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)