Anatomy - Lower Limb V1c

U n i v e r s i t y o f D e b r e c e nG e n e r a l M e d i c i n e

1 s t y e a r , 2 n d s e m e s t e rA n a t o m y

T o p i c s f o r l o w e r l i m b

Lower limb topics Composed by : Ragnheiður Hera Sigurðardóttir (group 5), Sveinn Rúnar Sigurðsson (group 5), Sigrún Katrín Kristjánsdóttir (group 5), Nína Björnsdóttir (group 7), Elia Kashani (group 5), Fanny Lirfeldt (group 7) , Itay Chen (Tables of muscle origins / insertions) Supervisor : Tamas Juhasz Document maintained by : Sveinn Rúnar Sigurðsson Feedback / Additions : [email protected] Resources : Clinical Anatomy (Moore), Anatomy Atlas (Netter), Tamas Juhasz lectures / handouts Document version : 1b Last updated : 2009‐04‐11

Anatomy Lower limb

ANSWERS

Anatomy – lower limb Page 2

Anatomy ‐ Lower limb exam topics Use : Similarly to Netter, we present muscle origins in dark‐red text, muscle insertions in blue. Important definitions / anatomical locations in indented light blue boxes. Instead of including too many images in the document, I added accurate references to Netter and Moore. Summaries from Moore’s blue boxes are displayed... in blue boxes here as well . Enjoy. Svenni / Hera / Nína / Elia / Sigrun / Fanney

Table of Contents

1. Bones, joints and ligaments of the pelvic girdle. ................................................................... 3 2. Gluteal muscles. Blood vessels and nerves of the gluteal region. ......................................... 8 3. Subinguinal hiatus. Femoral canal. ...................................................................................... 11 4. Femur. Hip joint. ................................................................................................................... 13 5. Muscles, blood vessels and nerves of the anterior and medial compartments of the thigh. .................................................................................................................................................. 16 6. Femoral triangle. Adductor canal. ........................................................................................ 19 7. Muscles, blood vessels and nerves of the posterior compartment of the thigh. ................ 20 8. Popliteal fossa. Knee joint. ................................................................................................... 21 9. Bones of the leg. Muscles, blood vessels and nerves of the anterior and lateral compartments of the leg. ......................................................................................................... 24 10. Bones of the leg. Muscles, blood vessels and nerves of the posterior compartment of the leg. ............................................................................................................................................ 26 11. Ankle joint. Medial and lateral malleolar regions. ............................................................. 30 12. Bones, joints and ligaments of the foot. Arches of the foot. ............................................. 33 13. Muscles, blood vessels and nerves of the sole (plantar region). ....................................... 36 14. Muscles, blood vessels and nerves of the dorsum of the foot. ......................................... 42 15. Blood and lymphatic vessels, and cutaneous innervations of the lower limbs ................. 43 A GUIDE TO THE MUSCLES OF THE LOWER LIMB .................................................................... 55


1. Bones, joints and ligaments of the pelvic girdle. The Pelvic girdle (PV) is formed by the two hip bones and the Sacrum NETTER P. 354

The PV is divided into 2 regions :

Greater Pelvis : Protects the abdomen

Lesser Pelvis : Framework for Pelvic cavity and Perineum

Perineum: the area of surface of trunk between the thighs and buttocks, extending from coccyx to pubis, and to shallow compartment lying superior, also inferior to pelvic diaphragm. (anus, external genitalia).

Function of the PV: Bears weight of upper body Transfers weight from axial to lower appendicular skeleton Attachment for muscles of locomotion and abdominal wall

BONES The Hip bone (os coxae): NETTER P.486

It is formed by the fusion of the ilium, ischium and pubis.

Large flat bone

The two hip bones unite anteriourly by the pubic symphysis

posteriourly they make a bony connection with the Sacrum

at puberty the three primary bones are still separated, by an Y‐shaped triradiate cartilage in the acetabulum

Fusion is completed at ages 20‐25. Ilium is located superiorly to Ischium and Pubis.

Fan shaped

body: corpus ossis ili

Structures ‐ anterior superior iliac spine (palpable) ‐ anterior inferior iliac spine ‐ iliac crest (long curved superior border of the ala (the wing)): ‐ wing‐like surface (posterolateral): ala, ala ossis ili, where

Laterally : gluteal muscles attach Medially : iliac muscles medially will attach

‐ tuberositas glutealis / Gluteal lines / 3 lines Posterior gluteal line : Gluteus Maximus muscle Anterior gluteal line : Gluteus Medius muscle Inferior gluteal line : Gluteus Minimus muscle

- tuberositas sacralis - posterior superior iliac spine ‐ iliac tubercle : the prominence on the external lip of the crest ‐ the greater sciatic notch: the posterior superior iliac spine ends ‐ iliac fossa ‐ auricular surface articulation surface of the sacrum


Ischium Has a body and a ramus. Body corpus ossis ischii

The body of Ischium forms a part of the obturator foramen.

At the junction of the ramus and the body we find the Ischial spine

The lesser sciatic notch is formed entirely by the Ischium but the Greater sciatic notch is formed together with the ilium.

Structures ‐ Ischial Spine ‐ Lesser Sciatic notch / Greater sciatic notch ‐ Ischial tuberosity ‐ Ramus of ischium

Pubis

The superior part of the bone helps to form the Acetabulum.

While the inferior part contributes to the obturator foramen

The anterior part of the body of pubis thickens (Pubic crest) and results in the Pubic tubercle

Structures ‐ Acetabular notched (formed with Ischium) ‐ Inferior pubic ramus / Superior pubic ramus ‐ Pectineal line ‐ Obturator groove ‐ Symphyseal surface

‐ Pubic tubercle

The pubic arch is formed by the ischiopubic rami. Meet at pubic symphysis. Inferior borders define the subpubic angle, with determined by distandce btw right and left ischial tuberosities.

2 Very important structures of the hip bone. Obturator foramen

Large oval triangular space

passage way of the obturator nerve and vessels

closed by the obturator membrane Acetabulum

large cup‐shaped cavity or socket , articulates with the head of the femur

acetabular notch: margin of the acetabulum (limbus)

acetabular fossa (we find fat here, covered with synovial membrane

lunate surface (Articular surface of the Acetabulum)

Acetabular labrum (labrum acetabulare) (fibrocartilaginous) Sacrum (Sacrum os sacrale) : Triangular, wedge shaped bone.

Five fused (Synostosis) sacral vertebrae in adults after 20 years.

Forms the roof and posterosuperior wall of the posterior pelvic cavity.

Provides strength and stability to the pelvis, transmits the weight of the body to the pelvic girdle.

Sacral canal: continuation of the vertebral canal, contains spinal nerve roots inferior to the L1 vertebra (cauda equina).

On the posterior side are 4 pairs of sacral foramina exits o For the posterior and anterior rami of spinal nerves. o The anterior foramina are larger than posterior ones.


Base of sacrum: formed by superior surface of S1. sacral promontory on the anterior.

Apex of sacrum: oval facet for articulation with the coccyx.

Pelvic surface: smooth and concave.

Dorsal surface: rough convex and marked by 5 prominent longitudinal ridges. o Median sacral crest (spinous processes) o Intermediate sacral crest (articular processes) o Lateral sacral crest (transverse processes) o U shaped hiatus: absence of the laminae and spinous processes of S5, leads

into the sacral canal. o Sacral cornua: inferior articular processes of S5 project on each side of hiatus.

Auricular surface on lateral surface.synovial part of sacroiliac joint btw. Sacrum and ilium.

Pelvic intlet (superior pelvic aperture) is formed by the o Promontory and ala of sacrum o Right and left linea terminalis (acruate line on inner ilium) pecten

Pelvic outlet (inferior pelvic aperture) formed by the o Pubic arch anteriorly o Ischial tuberosities laterally o Inferior margin of sacrotuberous ligament posterolaterally o Tip of coccyx posteriorly

True pelvis: concave superior surface of musculofascial pelvic diaphragm forms the floor. Convex inferior surface of pelvic diaphragm forms the roof of perineum.

Are united by triradiate in infants and fuse after puberty in the acetabulum. The hip bones are joined together anteriorly by symphysis pubis and posteriorly at sacrum by sacroiliac joints..

Coccyx fusion of the 3‐5 rudimentary coccygeal vertebrae. Remanant of embryonic tail in embryos from the end of 4th week until beginning of

8th week. Pelvic surface: smooth and concave. Posterior surface: articular processes. Articular processes from Co1 form the coccygeal cornua which articulate with the

sacral cornua. Provides attachments for parts of gluteus maximus, coccygeus muscles and

anococcygeal ligament.

Joints Sacroiliac joints: link axial skeleton and inferior appendicular skeleton.

o Anterior synovial joint between the auricular surfaces of the sacrum and ilium.

Limited mobility, transmit weight to hip bones. o Posterior syndesmosis between the tuberosities of the same bones.

Pubic symphysis joint: cartilaginous joint, fibrocartilaginous interpubic disc and surrounding ligaments, unite the pubic bones in a median plane.

o Interpubic disc: wider in women, ligaments joining the bones thickened superior and inferior of symphysis


Lumbosacral joints: L5 and S1 vertebrae articulate at ant. Intervertebral joint formed by the 4th disc between their bodies and at two post. Zygapophysial joints btw. The articular processes of the vertebrae. Strengthened by iliolumbar ligaments.

sacrococcygeal joints: secondary cartilaginous joint with an 4th disc. Fibrocartilage and ligaments join the apex of sacrum to base of coccyx.

Ligaments: Sacroiliac joint ligaments:

Anterior sacroiliac ligaments: ant. Part of fibrous capsule of synovial part of sacroiliac joint.

Interosseous sacroiliac ligaments: lie deep btw. Tuberosities of sacrum and ilium. o Transfer weight of upper body to ilia.

Posterior sacroiliac ligaments: post. Ecternal continuation of the same mass of fibrous tissue. Run obliquely out and up from sacrum.

o Are joined inferiorly by fibers from the posterior ilium and the base of coccyx to form sacrotuberous ligaments. They pass from post. Ilium and lateral sacrum/coccyx to ischial tuberosity transforming the sciatic notch of the hip bone into a large sciatic foramen.

Sacrospinous ligament: passes from lateral sacrum and coccyx to ischial spine and divides the foramen further to greater & lesser sciatic foramina.

Pubic symphysis joint ligaments: o Superior pubic ligament: connects sup. Pubic bodies and interpubic disc.

Extend to pubic tubercles. o Inferior (arcuate) pubic ligament: thick arch of fibers connects inferior pubic

bodies and rounds off subpubic angle and forms apex of pubic arch. Lumbosacral joint ligaments:

o Iliolumbar ligaments radiate from the transverse processes of L5 vertebrae to ilia.

Sacrococcygeal joint ligaments: o Sacrococcygeal ligaments: long strands, reinforce the joint

Pelvic fractures:

anteroposterior compression = fracture of pubic rami lateral compression = acetabulum and ilium fracture weak areas are: pubic rami, acetabulum, sacroiliac joint, ala of ilium. Fractures in puboobturator area area common and complicated because of

relationship with urinary bladder & urethra Differences between the male and female pelvis:

Male o Thick, heavy o Greater pelvis deep o Lesser pelvis narrow, deep o Pelvic inlet heart shaped o Pelvic outlet small o Pubic arch narrow <70°


o Obturator foramen round o Acetabulum large o Greater sciatic notch narrow 70°

Female o Thin, light o Greater pelvis shallow o Lesser pelvis wide and shallow o Pelvic inlet oval and rounded o Pelvic outlet large o Pubic arch wide >80° o Obturator foramen oval o Acetabulum small o Greater sciatic notch almost 90°


2. Gluteal muscles. Blood vessels and nerves of the gluteal region.

Borders of the gluteal region:

Posteriourly : Clunes / buttocks

Laterally : coax/hip

Superior : Iliac crest

Medially : intergluteal (natal) cleft

Inferiourly : skin fold (underlying the buttock) (gluteal fold/sulcus glutealis). Skin innervation:

Lateral cutaneous branch of the iliohypogastric nerve (lumbar plexus) supplies superolateral quadrant of buttock.

Superior clunial nerves (L1‐3 post rami) supply skin in superior and central parts of buttocks.

Medial clunial nerves (S1‐3 post rami) supply skin of medial buttock and intergluteal cleft.

Inferior clunial nerves (post cutaneous nerve of thight) supply skin of inferior buttock (gluteal fold).

Intergluteal cleft separates the buttocks

Ligaments Sacrotuberous and sacrospinous ligaments convert the sciatic notches in the hip

bones into the lesser and greater sciatic foramina. o Lesser foramen (structures from/to perineum – pudendal n.) o Greater foramen (structures from/to pelvis – sciatic n.)

Muscles Superficial layer: mainly extensors, abductors and medial rotators of thigh.

o Gluteus maximus: Prox. attachment: ilium, dorsal sacrum & coccyx and sacrotuberous

ligament. Dist. Attachment: most fibers end in iliotibial tract, some (deep fibers

of inferior part of muscle) attach to gluteal tuberosity of femur. Innervation: Inferior gluteal nerve enter the deep in middle muscle. Arteries: inferior and superior gluteal arteries. Sciatic nerve passes deep to the gluteus. Function: extension and lateral rotation of the thigh. Gluteal bursae separate the gluteus maximus from adjacent

structures: Trochanteric bursa: separates sup. Fibers of glut.max. from

greater trochanter (largest bursa). Ischial bursa: separates inf. Of glut. max. from ischial tuberosity

(often absent) Gluteofemoral bursa: separates the iliotibial tract from sup.

Part of prox. Attachment of vastus lateralis.


o Gluteus medius: Prox. Attachm: ext. surface of ilium btw. Ant. & post. Gluteal lines. Dist. Attachm: lateral surface of greater trochanter of femur. Innervation: superior gluteal nerve Arteries: superior gluteal artery Function: abduct and medially rotate thigh

o Gluteus minimus: Prox, attachm: ext. surface of ilium btw. Ant. & post. Gluteal lines. Dist. Attachm: ant. Surface of greater trochanter of femur Innervation: superior gluteal nerve Arteries: superior gluteal artery Function: abduct and medially rotate thigh

o Tensor fascia lata: Prox, attachm: ant.sup. iliac spine, ant. Part of iliac crest. Dist. Attachm: iliotibial tract (attaches to lateral condyle of tibia) Innervation: superior gluteal nerve Arteries: deep branch of superior gluteal artery Function: flexor of the thigh (with iliopsoas and rectus femoris – when

iliopsoas is paralyzed the tensor becomes hypertrophic to compensate), tenses fascia lata and iliotibial tract.

Deep layer: lateral rotators of thigh and stabilize the hip joint. o Piriformis:

Superior gluetal vessels and nerve emerge superior to it Inferior gluteal vessels and nerve emerge inferior to it Prox, attachm: ant. Surface of sacrum, sacrotuberous ligament. Dist. Attachm: sup. Border of greater trochanter of femur, Innervation: branches of ant. Rami of S1, S2 Arteries: Function: laterally rotates and abducts thigh, fastens femoral head in

acetabulum o Obturator internus:

Prox, attachm: pelvic surface of obturator membrane and surrounding bones.

Dist. Attachm: medial greater trochanter of femur. Innervation: nerve to obturator internus Arteries: inferior gluteal artery Function: laterally rotates and abducte thigh, fastens femoral head in

acetabulum Obturator internus bursa: movement of muscle over post. Ischium.

o Superior & inferior gemelli: Prox, attachm:

Superior: ischial spine Inferior: ischial tuberosity

Dist. Attachm: medial greater trochanter of femur Innervation:

Superior: nerve to obturator internus Inferior: nerve to quadratus femoris


Arteries: Function: laterally rotate and abduct thigh, fasten femoral head in

acetabulum o Quadratus femoris:

Prox, attachm: lateral border of ischial tuberosity Dist. Attachm: quadrate tubercle on intertrochanteric crest of femur Innervation: nerve to quadratus femoris Arteries: inferior gluteal artery Function: laterally rotates thigh and fasten femoral head in

acetabulum Triceps coxae: obturator internus, gemelli sup. And inf.


3. Subinguinal hiatus. Femoral canal.

Subinguinal region Superiorly: inguinal ligament.

Inferiorly: transverse line across the gluteal groove.

Laterally: line perpendicular to the ant.sup.iliac spine

Medially: medial edge of the thigh. Inguinal ligament actually a flexor retinaculum Superficial arteries:

Originate from femoral artery and pass through saphenous hiatus toward the navel: o Superficial epigastric o Superficial circumflex iliac o External pudendal artery

Cutaneous nerves: Lateral femoral cutaneous nerve (medial to ant.sup.iliac spine) Anterior femoral cutaneous nerve (along medial/lateral margins of Sartorius) Femoral branch of the genitofemoral nerve (exits from saphenous hiatus)

Veins: Great saphenous vein ascends medially and joins femoral vein aftera passing through

the saphenous hiatus Subinguinal hiatus: Borders: Superior: subinguinal ligament Inferior: ant.sup. iliac spine – ant border of ala ileum – iliopubic eminence – sup. Ramus of pubis – body of pubis – pectineal fascia and muscle – pubic tubercle. Divided into 3 compartments:

Lacuna musculonervosa o Lateral part of subinguinal hiatus. o Borders:

Superior: Inguinal ligament Inferior: ant.sup.iliac spine, iliopubic eminence, ramus of pubis.

o Iliopsoar muscle (iliacus laterally and psoas major medially) and femoral nerve pass through from greater pelvis to ant. Thigh medial to iliopectineal arch (thickening of iliopsoas fascia divides ligament into compartments).

o Lateral cutaneous femoral nerve Lacuna vasorum

o Middle compartment, femoral sheat surrounds the vessels. o Borders:

Superior: Inguinal ligament Lateral: psoas part of iliopsoas muscle Medial: lacuna lymphatica and pectineus fascia (lines pectineus

muscle)


o Passage of major vascular structures (veins, arteries, lyphatics) enter femoral triangle and the names of vessels change from external iliac to femoral!

o Lateral to medial content: Lateral: femoral artery Middle: femoral branch of genitofermoral nerve Medial: femoral vein

Lacuna lymphatica o Medial corner o Lymphatic vessels from lower limb to abdominal cavity o Borders:

Superior: Inguinal ligament Inferior: pectineal fascia and muscle, conjoint ligament Lateral: lacuna vasorum

o Contents: Femoral hiatus closed by femoral septum Lacunar ligament Rosenmüller lymph nodes

Femoral canal

This is the smallest and the most medial compartment of the femoral sheath. Located around the femoral ring. Is a virtual space unless hernia and femoral septum is broken.


4. Femur. Hip joint.

Longest, heaviest bone in the body. Transmits weight from hip bone to tibia. Proximal head:

Head, neck, 2 trochanters (greater/lesser) Head: fovea for ligament of the head of femur also artery of the head of femur. Angle of inclination: greatest at birth until 115‐140°, less in females because of wider

pelvis. Angle of declination: 7° in males 12° in females. Abductors and rotators of thigh attach mainly on greater trochanter Flexors of thigh attach on lesser trochanter Where neck joins shaft: lesser and greater trochanter (intertrochanteric line –

ileofemoral ligament attaches) o Greater laterally o Lesser medially o Intertrochanteric crest joines the trochanters posteriorly – on crest is

quadrate tubercle near the greater trochanter. Shaft: posteriorly is linea aspera – provides aponeurotic attachment for adductors of

the thigh. Area divided to medial and lateral lips (lateral lip blends with gluteal tuberosity)

o Pectineal line from central part of linea aspera to the base of lesser trochanter.

o Inferiorly the linea aspera divides to medial and lateral supraepicondylar lines. Medial and lateral femoral condyles on distal head.

o Articulate with menisci and tibial condyles to form knee joint. o Separated by intercondylar fossa/notch posteriorly o Merge anteriorly to form patellar surface o Above the medial epicondyle is the adductor tubercle

Hip joint

Multiaxial ball and socket type of synovial joint. Femoral head = ball, acetabulum = socket.

Articular surface: round head of femur articulates with cup like acetabulum of hip bone.

o All head of femur covered with articular cartilage exept fovea for ligament and artery of head of femur.

o Acetabulum: hemispherical, hollow on lateral aspect, fusion of 3 bones. o Lunate surface of acetabulum and acetabular labrum form ¾ of a circle the ¼

is acetabular notch inferiorly. The transverse acetabular ligament bridges the acetabular notch in continuation from labrum.

o Acetabular fossa is deep and non articular part formed by ischium. Fat pad in fossa.

Joint capsule of the hip joint: o External fibrous layer and internal synovial membrane.


o Fibrous layer attaches proximally to acetabulum and distally to femoral neck at intertrochanteric line. Spirals from hip bone to intertrochanteric line and some pass circularly around neck forming orbicular zone.

o Thick parts of fibrous layer form ligaments of hip joint. Draws femoral head into acetabulum.

o Iliofemoral ligament: ant. & sup.Y‐shaped attaches to : ant.inf.iliac spine and acetabular rim proximally inertrochanteric line distally bodys strongest ligament prevents hyperextension during standing.

o Pubofemoral ligament: comes from obturator crest of pubic bone and passes laterally & inferiorly to merge with fibrous layer.

Blends with medial part of iliofemoral ligament Tightens during extension and abduction Prevents overabduction

o Ischiofemoral ligament: from ischial part of acetabular rim Weakest of three ligaments. Spirals superolaterally to femoral neck medial to base of greater

trochanter. o Synovial folds cover neck, retinacular arteries (branches of medial and lateral

circumflex femoral artery) supply femoral head and neck in synovial folds. o Ligament of head of femur: attaches to foeva for ligament of head and artery.

Movements of hip joint: o Degree of flexion/extension of hip joint depends on position of knee. o 60° abduction when thigh is extended, more when flexed o Iliopsoas: strongest flexor of hip o Adductor magnus flexor/extensor also in addition to adductor. o Muscles participate in both flexion and adduction

Pectineus, gracilis, all three adductor muscles o Ant. Gluteus medius and minimus are in addition to abduct also medial

rotators. o Gluteus maximus primary extensor from flexed to straight position and also

lateral rotator.

Blood supply to hip joint: o Medial and lateral circumflex femoral arteries – branches of deep artery of

thigh or branches of femoral artery. o Artery to head of femur – branch of obturator artery o Main blod supply from retinacular arteries from circumflex femoral (medial

most) (lateral least‐penetrate iliofemoral ligament) arteries.

Nerve supply to hip joint: o Flexors innervated by femoral nerve pass anterior to hip joint = femoral nerve

innervates anterior hip joint.


o Lateral rotators pass inferior & posterior to hip joint = obturator nerve innervates inferior hip joint, nerve to quadratus femoris innervates posterior hip joint.

o Adductors innervated by superior gluteal nerve pass superior to hip joint = gluteal nerve innervates superior hip joint.

Flexors of hip joint: 9 o Iliopsoas o Sartorius o Tensor fascia lata o Rectus femoris o Pectineus o Adductor longus o Adductor brevis o Adductor magnus (ant part) o gracilis

Adductors of hip joint: 6 o Adductor longus o Adductor brevis o Adductor magnus o Gracilis o Pectineus o Obturator externus

Lateral rotators of hip joint: 8 o Obturator externus o Obturator internus o Gemelli o Piriformis o Quadratus femoris o Gluteus maximus

Extensors of hip joint: 5 o Hamstrings (semitendinosus, semimembranosus, longhead biceps femoris) o Adductor magnus (post part) o Gluteus maximus

Abductors of hip joint: 3 o Gluteus medius o Gluteus minimus o Tensor fascia lata

Medial rotators of hip joint: 3 o Gluteus medius (ant. Part) o Gluteus minimus (ant. Part) o Tensor fascia lata


5. Muscles, blood vessels and nerves of the anterior and medial compartments of the thigh.

Great saphenous vein Fascia lata turns to iliotibial tract laterally Sartorius and gracilis have own fascial sheaths Femoral artery and vein, saphenous nerve in groove formed by extensors and adductors and goes under Sartorius. Cutaneous nerves:

Ant. Cutaneous branch of femoral nerve (medial and ant thigh) Cutaneous branch of obturator nerve (middle medial thigh) Lateral cutaneous nerve of thigh (from lumbar plexus) (ant and lat thigh) Genitofemoral nerve (lumbar plexus) (femoral branch ‐lat.femoral triangle ; genital

branch – ant. Scrotum and labia majora) Ilioinguinal nerve (lumbar plexus) (medial femoral triangle)

Muscles: flexors of hip and extensors of knee Pectineus:

o Proximal attachm: superior ramus of pubis o Distal attachm: pectineal line of femur o Innervation: femoral nerve (also possible branch from obturator nerve) o Artery: o Function: adducts/flexes thigh, assist medial rotation of thigh

Iliopsoas: o Proximal attachm:

Major: sides of T12‐L5, transverse processes Minor: sides of T12‐L1 Iliacus: iliac crest/fossa, ala of sacrum, ant. Sacroiliac ligaments

o Distal attachm: Major: lesser trochanter of femur Minor: pectineal line, iliopectineal eminence Iliacus: tendon of psoas major, lesser trochanter and femur

o Innervation: Major: ant. Rami of lumbar nerves 1‐3 Minor: ant. Rami of lumbar nerves 1‐2 Iliacus: femoral nerve

o Artery: o Function: flex thigh at hip joint. Stabilize joint.

Sartorius: o Proximal attachm: ant.sup.iliac spine o Distal attachm: superior medial tibia o Innervation: femoral nerve o Artery: o Function: flex, abduct and laterally rotate thigh at hip joint. Flex leg at knee

joint. Quadriceps femoris: is rectus femoris and the vastus muscles!

o Rectus femoris:


Proximal attachm: ant.inf.iliac spine and ilium sup. To acetabulum. Distal attachm: quadriceps tendon and aponeourosis of patella Innervation: femoral nerve Artery: Function: extend leg at knee joint and steady hip joint, helps iliopsoas

flex thigh o Vastus lateralis:

Proximal attachm: Distal attachm: quadriceps tendon and aponeourosis of patella Innervation: femoral nerve Artery: Function: extend leg at knee joint

o Vastus medialis Proximal attachm: Distal attachm: quadriceps tendon and aponeourosis of patella Innervation: femoral nerve Artery: Function: extend leg at knee joint

o Vastus intermediate: Proximal attachm: Distal attachm: quadriceps tendon and aponeourosis of patella Innervation: femoral nerve Artery: Function: extend leg at knee joint

Muscles: medial thigh muscles, adductor group Adductor longus:

o Proximal attachm: body of pubis inf. To pubic crest o Distal attachm: middle third of linea aspera o Innervation: obturator nerve, branch of ant. division o Artery: o Function: adducts thigh

Adductor brevis: o Proximal attachm: body and inf. Ramus og pubis o Distal attachm: pectineal line and proximal linea aspera o Innervation: obturator nerve, branch of ant. division o Artery: o Function: adducts thigh

Adductor magnus: o Proximal attachm:

Adductor part: inferior ramus of pubis, ramus of ischium Hamstring part: ischial tuberosity

o Distal attachm: Adductor part: gluteal tuberosity, linea aspera, medial supracondylar

line Hamstring part: adductor tubercle of femur

o Innervation: Adductor part: obturator nerve, branch of post. division


Hamstring part: tibial part of sciatic nerve o Artery: o Function: adducts thigh

Adductor part: flexes thigh Hamstring part: extends thigh.

Gracilis: o Proximal attachm: body & inf. Ramus of pubis o Distal attachm: sup. Medial tibia o Innervation: obturator nerve o Artery: o Function: adducts thigh, flexes leg and helps medial rotation.

Obturator externus: o Proximal attachm: margins of obturator foramen and membrane o Distal attachm: trochanteric fossa o Innervation: obturator nerve o Artery: o Function: lat rotation of thigh, steadies head of femur in acetabulum.


6. Femoral triangle. Adductor canal.

Femoral triangle: Subfacial space. Appears as a triangular depression inferior to the inguinal ligament. Borders: Superior: inguinal ligament forms the base of the triangle. Medial: adductor longus Lateral: Sartorius Apex: lateral border of Sartorius crosses the medial border of adductor longus. Floor: iliospoas laterally and pectineus medially Roof: fascia lata and cribriform fascia, subcutaneous tissue, skin. Contents from lateral to medial:

o Femoral nerve and its terminal branches. o Femoral artery and several of its branches o Femoral vein and its proximal tributaries (great saphenous and deep femoral) o Deep inguinal lymph nodes and associated lymphatic vessels.

femoral artery and vein pass through the apex into and from the adductor canal (intramuscular passage way).

Adductor hiatus: Opening/gap btw. Aponeurotic distal attachment of adductor part of adductor

magnus and tendinosus distal attachment of hamstring. 15 cm narrow passageway in middle third of thigh. Extends from apex of femoral triangle to the adductor hiatus in the tendon of

adductor magnus. Transmits the femoral artery and vein from adductor canal in the thigh to the

popliteal fossa. Also the sapheonus nerve and the nerve to vastus medialis. Opening is lateral & superior to adductor tubercle of femur. Borders:

o Anterior & lateral: vastus medialis. o Posterior: adductor longus & magnus o Medial: Sartorius it also forms the roof of the canal.


7. Muscles, blood vessels and nerves of the posterior compartment of the thigh.

Flexor muscles lat (biceps femoris) med (semitendinosus) beneath (semimembr) Sciatic nerve between flexors and add magnus Posterior femoral cutaneous nerve Small saphenous vein (vein of giacomini) Muscles: 3 of 4 are hamstrings

Semitendinosus: o Prox. Attach: ischial tuberosity o Distal attach: medial superior tibia o Innervation: tibial division of sciatic nerve o Artery: o Function: extend thigh, flex & med rotate flexed knee

Semimembranosus: o Prox. Attach: ischial tuberosity o Distal attach: post medial condyle of tibia o Innervation: tibial division of sciatic nerve o Artery: o Function: extend thigh, flex & med rotate flexed knee

Biceps femoris long head o Prox. Attach: ischial tuberosity o Distal attach: lateral head of fibula o Innervation: tibial division of sciatic nerve o Artery: o Function: flex and laterally rotates leg

Biceps femoris short head o Prox. Attach: linea aspera and lat.supracondylar line o Distal attach: lateral head of fibula o Innervation: common fibular division of sciatic nerve o Artery: o Function: flex and laterally rotates leg


8. Popliteal fossa. Knee joint.

Popliteal fossa /posterior genicular region Borders: diamond shaped

Superiorly: 3 fingers above midpopliteal groove o Superolateral: biceps femoris o Superomedial: semimembranosus

Inferiorly: 3 fingers below midpopliteal groove o Inferolateral: lateral head of gastrocnemius o Inferomedial: medial head of gastrocnemius

Medially & laterally: vertical line from epicondyle of femur and capitulum og fibula. Superficial structures: posterior femoral cutaneous nerve – posterior femoral

cutaneous vein – lateral & medial sural cutaneous nerve Popliteal fascia continues sup: fascia lata and inf: deep fascia of leg. Often pierced by

small saphenous vein. Forms floor of fossa! Contents of fossa:

o Termination of small saphenous vein Small saphenous vein passes from post. Of lateral malleolus

into fossa, pierces the fascia and enters popliteal vein. o Popliteal arteries and veins, branches

Popliteal artery: continuation of femoral artery – femoral passes through adductor hiatus.

popliteal artery divides after fossa into anterior and posterior tibial arteries

5 genicular branches supply the capsule and ligaments of knee joint. Genicular anastomosis (blood flow during flexion of knee)

Superior lateral genicular artery Superior medial genicular artery Middle genicular artery Inferior lateral genicular artery Inferior medial genicular artery Other contributions to the anastomosis are:

Descending genicular branch of femoral artery (sup.med)

Descending branch of lateral femoral circumflex artery (sup.lat)

Anterior tibial recurrent branch of anterior t ibial artery (inf.lat)

popliteal vein: continuation of posterior tibial vein – lies close to popliteal artery but superficial to it in same sheath.

Superiorly to the vein it becomes the femoral vein as it traverses the adductor hiatus.

Small saphenous vein passes from post. Of lateral malleolus into fossa, pierces the fascia and enters popliteal vein.

o Tibial and common fibular nerves – branches from sciatic nerve!


Tibial medial and larger and most superficial. Tibial gives branches to soleus, gastrocnemius, plantaris and popliteus. Tibial (anterior division of anterior rami L4‐S3)

Medial sural cutaneous nerve – branches from tibial nerve → joined by the sural communicating branch of the common fibular nerve to form the Sural nerve (suppl. Lateral leg and ankle)

Common fibular is lateral and smaller (posterior division of anterior rami L4‐S2).

Follows medial border of biceps femoris and its tendon in fossa and leaves passing superficial to the lateral gastrocnemius head – post. Head of fibula around fibular neck and divides into terminal branches.

o Posterior cutaneous nerve of thigh Supplies skin over fossa

o Popliteal lymph nodes and vessels Superficial popliteal lymph nodes: small in subcutaneous tissue. Deep popliteal lymph nodes: surround the vessels receive lymph from

joint capsule and lymph vessels from leg. Vessels from popliteal lymph nodes follow femoral vessels to the deep

inguinal lymph nodes. Knee joint, articulate. genus:

Largest most superficial joint. Hinge joint, synovial also glide and roll with rotation around vertical axis.

Has 3 articulations: (fibula not involved in the joint) o Lateral femorotibial articulation (btw. Lateral femoral and tibial condyles) o Medial femorotibial articulation (btw. Medial femoral and tibial condyles) o Femoropatellar articulation (btw. Patella and femur)

Most important muscle in stabilizing the knee joint = quadriceps femoris (inferior fibers of vastus medialis and lateralis).

Is most stable in extended position (collateral and cruciate ligaments are taut) Joint capsule of the knee joint:

o External fibrous layer Superiorly: attaches to femur Posteriorly: encloses condyles and intercondylar fossa (has opening on

lateral tibial condyle for tendon of popliteus to go out and attach to tibia)

Inferiorly: attaches to tibial plateau, articular margin og the tibia. Anteriorly: the quadriceps tendon, patella and patellar ligament

replace the fibrous layer o Internal synovial membrane

Attaches to periphery of articular cartilage covering femoral and tibial condyles, posterior patella and menisci.

Posteriorly: it goes into intercondylar region and covers cruciate ligaments and infrapatellar fat‐pad creating a median infrapatellar synovial fold. Almost divides the cavity to left and right cavities.

Lateral & medial alar folds cover inner surface of fat pads.


Continues superiorly as lining of suprapatellar bursa Articular muscle of the knee attaches to the membrane and retracts

bursa in extension of knee. o Menisci: fibrocartilaginous discs between the tibial and femoral articular

surfaces. o Laterally the tendon of the popliteus muscle passes out of the joint.

Extracapsular ligaments of knee joint: o Joint capsule strengthened by 5 ingrinsic ligaments: also called (external

ligaments) Patellar ligament:

Distal part of quadriceps tendon, passes from apex of patella to tibial tuberosity. Strong attachment

Is the anterior ligament of knee joint Laterally receives medial and lateral patellar retinacula (make

up joint capsule on each side of patella) and aponeurosis of vastus medialis/lateralis.

Fibular collateral ligament: Is lateral collateral ligament – strong, rounded and cordlike Inferiorly from lateral epicondyle of femur to lateral fibular

head. Dendon of popliteus passes deep to it, separating it from the

lateral meniscus. Tendon of biceps femoris split into two parts by it.

Tibial collateral ligament: Medial collateral ligament – strong (weaker than FCL, more

often damaged) From medial epicondyle of femur to medial condyle and

superior medial tibia. Firmly attached to medial meniscus

Oblique popliteal ligament: Expansion of tendon of semimembranosus posteriorly and

spans intracondylar fossa. Passes post. To medial tibial condyle and passes sup.lat toward

lateral femoral condyle. Arcuate popliteal ligament:

From posterior fibular head, passes sup.med over endon of popliteus and goes over post. Surface of knee joint.

Intra articular ligaments of knee joint: o Cruciate ligaments:

Crisscross within joint capsule but outside synovial cavity. In center of joint and cross each other obliquely like X

o Menisci o Popliteal tendon also during part of its course


9. Bones of the leg. Muscles, blood vessels and nerves of the anterior and lateral compartments of the leg.

Femur head of the femur: project superomedially and slightly anteriorly neck of the femur the angle between the neck and the head is 115‐140° lesser trochanter rounded conical greater trochanter intertrochanteric line intertrochanteric crest quadrate tubercle trochanteric fossa body of the femur linea aspera (broad line of the femur medial and lateral lips, or margins gluteal tuberosity spiral line (the medial lip continue in a spiral rough line) pectineal line medial and lateral supracondylar lines intercondylar fossa patellar surface lateral epicondyle medial epicondyle adductor tubercle

Tibia

medial and lateral epicondyles superior articular surface tibial plateau intercondylar eminence intercondylar fossa fibial articular surface body of the tibia tibial tuberosity anterior border of the tibia medial malleolus interosseus membrane soleal line inferior articulating surface nutrient foramen

Fibula

head of the fibula facies articularis capitis fibulae apex of the fibula body of the fibula


the distal part is rather triangular margo interosseus lateral malleolus facies articularis malleoli

Anterior compartment: Dorsiflexor (extensor) compartment is anterior to the interosseous membrane.

Divided by tibia and anterior intermuscular septum. Has 4 muscles: Tibialis anterior, extensor digitorum longus and extensor hallucis

longus and fibularis tertius. Inferior there are 2 band like thickenings of the fascia to form retinacula that bind the

tendons of the ant. Muscles before & after they cross the ankle joint. o Superior extensor retinaculum: strong broad band from fibula to tibia

proximal to the malleoli. o Inferior extensor retinaculum: Y shaped attaches laterally to anterosuperior

calcaneus, loops around the tendons of fibularis tertius and extensor digitorum longus.

Muscles: Tibialis anterior: most medial and superficial (lies against lateral tibia), strongest

dorsiflexor. o Origin: lateral condyle and sup.lat. tibia and interosseous membrane. o Attachment: medial and inferior surface of medial cuneiform and base of 1st

metatarsal o Innvervation: deep fibular nerve o Artery: anterior tibial artery o Function: dorsiflexion and invertion

Extensor digitorum longus: most lateral, has common synovial sheath with fibularis tertius. Each tendon forms a extensor expansion over dorsum of phalanges

o Origin: lateral condyle of tibia, sup. ¾ of fibula and interosseous membrane. o Attachment: middle & distal phalanges of lat. 4 digits o Innvervation: deep fibular nerve o Artery: anterior tibial artery o Function: extends digits and dorsiflexion

Extensor hallucis longus: lies deep between TA and EDL o Origin: middle ant. Fibula and interosseous membrane o Attachment: dorsal base of distal phalanx of hallux o Innvervation: deep fibular nerve o Artery: anterior tibial artery o Function: extend hallux and dorsiflexion

Fibularis tertius: separate part of extensor digitorum longus (shares it´s synovial sheath). Most common sprained ligament of the body and the muscle is not always present.

o Origin: inferior 1/3 ant. Fibula and interosseous membrane o Attachment: dorsum of base of 5th metatarsal o Innvervation: deep fibular nerve o Artery: anterior tibial artery o Function: dorsiflexion and aids in inversion


Nerve: o Deep fibular nerve one of the two terminal branches of the common peroneal

(fibular) nerve. Comes btw. Fibularis longus muscle and neck of fibula. Accompanies the anterior tibial artery along the leg.

o Lesion to it: inability to dorsiflex (footdrop) Artery:

o Anterior tibial artery supplies anterior structures. It is the smaller terminal branch of the popliteal artery. Pierces interosseous membrane to go anteriorly. It becomes the dorsal artery of the foot at the ankle.

Lateral compartment Smallest compartment, has the evertors. Medially bounded by fibula, anteriorly by

anterior intermuscular septum and posteriorly by posterior intermuscular septum. The compartment ends inferiorly at the superior fibular retinaculum. The tendons enter a common synovial sheath passing through the retinaculum. Muscles: Fibularis longus:

o Origin: head and sup. 2/3 of lat. fibula o Attachment: base of 1st metatarsal and medial cuneiform o Innervation: superficial fibular nerve o Artery: o Function: eversion and weak plantarflexion

Fibularis brevis: o Origin: inferior 2/3 of lat. fibula o Attachment: dorsal tuberosity on lat. Base of 5th metatarsal o Innervation: superficial fibular nerve o Artery: o Function: eversion and weak plantarflexion

Nerves: o Superficial fibular nerve a terminal branch of the common peroneal nerve.

After innervating the muscles it continues as a cutaneous nerve. (dorsal digital cutaneous nerve)

Blood vessels: o Has no artery, just perforating branches of the anterior tibial artery proximally

and perforating branches of the fibular artery inferiorly

10. Bones of the leg. Muscles, blood vessels and nerves of the posterior compartment of the leg.

Femur


head of the femur: project superomedially and slightly anteriorly neck of the femur the angle between the neck and the head is 115‐140° lesser trochanter rounded conical greater trochanter intertrochanteric line intertrochanteric crest quadrate tubercle trochanteric fossa body of the femur linea aspera (broad line of the femur medial and lateral lips, or margins gluteal tuberosity spiral line (the medial lip continue in a spiral rough line) pectineal line medial and lateral supracondylar lines intercondylar fossa patellar surface lateral epicondyle medial epicondyle adductor tubercle

Tibia

medial and lateral epicondyles superior articular surface tibial plateau intercondylar eminence intercondylar fossa fibial articular surface body of the tibia tibial tuberosity anterior border of the tibia medial malleolus interosseus membrane soleal line inferior articulating surface nutrient foramen

Fibula

head of the fibula facies articularis capitis fibulae apex of the fibula body of the fibula the distal part is rather triangular margo interosseus lateral malleolus facies articularis malleoli

posterior compartment:


largest of the 3 compartments. Divided to deep (4) and superficial (3). By transverse intermuscular septum. NB!! The deep compartment is tightly packed between the two leg bones,

interosseous membrane and the transverse intermuscular septum, and nerve and blood vessels supplying the posterior compartment and sole of the foot pass through it. So when swelling occurs it leads to a compartment syndrome that can damage foot.

Gastrocnemius and soleus = calcaneal tendon and called triceps surae Calcaneal tendon:

o Most powerful and tickest tendon in the body. Inserts on the posterior calcaneal tuberosity

o Subcutaneous calcaneal bursa between skin and tendon. o Deep bursa of calcaneal tendon between tendon and calcaneus

Superficial muscles: Gastrocnemius:

o Origin: Lateral head: lateral condyle of femur Medial head: popliteal surface of femur

o Attachment: posterior surface of calcaneus via calcaneal tendon o Innervation: Tibial nerve o Artery: o Function: plantarflexion, rais ankle

Soleus: has proximally tendinous arch of soleus : popliteal artery and tibial nerve exit popliteal fossa by passing through it.

o Origin: post. Head of fibula o Attachment: posterior surface of calcaneus via calcaneal tendon o Innervation: Tibial nerve o Artery: o Function: plantarflexion

Plantaris: short belly and loooong tendon (fools nerve) absent in 5‐10% o Origin: inferior lateral supracondylar line of femur and oblique popliteal

ligament o Attachment: posterior surface of calcaneus via calcaneal tendon o Innervation: Tibial nerve o Artery: o Function: assist in plantarflexion

Deep muscles: Popliteus: acts on knee joint not on ankle and toes like the others. Popliteus bursa: deep to popliteus tendon

o Origin: lateral condyle of femur and lateral meniscus o Attachment: posterior tibia superior to soleal line o Innervation: tibial nerve o Artery: o Function: weak flexion of knee

Flexor hallucis longus: o Origin: inferior 2/3 post. Fibula and inferior interosseous membrane o Attachment: base of distal phalanx of hallux


o Innervation: tibial nerve o Artery: o Function: flex toe, weak plantarflexion and supports medial longitudinal

arches of foot. Flexor digitorum longus:

o Origin: medial post. Tibia inferior to soleal line o Attachment: base of distal phalanges o Innervation: tibial nerve o Artery: o Function: flex digits, plantarflexion and support longitudinal arches

Tibialis posterior: o Origin: interosseous membrane, post tibia o Attachment: navicular tuberosity, cuneiform and cuboid, base of 2, 3, 4th

metatarsals o Innervation: tibial nerve o Artery: o Function: plantarflexion and invertion

Nerves: o Tibial nerve supplies both deep and superficial is larger of 2 terminal sciatic

branches. Divides at ankle to medial and lateral plantar nerves. o Medial sural cutaneous nerve also merges with the lateral sural cutaneous

nerve (from common peroneal) to form Sural nerve Blood vessels:

o Posterior tibial and fibular vessels supply both larger and more direct branch of popliteal artery.

o Posterior tibial artery gives largest branch the fibular artery. Most important and largest branch of tibial artery, descends obliquely

towards fibula and passes along medial side. Gives perforating branch: pierces interosseous membrane and passes

to dorsum of foot and anastomosis with arcuate artery. o Runs between tendons of Harry and Dick and divides to medial and lateral

plantar arteries.


11. Ankle joint. Medial and lateral malleolar regions.

Tibiofibular joints proximal and distal tibiofemoral joint proximal tibiofibular joints articular surface of the fibula posterolaterally of the tibia articular capsule fibrous capsule anterior ligament of the head of the fibula passes superomedially from the anterior

aspect of the fibular head to the anterior part of the lateral tibial condyle posterior ligament of the head of the fibula popliteus bursa distal tibiofibula joint syndesmosis articular surface interosseus ligament

Ankle joint hinge type of joint (talocrural articulation)

articular surface of the ankle joint distal ends of the fibula and tibia and the pulley shaped trochlea of the

talus the medial surface of the lateral malleolus articulates with the lateral

surface of the talus the tibia articulate two places: inferior surface forms the roof of the

mortise, the medial malleolus articulates with the medial surface of the talus

Articular capsule of the ankle joint fibrous capsle: thin anteriorly and posteriorly but supported each side

by strong ligaments Ligaments of the ankle joint lateral ligaments anterior talofibular ligament: from the lateral malleolus to the neck of the talus posterior talofibular ligament: runs horizontally medially and slightly posteriorly from

the malleolar fossa to the lateral tubercle of the talus calcaneofibular ligament passes posteriorly from the tip of the lateral malleolus to

the lateral surface of the calcaneus medial ligament deltoid ligament (from the malleolus to the talus, calcaneus and navicular) tibionavicular ligament anterior and posterior tibiotalar ligament tibiocalcaneal ligament Movement of the ankle joint


dorsiflexion (muscles in ant.compartment of leg, limited by triceps surae) plantarflexion (muscles in post.compartment of leg) Blood supply of the ankle the malleolar branches of the fibular and anterior and posterior tibial arteries Nerve supply tibial nerve deep fibular nerve division of common fibular nerve

Lateral ankle (regio malleolaris lateralis)

Borders line above 1 cm to the lateral malleolus lateral part of the sole anteriorly the side of the fibula until the apex of the malleolus lateralis and to the V

metatarsal tuberosity posteriorly the midline Vein smaller saphenous vein rete malleolare laterale Nerve surralis nerve nervus cutaneus dorsalis pedis Muscle the tendon of the fibularis longus and brevis abductor digiti minimi tendon of the Achilles (corpus adiposum subachilleum) bursa tendinis calcanei Osteofibrous canal lateral malleolus talus calcaneus retinaculum extensorum peroneum retinaculum peroneus superius retinaculum peroneus inferius Artery malleolaris posterior lateralis rr. calcanei laterales terminal branch of the arteria fibularis Lateralis parittya sling peroneus brevis peroneus tercius arcus plantarisokat tartja

Medial ankle greater saphenus vein saphenus nerve posteriorly


tibialis posterior flexor digitorum longus posterior tibial artery tibial nerve flexor hallucis longus retinaculum flexorum

Medial Ankle Border

horizontal line in the middle of the medial malleolus midline of the heel anteriorly line from the caput tali until the sole of the foot

Nerve saphenous nerve smaller saphenous vein

Retinaculum musculorum flexorum tibial nerve posterior tibial artery Septums of the retinaculum Tom, Dick and Harry

Medial sling tibialis posterior tibialis anterior

Stirrup or stapes peroneus longus tibialis anterior


12. Bones, joints and ligaments of the foot. Arches of the foot.

Bones of the foot 7 tarsal bones, 5 metatarsal bones, 14 metatarsal bones

Tarsus calcaneus (heel bone) longer the talus largest and strongest bone anteriorly articulate with the cuboid, superiorly the talus sustentaculum tali: project from the superior border of the medial surface( facies

articularis talaris media fibular trochlea: lateral oblique ridge calcaneal tuberosity: posterior prominence tuber calcanei: attachment of the achilles tendon letaral, medial, anterior tubercles facies articularis talaris posterior sulcus calcanei sinus tarsi facies articularis talaris anterior facies articularis cuboidea sulcus tendinis musculi flexoris hallucis longi

talus it has a body tail and neck articulate with the fibula, calcaneus, and navicular bone it has no muscular and tendineous attachment trochlea tali convex cartilaginous surface, it is wider anteriorly, the middle a little

depressed talar head rest in the sustentaculum tali on the body groove of the talus facies articulareis calcanea posterior facies articulareis calcanea media facies articulareis calcanea anterior processus lateralis tali processus posterior tali sulcus tendinis musculi flexoris hallucis longi lateral tubercle, medial tubercle

navicular (little ship)

it is between the talar head and the three cuneiforms anteriorly navicular tuberosity: projection from the medial surface

cuboid

cubical shape the most lateral bone in the distal row of the tarsus tuberosity of the cuboid groove on the lateral and inferior surface: sulcus tendinis musculi

peronei longi


cuneiform bones

medial cuneiform is the largest similar to a half moon the intermediate cuneiform is the smallest lateral cuneiform articulate with the cuboid the others with the navicular bone

Metatarsus

the first metatarsal is shorter the 2nd is the longest bases articulate with the cuneiform and cuboid bones the 5th metatarsal has a large tuberosity on the plantar surface of the 1st medial and lateral semasoid bones

Phalanges 1st digit is the greater two phalanges Body proximal distal end Three phalanges

Foot joints Transverse tarsal joint

formed by the talonavicular part of the talocalcaneonavicular and calcaneocuboid joints

surgical amputation of the foot subtalar joint

the place where the talus rests on the calcaneus the fibrous capsule is supported by medial, lateral, posterior, and interosseus

talocalcaneal ligaments Ligaments of the foot

plantar calcaneonavicular ligament : extends from the sustentaculum tali to the posteriorinferior surface of the navicular, maintain the longitudinal arch of the foot

long plantar ligament: passes through the plantar surface of the calcaneus to the groove on the cuboid and form the longitudinal arch of the foot

plantar calcaneocuboid ligament: deep to the long plantar ligament, anterior surface of the calcaneus to the inferior surface of the cuboid

ligamentum bifurcatum: the calcaneocuboideum and the dorsal navicular ligament Movement Eversio Inversion

Arches of the foot the tarsal and metatarsal bones are arranged in longitudinal and transverse arches

that add to the weightbearing capabilities of the foot Longitudinal arch of the foot medial longitudinal arch: higher than the lateral, composed of the calcaneus, talus,

navicular and the 3 cuneiforms, and 3 metatarsals, the tibialis anterior attach to the 1st metatarsal and medial cuneiform, helps strengthening the medial longitudinal arches


lateral longitudinal arches: much flatter than the medial. Composed of calcaneus, cuboid, lateral 2 metatarsal

Transverse arch of the foot it is formed by the cuboid, cuneiforms, and the bases of the metatarsals the tendon of the fibularis longus cross the sole oblique and maintain the curvature

of the transverse arch Amputation lines

Lissfranck line: the line of the metatarsotasal joint Chopart line S shaped line (talus calcaneus and cuboideum and naviculare)


13. Muscles, blood vessels and nerves of the sole (plantar region).

It is a bit dangerous to talk about this region layer by layer because some things are in more than one layer. If this is your topic, then don’t mention any layers, just go through them muscle by muscle. Its only written here in layers to help you remember them and have a structure.

Layers

1. Skin Dense regular keratinized connective tissue.

7:3 – Innervation 2. Adipose tissue.

This fat pad is extremely thick since it works as a shock absorber for the calcaneus. Normally its 2 cm thick, but can be up to 4‐5 cm thick depending on how much you walk w/out shoes. This fat pad can never be lost.

3. Fascia

becomes aponeurosis plantaris a. Plantar fascia → Aponeurosis of the sole of foot b. Devides the sole into 3 compartments

i. Lateral ii. Intermediate iii. Medial

Aponeurosis plantaris gives Septum: Medial plantar groove: vessels and

nerves go through here Lateral plantar groove

4. Muscle

The layers are all different in Moore, Greys and Personal lab. notes.

Muscle (1st muscle layer)

a. Abductor hallucis Origin: Medial tubercle of tuberosity of calcaneus: flexor retinaculum; plantar aponeurosis Insertion: Med. side of base of prox. phalanx of 1st digit. Innervation: Med. Plantar n.


b. Flexor digitorum brevis Origin: Med. tubercle of tuberosity of calcaneus; plantar aponeurosis; intermuscular septa. Insertion: Both sides of middle phalanges of lat. 4 digits. Innervation: Med. Plantar n. c. Abductor digiti minimi Origin: Med. & Lat. tubercles of tuberosity of calcaneus; plantar aponeurosis; intermuscular septum. Insertion: Lat. side of base of prox. phalanx of 5th digit. Innervation: Lat. Plantar n.

5. Muscle (2nd layer) a. Quadratus plantae Origin: Med. surface & Lat. margin of plantar surface of calcaneus. Insertion: Post.lat. margin of tendon of Flx. Digitorum longus. Innervation: Lat. Plantar n. b. Lumbrical muscles Origion: Tendons of Flx. Digitorum longus Insertion: Med. aspect of expansion over Lat. 4 digits. Innervation: Med. 1: Med. plantar n. Lat. 3: Lat. plantar n.

6. Muscle (3rd layer)

a. Flx. hallucis brevis O: Plantar surfaces of Cuboid & Lat. Cuneiforms. I: Both sides of base of Prox. phalanx of 1st digit. Inv: Med. Plantar n. b. Adductor hallucis Origion: Oblique head: bases of metatarsals 2‐4 Transverse: Plantar lig. of metatarsophalangeal joints. Insertion: Tendons of both heads attach to Lat. side of base of Prox. phalanx of 1st digit.

Innervation: Deep branch of Lat. Plantar n. 7. Muscle (4th layer)

a. Plantar interossei (3 muscles) Origion: Bases & Med. sides of metatarsals 3‐5. Insertion: Med. sides of bases of phalanges of 3rd – 5th digits. Innervation: Lat. Plantar n. b. Dorsal interossei (4 muscles) Origion: Adjacent sides of metatarsals 1‐5 Insertion: 1st : Med. side of Prox. phalanx of 2nd digit. 2nd – 4th: Lat. sides of 2nd – 4th digits


Innervation: Lat. Plantar n. PDP DPD D (start w/ little toe) At this level, you can also see the tendon of the peroneus longus crossing the sole of the foot. Function: Plantar: Adducts (PAD) Dorsal: Abducts (DAB) c. Extens. digitorum brevis Origion: Calcaneus, interosseous talocalcaneal lig.: Stem of inf. Extens. Retinaculum. Insertion: Long flx. Tendons of four medial to es (digits 2‐5) Innervation: Deep peroneal n. d. Extens. Hallucis brevis Origin: In common w/ extens. Digitorum brevis (above) Insertion: Dorsal aspect of base of prox. phalanxs of hallux (1st digit) Innervation: Deep peroneal n.

8. Ligaments

a. Long plantar ligament

9. Ligaments a. Small ligaments of the tarsal

You better know ALL the small lig. Cuz Prof. Antal will ask them fo sure!! Check topic # 11 & 12.

10. Bones Calcaneus Talus Navicular Lat, Intermediate, & Med. Cuneiform Cuboid Metatarsals Proximal, Middle, and Distal phalanges


Arteries of sole of foot Are derived from the Post. Tibial artery. It splits into the Med. & Lat. plantar arteries. The Med. Plantar artery passes along the medial part of the sole of the foot & terminates by branching into digital branches. The Lat. Plantar artery becomes the plantar arterial arch which anastomoses by way of a perforating artery with the dorsal pedis artery. The arch gives rise to several metatarsal branches which split into digital branches. Veins of sole of foot Small saphenous vein arises on the lat. side of the foot from the union of the dorsal vein of the little toe w/ the dorsal venous arch. The small saphenous vein 1. Ascends post. to the Lat. malleolous as a continuation of the Lat. marginal vein. 2. Passes along the Lat. border of the calcaneal tendon. 3. Inclines to the midline of the fibula & penetrates the deep facia. 4. Ascends between the heads of the gastrocnemius muscle. 5. Empties into the popliteal vein in the popliteal fossa. The small saphenous vein gives superficial & deep branches: Superficial: Lat. marginal vein of foot

Plantar venous network. Deep: Plantar digital veins

Plantar arch Although dorsal venous arch drains primarily via the superficial saphenous, perforating veins penetrate the deep facia, forming & continually supplying an Anterior Tibial vein in the Anterior Leg. Medial and Lateral Plantar veins from the plantar aspect of the foot form the Posterior. Tibial and Peroneal veins posterior to the Medial and Lateral malleoli. All 3 deep veins from the leg flow into the popliteal vein posterior to the knee, which becomes the femoral vein in the thigh. Veins accompanying the perforating arteries of the deep artery of the thigh drain blood from the thigh muscles and terminate in the deep vein of the thigh, which joins the femoral vein. Femoral vein passes deep to the inguinal lig. to become the external iliac vein of the trunk.


Nerves of sole of foot After the plantar aponeurosis has been removed you can see the muscles that make up the first layer of the sole of the foot and the arteries and nerves entering the foot. The muscles of the first layer are:

1. abductor hallucis 2. flexor digitorum brevis 3. abductor digiti minimi

The nerves are the: medial plantar lateral plantar

The Med. and Lat. plantar nerves supply the muscles as well as the skin on the sole of the foot. They are branches of the tibial nerve. The medial plantar nerve supplies the:

abductor hallucis muscle flexor digitorum brevis flexor hallucis brevis (in the third layer) 1st lumbrical

The lateral plantar nerve supplies the remaining muscles in the sole of the foot. In a way, it is similar to the ulnar which supplies most of the small muscles of the hand. The muscles supplied are the:

abductor digiti minimi accessory flexor (quadratus plantae) adductor hallucis flexor digiti minimi brevis interossei lumbricals 3, 4, & 5

When the flexor digitorum brevis is removed, the muscles of the second layer can be seen:

1. accessory flexor (quadratus plantae) 2. lumbricals 3. tendons of the flexor digitorum longus from which the lumbricals arise

The medial and lateral plantar nerves supply muscles and skin of the sole of the foot. The medial plantar nerve gives rise to digital branches which then give rise to common digital branches and finally, the terminal branches. This nerve supplies the skin of the medial 3 and 1/2 half digits. The lateral plantar nerve gives rise to motor branches, a deep branch and finally branches to the skin of the lateral 1 and 1/2 digits. – Remember 7:3


Ligaments of the sole of the Foot The long plantar ligament and the plantar calcaneocuboid ligament lie deep to the muscles of the fourth layer. The long plantar ligament stretches from the calcaneus to the cuboid and to the bases of the 2, 3 and 4 metatarsal bones. The plantar calcaneocuboid ligament, reaches the calcaneus to the cuboid on the deep aspect of the long plantar ligament. The plantar calcaneonavicular ligament extends from the calcaneus to the navicular bone & prevents the head of the talus from pushing down between the calcaneus & the navicular bones. This ligament is also known as the spring ligament since it is believed to give a spring‐like action the foot when walking. Arches of the foot All of the bones of the foot are held together by ligaments but there are 3 that are strongly implicated in maintaining the arches of the foot:

long plantar ligament calcaneocuboid ligament calcaneonavicular ligament

The muscles of the foot have 2 primary functions. 1. Responsible for the movement which is made during walking 2. maintain the arches of the foot. The arches are arranged both longitudinally and transversely, & are caused primarily by the conformation of the bones of the foot & the lig. which binds them together, & secondarily by the muscles which act upon the bones. The longitudinal arch of the foot is higher on the medial side, where it forms the instep as can be seen on a foot‐print. It’s made up of the 1st three digits and their metatarsals, the cuneiforms, the navicular & talus. The lateral longitudinal arch: made up of digits 4 & 5 & their metatarsals, the cuboid & the calcaneus. It is much shallower than the medial arch. Transverse arch of foot: primarily formed by the metatarsal bones. Every ligament that connects the bones of the foot plays a part in the maintenance of the arches, but some which pass across 2 or more joints are especially important. Among these are the long plantar, the plantar calcaneocuboid & the plantar calcaneonavicular lig. ‐ on which the head of the talus rests. The long muscles which are inserted by tendons into the bones of the foot have an important role in keeping the arches intact. These are the tendons of the tibialis anterior, tibialis posterior, peroneus longus & the tendons of the flexor hallucis longus & flexor digitorum longus. Finally, more superficially, the plantar aponeurosis also plays an important part in maintaining the medial longitudinal arch.


14. Muscles, blood vessels and nerves of the dorsum of the foot.

Dorsum of the foot Borders

the line beween the 2 ankle proximally bases of the phalange distally meidally ankle to the head of the talus and than to the medial side of the sole laterally from the ankle to the tuberosity of the V.th metatarsal

Deep fascia of the foot superior extensor retinaculum inferior extensor retinaculum 4 septums ‐ tendon of the tibialis anterior ‐ n fibularis profundus, a. v. dorsalis pedis ‐ tendon of the extensor hallucis longus ‐ tendon of the extensor digitorum longus it continous with the plantar fascia the thick of this fascia forms the plantar aponeurosis

Deep muscles extensor hallucis brevis extensor digitorum brevis

Veins arcus venosus dorsalis pedis saphena parva, magna

Nerves superficial and deep fibular nerve, supply between the 2 ankle (nervus dorsalis pedis) medial cutaneous nerve pedis, intermedial cutaneous nerve pedis, deep cutaneous

nerve pedis, nervus cutaneus dorsalis (skin next to the little finger)

Atery arteria tibialis anterior – arteria dorsalis pedis deep plantar artery (between the two tendon of the hallucis longus and digitorum

longus) plantar arch malleolaris anterior medialis and lateralis from the arteria dorsalis pedis a tarsae laterals mediales arteria arcuata: arises the base of the II metatarsus deep to the tendons of the brevis

extensors anastomise with the lateral tarsal artery


15. Blood and lymphatic vessels, and cutaneous innervations of the lower limbs

Arteries of the lower limbs

Overview of arteries Femoral artery Deep artery of the thigh Medial circumflex femoral

artery Lateral circumflex femoral

artery Obturator artery Superior Gluteal artery Inferior gluteal artery Internal pudental artery Perforating artery Popliteal artery Anterior tibial artery Dorsal artery of foot

(dorsalis pedis) Posterior tibial artery Fibular artery

o Femoral artery Origin Continuation of external iliac artery distal to inguinal ligament Course

Descends through femoral triangle bisecting it

Adductor canal

Terminates as it transverses adductor hiatus (becomes popliteal artery)

Supplies

Anterior and anteromedial aspects of thigh

o Deep artery of the thigh Origin


Femoral artery, 1‐5 cm inferior to inguinal ligament Course

Passes deeply between pectineus and adductor longus

Descends posterior to latter on medial side of femur

three to four perforating branches pass through the adductor magnus muscle, winding around femur.

Supplies

Muscle s in the medial, posterior and lateral part of anterior compartments

o Medial circumflex femoral artery Origin

Deep artery of thigh

May arise from femoral artery Course

Passes medially and posteriorly between the pectineus and iliopsoas

Enters gluteal region and gives rise to posterior retinacular arteries

Terminates by dividing into transverse and ascending branches Supplies

Most of blood to head and neck of femur

Transverse branch takes part in cruciate anastomosis of thigh

Ascending branch joins inferior gluteal artery o Lateral circumflex femoral artery

Origin

Deep artery of thigh

May arise from femoral artery Course

Passes laterally deep to sartorious and rectus femoris

Devides into ascending, transverse and descending arteries Supplies

Ascending branch → Anterior part of gluteal region

Transverse branch → Winds around femur

Descending branch → joins genicular periarticular anastomosis o Obturator

Origin

Internal iliac artery or…

An accessory artery (in ~20%) or…

Replaced obturator artery from the inferior epigastric artery Course

Passes through obturator foramen

Enters medial compartment of thigh and devides into …

anterior and posterior branches…

Which pass on the anterior and posterior sides of the adductor brevis

Supplies


Anterior branch → Obturator externus, pectineus, adductors of thigh and gracilis

Posterior branch → Muscles attached to ischial tuberosity o Superior Gluteal artery

Course

Enters gluteal region through greater sciatic foramen superior to piriformis

Divides into superficial and deep branches

Anastomoses with inferior gluteal and medial circumflex arteries

Supplies

Superficial branch → Gluteus maximus

Deep branch → Runs between gluteus medius and minimus → Supplies them and fascia lata

o Inferior gluteal artery Course

Enters gluteal region through greater sciatic foramen inferior to piriformis

Descends on medial side of sciatic nerve

Anastomoses with superior gluteal artery and participates in cruciate anastomosis of thigh (involving first perforating artery of deep femoral and medial and lateral circumflex arteries

Supplies

Gluteus maximus

Obturator internus

Quadratus femoris

Superior parts of hamstrings o Internal pudental artery

Course

Enters gluteal region through greater sciatic foramen

Descends posterior to ischial spine

Enters perineum through lesser sciatic foramen Supplies

External genitalia

Muscles in perineal region

Does not supply gluteal region o Perforating artery

Course

Enters posterior compartment by perforating aponeurotic portion of adductor magnus attachment and medial intermuscular septum

After providing muscular branches of hamstrings, it continues on to anterior compartment by piercing lateral intermuscular septum

Supplies

Majority (central portions) of hamstring muscles


Continues to supply vastus lateralis in anterior compartment o Popliteal artery

Origin

Continuation of femoral artery at adductor hiatus in adductor magnus

Course

Passes through popliteal fossa to leg

Ends at lower border of popliteus muscle by dividing into anterior and posterior tibial arteries.

Supplies

Both lateral and medial aspects of the knee (superior, middle and inferior genicular arteries)

o Anterior tibial artery Origin

Popliteal artery Course

Passes between tibia and fibula

Goes into anterior compartment through gap in superior part of interosseous membrane

Descends this membrane between tibialis anterior and extensor digitorum longus

Supplies

Anterior compartment of the leg o Dorsal artery of foot (dorsalis pedis)

Origin

Continuation of anterior tibial artery distal to inferior extensor retinaculum

Course

Descends anteriomedically to first interosseous space

Devides into plantar and arcuate arteries Supplies

Posterior and lateral compartments of leg

Pierces first dorsal interosseous muscle as deep plantar artery to contribute to formation of plantar arch.

o Posterior tibial artery Origin

Popliteal artery Course

Passes through posterior compartment of leg

Terminates distal to flexor retinaculum by dividing into medial and lateral plantar arteries

Supplies

Posterior and lateral compartments of leg

Circumflex fibular branch joins anastomoses around knee

Nutrient artery passes to tibia o Fibular artery


Origin

Posterior tibial artery Course

Descends in posterior compartment adjacent to posterior intermuscular septum

Supplies

Posterior compartment of leg

Perforating branches supply lateral compartment of leg


Veins of the lower limbs

Superficial veins of the lower limbs

o The great saphenous vein Origin

Formed by union of the dorsal vein of the great toe and the dorsal venous arch of the foot

Course

Ascends anterior to the medial malleolus

Passes posterior to the medial ccondyle of the femur

Anastomoses freely with the small saphenous vein

Traverses the saphenous opening in the fascia lata

Empties into the femoral vein Valves

Contains 10‐12 valves mostly in the leg but also thigh

Usually located inferior to the perforating veins o The small saphenous vein

Origin

Arises on the lateral side of the foot from the union of the dorsal vein of the little toe with the dorsal venous arch

Course

It ascends posterior to the lateral malleolus as a continuation of the lateral marginal vein


Passes along the lateral border of the calcaneal tendon

Inclines to the midline of the fibula and penetrates the deep fascia

Ascends between the heads of the gastrognemicus muscle

Empties into the popliteal vein in the popliteal fossa o Accessory saphenous vein

As the great saphenous vein ascends in the leg and the thigh, it receives a numerous tributaries and communicates in several locations with the small saphenous vein.

KGB is after me! Tributaries from the medial and posterior aspects of the thigh

frequently unite to form the accessory saphenous vein When precent this vein becomes the main communication between

the great and the small saphenous vein o Lateral and Anterior cutaneous vein

Arise from networks of veins in the inferior part of the thigh and enter the great saphenous vein superiorly, just before it enters the femoral vein.

Near it’s termination, the great saphenous vein also receives the…

Superficial circumflex iliac vein

Superficial epigastric vein

External pudental veins Deep veins of the lower limbs

o Accompany the major arteries and their branches o Usually occur as paired, frequently interconnecting veins that flank the artery

they accompany o Dorsal venous arch drains primarly via the superficial saphenous veins o Perforating veins penetrate the deep fascia → form and continually supply an

anterior tibial vein in the anterior leg o Medial and lateral plantar veins from the plantar aspects of the foot form the

posterior tibial and fibular veins posterior to the medial and lateral malleoli o All deep veins from the popliteal veins from the leg flow into the popliteal

vein posterior to the knee, which becomes the femoral vein in the thigh. o Veins accompanying the perforating arteries of the deep artery of the thigh

drain blood from the thigh muscles and terminate in the deep vein of the thigh, which joins the terminal portion of the femoral vein.

o The femoral vein passes deep to the inguinal ligament to become the external iliac vein of the trunk.

o The deep veins are more variable and anastomose much more frequently than the arteries they accompany

Lymphatic vessels of the lower limbs See picture on page 582


Superficial lymphatic vessels o Converge on and accompany the saphenous veins and their

tributaries o The lymphatic vessels accompanying the great saphenous vein end in

the vertical group of superficial inguinal lymph nodes o Most lymph from these nodes passes directly to the external iliac

lymph nodes Located along the external iliac vein

o Lymph may also pass into the deep inguinal lymph nodes Lie under the deep fascia on the medial aspect of the femoral

vein o The lymphatic vessels accompanying the small saphenous vein enter

the popliteal lymph nodes, which surround the popliteal vein in the fat of the popliteal fossa

o The deep lymphatic vessel from the leg accompany deep veins and enterthe popliteal lymph nodes

o Most lymph from thease nodes ascends through deep lymphatic vessels to the deep inguinal lymph nodes

o Lymph from the deep nodes passes to the external and common iliac lymph nodes and is then received by the lumbar lymphatic trunks

Cutaneous innervation of the lower limb Cutaneous nerves in the subcutaneous tissue supply the skin of the lower limb Thease nerves are branches of the lumbar and sacral plexuses (exept for some

proximal unisegmental nerves arising from T12 to L1 spinal nerves) The areas of skin supplied by individual spinal nerves, including those contributing to

the plexuses are called dermatomes. Dermatomes L1‐L5 extend as a series of bands from the posterior midlineof the trunk

into the limbs, passing laterally and inferiorly around the lymb to its anterior and medial aspects, reflecting the medial rotation that occurs developementally.

Dermatomes S1 and S2 pass inferiorly down the posterior aspect of the limb, separating near the ankle to pass to the lateral and medial marigins of the foot.

Table 5.1 – pp 586 – 587. See also: picture on page 586 Subcostal nerve

o Origin T12 anterior ramus

o Course Courses along inferior border of 12th rib Lateral cutaneous branch descends overiliac crest

o Distribution in lower limb Lateral cutaneous branch supplies skin of hip region interior to

anterior iliac crest and anterior to greater trochanter


Iliohypogastric nerve o Origin

Lumbar plexus (L1; occasionally T12) o Course

Parallels iliac crest Devides into lateral and anterior cutaneous branches

o Distribution in lower limb Lateral cutaneous branch supplies superolateral quadrant of buttock

Ilioinguinal nerve o Origin

Lumbar plexus (L1; occasionally T12) o Course

Passes through inguinal canal Divides into femoral and scrotal or labial branches

o Distribution in lower limb Femoral branch supplies skin over medial femoral triangle

Genitofemoral o Origin

Lumbar plexus (L1‐L2) o Course

Descends anterior surface of psoas major Divides into genital and femoral branches

o Distribution in lower limb Femoral branch supplies skin over lateral femoral triangle Genital branch supplies anterior scrotum or labia majora

Lateral cutaneous nerve of the thigh o Origin

Lumbar plexus (L2‐L3) o Course

Passes deep to inguinal ligament 2‐3 cm medial to anterior superior iliac spine

o Distribution in lower limb Supplies skin on anterior and lateral aspects of thigh

Anterior cutaneous branches o Origin

Lumbar plexus via femoral nerve (L2‐L4) o Course

Arise in femoral triangle Pierce facia lata along path of sartorious muscle

o Distribution in lower limb Supply skin of anterior and medial aspects of thigh

Cutaneous branch of obturator nerve o Orgin

Lumbar plexus via obturator nerve anterior branch (L2‐L4) o Course

Following its descent between adductors longus and brevis, anterior division of obturator nerve pierces fascia lata to reach skin of thigh


o Distribution in lower limb Skin of middle part of medial thigh

Posterior cutaneous nerve of the thigh o Origin

Sacral plexus o Course

Enters gluteal region via infrapiriform portion of greater sciatic foramen deep to gluteus maximus

Descends deep into fascia lata o Distribution in lower limb

Terminal branches pierce fascia lata to supply skin of postgerior thigh and popliteal fossa

Saphenous Nerve o Origin

Lumbar plexus via femoral nerve o Cource

Traverses adductor canal but does not pass through adductor hiatus Crosses medial side of the knee deep to sartorius tendon

o Distribution in lower limb Skin on medial side of leg and foot

Superficial fibular nerve o Origin

Common fibular nerve o Course

Courses through lateral compartment of leg After supplying fibular muscles, perforates crural fascia

o Distribution in lower limb Skin of anterolateral leg Dorsum of foot Excluding web between great and 2nd toe

Deep fibular nerve o Origin

Common fibular nerve o Course

After supplying muscles on dorsum of foot it pierces deep fascia superior to heads of 1st and 2nd metatarsals

o Distribution in lower limb Skin of web between great and 2nd toes

Sural nerve o Origin

Tibial and common fibular nerves o Course

Medial sural cutaneous branch of tibial nerve and lateral sural cutaneous branch of fibular nerve merge at varying levels on posterior leg

o Distribution in lower limb Skin of posterolateral leg and lateral margin of foot


Medial plantar nerve o Origin

Tibial nerve o Course

Passes between the first and second layers of plantar muscles Then between the medial and middle muscles of the first layer (we are talking about Moore layers. – The layers are different after the

book you read) o Distribution in lower limb

Skin on medial side of sole and sides Plantar aspects and nail beds of medial 3½ toes

Lateral plantar nerve

o Origin Tibial nerve

o Course Passes between first and second layers of plantar muscles Passes between middle and lateral muscles of first layer

o Distribution in lower limb Skin on lateral side of sole and sides Plantar aspect, and nail beds of lateral 1½ toes

Calcaneal nerves o Origin

Tibial and sural nerves o Course

Lateral and medial branches of tibial and sural nerves, respectively, over calcaneal tuberosity

o Distribution in lower limb Skin of heel

Superior clunial nerves o Origin

Posterior rami o Course

Penetrate thoracodorsal fascia Course laterallyl and inferiourly in subcutaneous tissue

o Distribution in lower limb Skin overlying superior superior and central parts of buttock

Medial clunial nerves o Origin

Posterior rami o Course

Emerge from dorsal sacral foramina Directly enter overlying subcutaneous tissue

o Distribution in lower limb Skin of medial buttock and intergluteal cleft

Interior cluneal nerves


o Origin Posterior cutaneous nerve of thigh

o Course Arise deep to gluteus maximus Emerge from beneath interior border of muscle

o Distribution in lower limb Skin of inferior buttock (overlying gluteal fold)


A GUIDE TO THE MUSCLES OF THE LOWER LIMB Category Muscle Function Origin Insertion Nerve Blood Supply

Gluteal Region

Gluteus maximus Hip extensor Lateral rotator (H)

Suface of ilium, sacrum

Iliotibial tract and gluteal tuberosity of the femur

Inferior gluteal (L5, S1, S2)

Inf. & Sup. Gluteal

Gluteus medius Hip abductor Medial rotator (H)

External Surface of ilium

Greater trochanter

Superior gluteal

Superior gluteal

Gluteus minimus Hip abductor Medial rotator (H)

External Surface of ilium

Greater trochanter

Superior gluteal

Superior gluteal

Tensor Fascia Latae

Hip abductor Medial rotator (H) ,assists glut. max to extend knee

Anterior superior iliac spine; anterior part of iliac crest

Iliotibial tract Superior gluteal

Superior gluteal

Pelvic Region

Piriformis Lateral rotator (H) Sacrum Greater trochanter

Sacralplexus, nerve to piriformis S1, S2

Inf. & Sup. Gluteal

Obturator internus Lateral rotator (H) Inner surface of obturator foramen

Greater trochanter

Sacral plexus, Nerve to obturator internus (L5, S1)

Inf. Gluteal

Superior gemellus Lateral rotator (H) Ischial spine Greater trochanter

Sacral plexus, Nerve to obturator internus (L5, S1)

Inf. Gluteal

Inferior gemellus Lateral rotator (H) Ischial tuberosity Greater trochanter

Nerve to quadratus femoris

Inf. Gluteal

Obturator externus

Lateral rotator (H) Outer surface of obturator foramen

Greater trochanter

Obturator posterior

Med. circumflex femoral & Obturator

Quadratus femoris Lateral rotator (H) ischial tuberosity intertrochanteric crest of femur

Nerve to quadratus femoris

Inferior glutial artery

Hip exceptions

Iliacus (part of iliopsoas)

flexing thigh at hip joint

Iliac crest, iliac fossa, ala of sacrum, and anterior sacroiliac ligaments

Tendon of psoas major, lesser trochanter.

Femoral nerve

Medial femoral circumflex

Psoas major (part of iliopasoas)

flexing thigh at hip joint

Sides of T12‐L5 vertebrae and discs between them.

Lesser trochanter of femur

Anterior rami of lumbar nerves

Lumbar branch of iliolumbar artery

Psoas minor flexing thigh at hip joint

Sides of T12‐L1 vertebrae and intervertebral disc

Pectineal line, iliopectineal eminence.

Anterior rami of lumbar nerves

lumbar artery

Anterior Thigh

Pectineus

Hip Flexor Hip Adductor Medial roatation

superior Pubic ramus

Pectineal line of femur

Femoral Med. Circumflex femoral & Obturator

Sartorius

Hip Flexor Hip Abductor Lateral Rotator (H) Knee extensor

Anterior superior iliac spine

Upper medial tibia

Femoral Femoral

Rectus femoris Extend leg at knee Anterior inferior Patellar ligament Femoral Lateral circumflex


joint, help in hip flexion.

iliac spine and ilium superior to acetabulum

femoral

Vastus medialis Extend leg at knee joint

Intertrochanteric line and medial lip of linea aspera of femur

Patellar ligament Femoral Femoral (profunda femoris)

Vastus lateralis Extend leg at knee joint

Greater trochanter and lateral lip of linea aspera of femur

Patellar ligament Femoral Lateral circumflex femoral

Vastus intermedius

Extend leg at knee joint

Anterior andlateral surfaces of shaft of femur

Patellar ligament Femoral Lateral circumflex femoral

Medial Thigh

Gracilis

Knee Flexor Hip Adductor

Inferior Pubic ramus

Upper medial tibia

Obturator Med circumflex femoral & obturator

Adductor magnus Adductor part: adduction Hamstrings part: extends thigh

Adductor part: inferior ramus of pubis, ramus of ischium Hamstrings part: ischial tuberosity

Adductor part: gluteal tuberosity, linea aspera, medial supracondylar line Hamstrings part: adductor tubercle of femur

Adductor part: obturator nerve, Hamstrings part: tibial part of sciatic nerve.

Med circumflex femoral & obturator

Adductor brevis Hip AdductorThigh flexor

Pubic ramus Pectineal line and proximal part of linea aspera of femur


Adductor Longus Hip AdductorThigh flexion

Anterior surface of body of pubis

Middle third of linea aspera of femur


Posterior Thigh

Semitendinosus Hip Extensor Knee Flexor (roatat the leg medialy when the knee is flexed)

Ischial tuberosity Medial surface of superior part of tibia

Tibial Perforating br. Of deep femoral

Semimembranosus Hip Extensor Knee Flexor (roatat the leg medialy when the knee is flexed)

Ischial tuberosity Posterior part of medial condyle of tibia

Tibial Perforating br. Of deep femoral

Long head of biceps femoris

Hip Extensor Knee Flexor Lateral rotator (H)

Ischial tuberosity Fibular head Tibial Perforating br. Of deep femoral

Short head of biceps femoris

Knee Flexor Lateral rotator (H)

linea aspera and lateral supracondylar line of femur

Fibular head Common Fibular

Perforating br. Of deep femoral

Posterior Leg

Gastrocnemius Plantar flexion(A)Knee Flexor

Medial and lateral epicondyles of

Calcaneus(via calcaneal tendon)

Tibial Sural br. Of popliteus


femur

Plantaris Plantar flexion(A)

lateral supracondylar line of distal femur


Tibial Sural br of popliteus

Soleus Plantar flexion(A) Posterior aspect of head of fibula, medial border of tibial shaft,


Tibial Sural br of popliteus & posterior tibial

Flexor digitorum longus

Plantar flexion(A)Flexes toes 2‐5, supports longitudinal arches of foot

Posterior surface of tibia

bases of 2nd ‐5th distal phalanges (go under medial malleulus)

Tibial Posterior tibial

Flexor hallucis longus

Plantar flexion(A)Flexes toe 1, supports medial longitudinal arches of foot

posterior surface of fibula, interosseous membrane

Base of distal phalanx of great toe (go under medial malleulus)

Tibial Posterior tibial

Tibialis posterior Plantar flexion(A)Inversion

Posterior surface of tibia and fibula &interosseous membrane

Navicular, cuniform, cuboid, bases of 2‐4 metatarsals. (go under medial malleulus)

Tibial Posterior tibial, peroneal

Popliteus Rotates knee medially and flexes the leg on the thigh

Lateral surface of lateral condyle of femur and lateral meniscus

Posterior surface of tibia, superior to soleal line

Tibial nerve

Medial inferior genicular & Posterior tibial

Dorsum of Foot

Extensor digitorum brevis

Extensor of toes (by aiding the extensor digitorum longus)

Calcaeneus, interosseous talocalcaneal ligament

Long flexor tendons of four medial toes

Deep fibular

Dorsalis pedis

Extensor Hallucis Brevis

Extends great toe In common with extensor digitorum brevis

Dorsal aspect of base of proximal phalanx 1

Deep fibular

Dorsalis pedis

Lateral Leg

Fibularis longus Plantarflexion (A)Eversion

Head and superior two thirds of lateral surface of fibula

Metatarsal oftoe #1 & medial cuneiform (go under lateral malleulus)

Superficial fibular

Fibular artery

Fibularis brevis Plantarflexion (A)Eversion

Inferior two thirds of lateral surface of fibula

Base Metatarsal of toe #5 (go under lateral malleulus)

Superficial fibular

Fibular artery

Anterior Leg

Tibialis anterior Dorsiflexes ankle and inverts foot

Lateral condyle and superior lateral surface of tibia and interosseous membrane

Medial cuneiform/first metatarsal

Deep fibular

Anterior tibial

Extensor hallucis longus

Extends great toe and dorsiflexes ankle

Middle part of anterior surface of fibula and interosseous membrane

Distal phalanx of toe #1 (dorsum)

Deep fibular

Anterior tibial

Extensor digitorum longus

Dorsiflexion (A)Extensor of toes

Lateral condyle of tibia and medial surface of fibula and

Extensor expansion of lateral 4 toes

Deep fibular

Anterior tibial


interosseous membrane

Fibularis tertius Dorsiflexes ankle and aids in eversion of foot

distal anterior surface of the fibula

metatarsal of toe #5

Deep fibular

Anterior tibial

Plantar Foot

Level 1 Abductor hallucis Abducts toe #1Flexes toe #1

Medial tubercle of calcaeneum

Medial side of base of proximal phalanx of 1st digit

Medial plantar (Tibial)

Medial plantar(post. Tibial)

Flexor digitorum brevis

Flexes lateral four digits

Medial tubercle of calcaeneum

Middle phalanx of toes #2‐5



Abductor digiti minimi

Abducts and flexes little toe

Calcaeneum Lateral base of phalanx #5

Lateral plantar (Tibial)

Lateral plantar(post. Tibial)

Level 2

Quadratus plantae Assists flexor digitorum longus in flexing lateral four digits

Calcaeneum Tendons of flexor digitarum longus

Lateral plantar (Tibial)


Lumbricals Flex proximal phalanges, extend middle and distal phalanges of lateral four digits

Tendons of flexor digitorum longus

Medial aspect of expansion over lateral four digits

Medial one: medial plantar nerve. Lateral three: lateral plantar nerve.

Medial and Lateral plantar arteries

Flexor digitorum longus tendon

Passes in the sustentaculum tali and crosses with the flexor hallucis longus tendon

Level 3 Flexor hallucis brevis

Flexes big toe Cuboid and lateral cuneiform

Base of proximal phalanx of toe #1



Adductor hallucis Adducts big toe and assists in transverse arch of foot.

Oblique Head: proximal ends of middle 3 metatarsal bones; Transverse Head: MTP ligaments of middle 3 toes

Lateral side of proximal phalanx of big toe #1

Lateral plantar

lateral plantar(post. Tibial)

Flexor digiti minimi brevis

Flexes pinky toe Base of metatarsal bone #5

base of the proximal phalanx of toe #5

Superficial branch of lateral plantar nerve


Flexor hallucis longus tendon

Level 4 Plantar interossei 3

Adduct digits (2‐4) and flex metatarsophalangeal joints

Bases and medial sides of metatarsals 3‐5

Medial sides of bases of phalanges 3‐5

Lateral plantar


Dorsal interossei 4 Abduct digits (2‐4) and flex metatarsophalangeal joints

Adjacent sides of metatarsals

Phlanages and dorsal expansion of corresponding toes

Lateral plantar


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Anatomy - Lower Limb V1c