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1. ARCHES OF FOOT
•The foot has three arches:
•two longitudinal (medial and lateral) arches and
• one anterior transverse arch (Fig. 1).
•They are formed by the tarsal and metatarsal
bones, and supported by ligaments and tendons
in the foot.

Medial Arch
• The medial arch is the higher of the two longitudinal arches. It is
formed by the calcaneus, talus, navicular, three cuneiforms and
first three metatarsal bones. It is supported by:
• Muscular support: Tibialis anterior and posterior, fibularis
longus, flexor digitorum longus, flexor hallucis, and the intrinsic
foot muscles
• Ligamentous support: Plantar ligaments (in particular the long
plantar, short plantar and plantar calcaneonavicular ligaments),
medial ligament of the ankle joint.
• Bony support: Shape of the bones of the arch.
• Other: Plantar aponeurosis.

Lateral Arch
• The lateral arch is the flatter of the two longitudinal arches, and
lies on the ground in the standing position. It is formed by the
calcaneus, cuboid and 4th and 5th metatarsal bones. It is
supported by:
• Muscular support: Fibularis longus, flexor digitorum longus,
and the intrinsic foot muscles.
plantar, short plantar and plantar calcaneonavicular ligaments).
• Other: Plantar aponeurosis

Transverse Arch
• The transverse arch is located in the coronal plane of the foot.
It is formed by the metatarsal bases, the cuboid and the three
cuneiform bones. It has:
• Muscular support: Fibularis longus and tibialis posterior.
plantar, short plantar and plantar calcaneonavicular ligaments)
and deep transverse metatarsal ligaments.
• Other support: Plantar aponeurosis.
• Bony support: The wedged shape of the bones of the arch

• Pes Cavus (High Arches)
• Pes cavus is a foot condition characterised by an unusually high medial
longitudinal arch. It can appear in early life and become symptomatic
with increasing age. Due to the higher arch, the ability to shock absorb
during walking is diminished and an increased degree of stress is
placed on the ball and heel of the foot.
• Pes Planus (Flat Footed)
• Pes planus is a common condition in which the longitudinal arches
have been lost. Arches do not develop until about 2-3 years of age,
meaning flat feet during infancy is normal.

30. ANKLE JOINT
• T h e a n k l e j o i n t ( o r
t a l o c r u r a l j o i n t ) i s a
synovial joint located in the
lower limb. It is formed by
the bones of the leg (tibia
and fibula) and the foot
(talus).
• Functionally, it is a hinge
type joint, permitting
d o r s i f l e x i o n a n d
plantarflexion of the foot.

Articulating Surfaces
• The ankle joint is formed by three bones; the tibia and fibula of the
leg, and the talus of the foot:
The tibia and fibula are bound together by strong tibiofibular ligaments.
Together, they form a bracket shaped socket, covered in hyaline cartilage.
This socket is known as a mortise.
The body of the talus fits snugly into the mortise formed by the bones of
the leg. The articulating part of the talus is wedge shaped – it is broad
anteriorly, and narrow posteriorly:
Dorsiflexion – the anterior part of the talus is held in the mortise, and the
joint is more stable.
Plantarflexion – the posterior part of the talus is held in the mortise, and
the joint is less stable.

Ligaments
• Medial Ligament
• The medial ligament (or deltoid ligament) is attached to the medial malleolus (a
bony prominence projecting from the medial aspect of the distal tibia).
• It consists of four ligaments, which fan out from the malleolus, attaching to the talus,
calcaneus and navicular bones. The primary action of the medial ligament is to
resist over-eversion of the foot.
• Lateral Ligament
• The lateral ligament originates from the lateral malleolus (a bony prominence
projecting from the lateral aspect of the distal fibula).
• It resists over-inversion of the foot, and is comprised of three distinct and
separate ligaments:
• Anterior talofibular – spans between the lateral malleolus and lateral aspect of the
talus.
• Posterior talofibular – spans between the lateral malleolus and the posterior
aspect of the talus.
• Calcaneofibular – spans between the lateral malleolus and the calcaneus.

67. LIGAMENTS SUPPORTING MEDIAL
LONGITUDINAL ARCH OF FOOT
• Medial Arch
• The medial arch is the higher of the two longitudinal arches. It is
formed by the calcaneus, talus, navicular, three cuneiforms and first
three metatarsal bones. It is supported by:
• Muscular support: Tibialis anterior and posterior, fibularis longus,
flexor digitorum longus, flexor hallucis, and the intrinsic foot muscles
plantar, short plantar and plantar calcaneonavicular ligaments),
medial ligament of the ankle joint.
• Other: Plantar aponeurosis

• Ligaments
• The supporting ligaments provide more stability than the bones
of the arch. One of these ligamentous structures, the plantar
aponeurosis, acts as a supporting beam between the two pillars.
Another important structure, the spring ligament, supports the
head of the talus. The talocalcaneal ligament and the anterior
fibres of the deltoid ligament also provide stability for this arch.

2. Supraspinatus muscle
• The supraspinatus muscle is one of the four muscles that
make up the rotator cuff, the others being: infraspinatus, teres
minor, and subscapularis.
• Summary
• origin: supraspinous fossa of the scapula
• insertion: superior facet of the greater tubercle of the humerus
• innervation: suprascapular nerve (C5,6)
• arterial supply: suprascapular and dorsal scapular arteries 2
• action: abduction of the humerus. It is the main agonist muscle
for this movement during the first 15 degrees of its arc.

• The supraspinatus muscle tendon is often ruptured in sports
involving sudden forceful movements of the upper limb and is
the most commonly ruptured rotator cuff muscle. The muscle
can also degenerate in the elderly leading to increased
instability and loss of function at the shoulder joint.
• The supraspinatus tendon can also become inflamed, in
persons of any age, leading to supraspinatus tendinitis which is
often associated with shoulder impingement syndrome.

13. BLOOD SUPPLY OF SPINAL CORD
• The arterial supply to the spinal cord is via three
longitudinal arteries – the anterior spinal artery and the
paired posterior spinal arteries.
• Anterior spinal artery – formed from branches of the
vertebral arteries. They travel in the anterior median
fissure.
• Posterior spinal arteries – originate from the vertebral
artery or the posteroinferior cerebellar artery. They
anastamose with one another in the pia mater.

•Additional arterial supply is via
the anterior and posterior segmental
medullary arteries – small vessels which enter
via the nerve roots. The largest anterior
segmental medullary artery is the artery of
Adamkiewicz. It arises from the inferior
intercostal or upper lumbar arteries, and supplies
the inferior 2/3 of the spinal cord

•Venous drainage is via three anterior and three
posterior spinal veins. These veins are
valveless, and form an anastamosing network
along the surface of the spinal cord. They also
receive venous blood from the radicular veins.
The spinal veins drain into the internal and
external vertebral plexuses, which in turn empty
into the systemic segmental veins. The internal
vertebral plexus also empties into the dural
venous sinuses superiorly.

17. ROTATOR CUFF
• The rotator cuff muscles are a group of four muscles that
originate from the scapula and attach to the humeral head.
Collectively, the resting tone of these muscles acts to ‘pull’ the
h u m e r a l h e a d i n t o t h e g l e n o i d f o s s a . T h i s
gives the glenohumeral joint a lot of additional stability.
• In addition to their collective function, the rotator cuff muscles
also have their own individual actions.

Supraspinatus
•Attachments: Originates from the supraspinous fossa of
the scapula, attaches to the greater tubercle of the
humerus.
•Innervation: Suprascapular nerve.
•Actions: Abducts the arm 0-15o, and assists deltoid for 15-
90o
Infraspinatus
•Attachments: Originates from the infraspinous fossa of
the scapula, attaches to the greater tubercle of the
humerus.
•Innervation: Suprascapular nerve.

Subscapularis
•Attachments: Originates from the subscapular fossa, on
the costal surface of the scapula. It attaches to the lesser
tubercle of the humerus.
•Innervation: Upper and lower subscapular nerves.
•Actions: Medially rotates the arm.
Teres Minor
•Attachments: Originates from the posterior surface of the
scapula, adjacent to its lateral border. It attaches to the
greater tubercle of the humerus.
•Innervation: Axillary nerve.
•Actions: Laterally rotates the arm.

Clinical Relevance: Rotator Cuff Tendonitis
Rotator cuff tendonitis refers to inflammation of the tendons of the rotator cuff muscles.
This usually occurs secondary to repetitive use of the shoulder joint.
The muscle most commonly affected is the supraspinatus. During abduction, it ‘rubs’
against the coraco-acromial arch. Over time, this causes inflammation and degenerative
changes in the tendon itself.
Conservative treatment of rotator cuff tendonitis involves rest, analgesia, and
physiotherapy. In more severe cases, steroid injections and surgery can be considered.

4. Brachial plexus
• The plexus is formed by the anterior rami (divisions) of cervical
spinal nerves C5, C6, C7 and C8, and the first thoracic spinal
nerve, T1.

• Roots
• The ‘roots’ refer the anterior rami of the spinal nerves that
comprise the brachial plexus. These are the anterior rami of
spinal nerves C5, C6, C7, C8, and T1.
• Trunks
• At the base of the neck, the roots of the brachial plexus
converge to form three trunks. These structures are named by
their relative anatomical location:
• Superior trunk – a combination of C5 and C6 roots.
• Middle trunk – continuation of C7.
• Inferior trunk – combination of C8 and T1 roots.

• Divisions
• Each trunk divides into two branches within the posterior triangle of
the neck. One division moves anteriorly (toward the front of the
body) and the other posteriorly (towards the back of the body). Thus,
they are known as the anterior and posterior divisions.
• Cords
• Once the anterior and posterior divisions have entered the axilla,
they combine together to form three cords, named by their position
relative to the axillary artery.
• The lateral cord is formed by the anterior division of the superior
trunk and middle trunk
• The posterior cord is formed by the posterior division of the superior
trunk, middle trunk and inferior trunk
• The medial cord is formed by the anterior division of the inferior
trunk.

•Terminal
branches
• Musculocutaneous nerve
• Axillary nerve
• Radial nerve
• Median nerve
• Ulnar nerve

22.PETITS TRIANGLE AND ITS
IMPORTANCE
• The [lumbar triangle] is a well-defined triangular space in the
posterolateral lumbar region. Also known as the inferior lumbar
triangle,
• its boundaries are:
• inferior, the iliac crest;
• anteromedial: latissimus dorsi muscle;
• posterolateral: posterior border of the external oblique muscle.
• The triangle has a superior apex, and the floor of the triangle is
the internal oblique muscle.

• The lumbar triangle is an area that is not as thick as the rest of
the abdominal wall and as such it is a site of potential weakness
that can lead to a lumbar hernia, also known as Petit’s hernia.

23. TYPICAL LUMBAR VERTEBRAAND
ITS SIGNIFICANCE

• Lumbar Vertebrae Function
• The lumbar vertebrae’s function is to support the great weight of
the body and allow certain movements, such as lifting objects.
The lumbar vertebrae flex and extend through rotation between
the vertebrae and movements in the sagittal plane between
them
• These bones also protect the spinal cord and nerves from injury
and provide a measure of support. The lumbar vertebrae are
the biggest vertebral bones. They increase in size further down
the spine in order to support the increasing weight of the body.

• Musculus longus colli or Musculus longus cervicis is one of the
four deep cervical flexor muscles (AKA anterior cervical muscles)
together with Longus Capitis, Rectus Capitis
Anterior and Rectus Capitis Lateralis
• It consists of three portions:
•
• Superior Oblique
• Inferior Oblique
• Vertical

• Origin
• C3 to T3
• Anterior tubercles and anterior surfaces of bodies of C3 to T3
• Superior Oblique portion arises from anterior tubercles of the
transverse processes of the third, fourth, and fifth cervical
vertebræ
• Inferior Oblique portion arises from the front of the bodies of the
first two or three thoracic vertebræ
• Vertical portion arises from the front of the bodies of the upper
three thoracic and lower three cervical vertebræ

• Insertion
• Anterior arch of atlas, anterior tubercles of C5-6, anterior
surfaces of bodies of vertebrae C2-4
• Superior Oblique portion inserts into the tubercle on the anterior
arch of the atlas
• Inferior Oblique portion into the anterior tubercles of the
transverse processes of the fifth and sixth cervical vertebræ
• Verticle portion into the front of the bodies of the second, third,
and fourth cervical vertebræ

Artery ascending cervical artery,
Ascending Pharyngeal and
Vertebral Arteries
Nerve C2-C6 Ventral rami
Actions Flexes the neck and head

• Function
• As well as acting with the other cervical flexors to produce neck
flexion, Longus Colli has been shown to have a postural
function on cervical curvature, counteracting the lordosis
increment related to the weight of the head and to the
contraction of the posterior cervical muscles[2].
• It is commonly implicated in whiplash[3]
• Impaired strength and endurance of the deep neck flexors has
been found to be a feature of cervicogenic headache[4].

31. VERTEBRAL CANAL
• The spinal canal, also known as the vertebral canal, is the
cavity within the vertebral column which contains the spinal cord.

Gross anatomy
• The spinal canal becomes progressively narrower from its superior
opening at the foramen magnum to its inferior opening at the sacral
hiatus 1. The canal itself is primarily formed by the vertebral foramen
of adjacent vertebrae. Allowing for variation, the spinal cord occupies
the superior two-thirds of the spinal canal and terminates at
approximately the middle of the L1 vertebral body 2.
• The canal has a typical shape depending on it's level:
• cervical: small and triangular
• thoracic: small and round
• lumbar: large and triangular

• Boundaries
• anterior: vertebral bodies, intervertebral discs, posterior
longitudinal ligament
• posterior: ligamentum flavum lining the laminae
• lateral: vertebral pedicles 1
• Contents
• spinal meninges
• spinal cord with its associated nerve roots and vessels
(see blood supply of the spinal cord)
• epidural space

41. ERBS POINT
• The nerve point of the neck, also known as Erb's point[1] is a
site at the upper trunk of the brachial plexus located 2–3 cm
above the clavicle.
• It is named for Wilhelm Heinrich Erb.[2]
• Taken together, there are six types of nerves that meet at this
point.

• Convergence of nerves[edit]
• Erb's point is formed by the union of the C5 and C6 nerve roots,
which later converge. At the nerve trunk, branches
of suprascapular nerves and the nerve to the subclavius also
merge. The merged nerve divides into
the anterior and posterior division of C5 and C6

• Clinical significance[edit]
• Injury to Erb's point is commonly sustained at birth or from a fall
onto the shoulder. The nerve roots normally involved are C5
and partly C6. Symptoms include paralysis of
the biceps, brachialis, and coracobrachialis (through
the musculocutaneous nerve); the brachioradialis (through
the radial nerve); and the deltoid (through the axillary nerve).
The effect is called "Erb's palsy". Typically, an affected person's
arm hangs at the side with the hand rotated medially, like
a porter waiting for a tip; hence the colloquial name "porter's tip
hand".[4]

43. ATLANTO AXIAL JOINT
• The atlanto-axial articulation is a complex of three synovial joints,
which join the atlas (C1) to the axis (C2)
• Articulations
• paired lateral atlanto-axial joints: classified as planar-type synovial
joint between the lateral masses of C1 and C2, though somewhat
more complex in shape with concavity of the superior axial facets
• median atlanto-axial (atlanto-dental or atlanto-odontoid) joint: pivot-
type synovial joint with anterior and posterior articulations of odontoid
process/dens of C2 and anterior arch and transverse ligament of C1
• fibrous capsules of the lateral and medial joints are thin and provide
only minimal support, therefore ligamentous attachments provide the
majority of support

Key facts about the atlantoaxial joint
Type Atlantoaxial joint complex: Synovial joint; biaxial
Articular
surfaces
Median atlantoaxial joint: dens of axis (C2), osteoligamentous
ring (anterior arch of atlas [C1], transverse ligament of atlas)
Lateral atlantoaxial joints: inferior articular surface of lateral
mass for atlas, superior articular facet of axis
Ligaments Cruciform ligament (transverse ligament of atlas, superior and
inferior longitudinal bands), tectorial membrane, alar ligaments,
apical ligament of dens
Innervation Ventral primary ramus of the second cervical spinal nerve
Blood
supply
Deep cervical, occipital, vertebral arteries
Movements Principal movement; axial rotation,

Attachments
• anterior longitudinal ligament: thick fibrous band attaches from inferior
border of anterior arch of C1 to the anterior axial body
• posterior atlanto-occipital membrane (continuation of ligamenta flava):
attaches from lower border of atlantal arch (and more superiorly to the
occipital bone) and upper borders of lamina of C2
• cruciform ligaments: superior, transverse and inferior bands posterior to
dens; transverse is strongest portion which stabilizes odontoid to the lateral
mass of C1 limiting lateral motion of C1 over C2 and limiting subluxation of
the joint 1
• accessory atlanto-axial ligament: from posterior body of C2 to lateral mass
of C1
• there are a number of ligaments which attach the axis to the occipital bone
including the tectorial membrane, the paired alar ligaments, median apical
ligament and the longitudinal parts of the cruciform ligaments

• Function
• The atlanto-axial joint allows 10-15o of flexion/extension, 30o of
axial rotation and only minimal lateral flexion

49. STRUTHERS LIGAMENT
• Struthers' ligament is a feature of human anatomy consisting
of a band of connective tissue at the medial aspect of the
distal humerus.
• It courses from the supracondylar process of the humerus (also
known as avian spur) to the medial humeral epicondyle.[2] It is
not a constant ligament,[3][4][5] and can be acquired or congenital.

• The clinical significance of this structure is due to the median
nerve and brachial artery which may pass underneath the "arch"
formed by the process and ligament over the humeral body.
Within this space the nerve may be compressed leading
to supracondylar process syndrome.[6][7][8][9]
• The ligament may also affect the ulnar nerve after an anterior
transposition surgery, which is a commonly performed to
manage patients with a cubital tunnel syndrome, a form of ulnar
nerve entrapment.

28. POSTERIOR CORD OF BRACHIAL
PLEXUS
• The posterior cord is a part of the brachial plexus. It consists of
contributions from all of the roots of the brachial plexus.[1]
• The posterior cord is formed by:
• The posterior division of the superior trunk
• The posterior division of the middle trunk
• The posterior division of the inferior trunk
• The posterior cord gives rise to the following nerves:[2]

Name Roots Supplies
upper subscapular nerve C5-C6 subscapularis muscle of the rotator cuff
lower subscapular nerve C5-C6 subscapularis muscle, teres major muscle
thoracodorsal nerve C6-C8 latissimus dorsi muscle
axillary nerve C5-C6
sensation to the shoulder and motor to
the deltoid muscle, the teres minor and
the triceps brachii (long head) muscle
radial nerve C5-C8, T1
triceps brachii muscle,
the brachioradialis muscle, the extensor
muscles of the fingers and wrist (extensor carpi
radialis muscle), supinator, and the extensor
and abductor muscles of the thumb

29. AXILLARY ARTERY
• The axillary artery represents the continuation of
the subclavian artery and is a major artery of the upper limb.
• Summary
• origin: continuation of the subclavian artery as it passes under
the midpoint of the clavicle on the outer edge of the first rib
• termination: continues as the brachial artery at the lower
border of teres major

• The axillary artery lies deep to the pectoralis minor and
is enclosed in the axillary sheath (a fibrous layer
that covers the artery and the three cords of the brachial plexus).
• Importantly, the artery can be divided into three parts based on
its position relative to the pectoralis minor muscle:
• First part – proximal to pectoralis minor
• Second part – posterior to pectoralis minor
• Third part – distal to pectoralis minor

First Part Second Part Third Part
Superior thoracic
artery
Thoracoacromial
artery
Lateral thoracic artery
Subscapular artery
Anterior and posterior
circumflex arteries
The main branches of the axillary artery include:
The anterior and posterior circumflex humeral arteries form
an anastomotic network around the surgical neck of the humerus
and can be damaged in cases of fracture.
At the lower border of the teres major muscle, the axillary artery is
renamed the brachial artery.

5. Tensor fascia lata
• The tensor fascia lata is a
gluteal muscle that acts as a
flexor, abductor, and internal
rotator of the hip. Its name,
however, is derived from its
additional role in tensing the
fascia lata

Origin Anterior superior iliac spine
Insertion Iliotibial tract (via greater trochanter)
Artery Primarily lateral circumflex femoral
artery, superior gluteal artery
Nerve Superior gluteal nerve (L4, L5, S1)
Actions Hip - flexion, medial
rotation, abduction, knee - lateral rotation, Torso -
stabilization

• Patellar ligament – a continuation of the quadriceps
femoris tendon distal to the patella. It attaches to the tibial
tuberosity.
• Collateral ligaments – two strap-like ligaments. They act
to stabilise the hinge motion of the knee, preventing
excessive medial or lateral movement
• Tibial (medial) collateral ligament – wide and flat ligament,
found on the medial side of the joint. Proximally, it attaches to
the medial epicondyle of the femur, distally it attaches to the
medial condyle of the tibia.
• Fibular (lateral) collateral ligament – thinner and rounder
than the tibial collateral, this attaches proximally to the lateral
epicondyle of the femur, distally it attaches to a depression on
the lateral surface of the fibular head.

• Cruciate Ligaments – these two ligaments connect the
femur and the tibia. In doing so, they cross each other,
hence the term ‘cruciate’ (Latin for like a cross)
• Anterior cruciate ligament – attaches at the anterior
intercondylar region of the tibia where it blends with the
medial meniscus. It ascends posteriorly to attach to the
femur in the intercondylar fossa. It prevents anterior
dislocation of the tibia onto the femur.
• Posterior cruciate ligament – attaches at the posterior
intercondylar region of the tibia and ascends anteriorly to
attach to the anteromedial femoral condyle. It prevents
posterior dislocation of the tibia onto the femur

8. FEMORAL TRIANGLE( scarpas
triangle)
• The femoral triangle is a
w e d g e - s h a p e d a r e a
l o c a t e d w i t h i n t h e
superomedial aspect of the
anterior thigh.
• It acts as a conduit for
structures entering and
leaving the anterior thigh.

Borders
• The femoral triangle consists of three borders, a floor and a roof:
• Roof – fascia lata.
• Floor – pectineus, iliopsoas, and adductor longus muscles.
• Superior border – inguinal ligament (a ligament that runs from
the anterior superior iliac spine to the pubic tubercle).
• Lateral border – medial border of the sartorius muscle.
• Medial border – medial border of the adductor longus muscle.
The rest of this muscle forms part of the floor of the triangle.
• The inguinal ligament acts as a flexor retinaculum, supporting
the contents of the femoral triangle during flexion at the hip.

Contents
• The femoral triangle contains some of the major neurovascular
structures of the lower limb. Its contents (lateral to medial) are:
• Femoral nerve – innervates the anterior compartment of the
thigh, and provides sensory branches for the leg and foot.
• Femoral artery – responsible for the majority of the arterial
supply to the lower limb.
• Femoral vein – the great saphenous vein drains into the femoral
vein within the triangle.
• Femoral canal – contains deep lymph nodes and vessels.
• The femoral artery, vein and canal are contained within a fascial
compartment – known as the femoral sheath

Anterior Approach to the Hip
• Make a longitudinal
incision along the
anterior half of the
iliac crest to the
anterior superior iliac
spine. From there,
curve the incision
down so that it runs
vertically for some 8
to 10 cm.

• The internervous
plane lies
between the
sartorius
(femoral nerve)
and the tensor
fasciae latae
(superior gluteal
nerve).

• The deeper
internervous plane
lies between the
rectus femoris
(femoral nerve) and
the gluteus medius
(superior gluteal
nerve).

14. SCIATIC NERVE
• The sciatic
nerve is a major
nerve of the lower
limb. It is a thick flat
band,
approximately 2cm
wide – the largest
nerve in the body.
• Nerve roots: L4-S3

Origin
•The sciatic nerve originates from lumbosacral plexus L4-
S3
• tibial division
• orginates from anterior preaxial
branches of L4,L5,S1,S2,S3
• peroneal division
• originates from from postaxial
branches of L4,L5,S1,S2

Course
•Exits sciatic notch
• runs anterior or deep to
piriformis
• runs posterior or superficial to
short external rotators (superior
gemellus, inferior gemellus,
obturator internus)
•Posterior leg
• It then runs down the posterior
leg where it breaks into its three
main divisions at the level of the
mid thigh
•Terminal branches
• common peroneal nerve
• tibial nerve

• Motor functions:Innervates the muscles of the posterior thigh
(biceps femoris, semimembranosus and semitendinosus) and
the hamstring portion of the adductor magnus (remaining
portion of which is supplied by the obturator nerve).
• Indirectly innervates (via its terminal branches) all the muscles
of the leg and foot.
• Sensory functions: No direct sensory functions. Indirectly
innervates (via its terminal branches) the skin of the lateral leg,
heel, and both the dorsal and plantar surfaces of the foot.

• The sciatic nerve also indirectly innervates several other
muscles, via its two terminal branches:
• Tibial nerve – the muscles of the posterior leg (calf muscles),
and some of the intrinsic muscles of the foot.
• Common fibular nerve – the muscles of the anterior leg, lateral
leg, and the remaining intrinsic foot muscles.
• In total, the sciatic nerve innervates the muscles of the posterior
thigh, entire leg and entire foot.

The sciatic nerve does not have
any direct cutaneous functions.
It does provide indirect sensory
innervation via its terminal
branches:
•Tibial nerve – supplies the skin
of the posterolateral leg, lateral
foot and the sole of the foot.
•Common fibular nerve –
supplies the skin of the lateral
leg and the dorsum of the foot.

15. SYNOVIAL PLICAE
• Plica syndromedefined as a
painful impairment of knee
function resulting from the
thickened and
inflamed synovial folds
• usually only medial plica
• 50% present with history of
blunt trauma to the anterior
knee

•Plica
• are embryologic remnant synovial folds. Most common plicae
are
• ligamentum mucosum
• most common plica
• located in the intercondylar notch
• suprapatellar plica
• located in the suprapatellar space, extending from the
medial wall of the knee toward the lateral wall
• medial plica
• extends from the infrapatellar fat pad to the medial
wall of the knee
• most commonly irritated from the abrading the medial
femoral condyle

Presentation
•Symptoms
• snapping sensations
• buckling
• knee pain on sitting
• pain with repetitive activity
Physical exam
•tenderness in the medial parapatellar region
•painful, palpable medial parapatellar cord
•can be rolled and popped beneath the examiners finger
•provacative test
•hold the knee in full extension while examiner tries to flex
against the patient’s resistance.
•the examiner again pushes the patella medially while palpating its
medial border.
•pain produced with or without a click is considered a positive test.

Imaging
•MRI
• can detect plica but has low sensitivity
Treatment
•Nonoperative
• activity restriction, NSAIDS, and physical therapy
• indications
• most cases can be treated nonoperatively
• physical therapy
• moist heat applications
• hamstring stretching
• resistive strengthening exercises are avoided in early rehabilitation phases
•Operative
• arthroscopic resection of lesion
• indications
• only utilized in rare cases of plica band syndrome not responding to
nonoperative treatment

21. BLOOD SUPPLY OF FEMORAL
HEAD IN ADULTS

24. LIGAMENT OF BIGELOW AND ITS
IMPORTANCE

26. ANTERIOR CRUCIATE LIGAMENT
•The anterior cruciate ligament (ACL) is a band of
dense connective tissue which courses from the
femur to the tibia.
• The ACL is a key structure in the knee joint, as it
resists anterior tibial translation and rotational
loads.
•Blood supply
•arterial: middle genicular artery

• Origin
• Arises from the posteromedial corner of medial aspect of lateral
femoral condyle in the intercondylar notch[
• Orientation
• It runs inferiorly, medially and anteriorly.
• Insertion
• Anterior to the intercondyloid eminence of the tibia, being
blended with the anterior horn of the medial meniscus

• Like the posterior cruciate ligament, the ACL is intracapsular but
extrasynovial.
• The ACL consists of two components 4:
1.anteromedial bundle (AMB)
1.attaches to roof of intercondylar notch
2.posterolateral bundle (PLB)
1.more vertically oriented, and slightly shorter
2.attaches to wall of intercondylar notch

• Function
• The ACL functions to prevent posterior translation of the femur
on the tibia (or anterior displacement of the tibia) during flexion-
extension of the knee.
• The AMB is responsible for the posterior translation of the femur
at 30 degrees flexion, and the PLB resists hyperextension and
prevents posterior translation of the femur in extension

72. POSTERIOR CRUCIATE LIGAMENT
• Gross anatomy
• The PCL attaches to the posterior intercondylar area and passes
anterosuperiorly to insert into the lateral surface of the medial
femoral condyle.
• When the knee is in extension, it makes an almost 90º turn as it
passes anterosuperiorly. The anterior cruciate ligament passes
lateral to it and curves around it.
• The PCL is intracapsular but extrasynovial and is approximately 13
mm in length and less than 6 mm in anteroposterior diameter. It
contains two fiber bundles named according to their relative
attachments 1:
1.anterolateral
2.posteromedial

• Function
• During flexion, the anterolateral band becomes tight, whereas
the posteromedial bundle tightens during extension 1 and the
PCL as a whole acts to resist anterior translation of the femur on
the tibia 2.
• Vascular Supply
• The middle geniculate artery perforates the posterior capsule
running parallel to the superior edge of the synovial septum. It
has branches to the synovium around the PCL forming a plexus
of vessels supplying the PCL. There is also a potential supply
from a branch of the inferior geniculate artery

36. HAMSTRING MUSCLES
• The muscles in the posterior compartment of the thigh are
collectively known as the hamstrings.
• They consist of the biceps femoris, semitendinosus and
semimembranosus, which form prominent tendons medially
and laterally at the back of the knee.
• As group, these muscles act to extend at the hip, and flex at the
knee.
• They are innervated by the sciatic nerve (L4-S3)
• Note: The hamstring portion of the adductor magnus has a
similar action to these muscles, but is located in the medial thigh.

Biceps Femoris
• Like the biceps brachii in the arm, the biceps femoris muscle has two
heads – a long head and a short head.
• It is the most lateral of the muscles in the posterior thigh – the
common tendon of the two heads can be felt laterally at the posterior
knee.
• Attachments: The long head originates from the ischial tuberosity of
the pelvis. The short head originates from the linea aspera on
posterior surface of the femur. Together, the heads form a tendon,
which inserts into the head of the fibula.
• Actions: Main action is flexion at the knee. It also extends the thigh
at the hip, and laterally rotates at the hip and knee.
• Innervation: Long head innervated by the tibial part of the sciatic
nerve, whereas the short head is innervated by the common fibular
part of the sciatic nerve.

Semitendinosus
• The semitendinosus is a largely tendinous muscle. It lies
medially to the biceps femoris, and covers the majority of the
semimembranosus.
• Attachments: It originates from the ischial tuberosity of the
pelvis, and attaches to the medial surface of the tibia.
• Actions: Flexion of the leg at the knee joint. Extension of thigh
at the hip. Medially rotates the thigh at the hip joint and the leg
at the knee joint.
• Innervation: Tibial part of the sciatic nerve.

Semimembranosus
• The semimembranosus muscle is flattened and broad. It is
located underneath the semitendinosus.
• Attachments: It originates from the ischial tuberosity, but does
so more superiorly than the semitendinosus and biceps femoris.
It attaches to the medial tibial condyle.
• Actions: Flexion of the leg at the knee joint. Extension of thigh
at the hip. Medially rotates the thigh at the hip joint and the leg
at the knee joint.
• Innervation: Tibial part of the sciatic nerve

53. FEMORAL ANTEVERSION
• Also called hip anteversion, femoral anteversion is a forward
(inward) rotation in the femur (thighbone), which connects to the
pelvis to form the hip joint. In other words the knee is
excessively twisted inward relative to the hip.
Top-view illustrations of excessive femoral
anteversion

• Many children are born with femoral anteversions that they
eventually grow out of. In people who do not grow out of it, a
mildly anteverted femoral head may cause no significant health
problems.
• But an excessive anteversion of the femur overloads the
anterior (front) structures of the hip joint, including the labrum
and joint capsule. When the foot is positioned facing directly
forward, the femoral head may sublux (partially dislocate) from
the socket of the hip joint, called the acetabulum. This torsional
malalignment places abnormal stress on both the hip and knee
joints, often leading to pain and abnormal joint wear.

• Causes of femoral anteversion
• The exact cause is unknown, however, femoral anteversion is
congenital (present since birth) and develops while a child is in the
womb.
• Signs and symptoms of femoral anteversion include:
• In-toeing, in which a person walks "pigeon-toed," with each foot
pointed slightly toward the other.
• Bowlegs (also called bowed legs). Keeping the legs in this position
often helps a patient maintain balance.
• Pain in the hips, knees and/or ankles.
• Snapping sound in the hip while walking.

• Treatment for femoral anteversion
• While many children grow out of their femoral anteversion
conditions, excessive anteversion may require surgical
correction, as a procedure known as a femoral osteotomy. This
surgery involves cutting and realigning the femur.

55. PERFORATORS OF THIGH
• The perforating veins of the lower limb (PV or
“perforators”) are so called because they perforate
the deep fascia of muscles, to connect the superficial
venous systems of the lower extremity with the deep
veins where they drain.
• There are numerous veins in variable arrangement,
connection, size, and distribution
• They have valves which prevent blood flowing back
(regurgitation) from deep to superficial veins in muscular
systole [3] or contraction.

• Perforators of the thigh (venae perforantes femoris)
• medial thigh perforators
• perforators of the femoral canal (Dodd)
• inguinal perforators
• anterior thigh perforators
• lateral thigh perforators
• posterior thigh perforators
• posteromedial thigh perforators
• sciatic perforators
• posterolateral thigh perforators “perforator of Hach”
• pudendal perforators

58. PROXIMAL END OF FEMUR
• The proximal aspect of the femur articulates with the
acetabulum of the pelvis to form the hip joint.
• It consists of a head and neck, and two bony processes –
the greater and lesser trochanters. There are also two bony
ridges connecting the two trochanters; the intertrochanteric line
anteriorly and the trochanteric crest posteriorl

• Head – articulates with the acetabulum of the pelvis to form the
hip joint. It has a smooth surface, covered with articular cartilage
(except for a small depression – the fovea – where ligamentum
teres attaches).
• Neck – connects the head of the femur with the shaft. It is
cylindrical, projecting in a superior and medial direction. It is set
at an angle of approximately 135 degrees to the shaft. This
angle of projection allows for an increased range of movement
at the hip joint.

• Greater trochanter – the most lateral palpable projection of
bone that originates from the anterior aspect, just lateral to the
neck.
• It is the site of attachment for many of the muscles in the gluteal region,
such as gluteus medius, gluteus minimus and piriformis. The vastus
lateralis originates from this site.
• An avulsion fracture of the greater trochanter can occur as a result of
forceful contraction of the gluteus medius.
• Lesser trochanter – smaller than the greater trochanter. It
projects from the posteromedial side of the femur, just inferior to
the neck-shaft junction.
• It is the site of attachment for iliopsoas (forceful contraction of which
can cause an avulsion fracture of the lesser trochanter).

• Intertrochanteric line – a ridge of bone that runs in an
inferomedial direction on the anterior surface of the femur,
spanning between the two trochanters. After it passes the lesser
trochanter on the posterior surface, it is known as the pectineal
line.
• It is the site of attachment for the iliofemoral ligament (the strongest
ligament of the hip joint).
• It also serves as the anterior attachment of the hip joint capsule.
• Intertrochanteric crest – like the intertrochanteric line, this is a
ridge of bone that connects the two trochanters. It is located on
the posterior surface of the femur. There is a rounded tubercle
on its superior half called the quadrate tubercle; where
quadratus femoris attaches.

70. SHORT EXTERNAL ROTATORS OF
HIP

3. Iliotibial band
• The iliotibial
tract or iliotibial band is
a longitudinal fibrous
reinforcement of
the fascia lata.runs along
the lateral thigh and
serves as an important
structure involved in
lower extremity motion

• Origin
• It originates at the anterolateral iliac tubercle portion of the
external lip of the iliac crest
• Insertion
• Inserts at the lateral condyle of the tibia at Gerdy's tubercle
• Nerve
• The ITB shares the innervation of the TFL and gluteus
maximus via the superior gluteal nerve (SGN) and inferior
gluteal nerve (IGN
• Artery
• The ITB, being a tendinous extension of the tensor fascia lata
(TFL), shares the same arterial supply:
• Ascending branch of the lateral femoral circumflex artery (LFCA)
• Superior gluteal artery (SGA)

• Function.
• The action of the muscles associated with the ITB (TFL and
some fibers of Gluteus Maximus) flex, extend, abduct, and
laterally and medially rotate the hip.
• The ITB contributes to lateral knee stabilization.
• During knee extension the ITB moves anterior to the lateral
condyle of the femur, while ~30 degrees knee flexion[2], the ITB
moves posterior to the lateral condyle.

• Clinical relevance
• External snapping hip syndrome, or externa coxa saltans
• chronic pain in the lateral aspect of the hip located over the
greater trochanter of the femur
• thickening of the posterior aspect of the ITB or anterior tendon
fibers of the gluteus maximus muscle near its insertion
• This portion of the band remains posterior to the greater
trochanter in hip extension, however, moves anteriorly when
flexed, adducted, or internally rotated causing a "snapping"
mechanism. This snapping is the tense fascial structure
catching on the greater trochanter as it moves in the before
mentioned motions

• Assessment
• Clinical examination testing for ITB dysfunction is best elicited
utilizing the Ober Test.
• Treatment
• Treatment generally initiates with ITB stretching ,therapeutic
exercises and physical therapy. NSAID use may be beneficial to
reduce inflammation. Surgery is a last resort used for refractory
cases.

16. PSOAS MAJOR
Details
Origin Transverse processes of T12-L4 and the lateral
aspects of the discs between them
Insertion In the lesser trochanter of the femur
Artery lumbar branch of iliolumbar artery
Nerve Lumbar plexus via anterior branches of L1-L3
nerves
Actions Flexion in the hip joint
Antagonist Gluteus maximus

19. EXTENSOR MECHANISM OF KNEE
• The extensor mechanism of the knee comprises the
• quadriceps muscle and tendon,
• the patella, and
• the patellar tendon (also known as the infra-patellar ligament).
• Disruption of any of these components impedes a person’s
ability to actively extend the knee or resist passive flexion

•The extensor lever arm is greatest at 20 degrees of flexion
and the quadriceps force required for knee extension increases
significantly in the last 20 degrees of extension

The length of lever arm varies as a function of geometry
of trochlea varying petallo femoral contact areas and
the varying centre of rotation of knee

OPEN KINETIC CHAIN- during knee extension, tibia glides anteriorly on femur. more
precisely, from 200 knee flexion to full extension, tibia rotatesexternally.
During knee flexion, tibia glides posteriorly on femur and from full knee extension to 200
flexion, tibia rotatesinternally
CLOSED KINETIC CHAIN - during knee extension, femur glides posteriorly on tibia. to be
more specific, from 200 knee flexion to full extension, femur rotates internally on stable tibia.
during knee flexion, femur glides anteriorly on tibia and from full knee extension to 200 flexion,
femur rotates externally on stable tibia.

THE "SCREW HOME MECHANISM"
the "screw-home" mechanism, considered to be a key element to knee stability, is the rotation
between the tibia and femur. it occurs at the end of knee extension, between full extension (0
degrees) and 20 degrees of knee flexion. the tibia rotates internally during the open chain
movements (swing phase) and externally during closed chain movements (stance phase). external
rotation occurs during the terminal degrees of knee extension and results in tightening of both
cruciate ligaments, which locks the knee. the tibia is then in the position of maximal stability with
respect to the femur

60. COMMON PERONEAL NERVE
• Overview
• Nerve roots: L4 – S2
• Motor: Innervates the short head of the biceps femoris directly.
Also supplies (via branches) the muscles in the lateral and
anterior compartments of the leg.
• Sensory: Innervates the skin of the lateral leg and the dorsum
of the foot.

Anatomical Course
• The nerve begins at the apex of the popliteal fossa, where the
sciatic nerve bifurcates into the tibial and common fibular nerves.
• The common fibular nerve follows the medial border of the biceps
femoris, running in a lateral and inferior direction, over the lateral
head of the gastrocnemius. At this point, the nerve gives rise to two
cutaneous branches, which contribute to the innervation of the skin
of the leg.
• To enter the lateral compartment of the leg, the nerve wraps around
the neck of the fibula, passing between the attachments of
the fibularis longus muscle. Here, the common fibular nerve
terminates by dividing into the superficial fibular and deep fibular
nerves

Motor Functions
• The common fibular nerve innervates the short head of
the biceps femoris muscle (part of the hamstring muscles, which
flex at the knee)
• In addition, its terminal branches also provide innervation to
muscles:
• Superficial fibular nerve: Innervates the muscles of the lateral
compartment of the leg; fibularis longus and brevis. These
muscles act to evert the foot.
• Deep fibular nerve: Innervates the muscles of the anterior
compartment of the leg; tibialis anterior, extensor digitorum longus
and extensor hallucis longus. These muscles act to dorsiflex the
foot, and extend the digits. It also innervates some intrinsic
muscles of the foot.
• If the common fibular nerve is damaged, the patient may lose the
ability to dorsiflex and evert the foot, and extend the digits.

Sensory Functions
• There are two cutaneous branches that arise directly from the common
fibular nerve as it moves over the lateral head of the gastrocnemius.
• Sural communicating nerve: This nerve combines with a branch of
the tibial nerve to form the sural nerve. The sural nerve innervates the
skin over the lower posterolateral leg.
• Lateral sural cutaneous neve: Innervates the skin over the upper
lateral leg.
• In addition to these nerves, the terminal branches of the common fibular
nerve also have a cutaneous function:
• Superficial fibular nerve: Innervates the skin of the anterolateral leg,
and dorsum of the foot (except the skin between the first and second
toes).
• Deep fibular nerve: Innervates the skin between the first and second
toes.

Attachments
• Musculotendinous
• nil
• Ligamentous
• intrinsic ligaments
• scapholunate ligament
• lunotriquetral ligament
• extrinsic ligaments
• palmar: radiolunotriquetral, radioscapholunate, ulnolunate ligaments
• Blood supply[edit]
• The lunate receives its blood supply from dorsal and palmar
branches

18. CARPAL TUNNEL
• The carpal tunnel is a narrow passageway found on the anterior
portion of the wrist. It serves as the entrance to the palm for
several tendons and the median nerve.
• Borders
• The carpal tunnel is formed by two layers: a deep carpal
arch and a superficial flexor retinaculum. The deep carpal
arch forms a concave surface, which is converted into a tunnel
by the overlying flexor retinaculum (transverse carpal ligament).

Carpal Arch
•Concave on the palmar side, forming the base and sides of the
carpal tunnel.
•Formed laterally by the scaphoid and trapezium tubercles
•Formed medially by the hook of the hamate and the pisiform
Flexor Retinaculum
•Thick connective tissue which forms the roof of the carpal
tunnel.
•Turns the carpal arch into the carpal tunnel by bridging the
space between the medial and lateral parts of the arch.
•Spans between the hook of hamate and pisiform (medially) to
the scaphoid and trapezium (laterally).

• Contents
• The carpal tunnel contains a total of 9 tendons, surrounded by
synovial sheaths, and the median nerve. The palmar
cutaneous branch of the median nerve is given off prior to the
carpal tunnel, travelling superficially to the flexor retinaculum.
• Tendons
• The tendon of flexor pollicis longus
• Four tendons of flexor digitorum profundus
• Four tendons of flexor digitorum superficialis

Clinical Relevance: Carpal Tunnel
Syndrome
• Compression of the median nerve within the carpal tunnel can
cause carpal tunnel syndrome (CTS).
• It is the most common mononeuropathy and can be caused by
thickened ligaments and tendon sheaths.
• Its aetiology is, however, most often idiopathic. If left
untreated, CTS can cause weakness and atrophy of the thenar
muscles.

27. SCAPHOID
• The scaphoid is the largest of the proximal row of carpal
bones and sits on the radial side of the lunate. It is a boat-
shaped bone that is oriented obliquely with its long axis
aligned from the medial portion of the distal radius
proximally to the articulation of the 1st and 2nd metacarpals
distally.
• The scaphoid can be divided into proximal and distal poles.
The waist (between the two) is the commonest site
of scaphoid fracture. The scaphoid tubercle is a bony
prominence on the ventral surface of the lateral portion of
the distal pole

•Articulations
•The scaphoid articulates with five bones: the
radius, trapezoid, trapezium, lunate and capitate.
•proximal surface: radius
•distal surface: laterally with
the trapezoid and trapezium; medially with
the capitate
•ulnar surface: lunate

• Attachments
• Musculotendinous
• There are no musculotendinous attachments to the scaphoid bone.
• Ligamentous
• dorsal surface: dorsal radiocarpal ligament
• radial surface: radial collateral ligament
• scapholunate ligament
• radioscapholunate ligament
• scaphocapitate ligament
• transverse carpal ligament

•Arterial supply
•Approximately 75% of the arterial supply is from
branches of the radial artery through vascular
perforations on the dorsal surface near the
tubercle and waist 2. As the vascular supply to the
proximal pole is mainly retrograde,
a fracture through the tubercle or the waist places
the proximal pole at risk of avascular necrosis.

37. POSTERIOR INTEROSSEOUS
NERVE
Course
•Origins
• originates from the radial nerve at the radiohumeral joint line
•Course
• arcade of Frosche at radial head
• dives under supinator at arcade of Frohse (thickened edge of
between heads of supinator)
• forearm posterior compartment
• winds around radial neck within substance of muscle to posterior
compartment of forearm
• interosseous membrane
• reaches interosseous membrane of forearm and ends as
sensation to dorsal wrist capsule
• dorsal wrist capsule

Motor Innervation
•Motor
• common extensors
• ECRB (often from radial nerve proper, but can be from PIN)
• Extensor digitorum communis (EDC)
• Extensor digiti minimi (EDM)
• Extensor carpi ulnaris (ECU)
• deep extensors
• Supinator
• Abductor pollicis longus (APL)
• Extensor pollicus brevis (EPB)
• Extensor pollicus longus (EPL)
• Extensor indicis proprius (EIP)

Senory Innervation
•Sensory
• sensory fibers to dorsal wrist capusle
• provided by terminal branch which is located on the floor of
the 4th extensor compartment
• no cutaneous innervation
Clinical
•PIN compression Syndrome
• in PIN palsy, the last muscle to recover is the extensor indicis
proprius
•Dorsal Approach to Radius (Thompson)

• Overview
• Nerve roots – C5-T1.
• Sensory – Innervates most of the skin of the posterior forearm,
the lateral aspect of the dorsum of the hand, and the dorsal
surface of the lateral three and a half digits.
• Motor – Innervates the triceps brachii and the extensor muscles
in the forearm.

Anatomical Course
• The radial nerve is the terminal continuation of the posterior
cord of the brachial plexus. It therefore contains fibres from
nerve roots C5 – T1.
• T h e n e r v e a r i s e s i n t h e a x i l l a r e g i o n , w h e r e i t i s
situated posteriorly to the axillary artery. It exits the axilla
inferiorly (via the triangular interval), and supplies branches to
the long and lateral heads of the triceps brachii.
• The radial nerve then descends down the arm, travelling in a
shallow depression within the surface of the humerus, known as
the radial groove.

• As it descends, the radial nerve wraps around the humerus
laterally, and supplies a branch to the medial head of the triceps
brachii. During much of its course within the arm, it is
accompanied by the deep branch of the brachial artery.
• To enter the forearm, the radial nerve travels anterior to
the lateral epicondyle of the humerus, through the cubital
fossa. The nerve then terminates by dividing into two branches:
• Deep branch (motor) – innervates the muscles in the posterior
compartment of the forearm.
• Superficial branch (sensory) – contributes to the cutaneous
innervation of the dorsal hand and fingers.

Motor Functions
• The radial nerve innervates the muscles located in the posterior
arm and posterior forearm.
• In the arm, it innervates the three heads of the triceps
brachii, which acts to extend the arm at the elbow. The radial
nerve also gives rise to branches that supply the brachioradialis
and extensor carpi radialis longus (muscles of the posterior
forearm).
• A t e r m i n a l b r a n c h o f t h e r a d i a l n e r v e , t h e d e e p
branch, innervates the remaining muscles of the posterior
forearm. As a generalisation, these muscles act to extend at the
wrist and finger joints, and supinate the forearm

Sensory Functions
• There are four branches of the radial nerve that provide cutaneous
innervation to the skin of the upper limb. Three of these branches
arise in the upper arm:
• Lower lateral cutaneous nerve of arm – Innervates the lateral
aspect of the arm, inferior to the insertion of the deltoid muscle.
• Posterior cutaneous nerve of arm – Innervates the posterior
surface of the arm.
• Posterior cutaneous nerve of forearm – Innervates a strip of skin
down the middle of the posterior forearm.
• The fourth branch – the superficial branch – is a terminal division of
the radial nerve. It innervates the dorsal surface of the lateral three
and half digits and the associated area on the dorsum of the hand.

61. NUTRIENT ARTERY
• The nutrient artery (arteria nutricia) or medullary, usually
accompanied by one or two veins, enters the bone through the
nutrient foramen, runs obliquely through the cortex, sends
branches upward and downward to the bone marrow, which
ramify in the endosteum–the vascular membrane lining
the medullary cavity–and give twigs to the adjoining canals.
Nutrient arteries are the most apparent blood vessels of
the bones.

• All bones possess larger or
smaller foramina for the entrance
of the nourishing blood-vessels;
these are known as the nutrient
foramina, and are particularly
large in the shafts of the
larger long bones, where they
lead into a nutrient canal, which
extends into the medullary cavity
(bone marrow cavity).[1

65. CORONA MORTIS
• The "corona mortis" is an anatomical variant, an anastomosis
between the obturator and the external iliac or inferior epigastric
arteries or veins.
• It is located behind the superior pubic ramus at a variable
distance from the symphysis pubis (range 40-96 mm).
• The name "corona mortis" or crown of death testifies to the
importance of this feature, as significant hemorrhage may occur
if accidentally cut and it is difficult to achieve subsequent
hemostasis.
• It constitutes a hazard for orthopedic surgeons especially in the
anterior approach to the acetabulum.

• a paradox: in anatomical dissections a large vessel was identified
behind the superior pubic ramus, whereas in clinical practice this
vessel does not seem to be as great a threat as initially
perceived.
• Orthopedic surgeons planning an anterior approach to the
acetabulum, such as the ilioinguinal or the intrapelvic approach
(modified Stoppa), have to be cautious when dissecting near the
superior pubic ramus.
• Despite the high prevalence of these large retropubic vessels in
the dissecting room, surgeons should exercise caution but not
alter their surgical approach for fear of excessive hemorrhage.

Zone II
• Zone II extends from the middle of the middle phalanx to distal
palmar crease.
• It contains both flexor tendon superficialis and flexor tendon
profundus.
• Proximal to zone II, the flexor digitorum superficialis tendons lie
superficial to the FDP tendons.
• Within zone II and at the level of the proximal third of the
proximal phalanx, the FDS tendons split into 2 slips, collectively
known as Camper chiasma.

• These slips then divide around the FDP tendon and reunite on
the dorsal aspect of the FDP, inserting into the distal end of the
middle phalanx.
• It has been called “No Man’s Land” or “No Man’s Zone” because
repair in this zone is very difficult.
• Both the tendons are interwoven and surrounded by a number
of pulleys in this zone

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