Lower Limb - Objectives

The lectures will only guide to understand the lower limb anatomy The student should read the standard test books and gather detailed anatomical knowledge The student should be able to describe all the muscles with the attachments, nerve supply, blood supply and their actions Describe the gross anatomy of the femoral triangle, fascial compartments of the thigh and the leg, and their clinical importance Describe the venous drainage and the arterial supply of the lower limb Describe all the joint (including relations, muscles acting and the clinical significance)

Describe the arches of the foot and the phases of walking

Identify all the structures in the cadaver (Dissected specimen) Copying these lecture notes is not helpful in most of the situations

Gluteal region

Extends from iliac crest to gluteal fold and natal cleft to the greater trochanter Blood supply is from superior and inferior gluteal arteries Lymphatics drain to the lateral group of superficial inguinal lymph nodes

Gluteal region

Muscles in the region

1.

2.
3. 4. 5. 6. 7. 8. 9.

gluteus maximus gluteus medius gluteus minimus piriformis superior gemellus obturator internus inferior gemellus obturator externus quadratus femoris

Gluteus maximus

Largest and most powerful There are 3 bursae under the muscle

Over the ischeal tuberosity Over the greater trochanter Over vastus lateralis muscle

Nerve supply from the inferior gluteal nerve

Gluteus maximus

Combination of lateral rotation extension of hip joint Stabilizes the extended knee through ileotibial tract Extensor of hip during extreme movements

Eg. Running, climbing stairs

Main antigravity muscle during the process of sitting down

Gluteus medius and minimus

Gluteus medius

Posterior one third is covered with gluteus maximus A bursa separates the tendon from upper lateral surface of greater trochanter Deep to gluteus medius A bursa separates the tendon from anteromedial surface of greater trochanter

Gluteus minimus

Gluteus medius and minimus

Gluteus medius and minimus..

Action of the gluteus medius and minimus

Abducts the hip Medial rotation of the hip Necessary for the maintain gait during walking

Clinical importance..

Trendelenburgs test

Possitive in paralysis, fracture, dislocation

Paralysis results in Lurching gait Bilateral paralysis waddling gait

Piriformis muscle

Important as a land mark in gluteal region Arises from middle 3 pieces of sacrum and runs through greater sciatic foramen Inserted to medial surface of upper border of greater trochanter

Obuturator internus and gemelli

Through the lesser sciatic notch enters the gluteal region Separates deep tendinous surface from lesser sciatic notch by a bursa Superior and inferior gemelli blend with the tendon to be inserted into the medial surface of the greater trochanter

Pudendal nerve

Leaves the pelvis through greater sciatic foramen Enters into the perineum by crossing the ischeal spine Runs in the pudendal canal with pudendal vessels Branches

Inferior rectal nerve

Supply external anal sphincter and perineal skin Supply sphincter urethrae Supply muscles of anterior perineum

Perineal nerve

Dorsal nerve of penis

Used for forceps delivery in obstetrics

Pudendal block

Sciatic nerve (L 4-5, S1-3)

largest nerve in the body Emerges from greater sciatic foramen distal to piriformis muscle Descends on adductor magnus muscles supplied in thigh

Hamstring muscles ( biceps,semimembranosus, semitendinosus) Adductor magnus Damage to sciatic nerve in gluteal region causes foot drop and sensory lose below knee except the area supplied by saphenous branch of femoral nerve

Clinical importance

Hip joint

Ball and socket type, multi axial joint High degree of stability and range of movements Long neck, which is narrower than head, causes increase range of movements Acetabulum

Ileum, ischium, pubic bone contributes for acetabulum C shaped articular surface is covered with hyaline cartilage Labrum acetabulare is a rim of fibrocartilage on edge of the acetabulum to deepen the cavity and continues over the acetabular notch as transverse ligament

Head of femur

Spherical head is covered with hyaline cartilage Fovea - non articulating area on the head Ligament of the head of the femur (Ligamentum teres) is attached to fovea and acetabulular notch and covered by synovium Blood vessels Loose but extremely strong Circumferentially attaches to the labrum and transverse ligament Anteriorly in the neck of the femur, capsule is attached to intertrochantric line, but posteriorly attached half way along the neck of the femur In the neck of the femur capsule is reflected up to the articular margin (Retinacular fibers)

Capsule

Ligaments

Three ligaments from each bone of acetabulum Iliofemoral

Strongest Inverted V shape Attached to lower part of anterior inferior iliac spine and intertrochanteric line

Pubofemoral

Attached to the superior ramus and obturator line of the pubic bone and blends with capsule Arises from posteroinferior part of acetabulum and blends with circular fibers of capsule

Ischiofemoral

Movements

Flexion
Normal range is about 120 degrees Psoas major, iliacus, rectus femoris, sartorius and pectineus muscles are used

Extension
Range is about 20 degrees Hamstring muscles are used Gluteus maximus at extreme of movement

Adduction
Is about 30 degrees By pectineus, adductor longus, brevis, magnus and gracillis

Abduction

Is about 60 degrees By gluteus medius and minimus Assisted by tensor fascia lata and sartorius In sitting position by piriformis, gemelli causes abduction About 40 degrees Anterior fibers of gluteus medius and minimus with tensor fascia lata

Medial rotation

Lateral rotation

About 40 degrees Piriformis, obturator internus, gemelli, quadratus femoris obturator externus Assisted by gluteus maximus and sartorius

Stability of the hip joint

Deepening by the labrum Ligaments (iliofemoral ligament) Short muscles of the gluteal region Joint is weakest when flexed and adducted

Dislocation of the hip

Posterior dislocation
Is common Occur when hip is in flexed position Associated with acetabular fracture when the thigh is flexed and adducted at the time of injury Sciatic nerve can get damaged Reduction is by relaxing surrounding muscles and then flexing and rotating into the neutral position

Anterior dislocation

By forcible abduction Head passes through the acetabulum from height eg. Fallen

Central dislocation

Thigh

Great saphenous vein

Longest vein in body. Has 20 valves ( more below knee) Begins as medial marginal vein of the foot Courses anterior to the medial maliolus. Ends at saphenous opening piercing cribriform plate. Incompetence of valves cause varicosities. used as vascular graft.

Superficial fascia Contains lymph nodes superficial inguinal Vessels and nerves

Well formed deep fascia Attached above with the boundary line with the lower limb and the pelvis Inferiorly with the bony prominences of the knee Divide the thigh in to two compartment by septae

Femoral Triangle

Profunda femoris