Kaan Yücel M.D., Ph.D.

1. CLINICAL ANATOMY OF LOWER LIMB PART I • Kaan Yücel M.D., Ph.D. • 28.February.2012 Tuesday

2. III. COMMITTEE ANATOMY 27 Questions 4 Questions 15% 1 TUS QUESTION 2 MID-COMMITTEE QUESTIONS (1 FROM GROUP A EXAM 1 FROM GROUP B EXAM) 1 Y-CAL CASE 27Questions 14 Questions Axilla, Brachialplexus, Superficialmuscles of theback, Pectoralregion & mammaryglandsShoulder, Arm, Forearm, Hand 13 Questions The rest 27-4= 23 Questions85% 15 PureAnatomyQuestions 56% 5 ClinicalAnatomyQuestions 18% 3 Clinicalcases 11%

3. ClinicalAnatomy of theUpperLimbPart I Axilla & BrachialPlexus ClinicalAnatomy of theUpperLimbPart II Superficialmuscles of theback, Pectoralregion & Mammaryglands, Shoulder,Arm, Forearm,Hand NerveBlocks NeurologicalExamination: An anatomicalview

4. CLINICAL ANATOMY OF LUMBOSACRAL PLEXUS

5. FemoralNerveL2-L4 Largestbranch of thelumbarplexus Flexorsof hip & extensors of knee Skin of theanteriorandlateralthigh, mediallegandfoot Saphenousnerve Skin of medialaspects of legandfoot Iliacus, psoasmajor, pectineus, quadricepsfemoris (rectusfemoris, vastusintermedius, vastuslateralisandvastusmedialis), sartorius ObturatorNerveL2-L4 Adductormusclesof leg Skin on thesuperiormedialthigh externaloblique, pectineus, adductorlongus, adductorbrevis, adductormagnus, andgracilis.

6. SciaticNerveL4-S3 • Hamstringmuscles • Extensionat thehipjoint • Flexionat thekneejoint • Commonfibularnerve • Suralcommunicatingnervelowerposterolateralside of theleg • Lateralsuralcutaneousnerveupperlateralleg. • Muscles of theleg • Ant. Compartment • Dorsiflexors of ankle • Deepfibularnerve (L4, L5) • LateralCompartment • Evertors of foot & weakplantarflexors of ankle • Superficialfibularnerve(L5, S1, S2) • PosteriorCompartment • Plantarflexors of ankle • Tibialnerve (S1, S2) posteriorthighmuscles, thatflexthekneeandallmusclesthatworktheankleandfoot Tibialnerve (S1, S2) Suralnerveskin on thelowerposterolateralsurface of thelegandthelateralside of thefootandlittletoe medialcalcanealnerveskin on themedialsurfaceand sole of theheel.

7. FemoralNerveInjury Injuredin staborgunshotwounds, completedivision of thenerve is rare. Weaknessof hipflexion, loss of kneeextension (nopatellarreflex), sensoryloss on anteromedialthigh, knee, leg, andfoot. alongthemedialborder of thefoot as far as theball of thebigtoe; thisarea is normallysuppliedbythesaphenousnerve.

8. SciaticNerveInjury • Penetratingwounds • Fracturesof thepelvis • Dislocationsof thehipjoint • Mostfrequentlyinjured • during I.M. injections • Mostnervelesionsareincomplete • Commonperonealpart of thenervemostaffected • mostsuperficial in thesciaticnerve

9. SciaticNerveInjury Motor:Hamstringmusclesparalyzed, but weakflexion of theknee is possibletnxtosartorius(femoralnerve) & gracilis (obturatornerve). Allthemusclesbelowthekneeareparalyzed, footdrop. Sensory:Sensation is lostbelowtheknee, exceptfor a narrowareadownthemedialside of thelowerpart of thelegandalongthemedialborder of thefoot as far as theball of thebigtoe, which is suppliedbythesaphenousnerve (femoralnerve).

10. Sciatica [Sciaticneuralgia] Definiton:thecondition in whichpatientshavepainalongthesensorydistribution of thesciaticnerve. Symptom:Pain in theposterioraspect of thethigh, theposteriorandlateralsides of theleg, andthelateralpart of thefoot. Causes: Prolapseof an intervertebraldiscwithpressure on oneormoreroots of thelowerlumbarandsacralspinalnerves, intrapelvictumor, inflammationof thesciaticnerveorits terminal branches.

11. ObturatorNerveInjury Rare penetratingwounds, anteriordislocations of thehipjointabdominalherniaethroughtheobturatorforamen. pressedon bythefetalheadduringparturition. Motor:Alltheadductormusclesparalyzedexceptthehamstringpart of theadductormagnussuppliedbythesciaticnerve. Sensory:Thecutaneoussensoryloss is minimal on themedialaspect of thethigh.

12. ReferredPainfromtheHipJoint Thefemoralnervesuppliesthehipjoint + viaintermediateandmedialcutaneousnerves of thethigh, skin of thefrontandmedialside of thethigh. painoriginating in thehipjointto be referredtothefrontandmedialside of thethigh. Theposteriordivision of theobturatornervesuppliesboththehipandkneejoints. Thiswouldexplainwhyhipjointdiseasesometimesgivesrisetopain in thekneejoint.

13. PressurefromtheFetalHead on theSacralPlexus Duringthelaterstages of pregnancy, whenthefetalhead has descendedintothepelvis, themotheroftencomplains of discomfortorachingpainextendingdownone of thelowerlimbs oftenrelievedbychangingposition, such as lying on theside in bed.

14. Invasionof theSacralPlexusbyMalignantTumors Thenerves of thesacralplexus can becomeinvadedbymalignanttumorsextendingfromneighboringviscera. A carcinoma of therectum, forexample, can cause severe intractablepaindownthelowerlimbs.

15. ReferredPainfromtheObturatorNerve Theobturatornervelies on thelateralwall of thepelvisandsuppliestheparietalperitoneum. An inflamedappendixhangingdownintothepelviccavity Irritationof theobturatornerveendings Referredpaindowntheinnerside of therightthigh Inflammation of theovaries

16. CLINICAL ANATOMY OF GLUTEAL REGION

17. Intramuscularinjections . Theglutealregiondividedintoquadrantsbytwoimaginarylinesusingpalpablebonylandmarks linedescendsverticallyfromthehighestpoint of theiliaccrest. linehorizontalandpassesthroughthefirstlinemidwaybetweenthehighestpoint of theiliaccrestandthehorizontalplanethroughtheischialtuberosity.

18. GluteusMediusandMinimusandPoliomyelitis Gluteusmediusandminimus paralyzedwhenpoliomyelitisinvolvesthelowerlumbarandsacralsegments of thespinalcord. Superiorglutealnerve (L4 and 5 and S1) Problem in theability of thepatienttotiltthepelviswhenwalking.

19. GluteusMaximusandBursitis causedbyacuteorchronictrauma. can be extremelypainful. Thebursaeassociatedwiththegluteusmaximusarepronetoinflammation. Thegluteusmaximusbursitis is painradiatingtotheposterolateralaspect of thethigh, paraesthesiae in thelegs, andtendernessovertheiliotibialtract.

20. Piriformissyndrome Sciaticacausedbycompression of thesciaticnervebythepiriformismuscle Buttockpain, andlesscommonlylowbackpain, radiatinglegpainareamongthesymptoms.

21. Iliotibialbandsyndrome Mostcommoncause of pain on theoutside of theknee in runners, with an incidence as high as 12% of allrunning-relatedoveruseinjuries. Althoughit is not difficulttodiagnose, it can be a challengetotreat, especially in highermileagerunnerswhoplaceenormousloads on theirbodies. IliotibialBandFrictionSyndrome Injection of the anserine bursa and iliotibial tract Iliotibial Band Friction Syndrome and Greater Trochanteric Bursitis

22. CLINICAL ANATOMY OF THIGH

23. Ruptureof theRectusFemoris Therectusfemorismuscle can rupture in suddenviolentextensionmovements of thekneejoint. Rupture of theLigamentumPatellae This can occurwhen a suddenflexingforce is appliedtothekneejointwhenthequadricepsfemorismuscle is activelycontracting.

24. CollateralCirculation Ifthearterialsupplytotheleg is occluded, necrosisorgangrenewillfollowunless an adequate bypass totheobstruction is present—that is, a collateralcirculation. Suddenocclusion of thefemoralarterybyligatureorembolism, forexample, is usuallyfollowedbygangrene.

25. FemoralArteryCatheterization • A long, finecatheter can be insertedintothefemoralartery as it descendsthroughthefemoraltriangle. • Anatomyof Technique • Thefemoralartery is firstlocatedjustbelowtheinguinalligamentmidwaybetweenthesymphysispubisandtheanteriorsuperioriliacspine. Theneedleorcatheter is theninsertedintotheartery. • Thefollowingstructuresarepierced: • Skin • Superficialfascia • Deepfascia • Anteriorlayer of thefemoralsheath

26. FemoralArteryCatheterization Anatomyof Complications Enteringintothefemoralvein Piercingthepsoasmajor & enteringthehipjointcavity

27. Traumatic InjurytoArteries of theLowerLimb Injurytothelargefemoralartery can causerapidexsanguinationof thepatient. Unlikein theupperextremity, arterialinjuries of thelowerlimb do not have a goodprognosis. Thecollateralcirculationsaroundthehipandkneejoints, althoughpresent, are not as adequate as thataroundtheshoulderandelbow. Thefemoralartery is superficialwhere it lies in thefemoraltriangleand in consequenceeasilyinjured.

28. Aneurysms of theLowerExtremity MuchlessfrequentlythanabdominalaorticaneurysmsCommonsitesarethefemoralandpoplitealarteries. Patientsmaypresent in theemergencydepartmentwithcomplications, whichincludesuddenembolicobstructiontoarteriesdistaltotheaneurysmorsuddenthromboticocclusion of theaneurysm. Pressureon neighboringnervesmaygiverisetosymptoms; forexample, an enlargingpoplitealaneurysmmaypress on thetibialnerve, causingpain in thefoot.

29. Great SaphenousVein in Coronary Bypass Surgery

30. FemoralVeinCatheterization Rapidaccessto a largevein is needed Anatomy of theProcedure 1. Theskin of thethighbelowtheinguinalligament is suppliedbythegenitofemoralnerve; thisnerveisblockedwith a localanesthetic. 2. Thefemoralpulse is palpatedmidwaybetweentheanteriorsuperioriliacspineandthesymphysispubis, andthefemoralveinliesimmediatelymedialto it. 3. At a site abouttwofingerbreadthsbelowtheinguinalligament, theneedle is insertedintothefemoralvein.

31. CLINICAL ANATOMY OF POPLITEAL FOSSA

32. ArterialPalpation Arresting a severe hemorrhageorpalpatedifferentparts of thearterialtree in patientswitharterialocclusion. Femoralartery entersthethighbehindtheinguinalligament at a pointmidwaybetweentheanterosuperioriliacspineandthesymphysispubis. Poplitealartery passivelyflexingthekneejoint.