The lower limb

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The lower limb(1)

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• ???

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Muscles of lower limb

• The muscles of lower limb are divided into the
  muscles of hip, thigh, leg and foot.
• Muscles of hip
• anterior group
• Iliopsoas ???
• iliacus ??
• psoas major ???
• Psoas minor ???
• Tensor fasciae latae ?????

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• Posterior group
• Gluteus maximus ???
• Gluteus medius ???
• Gluteus minimus ???
• Piriformis ???
• Obturator internus ????
• Quadratus femoris ???
• Obturator externus ????

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Muscles of thigh

• Anterior group
• Sartorius ???
• Quadricep ????
• Rectus femoris ???
• Vastus medialis ????
• Vastus lateralis ????
• Vastus intermedius????

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• Medial group
• Pectineus ???
• Adductor longus ???
• Adductor brevis ???
• Adductor magnus???
• Gracilis ???
• adduct thigh at hip joint

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• Posterior group
• Biceps femoris ????
• Semitendinosus ???
• Semimembranosus ???
• flex the leg at knee joint extend the thigh
  at hip joint

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Muscles of leg

• Anterior group
• Tibialis anterior ????
• Extensor hallucis longus ????
• Extensor digitorum longus ????
• Peroneus tertius
• ?????

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• Lateral group
• Peroneus longus ????
• Peroneus brevis ????
• plantarflex and evert the foot

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• Posterior group
• Superficial lager triceps surae?????
• Gastrocnemius ???
• Soleus ????
• Deep layer
• Popliteus ??
• Flexor digitorum longus????
• Flexor hallucis longus????
• Tibialis posterior ????

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• Muscles of foot
• Muscles on dorsum extensor digitorum brevis
• Muscles in sole medial, lateral and intermediate
  groups

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Major muscles of lower limb

• Iliopsoas
• Origin
• Psoas major transverse processes and lateral
  surface of bodies of lumbar vertebrae
• Iliacus iliac fossa
• Insertion lesser trochanter of femur
• Action flexes thigh on trunk
• Nerve supply lumbar plexus

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• Gluteus maximus
• Origin gluteal surface of ilium and dorsal
  aspect of sacrum
• Insertion gluteal tuberosity of femur and
  iliotibial tract
• Action extends and laterally rotates thigh at
  hip joint raises trunk when the lower limb is
  fixed
• Nerve supply inferior gluteal n.

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• Piriformis
• Origin anterior surface of sacrum
• Insertion greater trochanter of femur
• Divided the greater sciatic foramen into
  suprapiriform foramen ????? and infrapiriform
  foramen ?????
• Action rotates thigh laterally at hip joint
• Nerve supply sacral plexus

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• Sartorius
• Origin anterior superior iliac spine
• Insertion upper medial surface of tibia
• Action flexes hip and knee joints rotates
  flexed knee medially
• Nerve supply femoral n.

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• Quadriceps femoris
• Origin
• Rectus femoris anterior inferior iliac spine
• Vastus medialis medial lip of linea aspera
• Vastus lateralis lateral lip of linea aspera
• Vastus intermedius anterior surface of femur
• Insertion tibial tuberosity via patellar
  ligament
• Action extends leg at knee joint rectus femoris
  also flexes thigh at hip joint
• Nerve supply femoral n.

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• Tibialis anterior
• Origin lateral surface of tibia
• Insertion medial cuneiform and base of 1st
  metatarsal
• Action dorsiflexes and inverts foot
• Nerve supply deep peroneal n.

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• Triceps surae
• Origin
• Gastrocnemius medial and lateral condyles of
  femur
• Soleus soleal line of tibia and upper third of
  fibula
• Insertion calcaneum via tendo calcaneus
• Action flexes knee joint and plantarflexes foot
  at ankle joint steadies leg on foot during
  standing
• Nerve supply tibial n.

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• Tibialis posterior
• Origin posterior surface of tibia and ffibula
  and interosseous membrane
• Insertion tuberosity of navicular, all cuniforms
• Action plantarflexes and inverts foot
• Nerve supply tibial n.

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Arteries of lower limb

• Femoral a.
• Continuation of the external iliac a.
• Begins midpoint of inguinal ligament
• Principal branch deep
  femeral a.???? arises from the posterolateral
  surface of the femoral artery about 5 cm below
  the inguinal ligament.
• Distributed to all three muscle compartments by
  medial and lateral femoral circumflex???????? and
  four perforating arteries ???of deep femoral a.

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• Popliteal a.
• Continuation of femoral a. at adductor hiatus
• Divided into anterior and posterior tibial
  arteries at lower border of poplitus
• Posterior tibial a.
• Passes downwars deep to gastrocnemius and soleus
• Passes behind medial mallealus by dividing into
  medial and lateral plantar arteries
• Branches peroneal a., medial and lateral plantar
  a,

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• Anterior tibial a.
• Descends on anterior surface of interosseous
  membrane
• In front of ankle joint becomes dorsal a. of foot
• Dorsal a. of foot
• Passes forward between tendons of extensor longus
  and extensor digitorum longus to the proximal
• End of first intermetatarsal space

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• Obturator a.
• Branch of internal iliac a.
• Passes through the obturator foramen and enters
  medial compartment of thigh
• supplies obturator externus, pectineus, adductors
  of thigh, and gracilis

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Veins of lower limb

• Deep veins anterior and posterior tibial v. ?
  popliteal v.? femoral v. ? external iliac v.
• Great saphenous v. ????
• Begins the medial end of dorsal venous arch of
  food
• Passes anterior to the medial malleolus and
  ascends on the medial side of the leg, then
  passes behind the knee and curves forward around
  the medial side of the thigh
• Inclines anteriorly through the thigh to enter
  the femoral vein through the saphenous opening
  which lies about 34 cm below and lateral to the
  pubic tubercle
• Tributaries
• Superficial medial femoral v.
• Superficial lateral femoral v.
• External pudendal v.
• Superficial epigastric v.
• Superficial iliac circumflex v.

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• Small saphenous v.
• Arises from the lateral part of the dorsal venous
  arch of foot
• Ascends behind lateral malleolus and then passes
  upward to the midline of the clft
• Pierces the deep fascia and enters the popliteal
  v.
• It drains the lateral side of the foot and ankle
  and the back of the leg.

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Lymph nodes and vessels of lower limb

• Popliteal ln.
• Embedded in the fatty connective tissue of
  popliteal fossa
• Receive superficial lymphatic vessels from
  posterolateral part of calf, and from deep
  lymphatic vessels accompanying anterior and
  posterior tibial a.
• Efferents pass to the deep inguinal ln.

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• Superficial inguinal lymph nodes
• Superior group
• Lies just distal to the inguinal ligament
• Receive lymph from anterior abdominal wall below
  umbilicus, gluteal region, perineal region,
  external genital organs
• Inferior group
• Lies vertical along the terminal great saphenous
  v.
• Receives all superficial lymphatics of lower
  limb, except for those from the posterolateral
  part of calf
• Efferent vessels drain into the deep inguinal ln.
  or external iliac ln.

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• Deep inguinal lymph nodes
• Lie medial to the femoral v.
• Receive deep lymphatics of lower limb, perineal
  region, and efferent lymphatics from the
  superficial inguinal ln.
• Drain into the external iliac ln.

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Nerves of lower limb

• Femoral n. supplies anterior thigh muscles
  (quadriceps, sartorius and pectineus), hip and
  knee joint, and skin on anteromedial side of
  thigh, saphenous nerve is distributed to skin of
  medial side of leg and foot
• Obturator n. enters thigh through obturator
  foramen supplies medial group of muscles of
  thigh, obturator externus, and skin of medial
  side of thigh

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Branches of sacral plexus

• Superior gluteal n.
• leaves pelvis through suprapiriform foramen
  and passes between gluteus medius and minimus to
  supplies these muscles and tensor fasciae latae
• Inferior gluteal n.
• leaves pelvis through infrapiriform
  foramen,and supplies gluteus maximus
• Posterior femoral cutaneous leaves pelvis
  through infrapiniform foramen,runs deep to
  gluteus maximus, and emerges from ite inferior
  border to supply skin of buttock and then surface
  skin over posterior of thigh and calf

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• Sciatic n. ????
• Leaves pelvis through infrapiriform foramen to
  enter gluteal region, runs inferiorly laterally
  deep to gluteus maximus, passing midway between
  the greater trochanter of femur and ischial
  tuberosity to back of thigh, lying deep to long
  head of biceps femoris, normally divided into
  tibial and common peroneal nerves just above
  popliteal fossa
• Innervates semitendinosus, semimembranosus and
  biceps femoris and has articular branches to hip
  and knee joints

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• Common peroneal n. ???? passes over posterior
  aspect of head of fibula and then winds around
  neck of fibula, deep to peroneus longus, where it
  divides into deep and superficial peroneal nerves
• Deep peroneal n. ???? descends on interosseous
  membrane and enters dorsum of foot supplies
  anterior muscles of leg, and skin of first
  interdigital cleft
• Superficial peroneal n. ???? supplies peroneus
  longus and brevis and skin on anterior surface of
  leg and dorsum of foot

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• Tibial n. ???
• Runs inferiorly with posterior tibial vessels and
  terminates beneath flexor retinaculum by dividing
  into medial and lateral plantar nerves
• Supplies posterior muscles of leg and knee joint

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Regional anatomy of the lower limb

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Parts and regions of the lower limb

• Gluteal region-between iliac crest superiorly and
  gluteal fold inferiorly
• Thigh-between hip and knee
• knee-joint between leg and thigh
• Leg-between knee and foot
• Ankle
• Foot

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Surface anatomy

• Gluteal region and thigh-anterior superior and
  inferior iliac spines,tubercle of iliac
  crest,ischial tuberosity,greater trochanter,
  pubic tubercle, pubic crest, superior border of
  pubic symphysis
• Knee-patella ligament, tuberosity of tibia,
  medial and lateral condyles and epicondyles,
  tendon of biceps femoris, tendons of
  semitendinosus and semimembranosus, head of
  fibula
• Leg-anterior border of tibia, neck of fibula
• Ankle and foot-medial and lateral malleolus,
  calcaneal tuberosity, tuberosity of navicular
  bone, and tuberosity of fifth metatarsal bone

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Anterior and Medial Region of Thigh

• Superficial structures-superficial fascia
• Superficial arteries
• superficial epigastric a.
• superficial iliac circumflex a.
• external pudendal a.
• Superficial veins-great saphenous v.,
• superficial epigastric v.
• superficial iliac circumflex v.
• external pudendal v.
• superficial medial femoral v.
• superficial lateral femoral v.
• Superficial inguinal lymph nodes
• superior group
• inferior group
• Cutaneous nerves
• lateral femoral cutaneous n.
• anterior and medial cutaneous branches of femoral
  n.

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• Deep fascia fascia lata ???
• Iliotibial tract ???
• Saphenous hiatus ?????
• falciform margin ???
• cribriform fascia ???

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• Lacuna musculorum ???
• Bounded by lateral portion of inguinal ligament
  anteriorly, ilium posterolaterally, iliopectinal
  arch medially
• Contents iliopsoas, femoral n. and lateral
  femoral cutaneous n.

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Lacuna vasorum ????

• Bounded by medial portion of inguinal ligament
  anteriorly, pectineal ligament posteromedially,
  lacunar ligament medially, and iliopectinal arch
  posterolaterally
• Contents
• femoral sheath, femoral a. and v., genital branch
  of genitofemoral n. and lymphatic vessels,
  femoral ring

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Femoral triangle

• This triangle is bounded by the inguinal
  ligament (base) superiorly the medial border of
  sartorius laterally the medial border of
  adductor longus medially. Inferiorly, the apex of
  the triangle is continuous with adductor canal.
• The anterior wall is fascia lata
• The posterior wall consists of adductor longus,
  pectineus and iliopsoas , from medial to lateral
  side.

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Contents of the femoral triangle

• 1. The femoral artery and its branches-the
  profunda femoris artery,The lateral and medial
  circumflex arteries,The deep external pudendal.
• 2. The femoral vein and its tributaries.
• 3. Three or four deep inguinal lymph nodes lie
  along the medial side of the femoral vein.
• 4. The femoral nerve.
• 5. The femoral canal.

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Femoral sheath

• The femoral sheath is a a funnel- shaped sheath ,
  derived from transversalis fascia anteriorly and
  iliac fascia posteriorly. It surroumds the
  femoral vessels and lymphatic about 2.5cm belower
  the inguinal ligamemt. Its lower end disappears
  at the lower margin of the saphenous opening
  where the sheath fuses with the adventitia of the
  vessels.

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• The femoral sheath is divided into three
  compartments by two fibrous septa. The femoral
  artery occupies the lateral compartment of the
  sheath. The femoral vein lies the middle
  compartment. The medial compartment is small,
  called the femoral canal.

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The femoral canal

• It is about 1.3cm long , and its upper opening is
  called the femoral ring .
• The boundaries of the femoral ring are the
  inguinal ligament, anteriorly the lacunar
  ligament???? medially the pecten of pubis,
  posteriorly the femoral vein, laterally. covered
  by femoral septum??? superiorly.
• The canal contains a little loose fatty tissue, a
  small lymph node, and some lymph vessels.

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Femoral hernia

• A femoral hernia is common in women than in
  men (possibly due to a wider pelvis and femoral
  canal ). If a loop of intestine is forced into
  the femoral ring, it expands to form a swelling
  in the upper part of the thigh.

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Femoral nerve

• It arises from the lumbar plexus in the abdomen,
  and enters the thigh posterior to the inguinal
  ligament and lateral to the femoral artery. It
  ends by dividing into a number of branches 2 cm
  below the inguinal ligament.
• Muscular branche to pectineus, sartorius,
  quadriceps femoris

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• Cutaneous branches
• (1) Anterior cutaneous nerves of the thigh
  (medial and lateral).
• (2) Saphenous nerve is the longest branch of the
  femoral nerve. It accompanies the femoral vessels
  in the adductor canal, then accompanies the great
  saphenous vein to the medial side of the leg and
  food.

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Femoral artery

• This is the main artery of the lower limb and is
  directly continuous with the external iliac
  artery of the abdomen behind the inguinal
  ligament at the mid- inguinal point. It becomes
  the popliteal artery by passing through the
  adductor tendinous opening.

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• Profunda femoris
• which arises from the posterolateral surface
  of the femoral artery about 5 cm below the
  inguinal ligament.
• Lateral circumflex artery
• It arises from the profunda near its origin
  and runs laterally among the branches of the
  femoral nerve and then deep to rectus femoris.
  Here it divides into ascending, transverse, and
  descending branches.
• Medial circumflex artery
• arises either from the profunda near its
  origin or occasionally direct from the femoral
  artery.

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Femoral vein

• This is the direct continuation of the popliteal
  vein. It begins at the adductor tendinous opening
  and accompanies the femoral artery to the
  inguinal ligament behind which it becomes the
  external iliac vein.
• The femoral vein contains several valves.

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The deep inguinal lymph nodes

• Three or four deep inguinal lymph nodes lie along
  the medial side of the femoral vein. Afferent
  lymph vessels reach them from the superficial
  inguinal and popliteal lymph nodes and from the
  deep structures of the limb. Efferent lymph
  vessels pass from the deep inguinal nodes along
  the femoral vessels to the external iliac nodes
  on the external iliac vessels in the abdomen.

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Adductor canal

• Extends from apex of femoral triangle to adductor
  hiatus
• Bounded by vastus medialis laterally, adductors
  longus and magmus posteriorly, and adductor
  lamina and sartorius anteriorly
• Contents saphenous nerve, femoral a., femoral
  v., lymphatic vessels, and loose connective tissue

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Blood vessels and nerve of medial side of thigh

• Obturator a.
• arises from internal iliac artery in the
  lesser pelvis, passes through the obturator canal
  where it divides into anterior and posterior
  branches.
• Obturator n.
• arises from the lumbar plexus in the
  abdomen. It enters the thigh through the
  obturator canal where it divides into anterior
  and posterior branches. The anterior branch
  descends anterior to the adductor brevis. The
  posterior branch descends between adductors
  brevis and magnus supplying both.

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Front of the leg and dorsum of the foot

• Superficial veins
• The dorsal venous arch lies on the distal parts
  of the bodies of the metatarsals. It drains the
  dorsum of the foot and toes.
• The small saphenous vein runs posteriorly,
  passing first inferior and then posterior to the
  lateral malleolus. It ascends to the popliteal
  fossa in the back of the leg.
• The great saphenous vein passes posterioriy on
  the medial side of the foot. It ascends anterior
  to the medial malleolus, then obliquely across
  the distal third of the medial surface of the
  tibia.

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• Cutaneous nerves
• The upper two-thirds of the front of the leg is
  supllied by the saphenous nerve (L3,4) medially,
  and the lateral cutaneous nerve of the calf
  laterally.
• The lower third is supplied by the superficial
  peroneal and saphenous nerves.
• The dorsum of the foot is mainly supplied by the
  medial and intermediate cutaneous branches of the
  superficial peroneal nerve. However, the lateral
  margin is supplied by the sural nerve and the
  medial margin by the saphenous nerve proximally
  and the superficial peroneal distally.
• The first interdigital cleft and the skin
  immediately proximal to it are supplied by the
  deep peroneal nerve.

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• Deep fascia
• The deep fascia of the leg is very strong.
• Superior extensor retinaculum??????
• Inferior extensor retinaculum??????

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• Deep peroneal nerve
• It arises from the common peroneal nerve between
  the neck of the fibula and the peroneus longus
  muscle
• It descends in the anterior compartment of the
  leg with the anterior tibial vessels.
• It supplies all the muscles of the anterior
  compartment of the leg and extensor digitorum
  brevis.
• If the nerve is destroyed, dorsiflexion of the
  ankle and extension of the metatarsophalangeal
  joints is lost, and inversion is weakened the
  condition known as drop foot.

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• Anterior tibial artery
• It from the popliteai artery at the lower border
  of popliteus. It passes forwards above the
  interosseous membrane, and turns downwards on the
  anterior surface of that membrane with the deep
  peroneal nerve.
• It becomes the dorsalis pedis artery, midway
  between the malleoli.
• The anterior tibial veins are closely applied to
  the artery.

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• Dorsalis pedis artery
• It begins on the anterior surface of the ankle
  joint and runs with the deep peroneal nerve
• it divides into the arcuate artery and the first
  dorsal metatarsal artery at the proximal end of
  the first intermetatarsal space.
• On the dorsum of the foot it lies on the tarsal
  bones and is readily palpated against them
  between the tendons of extensor hallucis longus
  and extensor digitorum longus.

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Dissetion
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Deep peroneal n.
Superficial peroneal n.
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The gluteal region and back of thigh and leg

• ??????? ?????
• ???

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Cutaneous nerves
Medial cluneal n.
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suprapiriform foramen

• infrapiriform foramen

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• Structures passing suprapiriform foramen
• Superior gluteal n., a., v. from lateral to
  medial side
• Structures passing infrapiriform foramen
• Sciatic n., posterior femoral cutaneous n.,
  inferior gluteal n., a.,v., internal pudendal
  v., a., and pudendal n. from lateral to
  medial side

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• Pudendal nerve, internal pudendal artery
• These structures enter the gluteal region through
  the infrapiriform foramen.
• They then curve forwards to enter the perineum
  through the lesser sciatic foramen.

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• ?Sciatic nerve
• Course It arises from the sacral plexus and
  passes through infrapiriform foramen into the
  gluteal region, deep to gluteus maximus, passing
  midway between the greater trochanter of femur
  and ischial tuberosity to back of thigh, the
  nerve lies deep to the long head of biceps on the
  posterior surface of adductor magnus. The sciatic
  nerve usually ends half-way down the back of the
  thigh by dividing into the common peroneal and
  tibial nerves.
• Distribution semitendinosus, semimembranosus and
  biceps femoris and has articular branches to hip
  and knee joints

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• Relationship of sciatic n. to the piriformis

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Boundaries of the popliteal fossa ??

• Diamond-shaped
• Upper lateral boundary Biceps femoris
• Upper medial boundary
• semimembranosus and semitendinosus
• Two lower boundaries are the heads of
  gastrocnemius
• Posterior wall deep fascia
• Anterior wall popliteal surface of the femur,
  the posterior capsule of the knee joint, and the
  fascia covering poplitells

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Contents of the popliteal fossa

• Tibial and common peroneal nerves and their
  branches
• Popliteal vein and its tributaries
• Popliteal artery and its branches
• Popliteal lympn nodes
• Fatty tissue

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Popliteal artery

• It begins at the adductor tendinous opening in.
  Here it is continuous with the femoral artery. It
  ends at the lower border of the popliteus muscle
  where it divides into anterior and posterior
  tibial arteries.
• Branches
• 1. Superior, inferior, and middle genicular
  arteries
• 2. Muscular branches

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• Popliteal vein
• This is formed by the junction of the anterior
  and posterior tibial veins near the lower border
  of the popliteus muscle.
• Popliteal lymph nodes
• There may be one or two nodes just under the deep
  fascia, close to the popliteal fossa vessels.
• They drain the deep tissues of the leg and foot
  and the knee joint. They also receive superficial
  lymph vessels from the lateral side of the foot,
  the heel, and the back of the calf. These drain
  along the line of the small saphenous vein.

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The back of the leg

• Find the small saphenous vein
• Find the Sural nerve and Peroneal communicating
  nerve

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• Find out
• Gastrocnemius
• Soleus
• Plantaris
• Tibial nerve
• Popliteal artery and branches (Peroneal artery )
• Popliteus
• Flexor hallucis longus
• Flexor digitorum longus
• Tibialis posterior

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• Malleolar canal
• Formed by midial surface of calcaneus, flexor
  retinaculum and medial malleolus
• Structures passing Malleolar canal
• Tibialis posterior
• Flexor digitirum longus
• Posterior tibial a. v. and n.
• Flexor hallucis longus

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