Lower Limb

PREPARED BY MICHAEL C. DAVID ON 23/08/08. PAGE 1 OF 52

T H E L OW E R L I M B. TABLE OF CONTENTS

Hip Bone ................................................................................................................... 3 Femur ......................................................................................................................... 4 Saphenous Veins ...................................................................................................... 4 Cutaneous nerves ..................................................................................................... 6 Fascia Lata ................................................................................................................. 6 Lymphatic Drainage of Anterior Thigh ............................................................... 7 Adductor Muscles .................................................................................................... 8 Obturator Nerve & Artery ..................................................................................... 9 Flexor Muscles ........................................................................................................ 10 Boundaries .............................................................................................................. 12 The Subsartorial Canal .......................................................................................... 12 Femoral Vein .......................................................................................................... 12 Femoral Artery ....................................................................................................... 13 Femoral Sheath ....................................................................................................... 15 Femoral Nerve........................................................................................................ 16 Gluteal Muscles ...................................................................................................... 17 Gluteal Nerves ........................................................................................................ 19 Gluteal Arteries ...................................................................................................... 21 Gluteal Veins .......................................................................................................... 21 Posterior Thigh Muscles ....................................................................................... 22 Articular Surfaces ................................................................................................... 23 Inrinsic Ligaments ................................................................................................. 24 Innervation to Hip Joint ....................................................................................... 24 Arterial Supply to Hip Joint ................................................................................. 25 Articular Surfaces ................................................................................................... 26 Articular Capsule .................................................................................................... 26

Synovial Capsule ..................................................................................................... 26 External Intrinsic Ligaments ................................................................................ 27 Internal Intrinsic Ligaments ................................................................................. 28 Menisci of the knee joint ...................................................................................... 29 Bursae Of the Knee ............................................................................................... 30 Superficial Muscles ................................................................................................. 31 Deep Muscles.......................................................................................................... 33 Tibial Nerve ............................................................................................................ 34 Structures Under The Flexor Retinaculum ........................................................ 34 Arterial Supply ........................................................................................................ 35 Extensor Retinacula ............................................................................................... 36 Boundaries ............................................................................................................... 36 Muscles Of The Anterior Compartment............................................................ 37 Deep Peroneal Nerve ............................................................................................ 39 Anterior Tibial Artery ............................................................................................ 39 Boundaries ............................................................................................................... 40 Peroneal RetinaculA .............................................................................................. 40 Superficial Peroneal Nerve ................................................................................... 40 Arterial Supply ........................................................................................................ 40 Muscles of Lateral Compartment ........................................................................ 41 Articular Surfaces ................................................................................................... 42 Ligaments ................................................................................................................ 42 Neurovascular Supply to Ankle ........................................................................... 43 Movements .............................................................................................................. 43 Talo-Calcaneal Joint (SUB-TALAR JOINT) ........................................................... 44 Talo-Calcaneo-Navicular Joint ............................................................................. 44


Intrinsic Ligaments ................................................................................................ 45 Movements.............................................................................................................. 45 Calcaneo-Cuboid Joint .......................................................................................... 46 1st Layer of Plantar Muscles ................................................................................. 47 2nd Layer of Plantar Muscles ................................................................................ 47 3rd Layer of Plantar Muscles ................................................................................. 48

4th layer of Plantar Muscles ................................................................................... 48 Muscles of Dorsum of Foot ................................................................................. 50 Supports of Arches of Foot ................................................................................. 50 Arterial Supply To Foot ........................................................................................ 51 Cutaneous Nerve Distribution in The Foot ...................................................... 52


THE HIP AND THIGH AREAS

HIP BONE

Consists of three separate bones that only fuse together at the Acetabulum at 15-17 years. Complete fusion only after 23.

ILIUM

Iliac crest form superior border of Ilium, with an internal and external lip. It terminates anteriorly at the Anterior Superior Iliac Spine, and posteriorly at the Posterior Superior Iliac Spine. Highest point of Iliac Crest lies at level of L4.

Posterior part of internal surface of ilium articulates with the sacrum at the sacroiliac joint. Inferior to this is the greater sciatic notch.

ISCHIUM

Inferior end of body, has a rough projection = Ischial Tuberosity. Ischial spine separates the greater sciatic notch from the lesser sciatic notch. Sacrospinous ligament spans the greater sciatic notch, converting it to the greater sciatic foramen. Sacrotuberous & Sacrospinous ligaments convert the lesser sciatic notch into the lesser sciatic foramen.

Ramus of the Ischium passes medially, to form the Ischiopubic Ramus, that inferiorly bounds the Obturator Foramen.

PUBIS

Superior Ramus travels supero-laterally, up to the Acetabulum, where it fuses with the Ischium and the Ilium. Inferior Ramus travels poster-inferiorly, to form the Pubic Arch and the Ischiopubic Ramus. Body of Pubis lies medially, and joins body of opposite Pubis, at the Pubic Symphysis. Superior border of pubis is thickened = Pubic Crest. Pubic Tubercle projects anterior, and lies 2.5-cm lateral from the median plane. From here two ridges diverge laterally: the Pecten Pubis (Pectineal Line), and the Obturator Crest.


FEMUR

Head is smooth and spherical, and directed supero-antero-medially, into the acetabulum. A little inferior and posterior to its centre, is the fovea / pit. This is where the Ligament of Head is attached.

Angle between shaft and neck = 125. If angle reduced Coxa Vara through fracture of neck. If angle greater Coxa Valga through congenital dislocation of the hip.

Greater Trochanter is lateral, and Lesser Trochanter is medial. Connected anteriorly by Intertrochanteric Line (produced by Iliofemoral ligament), and posteriorly by the Intertrochanteric Crest.

Anterior shaft is featureless. Posterior shaft has: Linea Aspera = rough ridge of bone with medial and lateral lips. Gluteal Tuberosity = proximal divergence of lateral lip of Linea Aspera. Spiral Line = proximal divergence of medial lip of Linea Aspera, terminating anteriorly at the Intertrochanteric Line. Lateral Supracondylar Line = distal divergence of lateral lip of Linea Aspera, that bounds the lateral Condyle of the Femur. Medial Supracondylar Line = distal divergence of medial lip of Linea Aspera, that bounds the medial Condyle of the Femur, and terminates as the

Adductor Tubercle.

SAPHENOUS VEINS

GREAT SAPHENOUS VEIN

Begins at medial end of dorsal venous arch of the foot. Passes anteriorly to medial malleolus of tibia, accompanied by the Saphenous nerve. Ascends obliquely up antero-medial aspect of tibia to medial side of knee. Here it lies superficial to the medial epicondyle, a handbreadth posterior to the

medial border of the patella.

Ascends superolaterally, up the femur, to the Saphenous opening, where it turns posteriorly, and pierces the anterior femoral sheath, to drain into Femoral Vein.


Drains: Dorsal Venous Arch of the foot. Medial Dorsal Vein of the great toe. Medial Marginal Veins of sole of foot. Numerous tributaries from leg and thigh alternatively these can form the Accessory Saphenous vein. Communications from the Small Saphenous Vein. Lateral & Anterior Cutaneous Veins, from networks of veins in the inferior thigh. Superficial Circumflex Iliac Vein from lateral groin. External Pudendal Veins drains superficial aspects of external genitalia. Superficial Epigastric Vein from superficial abdominal veins below umbilicus.

SMALL SAPHENOUS VEIN

Begins posterior to the lateral malleolus, from the union of veins arising from: The lateral part of the Dorsal Venous Arch of the foot. The dorsum of the 5th digit. The lateral edge of the foot and sole.

Passes on lateral side of foot with the Sural nerve. Passes lateral to tendo calcaneus, and ascends tibia in the deep fascia between the two heads of Gastrocnemius. At popliteal fossa, it perforates the deep popliteal fascia, and terminates as the Popliteal Vein.

GENERAL VENOUS DRAINAGE

Three groups of veins: Superficial saphenous veins. Deep formed by Venae Comitantes of arteries. Perforating connects deep and superficial veins, and are found in ankle & lower leg.

Veins have valves to help the return of blood to the heart. Perforating Veins have specialised valves that prevent blood from passing from deep to superficial veins. Deep veins have muscles and arteries close by that raise the pressure, but superficial veins carry blood at low pressure. Thus valves oppose the natural pressure gradient, that would otherwise distend the superficial veins. Damage of these valves causes varicose veins.


CUTANEOUS NERVES

Anterior thigh, is innervated directly/indirectly by the Lumbar Plexus, situated in the posterior abdominal wall, and formed by the ventral primary rami of L1 to L4.

NERVE. ROOT. INNERVATION

Femoral Br. Of Genitofemoral Nerve L1, L2 Skin immediately below central third of Inguinal Ligament, on anterior thigh.

Lies in hollow femoral sheath of saphenous opening.

Passes superficially through sheaths anterior wall, and Fascia Lata.

Ilio-inguinal nerve L1 1. Lowest part of anterior abdominal wall 2. Medial branches innervate external genitalia. 3. Main branch supplies skin under medial end of Inguinal Ligament.

Lateral Cutaneous Br. Of Subcostal n. T12 Skin anterior to greater Trochanter of Femur.

Lateral Cutaneous Br. Of Iliohypogastric n. L1 Innervates skin over lateral part of anterior thigh, below the Iliac Crest.

Femoral Nerve

Medial Cutaneous n. of Thigh Posterior branches of L2 & L3 Anterior and medial thigh, up to knee. Intermediate Cut. Nerve of

Thigh

Saphenous nerve L4 Skin below knee joint.

Lateral Cutaneous nerve of Thigh L2, L3 Skin over lateral part of anterior thigh.

Passes underneath Inguinal Ligament, deep to Fascia Lata.

Pierces Fascia Lata, 4 cm below Inguinal Ligament, Passes superficially.

FASCIA LATA

Deep fascia of thigh, that forms a sleeve around the muscle, to increase their efficiency, by allowing them to move across each other. Anteriorly attached to: Pubis (medially), the external lip of the Iliac Crest (laterally), and the Curved Lower border of the Inguinal Ligament. Just below medial end of Inguinal Ligament, it splits into 2 overlapping layers: a deeper medial layer, and a lateral layer. Between these layers is the Saphenous Opening, in which lies the Femoral Sheath.


LYMPHATIC DRAINAGE O F ANTERIOR THIGH

Superficial Inguinal Lymph Nodes, in superficial fascia below Inguinal Ligament.

Horizontal group. Lies inferiorly and parallel to the Inguinal Ligament. Medial nodes drain: Superficial vessels of anterior abdominal wall below umbilicus Superficial vessels of Perineum (= external genitalia, and lower half of anal canal, but NOT

testes).

Lateral nodes drain: Superficial vessels from back, below level of Iliac Crests.

Vertical Group. Lies along terminal part of Great Saphenous Vein (i.e. proximal femur) Drains majority of superficial vessels of lower limbs.

Superficial Inguinal Nodes, themselves drained by vessels passing through the Saphenous Opening, to the Deep Inguinal Lymph Nodes.

Deep nodes lie medial to Femoral Vein.


MEDIAL COMPARTMENT OF THIGH

ADDUCTOR MUSCLES

NAME. ORIGIN. INSERTION INNERVATION ACTION

Pectineus Pecten Pubis on superior ramus of Pubis

Pectineal Line of Femur 1. Femoral nerve (L2, L3) 2. Branch of Obturator nerve

1. Adducts thigh 2. Flexes thigh

Adductor Longus Body of Pubis (inferior Ramus to the Pubic Crest)

Middle third of Linea Aspera Anterior branch of Obturator nerve (L2, L3, L4)

Adducts thigh

Adductor Brevis 1. Body of Pubis 2. Inferior Ramus of Pubis

1. Pectineal (Spiral) Line 2. Proximal part of Linea

Aspera Obturator Nerve (L2, L3, L4)

1. Adducts thigh 2. Partially flexes thigh

Adductor Magnus

1. Adductor Ischiopubic Ramus

2. Hamstring Ischial Tuberosity

Adductor 1. Gluteal Tuberosity 2. Medial lip of Linea Aspera 3. Medial Supracondylar Line Hamstring Adductor Tubercle of Femur

1. Adductor Obturator nerve (L2, L3, L4)

2. Hamstring Tibial portion of Sciatic nerve (L4)

1. Adducts thigh 2. Adductor flexes thigh 3. Hamstring extends thigh

Gracilis 1. Body of Pubis 2. Inferior Ramus of Pubis

Superior part of medial surface of Tibia

Obturator Nerve (L2, L3) 1. Adducts thigh 2. Flexes leg 3. Medial rotation of leg

Obturator Externus 1. Obturator Foramens

margins 2. Obturator membrane

Greater Trochanter of Femur (as a single tendon)

Obturator Nerve (L3, L4) 1. Lateral rotation of thigh 2. Steadies head of Femur in

Acetabulum.


OBTURATOR NERVE & ARTERY

OBTURATOR NERVE

Nerve of medial compartment. Branch of Lumbar Plexus, within Psoas Major on posterior abdominal wall. Anterior divisions of ventral primary rami of L2, L3, L4. Anterior and posterior divisions straddle Adductor Brevis. Gives a cutaneous supply to the medial skin of thigh in some cases. Gives articular branches to Hip & Knee joints.

OBTURATOR ARTERY

Enters medial compartment through Obturator Canal, along with the Obturator nerve. Supplies medial compartment, and hip joint. Originates as a branch of the Internal Iliac Artery, in the pelvic cavity. A branch of its posterior division forms the Artery to head of Femur.


ANTERIOR COMPARTMENT OF THIGH

FLEXOR MUSCLES


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Rectus Femoris

1. Straight head Anterior Inferior Iliac Spine

2. Reflected head outer surface of Ilium, above Acetabulum

1. Reflected head merges with posterior aspect of Straight Head.

2. Fused bellies becomes tendonous, and fuses with aponeurosis

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Femoral nerve (posterior divisions of L2, L3, L4)

Vastus Medialis 1. Lower fibres run

horizontally, and fix Patella, preventing its lateral displacement

Rectus Femoris 2. Steadies hip joint 3. Helps Iliopsoas to flex thigh Quadriceps 4. Extends leg at knee joint

Vastus Lateralis

1. Half way up Intertrochanteric line

2. Greater Trochanter 3. Gluteal tuberosity 4. Lateral lip of Linea Aspera

Extensive aponeurosis on deep aspect of muscle belly.

Vastus Medialis

1. Mid-point of Intertrochanteric Line

2. Lesser Trochanter 3. Spiral Line 4. Medial lip of Linea Aspera 5. Upper half of Medial

Supracondylar Line


Vastus Intermedius

Anterior and lateral surfaces of shaft of Femur



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1. Sides of T12 to L5 vertebrae 2. intervertebral discs between

them Bellies fuse, and pass behind lateral two-thirds of Inguinal Ligament, to insert onto the Lesser Trochanter of the Femur.

Ventral rami of L1, L2, L3 1. Flex thigh at hip 2. Stabilise joint 3. Allows sitting up from

supine position, if thigh is fixed.

4. Where it crosses hip joint cavity, is a Psoas Bursa.

Iliacus

1. Iliac crest 2. Iliac fossa 3. Ala of Sacrum 4. Anterior Sacroiliac ligaments

Femoral nerve (L2, L3)

Tensor Fasciae Lata 1. Anterior Superior Iliac Spine 2. Anterior part of external lip

of Iliac crest

Iliotibial tract, that attaches to the lateral condyle of Tibia

Superior Gluteal nerve (L4, L5)

1. Abducts thigh 2. Medially rotates thigh 3. Flexes thigh 4. Helps keeps knee extended 5. Steadies trunk on thigh

Sartorius 1. Anterior Superior Iliac Spine 2. Superior part of Sciatic

notch (just inferior to it)

Superior part of medial surface of Tibia

Femoral nerve (L2, L3) 1. Flexes thigh at hip 2. Abducts thigh at hip 3. Laterally rotates thigh at hip


THE FEMORAL TRIANGLE

BOUNDARIES

Superior = Inguinal Ligament Medial = medial border of Adductor Longus Lateral = medial border of Sartorius Floor = Adductor Longus, Pectineus & Iliopsoas muscles (medial

lateral)

Roof = overlying Fascia Lata (including Cribiform fascia that covers the Saphenous Opening)

Ends inferiorly as the Adductor / Subsartorial canal.

THE SUBSARTORIAL CANAL

15 cm long, narrow fascia tunnel, deep to central third of Sartorius. Ends at Adductor Hiatus of Adductor Magnuss extensive aponeurosis.

Lateral boundary = Vastus Medialis Postero-medial boundary = Adductor Longus Anterior boundary = Sartorius (+ subsartorial fascia contains

subsartorial nerve plexus that supplies overlying skin)

Contain the Femoral Artery (medial) and Vein (lateral), but not the Profunda Femoris vessels.

Contains the Saphenous nerve (a cutaneous branch of the Femoral nerve) medial to Femoral Artery

Contains the Nerve To Vastus Medialis (accompanies the proximal part of the Femoral Artery.

FEMORAL VEIN

Begins at the Adductor Hiatus Ends at the Inguinal Ligament, where it continues on as the External Iliac Vein. Superiorly in triangle, it lies medial to the Femoral Artery. As it runs down, it moves posteriorly, and then lateral to the Femoral artery.


FEMORAL ARTERY

Continuation of External Iliac artery, as it passes deep to the Mid-Inguinal Point. mid-inguinal point is between Anterior Superior Iliac Spine and Pubic Symphysis mid-point of Inguinal Ligament is between the Anterior Superior Iliac Spine and the Pubic Tubercle ( a little more lateral)

Passes inferiorly down the triangle, and passes inferiorly at the Femoral Triangles apex, deep to Sartorius, and enters the Sub-Sartorial Canal. At distal end of canal, it passes through the Adductor Hiatus, to enter the posterior aspect of the Femur, and passes along posterior aspect of knee, as the

Popliteal Artery.

Separated from Femur by Vastus Medialis protected. Three proximal branches within Femoral Sheath: Superficial Circumflex Iliac Artery Superficial Epigastric Artery lower part of abdominal wall, up to umbilicus External Pudendal Artery external genitalia.

Below the sheath, there is only one major branch = Profunda Femoris artery. Branch occurs at lateral aspect of Femoral artery, 4 cm inferior to Inguinal Ligament.

Profunda Femoris Turns inferiorly to lie on lower part of Iliopsoas tendon, and runs parallel to the Femoral artery, on Pectineus muscle, before passing deep to Add. Longus. Lies close to Linea Aspera on Femur at risk of injury during fracture. Proximal branches: Lateral Circumflex artery:

Ascending branch goes to Greater Trochanter

Transverse branch continues laterally (deep to Rectus Femoris), and enters cleft between Vastus Intermedius and Lateralis.

Descending branch declines through Quadriceps Femoris, to medial aspect of knee. Medial Circumflex artery

Originates from posterior aspect of Profunda Femoris

Travels posteriorly to Cleft between Iliopsoas and Pectineus, and then beneath Neck of Femur & Articular Capsule, onto the posterior aspect of the thigh. Supplies head & neck of Femur (i.e. clinically important).

At upper and lower margins of Quadratus Femoris, it terminates into an Ascending & Transverse branch.


FEMORAL SHEATH

Oval, funnel-shaped fascial tube that encloses the proximal parts of the femoral vessels. Does not enclose the Femoral nerve. In abdomen, external iliac vessels lie within the extra-peritoneal fatty tissue plane, and grow down into 2nd diverticulum, to form the femoral sheath. Nerves lie between the muscle wall and the fascial envelope grow outside the Femoral sheath, since they lie in a different plane.

A diverticulum (inferior prolongation) of fascia lining the abdomen: Transversalis fascia, anteriorly. Iliac fascia, posteriorly.

Ends 4 cm inferior to the Inguinal Ligament, by merging with the adventitious tissue of the femoral vessels. Allows the femoral vessels to slide in and out, beneath the Inguinal Ligament, during hip movement. Pierces medially by Great Saphenous Vein & Lymphatics. Sheath is divided by two vertical septa, into three compartments A lateral compartment to hold the Femoral artery, and the Femoral branch of the Genitofemoral Nerve. Nerve lies between muscle wall, and fascial envelope. Pierces the extra-peritoneal fatty tissue. Genital branch enters the Internal Spermatic Fascia. Femoral branch enters lateral compartment, by piercing the anterior wall supplies skin below central third of Inguinal Ligament, on anterior thigh.

An intermediate compartment to hold the Femoral Vein. A medial compartment/space = Femoral Canal.

Femoral Canal: Begins at Femoral Ring, and ends at the Saphenous Opening allows expansion of Femoral vein, during increased venous return. Contains loose connective and fatty tissue, which merges with extra-peritoneal fatty tissue of abdomen. Merging occurs at Femoral Ring. Contains a few lymph vessels, and a Deep Inguinal Lymph Node (1 of 3) drains Superficial Inguinal Lymph nodes, and sends lymph to the External Iliac

Lymph Nodes.

Femoral Ring: - mouth of Femoral Canal only, about 1 cm wide. Closed by extra-peritoneal fatty tissue = Femoral Septa (pierced by Lymph vessels connecting Inguinal and External Iliac Nodes). Anterior margin = Inguinal Ligament Posterior margin = Pectineal Line on Superior Pubic Ramus Medial margin = Fibrous Septa (medial to Femoral Vein) Lateral margin = fibres of Inguinal Ligament that insert into Pectineal Line of Superior Pubic Ramus = Lacunar Ligament.


FEMORAL NERVE

Largest branch of the Lumbar Plexus (L2, L3, L4) forms in the abdomen, within Psoas Major. Passes lateral to the Femoral Artery, outside the Femoral Sheath. Enters thigh beneath the Mid-point of the Inguinal Ligament (a little lateral to the mid-inguinal point. Travels 1 inch inferiorly, and then divides: Muscular branches to Pectineus, Sartorius and Quadriceps Femoris (anterior thigh muscles) Medial Cutaneous Nerve of Thigh. Intermediate Cutaneous Nerve of Thigh. Saphenous Nerve (L3, L4): Accompanies the Femoral artery within the Subsartorial Canal. At Adductor Hiatus, it becomes superficial, by passing between Sartorius and Gracilis. Then passes across medial knee, and accompanies the Great Saphenous vein down the leg. Cutaneous supply to antero-medial aspects of knee, leg and foot.

} Antero-medial cutaneous distribution (L2, L3)


GLUTEAL REGION

GLUTEAL MUSCLES


Gluteus Maximus

1. External surface of Ala of Ileum

2. Dorsal surface of Sacrum, Coccyx and Sacrotuberous ligament

1. Gluteal Tuberosity 2. Deep Fibres Iliotibial Tract

(inserts onto lateral condyle eof Tibia)

Inferior Gluteal nerve (L5, S1, S2)

1. Extends thigh 2. Assists lateral rotation 3. Steadies thigh 4. Assists in raising trunk,

from a flexed position.

Gluteus Medius

External surface of Ilium, between Anterior Superior Iliac Spine and Posterior Superior Iliac Spine.

Lateral surface of Greater Trochanter of Femur.

Superior Gluteal Nerve (L5,S1)

1. Abducts thigh 2. Medially rotates thigh 3. Steadies pelvis (damage

results in Waddlers Gait / Trendelenburg Sign) Gluteus Minimus

External surface of Ilium (inferiorly)

Anterior surface of Greater Trochanter of Femur

Piriformis 1. Anterior surface of Sacrum 2. Sacrotuberous ligament

Superior border of Greater Trochanter of Femur

Direct branches from ventral Rami of S1 & S2.

1. Laterally rotates extended thigh (in addition to Obturator Externus)

2. Abduction of flexed thigh (not Quadratus Femoris)

3. Steadies femoral head in Acetabulum

Obturator Internus 1. Pelvic surface of Obturator

membrane 2. Surrounding bone

Medial surface of Greater Trochanter of Femur

Nerve to Obturator Internus (L5, S1)

Superior Gamellus Ischial spine Nerve to Obturator Internus (L5, S1)

Inferior Gamellus Ischial tuberosity Nerve to Quadratus Femoris (L5, S1)

Quadratus Femoris Lateral border of Ischial Tuberosity

Quadrate Tubercle on Intertrochanteric Crest of Femur + inferior to this.

Nerve to Quadratus Femoris (L5, S1)


GLUTEAL NERVES

NERVE. ROOT. INNERVATION

Superior Cluneal Nerves Lateral branches of dorsal rami of L1, L2, L3 Cutaneous supply to superior two-thirds of buttocks

Middle Cluneal Nerves Lateral branches of dorsal rami of S1, S2, S3 Cutaneous supply to skin over sacrum, and adjacent area of buttocks

Inferior Cluneal Nerves Gluteal Br. Of Posterior Femoral Cutaneous Nerves (ventral rami of S1, S2, S3)

Curves around inferior border of Gluteus Maximus Cutaneous supply to inferior third of buttocks

Superior Gluteal Nerve Posterior divisions of ventral rami of L4, L5

Travels through superior part of Greater Sciatic Foramen with superior gluteal artery

Superior branch supplies Gluteus Maximus Inferior branch supplies Gluteus Medius & Minimus, and

Tensor Fascia Latae

Inferior Gluteal nerve

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Posterior divisions of ventral rami of L5, S1, S2 Accompanies inferior gluteal artery Breaks up into several branches supplying Gluteus Maximus

Sciatic Nerve Ventral rami of L4, L5, S1, S2, S3

Large flattened band + most lateral structure of inferior part of Greater Sciatic Foramen

Runs infero-laterally through Gluteal area, supplying nothing Two-thirds down posterior thigh, divides:

Tibial nerve (supplies flexors) Common Peroneal nerve (supplies abductors &

extensors, before entering Peroneum tissue)

Posterior Femoral Cutaneous Nerve

1. Posterior divisions of ventral rami of S1, S2 2. Anterior divisions of ventral rami of S2, S3

Posterior divisions supply skin of inferior part of buttocks Anterior divisions supply peroneum Skin of posterior thigh and proximal posterior leg.

Nerve to Quadratus Femoris Anterior divisions of ventral rami of L4, L5, S1 Supplies hip joint, Quadratus Femoris & Superior Gamellus

Nerve to Obturator Internus Anterior divisions of ventral rami of L5, S1, S2 Passes through Greater Sciatic foramen, winds around Ischial

spine to supply Superior Gamellus. Re-enters pelvis via Lesser Sciatic Foramen, supplying Obturator Internus.

Pudendal nerve Anterior divisions of ventral rami of S1, S2, S3 Supplies perineum (genitalia, sphincters of urethra and anus)


GLUTEAL ARTERIES

SUPERIOR GLUTEAL ARTERY

Main branch of Internal Iliac artery, in pelvic cavity. Leaves pelvic cavity through Superior part of Greater Sciatic Foramen,

superior to Piriformis.

Divides immediately into: Superficial branch supplies Gluteus Maximus and skin over its

proximal attachment.

Deep branch supplies Gluteus Medius, Gluteus Minimus and Tensor Fascia Latae muscles.

Other branches terminate at Trochanteric Anastomosis, where at the Greater Trochanter, they meet the Ascending branch of the Lateral Circumflex Humoral artery.

INFERIOR GLUTEAL ARTERY

Arises in pelvic cavity, as a branch of the Internal Iliac artery. Leaves pelvic cavity through Inferior part of Greater Sciatic Foramen,

inferior to Piriformis.

Lies lateral to Internal Pudendal artery. Supplies Gluteus Maximus, Obturator Internus, Quadratus Femoris and

superior part of Hamstrings.

May anastomose with Superior Gluteal artery. Cruciate anastomosis lies at junction of gluteal region and thigh. Descending branch of Inferior Gluteal artery + top perforating

branch of Profunda Femoris artery

Transverse branches of Lateral & Medial Circumflex Femoral arteries.

Allows collateral circulation between Internal and External Iliac arteries.

INTERNAL PUDENDAL ARTERY

Arises in pelvic cavity, as a branch of the Internal Iliac artery. Leaves pelvic cavity through Inferior part of Greater Sciatic Foramen,

inferior to Piriformis.

Descends posterior to Ischial Spine, and re-enters the pelvis through the Lesser Sciatic Foramen.

Enters perineum, lateral to Pudendal nerve. Supplies external genitalia and muscles in pelvic and gluteal regions.

GLUTEAL VEINS

Tributaries of the Internal Iliac Veins.

GLUTEAL VEINS

Superior and inferior gluteal veins accompany the corresponding arteries though the Greater Sciatic Foramen, as venae comitantes.

Anastomose with tributaries of Femoral Vein, to allow a collateral circulation.

INTERNAL PUDENDAL VEINS

Venae comitantes of corresponding arteries. Forms a single vein that joins the Internal Iliac Vein. Drains external genitalia and perineal region.


POSTERIOR COMPARTMENT OF THIGH

POSTERIOR THIGH MUSC LES


Semitendonosus

Ischial Tuberosity

Medial surface of superior part of Tibia

Tibial division of Sciatic nerve (L5, S1, S2)

1. Extend thigh 2. Flex leg 3. Medial rotation of leg 4. When thigh & leg are flexed,

it can extend trunk Semimembranosus

Posterior part of medial condyle of Tibia

Biceps Femoris

1. Long head Ischial Tuberosity

2. Short head lateral lip of Linea Aspera & lateral Supracondylar line

1. Lateral side of head of Fibula

2. Tendon is split at this site by the Fibular Collateral Ligament of knee

Long head - Tibial division of Sciatic nerve (L5, S1, S2)

Short head Fibular division of Sciatic nerve (L5, S1, S2)

1. Flexes leg 2. Laterally rotates leg 3. Long head extends thigh


HIP JOINT

ARTICULAR SURFACES

Acetabulum lunate surface Floor is non-articular = acetabular fossa occupied by a fat pad, and covered by synovial membrane. Acetabular notch = inferior deficiency in rim bridged by transverse acetabular ligament (not in contact with bone, but continuous with Ligament of Head of

Femur

Acetabular Labrum = ring of fibrocartilage attached to rim of acetabulum. Free edge clasps head of Femur, to increase stability.

Head of Femur except for Pit, which is attached to Ligament of Head of Femur.

Articular Capsule: Strong and dense. Proximally attached to rim of Acetabulum (just distal to Labrum). Distally attached to Intertrochanteric Line & root of Greater Trochanter (anteriorly), and the neck proximal to the Intertrochanteric Crest (posteriorly). Forms a cylindrical sleeve that encloses the hip joint and most of the neck of the femur. Most fibres run spirally to lateral portion of Intertrochanteric line. Circular fibres around neck of Femur form an Orbicular zone constricts capsule, and help hold head of Femur in the Acetabulum. Deep Longitudinal fibres (Retinacula), contain blood vessels that nourish the head and neck of femur reflected back along superior surface of neck of

femur.

Further longitudinal capsular fibres form Intrinsic Ligaments. Anterior ligaments spiral inferolaterally Posterior ligaments spiral superolaterally

Synovial Membrane lines internal surface of articular capsule, and is reflected onto neck of femur. Forms a sleeve to exclude the Ligament of Head of Femur. Lines acetabular fossa, and fat-pad. Attached to edges of fossa and transverse acetabular ligament Protrudes inferior to Articular Capsule posteriorly, to form the Obturator Externus Bursa.

} Flexion will thus slacken the ligaments, and extension will tighten them.


INRINSIC LIGAMENTS

NAME. PROXIMAL ATTACHMENT DISTAL ATTACHMENT FUNCTIONS / NOTES

Iliofemoral Ligament 1. Anterior Superior Iliac Spine 2. Acetabulum rim

Runs inferolaterally to Intertrochanteric line of Femur

1. Prevents hyperextension during standing maintains erect posture

2. Screws head of femur into acetabulum joint integrity

Pubofemoral Ligament 1. Pubic part of Acetabulum rim 2. Iliopubic eminence

Blends with medial part of Iliofemoral Ligament

1. Strengthens the Articular Capsule anteriorly + inferiorly 2. Relatively weak, but prevents hyperabduction of thigh

Ischiofemoral Ligament Ischial part of Acetabulum rim Spirals superolaterally to neck of femur (medial to base of Greater Trochanter)

1. Strengthens the Articular Capsule posteriorly 2. Prevents hyperextension, by screwing femoral head

medially into acetabulum during extension

Ligament of Head of Femur

1. Margins of Acetabular notch 2. Floor of Acetabular fossa 3. Inner margin of Transverse

Acetabular Ligament

Fovea / Pit of head of Femur

1. Intra-capsular 2. Contains the small artery to head of femur (branch of

obturator artery) atrophies after 7-8 years old. 3. Surrounded by a sleeve of Synovial membrane 4. Tightens during Adduction + lateral rotation

INNERVATION TO HI P JOINT

Femoral nerve (via Nerve to Rectus Femoris) Obturator Nerve (anterior division) Sciatic nerve (via Nerve to Quadratus Femoris) Superior Gluteal Nerve


ARTERIAL SUPPLY TO H IP JOINT


THE KNEE JOINT

ARTICULAR SURFACES

Large curved condyles of the femur The flattened condyles of the tibia Facets of the Patella On the superior surface of each tibial condyle, there is an articular area for the corresponding femoral condyle. These medial & lateral tibial plateaux, are separated by a narrow non-articular ridge, that widens anteriorly and posteriorly to form the anterior & posterior

intercondylar areas.

ARTICULAR CAPSULE

Superiorly attached to the femur, just proximal to articular margins of the condyles, and to the intercondylar line posteriorly. Deficient on the lateral condyle, to allow tendon of Popliteus out, to attach to Tibia.

Inferiorly attached to the articular margin of the Tibia. Except where the tendon of Popliteus crosses here the fibrous capsule is prolonged inferolaterally, to loop over Popliteus, and onto the head of the

Fibula = Arcuate Popliteal Ligament.

Five external intrinsic ligaments strengthen fibrous capsule.

SYNOVIAL CAPSULE

Lines inner aspect of fibrous capsule, and is reflected onto the articulating bones, as far as their articular cartilages. Attached to the periphery of the Patella. Separated from the Patella Ligament by the Infrapatella Fatpad.


EXTERNAL INTRINSIC L IGAMENTS

PATELLA LIGAMENT

Continuation of tendon of Quadriceps Femoris. Patella is a sesamoid bone within this tendon. Continuous with the fibrous capsule of the knee. Superior part of its deep surface is separated from the synovial

membrane of the knee, by the loose infrapatella fatpad.

Inferior part of ligament separated from anterior Tibia by the infrapatella bursa.

FIBULAR COLLATERAL LIGAMENT

Round cord, 5 cm long. Extends inferiorly from the lateral epicondyle of the femur, to the lateral

surface of the head of the fibula.

Tendon of Popliteus passes deep to it separating it from the lateral Meniscus.

Tendon of Biceps Femoris, split by Fibular Collateral Ligament. Fuses with fibrous capsule superiorly = intrinsic. Inferiorly, separated by fat from fibrous capsule = extrinsic.

TIBIAL COLLATERAL LIGAMENT

Strong, flat band. 8 to 9 cm long. Extends from medial epicondyle of femur to the medial condyle &

supero-medial part of tibia.

Thickening of fibrous capsule, which is partly continuous with the tendon of Adductor Magnus.

Inferiorly, separated from the tibia by the medial-inferior genicular vessels and nerve.

Deep fibres firmly attached to fibrous capsule and medial meniscus.

OBLIQUE POPLITEAL LIGAMENT

Expansion of Semimembranosus muscle. Strengthens fibrous capsule posteriorly. Arises from the medial condyle of tibia. Passes superolaterally, to attach to the central part of the posterior aspect

of the fibrous capsule.

ARCUATE POPLITEAL LIGAMENT

Strengthens articular capsule posteriorly. Arises from posterior aspect of head of fibula. Passes supero-medially over tendon of Popliteus, spreading out over

posterior surface of knee joint.

Inserts onto posterior intercondylar area of tibia + posterior aspect of lateral epicondyle of femur.


INTERNAL INTRINSIC L IGAMENTS

Cruciate ligaments are named according to their site of attachment on the Tibia. They are essential to the antero-posterior stability of the knee joint, especially when flexed. Damage to either can result in the anterior/posterior Drawer Sign.

ANTERIOR CRUCIATE LIGAMENT

Arises from the anterior part of the intercondylar area of the Tibia just posterior to the attachment of the medial meniscus.

Extends superiorly, posteriorly and laterally to attach to the posterior part of the medial side of the lateral condyle of the femur.

Prevents posterior displacement of the femur on the tibia, and hyperextension of the knee.

POSTERIOR CRUCIATE LIGAMENT

Arises from the posterior part of the intercondylar area of the Tibia. Passes superiorly and anteriorly, to the medial side of the Anterior

Cruciate.

Inserts onto the anterior part of the lateral surface of the medial condyle of the femur.

Prevents anterior displacement of the femur on the tibia, and hyperflexion of the knee.

Main stabilising factor of the weight bearing knee (e.g. when walking downhill).


MENISCI OF THE KNEE JOINT

MEDIAL MENISCUS

Attached to anterior intercondylar area of tibia anterior to the attachment of anterior cruciate ligament.

Attached to posterior intercondylar area of tibia just anterior to the attachment of posterior cruciate ligament.

Between attachments of posterior lateral meniscus, and the posterior cruciate ligament.

Medial meniscus is firmly attached to the deep surface of the Tibial Collateral Ligament.

LATERAL MENISCUS

Nearly circular, and more freely moveable. Covers a larger area of articular surface than medial meniscus.

Anterior and posterior horns are attached close together, in the anterior and posterior intercondylar areas of the tibia.

Posterior Meniscofemoral Ligament joins the lateral meniscus to the posterior cruciate ligament + the medial femoral condyle.

Separated from the deep surface of the Fibula Collateral Ligament by the tendon of Popliteus.

Superior, concave surfaces accept femoral condyles. Inferior, flattened surfaces rest on Tibia. Peripherally thick, while thin internally. Act as shock absorbers. They deepen the articular surfaces of the tibia. Flexible to accept the different shape of the femur, in

flexion-extension.

Divide the joint, to allow two planes of movement. Between femur + menisci = flexion-extension. Between menisci + tibia = rotation.


BURSAE OF THE KNEE

BURSA LOCATION / FUNCTION

Suprapatellar (Quadriceps) Bursa 1. Passes superiorly between femur and quadriceps femoris muscle extends 8 cm above base of Patella 2. Allows free movement of Quadriceps tendon over distal end of Femur allows full extension and flexion at knee.

Popliteus Bursa Lies between tendon of Popliteus and lateral condyle of Tibia.

Anserine Bursa Several diverticuli that separate tendons of Gracilis, Sartorius & Semitendinosus, from the proximal part of the medial surface of the Tibia.

Gastrocnemius Bursa Lies deep to proximal attachment of medial head of Gastrocnemius separates tendon from Femur.

Semimembranosus Bursa Lies between medial head of Gastrocnemius, and the Semimembranosus tendon often a prolongation of Gastrocnemius Bursa.

Subcutaneous Pre-Patellar Bursa 1. Lies between skin and anterior surface of Patella allows movement of skin over patella during flexion-extension. 2. Easily inflamed Housemaids Knee.

Subcutaneous Infra-Patellar Bursa 1. Lies between skin and Tibial Tuberosity 2. Allows skin to glide over Tibial Tuberosity, and withstand pressure during kneeling.

Deep Infra-Patellar Bursa 1. Lies between Patellar Ligament and anterior surface of Tibia (superior to Tibial Tuberosity). 2. Separated from knee joint cavity by the Infra-Patellar Fat Pad.


POSTERIOR COMPARTMENT OF LEG

SUPERFICIAL MUSCLES


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Gastrocnemius

Lateral head lateral aspect of lateral condyle of femur. (Possible presence of sesamoid Fabella bone) Medial head popliteal surface of femur, superior to medial condyle.

Heads merge at inferior margin of Popliteal Fossa

Posterior surface of Calcaneus by Calceneal Tendon Achilles Tendon 1. 15 cm long 2. Strongest tendon 3. Bursa between tendon and

bony Calcaneus

4. Fibres spiral through 90, to allow elongation & elastic

recoil allows storage and release of energy during locomotion.

Tibial nerve (S1, S2)

1. plantar-flexes foot 2. raises heel during walking 3. flexes knee joint Most powerful muscle in compartment,

but cannot do both at maximum tension, together.

4. Rapid contraction provided by vertical fibres

Soleus

1. Posterior aspect of head of Fibula

2. Superior quarter of posterior Fibula

3. Soleal line & medial border of Tibia

Tibial nerve (S1, S2)

1. Plantar-flexes foot 2. Steadies leg on foot, against

gravity 3. Multipennate fibres passing

postero-inferiorly, between two aponeurotic sheets

4. Aids in Calf Pump, to return blood to heart.

Plantaris 1. Inferior end of lateral

supracondylar line of Femur 2. Oblique popliteal ligament

Lies between Gastrocnemius and Soleus. Fibres merge with them, and the common Calceneal Tendon

Tibial nerve (S1, S2) Weakly assist Gastrocnemius in plantar-flexing foot & flexing knee.


DEEP MUSCLES

Separated from superficial group, by the Superficial Transverse Septum. This lies between the medial border of the Tibia, and the posterior border of the Fibula. The Deep Transverse Septum lies between the vertical line of the Tibia, and the medial crest of the Fibula.


Popliteus Lateral surface of lateral condyle of Femur + lateral meniscus

Posterior surface of Tibia (superior to the Soleal Line)

Tibial Nerve (L4, L5, S1)

1. Weakly flexes knee 2. Unlock knee from screw

home position, by laterally rotating Femur on fixed Tibia (or vice-versa).

Flexor Hallucis Longus

1. Inferior 2/3 posterior Fibula 2. Inferior part of Interosseous

Membrane

Base of distal phalanx of Hallux (big toe)

Tibial Nerve (S2, S3)

1. Flexes Hallux at MP and IP joints

2. Plantar-flexes foot 3. Supports longitudinal arch

of foot

Flexor Digitorum Longus

1. Medial part of posterior surface of Tibia (inferior to Soleal Line)

2. Broad aponeurosis to Fibula

Bases of distal phalanges of lateral 4 digits

Tibial Nerve (S2, S3)

1. Flexes lateral 4 digits at MP and IP joints

2. Plantar-flexes foot 3. Supports longitudinal arch

of foot

Tibialis Posterior

1. Interosseous membrane 2. Posterior Tibia (inferior to

Soleal Line) 3. Posterior surface of Fibula

1. Tuberosity of navicular, cuneiform & cuboid bones

2. Bases of 2nd, 3rd, & 4th Metatarsals

Tibial Nerve (L4, L5) 1. Plantar-flexion at ankle 2. Inversion at sub-Talar joint

complex


TIBIAL NERVE

Supplies all muscles of the posterior compartment. Arises as the larger of the two terminal branches of the Sciatic Nerve.

Contains anterior branches of the ventral primary rami of L4 to S3.

Descends through popliteal fossa, posterior to Popliteal vessels. Descends deep to tendonous arch of origin of Soleus, and descends leg,

deep to Soleus.

Runs inferiorly on Tibialis Posterior, with Posterior Tibial vessels. Leaves leg, by passing beneath Flexor Retinaculum, between medial

malleolus and Calcaneus lies between Posterior Tibial vessels, and Flexor Hallucis Longus.

Postero-inferiorly to Medial Malleolus, it divides into Medial & Lateral Plantar Nerves.

Branches: Muscular branches to all muscles in posterior compartment. Medial Sural Cutaneous Nerve unites with communicating branch of

Common Peroneal nerve, to form the Sural Nerve.

Sural Nerve supplies skin on postero-lateral of inferior third of leg + lateral foot.

Articular branches to knee joint. Medial Calcaneal branches to skin of heel (including weight-bearing

surface).

Damaged during lacerations of the popliteal fossa, or posterior displacements of the knee:

Paralysis of posterior compartment muscles + intrinsic muscles of sole.

Unable to curl toes or stand on them. Loss of plantar-flexion. Loss of sensation to sole of foot vulnerable to pressure sores.

STRUCTURES UNDER THE FLEXOR RETINACUL UM

From medial to lateral:

1. Tibialis Posterior 2. Flexor Digitorum Longus 3. Posterior Tibial Artery 4. Tibial Nerve 5. Flexor Hallucis Longus


ARTERIAL SUPPLY

The Popliteal artery is a continuation of the Femoral artery. It terminated by dividing into the Anterior and Posterior Tibial arteries, at the inferior border of Popliteus. The Anterior Tibial artery leaves the posterior compartment above or through the Interosseous membrane.

POSTERIOR TIBIAL ARTERY

Descends deep to the origin of Soleus. Accompanies by Tibial nerve and 2 venae comitantes (deep to Transverse Intermuscular Septum) Runs posterior to Medial Malleolus separated from it by tendons of Tibialis Posterior and Flexor Digitorum Longus. Runs deep to Flexor Retinaculum, between tendons of FDL and FHL. Here it divides into Medial & Lateral Plantar arteries. Branches include: muscular branches: Peroneal Artery Circumflex Fibula Artery arises near the Posterior Tibial arterys origin, and passes laterally over neck of Fibula, to join the anastomosis at the knee. Nutrient Artery to Tibia proximal branch that enters nutrient foramen, just distal to Soleal Line on posterior surface of Tibia. (medial) Calceneal branches joins branches from Peroneal artery, to form an anastomosis around the ankle.

PERONEAL ARTERY

Branches 2.5 cm inferior to lower border of Popliteus. Descends obliquely towards Fibula, and then along medial side of Fibula lies in a fibrous tunnel, in front of or within FHL. Muscular branches to Popliteus + other muscles in posterior & lateral compartments of leg. Supplies Nutrient Artery to Fibula + communicating branch to Posterior Tibial artery. Lateral Calceneal branches, contribute to anastomosis around ankle. Pierces interosseous membrane, enters dorsum of foot, and anastomoses with Arcuate Artery.

All arteries are accompanied by venae comitantes, which drain into the Popliteal Vein.


EXTENSOR COMPARTMENT OF LEG

EXTENSOR RETINACULA

SUPERIOR EXTENSOR RETINACULUM

Broad, rectangular shaped. (2 cm deep). Proximal to ankle joint. Attached to: Medial surface of Tibia Triangular subcutaneous surface of Fibula.

INFERIOR EXTENSOR RETINACULUM

Y-shaped, lying transversely. Stem attached to upper surface of Calcaneus. Proximal limb attached to medial malleolus of Tibia. Distal limb blends with deep fascia on medial side of foot.

Tendons that pass inferior to the retinacula, have synovial sheaths. Inflammation of sheaths = tendosynovitus Pain, local swelling and Crepitis sound of crinkling tissue paper.

BOUNDARIES

1. Lateral surface of Tibia 2. Interosseous Membrane 3. Extensor Surface of Fibula 4. Anterior (Crural) Intermuscular Septum 5. Overlying (Crural) Fascia


MUSCLES OF THE ANTERIOR COMPARTMENT


Tibialis Anterior

1. Lateral condyle of Tibia 2. Superior 2/3 of lateral

surface of Tibia 3. Interosseous membrane

1. Circumpennate fibres form a tendon that splits superior extensor retinaculum.

2. Medial & inferior surfaces of medial cuneiform

3. Base of 1st metatarsal

Deep Peroneal Nerve (L4, L5) 1. Dorsi-flexion at ankle 2. Inversion at sub-talar joint

complex

Extensor Hallucis Longus

1. Central part of extensor (anterior) surface of Fibula

2. Adjacent interosseous membrane

Dorsal aspect of base of distal phalanx of Hallux

Deep Peroneal Nerve (L5, S1)

1. Extends big toe 2. Dorsi-flexes foot at ankle

Extensor Digitorum Longus

(unipennate)

1. Lateral condyle of Tibia 2. Superior of extensor

surface of Fibula 3. Interosseous membrane

1. Tendon divides into 4, deep to inferior extensor retinaculum.

2. Dorsal expansion at proximal phalanx of 2nd to 5th digit

3. Central slip attaches to base of middle phalanx

4. 2 collateral slips attach to base of distal phalanx

1. Extension of lateral 4 toes 2. Dorsi-flexion at ankle 3. May assist eversion at sub-

talar joint complex

Peroneus Tertius 1. Distal extensor surface of

Fibula 2. Interosseous membrane

Base of dorsum of 5th metatarsal an expansion continues down its superior surface.

1. Eversion 2. Dorsi-flexion


Extensor Digitorum Brevis

1. Upper surface of Calcaneus 2. Stem of Inferior Extensor

Retinaculum

1. Base of proximal phalanx of Hallux

2. Under tendons of EDL, to respective dorsal expansion

Deep Peroneal Nerve

1. Aids extension of MP and IP joints.

2. EDB action is independent of ankle joint compensates for the weakened action of EDL prior to take-off (when ankle is dorsi-flexed)

1st Dorsal Interosseous

1st and 2nd metatarsal sides Extensor expansion of 2nd toe Lateral Plantar Nerve (S2, S3) 1. Abducts 2nd digit medially 2. Flexes MP joint


DEEP PERONEAL NERVE

Terminal branch of the Common Peroneal Nerve begins between Fibula and Peroneus Longus

Exposed here dangerous: Easily pressed against bone Damaged during fracture of neck of Fibula Pressure from plaster-cast

Damage could lead to motor and sensor problems. (Foot drop)

Runs infero-medially down Fibula, deep to EDL. Pierces Anterior Intermuscular Septum, and EDL. Descends anterior compartment of leg, over interosseous membrane. Travels down between Extensor Hallucis Longus and Tibialis Anterior

accompanied by Anterior Tibial Artery.

Passes deep to Superior Extensor Retinaculum, enters centre of foot (between two malleoli).

Deep to Inferior Extensor Retinaculum, divides into a medial and lateral branch.

Medial branch passes over Tarsals, and 1st Dorsal Interossei. Divides to supply skin in cleft between 1st & 2nd digit.

Lateral branch supplies Extensor Digitorum Brevis.

Supplies: All muscles of anterior compartment Branches to Posterior Tibial and Peroneal arteries Articular branches to ankle and tarsal joints. Cutaneous supply between 1st and 2nd digits

ANTERIOR TIBIAL ARTE RY

Smaller terminal branch of Popliteal artery begins opposite the inferior margin of Popliteus.

Descends down the leg with the Deep Peroneal nerve, between Extensor Hallucis Longus and Tibialis Anterior muscles.

Distally in leg, it lies more superficially on the Tibia. Terminates at ankle joint, as it enters the foot, centrally between the two

malleoli hereafter called the Dorsalis Pedes artery. Supplies: Muscles of anterior compartment Anterior Tibial recurrent arteries join anastomosis around knee. Medial & lateral Anterior Malleoli arteries join anastomosis around

ankle.

DORSALIS PEDES ARTERY

Runs down tarsals gives off Lateral Tarsal Artery Which forms Arcuate artery.

Arcuate artery runs across bases of tarsals Gives off 3 dorsal metatarsal arteries. Each of these then divide into 2 digital branches that supply the toes.

At 1st metatarsal space, it gives off 1st Dorsal Metatarsal artery Enters the sole of the foot, where it forms the Plantar Arch, by

anastomosis with the Lateral Plantar artery.


PERONEAL (LATERAL) COMPARTMENT OF LEG

BOUNDARIES

1. lateral surface of Fibula 2. Anterior (Crural) Intermuscular Septum 3. Posterior (Crural) Intermuscular Septum 4. Overlying (Crural) Fascia

PERONEAL RETINACULA

Superior Peroneal Retinaculum holds tendons of Peroneus muscles against the back of the Lateral Malleolus.

Origin = Lateral Malleolus Insertion = Calcaneus

Inferior Peroneal Retinaculum divided into a Superior Compartment (Peroneus Brevis), and an Inferior Compartment (Peroneus Longus).

Lies over the Peroneal Trochlea of the Calcaneus (lateral aspect).

SUPERFICIAL PERONEAL NERVE

Terminal branch of the Common Peroneal Nerve begins between Fibula and Peroneus Longus

Lies antero-lateral to Fibula, in between Peroneal Muscles, and Extensor Digitorum Longus.

Supplies peroneal muscles. Pierces deep fascia, to lie superficial in distal 1/3 of leg travels along

anterior margin of Peroneus Brevis.

Cutaneous supply to: (via medial & intermediate terminal branches) Distal part of anterior surface of leg. Nearly all of dorsum of foot. Most of the digits.

ARTERIAL SUPPLY

There are no arteries in the Peroneal Compartment, except for muscular branches of the Peroneal Artery (branch of Posterior Tibial artery), to the Peroneal muscles.


MUSCLES OF LATERAL C OMPARTMENT


Peroneus Longus 1. Head of Fibula 2. Superior 2/3 of lateral

surface of Fibula

1. Crosses lateral edge of Calcaneus of foot, to the base of 1st metatarsal

2. Medial Cuneiform bone

Superficial Peroneal Nerve (L5, S1, S2)

1. Eversion of foot 2. Weak plantar-flexion

Peroneus Brevis Inferior 2/3 of lateral surface of Fibula (Brevis in front of Longus at overlap)

Dorsal surface of tuberosity on lateral side of base of 5th metatarsal Tuberosity of 5th metatarsal can be avulsed during violent inversion of foot; causing damage to superficial peroneal

nerve paralysed inverted foot.


THE ANKLE JOINT

ARTICULAR SURFACES

Articular surface of Lateral Malleolus of Fibula (faces medially). Inferior surface of Tibia wider anteriorly than posteriorly. Lateral surface of Medial Malleolus of Tibia. Trochlea of Talus convex antero-posteriorly, concave side to side, and wider anteriorly. Lateral aspect of Talus triangular facet. Medial aspect of Talus comma-shaped facet. Neck of Talus is enclosed within capsule. Related to an intra-capsular, but extra-synovial fat pad.

LIGAMENTS

LATERAL COLLATERAL

Anterior Talo-Fibular Ligament Flat band weak. Lateral malleolus neck of Talus.

Posterior Talo-Fibular Ligament Thick, strong band. Malleolar Fossa of Fibula Lateral Tubercle of posterior process of

Talus

Calcaneo-fibular Ligament Round cord Tip of lateral malleolus of Fibula lateral surface of Calcaneus

(runs postero-inferiorly)

MEDIAL COLLATERAL (DELTOID)

Superficial Part crosses ankle and sub-talar joint complex. Apex = Medial Malleolus of Tibia Base = Tuberosity of Nacicular Medial edge of Spring Ligament Sustentaculum Tali of Calcaneus Medial tubercle of posterior process of Talus

Deep Part crosses ankle only Medial Malleolus area below comma-shaped facet on medial

aspect of Talus.

Anterior parts resists Plantar-flexion, while posterior parts resists Dorsi-flexion.


NEUROVASCULAR SUPPLY TO ANKLE

Malleolar anastomosis between Anterior Tibial artery, and Posterior Tibial & Peroneal arteries. Articular nerves are branches of Tibial & Deep Peroneal nerves.

MOVEMENTS

DORSI-FLEXION

Range of motion is 0 to 35 Maximum congruence between articulating surfaces during dorsi-flexion stability. Also: maximum tension in ligaments.

This is the position used for the origin of all locomotive movements. Aids stability when walking down a slope.

Involves: Tibialis Anterior Extensor Hallucis Longus Extensor Digitorum Longus Peroneus Tertius

PLANTAR-FLEXION

Range of motion is 0 to -55 Smallest area of Talus in contact with mortise less stable. Involves: Triceps Surae (Gastrocnemius & Soleus) Plantaris Longus Flexor Hallucis Longus Flexor Digitorum Longus Tibialis Posterior Peroneus Longus Peroneus Brevis


SUB-TALAR JOINT COMPLEX

Sub-talar joint complex comprises of the TC joint, and the TC part of the TCN joint.

TALO-CALCANEAL JOINT ( S U B - TA L A R J O I N T )

Articular Facets: Oval facet on posterior (inferior) surface of Talus Oval facet on upper surface of Calcaneus. Long axis of facet lies obliquely.

Fibrous capsule attached close to articular margins short fibres.

In front of articular surfaces are: Sulcus Tali Sulcus Calcaneus

Associated with transmission of body weight to lateral longitudinal arch.

TALO-CALCANEO-NAVICULAR JOINT

Multi-axial, ball and socket joint. Socket facets: Calcaneus: Facet on upper surface of Sustentaculum Tali. Facet on anterior part of superior surface.

Concave articular facet on posterior surface of Navicular. Spring Ligament (Plantar Calcaneo-navicular Ligament). Origin = anterior margin & medial border of Sustentaculum

Tali.

Insertion = plantar surface of Navicular. Function = prevents body weight driving Talus head

downwards + prevents collapse of medial longitudinal arch.

(Tendon of Tibialis Posterior acts as a sling, to provide inferior support for the ligament).

Medial Limb of Bifurcate Ligament. Base of V attached to dorsal surface of Calcaneus. Medial limb attached to Navicular. (Lateral limb attached to Cuboid).

Ball = head of Talus, and neck of Talus up to Sulcus Tali. Fibrous capsule attached to articular margins, and articular ligaments. Lined with synovial membrane (covering non-articular surfaces).

Associated with transmission of body weight to medial longitudinal arch.

Form the Tarsal Canal (contains 2 intrinsic ligaments) }


INTRINSIC LIGAMENTS

interosseous Talo-Calcaneal Ligament Lies within the Tarsal Canal, as a thickening of the adjacent fibrous

capsules of the TC & TCN joints.

Resists eversion. Ligament of Neck of Talus Origin lateral end of Tarsal Canal. Attachment Calcaneus & Neck of Talus. Tight in inversion.

Talus bound to Calcaneus by: Fibrous capsule of TC and TCN joint. Interosseous Talo-Calcaneal Ligament. Ligament of Neck of Talus. Parts of medial & lateral Collateral Ligaments of ankle.

MOVEMENTS

Axis for inversion: from lateral process of Calcaneus Runs supero-medially, and bisects the Tarsal Canal. Lies below TC joint, and above TCN joint.

Inversion: By Tibialis Anterior & Posterior muscles. Checked by: 1. Calcaneo-Fibula Ligament (laterally)

2. Ligament of Neck of Talus

Eversion: By Peroneus Longus, Brevis & Tertius, and by EDL. Checked by: 1. Deltoid Ligament (medially)

2. Interosseous Talo-Calcaneal Ligament

.


CALCANEO-CUBOID JOINT

Articular surfaces: (quadrilateral, reciprocally convex/concave) Anterior surface of Calcaneus Posterior surface of Cuboid

Simple capsule, thickened above & below.

CC joint + TN part of TCN joint = Transverse Tarsal Joint.

Transverse Tarsal joint involves inversion/eversion, as well as some gliding/rotation.

INTRINSIC LIGAMENTS

Plantar Calcaneo-Cuboid Ligament (Short Plantar Ligament) Origin = just behind articular margin of Calcaneus Insertion = plantar surface of Cuboid, up to groove for Peroneus Longus.

Long Plantar Ligament Origin = posterior surface of Calcaneus Insertion = distal on Cuboid + 1st, 2nd & 3rd Metatarsals. Converts groove for Peroneus Longus, into a tunnel. Lies superficial to Short Plantar Ligament covers it, except for its medial edge.

Lateral Limb of Bifurcate Ligament supports dorsal aspect of CC Joint.


THE FOOT

1 S T LAYER OF PLANTAR MUS CLES


Abductor Hallucis Calcaneus Medial side of base of proximal phalanx of hallux

Medial Plantar Nerve (S2, S3)

1. Abducts big toes 2. Flexes bit toe 3. Supports medial longitudinal

arch

Flexor Digitorum Brevis

Calcaneus Middle phalanges of 2nd to 5th toes

1. Flexes lateral four toes 2. Supports medial and lateral

longitudinal arches

Abductor Digiti Minimi

Calcaneus Lateral side of base of proximal phalanx of 5th digit

Lateral Plantar Nerve (S2, S3)

1. Abducts little toe 2. Flexes little toe 3. Supports lateral longitudinal

arch

2 N D LAYER OF PLANTAR MUSCLES


Flexor Digitorum Accessorius (Plantae Quadratus)

2 heads from plantar surface of Calcaneus

Postero lateral margin of tendon of Flexor Digitorum Longus

Lateral Plantar Nerve (S2, S3) Assists FDL in flexing lateral 4 toes

Lumbricals Tendon of FDL

1. Medial sides of proximal phalanges of lateral 4 toes

2. Extensor expansions of tendons of EDL

Medial 1: Medial Plantar Nerve Lateral 3: Lateral Plantar Nerve

(S2, S3)

1. Flex MP-joints of lateral 4 toes

2. Extend IP-joints of lateral 4 toes

Tendon of Flexor Hallucis Longus and tendons of Flexor Digitorum Longus, will act as muscular tie-bars to support the medial and lateral longitudinal arches.


3 R D LAYER OF PLANTAR MUSCLES


Flexor Hallucis Brevis

1. Cuboid 2. Lateral Cuneiform

Both sides of proximal phalanx of hallux (passes over 2 sesamoid bones)

Medial Plantar Nerve (S1, S2)

1. Flexes big toe at MP-joint

Adductor Hallucis

Oblique head bases of 2nd to 4th metatarsals Transverse head plantar ligaments of MP-joints

Both heads lateral side of base of proximal phalanx of hallux

Lateral Plantar Nerve (deep branch)

(S2, S3)

1. Adducts big toes 2. Flexes big toes 3. Transverse head Assists

maintaining transverse arch of foot

Flexor Digiti Minimi Base of 5th Metatarsal Base of proximal phalanx of 5th digit

Lateral Plantar Nerve (superficial branch)

(S2, S3) Aids flexion of little toe.

4 T H LAYER OF PLANTAR MUSCLES


Plantar Interossei (3) Bases and sides of 3rd to 5th metatarsals (unipennate)

Medial sides of bases of proximal phalanges of 3rd-5th toes

Lateral Plantar Nerves (S2, S3)

1. Adducts 2nd to 4th digits 2. Flexes MP-joints

Dorsal Interossei (4) Adjacent sides of 1st to 5th metatarsals (bipennate)

1st medial side of proximal phalanx of 2nd digit 2nd to 4th lateral sides of 2nd to 4th digits

1. Abducts 2nd to 4th digits 2. Flexes MP-joints

Tendon of Tibialis Posterior muscle lies in this layer. The tendon for Peroneus Longus also acts as a tie-bar for the transverse arch of the foot.


MUSCLES OF DORSUM OF FOOT


Extensor Digitorum Brevis

1. Anterior part of dorsum of Calcaneus

2. Inferior Extensor Retinaculum

Lateral edge of corresponding tendon of EDL, to the 2nd to 4th digit. Deep Peroneal Nerve (S1, S2)

Extends 2nd to 4th digits at MP-joints.

Extensor Hallucis Brevis

Base of proximal phalanx of Hallux

Extends big toes at MP-joint.

SUPPORTS OF ARCHES OF FOOT

MEDIAL LONGITUDINAL ARCH

1. Plantar Aponeurosis 2. Flexor Hallucis Longus 3. Abductor Hallucis 4. Spring Ligament 5. Tibialis Anterior (pulls on arch)

LATERAL LONGITUDINAL ARCH

1. Plantar Aponeurosis 2. Flexor Digitorum Brevis 3. Abductor Digiti Minimi 4. Long Plantar Ligament 5. Short Plantar Ligament 6. Peroneal Muscles (pull on arch)

TRANSVERSE ARCH

1. Peroneus Longus 2. Transverse head of Adductor Hallucis 3. Deep Transverse Ligament


ARTERIAL SUPPLY TO F OOT


CUTANEOUS NERVE DIST RIBUTION IN THE FOOT

Hip BoneIliumIschiumPubis

FemurSaphenous VeinsGreat Saphenous VeinSmall Saphenous VeinGeneral Venous Drainage

Cutaneous nervesFascia LataLymphatic Drainage of Anterior ThighAdductor MusclesObturator Nerve & ArteryObturator NerveObturator Artery

Flexor MusclesBoundariesThe Subsartorial CanalFemoral VeinFemoral ArteryFemoral SheathFemoral NerveGluteal MusclesGluteal NervesGluteal ArteriesSuperior Gluteal ArteryInferior Gluteal ArteryInternal Pudendal Artery

Gluteal VeinsGluteal VeinsInternal Pudendal Veins

Posterior Thigh MusclesArticular SurfacesInrinsic LigamentsInnervation to Hip JointArterial Supply to Hip JointArticular SurfacesArticular CapsuleSynovial CapsuleExternal Intrinsic LigamentsPatella LigamentFibular collateral LigamentTibial Collateral Ligamentoblique Popliteal LigamentArcuate Popliteal Ligament

Internal Intrinsic LigamentsAnterior CrucIate LigamentPosterior Cruciate Ligament

Menisci of the knee jointMedial MeniscusLateral Meniscus

Bursae Of the KneeSuperficial MusclesDeep MusclesTibial NerveStructures Under The Flexor RetinaculumArterial SupplyPosterior Tibial ArteryPeroneal Artery

Extensor RetinaculaSuperior Extensor RetinaculumInferior Extensor Retinaculum

BoundariesMuscles Of The Anterior CompartmentDeep Peroneal NerveAnterior Tibial ArteryDorsalis Pedes Artery

BoundariesPeroneal RetinaculASuperficial Peroneal NerveArterial SupplyMuscles of Lateral CompartmentArticular SurfacesLigamentsLateral CollateralMedial Collateral (Deltoid)

Neurovascular Supply to AnkleMovementsDorsi-FlexionPlantar-Flexion

Talo-Calcaneal Joint (sub-talar joint)Talo-Calcaneo-Navicular JointIntrinsic LigamentsMovementsCalcaneo-Cuboid JointIntrinsic Ligaments

1st Layer of Plantar Muscles2nd Layer of Plantar Muscles3rd Layer of Plantar Muscles4th layer of Plantar MusclesMuscles of Dorsum of FootSupports of Arches of FootMedial Longitudinal Arch

Arterial Supply To FootCutaneous Nerve Distribution in The Foot

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Lower Limb