ANATOMY OF THE LOWER LIMB

ANATOMY OF THE LOWER LIMB
By DR. G. TOWO

The Lower Limb The lower limb extends from the gluteal region to the foot. It is specialized for weight-bearing and locomotion

Organization of the Lower Limb
Gluteal region- between iliac crest superiorly and gluteal fold inferiorly Thigh- Anteriorly between inguinal ligament and knee joint, Posteriorly between the gluteal fold and the knee. Knee- joint between the thigh and the leg Leg- between knee and foot Ankle- between the leg and the foot. Foot- Everything from the ankle joint distally

Surface Anatomy: Anterior Thigh + Leg
Palpate Patella Condyles of femur Femoral Triangle Sartorius (lateral) Adductor longus (medial) Inguinal ligament (superior) Contents: Femoral a + v, nerve and lymph nodes Floor: iliopsoas laterally and pectineus medially. Roof: fascia lata, cribriform fascia, subcutaneous tissue, and skin Clinically: femoral puncture

Surface Anatomy: Posterior Leg
Calcaneal (Achilles) tendon

Surface anantomy- posterior leg

Surface anatomy- posterior leg
Popliteal fossa -Diamond-shaped intramuscular space behind knee -Boundaries- Biceps femoris (sup-lat), Semitendinosus + semimembranosus (sup-med), Gastrocnemius heads (inf) -Contents- Popliteal a + v, termination of small saphenous vein, tibial and common peroneal nerves, popliteal lymph nodes and lymphatic vessels -Roof- Skin and popliteal fascia -Floor- Popliteal surface of femur, posterior capsule of knee joint, and popliteus fascia covering the popliteus muscle -Clinically- Injury to common peroneal nerve(common in fractures of upper part of fibula) causes foot drop

Popliteal fossa – foot drop
Foot drop is the inability to lift the foot and toes properly when walking. It is characterized by steppage gait (drop foot gait). Foot Drop Splint helps to support the foot when stepping/walking

Surface Anatomy Of Lower Limb
Achilles (Calcaneal) tendon Lateral malleolus of fibula Medial malleolus of tibia Dorsal venous arch Tendons of extensor digitorum longus muscle

Bones of the Lower Limb Pelvis Femur Tibia, fibula Patella Tarsals
Digits Metatarsals Phalanges

Bones of the Lower Limb

Bones of the Lower Limb- The Foot
Function: Support weight Act as lever when walking Tarsals Talus = ankle Between tibia + fibula Articulates w/both Calcaneus = heel Attachment for Calcaneal tendon Carries talus Metatarsals Homologous to metacarpals Phalanges Smaller, less nimble

Bones of the Lower Limb Function: Components: Locomotion
Carry weight of entire erect body Support Points for muscular attachments Components: Thigh Femur Knee Patella Leg Tibia (medial) Fibula (lateral) Foot Tarsals (7) Metatarsals (5) Phalanges (14)

Thigh Femur The femur is the longest and largest bone.
There are four eminences, or protuberances, in the femur: the head, the greater trochanter, the lesser trochanter, and the lower extremity. The shaft of femur is cylindrical with a rough line on its posterior surface (linea aspera).

Knee Patella Triangular sesamoid bone Protects knee joint
Improves leverage of thigh muscles acting across the knee Contained within patellar ligament

Leg Tibia Receives the weight of body from femur and transmits to foot Second to femur in size and weight Articulates with fibula proximally and distally Interosseous membrane Fibula Does NOT bear weight Muscle attachment Not part of knee joint Stabilize ankle joint

Foot Function: Supports the weight of the body
Act as a lever to propel the body forward Parts: Tarsals Talus = ankle Between tibia and fibula Articulates with both Calcaneus = heel Attachment for Calcaneal tendon Carries talus Navicular Cuboid Medial, lateral and intermediate cuneiforms Metatarsals Phalanges

Foot 3 arches Function Medial Lateral Transverse Recoil after stepping
Has tendons that run inferior to foot bones Help support arches of foot Function Recoil after stepping Longitudinal

Joints of Lower Limb Hip (femur + acetabulum) Knee (femur + patella)
Ball + socket Multiaxial Synovial Knee (femur + patella) Plane Gliding of patella Knee (femur + tibia) Hinge Biaxial

Joints of Lower Limb Proximal Tibia + Fibula Distal Tibia + Fibula
Plane Gliding Synovial Distal Tibia + Fibula Slight “give” Fibrous Ankle (Tibia/Fibula + Talus) Hinge Uniaxial

Hip Joint Articulation- between head of femur and acetabulum.
Type- Synovial ball and socket joint. Capsule- encloses the joint. Medially- attached to acetabular lubrum. Laterally- attached to intertrochanteric line of femur infront and half way along posterior aspect of neck behind.

Hip Joint Ligaments- -Iliofemoral lig. –Strong inverted Y-shaped It’s Base attached to anterior inferior iliac spine above. Two Limbs of Y- attached to upper and lower part of intertrochanteric line of femur below. -Pubofemoral lig.- Triangular I shape. The Base-attached to superior ramus of pubis. Apex-attached below to the lower part of intertrochanteric line. This lig. Limits extension and abduction. -Ischiofemoral lig. – Spiral shaped. Attached to body of ischium near acetabular margin. Fibers pass upwards and laterally and attached to greater trochanter. This lig. Limits extension.

Hip Joint Ligaments -Transverse acetabular lig.- Formed by the acetabular lubrum as it bridges the acetabular notch. This lig. Converts the notch into a tunnel through which blood vessela and nerves enter the joint. -Lig. Of head of femur- Flat and triangular. Attached by it’s apex to thepit on the head of femur(fovea capitis) and by it’s base to transverse lig. and margins of acetabular notch. Lies within the joint and ensheathed by synovial membrane.

Hip Joint Synovial membrane- Lines the capsule and is attached to margins of articular surfaces. Nerve supply- Femoral, obturator, and sciatic nerves and the nerve to the quadratus femoris supply the area. Movements -Flexion- iliopsoas, rectus femoris, and sartorius and also by adductor muscles

Hip Joint -Extension-gluteus maximus and hamstring muscles -Abduction- gluteus medius and minimus, assisted by sartorius,tensor fasciae latae and piriformis -Adduction- adductor longus and brevis and adductor fibers of adductor magnus, These muscles are assisted by pectineus and gracilis.

Hip Joint -Lateral rotation- piriformis, obturator internus and externus,superior and inferior gemelli, and quadratus femoris, assisted by gluteus maximus -Medial rotation- anterior fibers of gluteus medius and gluteus minimus and the tensor fasciae latae -Circumduction- a combination of the previous movements.

Hip Joint

Hip Joint Clinical points Arthritis of hip joint
-Osteoarthritis is the most common type of hip arthritis (also called wear-and-tear arthritis) -Osteoarthritis is characterized by: Pain with activities, limited range of motion and stiffness of the hip

Hip Joint- osteoarthritis

Hip Joint- Dislocation
Hip Dislocation Occurs when the head of femur slips out of acetabulum. 90% are posterior dislocations. Anterior dislocations are also possible. - A hip dislocation is very painful and patients are unable to move the leg. - Motor vehicle accidents are the most common cause of hip dislocations. (Wearing a seatbelt can greatly reduce your risk.) - Falls from a height (such as a fall from a ladder) or industrial accidents can also generate enough force to dislocate a hip.

Hip Joint - dislocation

Knee Joint Articulation- femoral condyles above, tibial condyles below, and in front is the articulation between lower end of femur and patella. Type- Joint between femur and tibia is synovial of hinge variety. The joint between patella and femur is synovial joint of plane gliding variety.

Knee Joint Capsule- Attached to the margin of the articular surfaces and surrounds the sides and posterior aspects of the joint. It is deficient anteriorly hence leaving a space for out pouching of synovial membrane beneath quadriceps tendons to form a suprapatellar bursa, strengthened medially and laterally by V.laterallis and mediallis tendon expansions. Posteriorly it is strengthened by expansion of semimembraneous muscle called oblique popliteal ligament.

Knee Joint

Knee Joint Ligaments Extracapsular ligaments- lie outside the capsule.
-Ligamentum patellae- Attached to the lower border of patella and tibia tuberosity( a continuation of common tendon of Q.femoris muscle. -Lateral collateral ligament- Cord like ,attached to the lateral condyle of femur above and to head of fibula below. Tendon of popliteus intervenes btn the ligament and the lat meniscus.

Knee Joint -Medial collateral ligament- Attached to the medial femoral condyle above and medial side of the shaft of tibia below. Is firmly attached to the edge of medial meniscus. -Oblique popliteal ligament- Tendinous expansion derived from semimembranosus muscle. It strengthens the posterior aspect of the capsule.

Knee Joint Intracapsular ligaments
-Cruciate ligaments; ant. and post. Cross each other in joints. Named according to their relative attachments to the tibia. -Anterior cruciate ligament- Attached to ant. intercondylar area passing upward, backward and laterally to be attached to the medial surface of the lateral femoral condyle. Prevents posterior displacement of femur on tibia whereas it prevents anterior displacement of tibia when the joint is flexed.

Knee Joint -Posterior cruciate ligament- Attached to posterior intercondylar area of tibia and passes upward ,forward to the lateral surface of medial femoral condyle. Prevents anterior displacement of the femur on tibia. With knee flexed ,it prevents the posterior displacement of the tibia. Menisci- C-shaped fibro cartilage whose peripheral border being thicker and attached to the capsule. The inner border is thin and concave and form a free edge.

Knee Joint

Knee Joint -Functions of minisci 1.Deepens tibial articular surface to accommodate convex femoral condyles. 2. Cushioning btn 2 bones . -medial meniscus is attached to the medial collateral ligament hence less mobile.

Knee Joint Synovial membrane- Lines the capsule and attached to margins of articular surfaces. -On the front and above,the joint forms a pouch beneath quadriceps femoris forming suprapatella bursa. At the back the membrane is prolonged downwards on the deep surface of popliteus tendon-popliteal bursa. -The membrane is reflected forward from the post part of the capsule around the front of the cruciate ligament . In this way, cruciate ligament lie behind the synovial cavity and are not bathed in synovial fluid. -In the ant part of the joint, the synovial membrane is reflected backward from the post surface of the ligament on the patella to form the infrapatella fold. -The free borders of the fold are called alar folds.

Knee Joint Blood supply
-Genicular anastomoses- Middle genicular artery ,branch of the popliteal artery penetrate the fibrous capsule supplying the cruciate ligaments,synovial capsule & peripheral margins of the menisci. Nerve supply- The femoral, obturator, common peroneal and tibial nerves

Knee Joint

Knee Joint Movements -Flexion-harmstring, b/femoris, semitendinosus
and semimembranosus muscles assisted by gracilis, sartorius and popleteus muscles -Extension- quadriceps femoris -Medial rotation-sartorius, gracilis and semitendinosus. -Lateral rotation- biceps femoris

Knee Joint Stability of a knee joint
-Depends on the tone (most important) of the strong muscles acting on the joint and the strength of the ligaments. -Most important is quadriceps femoris muscle particularly inferior fibers of vastus medialis and lateralis muscles.

Knee Joint Clinical Points Common Knee Injuries
-Injuries to knee ligaments are common. Of the four major ligaments found in the knee, the anterior cruciate ligament (ACL) and the medial collateral ligament (MCL) are often injured in sports. The posterior cruciate ligament (PCL) may also be injured. -ACL injury Changing direction rapidly, slowing down when running, and landing from a jump may cause tears in the ACL. -MCL injury Is usually caused by a direct blow to the outside of the knee. This type of injury often occurs in contact sports, such as football. -PCL injury The PCL is often injured when a person receives a blow to the front of the knee or makes a simple misstep on the playing field. -Torn cartilage Torn knee cartilage usually referrs to a torn meniscus. The mensicus is a tough, rubbery cartilage that is attached to the knee's ligaments. The meniscus acts like a shock absorber. In sports, tears in the meniscus can occur when twisting, cutting, pivoting, decelerating, or being tackled. Direct contact is often involved.

Knee Joint

Knee Joint Arthritis of the Knee Joint
-Osteoarthritis (OA)- is the most common form of knee arthritis in which the joint cartilage gradually wears away. It most often affects middle-aged and older people. -Pain, swelling and joint stiffness are associated with this condition making it difficult to bend or straighten the knee

Knee Joint Osteoarthritis of knee joint

Proximal Tibiofibular Joint
Articulation- btn lateral condyle of tibia and head of fibula. Articular surfaces are flattened and covered by hyaline cartilage. Type- Synovial, plane, gliding joint. Capsule- Surrounds the joint and is attached to the margins of articular surfaces. Ligaments Anterior and Posterior ligaments strengthen the capsule. Interosseous membrane connects the shafts of tibia and fibula together and therefore greatly strengthens the joint

Proximal Tibiofibular Joint
Synovial membrane- lines the capsule is attached to the margins of articular surfaces. Nerve supply- common peroneal nerve. Movements- small amount of gliding movement takes place during movements at the ankle joint.

Distal Tibiofibular Joint
Articulation- fibular notch on lower end of tibia and lower end of fibular. Type- fibrous joint. Capsule- no capsule. Ligaments Interosseous lig.- strong, thick band of fibrous tissue that binds the two bones together. Interosseous membrane connects the shafts of the tibia and fibula together and greatly strengthens the joint.

- Anterior and Posterior Tibiofibular lig.- Connect the two bones together in front and behind the interosseous ligament - Inferior Transverse lig- runs from medial surface of upper part of lateral malleolus to the posterior border of the lower end of tibia Nerve supply- Deep peroneal and tibial nerves Movements- A small amount of movement takes place during movements at the ankle joint.

Ankle Joint Articulation- btn the lower end of tibia, the two malleoli, and the body of talus. Type- Synovial hinge joint. Capsule- encloses the joint and is attached to the bones near their articular margins. Synovial membrane- lines the capsule. Nerve supply- Deep peroneal and tibial nerves. Blood supply- malleolar branches of anterior tibial and peroneal arteries.

Ankle Joint Ligaments Medial/Deltoid lig.- Is strong and stabilizes the ankle joint during eversion of the foot and prevents subluxation (partial dislocation) of the ankle joint. -It’s apex attaches proximally to tip of medial malleolus and fans out from it to attach distally to talus, calcaneus, and navicular via four adjacent and continuous parts: -tibionavicular part, -tibiocalcaneal part, -ant. and post. tibiotalar parts.

Ankle Joint - Lateral lig.-Is weaker than the medial lig. and consists of three bands: -Ant. Talofibular lig.-runs from lateral malleolus to lateral surface of talus -Post. Talofibular lig.- runs from lateral malleolar fossa to posterior tubercle of talus -Calcaneofibular lig.-runs from the tip of lateral malleolus downward and backward to lateral surface of calcaneum

Ankle Joint

Ankle Joint Movements -Dorsiflexion of the foot- muscles of anterior compartment of the leg-tibialis anterior, extensor digitorum longus, extensor hallucis longus, fibularis or peroneus tertius -Plantar flexion- muscles of posterior compartment of the leg- gastrocnemius, soleus, plantaris, flexor hallucis longus, flexor digitorum longus, and tibialis posterior.

Ankle Joint Important relations
-Anteriorly- tibialis anterior, extensor hallucis longus, anterior tibial vessels, deep peroneal nerve, extensor digitorum longus, and peroneus tertius. -Posteriorly- tendo calcaneus and plantaris -Posterolaterally(behind lat. malleolus)- peroneus longus and brevis. -Posteromedially(behind med. malleolus)- tibialis posterior, flexor digitorum longus, posterior tibial vessels, tibial nerve, flexor hallucis longus.

Ankle Joint

Ankle Joint Ankle Injuries
Clinical Points Ankle Injuries -Sprains: Single most common injury in athletics caused by sudden inversion or eversion moments -Inversion Sprains: Most common and result in injury to the lateral ligaments Anterior talofibular ligament is injured with inversion, plantar flexion and internal rotation Occasionally the force is great enough for an avulsion fracture to occur at the lateral malleolus

Ankle Joint - Injuries With inversion sprains the foot is forcefully inverted or occurs when the foot comes into contact with uneven surfaces

Ankle Arthroplasty A Growing alternative to ankle fusion for the treatment of ankle arthritis.

Tarsal Joints Subtalar joint Talocalcaneonavicular joint
Calcaneocuboid joint Cuneonavicular joint Cuboideonavicular joint Intercuneiform and Cuneocuboid joints Tarsometatarsal and Intermetatarsal joints Metatatarsophallangeal and Interphallangeal joints

Tarsal Joints

Tarsal Joints Subtalar Joint- provides shock absorption and the movements of inversion and eversion. Articulation- btn inferior surface of body of talus and facet on the middle of upper surface of calcaneum Type- synovial of the plane variety Capsule- encloses the joint and is attached to margins of the articular ares of the two bones Synovial membrane- lines the capsule

Tarsal Joints- Subtalar
Ligaments -Medial and Lateral(Talocalcaneal) ligaments- Strengthen the capsule -Interosseous(Talocalcaneal) ligament- strong, is the main bond of union between the two bones. Is attached above to the sulcus tali and below to the sulcus calcanei Movements- gliding and rotatory movements are possible

Blood Supply of Lower Limb

Arteries of the Lower Limb
Main arteries Common iliac External iliac Femoral (+ superficial/deep branches) Profunda femoris Anastomosis around knee (genicular arteries, branch of lat femoral circumflex) Popliteal Anterior/posterior tibial Peroneal Medial/lateral plantar Plantar arch Dorsalis pedis

Arteries of the Lower Limb

Veins of the Lower Limb

Veins of the Lower Limb Venous anatomy of the LL is divided into 3 groups: Superficial (dermis > Muscular Fascia) veins Deep (deep to muscular fascia) veins Perforating veins- are vessel that run btn the superficial and deep veins

Veins of the Lower Limb The deep veins
-In the lower limb the deep veins accompany all the major arteries and their branches. -They are contained within a vascular sheath with the arteries, whose pulsations also help compress and move blood in the veins. -The deep veins from the leg flow into the popliteal vein posterior to the knee, which becomes the femoral vein in the thigh. -The deep vein of the thigh joins the terminal portion of the femoral vein. -The femoral vein passes deep to the inguinal ligament to become the external iliac vein in the pelvis.

Veins of the Lower Limb Deep Veins of the Thigh Common femoral vein
Deep femoral vein Deep femoral communicating veins Medial circumflex femoral vein Lateral circumflex femoral vein

Veins of the Lower Limb Deep Veins of the Knee Popliteal vein
Genicular venous plexus Deep Veins of the Leg Posterior and Anterior tibial veins Peroneal Veins

Veins of the Lower Limb Superficial Veins The Great Saphenous Vein
-Two major superficial veins are: great and small saphenous veins The Great Saphenous Vein -Formed by the union of the dorsal digital vein of the great toe and the dorsal venous arch of the foot -Ascends anterior to the medial malleolus and passes posterior to the medial condyle of femur (about a hand's breath posterior to the medial border of the patella). -Anastomoses freely with the small saphenous vein and traverses the saphenous opening in the fascia lata. -Empties into the femoral vein at Sapheno-femoral Junction .

Veins of the Lower Limb The Small Saphenous Vein
-Arises from the union of the dorsal digital vein of the fifth digit with the dorsal venous arch. -Ascends posterior to the lateral malleolus as a continuation of the lateral marginal vein and passes along the lateral border of the calcaneal tendon. -Inclines to the midline of the fibula and penetrates the deep fascia. -Ascends between the two heads of gastrocnemius muscle. -Empties into the popliteal vein at the sapheno-popliteal junction in the popliteal fossa.

Veins of the Lower Limb Perforating veins
-They penetrate the deep fascia close to their origin from the superficial veins. -They contain valves that allow blood to flow only from the superficial veins to the deep veins. -The perforating veins pass through the deep fascia at an oblique angle so that when muscles contract and pressure increases inside the deep fascia, the perforating veins are compressed and therefore prevents blood from flowing from the deep to the superficial veins. (musculovenous pump).

Veins of the Lower Limb Superficial veins The Thigh
-Great (long) saphenous vein -Sapheno-femoral Junction Posterior lower leg -Small (short) saphenous vein -Sapheno-popliteal junction Lower Leg perforators

Veins of the Lower Limb Great (long) saphenous vein
Small (short) saphenous vein Sapheno-popliteal junction

Veins of the Lower Limb Clinical points
Deep Vein Thrombosis (DVT)- Inactivity and immobilization, as with orthopedics casts, sitting, travel, bed rest, and hospitalization leads to lack of muscular contractions causing stasis of blood and formation of thrombi in the deep veins of legs which cause pain, swelling, and warmth. Varicose veins- are veins that have become enlarged and tortuous, commonly refers to superficial veins of the legs, which are subject to high pressure when standing. -Besides being a cosmetic problem, varicose veins can be painful, especially when standing. Severe long-standing varicose veins can lead to leg swelling, venous eczema, skin thickening and ulceration

DVT and VARICOSE VEINS

Veins of the Lower Limb Great Saphenous Vein Cutdown
-The greater saphenous vein is the most common vessel used for the venous cutdown -Intravenous access is one of the crucial first steps in the resuscitation of any critically ill or injured patient who presents to the emergency department. -When peripheral intravenous access fails, alternative routes must be sought to obtain rapid access for the purpose of infusing intravenous fluids, blood products, or medications -The greater, or long, saphenous vein, which is the longest vein in the body, originates at the ankle as a continuation of the medial marginal vein of the foot and ends at the femoral vein within the femoral triangle. -At the ankle, it crosses 1 cm anterior to the medial malleolus and continues up the anteromedial aspect of the lower leg.

Veins of Lower Limb-Venous cutdown

Lymphatic Drainage Of Lower Limb
Three main groups Superficial inguinal lymph nodes Deep inguinal lymph nodes Popliteal lymph nodes

The superficial inguinal lymph nodes form a chain immediately below the inguinal ligament. They receive as afferents lymphatic vessels from the following: integument of the penis Scrotum Perineum Buttock abdominal wall below the level of the umbilicus Vulva anus (below the pectinate line) the lower extremity (foot, leg and thigh)

The deep inguinal lymph nodes are located medial to the femoral vein and under the cribriform fascia. There are approximately 3 to 5 deep nodes. The superior-most node is located under the inguinal ligament and is called Cloquet's node. The deep inguinal lymph nodes drain superiorly to the external iliac lymph nodes, then to the pelvic lymph nodes and on to the paraaortic lymph nodes.

The popliteal lymph nodes, small in size and some six or seven in number, are imbedded in the fat contained in the popliteal fossa. They receive lymph from: knee joint Deep lymph vessels from leg along anterior & posterior tibial arteries Some superficial lymph vessels from leg & foot along small saphenous vein Their efferents drain into deep inguinal lymph nodes

Nerve Supply of the Lower Limb
Lumbosacral plexus -The anterior divisions of the lumbar, sacral, and coccygeal nerves form the lumbosacral plexus, the first lumbar nerve being frequently joined by a branch from the twelfth thoracic. -For descriptive purposes this plexus is usually divided into three parts—the lumbar, sacral, and pudendal plexuses.

Nerve supply of the lower limb
The Lumbar plexus -The plexus of nerves formed by anterior divisions of L1, L2, L3, and greater part of L4 nerves. -L1 often receives a branch from T12. -Smaller part of L4 joins with L5 to form lumbosacral trunk, which assists in the formation of sacral plexus. -L4 is named the nervus furcalis, from the fact that it is subdivided btn the two plexuses. -Lumbar plexus is situated in the posterior part of Psoas major muscle, in front of the transverse processes of the lumbar vertebrae. 4

LUMBAR PLEXUS

Lumbar plexus

Lumbosacral plexus Branches of lumbar plexus: -Iliohypogastric L1
-Ilioinguinal L1 -Genitofemoral L1, L2. Dorsal divisions. -Lateral femoral cutaneous L2, L3. -Femoral L2, L3, L4 (largest branch of lumbar plexus) Ventral divisions. -Obturator L2, L3, L4 . -Accessory obturator L3, L4.

Lumbosacral Plexus Lumbar plexus- muscular divisions.
-The main branches innervate anterior thigh via femoral nerve. -Medial thigh and adductor muscles are innervated by the obturator nerve. Femoral nerve. Cutaneous branches: Thigh, leg, foot (e.g. saphenous nerve) Motor branches: Anterior thigh muscles (e.g. quadriceps, sartorius, iliopsoas)

Lumbar plexus Obturator nerve Sensory
Skin medial thigh; hip, knee joints Motor Adductor muscles Lateral femoral cutaneous Skin lateral thigh Genitofemoral Skin scrotum, labia major, anterior thigh Cremasteric muscle

Sacral plexus The Sacral Plexus
-Is a nerve plexus derived from the anterior/ventral rami of spinal nerves L4, L5, S1, S2, S3, and S4. -Each of these anterior rami gives rise to anterior and posterior branches. -The anterior branches supply flexor muscles of the lower limb, and posterior branches supply the extensor and abductor muscles -Located on posterior wall of true pelvis on anterior surface of piriformis muscle -Branches supply: lower limb; pelvic floor and wall and perineum -Most branches leave the pelvis through greater sciatic foramina -Two major branches are the sciatic nerve and pudendal nerve -sacral plexus is part of the larger lumbosacral plexus.

Sacral Plexus

Sacral Plexus Sciatic Superior gluteal nerve Motor: Branches into:
Hamstring Branches into: Tibial nerve Cutaneous Posterior leg and sole of foot Motor Posterior leg, foot Common fibular (peroneal) nerve Anterior and lateral leg, dorsum foot Lateral compartment, tibialis anterior, toe extensors Superior gluteal nerve Gluteus medius and minimus, tensor fasciae latae

Sacral Plexus (continued)
Inferior gluteal nerve Motor Gluteus maximus Posterior femoral cutaneous nerve Sensory Inferior buttocks, posterior thigh, popliteal fossa Pudendal nerve External genitalia, anus Muscles of perineum

Lumbosacral plexus Blood supply
-Arterial Supply - originates from two sources: -The middle sacral artery divides to provide dorsal and caudal arterial branches to the lumbosacral spine. The dorsal branch enters epaxial musculature by passage through the angle formed by the ilium and vertebral column. The caudal branch runs into the pelvis in company with the sympathetic trunk. - The segmental lumbar artery that courses through the intervertebral foramen and branches to the segmental spinal artery. Within the spinal canal, the artery divides into a small dorsal and slightly larger ventral branch. The ventral branches coalesce on the midline to form the ventral mater to nourish spinal tissue

Lumbosacral plexus Venous drainage:- two sources:
From arborized spinal venules blood is returned to the left and right vertebral sinuses. The vertebral sinuses are continuous with spinal veins and drain cranially or to the median sacral and common iliac veins. Additional drainage arises from the anastomosis of intervertebral and interspinous veins of the ipsilateral and contralateral portions of the spinal segment to form the dorsal external venous plexus

Lumbosacral plexus Clinical points Pudendal Nerve Block
-Performed to relieve perineal pain during childbirth. -Anesthetic agent is injected into tissues around pudendal nerve. -Injection is normally done transvaginally -Physician palpates the ischial spine and uses his or her fingers to direct the needle so that the anesthetic is injected in the region of the ischial spine, where the pudendal nerve wraps around it to enter the lesser sciatic foramen -Pudendal blocks do not relieve the pain of contractions

Lower Limb Dermatomes

Lower Limb Dermatomes Key dermatomes* of the Lower Limb
hip crease - L1 great toe - L4 5th toe - S1

Iliacus Psoas Pectineus Rectus femoris Vastus lateralis
MUSCLES OF THE ANTERIOR FASCIAL COMPARTMENT OF THE THIGH MUSCLE ORIGIN INSERTION NERVE SUPPLY & ROOT ACTION Sartorius anterior superior iliac spine upper medial surface of shaft of tibia Femoral nerve L2,3 At hip joint-flexes, abducts, laterally rotates thigh At knee joint-flexes, medially rotates leg Iliacus Iliacus fossa of hip bone With psoas into lesser trochanter of femur Flexes thigh on trunk; If the thigh is fixed it flexes the trunk on the thigh as in sitting up from lying down Psoas Transeverse process, bodies and intervertebral dics of 12th thoracic and five lumbar vertebrae With iliacus into lesser trochanter of femur Lumber plexus L1,2, 3 Pectineus superior ramus of pubis Upper end of linea aspera of shaft of femur Femoral nerve Flexes and adducts thigh at hip joint Rectus femoris Straight head-inferior iliac spine Reflected head-ilium above acetabulum Quadricepstendon into patella,then via patella ligament into tibial tubercle L2,3,4 Extension of leg at knee joint Flexes thigh at hip joint Vastus lateralis Upper end and shaft of femur Quadricepstendon into patella,then via patella ligament into tibial tubercle extension of leg at knee joint Vastus medialis Upper end and shaft of femur extension of leg at knee joint Stabilizes patella Vastus intermedius Anterior and lateral of shaft of femur Femoral nerve Articularis genus retracts synovial membrane

MUSCLES OF THE MEDIAL FASCIAL COMPARTMENT OF THE THIGH MUSCLE ORIGIN INSERTION NERVE SUPPLY AND ROOT ACTION Gracilis inferior ramus of pubis, ramus of ischium upper part of shaft of tibia on medial surface obturator nerve L2, 3 adducts thigh at hip joint, flexes leg at knee joint Adductor longus body of pubis, medial to pubic tubercle posterior surface of shaft of femur(linea aspera obturator nerve L2, 3, 4 adducts thigh at hip joint, and assists in lateral rotation Adductor brevis inferior ramus of pubis obturator nerve Adductor magnus inferior ramus of pubis, ramus of ischium, ischial tuberosity posterior surface of shaft of femur, adductor tubercle of femur adductor portion-obturator nerve hamstring portion-sciatic nerve hamstring portion extends thigh at hip joint Obturator externus outer surface of obturator membrane , pubic and ischial rami medial surface of greater trochanter L3, 4 laterally rotate thigh at hip joint

long head-ischial tuberosity
MUSCLES OF THE POSTERIOR FASCIAL COMPARTMENT OF THE THIGH MUSCLE ORIGIN INSERTION NERVE SUPPLY AND ROOT ACTION Biceps femoris long head-ischial tuberosity short head-linea aspera, lateral supracondylar ridge of shaft of femur head of fibular long head-tibial portion of sciatic nerve short head-common peroneal portion of sciatic nerve L5, s1, 2 flexes and laterally rotates leg at knee joint long head also extends thigh at hip joint Semitendinosus ischial tuberosity upper part of medial surface of shaft of tibia tibial portion of sciatic nerve L5,;s1, 2 flexes and medially rotates leg at knee joint; extends thigh at hip joint Semimembranosus medial condyle of tibia tibial portion of sciatic nerve L5; s1, 2 Adductor magnus(hamstring portion) adductor tubercle of femur L2, 3, 4 extends thigh at hip joint

MUSCLES OF THE ANTERIOR FASCIAL COMPARTMENT OF THE LEG
ORIGIN INSERTION NERVE SUPPLY AND ROOT ACTION Tibialis anterior lateral surface of sahaft of tibia and interosseous membrane medial cuneiform and base of first metatarsal bone deep peroneal nerve L4, 5 extends(dorsiflexion) foot at ankle joint; inverts foot at subtalara and transeverse tarsal joints; holds up medial longitudinal arch of foot Extensor: -digitorum longus -peroneus tertius anterior surface of shaft fo fibular anterior surface of shaft fo fibular extensor expansion of lateral four toes base of fifth metatarsal bone L5; s1 deep peroneal nerve extends toes; extends foot at ankle joint; extends foot at ankle joint; everts foot at subtalar and transeverse tarsal joints Extensor hallucis longus base of digital phalanx of great toe extends big toe; extends foot at ankle joint; inverts foot at subtalara and transeverse tarsal joints Extensor digitorum brevis calcaneum by four tendons into the proximal phalanx of big toe and long extensor tendons to second, third, and fourht toes S1, 2 extends toes

MUSCLE ORIGIN INSERTION NERVE SUPPLY AND ROOT ACTION
MUSCLES OF THE LATERAL FASCIAL COMPARTMENT OF THE LEG MUSCLE ORIGIN INSERTION NERVE SUPPLY AND ROOT ACTION PERONEUS LONGUS LATERAL SURFACE OF SHAFT OF FIBULAR BASE OF FIRST METATARSAL AND THE MEDIAL CUNEIFORM SUPERFICIAL PERONEAL NERVE L5; S1, 2 PLANTAR FLEXES FOOT AT ANKLE JOINT; EVERTS FOOT AT SUBTALAR AND TRANSEVERSE TARSAL JOINTS; SUPPORTS LATERAL LONGITUDINAL AND TRANSEVERSE ARCHES FO FOOT PERONEUS BREVIS BASE OF FIRST METATARSAL AND THE MEDIAL CUNEIFORM BASE OF FIFTH METATARSAL BONE PLANTAR FLEXES FOOT AT ANKLE JOINT; EVERTS FOOT AT SUBTALAR AND TRANSEVERSE TARSAL JOINTS; SUPPORTS LATERAL LONGITUDINAL ARCH OF FOOT

via tendo calcaneus into posterior surface of calcaneum tibial nerve
MUSCLES OF THE POSTERIOR FASCIAL COMPARTMENT OF THE LEG MUSCLE ORIGIN INSERTION NERVE SUPPLY AND ROOT ACTION SUPERFICIAL GROUP Gastrocnemius lateral head from lat. condyle of femur and medial head from above medial condyle via tendo calcaneus into posterior surface of calcaneum tibial nerve s1, 2 plantar flexes foot at ankle joint ; flexes knee joint Plantaris lateral supracondylar ridge of femur posterior surface of calcaneum tibial nerve plantar flexes foot at ankle joint; flexes knee joint Soleus shafts of tibia and femur together with gastrocnemius and plantaris is powerful plantar flexor of ankle joint; provides main propulsive force in walking and running DEEP GROUP Popliteus lateral surface of lateral condyle of femur posterior surface of shaft of shaft of tibia above soleal line l4, 5; s1 flexes leg at knee joint; unlocks knee joint by lateral rotation of femur on tibia and slackens ligaments of joint Flexor digitorun longus posterior surface of shaft of tibia bases of distal phallanges of lateral four toes s2, 3 flexes distal phalanges of lateral four toes; plantar flexes the foot at ankle joint; supports medial and lateral longitudinal arches of foot Flexor hallucis longus posterior surface of shaft of fibula base of distal phalanx of big toe tibial nerve flexes distal phalanx of big toe; plantar flexes foot at ankle joint; supports medial longitudinal arch of foot Tibialis posterior posterior surface of shaft of tibia and fibula and interosseous membrane tuberosiry of navicular bone and other neighbouring bones l4, 5 plantar flexes foot at ankle joint; inverts foot at subtalar and transverse tarsal joints; supports medial longitudinal arch of foot

medial tuberosity of calcaneum and flexor retinaculum
MUSCLES OF THE SOLE OF THE FOOT MUSCLE ORIGIN INSERTION NERVE SUPPLY AND ROOT ACTION FIRST LAYER Abductor hallucis medial tuberosity of calcaneum and flexor retinaculum base of proximal phalanx of big toe medial plantar nerve S2, 3 flexes and abducts big toe; braces medial longitudinal arch Flexor digitorum brevis medial tubercle of calcaneum four tendons to four lateral four- inserted into borders of middlephalanx; tendons perforated by those of flexor digitorum longus medial plantar nerve flexes lateralfour toes; braces medial and lateral longitudinal arches Abductor digit minimi medial and lateral tubercles of calcaneum base of proximal of fifth toe LATERAL plantar nerve flexes and abducts fifth toe; braces lateral longitudinal arch SECOND LAYER Quadratus plantae Medial and lateral sides of calcaneum tendon of flexor digitorum longus assists flexor digitorum longus in flexing lateral four toes Lumbricals(4) tendons of flexor digitorum longus dorsal extensor expansion; bases of proximal phalanges of lateral four toes FIRST lumbrical: medial plantar nerve; reminder: lateral plantar nerve extends toes at interphalangeal joints Flexor digitorum longus tendon and Flexor hallucis longus tendon see above

Flexor hallucis brevis
MUSCLES OF THE SOLE OF THE FOOT MUSCLE ORIGIN INSERTION NERVE SUPPLY AND ROOT ACTION THIRD LAYER Flexor hallucis brevis cuboid, lateral cuneiform, tibialis posterior insertion medial tendon into medial side of base of proximal phalanx of big toe; lateral tendon intolateral side of base of proxima lphalanx of big toe medial plantar nerve s2, 3 flexes metatarsophalangeal joints of big toe; supports medial longitudinal arch Adductor hallucis oblique head bases of second, third and fourth metatarsal bones; transverse head from plantar ligaments lateral side of base of proximal phalanx of big toe deep branch lateral plantar nerve flexes metatarsophalangeal joints of big toe; holds together metatarsal bones Flexor digit minimi brevis base of fifth metatarsal bone lateral side of base of proximal phalanx of little toe lateral plantar nerve flexes metatarsophalangeal joints of little toe; FOURTH LAYER Interosseous- dorsal (4) adjucent sides of metatarsal bones base of proximal phalanges-first: medial side of second toe; reminder; lateral sides of second, third and fourth toes-also dorsal extensor expansion abduction of toes; flexes metatarsophalangeal joints and extends interphalangeal joints Interosseous-plantar (3) inferior surfaces of third, fourth, and fifth metatarsal bones medial side of bases of proximal phalanges of lateral three toes adduction of toes; flexes metatarsophalangeal joints and extends interphalangeal joints Peroneuslongus tendon and tibialis posterior tendon See above

Extensor digtitorum brevis
MUSCLES OF THE DORSUM OF THE FOOT MUSCLE ORIGIN INSERTION NERVE SUPPLY AND ROOT ACTION Extensor digtitorum brevis Anterior part of upper surface of calcaneum and from the inferior extensor retinaculum By four tendons into the proximal phalanx of big toe and long extensor tendons to second, third and fourth toes Deep peroneal nerve S1,S2 Extends toes

Anterior/Post. Compartments of Thigh and Leg
ANTERIOR COMPARTMENT POSTERIOR COMPARTMENT MOVEMENT Extension Flexion MUSCLES Quadriceps-thigh Shin muscles-leg Hamstrings-thigh Gastrocs-leg NERVES Femoral n. (lumbar plexus) Sciatic n. (sacral plexus) Frolich, Human Anatomy, Lower LImb

Gluteal Region: Post & Lat hip
(a)Gluteus muscles Maximus- extensor of thigh Medius- abductor of thigh, pelvic tilt when walking Minimus-abductor of thigh, pelvic tilt (b)Lateral rotators- piriformis, obturator internus and externus, quadratus fermoris, superior and inferior gemelli Frolich, Human Anatomy, Lower LImb

Anterior Hip Iliopsoas-flexors of thigh iliacus psoas
Frolich, Human Anatomy, Lower LImb

Anterior thigh (femoral nerve.)
Sartorius (Tailor’s muscle) Quadriceps (four) Rectus femoris (crosses hip) 3 vastus muscles. (vast-big) Frolich, Human Anatomy, Lower LImb

Posterior thigh (sciatic nerve)
Hamstrings Biceps femoris Semimembranous Semitendinous Frolich, Human Anatomy, Lower LImb

Posterior thigh (sciatic nerve)

Medial thigh (obturator nerve)
Adductor muscles Gracilis Adductor Magnus Longus brevis Frolich, Human Anatomy, Lower LImb

Anterior Leg (deep fibular nerve)
Extensors of foot (dorsiflexors) Fibularis (peroneus) longus Extensor digitorum longus Extensor hallicus longus Tibialis anterior Frolich, Human Anatomy, Lower LImb

Lateral Leg (superficial fibular nerve.)
Fibularis brevis and longus muscles Frolich, Human Anatomy, Lower LImb

Posterior Leg (tibial nerve)
Flexors of foot (plantarflexors) Gastrocs. and soleus plantaris Flexor digitorum longus Flexor hallucus longus Tibialis posterior Frolich, Human Anatomy, Lower LImb

Muscles of the Sole of the Foot

Dorsum of the foot

Refferences Grays Anatomy for students
Clinical Anatomy by Regions - Snell Netter Atlas .com, search word: Anatomy of lower limb

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ANATOMY OF THE LOWER LIMB

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