3. Lower Limb, Thigh, Knee Flashcards
Flexors of the hip joint:
pectineus,
iliopsoas (psoas major, iliacus)
sartorius
Quadriceps femoris muscles
rectus femoris,
vastus lateralis,
vastus medialis
vastus intermedius)
the quadriceps tendon and the patella ligament
Adductor muscles
adductor longus,
adductor brevis,
adductor magnus,
gracilis and obturator externus
Vessels of femoral triangle
’ Femoral artery and its profunda femoris branch (profunda means deep)
– Femoral vein
– Lymphatics
– Great (long) saphenous vein
PECTINEUS muscle
Origin
• Pectineal line of the superior pubic ramus
Insertion
• Upper and linea aspera of femur
Action
• Flexes and the adducts the thigh at the hip joint
Nerve supply
• Femoral nerve (l3,l4) - anterior branch
Pectineus = muscle
• Originates at superior pubic ramus
4 things in loose connective tissue
– fat
– cutaneous nerves
– superficial veins
– lymphatic vessels and nodes
Compartments of thigh
- Anterior = contains quads and pectineus
- Posterior = hamstring muscles supplied by sciatic
- Medial compartment
- Femur
Deep fascia of lower limb - attachments
Covers lower limb like stocking
– inguinal ligament
– iliac crest
– Sacrum, coccyx, sacrotuberous lig, ischial tuberosity/ ischiopubic ramus
Deep fascia of lower limb - names
- in the thigh = “fascia lata”
* in the leg = “crural fascia”
Fascia lata (deep fascia)
Laterally thickened to form iliotibial tract
– inserts into anterolateral tubercle of tibia (Gerdy’s tubercle)**
Tensor fascia lata - muscle
- Supplied by superior gluteal nerve
* Adduction of hip
Deep fascia forms 3 compartments of thigh
• Anterior
• Medial
• Posterior
Compartments separated by intermuscular septum
• Infection in one compartment can spread along fascia planes
Deep fascia - saphenous opening
- Inguinal ligament = 4cm inferior and lateral to pubic tubercle, drains vascular beds
- The superficial vein (great saphenous) dives through deep fascia to join the deep venous system (femoral vein)
- The membranous layer blends into the deep fascia above the saphenous opening and forms perforated cribiform fascia over the opening : pierced by great saphenous v, lymphatics, smaller veins
Superficial fascia of anterolateral abdominal wall organised into 2 layers:
- Camper’s fascia – fatty layer
* Scarpa’s fascia – membranous layer
Great saphenous vein
Formed by dorsal vein of great toe and dorsal venous arch of foot
- Has multiple valves… these can “go wrong” (varicose veins) = aids blood going up as gravity likes to pull it down
- Receives several tributaries especially near termination
Great saphenous vein - surface markings
• anterior to medial malleolus
→ hand’s breadth post to medial border of patella
→passes through saphenous opening
Lymphatic drainage
Superficial lymphatic vessels accompany saphenous vein
lots of lymph that End in the vertical group of superficial inguinal lymph nodes
• Lymphatic vessels from the superficial nodes pass through cribriform fascia – directly to external iliac lymph nodes – some pass to deep inguinal lymph nodes on medial aspect of femoral vein
3 compartments of thigh - nerves
- Anterior group innervated by femoral nerve
- Medial group by obturator nerve ( has two branches anterior and posterior)
- Posterior group by sciatic nerve
Anterior compartment of the thigh
Usually the largest compartment
• Includes femur and anterior thigh muscles – flexors of hip – extensors of knee
3 major muscles in anterior thigh
• pectineus
• sartorius
• quadriceps femoris (the end of the iliopsoas muscle passes into the anterior compartment too)
Anterior compartment muscles
Sartorius
• Sartorius = attaches to anterior inferior illaic spine
Tailors muscle = all the functions of Sartorius:
• Hip - flexes, abducts, laterally rotates
• Knee - flexes (medial rotating when flexed
Anterior compartment muscles -
Illiopsoas
Most powerful hip flexor walking and climbing
• Maintains posture while standing
2 muscles, with a common tendon inserting on lesser trochanter
Innervation:
• Psoas major = anterior rami first three lumbar nerves (mainly L2)
• Iliacus = femoral nerve (L2,3)
How to remember order of vessels in femoral triangle
NAVY • Nerve • Artery • Vein • Y front Goes from lateral to medial (nerve is medial)
Femoral artery
• Midpoint between anterior superior iliac spine and pubic tubercle
Quadriceps femoris -4 muscles
(rectus femoris, vastus lateralis, vastus medialis and vastus intermedius)
Rectus femoris originates on ilium
Vastus muscles originate around the proximal end of the femur
1 common insertion (quadriceps tendon)
All 4 innervated by femoral nerve
Retinacula
(connective tissue) play role in keeping patella aligned over femur
major muscles in the medial thigh:
- Gracilis
- Obturator externus
- Adductor brevis
- Adductor longus
- Adductor magnus
- Pectineus also acts as adductor
Nerve supply to medial thigh muscles
Obturator nerve supplies these muscles, all of which adduct the thigh
Adductors - all adductor muscles
- Obtruator externus
- Pectineus
- Adductor longus, brevis, magnus (insert into linea aspera)
- Grasilis
Adductor magnus
Adductor part of magnus will also flex the thigh (weakly)
Proximal origin of hamstring part of magnus more posterior - ischial tuberosity- and inserts onto adductor tubercle so extends the hip (sciatic nerve)
Adductor magnus contains adductor hiatus
Adductor hiatus – pes anserinus
Opening between the 2 distal attachments of adductor magnus
• Transmits femoral artery and vein from adductor canal to popliteal fossa (posterior knee)
Pes anserinus
• Sartorius
• Gracilis
• s.tendinousous
Pes anserinus
- Sartorius
- Gracilis
- s.tendinousous
Gracilis (slender) and obturator externus
- Lateral or external rotator
- Perforations for branches of arteries
- Adductors canal/ hunters canal
Boundaries of Femoral triangle
- Superiorly – inguinal ligament
- Medially – medial border of adductor longus
- Laterally – medial border of sartorius
- Floor- pectineus and Iliopsoas
- Roof – fascial lata, cribriform fascia, skin, subcutaneous tissue
Retro- inguinal space
—> behind inguinal ligament
Gets things out of pelvic part into thigh
Inguinal ligament = ASIS → pubic tubercle
Retro-Inguinal Space is deep to ligament…
Important passageway between abdominal cavity and lower limb
Femoral nerve (L2-L4)
Divides into several branches to:
• anterior thigh muscles
• articular branches to hip and knee,
• cutaneous branches to anteromedial side of thigh
• Continues as the saphenous nerve through adductor canal - but comes out bet wee n s a rto riu s and gracilis
Saphenous nerve accompanies saphenous veinm
Femoral sheath
Fascial tube
• 4cm long
• deep to inguinal ligament
• blends with adventitia of femoral vessels
• Allows femoral artery and vein to glide deep to inguinal ligament during movemen
Femoral canal
Short and blind ending canal
• Allows femoral vein to expand eg exercise
• Contains fat and lymphatics, sometimes deep inguinal lymph node (Cloquet’s node) - allows expansion
Boundaries of femoral ring
Opening of femoral canal
Laterally – septum between femoral vein and canal
• Posteriorly – pectineus (superior ramus of pubis)
• Medially – lacunarligament
• Anteriorly – Inguinalligament
Femoral artery
First branches
• Superficial epigastric
• Superficial circumflex iliac
• Superficial and deep external pudendal
Profunda femoris Artery
• main artery of thigh, gives off 3 -4 perforating arteries which supply all 3 compartments of thigh and hip (giving off the circumflex femoral vessels)
Femoral vein
A continuation of popliteal vein
• Receives profunda femoris vein (formed by union of 3 or 4 perforating veins), saphenous vein and other tributaries
• Continues as the external iliac vein
Adductor canal - boundaries
- laterally and anteriorly = vastus medialis
- posteriorly = adductor longus and magnus
- anteriorly and medially –sartorius (forms the roof)
What is in the adductor canal ?
- femoral artery
- femoral vein
- saphenous nerve (from femoral)
- nerve to vastus medialis
2 important sites for muscle attatchment
Anterior superior illiac spine
Anterior inferior illioc spine
Function of femoral candl
Allow femoral vein to expand when there is increased venous return from lower limb
- roulte for efferent lymphatic drainage from deep inguinal nodes
Actions of quadriceps femoris muscles
Extend leg or knee joint
Flex thigh at hip joint
Vastus medialis function
Sends some fibres horizontally to insert onto patella to stabilise patella and prevent patella dislocation
Virchows triad
3 factors important in venous thrombosis development
- venous stasis
- activation of blood coagulation
- vein damage
Femoral hernia
Protrusion of abdominal viscera through femoral ring
- found below and lateral to pubic tubercle
Inguinal hernia
- found above and medial to pubic tubercle
Typical sites for valvular incompetence
Mid proximal thigh (hunteran perforator) Proximal calf (boyd perforators)
