Lecture Notes about Anatomy of the Lower Limb

Anatomy of the Lower Limb The Hip and the Thigh The femoral triangle Boundaries Made out of three boarders, a floor and a roof: • • • • • Roof: fascia lata Floor: pectineus, iliopsoas, and adductor longus muscles Superior boarder: inguinal ligament (a ligament that runs from the anterior superior iliac spine to the pubic tubercle). Lateral boarder: medial border of the sartorius muscle. Medial boarder: medial border of the adductor longus muscle. The rest of this muscle forms part of the floor of the triangle. Contents • • • • Femoral nerve Femoral artery Femoral vein Femoral canal Clinical Question: What is the significance of the femoral triangle? • Site for vascular catheterisation and correct procedures Iliac Muscle Name Iliopsoas Origin Insertion Innervation • Iliacus: femoral nerve (L2-L4) • Psoas major: anterior rami of spinal nerves (L1L3) Function Flexion and external rotation of the thigh at the hip joint; flexion of the trunk at the hip, lateral flexion of the trunk (psoas major only) Superficial Gluteal Muscles Name Tensor fascia latae Origin Outer lip of anterior iliac crest, Anterior superior iliac spine (ASIS Insertion Lateral condyle of tibia (via iliotibial tract) Innervation Superior gluteal nerve (L4S1) Gluteus maximus Lateroposterior surface of sacrum and coccyx, gluteal surface of ilium (behind posterior gluteal line), thoracolumbar fascia, Sacrotuberous ligament Gluteal surface of ilium (between anterior and posterior gluteal lines) Gluteal surface of ilium (between anterior and inferior gluteal lines) Iliotibial tract, gluteal tuberosity of femur Inferior gluteal nerve (L5, S1, S2) Lateral aspect of greater trochanter of femur Superior gluteal nerve (L4S1) Hip joint: Thigh abduction, thigh internal rotation (anterior part); Pelvis stabilization Anterior aspect of greater trochanter of femur Superior gluteal nerve (L4S1) Hip joint: Thigh abduction, thigh internal medial rotation (anterior part); Pelvis stabilization Gluteus medius Gluteus minimus Function Hip joint: Thigh internal rotation, (Weak abduction); Knee joint: Leg external rotation, (Weak leg flexion/ extension); Stabilizes hip & knee joints Hip joint: Thigh extension, thigh external rotation, thigh abduction (superior part), thigh adduction (inferior part) Deep Gluteal Muscles Name Piriformis Origin Anterior surface of the sacrum (between the S2 and S4), Gluteal surface of ilium (near posterior inferior iliac spine), (Sacrotuberous ligament) Ischial spine Insertion (Apex of) Greater trochanter of the femur Innervation Nerve to piriformis (S1-S2) Function Hip joint: Thigh external rotation, Thigh abduction (from flexed hip); Stabilizes head of femur in acetabulum Medial surface of greater trochanter of femur (via tendon of obturator internus) Nerve to obturator internus (L5-S1) Obturator internus Posterior surface of the obturator membrane; bony boundaries of the obturator foramen Medial surface of greater trochanter of femur Nerve to obturator internus (L5 and S1) Inferior gemellus Ischial tuberosity Medial surface of greater trochanter of femur (via tendon of obturator internus) Nerve to quadratus femoris (L4/5, S1) Obturator externus Anterior surface of obturator membrane, bony boundaries of obturator foramen Trochanteric fossa of femur Obturator (L3, L4) Hip joint: Thigh external rotation, thigh abduction (from flexed hip); stabilizes head of femur in acetabulum • External rotation of extended thigh. • Abduction of flexed thigh. • Stabilization of hip joint Hip joint: Thigh external rotation, thigh abduction (from flexed hip), stabilizes head of femur in acetabulum Hip joint: Thigh external rotation, thigh abduction (from flexed hip); Stabilizes head of femur in acetabulum Super gemellus Anterior Thigh Muscles Name Sartorius Origin Anterior superior iliac spine (ASIS) Insertion Proximal end of tibia below medial condyle (via pes anserinus) Innervation Femoral nerve (L2L3) Rectus Femoris Anterior inferior iliac spine, supraacetabular groove Tibial tuberosity (via patellar ligament), patella Femoral nerve (L2L4) Vastus Medialis Intertrochanteric line, pectineal line of femur, linea aspera, medial supracondylar line of femur Intertrochanteric line, greater trochanter, gluteal tuberosity, linea aspera of femur Tibial tuberosity (via patellar ligament), patella, (medial condyle of tibia) Femoral nerve (L2L4) Tibial tuberosity (via patellar ligament), patella, (lateral condyle of tibia) Femoral nerve (L2L4) Vastus Anterior surface of Intermedius femoral shaft Tibial tuberosity (via patellar ligament), patella Femoral nerve (L2L4) Pectineus Pectineal line of femur, linea aspera of femur Vastus Lateralis Superior pubic ramus (pectineal line of pubis) • • Femoral nerve (L2, L3) (Obturator nerve (L2, L3)) Function • Hip joint: thigh flexion, thigh abduction, thigh external rotation. • Knee joint: leg flexion, leg internal rotation • Hip joint: Thigh flexion (rectus femoris only). • Knee joint: Leg extension • Hip joint: Thigh flexion (rectus femoris only); • Knee joint: Leg extension • Hip joint: Thigh flexion (rectus femoris only); • Knee joint: Leg extension • Hip joint: Thigh flexion (rectus femoris only); • Knee joint: Leg extension Hip joint: Thigh flexion, thigh adduction, thigh external rotation, thigh internal rotation; pelvis stabilization Medial Thigh Muscles Name Gracilis Origin Anterior body of pubis, inferior pubic ramus, ischial ramus Insertion Medial surface of proximal tibia (via pes anserinus) Innervation Obturator nerve (L2-L3) Adductor Anterior body of pubis, brevis inferior pubic ramus Linea aspera of femur (medial lip) Obturator nerve (L2-L3) Adductor Body of pubis, inferior to longus pubic crest and lateral to the pubic symphysis Adductor • Adductor part: magnus Inferior pubic ramus, ischial ramus • Ischiocondylar part: Ischial tuberosity Medial third of linea aspera of femur (medial lip) • Adductor part: Gluteal tuberosity, linea aspera (medial lip), medial supracondylar line • Ischiocondylar part: Adductor tubercle of femur Obturator nerve (L2-L3) • • Adductor part: Obturator nerve (L2-L4) Ischiocondylar part: Tibial division of sciatic nerve (L4) Mnemonic: African Mouse Sneaks Out (refers to Adductor Magnus Sciatic Obturator) Function • Hip joint: Thigh flexion, thigh adduction. • Knee joint: leg flexion, leg internal rotation Hip Joint: thigh flexion, thigh adduction, thigh external rotation, pelvis stabilization Hip Joint: thigh flexion, thigh adduction, thigh external rotation, pelvis stabilisation • Adductor part: - Hip joint - Thigh flexion, thigh adduction, thigh external rotation. • Hamstring part: - Hip joint - Thigh extension, thigh internal rotation. - Entire muscle: Pelvis stabilization Posterior Thigh Muscles Name Semitendinosus Origin (Posteromedial impression of) Ischial tuberosity Semimembranosus Superolateral impression of ischial tuberosity • Biceps femoris • Long head: (inferomedial impression of) ischial tuberosity, sacrotuberous ligament Short head: linea aspera of femur (lateral lip), lateral supracondylar line of femur Insertion Proximal medial tibia Innervation Tibial division of sciatic nerve (L5-S2 Medial condyle of tibia Tibial division of sciatic nerve (L5 – S2) (Lateral aspect of) head of fibula • • Long head: tibial division of sciatic nerve (L5S2) Short head: common fibular division of sciatic nerve (L5S2) Function • Hip joint: Thigh extension, thigh internal rotation, stabilizes pelvis. • Knee joint: Leg flexion, leg internal rotation. • Hip joint: thigh extension and internal rotation. • Knee joint: flexion and internal rotation of the leg • Stabilizes pelvis • Hip joint: thigh extension, thigh external rotation. • Knee joint: leg flexion, leg external rotation; stabilizes pelvis For the following blood vessels and nerves, identify the origin, course and major branches Arteries • • Internal iliac - Superior and inferior gluteal ✓ The superior gluteal artery supplies the obturator internus, gluteous minimus, medius and tensa late fascia. ✓ The inferior gluteal artery supplies the PGOGOQ complex. - Internal pudendal - Obturator: supplies the medial compartment muscles, as well as the piriformis and the obturator externus. Femoral - Profunda femoris: The anterior branch of the profunda femoris artery supplies the pectineus, obturator externus, adductor muscles and gracilis. The posterior branch supplies some of the deep gluteal muscles. - Perforating (3): posterior compartment of the thigh and some of the medial compartment of the thigh. - Medial and lateral circumflex: medial supplies the femur head and neck and the lateral supplies the knee and hip joints. • Popliteal - Tibial - Sural - Genicular Veins • • Superficial - Great saphenous Depp veins - Femoral - Popliteal - Venae Commitantes of arteries ✓ (usually) paired veins travelling and lying either side of a particular artery (of the same name) Nerves • • • Femoral - Saphenous nerve Obturator Sciatic The leg The leg describes the region between the knee and the ankle and includes the transitional areas of the popliteal fossa posterior to the knee and the tarsal tunnel at the ankle Popliteal fossa Boundaries • • • • Superomedial border – semimembranosus. Superolateral border – biceps femoris. Inferomedial border – medial head of the gastrocnemius. Inferolateral border – lateral head of the gastrocnemius and plantaris. Contents • • • • • • Popliteal artery Popliteal vein Tibial vein Common fibular (peroneal) nerve Small saphenous vein (termination) Lymph vessels Which muscles are innervated by the common fibular (peroneal) nerve? Anterior leg muscles (tibialis anterior, extensor hallucis longus, extensor digitorum longus); lateral leg muscles (fibularis longus, fibularis brevis); dorsal foot muscles (extensor digitorum brevis, extensor hallucis brevis) Which muscles are innervated by the tibial nerve? Posterior compartment of the leg, all intrinsic muscles (except extensor digitorum brevis) Clinical Question What is the clinical significance of the popliteal fossa? Joints Tibiofibular joint • Proximal - Formed by an articulation between the head of the fibula and the lateral condyle of the tibia. - It is a plane type of synovial joint, where the bones to glide over one another to create movement. • Distal - Consists of an articulation between the fibula notch of the distal tibia and fibula - It is an example of a fibrous joint, where the surfaces ae by bound by tough fibrous tissue Anterior Leg Muscles Name Tibialis Anterior Origin Proximal lateral tibia condyle Extensor Hallucis longus Extensor Digitorum Longus Medial fibula and interosseus membrane Lateral tibia condyle and sup. ¾ of fibula Fibularis (peroneus) tertius Distal third of fibula and interosseous membrane Insertion Med. and inf. surfaces of medial cuneiform and base of 1stmetatarsa Base of distal phalanx of big toe Base of middle and distal phalanges (4 smaller toes) Base of 5th metatarsal Innervation Deep peroneal nerve Function Dorsiflex & invert of the foot Deep peroneal nerve Deep peroneal nerve Dorsiflex and extend big toe Deep peroneal nerve Dorsiflex and weak eversion Insertion Plantar medial cuneiform, 1st metatarsal base Base of 5th metatarsal Innervation Superficial fibular nerve Function Plantar flex/stabilization when standing Superficial fibular nerve Foot eversion Dorsiflexion and toe extension Lateral Leg Muscles Name Fibularis longus Origin Proximal lateral fibula (head) Fibularis brevis Distal lateral fibula Posterior Leg Muscles Important Note: all muscles of the posterior leg except for popliteus are considered extrinsic muscles of the foot Name Origin Gastrocnemius Lateral and medial femoral condyles Soleus Posterior fibular head and soleal line of tibia Plantaris Lateral femoral supracondylar ridge Popliteus Lateral femoral condyle Insertion Calcaneus via calcaneal tendon Calcaneus via calcaneal tendon Calcaneus via calcaneal tendon Proximal posterior tibia Innervation Tibial nerve Function Plantarflexion Tibial nerve Plantarflexion Tibial nerve Weak plantarflexion Tibial nerve Flexor halluces longus Flexor dithorium Tibialis Posterior Base of distal phalanx of big toe Bases of distal phalanges Tibial nerve Weak knee flexor, unlocks knee by weak internal rotation Big toe flexion Tibial nerve Toe (plantar) flexion Posterior fibula Posterior tibia Posterior tibia, posterior fibula and interosseous membrane Plantar surface of cuneiform and navicular Plantar flexion and invert foot joints and bases of metatarsals 2-4 Blood vessels and nerves For the following blood vessels and nerves, identify the origin, course, and major branches Arteries • • Posterior tibial - Peroneal: lateral leg. - Fibular Anterior tibial: anterior compartment of the thigh. Veins • • Superficial - Great saphenous - Small saphenous Deep veins - Venae Commitantes of arteries - Venae Commitantes of arteries Nerves • • Tibial - Sural Common fibular (either fibular or peroneus can be used) - Superficial fibular (either fibular or peroneus can be used) - Deep fibular (either fibular or peroneus can be used) The ankle and the foot Bones and Joints • • • • • • • • • • Talus (head, neck and body) - The talus is the only bone that articulates with the leg bones. - Trochlea of the talus is held by the malleoli of the tibia. Calcaneus (largest bone in the foot, articulates and takes weight from talus) Cuboid Navicular Lateral cuneiform Intermediate cuneiform Medial cuneiform Five metatarsals numbered medial to lateral (1-5) Two phalanges on the great toe (1st) – proximal and distal Three phalanges on all other toes – proximal, middle and distal Tarsal Tunnel • • Is a fibro-osseous space located on the posteromedial aspect of the ankle It acts a passageway for the tendons, nerves and vessels to travel between the posterior leg and the foot. Ankle Joint (synovial joint) • • Movements: - Hinge type joint: movement permitted in one plane. - Plantarflexion and dorsiflexion Articular surface - Formed by three bones: tibia, fibula, and talus of the foot. - Board notch, formed by the curved under surface of the tibia, the inner surfaces of the medial malleolus, and the lateral malleolus. Ligaments of the ankle Ligament Name Medial (deltoid) Anterior talofibular (Weakest of the lateral collateral ankle ligament) Posterior talofibular Calcaneofibular Attachments Function A weak, flat band that originates on the lateral malleolus of the fibula and extends anteromedially to the lateral side of the neck of the talus. Stabilizes the talus A strong band that extends medially and posteriorly Plays only a supplemental role in ankle from the distal part of the lateral malleolar fossa of stability when the lateral ligament complex the fibula to the lateral tubercle of the talus. It is also is intact connected to the medial malleolus by a tibial slip of fibres. a long band that originates from the apex of the • Provides lateral stabilisation to the lateral malleolus of the fibula, and extends ankle joint and the subtalar joint. posteroinferiorly to attach on a tubercle on the • Allows flexion and extension lateral aspect of the calcaneus. movements to occur at the ankle. • Serves as a primary restraint to inversion in neutral or dorsiflexed position at the talocrural joint. • Serves to resist joint inversion. Arches of the foot Joints of the foot Joint Name Intertarsal Subtalar Tarsometatarsal Intermetatarsal Metatarsophalangeal Interphalangeal Movements Articular Surfaces Ligaments of the foot Name of Ligament Calcaneal tendon (Achilles tendon) Attachments It is the common tendon of the two constituting muscles of the triceps surae; gastrocnemius and soleus, attaching them to the posterior surface of calcaneus bone. Plantar fascia Plantar calcaneonavicular Calcaneocuboid subtalar Lisfranc Intermetatarsals Joint capsule of the big toe Extrinsic muscles of the foot Already covered above. Intrinsic Muscles of the foot Function Plantar flexion of the foot, ankle joint stabilizer Muscle Name Extensor Digitorum Brevis Extensor Hallucis Brevis Origin Superolateral surface of calcaneus bone, interosseous talocalcaneal ligament; stem of inferior extensor retinaculum Superolateral surface of calcaneus bone Insertion Extensor digitorum longus tendons of toes 2–4 Innervation Deep fibular/peroneal nerve (L5, S1) Function Distal interphalangeal joints 2-4: Toe extension Proximal phalanx of great toe Deep fibular/peroneal nerve (S1, S2) Metatarsophalangeal joint 1: Toe extension Intrinsic Muscles of the Sole First Layer Muscle Name Flexor digitorum brevis Abductor digiti minimi Abductor hallucis Origin Medial process of calcaneal tuberosity, plantar aponeurosis and intermuscular septum Calcaneal tuberosity, plantar aponeurosis Insertion Middle phalanges of digits 2-5 Innervation Medial plantar nerve (S1-S3) Function Metatarsophalangeal joints 2-5: Toe flexion; supports longitudinal arch of foot Base of proximal phalanx of digit 5, metatarsal bone 5 Lateral plantar nerve (S1-S3) Medial process of calcaneal tuberosity, flexor retinaculum, plantar aponeurosis Base of proximal phalanx of great toe Metatarsophalangeal joint 5: Toe abduction, toe flexion; Supports longitudinal arch of foot Medial plantar nerve (S1-S3) Metatarsophalangeal joint 1: Toe abduction, toe flexion; Support of longitudinal arch of foot Second Layer Muscle Name Quadratus plantae Lumbricals Origin Medial surface of calcaneus bone, lateral process of calcaneal tuberosity Tendons of flexor digitorum longus Insertion Tendon of flexor digitorum longus Medial bases of proximal phalanges and extensor expansion of digits 25 Innervation Lateral plantar nerve (S1-S3) • Lumbrical 1: Medial plantar nerve (S2, S3); Function Metatarsophalangeal joints 2-5: Toe flexion • • Metatarsophalangeal joints 2-5: Toe flexion, Toes adduction. Interphalangeal joints 25: Toes extension • Lumbricals 2-4: Lateral plantar nerve (S2-S3) Third Layer Muscle Name Flexor digiti minimi brevis Origin Hook of hamate, flexor retinaculum • Adductor hallucis Oblique head: bases of metatarsal bones 2-4, cuboid bone, lateral cuneiform bone, tendon of fibularis longus • Transverse head: plantar metatarsophalangeal ligaments of toes 35, deep transverse metatarsal ligaments of toes 3-5 Tendon of tibialis posterior, medial cuneiform bone, lateral cuneiform bone, cuboid bone Flexor hallucis brevis Insertion Base of proximal phalanx of digit 5 Lateral aspect of base of proximal phalanx of great toe Lateral and medial aspects of base of proximal phalanx of great toe Innervation Deep branch of ulnar nerve (C8, T1) Lateral plantar nerve (S2, S3) Medial plantar nerve (S1, S2) Function Metacarpophalangeal joint 5: Finger flexion (+ finger lateral rotation/opposition) Metatarsophalangeal joint 1: Toe adduction, toe flexion; Support of longitudinal and transverse arches of foot • • Blood vessels and nerves For the following blood vessels and nerves identify the origin, course and major branches Arteries • Dorsalis pedis Metatarsophalangeal joint 1: Toe flexion. Support of longitudinal arch of foot • - Deep plantar Medial and lateral plantar Veins • • Superficial - Great saphenous - Small saphenous Deeps - Venae Commitantes of arteries Nerves • • Medial planter Lateral plantar - Superficial and deep terminal branches