1. Anatomy of lower limb
Dr. Nouh Ismail General surgeon
Assistant professor
2. Study the lower limb in
the following order:
• Introduction
• bones of the lower limb
• anterior region of the thigh
• medial region of the thigh
• gluteal region
• posterior region of the thigh
• anterior region of the leg and dorsal
region of foot
• lateral region of the leg
• posterior region of the leg
• sole of the foot
• ankle
• joints of the lower limb
2
3. 3
• The lower limbs (extremities) are extensions from the trunk
specialized to support body weight, for locomotion (ability to move
from one place to another), and to maintain balance.
• The lower limb: Major divisions:
The gluteal region,
Thigh / femoral region
Knee region
Leg/ caff region,
Ankle region &
The foot
Introduction
4. • The gluteal region is bounded superiorly by the iliac crest, medially by the
intergluteal cleft, and inferiorly by the skin fold
• the femoral region, boundary between the abdominal and perineal
regions and the femoral region is demarcated by the inguinal ligament
anteriorly and the ischiopubic ramus of the hip bone medially. Posteriorly,
the gluteal fold separates the gluteal and femoral regions
• The knee region the prominences (condyles) of the distal femur and
proximal tibia, head of the Fibula, and patella
• The leg (L. crus) connects the knee and foot.
• The ankle (includes the medial and lateral prominences (malleoli).
• The Foot is the distal part of the lower limb containing the tarsus,
metatarsus, and phalanges (toe bones).
5. Bones of the
Lower Limb
The skeleton of the lower limb (inferior appendicular skeleton) may be
divided into two functional components: the pelvic girdle and the bones
of the free lower limb
There are 31 bones found in the lower limb:
• hip bone (1)
• femur (1)
• patella (1)
• tibia (1)
• fibula (1)
• tarsals (7)
• metatarsals (5)
• proximal phalanges (5)
• intermediate phalanges (5)
• distal phalanges (4)
• The big toe (hallux) only has 2 phalanges
• There are also 2 extra bones in the foot, called sesamoid bones.
These small bones develop within tendon of flexor hallucis longus m
5
6. Functions &
Bones of
Lower Limb
• A major function of the lower limb is to support
the weight of the body
• A second major function is to move body
through space
• bones of gluteal region & thigh are pelvic bone
& femur.
• Femur, at its distal end, its major weight-bearing
articulation is with tibia
• patella is the largest sesamoid bone is
embedded in quadriceps femoris tendon.
• knee joint allows femur to rotate on tibia.
6
7. Functions &
Bones of
Lower Limb
This rotation contributes to 'locking' of the knee
when fully extended, particularly when standing.
• The leg contains two bones: the tibia is medial in
position, is larger than the laterally positioned
fibula, and is the weightbearing bone.
• tibia & fibula are linked along their lengths by an
interosseous membrane, and at their distal ends by
a fibrous inferior tibiofibular joint.
• distal surfaces of tibia & fibula together form a deep
recess: ankle joint is formed by this recess & part
of talus, which projects into the recess.
• ankle is most stable when dorsiflexed.
• bones of the foot consist of tarsal bones ,
metatarsals, & phalanges.
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8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20. Fascia Lata
• thigh is completely surrounded by a dense
layer of deep fascia called fascia lata.
• fascia lata is thickened on lateral aspect of
thigh & is named the iliotibial tract.
• This tract extends from the iliac crest to the
lateral condyle of the tibia.
20
21.
22. Anterior Thigh
• After removing skin from anterior thigh,
cutaneous nerves & veins of the thigh &
fascia lata are identified.
• Fascia lata is a dense layer of deep fascia
surrounding large muscles of the thigh.
• great saphenous vein reaches femoral
vein by passing thru fossa ovalis which has
a sharp margin called falciform margin.
22
23. Anterior Thigh: Lymph Nodes
& Cutaneous Nerves
• superficial inguinal lymph nodes:
• high in the thigh, just below inguinal ligament, usually
arranged in a T-shape.
• receive lymph from entire lower limb & superficial
structures of perineum.
• Cutaneous nerves:
• found piercing deep fascia are:
• lateral femoral cutaneous n, (branch of Lumbar
plexus: L2-L3)
• intermediate cutaneous n, &
• medial cutaneous n of the thigh, branches of femoral
nerve
24. Anterior Compartment of the Thigh: Muscles
• The large anterior compartment of the thigh contains the anterior
thigh muscles, the flexors of the hip
and extensors of the knee.
• anterior compartment contains a large muscle, consisting of four heads, the
quadriceps femoris muscle:
• This is a strong extensor of the knee.
• four heads of quadriceps femoris are:
• rectus femoris
• vastus lateralis
• vastus medialis
• vastus intermedius
• One other muscle of the anterior compartment is the sartorius.
29. Femoral Triangle
• femoral triangle: an anatomical region of upper thigh with the following
boundaries:
• inguinal ligament
• sartorius
• adductor longus
• The floor of the triangle is made up of:
• iliopsoas muscle
• pectineus muscle
• contents of femoral triangle (from lateral to medial):
• femoral nerve
• femoral artery
• femoral vein
• femoral lymph
29
32. Adductor canal (subsartorial
canal, Hunter canal):
• extends from apex of femoral triangle, (where
sartorius crosses over adductor longus), to
adductor hiatus in the tendon of adductor magnus.
• It provides an intermuscular passage for femoral
artery & vein, saphenous nerve, & nerve to vastus
medialis.
• The adductor canal is bounded.
1. Anteriorly and laterally by the vastus medialis.
2. Posteriorly by the adductors longus and magnus.
3. Medially by the sartorius, which overlies the groove
between the above muscles, forming the roof of the
canal.
32
33.
34. Femoral Sheath
• Femoral sheath:
• sheath of deep fascia, extending down from abdominal wall.
• contains the following structures, from lateral to medial:
• femoral artery
• femoral vein
• femoral canal (usually containing lymph node).
• femoral canal is site of femoral hernia.
• femoral nerve is not in the sheath.
36. Nerve of Anterior
Compartment of Thigh
• femoral nerve (L2, L3, L4) supplies muscles of
anterior compartment of the thigh (quadriceps
femoris), including pectineus muscle.
• psoas m. receives its nerve supply from the lumbar
plexus.
36
37. Artery of Anterior
Compartment of the Thigh
• femoral artery: chief artery to lower limb
• continuation of external iliac artery distal to inguinal
ligament
• enters femoral triangle deep to midpoint of inguinal
ligament & lateral to femoral vein
• Bisects femoral triangle & exits at its apex to enter
adductor canal, deep to sartorius
• Exits adductor canal by passing thru adductor hiatus
(opening in adductor magnus) & becomes popliteal artery
38. Artery of Anterior
Compartment of the Thigh
• Femoral artery (1): principal supply to anterior
compartment of thigh & rest of the lower limb.
Its branches are:
• superficial iliac circumflex supplies lower abdomen and
upper thigh.
• Superficial epigastric: runs up to the area of umbilicus
• external pudendal : supplies superficial perineal structures
(scrotum & labia majora).
• profunda (deep) femoris
• lateral femoral circumflex
• medial femoral circumflex
39.
40.
41. Arteries of the
Thigh
1. Trochanteric Anastomosis:
• Sourse of main blood supply to head of Femur
• The following take part in formation of the anastomosis:
• Superior gluteal (internal ileac artery)
• Inferior gluteal (internal ileac artery)
• Medial femoral circumflex (profunda femoris artery)
• Lateral femoral circumflex (profunda femoris artery)
2. Cruciate Anastomosis:
• Located at level of lesser trochanter of femur
• Formed by the following arteries:
1. inferior gluteal
2. Medial femoral circumflex
3. Lateral femoral circumflex
4. 1st perforating artery (profunda femoris artery)
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42. Medial Compartment of Thigh
• The muscles of the medial compartment of the thigh comprise the
adductor group, consisting of the
1. adductor longus,
2. adductor brevis,
3. adductor magnus,
4. gracilis, and
5. obturator externus.
• The medial compartment of the thigh is frequently called the adductor
compartment because the major action of this group of muscles is adduction
of thigh.
42
43. Continuous… Medial Compartment of Thigh
except for hamstring portion of the adductor magnus which performs as a
hamstring and is supplied by a different nerve sciatic nerve
• Sometimes pectineus included in this group, but it really belongs to the
anterior compartment & is supplied by the femoral nerve, nerve of the
anterior compartment.
• the obturator nerve supplies the muscles of the medial compartment
(adductor compartment).
• All adductor muscles, except the “hamstring part” of the adductor
magnus and part of the pectineus, are supplied by the obturator nerve
(L2–L4).
• The hamstring part of the adductor magnus is supplied by the tibial
part of the sciatic nerve (L4).
43
45. Medial Compartment of Thigh
• pectineus & adductor longus are reflected the second
layer of muscles can be identified: adductor brevis
• obturator nerve exits pelvis by passing thru a small canal
in upper part of the obturator foramen.
• It then pierces obturator externus m. & splits (on either
side of adductor brevis m.) as an anterior and posterior
branch.
• It then supplies the adductor muscles.
anterior division of obturator nerve lies on anterior surface
of adductor brevis muscle.
• (posterior division lies posterior to adductor brevis & on
adductor magnus)
45
46. Medial Compartment of Thigh
• Adductor magnus: deepest & largest muscle in the medial
compartment.
• Most of Adductor magnus inserts along the linea aspera of
femur.
• one-part inserts into adductor tubercle of femur: this
part is called hamstring portion of Adductor magnus
• thus, supplied by tibial part of sciatic nerve: and
functions with hamstrings in posterior compartment of the
thigh.
46
50. GLUTEAL
AND
POSTERIOR
THIGH
REGIONS
• Gluteal region (hip & buttocks) is the prominent
area posterior to pelvis in Physically part of the
trunk, Functionally, the gluteal region is part
of the lower limb.
• The shape is formed by a mass of gluteal muscles &
a layer of fat covers these muscles.
Boundaries:
• Superiorly: iliac crest & extends laterally to
posterior margin of greater trochanter
• Inferiorly: gluteal fold
• Intergluteal cleft separates the buttocks
52. Gluteal Ligaments
• Hip bones, are bound together by dense ligaments
• posterior sacroiliac ligament is continuous inferiorly with sacrotuberous
ligament.
• sacrotuberous ligament extends across sciatic notch of hip bone, converting the
notch into a foramen, further subdivided by sacrospinous ligament & ischial
spine, creating the greater & lesser sciatic foramina.
53.
54.
55. Gluteal Ligaments
• greater sciatic foramen is the
passageway for structures entering
or leaving the pelvis:
Example: Sciatic nerve
• lesser sciatic foramen is the
passageway for structures entering
or leaving the perineum:
Example: Pudendal nerve
55
56. Gluteal Region of
Lower Limb
• Superficial Nerves
• After skin of gluteal region has been
removed, you should be able to identify
cutaneous nerves in gluteal area:
• Cutaneous nerves in gluteal area are:
• branches of subcostal nerve: T12
• dorsal rami of lumbar nerves
• dorsal rami of sacral nerves
• inferior cluneal nerves
• posterior femoral cutaneous n.
56
57. Muscles of Gluteal Region
• The muscles of the gluteal region share a common compartment but are
organized into two layers, superficial and deep:
• The superficial layer of muscles of the gluteal region consists of the three
large overlapping glutei (maximus, medius, and minimus) and the tensor
fasciae latae, this muscles are mainly extensors, abductors, and medial
rotators of the thigh.
• The deep layer of muscles of the gluteal region consists of smaller muscles
(piriformis, obturator internus, superior and inferior gemelli, and quadratus
femoris) covered by the inferior half of the gluteus maximus. These muscles
are lateral rotators of the thigh, but they also stabilize the hip joint, head in
the acetabulum.
58.
59.
60.
61. Muscles of the
Gluteal Region
• Muscles of gluteal region consist
predominantly of extensors, rotators,
& abductors of the hip joint.
• Major flexor muscles of the hip
(iliopsoas:-psoas major & iliacus) do
not originate in the gluteal region or
the thigh: originate from posterior
abdominal wall & descend through
the gap b/n inguinal ligament &
pelvic bone to attach to proximal end
of femur
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62.
63. Muscles of
the Gluteal
Region
• piriformis muscle: most superior of deep group of mm.
• Supplied by Branches of anterior rami of S1, S2
• Is a muscle of pelvic wall & the gluteal region.
• In addition to its action on the hip joint, the piriformis is
an important landmark,
• It divides the greater sciatic foramen into two
regions, one above and one below the
piriformis.
• The superior gluteal nerves and vessels pass through the
greater sciatic foramen above piriformis;
• All other vessels and nerves passing between the pelvis
and the gluteal region, including the sciatic nerve, pass
through the greater sciatic foramen below the piriformis.
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65. Arteries of
Gluteal Region
• There are three arteries coming
into the gluteal region through the
greater sciatic foramen:
• superior gluteal
• inferior gluteal
• internal pudendal
• These arteries are branches of
the internal iliac artery which lies
inside the pelvis.
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66. Nerves of Gluteal
Region
• Nerves of gluteal region are branches
of lumbosacral plexus.
• Seven nerves enter gluteal region from
pelvis thru greater sciatic foramen.
1. superior gluteal
1. (only branch that comes thru
superior part of greater sciatic
foramen).
2. Supplies gluteus medius &
minimus & tensor fasciae latae
m.
2. inferior gluteal
3. sciatic
4. posterior femoral cutaneous
5. pudendal
6. nerve to quadratus femoris and
inferior gemellus muscles
7. nerve to obturator internus and
superior gemellus muscles 66
67. Gluteal Region : Relations
Areas of communication B/n Lower Limb & true pelvis:
Three apertures in pelvic wall communicate with lower limb:
(i). the obturator canal
(ii). the greater sciatic foramen
(iii). the lesser sciatic foramen.
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68. Gluteal Region : Relations
1.obturator canal is formed in superior aspect of obturator foramen, b/n bone, a
connective tissue membrane & muscles that fill the foramen.
• obturator canal forms a passageway b/n pelvic cavity & adductor region of the thigh,
obturator nerve & vessels pass through it from pelvic cavity to the thigh
68
69. Gluteal Region : Relations
2. The greater sciatic foramen:
• is a major route of communication b/n pelvic cavity & lower limb.
• It is formed by greater sciatic notch, sacro-tuberous & sacrospinous ligaments &
spine of ischium.
• piriformis muscle passes through it, dividing it into two parts: superior (above
piriformis) & inferior (below piriformis) parts:
superior gluteal nerves & vessels pass through superior part
• Passing through inferior part are inferior gluteal nerves & vessels, sciatic nerve,
pudendal nerve, internal pudendal vessels, posterior femoral cutaneous nerves,
nerves to obturator internus & quadratus femoris muscles.
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70. Gluteal Region : Relations
3. Lesser sciatic foramen:
• formed by lesser sciatic notch, ischial spine, sacrospinous & sacrotuberous ligaments.
• tendon of obturator internus muscle (pelvic wall) passes through lesser sciatic foramen
to enter gluteal region of lower limb.
• because it lies below attachment of pelvic floor, provides communication b/n gluteal
region & perineum:
pudendal nerve & internal pudendal vessels pass b/n the pelvic cavity & perineum,
by first passing out of pelvic cavity thru greater sciatic foramen, pass thru lesser
sciatic foramen to enter the perineum.
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72. Posterior Compartment
of Thigh
Muscles:
• muscles of posterior compartment of
the thigh are called the hamstrings.
• To be called a hamstring, the muscle
must arise from the ischial tuberosity.
• The hamstrings are:
• biceps femoris (long head)
• semimembranosus
• semitendinosus
• hamstring part of the adductor
magnus 72
73. The hamstrings Muscles
• share the following common features:
1) Proximal attachment to the ischial
tuberosity deep to the gluteus
maximus.
2) Distal attachment to the bones of the
leg. Thus, they span and act on two
joints, producing extension at the hip
joint and flexion at the knee joint.
3) Innervation by the tibial division of the
sciatic nerve.
74.
75.
76.
77. Nerves of Posterior
Compartment
• Nerves:
• Muscles of posterior
compartment of the thigh are
innervated by the tibial (medial)
part of sciatic nerve.
• Short head of biceps is
innervated by a branch of common
peroneal nerve.
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78. Arteries of Posterior Compartment
• Arteries of the posterior compartment of the thigh
arise from two major arteries:
• inferior gluteal (upper posterior compartment)
• perforating branches of the profunda femoris
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79. • The arteries of the gluteal region arise, directly or indirectly, from the
internal iliac arteries, but the patterns of origin of the arteries are
variable The major branches of the internal iliac artery that supply or
traverse the gluteal region are the
(1) superior gluteal artery,
(2) inferior gluteal artery, and
(3) internal pudendal artery.
• The posterior compartment of the thigh has no major artery exclusive
to the compartment; it receives blood from multiple sources: inferior
gluteal, medial circumflex femoral, perforating, and popliteal arteries.
80.
81. Popliteal Fossa
• The popliteal fossa is an anatomical region behind the
knee with boundaries.
• Identify the bony background and the boundaries of the
popliteal fossa.
• Bones of the popliteal fossa are:
• Femur:
• medial condyle
• lateral condyle
• tibia:
• medial condyle
• lateral condyle
81
82. Popliteal Fossa
• The boundaries are:
• superior & medial: - semitendinosus (ST)
• inferior & medial: - medial head of
gastrocnemius (MG)
• superior & lateral: - biceps femoris (B)
• inferior & lateral - lateral head of
gastrocnemius
82
83. Popliteal Fossa
• With nerves and arteries removed & muscles reflected,
identify the structures making up floor of the popliteal fossa:
• posterior surface of femur
• posterior surface of tibia
• oblique popliteal ligament
• popliteus muscle
83
84. muscles & contents of popliteal fossa
• Muscles:
• semitendinosus
• biceps femoris
• medial head of gastrocnemius
• lateral head of gastrocnemius
• Arteries:
• popliteal artery - continuation of femoral artery
• superior medial and lateral genicular arteries
• inferior medial and lateral genicular arteries
• Nerves:
• tibial nerve
• common peroneal nerve
84
87. Anterior Compartment of Leg
• Muscles:
• The anterior compartment contains muscles that are basically
extensors of the ankle & toes:
• tibialis anterior
• extensor digitorum longus
• extensor hallucis longus
87
88.
89. Nerves
• The nerve of the anterior compartment of the
leg is the deep peroneal nerve.
• This nerve terminates b/n the big toe &
second toe and can be tested at this point.
• it supplies skin b/n big toe & second toe.
89
94. Anterior Compartment of
Leg
• Arteries:
• artery of the anterior compartment of the leg is
anterior tibial artery (a branch of popliteal artery).
• Its terminal branch, the dorsalis pedis, can be
palpated on the dorsum of the foot between the 1st
and 2nd metatarsal bones.
94
96. Lateral Compartment
of Leg
• The lateral crural compartment, also called
the peroneal compartment, is made up of
two muscles whose tendons cross the ankle
joint posterior to and under the lateral
malleolus.
• This makes them evertors of the foot.
These muscles are the:
• peroneus longus
• peroneus brevis
96
97.
98. Nerves of Lateral
Compartment of Leg
• The superficial peroneal nerve branches from the common
peroneal nerve near the neck of the fibula and passes b/n
peroneus longus & brevis muscles, at which point they supply
the muscles.
• The superficial branch then continues onto the dorsum of
the foot to supply the skin there.
98
99. Arteries of the Lateral Leg
Arteries:
• The arteries to the tissues in the lateral compartment are from both the
anterior and posterior tibial branches of the popliteal artery.
99
100. Posterior Compartment of the
Leg
• posterior compartment of leg is subdivided into superficial
and deep parts.
• The superficial structures to identify are:
• small saphenous vein
• peroneal communicating branch of common peroneal n
• medial cutaneous nerve of the calf (medial sural
cutaneous)
• Sural Nerve
100
101. Posterior Compartment of the
Leg
• The superficial part of the posterior compartment of the
leg is made up of three muscles:
• gastrocnemius
• plantaris
• soleus
101
102. Posterior Compartment of
the Leg
• The deepest layer of muscles includes the:
• tibialis posterior
• flexor digitorum longus
• flexor hallucis longus
102
105. Nerves of Posterior Compartment of Leg
• muscles of the posterior
compartment of leg are all supplied
by tibial nerve.
105
106. Artery of Posterior
Compartment of Leg
• posterior tibial artery supplies tissues of posterior
compartment of leg.
• It is one of the terminal branches of popliteal artery.
106
114. Sole of the Foot
• This is the sole of the left foot.
• When standing, foot touches the ground mainly at
calcaneus bone & heads of metatarsals (H).
• Note two small bones, sesamoid bones (S) under the head
of the 1st metatarsal.
• These small bones develop in the tendons of flexor
hallucis brevis muscle & probably serve as a fulcrum for the
muscle to act more strongly.
• During walking, our main lift off is at the big toe.
114
115. Sole of the Foot
• sustentaculum tali: a shelf-like extension of calcaneous,
supports head of talus when standing.
• spring ligament (plantar calcaneo-navicular Ligament),
one of the more important ligaments of foot, crosses under
head of talus adding more support.
• Note the major joints for eversion & inversion of the foot:
• subtalar joint (ST)
• transverse tarsal joint (TT)
115
116. Plantar Aponeurosis
Plantar Aponeurosis:
• Once the skin of the sole of the foot has been
removed plantar aponeurosis.
• Plantar aponeurosis: dense, organized layer of
deep fascia that runs down the middle of the sole.
• it helps maintain the medial longitudinal arch of
the foot.
• Formed by central part of palmar fascia.
• Consists of longitudinally arranged band of dense
connective tissue.
• Support longitudinal arch & hold parts of the foot
togather.
117. Intrinsic Muscles of the Foot
Intrinsic Muscles of Dorsum of the Foot:
• Extensor digitorum brevis
• Extensor hallucis brevis
117
118.
119. Muscles of Sole of the
Foot: I-Layer
Muscles in I – Layer:
• Abducter hallucis
• Flexor digitorum brevis
• Abductor digiti minimi
119
121. Muscles of Sole of the
Foot
• When the flexor digitorum brevis is removed, the
muscles of the second layer can be seen:
• accessory flexor (quadratus plantae)
• lumbricals
• tendons of the flexor digitorum longus from
which the lumbricals arise
121
123. Muscles of Sole of the Foot:
III-Layer
• The muscles of the third layer include the:
• flexor hallucis brevis
• adductor hallucis
• oblique head
• transverse head
• flexor digiti minimi brevis
123
125. Sole of the Foot
• The fourth layer of muscles:
•
• dorsal interossei (dab) meaning dorsal abduct
• 2. plantar interossei (pad) meaning plantar
adduct
• Note tendon of peroneus longus crossing sole of
the foot.
125
128. Muscles of Sole of the Foot: First Layer
Muscle Origin Insertion Action Nerve
Supply
abductor
hallucis
medial tubercle
of calcaneum
medial side,
base proximal
phalanx big toe
flexes, abducts
big toe.
Supports
medial
longitudinal
arch
medial plantar
flexor
digitorum
brevis
medial tubercle
of calcaneum
middle phalanx
of four lateral
toes
flexes lateral
four toes.
Supports
medial & lateral
longitudinal
arches
medial plantar
abductor
digiti minimi
medial and
lateral
tubercles of
calcaneum
lateral side
base proximal
phalanx fifth
toe
flexes, abducts
fifth toe.
Supports lateral
longitud. arch
lateral plantar
128
129. Muscles of Sole of the Foot: II-Layer
Muscle Origin Insertion Action Nerve
Supply
Second Layer
accessory
flexor
(quadratus
plantae)
medial and
lateral sides
of
calcaneum
tendon
flexor
digitorum
longus
aids long
flexor
tendon to
flex lateral
four toes
lateral plantar
nerve
lumbricals tendons of
flexor
digitorum
longus
dorsal
extensor
expansion
of lateral
four toes
extends
toes at
interphal
angeal
joints
I- lumbrical-
med plantar;
remainder-
deep branch
lateral plantar
129
130. Muscles of Sole of the Foot: III-Layer
Muscle Origin Insertion Action Nerve
Supply
Third Layer
flexor hallucis
brevis
cuboid, lateral
cuneiform;
tibialis posterior
insertion
medial and lateral
sides of base of
proximal phalanx
of big toe
flexes
metatarsophalang
eal joint of big
toe; supports
medial
longitudinal arch
medial plantar
adductor
hallucis, oblique
head
bases second,
third, fourth
metatarsal
bones
lateral side base
proximal phalanx
big toe
adducts big toe,
supports
transverse arch
deep branch
lateral plantar
adductor
hallucis,
transverse head
capsules 3, 4, 5
metatarsophalan
geal joints
lateral side of base
of proximal
phalanx, big toe
adduct big toe deep branch
lateral plantar
flexor digiti
minimi brevis
base of fifth
metatarsal
lateral side base of
proximal phalanx
small toe
flexes little toe lateral plantar
130
131. Muscles of Sole of the Foot: IV-Layer
Muscle Origin Insertion Action Nerve
Supply
Fourth Layer
dorsal
interossei (4)
adjacent sides of
metatarsals
bases of
phalanges and
dorsal expansion
of corresponding
toes
abduct toes,
using second toe
as reference
flex
metatarsophalan
geal joints;
extend
interphalangeal
joints
lateral plantar
plantar
interossei (3)
3rd, 4th, 5th
metatarsals
bases phalanges
and dorsal
expansion 3rd,
4th, 5th toes
adduct toes using
second toe as
reference
flex metatarso
phalangeal
joints; extend
interphalangeal
joints
lateral plantar
131
132. Nerves of Sole of the Foot
• Medial & lateral plantar nerves, branches of tibial
nerve, supply muscles & skin on sole of the foot.
• medial plantar nerve supplies:
• abductor hallucis muscle (first layer)
• flexor digitorum brevis (first layer)
• 1st lumbrical (second layer)
• flexor hallucis brevis (third layer)
132
133. Nerves of Sole of the Foot
• lateral plantar nerve supplies the remaining
muscles in sole of the foot:
• abductor digiti minimi (first layer)
• accessory flexor (quadratus plantae): (2nd layer)
• adductor hallucis (third layer)
• flexor digiti minimi brevis (third layer)
• interossei (fourth layer)
• lumbricals 2, 3, & 4.
• lateral plantar nerve is similar to the ulnar n.
which supplies most of the small muscles of the
hand.
133
134. Nerves of the Sole of the
Foot
• The medial & lateral plantar nerves supply muscles &
skin of sole of the foot.
• medial plantar nerve gives rise to digital branches
which then give rise to common digital branches &
then, terminal branches.
• medial plantar nerve supplies skin of the medial
three & one half digits.
• lateral plantar nerve gives rise to motor branches, a
deep branch & finally branches to the skin of the lateral
one & one-half digits.
134
136. Nerves of the foot
• Medial plantar N, Lateral plantar N., Sural N.,
• Saphenous N., Superficial & deep Peroneal nerves.
137.
138.
139.
140. Nerves of the Lower
Limb
• Somatic motor & general sensory innervation
of lower limb is by peripheral nerves from
lumbar & sacral plexuses on posterior
abdominal & pelvic walls.
• These plexuses are formed by anterior rami of
L1 to L3 & most of L4 (lumbar plexus) & L4 to
S5 (sacral plexus).
• Nerves originating from lumbar & sacral
plexuses & entering lower limb carry fibers
from spinal cord levels L1 to S3
• Nerves from lower sacral segments innervate
the perineum.
140
142. Nerves of the Lower Limb
• lumbar & upper sacral nerves are tested clinically by
examining the lower limb.
• Dermatomes in lower limb that can be tested for
sensation & are reasonably autonomous (have
minimal overlap) are:
• over the inguinal ligament: -L1;
• lateral side of the thigh: -L2;
• lower medial side of the thigh: -L3;
• meidal side of great toe (digit 1): -L4;
• meidal side of digit 2: -L5;
• little toe (digit 5): -S1;
• back of the thigh: -S2;
• skin over the gluteal fold: -S3.
• dermatomes of S4 & S5 are tested in the perineum. 142
143. Nerves of the Lower Limb
• Selected joint movements are used to test myotomes :
example: flexion of hip is controlled primarily by L1 & L2;
• extension of knee is controlled mainly by L3 & L4;
• knee flexion is controlled mainly by L5 to S2;
• plantarflexion of the foot: controlled by S1 & S2;
• adduction of the digits is controlled by S2 & S3.
• In an unconscious patient, both somatic sensory & somatic motor functions of spinal
cord levels can be tested using tendon reflexes: a 'tap' on patellar ligament at the
knee tests predominantly L3 & L4;
• a tendon tap on calcaneal tendon posterior to the ankle (tendon of gastrocnemius &
soleus) tests S1 & S2.
143
145. Nerve
Origin (contributing
spinal nerves) Course Distribution in Lower Limb
Subcostal T12 anterior ramus Courses along inferior border of 12th
rib; lateral cutaneous branch descends
over iliac crest
Lateral cutaneous branch supplies
skin of hip region interior to
anterior iliac crest and anterior to
greater trochanter
Iliohypogastric Lumbar plexus (L1;
occasionally T12)
Parallels iliac crest; divides into lateral
and anterior cutaneous branches
Lateral cutaneous branch supplies
superolateral quadrant of buttock
Ilioinguinal Lumbar plexus (L1;
occasionally T12)
Passes through inguinal canal; divides
into femoral and scrotal or labial
branches
Femoral branch supplies skin over
medial femoral triangle
Genitofemoral Lumbar plexus (L1-L2) Descends anterior surface of psoas
major; divides into genital and femoral
branches
Femoral branch supplies skin over
lateral femoral triangle; genital
branch supplies anterior scrotum
or labia majora
Lateral cutaneous
nerve of thigh
Lumbar plexus (L2-L3) Passes deep to inguinal ligament, 2-3
cm medial to anterior superior iliac
spine
Supplies skin on anterior and
lateral aspects of thigh
Anterior cutaneous
branches
Lumbar plexus via
femoral nerve
(L2-L4)
Arise in femoral triangle; pierce fascia
lata along path of sartorius muscle
Supply skin of anterior and
medial aspects of thigh
Cutaneous branch
of obturator nerve
Lumbar plexus via
obturator nerve, ant.
branch (L2-L4)
Following its descent between
adductors longus and brevis, anterior
division of obturator nerve pierces
fascia lata to reach skin of thigh
Skin of middle part of medial
thigh
Posterior
cutaneous nerve of
thigh
Sacral plexus
(S1-S3)
Enters gluteal region via infrapiriform
portion of greater sciatic foramen
deep to gluteus maximus; then
descends deep to fascia lata
Terminal branches pierce fascia
lata to supply skin of posterior
thigh and popliteal fossa
146. Nerve
Origin (contributing
spinal nerves) Course Distribution in Lower Limb
Saphenous nerve Lumbar plexus via
femoral nerve (L3-L4)
Traverses adductor canal but does not pass
through adductor hiatus; crossing medial side
of knee deep to sartorius tendon
Skin on medial side of leg and
foot
Superficial fibular
nerve
Common fibular nerve
(L4-S1)
Courses through lateral compartment of leg;
after supplying fibular muscles, perforates
crural fascia
Skin of anterolateral leg and
dorsum of foot, excluding web
between great and 2nd toes
Deep fibular
nerve
Common fibular nerve
(L5)
After supplying muscles on dorsum of foot,
pierces deep fascia superior to heads of 1st
and 2nd metatarsals
Skin of web between great and
2nd toes
Sural nerve Tibial and common
fibular nerves (S1-S2)
Medial sural cutaneous branch of tibial nerve
and lateral sural cutaneous branch of fibular
nerve merge at varying levels on posterior leg
Skin of posterolateral leg and
lateral margin of foot
Medial plantar
nerve
Tibial nerve (L4-L5) Passes between first and second layers of
plantar muscles; then between medial and
middle muscles of first layer
Skin on medial side of sole and
sides, plantar aspect, and nail
beds of medial 3½ toes
Lateral plantar
nerve
Tibial nerve (S1-S2) Passes between first and second layers of
plantar muscles; then between middle and
lateral muscles of first layer
Skin on lateral side of sole and
sides, plantar aspect, and nail
beds of lateral 1½ toes
Calcaneal nerves Tibial and sural nerves
(S1-S2)
Lateral and medial branches of tibial and
sural nerves, respectively, over calcaneal
tuberosity
Skin of heel
Superior clunial
nerves
L1-L3 posterior rami Penetrate thoracodorsal fascia; course
laterally and inferiorly in subcutaneous tissue
Skin overlying superior and
central parts of buttock
149. Arteries of the Sole of
the Foot
• arteries of sole of the foot are derived from
posterior tibial artery.
• It splits into medial & lateral plantar arteries.
• medial plantar artery passes along the medial
part of sole of the foot & terminates by branching
into digital branches.
• lateral plantar artery becomes the plantar
arterial arch which anastomoses by way of a
perforating artery with the dorsal pedis artery.
• The arch gives rise to several metatarsal
branches which split into digital branches.
149
156. Ligaments of the Sole of the
Foot
• The long plantar ligament & plantar calcaneocuboid
ligament lie deep to the muscles of the fourth layer.
• long plantar ligament stretches from calcaneum to cuboid
and to the bases of 2nd, 3rd & 4th metatarsal bones.
• plantar calcaneocuboid ligament, extends from calcaneum
to the cuboid on the deep aspect of the long plantar
ligament.
156
157. Ligaments of the Sole of the
Foot
• plantar calcaneo- navicular ligament extends from
calcaneus to navicular bone & prevents the head of talus
from pushing down b/n calcaneus & navicular bones.
plantar calcaneonavicular ligament is known as spring
ligament since it is believed to give a spring-like action to
the foot when walking.
157
158. Arches of the Foot
• All bones of the foot are held together by ligaments.
• The three most important strongly implicated in
maintaining the arches of the foot are:
• long plantar ligament
• calcaneocuboid ligament
• calcaneonavicular ligament
• Functions of muscles of the foot:
• responsible for movement made during walking
• help maintain the arches of the foot.
158
159. Arches of the Foot
• Arches of the foot are arranged
longitudinally & transversely, and are
caused:
• *primarily by conformation of
bones of foot & ligaments which bind
them together,
• *secondarily by muscles which act
upon the bones.
• longitudinal arch of the foot is higher
on medial side, where it forms the instep
as can be seen on a foot-print medial
longitudinal arch
159
160. Arches of the Foot
• medial longitudinal arch is made up of 1st three digits &
their metatarsals, cuneiforms, navicular bone & talus.
• lateral longitudinal arch is made up of digits 4 & 5 and
their metatarsals, the cuboid & calcaneum.
• It is much shallower than the medial arch.
• transverse arch is primarily formed by bases of 5
metatarsal bones, cuboid & the 3 cuneiform bones.
160
162. Arches of the Foot
• Every ligament that connects bones of foot plays a part in maintenance of the arches, but some which pass
across two or more joints are especially important:
• long plantar ligament, plantar calcaneo- cuboid ligament & plantar calcaneonavicular ligament.
• small intrinsic muscles also play an important role in keeping the arches intact,
But, the long muscles which are inserted by tendons into bones of the foot have more important role:
These are tendons of: tibialis anterior muscle, tibialis posterior, peroneus longus & of flexor hallucis longus &
flexor digitorum longus muscles.
more superficially, plantar aponeurosis also plays an important part in maintaining the medial longitudinal arch.
162
163. Maintaining Arches of the Foot
Maintenance of the Medial Longitudinal Arch:
1. Shape of the bones
2. Inferior edges of the bones are tied together: by plantar ligaments.
the plantar calcanionavicular lig. is most important
tendons of tibialis anterior & posterior also play important role.
3. The ends of the arch are tied together: by plantar aponeurosis, flexor
digitorum brevis, abductor hallucis, flexor hallucis longus, flexor
digitorum longus & flexor hallucis brevis.
4. The arch is suspended from above by tibialis anterior & postirior and
medial ligament of ankle joint
163
164. Maintaining Arches of the Foot
Maintenance of the Lateral Longitudinal Arch:
1. Shape of the bones
2. Inferior edges of the bones are tied together: by long & short plantar
ligaments and short muscles of the foot
3. The ends of the arch are tied together: by plantar aponeurosis,
abductor digiti minimi, flexor digitorum longus & brevis.
4. The arch is suspended from above by peroneus longus & brevis
164
165. Maintaining Arches of the Foot
Maintenance of the Transverse Arch:
1. Shape of the bones.
2. Inferior edges of the bones are tied together: by deep transverse
ligaments, the very strong plantar ligaments, plantar muscles, dorsal
interossei, transverse head of adductor hallucis are important.
3. The ends of the arch are tied together: by peroneus longus tendon.
4. The arch is suspended from above by peroneus longus tendon &
peroneus brevis
165
166. Ankle
• Over ones life-time, the lower limb receives
much trauma from walking & carrying
around weight of the body.
• Add to that any athletics and exercise
• One area of the lower limb that receives the
trauma is the ankle.
• The ankle also needs to be as stable as
possible.
• stability of the ankle depends on the
tendons of very strong muscles that cross
the ankle joint & on ligaments around the
ankle joint.
166
167. The Ankle
On medial side of the ankle identify the:
1. structures passing anterior to medial
malleolus:
tendon of tibialis anterior
2. structures passing posterior to medial
malleolus (Tom, Dick & Harry):
• tibialis posterior (T)
• flexor digitorum longus (D)
• flexor hallucis longus (H)
167
168. The Ankle
• For flexor & extensor tendons to
perform properly, they must be kept
close to bones of the ankle.
• The structures that keep them close
are the retinaculae:
• superior extensor retinaculum
• flexor retinaculum
• inferior extensor retinaculum
168
169. The Ankle
• On lateral side, tendons of muscles passing
behind lateral malleolus are:
• peroneus longus
• peroneus brevis
• Structures passing anterior to the ankle:
• peroneus tertius
• tendons of the extensor digitorum longus
• tendon of the extensor hallucis longus
• tendon of tibialis anterior
169
170. Joints of the Lower
Limb
• The Hip Joint
• The hip joint is an articulation b/n the hemispherical
head of the femur & the cup-shaped acetabulum of the hip
bone.
170
171. Hip Joint
• The acetabular notch at the lower part
of the acetabulum is bridged by the
transverse ligament of acetabulum.
171
172. Hip Joint
• acetabular labrum a fibrocartilaginous
ring, firmly attached to the rim of the
acetabulum deepens the acetabulum
& clasps head of the femur to form a
more stable joint.
• round ligament of head of femur is
attached to the transverse acetabular
ligament & extends to the fovea centralis
on the head of the femur.
172
173. Hip Joint
• articular capsule of hip joint from has attachment to the
intertrochanteric line & to bases of greater & lesser
trochanters.
• the iliofemoral ligament is the strongest of ligaments of the
capsule
• it is Y-shaped, & prevents overextension during
standing
• Note that its apex is attached to the ilium b/n the two
heads of rectus femoris muscle.
• Identify the two limbs of the ligament, one passing to
base of greater trochanter & other to the base of lesser
trochanter.
173
174. Hip Joint
• the pubofemoral ligament is triangular shape, found on
the inferomedial aspect of the capsule.
• pubofemoral ligament: limits extension & abduction
• attachment of the ligament is to base of lesser trochanter
& its wide attachment to superior ramus of the pubis, just
above the obturator foramen.
• this capsular ligament is thinner than the iliofemoral
ligament.
174
175. Hip Joint
• the ischiofemoral ligament in posterior aspect of
hip joint, sweeps over neck of femur
• attached to ischium & neck of femur.
• ischiofemoral ligament: limits extension
• capsule of hip joint is very loose as it covers
posterior aspect of neck of the femur & does not
cover neck completely: Posterior Dislocation
more.
• The hip joint receives its blood supply from small
vessels which reach it by running up the neck of
the bone.
• arteries that supply branches to hip joint are:
• medial circumflex
• lateral circumflex
• obturator
• inferior gluteal 175
176. Hip Joint
Movements at the Hip Joint:
• Movements which take place at the hip joint are:
• flexion, mainly due to contraction of the iliopsoas muscle, with help from
sartorius, rectus femoris & pectineus.
• extension, chiefly by the gluteus maximus muscle with help by the hamstrings
• adduction, by the adductors longus, brevis, magnus and the gracilis
• lateral rotation, by gluteus maximus, quadratus femoris, piriformis, obturator
internus and externus, gemelli.
• medial rotation, by anterior part of the gluteus minimus and medius and
tensor fasciae latae muscles
176
177. Hip Joint
Nerves to hip joint:
• The hip joint is supplied by the:
1.femoral
2.obturator
3.sciatic
4.nerve to quadratus femoris
direct branches of sacral plexus
177
178. The Knee Joint
• The knee joint is an articulation b/n condyles of femur & of tibia as
well as the lower end of the femur & the patella.
• It is a synovial joint
• articulation b/n femur & tibia is a hinge joint with a very small
amount of rotation possible.
• articulation b/n femur & patella is a synovial plane joint where
the patella glides on the femur.
• The condyles of the tibia are separated by the intercondylar
eminence.
178
179. Knee Joint
• There are anterior and posterior condylar areas of the
tibia that serve as attachments to the anterior & posterior
cruciate ligaments, respectively.
179
180. Knee Joint
• The quadriceps femoris attaches into the
patella & from that into the tibia via the
patellar ligament.
• The vastus lateralis & medialis part of this
muscle strengthens the capsule of the knee
joint.
• If part of the capsule is removed, you can
identify the tibial (medial) collateral capsular
ligament.
• This tibial collateral ligament is fixed to
medial meniscus & thus more prone to
certain sports injuries.
180
182. Knee Joint
• Note that there is a fairly large fat pad beneath the
patella
• Usually this will provide freedom of movement b/n
the patellar ligament and the bony knee structures
allowing for compression & decompression in this area.
182
183. Knee Joint
• LATERAL VIEW of Knee Joint:
• Note attachment of very strong iliotibial tract, tensed
by tensor fasciae latae muscle.
• also identify tendon of the very strong biceps femoris
muscle, inserted into head of fibula.
• fibular (lateral) collateral ligament: is free from
capsule of knee joint &, thus, not likely to be injured in
knee injuries occurring during games such as american
football.
183
184. Knee Joint
• POSTERIOR VIEW:
• Identify the arcuate popliteal ligament arches upwards &
medially over popliteus from head of fibula.
• tendon of popliteus arises from lateral condyle of femur, within
the capsule of knee joint
• its tendon separates lateral meniscus from fibular (lateral)
collateral ligament.
• removal of the two heads of gastrocnemius m & vessels & nerves
in the area, oblique popliteal ligament can be identified.
184
185. Knee Joint
• When patella is cut away from quadriceps muscle &
reflected downwards, internal makeup of the knee joint is
seen.
• Note articularis genu muscle, a small muscle originating
from lower anterior surface of femur & attaches into
upper part of the joint capsule.
• the synovial infrapatellar fold is also visiblenotice liying
deep to patella.
185
186. Knee Joint
• inner structures making up knee joint can be identified
when knee is flexed & various synovial folds removed :
• anterior cruciate ligament
• posterior cruciate ligament
• lateral meniscus
• medial meniscus - firmly attached to the tibial collateral
ligament
• transverse ligament
• fibular (lateral) collateral ligament
• tibial (medial) collateral ligament
186
189. Ligaments of the knee
joint
• major ligaments associated with the knee joint are:
1. patellar ligament,
2. tibial (medial) & fibular (lateral) collateral ligaments,
3. anterior & posterior cruciate ligaments.
1. patellar ligament:
• is continuation of quadriceps femoris tendon inferior to patella.
• attached above to margins & apex of patella & below to tibial
tuberosity.
189
190. Ligaments of the knee
joint
2. Collateral ligaments:
• one on each side, stabilize the hinge-like motion of knee .
(i). fibular collateral ligament:
• cord-like, & superiorly attached to lateral femoral epicondyle.
• Inferiorly, to a depression on lateral surface of fibular head.
• It is separated from the fibrous membrane by a bursa.
190
191. Ligaments of the knee
joint
2.Collateral ligaments:
(ii) tibial collateral ligament:
• Is broad & flat; attached to medial meniscus &
underlying fibrous membrane.
• is anchored superiorly to medial femoral epicondyle
& attaches to medial margin & medial surface of
tibia above & behind attachment of sartorius,
gracilis, & semitendinosus tendons.
191
192. Ligaments of the knee joint
3.Cruciate ligaments:
• are in the intercondylar region of the knee &
interconnect femur & tibia
• They are termed 'cruciate' (Latin for shaped like a
cross) because they cross each other b/n their femoral
& tibial attachments:
anterior cruciate ligament attaches to anterior part
of intercondylar area of tibia & ascends posteriorly to
attach to a facet at the back of lateral wall of
intercondylar fossa of femur.
192
193. Ligaments of the knee joint
3.Cruciate ligaments:
• the posterior cruciate ligament attaches to posterior
aspect of intercondylar area of tibia & ascends
anteriorly to attach to medial wall of the intercondylar
fossa of femur.
• anterior cruciate ligament crosses lateral to posterior
cruciate ligament as they pass thru the intercondylar
region.
193
194. Ligaments of the knee joint
Extra Capsular Ligaments:
1. Patellar Ligament:
• Attached to lower border of patella (above) & to
tuberosity of tibia (below)
• Is a continuation of common tendon of quadruceps
femoris m
• Separated from the synovial membrane by intrapatellar
fat pad
2. Lateral collateral ligament:
• Attached above to lateral condyle of femur & below to
head of fibula
• Popliteus tendon intervene b/n it & lateral meniscus
Not tightly held to lateral meniscus mobility not
limited.
194
3.Medial Collateral Ligament:
Attached to medial condyle of femur & to medial surface
of shaft of Tibia
Firmly attached to edge of medial meniscus mobility
limited
4.Oblique popliteal ligament:
Derived from semitendinosus m.
Strengthens posterior aspect of the capsule
196. Ligaments of the knee joint
Intra Capsular Ligaments:
I. Cruciate Ligaments:
• Two very strong intracapsular ligaments, which cross
each other within joint cavity.
• They are named Anterior & Posterior according to their
Tibial attachments
• They are the main bond b/n femur & tibia
196
197. Ligaments of the knee joint
1. Anterior Cruciate Ligament:
• Attached to anterior intercondylar area of Tibia
• Passes upward, backward & laterally to be attached to posterior part of
medial surface of lateral condyle of femur.
• It is slack when knee is flexed but taut when knee is fully extended
• prevents posterior displacement of femur on Tibia.
• With knee joint flexed, anterior cruciate ligament prevents tibia from being
pulled anteriorly
197
198. Ligaments of the knee joint
2. Posterior Cruciate Ligament:
• Attached to posterior intercondylar area of Tibia
• Passes upward, forward & medially to be attached to anterior part of
lateral surface of medial condyle of femur.
• Anterior fibers become slack when knee is extended, but become taut in
flexion
• Posterior fibers are taut in extension.
• Posterior Cruciate Ligament prevents anterior displacement of Femur on
Tibia
• With knee joint flexed, Posterior Cruciate Ligament prevents the Tibia
from being pulled posteriorly
198
200. Ligaments of the
knee joint
II. Menisci (Semilunar Cartilages):
• C-shaped fibrocartilage
• Peripheral border is thick & convex
& attached to the capsule
• Inner border is thin & concave and
forms a free edge.
• Menisci’s function is to deepen the
articular surfaces of Tibial condyles
to receive the convex Femoral
condyles
• They also serve as cushions b/n
Tibia & Femur 200
201. Ligaments of the knee joint
1. Medial Meniscus:
• Nearly semicircular
• Anterior horn attached to anterior intercondylar area of
Tibia & Posterior horn attached to posterior intercondylar
area
• Also connected to lateral meniscus by Transverse
Ligament
• Peripheral border attached to the Capsule & to Medial
Collateral Lig.
• because of this, Medial Meniscus is relatively fixed
mobility limited more prone to injury
201
202. Ligaments of the knee joint
2. Lateral Meniscus:
• Nearly circular
• Anterior horn attached to anterior intercondylar area of
Tibia & Posterior horn attached to posterior
intercondylar area
• Peripheral border is separated from the Lateral
Collateral Ligament by popliteus tendon
• because of this, Lateral Meniscus is less fixed than
Medial Meniscus mobility unlimited less prone to
injury
202
204. Movements of the Knee Joint
• The main movements at the knee joint: flexion and extension.
• when knee is bent with foot on the ground, some rotation of distal end of femur is possible on
upper end of tibia.
Such rotation is possible only when the joint is flexed because this is the only position in which
tibial collateral, fibular collateral & cruciate ligaments are not tense.
When knee is flexed & the ligaments are loose, knee has a tendency to fall off the tibia if it
weren't for the cruciate ligaments which prevent this movement:
posterior cruciate prevents movement of femur forward on tibia (anterior dislocation) & the
anterior cruciate prevents the movement of the femur backward (posterior dislocation of femur).
• Tears of anterior cruciate ligament are more common
204
205. Knee Joint
• There are several muscles that flex the leg at the knee joint:
• hamstring muscles
• sartorius
• gracilis
• gastrocnemius
The main extensor is the quadriceps femoris muscle.
muscle that lock the knee into full extension are the tensor fasciae latae & gluteus maximus by way of the iliotibial tract.
To break full extension and start flexion (unlocking the knee joint), the popliteus muscle is called into action.
popliteus m pulls on lateral condyle of femur causing femur to laterally rotate on tibia. (popliteus m. is innervated by
Tibial nerve).
• During normal stages of walking, the knee is extended during the swing thru phase & flexed during the push off phase.
When knee is extended during walking, foot is laterally rotated.
This makes sense because if the foot rotated medially, you would trip over your own feet.
205
206. Knee Joint
Locking mechanism:
• during standing, knee joint is 'locked' into position, thereby reducing the amount of
muscle work needed to maintain the standing position.
• in flexion, articular surfaces b/n femur & tibia are reduced & in extension articular
surfaces are increased.
• joint surfaces become larger & more stable in extension.
• Medial rotation & full extension tighten all associated ligaments.
• Another feature that keeps the knee extended when standing is body's center of gravity
• popliteus muscle unlocks the knee by initiating lateral rotation of femur on tibia.
206
207. Arteries of the Knee Joint
• Vascular supply & innervation
• Vascular supply to the knee joint is mainly thru
descending & genicular branches from femoral,
popliteal, and lateral circumflex femoral arteries
in the thigh and the circumflex fibular artery and
recurrent branches from the anterior tibial artery
in the leg.
• These vessels form an anastomotic network
around the joint
• The knee joint is innervated by branches from
obturator, femoral, tibial, and common fibular
nerves
208. The Ankle
Tarsal tunnel:
• is formed on posteromedial side of the
ankle by:
a depression formed by medial malleolus,
medial & posterior surfaces of talus,
medial surface of calcaneus & inferior
surface of sustentaculum tali
an overlying flexor retinaculum
208
211. Ankle Joint
• The ankle joint is an
articulation between the tibia,
fibula and talus.
• It is a synovial hinge joint
with only two movements
possible, dorsiflexion
(extension) or plantarflexion
(flexion).
211
212. Ankle Joint
• Looking at the lateral view of the ankle
joint, identify the following ligaments:
•
• anterior talofibular ligament
• calcaneofibular ligament
• talocancaneal ligament
• calcaneonavicular ligament
212
213. Ligaments of the Ankle
Joint
• On the medial side of the
ankle joint, identify the:
• deltoid ligament:
• Posterior tibiotalar part
• tibionavicular part
• tibiocalcaneal part
213
215. Ligaments of the
Ankle Joint
• Ankle Sprain / Forced Inversion:
• Results from rupture of calcaneofibular & talofibular
ligaments and a fracture of lateral malleolus.
215
216. Ligaments of the Ankle Joint
• Acute sprain of lateral ankle:-
• lateral sprain is more common than medial sprain,
• results from excessive inversion of the foot with plantar flexion of the ankle.
• The antrior talofibular & calcaniofibular ligament partially torn resulting in
pain & local swelling
• The opposite (medial sprain) medially pulling result in medial ligament &
medial malleolus injury.
217. Ligaments of the Ankle Joint
• From the posterior aspect of the ankle joint, identify the:
• calcaneofibular ligament
• posterior talofibular ligament
• posterior tibiotalar part of deltoid ligament
217
218. Joints of the Foot
• In the sole of the foot, identify the following ligaments:
• long plantar ligament
• calcaneocuboid ligament
• calcaneonavicular (spring) ligament
218
The lower limbs have six major regions
The gluteal region
The emoral region
The knee region
The leg region
The ankle (L. tarsus) or talocrural region
The oot (L. pes) or oot region
The transition from the trunk to the free lower limb occurs abruptly in the inguinal region (groin)
superiorly by the inguinal ligament (thickened inerior margin o external oblique aponeurosis) that orms the base o the emoral triangle. medially by the lateral border o the adductor longus. laterally by the sartorius; the apex o the emoral triangle is where the medial border o the sartorius crosses the lateral border o the adductor longus
The gluteal muscles (gluteus maximus, medius, and minimus and tensor asciae latae) orm the bulk o the region. The gluteal old demarcates the inerior boundary o the buttocks and the superior boundary o the thigh.
It is helpul to think o the greater sciatic oramen as the “door” through which all lower limb arteries and nerves leave the pelvis and enter the gluteal region. The piriormis muscle (Fig. 7.35D–G; Table 7.6) also enters the gluteal region through the greater sciatic oramen and lls most o it.
The superficial layer of muscles of the gluteal region consists of the three large overlapping glutei (maximus, medius, and minimus) and the tensor fasciae latae These muscles all have proximal attachments to the posterolateral (external) surface and margins of the ala of the ilium and are mainly extensors, abductors, and medial rotators of the thigh.
The deep layer of muscles of the gluteal region consists of smaller muscles (piriformis, obturator internus, superior and inferior gemelli, and quadratus femoris) covered by the inferior half of the gluteus maximus. These muscles all have distal attachments on or adjacent to the intertrochanteric crest o the emur. These muscles are lateral rotators o the thigh, but they also stabilize the hip joint, working with the strong ligaments o the hip joint to steady the emoral head in the acetabulum.
The hamstrings received their name because it is common to tie hams (pork thighs) up or curing and/or smoking using the long tendons o these muscles (Fig. 7.41F). This also explains the expression “hamstringing the enemy” by slashing these tendons lateral and medial to the knees.
A person with paralyzed hamstrings tends to fall forward because the gluteus maximus muscles cannot maintain the necessary muscle tone to stand straight.
