Lower Limb, Gluteal Region, Hip Joint Flashcards by Pamela Panahon

Lower Extremities vs Upper Extremities

Upper extremity
- Non-weight bearing
- Highly mobile
Lower extremities
- Weight bearing
- Standing/walking = locomotion
- Anti-gravity
  - Ie Gravity causes excess flexion at the knee > quadriceps (extensor) resist
- Very stable > strong ligaments and muscles

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Lower Limb Rotation and Compartments

All limbs same position > palms/soles anterior, thumbs/toes superior
6-8^th week > rotation
- Upper limbs rotate laterally > elbow posterior, thumbs lateral
- Lower limbs rrotate medially >.knees anterior, toes medial
Muscle mass
- Muscle masses migrate with innervation into the limb
- Ventral muscle mass = flexors
  - Upper limbs: ventral muscle mass > anatomically anterior
  - Lower limbs: ventral muscles mass > anatomically posterior
- Dorsal muscle mass = extensors
  - Upper limbs: dorsal muscle mass > anatomically posterior
  - Lower limbs: dorsal muscle mass > anatomically anterior

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Innervation of the Lower Limb

Collateral Nerves

Terminal Nerves

Lumbosacral plexus > innervation to the lower limb
Union of lumbar plexus and sacral plexus by lumbosacral trunk
L2-L3 ventral rami > anterior/posterior divisions > collateral/terminal nerves
- Posterior division nerve fibers innervate anterior compartment muscles
- Anterior division nerve fibers innervate posterior compartment muscles
Sciatic > splits at knee > tibial and common fibular
Proximo-distal gradient
- Superior rami innervate proximal muscles
- Interior rami innervate distal muscles

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Innervation of the Lower Limb

Collateral Nerves

Terminal Nerves

Lumbosacral plexus > innervation to the lower limb
Union of lumbar plexus and sacral plexus by lumbosacral trunk
L2-L3 ventral rami > anterior/posterior divisions > collateral/terminal nerves
- Posterior division nerve fibers innervate anterior compartment muscles
- Anterior division nerve fibers innervate posterior compartment muscles
Sciatic > splits at knee > tibial and common fibular
Proximo-distal gradient
- Superior rami innervate proximal muscles
- Interior rami innervate distal muscles

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Innervation of the Lower Limb: Dermatomes

Lumbosacral plexus > innervation to the lower limb
Union of lumbar plexus and sacral plexus by lumbosacral trunk
L2-L3 ventral rami > anterior/posterior divisions > collateral/terminal nerves
- Posterior division nerve fibers innervate anterior compartment muscles
- Anterior division nerve fibers innervate posterior compartment muscles
Sciatic > splits at knee > tibial and common fibular
Proximo-distal gradient
- Superior rami innervate proximal muscles
- Interior rami innervate distal muscles

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Arteries of the Lower Limb

Internal iliac > gluteal region
Femoral artery > rest of lower limb
Internal iliac and femoral artery anastomose at the cruciate anastomosis (cross-shaped)
- Inferior gluteal artery
- Medial femoral circumflex artery
- Lateral femoral circumflex artery
- 1^st perforating artery
Know:
- Hip – femoral and internal iliac
- Thigh – deep femoral (like produnda brachii)
- Knee – popliteal
- Leg – anterior/posterior tibial
- Foot – plantar arches

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Venous Drainage of the Lower Limb

All veins drain into:
- Femoral vein
- Iliac vein
Muscular venous pump system
- Relaxation > superficial > perforating veins (no backflow) > deep veins > contraction > superiorly
- Great saphenous vein (analogous to the great saphenous)
  - Superficial vein
  - Used as a graft in CABG > invert bc of valves
  - Distally: anterior to the medial malleolus
- DVT
  - Forms in deep vein (usually calf or thigh)
  - Can lead to pulmonary emboli
  - IVC filter for PE prevention

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Lymphatic Drainage of the Lower Limb

Superficial (vertical) inguinal node
Deep inguinal node
Popliteal node
Superficial lymphatics > superficial inguinal node or popliteal node > deep inguinal node > external iliac node

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Hip: Pelvis Bone

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Hip: Pelvis Bone Ligaments

Ischial spine= landmark

Obturator canal > obturator AVN

Sacrotuberous Ligament

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Hip: Femur Bone

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Gluteal Region

4 functional groups
- Hip abductors (Superior gluteal nerve)
- Medial rotators (Superior gluteal nerve)
- Lateral rotators (Superior gluteal nerve)
- Extensors (Inferior gluteal nerve)

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Gluteal Region

4 functional groups
- Hip abductors (Superior gluteal nerve)
- Medial rotators (Superior gluteal nerve)
- Lateral rotators (Superior gluteal nerve)
- Extensors (Inferior gluteal nerve)

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Gluteal Region

4 functional groups
- Hip abductors (Superior gluteal nerve)
- Medial rotators (Superior gluteal nerve)
- Lateral rotators (Superior gluteal nerve)
- Extensors (Inferior gluteal nerve)

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Gluteal Region

4 functional groups
- Hip abductors (Superior gluteal nerve)
- Medial rotators (Superior gluteal nerve)
- Lateral rotators (Superior gluteal nerve)
- Extensors (Inferior gluteal nerve)

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Gluteal Region: Blood supply

Superior gluteal artery
Inferior gluteal artery
Branches of the internal iliac
At hip > cruciate anastomosis
- Femoral artery and iliac artery anastomose
- Medial circumflex femoral artery
- Lateral circumflex femoral artery
- 1^st perforating artery
- Inferior gluteal artery

Gluteal Region: Clinical considerations

Sciatic nerve variations
- Piriformis syndrome
  - Piriformis compresses sciatic nerve at the greater sciatic foramen
  - Normal: Common fibular nerve inferior to piriformis
  - Abnormal: Common fibular nerve through/superior to piriformis
  - Pain radiating down the limb > muscle weakness
- Intragluteal injections risk

Hip Joint

Ball and socket
Synovial
Head of femur and acetabulum of coxal bone (bony pelvis)
Stabilized by:
- Deep bony socket
- Fibrocartilagenous acetabular labrum
- Extrascapular ligaments (resist hyperextention)
  - Iliofemoral - strongest
  - Ischiofemoral
  - Pubofemoral
  - Round ligament of the femus = intrascapular
    - Contains foveal artery
Strong muscles

Hip: Center of Gravity

Hip Blood Supply

Hip Movements

Flexion/extension
- Around transverse axis
- In sagittal plane
Abduction/adduction
- Around anteroposterior axis
- In coronal plane
Medial/lateral rotation
- Around vertical axis
- In transverse plane
Circumduction
Pelvic tilt
- Tilts around anteroposterior axis toward the unsupported limb
- Controlled by hip abductors
- Gait
  - Line of gravity shifts anterior/posterior to the transverse axis > pelvis tilts in flexion and extension
  - Controlled by gluteus maximus and tensor fascia lata

Hip Clinical Considerations

Hip Fracture

Hip Dislocation

Hip Fractures
- Post-menopausal women with osteoporosis > femoral neck fracture
- Sometimes tear:
  - Round periosteum
  - Branches of the medial femoral circumflex artery
    - Bone tissue can become necrotic
    - Avascular necrosis

Hip Clinical Considerations

Hip Fracture

Hip Dislocation

Congenital hip dislocation
- Result of lax ligaments or acetabular dysplasia
- More in girls
- Unilateral left 70%
- Associated with
  - Family history
  - Breech delivery
- S/S
  - Unable to abduct hip
  - Affected limb appears shorter
Acquired hip dislocation
- Uncommon
- Traumatic injury (car accident)
- Usually posterior in direction > fractures femoral head and acetabulum

Hip Surgery

Fracture Repair

Total Hip Replacement

Hip Resurfacing