ANATOMY LIMBS; Lecture 6, 7 and 8 - Hip, buttocks and thigh; Knee, leg, ankle and foot; Review of nerves and vessels of Lower limb Flashcards
By the lower limb twisting during development, what changes?
Permanent pronation at mid thigh level makes terminology and dermatomes confusing
What are the regions of the lower limb?
Gluteal region and free lower limb (thigh, leg and foot)
What are the movements of the free lower limb?
What are the bones of the upper lower limb?
Pelvis (ischium, ileum, pubis), femur
What are the bones of the hip?
What is the femur?
What are the common sites of injury in the femur?
What are the ligaments present in the pelvis?
x
What are the fascia present in the thigh?
Superficial fascia (subcut tissue) and deep fascia (fascia lata)
What are the compartments of the lower limb?
Gluteal, anterior, medial, posterior compartment of thigh
What are the muscles in the gluteal region?
- Gluteal muscles:
- Gluteus maximus
- Gluteus medius
- Gluteus minimus
- (Tensor fasciae latae)
- Short external (lateral) rotators of the hip:
- Piriformis (comes of sacrum)
- Obturator internus
- The gemelli (sup. and inf.)
- Quadratus femoris
Where does gluteus maximus insert?
Inserts into the gluteal tuberosity; majority of fibres enters in the ilio-gluteal tract
How are the gluteal muscles arranged?
NB: piriformis is an important landmark of the region with other muscles described in relation to it
What is the function of the muscles in the diagram (bold)?
Lateral rotators and to stabilise the hip joint
What are the muscles of the anterior compartment of the thigh?
HIP FLEXORS; KNEE EXTENSORS
- Pectineus
- Ilio-psoas (joining of psoas major and iliacus -> major hip flexor)
- (Tensor fasciae latae)
- Sartorius
- Quadriceps femoris ->
- Rectus femoris
- Vastus medialis
- Vastus intermedius
- Vastus lateralis
What is the function and attachments of sartorius?
Off ASIS then extends inferiorly and medially across knee joint and attaches to tibia - helps cross legs
What are the quadriceps?
- Vastus lateralis,
- Vastus medialis,
- Vastus intermedialis
- rectus femoris -> act through patella; extensors of the knee
How do the quads attach to the knee?
What are the muscles in the medial compartment of the thigh?
HIP ADDUCTORS
- Adductor longus
- Adductor brevis
- Adductor magnus
- Gracilis
- Obturator externus
What is the adductor hiatus?
Between the adductor magnus muscle and the femur that allows the passage of the femoral vessels from the anterior thigh to the posterior thigh and then the popliteal fossa. -> termination of adductor canal
What are the muscles of the posterior compartment of the thigh?
KNEE FLEXORS AND HIP EXTENSORS
- Semimembranosus
- Semitendinosus (both attach to tibia but only ST contributes to goose foot with sartorius and gracilis)
- Biceps femoris
What is the femoral triangle?
- Outlined by:
- sup - inguinal ligament,
- med - adductor longus,
- laterally - sartorius;
- contains: femoral NAV (lat to med)
What is the Adductor canal (hunter’s canal/subsartorial canal)?
- Extends along medial aspect of thigh, from apex of the femoral triangle ->
- formed by:
- Vastus medialis (ant),
- adductor longus/magnus (post) and
- sartorius (medially)
- contains Femoral artery, vein and saphenous nerve
What are landmarks of the gluteal region?
Greater/lesser sciatic notch turned into the Greater/lesser sciatic foramen by the sacrotuberous+sacrospinous ligament
What is the function of the greater sciatic foramen?
Structures passing from pelvis to thigh (SCIATIC NERVE)
What is the function of the lesser sciatic foramen?
Structures passing from pelvis to perineum
What is the journey of the sciatic nerve?
- Passes from pelvis to buttock via greater sciatic notch/foramen In the buttock,
- lies in the inferior and medial quadrant ->
- Passes along posterior aspect of the thigh ->
- Divides into the tibial nerve and the common peroneal nerve (inconstant level) ->
- Supplies all the hamstring muscles and all the muscles below the level of the knee
What is the safe area for IM injection?
Superior and lateral quadrant to avoid the sciatic nerve
What is the Trendelenberg test?
Abductors of the thigh prevent tilting of pelvis when limb is raised -> if paralysed then the hip drops on the lifting side
What is the hip joint?
- Synovial ball and socket joint between head of the femur and the acetabulum,
- Acetabular labrum,
- Transverse acetabular ligament (within acetabulum)
- Capsule of hip joint
What is the capsule of the hip joint?
- Extends further anteriorly than posteriorly -> down neck of femur
- Within capsule runs the blood supply of the femur head
- Hip fractures are classified intracapsular and extracapsular (reflect differential blood supply disruption)
What are the ligaments of the hip joint?
- Ilio-femoral,
- pubo-femoral,
- ischio-femoral
- ligament of the head of the femur
Why is winding of the ligaments helpful?
Draws structures together, adding extra structure to the joint
What is the blood supply to the head of the femur?
- Medial and lateral circumflex arteries
- The artery of the head of the femur (more important in children).
- Damaged in intracapsular fractures of the femoral neck = Avascular necrosis of the femoral head
Which muscles move the hip joint (adductors, flexors and extensors)?
Which muscles move the hip joint (Abductors, external/internal rotators)?
What are the arteries in the thigh?
- External iliac artery
- Femoral artery – midinguinal point
- Femoral artery lies between the femoral vein (medial) and the femoral nerve (lateral)
- Profunda femoris artery
- Circumflex vessels
- Femoral artery continues as the superficial femoral artery and subsequently as the popliteal artery
What is the journey of the femoral artery?
- External iliac artery passes from pelvis beneath inguinal ligament (midpoint) and
- proceeds as femoral artery (gives off profunda femoris artery and both arteries give off circumflex arteries supplying hip joint) and
- continues after PFA as the superficial femoral artery.
- Pass from the anterior compartment to the posterior of the knee (the popliteal fossa) through the hiatus of adductor magnus muscle.
- At the knee it becomes the polpiteal artery
What are the veins of the lower limb?
- Superficial veins
- Long saphenous vein
- Joins the femoral artery at the sapheno-femoral junction
- Valve!
- Deep veins
- Popliteal vein
- Femoral vein
- External iliac vein
- Sapheno-femoral junction
- Venae comitantes of the profunda femoris artery
What is the lymphatic drainage of the lower limb?
- Lymph flows with the superficial and deep veins
- Superficial inguinal lymph nodes (runs with short/long saphenous veins, present in groin)
- Deep inguinal lymph nodes
- External iliac lymph nodes
What are the nerves to the lower limb emerging from lumbrosacral plexus?
What are the different nerve supplies of the region?
Motor Segmental Supply Motor Peripheral Supply Sensory Segmental Supply Sensory Peripheral Supply
What are the nerves that supply motor segmental?
Hip Flexors L23 Hip Extensors L45 Knee Extensors L34 Knee Flexors L5S1
What are the nerves that supply motor peripheral?
What are the nerves that supply sensory segmental?
Dermatomal distribution
- Front of the thigh : T12, L123
- Back of the thigh : S123
- Buttock S234
What is the fascia lata?
Extends like stocking under skin -> ilio-tibial tract is a lateral thickened area of it
What is the femoral sheath?
Encloses the femoral artery and vein, with portion of it medially forming the femoral canal
What is the acetabular labrum?
Tissue around rim of the bony acetabulum
What is the journey of the venous drainage of the thigh?
Main is the long saphenous vein which runs from medial border of foot, passing knee on medial aspect, passes up medial aspect of thigh to join deep system at sapheno-femoral junction. LSV pierces fascia of thigh to join the deep system at femoral triangle (valve present to stop blood from passing deep to superficial which can lead to often faulty and incompetent veins); deep veins of thigh flow into popliteal vein at level of knee, running along popliteal and femoral arteries to form femoral vein; passes beneath inguinal ligament to form external iliac vein (receives LSV at sapheno-femoral junction -> also venae comitantes of profunda femoris artery
What supplies the sensory peripheral?
Distributed by system of peripheral nerves derived from lumbro-sacral plexus ->
- Subcostal nerve (T12)
- Ilio-hypogastric (L1),
- ilio-inguinal (L1),
- genitofemoral (L1,2),
- lateral cutaneous nerve of thigh (L2,3),
- sensory branches of femoral nerve (L2,3,4),
- sensory branches of obturator (L2,3,4),
- posterior cutaneous nerve of thigh (S2,3),
- saphenous nerve (terminal branch of femoral nerve L234),
- buttock nerves derived from sacral plexus (L1 to S3)
What are the characteristics of the femur?
Head, neck, 2 trochanters proximally (greater and lesser joined by intertrochanteric line anteriorly, and intertrochanteric crest posteriorly). Linea aspera is a long ridge on the posterior shaft of the femur
What is the torsion angle of the femoral neck?
Angular difference between axis of femoral neck and transcondylar axis of knee -> adults = 12degrees and at birth its around 30-40degrees which reduces by a degree each year until 20+. Intoeing is due to higher anteversion angle
How would you ID the iliac crest, iliac tubercle, femoral head and greater trochanter of femur?
IC: place hands on hips -> top at L4/5. IT: L5 level FH: Midpoint between ASIS and pubic symphysis/site of femoral artery pulsation GTF: Bony prominence on lateral side of upper thigh about 10 cm below iliac crest
Where is the inguinal ligament (surface)?
Between ASIS and pubic tubercle
Where is the femoral pulse felt (femoral nerve/vein)?
Mid inguinal point between ASIS and pubic symphysis. Vein is medial and Nerve is lateral
Where is the gluteal fold?
Inferior border of gluteus maximus, extending thigh at hip joint and feel muscle contracting and producing rounded contour of buttock
Where is the gluteal sulcus?
Visible skin crease separating buttock and thigh which crosses true gluteal fold obliquely
How can you test for gluteus maximus?
Subject lies prone with knee flexed. Ask patient to extend thigh at hip joint whilst applying resistance at distal end of thigh and examiner palpates rounded contour of buttock for muscle contraction
How can you test for gluteus medius and minimus?
Subject lies on side with lower limb fully extended. Ask patient to abduct limb at hip joint whilst applying resistance at distal end of thigh. Examiner palpates contraction of gluteus medius just inferior to iliac crest
How can you test for tensor fascia lata?
Same as gluteus medius but subject is rolled slightly supine and examiners finger tip on TFL musle and the ilio tibial band
How can you test for hamstrings?
Subject lies prone with knee flexed to 30” examiner applies opposing force just above posterior side of ankle whilst subject flexes knee FURTHER, with tendons seen in popliteal region and muscle contraction palpable on post side of mid thigh
How can you test for quadriceps?
Subject sits on couch with knees bent to 90” over the edge and examiner applies pressure at the distal part of the leg while subject attempts to extend it and contracting quads felt on anterior thigh
What occurs to the knee joint during full extension and flexion from full extension?
Some passive medial rotation (5”) of femur on tibia during full extension and an active lateral rotation (5”) during flexion from fully extended position
What is inversion of the foot?
Moving the sole of foot towards median plane
What is eversion of the foot?
Moving sole of foot away median plane
What is the Trendelenberg test?
Subject stand on both legs and feel for pelvis level on both sides; then subject raises one leg off the ground, pelvis should remain horizontal
What is true leg length?
Distance between medial malleolus of ankle and fixed bony part of pelvis (ASIS) and if >1.5cm then discrepancy
What is apparent leg length?
Distance between middle malleolus of ankle and non-fixed landmark such as xiphisternum -> difference > 1.5cm is discrepancy
What can cause discrepancy in leg length?
Pelvic tilt/rotation, hip joint or sacroiliac joint abnormalities are the main causes
What are the bones of the leg?
Tibia, fibula, patella, bones of the foot
What are the bones of the foot?
NB: Navicular, cuboid and talus articulate to form the transverse tarsal joint.
NB: Sesamoid bones are present in the thumb of foot and appear on XR
How is the foot placed with the arches?
NB: sesamoid bones in flexor hallucis brevis
What are the compartments of the lower leg?
Anterior, lateral and posterior compartment of the leg; intrinsic muscles of foot -> sole (4 layers) and dorsum (2 muscles)
Which muscles act across the knee joint?
TFL, sartorius, Quads; gracilis; semimembranosus, semitendinosus, biceps femoris
Which muscles are present in the anterior compartment of leg?
ANKLE DORSIFLEXORS;
- Tibialis anterior
- Extensor digitorum longus
- Extensor hallucis longus (hallucis = toe)
What artery/nerve supplies the anterior compartment of leg?
Deep peroneal nerve; anterior tibial artery
What is the extensor digitorum longus?
Long tendons, supplying lateral four toes
What is the extensor hallucis longus?
Single long tendon attaching to big toe only
What are the muscles of the lateral compartment?
EVERSION OF FOOT;
- Peroneus longus,
- peroneus brevis
- supplied by peroneal artery and superficial peroneal nerve.
- Tendons go behind malleolus and attach to the foot
What are the main functions of the anterior and lateral compartment of the leg?
Anterior compartment muscles extend (dorsiflex) the foot at the ankle joint and extend the digits. Supplied by the deep branch of the peroneal nerve. Lateral compartment muscles evert the foot and can contribute to dorsiflexion
What are the muscles in the posterior compartment of the leg?
ANKLE PLANTARFLEXORS; Superficial Gastrocnemius Soleus Plantaris Deep Popliteus Flexor Digitorum Longus Flexor Hallucis Longus Tibialis Posterior
What supplies the post compartment of the leg?
Tibial nerve and posterior tibial artery
How is the calcaneal tendon formed?
Gastronemicus and soleus together form triceps surae whose distal tendon is tendocalcaneus
How is the deep posterior compartment of leg organised?
- Popliteus helps unlock the knee when flexing after complete extension.
- FDL has 4 tendon and FHL has 1.
- FHL moves through the sesamoid bones to form a canal for the FHL so that it isn’t compressed
What is present in the sole of the foot?
- 4 layers,
- intrinsic muscles (act as shock absorbers, adjusting foot to uneven surfaces) and
- supplied by tibial nerve
What is present in the dorsum of the foot?
EDB (common peroneal nerve), EHB
What is in the layers 1 and 2 of the sole of the foot?
FDB, abductor hallucis, abductor digiti minimi; lumbricals, FHL, FDL, quadratus plantae
What is in the layers 3 and 4 of the sole of the foot?
Adductor hallucis, FHB, FDMB, plantar interossei and dorsal interossei
What is the popliteal fossa?
- Diamond shaped space post to knee joint ->
- Boundaries
- Biceps Femoris
- Semimembranosus
- Lateral head of gastrocnemius
- Medial head of gastrocnemius
- Skin and fascia
- Femur
What is present in the popliteal fossa?
- Popliteal artery and vein
- Tibial Nerve and
- Common Peroneal Nerve
- Short saphenous vein
- Popliteal lymph nodes
What is the knee joint?
- Largest joint; superficial;
- 1ry hinge type synovial joint with some gliding, rolling and rotation.
- Shapes of bones involved don’t predict stable arrangement
What are the ligaments and menisci of the knee joint?
- Anterior cruciate ligament
- Posterior cruciate ligament
- Medial collateral ligament
- Lateral Collateral Ligament
- Menisci help stabilise the knee:
- Medial Meniscus
- Lateral Meniscus
What are the extensors of the knee?
- Quadriceps
- Quadriceps tendon
- Patella
- Patellar ligament
- Tibial tuberosity
What are the bursae in the knee joint?
Pre-patellar bursa Pre-patellar bursa Popliteal bursa
How is the distal femur specialised for the knee joint?
Wider angle in women due to wider hip angle
How is the proximal tibia adapted for the knee?
Fibula articulates only with tibia not femur
How is the tibial plateau organised?
Posterior ligaments aren’t in joint cavity, covered in synovial space
What are the bursae of the knee?
When inflamed (bursitis) can be very painful
What are the other joints of the leg and foot?
- Proximal and Distal Tibio-Fibular Joints
- Ankle Joint
- Subtalar Joint
- Midtarsal Joint
- Metatarso-phalangeal joints
- Interphalangeal Joints
What takes part in weight-bearing in the ankle?
The weight-bearing at the ankle joint is by talus via it’s superior articulation with tibia.
Fibula is not weight-bearing, but it’s distal lateral malleolus, with tibia’s medial malleolus, forms the square socket of the ankle joint.
What are the joints of the foot?
NB: Talus is wider at the front than at the back, so it is more stable in plantarflexion than in dorsiflexion
What are the arches of the foot?
Medial longitudinal, lateral longitudinal and transverse metatarsal arch
Which structure maintain the arches of the foot?
x
How do adult feet differ from child’s feet?
What is the gait cycle?
What are the arteries below the knee?
- Popliteal artery-
- genicular (knee) branches
- Popliteal “Trifurcation”
- Anterior tibial artery : anterior compartment
- Posterior tibial artery : posterior compartment
- Peroneal artery : lateral compartment
At the ankle
- Posterior Tibial Artery : sole of the foot via the medial and lateral plantar arteries
- Dorsalis pedis artery (continuation of the anterior tibial artery) and supplies the dorsum of the foot and the digits
What is the superficial venous drainage below the leg?
- Superficial veins
- Dorsal venous arch
- Long saphenous vein
- Short saphenous vein
- Perforating veins to the deep system (mainly in the calf) Valves!
What is the deep venous drainage below the leg?
- Deep veins
- Deep calf veins – venae comitantes of arteries
- Popliteal vein
- Femoral vein
- External iliac vein
- Sapheno-femoral junction
- Venae comitantes of the profunda femoris artery
How is the sensory supply organised?
Dermatomal distribution
“L3 to the knee and L4 to the floor”
L5 to the great toe
S1 to the lateral side of the foot
S1 to the sole of the foot
What is the motor peripheral supply?
Femoral nerve : Knee Extensors Sciatic Nerve : Hamstrings Tibial nerve : Posterior Compartment and Foot intrinsics Common Peroneal Nerve : Anterior and Lateral Compartments
What is the motor peripheral supply?
Femoral nerve : Knee Extensors Sciatic Nerve : Hamstrings Tibial nerve : Posterior Compartment and Foot intrinsics Common Peroneal Nerve : Anterior and Lateral Compartments
What is the tibial nerve?
Posterior Compartment of the Leg Passes behind medial malleolus to divide into: Medial plantar nerve Lateral plantar nerve All intrinsics except extensor digitorum brevis
How are the spinal nerve organised in relation to the body?
C1-4 = neck; C5-T1 = upper limb; T2-L1 = trunk; L2-S3 = lower limb; S2-C1 = perineum
What are the 2 types of innervation?
Segemental (dermatomes) or peripheral
What are the nerves that emerge from the lumbosacral plexus to the lower limb?
- Femoral n. supplies anterior compartment of thigh.
- Obturator n. supplies medial (adductor) compartment of thigh.
- Sciatic n. (or its terminal branches Tibial and Common Peroneal ns.) supply the remaining compartments (i.e. post. thigh, ant. and post. leg, foot)
What is the general organisation of the lumbosacral plexus?
Which are the nerves in the buttock and posterior thigh?
Piriformis is an important landmark of the region
What are the nerves of the leg and the foot?
What are the nerves of the lower limb?
x
What is the segmental motor supply to the limbs?
C5-T1 = upper limb; L5-S3 = lower limb and plexi for each limb present -> anterior divisions = flexor muscles and posterior = extensor muscles
What are the prinicples of segmental supply to limbs?
Muscles supplied by 2 adjacent segments -> if same action on joint then same nerve supply; if opposing muscles then 1-2 segments above/below. More distal in limb = more caudal in spine
What is the segmental motor supply to the lower limb?
HIP: FLEX = L23, EXT = L45.
KNEE: EXT= L34, FLEX = L5S1.
ANKLE: DORSI = L45, PLANTAR = S12
What is the segmental sensory supply to the lower limb?
What are the dermatomes of the lower limb?
Where does the obturator nerve supply cutaneously?
What are the peripheral cutaneous nerves of the lower limb?
What are the peripheral cutaneous nerves of the foot?
How do you assess nerve function?
Motor, sensory, reflex and autonomic
What would be the assessment of a root injury: prolapsed intervertebral disc at L5/S1?
Motor -> loss of eversion; sensory -> loss of outer border foot sensation; reflex -> loss of ankle jerk; autonomic -> minimal
What would be the assessment of a lesion of common peroneal nerve at fibular neck?
Motor -> foot drop; sensory -> dorsum of foot at least; no reflex problems and minimal autonomic deficits
How does the aorta flow to the feet?
Aorta -> common iliac -> external/internal iliac -> femoral -> [profunda femoris and circumflex femoral arteries] -> popliteal -> TRIFURCATION: anterior tibial (forms dorsalis pedis artery), posterior tibial and peroneal artery
What are the main leg pulses?
Femoral artery, posterior tibial artery, dorsalis pedis
What are the borders of the femoral triangle?
Sartorius, adductor longus and inguinal ligament
Where do the femoral artery and vein travel through to get to popliteal fossa?
Pass from anterior compartment to posterior of knee through hiatus of adductor magnus muscle, where they are then called popliteal artery and vein
What is the popliteal fossa?
What are the arteries of the ankle?
What are the arteries of the foot?
How do you find the femoral pulse?
How do you find the dorsalis pedis pulse?
How do you find posterior tibial pulse?
What are the superficial veins of the lower limb?
Dorsal venous arch, long saphenous vein, short saphenous vein, perforating veins, saphenofemoral junction -> blood flow from sup to deep
What are the deep veins of the lower limb?
Run with arteries, venae comitantes -> use muscle pumps in calf; Ant and post tibial vein, popliteal vein (receives SSV), profunda femoris vein, femoral vein (receives LSV), external iliac vein
How would you find the long saphenous vein and why would you need to find it?
2 cm proximal and lateral to medial malleolus -> when patient is shocked or in advanced trauma life support
What are some common problems that can occur in the lower limb?
Arterial embolism, compartment syndrome
What occurs when there is an arterial embolism in the lower limb?
Sudden occlusion, acute ischemia and intermittent claudication (muscle pain commonly in calf during activity)
What is compartment syndrome?
Ischemia caused by trauma induced increased pressure in confined limb compartment (common in ant, post and lateral of leg) -> 25mmHg normal pressure, with 50-60 collapsing vessels, so pulse can still be felt -> acute due to trauma and chronic due to exercise
How do you treat acute compartment syndrome?
Emergency fasciotomy to prevent death of muscles in affected compartment
What is important about lower limb veins?
Veins from superficial to deep have valve that only flows towards deep, which when compromised, means blood is pushed from deep to superficial, leading to varicose veins
What are the causes of varicose veins?
Valves in superficial, deep and perforating veins, with sapheno-femoral valve most improtant; venous insufficiency; lipodermatosclerosis; venous ulcers
What is DVT and what can it cause?
Clot in deep veins -> diagnosed with risk factors; relationship to PE, post-phlebitic syndrome, superficial thrombophlebitis
What can veins be used for?
Coronary artery bypass grafts, arterial by-pass surgery
