The Lower Limb

Pelvis, Thigh, Leg and Foot

dr. Irwan Bagian anatomi FK Unsri

Surface Anatomy

Surface Anatomy

Gluteal region / posterior pelvis

Iliac

crest Gluteus maximus

Cheeks
Natal/gluteal

cleft

Vertical midline; Crack

Gluteal

folds

Bottom of cheek; prominence

Nelatons line

a line drawn from the anterior superior lilac spine to the ischial tuberosity, passing over or near the top of the greater trochanter. The trochanter can be felt superior to this line in a person which a dislocated hip or a fractured femoral neck.

Normal angle of inclination 1250-1300

Coxa vara (abnormally decreased angle of inclination, it occurs in fractures of the neck of the femur and slipping of the femoral epiphysis )

Coxa valga (abnormally increased angle of inclination, in cases of congenital dislocation of the hip)

1700

>1700

<1700

Normal alignment

Genu varum (bowleg) O

Genu valgum X

Surface Anatomy

Anterior thigh and leg

Palpate

Patella Condyles of femur

Femoral

Triangle

Boundaries:
Sartorius (lateral) Adductor longus (medial) Inguinal ligament (superior) Femoral artery, vein and nerve, lymph nodes

Contents:

Surface Anatomy

Posterior leg
Popliteal fossa Diamond-shape fossa behind knee Boundaries

Biceps femoris (superior-lateral) Semitendinosis and semimembranosis (superior-medial) Gastrocnemius heads (inferior) Popliteal artery and vein

Contents

Calcaneal

(Achilles)

tendon

Surface Anatomy

Anterior leg bones

Tibia

Tibial tuberosity Anterior crest Medial surface Medial malleolus

Fibula

Lateral malleolus

Superficial structures
Great saphenous vein

Drains the medial end of dorsal venous arch of foot Passes upward directly in front of the medial malleolus. Then ascends on medial side of the leg. Passes behind the knee and curves forward around the medial side of the thigh. Passes through the saphenous hiatus in the deep fascia and joins the femoral vein about 4 cm below and lateral to the pubic tubercle.

Superficial structures

Tributaries:

Superficial lateral femoral v. Superficial medial femoral v. External pudendal v. Superficial epigastric v. Superficial iliac circumflex v.

Superficial epigastric v. Superficial circumflex iliac v.

Superficial lateral femoral v.

External pudendal v. Superficial medial femoral v. Great saphenous v.

Varicose veins

Superficial structures
Superficial fascia

Superficial arteries: superficial epigastric a. superficial iliac circumflex a. external pudendal a. Cutaneous nerves: lateral femoral cutaneous n. anterior and medial cutaneous branches of femoral n. cutaneous branches of obturator n.

lateral femoral cutaneous n.

anterior and medial cutaneous branches of femoral n.

Cutaneous branches of obturator n.

Superficial structures
Superficial inguinal lymph nodes Superior group:
Lies just distal to the inguinal ligament Receive lymph vessels from anterior abdominal wall below umbilicus, gluteal region, perineal region, external genital organs Inferior group: Lies vertical along the terminal great saphenous v. Receives all superficial lymph vessels of lower limb, except for those from the posterolateral part of calf

Efferent vessels drain into the deep inguinal ln. or external iliac ln.

Deep fascia of the thigh

Fascia lata
The deep fascia encloses the thigh like a trouser leg.

Saphenous hiatus

A gap in the deep fasica which lies about 4 cm below and lateral to the pubic tubercle. The falciform margin is the lower lateral border of the opening, which lies anterior to the femoral vessels. Filled with loose connective tissue called the cribriform fascia

Deep fascia of the thigh

Iliotibial tract
laterally the deep fascia forms a thick band, from the iliac tubercle to the lateral condyle of tibial. The fascia lata sends intermuscular septa to the linea aspera of the femur. These separate the thigh into three compartments each of which contains a group of muscles, the vessels and the nerves.

Skeletal Composition

Bones of the Lower Limb

Function:

Locomotion Carry weight of entire erect body Support Points for muscular attachments Thigh

Components:

Femur
Patella Tibia (medial) Fibula (lateral) Tarsals (7) Metatarsals (5) Phalanges (14)

Knee

Leg

Foot

Thigh

Femur
Largest,

longest, strongest bone in the body!! Receives a lot of stress Courses medially

More in women!

Articulates

with acetabulum proximally Articulates with tibia and patella distally

Knee

Patella
Triangular

sesamoid

bone Protects knee joint Improves leverage of thigh muscles acting across the knee Contained within patellar ligament

Leg

Tibia

Receives the weight of body from femur and transmits to foot Second to femur in size and weight Articulates with fibula proximally and distally

Interosseous membrane

Fibula

Does NOT bear weight Muscle attachment Not part of knee joint Stabilize ankle joint

Foot

Function:

Supports the weight of the body Act as a lever to propel the body forward
Tarsals

Parts:

Talus = ankle

Between tibia and fibula Articulates with both Attachment for Calcaneal tendon Carries talus

Calcaneus = heel

Navicular Cuboid Medial, lateral and intermediate cuneiforms

Metatarsals Phalanges

Foot

3 arches
Medial Lateral
Longitudinal

Transverse Has tendons that run inferior to foot bones

Help support arches of foot

Function
Recoil

after stepping

Joints of Lower Limb

Hip (femur + acetabulum)

Ball + socket Multiaxial Synovial Hinge (modified) Biaxial Synovial Contains menisci, bursa, many ligaments Plane Gliding of patella Synovial

Knee (femur + tibia)

Knee (femur + patella)

Joints of Lower Limb

Proximal Tibia + Fibula

Plane, Gliding Synovial

Distal Tibia + Fibula

Slight give (synarthrosis) Fibrous (syndesmosis)

Ankle (Tibia/Fibula + Talus)

Hinge, Uniaxial Synovial

Intertarsal & Tarsal-metatarsal

Plane, synovial
Condyloid, synovial Hinge, uniaxial

Metatarsal-phalanges Interphalangeal

Muscles

Muscles of Hip and Thigh

Gluteals

Posterior pelvis Extend thigh Rotate thigh Abducts thigh Flexes thigh at hip Extends leg at knee

Anterior Compartment Thigh

Medial/Adductor Compartment

Adducts thigh Medially rotates thigh

Posterior Compartment Thigh

Extends thigh Flexes leg

Gluteals

Gluteus maximus

Origin - Ilium, sacrum and coccyx Insertion - Gluteal tuberosity of femur, iliotibial tract Action - Extends thigh, some lateral rotation and abduction Innervation - Inferior gluteal nerve

Gluteus medius Gluteus minimus

Origin - Ilium Insertion - Greater trochanter of femur Action - Abduction, medial rotation Innervation - Superior gluteal nerve

Lesser Gluteals help stabilize hip to allow fluent bipedal walking

Posterior Pelvis

Tensor fasciae latae

iliac crest and anterior inferior iliac spine Insertion iliotibial tract Action - Flex thigh, abduct thigh, medial rotation of thigh Innervation Superior gluteal nerve
Origin

Anterior Compartment Thigh

Quadriceps femoris Rectus femoris Origin anterior inferior iliac spine, margin of acetabulum Insertion patella and tibial tuberosity via the patellar ligament Action extends knee, flexes thigh Vastus lateralis Vastus medialis Vastus intermedius Origin - femur Insertion patella and tibial tuberosity via the patellar ligament Action extends knee Sartorius Origin - anterior superior iliac spine Insertion medial tibia Action - flex, abduct, lat rotate thigh; weak knee flexor All above innervated by the femoral nerve!!!

Anterior Compartment Thigh

Iliopsoas

Origin - Ilia, sacrum, lumbar vertebrae Insertion lesser trochanter Action flexor of thigh Innervation femoral nerve

Adductors

Adductor longus Adductor brevis Adductor magnus

Origin inferior pelvis Insertion - femur Action adducts and medial rotates Innervation Obturator nerve Origin - pubis Insertion lesser trochanter Action adducts, medial rotates Innervation femoral, sometimes obturator

Pectineus

Gracilis

Origin - pubis Insertion medial tibia Action adducts thigh, flex, medial, rotates leg Innervation Obturator nerve

Posterior Compartment - Hamstring

Biceps femoris (2 heads) Origin ischial tuberosity, distal femur Insertion - lateral tibia, head fibula Action - thigh extension, knee flexion, lateral rotation Semitendinosus Semimembranosus Origin - ischial tuberosity Insertion - medial tibia Action - thigh extension, knee flexion, medial rotation

Sciatic nerve innervates all of the above muscles!!!

Muscles of the Leg

Anterior Compartment
Dorsiflex

ankle, invert foot, extend toes Innervation: Deep fibular nerve

Lateral Compartment
Plantarflex,

evert foot Innervation: Superficial Fibular nerve

Posterior Compartment
Superficial

and deep layers Plantarflex foot, flex toes Innervation: Tibial nerve

Anterior Compartment

Tibialis anterior

Origin - tibia Insertion - tarsals Action - dorsiflexion, foot inversion Origin tibia and fibula Insertion - phalanges Action toe extension Origin fibula, interosseous membrane Insertion big toe Action - extend big toe, dorsiflex foot

Extensor digitorum longus

Extensor hallucis longus

All innervated by deep fibular nerve

Lateral Compartment

Fibularis (peroneus) longus

lateral fibula Insertion 5th metatarsal, tarsal Action - plantarflex, evert foot
Origin

Fibularis (peroneus) brevis

distal fibula Insertion - proximal fifth metatarsal Action same as above!!
Origin

All innervated by the superficial fibular nerve

Superficial Posterior Compartment

Triceps surae

Gastrocnemius (2 heads)

Origin - medial and lateral condyles of femur Insertion - posterior calcaneus via Achilles tendon

Soleus

Origin tibia and fibula Insertion same as above

Action of both plantarflex foot

Plantaris (variable)

All innervated by the tibial nerve

Origin posterior femur Insertion same as above! Action plantarflex foot, week knee flexion

Deep Posterior Compartment

Popliteus

Origin - lateral condyle femur and lateral meniscus Insertion proximal tibia Action flex and medially rotate leg

Flexor digitorum longus

Origin - tibia Insertion - distal phalanges of toe 2-5 Action plantarflex and invert foot, flex toe

Flexor hallucis longus

Origin - fibula Insertion - distal phalanx of hallux Action - plantarflex and invert foot, flex toe

Tibialis posterior
Origin tibia, fibula, and interosseous membrane Insertion - tarsals and metatarsals Action - plantarflex and invert foot

All innervated by the tibial nerve

Innervation

Plexuses of the Lower Limb

Lumbosacral plexus Lumbar Plexus

Arises from L1-L4 Lies within the psoas major muscle Mostly anterior structures Arises from spinal nerve L4-S4 Lies caudal to the lumbar plexus Mostly posterior structures

Sacral Plexus

Lumbar Plexus

Femoral nerve

Cutaneous branches

Thigh, leg, foot (e.g. saphenous nerve)

Anterior thigh muscles (e.g. quadriceps, sartorius, iliopsoas)

Motor branches

Obturator nerve

Sensory

Skin medial thigh; hip, knee joints

Adductor muscles

Motor

Lateral femoral cutaneous

Sensory

Skin lateral thigh

Genitofemoral

Sensory

Skin scrotum, labia major, anterior thigh Cremaster muscle

Motor

Sacral Plexus

Sciatic

Motor:

Hamstring Tibial nerve

Branches into:

Cutaneous Posterior leg and sole of foot Motor Posterior leg, foot Cutaneous Anterior and lateral leg, dorsum foot Motor Lateral compartment, tibialis anterior, toe extensors

Common fibular (peroneal) nerve

Superior gluteal nerve

Motor

Gluteus medius and minimus, tensor fasciae latae

Sacral Plexus (continued)

Inferior gluteal nerve

Motor Gluteus maximus

Posterior femoral cutaneous nerve

Sensory Inferior buttocks, posterior thigh, popliteal fossa

Pudendal nerve
Sensory External genitalia, anus
Motor Muscles of perineum

Vasculature

Arteries

Common iliac (from aorta) branches into:

Internal

iliac iliac

Supplies pelvic organs

Supplies lower limb

External

Arteries

Internal iliac branches into:

Cranial

and Caudal Gluteals (Superior and Inferior)

Gluteals

Internal Pudendal Perineum, external genitalia

Obturator Adductor muscles

Other

branches supply rectum, bladder, uterus, vagina, male reproductive glands

Arteries

External iliac becomes.

Femoral

Once passes the inguinal ligament Lower limb Branches into Deep femoral

Adductors, hamstrings, quadriceps Branches into Medial/lateral femoral circumflex Head and neck of femur

Femoral becomes

Popliteal (continuation of femoral)

Branches into:

Geniculars Knee Anterior Tibial Anterior leg muscles, further branches to feet Posterior Tibial Flexor muscles, plantar arch, branches to

Splits into:

Veins

Deep Veins: Mostly share names of arteries

Ultimately empty into Inferior Vena Cava

Plantar Tibial Fibular Popliteal Femoral External/internal iliac Common iliac

Superficial Veins

Dorsal venous arch (foot) Great saphenous (empties into femoral) Small saphenous (empties into popliteal)