Lower leg
Terms
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- Gluteal region has 3 main mucles - name them
-
Gluteus medius
Gluteus minimus
Tensor fasciae latae - All 3 gluteal muscles act as _ and _
-
Hip abductors
Medial rotators - All 3 gluteal muscles receive _ nerve and artery
- Superior gluteal
- Name pelvic muscles in order
-
Gluteus maximus
Piriformis
Superior gemellus
Obturator internus
Inferior gemellus
Quadratus femoris
Obturator externus - All pelvic muscles are _ but gluteus maximus is also very good _
-
Lateral rotators of hip
Hip extensor - All classic lateral rotators insert into _
- Greater trochanter
- Piriformis gets blood supply from both _ and _
- Inferior and superior gluteals
- Name muscles of anterior thigh
-
Sartorius
Iliopsoas
Pectineus
Rectus femoris
Vastus medialis, intermedius, lateralis - Quadriceps femoris function is to _
- Extend knee
- Which muscles of anterior compartment span two joints
- Sartorius and rectus femoris
- Anterior compartment of thigh is innervated by _
- Femoral nerve
- Name medial thigh muscles
-
Gracilis
Adductor longus
Adductor brevis
Adductor magnus - Medial thigh muscles are all _
- hip adductor
- Medial thigh muscles are innervated by _
- Obturator nerve
- Which muscle of medial thigh compartment spans two joints
- Gracilis
- In addition to being _ , gracilis is also _
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Hip adductor
Knee flexor - Name adductors from anterior to posterior
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Longus
Brevis
Magnus - Hamstring part of adductor magnus is innervated by _
- Sciatic nerve
- Name muscles of posterior thigh
-
Biceps femoris
Semitendinosus
Semimembranosus
Hamstring part of adductor magnus - Posterior thigh muscles are also called
- Hamstrings
-
Biceps femoris has dual innervation
Long head innervated by _
Short head innervated by _ -
Tibial
Fibular - Hamstring muscles except _ are innervated by _
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Short head of biceps
Tibial - Blood supply to posterior thigh is by _
- Perforating branches of profunda femoris
- All hamstrings originate from _
- Ischial tuberosity
- Hamstrings function is _ and _ (except _ )
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Extension of the hip
Flexion of the knee
Adductor magnus - extension of hip only - Name anterior leg muscles
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Tibialis anterior
Extensor hallucis longus
Extensor digitorum longus
Fibularis Tertius - All anterior leg muscles share function of _
- Dorsiflexion
-
Tibialis anterior and Extensor hallucis longus do _
Extensor digitorum longus
Fibularis Tertius do _ -
Inversion
Eversion - All muscles of anterior leg are innervated by _ , blood supply by _
-
Deep fibular
Anterior tibial - Lateral leg muscles are
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Fibularis longus
Fibularis brevis - Lateral leg muscles share function of _
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Plantarflexion
Eversion -
Lateral leg muscles are innervated by _
Blood supply is _ -
Superficial fibular
Fibular artery - Name muscles of posterior leg
-
Gastrocnemius
Soleus
Plantaris
Popliteus
Tibialis posterior
Flexor digitorum longus
Flexor Hallucis Longus - Which muscle unlocks knee
- Popliteus
- Popliteus inserts at
- Tibia shaft
- _ and _ converge in Achilles tendon which inserts in _
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Gastrocnemius
Soleus
Calcaneus - Functions of gastrocnemius, soleus, plantaris
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Plantarflexion
Knee flexion - Function of tibialis posterior and flexor hallucis longus
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Plantarflexion
Inversion - Flexor digitorum does _ only
- Plantarflexion
- All posterior leg muscles have blood supply from _
- Tibial artery
- Soleus has innervation from 3 nerves - they are _
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Posterior tibial
Fibular
Sural - Gastrocnemius is innervated by _ as well as _
-
Sural
Plantaris - Name muscles of dorsal foot
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Extensor hallucis brevis
Extensor digitorum brevis - Muscles of dorsal foot originate from _ , insert to _
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Calcaneus
Phalanges - Innervation of dorsal foot
- Deep fibular
- Blood supply to dorsal foot
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Dorsalis pedis
Arcuate - 1st layer of plantar foot
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Abductor hallucis
Abductor digiti minimi
Flexor digitorum brevis - 2nd layer of plantar foot
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Quadratus plantae
Lumbricals - 3d layer of plantar foot
-
Flexor hallucis brevis
Adductor hallucis
Flexor digiti minimi - Plantar foot , layer 4
- Dorsal and Plantar interossei
- Plantar foot muscles are supplied by _ nerve, except _ muscles which are supplied by _ nerve
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Lateral plantar
Abductor hallucis
Flexor digitorum brevis
1st lumbrical
Flexor hallucis brevis
Medial plantar - Interossei mnemonic
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DAB - dorsal - abduction
PAD - plantar - adduction - Medial and lateral plantar arteries come from _
- Posterior tibial
- Dorsalis pedis and arcuate arteries come from _
- Anterior tibial
- Which cutaneous nerve provides most innervation to dorsum of foot
- Superficial fibular
- Which artery is used to palpate pulse on foot
- Dorsalis pedis
- Muscle that provides major support to transverse arch
- Fibularis longus
- SI joint is what type of joint
- Plane, in infant articular surfaces are almost flat, in adults rough
- Ligaments of SI joint
- Ventral, dorsal, interosseous SI ligaments
- Hip joint is what kind of joint
- Ball and socket joint
- Capsule of hip joint has two layers - what are they
-
Longitudinally arranged superficial layer
Deep layer that makes circular ZONA ORBICULARIS - Strongest ligament of the body is _
- Iliofemoral ligament
- Origination and insertion of iliofemoral ligament
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Origin - AIIS, rim of acetabulum
Insertion - intertrochanteric line - Shape of iliofemoral ligament
- y shaped , medial and lateral
- Iliofemoral ligament mainly prevents _
- hip extension
-
Lateral part of iliofemoral ligament restricts _
Medial part of iliofemoral ligament restricts _ -
Lateral rotation + adduction
Medial rotation - Describe ischiofemoral ligament
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Originates from ischium below acetabulum - runs almost horizontally over the neck of the femur, attaches to root of greater trochanter and iliofemoral ligament
Some fibers run to zona orbicularis - Ischiofemoral ligament restricts
- Medial rotation
- Describe pubofemoral ligament
-
Weakest of external ligaments
Originates from obturator crest and membrane, attaches at neck of femur at lesser trochanter, some fibers radiate to zona orbicularis - Pubofemoral ligament restricts _
- Abduction
- Innervation of ligamentum teres capitis femoris
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Femoral nerve
Superior and inferior gluteal nerves - Blood supply of ligamentum teres
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-Medial and lateral femoral circumflex
-Obturator artery
-Superior and inferior gluteal arteries - Knee joint is what type of joint?
- Modified hinge joint - some rotation is possible especially when knee is flexed
- Name articular surfaces of knee joint
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Patella
Tibial condyles
Femoral condyles - Medial and lateral patellar retinacula are expansions of _
- Tendon of quadriceps
- Lateral and medial patellar retinacula attach to _
- Tibial condyles in front of collateral ligaments
- Patellar ligament goes from _ to _ . Its an extension of _ ligament
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Patella to tibial tuberosity
Quadriceps - There are two popliteal ligaments - name them and describe
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Oblique and arcuate
Oblique - expansion of semimembranosus tendon laterally radiating to the capsule
Arcuate - originates from fibular head, arches over popliteus - Describe medial collateral ligament
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Also called tibial ligament
-Flattened triangular ligament
-From medial femoral epicondyle to tibia below tibial condyle
-Attached to medial meniscus - Describe lateral collateral ligament
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Also called fibular ligament
-Cord like thin ligament
-From lateral femoral epicondyle to head of fibula
- NOT attached to meniscus or capsule
-Tendon of popliteus separates it from capsule - Synovial membrane covers inner side of knee joint except _ and _
- Cruciate ligaments and knee surface
- Infrapatella synovial fold extends from _ to _
- Infrapatellar fat to crucial ligament
- Infrapatellar fat pad is inserted between_
- Synovial and fibrous membranes of the capsule under patella
-
Communicating bursae is _
Non communicating bursae is _ -
Superpatellar
Infrapatellar and prepatellar - Anterior cruciate ligament goes from _ to _
- Medial surface of LATERAL femoral condyle to anterior intercondylar area on tibia
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ACL prevents _
PCL prevents _ -
Anterior displacement of tibia
Posterior displacement of tibia - Posterior cruciate ligament goes from _ to _
- Lateral surface of MEDIAL femoral condyle to posterior intercondylar area of tibia
- Medial meniscus is _ in shapee while lateral is _ in shape
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Semilunar
Almost circular - What connects menisci anteriorly
- Transverse genicular ligament
- Medial meniscus is fused with _
- Tibial (medial) collateral ligament
- Why is rotation of the knee possible in flexion
- Collateral ligaments relax - cruciate are contracted
- Which ligaments contract in extension
- Anterior cruciate and collateral ligaments
- which rotation of knee is bigger in range
- Lateral
-
When you have genu varum, your knee sticks out _
genu valgum _ -
Laterally
Medially - Medial side of foot has how many ligaments ? Lateral? Why?
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Medial - 4
Lateral -3, no navicular bones so no navicular ligaments - Ankle joint is what kind of joint
- Hinge
- Combined, medial ligaments are called _
- Deltoid
- Which ligaments comprise deltoid ligament
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Anterior and posterior tibiotalar
Tibionavicular
Tibiocalcaneal - Name lateral ligaments of the foot
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Anterior and posterior talfibular
Calcaneofibular - Innervation of ankle joint
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Tibial
Deep fibular - Blood supply ankle joint
- Malleolar network
- Subtalar joint is what kind of joint
- Pivot
- Subtalar joint movements
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Eversion
Inversion - Talocalcaneonavicular joint is what kind of joint_
- Ball and socket
- Ligament that prevents head of talus to sink between calcaneus and navicular bone
- Plantar calcaneonavicular ligament - spring ligament
- Tarsometatarsal and intermetatarsal joints are what kind of joints
- Plane
- Name 3 types of hip x rays
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AP hip
AP pelvis
Lateral - frog leg - Describe AP view of the hip
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Patient on the back
Hips and knees are extended
Feet inverted
Lesser trochanter - posterior - What can you evaluate with AP of the hip
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Femoral head
Acetabulum
Femoral neck
Lesser and greater trochanter
Iliopectineal line - In frog leg position (lateral x ray ) hip is _
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Externally rotated
Abducted
Flexed - In which x ray can you see angle of inclination
- AP
- Which structure can NOT be evaluated in lateral hip x ray
- Femoral neck
- What does AP of pelvis give you
- Symmetry of pelvis and proximal femurs
- What things do you see on xray with DJD
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Osteophytes
Subchondral sclerosis
Joint space narrowing - Which fracture of femur is more dangerous - at neck or proximal
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At neck because you damage medial circumflex femoral artery and acetabular branch of obturator artery might not be enough so you get avascular necrosis of the head of the femur.
If you fracture femur proximally vessels are not damaged and you have good prognosis - Describe position of the leg in femur fracture
- Shortened and externally rotated since greater trochanter is displaced and gluteus medius, minimus, piriformis all insert there
- Name types of xrays of knee
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AP
Lateral
Sunrise - Patella on xray appears as _
- Shadow overlying distal femur
- Why does joint space between tibia and femur appear large on plane x ray
- Menisci and cartilage are not visible on plane x rays
- How can you differentiate age by looking at knee x ray only
- Growth plates in children are visible, in adult they are ossified and not visible (can only see epiphyseal scars)
- Distance from lateral condyle to lateral tibial plateau should be same as _
- Distance from medial condyle to medial tibial plateau
- Lateral vs Medial tibial plateau on lateral x ray
-
Lateral is flatter
Medial more curved - Describe sunrise view of the knee
- Tangential x ray of patella - patella is perpendicular to the film
- Sunrise view of knee is used to see _
- Patellofemoral articulation
- When do fractures of tibial plateau usually occur
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As a result of decceleration injury --> MVA or falling on extended legs
Should also suspect other injuries like aorta or spleen rupture - If on x ray patella is in two pieces it means patient has _
- Avulsion fracture - rupture of ligament or tendon inserting on the bone breaks part of the bone with it
- Fractured fibula with fractured malleoli is called
- Potts fracture
- Unhappy triad injury - describe and cause
-
Cause - lateral blow to the knee
Medial meniscus
Tibial collateral ligament
ACL - If you have fracture to the neck of the fibula what nerve is damaged and what happens as result
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Common peroneal (deep peroneal) nerve is damaged
You get foot drop because your extensors are paralyzed and you cant dorsiflex - What is the best way to visualize distal tibial fracture
- CT scan
- Describe fat, tendons, muscles as seen on MRI
-
Fat - white
Tendons - black
Muscles - various shades of grey - Why is MRI darker in coronal view
- Fat is blocked and fat shows up white on the MRI
- Subinguinal hiatus is located _
- Between bony rim of pelvis and inguinal ligament
- Lacuna musculonervosa includes _
-
Iliopsoas covered by fascia
Femoral nerve
Lateral cutaneous femoral nerve - Lateral vasorum includes
- Femoral artery and vein
- Lacuna lymphatica includes
- Lymph vessels and nodes in connective tissue (femoral ring)
- Borders, floor and roof of femoral triangle
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Superior - inguinal ligament
Lateral - sartorius
Medial - adductor longus
Roof - fascia lata with saphenous hiatus
Floor - Iliopsoas, pectineus + fascia - Sapenous hiatus - what is it, what passes through
-
Opening in fascia lata, covered by cribiform fascia
- Great saphenous vein
-External pudendal artery
-Superficial epigastric artery
-Superficial circumflex iliac artery - Femoral canal is _ canal
- Virtual
- Internal and external opening of femoral canal
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External - saphenous opening
Internal - lacuna lymphatica (femoral ring) - Borders of femoral canal
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Anterior - fascia lata
Posterior - pectineal fascia
Lateral - femoral vein - Obturator artery is a branch of _ . It passes through _
-
Internal iliac
Obturator canal - Branches of obturator artery
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Anterior branch - adductors
Posterior branch - muscles of ischial tuberosity
Acetabular branch - artery of ligamentum capitis femoris of femoral head - Femoral artery is a cotinuation of _ It passes through -
-
External iliac from inguinal ligament
Runs in subinguinal hiatus --> femoral triangle --> adductor canal and gets to popliteal fossa as popliteal artery - Branches of femoral artery
-
Superficial circumflex iliac
Superficial epigastric
External pudendal
Deep femoral
Descending genicular
Popliteal - Deep femoral artery runs between _
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Adductor longus
Adductor magnus - Describe branches of deep femoral artery
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Lateral circumflex femoral --> has 3 branches -
-Ascending
-Descending
-Transverse
Medial circumflex femoral --> has 2 branches
-Transverse
-Ascending
Perforating arteries - perforate adductor magnus and go to flexor compartment of the thigh - Describe path and branches of descending genicular artery
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Runs in adductor canal with femoral artery --> perforates vasoadductor membrane --> leaves adductor
canal and descends on the medial side of the knee passing between sartorius and gracilis
-Muscular branches - to vastus medialis
-Articular branches - to knee joint - Great saphenous vein runs _ and enters _
-
Medial side of the leg
Femoral vein through saphenous hiatus - Lymph from lower leg drains to _
- Superficial inguinal nodes
- Cutaneous innervation of superior lateral part of thigh
- Iliohypogastric nerve
- Cutaneous innervation of proximal anteromedial thigh
- Ilioinguinal
- Describe innervation and branches of genitofemoral nerve
-
Genital branch - runs in inguinal canal and innervates upper most part of medial thigh just under inguinal ligament
Femoral branch - passes through subinguinal hiatus in the middle of inguinal ligament and innervates small area distal to inguinal ligament - Describe lateral femoral cutaneous nerve
-
Passes through subinguinal hiatus at ASIS
Perforates fascia lata under it
Innervates lateral thigh - Describe course of femoral nerve
-
Largest branch of lumbar plexus
Passes through subinguinal hiatus covered by psoas fascia, LATERAL to femoral vessels
Runs in femoral triangle where it divides into branches
Terminal branch is saphenous nerve which goes through adductor canal - Branches of femoral nerve
-
Articular - knee + hip joints
Muscular --> anterior thigh muscles
Anterior cutaneous branches
Saphenous nerve - Name terminal branch of femoral nerve and describe its path and innervation
-
Saphenous nerve --> terminal branch, purely sensory, runs in the adductor canal - pierces vaso- adductor membrane, leaves canal and passes between sartorius and gracilis
Cutaneous innervation of anterior medial leg, knee, and medial malleolar region - Describe course of obturator nerve
- From lumbar plexus --> goes through obturator canal --> ramifies among adductor muscles
- Describe branches of obturator nerve
-
Muscular branch --> to obturator externus
Anterior --> between adductor longus and brevis, innervates them and gracilis, gives cutaneous innervation to medial proximal thigh just under the area of genitofemoral nerve innervation
Posterior --> to adductor magnus - Which nerve innervated peroneus longus and peroneus brevis
- Superficial peroneal
- Vastoadductor membrane is attached to _
- Adductor magnus
- Name branches of internal iliac artery in glueal region
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Superior gluteal
Inferior gluteal
Internal pudendal - Muscles that insert to pes anserinus
-
Sartorius
Gracilis
Semitendinosus - Nerve to quadratus femoris and inferior gemellus levels
- L4-S1
- Nerve to obturator internus and superior gemellus levels
- L5-S2
- Nerve to piriformis levels
- S1, S2
- Superior gluteal nerves levels
- L4-S1
- Inferior gluteal nerve levels
- L5-S2
- Posterior femoral cutaneous nerve levels
- S1-S3
- Pudendal nerve levels
- S2-S4
- Sciatic nerve levels
- L5-S3
- Describe course and innervation of posterior femoral cutaneous nerve
-
Goes below piriformis
To posterior thigh
Gives off inferior cluneal
Cutaneous innervation of posterior thigh - Branches of sciatic nerve
-
Muscular branches
2 terminal branches - tibial + common fibular - Blood supply of sciatic nerve
-
Internal pudendal
Inferior gluteal
Perforating arteries of deep femoral
Popliteal - Path of pudendal nerve
- Out of superior gluteal foramen --> turns around sacrospinous ligament --> turns back in lesser sciatic foramen
- Boundaries of popliteal fossa
-
Lateral superior - biceps femoris
Medial superior - semitendinosus + semimembranosus
Inferior - medial and lateral heads of gastrocnemius - Describe path of anterior tibial artery
-
Perforates interosseous membrane at inferior border of popliteus
On the leg it runs with deep fibular nerve between tibialis anterior and extensor hallucis longus
At distal part of leg it crosses tendon of extensor hallucis longus and runs between it and tendon of extensor digitorum longus
At ankle it becomes dorsalis pedis - Branches of anterior tibial artery
-
Posterior and anterior recurrent tibial arteries --> to genicular rete
Medial and lateral malleolar arteries
Dorsalis pedis - terminal branch - Describe path and branches of dorsalis pedis
-
Dorsalis pedis runs on lateral side of extensor hallucis longus, under extensor digitorum brevis, together with deep fibular nerve
Branches : Lateral and medial tarsal
Arcuate - at tarsometatarsal joints, anastomoses with lateral tarsal
Arcuate arteries give following branches - dorsal metatarsal, dorsal digital, perforating branches - Course of common fibular nerve
-
Runs along biceps femoris at the lateral margin of popliteal fossa
Winds around neck of fibula
Pierces fibularis longus and divides there into superficial and deep branches - Describe branches of common fibular nerve
-
Later cutaneous sural -> with medial cutaneous sural forms sural that runs with lesser saphenous vein on gastrocnemius, turns around back of medial malleolus and gives cutaneous innervation to lateral side of foot (lateral pinkie) and lateral calcaneal cutaneous branches to heel
Superficial fibular nerve --> predominantly sensory, passes between fibularis longus and fibula and gets to DORSUM of foot --> gives off
-muscular branches
-medial dorsal cutaneous nerve
-intermediate dorsal cutaneous nerve
Deep fibular nerve --> motor to extensor compartment
Gives off muscular and cutaneous branches (to 1st and 2nd toe) - Cutaneous innervation of medial malleolus
- Saphenous
- Plantar aponeurosis consists of
- Superficial longitudinal fibers + deep transverse fibers
- Posterior tibial artery supplies _ and divides into_
-
Plantar foot
Medial and lateral plantar arteries - Describe lateral plantal artery
-
Between quadratus plantae and flexor digitorum brevis, forms plantar arch which anastomoses with deep branch of dorsalis pedis
Gives plantar metatarsal branches - Medial plantar artery
- Superficial and deep branches