Lower Limb

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Lower Limb : 

Lower Limb By Dr. Seharish Zulfiqar Asstt. Prof. Anatomy Dept. University Medical & Dental College Faisalabad, Pakistan.

Femur : 

Femur

The Muscles and Fasciæ of the Iliac Region : 

The Muscles and Fasciæ of the Iliac Region

Slide 16: 

The muscles of the lower extremity are subdivided into groups corresponding with the different regions of the limb.  I. Muscles of the Iliac Region II. Muscles of the Thigh III. Muscles of the Leg IV. Muscles of the Foot

The Muscles of the Iliac Region : 

The Muscles of the Iliac Region Psoas major Psoas minor Iliacus

Fascia Covering the Psoas and Iliacus : 

Fascia Covering the Psoas and Iliacus Is thin above And becomes gradually thicker below as it approaches the inguinal ligament The portion covering the Psoas Is thickened above to form the medial lumbocostal arch which stretches from the transverse process of the first lumbar vertebra to the body of the second. Medially, it is attached by A series of arched processes to the intervertebral fibrocartilages, and prominent margins of the bodies of the vertebræ To the upper part of the sacrum The intervals left, opposite the constricted portions of the bodies, transmit the lumbar arteries and veins and filaments of the sympathetic trunk. Laterally, above the crest of the ilium, it is continuous with the fascia covering the front of the Quadratus lumborum While below the crest of the ilium it is continuous with the fascia covering the Iliacus.

Slide 22: 

The portions investing the Iliacus (fascia iliaca; iliac fascia) Is connected Laterally to the whole length of the inner lip of the iliac crest Medially, to the linea terminalis of the lesser pelvis Lateral to the femoral vessels it is intimately connected to the posterior margin of the inguinal ligament & is continuous with the transversalis fascia Immediately lateral to the femoral vessels the iliac fascia is prolonged backward and medialward from the inguinal ligament as a band, the iliopectineal fascia, which is attached to the iliopectineal eminence. This fascia divides the space between the inguinal ligament and the hip bone into two lacunæ or compartments The medial of which transmits the femoral vessels The lateral the Psoas major and Iliacus and the femoral nerve On the thigh the fasciæ of the Iliacus and Psoas form a single sheet termed the iliopectineal fascia. Where the external iliac vessels pass into the thigh, the fascia descends behind them, forming the posterior wall of the femoral sheath. The external iliac vessels lie in front of the iliac fascia, but all the branches of the lumbar plexus are behind it; it is separated from the peritoneum by a quantity of loose areolar tissue

The Muscles of the Iliac Region : 

The Muscles of the Iliac Region Psoas major Psoas minor Iliacus

Psoas Major : 

Psoas Major Origin: Anterior surfaces and lower borders of transverse processes of L1 - L5 Bodies and discs of T12 - L5 Insertion: Lesser trochanter Action: Flex the torso and thigh with respect to each other A large bursa which may communicate with the cavity of the hip-joint, separates the tendon from the pubis and the capsule of the joint.

Slide 26: 

Psoas Iliacus

Psoas Minor : 

Psoas Minor The Psoas minor is a long slender muscle, placed in front of the Psoas major. Origin: Sides of the bodies of the twelfth thoracic and first lumbar vertebræ From the fibrocartilage between them Insertion: It ends in a long flat tendon which is inserted into the pectineal line and iliopectineal eminence, and, by its lateral border, into the iliac fascia Action: The Psoas minor is a tensor of the iliac fascia

Iliacus : 

Iliacus Flat, triangular muscle, which fills the iliac fossa Origin: Internal lip of iliac crest Upper 2/3 of iliac fossa of ilium Lower portion of iliolumbar ligament Lateral aspect of sacrum Ventral sacroiliac ligament Insertion: Lesser trochanter Action: Flex the torso and thigh with respect to each other

Nerves : 

Nerves The Psoas major is supplied by branches of the second and third lumbar nerve The Psoas minor by a branch of the first lumbar nerve The Iliacus by branches of the second and third lumbar nerves through the femoral nerve

The Muscles and Fasciæ of the Thigh : 

The Muscles and Fasciæ of the Thigh

The Anterior Femoral Muscles : 

The Anterior Femoral Muscles Sartorius Quadriceps femoris Rectus femoris Vastus lateralis Vastus medialis Vastus intermedius Articularis genu

Superficial Fascia : 

Superficial Fascia The superficial fascia forms a continuous layer over the whole of the thigh It consists of areolar tissue containing in its meshes much fat, and may be separated into two or more layers, between which are found the superficial vessels and nerves It varies in thickness in different parts of the limb; in the groin it is thick, and the two layers are separated from one another by the Superficial inguinal lymph glands Great saphenous vein Several smaller vessels The superficial layer is continuous above with the superficial fascia of the abdomen The deep layer of the superficial fascia is Very thin Fibrous stratum, best marked on the medial side of the great saphenous vein and below the inguinal ligament It is placed beneath the subcutaneous vessels and nerves and upon the surface of the fascia lata It is intimately adherent to the fascia lata a little below the inguinal ligament It covers the fossa ovalis (saphenous opening), being closely united to its circumference, and is connected to the sheath of the femoral vessels The portion of fascia covering this fossa is perforated by The great saphenous vein Numerous blood and lymphatic vessels Hence it has been termed the fascia cribrosa A large subcutaneous bursa is found in the superficial fascia over the patella.

Deep Fascia : 

Deep Fascia The deep fascia of the thigh is named, from its great extent, the fascia lata It constitutes an investment for the whole of this region of the limb, but varies in thickness in different parts Thus, it is thicker in the upper and lateral part of the thigh, where it receives a fibrous expansion from the Glutæus maximus, and where the Tensor fasciæ latæ is inserted between its layers It is very thin behind and at the upper and medial part, where it covers the Adductor muscles It again becomes stronger around the knee, receiving fibrous expansions from the Tendon of the Biceps femoris laterally From the Sartorius medially From the Quadriceps femoris in front

Slide 36: 

The fascia lata is attached Above and behind, to the back of the sacrum and coccyx Laterally, to the iliac crest In front, to the Inguinal ligament The superior ramus of the pubis Medially, to the Inferior ramus of the pubis Inferior ramus and tuberosity of the ischium Lower border of the sacrotuberous ligament From its attachment to the iliac crest it passes down over the Glutæus medius to the upper border of the Glutæus maximus, where it splits into two layers, one passing superficial to and the other beneath this muscle; at the lower border of the muscle the two layers reunite. Laterally, the fascia lata receives the greater part of the tendon of insertion of the Glutæus maximus, and becomes proportionately thickened The portion of the fascia lata attached to the front part of the iliac crest, and corresponding to the origin of the Tensor fasciæ latæ, extends down the lateral side of the thigh as two layers, one superficial to and the other beneath this muscle; at the lower end of the muscle these two layers unite and form a strong band, having first received the insertion of the muscle. This band is continued downward, under the name of the iliotibial band (tractus iliotibialis) and is attached to the lateral condyle of the tibia.

Slide 38: 

The part of the iliotibial band which lies beneath the Tensor fasciæ latæ is prolonged upward to join the lateral part of the capsule of the hip-joint. Below, the fasciæ lata is attached to all the prominent points around the knee-joint, viz., the condyles of the femur and tibia, and the head of the fibula. On either side of the patella it is strengthened by transverse fibers from the lower parts of the Vasti, which are attached to and support this bone. Of these the lateral are the stronger, and are continuous with the iliotibial band. The deep surface of the fascia lata gives off two strong intermuscular septa, which are attached to the whole length of the linea aspera and its prolongations above and below The lateral and stronger one Extends from the insertion of the Glutæus maximus to the lateral condyle Separates the Vastus lateralis in front from the short head of the Biceps femoris behind, and gives partial origin to these muscles The medial and thinner one Separates the Vastus medialis from the Adductores and Pectineus Besides these there are numerous smaller septa, separating the individual muscles, and enclosing each in a distinct sheath

The Fossa Ovalis (saphenous opening) : 

The Fossa Ovalis (saphenous opening) At the upper and medial part of the thigh, a little below the medial end of the inguinal ligament, is a large oval-shaped aperture in the fascia lata It transmits the great saphenous vein, and other, smaller vessels, and is termed the fossa ovalis The fascia cribrosa, which is pierced by the structures passing through the opening, closes the aperture and must be removed to expose it. The fascia lata in this part of the thigh is described as consisting of a superficial and a deep portion

Slide 42: 

The superficial portion of the fascia lata is the part on the lateral side of the fossa ovalis It is attached Laterally, to the Crest Anterior superior spine of the ilium Whole length of the inguinal ligament Pectineal line in conjunction with the lacunar ligament From the tubercle of the pubis it is reflected downward and lateralward, as an arched margin, the falciform margin, forming the lateral boundary of the fossa ovalis This falciform margin overlies and is adherent to the anterior layer of the sheath of the femoral vessels: to its edge is attached the fascia cribrosa.

Slide 43: 

The deep portion is situated on the medial side of the fossa ovalis, and at the lower margin of the fossa is continuous with the superficial portion Traced upward, it covers the Pectineus, Adductor longus, and Gracilis, and, passing behind the sheath of the femoral vessels, to which it is closely united Is continuous with the iliopectineal fascia, and is attached to the pectineal line.   From this description it may be observed that the superficial portion of the fascia lata lies in front of the femoral vessels, and the deep portion behind them, so that an apparent aperture exists between the two, through which the great saphenous passes to join the femoral vein.

Tensor Fascia Lata : 

Tensor Fascia Lata Origin: Anterior superior iliac spine Outer lip of anterior iliac crest and fascia lata Insertion: Iliotibial band Action: Helps stabilize and steady the hip and+ knee joints by putting tension on the iliotibial band of fascia

Sartorius : 

Sartorius Origin: Anterior superior iliac spine Insertion: Superior aspect of the medial surface of the tibial shaft, near the tibial tuberosity Action: Flexes and laterally rotates the hip joint and flexes the knee

Quadriceps femoris : 

Quadriceps femoris Includes the four remaining muscles on the front of the thigh It is the great extensor muscle of the leg, forming a large fleshy mass which covers the front and sides of the femur Rectus femoris Vastus lateralis Vastus medialis Vastus intermedius.

Rectus Femoris : 

Rectus Femoris The Rectus femoris is situated in the middle of the front of the thigh It is fusiform in shape Its superficial fibers are arranged in a bipenniform manner The deep fibers running straight down to the deep aponeurosis Origin: Straight head from anterior inferior iliac spine Reflected head from groove just above acetabulum Insertion: Base of patella to form the more central portion of the quadriceps femoris tendon Action: Extends the knee

Vastus Lateralis : 

Vastus Lateralis Origin Superior portion of intertrochanteric line Anterior and inferior borders of greater trochanter Superior portion of lateral lip of linea aspera Lateral portion of gluteal tuberosity of femur Insertion: Lateral base and border of patella Forms the lateral patellar retinaculum And lateral side of quadriceps femoris tendon Action: Extends the knee

Vastus Intermedius : 

Vastus Intermedius Origin: Superior 2/3 of anterior and lateral surfaces of femur From lateral intermuscular septum of thigh Insertion: Lateral border of patella Forms the deep portion of the quadriceps tendon Action: Extends the knee

Vastus Medialis : 

Vastus Medialis Origin: Inferior portion of intertrochanteric line Spiral line Medial lip of linea aspera Superior part of medial supracondylar ridge of femur Medial intermuscular septum Insertion: Medial base and border of patella Forms the medial patellar retinaculum & Medial side of quadriceps femoris tendon Action: Extends the knee

Slide 52: 

The tendons of the different portions of the Quadriceps unite at the lower part of the thigh, so as to form a single strong tendon, which is inserted into the base of the patella, some few fibers passing over it to blend with the ligamentum patellæ. More properly, the patella may be regarded as a sesamoid bone, developed in the tendon of the Quadriceps; and the ligamentum patellæ, which is continued from the apex of the patella to the tuberosity of the tibia A bursa, which usually communicates with the cavity of the knee-joint, is situated between the femur and the portion of the Quadriceps tendon above the patella Another is interposed between the tendon and the upper part of the front of the tibia A third, the prepatellar bursa, is placed over the patella itself.

Slide 53: 

The Articularis genu is a small muscle, usually distinct from the Vastus intermedius, but occasionally blended with it It arises from the anterior surface of the lower part of the body of the femur Inserted into the upper part of the synovial membrane of the knee-joint. It sometimes consists of several separate muscular bundles

Nerves : 

Nerves The muscles of this region are supplied by the second, third, and fourth lumbar nerves, through the femoral nerve.

The Medial Femoral Muscles : 

The Medial Femoral Muscles Gracilis Adductor longus Adductor magnus Pectineus Adductor brevis

Gracilis : 

Gracilis The Gracilis is the most superficial muscle on the medial side of the thigh. It is thin and flattened, broad above, narrow and tapering below Origin: Inferior margin of pubic symphysis Inferior ramus of pubis Adjacent ramus of ischium Insertion: Medial surface of tibial shaft Just posterior to sartorius At its insertion the tendon is situated immediately above that of the Semitendinosus Upper edge is overlapped by the tendon of the Sartorius Action: Flexes the knee Adducts the thigh Helps to medially rotate the tibia on the femur

Adductor Longus : 

Adductor Longus Origin: Anterior surface of body of pubis Just lateral to pubic symphysis Insertion: Middle third of linea aspera Between the more medial adductor magnus and brevis insertions The more lateral origin of the vastus medialis Action: Adducts and flexes the thigh Helps to laterally rotate the hip joint

Adductor Magnus : 

Adductor Magnus Origin: Inferior pubic ramus Ischial ramus Inferolateral area of ischial tuberosity Insertion: Gluteal tuberosity of femur Medial lip of linea aspera Medial supracondylar ridge Adductor tubercle At the insertion of the muscle, there is a series of osseoaponeurotic openings, formed by tendinous arches attached to the bone The upper four openings are small, and give passage to the perforating branches of the profunda femoris artery The lowest is of large size, and transmits the femoral vessels to the popliteal fossa. Action: Powerful thigh adductor Superior horizontal fibers also help flex the thigh Vertical fibers help extend the thigh

Pectineus : 

Pectineus Origin: Pecten pubis Pectineal surface of the pubis Insertion: Pectineal line of femur Action: Adducts the thigh and flexes the hip joint

Adductor Brevis : 

Adductor Brevis Origin: Anterior surface of inferior pubic ramus Inferior to origin of adductor longus Insertion: Pectineal line Superior part of medial lip of linea aspera Action: Adducts and flexes the thigh Helps to laterally rotate the thigh

Nerves : 

Nerves The three Adductores and the Gracilis are supplied by the third and fourth lumbar nerves through the obturator nerve The Adductor magnus receiving an additional branch from the sacral plexus through the sciatic. The Pectineus is supplied by the second, third, and fourth lumbar nerves through the femoral nerve, and by the third lumbar through the accessory obturator when this latter exists. Occasionally it receives a branch from the obturator nerve.

Femoral Triangle : 

Femoral Triangle The femoral triangle corresponds to the depression seen immediately below the fold of the groin. Its apex is directed downward The sides are formed Laterally by the medial margin of the Sartorius Medially by the medial margin of the Adductor longus Above by the inguinal ligament Roof is formed by Skin Superficial fascia containing Inguinal lymph nodes Femoral branch of genitofemoral nerve Branches of the ilioinguinal nerve Superficial branches of femoral artery with accompanying veins Upper part of great saphenous vein Deep fascia with cribriform fascia Floor of the space is formed from its lateral to its medial side by The Iliacus Psoas major Pectineus In some cases a small part of the Adductor brevis, and the Adductor longus

Contents of femoral triangle : 

Contents of femoral triangle Femoral triangle is divided into two nearly equal parts by the femoral vessels Femoral vessels extend from near the middle of its base to its apex The femoral artery giving off in this situation its three superficial and three profunda branches Superficial branches are Superficial external pudendal a. Superficial epigestric a. Superficial circumflex iliac a. Deep or profunda branches are Profunda femoris a. Deep external pudendal a. Muscular branches Profunda femoris a. is the largest branch of femoral artery and this in turn gives rise to Medial and Lateral circumflex femoral arteries

Contents of femoral triangle : 

Contents of femoral triangle The femoral vein receiving the deep femoral and great saphenous tributaries. Vein is medial to artery at the base of triangle, but posteromedial at the at the apex. Femoral sheath encloses upper 4 cms of femoral vessels Nerves: On the lateral side of the femoral artery is the femoral nerve dividing into its branches Femoral nerve is out side the femoral sheath It is present in the groove between iliacus and psoas major Nerve to pectineus Arise from femoral nerve just above inguinal ligament. It passes behind the femoral sheath to reach the anterior surface of pectineus Femoral branch of genitofemoral nerve Occupies the lateral compartment of femoral sheath along with femoral artery It supplies most skin over the femoral triangle Lateral cutaneous nerve of thigh Crosses the lateral angle of triangle Besides the vessels and nerves, this space contains some fat and lymphatics Deep inguinal lymph nodes

The femoral sheath (crural sheath) : 

The femoral sheath (crural sheath) The femoral sheath is formed by downward prolongation of fascia of abdomen Anterior Wall: Formed by the fasciæ which line the abdomen, the transversalis fascia being continued down in front of the femoral vessels Posterior Wall : Formed by the iliac fascia behind the vessels The sheath assumes the form of a short funnel, the wide end of which is directed upward, while the lower, narrow end fuses with the fascial investment of the vessels, about 4 cm. below the inguinal ligament. The lateral wall of the sheath is vertical and is perforated by the lumboinguinal nerve The medial wall is directed obliquely downward and lateralward, and is pierced by the great saphenous vein and by some lymphatic vessels. The sheath is divided by two vertical partitions which stretch between its anterior and posterior walls. The lateral compartment contains the femoral artery The intermediate compartment contains the femoral vein While the medial and smallest compartment is named the femoral canal, and contains some lymphatic vessels and a lymph gland imbedded in a small amount of areolar tissue

Femoral Canal : 

Femoral Canal The femoral canal is conical and measures about 1.25 cm. in length. Its base, directed upward and named the femoral ring Femoral ring is oval in form, its long diameter being directed transversely and measuring about 1.25 cm. The femoral ring is bounded In front by the inguinal ligament Behind by the Pectineus covered by the pectineal fascia Medially by the crescentic base of the lacunar ligament Laterally by the fibrous septum on the medial side of the femoral vein. The spermatic cord in the male and the round ligament of the uterus in the female lie immediately above the anterior margin of the ring, while the inferior epigastric vessels are close to its upper and lateral angle. The femoral ring is closed by a somewhat condensed portion of the extraperitoneal fatty tissue, named the septum femorale (crural septum), the abdominal surface of which supports a small lymph gland and is covered by the parietal layer of the peritoneum. The septum femorale is pierced by numerous lymphatic vessels passing from the deep inguinal to the external iliac lymph glands, and the parietal peritoneum immediately above it presents a slight depression named the femoral fossa.

Adductor Canal (Hunter’s Canal) : 

Adductor Canal (Hunter’s Canal) The adductor canal (Hunter’s canal) is an aponeurotic tunnel in the middle third of the thigh Extending from the apex of the femoral triangle to the opening in the Adductor magnus. It is bounded In front and laterally, by the Vastus medialis Behind by the Adductor longus and magnus Is covered in by a strong aponeurosis which extends from the Vastus medialis, across the femoral vessels to the Adductores longus and magnus Lying on the aponeurosis is the Sartorius muscle. The canal contains the Femoral artery and vein Saphenous nerve Nerve to the Vastus medialis.

The Femoral Artery : 

The Femoral Artery The femoral artery begins immediately behind the inguinal ligament, at midinguinal point It ends where it passes through an opening in the Adductor magnus to become the popliteal artery. The first 4 cm. of the vessel is enclosed, together with the femoral vein, in a fibrous sheath—the femoral sheath. In the upper third of the thigh the femoral artery is contained in the femoral triangle (Scarpa’s triangle), and in the middle third of the thigh, in the adductor canal (Hunter’s canal).

Branches : 

Branches The femoral artery giving off in this situation its three superficial and three profunda branches Superficial branches are Superficial external pudendal a. Superficial epigestric a. Superficial circumflex iliac a. Deep or profunda branches are Profunda femoris a. Deep external pudendal a. Muscular branches Profunda femoris a. is the largest branch of femoral artery and this in turn gives rise to Medial and Lateral circumflex femoral arteries and 4 perforating arteries

The Lumbar Plexus : 

The Lumbar Plexus The lumbar plexus is formed by Anterior divisions of the first three and the greater part of the fourth lumbar nerves The first lumbar often receives a branch from the last thoracic nerve It is situated in the posterior part of the Psoas major, in front of the transverse processes of the lumbar vertebræ.

Slide 78: 

The first lumbar nerve, frequently supplemented by a twig from the last thoracic, splits into an upper and lower branch The upper and larger branch divides into the Iliohypogastric nerve Ilioinguinal nerves The lower and smaller branch unites with a branch of the second lumbar to form the genitofemoral nerve The remainder of the second nerve, and the third and fourth nerves, divide into ventral and dorsal divisions The ventral division of the second unites with the ventral divisions of the third and fourth nerves to form the obturator nerve. The dorsal divisions of the second and third nerves divide into two branches A smaller branch from each uniting to form the lateral femoral cutaneous nerve A larger branch from each joining with the dorsal division of the fourth nerve to form the femoral nerve. The accessory obturator, when it exists, is formed by the union of two small branches given off from the third and fourth nerves

Slide 79: 

The branches of the lumbar plexus may therefore be arranged as follows:    Iliohypogastric L1 Ilioinguinal L1 Genitofemoral L 1, 2 Dorsal divisions Lateral femoral cutaneous L 2, 3 Femoral L 2, 3, 4 Ventral divisions Obturator L 2, 3, 4 Accessory obturator L 3, 4.

The Iliohypogastric Nerve : 

The Iliohypogastric Nerve Arises from the first lumbar nerve It emerges from the upper part of the lateral border of the Psoas major, and crosses obliquely in front of the Quadratus lumborum to the iliac crest Near the crest of the ilium, and into a lateral and an anterior cutaneous branch The lateral cutaneous branch is distributed to the skin of the gluteal region The anterior cutaneous branch is distributed to the skin of the hypogastric region The iliohypogastric nerve communicates with the last thoracic and ilioinguinal nerves

The Ilioinguinal Nerve : 

The Ilioinguinal Nerve Arises with it from the first lumbar nerve It emerges from the lateral border of the Psoas major just below the iliohypogastric The nerve then pierces the Internal Oblique, distributing filaments to it, is distributed to the Skin of the upper and medial part of the thigh Skin over the root of the penis and upper part of the scrotum in the male Skin covering the mons pubis and labium majus in the female

The Lateral Femoral Cutaneous Nerve : 

The Lateral Femoral Cutaneous Nerve Arises from the dorsal divisions of the second and third lumbar nerves It emerges from the lateral border of the Psoas major Passes under the inguinal ligament and over the Sartorius muscle into the thigh, where it divides into two branches, and anterior and a posterior. The anterior branch divides into branches which are distributed to the skin of the anterior and lateral parts of the thigh, as far as the knee. The terminal filaments of this nerve frequently communicate with the anterior cutaneous branches of the femoral nerve, and with the infrapatellar branch of the saphenous nerve, forming with them the patellar plexus The posterior branch subdivides into filaments which pass backward across the lateral and posterior surfaces of the thigh, supplying the skin from the level of the greater trochanter to the middle of the thigh