Human anatomy of Lower limb

1. jigjiga univsersity
college of medicine and
other health science
school of medicine
GROSS ANATOMY
lower limb
for pc-1 medical students

2. LOWER LIMB

3. Outline
• Introduction
• Bones of the lower limb
• Superficial structures of lower limb
• Thigh and gluteal region
• Popliteal fossa
• Leg
• Foot
• Joints of lower limb
3

4. Lower limb
• Has six regions
1. Gluteal region
2. Femoral (thigh) region
3. Knee region
4. leg region
5. Ankle region
6. Foot region

6. 6

7. Pelvic Girdle
• Basin-shaped ring of bones that connects the
vertebral column to the femurs
Function
–Bear the weight of the upper body when
sitting and standing
–Transfer the weight of the body from the
axial to appendicular skeleton
–Provide attachment for muscles and
abdominal wall
–Contain and protect the pelvic and inferior
abdominal viscera
–Provide attachment for the erectile bodies of
the external genitalia

8. Pelvic Girdle cont…
 The bony pelvis is formed by 4 bones united by
4 joints
–Bones: 2 hip bones, sacrum and coccyx
–Joints: 2 sacroiliac joints, pubic symphysis
and sacrococcygeal joint
 The hip bones are joined at the pubic
symphysis anteriorly and to sacrum posteriorly
at sacroiliac joints.

9. Pelvic Girdle cont…
• Each hip bones formed by fusion of three bones
-ilium,
-ischium, and
- pubis
• This bone fused at the acetabulum by a y-
shaped triradiate cartilage
• Begin to fuse at 15-17 years and complete at 20-
25 years of age

11. 11

12. Acetabulum
The cup-shaped depression on the lateral
aspect of the hip bone with which the head of
the femur articulates to form hip joint.
All three primary bones forming the hip bone
contribute to the formation of the acetabulum.

13. 13

14. The ilium
Is the superior, flattened, fan-shaped part of the
hip bone:
Has two parts
1.Ala (wing): spread of the fan.
origins for gluteus minimus, medius and
maximus muscles
 the anterior concave part of the ala forms the
iliac fossa
2. Body: forms the superior part of the
acetabulum
– joins ischium and pubis at acetabulum

16. Iliac crest
–the rim of the ilium
–has a curve that follows the contour of the ala
between the anterior and the posterior superior
iliac spines
–a line joining the most superior point of the
bilateral iliac crests will cross the 4th lumbar
spine (L4)
Landmarks
–Anterior superior & inferior iliac spine
–Posterior superior & inferior iliac spine
–Greater sciatic notch 16

17. 17

18. The ischium: posteroinferior part of hip bone
• has a body and a ramus
Body
–forms the posterior part of the acetabulum
–joins ilium and superior ramus of pubis to
form acetabulum
Ramus
–fuses with the inferior ramus of pubis
–forms part of the inferior boundary of the
obturator foramen

19. Landmarks
–Ischial tuberosity
• large posteroinferior protuberance of the
ischium
• supports body during sitting
–Ischial spine
• Small pointed posterior projection near the
junction of the ramus and body
–lesser sciatic notch
19

21. Pubis
• Anteromedial part of hip bone
• Forms anterior part of the acetabulum
• Angulated bone; has two rami (inferior & superior)
and body
Body
– has a symphyseal surface for articulation with the
contralateral pubis
Rami
– Superior pubic ramus: forms anterior part of
acetabulum
– Inferior pubic ramus: forms part of the inferior
boundary of the obturator foramen
21

22. Landmarks
–pecten pubis or pectineal line
• oblique ridge on superior pubic ramus on its
superior aspect
–pubic crest
• thickening on the anterior part of the body
of the pubis
• ends laterally as a swelling - pubic tubercle
22

24. 24

25. 25

26. Pubic arch (sub pubic angle)
–formed by the ischiopubic rami (conjoined
inferior rami of the pubis and ischium) of the
two sides
–their inferior borders define the subpubic
angle
• the distance between right and left ischial
tuberosities
• measured with the fingers in the vagina
during a pelvic examination
26

27. 27

28. Greater sciatic foramen
–Passageway for structures entering or
leaving the pelvis
–It is a door through which all lower limb
arteries and nerves leave the pelvis and
enter the gluteal region
–The piriformis also enters the gluteal region
through the greater sciatic foramen and
almost fills it
Lesser sciatic foramen
–Passageway for structures entering or
leaving the perineum
11

30. Obturator foramen
 The obturator foramen is a large oval or
irregularly triangular opening in the hip bone.
 It is bounded by the pubis and ischium and
their rami.
 Except for a small passageway for the
obturator nerve and vessels (the obturator
canal), it is closed by obturator membrane.
 Its closure by the obturator membrane provides
extensive surface area for muscle attachment.

32. Femur
• The femur is the longest and heaviest bone in
the body
• linea aspera: a prominent double-edge ridge
on its posterior aspect of shaft of femur
• The proximal end of the femur consists of
A head
Neck, and
Two trochanters
Shaft: posses linea aspera

34. Fovea capits: medially placed depression or pit of
head of femure.
lesser trochanter: extends medially from the
posteromedial part of the junction of the femoral
neck and shaft
Greater trochanter: is a large, laterally placed
mass that projects superomedially where the
neck joins the shaft

35. The distal end of the femur consists of:
Femoral condyles (medial and lateral):
spirally curved articular surfaces
•Condyles articulate with the tibial condyles to
form the knee joint.
Medial epicondyle: is a rounded eminence on the
medial condyle and
Lateral epicondyle: on lateral surface of the
lateral condyle. Just posterosuperior to the medial
epicondyle is the adductor tubercle.
Patelar surface: depresion anteriorly b/n
condyles.

36. Patella (knee cap)
• Large sesamoid bone, formed intratendinously
• Located anterior to knee joint
• Triangular in shape
• Articulate with patellar surface of femur
• Anterior surface is convex
• Base – superior border
• Lateral and medial border converge to form apex

37. Tibia
• Large, weight bearing
Articulate:
– proximally with condyles of femur at knee joint
– distally with the talus of ankle
– laterally at its proximal and distal ends with fibula
Have
• Medial & lateral condyles
• Tibial tuberosity
• Medial malleolus - inferiorly directed projection from
medial side of distal end

39. Fibula
• Long, slender bone on the lateral side of leg
• Serves mainly for muscle attachment than for
support
• has head and neck
• Distal end enlarges to form lateral malleolus
• Fractures commonly occur just proximal to
lateral malleolus and often are associated with
dislocation of ankle joint
• Fibula is a common source of bone for grafting

40. Bones of Foot
Tarsal Bones
–7 bones which form the ankle joint; talus,
calcaneus, navicular, 3 cuneiforms & cuboid
–Only talus articulate with leg bones
• Calcaneus
–Heel bone
–Largest and strongest bone
–Articulate with talus and cuboid
40

42. • Talus
–Rests on anterior 2/3 of calcaneus
–Superior surface, trochlea of talus, bears
weight of the body and articulates with two
malleoli
–Head articulate with navicular
• Navicular
–Flattened, boat shaped
–Located between talar head and cuneiforms
42

43. • Cuboid
–Most lateral
• Cuneiforms: medial, intermediate and lateral
–Wedge shaped
–Each articulate with navicular posteriorly and
metatarsal anteriorly
43

45. Metatarsal Bones
–5 bones which form middle part of the foot
–Each bone has base, body & head
–Bases articulate with cuneiform and cuboid
bones
–Heads articulate with proximal phalanges
Phalanges
–14 bones
–Lateral four digits have proximal, middle &
distal phalanx
–Great toe (hallux) has only proximal & distal
phalanx
–Each phalanx has base, body & head
45

46. Arches of foot
• The bones of the foot do not lie in a horizontal
plane
• Instead, they form longitudinal and
transverse arches relative to the ground.
Functions
–distribute weight over the foot
–act as shock absorber
–act as spring boards for propelling during
walking
46

48. • The weight of the body is transmitted to talus
from tibia.
• Then, to calcaneus and heads of metatarsal
Transverse arch
This consists of:
– bases of the metatarsal bones
–the cuboid and
–the three cuneiform bones.
48

49. Longitudinal arch
• Medial longitudinal arch
– formed by:
• Navicular
• Talus
• 3 medial digits and their metatarsals
• 3 cuneiforms
• Lateral longitudinal arch
– formed by:
• 2 lateral digits and their metatarsals
• cuboid
• calcaneus
49

53. • The three most important
strongly implicated in
maintaining the arches
of the foot are:
1.Long plantar ligament
2.Calcaneocuboid
ligament
3.Calcaneonavicular
ligament
53
Maintaining Arches of the Foot

54. 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 & posterior and medial ligament of
ankle joint
54

55. 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
55

56. 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
56

57. Fractures of hip bone
• Commonly referred to as pelvic fractures
• The term hip fracture is most commonly applied
to fractures of the femoral heads, neck, or
trochanters
• Avulsion fractures of the hip bone
–may occur during sports that require sudden
acceleration or deceleration forces
–A small part of the bone with a piece of
tendon or ligament attached is avulsed (torn
away).
57

59. Normal angle of neck of femur
• Normal angle b/n neck & shaft in children
160 degree & in adults 125 degree.
• Increased angle of inclination:  coxa valga
(rare; occurs in congenital hip dislocation;
forced abduction fractures)
• Decreased angle of inclination: is coxa vara,
occurs in fracture of neck of femur
This may also result from adduction fractures,
slipped the femoral epiphysis or bone-softening
diseases.
59

61. Fracture of the Femur
• The neck of the femur is most frequently
fractured because it is the narrowest and
weakest part of the bone and it lies at a marked
angle to the line of weight-bearing (pull of
gravity).
• It becomes increasingly vulnerable with age,
especially in females, secondary to
osteoporosis.
• Fractures of femoral neck will interrupt
completely blood supply from the diaphysis 
resulting in Avascular Necrosis
61

62. Fracture of femur cont…
Sub capital fracture
• Common in elderly & particularly in women
after menopause:  caused as a result of
estrogen deficiency
• If considerable displacement occurs, the strong
muscles of the thigh (rectus femoris, adductor
muscles, & hamstring muscles) pull the
fragment upward:
 shortened lower limb; & toes pointing
laterally.
• The gluteus maximus, piriformis, etc… rotate
the distal fragment laterally.

63. Fractures of femur

64. Trochanteric fracture of femur
• Commonly occurs in young & middle aged
adults
results in shortening & lateral rotation of the
leg.
• Fracture of Neck of Femur may damage medial
femoral circumflex artery & interrupts blood
supply local areas.

65. • Fractures of the femoral shaft are accompanied
by considerable shortening of the lower limb due
to longitudinal contraction of the extremely
strong surrounding muscles:
The proximal segment is flexed by iliacus and
psoas and abducted by gluteus medius and
minimus, whereas the distal segment is pulled
medially by the adductor muscles.
Fracture of femoral shaft

66. Fracture of femoral shaft

67. i) Upper 3rd Fracture of shaft of femur
• Proximal fragment flexed by iliopsoas
• Abducted by gluteus medius & minimus, laterally
rotated by gluteus maximus, piriformis, obturator-
internous, etc
ii) Fracture of middle 3rd
• Distal fragment pulled up by hamstrings & quadriceps
femoris result in considerable shortening of lower limb.
iii) Fracture of the distal 3rd
• Displacement similar to middle 3rd
• Since distal fragment is small, gastrocnemius muscle
may rotate backward & may exert pressure on popliteal
artery & interfere in the blood supply of the leg.
Fracture of femoral shaft

69. Tibial Fractures
• The tibial shaft is narrowest at the junction of
its middle and inferior thirds, which is the most
frequent site of fracture.
• This area of the bone has the poorest blood
supply.
• Compound tibial fractures may result from direct
trauma (e.g., a “bumper fracture” caused when a
car bumper strikes the leg).
• It is associated with a common peroneal nerve
injury

72. Fibular Fractures
• Fibular fractures commonly occur 2-6 cm
proximal to the distal end of the lateral malleolus
• Often associated with fracture-dislocations of the
ankle joint, which are combined with tibial
fractures.
• Relatively common in soccer and basketball
players.
• Fibular fractures can be painful owing to
disrupted muscle attachments.

73. • Calcaneal fracture – a fall from a ladder
• Talus fracture is common at the neck while
dorsiflexing the foot severely
• Fracture of metatarsal bones- heavy object
fall on the foot

75. Fracture associated with ligaments
Transverse Patellar Fracture:
• Results from a blow to the knee.
• The proximal fragment of the patella is pulled
superiorly with the quadriceps tendon and the
distal fragment remains with the patellar
ligament.
Ankle Sprain / Forced Inversion:
• Results from rupture of the calcaneofibular and
talofibular ligaments and a fracture of the lateral
malleolus.

76. Fracture associated with nerves
Fracture of the Fibular Neck:
•May cause injury to common peroneal nerve
which laterally winds around the neck of the
fibula.
•This results in paralysis of all muscles in the
anterior & lateral compartments of the leg and
presents with Foot Drop.

77. Fracture associated with arteries
Dislocated Knee or Fractured Distal Femur
• May injure the popliteal artery because of its
deep position adjacent to the femur and the
knee joint capsule.

78. Superficial structures of lower limb
Fascia lata
• It is deep fascia of the thigh
• Limits outward extension of contracting muscles,
making muscular contraction more efficient in
compressing veins to push blood toward the heart
• Extends downwards over the subcutaneous
surface of knee and the tibia (deep fascia of leg)
• It is particularly dense laterally to form iliotibial
tract
78

80. Iliotibial tract
–extends from iliac tubercle to tibial tubercle
–receives the aponeurosis of tensor fasciae
latae and gluteus maximus muscles
–when tensed by its attached muscles, assists
in the stabilization of the hip and the
extended knee when standing
80

81. 81

82. Fascia of the leg (crural fascia)
• Continuous with fascia lata
• Attaches to anterior and medial borders of tibia
• Thick proximally and thin distally
• Forms extensor retinacula at distal end
82

84. Plantar fascia
• Attached
–posteriorly to the medial process of the
calcaneus
–anteriorly to the heads of metatarsals by 5
bands
• Thin in the medial and lateral portions
• Thick centrally as the plantar aponeurosis.
84

86. Venous drainage of lower limb
• Superficial and deep veins
• Superficial veins are in subcutaneous tissue
and deep veins accompany arteries
86

87. Superficial veins of the lower limb
Great saphenous vein
Origin
– It arises from the union of dorsal digital
vein of great toe and dorsal venous arch on
the dorsum of the foot
Course
– runs anterior to the medial malleolus
– lies posterior to the medial border of patella
at the knee
87

88. 88

89. –runs up and passes through the saphenous
opening and joins with the femoral vein, 4 cm
inferolateral to the pubic tubercle
–Anastomoses with the small saphenous vein,
below the knee and communicates along
intermuscular septa with the deep veins
Tributaries
–3 superficial veins near the inguinal ligament
89

90. Small saphenous vein
• Origin
–Arises on lateral side of the foot from the
union of dorsal digital vein of little toe with
dorsal venous arch
• Course
–Ascend posterior to lateral malleolus
–Pass along lateral border of calcaneal tendon
–Ascends between 2 heads of gastrocnemius
muscle
–Empties into popliteal vein in popliteal fossa
90

91. Perforating veins
• Originate from superficial veins
• Penetrate deep fascia and join deep veins
• Contain valves that allow blood to flow from
superficial veins to deep vein
• This pattern is important for venous return
because it enables muscular contractions to
propel blood toward the heart
91

92. 92

93. Deep veins of the lower limb
• Accompany arteries
• Contained within vascular sheath with the artery
• Dorsal venous arch drains primarily via the
great & small saphenous veins, but perforating
veins penetrate the deep fascia, drain into
anterior tibial vein in the anterior leg.
• Medial and lateral plantar veins from the
plantar aspect of the foot form the posterior
tibial and fibular veins posterior to the medial
and lateral malleoli.
93

95. Deep veins of the lower limb cont…
• All three deep veins and small saphenous vein
from the leg flow into the popliteal vein
posterior to the knee, which becomes the
femoral vein in the thigh.
• Profunda femoris vein drain blood from the
thigh muscles and joins the terminal portion of
the femoral vein.
• The femoral vein passes deep to the inguinal
ligament to become the external iliac vein.
95

96. 96

97. 1. Femoral vein
A continuation of popliteal Vein at Adductor
hiatus
After passing inguinal lig. → external iliac
vein
 Tributaries
1. Descending genicular
2. Profunda femoris (with its tributaries)
3. Great saphenous

98. Cannulation of femoral vein
• To secure blood samples and take pressure
recordings from the right side of the heart and
pulmonary artery and to perform right cardiac
angiography, catheter is inserted into the femoral
vein at femoral triangle.
• The catheter is passed superiorly through the
external and common iliac veins into the inferior
vena cava and right atrium of the heart.
• Femoral venous puncture may also be used for
the administration of fluids.

99. 2. Popliteal vein
 formed at distal end of popliteus
Terminate in the adductor hiatus
Course in relation to the artery; posterior, and in
relation to tibial nerve: deep .
Tributaries
1. Anterior and
2. Posterior tibial vein
3. Fibular vein
4. Genicular veins
5. Small saphenous vein

100. Clinical correlates
Varicose veins
–larger diameter than normal, elongated &
tortous
–occurs in superficial veins of lower limb
– caused by:
 Hereditary
 Weakness of vein wall
 In competent valves
 Increase intrabdominal pressures etc
100

101. Varicose vein:
•Dilated, tortuous vein in
subcutaneous tissue

102. How do veins work?

103. Thrombosis and thromboembolism
–The veins of the lower limb are subject to venous
thrombosis (blood clotting).
Cause
 Bone fracture
 Muscular inactivity, and
 External pressure on the veins (tight cast)
–Venous stasis (stagnation) is an important cause of
thrombus formation
–A thrombus that breaks free and travels to the
lungs results in a pulmonary thromboembolism
(obstruction of the pulmonary artery) 103

104. Saphenous vein grafts
–Vein grafts obtained by surgically harvesting
parts of the great saphenous vein are used to
bypass obstructions in blood vessels (e.g., an
occlusion of a coronary artery or its branches)
–When part of the vein is used as a bypass, it is
reversed so that the valves do not obstruct blood
flow
–Because there are so many other leg veins,
removal of the great saphenous vein rarely
affects circulation, provided the deep veins are
intact
104

105. Lymphatic drainage of lower limb
• Superficial and deep lymph vessels
• Superficial lymph vessels
–There are many than the deep vessels
–Many of them follow the great saphenous vein
and end in the superficial inguinal lymph
nodes
–Few of them follow the small saphenous vein
and end in to popliteal lymph nodes
• Deep lymph vessels of the leg
–follow the deep veins and enter popliteal lymph
nodes from which lymph drain into the deep
inguinal lymph nodes 105

107. Lymph nodes
• Inguinal lymph nodes
–palpable
–divided into superficial and deep groups
• Superficial inguinal lymph nodes
–divided into
• superior horizontal (superolateral and
superomedial) group
–drain
»subcutaneous tissues of the anterior
abdominal wall inferior to the umbilicus
»penis and scrotum, or the vulva
»distal part of the vagina 107

108. »gluteal region, perineum
»distal part of the anal canal
• inferior vertical group
–lies along the great saphenous vein
–receives most lymph vessels of the lower
limb
• Deep inguinal lymph nodes
–Receive efferent vessels from superficial
nodes
–Efferent from the deep inguinal lymph nodes
end into the external iliac lymph nodes 108

109. 109

110. 110

111. Cutaneous innervation of the lower limb
• Cutaneous nerves arise from lumbar and sacral
plexuses
• They pierce the deep fascia along the upper
border of the sartorius
• Those arising from the femoral nerve form the
anterior femoral cutaneous nerve (the
intermediate and medial cutaneous nerves of
the thigh)
• Others arise from the saphenous nerve
111

112. • Arise from 10 spinal cord segments – T12- S4
– Upper and lateral gluteal region - T12 & L1,2
– Front, medial and lateral thigh - L1,2,3
– Medial and front of the leg - L 4
– Lateral and front of the leg and intermediate of the
dorsum of the foot - L5
– Lateral border of the foot - S1
– Sole of the foot medial part - L4
– Sole of the foot intermediate part - L5
– Sole of the foot lateral part - S1
– Back of the leg and thigh - S2
– Inferior and medial part of gluteal region and perianal
region - S3,4 112

113. 113

114. 1. Hip region – iliohypogastric and CLUNIAL
N.(post. Rami of S1-3 and L1-3) for lateral and
medial regions respectively
2. Thigh
A. lateral – lateral cutaneous nerve of the thigh
B. superolatetal- Sub costal
C. superoventral- genitofemoral
D. superomedial- ilioinguinal
E. Middle of the medial part- obturator
F. ventromedial – medial femoral Cut
G. ventrolateral- intermediate femoral Cut
H. posterior – posterior cutaneous nerve of the
Thigh

116. 3. The leg
Ventromedial – saphenous
upper Lateral - lateral cutaneous nerves of the
calf
Ventral and inferior- superficial peroneal
Lateral and inferior- sural

117. 4. Foot
Dorsum
Lateral – sural
Medial- saphenous
Intermdiate- superficial peroneal
Adjacent areas of the 1st and 2nd digit - DEEP
FIBULAR
Sole
Medial side and skin of the medial 3½ toes –
medial plantar
Lateral side of skin over the lateral 1½ toes-
lateral plantar

119. Surface Anatomy of Gluteal Region
• It is the region behind the pelvis, extending from
the iliac crest superiorly to the gluteal fold
(fold of the buttock) inferiorly
• Gluteal fold indicates the lower border of the
gluteus maximus muscle (gluteal sulcus/crease
is a skin crease for the hip joint)
• A deep midline groove, the natal (intergluteal)
cleft separates the buttocks from each other.

120. Surface Anatomy of Gluteal Region

121. Ligaments of the Gluteal Region
• 2 ligaments
–Sacrospinous, connecting sacrum to ischial
spine
–Sacrotuberous, connecting sacrum to ischial
tuberosity
• They convert the greater & lesser sciatic notches
into greater & lesser sciatic foramina
• Their main function is to:
–Stabilize the sacrum
–Prevent its posterior rotation at the sacroiliac
joint

122. Ligaments of the Gluteal Region

123. Structures passing through the greater sciatic foramen
Piriformis: an important landmark
Above the piriformis:
Superior gluteal vessels & nerve
Below the piriformis:
Inferior gluteal vessels & nerve
Sciatic nerve
Posterior cutaneous nerve of thigh
Pudendalnerve & Internal
pudendal vessels
Nerve to obturator internus
Nerve to quadratus femoris

124. Structures passing through the lesser sciatic
foramen
Entering:
Pudendal nerve &
Internal pudendal vessels
Exiting:
Tendon of obturator internus
Nerve to obturator internus

125. Muscles Crossing the Hip and Knee
• Muscles crossing the hip and knee can be
grouped into
–Gluteal muscles (superficial groups)
–Lateral rotators (deep groups)
–Hip flexors (hip muscles)
–Medial compartment ( adductors)
–Anterior compartment (knee extensors)
–Posterior compartment ( knee flexors)

126. Muscles of the Gluteal Region
Superficial Groups
•Gluteus maximus
•Gluteus medius
•Gluteus minimus
•Tensor fascia lata
Deep Groups
•Piriformis
•Superior Gemellus
•Inferior Gemellus
•Obturator internus
•Quadratus femoris

127. Gluteus maximus
O: dorsal ileum, sacrum and coccyx
I: iliotibial tract and gluteal tuberosity of femur
A: Extends thigh (especially from flexed position)
and assists in its lateral rotation; steadies thigh
and assists in rising from sitting position
Inn: inferior gluteal nerve

129. Gluteus maximus cont…
 Gluteus maximus is the chief antigravity muscle
of the hip.
 It is used in standing up from a sitting position,
running & climbing up stairs.
 In each case extension of the hip moves the trunk
upwards.
 The muscle must be extremely powerful to raise
the weight of the body against gravity. This is
called "forced extension".

130. Gluteus medius
O - between anterior and
posterior gluteal lines on
lateral surface of ilium
I - greater trochanter of
femur
A - Abducts & medially
rotates the thigh
Stablizes pelvis
Inn: Superior gluteal
Nerve

131. Gluteus minimus
O - between anterior and inferior
gluteal lines on external surface
of ilium
I - greater trochanter of femur
A - abducts and medially rotates
thigh and with gluteus medius
prevent tilting of the pelvis
Inn - superior gluteal N

133. Tensor fascia latae
O - anterior aspect of iliac
crest
I - iliotibial tract
A – flexes, abducts and
medially rotate thigh
Inn- superior gluteal
nerve

134. Lateral rotators of the hip joint
It includes:
Piriformis
Superior Gemellus
Inferior Gemellus
Obturator internus
Quadratus femoris
Obturator externus

135. Lateral rotators of the hip joint

136. Piriformis
Key muscle – divide the greater sciatic foramen into 2.
Above piriformis
- superior gluteal N and Vessels
Below piriformis
- nerves- sciatic, inf. Glut. Nerve, Pudendal, Nerve to
Quadratus femoris and obturator internus
- vessels- inferior gluteal, internal pudendal
O: pelvic surface of sacrum
I: Greater Trochanter
Inn: ventral rami of S1 and S2

137. The quadratus femoris
O: Ischial tuberosity
I: Greater trochanter
Inn: nerve to quadratus femoris (L4, 5, S1).
The obturator internus
O: pelvic surface of the obturator membrane,
I: Greater trochanter.
Inn: nerve to obturator internus (L5, S1, 2).

138. The superior gemillus
O: the ischial spine.
I: Medial surface of greater trochanter
Inn: nerve to obturator internus (L5, S1, 2).
The inferior gemillus
O: the ischial tuberosity.
I: Medial surface of greater trochanter
Inn: -nerve to quadratus femoris (L4, 5, S1).
N.B Both distal tendons of the gemelli join with
that of the obturator internus.

140. Muscles of the thigh
There are located in 3 compartment
Anterior thigh muscle: flexor of hip & extensor
of knee.
Medial thigh muscles: Adductor of the thigh
Posterior thigh/ hamstring/ muscles: Extensor
hip & Flexor of knee.

141. Anterior thigh muscle
 The anterior thigh muscles include the
pectineus, iliopsoas, sartorius, and
quadriceps femoris
 Quadriceps femoris ( four muscles)
• Vastus lateralis
• Vastus medialis
• Vastus intermedius
• Rectus femoris
The nerve supply- femoral nerve

144. Iliacus
O- iliac fossa
I- lesser trochanter of
femur
A- strong hip flexor
Inn- femoral branch in
the abdomen

145. Psoas major
O - transverse processes and
bodies of T12 and all
lumbar vertebrae
I - lesser trochanter of femur
A – strong hip flexor
• Inn - Anterior rami of
lumbar nerves (L1, L2,
L3)

146. Psoas minor
O - Transverse
processes and
bodies of T12 and
L1
I - Rim of acetabulum
A - flexes lumbar
vertebrae
Inn - Anterior rami of
lumbar nerves (L1,
L2)

147. Pectineus
O - pectineal line of pubis
I - lesser trochanter of
femur
A - adducts, flexes, and
laterally rotates thigh
Inn – Femoral nerve

148. Sartorius (the “tailor’s muscle”)
O - anterior superior iliac
spine
I - medial aspect of
proximal tibia
A - flexes, abducts and
laterally rotates thigh at
hip joint
–flexes leg at knee joint

149. Quadricep femoris
• Muscles include
–Rectus femoris
–Vastus lateralis
–Vastus medialis
–Vastus intermedius
 All insert into patella and tibial tuberosity by
a common distal tendon - quadriceps tendon.
 The patellar ligament, attached to the tibial
tuberosity, is the continuation of the
quadriceps tendon

150. Rectus femoris
O - anterior inferior
iliac spine
I - patella and tibial
tuberosity
A - extends knee and
flexes thigh at hip
Inn – Femoral nerve

151. Vastus lateralis
O - greater trochanter,
intertrochanteric line
I - patella and tibial
tuberosity
A - extends knee
Inn – Femoral nerve

152. Vastus medialis
O - linea aspera,
intertrochanteric line
I - patella and tibial
tuberosity
A - extends knee
Inn – Femoral nerve

153. Vastus intermedius
O - anterior and lateral
surfaces of proximal
shaft of femur
I - patella and tibial
tuberosity
A - extend knee
Inn – Femoral nerve

154. Paralysis of quadriceps
– Tested with a person in supine position with the knee
partly flexed then extend the knee against resistance
– If the muscle is paralyzed, the person cannot extend
leg against resistance.
– Result from arthritis or trauma to the knee joint
Patellar tendon reflex
– Tapping the patellar ligament with a reflex hammer
normally elicits patellar tendon reflex (knee jerk)
– Causes leg to extend
– It tests L2-L4 nerves
– Absence of patellar tendon reflex may result from any
lesion that interrupts innervation of quadriceps muscle
154

155. Medial thigh muscles
• Collectively called Adductor group
• Originate from the pubis and ischium inserted to
the linea aspera of femur.
• All are supplied by Obturator nerve except
hamstring part of adductor Magnus
• Adductor muscles are:
– Adductor Magnus
– Adductor longus
– Adductor brevis
– Gracilis
– Obturator externus 155

156. Adductors are
arranged in three
layers
A. Superficial-
Gracilis and
adductor Longus
B. Middle- Adductor
Brevis
C. Deep- Adductor
Magnus &
obturator externus

157. Adductor longus
O - pubis near pubic
symphysis
I - linea aspera of femur
A - adducts, flexes and
laterally rotates thigh
Inn: Obturator N (anterior
branch)

158. Gracilis
O - Inferior ramus and body of pubis
I - Medial surface of tibia just inferior to medial
condyle (pes ansarenus)
A - Adducts and flex the thigh, flexes and medially
rotates the leg
Inn: anterior branch of obturator nerve
• The gracilis joins with two other muscles (the
sartorius and semitendinosus muscles).
• They have a common tendinous insertion, the pes
anserinus, into the superior part of the medial
surface of the tibia.

160. Adductor brevis
O - body and inferior
ramus of pubis
I - linea aspera of femur
A – adducts, laterally
rotates, and flex (weak)
of the thigh
Inn: anterior branch of
obturator nerve

161. Adductor magnus
O - ischial and pubic rami and ischial tuberosity
I - linea aspera (medial lip) and supracondylar line
and adductor tubercle
Composite muscle (hamstring and adductor part)
A - Adductor part adducts and hamstring part
extends the hip
Inn: Adductor part – Posterior division of obturator
nerve and hamstring part - sciatic nerve

163. Obturator externus
O. obturator membrane
I. the back of the
femoral neck.
A. Lateral rotator of
the hip joint
Inn: Posterior division
of obturator nerve

164. Groin Pull
• Sports broadcasters refer to a “pulled groin” or
“groin injury.”
• These terms mean that a strain, stretching, and
probably some tearing of the proximal
attachments of the anteromedial thigh muscles.
• The injury usually involves the flexor and
adductor thigh muscles.
• Groin pulls usually occur in sports that require
quick starts (e.g., sprinting and base stealing in
baseball), or extreme stretching (e.g., gymnastics).

165. Hamstring muscle (posterior compartment of
the thigh)
Arise from the ischial tuberosity
Insert into the tibia or fibula
Are innervated by the tibial division of the
sciatic nerve, except the short head of the
biceps femoris which is innervated by common
fibular (peroneal) division.
It includes:
The Biceps femori, semimembranosus and
semitendinosus
Extend hip and flex knee joint.

166. Biceps femoris
O - (long head) ischial tuberosity, (short head)
linea aspera
I –head of fibula, lateral condyle of tibia and head
of fibula
A - Long head extends and laterally rotates the
thigh and flexes knee, short head flex the knee
and laterally rotates leg
Inn: long head- tibial nerve and short head-
common fibular (peroneal) nerve

168. Semi- tendinous
O - ischial tuberosity
I - medial aspect of
upper tibial shaft(pes
ansernus)
A - extends thigh at hip;
flexes knee, medially
rotates leg
Inn: similar to long head
of biceps

169. Semi- membranous
O - ischial tuberosity
I - medial condyle of
tibia(deeper and slightly
medial to semitendinous)
A - extends thigh and
flexes knee, medially
rotates leg
Inn: similar to long head of
biceps

170. Hamstring injuries
• Hamstrings strains (pulled and/or torn
hamstrings) are common in people who run
and/or kick hard (e.g., in running, jumping and
quick-start sports such as baseball and soccer)
• The violent muscular exertion required to excel
in these sports may tear part of the proximal
attachments of the hamstrings to the ischial
tuberosity
• Hamstring injuries may result from inadequate
warming up before practice or competition

171. The Femoral Triangle
Boundaries-
• Medial- medial
boarder of adductor
longus
• Lateral- medial
boarder of Sartorius
• Superior- inguinal
ligament
• Floor- adductor
longus, pectineus,
terminal part of psoas
major and iliacus

172. The Femoral Triangle…
The contents of the femoral triangle, from lateral
to medial are :
• Femoral nerve and its (terminal) branches.
• Femoral sheath and its contents:
• Femoral artery and several of its branches.
• Femoral vein and its proximal tributaries (e.g., the
great saphenous and profunda femoris veins).
• Deep inguinal lymph nodes and associated
lymphatic vessels.

175. Adductor canal
 Extends from the outlet of the femoral triangle to beginning of
Popliteal fossa
The walls of the adductor canal are:
 anterolaterally- vastus medialis
 Anteromedially – Sartorius
 Posteriorly (floor)-the adductor longus and magnus
Contents of the adductor canal:
 the femoral artery after passing becomes the popliteal artery.
 Femoral vein
 The saphenous nerve
 The nerve to vastus medialis accompanying its muscle.

177. Adductor Hiatus
• The adductor hiatus is an
opening b/n the distal
attachment of the adductor &
hamstring part of the adductor
magnus.
• The adductor hiatus transmits
the femoral artery and vein from
the adductor canal to the
popliteal fossa posterior to the
knee.

178. Femoral Sheath
• The femoral sheath is a funnel-shaped fascial
tube of 3–4 cm long that passes deep to the
inguinal ligament.
• The sheath encloses proximal parts of the
femoral vessels and creates the femoral canal
medial to them.
• The femoral sheath is formed by an inferior
prolongation of transversalis and iliopsoas
fascia from the abdomen.
• The femoral sheath does not enclose the femoral
nerve because passes thru the muscular comp`t.

180. Femoral Sheath cont…
• The femoral sheath subdivided internally into three
smaller compartments:
• Lateral compartment for the femoral artery.
Intermediate compartment for the femoral vein.
Medial compartment, which is the femoral canal.
• Femoral canal allows the femoral vein to expand
when venous return from the lower limb is
increased, or when increased intraabdominal
pressure causes a temporary stasis in the vein.
• Contains loose connective tissue, fat, a few
lymphatic vessels, and sometimes a deep inguinal
lymph node (lacunar lymph node).

181. Femoral Sheath cont…
• The base of the femoral canal is the oval femoral
ring formed by the small (1 cm wide) proximal
opening at its abdominal end.
• This opening is closed by extraperitoneal fatty
tissue that forms the transversely oriented
femoral septum.
• The abdominal surface of the septum is covered
by parietal peritoneum.
• The femoral septum is pierced by lymphatic
vessels connecting the inguinal and external iliac
lymph nodes.

182. Femoral Hernias
• Femoral hernia, a protrusion of
abdominal viscera (often a loop of
small intestine) through the
femoral ring into the femoral
canal.
• The femoral ring is a weak area in
the anterior abdominal wall about
the size to admit the tip of the little
finger.
• A femoral hernia appears as a
mass, often tender, in the femoral
triangle.

183. Blood vessels of the thigh
Femoral artery- main, continuation of external iliac artery.
• After adductor hiatus becomes - popliteal artery
• 6 branches-
1. superficial epigasteric
2. superficial circumflex iliac
3. superficial external pudendal
4. Deep external pudendal
5. Profunda femoris (deep femoral)
6. Descending genicular (gives articular and saphenous
branch)
N.B. the upper 5 arise in the femoral triangle and the
last in the adductor canal

185. Superficial groups (pierce fascia lata)
Superficial epigastric- runs up crossing inguinal
ligament towards umbilicus
Superficial circumflex iliac- runs toward
ant.sup.iliac spine below inguinal ligament to
form anastamosis
Superficial external pudendal- runs infront of
spermatic cord and femoral vein to supply
scrotum (L. majora) and penis
Deep external pudendal- arise lower and runs
behind great saphoneus vein to supply scrotum
(L. majora)

186. Deep femoral artery (profunda) – origin from
postero-lateral aspect - leave femoral triangle b/n
pectineus and adductor longus and lies over
adductor brevis and magnus
Branches
1- Medial circumflex Femoral-
• Gives Ascending & transverse branches to
trochanteric and cruciate anastamosis
respectively

187. 2. Lateral circumflex Femoral- gives three
branches ascending, transverse and descending
to trochanteric and cruciate anastamosis and the
last supplies vastus lateralis & intermedius
running in between to knee anastamosis.
3. Three perforating branches and terminates at
the fourth perforating

189. Blood supply to the hip joint
Trochanteric anastamosis
1. Lateral circumflex femoral
2. Medial circumflex femoral
3. A branch from 1st perforating
4. Deep branch of superior gluteal
5. Inferior gluteal

190. Blood supply to the hip joint cont…
Cruciate anastomosis: below quadratus femoris
Formed by:
1. transverse branch of medial circumflex femoral
2. transverse branch of lateral circumflex femoral
3. ascending branch from 1st perforating
4. descending branches from inferior gluteal artery

192. Cannulation of femoral artery
• Cannulated just inferior to the midpoint of the inguinal
ligament.
• In left cardiac angiography, catheter is inserted into the
artery and passed up the external iliac artery, common
iliac artery, and aorta to the left ventricle of the heart.
• This same approach is used to visualize the coronary
arteries in coronary arteriography.
• Blood may also be taken from the femoral artery for
blood gas analysis (the determination of oxygen and
carbon dioxide concentrations and pH of the blood by
laboratory tests).

193. Other arteries of the thigh
Obturator artery
From anterior division of internal iliac
Two divisions – anterior (to upper adductors)
and posterior (to the ligament of head of femur).
Branches – muscular, acetabular (twigs to fat in
the fossa and twigs to the head of femur )

194. Other arteries of the thigh cont…
Superior gluteal artery: from internal iliac
artery
 branches- superficial and deep
1. Superficial – Gluteus maximus
2. Deep- upper and lower branches; gluteus
medius, minimus & tensor fascia L, hip J
Inferior gluteal artery: Arises from the internal
iliac artery
• Supplies gluteus maximus, obturator internus,
quadratus femoris, and superior parts of the
hamstrings

196. Femoral Nerve (L2-4)
Branch to iliacus- in the abdomen
Branch to pectineus- below inguinal lig.
Two division- anterior and posterior
Anterior division
1. Intermediate cut. N. of the thigh
2. Medial cut. N. of the thigh
3. branch to sartorius
Posterior division
1. Muscular braches to quadriceps femoris
2. Saphenous
N.B- saphenous nerve crosses femoral vessels at the apex of
femoral ∆

197. Common injuries of Femoral nerve
 is usually due to penetrating injuries of lower
abdomen, as
-hematoma in pelvis
-catheterization of femoral artery and others
Effects
motor – Causes impaired flexion of the hip an
impaired extension of leg
- difficulty of walking up stairs
sensory- front & medial side of thigh
- medial side of the leg and the foot

199. Obturator Nerve (L2-4)
• Enters the via the obturator foramen
• Two divisions – anterior and posterior
Anterior division
Adductor longus
Adductor brevis
Gracilis
Articular branch to hip joint
Cutaneous branch to skin overlying adductor canal
(lower dedial thigh)
Posterior division
Obturator externus
Adductor magnus (adductor part)

200. Injuries of Obturator nerve
obstetric procedure and pelvic disease such as
ovarian tumor may cause the injury.
Effects
 Motor- Causes a weakness of adduction,
because adductor muscles of the thigh will
be paralyzed.
Sensory- medial of skin the thigh

201. Superior gluteal
nerve - gluteus
medius, minimus,
tensor fascia lata
Inferior gluteal
nerve – gluteus
maximus

202. Injury to Superior Gluteal Nerve/Gluteus Medius
Limp/Gluteal Gait
 Is a tilting (dipping) or waddling gait characterized
by the pelvis falling toward the unaffected side when
the opposite leg is raised.
 It results from paralysis of the gluteus medius muscle,
and damage to the superior gluteal nerve.
 It is caused by fracture of greater trochanter & hip
joint dislocation
 When a person who has suffered a lesion of the
superior gluteal nerve is asked to stand on one leg, the
pelvis on the unsupported side descends.
 This indicates that the gluteus medius and minimus on
the supported side are weak or non-functional.

203. Injury to Superior Gluteal Nerve cont…
 If the right gluteus medius is paralyzed then:
1) The unsupported left pelvis will drop below
horizontal level when the patient is asked to stand on his
right leg & raise his left leg clear of the ground;
2) when the patient is asked to walk, he/she tilts to
the right (paralyzed side) to raise his left leg clear of the
ground  Tilting/Dipping Gait.
 If both the right & left gluteus medius are paralyzed,
patient tilts to both sides  Waddling Gait

204. Sciatic Nerve
The sciatic nerve is the thickest and longest nerve
in the body
Terminal branch of sacral plexus and terminate
by dividing in to tibial and common peroneal
The sciatic nerve leaves the pelvis below
piriformis
Motor for hamstring muscles

206. Sciatic Nerve cont…
Muscular branch
Bicep femoris
Semitendinous
Semimembranous
Adductor magnus
Cutaneous branches
Posterior thigh

207. Sciatic Nerve injuries
Causes- pelvic fracture, intramuscular injection, pelvic
tumor, disc prolapse
Deficits
Motor- Hamstring muscles paralyzed, all muscles below
the knee are paralyzed
• Causes impaired extension at hip & impaired flexion at
the knee, loss of dorsi-flexion and plantar flexion at the
ankle , foot drop
• But week flexion of knee possible because sartorius
(femoral nerve) & gacilis (obturature nerve).
Sensory – Sensation below the knee except medial, lower
part of leg & medial border of foot (saphenous from
femoral nerve)

208. Piriformis syndrome
–A pain in the buttock may result from
compression of the sciatic nerve by the
piriformis muscle
–Individuals involved in sports that require
excessive use of the gluteal muscles (e.g., ice
skaters, cyclists, and rock climbers) are more
likely to develop this syndrome

209. Safe Area for Intramuscular Injection
• Intramuscular injection enables a large amount of a
drug to be introduced at once but absorbed gradually.
• The injection site must be carefully selected to avoid
injury to the underlying large vessels and nerves.
Outer upper quadrant of the
buttock is the safe area for
intramuscular injection to
avoid injury to the
underlying sciatic nerve

210. The Popliteal Fossa
Diamond shaped, the boundaries are
 laterally & inferiorly – lateral head of
gastrocnemius
Medially & inferiorly- medial head of
gastrocnemius
Laterally & superiorly - biceps femoris
Medially & superiorly – semimembranosus

211. 211

212. The Popliteal Fossa cont…
• The floor of the popliteal fossa is formed by
the popliteal surface of the femur
the capsule of the knee joint
the fascia over the popliteus muscle
• Contents of the popliteal fossa
The popliteal vessels (artery, vein and
lymphatics)
The tibial and common peroneal (fibular)
nerves
The small saphenous vein

213. Muscles of the leg -Anterior Compartment
• Muscles of the anterior compartment are
primarily toes extensors and dorsiflexors of
ankle joints
–Tibialis anterior
–Extensor digitorum longus
–Extensor hallucis longus
–Febularis (peroneus) tertius
Inn: Deep branch of common fibular
(peroneal) nerve

214. Tibialis anterior
O – lateral surface of upper
2/3 of tibia, fascia crura,
interosseous surface
I - inferior medial surface of
medial cuneiform and 1st
metatarsal bone
A - dorsiflexion, inverts foot

215. Extensor digitorum longus
O – medial surface of proximal
3/4 of fibula, interosseous
memb, proximal tibia
I - extensor expansion of toes 2-5
A - Dorsiflexion, extension of
lateral four digits

216. Extensor hallucis longus
O - middle ½ medial fibular
shaft and interosseous
membrane
I - distal phalanx of great toe
A - extends great toe,
dorsiflexes foot

217. Peroneus tertius
O - distal surface of fibula
and interosseous membrane
I - dorsum of fifth metatarsal
A - dorsiflexes and everts
foot

218. Muscles - Lateral Compartment
Plantar flexor and evertor of the foot and
maintain transverse arch
–Febularis (peroneus) longus
–Febularis (peroneus) brevis
Inn: superficial branch of common fibular
(peroneal) nerve

220. Peroneus longus
O - head and lateral upper
1/3 portion of fibula
I - under the foot to first
metatarsal and medial
cuneiform
A - Plantar flexes and everts
foot

221. Peroneus brevis
O - distal lateral 2/3 shaft of
fibula
I - proximal end of the 5th
metatarsal (lateral tubercle)
A - Plantar flexes
and everts foot

222. Muscles of Posterior Compartment
• Primarily plantar flexors and
flex the toes
• All innervated by tibial nerve
• Superficial
– Gastrocnemius
– Soleus
– Plantaris
• Deep
– Tibialis posterior
– Flexor digitorum longus
– Flexor hallucis longus
– Popliteus

223. Gastrocnemius
O - from medial (slightly above)
and lateral condyles of femur
I - calcaneus via calcaneal
tendon (achiles tendon)
A - plantar flexes foot, flexes
knee

224. Soleus
O – head and upper 1/3 posterior
shaft of fibula, interosseus
membrane and soleal line of
tibia
I - calcaneus via calcaneal
tendon
A - plantar flexes ankle

225. Plantaris
O - posterior femur
above lateral condyle
I - calcaneus
A - plantar flexion, knee
flexion

226. Popliteus
O - lateral condyle of femur
(intracapsular)
I - proximal tibia (posterior
surface)
A - flexes and rotates knee
medially to unlock knee
from full extension,
strengthen the articular
capsule of the knee Joint

227. Flexor digitorum longus
O - posterior tibia below soleal
line and medial to vertical
line
I - distal phalanges of toes 2-5
A - plantar flexes and flexes the
lateral 4 toes, inversion,
stabilize longitudinal arch of
the foot

228. Flexor hallucis longus
O –lower 2/3 posterior
part of shaft of fibula,
interosseous
membrane
I - distal phalanx of
great toe
A - plantar flexes and
inverts foot, flexes
great toe

229. Tibialis posterior
O – tibia (dorsal surface below
soleal line, lateral to vertical line)
and fibula (below origin of soleus)
and interosseous membrane
I – tuberosity of navicular bone ,
metatarsals 2nd and lateral two
cuneiforms
A – inversion (strong), plantar
flexion (weak), stablize transverse
arch

230. Flexor retinaculum
• Medial malleolus – calcaneus
• Content – from medial to lateral
–Tendon of tibialis posterior
–Tendons of flexor digitorum longus
–Termination of posterior tibial artery and
beginning of lateral and medial plantar
arteries.
–Termination of tibial nerve and beginning of
medial and lateral plantar nerves
–Tendon of flexor hallucis longus

232. Extensor retinaculum
Superior- Tibia – fibula
Inferior – Calcaneus – Medial malleolus and deep
fascia
Contents – Medial- lateral
1.Tendon of tibialis anterior
2.Tendon of extensor hallucis longus
3.Anterior tibial vs dorsalis pedis artery
4.Anterior tibial nerve
5.Tendon of extensor digitorum longus
6.Peroneus tertius

234. Blood supply to the leg and foot
The popliteal artery
•Continuation of the femoral artery
•branches – cutaneous , articular and muscular
Articular
1- Superior medial genicular
2. Superior lateral genicular
3. Middle genicular
4. Inferior medial genicular
5. Inferior lateral genicular
Terminal branches - anterior and posterior tibial
arteries behind the tibia.
The posterior tibial artery gives off the peroneal
artery.

236. The Anterior Tibial Artery
 Reach the anterior compartment of the leg in the upper
part of interosseous membrane medial to the neck of the
fibula.
Branches
1. Anterior tibial recurrent
2. Posterior tibial recurrent
3. Muscular branches
4. Medial and lateral malleolar arteries
Termination: Continues as dorsalis pedis artery after
the extensor retinaculum.

238. Posterior Tibial Artery
• begins distal border of popliteus muscle
• Passes deep to tendinous arch
Branches
1. Circumflex fibular
2. Peroneal (fibular)
3. Nutrient artery for tibia
4. Muscular
5. Calcaneal branch
Termination – Divide into medial and lateral plantar
arteries

240. The Peroneal (fibular)Artery
• Arises from the posterior tibial artery
 runs along medial crest of fibula,
Branches
1. Muscular
2. Nutrient artery to fibula
3. Perforating branch
Termination: ends as lateral calcaneal artery.

242. Blood supply to the knee joint
• 5 genicular from popliteal artery
• Descending genicular from femoral artery
• Anterior & posterior tibial recurrent from
anterior tibial
• Circumflex fibular from posterior tibial
• descending branch of lateral circumflex
femoral

244. Dorsalis pedis artery
Continuation of anterior tibial artery
Branches
1. Medial tarsal arteries
2. Lateral tarsal arteries
3. Arcuate artery
give dorsal metatarsal arteries which in turn gives dorsal
proper digital arteries
 joined by perforating branches of the deep plantar arch .
Anastomosis with lateral tarsal
Termination – in the sole of the foot, join plantar arch by deep
plantar artery
N.B before termination – gives first dorsal metatarsal artery.

246. Blood supply of the sole of the foot
1. Medial plantar artery
• Is the smaller terminal branch of the post. tibial artery
• Between abductor hallucis and flexor digitorum brevis
Branches- gives branch to join 1st to 3rd plantar metatarsal.
2. Lateral plantar artery
• Is the larger terminal branch of the post. tibial artery
• Gives off calcaneal, cutaneous, muscular and
articular branches.
• Forms the plantar arch by joining with the deep plantar
branch of the dorsalis pedis artery.
• plantar arch 4 plantar metatarsal proper plantar
digital

248. Common site for arterial pulse in the lower limb
Femoral A- mid point of inguinal ligament
Popliteal A- In popliteal fossae
Posterior tibial artery – behind medial malleolus
Dorsalis pedis – lateral to the tendon of extensor HL

249. Tibial Nerve
Continuation of the medial popliteal nerve
Muscular branches
1. To medial head of gastrocnemius
2. To lateral head of gastrocnemius
3. To plantaris
4. To soleus
5. To popliteus
6. Tibialis posterior
7. Flexor digitorum longus
8. Flexor hallicus longus
NB: terminated as medial and lateral plantar below
medial malleolus

250. Damage to Tibial Nerve
Motor: All muscles of posterior compartment of
leg & sole of the foot are paralysed:  this causes
loss of plantar flexion of foot & impaired
inversion
Foot is dorsiflexed at ankle joint & everted at
subtalar & transverse tarsal joints by opposing
muscles:  this condition is known as calcaneo-
valgus.
Sensory: loss of sensation of skin in sole of foot

251. Common Peroneal (lateral popliteal) Nerve
Branch of sciatic nerve
Branches
1. Cutaneous
• Sural communicating
• Lateral cutaneous nerve of the leg
• 2. Terminal- anterior (deep peroneal ) and
musculocutaneous (superficial peroneal )

252. Damage to Common Peroneal Nerve
• The most injured nerve in the lower limb.
• May occur from fracture of fibula neck, knee
joint injury or dislocation
Motor- muscles of anterior & lateral
compartments of the leg paralyzed, namely:
(TA, EDL, EHL, EHB, EDB, & PT supplied
by deep peromeal nerve); and peroneus
longus & brevis (supplied by superficial
peroneal nerve).

253. Damage to Common Peroneal Nerve cont…
loss of dorsi flexion & eversion of foot.
 as a result, opposing muscles: (plantar flexors
of flexion of ankle joint & invertors at subtalar
& transverse tarsal joints) cause the foot to be
plantar flexed (foot drop) & inverted: this
condition is known as Equinovarus.
• Sensory - Loss of sensation down the anterior
& lateral aspect of the leg,dorsum of the foot &
digits.

254. Deep fibular (peroneal) nerve
Origin at the lateral side of the neck of fibula,
reach the anterior compartment by piercing the
intermuscular septum
Branches
1. Muscular – extensor digitorum longus & brevis,
extensor hallucis brevis & longus, tibialis anterior
2. Cutaneous – skin to the adjacent sides of 1st &
2nd toes

255. Damage to Deep Peroneal Nerve
Motor
• Results in Foot Drop and a high stepping gait,
because muscles of anterior compartment of the
leg (tibialis anterior, extensor digitorum longus
& extensor hallucis longus ) are paralyzed.
Sensory
• Loss of sensation of cleft b/n big toe & 2nd toe.

256. Musculocutaneous (Superficial peroneal)
 One of the terminal branch of common peroneal
nerve
 Divide into lateral and medial terminal
branches (dorsal cutaneus) at lower leg.
Branches
1. Cutaneous- lower part of the leg, intermediate
part of the dorsum of the foot
2. Muscular – peroneus longus and brevis

257. Damage to Superficial Peroneal Nerve
• loss of eversion of foot because the lateral
compartment muscles (peroneus longus &
brevis) paralysed.
• But no foot drop
Sensory - Loss of sensation down the lateral
aspect of leg ,dorsum of the foot & digits.

258. The lateral plantar nerve
Has
 cutaneous branches to the lateral
1.5 digit
 motor branches to the:
1.quadratus plantae
2.abductor digiti minimi
3.flexor digiti minimi
4.3 lateral lumbricals
5.7 interossei
6.adductor hallucis

259. 259

260. The medial plantar nerve
cutaneous branches to the
medial 3.5 digits
motor branches to the:
1.Abductor hallucis
2.Flexor digitorum brevis
3.Flexor hallucis brevis
4.Lumbrical 1

261. The dorsum foot
Two Muscles:
1. Extensor digitorum brevis
2. Extensor hallucis brevis ( medial slip of the extensor
digitorum brevis )
 Origin- anterio- lateral part of calcaneus, inferior
extensor retinaculum
 Insertion - extensor H. B proximal phalanx of big toe
and E. digitorum B. extensor expansion of 2nd , 3rd ,
and 4th toes
 Inn – deep branch of common peroneal N

263. The sole of the foot
 Plantar aponeurosis- thickened deep fascia
 Attachments- posterior- tubercle of calcaneus;
anteriorly-divide in to five slips and again each
divide in to two and become continuous with flexor
sheaths of the digits
 Function – protection, keep the longitudinal arch
 Four layers
1. First layer – three muscles
2. Second layer – two muscles and two tendons
3. 3rd layers : Three muscles
4. 4th layer-Two muscles and two tendons

264. First layer
 Two abductors and one flexor in b/n the
abductors
 Origin – calcaneus
1. Abductor hallucis inserts in to the proximal
phalanx of hallux medially.
Inn - Medial plantar
2. Abductor digiti minimi inserts in the proximal
phalanx of toe 5 medially
Inn - Lateral plantar
3. Flexor digitorum brevis inserts in to the middle
phalanges of 2- 5 by splitting in to 2 bands
Inn: Medial plantar

266. Second layer
• Muscles include flexor accessories and
lumbricals including long tendons.
Flexor digitorum accessorius (quadratus
Plantae)
O-has two heads (medial and lateral); from
medial and lateral process of calcaneus
I- lateral aspect of FDL before spliting in to 5
bands
A- assists FDL
Supplied by L. plantar nerve

268. Four lumbricales
O- form medial side of the long tendons of flexor
muscles arranged from 1st to 4th from medial to
lateral.
I- Extensor surface medialy near proximal
interphalayigeal joint
A- Flexion of metatarsophalangeal joint and extension
of interphalangeal joints
Inn-The lateral 3 are innervated by deep division of
lateral plantar and the 1st by medial plantar
Tendons – flexor hallucis longus and flexor digitorium
longus

269. Third layer
 Three muscles
1. Flexor hallucis brevis
O. Cuboid, lateral cuneiform
I. Two slips, lateral and medial sides of the proximal phalanx
Inn - medial plantar
2. Flexor digiti minimi- originate from base of 5th metatarsal and
inserts in to the base of the proximal phalanx Of 5th digit.
Inn- is from superficial branch of lateral plantar
3. Adductor hallucis (two heads, transverse and oblique )
O. transverse -metatarsophalangeal ligaments of 3rd , 4th , 5th
toes
Oblique head- base of 2nd, 3rd , & 4th metatarsal
I. lateral side of proximal phalanx
Inn- Deep part of lateral plantar

271. Fourth layer
• Tendons of tibialis posterior and peroneus
longus
• Muscles
1. Plantar interossei – three
1st - arise from 3rd metatarsal medially, act
on the base of 3rd digit medially
2nd – 4th metatarsal , acts on 4th
3rd – 5th metatarsal, acts on 5th
Inn – 1st & 2nd – deep division of lateral
plantar; 3rd by superficial branch of lateral P
Action: adduct 3rd, 4th, and 5th toes toward 2nd
toe

273. fourth layer cont…
2. Dorsal interossei- 4 , each arise from adjacent
metatarsal (bipennate arrangement)
1st arise from 1st & 2nd ; acts on 2nd medialy
2nd – 2nd & 3rd ; acts on 2nd lateraly
3rd – 3rd & 4th ; acts on 3rd lateraly
4th - 4th & 5th ; acts on 4th lateraly
Inn - 1st , 2nd &3rd deep div. of lateral P and 4th
superficial div. of lateral P
Action- abduction of 2nd , 3rd &4th digits away
from line of 2nd toe,
N. B. All interossei are innervated by lateral
plantar

274. summary of four layers of plantar aponeourosis
1st.layer has three muscles
1.abductor hallucis
2.abductor digiti minimi
3.flexor digitorum brevis
2nd.layer has two muscles and two tendons
muscles
1.flexor digitorum accessories (quadratus plantae)
2.lumbricals
tendons
1.FDLAND 2.FHL
3rd.three muscles
1.flexor hallucis brevis
2.flexor digiti minimi
3.adductor hallucis
4th.two muscles and two tendons
muscles
1.plantar interosses
2.dorsal interoses
tendons
1.tibials posterior
2.peroneus longus

275. The hip joint
• The hip is the largest joint in the body.
• It is a perfect example of a ball-and-socket joint.
• Its articular surfaces are the femoral head and the
horse-shoe shaped articular surface of the
acetabulum, which is deepened by the
fibrocartilaginous labrum acetabulare.
• The non-articular lower part of the acetabulum, the
acetabular notch, is closed off below by the
transverse acetabular ligament.

277. • From this notch is given off the ligamentum teres,
passing to the fovea on the femoral head
• The capsule of the hip is attached proximally to the
margins of the acetabulum and to the transverse
acetabular ligament.
• Distally, it is attached along the trochanteric line,
the bases of the greater and lesser trochanters and,
• posteriorly, to the femoral neck about (12mm)
from the trochanteric crest.

278. Three ligaments reinforce the capsule:
1) the iliofemoral (Y-shaped ligament of Bigelow),
which arises from the
• anterior inferior iliac spine, bifurcates, and is
inserted at each end of the trochanteric line
2) the pubofemoral—arising from the iliopubic
junction to blend with the medial aspect of the
capsule;
3) the ischiofemoral—arising from the ischium to
be inserted into the base of the greater
trochanter.

280. Movements
• The hip is capable of a wide range of movements:
• flexion, extension,
• abduction, adduction,
• medial and lateral rotation and
• circumduction.

281. BLOOD SUPPLY OF HIP JOINT
• Arteries supplying the hip joint include the
following:
• medial and
• lateral circumflex femoral arteries,
• which are usually branches of the deep artery of
the thigh but occasionally arise as branches of the
femoral artery.

282. • The artery to the head of the femur, which is
a branch of the obturator artery of variable
size; it traverses the ligament of the head.
• NERVE SUPPLY OF HIP JOINT
• according to Hilton's law states that the
nerves supplying the muscles extending
directly across and acting at a given joint also
innervate the joint.

283. The knee joint
• The knee is a hinge joint made up of the
articulations between the femoral and
tibial condyles and between the patella
and the patellar surface of the femur.

284. Articular Surfaces of the Knee Joint
• The bones involved are the femur, tibia, and patella.
• The articular surfaces are the large curved condyles of
the femur, the flattened condyles of the tibia, and the
facets of the patella.
• The knee joint is relatively weak mechanically because
of the configurations of its articular surfaces.
• It relies on the ligaments that bind the femur to the
tibia for strength.

285. Surface Anatomy of the Knee Joint
• This joint may be felt as a slight gap on each side
between the corresponding femoral and tibial
condyles.
• When the leg is flexed or extended, a depression
appears on each side of the patellar ligament.
• The articular capsule is very superficial in these
depressions.
• The knee joint lies deep to the apex of the patella.

286. Movements of the Knee Joint
• The principal movements occurring at this joint are
flexion and extension of the leg,
• but some rotation also occurs in the flexed position.
• Flexion normally stops when the calf contracts the
thigh.
• The ligaments of the knee stop extension of the leg.

287. • The following muscles produce movements of the
knee joint.
• Flexion
The biceps femoris, semitendinosus, and
semimembranosus muscles, assisted by the
gracilis, sartorius, and popliteus muscles, produce
flexion.
Flexion is limited by the contact of the back of the
leg with the thigh.

288. • Extension
 The quadriceps femoris produces extension.
 Extension is limited by the tension of all the major
ligaments of the joint.
• Medial Rotation
 The sartorius, gracilis, and semitendinosus produce medial
rotation.
• Lateral Rotation
 The biceps femoris produces lateral rotation.
• The stability of the knee joint depends on the tone of the
strong muscles acting on the joint and the strength of the
ligaments.

289. Capsule
• The capsule is attached to the margins of the
articular surfaces and surrounds the sides and
posterior aspect of the joint.
• On the front of the joint, the capsule is absent,
permitting the synovial membrane to pouch
upward beneath the quadriceps tendon, forming
the suprapatellar bursa.

291. Ligaments
• The ligaments may be divided into those that lie
outside the capsule and those that lie within the
capsule.
• Extracapsular Ligaments:
• The ligamentum patellae is attached above to
the lower border of the patella and below to the
tuberosity of the tibia.
• It is, in fact, a continuation of the central portion
of the common tendon of the quadriceps femoris
muscle.

292. • The lateral collateral ligament is cordlike and is attached
above to the lateral condyle of the femur and below to the
head of the fibula.
• The medial collateral ligament is a flat band and is
attached above to the medial condyle of the femur and
below to the medial surface of the shaft of the tibia.
• The oblique popliteal ligament is a tendinous expansion
derived from the semimembranosus muscle. It strengthens
the posterior aspect of the capsule.

293. Intracapsular Ligaments
• The cruciate ligaments are two strong
intracapsular ligaments that cross each other
within the joint cavity.
They are named anterior and posterior,
according to their tibial attachments.
These important ligaments are the main bond
between the femur and the tibia throughout the
joint's range of movement.

295. Anterior Cruciate Ligament
• The anterior cruciate ligament is attached to the anterior
intercondylar area of the tibia and passes upward,
backward, and laterally, to be attached to the posterior part
of the medial surface of the lateral femoral condyle.
• The anterior cruciate ligament prevents posterior
displacement of the femur on the tibia.
• With the knee joint flexed, the anterior cruciate ligament
prevents the tibia from being pulled anteriorly.

296. Posterior Cruciate Ligament
• The posterior cruciate ligament is attached to the
posterior intercondylar area of the tibia and passes
upward, forward, and medially to be attached to the
anterior part of the lateral surface of the medial
femoral condyle.
• The posterior cruciate ligament prevents anterior
displacement of the femur on the tibia. With the knee
joint flexed, the posterior cruciate ligament prevents
the tibia from being pulled posteriorly.

297. Menisci
• The menisci are C-shaped sheets of fibrocartilage.
• The peripheral border is thick and attached to the
capsule, and the inner border is thin and concave
and forms a free edge.
• The upper surfaces are in contact with the femoral
condyles.
• The lower surfaces are in contact with the tibial
condyles.

298. • Their function is to deepen the articular surfaces
of the tibial condyles to receive the convex
femoral condyles; they also serve as cushions
between the two bones.
• Each meniscus is attached to the upper surface of
the tibia by anterior and posterior horns.
• Because the medial meniscus is also attached to
the medial collateral ligament, it is relatively
immobile.

300. Synovial Membrane
• The synovial membrane lines the capsule and is attached to
the margins of the articular surfaces.
• On the front and above the joint, it forms a pouch, which
extends up beneath the quadriceps femoris muscle for
three fingerbreadths above the patella, forming the
suprapatellar bursa.
• At the back of the joint, the synovial membrane is
prolonged downward on the deep surface of the tendon of
the popliteus, forming the popliteal bursa.

301. Bursae Related to the Knee Joint
• Numerous bursae are related to the knee joint.
• They are found wherever skin, muscle, or tendon
rubs against bone.
• Four are situated in front of the joint and six are
found behind the joint.
• The suprapatellar bursa and the popliteal bursa
always communicate with the joint, and the
semimembranosus bursa may communicate with
the joint.

302. Anterior Bursae
• The suprapatellar bursa lies beneath the quadriceps muscle
and communicates with the joint cavity.
• The prepatellar bursa lies in the subcutaneous tissue
between the skin and the front of the lower half of the
patella and the upper part of the ligamentum patellae.
• The superficial infrapatellar bursa lies in the subcutaneous
tissue between the skin and the front of the lower part of
the ligamentum patellae.
• The deep infrapatellar bursa lies between the ligamentum
patellae and the tibia.

304. Posterior Bursae
• The popliteal bursa is found in association with
the tendon of the popliteus and communicates
with the joint cavity.
• The semimembranosus bursa is found related
to the insertion of the semimembranosus
muscle and may communicate with the joint
cavity.

305. • The remaining four bursae are found related to the
tendon of insertion of the biceps femoris; sartorius,
gracilis, and semitendinosus
Nerve Supply
• The femoral, obturator, common peroneal, and
tibial nerves supply the knee joint.

306. • BLOOD SUPPLY OF KNEE JOINT
• The arteries supplying the knee joint are the 10 vessels that
form the periarticular genicular anastomoses around the
knee:
 the genicular branches of the
 femoral
 popliteal
 anterior and posterior recurrent branches of the anterior
tibial recurrent and
 circumflex fibular arteries.
• The middle genicular branches of the popliteal artery
penetrate the fibrous layer of the joint capsule and supply
the cruciate ligaments, synovial membrane, and peripheral
margins of the menisci.

307. Important Relations
• Anteriorly: The prepatellar bursa
• Posteriorly: The popliteal vessels; tibial and common
peroneal nerves; lymph nodes; and the muscles that form
the boundaries of the popliteal fossa, namely, the
semimembranosus, the semitendinosus, the biceps
femoris, the two heads of the gastrocnemius, and the
plantaris
• Medially: Sartorius, gracilis, and semitendinosus muscles
• Laterally: Biceps femoris and common peroneal nerve

308. Proximal Tibiofibular Joint
• Articulation: articulation is between the lateral
condyle of the tibia and the head of the fibula.
• The articular surfaces are flattened and covered by
hyaline cartilage.
• Type : this is a synovial, plane, gliding joint.
• Capsule: the capsule surrounds the joint and is
attached to the margins of the articular surfaces.

309. • Ligaments: anterior and posterior ligaments strengthen
the capsule.
• The interosseous membrane, which connects the shafts of
the tibia and fibula together, also greatly strengthens the
joint.
• Synovial Membrane: the synovial membrane lines the
capsule and is attached to the margins of the articular
surfaces.
• Nerve Supply: the common peroneal nerve supplies the
joint.
• Movements: a small amount of gliding movement takes
place during movements at the ankle joint.

310. Distal Tibiofibular Joint
• Articulation: articulation is between the fibular
notch at the lower end of the tibia and the lower
end of the fibula.
• The opposed bony surfaces are roughened.
• Type: the distal tibiofibular joint is a fibrous joint.
• Capsule: there is no capsule.
• Ligaments: the interosseous ligament is a strong,
thick band of fibrous tissue that binds the two
bones together.

311. • The interosseous membrane, which connects the
shafts of the tibia and fibula together, also greatly
strengthens the joint
• Blood Supply: the inferior lateral genicular and
anterior tibial recurrent arteries
• Nerve Supply: deep peroneal and tibial nerves
supply the joint.
• Movements: a small amount of movement takes
place during movements at the ankle joint.

312. The ankle(talocrural)
• The ankle is a hinge joint between a mortice
formed by the malleoli and lower end of the tibia
and the body of the talus.
• The capsule of the joint fits closely around its
articular surfaces, and, as in every hinge joint, it
is weak anteriorly and posteriorly but reinforced
laterally and medially by collateral ligaments.

314. Articular Surfaces of the Talocrural Joint
• The inferior ends of the tibia and fibula form a deep
socket or box-like mortise into which the pulley-
shaped trochlea of the talus fits.
• The two malleoli and the inferior end of the tibia
form the three-sided mortise.
• The fibula has an articular facet on its lateral
malleolus, which faces medially and articulates with
the facet on the lateral surface of the talus.

315. • The tibia articulates with the talus in two places:
(1) its inferior surface forms the roof of the mortise, which
is wider anteriorly than posteriorly; and
(2) the lateral surface of its medial malleolus articulates
with the talus.
• The talus has three articular facets, which articulate with
the inferior surface of the tibia and malleoli.
• The trochlea of the talus is wider anteriorly than
posteriorly and slightly concave side to side.

317. Movements of the ankle
• The ankle joint is capable of being flexed and
extended (plantar and dorsiflexion).
• The body of the talus is slightly wider anteriorly
and, in full extension, becomes firmly wedged
between the malleoli.
• Conversely, in flexion, there is slight laxity at the
joint and some degree of side to side tilting is
possible:

318. • The principal muscles acting on the ankle are:
Dorsiflexors : tibialis anterior assisted by
extensor digitorum longus, extensor hallucis
longus and peroneus tertius;
 Plantarflexors: gastrocnemius and soleus
assisted by tibialis posterior, flexor hallucis
longus and flexor digitorum longus.

319. • The fibrous capsule is thin anteriorly and
posteriorly, but it is supported one each side
by strong collateral ligaments (medial or
deltoid and lateral ligaments).
1, The Medial or Deltoid Ligament:
• This strong ligament attaches the medial
malleolus to the tarsus (tarsal bones).

320. • it consists of four parts, which are named
according to their bony attachments:
(1) tibionavicular,
(2) and (3) anterior and posterior tibiotalar,
and
(4) tibiocalcanean ligaments.
• They strengthen the joint and hold the
calcaneus and navicular bones against the
talus.

322. 2, The Lateral Ligament of the Ankle
• On the lateral side of the ankle there are three
ligaments that attach the lateral malleolus to the
talus and calcaneus.
• These are not as strong as the medial ligament.
• These are:
• The anterior talofibular ligament is a flat band
that extends anteromedially from the lateral
malleolus to the neck of the talus.

323. • The posterior talofibular ligament is thick and fairly
strong.
• It runs horizontally medially and slightly posteriorly from
the malleolar fossa to the lateral tubercle of the
posterior process of the talus.
• The calcaneofibular ligament is a round cord that passes
posteroinferiorly from the tip of the lateral malleolus to
the lateral surface of the calcaneus.
• It is crossed superficially by the tendons of the fibularis
(peroneus) longus and brevis muscles.