1. IUSM-NW AY13-14 1 The Lower Limb Ernest F. Talarico, Jr., Ph.D. Associate Director of Medical Education Associate Professor of Anatomy & Cell Biology Indiana University School of Medicine – Northwest Campus

2. OBJECTIVES 1.Osteology 2.Fascia and fascial compartments 3.Muscles (origin, insertion, innervation, action) 4.Vessels (including lymphatics) – name and course 5.Lumbar plexus (variations) 6.Clinical Correlates 7.Embryology of extremities 8.Medical Imaging IUSM-NW AY13-14 2

3. IUSM-NW AY13-14 3 Osteology

4. IUSM-NW AY13-14 4 Fascia & Compartments

5. IUSM-NW AY13-14 5 Superficial Veins lateral N A V E L medial

6. IUSM-NW AY13-14 6 The Thigh Anterior Compartment

7. IUSM-NW AY13-14 7 The Thigh Posterior Compartment Sciatic Nerve –Largest & longest nerve in the human body –Innervation to muscles of the posterior thigh; anterior, posterior and lateral compartments of the leg –KEEP INTACT

8. IUSM-NW AY13-14 8 The Thigh Medical Compartment Obturator Nerve Adductor magnus (adductor portion); adductor longus and adductor brevis; gracilis muscles Sciatic Nerve Adductor magnus (hamstring portion

9. IUSM-NW AY13-14 9 The Adductor Compartment & Adductor Canal Medical Students Study the thigh dissected by prosectors. Fern Jones Murphy

10. IUSM-NW AY13-14 10 Gluteal Region Superficial Layer Intermediate Layer Deep Layer S I D

11. IUSM-NW AY13-14 11 Arteries of the Lower Limb -- >>> N A V E L -- >>>

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13. IUSM-NW AY13-14 13 CLNICAL CORRELATION This patient sustained a contaminated open femur fracture with bone loss after a motorcycle crash An antegrade nail was used to stabilize the femur, and antibiotic beads were used to fill the dead space.

14. IUSM-NW AY13-14 14 Iliac crest bone grafting was performed at 6 weeks. Healing proceeded uneventfully.

15. IUSM-NW AY13-14 15 CLNICAL CORRELATION High-velocity rifle injury to the hip. Anteroposterior (left) and lateral (right) radiographs of the left hip show the typical lead snowstorm appearance of a high- velocity soft-point rifle bullet. The bullet was traveling from front to back. On the anteroposterior view (left), the lead fragments are distributed in a circular pattern. On the lateral view (right), the fragments show a conical distribution, with the apex of the cone at the femoral fracture site and the base of the cone posterior. This distribution of lead confirms the direction of travel. The severe comminution of the fracture from this high-energy injury makes it difficult to use beveling of the bone to help determine the direction of travel.

16. IUSM-NW AY13-14 16 CLNICAL CORRELATION A 44 year-old male patient was admitted in our clinic with a giant tumor in the right thigh, which started to grow two years before, with progressive increase in size. The local examination of the right thigh revealed a 35/30 cm high consistency tumor, with reduced mobility. There was no right inguinal adenopathy.

17. IUSM-NW AY13-14 17 Radiographic examination of the right thigh showed non-homogeneous enlargement of soft parts at this level, with linear opacities.

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19. IUSM-NW AY13-14 19 Liposarcomas are mesenchymal tumors that represent the most common type of adult sarcomas, differentiated liposarcomas accounting for 40-50% of all adult liposarcomas. The most frequent locations of lipomatous tumors are the following: the extremities, retroperitoneal, the groin, scrotum, and the abdominal wall. Surgical treatment and histology are the most important prognostic factors for patients with lipomatous tumors, as complete surgical excision reduces local recurrence rate.

20. IUSM-NW AY13-14 20 CADAVER PROSECTION TEAM 2004

21. IUSM-NW AY13-14 21 Anterior & Lateral Leg Prosection 2005

22. IUSM-NW AY13-14 22 Muscle Layers of the Foot The Prosectors wait to feast. Giving thanks to our Donors and their families.

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24. IUSM-NW AY13-14 24 Arteries of the Lower Limb -- >>> N A V E L -- >>>

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26. Knee Articulation IUSM-NW AY13-14 26

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29. IUSM-NW AY13-14 29 BURSA a fluid-filled sac or saclike cavity situated in places in tissues where friction would otherwise occur

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31. IUSM-NW AY13-14 31 Medical Imaging MRI Transverse –Thigh –Leg Which lower limb is pictured here?

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34. IUSM-NW AY13-14 34 CLNICAL CORRELATION

35. IUSM-NW AY13-14 35 CLNICAL CORRELATION

36. IUSM-NW AY13-14 36 CLNICAL CORRELATION

37. IUSM-NW AY13-14 37 Radionuclide image of the posterior pelvis shows abnormal radiotracer uptake from metastases involving the left iliac bone and sacrum (arrows). CLNICAL CORRELATION

38. IUSM-NW AY13-14 38 A patient with a malignant phyllodes breast tumor, who then had a ten-year disease free interval before she developed a left pelvic bone metastasis and soft tissue invasion. Cross- sectional and radionuclide imaging of its musculoskeletal metastasis is presented.

39. IUSM-NW AY13-14 39 Overview of Phyllodes Breast Tumor: Phyllodes tumor is a very rare type of breast tumor, which can be benign (harmless) or malignant (cancerous). This type of tumor is called a "sarcoma," because it occurs in the connective tissue (stroma) of your breast, rather than in epithelial tissue (lining of ducts and lobes). Phyllodes tumors take their name from the Greek word phullon (leaf) because of their leaf-shaped growth pattern. Phyllodes Tumor is a Rare Diagnosis: Phyllodes tumors account for less than 1% of all breast cancers. Even though the tumor may be benign, it is still considered a type of breast cancer, because it has the potential to become malignant.

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