THE LOWER LIMB


THE LIST OF TOPICS:

Gluteal region

Thigh and popliteal fossa

Leg and dorsum of foot

Sole of foot

Joints of the lower limb

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Gluteal region

Text:  Gross Anatomy, K. W. Chung, 6th edition: pp. 78-81, 91-96, 108-109, 110
Reference:  Clinically Oriented Anatomy, K.L. Moore, A.F. Dalley, 5th edition: pp. 555-566, 573, 578-583, 585, 607-616; 6th edition:  510-520, 525-527, 532-541, 562-569, 581-583
Dissector:

The hip bone (os coxae) is formed by 3 bones fusing at the acetabulum (the articular depression for the head of the femur) by a y-shaped cartilage around the 16th - 23rd year (Clemente 265-266; Grant p. 397; Netter 3e 468; 4e 486).

The 3 bones are the:

The ilium (located superior to the acetabulum) has the following landmarks:

ISCHIUM, located posteroinferior to the acetabulum, has the following landmarks (Clemente 265-266; Grant p. 397; Netter 3e 468; 4e 486):

PUBIS, located anteroinferior to the acetabulum, has the following landmarks (Clemente 265-266, 270-273; Grant p. 196-199; Netter 3e 340-341, 468-469; 4e 352-355, 486)

The proximal end of femur (Clemente 430-431; Grant p. 380-381; Netter 3e 470-471; 4e 488-489) has the following landmarks:

Gluteus maximus (Clemente 383-385; Grant p. 383-384; Netter 3e 476-477; 4e 494-495):

STRUCTURES DEEP TO THE GLUTEUS MAXIMUS

Superior gluteal vessels and nerve emerge above the piriformis (Clemente 387; Grant p. 389; Netter 3e 484-485; 4e 502-503).

2 groups of nerve and vessels emerge inferior to piriformis

A group of 5 structures (Grant 385, 388-389; Netter 3e 484, 527; 4e 502-503, 540):

1) Sciatic nerve (L4, 5, S1, 2, 3) lies between the ischial tuberosity and the greater trochanter. Its "safe" side for gluteal injection is the lateral side where it has no branches. It may divide in this region into the common peroneal (L4, 5, S1, 2) and the tibial (L4, 5, S1, 2, 3) nerves.
2) Inferior gluteal nerve.
3) Inferior gluteal artery and 4) vein supply the piriformis, obturator internus and gluteus maximus.
5) Posterior femoral cutaneous nerve.

A group of 3 structures (Clemente 386-387, 393; Grant p. 388-389; Netter 3e 484-485; 4e 502-503):

1) Nerve to obturator internus (L5, S1, 2)
2) Internal pudendal vessels
3) Pudendal nerve (S2, 3, 4)

The obturator internus is the only structure entering the gluteal region via the lesser sciatic foramen (Clemente 391-392; Grant p. 387, 391; Netter 3e 477, 484-485; 4e 503).

The greater trochanter serves as attachment point for 5 muscles. The:

1) Gluteus medius attaching from the gluteal surface of the ilium to the lateral greater trochanter (Clemente 391; Grant p. 386; Netter 503).
2) Gluteus minimus attaching from the gluteal surface of the ilium to the anterior aspect of the greater trochanter.
*Glutei medius and minimus abduct the hip joint and prevent adduction of the thigh when the body weight is on the same leg.
3) Piriformis attaching from the sacrum through the greater sciatic notch to the apex of the greater trochanter (Clemente 503; Grant p. 390; Netter 3e 484-485; 4e 391-392).
4) Obturator internus and gemelli
5) Obturator externus

The superior gluteal nerve (L4, 5, S1; Clemente 387; Grant p. 389; Netter 3e 484-485; 4e 502-503)

Tensor fasciae latae (Clemente 383; Grant p. 383; Netter 3e 476; 4e 494)

Small lateral rotator muscles stabilize the hip joint:

1) The quadratus femoris ( the "carpet" of the sciatic nerve; Clemente 386; Grant p. 385; Netter 3e 477, 484-485; 4e 502-503) is innervated by a sciatic nerve branch called the nerve to quadratus femoris (L4, 5, S1). The obturator internus and the gemelli lie above the quadratus femoris.
2) The obturator internus (Clemente 371, 385-387; Grant p. 391, 395; Netter 3e 484-485; 4e 490-491, 502-503) arises from the pelvic surface of the obturator membrane, makes a sharp turn, through the lesser sciatic foramen (a bursa exists underneath), inserts into the upper border of the greater trochanter. It is innervated by the nerve to obturator internus (L5, S1, 2).
3) The superior gemellus arises from the upper margin of the lesser sciatic foramen by the ischial spine. It is innervated by the nerve to obturator internus (L5, S1, 2).
4) The inferior gemellus arises from the lower margin of the lesser sciatic foramen by the ischial tuberosity. It is innervated by the nerve to quadratus femoris (L4, 5, S1).
Both distal tendons of the gemelli join with that of the obturator internus.
5) Piriformis.
6) Obturator externus arises from the lateral surface of the obturator membrane and attaches to the back of the femoral neck (Clemente 386-387; Grant p. 394; Netter 3e 483; 4e 490-491, 493, 539).

Gluteal arteries:

The posterior femoral cutaneous nerve (Clemente 373; Grant p. 359; Netter 3e 527; 4e 540) duplicates subcutaneously the line of the sciatic nerve. It has 2 large branches: gluteal and cluneal.

updated 9/3/2009



Thigh and popliteal fossa

Text:  Gross Anatomy, K. W. Chung, 6th edition: pp. 79-81, 91-101, 107-109, 110- 112
Reference:  Clinically Oriented Anatomy, K.L. Moore, A.F. Dalley, 5th edition: pp. 555-566, 573 -575, 578-607, 616-636; 6th edition:  pp.  510-522, 525-527, 532-541, 545-562, 569-587
Dissector:
Clemente’s Anatomy Dissector, 2nd edition:  pp.  209-212, 216-233
Grant’s Dissector, P.W. Tank, 13th edition:  pp. 148-159, 163-167
 

ANTERIOR ASPECT OF THE THIGH

The deep fascia is called the fascia lata (Clemente 370, Grant p. 368; Netter 3e 482; 4e 500).
It is reinforced laterally by the iliotibial tract, which is a joint attachment point of tensor fasciae latae and gluteus maximus (Clemente 383; Grant p. 368; Netter 3e 476; 4e 494).
Medially, the great saphenous vein ascends subcutaneously (Clemente 368-370; Grant p. 342-345; Netter 3e 526-528; 4e 544).

The course of the great saphenous vein

The great saphenous vein:

Superficial branches of the femoral artery (Clemente 368; Grant p. 370; Netter 3e 482; 4e 512).

1) Superficial external pudendal artery crosses anterior to the spermatic cord to supply scrotum and labium majus.
2) Superficial epigastric artery passes towards the umbilicus.
3) Superficial circumflex iliac artery, passes laterally, just inferior to the inguinal ligament.

Inguinal lymph nodes are palpable and are divided into superficial and deep groups.

Superficial nodes are divided into (Clemente 369; Grant p. 367; Netter 3e 528; 4e 546):

 Cutaneous nerves arise from the ventral rami of L1, 2, 3, 4.  They pierce the deep fascia along the upper border of the sartorius. 

The femoral sheath is a prolongation of extraperitoneal areolar tissue which envelops the external iliac vessels in the abdomen (Clemente 257; Grant p. 106, 350, 352-353; Netter 3e 242, 528; 4e 262, 546).

The femoral sheath has 3 compartments (Clemente 369; Grant p. 371; Netter 3e 528; 4e 262, 546):

The mouth of the femoral canal is the femoral ring.

The femoral ring is bounded:

Bony landmarks on the femur (Clemente 430; Grant p. 355; Netter 3e 471; 4e 489)

The femoral triangle (Clemente 371-372, 374; Grant p. 372-373; Netter 3e 482; 4e 492).

Contents of the femoral triangle:

The profunda femoris artery:

The femoral vein

*At the apex of the femoral triangle, a stab or bullet may penetrate all 4 vessels of the thigh (Clemente 377, 379; Grant p. 373; Netter 3e 482; 4e 500-501).

Venous valves are found in the saphenous and femoral veins (not in the inferior vena cava or in the common iliac vein; Grant p. 370).

The femoral nerve (Clemente 372, 377, 379; Grant p. 372; Netter 3e 482-483; 4e 500-501):

Relationships:

Adductor canal (of Hunter; Clemente 377; Grant p. 373; Netter 3e 482; 4e 500-501)

The walls of the adductor canal are:

Overview of the adductor muscles

Adductor muscles attach (Clemente 371, 374, 375, 378; Grant p. 378-379; Netter 3e 482-483; 4e 492-493) from the pubis and ischium to the linea aspera.

Contents of the adductor canal:

The sartorius (Clemente 371; Grant p. 375; Netter 3e 474; 4e 492)

The quadriceps femoris (Clemente 492; Grant p. 375; Netter 3e 474, 4e 374-375)

An internervous line exists between the motor territories of the gluteal and femoral nerve: It runs down in a vertical line from the anterior superior iliac spine.

Posteromedial region of the thigh.

The anterior wall is formed by the adductor magnus and vastus lateralis muscles.

HAMSTRING MUSCLES

The biceps femoris (Clemente 391; Grant p. 384-385; Netter 3e 484, 488; 4e 495)

The semimembranosus and semitendinosus also rotate the leg medially, being attached to the medial head of the tibia (Clemente 391; Grant p. 366-367, 369; Netter 3e 484, 488, 4e 495).

The sciatic nerve is accessible between the gluteus maximus and the long head of the biceps.

Medial region of the thigh

The muscles in this region (Clemente 371-381; Grant p. 378; Netter 3e 482-483, 4e 492-493):

Prevalent hernias in this region are (Grant p. 372):

The obturator nerve (L2,3,4; Clemente 379; Grant p. 356; Netter 3e 521, 4e 501, 539)

The obturatory artery supplies the adductors (Clemente 379; Grant p. 362; Netter 3e 494, 4e 512).

The course of the profunda femoris artery (Clemente 362; Netter 4e 512)

The anastomosis at the hip joint is formed by the medial and lateral circumflex arteries with the inferior gluteal artery and the first perforating artery (Clemente 363, 376, 393; Grant p. 393; Netter 3e 486-494, 4e 504, 512).

The popliteal fossa:

The floor of the popliteal fossa is formed by (Clemente 418; Grant p. 404-405; Netter 3e 493, 4e 511):

Contents of the popliteal fossa (Clemente 412-413, 415-419; Grant p. 402-404; Netter 3e 498-499, 4e 502):

The tibial nerve (L4, 5, S1, 2, 3; Clemente 417; Grant p. 403; Netter 3e 523, 4e 541)

The arrangement in the inferior portion of the fossa is tibial nerve, popliteal vein and artery from superficial to deep, from a posterior view (Clemente 417; Grant p. 404; Netter 3e 498-499, 4e 516-517). They are bounded by a femoral condyle and a head of the gastrocnemius on each side (Clemente 413, 421; Grant p. 404; Netter 3e 498, 4e 511).

The popliteal artery (Clemente 419, 443; Grant p. 404, 416; Netter 3e 500, 4e 512):

The popliteal vein begins as an assembly of venae comitantes below the knee.

The common peroneal (fibular) nerve (L4, 5, S1, 2; Clemente 402; Grant p. 424; Netter 3e 498, 502, 4e 520)

The sural nerve (Clemente 412; Grant p. 359; Netter 3e 498, 4e 516, 540) arises from the tibial nerve, runs with the small saphenous vein and is joined by a branch of the common peroneal nerve (the communicating peroneal nerve).

The small saphenous vein

updated 9/03/2009


The leg and the dorsum of the foot

Text:  Gross Anatomy, K. W. Chung, 6th edition: pp. 81-84, 91-93, 101-104, 108-110, 112-114
Reference:  Clinically Oriented Anatomy, K.L. Moore, A.F. Dalley, 5th edition: pp. 567-572, 574-578, 636-658; 6th edition:  520-529, 587-608.
Dissector:
Grant’s Dissector, P.W. Tank, 14th edition:  pp. 165-175

Clemente’s Anatomy Dissector, 2nd edition:  pp. 234-253

The leg or crus is the portion of the lower limb between the knee and the ankle. It is divided into (Clemente 400; Grant p. 472; Netter 3e 504, 4e 522):

The bones of the leg are the tibia and the fibula (Clemente 446-447; Grant p. 423; Netter 3e 495, 4e 513-514)

Osteology of the foot (Clemente 450-451; Grant p. 427; Netter 3e 505, 4e 523-524):

The anterior tibial artery (Clemente 402, 411; Grant p. 424-425; Netter 3e 502, 4e 520, 530, 531)

The branches of the anterior tibial artery are the:

*Dorsal metatarsal arteries to the medial side of the 1st toe and lateral side of the 5th toe receive digital branches from the 1st and 4th metatarsal arteries, respectively (Clemente 411; Grant p. 427; Netter 3e 512-513, 4e 530-531) .
*Dorsal digital arteries may also originate from the perforating branch of the peroneal artery.

Muscles of the anterior crural region

1. The tibialis anterior (Clemente 399; Grant p. 422; Netter 3e 502-503, 4e 519)

2. The extensor digitorum longus (Clemente 402; Grant p. 422; Netter 3e 501, 4e 519-520)

3. The peroneus tertius (Clemente 399; Grant p. 426; Netter 3e 501, 4e 519)

4. The extensor hallucis longus (Clemente 407-411; Grant p. 424; Netter 3e 502, 4e 519-520):

The extensor digitorum brevis

In the anterior compartment syndrome, there is edema in the anterior compartment. Since the extensor retinaculum over the deep fascia is tight, the swelling shuts off the circulation and results in worsening of the condition. Shin splints are a mild form of the anterior compartment syndrome.

The common peroneal nerve divides into a superficial peroneal nerve and a deep peroneal nerve (Clemente 402; Grant p. 424; Netter 3e 523, 4e 520).

The deep peroneal nerve

The superficial peroneal nerve (Clemente 402; Grant p. 425; Netter 3e 524, 4e 520, 542)

The extensor retinaculum (Clemente 399; Grant p. 422, 426; Netter 3e 501, 4e 530)

There is also a superior and an inferior peroneal (fibular) retinaculum for the the tendons of the peroneus brevis and longus (Clemente 404; Grant p. 425, 430; Netter 3e 503, 4e 529)

The peroneal (fibular) region

The peroneus longus and brevis muscles

The tibialis anterior also inserts into the medial cuneiform and metatarsal 1, but from the medial aspect of the foot: the peroneus longus and the tibialis anterior are thus antagonists.

OSTEOLOGY OF THE FIBULA (Clemente 447; Grant p. 354, 423, 433, 442; Netter 3e 495-497, 4e 513-514)

Ossification of the fibula

The posterior crural region

Bony landmarks (Clemente 447-449; Grant p. 433; Netter 3e 495, 4e 513, 515):

The superficial group has 3 muscles:

All 3 muscles plantar flex the foot.

The gastrocnemius

The soleus (Clemente 415-416; Grant p. 432, 435; Netter 3e 499, 4e 517)

The plantaris (Clemente ; Grant 432; Netter 3e 498-499, 4e 517)

The deep group of muscles contains (Clemente 418; Grant p. 432, 436-437; Netter 3e 500, 4e 518):

  1. the popliteus
  2. the flexor hallucis longus
  3. the flexor digitorum longus (to terminal phalanges of the toes)
  4. the tibialis posterior (to every small tarsal and most metatarsals)

Muscles 2-4 plantar flex the foot.

The popliteus (Clemente 396, 418; Grant p. 415; Netter 3e 500 4e 511,)

The tibialis posterior (Clemente 418; Grant p. 432, 437; Netter 3e 500, 4e 518)

The flexor digitorum longus (Clemente 421; Grant p. 432, 437; Netter 3e 500, 510, 4e 518)

The flexor hallucis longus (Clemente 421; Grant p. 432, 436-437; Netter 3e 500, 4e 518)

Tendons posterior to the ankle

The tibial nerve

The branches of the tibial nerve are:

The posterior tibial artery:

The peroneal (fibular) artery:

updated 09/03/2009



The sole of the foot
Text:  Gross Anatomy, K. W. Chung, 6th edition: pp. 104-107, 110, 113
Reference:  Clinically Oriented Anatomy, K.L. Moore, A.F. Dalley, 5th edition: pp. 658-672; 6th edition:  522-525, 530-531, 542-544, 609-626
Dissector:
Clemente’s Anatomy Dissector, 2nd edition:  pp. 253-259.
Grant’s Dissector, P.W. Tank, 14th edition:  pp. 175-180

Osteology of the foot (Clemente 451; Grant p. 444; Netter 3e 505-508, 4e 523-524)

The medial longitudinal arch (Clemente 451; Grant p. 452, 466; Netter 3e 489, 4e 524) is formed by:

The lateral longitudinal arch (Clemente 451; Grant p. 431, 466; Netter 3e 489, 4e 524) is formed by:

Ossification sequence of the foot

The plantar fascia (Clemente 422; Grant p.443; Netter 3e 514, 4e 532)

Cutaneous nerves

There are 4 layers of plantar muscles, organized as follows:

  1. 3 muscles
  2. 2 muscles and 2 tendons
  3. 3 muscles
  4. 2 muscles and 2 tendons

The most superficial layer (layer 1) is formed by 3 muscles (Clemente 423; Grant p. 444; Netter 3e 515, 4e 533)

Abductor hallucis

Abductor digiti minimi

Flexor digitorum brevis

Layer 2 is formed by 2 muscles and 2 tendons (Clemente 424; Grant p. 445; Netter 3e 516, 4e 534):

The flexor digitorum longus tendon

The quadratus plantae (flexor digitorum accessorius)

The lumbricals

Flexor hallucis longus tendon

Layer 3 is formed by 3 muscles: An adductor lying between 2 flexors (Clemente 427; Grant p. 446; Netter 3e 517, 4e 535).

Adductor hallucis

Flexor hallucis brevis

Flexor digiti minimi

Layer 4 is formed by 2 muscles and 2 tendons (Clemente 428, 455; Grant p. 447, ; Netter 3e 517-519, 4e 536-537):

The 7 interossei (4 dorsal and 3 plantar) keep the foot from spreading by holding the heads of the metatarsals together.

The tibialis posterior tendon (Clemente 455; Grant p. 447; Netter 3e 509-511, 4e 536).

The peroneus (fibularis) longus tendon.

Blood supply of the sole of the foot

The medial plantar artery (Clemente 425, 426, 428; Grant p. 444, 446; Netter 3e 516-517, 4e 533-535)

Lateral plantar artery (Clemente 425-426; Grant p. 441, 446; Netter 3e 516-517, 534-535)

Anastomoses in the foot are important due to its vulnerability to arteriosclerosis.

The plantar arterial arch

The lateral plantar nerve has (Clemente 426; Grant p. 444, 446; Netter 3e 523, 4e 541):

The medial plantar nerve has (Clemente 425; Grant p. 444, 446; Netter 3e 523, 4e 541):

updated 09/03/2009


Joints of the lower limb

Text:  Gross Anatomy, K. W. Chung, 6th edition: pp. 78-91
Reference:  Clinically Oriented Anatomy, K.L. Moore, A.F. Dalley, 5th edition: pp.  672-724; 6th edition:  626-669
Dissector:
Clemente’s Anatomy Dissector, 2nd edition:  pp. 260-279
Grant’s Dissector, P.W. Tank, 14th edition:  pp. 180-185

The hip joint

The ossification of the head of the femur begins during year 1 and is done by year 20 (Grant p. 468).

The pelvic acetabulum

The hip joint

Ligaments of the hip joint consist of:

The ligament of the head of the femur:

The iliofemoral ligament (Clemente 432; Grant p. 394-395; Netter 3e 469, 4e 487):

The pubofemoral and ischiofemoral ligaments (Clemente 432; Grant p. 395; Netter 3e 469, 4e 487):

*The tendon of the psoas major muscle lies between the iliofemoral and pubofemoral ligaments.

Blood supply of the hip joint (Clemente plate 376; Grant p. 362, 400; Netter  3e 486, 4e 504)

Nerve supply of the hip joint

Movements of the hip joint (Clemente 380; Grant p.357)

The knee joint

Knee articulations

Tibiofemoral (condylar) articulations

The fibrous capsule includes (Clemente 435-443; Grant p. 410-411; Netter 3e 490-491, 4e 506-511):

The fibrous capsule:

Ligaments of the knee

Collateral ligaments are lax when the knee is flexed and allow for some degree of medial and lateral rotation. They are taut when the knee is extended.

Collateral ligaments (Clemente 437-442; Grant p. 408-415; Netter 3e 473-475, 491, 4e 506-511)

Tibial (medial) collateral ligament:

Fibular (lateral) collateral ligament runs from the lateral epicondyle of the humerus to the head of the fibula .

Cruciate ligament (Clemente 436, 438-440, 443; Grant p. 411-413; Netter 3e 490-491, 4e 508-509

The anterior cruciate ligament:

The posterior cruciate ligament:

Intercondylar septum

3 bursae of the knee

Ossification of the knee

Blood supply of the knee joint

The nerve supply of the knee joint is supplied:

The ankle (talocrural) joint

Collateral ligaments of the ankle

The blood supply of the ankle joint is supplied by all blood vessels around the joint.

The nerve supply is derived from the deep peroneal and tibial nerves.

Joints of the foot are joints of inversion and eversion

The plantar calcaneonavicular joint is joined by the plantar calcaneonavicular (spring) ligament (Clemente 455; Grant p.464-465; Netter 3e 510, 4e 528) which contributes to the longitudinal arch of the foot.

The inferior surface of the talus has an anterior, middle (both concave) and posterior (convex) talar facets (Clemente 454; Grant p.459;  Netter 4e 525) which fit into corresponding surfaces on the calcaneus.

The tarsal sinus (sulcus tali) is found between the posterior and middle tarsal facets and contains the interosseous talocalcanean ligament.

Ligaments of the foot

Joints of the foot

The bifurcate ligament is the collateral ligament for the talonavicular and calcaneocuboid joints (Clemente 452-454; Grant p. 458; Netter 3e 509, 4e 527).

The plantar calcaneocuboid ("short plantar") ligament runs from the inferior surface of the calcaneus to the large area inferior to the ridge on the cuboid (Clemente 455; Grant p. 465; Netter 3e 510, 4e 528).

The long plantar ligament converts the groove on the cuboid into a tunnel for the peroneus (fibularis) longus tendon (Clemente 455; Grant p.464; Netter 3e 510, 4e 528).


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