Transcript Lecture Lower limb I 2010

Lower Limb, part I
Bones of the Lower Extremity
Movements of the Lower Extremity
For comparison:
Rotation around long axis of the femur
Internal rotation = medial rotation
External rotation = lateral rotation
Gateways to the Lower Extremity
Greater and lesser sciatic foramina
The greater sciatic foramen is the passageway for structures
entering or leaving the pelvis! (e.g. sciatic nerve)
The lesser sciatic foramen is the passageway for structures
entering or leaving the perineum! (e.g. pudendal nerve)
What structures make their exit from the pelvis through the greater
sciatic foramen?
What structures re-enter the pelvis or perineum via the lesser sciatic
foramen?
Greater and lesser sciatic foramina
Greater sciatic foramen:
Lesser sciatic foramen:
7 nerves (nerves of sacral plexus):
- Sciatic nerve
- Superior gluteal nerve
- Inferior gluteal nerve
- Pudendal Nerve
- Posterior femoral cutaneous nerve
- Nerve to quadratus femoris
- Nerve to obturator internus
3 Vessel Sets:
- Superior gluteal artery & Vein
- Inferior gluteal artery & vein
- Internal Pudendal Artery & vein
1 Muscle:
- Piriformis
2 nerves:
- Pudendal Nerve
- Nerve to obturator internus
1 Vessel Set:
- Internal Pudendal Artery & vein
1 Muscle:
- Tendon of the obturator internus
Hip Joint – synovial, ball and socket
greater
trochanter
lesser
trochanter
The ligament of the head of the femur
•= ligamentum teres femoris = round ligament of the femur,
• arises from the floor of the acetabular fossa and attaches to the fovea capitis femo
This structure is not that
important as a ligament, but can
often be vitally important as a
conduit of a small artery to the
head of the femur. This arterial
branch is not present in everyone
but can become the only blood
supply to the bone in the head of
the femur when the neck of the
femur is fractured or disrupted
by injury in childhood.
[Lig. of Bigelow –
the strongest ligament
in the body!!!!
Iliofemoral ligament
Iliopectineal bursa (over gap in lig.)
Pubofemoral ligament
Anterior inferior iliac spine
Superior public ramus
Greater trochanter
Lesser trochanter
Intertrochanteric line
Iliofemoral ligament
Ischiofemoral ligament
Greater
trochanter
Ischial spine
Protrusion
of
synovial
membrane
Arteries of the Hip Joint
Medial and lateral
circumflex femoral arteries
(typically branches of the
profunda femoris artery)
Branches of the obturator
artery
Retinacular branches to
the head and neck of the
femur.
GLUTEAL REGION
GLUTEUS MEDIUS
GLUTEUS MAXIMUS
GLUTEUS MINIMUS
INFERIOR GLUTEAL N
PUDENDAL N
SUPERIOR GLUTEAL N
PIRIFORMIS M
SHORT ROTATOR MM
Nerve to obturator internus
SACROTUBEROUS
LIGAMENT
ISCHIAL
TUBEROSITY
POSTERIOR
CUTANEOUS
nerve of thigh
GREAT TROCHANTER
SCIATIC N
Pudendal nerve leaves greater sciatic
foramen and dips down into lesser
sciatic foramen
Gluteal muscles
Superficial layer:
1. Gluteus maximus extension and lateral rotation
of the thigh
2. Gluteus medius –
abduction and medial rotation
of the thigh
3. Gluteus minimus –
abduction and medial rotation
of the thigh
4. Tensor fascia lata –
abduction and medial rotation
of the thigh
Innervation:
inferior gluteal n. (L5 - S2)
superior gluteal n. (L4 - S1)
Deep layer:
1. Piriformis
2. Obturator internus
3. Superior and inferior
gemelli
4. Quadratus femoris
These muscles are lateral
rotators of the thigh and
they stabilize the hip joint!
Innervation:
Nerve to obturator internus (and sup.gemellus)
(L5 - S2)
Nerve to quadratus femoris (and inf. gemellus)
(L4 - S1)
Nerve to piriformis ( S1- S2)
Lateral rotators of
thigh:
-Gluteus maximus
-Piriformis
-Obturator internus
-Superior and inferior
gemelli
-Quadratus femoris
Medial rotators of
thigh (and abductors):
-Gluteus minimus
- gluteus medius
- tensor fascia lata
Extension of thigh:
- Gluteus maximus
Innervation of the Lower Extremity
Lumbar plexus - branches
1. Femoral nerve (L2-L4):
anterior compartment of the thigh
2. Obturator nerve (L2-L4):
medial compartment of the thigh
3. Genitofemoral nerve (L1-L2)
4. Lateral cutaneous nerve of thigh ( L2-L3)
Sacral plexus - branches
1. Superior gluteal nerve (L4-S1):
gluteus medius and minimus, tensor fascia lata.
2. Inferior glutael nerve (L5-S2):
gluteus maximus
3. Sciatic nerve (L4-S3)- largest nerve in the body
4. Nerve to obturator internus muscle (L5-S2):
obturator internus and superior gemellus muscles
5. Nerve to quadratus femoris muscle (L5-S1):
quadratus femoris and inferior gemellus muscles
6. Posterior femoral cutaneous (S1-S3):
gives rise to several inferior cluneal nerves and perineal branches
POSTERIOR THIGH
POSTERIOR CUTANEOUS
NERVE OF THIGH
SCIATIC N
SEMITENDINOSUS M
BICEPS FEMORIS
SEMIMEMBRANOSUS M
POPLITEAL A AND V
TIBIAL N
COMMON FIBULAR N
Action of the posterior Thigh Muscles
Collectively known as the “hamstring” muscles.
All except the short head of the biceps femoris cross both:
the hip and the knee joints.
Action:
All (except the short head) extend the hip joint and flex the knee joint!
Additionally:
Biceps femoris – laterally rotates the thigh
Semimembranosus and semtedinosus – medially rotate the thigh.
Semitendinosus m,
Semimembranosus m.,
Biceps femorus
Hamstring of adductor magnus
Both heads of the Biceps Femoris perform knee flexion. Since the
long head originates in the pelvis it is also involved in hip extension.
The long head of the biceps femoris is a weaker knee flexor when the
hip is extended (because of active insufficiency). For the same reason
the long head is a weaker hip extender when the knee is flexed.
In addition to extending the hip and flexing the knee joints, the biceps
femoris laterally rotates the thigh.
The semimembranosus and semitendinosus are medial, and therefore
medially rotate the thigh in addition to extending the hip and flexing
the knee joint.
Nerves of the Gluteal Region and Posterior Thigh
These nerves arise from the sacral plexus and leave the pelvis through the
greater sciatic foramen.
1. Inferior gluteal n. (L5-S2) – gluteus maximus
2. Superior gluteal n. (L4-S1) – gluteus medius, minimus and tensor fascia lata
3. Sciatic n. (L4-S3) – posterior compartment of thigh
a. tibial nerve
b. common fibular (peroneal) nerve
*superficial fibular (peroneal) nerve
* deep fibular (peroneal) nerve
4. Pudendal n. (S2-S4) - nerve to perineum
5. Posterior cutaneous n. of thigh (S1-S3) – skin over posterior thigh and
popliteal fossa
6. Nerve to quadratus femoris (L4-S1) – quadratus femoris, inf. gemellus, hip joint
7. Nerve to obturator internus (L5-S2) – obturator internus and sup. gemellus
ANTERIOR/MEDIAL THIGH
INGUINAL LIGAMENT
Medial to lateral:
VAN
Pectineus m.
N = FEMORAL N
A = FEMORAL A
Femoral triangle
V =FEMORAL V
Adductor longus m.
Rectus femoris m.
FEMORAL A AND SAPHENOUS N
(ADDUCTOR CANAL)
Adductor magnus m.
Which muscle is the most
powerful hip flexor?
Adductor magnus
Quadriceps tendon
Patellar ligament
MEDIAL EPICONDYLE (ADDUCTOR
TUBERCLE) = FEMORAL A ENTERS THE
POPLITEAL FOSSA, POPLITEAL A
4 big heads
In quadriceps tendon, can find
patella (patella ligament, which then
attaches to fibula)
Sartorious muscle
-flexion, abduction and lateral
rotation of hip joint
- flexion of knee joint
Iliopsoas- blend of ilaicus m. and
psoas major.
External iliac a. becomes femoral
artery once it crosses hip.
Femoral triangle
The femoral triangle is an anatomical region of the upper inner human thigh,
bounded by:
* inguinal ligament (superiorly)
* adductor longus m. (medially)
* sartorius m. (laterally)
•The floor of the femoral triangle is formed by the iliopsoas (laterally) and
pectineus (medially),
•The roof of the femoral triangle is formed by the fascia,
subcutaneous tissue and skin.
The contents of the femoral triangle, from lateral to medial , are the:
1. femoral nerve and its branches
2. femoral sheath and its contents:
a. femoral artery and its branches
b. femoral veins and its tributaries
c. deep inguinal lymph nodes and lymphatic vessels
Right femoral triangle
Right femoral triangle
pectineus m.
pectineus m.
femoral vein
femoral vein
adductor longus m.
adductor longus m.
iliopsoas m.
iliopsoas m.
gracilis m.
gracilis m.
great saphenus vein
great saphenous vein
femoral nerve
femoral artery
femoral artery
sartorius m.
sartorius m.
tensor fasciae latae m.
tensor fasciae lata m.
rectus femoris m.
Copyright – Dr. B. Kraszpulska
Dept. of Neurobiology and Anatomy
West Virginia University
Medial thigh muscles
L2, L3, L4
Obturator N
Obturator externus M
Adductor brevis M
Which muscle of the medial
compartment has double
innervation and why?
Adductor hiatus
Adductor longus M
Adductor magnus M (2 parts)
Gracilis M
Adductor canal of the right thigh
femoral vein
saphenous nerve
femoral artery
sartorius m.
vastus medialis m.
adductor longus m.
1
adductor magnus m.
gracilis m.
great saphenous vein
1 – probe in the adductor hiatus
Adductor canal
(Hunter’s canal)
Adductor canal is a long, narrow passageway in the middle third of the thigh,
extending from the apex of the femoral triangle (where sartorius crosses over
the adductor longus) to the adductor hiatus (in the tendon of the adductor magnus).
The canal is bounded:
* anteriorly and laterally by the vastus medialis m.
* posteriorly by the adductor longus and magnus m.
* medially by sartorius m.
The canal contains:
1. femoral artery (leaves the adductor canal through the adductor hiatus)
2. femoral vein (leaves the adductor canal through the adductor hiatus)
3. saphenous nerve (does NOT leave the adductor hiatus)
4. nerve to vastus medialis (does NOT leave the adductor hiatus)
The vascular structures pass through the adductor hiatus becoming popliteal in name.
LOWER LIMB ARTERIES
EXTERNAL ILIAC A
COLLATERAL
CIRCULATION
FEMORAL A
DEEP FEMORAL A
COLLATERAL
CIRCULATION
(GENICULAR)
POPLITEAL A
ANTERIOR AND
POSTERIOR
TIBIAL AA
“INTEROSSEOUS
ARTERIES”
Lower limb arteries
ABDOMINAL AORTA
Right Common iliac a.
Left Common iliac a.
Femoral artery
Internal iliac a.:
1. superior gluteal artery
2. inferior gluteal artery
3. obturator artery
Popliteal artery
Anterior tibial a.
External iliac a.
Deep femoral a.:
1. medial femoral
circumflex a.
2. Lateral femoral
circumflex a.
Posterior tibial a.
Medial plantar a.
Fibular (peroneal) a.
Lateral plantar a.
Dorsal pedis a.
Arteries of Femoral Head and Neck
ILIOPSOAS M
FEMORAL A.
GREATER TROCHANTER
PECTINEUS M
MEDIAL FEMORAL CIRCUMFLEX A
LATERAL FEMORAL
DEEP (PROFUNDA) FEMORAL A
CIRCUMFLEX A
POSTERIOR AND ADDUCTOR
COMPARTMENTS
HIP JOINT
Which artery serve as the most important source of blood for adult femoral
head and neck?
Superficial veins of lower limb
Femoral V.
Superficial veins
Perforating veins
Deep veins
Great
Saphenous V.
Small
Saphenous V.
What is the importance
of the perforating veins?
The veins in the leg are divided into two systems – the deep veins and the
superficial veins. The two systems are linked periodically by perforating veins. A
superficial vein can become varicose because a perforating vein is allowing blood
to flow the wrong way (outwards).
Superficial left lower limb
great saphenous vein
Innervation of the thigh and the gluteal region
Posterior thigh:
Anterior thigh:
All muscles - femoral n. (L2-L4)
Gluteal region:
Gluteus max. – inf. gluteal n. (L5-S2)
Gluteus med.
Gluteus min.
Sup. gluteal n. (L5-S1)
Tensor fascia
Quadratus fem. N. to quadratus fem.
Inf. gemellus
(L5-S1)
Obturator internus N. to obturator int.
Sup. gemellus
(L5-S1)
Piriformis – branches of anterior rami
of S1, S2
}
}
}
}
Semitendinosus
sciatic n. tibial division
Semimembranosus
(L5-S2)
Biceps femoris:
long head – sciatic n. tibial div. (L5-S2)
short head – sciatic n. common fibular
division (L5-S2)
Medial thigh:
Adductor longus
Adductor brevis
obturator n.
Gracilis
(L2-L4)
Obturator externus
Adductor magnus:
adductor part – obturator n. (L2-L4)
hamstrings part – sciatic n. tibial
division (L5-S2)
}
Anterior thigh:
1. Sartorius
2. Quadriceps
1. Vastus medialus
2. Vastus intermedialus
3. Vastus lateralis
4. Rectus femoris
1. Origininates on lium
3. Pectineus
Vastus mm. originate on the femur (trochanters)
The anterior thigh is an extensor of the knee and a
flexor of the hip
Motor branches to the:
Iliacus
Quadriceps
Sartorius
Pectineus
Sensory branches to the:
Anterior thigh
Anterior leg (saphenous n.)
Motor branches to the:
Muscles of the medial compartment
of the thigh.
The obturator nerve splits into:
anterior branch (on the top of the
obturator brevis muscle)
posterior branch (posterior to the
obturator brevis muscle).
Abductor brevis m.
- Beneath abductor longus?
Sensory branches to the:
Small area of the medial thigh
Cutaneous nerves of Lower Extremity
Questions of the day!
1. A serious complication of fractures of the femoral neck is avascular
necrosis of the femoral head. This usually results from rupture of
which artery?
2. The pulse of the femoral artery is best felt at which superficial
point?
3. Inability to extend the knee and loss of cutaneous sensation over
the anterior surface of the thigh would indicate a lesion or
compression of which nerve?
1. Injury to the superior gluteal n. – a possitive Trendelenburg test (COA: p.582)
2. Injury to sciatic nerve – piriformis syndrome (COA: p.582)
1. Sciatic nerve is being smushed by piriformis
3. Intragluteal injection – safe place is superolateral quadrant (COA: p.582)