Transcript WINDSOR UNIVERSITY SCHOOL OF MEDICINE

DEPARTMENT OF ANATOMY
Lower limb
Dr. SREEKANTH THOTA
Muscle compartments in the thigh
• In the thigh, there are medial (adductor),
anterior (extensor), and posterior (flexor)
compartments.
Anterior Compartment of the Thigh
• Muscles: Sartorius, iliacus, psoas, pectineus,
and quadriceps femoris
• Blood supply: Femoral artery
• Nerve supply: Femoral nerve
Anterior Thigh Muscles
• Anterior thigh muscles are the flexors of the
hip and extensors of the knee.
SARTORIUS
• Origin : A.S.I.S.
•Insertion : Upper medial surface of
shaft of tibia
• N. supply: Femoral nerve
• Action :1.Flexion, abduction and
Lateral rotation of thigh at hip joint.
2. Flexion leg at knee joint
ILIACUS
• Origin : Iliac fossa of hip bone
• Insertion : Along with psoas into
lesser trochanter of femur
• N. supply: Femoral nerve
• Action :Flexes thigh on trunk
• Eg.: Sitting up from lying down
PSOAS
• Origin : Transverse process, bodies &
I.V.D.’S of T12 & L 1-L5 vertebrae
• Insertion : Along with Iliacus into lesser
trochanter of femur
• N. supply: Lumbar plexus
• Action : Flexes thigh on trunk
• Eg.: Sitting up from lying down
T12
1
2
3
4
5
PECTINEUS
• Origin : Superior ramus of Pubis
• Insertion :
Upper end of linea aspera of
shaft of femur
• N. supply: Femoral nerve
• Action :Flexion, adduction of thigh
at hip joint
QUADRICEPS FEMORIS
RECTUS FEMORIS :
• Origin : Straight Head:
A.I.I.S
Reflected Head:
Ilium (Above Acetabulum)
• Insertion :
Quadriceps tendon in to patella
Via lig.patellae in to tibial tubercle
•N. supply: Femoral nerve
• Action : Flexion of thigh at hip joint
•Extension of Leg at Knee joint
Patellar ligament
• The patellar
ligament is the central
portion of the common
tendon of
the Quadriceps femoris,
which is continued
from the patella to the
tuberosity of the tibia.
VASTUS LATERALIS
• Origin : Upper end & shaft of femur
• Insertion : Quadriceps tendon in to
patella via Lig.patellae in to
tubercle of tibia
• N. supply: Femoral nerve
• Action : Extension of Leg at Knee joint
VASTUS MEDIALIS
• Origin : Upper end & shaft of femur
• Insertion : Quadriceps tendon in to
patella Via Lig.patellae in to
tubercle of tibia
• N. supply: Femoral nerve
• Action : Extension of Leg at Knee &
Stabilizes Patella
VASTUS INTERMEDIUS
• Origin : Anterior & lateral surface
of shaft of femur
• Insertion : Quadriceps tendon in to
patella Via Lig.patellae
in to tubercle of tibia
• N. supply: Femoral nerve
• Action : Extension of Leg at Knee joint
Summary of Ant compt of thigh
Muscle Movements
• Anterior compartment
– Flexors of hip
• Sartorius (also abducts and
laterally rotates hip and
flexes and medially rotates
knee)
• Iliopsoas
• Pectineus (also adducts
hip)
– Extensor of knee
• Quadriceps femoris
– Rectus femoris (also flexes
hip)
– Vastus lateralis
– Vastus intermedius
– Vastus medialis (also
stabilizes patella)
Patellar tendon reflex
• Tapping the patellar
ligament with a
hammer elicits the
patellar tendon reflex
(knee jerk)
• Tests the L2-L4 nerves
• Diminution or
absence—result from
interruption of
innervation of
quadriceps .
Medial compartment of thigh
Muscles: Gracilis, adductor longus, adductor brevis,
adductor magnus, and obturator externus.
• Blood supply: Profunda femoris
artery and obturator artery.
• Nerve supply: Obturator nerve
GRACILIS
• Origin : Inferior ramus of Pubis &
ramus of Ischium
• Insertion :Medial aspect of upper
part of shaft of tibia
• N. supply: Obturator nerve
• Action : Adduction of thigh at hip joint
Flexion of Leg at Knee joint
ADDUCTOR LONGUS
• Origin : Body of Pubis, medial
to pubic tubercle
• Insertion : Posterior surface of
shaft of femur
• N. supply: Obturator nerve
• Action : Adduction of thigh at
hip joint
Assists Lateral rotation
ADDUCTOR BREVIS
• Origin : Inferior ramus of pubis
• Insertion : Posterior surface of
shaft of femur
• N. supply: Obturator nerve
• Action : Adduction of thigh at
hip joint
Assists Lateral rotation
ADDUCTOR MAGNUS
• Origin : Inferior ramus of pubis
Ramus of ischium
Ischial tuberosity
(HAMSTRING PORTION)
• Insertion :Posterior surface of
shaft of femur
Adductor tubercle of femur
(HAMSTRING PORTION)
• N. supply: Obturator + Sciatic
nerves
• Action : Adduction of thigh at hip
Assists Lateral rotation &
Extension of thigh at hip joint
Adductor Hiatus
• The adductor hiatus
is an opening or gap
between the
aponeurotic distal
attachment of the
adductor part of the
adductor magnus
and the tendinous
distal attachment of
the hamstring part.
• The adductor hiatus
transmits the femoral
artery and vein from the
adductor canal in the thigh
to the popliteal fossa
posterior to the knee.
OBTURATOR EXTERNUS
• Origin : Outer surface of
Obturator membrane
Pubic & Ischial rami
• Insertion :Medial surface of
greater trochanter
• N. supply: Obturator nerve
• Action : Lateral rotation of thigh at
hip joint
Obturator nerve
• As the obturator nerve enters the thigh, it divides into
two branches, an anterior branch and a posterior
branch, which are separated by the adductor brevis
muscle:
• Anterior branch: adductor longus, gracilis, and
adductor brevis muscles, and often contributes to the
supply of the pectineus muscle, and cutaneous
branches innervate the skin on the medial side of the
thigh.
• Posterior branch: obturator externus and adductor
brevis muscles and the part of adductor magnus that
attaches to the linea aspera
Obturator nerve
Obturator nerve
Deep artery of thigh (Profunda
femoris artery)
• Branches :lateral and medial circumflex femoral
branches and four perforating branches.
• Lateral circumflex femoral artery: 3 branches
• 1. Ascending branch
• 2. Descending branch
• 3. Transverse branch
• Medial femoral circumflex artery: It takes part in
the formation of the cruciate anastomosis.
Obturator Artery
• The obturator
artery is a branch
of the internal iliac
artery.
• It gives off
muscular branches
and an articular
branch to the hip
joint.
Gluteal Region
• The gluteal region lies posterolateral to the
bony pelvis and proximal end of the femur.
• Muscles in the region mainly abduct, extend,
and laterally rotate the femur relative to the
pelvic bone.
Ligaments of the Gluteal Region
• Sacrotuberous Ligament: sacrotuberous
ligament connects the back of the sacrum to
the ischial tuberosity
• Sacrospinous Ligament: sacrospinous ligament
connects the back of the sacrum to the spine
of the ischium.
Foramina of the Gluteal Region
• Greater Sciatic Foramen:The greater sciatic
foramen is formed by the greater sciatic notch
of the hip bone and the sacrotuberous and
sacrospinous ligaments.
• It provides an exit from the pelvis into the
gluteal region.
Lesser Sciatic Foramen:
• Formed by the lesser
sciatic notch of the hip
bone and the
sacrotuberous and
sacrospinous ligaments.
• It provides an entrance
into the perineum from
the gluteal region.
Nerves of the Gluteal Region
• Sacral Plexus:
• The sacral plexus lies on the posterior pelvic
wall in front of the piriformis muscle .
• It is formed from the anterior rami of the
lumbar nerves and the anterior rami of the
sacral nerves.
Posterior wall of the pelvis
Branches
• Branches to the lower limb that leave the
pelvis through the greater sciatic foramen .
• 1. Sciatic (L4, L5, S1, S2, S3): Articular
branches to hip joint and muscular branches.
• It is the largest nerve in the body and
consists of the tibial and common peroneal
nerves bound together with fascia.
• Innervates all muscles in the posterior
compartment of the thigh that flex the knee
and all muscles that work the ankle and foot.
llmusclein leg and foot
• 2. Superior gluteal (L4, L5,
S1) : Gluteus medius and
gluteus minimus muscles
• 3. Inferior gluteal (L5, S1,
S2): Gluteus maximus
• 4. Nerve to obturator internus ( L5, S1, S2) :
Obturator internus and superior gemellus
muscles
• 5. Nerve to quadratus femoris (L4, L5, S1) :
Quadratus femoris and inferior gemellus
muscles
• 6. Posterior cutaneous nerve of the thigh(S2,
S3) : Cutaneous branches to buttock and
uppermost medial and posterior surfaces of
thigh.
Branches to the pelvic muscles, pelvic viscera, and
perineum:
• 1. Pudendal (S2, S3, S4) : Structures in
perineum: sensory to genitalia; muscular
branches to perineal muscles, external
urethral sphincter, and external anal sphincter
• 2. Nerve to piriformis (S1, S2) : Piriformis
muscle
Muscles of the Gluteal Region
• Muscles of the gluteal region are mainly in
two groups:
1. Superficial group of larger muscles:
Gluteus minimus, gluteus medius, and
gluteus maximus-and tensor fasciae latae.
2. Deep group of small muscles:
Piriformis, obturator internus, gemellus
superior, gemellus inferior, and quadratus
femoris.
• Extensor of hip
– Gluteus maximus (also helps in lateral rotation)
• Abductors of hip (help in Medial rotation)
– Gluteus medius
– Gluteus minimus
– Tensor Fascia lata (also stabilizes knee in extension)
• Function of all 3
– Contract to prevent sagging of unsupported side of hip during
locomotion, enabling opposite foot to swing through (e.g.,
Trendelenburg test)
Gluteus maximus
• Origin : Outer surface of
ilium, sacrum, coccyx,
sacrotuberous ligament
Insertion :Iliotibial tract and
gluteal tuberosity of femur
• N. supply:Inferior gluteal
nerve
• Action :Extends and laterally
rotates hip joint
Gluteus medius
• Origin : Outer surface of ilium
Insertion :Lateral surface of
greater trochanter of femur
• N. supply: Superior gluteal
nerve
• 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
• N. supply: Superior gluteal
nerve
• Action :Abducts thigh at
hip joint; tilts pelvis when
walking to permit
opposite leg to clear
ground
Positive Trendelenburg's sign
• If right gluteus
medius and
minimus muscles
are paralyzed, the
unsupported left
side of the pelvis
falls (sags)
instead of rising;
normally, the
pelvis rises.
Tensor fasciae latae
• Origin : Iliac crest
Insertion :Iliotibial tract
• N. supply: Superior gluteal
nerve
• Action :Assists gluteus
maximus in extending the
knee joint
Deep group of small muscles
•
•
•
•
Lateral Rotators of the Hip.
Small Muscles
Mostly attach near or on greater trochanter
All but one innervated by named nerves specific to
one or two of them
The exception is the obturator externus – innervated
by posterior branch of obturator n.
PYRIFORMIS
• Origin :
Anterior surface of sacrum;
sacrotuberous ligament
• Insertion : Upper border of
Greater trochanter of femur
• N. supply: 1st & 2nd Sacral nerves
• Action : Lateral rotation of thigh at
hip joint
OBTURATOR INTERNUS
• Origin : Inner surface of
Obturator membrane
• Insertion : Upper border of
Greater trochanter of femur
• N. supply: Nerve to obturator internus
• Action : Lateral rotation of thigh
at hip joint
SUPERIOR GEMELLUS
• Origin : Spine of ischium
• Insertion : Upper border of
Greater trochanter of femur
• N. supply: Nerve to obturator
internus
• Action : Lateral rotation of
thigh at hip joint
INFERIOR GEMELLUS
• Origin : Ischial tuberosity
• Insertion : Upper border of
Greater trochanter of femur
• N. supply: Nerve to quadratus
femoris (L5, S1)
• Action :
Lateral rotation of thigh at hip joint
QUADRATUS FEMORIS
• Origin : Lateral border of
ischial tuberosity
• Insertion : Quadrate tubercle of
femur
• N. supply: Nerve to quadratus
femoris (L5, S1)
• Action :
Lateral rotation of thigh at hip joint
Nerves of the Gluteal Region
•
•
•
•
•
•
•
1. Sciatic Nerve: L4 to S3
2. Posterior Cutaneous Nerve of the Thigh
3. Superior Gluteal Nerve: L4 to S1
4. Inferior Gluteal Nerve: L5 to S2
5. Nerve to the Quadratus Femoris
6. Pudendal Nerve:S2 to S4
7. Nerve to Obturator Internus
Intramuscular injections
• The safest place
to inject is the
upper outer
quadrant of either
gluteal region.
Arteries of the Gluteal Region
• 1. Superior Gluteal Artery
• 2. Inferior Gluteal Artery
Posterior compartment of thigh
• Muscles:
• Biceps femoris, semitendinosus,
semimembranosus, and a small part of the
adductor magnus (hamstring muscles)
• Blood supply: Branches of the profunda
femoris artery
• Nerve supply: Sciatic Nerve
Biceps femoris
• Origin :Long head: Ischial tuberosity
• Short head: linea aspera, lateral
supracondylar ridge of shaft of femur
• Insertion :Head of fibula
• N. supply: Long head: tibial portion of sciatic
nerve
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
Semitendinosus
• Origin :Ischial tuberosity
• Insertion :Upper part of medial
surface of shaft of tibia
• N. supply: Tibial portion of sciatic
nerve
• Action : Flexes and medially rotates
leg at knee joint; extends thigh at
hip joint
Semimembranosus
• Origin :Ischial tuberosity
• Insertion :Medial condyle of
tibia
• N. supply: Tibial portion of
sciatic nerve
• Action : Flexes and medially
rotates leg at knee joint;
extends thigh at hip joint
Adductor magnus (hamstring portion)
• Origin :Ischial tuberosity
• Insertion :Adductor tubercle of femur
• N. supply: Tibial portion of sciatic nerve
• Action : Extends thigh at hip joint
• Hamstrings
• Together extend hip (except short head of
biceps femoris) and flex knee (except add
mag)
– Biceps femoris- (laterally rotates knee)
– Semitendinosus- (medially rotates knee)
– Semimembranosus- (medially rotates knee)
Blood Supply of the Posterior
Compartment of the Thigh
• The four
perforating
branches of
the profunda
femoris
artery
provide a rich
blood supply
to this
compartment