1. Common hepatic artery

--> Gastroduodenal artery

--> Right gastro-omental artery (anastomoses w/ L)

--> Right gastric artery (anastomoses w/ L)

--> Hepatic proper artery

--> L & R branches of hepatic artery

2. Left Gastric artery (anastomoses w/ R)

--> Branches to the esophagus 

3. Splenic artery

--> Short gastric arteries

--> Left gastro-omental artery (anastomoses w/ R)

Run parallel to arteries

Left and Right gastric veins --> portal vein

Short gastric veins and left gastro-omental vein --> splenic vein

IMV --> splenic or right at junction of splenic and SMV

Right gastro-omental vein --> SMV

Prepyloric vein --> Right gastric vein

Portal vein= union of the plenic and SMV

Initial drainage to gastric and gastro-omental nodes

Ultimately drain to the celiac nodes (which surround the origin of the celiac trunk)

Additional nodes:

Pancreaticosplenic nodes

Pyrloric nodes

Pancreaticoduodenal nodes

Parasympathetic innervation by vagal trunk

Sympathetic innervation by greater thoracic splanchnic nerve (T6-T9)

Pain fibers (visceral afferents) accompany sympathetic nerves

Common bile duct, major hepatic duct, and minor hepatic duct all enter 2nd part of duodenum

Since it is retroperitoneal, it has no mesentery, so volvulus (twisting of structure upon itself) cannot occur (retroperitoneal structures are fixed).

Relationship of duodenum to the

pancreas

hepatoduodenal ligament

SMV and SMA

Head and uncinate process of pancreas at the posterior body wall of duodenum

Hepatoduodenal ligament contains the bile duct (which supplies the 2nd segment of the duodenum

SMV is to the right of the SMA as it passes in front of the uncinate process and 3rd part of the duodenum

Common bile duct and main pancreatic duct empty into the major duodenal papilla 

Accessory pancreatic duct empties into the minor duodenal papilla

Celiac artery (foregut)

Superior mesenteric artery (midgut)

Gastroduodenal (supplies blood to pylorus and proximal part of duodenum)

Ant/post superior pancreaticoduodenal arteries (branches from the gastroduodenal)

Ant/post inferior pancreaticoduodenal arteries (branches from the SMA)

Anterior vessels drain to pancreaticoduodenal nodes or pyloric nodes (near junction of stomach and duodenum)

Posterior vessels drain to superior mesenteric nodes (near origin of SMA)

Ultimately, all nodes drain to the celiac group of nodes (like stomach)

Right and Left hepatic ducts leave the liver

join to become the common hepatic duct

common hepatic duct joins the cystic duct from the gall bladder to form the common bile duct

which enters the posterior 2nd segment of the duodenum.

Submucosa of inferior esophagus

submucosa of anal canal

periumbilical region

posterior aspects (bare areas) of secondary retroperitoneal viscera

Common bile duct and Major pancreatic duct (Wirsung) empties to major duodenal papilla

10% of population, there is a minor pancreatic duct of Santorini which opens up into the minor duodenal papilla

Bile duct

Hepatic artery proper

Portal vein

Preganglionic fibers of greater and lesser spanchnic nerves (T5-T9) to celiac and superior mesenteric ganglia

Postganglionic fibers travel along intestinal arteries to the small bowel

Retrocecal position at McBurney's Point (1/3 of the distance from the ASIS to the umbilicus)

(~30% in pelvic region)

part of the duodenum and pancreas

all of jejunum, ileum, appendix, cecum, ascending colon, and 3/4 transverse colon

(from embryonic midgut)

Jejunal and ileal branches on left side

Ileocolic branch (terminal branch...gives rise to appendicular branch), right colic, and middle colic, and ant and post inferior pancreaticoduodenal

Distal 1/4 of transverse colon

descending colon

2-3 branches to sigmoid colon

terminates as the superior rectal artery

Ascending and descending Left colic branches

sigmoidal branches (2-3)

superior rectal branch

Epiploic nodes (along omental appendices)

Paracolic nodes (along margin of colon)

Intermediate colic nodes (along major branches of the SMA and IMA)

Superior and inferior mesenteric nodes (at bases of SMA and IMA)

....drain to intestinal lymphatic trunks which drain to the CISTERNA CHYLI (=beginning of where the thoracic duct originates)

Preganglionic fibers of vagus innervate up to 3/4 of transverse colon (synapse in wall of colon)

Remaining colon innervated by pelvic spanchnic nerves via inferior hypogastric nerve plexus (S2,S3,S4)

Thoracic and lumbar spanchnic nerves (T10-L2) synapse at superior and inferior mesenteric ganglia

Postganglionic fibers travel along colic arteries to the colon

Psoas fascia (attached medially to lumbar vertebrae and pelvic brim - thickens superiorly to form the medial arcuate ligament (tendinous fascia that arches over the psoas muscle))

Quadratus lumborum fascia (anterior layer of the throacolumbar fascia - thickens superiorly to form lateral arcuate ligament)

Thoracolumbar fascia (middle posterior layers enclose erector spinae)

Psoas major

Quadratus lumborum

Iliacus

Attachments, innervations, and actions of 

psoas major muscle

iliacus

quadratus lumborum

Psoas major:

Attachments: transverse processes and bodies of T12-L5 to lesser trochanter of femur

Innervation: Anterior rami of L1,L2,L3

Action: Flexes thigh (w/ iliacus), flexes vertebral column laterally, balances trunk, flexes trunk when sitting (w/ iliacus)

Iliacus: 

Attachments: Superior 2/3 of iliac fossa, ala of sacrum, anterior sacroiliac ligaments to lesser trochanter of femur and shaft inferior to it and to psoas major tendon

Innervation: Femoral nerve (L2-L4)

Action: Flexes thing and stabilizes hip joint

Quadratus lumborum:

Attachments: medial half of inferior 12th rib and tips of lumbar transverse processes to iliolumbar ligament and internal lip of iliac crest

Innervation: Anterior branches of T12 and L1-L4 nerves

Action: Extends and laterally flexes vertebral column and flexes 12th rib during inspiration

Subcostal (T12)

Lumbar plexus (L1-L4):

Ilioinguinal (L1)

Iliohypogastric (L1)

Genitofemoral (L1,L2)

Lateral femoral cutaneous (L2,L3)

Femoral (L2,L3,L4)

Obtruator (L2,L3,L4)

Lumbosacral trunk (L4,L5)

**Genitofemoral nerve only one to pierce the psoas major muscle (comes out of psoas anteriorly)

**Genitofemoral nerve associated w/ cremasteric reflex (brush thigh to stimulate genitofemoral nerve which causes testicle on that side to rise)

Typical location of an abdominal aneurysm

GI tract still receives blood flow from...

Typical location is below the renals and above the bifurcation

Though IMA blocked, GI tract still receives blood flow b/c of collateral flow b/w the IMA and SMA

Stomach:

Esophageal (IVC) and Left gastric (portal)

Umbilical:

Epigastric (IVC) and Paraumbilical (portal)

Anus:

Middle and inferior rectal (IVC) and Superior rectal (portal)

Colon:

Retroperitoneal (IVC) and Colic veins (portal)

Lymphatics from lower half of body drain to...

T10

(travels w/ esophagus)

Arterial supply to the diaphragm

Venous drainage of the diaphragm

Arteries that supply blood to the diaphragm:

Pericardiocophrenic

Musculophrenic

Superior phrenic

Inferior phrenic

Venous drainage of the diaphragm:

Pericardiocophrenic

Musculophrenic

Inferior phrenic

Motor innervation: phrenic (C3,C4,C5)

Sensory innervation: laterally by intercostals, centrally by phrenic

Recess b/w the kidney and liver

Recess above the liver

Hepatorenal recess

Subphrenic recess

The 3 ureteric constrictions (potential sites of obstruction by kidney stones)

Dermatomes of referred pain associated w/ kidney stones

1. Junction w/ renal pelvis

2. Brim of pelvic inlet

3. Bladder wall

T11-L2 ("loin to groin")

Superior suprarenal arteries receive blood from the inferior phrenic artery

Middle suprarenal arteries receive blood from the abdominal aorta

Inferior suprarenal arteries receive blood from the renal artery

Internal iliac artery (principle artery of the pelvis)

Median sacral artery

Superior rectal artery (branch of IMA)

Ovarian arteries (females)

Posterior division supplies the pelvic wall and muscles

Anterior division supplies pelvic viscera

Iliolumbar artery (runs superolaterally)

- Iliac branch (supplies iliacus muscle and ilium)

- Lumbar branch (supplies psoas major and quadratus lumborum muscles)

Lateral sacral arteries (runs inferomedially)

- Spinal branches to spinal meninges and branches to piriformis muscle

Superior gluteal artery

- Runs posteriorly b/w lumbosacral trunk (L4/L5) and S1 spinal nerves

- Exits pelvis via greater sciatic foreman superior to piriformis muscle

- Supplies gluteal muscles

Umbilical artery

Superior vesical artery (supplies superior aspect of urinary bladder)

Obturator artery (supplies medial thigh)

Middle rectal artery

Inferior gluteal artery (supplies gluteal region)

Internal pudendal artery (supplies perineum)

Inferior vesical artery (males) (supplies inferior aspect of urinary bladder, prostate gland, and seminal glands)

Vaginal artery

Uterine artery

Most pelvic blood drains back to internal iliac veins --> common iliac veins --> IVC

Some exceptions...

Some blood of lateral sacral veins drains to internal iliac veins, some drains to the internal vertebral venous plexus

Superior rectal veins drain to portal system

Ovarian veins drain to IVC or renal veins

External iliac nodes (pelvic viscera and inguinal nodes)

Internal iliac nodes (inferior pelvic viscera, deep perineum, and gluteal region)

Sacral nodes (posteroinferior pelvic viscera)

..all drain to

Common iliac (drains to caval nodes)

Somatic and autonomic pelvic nerves

Somatic: Sacral plexus

Sciatic nerve (L4-S3)

Pudendal nerve (S2-S4)

Superior gluteal nerve (L4-S1)

Inferior gluteal nerve (L5-S2)

Autonomic:

Sacral sympathetic trunks

Periarterial plexuses

Hypogastric plexuses

Pelvic splanchnic nerves

Superior hypogastric plexuses continuous w/...

Contains what kind of nerve fibers?

supplies...

Superior hypogastric plexuses continuous with intermesenteric and inferior mesenteric plexuses inferior to bifurcation of aorta

Contains postsynaptic sympathetic and visceral afferent nerve fibers

Supplies ureteric and testicular plexuses

Inferior hypogastric plexuses formed by...

Contains what kind of nerve fibers?

Innervates...

Inferior hypogastric plexuses formed by hypogastric nerves and pelvic splanchnic nerves

Contains presynaptic parasympathetic, postsynaptic sympathetic, and visceral afferent nerve fibers

Subplexuses to innervate pelvic viscera

Urinary bladder

pelvic genital organs

rectum

blood vessels, nerves, lymphatics

2 hip bones (each made up of and ilium, ischium, pubis), sacrum (5 sacral vertebrae), coccyx (4 coccygeal vertebrae)

Pudendal nerve made up of which spinal nerves?

What does it innervate and how does it get there?

S2,S3,S4

Exits greater sciatic foreman, crosses sacrospinous ligament and goes through pelvis to get to the perineum.

Pubic symphysis

pubic crest

pectin pubis

arcuate line of the ilium

ala of the sacrum

sacral promontory

Greater sciatic foramen allows structures to pass b/w the pelvic cavity and gluteal region

Lesser sciatic foramen allows structures to pass b/w the gluteal region and perineum

Obturator foramen allows structures to pass b/w the pelvic cavity and thigh

Lateral wall of the pelvis

Posterior wall of the pelvis

Obturator internus muscle

(covers obturator foramen area

forms a small tendon that makes its way out through the lesser sciatic foramen and connects to the femur to laterally rotate the hip)

Piriformis muscle

(attaches to anterior sacrum and makes way out through greater sciatic foramen to connect to the femur - also rotates the hip)

Borders of the inferior aperture of the pelvic cavity (pelvic outlet)

Anterior: pubic symphysis

Anterolateral: inferior pubic rami and ischial tuberosities

Posterolateral: sacrotuberous ligaments

Posterior: tip of the coccyx

Female pelvis:

shallower

wider

everted ischial spine

sacrum less curved

larger pelvic inlet and outlet

The narrowest fixed distance the baby's head must pass through - distance b/w sacral promontory and pubic symphysis (measured by imaging - bladder in the way)

**oblique conjugate diameter increases during delivery b/c sacroiliac joint opens up a little

Boundary b/w the pelvis and perineum

what is it comprised of?

Pelvic diaphragm - forms the floor of the pelvic cavity and roof of the perineum

comprised of striated muscles:

coccygeus:

originates from ischial spine and attaches to sacrum

steadies the bony pelvis and forms muscular closure of pelvic outlet

**not a part of the levator ani group!

levator ani:

attaches posterioly to the coccyx and sacrum, anteriorly to pubic bones, and laterally to the ischial spines and ATLA

arcus tendinous levator ani (aka fascial white line): a thickened portion of the obturator internus fascia

**obturator internus not a part of the diaphragm!

Muscles of the levator ani

Functions of the levator ani

Puborectalis muscle

Pubococcygeal muscle

Iliococcygeus muscle

supports abdominopelvic viscera

helps maintain urinary and fecal continence (puborectalis contracts to prevent defecation and relaxes to facilitate it)

**coughing, sneezing, and lifting actively contracts puborectalis

urinary and fecal incontinence

chronic pelvic pain syndromes

sexual dysfunction

visceral prolapse

Anterior: base of the urogenital diaphragm

Posterior: sacrotuberous ligaments and gluteus maximus posterior

Medial: levator ani

Lateral: ischium and inferior part of the obturator internus

**spaces filled w/ fat and loose connective tissue - allows for an canal expansion and support

Internal pudendal artery

internal pudendal vein

pudendal nerve

nerve to the obturator internus

**Pudendal canal runs through the ischioanal (ischiorectal) fosse

Bulb of penis - hollow area that forms the corpus spongiosum (urethra passes through here)

Left and right crus - attached to hip bones and forms the corpus cavernosum

Corpus spongiosum and the 2 corpus cavernosa join to form the root of the penis

Anal triangle: anus and anal canal

Urogenital triangle: female - external genitalia

male - root of scrotum and penis

**remember, these triangles lie on different planes

Superficial layers:

Fatty later = Camper's fascia (continuous w/ abdomen)

Membranous layer = Colles' fascia (continuous w/ Scarpa's - covers UG triangle (but not anal))

Deep layer:

invests the ischiocavernosus, bulbospongiosus, and superficial transverse perineal muscles

Pubic arch

fascia lata (deep fascia) of the thigh

posterior margin of perineal membrane (posterior margin of UG triangle)

Space b/w the membranous layer of the superficial perineal (Colles') fascia and the perineal membrane

roof = perineal membrane

Crura of the clitoris and covering muscle (ischiocavernosous muscle)

bulbs of vestibule and covering muscle (bulbospongiosus muscle)

superficial transverse perineal muscles

greater vestibular glands

branches of internal pudendal vessels

branches of pudendal nerves

Deep layer of perineal fascia invests...

attaches...

Deep layer of perineal fascia invests ischiocavernosus, bulbospongiosus, and superficial transverse perineal muscles

Attaches laterally to the ischiopubic ramus

continuous w/ deep fascia covering the external oblique and rectus sheath

Fuses w/ the suspensory ligament of the penis or clitoris

inferior rectal nerve

perineal nerve

dorsal nerve of the penis or clitoris

bulb and crura of penis and covering muscles (bulbospongiosus muscle and ischiocavernosus muscle)

proximal portion of spongy urethra

superficial transverse perineal nerves

branches of internal pudendal vessels

branches of pudendal nerves

Superior border= the inferior fascia of the pelvic diaphram

Inferior border= perineal membrane (inferior fascia of UG diaphragm)

portion of the urethra

portion of the vagina

sphinctor urethrae muscle

deep transverse perineal muscle

branches of pudendal nerve, internal pudendal artery and vein

anterior recesses of fat fill ichioanal fossae

membranous portion of the urethra

sphincter urethrae muscle

bulbourethral glands

deep transverse perineal muscle

branches of pudendal nerve, internal pudendal artery, and vein

anterior recesses of the fat filled ischioanal fossae

the 2 layers of membranous pelvic fascia

Thickened areas meet to create...

Parietal pelvic fascia = deep fascia of the muscles - line muscles of the pelvic wall and floor

Visceral pelvic fascia = adventitial layer of pelvic viscera - layer of connective tissue

Thickened areas of fascia layers meet to create the Tendinous Arch of pelvic fascia

Anterior aspect of tendinous arch in males: puboprostatic ligament

anterior aspect in females: pubovesical ligament

posterior aspect: sacrogenital ligament

Region of very loose areolar tissue with some vessels and nerves that comprises the potential space b/w the pelvic viscera and pelvic wall

-Retropubic space (posterior to pubic bone)

-Retrorectal space (posterior to rectum and anterior to sacrum)

Condensation of endopelvic areolar tissue creates ligaments that span from the lateral walls of the pelvis to the pelvic viscera. Conveys all the neurovascular structures of the pelvic viscera and provides support. Also covers the hypogastric plexus so also referred to as the Hypogastric Sheath.

Goes anterior and medial to external iliac/pelvic brim

posterolateral to ductus deferens in males

inferior to uterine artery in females

posterosuperior angle of the bladder

Renal artery

gonadal artery

aorta

common iliac

internal iliac

superior vesical artery

uterine artery (F)

middle rectal artery

vaginal artery (F)

inferior vesical artery (M)

Urinary bladder rests on...(anteriorly and posteriorly)

Retropubic space of Retzius

Neck of the urinary bladder firmly held by...

Urinary bladder rests on the pubic bone and pubic symphysis anteriorly and on the vagina or prostate posteriorly.

Retropubic space of Retzius= potential space b/w the pubic bone and bladder

Neck of the urinary bladder firmly held by lateral ligaments of the bladder and tendinous arch of the pelvic fascia.

Ureteric orifices (openings of ureter into bladder)

internal urethral orifice (opening of bladder into urethra)

trigone of the bladder (points made up of 2 ureteric orifices and internal urethral orifice)

uvula of the bladder (raised portion of inferior aspect of trigone)

detrusor muscle (muscles of the bladder)

involuntary internal urethral sphinctor (only in males! prevents reflux of semen into the bladder during ejaculation)

Superior vesical arteries (branch of the anterior division of the internal iliac)

Inferior vesical arteries (in males)

Vaginal arteries (in females)

(both from anterior division of internal iliac)

*Sometimes receives branches from obturator arteries and inferior gluteal arteries

In males, vesical venous plexus and prostatic venous plexus 

In females, vesical venous plexus

Plexuses drain to the internal iliac vein

Parasympathetic fibers innervate the detrusor muscles (contraction-->urination)

Parasympathetic and sympathetic fibers innervate the internal urethral sphinctor muscle (parasympathetic inhibits the internal urethral sphinctor, sympathetic causes contraction of internal urethral sphinctor)

Visceral afferent fibers:

Reflex afferent and pain sensation fibers from inferior part of bladder follow parasympathetic fibers retrogradely to S2,S3,S4

Pain sensation fibers from the superior part of the bladder follow sympathetic fibers retrogradely

18-22 cm long from internal urethral orifice to external urethral orifice

4 parts:

Intramural (preprostatic) part

Prostatic (widest and most distensible)

Intermediate (membranous and passes through perineum - shortest and least distensible)

Spongy (15-16 cm)

4 cm in length

on anterior of vaginal wall - opens into the vestibule of the vagina

Sigmoid colon w/ anal canal

**Rectosigmoid junction at level of S3

Sacral flexure

anorectal flexure - important mechanism for fecal continence

Superior and inferior lateral flexures (on left) and middle lateral flexure (on right)

= transverse rectal folds (thickened circular muscle)

Ampulla - dilated distal portion of the rectum

*superior to and supported by the pelvic diaphragm

Posterior: S3-S5 vertebrae, coccyx, median sacral vessels, sacral sympathetic trunk

Laterally: pararectal fossae

Superior: peritoneum

Anterior -

Males: Rectovesical pouch, fundus of bladder, ureters, ductus deferens, seminal glands, prostate

Females: Rectouterine pouch, vagina, cervix of uterus

Superior rectal artery (continued terminal branch of the IMA)

Middle rectal arteries (branch of the anterior division of the internal iliac artery)

Inferior rectal arteries (branch of the internal pudendal arteries (which is a branch of the anterior division of the internal iliac artery))

All anastomose

Superior rectal vein (follows portal system)

Middle and inferior rectal veins (follow caval system)

Portocaval anastomoses at rectal venous plexus (internal submucosal surrounds rectum, external subcutaneous surrounds anal canal) - allows for collateral circulation in case of obstruction of portal vein

Sympathetic innervation by inferior hypogastric/pelvic plexuses and peri-arterial plexus via superior rectal artery

Parasympathetic innervation by inferior hypogastric/rectal plexuses

Visceral afferent fibers follow parasympathetic fibers retrogradely to S2-S4 spinal ganglia

Internal anal sphinctor:

Thickening of circular muscle layer that is involuntary - sympathetic innervation --> contraction

parasympathetic innervation --> relaxation

External anal sphinctor:

Voluntary muscle - attached to:

Anterior: perineal body

Posterior: coccyx via anococcygeal ligament

Superior: puborectalis

-innervated by the inferior rectal nerve (branch of pudendal nerve)

the superior (visceral) from the inferior (somatic) anal canal.

Superior anal canal derived from the embryonic hindgut

Inferior anal canal derived from the embryonic proctodeum

Superior part:

superior rectal artery

superior rectal vein

internal iliac lymph nodes

visceral innervation by inferior hypogastric plexus (only sensitive to stretching)

Inferior part:

inferior rectal artery

inferior rectal vein

superficial inguinal lymph nodes

somatic innervation by inferior rectal nerves (sensitive to pain, touch, and temperature)

testis

prostate

bulbourethral glands

seminal glands

epididymis

vas (ductus) deferens

ejaculatory duct

urethra

penis

Ductus deferens

**thick muscular wall and a minute lumen

primary component of the spermatic cord

crosses over external iliac vessels and enters pelvis

passes along the lateral wall, external to parietal peritoneum

join the duct of the seminal gland to form ejaculatory duct

the umbilical artery

**umbilical artery is the first branch of the anterior division of the internal iliac artery. Gives off a branch to the ductus deferens and superior vesical arteries before becoming the obliterated umbilical artery w/in the medial umbilical fold.

Anterior: muscular, retropubic space

Posterior: ampulla of the rectum

2 inferolateral surfaces: levator ani

enlarged prostate impedes urination by distorting the prostatic urethra

Digital rectal examination w/ full bladder

Arterial supply mostly by inferior vesical arteries, also some branches from middle rectal arteries and internal pudendal arteries (all from anterior division of internal iliac artery)

Venous drainage via prostatic venous plexus - continues w/ vesical venous plexus --> communicates w/ internal venous plexus --> drains to internal iliac veins

Sympathetic fibers --> contraction of internal urethral sphincter,

rapid peristalic-like contraction of the ductus deferens (--> forces sperm superiorly),

contraction and secretion of seminal glands and prostate

Parasympathetic fibers --> cavernosus nerve to erectile bodies/penile erection

uterine tubes

ovarian ligament

round ligament of the uterus

Mesosalpinx - covers uterine tube

Mesovarium - suspends the ovaries

Mesometrium - majority of the broad ligament

Ovaries suspended in peritoneal cavity by...

Ovaries covered by...

Suspensory ligament of the ovary covered by...and contains...

Ovaries suspended in peritoneal cavity by the mesovarium (portion of the broad ligament)

Ovaries covered by thin layer of epithelium (not peritoneum!)

Suspensory ligament of the ovary covered by peritoneum and contains the ovarian arteries, veins, some nerves and lymphatics.

Uterine part: opens into uterine ostium

Isthmus: thick wall, narrow tube

Ampulla: major part of the uterine tube - site of fertilization and ectopic tubal pregnancy

Infundibulum: opening of tube into abdominal ostium and site of fibriae (finger-like processes that captures the oocytes)

Ovaries supplied by ovarian artery (arises from abdominal aorta inferior to the renal arteries) which also gives branches to the ovarian tube

Uterus supplied by uterine artery (from the anterior division of the internal iliac artery) which also sends branches to the uterine tube and ovaries - anastomoses w/ ovarian artery

**Right ovarian vein drains to IVC, left ovarian vein drains to the left renal vein

1. Body of the uterus= superior 2/3 of uterus - most superior part of the body of the uterus is the fundus

2. Isthmus= constricted segment b/w the body and the cervix - contains in the internal os= opening of the uterine body cavity into the cavity of the cervix

3. Cervix of the uterus= cylindrical inferior 1/3 of uterus 

- 2 parts of the cervix:

1. Supravaginal part

2. Vaginal part= part of the cervix that protrudes 

    into the vagina

    - Contains the external os= opening of uterus 

       into the vagina

    - Vaginal fornix= recesses b/w protruding

               cervix and vaginal wall

Body superior to the bladder

Cervix b/w the bladder and rectum

Angle of anteflexion= angle b/w axis of the uterine body and axis of the cervix

Angle of anteversion= angle b/w the axis of the cervix and axis of the vagina

Active support:

pelvic diaphragm (levator ani and coccygeus)

Passive support:

its position (anteflexed and anteverted)

uterine ligaments (condensation of endopelvic fascia: transverse cervical (cardinal) ligaments= cervix to lateral wall

uterosacral ligaments= cervix to sacrum (palpable during rectal exam))

Anteriorly: vesicouterine pouch

superior surface of urinary bladder (fibrous connective tissue separates posterior superior aspect of bladder from inferior anterior aspect of uterous)

Posteriorly: rectaluterine pounch

Laterally: broad ligament

ureters run inferiorly to uterine arteries

Anterior: fundus of the bladder and urethra

Posterior: anal canal, rectum, rectouterine pouch

Lateral: levator ani, visceral pelvic fascia, ureters

Vaginal artery (branches from the internal iliac. ascending and descending branches of the vaginal artery)

Internal pudendal artery supplies the posterior aspect of the vagina

**parallel venous drainage

Lymphatic drainage of the ovaries and uterine tubes follow the ovarian vessels to the lumbar nodes.

Uterus:

Lymphatic drainage of the fundus can follow ovarian vessels to the lumbar nodes or the round ligament to the superficial inguinal nodes.

Drainage of the body follows the broad ligament to the external iliac nodes.

Drainage of the cervical region can follow uterine vessels to the internal iliac nodes or the uterosacral ligament to hte sacral nodes (and eventually to internal iliac nodes).

Superior vaginal lymph drains to the internal and external iliac nodes

Middle vaginal lymph drains to the internal iliac nodes

Inferior vaginal lymph drains to the sacral nodes and the common iliac nodes

Lymph of the external orifice drains to the superficial inguinal nodes

Sympathetic:

Nerve fibers from T12-L2/L3

3-4 Lumbar splanchnic nerves

Preganglionic sympathetic fibers synapse at intermesenteric ganglia and form the intermesenteric plexus which continues to the bifurcation of the abdominal aorta - inferior to this bifurcation it becomes the superior hypogastric plexus. These fibers unite to creat the Right and Left Hypogastric nerves which follow the lateral wall into the pelvis and form the inferior hypogastric plexus.

Parasympathetic:

S2-S4

Follow pelvic splanchnic nerves and join the nerve fibers of the hypogastric nerves to form the inferior hypogastric plexus.

Uterovaginal plexus(ANS)= subplexus of the inferior hypogastric plexus - travels w/ the uterine artery and innverates the uterus, ovaries, uterine tubes, and superior 3/4 of the vagina.

Deep perineal nerve (branch of the pudendal nerve (SMS)= somatic innveration of the inferior 1/4 of the vagina.

Pelvic pain line signifies the separation of the intraperitoneal and subperitoneal structures. (Intraperitoneal structures= fundus and body of the uterus, ovaries, and uterine tubes - follow sympathetic fibers retrograde to T12-L2

Subperitoneal structures= uterine cervix and vagina - follow parasympathetic fibers retrograde to S2-S4 through pelvic splanchnic nerves)

Clinical significance during child birth:

Pudendal nerve block anesthetizes the distal 1/4 of the vagina.

Caudal epidural block blocks parasympathetic nerve fibers from S2-S4 which anesthetizes the proximal 3/4 of the vagina and the uterine cervix.

Movements of the hip

knee

ankle

Hip: flexion (forward), extension (backward), abduction (laterally away from body), adduction (towards body), lateral and medial rotation (greater trochanter moves away or towards the ASIS)

Knee: flexion (bend knee 90 degrees, toes facing the floor) and extension (return foot to ground)

Ankle: Dorsiflexion (inversion - toes up) and plantarflexion (eversion - toes down)

Hip joint: b/w hip bone and head of the femur

Knee joint: b/w distal part of femur, tibia, and patella

Ankle joint: b/w tibia and fibula and talus of the foot

Vertebral column transmits weight through the sacroiliac joint to the hip bones.

Hip bones transmit weight through the hip joint to the femur.

Femur travels inferomedially (obliquely) and weight is distributed to center of gravity, just anterior to axis of the ankle joint.

Erector spinae muscles (long muscles of the back)

Iliopsoas muscle

Plantar flexor muscles (muscles of posterior leg)

Angle of inclination is the angle b/w the neck and shaft of the femur.

Normal angle of inclination is 126°

A small angle of inclination= Coxa Vara

A larger angle of inclination= Coxa Valga

Angle b/w the axis of the neck of the femur and the axis of the 2 condyles.

Larger angle --> toeing in

Smaller angle --> toeing out

Transcervical fracture of the femoral neck (most common)

Intertrochanteric fracture (fracture at intertrochanteric line or crest)

Spiral fracture (fracture of the shaft)

7 Tarsal bones

5 Metatarsal bones

14 Phalanges

Forefoot (14 phalanges)

Midfoot (5 tarsal bones + the 5 metatarsal bones)

Hindfoot (calcaneus + talus)

Tarsus:

- Calcaneous

- Talus

- Cuboid

- Lateral cuneiform

- Intermediate cuneiform

- Medial cuneiform

- Navicular

Medatarsus:

- 5 Metatarsal bones

Forefoot:

- 5 Proximal phalanges (including 1 proximal phalanx of the great toe)

- 4 Middle phlanges

- 4 Distal phalanges (including 1 distal phalanx of the great toe)

Injury to the common fibular nerve - nerve just inferior to fibular head that passes around fibular neck and innervates muscles of the anterior aspect of the leg. Located in subcutaneous tissue and therefore is at high risk of injury.

Paralysis of anterior leg muscles --> no dorsiflexion

Continuous w/ Scarpa's fascia of the anterior abdominal wall

Fascia lata (deep fascia of the thigh)

Popliteal fascia (deep fascia of the posterior aspect of the knee)

Crural fascia (deep fascia of the leg)

Deep fascia of the foot

Retinaculum (strong bands of deep fascia around the ankle)

**Forms intermuscular septa - arise from deep surface of the deep fascia and attach to the femor or fibula

Trauma can cause hemorrhage, edema, or inflammation in lower limbs. If pressure is significantly increased within a compartment, compression of the neurovascular structures w/in the intermuscular septa can occur which can lead to ischemia or permanent injuries to distal structures.

Can be treated with fasciotomy (surgical opening of compartment to release pressure).

Great saphenous vein= superficial vein of the lower limb

Begins on medial surface of the foot

ascends anterior to the medial malleolus

continues on medial aspect of the leg (with lateral branches) and medial aspect of the knee

continues posterior to medial epicondyle of the femur

goes to thigh and drains anteriorly into the femoral vein

**Accompanied by the saphenous nerve

May have an accessory saphenous vein to help collect blood from the thigh

10-12 venous valves present

Small saphenous vein= superficial vein of the posterior lower limb

Collects blood from later aspect of the foot

ascends posterior to the lateral malleolus and posterior aspect of the leg

pierces deep fascia to empty into the popliteal vein.

**Accompanied by the sural nerve

Cutaneous innervation of:

lateral thigh

anterior thigh

posterior thigh

lateral leg

medial leg

posterior leg

dorsal foot

ventral foot

skin b/w great and adjacent toe on anterior aspect of foot

Lateral thigh - lateral femoral cutaneous (L2,L3 of lumbar plexus)

Anterior thigh - anterior femoral cutaneous (branch of femoral nerve)

Posterior thigh - posterior femoral cutaneous (S2,S3 of sacral plexus)

Lateral leg - common fibular nerve and lateral sural cutaneous nerve

Medial leg - saphenous nerve

Dorsal foot - superficial fibular nerve

Ventral foot - medial and lateral cutaneous plantar nerves

Anterior skin b/w great and adjacent toe - deep fibular nerve

Fascia ovalis in the fascia lata

It is a hiatus/opening in the fascia lata just inferior to the inguinal ligament where the great saphenous vein enters to drain into the femoral vein. 

Falciform margin= sharp crescentic lateral and inferior margin of the saphenous opening

Cribiform fascia= fibrofatty tissue covering and closing the saphenous opening on the medial margin - continuous w/ the fascia lata (not a sharp or distinct margin)

Region of thickened and strengthened double layer of fascia lata on the lateral aspect of the thigh.

Extends from the iliac tubercle to Gerdy's tubercle (aka anterolateral tibial tubercle)

Provides attachment for the tensor of the fascia lata and the gluteus maximus muscle and stabilizes the hip and knee.

Extensors of the knee

Some flexors of the hip

*all innervated by the femoral nerve

Some muscles are biarticular (cross both hip and knee joint), some just monoarticular

Sartorius (longest muscle in the human body)

Quardiceps femoris (strongest muscle in the human body)

- rectus femoris

- vastus lateralis

- vastus medialis

- vastus intermedius

Iliopsoas (iliacus, psoas major, psoas minor)

Pectineus (transitional muscle b/w ant and med compartments)

Proximally attached to ASIS, distally attached to the medial aspect of the tibia

Innervated by the femoral nerve

Flexes, abducts, and laterally rotates the thigh; flexes the leg at the knee

Rectus femoris: AIIS to the quadriceps tendon which covers the patella and continues inferiorly as the patellar ligament which attaches to the tibial tuberosity

- steadies and flexes the hip and flexes the thigh (crosses both joints (biarticular muscle))

Vastus lateralis: greater trochanter to the quadriceps tendon

Vastus intermedius: intertrochanteric line to quadriceps tendon

Vastus medialis: lesser trochanter to quadriceps tendon

**All muscles innervated by the femoral nerve

**All of these muscles work together to extend the leg at the knee

**parts of the muscles that do not join the quardiceps tendon descend along either side of the patella to form the medial and lateral patellar retinaculums

Femoral nerve (L2, L3, L4)

results in contraction of the quadriceps femoris muscles

Attachments: Psoas major muscle proximally attached to T12-L5, iliacus muscle proximally attached to the iliac crest and iliac fossa

Both distally attache to the lesser trochanter of the femur

Psoas major muscle innervated by lumbar nerves

Iliacus innervated by the femoral nerve

Actions: Flexes the hip and thigh, stabilizes the hip joint, controls deviation of the trunk (active during standing)

**Trough b/w the psoas and the iliacus is where the femoral nerve can be found.

Proximally attached to the superior pubic ramus and distally attached to the pectineal line of the femur

Dual innervation: anterior aspect of innervated by the femoral nerve, posterior aspect innervate by the obturator nerve

Action: adduction and flexion at the knee

**Transitional muscle - in both the anterior and medial compartments of the thigh

Extension of the LEG

Flexion of the HIP joint

Main function and innervation of the medial compartment

Main function = ADDUCT the thigh (medial compartment=adductor group)

Innervated by the obturator nerve

Pectineus

Adductor longus

Adductor brevis

Adductor magnus

Gracilis

Obturator externus

Adductus longus: Proximally attached to the body of the pubis and distally attached to the middle 1/3 of the linea aspera

Adductus brevis: Deep and superior to the adducust longus, it is proximally attache to the body and inferior pubic ramus and distally attached to the pectineal line

Both innervated by the obturator nerve and both adduct the thigh

Adductor magnus muscle separated into 2 parts:

Adductor part: Proximally attached to the ischiopubic ramus and distally attached to the gluteal tuberosity of the linea aspera and medial supracondyle line.

Innervated by the posterior branch of the obturator nerve.

Flex the thigh.

Hamstring part: Proximally attached to the ischial tuberosity and distally attached to the adductor tubercle of the femur.

Innervated by the tibial part of the sciatic nerve.

Extends the thigh.

**Together, they adduct the thigh

**B/w the adductor magnus and the femur is the adductor hiatus - allows for the passage of femoral vessels to the popliteal fossa

**Adductor magnus has usually 4 perforations at distal attachment for the passage of branches of the deep artery of the thigh

Gracilis: Proximally attached to the body and inferior ramus of the pubis and distally attached to the superior part of the medial aspect of the tibia

Innervated by the obturator nerve

Adducts thigh, flexes leg, helps rotate medially

Obturator externus: Proximally attached to the external margin of the obturator foramen and obturator membrane and distally attached to trochanteric fossa (on posterior aspect of the femur)

Laterally rotates thigh and steadies the head of the femur in the acetabulum

Conjoined tendons of 3 muscles at proximal tibia - the pes anserinus

Satorius (from the ilium and innervated by the femoral nerve)

Gracilis (from the pubis and innervated by the obturator nerve)

Semitendinosus (from the ischium and innervated by teh sciatic nerve)

Muscular lacuna (lateral to iliopectineal arch): iliopsoas muscle and femoral nerve (b/w the iliacus and psoas major)

Vascular lacuna (medial to iliopectineal arch): femoral branch of the genitofemoral nerve (L1,L2), femoral artery, femoral vein, Rosenmuller lymph node

Contents of subinguinal space exit into the femoral triange.

Borders: Medial border of Sartorius, inferior border of inguinal ligament, and superior border of adductor longus

Floor: inferior part of iliopsoas on lateral side and pectineus on medial side

Contents: (lateral to medial=NAVL) femoral nerve, femoral artery, femoral vein, lymphatics

(lymphatics contained w/in "empty" fat-filled space)

aka Subsartorial (b/c covered by sartorius muscle) or Hunter's Canal

Intermuscular passageway delivering the femoral vessels from the femoral triangle to the popliteal fossa - extends from the apex of the femoral triangle to the adductor hiatus

Relationship of femoral nerve to femoral artery in the femoral triangle

Superficial branches of the femoral nerve

Femoral nerve is lateral to the femoral artery

**NOT w/in the femoral sheath

Superficial branches:

Anterior cutaneous femoral branches innervate the skin of the anterolateral thigh

Saphenous nerve innervates the skin of the medial leg and foot

**Saphenous nerve does NOT pass through the adductor hiatus

Funnel shaped fascial tube lining the vascular lacuna of the subinguinal space enclosing the femoral artery and vein.

**Does NOT enclose the femoral nerve

**Great saphenous vein pierces the femoral sheath to drain blood into the femoral vein

Canal within the femoral sheath medial to the femoral vein...Femoral sheath enclosing the femoral artery, vein, and lymphatic vessels also contains septa to separate the vessels (2 septa creating 3 canals...Femoral canal is the most medial one containing the "empty" fatty space containing the lymph vessels).

**Possible site of femoral hernia...if abberant obturator artery present, femoral hernia may damage the artery.

Medial circumflex femoral artery

-branch of deep artery of the thigh which is a branch of the femoral artery

Medial circumflex femoral artery (supplies head and neck of the femur)

Lateral circumflex femoral artery (ascending and descending branch)

Perforating arteries (course through perforations of the adductus magnus to bring blood to all 3 compartments of the thigh)

**deep artery of the thigh is posterior to the adductor longus muscle

Medial circumflex femoral artery (branches from the deep artery of the thigh) - supplies blood to the head and neck of the femur

**Rupture of the medial circumflex femoral artery --> aseptic vascular necrosis

Anteriormost part of the tendinous arch

Posteriormost part part of the tendinous arch

Puboprostatic ligament in males

Pubovesical ligament in females

Sacrogenital ligaments

Superficial epigastric artery - leaves femoral sheath, travels superiorly over the inguinal ligament and ascends in b/w the 2 superficial fascia layers as far as the umbilicus.

Superficial circumflex iliac artery - smallest of the cutaneous brances of the femoral artery - pierces fascia lata, runs lateral and parallel w/ inguinal ligament as far as the iliac crest.

Superficial and deep external pudendal artery - superficial external pudendal artery pierces the femoral sheath and travels medially over the spermatic cord/round ligament of the uterus and distributed to the lower abdomen, and penis and scrotum/labium majum.

the deep external pudendal artery passes medially across the pectineus and adductus longus, pierces the femoral sheath and distrubuted to the scrotum and perineum/labium majum.

Deep femoral artery of the thigh - courses posterior to the adductus longus

gluteus maximus

gluetus medius

gluteus minimis

tensor of the fascia lata

piriformis (deep to the gluteus maximus)

obturator internus

superior gemellus

inferior gemellus

quadratis femoris

obturator externus

Proximally attached to the posterior ilium, posterior sacrum and coccyx, and sacrotuberous ligament. Distally attached to the IT band and gluteal tuberosity of the femur.

Innervated by inferior gluteal nerve (L5, S1, S2)

Extends and laterally rotates the thigh

Gluteus medius proximally attached to the external surface of the ilium b/w the posterior and anterior gluteal lines...gluteus minimus proximally attached in b/w the anterior and inferior gluteal lines. Both distally attached to the greater trochanter of the femur.

Innervated by superior gluteal nerve (L4, L5, S1)

Abducts and medially rotates the thigh and keeps the pelvis level.

Proximally attached to the ASIS and anterior iliac crest, distally attached to the IT band (attached to the lateral condyle of the tibia aka Gerdy's tubercle).

Innervated by superior gluteal nerve (L4,L5,S1)

Assists in abduction, flexion, and medial rotation of the thigh (not a very strong muscle).

Proximally attached to the anterior surface of the sacrum and distally attached to the greater trochanter of the femur (exits pelvis through greater sciatic foamen - superior border= line b/w PSIS and grater torchanter).

Innervated by anterior rami of S1, S2.

Laterally rotates the extended thigh, abducts the flexed thigh, and steadies the femoral head in the acetabulum.

obturator internus: proximal attachment to the internal aspect of the inferior margin of the obturator foramen

superior gemellus: proximal attachment to the ischial spine

inferior gemellus: proximal attachment to the ischial tuberosity

All distally attached to the trochanteric fossa

Obturator internus and superior gemellus innervated by the nerve to the obturator foramen (L5,S1,S2)

Inferior gemellus innervated by the nerve to the quadratis femoris (L4,L5,S1)

TOGETHER: laterally rotate extended thigh,abducts flexed thigh, and steadies the hip joint

Proximally attached to the ischial tuberosity and distally attached to the quadrate tubericle on introchanteric crest of the femur.

Innervated by nerve to the quadratus femoris (L4,L5,S1).

Laterally rotates the thigh and steadies the hip joint.

Superior gluteal nerve (L4,L5,S1) (small superficial and large deep branches b/w medius and minimus)

Inferior gluteal nerve (L5,S1,S2)

Pudendal nerve (S2,S3,S4)

Posterior cutaneous nerve of the thigh (S1,S2,S3)

Nerve to the obturator internus (L5,S1,S2)

Nerve to the quadratis femoris (L4,L5,S1)

Sciatic nerve (L4,L5,S1,S2,S3)

Usually, sciatic nerve enters gluteal region inferior to the piriformis. ~12%, common fibular portion pierces the piriformis...much less enters superior to the piriformis.

**Compression of sciatic nerve by piriformis --> inflammation, sacroiliac disease, pelvic disease, hypertrophy, muscular spasms

Piriformis muscle syndrome often under-diagnosed as cause of sciatica

Lymph from deep tissue --> superior/inferior gluteal nodes --> internal iliac nodes --> common iliac nodes --> aortic lumbar nodes

Lymph from superficial tissue --> superfiical inguinal lymph nodes --> external iliac lymph nodes

Long head of the biceps femoris

semitendinosus

semimembranosus

**All attach to the ischial tuberosity

Long head of the biceps femoris, semitendinosus, and semimembranosus all proximally attached to the ischial tuberosity.

Long head of the biceps femoris distally attached to the lateral aspect of fibular head - knee flexion and slight laterally rotates the leg.

Semitendinosus distally attached to medial aspect of the head of the tibia - hip extension, knee flexion, slightly laterally rotates the leg.

Semimembranosus distally attached to the medial aspect of the tibia - hip extension, knee flexion

All innervated by the tibial nerve (L4,L5,S1,S2,S3)

Superolateral: semitendinosus and semimembranosus tendons

Superomedial: biceps femoris tendon

Inferomedial and inferolateral: gastrocnemius medial and lateral heads

Tibial nerve (sciatic nerve may bifurcate earlier, or at superior border of the popliteal fossa)

Popliteal vein

Popliteal artery

(NVA)

**Popliteal vein and artery in a common sheath

Popliteal muscle (unlocks the knee joint) = floor of the popliteal fossa

superior medial genicular artery (branches on anterior side of the knee from the descending genicular artery)

superior lateral genicular artery

*both just superior to gastrocnemius attachments

middle genicular artery - supplies knee joint

inferior medial genicular artery

inferior lateral genicular artery

Superficial lymphatics of thigh follow the great saphenous vein and drain to superficial inguinal lymph nodes.

Superficial lymphatics of the leg follow the small saphenous vein and drain to the popliteal lymph nodes.

Deep lymphatics of leg follow deep veins to the popliteal lymph nodes as well - most lymph from popliteal nodes ascend to the deep inguinal lymph nodes.

medial side of tibial tuberosity

(pes anserinus= common attachment of sartorius, gracilis, and semitendinosus)

anterior and posterior tibial arteries

Posterior tibial artery stays in posterior compartment and descends b/w the superficial and deep muscles of the posterior compartment...gives off a fibular branch to the fibula which gives off perforating branches to supply the lateral compartment. Posterior tibial continues down to travel throug the tarsal tunnel and into the foot.

Anterior tibial artery enters the anterior compartment through the superior aperture of the interosseous membrane. Descends on the anterior surface of the interosseous membrane w/ the deep fibular nerve (from the common fibular nerve which travels to anterior surface from around the fibular head). Cross the ankle to become the dorsalis pedis artery.

medial plantar artery (--> great toe)

lateral plantar artery (makes way across the foot to the lateral side and terminates in the deep plantar arc)

Superficial:

gastrocnemius

soleus

plantaris

Deep:

flexor hallucis longus

flexor digitorum longus

tibialis posterior

popliteus

**All innervated by the tibial nerve (L4,L5,S1,S2,S3)

superifical fibular nerve (innervates muscles of the lateral compartment)

and the deep fibular nerve (innervates muscles of the anterior compartment - runs on anterior surface of interosseous membrane w/ the ant. tibial artery)

Tibialis anterior

extensor digitorum longus

extensor hallucis longus

fibularis tertius

**All innervated by the deep fibular nerve, and blood supply is from anterior tibial artery

fibularis longus

fibularis brevis

Fibularis longus: proximally, broad attachment along fibula...tendon travels through groove of cubiform, across the anterior foot and attaches on the medial side of the cuneiform and base of the 1st metatarsal.

Fibularis brevis: proximally, broad attachment about half way down fibula and attaches to protuberance of 5th metatarsal.

Both innervated by superfial fibular nerve (from bifurcation of common fibular) and both evert the foot as well as help stabilize the foot and ankle when standing on one leg by co-contracting.

Tibialis anterior: proximally, broadly attached to tibia and distally attached to medial cuneiform and base of the 1st metatarsal. Dorsiflexes and inverts the foot.

Extensor hallucis longus: proximally attached to tibia and a little bit of the fibula and interosseous membrane, and distally attached to the great phalynx. Extends the toe and dorsiflexes the foot.

Extensor digitorum longus: proximally attached to lateral condyle of the tibia and interosseous membrane, distally attached to the 4 lateral toes w/ 4 tendons. Extends the toes and dorsiflexes the foot

Fibularis tertius: proximally attached to inferolateral surface of the fibula, distally attached to anterior surface of the 5th metatarsal. Assists w/ dorsiflexion and eversion.

Gastrocnemius: proximally, lateral and medial heads attached to the lateral and medial condyles of the femur. Distally attached to the calcaneous via achilles tendon. Plantarflexion and knee flexion.

Soleus: proximally attached to soleal line of the tibia, distally attached to achilles tendon (soleal tendon joins w/ achilles tendon). Plantarflexion.

**does not cross the knee joint

Plantaris: proximally attached to lateral aspect of the femur, distally attachment blends w/ achilles tendon on medial side. Assists in plantar flexion.

All innervated by tibial nerve.

Popliteal muscle: proximally attached to lateral condyle of the femur, distally attached under medial tibial condyle. Unlocks the knee joint.

Tibialis posterior: proximally attached to lateral aspect of the tibia and interosseous membrane, distally attached to the navicular tuberosity. Plantarflexion.

Flexor hallicus longus: proximally attached to inferolateral interosseous membrane and fibula, distally attached to dista phalynx (big toe). Flexes great toe and plantarflexion of the foot.

Flexor digitorum longus: proximally attached to posterior surface of the tibia, distally attached to the four lateral phalanges. Flexion of the toes and contributes to plantarflexion.

All innervated by the tibial nerve.

Concentric (length of muscle decreases)

Eccentric (length of muscle increases)

Isocentric (length of muscle doesn't change)

Stance phase: when reference foot is on the ground (60% of gait cycle)

Swing phase: when reference foot is off the ground (40% of gait cycle)

Muscle activity during gait:

gluteus maximus and hamstrings

gluteus medius

hip flexors

at the knee

ankle dorsiflexors

ankle plantarflexors

Gluteus maximus and hamstrings put the breaks on (extend the hip)

Gluteus medius contracts just before heel strinke and through most of stand to provide hip stability.

Hip flexors contract at toe off and continue into early swing phase.

At the knee, hamstrings and quadriceps co-contract from heel strike to midstance...during swing phase, no muscle activity at the knee joint.

Ankle dorsiflexors active during swing phase and when heel strikes to control descent of foot to the ground.

Ankle plantarflexors gradually increase activity from heal strike throughout stance, and burst of activity at heel off and toe off.

2nd toe very secure - wedged in b/w the medial and lateral cuneiforms.

2nd toe= reference point in which everything else moves around.

True/false: The talus bone is the only bone in the foot that articulates with the leg.

True/false: The talus bone has no muscular attachments.

Both are true.

The talus bone is held in place by ligaments and boney architecture...movement dictated by muscles that cross the talus.

Intertarsal joints (b/w the 7 tarsal bones)

Subtalor joint (talus and calcaneous - not entire talus, just posterior facet)

Talocalcaneonavicular joint (medial aspect)

Calcaneocuboid joint (calcaneous and cuboid)

Tarso-metatarsal joints (tarsal and metatarsals)

Metatarsophlangeal joints (MTP joints)

Interphalangeal joints (IP joints)

Plantar calcaneonavicular ligament aka spring ligament

From calcenous (sustinaculum tali) to navicular bone - floor of the talus

Short plantar ligament attached to the calcanenous and cuboid on inferior aspect of the foot.

Long plantar ligament attached to the calcenous and the bases of the lateral 4 metatarsals on inferior aspect of the foot.

**Long plantar ligament helps support arch of the foor and forms a tunnel for the tendon of the fibularis longus.

Transverse arch

lateral longitudinal arch

medial longitudinal arch

Deep fascia bound to skin and superficial fascia of the plantar surface of the foot - attached from the medial process of the calcaneal tuberosity (most ant. portion of the calcaneous) and has 5 bands that approach the digits.

Distally, has transverse fibers that form superficial transverse metatarsal ligaments.

Supports the longitudinal arch and protects deeper structures.

Flexor retinaculum attached from the calcaneous to the lateral malleolus. Creates the tarsal tunnel which contains:

("Tom, Dick, And Very Nervous Harry")

tendon of the Tibialis posterior

tendon of the flexor Digitorum longus

posterior tibial Artery and 2 accompanying Veins

tibial Nerve

tendon of the flexor Hallucis longus

Compression of any of the contents of the tarsal tunnel

(tendon of the tibial posterior, tendon of the flexor digitorum longus, posterior tibial artery or veins, tibial nerve, tendon of the flexor hallucis longus)

Can be caused if increase activity level too quickly or extremely pronated foot (stretchs flexor retinaculum and causes compression w/in the tunnel0

Superior extensor retinaculum from the lateral to medial malleolus

Inferior extensor retinaculum from calcaneous, then bifurcates across ankle to the lateral malleolus, and the other to blend w/ the plantar aponeurosis.

Contains tendons from the anterior compartment of the leg.

Superior fibular retinaculum from calcaneous to the lateral malleolus

Inferior fibular retinaculum from calcaneous to calcaneous

Contains tendons of the fibular longus and brevis

Fibularis tertius: proximally attached to the inferior anterior surface of the fibula to the 5th metatarsal. Assists w/ dorsiflexion.

Extensor digitorum brevis: proximally attached to dorsal surface of calcaneous, distally attached to the dorsal aspects of the middle phalanges 2-4. Dorsiflexion.

Extensor hallucis brevis: proximally attached to calcaneous, distally to the proximal phalynx (great toe). Helps extend the big toe and contracts to stabilize the toe as we push off.

All innervated by the deep fibular nerve.

Posterior tibial artery gives rise to the lateral and medial plantar arteries.

Lateral plantar artery --> deep plantar arch which gives off plantar metatarsal arteries.

Plantar metatarsal arteries continue as the common plantar digital arteries which split and become the proper plantar digital arteries. These communicate w/ arteries of the dorsum of the foot via anterior perforating branches.

(lateral plantar a --> deep plantar arch --> plantar metatarsal aa --> common plantar digital aa --> proper plantar digital aa)

Anterior tibial artery becomes the dorsalis pedis artery after crossing the ankle. Dorsalis pedis gives lateral and medial tarsal branches, and the arcuate arch. Arcuate arch gives off dorsal metatarsal arteries and posterior perforating arteries. Dorsal metatarsal arteries split to from the dorsal digital arteries.

(dorsalis pedis a --> medial and lateral tarsal aa and arcuate arch a --> posterior perforating aa and dorsal metatarsal aa --> dorsal digital aa)

abductor hallucis - to 1st proximal phalynx

flexor digitorum brevis - to 2nd-5th middle phalynx

abductor digiti minimi - to 5th proximal phalynx

All originate from the calcaneous

abductor hallucis and flexor digitorum brevis innervated by medial plantar nerve

abductor digiti minimi innervated by lateral plantar nerve

quadratus plantae - calcaneous to tendon of flexor digitorum longus. Flexes 2-5th digits and assist by 'lateral pull.'

lumbricals - tendon of flexor digitorum longus to extensor expansions of 2nd-5th digits. Flexes MTP joints and extends IP joints.

Quadratus plantae innervated by lateral plantar nerve.

Most medial lumbrical (of 2nd digit) is innervated by medial plantar nerve, while ther rest (3rd-5th) are innervated by lateral plantar nerve.

**Lateral plantar nerve and artery and medial plantar nerve and artery can be seen superficial to the 2nd layer. Lateral plantar nerve and artery cross superficial to the quadratis plantae muscle.

flexor hallucis brevis - 2 portions, innervated by medial plantar nerve

adductor hallucis - oblique and transverse heads - innervated by lateral plantar nerve (deep branch)

flexor digiti minimi brevis - innervated by lateral plantar nerve (superficial branch)

All attached distally to the proximal phalynx of 1st or 5th digit.

Sesamoid bone (= small round bones embedded in tendon or muscle) present in tendons of the flexor hallucis brevis...creates a valley for the flexor hallucis longus.

Dorsal interossei - abducts toes 2-4 (DAB)

Plantar interossei - adducts toes 3-5 (PAD)

All also flex MTP joints and extend IP joints (due to attachments to extensor expansions)

All innervated by branches of the lateral plantar nerve.

Ligamentum teres aka ligament of the head of the femur= fold of synovial membrane; transmits branch of the obturator artery and moves synovial fluid around. From fovea of femur head to deep into acetabulum.

Transverse acetabular ligament bridges the acetabular notch to create a foramen; Branch of obturator artery enters through this foramen to enter the ligamentum teres.

*Thickenings of joint capsule

Iliofemoral ligament: AIIS --> greater and lesser trochanters (Y-shaped ligament) - limits hip extension, lateral rotation, and maintains upright posture.

Pubofemoral ligament: iliopubic eminence --> femur - limits hip extension and abduction.

Ischiofemoral ligament: ischium on posterior side of the acetabulum --> intertrochanteric line (blends w/ joint capsule) - limits hip extension and medial rotation.

**zona orbicularis= ligamentous fibers deep to the ischiofemoral ligament

FABER

(Flexion, ABduction, External Rotation)

Reduces friction b/w the iliotibial band and greater trochanter.

Short IT band can cause inflammation of trochanteric bursa.

**many other bursa around hip joint

**Length of IT band tested using the Ober test

Anterior collateral ligament (ACL) - attached to lateral condyle of the femur - limits knee extension, anterior tibial translation and medial rotation of the tibia. Tested using Lachman test.

Posterior collateral ligament (PCL): attached to medial condyle of the femur (more vertical than ACL). Twice as strong and 50% thicked than ACL. Limites posterior tibial translation and medial rotation of the tibia.

**Named by attachment site on the TIBIA

**IntraCAPSULAR, but EXTRAsynovial

Menisci of the knee joint made up of...and purpose is...

Vascular supply?

What connects menisci anteriorly?

How are they attached to the capsule?

Movements w/ knee?

Made up of fibrocartilagenous disks.

Fuctions= increase contact area and stability, shock absorption, and aid in joint librication.

Vascular supply to outer 1/3 by genicular arteries. (torn outer meniscus can be repaired, but w/o blood supply, the inner 2/3 of the meniscus will not repair on its own.)

Connected anteriorly by transverse ligament of the knee.

Attached to capsule by the coronary ligaments.

Mensici move anterior w/ knee extension and posteriorly w/ knee flexion.

Medial meniscus:

C-shaped

frequently injured

firmly attached to the tibial collateral ligament

Lateral meniscus:

circular-shaped

less frequently injured

not attached to fibular collateral ligament

posterior area of lateral meniscus attached to the posterior meniscofemoral ligament (aka Ligament of Wrisberg) - crosses posterior and superior to the posterior cruciate ligament and attaches to the medial condyle of the femur.

**b/c lateral meniscus not attached to fibular collateral ligament, it has more mobility and can escape trauma.

**Popliteus muscle tendon separates lateral meniscus from fibular collateral ligament

**Transverse ligament helps support anterior portions of the menisci

Tibial (medial) collateral ligament: limits lateral motion of the tibia (abduction) and lateral rotation of the tibia.

Fibular (lateral) collateral ligament: limits medial motion of the tibia (adduction) and lateral rotation of the tibia.

Patellar ligament

Oblique popliteal ligament: comes off of tendon of semimembranosus muscle and offers posterior support to capsule.

Arcuate popliteal ligament: from fibula, bifurcates towards lateral femur and centrally towards joint. *Superficial to the popliteus muscle

**MCL= thickening of joint capsule...LCL is a distinct tendon

Valgus stress test for MCL injury (palpate medial aspect and press on lateral aspect of knee)

Varus stress test for LCL injury (palpate lateral aspect and press on medial aspect of knee)

Trauma to outside of the knee - injury can involve

Tibial collateral ligament (MCL)

Anterior cruciate ligament (ACL)

Medial meniscus

Sacs containing synovial fluid that reduce friction b/w opposing surfaces

Suprapatellar bursa - communicates w/ the knee joint capsule

Prepatellar bursa - right in front of patella; edema may occur if on knee's a lot (Housemaid's syndrome)

Infrapatellar bursa - superficial and deep bursae on either side of the patellar ligament

...many others.

Patellofemoral joint

w/o a patella, need much stronger quadriceps muscles for bending the knee...patellofemoral joint enables easier extension of the knee b/c it creates a longer lever.