Femoral nerve - BeKnowledge

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Femoral nerve - BeKnowledge Powered By Docstoc
					   The lower extremity

            Lecture 8
             Handout
BryanLGH College of Health Sciences
               The lower limb
• directly anchored to the axial skeleton 
  sacroiliac joint + ligaments  link the pelvic
  bone to the sacrum
• divided into:
• Gluteal region  posterolateral and between
  the iliac crest and the fold of skin (gluteal fold;
  defines the lower limit of the buttocks)
• Thigh (anteriorly)  between the inguinal
  ligament and the knee joint
• Leg  between the knee and ankle joint
• Foot  distal to the ankle joint
 The femoral triangle and popliteal
               fossa
• important areas of transition through which
  structures pass between regions
• femoral triangle  pyramid-shaped
  depression formed by muscles in the
  proximal regions of the thigh and by the
  inguinal ligament
• blood supply and femoral nerve  enter
  into the thigh from the abdomen 
  passing under the inguinal ligament and
  into the femoral triangle
               continued
• popliteal fossa  posterior to the knee
  joint
• major contents of the popliteal fossa:
• popliteal artery
• popliteal vein
• tibial and common fibular nerves
  FUNCTION -- Support the body
           weight
• standing erect  center of gravity is
  anterior to the edge of the SII vertebra in
  the pelvis
• organization of ligaments at the hip and
  knee joints + the shape of the articular
  surfaces, (particularly at knee) 
  facilitates 'locking' of these joints
               Locomotion
• integration of movements at all joints in the
  lower limb
• at the hip joint  flexion, extension,
  abduction, adduction, medial and lateral
  rotation, and circumduction
• at knee  flexion and extension
• at ankle  dorsiflexion (movement of the
  dorsal side of foot towards the leg) and
  plantarflexion
  RELATIONSHIP TO OTHER REGIONS
• four major entry and exit points between the
  lower limb and the abdomen, pelvis, and
  perineum:
• the gap between the inguinal ligament and
  pelvic bone
• the greater sciatic foramen
• the obturator canal (at the top of the obturator
  foramen)
• the lesser sciatic foramen
• Abdomen
• lower limb + abdomen  communicate directly
  through a gap between the pelvic bone and the
  inguinal ligament
                 continued
• Structures:
• muscles-psoas major, iliacus, and pectineus
• femoral and femoral branch of the genitofemoral
  nerves, lateral cutaneous nerve
• femoral artery and vein
• lymphatics
• The gap between the pelvic bone and the
  inguinal ligament  weak area in the abdominal
  wall, often associated femoral hernia(usually
  occurs where the lymphatic vessels pass
  through the gap = the femoral canal)
                  continued
• Pelvis
• Structures within the pelvis communicate with
  the lower limb through two major apertures:
• Posteriorly  through the greater sciatic
  foramen and include:
• a muscle-piriformis
• nerves-sciatic, superior and inferior gluteal, and
  pudendal nerves
• vessels-superior and inferior gluteal arteries and
  veins, and the internal pudendal artery.
• sciatic nerve  largest peripheral nerve
  of the body and major nerve of the lower
  limb
• Anteriorly, through the obturator canal 
  the obturator nerve and vessels pass
  between the pelvis and thigh
                 continued
• Perineum
• Structures pass through the lesser sciatic
  foramen between the perineum and gluteal
  region:
• most important with respect to the lower limb 
  tendon of the obturator internus muscle
• the internal pudendal artery and pudendal
  nerve  pass out of the pelvis through the
  greater sciatic foramen into the gluteal region,
  then immediately pass around the ischial spine
  and sacrospinous ligament, through the lesser
  sciatic foramen to enter the perineum
                   Innervation
• lumbar and sacral plexuses
• plexuses  formed by the anterior rami of L1 to L3 and
  most of L4 (lumbar plexus) and L4 to S5 (sacral plexus)
• Terminal nerves  exit the abdomen and pelvis through
  a number of apertures and foramina and enter the limb
• consequence of this innervation  lumbar and upper
  sacral nerves are tested clinically by examining the lower
  limb
• clinical signs (as pain, 'pins and needles', paresthesia,
  and fascicular muscle twitching) resulting from any
  disorder affecting these spinal nerves (e.g. herniated
  intervertebral disc in the lumbar region) appear in the
  lower limb
    Dermatomes in the lower limb
•   over the inguinal ligament-L1;
•   lateral side of the thigh-L2;
•   lower medial side of the thigh-L3;
•   meidal side of the great toe (digit 1)-L4;
•   meidal side of digit 2-L5;
•   little toe (digit 5)-S1;
•   back of the thigh-S2;
•   skin over the gluteal fold-S3.
•   The dermatomes of S4 and S5 are tested in the
    perineum
 Selected joint movements are used to
             test myotomes
• flexion of the hip is controlled primarily by L1
  and L2;
• extension of the knee is controlled mainly by L3
  and L4;
• knee flexion is controlled mainly by L5 to S2;
• plantarflexion of the foot is controlled
  predominantly by S1 and S2;
• adduction of the digits is controlled by S2 and
  S3.
  Innervation of muscle groups
• large muscles in the gluteal region  innervated
  by the superior and inferior gluteal nerves
• most muscles in the anterior compartment of the
  thigh  innervated by the femoral nerve
  (except the tensor fasciae latae, which is
  innervated by the superior gluteal nerve)
• most muscles in the medial compartment 
  innervated mainly by the obturator nerve
  (except the pectineus, which is innervated by the
  femoral nerve, and part of the adductor magnus,
  which are innervated by the tibial division of the
  sciatic nerve)
                 continued
• most muscles in the posterior compartment of
  the thigh and the leg and in the sole of the foot
   innervated by the tibial part of the sciatic
  nerve (except the short head of the biceps
  femoris in the posterior thigh, which are
  innervated by the common fibular division of the
  sciatic nerve;
• the anterior and lateral compartments of the leg
  and muscles associated with the dorsal surface
  of the foot  innervated by the common fibular
  part of the sciatic nerve
                  continued
• Sensation from the following areas can be used
  to test for peripheral nerve lesions:
• the femoral nerve  innervates skin on the
  anterior thigh, medial side of the leg, and medial
  side of the ankle
• the obturator nerve  innervates the medial side
  of the thigh
• the tibial part of the sciatic nerve  innervates
  the lateral side of the ankle and foot
• the common fibular nerve  innervates the
  lateral side of the leg and the dorsum of the foot
       Nerves related to bone
• The common fibular branch of the sciatic
  nerve  curves laterally around the neck of the
  fibula when passing from the popliteal fossa into
  the leg
• the nerve can be rolled against bone just distal
  to the attachment of biceps femoris to the head
  of the fibula
• In this location  the nerve can be damaged by
  impact injuries, fractures to the bone, or leg
  casts that are placed too high
 Pelvis,lower limb and fractures
• Soft tissue and visceral organ damage  must
  be suspected when the pelvis is fractured
• Pelvic fractures can be associated with:
• appreciable blood loss (concealed
  exsanguination)
• this bleeding  tends to form a significant pelvic
  hematoma  can compress nerves, press on
  organs, and inhibit pelvic visceral function
                   continued
• Pelvic fractures are generally of four types:
• Type 1 injuries  occur without disruption of the
  bony pelvic ring (e.g. a fracture of the iliac crest)
• unlikely to represent significant trauma
• Type 2 injuries  occur with a single break in
  the bony pelvic ring (e.g. single fracture with
  diastasis, separation, of the symphysis pubis).
  relatively benign in nature
               continued
• Type 3 injuries  occur with double
  breaks in the bony pelvic ring
• bilateral fractures of the pubic rami  may
  produce urethral damage
• fractures of the pubic rami and disruption
  of the sacro-iliac joint with or without
  dislocation  significant visceral pelvic
  trauma and hemorrhage
               continued
• Type 4 injuries  occur at and around the
  acetabulum
• also stress fractures and insufficiency
  fractures, as seen in athletes and elderly
  patients with osteoporosis
               The femur
• bone of the thigh, the longest bone in the
  body
• proximal end:
• characterized by a head, neck, and two
  large projections  the greater and lesser
  trochanters
In the clinic-- Blood supply to the femoral
                head and neck
• extracapsular arterial ring  formed
  around the base of the femoral neck
• medial femoral circumflex artery, branches
  of the lateral femoral circumflex artery
    In the clinic -- Femoral neck
               fractures
• Most femoral neck fractures  intracapsular and
  disrupt the cervical vessels  femoral head
  may necrose
• typical fracture at and around the hip joint 
  intertrochanteric fracture
• preserve the femoral neck blood supply and do
  not render the femoral head ischemic
• Femoral shaft fracture
• accompanied by damage to the surrounding soft
  tissues
  Nerves that enter the lower limb
   from the abdomen and pelvis
• Femoral nerve
• contributions from the anterior rami of L2 to L4
• innervates all muscles in the anterior
  compartment of the thigh
• gives rise to branches that innervate the iliacus
  and pectineus muscles
• innervates skin over the anterior aspect of the
  thigh, anteromedial side of the knee, the medial
  side of the leg, and the medial side of the foot.
                 continued
• Obturator nerve
• originates from L2 to L4
• innervates:
• all muscles in the medial compartment of the
  thigh, except the part of adductor magnus
  muscle that originates from the ischium and the
  pectineus muscle  innervated by the sciatic
  and the femoral nerves
• the obturator externus muscle
• skin on the medial side of the upper thigh
                     continued
• Sciatic nerve
• contributions from L4 to S3
• in the posterior compartment of the thigh it divides into
  its two major branches:
• the common fibular nerve
• the tibial nerve
• innervates:
• all muscles in the posterior compartment of the thigh
• the part of adductor magnus originating from the ischium
• all muscles in the leg and foot
• skin on the lateral side of the leg and the lateral side and
  sole of the foot
                  continued
•   Gluteal nerves
•   superior gluteal nerve
•   contributions from L4 to S1
•   innervates:
•   the gluteus medius and minimus muscles
•   the tensor fasciae latae muscle
•   inferior gluteal nerve
•   contributions from L5 to S2
•   supply the gluteus maximus
                continued
•   ilio-inguinal nerve
•   genitofemoral nerve
•   lateral cutaneous nerve of the thigh
•   nerve to quadratus femoris
•   nerve to obturator internus
•   posterior cutaneous nerve of the thigh
•   perforating cutaneous nerve
                 Arteries
• Femoral artery
• continuation of the external iliac artery in
  the abdomen
• Branches supply most of the thigh and all
  of the leg and foot
• superior and inferior gluteal arteries 
  originate in the pelvic cavity as branches
  of the internal iliac artery
• supply the gluteal region
                  continued
• obturator artery  a branch of the internal iliac
  artery in the pelvic cavity
• supply the medial compartment of the thigh
• Branches of the femoral, inferior gluteal,
  superior gluteal and obturator arteries, together
  with branches from the internal pudendal artery
  of the perineum  interconnect to form an
  anastomotic network in the upper thigh and
  gluteal region
• anastomotic channels  provide collateral
  circulation when one of the vessels is interrupted
                    Veins
• draining the lower limb form superficial and deep
  groups
• The deep veins  generally follow the arteries
  (femoral, superior gluteal, inferior gluteal, and
  obturator)
• major deep vein  femoral vein  becomes
  the external iliac vein when it passes under the
  inguinal ligament to enter the abdomen
• The superficial veins  in the subcutaneous
  connective tissue
                   contined
• the great saphenous vein  originates from
  the medial side of the dorsal venous arch, and
  then ascends up the medial side of the leg,
  knee, and thigh to connect with the femoral vein
• the small saphenous vein  originates from
  the lateral side of the dorsal venous arch,
  ascends up the posterior surface of the leg,
  penetrates deep fascia to join the popliteal vein
  posterior to the knee
• proximal to the knee  popliteal vein becomes
  the femoral vein
 In the clinic -- Varicose veins
• normal flow of blood in the venous system
   depends upon the presence of
  competent valves, which prevent reflux
• Venous return  supplemented with
  contraction of the muscles in the lower
  limb, which pump the blood towards the
  heart
• venous valves become incompetent 
  tend to place extra pressure on more distal
  valves  may also become incompetent
               continued
• this condition  produces dilated tortuous
  superficial veins = varicose veins in the
  long and short saphenous venous systems
• Typical sites for valvular incompetence
  include:
• junction between the long saphenous vein
  and the femoral vein, perforating veins in
  the mid-thigh, and the junction between
  the short saphenous vein and the popliteal
  vein
                  Lymphatics
• drain into superficial and deep inguinal nodes in fascia
  just inferior to the inguinal ligament
• The superficial inguinal nodes  in the superficial
  fascia and parallel the course of the inguinal ligament in
  the upper thigh
• receive lymph from the gluteal region, lower abdominal
  wall, perineum, and superficial regions of the lower limb
• The deep inguinal nodes  receive lymph from deep
  lymphatics associated with the femoral vessels and from
  the glans penis (or clitoris) in the perineum
• The popliteal nodes  receive lymph from superficial
  vessels, drain into the deep and superficial inguinal
  nodes
                continued
• Deep fascia and the saphenous
  opening
• Fascia lata
• The outer layer of deep fascia in the lower
  limb  forms a thick 'stocking-like'
  membrane  covers the limb and lies
  beneath the superficial fascia
• particularly thick in the thigh and gluteal
  region  termed the fascia lata
 In the clinic -- Vascular access to the
                 lower limb
• Deep and inferior to the inguinal ligament  the
  femoral artery and femoral vein
• femoral artery  palpable as it passes over the
  femoral head, may be easily demonstrated using
  ultrasound
• arterial or venous access is needed rapidly  a
  physician can use the femoral approach to these
  vessels
• radiological procedures  involve
  catheterization of the femoral artery or the
  femoral vein to obtain access to:
                  continued
• contralateral lower limb, ipsilateral lower limb,
  vessels of the thorax and abdomen, cerebral
  vessels
• femoral artery  place catheters in vessels
  around the arch of the aorta and into the
  coronary arteries to perform coronary
  angiography and angioplasty
• femoral vein  catheters into the renal veins,
  the gonadal veins, the right atrium, and right
  side of the heart including the pulmonary artery
  and distal vessels of the pulmonary tree
          GLUTEAL REGION
• lies posterolateral to the bony pelvis and
  proximal end of the femur
• Muscles in the region  mainly abduct, extend,
  and laterally rotate the femur relative to the
  pelvic bone
• communicates anteromedially with the pelvic
  cavity and perineum through the greater and
  lesser sciatic foramina
• sciatic nerve  enters the lower limb from the
  pelvic cavity by passing through the greater
  sciatic foramen and descending through the
  gluteal region into the posterior thigh and then
  into the leg and foot
                 continued
• pudendal nerve and internal pudendal vessels
   pass between the pelvic cavity and perineum
  by passing through the greater sciatic foramen
  to enter the gluteal region  then immediately
  pass through the lesser sciatic foramen to enter
  the perineum
• other nerves and vessels passing through the
  greater sciatic foramen from the pelvic cavity 
  supply structures in the gluteal region itself
        Muscles of the gluteal region

•   Piriformis
•   Obturator internus
•   Gemellus superior
•   Gemellus inferior
•   Quadratus femoris
•   Gluteus minimus
•   Gluteus medius
•   Gluteus maximus
•   Tensor fasciae latae
       Nerves in gluteal region
• Seven nerves enter the gluteal region from the pelvis
  through the greater sciatic foramen:
• the superior gluteal nerve
• sciatic nerve
• nerve to the quadratus femoris
• nerve to the obturator internus
• posterior cutaneous nerve of the thigh
• pudendal nerve
• inferior gluteal nerve
• (perforating cutaneous nerve, enters the gluteal region
  by passing directly through the sacrotuberous ligament)
       In the clinic -- Intramuscular
                  injections
• to administer drugs intramuscularly  direct injection
  into muscles
• without injuring neurovascular structures
• typical site  gluteal region
• safest place to inject is the upper outer quadrant of either
  gluteal region
• gluteal region  divided into quadrants by two imaginary
  lines
• anterior corner of the upper lateral quadrant  normally
  used for injections to avoid injuring any part of the sciatic
  nerve or other nerves and vessels in the gluteal region
• needle placed in this region  enters the gluteus medius
  anterosuperior to the margin of the gluteus maximus
                Arteries
• Inferior gluteal artery
• originates from the anterior trunk of the
  internal iliac artery in the pelvic cavity
• leaves the pelvic cavity with the inferior
  gluteal nerve through the greater sciatic
  foramen
• supplies adjacent muscles and descends
  through the gluteal region and into the
  posterior thigh
                  continued
• Superior gluteal artery
• originates from the posterior trunk of the internal
  iliac artery in the pelvic cavity
• leaves the pelvic cavity with the superior gluteal
  nerve through the greater sciatic foramen
• divides into a superficial branch and a deep
  branch:
• the superficial branch  passes onto the deep
  surface of the gluteus maximus muscle
• the deep branch  passes between the gluteus
  medius and minimus muscles
                    THIGH
• the region of the lower limb, approximately
  between the hip and knee joints
• Structures enter and leave the top of the thigh by
  three routes:
• Posteriorly  the thigh is continuous with the
  gluteal region
• major structure passing between the two regions
  is the sciatic nerve
• Anteriorly  thigh communicates with the
  abdominal cavity through the aperture between
  the inguinal ligament and pelvic bone
               continued
• major structures passing through this
  aperture are the iliopsoas and pectineus
  muscles, the femoral nerve, artery and
  vein, and lymphatic vessels
• Medially  structures (including the
  obturator nerve and associated vessels)
  pass between the thigh and pelvic cavity
  through the obturator canal
       Thigh is divided into three
            compartments
• by intermuscular septa
• the anterior compartment of thigh  contains
  muscles that mainly extend the leg at the knee
  joint
• the posterior compartment of thigh 
  contains muscles that mainly extend the thigh at
  the hip joint and flex the leg at the knee joint
• the medial compartment of thigh  consists
  of muscles that mainly adduct the thigh at the
  hip joint
        Muscles of the anterior
        compartment of thigh
•   Psoas major
•   Iliacus
•   Vastus medialis
•   Vastus intermedius
•   Vastus lateralis
•   Rectus femoris
•   Sartorius
Muscles of the medial compartment
              of thigh
•   Gracilis
•   Pectineus
•   Adductor longus
•   Adductor brevis
•   Adductor magnus
•   Obturator externus
     Muscles of the posterior
      compartment of thigh
• Biceps femoris
• Semitendinosus
• Semimembranosus
In the clinic -- Muscle injuries to the
               lower limb
• Muscle injuries  a result of direct trauma or as
  part of an overuse syndrome
• minor muscle tear  demonstrated as a focal
  area of fluid within the muscle
• increasingly severe injuries  more muscle
  fibers are torn  may result in a complete
  muscle tear
• usual muscles in the thigh that tear  hamstring
  muscles
• tears in the muscles below the knee  typically
  within the soleus muscle
                Arteries
• Three arteries enter the thigh:
• the femoral artery
• the obturator artery
• the inferior gluteal artery
• femoral artery  largest and supplies
  most of the lower limb
• all three arteries contribute to an
  anastomotic network of vessels around the
  hip joint
        In the clinic -- Peripheral
             vascular disease
• characterized by reduced blood flow to the legs
• may be due to stenoses (narrowings) and/or occlusions
  (blockages) in the lower aorta, iliac, femoral, tibial, and
  fibular vessels
• Patients typically present with chronic leg ischemia and
  'acute on chronic' leg ischemia
• Chronic leg ischemia
• vessels have undergone atheromatous change and often
  there is significant luminal narrowing (usually over 50%)
• Some patients  develop such severe ischemia that the
  viability of the limb is threatened = critical limb
  ischemia
                 continued
• commonest symptom of chronic leg ischemia 
  intermittent claudication
• history of pain that develops in the calf muscles
  (usually associated with occlusions or narrowing
  in the femoral artery) or the buttocks (usually
  associated with occlusion or narrowing in the
  aortoiliac segments)
• pain experienced in these muscles  cramp-like
  and occurs with walking
                continued
• Acute on chronic ischemia
• acute event blocks the vessels or reduces
  the blood supply to such a degree that the
  viability of the limb is threatened
• Critical limb ischemia
• blood supply to the limb is so poor that the
  viability of the limb is severely threatened
• many patients present with gangrene,
  ulceration, and severe rest pain in the foot
                   Knee joint
• the largest synovial joint in the body
• consists of:
• the articulation between the femur and tibia
  (weightbearing)
• the articulation between the patella and the femur
  (allows the pull of the quadriceps femoris muscle to be
  directed anteriorly over the knee to the tibia without
  tendon wear)
• Two fibrocartilaginous menisci (one on each side,
  between the femoral condyles and tibia accommodate
  changes in the shape of the articular surfaces during
  joint movements)
               continued
• knee joint  reinforced by collateral
  ligaments, one on each side of the joint
• two very strong ligaments (the cruciate
  ligaments)  interconnect the adjacent
  ends of the femur and tibia and maintain
  their opposed positions during movement
In the clinic -- Soft tissue injuries
            to the knee
• common at and around the knee joint
• typical injuries include:
• tears of the anterior and posterior cruciate
  ligaments, meniscal tears, and trauma to the
  collateral ligaments
• Any soft tissue injury at and around the knee
  joint  may involve the neurovascular bundle
  and assessment of neurovascular structures is
  critical in the management of patients with injury
  to the soft tissues
            Degenerative joint
          disease/Osteoarthritis
• occurs throughout many joints within the body
• Typically degenerative joint disease  occurs in
  synovial joints = osteoarthritis
• typical findings include: reduction in the joint
  space, eburnation (joint sclerosis), osteophytosis
  (small bony outgrowths), and bony cyst
  formation
• in the lower limb  the hip and knee are
  typically affected
                           LEG
• part of the lower limb between the knee joint and ankle
  joint
• bony framework of the leg:
• tibia
• fibula
• leg is divided into anterior (extensor), posterior (flexor),
  and lateral (fibular) compartments by:
• an interosseous membrane
• two intermuscular septa
• direct attachment of the deep fascia to the periosteum of
  the anterior and medial borders of the tibia
Superficial group of muscles in the
  posterior compartment of leg
• Gastrocnemius
• Plantaris
• Soleus
      Deep group of muscles in the
      posterior compartment of leg
•   Popliteus
•   Flexor hallucis longus
•   Flexor digitorum longus
•   Tibialis posterior
Muscles of the lateral compartment
              of leg
• Fibularis longus
• Fibularis brevis
                     FOOT
• the region of the lower limb distal to the ankle
  joint
• subdivided into the:
• Ankle
• Metatarsus
• Digits
• foot has a superior surface = dorsum of foot
• inferior surface = sole
                Bones
• There are three groups of bones:
• the seven tarsal bones  form the
  skeletal framework for the ankle
• metatarsals (I to V)  the bones of the
  metatarsus
• phalanges  the bones of the toes -each
  toe has three phalanges, except for the
  great toe (two)
 In the clinic -- Fracture of the talus
• problems with fractures of the talus  blood
  supply to the bone is vulnerable to damage
• main blood supply to the bone  enters the
  talus through the tarsal canal from a branch of
  the posterior tibial artery
• Fractures of the neck of the talus  often
  interrupt the blood supply to the talus  making
  the body and posterior aspect of the talus
  susceptible to osteonecrosis  may in turn lead
  to premature osteoarthritis
          Flexor retinaculum
• is a strap-like layer of connective tissue that
  spans across the bony depression formed by the
  malleolus, talus, calcaneus, sustentaculum tali
• retinaculum  continuous above with the deep
  fascia of the leg and below with deep fascia
  (plantar aponeurosis) of the foot
• Septa from the flexor retinaculum  convert
  grooves on the bones into tubular connective
  tissue channels for the tendons of the flexor
  muscles as they pass into the sole of the foot
  from the posterior compartment of leg  free
  movement of the tendons in the channels
           Arches of the foot
• The bones of the foot  form longitudinal and
  transverse arches relative to the ground
• Longitudinal arch
• formed between the posterior end of the
  calcaneus and the heads of the metatarsals
• Transverse arch
• highest in a coronal plane that cuts through the
  head of the talus and disappears near the heads
  of the metatarsals
    Intrinsic muscles of the foot
• originate and insert in the foot
• there is one intrinsic muscle  extensor
  digitorum brevis  on the dorsal aspect of the
  foot
• other intrinsic muscles:
• dorsal and plantar interossei
• flexor digiti minimi brevis
• flexor hallucis brevis
• flexor digitorum brevis
                 continued
•   quadratus plantae (flexor accessorius)
•   abductor digiti minimi
•   abductor hallucis
•   lumbricals
•   all are on the plantar side of the foot
•   are organized into four layers
                  Arteries
• branches of the:
• posterior tibial
• dorsalis pedis (dorsal artery of the foot)
                    Nerves
•   foot is supplied by:
•   Tibial
•   Deep fibular
•   Superficial fibular
•   Sural
•   Saphenous

				
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