THE LOWER LIMB I mpeg 2010withaudio

THE LOWER LIMB I:ANTERIOR AND MEDIAL THIGH : 

3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 1 THE LOWER LIMB I:ANTERIOR AND MEDIAL THIGH Dr. Bruce Giffin

Limb Dissections : 

Limb Dissections Front-loaded overviews of upper and lower limb lectures for each region Prepare for dissection by having a preliminary understanding of regional osteology, compartmetalization (muscle attachments, actions, nerve and blood supply) Each limb dissected by a two members of the team Dissection labs begin with lower limb followed by the upper limb Assigned dissections roughly follow lecture sequence As you dissect think about the actions of the muscles and deficits when not functioning No dissection of superficial structures – prosection only Plantar foot and knee joint studied via prosected specimens Surface anatomy exercises include clinical testing of muscle strength 2

EVOLUTION OF THE LOWER EXTREMITIES : 

3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 3 EVOLUTION OF THE LOWER EXTREMITIES

Problems of the lower extremity include: : 

3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 4 Problems of the lower extremity include: Peripheral nerve injuries Arthritis Varicose veins Ankle joint injuries Vascular deficiencies Bursitis Fractures Sprains Dislocations Lacerations Knee effusions Femoral hernia Pulled muscles

CLINICAL CORRELATION QUESTION: A 45-year-old woman complaining of abdominal pain and repeated vomiting was seen in the emergency room of University Hospital. On questioning, the patient stated that the pain was severe and colicky in nature and most intense in the region of the umbilicus. On examination, the patient showed obvious signs of dehydration, namely, dry skin, dry tongue, and sunken eyes. The abdomen showed no distention, but excessively loud bowel peristaltic sounds (borborygmi) could be heard with the stethoscope. A small, tender, tense swelling was found in the front of the left thigh. When the patient was asked to cough, there was no expansion of the swelling. The swelling was located below and lateral to the left pubic tubercle. The patient said she had first noticed the swelling about 3 years ago and that 2 days ago, after coughing, it had increased in size and became tender. What is your diagnosis? : 

3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 5 CLINICAL CORRELATION QUESTION: A 45-year-old woman complaining of abdominal pain and repeated vomiting was seen in the emergency room of University Hospital. On questioning, the patient stated that the pain was severe and colicky in nature and most intense in the region of the umbilicus. On examination, the patient showed obvious signs of dehydration, namely, dry skin, dry tongue, and sunken eyes. The abdomen showed no distention, but excessively loud bowel peristaltic sounds (borborygmi) could be heard with the stethoscope. A small, tender, tense swelling was found in the front of the left thigh. When the patient was asked to cough, there was no expansion of the swelling. The swelling was located below and lateral to the left pubic tubercle. The patient said she had first noticed the swelling about 3 years ago and that 2 days ago, after coughing, it had increased in size and became tender. What is your diagnosis?

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3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 6

OSTEOLOGY OF THE FEMUR(A self-study activity) : 

3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 7 OSTEOLOGY OF THE FEMUR(A self-study activity)

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Fractures of the femoral shaft : 

3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 9 Fractures of the femoral shaft

Innervation of the myotomes of the lower limb by multiple spinal cord levels : 

3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 10 Innervation of the myotomes of the lower limb by multiple spinal cord levels Development of nerve plexus pattern Sciatic nerve myotomes NERVE PLEXUSES:Myotomes undergo migration and drag their somite nerves wherever they go.Many of the extremity muscles contain contributions from more than one myotome.During development , axons from multiple spinal cord levels intermingle and form a plexus.

CUTANEOUS INNERVATION OF THE SKIN OF THE ANTERIOR AND MEDIAL THIGH : 

3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 11 CUTANEOUS INNERVATION OF THE SKIN OF THE ANTERIOR AND MEDIAL THIGH IN THE CLINIC: Clinicians refer to the intermediate and medial cutaneous nerves of the thigh as the ANTERIOR CUTANEOUS NERVE OF THE THIGH.

IN THE CLINIC:Compression of the lateral cutaneous nerve of the thigh can cause abnormal sensations (tingling, burning) in the distribution of this nerve. This is a common occurrence in obesity. : 

3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 12 IN THE CLINIC:Compression of the lateral cutaneous nerve of the thigh can cause abnormal sensations (tingling, burning) in the distribution of this nerve. This is a common occurrence in obesity.

Mature dermatomes (areas of skin supplied by cutaneous branches from a single spinal nerve) spiral down the limbs during medial rotation of the lower limbs (6th – 8th weeks) : 

3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 13 Mature dermatomes (areas of skin supplied by cutaneous branches from a single spinal nerve) spiral down the limbs during medial rotation of the lower limbs (6th – 8th weeks)

Dermatomes L1-L5: anterior region-Dermatomes S1-S2: posterior region-Dermatomes S3-S5: coccygeal region : 

3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 14 Dermatomes L1-L5: anterior region-Dermatomes S1-S2: posterior region-Dermatomes S3-S5: coccygeal region

IN THE CLINIC: Testing abnormalities of sensory function. In most instances, more than one segment of the spinal cord is supplying an area of skin with cutaneous innervation. The peripheral nerve distribution of the major cutaneous nerves must be interpreted as anatomically different from the dermatomal distribution of the spinal cord segments. To test for pain sensation, a sharp object is used. Drag it over the dermatomes and keep asking whether the “pinprick” sensation is felt. If sensory loss to pain exists, the spinal cord segment(s) involved can be determined – if you know your dermatomal distributions! : 

3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 15 IN THE CLINIC: Testing abnormalities of sensory function. In most instances, more than one segment of the spinal cord is supplying an area of skin with cutaneous innervation. The peripheral nerve distribution of the major cutaneous nerves must be interpreted as anatomically different from the dermatomal distribution of the spinal cord segments. To test for pain sensation, a sharp object is used. Drag it over the dermatomes and keep asking whether the “pinprick” sensation is felt. If sensory loss to pain exists, the spinal cord segment(s) involved can be determined – if you know your dermatomal distributions!

SUPERFICIAL VEINS : 

3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 16 SUPERFICIAL VEINS

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3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 18 IN THE CLINIC: Varicose veins form when valves of the superficial veins become incompetent. Gravity causes an increase in the intralaminar pressure of the superficial veins, which then become tortuous and dilated.

THE INGUINAL LYMPH NODES : 

3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 19 THE INGUINAL LYMPH NODES

Enlarged inguinal lymph nodes : 

3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 20 Enlarged inguinal lymph nodes IN THE CLINIC: The superficial and deep inguinal node drain the lower limb and skin and superficial fascia of the anterior and posterior abdominal walls below the umbilicus. Lymph from the external genitalia and the mucous membrane of the lower half of the anal canal also drains into these nodes.

Long saphenous vein, its tributaries and superficial inguinal lymph nodes lying in superficial fascia : 

3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 21 Long saphenous vein, its tributaries and superficial inguinal lymph nodes lying in superficial fascia

THE FASCIA OF THE THIGH : 

3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 22 THE FASCIA OF THE THIGH

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FASCIAL COMPARTMENTS OF THE THIGH : 

3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 24 FASCIAL COMPARTMENTS OF THE THIGH

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3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 25 ANTERIOR COMPARTMENT POSTERIOR COMPARTMENT Dorsiflexion Plantarflexion

MOVEMENTS OF THE THIGH AT THE HIP JOINT : 

3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 26 MOVEMENTS OF THE THIGH AT THE HIP JOINT

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3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 27 From the (Fredonia New York) Leader

THE ANTERIOR COMPARTMENT OF THE THIGH : 

3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 28 THE ANTERIOR COMPARTMENT OF THE THIGH IT IS AN EXTENSOR COMPARTMENT THE MUSCLES ARE INNERVATED BY THE FEMORAL NERVE THE BLOOD SUPPLY IS VIA THE FEMORAL ARTERY

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3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 29 Muscles that ENTER the anterior compartment and flex the thigh

Muscles of the anterior compartment of the thigh after removal of the skin and fascia lata : 

3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 30 Muscles of the anterior compartment of the thigh after removal of the skin and fascia lata

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Muscles of the anterior compartment of the thigh after removal of the skin and fascia lata : 

3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 33 Muscles of the anterior compartment of the thigh after removal of the skin and fascia lata

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3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 34 QUADRICEPS FEMORIS

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3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 35 QUADRICEPS FEMORIS (rectus femoris removed)

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Muscles comprising quadriceps femoris. The sartorius and tensor fasciae latae have been cut. : 

3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 38 Muscles comprising quadriceps femoris. The sartorius and tensor fasciae latae have been cut.

Quadriceps femoris. Vastus intermedius is partially revealed by removal of the rectus femoris. : 

3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 39 Quadriceps femoris. Vastus intermedius is partially revealed by removal of the rectus femoris.

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3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 40 Tensor fasciae latae

Attachment of gluteus maximus and tensor fasciae latae to the iliotibial tract. : 

3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 41 Attachment of gluteus maximus and tensor fasciae latae to the iliotibial tract.

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IN THE CLINIC: Iliotibial band (ITB) friction syndrome is a common cause of lateral knee pain, particularly among runners, military personnel, and cyclists. Predisposing factors (excessive amount of friction between the ITB itself and the lateral femoral epicondyle) for the development of IT band inflammation include training error and abnormal biomechanics. Some runners make the mistake of only running on one side of the road. Most roads are higher in the center and slope off on either side. The foot that is on the outside part of the road is therefore lower than the other. This causes the pelvis to tilt to one side and stresses the IT band. The biomechanical abnormalities that may lead to IT band problems are, excessive pronation of the foot, leg length discrepancy, lateral pelvic tilt, and "bowed" legs. : 

3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 44 IN THE CLINIC: Iliotibial band (ITB) friction syndrome is a common cause of lateral knee pain, particularly among runners, military personnel, and cyclists. Predisposing factors (excessive amount of friction between the ITB itself and the lateral femoral epicondyle) for the development of IT band inflammation include training error and abnormal biomechanics. Some runners make the mistake of only running on one side of the road. Most roads are higher in the center and slope off on either side. The foot that is on the outside part of the road is therefore lower than the other. This causes the pelvis to tilt to one side and stresses the IT band. The biomechanical abnormalities that may lead to IT band problems are, excessive pronation of the foot, leg length discrepancy, lateral pelvic tilt, and "bowed" legs. Location of pain

THE FEMORAL TRIANGLE : 

3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 45 THE FEMORAL TRIANGLE

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3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 46 BOUNDARIES OF THE FEMORAL TRIANGLE Lateral

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3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 47 THE FLOOR AND CONTENTS OF THE FEMORAL TRIANGLE Lateral

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3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 48 CONTENTS OF THE FEMORAL TRIANGLE Note: This is now lateral

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3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 49 THE FEMORAL SHEATH

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Contents of the femoral triangle exposed by removal of its roof (fascia lata). : 

3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 52 Contents of the femoral triangle exposed by removal of its roof (fascia lata).

Floor of the femoral triangle after removal of its roof and contents : 

3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 53 Floor of the femoral triangle after removal of its roof and contents

THE ADDUCTOR CANAL (SUBSARTORIAL TUNNEL) : 

3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 54 THE ADDUCTOR CANAL (SUBSARTORIAL TUNNEL)

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3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 55

Contents (femoral artery and vein, saphenous nerve, deep lymph vessels) and boundaries of the subsartorial canal exposed by displacement of the sartorius muscle laterally : 

3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 56 Contents (femoral artery and vein, saphenous nerve, deep lymph vessels) and boundaries of the subsartorial canal exposed by displacement of the sartorius muscle laterally Anterior boundary Posterior boundary (and adductor magnus) Vastus medialis (lateral boundary)

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3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 57 FEMORAL HERNIA

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3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 58 FEMORAL HERNIA

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3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 59 Femoral artery in the adductor canal (view: anterior thigh) Femoral artery emerging from the adductor hiatus as the popliteal artery (view: posterior thigh)

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3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 60

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3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 61 The femoral artery is the principal supply to the anterior compartment of the thigh, as well as the rest of the lower limb.Its branches are: superficial iliac circumflex. This branch travels along the lower border of the inguinal ligament and supplies lower abdomen and upper thigh. superficial epigastric to region of umbilicus external (superficial and deep) pudendal. These branches suppliy superficial perineal structures. profunda femoris . The deep (profunda) femoris artery descends along the attached margin of the adductor magnus muscle, giving rise to perforating branches; lateral femoral circumflex. The lateral circumflex travels around the anterior surface of the surgical neck of the femur and anastomoses with the medial circumflex. medial femoral circumflex. The medial circumflex travels around the posterior surface of the neck of the femur. descending genicular to the knee joint The femoral artery changes its name to become the popliteal artery after it passes through the adductor hiatus. BLOOD SUPPLY OF THE ANTERIOR COMPARTMENT OF THE THIGH

Profunda femoris vessels seen after removal of segments of the femoral artery and vein : 

3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 62 Profunda femoris vessels seen after removal of segments of the femoral artery and vein

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3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 63

THE FEMORAL VEIN AND ITS TRIBUTARIES : 

3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 64 THE FEMORAL VEIN AND ITS TRIBUTARIES

ANTERIOR COMPARTMENT NERVE SUPPLY : 

3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 65 ANTERIOR COMPARTMENT NERVE SUPPLY

IN THE CLINIC: The knee-jerk (patellar) reflex tests both afferent and efferent divisions of the L4 femoral nerve component. Injury, usually as a result of trauma to the femoral triangle, produces weakness of hip flexion with the inability to extend the knee, as indicated by loss of the patellar reflex. Also there will be anesthesia over the anterior thigh and medial leg. : 

3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 66 IN THE CLINIC: The knee-jerk (patellar) reflex tests both afferent and efferent divisions of the L4 femoral nerve component. Injury, usually as a result of trauma to the femoral triangle, produces weakness of hip flexion with the inability to extend the knee, as indicated by loss of the patellar reflex. Also there will be anesthesia over the anterior thigh and medial leg.

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3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 67 This is from an International House of Pancakes place mat!

THE MEDIAL COMPARTMENT OF THE THIGH : 

3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 68 THE MEDIAL COMPARTMENT OF THE THIGH IS AN ADDUCTOR COMPARTMENT MUSCLES HAVE THEIR ORIGIN ON BONE AROUND THE OBTURATOR FORAMEN AND INSERT INTO THE FEMUR

THE MEDIAL COMPARTMENT OF THE THIGH : 

3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 69 THE MEDIAL COMPARTMENT OF THE THIGH MOST MUSCLES INNERVATED BY THE OBTURATOR NERVE BLOOD SUPPLY VIA PROFUNDA FEMORIS AND OBTURATOR ARTERIES

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Anterior layer of muscles of the medial compartment of the thigh revealed by removal of the fascia lata : 

3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 72 Anterior layer of muscles of the medial compartment of the thigh revealed by removal of the fascia lata

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3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 73

Anterior layer of muscles of the medial compartment of the thigh revealed by removal of the fascia lata : 

3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 74 Anterior layer of muscles of the medial compartment of the thigh revealed by removal of the fascia lata

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Adductor brevis and branches of the anterior division of the obturator nerve revealed by removal of part of the adductor longus : 

3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 76 Adductor brevis and branches of the anterior division of the obturator nerve revealed by removal of part of the adductor longus

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3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 77 Has HAMSTRING PART (extends thigh-tibial division of sciatic nerve) and ADDUCTOR PART (obturator nerve)

Adductor magnus and the posterior division of the obturator nerve. Adductor brevis has been removed. : 

3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 78 Adductor magnus and the posterior division of the obturator nerve. Adductor brevis has been removed.

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3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 79 IN THE CLINIC: This muscle is whimpy and is sometimes transplanted along with its nerve and blood supply to replace a damaged muscle (e.g., in the hand).

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Anterior layer of muscles of the medial compartment of the thigh revealed by removal of the fascia lata : 

3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 81 Anterior layer of muscles of the medial compartment of the thigh revealed by removal of the fascia lata

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Obturator externus completely revealed by removal of parts of the iliopsoas and adductor magnus : 

3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 83 Obturator externus completely revealed by removal of parts of the iliopsoas and adductor magnus

IN THE CLINIC: The muscles involved in a groin pull are the thigh adductors. Pain is located in the groin down to the middle of the thigh and is made worse by hip abduction (like doing a split). A variety of activities can stretch or tear the adductor muscles at their tendinous origins around the obturator foramen: running, skating, kicking in soccer, playing basketball and hockey, etc.). : 

3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 84 IN THE CLINIC: The muscles involved in a groin pull are the thigh adductors. Pain is located in the groin down to the middle of the thigh and is made worse by hip abduction (like doing a split). A variety of activities can stretch or tear the adductor muscles at their tendinous origins around the obturator foramen: running, skating, kicking in soccer, playing basketball and hockey, etc.). Teemu Selanne is scratched with a pulled groin muscle.

BLOOD SUPPLY TO THE MEDIAL COMPARTMENT : 

3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 85 BLOOD SUPPLY TO THE MEDIAL COMPARTMENT The distribution of the obturator artery (right side)

MEDIAL COMPARTMENT: NERVE SUPPLY : 

3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 86 MEDIAL COMPARTMENT: NERVE SUPPLY

Divisions of the obturator nerve revealed by removal of the adductor longus and part of the pectineus. In this specimen the posterior division lies in front of the obturator externus. : 

3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 87 Divisions of the obturator nerve revealed by removal of the adductor longus and part of the pectineus. In this specimen the posterior division lies in front of the obturator externus.

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3/1/2011 LOWER LIMB I: ANTERIOR AND MEDIAL THIGH 88 THE END