The Lower Limb

Blood and Nerve Supply of Lower Limb and Other Notable Components

Fascia of Lower Limb

The fascia of the lower limb consists of deep and superficial layers.
The subcutaneous superficial fascia, lies deep to the skin and consists of loose
connective tissue containing variable amounts of fat, cutaneous nerves, superficial
veins, lymphatics and lymph nodes. At the knee the subcutaneous tissue loses its fat
and blends with the deep fascia but fat is present in the subcutaneous tissue of leg.
The deep fascia is a dense layer of connective tissue between the subcutaneous tissue
and the muscles. It forms septa that separate muscles from one another and invest
them. The deep fascia prevents muscles from bulging during contraction. The deep
fascia of the thigh is called the fascia lata. The deep fascia of the leg is called the
crural fascia.

The fascia lata is continuous with the crural fascia.

The fascia lata is thickened laterally by additional longitudinal fibres to form the
iliotibial tract. This broad band of fibres is the conjoint aponeurosis of the tensor of
fascia lata and the gluteus maximus muscles. The iliotibial tract extends from the
iliac tubercle to the lateral condyle of the tibia.
The saphenous opening in the fascia lata is a deficiency inferior to the medial part of
the inguinal ligament. Its medial margin is smooth but its lateral, superior and inferior
margins form a crescenteric edge, the falciform margin.
This sickle-shaped margin of the saphenous opening is joined at its medial margin by
fibrofatty tissue – the cribriform fascia. This fascia is sievelike as it is pierced by
numerous openings for the passage of lymphatics and the great saphenous vein and its
tributaries.

The crural fascia is thick in the proximal part of the leg and thin in the distal part.
The crural fascia thickens where it forms the extensor retinacula.

Venous Drainage of the Lower Limb

The lower limb has superficial and deep veins; the superficial veins are in the
subcutaneous tissue; the deep veins accompany all major arteries. Both sets of veins
have valves although the deep veins have more.

Superficial Veins of the Lower Limb

The two major superficial veins of the lower limb are the great and small saphenous
veins.

The great saphenous vein is formed by the union of the dorsal vein of the great toe
and the dorsal venous arch of the foot. It ascends anterior to the medial malleolus,
passes posterior to the medial condyle of the femur, traverses the saphenous opening
in the fascia lata and empties into the femoral vein.

The small saphenous vein arises from the union of the dorsal vein of the little toe and
the dorsal venous arch. It ascends posterior to the lateral malleolus, ascends between
the heads of the gastrocnemius muscle and empties into the popliteal vein in the
popliteal fossa.
 The Lower Limb

Perforating veins penetrate the deep fascia close to their origin from the superficial
veins and contain valves that, when functioning normally, only allow blood to flow
from the superficial veins to the deep veins.

Deep Veins of the Lower Limb

The deep veins accompany all the major arteries. The deep veins usually occur as
paired, inter-connecting veins that flank the artery they accompany. They are
contained within the vascular sheath containing the artery, whose pulsations help
compress and move blood in the veins.

Lymphatic Drainage of the Lower Limb

The lower limb has superficial and deep lymphatic vessels. The superficial vessels
accompany the saphenous veins and their tributaries. The vessels following the great
saphenous vein end in the superficial inguinal lymph nodes. Most lymph from here
passes to the external iliac nodes. The lymphatic vessels accompanying the small
saphenous vein enter the popliteal lymph nodes. The deep vessels accompany the
deep veins and enter the popliteal lymph nodes. Most6 lymph from the popliteal
nodes ascends to the deep inguinal lymph nodes and then the external iliac nodes.

Cutaneous Innervation of the Lower Limb

Cutaneous nerves in the subcuatenous tissue supply the skin of the lower limb. These
nerves are branches of the lumbar and sacral plexuses. The are supplied by branches
from a single spinal nerve is called a deramtome. The cutaneous nerves are:
- subcostal nerve (T12)
- iliohypogastrci nerve (L1)
- ilioinguinal nerve (L1)
- genitofemoral nerve (L2-L3)
- lateral femoral cutaneous nerve (L2-L3)
- femoral nerve (L2,3,4)
- anterior femoral cutaneous nerves (from femoral nerve)
- obturator nerve (L2,3,4)
- posterior femroal cutaneous nerve (S2-S3)
- sciatic nerve (L4-S3)

The Adductor Canal

The adductor canal (subsartorial canal; Hunters Canal) is a narrow fascial tunnel in
the thigh running from the apex of the femoral triangle to the adductor hiatus in the
tendon of adductor magnus. It provides an intermuscular passage through which the
femoral vessels pass to reach the popliteal fossa and become the popliteal vessels.
The contents of the canal are the:
- femoral artery and vein
- saphenous nerve
- nerve to vastus medialis
The boundaries of the canal are:
- anteriorly and laterally: vastus medialis
- posteriorly: adductor magnus and longus
 The Lower Limb

- medially: sartorius
The Femoral Triangle
The femoral triangle is a triangular fascial space in the superoanterior third of the
thigh. Its boundaries are:
- superiorly; the inguinal ligament
- medially; adductor longus
- laterally; sartorius
The base of the femoral triangle is formed by the inguinal ligament and its apex is
where the lateral border of sartorius crosses the medial border of adductor longus.

The muscular floor of the triangle is formed by the iliopsoas and pectineus.
The roof is formed by fascia lata and the cribriform fascia, subcutaneous tissue and
skin.

The contents of the triangle are (from lateral to medial):

- femoral nerve and branches
- femoral sheath and its contents
- femoral artery and branches
- femoral vein and tributaries

The Femoral Nerve

The femoral nerve (L2-L4) is the largest branch of the lumbar plexus; it forms within
psoas major in the abdomen and descends posterolaterally to the midpoint of the
inguinal ligament. It passes deep to the ligament and enters the femoral triangle lateral
to the femoral vessels. It supplies:
- the anterior thigh muscles
- the hip joint
- the knee joint
- skin on the anteromedial thigh
the terminal cutaneous branch of the femoral nerve is the saphenous nerve which
descends through the femoral triangle and accompanies the femoral artery and vein
through the adductor canal, lateral to the femoral sheath. It then becomes superficial
and runs to supply the skin and fascia on the anteromedial side of the knee, leg and
foot.

The Femoral Sheath

The femoral sheath is a funnel-shaped fascial tube enclosing the proximal parts of the
femoral vessels and the femoral canal. The sheath does not enclose the femoral nerve
and ends by becoming continuous with the adventitia of the vessels.
The compartments of the femoral sheath are:
- lateral compartment for the femoral artery
- intermediate compartment for the femoral vein
- medial compartment which is the femoral canal

The femoral canal is the smallest compartment and is short and conical. The base of
the femoral canal (its abdominal end) is called the femoral ring. The femoral canal
contains loose connective tissue, fat, lymphatic vessels and sometimes a deep inguinal
lymph node (Cloquet’s node). The femoral ring is closed by extraperitoneal fatty
 The Lower Limb

tissue forming the femoral septum which is pierced by lymphatic vessels connecting
the inguinal and external iliac lymph nodes.

The Femoral Artery

The femoral artery is the continuation of the external iliac artery.
It begins at the inguinal ligament and enters the femoral triangle deep to the ligament
and lateral to the femoral vein. It lies posterior to the fascia lata, and passes through
the femoral triangle to enter the adductor canal. It exits the adductor canal by passing
through the adductor hiatus and becoming the popliteal artery.

The deep artery of the thigh (profunda femoris) arises in the femoral triangle from the
lateral side of the femoral artery. It passes posterior to the femoral artery and vein and
medial to the femur. It leaves the femoral triangle between pectineus and adductor
magnus and gives off perforating arteries to supply adductor magnus and hamstrings.

The circumflex femoral arteries are ussually branches of the deep artery of the thigh.
They anastamose with one another and supply the thigh muscles and the proximal end
of the femur.

The obturator artery helps supply the adductor muscles of the thigh. It usually arises
from the internal iliac artery, passes through the obturator foramen and enters the
thigh, dividing into an anterior and posterior branch which anastamose. The posterior
branch gives the artery to the head of the femur.

The Femoral Vein

The femoral vein is the continuation of the popliteal vein, proximal to the adductor
hiatus. The femoral vein enters the femoral sheath lateral to the femoral canal and
ends posterior to the inguinal ligament where it becomes the external iliac vein.

The femoral vein receives the deep vein of the thigh, the great saphenous vein and
other tributaries.

Gluteal Region – Gluteal Nerves

Several important nerves arise from the sacral plexus and either supply the gluteal
region or pass through to supply the perineum or thigh.

Superficial Gluteal Nerves

The skin of the gluteal region is richly innervated by superior, middle and inferior
clunial nerves.

Deep Clunial Nerves

The deep gluteal nerves are:
- sciatic nerve
- posterior cutaneous nerve of thigh
- superior gluteal nerve
- inferior gluteal nerve
- nerve to quadratus femoris
 The Lower Limb

- pudendal nerve
- nerve to obturator internus

The Sciatic Nerve

The largest nerve in the body is formed from the ventral rami of L4-S3. It passes
through the inferior part of the greater sciatic foramen and emerges inferior to
piriformis. It runs inferolaterally under gluteus maximus, midway between the ischial
tuberosity and the greater trochanter. It receives its own blood supply from the
inferior gluteal artery.

The sciatic nerve supplies no structures in the gluteal region. It supplies the skin of the
foot, most of the leg, the posterior thigh muscles and all leg and foot muscles. It also
supplies branches to all joints of the lower limb.
The sciatic nerve branches into:
- common peroneal nerve
- tibial nerve

Summary of Other Nerves

Nerve Origin Course Distribution
Gives off inferior clunial
Posterior cutaneous Sacral plexus Leaves pelvis through nerve; Supplies skin of
nerve of thigh (S1-S3) greater sciatic foramen buttock, posterior thigh
inferior to piriformis and calf, lateral perineum
and upper medial thigh

Superior gluteal L4-S1 Leaves pelvis through Innervates gluteus

greater sciatic foramen medius, gluteus minimis
inferior to piriformis and tensor fasciae latae

Inferior gluteal L5-S2 Leaves pelvis through Supplies gluteus maximus

greater sciatic foramen
inferior to piriformis

Nerve to quadratus L4, L5, S1 Leaves pelvis through Innervates hip joint,
femoris greater sciatic foramen inferior gemellus and
deep to sciatic nerve quadratus femoris
Enters gluteal region
Pudendal nerve S2-S4 through greater sciatic Supplies perineum;
foramen, enters supplies no structures in
perineum through lesser gluteal region
sciatic foramen
Enters gluteal region
Nerve to obturator L5, S1, S2 through greater sciatic Supplies superior
internus foramen, descends gemellus and obturator
posterior to ischial internus
spine and enters lesser
sciatic foramen

Gluteal Arteries
 The Lower Limb

The gluteal arteries arise, directly of indirectly, from the internal iliac artery:
- superior gluteal artery
- inferior gluteal artery
- internal pudendal artery
The Popliteal Fossa
The popliteal fossa is the diamond-shaped depression of the posterior aspect of the
knee. The fossa is bounded superiorly by the hamstrings and inferiorly by the two
heads of gastrocnemius and plantaris. All important vessels and nerves from the thigh
to the leg pass through this fossa.

The fossa is formed:

- superolaterally by biceps femoris
- superomedially by semimebranosus, lateral to which is semitendinosus
- inferolaterally and inferomedially by gastrocnemius
- posteriorly (roof) by skin and fascia
- anteriorly (floor) by popliteal surface of femur and popliteal fascia over popliteus

The contents of the fossa are:

- small saphenous vein
- popliteal arteries and veins
- tibial and common peroneal nerves
- posterior cutaneous nerve of thigh
- popliteal lymph nodes and lymphatic vessels

The popliteal artery is the continuation of the femoral artery and begins when this
artery passes through the adductor hiatus. It passes through the popliteal fossa and
ends at the inferior border of popliteus by dividing into anterior and posterior tibial
arteries. Five genicular branches supply the knee joint They participate in the
foramtion of the genicular anastamosis, a network of vessels around the knee.

The popliteal vein is formed at the distal border of the popliteus. The popliteal vein
has several valves and ends at the adductor hiatus by becoming continuous with the
femoral vein. The small saphenous vein pierces the deep popliteal fascia and empties
into the popliteal vein.

The sciatic nerve ususally ends at the superior angle of the popliteal fossa by
dividing into the tibial and common peroneal nerves.

The tibial nerve is the medial and larger terminal branch of the sciatic nerve. While in
the fosssa it gives branches to:
- soleus - plantaris
- gastrocnemius - popliteus
A medial sural nerve derives from the tibial nerve and joins with the lateral sural
nerve to form the sural nerve which supplies the lateral leg and ankle cutaneously.

The common peroneal nerve is more lateral and leaves the fossa by passing
superficial to the lateral head of gastrocnemius and over the posterior aspect of the
head of the fibula. It winds around the fibular neck and divided into terminal branches
 deep and superficial peroneal nerves.
 The Lower Limb

Lymph Nodes in the Popliteal Fossa

Superficial Popliteal Lymph nodes – lymph from small saphenous vein
Deep Popliteal Lymph nodes – lymph from knee joint and arteries of leg.
This lymph follows the femoral vessels to the deep inguinal lymph nodes.
Anterior Compartment of Leg
The nerve in the anterior compartment of the leg is the deep peroneal nerve.
It accompanies the anterior tibial artery which ends at the ankle joint midway
between the malleoli, becoming the dorsalis pedis artery, or dorsal artery of the foot.

Lateral Compartment of the Leg

The superficial peroneal nerve is the nerve of the lateral compartment. It supplies
skin on the dital part of the leg and most of the dorsum of the foot.
The lateral compartment does not have an artery; the muscles are supplied by
branches of the anterior tibial artery and perforating branches of the fibular artery.

Posterior Compartment of the Leg

The tibial nerve leaves the popliteal fossa between the two heads of gastrocnemius
and supplies all the muscles in the posterior compartment of the leg, both superficial
and deep. At the ankle the nerve lies between the flexor hallucis longus and the flexor
digitorum longus. The tibial nerve divides into the medial and lateral plantar nerves.
A branch of the tiobial nerve, the medial sural nerve joins the lateral sural nerve to
form the sural nerve which supplies skin on the lateral and posterior leg and the
lateral foot.
The posterior tibial artery provides the main blood supply to this compartment and
to the foot

Summary of the Nerves of the Leg

Nerve Origin Course Distribution
Descends through
Saphenous nerve Femoral nerve femoral triangle and Skin on medial side of
adductor canal then foot
follows great saphenous
vein
Descends between heads
Sural nerve Tibial nerve of gastrocnemius, then Skin on posterior and
and common with small saphenous lateral leg
peroneal nerve vein to lateral foot Skin on lateral foot
Descends through
Tibial nerve Sciatic nerve popliteal fossa, runs with Posterior muscles of leg
posterior tibial vessels, Knee joint
divides into medial and
lateral planter nerves at
flexor retinaculum
Through popliteal fossa,
Common Sciatic nerve around neck of fibula, Skin on lateral posterior
peroneal nerve divides into deep and leg via lateral sural
superficial nerves cutaneous nerve
Descends in lateral
Superficial Common compartment of leg, Peroneus longus and
 The Lower Limb

peroneal nerve peroneal nerve pierces fascia to become brevis; skin on anterior
subcutaneous leg and dorsum of foot
Descends on interosseus
Deep peroneal Common membrane, crosses tibia Anterior muscles of leg
nerve peroneal nerve to enter dorsum of foot Dorsum of foot
The Foot