Bone

Anterior View:

Posterior View:

Lesser Sciatic Foramen

BoundariesFront: tuberosity of ischiumAbove: spine of ischium and sacrospinous ligmanetBehind: sacrotuberous ligament

ContentsTendon of obturator internusInt pudendal artery and veinPudendal nerve

The Hip Joint

Type: multiaxial ball and socket; synovialArticulating Surfaces: head of femur (2/3 of sphere), acetabulum (accommodates >1/2 femoral surface in lunate surface)Acetabular Labrum: increases depth of acetabulumCapsule: strong; attaches to edge of acetabulum and transverse acetabular ligament; anteriorly attached to intertrochanteric line and root of greater trochanter, posteriorly attached to neck proximal to greater trochanter; some reflects back as retinaculum that carries blood vessels to head and neckLigaments:

1) Iliofemoral – strong, anterior, AIIS and acetabular rim intertrochanteric line; prevents over-extension

2) Pubofemoral – iliopubic eminence and pubic part of acetabular rim iliofemoral ligament; strengthen inf and ant joint; prevents overabduction

3) Ischiofemoral – posterior; ischial acetabular rim neck of femur; prevents hyperextension4) Ligament of head of femur – intracapsular; of little importance; acetabular notch fovea;

contains branch of obturator arteryAnterior aspect strengthen by ligaments, posterior by muscles

Pelvic Ligaments

Sacrotuberous: sacrum and ischial tuberositySacrospinous: sacrum and ischial spine

Greater Sciatic Foramen

BoundariesAntlat: greater sciatic notch of iliumPostmed: sacrotuberous ligamentInf: sacrospinous ligament and ischial spineSup: ant sacroiliac ligament

ContentsAbove Piriformis: sup gluteal vessels

sup gluteal nerveBelow Piriformis: inf gluteal and int pudendal vessels

inf gluteal, pudendal, sciatic, post femoral cutaneous nerves; nerves to obturator internus and quadratus femoris

Inguinal: ASIS and pubic tubercle

Knee Joint

Type: synovial, hingeMovements: flexion and extension, rotation; knee locks 2Y to MED ROTATION OF FEMUR on tibia; popliteus unlocks knee by laterally rotating femurArticulations: 1) Femorotibial (lateral and medial) – femoral and tibial condyles

2) FemoropatellarFibular IS NOT involved

Strength: from muscles (esp. vastus medalis) > ligamentsCapsule: attaches to femur (just above condyles), tibial plateau; has an opening just post to lat tibial condyle for popliteus to pass through whereit is prolonged inflate over popliteus to head of fibula (arcuate popliteal lig); ant part is formed by quads tendonSynovial membrane: posteriorly it reflects into intercondylar region covering cruciatesContinuous with: suprapatellar, popliteus, anserine and gastrocnemius bursaeArtery: genicular anastomosis (from femoral, popliteal, ant and post recurrentbranches of ant tibial recurrent and circumflex fibular arteries). Intra-articular components supplied by middle genicular branch of popliteal. Nerve: femoral, tibial, common fibular, obturator, saphenousMenisci: wider externally; attached to intercondylar tibia; coronary ligaments extend from menisci to tibial condyles

1) Medial – C-shaped; broader posteriorly; adheres to surface of TCL therefore less mobile2) Lateral – nearly circular; smaller; more moveable

Ligaments: EXTRACAPSULAR

1 Patellar – distal part of quads tendon; from apex of patella to tibial tuberosity; receives medial and lateral patellar retinacula from vastus medialis and lateralis

2 Fibular collateral – cord like; 5cm; extracapsular; strong; lat epicondyle of femur to lat fibular head; tendon of popliteus passes deep to it, separating it from lat meniscus

3 Tibial collateral – weaker flat band; intracapsular; med epicondyle of femur to med condyle of tibia; fibres firmly attached to medial meniscus

INTRA-ARTICULARCruciates WIND on in rotation, and UNWIND on ex rotation; maintain contact of femur with tibia during flexion

Factoid: inf fibres of vastus medialis stabilize patella when knee extended; PCL stabilizes knee when knee flexedSuprapatellar bursa ascends 5cm+ above patellaThere is no active rotation of extended kneeSynovial membrane does not cover back of PCA

Ankle Joint

Medial:

1-Anterior cruciate – weaker; from ANT INTERCONDYLAR TIBIA sup, post, lat POST LAT CONDYLE OF FEMUR; limits POST MOVEMENT OF FEMUR ON TIBIATightens on knee extension

2-Posterior cruciate – stronger; from POST INTERCONYLAR TIBIA sup, ant, med ANT MED CONYLE OF FEMUR; limits ANT MOVEMENT OF FEMUR ON TIBIA

3-Popliteal tendon a)oblique: expansion of tendon of semimembranosus; from med tibial condyle to lat femoral condyle, blending with joint capsule b)arcuate: from post fibular head to post knee joint

Lateral:

Type: hinge, synovialArticulating Surfaces: tibia, fibula, trochlea of talusCapsule: synovial membrane can extends superiorly to IO ligamentLigaments:

1) Lateral ligament of the ankle:a. Anterior talofibular ligament: flat, weak band; lat malleolus neck of talusb. Posterior talofibular ligament: thick, strong; malleolar fossa lat tubercle of talusc. Calcaneofibular ligament: round cord; lat malleolus lat calcaneus

2) Deltoid ligament: medial malleolus talus, calcaneus, navicular; stabilizes during eversionArtery: malleolar branch of fibular, ant and post tibial arteriesNerve: tibial and deep fibularFactoid: most stable during dorsiflexion

SubTalar (Talocalcanean) Joint

Type: synovialArticulating Surfaces: body of talus (concave), sup calcaneus (convex)

clinical subtalar jt also contains talocalcaneal part of talocalcaneonavicular jtCapsule: weakLigaments: med, lat ad post talocalcanean ligament

interosseous talcocalcanean ligament (anterior) – strong, within tarsal sinusMovement: inversion and eversion

Talocalcaneonavicular Joint

Type: synovial, ball and socketArticulating Surfaces: head of talus, post navicular, sup surface of plantar calcaneonavicular (spring) lig, sustentaculum tali, calcaneusCapsule: blends with interosseous talocalcanean ligament posteriorlyLigaments: dorsal talonavicular ligament

spring ligament (sustentaculum tali (talar shelf) postinf navicular bone) – supports talus, maintains longitudinal arch

Talus

Calcaneus

Calcaneal Tendon15cm long; continuation of aponeurosis formed halfway down calf; inserts on calcaneal tuberosity; fibres spiral 90deg (gastrocnemius fibres attach laterally, soleal medially)Subcutaneous calcaneal bursa

Arches of Foot

Areas

Saphenous OpeningOpening in fascia lata inf to med inguinal ligament; suplatinf margin formed by falciform ligament (attaches to inguinal ligament); gt saphenous vein passes through suplaterally to enter femoral vein. Post wall lies ant to pectineus.

Femoral Triangle

Transverse

Bones: cuboid, cuneiforms, bases of MT’s

Support: tibialis anterior and fibularis longus

Longitudinal

Medial part: higher; calcaneus, talus (keystone), navicular, 3 cuneiforms, 3 MT’sLateral part: flatter; calcaneus, cuboid, lat 2 MT’s

Support: tibialis anterior, fibularis longus, flexor hallicus longus, spring and plantar ligament, plantar aponeurosis

BoundariesSuperior: inguinal ligament (inf margin of ex oblique aponeurosis)Medial: med border of adductor longusLateral: med border of sartoriusFloor: iliopsoas (lateral), pectineus (medial), adductor longusRoof: fascia lata and cribiform fascia, sub cut tissue, skin

ContentsFemoral nerveFemoral sheath: femoral artery, vein and inguinal lymphLat cutaneous nerve, femoral branch of genitofemoral nerve

Ileopectineal arch splits area post to inguinal ligament into 2

Femoral sheath: formed by transversalis and iliopsoas fascia; 3 compartments1) Lateral - artery2) Intermediate - vein3) Medial = femoral canal; allows femoral vein to expand; femoral ring = base; can contain lymph

node of CloquetFactoid - femoral branch of genitofemoral nerve lies within femoral sheath but pierces it anteriorly to

supply skin overlying femoral triangle- mid-inguinal point is half way between ASIS and pubic symphysis- femoral pulse is 2-3cm inf to midpoint of inguinal ligament- femoral nerve is midway between ASIS and pubic tubercle- long saphenous vein joins femoral vein within triangle

Adductor Canal

Course: From apex of femoral triangle to adductor hiatus

Contents: femoral artery and vein, saphenous nerve, nerve to vastus medialisNOT FEMORAL NERVE

Boundaries: ant and lat – vastus medialisfloor – adductor longus and magnusmedial – adductor longus and magnus, sartoriusroof – fascia, sartorius

Popliteal Fossa

Boundaries

Upper: semimembranosusbiceps femoris

Lower: gastrocnemiusplantaris

Floor: popliteus (inf), capsule (mid), femur (sup)Roof: skin and Popliteal fascia

Deeply, sup boundary by med and lat supracondylar lines

ContentsSmall saphenous vein entering popliteal veinPopliteal artery and veinTibial and common fibular nerve - tibial is largest, most superficialPost cut nerve of thighLymph nodes and vessels

FactoidsPopliteal artery is deep to popliteal vein which is deep to nervesSkin overlying popliteal fossa supplied by post cut nerve of thigh

Posterior to Medial MalleolusTom Dick And Very Nervous HarryTibialis posterior tendonFlexor Digitorum Longus tendonPosterior tibial ArteryPosterior tibial VeinTibial NerveFlexor Hallicus longus tendon

MusclesMuscles Inserting Onto Greater Trochanter

Gluteal Region

Gluteus medius and minimus (maximus goes to iliotibial tract)Gemellus superior and inferiorObturator internus and externusPiriformisQuadratus femoris

Gluteus MaximusCourse: post gluteal line, post sacrum and coccyx, sacrotuberous ligament iliotibial tract, gluteal tuberosity of femur

Action: extends and laterally rotates thighNerve: inf glutealArtery: sup and inf gluteal

Gluteus MediusCourse: ext ilium between post and ant gluteal lines greater trochanter of femurAction: abduct and medially rotates thighNerve: sup glutealArtery: sup gluteal

Gluteus MinimusCourse: ext ilium between ant and inf gluteal lines greater trochanter of femurAction: abducts and medially rotates thighNerve: sup glutealArtery: sup gluteal

PiriformisCourse: ant sacrum upper greater trochanter of femurAction: laterally rotates and abducts thighNerve: S1 – 2Artery:Factoid: passes through greater sciatic foramen

Superior GemellusCourse: ischial spine obturator internus tendonAction: laterally rotates femurNerve: nerve to obturator internusArtery: inferior gluteal

Inferior GemellusCourse: ischial tuberosity obturator internus tendonAction: laterally rotates femurNerve: nerve to quadratus femorisArtery: inferior gluteal

Obturator InternusCourse: internal obturator membrane and margin of obturator foramen med greater trochanter above trochanteric fossaAction: laterally rotates and abducts thighNerve: nerve to obturator internusArtery: obturator

Obturator ExternusCourse: external obturator membrane and sup and inf pubic rami trochanteric fossa of femurAction: laterally rotates thighNerve: obturatorArtery: obturator

Quadratus FemorisCourse: lat ischial tuberosity quadrate line of femur below intertrochanteric crestAction: laterally rotates thighNerve: nerve to quadratus femorisArtery: inf gluteal

Posterior Thigh

SemimembranosusCourse: upper lateral ischial tuberosity med condyle of tibiaAction: Extends thigh, flexes kneeNerve: tibialArtery: deep femoral

SemitendinosusCourse: lower, med ischial tuberosity (common tendon with biceps femoris) med tibia (via pes anserinus)Action: extends thigh, flexes kneeNerve: tibialArtery: deep femoralFactoid: pes anserinus is common insertion for gracilis, sartorius and semitendinosus

Bicep femorisLong head: ischial tuberosity head of fibula and lat condyle of tibiaShort head: lat lip of linea aspera head of fibula and lat condyle of tibiaAction: extends thigh, flexes kneeNerve: long head – tibial nerve

short head – common fibular nerveArtery: deep femoral

Medial Thigh

Adductor MagnusCourse: ischiopubic ramus and ischial tuberosity linea aspera and adductor tubercle of femurAction: adducts, flexes and medially rotates thigh

ischiocondylar part: extends thighNerve: post division of obturator nerve

ischiocondylar part: tibial nerveArtery: obturator, deep femoral, medial femoral circumflex

GracilisCourse: pubic symphysis and inf pubic ramus med tibia (via pes anserinus)Action: adducts, flexes and medially rotates thigh, flexes kneeNerve: ant division of obturator nerveArtery: obturator

Adductor BrevisCourse: inf pubic ramus pectineal line and linea asperaAction: adducts, flexes and medially rotates thighNerve: ant division of obturator nerveArtery: obturator, deep femoral

Adductor LongusCourse: med sup pubic ramus lower 2/3 linea aspera of femurAction: adducts, flexes and medially rotates thighNerve: ant division of obturator nerveArtery: obturator, deep femoral

Anterior Compartment of Thigh

IliacusCourse: iliac fossa and crest, ala of sacrum lesser trochanter of femurAction: flexes thighNerve: femoralArtery: iliolumbarFactoid: inserts with psoas major via iliopsoas tendon

IliopsoasCourse: iliac fossa, bodies and transverse processes of lumbar vertebrae lesser trochanter of femurAction: flexes thigh, flexes lumbarNerve: L2-4, femoralArtery: iliolumbar

PectineusCourse: pectin of pubis pectineal line of femurAction: adducts, flexes, and medially rotates thighNerve: femoral and ant division of obturator – DUAL NERVE SUPPLYArtery: med femoral circumflex

SartoriusCourse: ant sup iliac spine med tibia (pes anserinus)Action: flexes, abducts and laterally rotates thigh, flexes kneeNerve: femoralArtery: lat femoral circumflex, saphenous

Quadriceps Femoris1) Rectus Femoris

a. Straight head: ant inf iliac spine patellar ligament (patella and tibial tuberosity)b. Reflected head: sup rim of acetabulum patellar ligament

2) Vastus Intermedius: ant lat femur patella3) Vastus Lateralis: lat IM septum, lat linea aspera and gluteal tuberosity patella and med patellar

retinaculum4) Vastus Medialis: med IM septum, med linea aspera patella and med patellar retinaculum

Action: extends knee (all), flexes thigh (rectus femoris)Nerve: femoralArtery: lat circumflex femoral (all), perforating branches of deep femoral (vastus medialis)

Anterior Compartment Leg

Tibialis AnteriorCourse: lat tibial condyle and upper lat tibia med medial cuneiform and 1st MTAction: dorsiflexes and inverts footNerve: deep fibularArtery: ant tibialFactoid: ant tibial artery lies lateral to this

Extensor Digitorum LongusCourse: lat condyle of tibia, ant fibula, lat IO membrane extensor expansions lat 4 toesAction: extends MTP, PIP and DIPJ lat 4 toesNerve: deep fibular

Artery: ant tibialFactoid: ant tibial artery lies medial to this

Extensor Hallicus LongusCourse: med ½ ant fibula and IO membrane base DP GTAction: extends MTP and IPJ GTNerve: deep fibularArtery: ant tibial

Fibularis TertiusCourse: distal ant fibula dorsum shaft 5th MTAction: everts footNerve: deep fibularArtery: ant tibial

Lateral Compartment Leg

Boundaries:Lat surface fibulaAnt and post IM septaDeep fascia legSuperior fibular retinaculum

Posterior Compartment Leg

SUPERFICIAL

Fibularis BrevisCourse: lower 1/3 lat fibula tuberosity base 5th MTAction: plantar flexes and everts footNerve: sup fibularArtery: fibular

Fibularis LongusCourse: upper 2/3 lat surface fibula past groove on ant-inf aspect of cuboid deep to intrinsic muscles of foot med cuneiform and base 1st MTAction: plantar flexes and everts footNerve: superficial fibularArtery: fibular

Tendons are posterior to lat malleous, through sup fibular retinaculum (from lat malleolus to calcaneus)

DEEP

GastrocnemiusMedial head: above medial femoral condyle dorsum of calcaneus via calcaneal tendonLateral head: above lateral femoral condyle dorsum of calcaneus via calcaneal tendonAction: flexes knee, plantar flexes footNerve: tibialArtery: sural, post tibial

SoleusCourse: post head and upper shaft fibula, soleal line tibia calcaneus via Achille’s tendonAction: plantar flexionNerve: tibialArtery: post tibial

PlantarisCourse: above lat femoral condyle calcaneus medial to calcaneal tendonAction: flex knee, plantar flexionNerve: tibialArtery: popliteal

Muscles of the Foot

1ST LAYER

Flexor Hallicus LongusCourse: lower 2/3 post fibula base DP GTAction: flexes MTP and PIPJ GT, plantar flexes footNerve: tibialArtery: fibular, tibialFactoid: important in ‘push off’

Flexor Digitorum LongusCourse: mid ½ post tibia bases DP digitsAction: flexes MTP, PIP and DIPJ, plantar flexes footNerve: tibialArtery: tibial

Tibialis PosteriorCourse: IO membrane, postmed fibula, postlat tibia tuberosity of navicular and med cuneiform, MT’sAction: plantar flexes and inverts footNerve: tibialArtery: fibular, tibial

PopliteusCourse: lat condyle femur post tibia above soleal lineAction: flexes knee, med rotate femurNerve: tibialArtery: poplitealFactoid: unlocks knee to initiate flexion of knee; lies immediately deep to popliteal art; may attach to lat meniscus

2ND LAYER

1. Abductor HallicusCourse: med tuberosity of calcaneus, flexor retinaculum, plantar aponeurosis med base PP gt toeAction: abducts GT, flexes MTPJNerve: medial plantarArtery: med plantar

2. Flexor Digitorum BrevisCourse: med tuberosity of calcaneus, plantar aponeurosis, IM septum base MP 2-5Action: flexes MTP and PIPJ 2-5Nerve: med plantarArtery: med and lat plantarFactoid: splits to allow passage of flexor digitorum longus

3. Abductor digiti minimiCourse: med and lat tuberosity of calcaneus, plantar aponeurosis, IM septum lat base PP 5th digit Action: abducts LT, flexes MTPJNerve: lat plantar nerveArtery: lat plantar

3RD LAYER

1. Quadratus PlantaeCourse: med plantar surface of calcaneus postlat tendon of flexor digitorum longusAction: flexes lat 4 digitsNerve: lat plantar

2. LumbricalsCourse: tendons of FDL med expansionAction: flex PIP, extend MIP and DIPNerve: med plantar (med 1), lat plantar (lat 3)

3. Flexor Digitorum LongusCourse: mid ½ post tibia bases DP digitsAction: flexes MTP, PIP and DIPJ, plantar flexes footNerve: tibialArtery: tibial

4. Flexor Hallicus LongusCourse: lower 2/3 post fibula base DP GTAction: flexes MTP and PIPJ GT, plantar flexes footNerve: tibialArtery: fibular, tibialFactoid: important in ‘push off’

4TH LAYER

Dorsal Interosseous (4)Course: shafts MT base PPAction: abduct 2-4; flex MTPJ and extend IPJNerve: lat plantar (deep branch)Artery: dorsal metatarsal

Plantar Interossei (3)Course: bases and med sides MT med bases of PAction: adducts digits, flex MTPJNerve: lat plantar

1. Flexor Hallicus BrevisCourse: cuboid, lat cuneiform, med 1st MT med PP GT, lat PP GTAction: flexes MTPJ GTNerve: med plantarArtery: med plantarFactoid: tendons of insertion contain sesamoid bone

2. Adductor HallicusOblique head: bases of MT 2-4 lat side base PP GTTransverse head: heads of MT 3-5 lat side base PP GTAction: adducts GTNerve: lat plantar (deep branch)Artery: plantar arterial archFactoid: plantar arterial arch passes sup to oblique head of adductor hallucis

3. Flexor Digiti Minimi BrevisCourse: base 5th MT lat base PP LTAction: flexes MTPJ LTNerve: lat plantarArtery: lat plantar

Extensor Digitorum BrevisCourse: suplat calcaneus extensor expansion toes 1-4Action: extends toes 1-4Nerve: deep fibularArtery: dorsalis pedis

Extensor Hallicus BrevisCourse: suplat calcaneus dorsum of base PP GTAction: extends GTNerve: deep fibularArtery: dorsalis pedis

MUSCLE ATTACHMENTS

ARTERIES

Blood Supply to HipTrochanteric anastomosis (gter trochanter): descending sup gluteal

inf glutealascending branches of med and lat circumflex femoral

Cruciate anastomosis (lesser trochanter): descending branch of inf glutealascending branch of 1st perforating arterytransverse branches of med and lat circumflex femoral

Femoral Artery

Profunda FemorisArises from lat side of fem art within fem triangle, 4cm inf to inguinal ligament runs lat to fem art passes posterior leaving fem triangle between pectineus and adductor longus descends post to adductor longusBranches: perforating branches – perforate adductor magnus to post and lat compartments of thigh

circumflex femoral – med branch – passes between iliopsoas and pectineus; supplies blood to head and neck of femur

lat branch – passes deep to sartorius and rectus femoris

Popliteal Artery

Continuation of ex iliac beginning at femoral triangle descends on iliopsoas, pectineus and adductor longus enters adductor canal (vein lies post to artery, saphenous nerve ant to artery) pass through adductor hiatus becomes popliteal arteryFactoid: bisects femoral triangle

Popliteal

Begins when femoral artery passes through adductor hiatus of adductor magnus Passes inferolaterally through fossa Divides at inf border of popliteus ant and post tibial arteriesStarts medial to tibial nerve, ends lateral to it. Popliteal vein lies between the twoGives off sural arteries to supply gastrocnemius

Branches form genicular anastomosis1) Inf lat genicular2) Inf med genicular3) Sup lat genicular4) Sup med genicular5) Mid genicular

Also contribute to anastomosis:

Descending genicular branch of femoral art

Descending branch of lat femoral circumflex art

Ant tibial recurrent branch of ant tibial art

Anterior Tibial ArteryBegins at inf border of popliteus passes anteriorly through IO membrane descends on ant surface of IO membrane between EHL and TA with deep fibular nerve changes name to dorsalis pedisGive off ant and post tibial recurrent arteries at knee; malleolar arteries over med and lat malleoliAccompanied by ant tibial vein

Posterior Tibial ArteryBegins at distal border of popliteus as popliteal artery passes deep to tendinous arch of soleus and gives off fibular artery accompanied by tibial nerve runs post to medial malleolus runs between tendons of FHL and FDL divides into med and lat plantar arteriesGives off tibial nutrient arteryAccompanied by deep tibial vein

Fibular ArteryArises from post tibial artery inf to distal border of popliteus and tendinous arch of soleus descends to med side of fibula within FHLBranches: nutrient artery of fibula

perforating branch – pierves IO membranelat calcaneal branch heellat malleolar branch

Dorsalis Pedis ArteryContinuation of ant tibial artery. Travels deep to extensor hallicus longus in ankle lies lat to tendon of EHL ends when divides to form 1st dorsal metatarsal and deep plantar arteryJoins lat plantar artery to form plantar arch

VEINSFemoral VeinAscends through adductor canal, passing from postlat to fem art to posterior femoral canal becomes ex iliac vein. Receives greater saphenous vein in femoral triangle

Popliteal Vein

Begins at distal border of popliteus as post tibial and ant tibial veins meet peroneal vein drains into itLies in sheath with popliteal artery, passing from med to lat side of arteryBecomes femoral vein as passes through adductor hiatusSmall saphenous vein drains in in popliteal fossa

Med and lat plantar veins form post tibial and fibular veins POST TO MED AND LAT MALLEOLI

NERVES

Clunial Nerve

Great Saphenous VeinFormed by union of dorsal vein of gt toe and dorsal venous arch ascends ANTERIOR TO MEDIAL MALLEOLUS POST TO MEDIAL CONDYLE OF FEMUR passes through saphenous opening in fascia lata enters femoral vein in femoral triangleAccompanied by saphenous nerve

Small Saphenous VeinFormed by union of dorsal vein of lt toe and dorsal venous arch ascends POST TO LAT MALLEOLUS along lateral border of calcaneal tendon penetrates deep fascia between 2 heads of gastrocnemius ascends enters popliteal veinAccompanied by sural nerve

Superior, middle and inferior clunial nerve – supply skin over iliac crest

Superior Gluteal NerveCourse: runs between gluteus medius and minimus with deep branch of sup gluteal arterySupplies: gluteus medius and tensor of fascia lataLesion: loss of abduction at hip

Inferior Gluteal NerveCourse: runs through greater sciatic foramen (inf to Piriformis, deep to gluteus maximus and sup to sciatic nerve) with inf gluteal vesselsSupplies: gluteus maximusLesion: loss of extension of hip

Sciatic Nerve

Pudendal NerveMost medial structure to exit greater sciatic foramen inf to Piriformis enters perineum through lesser sciatic foramen

Femoral Nerve

Course: formed at inf border of Piriformis; most lateral structure coming through greater sciatic foramen runs inflat under gluteus maximus midway between greater trochanter and ischial tuberosity rests on ischium passes post to obturator internus, quadratus femoris and adductor magnus travels in thigh deep to biceps femoris

Accompanied by post femoral cutaneous nerve and inf gluteal artery

Branches: tibial and common fibular nerve

Supplies: post thigh muscles, all muscles of leg and foot, most skin of leg and foot

Lesion: loss of all motor except adduction and flexion of thigh and extension of kneeloss of sensation lower leg and foot

Surface marking: midpoint between ischial tuberosity and gter trochanter apex of popliteal fossa

Course: descends through psoas major down between psoas major and iliacus deep to inguinal ligament midpoint splits into ant and post divisions through femoral triangle where separated from femoral artery by portion of psoas majorAnterior division: anterior cutaneous branch (intermediate and medial cutaneous)

muscular branches – to pectineus and sartoriusPosterior division: saphenous – accompanies femoral artery and vein in adductor canal becomes

superficial by passing between sartorius and gracilis skin and fascia on antmed knee, leg and foot

muscular branches – to quadsarticular branches – to knee and hip

Factoid: largest branch of lumbar plexus)comes from POSTERIOR divisions of anterior rami

Obturator Nerve

Splits into superficial (R) and deep (L) groups

Sup: 2 muscular, 2 cutaneousDeep: 2 muscular, 2 cutaneous

From ventral divisions of L2-4 descends through psoas major pierces psoas fascia, crosses sacroiliac joint, passes lat to in iliac vessels and ureter leaves pelvis through obturator foramen divides into ant and post branches which are separated by obturator externus then adductor brevis

Supplies: obturator externus, pectineus, adductor longus, adductor brevis, gracilis, adductor magnus, and med thigh

Tibial NerveFormed at bifurcation of sciatic nerve at top of popliteal fossa where it lies medial to vessels passes between 2 heads of gastrocnemius deep to tendinous arch of soleus with post tibial vessels descends in post compartment of leg deep to soleus on tibialis posterior lies between tendons of FHL and FDL POSTERIOR TO MEDIAL MALLEOLUS terminates as med and lat plantar nerves

Gives branches in fossa – gastrocnemius, soleus, plantaris, popliteus. Also supplies tibialis posterior, FDL, FHLMed plantar – supplies AbH, FDB, 1st lumbrical, medial sole of foot and med 3.5 toesLat plantar – supplies quadratus plantae, FDM, AdH, IO, AbDM and 3 lumbricals, lat sole and lat 1.5 toes

Med sural cutaneous (joined by sural communicating branch from fibular sural nerve) skin of inf leg and lat foot

Lesion: loss of flexion of toes and inversion of foot; loss of sensation sole of foot

Common Fibular NerveFrom dorsal branches L4+5, S1+2 begins at top of popliteal fossa Follows med border of biceps femoris in lat popliteal fossa Passes superficial to lat head of gastrocnemius passes between soleus and fibularis longus Winds around post neck of fibula runs deep to fibularis longus Divides into superficial and deep fibular nerveLesion: loss of extension toes and foot; loss of sensation lat lower leg and upper foot

Before division: articular branch to knee lat sural cutaneous – postlat calf

Superficial Fibular NerveBegins between fibularis longus and fibula runs between fibular muscles and EDL pierces deep fascia to become superficial at lower 1/3 leg divides into medial and intermediate dorsal cutaneous nerveSupplies: fibularis longus and brevis; skin of distal ant leg and dorsum of footAction: everts foot

Deep Fibular NerveArises between fibularis longus and neck of fibula accompanies ant tibial artery between tibialis anterior and EDL pierces ant crural intermuscular septum and EDL runs deep to EDL descends ant to IO membrane with ant tibial artery between TA and EHL divides into lateral and medial terminal branch at ankleSupplies: skin of 1st webspace, tibialis anterior, EDL, fibularis tertius, EHL, ankleAction: dorsiflexion, extension toes

Sural NerveFormed by medial sural cutaneous and peroneal anastomotic branches passes down with small saphenous vein, near lat margin of tendocalcaneus, behind lat malleolus. Becomes lat dorsal cutaneous nerve