Clavicle: muscles and ligamentsFemur: Muscles, ligaments and Innervation

B.Sc Physiotherapy Intake 2010

Desiree Vella BrincatSarah GrimaRebecca Gatt

Matthew CamilleriPeter Naudi

Sarah Ann Grech

THE CLAVICLE

The clavicle is a sub-cutaneous bone between the sternum and the Acromion. The medial two thirds is triangular and convex forwards, the lateral third is flattened and

concave forward. It articulates with the sternum at the sterno-clavicular joint and the acromion at the acromio-

clavicular joint. The clavicle acts as a strut for the upper limb and it transfers stress from the upper limb to

the axial skeleton.

Muscles originating from the clavicle:

Deltoid:

Origin : Anterior fibres originate from the anterior and superior surfaces of the lateral one third of the clavicle. Lateral fibres originate from the Acromion process, and posterior fibres originate from the lower lip of the spine of the scapula.

Insertion : They insert into the deltoid tuberosity on the middle of the lateral aspect of the shaft of the humerus.

Innervation : It is Innervated by the Axillary nerve

Action : shoulder abduction, flexion and hyper extension.

Sternohyoid:

Origin : The posterior surface of the medial third of the clavicle, the posterior sternoclavicular ligament and the upper and posterior manubrium sterni.

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Insertion : into the hyoid bone.

Innervation : the ansa cervicalis

Action : depresses the hyoid bone.

Pectoralis Major:

Origin : The anterior surface of the medial half of the clavicle and the anterior surface of the sternum, the superior six costal cartilages, and the aponeurosis of the external oblique muscle.

Insertion : into the lateral lip of the Bicipital groove.

Innervation : the medial and lateral pectoral nerves, C5 - T1.

Action : The clavicular head flexes the humerus and the sternocostal head extends the humerus. As a whole it adducts and medially rotates the humerus. It also draws the scapula anteriorly and inferiorly.

Sternocleidomastoid:

Origin : The sternal head originates from the superior anterior surface of the manubrium sternum and the clavicular head originates from the superior anterior aspects of the medial one third of the clavicle.

Insertion : The lateral aspect of the mastoid process.

Innervation : the accessory nerve and the cervical plexus.

Action : Acting alone, tilts head to its own side and rotates it so the face is turned towards the opposite side. Acting together, flexes the neck, raises the sternum and assists in forced inspiration.

Muscles inserting into the clavicle:

Trapezius:

Origins : the upper fibres originate from the external occipital protuberance, ligamentum nuchae and the medial third of the superior nuchal line of the external protuberance. The middle fibres private from C7 - T3 and the lower fibres originate from T4 - T12.

Insertions : The upper fibres insert into the posterior aspect of the lateral one third of the clavicle. The middle fibres insert into the medial border of the Acromion and the superior lip of the spine of the scapula and the lower fibres insert into the medial aspect of the spine of the scapula.

Innervation: It is Innervated by C3 and C4,

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Action: rotates, retracts, elevates and depresses the scapula.

Subclavius:

Origin: The first rib

Insertion: the subclavian groove on the inferior aspect of the clavicle (in the middle)

Innervation: the nerve to sub-clavius

Action: depresses the clavicle.

Levator Claviculae:

Only present in 2-3% of population.

Origin: Anterior portion of transverse processes of C1 - C4 vertebrae

Insertion: Lateral half of the clavicle

Nerve: C2-C5

Action: Lifts clavicle

THE FEMUR

The femur is the longest bone in the body. It has a head, a neck, a greater trochanter and a lesser trochanter on the upper end The head of the femur articulates with the acetabulum at the hip joint In the middle of a head there is a small depression called the fovea capitis. The shaft of the femur is smooth and rounded on the anterior surface but has a ridge

posteriorly called the linea aspera. At the lower end the femur has 2 condyles (medial and lateral) which are separated

posteriorly by the intercondylar notch. Above the condyles are the medial and lateral epicondyles. The condyles articulate with the

tibia to form the knee joint.

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Muscles originating from the femur

Vastus lateralis:

Origin : Upper end and shaft of femur

Insertion : Quadriceps tendon into patella, then via ligamentum patellae into tubercle of tibia

Innervation : Femoral nerve (L2-4)

Action : Extension of leg at knee joint

Vastus medialis:

Origin : Upper end and shaft of femur

Insertion : Quadriceps tendon into patella, then via ligamentum patellae into tubercle of tibia

Innervation : Femoral nerve (L2-4)

Action : Extension of leg at knee joint; stabilizes patella

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Vastus intermedius:

Origin : Anterior and lateral surfaces of shaft of femur

Insertion : Quadriceps tendon into patella, then via ligamentum patellae into tubercle of tibia

Innervation : Femoral nerve (L2-4)

Action : Extension of leg at knee joint; articularis genus retracts synovial membrane

Biceps femoris:

Origin : The long head from the ischial tuberosity and the short head from the linea aspera, lateral supracondylar ridge of shaft of femur

Insertion : Head of fibula

Innervation : The long head: tibial portion of sciatic nerve and the short head: common peroneal portion of sciatic nerve

Action : Flexes and laterally rotates leg at knee joint; long head also extends thigh at hip joint

Muscles inserting into the femur:

Gluteus maximus:

Origin : Outer surface of ilium, sacrum, coccyx, sacrotuberous ligament

Insertion : Iliotibial tract and gluteal tuberosity of femur

Innervation : Inferior gluteal nerve (L5; S1, S2)

Action : Extends and laterally rotates hip joint; through iliotibial tract, it extends knee joint

Gluteus medius:

Origin : Outer surface of ilium

Insertion : Lateral surface of greater trochanter of femur

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Innervation : Superior gluteal nerve (L5; S1)

Action : Abducts thigh at hip joint; tilts pelvis when walking to permit opposite leg to clear ground

Gluteus minimus:

Origin : Outer surface of ilium

Insertion : Anterior surface of greater trochanter of femur

Innervation : Superior gluteal nerve (L5;S1)

Action : Abducts thigh at hip joint; tilts pelvis when walking to permit opposite leg to clear ground

Piriformis:

Origin : Anterior surface of sacrum

Insertion : Upper border of greater trochanter of femur

Innervation : First and second sacral nerves (L5;S1, S2)

Action : Lateral rotator of thigh at hip joint

Obturator internus:

Origin : Inner surface of obturator membrane

Insertion : Upper border of greater trochanter of femur

Innervation : Sacral plexus (L5; S1)

Action : Lateral rotator of thigh at hip joint

Gemellus superior:

Origin : Spine of ischium

Insertion : Upper border of greater trochanter of femur

Innervation : Sacral plexus (L5; S1)

Action : Lateral rotator of thigh at hip joint

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Gemellus inferior:

Origin : Ischial tuberosity

Insertion : Upper border of greater trochanter of femur

Innervation : Sacral plexus (L5; S1)

Action : Lateral rotator of thigh at hip joint

Quadratus femoris:

Origin : Lateral border of ischial tuberosity

Insertion : Quadrate tubercle of femur

Innervation : Sacral plexus (L5; S1)

Action : Lateral rotator of thigh at hip joint

Iliacus:

Origin : Iliac fossa of hip bone

Insertion : With psoas into lesser trochanter of femur

Innervation : Femoral nerve (L2, L3)

Action : Flexes thigh on trunk; if thigh is fixed, it flexes the trunk on the thigh as in sitting up from lying down

Psoas:

Origin : Transverse processes, bodies, and intervertebral discs of the 12th thoracic and five lumbar vertebrae

Insertion : With iliacus into lesser trochanter of femur

Innervation : Lumbar plexus (L1, L2, L3)

Action : Flexes thigh on trunk; if thigh is fixed, it flexes the trunk on thigh as in sitting up from lying down

Pectineus:

Origin : Superior ramus of pubis

Insertion : Upper end of linea aspera of shaft of femur

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Innervation : Femoral nerve (L2, L3)

Action : Flexes and adducts thigh at hip joint

Adductor longus:

Origin : Body of pubis, medial to pubic tubercle

Insertion : Posterior surface of shaft of femur (linea aspera)

Innervation : Obturator nerve (L2, L3, L4)

Action : Adducts thigh at hip joint and assists in lateral rotation

Adductor brevis:

Origin : Inferior ramus of pubis

Insertion : Posterior surface of shaft of femur (linea aspera)

Innervation : Obturator nerve (L2, L3, L4)

Action : Adducts thigh at hip joint and assists in lateral rotation

Adductor magnus:

Origin : Inferior ramus of pubis, ramus of ischium, ischial tuberosity

Insertion : Posterior surface of shaft of femur, adductor tubercle of femur

Innervation : Adductor portion: obturator nerve and the Hamstring portion: sciatic nerve

Action : Adducts thigh at hip joint and assists in lateral rotation; hamstring portion extends thigh at hip joint.

Obturator externus:

Origin : Outer surface of obturator membrane and pubic and ischial rami

Insertion : Medial surface of greater trochanter

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Innervation : Obturator nerve (L3, L4)

Action : Laterally rotates thigh at hip joint

INNERVATION OF THE LOWER LIMB

The nerve supply of the lower limbs is provided by the lumbo-sacral plexus of nerves.

Lumbar plexus

Is made up of the anterior rami of : last thoracic nerve (T12) first 4 lumbar nerves ( L1-L4)

This is found in the lumbar region over psoas muscle and supplies muscles around the hip joint and anterior thigh.

Sacral plexus

This is made up of the anterior rami of L4, L5, S1, S2 and S3Providing motor and sensory nerves for the:

posterior thigh most of lower leg entire foot part of pelvis.

Nerve Supply of the hip joint

femoral nerve (anterior) obturator nerve (medial) sciatic nerve (posterior) dividing into:

o tibial

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o common peroneal superficial deep

Nerve supply of the knee joint

femoral nerve obturator nerve sciatic : tibial , common peroneal

Nerve supply of the ankle joint

Deep peroneal tibial

Femoral nerve (L2, L3, L4)

This is the largest nerve of the lumbar plexus. It runs downwards and laterally between psoas and iliacus and enters the thigh behind the inguinal ligament lateral to the femoral vessels and femoral sheath. This nerve supplies various muscles including:

quadriceps femoris iliopsoas pectineus Sartorius

It also supplies skin on the anterior surface of the thigh, the medial side of the leg and foot and the hip and knee joint. Immediately after passing under the inguinal ligament: Divides into:

Anterior branch Posterior branch

These both supply the: anterior compartment of the thigh skin on anterior and medial aspects of the thigh and medial side of leg and foot.

Branches of the femoral nerve include: Anterior cutaneous branch: penetrate deep fascia and supply skin on the front of the thigh

and knee Numerous motor nerves supplying the quadriceps, femoris muscles, Sartorius. One long cutaneous nerve: the saphenous nerve which supplies skin till the medial side of

foot.Therefore saphenous nerve is given off just below the inguinal ligament and passes across the thigh to the medial side of the knee, continuing along the medial side of leg and foot to base of big toe.

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Obturator nerve ( L2, L3, L4 )

This nerve arises from the lumbar plexus and passes through the obturator foramen and divides into the anterior and posterior division. It supplies all the muscles that bring about adduction of the hip, including:

adductor longus, adductor magnus adductor brevis gracilis

It also supplies the skin on the medial side of the thigh, the hip and knee joint and the muscles obturator externus and pectineus.

Sciatic nerve

Is the longest and widest single nerve in the body. It supplies nearly the whole of the skin of the leg, the muscles of the back of the thigh, and those of the leg and foot. It is derived from spinal nerves L4 through S3. It contains fibres from both the anterior and posterior divisions of the lumbosacral plexus.In the posterior compartment, the sciatic nerve lies on adductor magnus and is crossed by the long head of biceps femoris.

Proximal to the knee, the sciatic nerve divides into its terminal branches: Tibial nerve Common peroneal nerve

These nerves travel down the thigh into the popliteal fossa at the back of the knee where they meet the popliteal artery and vein.

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Tibial nerve

This never supplies (before or after separation) branches to all muscles in the posterior compartment of the thigh

Long head of biceps Semimembranosus Semitendinosus

(short head of biceps is supplied by the common peroneal nerve)

This nerve descends in the popliteal possa deep to the tendonous arch of soleus. Crosses leg between flexors digitorum nd hallucis longus, behind median malleolus, deep to flexor retunaculum and enters the posterior compartment of the leg, and then goes to the sole of the foot where it divides into medial and lateral nerves.

This innervates:

All muscles in posterior compartment of leg All intrinsic muscles in the sole of the foot except for the first two dorsal interossei muscles,

which are innervated by the deep peroneal nerve Skin on poterolateral side of the lower half of the leg and medial side of the ankle, foot, and

little toe; and skin on the sole of the foot and toes

The medial plantar nerve supplies:

Adductor hallucis Flexor digitorum brevis 1st (medial lumbrical)

The lateral plantar nerve supplies:

Flexors accessorius and digiti minimi brevis Abductor digiti minimi Adductor hallucis Lateral 3 lumbricals Plantar and dorsal interossei

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Cutaneous supply of the tibial nerve

Sural nerve is the major sensory branch of the tibial nerve running from popliteal fossa to base of little toe; it supplies skin posterior and lateral surfaces of leg, lateral border foot and little toe.

Medial calcaneal nerve supplies skin over the heel.

Common peroneal nerve

Innervates the short head of biceps (hamstrings) and then continues into the lateral and anterior compartment of the leg and onto the foot.

This innervates:

All muscles in the anterior and lateral compartments of the leg One muscle (extensor digitorum brevis) on the dorsal aspect of the foot First 2 dorsal interossei muscles in the sole of the foot Skin over the lateral aspect of the leg*, ankle, and over dorsal aspect of the foot and toes

* lateral cutaneous nerve of the calf is the only branch of the common peroneal nerve

When the common peroneal nerve croses the popliteal fossa it passes around the neck of the fibula where it divides into:

Deep peroneal nerve Superficial peroneal nerve

Deep peroneal nerve

This supplies: Tibialis anterior Flexor digitorum longus Flexor hallucis longus Peroneus tertuis Extensor digitorum brevis

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It has an extensive supply over the lateral side of the calf and dorsum of the foot and toes except the interspace between the hallux and second toe, which is supplied by the deep peroneal nerve.

Superficial peroneal nerve

Supplies:

Peroneus longus Peroneus brevis

Ligaments attached to the clavicle

The interclavicular, superior sternoclavicular and posterior sternoclavicular ligaments help stabilize the sternoclavicular joint.

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The costoclavicular ligament is extracapsular and passes from the inferior surface of the medial end of the clavicle to the posterior surface of the first costal cartilage. It limits clavicular elevation and prevents excessive anterior and posterior movement.

The coracoclavicular ligament is also an extracapsular ligament and is made up of the conoid and trapezoid ligaments. The conoid ligament attaches to the conoid tubercle and the trapezoid ligament attaches to the trapezoid line. Together they fix the lateral end of the clavicle to the coracoid process and prevent medial displacement of the acromion under the lateral end of the clavicle. The conoid part limits forward movement of the clavicle while the trapezoid part limits backward movement.

The superior and inferior acromioclavicular ligaments provide horizontal stability to the acromioclavicular joint. The superior acromioclavicular ligament is a quadrilateral band, covering the superior part of the articulation, and extending between the upper part of the acromial end of the clavicle and the adjoining part of the upper surface of the acromion The inferior acromioclavicular ligament is thinner and covers the under part of the articulation, and is attached to the adjoining surfaces of the two bones.

Ligaments attached to the Femur

Proximal end of the femur

Proximally the femur has three ligaments which are there to reinforce the external part of the fibrous membrane and also stabilize the joint. These are:

Iliofemoral ligament Pubofemoral ligament Ischiofemoral ligament

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The iliofemoral ligament is thick, strong and triangular shaped. It is found between the anterior inferior iliac spine and the margin of the adjacent acetabulum, and also the intertrochanteric line. The reason why it is Y shaped is because the parts of the ligament attached above and below the intertrochanteric line are thicker than the ligament attached in the centre. This makes the outer bands stronger than the central part. This ligament limits extension, lateral rotation, abduction (lower band) and adduction (upper band).

The pubofemoral ligament is also triangular shaped and is anterior and inferior to the hip joint; the joint between the iliopubic eminence and superior pubic ramus, and the lower part of the intertrochanteric line. Limits extension, lateral rotation and abduction.

The ischiofemoral ligament is a spiral ligament found on the posterior aspect. It is attached to the ischium medially and posterioinferior to the acetabulum. Laterally it attaches to the greater trochanter of the femur.Limits extension, medial rotation and adduction.

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Distal end of the femur

The following ligaments are found within or around the knee joint which involve the femur.

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Collateral Ligaments

Medial (tibial) collateral ligaments: this is a strong ligament which attaches from the medial epicondyle of the femur to the medial condyle and shaft of the tibia.

Lateral (fibular) ligament: it is a cord-like ligament which attaches superiorly to the lateral condyle of the femur just about the groove for the popliteus tendon. Inferiorly it is attached to a depression on the lateral surface of the fibular head. This ligament is separate from the joint capsule.

These ligaments provide stability of the knee both laterally and medially.

Cruciate Ligaments

The cruciates cross each other between their femoral and tibial attachments.

The anterior cruciate ligament passes posteriorly, laterally and proximally from the anterior tibial spine to the medial surface of the lateral femoral condyle. As it passes this course, it spirals 110 degrees.

The posterior cruciate ligament anteriorly, medially and proximally from the posterior intercondylar area of the tibia to the lateral side of the medial femoral condyle.

The anterior cruciate ligament prevents anterior displacement of the tibia with respect to the femur. Hence, the posterior cruciate ligament resists posterior displacement.

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