dr.ahmed salman -...
TRANSCRIPT
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THE LOWER LIMB
Dr.Ahmed SalmanAssistant Prof. of Anatomy. The University Of Jordan
The University Of Jordan Faculty Of Medicine
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Gluteal Region
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1. Lateral cutaneous branch of subcostal nerve(T12)2. Lateral cutaneous branch of iliohypogastric nerve (L1).3. Cutaneous branches from dorsal rami of upper 3 lumbar nerves
(L1, L2, L3) and upper 3 sacral nerves (S1, S2, S3).4. Lateral cutaneous nerves of the thigh (L2, L3).5. Posterior cutaneous nerves of the thigh (S1, S2, S3)
Cutaneous nerve supply of (Gluteal region)
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3 4
Upper Medial quadrant
Lower Medial quadrant
Lower Lateralquadrant
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Upper Lateral quadrant is supplied by the:Lateral cutaneous branch of subcostal nerve(T12)Lateral cutaneous branch of iliohypogastric nerve (L1).
Upper Medial quadrant is supplied by the:Cutaneous branches from dorsal rami of upper 3 lumbar nerves (L1, L2, L3) and upper 3 sacral nerves (S1, S2, S3).Lower Lateral quadrant is supplied by the:Lateral cutaneous nerves of the thigh (L2, L3).
Lower Medial quadrant is supplied by the:Posterior cutaneous nerves of the thigh (S1, S2, S3)
Cutaneous nerve supply of (Gluteal region)
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Iliotibial tract
Fascia lata Is a strong fibrous sheet that surrounds the whole of
the thigh like a tight trousersThe deep fascia of the thigh is thickened laterally to form iliotibial tract Attachment :
Above : iliac tubercle Below : the lateral condyle of the tibia.
It receives the insertion of the tensorfasciae latae and gluteus maximus muscles Function : extends the knee
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All are innervated by the Superior gluteal nerve EXCEPT
Gluteal maximus by inferior gluteal nerve
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Origin :1-Back of Ilium behind the posterior
gluteal line, 2-Back of sacrum and coccyx and
sacrotuberous ligament
Insertion : Gluteal tuberosity of femur (1/4),
iliotibial tract (3/4)
Nerve Supply: Inferior gluteal nerve, L5;S1,2
Action :Extends thighlateral rotation and abduction of thigh.Also extend knee
Gluteus maximus
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STRUCTURES UNDER THE COVER OF GLUTEUS MAXIMUS MUSCLE
Dr Amjad Shatarat
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STRUCTURES UNDER THE COVER OF GLUTEUS MAXIMUS MUSCLE
Dr Amjad Shatarat
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– Origin : iliac crest
– Insertion : iliotibial tract
– Nerve Supply : Superior
gluteal nerve . (L4,L5)
– Action : Extend knee,
flexion,abduction and
medial rotation of thigh
Tensor fasciae latae
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Gluteus medius and minimus
– Origin:Ilium outer surface – Insertion : Greater trochanter of
femur – Nerve supply : Superior gluteal
nerve– Action :Abduction, medial rotation
• Medius and minimus help stabilize• hip to allow balanced walk.
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1. In unilateral paralysis of G. medius and minimus, the patient
exhibits a lurching gait with a positive Trendelenburg's sign.
In standing on the affected side, the pelvis will tilt towards the
unsupported side. causes Lurching gait
2. In bilateral paralysis of G. medius and minimus, the patient
exhibits a waddling gait in which the trunk is flexed from side
to side with each step during walking.
On standing on the diseased side the sound side sags
Clinical Anatomy:
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The positive Trendelenburg test is seen if:
A- The hip abductors are paralysed (e.g. poliomyelitis)
B-Congenital dislocation of the hip
C-The head of the femur has been destroyed by disease
Or removed operatively (pseudarthrosis),
D-There is an un-united fracture of the femoral neck
E-There is a very severe degree of coxa vara
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CLINICAL ANATOMY
• I.M (Intramuscular injection)
Which the most suitable
quadrangle for IM injection?
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Clinical Notes
The great thickness of gluteus
maximus muscle makes it ideal
for intramuscular injections.
To avoid injury to the underlying
sciatic nerve, the injection should
be given well forward on the
upper outer quadrant of the
buttock.
However, the upper lateral
quadrant, most likely to be made
by the Gluteus medius muscle
Dr Amjad Shatarat
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Muscle Origin Insertion Nerve Supply Action
Gluteus maximus Outer surface of ilium, sacrum,
coccyx, sacrotuberous ligament
Iliotibial tract
and gluteal
tuberosity of
femur
Inferior gluteal
nerve
Extends and
laterally
rotates hip
joint; through
iliotibial tract,
it extends
knee joint
Gluteus medius Outer surface of ilium Lateral surface
of greater
trochanter of
femur
Superior
gluteal nerve
Abducts thigh
at hip joint;
tilts pelvis
when walking
to permit
BALANCED
WALK
Gluteus minimus Outer surface of ilium Anterior
surface of
greater
trochanter of
femur
Superior
gluteal nerve
Abducts thigh
at hip joint;
tilts pelvis
when walking
to permit
BALANCED
WALK
Tensor fasciae
latae
Iliac crest Iliotibial tract Superior
gluteal nerve
Assists gluteus
maximus in
extending the
knee joint
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Lateral rotators of the thigh (Hip)
1. Piriformis
2. Quadratus femoris
3. Superior gemillus
4. Inferior gemillus
5. Obturator internus
6. Obturator externus
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Piriformis
Quadrates Femoris
Obturator internus and two Gemelli
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Lateral Rotators
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Origin of piriformis
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N.SupplyInsertionOriginThe Muscle
1st and 2nd sacral nerves of the sacral plexus
greater trochanter of the femur (top)
pelvic surface of the middle 3 pieces of the sacrum
1-piriformis
Nerve to obturator internus from the sacral plexus.
medial surface of the greater trochanter of the femur
pelvic surface of the obturator membrane and the bones surrounding the obturator foramen
2.Obturator internus
N. to obturator internus
tendon of the obturatorinternus muscle
ischial spine3.Superior gemellus
N. to quadratus femoris of the sacral plexus
tendon of the obturatorinternus muscle
ischial tuberosity4.Inferior gemellus
N. to quadratus femoris of the sacral plexus
Into the quadrate tubercle of the inter-trochanteric crest of the femur
ischial tuberosity5.Quadrats femoris
Posterior division of the obturator N. of the lumbar plexus
trochanteric fossa external surface of the obturator membrane and the adjacent margin of the obturator foramen
6.Obturator externus
Lateral rotators of the thigh (Hip)
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Lateral rotators of the thigh
1-PiriformisN.S: L5,S1,S2
2-Obturator internusN.S: Nerve to obturator internus (L5,S1)
3-Superior gemillusN.S: Nerve to obturator internus (L5,S1)
4-Quadratus femorisNerve to quadratus femoris. (L5,S1)
5-Inferior gemillusN.S: Nerve to quadratus femoris. (L5,S1)
6-Obturator externus:N.S: Obturator nerve (L3,L4)
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F
Identify the marked muscles and their nerve supply
A-
B-
C-
D-
E-
F-
G-
H-
G
H
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Greater and lesser sciatic foramens
Sacrospinous ligament between ischial spine and back of sacrum& coccyx
Sacrotuberous ligamentBetween ischial tuberosity and back of sacrum& coccyx
Greater sciatic foramenBetween greater sciatic notch, sacrospinous and sacrotuberous ligaments.
Lesser sciatic foramenBetween lesser sciatic notch, sacrospinous and sacrotuberous ligaments.
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Structures Passing in Greater and Lesser Sciatic Foramina
Greater sciatic foramen (7 nerves+3 vesseles+1 muscle)
Above PiriformisSuperior gluteal nerve and vesselsBelow Piriformis
• Sciatic nerve• Posterior cutaneous nerve of the thigh• Inferior Gluteal nerve and vessels• Nerve to Quadratus femoris• Pudendal nerve• Internal pudendal vessels• Nerve to Obturator Internus
Lesser Sciatic foramen• Tendon of Obturator Internus Muscle• Pudendal nerve• Internal pudendal vessels• Nerve to obturator internus
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1-Superior Gluteal Artery
is a branch from the internal iliac artery
enters the gluteal region through the
greater sciatic foramen above the piriformis
2-Inferior Gluteal Artery
is a branch of the internal iliac artery
enters the gluteal region through the
greater sciatic foramen, below the
piriformis
Arteries of the Gluteal Region
It divides into superficial
and deep branches.
The superficial branch
supplies the gluteus maximus
muscle
The deep branch supplies
the glutei medius and
minimus.
It divides into numerous branches that are
distributed throughout the gluteal region.
Dr Amjad Shatarat
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Posterior Compartment of thigh - Hamstring
1. Biceps femoris (long and short heads)
2. Semitendinosus
3. Semimembranosus
4. Adductor Magnus (Ischial head)
All above are innervated by tibial branch of Sciatic nerve.
EXCEPTShort head of biceps femoris by common peroneal branch of
Sciatic nerve
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M
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Origin :
All from ischial tuberosity EXCEPT Short head of biceps femoris from
linea aspera and lateral supracondylar line.
Insertion :
Biceps femoris : styloid process of the fibula.
Semitendinosus: upper part of medial surface of the tibia (SGS).
Semimembranosus: medial condyle of the tibia
Adductor Magnus (Ischial head) :Adductor tubercle of femur
All are Extends the hip and flexes the kneeLateral muscle rotate the knee laterallyMedial muscle rotate the knee medially
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The Muscle Origin Insertion N.Supply Action
1- Biceps Femoris
2-Semitendinosus
3-Semimembranosus
4-Adductor magnus
(Ischial head)
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Muscle Origin Insertion Nerve Supply Action
Biceps femoris Long head:
Ischial tuberosity
Short head: linea
spera, lateral
supracondylar
ridge of shaft of
femur
Head of fibula Long head: tibial
portion of sciatic
nerve
Short head: common
peroneal portion of
sciatic nerve
Flexes and laterally
rotates leg at knee joint;
long head also extends
thigh at hip joint
Semitendinosus Ischial tuberosity Upper part of
medial surface
of shaft of tibia
Tibial portion of
sciatic nerve
Flexes and medially
rotates leg at knee joint;
extends thigh at hip
joint
Semimembranosus Ischial tuberosity Medial
condyle of
tibia
Tibial portion of
sciatic nerve
Flexes and medially
rotates leg at knee joint;
extends thigh at hip
joint
Adductor
magnus
(hamstring
portion)
Ischial tuberosity Adductor
tubercle of
femur
Tibial portion of
sciatic nerve
Extends thigh at hip
joint
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Anterior/Posterior thigh compartments
ANTERIOR COMPARTMENT
POSTERIOR COMPARTMENT
MOVEMENT
MUSCLES
NERVES …………………nerve
(…………….plexus)
…………………nerve
(…………….plexus)
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