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Hi, everyone. Sorry that we have um started a little bit late. There was some technical difficulties on my part, so I do apologize for that. Um So welcome to this session on lower limb anatomy. Um that is being held held by um medical. Um Our lecture today is on lower limb anatomy and it's set to be conducted by Tim Campbell and George West. Um Before we start a reminder that all participants um that there are um feedback forms that will be just uh um that will be sent out following the conclusion of today's me. Now, um as you know, your insights are valuable in helping us to enhance the quality of our future events. Um If you have any questions, feel free to contact us via our email and through any of our social media, so I'll hand it over to you guys. Thanks very much. Um Thanks Deborah. So, hi, everyone. Sorry, it's a late start. Um My name is Tim Campbell. I'm a actually a max fax trainee um in Kent, which is just about a bit south of London. Um So that's where I'm working at the moment. Um And I'm gonna talk to you about the anatomy of the lower limb. Um, and Georgia is gonna help me out as it's a bit far away from my normal end of the body. Um, I think there's a chat so, um, that George will keep an eye on. So if there's any questions or anything you want to ask, um, or talk about, then, you know, please fire that in. Um, and I think we're gonna try and finish sort of around eight o'clock. Um But we'll see how it goes. Um So, yeah, I hope it's helpful. Um I think you guys are all sort of medical school. Um So we've sort of tried to keep it at that level. Um And Deborah, I think you're gonna do the slides for me if that's alright. Yeah, that's fine. Um So can we go to the next one, please? So this is what I'll try and cover today. Um We'll go through the thigh, um The femoral triangle, the Popliteal fossa, we might have a little break um depending on time and then we'll look at the leg, um the ankle and then brief and the foot and then briefly um the derms and dermatomes and myotomes. Um Those are sort of um the lower limb covers quite a lot of important structures. Um And it's quite a lot. So we'll try and get through those bit uh slides, please. Um There are some big structures that we won't cover um which are named there that it might be worth looking at. The pelvis is a big one. I guess that's kind of in between the abdomen and the lower limb. But um the sciatic nerve obviously, um and just knowing where that is is important with the surface markings, I'm not gonna talk about the knee joint. Um but knowing about the meniscal disc um is is important and there's another space called the adapter canal that's worth looking at the three things at the bottom there, the blood supply to the foot, more details about the little ligaments of the foot and the arteries of the foot. Um They are anatomical topics. Um II think it's worth sort of, they're probably a bit beyond med school level. Um But I don't know what your med school will sort of expect of you. Um slide, please, but it might be worth looking at those things. Um I think George talked a bit about it last time you were here. Um But certainly with learning anatomy. Um and a lot of medicine where you just have to kind of remember a lot of facts. Um Repetition is really key and I certainly used to spend a long time um looking at things and I didn't feel like they were going into my brain. Um but just repeating it um is is important and it will stick um using pro sections and dissection stuff if you can and if they do that your medic medical school is important. Um And looking at things from a different angle um and knowing the clinical relevance of some stuff cos um a lot of anatomy has a lot of clinical relevance. And when you understand um a clinical scenario that a patient experiences something, um the anatomy lets you sort of work out why. And then I found for me, it certainly will click in my head. Um The one thing I didn't do, I remember when I was at medical school, um that on reflection, I found would have been useful is just to have a look at the textbooks and the sort of set reading list that your medical school will provide. Um because whilst anatomy is anatomy to an extent and it's, it is facts, you will find um that different sources say slightly different things and there are some nuances. Um So knowing that the textbooks um that your medical school recommends, I think is important. So um a lot of um anatomy exams, certainly in the UK like to use Grey's Anatomy. And if you use other big sort of textbooks and sources, there will be some nuances and differences in terms of little branches of vessels and stuff. And when you're um trying to memorize stuff, certainly l learning at the right way around the first time is, is helpful. So um checking what your w the set text that your medical school says is, is probably worthwhile. So that, you know what they will test you on and, and what they want you to say, the answer is if that sort of makes sense and again, knowing where muscles sort of start and finish, um is, is relevant to help you work out their action. And then, um, um m means you're more likely to remember it. Um And I, for example, with the ligaments in the foot, um you look at the f there's ligaments everywhere. But if you know the bones and you work out where they start and finish, um it, it helps you work out the actual name of the ligaments. So, um that's, I find that useful sort for sort of remembering things uh slide, please. So I think George showed you this picture last time. Um It's worth knowing the different planes because um when you talk about stuff, they'll say dorsal, this and ventral that and medial, this and medial that and um and, and knowing those planes and when you look at sort of CT scans and stuff and understanding the angle that you're looking at things um is important because um anatomy again, it's, it's a 3d thing and you're, you're basically building a picture inside your head um of the body and knowing how different bits of anatomy relate to each other, um allows you to work out what it is. So, in exams, you'll be given a picture or something and um say, for example of the er pelvis and um it's quite overwhelming. But if you know, one big structure, so for example, you see this big nerve perhaps in the middle and you think, OK, that's the sciatic nerve and you're looking at the back of it that will orientate yourself and be able to work out what is what. So, you know, OK, well, this muscle's lateral outside from the nerve, so laterals towards the outside of the body. Um And again, that can help you um orientate yourself and go from there and even the professors and stuff I think will, will say that as well. I remember being told that is um getting your bearings, so to speak while you go through the sort of map that you've created in your head, I think is the idea with anatomy. OK. Uh Slide, please. So we're just gonna start off at the, at the thigh and the obviously the main bone, the big bone running through the thigh. I'm sure, you know, um is the femur, it's the longest heaviest and er strongest bone in the body. Um And you've got different parts of the fe femur that are worth knowing about. So you've got the head there. It's a, it's a ball and socket joint, which literally sort of means what it says. You've got the head of the femur, which is the round bit that sits in the, the socket, which is the acetabulum, uh the round sort of socket of the pelvis. Um And then below that, you've got um, the neck of the femur where you'll often um see a fracture, which I think is on the next slide. But um the other different parts you've got the greater trachaner, um which is on the um outside there, if you can see the labels, um, and the lesser trachaner, and again, you'll find a lot of the muscles that come from the, from the pelvis and the gluteal region will attach there. Um So you'll have the ceras major and the er Iliacus. So the ilio sous muscle, which comes from the back, which you'll come across one of the big muscles, again, attaches to the lesser tranter. Um and again, um orientating yourself. So, um if you look at the pictures, um the lesser trantas um on the medial side, so it's towards the, the middle of the body. Um and the ilio cerus muscle goes up towards the back. So when that contracts, it's gonna pull the femur up the way. So again, just understanding where the muscles go to and if you think, well, when they contract, what are they gonna do will allow you um to work out the um uh their action, which is, again, uh obviously, something that you can, you can be asked about, um, the long part of the femur is, is called the shaft of the femur. Um And again, if you look at the picture and the sort of posterior view there on your screen, you've got an area called the linear spur, which is where some of the hamstring muscles attach. Um And um and knowing the the different areas, um the major areas I think is important and that picture is fairly detailed, but um certainly, you know, the greater tranter, the less tranter the head, um um and the linear spur around the back and the neck, those are the sort of major structures that um you need to know about. Um the there's an area on the tip of the head called the fovea, um which has a ligament that runs through it. Um And I'm not gonna go into this too much, but um I think there's another picture if you can uh do the next slide, please. Um At the bottom right hand corner there, you've got a picture of the, the fovea. So that, that's the ball and socket joint, which has got structures in it that makes it tries to make it more stable, but obviously, it is an area that's um at risk of dislocation and damage. Um But you have a um an artery of the uh ligament of the head of the head of the ligament there that, that, that goes through the fovea. Um And um yeah, so this slides a bit about the blood supply to the femoral head. Um And the reason why I included that is because um in, in orthopedics, uh a common thing that you will see is a, a fracture of the head of the femur, a fracture of the neck of the femur. So the X ray at the top of your screen. Um So again, x-rays anatomy about orientating yourself. So there's a fracture on the left hand side, neck of femur, there um where a patient will often present with a uh a shortened and um it internally, internally rotated leg, um which is a common clinical finding. Um And the reason why um orthopedic surgeons like to fix this because there is a risk um when you have a fracture like that, there is a fairly common presentation of um avascular necrosis uh to the head of the femur. Um So that means that the bone sort of dies off because it hasn't got a good, a good blood supply. Um The majority of the blood supply to the head of the femur is from arteries called the retinacular arteries um which come from um an extracapsular anastomosis. So, outside the capsule of the joint, um an anastomosis is where these, these uh blood vessels and arteries from different parts come together and anastomosis with each other to form a sort of ring around it. Um And the anastomosis is formed posteriorly by the medial femoral circumflex artery. That's the name and then anteriorly at the front um from the lateral um circumflex artery. And then you have a little uh ligamentum teres, which is an artery of the obturator artery there as well, which helps out the medial and the lateral circumflex arteries. Um come from an artery called the profunda femoris artery, which is also the deep femoral artery, um which runs down the leg which you should be able to see on that diagram in your screen. Um And as I said, the clinical relevance is that is that you can get these risk of avascular necrosis if um the bone doesn't heal and understanding that blood supply is quite important, especially if you want to, I guess, go on to do um orthopedics. Um next slide, please. Ok. So we're gonna go on to the thigh. Um The thighs got three compartments um which are shown there on your screen, an anterior posterior and a lateral compartment compartments are groups of muscles that are divided up by fascia, which is a um a structure that um I separates the muscles and allows things to sort of glide over each other. And we talk about um fascia in medicine because um you, you might hear something called compartment syndrome um which you can get in all different parts of the body and I'll talk about it a bit later again. Um But that's when you, it can be caused by lots of things, but often it's trauma and you get swelling in these compartments and that swelling causes pressure and stops blood supply um to the muscles and it's really serious. I'll, I'll talk about it a bit more later, but knowing the different compartments is important. So, um so you've got three compartments, as I said, um and um the muscles um in the um sort of anterior compartment, which are the quad muscles, I'm sure you will have the quadriceps. And you've got three vastus muscles or um a vastus lateralis which is on the outside, a vastus medialis which is uh goes down the middle and then an intermedius as well. Um And um these muscles insert onto the patella, which I'm sure, you know, is um the little um floating sort of bony structure at the front of the knee makes the knee cap. Um And then you also got the rectus femoris muscle, um which is the big muscle going right down the middle. Um and then avast medialis as well, which is on is on the medial side. And those are the, the muscles that will make up the um the commonly known quadriceps muscle. Um The slide there has the um origins and attachments and as you can see, um quite a lot of those muscles, some of them attached to the greater tranter um at the top there um of the femur and some attached to a part of the pelvis. Um which is why knowing the major bony points in the pelvis um is important um knowing where they come from and go to. Um and again, um if you think about these muscles that are the front of the leg and, uh, if you see where they attach and they go towards tell us. So, so when these muscles contract, um, they're gonna extend the knee like you're kicking a football. Um, and also do a bit of flexion of the hip, um, and the nerve supply um to these muscles. Again, it's on the screen there, but this is, this is the femoral nerve that will, um supply the majority of these. I've got a picture of um on the top of your screen is something called the pas anus, which is known as the goosey foot, which attaches on the lateral aspect of the knee a bit lower down. Um You've got three muscles. I haven't mentioned them yet, but um the sartorius, um the gracilis and semitendinosus. Um So this is they attach on an area on the um lateral aspect of the tibia. Um And it's quite a common question to be asked and they, they, they like to know the order of these muscles and being able to identify them. Um And um there's lots of pneumonics in medicine and um the one that I use for this is called say grace before t that's a se grace before t, so that means the se is the sartorius muscle, which is the first one and then the gracilis. So that's grace and then um semitendinosis. So the T is for the tendinosis part of that. Um Next slide, please So we're moving around to the back of the leg now, which is the, um, hamstring muscles, uh, group of muscles that again, I'm sure you've all heard about. Um, and the picture there is that. So this is the back for you. So you're looking at someone's leg from the back, which will give you the hamstring not muscles. So, the innervation to, um, these muscles is the, er, tibial nerve. Um, and the tibial nerve is a branch of the sciatic nerve, um which is one of the, I think it's the biggest nerve in the body. Um Although I don't take my word for that, I check, I think it is. Um So the sciatic nerve comes from nerve roots, L4 to L3, which is um important to know. So, l being the lumbar part of the spine, um L4 to S3, sorry. Um not L3. Um uh and that runs down through the um posterior leg and gives off the tibial nerve um supplying these muscles. Um So these muscles, again, if you think about where they are at the back of the leg and you can see where they attach. So when these muscles flex, um they're going um when these muscles contract, they're gonna do flexion of the knee, so they're gonna bend your knee um and do a bit of extension of the thigh at the hip as well. Um So again, thinking about where they start and finish allows you to help work out the action of these muscles. Um You'll note there that the biceps, uh femoris, which is um on the lateral aspect, um has got a joint nerve supply. So it's got a long head and a short head. The long head being supplied by the tibial nerve and the short head, uh being supplied by the perineal nerve, which is uh a branch again of the sciatic. Um And there's those little nuances um in anatomy that it is worth knowing. So they might say, you know which nerve supplies the biceps and it's got that joint, joint nerve supply um for, for the different, different bit. So when these muscles, um all contract together, they'll flex the knee, as I said, but when they work independently, uh the biceps femoris, for example, on its own, it will do flexion, but it also does a bit of lateral rotation. Um And again, if you look, think about where it um goes attaches and goes to that will help work out what it does. It's on the lateral aspect. So it's gonna laterally rotate the hip and knee a little bit. Whereas the semitendinosis and semimembranosus um uh uh on the more medial side. Um and um they again, when they contract, they're gonna flex the knee, but um they're gonna do a bit of medial rotation of the thigh and hip as well. So, knowing the different um um purposes or of these muscles is important just to, to remember as well that they will do something slightly different when they contract individually, but as a group, they will just um flex the knee. Um OK, I think slide, please. OK. So next is the femoral triangle. Um A lot of structures in anatomy allow for the passage of major um vessels and nerves from different parts of the body. So the femoral triangle is big, major structure. I would say, you definitely need to know about that. Um And knowing the boundaries um of the uh femoral triangle and the contents I think is really important. And the femoral triangle is a sort of conceptual space. Um You'll see on the right hand side of your screen, there's sort of that green sort of triangle shape and it, it, it, it, it's triangular and again, it's obviously 3d, but it allows the, the, the passage um of um the femoral artery, femoral vein, femoral nerve all coming from the abdomen, uh going down to the lower leg to give the nerve and blood supply and venous drainage um going going through there. So, um you know, if you're operating in the area of the hernias and things like that, then then knowing the order of um order of the structures and what's there is really important. So, in terms of the boundaries, um superiorly, um you'll see in your picture, you've got the um inguinal ligament um laterally, I is the sartorius muscle um which is also known as the Taylor's muscle. So it helps if you lift your leg and cross, um, put your foot on your opposite knee. So you're crossing your legs, you're sitting cross legged. That's this arterious muscle helps do that action. So it's sort of commonly known as a Taylor's muscle. Um That's the lateral border and then the medial border is the adductor longus. Um Those are the three major boundaries. Um And then the floor is formed by the Ilio Pectineus, a ductal longus which are some of the deeper muscles in the thigh. And then the roof, if you think about is the skin, some superficial fascia and the fascial lata. And then on your screen, I've, I've mentioned the contents and knowing the order, as I said of the contents from medial to lateral is important. Um So, um the most medial vessel or the most medial y you can see the lymph nodes which are in green there on your screen. And then you've got the uh femoral vein, the femoral artery and the um femoral nerve and the pneumonic that a lot of people use. It is navy. So, um n being the lateral structure, the nerve and then the artery um and then the vein. Um So, nav Y and I think the Y means Y front, like a gentleman who's wearing yy front pants. So that's the most medial portion. Um The femoral artery um is, it's important to know where that is. Um So the surface marking for the femoral artery is the mid andal point, which is halfway between the pubic symphysis, which is on the um pelvis and the aces, the anterior suprailiac spine. Um And um halfway between that, you'll palpate the femoral arteries. So, um if you need to take a uh blood sample, for example, from the, from the vein, um then palpating the artery and then you go and then you know that if you go medial to where you can palpate the artery that you feel pulsating, you'll know that you'll be one away from the nerve and two. you know that the vein is medial. Um If you, if you want to, to get that um as well. OK. Uh Next slide, please. OK. So this is the popliteal fossa. So popliteal fossa is a structure. So it's triangular straight shape to structure um it's on the back of your knee. So you're looking at the back of someone's knee and again, it's something that is commonly um asked about. And again, knowing the, the boundaries and the contents I think is important. Um So if you look at the, the pictures on your screen, you'll see um this, it, it's a, a diamond shaped structure. So um the lateral borders superiorly. So at the top, you have the biceps femoris muscle um and then at the bottom or inferiorly, the lateral border is the gastric NEMIS and plantaris So these are the calf muscles that we'll come to in a minute. Um And then the medial border. So going on to the inside. Now, at the top, you'll have the semimembranosus and the semitendinosis. And then the medial border at the bottom will be the gastric neus one of the calf muscles, again, medial head of the gastric neus muscle. Um So those are the major borders. Um The floor of the popliteal fossil uh is formed by the um popliteal surface of the femur um and the knee uh ligament joint and then the roof is the superficial and the deep fascia. Um I think on your picture as well, I've put there, you've got some contents of the BTE fossil, which is important to know about. Um so the contents um will be the uh tibial nerve which again, as I said, it comes down off the sciatic. You have the popliteal vein, the popliteal artery, some lymph nodes and the small saphenous vein there as well. Um They like you to know the um order of the structures in terms of which one's superficial and which one's deeper. So the nerve is the most superficial structure. Um and the artery is the deepest structure and the nerve starts laterally and then it um passes as it goes, travels down, it will end up lying immediately as well. Um The main sort of clinical reason behind that is in older patients. It's not uncommon to see a supracondylar fracture of the femur. So this is a fracture of the femur bone above condyles. So, um just above the knee joint, um and if you see someone with that, you've got to be concerned for damage to the popliteal artery, which is the because it's the deepest structure in the knee. So if you saw that you'd think about um sort of doing a vascular exam, making sure the patient's got a blood supply to the lower leg, maybe some imaging like a CT angiogram or something like that. Um OK, so next slide, please. Uh So this is a prosection view um of the er popliteal fossa. Um So I'll just go through some of the more major structures, but I don't think knowing all of that is probably not completely vital. But um I think with anatomy, as I sort of said earlier, you, if you, if you look at one picture, you'll learn that one picture but looking at different views and different textbooks and different pictures and pictures of dissections like this, I think is important as well because obviously anatomy varies a little bit to an extent. Um And understanding that it might look slightly different in a different picture um is helpful. Um So if you look at number one, which is at the sort of top of the picture there. Um So again, if you think it's, it's, it's on the lateral aspect. So that's gonna be the biceps um femoris and then if you stay at that plane and, and, and look at the other side at the more melas bit, you're gonna see the um, semimembranosus muscle, which is, um, number 11. And then you've got a big structure running down the middle, um, which is number 15, running down the middle there. So that's the, the tibial tibial nerve, um going right down the middle. And if you look back to number one, and just below that, I think it, it's labeled as number two. So that's the common perineal nerve um which hooks around the head of the fibula. Um that can often be damaged and that will innovate, innervate parts of the lower leg, which I'll talk about in a minute. Um But that's in the later aspect. So that's definitely worth knowing where that is. And then if you look again back to uh the tibial nerves, number 15, and then deeper inside the knee, you'll see number eight, which is the um popliteal artery. And you can see that's the most deepest, the deepest structure in the knee. And then at the bottom of the screen, if you look at number three, which is below the um biceps femoris, um that's the last lateral head of the gastric NEMIS. And then number four on the other side is the medial head. So those are your sort of two other major boundaries um in the popal fossa. The picture on your screen is a picture of the back of someone's knee and they've clearly got a swelling there um on their left back of their left knee, which um is a baker's cyst. So sometimes you get asked for differentials um of different things in the popliteal fossa and you get lumps and bumps and you get asked about what, what could it be and you'll get asked to come up for a list of differential diagnosis. Um a fairly good approach to thinking about differentials with lumps and bumps is to think anatomically. Well, what, what's in that region? Um So if you think about a lump at the back of the knee, um you break it up into the an anatomical structures and it's gonna be something from the back of the knee. Uh There's gonna be something that is anatomically there. So, a baker's cyst is um a, a bulge in the synovial sac of, of the knee joint um which you know, that has the knee joints there, but it could be something else like a, an aneurysm. So an a a swelling relates to the popliteal artery could be that could be a popliteal vein, um varicosity. So, varicose vein relates to the popliteal vein, you know, the popal veins there, a Schwannoma which is um a nerve tumor. So, you know, there's a big nerve running through there. It could be that it could be a lipoma which is soft, swelling of fatty tissue cos it's gonna be fat in the skin there. Um And then, or a sebaceous cyst which is a skin infection. Um Again, cos you've got skin there, so it's a good to break it up into different structures will help you sort of think about uh differentials um for lumps and bumps um slide, please. I was gonna take a break at this point, but I'm happy to keep going if you guys are OK? Um As we started a bit late, I don't think anyone can talk. So if anyone objects in the chat, OK, we'll keep going fine. Um All right. So the leg, so anatomically, um you've got the thigh and, and the leg. So the leg anatomically is actually your lower leg like below the knee. Um Whereas above your knee is anatomically known as the thigh. So that's why I've called it a leg. It's split up into. Um You've got three compartments. I mentioned compartments in the thigh. You've got three compartments of the leg which are often asked about much more than the thigh compartments and what's in them. Um So you've got an anterior posterior and a lateral compartment. The posterior compartment is often it is, is split up and just superficial and deep compartment. I would say knowing the contents, the blood supply and the nerve um to all of those is important, it sounds like a lot. But again, um just repetition and keep, keep thinking about it is important. Um next slide, please. So the, so I've got a picture in the middle um which is um the blood supply of, of the going through the popliteal fossa, going through the knee to the leg. And the, the images are um angiograms. Um So if you look at the angiogram, so these are, it's an X ray that's um got the blood supply of the lower leg. So pa is the, is the perineal artery. um and then that splits into at which is the anterior tibial tibial artery. Um And the PT there, which is the posterior tibial artery. Um um And the um you also have the um uh tibioperoneal trunk, which is a short bit that um connects the um perineal artery and the posterior tibial artery. Um So you might get shown that imaging and potentially be asked to identify the different vessels. Those are the vessels that will supply the um lower or, or that will supply the different comp part of the lower leg. So, um you might have had, I don't know how much you've done, but the, you've got the perineal compartment of the lower leg of the lateral compartment, also the lateral compartment. Um And obviously, the perineal artery will supply supply that. So, um I think they're quite nice pictures to help you understand, again, the 3d relationship of the different blood vessels with anterior tibial artery, gonna supply the anterior front part of the leg. And next slide, please Um So I said that the tibial nerve, we know we were talking about that running through the fossa. So that continues down the tibial nerve to supply the posterior leg compartment. Um and that supplies both the superficial and the deep posterior leg compartment. Um In terms of what's in the posterior compartment, there's a couple of pneumonics there on your screen of GPS and PFT or Pff T. So GPS is the um is the the superficial. So the muscles on the outside um which are the gastric neus, which again, we talked about making it a pop of fossa boundaries, the solus and the plantaris and then the pif of the, the deeper muscles in the posterior compartment, er the pops um flex ha long flexor, digita, digitalis, longus and the tibialis posterior. So, um again, flex haus is longus, a lot of anatomies like this. Um flex Hauss Longus. So flexor, so it's gonna flex haus means the hallux, which is the big toe and it's a long. So it's a really one of the longer, it's a long muscle. So that's um the long muscle that's gonna gonna go and attach to and flex the big toe. And digitalis, flexor digitalis, again, flexor digitalis is the rest of the toes. So again, it's gonna flex the rest of the toes. And usually if you've got a longus, you also have a, a shorter muscle as well, which is called the brevis muscle. And if you look at the lateral compartment there. You've got the Peroneus longus and Peroneus brevis. So you have a long and a short version of the muscle. Um and, and, and Peroneus, it means it means lateral and it's also known as the fibula. So again, you might find some names that are interchangeable. So if you see something you don't recognize, just double check it, it's not meaning the same thing and it's not interchangeable. So don't let that throw you too much. Um At the top of your screen, you've got the different colors there which are highlighted in the different compartments of the knee and again, like the thigh, they're separated by a fascial planes um and an intraosseous membrane. Um And um I think knowing the names of the different fascia is probably too detailed. Um but the idea again is is of this compartment syndrome, which is this um damage to muscles and you get swelling. Um And that really needs to be released quite quickly. And that picture of a um is a picture of compartment syndrome that's had fasciotomies that had cuts made um due to swelling, although it's obviously of the arm here rather than the leg, but it is quite common, more common to see it in, in the leg than it is in different places, but it can theoretically happen um in any area of the body. Um that's got compartments and you get a classic presentation of, of pain that's completely out of proportion to the injury. So severe pain, um after trauma, you'd sort of think of um compartment syndrome. Um you can get, it's known as the pea, so you might get paresthesia, pulselessness paralysis. These are all more late signs. Um but pain is the one that you really need to think about. Um So next slide please. So these are some nice pictures of the anterior and lateral compartments and the muscles that make those up and you can see where they sort of start and finish. Um It's not, I don't think it's that helpful for me to sort of just read them out. And um it's a case of, of, of looking at them and, and, and spending some time um learning those. But again, tibialis anterior, I mean, so you've got the tibia bone, there's two bones in the leg, the tibia and the fibula. And um so the answer is gonna be the anterior compartment. Um And um it again, it's gonna help dorsiflex, flex um um extended foot. Um and you'll have the deep perineal nerve that is, is innervating. So the common perineal nerve gives off two branches of superficial and the deep one. And I say the common perineal nerve is a nerve that comes out of popal fossa and it wraps around the head of the fibula where it's often damaged. Um and that innervates the anterior and then the lateral or the perineal compartment as well by giving off those two branches which are, which are shown there in the in the picture. So the superficial peroneal nerve does the lateral compartment, the deep perineal nerve does the um does the anterior compartment um knowing those nerves I think is important. So um those nerves travel down and uh supply areas of the foot. The deep perineal nerve will supply an area called the first web space which is between the big toe at the front there. And you might get asked that because that area, if that nerve is damaged, that is an area that will become numb. Um Whereas the superficial perineal nerve down, the lateral compartment will supply the dorsal surface of the foot, the top surface of the foot. So there'll be a difference in um sensory innervation depending on sensory affect, depending on which um which nerve is damaged. Uh Next slide, please. Thank you. Um So this is the um posterior compartment, this is the superficial muscles. So this is the GPS muscles, gastrinemia. So big. Those are the big calf muscles that you see on the back of someone's leg and the plantaris and Solus, which is slightly deeper is SPD by the tibial nerve and they're gonna help plantar flex the foot, um which is standing on tiptoes essentially. Um And these are, of course, the muscles that make up the achilles tendon, um which is at the back which I'm sure you all know about. And you've heard of. Um So those are the muscles that make up that and they go in and out the Calcaneus, which is one of the ankle bones. Um Next slide please. Um And then the more the deeper muscles of the posterior compartment, puffed muscles. So pop tear flexal longus, uh flexi digital longus tibialis, posterior. Um And again, these will help in plantar flexing and do some other minor movements as well that are mentioned there again, all supplied um by the uh by the tibial nerve. OK. Just bearing in mind time. Can we have the next slide, please? All right. So this is the foot. Um There's a lot of bones in the foot can be quite overwhelming. Um Take your time. You will i if I can learn it, doing what my sort of head and neck stuff, you, you will be able to learn it. So just take your time again, orientate yourself, work out what it is that you're looking at. So the pits on the left side of your screen bones of the foot. Um So you can work out, you know which side it is. So I would look at that and say um um this is, this is the left foot because you can, you can see um if you think about the big bone at the back um is that's the heel bone, the calcaneous bone. So you know where you are. So it's the back and then the thinner bones are the metatarsal bones towards the front. So, um, and then you can see that, that um, number three, there is that Hallux or the big toe, you won't work. I think that's, that's the left foot and then you can try and determine which side you're looking at. So if you know, you're looking at the big toe, um um then you know which, um, which side of the foot it is, whether it's the medial um or the or the lateral, lateral side of the foot. Um You've got the, um you've got the um metatarsals which are labeled as number three there. Um So you have five of those as they run through. Um And then number two, there is the cuboid bone um in the middle. Um That's number two. And then next to that is the um is the cuneiform bones. So there's three of those which are the medial, intermediate and lateral. Again, thinking about whether you're on the medial, the m towards the middle of the body or lateral towards the outside. And then uh 15 just above that is the navicular bone, which I think is navicular means to do with a ship. It's mentally like a ship. So that's the origin of the, of the name of that bone. Um And then number seven is the talus bone which is like the keystone joint of the ankle. Um And the, and then the phalanges are the little bones at the end, which aren't shown on that, that particular image of bones. Um but it is on the labeled image on the other side. And then you've got Dorty flexion and plantar flexion at the top of your screen, which are the movements um of the ankle, the ankle joint itself um is between the talus. So that's number seven and the tibia and the fibula above it. And it's known as a synovial, it's a hinge joint um um between the trochlear surface that which is the surface of the, of the talus bone itself and the lower end of the tibia and the fibula. And you'll get um dorty flexion and plantar flexion that will happen at the ankle joint. And then there's another joint which is called the subtalar joint. And um so subtalar. So below the talus joint, which is number seven. And then the, that um articulates with, with the calcaneus, that big heel, heel bone at the back there. Um And at this joint, um you'll get inversion and evasion, which is inversion is the ankle moving in the way and e version is moving out the way. So those are the movements that happen at the subtalar joint, which is um a question that you might be asked. Um And again, the movements of the ankle um will be determined by the muscles that we talked about in the leg. So, plantar flexion, you'll have the posterior compartment of the leg working to go on your tiptoes, you go on your tiptoes and you'll see the calf muscles working at the back there. The, the GPS, the gastric anemia, sous, plantaris working and the deeper muscles, the puff muscles uh uh um uh that are deeper in the posterior compartment and then dorsi flexion. So, lifting your big toe up the way you have the muscles in the anterior compartment and maybe the lateral compartment working as well. So the tibialis anterior extends all this longus, extending your hallux, your big toe extends the digital and longus, extending little bones in your foot. Um And the Peroneus tertius as well, all do dorsi flexion. Uh And then the question you might be asked is which, which uh part is which action is more stable. So, is it more stable to, to, to dorsi flex or um plantar flex? So, so if you sort of think about it, is it more stable to be walking around on your tiptoes or is it more stable to be walking around on your heel? And it is more stable to be walking around on your heel? Um And this is to do with the shape of the bones in the ankle and the talus bones that's um is number seven. um and it's to do with how that articulates with the tibia and the fibula and it's slightly wider when you're in dorsiflexion, um which makes it less mobile, which kind of makes sense if you think that if you, it is more stable, you can walk around on your heels, whereas walking around on your tiptoes is is more difficult. Um So that's the question that um I've been asked before. Um next slide, please. So these are the ligaments. So there's lots of ligaments in the ankle and uh used to overwhelm me an awful lot. The two main groups of ligaments that you need to know about. Uh I is the deltoid ligament and the lca of the lateral collateral ligament. So the deltoid, so this is on the medial side of your ankle and the lateral collateral again, the lateral. So it's gonna be on the outside. Um And if anyone's ever sprained their ankle, um it's usually in virtually the ankle will go on the inside and you'll damage the lateral collateral ligament. So LCL, so the lateral collateral ligaments got three components to it. Um And, and these come from the lateral malleolus. So it's on the outside. So it's gonna be the fibula. And um there again, I said that the names of the ligaments of the ankle, you can work out from the different parts that they attach to. So you, so the lateral collateral has got the anterior talofibular ligament. So, talar and fibular. So that's from the talus to the fibula and then you have a posterior posterior talar fibula, talus to fibula and the calcaneofibular ligaments, those are the three calcaneofibular. So, from the calcaneous bone to the fibula and they're all labeled on the screen there and then the deltoid which is on the medial side, um It's got four ligaments. Um Again, think the names of these ligaments are where they go to and from. So you've got the anterior tibiotalar, we're going from the tibia to the talar ligament, the tibial navicular ligament, tibial calcaneal ligament, tibia to calcaneous bone and then a deeper um posterior tibial talar ligament. Um And there is a variety of other smaller ligaments. I thi I think knowing those two is, is probably enough for me. Um um but there are some more on the, on the screen there that um that you will see in textbooks and stuff. But I think certainly starting with those two is probably a good um a good place to start at the top towards the top of the screen again, I've got pictures of some um I put some pictures of some dissections and stuff there. Um And you can s uh so on the right hand side. So see, so that's the deltoid. So that's number six, which is, which is more like one big ligament. So that's why it's often named the deltoid ligament. Whereas the LCL um on, on D on the left hand side of the screen, you can more easily um determine the three parts of the ligament. So number three there, for example, um is um going from the uh Calcaneous bone to the to the fibular bone. So that's the calcaneofibular part of the um the lateral collateral ligament. Um And just so knowing the bone and then you can work up which bit is going where and a lot of anatomy is, is like that. Uh Next slide, please. Ok. So nearly finished if you're still with us. Um They like to ask about structures going behind the medial malleolus. Um So medial, so on the medial side, a malleolus is the bony bit of the ankle that sticks out, you can feel it nice and clearly if you feel your own ankle. Um so it's on the medial side and the structures passing um behind this. Um They do like to ask about um these are structures um that are, that are in the um posterior compartments. So they are gonna be in the back of the leg rather than the anterior compartment. Cos that's again, anything goes to the front of the leg. Um And the mnemonic that I use is Tom Dick and very naughty Harry. And that's also the or the order they are in if you look at the picture from back to front. So the Tom is um tibialis uh posterior and then the um the dick is flexor digital longus and then um A is the uh the artery, the posterior tibial artery, po uh the posterior tibial vein is the v tibial nerve and then the H is flexor haly um Longus. Um You can feel the posterior tibial artery pulse, um which when you learn to do vascular exams and ankle exams, they might expect you to feel that which is behind the medial malleolus, which is one of the structures mentioned there. Um And the other pulse that they commonly ask you to feel is the um dorsalis pedis. So that's at the top of the foot, at the front. Um So this is found between the two metatarsal bones. Um And um it's deep to the extensor ha longus. So this is again at the front now. Um But if you feel it on the top of your foot, again, you can palpate it on yourself between the two metatarsals. That's something that you definitely, it's, it's good to examine a patient if you're concerned about um blood supply, lack of blood supply to the foot. And again, you'll see on that picture there on the right hand screen, I've put a picture. Um All right, next slide, please. Right. So, last bit now, um I'm not gonna talk too much um on the right of, on the right of your screen are the um are the dermatomes. Um Unless George can tell me, I don't know any way to her to try and learn this in an easier way other than just sort of repetition and looking at it. Um But having an idea of the, of the big structures and, and, and their um what innervates them. So, for example, the foot, you'll see s one at the bottom there of the foot. So that's gonna be the, the lateral aspect of the foot and the lateral malleolus. So they might ask, you know, if I touch the lateral malleolus, what dermatome is that? In case? S one and then L4 is more on the, on the, on the medial side. Um But um yeah, just, just trying to learn those I think is, is, is worthwhile. Um And then on the other screen there's quite a nice diagram of various um sort of reflexes and stuff. Um And the ones that I remembered. So, so when you do the knee jerks, when you tap someone's knee down, and that's the knee jerk response. So that's L3 or L4. Um The other one that is, again, you'll learn this when you do your neuro exams. Um So for example, extending the big toe is L5 and then checking the um achilles reflexes is S one and S two. But having an idea of those I think is important in terms of the um lower limb. Um And I think that is the last slide after this. So thank you for listening if you're still out there. Um And I hope it was helpful. I'm happy to answer any questions if you'd like. Um But good luck if you've got exams and all the best. Thanks. T that was really helpful lecture. And thank you. Everyone for joining today's lecture. I don't think there's any questions in the chat, but if you do have any questions, please um contact us by email or on our social media and we can pass them over and Tim has also provided his.