Superficial Viens

• carry blood from inferior to superior
• can be seen through skin
• generally pass superficial to the cutaneous nerves

Common Dorsal Digital Viens

• 1 to 8 from medial to lateral
• Drain into dorsal metatarsal viens

Where do the following viens drain into?

• 1st and 2nd CDDV
• 3rd and 4th CDDV
• 5th and 6th CDDV
• 7th and 8th CDDV

• 1st dorsal metatarsal vien
• 2nd dorsal metatarsal vien
• 3rd dorsal metatarsal vien
• 4th dorsal metatarsal vien

What vien becomes the medial marginal vien and what does it drain?

 proper dorsal digital vein of the hallux

drains the dorsalmedial aspect of the hallux and the 1st metatarsalphalangeal joint

 What vien becomes the lateral marginal vien and what does it drain?

proper dorsal digital vein of the 5th toe

drains the dorsolateral aspect of the 5th toe and the 5th metatarsophalangeal joint

What vien drains into the great saphenous vien?

medial marginal vien

what vien drains into the small saphenous vien?

lateral marginal vien

where do the dorsal metatarsal veins recieve blood from?

2 adjacent CDDV and 2 perforating branches from deep layers of the foot

where do the dorsal metatarsal veins drain into?

dorsal venous arch

Dorsal Metatarsal Veins

• one for each metatarsal space
• numbered medial to lateral

 What crosses the dorsum of the foot at the level of the metatarsal bases?

dorsal venous arch

Where does the dorsal venous arch recieve blood from and where does it drain into?

recieves from dorsal metatarsal viens

drains into great saphenous medially and small saphenous laterally

Where does the small saphenous vein begin, what is its course and where does it terminate?

begins as the union of the lateral end of the dorsal venous arch and lateral marginal vien

passes posterior to lateral malleolus travels superiorly near the midline of the leg on posterior region to popliteal region where it passes through the deep facia to join the popliteal vien

Where does the great saphenous vein begin, what is its course and where does it terminate?

begins as union of the medial dorsal venous arch and the medial marginal vein. passes anterior to the medial malleolus travels superiorly on the medial side of the leg passes posteromedially along the popliteal surface and continue to the groin where it passes through the fossa ovalis to join the femoral vein

What opening does the great saphenous vein go through to meet up with the femoral vein?

fossa ovalis

superficial plantar venous network

• very thin
• intadermal or subdermal
• no valves
• drain into medial and lateral marginal viens or dorsal digital viens through perforating branches

what is unique about the superficial plantar venous network?

no valves

what are the two groups of superficial inguinal lymph nodes?

Horizontal

Vertical

Where is the horizontal group located and what areas do they drain?

along the inguinal ligament

drains superficial areas of the abdominal wall and a small area of the proximal anterior thigh

Where do the efferent vessels of the superficial inguinal lymph nodes pass to?

mostly to the external iliac lymph nodes and a few pass to the deep inguinal lymph nodes

Where is the vertical group located and what areas do they drain?

along the termination of the great saphenous vein and fossa ovalis

drains superficial areas of thigh, leg, and foot

What are the two areas that the vertical group does not drain?

posterolateral aspect of the leg and the lateral aspect of the foot

Are deep inguinal lymph nodes palpable?

only when inflammed

where are the deep inguinal lymph nodes located and what areas do they drain?

deep to the fascia lata along the femoral vein near its termination

Drain the deep tissues of the lower limb

(tissues deep to the deep facia)

Where do the efferent vessels of the deep inguinal lymph nodes pass?

external iliac lymph nodes in the pelvis

where are the popliteal lymph nodes located and what areas do they drain?

along the small saphenous vein near termination deep to the popliteal facia

drain posterolateral aspect of the leg and lateral aspect of the foot

Where do the efferent vessels of the popliteal lymph nodes pass?

to the deep inguinal lymph nodes

where do the anterior tibial lymph nodes lie?

near the proximal end of the anterior tibial artery near the interosseous membrane deep to the muscles here

where do the efferent vessels of the anterior tibial lymph nodes pass?

to the deep inguinal lymph nodes

Infection of the 5th toe will causes inflammation of which lymph nodes in order?

popliteal lymph nodes first and then the deep inguinal lymph nodes

an infection of the hallux will cause inflammation of which lymph nodes in order

 vertical superficial iniguinal lymph nodes first

deep inguinal lymph nodes (maybe)

external iliac lymph nodes (definitely)

where will inflammation been seen in deep pedal infections from

Any area

dorsum surface

planta surface?

deep inguinal lymph nodes

anterior tibial lymph node first

popliteal lymph nodes first

Subcostal nerve

T-12

exit: anterior to iliac tubercle

supply: small area anterolateral aspect of thigh just inferior to groin

Femoral branch of the gentiofemoral nerve

L-1 & L-2

exit: near the fossa ovalis

supply: anterior thigh inferior to groin and medial to subcostal nerve distribution

ilioinguinal nerve

 L-1

exit: through superficial inguinal ring

supply: medial aspect of thigh inferior to groin

Lateral femoral cutaneous nerve

L-2 & L-3

exit: anterior aspect of iliac crest

supply: anterolateral aspect of thigh from subcostal distribution to knee

Intermediate femoral cutaneous nerve

L-2 & L-3

exit: through the sartorius muscle lateral to fossa ovalis

supply: anterior aspect of thigh from ilioinguinal distribution to knee

Medial femoral cutaneous nerve

 L-2 & L-3

exit: inferolateral to fossa ovalis

supply: anteromedial aspect of thigh from ilioinguinal distribution to knee

Obturator Nerve

L-2, L-3, L-4

exit: medial aspect of thigh near jnct of prox and midd thirds

supply: central part of medial aspect of thigh from ilioinguinal distribution to inferior 1/3

Lateral cutaneous nerve of the calf

L-5, S-1 & S-2

exit: posterolateral edge of the knee region

supply: lateral 1/2 of the leg from knee to inferior 1/3 of leg

Saphenous Nerve

L-3, L-4

exit: inferior medial aspect of thigh near knee

supply: entire medial 1/2 of leg from knee to foot

superficial fibular (peroneal) nerve

L-4, L-5 & S-1

Exit: anterolateral aspect of leg near midlevel

supply: anterolateral aspect of inferior 1/3 of leg, anterolateral aspect of the ankle and the dorsum of the foot except lateral 1/2 of the 5th digit and 1st webspace

Deep fibular (peroneal) nerve

L-5, S-1 & S-2

exit: posteromedial aspect of ankle near calcaneous

supply: medial 1/2 of heel; medially, plantarly and posteriorly

Sural Nerve

S-1 & S-2

exit: posterior aspect of leg in proximal 1/3

supply: posterior aspect of the leg from midcalf to posterolateral aspect of the ankle , lateral aspect of foot, lateral longitudinal arch, lateral 1/2 of 5th toe

iliohypogastric nerve

L-1

exit: lateral aspect of iliac crest

Supply: superoposterolateral area of the gluteal skin

Superior Cluneal Nerves

Dorsal Rami

L-1, L-2 & L-3

exit: posterior aspect of iliac crest

supply: superolateral aspect gluteal

Middle Cluneal Nerves

Dorsal Rami

S-1, S-2 & S-3

Exit: over the sacrum

Supply: skin of the medial aspect of gluteal

Posterior Femoral Cutaneous

S-1, S-2 & S-3

Main branch on anterior surface of facia lata

exit: small branches posterior aspect of thigh, popliteal, and calf

supply: inferior gluteal, posterior thigh, popliteal fossa, superior central aspect of calf

inferior cluneal nerves

S-1, S-2 & S-3

exit: gluteal fold

Supply: inferior aspect of gluteal region

branches of posterior femoral cutaneous

Perforating Cutaneous Nerve

S-2 & S-3

Branch of sacral plexus

exit: inferomedial aspect of gluteal region

supply: inferomedial gluteal area skin

 Lateral cacaneal nerves

S-1 & S -2

Branches of sural nerve

arises in superficial facia btwn calf and ankle

supply: lateral half of heel laterally, plantarly, and posteriorly

Medial Plantar Nerve

 L-4 & L-5

exit: medial 2/3 of the plantar midfoot and forefoot

supply: plantar medial aspect of foot from just distal to the heel to the medial 3 1/2 toes

lateral plantar nerve

S-1 & S-2

exit: later 1/3 of the plantar midfoot and forefoot

supply: plantar aspect of foot from just distal to the heel to the lateral 1 1/2 toes

Superficial Fibular Nerve

L-4, L-5 & S-1

courses inferomedially and divides just proximal to ankle

what two nerves does the superficial fibular nerve divide into?

medial: medial dorsal cutaneous nerve

Lateral: intermediate dorsal cutaneous nerve

what two nerves does the medial dorsal cutaneous nerve divide into?

medial: proper dorsal digital nerve 1

Lateral: 1st common digital dorsal nerve

What does the proper dorsal digital nerve 1 supply?

dorsomedial aspect of the hallux

What space does the 1st common dorsal digital nerve pass into?

2nd metatarsal space

What are the two branches of the 1st common dorsal digital nerve what toes do they supply?

2nd toe = proper dorsal digital nerve 4

3rd toe = proper dorsal digital nerve 5

What are the two divisions of the intermediate dorsal cutaneous nerve?

 2nd common dorsal digital nerve

3rd common dorsal digital nerve

what spaces do the 2nd and 3rd common dorsal digital nerves pass into?

2nd = 3rd intermetatarsal space

3rd = 4th intermetatarsal space

What are the branches of the 2nd common dorsal digital nerve and what toes do they supply?

3rd toe = proper dorsal digital nerve 6

4th toe = proper dorsal digital nerve 7

what are the branches of the 3rd common digital dorsal nerve and what toes do they supply?

4th toe = proper dorsal digital nerve 8

5th toe = proper dorsal digital nerve 9

Lateral dorsal cutaneous nerve

S-1 & S-2

Already in superficial facia

continuation of sural nerve and renamed

supply: lateral border of the foot

Proper dorsal digital nerve 10

S-1 & S-2

continuation of lateral dorsal cutaneous

supplies dorsolateral aspect of 5th toe

Deep fibular nerve

L-5, S-1 & S-2

Exit: 1st metatarsal space

Supply: 1st metatarsal space

what are the two divisions of the deep fibular nerve?

proper dorsal digital nerve 2

proper dorsal digital nerve 3

proper dorsal digital nerve 2

supplies the dorsolateral aspect of the hallux and medial 1st intermetatarsal space

proper dorsal digital nerve 3

supplies the dorsomedial aspect of the 2nd toe and lateral 1st intermetatarsal space

saphenous nerve

L-3, L-4

supplies medial border of midfoot and part of medial longitudinal arch

medial plantar nerve

L-4, L-5

deep to plantar fascia

divides near forefoot 

What are the four branches of the medial plantar nerve?

proper digital plantar nerve 1

1st common digital plantar nerve

2nd common digital plantar nerve

3rd common digital plantar nerve

proper digital plantar nerve 1

exit near the distal 1st metatarsal shaft

supplies plantar medial aspect of hallux and the 1st metatarsophalangeal joint

1st common digital plantar nerve

passes area of 1st metatarsal space

exit at metatarsal necks

supplies hallux = proper digital plantar nerve 2

and 2nd toe = proper digital plantar nerve 3

2nd common digital plantar nerve

passes 2nd intermetatarsal space

exits at level of metatarsal necks

supplies 2nd toe = proper digital plantar nerve 4

and 3rd toe = proper digital plantar nerve 5

3rd common digital plantar nerve

passes 3rd intermetatarsal space

exits at level of metatarsal necks

supplies 3rd toe = proper digital plantar nerve 6

4th toe = proper digital plantar nerve 7

Lateral plantar nerve

S-1 & S-2

passes deep to deep fascia and then divides

what are the division of lateral plantar nerve?

communicating branch

proper digital plantar nerve 10

4th common digital plantar nerve

communicating branch

medial branch joing the 3rd common digital plantar nerve

4th common digital plantar nerve

passes 4th intermetatarsal space

exits at level of metatarsal necks

supplies 4th toe = proper digital plantar nerve 8

5th toe = proper digital plantar nerve 9

proper digital plantar nerve 10

exits ner the distal 5th metatarsal shaft

supplies plantar lateral aspect of the 5th toe

saphenous nerve

L-3, L-4

small area of medial longitudinal arch plantarly

sural nerve

S-1, S-2

small area of the lateral longitudinal arch plantarly

medial calcaneal nerve

S-1, S-2

medial 1/2 of the calcaneal region

lateral calcaneal nerves

 S-1, S-2

branches of sural nerve supplying lateral 1/3 to 1/2 of the calcaneal region

what is retinaculum

thickening of deep fascia that holds soft tissue structures in place

what is fascia lata?

deep fascia of the thigh

What is the iliotibial band?

thickening of the fascia lata at the lateral aspect of the thigh

what is cribriform fascia?

very thin layer of facia lata over the fossa ovalis

what is fascia cruris?

deep fascia of the leg

what is popliteal fascia?

deep fascia of the popliteal region

what is fascia dorsalis pedis?

deep fascia of the superior aspect of the foot

what is plantar fascia?

deep fascia of the inferior aspect of the foot

What is flexor retinaculum?

 thickening of fascia cruris, fascia dorsalis pedis, and plantar fascia

holds flexor tendons of the foot and creates a pulley

all tendons have seperate tendon sheaths

What is the superior extensor retinaculum/transverse crural ligament?

thickening of fascia cruris

distal tibia shaft and distal fibular shaft

holds extensor tendons of the foot and maintains their postions near tibia

what is the inferior extensor retinaculum/ cruciate crural ligament?

y shaped band with stem laterally

thickening of fasciae cruris and dorsalis pedis

described with 3 roots and 7 sinus tarsi attachments

all tendons have tendon sheaths

what is the frondiform ligament?

stem of the inferior extensor retinaculum

what is the superior fibular (peroneal) retinaculum?

  formed from fascia cruris

posteroinferior lateral malleolus and lateral calcaneous

holds peroneal tendons and creates a pulley at lateral malleolus

single tendon sheaths

inferior fibular (peroneal) retinaculum?

formed from dorsalis pedis

holds peroneal tendons and creates pulley for fibularis longus tendon

tendon sheath divides at this point

what are intermuscular septae?

extensions of deep fascia that attach to bone and seperate muscles or groups of muscles

in the leg the septae aid in venous return

What is the nail plate?

body of nail .5 - .75 mm thick

hardening of the epidermis

cells have no nuclei

what is the function of the nail plate?

 protect the distal end of the digit/toe

what is the matrix?

root of the nail

specialized cells within the roof and floor of the proximal nail fold

attachs to base of distal phalanx

what is the function of the matrix?

produce the nail plate

What is the eponychium/proximal nail fold?

the skin at the proximal edge of the nail plate

overlies the matrix

what is the cuticle?

small ridge of trasparent skin dorsal to the proximal edge of the nail plate continuous with the eponychium

what is the function of the cuticle?

prevent infection by sealing the area adjacent to the nail plate

what is the nail bed?

skin directly beneath and attached to the nail plate contains some nail forming cells

what is the function of the nail bed?

anchor the nail plate and allow its distal growth

what is the lunula?

small half moon shaped area near the eponychium

what is the function of the lunula?

produce the nail

what is the free edge of the nail plate?

distal edge of nail plate that overhangs the toe

what is the function of the free edge of the nail plate?

protect the distal tuft of the toe from blunt trauma

what is the hyponychium?

the thickened skin adjacent to the free edge of the nail plate

what is the function of the hyponychium?

prevent infection by sealing this area adjacent to the nail plate

what is the distal nail groove?

the shallow transverse groove between the hyponychium and the skin of the distal tuft of the toe

what are the lateral nail folds/ungualabia?

convex skin folds at the sides  of the nail plate

what are the lateral nail grooves?

the concave junction of the lateral nail fold with the nail bed.

nail growth?

grow from matrix and proximal nail bed

pushed distally

faster in young and summer

fingers faster than toes

how long does it take for finger and toenail replacement to occur?

finger = 6 months

toe = 9 months

what causes little white spots in nails?

incomplete keratinization of the nail plate

cells still have nuclei or there is a air bubble

what causes longitudinal ridges in nails?

mechanical damage to matrix cells

the myotomes active during hip flexion, adduction, medical rotation arise from which ventral roots?

L-1 through L-4

the myotomes active during hip extension, abduction, and lateral rotation arise from which ventral roots?

L-4 through S-1

 the myotomes active during knee extension arise from which ventral roots?

L-2 through L-4

the myotomes active during knee flexion arise from which ventral roots?

L-5 through S-1

the myotomes active during ankle joint dorsiflexion arise from which ventral roots?

 L-4 & L-5

the myotomes active during ankle joint plantarflexion arise from which ventral roots?

 S-1 & S-2

the myotomes active during subtalar joint inversion/supination arise from which ventral roots?

L-4 & L-5

the myotomes active during subtalar joint eversion/pronation arise from which ventral roots?

L-5 & S-1

the myotomes active during metatarsophalangeal joint dorsiflexion are?

L-5 & S-1

the myotomes active during metatarsophalangeal joint plantar flexion arise from which ventral roots?

S-1 & S-2

what is a deep tendon reflex?

a muscle stretch reflex

mediated in the spinal cord

 what is a spinal reflex?

a withdrawl response

a protective reflex

mediated in the spinal cord

what are the two most common deep tendon reflexes in the lower limb?

patellar reflex

achilles reflex

what spinal segments does the patellar reflex test?

L-2, L-3 and L-4

what spinal segments does the achilles reflex test?

S-1 and S-2

What is the spinal reflex test in the lower extermity?

babinski test