ocpm notes

7/30/2019 OCPM Notes

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LOWER

EXTREMITYANATOMY

CLASS NOTESSPRING 2010

KATHY J. SIESEL, D.P.M.


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This book of notes is to be used in conjunction with the drawings presented in class. Ananatomy atlas will be very useful in this course as will attendance in the lecture and laboratorysessions, and completion of dissections in the laboratory.

TOPIC #1 INTRODUCTION AND REVIEW

I. LOWER EXTREMITY REGIONS AND SURFACES

A. Regions

1. Gluteal Region- the buttock, extends from the posterior iliac crest to the gluteal fold

2. Hip Region / Coxal Region- anterolateral from inguinal ligament to the inferior extent of the

hip joint

3. Thigh Region / Femoral Region- from the inferior aspect of the pelvis to the knee- has anterior, posterior and medial regions

4. Knee Region / Genus Region- between thigh and leg regions- has anterior and posterior regions

5. Leg Region / Crus Region- from the knee to the ankle- has anterior, posterior and lateral regions

a. Calf Region / Sural Region- the rounded (shapely) part at the proximal posterior leg region

6. Ankle Region / Talus Region- between the leg and the foot- includes the medial and lateral malleoli

7. Foot Region / Pes Region

a.Dorsal Region- the superior part or dorsum of the foot

b. Plantar Region- the inferior part or planta of the foot- is divided into medial, lateral and central regions

c. Calcaneal Region- the heel; medially, laterally and plantarly


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B. Surfaces of the Lower Limb

- described relative to anatomic position

1. Anterior Surface / Ventral Surface- the front side of a part, except the foot

2. Posterior Surface / Dorsal Surface- the back side of a part, except the foot

3. Medial Surface- the inner side of a part, toward bodys midline

4. Lateral Surface- the outer side of a part, opposite bodys midline

5. Flexor Surface- the surface over the flexor muscles- ex. the flexor surface of the leg is the posterior surface of the leg (opposite for

the upper limb, due to limb rotations)

6. Extensor Surface- the surface over the extensor muscles- ex. the extensor surface of the thigh is the anterior surface of the

thigh (opposite for the upper limb, due to limb rotations)

7. Adductor Surface- the surface over the adductor muscles- ex. the adductor surface of the thigh is the medial surface of the thigh

8. Abductor Surface

- the surface generally over the abductor muscles- ex. the abductor surface of the thigh is the lateral surface of the thigh9. Patellar Surface

- the anterior surface of the knee region, over the patella10. Popliteal Surface

- the posterior surface of the knee region11. Medial Malleolar Surface

- the surface over the medial malleolus of the tibia at the ankle region12. Lateral Malleolar Surface- the surface over the lateral malleolus of the fibula at the ankle region13. Dorsal Surface of the Foot

- the superior surface or dorsum of the foot14. Plantar Surface of the Foot

- the inferior surface, sole or planta of the foot


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II. ANATOMIC POSITION

- The anatomic position is one in which the body is standing erect with the toes andpalms facing anterior.

- the position of reference for much terminology- In relaxed standing, the torso is slightly slouched; the toes are often directed slightly

lateral and the palms are facing medially.

III. TERMINOLOGY

A. Descriptive- used to describe position

1. Superior, Cephalic, Cranial- toward the head- The knee is superior to the ankle.

2. Inferior, Caudal- away from the head- The foot is inferior to the ankle.

3. Anterior, Ventral- toward the front side- ventral is usually reserved for embryology- The patellar surface is anterior to the popliteal surface.

4. Posterior, Dorsal- toward the back side- dorsal is usually reserved for embryology, except when referring to the foots

dorsum- The popliteal region is posterior to the patellar region.5. Medial

- closer to the midline (central line) of the body- The hallux (great toe) is medial to the 5th pedal digit.

6. Lateral- farther from the midline- The 4th pedal digit is lateral to the hallux.

7. Intermediate- between 2 structures- The ankle is intermediate to the leg and foot.

8. Ipsilateral- on the same side of the body- The right forearm is ipsilateral to the right lower limb.- most often used for neurology


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terminology, descriptive, cont

9. Contralateral- on the opposite side of the body- The left arm is contralateral to the right thigh.- most often used for neurology

10. Proximal- closer to the origin/main structure- The thigh is proximal to the leg.

11. Distal- farther from the origin/main structure- The foot is distal to the knee.

12. Superficial- closer to the surface- Skin is superficial to bone.

13. Deep- farther from the surface, closer to the center- Muscles are deep to skin.

B. Terminology of Movement

1. Flexion- decreasing the angle between body parts, generally- usually an anterior direction except at the knee and more distal joints where it

is a posterior direction

2. Extension- increasing the angle between body parts, generally- usually a posterior direction except at the knee and more distal joints where it

is an anterior direction

a.Hyperextension- extension beyond the anatomic position- occurs normally at the neck, wrist, hip, ankle and MTP joints; The

term is not usually used for hip, ankle or MTP joints

3. Abduction- moving a part away from the bodys midline

4. Adduction- moving a part toward the midline of the body

5. Rotation- moving around the long axis of a part- occurs primarily at the hip and shoulder joints


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terminology of movement, rotation, cont

a.Medial Rotation / Internal Rotation- anterior surface of the part moves toward the body's midline

b.Lateral Rotation / External Rotation

- anterior surface of the part moves away from the body's midline6. Circumduction

- movement of a part in a circular pattern- combines flexion and extension with abduction and adduction; movements

must occur in alternating sequence

7. Eversion- moving the sole of the foot away from the bodys midline

8. Inversion- moving the sole of the foot toward the bodys midline

9. Dorsiflexion- extension of the ankle joint or joints distal to the ankle joint- bringing the dorsum of the foot closer to the anterior surface of the leg

10. Plantar Flexion- flexion of the ankle joint or joints distal to the ankle joint- moving the dorsum of the foot farther from the anterior surface of the leg

11. Supination- We will discuss supination as it relates to lower extremity anatomy, not the

upper limb.- combination of plantar flexion, adduction and inversion of the foot- motion occurs at the functional subtalar joint and the midtarsal joint

12. Pronation- We will discuss pronation as it relates to lower extremity anatomy, not the

upper limb.- combination of dorsiflexion, abduction and eversion of the foot- motion occurs at the functional subtalar joint and the midtarsal joint

IV. BODY PLANES

A. Frontal Planes / Coronal Planes

- divide the body or body parts into anterior and posterior sections

B. Transverse Planes- divide the body or body parts into superior and inferior sections

C. Sagittal Planes- divide the body or body parts into right and left sections


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body planes, sagittal planes, cont

1. Midsagittal Plane / Median Sagittal Plane- divides into equal right and left halves

2. Parasagittal Plane

- any sagittal plane except the midsagittal plane

D. Cardinal Body Planes- that plane which divides the body into equal parts

1. Cardinal Sagittal Plane- the midsagittal plane

2. Cardinal Frontal Plane / Cardinal Coronal Plane- divides the body into equal anterior and posterior halves

3. Cardinal Transverse Plane

- divides the body into equal superior and inferior halves

V. JOINTS / ARTICULATIONS- where two bones meet

A. Arthrology- the study of joints

B. Classification

1. Functional- based on the amount of movement available at a joint

a. Synarthrosis - an immovable jointex. sutures of the skull

b.Amphiarthrosis - a slightly movable jointex. symphysis pubis

c.Diarthrosis - a freely movable joint- primarily these in lower limbex. hip joint

2. Structural

- based on the material that unites the bone ends

a. Fibrous - united by fibrous tissue

i. Sutures - of the skull- functional synarthroses

ii. Gomphosis - between a tooth and the alveolus/socket- functional synarthroses


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joints, structural classification, fibrous, contiii. Syndesmosis 2 bones held together by a sheet of fibrous tissue

ex. tibiofibular syndesmosis- functional amphiarthroses

b. Cartilaginous - united by cartilage

i.Primary Cartilaginous Joints united by hyaline cartilage- temporary jointsex. Epiphyseal/growth plates

- functional synarthroses

ii. Secondary Cartilaginous Joints- united by fibrocartilage- permanent jointsex. intervertebral discs or symphysis pubis

- functional amphiarthroses

c. Synovial primary type in lower limb- 5 components of synovial joints

articular capsule/fibrous joint capsule unites the bone ends articular cartilage (usually hyaline cartilage) on the bone ends synovial membrane lines the joint cavity except the articular cartilage

and produces synovial fluid synovial fluid produced by the synovial membrane and fills the joint

cavity- lubricates and protects the articular cartilage

joint cavity, space between the bone ends and within the capsule- all synovial joints are functional diarthroses

i.Plane/Planar/Gliding- bone ends are both flat surfaces- allow gliding movements only, no rotationex. intertarsal joints

ii.Hinge/Ginglymus- complex surface shapes that may involve more than 2 bones- allow movement in one plane; flexion and extensionex. ankle joint

iii. Condyloid/Ellipsoid- 1 rounded, ball-like projection and 1 shallow saucer-like surface

- allow movement in two planes; flexion and extension, abductionand adduction, and circumductionex. metatarsophalangeal joints

iv. Saddle/Sellar- 2 saddle shaped surfaces- allow movement in two planes; flexion and extension or abductionand adduction (not both at the same time)

- have a small amount of rotation due to joint surface shapesex. calcaneocuboid joint


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joints, synovial, cont

v.Bicondylar

- 2 large rounded projections contacting 2 saucer-like areas

- allow movement primarily in one plane with a small amount

of rotationex. knee joint

vi.Ball and Socket/Spheroid- 1 large rounded, ball-like projection and 1 cup-like depression- allow movements in three planes- have all movements - flexion, extension, abduction, adduction,circumduction, internal rotation and external rotationex. hip joint

VI. BONE

A. Osteology- the study of bone

1. Ligament- dense connective tissue that connects bone to bone- often blend with articular capsules

B. Types

1. Compact, cortical or dense- very solid- appears white on radiographs due to closely packed cells

- provides strength to the bone

2. Cancellous, trabecular or spongy- appears as thin interlaced plates on radiographs due to looselypacked cells- has good blood supply for rapid healing

a. Trabeculae - the "plates" or lattice pieces

C. Classification

1. Placement

a.Axial Bones- part of the axial skeleton- includes the skull, vertebrae, ribs, sternum and manubrium

b.Appendicular Bones- part of the appendicular skeleton/limbs


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bone, appendicular, cont

i. Upper Limb - pectoral girdle (scapula and clavicle), humerus,radius, ulna, carpus, metacarpus, and manual phalanges

ii.Lower Limb - pelvic girdle (os coxa), femur, patella, tibia, fibula,

tarsus (greater and lesser), metatarsus, and pedal phalanges (in thetoes)

2. Shape

a.Long Bones- usually have greater length than width- found in the limbs- slight posterior/plantar concavity (curvature) in the lower limb for strengthex. femur

i.Diaphysis/Shaft/Body

- the central tubular part- primarily compact bone

aa.Medullary Cavity- the hollow core in the diaphysis- contains bone marrow

ii.Epiphyses - the ends of the bone- core of cancellous bone with a thin covering of compact bone,areas of articulation are covered with cartilage

- epiphysis is singular

iii.Metaphyses - flared part between the diaphysis and the epiphyses- core of cancellous bone with a thin covering of compact bone- metaphysis is singular

b. Short Bones- roughly cube-shaped- found only in the carpus and tarsus- core of cancellous bone with a thin covering of compact boneex. cuboid and cuneiforms

c.Irregular Bones- complex shapes with varying amounts of cancellous and compact boneex. vertebrae and facial bones

d. Flat Bones- two parallel plates of compact bone with a minute amount ofcancellous bone between the two platesex. ribs and skull


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bone, shapes, cont

e. Sesamoid Bones- round or oval bones located within tendons and often joint capsules- functions:

1. protect the tendon from wear2. create a mechanical advantage for the muscle by changing the angleof the pull and altering the muscle actionex. patella - largest sesamoid in the body

and the sesamoids of the first metatarsal bone

f.Accessory Bones / Accessory Ossicles- small bones with smooth regular edges- may be a non-fused portion of an existing bone or an extra bone- may be located within joint capsulesex. os intermetatarseum (between the metatarsal bases) and

os supratalare- many in the foot

D. Bone MarkingsThe parentheses contain plural forms of these terms, which are not typicalEnglish plurals.

1. Foramen (foramina)- an opening (hole) for the passage of vessels and nerves

ex. nutrient foramen, sacral foramina

2. Sulcus, Groove (sulci)- a ditch-like furrow for the passage of soft tissue structures

ex. obturator groove, lateral malleolar sulcus

3. Fossa (fossae)- a depression in or on a bone

ex. iliac fossa, lateral malleolar fossa

4. Notch

- an indentation along the edge of a bone

ex. greater sciatic notch

5. Condyle- a large rounded or depressed articular prominence

ex. medial femoral condyle

6. Epicondyle- a small prominence superior to a condyle

ex. medial epicondyle of the femur

7. Facet- a smooth flat surface for articulation

ex. middle facet of the calcaneus


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bone, bone markings, cont

8. Tubercle- a small rounded prominence for the attachment of soft tissue structures

ex. adductor tubercle of the femur

9. Tuberosity- a large rounded prominence, often roughened for the attachment of soft

tissue structuresex. tibial tuberosity

10. Trochanter- a large blunt process only on the femur

ex. greater trochanter

11. Crest- a prominent border or ridge

ex. median sacral crest

12. Line, Ridge- a ridge, much less prominent than a crest

ex. soleal line of the tibia

E. Ossification- all lower extremity bones begin as cartilage except the tufts of thedistal phalanges

- the tufts of the distal phalanges ossify through a process calledintramembranous ossification

- the ossification process from cartilage to bone is called

endochondral bone formation or intracartilaginous ossification

1. Long Bones

a. Primary Ossification Center- at midshaft of the bone- Primary ossification centers of all of the lower limb long bones arepresent at birth.

- forms the major part of the diaphysis

b. Secondary Ossification Centers- in the extremities (ends)- may be present at birth- one or more for each extremity- form the epiphyses

c.Epiphyseal Plate/Physis- area of cartilage between the diaphysis and the epiphyses- allows for length-wise growth of bone- form the metaphyses and part of the diaphysis


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bone, ossification, cont

2. Short Bones

a. Center of Ossification- in the bones center

- The center of ossification of some short bones is present at birth.- most only have one center of ossification- the calcaneus is an exception

- secondary center of ossification is located posteriorly and is calledthe calcaneal apophysis

b.Determination of Age- The appearance of the centers of ossification of the short bones of thefoot can be used to determine a child's age radiographically. Using thebones of the hand is more accurate as there is less variability in the ageof appearance of the centers of ossification of the manual short bones.

VII. MUSCLES

A. Myology - the study of muscles

1. Associated Structures

a. Tendon - connective tissue continuation of the muscle- attaches muscle to bone

i. Tendon Sheath - a double layer of connective tissue around atendon with a small amount of fluid between the layers- allows tendon to glide freely when the muscle contracts orrelaxes and prevents friction or damage to the tendon

aa.Mesotendon - where the layers of tendon sheath meet each other- may remain as a single structure or partially orcompletely degenerate

- Vincula - name given to areas of mesotendon that arepresent on the flexor tendons of the hand or foot- function: are areas for passage of vessels that

nourish the tendon

ii. Watershed Area - on tendons that do not have tendon sheaths

- the area of a tendon where there is the greatest potential ofinjury due to a lack of blood supply

- tendons without sheaths receive blood from the bone to which itattaches and from the muscle, majority from muscle

- this creates an area where the two sources meet at the watershed

b.Aponeurosis - flat connective tissue sheet- attaches muscle to muscle, muscle to bone or muscle to skinex. plantar aponeurosis/plantar fascia


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muscles, associated structures, cont

c.Bursa - a fluid-filled sac that decreases friction between 2structures; ligament and bone, ligament and ligament, muscle andbone, tendon and tendon, bone and skin

i.Adventitious Bursa - located just beneath the skin and develops as aresult of abnormal frictionex. over a bunion

B. Types

1. Cardiac Muscle- heart muscle tissue

2. Non-striated Muscle / Smooth Muscle- muscle of viscera

3. Skeletal- voluntary muscle- also called striated muscle

- poor terminology because cardiac muscle is also striated- preferable not to use this term

a.Belly - contractile part of a skeletal muscle- actual muscle tissue

b. Origin - the functional stable attachment that does not move- the proximal attachment from an anatomic view (and in this course)

c.Insertion - the functional mobile attachment- the distal attachment from an anatomic view (and in this course)

C. Naming

1. Direction of fibers- with respect to the body midline/part midline

a.Rectus - parallel to midlineex. rectus femoris muscle and rectus abdominis muscles

b. Transversus - perpendicular to midlineex. transversus abdominis muscle and transverse head of

adductor hallucis muscle

c. Oblique - angle less than perpendicular to the midlineex. oblique head of adductor hallucis muscle and

internal oblique muscle (of abdomen)


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muscles, naming, cont

2. Location- within the bodyex. tibialis anterior muscle and plantar interossei muscles

3. Size

a.Maximus - largestex. gluteus maximus muscle

b.Minimus - smallestex. gluteus minimus muscle

c.Magnus - largeex. adductor magnus muscle

d.Longus - longest

ex. adductor longus muscle

e.Brevis - shortestex. adductor brevis muscle

4. Number of Origins

a. quadriceps femoris muscle has 4 originsb. biceps brachii muscle has 2 origins

5. Shape

a. quadratus plantae muscle quadrangularb. trapezius muscle - trapezoid6. Origin and/or Insertion

a. sternocleidomastoid muscle- mastoid process, sternum and clavicle

b. iliacus muscle- iliac fossa

7. Action/Function

a.flexor digitorum longus muscle- flexes the digitsb. abductor hallucis muscle

- abducts the hallux

D. General Rule: Any muscle that crosses a joint has an action at that joint.(If you know the origin, course and insertion of a muscle, you can figure outthe action or function.)


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VIII. VESSELS

A. Types

1. Arteries- carry blood away from the heart

a. Conducting / Elastic- large arteries- lumen diameter greater than wall thickness

-ex. aorta, branches from aortic arch and the common iliac arteries- conduct blood (from the heart) to medium-sized arteries

i. Vasa Vasorum - tiny vessels within the walls of conducting arteries tonourish these large vessels

b.Distributing / Muscular- medium-sized arteries

- lumen diameter about equal to wall thickness-ex. external and internal iliac, femoral, popliteal, anterior and posteriortibial, and peroneal arteries

- distribute blood to different body parts; to arterioles in these parts

c.Arterioles- small to very small arteries- large amount of smooth muscle in the walls that can change bloodpressure by contracting or relaxing

- supply individual structures within parts- direct blood to capillary beds; for exchange of nutrients and wastes

d.End- an artery that is the only blood supply for an area- occlusion results in death of area-ex. ophthalmic artery, proper digital arteries

2. Veins- carry blood toward the heart- distal to proximal direction in limbs

- valves - present within the veins- prevent the back flow of blood- aid the muscular pump in lower limbs to return blood to the heart;

muscles contract and compress veins, blood flows proximal

a. Veins / Venae Comitans- large veins- a vena comitans travels with its respective artery

ex. femoral artery and femoral vein

i. Vasa Vasorum - tiny vessels within the large vessel walls toprovide nourishment

ii. Superficial Veins - travel without arteries in the superficial fascia(layer beneath the skin)


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vessels, veins, cont

b. Venae Comitantes / Venules- 2 or 3 small veins that accompany an artery- inferior to the knee in lower limb- referred to as venae comitantes of the _______ artery

(ex. anterior tibial)- small veins that carry blood to large veins

3. Capillaries- microscopic vessels that allow exchange of nutrients and wastes for cells- direct blood to venules

4. Lymph Vessels- vessels that carry lymph fluid (like plasma), which extravasates (escapes)

from capillaries

- valves - present within lymph vessels

- greater number than in veins; due to lower pressure in the lymphaticsystem to prevent back flow of the lymph fluid

a.Lymph Capillaries - microscopic vessels that begin between cells;open-ended

- transport lymph to afferent lymph vessels

b.Afferent Lymph Vessels - small vessels that carry lymph fluid to lymphnodes

c.Lymph Nodes - oval or kidney-shaped structures that filter lymph fluidbefore returning it to the general circulation

d.Efferent Lymph Vessels - small vessels that carry lymph fluid away fromfrom lymph nodes

e.Lymph Trunks - large lymph vessels that collect lymph fluid froma region-ex. lumbar trunk collects from lower limb

B. Anastomoses- communications between arteries and/or veins

1. Arterial

- artery to artery communication- provides alternate source of blood supply to an area; more than one route

to the same end- often called "collateral circulation", however it is actually not because

collateral circulation has new vesselsex. genicular anastomosis


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vessels, anastomoses, cont

2. Venous - vein to vein communication- provides alternate return route for blood- very common; possibly because of the lower pressure in the venous system

as compared to the arterial system which makes it easier to occlude

venous vessels

C. Arteriovenous Shunts- communication between an arteriole and a venule- help regulate body temperature by directing blood away from the surface to

deeper tissues or to the surface from deeper tissues- can be traumatically induced as in gunshot wounds and may need to be

surgically repaired

D. General Rule: Arteries tend to cross the flexor surface of muscles to prevent

collapse, so they do not get stretched to closing or crushed.

IX. NERVES

A. Central Nervous System (CNS)- contained within the skull and spinal column

1. Brain- within the skull

a.Afferent Fibers - carry impulses to nerve cell bodies in the brain

b.Efferent Fibers - carry impulses to other (lower) nerve cell bodies in the CNS

c.Nerve Cell Bodies

2. Spinal Cord- within the spinal column

a.Afferent Fibers - carry impulses to other (higher) neurons in the CNS

b.Efferent Fibers - carry impulses to other (lower) neurons in the CNS

c.Nerve Cell Bodies - in the central grey matter- dorsal, ventral and lateral horns

3. Spinal Roots- within the spinal column- inferior to the spinal cord near the second lumbar vertebra, the spinal roots

are long and are calledCauda Equina which means horse's tail


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nerves, spinal roots, cont

a.Dorsal Root/Dorsal Spinal Root

i.Afferent Fibers - carry sensory impulses from peripheral areas to nervecell bodies in the dorsal root ganglion

ii.Dorsal Root Ganglion - collection of nerve cell bodies in the dorsal root

b. Ventral Root/Ventral Spinal Root

i.Efferent Fibers - carry motor impulses from nerve cell bodies in thecentral nervous system to peripheral areas (muscles)

B. Peripheral Nervous System (PNS)- outside the skull and spinal column

1. Spinal Nerves- junction of dorsal and ventral roots, located at the intervertebral foramina

a.Dorsal Primary Rami / Dorsal Primary Ramus- contain afferent and efferent fibers- caudal ones are small branches; lumbar, sacral and coccygeal dorsal rami

supply motor and sensory innervation to the muscles of the spinal column

b. Ventral Primary Rami / Ventral Primary Ramus- contain afferent and efferent fibers- large branches; lumbar, sacral and coccygeal ventral rami form plexuses

and supply motor and sensory innervation to the lower limb

C. Autonomic Nervous System (ANS)- innervates the viscera and smooth (non-striated) muscle of blood vessels

and glands- an efferent or motor system

1. Sympathetic Nervous System- responses of stress or emergency situations

- "fight, fright and flight" responses- increased heart rate and blood pressure

- arise from thoracic and lumbar spinal cord and are distributed via thesympathetic chain; lower limb supply from T-10 through L-2 segments

- follow blood vessels (external iliac and femoral aa.) or nerves (femoral n.) in

the lower limb


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nerves, ANS, cont

2. Parasympathetic Nervous System- conservation responses

- decreased heart rate and respiration- arise from cranial and sacral segments of the central nervous system

- follow other nerves or form nerves (pelvic splanchnic nerves) to supply the area- no supply to lower limb

Topic # 2 SUBCUTANEOUS LAYER, DEEP FASCIAE ANDRETINACULA, NAIL ANATOMY, DERMATOMES

I. SUPERFICIAL FASCIA

A. Def'n: the subcutaneous layer, immediately deep to the skin/cutaneous layer- composed of loose connective tissue and adipose (fat) tissue

B. Contents- superficial veins, superficial lymph nodes and lymph vessels, and cutaneous nerves

1. Superficial Veins- carry blood from inferior to superior- can generally be seen through the skin

- in athletes, many bulge beneath the skin- have a greater number of valves than in other regions of the body to counteract gravityand prevent backflow- in general, pass superficial to the cutaneous nerves

a. Common Dorsal Digital Veins (8)- label as 1 to 8 from medial to lateral or as medial and lateral of the digit- collect blood from the toe and drain into dorsal metatarsal veins

ex. the 1st and 2nd common dorsal digital veins drain into the 1st

dorsalmetatarsal vein; and so on

b. Proper Dorsal Digital Veins (2)

i.Proper Dorsal Digital Vein of the Hallux- drains from the dorsomedial aspect of the hallux and 1st metatarsophalangeal

joint- becomes the medial marginal vein

ii.Proper Dorsal Digital Vein of the 5th

Toe- drains from the dorsolateral aspect of the 5 th toe and 5th metatarsophalangeal

joint- becomes the lateral marginal vein


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superficial veins, cont

c.Marginal Veins- much variation with veins, can be difficult to distinguish these, may be absent

i.Medial Marginal Vein

- drains from the medial border of the forefoot and the proper dorsal digital veinof the hallux- drains into the great saphenous vein

ii.Lateral Marginal Vein- drains from the lateral border of the forefoot and the proper dorsal digital vein

of the 5th

toe- drains into the small saphenous vein

d.Dorsal Metatarsal Veins (4)- one for each intermetatarsal space- label as 1 through 4 from medial to lateral- each receives blood from 2 adjacent common dorsal digital veins and two

perforating branches from deep layers of the foot- drain into the dorsal venous arch

e.Dorsal Venous Arch- passes across the dorsum of the foot often at the level of the metatarsal bases- receives blood from dorsal metatarsal veins and sometimes the proper dorsal

digital veins- drains into the great saphenous vein, medially and the small saphenous vein,

laterally

f. Small Saphenous Vein- begins as the union of the lateral end of the dorsal venous arch and the lateral

marginal vein (or the proper dorsal digital vein of the fifth digit), then passesposterior to the lateral malleolus at the ankle region- travels superiorly near the midline of the leg, at the posterior aspect, to the

popliteal area where it passes through the deep fascia to join the poplitealvein, which is part of the deep venous system.

- venous blood moves from superficial to deep

g. Great Saphenous Vein- begins as the union of the medial part of the dorsal venous arch and themedial marginal vein (or the proper dorsal digital vein of the hallux), thenpasses anterior to the medial malleolus at the ankle region- travels superiorly at the medial aspect of the leg, passes posteromediallyalong the popliteal surface (usually about 1 hand breadth posterior to the

medial edge of the patella) and continues in a superolateral direction to thegroin where it passes through the saphenous opening/fossa ovalis in thedeep fascia to join the femoral vein which is part of the deep venous system

- venous blood moves from superficial to deep

h. Superficial Plantar Venous Network- very thin intradermal and subdermal veins without valves- drain into medial and lateral marginal veins or into dorsal digital veins

through perforating branches


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superficial fascia, contents, cont

2. Lymph Nodes

a.Inguinal Lymph Nodes- located in the inguinal region, groin (where the thigh meets the hip)- organized as 3 groups

i. Superficial Inguinal Lymph Nodes- lie in the superficial fascia and are arranged as 2 groups- are usually palpable, but are firm and tender (painful to the patient)

when inflamed- most efferent vessels pass to the external iliac lymph nodes in the pelvis; a

few pass to the deep inguinal lymph nodes

aa.Horizontal Group- lie along the inguinal ligament- drains the superficial areas of the inferior abdominal wall and a small

area of the proximal anterior thigh

bb. Vertical Group- lie along the termination of the great saphenous vein and the fossa ovalis- drains from the superficial areas of the thigh, leg and foot except theposterolateral aspect of the leg and the lateral aspect of the foot

ii.Deep Inguinal Lymph Nodes (not pictured)- palpable only when inflamed- lie deep to the fascia lata, along the femoral vein near its termination- not in the subcutaneous layer- drain the deep tissues of the lower limb (tissues deep to the deep fascia)- efferent vessels pass to the external iliac lymph nodes in the pelvis

b. Popliteal Lymph Nodes- are deep lymph nodes and palpable only when inflamed- lie along the small saphenous vein near its termination and deep to thepopliteal fascia- drain the posterolateral aspect of the leg and the lateral aspect of the foot- efferent vessels pass to the deep inguinal lymph nodes

c.Anterior Tibial Lymph Node (not pictured)

- usually one or two deep lymph node(s)

- lie near the proximal end of the anterior tibial artery near the interosseous

membrane, deep to the muscles here- efferent vessels pass to the deep inguinal lymph nodes

d. Subcutaneous Pedal Infections- an infection of the 5th toe will generally cause inflammation of the popliteal

lymph nodes first, then inflammation of the deep inguinal lymph nodes- an infection of the hallux will generally cause inflammation of the vertical

superficial inguinal lymph nodes first and this may pass to the deep inguinallymph nodes, but definitely will pass to the external iliac lymph nodes


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superficial fascia, contents, conte.Deep Pedal Infections / Deep Infections of the Foot

- from any area, will create inflammation of the deep inguinal lymph nodes

- from dorsum of foot, will generally create inflammation of the anterior tibial

lymph node, first

- from planta of foot and calcaneal region, will generally create inflammationof the popliteal lymph nodes, first

3. Cutaneous Nerves- are nerves that exit the deep fascia and travel in the superficial fascia to supply

the skin, sensory and autonomic sympathetic fibers- all are from ventral rami except where noted - know these

a. anterior view

i. Subcostal Nerve, T-12- exits the deep fascia anterior to the iliac tubercle (lateral aspect of the hip)- supplies a small area at the anterolateral aspect of the thigh just inferior to

the groin- cutaneous supply only in lower extremity

ii. Femoral Branch of the Genitofemoral Nerve, L-1 & L-2- passes deep to the inguinal ligament and exits the deep fascia near the

fossa ovalis- supplies a small area at the anterior thigh just inferior to the groin and

medial to subcostal nerve distribution

iii.Ilioinguinal Nerve, L-1- exits the deep fascia through the superficial inguinal ring (with the

spermatic cord or round ligament of uterus)

- supplies a small area at the medial aspect of the thigh just inferior tothe groin

iv.Lateral Femoral Cutaneous Nerve, L-2 & L-3- also called the lateral cutaneous nerve of the thigh- exits the deep fascia near the anterior aspect of the iliac crest- supplies the anterolateral aspect of the thigh (from the subcostal nerve

distribution to the knee)

v.Intermediate Femoral Cutaneous Nerve, L-2 & L-3- also called the intermediate cutaneous nerve of the thigh- sometimes replaced by the femoral branch of the genitofemoral nerve orbranches of the lateral femoral cutaneous nerve

- exits the deep fascia through the sartorius muscle lateral to the fossa ovalis- supplies the anterior aspect of the thigh (from the ilioinguinal and

genitofemoral nerve distributions to the knee)

vi.Medial Femoral Cutaneous Nerve, L-2 & L-3- also called medial cutaneous nerve of the thigh- exits the deep fascia inferolateral to the fossa ovalis- supplies the anteromedial aspect of the thigh (from the ilioinguinal nervedistribution to the knee)


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cutaneous nerves, anterior view, cont

vii. Obturator Nerve, L-2, L-3 & L-4- exits the deep fascia at the medial aspect of the thigh near the junction of

the proximal and middle thirds- supplies the central part of the medial aspect of the thigh (from the

ilioinguinal nerve distribution to the inferior 1/3)

viii.Lateral Cutaneous Nerve of the Calf, L-5, S-1 & S-2- also called the lateral sural nerve- exits the deep fascia at the posterolateral edge of the knee region- supplies the lateral 1/2 of the leg from the knee to the inferior 1/3 leg

ix. Saphenous Nerve, L-3 & L-4- the only nerve of the leg region that can be traced to the lumbar plexus- exits the deep fascia at the inferomedial aspect of the thigh near the knee- supplies the entire medial of the leg from the knee to the foot including

the medial longitudinal arch; does not include the heel

x. Superficial Fibular Nerve / Superficial Peroneal Nerve, L-4, L-5 & S-1- exits the deep fascia at the anterolateral aspect of the leg near midlevel- supplies the anterolateral aspect of the inferior 1/3 of the leg, the

anterolateral aspect of the ankle and the dorsum of the foot except thelateral of the 5

thdigit and the 1

stweb space

xi.Deep Fibular Nerve / Deep Peroneal Nerve, L-5, S-1 & S-2- exits the deep fascia at the 1

stwebspace

- supplies the 1st

web space and the adjacent sides of the 1st

and 2nd

toes

xii.Medial Calcaneal Nerve, S-1 & S-2

- exits the deep fascia at the posteromedial aspect of the ankle near thecalcaneus; pierces the flexor retinaculum

- supplies the medial of the heel; medially, plantarly and posteriorly

xiii. Sural Nerve, S-1 & S-2- exits the deep fascia at the posterior aspect of the leg in the proximal 1/3- supplies a small area of the posterior aspect of the leg from mid-calf, to

the posterolateral aspect of the ankle, the lateral aspect of the foot, thelateral longitudinal arch and the lateral of 5

thtoe

b. posterior view

i.Iliohypogastric Nerve, L-1- exits the deep fascia near the lateral aspect of the iliac crest- supplies the superoposterolateral area of the gluteal skin, small area

ii. Superior Cluneal Nerves,dorsalrami of L-1, L-2 & L-3- also called the superior cutaneous nerves of the gluteal region- exit the deep fascia at the posterior aspect of the iliac crest- supply skin of superolateral aspect gluteal region


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cutaneous nerves, posterior view, cont

iii.Middle Cluneal Nerves,dorsal rami of S-1, S-2 & S-3- also called the middle cutaneous nerves of the gluteal region- exit the deep fascia over the sacrum- supply skin of the medial aspect gluteal region

iv. Posterior Femoral Cutaneous Nerve, S-1, S-2 & S-3- main branch passes inferiorly along the anterior aspect of the fascia lata- small branches from the main branch exit the deep fascia all along theposterior aspect of the thigh, popliteal and calf regions

- supplies the inferior gluteal region, the posterior aspect of the thigh, thepopliteal fossa and the superior central aspect of the calf

aa. inferior cluneal nerves, S-1, S-2 & S-3- branches of the posterior femoral cutaneous nerve that supply the

inferior area of the gluteal region- exit the deep fascia at the gluteal fold

v. Perforating Cutaneous Nerve, S-2 & S-3- branch from the sacral plexus- exits deep fascia at the inferomedial aspect of the gluteal region- supplies the inferomedial gluteal area skin

vi. Obturator Nerve, L-2, L-3 & L-4

- described above

vii.Medial Femoral Cutaneous Nerve, L-2 & L-3

- described above

viii.Lateral Femoral Cutaneous Nerve, L-2 & L-3- described above

ix. Saphenous Nerve, L-3 & L-4- described above

x.Lateral Cutaneous Nerve of the Calf, L-5, S-1 & S-2- described above

xi. Sural Nerve, S-1 & S-2- described above

aa. lateral cacaneal nerves, S-1 & S-2- branches of the sural nerve- arises in the superficial fascia between the calf and the ankle- supplies the lateral of heel; laterally, plantarly and posteriorly

xii. Superficial Fibular Nerve/Superficial Peroneal Nerve, L-4, L-5, S-1- described above


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cutaneous nerves, posterior view, cont

xiii.Medial Plantar Nerve, L-4 & L-5- small branches exit the deep fascia along the medial 2/3 of the plantar

midfoot and forefoot- supplies the plantar medial aspect of the foot from just distal to the heel to

the medial 3 toes

xiv.Lateral Plantar Nerve, S-1 & S-2- small branches exit the deep fascia along the lateral 1/3 of the plantar

midfoot and forefoot- supplies the plantar lateral aspect of the foot from just distal to the heel to

the lateral 1 toes

xv.Medial Calcaneal Nerve, S-1 & S-2- described above

c. cutaneous nerves of the dorsum of the foot

i. Superficial Fibular Nerve / Superficial Peroneal Nerve, L-4, L-5 &S-1- courses inferomedially and divides just proximal to the ankle

aa.Medial Dorsal Cutaneous Nerve- the medial division- passes anterior to the ankle near the center and is palpable here- supplies the medial part of the dorsal midfoot, then divides- aids in supply to 1

stwebspace

- Proper Dorsal Digital Nerve 1- the medial branch- supplies the dorsomedial aspect of the hallux

- 1stCommon Dorsal Digital Nerve- the lateral branch, passes in the 2

ndintermetatarsal space dorsally and

divides to supply the adjacent sides of the 2nd

and 3rd

toes as ProperDorsal Digital Nerves 4 and 5, respectively

bb.Intermediate Dorsal Cutaneous Nerve- the lateral division of the superficial fibular nerve- passes anterior to the ankle near the lateral malleolus- is easily palpated here- supplies the dorsolateral part of the midfoot and divides

- 2ndCommon Dorsal Digital Nerve- the medial branch, passes in the 3

rdintermetatarsal space dorsally and

divides to supply the adjacent sides of the 3rd

and 4th


- 3rd

Common Dorsal Digital Nerve- the lateral branch, passes in the 4

thintermetatarsal space dorsally and

divides to supply the adjacent sides of the 4th

and 5th



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cutaneous nerves, dorsum of foot, cont

ii.Lateral Dorsal Cutaneous Nerve, S-1 & S-2- is already in the superficial fascia at this level- the continuation of the sural nerve once it passes posterior to the lateral

malleolus; the sural nerve is renamed at this point

- supplies the lateral border of the foot

aa.Proper Dorsal Digital Nerve 10- the continuation of the lateral dorsal cutaneous nerve when it enters

the fifth toe; the lateral dorsal cutaneous nerve is renamed at this point- supplies the dorsolateral aspect of the 5

thtoe

iii.Deep Fibular Nerve / Deep Peroneal Nerve, L-5, S-1 & S-2- exits the deep fascia in the 1

stinterspace, supplies it and divides

aa.Proper Dorsal Digital Nerve 2- supplies the dorsolateral aspect of the hallux and medial 1

stinterspace

bb.Proper Dorsal Digital Nerve 3- supplies the dorsomedial aspect of the 2

ndtoe and lateral 1

stinterspace

iv. Saphenous Nerve, L-3 & L-4- passes anterior to the ankle near the medial malleolus- supplies the medial border of the midfoot and part of the medial

longitudinal arch

d. cutaneous nerves of the plantar foot

i.Medial Plantar Nerve, L-4 & L-5- larger of the two terminal branches of the tibial n.

- passes along the foot deep to the plantar fascia, sends cutaneous branchesto the skin and divides near the forefoot

aa.Proper Digital Plantar Nerve 1- passes along the medial side of the forefoot, plantarly, exiting the deep

fascia near the distal 1st

metatarsal shaft

- supplies the plantar medial aspect of the hallux and 1st

metatarsophalangeal joint

bb. 1st

Common Digital Plantar Nerve- passes in the area of the 1

stintermetatarsal space, plantarly

- exits the deep fascia at the level of the metatarsal necks

- supplies this area and adjacent sides of the hallux and 2ndtoe as theProper Digital Plantar Nerves 2 and 3, respectively

cc.2nd


ndintermetatarsal space, plantarly

- exits the deep fascia at the level of the metatarsal necks- supplies this area and adjacent sides of the 2

ndand 3

rdtoes as the

Proper Digital Plantar Nerves 4 and 5, respectively


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cutaneous nerves, planta of foot, cont

dd.3rdCommon Digital Plantar Nerve- passes in the area of the 3

rdintermetatarsal space, plantarly

- exits the deep fascia at the level of the metatarsal necks- supplies this area and adjacent sides of the 3

rdand 4

thtoes as the

Proper Digital Plantar Nerves 6 and 7, respectively

ii.Lateral Plantar Nerve, S-1 & S-2- smaller of the two terminal branches of the tibial n.- passes along the plantar midfoot deep to the deep fascia, sends cutaneousbranches to the skin and divides

aa. Communicating Branch- a medial branch which joins the 3

rdcommon digital plantar nerve

bb.4th


thintermetatarsal space, plantarly

- exits the deep fascia at the level of the metatarsal necks- supplies this area and adjacent sides of the 4th

and 5th

toes as theProper Digital Plantar Nerves 8 and 9, respectively

cc.Proper Digital Plantar Nerve 10- passes along the lateral forefoot, plantarly, exiting the deep fascia nearthe distal 5

thmetatarsal shaft

- supplies this area of the forefoot and the plantar lateral aspect of the5

thtoe

iii. Saphenous Nerve, L-3 & L-4- supplies a small area of the medial longitudinal arch of the foot, plantarly

iv. Sural Nerve, S-1 & S-2- supplies a small area of the lateral longitudinal arch of the foot, plantarly

v.Medial Calcaneal Nerve, S-1 & S-2- small branches which supply the medial of the calcaneal region

vi.Lateral Calcaneal Nerves, S-1 & S-2- small branches of the sural nerve which supply the lateral 1/3 to 1/2 of the

calcaneal region

II. DEEP FASCIAE AND RETINACULA

A. Def'n: deep fascia - dense connective tissue layer that surrounds muscles andattaches to many bony prominences and structures

- deep fascia is continuous from one region to the next

retinaculum - thickening of the deep fascia that holds soft tissue structuresin place (ex. tendons)


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B. Deep Fasciae

1. Fascia Lata- deep fascia of the thigh

a.Iliotibial (IT) Band / Iliotibial Tract

- thickening of the fascia lata at lateral aspect of the thigh- provides partial origin or insertion site for several muscles- often visible at lateral edge of extended knee; especially in athletes

b. Cribriform Fascia- very thin area of the fascia lata over the fossa ovalis / saphenous openingnear the groin

2. Fascia Cruris- deep fascia of the leg region- aids in forming several retinacula near ankle

3. Popliteal Fascia- deep fascia of the popliteal region

4. Fascia Dorsalis Pedis- deep fascia of the superior aspect of the foot- aids in forming several retinacula near ankle

5. Plantar Fascia / Plantar Aponeurosis- deep fascia of the inferior aspect (sole) of the foot, a complex structure- several layers, some fibers attach to skin at all points along the plantar foot

- aids in forming the retinacula near the ankle

C. Retinacula

1. Flexor Retinaculum / Laciniate Ligament- thickening of fascia cruris, fascia dorsalis pedis and plantar fascia- attaches to the distal posterior aspect of the medial malleolus and to the medialaspect of the calcaneus

- holds flexor tendons of the foot and creates a pulley to improve the musclefunction

- all tendons pass through the retinaculum and have separate tendon sheaths here

2. Superior Extensor Retinaculum / Transverse Crural Ligament

- thickening of fascia cruris- attaches to the distal tibial shaft and to the distal fibular shaft, anteriorly- fibers are continuous with the flexor and superior fibular retinacula- holds extensor tendons of the foot and maintains their positions near the tibia- only one tendon sheath at this level; for the tibialis anterior muscle- all tendons pass deep to the retinaculum


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retinacula, cont

3. Inferior Extensor Retinaculum / Cruciate Crural Ligament- Y-shaped band with the stem laterally- thickening of fasciae cruris and dorsalis pedis- attaches to the distal anterior medial malleolus and the medial plantar medial

cuneiform, then to the lateral talus (neck) and the superior aspect of thecalcaneus (in the sinus tarsi); described with 3 roots and 7 sinus tarsi attachments- continuous with the inferior fibular retinaculum- all tendons have tendon sheaths at this level and pass through this retinaculum-frondiform ligament- the stem of the inferior extensor retinaculum, attaches in

the sinus tarsi

4. Fibular Retinaculum / Peroneal Retinaculum / External Annular Ligament- really 2 separate retinacula- thickening of fasciae cruris and dorsalis pedis

a. Superior Fibular Retinaculum / Superior Peroneal Retinaculum

- attaches to the posteroinferior lateral malleolus and to the lateral calcaneus(retrotrochlear eminence)- formed by fascia cruris- holds peroneal tendons and creates a pulley at the lateral malleolus- both are in single tendon sheath here and pass deep to retinaculum- fibers are continuous with superior extensor retinaculum

b.Inferior Fibular Retinaculum / Inferior Peroneal Retinaculum- attaches to the sinus tarsi (anterolaterosuperior calcaneus) and to thefibular trochlea (posterolaterocentral calcaneus) then to posterolateroinferiorcalcaneus (near the lateral tubercle)

- formed by fascia dorsalis pedis- holds peroneal tendons and creates a pulley for fibularis longus tendon at

the distoplantar calcaneus- tendon sheath divides at this point and each tendon passes deep, separately- fibers continuous with lateral root of frondiform ligament

D. Intermuscular Septae (not pictured)- extensions of deep fascia that attach to bone and separate muscles or groups ofmuscles

- muscles often take partial origin from or partially insert onto septae- in the leg, these septae aid in venous return (venous pump); there is littleelasticity of the septae and muscular action creates compression on the deepveins which forces fluids superiorly (the valves normally prevent inferior flow),

the empty deep veins refill from the superficial veins and so on


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III. NAIL ANATOMY

A. Parts and Functions

1. Nail Plate- body of the nail (main part), normally .5 - .75 mm thick in an adult- is a hardening of the epidermis- cells have no nuclei, therefore are transparent, so can see the capillary bed- function: protect the distal end of the digit / toe

2. Matrix- "root" of the nail- specialized cells within the roof and floor of the proximal nail fold- attached to the base of the distal phalanx- extends approximately 5 mm proximal to visible nail edge- function: produce nail plate

3. Eponychium / Proximal Nail Fold- the skin fold at the proximal edge of the nail plate- overlies the matrix

4. Cuticle- small ridge of transparent skin dorsal to the proximal edge of the nail plate

which is continuous with the eponychium- creates a seal around the nail- function: prevent infection by sealing the area adjacent to the nail plate

5. Nail Bed- skin directly beneath and attached to the nail plate, contains some nail-

forming cells; the cells that are attached to the nail plate migrate distally andare shed at the free edge of the nail, nail production is not significant

- from matrix and lunula to the hyponychium- function: anchor the nail plate and allow its distal growth- sensory innervation to the nail bed is variable and may be entirely from the

proper digitalplantarnerves or from theplantar and dorsal proper digitalnerves; therefore, you must take care when anesthetizing (blocking) digits forfor nail procedures

- it is safest to anesthetize both sets of nerves

6. Lunula- the small pale half-moon-shaped area near the eponychium; whitish because

the cells retain nuclei and the capillaries beneath this portion of the nail

plate are not visible- function: produce nail

7. Free Edge of the Nail Plate- distal edge of nail plate that overhangs the toe- function: protect the distal tuft of the toe from blunt trauma (being smashed)

8. Hyponychium- the thickened skin adjacent to the free edge of the nail plate- function: prevent infection by sealing this area adjacent to the nail plate


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nail anatomy, cont

9. Distal Nail Groove- the shallow transverse groove between the hyponychium and the skin of the

distal tuft of the toe

10. Lateral Nail Folds /Ungualabia- the convex skin fold at the sides of the nail plate- after a successful permanent nail procedure the lateral nail folds will abut the

remaining nail plate

11. Lateral Nail Grooves- the concave junction of the lateral nail fold with the nail bed- under the side edges of the nail plate

B. Growth of Nails- nails grow primarily from the matrix and the proximal nail bed (level of the

lunula) and are pushed distally- the cells of the nail bed migrate with the nail plate

- nails grow faster in younger people and faster in the summer- finger nails grow faster than toe nails

- finger nail takes approximately 6 months for replacement- toe nail takes approximately 9 months for replacement

- sickness causes a disturbance in growth of the nail plate- nail growth requires much protein synthesis and illness retards this- have a resultant transverse ridge / Beaus Line

- little white spots - due to incomplete keratinization of the nail plate, cells stillhave nuclei or an air bubble formed in the nail plate due to a minor disturbancein growth

- longitudinal ridges - often due to mechanical damage to the matrix cells

IV. DERMATOMES

A. Def'n: the sensory innervation of an area of skin which is supplied by a singlespinal nerves dorsal root

B. Distribution in the lower limb

- there is overlap among adjacent segments, so often it is necessary to destroymore than 1 spinal nerve dorsal root to have a noticeable area of deficit- all begin at the spinal level indicated and travel in a general spiral manneras they pass distal

1. L-1 / first lumbar- posterior at the level of the 1

stlumbar vertebra

- supplies an area superior to the hip, posteriorly and superior thigh at thegroin near its termination


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dermatomes, cont

2. L-2 / second lumbar- posterior at the level of the 2

ndlumbar vertebra

- courses just inferior to L-1- supplies an area over the posterolateral iliac crest (hip bone prominence)

and the anterosuperior aspect of the thigh to the mid-level at the medialaspect of the thigh

3. L-3 / third lumbar- posterior at the level of the 3

rdlumbar vertebra, the mid-low back area

- supplies an area over the posterior iliac crest, the superior part of the lateralaspect of the thigh, the central part of the anterior aspect of the thigh, the inferiorpart of the medial aspect of the thigh, the medial aspect of the knee region -not thepatellar surface- and the superior of the medial aspect of the leg

4. L-4 / fourth lumbar- posterior at the level of the 4

thlumbar vertebra

- supplies an area over the posterosuperior gluteal region, the anteroinferiorthigh, the patellar surface, the central part of the anterior aspect of the leg, themedial malleolus and the medial aspect of the midfoot and forefoot,including the hallux

5. L-5 / fifth lumbar- posterior at the level of the 5

thlumbar vertebra, the low back

- supplies an area over the posterior iliac crest near the spine, thesuperolateral gluteal region, the inferior part of the lateral aspect of the thigh, thelateral aspect of the knee region, the anterolateral aspect of the leg, the anterioraspect of the ankle, the central part of the dorsum of the foot, toes 2 through 4, thecentral part of the plantar aspect of the forefoot and a small part of the calcanealregion (plantar and posterior, lateral to midline)

6. S-1 / first sacral- posterior at the level of the 1

stsacral vertebra, the low back

- supplies an area of the posterior mid-gluteal region, the posterolateral aspectsof the thigh and leg, the lateral malleolus, and the lateral aspects of the calcanealregion, midfoot and forefoot, including the fifth toe

7. S-2 / second sacral- posterior at the level of the 2

ndsacral vertebra

- supplies an area of the posterior central gluteal region, the posteromedialaspects of the thigh (including the perigenital area), knee and leg regions, and themedial of the calcaneal region

8. S-3, S-4, S-5 & Co-1 / third, fourth and fifth sacral and first coccygeal - all begin posteriorly at the respective spinal vertebral level- all form concentric arcs; with the third sacral being the largest over the

posteromedial gluteal area, and the first coccygeal being the smallest aroundthe perianal area


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V. MYOTOMES

A. Def'n: the group of muscles that are supplied by a single spinal nerves ventral root

B. Distribution- described in terms of movements at joints

- have overlap of the segments- are sometimes reported with slightly different levels because it is difficult to trace

nerves

1. Hip Joint

a. Flexion, Adduction, Medial Rotation- L-1 through L-4

b.Extension, Abduction, Lateral Rotation- L-4 through S-1

2. Knee Joint

a.Extension- L-2 through L-4

b. Flexion- L-5 & S-1

3. Ankle Joint

a.Dorsiflexion- L-4 & L-5

b. Plantar flexion- S-1 & S-2

4. Subtalar Joint

a.Inversion/Supination- L-4 & L-5

b.Eversion/Pronation- L-5 & S-1

5. Metatarsophalangeal Joints

a.Dorsiflexion- L-5 & S-1

b. Plantar flexion- S-1 & S-2


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myotomes, cont

C. Deep Tendon Reflexes/Spinal Reflexes

1. Def'n:

a. deep tendon reflex (DTR)- a muscle stretch reflex (These are commonly tested in a physician's office.)- mediated in the spinal cord

b. spinal reflex- a withdrawal response- a protective reflex- mediated in the spinal cord

2. Deep Tendon Reflexes

We will discuss the most commonly tested reflexes for the lower limb. There are

others, but these test the majority of the spinal segments for the lower limb.

a. Patellar Reflex- at the anterior knee/patellar tendon; with the knee flexed and relaxed, tapthe tendon and normally will get a small extension response

- tests spinal segments L-2, L-3 & L-4, the knee extensor myotome

b.Achilles Reflex- at the posterior ankle/Achilles tendon; with the ankle slightly dorsiflexed,tap the tendon and normally will feel the contraction of the calf muscles

- tests spinal segments S-1 & S-2; the ankle plantar flexor myotome

3. Spinal Reflexes

a.Babinski Test- stroke the sole of the foot from central plantar heel in an arc to the base of thefifth metatarsal with a firm blunt object (ex. pen cap, finger nail tip)

- normally will see plantar flexion of the toes; expected reaction- dorsiflexion of the hallux with abduction of the lesser digits (flaring of toes)

is abnormal after 2 years of age

TOPIC #3 OSTEOLOGY - GLUTEAL AND PELVIC REGIONS

I. Pelvis - composed of 4 bones:2 pelvic (hip) bones, the os coxae1 sacrum1 coccyx

-function: contain and protect pelvic organsaid in locomotion via force transfer


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osteology of pelvis, cont

- Pelvic Girdle = 2 pelvic bones-function: attach lower limb to the trunk

A. Sacrum

- forms a primary curvature of spinal column, same direction as fetal curvature- 5 vertebrae fused into one wedge-shaped bone- recognized by its distinctive shape

- used to determine gender: Male: base is narrower and length is longer. Female: base

is wider and length is shorter.

1. Base - superior end- articulates with L-5 vertebra

2. Apex - inferior end- articulates with the coccyx

B. Coccyx (tail bone)- 4 vertebrae fused into 2 or 3 segments

1. Base - superior end- articulates with the apex of the sacrum

2. Apex - inferior end

C. Features of Sacrum and Coccyx

anterior surface of the sacrum

- concave side to side and superior to inferior

1. Transverse Ridges (4)- formed by fusion of the vertebral bodies- last area in the body to complete ossification

2. Anterior Sacral Foramina (4 pair)- allow passage of the ventral rami S-1 through S-4- holes at anterolateral sacral canal

3. Sacral Promontory- anterior superior edge of S-1 vertebra

- projects in anteroinferior direction in body

4. Sacral Alae (ala means wing)- expansions from the base, laterally- the fused transverse processes of S-1 vertebrae

5. Superior Articular Processes- unfused superior articular processes of S-1- visible from anterior side, are part of the posterior aspect- articular surface is posterior

pelvic osteology, sacrum, cont


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anterior surface of coccyx- no true features from anterior

posterior surface of sacrum

1. Superior Articular Processes- described above

2. Sacral Alae- described above

3. Sacral Canal- spinal canal of the sacrum for passage of cauda equina

4. Median Sacral Crest- midline projection from sacrum

- the fused spinous processes of S-1 through S-4

5. Sacral Hiatus- the inferior opening of the sacral canal- formed by the lamina from S-5 that do not fuse- for passage of meninges and spinal nerves

6. Sacral Cornu- small projections at the lateral margins of the sacral hiatus- formed by ligamentous attachment

7. Posterior Sacral Foramina (4 pair)

- for passage ofdorsal rami S-1 through S-4

8. Intermediate Sacral Crest- projection at the medial edge of the dorsal sacral foramina, and lateral to

the median sacral crest- formed by fusion of the superior and inferior articular processes

9. Sacral Groove- depressed area between median and intermediate sacral crests- formed by fusion of the vertebral laminae S-1 through S-4

10. Lateral Sacral Crest- projection lateral to the dorsal sacral foramina

- formed by fusion of the transverse processes

posterior surface of coccyx

1. Coccygeal Cornu- superior articular processes of Co-1 vertebra- articulate with sacral cornu via ligamentous attachment


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pelvic osteology, sacrum, cont

lateral view of sacrum and coccyx

1. Lateral Surfaces

a.Auricular Surface- anterior part of the lateral surface, articulates with the pelvic bone- part of the sacroiliac joint, a synovial joint

b. Sacral Tuberosity- posterior part of the lateral surface, for attachment of ligaments

2. Sacral Ala - described above

3. Sacral Promontory - described above

4. Superior Articular Process - described above

5. Posterior Sacral Foramina 1,4 - described above

6. Median Sacral Crest - described above

7. Sacral Groove - described above

8. Intermediate Sacral Crest - described above

9. Sacral Cornu - described above

10. Lateral Sacral Crest - described above

11. Coccygeal Cornu - described above

D. Ossification of Sacrum

1. Primary Centers of Ossification- all present at birth- one in each vertebral body, one in each segment of the lateral masses, one in

each of the lamina (around the sacral canal)

2. Secondary Centers of Ossification- appear between puberty and age 20 years

- (epiphyseal rings (i.e. the upper and lower surfaces of the bodies), the tip of thespinous processes, the transverse processes, and the lateral surfaces that form the ala)- all fused by age 25 years except transverse ridges which take until middle age


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pelvic osteology, cont

E. Pelvic Bone (2)- also called os coxa or innominate bone- articulates posteriorly with the lateral surface of the sacrum, anteriorly with the

symphyseal surface of the other pelvic bone and laterally with the femoral head

- composed of three bones fused into one- recognized by its distinctive shape

1. Ilium (not ileum) - the large superior portion of the pelvic bone

a. iliac body - the central part (more inferior)

b. iliac ala - the wing (large flattened part)

2. Ischium - the posteroinferior portion of the pelvic bone

a. ischial body - the posterosuperior part; triangular in a cross-sectional view

i. femoral surface - the external surface; faces laterally (not seen on picture)

ii. pelvic surface - the internal surface; faces medially

iii. dorsal surface - the posterior surface (not seen on picture)

b. ischial ramus - the anteroinferior projection

i. anterior surface - the external surface; faces laterally- rough from soft tissue attachment

ii. posterior surface - the internal surface; faces medially- smooth area

3. Pubis - the anteroinferior portion of the pelvic bone

a.pubic body - the large anteromedial part

i. symphyseal surface - the flattened medial surface of the body- articulates with the other symphyseal surface at the pubic symphysis

ii. femoral surface - the anterior/external surface (not seen on picture)

iii. pelvic surface - the posterior/internal surface (not seen on picture)

b. superior pubic ramus - the superior posterolateral projection

i. obturator surface - the anterior surface at the medial end which spirals toan inferior position at the lateral end and is the continuation of the femoralsurface of the body

ii. pectineal surface - the superior surface- narrow medially, expands laterally


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pelvic osteology, pelvic bone, superior pubic ramus, cont

iii. pelvic surface - the internal surface- wide medially, narrows laterally

c. inferior pubic ramus - the inferoposterolateral projection

- joins the ischial ramus- together the inferior pubic ramus and the ischial ramus may be referred

to as the conjoined ramus or ischiopubic ramus

- can not distinguish one bone from the other after fusion

F. Features of the Pelvic Bone

medial view

1. Iliac Crest

- the superior border of the ilium or of the iliac ala- can be palpated along its entire length- most patients call this the hip bone

2. Anterior Superior Iliac Spine (ASIS)- the anterior rounded end of the iliac crest- can be palpated- often used as a reference point to measure limb length- for attachment of ligaments and muscle

3. Posterior Superior Iliac Spine (PSIS)- the posterior rounded end of the iliac crest- can be palpated, but may be difficult- lies beneath the skin dimple at the low back- for attachment of ligaments and muscle

4. Anterior Inferior Iliac Spine (AIIS)- the small projection on the anterior border of the ilium just inferior to theanterior superior iliac spine

- can often be palpated just medial and inferior to the anterior superior iliacspine depending upon weight

- for attachment of muscle and ligament

5. Posterior Inferior Iliac Spine (PIIS)- the small projection on the posterior border of the ilium just inferior to the

posterior superior iliac spine

6. Iliac Fossa- the flattened internal or pelvic surface of the ala (wing) of the ilium- for attachment of a muscle


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pelvic osteology, pelvic bone features, cont

7. Iliac Tuberosity- roughened area on the posteromedial surface of the ilium, posterior

to the iliac fossa and anterior to the posterior superior iliac spine- for the attachment of ligaments

8. Auricular Surface- the synovial joint surface on the posteromedial surface of the ilium, posterior

to the iliac fossa and inferior to the level of the posterior superior iliac spine- for articulation with the auricular surface of the sacrum at the sacroiliac joint- used as an age indicator. Young: well defined edges and surfaces. Old: irregular

surfaces and edges with pitting and lipping .

9. Ischial Spine- the small sharp projection on the posterior border of the ischium- inferior to the posterior inferior iliac spine- for attachment of ligament

10. Greater Sciatic Notch- the large concavity posteriorly- intermediate to the posterior inferior iliac spine and the ischial spine- closed by the sacrospinous ligament to form the greater sciatic foramen,

then allows passage of neurovascular structures and the piriformis m.

- used to determine gender. Male: narrow , 40-60 degree angle. Female: wide,

- 80-90 degree angle.

11. Ischial Tuberosity- the large blunt projection on the posterior inferior aspect of the ischium- weight-bearing when seated; the area of problem when "saddle sore"

- can be palpated through the soft tissue at the inferomedial gluteal region- for attachment of ligament and muscles

12. Lesser Sciatic Notch- the small concavity intermediate to the ischial spine and the ischial tuberosity- closed by the sacrotuberous ligament to form the lesser sciatic foramen,

then allows passage of neurovascular structures and obturator internus m.

13. Obturator Foramen- the large hole in the pelvic bone formed by the ischial ramus, the ischial body,

the pubic body and the pubic rami- covered by the obturator membrane

14. Pubic Crest- the small roughened ridge at the anterior surface of the pubis- extends from the symphyseal surface to the pubic tubercle- can be palpated at the anteroinferior aspect of the abdomen- for attachment of ligament and muscle


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15. Pubic Tubercle- the small prominence at the lateral edge of the pubic crest- can be palpated about 1" from the median plane

- for attachment of ligaments

16. Arcuate Line- separates the iliac body and ala

17. Pecten Pubis / Pectineal Line of the pubis- the border between the pectineal and pelvic surfaces of the pubis- continuous with the arcuate line of the ilium via the iliopectineal line

18. Iliopectineal Eminence / Iliopubic Eminence- a rise located at the junction of the iliac body and the superior pubic ramus- the iliopectineal line traverses its medial edge and connects the pectineal

line with the arcuate line- used to determine gender. Male: robust and wide as viewed from above. Female:gracile and narrow as viewd from above.

19. Obturator Groove / Obturator Sulcus- central at the inferior part of the superior ramus of the pubis- at the superior edge of the obturator foramen- closed to form the obturator canal by the obturator membrane, then allows

passage of neurovascular structures

20. Symphyseal Surface- the flat surface on the medial surface of the pubic body

- for articulation with the symphyseal surface of the opposite pelvic boneat the pubic symphysis, a secondary cartilaginous joint

lateral view

1. Iliac Crest - described above

2. Anterior Superior Iliac Spine - described above

3. Posterior Superior Iliac Spine - described above

4. Anterior Inferior Iliac Spine - described above

5. Posterior Inferior Iliac Spine - described above

6. Greater Sciatic Notch - described above

7. Lesser Sciatic Notch - described above

8. Ischial Spine - described above


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9. Ischial Tuberosity - described above

10. Iliac Tubercle

- a prominence at the lateral lip of the iliac crest 1" to 2" posterior to theanterior superior iliac spine

- can often be palpated at the superior lateral margin of the iliac crest- for attachment of ligaments and muscles

11. Posterior Gluteal Line- shortest marking line on the external iliac ala- directed anteroinferiorly from near the posterior superior iliac spine to the

level of the posterior inferior iliac spine- separates muscle attachments.

12. Anterior Gluteal Line

- longest and most distinct marking line on external iliac ala- directed posteroinferiorly from the iliac tubercle to the superior margin ofthe greater sciatic notch

- sometimes continues anteriorly to the anterior superior iliac spine- separates muscle attachments

13. Inferior Gluteal Line- least defined marking line on external iliac ala- directed posteriorly from intermediate to the anterior superior iliac spine

and the anterior inferior iliac spine to the greater sciatic notch- separates muscle attachments

14. Acetabulum- the large cup-like depression where the three bones meet- articulates with the femur at the hip joint, a synovial spheroid joint

superior 2/5 or 40%- formed by the body of the ilium

posterior inferior 2/5 or 40%- formed by the body of the ischium

anterior inferior 1/5 or 20%- formed by the superior pubic ramus

a.Lunate Surface- the smooth, crescent-shaped, synovial articular surface of the acetabulum

- for articulation with the femoral head

b.Acetabular Fossa- the roughened central depression within the acetabulum- formed mostly by the ischial body- for passage of ligament and neurovascular structures

c.Acetabular Notch- the depressed area between the ends of the lunate surface- formed mostly by the ischial body


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- closed to the acetabular foramen by the transverse acetabular ligament- for the passage of neurovascular structures

d.Acetabular Rim- the outer, raised edge of the acetabulum- for attachment of ligaments and muscle

15. Obturator Foramen - described above

16. Obturator Crest- the sharp border between the pectineal and obturator surfaces of the pubis- at the anterior edge of the obturator groove

G. Ossification of the Pelvic Bone

- from 3 primary centers and 4 secondary centers

1. Primary Centers- one in each component bone

a. ilium - appears near9th

fetal week- in the iliac ala

b. ischium - appears early 4th

fetal month- in the ischial body

c.pubis - appears late 4th

fetal month- in the superior pubic ramus

2. Secondary Centers- appear near puberty and fuse from ages 15 to 25 years

a. iliac crestb. acetabulumc.pubic symphysisd. ischial tuberositye. anterior-inferior iliac spine

H. Anatomic Position- in a living being, the pelvis is situated so that the anterior superior iliac spinesand the pubic tubercles lie in the same coronal / frontal plane

- pelvis appears to be tilted forward

J. Pelvis

1. Brim of the Pelvis / Pelvic Inlet- the entrance to the true pelvis- structures that divide the pelvis into superior and inferior portions are:


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pelvic osteology, pelvis, cont

a.Linea Terminalis- continuous line of the lateral and anterior walls of the pelvis, internally- formed by four separate structures that align end to end

i. Arcuate Lineii. Iliopectineal Lineiii. Pectineal Line / Pecten Pubisiv. Pubic Crest

b. imaginary line- across the sacral promontory and sacral alae (from one arcuate line to the

other arcuate line)

c. imaginary line

- across the symphysis pubis- from one pubic crest to the other pubic crest

2. Greater Pelvis / False Pelvis- the pelvic area superior to the pelvic brim- located superior and anterior to the lesser pelvis- formed primarily by the iliac alae

3. Lesser Pelvis / True Pelvis- the pelvic area inferior to the pelvic brim- located posterior and inferior to the greater pelvis- formed by the pubic bones, ischial bones, iliac bodies, sacrum and coccyx

4. Pelvic Outlet- the inferior opening (exit) of the true pelvis- border between pelvis and perineum- Males: heart shaped- Females: oval shaped- Subpubic arch.

Males: Narrow, inverted V-shape. Females: Wide, inverted U-shape

II. FEMUR- the bone of the thigh- recognized by the angled head and the trochanters

- largest bone in the body

A. Features

anterior view

1. Proximal Extremity- the superior end


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osteology, femoral features, anterior view, proximal extremity, cont

a.Head / Proximal Epiphysis- the smooth ball-like knob

- articulates with the os coxa at the lunate surface of the acetabulum

i. Fovea Capitis Femoris- the depression at the medial edge- for attachment of ligament and passage of a vessel

b.Neck- the cylindrical part connecting the head with the body (shaft)

c. Greater Trochanter / Trochanter Major- the large lateral bony projection at the junction of the neck and shaft

- can be palpated at the lateral aspect of the hip- for attachment of ligament and muscle

d.Lesser Trochanter / Trochanter Minor- small posteromedial projection at the junction of the neck and shaft- for attachment of muscle

e.Intertrochanteric Line- ridge from the greater trochanter to just inferior to the lesser trochanter- for attachment of ligament and muscle

2. Shaft / Diaphysis

- smooth, cylindrical area

3. Distal Extremity / Distal Epiphysis- inferior end of the femur- primarily smooth for articulation with the tibia at the knee joint

a.Medial Condyle- the medial part of the epiphysis- can be easily palpated at the medial aspect of the knee joint

- a synovial bicondylar joint

i. Medial Epicondyle

- the prominence on the medial aspect of the medial condyle- can be palpated at the proximomedial aspect of the knee- for attachment of the medial collateral ligament

ii. Adductor Tubercle- the small sharp prominence at the superior edge of the medial epicondyle- can determine the area but is too surrounded by muscle to palpate it- for attachment of muscle


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osteology, femoral features, cont

b.Lateral Condyle- the lateral part of the epiphysis- easily palpated at the lateral aspect of the knee joint

i. Lateral Epicondyle- the prominence at the lateral aspect of the lateral condyle- easily palpated at the proximolateral aspect of the knee- for attachment of the lateral collateral ligament

c. Patellar Surface- smooth anterior surface of the condyles for articulation with the patella- can palpate the margins with the knee flexed

posterior view of femur

1. Proximal Extremity

a.Head- described above

i. Fovea Capitis Femoris - described above

b.Neck- described above

c. Greater Trochanter- described above

i. Trochanteric Fossa- on the medial surface of the greater trochanter where it meets the neck

of the femur- the more posterior and more distinct depression- for attachment of the obturator externus muscle

ii. Unnamed Fossa- on the medial surface of the greater trochanter just anterior to the

trochanteric fossa; sometimes very ill-defined- for attachment of three muscles: superior and inferior gemellus muscles and

the obturator internus muscle.

d.Lesser Trochanter- described above

e.Intertrochanteric Crest- ridge from the greater trochanter to the lesser trochanter (posteriorly)

i. Quadrate Tubercle- small square-shaped projection about midway along the

intertrochanteric crest- for attachment of muscle


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osteology, femoral features, linea aspera, cont

2. Shaft

a.Linea Aspera- ridge consisting of three lines that passes lengthwise along the entire shaft

on its posterior surface- for attachment of muscle

i. Medial Lip- medial edge of the linea aspera- for muscular attachment

aa. Spiral Line- superior continuation of the medial lip of the linea aspera- continuous with the intertrochanteric line anteriorly

bb.Medial Supracondylar Line

- inferior continuation of the medial lip of the linea aspera- ends at the adductor tubercle

ii. Intermediate Lip- central line of the linea aspera- only well-defined superiorly- for muscular attachment

aa. Pectineal Line of the femur- superior continuation of the intermediate lip of the linea aspera- ends at the lesser trochanter

iii. Lateral Lip- lateral edge of the linea aspera- for muscular attachment

aa. Gluteal Tuberosity- superior continuation of the lateral lip; also has medial and lateral divisions- if enlarged, is called the GlutealTrochanter / Third Trochanter

bb.Lateral Supracondylar Line- inferior continuation of the lateral lip of the linea aspera- ends at the lateral epicondyle

b. Popliteal Surface- the posterior inferior surface of the shaft of the femur

c.Nutrient Foramen- hole directed superiorly, because it angles away from the more rapidly

growing end of the bone- usually near the midpoint of the femur and between the medial and lateral

lips of the linea aspera- may be two: in which case one is more proximal and one more distal- allows passage of vessels to nourish the shaft of the bone


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femoral features, posterior view, linea aspera, cont

3. Distal Extremity

a.Medial Condyle - described above

i. Medial Epicondyle - described above

ii. Adductor Tubercle - described above

b.Lateral Condyle - described above

i. Lateral Epicondyle - described above

c.Intercondylar Notch / Intercondylar Fossa- the large depression between the medial and lateral condyles- provides attachment for the cruciate ligaments

d.Intercondylar Line- superior edge of the intercondylar fossa- for attachment of the oblique popliteal ligament

B. Ossification of the femur- 5 regular centers of ossification- the secondary centers fuse in reverse order of appearance between the 16

thand

20th

years

1. Primary Center- in the shaft of femur, near midshaft- appears during the 7

thfetal week

2. Secondary Centers

a. the femoral condyles- appears nearbirth, may be one or two

b. the head of the femur- appears by 1

styear

c. the greater trochanter- appears between the 4

thand 5

thyears

d. the lesser trochanter- appears between the 12th and 14th years

C. Anatomic Position

1. Bicondylar Angle, Carrying Angle)- in living beings, the head and neck are angled in an anteromedial direction andthe distal extremity is positioned medially (with the two femoral condyles resting on ahorizontal surface, parallel to the floor)


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femoral features, posterior view, arthrology, syndesmology, cont

- indicates bipedal locomotion. Only Humans and their fossil ancestors have a femoralbicondylar angle. Earliest evidence: 4.4-million yrs b.p. (Australopithecus ramidus)

- the average bicondylar angle in modern humans is 9o to 10o in the frontal plane.

- Male average 9.4o

Range: 7.5-11o

Female average 10.5o

Range: 8-13o

- Fossil ancestors Range: 9-11o

Great Apes 0-2o

- The smaller the angle the less efficient the bipedalsim.

2. Angle of Inclination- the angle formed by the long axis of the head and neck with the long axis of

the shaft; the angle varies with age- frontal plane view- greater at birth (about 150o) and decreases until adulthood (range 125 - 129o)- the angle relates to joint mobility. A high angle conveys greater joint mobility.- smaller angle can be an indicator of avascular necrosis of femoral head

2. Angle of Femoral Torsion (Angle of Declination- the angle formed by the long axis of the head and neck with the line of thebicondylar plane (usually the coronal plane of the condyles)

- viewed on end, a transverse plane view- measures the amount of longitudinal twisting in the bone- varies with age; greater at birth (about 40o), decreases into adulthood (about 10o)- large angle = anteversion, small angle = retroversion- the greater the anteversion the more the lesser trochanter is positioned medially.

ARTHROLOGY & SYNDESMOLOGY OF THE PELVIS

I. SYNDESMOLOGY

A. Anterior View

1. Ventral Sacroiliac Ligament- anterior thickening of the sacroiliac joint capsule (joint between the auricular

surfaces of the sacrum and the ilium)

- stabilizes sacroiliac joint

2. Sacrotuberous Ligament- from the posterior superior iliac spine, posterior inferior iliac spine, the

dorsolateral aspect of the sacrum and the dorsolateral aspect of the coccyxto the ischial tuberosity

- stabilized the sacroiliac joint, prevents superior rotation of pelvic bone- closes the lesser sciatic notch and forms the lesser sciatic foramen

- for passage of a muscle and neurovascular structures

3. Sacrospinous Ligament


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pelvic region, syndesmology, cont

- from the dorsolateral margin of the inferior one-half of the sacrum and thedorsolateral margin of the coccyx to the ischial spine

- stabilized the sacroiliac joint, prevents superior rotation of pelvic bone

- closes the greater sciatic notch and forms the greater sciatic foramen- for passage of a muscle and neurovascular structures

4. Inguinal Ligament / Poupart's Ligament- from the anterior superior iliac spine to the pubic tubercle- the division between the hip and thigh regions, anteriorly

5. Lacunar Ligament / Gimbernat's Ligament- the most medial portion of the inguinal ligament where the fibers change

direction and pass inferiorly

6. Pectineal Ligament / Cooper's Ligament- the extension of the lacunar ligament along the pubic pectineal line

7. Iliolumbar Ligament- stabilizes the sacroiliac joint

a. Upper Band- from the anterior aspect of the 5

thlumbar vertebra to the posterior part of

the internal lip of the iliac crest

b.Lower Band- from the anterior aspect of the 5

thlumbar vertebra to the anterolateral

aspect of the sacrum, superiorly

B. Dorsal View

1. Dorsal Sacroiliac Ligament- stabilize sacroiliac joint

a.Long Dorsal Sacroiliac Ligament- from lateral crests of 3

rdand 4

thsacral vertebrae to the posterior superior

ocpm notes

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