presentation 4 - leg (ep)

7/31/2019 Presentation 4 - Leg (EP)

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Superficial Anatomy:POSTERIOR LOWER LIMB

- Cluneal nerves (superior, middle, and inferior)- innervate skin of gluteal

region

-Posterior cutaneous nerve of thigh- Small saphenous vein, from lateral end ofdorsal venous arch, joins

popliteal vein by penetration deep fascia in popliteal fossa

- Sural nerve runs down posterior leg parallel to small saphenous vein,

lateral skin of ankle and foot

ANTERIOR LOWER LIMB

- Great saphenous vein, from medial end ofdorsal venous arch, accompanied

bysaphenous nerve,perforating veins connect to deep venous system

- Superficial external pudendal, superficial epigastric, and superficial

circumflex iliac all join great saphenous near proximal end

-Lateral femoral cutaneous nerve

-Anterior cutaneous branches of femoral nerve

- Cutaneous branches of the obdurator nerve

- Saphenous nerve

- Superficial fibular (peroneal) nerve, innervates dorsum of foot and sends as

branches dorsal digital nerves, 1st and 2nd toes receive dorsal digital branches

of deep fibular nerve

- Superficial inguinal lymph nodes: horizontal group, then vertical group

inferior to saphenous opening

collect lymph from lower limb, lower anterior abdominal wall, glutealregion, perineum, external genitalia, drain into deep inguinal lymph nodes

-fascia lata (of thigh) laterally iliotibial tract

- crural fascia (of leg)

-pedal fascia (of foot)

Gluteal Regionorigin insertion innervation function

MUSCLE: SUPERFICIAL

Gluteus

maximus

Ilium behind

posterior gluteal

line, sacrum,

coccyx, and

sacrotuberous

ligament

Iliotibial tract

laterally,

elongate gluteal

tuberosity of

femur deep and

distally

Inferior

gluteal nerve

Extends thigh,

stabilizes knee

and hip


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Gluteus

medius

Between anterior

and posterior

gluteal lines on

ilium

Greater

trochanter

Superior

gluteal nerve

Abduct femur,

reduce pelvic

drop

Gluteusminimus Between inferiorand anterior gluteal

lines on ilium

Greatertrochanter Superiorgluteal nerve Abduct femur,reduce pelvic

drop

Tensor

fasciae

latae

Anterior superior

iliac spine to

tubercle of iliac

crest

Iliotibial tract Superior

gluteal nerve

Stabilizes knee

in extention,

helps hold

femoral head in

acetabulum

MUSCLE: DEEP

Piriformis Between anterior

sacral foramina

Greater

trochanter

Nerve to

piriformis(from S1, S2)

Lateral

rotation,abducts femur

Obdurator

internus

Medial surface of

obturator membrane

and bone of

obdurator foramen

Just inferior to

piriformis on

greater

trochanter

Obturator

nerve

Lateral

rotation,

abducts femur

Gemellus

Superior

Ischial spine With O.I. on

greater

trochanter

Nerve to

obdurator

internus

Lateral

rotation, abduct

femur

GemellusInferior

Ischial tuberosity With O.I. ongreater

trochanter

Nerve toquadratus

femoris

Lateralrotation, abduct

femur

Quadratus

femoris

Lateral aspect of

ischium anterior to

tuberosity

Quadrate

tubercle of

intertrochanteric

crest of proximal

femur

Nerve to

quadratus

femoris

Lateral rotation

only

OTHER NERVES

Posterior cutaneous nerve of the

thigh

Skin over the gluteal fold, scrotum, labia majora,

posterior thigh, and posterior leg

Pudendal nerve No branches in gluteal region

Perforating cutaneous nerve Pierces sacrotuberous ligament, skin over medial

aspect of gluteus maximus

BLOOD SUPPLY: ARTERIES


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Inferior gluteal artery From anterior trunk of internal iliac, through

gluteal region into posterior thigh, anastomoses

with perforating branches of femoral artery

Superior gluteal artery From posterior trunk of internal iliac, superficial

branch: onto deep surface of glut.max., deepbranch: between glut.med. and glut.min.,

anastomose with medial and lateral femoral

circumflex artery and with inferior gluteal artery

BLOOD SUPPLY: VEINS

Inferior and Superior gluteal veins

LYMPHATICS

Deep lymphatic vessels Travel with blood vessels into pelvis internal

iliac nodes

Superficial lymphatics To superficial inguinal nodes on anterior thigh

Note:

greater sciatic foramen

Above piriformis: superior gluteal nerve, artery, and vein

Below piriformis: inferior gluteal nerve, artery, and vein, sciatic nerve,

posterior cutaneous nerve of thigh, pudendal nerve, internal pudendal vessels

Posterior Thighorigin insertion innervation function

MUSCLE (hamstrings)

Biceps femoris (2 heads):

Long head Ischial

tuberosity

Head of

fibula

(extensions

blend with

fibular

collateral

ligament)

Tibial

division of

sciatic nerve

Flexes leg,

extends and

laterally

rotates hip

Short head Lateral lip

of linea

aspera

Common

fibular

division of

sciatic nerve

Flexes leg

semitendinosis Ischial

tuberosity

Medial

surface of

superior part

of tibia

Tibial

division of

sciatic nerve

Extends and

medially

rotates

thigh, flexes

and

medially


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rotates leg

semimenbranosus Ischial

tuberosity

Medial and

posterior

surfaces of

medial tibialcondyle

Tibial

division of

sciatic nerve

Extends and

medially

rotates

thigh, flexesand

medially

rotates leg

POPLITEAL FOSSA:

Bounded by biceps femoris (superolaterally), semimembranosus and

semitendinosus (superomedially), gastrocnemius muscles (inferiorly), skin

and deep fascia (posteriorly), popliteal surface of femur and popliteus

(anteriorly)

Sciatic divides into:

Tibial nerve (medially)- deep to gastrocnemiusCommon fibular nerve (laterally)- superficial to gastrocnemius

Division usually proximal to knee, but may occur in pelvis

Popliteal artery and vein enclosed by a common connective tissue sheath

Superior medial and lateral genicular arteries (proximal to level of

gastrocnemius attachments)

Inferior medial and lateral genicular arteries

Note:

Pes anserinus= where sartorius, gracilis, and semitendinosus tendons

converge at proximal end of tibia

Anterior Thighorigin insertion innervation function

MUSCLE

iliacus Iliac fossa

(posterior

abdominal wall)

Lesser

trochanter

Femoral

nerve

Iliopsoas:

Flexes and

laterally

rotates thighPsoas major Vertebrae of

TXII to LV(posterior

abdominal wall)

Lesser

trochanter

Anterior

rami of L1,L2, L3

sartorius Anterior

superior iliac

spine

Medial

surface of

proximal

shaft of tibia

Femoral

nerve

Lateral

margin of

femoral

triangle,


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anterior wall

of adductor

canal

Flexes thigh

and leg,abducts and

laterally

rotates thigh

Quadriceps femoris (4 parts):

Rectus

femoris

Pelvic bone:

straight head

from anterior

inferior iliac

spine, reflected

head fromimmediately

superior to

acetabulum

Tibial

tuberosity via

quadriceps

femoris

tendon and

patellarligament

Femoral

nerve

Flexes thigh

and extends

leg

Vastus

medialis

Femur: Medial

lip of linea

aspera and

intertrochanteric

line

Femoral

nerve

Extends leg

Vastusintermedius Femur: Anteriorand lateral

surfaces of

femur

Femoralnerve Extends leg

Vastus

lateralis

Femur: Lateral

lip of linea

aspera and

greater

trochanter

Femoral

nerve

Extends leg

(articularis

genus)

Femur: inferior

to origin ofvastus

intermedius

Suprapatellar

bursa

Pulls bursa

away fromknee joint

during

extension


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SAPHENOUS OPENING:

Great saphenous vein (superficial) joins femoral vein and deeper anterior

thigh

FEMORAL TRIANGLE:

Femoral sheath envelopes(1) femoral artery (lateral)

branches: superficial external pudendal artery

superficial epigastric artery

superficial circumflex iliac artery

deep pudendal artery

largest branch = deep artery of thigh (e.g. deep femoral artery), between

pectineus and adductor longus, then between adductor brevis and adductor

longus, connects with popliteal artery

lateral circumflex femoral artery: anastomoses with medial femoral

circumflex, popliteal, inferior gluteal, first perforating medial femoral circumflex artery: branch through acetabular notch

that anastomoses with obdurator artery, also with inferior gluteal, lateral

circumflex, first perforating artery

together form cruciate anastomoses around hip

perforating arteries, anastomose superiorly and inferiorly, posterior to

adductor magnus

(2) femoral vein (intermediate)

branches: great saphenous vein

(3) deep inguinal lymph nodes (medial = femoral canal, proximal opening =femoral ring)

Borders include adductor longus, sartorius, and inguinal ligament, floor is

formed by iliopsoas and pectineus

Femoral nerve lies lateral to femoral artery, note anterior cutaneous

branches, motor nerves, and saphenous nerve (does not pass through

adductor hiatus)

ADDUCTOR CANAL:

Begins at apex of femoral triangle, ends at adductor hiatus (opening in

tendon of adductor magnus)

After adductor canal vessel names change from femoral to popliteal

Nerve to vastus medialis and saphenous nerve also in adductor canal

Medial Thighorigin insertion innervation function


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MUSCLE (adductor group)

Gracilis Ischiopubic

ramus

Medial

surface of

proximal

shaft of tibia

Obdurator

nerve

Adducts

thigh, helps

in flexion of

legPectineus Pectineal line

of pelvic

bone

Base of lesser

trochanter to

linea aspera

Femoral

nerve (may

receive

contribution

from

obdurator

nerve)

Adducts and

flexes thigh

Adductor

longus

Rough

triangular

area inferiorto pubic crest

Middle third

of linea

aspera

Obdurator

nerve

Adducts and

medially

rotates thigh

Adductor

brevis

Body and

inferior

ramus of

pubis

Pectineal line

and linea

aspera of

femur

Obdurator

nerve

Adducts

thigh

Adductor

magnus:

lateral,

adductorpart

Ishiopubic

ramus

Gluteal

tuberosity,

linea aspera,

medialsupracondylar

line

Obdurator

nerve

Adducts and

medially

rotates thigh,

help formadductor

hiatus

Adductor

magnus:

medial,

hamstring

part

Ischial

tuberosity

Adductor

tubercle on

medial

condyle of

distal head of

femur

Tibial

division of

sciatic nerve

Obdurator

externusmuscle

External

surface ofobdurator

membrane

and bone

Lateral wall

oftrochanteric

fossa

Obdurator

nerve

Lateral

rotator ofthigh


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VESSELS:

Deep artery of the thigh- between pectineus and adductor longus

perforating arteries- penetrate adductor brevis and encircle femur, supply

medial and posterior compartments

NERVES:Anterior branches of obdurator nerve- anterior to adductor brevis

Posterior branches of obdurator nerve- posterior to adductor brevis, anterior

to adductor magnus

Anterior Compartment of Leg:origin insertion innervation function

MUSCLE (extensors: dorsiflex foot, extend toes, invert foot)

Tibialis

anterior

Lateral

surface oftibia and

interosseous

membrane

Medial and

inferiorsurfaces of

medial

cuneiform

and adjacent

surfaces on

base of

metatarsal I

Deep fibular

nerve

Dorsiflexion

of foot,inversion of

foot, support

of medial

arch

Extensor

hallucislongus

Medial

surface offibula and

interosseous

membrane

Dorsal

surface ofdistal

phalanx of

great toe

Deep fibular

nerve

Extends great

toe,dorsiflexes

foot

Extensor

digitorum

longus

Medial

surface of

fibula and

head of

lateral

condyle of

tibia

Distal and

middle

phalanges of

lateral 4 toes

Deep fibular

nerve

Extension of

lateral 4 toes,

dorsiflexion

of foot

Fibularis

tertius

Usually considered as part of extensor digitorum longus


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VESSELS:

Anterior tibial artery- from popliteal artery, passes anterior through aperture

in interosseous membrane, continues onto dorsal aspect of foot as dorsalis

pedis artery, joined by perforating branch of fibular artery distally, distally

gives rise to:anterior medial malleolar artery

anterior lateral malleolar artery

NERVES:

Deep fibular nerve- originates in lateral compartment

Also supplies extensor digitorum brevis, 1st 2 dorsal interossei muscles, skin

between great and second toes

Dorsum of Foot:

BONES (tarsals:7, metatarsals:5, phalanges:14)calcaneous Cuboid (lateral) metatarsals phalanges

talus Navicular

(medial)

cuneiform (L,

I, M)

origin insertion innervation function

MUSCLES

Extensor

digitorum

brevis

calcaneous Lateral sides

of tendons of

extensor

digitorum

longus, toes2-4

Deep fibular

nerve

Extension of

toes

Extensor

hallucis

brevis

calcaneous Proximal

phalanx of

great toe

Deep fibular

nerve

Extension of

great toe

VESSELS:

Anterior tibial artery dorsalis pedis arteryarcuate artery dorsal

metatarsal arteries dorsal digital arteries

Also note:

Lateral tarsal artery branches from dorsalis pedis artery, goes deepDeep plantar artery branches from dorsalis pedis artery, goes deep to

anastomose with deep plantar arch

NERVES:

Common fibular nerve deep fibular nerve (runs parallel to anterior tibial

artery) two dorsal digital branches of deep fibular nerve (between toes 1

and 2)


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Superficial fibular nerve innervates all other skin on dorsum of foot

Posterior Compartment of Leg:origin insertion innervation function

MUSCLE (flexors: plantarflex ankle, flex toes, invert foot)SUPERFICIAL

Gastrocnemius Medial head:

above

articular

surface of

medial

condyle of

femur

Lateral head:

upper lateral

surface of

lateral

condyle of

femur

Calcaneous Tibial nerve Plantarflex

foot, flex

knee

Plantaris Lower part of

lateral

supracondylar

ridge and

obliquepopliteal

ligament


foot, flex

knee

Soleus Proximal

ends of tibia

and fibula

and a

tendinous

ligament

between them


foot

DEEP

Popliteus Posterior

surface of

proximal tibia

Lateral

femoral

condyle

Tibial nerve Unlocks

extended

knee at

initiation of

flexion


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Flexor hallucis

longus

Lower 2/3 of

fibula and

interosseous

membrane

Plantar

surface of

great toe

(distal

phalanx)

Tibial nerve Flexes great

toe (during

toe-off),

plantarflexion

of footFlexor

digitorum

longus

Medial side

of posterior

of tibia

Plantar

surfaces of

distal

phalanges,

toes II-V

Tibial nerve Flexes lateral

4 toes (end of

stance phase)

Tibialis

posterior

Interosseous

membrane

and adjacent

posterior

surfaces oftibia and

fibula

Plantar

surfaces of

medial

tarsals

(tuberosityof navicular,

medial

cuneiform)

Tibial nerve Inverts and

plantarflexes

foot

VESSELS (Note: veins follow arteries)

Popliteal artery Passes under tendinous ach formed by

medial and lateral heads of soleus,

branches into

Anterior tibial artery Enters and supplies anterior compartment

of leg, dorsum of footPosterior tibial artery Supplies posterior ad lateral compartments,

sole of foot

Passes through tarsal tunnel behind medial

malleolus

Circumflex

tibial artery

Laterally through soleus, around fibula,

anastomoses with vessels around knee

Fibular

artery

Parallels posterior tibial artery, travels

along posterior surface of fibula between

flexor hallucis longus and tibialis

posterior, supplies posterior and lateral

compartments

perforating

branch

Through inferior aperture in

interosseous membrane,

anastomoses with anterior

tibial artery


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NERVES:

Tibial nerve= major branch of sciatic, through tendinous arch of soleus,

enters the foot via tarsal tunnel, gives rise to 2 cutaneous branches:

sural nerve-

originates between 2 heads of gastrocnemius, runs superficially, suppliesskin on lower posterolateral surface of leg and lateral side of foot and little

toe

medial calcaneal nerve-

originates low in leg near ankle, descends onto medial side of heel, skin on

medial surface and sole of heel

Lateral Compartment of Leg:origin insertion innervation function

MUSCLEFibularis

longus

Upper lateral

surface of

fibula, fibular

head, lateral

tibial condyle

Undersurface

of lateral

sides of distal

end of medial

cuneiform

and base of

metatarsal I

Superficial

fibular nerve

Everts and

plantarflexes

foot, helps

support

lateral and

transverse

arches

Fibularis

brevis

Lower 2/3 of

lateral shaft

of fibula

Tubercle on

lateral

surface ofmetatarsal V

Superficial

fibular nerve

Evert foot

VESSELS:

Branches of fibular artery, deep veins follow the arteries

NERVES:

Superficial fibular nerve- branch of common fibular nerve (from sciatic

nerve), supplies lateral compartment and most of dorsum of foot

Common fibular nerve

sural communicating nerve

lateral sural cutaneous nerve

Sole of Foot:Plantar

aponeurosis

LAYER 1: origin insertion innervation function


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Flexor

digitorum

brevis

Calcaneal

tuberosity

and

digitorum

brevis

Middle

phalanges of

lateral 4 toes

Flexes lateral

4 toes

Abductor

hallucis

Medial side

of calcaneal

tuberosity

and plantar

aponeurosis

Medial side

of base of

proximal

phalanx of

great toe

Abducts great

toe

Abductor

digiti minimi

Lateral side

of calcaneal

tuberosity

and plantar

aponeurosis

Lateral side

of base of

proximal

phalanx of 5th

toe

Abducts the

5th toe

Medial and lateral plantar nerves common and proper plantar digital

nerves


Quadratus

plantae

calcaneous Tendon of

flexor

digitorum

longus

Assists in

flexing lateral

4 toes

Lumbricals

(4)

Tendons of

flexordigitorum

longus

Extensor

expansions oflateral 4 toes

LAYER 3: origin insertion innervation Function

Flexor

hallucis

brevis

(medial and

lateral heads)

First

metatarsal,

cuboid, 3rd

metatarsal

Proximal

phalanx of

great toe,

sesamoid

bones found

in tendons

(protect

tendon of

flexor

hallucis

longus)

Flexes great

toe

Adductor Lateral side Adducts great


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hallucis

(transverse

and oblique

heads)

of proximal

phalanx of

great toe

toe

Flexor digitminimi Base of 5

th

metatarsal Proximalphalanx of 5th

toe

Flexes 5

th

toe

Posterior tibial nerve and artery medial and lateral plantar nerves and

arteries


Interosseous

(DAB and

PAD)

Structures passing into:

Fibularis longus tendon occupies deepest plane on sole1st metatarsal and

1st cuneiform

Tibialis posterior tendon navicular, all 3 cuneiform, bases of 2nd, 3rd, and

4th metatarsals

Flexor hallucis longus tendon crosses sustentaculum tali (changes direction

of force) through an interosseous tunnel

VESSELS:

Deep plantar arch anastomoses with deep plantar branch of dorsalis pedis

artery

NERVES:Medial plantar nerve innervates:

Abductor hallucis, flexor digitorum brevis, flexor hallucis brevis, medial

lumbrical, cutaneous innervation to plantar surfaces of medial 3 toes

Lateral plantar nerve innervates:

All other muscles in sole, cutaneous innervation to lateral 1 toes

JOINTS:

(1) HIPIlium

Ischium

Pubis

Head

Fovea for ligament of head

Neck


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Intertrochanteric line

Fibrous joint capsule: iliofemoral, ischiofemoral, and pubofemoral ligaments

Ligament of head of femur (with artery), in acetabular notch

Articular surface of head of femur and lunate surface of acetabulum

Transverse acetabular ligament

Acetabular labrum

(2) KNEE

Femur: medial condyle, lateral condyle, intercondylar fossa

Tibia: superior articular surface, medial condyle, lateral condyle,

intercondylar eminence

Patella: articular and anterior surfaces

Tibial collateral ligament- attached to medial meniscus through joint capsule

Fibular collateral ligament- not attached to lateral meniscusOutside synovial cavity but inside joint capsule:

Posterior cruciate ligament (taut in flexion)

Anterior cruciate ligament (taut in externsion)

Tendon of quadriceps femoris and patellar ligament, also patellar retinacula

Menisci

Unhappy Triad

(3) ANKLE

Fibula: lateral malleolus

Tibia: medial malleolus

Talus :trochlea

Medial ligament: posterior tibiotalar, anterior tibiotalar, tibiocalcaneal,

tibionavicular

Lateral ligament: posterior talofibular, anterior talofibular, calcaneofibular

Inversion and eversion joints:

Eversion- fibularis brevis and fibularis longusInversion- tibialis anterior and tibialis posterior

Transverse talar joint (calcaneocuboid and talonavicular)

Subtalar joint

Longitudinal arch, supported by ligaments spanning tarsal bones

Long plantar ligament, short plantar ligament


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Plantar calcaneonavicular (spring) ligament (and tibialis posterior tendon)

support head of talus and longitudinal arch

presentation 4 - leg (ep)

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