Anatomy :lower extremityhumaryanto

hip

The hip bones are divided into 5 areas, which are:The sacrum: This is a bone at the base of the vertebral column that is created by the fusion of 5 vertebrae. It attaches to the ilium on the sides. It also provides a point of muscle attachment for back muscles. The coccyx (also called the tail bone): This is a small vestigial bone that attaches to the base of the sacrum. It is created from the fusion of up to 5 small vertebrae. The ilium: This is the largest area of the hip bones. It consists of 2 large broad plates, one on each side, which serve to support the internal organs, and to provide attachment for muscles of the back, sides, and buttocks. The hip joint of the femur is part of the ilium. The ischium: The ischium consists of 2 broad curves of bone, one on each side, which lie below the ilium, and are attached to the pubis in the front and the ilium in the back. The ischium serves as a place of attachment for muscles. When a person's butt hurts from sitting on a hard surface, it is the result of the sharp ischium pressing on the buttocks. The pubis: The pubis is the front-most area of the hip bones. It attaches to the ilium on the sides and the ischium on the bottom. It provides structural support, and serves as a place of attachment for the muscles of the inner thigh.

Pelvis and hip

Ligaments

The hip joint is reinforced by three main ligaments.At the front of the joint, the strong iliofemoral ligament attaches from the pelvis to femur. This Y-shaped ligament is also known as the ligament of Bigelow. This ligament seeks to resist excessive extension of the hip joint. It is often considered to be the strongest ligament in the human body. The pubofemoral ligament attaches across the front of the joint from the pubis bone of the pelvis to the femur. This ligament is oriented more inferiorly than the iliofemoral ligament and reinforces the inferior part of the hip joint capsule. It also blends with the medial parts of the iliofemoral ligament. The posterior of the hip joint capsule is reinforced by the ischiofemoral ligament that attaches from the ischial part of the acetabular rim to the femur. There is also a small ligament called ligamentum teres or the ligament of the head of the femur. The ligament is a triangularly shaped band with its base on both sides of peripheral edge of acetabular notch. This structure is not that important as a ligament but can often be vitally important as a conduit of a small artery to the head of the femur. This arterial branch is not present in everyone but can become the only blood supply to the bone in the head of the femur when the neck of the femur is fractured or disrupted by injury in childhood.

Muscles of pelvis and hipFLEXORSILIACUSPSOASPECTINEUSRECTUS FEMORISSARTORIUSADDUCTORSPosterior adductor magnusAdductor brevisAdductor longusGracilis

Muscles of pelvis and hipEXTERNAL ROTATORSGluteus maximusPiriformisObturator externusObturator internusSuperior gemellusInferior gemellusQuadratus femorisABDUCTORSGluteus mediusGluteus minimusTensor fasciae latae

Posterior hip muscles

Anterior hip muscles

Blood supply and nerve supply of the hip joint

The hip joint is supplied with blood from the medial circumflex femoral and lateral circumflex femoral arteries, which are both usually branches of the deep artery of the thigh (profunda femoris), but may also arise directly from the femoral artery. There is also a small contribution from a small artery in the ligament of the head of the femur which is a branch of the posterior division of the obturator artery, which becomes important to avoid avascular necrosis of the head of the femur when the blood supply from the medial and lateral circumflex arteries are disrupted (e.g. through fracture of the neck of the femur along their course).The hip has two anatomically important anastomoses, the cruciate and the trochanteric anastomoses. These exist between the femoral artery or profunda femoris and the gluteal vessels.The hip joint is supplied by a number of nerves (proprioception, nociception, etc...) including the femoral nerve, the obturator nerve, superior gluteal nerve, and the nerve to quadratus femoris.

In art and culture, a woman's hips are often viewed as a symbol of fertility.

thighOsteologyMuscle of anterior thighMedial thighPosterior thigh

Muscle of anterior thighVastus lateralisOrigin : iliotibial line, greater troch., lateral linea asperaInsertion : lateral patelaInnervation : femoralVastus medialisOrigin : iliotibial line, med.linea aspera, supracondylar lineInsertion : medial patelaInnervation : femoralVastus intermediusOrigin : proximal anterior femoral shaftInsertion : patelaInnervation : femoral

Medial of thighPosterior adductor magnusAdductor brevisAdductor longusGracilis

Muscles of posterior thighBiceps (long head)Biceps (short head)SemitendinosusSemimembranosus

Figure 15-2 Horizontal section through the middle of the thigh. In A, the nerves and vessels are identified. B shows the quadriceps (supplied by the femoral nerve) anteriorly, the adductors (supplied mostly by the obturator nerve) medially, and the hamstrings (supplied mostly by the sciatic nerve) posteriorly. The adductor longus is shown immediately anterior to the adductor magnus. The sartorius (5) has descended in a spiral from the anterior group and hence is supplied by the femoral nerve. The femoral vessels are situated subsartorially in the adductor canal. Although not shown here, the adductor magnus, in addition to its adductor part (supplied by the obturator nerve), has an extensor component supplied by the sciatic nerve. Ad.M., adductor magnus; B.F., biceps femoris; Gr., gracilis; R.F., rectus femoris; S., sartorius; S-m., semimebranosus; S-t., semitendinosus; V.I., vastus intermedius; V.L., vastus lateral is; V.M., vastus medialis.

L E GOSTEOLOGYMUSCLES OF ANTERIOR COMP.MUSCLES OF LATERAL COMP.MUSCLES OF SUPERFICIAL POSTERIORDEEP POSTERIOR COMP.

Anterior compartment :Tibialis anteriorExtensor hallucis longus (EHL)Extensor digitorum longus (EDL)Peroneur tertius

POSTERIOR COMPARTMENTSUPERFICIAL POSTERIORGASTROCNEMIUSSOLEUSPLANTARIS

DEEP POSTERIORPOPLITEUSFLEXOR HALLUCIS LONGUS (FHL)FLEXOR DIGITORUM LONGUS (FDL)TIBIALIS POSTERIOR

LATERAL COMPARTMENTPeroneus longusOrigin : proximal fibulaInsertion : med.cuneiform, 1st metatarsalInnervation : superficial peronealPeroneus brevisOrigin : distal fibulaInsertion : tuberosity of 5th MTInnervation : superficial peroneal

knee

ligaments

Cruciate ligament

MenisciThese are cartilaginous elements within the knee joint which serve to protect the ends of the bones from rubbing on each other and to effectively deepen the tibial sockets into which the femur attaches. They also play a role in shock absorption. There are two menisci in each knee, the medial meniscus and the lateral meniscus. Either or both may be cracked, or torn, when the knee is forcefully rotated and/or bent.

Blood supply

The femoral artery and the popliteal artery help form the arterial network surrounding the knee joint (articular rete). There are 6 main branches:1. Superior medial genicular artery 2. Superior lateral genicular artery 3. Inferior medial genicular artery 4. Inferior lateral genicular artery 5. Descending genicular artery 6. Recurrent branch of anterior tibial arteryThe medial genicular arteries penetrate the knee joint

Ankle & foot

Subtalar joint

Fig. 17-7 The facets of the ankle, subtalar, and talocalcaneonavicular joints. A, Diagram of the talus from above to show the three-surfaced trochlea that fits into the mortise formed by the lower ends of the tibia and fibula. B, Diagram of the calcaneus from above to show the posterior facet (P) for the subtalar joint, separated by the canalis and sinus tarsi from the middle (M) and anterior (A) facets of the talocalcaneonavicular joint. The socket of this latter joint is completed by the spring ligament and the concavity of the navicular. C, Diagram of the talus from below to show its corresponding facets for the subtalar and calcaneonavicular joints. Cf. fig. 12-36. A broad arrow in A emphasizes that the head of the talus is directed anteromedially.

ankleThe medial, or deltoid, ligament runs from the medial malleolus to the talus, navicular, and calcaneus. It is crossed by the tendons, vessels, and nerves that have entered the foot by passing posterior to the medial malleolus. The lateral ligaments consists of (1) the anterior talofibular ligament, between the neck of the talus and the lateral malleolus; (2) the calcaneofibular ligament; and (3) the posterior talofibular ligament, between the talus and the malleolar fossa. The medial and lateral ligaments prevent anterior and posterior slipping of the talus. They may be torn in injuries to the ankle, with the lateral ligaments being significantly weaker and more liable to sprain

Fig. 17-5 The ligaments of the ankle joint. The medial view shows the medial ligament, which forms a dense, almost continuous deltoid ligament. The ligaments on the lateral side, however, are usually separated from one another. Note the sinus tarsi in the lateral view.

Fig. 17-6 Movements of the foot and ankle. Dorsiflexion and plantar flexion are shown as in walking up and down hill. Movement occurs at the ankle joint. Eversion and inversion are shown as in standing sideways on a hill. Movement occurs at the tarsal joints, the talus remaining fixed. (Based on Mollier.)

footThe major bones in the human foot are:Phalanges: The bones in the toes are called phalanges. Metatarsals: The bones in the middle of the foot are called metatarsal bones. Cuneiforms: There are three bones in the middle of the foot, towards the centre of the body called cuneiforms. Cuboid: The bone sitting adjacent to the cuneiforms on the outside of the foot is called the cuboid. Navicular: This bone sits behind the cuneiforms. Talus: Also called the ankle bone, the talus sits directly behind the navicular. Calcaneus: Also called the heel bone, the calcaneus sits under the talus and behind the cuboid. The foot also contains sesamoid bones in distal portion of the first metatarsal bone.

Articulations

The articulations of the foot are:ankle intertarsal articulations metatarsophalangeal articulations interphalangeal articulations of foot

The muscles of the foot includeDorsal extensor digitorum brevis extensor hallucis brevis Plantar abductor hallucis flexor digitorum brevis abductor digiti minimi quadratus plantae lumbrical muscle flexor hallucis brevis adductor hallucis flexor digiti minimi brevis dorsal interossei plantar interossei

Fig. 17-8 The tendons and ligaments of the foot, plantar aspect. Note the widespread insertion of the tibialis posterior. The fibularis longus tendon crosses the sole obliquely to reach the medial cuneiform, to which the tibialis anterior is also attached: the two muscles thus form a sling or stirrup.

Nerves of foot

The medial plantar nerve, the larger terminal branch of the tibial nerve, arises posterior to the medial malleolus, deep to the flexor retinaculum and the abductor hallucis (see fig. 17-4A). It runs anteriorly between the abductor hallucis and the flexor digitorum brevis and supplies these muscles (see fig. 15-2) as well as the skin on the medial side of the foot. It ends as plantar digital nerves that supply the flexor hallucis brevis, the first lumbrical, and the skin of the medial toes, including their nail beds. The medial plantar nerve is comparable to the median nerve in the hand. The lateral plantar nerve arises posterior to the medial malleolus. It runs anteriorly and laterally, deep to the flexor digitorum brevis, and divides into superficial and deep branches. It supplies the quadratus plantae and abductor digiti minimi muscles, as well as the lateral side of the sole. The superficial branch supplies the flexor digiti minimi brevis muscle and gives rise to plantar digital nerves to the lateral toes. The deep branch turns medially and supplies the interossei, lumbricals 2 to 4, and the adductor hallucis. The lateral plantar nerve is comparable to the ulnar nerve in the hand.

Vessels of foot

The medial plantar artery, one of the terminal branches of the posterior tibial artery, arises deep to the flexor retinaculum and the abductor hallucis muscle. It runs anteriorly with its companion nerve and gives digital branches to the medial toes (fig. 17-4A). The lateral plantar artery, with its companion nerve, runs anteriorly and laterally, deep to the flexor digitorum brevis muscle. It then turns medially and forms the plantar arch, which lies between the third and fourth layers of the muscles of the sole. The arch gives off a series of metatarsal and digital arteries. The dorsal artery of the foot, variable in size and course, is the continuation of the anterior tibial artery at a point midway between the malleoli (fig. 17-4C). This artery extends to the posterior end of the first intermetatarsal space. The dorsal artery of the foot is important clinically in assessing peripheral circulation. Its pulsations should be sought, and can generally be felt, between the tendons of the extensor hallucis longus and extensor digitorum longus (fig. 17-4C). The artery is crossed by the inferior extensor retinaculum and extensor hallucis brevis. It lies successively on the capsule of the ankle joint, the head of the talus, the navicular, and the intermediate cuneiform. Its branches form an arterial network on the dorsum of the foot. The tendon of the extensor hallucis longus crosses either the anterior tibial artery or the dorsal artery of the foot and comes to lie on the medial side of the latter. The dorsal artery of the foot ends in a deep plantar branch, which passes to the sole between the heads of the first dorsal interosseus and completes the plantar arch.

Fig. 17-4 The structures on (A) the medial, (B) the lateral, and (C) the anterior portions of the ankle. The various retinacula are shown, but the synovial sheaths (see fig. 17-1) are not indicated. The posterior tibial artery is situated (in A) between the medial malleolus and the calcaneal tendon. The dorsal artery of the foot is found (in C) between the digitorum and hallucis tendons. The pulsations of these arteries are sought in clinical examinations of the lower limb.