$y the anterior %om.artment has a s$ight$y higher s.ina$ $e!e$ than the .osterior %om.artment& in the $ower $im".

*E+M/T)ME P/TTE+N )2 L)4E+ L M0 'N>11(: 4e a$most get a .arber'"ole E--ect with the different s.ina$ $e!e$s as yo# tra!e$ down the $ower $im". L3M0/+ genera$$y %o!ers the anterior $eg. S/C+/L genera$$y %o!ers the .osterior $eg.

C3T/NE)3S NNE+1/T )N )2 TH 5H and LE5: *osterior &emoral )utaneous Nerve inner!ates the .osterior thigh. o t %omes dire%t$y off the Sa%ra$ P$ex#s. -ranc"es o. t"e &emoral inner!ate the anterior thigh. (ap"enous Nerve+ nner!ates the media$ .art of the $eg and foot. o t %omes off the 2emora$ Ner!e. o t only travels with the Saphenous Vein in the Leg -- not in the thigh!! n the thigh& the Sa.heno#s Ner!e has a different .ath than the %orres.onding !ein.

The Lower Extremity Page 7 of 12 t gi!es residual innervation to the -oot. f yo# $ose the Ti"ia$ Ner!e 'from the S%iati%(& yo# won/t lose all o- your sensation in the -oot '' because o- the !aphenous.

CL N C/L 'N>1A0( ,, C#taneo#s inner!ation of the #eep "eroneal erve is assessed at the web o- skin between the -irst and second toes. This is a %ommon way to assess $ower,damage from an in<#ry. HERNI%TED (*IN%L DI($(+ Pin%hing a ner!e in the ner!e,root of the s.ina$ %hord& d#e to an o#tward herniation of the nucleus pulposus in the s.ina$ %o$#mn. To see whi%h L#m"ar S.ina$ Le!e$ is %om.romised& yo# %an #se !ario#s tests: L7 C)MP+)M SE /rea of Pain: /rea of N#m"ness: Motor 4ea-ness: Shooting .ain a$ong the $ower extremity /nteromedia$ Thigh Loss of C#adri%e.s ,, weaf$exion of thigh and extension of $eg (/uat<Rise ,, This reD#ires the D#ads& i.e. thigh,f$exion and $eg,extension L> C)MP+)M SE Shooting .ain on $atera$ $eg Latera$ $eg No *orsif$exion of 5reat Toe and 2oot )annot 5alk on "eels& d#e to ina"i$ity to dorsif$ex the foot. S1 C)MP+)M SE Posterior thigh and $eg& and $atera$ foot Posterior $eg and so$e of foot No P$antarf$exion of foot

S%reening Exam:

)annot 5alk on toes& d#e to ina"i$ity to .$antar f$ex foot. No %nkle=>erk Re.le0& d#e to $ost inner!ation of the Ca$%aneo#s '/%hi$$es( Tendon

+ef$ex,Tests:

No $nee=>erk Re.le0 ,, None "e%a#se the C#ads insert on the Pate$$ar Ligament

THE HI* %ND THI7H THE L 3M: Externa$ s#rfa%e of $e#m has three 5$#tea$ $ines for the 5$#te#s m#s%$es& from s#.erior to inferior in the fo$$owing order: o *osterior 7luteal Line o %nterior 7luteal Line o In.erior 7luteal Line

THE 2EM3+ 'N7>B(: Linea %spera+ m.ortant ridge on the posterior sur-ace of the fem#r& whi$e the anterior s#rfa%e is smooth. Hen%e this is a good way to te$$ the differen%e "etween the two s#rfa%es. 5reater and Less Tro%hanter: o Intertroc"anteric Line %onne%ts them anteriorly. o Intertroc"anteric (pine %onne%ts them posteriorly.

C)LL/TE+/L C +C3L/T )N /+)3N* THE NEC9 )2 THE 2EM3+ 'N7E7a(: Lateral an! Me!ial )ircum.le0 &emoral %rteries == s#..$y the head and ne%- of the fem#r. o /s we$$ they s#..$y the intertroc"anteric re#ion& regions "etween the greater and $esser tro%hanter. INTERTRO)H%NTERI) &R%)T'RE+ 2ra%t#re right a%ross the intertro%hanteri% $ine& at the "ottom of the ne%-. o Yo# retain "$ood s#..$y to the head and the ne%- of the fem#r& so this has a good %han%e of hea$ing. Head 0$ood S#..$y: Retinacular %rteries Ne%- 0$ood S#..$y: Cir%#mf$ex 2emora$ /rteries ('-)%*IT%L &R%)T'RE+ 2ra%t#re right "eneath the head& at the to. of the ne%-.

The Lower Extremity Page > of 12 Yo# L)SE 0L))* S3PPLY T) THE HE/*& res#$ting in %vascular Necrosis 1%VN2 o. t"e "ea! o. t"e .emur? 0ad news d#de. )ruciate %nastomosis+ n a signifi%ant .er%entage of the .o.#$ation& anastomoses "etween the fo$$owing !esse$s: o nferior 5$#tea$s o 1st .erforating "ran%h of the 2emora$ Prof#nda artery o Media$ and Latera$ 2emora$ Cir%#mf$ex. n the e!ent of a 2emora$ /rtery )%%$#sion& there wi$$ sti$$ "e some "$ood s#..$y to the $eg& "e%a#se of this %o$$atera$ %ir%#$ation. o

SCH /L SP NE: s the "ony .rot#"eran%e that mar-s the se.aration "etween the 5reater and Less S%iati% 2oramina. /NTE+ )+ C)MP/+TMENT )2 THE TH 5H: /%tion F f$exion of thigh and extension of $eg. nner!ation F 2emora$ Ner!e

P)STE+ )+ C)MP/+TMENT )2 THE TH 5H: /%tion F Extension of thigh and f$exion of $eg nner!ation F S%iati% Ner!e CL N C/L ,, 4HE+E T) 5 1E / SH)T: The 'pper Outer @ua!rant, whi%h is an intramuscular in0ection into the 5$#te#s Medi#s and Minim#s. o The o"<e%t: avoid the !ciatic nerve& whi%h is in the $ower media$ D#adrant. CL N C/L ,, *'LLED H%M(TRIN7( ,, / %ommon in<#ry to this area. o Can o%%#r at %ommon origin 'is%hia$ t#"erosity( or %ommon tendon 'media$ %ondy$e of ti"ia& or head of fi"#$a for "i%e.s femoris(

ME* /L '/**3CT)+( C)MP/+TMENT )2 THE TH 5H: /%tion F /dd#%tion of thigh nner!ation F )"t#rator Ner!e

C3/*+ CEPS: These fo#r m#s%$es& whi%h insert on the C#adri%e.s tendon on the Pate$$a& ha!e a %r#%ia$ ro$e in -nee sta"i$ity. 5/ T G 4/L9 N5 G PEL1 C T LT: 4hen wa$-ing& yo# ha!e to ti$t #. yo#r .e$!is on the side of the "ody not .$anted. This in!o$!ed %ontra%tion of 1luteus 2inimus and 2edius m#s%$es. o S$ight$y /"d#%ting the thigh and media$$y rotating it. )LINI)%L == 7L'TE%L 7%IT+ f yo# $ose the s#.erior g$#tea$ ner!e& yo# wi$$ no $onger "e a"$e to $ist the hi.. 4hen wa$-ing& this $oo-s $i-e a g$#tea$ gait. o To %om.ensate for this& the $eg swings o#t $atera$$y so that the foot %an mo!e forward& so wa$-ing -ind of $oo-s $i-e a sh#ff$e. o This %an "e %a#sed "y $oss of two different ner!es: (uperior 7luteal Nerve 'no a"d#%tion of thigh( O,turator Nerve 'no add#%tion of thigh(

S3PE+ )+ 5L3TE/LS 'N7E6(: The !ein& artery& and ner!e tra!e$: S#.erior to the Piriformis m#s%$e. Then between the gluteus minimus and medius muscles.

&%()I% L%T% 1N8A4, N8;82+ The fas%ia on the thigh is !ery dense. S#.erior Limit: The ng#ina$ Ligament and $ia% Crest& it is a %ontin#ation of the Trans!ers#s /"dominis. nferior Limit: t merges with the $ioti"ia$ Tra%t& whi%h is aro#nd the $atera$ of the $eg.

The Lower Extremity Page H of 12 ILIOTI-I%L TR%)T 1N8;82+ nserts onto the ti"ia& aro#nd the $atera$ as.e%t of the -nee. t is %ontin#o#s s#.eromedia$$y with the fas%ia $ata. 4hen standing #.right& it ho$ds the -nee in .$a%e.

7R%)ILI( M'()LE+ / 5))* SP/+E P/+T. This wea- add#%tor has a ni%e ner!e and artery that are dis.ensa"$e and %an "e grafted to other $o%ations. N6%6V6E6L6+ The order of femora$ !esse$s entering thro#gh the o"t#rator foramen into the media$ thigh& starting from the /S S and wor-ing inferomedia$$y to the .#"i% t#"er%$e. N: Ner!e /: /rtery 1: 1ein ,, the -emoral nerve is not a part o- the -emoral sheath, while the others are. E: Em.ty S.a%e L: La%#nar Ligament

&EMOR%L TRI%N7LE+ +egion of media$ thigh& where the &emoral ("eat" ends and $ets o#t the 2emora$ /rtery and 1ein. 2$oor of the 2emora$ Triang$e is %om.osed of the fo$$owing m#s%$es: o Iliopsoas o *ectineus o %!!uctor Lon#us 0orders of 2emora$ Triang$e: o (artorius+ nferior "ase of triang$e o In#uinal Li#ament+ S#.erior $imit of triang$e o %!!uctor Lon#us+ More or $ess the $atera$ $imit )LINI)%L == &EMOR%L HERNI%+ /"domina$ %ontents %an s.i$$ thro#gh the 2emora$ Sheath into the 2emora$ Triang$e. o How to disting#ish it from ing#ina$ hernias: / femora$ hernia is %om.$ete$y inferior to the ing#ina$ $igament and $atera$ to the .#"i% t#"er%$e.

&emoral Vessels 1N8A42+ Tra!e$ thro#gh the thigh "etween the anterior and media$ %om.artments in the #..er thigh. &emoral Nerve+ Enters the thigh "y tra!e$ing <#st dee. to the In#uinal Li#ament& on the anterior s#rfa%e of the *soas Muscle6 This %reates a ner!e,sandwi%h= This entry,.oint is <#st media$ to that of the $atera$ femora$ %#taneo#s ner!e. Nerve Entrapment %an o%%#r "etween the Psoas M#s%$e and the ng#ina$ Ligament.

Lateral &emoral )utaneous Nerve+ Enters the thigh "y tra!e$ing #nder the In#uinal Li#ament at the !ery $atera$ as.e%t of the ng#ina$ Ligament. Nerve Entrapment+ Hen%e the ner!e %an get .in%hed& es.e%ia$$y in o!erweight fo$-s. That wo#$d res#$t in .aresthesia in the $atera$ region of the thigh.

&EMOR%L %RTERY 1N8AB, N89B2+ The %ontin#ation of the Externa$ $ia% /rtery& "eyond the ng#ina$ Ligament. 0+/NCHES o Deep &emoral %rter ,, goes aro#nd the .osterior side of the -nee and h#gs the "a%- of the -nee <oint. Sends 6 *er.oratin# -ranc"es to .osterior %om.artment. 5i!es off Lateral )ircum.le0 %rter that anastomoses "oth at the head of the fem#r and at the -nee '!ia $atera$ s#.erior geni%#$ar( o *opliteal %rter == aro#nd .osterior of -nee& gi!es off three "ran%hes: %nterior Ti,ial %rter ,, main "$ood s#..$y down anterior $eg *osterior Ti,ial %rter ,, main "$ood s#..$y down .osterior $eg.

The Lower Extremity Page E of 12 *eroneal %rter ,, it may .$ay a signifi%ant ro$e if one of the a"o!e is a"sent or damaged. o CL N C/L ,, a -nee in<#ry aro#nd the "a%- of the -nee %an in<#re the .o.$itea$ artery& "#t that #s#a$$y doesn:t ha..en "e%a#se the .o.$itea$ is !ery dee.. The 2emora$ /rtery "e%omes the Po.$itea$ after it has tra!e$ed thro#gh the %!!uctor Hiatus on the media$ dista$ thigh. o /t the same time it pierces the Adductor Magnus tendon. CL N C/L ,, &EMOR%L )%THETER. The Femoral Artery lies hal way in-between the ASIS and the !ubic Tubercle" as it runs beneath the Inguinal Ligament. o This is the $o%ation where yo# wo#$d .#t a %atheter into the 2emora$ /rtery. This is a %ommon .$a%e to in<e%t dye for arteriogra.hs. CL N C/L ,, &EMOR%L %RTERY O))L'(ION+ o Common$y o%%#rs at two .oints: I#st as the 2emora$ /rtery enters the anterior thigh #nder the ng#ina$ Ligament.& at the 2emora$ Triang$e. /s the 2emora$ /rtery goes thro#gh the /dd#%tor Hiat#s& going "a%- into the Po.$itea$ 2ossa.

5L3TE/L M3SCLES: The order of m#s%$es "e$ow the g$#te#s maxim#m and minim#m& going from s#.erior to inferior: Piriformis o !ciatic erve comes out right below the "iri-ormis S#.erior 5eme$$#s )"t#rator ntern#s nferior 5eme$$#s C#adrat#s 2emoris

THE $NEE %ND LE7 2 03L/: Latera$& sma$$er "one. The .roxima$ .art %an "e #sed as a s.are .art for "one grafts. The 2i"#$a has no arti%#$ation at the -nee "#t some arti%#$ation at the an-$e <oint.

T 0 /: Media$& $arger "one. The anterior .art of the ti"ia has a$most no tiss#e asso%iated with it. So it is the most %ommon .$a%e to see an o.en fra%t#re.

THE 9NEE,I) NT 'N7EB(: Three gro#.s of $igaments. Co$$atera$ Ligaments o &i,ular 1lateral2 )ollateral Li#ament ,, $ongit#dina$ $igament on $atera$ as.e%t of Pate$$a. o Ti,ial 1me!ial2 )ollateral Li#ament Cr#%iate Ligaments: They s.an the Intercon! lar &ossa and insert onto the Intercon! lar Eminence of the Ti"ia. They are %r#%ia$ to -nee sta"i$ity. o %nterior )ruciate Li#ament o *osterior )ruciate Li#ament Carti$agino#s Ligaments: They .ro!ide more arti%#$ation s.a%e for the %ondy$es of the fem#r. o Me!ial Meniscus does connect to the Tibial #medial$ %ollateral Ligament So if the Ti"ia$ Co$$atera$ Ligament is damaged& the Media$ Menis%#s %o#$d easi$y "e damaged with it. o Lateral Meniscus does not connect to the Fibular #lateral$ %ollateral Ligament The *ATERA* 2E I!$3! I! 2ORE 2O.I*E THA THE 2E#IA* 2E I!$3!. o The *opliteus Muscle '.osterior $eg( has an insertion "etween the $atera$ menis%#s and the <oint& %reating more room on the $atera$ side.

C)LL/TE+/L C +C3L/T )N /+)3N* THE 9NEE 'N7J1(:

The Lower Extremity Page J of 12 (uperolateral 7enicular %rter o /nastomoses with the Lateral )ircum.le0 %rter & a$$ the way from the fem#r. In.erolateral 7enicular %rter (uperome!ial 7enicular %rter In.erome!ial 7enicular %rter

*O*LITE%L %RTERY 1N89A2+ Posterior artery aro#nd the -nee& the %ontin#ation of the 2emora$ /rtery& right after it .asses tho#gh the /dd#%tor Hiat#s. t is the basic blood supply to everything below the knee. 0+/NCHES o *osterior Ti,ial %rter + Comes aro#nd the medial malleolus 'an-$e( and .erf#ses the so$e of the foot. CL N C/L ,, yo# %an test the integrity of the .osterior ti"ia$ "y .a$.ating for a .#$se on the so$e of the foot. o %nterior Ti,ial %rter + Comes down thro#gh the anterior $eg and onto the dors#m of the foot. Dorsalis *e!is %rter is the %ontin#ation of the /nterior Ti"ia$ onto the dors#m of the foot. o )ommon *eroneal %rter o (ural %rter + Termina$ "ran%hes of the Po.$itea$ /rtery& s#..$ying the heads of the gastro%s. They are the e)clusive supplier o- the 1astrocnemius. It contains no collateral circulation6 f yo# $ose yo#r "$ood s#..$y there& a $ot of %ram.ing of the $eg wi$$ res#$t. t %an "e affe%ted "y a femora$ artery o%%$#sion& and it is not ne%essari$y fixed "y "y.ass s#rgery. CL N C/L ,, ('*R%)ONDYL%R &R%)T'RE of the dista$ fem#r %an harm the .o.$itea$ artery. o 7astrocnemius Muscle %an threaten the .o.$itea$ artery at its origin& where it f$exes the dista$ fem#r. Tearing of the artery wo#$d %#t "$ood s#..$y to entire $eg essentia$$y. o A $ast -or this -racture should be made with the leg in the -le)ed position& so .#$$ from the 5astro%nemi#s on the fem#r is minima$.

P)PL TE/L 1E N: May t"rom,ose& for exam.$e& d#ring .regnan%y& when the Externa$ $ia%s are .in%hed. The throm"#s has .otentia$ to "rea- $ose and ma-e its way "a%- to the $#ngs. Not good as #s#a$. *O*LITE%L &O((% 1N8AC2+ The area "ehind the -nee. 0orders: o Latera$ "order: 0i%e.s 2emoris o Media$ "order: Semimem"ranos#s and semitendinos#s m#s%$es. o nferior "order: The $atera$ and media$ head of the gastro%nemi#s. C)NTENTS: o The origin of the *opliteal %rter and termin#s of the *opliteal Vein o The Lesser (ap"enous Vein d#m.s into the .o.$itea$ !ein at the Po.$itea$ 2ossa. o (ciatic Nerve %an "if#r%ate into the Ti"ia$ and Common Peronea$ as far inferior$y as the .o.$itea$ fossa. The order of things going thro#gh Po.$itea$ 2ossa& from media$ to $atera$ o /+TE+Y '.o.$itea$ artery( o 1E N '.o.$itea$ !ein( o NE+1E 's%iati% or ti"ia$ ner!e(

/NTE+ )+ C)MP/+TMENT )2 THE LE5: /%tion F *orsif$exion of foot and some extension of digits nner!ation F *ee. Peronea$ Ner!e

C)MM)N PE+)NE/L NE+1E: Yo# %an fee$ it o!er the head and ne%- of the fi"#$a. t di!ides into: o Deep *eroneal Nerve ,, /nterior $eg o (uper.icial *eroneal Nerve ,, Latera$ $eg

The Lower Extremity Page B of 12 CL N C/L ,, T C/N 0E NI3+E* where it $ies against the head of the fi"#$a 'a fra%t#re of the .roxima$ fi"#$a( or aro#nd the $atera$ -nee 'the $atera$ %o$$atera$ $igament(. o The te$$ing sign for this in<#ry is D.oot !ropD& res#$ting from damage to the *ee. Peronea$ Ner!e 'anterior %om.artment ,, no dorsif$exion of foot(. o Yo# wi$$ a$so Varus with this in<#ry& d#e to in<#ry to the S#.erfi%ia$ Peronea$ Ner!e '$atera$ %om.artment ,, no e!ersion of foot(

P)STE+ )+ C)MP/+TMENT )2 THE LE5: /%tion F 2$exion of -nee& .$antarf$exion of foot& some f$exion of digits. nner!ation F Ti"ia$ Ner!e. (ural arter : So$e s#..$ier of the 5astro%nemi#s& and it has no %o$$atera$ %ir%#$ation. (ural nerve: / SP/+E P/+T. t does not innervate the gastro%s ,, the Ti"ia$ Ner!e does. Transverse Intermuscular (eptum+ Se.arates the s#.erfi%ia$ and dee. %om.artments of the .osterior $eg. 7astrocnemius an! (oleus+ 0oth of these m#s%$es are essentia$ for yo# to .#sh off when yo# wa$-& and to %hange dire%tion. o They are the .rimary .$antar f$exors of the foot ,, $et yo# stand on yo#r toes.

L/TE+/L C)MP/+TMENT )2 THE LE5: /%tion F e!ersion of foot nner!ation F S#.erfi%ia$ Peronea$ Ner!e. >ONE(E &R%)T'RE+ P#$$ing off or "rea-ing a .ie%e of the fi"#$a dista$$y& as often o%%#rs with a s.rained an-$e. o This often res#$ts in damage to the *eroneus -revis m#s%$e& as its origin is on the fi"#$a& whi%h in t#rn means no e!ersion of the $eg.

THE %N$LE %ND &OOT THE /N9LE L 5/MENTS 'N7B7& N7B>( *ateral $ollateral *igament o %nterior an! *osterior Talo.i,ular Li#aments 'Ta$#s KFFFF@ 2i"#$a( o )alcaneo.i,ular Li#ament 'Ca$%aneo#s KFFFF@ 2i"#$a( ,, it %rosses the S#"ta$ar <oint to he$. s#..ort it. SP+/ NE* /N9LE: o )ften ha..ens "y an inversion in<#ry& where the foot is in!erted& .$a%ing too m#%h .ress#re on the %nterior Talo.i,ular Li#ament& whi%h yo# %an sometimes see "a$$ #.. Deltoi! 1Me!ial2 Li#ament+ 5ro#. of fo#r $igaments %om.osing the media$ an-$e. 1ario#s ti"iotarsa$ $igaments. Transverse Tarsal >oint F Li#ament+ a-a )"opartEs >oint. /$$ows for .ronation and s#.ination of the foot. / %ommon .oint of am.#tation. LI(&R%N)E( >OINT+ T%R(OMET%T%R(%L >OINT ,, !ery im.ortant <oint. n<#ries to this area are %ommon. o %ractures o- the &nd metatarsal are common, "e%a#se the 2nd metatarsa$ is $ess mo"i$e "e%a#se it is inset from the 2nd %#neiform. )ervical Li#ament -i.urcate Li#ament Lon# *lanter Li#ament+ He$.s maintain the ar%h of the foot. )alcaneonavicular 1(prin#2 Li#ament+ He$.s maintain the ar%h of the foot.

PL/NT/+ /P)NE3+)S S: Simi$ar to the .a$mar a.one#rosis& it -ee.s the s-in on the so$e of yo#r foot immo"i$e& so yo# %an wa$- on it. )rigin from Ca$%aneo#s T#"erosity. nserts on m#%h of the s-in of the so$e of the foot.

+ET N/C3L/:

The Lower Extremity Page 1A of 12 *ERONE%L RETIN%)'L'M+ Latera$ side of foot o Contents: Perone#s Long#s and Perone#s 0re!is tendons. o Contin#o#s with the inferior .art of the extensor retina%#$#m EXTEN(OR RETIN%)'L'M+ /$ong dors#m of foot o t is Y,Sha.ed& di!iding into a s#.erior and inferior .ortion on the $atera$ side of the foot. The stem of the Y is on the media$ side and is %ontin#o#s with the Peronea$ +etina%#$#m. o Contents: Extensor *igitor#m Long#s tendon Extensor Ha$$#%is Long#s tendon Perone#s Terti#s tendon Dorsalis *e!is %rter and Deep *eroneal Nerve .ass #nderneath. &LEXOR RETIN%)'L'M+ )n the media$ side of the foot& from the media$ ma$$eo$#s to the %a$%aneo#s. /$$ of the f$exor tendons .ass thro#gh it as they wra. aro#nd to the .$antar as.e%t of the foot. o Contents: Tom *i%- /Nd Harry Ti,ialis *osterior tendon &le0or Di#itorum Lon#us tendon *osterior Ti,ial %rter *osterior Ti,ial Nerve &le0or Hallucis Lon#us tendon

T/+S/L T3NNEL SYN*+)ME: Simi$ar to Car.a$ T#nne$ syndrome& %om.ression of the ti,ial nerve #nder the .le0or retinaculum. 0)NES )2 THE 2))T 'N7B2& N7B6(: )alcaneous+ The hee$. The inferior,most as.e%t of the foot. o Made .rimari$y of %an%e$$o#s "one o Has three arti%#$ar s#rfa%es that arti%#$ate with the Ta$#s at the S#"ta$ar <oint. Posterior /rti%#$ar S#rfa%e Midd$e /rti%#$ar S#rfa%e /nterior /rti%#$ar S#rfa%e Talus+ The an-$e,region& whi%h arti%#$ates with the Ti"ia. o /rti%#$ates with the Ti"ia& the 2i"#$a& and the Na!i%#$ar "one. o There are no blood vessels going to the Talus. There are no muscle attachments to the Talus. o / $ot of the Ta$#s "$ood s#..$y %omes from the (inus Tarsi. o Has three fa%ets that arti%#$ate with the Ca$%aneo#s *osterior &acet Mi!!le &acet %nterior &acet Tarsal -ones+ The ana$og to the %ar.a$ "ones in the wrist: o )u,oi! -one+ Most $atera$& near the >th digit o Navicular -one+ Most media$ and .roxima$& arti%#$ating with the Ta$#s and Ca$%aneo#s. Most .rominent of the Tarsa$ "ones. t has a .a$.a"$e Navicular Tu,erosit 6 o Lateral, Interme!iate, Me!ial )unei.orm -ones+ Most dista$ and on the $atera$ side& arti%#$ating with the metatarsa$s. Metatarsal -ones *ro0imal, Mi!!le, Distal *"alan#es

/+CHES )2 THE 2))T 'N7B>& N7BH(: The ar%hes: o Me!ial Lon#itu!inal %rc"+ Ta$#s is .rimary %onne%tion here. o Lateral Lon#itu!inal %rc"+ o Transverse %rc"+ The *eroneus Lon#us Ten!on he$.s s#..ort the Trans!erse ar%h of the foot 'on the $atera$ side of the foot(. 4hat -ee.s the foot ar%hedL

The Lower Extremity Page 11 of 12 o Sha.e of the "ones o Ligaments o Some m#s%#$ar s#..ort Three P$antar Ligaments he$. to maintain the Lon#itu!inal %rc": o )alcaneonavicular 1(prin#2 Li#ament+ Conne%t na!i%#$ar "one to the Ca$%ane#s. o Lon# an! ("ort *lantar Li#aments+ /$ong "ottom of foot& he$. to maintain its ar%h. M#s%$es that he$. the ar%h: %le)or Hallucis *ongus Tendon %onne%ts from the hee$ to the "ig toe& ho$ding the two ends of the Media$ /r%h together. &lat=&oot De.ormit + o The $ongit#dina$ ar%h is $ost in some f$at,foot deformities.

('-T%L%R >OINT+ The <oint "etween the Ta$#s and Ca$%ane#s. This <oint he$.s yo# wa$- on #n$e!e$ gro#nd. t a%%ommodates with e!ersion and in!ersion of the hindfoot. (u,talar %rt"ritis wo#$d .re!ent a .erson from "eing a"$e to wa$- on #n$e!e$ gro#nd easi$y ,, no e!ersion and in!ersion of hindfoot.

C3/*+/T3S PL/NT/+ M3SCLE '2nd $ayer(: )L%W=TOE *eformity res#$ts from s%arring of this m#s%$e. The 2$exor *igitor#m $ong#s tendons are <#st s#.erfi%ia$ to this m#s%$e& and they wi$$ %ontra%t with s%arring of this m#s%$e. This is a %ommon sym.tom of a compartment syndrome in this %om.artment in the foot.

MasterEs $not o. Henr 1N83A2+ The %rossing of the 2$exor *igitor#m Long#s and 2$exor Ha$$#%is Long#s tendons& on the media$ side of the foot. The two r#n together down the media$ $eg& "ehind the media$ ma$$eo$#s. /fter they .ass the media$ ma$$eo$#s& they %ross.

-'NION+ )!er,.#$$ and %ontra%tion of the /dd#%tor Ha$$#%is '6rd $ayer( M#s%$e.: 2irst toe "ends in media$$y 'in !a$g#s( n s#rgery& "#nions are often fixed "y re$easing the m#s%$e in the first we",s.a%e.

/+TE+ ES )2 THE 2))T P)STE+ )+ T 0 /L /+TE+Y: 2o$$ows the .osterior ti"ia$ ner!e& to s#..$y the .$antar as.e%t of the foot o Me!ial *lantar %rter o Lateral *lantar %rter o *L%NT%R %R)H+ s formed "y the media$ and $atera$ .$antar arteries. o *er.oratin# -ranc"es are sent #. between -irst and second metatarsals& to .ro!ide anastomosis "etween .osterior ti"ia$ and dorsa$is .edis arteries. f one of the a"o!e arteries is %#t off& therefore& yo# %an sti$$ get "$ood s#..$y to the foot. /NTE+ )+ T 0 /L /+TE+Y: T#rns into the *orsa$is Pedis o Dorsalis *e!is %rter ,, s#..$ies the dors#m of the foot. t .asses #nderneath the extensor retina%#$#m. This is a good .$a%e to fee$ for .#$ses& as the artery is !ery s#.erfi%ia$. 5i!es off an %rcuate %rter whi%h forms a Dorsal (uper.icial %rc" and in t#rn gi!es off Dorsal Metatarsal %rteries. PE+)NE/L /+TE+Y: Norma$$y sma$$& #n$ess one of the a"o!e is a"sent. t norma$$y .eters o#t on to. of the %a$%aneo#s.

NE+1ES )2 THE 2))T: T 0 /L NE+1E ,, *i!ides into o Me!ial an! Lateral *lantar Nerves ,, the .rimary motor inner!ation of the foot. S/PHEN)3S NE+1E *EEP PE+)NE/L NE+1E S3PE+2 C /L PE+)NE/L NE+1E

The Lower Extremity Page 12 of 12 S3+/L NE+1E

C)MP/+TMENTS )2 THE 2))T: Media$ Com.artment Centra$ Com.artment Latera$ Com.artment nterosse#s Com.artment

CL N C/L ,, )%L)%NEO'( &R%)T'RE( are %ommon with fa$$s. The %a$%aneo#s is $arge$y %an%e$$o#s rather than %orti%a$ "one& whi%h ma-es it s#"<e%t to "rea-ing. Common mode of a%tion: The Ta$#s gets dri!en inferior$y into the %a$%aneo#s. o -oe"lerEs %n#le F the ang$e "etween the %a$%aneo#s and ta$#s. t "e%omes f$attened. o 2ra%t#res are most %ommon thro#gh the Posterior 2a%et of the Ta$#s. f yo# don:t o.erate yo# %an $ose the height o- the -oot& ma-ing it so shoes don:t fit !ery we$$=

L S2+/NC 'T/+S)MET/T/+S/L( I) NT 2+/CT3+ES ,, most %ommon$y o%%#r at the 2nd metatarsa$ "one& "e%a#se it is inset next to the 2nd %#neiform. This is the $o%ation of the trans!erse ar%h of the foot. Yo# %an get .ain in this fra%t#re "e%a#se the s#.erfi%ia$ .eronea$ ner!e is dire%t$y dorsa$ to the <oint& too. Chroni% .ain and arthritis is %ommon with this& and the <oint m#st "e fixated to restore anatomi%a$ norma$ity.

ST+ESS 2+/CT3+E: / fra%t#re that doesn:t res#$t from tra#ma& "#t res#$ts from fatig#e in a "one. The fra%t#re is #s#a$$y sma$$ andGor diff#se. Co.yright 1BBB& S%ott 5oodman& a$$ rights reser!ed