ملخص في lower limb حاجة مشاء الله

Lower Limb
Venous Drainage of Lower Limb

The veins of the lower limb can be divided into 2 groups
supf
under the skin in supf fascia
deep
accompany art deep to deep fascia
Both sets provided with valves (more numerous in deep veins)

Superficial Veins

· bld from the foot drains into 1) dorsal digital veins
2) communicating veins from sole
3) metatarsal veins
4) med & lat marginal veins
· metatarsal veins from dorsal venous arch
· medially: arch gives rise to great saphenous vein
laterally: arch gives rise to small saphenous vein


Great Saphenous Vein
Small Saphenous Vein
Origin
union of med digital vein of big toe & med side of dorsal venous arch
union of dorsal digital vein of little toe with lat end of dorsal venous arch
Course
· passes ant to med malleolus of tibia assoc with saphenous n
· asc on tibial side of leg over med subcut surface of tibia
· passes post to med condyle of femur à enters thigh
· ends by joining femoral vein
· passes post to lat malleolus of fibula assoc with sural n
· asc along midline of calf to lower part of popliteal fossa
· pierces popliteal fascia & passes btw 2 heads of gastrocnemius
· enters popliteal vein
Tributaries
1. supf circumflex iliac vein
2. supf epigastric vein
3. supf ext pudendal vein
no impt tributaries


Deep Veins

· arise from venae comitantes that accompany the main arteries of the leg & foot
· possess numerous valves
· communicate with the supf veins via perforating veins


Popliteal Vein
Femoral Vein
Origin
at lower border of popliteus
formed from
1. venae comitantes of ant & post tibial art
2. small saphenous vein
continuation of popliteal vein in adductor canal
Course
· in popliteal fossa
lie btw tibial n & popliteal art
· asc through adductor magnus hiatus
· enters adductor canal
à becomes femoral vein
· lies post to femoral art
· runs towards apex of femoral triangle
- lies post to femoral art
- ant to profunda femoris vein & art
· runs upwards in femoral triangle
- med to femoral art
- lat to femoral canal
· passes bhd ing lig
à continues as ext iliac vein
Tributaries

1. profunda femoris vein
2. great saphenous vein
3. med & lat circumflex femoral veins
4. muscular veins
· Also, sup & inf gluteal & obturator veins accompany corresponding arteries
à drain into int iliac vein

Mechanism of Venous Return

1. calf muscles pump (esp for deep veins)
2. valves - prevent backflow

Clinical Notes

1. coronary bypass surgery: great saphenous vein used to replace coronary art
2. varicose veins (esp supf veins) due to deep venous thrombosis


Lymphatic Drainage

· Most of the lymph passes through a terminal group of lymph nodes
à supf & deep ing nodes
· Before reaching these nodes,
they may pass through a series of outlying, intermediary nodes

Lymph Nodes

1. Superficial Inguinal Lymph Nodes

- arranged in horiz & vertical rows
Horiz Row
· chain of 5-6 nodes found in supf fascia below ing lig
· lat members à drain gluteal region
& ant abd wall below umb
· med members à drain ext genitalia (except glans penis)
à lower part of anal canal & peri-anal region
Vertical Row
· 4-5 nodes along terminal part of great saphenous vein
· receive all supf lymph vsls of lower limb
except area drained by small saphenous vein
- The supf ing nodes drain into the ext iliac nodes
2. Deep Inguinal Lymph Nodes

- vary from 1-3
- situated on med side of femoral vein
- receive lymph from 1. deep lymph vsls accompanying femoral vsls
2. glans penis / clitoris
- they drain into ext itlac nodes
3. Outlying Intermediate Lymph Nodes

- are few in no. & deeply placed
- the impt ones are
Anterior Tibial Node
only 1
found at upper end of ant tibial vsls adjoining interosseous mbm
Popliteal Lymph Nodes
· 6-7 in no.
· situated along popliteal vsls in popliteal fossa
· drains 1) area drained by small saphenous vein
2) knee jt
3) lymph vsls accompanying ant & post tibial vsls
- they drain into supf & deep ing nodes


Lymph Vessels

1. Superficial Vessels

- begins in lymphatic plexuses beneath skin
- divided into med & lat groups
med gp
· begin on tibial side of dorsum of foot
· accompany great saphenous vein
· end in vertical row of supf ing LN
lat gp
· begin on fibular side of dorsum of foot
· some cross front of leg to join med gp
· others accompany small saphenous vein & end in popliteal nodes
- supf vsls of buttock terminate in horizontal row of supf ing nodes
2. Deep Vessels

- accompany the main BV
à ant & post tibial nodes
peroneal nodes
popliteal nodes
femoral groups à end in corresponding nodes
- deep vsls of gluteal & ischial regions follow corresponding BV & most end in int iliac nodes

Clinical Notes

1. enlargement of supf ing nodes due to disease in their area of drainage
eg. scrotal carcinoma
abscess in perineum & anal canal
2. lesion of lat side of heel à inflammation of popliteal nodes


Hip Joint

Type

synovial ball & socket jt

Articulation

1. head of femur
2. acetabulum of hip bone
- articular surface of acetabulum deficient inferiorly à acetabular notch
- cavity of acetabulum deepened by presence of fibrocartilaginous rim
à acetabular labrum

Capsule

· encloses jt
· medially: attached to acetabular labrum
laterally: attached to intertrochanteric line & post aspect of neck of femur
· anteriorly part of capsule reflects back towards the head as the retinacula
à convey bld supply to head & neck of femur

Ligaments

1
iliofemoral lig
· strong & Y-shaped
· from ant inf iliac spine to intertrochanteric line
· prevents overextension during standing
2
ischiofemoral lig
· spiral in shape
· from body of ischium to greater trochanter
· limits extension
3
pubofemoral lig
· triangular in shape
· from sup ramus of pubis to intertrochanteric line
· limits extension & abduction
4
tnvs acetabular lig
· formed by acetabular labrum
· bridges acetabular notch
5
lig of head of femur
· from tnvs lig to fovea capitis

Synovial Membrane

· lines capsule
· attached to margins of articular surfaces
· forms a bursa: psoas bursa beneath psoas tendon

Nerve Supply

1. femoral n (via branch to rectus femoris)
2. obturator & sciatic n
3. n to quadratus femoris


Blood Supply

1. sup & inf gluteal art
2. circumflex femoral & obturator arteries
These form trochanteric anastomosis to supply the jt

Movements

· wide range of movements, but less than shoulder jt
· some of the movement sacrificed for stability

movements
muscles responsible
1
flexion
1. iliopsoas
2. rectus femoris
3. sartorius
4. adductor muscles
2
extension
1. gluteus maximus
2. hamstrings
3
abduction
gluteus medius & minimus
4
adduction
1. adductor longus & brevis
2. adductor fibres of adductor magnus
5
lat rotation
1. piriformis
2. obturator int & ext
3. quadratus femoris
6
med rotation
1. ant fibers of gluteus medius & minimus
2. tensor fasciae lata
7
circumduction
combination of the above movements

Relations

Anteriorly
1. iliopsoas
2. pectineus
3. rectus femoris
These sep the jt from femoral vsls & n
Posteriorly
1. obturator internus
2. gemelli
3. quadratus femoris
These sep the jt from sciatic n
Superiorly
1. piriformis
2. gluteus minimus
Inferiorly
obturator ext tendon


Stability

· relatively stable jt
· stability maintained by several factors
1
bony factors
· acetabulum is deep
· additional depth provided by acetabular labrum
à provide snug fit for head of femur
2
capsule
encloses jt
strong anteropost, thin & loosely attached posteroinf
3
ligaments
1. iliofemoral
2. ischiofemoral
3. pubofemoral
4
muscles
· anteriorly - iliopsoas
- rectus femoris
· anterolat - gluteus medius
- gluteus minimus
· posteriorly - piriformis
- obturator internus
- gemelli
- quadratus femoris
covered by gluteus maximus
· posteroinf - obturator externus
5
synovial fluid
provides strong cohesive force

Clinical Notes

1. jt disease: osteoarthritis (arthrosis)
2. post dislocation à involves sciatic n


Knee Joint

The knee it consist of 3 jts: 2 condylar jts & 1 gliding jt

Type

· the 2 condylar jts are synovial hinge jts (with some rotatory movement)
· the gliding jt is of the plane variety

Articulation


articulation
type of jts
1
btw med condyles of femur & tibia
condylar jt
2
btw lat condyles of femur & tibia
condylar jt
3
btw patella & lower end of femur
gliding jt
The articular surfaces are covered with hyaline cartilage

Capsule

· fibrous capsule
· surround sides & post aspects of jt, absent anteriorly
· attachments

attached to
remarks
superiorly
femur
· articular margins of condyles
· intercondylar line posteriory
· deficient on lat condyle due to passage of popliteus tendon
inferiorly
tibia
· articular margins of condyles, except at lat condyle to allow passage of popliteus tendon
· prolonged inferolat over popliteus to head of fibula
à arcuate popliteal lig

Ligaments

1. Extracapsular

ligamentum patallae
· continuation of quadriceps femoris
· sep from synovial mbm by infrapatellar pad of fat
· sep from tibia by deep infrapatellar bursa
· attachments
sup à lower border of patella
inf à tubercle of tibia
lat collat lig
· sep from lat meniscus by popliteus tendon
· splits biceps femoris tendon into 2 parts
· attachments
sup à lat condyle of femur
inf à head of fibula
med collat lig
· attachments
sup à med condyle of femur
inf à med surface of shaft of tibia
Note: attached to edge of med meniscus & fibrous capsule
oblique popliteal lig
· derived from semimembranosus tendon
· strengthens post aspect of capsule
· arises post to med condyle of tibia, passes superolat
& attached to central part of post aspect of capsule
arcuate popliteal lig
· strengthens post aspect of capsule
· arises from capsule
2. Intracapsular

ant cruciate lig
· extends superiorly, posteriorly & laterally
· attachments
sup à post part of med surface of lat femoral condyle
inf à ant intercondylar area of tibia
· functions 1) prevent post displacement of femur on tibia
2) prevent hyper-extension of knee it.
post cruciate lig
· extends superiorly, anteriorly & medially
· attachments
sup à ant part of lat surface of med femoral condyle
inf à post intercondylar area
· functions 1) prevent ant displacement of femur on tibia
2) prevent hyperflexjon of_knee jt

Menisci

· C-shaped rings of fibrocartilage
à called semi-lunar cartilages
· lie on articular surface of tibia
· consist of med & lat semilunar cartilages
· attachments
ant horn
ant intercondylar area
post horn
post intercondylar area
peripheral margins
fibrous capsule of knee jt
· functions 1) deepen articular surfaces of tibia
2) lubrication & shock absorption

Synovial Membrane

· lines inner aspect of capsule
· attachments 1) margins of articular surfaces
2) peripheral edges of menisci
· folds
anteriorly
infrapatella & alar folds
posteriorly
around cruciate lig
At these folds, do not line capsule


Bursae

anterior
1. suprapatellar
2. prepatellar
3. supf infrapatellar
4. deep infrapatellar
posterior
1. popliteal
2. semimembranosus

Nerve Supply

1. femoral n
2. obturator n
3. common peroneal n
4. tibial n

Blood Supply

1. femoral art
2. lat femoral circumflex art
3. ant tibia art
4. popliteal art

Movements

flexion
· limited by contact of back of leg with thigh
· carried out by biceps femoris, semitendinosus & semimbm
· assisted by gracilts, sartorius, popliteus
extension
· limited by ant & post cruciate & other lig
· carried out by quadriceps femoris & tensor fascia lata
med rotation
· accompanies extension from flexed position
· carried out by popliteus, semimbm, semitendinosus, sartorius & gracilis
lat rotation
· accompanies flexion
· carried out by biceps femoris

Relations

Anteriory
1. prepatellar bursa
2. tendinous expansions from vastus medialis & lateralis
Posteriorly
1. popliteal vsls
2. tibial & common peroneal n
3. lymph nodes
4. muscles forming boundary of popliteal fossa
à semimbm, semitendinosus, biceps femoris,
2 heads of gastrocnemius & plantaris
Medially
1. sartorius
2. gracilis
3. semitendinosus
Laterally
biceps femoris

Stability

1. tone of muscles, esp quadriceps femoris & iliotibial tract
2. ligaments esp ant cruciate & the 2 collat lig

Clinical Notes

1. injuries to menisci (esp med) à wedged btw articular surfaces
à movement impossible
2. injuries to collat lig (esp med) & cruciate lig
3. inflammation & swelling in synovial cavity may spread into suprapatellar bursa


Ankle Joint

Type

synovial hinge jt

Articulation

1. inf ends of tibia & fibula, which form a deep socket,
articulate with trochlea of talus
2. lat malleolus of fibula with lat surface of talus
3. med malleolus of tibia with med surface of talus

Capsule

· attachments
sup à borders of articular surfaces of tibia & malleolus
inf à talus
· thickened at sides to prevent rocking movements

Ligaments

med (deltoid) lig
· attachments
apex à margins & tips of med malleolus
base = post tibiotalar part à talus
= tibionavicular part à navicular
= tibiocalcanean part à calcaneus
· functions - attach med malleolus to talus
- strengthen ankle jt
- hold calcaneus & navicular bone to talus
lat lig
· 3 parts
1. ant talofibular lig = from lat malleolus to talus
2. calcaneofibular lig = from lat malleolus to calcaneus
3. post talofibular lig = from lat malleolus to post tubercle of talus
· function: attach lat malleolus to talus & calcaneus


Synovial Membrane

· lines capsule
· projects superiorly btw tibia & fibula for short distance

Nerve Supply

1. tibial n
2. deep peroneal

Blood Supply

malleolar branch of 1) peroneal art
2) ant & post tibial art

Movements

movements
limited by
produced by
dorsiflexion
1. tension of tendo calcaneus
2. post fibres of med lig
3. calcaneofibular lig
1. tibialis ant
2. extensor hallucis longus
3. extensor digitorum longus
4. peroneus tertius
plantar flexion
1. tension of opposing muscles
2. ant fibres of med lig
3. ant talofibular lig
1. gastrocnemius
2. soleus
3. plantaris
4. peroneus longus & brevis
5. tibialis post
6. flexor digitorum longus
7. flexor hallucis longus

Relations

Anteriorly
(med to lat)
1. tibialis ant
2. ext hallucis longus
3. ant tibial vsls
4. deep peroneal n
(ant tibial n)
5. ext digitorum longus
6. peroneus tertius
Posteriorly
1. tendocalcaneus
2. plantaris
Postero-laterally
(bhd lat malleolus)
1. peroneus longus
2. peroneus brevis
Postero-medially
(bhd med malleolus)
1. tibialis post
2. flexor digitorum longus
3. post tibial vsls
4. tibial n
5. flexor hallucis longus

Stability

· strong during dorsiflexion - supported by strong lig
- crossed by tendons
- talus fills socket btw med & lat malleoli
· weak during plantar flexion because the ligs are less taut

Clinical Notes

1. sprains: caused by excessive inversion of foot
à ant talofibular & calcaneofibular lig partially torn
2. fracture dislocations: caused by forced ext rotation & over-eversion
à tip of med malleolus may be pulled off due to tightening of med hg


Femoral Triangle

It is a triangular depressed area situated in upper part of med aspect of thigh, just below inguinal lig

Boundaries

base
ing lig
med border
med border of adductor longus
lat border
med border of sartorius
apex
meeting of med border of adductor longus & sartorius
floor
med = adductor longus & pectineus
lat = iliopsoas
roof
skin & fascia

Contents

From lat to med

1. femoral n & its terminal branches, one of which is the saphenous n
2. femoral art which gives rise to
3. profunda femoris art which runs medially & gives rise to med & lat circumflex femoral art
4. femoral vein which crosses the art posteriorly from lat to med
5. deep ing lymph nodes
Other structures also fd are

6. lat femoral cutaneous n
7. femoral branch of genitofemoral n

Clinical Notes

1. withdrawal of bld from femoral art
à arterial pulse can be taken
2. venipuncture of femoral vein

Note: Structures on Roof
1. great saphenous vein
2. supf ing lymph nodes


Popliteal Fossa

It is a diamond-shaped fossa located bhd the knee jt

Boundaries

superolat
lower (med) border of biceps
superomed
lat border of semitendinosus, semimbm & adductor magnus
inferolat
lat head of gastrocnemius & plantaris
inferomed
med head of gastroenemius
floor
upper part formed by post surface of lower 1/3 of femur
lower part formed by capsule of knee jt & popliteus muscle
roof
formed by deep fascia (popliteal fascia), fat, supf fascia& skin

Contents found on Roof

1. sural communicating n of common peroneal n
2. small saphenous vein
3. post division of med cutaneous n of thigh
4. post cutaneous n of thigh

Contents in Fossa

1. popliteal art
2. popliteal vein
3. tibial n
4. common peroneal n situated just beneath biceps femoris
5. popliteal lymph nodes
In upper portion, the art is most med, then the vein & then the tibial n most lat
Inferiorly there is a rotation in vertical axis à the tibial n is most supf

Other Structures found are

1. small saphenous vein as it pierces popliteal fascia to join popliteal vein
2. genicular branch of obturator n

Clinical Notes

1. the popliteal art is prone to aneurysms
2. if popliteal art is occluded at hiatus of adductor magnus gangrene of lower leg can occur


Femoral Artery

Origin

continuation of ext iliac art at ing lig

Course

· enter thigh by passing under ing lig midway
btw ant sup iliac spine & symphysis pubis
ie at mid-inguinal pt
· descends through femoral triangle & adductor canal
· reaches adductor tubercle of temur
· ends at opening of adductor magnus
· enters popliteal space & continues as popliteal artery
Note: in femoral triangle, the artery is supf

Relations

Anteriorly
upper part (in femoral triangle): skin & fascia
lower part (in adductor canal):1. sartorius
2. ant wall of femoral sheath
3. med cutaneous n of thigh
4. saphenous n crosses from lat to med
Posteriorly
1. psoas major
2. pectineus
3. adductor longus
4. femoral vein (in lower part of its course)
5. adductor magnus
Medially
femoral vein
Laterally
femoral n & branches

Branches

supf circumflex iliac
passes through saphenous opening
à area around ant sup iliac spine
supf epigastric
passes through saphenous opening
à umb region à supply skin of ant abd wall
supf ext pudendal
passes through saphenous opening
à pubic tubercle à supply skin of scrotum / labia majora
deep ext pudendal
passes medially à supply skin of scrotum / labia majora
profunda femoris
· arise from lat side abt 4 cm below ing hg
· gives off med & lat circumflex femoral art
· enters med compartment of thigh bhd adductor longus
· gives off 3 perforating art & ends as 4th perforating art
descending genicular
arises near its termination
à supplies knee jt


Surface Marking

· thigh in flexion, abduction & lat rotation
· knee in flexion
· draw line btw midinguinal pt & adductor tubercle
· the artery is the first 3/4 of the line

Clinical Notes

1. arterial pulse
2. withdraw bld
3. catheterisation: pass dye into bld so as to take X-rays or angiograms


Sciatic Nerve

It is the thickest nerve in the body

Origin

· largest branch of sacral plexus in the pelvis
· L4, 5, S1, 2, 3
· consists of 2 parts 1) tibial part
2) common peroneal part

Course

· enters gluteal region through greater sciatic foramen below piriformis
· runs downwards & laterally
· enters back of the thigh at lower border of gluteus maximus
· runs vertically downwards in the midline to sup angle of popliteal fossa
· terminates by dividing into tibial & common peroneal nerves

Relations

· In the qluteal region,
supf (post)
1. gluteus maximus
2. post cutaneous n of thigh
deep (ant)
1. body of ischium
2. obturator internus & gemellus
3. quadratus femoris
4. capsule of hip jt
medial
inf gluteal n & vsls
· In the thigh
supf (post)
long head of biceps femoris
deep (ant)
adductor magnus
medial
1. post cutaneous n of thigh
2. semitendinosus
3. semimembranosus
lateral
biceps femoris

Branches

1. articular branches to hip jt
2. muscular branches
(1) tibial part to a) semitendinosus & semimembranosus
b) long head of biceps femoris
c) hamstring part of adductor magnus
(2) common peroneal part to short head of biceps femoris
3. terminal branches - tibial n
- common peroneal n


Clinical Notes

1. It is often injured by badly-placed intramuscular injections in gluteal region
2. post dislocation of hip jt, penetrating wound or fracture of the pelvis can all result in injury to the nerve
3. compression & irritation of one of the nerve roots usu results in pain along the areas of distribution of the nerve
à sciatica
4. effects of lesion
- paralysis of hamstring muscles
- paralysis of all muscles below the knee, leading to footdrop
- loss of sensation below the knee except for narrow area
down med side of leg & med border of foot
which is supplied by saphenous n (femoral n)


Tibial Nerve

Origin

· terminal branch of sciatic n
· arises in lower 1/3 of thigh in most cases
· L4, 5, S1, 2 & 3

Course & Relations

· runs downwards through popliteal fossa
· crosses bhd popliteal artery from lat to med
· sep from artery by popliteal vein
· nerve enters post compartment of leg by passing deep to
2 heads of gastrocneniius & soleus muscle
· lies on post surface of tibialis post
then on post surface of tibia
· crosses post tibial artery from med to lat
· passes bhd med malleolus, btw
tendons of flexor digitorum longus & flexor hallucis longus
· passes under flexor retinaculum
· divides into med & lat plantar n

Branches

· In the popliteal fossa
1
cutaneous
sural n to 1) lat & post part of leg
2) lat border of foot
2
muscular
both heads of 1) gastrocnemius
2) plantaris
3) soleus
4) popliteus
3
articular branches
knee jt
· In the leg (post compartment)
1
cutaneous
med calcaneal branch
2
muscular
1) soleus
2) flexor digitorum longus
3) flexor hallucis longus
4) tibialis post
3
articular
ankle jt
4
terminal branches
1) med plantar n
2) lat plantar n


Surface Marking

Pt 1: apex of popliteal fossa
Pt 2: midline at level of neck of fibula
Pt 3: midway btw med malleolus & tendo calcaneus
Join all 3 points

Clinical Notes

Lesion results in
1. paralysis of all the muscles in post compartment of leg
2. paralysis of all muscles in sole of foot
3. opposing muscles dorsiflex foot at ankle jt & evert foot at subtalar jt
à calcaneovalgus
4. loss of sensation from sole of foot


Common Peroneal Nerve

Origin

· smaller terminal lateral branch of sciatic n
· arises in most cases in lower 1/3 of thigh, at sup angle of popliteal fossa

Course & Relations

· runs along superolat boundary of popliteal fossa
· follows med border of biceps femoris
· leaves popliteal fossa by crossing lat head of gastrocnemius & soleus
· passes bhd head of fibula
· winds laterally around neck of fibula
· pierces peroneus longus
· deep to peroneus longus à divides into 2 terminal branches
1. supf peroneal n
2. deep peroneal n

Branches

cutaneous
1. sural communicating n à joins sural n
2. lat cutaneous n of calf à supplies skin on lat side of back of leg
muscular
short head of biceps femoris
articular
knee jt

Terminal Branches

Terminal Branches
Supply
supf peroneal n
1. muscles of lat compartment of leg
ie. peroneus longus & brevis
2. lower part of front of leg & dorsum of foot
deep peroneal n
1. muscles of ant compartment of leg
ie tibialis ant, extensor digitorum longus & brevis,
extensor hallucis longus & peroneus tertius
2. ankle jt

Surface Marking

Pt 1: apex of popliteal fossa
Pt 2: back of neck of fibula
Join the 2 pts


Clinical Notes

· Lesions at neck of fibular caused by 1.fractune of neck of fibula
2. pressure from plaster casts / splints
· Effects of Lesion
Motor Effects
1. paralysis of muscles of ant compartment (supplied by deep peroneal n)
ie tibialis ant
extensor digitorum longus & brevis
peroneus tertius
extensor hallucis longus
2. Paralysis of muscles of lat compartment (supplied by supf peroneal n)
ie. peroneus longus & brevis
3. as a result of action by the opposing muscles, the foot becomes
a) plantar-flexed at ankle jt (foot-drop)
b) inverted at subtalar & tnvs tarsal jts
Sensory Effects
· loss of sensation : down ant & lat sides of leg
: on dorsum of foot & toes
: on med side of big toe
· unaffected : lat border of foot & lat side of little toe
: border of foot up to big toe
à supplied by saphenous n


Popliteal Artery

Origin

continuation of femoral art as it passes through opening in adductor magnus muscle

Course

· from its origin it runs downwards & slightly laterally in popliteal fossa
· passes through intercondylar fossa
· reaches lower border of popliteus
· terminates by dividing into ant & post tibial arteries

Relations

anteriorly
1. popliteal surface of femur
2. oblique popliteal lig of knee jt
3. popliteus
posteriorly
1. popliteal vein – cross from lat to med
2. tibial n – cross from lat to med
3. above = semimembranosus
4. below = gastrocnemius & plantaris
laterally
Above are
1. biceps femoris
2. popliteal vein
3. tibial n
4. lat condyle of femur
Below are
5. plantaris
6. lat head of gastrocnemius
medially
Above are
1. semimembranosus
2. med condyle of femur
Below are
3. tibial vein
4. tibial n
5. med head of gastrocnemius

Branches

cutaneous
supplies 1. skin over popliteal fossa
2. back of upper part of leg
muscular
supplies 1. hamstring muscles
2. gastrocnemius, plantaris & soleus
articular
knee jt = lat & med sup genicular
middle genicular
lat & med inf genicular


Surface Marking

Pt 1: junction of middle & lower 1/3 of thigh
2.5 cm med to midline at back of thigh
Pt 2: midline at level of knee jt
Join pts 1 & 2
Draw a line vertically from pt 2 to level of tibial tuberosity

Clinical Notes

1. recording of bld pressures of lower limb by catheterization
2. aneurysms
3. atherosclerosis


Femoral Nerve

Origin

· largest branch of lumbar plexus
· post division of ventral rami of L2, 3 & 4

Course & Relations

· from lat border of psoas within abd
· desc btw psoas & iliacus
· enters thigh bhd ing lig, lat to femoral art & femoral sheath
· abt 1 1/2 inches (4 cm) below mg hg
à divides into ant & post divisions
to supply musdes of ant compartment of thigh

Branches

From Ant Division
1. med cutaneous n of thigh
2. intermediate culaneous n
3. muscular branches to
(a) sartorius
(b) pectineus

supplies skin of med & lat aspect of thigh
supplies skin of med & lat aspect of thigh
From Post Division
1. saphenous n







2. muscular branches to
a. pectineus
b. quadriceps femoris
c. rectus femoris
d. vasti
· crosses femoral art from lat to med
· desc down med side of leg with great saphenous vein
· runs along med border of foot & ends in region of ball of big toe
à supplies skin of med side of leg
& med border of fool




also supplies hip jt
also supplies knee jt

Clinical Notes

· may be injured in gunshot / stab wounds
· effects:
a. Motor - quadriceps femoris paralysed à unable to extend knee
In walking, this is somewhat compensated for by the adductors
b. Sensory - Loss of sensation over med side of leg & med border of foot
(ie. area supplied by saphenous n)


Arches of Foot (Medial & Lateral Longitudinal)

· An arched foot is a distinctive feature in man
· The arches are formed & maintained by
the bones, ligaments, muscles, tendons & aponeuroses

Principles involved in Arch Support / Formation

· An arch is made up of a no. of segments
· The basic principles involved are
1. shape of the segments, ie bones
2. intersegmental ties which must be particularly strong on the inf surface
3. tie beams connecting both ends of the arch
4. suspension of the arch

Medial Longitudinal Arch & Lateral Longitudinal Arch


Medial Longitudinal Arch
Lateral Longitudinal Arch
Bones
1. calcaneum
2. talus = keystone
3. navicular
4. 3 cuneiforms
5. first 3 metatarsals
1. calcaneum
2. cuboid
3. 4th & 5th metatarsals
Support & Maintenance
1. Shape of Bones

· sustentaculum tali
holds up the talus
· rounded head of talus
fits into concavity of navicular
· navicular in turn
fits into med cuneiform
Talus = keystone

· not very impt
· minimal shaping
btw calcaneum & cuboid
cuboid = keystone
2. Intersegmental Ties
inf edges of bones are tied tog by
1. plantar lig esp calcaneonavicular (spring) lig
2. insertions of tibialis post
inf edges of bines are tied tog by
1. long & short plantar lig
2. origins of short muscles from forepart of foot
3. Beams connecting both ends of arch
1. md part of plantar apo
2. med part of flexor dig longus & brevis
3. flexor hallucis longus & brevis
4. abductor hallucis
1. plantar aponeurosis
2. lat part of flexor dig longus & brevis
3. abductor digiti minimi
4. Suspension from above
by 1. tibialis ant & post
2. med lig of ankle jt
peroneus longus & brevis


Functions of the Arches

1. weight bearing à distribute wt of body to wt-bearing pts of the sole
ie. heels & balls of toes
2. assist in locomotion
Note: 1) static support provided by bones & lig
2) muscles are involved only in movement

Clinical Notes

collapse of arches à flat foot


Gluteal Muscles

The gluteal muscles are: gluteus maximus, gluteus medius & gluteus minimus

Gluteus Maximus

· It is the largest musde in the body.
· It is responsible for the prominence of the buttock
Origin
from 1. outer surface of ilium bhd post gluteal line
2. post surface of sacrum & coccyx
3. sacrotuberous lig
Insertion
into: 1. iliotibial tract
2. gluteal tuberosity of femur
Nerve Supply
inf gluteal n (L5-S2)
Actions
1. extends
2. laterally rotates
3. supports knee jt via iliotibial tract

Gluteus Medius

Origin
from 1. outer surface of ilium bounded by
2. iliac crest superiorly
3. post gluteal line posteriorly &
4. middle gluteal line inferiory
Insertion
into lat surface of greater trochanter of femur
Nerve Supply
sup gluteal n (L4-S2)
Actions
1. abducts
2. medially rotates
3. supporls pelvis during walking & running
ie. prevents pelvis from dipping downwards on opposite side

Gluteus Minimus

Origin
from outer surface of ilium btw middle & inf gluteal lines
Insertion
into ant surface of greater trochanter
Nerve Supply
sup gluteal n (L4-S2)
Actions
1. abducts
2. medially rotates
3. supports pelvis during movement

Clinical Notes

· Gluteaus maximus
- intramuscular injections
à given in upper outer quadrant of buttock
· Paralysis of gluteus medius & minimus
- result: raise foot on normal side
à pelvis falls towards that side
- thus when walking = waddling gait (gluteal gait)
= pelvis falls towards normal side
· Trendelenberg test - stand upright
- lift up one leg
à If pelvis dips, gluteus on oppo side damaged


Cutaneous Innervation of Lower Limb

· Difference in cutaneous innervation of the lower limb is due to the development of different parts from diff dermatomes
· The cut n are derived from the ant & post rami of the spinal n, namely those from the lumbar & the sacral plexus

A. Gluteal Region

Upper med quadrant
Upper lat quadrant
Lower med quadrant
Lower lat quadrant
post rami of
1. upper 3 lumbar (L1, 2, 3) n
2. upper 3 sacral (S1, 2, 3) n
1. lat br of iliohypog (L1)
2. subcostal n (T12 ant rami)
gluteal & perineal br fr post cut n of thigh
(S1, 2, 3 ant rami)
lat cut n of thigh
(L2, 3 ant rami)

B. Thigh Region

1. Ant Aspect of Thigh

Femoral br of genitofemoral n (L1, 2)
· enters thigh bhd middle of ing hg
· thus supply
1. a small area of skin just below ing ing anteriorly
2. skin of femoral triangle
Intermediate cut n of thigh (L2, 3)
· br of femoral n
· supply ant aspect of thigh
2. Medial Aspect of Thigh

1. Ilioinguinal n
(L1)
· enters thru supf ing ring
· small skin area below med part of ing lig
2. Obturator n
(L2, 3, 4 post rami)
variable area of skin on med aspect of thigh
3. Med cut n of thigh
(L2, 3 ant rami)
· br of femoral n
· supplies med aspect of thigh,
joins patellar plexus
3. Lat & Post Aspect of Thigh

Lat Aspect
Post Aspect
Lat cut n of thigh (L2, 3 ant rami)
· enter bhd lat end of ing lig
· supplies skin of lat aspect of thigh & knee
Post cut n of thigh (S1, 2, 3; br of sacral pl)
· enters thru lesser sciatic foramen below piriformis
· supplies back of thigh & upper part of leg & skin over popliteal fossa


C. Leg Region

1. Ant & Lat Aspect of Leg

1. Br of lat cut n of calf
(L5, S1, 2)
· br of common peroneal
· skin on upper art of ant lat surface of leg
2. Supf peroneal n
(L4, 5, S1)
· br of common peroneal
· skin on lower part of ant lat surface of leg
2. Med Aspect of Leg

· Saphenous n (L3,4)
- br of femoral n
- skin on ant med surface of leg
3. Post Aspect of Leg

1. lat cut n of calf
lat side of post aspect of leg
2. br of saphenous n
med side of post aspect in upper part of leg
3. sural / peroneal communicating br
br of common peroneal
4. sural n
(L5, S1 ,2)
supplies post aspect of lower part of leg

D. Foot

1. Plantar Aspect (Side)

1. med calcaneal br
br of tibial n
med side of heel
2. med plantar n
med 2/3 of sole
med 3 1/2 toes
3. lat plantar n (supf br)
lat 1/3 of sole
lat 1 1/2 toes
2. Dorsal Aspect

1. Supf peroneal n
· divides into med & lat br
· med br: med side of big toe
adj sides of 2nd & 3rd toes
lat br: adj sides of 3rd to 5th toes
2. Saphenous n
· passes in front of med malleolus
· supplies skin on med side till head of 1st MT
3. Sural n
supplies skin along lat side & little toe