Mrcs Ana 3
Mrcs Ana 3
Mrcs Ana 3
Investigations
show a large ovarian cyst. Compression of which of the nerves listed below is the
most likely underlying cause?
A. Sciatic
B. Genitofemoral
C. Obturator
D. Ilioinguinal
E. Femoral cutaneous
Obturator nerve
The obturator nerve arises from L2, L3 and L4 by branches from the ventral divisions
of each of these nerve roots. L3 forms the main contribution and the second lumbar
branch is occasionally absent. These branches unite in the substance of psoas major,
descending vertically in its posterior part to emerge from its medial border at the
lateral margin of the sacrum. It then crosses the sacroiliac joint to enter the lesser
pelvis, it descends on obturator internus to enter the obturator groove. In the lesser
pelvis the nerve lies lateral to the internal iliac vessels and ureter, and is joined by the
obturator vessels lateral to the ovary or ductus deferens.
Supplies
Obturator canal
Connects the pelvis and thigh: contains the obturator artery, vein, nerve which
divides into anterior and posterior branches.
A. Tibialis anterior
B. Peroneus longus
E. Peroneus tertius
Peroneus longus is innervated by the superficial peroneal nerve (L4, L5, S1).
Image sourced from Wikipedia
Origin From the common peroneal nerve, at the lateral aspect of the
fibula, deep to peroneus longus
Nerve root values L4, L5, S1, S2
Course and Pierces the anterior intermuscular septum to enter the
relation anterior compartment of the lower leg
Passes anteriorly down to the ankle joint, midway between
the two malleoli
Terminates In the dorsum of the foot
Muscles Tibialis anterior
innervated Extensor hallucis longus
Extensor digitorum longus
Peroneus tertius
Extensor digitorum brevis
After its bifurcation past the ankle joint, the lateral branch of the deep peroneal nerve
innervates the extensor digitorum brevis and the extensor hallucis brevis
The medial branch supplies the web space between the first and second digits.
hich of the following forms the medial wall of the femoral canal?
A. Pectineal ligament
B. Adductor longus
C. Sartorius
D. Lacunar ligament
E. Inguinal ligament
Femoral canal
The femoral canal lies at the medial aspect of the femoral sheath. The femoral sheath
is a fascial tunnel containing both the femoral artery laterally and femoral vein
medially. The canal lies medial to the vein.
Contents
Lymphatic vessels
Cloquet's lymph node
Physiological significance
Allows the femoral vein to expand to allow for increased venous return to the lower
limbs.
Pathological significance
As a potential space, it is the site of femoral hernias. The relatively tight neck places
these at high risk of strangulation.
You decide to take an arterial blood gas from the femoral artery. Where should the
needle be inserted to gain the sample?
Boundaries
Superiorly Inguinal ligament
Laterally Sartorius
Medially Adductor longus
Floor Iliopsoas, adductor longus and pectineus
Roof Fascia lata and Superficial fascia
Superficial inguinal lymph nodes (palpable below the inguinal
ligament)
Great saphenous vein
A 34 year old man is shot in the postero- inferior aspect of his thigh. Which of the
following lies at the most lateral aspect of the popliteal fossa?
A. Popliteal artery
B. Popliteal vein
D. Tibial nerve
The sural nerve is a branch of the tibial nerve and usually arises at the inferior aspect
of the popliteal fossa. However, its anatomy is variable.
Popliteal fossa
Contents
C. Peroneal artery
D. Popliteal artery
Foot- anatomy
Intertarsal joints
Sub talar joint Formed by the cylindrical facet on the lower surface of the
body of the talus and the posterior facet on the upper surface
of the calcaneus. The facet on the talus is concave
anteroposteriorly, the other is convex. The synovial cavity
of this joint does not communicate with any other joint.
Talocalcaneonavicular The anterior part of the socket is formed by the concave
joint articular surface of the navicular bone, posteriorly by the
upper surface of the sustentaculum tali. The talus sits within
this socket
Calcaneocuboid joint Highest point in the lateral part of the longitudinal arch. The
lower aspect of this joint is reinforced by the long plantar
and plantar calcaneocuboid ligaments.
Transverse tarsal joint The talocalcaneonavicular joint and the calcaneocuboid joint
extend accross the tarsus in an irregular transverse plane,
between the talus and calcaneus behind and the navicular
and cuboid bones in front. This plane is termed the
transverse tarsal joint.
Cuneonavicular joint Formed between the convex anterior surface of the navicular
bone and the concave surface of the the posterior ends of the
three cuneiforms.
Intercuneiform joints Between the three cuneiform bones.
Cuneocuboid joint Between the circular facets on the lateral cuneiform bone
and the cuboid. This joint contributes to the tarsal part of the
transverse arch.
A detailed knowledge of the joints is not required for MRCS Part A. However, the
contribution they play to the overall structure of the foot should be appreciated
Detailed knowledge of the foot muscles are not needed for the MRCS part A
Medial plantar artery. Passes forwards medial to medial plantar nerve in the
space between abductor hallucis and flexor digitorum brevis.Ends by uniting
with a branch of the 1st plantar metatarsal artery.
Lateral plantar artery. Runs obliquely across the sole of the foot. It lies lateral
to the lateral plantar nerve. At the base of the 5th metatarsal bone it arches
medially across the foot on the metatarsals
D. Obturator artery
The inferior gluteal artery runs on the deep surface of the gluteus maximus muscle. It
is a branch of the internal iliac artery. It is commonly divided during the posterior
approach to the hip joint.
Hip joint
Ligaments
Transverse ligament: joints anterior and posterior ends of the articular
cartilage
Head of femur ligament (ligamentum teres): acetabular notch to the fovea.
Contains arterial supply to head of femur in children.
Extracapsular ligaments
Iliofemoral ligament: inverted Y shape. Anterior iliac spine to the trochanteric
line
Pubofemoral ligament: acetabulum to lesser trochanter
Ischiofemoral ligament: posterior support. Ischium to greater trochanter.
Blood supply
Medial circumflex femoral and lateral circumflex femoral arteries (Branches of
profunda femoris)
2 anastomoses: Cruciate and the trochanteric anastomoses (provides most of the blood
to the head of the femur) Hence the need for hemiarthroplasty when there is a
displaced femoral head fracture. These anastomoses exist between the femoral artery
or profunda femoris and the gluteal vessels.
Which of the following nerves passes through the greater and lesser sciatic foramina?
A. Pudendal nerve
B. Sciatic nerve
Pudendal nerve
Internal pudendal artery
Nerve to obturator internus
It passes between the piriformis and coccygeus muscles and exits the pelvis through
the the greater sciatic foramen. It crosses the spine of the ischium and reenters the
pelvis through the lesser sciatic foramen. It passes through the pudendal canal.
The pudendal nerve gives off the inferior rectal nerves. It terminates into 2 branches:
perineal nerve, and the dorsal nerve of the penis or the dorsal nerve of the clitoris.
Contents
Nerves Sciatic Nerve
Superior and Inferior Gluteal Nerves
Internal Pudendal Nerve
Posterior Femoral Cutaneous Nerve
Nerve to Quadratus Femoris
Nerve to Obturator internus
Piriformis
The piriformis is a landmark for identifying structures passing out of the sciatic notch
Pudendal nerve
Internal pudendal artery
Nerve to obturator internus
A 65 year old man with long standing atrial fibrillation develops an embolus to the
lower leg. The decision is made to perform an embolectomy, utilising a trans popliteal
approach. After incising the deep fascia, which of the following structures will the
surgeons encounter first on exploring the central region of the popliteal fossa?
A. Popliteal vein
B. Common peroneal nerve
C. Popliteal artery
D. Tibial nerve
The tibial nerve lies superior to the vessels in the inferior aspect of the popliteal fossa.
In the upper part of the fossa the tibial nerve lies lateral to the vessels, it then passes
superficial to them to lie medially. The popliteal artery is the deepest structure in the
popliteal fossa.
Popliteal fossa
Contents
A 43 year old lady presents with varicose veins and undergoes a saphenofemoral
disconnection, long saphenous vein stripping to the ankle and isolated hook
phlebectomies. Post operatively she notices an area of numbness superior to her ankle.
What is the most likely cause for this?
The sural nerve is related to the short saphenous vein. The saphenous nerve is related
to the long saphenous vein below the knee and for this reason full length stripping of
the vein is no longer advocated.
Saphenous vein
Originates at the 1st digit where the dorsal vein merges with the dorsal venous
arch of the foot
Passes anterior to the medial malleolus and runs up the medial side of the leg
At the knee, it runs over the posterior border of the medial epicondyle of the
femur bone
Then passes laterally to lie on the anterior surface of the thigh before entering
an opening in the fascia lata called the saphenous opening
It joins with the femoral vein in the region of the femoral triangle at the
saphenofemoral junction
Tributaries
Medial marginal
Superficial epigastric
Superficial iliac circumflex
Superficial external pudendal veins
Short saphenous vein
Originates at the 5th digit where the dorsal vein merges with the dorsal venous
arch of the foot, which attaches to the great saphenous vein.
It passes around the lateral aspect of the foot (inferior and posterior to the
lateral malleolus) and runs along the posterior aspect of the leg (with the sural
nerve)
Passes between the heads of the gastrocnemius muscle, and drains into the
popliteal vein, approximately at or above the level of the knee joint.
A 34 year old man undergoes excision of a sarcoma from the right buttock. During the
procedure the sciatic nerve is sacrificed. Which of the following will not occur as a
result of this process?
B. Foot drop
Extension of the knee joint is caused by the obturator and femoral nerves.
Sciatic nerve
Terminates At the upper part of the popliteal fossa by dividing into the
tibial and peroneal nerves
The nerve to the short head of the biceps femoris comes from the common
peroneal part of the sciatic and the other muscular branches arise from the
tibial portion.
The tibial nerve goes on to innervate all muscles of the foot except the
extensor digitorum brevis (which is innervated by the common peroneal
nerve).
24 year old lady is stabbed in the buttock. Following the injury the wound is
sutured in the emergency department. Eight weeks later she attends the clinic,
as she walks into the clinic room she has a waddling gait and difficulty with
thigh abduction. On examination she has buttock muscle wasting. Which
nerve has been injured?
B. Obturator nerve
C. Sciatic nerve
D. Femoral nerve
A. S2,3
B. L5, S1
C. S4,5
D. S5
E. S2,3,4
The external anal sphincter is innervated by the inferior rectal branch of the pudendal nerve,
this has root values of S2, 3 and the perineal branch of S4.
Anal sphincter
Internal anal sphincter composed of smooth muscle continuous with the circular
muscle of the rectum. It surrounds the upper two- thirds of the anal canal and is
supplied by sympathetic nerves.
External anal sphincter is composed of striated muscle which surrounds the internal
sphincter but extends more distally.
The nerve supply of the external anal sphincter is from the inferior rectal branch of
the pudendal nerve (S2 and S3) and the perineal branch of the S4 nerve roots.
A 72 year old man has a fall. He is found to have a fractured neck of femur and goes
on to have a left hip hemiarthroplasty. Two months post operatively he is found to
have an odd gait. When standing on his left leg his pelvis dips on the right side. There
is no foot drop. What is the cause?
A. Sciatic nerve damage
B. L5 radiculopathy
D. Previous poliomyelitis
This patient has a trendelenburg gait caused by damage to the superior gluteal nerve
causing weakness of the abductor muscles. Classically a patient is asked to stand on
one leg and the pelvis dips on the opposite side. The absence of a foot drop excludes
the possibility of polio or L5 radiculopathy.
Gluteal region
Gluteal muscles
Gluteus maximus: inserts to gluteal tuberosity of the femur and iliotibial tract
Gluteus medius: attach to lateral greater trochanter
Gluteus minimis: attach to anterior greater trochanter
All extend and abduct the hip
Piriformis
Gemelli
Obturator internus
Quadratus femoris
Nerves
Superior gluteal nerve (L5, S1) Gluteus medius
Gluteus minimis
Tensor fascia lata
B. Pectineus
C. Psoas major
D. Iliacus
The iliacus lies posterior to the femoral nerve in the femoral triangle. The femoral sheath lies
anterior to the iliacus and pectineus muscles.
Femoral nerve
Innervates Pectineus
Sartorius
Quadriceps femoris
Vastus lateralis/medialis/intermedius
Path
Penetrates psoas major and exits the pelvis by passing under the inguinal ligament to enter
the femoral triangle, lateral to the femoral artery and vein.
Image sourced from Wikipedia
V astus
Q uadriceps femoris
S artorius
PE ectineus
Which of the following ligaments contains the artery supplying the head of femur in
children?
A. Transverse ligament
B. Ligamentum teres
C. Iliofemoral ligament
D. Ischiofemoral ligament
E. Pubofemoral ligament
Hip joint
Ligaments
Transverse ligament: joints anterior and posterior ends of the articular cartilage
Head of femur ligament (ligamentum teres): acetabular notch to the fovea. Contains
arterial supply to head of femur in children.
Image sourced from Wikipedia
Extracapsular ligaments
Iliofemoral ligament: inverted Y shape. Anterior iliac spine to the trochanteric line
Pubofemoral ligament: acetabulum to lesser trochanter
Ischiofemoral ligament: posterior support. Ischium to greater trochanter.
Blood supply
Medial circumflex femoral and lateral circumflex femoral arteries (Branches of profunda
femoris)
2 anastomoses: Cruciate and the trochanteric anastomoses (provides most of the blood to
the head of the femur) Hence the need for hemiarthroplasty when there is a displaced
femoral head fracture. These anastomoses exist between the femoral artery or profunda
femoris and the gluteal vessels.
A 68 year old man with critical limb ischaemia is undergoing a femoro-distal bypass
graft. During mobilisation of the proximal part of the posterior tibial artery which of
the following is at greatest risk of injury?
A. Tibial nerve
B. Sciatic nerve
C. Saphenous nerve
The tibial nerve is closely related to the posterior tibial artery. The tibial nerve crosses
the vessel posteriorly approximately 2.5cm distal to its origin. At its origin the nerve
lies medial and then lateral after it crosses the vessel as described.
A. Popliteal artery
B. Popliteal vein
C. Tibial nerve
Popliteal fossa
Im
An intravenous drug user develops a false aneurysm and requires emergency surgery. The
procedure is difficult and the femoral nerve is inadvertently transected. Which of the
following muscles is least likely to be affected as a result?
A. Sartorius
B. Vastus medialis
C. Pectineus
D. Quadriceps femoris
E. Adductor magnus
Mnemonic for femoral nerve
supply
V astus
Q uadriceps femoris
S artorius
PE ectineus
Adductor magnus is innervated by the obturator and sciatic nerve. The pectineus muscle is
sometimes supplied by the obturator nerve but this is variable. Since the question states
least likely, the correct answer is adductor magnus
Femoral nerve
Innervates Pectineus
Sartorius
Quadriceps femoris
Vastus lateralis/medialis/intermedius
Path
Penetrates psoas major and exits the pelvis by passing under the inguinal ligament to enter
the femoral triangle, lateral to the femoral artery and vein.
Image sourced from Wikipedia
V astus
Q uadriceps femoris
S artorius
PE ectineus
Which of the following structures does not pass posteriorly to the medial malleolus?
B. Tibial nerve
C. Tibialis anterior tendon
Medial malleolus
A 44 year old man has a malignant melanoma and is undergoing a block dissection of the
groin. The femoral triangle is being explored for intra operative bleeding. Which of the
following forms the medial border of the femoral triangle?
A. Femoral artery
B. Biceps femoris
C. Adductor longus
D. Sartorius
E. Adductor magnus
Vastus medialis forms the lateral border of the adductor canal. The sartorius muscles forms
the roof of the adductor canal.
Adductor longus forms the medial boundary of the femoral triangle (see below).
Boundaries
Laterally Sartorius
Contents
The foramen marking the termination of the adductor canal is located in which of the
following?
A. Adductor longus
B. Adductor magnus
C. Adductor brevis
D. Sartorius
E. Semimembranosus
The foramen marking the distal limit of the adductor canal is contained within adductor
magnus. The vessel passes through this region to enter the popliteal fossa.
Adductor canal
Immediately distal to the apex of the femoral triangle, lying in the middle third of
the thigh. Canal terminates at the adductor hiatus.
Borders Contents
Laterally Vastus medialis muscle Saphenous nerve
In the image below the sartorius muscle is removed to expose the canal contents
A 24 year old motor cyclist is involved in a road traffic accident. He suffers a tibial
fracture which is treated with an intra medullary nail. Post operatively he develops a
compartment syndrome. Surgical decompression of the anterior compartment will
relieve pressure on all of the following muscles except?
A. Peroneus brevis
B. Peroneus tertius
C. Extensor digitorum longus
D. Tibialis anterior
Anterior compartment
Muscle Nerve Action
Tibialis anterior Deep peroneal Dorsiflexes ankle joint, inverts foot
nerve
Extensor digitorum Deep peroneal Extends lateral four toes, dorsiflexes
longus nerve ankle joint
Peroneus tertius Deep peroneal Dorsiflexes ankle, everts foot
nerve
Extensor hallucis Deep peroneal Dorsiflexes ankle joint, extends big toe
longus nerve
Peroneal compartment
Muscle Nerve Action
Peroneus longus Superficial peroneal nerve Everts foot, assists in plantar flexion
Peroneus brevis Superficial peroneal nerve Plantar flexes the ankle joint
A. Sural
B. Superficial peroneal
C. Deep peroneal
D. Medial plantar
E. Lateral Plantar
Region Nerve
Lateral plantar Sural
Dorsum (not 1st web space) Superficial peroneal
1st Web space Deep peroneal
Extremities of toes Medial and lateral plantar nerves
Proximal plantar Tibial
Medial plantar Medial plantar nerve
Lateral plantar Lateral plantar nerve
A sprinter attends A&E with severe leg pain. He had forgotten to warm up and ran a 100m
sprint race. Towards the end of the race he experienced pain in the posterior aspect of his
thigh. The pain worsens, localising to the lateral aspect of the knee. The sprinter is unable to
flex the knee. What structure has been injured?
C. Semimembranosus tendon
D. Semiteninosus tendon
The biceps femoris is commonly injured in sports that require explosive bending of the knee
as seen in sprinting, especially if the athlete has not warmed up first. Avulsion most
commonly occurs where the long head attaches to the ischial tuberosity. Injuries to biceps
femoris are more common than to the other hamstrings.
Biceps femoris
The biceps femoris is one of the hamstring group of muscles located in the posterior upper
thigh. It has two heads.
Long head
Arterial Profunda femoris artery, inferior gluteal artery, and the superior muscular
supply branches of popliteal artery
Image demonstrating the biceps femoris muscle, with the long head outlined
Image sourced from Wikipedia
Short head
Origin Lateral lip of linea aspera, lateral supracondylar ridge of femur
Arterial Profunda femoris artery, inferior gluteal artery, and the superior muscular
supply branches of popliteal artery
A. Gluteus maximus
D. Gluteus medius
The gluteus medius does not extend around to the sciatic nerve.
Sciatic nerve
Terminates At the upper part of the popliteal fossa by dividing into the
tibial and peroneal nerves
The nerve to the short head of the biceps femoris comes from the common
peroneal part of the sciatic and the other muscular branches arise from the
tibial portion.
The tibial nerve goes on to innervate all muscles of the foot except the
extensor digitorum brevis (which is innervated by the common peroneal
nerve).
A 72 year old lady is suspected of having a femoral hernia. At which of the following sites is it
most likely to be identifiable clinically?
Femoral hernias exit the femoral canal below and lateral to the pubic tubercle. Femoral
hernia occur mainly in women due to their difference in pelvic anatomy. They are at high risk
of strangulation and therefore should be repaired.
Femoral canal
The femoral canal lies at the medial aspect of the femoral sheath. The femoral sheath is a
fascial tunnel containing both the femoral artery laterally and femoral vein medially. The
canal lies medial to the vein.
Contents
Lymphatic vessels
Cloquet's lymph node
Physiological significance
Allows the femoral vein to expand to allow for increased venous return to the lower limbs.
Pathological significance
As a potential space, it is the site of femoral hernias. The relatively tight neck places these at
high risk of strangulation.
hich of the following represents the root values of the sciatic nerve?
A. L4 to S3
B. L1 to L4
C. L3 to S1
D. S1 to S4
E. L5 to S1
Sciatic nerve
Terminates At the upper part of the popliteal fossa by dividing into the
tibial and peroneal nerves
The nerve to the short head of the biceps femoris comes from the common
peroneal part of the sciatic and the other muscular branches arise from the
tibial portion.
The tibial nerve goes on to innervate all muscles of the foot except the
extensor digitorum brevis (which is innervated by the common peroneal
nerve).
he common peroneal nerve, or its branches, supply the following muscles
except:
A. Peroneus longus
B. Tibialis anterior
This nerve supplies the skin and fascia of the anterolateral surface of the leg
and the dorsum of the foot. It also innervates the muscles of the anterior and
peroneal compartments of the leg, extensor digitorum brevis as well as the
knee, ankle and foot joints.
It is laterally placed within the sciatic nerve. From the bifurcation of the sciatic
nerve it passes inferolaterally in the lateral and proximal part of the popliteal
fossa, under the cover of biceps femoris and its tendon. To reach the posterior
aspect of the fibular head. It ends by dividing into the deep and superficial
peroneal nerves at the point where it winds around the lateral surface of the
neck of the fibula in the body of peroneus longus, approximately 2cm distal to
the apex of the head of the fibula. It is palpable posterior to the head of the
fibula.
Branches
In the thigh Nerve to the short head of biceps
Articular branch (knee)
In the popliteal fossa Lateral cutaneous nerve of the calf
Neck of fibula Superficial and deep peroneal nerves
An 83 year old lady presents with a femoral hernia and undergoes a femoral hernia repair.
Which of the following forms the posterior wall of the femoral canal?
A. Pectineal ligament
B. Lacunar ligament
C. Inguinal ligament
D. Adductor longus
E. Sartorius
Femoral canal
The femoral canal lies at the medial aspect of the femoral sheath. The femoral sheath is a
fascial tunnel containing both the femoral artery laterally and femoral vein medially. The
canal lies medial to the vein.
Borders of the femoral canal
Contents
Lymphatic vessels
Cloquet's lymph node
Physiological significance
Allows the femoral vein to expand to allow for increased venous return to the lower limbs.
Pathological significance
As a potential space, it is the site of femoral hernias. The relatively tight neck places these at
high risk of strangulation.
hich of the following structures does not pass behind the lateral malleolus?
B. Sural nerve
Lateral malleolus
Sural nerve
Short saphenous vein
A. Iliohypogastric nerve
B. Ilioinguinal nerve
C. Lateral cutaneous nerve of the thigh
D. Femoral nerve
E. Saphenous nerve
F. Genitofemoral nerve
Please select the most likely nerve implicated in the situation described. Each option
may be used once, more than once or not at all.
14. A 42 year old woman complains of a burning pain of her anterior thigh which
worsens on walking. There is a positive tinel sign over the inguinal ligament.
The lateral cutaneous nerve supplies sensation to the anterior and lateral aspect
of the thigh. Entrapment is commonly due to intra and extra pelvic causes.
Treatment involves local anaesthetic injections.
15. A 29 year old woman has had a Pfannenstiel incision. She has pain over the
inguinal ligament which radiates to the lower abdomen. There is tenderness
when the inguinal canal is compressed.
16. A 22 year man is shot in the groin. On examination he has weak hip flexion,
weak knee extension, and impaired quadriceps tendon reflex, as well as sensory
deficit in the anteromedial aspect of the thigh.
Femoral nerve
A variety of different procedures carry the risk of iatrogenic nerve injury. These are
important not only from the patients perspective but also from a medicolegal
standpoint.
The following operations and their associated nerve lesions are listed here:
There are many more, with sound anatomical understanding of the commonly
performed procedures the incidence of nerve lesions can be minimised. They
commonly occur when surgeons operate in an unfamiliar tissue plane or by blind
placement of haemostats (not recommended).
23 year old man is stabbed in the groin, several structures are injured and the adductor
longus muscle has been lacerated. Which of the following nerves is responsible for the
innervation of adductor longus?
A. Femoral nerve
B. Obturator nerve
C. Sciatic nerve
E. Ilioinguinal nerve
Adductor longus
Action Adducts and flexes the thigh, medially rotate the hip
The schematic image below demonstrates the relationship of the adductor muscles
Image sourced from Wikipedia
hich of the following muscles does not recieve any innervation from the sciatic nerve?
A. Semimembranosus
B. Quadriceps femoris
C. Biceps femoris
D. Semitendinosus
E. Adductor magnus
Sciatic nerve
Terminates At the upper part of the popliteal fossa by dividing into the
tibial and peroneal nerves
The nerve to the short head of the biceps femoris comes from the common
peroneal part of the sciatic and the other muscular branches arise from the
tibial portion.
The tibial nerve goes on to innervate all muscles of the foot except the
extensor digitorum brevis (which is innervated by the common peroneal
nerve).
B. It supplies sartorius
Femoral nerve
Innervates Pectineus
Sartorius
Quadriceps femoris
Vastus lateralis/medialis/intermedius
Path
Penetrates psoas major and exits the pelvis by passing under the inguinal ligament to enter
the femoral triangle, lateral to the femoral artery and vein.
V astus
Q uadriceps femoris
S artorius
PE ectineus
Sartorius
Important The middle third of this muscle, and its strong underlying fascia forms
relations the roof of the adductor canal , in which lie the femoral vessels, the
saphenous nerve and the nerve to vastus medialis.
A. Sciatic nerve
B. Peroneal nerve
C. Tibial Nerve
D. Obturator nerve
E. Ilioinguinal nerve
F. Femoral nerve
G. None of the above
Please select the most likely nerve injury for the scenario given. Each option may be
used once, more than once or not at all
27. A 56 year old man undergoes a low anterior resection with legs in the Lloyd-
Davies position. Post operatively he complains of foot drop.
Peroneal nerve
Positioning legs in Lloyd- Davies stirrups can carry the risk of peroneal nerve
neuropraxia if not done carefully.
28. A 23 year old man complains of severe groin pain several weeks after a
difficult inguinal hernia repair.
Ilioinguinal nerve
The ilioinguinal nerve may have been entrapped in the mesh causing a
neuroma.
29. A 72 year old man develops a foot drop after a revision total hip replacement.
Sciatic nerve
Anterior compartment
Muscle Nerve Action
Tibialis anterior Deep peroneal Dorsiflexes ankle joint, inverts foot
nerve
Extensor digitorum Deep peroneal Extends lateral four toes, dorsiflexes
longus nerve ankle joint
Peroneus tertius Deep peroneal Dorsiflexes ankle, everts foot
nerve
Extensor hallucis Deep peroneal Dorsiflexes ankle joint, extends big toe
longus nerve
Peroneal compartment
Muscle Nerve Action
Peroneus longus Superficial peroneal nerve Everts foot, assists in plantar flexion
Peroneus brevis Superficial peroneal nerve Plantar flexes the ankle joint
A. Peroneus tertius
B. Sartorius
C. Adductor magnus
D. Peroneus brevis
E. Gracilis
Supplies
Path
Passes between peroneus longus and peroneus brevis along the length of the
proximal one third of the fibula
10-12 cm above the tip of the lateral malleolus, the superficial peroneal nerve
pierces the fascia
6-7 cm distal to the fibula, the superficial peroneal nerve bifurcates into
intermediate and medial dorsal cutaneous nerves
Which of the following structures separates the posterior cruciate ligament from the
popliteal artery?
B. Transverse ligament
C. Popliteus tendon
D. Biceps femoris
E. Semitendinosus
The posterior cruciate ligament is separated from the popliteal vessels at its origin by the
oblique popliteal ligament. The transverse ligament is located anteriorly.
Knee joint
The knee joint is a synovial joint, the largest and most complicated. It consists of two
condylar joints between the femure and tibia and a sellar joint between the patella and the
femur. The tibiofemoral articular surfaces are incongruent, however, this is improved by the
presence of the menisci. The degree of congruence is related to the anatomical position of
the knee joint and is greatest in full extension.
Fibrous capsule
The capsule of the knee joint is a complex, composite structure with contributions from
adjacent tendons.
Anterior The capsule does not pass proximal to the patella. It blends with the tendinous
fibres expansions of vastus medialis and lateralis
Posterior These fibres are vertical and run from the posterior surface of the femoral
fibres condyles to the posterior aspect of the tibial condyle
Medial Attach to the femoral and tibial condyles beyond their articular margins,
fibres blending with the tibial collateral ligament
Lateral Attach to the femur superior to popliteus, pass over its tendon to head of
fibres fibula and tibial condyle
Bursae
Medially Bursa between medial head of gastrocnemius and the fibrous capsule
Bursa between tibial collateral ligament and tendons of sartorius, gracilis
and semitendinosus
Bursa between the tendon of semimembranosus and medial tibial condyle
and medial head of gastrocnemius
Ligaments
Medial collateral Medial epicondyle femur to medial tibial condyle: valgus stability
ligament
Anterior cruciate Anterior tibia to lateral intercondylar notch femur: prevents tibia
ligament sliding anteriorly
Posterior cruciate Posterior tibia to medial intercondylar notch femur: prevents tibia
ligament sliding posteriorly
Patellar ligament Central band of the tendon of quadriceps femoris, extends from
patella to tibial tuberosity
Menisci
Medial and lateral menisci compensate for the incongruence of the femoral and tibial
condyles.
Composed of fibrous tissue.
Medial meniscus is attached to the tibial collateral ligament.
Lateral meniscus is attached to the loose fibres at the lateral edge of the joint and is
separate from the fibular collateral ligament. The lateral meniscus is crossed by the
popliteus tendon.
Nerve supply
The knee joint is supplied by the femoral, tibial and common peroneal divisions of the sciatic
and by a branch from the obturator nerve. Hip pathology pain may be referred to the knee.
Blood supply
Genicular branches of the femoral artery, popliteal and anterior tibial arteries all supply the
knee joint.
A 25 year old man undergoes an excision of a pelvic chondrosarcoma, during the operation
the obturator nerve is sacrificed. Which of the following muscles is least likely to be affected
as a result?
A. Adductor longus
B. Pectineus
C. Adductor magnus
D. Sartorius
E. Gracilis
Obturator nerve
The obturator nerve arises from L2, L3 and L4 by branches from the ventral divisions of each
of these nerve roots. L3 forms the main contribution and the second lumbar branch is
occasionally absent. These branches unite in the substance of psoas major, descending
vertically in its posterior part to emerge from its medial border at the lateral margin of the
sacrum. It then crosses the sacroiliac joint to enter the lesser pelvis, it descends on obturator
internus to enter the obturator groove. In the lesser pelvis the nerve lies lateral to the
internal iliac vessels and ureter, and is joined by the obturator vessels lateral to the ovary or
ductus deferens.
Supplies
Obturator canal
Connects the pelvis and thigh: contains the obturator artery, vein, nerve which
divides into anterior and posterior branches.
A. Popliteal nerve
D. Tibial nerve
E. Saphenous nerve
The first web space is innervated by the deep peroneal nerve. See diagram below:
Deep peroneal nerve
Origin From the common peroneal nerve, at the lateral aspect of the
fibula, deep to peroneus longus
Nerve root values L4, L5, S1, S2
Course and Pierces the anterior intermuscular septum to enter the
relation anterior compartment of the lower leg
Passes anteriorly down to the ankle joint, midway between
the two malleoli
After its bifurcation past the ankle joint, the lateral branch of the deep peroneal nerve
innervates the extensor digitorum brevis and the extensor hallucis brevis
The medial branch supplies the web space between the first and second digits.
Which of the following structures does not pass behind the piriformis muscle in the greater
sciatic foramen?
A. Sciatic nerve
D. Obturator nerve
The obturator nerve does not pass through the greater sciatic foramen.
Contents
Piriformis
The piriformis is a landmark for identifying structures passing out of the sciatic notch
Pudendal nerve
Internal pudendal artery
Nerve to obturator internus
A 78 year old lady falls over in her nursing home and sustains a displaced intracapsular
fracture of the femoral neck. A decision is made to perform a hemi arthroplasty through a
lateral approach. Which of the following vessels will be divided to facilitate access?
A. Saphenous vein
During the Hardinge style lateral approach the transverse branch of the lateral circumflex
artery is divided to gain access. The vessels and its branches are illustrated below:
Image sourced from Wikipedia
Hip joint
Ligaments
Transverse ligament: joints anterior and posterior ends of the articular cartilage
Head of femur ligament (ligamentum teres): acetabular notch to the fovea. Contains
arterial supply to head of femur in children.
Iliofemoral ligament: inverted Y shape. Anterior iliac spine to the trochanteric line
Pubofemoral ligament: acetabulum to lesser trochanter
Ischiofemoral ligament: posterior support. Ischium to greater trochanter.
Blood supply
Medial circumflex femoral and lateral circumflex femoral arteries (Branches of profunda
femoris)
2 anastomoses: Cruciate and the trochanteric anastomoses (provides most of the blood to
the head of the femur) Hence the need for hemiarthroplasty when there is a displaced
femoral head fracture. These anastomoses exist between the femoral artery or profunda
femoris and the gluteal vessels.
A 72 year old lady with osteoporosis falls and sustains an intracapsular femoral neck
fracture. The fracture is completely displaced. Which of the following vessels is the main
contributor to the arterial supply of the femoral head?
The vessels which form the anastomoses around the femoral head are derived from the
medial and lateral circumflex femoral arteries. These are usually derived from the profunda
femoris artery.
Hip joint
Ligaments
Transverse ligament: joints anterior and posterior ends of the articular cartilage
Head of femur ligament (ligamentum teres): acetabular notch to the fovea. Contains
arterial supply to head of femur in children.
Extracapsular ligaments
Iliofemoral ligament: inverted Y shape. Anterior iliac spine to the trochanteric line
Pubofemoral ligament: acetabulum to lesser trochanter
Ischiofemoral ligament: posterior support. Ischium to greater trochanter.
Blood supply
Medial circumflex femoral and lateral circumflex femoral arteries (Branches of profunda
femoris)
2 anastomoses: Cruciate and the trochanteric anastomoses (provides most of the blood to
the head of the femur) Hence the need for hemiarthroplasty when there is a displaced
femoral head fracture. These anastomoses exist between the femoral artery or profunda
femoris and the gluteal vessels.
The following statements relating to the ankle joint are true except?
B. The sural nerve lies medial to the Achilles tendon at its point of
insertion
The sural nerve lies behind the distal fibula. Inversion and eversion are sub talar
movements. The structures passing behind the medial malleolus from anterior to
posterior include: tibialis posterior, flexor digitorum longus, posterior tibia vein,
posterior tibial artery, nerve, flexor hallucis longus.
Ankle joint
The ankle joint is a synovial joint composed of the tibia and fibula superiorly and the
talus inferiorly.
The calcaneofibular ligament is separate from the fibrous capsule of the joint. The two
talofibular ligaments are fused with it.
Nerve supply
Branches of deep peroneal and tibial nerves.
References
Golano P et al. Anatomy of the ankle ligaments: a pictorial essay. Knee Surg Sports
Traumatol Arthrosc. 2010 May;18(5):557-69
A 19 year old man is playing rugby when he suddenly notices a severe pain at the
posterolateral aspect of his right thigh. Which of the following muscle groups is most likely
to have been injured?
A. Semimembranosus
B. Semitendinosus
D. Gastrocnemius
E. Soleus
Biceps femoris
The biceps femoris is one of the hamstring group of muscles located in the posterior upper
thigh. It has two heads.
Long head
Arterial Profunda femoris artery, inferior gluteal artery, and the superior muscular
supply branches of popliteal artery
Image demonstrating the biceps femoris muscle, with the long head outlined
Image sourced from Wikipedia
Short head
Origin Lateral lip of linea aspera, lateral supracondylar ridge of femur
Arterial Profunda femoris artery, inferior gluteal artery, and the superior muscular
supply branches of popliteal artery
A 22 year old man is involved in a fight and is stabbed in the posterior aspect of his
right leg. The knife passes into the popliteal fossa. He sustains an injury to his tibial
nerve. Which of the following muscles is least likely to be compromised as a result?
A. Tibialis posterior
D. Soleus
E. Peroneus tertius
Tibial nerve
Begins at the upper border of the popliteal fossa and is a branch of the sciatic nerve.
Muscles innervated
Popliteus
Gastrocnemius
Soleus
Plantaris
Tibialis posterior
Flexor hallucis longus
Flexor digitorum brevis
Rate question: 1
2
3
4
5
At which of the following anatomical locations does the common peroneal nerve
bifurcate into the superficial and deep peroneal nerves?
The common peroneal nerve bifurcates at the neck of the fibula (where it is most
likely to be injured).
Derived from the dorsal divisions of the sacral plexus (L4, L5, S1 and S2).
This nerve supplies the skin and fascia of the anterolateral surface of the leg and the
dorsum of the foot. It also innervates the muscles of the anterior and peroneal
compartments of the leg, extensor digitorum brevis as well as the knee, ankle and foot
joints.
It is laterally placed within the sciatic nerve. From the bifurcation of the sciatic nerve
it passes inferolaterally in the lateral and proximal part of the popliteal fossa, under
the cover of biceps femoris and its tendon. To reach the posterior aspect of the fibular
head. It ends by dividing into the deep and superficial peroneal nerves at the point
where it winds around the lateral surface of the neck of the fibula in the body of
peroneus longus, approximately 2cm distal to the apex of the head of the fibula. It is
palpable posterior to the head of the fibula.
Branches
In the thigh Nerve to the short head of biceps
Articular branch (knee)
In the popliteal fossa Lateral cutaneous nerve of the calf
Neck of fibula Superficial and deep peroneal nerves
A 48 year old motor cyclist sustains a complex lower limb fracture in a motor
accident. For a time the popliteal artery is occluded and eventually repaired.
Subsequently he develops a compartment syndrome and the anterior and superficial
posterior compartments of the lower leg are decompressed. Unfortunately, the
operating surgeon neglects to decompress the deep posterior compartment. Which of
the following muscles is least likely to be affected as a result?
B. Plantaris
C. Tibialis posterior
Tibialis posterior
Flexor hallucis longus
Flexor digitorum longus
Popliteus
The plantaris muscle lies within the superficial posterior compartment of the lower
leg.
Anterior compartment
Muscle Nerve Action
Tibialis anterior Deep peroneal Dorsiflexes ankle joint, inverts foot
nerve
Extensor digitorum Deep peroneal Extends lateral four toes, dorsiflexes
longus nerve ankle joint
Peroneus tertius Deep peroneal Dorsiflexes ankle, everts foot
nerve
Extensor hallucis Deep peroneal Dorsiflexes ankle joint, extends big toe
longus nerve
Peroneal compartment
Muscle Nerve Action
Peroneus longus Superficial peroneal nerve Everts foot, assists in plantar flexion
Peroneus brevis Superficial peroneal nerve Plantar flexes the ankle joint
C. Femoral artery
D. Femoral nerve
The deep external pudendal artery runs under the long saphenous vein close to its
origin and may be injured. It is at greatest risk of injury during the flush ligation of the
saphenofemoral junction. Provided an injury is identified and vessel ligated, injury is
seldom associated with any serious adverse sequelae.
Saphenous vein
Originates at the 1st digit where the dorsal vein merges with the dorsal venous
arch of the foot
Passes anterior to the medial malleolus and runs up the medial side of the leg
At the knee, it runs over the posterior border of the medial epicondyle of the
femur bone
Then passes laterally to lie on the anterior surface of the thigh before entering
an opening in the fascia lata called the saphenous opening
It joins with the femoral vein in the region of the femoral triangle at the
saphenofemoral junction
Tributaries
Medial marginal
Superficial epigastric
Superficial iliac circumflex
Superficial external pudendal veins
Originates at the 5th digit where the dorsal vein merges with the dorsal venous
arch of the foot, which attaches to the great saphenous vein.
It passes around the lateral aspect of the foot (inferior and posterior to the
lateral malleolus) and runs along the posterior aspect of the leg (with the sural
nerve)
Passes between the heads of the gastrocnemius muscle, and drains into the
popliteal vein, approximately at or above the level of the knee joint.
A 52 year female post hysterectomy attends clinic. She reports pain and reduced sensation
over the medial aspect of her thigh. Clinically thigh adduction is weak. What is the most
likely nerve injury?
A. Obturator nerve
B. Sciatic nerve
C. Femoral nerve
D. L3 cord compression
The obturator nerve supplies sensation to the medial aspect of the thigh and causes
adduction and internal rotation of the thigh.
Injury occurs during pelvic or abdominal surgery.
L3 cord compression is unlikely.
Obturator nerve
The obturator nerve arises from L2, L3 and L4 by branches from the ventral divisions of each
of these nerve roots. L3 forms the main contribution and the second lumbar branch is
occasionally absent. These branches unite in the substance of psoas major, descending
vertically in its posterior part to emerge from its medial border at the lateral margin of the
sacrum. It then crosses the sacroiliac joint to enter the lesser pelvis, it descends on obturator
internus to enter the obturator groove. In the lesser pelvis the nerve lies lateral to the
internal iliac vessels and ureter, and is joined by the obturator vessels lateral to the ovary or
ductus deferens.
Supplies
Obturator canal
Connects the pelvis and thigh: contains the obturator artery, vein, nerve which
divides into anterior and posterior branches.
A. It is derived from L4 to S3
B. It contains nerve roots from the posterior division of the lumbosacral
plexus only
It is derived from both anterior and posterior divisions of the lumbosacral plexus. The
sciatic nerve is the longest and widest nerve in the human body. It is particularly
susceptible to trauma in the posterior approach to the hip.
Sciatic nerve
Terminates At the upper part of the popliteal fossa by dividing into the
tibial and peroneal nerves
The nerve to the short head of the biceps femoris comes from the common
peroneal part of the sciatic and the other muscular branches arise from the
tibial portion.
The tibial nerve goes on to innervate all muscles of the foot except the
extensor digitorum brevis (which is innervated by the common peroneal
nerve).
A. Saphenous nerve
B. Sural nerve
C. Femoral nerve
E. Saphenous vein
It contains the saphenous nerve and the superficial branch of the femoral artery.
Adductor canal
Immediately distal to the apex of the femoral triangle, lying in the middle third of
the thigh. Canal terminates at the adductor hiatus.
Borders Contents
In the image below the sartorius muscle is removed to expose the canal contents
Image sourced from Wikipedia
A 56 year old lady with metastatic breast cancer develops an oestolytic deposit in the
proximal femur. One morning whilst getting out of bed she notices severe groin pain.
X-rays show that the lesser trochanter has been avulsed. Which muscle is the most
likely culprit?
A. Vastus lateralis
B. Psoas major
C. Piriformis
D. Gluteus maximus
E. Gluteus medius
The psoas major inserts into the lesser trochanter and contracts when raising the trunk
from the supine position. When oestolytic lesions are present in the femur the lesser
trochanter may be avulsed.
Psoas Muscle
Origin
The deep part originates from the transverse processes of the five lumbar vertebrae,
the superficial part originates from T12 and the first 4 lumbar vertebrae.
Insertion
Lesser trochanter of the femur.
Innervation
Anterior rami of L1 to L3.
Action
Flexion and external rotation of the hip. Bilateral contraction can raise the trunk from
the supine position.
A 34 year old man is injured by farm machinery and sustains a laceration at the
superolateral aspect of the popliteal fossa. The medial aspect of biceps femoris is
lacerated. Which of the following underlying structures is at greatest risk of injury?
A. Gracilis
B. Sural nerve
C. Nerve to semimembranosus
D. Popliteal artery
The common peroneal nerve lies under the medial aspect of biceps femoris and is
therefore at greatest risk of injury. The tibial nerve may also be damaged in such an
injury (but is not listed here). The sural nerve branches off more inferiorly.
Derived from the dorsal divisions of the sacral plexus (L4, L5, S1 and S2).
This nerve supplies the skin and fascia of the anterolateral surface of the leg and the
dorsum of the foot. It also innervates the muscles of the anterior and peroneal
compartments of the leg, extensor digitorum brevis as well as the knee, ankle and foot
joints.
It is laterally placed within the sciatic nerve. From the bifurcation of the sciatic nerve
it passes inferolaterally in the lateral and proximal part of the popliteal fossa, under
the cover of biceps femoris and its tendon. To reach the posterior aspect of the fibular
head. It ends by dividing into the deep and superficial peroneal nerves at the point
where it winds around the lateral surface of the neck of the fibula in the body of
peroneus longus, approximately 2cm distal to the apex of the head of the fibula. It is
palpable posterior to the head of the fibula.
Branches
In the thigh Nerve to the short head of biceps
Articular branch (knee)
In the popliteal fossa Lateral cutaneous nerve of the calf
Neck of fibula Superficial and deep peroneal nerves
A laceration to the upper lateral margin of the popliteal fossa may injure which of the
following nerves?
B. Sural nerve
C. Sciatic nerve
D. Saphenous nerve
E. Tibial nerve
The sural nerve exits at the lower latero-medial aspect of the fossa and is more at risk in
short saphenous vein surgery. The tibial nerve lies more medially and is even less likely to be
injured in this location.
Popliteal fossa
Laterally Biceps femoris above, lateral head of gastrocnemius and plantaris below
Floor Popliteal surface of the femur, posterior ligament of knee joint and popliteus
muscle
Contents
n elderly lady falls and lands on her hip. On examination her hip is tender to palpation and x-
rays are taken. There are concerns that she may have an intertrochanteric fracture. What is
the normal angle between the femoral neck and the femoral shaft?
A. 90o
B. 105o
C. 80o
D. 130o
E. 180o
The normal angle between the femoral head and shaft is 130o. Changes to this angle may
occur as a result of disease or pathology and should be investigated.
Hip joint
Ligaments
Transverse ligament: joints anterior and posterior ends of the articular cartilage
Head of femur ligament (ligamentum teres): acetabular notch to the fovea. Contains
arterial supply to head of femur in children.
Extracapsular ligaments
Iliofemoral ligament: inverted Y shape. Anterior iliac spine to the trochanteric line
Pubofemoral ligament: acetabulum to lesser trochanter
Ischiofemoral ligament: posterior support. Ischium to greater trochanter.
Blood supply
Medial circumflex femoral and lateral circumflex femoral arteries (Branches of profunda
femoris)
2 anastomoses: Cruciate and the trochanteric anastomoses (provides most of the blood to
the head of the femur) Hence the need for hemiarthroplasty when there is a displaced
femoral head fracture. These anastomoses exist between the femoral artery or profunda
femoris and the gluteal vessels.
An 18 year old athlete attends orthopaedic clinic reporting pain and swelling over the
medial aspect of the knee joint. The pain occurs when climbing the stairs, but is not
present when walking on flat ground. Clinically there is pain over the medial,
proximal tibia and the McMurray test is negative. What is the most likely cause of this
patient's symptoms?
E. Fracture of tibia
Pes anserinus: GOOSE'S FOOT
Pes Anserinus Bursitis is common in sportsmen due to overuse injuries. The main
sign is of pain in the medial proximal tibia. As the McMurray test is negative, medial
meniscal injury is excluded.
Sartorius
Important The middle third of this muscle, and its strong underlying fascia forms
relations the roof of the adductor canal , in which lie the femoral vessels, the
saphenous nerve and the nerve to vastus medialis.
Which of the following nerves innervates the long head of the biceps femoris muscle?
B. Tibial nerve
E. Obturator nerve
The short head of biceps femoris, which may occasionally be absent, is innervated by the
common peroneal component of the sciatic nerve. The long head is innervated by the tibial
nerve.
Biceps femoris
The biceps femoris is one of the hamstring group of muscles located in the posterior upper
thigh. It has two heads.
Long head
Arterial Profunda femoris artery, inferior gluteal artery, and the superior muscular
supply branches of popliteal artery
Image demonstrating the biceps femoris muscle, with the long head outlined
Image sourced from Wikipedia
Short head
Origin Lateral lip of linea aspera, lateral supracondylar ridge of femur
Arterial Profunda femoris artery, inferior gluteal artery, and the superior muscular
supply branches of popliteal artery
Which of the following bones is related to the cuboid at its distal articular surface?
A. All metatarsals
B. 5th metatarsal
C. Calcaneum
D. Medial cuneiform
E. 3rd metatarsal
Foot- anatomy
The longitudinal arch is higher on the medial than on the lateral side. The posterior
part of the calcaneum forms a posterior pillar to support the arch. The lateral part of
this structure passes via the cuboid bone and the lateral two metatarsal bones. The
medial part of this structure is more important. The head of the talus marks the
summit of this arch, located between the sustentaculum tali and the navicular bone.
The anterior pillar of the medial arch is composed of the navicular bone, the three
cuneiforms and the medial three metatarsal bones.
The transverse arch is situated on the anterior part of the tarsus and the posterior
part of the metatarsus. The cuneiforms and metatarsal bases narrow inferiorly,
which contributes to the shape of the arch.
Intertarsal joints
Sub talar joint Formed by the cylindrical facet on the lower surface of the body of
the talus and the posterior facet on the upper surface of the
calcaneus. The facet on the talus is concave anteroposteriorly, the
other is convex. The synovial cavity of this joint does not
communicate with any other joint.
Talocalcaneonavicular The anterior part of the socket is formed by the concave articular
joint surface of the navicular bone, posteriorly by the upper surface of
the sustentaculum tali. The talus sits within this socket
Calcaneocuboid joint Highest point in the lateral part of the longitudinal arch. The lower
aspect of this joint is reinforced by the long plantar and plantar
calcaneocuboid ligaments.
Transverse tarsal joint The talocalcaneonavicular joint and the calcaneocuboid joint extend
accross the tarsus in an irregular transverse plane, between the
talus and calcaneus behind and the navicular and cuboid bones in
front. This plane is termed the transverse tarsal joint.
Cuneonavicular joint Formed between the convex anterior surface of the navicular bone
and the concave surface of the the posterior ends of the three
cuneiforms.
Cuneocuboid joint Between the circular facets on the lateral cuneiform bone and the
cuboid. This joint contributes to the tarsal part of the transverse
arch.
A detailed knowledge of the joints is not required for MRCS Part A. However, the contribution
they play to the overall structure of the foot should be appreciated
Abductor Medial side of the calcaneus, Medial side of Medial Abducts the great toe
hallucis flexor retinaculum, plantar the base of plantar
aponeurosis the proximal nerve
phalanx
Flexor Medial process of the Via 4 tendons Medial Flexes all the joints of
digitorum calcaneus, plantar into the plantar the lateral 4 toes except
brevis eponeurosis. middle nerve for the interphalangeal
phalanges of joint.
the lateral 4
toes.
Abductor From the tubercle of the Together with Lateral Abducts the little toe at
digit calcaneus and from the flexor digit plantar the metatarsophalangeal
minimi plantar aponeurosis minimi brevis nerve joint
into the lateral
side of the
base of the
proximal
phalanx of the
little toe
Flexor From the medial side of the Into the Medial Flexes the
hallucis plantar surface of the cuboid proximal plantar metatarsophalangeal
brevis bone, from the adjacent part phalanx of the nerve joint of the great toe.
of the lateral cuneiform bone great toe, the
and from the tendon of tendon
tibialis posterior. contains a
sesamoid
bone
Adductor Arises from two heads. The Lateral side of Lateral Adducts the great toe
hallucis oblique head arises from the the base of plantar towards the second toe.
sheath of the peroneus longus the proximal nerve Helps maintain the
tendon, and from the plantar phalanx of the transverse arch of the
surfaces of the bases of the great toe. foot.
2nd, 3rd and 4th metatarsal
bones. The transverse head
arises from the plantar
surface of the lateral 4
metatarsophalangeal joints
and from the deep transverse
metatarsal ligament.
Extensor On the dorsal surface of the Via four thin Deep Extend the
digitorum foot from the upper surface tendons which peroneal metatarsophalangeal
brevis of the calcaneus and its run forward joint of the medial four
associated fascia and medially toes. It is unable to
to be inserted extend the
into the interphalangeal joint
medial four without the assistance of
toes. The the lumbrical muscles.
lateral three
tendons join
with hoods of
extensor
digitorum
longus.
Detailed knowledge of the foot muscles are not needed for the MRCS part A
Plantar arteries
Arise under the cover of the flexor retinaculum, midway between the tip of the medial
malleolus and the most prominent part of the medial side of the heel.
Medial plantar artery. Passes forwards medial to medial plantar nerve in the space
between abductor hallucis and flexor digitorum brevis.Ends by uniting with a branch
of the 1st plantar metatarsal artery.
Lateral plantar artery. Runs obliquely across the sole of the foot. It lies lateral to the
lateral plantar nerve. At the base of the 5th metatarsal bone it arches medially
across the foot on the metatarsals
C. L5
D. L3
E. L4
Prolapsed disc
A prolapsed lumbar disc usually produces clear dermatomal leg pain associated with
neurological deficits.
Features
The table below demonstrates the expected features according to the level of
compression:
Management
Onto which of the following structures does the anterior cruciate ligament insert?
The anterior cruciate ligament is attached to the anterior intercondylar area of the tibia. Is
then passes posterolaterally to insert into the posteromedial aspect of the lateral femoral
condyle.
Knee joint
The knee joint is a synovial joint, the largest and most complicated. It consists of two
condylar joints between the femure and tibia and a sellar joint between the patella and the
femur. The tibiofemoral articular surfaces are incongruent, however, this is improved by the
presence of the menisci. The degree of congruence is related to the anatomical position of
the knee joint and is greatest in full extension.
Fibrous capsule
The capsule of the knee joint is a complex, composite structure with contributions from
adjacent tendons.
Anterior The capsule does not pass proximal to the patella. It blends with the tendinous
fibres expansions of vastus medialis and lateralis
Posterior These fibres are vertical and run from the posterior surface of the femoral
fibres condyles to the posterior aspect of the tibial condyle
Medial Attach to the femoral and tibial condyles beyond their articular margins,
fibres blending with the tibial collateral ligament
Lateral Attach to the femur superior to popliteus, pass over its tendon to head of
fibres fibula and tibial condyle
Bursae
Medially Bursa between medial head of gastrocnemius and the fibrous capsule
Bursa between tibial collateral ligament and tendons of sartorius, gracilis
and semitendinosus
Bursa between the tendon of semimembranosus and medial tibial condyle
and medial head of gastrocnemius
Ligaments
Medial collateral Medial epicondyle femur to medial tibial condyle: valgus stability
ligament
Anterior cruciate Anterior tibia to lateral intercondylar notch femur: prevents tibia
ligament sliding anteriorly
Posterior cruciate Posterior tibia to medial intercondylar notch femur: prevents tibia
ligament sliding posteriorly
Patellar ligament Central band of the tendon of quadriceps femoris, extends from
patella to tibial tuberosity
Image sourced from Wikipedia
Image sourced from Wikipedia
Menisci
Medial and lateral menisci compensate for the incongruence of the femoral and tibial
condyles.
Composed of fibrous tissue.
Medial meniscus is attached to the tibial collateral ligament.
Lateral meniscus is attached to the loose fibres at the lateral edge of the joint and is
separate from the fibular collateral ligament. The lateral meniscus is crossed by the
popliteus tendon.
Nerve supply
The knee joint is supplied by the femoral, tibial and common peroneal divisions of the sciatic
and by a branch from the obturator nerve. Hip pathology pain may be referred to the knee.
Blood supply
Genicular branches of the femoral artery, popliteal and anterior tibial arteries all supply the
knee joint.
A 40 year old lady presents with varicose veins, these are found to originate from the short
saphenous vein. As the vein is mobilised close to its origin which of the following structures
is at greatest risk of injury?
A. Sciatic nerve
B. Sural nerve
D. Tibial nerve
E. Popliteal artery
The sural nerve is closely related and damage to this structure is a major cause of litigation.
The other structures may all be injured but the risks are lower.
Popliteal fossa
Floor Popliteal surface of the femur, posterior ligament of knee joint and popliteus
muscle
Contents
A 72 year old man with non reconstructible arterial disease is undergoing an above
knee amputation. The posterior compartment muscles are divided. Which of the
following muscles does not lie in the posterior compartment of the thigh?
A. Biceps femoris
B. Quadriceps femoris
C. Semitendinosus
D. Semimembranosus
Which of the following structures is not closely related to the posterior tibial artery?
A. Soleus posteriorly
E. Popliteus
The deep peroneal nerve lies in the anterior compartment. The tibial nerve lies
medially. At its termination it lies deep to the flexor retinaculum.
A 30 year old man presents with back pain and the surgeon tests the ankle reflex.
Which of the following nerve roots are tested in this manoeuvre?
A. S3 and S4
B. L4 and L5
C. L3 and L4
D. S1 and S2
E. S4 only
Ankle reflex
The ankle reflex is elicited by tapping the Achilles tendon with a tendon hammer. It
tests the S1 and S2 nerve roots. It is typically delayed in L5 and S1 disk prolapses.
Which of the following structures is not closely related to the piriformis muscle?
B. Sciatic nerve
The piriformis muscle is an important anatomical landmark in the gluteal region. The
following structures are closely related:
Sciatic nerve
Inferior gluteal artery and nerve
Superior gluteal artery and nerve
Gluteal muscles
Gluteus maximus: inserts to gluteal tuberosity of the femur and iliotibial tract
Gluteus medius: attach to lateral greater trochanter
Gluteus minimis: attach to anterior greater trochanter
All extend and abduct the hip
Piriformis
Gemelli
Obturator internus
Quadratus femoris
Nerves
Superior gluteal nerve (L5, S1) Gluteus medius
Gluteus minimis
Tensor fascia lata
Foot- anatomy
The longitudinal arch is higher on the medial than on the lateral side. The posterior
part of the calcaneum forms a posterior pillar to support the arch. The lateral part of
this structure passes via the cuboid bone and the lateral two metatarsal bones. The
medial part of this structure is more important. The head of the talus marks the
summit of this arch, located between the sustentaculum tali and the navicular bone.
The anterior pillar of the medial arch is composed of the navicular bone, the three
cuneiforms and the medial three metatarsal bones.
The transverse arch is situated on the anterior part of the tarsus and the posterior
part of the metatarsus. The cuneiforms and metatarsal bases narrow inferiorly,
which contributes to the shape of the arch.
Intertarsal joints
Sub talar joint Formed by the cylindrical facet on the lower surface of the body of
the talus and the posterior facet on the upper surface of the
calcaneus. The facet on the talus is concave anteroposteriorly, the
other is convex. The synovial cavity of this joint does not
communicate with any other joint.
Talocalcaneonavicular The anterior part of the socket is formed by the concave articular
joint surface of the navicular bone, posteriorly by the upper surface of
the sustentaculum tali. The talus sits within this socket
Calcaneocuboid joint Highest point in the lateral part of the longitudinal arch. The lower
aspect of this joint is reinforced by the long plantar and plantar
calcaneocuboid ligaments.
Transverse tarsal joint The talocalcaneonavicular joint and the calcaneocuboid joint extend
accross the tarsus in an irregular transverse plane, between the
talus and calcaneus behind and the navicular and cuboid bones in
front. This plane is termed the transverse tarsal joint.
Cuneonavicular joint Formed between the convex anterior surface of the navicular bone
and the concave surface of the the posterior ends of the three
cuneiforms.
A detailed knowledge of the joints is not required for MRCS Part A. However, the contribution
they play to the overall structure of the foot should be appreciated
Abductor Medial side of the calcaneus, Medial side of Medial Abducts the great toe
hallucis flexor retinaculum, plantar the base of plantar
aponeurosis the proximal nerve
phalanx
Flexor Medial process of the Via 4 tendons Medial Flexes all the joints of
digitorum calcaneus, plantar into the plantar the lateral 4 toes except
brevis eponeurosis. middle nerve for the interphalangeal
phalanges of joint.
the lateral 4
toes.
Abductor From the tubercle of the Together with Lateral Abducts the little toe at
digit calcaneus and from the flexor digit plantar the metatarsophalangeal
minimi plantar aponeurosis minimi brevis nerve joint
into the lateral
side of the
base of the
proximal
phalanx of the
little toe
Flexor From the medial side of the Into the Medial Flexes the
hallucis plantar surface of the cuboid proximal plantar metatarsophalangeal
brevis bone, from the adjacent part phalanx of the nerve joint of the great toe.
of the lateral cuneiform bone great toe, the
and from the tendon of tendon
tibialis posterior. contains a
sesamoid
bone
Adductor Arises from two heads. The Lateral side of Lateral Adducts the great toe
hallucis oblique head arises from the the base of plantar towards the second toe.
sheath of the peroneus longus the proximal nerve Helps maintain the
tendon, and from the plantar phalanx of the transverse arch of the
surfaces of the bases of the great toe. foot.
2nd, 3rd and 4th metatarsal
bones. The transverse head
arises from the plantar
surface of the lateral 4
metatarsophalangeal joints
and from the deep transverse
metatarsal ligament.
Extensor On the dorsal surface of the Via four thin Deep Extend the
digitorum foot from the upper surface tendons which peroneal metatarsophalangeal
brevis of the calcaneus and its run forward joint of the medial four
associated fascia and medially toes. It is unable to
to be inserted extend the
into the interphalangeal joint
medial four without the assistance of
toes. The the lumbrical muscles.
lateral three
tendons join
with hoods of
extensor
digitorum
longus.
Detailed knowledge of the foot muscles are not needed for the MRCS part A
Plantar arteries
Arise under the cover of the flexor retinaculum, midway between the tip of the medial
malleolus and the most prominent part of the medial side of the heel.
Medial plantar artery. Passes forwards medial to medial plantar nerve in the space
between abductor hallucis and flexor digitorum brevis.Ends by uniting with a branch
of the 1st plantar metatarsal artery.
Lateral plantar artery. Runs obliquely across the sole of the foot. It lies lateral to the
lateral plantar nerve. At the base of the 5th metatarsal bone it arches medially
across the foot on the metatarsals
A. Sartorius
B. Quadratus femoris
C. Semimembranosus
D. Gluteus medius
E. Piriformis
Theme from 2011 Exam
Trendelenberg test
Injury or division of the superior gluteal nerve results in a motor deficit that consists
of weakened abduction of the thigh by gluteus medius, a disabling gluteus medius
limp and a compensatory list of the body weakened gluteal side. The compensation
results in a gravitational shift so that the body is supported on the unaffected limb.
When a person is asked to stand on one leg the gluteus medius usually contracts as
soon as the contralateral leg leaves the floor, preventing the pelvis from dipping
towards the unsupported side. When a person with paralysis of the superior gluteal
nerve is asked to stand on one leg, the pelvis on the unsupported side descends,
indicating that the gluteus medius on the affected side is weak or non functional ( a
positive Trendelenberg test).
A 78 year old man presents with symptoms consistent with intermittent claudication. To
assess the severity of his disease you decide to measure his ankle brachial pressure index. To
do this you will identify the dorsalis pedis artery. Which of the following statements relating
to this vessel is false?
The dorsalis pedis artery is a direct continuation of the anterior tibial artery.
Foot- anatomy
The longitudinal arch is higher on the medial than on the lateral side. The posterior
part of the calcaneum forms a posterior pillar to support the arch. The lateral part of
this structure passes via the cuboid bone and the lateral two metatarsal bones. The
medial part of this structure is more important. The head of the talus marks the
summit of this arch, located between the sustentaculum tali and the navicular bone.
The anterior pillar of the medial arch is composed of the navicular bone, the three
cuneiforms and the medial three metatarsal bones.
The transverse arch is situated on the anterior part of the tarsus and the posterior
part of the metatarsus. The cuneiforms and metatarsal bases narrow inferiorly,
which contributes to the shape of the arch.
Intertarsal joints
Sub talar joint Formed by the cylindrical facet on the lower surface of the body of
the talus and the posterior facet on the upper surface of the
calcaneus. The facet on the talus is concave anteroposteriorly, the
other is convex. The synovial cavity of this joint does not
communicate with any other joint.
Talocalcaneonavicular The anterior part of the socket is formed by the concave articular
joint surface of the navicular bone, posteriorly by the upper surface of
the sustentaculum tali. The talus sits within this socket
Calcaneocuboid joint Highest point in the lateral part of the longitudinal arch. The lower
aspect of this joint is reinforced by the long plantar and plantar
calcaneocuboid ligaments.
Transverse tarsal joint The talocalcaneonavicular joint and the calcaneocuboid joint extend
accross the tarsus in an irregular transverse plane, between the
talus and calcaneus behind and the navicular and cuboid bones in
front. This plane is termed the transverse tarsal joint.
Cuneonavicular joint Formed between the convex anterior surface of the navicular bone
and the concave surface of the the posterior ends of the three
cuneiforms.
Cuneocuboid joint Between the circular facets on the lateral cuneiform bone and the
cuboid. This joint contributes to the tarsal part of the transverse
arch.
A detailed knowledge of the joints is not required for MRCS Part A. However, the contribution
they play to the overall structure of the foot should be appreciated
Abductor Medial side of the calcaneus, Medial side of Medial Abducts the great toe
hallucis flexor retinaculum, plantar the base of plantar
aponeurosis the proximal nerve
phalanx
Flexor Medial process of the Via 4 tendons Medial Flexes all the joints of
digitorum calcaneus, plantar into the plantar the lateral 4 toes except
brevis eponeurosis. middle nerve for the interphalangeal
phalanges of joint.
the lateral 4
toes.
Abductor From the tubercle of the Together with Lateral Abducts the little toe at
digit calcaneus and from the flexor digit plantar the metatarsophalangeal
minimi plantar aponeurosis minimi brevis nerve joint
into the lateral
side of the
base of the
proximal
phalanx of the
little toe
Flexor From the medial side of the Into the Medial Flexes the
hallucis plantar surface of the cuboid proximal plantar metatarsophalangeal
brevis bone, from the adjacent part phalanx of the nerve joint of the great toe.
of the lateral cuneiform bone great toe, the
and from the tendon of tendon
tibialis posterior. contains a
sesamoid
bone
Adductor Arises from two heads. The Lateral side of Lateral Adducts the great toe
hallucis oblique head arises from the the base of plantar towards the second toe.
sheath of the peroneus longus the proximal nerve Helps maintain the
tendon, and from the plantar phalanx of the transverse arch of the
surfaces of the bases of the great toe. foot.
2nd, 3rd and 4th metatarsal
bones. The transverse head
arises from the plantar
surface of the lateral 4
metatarsophalangeal joints
and from the deep transverse
metatarsal ligament.
Extensor On the dorsal surface of the Via four thin Deep Extend the
digitorum foot from the upper surface tendons which peroneal metatarsophalangeal
brevis of the calcaneus and its run forward joint of the medial four
associated fascia and medially toes. It is unable to
to be inserted extend the
into the interphalangeal joint
medial four without the assistance of
toes. The the lumbrical muscles.
lateral three
tendons join
with hoods of
extensor
digitorum
longus.
Detailed knowledge of the foot muscles are not needed for the MRCS part A
Plantar arteries
Arise under the cover of the flexor retinaculum, midway between the tip of the medial
malleolus and the most prominent part of the medial side of the heel.
Medial plantar artery. Passes forwards medial to medial plantar nerve in the space
between abductor hallucis and flexor digitorum brevis.Ends by uniting with a branch
of the 1st plantar metatarsal artery.
Lateral plantar artery. Runs obliquely across the sole of the foot. It lies lateral to the
lateral plantar nerve. At the base of the 5th metatarsal bone it arches medially
across the foot on the metatarsals
B. When the knee is fully extended all ligaments of the knee joint are taut
The posterior aspect is intrasynovial and the knee itself comprises the largest synovial joint
in the body. It may swell considerably following trauma such as ACL injury. Which may be
extremely painful owing to rich innervation from femoral, sciatic and ( a smaller)
contribution from the obturator nerve. During full extension all ligaments are taut and the
knee is locked.
Knee joint
The knee joint is a synovial joint, the largest and most complicated. It consists of two
condylar joints between the femure and tibia and a sellar joint between the patella and the
femur. The tibiofemoral articular surfaces are incongruent, however, this is improved by the
presence of the menisci. The degree of congruence is related to the anatomical position of
the knee joint and is greatest in full extension.
Fibrous capsule
The capsule of the knee joint is a complex, composite structure with contributions from
adjacent tendons.
Anterior The capsule does not pass proximal to the patella. It blends with the tendinous
fibres expansions of vastus medialis and lateralis
Posterior These fibres are vertical and run from the posterior surface of the femoral
fibres condyles to the posterior aspect of the tibial condyle
Medial Attach to the femoral and tibial condyles beyond their articular margins,
fibres blending with the tibial collateral ligament
Lateral Attach to the femur superior to popliteus, pass over its tendon to head of
fibres fibula and tibial condyle
Bursae
Medially Bursa between medial head of gastrocnemius and the fibrous capsule
Bursa between tibial collateral ligament and tendons of sartorius, gracilis
and semitendinosus
Bursa between the tendon of semimembranosus and medial tibial condyle
and medial head of gastrocnemius
Ligaments
Medial collateral Medial epicondyle femur to medial tibial condyle: valgus stability
ligament
Anterior cruciate Anterior tibia to lateral intercondylar notch femur: prevents tibia
ligament sliding anteriorly
Posterior cruciate Posterior tibia to medial intercondylar notch femur: prevents tibia
ligament sliding posteriorly
Patellar ligament Central band of the tendon of quadriceps femoris, extends from
patella to tibial tuberosity
Image sourced from Wikipedia
Image sourced from Wikipedia
Menisci
Medial and lateral menisci compensate for the incongruence of the femoral and tibial
condyles.
Composed of fibrous tissue.
Medial meniscus is attached to the tibial collateral ligament.
Lateral meniscus is attached to the loose fibres at the lateral edge of the joint and is
separate from the fibular collateral ligament. The lateral meniscus is crossed by the
popliteus tendon.
Nerve supply
The knee joint is supplied by the femoral, tibial and common peroneal divisions of the sciatic
and by a branch from the obturator nerve. Hip pathology pain may be referred to the knee.
Blood supply
Genicular branches of the femoral artery, popliteal and anterior tibial arteries all supply the
knee joint.
hich of the following does not exit the pelvis through the greater sciatic foramen?
C. Sciatic nerve
D. Obturator nerve
Contents
Piriformis
The piriformis is a landmark for identifying structures passing out of the sciatic notch
Pudendal nerve
Internal pudendal artery
Nerve to obturator internus
A 78 year old man is undergoing a femoro-popliteal bypass graft. The operation is not
progressing well and the surgeon is complaining of poor access. Retraction of which of the
following structures will improve access to the femoral artery in the groin?
A. Quadriceps
B. Adductor longus
C. Adductor magnus
D. Pectineus
E. Sartorius
At the lower border of the femoral triangle the femoral artery passes under the sartorius
muscle. This can be retracted to improve access.
Boundaries
Laterally Sartorius
Contents
A builder falls off a ladder whilst laying roof tiles. He sustains a burst fracture of L3.
The MRI scan shows complete cord transection at this level as a result of the injury.
Which clinical sign will not be present?
D. Incontinence
E. Loss of patellar tendon reflex
In lower motor neuron lesions
everything is reduced
The main purpose of this question is to differentiate the features of an UMN lesion
and a LMN lesion. The features of a LMN lesion include:
For lesions below L1 LMN signs will occur. Hence in an L3 lesion, there will be loss
of the patella reflex but there will be no extensor plantar reflex.
Spinal cord
There are some key points to note when considering the surgical anatomy of the
spinal cord:
* During foetal growth the spinal cord becomes shorter than the spinal canal, hence
the adult site of cord termination at the L1-2 level.
* Due to growth of the vertebral column the spine segmental levels may not always
correspond to bony landmarks as they do in the cervical spine.
* The spinal cord is incompletely divided into two symmetrical halves by a dorsal
median sulcus and ventral median fissure. Grey matter surrounds a central canal
that is continuous rostrally with the ventricular system of the CNS.
* Afferent fibres entering through the dorsal roots usually terminate near their point of
entry but may travel for varying distances in Lissauers tract. In this way they may
establish synaptic connections over several levels
* At the tip of the dorsal horn are afferents associated with nociceptive stimuli. The
ventral horn contains neurones that innervate skeletal muscle.
The key point to remember when revising CNS anatomy is to keep a clinical
perspective in mind. So it is worth classifying the ways in which the spinal cord may
become injured. These include:
The anatomy of the cord will, to an extent dictate the clinical presentation. Some
points/ conditions to remember:
66 year old man with peripheral vascular disease is undergoing a below knee
amputation. In which of the lower leg compartments does peroneus brevis lie?
A. Lateral compartment
B. Anterior compartment
The interosseous membrane separates the anterior and posterior compartments. The
deep and superficial compartments are separated by the deep transverse fascia. The
peroneus brevis is part of the lateral compartment.
A 70 year old man is due to undergo an arterial bypass procedure for claudication and
foot ulceration. The anterior tibial artery will form the site of the distal arterial
anastomosis. Which of the following structures is not closely related to it?
A. Interosseous membrane
As an artery of the anterior compartment, the anterior tibial artery is closely related to
tibialis anterior.
Which of the following muscles does not cause lateral rotation of the hip?
A. Obturator internus
B. Quadratus femoris
C. Gemellus inferior
D. Piriformis
E. Pectineus
Piriformis
Gemellus superior
Obturator internus
Gemellus inferior
Obturator externus
Quadratus femoris
Pectineus adducts and medially rotates the femur.
Hip joint
Ligaments
Transverse ligament: joints anterior and posterior ends of the articular cartilage
Head of femur ligament (ligamentum teres): acetabular notch to the fovea. Contains
arterial supply to head of femur in children.
Extracapsular ligaments
Iliofemoral ligament: inverted Y shape. Anterior iliac spine to the trochanteric line
Pubofemoral ligament: acetabulum to lesser trochanter
Ischiofemoral ligament: posterior support. Ischium to greater trochanter.
Blood supply
Medial circumflex femoral and lateral circumflex femoral arteries (Branches of profunda
femoris)
2 anastomoses: Cruciate and the trochanteric anastomoses (provides most of the blood to
the head of the femur) Hence the need for hemiarthroplasty when there is a displaced
femoral head fracture. These anastomoses exist between the femoral artery or profunda
femoris and the gluteal vessels.
Which of the following structures does not pass anterior to the lateral malleolus?
C. Tibialis anterior
D. Peroneus brevis
E. Peroneus tertius
Lateral malleolus
Sural nerve
Short saphenous vein
It inserts into the medial aspect of the upper part of the tibia.
Sartorius
Important The middle third of this muscle, and its strong underlying fascia forms
relations the roof of the adductor canal , in which lie the femoral vessels, the
saphenous nerve and the nerve to vastus medialis.
Which of the following structures are not closely related to the adductor longus muscle?
B. Tendon of iliacus
D. Pectineus muscle
E. Femoral nerve
Femoral triangle:
Adductor longus
medially
Inguinal ligament
superiorly
Sartorius muscle
laterally
Adductor longus forms the medial border of the femoral triangle. It is closely related to the
long saphenous vein which overlies it and the profunda branch of the femoral artery. The
femoral nerve is related to it inferiorly. However, the tendon of iliacus inserts proximally and
is not in contact with adductor longus.
Adductor longus
Action Adducts and flexes the thigh, medially rotate the hip
The schematic image below demonstrates the relationship of the adductor muscles
Which of the following muscles is not within the posterior compartment of the lower
leg?
A. Peroneus brevis
C. Soleus
D. Popliteus
The femoral nerve supplies the quadriceps muscle which is responsible for extension at the
knee joint.
Femoral nerve
Innervates Pectineus
Sartorius
Quadriceps femoris
Vastus lateralis/medialis/intermedius
Path
Penetrates psoas major and exits the pelvis by passing under the inguinal ligament to enter
the femoral triangle, lateral to the femoral artery and vein.
Image sourced from Wikipedia
V astus
Q uadriceps femoris
S artorius
PE ectineus
Which of the following structures are at risk of direct injury following a fracture dislocation
of the femoral condyles?
A. Popliteal artery
B. Sciatic nerve
C. Plantaris muscle
D. Tibial artery
E. Tibial nerve
The heads of gastrocnemius will contract to pull the fracture segment posteriorly. The
popliteal artery lies against the bone and may be damaged or compressed.
Popliteal fossa
Laterally Biceps femoris above, lateral head of gastrocnemius and plantaris below
Floor Popliteal surface of the femur, posterior ligament of knee joint and popliteus
muscle