Transcript ANATOMY OF LOWER LIMB

ANATOMY OF THE LOWER LIMB
DR. G. TOWO
The Lower Limb
• The lower limb extends
from the gluteal region
to the foot.
• It is specialized for
weight-bearing and
locomotion
Organization of the Lower Limb
• Gluteal region- between
iliac crest superiorly and
gluteal fold inferiorly
• Thigh- Anteriorly between
inguinal ligament and knee
joint, Posteriorly between the
gluteal fold and the knee.
• Knee- joint between the thigh
and the leg
• Leg- between knee and foot
• Ankle- between the leg
and the foot.
• Foot- Everything from the
ankle joint distally
Surface Anatomy:
Anterior Thigh + Leg
• Palpate
– Patella
– Condyles of femur
• Femoral Triangle
–
–
–
–
Sartorius (lateral)
Adductor longus (medial)
Inguinal ligament (superior)
Contents: Femoral a + v, nerve and
lymph nodes
– Floor: iliopsoas laterally and
pectineus medially.
– Roof: fascia lata, cribriform fascia,
subcutaneous tissue, and skin
– Clinically: femoral puncture
Surface Anatomy: Posterior Leg
• Calcaneal (Achilles) tendon
Surface anantomy- posterior leg
Surface anatomy- posterior leg
• Popliteal fossa
-Diamond-shaped intramuscular space behind knee
-Boundaries- Biceps femoris (sup-lat), Semitendinosus +
semimembranosus (sup-med), Gastrocnemius heads
(inf)
-Contents- Popliteal a + v, termination of small
saphenous vein, tibial and common peroneal nerves,
popliteal lymph nodes and lymphatic vessels
-Roof- Skin and popliteal fascia
-Floor- Popliteal surface of femur, posterior capsule of
knee joint, and popliteus fascia covering the popliteus
muscle
-Clinically- Injury to common peroneal nerve(common
in fractures of upper part of fibula) causes foot drop
Popliteal fossa – foot drop
• Foot drop is the inability to lift the foot and
toes properly when walking. It is characterized
by steppage gait (drop foot gait).
• Foot Drop Splint helps to support the foot
when stepping/walking
Surface Anatomy Of Lower Limb
• Achilles (Calcaneal)
tendon
• Lateral malleolus of
fibula
• Medial malleolus of
tibia
• Dorsal venous arch
• Tendons of extensor
digitorum longus
muscle
Bones of the Lower Limb






Pelvis
Femur
Tibia, fibula
Patella
Tarsals
Digits


Metatarsals
Phalanges
Bones of the Lower Limb
Bones of the Lower Limb- The Foot

Function:



Support weight
Act as lever when walking
Tarsals

Talus = ankle
• Between tibia + fibula
• Articulates w/both

Calcaneus = heel
• Attachment for Calcaneal
tendon
• Carries talus

Metatarsals


Homologous to
metacarpals
Phalanges

Smaller, less nimble
Bones of the Lower Limb
• Function:
– Locomotion
– Carry weight of entire erect
body
– Support
– Points for muscular
attachments
• Components:
– Thigh
• Femur
– Knee
• Patella
– Leg
• Tibia (medial)
• Fibula (lateral)
– Foot
• Tarsals (7)
• Metatarsals (5)
• Phalanges (14)
Thigh
• Femur
The femur is the longest
and largest bone.
There are four eminences,
or protuberances, in the
femur: the head, the
greater trochanter, the
lesser trochanter, and the
lower extremity.
The shaft of femur is
cylindrical with a rough line
on its posterior surface
(linea aspera).
Knee
• Patella
– Triangular sesamoid
bone
– Protects knee joint
– Improves leverage of
thigh muscles acting
across the knee
– Contained within
patellar ligament
Leg
• Tibia
– Receives the weight of body
from femur and transmits to
foot
– Second to femur in size and
weight
– Articulates with fibula
proximally and distally
• Interosseous membrane
• Fibula
–
–
–
–
Does NOT bear weight
Muscle attachment
Not part of knee joint
Stabilize ankle joint
Foot
•
•
Function:
– Supports the weight of the body
– Act as a lever to propel the body
forward
Parts:
– Tarsals
• Talus = ankle
– Between tibia and fibula
– Articulates with both
• Calcaneus = heel
– Attachment for Calcaneal
tendon
– Carries talus
• Navicular
• Cuboid
• Medial, lateral and intermediate
cuneiforms
– Metatarsals
– Phalanges
Foot
• 3 arches
– Medial
– Lateral
– Transverse
Longitudinal
• Has tendons that run
inferior to foot bones
– Help support arches of
foot
• Function
– Recoil after stepping
Joints of Lower Limb

Hip (femur + acetabulum)




Knee (femur + patella)




Ball + socket
Multiaxial
Synovial
Plane
Gliding of patella
Synovial
Knee (femur + tibia)



Hinge
Biaxial
Synovial
Joints of Lower Limb

Proximal Tibia + Fibula




Distal Tibia + Fibula



Plane
Gliding
Synovial
Slight “give”
Fibrous
Ankle (Tibia/Fibula +
Talus)



Hinge
Uniaxial
Synovial
Hip Joint
• Articulation- between head of femur and
acetabulum.
• Type- Synovial ball and socket joint.
• Capsule- encloses the joint. Mediallyattached to acetabular lubrum. Laterallyattached to intertrochanteric line of femur
infront and half way along posterior aspect of
neck behind.
Hip Joint
• Ligaments-Iliofemoral lig. –Strong inverted Y-shaped.
It’s Base
attached to anterior inferior iliac spine above. Two Limbs of Yattached to upper and lower part of intertrochanteric line of
femur below.
-Pubofemoral lig.- Triangular I shape. The Base-attached
tosuperior ramus of pubis. Apex-attached below to the lower
part of intertrochanteric line. This lig. Limits extension and
abduction.
-Ischiofemoral lig. – Spiral shaped. Attached to body of
ischium near acetabular margin. Fibers pass upwards and
laterally and attached to greater trochanter. This lig. Limits
extension.
Hip Joint
• Ligaments
-Transverse acetabular lig.- Formed by the acetabular
lubrum as it bridges the acetabular notch. This lig.
Converts the notch into a tunnel through which blood
vessela and nerves enter the joint.
-Lig. Of head of femur- Flat and triangular. Attached by
it’s apex to thepit on the head of femur(fovea capitis) and
by it’s base to transverse lig. and margins of acetabular
notch. Lies within the joint and ensheathed by synovial
membrane.
Hip Joint
• Synovial membrane- Lines the capsule and is
attached to margins of articular surfaces.
• Nerve supply- Femoral, obturator, and sciatic
nerves and the nerve to the quadratus femoris
supply the area.
• Movements
-Flexion- iliopsoas, rectus femoris, and sartorius
and also by adductor muscles
Hip Joint
-Extension-gluteus maximus and hamstring
muscles
-Abduction- gluteus medius and minimus,
assisted by sartorius,tensor fasciae latae and
piriformis
-Adduction- adductor longus and brevis and
adductor fibers of adductor magnus, These
muscles are assisted by pectineus and gracilis.
Hip Joint
-Lateral rotation- piriformis, obturator internus
and externus,superior and inferior gemelli, and
quadratus femoris, assisted by gluteus maximus
-Medial rotation- anterior fibers of gluteus
medius and gluteus minimusand the tensor
fasciae latae
-Circumduction- a combination of the previous
movements.
Hip Joint
Hip Joint
Hip Joint
Hip Joint
Hip Joint
• Clinical points
• Arthritis of hip joint
-Osteoarthritis is the most common type of hip
arthritis (also called wear-and-tear arthritis)
-Osteoarthritis is characterized by: Pain with
activities, limited range of motion and stiffness
of the hip
Hip Joint- osteoarthritis
Hip Joint- Dislocation
• Hip Dislocation
- Occurs when the head of femur slips out of acetabulum.
- 90% are posterior dislocations. Anterior dislocations are
also possible.
- A hip dislocation is very painful and patients are unable to
move the leg.
- Motor vehicle accidents are the most common cause of hip
dislocations. (Wearing a seatbelt can greatly reduce your risk.)
- Falls from a height (such as a fall from a ladder) or
industrial accidents can also generate enough force to
dislocate a hip.
Hip Joint - dislocation
Knee Joint
• Articulation- femoral condyles above, tibial
condyles below, and in front iss the
articulation between lower end of femur and
patella.
• Type- Joint between femur and tibia is
synovial of hinge variety. The joint between
patella and femur is synovial joint of plane
gliding variety.
Knee Joint
• Capsule- Attached to the margin of the articular
surfaces and surrounds the sides and posterior
aspects of the joint. It is deficient anteriorly
hence leaving a space for out pouching of
synovial membrane beneath quadriceps tendons
to form a suprapatellar bursa, strengthened
medially and laterally by V.laterallis and mediallis
tendon expansions. Posteriorly it is strengthened
by expansion of semimembraneous muscle called
oblique popliteal ligament.
Knee Joint
Knee Joint
Knee Joint
• Ligaments
 Extracapsular ligaments- lie outside the capsule.
-Ligamentum patellae- Attached to the lower
border of patella and tibia tuberosity( a
continuation of common tendon of Q.femoris
muscle.
-Lateral collateral ligament- Cord like ,attached to
the lateral condyle of femur above and to head of
fibula below. Tendon of popliteus intervenes btn
the ligament and the lat meniscus.
Knee Joint
-Medial collateral ligament- Attached to the
medial femoral condyle above and medial side
of the shaft of tibia below. Is firmly attached
to the edge of medial meniscus.
-Oblique popliteal ligament- Tendinous
expansion derived from semimembranosus
muscle. It strengthens the posterior aspect of
the capsule.
Knee Joint
Intracapsular ligaments
-Cruciate ligaments; ant. and post. Cross each
other in joints. Named according to their relative
attachments to the tibia.
-Anterior cruciate ligament- Attached to ant.
intercondylar area passing upward, backward
and laterally to be attached to the medial
surface of the lateral femoral condyle.
Prevents posterior displacement of femur on
tibia whereas it prevents anterior
displacement of tibia when the joint is flexed.
Knee Joint
-Posterior cruciate ligament- Attached to
posterior intercondylar area of tibia and passes
upward ,forward to the lateral surface of medial
femoral condyle. Prevents anterior displacement
of the femur on tibia. With knee flexed ,it
prevents the posterior displacement of the tibia.
• Menisci- C-shaped fibro cartilage whose
peripheral border being thicker and attached
to the capsule. The inner border is thin and
concave and form a free edge.
Knee Joint
Knee Joint
Knee Joint
Knee Joint
-Functions of minisci
1.Deepens tibial articular surface to
accommodate convex femoral condyles.
2. Cushioning btn 2 bones .
-medial meniscus is attached to the medial
collateral ligament hence less mobile.
Knee Joint
 Synovial membrane- Lines the capsule and attached to
margins of articular surfaces.
-On the front and above,the joint forms a pouch beneath
quadriceps femoris forming suprapatella bursa. At the back
the membrane is prolonged downwards on the deep surface
of popliteus tendon-popliteal bursa.
-The membrane is reflected forward from the post part of
the capsule around the front of the cruciate ligament . In this
way, cruciate ligament lie behind the synovial cavity and are
not bathed in synovial fluid.
-In the ant part of the joint, the synovial membrane is
reflected backward from the post surface of the ligament on
the patella to form the infrapatella fold.
-The free borders of the fold are called alar folds.
Knee Joint
• Blood supply
-Genicular anastomoses- Middle genicular
artery ,branch of the popliteal artery penetrate
the fibrous capsule supplying the cruciate
ligaments,synovial capsule & peripheral margins
of the menisci.
• Nerve supply- The femoral, obturator,
common peroneal and tibial nerves
Knee Joint
Knee Joint
• Movements
-Flexion-harmstring, b/femoris, semitendinosus
and semimembranosus muscles assisted by
gracilis, sartorius and popleteus muscles
-Extension- quadriceps femoris
-Medial rotation-sartorius, gracilis and
semitendinosus.
-Lateral rotation- biceps femoris
Knee Joint
• Stability of a knee joint
-Depends on the tone (most important) of the
strong muscles acting on the joint and the
strength of the ligaments.
-Most important is quadriceps femoris muscle
particularly inferior fibers of vastus medialis and
lateralis muscles.
Knee Joint
• Clinical Points
• Common Knee Injuries
-Injuries to knee ligaments are common. Of the four major ligaments found
in the knee, the anterior cruciate ligament (ACL) and the medial collateral
ligament (MCL) are often injured in sports. The posterior cruciate ligament
(PCL) may also be injured.
-ACL injury
Changing direction rapidly, slowing down when running, and landing from a
jump may cause tears in the ACL.
-MCL injury
Is usually caused by a direct blow to the outside of the knee. This type of
injury often occurs in contact sports, such as football.
-PCL injury
The PCL is often injured when a person receives a blow to the front of the
knee or makes a simple misstep on the playing field.
-Torn cartilage
Torn knee cartilage usually referrs to a torn meniscus. The mensicus is a
Knee Joint
Knee Joint
• Arthritis of the Knee Joint
-Osteoarthritis (OA)- is the most common form
of knee arthritis in which the joint cartilage
gradually wears away. It most often affects
middle-aged and older people.
-Pain, swelling and joint stiffness are associated
with this condition making it difficult to bend or
straighten the knee
Knee Joint
• Osteoarthritis of knee joint
Proximal Tibiofibular Joint
• Articulation- btn lateral condyle of tibia and head of
fibula. Articular surfaces are flattened and covered by
hyaline cartilage.
• Type- Synovial, plane, gliding joint.
• Capsule- Surrounds the joint and is attached to the
margins of articular surfaces.
• Ligaments
- Anterior and Posterior ligaments strengthen the
capsule.
- Interosseous membrane connects the shafts of tibia
and fibula together and therefore greatly strengthens
the joint
Proximal Tibiofibular Joint
• Synovial membrane- lines the capsule is
attached to the margins of articular surfaces.
• Nerve supply- common peroneal nerve.
• Movements- small amount of gliding
movement takes place during movements at
the ankle joint.
Distal Tibiofibular Joint
• Articulation- fibular notch on lower end of tibia
and lower end of fibular.
• Type- fibrous joint.
• Capsule- no capsule.
• Ligaments
- Interosseous lig.- strong, thick band of fibrous
tissue that binds the two bones together.
- Interosseous membrane connects the shafts of
the tibia and fibula together and greatly
strengthens the joint.
Distal Tibiofibular Joint
- Anterior and Posterior Tibiofibular lig.- Connect
the two bones together in front and behind the
interosseous ligament
- Inferior Transverse lig- runs from medial surface
of upper part of lateral malleolus to the posterior
border of the lower end of tibia
• Nerve supply- Deep peroneal and tibial nerves
• Movements- A small amount of movement takes
place during movements at the ankle joint.
Distal Tibiofibular Joint
Distal Tibiofibular Joint
Ankle Joint
• Articulation- btn the lower end of tibia, the two
malleoli, and the body of talus.
• Type- Synovial hinge joint.
• Capsule- encloses the joint and is attached to the
bones near their articular margins.
• Synovial membrane- lines the capsule.
• Nerve supply- Deep peroneal and tibial nerves.
• Blood supply- malleolar branches of anterior
tibial and peroneal arteries.
Ankle Joint
• Ligaments
- Medial/Deltoid lig.- Is strong and stabilizes the
ankle joint during eversion of the foot and
prevents subluxation (partial dislocation) of the
ankle joint.
-It’s apex attaches proximally to tip of medial
malleolus and fans out from it to attach distally to
talus, calcaneus, and navicular via four adjacent and
continuous parts: -tibionavicular part,
-tibiocalcaneal part,
-ant. and post. tibiotalar parts.
Ankle Joint
- Lateral lig.-Is weaker than the medial lig. and
consists of three bands:
-Ant. Talofibular lig.-runs from lateral
malleolus to lateral surface of talus
-Post. Talofibular lig.- runs from lateral
malleolar fossa to posterior tubercle of talus
-Calcaneofibular lig.-runs from the tip of
lateral malleolus downward and backward to
lateral surface of calcaneum
Ankle Joint
Ankle Joint
Ankle Joint
• Movements
-Dorsiflexion of the foot- muscles of anterior
compartment of the leg-tibialis anterior,
extensor digitorum longus, extensor hallucis
longus, fibularis or peroneus tertius
-Plantar flexion- muscles of posterior
compartment of the leg- gastrocnemius, soleus,
plantaris, flexor hallucis longus, flexor digitorum
longus, and tibialis posterior.
Ankle Joint
• Important relations
-Anteriorly- tibialis anterior, extensor hallucis
longus, anterior tibial vessels, deep peroneal nerve,
extensor digitorum longus, and peroneus tertius.
-Posteriorly- tendo calcaneus and plantaris
-Posterolaterally(behind lat. malleolus)- peroneus
longus and brevis.
-Posteromedially(behind med. malleolus)- tibialis
posterior, flexor digitorum longus, posterior tibial
vessels, tibial nerve, flexor hallucis longus.
Ankle Joint
Ankle Joint
Ankle Joint
• Clinical Points
• Ankle Injuries
-Sprains:
– Single most common injury in athletics caused by sudden
inversion or eversion moments
-Inversion Sprains:
– Most common and result in injury to the lateral ligaments
– Anterior talofibular ligament is injured with inversion, plantar
flexion and internal rotation
– Occasionally the force is great enough for an avulsion fracture to
occur at the lateral malleolus
Ankle Joint - Injuries
• With inversion
sprains the foot is
forcefully inverted
or occurs when the
foot comes into
contact with
uneven surfaces
Ankle Arthroplasty
A Growing
alternative to
ankle fusion
for the
treatment of
ankle
arthritis.
Tarsal Joints
•
•
•
•
•
•
•
•
Subtalar joint
Talocalcaneonavicular joint
Calcaneocuboid joint
Cuneonavicular joint
Cuboideonavicular joint
Intercuneiform and Cuneocuboid joints
Tarsometatarsal and Intermetatarsal joints
Metatatarsophallangeal and Interphallangeal
joints
Tarsal Joints
Tarsal Joints
 Subtalar Joint- provides shock absorption and the
movements of inversion and eversion.
• Articulation- btn inferior surface of body of talus
and facet on the middle of upper surface of
calcaneum
• Type- synovial of the plane variety
• Capsule- encloses the joint and is attached to
margins of the articular ares of the two bones
• Synovial membrane- lines the capsule
Tarsal Joints- Subtalar
• Ligaments
-Medial and Lateral(Talocalcaneal) ligamentsStrengthen the capsule
-Interosseous(Talocalcaneal) ligament- strong,
is the main bond of union between the two
bones. Is attached above to the sulcus tali and
below to the sulcus calcanei
• Movements- gliding and rotatory movements
are possible
Blood Supply of Lower Limb
Arteries of the Lower Limb
Main arteries
• Common iliac
• External iliac
• Femoral (+ superficial/deep
branches)
• Profunda femoris
• Anastomosis around knee
(genicular arteries, branch of lat
femoral circumflex)
• Popliteal
• Anterior/posterior tibial
• Peroneal
• Medial/lateral plantar
• Plantar arch
• Dorsalis pedis
Arteries of the Lower Limb
Arteries of the Lower Limb
Arteries of the Lower Limb
Veins of the Lower Limb
Veins of the Lower Limb
Venous anatomy of the LL
is divided into 3 groups:
• Superficial (dermis >
Muscular Fascia) veins
• Deep (deep to muscular
fascia) veins
• Perforating veins- are
vessel that run btn the
superficial and deep
veins
Veins of the Lower Limb
• The deep veins
-In the lower limb the deep veins accompany all the major
arteries and their branches.
-They are contained within a vascular sheath with the
arteries, whose pulsations also help compress and move
blood in the veins.
-The deep veins from the leg flow into the popliteal vein
posterior to the knee, which becomes the femoral vein in the
thigh.
-The deep vein of the thigh joins the terminal portion of the
femoral vein.
-The femoral vein passes deep to the inguinal ligament to
become the external iliac vein in the pelvis.
Veins of the Lower Limb
Deep Veins of the Thigh
• Common femoral vein
• Femoral vein
• Deep femoral vein
• Deep femoral
communicating veins
• Medial circumflex femoral
vein
• Lateral circumflex femoral
vein
Veins of the Lower Limb
Deep Veins of the Knee
• Popliteal vein
• Genicular venous plexus
Deep Veins of the Leg
• Posterior and Anterior
tibial veins
• Peroneal Veins
Veins of the Lower Limb
Superficial Veins
-Two major superficial veins are: great and small
saphenous veins
• The Great Saphenous Vein
-Formed by the union of the dorsal digital vein of the
great toe and the dorsal venous arch of the foot
-Ascends anterior to the medial malleolus and passes
posterior to the medial condyle of femur (about a
hand's breath posterior to the medial border of the
patella).
-Anastomoses freely with the small saphenous vein
and traverses the saphenous opening in the fascia lata.
-Empties into the femoral vein at Sapheno-femoral
Junction
Veins of the Lower Limb
• The Small Saphenous Vein
-Arises from the union of the dorsal digital vein of the
fifth digit with the dorsal venous arch.
-Ascends posterior to the lateral malleolus as a
continuation of the lateral marginal vein and passes
along the lateral border of the calcaneal tendon.
-Inclines to the midline of the fibula and penetrates the
deep fascia.
-Ascends between the two heads of gastrocnemius
muscle.
-Empties into the popliteal vein at the saphenopopliteal junction in the popliteal fossa.
Veins of the Lower Limb
• Perforating veins
-They penetrate the deep fascia close to their origin
from the superficial veins.
-They contain valves that allow blood to flow only from
the superficial veins to the deep veins.
-The perforating veins pass through the deep fascia at
an oblique angle so that when muscles contract and
pressure increases inside the deep fascia, the perforating
veins are compressed and therefore prevents blood from
flowing from the deep to the superficial veins.
(musculovenous pump).
Veins of the Lower Limb
Superficial veins
• The Thigh
-Great (long) saphenous vein
-Sapheno-femoral Junction
Posterior lower leg
-Small (short) saphenous
vein
-Sapheno-popliteal junction
Lower Leg perforators
Veins of the Lower Limb
• Great (long) saphenous
vein
• Small (short) saphenous
vein
• Sapheno-popliteal
junction
Veins of the Lower Limb
• Clinical points
• Deep Vein Thrombosis (DVT)- Inactivity and immobilization,
as with orthopedics casts, sitting, travel, bed rest, and
hospitalization leads to lack of muscular contractions causing
stasis of blood and formation of thrombi in the deep veins of
legs which cause pain, swelling, and warmth.
• Varicose veins- are veins that have become enlarged and
tortuous, commonly refers to superficial veins of the legs,
which are subject to high pressure when standing.
-Besides being a cosmetic problem, varicose veins can be painful,
especially when standing. Severe long-standing varicose veins
can lead to leg swelling, venous eczema, skin thickening and
ulceration
DVT and VARICOSE VEINS
Veins of the Lower Limb
• Great Saphenous Vein Cutdown
-The greater saphenous vein is the most common vessel used for the
venous cutdown
-Intravenous access is one of the crucial first steps in the resuscitation
of any critically ill or injured patient who presents to the emergency
department.
-When peripheral intravenous access fails, alternative routes must be
sought to obtain rapid access for the purpose of infusing intravenous
fluids, blood products, or medications
-The greater, or long, saphenous vein, which is the longest vein in the
body, originates at the ankle as a continuation of the medial marginal
vein of the foot and ends at the femoral vein within the femoral
triangle.
-At the ankle, it crosses 1 cm anterior to the medial malleolus and
continues up the anteromedial aspect of the lower leg.
Veins of Lower Limb-Venous cutdown
Lymphatic Drainage Of Lower Limb
• Three main groups
1. Superficial inguinal
lymph nodes
2. Deep inguinal lymph
nodes
3. Popliteal lymph nodes
Lymphatic Drainage Of Lower Limb
•
•
o
o
o
o
o
o
o
o
The superficial inguinal lymph nodes
form a chain immediately below the
inguinal ligament.
They receive as afferents lymphatic
vessels from the following:
integument of the penis
Scrotum
Perineum
Buttock
abdominal wall below the level of the
umbilicus
Vulva
anus (below the pectinate line)
the lower extremity (foot, leg and
thigh)
Lymphatic Drainage Of Lower Limb
• The deep inguinal lymph
nodes are located medial to
the femoral vein and under
the cribriform fascia. There are
approximately 3 to 5 deep
nodes. The superior-most
node is located under the
inguinal ligament and is called
Cloquet's node.
• The deep inguinal lymph
nodes drain superiorly to the
external iliac lymph nodes,
then to the pelvic lymph
nodes and on to the paraaortic
lymph nodes.
Lymphatic Drainage Of Lower Limb
• The popliteal lymph nodes, small
in size and some six or seven in
number, are imbedded in the fat
contained in the popliteal fossa.
•
1.
2.
3.
•
They receive lymph from:
knee joint
Deep lymph vessels from leg
along anterior & posterior
tibial arteries
Some superficial lymph vessels
from leg & foot along small
saphenous vein
Their efferents drain into deep
inguinal lymph nodes
Nerve Supply of the Lower Limb
• Lumbosacral plexus
-The anterior divisions of the lumbar, sacral, and
coccygeal nerves form the lumbosacral plexus,
the first lumbar nerve being frequently joined by
a branch from the twelfth thoracic.
-For descriptive purposes this plexus is usually
divided into three parts—the lumbar, sacral,
and pudendal plexuses.
Nerve supply of the lower limb
• The Lumbar plexus
-The plexus of nerves formed by anterior divisions of L1,
L2, L3, and greater part of L4 nerves.
-L1 often receives a branch from T12.
-Smaller part of L4 joins with L5 to form lumbosacral
trunk, which assists in the formation of sacral plexus.
-L4 is named the nervus furcalis, from the fact that it is
subdivided btn the two plexuses.
-Lumbar plexus is situated in the posterior part of Psoas
major muscle, in front of the transverse processes of the
lumbar vertebrae. 4
LUMBAR PLEXUS
Lumbar plexus
Lumbosacral plexus
• Branches of lumbar plexus:
-Iliohypogastric L1
-Ilioinguinal
L1
-Genitofemoral L1, L2.
Dorsal divisions.
-Lateral femoral cutaneous
L2, L3.
-Femoral L2, L3, L4 (largest branch of lumbar plexus)
Ventral divisions.
-Obturator L2, L3, L4 .
-Accessory obturator
L3, L4.
Lumbosacral Plexus
• Lumbar plexus- muscular divisions.
-The main branches innervate anterior thigh via femoral
nerve.
-Medial thigh and adductor muscles are innervated by
the obturator nerve.
• Femoral nerve.
– Cutaneous branches:
Thigh, leg, foot (e.g. saphenous nerve)
– Motor branches:
• Anterior thigh muscles (e.g. quadriceps, sartorius,
iliopsoas)
Lumbar plexus
• Obturator nerve
– Sensory
• Skin medial thigh; hip, knee joints
– Motor
• Adductor muscles
• Lateral femoral cutaneous
– Sensory
• Skin lateral thigh
• Genitofemoral
– Sensory
• Skin scrotum, labia major, anterior thigh
– Motor
• Cremasteric muscle
Sacral plexus
• The Sacral Plexus
-Is a nerve plexus derived from the anterior/ventral rami of spinal
nerves L4, L5, S1, S2, S3, and S4.
-Each of these anterior rami gives rise to anterior and posterior
branches.
-The anterior branches supply flexor muscles of the lower limb, and
posterior branches supply the extensor and abductor muscles
-Located on posterior wall of true pelvis on anterior surface of
piriformis muscle
-Branches supply: lower limb; pelvic floor and wall and perineum
-Most branches leave the pelvis through greater sciatic foramina
-Two major branches are the sciatic nerve and pudendal nerve
-sacral plexus is part of the larger lumbosacral plexus.
Sacral Plexus
Sacral Plexus
• Sciatic
– Motor:
• Hamstring
– Branches into:
• Tibial nerve
– Cutaneous
» Posterior leg and sole
of foot
– Motor
» Posterior leg, foot
• Common fibular (peroneal)
nerve
– Cutaneous
» Anterior and lateral
leg, dorsum foot
– Motor
» Lateral compartment,
tibialis anterior, toe
extensors
• Superior gluteal nerve
– Motor
• Gluteus medius and minimus,
tensor fasciae latae
Sacral Plexus (continued)
• Inferior gluteal nerve
– Motor
• Gluteus maximus
• Posterior femoral
cutaneous nerve
– Sensory
• Inferior buttocks, posterior
thigh, popliteal fossa
• Pudendal nerve
– Sensory
• External genitalia, anus
– Motor
• Muscles of perineum
Lumbosacral plexus
• Blood supply
-Arterial Supply - originates from two sources:
-The middle sacral artery divides to provide dorsal and caudal
arterial branches to the lumbosacral spine. The dorsal branch
enters epaxial musculature by passage through the angle formed
by the ilium and vertebral column. The caudal branch runs into
the pelvis in company with the sympathetic trunk.
- The segmental lumbar artery that courses through the
intervertebral foramen and branches to the segmental spinal
artery. Within the spinal canal, the artery divides into a small
dorsal and slightly larger ventral branch. The ventral branches
coalesce on the midline to form the ventral mater to nourish
spinal tissue
Lumbosacral plexus
• Venous drainage:- two sources:
- From arborized spinal venules blood is returned
to the left and right vertebral sinuses. The
vertebral sinuses are continuous with spinal veins
and drain cranially or to the median sacral and
common iliac veins.
- Additional drainage arises from the anastomosis
of intervertebral and interspinous veins of the
ipsilateral and contralateral portions of the spinal
segment to form the dorsal external venous
plexus
Lumbosacral plexus
Clinical points
• Pudendal Nerve Block
-Performed to relieve perineal pain during childbirth.
-Anesthetic agent is injected into tissues around pudendal
nerve.
-Injection is normally done transvaginally
-Physician palpates the ischial spine and uses his or her fingers
to direct the needle so that the anesthetic is injected in the
region of the ischial spine, where the pudendal nerve wraps
around it to enter the lesser sciatic foramen
-Pudendal blocks do not relieve the pain of contractions
Lower Limb Dermatomes
Lower Limb Dermatomes
Key dermatomes*
of the Lower
Limb
 hip crease - L1
 great toe - L4
 5th toe - S1
MUSCLES OF THE ANTERIOR FASCIAL COMPARTMENT OF THE THIGH
ORIGIN
INSERTION
NERVE SUPPLY &
ROOT
ACTION
anterior superior iliac spine
upper medial surface of shaft of
tibia
Femoral nerve
L2,3
Iliacus fossa of hip bone
With psoas into lesser trochanter
of femur
Femoral nerve
L2,3
Transeverse process, bodies and
intervertebral dics of 12th thoracic
and five lumbar vertebrae
superior ramus of pubis
With iliacus into lesser trochanter
of femur
Lumber plexus
L1,2, 3
At hip joint-flexes, abduc
thigh
At knee joint-flexes, med
Flexes thigh on trunk; If t
flexes the trunk on the th
from lying down
Flexes thigh on trunk; If t
flexes the trunk on the th
from lying down
Flexes and adducts thigh
Straight head-inferior iliac spine
Reflected head-ilium above
acetabulum
Upper end and shaft of femur
Quadricepstendon into
patella,then via patella ligament
into tibial tubercle
Quadricepstendon into
patella,then via patella ligament
into tibial tubercle
Quadricepstendon into
patella,then via patella ligament
into tibial tubercle
Quadricepstendon into
patella,then via patella ligament
Upper end and shaft of femur
Anterior and lateral of shaft of femur
Upper end of linea aspera of shaft Femoral nerve
of femur
L2,3
Femoral nerve
L2,3,4
Extension of leg at knee
Flexes thigh at hip joint
Femoral nerve
L2,3,4
extension of leg at knee
Femoral nerve
L2,3,4
extension of leg at knee
Stabilizes patella
Femoral nerve
L2,3,4
extension of leg at knee
Articularis genus retracts
MUSCLES OF THE MEDIAL FASCIAL COMPARTMENT OF THE THIGH
ORIGIN
INSERTION
NERVE SUPPLY AND ROOT
ACTION
inferior ramus of pubis, ramus of
ischium
upper part of shaft of tibia on
medial surface
obturator nerve
L2, 3
adduc
leg at k
body of pubis, medial to pubic
tubercle
posterior surface of shaft of
femur(linea aspera
obturator nerve
L2, 3, 4
adduc
assists
inferior ramus of pubis
posterior surface of shaft of
femur(linea aspera
obturator nerve
L2, 3, 4
adduc
assists
inferior ramus of pubis, ramus of
ischium, ischial tuberosity
posterior surface of shaft of femur,
adductor tubercle of femur
adductor portion-obturator nerve
hamstring portion-sciatic nerve
L2, 3, 4
outer surface of obturator
membrane , pubic and ischial rami
medial surface of greater
trochanter
obturator nerve
L3, 4
adduc
assists
hamstr
hip join
latera
g
MUSCLES OF THE POSTERIOR FASCIAL COMPARTMENT OF THE THIGH
ORIGIN
INSERTION
NERVE SUPPLY AND ROOT
ACTI
long head-ischial tuberosity
short head-linea aspera, lateral
supracondylar ridge of shaft of
femur
head of fibular
flexe
knee
long
joint
ischial tuberosity
upper part of medial surface of
shaft of tibia
long head-tibial portion of sciatic
nerve
short head-common peroneal
portion of sciatic nerve
L5, s1, 2
tibial portion of sciatic nerve
L5,;s1, 2
ischial tuberosity
medial condyle of tibia
tibial portion of sciatic nerve
L5; s1, 2
flexe
knee
joint
ischial tuberosity
adductor tubercle of femur
tibial portion of sciatic nerve
L2, 3, 4
exte
flexe
knee
joint
MUSCLES OF THE ANTERIOR FASCIAL COMPARTMENT OF THE LEG
ORIGIN
INSERTION
NERVE SUPPLY AND ROOT
ACT
lateral surface of sahaft of tibia medial cuneiform and base of
and interosseous membrane
first metatarsal bone
deep peroneal nerve
L4, 5
us
anterior surface of shaft fo
fibular
extensor expansion of lateral
four toes
deep peroneal nerve
L5; s1
ext
ank
sub
join
long
ext
ank
s
anterior surface of shaft fo
fibular
base of fifth metatarsal bone
deep peroneal nerve
L5; s1
anterior surface of shaft fo
fibular
base of digital phalanx of great deep peroneal nerve
toe
L5; s1
calcaneum
by four tendons into the
deep peroneal nerve
proximal phalanx of big toe and S1, 2
long extensor tendons to
second, third, and fourht toes
exte
eve
tran
ext
at a
sub
join
ext
MUSCLES OF THE LATERAL FASCIAL COMPARTMENT OF THE LEG
MUSCLE
ORIGIN
INSERTION
NERVE SUPPLY ACTION
AND ROOT
PERONEUS
LONGUS
LATERAL SURFACE OF
SHAFT OF FIBULAR
BASE OF FIRST
METATARSAL AND
THE MEDIAL
CUNEIFORM
SUPERFICIAL
PERONEAL
NERVE
L5; S1, 2
PERONEUS
BREVIS
LATERAL SURFACE OF BASE OF FIFTH
SHAFT OF FIBULAR
METATARSAL BONE
BASE OF FIRST
METATARSAL AND THE
MEDIAL CUNEIFORM
SUPERFICIAL
PERONEAL
NERVE
L5; S1, 2
PLANTAR FLEXES FOOT AT
ANKLE JOINT; EVERTS FOOT
AT SUBTALAR AND
TRANSEVERSE TARSAL
JOINTS; SUPPORTS LATERAL
LONGITUDINAL AND
TRANSEVERSE ARCHES FO
FOOT
PLANTAR FLEXES FOOT AT
ANKLE JOINT; EVERTS FOOT
AT SUBTALAR AND
TRANSEVERSE TARSAL
JOINTS; SUPPORTS LATERAL
LONGITUDINAL ARCH OF
FOOT
MUSCLES OF THE POSTERIOR FASCIAL COMPARTMENT OF THE LEG
ORIGIN
INSERTION
NERVE SUPPLY AND ROOT
lateral head from lat. condyle of
femur and medial head from
above medial condyle
lateral supracondylar ridge of
femur
via tendo calcaneus into posterior tibial nerve
surface of calcaneum
s1, 2
plantar flexe
knee joint
posterior surface of calcaneum
plantar flexe
knee joint
shafts of tibia and femur
via tendo calcaneus into posterior tibial nerve
surface of calcaneum
s1, 2
lateral surface of lateral condyle
of femur
posterior surface of shaft of shaft
of tibia above soleal line
tibial nerve
l4, 5; s1
posterior surface of shaft of tibia
bases of distal phallanges of
lateral four toes
tibial nerve
s2, 3
posterior surface of shaft of fibula
base of distal phalanx of big toe
tibial nerve
s2, 3
posterior surface of shaft of tibia
tuberosiry of navicular bone and
tibial nerve
tibial nerve
s1, 2
ACTION
together wit
is powerful p
provides mai
and running
flexes leg at
by lateral rot
slackens ligam
flexes distal
plantar flexes
supports med
arches of foo
flexes distal
flexes foot at
longitudinal a
plantar flexe
on
ORIGIN
MUSCLES OF THE SOLE OF THE FOOT
INSERTION
NERVE SUPPLY AND ROOT
ACTI
medial tuberosity of calcaneum
and flexor retinaculum
base of proximal phalanx of big toe
medial plantar nerve
S2, 3
flexe
medi
medial tubercle of calcaneum
four tendons to four lateral fourinserted into borders of
middlephalanx; tendons perforated
by those of flexor digitorum longus
base of proximal of fifth toe
medial plantar nerve
S2, 3
flexe
medi
arche
LATERAL plantar nerve
S2, 3
flexe
later
tendon of flexor digitorum longus
LATERAL plantar nerve
S2, 3
assis
flexin
medial and lateral tubercles of
calcaneum
Medial and lateral sides of
calcaneum
tendons of flexor digitorum longus
see above
dorsal extensor expansion; bases of FIRST lumbrical: medial plantar
proximal phalanges of lateral four
nerve; reminder: lateral plantar
toes
nerve
exte
joint
ORIGIN
cuboid, lateral cuneiform, tibialis
posterior insertion
oblique head bases of second, third
and fourth metatarsal bones;
transverse head from plantar
ligaments
base of fifth metatarsal bone
adjucent sides of metatarsal bones
inferior surfaces of third, fourth,
and fifth metatarsal bones
MUSCLES OF THE SOLE OF THE FOOT
INSERTION
NERVE SUPPLY AND ROOT
ACTI
medial tendon into medial side of
base of proximal phalanx of big toe;
lateral tendon intolateral side of
base of proxima lphalanx of big toe
lateral side of base of proximal
phalanx of big toe
medial plantar nerve
s2, 3
flexe
big to
longi
deep branch lateral plantar nerve
s2, 3
flexe
big to
bone
lateral side of base of proximal
phalanx of little toe
lateral plantar nerve
s2, 3
flexe
little
base of proximal phalanges-first:
medial side of second toe;
reminder; lateral sides of second,
third and fourth toes-also dorsal
extensor expansion
medial side of bases of proximal
phalanges of lateral three toes
lateral plantar nerve
s2, 3
abdu
meta
exten
lateral plantar nerve
s2, 3
addu
meta
exten
ORIGIN
Anterior part of upper surface of
calcaneum and from the inferior
extensor retinaculum
MUSCLES OF THE DORSUM OF THE FOOT
INSERTION
NERVE SUPPLY AND ROOT
By four tendons into the proximal
phalanx of big toe and long
extensor tendons to second, third
and fourth toes
Deep peroneal nerve
S1,S2
ACTI
Exten
Anterior/Post. Compartments of Thigh and Leg
ANTERIOR
POSTERIOR
COMPARTMENT COMPARTMENT
MOVEMENT
Extension
MUSCLES
Quadriceps-thigh Hamstrings-thigh
Shin muscles-leg Gastrocs-leg
NERVES
Femoral n.
(lumbar plexus)
Frolich, Human Anatomy,
Lower LImb
Flexion
Sciatic n.
(sacral plexus)
Gluteal Region: Post & Lat hip
(a)Gluteus muscles
– Maximus- extensor of thigh
– Medius- abductor of thigh, pelvic tilt
when walking
– Minimus-abductor of thigh, pelvic tilt
Frolich, Human Anatomy,
Lower LImb
(b)Lateral rotators- piriformis,
obturator internus and externus,
quadratus fermoris, superior and
inferior gemelli
Anterior Hip
Iliopsoasflexors of thigh
– iliacus
– psoas
Frolich, Human Anatomy,
Lower LImb
Anterior thigh (femoral nerve.)
• Sartorius (Tailor’s
muscle)
• Quadriceps (four)
– Rectus femoris
(crosses hip)
– 3 vastus muscles.
(vast-big)
Frolich, Human Anatomy,
Lower LImb
Posterior thigh (sciatic nerve)
• Hamstrings
– Biceps femoris
– Semimembranous
– Semitendinous
Frolich, Human Anatomy,
Lower LImb
Posterior thigh (sciatic nerve)
Medial thigh (obturator nerve)
• Adductor
muscles
– Gracilis
– Adductor
• Magnus
• Longus
• brevis
Frolich, Human Anatomy,
Lower LImb
Anterior Leg (deep fibular nerve)
• Extensors of foot
(dorsiflexors)
– Fibularis (peroneus)
longus
– Extensor digitorum
longus
– Extensor hallicus
longus
– Tibialis anterior
Frolich, Human Anatomy,
Lower LImb
Lateral Leg (superficial fibular nerve.)
• Fibularis
brevis
and
longus
muscles
Frolich, Human Anatomy,
Lower LImb
Posterior Leg (tibial nerve)
• Flexors of foot
(plantarflexors)
– Gastrocs. and
soleus
– plantaris
– Flexor
digitorum
longus
– Flexor
hallucus
longus
– Tibialis
posterior
Frolich, Human Anatomy,
Lower LImb
Muscles of the Sole of the Foot
Muscles of the Sole of the Foot
Dorsum of the foot
Refferences
•
•
•
•
Grays Anatomy for students
Clinical Anatomy by Regions - Snell
Netter Atlas
www.google .com, search word: Anatomy of
lower limb
THANK YOU
FOR
LISTENING!