GOOD GOOD AFTERNOONAFTERNOON

OBJECTIVESOBJECTIVES

To provide To provide understandingunderstanding of of morphological, physiological & psychological morphological, physiological & psychological principlesprinciples which determine & influence which determine & influence man as a functioning unit.man as a functioning unit.

To correlate & interpret structural organism To correlate & interpret structural organism & normal physiology of body & thus to & normal physiology of body & thus to provide data in which disturbances of provide data in which disturbances of function are anticipated.function are anticipated.

OBJECTIVESOBJECTIVES Enable student to Enable student to recognize recognize

anatomical basis of clinical signs anatomical basis of clinical signs & symptoms of disorders due to & symptoms of disorders due to injury, disease & mal-injury, disease & mal-developmentdevelopment..

Enable student to Enable student to understand understand factors involved in development factors involved in development of pathological processes & of pathological processes & possible complicationspossible complications which may which may arise there from.arise there from.

OBJECTIVESOBJECTIVES To impart such knowledge of pre-clinical To impart such knowledge of pre-clinical

subjects which will enable student to subjects which will enable student to employ (or judging & recommending in employ (or judging & recommending in cases of surgery) competently & rationally cases of surgery) competently & rationally all common methods of exam & treatment all common methods of exam & treatment (including surgery) (including surgery)

To enable student to find out strange & To enable student to find out strange & uncommon symptoms from uncommon symptoms from pathognomonic symptoms for pathognomonic symptoms for individualization of patients & drugs for individualization of patients & drugs for purpose of applying law of similar in purpose of applying law of similar in homoeopathic practicehomoeopathic practice

ANATOMY OF LOWER ANATOMY OF LOWER LIMBLIMB

PRESENTED BY-PRESENTED BY-

DR. SARSIJ SHARMADR. SARSIJ SHARMA

MODERATORMODERATOR- -

DR. J. P. GHILDIYALDR. J. P. GHILDIYAL

AIMS AND OBJECTIVESAIMS AND OBJECTIVES

To studyTo study : : Embryology- Development and congenital defectsEmbryology- Development and congenital defects The Bones- Relevant anatomy The Bones- Relevant anatomy Muscles- origin, insertion, nerve supply, actionMuscles- origin, insertion, nerve supply, action Arteries- course and branches Arteries- course and branches Veins- tributaries and course Veins- tributaries and course Nerves- Course and muscles suppliedNerves- Course and muscles supplied Applied anatomyApplied anatomy

EMBRYOLOGY Lower limb bud (opposite Lumber and upper sacral segments) : Lower limb bud (opposite Lumber and upper sacral segments) :

28-29 days28-29 days L.L. bud become flattened to form footplate : 40-42 daysL.L. bud become flattened to form footplate : 40-42 days Entire limb skeleton is cartilagenous : 40- 42 daysEntire limb skeleton is cartilagenous : 40- 42 days L.L. bud rotates medially (90 degree) - extensor muscles on L.L. bud rotates medially (90 degree) - extensor muscles on

anterior surface and great toe medially : 47-49 daysanterior surface and great toe medially : 47-49 days Separate digits are formed : 54-56 days Separate digits are formed : 54-56 days

CONGENITAL DEFECTSCONGENITAL DEFECTS

LL malformation - 1.1/10,000 births.

Meromelia – Partial absence of one or more extremity.

Amelia – Complete absence of one or more extremity.

Phocomelia (a form of amelia) – rudimentary hands and feet are attached to the trunk by small,irregularly shaped bones – due to Thalidomide.

CONGENITAL DEFECTSCONGENITAL DEFECTS

Clubfoot (CTEV) – Foot inverted, planter flexed and adducted since birth.

Congenital dislocation of hip – under development of head of femur and acetabulum.

Polydactyly - Extra fingers/toes

Syndactyly – Abnormal fusion Ectrodactyly – Absence of a

digit

BONES OF LOWER LIMBHip Bone/Innominate (Left) :

Outer Surface Inner Surface

Femur Femur (Right)(Right)

Anterior View Posterior view

PATELLA(RIGHT)

Largest Sesamoid bone – in tendon of quadriceps femorisImproves the leverage of quadriceps femorisProtects the knee joint

Tibia-Fibula (Left)

Anterior View Posterior View

Foot (Right)

Superior and Lateral View

MUSCLES OF LOWER LIMB

Iliopsoas- - Origin- -

Psoas Major-Psoas Major- Transverse process Transverse process & lat. surface of bodies of lumber & lat. surface of bodies of lumber vertebravertebra

IliacusIliacus- - Upper 2/3 of iliac fossa, Upper 2/3 of iliac fossa, Inner lip of iliac crestInner lip of iliac crest

Insertion- - Lesser trochanter of femurLesser trochanter of femur

Nerve supply- Lumber plexus L2,3Lumber plexus L2,3

Action- - Flexes thigh on trunkFlexes thigh on trunk Applied Anatomy- Pus from

tubercular infection of thoracic & lumber vertebre may track down to thigh producing a soft swelling in F. triangle

MUSCLES OF THIGH

Intermuscular SeptaIntermuscular Septa 3 intermuscular septa divide thigh 3 intermuscular septa divide thigh

into 3 compartments-into 3 compartments-

1. 1. Lateral intermuscular septum-Lateral intermuscular septum- extends from iliotibial tract to extends from iliotibial tract to lat.lip of linea aspera.lat.lip of linea aspera.

2. 2. Medial IM septum-Medial IM septum- attached attached from medial lip of linea aspera & from medial lip of linea aspera & fascia lata.fascia lata.

3. 3. Posterior IM septum-Posterior IM septum- poorly poorly defined because of adductor defined because of adductor magnus- has fused adductor & magnus- has fused adductor & hamstrings componentshamstrings components

MUSCLES OF HIP AND THIGH

Gluteals Extend thighrotate thighAbducts thigh

Anterior CompartmentFlexes thigh at hipExtends leg at knee

Medial/Adductor CompartmentAdducts thighMedially rotates thigh

Posterior CompartmentExtends thighFlexes leg

GLUTEAL REGION Gluteus MaximusGluteus Maximus – – OriginOrigin- Iliac crest dorsal - Iliac crest dorsal

segment, posterior gluteal line segment, posterior gluteal line and gluteal surface behind it, and gluteal surface behind it, dorsal surface lower sacrum, side dorsal surface lower sacrum, side of coccyxof coccyx

InsertionInsertion- gluteal tuberosity of - gluteal tuberosity of femur, Iliotibial tractfemur, Iliotibial tract

Nerve supply-Nerve supply- Inferior gluteal Inferior gluteal nervenerve

ActionAction-Chief extensor of thigh at -Chief extensor of thigh at hip joint, lateral rotation of thigh, hip joint, lateral rotation of thigh, abduction of thigh abduction of thigh

Gluteus Medius and Gluteus Medius and MinimusMinimus – –

OriginOrigin- Gluteal surface of - Gluteal surface of ilium betweem anterior and ilium betweem anterior and posterior gluteal linesposterior gluteal lines

InsertionInsertion- Greater - Greater trochanter of femurtrochanter of femur

Nerve supply-Nerve supply- Superior Superior gluteal nervegluteal nerve

ActionAction- Abduction of thigh - Abduction of thigh at hip, medial rotation, at hip, medial rotation, stablises hip in walking and stablises hip in walking and runningrunning

Lateral Rotators Of Thigh -

Muscles are- Piriformis, Gamellus (Sup. & Inf.), Obturator internus & externus, Quadratus femoris.

Piriformis- - Origin- Pelvic surface of middle 3 pieces of Origin- Pelvic surface of middle 3 pieces of

sacrum by 3 digitations, greater sciatic notch, sacrum by 3 digitations, greater sciatic notch, sacrotuberous lig.sacrotuberous lig.

Insertion- greater trochanterInsertion- greater trochanter Nerve supply- ventral rami of S1,2 Nerve supply- ventral rami of S1,2 Gemellus Superior- Origin- Ischial SpineOrigin- Ischial Spine Insertion- Into tendon of obturator internusInsertion- Into tendon of obturator internus Nerve supply- Nerve to obturator internusNerve supply- Nerve to obturator internus

Gemellus Inferior-Gemellus Inferior-

Origin- Ischial tuberosityOrigin- Ischial tuberosity

Insertion- Into tendon of obturator internusInsertion- Into tendon of obturator internus

Nerve supply- Nerve to Quadratus femorisNerve supply- Nerve to Quadratus femoris Obturator Internus-Obturator Internus-

OriginOrigin- Pelvic surface of- Obt. membrane, - Pelvic surface of- Obt. membrane, body of ischium, ischial tuberosity, body of ischium, ischial tuberosity, ischiopubic ramiischiopubic rami

Insertion-Insertion- tendon leaves pelvis through lesser tendon leaves pelvis through lesser sciatic foramen, bends at right angle- inserts sciatic foramen, bends at right angle- inserts on greater trochanteron greater trochanter

Nerve supply-Nerve supply- Nerve to obturator internus Nerve to obturator internus

Quadratus Femoris- OriginOrigin- Ischial Tuberosity- Ischial Tuberosity InsertionInsertion- Quadrate Tubercle- Quadrate Tubercle Nerve supply-Nerve supply- Nerve to Quadratus Nerve to Quadratus

femorisfemoris Obturator Externus-Obturator Externus- OriginOrigin- - Outer surface of – obturator Outer surface of – obturator

membrane, margins of obturator foramenmembrane, margins of obturator foramen

InsertionInsertion- - Trochanteric fossaTrochanteric fossa

Nerve supply-Nerve supply- O Obturator nervebturator nerve

Tensor Fasciae Latae-

OriginOrigin- - Ant. Outer lip of Ant. Outer lip of iliac crest, ant. sup. Iliac iliac crest, ant. sup. Iliac spinespine

InsertionInsertion- - Iliotibial tractIliotibial tract

Nerve supply-Nerve supply- Superior Superior gluteal Ngluteal N..

ActionAction- - Abductor and Abductor and Medial rotator of thigh, Medial rotator of thigh, extensor of kneeextensor of knee..

ANTERIOR COMPARTMENT OF THIGH

Muscles- Sartorius & Quadriceps Femoris

Sartorius- Origin- Anterior

superior iliac spine Insertion- Upper

medial surface of tibia

Action- Abductor, flexor, lateral rotator of thigh, weak knee flexor

Quadriceps Femoris- Origin-

A. Rectus femoris-Rectus femoris- Ant. inf. iliac spine, margin of acetabulum

B. Vastus lateralis-Vastus lateralis- upper part of intertrochanteric line, upper part of lat. lip of linea aspera

C. V. medialis-V. medialis- lower part of intertrochanteric line, spiral line, med. lip of linea aspera

D.D. V. Intermedius-V. Intermedius- Upper anterior and Upper anterior and lateral surface of shaft lateral surface of shaft of femurof femur

Insertion-Insertion- patella and tibial patella and tibial tuberosity via the patellar tuberosity via the patellar ligamentligament

Action-Action- Strong extensor of Strong extensor of leg- in addition rectus leg- in addition rectus femoris flexes the hip jointfemoris flexes the hip joint

Nerve Supply-Nerve Supply- All muscles of All muscles of anterior compartment are anterior compartment are supplied by supplied by Femoral Femoral nervenerve

ADDUCTOR COMPARTMENT OF THIGH

Muscles are- Adductor longus, brevis & magnus, Gracilis, Pectineus

Adductor Longus-

Origin- Body of pubisOrigin- Body of pubis

Insertion- Linea aspera (middle Insertion- Linea aspera (middle part)part)

Adductor Brevis-

Origin- Body of pubis, inferior Origin- Body of pubis, inferior ramus of pubisramus of pubis

Insertion- Lesser trochanter, Insertion- Lesser trochanter, upper part of linea asperaupper part of linea aspera

Adductor magnus-

Origin- Ischial Tuberosity, Origin- Ischial Tuberosity, Ramus of ischium, inf. Ramus of ischium, inf. ramus of pubisramus of pubis

Insertion- gluteal Insertion- gluteal tuberosity, linea aspera, tuberosity, linea aspera, adductor tubercleadductor tubercle

Gracilis- -

Origin- Body of pubis, inf. Origin- Body of pubis, inf. ramus of pubisramus of pubis

Insertion- Medial surface of Insertion- Medial surface of tibia behind sartorius and tibia behind sartorius and infront of semitendinosusinfront of semitendinosus

Pectineus- Origin- - Origin- Pecten pubis, superior Pecten pubis, superior ramus of pubisramus of pubis

Insertion- Lesser Insertion- Lesser trochantertrochanter

Nerve Supply-Nerve Supply- All the All the muscles of adductor muscles of adductor compartment are compartment are supplied by Obturator supplied by Obturator Nerve. Two muscles have Nerve. Two muscles have double nerve supply-double nerve supply-

1. 1. Adductor magnus- Adductor part- Obturator Adductor magnus- Adductor part- Obturator nerve, hamstring part- Tibial part of sciatic nerve, hamstring part- Tibial part of sciatic nerve.nerve.

2. Pectineus- Anterior fibers- Femoral nerve, 2. Pectineus- Anterior fibers- Femoral nerve, posterior fibers- Obturator nerveposterior fibers- Obturator nerve

ACTIONS-ACTIONS-1.1. Adductor longus,brevis and magnus- powerful Adductor longus,brevis and magnus- powerful

adductors of thigh.adductors of thigh.

2.2. Hamstring part of adductor magnus extends Hamstring part of adductor magnus extends the thigh.the thigh.

3.3. Gracilis- Flexor and medial rotator of thighGracilis- Flexor and medial rotator of thigh

4.4. Pectineus- Adducts and flexes the thighPectineus- Adducts and flexes the thigh..

POSTERIOR COMPARTMENT OF POSTERIOR COMPARTMENT OF THIGH (HAMSTRINGS)THIGH (HAMSTRINGS)

Muscles are-Muscles are- Ischial head of Ischial head of Add. Magnus, Semitendinosus, Add. Magnus, Semitendinosus, Semimembranosus, long head Semimembranosus, long head of Biceps femorisof Biceps femoris

Ischial head of Ischial head of Adductor Adductor MagnusMagnus..

SemitendinosusSemitendinosus- - Origin- Ischial tuberosityOrigin- Ischial tuberosity

Insertion- Medial surface Insertion- Medial surface of tibia behind sartorius of tibia behind sartorius and gracilisand gracilis

SemimembranosusSemimembranosus- -

Origin- Ischial tuberosityOrigin- Ischial tuberosity Insertion- Posterior Insertion- Posterior

surface of medial surface of medial condyle of the tibiacondyle of the tibia

Biceps Femoris-Biceps Femoris- Origin- Origin-

A. Long head- Ischial A. Long head- Ischial tuberositytuberosity

B. Short head- linea B. Short head- linea aspera between aspera between adductor magnus and adductor magnus and vastus lateralisvastus lateralis

Insertion- Head of fibulaInsertion- Head of fibula

Nerve Supply-Nerve Supply- All the hamstring muscles- supplied by tibial All the hamstring muscles- supplied by tibial

part of sciatic n. except short head of biceps part of sciatic n. except short head of biceps femoris- supplied by Commom peroneal n.femoris- supplied by Commom peroneal n.

Actions-Actions-1. Chief flexors of knee.1. Chief flexors of knee.2. Weak extensors of hip.2. Weak extensors of hip.3. When knee is semiflexed Biceps femoris is 3. When knee is semiflexed Biceps femoris is

lateral rotator of leg and semimembranosus lateral rotator of leg and semimembranosus and semitendinosus are medial rotators of and semitendinosus are medial rotators of leg.leg.

MUSCLES OF LEGMUSCLES OF LEG Extensions of deep fascia Extensions of deep fascia

of leg form intermuscular of leg form intermuscular septum that divide leg septum that divide leg into 3 compartments.into 3 compartments.

Anterior & Posterior Anterior & Posterior intermuscular septa are intermuscular septa are attached to ant. & post. attached to ant. & post. Border of fibula Border of fibula respectively.respectively.

3 Compartments- 3 Compartments- Anterior, Lateral & Anterior, Lateral & Posterior.Posterior.

MUSCLES OF LEGMUSCLES OF LEG Anterior CompartmentAnterior Compartment

Dorsiflexion of ankle, inversion and eversion Dorsiflexion of ankle, inversion and eversion foot, extension of toesfoot, extension of toes

Innervation: Deep Peroneal (Fibular) nerveInnervation: Deep Peroneal (Fibular) nerve Lateral CompartmentLateral Compartment

Eversion and planterflexion of footEversion and planterflexion of foot Innervation: Superficial Peroneal (Fibular) Innervation: Superficial Peroneal (Fibular)

nervenerve Posterior CompartmentPosterior Compartment

Superficial and deep layersSuperficial and deep layers Plantarflexion and inversion of foot, flexion of Plantarflexion and inversion of foot, flexion of

toestoes Innervation: Tibial nerveInnervation: Tibial nerve

ANTERIOR COMPARTMENT OF ANTERIOR COMPARTMENT OF LEGLEG

Muscles areMuscles are- Tibialis - Tibialis anterior, Extensor hallucis anterior, Extensor hallucis longus, Extensor digitorum longus, Extensor digitorum longus, Peroneus tertiuslongus, Peroneus tertius

Tibialis Anterior-Tibialis Anterior-

OriginOrigin- Lat. condyle of - Lat. condyle of tibia, upper part of lat. tibia, upper part of lat. surface of the shaft of surface of the shaft of tibia, adjoining tibia, adjoining interosseous memb.interosseous memb.

InsertionInsertion- Medial - Medial cuneiform, base of 1cuneiform, base of 1stst metatarsal bonemetatarsal bone

Extensor Hallucis Extensor Hallucis Longus-Longus- OriginOrigin- Post. & - Post. & medial surface of shaft of medial surface of shaft of fibula in the middle, fibula in the middle, adjoining interosseous adjoining interosseous membranemembrane

InsertionInsertion- Base of distal - Base of distal phalanx of great toe phalanx of great toe dorsallydorsally

Peroneus Tertius-Peroneus Tertius- OriginOrigin- Lower part of - Lower part of

medial surface of shaft of medial surface of shaft of fibula, adjoining fibula, adjoining interosseous membraneinterosseous membrane

InsertionInsertion- Base of 5- Base of 5thth metatarsal bone dorsallymetatarsal bone dorsally

Extensor Digitorum Extensor Digitorum Longus-Longus-

OriginOrigin- - Lat. condyle of tibia, Lat. condyle of tibia, Upper and anterior half of Upper and anterior half of medial surface of shaft of medial surface of shaft of fibula, adjoining fibula, adjoining interosseous membraneinterosseous membrane

InsertionInsertion- Divides into 4 - Divides into 4 tendons for lat. 4 toes and tendons for lat. 4 toes and gets inserted on bases of gets inserted on bases of middle and distal phalangesmiddle and distal phalanges

LATERAL COMPARTMENT OF LATERAL COMPARTMENT OF LEGLEG

Peroneus Longus-Peroneus Longus-

Origin-Origin- Head of fibula, Upper Head of fibula, Upper part of lateral surface of part of lateral surface of fibulafibula

InsertionInsertion- Base of 1- Base of 1stst metatarsal bone on lat. metatarsal bone on lat. side, Medial cuneiform boneside, Medial cuneiform bone

Peroneus Brevis-Peroneus Brevis-

Origin-Origin- Lower part of shaft Lower part of shaft of fibula on lateral surfaceof fibula on lateral surface

InsertionInsertion- Base of 5- Base of 5thth metatarsal bone on lateral metatarsal bone on lateral sideside

POSTERIOR COMPARTMENT OF POSTERIOR COMPARTMENT OF LEGLEG

SUPERFICIAL MUSCLES-SUPERFICIAL MUSCLES- Gastrocnemius, Gastrocnemius, Soleus, Plantaris.Soleus, Plantaris.

GastrocnemiusGastrocnemius- - OriginOrigin- -

A. Medial Head- Back of A. Medial Head- Back of medial condyle of femur, medial condyle of femur, popliteal surface of shaft popliteal surface of shaft of femurof femur

B. Lat. Head- Lat. surface B. Lat. Head- Lat. surface of lat. condyle of femurof lat. condyle of femur

Soleus-Soleus- Origin-Origin-

A. Tibia- Soleal line, A. Tibia- Soleal line, middle of medial border middle of medial border of shaftof shaft

B. Fibula- Back of head, B. Fibula- Back of head, upper part of posterior upper part of posterior surface of shaftsurface of shaft

Insertion-Insertion- Tendon of both Tendon of both muscles (=Triceps Surae) muscles (=Triceps Surae) fuses to form fuses to form Tendocalcaneus (Achillis) Tendocalcaneus (Achillis) which is inserted to which is inserted to posterior surface of posterior surface of calcaneumcalcaneum

PlantarisPlantaris- -

OriginOrigin- Lower part - Lower part of lat. of lat. supracondylar line supracondylar line of femurof femur

InsertionInsertion- Post. - Post. surface of surface of calcaneumcalcaneum

DEEP MUSCLES-DEEP MUSCLES- Popliteus, Popliteus, Flexor digitorum longus, Flexor digitorum longus, Flexor hallucis longus, Flexor hallucis longus, Tibialis posterior.Tibialis posterior.

PopliteusPopliteus-- OriginOrigin- Post. surface of tibia - Post. surface of tibia

above the soleal lineabove the soleal line

InsertionInsertion- Lat. surface of lat. - Lat. surface of lat. condyle of femur, outer condyle of femur, outer margin of lat. meniscus of margin of lat. meniscus of knee jointknee joint

Action-Action- unlocks knee joint, unlocks knee joint, flexion at knee jointflexion at knee joint

Flexor Digitorum Flexor Digitorum Longus-Longus-

OriginOrigin- upper 2/3 of - upper 2/3 of medial part of post medial part of post surface of tibiasurface of tibia

InsertionInsertion- Tendon divides - Tendon divides into 4 slips for lat. 4 toes into 4 slips for lat. 4 toes and gets attached to and gets attached to planter surface of distal planter surface of distal phalanxphalanx

Flexor Hallucis Longus-Flexor Hallucis Longus- OriginOrigin- Lower ¾ of - Lower ¾ of

posterior surface of fibulaposterior surface of fibula Insertion-Insertion- Planter surface Planter surface

of base of distal phalanx of base of distal phalanx of great toeof great toe

Tibialis Posterior-Tibialis Posterior-

OriginOrigin- Upper lat. part - Upper lat. part of post. surface of tibia of post. surface of tibia below soleal line, post. below soleal line, post. part of interosseus part of interosseus membranemembrane

InsertionInsertion- Tuberosity of - Tuberosity of navicular bonenavicular bone

Muscles of FootMuscles of Foot

Arranged in 4 layers-Arranged in 4 layers-

Ms. Of 1Ms. Of 1stst Layer- Flexor digitorum brevis, Abductor Layer- Flexor digitorum brevis, Abductor hallucis, Abductor digiti minimihallucis, Abductor digiti minimi

Ms. Of 2Ms. Of 2ndnd Layer- Flexor digitorum accessorius, 4 Layer- Flexor digitorum accessorius, 4 lumbricals lumbricals

Ms. Of 3Ms. Of 3rdrd Layer- Flexor hallucis brevis, Adductor Layer- Flexor hallucis brevis, Adductor hallucis, Flexor digiti minimi brevishallucis, Flexor digiti minimi brevis

Ms. Of 4Ms. Of 4thth layer- 3 plantar & 4 dorsal introssei. layer- 3 plantar & 4 dorsal introssei.

ARTERIAL SUPPLY OF LOWER ARTERIAL SUPPLY OF LOWER LIMBLIMB

Femoral Femoral Artery-Artery- Chief Chief artery of LL. Begins artery of LL. Begins behind the inguinal behind the inguinal ligament at mid-ligament at mid-inguinal point. It inguinal point. It passes in the femoral passes in the femoral triangle then in the triangle then in the adductor canal. At adductor canal. At lower end of canal it lower end of canal it passes through an passes through an opening in the opening in the adductor magnus adductor magnus (Hiatus Magnus) to (Hiatus Magnus) to become the Popliteal become the Popliteal a.a.

Branches of Femoral Artery-Branches of Femoral Artery- A. A. Superficial Branches-Superficial Branches- 1. External Pudendal1. External Pudendal 2. Circumflex Iliac2. Circumflex Iliac 3. Epigastric 3. Epigastric B. B. Deep Branches-Deep Branches- 1.1. External Pudendal- External Pudendal- Passes deep to Passes deep to

Spermatic cord/round ligament and Spermatic cord/round ligament and supplies scrotum/ labiumsupplies scrotum/ labium majusmajus

2. Muscular2. Muscular

3. Profunda Femoris 3. Profunda Femoris (Deep A. of Thigh)- (Deep A. of Thigh)- Largest branch of femoral Largest branch of femoral a. Chief artery to supply all a. Chief artery to supply all 3 compartments of thigh.3 compartments of thigh.

BranchesBranches--

a. Medial Circumflex a. Medial Circumflex femoral femoral

b. Lateral Circumflex b. Lateral Circumflex femoral femoral

c. Four perforating c. Four perforating arteriesarteries

Politeal A.-Politeal A.- Begins at Begins at Hiatus magnus & reaches lower Hiatus magnus & reaches lower border of Popliteus & terminates border of Popliteus & terminates by dividing into Ant. and Post. by dividing into Ant. and Post. Tibial arteries.Tibial arteries.

BranchesBranches- -

A. A. MuscularMuscular-- supply supply Hamstrings above and Hamstrings above and gastrocnemius & soleus belowgastrocnemius & soleus below

B. B. GenicularGenicular-- Medial & lateral Medial & lateral superior, Medial & lateral superior, Medial & lateral inferior & middle genicular a.inferior & middle genicular a.

Applied A-Applied A- Most common Most common artery prone to aneurysm.artery prone to aneurysm.

Anterior Tibial A.-Anterior Tibial A.- Main Main artery of ant. compartment of artery of ant. compartment of leg. Enters ant. compartment leg. Enters ant. compartment by an opening through the by an opening through the upper part of interosseous upper part of interosseous membrane, runs downward membrane, runs downward and ends by becoming Dorsalis and ends by becoming Dorsalis Pedis a.Pedis a.

BranchesBranches- - A. MuscularA. Muscular B. Anastomotic- Ant. and post. B. Anastomotic- Ant. and post.

tibial recurrent take part in tibial recurrent take part in anastomosis round the knee anastomosis round the knee joint. Ant. medial malleolar & joint. Ant. medial malleolar & ant. lateral malleolar round ant. lateral malleolar round ankle joint. ankle joint.

Dorsalis Pedis A.-Dorsalis Pedis A.- Begins in Begins in front of ankle between 2 malleoli. front of ankle between 2 malleoli. Passes forwards along dorsum of Passes forwards along dorsum of foot & dips downwards between 2 foot & dips downwards between 2 heads of 1heads of 1stst dorsal interosseous ms. dorsal interosseous ms. & ends in sole by completing & ends in sole by completing plantar arterial arch.plantar arterial arch.

BranchesBranches--

A. Lat. tarsal a.A. Lat. tarsal a.

B. Med. tarsal branchesB. Med. tarsal branches

C. Arcuate a.- Ends by C. Arcuate a.- Ends by anastomosing with lat. tarsal and anastomosing with lat. tarsal and lat. plantar a. Gives off 2, 3 & 4lat. plantar a. Gives off 2, 3 & 4thth dorsal metatarsal a.dorsal metatarsal a.

D. 1D. 1stst dorsal metatarsal a.- just dorsal metatarsal a.- just before it dips into the solebefore it dips into the sole

Posterior Tibial A.-Posterior Tibial A.- Larger Larger terminal branch of popliteal a. terminal branch of popliteal a. Supplies back & lat. Supplies back & lat. compartment of leg, & sole of compartment of leg, & sole of foot. It runs downwards to reach foot. It runs downwards to reach midway between medial midway between medial malleolus & calcaneum. It malleolus & calcaneum. It terminates by dividing into lat. terminates by dividing into lat. and medial planter a.and medial planter a.

BranchesBranches- -

A. Peroneal Artery- Largest A. Peroneal Artery- Largest branchbranch

B. MuscularB. Muscular

C. Nutrient artery to tibiaC. Nutrient artery to tibia

Lateral Planter arteryLateral Planter artery forms the forms the plantar archplantar arch which is completed medially by dorsalis pedis a.which is completed medially by dorsalis pedis a.

Obturator Artery-Obturator Artery- Branch of Posterior division of Branch of Posterior division of Internal Iliac artery, supplies the adductor Internal Iliac artery, supplies the adductor compartment of thighcompartment of thigh

Applied A-Applied A-

1. Pulsations of Femoral a. can be felt against 1. Pulsations of Femoral a. can be felt against head of femur at midinguinal point.head of femur at midinguinal point.

2. In 10 % of subjects the dorsalis pedis a. may be 2. In 10 % of subjects the dorsalis pedis a. may be absentabsent

VEINS OF LOWER LIMBVEINS OF LOWER LIMB

DEEP VEINSDEEP VEINS::

Anterior and Anterior and Posterior tibial v. Posterior tibial v. (drains Peroneal (drains Peroneal v.) → Popliteal v.→ v.) → Popliteal v.→ Femoral v. → Femoral v. → External iliac v.External iliac v.

SUPERFICIAL VEINS-SUPERFICIAL VEINS- Great saphenous Great saphenous

vein-vein- Begins at medial Begins at medial

end of dorsal end of dorsal venous arch of footvenous arch of foot

Passes ant. to the Passes ant. to the medial malleolus & medial malleolus & ascends on medial ascends on medial side of leg, then side of leg, then passes behind knee passes behind knee & curves forward & curves forward around medial side around medial side of the thighof the thigh

Inclines ant. through the thigh to Inclines ant. through the thigh to saphenous opening- pierces cribriform saphenous opening- pierces cribriform fascia to enter femoral vein (lies about fascia to enter femoral vein (lies about 3~4 cm below and lat. to pubic tubercle)3~4 cm below and lat. to pubic tubercle)

Contains 10-15 valve. 1 valve always Contains 10-15 valve. 1 valve always present at the sapheno-femoral junction.present at the sapheno-femoral junction.

Connected to deep veins by perforators- 3 Connected to deep veins by perforators- 3 medial perforators just above ankle, 1 just medial perforators just above ankle, 1 just below knee, 1 in adductor canalbelow knee, 1 in adductor canal

Accompanied by saphenous nerveAccompanied by saphenous nerve

Small saphenous vein-Small saphenous vein- Arises from the lateral Arises from the lateral

part of the dorsal venous part of the dorsal venous arch of footarch of foot

Ascends behind lat. Ascends behind lat. malleolus & then passes malleolus & then passes upward to the midline of upward to the midline of the calf the calf

Pierces deep fascia & Pierces deep fascia & enters the popliteal v.enters the popliteal v.

It drains lateral side of the It drains lateral side of the foot & ankle & the back of foot & ankle & the back of the leg.the leg.

Accompanied by sural Accompanied by sural nervenerve

Applied Applied Anatomy-Anatomy-

Calf pump/ Peripheral heart-Calf pump/ Peripheral heart-SOLEUS.SOLEUS.

Vericose Veins & Ulcers- Valves of Vericose Veins & Ulcers- Valves of the perforating veins become the perforating veins become incompetent- high pressure from incompetent- high pressure from deep veins transmitted to sup. deep veins transmitted to sup. VeinsVeins

Tests- 1. Trendelenburg TestTests- 1. Trendelenburg Test

2. Perthe’s Test2. Perthe’s Test

NERVES OF LOWER LIMBNERVES OF LOWER LIMB

Lumbar PlexusLumbar Plexus Arises from L1-L4Arises from L1-L4 Lies within the psoas major muscleLies within the psoas major muscle Mostly anterior structuresMostly anterior structures

Sacral PlexusSacral Plexus Arises from spinal nerve L4-S4Arises from spinal nerve L4-S4 Lies caudal to the lumbar plexusLies caudal to the lumbar plexus Mostly posterior structuresMostly posterior structures

Femoral nerveFemoral nerve - - Largest branchLargest branch

- lies lateral to femoral artery in femoral triangle- lies lateral to femoral artery in femoral triangle Motor branchesMotor branches - - Anterior compartment musclesAnterior compartment muscles

Cutaneous branchesCutaneous branches - - Thigh, leg, foot (e.g. saphenous nerve)Thigh, leg, foot (e.g. saphenous nerve)

ArticularArticular- - - Hip and knee joint- Hip and knee joint Vascular-Vascular- - Femoral a. & branches - Femoral a. & branches

Obturator nerveObturator nerve SensorySensory- Skin medial thigh; hip, knee - Skin medial thigh; hip, knee

jointsjoints MotorMotor- Adductor muscles- Adductor muscles

Genitofemoral NGenitofemoral N SensorySensory- Skin scrotum/ labia majora, - Skin scrotum/ labia majora,

Femoral triangleFemoral triangle Motor-Motor- Cremaster muscle Cremaster muscle

Ilioinguinal NIlioinguinal N SensorySensory- Root of penis/mons pubis, ant. - Root of penis/mons pubis, ant.

1/3 of scrotum/labium majus, upper 1/3 of scrotum/labium majus, upper medial thighmedial thigh

Sciatic N-Sciatic N- Thickest nerve in body, enters gluteal Thickest nerve in body, enters gluteal

region through greater sciatic foramen, runs region through greater sciatic foramen, runs downward & at superior angle of popliteal downward & at superior angle of popliteal fossa divides into Tibial and Common fossa divides into Tibial and Common Peroneal n.Peroneal n.

Motor:Motor: Hamstring Hamstring

BranchesBranches:: A.A. Tibial nerveTibial nerve-- Larger terminal br.Larger terminal br. Cutaneous- Post. leg and sole of footCutaneous- Post. leg and sole of foot Motor- Post. compartment of legMotor- Post. compartment of leg.. Terminates by dividing into medial & Terminates by dividing into medial &

lat. planter n.lat. planter n.

B. B. Common peroneal (fibular) nerveCommon peroneal (fibular) nerve

Smaller terminal branch, winds round the Smaller terminal branch, winds round the neck of fibula, pierces peroneus longus and neck of fibula, pierces peroneus longus and divides into superficial and deep peroneal divides into superficial and deep peroneal nervesnerves

1. 1. Deep peroneal NDeep peroneal N.-.-

Nerve of ant. compartment of leg, enters Nerve of ant. compartment of leg, enters ant. Comp. by piercing ant. Intermuscular ant. Comp. by piercing ant. Intermuscular septumseptum

2. 2. Superficial peroneal N.Superficial peroneal N. – –

Nerve of lat. comp. , terminal branch of Nerve of lat. comp. , terminal branch of Comm. Peroneal, supplies lower 1/3 of lat. Comm. Peroneal, supplies lower 1/3 of lat. side of leg & dorsum of footside of leg & dorsum of foot

Superior gluteal nerveSuperior gluteal nerve MotorMotor

Gluteus medius and minimus, tensor fasciae Gluteus medius and minimus, tensor fasciae lataelatae

Inferior gluteal nerveInferior gluteal nerve MotorMotor

Gluteus maximusGluteus maximus

Pudendal nervePudendal nerve SensorySensory

External genitalia, anusExternal genitalia, anus MotorMotor

Muscles of perineumMuscles of perineum

Applied Anatomy-Applied Anatomy-

Compression of sciatic nerve – sleeping footCompression of sciatic nerve – sleeping foot

Shooting pain along the cutaneous distribution Shooting pain along the cutaneous distribution ( back of thigh, lat. Side of leg, dorsum of foot) – ( back of thigh, lat. Side of leg, dorsum of foot) – Sciatica (due to compression/irritation)Sciatica (due to compression/irritation)

Sciatic N. injury- Foot dropSciatic N. injury- Foot drop..

LYMPHATIC DRAINAGELYMPHATIC DRAINAGE Lymph Nodes-Lymph Nodes-

A. A. Superficial Inguinal LN-Superficial Inguinal LN- Drain skin & fascia of LL, Drain skin & fascia of LL, perineum, trunk below umbilical plane. 3 sets-perineum, trunk below umbilical plane. 3 sets-

1. 1. Upper lateral grUpper lateral gr. : 2-3 nodes, drain- lat. side of . : 2-3 nodes, drain- lat. side of thigh, buttock, flank & back below umbilical planethigh, buttock, flank & back below umbilical plane

2. 2. Upper medial grUpper medial gr. : 2-3 nodes, drain- ant. abd. . : 2-3 nodes, drain- ant. abd. Wall below umbilicus, perineum (external genitalia Wall below umbilicus, perineum (external genitalia except glans), anal canal below pectinate line, except glans), anal canal below pectinate line, penile part of male urethera, superolat. Angle of penile part of male urethera, superolat. Angle of uterusuterus

3. 3. Lower vertical grLower vertical gr. : along terminal part of great . : along terminal part of great saphenous vein, 4-5 nodes, drain- lower limb except saphenous vein, 4-5 nodes, drain- lower limb except buttock & short saphenous territorybuttock & short saphenous territory

Efferents pass to Deep inguinal N.Efferents pass to Deep inguinal N.

Deep Inguinal LNDeep Inguinal LN:: 4-5 in nodes, lie med. to upper 4-5 in nodes, lie med. to upper part of femoral v., afferents -(1) sup. inguinal (2) part of femoral v., afferents -(1) sup. inguinal (2) popliteal (3) glans penis/clitoris (4) deep lymphatics popliteal (3) glans penis/clitoris (4) deep lymphatics of LL accompanying femoral vesselsof LL accompanying femoral vessels

Popliteal LN-Popliteal LN- near termination of small saphenous near termination of small saphenous V. , drain the territory of small saph. , deep parts of V. , drain the territory of small saph. , deep parts of leg, efferents run along popliteal & femoral vessels leg, efferents run along popliteal & femoral vessels to end in deep inguinal LNto end in deep inguinal LN

Applied Anatomy-Applied Anatomy- (a) Elephantiasis- lymphatic obst. (a) Elephantiasis- lymphatic obst. resulting in great hypertrophy of skin & resulting in great hypertrophy of skin & subcutaneous tissuesubcutaneous tissue

(b) Commenest swelling in subinguinal area- LN (b) Commenest swelling in subinguinal area- LN enlargement due to infection, carcinomaenlargement due to infection, carcinoma

REGIONAL & APPLIED REGIONAL & APPLIED ANATOMYANATOMY

Deep fascia of thigh (Fascia Lata)-Deep fascia of thigh (Fascia Lata)- Modifications- Modifications-

(A) (A) Iliotibial tract-Iliotibial tract- thickened laterally to form 2” thickened laterally to form 2” wide band, Attached sup- tubercle of iliac crest & wide band, Attached sup- tubercle of iliac crest & capsule of hip joint, inf- lat. Condyle of tibia ant. 2 capsule of hip joint, inf- lat. Condyle of tibia ant. 2 muscles are attached – greater part of G. muscles are attached – greater part of G. maximus & tensor fascia latae. Stabilizes knee maximus & tensor fascia latae. Stabilizes knee jointjoint

(B) (B) Saphenous opening-Saphenous opening- opening in fascia lata 4 opening in fascia lata 4 cm below & lat. To pubic tubercle, closed by cm below & lat. To pubic tubercle, closed by cribriform fascia.cribriform fascia.

Applied Anatomy(AA)-Applied Anatomy(AA)- Fascia lata is attached to Fascia lata is attached to inguinal ligament, flexion of thigh relaxs abdomen inguinal ligament, flexion of thigh relaxs abdomen fully for examinationfully for examination

Femoral Femoral TriangleTriangle

BoundariesBoundaries- the - the inguinal ligament inguinal ligament (base) superiorly; the (base) superiorly; the medial border of medial border of sartorius laterally; sartorius laterally; the medial border of the medial border of adductor longus adductor longus medially. Inferiorly, medially. Inferiorly, apex of triangle is apex of triangle is continuous with continuous with adductor canal.adductor canal.

Anterior wall-Anterior wall- skin, skin, sup.fascia containing- sup. sup.fascia containing- sup. Ing. LN. , femoral br. Of Ing. LN. , femoral br. Of genitofemoral N. , genitofemoral N. , Superficial branches of Superficial branches of femoral A. with Veins , femoral A. with Veins , upper part of great saph. upper part of great saph. V. , fascia lata- saph. V. , fascia lata- saph. Opening & cribriform Opening & cribriform fasciafascia

Posterior Wall-Posterior Wall- consists consists of adductor longus, of adductor longus, pectineus and iliopsoas , pectineus and iliopsoas , from med. to lat. sidefrom med. to lat. side

Contents-Contents-1. Femoral a. & its branches- superficial & 1. Femoral a. & its branches- superficial &

deepdeep

2. Femoral vein and its tributaries.2. Femoral vein and its tributaries.

3. Deep inguinal LN. 3. Deep inguinal LN.

4. The femoral nerve.4. The femoral nerve.

5. The femoral sheath- encloses upper 3-4 cm 5. The femoral sheath- encloses upper 3-4 cm of femoral vessels. Ant. Wall of sheath- of femoral vessels. Ant. Wall of sheath- fascia trasversalis, post. Wall- Fascia iliacafascia trasversalis, post. Wall- Fascia iliaca

3 compartments- Lateral- Femoral artery & 3 compartments- Lateral- Femoral artery & femoral br. Of genitofemoral N, Middle- femoral br. Of genitofemoral N, Middle- Femoral v. , Medial- Femoral Canal.Femoral v. , Medial- Femoral Canal.

Femoral Femoral CanalCanal

About 1.3cm long ,upper About 1.3cm long ,upper opening is called the opening is called the Femoral Femoral ringring. .

Boundaries of Femoral Boundaries of Femoral ringring: the inguinal ligament : the inguinal ligament ant. ; lacunar ligament med.; ant. ; lacunar ligament med.; pectineus & its covering fascia pectineus & its covering fascia post.; septum separating it post.; septum separating it from femoral vein lat. Covered from femoral vein lat. Covered by femoral septum superiorly. by femoral septum superiorly.

The canal contains a little The canal contains a little areolar tissue, a lymph node , areolar tissue, a lymph node , and some lymphatics.and some lymphatics.

Femoral Femoral HerniaHernia

- Femoral canal- area of potential weaknessFemoral canal- area of potential weakness- Femoral hernia more common in females- Femoral hernia more common in females-

wider canalwider canal- Typical course - 1Typical course - 1stst passes through F. canal passes through F. canal

then forward through Saph. Opening, finally then forward through Saph. Opening, finally upwards along superficial epigastric & Sup. upwards along superficial epigastric & Sup. Circumflex iliac vesselsCircumflex iliac vessels

- Chances of strangulation are very highChances of strangulation are very high- To enlarge femoral ring- have to cut To enlarge femoral ring- have to cut

lacunar lig. Beware – sometimes abnormal lacunar lig. Beware – sometimes abnormal Obturator A. may lie along the edge.Obturator A. may lie along the edge.

Adductor/Subsartorial/Hunter’s Adductor/Subsartorial/Hunter’s CanalCanal

Extends from apex of femoral triangle Extends from apex of femoral triangle to the tendinous opening in adductor to the tendinous opening in adductor magnus (adductor hiatus)magnus (adductor hiatus)

BoundriesBoundries- vastus medialis- ant. wall, - vastus medialis- ant. wall, adductors longus above and magnus adductors longus above and magnus below- posterior wall (floor), medial below- posterior wall (floor), medial wall (roof)- fibrous membrane joining wall (roof)- fibrous membrane joining ant. & post. walls overlapped by ant. & post. walls overlapped by sartoriussartorius

Subsartorial plexus of nerves lies in the Subsartorial plexus of nerves lies in the fibrous roof fibrous roof

Contents Contents –Femoral a.- lies between Femoral –Femoral a.- lies between Femoral v. & saph. N. at all levels , femoral v.- v. & saph. N. at all levels , femoral v.- ascends posteriorly , Saphenous nerve- ascends posteriorly , Saphenous nerve- crosses lat. To medial anteriorly , nerve to V. crosses lat. To medial anteriorly , nerve to V. medialis, Obturator Nmedialis, Obturator N

Applied Anatomy-Applied Anatomy- - Femoral a. is exposed in the adductor - Femoral a. is exposed in the adductor

canal for various surgical procedures.canal for various surgical procedures. - After ligature of femoral a. in adductor - After ligature of femoral a. in adductor

canal collateral circulation is established canal collateral circulation is established between (1) lateral circumflex femoral & between (1) lateral circumflex femoral & descending genicular a. (2) 4descending genicular a. (2) 4thth perforating a. perforating a. & muscular branches of popliteal a.& muscular branches of popliteal a.

Popliteal Popliteal FossaFossa

Diamond-shaped Diamond-shaped Upper lateral Upper lateral

boundary: Biceps boundary: Biceps femoris femoris

Upper medial Upper medial boundary: boundary: semimembranosus semimembranosus and semitendinosus and semitendinosus

2 lower boundaries- 2 lower boundaries- heads of heads of gastrocnemius gastrocnemius

Roof: Deep fascia Roof: Deep fascia (Popliteal), (Popliteal), superficial fascia superficial fascia contains short contains short saphenous v.saphenous v.

Floor: Popliteal Floor: Popliteal surface of femur, surface of femur, posterior capsule of posterior capsule of knee joint, fascia knee joint, fascia covering popliteus covering popliteus Ms.Ms.

ContentsContents

Deep to superficialDeep to superficial Popliteal artery and its Popliteal artery and its

branchesbranches Popliteal vein and its Popliteal vein and its

tributariestributaries Tibial and common Tibial and common

peroneal nerves and peroneal nerves and their branchestheir branches

Popliteal lymph nodesPopliteal lymph nodes FatFat

Subcutaneous BursaeSubcutaneous Bursae

Prepatellar Bursa-Prepatellar Bursa- - lies in front of lower part of patella in upper part of - lies in front of lower part of patella in upper part of

ligamentum patellaeligamentum patellae

- Chronic enlargement – Housemaid’s knee- Chronic enlargement – Housemaid’s knee

- Infection common in miners – Miner’s beat knee- Infection common in miners – Miner’s beat knee

Infrapatellar Bursa-Infrapatellar Bursa- - lies in front of tibial tuberosity & lower part of ligamentum - lies in front of tibial tuberosity & lower part of ligamentum

patellaepatellae

- Chronic enlargement- Clergyman’s knee- Chronic enlargement- Clergyman’s knee

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