LE Hip Region, Movement Patterns, Fascia and Bony Landmarks PDF

Lower Extremity: Movement Patterns, Fascia, and Bony Landmarks Jason Dring, PT, DPT Heavy Contributions By: E. Costello, PT, PhD, Joe Signorino, PT, DPT  LE Lecture Unit Overall Unit Objectives  Demonstrate a working knowledge of attachments, a...

Lower Extremity: Movement Patterns, Fascia, and Bony Landmarks Jason Dring, PT, DPT Heavy Contributions By: E. Costello, PT, PhD, Joe Signorino, PT, DPT  LE Lecture Unit Overall Unit Objectives  Demonstrate a working knowledge of attachments, action and innervation of all muscles presented in this unit  Identify blood supply to respective soft tissue and joints  Identify impairments and functional limitations associated with LE peripheral nerve lesions  Classify joints according to the shape number of articular surfaces and degrees of freedom  Demonstrate an understanding of the pathologies discussed within the context of lecture material  Lower Extremity Movement Femur on Pelvis Hip Ankle Lateral = Knee External Medial = Internal  Lower Extremity Movement Pelvis on Femur ABD ADD Reference Limb: RIGHT lower extremity Fascia of the Lower Limb Superficial Fascia (aka subcutaneous fascia)  Lies deep to the skin  Comprised of a loose connective tissue  Contains fat, cutaneous nerves, superficial veins, & lymphatics  Continuous with the fascia of the inferior, anterolateral abdominal wall & buttocks http://home.comcast.net/~wnor/fascia.jpg http://m1.ikiwq.com/img/xl/jAVn8fq83OkNh8jMCZ2Eqd.png  Fascia of the Lower Limb  Deep Fascia (“Fascia Lata”)  Definition: dense layer of connective tissue between the subcutaneous tissue and the muscles in the thigh  Non-elastic  Especially strong in LE  Encircles limb like a stocking  Prevents bulging of muscles during contraction making more efficient  Continuous with the deep fascia of the leg (crural fascia) Deep fascia (aka fascia lata) = nonelastic Fasciotomy https://www.cambridge.org/core/books/atlas-of-surgical-techniques-in-trauma/lower-extremity-fas ciotomies/77D7FC675CE694F2F7BF051F6D70428F http://img.medscape.com/pi/emed/ckb/plastic_surgery/1271089-1287360-1824.jpg  PELVIS BONE IDENTIFICATION Comprised of: - Ilium (tan) - Ischium (blue) - Pubis (red) - Sacrum (not viewed) - Coccyx (not viewed) Includes: - 2 sacroiliac joints - pubic symphysis  Bony Landmarks – Internal ASIS View AIIS PSIS PIIS Iliac crest Wing of ilium: iliac fossa Auricular surface of the ilium Greater sciatic notch Ischial spine Lesser sciatic notch Body of ischium Ischial tuberosity Obturator foramen Arcuate line* Pectineal line* Bony Landmarks – External View ASIS AIIS PSIS PIIS Ant gluteal line Iliac Crest Wing of ilium: gluteal surface Post gluteal line Gluteal Lines (ant., post., Inf gluteal line inf.) Greater Sciatic Notch Ischial Spine Lesser Sciatic Notch Body of ischium Ischial Tuberosity Obturator Foramen Acetabulum  PELVIS BONE IDENTIFICATION Gluteal – EXTERNAL surface of VIEW the wing of the ilium Anterior Inferior Iliac Spine (AIIS) Citation: Chapter 35. Gluteal Region and Hip, Morton DA, Foreman K, Albertine KH. The Big Picture: Gross Anatomy; 2011. Available at: https://accessmedicine.mhmedical.com/content.aspx?bookid=381&sectionid=40140046 Accessed: September 18, 2018 Copyright © 2018 McGraw-Hill Education. All rights reserved  PELVIS LIGAMENTOUS IDENTIFICATION Greater Sciatic Foramen Lesser Sciatic Foramen Obturator Foramen  More Bony Landmarks Acetabulum ( all 3 bones contribute) Acetabular notch Body of the Ischium Pubic tubercle Superior ramus of pubis Inferior ramus of the Pubis x SACRUM/COCCYX- Landmarks Sacral canal Ala of the Sacrum Sacral Canal Body of SV1 Auricular Surface (lateral SV1 view) Sacral Promontory Sacral Foramina Cornu of the Sacrum (posterior view only) and Coccyx Transverse Process of the c Coccyx x Tip of Coccyx Note: Lateral & Median sacral crest & sacral & coccygeal cornu Transverse Cross Section View: Sacral Canal Sagittal Cross Section: Sacral Canal  Sacroiliac Joint Part synovial, part fibrous joint Irregular planar joint by shape Articulation between auricular surface of the ilium and lateral aspect of sacral segments Sacroiliac Ligaments: Anterior, Posterior and Interosseus sacroiliac ligament (between Ant and Post lig) Accessory Ligaments: sacrospinous Lig., sacrotuberous Lig , iliolumbar Lig.  Anterior View: SIJ Note: Anterior SI, sacrospinous, & sacrotuberous ligaments Posterior View: SIJ Note: Posterior sacroiliac, sacrospinous, and sacrotuberous ligaments Sacroiliac joint  Clinical Impact: Iliopectineal Line Arcuate line Pectineal line https://upload.wikimedia.org/wikipedia/commons/4/4a/Arcuate_line_of_ilium_03_anterior_view.png  Iliopectineal line https://radiopaedia.org/ articles/pelvic-radiograph-an- approach?lang=us  PUBIC SYMPHYSIS Cartilaginous Joint Articulation between the superior rami of the right and left pubic bones Hyaline cartilage on articular surfaces Fibrocartilage interpubic disc – Reason why “blank” on plain film imaging Jt. also strengthened by fibers of the rectus abd. m. and ext. oblique m. (both attach here)  SACROCOCCYGEAL JOINT Cartilaginous joint Articulation between the apex of the sacrum and the base of the coccyx Sacrococcygeal ligaments – Anterior (ventral) x – Posterior (dorsal) – Lateral Fibrocartilaginous intervertebral disc  PELVIC BRIM Formed by:  superior margin of the pubic symphysis  pubic crest: (med to pubic tubercle)  pectin pubis (pectineal line)  arcuate line of the ilium  ant. border of the ala of the sacrum  promontory of the sacrum  PELVIC BRIM Pelvic Brim  Superior pelvic aperture or pelvic inlet false  formed by the pelvic brim  separates true and false pelvis true  Inferior pelvic aperture or pelvic outlet (mickey mouse hole)  bounded posteriorly by the sacrum and coccyx, anteriorly by the pubic symphysis, laterally by ischial tuberosities  closed by the pelvic diaphragm Inferior Pelvic Aperture  PELVIS MAJOR Aka: False pelvis – “Above blue circle” – Found in Abdominal cavity – Lies between the iliac fossae superior to the pelvic brim – Bounded anteriorly by the abdominal wall, laterally by the iliac fossae, and posteriorly by L5 and S1 vertebrae  PELVIS MINOR AKA: True pelvis  Lies inferior to the superior pelvic aperture and limited inferiorly by the inferior pelvic aperture  Pelvic cavity containing pelvic viscera  Bounded posteriorly by the sacrum and the coccyx, anteriorly by the pubic symphysis, body of pubis and pubic rami, and laterally by the ilium and ischium MALE PELVIS compared to FEMALE Thicker, heavier structure More prominent bone markings Round obturator foramen Larger acetabulum Heart Shaped superior pelvic aperture Smaller inferior pelvic aperture Narrow pelvis major Deep pelvis minor  FEMALE PELVIS Thinner structure Less prominent bone markings Oval obturator foramen Small acetabulum Oval or round superior pelvic aperture Larger inferior pelvic aperture Shallow pelvis major Wide and shallow pelvis minor  Obturator Foramen Formed by the bodies and rami of the pubis and ischium Nearly closed by an obturator membrane Obturator N., A., and V. leave pelvis through the obturator foramen through the obturator canal Obturator Foramen  Greater Sciatic Foramen Formed  anteriorly & superiorly by the greater sciatic notch  inferior by the sacrospinous ligament, and  posterior by the sacrotuberous ligament Acts as exit from inner pelvis for vessels and nerves  Greater Sciatic Foramen Greater Sciatic Foramen Superior/lateral portion made up of the greater sciatic notch of the ilium Inferior/medial portion made up of the sacrospinous and sacrotuberous ligaments: The more vertical fibers are sacrotuberous The more horizontal fibers are sacrospinous  Lesser Sciatic Foramen  Formed by:  anteriorly by the lesser sciatic notch  Superiorly by the ischial spine and sacrospinous ligament  posteriorly by the sacrotuberous ligament  Transmits:  Obturator internus tendon  N. to obturator internus  Internal pudendal a. and v., and pudendal n.