Lower Limb Review

8/2/2019 Lower Limb Review

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SUPERFICIAL STRUCTURES OF THE LOWER LIMB

Iliotibial tract: Laterally, the fascia lata is thickened to form the iliotibial tract.The iliotibial tract receives the insertions of the tensor fascia lata and gluteus maximus muscles.

In the upper part, it has two layers- superficial layer attached to the iliac tubercle (superficial to the Tensor

fascia lata), and the deep layer attached to the fibrous capsule of the hip-joint.The two layers fuse below the tensor fascia lata to form a single band down the lateral side of the thigh and is

attached to the lateral condyle of the tibia.

Dermatomes:

Lower limb Spinal Nerve Dermatomes:

L1 = groin (hand in jeans pocket)

L2 = lateral thigh

S1 = Lateral aspect of the foot, the heel & most of the sole of the foot

S2 = median posterior strip of thigh & leg

S3 = sitting area of the buttock

KNOW IN DETAIL the cleft between the toes, dermatomes and cutaneous nerves of the femoral triangle andthe FOOT! (Cutaneous innervation of the hand and the foot are very very important)

CUTANEOUS INNERVATION OF THE LOWER LIMB

1. Iliohypogastric nerve: (L1-from lumbar plexus) Supplies the skin of the buttock.

2. Ilioinguinal nerve: (L1-from lumbar plexus) Supplis the skin of the proximal, medial thigh.

3. Genitofemoral nerve: (L1 & L2- from lumbar plexus) Supplis the skin of the proximal, anterior thigh,

just inferior to inguinal ligament.

4. Saphenous nerve: (L2,L3 & L4) It is the terminal branch of the femoral nerve. It supplies the skin of th

anterior and medial side of the leg and the medial side of the footexcept the medial side of the big toe.

5. Sural nerve: It is a branch of the tibial nerve. It Supplies the skin on the posterior and lateral aspects of

the leg and lateral side of the foot.

6. Sural communicating nerve: It is a branch of the common peronealnerve. It Supplies the skin of theposterolateral leg.

7. Superficial peroneal (fibular) nerve: It is a branch of the common peronealnerve. It supplies the skin o

the lower third of the leg and the dorsal part of the foot and medial side of the great toe, except the cleft

between the great and 2nd toes.

8. Deep peroneal (fibular) nerve: Is a branch of the common peronealnerve.It supplies skin on the cleftbetween the great and 2nd toes.

9. Medial and lateral plantar nerves: are branches of the tibial nerve. They supply the skin of the sole of

the foot. The medial plantar nerve supplies medial 3 digits. The lateral plantar nerve supplies lateral 1


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digits.

Great saphenous vein:Extent:

It begins on the medial side of the dorsum of the foot by the union of the dorsal vein of the great toe and themedial end of the dorsal venous arch.

It ends in the femoral vein about 3 cm. below the inguinal ligament.

Course:

It ascends infront of (anterior to) the medial malleolus and along the medial side of the leg accompanie

by the saphenous nerve.

Passes through the saphenous opening (hooks around the falciform margin of the saphenous opening),pierces the cribriform fascia and ends in the femoral vein.

Small saphenous veinExtent:

It begins on the lateral side of the foot from the union of the dorsal vein of the small (little) toe with thelateral end of the dorsal venous arch.

It ends by openingto thepopliteal vein in the popliteal fossa.

Varicose veins :

When the superficial veins become abnormally dilated and tortuous (twisted), they are called varicose veins.

Most commonly the great saphenous vein is involved. They often cause discomfort. Varicosity may be due to

following reasons:

a. hereditary weakness of the venous wallsb. incompetence of the valves therefore allows the backflow of blood and they dilate

c. increased intra-abdominal pressure- in multiple pregnancies or abdominal tumors.

d. thrombophlebitis of the deep veins

To relieve the condition, the superficial veins and tributaries and/or the incompetent perforator veins are

ligated and removed.

Vericoses also occur in the testicles

Trendelenburgs test I: is performed to test the incompetency of the perforators & superficial veins(trendelenburgs test II is performed for assessing gluteal muscles).

Saphenous cutdown : Great saphenous vein is easily be located by making a skin incision anterior to

the medial malleolus. This procedure is called saphenous cutdown. This procedure is used for insertion oa canula for prolonged administration of medication in infants and obese persons, or in patients in shock.

The saphenous nerve may be cut during this procedure and the patient may complain of pain along themedial border of the foot.

Lie in the supine position, raise you leg and empty the vein, tie a bandage arund the saphenous opening. Standup and after 60 secs the tonicate is removed and in ~ 30 sec the entire leg should fill with blood (competent

valves).


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Lymphatic drainage of the lower limb:

Lymph nodes of the lower limb consist of-

Inguinal lymph nodes (superficial and deep group)

Popliteal lymph nodes

Anterior tibial lymph node

FEMORAL TRIANGLEBoundaries:

Laterally - by the Sartorius

Medially- by the medial margin of the Adductor longus

Base - is directed above and formed by the inguinal ligament (thickening of lower border of ext oblique).

Attach to the sup. Ant. Ilic crest and pubic tubercle- mid point of inguinal ligament (between the ant. Sup iliac crest and pubic tubercle) is different from the

mid-inguinal point (mid point of line drawn between ant. Sup. Iliac spine and pubic symphysis)Apex - is directed downward and is formed by the crossing of sartorius over the adductor longus.

Roof Skin

Superficial fasciaSuperficial inguinal lymph nodes and superficial blood vessels (know the names of the blood vessels

found on the roof ie. Exam. Which of these structures is not part of the roof of the triangle)

1. Superficial epigastric

2. Sup. Ext iliac3. Sup ext pudental arteries

Deep fascia

Floor - lateral to its medial side by: 1. Iliacus lateral (at this point the iliacus and iliopsoas have united and

are now called the liopsoas)

2. Psoas major -3. Pectineus -

4. Adductor longus medial boundary (therefore also forms floor)

5. In some cases a small part of the Adductor brevis

Contents: 1. A pad of fat

2. Deep Inguinal lymph nodes and the Lymph vessels

3. Femoral artery and its branches- 3 superficial branches (superficial ext.pudendal,superficial epigastric, superficial circumflex iliac)

Deep external pudendal A,Profunda femoris A,

Muscular branches

4. Femoral vein- it is medial to the femoral artery in the upper part of the triangle, butcomes to its posterior aspect near the apex of the triangle.

It receives the great saphenous vein and the profunda femoris vein in the triangle.


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5. Femoral nerve it lies lateral to the femoral artery and outside the femoral sheath.

It soon divides into its branches.

6. Femoral branch of the genitorfemoral nerve. It descends close to the femoral artery.7. Femoral sheath- it encloses the femoral vessels and the femoral canal

FEMORAL SHEATH

It does not enclose the femoral nerve. femoral nerve lies deep to fascia iliacus and therefore does not getcovered by the sheath.

The anterior wall of the sheath is formed by the downward prolongation of thefascia transversalis of the

abdomen, in front of the femoral vessels.The posterior wall of the sheath is formed by the downward prolongation of thefascia iliaca behind the femora

vessels.

The interior of the sheath is divided into 3 compartments by two anteroposterior septa that stretch between its

anterior and posterior walls.

The lateral compartmentcontains the femoral artery and the femoral branch of the genitofemoral N (lateral to thartery).

The middle compartmentcontains the femoral veinThe medial and smallest compartmentis named the femoral canal, and contains some lymphatic vessels and a

lymph gland (Cloquets lymph node is a deep inguinal lymph node).

Femoral canal- It is conical and measures about 1.25 cm. in length.Its base is directed upward and open to the

abdomen and named thefemoral ring(upper end of the femoral canal).

It is closed by thefemoral septum.

Its lower end extends to the level of the saphenous opening

Femoral hernia can occur through the femoral ring into the femoral canal.The direction of course of the femoral hernia is downwards through the femoral canal, then forwards through

the saphenous opening, and finally upwards and laterally (U-shape). Organs such as the intestine may pertrud

into femoral ring. Usually, herniation will be confined to femoral sheath but sometimes it can go inferiorlyand pass through the saphenous opening and lie right under the skin. There can be a strangulation of the

herniated structure and the blood supply is lost leading to necrosis of the organ

It can be reduced by following in reverse order. While releasing strangulation of the femoral hernia, thelacunar ligament is incised. Before incising the lacurnar ligament for enlarging the femoral ring, care should

be taken to avoid injury to the accessory obturator artery (not always there called a common variation),

which may run along its concave free margin. May lead to severe bleeding. This artery is a branch of the

inferior epigastric artery which comes from the external iliac artery

ADDUCTOR CANALBoundaries:

Anterolaterally - by the Vastus medialis

Posteriorly - by the Adductor longus in the upper half


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Adductor magnus in the lower half.

At the junction of the middle and lower of the thigh, there is an opening in

(in the adductor magnus) for the femoral vessels

Roof formed by 1. Afibrous sheetwhich extends from the Vastus medialis, across the femoral

Vessels to the Adductor longus and magnus.

2. Sartorius muscle lying on the aponeurosis3. Subsartorial plexus of nerves lies on the fibrous roof.

The subsartorial plexus is formed by branches from-

a) medial cutaneous N of the thigh. b) saphenous N c) obturator N

Contents 1. Femoral artery

2. Femoral vein

3. Saphenous nerve branch of the femoral nerve,

4. Nerve to the Vastus medialis branch of femoral nerve

Muscle ActionNerve

Supplysartorius flexes, abducts,

laterally rotates

thigh; flexes andmedially

rotates leg at knee

Also, slight flexion ofthe thigh

femoral nerve

iliacus Chief flexor of the

thigh. When the

thigh is fixed, it flexesthe trunk on the thigh

as in sitting up. It is a

postural muscle

femoral nerve

psoas major same as iliacus Ventral rami ofthe L2 & L3

(roots of the

lumbar plexus

(L1-L4))

pectineus flexes and adductsthigh

femoral nerveSome times by

obturator or

accessoryobturator nerves


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rectus femoris extension of leg

Assists on flexion of

the thigh(Note: observe its

origin)

femoral nerve

vastus lateralis extension of leg femoral nerve

(L2-L4)

vastus medialis extension of leg femoral nerve

vastus intermedius extension of leg femoral nerve

Articularis genu Pulls up the synovial

membrane duringextension of the knee

joint prevents

crushing of synovialmembrane during

extension

Femoral nerve

Tensor fascia lata Abduction and medial

rotation of the thigh.Steadies the tibia on

the femur while

standing

Superior gluteal

nerve (fromsacral plexus)

Femoral artery:It is the direct continuation of the external iliac artery.

It begins immediately behind the inguinal ligament at the mid-inguinal point (midpoint between the anterior

superior iliac spine and the symphysis pubis). This is where you feel for the pulse of the artery

Termination:It ends at thejunction of the middle with the lower third of the thigh, where it passes through an opening in theAdductor magnus to become the popliteal artery.

Know relations to femoral artery and nerve and that is is covered in a femoral sheath

Relations:

In the femoral triangle :

The first 4 cm. of the vessel is enclosed, together with the femoral vein, in a fibrous sheaththe

femoral sheath. The femoral artery lies in the lateral compartmentof the femoral sheath along with

the femoral branch of the genitofemoral nerve.

In the femoral triangle, the artery is superficial. In front of it are the skin and superficial fascia, the

superficial inguinal lymph glands, the superficial circumflex iliac vessels, fascia lata and the anterior

wall of the femoral sheath.


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Laterally: 1.The femoral branch of the genitofemoral nerve

2. The femoral nerve & its branches (Femoral nerve liesoutside the femoral

sheath)

Posterior: Behind the artery are -1. Posterior wall of the femoral sheath

(Bed) 2. Psoas major tendon

3. Pectineus4. Adductor longus.

5. Fibrous Capsule of the hip joint

6. Femoral vein (in the lower part)The artery is separated from the capsule of the hip-joint by the tendon of the Psoas major

Medially: The femoral vein

NOTE:(femoral vein lies on the medial side of the upper part of the artery, but is behind(posterior to-) the femoral artery in the lower part of the femoral triangle).

The profunda femoris artery

Branches: In femoral triangle, gives off 2 branches Medial Circumflex Femoral- arises from the medial side. It anastomoses with the inferior gluteal,

lateral femoral circumflex, and first perforating arteries (cruciate anastomosis).The acetabular branch of the medial circumflex femoral artery supplies hip joint.

Lateral Circumflex Femoral A- arises from the lateral side of the profunda, It takes part in thecruciate anastomosis on the back of the thigh.

Lumbar PlexusRoot value- L1, L2, L3, L4.

It is located in the posterior abdominal wall within the psoas major muscle.

The branches of the lumbar plexus are:

Iliohypogastric- L.1 (lateral)Ilioinguinal- L.1 (lateral)

Genitofemoral- L. 1, 2 (anterior)

Lateral cutaneous nerve of the thigh- L 2, 3 (lateral)Femoral - L 2, 3, 4 (Dorsal divisions of the ventral rami) (lateral)

Obturator - L 2, 3, 4. (Ventral divisions of the ventral rami) (medial)

Accessory obturator - L 3, 4 (Ventral divisions of the ventral rami)

Femoral Nerve

Root value (Origin) from the lumbar plexus,Dorsal divisions of the ventral rami of L2, L3, L4.Origin is in the posterior wall of the abdominal cavity within the psoas major muscle.

It emerges from the muscle at the lower part of its lateral border.

In the femoral triangle, it lies lateral to the femoral vessels andoutside the femoral sheath. It soon splitsinto an anterior and a posterior division.

Branches

I. Within the abdomen


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1. Small branches to the Iliacus

2. A branch to the upper part of the femoral artery

3. Nerve to pectineus it crosses behind the femoral sheath to reach the muscle.KNOW that it innervates the iliacus and pectineus in the pelvis

B. Branches from the posterior division of the femoral nerve (mainly muscular)1. Saphenous nerve only cutaneous nerve from this division. Runs lateral to femoral artery and then

medial to artery through adductor canal. Does not go through adductor hiatus but pierced through roof of

canal and goes medial to knee joint and ends at the ball of the great toe (first metatarsal joint) (Knowsaphenous nerve in detail*** It is the longest cutaneous nerve in the body

2. Branches to the quadriceps femoris muscles (Rectus femoris, Vastus lateralis, Vastus

intermedius, Vastus medialis).

o The branch supplying the rectus femoris gives an articular branch to the hip joint

o The branch supplying the vastus intermedius gives an articular branch to the knee joint

3. Articular branch (goes to joint) to the medial side of the knee joint - comes from the nerve from thevastus medialis

Saphenous Nerve

It is the largest cutaneous branch of the femoral nerve.

In the lower part of the femoral triangle and upper part of the adductor canal it lies lateral to the femoral artery.

Then it crosses in front of the artery from lateral to medial side. In the lower part of the adductor canal it lies

medial to the artery as far as the opening in the lower part of the Adductor magnus. It pierces the deep fascia andaccompanies the saphenous artery. In the leg, it accompanies the great saphenous vein to the front of the medial

malleolus and then runs forward on the medial border of the foot, and is distributed to the skin on the medial side

of the foot, as far as the ball of the great toe.

MUSCLES OF THE MEDIAL SIDE OF THE THIGH

Muscle ActionNerve

Supply

adductorlongus

adducts thighand assists

in lateral

rotation

obturator nerve(Ant. Division)

adductorbrevis

adducts thighand assists in

lateral rotation

obturator nerve(Ant. Division)


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adductor

magnus

Adductor part-inferior

ramus of pubis; ramus

of ischium (ischiopubicramus)

Hamstring part- ischial

tuberosity

Adductor part- gluteal

tuberosity, linea aspera,

medial supracondylarline.

Hamstring part-

adductor tubercle offemur

Adducts thigh

and assists in

lateralrotation.

Hamstring part

extends thigh

Adductor part-

obturator nerve

(Post. Division)Hamstring part-

tibial part of sciati

nerve

Openings in the adductor magnus- (5 osseoaponeurotic openings): At the insertion of the adductor magnus,

there is a series of osseoaponeurotic openings, formed by tendinous arches attached to the bone. The upper fouropenings are small, and give passage to the perforating branches of the profunda femoris artery. The lowest is of

large size (hiatus magnus), and transmits the femoral vessels to the popliteal fossa.

The Obturator NerveThe anterior division descends in front of the Obturator externus and the Adductor brevisThe posterior division pierces the anterior part of the Obturator externus, and supplies this muscle.

It then passes behind the Adductor brevis on the front of the Adductor magnus.

LEG

ANTERIOR COMPARTMENT OF THE LEG AND DORSUM OF THE

FOOT

Structures passing deep to the superior extensor retinaculum are- (KNOW THE ARRANGMENT!)From medial to lateral:

Tibialis anterior

Extensorhallucis longus

Anterior tibial artery (& vein)

Anterior tibial nerve (deep peroneal N).

Extensordigitorum longus

Peroneus tertius

MUSCLES OF THE ANTERIOR COMPARTMENT OF THE LEG AND DORSUM OF

THE FOOT

KNOW THE JOINTS THAT THESE MUSCLES ACT ON!

Muscle Action Nerve

Supply

tibialis anterior Extends (dorsiflexion) the foot at ankle; deep peroneal nerve


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inverts foot at subtalar joint

helps to maintain the medial longitudinal arch of foot

(SUBTALAR JOINT)

(anterior tibial N)

Innervates cleft

between 1st and 2nd t

extensor digitorum longus extends the lateral 4 toes; dorsiflexes (extends) foot atthe ankle. Flexes all the joints that it crosses which are

many

deep peroneal nerve(anterior tibial N)

peroneus tertius dorsiflexes (extends) foot; everts foot at subtalar joint deep peroneal nerve

(anterior tibial N)

extensor hallucis longus extends big toe; dorsiflexes foot; inverts foot at subtalar

joint

deep peroneal nerve

(anterior tibial N)

extensor digitorum brevis Extend the 2nd, 3rd, & 4th toes at the

metatarsophalangeal joints.

deep peroneal nerve

(anterior tibial N)

extensor hallucis brevis (is themedial most part of the extensor

digitorum brevis)

extends big toedeep peroneal nerve(anterior tibial N)

Anterior Tibial Arteryit becomes the dorsalis pedis artery

Dorsalis Pedis Artery

It is the continuation of the anterior tibial artery.

Extent: From the midpoint of the front of the ankle jointit runs forwards in the dorsum of the foot to the

proximal part of the first intermetatarsal space.Termination:It dipsbetween the two heads of the 1st dorsal interosseous and joins the lateral plantar artery tocomplete the plantar arch.

The pulse is felt

On its medial side is the tendon of the Extensor hallucis longus

On its lateral side, the first tendon of the Extensor digitorum longus , and the termination of the deep

The arcuate artery

Clinical: pulsations of the dorsalis pedis artery can be easily felt.

Deep Peroneal Nerve

Foot drop:Common peroneal nerve is in danger of injury because of its superficial position (neck of fibula). Injury leads to

paralysis of all the dorsiflexors and evertors of the foot (muscles of the anterior and lateral compartments)

resulting in foot drop. The toes drag on the foot while walking. Cutaneous sensibility is lost in the


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anterolateral aspect of the leg and dorsum of the foot excepting the outer and inner border of the foot (supplied by

the sural and saphenous nerves respectively).

MAY BE DUE TO FRACTURE OF THE FEMUR!!!!

LATERAL COMPARTMENT OF THE LEG

Lateral compartment of the leg consists of the two evertors of the foot- Peroneus longus and Peroneus brevis.

ALL PERONIAL MUSCLES EVERT THE FOOT BUT ONLY THE LONGUS AND BREVIS ARE SUPPLIED

BY THE SUPERFICIAL PERONIAL NERVE (IE. NOT THE TERTIOUS DEEP PERONIAL NERVE)

KNOW WHICH JOINTS THEY ACT ON!

Muscle Action Nerve

Supply

peroneus

longus

everts foot

at subtalar joint. Plantar flexes (flexes) foot. supports laterallongitudinal arch (sling)and transverse arch (bow string) of foot

superficial peroneal

(musculocutaneous) nerve

peroneus

brevis

everts foot

at subtalar joint. plantar flexes (flexes) foot. Holds up lateral

longitudinal arch

superficial peroneal nerve

(musculocutaneous nerve)

Superficial Peroneal NerveIt supplies-

Peroneus longus

Peroneus brevis

Skin of the dorsal surfaces of all the toes except the cleft between the 1stand 2nd toes

(supplied by the deep peroneal nerve), and the lateral side of the little toe (supplied by

the sural nerve)

MUSCLES OF THE POSTERIOR COMPARTMENT OF THE LEG

Soleus is the peripheral heart (calf pump)

Two heads of the gastrocnemius and the soleus are together called Triceps surae

Superficial Group

Muscle Insertion Action Nerve

Supply


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gastrocnemius Middle of the posterior

surface of calcaneum via

tendocalcaneus

plantar flexes (flexes) foot at the ankle;

raises heel during walking; flexes knee

tibial nerve

Plantaris (short musclewith long slender

tendon)

Middle of the posteriorsurface of calcaneum via

tendocalcaneus

plantar flexes foot; flexes knee tibial nerve

Soleus (Bulky muscle) Middle of the posterior

surface of calcaneum viatendocalcaneus

with gastrocnemius, a powerful plantar

flexor of ankle; steadies leg on foot; mainpropulsive force in walking and running

tibial nerve &

posterior tibialnerve

Deep Group

Popliteus Intracapsular, but

extrasynovial;Popliteal groove on

the lateral surface of

the lateral condyle of

femur, lateralmeniscus of the knee

joint

Becomes extracapsular

and inserted into thetriangular area above the

soleal line on the

posterior surface of the

tibia

Key muscle which unlocks

the knee (flexes) at the beginningof the flexion; draws the lateral

meniscus backwards and prevents

it from getting crushed duringflexion of the knee

tibial nerve

( nerve to popliteuwinds around its

lower border &

supplies its anterio

surface)

flexor

digitorumlongus

flexes distal

phalanges of lateralfour toes;

plantar flexes foot;

supports laterallongitudinal arch of

foot

tibial nerve

(posterior tibial)

flexor

hallucislongus

flexes distal phalanx

of big toe; plantarflexes foot; supports

medial longitudinal

arch of foot

tibial

nerve(posteriortibial)

tibialisposterior

Lateral of posteriorsurface of tibia

below soleal line;

posterior surface offibula and

interosseous

membrane

(enters 4th layer of thesole) tuberosity of

navicular bone mainly,

and to all the tarsal

bones except the Talus

plantar flexes foot; inverts foot(powerful) at subtalar joint.

supports medial longitudinal arch

of foot

tibial nerve(posterior tibial)

Posterior Tibial Artery


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Termination: It ends under cover of the flexor retinaculum, midway between the medial malleolus and media

tubercle of the calcaneum by dividing into medial and lateral plantar arteries.

Relations

Behind the medial malleolus, the tendons, blood vessels, and nerve are arranged, under cover of the flexorretinaculum in the following order from the medial to the lateral side:

(1) Tibialis posterior (medial)

(2) Flexor digitorum longus,(3) Posterior tibial artery, with a vein on either side of it

(4) Tibial nerve

(5) Flexor hallucis longus. (lateral)

**MUST KNOW THIS ARRANGMENT***

(TOM DICK AND VERY NERVOUS HARRY)

Note that bleow the medial melleolus you feel for the Posterior Tibial Pulse

Posterior tibial nerve

Root Value?

it divides into two branches- medial and lateral plantar nerves.

MUSCLES OF THE GLUTEAL REGION

Muscle Origin Insertion Action Nerve

Supply

gluteus

maximus

Outer surface of

ilium- from the

posterior gluteal lineand the area behind.

From sacrum, coccyx,

sacrotuberousligament

Most fibers to

the iliotibial

tract, some

fibers to the

gluteal

tuberosity

of femur

(veryimportant to

know for

exams)

Chief extensor

at the hip joint.

Extends andlaterally rotates

thigh at hip;

through iliotibialtract it extends

knee joint andsteadies thefemur on tibia in

standing (assists

in rising fromsitting position or

in climbing

stairs)

inferior

gluteal nerve

(L5,S1,S2)


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gluteus

mediusAbducts and medially rotates

the thigh at hip; tilts pelvis

when walking. Keeps pelvis

level when opposite leg is

raised during walking

therefore, when they areparalyzed, unsupported (leg

off ground) side will sag.

LOOK UP

TRENDELENBERGH TEST

II test competency of the

sup. Gluteal nerve

superior gluteal

nerve (L4,L5,S1)

gluteusminimus

abducts and medially rotates

the thigh at hip; keeps pelvis

level when opposite leg is

raised

superior glutealnerve

tensorfascia lata

Abduction and medial

rotation of the thigh. Steadies

the femur on tibia in

standing. Assists gluteus

maximus in extending knee

joint

superior glutealnerve

piriformis Lateral rotator of thigh.Abduct the thigh when the

thigh is flexed. Steadies

femoral head in acetabulum

Ventral rami of

sacral nerves S1

and S2

superiorgemellus

lateral rotator of thigh Nerve to obturatorinternus

(L5,S1,S2)

obturator

internuslateral rotator of thigh Nerve to obturator

internus

(L5,S1,S2)

inferiorgemellus

lateral rotator of thigh Nerve to quadratusfemoris (L4,L5,S1)

obturator

externusLateral rotator of thigh.

steadies the head of femur in

acetabulum

obturator nerve

posterior division

quadratusfemoris

lateral rotator of thigh Nerve to quadratusfemoris(L4,L5,S1)

(STRUCTURES DEEP TO THE GLUTEUS MAXIMUS)

Communication between the pelvis and the gluteal region is done via the greater sciatic foramen


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The piriformis muscle is the key to this region.

Superior gluteal vessels and nerve emerge above the piriformis. All other structures are below the piriformis.

1. Bony structures- Greater trochanter, Ischial tuberosity, Ischial spine2. Bursae- trochanteric bursa, Ischial bursa, gluteofemoral bursa

3. Ligaments- Sacrotuberous ligament, Sacrospinous ligament

4. Muscles-1) Gluteus medius

2) Gluteus minimus

*Glutei medius and minimus abduct the hip joint and prevent adduction of the thigh when the body weight ison the same leg.

3) Piriformis key because many structures pass above and below

EXAM What structures pass above and below piriformis

Above superior gluteal nerve and vesselsBelow PIN structures (pudendal nerve, internal pudendal artery, nerve to obturator internus)

- inferior gluteal nerve

- sciatic nerve

- posterior cutaneous nerve of the thigh (passes posterior or superficial to the sciatic nerve)- nerve to quadratus femoris

4) Superior gemellus another key muscle because many structures that pass above and below

piriformis

5) Obturator internus6) Inferior gemellus

7) Quadratus femoris

8) Upper part of adductor magnus9) Origin of hamstrings

5. Nerves-

Nerve emerging above the piriformis:

1) Superior gluteal nerve

Nerves those emerge inferior to piriformis

1) Sciatic nerve (L4, 5, S1, 2, 3) lies between the ischial tuberosity and the greater trochanter. Its "safe"side for gluteal injection is the lateral side where it has no branches. It may divide in this region into the

common peroneal (L4, 5, S1, 2) and the tibial (L4, 5, S1, 2, 3) nerves.

2) Nerve to quadratus femoris3) Posterior cutaneous nerve of the thigh

4) Inferior gluteal nerve.

5) Pudendal nerve (S2, 3, 4)

6) Nerve to obturator internus (L5, S1, 2)


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6. Blood vessels

1. Superior gluteal artery & vein branch of the posterior division of the internal iliac artery2. Inferior gluteal artery & vein branch of the anterior division of the internal iliac artery

3. Internal pudendal vessels branch of the anterior division of the internal iliac artery

4. Cruciate anastomosis5. Trochanteric anastomosis

Clinical correlations:Clinical correlation of the superior gluteal nerve:

Trendelenburg sign: (II) This test is performed to assess the functions of the gluteus medius and minimus

muscles. ). During normal walking, the gluteus medius and minimus contract first on one side, then on the

other side (contract alternately). When they contract, they raise the pelvis on the unsupported (opposite) side.This permits the leg to be raised off the ground before taking a forward step. Normally the gluteus medius and

minimus contract on the supported side as soon as the contralateral foot leaves the floor, preventing tipping o

the pelvis to the unsupported side. When a person who has suffered a lesion of the superior gluteal nerve is

asked to stand on one leg, the pelvis on the unsupported side drops (sags), indicating that the gluteus mediusand minimus muscles on the supported side are weak or non-functional. The patient exhibits a dipping or

lurching gait. This is referred clinically as positive trendelenburg test. It can also result due to fracture othe greater trochanter or dislocation of the hip joint.

Piriformis syndrome: Compression of the sciatic nerve by the piriformis muscle. In 50% of the cases, casehistories indicate trauma to the buttock associated with hypertrophy & spasm of the piriformis. Skaters, cyclists

who excessively use the gluteal muscles, and women are more likely to develop this syndrome.

In 12% of individuals common peroneal division of sciatic nerve passes through piriformis and may be

compressed.

Intragluteal Injections:

Gluteal region is a common site for intramuscular injections because the muscles are thick and large. The needlepierces skin, fascia, and the 3 gluteal muscles. Injected substances are absorbed into the intramuscular veins.

Injections into the buttock are safe only in the superolateral quadrant of the buttock well away from the sciatic

nerve. It can be given superior to a line extending from the PSIS to the superior border of the greater traochanter.

Everyone giving injections into this region must be aware of the danger of hitting the sciatic nerve.

With respect to sciatic nerve, the lateral side of the buttock is the side of safety and medial side is the side of

danger.

Sciatica: pain along the sciatic nerveis a relatively common form of low back pain and leg pain. This pain

along the sciatic nerve can be caused when a root of the sciatic nerve is pinched or irritated (referred asradiculopathy). Sciatica is usually caused by pressure on the sciatic nerve from a herniated disc (also referred to

as a ruptured disc, pinched nerve, slipped disk, etc.). For some people, the pain from sciatica can be severe and

debilitating.

Tibial component of Sciatic (or can also say the sciatic) supplies all the hamstring muscles, except the short

head of the biceps femoris which is the peronial


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MUSCLES OF THE POSTERIOR COMPARTMENT OF THE THIGH

Muscle Action Nerve

Supply

biceps femoris, long head flexes and laterally rotates leg when knee is flexed,extends thigh(when starting to walk)

tibial part of sciatic nerve

biceps femoris, short head Same as above common peroneal part of

sciatic nerve

semitendinosus flexes and medially rotates leg; extends thigh at the hip tibial part of sciatic nerve

semimembranosus flexes and medially rotates leg; extends thigh at the hip tibial part of sciatic

adductor magnus (hamstringpart)

extends thigh tibial part of sciatic N

The Sciatic NerveBranches: It does not supply any structure in the gluteal region.

The articular branches supply the hip-joint

The muscular branches From the tibial component: to the hamstring muscles-

1. Long head of Biceps femoris

2. Semitendinosus3. Semimembranosus

4. Adductor magnus (ischial part)

o From the common peroneal part: Short head of the biceps femoris

Sciatic Nerve Clinical correlation:

1. Sciatica: Pressure or irritation of the roots of the sciatic nerve causes shooting pain along the course of the

sciatic nerve on the back of the thigh. In sciatica, anaesthetic drug is injected into the nerve midway between

the greater trochanter and ischial tuberosity to relieve the pain.

3. The sciatic nerve may be injured in posterior dislocation of the hip joint.

If the injury is complete, all the hamstring muscles and the muscles below the knee joint are paralysed. It

results in Foot drop.

Further, all cutaneous sensations below the knee are lost except the medial side of the lower part of the

leg and medial border of the foot as far as the ball of the great toe (area supplied by the saphenous nerve).

POPLITEAL FOSSABoundaries Above and laterally: Biceps femoris

Above and medially: Semitendinous and SemimembranosusBelow and laterally: Lateral head of the Gastrocnemius and Plantaris

Below and medially: Medial head of the Gastrocnemius

Floor: Popliteal surface of the femur


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Oblique popliteal ligament of the knee-joint

Upper end of the tibia

Fascia covering the PopliteusPopliteus

Roof: Skin, superficial fascia, deep fascia (popliteal fascia)Contents A pad of fat

Popliteal lymph nodes (2-3)

Popliteal artery and its 5 genicular branchesPopliteal vein

Terminal part of the short saphenous vein

Tibial nerve

Common peroneal nerveLower part of the posterior cutaneous nerve of the thigh

Articular branch from the obturator nerve

The tibial nerve descends through the middle of the fossa, lying under the deep fascia and crossing thevessels posteriorly from the lateral to the medial side. (THIS IS THE MOST ANTERIOR STRUCTURE NVA)

The popliteal vein separates the popliteal artery from the tibial nerve through out its course in the

popliteal fossa.

Popliteal artery

It ends at the lower border of the Popliteus by dividing into anterior and posterior tibial arteries.

Common Peroneal NerveIt descends obliquely along the lateral side of the popliteal fossa to the head of the fibula, close to the medial

margin of the Biceps femoris muscle.It lies between the tendon of the Biceps femoris and lateral head of the Gastrocnemius muscle, winds around

the neck of the fibula, between the Peroneus longus and the bone,.

It ends by dividing under cover of the peroneus longus into the superficial and deep peroneal nerves.

HIP JOINT

Bones taking part:Cup like acetabulum of the hip bone and the round head of the femur

Within the acetabulum there is a horse-shoe shaped lunate surface covered with articular cartilage.Lower part o

the cup is non-articularand called acetabular fossa (filled with fat).

Iliofemoral ligament- It is the strongest ligament in the body. It lies on the anterior surface of the fibrous

capsule. It is inverted Y shaped.It is attached above to the anterior inferior iliac spine and below to the intertrochanteric line of femur.


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Pubofemoral ligament- It lies anteroinferior to the hip joint. It is attached above to the pubic crest and below

blends with the iliofemoral ligament.

Ischiofemoral ligament: It lies posteroinferior to the fibrous capsule. It is attached superiorly to the ischiumbehind the acetabulum and inferiorly it blends with the fibrous capsule.

Movements of the hip joint:The movements of the hip joint are:

Flexion, extension, abduction, adduction, lateral rotation, medial rotation, and circumduction

Note that when the foot is off the ground (eg. walking), the thigh is free to move on the trunk. When the foot is onthe ground (from sitting position to the standing position or bending forward to pick up an object) the trunk can b

made to move on a fixed thigh.

Flexion- Iliopsoas, sartorius, tensor fascia lata, rectus femoris, pectineus

Extension- chiefly by the gluteus maximus muscle with help by the hamstringsAbduction- Gluteus medius, gluteus minimus, tensor fascia lata

Adduction- by the adductors longus, brevis, magnus and the gracilis, pectineus, obturator externus

Medial rotation- by anterior part of the gluteus minimus and medius and tensor fascia lata muscles

Lateral rotation- by gluteus maximus, quadratus femoris, piriformis, obturator internus and externus, superior andinferior gemelli.

KNOW ABOUT POST. DISLOCATION OF THE HIP JOINT!

KNEE JOINT

Ligaments of the knee joint:

1. Fibrous capsule

2. Ligamentum patellae

3. Tibial collateral ligament (Medial collateral ligament)4. Fibular collateral ligament (Lateral collateral ligament)5. Oblique popliteal ligament

6. Anterior cruciate ligament

7. Posterior cruciate ligament8. Medial meniscus (medial semilunar cartilage)

9. Lateral meniscus (lateral semilunar cartilage)

Ligamentum patellae: It is the anterior ligament of the knee joint. It is the distal part of the tendon of the

quadriceps femoris muscle. It extends from the apex of the patella to the upper half of the tuberosity of tibia.

Medial and lateral patellar retinacula are expansions from the vastus medialis and lateralis on either side of the

ligamentum patellae.

Cruciate ligaments join the femur and tibia in the center of the knee joint. They are called cruciate because they

cross each other like letter X. They are named anterior and posterior by their attachments to the tibia . They are

intracapsular (situated within the capsule), but extrasynovial. (like the popliteal tendon). They provide

stability to the knee joint.

Anterior cruciate ligament (I.D. - Picture): It is attached below to the anterior part of the intercondylar area


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between the attachments of the anterior horns of the medial and lateral menisci. It passes superiorly, posteriorly

and laterally to be attached to the medial surface of the lateral condyle of the femur.

It becomes taut when the knee is fully extended. It prevents posterior displacement of the femur on the tibia.

Posterior cruciate ligament (I.D. - Picture): It is the stronger of the two. It is attached to the posterior

intercondylar area of the tibia behind the attachments of the lateral and medial menisci. It passes upwards andforwards medial to the anterior cruciate ligament and is attached to the lateral surface of the medial condyle of the

femur.It becomes taut during flexion of the knee joint.It prevents anterior displacement of the femur on thetibia. It is the main stabilizing factor for the femur when walking downhill.

Medial meniscus (medial semilunar cartilage): is C shaped. Its outer border is thick, convex and attached to the

fibrous capsule. Its inner border is thin, concave and free. Its anterior horn (end) is attached to the anterior

intercondylar area of the tibia, anterior to the attachment of the ACL. Its posterior horn (end) is attached to theposterior intercondylar area, anterior to the attachment of the PCL. Its outer margin is firmly attached to thetibial collateral ligament.

Lateral meniscus (lateral semilunar cartilage): It is nearly circular, smaller and more freely movable than themedial meniscus. Its anterior horn is attached to the anterior intercondylar area, behind the attachment of the ACL

The posterior horn is attached to the intercondylar area behind the intercondylar tubercle, in front of the posteriorhorn of the medial meniscus.

The convex outer border of the lateral meniscus is not attached to the fibular collateral ligament.

The tendon of the popliteus muscle separates the lateral meniscus from the fibular collateral ligament. Few

fibers of the popliteus muscle take origin from the lateral meniscus. The popliteus muscle pulls the lateral

meniscus posteriorly during flexion and hence, prevents it from being crushed.

UNHAPPY TRIAD 3 structures that are commonly injured in the knee joint1) medial collateral ligament

2) medial meniscus

3) ant. Cruciate ligament (ie. Torn ACL)

Bursae around the knee: (Clinical Question)

There are as many as 12-15 bursae around the knee. Some of them communicate with the joint cavity. Can beindependent or an extension of the synovial cavity of the joint.

1. Suprapatellar bursa- deep to the quadriceps tendon- Communicates with the joint cavity. Articularis genu get

attached to this bursa. EXAM QUESTION if get stabbed in lower ant leg, what bursa is likely to get inflamed

musct know position of bursa to dtermine this

2. Prepatellar bursa- between patella and skin normally inflamed in maids due to kneeling and moping the

floor (Called HOUSMAIDS KNEE/BURSITIS)

3. Subcutaneous (or superficial) infrapatellar bursa- between the skin and tuberosity of tibia (When inflamedcalled CLERGYMANS KNEE)

4. Deep infrapatellar bursa- between ligamentum patellae and tibia, can communicate with capsul of knee joint

***LOCKING OF THE KNEE OR SCREW HOME MOVEMENT

In the last stage of extension of the knee, the thigh (femur) is rotated medially or the leg (tibia) is rotated

laterally and the joint is said to be screwed into home and locked.


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With the foot on the ground, it is the femur that moves on the stationary tibia. The medial rotation of femur which

occurs as part of the final stage of extension of the knee is called Locking.With the foot off the ground, extension is associated with lateral rotation of tibia on stationary femur.

***UNLOCKING OF THE KNEEFlexion of the knee from the fully extended position: This movement is the reverse of the locking movement.

While flexing the knee (from the fully extended position), the joint has to be unlocked by a reverse rotation and

this is done by the popliteus muscle. Hence, Popliteus is called unlocking muscle (know this !!!!!).When the foot is on the ground, femur is made to rotate laterally by the popliteus.

ANKLE JOINT

Talocrural joint

Bones:

Proximally1. Distal articular surface of the tibia and its medial malleolus

2. Lateral malleolus of the fibula3. Inferior transverse tibiofibular ligament

Distally- Trochlea of the talus

2. Medial ligament: (deltoid ligament) Is strong. It is triangular in shape. Its apex is attached to the medial

malleolus. It fans out distally and gets attached to the 1) talus, 2) calcaneus and 3) navicular bones.

The deltoid ligament stabilizes the ankle joint during eversion and prevents subluxation (partial dislocation)

of the joint.

3. Lateral ligament: It is weaker than the medial ligament. It is composed of 3 parts- anterior talofibular

ligament, posterior talofibular ligament and the calcaneofibular ligament.

Lateral and medial ligament strengthens the sides of the joint

Movements:Dorsiflexion and plantar flexion.

Dorsiflexion- by the muscles in the anterior compartment of the leg (Tibialis anterior, Extensor hallucis longus,

Extensor digitorum longus, Peroneus tertius)

Plantarflexion- by the muscles in the posterior compartment of the leg (soleus, gastrocnemius, tibialis posterior,flexor hallucis longus, flexor digitorum longus)

PLANTAR APONEUROSIS

It is the thickened central part of the deep fascia of the sole of the foot. It is triangular in shape. Its functionsare-

1. holds the parts of the foot together

2. protects the plantar surface from injury3. supports the longitudinal arch of the foot


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Posterior end (apex) is attached to the medial tubercle of the calcaneum.

Base (anterior end) is divided into 5 slips- one to each toe that split to enclose the digital tendons.From the sides of the plantar aponeurosis, vertical septa extend deeply to form 3 compartments of the sole of the

foot- medial, central and lateral compartment.

Deep to the plantar aponeurosis are the muscles (arranged in 4 layers), blood vessels and nerves of the sole of thefoot.

Clinical correlation:

Plantar fasciitis - Straining and inflammation of the plantar aponeurosis causing severe pain and tenderness o

the sole of the foot. Can occur in runners with inappropriate shoes.

Calcaneal spur Repeated attacks of plantar fasciitis produce ossification in the posterior attachment of theplantar aponeurosis. This is called calcaneal spur. The condition is heel spur syndrome.

MUSCLES OF THE SOLE OF THE FOOT

First Layer

abductor hallucis

Flexes, abducts big

toe (hallux).Supports medial

longitudinal arch

medial plantarN

flexor digitorum

brevis (I.D.)

Flexes lateral four

toes. Supportsmedial and lateral

longitudinal arches

medial plantar

N

abductor digiti

minimi

Flexes, abducts 5th

toe. Supports laterallongitudinal arch

lateral plantar N

Second Layer tendons from flexor digitorum longus and flexor hallicus longus are found in this layer

Between first and second layer you see the passage of the neuromuscular bundle consisting of the medialand lateral plantar artery and nerves

flexor digitorum

accessorius

(quadratusplantae) ON

EXAM

Lateral

margin of

the tendonof flexor

digitorum

longus

aids flexor digitorum longus

tendon to flex lateral fourtoes (helps to straighten the

direction of the pull)

lateral plantarnerve

Lumbricals (4 innumber)

Tendons of flexordigitorum longus (1st-

single head

(unipennate), from

dorsaldigital

expansion

(extensor

extends toes at interphalangealjoints; flex metatarso

phalangeal joints (prevents

buckling of the toes in walking

1st lumbrical-medial plantar N;

2nd, 3rd, & 4th-


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medial side of the

tendon of Fl.Dig.L.

going to the 2nd toe. Restof the lumbricals arise

each by two heads

(bipennate) fromadjacent sides of the

tendons going to the 2nd,

3rd, 4th, and 5th toes

expansion)

of lateral

four toes(middle

and

terminalphalanx)

and running) deep branch of

the lateral

plantar N

Medial plantar artery

It is the smaller of the 2 terminal branches of theposterior tibial artery.It begins under cover of the flexor retinaculum. It passes forward along the medial side of the foot.

It runs between the 1st and 2nd layers of the sole of the foot.

It lies medial to the medial plantar nerve. At the base of the first metatarsal bone, it passes along the medialborder of the first toe, anastomosing with the first dorsal metatarsal artery.

Lateral plantar artery

It is the larger of the 2 terminal branches of the posterior tibial artery. It begins deep to the flexor retinaculum. It

passes obliquely laterally between the 1st and 2nd layers of the sole of the foot, to the base of the fifth metatarsalbone. It then turns medially to the interval between the bases of the first and second metatarsal bones between the

3rd and the 4th layers, where it unites with the deep plantar branch of the dorsalis pedis artery, thus completingthe plantar arch.

Medial plantar nerve

It is the larger of the two terminal divisions of the posterior tibial nerveBRANCHES (1) Muscular - Abductor hallucis

Flexor digitorum brevisFlexor hallucis brevis (by a branch from proper digital to the great toe)

1st Lumbrical (by the 1st common digital nerve)

(2) Cutaneous - to the skin on the medial half of the sole of the foot.(3) Articular to the tarsal and metatarsal joints

(4) Proper digital nerve to the medial side of the great toe called proper cuz it supplies on 1 toe(the big or great toe that is)

(5) Three common digital nerves. called common because they supply two toes each

Each common digital nerve splits into two proper digital nerves which supply the skin of the

medial 3 toes. The distribution of these digital nerves is similar to those of the median nerve in the hand.Thefirst common digital nerve supplies the 1st Lumbrical.


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Lateral Plantar Nerve

Superficial branch-

Muscular-

Flexor digiti minimi brevis 3rd plantar interosseous

4th dorsal interosseousCutaneous- Skin of the lateral 1 toes.

Deep branch supplies:

Lateral 3 lumbricals

First 2 plantar interossei

First 3 dorsal interossei

Adductor hallucis

Medial longitudinal arch: It is formed by calcaneus, the talus, the navicular, the three cuneiforms, and the 1st

, 2n

& 3rd metatarsals. The head of the talus is the key stone of the medial longitudinal arch.

Tibialis anterior and peroneus longus help to maintain this arch. It is strengthened by the tibialis posterior

and plantar aponeurosis

Lateral longitudinal arch: It is formed by calcaneus, the cuboid, and the 4 th and 5th metatarsals. It is much flatter

Lower Limb Review

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