organization of the lower limb - ohio university
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Organization of the Lower LimbAudrone Biknevicius, Ph.D.
Dept. Biomedical Sciences, OU HCOM at DublinClinical Anatomy Immersion 2015
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LIMB FUNCTION
Mobility versus Body weight supportDexterity Locomotion
Equilibrium & Stability
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Pectoral Girdle Pelvic Girdle
Mobility versus Body weight supportDexterity Locomotion
Equilibrium & Stability
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Arm – forearm – hand Thigh – leg – foot
The upper and lower limbs are innervated by:
A. Posterior (dorsal) rami of spinal nn.B. Anterior (ventral) rami of spinal nn.
5Poste
rior (d
orsal) r
ami of s
pin..
Anterior (v
entral) r
ami o
f sp...
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CORRECTED SLIDE #5
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Week 5
RULE #1Limbs are outgrowths of the ventral body wall
Upper limb: C5-T1 trunk segments
Lower limb: L2-S3 trunk segments(morphogenesis ~1-2 days later)
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RULE #1 (continued)Limbs are outgrowths of the ventral body wall that undergo distal growth, differentiation and rotation
Week 7
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Before rotation
• Pollex and hallux both preaxial • Anteriomedially-directed palms and soles
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Upper limb rotates 90◦ laterally:-Extensor mm. on posterior surface-Future elbow directed posteriorly-Supine hand in anatomical position-Pollex positioned laterally
Lower limb rotates 90◦ medially:-Extensor mm. on anterior surface-Future knee directed anteriorly-Foot fixed in prone position-Hallux positioned medially
Post rotation
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Spinal nerveDorsal primary ramusVentral primary ramus (L2-S3)
Anterior (ventral) divisionPosterior (dorsal) division
limb axisStern Essential of Gross Anatomy
RULE #2: Innervation of lower limb mm. established in early embryogenesis – resulted in dedicated nerve-compartment relationships
Brachial Plexus(right side; simplified)
TerminalBranches
“Roots of BP” (=ventral rami)
C5C6
C7
C8
T1
Trunks
U
M
L
Cord
LatPost
Med
Divisions
Anterior (ventral) division
Posterior (dorsal) division 11
Stern E
ssential of Gross A
natomy
Radial n.
Musculocutaneous n.
Median n.
Ulnar n.
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Ventral divisionDorsal division
Lumbosacral trunk (to sacral plexus)Obturator Nerve
(L2,3,4)
Lumbar Plexus
Ventral divisionDorsal division
Sacral Plexusaccessphysiotherapy.m
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As a result of the opposite rotation of the lower limb, in which compartment will the developmentally dorsal muscles be located?
A. Anterior compartmentB. Posterior compartment
14Anterio
r compartm
ent
Posterio
r compartm
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Week 7
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Forearm
Hand
Arm
Leg
Foot
Thigh
Upper Limb Lower Limb
Ant
Post
MedLat
Developmentally ventral vs. dorsal mm.S
tern Essential of G
ross Anatom
y
Hence, posterior division nn. serve anterior compartments in LL
The fact that the anterior compartment muscles are innervated by posterior division nerve is …
A. Functionally relevantB. Downright confusing
16Functi
onally re
levant
Downright c
onfusing
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Palmar
Dorsum
LatMed
Dorsum
Plantar
MedLat
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Leg
Foot
Thigh
Compartments: Anterior Posterior Medial Lateral
Upper Limb Lower Limb
Ant
Post
MedLat
Limb Muscle Compartments
MP
A
ALP
A
P
APForearm
Hand
Arm
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No motor distribution distal to knee*pectineus usually innervated by femoral n.
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Leg
Foot
Thigh
Compartments: Anterior Posterior Medial Lateral
Ant
Post
MedLat
Lower Limb Muscle Compartments
Compartments: Dorsum Plantar
Femoral n.
Obturator n.
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The Sacral Plexus
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Leg
Foot
Thigh
Compartments: Anterior Posterior Medial Lateral
Ant
Post
MedLat
Lower Limb Muscle Compartments
Compartments: Dorsum Plantar
Femoral n.
Obturator n.
Tibial n.
Tibial n.
Tibial n.
Including Adductor magnus (hamstring part)
Common fibular n.: Biceps femoris short head
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The Sacral Plexus
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Lateral compartment
Anteriorcompartment
dorsum of foot!“Peroneal” = “Fibular”
Deep fibular n.
Superficial fibular n.
Common fibular n.
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Leg
Foot
Thigh
Compartments: Anterior Posterior Medial Lateral
Ant
Post
MedLat
Lower Limb Muscle Compartments
Compartments: Dorsum Plantar
Femoral n.
Obturator n.
Tibial n.
Tibial n.
Tibial n.
Deep fibular n.Superficial fibular n.
Deep fibular n.
Including Adductor magnus (hamstring part)
Common fibular n.: Biceps femoris short head
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Compartmental Organization of the Thigh
Fascia lata (& intermuscular septa)
Anterior – Femoral n.
Medial – Obturator n.(exception: Femoral n. –adductor magnus, hamstring part)
Posterior – Tibial n.(exception: Common fibular n. – biceps femoris, short head)
Primary functions: Hip & Knee
medical-dictionary.thefreedictionary.com
Medial compartmentAdductors of thighObturator n.
Posterior compartmentExtensors of thigh Tibial n.
Anterior compartmentFlexors of thighFemoral n.
Many are biarticular muscles that also affect the knee joint
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Attached to ischial tuberosity: • Thigh extension, Leg flexion: Biceps femoris (long head)*,
Semitendinosus* & Semimembranosus* mm.• Thigh extension, Thigh adduction: Adductor magnus (hamstring part)* biarticular mm.
Tibial n.
Posterior compartment of thighHip extension; Knee flexion
Exception: Biceps femoris (short head); common fibular n.; knee flexion
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Adductor magnus
Hamstring part:-Attaches to ischial tuberosity-Tibial n.
Adductor part:-Attaches to pubis-Obturator n.
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Anterior Compartment of ThighHip flexion; Knee extension
Attached to ilium:• Thigh flexion: Iliopsoas• Thigh flexion, Leg flexion:
Sartorius*• Thigh flexion, Leg extension:
Rectus femoris m.*
• Leg extension (no action at hip) – remainder of Quadriceps femoris (vasti)
* biarticular mm.
Femoral n.
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Medial Compartment of ThighHip adduction; Hip flexion
Attachment to pubis:• Thigh adduction: Adductor
longus, Adductor brevis, Adductor magnus(pubofemoral part)
• Thigh adduction, Leg flexion: Gracilis
Obturator n.
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Pectineus – “the exception”
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Attaches to superior ramus of pubis
Pectineus m. mostly innervated by femoral n. (~25% by obturator n.)
All other mm. attaching to pubis are innervated by obturator n.
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Gluteal group (externally)Iliopsoas (internally)
Adductor grpHamstring & latrotator grp
Relative positions of muscles producing movements of hip joint
Adapted from Moore et al., Essential Clinical Anatomy
What are the actions of muscles attached to the anterior aspect of the hip?
A. Thigh extensionB. Thigh flexion
33Thigh
extensio
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Thigh
flexio
n
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Gluteal group (externally)Iliopsoas (internally)
Adductor grpHamstring & latrotator grp
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Gluteal group (externally)Iliopsoas (internally)
Adductor grpHamstring & latrotator grp
Hip FlexorsFemoral n.: iliopsoas, sartorius, rectus femoris, pectineusSuperior gluteal n.: tensor fasciae lataeObturator n.: adductor longus, brevis & magnus (anterior), gracilis
Hip ExtensorsTibial n.: biceps femoris (long head), semitendinosis, semimembranosus, adductor magnus (posterior)Inferior gluteal n.: Gluteus maximus
Adapted from Moore et al., Essential Clinical Anatomy
What are the actions of muscles attached to the superolateral aspect of the hip?
A. Thigh adductionB. Thigh abduction
35Thigh
adducti
on
Thigh
abducti
on
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Gluteal group (externally)Iliopsoas (internally)
Adductor grpHamstring & latrotator grp
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Gluteal group (externally)Iliopsoas (internally)
Adductor grpHamstring & latrotator grp
AdductorsObturator n.: adductor longus, brevis & magnus(anterior), gracilisTibial n.: adductor magnus (posterior)Femoral n.: Pectineus
AbductorsSuperior gluteal n.: gluteus medius & minimum, tensor fasciae latae
Adapted from Moore et al., Essential Clinical Anatomy
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Gluteal group (externally)Iliopsoas (internally)
Adductor grpHamstring & latrotator grp
Lateral RotatorsN. obturator internus: obturator internus, superior gemellusN. quadratus femoris: quadratus femoris, inferior gemellusObturator n.: obturator externusN. piriformis: piriformisInferior gluteal n.: gluteus maximus
Medial RotatorsSuperior gluteal n.: gluteus medius & minimum, tensor fasciae latae
Adapted from Moore et al., Essential Clinical Anatomy
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Compartmental Organization of the Leg
Crural fascia of leg (& intermuscular septa)
Anterior – Deep fibular n.
Lateral – Superficial fibular n.
Posterior – Tibial n.
(no medial compartment; tibial shaft)
Primary Actions: Ankle & Foot
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Primary Movements of Foot
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Subtalar joints
Ankle Joint (Talocrural Joint)
What is the likely action of the muscles of the anterior compartment at the ankle?
A. Foot dorsiflexionB. Foot plantarflexion
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ot dorsi
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Foot p
lantarfle
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plantarflexiondorsiflexion
What is the likely action of the muscles of the lateral compartment of the leg at the subtalar
joints?A. Foot eversionB. Foot inversion
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ot eve
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Foot in
versi
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Medial malleolus
Lateral malleolus
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Anterior Compartment of LegDorsiflexor (extensor) Compartment
Also foot inversion:Tibialis anterior
Also foot eversion:Fibularis (peroneus) tertius
Also toe extension:Extensor hallicus longus Extensor digitorum longus
Deep fibular n.
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Lateral Compartment of LegEvertor Compartment
Fibularis (peroneus) longusFibularis (peroneus) brevis(also weak plantarflexors)
Superficial fibular n.
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Posterior Compartment of LegPlantarflexor Compartment
Superficial mm.:Gastrocnemius (also knee flexor)SoleusPlantaris
Deep mm.: Popliteus (unlocks knee) Flexor digitorum longusFlexor hallucis longusTibialis posterior (also inversion)
Tibial n.
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plantarflexiondorsiflexion
Dorsiflexion (flexion)Deep fibular n.: Tibialis anterior, EHL, EDL, fibularis tertius
Plantarflexion (extension)Tibial n.: gastrocnemius, soleus, plantaris, tibialis posterior
(Superficial fibular n.: weak fibularis longus & brevis)
* Triceps surae: medial and lateral gastrocnemius and soleus
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Inversion:Tibialis anterior (deep fibular n.)Tibialis posterior (tibial n.)
Eversion:Fibularis longis & brevis (superficial fibular n.)Fibularis tertius (deep fibular n.)
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en.wikipedia.org
Central/Axial Lines3rd digit in hand 2nd digit in foot
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Dorsal interossei muscles
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Plantar (posterior) Compartment of Foot
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1st layer:Abductor hallucisFlexor digitorum brevisAbductor digit minimi
2nd layer:Quadratus plantaeLumbricals
3rd layer:Flexor hallucis brevisAdductor hallucisFlexor digit minimi brevis
4th layer:Plantar interosseiDorsal interossei
Tibial n.: medial and lateral plantar nn.
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Plantar (posterior) Compartment of FootMedial plantar n.(“median n. of foot”):Abductor hallucisFlexor hallucis brevis1st lumbrical
Flexor digitorum brevis
Lateral plantar n.(“ulnar n. of foot”):Abductor digiti minimiFlexor digiti minimi brevis
Dorsal interosseiPlantar interosseiAdductor hallucisRemaining lumbricals
Quadratus plantae
Upper roots of the lumbosacral plexus innervate proximal muscles (hip, knee)
Lower roots of the lumbosacral plexus innervate distal muscles (ankle, toes)
RULE #3: Proximal-to-Distal Rule
51Dorsiflexion-PlantarflexionInversion-Eversion
Patellar tendon reflex“Knee (jerk) reflex”
(predominantly L3, L4)
Deep Tendon Reflexes (DTR)
Achilles tendon reflex“Ankle (jerk) reflex”
(S1, S2)
“MIXED FUNCTIONAL MODALITIES”
Some terminal branches of the lumbosacral plexus are cutaneous nerves.
RULE #4A
What of the following functional modalities is NOT present in neurons contained within cutaneous nerves?A. Somatic motorB. Somatic sensoryC. Sympathetics
54So
matic m
otor
Somatic
senso
ry
Sympathetic
s
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Obturator Nerve (L2,3,4)
“MIXED FUNCTIONAL MODALITIES”
All terminal branches of the lumbosacral plexus are mixed fiber nerves:
1. Somatic motor and somatic sensory (prioprioception) to skeletal mm.
2. Then, cutaneous innervation with somatic sensory and sympathetics to skin
RULE #4 B
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Obturator n.
Cutaneous brs.
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Femoral n.
Anterior femoral cutaneous nn.
Saphenous n.
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Common Fibular n.
Lateral sural cutaneous n.
Superficial fibular n.
Dorsal digital nn.
Deep fibular n.
Dorsal digital nn.
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Tibial n.
Medial sural cutaneous n.
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Cutaneous Innervation of Foot
Dorsum – Superficial fibular n.(deep fibular between digits I & II)Plantar – Tibial n. (medial & lateral plantar nn.Medial – Saphenous n. (femoral n.)Lateral – Sural n.
L2-S3Lower Limb
RULE #5: Cutaneous Nerve vs. DermatomesDistribution
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Cutaneous Nerve Distribution vs. Dermatomesw
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Dermatome Mapsw
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Keegan & Garrett (1948) - DevelopmentFoerster (1933) - Clinical
65*Lower sacral cord largely confined to perineum
Dermatomes
Upper sacral cordMostly posterior aspect
Lumbar spinal cordAnterior & medial aspectsMost of lateral aspects
Autonomous Sensory Zones
S3
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L1: Over inguinal ligament
L2: Lateral side of thigh
L3: Lower medial side of thigh
L4: Medial malleolus, Medial side of foot(medial side of hallux)
L5: Medial side of digit II
S1: Lateral malleolus; Lateral side of foot(lateral side of little toe)
S2: Back of thigh
S3: Skin over gluteal fold
Radiculopathy
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brain
Cervical spinal nerve
Lumbar spinal nerves
Caudal equina
spin
al c
ord
Which dermatome is affected in a L4/L5 disk herniation?
A. L4B. L5C. S1
68L4 L5 S1
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Where will pain from a L4/L5 disk herniation radiate?
A. Medial aspect of leg, ankle (medial malleolus) & hallux
B. Lateral leg to dorsum of footC. Lateral aspect of ankle
(lateral malleolus) & lateral side of digit V
69Medial asp
ect of le
g, an
kle ...
Later
al leg
to dorsu
m of foot
Later
al asp
ect of a
nkle (la
ter..
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Dermatomes
Which deep tendon reflex will a longstanding L4/L5 disk herniation weaken?
A. Knee jerk/patellar tendonB. Ankle jerk/Achilles tendonC. Neither
71Knee j
erk/p
atellar
tendon
Ankle je
rk/Ach
illes t
endon
Neither
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CORRECTED SLIDE #71
IVD Root Sensory Loss Motor Weakness L3-L4 L4 Medial ankle Patellar tendon reflex
L4-5 l5 Dorsum of foot
L5-S1 S1 Lateral ankle Achilles tendon reflex
LOWER LIMB RADICULAR SYNDROMES
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