presentation 4 - leg (ep)
TRANSCRIPT
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Superficial Anatomy:POSTERIOR LOWER LIMB
- Cluneal nerves (superior, middle, and inferior)- innervate skin of gluteal
region
-Posterior cutaneous nerve of thigh- Small saphenous vein, from lateral end ofdorsal venous arch, joins
popliteal vein by penetration deep fascia in popliteal fossa
- Sural nerve runs down posterior leg parallel to small saphenous vein,
lateral skin of ankle and foot
ANTERIOR LOWER LIMB
- Great saphenous vein, from medial end ofdorsal venous arch, accompanied
bysaphenous nerve,perforating veins connect to deep venous system
- Superficial external pudendal, superficial epigastric, and superficial
circumflex iliac all join great saphenous near proximal end
-Lateral femoral cutaneous nerve
-Anterior cutaneous branches of femoral nerve
- Cutaneous branches of the obdurator nerve
- Saphenous nerve
- Superficial fibular (peroneal) nerve, innervates dorsum of foot and sends as
branches dorsal digital nerves, 1st and 2nd toes receive dorsal digital branches
of deep fibular nerve
- Superficial inguinal lymph nodes: horizontal group, then vertical group
inferior to saphenous opening
collect lymph from lower limb, lower anterior abdominal wall, glutealregion, perineum, external genitalia, drain into deep inguinal lymph nodes
-fascia lata (of thigh) laterally iliotibial tract
- crural fascia (of leg)
-pedal fascia (of foot)
Gluteal Regionorigin insertion innervation function
MUSCLE: SUPERFICIAL
Gluteus
maximus
Ilium behind
posterior gluteal
line, sacrum,
coccyx, and
sacrotuberous
ligament
Iliotibial tract
laterally,
elongate gluteal
tuberosity of
femur deep and
distally
Inferior
gluteal nerve
Extends thigh,
stabilizes knee
and hip
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Gluteus
medius
Between anterior
and posterior
gluteal lines on
ilium
Greater
trochanter
Superior
gluteal nerve
Abduct femur,
reduce pelvic
drop
Gluteusminimus Between inferiorand anterior gluteal
lines on ilium
Greatertrochanter Superiorgluteal nerve Abduct femur,reduce pelvic
drop
Tensor
fasciae
latae
Anterior superior
iliac spine to
tubercle of iliac
crest
Iliotibial tract Superior
gluteal nerve
Stabilizes knee
in extention,
helps hold
femoral head in
acetabulum
MUSCLE: DEEP
Piriformis Between anterior
sacral foramina
Greater
trochanter
Nerve to
piriformis(from S1, S2)
Lateral
rotation,abducts femur
Obdurator
internus
Medial surface of
obturator membrane
and bone of
obdurator foramen
Just inferior to
piriformis on
greater
trochanter
Obturator
nerve
Lateral
rotation,
abducts femur
Gemellus
Superior
Ischial spine With O.I. on
greater
trochanter
Nerve to
obdurator
internus
Lateral
rotation, abduct
femur
GemellusInferior
Ischial tuberosity With O.I. ongreater
trochanter
Nerve toquadratus
femoris
Lateralrotation, abduct
femur
Quadratus
femoris
Lateral aspect of
ischium anterior to
tuberosity
Quadrate
tubercle of
intertrochanteric
crest of proximal
femur
Nerve to
quadratus
femoris
Lateral rotation
only
OTHER NERVES
Posterior cutaneous nerve of the
thigh
Skin over the gluteal fold, scrotum, labia majora,
posterior thigh, and posterior leg
Pudendal nerve No branches in gluteal region
Perforating cutaneous nerve Pierces sacrotuberous ligament, skin over medial
aspect of gluteus maximus
BLOOD SUPPLY: ARTERIES
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Inferior gluteal artery From anterior trunk of internal iliac, through
gluteal region into posterior thigh, anastomoses
with perforating branches of femoral artery
Superior gluteal artery From posterior trunk of internal iliac, superficial
branch: onto deep surface of glut.max., deepbranch: between glut.med. and glut.min.,
anastomose with medial and lateral femoral
circumflex artery and with inferior gluteal artery
BLOOD SUPPLY: VEINS
Inferior and Superior gluteal veins
LYMPHATICS
Deep lymphatic vessels Travel with blood vessels into pelvis internal
iliac nodes
Superficial lymphatics To superficial inguinal nodes on anterior thigh
Note:
greater sciatic foramen
Above piriformis: superior gluteal nerve, artery, and vein
Below piriformis: inferior gluteal nerve, artery, and vein, sciatic nerve,
posterior cutaneous nerve of thigh, pudendal nerve, internal pudendal vessels
Posterior Thighorigin insertion innervation function
MUSCLE (hamstrings)
Biceps femoris (2 heads):
Long head Ischial
tuberosity
Head of
fibula
(extensions
blend with
fibular
collateral
ligament)
Tibial
division of
sciatic nerve
Flexes leg,
extends and
laterally
rotates hip
Short head Lateral lip
of linea
aspera
Common
fibular
division of
sciatic nerve
Flexes leg
semitendinosis Ischial
tuberosity
Medial
surface of
superior part
of tibia
Tibial
division of
sciatic nerve
Extends and
medially
rotates
thigh, flexes
and
medially
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rotates leg
semimenbranosus Ischial
tuberosity
Medial and
posterior
surfaces of
medial tibialcondyle
Tibial
division of
sciatic nerve
Extends and
medially
rotates
thigh, flexesand
medially
rotates leg
POPLITEAL FOSSA:
Bounded by biceps femoris (superolaterally), semimembranosus and
semitendinosus (superomedially), gastrocnemius muscles (inferiorly), skin
and deep fascia (posteriorly), popliteal surface of femur and popliteus
(anteriorly)
Sciatic divides into:
Tibial nerve (medially)- deep to gastrocnemiusCommon fibular nerve (laterally)- superficial to gastrocnemius
Division usually proximal to knee, but may occur in pelvis
Popliteal artery and vein enclosed by a common connective tissue sheath
Superior medial and lateral genicular arteries (proximal to level of
gastrocnemius attachments)
Inferior medial and lateral genicular arteries
Note:
Pes anserinus= where sartorius, gracilis, and semitendinosus tendons
converge at proximal end of tibia
Anterior Thighorigin insertion innervation function
MUSCLE
iliacus Iliac fossa
(posterior
abdominal wall)
Lesser
trochanter
Femoral
nerve
Iliopsoas:
Flexes and
laterally
rotates thighPsoas major Vertebrae of
TXII to LV(posterior
abdominal wall)
Lesser
trochanter
Anterior
rami of L1,L2, L3
sartorius Anterior
superior iliac
spine
Medial
surface of
proximal
shaft of tibia
Femoral
nerve
Lateral
margin of
femoral
triangle,
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anterior wall
of adductor
canal
Flexes thigh
and leg,abducts and
laterally
rotates thigh
Quadriceps femoris (4 parts):
Rectus
femoris
Pelvic bone:
straight head
from anterior
inferior iliac
spine, reflected
head fromimmediately
superior to
acetabulum
Tibial
tuberosity via
quadriceps
femoris
tendon and
patellarligament
Femoral
nerve
Flexes thigh
and extends
leg
Vastus
medialis
Femur: Medial
lip of linea
aspera and
intertrochanteric
line
Femoral
nerve
Extends leg
Vastusintermedius Femur: Anteriorand lateral
surfaces of
femur
Femoralnerve Extends leg
Vastus
lateralis
Femur: Lateral
lip of linea
aspera and
greater
trochanter
Femoral
nerve
Extends leg
(articularis
genus)
Femur: inferior
to origin ofvastus
intermedius
Suprapatellar
bursa
Pulls bursa
away fromknee joint
during
extension
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SAPHENOUS OPENING:
Great saphenous vein (superficial) joins femoral vein and deeper anterior
thigh
FEMORAL TRIANGLE:
Femoral sheath envelopes(1) femoral artery (lateral)
branches: superficial external pudendal artery
superficial epigastric artery
superficial circumflex iliac artery
deep pudendal artery
largest branch = deep artery of thigh (e.g. deep femoral artery), between
pectineus and adductor longus, then between adductor brevis and adductor
longus, connects with popliteal artery
lateral circumflex femoral artery: anastomoses with medial femoral
circumflex, popliteal, inferior gluteal, first perforating medial femoral circumflex artery: branch through acetabular notch
that anastomoses with obdurator artery, also with inferior gluteal, lateral
circumflex, first perforating artery
together form cruciate anastomoses around hip
perforating arteries, anastomose superiorly and inferiorly, posterior to
adductor magnus
(2) femoral vein (intermediate)
branches: great saphenous vein
(3) deep inguinal lymph nodes (medial = femoral canal, proximal opening =femoral ring)
Borders include adductor longus, sartorius, and inguinal ligament, floor is
formed by iliopsoas and pectineus
Femoral nerve lies lateral to femoral artery, note anterior cutaneous
branches, motor nerves, and saphenous nerve (does not pass through
adductor hiatus)
ADDUCTOR CANAL:
Begins at apex of femoral triangle, ends at adductor hiatus (opening in
tendon of adductor magnus)
After adductor canal vessel names change from femoral to popliteal
Nerve to vastus medialis and saphenous nerve also in adductor canal
Medial Thighorigin insertion innervation function
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MUSCLE (adductor group)
Gracilis Ischiopubic
ramus
Medial
surface of
proximal
shaft of tibia
Obdurator
nerve
Adducts
thigh, helps
in flexion of
legPectineus Pectineal line
of pelvic
bone
Base of lesser
trochanter to
linea aspera
Femoral
nerve (may
receive
contribution
from
obdurator
nerve)
Adducts and
flexes thigh
Adductor
longus
Rough
triangular
area inferiorto pubic crest
Middle third
of linea
aspera
Obdurator
nerve
Adducts and
medially
rotates thigh
Adductor
brevis
Body and
inferior
ramus of
pubis
Pectineal line
and linea
aspera of
femur
Obdurator
nerve
Adducts
thigh
Adductor
magnus:
lateral,
adductorpart
Ishiopubic
ramus
Gluteal
tuberosity,
linea aspera,
medialsupracondylar
line
Obdurator
nerve
Adducts and
medially
rotates thigh,
help formadductor
hiatus
Adductor
magnus:
medial,
hamstring
part
Ischial
tuberosity
Adductor
tubercle on
medial
condyle of
distal head of
femur
Tibial
division of
sciatic nerve
Obdurator
externusmuscle
External
surface ofobdurator
membrane
and bone
Lateral wall
oftrochanteric
fossa
Obdurator
nerve
Lateral
rotator ofthigh
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VESSELS:
Deep artery of the thigh- between pectineus and adductor longus
perforating arteries- penetrate adductor brevis and encircle femur, supply
medial and posterior compartments
NERVES:Anterior branches of obdurator nerve- anterior to adductor brevis
Posterior branches of obdurator nerve- posterior to adductor brevis, anterior
to adductor magnus
Anterior Compartment of Leg:origin insertion innervation function
MUSCLE (extensors: dorsiflex foot, extend toes, invert foot)
Tibialis
anterior
Lateral
surface oftibia and
interosseous
membrane
Medial and
inferiorsurfaces of
medial
cuneiform
and adjacent
surfaces on
base of
metatarsal I
Deep fibular
nerve
Dorsiflexion
of foot,inversion of
foot, support
of medial
arch
Extensor
hallucislongus
Medial
surface offibula and
interosseous
membrane
Dorsal
surface ofdistal
phalanx of
great toe
Deep fibular
nerve
Extends great
toe,dorsiflexes
foot
Extensor
digitorum
longus
Medial
surface of
fibula and
head of
lateral
condyle of
tibia
Distal and
middle
phalanges of
lateral 4 toes
Deep fibular
nerve
Extension of
lateral 4 toes,
dorsiflexion
of foot
Fibularis
tertius
Usually considered as part of extensor digitorum longus
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VESSELS:
Anterior tibial artery- from popliteal artery, passes anterior through aperture
in interosseous membrane, continues onto dorsal aspect of foot as dorsalis
pedis artery, joined by perforating branch of fibular artery distally, distally
gives rise to:anterior medial malleolar artery
anterior lateral malleolar artery
NERVES:
Deep fibular nerve- originates in lateral compartment
Also supplies extensor digitorum brevis, 1st 2 dorsal interossei muscles, skin
between great and second toes
Dorsum of Foot:
BONES (tarsals:7, metatarsals:5, phalanges:14)calcaneous Cuboid (lateral) metatarsals phalanges
talus Navicular
(medial)
cuneiform (L,
I, M)
origin insertion innervation function
MUSCLES
Extensor
digitorum
brevis
calcaneous Lateral sides
of tendons of
extensor
digitorum
longus, toes2-4
Deep fibular
nerve
Extension of
toes
Extensor
hallucis
brevis
calcaneous Proximal
phalanx of
great toe
Deep fibular
nerve
Extension of
great toe
VESSELS:
Anterior tibial artery dorsalis pedis arteryarcuate artery dorsal
metatarsal arteries dorsal digital arteries
Also note:
Lateral tarsal artery branches from dorsalis pedis artery, goes deepDeep plantar artery branches from dorsalis pedis artery, goes deep to
anastomose with deep plantar arch
NERVES:
Common fibular nerve deep fibular nerve (runs parallel to anterior tibial
artery) two dorsal digital branches of deep fibular nerve (between toes 1
and 2)
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Superficial fibular nerve innervates all other skin on dorsum of foot
Posterior Compartment of Leg:origin insertion innervation function
MUSCLE (flexors: plantarflex ankle, flex toes, invert foot)SUPERFICIAL
Gastrocnemius Medial head:
above
articular
surface of
medial
condyle of
femur
Lateral head:
upper lateral
surface of
lateral
condyle of
femur
Calcaneous Tibial nerve Plantarflex
foot, flex
knee
Plantaris Lower part of
lateral
supracondylar
ridge and
obliquepopliteal
ligament
Calcaneous Tibial nerve Plantarflex
foot, flex
knee
Soleus Proximal
ends of tibia
and fibula
and a
tendinous
ligament
between them
Calcaneous Tibial nerve Plantarflex
foot
DEEP
Popliteus Posterior
surface of
proximal tibia
Lateral
femoral
condyle
Tibial nerve Unlocks
extended
knee at
initiation of
flexion
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Flexor hallucis
longus
Lower 2/3 of
fibula and
interosseous
membrane
Plantar
surface of
great toe
(distal
phalanx)
Tibial nerve Flexes great
toe (during
toe-off),
plantarflexion
of footFlexor
digitorum
longus
Medial side
of posterior
of tibia
Plantar
surfaces of
distal
phalanges,
toes II-V
Tibial nerve Flexes lateral
4 toes (end of
stance phase)
Tibialis
posterior
Interosseous
membrane
and adjacent
posterior
surfaces oftibia and
fibula
Plantar
surfaces of
medial
tarsals
(tuberosityof navicular,
medial
cuneiform)
Tibial nerve Inverts and
plantarflexes
foot
VESSELS (Note: veins follow arteries)
Popliteal artery Passes under tendinous ach formed by
medial and lateral heads of soleus,
branches into
Anterior tibial artery Enters and supplies anterior compartment
of leg, dorsum of footPosterior tibial artery Supplies posterior ad lateral compartments,
sole of foot
Passes through tarsal tunnel behind medial
malleolus
Circumflex
tibial artery
Laterally through soleus, around fibula,
anastomoses with vessels around knee
Fibular
artery
Parallels posterior tibial artery, travels
along posterior surface of fibula between
flexor hallucis longus and tibialis
posterior, supplies posterior and lateral
compartments
perforating
branch
Through inferior aperture in
interosseous membrane,
anastomoses with anterior
tibial artery
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NERVES:
Tibial nerve= major branch of sciatic, through tendinous arch of soleus,
enters the foot via tarsal tunnel, gives rise to 2 cutaneous branches:
sural nerve-
originates between 2 heads of gastrocnemius, runs superficially, suppliesskin on lower posterolateral surface of leg and lateral side of foot and little
toe
medial calcaneal nerve-
originates low in leg near ankle, descends onto medial side of heel, skin on
medial surface and sole of heel
Lateral Compartment of Leg:origin insertion innervation function
MUSCLEFibularis
longus
Upper lateral
surface of
fibula, fibular
head, lateral
tibial condyle
Undersurface
of lateral
sides of distal
end of medial
cuneiform
and base of
metatarsal I
Superficial
fibular nerve
Everts and
plantarflexes
foot, helps
support
lateral and
transverse
arches
Fibularis
brevis
Lower 2/3 of
lateral shaft
of fibula
Tubercle on
lateral
surface ofmetatarsal V
Superficial
fibular nerve
Evert foot
VESSELS:
Branches of fibular artery, deep veins follow the arteries
NERVES:
Superficial fibular nerve- branch of common fibular nerve (from sciatic
nerve), supplies lateral compartment and most of dorsum of foot
Common fibular nerve
sural communicating nerve
lateral sural cutaneous nerve
Sole of Foot:Plantar
aponeurosis
LAYER 1: origin insertion innervation function
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Flexor
digitorum
brevis
Calcaneal
tuberosity
and
digitorum
brevis
Middle
phalanges of
lateral 4 toes
Flexes lateral
4 toes
Abductor
hallucis
Medial side
of calcaneal
tuberosity
and plantar
aponeurosis
Medial side
of base of
proximal
phalanx of
great toe
Abducts great
toe
Abductor
digiti minimi
Lateral side
of calcaneal
tuberosity
and plantar
aponeurosis
Lateral side
of base of
proximal
phalanx of 5th
toe
Abducts the
5th toe
Medial and lateral plantar nerves common and proper plantar digital
nerves
LAYER 2: origin insertion innervation function
Quadratus
plantae
calcaneous Tendon of
flexor
digitorum
longus
Assists in
flexing lateral
4 toes
Lumbricals
(4)
Tendons of
flexordigitorum
longus
Extensor
expansions oflateral 4 toes
LAYER 3: origin insertion innervation Function
Flexor
hallucis
brevis
(medial and
lateral heads)
First
metatarsal,
cuboid, 3rd
metatarsal
Proximal
phalanx of
great toe,
sesamoid
bones found
in tendons
(protect
tendon of
flexor
hallucis
longus)
Flexes great
toe
Adductor Lateral side Adducts great
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hallucis
(transverse
and oblique
heads)
of proximal
phalanx of
great toe
toe
Flexor digitminimi Base of 5
th
metatarsal Proximalphalanx of 5th
toe
Flexes 5
th
toe
Posterior tibial nerve and artery medial and lateral plantar nerves and
arteries
LAYER 4: origin insertion innervation function
Interosseous
(DAB and
PAD)
Structures passing into:
Fibularis longus tendon occupies deepest plane on sole1st metatarsal and
1st cuneiform
Tibialis posterior tendon navicular, all 3 cuneiform, bases of 2nd, 3rd, and
4th metatarsals
Flexor hallucis longus tendon crosses sustentaculum tali (changes direction
of force) through an interosseous tunnel
VESSELS:
Deep plantar arch anastomoses with deep plantar branch of dorsalis pedis
artery
NERVES:Medial plantar nerve innervates:
Abductor hallucis, flexor digitorum brevis, flexor hallucis brevis, medial
lumbrical, cutaneous innervation to plantar surfaces of medial 3 toes
Lateral plantar nerve innervates:
All other muscles in sole, cutaneous innervation to lateral 1 toes
JOINTS:
(1) HIPIlium
Ischium
Pubis
Head
Fovea for ligament of head
Neck
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Intertrochanteric line
Fibrous joint capsule: iliofemoral, ischiofemoral, and pubofemoral ligaments
Ligament of head of femur (with artery), in acetabular notch
Articular surface of head of femur and lunate surface of acetabulum
Transverse acetabular ligament
Acetabular labrum
(2) KNEE
Femur: medial condyle, lateral condyle, intercondylar fossa
Tibia: superior articular surface, medial condyle, lateral condyle,
intercondylar eminence
Patella: articular and anterior surfaces
Tibial collateral ligament- attached to medial meniscus through joint capsule
Fibular collateral ligament- not attached to lateral meniscusOutside synovial cavity but inside joint capsule:
Posterior cruciate ligament (taut in flexion)
Anterior cruciate ligament (taut in externsion)
Tendon of quadriceps femoris and patellar ligament, also patellar retinacula
Menisci
Unhappy Triad
(3) ANKLE
Fibula: lateral malleolus
Tibia: medial malleolus
Talus :trochlea
Medial ligament: posterior tibiotalar, anterior tibiotalar, tibiocalcaneal,
tibionavicular
Lateral ligament: posterior talofibular, anterior talofibular, calcaneofibular
Inversion and eversion joints:
Eversion- fibularis brevis and fibularis longusInversion- tibialis anterior and tibialis posterior
Transverse talar joint (calcaneocuboid and talonavicular)
Subtalar joint
Longitudinal arch, supported by ligaments spanning tarsal bones
Long plantar ligament, short plantar ligament
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Plantar calcaneonavicular (spring) ligament (and tibialis posterior tendon)
support head of talus and longitudinal arch