Exam 3 Flashcards
1
Q
tibia
A
• Second longest, second strongest (bone of body)
o Slightly longer than fibula
• Males: nearly vertical
• Females: distal end more medial (compared to proximal end)
• Tibial plafond – Inferior surface
• Proximal extremity
o Greatly enlarged
o Superior surface – Tibial plateau
Oval shaped
Wider side to side
medial and lateral condyles – flattened
• Articulates with femoral condyles (central portions)
• Medial and lateral menisci
o Overly peripheral portions
2
Q
tibia cont
A
• Medial condyle
o Condyle larger
o Articular surface larger
o Medial surface – roughened
Attachment: tibial (medial) collateral ligament of knee joint
Non-articular intercondylar ridge (between condyles) – 3 structures:
• 1) Anterior intercondylar fossa
o 3 attachments (from anterior to posterior):
A) anterior horn of medial meniscus
B) anterior cruciate ligament
C) anterior horn of lateral meniscus
• 2) Intercondylar eminence (intermediate position)
o Ridge/spine located between two intercondylar fossae
o Contains (2) tubercles: medial & lateral intercondylar tubercles
Covered by articular cartilage
• Continuous with tibial condyles
• 3) Posterior intercondylar fossa
o 3 attachments (from anterior to posterior):
A) posterior horn of lateral meniscus
B) posterior horn of medial meniscus
C) posterior cruciate ligament
3
Q
tibial tuberosity and fibular facet
A
o Tibial tuberosity
Triangular prominence of bone
• Apex: directed inferior
o Attachment: patellar ligament (continuation of quadratus femoris tendon)
o Palpable
o Fibular facet (**FACET closest to the face)
Oval shaped
Posterolateral depression on lateral tibial condyle
Fibula and tibia articulation (proximal tibiofibular joint)
4
Q
tibia shaft
A
• Shaft
o 3 borders: anterior, medial, and lateral
Anterior
• Aka shin
• Subcutaneous and palpable (throughout its course)
• Extends: tibial tuberosity to medial malleolus (anterior border)
• Attachments:
o Crural fascia (deep fascia of the leg)
Medial
• Extends: medial condyle (below) to medial malleoulus (posterior border)
• 4 attachments:
o 1) Medial collateral ligament
o 2) popliteus
o 3) soleus
o 4) flexor digitorum longus
5
Q
tibia shaft cont
A
Lateral
• Aka interosseous crest
• Extends: articular facet from fibula (superiorly) to divides – forms two ridges (inferiorly)
o Ridges form anterior & posterior borders of fibular notch
Attachment: posterior (inferior) tibiofibular ligament
6
Q
medial tibia
A
Medial
• Smooth, convex
• Bounded by anterior & medial borders
• Superiorly – attachment of 3 muscles & common aponeurosis (superior to inferior) known as Pes anserinus (“goose’s foot”) – union of tendons
o 1) Sartorius
o 2) gracilis
o 3) Semitendinosus
Hint: these three Muscles can be remembered with the acronym “SGT” (T for semiTendinosus)
• Tibial collateral ligament
o Attachment at roughened area – superior portion, medial surface
• Inferiorly
o Medial surface is subcutaneous
o Crural fascia (deep fascia of the leg) attaches along medial surface of tibial shaft
7
Q
lateral tibia
A
Lateral • Narrow • One muscle attachment: o Tibialis anterior Upper ½ to 2/3, grooved by muscle origin • 4 tendons cover distal portion (from medial to lateral): 1) tibialis anterior 2) extensor hallucis longus 3) extensor digitorum longus 4) peroneus tertius (not depicted)
8
Q
posterior tibia
A
• Soleal line
o Oblique ridge extending superolateral to inferomedial
Superior portion, posterior surface, tibial shaft
o Partial origin of soleus muscle
• Vertical line
o Extends: inferior from soleal line
o Structures Lateral to vertical line
Tibialis posterior (partial origin)
Nutrient foramen
• From a branch of posterior tibial artery
• Just distal to soleal line
• Points distally – away from growing end of tibia (proximal end)
• Largest of nutrient foramen
o Medial to vertical line – attachment:
Flexor digitorum longus
Memory Hint: recall that the tibial proximal surface extends slightly medial on females, now picture the soleal line following that same course with the vertical line representing the fibula.
• Distal portion
o Smooth
o Covered by tendons:
Flexor digitorum longus
Tibialis posterior (deep)
Flexor hallucis longus
Hint: Distal Tibial Hallmarks – just remember that the tibialis posterior lies deep, and the other two are opposite of what you woud think – hallucis lying laterally, digitorum more medially in attachments.
9
Q
distal tibia
A
• Distal Extremity
o Larger than shaft, smaller than proximal extremity
o Five surfaces: anterior, posterior, lateral, medial, and inferior
Anterior surface
• Continuous with lateral surface – tibial shaft
• Distal portion:
o Transverse groove – attachment of capsule (ankle joint)
• Smooth surface (with above exception)
Posterior surface
• Continuous with posterior surface – tibial shaft (superiorly)
• Continuous with posterior aspect, medial malleolus (inferiorly)
• Grooves for tendons:
o Tibialis posterior (deep to FDL)
o Flexor hallucis longus
10
Q
distal tibia cont
A
Lateral surface • Fibular notch – articular location with fibula o Attachment (along margins): Anterior tibiofibular ligament Posterior tibiofibular ligament Medial surface • Continuous with medial malleolus (medial surface) Inferior surface • Aka tibial plafond • Quadrilateral shape o Wider anteriorly – than posteriorly o Concave anteroposteriorly o Convex side-to-side
11
Q
medial malleolus
A
Pyramidal shaped Extends inferiorly – beyond rest of tibia Lateral surface (articulates w/talus) • Comma shaped facet • Superiorly o Continuous with tibial plafond Medial surface • Subcutaneous (easily palpated) Inferiorly surface • Two slight elevations: anterior and posterior colliculi (“hills”) o Attachments: Deltoid ligament (portions – also attaches interfollicular sulcus) Note: Deltoid ligament attaches to intercollicular sulcus, anterior and posterior borders of medial malleolus. Posterior border • More pronounced than anterior border • Malleolar sulcus o Groove along posterior border o Location of 2 tendons: Tibialis posterior Flexor digitorum longus o Flexor retinaculum (attaches near malleolar sulcus)
12
Q
tibial arterial supply
A
o Genicular anastomosis Supply proximal end o Malleolar anastomosis Supply distal end o Anterior Tibial artery Supply periosteum (shaft) o Nutrient Artery Branch of posterior tibial artery Foramen of nutrient artery – largest of all long bones
13
Q
fibula
A
- Articulates with: tibia & talus (NOT femur)
- Non-weight bearing bone (anatomically)
- Function – muscle attachment
14
Q
fibular head
A
• Head o Irregular o Quadrate shape (somewhat) o Apex (styloid process) Superior projection – from posterolateral portion of head Two attachments: • Biceps femoris tendon (insertion) • Lateral collateral ligament of knee joint o Anterior aspect Attachments: 1) peroneus longus 2) extensor digitorum longus 3) anterior ligament of head of fibula o Posterior aspect Attachments: 1) soleus muscle 2) posterior ligament of head of fibula
15
Q
fibular neck and shaft
A
• Neck o Constricted region o Just distal (inferior) fibular head o Common peroneal nerve courses around the neck Often site of injury • Shaft o Four surfaces: anterior, medial, posterior, and lateral Anterior – flat, narrow • Origin of 3 muscles o 1) extensor hallucis longus o 2) extensor digitorum longus o 3) peroneus tertius Note: All but one of the anterior compartment muscles. Recall tibialis anterior attaches superiolaterally on the tibia and interosseous membrane. Medial • Origin (partial): tibialis posterior
16
Q
fibular shaft cont
A
Lateral
• Origin of 2 muscles
o 1) peroneus brevis
o 2) peroneus longus
Note: Both of the lateral compartment muscles.
Posterior
• Superiorly
o Origin (partial): Soleus muscle
• Nutrient foramen – branch of peroneal artery
• Midway
o Origin: Flexor hallucis longus
• Inferiorly
o Interosseous ligament attachment (unites tibia to fibula)
Hint: the posteromedial border is also known as the oblique border because distally it runs obliquely to join the anteromedial border, hense the posterior surface attachment of this ligament.
17
Q
fibula
A
o Four borders: anterolateral, anteromedial, posterolateral, and posteromedial Crural fascia (deep fascia of leg) • Forms TWO intermuscular septa o Attachments: Anterlolateral border • Seperates extensor muscles from lateral ones Posterolateral border • Seperates lateral muscles from flexors Anteromedial border • Aka interosseous crest o interosseous membrane attaches here Posteromedial border • Aka oblique ridge o Courses obliquely o Inferiorly blends with interosseous crest
18
Q
lateral malleolus
A
• Lateral malleolus
o Major feature of distal fibula
o Base: Continuous with shaft
o Apex: pointed distally
o Two surfaces: medial & lateral
Lateral
• Subcutaneous (easily palapable)
Medial
• Triangular shaped facet (articulates with talus)
o Lateral malleolar fossa located posterior to facet
Attachments:
• posterior tibiofibular ligament (superiorly)
• posterior talofibular ligament (inferiorly)
19
Q
lateral malleolus cont
A
o Two borders: anterior & posterior Anterior • Attachments: o anterior tibiofibular ligament o anterior talofibular ligament (roughened area) o calcaneofibular ligament (small inferior tubercle) also attaches apex of lateral malleolus Posterior • Shallow sulcus (groove) o Two tendons pass through 1) peroneus longus 2) peroneus brevis
20
Q
fascia of the leg
A
• Deep “crural” fascia – continuous with fascia lata (of thigh) proximally • Attachments: o Patella o patellar ligament o tibial tuberosity o condyles of tibia o head of fibula • forms popliteal fascia posteriorly • receives fibers from tendons of: o biceps femoris o sartious (“SGT”) o gracilis (“SGT”) o semitendinosus (“SGT”) o semimembranosus
21
Q
fascia of leg cont
A
• Subcutaneous periosteum of tibia – continuous with deep fascia anteriorly
o Thicker proximally (thins out as progresses distally)
o Distally – forms retinacula of the ankle
o Forms part of origins for:
tibialis anterior
extensor digitorum longus
o deep surface gives rise:
anterior intermuscular septa
posterior intermuscular septa
deep transverse fascia
Note: anterior and posterior intermuscular septa seperate peroneus longus and brevis from each other and from muscles of anterior and posterior crural compartments.
22
Q
tibialis anterior m
A
• Lateral to tibia • Thick muscle • Covers anterior tibial vessels & deep peroneal nerve (as courses distally in leg) • Origin: o Lateral condyle (tibia) o Upper 2/3, lateral surface (tibia) o Interosseous membrane o Deep crural fascia
• Insertion:
o Medial cuneiform (medial plantar surface)
o Base of 1st metatarsal (medial plantar surface)
• Innervation:
o Deep peroneal nerve
• Functions:
o Inversion (ankle)
o Dorsiflexion (ankle)
o Supination [adduction, inversion, plantarflexion] (intertarsal joints)
23
Q
extensor hallucis longus m
A
• Lateral to tibialis anterior
• DISTALLY: Anterior tibial vessels and deep fibular nerve – lie between EHL and tibialis anterior
• Passes lateral to medial
o inferior to extensor retinaculum
o Superficial to neurovascular structures
• Origin:
o Middle 2/3, anterior surface (fibula)
Medial to extensor digitorum longus origin
o Interosseous membrane (accessory origin)
• Insertion:
o Base of distal phalanx, 1st digit (crest)
o Base of 1st metatarsal (additional slip)
• Innervation:
o Deep peroneal nerve
• Functions:
o Extension (1st MTPJ)
o Dorsiflexion (ankle)
o Supination (intertarsal joint)
24
Q
extensor hallucis capularis
A
• Accessory Muscle – an extension of extensor hallucis longus • Origin: o Extensor hallucis longus tendon • Insertion: o Medial surface of capsule of 1st MPJ • Function: o Lifts capsule out of joint Prevents entrapment of the capsule in joint on extension
25
extensor digitorum longus m
```
• Lateral to extensor hallucis longus
• Lateral extreme of anterior crural compartment
• Origin:
o Lateral condyle (tibia)
o Head (fibula)
o Upper 3/4, anterior surface (fibula)
o Interosseous membrane
o Deep fascia
o Anterior intermuscular septum
(separating muscle from peroneus longus)
• Insertion:
o Extensor expansions (2-5 digits)
• Innervation:
o Deep peroneal nerve
• Functions:
o Extend MTPJ (4 lateral digits)
o Dorsiflexion (ankle)
o Eversion (ankle)
o Pronation [abduction & eversion] (intertarsal joints)
Hint: This muscle has more of a lateral distribution, not attaching to the hallux. Hense the functions.
```
26
fibularis peroneus tertius m
```
• Inconstant muscle
• Considered part of extensor digitorum longus
• Origin:
o Lower 1/3, anterior surface (fibula)
• Insertion:
o Base of 5th metatarsal
Passes with extensor digitorum longus tendon
• Innervation:
o Deep peroneal nerve
• Function:
o Dorsiflexion (ankle)
o Eversion (ankle)
o Pronation (intertarsal joints)
```
27
fibularis peroneus longus
• Most superficial in lateral compartment
• Creates opening between attachments – fibular head & body
o Location of common peroneal nerve passing into anterior compartment
• Origin:
o Lateral condyle (tibia)
o Head (fibula)
o Upper 2/3, lateral surface (fibula)
o Crural fascia
o Both intermuscular septa
• Insertion:
o Base of 1st metatarsal (lateral, plantar side)
o Medial cuneiform (lateral, plantar side)
o Base of 2nd metatarsal (occasional accessory insertion)
• Innervation:
o Superficial peroneal nerve
• Function:
o Plantar flexion (ankle)
o Eversion (ankle), pronation
28
peroneus longus course
Muscle ends in a long tendon ->
passes posterior to lateral malleolus (w/tendon of peroneus brevis) ->
deep to superior peroneal retinaculum ->
across calcaneus (distal to peroneal trochlea) ->
under the infereior peroneal retinaculum ->
lateral then plantar medial side of cuboid (sesamoid bone location: os peroneum) ->
under long plantar ligament -> inserions.
29
fibularis peroneus brevis
```
• Found deep to peroneus longus
• Origin:
o Lower 2/3, lateral surface (fibula)
o Crural fascia
o Both intermuscular fascia
• Insertion:
o Tuberosity of 5th metatarsal
```
```
• Innervation:
o Superficial peroneal nerve
• Function:
o Plantar flexion (ankle)
o Eversion (ankle)
o Pronation (intertarsal joint)
```
30
fibularis peroneus brevis course
Tendon passes posterior to lateral malleolus ->
| Anterior to tendon of peroneus longus -> Inserts.
31
gastrocnemius
• Most superficial muscle of the superficial group
• 2 heads
• Origin:
o Medial head
Medial condyle (femur) – proximal & posterior part
(posterior to adductor tubercle)
o Lateral head
Lateral condye (femur) – depression on lateral side
Note: both origins extend to adjacent areas on the femur and
knee joint capsule.
• Insertion:
o Two heads approach midline > tendinous raphe > aponeurosis of m
o Aponeurosis tapers distally > joins soleus m> tendocalcaneus
o Tendo calcaneus inserts central part, posterior surface, calcaneus
• Innervation:
o Tibial nerve
• Functions:
o Plantar Flexion (ankle)
o Supination [adduction & inversion] (intertarsal joints)
o Flexion (knee)
32
soleus m
• Deep to gastrocnemius
• Common insertion & actions of gastrocnemius – together called triceps surae
• Origin:
o Head & body, posterior surface (fibula)
o Soleal line, middle 1/3 (tibia)
o Tendinous arch (between tibia & fibula)
Popliteal vessels and tibial nerve pass through underneath
• Insertion:
o Tendo calcaneus, into calcaneus
• Innervation:
o Tibial nerve
• Functions:
o Plantar flexion (ankle)
33
plantaris m
```
• Tendon found between gastrocnemius & soleus
o Runs along medial border of tendo calcaneus
• Absent about 10% of cases
• Origin:
o Lateral supracondylar line (femur)
o Oblique popliteal ligament
• Insertion:
o Medial side, posterior surface (calcaneus)
o Tendo calcaneus (joins occasionally)
• Innervation:
o Tibial nerve
• Functions:
o Plantar flexion (ankle)
o Flexion (knee)
```
34
popliteus m
• Origin:
o Groove on lateral condyle (femur)
o Arcuate popliteal ligament
o Lateral meniscus
• Insertion:
o Body of tibia, proximal to soleal line (tibia)
• Innervation:
o Tibial nerve
• Functions:
o Flexion (knee)
o Rotation (knee)
Weight bearing – rotates the thigh laterally
Non-weight bearing – rotates the leg medially
Hint: “Popin Leg-in” (leg always ends up in/medial to thigh) and
“Un-Pops” the knee out of locked position (unlocks the knee joint)
Recall: The muscle courses with the soleal line so must pass from lateral to medial.
35
flexor hallucis longus m
```
• Bipennate muscle
• Origin:
o Distal 2/3, posterior surface (fibula)
o Interosseous membrane
o Posterior intermuscular septum
• Insertion:
o Base of distal phalanx, 1st digit
• Innervation:
o Tibial nerve
• Functions:
o Flexion (interphalangeal joints, 1st digit)
o Plantarflexion (ankle)
o Supination (intertarsal joints)
```
36
flexor hallucis longus course
Tendon passes in groove, posterior surface, distal tibia ->
Over posterior surface (talus) ->
Inferior surface (sustentaculum tali) ->
Sole of the foot, between two heads of flexor hallucis brevis ->Insertion.
37
flexor digitorum longus m
```
• Origin:
o Proximal 2/3 of body – posterior surface, medial to vertical line, below soleal line (tibia)
• Insertion:
o Bases, distal phalanges, digits 2-5
• Innervation:
o Tibial nerve
• Functions:
o Flexion (distal interphalangeal joints)
o Plantar flexion (ankle)
o Supination (intertarsal joints)
```
38
flexor digitorum longus course
```
Tendon passes posterior to medial malleolus (with tendon of tibialis posterior) ->
Passes superficially to deltoid lig. ->
Superifical to flexor hallucis longus ->
Joined by quadratus plantae ->
Divides into 4 tendons ->
Insertion.
```
39
tibialis posterior m
• Lies between flexor hallucis longus & flexor digitorum longus
• Origin:
o Posterior surface interosseous membrane
o posterior surface, lateral to vertical line, below soleal line (tibia)
o Proximal 2/3 Medail surface fibula
• Insertion:
o Tuberosity of navicular (major insertion)
o Sustantaculum tali (medial, intermediate, lateral)
o Three cuneiforms
o Cuboid
o Bases, 2-4 metatarsals
• Innervation:
o Tibial nerve
• Function:
o Supination (intertarsal joints)
o Plantar flexion (ankle)
40
tibialis posterior course
Tendon in groove FDL > posterior to medial malleolus>
Deep flexor retinaculum > superficial deltoid ligament >
Deep plantar calcaneonavicualr ligament (Os Tibialis sesmoid if present)>
Insertiosn
41
saphenous n
• Longest branch of femoral nerve
• Course:
o Enters adductor canal (with femoral artery)
o Crosses over the artery (lateral to medial)
Hint: original location NAV (lateral to medial)
o Leaves canal at adductor hiatus – passes to surface on medial side of knee
Note: Nerve does not pass through adductor hiatus***
o Becomes superficial – passes between tendons:
Sartorius
Gracilis
o Runs with great saphenous vein (along medial side of leg)
o Proximal 1/3 of leg, divides into 2 branches:
1) contribution to subsartorial nerve plexus
2) infrapatellar branch
• Provides cutaneous innervation to skin over the patella
42
tibial n
```
• Larger component of sciatic nerve
• Anterior divisions of L4-S3
• Course:
o Proximal thigh, lies lateral to popliteal artery & vein (“NAVL”)
o Popliteal fossa:
superficial to vessels
Crosses popliteus muscle
Leaves popliteal fossa medial to vessels
o Disappears between heads of gastrocnemius
Gives off muscular branches to:
• Gastrocnemius
• Plantaris
• Soleus
• popliteus
o Continues deep to soleus muscle
Gives off distal muscular branches to:
• Soleus
• Tibialis posterior
• Flexor digitorum longus
• Flexor hallucis longus (branch accompanies peroneal artery)
```
43
tibial n cont
o Proximal leg, lies medial to posterior tibial artery (recall it crossed medially when entering popliteal fossa)
o Inferior border popliteus > Courses lateral side of popliteal artery
Just distal, inferior border of popliteus
o Eventually travels medial to tendocalcaneus
o Gives off last branch:
Medial calcaneal nerves
• Innervate the skin of heel & medial sole
o Divides at flexor retinaculum into terminal branches:
Medial plantar nerve
Lateral plantar nerve
Note: Discussed in the foot section.
• Three articular branches to the knee joint
o 1st – corresponds with Superior genicular arteries
o 2nd – corresponds with Middle genicular arteries
o 3rd – corresponds with Inferior medial genicular arteries
• One articular branch
o Ankle joint
44
medial sural cutaneous n
• Branch off of tibial nerve
• Lies superficially in groove between heads of gastrocnemius
o Accompanied by small saphenous vein
• Course:
o Pierces fascia at mid leg
o Merges with communicating ramus of lateral sural cutaneous branch of common peroneal nerve
Together form sural nerve
45
sural n
• Continues distally
• Supplies cutaneous branches to the skin of posterior surface of leg
• Communicates with posterior femoral cutaneous nerve
• Passes inferior to lateral malleolus
o Continues as lateral dorsal cutaneous nerve
46
common peroneal n
• Smaller component of sciatic nerve
• Posterior divisions of L4-S2
• Course:
o Seperates from tibial nerve
o Gives rise to lateral sural cutaneous branch
Distribution to posterior & lateral surface of knee
Gives off Communicating ramus
• Joins medial sural cutaneous nerve
o Forms sural nerve
o Passes diagonally across lateral portion of popliteal fossa
Parallel to medial border of long head, biceps femoris
o As approaches head of fibula, passes between 2 muscles:
Long head of biceps femoris
Lateral head of gastrocnemius
47
common peroneal n cont
o Circles around the neck of the fibula
o Passes deep to fibularis (peroneus) longus
o Gives off three articular branches to the knee
1st – accompanies superior lateral genicular artery
2nd – accompanies inferior lateral genicular artery
3rd – accompanies anterior tibial recurrent artery
• Through tibialis anterior muscle to knee joint
o Divides into two terminal branches:
Superficial fibular (branch) nerve
• Course:
o Arises deep to peroneus longus
o Passes inferiorly between peroneus longus & extensor digitorum longus
o Two Muscular branches:
Peroneus longus
Peroneus brevis
o Gives rise to two dorsal cutaneous branches supplying the foot
Intermediate dorsal cutaneous nerve
medial dorsal cutaneous nerve
o Distal 1/3 of leg, divides into terminal branches:
1) Intermediate Dorsal Cutaneous Nerve
• Anterior & medial side of leg
• distally at end of ankle
2) Medial Dorsal Cutaneous Nerve
• Branch to medial side of foot as far as the ball of the foot
48
deep peroneal n
```
fibular (branch) nerve
• Course:
o Originates deep to peroneus longus
o Passes to anterior surface of interosseous membrane
o Provides muscular branches to anterior compartment muscles:
Tibialis anterior
Extensor digitorum longus
Peroneus tertius
Extensor hallucis longus
o Accompanies anterior tibial artery
From proximal 1/3 of leg
Passes together deep to extensor retinaculum
Provides branch to the ankle joint
o Immediately distal to extensor retinaculum – divides into:
Medial terminal branch
Lateral terminal branch
```
49
posterior tibial v
o veins of posterior compartment of leg
o accompany posterior tibial artery as venae comitantes
o location: between superficial & deep muscles of posterior compartment
drain blood from posterior muscles
o Also receive blood from superficial veins
o More consistent tributaries:
Fibular (peroneal) venae comitantes
• Accompany the fibular artery
• Drain blood primarily from lateral leg (posterior & lateral compartments)
50
anterior tibial vein
• Superior continuation of venae comitantes
• Accompany dorsalis pedis artery
• Course:
o Between tibialis anterior & extensor hallucis longus muscles (w/anterior tibial artery)
o Proximal end of leg, inferior to popliteal fossa, pass through interosseous membrane
Join posterior tibial veins
• Junction forms popliteal vein
51
femoral vein
• Superior continuation of popliteal vein at adductor hiatus
52
popliteal vein
• Tributaries correspond to branches of popliteal artery
• Also receives the small saphenous vein
• Formed by joining of anterior and posterior tibial veins
o Distal border, popliteus muscle
• Ascends into popliteal fossa
o Accompanies the artery
• Inferior end of fossa – lies medial to artery
• Upper end of fossa – lies superficial to artery
• Exits popliteal fossa through adductor hiatus
53
small lesser saphenous vein
• Continuation of lateral marginal vein
• Course:
o Begins along lateral aspect of foot
o Passes into leg from behind lateral malleolus
o Ascends along lateral border of tendocalcaneus
o Reaches middle, posterior leg
Communicates with great saphenous & posterior tibial veins
o Proceeds superiorly, middle, posterior leg – enters popliteal fossa
o Empties into popliteal vein
Between two heads of gastrocnemius
Note: may terminate in accessory saphenous or deep veins of posterior compartment of leg.
• Possesses about 7-13 valves, one of which is near its termination, accompanied by sural nerve.
54
great saphenous vein
* Continuation of medial marginal vein
* Begins at medial aspect of foot, accompanies saphenous nerve ascending up medial side of leg
* Joins femoral vein to become external iliac vein
55
popliteal artery
• Femoral artery -> exits adductor hiatus into popliteal fossa -> becomes popliteal artery
• Course:
o Inferior through floor of popliteal fossa
o Crosses knee joint (in intercondylar fossa)
Lies deep to the vein
• Both enclosed in dense connective tissue sheath (artery lies deep throughout)
o Anteirorly, artery lies against capsule of joint
o Posteirorly, artery deep to:
Semimembranosus
Popliteal vein
Tibial nerve
Gastrocnemius muscle
56
popliteal a cont
```
o Terminates at inferior border, popliteus muscle
Divides into 2 terminal branches:
• 1) anterior tibial artery
• 2) posterior tibial artery
• Branches:
o 1) Cutaneus
o 2) Muscular
o 3) Medial superior genicular
o 4) Lateral superior genicular
o 5) Medial inferior genicular
o 6) Lateral inferior genicular
o 7) Middle genicular
o 8) Posterior tibial
o 9) Anterior tibial
o 10) Sural
• Cutaneous Branches
o Directly or indirectly supply superficial structures – posterior leg
Can be located between heads of gastrocnemius muscle
Some branches follow small saphenous vein
• Muscular Branches
o 2 or 3 branches
From proximal end of artery
Supplies 2 muscles:
• Adductor magnus
• Hamstring muscles
```
57
popliteal genicular a branches
o Supply knee joint
o 5 genicular arteries given off (by popliteal artery)
2 superior (medial superior genicular, lateral superior genicular)
• Arise from medial and lateral sides
• Wind around superior aspect, femoral condyles
• Reach anterior side of knee – help form collateral circulation of the knee
• Both (medial & lateral) give off:
o Superficial branch – supplies muscle
o Deep branch – supplies knee joint
1 Middle genicular
• Small vessel
• Originates from poplieteal a. opposite knee joint
• Enters knee joint to supply:
o anterior cruciate ligament
o posterior cruciate ligaments
o Synovial membrane (interior of joint)
2 Inferior (medial inferior genicular, lateral inferior genicular)
• Originate distal to knee joint
• Medial inferior
o Larger (than lateral)
o Passes below medial collateral ligament
o Supplies: tibia & knee joint
• Lateral inferior
o Travels laterally, superior to head of fibula
o Deep to lateral collateral ligament & tendon of biceps femoris
o Branches contribute – genicular anastomosis (anterior knee)
58
sural arteries
```
o At knee joint - originates from popliteal artery
o Supply:
Gastrocnemius
Soleus
Plantaris muscles
Note: superficial compartment muscles
```
59
knee/genicular anastamosis
o Knee, largest joint in the body – needs anastomosis for blood supply
o Around anterior side of joint (around patella)
o Involved vessels include:
1) Descending genicular
•
2) Medial & Lateral superior genicular
•
3) Medial & Lateral inferior genicular
•
4) descending branch of lateral femoral circumflex
•
5) circumflex fibular
•
6) Anterior & Posterior tibial recurrent
•
Hint: Remember 3 genicular arteries, 1 femoral, 1 fibular, 2 tibial.
o Superificial branches of network supply – soft tissues around joint
o Deep branches of network supply – knee joint
o Sudden Popliteal Occlusion:
Anastomosing branches – often not sufficient
o Gradual Popliteal Occlusion:
Anastomosing branches increase in size – sufficient supply to knee
60
anterior tibial a
o Artery of anterior crural compartment
o Smaller of two terminal branches of popliteal artery
o Origin: inferior border of popliteus muscle
o Ends: anke joint, midway between medial and lateral malleoli
becomes dorsalis pedis artery
o Course:
Anteriorly – between 2 heads of tibialis posterior muscle
• Through interosseous membrane -> to anterior leg
Descends – anterior surface, interosseous membrane (inferomedial direction)
Accompanied by venae comitantes (either side of artery)
61
anterior tibial a cont
```
o Branches:
1) Posterior tibial recurrent
• 1st branch (usually) of Anterior tibial a.
• Small, inconstant branch
• Origin: before – anterior tibial enters anterior crural compartment
• Joins genicular anastomosis
2) Anterior tibial recurrent
• Origin: close to entrance into anterior crural compartment
• Supplies anterior knee
• Joins genicular anastomosis
3) circumflex fibular
• Small
• Ramifies around neck of fibula
• Supplies:
o Soleus muscle
o Fibularis (peroneus) longus muscle
Note: some texts have this artery issuing from posterior tibial artery, occasionally anterior tibial artery. Laboratory experience, shows usual origin off anterior tibial artery (40% of cases) followed by posterior tibial artery (32% of cases).
```
62
anterior tibial a cont cont
4) Anterior medial malleolar
• Origin: anterior tibial a. – 5 cm proximal to ankle joint
• Course:
o Interomedially, across proximal extensor retinaculum
o Deep to extensor hallucis longus & tibialis anterior
o Ramifies around medial malleolus
Anastomoses with posterior tibial & medial plantar arteries
5) Anterior lateral malleolar
• Origin: lateral side, anterior tibial artery (close to origin of medial malleolar branch)
• Course: deep to tendons:
o Extensor digitorum longus
o Fibularis (peroneus) tertius
• Supplies lateral side of ankle joint
6) Muscular Arteries
• Supplies muscles of anterior & lateral compartments of leg
• Some branches travel deep – anastomose with posterior tibial
63
posterior tibial a
```
o Larger of two terminal branches of popliteal artery
o Origin: inferior border, popliteus muscle
o Course:
Deep throughout descent
• Posterior suface, tibialis posterior muscle
• with tibial nerve
• with venae comitantes
Deep to origin of soleus muscle – inferomedial direction
Ankle
• Posterior to medial malleoulus
o Separated from malleoulus by tendons:
Tibialis posterior
Flexor digitorum longus
• Inferior to medial malleoulus
o Between tendons
Flexor digitourm longus
Flexor hallucis longus
```
64
posterior tibial a cont
```
o Branches of posterior tibial artery:
1) Muscular
• Distribution to:
o Flexor hallucis longus
o Peroneus longus
o Peroneus brevis
o Tibialis posterior
o Soleus
2) Fibular (peroneal) artery
• Largest branch of posterior tibial
• Deep, fibular side, posterior leg
• Origin: posterior tibial a. 2cm distal to inferior border of popliteus m.
• Course: inferiorly along medial side of fibula
• Supplies:
o Nutrient branch to fibula
o Muscular branches:
Posterior leg compartment
Lateral leg compartment
o Communicating branch
Joins communicating branch of posterior tibial artery
• Posterior lateral malleolar branches
o Small branches
o Course towards lateral malleolus
o Help form lateral malleolar network
• Terminal Branches (posterior to tibiofibular articulation):
```
65
posterior tibial a cont cont
o Lateral calcaneal branches
Lateral side of heel
Anastomose with other heel branches
```
3) Nutrient artery to tibia
• One of first branches
• Largest nutrient artery of bone in the body
o Nutrient foramen
Immediately distal – soleal line (posterior proximal part of the tibia)
• Origin: just inferior to bifurcation of popliteal artery
4) Posterior medial malleolar
• Small vessel
• Course: towards medial malleolus
• Contributes to malleolar network
5) Communicating
• Course: deep to flexor hallucis longus
• Joins communicating branch of peroneal artery
6) Medial calcaneal
7) Medial Plantar
8) Lateral Plantar
9) Circumflex fibular
• Branch of anteiror tibial (usually)
```
66
leg lymphatics
• Numerous vessels and nodes
• Closely parallel veins of the leg
o Two systems of lymphatics (coincide with two systems of veins), superficial & deep
• Lymph Nodes
o Anterior tibial lymph node & popliteal lymph node
Where lymphatics of leg drain into
67
anterior tibial node
• Anterior Tibial Node
o Inconsistent
(when present) – Located within anterior compartment of leg
• Near interosseous membrane
• Inferior to the hiatus
o Where anterior tibial vessels pass through interosseous membrane
• Receives lymph vessels coursing with anterior tibial artery and vein
• Efferent vessels (from anterior tibial lymph node)
o Pass to popliteal group of lymph nodes
• If absent- anterior lymp vessels drain into popliteal
68
lymphatic vessels
```
o Course with blood vessels
o Lymphatic vessels begin as blind CAP
Vessels course towards nodes = afferent
Vessels leave lymp nodes = efferent
o Superficial lymphatic vessels
Course with superficial fascia
Parallel cutaneous veins only
Medial lymphatic vessels
• Course with great saphenous vein
• Drain medial side of foot
• End in lower group of superficial inguinal nodes
Lateral lymphatic vessels
• Course with small saphenous vein
• Drain lateral side of foot
• End in superficial popliteal lymph node (most)
o Some cross to medial side with great saphenous
o Deep lymphatic vessels
Course with both arteries and veins
• 1) anterior tibial
• 2) posterior tibial
• 3) peroneal
```
69
knee joint
```
• Largest joint in body
• Compound joint: 2 joints
o Condyles of tibia/femur – Condylar joints
10-12 degrees from midline
Exaggeration > genu valgum
o Patella & femur – Saddle/Sellar joint
• One synovial membrane
• One cavity
• Movement- Condyloid Joint
o Hinge
o Gliding
o Rotation
o Mechanically weak- gains strength from tendons
• Articular surfaces
o Lined with articular cartilage
o Tibia- flat articular surface
o Femoral- rounded
• Nerve supply:
o articular branches femoral
o obturator
o common peroneal
o tibial
```
70
knee joint cont
• Blood supply-
o genicular anastomosis from descending genicular branch of femoral
o genicular popliteal
o recurrent branches of anterior tibial
o descending branch lateral femoral circumflex A
o circumflex fibular A
• Ligaments of articularting bones
1. Articular capsule
o Anterior- incomplete
Replaced by medial/lateral retinacula of quadriceps tendon
o attached margins of articulating surface
o Lateral: tendon popliteus m perices
o Inner: synovial membrane
2. Quadriceps tendon
3. Patellar ligament
o Continuation quadriceps tendon
o Attaches tibial tuberosity
o Strong flat band anterior/inferior part of joint
o 8 cm long
o infrapatellar fat pad- Inferior surface separates synovial membrane
o Infrapatellar bursa- protects ligament from tibia
71
knee joint ligaments
4. Lateral collateral
o Strong round fibrous
o Lateral epicondle femur above groove poplieus m
o Head of fibula (lateral side)
o Covered tendon biceps femoris m – splits attach fibular head either side of LCL
o NOT attached to capsule or lateral meniscus
o Tendon of popliteus deep
o Separated from lateral meniscus by articular capsule & tendon popliteus
5. Anterolateral ligament
o Proximal attach- lateral femoral condyle anterior to proximal attached of LCL w/ connecting fibers between the two ligaments
o Oblique course
o Distal attach- anterolateral aspect tibia btwn Gerdy’s tubercle & apex of fibula
o Attach lateral meniscus
o Fxn: check internal rotation btwn 30-90 knee flexion
72
knee joint ligaments
6. Medial collateral
o Broad flat band 10 cm long
o Proximal- medial epicondyle femur below adductor tubercle
o Distal- medial surface tibia 2-3 cm long
o SGT cross it superiorly
o Attach medial meniscus
o Capsule below ligament
7. Oblique popliteal
o Strengthen knee joint posteriorly
o Expansion semimebranosus m
o Obliquely from medial condly tibia to lateral condyle of femur
o Floor popliteal fossa
o Perforated by medial genicular on way to knee joint
8. Arcuate popliteal
o Thickened capsular fibers over politeus tendon
o Course medially from lateral condyle tibia and head fibula to posterior intercondylar area of the tibia
73
anterior and posterior cruciates
9. Anterior cruciate
o Anterior intercondylar are tibia
o Travels superolateral
o Posterior meidal surface of lateral femoral condyle
o Fxn: prevent hyperextnsion of knee – prevent femur posterior sliding on tibia
10. Posterior cruciate
o Stronger & shorter
o Posterior intercondylar tibia
o Travels obliquely upward crossing ACL
o Attach medial condyle (lateral surface)
o Fxn: prent hyperfelxion of knee – prevent femur forward sliding on tibial plateau
74
menisci
o Semilunar fibrocartilage discs deepn cavity of tibial condyles
o Otuer border thicker than central area
o Central area in contact with femoral condyles
o Covers 2/3 condyle of tibia
o Peripheral attachment: fibrous capsule (Coronary Ligament)- holds menisci to tibial condyles
75
medial meniscus
o Semicircular
o Attached to tibia anterior to ACL at anterior intercondylar area
o Posterior attach posterior intercondylar area
76
lateral meniscus
12. Lateral meniscus
o Together curve= almost circular
o Tendon popliteus separates it from LCL
o Extends form anterior itnerconydlar area to posterior intercondylar area
o Anterior/Posterior meniscofemoral ligaments –
o Posterior side- 70% cases fibers extend to medial condyl of femur
13. Transverse Ligament
o Unites two meniscis anteriorly
77
superior tibiofibular joint
1. Fibular facet of lateral tibial condyle
2. Articular facet medial aspect head of fibula
• Facets circular shaped
• Size/direction variable
• Fibrous capsule thickend by ligamengs:
1. Anterior superior tibiofibular ligament
2. Posterior superior tibiofibular ligament
• PLANE synovial JOINT
78
distal tibiofibular joint
• SYNDESMOSIS, fibrous joint
1. Triangular surface of distal fibula (in the inferior interossesous border)
2. Distal end of tibia
Ligaments:
1. Interosseous tibiofibular ligament
o distal continuation of interosseous membrane
2. Anterior inferior tibiofibular ligament
o Triangular shape
o Directed inferolateral
3. Posterior inferior tibiofibular ligament
o Quadrangular shape
o Directed inferolateral
o Superificial
o Deep portion- contains fibrocartilage = inferior transverse ligament
o Forms socket talus
o Lateral malleolar fossa to margin of medial malleolus
79
hip to ankle
```
• Long Bones
o Femur (thigh bone), Tibia & Fibula (leg bones)
o All composed of 3 portions:
Proximal (upper) extremity
Shaft
Distal (lower) extremity
```
80
patella
o Sesamoid bone
| o Forms within tendon of quadriceps femoris muscle
81
femur
o 1) head
Ball-shaped
Articulates with hip bone (at acetabulum)
2/3rds spherical – covered by hyaline cartilage
• Exception at the pit (fovea) – attachment of ligament of the head of femur
Entirely lies in articular capsule of hip joint
o 2) neck
Joins head and shaft of bone
• Joins shaft at femoral angle of inclination
o Angle greatest at time of birth
o Sex & body size determine angle
o Adult males – 125 degrees
o Adult females – 105 degrees
Wider bony pelvis
• Projects anteriorly from shaft - 12 to 14 degrees angle (angle of declination)
82
femur cont
```
Hourglass shape – thinnest at middle
Two surfaces: anterior & posterior
• Anterior surface
o Entirely in joint capsule of hip joint
o Convex, superior to inferior
o Concave side to side
o Many small vascular foramina
o Intertrochanteric line
Between greater and lesser trochanters
Continuous inferiorly with spiral line
```
• Posterior Surface
o More curved (than anterior)
o Upper ½ to 2/3rds lies within joint capsule
o Lower portion
Grooved by tendon of obturator externus
o Fewer but larger vascular foramina (vs. anterior surface)
o Joins shaft of femur – at intertrochanteric crest
Ridge of bone between greater and lesser trochanters
83
femur cont cont
Two borders: superior & inferior
• Superior border
o Short, thick
o Courses horizontally – ends at greater trochanter
• Inferior border
o Long, thin
o Courses vertically – ends at lesser trochanter
84
greater trochanter
Large, irregular, quadrilateral-shaped prominence
Location: lateral end of superior border of neck
Projection: lateral & posterior
Two (2) surfaces: Lateral & medial
• Lateral Surface
o Larger
o Palpable
o quadrilateral shape
o Oblique bony ridge
insertion of Gluteus medius
divides lateral surface into 2 triangular areas
• Tochanteric bursae overlie each area
• Upper triangular area – bursae for gluteus medius
• Lower triangular area – bursae for gluteus maximus
85
greater trochanter cont
• Medial Surface
o Trochanteric fossa (major feature)
Depression for insertion of obturator externus
o Obturator internus tendon inserts anterior to trochanteric fossa
Superior and Inferior gemelli muscles terminate/insert into tendon of obturator internus
Four (4) borders: superior, inferior, anterior, posterior
• Superior border
o Piriformis insertion
• Anterior border
o Gluteus minimus insertion
• Inferior border
o Vastus lateralis (partial origin)
• Posterior border
o ONLY border or surface with NO muscular attachment
o Free rounded edge inferiorly
Blends with intertrochanteric crest
86
lesser trochanter
```
o 4) lesser trochanter
Location: medial, near junction of femoral neck & shaft
Directed posteromedially
Attachment: iliopsoas
• Major flexor at the hip
• Only attachment
• Psoas major – inserts at apex
• Iliacus – inserts at base & between spiral & pectineal lines
```
87
intertrochanteric line
```
Anterior
Between greater and lesser trochanters
At junction of neck and shaft
3 Attachments:
• 1) iliofemoral ligament (part of fibrous capsule of hip)
• 2) vastus lateralis (partial origin)
• 3) vastus medialis (partial origin)
```
88
intertrochanteric crest
Intertrochanteric crest
Posterior
Between greater & lesser trochanters
Hip joint capsule – not attached to this crest
Quadrate tubercle
• Mid intertrochanteric location
• Site of insertion of quadratus femoris muscle
• Note: at times a (quadrate) line is present instead of a tubercle.
• Extends vertically – 5cm
• Superior extent located along intertrochanteric crest
89
femur shaft
o 3 borders: medial, lateral, and posterior
Medial and lateral – rough, poorly defined
Posterior border
• Linea aspera (major feature)
o Latin “rough line”
o Crest, posterior border, middle 1/3 of femur
o 2 lips: medial and lateral, rough intermediate area
• Superiorly linea aspera joined by 3 lines/ridges: spiral line, pectineal line, lateral line
90
femur shaft cont
o Spiral line (superior line/ridge)
Joins linea aspera
Medial line
proximally – continuous with intertrochanteric line
Hint: “Spirals medially up”
distally – continuous with linea aspera
o Pectineal line
Intermediate line
Proximally – ends at lesser trochanter
Distally – continuous with medial lip (linea aspera)
Insertion of pectineus muscle
o Lateral line
Extends from greater trochanter to lateral lip (linea aspera)
Extends almost vertically
Gluteal tuberosity located here
• Partial insertion of gluteus maximus (also inserts on iliotibial band)
91
posterior femur
• 1) Vastus medialis
o Medial lip, linea aspera (partial origin)
• 2) Iliacus
o Superiorly insert
o between adductor mangus & vastus medialis
• 3) Pectineus
o Superiorly insert
o between adductor mangus & vastus medialis
• 4) Adductor brevis
o Linea aspera insertion (superior to adductor longus)
o between adductor mangus & vastus medialis
• 5) Adductor longus
o Linea aspera insertion (inferior to adductor brevis)
o between adductor mangus & vastus medialis
92
posterior femur cont
• 6) Adductor magnus
o Linea aspera (extensive insertion)
o Gluteal tuberosity (superior – partial insertion)
o Lateral line (partial insertion)
o Lateral lip, linea aspera (partial insertion)
o Medial lip, linea aspera (lower fiber insertion)
o Medial supracondylar line (lower fiber insertion)
o Adductor tubercle (lower fiber insertion)
• 7) Gluteus maximus
o Gluteal tuberosity (superior – partial insertion)
• 8) Biceps femoris, short head
o Inferior to attachment of gluteus maximus
• 9) Vastus Lateralis
o Lateral lip, linea aspera (partial origin)
o Greater trochanter (small origin)
93
inferior posterior femur
• Lateral lip & medial lip (of linea aspera)
o Diverge as lateral & medial supracondylar lines (ridges)
Lateral supracondylar ridge
• More distinct
• Extends towards lateral epicondyle
Medial supracondylar ridge
• Ends at adductor tubercle
• Smooth, just proximal to adductor hiatus
o location femoral vessels pass to popliteal fossa
Form a triangular area – popliteal surface of the femur
94
anterior femur
```
• Smooth, convex
• Lies between medial and lateral borders
• Attachments:
o Vastus intermedius
Upper 2/3rd
o Articularis genu muscle
Distal attachment
Femur may be roughened, several small slips for origin
```
95
medial and lateral femoral condyles
o Major features of distal extremity
o Lateral condyle – more pronounced, broader
o Medial condyle – longer (starts at adductor tubercle)
o Articulations (both medial and lateral condyles)
Posterior surface of patella
Respective condyle of tibia
Large, rounded condyles, knob-like
• Project further posterior than anterior
o Lateral and medial sulci menisci
Groove (sulcus) on each condyle
Separate patellar and tibial surfaces of femoral condyles
Lateral sulcus menisci
• Completely separates patellar surface (lateral femoral condyle) from tibial surface
Medial sulcus menisci
• Deficient laterally (where tibial & patellar surfaces are continuous)
96
posterior inferior femur
o Intercondylar notch (intercondylar fossa) – separates femoral condyles posteriorly
Intercondylar line – serves as posterior boundary of the notch
• forms base of popliteal surface of femur
Attachments:
• Anterior cruciate ligament
o Medial surface of lateral condyle
o Posterior attachment on femur
• Posterior cruciate ligament
o Lateral surface of medial condyle
o Anterior attachment on femur
• Meniscofemoral ligament(s)
97
epicondyles
```
o Medial and Lateral epicondyles
Lie above respective condyles
Medial epicondyle
• Larger, palpable
• Just below adductor tubercle
o palpable
o Attachment:
adductor magnus tendon
• Attachment:
o Tibial (medial) collateral ligament (of knee joint)
o medial head of gastrocnemius muscle (just posterior to adductor tubercle)
```
98
lateral epicondyle
• Palpable
• Attachment: Fibular (lateral) collateral ligament (knee joint)
• Two grooves – Lower portion of epicondyle (for popliteus tendon which shifts with knee movement)
o Oblique groove – flexed knee
o Vertical (anterior) groove – extended knee
99
femoral arterial supply
o Extensive (largest bone of the body)
o Proximal extremity feeders:
1) obturator
• Branch of obturator
o Courses within ligament of head of femur
o Supplies femoral head
o Important in infants, children, teens during ossification of femur
o Unimportant in adults (medial femoral circumflex is the main supply in adults)
2) medial femoral circumflex- (branch profunda femoris)
• Major supply to femoral head in adults
• Enters at neck of femur
3) lateral femoral circumflex – enters at neck
4) inferior gluteal – enters at neck
5) first perforating – enters at neck
100
femoral shaft feeders
Nutrient artery – branch of second perforating artery
• Nutrient canal: posterior, upper end of linea aspera
o Directed obliquely upward
Away from growing end of bone during development
Note: for all long bones, nutrient canal is directed obliquely away from the growing end of the bone.
o Distal extremity feeders:
1) superior lateral genicular artery
2) superior medial genicular artery
3) descending genicular artery
4) descending branch of lateral femoral circumflex artery
101
patella
Sesamoid bone – forms in quadratus femorus tendon
o Largest sesamoid in the body
• Articulates with the femur (part of knee joint)
• Triangular shaped
o Apex – inferiorly directed
• Three borders: (4 muscular attachments)
o Superior (base; thickest)
Rectus femoris
Vastus intermedius
Vastus lateralis (lateral superior portion)
o Medial
Vastus medialis
o Lateral
Vastus lateralis
102
patella surfaces
```
• Two surfaces:
o Anterior
Convex
Longitudinal stria
• Attachment: quadratus tendon
Small nutrient foramina
o Posterior
Articulates with the femur (part of knee joint)
Upper 4/5th
• Smooth, oval shaped
• Vertical ridge
o Articulates with intercondylar groove of femur
o Separates two patellar facets
```
103
patella cont
• (2) patellar facets
o Covered by hyaline cartilage
o Articulate with femur as part of knee joint
o Larger lateral facet (also deeper, more concave)
Lower 1/5th
• Roughened, attachment: patellar ligament
• Nutrient foramen
• Arterial Supply
o Branches of genicular arteries (supplying quadriceps tendon)
• Petallar Ossification
o Variable number of centers – appear from 3-6 years; additional in later childhood
o Ossification complete around time of puberty
104
subcutaneous fascia
```
o Covers entire thigh
o Continuous w/subcutaneous fascia of entire anterior abdominal wall, gluteal region, leg
o Divided into Two Layers:
Superificial (fatty)
Deep (membranous)
• Attachments:
o fascia lata
Distal to inguinal ligament
Along upper medial area of the thigh
o Saphenous opening (fossa ovalis)
Fills opening with fascia cribrosa
Superifical vessels & nerves, inguinal lymph nodes, great saphenous vein found between layers
Large bursa found in subcutaneous fascia over the patella
```
105
fascia lata
```
o External layer of investing fascia of thigh
o Thick laterally
o Thin medially
Attachment:
• Ischial tuberosity
• Ischiopubic ramus
• External perineal fascia
```
106
fascia lata cont
```
o Continuous with:
Proximally:
• thoracolumbar
• external abdominal fasciae
Distally:
o investing fascia of leg
o Anterior part
Attachment:
• Pubic tubercle
• Anterior superior iliac spine
• Inguinal ligament
o Over femoral vessels
Thickened opening (saphenous opening (fossa ovalis))
• Passage of great saphenous vein
• Falciform margin – free lateral margin of opening
• Lateral part – very thick & buttressed by tendons:
o Gluteus maximus
o Tensor fasciae latae
• Superior attachment:
o Crest of ilium
o Dorsal sacrum
```
107
fascia lata cont cont
o Iliotibial band
Thickened tendon – within fascia lata on lateral thigh
Tensor fasciae latae muscle
• found between 2 layers of fascia lata laterally
o Posteriorly
Formed by fusion of two layers of gluteal fascia
Lateral & medial intermuscular septa
• Connect under surface of fascia lata with linea aspera
• Divide thigh into 3 myofacial compartments
108
sartorius
• Longest muscle in the body
Hint: “Sartorius is natorius for being the longest”
• Descends lateral to medial across the thigh
• Forms roof of adductor (subsartorial) canal & lateral border of femoral triangle
• Origin:
o Anterior superior iliac spine + inferior notch (below the spine)
• Insertion:
o Pes anserinus (proximal part of medial surface of body of the tibia)
In common with gracilis & semitendinosis (Hint: “SGT”superior to inferior)
• Course:
o Obliquely (lateral to medial) across upper thigh -> then descends nearly vertically to its insertion
• Nerve Supply:
o Femoral nerve (anterior compartment nerve)
• Functions:
o Flexion of hip
o Abduction of hip
o Lateral rotation of hip
o Flexion of knee
o Medial rotation of leg (from flexed position)
109
quadriceps femoris
• Consists of four thigh muscles
• Each muscle with unique origin
• Each muscle converges at a common insertion (tibial tuberosity via patellar ligament)
Note: Relationship between quadriceps tendon and patella. If the petalla is considered a sesamoid bone in quadriceps tendon, then proper tendon insertion is the “patellar ligament” (continues to tibial tuberosity). If the patella is not considered a sesamoid bone then the muscle can be thought to insert into the patella. Regardless the definition of insertion, the primary function is extension of the knee and hence the ultimate insertion of the group of muscles is the tibial tuberosity.
• Nerve Supply:
o Femoral nerve
• Functions:
o Extension of the knee
o Note: rectus femoris also assists in flexion of the hip due to origin & insertion
110
rectus femoris
o Two tendons
Straight (anterior) tendon – anterior inferior iliac spine
Reflected (posterior) tendon – groove above acetabulum
o Tendons merge & form broad aponeurosis on ventral surface of muscle
o Fibers of muscle arise from the aponeurosis
```
• Insertion:
o Base (superior border) of patella - through thick aponeurotic tendon to patellar ligament to tibial tuberosity
```
111
vastus lateralis
```
• Origin:
o Lateral lip linea aspera
o Lateral lip gluteal tuberosity
o Anterior & inferior borders of greater trochanter
o Proximal intertrochanteric line
• Insertion:
o Lateral border of patella
o Tendon of quadriceps femoris (patellar ligament to tibial tuberosity)
```
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vastus medialis
```
• Origin:
o Distal intertrochanteric line
o Medial intermuscular septum
o Tendons of adductor longus & magnus
o Proximal medial supracondylar line
o Medial lip of linea aspera
• Insertion:
o Medial border of patella
o Tendon of quadriceps femoris
(patellar ligament to tibial tuberosity)
```
113
vastus intermedius
• Origin:
o Proximal 2/3, anterior surface of femur
o Proximal 2/3, lateral surface of femur
• Insertion:
o Quadriceps tendon (patellar ligament to tibial tuberosity)
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articularis genu
```
• Small muscle located deep to vastus intermedius
• Origin:
o Anterior surface, distal femur
• Insertion:
o Synovial membrane of knee joint
• Nerve Supply:
o Femoral nerve
• Function:
o Draw synovium proximally
```
115
gracilis
• Thin muscle located superficially on medial thigh
• Origin:
o Pubic symphysis – inferior ½
o Pubic body
o Pubic arch (inferior pubic ramus) – superior ½
• Insertion:
o Pes anserinus (Proximal part, medial surface – tibia)
Note: In common with Sartorius and semitendinosus(SGT)
• Nerve Supply:
o Anterior division of obturator nerve
• Functions:
o Flexion at knee
o Adduction of hip
o Medial rotation of hip
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pectineus
• Origin:
o Pectin pubis
o Bone anterior to pectin pubis
Between pubic tubercle & iliopectineal eminence
• Insertion:
o Petineal line (between lesser trochanter & linea aspera)
• Nerve Supply:
o Femoral nerve
o Accessory obturator (if present, supplies a branch)
o Note: obturator nerve may also provide a branch
• Functions:
o Flexion at hip
o Adduction at hip
o Medial rotation at hip
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adductor longus
```
• Most anterior adductor muscle
• Origin:
o Pubic body (anterior)
• Insertion:
o Medial lip (linea aspera)
Between attachments of vastus medialis & adductor magnus
• Functions:
o Flexion at hip
o Adduction at hip
• Nerve Supply:
o Anterior branch of obturator nerve
```
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adductor brevis
```
• Just posterior to adductor longus
• Divisions of obturator (anterior & posterior) divide to surround the muscle
• Origin:
o Pubic body
o Inferior pubic ramus
Between gracilis & obturator externus
• Insertion:
o Linea aspera (proximal part)
• Nerve Supply:
o Obturator nerve (anterior division usually)
• Functions:
o Flexion at hip
o Adduction at hip
```
119
adductor magnus
```
• Largest of adductors
• Deep to adductor brevis
• Upper fibers – nearly horizontal
• Lower fibers – nearly vertical
• 5 openings in the muscle (typically)
o (4) for the passage of perforating branches of deep femoral artery
o Adductor hiatus (hiatus tendineus) – Most distal, largest opening
Passage of femoral vessels to popliteal fossa
• Origin:
o Inferior pubic ramus
o Ramus of ischium
o Ischial tuberosity (triangular region)
• Insertion:
o Gluteal tuberosity (line)
o Linea aspera
o Medial supracondylar line
o Adductor tubercle of femur
• Nerve Supply:
o Posterior division, obturator nerve
o Tibial portion, sciatic nerve
• Functions:
o Flexion of hip
o Adduction of hip
o Extension of hip
o Note: all possible because of different orientation of fibers. Additional controversial function of possible rotation of hip.
```
120
hamstring
• 3 components:
o Biceps femoris – found laterally, 2 heads (posterior compartment)
o Semitendinosus – found medially (posterior compartment)
o Semimembranosus – found medially (posterior compartment)
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biceps femoris
```
• Origin:
o Long head –
posterior part of ischial tuberosity
• Below oblique line
Common tendon with semitendinosus & sacrotuberous ligament
```
o Short head –
lateral lip (linea aspera)
• Between adductor magnus & vastus lateralis muscles
Lateral supracondylar line (femur)
Lateral intermuscular septum
• Insertion:
o Long head – pass obliquely/laterally across sciatic nerve
Aponeurosis (overlies the muscle)
• Narrows into tendon – inserts into:
o lateral side of styloid process (head of fibula)
o head of fibula
o lateral condyle of tibia
• tendon surrounds fibular collateral ligament
• common fibular nerve follows it’s medial border
o Short head – overlying aponeurosis
• Nerve Supply:
o Long head – tibial portion of sciatic nerve
o Short head – common fibular portion of sciatic nerve
• Functions:
o Both heads – Flexion of knee
o Both heads – Rotation, laterally (from flexed position)
o Long head:
Extension at hip
Rotation, laterally at hip
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semitendinosus
• Origin:
o Posterior ischial tuberosity (with long head of biceps femoris)
Below oblique line
With substantial aponeurosis – connecting two muscles (about 8cm from origin)
• Insertion:
o Long tendon (begins mid-thigh)
Lies medial border of popliteal fossa
Curves around medial condyle of tibia
Over tibial collateral ligament (usually intervening bursa)
o Pes anserinua (Inserts into proimal part, medial surface of tibia)
• Nerve Supply:
o Tibial portion of sciatic nerve
• Functions:
o Flexion of knee
o Medial rotation of knee (from full flexion)
o Extension at hip
123
semimembranosus
• Origin:
o Oblique line of ischial tuberosity – Upper/outer portion
Above semitendinosus & biceps femoris
o Aponeurotic expansion (tendon of origin)
• Insertion:
o Medial condyle (tibia) – Groove, medial surface
o Lateral condyle (femur) – posterior surface
o Fascia – covering popliteal muscle
o Fibers proceed superolaterally – forms oblique popliteal ligament
• Nerve Supply:
o Tibial portion of sciatic nerve
• Functions:
o Flexion of knee
o Medial rotation of knee (from full flexion)
o Extension at hip
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genitofemoral n
```
• Femoral branch (L1, 2)
o Lateral to genital branch
o Passes deep to inguinal ligament (
with eternal iliac/femoral artery
• lateral compartment of femoral sheath
o supplies skin on proximal, anterior surface of thigh
o Lays on top of Psoas Major
```
125
lateral femoral cutaneous
• (L2, 3)
• First appearance – middle, lateral border, psoas major
• Passes:
o over iliacus – toward anterior superior iliac spine
o under inguinal ligament
o over Sartorius muscle
• divides:
o Anterior branch
Supplies skin over lateral & anterior thigh
o Posterior branch
Supplies skin of lateral thigh (greater trochanter to mid-thigh)
126
obturator n
```
• (L2, 3, 4)
• Emerges into medial compartment of thigh – through obturator canal
o Divides into two branches:
Anterior (superficial) branch
• Anterior to adductor brevis
• Communicates with accessory obturator (when present)
• Passes over obturator externus
o Deep to pectineus & adductor longus
o Superficial to adductor brevis
• Articular branch to hip joint
• Musclular branches to:
o Adductor longus
o Gracilis
o Adductor brevis (sometimes)
o Pectineus – motor (rarely)
• cutaneous branches (when present) – skin on medial thigh, just above knee
Posterior (deep) branch
• Posterior to adductor brevis
• Anterior to adductor magnus
• Articular branch to knee joint
• Muscular branches:
o Obturator externus- goes through it
o Adductor magnus
o Adductor brevis (sometimes)
```
127
accessory obturator n
```
• (L3, 4)
• Present 10% of cases
• Passes deep to pectineus
o Sends muscular branch to pectineus
• Articular branch to hip joint (potential)
```
128
femoral n
```
• (L2, 3, 4)
• Passes under inguinal ligament (lateral to femoral artery)
• Lies OUTSIDE femoral sheath
• Immediately entering thigh divides:
o Cutaneous branches
Anterior femoral cutaneous branch
• Medial femoral cutaneous branch
o Skin of medial thigh, distally to leg
• Intermediate femoral cutaneous branch
o Skin of anterior thigh
o Muscular branches
All muscles of anterior compartment
• Sartorius
• Quadratus femoris (rectus femoris, vastus medialis, vastus lateralis, vastus intermedius)
• Articularis genu
Pectineus (sometimes)
```
129
saphenous n
• Longest branch of femoral nerve
• Enters adductor canal (with femoral artery)
o Crosses lateral to medial in canal – over artery
o Leaves canal – passes to medial side of knee
Does NOT pass through adductor hiatus
• Superficial – passes between tendons of Sartorius & gracilis muscles
• Runs with great saphenous vein (medial side of leg)
• Proximal 1/3 of leg, divides:
o 1) subsartorial nerve plexus contribution
o 2) infrapatellar branch (cutaneous innervation to skin over patella)
• Distal 1/3 of leg, divides (terminal branches):
o 1) skin supply:
anterior & medial side of leg
Ends at the ankle
o 2) medial side of foot
As far as ball of the foot
130
subsartorial nerve plexus
```
• Inferior margin adductor longus
• Deep to Sartorius muscle
• Formed by communications:
o Anterior branch of obturator
o Saphenous
o Medial femoral cutaneous nerves
```
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sciatic nerve
```
• Largest branch of sacral plexus
• Largest nerve in the body
• (L4-S3)
o Anterior divisions (L4-S3)
o Posterior divisions (L4-S2)
• Supplies:
o Posterior compartment muscles (thigh)
o ALL muscles of leg and foot
o Skin of foot
o Skin of leg (most)
o ALL joints of lower extremity
• Anatomically one nerve
• Physiologically two nerves (wrapped together in single connective tissue sheath)
Note: both nerves have separate origins from sacral plexus. Fibers do not mix while traveling together
o Splits as passes into distal 1/3, posterior thigh (as emerges from beneath long head, biceps femoris)
```
132
tibial n
Anterior divisions (L4-S3)
133
common peroneal n
Posterior divisions (L4-S2)… Two words, stops at S2
134
femoral artery 1
1) superficial epigastric
• Small vessel
• First branch of femoral
• Originates 1 cm inferior to inguinal ligament
• Course:
o Passes through femoral sheath
o Proceeds superiorly, anterior to inguinal ligament
o Superficial epigastric vein (medial to artery)
o Terminates: anastomosing with superficial epigastric & inferior epigastric artery
• Supplies – anterior abdominal wall (below umbilicus)
o Skin
o Superficial fascia
2) superficial circumflex iliac
• Smallest branch
• Originates: anterlolateral aspect of femoral a. – slightly below superficial epigastric
• Course:
o Travels laterally – parallels inguinal ligmanet
To iliac crest
• Anastomoses with:
o Deep circumflex iliac
o Superior gluteal
o Lateral femoral circumflex
135
femoral artery 2
```
3) superficial external pudendal
• Originates: medial side of femoral
o Across from origin of superficial circumflex iliac
• Course:
o Trevels medially
Crosses spermatic cord
Supplies perineal structures
Supplies lower abdominal wall
Anastomoses with branches of internal pudendal artery
```
4) Deep external pudendal (see “Pelvis and Gluteal Region”)
136
femoral a 3
5) Muscular branches
• Branches originate directly from the femoral:
o Vastus medialis
o Sartorius
o Adductor muscles
6) Profundus femoris (deep femoral)
• Largest branch
• 2-5 cm distal to inguinal ligament
• Origination: lateral aspect – femoral artery
• Course:
o Travels inferiorly – spirals posterior to femoral artery – then along medial side
o Lower 1/3 of thigh
Posterior to adductor longus
o Terminates – small branch, entering adductor magnus muscle
Known as fourth perforating artery
137
profundus femoris 1
• Branches:
o Lateral femoral circumflex
Origin: lateral side of profundus femoris
Note: 20% of time originates from stem of femoral artery
Course: laterally – deep to rectus femoris & sartorius muscles
(3) branches:
• 1) Ascending branch
o Travels superolaterally deep to fascia lata
o Lateral side of upper thigh
o Anastomoses – branches of superior gluteal & deep circumflex iliac arteris
• 2) Transverse branch
o Smallest branch
o Travels laterally around femur inferior to greater trochanter
o Pierces vastus lateralis
o Posterior aspect of thigh
o Posterior aspect of thigh - Participates in cruciate anastomosis, with:
Femoral circumflex
Inferior gluteal
First perforating artery
Hint: together with Transverse branch, first letter spell “FFIT” circumflex
• 3) Descending branch
o Courses inferlorly – below rectus femoris
o Supplies vastus lateralis muscle
o Reaches knee joint
Anastomoses with - lateral genicular branch of popliteal a.
138
profundus femoris 2
o Medial femoral circumflex
Origin: medial aspect of profundus femoris
25% of cases – originates directly from femoral artery
Medially disappears between pectineus & psoas major muscles
Winds around medial aspect of femur
Supplies:
• Adductor muscles
• Gracilis
• Obturator externus
Contributes to cruciate anastmoses along with:
• Inferior gluteal
• Transverse branch of lateral femoral circumflex
• 1st perforating artery
Acetabular branch
• Arises posterior to acetabular notch
• Enters acetabulum w/ acetabular branch of obturator artery
• Supplies:
o fat in acetabular fossa
o head of femur (traveling in the round ligament)
139
profundus femoris 3
```
o Perforating (4)
(3) originate from profunda femoris
(1) is terminating branch of profunda femoris
Perforate through adductor magnus to reach posterior thigh
First Perforating
• Superior to adductor brevis
Second Perforating
• Anterior to adductor brevis
• Gives off nutrient artery to femur
Third Perforating
• Distal to adductor brevis
Anastomose with each other
Supply:
• Adductor magnus (which they pierce through)
• Posterior thigh muscles
o Muscular branches
Many terminate in adductor muscles
Others supply posterior thigh
```
140
popliteal a
o Femoral changes name to popliteal –
once it exits adductor hiatus
• entering popliteal fossa
o courses (inferiorly) floor of popliteal fossa
o crosses knee joing –
lies in intercondylar fossa
• deep to vein – throughout its course in the fossa
o both vessels enclosed in a dense connective tissue sheath
• anteriorly – lies against capsule of the joint
• Posteriorly – deep to:
o semimembranosus muscle
o popliteal vein
o tibial nerve
o gastrocnemius muscle
141
popliteal a cont
o Branches in the thigh:
Muscular (2 or 3 at proximal end)
• Supply:
o Adductor magnus (lower ends)
o Hamstring muscles
Medial superior genicular
Lateral superior geniuclar
Sural (medial & latera)
• Originate from popliteal artery (at knee joint)
• Distributed to:
o Gastrocnemius (triceps surae)
o Soleus (triceps surae)
o Plantaris
o Branches to knee joint
Genicular arteries
• (5) total given off by poplite al artery
o (2) superior genicular arteries
Medial & lateral sides of popliteal artery
Wind around superior aspect of femoral condyles
• Reach anterior side of knee
• Help form collateral circulation of knee
Both give off two branches:
• Superficial branch
o Supplies muscles
• Deep branch
o Supplies knee joint
o (1) middle genicular artery
Small vessel
Originates from popliteal artery – opposite the knee joint
Enters knee to supply ligaments & synovial membrane (interior of joint)
o (2) inferior genicular arteries (medial & lateral)
Originate: popliteal – distal to knee joint
“see leg portion of outline”
142
popliteal cont cont
o Popliteal – terminates at inferior border of popliteus muscle
divides into two terminal branches:
• anterior tibial artery
• posterior tibial artery
143
superficial veins 1
o Great Saphenous Vein
Level of knee joint
• Courses posteriorly – passes behind medial condyles of tibia & femur
• Enters medial distal end of thigh
Course:
• Superiorly, gradually reaching anterior midline of thigh (3 cm inferior to inguinal ligament)
• Passes through saphenous hiatus
• Enters femoral sheath
• Opens into femoral vein
Review: behind medial condyles -> saphenous hiatus -> femoral sheath
-> femoral vein
Superficial group inguinal lymph nodes – surround proximal end
144
superficial veins 2
Cribriform fascia (continuation of superficial fascia)
• Covers saphenous opening
o Borders (superior, lateral, & inferior) form a sharp edge = Falcform margin
o Superficial epigastric & superficial external pudendal arteries
Contents of saphenous opening
Emerge through opening
Supply superficial structures
Corresponding veins – drain into great saphenous (before it enters saphenous opening)
o Great saphenous receives following before entering canal:
Accessory saphenous vein
• Formed by superifical venis along medial and posterior aspect of thigh uniting
• Drains into great saphenous
Superficial external pudendal vein
Superifical circumflex iliac vein
Superficial epigastric vein
145
deep veins
o Popliteal vein
Distal border of popliteus muscle – anterior & posterior tibial veins join to form popliteal vein
Ascends into popliteal fossa
• Accompanies the artery
o Inferior fossa – vein lies medial
o Superior fossa – vein lies superficial to artery
• Exits popliteal fossa – by passing through adductor hiatus
Tributaries correspond to branches of popliteal artery
Receives from small sapnenous vein
146
varicose veins
Discussion on Varicose Veins: superificial veins of the lower limb are involved in becoming vicose. Affected veins become dialated & tortous (producing pain & possible ulcer formation) due to overextension from accumulation of blood. Not massaged by muscle like the deeper veins. Blood usually shunted to deep veins – through small connecting veins (perforating veins). Valve arrangement only lets blood go from superficial to deep veins. When varicose, some can allow blood to pass from deep to superficial veins – through incompetent valves
147
femoral vein
Largest vein of thigh
Superior continuation of popliteal vein (at adductor hiatus)
Ascends into adductor canal
• Lies posterolateral to femoral artery
• Proximal end
o Enters apex of femoral triangle
Ascends from posterior side of artery to medial side
Inferior to inguinal ligament
• Occupies intermediate compartment of femoral sheath
Crosses inguinal ligament
• Becomes external iliac vein
Usually 4-5 valvaes in femoral vein
• One usually located inferio r to entrance of deep femoral vein
One of largest tributaries = deep femoral vein (profunda femoris)
• Formed by Junction of the 3 or 4 perforating veins
Also drains into interior gluteal vein (anastomotic channel between femoral and internal iliac veins)
3 cm inferior to inguinal ligament – receives largest tributary, great saphenous vein
Medial & lateral femoral circumflex veins – drain into either femoral or deep femoral vein
148
popliteal nodes 1
• 6 or 7 located in the popliteal fossa
• Subdivided into three groups related to popliteal blood supply (popliteal vein (posterior) vs. popliteal artery (anterior))
o 1) one node lies anterior (deep) to popliteal artery
Receives lymph from inside knee joint
o 2) one node lies posterior (superficial) to popliteal vein
Receives lympathics that course with small (short) saphenous vein)
o 3) 4 or 5 nodes lie within fat (lateral and medial sides of popliteal vessels)
Receive lymphatic vessels coursing with:
• anterior tibial blood vessels
• posterior tibial
• peroneal blood vessels
• Efferent lymphatic vessels
o Follow femoral vein -> femoral triangle -> deep inguinal lymph nodes
o Few vessels: course with great saphenous vein -> lower group superficial inguinal nodes
• Major & largest group of lymph nodes
• Receive lymphatic vessels from:
o Lower anterior abdominal wall
o Perineum
o Lower limb
• 2 major groups:
o 1) superifical
Within superficial fascia
o 2) deep
Lie deep to deep fascia (fascia lata)
Within femorl sheath
