ANATOMY II.pptx

ANATOMY II By Dr Guhram Jamali THE HIP BONE Hip or innominate bone is a large bone. It is made up of three parts. The ilium ( groin ) superiorly. The pubis (genital area) anteroinferiorly. The ischium (hip joint) posteroinferiorly. HIP BONE At the acetabulum the three parts are jo...

ANATOMY II By Dr Guhram Jamali THE HIP BONE Hip or innominate bone is a large bone. It is made up of three parts. The ilium ( groin ) superiorly. The pubis (genital area) anteroinferiorly. The ischium (hip joint) posteroinferiorly. HIP BONE At the acetabulum the three parts are joined. The obturator foramen is the oval opening by which the pubis and ischium are separated. The acetabulum articulates with the head of femur to form hip joint. The pubic parts of both hip bones meet anteriorly to form pubic symphysis. The teo hip bones form pelvic or hip girdle. The bony pelvis is formed by two hip bones along with sacrum znd coccyx. HIP BONE, SIDE DETERMINATION The acetabulum is directed laterally. The flat expanded ilium form the upper part of bone that lies above the acetabulum. The obturator foramen lies below the acetabulum. It is bounded anteriorly by the thin pubis and HIP BONE, ANATOMICAL POSITION The pubic tubercle and ASIS lies in the same coronal plane. The pelvic surface of body of the pubis is directed backwards and upwards. The symphyseal surface of body of pubis lies in the median plain. ILIUM The upper end is called iliac crest. The lower end is small and fused with pubis and ischium to form acetabulum. Three borders, anterior, posterior and medial. Three surfaces, gluteal surface, ILIAC CREST The iliac crest is a broad concave ridge forming the upper end. It can be felt in living. Vertically it is convex upwards. The highest point is situated a little behind the midpoint of the crest. It lies at the level of interval between spines of vertebrae L3 and 4. The anterior end is called ASIS and posterior end is called PSIS. The ASIS is easily felt in living. ILIAC CREST The iliac crest is divided into a long ventral segment and a short dorsal segment. The ventral segment forms anterior two third of the crest and has an outer lip, an inner lip and an intermediate area. The tubercle of crest is on outer lip 5 cm behind the ASIS. The dorsal segment forms posterior one third of the crest and has lateral and medial THE ILIAC CREST The ASIS gives attachment to the lateral end of the inguinal ligament, origin to Sartorius, the origin extends onto the upper half of the notch below spine. The outer lip of the iliac crest provides attachment to the fascia lata to its full extent, origin to tensor fascia lata in front of the tubercle, insertion to external oblique muscle in its anterior two third, and origin to latissimus dorsi behind the highest point of the crest. THE ILIAC CREST The intermediate area of the iliac crest gives origin to the internal oblique muscle in the anterior two third. The inner lip of the iliac crest provides origin to the transverse abdominis in its anterior two third, origin to quadratus lumbrum in its THE ILIAC CREST The attachment on dorsal segment are The lateral slope gives origin to gluteus medius. The medial slope gives origin to erector spinae. THE ILIUM anterior border The anterior border starts at the ASIS and runs downwards to the acetabulum. The upper part of the border presents a notch, while its lower part shows an elevated area called the AIIS. The lower half of this spine is large, irregular and rough. The upper half of the AIIS gives origin to the straight head of the rectus femoris. The rough lower part gives attachment to THE ILIUM Posterior Border The posterior border extends from the PSIS to the upper end of the posterior border of ischium. A few cms below PSIS it presents an other prominence called PIIS. Still lower down the posterior border is marked by a THE ILIUM Posterior Border It provides attachment to sacrotuberous ligament above the greater sciatic notch, and origin to the piriformis from upper margins of the greater sciatic notch. THE ILIUM Medial Border The medial border extends on the inner or pelvic surface from the iliac crest to the iliopubic eminence. It separates the iliac fossa from the sacropelvic surface. THE ILIUM Gluteal Surface It is the outer surface of the ilium, which is convex in front and concave behind, like the iliac crest. It is divided into four areas by three gluteal lines. The posterior gluteal line begins 5 cm in front of the PSIS ends at upper part of GSN. The anterior gluteal line begins 4 cm behind the ASIS and end at the middle of the upper border of GSN. The inferior gluteal line, the most ill defined, begins a little above and behind the AIIS THE ILIUM Gluteal Surface The attachments on gluteal surface are as follows. The area behind the posterior gluteal line gives origin to upper fibers of gluteus maximus. The area between anterior and posterior gluteal lines gives origin to gluteus medius. The area between anterior and inferior gluteal lines give origin to gluteus minimus. The area below the inferior gluteal line and THE ILIUM The iliac fossa Iliac fossa is the large concave area on the inner surface of the ilium, situated in front of the medial border. The iliac fossa from its upper two thirds gives origin to iliacus muscle. THE ILIUM Sacropelvic Surface Sacropelvic surface is the uneven area on the inner surface of ilium behind the medial border. It is subdivided into three parts, the iliac tuberosity, the auricular surface and the pelvic surface. The tuberosity is the upper, large and roughened part, lying just below the dorsal segment, it is raised in middle and depressed from above and below. It gives attachment to the interosseous sacroiliac THE ILIUM Sacropelvic Surface The auricular surface is articular. It articulated with sacrum to form the sacroiliac joint. The convex margin of auricular surface gives attachment to ventral sacroiliac ligament. THE ILIUM Sacroiliac surface The pelvic surface is smooth and lies anteroinferior to the auricular surface. Along with the upper part of GSN this surface is marked by the preauricular sulcus. This sulcus is deeper in females than males. The preauricular sulcus provides attachment to the lower fibers of the ventral sacroiliac ligament. The part of the pelvic surface lateral to the preauricular sulcus gives origin to a few fibers of THE PUBIS Pubis forms the anteroinferior part of the hip bone and the anterior 1/5 of the acetabulum, and also th forms the anterior boundary of the obturator foramen. It has A body anteriorly. A superior ramus superolaterally. An inferior ramus inferolaterally. THE PUBIS Body Body of the pubis is flattened from before backwards, and has A superior border called the pubic crest. A pubic tubercle at the lateral end of pubic crest. Three surfaces, anterior, posterior and medial. THE PUBIS Body The pubic tubercle is the lateral end of the pubic crest. The pubic tubercle provides attachment to the medial end of inguinal ligament and to ascending loops of cremaster muscle. In males the tubercle is crossed by the spermatic cord. The medial part of the pubic crest is crossed by the medial head of rectus THE PUBIS Body The anterior surface is directed downwards, forwards and slightly laterally. It is rough superomedially and smooth elsewhere. This surface provides attachment to the anterior pubic ligament medially, origin to adductor longus in the angle between the crest and the symphysis, origin to gracilis from the margins of symphysis and inferior ramus, origin to adductor brevis lateral to THE PUBIS Body The posterior or pelvic surface is smooth. It is directed upwards and backwards. It forms the anterior wall of pelvis and is related to the urinary bladder. This surface provides origin to levator ani from the middle part, origin to obturator internus laterally and attachment to puboprostatic/ THE PUBIS Body The medial or symphyseal surface articulates with the opposite pubis to form symphysis pubis. THE PUBIS Superior Ramus Superior ramus extends from the body of the pubis to the acetabulum above the obturator foramen. The superior border is called the pectineal line or pectin pubis. It is sharp crest extending from just behind pubic tubercle to posterior THE PUBIS Superior Ramus The pectineal line provides attachment to The conjoint tendon at the medial end The lacunar ligament in front of above. The pectineal ligament of Cooper along the whole length of the line lateral to the attachment of lacunar ligament. The pectineus muscle which arises from the whole length of the line. The fascia covering the pectineus. The psoas minor inserts when present. THE PUBIS Superior Ramus The anterior border or obturator crest is rounded ridge extending from the pubic tubercle to the acetabular notch. The inferior border is sharp and forms the upper border of obturator foramen. THE PUBIS Superior Ramus The pectineal surface is a triangular area between the anterior and superior borders extending from the pubic tubercle to the iliopubic eminence. The pectineal surface in its upper part gives origin to pectineus. THE PUBIS Superior Ramus The pelvic surface lies between the superior and inferior borders. It is smooth and is continuous with the pelvic surface of the body of pubis. The pelvic surface is crossed by the round ligament of uterus in THE PUBIS Superior Ramus The obturator surface lies between the anterior and inferior borders. It presents obturator groove. The obturator groove transmits the obturator vessels and nerve. THE PUBIS Inferior Ramus The inferior ramus extends from the body of the pubis to the ramus of ischium, medial to the obturator foramen. It unites with the ramus of ischium to form the THE ISCHIUM The ischium forms the posteroinferior of the gip bone, and the adjoining 2/5th acetabulum. It forms the posterior boundary of obturator foramen. The ischium has a body and a ramus. BODY. This is a thick and massive mass of bone that lies below and behind the acetabulum. It has: Two ends upper and lower Three borders- anterior, posterior and lateral Three surfaces- femoral, dorsal and pelvic. THE ISCHIUM Body ends The upper end forms posteroimferior 2/5 of the th acetabulum. The lower end forms the ischial tuberosity. It gives off the ramus which forms an THE ISCHIUM Borders The anterior border forms the posterior margin of the obturator foramen. The posterior border is continuous with the posterior border of ilium. Below it ends at the upper end of ischial tuberosity. It also forms part of the lower border of greater sciatic notch. Below the notch the posterior margin shows a projection called ischial spine. Below spine the posterior border shows a concavity called lesser sciatic notch. The ischial spine provides, attachment to the sacrospinous ligament along its margins, origin to the levator ani from its pelvic surface. Its dorsal surface is crossed by pudendal nerve, the internal pudendal vessels and by the nerve to obturator internus. THE ISCHIUM Borders The lesser sciatic notch is occupied by the tendon of obturator internus. The upper margin of the notch gives origin to superior gemellus and lower margin to inferior gemellus. THE ISCHIUM Borders The lateral border forms the lateral margin of the ischial tuberosity, except at the upper end where it is rounded. THE ISCHIUM Surfaces The femoral surface lies between the anterior and lateral borders. The femoral surface gives origin to obturator externus along the margin of obturator foramen, and to quadratus femoris along the lateral border of the ischial tuberosity THE ISCHIUM Surfaces The dorsal surface is continuous above with the gluteal surface of ilium. The ischial tuberosity is divided by a transverse ridge into an upper and lower area. The upper area is subdivided by an oblique ridge into a superolateral area and an inferomedial area. The lower area is subdivided by a longitudinal ridge into outer and inner area. The attachments on the ischial tuberosity are as follows. The superolateral area gives origin to semimembranosus. The inferomedial area to the semitendinosus and biceps femoris. The outer lower area to the adductor magnus. The sharp medial margin of the tuberosity gives attachment to the dacrotuberous ligament. The lateral border of ischial tuberosity gives attachment to the ischiofemoral ligament THE ISCHIUM Surfaces The pelvic surface is smooth and forms part of the lateral wall of true pelvis. The greater part of the pelvic surface of the ischium gives origin to the obturator THE ISCHIUM Conjoined ischiopubic Rami The inferior ramus of the pubis unites with the ramus of ischium on the medial side of the obturator foramen. The site of union may be marked a localized thickening. The conjoined rami have: BORDERS: Upper and Lower. The upper border forms part of the margin of the obturator foramen and gives attachment to the obturator membrane. The lower border forms the pubic arch along with the corresponding border of the bone of opposite side. The lower border provides attachment to the fascia lata and superficial fascia or Colles’ fascia of the perineum. THE ISCHIUM Conjoined Rami SURFACES: Inner and Outer. The inner surface is convex and smooth. It is divided into three areas, upper, middle and lower by two ridges. The perineal membrane is attached to the lower ridge. The upper area gives origin to obturator internus. Middle area gives origin to deep transversus perinei, is related to neve of penis, clitoris and to CONJOINED RAMI The outer surface is rough for attachment of muscles. The obturator externus near the obturator margin of both rami. The adductor brevis from pubic ramus. The gracilis from pubic ramus. ACETABULUM Acetabulum is a deep cup-shaped hemispherical cavity on the lateral aspect of the hip bone, about its center. It is directed laterally, downwards and forwards. The margin of acetabulum is deficient inferiorly and is called acetabular notch. It is bridged by transverse ligament. The non-articular roughened floor is called acetabular fossa. It is lined with hyaline cartilage and articulates with the head of femur to form the hip joint. OBTURATOR FORAMEN It is a large gap in the hip bone situated anteroinferior to acetabulum, between the pubis and ischium. It is large and oval in males and small and triangular in females. It is closed by the obturator membrane which is attached to its margins, except at the obturator groove where the obturator vessels and nerve pass out of the pelvis. OSSIFICATION The hip bone ossifies in cartilage from 3 primary and 5 secondary centers. The primary centers one for the ilium during 2nd month of intrauterine life, one for ischium during the 4th month and one for pubis during the 5th month of IUL. At birth the hip bone is ossified except for three cartilaginous parts I) the iliac crest II) a Y shaped cartilage separating the ilium, ischium and pubis. III) a strip along the inferior margin of the bone including the ischial tuberosity. Ossification The ischiopubic rami fuse with each other at 7th to 8th year of age. The secondary centers appear at puberty, 2 for the iliac crest, 2 for the Y shaped cartilage of the acetabulum and 1 for the ischial tuberosity. Ossification in the acetabulum is complete at 16th to 17th year, and the th th FEMUR The femur or thigh bone is the longest and strongest bone of the body. Femur has an upper rounded end, a lower bicondylar end and long shaft which is convex forwards. FEMUR Side determination The upper end bears a rounded head whereas the lower end is widely expanded to form 2 large condyles. The head is directed medially. The cylindrical shaft is convex forwards. FEMUR Anatomical Position The head is directed medially upwards and slightly forwards. The shaft is directed obliquely downwards and medially so that the lower surface of two condyles of femur lie in the same horizontal plane. FEMUR THE UPPER END. The upper end of the femur includes head, neck, greater trochanter, lesser trochanter, intertrochanteric line and intertrochanteric crest. HEAD. The head forms more than half a sphere and is directed medially, upwards and slightly forwards. It articulates with the acetabulum to form hip joint. A roughened pit is situated just below and p FEMUR Head The fovea on the head of femur provides attachment to the ligament of head of femur or round ligament or ligamentum teres/femoris. NECK. It connects head with shaft and is about 3.7 cm long. The neck has 2 borders and 2 surfaces. The upper border is concave and horizontal THE NECK Surfaces The anterior surface is flat and meets the shaft at intertrochanteric line. It is entirely intracapsular. The posterior surface is convex from above downwards and concave from side to side. It meets the shaft at intertrochanteric crest. The posterior surface is crossed by a horizontal groove for the tendon of obturator externus. The neck makes an angle of 125 with the shaft, the neck-shaft angle. It is less in females due to GREATER TOCHANTER This is a large quadrangular prominence at the upper part of the junction of neck with the shaft. The upper border of the trochanter lies at the level of center of the head. The greater trochanter has an upper border with an apex and 3 surfaces, anterior, medial and lateral. The anterior surface is rough in its lateral part. The medial surface presents a rough impression above, and deep trochanteric fossa below. The lateral surface is crossed by an oblique ridge directed downwards and forwards. GREATER TROCHANTOR The piriformis is inserted in to the apex. The gluteus minimus is inserted into the rough lateral part of the anterior surface. The obturator internus and the 2 gemelli are inserted into the upper rough impression on medial surface. The obturator externus is inserted into the trochanteric fossa. The gluteus medius is inserted into the THE LESSER TROCHANTER It is a conical eminence directed medially and backwards from the junction of the posteroinferior part of the neck with the shaft. The psoas major is inserted on the apex and medial part of the rough anterior surface. The iliacus is inserted on the anterior INTERTROCHANTERIC LINE It marks the junction of the anterior surface of the neck with the shaft. It is a prominent roughened ridge which begins above, at the anterosuperior angle of the greater trochanter as a tubercle. The line provides attachment to the capsular ligament of hip joint. To the upper band of iliofemoral ligament in its upper part. To the lower band of iliofemoral ligament in its lower part. Origin to the highest fibers of the vastus lateralis from the upper end. Origin to the highest fibers of the vastus medialis from lower end of the line. INTERTROCHANTERIC CREST It marks the junction of the posterior surface of the neck with the shaft. It is a smooth-rounded ridge, which begins above the posterosuperior angle of the greater trochanter and ends at the lesser trochanter. A rounded elevation, a little above its middle, is called the quadrate tubercle. The quadrate tubercle receives the SHAFT It is narrowest in the middle, and is more expanded inferiorly than superiorly. It is convex forwards and is directed obliquely downwards and medially, because the upper ends of 2 femora are separated by the width of the pelvis, and their lower ends are close together. In the middle 1/3rd the shaft has three borders, medial, lateral and posterior and 3 surface anterior, medial and lateral. The medial and lateral borders are rounded and ill defined and the posterior borders is in the form of a broad roughened ridge called the linea aspera. The linea aspera has a distinct medial and lateral lips. SHAFT The medial and lateral surfaces are directed more backwards than towards the sides. In the upper 1/3rd of shaft the two lips of linea aspera diverge to enclose an additional posterior surface. Thus this part has 4 borders-medial, lateral, spiral line and lateral lip of gluteal tuberosity. Four surfaces-anterior, medial, lateral and posterior. The gluteal tuberosity is a broad roughened ridge on the lateral part of the posterior surface. In the lower 1/3rd of the shaft also the 2 lips of SHAFT In the lower part the shaft also has 4 borders and 4 surfaces. The 4 borders are medial, lateral, medial supracondylar and lateral supracondylar line. The 4 surfaces are anterior, medial, lateral and popliteal. The medial border and medial supracondylar line meet inferiorly to obliterate the medial surface. Similarly the lateral border and lateral supracondylar line meet inferiorly to obliterate the lateral surface. SHAFT Attachments The medial and popliteal surfaces are bare except for a little extension of the origin of medial head of gastrocnemius to the medial part of popliteal surface. The vastus intermedius arises from the upper 3/4th of the anterior and lateral surfaces. The articularis genu arises just blow the vastus intermedius. The vastus lateralis arises from the upper part of the intertrochanteric line, anterior and inferior SHAFT Attachments Vastus medialis arises from the lower part of intertrochanteric line, the spiral line, medial lip of the linea aspera and medial supracondylar line. The gluteus maximus is inserted into the gluteal tuberosity. The adductor longus is inserted along the medial lip of linea aspera between vastus medialis and the adductor brevis and magnus. The adductor brevis is inserted into a line extending from the lesser trochanter to the SHAFT Attachments The adductor magnus is inserted into the medial margin of gluteal tuberosity, the linea aspera, the medial supracondylar line, and adductor tubercle. The paeciteus is inserted on a line extending from the lesser trochanter to the linea aspera. The short head of biceps femoris arises from the lateral lip of linea aspera and from the upper 2/3rd of lateral supracondylar line. SHAFT Attachments The lower end of the lateral supracondylar line gives origin to the plantaris above and lateral head of gastrocnemius below. The popliteal surface is covered with fat and forms the floor of the popliteal fossa. The origin of the medial head of gastrocnemius LOWER END OF FEMUR The lower end of femur is widely expanded to form 2 large condyles, medial and lateral. These form articular surface for the knee joint. Anteriorly the 2 condyles are united and are in line with the front of the shaft. Posteriorly they are separated by a deep gap, the intercondylar fossa or notch, and project backwards. THE FFEMORAL LOWER END. Articular surface The 2 condyles are partially covered by a large articular surface which is divisible into patellar and tibial parts. The articular surface for patella covers the anterior surfaces of both condyles and extends more on the lateral condyle. Between the 2 condyles the surface is grooved vertically. It is separated from the tibial surface by 2 faint grooves. The tibial surfaces cover the inferior and posterior surfaces of the 2 condyles, and merge anteriorly with the patellar surface. The part of the surface over the lateral condyle is short and straight anteroposteriorly. The part over the medial condyle is longer and is curved with its convexity directed medially. LATERAL CONDYLE The lateral condyle is flat laterally and is more in line with shaft. It therefore transmits greater weight to tibia. Though it is less prominent than the medial condyle, it is stouter and stronger. The lateral aspect presents the following. 1) A prominence called the lateral epicondyle. 2) The popliteal groove which lies just below the epicondyle. 3) A muscular impression posterosuperior to the epicondyle. Medial Condyle This condyle is convex medially. The most prominent part on it is called medial epicondyle. Posterosuperior to the epicondyle there is a projection, the adductor tubercle. This tubercle is an important Intercondylar fossa or intercondylar notch This notch separates the lower and posterior parts of the 2 condyles. It is limited anteriorly by the patellar articular surface, and posteriorly by the intercondylar line which separates the notch from the popliteal surface. Attachments to the lateral condyle The fibular collateral ligament of the knee joint is attached to the lateral epicondyle. The popliteus arises from the deep anterior part of the popliteal groove. When the knee is flexed the tendon of this muscle lies in the shallow posterior part of the groove. The muscular impression near the lateral epicondyle gives origin to the lateral head of gastrocnemius. Attachments on medial condyle The tibial collateral ligament of the knee joint is attached to the medial epicondyle. The adductor tubercle receives the insertion of the ischial head of the adductor magnus. The attachments on intercondylar notch The anterior cruciate ligament is attached to the posterior part of the medial surface of the lateral condyle on a smooth impression. The posterior cruciate ligament is attached to the anterior part of the lateral surface of medial condyle on a smooth impression. The intercondylar line provides attachment to the capsular ligament and laterally to ossification The femur ossifies from 1 primary and 4 secondary centers. The primary center for the shaft appears in the 7th week of IUL. The secondary centers appear, one for lower end at 9th month of IUL, for head during 6 month of life, for greater trochanter during the 4th year and for lesser trochanter during the 12th year. PATELLA The patella is the largest sesamoid bone in the body, developed in the tendon of the quadriceps femoris. It is situated in the front of the lower end of femur 1 cm above the knee joint. PATELLA Side Determination The patella is triangular with its apex directed downwards. The apex is non- articular posteriorly. The anterior surface is rough and non- articular. The upper 3/4th of the posterior surface are smooth and articular. The posterior articular surface is divided by a vertical ridge into a larger lateral and a smaller medial area. PATELLA Anatomical Position Anterior tough surface is put anteriorly with its apex pointing downwards. The posterior articular area is put posteriorly. PATELLA Features The patella has an apex, three borders- superior, lateral and medial and 2 surfaces- anterior and posterior. The apex directed downwards, is rough and vertically ridged. It is covered by an expansion from the tendon of the rectus femoris and is separated from the skin by the prepatellar bursa. The posterior surface is articular in its th PATELLA Features The articular area is divided by vertical ridge into a larger lateral and a smaller medial portion. The medial portion is again divided by a vertical ridge into a smaller and larger portions. The medial and lateral portions of the articular surface are divided by 2 transverse lines into 3 pairs of facets. During various phases of movements of the knee, different portions of the patella articulates with the femur. The lower pair of articular facets articulates during extension, middle pair during beginning of flexion, upper pair during midflexion and medial strip during full flexion of the knee. PATELLA ATTACHMENTS The superior border provides insertion to rectus femoris in front and to vastus intermedius behind. The lateral border provides insertion to vastus lateralis and medial border to vastus medialis. The non-articular area on the posterior surface provides attachment to the ligamentum patellae below. The quadriceps femoris is inserted into patella, from where ligamentum patellae arises which ends into PATELLA Ossification The patella ossifies from several centers which appear during 3-6 years of age. Fusion is complete at puberty. One or 2 centers at the superolateral angle may form separate pieces of bone. Such a patella is known as bipartite or tripartite patella. The condition is bilateral and symmetrical. TIBIA The tibia is medial and large bone of leg. Its upper end comprises 2 large condyles. Its lower end has a prominent medial malleolus. Shaft is between 2 ends. SIDE DETERMINATION The upper end is much larger than the lower. The medial side of lower end projects downwards beyond the shaft. The TIBIA Features The upper end of tibia is expanded from side to side to form 2 condyles. The upper end includes- a medial condyle, a lateral condyle, an intercondylar area and a tuberosity. MEDIAL CONDYLE. Medial condyle is larger than the lateral. Its superior surface articulates with the medial condyle of femur. The articular surface is oval and its long axis is anteroposterior. The central part of the surface is slightly concave and comes into direct contact with the femoral condyle. The peripheral part is flat and is separated from the femoral condyle by the medial meniscus. The posterior surface of the condyle has a groove. Attachments on the medial condyle The capsular ligament of the knee joint is attached to the upper border, which also gives attachment to the tibial collateral ligament. The semitendinosus is attached to the groove on posterior surface. The medial patellar retinaculum is attached to the anterior surface. Lateral condyle The lateral condyle overhangs the shaft more than the medial condyle. The superior surface of the condyle articulates with the lateral condyle of the femur. The articular surface is cricular. The central part is concave and comes in direct contact with femur, and the peripheral part is flat and separated from femur by lateral meniscus. Lateral condyle The posteroinferior aspect of the lateral condyle articulates with the fibula. The fibular facet is flat, circular and is directed downwards, backwards and laterally. Superomedial to the fibular facet, the posterior surface is marked by a Attachments on lateral condyle The iliotibial tract is attached to the flattened impression on the anterior surface. The capsular ligament of the superior tibiofibular joint is attached around the margins of the fibular facet. the groove on the posterior surface of the lateral condyle is occupied by the Intercondylar area Intercondylar area is the roughened on the superior surface, between the articular surfaces of the 2 condyles. The area is narrowest in its middle part. The part is elevated to form the intercondylar eminence which is flanked by the medial and lateral intercondylar tubercles. Attachments on intercondylar area The anterior horn of the medial meniscus just in front of the medial articular surface. The posterior horn of the medial meniscus to the depression behind the base of the medial intercondylar tubercle. The anterior cruciate ligament on a smooth area just behind the previous attachment. The posterior cruciate ligament to the posterior smooth area. The anterior horn of the lateral meniscus to the front of the intercondylar eminence and lateral to the ACL. TIBIAL TUBEROSITY The tuberosity of the tibia is a prominence located on the anterior aspect of the upper end of the tibia. It forms the anterior limit of the intercondylar area. Inferiorly it is continuous wit the anterior border of the shaft. The tuberosity is divided into an upper smooth and lower rough area. Attachment on tibial tubrosity The ligamentum patellae is attached to the upper smooth part of the tibial tuberosity. Lower rough area of tuberosity is subcutaneous. Shaft of tibia The shaft has three borders- anterior, medial and interosseous, and 3 surfaces- lateral, medial and posterior. The anterior border is sharped and S shaped being convex medially in upper part and convex laterally in its lower part. It extends from tibial tuberosity above to the anterior border of medial malleolus below. The anterior border of the tibia gives Medial border The medial border is rounded. It extends from the medial condyle above to the posterior border of medial malleolus below. The interosseous or lateral border extends from the lateral condyle a little below and in front of the fibular facet to the anterior border of the fibular notch. The shaft Surfaces The lateral surface lies between the anterior and interosseous borders. In its upper 3/4th it is concave and is directed laterally and in its lower 1/4th directed forwards. The tibialis anterior arises from the upper 2/3rd of lateral surface. Tibia Surfaces The medial surface lies between the anterior and medial borders. It is broad and most of it is subcutaneous. The upper part of the medial surface receives the insertions of Sartorius, gracilis and semitendinosus from before backwards. Posteriorly this surface gives attachment to the tibial collateral ligament along the medial border. Tibia Surfaces The posterior surface lies between the medial and interosseous borders. It is widest in its upper part and is crossed obliquely by a rough ridge called soleal line. The soleal line begins just behind the fibular facet, runs downwards and medially, and terminates by joining the medial border at the junction of the upper and middle thirds. Above the soleal line, the posterior surface Attachments to the posterior surface The soleus arises from the soleal line.the tendinous arch for origin of soleus is attached to atubercle at the upper end of soleal line. The popliteus is inserted on the triangular area above the soleal line. The medial area below the soleal line gives origin to flexor digitorum longus and lateral area gives origin to tibialis posterior. The rough upper part of the fibular notch gives attachment to interosseous tibiofibular ligament. FIBULA The fibula is the lateral and smaller bone of the leg. Fibula comprises an upper end or head, a lower end and a shaft between two ends. ANATOMICAL POSITION. The fibula is held vertically. SIDE DETERMINATION The upper end or head is slightly expanded in all directions. The lower end or lateral malleolus is expanded anteroposteriorly and is flattened from side to side. The medial side of the lower end bears a triangular articular facet anteriorly and a deep or malleolar fossa posteriorly. FEATURES The fibula has an upper end, a shaft and a lower end. UPPER END OR HEAD. The upper end or head is slightly expanded in all directions. The superior surface bears a circular articular facet which articulates with lateral condyle of the tibia. The apex of the head or styloid process projects upwards from its posterolateral aspect. HEAD OF FIBULA The head of fibula receives insertion of biceps femoris on the anterolateral slope of the apex. The insertion is C-shaped. The fibular collateral ligament of knee joint is attached within the C-shaped area. The capsular ligament of superior tibiofibular joint is attached around SHAFT The shaft has 3 borders-anterior posterior and interosseous, and 3 surfaces-medial lateral and posterior. BORDERS. The anterior border begins just below the anterior aspect of the head. At its lower end, it divides to enclose an elongated triangular area which is continuous with the lateral surface of the lateral malleolus. The posterior border is rounded. Its upper end SHAFT The interosseous or medial border. It lies just medial to the anterior border. It terminates below at the upper end of a roughened area above the talar facet of the lateral malleolus. In its upper 2/3 , the rd interosseous border lies very close to the anterior border. The SURFACES The shaft has 3 surfaces-medial, lateral and posterior. The MEDIAL SURFACE lies between the anterior and interosseous borders. In its upper 2/3rd it is very narrow, 1 mm or less. It gives origin to extensor digitorum longus from its upper 1/4th and anterior half of middle 2/4th, extensor hallucis from posterior half of SURFACES The LATERAL SURFACE lies between anterior and posterior borders. It is twisted backwards in its lower part. It gives origin to peroneus longus from its upper 1/3rd and posterior half of middle 1/3rd, peroneus brevis rd SURFACES The posterior surface is the largest and lies between the interosseous and posterior borders. In its upper 2/3rd it is divided into 2 parts by a vertical ridge called medial crest. The posterior surface between medial crest and posterior border gives origin to Soleus from upper 1/4th and Flexor Hallucis Longus from lower 3/4th. The posterior surface between medial crest THE LOWER END OR LATERAL MALLEOLUS The lower end is prolonged to form lateral malleolus. Its medial surface articulates with talus. It has the following four surfaces. 1) the anterior surface is rough and rounded. 2) the posterior surface is marked by groove. 3) the lateral surface is subcutaneous. LATERAL MALLEOLUS Attachments The anterior talofibular ligament to the anterior surface. The inferior transverse tibiofibular ligament above and posterior talofibular ligament below to the malleolar fossa. The capsule of the ankle joint along the edges of the malleolar articular surface. Slight notch on the lower border gives attachment to calcaneofibular ligament. THE FIBULA Ossification The fibula ossifies from one primary and 2 secondary centers. The primary center for shaft appears during 8th week of IU life. The secondary center for the lower end appears during 1st year and fuses with the shaft during 16th year. The other secondary center for upper end th TARSUS OR TARSALS The tarsus is made up seven tarsals, arranged in 2 rows. In the proximal row the talus is above and calcaneus is below. In the distal row 4 bones lying side by side, medial, intermediate and lateral cuneiforms and the cuboid. The navicular is in between the talus and 3 cuneiforms i, e, in between the 2 rows. Each tarsal bone is roughly cuboidal in TALUS It lies between the tibia above and calcaneum below, gripped on the sides by the 2 malleoli. SIDE DETERMINATION. The rounded head is directed forwards. The trochlear articular surface of the body is directed upwards and the concave articular surface downwards. The body bears a large triangular facet THE TALUS ANATOMICAL POSITION. Talus is placed horizontally with head placed anteriorly and body posteriorly. TALUS Head It is directed forwards and slightly downwards and medially. Its anterior surface is oval and convex. It articulates with the posterior surface of the navicular bone. The inferior surface is marked by 3 articular areas separated by indistinct ridges. The posterior facet is largest oval and concave. It articulates with middle facet on TALUS Neck This is the constricted part of the bone between head and body. The neck-body angle is 130-140 in infants and 150 in adults. The smaller angle in young children accounts for the inverted position of their feet. The medial part of its plantar surface is marked by a deep groove termed the sulcus tali. The sulcus tali lies opposite the TALUS Neck Attachments The distal part of the dorsal surface provides attachment to the capsular ligament of the ankle joint and to the dorsal talonavicular ligament. The inferior surface provides attachment to the talocalcanean and cervical ligament. THE TALUS Body The body is cuboidal in shape and has 5 surfaces. The superior or trochlear surface bears an articular surface, which is convex from before backwards and concave from side to side, and articulates with the lower end of tibia to form the ankle joint. The inferior surface bears an oval concave articular surface to articulate with the posterior facet of the calcaneum to form the subtalar joint. The medial surface is articular above and non-articular below. The articular surface is comma-shaped and articulates with the medial malleolus of tibia. THE TALUS Body The lateral surface bears a triangular articular surface for the lateral malleolus. It is concave from above downwards, and its apex forms the lateral tubercle of the talus. The posterior surface is small and is marked by an oblique groove. The groove is bounded by medial and lateral tubercles. The lateral tubercle is THE TALUS Body Attachments The lower non-articular part of the medial surface of the body gives attachment to the deltoid or anterior tibiotalar ligament. The groove on the posterior process/surface lodges the tendon of the flexor hallucis longus. The medial tubercle provides attachment to the deltoid ligament above and medial talocalcanean ligament below. The upper part of the posterior process/surface provides attachment to the posterior talofibular TALUS Ossification The talus ossifies from one center which appears during the 6th month of IU life. CALCANEUS OR CALCANEUM The calcaneus is the largest tarsal bone. It forms the prominence of heel. It is roughly cuboidal and has 6 surfaces. SIDE DETERMINATION. The anterior surface is small and bears a concavoconvex articular facet for the cuboid. The posterior surface is large and rough. The dorsal or upper surface bears a large convex articular surface in the middle. The plantar surface is rough and triangular. The lateral surface is flat and the medial is concave from above downwards. ANATOMICAL POSITION. Calcaneum is held horizontally. CALCANEUS Features The anterior surface is smallest surface of bone. It is covered by a concavoconvex, sloping articular surface for cuboid. The posterior surface is divided into 3 areas, upper middle and lower. The upper area is smooth while others are rough. The upper area is covered by a bursa. The middle rough area receives insertion of plantaris and attachment of CALCANEUS Surfaces The dorsal or superior surface can be divided into 3 areas. The anterior part of dorsal surface provides origin to extensor digitorum brevis. The plantar surface is rough and is marked by 3 tubercles, medial, lateral and anterior. The medial tubercle provides origin to abductor hallucis medially and flexor digitorum brevis anteriorly. CALCANEUS Surfaces The lateral tubercle gives origin to abductor digiti minimi. The anterior tubercle provides attachment to the short plantar ligament. The rough strip between the three tubercles afford attachment to the long plantar ligament. The lateral surface is rough and flat, it presents a small elevation called the trochlea or tubercle. The medial surface is concave from above downwards, the sustentaculum. CALCANEUS Ossification The calcaneus ossifies from one primary and one secondary center. The primary center appears during 3 rd month of IU life. The secondary center appears during 6th or 8th year and fuses by 14th-16th year. NAVICULAR BONE The navicular bone is boat shaped. It is situated on the medial side of the foot, in front of the head of the talus, and behind the 3 cuneiform bones. ANATOMICAL POSITION. It is held mediolaterally NAVICULAR Features The anterior surface is convex, divided into 3 facets for 3 cuneiform bones. The posterior surface is concave and oval for articulation with head of talus. The dorsal surface is broad and NAVICULAR Surfaces Plantar surface is small and concave from side to side. It is rough and non-articular. The medial surface has a blunt and prominent tuberosity, directed downwards, the tuberosity is separated from the plantar surface by a groove. NAVICULAR Attachments The tuberosity on medial surface provides insertion to the tibialis posterior. The groove below the tuberosity transmits the tendon of tibialis posterior to other bones. Various ligaments are attached NAVICULAR Ossification It ossifies from one center which appears during the third year of life. CUNEIFORM BONES There are three cuneiform bones, medial, intermediate and lateral. The medial cuneiform is the largest and intermediate is the smallest. CUNEIFORM BONES Medial cuneiform articulates proximally with the navicular, distally with the base of 1st metatarsal and laterally with intermediate cuneiform A greater part of tibialis anterior is inserted into an impression on anteroinferior angle of medial surface. The plantar surface receives a slip from tibialis posterior. THE CUNEIFORM BONES THE INTERMEDIATE CUNEIFORM Proximally it articulates with navicular bone and distally with the base of 2nd metatarsal bone, medially with medial cuneiform and laterally with lateral cuneiform The plantar surface receives a slip from the tibialis posterior. THE CUNEIFORM BONES THE LATERAL CUNEIFORM BONE. Proximally it articulates with the navicular, distally with the base of 3 metatarsal, medially with rd intermediate cuneiform and laterally with the cuboid bone. The plantar surface receives a slip THE CUBOID BONE The cuboid is the lateral bone of the distal row of the tarsus. It is situated in front of calcaneus and behind the 4th and 5th metatarsal bones. It has 6 surfaces. ANATOMICAL POSITION. Cuboid is held anteroposteriorly. THE CUBOID BONE Features It has 6 surfaces-proximal, distal, dorsal, plantar, lateral and medial. Proximally it articulates with the calcaneus and distally with the bases of 4th and 5th metatarsals and medially with the lateral cuneiform bone. The plantar surface provides insertion to tibialis posterior and origin to flexor hallucis brevis. THE CUBOID Ossification The cuboid bone ossifies from one center which appears just before birth. METATARSUS Metatarsus are made up of 5 metatarsal bones which are numbered from medial to lateral side. Each metatarsal is a miniature long bone and has the following parts. A) The shaft which is slightly convex dorsally and concave ventrally in its longitudinal axis. B) The base or proximal end. METATARSUS ANATOMICAL POSITION. The metatarsus are held anteroposteriorly. METATARSUS Identification The 1st metatarsal is the shortest, thickest and stoutest. The proximal of the base has a kidney- shaped facet, which is concave outwards. The 2nd metatarsal is the longest metatarsal. The lateral side of the base has 2 articular facets, a larger dorsal and a smaller plantar. The medial side of the base bears 1 facet, placed dorsally for the medial cuneiform. The 3rd metatarsal lateral side of base has 1 facet placed dorsally for the 4th metatarsal bone. METATARSUS Identification In the 4th metatarsal the proximal surface of the base is quadrangular. It articulates with the cuboid bone. The lateral side of base has 1 facet, placed dorsally, for the 5th metatarsal bone. The medial side of the base has 1 facet placed dorsally, which is subdivided into a proximal part for lateral cuneiform and a distal part for 3rd metatarsal. In the 5th metatarsal the lateral side of the base has large tuberosity or styloid process projecting backwards and laterally. The medial side of base METATARSUS Attachments Tibialis anterior is inserted on the medial side of base of 1st metatarsal. Peroneus longus is inserted on lateral surface of base of 1st metatarsal. Peroneus brevis is inserted on tuberosity of 5th metatarsal. Peroneus tertius is inserted on shaft of 5th metatarsal. Flexor digiti minimi brevis arises from base of 5 th metatarsal. METATARSUS Ossification Each metatarsal ossifies from 1 primary and 1 secondary center. The primary appears in the shaft For 1st metatarsal during 10th week foetal life For other four during 9th week of foetal life. Secondary center for base of 1st metatarsal during 3rd year and for heads of all others between 3rd and 4th years. All secondary centers unite with shaft by 18 th year. PHALANGES There are 14 phalanges in each foot, 2 in great toe and 3 for each of other toe. These are smaller than the phalanges of hands. ANATOMICAL POSITION. The phalanges are held anteroposteriorly. PHALANGES Attachments On the bases of proximal phalanges. A) 2nd, 3rd and 4th toes, a lumbrical on medial side and an interosseous muscle on each side. B) 5th toe, a plantar interosseous muscle on the medial side, and the abductor digiti minimi and flexor digiti minimi on lateral side. C) great toe, abductor hallucis and part of flexor hallucis brevis medially, and adductor hallucis and the remaining part of the flexor hallucis PHALANGES Attachments On the shaft and bases of middle phalanges. Flexor digitorum brevis on each side of the shaft on plantar surface, and part of extensor expansion on dorsal surface. PHALANGES Attachments On the bases of distal phalanges. A) Lateral 4 toes, flexor digitorum longus on the plantar surface and the extensor expansion on the dorsal surface. B) Great toe, flexor hallucis longus on the plantar surface and part of the extensor hallucis longus on the dorsal surface. PHALANGES Ossification The shaft of Phalanges ossify by 1 primary center appear in 10th week of foetal life. The single secondary center in base Of proximal phalanx in 2nd year Of middle phalanx in 3rd year Of distal phalanx in 6th year And they all fuse with respective shaft by 18th year. Big toe, Base of proximal phalanx secondary center appear in 2nd year Base of distal phalanx secondary center appear in 3rd year. THE LUMBAR PLEXUS The lumbar plexus is formed by the ventral rami of upper 4 lumber nerves ( L1,2,3,4) L1 receives a branch from T12. The plexus is formed within the substance of psoas major. The L1 divides into a upper larger and a lower smaller branch. The upper larger branch receives a branch from T12 and THE LUMBAR PLEXUS The lower smaller branch receives a branch from L2 and forms genitofemoral nerve. The remaining L2 and the L3, L4 divide into ventral and dorsal branches. Ventral branches of L2,3 and 4 unite to form obturator nerve. Accessory obturator nerve, when present, arises from ventral branches of L3 and 4. THE LUMBAR PLEXUS The dorsal branches of L2 and 3 further divided into a smaller and a larger branch. The both smaller branches unite to form lateral cutaneous nerve of thigh and the larger branches along with the dorsal branch of L4 The nerves of lumbar plexus 1) Iliohypogastric. 2) Ilioinguinal. 3) Genitofemoral. 4) Lateral cutaneous nerve of thigh. 5) Femoral. 6) Obturator. 7) Accessory obturator (occationally). ILIOHYPOGASTRIC NERVE The iliohypogastric nerve is the uppermost in the lumbar plexus. The nerve traverse the psoas major, courses in front of the quadratus lumborum, and reaching the area above the iliac crest. A little above ASIS it pierces the internal oblique muscle and terminates in the region above the pubis. The muscular branches are given off to the internal oblique and transversus abdominis muscle. The lateral cutaneous branch reaches the upper and lateral part of gluteus maximus and the anterior cutaneous branch reaches the area of skin of the anterior abdominal wall a short area above the pubis, where it supplies the skin. The ilioinguinal nerve. It is the continuation of the L1 spinal nerve. It perforates the transversus abdominus near the anterior part of iliac crest, then pierces the internal oblique to which it supplies. Cutaneous supply to the superomedial area of thigh. Cutaneous supply to the root of penis and upper part of scrotum in male and to the skin covering the mons pubis and adjoining part of the labium majus in female. The Genitofemoral Nerve The femoral branch receives L1 fibers and genital branch receives L2 fibers. The femoral branch (L1) enters the femoral sheath, pierces the anterior layer of the sheath and facia lata, supplies to the skin over the upper part if the femoral triangle. The genital branch (L2) enters the inguinal canal. Motor distribution to the cremaster muscle and sensory to the tunica vaginalis in female and spermatic fascia in male. The lateral cutaneous nerve of thigh The nerve is formed by the union of undivided primary of L2 and 3. The nerve pierces the psoas major muscle crosses the iliacus extends to the region of ASIS. Beneath the ASIS it divides into 2 branches, anterior and posterior. The anterior branch supplies to the skin of anterior aspect of thigh upto the knee joint. The posterior branch supplies to the upper 2/3rd of lateral aspect of thigh and to the lateral aspect of The femoral nerve Root value L2,3,4 posterior divisions. It is the principal nerve of the extensor compartment of thigh. It is a mixed nerve. Motor distribution to iliacus, quadriceps femoris, Sartorius and pectineus. Sensory to the skin of front and medial side of thigh. The nerve passes down between the iliacus and psoas major. It soon divides in to a superficial and deep branch. The femoral nerve The superficial branch supplies to the Sartorius and pectineus muscle. The cutaneous branches are intermediate and medial cutaneous branches, by which supplies to the front and medial side of thigh. By deep branch to quadriceps femoris and iliacus and cutaneous supply through sephanous nerve to the medial OBTURATOR NERVE Root value is L2,3,4 anterior divisions. It is the nerve of adductor compartment of thigh. It is a mixed nerve. Motor distribution to obturator externus, adductor longus, magnus and brevis and gracilis and pectineus. Cutaneous to the skin of middle of internal side of thigh. Articular to hip and knee joints. It divides in to anterior and posterior branches. The anterior supplies to adductor brevis adductor longus gracilis and pectineus. The posterior branch supplies to obturator externus, adductor brevis and magnus, and knee joint. THE SACRAL PLEXUS The sacral plexus is formed by the lumbosacral trunk (L4,5 ventral rami) and the ventral rani of S1,2,3,4. This is the plexus for the supply of lower limb and perineum. The lumbosacral trunk descends to join with upper 4 sacral nerves to form the sacral plexus. It lies in the front of piriformis and behind the internal iliac vessels. The sacral nerves give off certain branches and then divide in to anterior and posterior divisions. These divisions then give off branches which reunite to form the nerves of lower limb. These PUDENDAL NERVE S2,3,4 It is the nerve of perineum. It leaves the pelvis through the greater sciatic foramen below the piriformis, passes across the ischial spine and re- enters through the lesser sciatic foramen. It then runs in the pudendal canal in the rectal wall of the ischiorectal fossa. At this point it divides into, 1) inferior haemorrhoidal nerve 2) perinial nerve 3) and dorsal nerve of penis or clitoris. PERINEAL BRANCH OF S4 It passes between coccygeus and iliococcygeus to the roof of the ischiorectal fossa, near the coccyx. Distribution; to coccygeus and iliococcygeus, the intermediate part of the external sphincter and the surrounding skin. DORSAL NERVE OF THE PENIS OR CLITORIS S2,3,4 NERVE OF PIRIFORMIS S1,2 Distribution. It supplies to piriformis muscle. POSTERIOR CUTANEOUS NERVE OF THIGH S1,2,3 The nerve leaves the pelvis through the greater sciatic foramen below the piriformis. It lies posterior to the sciatic nerve. Below the gluteus maximus it becomes cutaneous but runs down beneath the facia lata in the mid line as far as the middle of the calf. Distribution. To the skin of the buttock, the perineum and posterior aspect of PERFORATING CUTANEOUS NERVE S2,3 It pierces the sacrotuberous ligament and the overlying gluteus maximus. Distribution. Skin on the lower internal side of the buttock. NERVE TO QUADRATUS FEMORIS L4,5,S1 It leaves the pelvis through greater sciatic foramen below the piriformis, and deep to the sciatic nerve. It then runs down deep to the obturator internus to supply quadratus femoris and gamellus inferior. NERVE TO THE OBTURATOR INTERNUS L5,S1,2 It leaves the pelvis through the greater sciatic foramen below the piriformis between the sciatic and pudendal nerves. It follows the pudendal nerve and re-enters the pelvis through the lesser sciatic foramen. Distribution. To obturator internus and gamellus superior. TIBIAL NERVE L4,5 S1,2,3, It forms a component of the sciatic nerve as far as the upper angle of the popliteal fossa. It is the nerve of the flexor compartment of the thigh and leg. Cutaneous; To the skin on the posterolateral part of the leg and the lateral side of the foot. Articular; To the knee and ankle joints. TIBIAL NERVE Course and important relations The nerve enters the upper part of the popliteal fossa in the mid line. It traverses the fossa vertically to the distal border of the popliteus. It is continued in to the leg to the posteromedial aspect of the ankle where it divides in to its terminal branches, the medial and plantar nerves, which continue in to the foot. TIBIAL NERVE Branches 1) Muscular to gastrocnemius, plantaris, soleus, popliteus, tibialis posterior, flexor digitorum longus, flexor hallucis longus. 2) Sural nerve, a cutaneous nerve to the skin on the posterolateral part of the leg and the lateral side of the foot. 3) Articular branches, genicular branches to the knee and ankle joints. 4) Medial cutaneous branches to supply weight bearing skin of heel. TIBIAL NERVE Branches MEDIAL PLANTAR NERVE. Motor to the flexor digitorum brevis, abductor hallucis, flexor hallucis brevis and 1st lumberical muscle. Cutaneous; surfaces of medial 3 ½ toes and their dorsal surfaces proximal to nail beds. TIBIAL NERVE Branches LATERAL PLANTAR NERVE. Motor to flexor accessories, abductor digiti minimi, flexor digiti minimi, adductor hallucis, lateral three lumbricals and all interossei. Cutaneous; to the plantar surfaces of the lateral 1 ½ toes and on their dorsal surfaces proximal to the nail beds. COMMON PERONEAL NERVE L4,5 S1,2 DISTRIBUTION. 1) Motor to the muscles of the peroneal and extensor compartment of the leg and dorsum of foot. 2) Cutaneous to the skin on the anterior, lateral and posterior surfaces of the leg, and skin on the dorsum of the foot. 3) Articular to the knee joint, tibiofibular joints, ankle joint and the joints of the foot.  CPN Course and important relations The nerve enters the upper part of popliteal fossa and runs along the medial border of the biceps tendon to the head of fibula. It curves around the neck of fibula, deep to the peroneus longus and divides into its terminal branches, the deep peroneal and superficial peroneal nerves. CPN Branches 1) Lateral cutaneous nerve of the calf. 2) Sural communicating branch. 3) Articular to knee joint. 4) Deep peroneal. 5) superficial peroneal. Deep peroneal nerve It pierces extensor digitorum longus and descends over interosseous membrane in anterior compartment of leg. It runs down lateral to anterior tibial vessels to the dorsum of the foot where it ends by st Deep peroneal nerve Branches 1) Muscular branches to extensor digitorum longus, tibialis anterior, extensor hallucis longus, peroneus tertius and extensor digitorum brevis. 2) Cutaneous to the web between 1 and 2 toes. st nd 3) Articular to ankle joint and joints SUPERFICIAL PERONEAL NERVE It runs in the peroneal compartment of the leg. BRANCHES. 1) Muscular to the peroneus longus and brevis. 2) Cutaneous to the skin of the distal 2/3 rd of the lateral aspect of the leg and most of the dorsum of the foot (except the 1st interdigital cleft). THE SCIATIC NERVE It is the largest nerve in the body. It consists of 2 nerves the tibial and common peroneal nerves, in one sheath which separate at the upper angle of the popliteal fossa. DISTRIBUTION. The main trunk supplies to the hamstring component of the thigh. Course and important relation. The nerve emerges through greater sciatic foramen below the piriformis, midway between the greater trochanter of the femur and ischial tuberosity under cover of gluteus maximus. It runs vertically down into the hamstring compartment over the obturator internus and gemelli, quadratus femoris and adductor magnus and is covered by the long head of biceps. It terminates usually at the upper angle of The Sciatic Nerve Branches 1) Muscular, to the hamstring muscle (biceps femoris, semitendinosus and semimembranosus) and the ischial head of adductor magnus. 2) Articular to the hip joint and to the knee joint. SUPERIOR GLUTEAL NERVE Superior gluteal nerve takes a lateral course leaving the pelvis via the greater sciatic foramen. It enters the buttock by passing above piriformis muscle and as it proceeds laterally it gives off branches to the gluteus medius and gluteus minimus. These two muscles has an important role in abduction and medial rotation of thigh. INFERIOR GLUTEA NERVE. The inferior gluteal nerve enters the buttock along with sciatic and posterior cutaneous nerve of thigh. On reaching the lower border of the piriformis it divides into a number of branches which supply the gluteus maximus. Deep peroneal nerve Branches JOINTS OF PELVIS 1) Lumbosacral joints’ 2) Sacrococcygeal and intercoccygeal joints. 3) Sacroiliac joints. 4) Pubicsymphysis joint LUMBOSACRAL JOINTS The lumbosacral disc is very thick and is thickest anteriorly. The stability of the 5th lumber vertebra on the sacrum is increased by, Widely spaced articular processes. Strong iliolumbar ligament which extends from the stout transverse process of the 5th lumber vertebra to the iliac crest. The ligament fans out inferiorly to be attached to the lateral part of the sacrum as the lumbosacral ligament.  The body of the 5th lumber vertebra makes an angle of about 120 open backwards with the sacrum. This is the lumbosacral or sacrovertebral angle. This region is subject to a number of variations which give rise to symptoms of backache. These are Sacralisation of 5th lumbar vertebra. Lumbarilisation of 1st sacral vertebra. Spina bifida. SACROCOCCYGEAL AND INTERCOCCYGEAL JOINT The sacrococcygeal joint is a cartilaginous joint between the apex of the sacrum and base of coccyx. The bones are united by 1) a thin intervertebral disc. 2) ventral sacrococcygeal ligament. 3) deep dorsal sacrococcygeal ligament 4) superficial dorsal sacrococcygeal ligament. 5) lateral sacrococcygeal ligament. 6) intercarnual ligament. In old age the joint is obliterated and the ligaments are ossified.  The intercoccygeal jjoints are present only in youngs. Fusion of the segments begin at the age of 20 and is complete at the age of 30 years. SACROILIAC JOINT TYPE. This is a synovial joint of the plane variety. The articular surfaces are flat in infants, but in adults show interlocking irregularities which discourage movement at this joint. ARTICULAR SURFACES. The joint is formed between Articular surface of the sacrum, which is covered with fibrocartilage. Articular surface of the ilium, which is covered with hyaline cartilage. SACROILIAC JOINT Ligaments The fibrous capsule. The ventral sacroiliac ligament. The interosseous sacroiliac ligament. The dorsal sacroiliac ligament. The vertebropelvic ligaments The iliolumbar ligament. The sacrotuberous ligament. The sacrospinous ligament. HIP JOINT TYPE. Ball and socket variety of synovial joint (multiaxial). ARTICULAR SURFACES. The head of the femur articulates with the acetabulum of hip bone to form the hip joint. The head of the femur forms more then half a sphere and is covered with hyaline cartilage except at the fovea capitis. The acetabulum presents a horseshoe-shaped lunate articular surface, an HIP JOINT The lunate surface is covered with cartilage. The hip joint is unique in having a high degree of stability and mobility. The stability or strength depends upon: A) depth of the acetabulum and the narrowing of its mouth by the acetabular labrum. B) tension and strength of ligaments. C) strength of surrounding muscles. D) length and obliquity of the neck of the femur. HIP JOINT Ligaments The fibrous capsule. The iliofemoral ligament. The pubofemoral ligament. The ischiofemoral ligament. The ligament of the head of femur. Acetabular labrum. The transverse acetabular ligament. HIP JOINT Movements Flexion. Iliopsoas, accessory pectineus rectus femoris and Sartorius. Extension. Gluteus maximus and hamstring. adduction. Adductor longus, brevis and magnus. Pectineus, gracillis. Abduction. Glutei medius and minimus. TFL and Sartorius. Medial rotation. TFL, glutei medius and minimus. Lateral rotation. 2 obturators, 2 gemelli and quadratus femoris. Accessory piriformis, gluteus KNEE JOINT The knee is the largest and most complex joint of the body. The complexity is the result of fusion of three joints in one. It is formed by fusion of the lateral femorotibial, medial femorotibial and femoropatellar joints. KNEE JPONT Type It is condylar synovial joint incorporating 2 condylar joint between the condyles of the tibia and femur and one saddle joint between the femur and patella. It is also a complex joint as the cavity is divided by the menisci. KNEE JOINT Articular surfaces The knee joint is formed by: 1) the condyles of the femur. 2) the patella. 3) the condyles of tibia. The femoral condyles articulate with the tibial condyles below and behind and with the patella in front. KNEE JOINT Ligaments Fibrous capsule. Ligamentum patellae. Tibial collateral or medial ligament. Fibular collateral or lateral ligament. Oblique popliteal ligament. Arcuate popliteal ligament. Anterior cruciate ligament. Posterior cruciate ligament. Medial meniscus. Lateral meniscus. Transverse ligament. KNEE JOINT Movements Flexion and extension are the chief movements. These take place in the upper compartment of the joint. Rotatory movements at the knee are of a small range. Rotation takes place round a vertical axis, and are permitted in the lower compartment of the joint below the menisci. Rotatory component may be combined wit flexion extension, or may occur independently in semiflexed position. KNEE JOINT Muscles performing movements Extension (from sitting on a chair to standing) Quadriceps femoris 4 heads. Locking (standing in attention) Vastus medialis. Unlocking (standing at ease) popliteus. Flexion biceps femoris, semitendinosus, semimembranosus. Medial rotation of flexed leg. Popliteus semimembranosus, semitendinosus. Lateral rotation of flexed leg. Biceps femoris. ANKLE JOINT TYPE This is a synovial joint of hinge variety. ARTICULAR SURFACES. The upper articular surface is formed by: 1) The lower end of tibia including medial malleolus. 2) The lateral malleolus of fibula. 3) The inferior transverse tibiofibular ligament. These structures form a deep socket. The inferior articular surface is formed by the articular areas on the upper, medial and lateral aspects of the talus. ANKLE JOINT Structurally the joint is very strong. The stability of the joint is ensured by: A. close interlocking of the articular surfaces. B. strong collateral ligaments on the side. C. the tendons that cross the joint, 4 in front, 3 on posteromedial side and 2 on posterolateral side. The depth of the superior articular socket is contributed by: The downward projection of medial and lateral malleoli on the corresponding sides of talus. By the inferior transverse tibiofibular ligament that bridges across the gap between the tibia and fibula behind the talus. ANKLE JOINT There are 2 factors that tend to displace the tibia and fibula forwards over the talus. These factors are: a. the forward pull of tendons which pass from the leg to the foot.  Displacement is prevented by the following factors. The talus is wedge-shaped, being wider anteriorly. The malleoli are oriented to fit this wedge. The posterior border of the lower end of the tibia is prolonged downwards. The presence of inferior transverse tibiofibular ligament. The deltoid ligament, calcaneofibular and ANKLE JOINT Ligaments Fibrous capsule. The deltoid or medial ligament. Lateral ligament. The interosseous tibiofibular ligament, inferior extensor retinaculum and inferior and superior peroneal retinacula also contribute to the stability of ankle joint. ANKLE JOINT Movements Active movements are dorsiflexion and plantar flexion. In dorsiflexion the forefoot is raised and the angle between the front of the leg and the dorsum of the foot is decreased. There is no chance of dislocation in dorsiflexion. In plantar flexion the forefoot is depressed and the angle between the leg and the foot is increased. High heels JOINTS OF THE FOOT The joints of the foot are numerous. They can be classified as: Intertarsal. Tarsometatarsal, are plane synovial joints. Intermetatarsal, are plane synovial joints. Metatarsophalangeal. JOINTS OF FOOT The main intertarsal joints are subtalar or talocalcanean joint, talocalcaneonavicular joint and the calcaneocuboid joint. Smaller intertarsal joints are cuneonavicular, cuboidonavicular, intercuneiform cuneocuboid joints. These are united by adjoining JOINTS OF FOOT Movements Movements permitted at these joints are: Intertarsal, tarsometatarsal and intermetatarsal joints permit gliding and rotatory movements, which jointly bring about inversion and eversion of foot. Pronation is a component of eversion and JOINTS OF FOOT Movements The metatarsophalangeal joints permit flexion, extension, adduction and abduction of the toes. The interphalangeal joints of hinge variety permit flexion and extension of the phalanges. Muscles producing movements of inversion and eversion. Inversion by Tibialis anterior and Tibialis posterior. Eversion by Peroneus longus and Peroneus brevis. GAIT OR WALKING Gait is a motion which carries the body forward. There are 2 phases of gait, swing and stance. Swing phase. Flexion of hip, flexion of knee and plantar flexion of ankle. Flexion of hip, extension of knee and dorsiflexion of ankle. Stance phase. Flexion of hip, extension of knee and foot on the ground. ARCHES OF FOOT Arches of foot help in fast walking, running and jumping. In addition these help in wait-bearing and in providing upright posture. The foot is really unique to human being. Arches are supported by intrinsic and extrinsic muscles of sole in addition to ligaments, aponeurosis and shape of the bones. The foot has to suffer from ARCHES OF FOOT Classification Longitudinal. Medial. Lateral. Transverse. Anterior. Posterior. FORMATION OR STRUCTURE OF ARCHES MEDIAL LONGITUDINAL ARCHE. This arch is considerably higher, more mobile and resilient than the lateral. This is considered as big arc of small circle. Bones are calcaneus, talus, navicular, three cuneiforms and 1st-3rd metatarsals. The formation is as follow. ENDS. The anterior end is formed by the heads of the 1st, 2nd and 3rd metatarsals. The posterior end is formed by the medial tubercle of calcaneum. Key  SUMMIT. The summit is formed by the superior articular surface of the body of the talus. PILLARS. The anterior pillar is long and weak. It is formed by talus, navicular, 3 cuneiform and 1st 3 metatarsals. The posterior pillar is short and strong. It is formed by medial part of calcaneum. The main joint of the arch is talocalcaneonavicular joint. Lateral Longitudinal arch. This arch is low, with less bones, less joint and has limited mobility, and is built to transmit weight and thrust to the ground. This is considered as a small arc of big circle. This acts as a shock absorber. Bone forming are calcaneus, cuboid and 4th & 5th metatarsals. The formation of lateral longitudinal arch is as follows. ENDS. The anterior end of the arch is formed by heads th th Lateral longitudinal arch SUMMIT. The summit lies at the level of calcaneum. PILLARS. The anterior pillar is long and weak. It is formed by cuboid and 4th & 5th metatarsals. The posterior pillar is short and strong and is formed by the lateral half of the calneum. The main joint of the arch is calcaneocuboid joint. TRANSVERSE ARCH ANTERIOR. It is formed by the heads of 5 metatarsala. ENDS. Heads of 1st and 5th metatarsal. POSTERIOR. It is formed by tarsus and bases of metatarsals. It is incomplete because only the lateral end comes in contact with ground (half dome). It is complete with the half dome of other foot. FEMORAL TIANGLE Femoral triangle is a triangular depression on front of upper 1/3rd of the thigh immediately below the inguinal ligament. BOUNDARIES. Laterally by the medial border of Sartorius. Medially by the medial border of adductor longus. Base by inguinal ligament. The apex is directed downwards and formed by the point where the medial and lateral borders FEMORAL TRIANGLE Boundaries The apex is continuous downwards as adductor canal. The roof is formed by, Skin. Superficial fascia containing superficial inguinal lymph nodes, femoral branch of genitofemoral nerve, branches of the ilioinguinal nerve, branches of femoral artery and upper part of great saphenous vein. Deep fascia. FEMORAL TRINGLE BOUNDARIES The floor of the triangle is formed, Medially by the adductor longus and pectineus. Laterally by the psoas major and iliacus. FEMORAL TRIANGLE Contents Femoral artery and its 6 branches, 3 superficial and 3 deep. Femoral vein and its branches. Femoral sheath. Nerves, femoral, the nerve to the pectineus, the femoral branch of genitofemoral nerve, the lateral cutaneous nerve of the thigh. The deep inguinal lymph nodes. FEMORAL ARTERY It is chief artery of lower limb. It is the continuation of external iliac artery. It begins behind inguinal ligament at midinguinal point. EXTENT AND COURSE. Femoral artery passes downwards and medially, first in the femoral triangle and then in the adductor canal. Femoral artery, Relations in femoral triangle ANTERIOR. Skin, superficial fascia, deep fascia and femoral sheath. POSTERIOR. Psoas major, pectineus and adductor longus. MEDIAL. Femoral vein. LATERAL. Femoral nerve. FEMORAL ARTERY Branches IN THE FEMORAL TRIANGLE. 3 SUPERFICIAL AND 3 DEEP BRANCHES. Superficial external pudendal. Superficial epigastric. Superficial circumflex iliac. Pudenda femoris. Deep external pudendal. Muscular. FEMORAL ARTERY Branches PODENDA FEMORIS ARTERY. It is largest branch of femoral artery, it is chief artery which supply to all 3 components of thigh. It arises from lateral side of femoral artery about 4 cm below inguinal ligament. The origin lies in front of iliacus. The profunda femoris artery gives off the medial and lateral circumflex femoral FEMORAL ARTERY Branches DEEP EXTERNAL PROFUNDA ARTERY. This branch of the femoral artery passes deep to the spermatic cord or the round ligament of the uterus, and supplies the scrotum or the labium majus. MUSCULAR BRANCHES. Numerous muscular branches arise from the femoral and profunda femoris artery, or its branches to supply muscles of thigh. DESCENDING GENICULAR BRANCH is given in FEMORAL VEIN Femoral vein begins as an upward continuation of popliteal vein at the lower end of the adductor canal, and ends by becoming continuous with the external iliac vein behind the inguinal ligament. Tributaries. It receives, The great saphenous vein. Vein accompanying 3 deep branches of femoral artery in femora triangle. Lateral and medial circumflex femoral veins. Descending genicular and muscular veins in the adductor canal. OBTURATOR ARTERY The obturator artery is a branch of internal iliac artery. At the upper margin of the obturator foramen, the obturator artery divides into anterior or medial and posterior or lateral branches which form a circle over the obturator membrane and anastomoses with the medial circumflex femoral artery. Both branches supply the neighbouring muscles, the posterior branch also gives an acetabular MEDIAL CIRCUMFLEX FEMORAL ARTERY The artery arises from the profunda femoris. It leaves the femoral triangle by passing backwards and ends by dividing into ascending and transverse branches. Ascending branch anastomoses with ascending branch of lateral circumflex femoral and superior gluteal artery to form trochanteric anastomoses. Transverse branch anastomoses with transverse branch of lateral circumflex femoral, inferior gluteal and 1st perforating branch of profunda  Before giving off the terminal branches, the artery gives off many muscular branches, and an acetabular branch which passes through the acetabular notch to supply fat in the acetabular fossa. It also sends a twig to the head of the femur along the round ligament, the foveolar artery. SUPERIOR GLUTEAL ARTERY It is a branch of posterior division of internal iliac artery. Superior gluteal artery enters the gluteal region through the greater sciatic foramen, passing above the piriformis. In the foramen it divides into superficial and deep branches. The superficial branch supplies the gluteus maximus. The deep branch subdivides into superior and inferior branches. The superior branch ends by anastomosing with the ascending branch of the lateral circumflex femoral artery. The inferior branch takes part in the trochanteric anastomoses. INFERIOR GLUTEAL ARTERY It is the branch of anterior division of the internal iliac artery. Inferior gluteal artery enters the gluteal region by passing through the greater sciatic foramen, below the piriformis. It supplies: Muscular branches to gluteus maximus and to all the muscles deep to it below the piriformis. Cutaneous branches to the buttock and the back of the thigh. An articular branch to the hip joint. Trochanteric and cruciate anastomotic branches. An artery to the sciatic nerve. A coccygeal branch which supplies the area over coccyx. INTERNAL PUNDENDAL ARTERY It is a branch of the anterior division of internal iliac artery. It enters the gluteal region through the greater sciatic foramen. It crosses the ischial spine and leaves the gluteal region by passing into the lesser sciatic foramen through which it reaches ischioanal fossa. STRUCTURES PASSING THROUGH THE GREATER SCIATIC FORAMEN The piriformis emerging from the pelvis fills the foramen completely. It is the key muscle of the region. Structures passing above the piriformis are: Inferior gluteal nerve. Inferior gluteal vessels. Sciatic nerve. Posterior cutaneous nerve of thigh. Nerve to quadratus femoris. Nerve to obturator internus. Internal pudendal vessels. Pudendal nerve. STRUCTURES PASSING THROUGH THE LESSER SCIATIC FORAMEN Tendon of the obturator internus. Pudendal nerve. Internal pudendal vessels. Nerve to obturator internus. The upper and lower parts of the foramen are filled by the origins of the two gemelli muscles. POPLITEAL FOSSA Popliteal fossa is a shallow diamond-shaped depression lying behind the knee joint at the lower part of the femur and upper part of tibia, felt best at the back of knee joint, when the knee joint is semi flexed. BOUNDARIES. Superolaterally. The biceps femoris. Superomedially. The semitendinosus, semimembranosus, gracilis, Sartorius and adductor magnus. Inferolaterally. Lateral head of the gastrocnemius and the plantaris. POPLITEAL FOSSA Boundaries The ROOF of the fossa is formed by the deep fascia or popliteal fascia and the superficial fascia containing the saphenous vein, the branches and terminal part of posterior cutaneous nerve of thigh, the medial cutaneous nerve of thigh and peroneal or sural communicating nerve. The FLOOR of the fossa is formed by: The popliteal surface of the femur. The capsule of knee joint and oblique popliteal CONTENTS OF POPLITEAL FOSSA The popliteal artery and its branches. The popliteal vein and its tributaries. The tibial nerve and its branches. The common peroneal nerve and its branches. The posterior cutaneous nerve of thigh. The genicular branch of the obturator nerve. The popliteal lymph nodes. The fat surrounds and supports all the above structures. POPLITEAL ARTERY Popliteal artery is the continuation of the femoral artery. It begins at the opening in the adductor magnus or hiatus magnus i.e. at the junction of middle 1/3rd with the lower 1/3rd of thigh. It runs downwards and slightly laterally to reach the lower border of the popliteus. It terminates at the lower border of popliteus by dividing into the anterior and posterior tibial arteries. POPLITEAL ARTERY Branches Several large muscular branches are given off. The upper 2 or 3 muscular branches supply the adductor magnus and hamstrings and terminate by anastomosing with the 4th perforating artery. The lower muscular or sural branches supply the gastrocnemius, soleus and plantaris. Cutaneous branches arise either directly or indirectly from its muscular branches. POPLITEAL ARTERY Branches Genicular branches are 5 in number, 2 superior 2 inferior and 1 middle. The middle supplies the cruciate ligaments and the synovial membrane of knee joint. The medial and lateral superior genicular arteries pass deep to the hamstrings. The medial and lateral inferior genicular arteries pass deep to the collateral ligaments of the knee. All these arteries POPLITEAL VEIN It begins at the lower border of the popliteus by the union of veins. The vein continues as the femoral vein at the opening in the adductor magnus. The popliteal vein receives the small saphenous vein and the corresponding to the branches of the popliteal artery. ANTERIOR TIBIAL ARTERY This is the main artery of the anterior compartment of the leg. The blood supply of anterior compartment of the leg is reinforced by the perforating branch of the peroneal artery. BEGINNING COURSE AND TERMINATION. The anterior tibial artery is the smaller terminal branch of the popliteal artery. It begins on the back of the leg at the lower border of the popliteus, opposite tibial tuberosity. It enters the anterior compartment of leg by passing forwards ANTERIOR TIBIAL ARTERY Branches Muscular branches supply adjacent muscles. Anastomotic branches are given to the knee and ankle. The anterior and posterior tibial recurrent branches take part in the anastomoses round the knee joint. Anterior medial malleolar and anterior lateral malleolar branches take part in anastomoses around the ankle joint. Lateral malleolar network lies just below DORSOLIS PEDIS ARTERY This is the chief palpable artery of dorsum of foot. It is a continuation of anterior tibial artery. The artery begins in the front of the ankle between 2 malleoli. It passes forwards along the medial side of the dorsum of the foot to reach the proximal end of the 1st intermetatarsal space. Here it dips downwards between the 2 heads of 1st dorsal interosseous muscle and ends in DORSALIS PEDIS ARTERY Branches The lateral tarsal artery, supplies to extensor digitorum brevis and neighbouring tarsal joints and ends in the lateral malleolar network. The medial tarsal branches,2 or 3 small twigs which join the medial malleolar network. The arcuate artery arises opposite the medial cuneiform and ends by anastomosing with the lateral tarsal and lateral plantar arteries. It gives off the 2nd,3rd and 4th dorsal metatarsal arteries. The 1st dorsal metatarsal artery arises just before dorsalis pedis artery dips into the sole. It gives a branch to medial side of the big toe and divides into dorsal digital branches for adjacent sides of 1 st & 2nd toes. POSTERIOR TIBIAL ARTERY It begins at the lower border of popliteus, between tibia and fibula deep to the gastrocnemius. It enters the back of the leg by passing deep to the tendinous arch of the soleus. In the leg it runs downwards and slightly medially to reach the posteromedial side of the ankle in midway between the medial malleolus and medial tubercle of the calcaneum. It terminates deep to flexor retinaculum by dividing into POSTERIOR TIBIAL ARTERY Branches The peroneal artery is the largest branch. Several muscular branches for muscles of the back of leg. A nutrient artery to tibia. The anastomotic branches. Terminal branches i.e. medial and lateral plantar arteries. PERONEAL ARTERY It is the largest branch of the posterior tibial artery. It supplies the posterior and lateral compartment of the leg. BRANCHES. Muscular branches to the lateral and posterior compartments. Nutrient artery to the fibula. Anastomotic branches. MEDIAL PLANTAR ARTERY Medial plantar artery is a smaller terminal branch of the posterior tibial artery. It lies along medial border of foot and divides into branches. BRANCHES. Cutaneous to the overlying skin. Three superficial digital branches. LATERAL PLANTAR ARTERY Lateral plantar artery is the larger terminal branch of the posterior tibial artery. At the base of 5th metatarsal bone it gives a superficial branch and then continues as plantar arch. BRANCHES. Muscular branches supply the adjoining muscles. Cutaneous branches. Anastomotic branches. Calcaneal branch. PLANTAR ARCH Plantar arch is formed by the direct continuation of the lateral plantar artery after it has given off the superficial branch and is completed medially by the dorsalis pedis artery. It extends from base of 5th metatarsal to proximal part of 1st intermetatarsal space. BRANCHES OF THE ARCHE. 4 plantar metatarsal arteries run distally, 1 in each intermetatarsal space, dividing into 2 plantar digital branches for adjacent sides of 2 digits. The 1st artery also gives off a branch to the medial side of the big toe. The lateral side of the PLANTAR ARCH Branches The plantar arch gives off 3 proximal perforating arteries. ANTERIOR ABDOMINAL WALL In the anterior median plane the anterior wall extends from xiphoid process to the pubic symphysis. Posteriorly and laterally the vertical extent of the abdominal wall is much less. The superolateral margins of the anterior abdominal wall are formed by the right and left costal margins. Each margin is formed by the 7th 8th 9th and 10th costal cartilages. The infrasternal or subcostal angle is formed between the right and left costal margins. The xiphoid process lies in a depression at the apex of the infrasternal angle at the level of the 9th thoracic vertebra. The iliac crest forms the lower limit of the abdominal wall at the side. The highest point of the iliac crest lies at the level of the 4th lumbar vertebra slightly below the normal level of umbilicus. ANTERIOR ABDOMINAL WALL Boundaries The ASIS lies at the level of the sacral promontory. The tubercle of the iliac crest is situated on the outer lip of the iliac crest about 5 cm of ASIS. The inguinal ligament extends from the ASIS to the pubic tubercle. It is placed at the junction of the anterior abdominal wall with the front of the thigh. Spermatic cord is a soft rounded cord present in the male. It can be felt through the skin near the ANTERIOR ABDOMINAL WALL Boundaries Anterior abdominal wall is divided into right & left halves by a vertical groove. It marks position of underlying linea alba. A little below the middle of the median furrow, there is an irregular depressed or elevated area called the umbilicus. It lies at level of junction between 3rd & 4th lumbar vertebrae. A few cms lateral to the median furrow, the abdominal wall shows a curved vertical groove. Its upper end reaches the costal margin at the 9 th ANTERIOR ABDOMINAL WALL Boundaries The angle between the last rib and outer border of erector spinea is known as the renal angle. It overlies the lower part of kidney. The 12th rib may only be just palpable lateral to the erector spinea. PSIS lies about 4 cm lateral to the median plane. 3 transverse furrows may be seen crossing the upper part of rectus abdominis. One lies opposite to umbilicus, the other opposite free end of xiphoid process and the third midway between the 2. ANTERIOR ABDOMINAL WALL Boundaries The transpyloric plane is an imaginary transverse plane often referred to in anatomical description. Anteriorly it passes through the tips of the 9th costal cartilages and posteriorly through the lower part of body of 5th lumbar vertebra. This place lies between the suprasternal notch and the pubic symphysis. It is roughly a hand’s breadth below the xiphisternal joint. It passes through pylorus of stomach, hila of SKIN AND THE SUPERFACIAL FASCIA The skin of the anterior abdominal wall is capable of underlying enormous stretching as seen in pregnancy; with accumulation of fat, called obesity or of fluid called ascites, and with growth of large abdominal tumours. Undue stretching may result in the formation of whitish streaks in the skin of the lower part of the anterior abdominal wall; these are known as lineae albicantes. SUPERFICIAL FASCIA Below the level of umbilicus the superficial of the anterior abdominal wall is divided into a superficial fatty layer, fascia of Camper, and a deep membranous layer, fascia of Scarpa. The various contents of the superficial fascia run between these 2 layers. In the penis it is devoid of fat, and in the scrotum it is replaced by the dartos Muscles of the Anterolateral Abdominal wall External Oblique Muscle. Internal Oblique Muscle. Transversus Abdominis Muscle. Rectus Abdominis Muscle. Action of Muscles of Anterior Abdominal Wall SUPPORT FOR ABDOMINAL VISCERA. The abdominal muscles provide a firm but elastic support to the abdominal viscera against gravity. This is chiefly due to tone of the oblique muscles, especially the internal oblique. EXPULSIVE ACTS. The oblique muscles, assisted by transversus, can compress the abdominal viscera and thus help in all expulsive acts, like micturition, defaecation, parturition, vomiting etc. this is one Action of muscles of anterior abdominal wall FORCEFUL EXPIRATORY ACT. The external oblique can markedly depress and compress the lower part of the thorax producing forceful expiration as in coughing, sneezing, blowing shouting etc. MOVEMENTS OF THE TRUNK. Flexion of the trunk or lumber spine is brought about mainly by the rectus abdominis. Lateral flexion of the trunk is done by one-sided contraction of the oblique muscles. Rotation of the trunk is produced by a combined action of external oblique with the opposite internal oblique. INGUINAL LIGAMENT The inguinal or Poupart’s ligament is formed by the lower border of external oblique aponeurosis which is thickened and folded backwards on itself. It extends from ASIS to the pubic tubercle, and lies beneath the CREMASTER MUSCLE The muscle is fully developed only in male. In the female, it is represented by a few fibers only. The cremaster helps to suspend the testis and can elevate it. The muscle also tends to close the superficial inguinal ring when intra- abdominal pressure is raised. Upon stroking the skin of the upper part of the medial side of the thigh, there is reflex contraction of cremaster muscle, as evidenced by elevation and retraction of testis. The reflex is PYRAMIDALIS It is small triangular muscle. It is rudimentary in human being. It is said to be tensor of the linea alba, but the need for such action is not clear. CLINICAL ANATOMY While examining the abdomen knees and hips must be flexed to relax the abdominal muscles. Muscles of anterior abdominal wall contract during expiration. Due to lack of exercise, tone of muscles of the anterior abdominal wall decreases leading to protrusion of wall. RECTUS SHEATH Rectus sheath is an aponeurotic sheath covering the rectus abdominis. Rectus sheath is formed by decussating fibers from 3 abdominal muscles of each side. Each forms a bilaminar aponeurosis at their medial borders. Fibers from all 3 anterior leaves run obliquely upwards, while the posterior fibers run obliquely downwards at right POSTERIOR ABDOMINAL WALL Abdominal Aorta. Inferior vena cava. Muscles of the posterior abdominal wall and thoracolumbar fascia. Nerves of the posterior abdominal wall including lumbar POSTERIOR ABDOMINAL WALL ABDOMINAL AORTA. The abdominal aorta begins in the midline at the aortic opening of the diaphragm, opposite the lower border of T12 vertebra. It runs downwards and slightly to the left in front of the lumbar vertebrae, and ends in front of the lower part of body of 4th lumbar vertebra, by dividing into left and right common iliac arteries. Aortic pulsations can be felt in the region of umbilicus, ABDOMINAL AORTA Branches Ventral branches. Coeliac trunk. Superior mesenteric artery. Inferior mesenteric artery. Lateral branches. Inferior phrenic arteries. Middle suprarenal arteries. Renal arteries. Gonadal (Testicular or ovarian) arteries. ABDOMINAL AORTA Branches Dorsal branches. Lumber arteries-four in pair. Median sacral artery-unpaired. Terminal arteries. Left common iliac artery. Right common iliac artery. INFERIOR VENA CAVA The inferior vena cava is formed by the union of the right and left common iliac veins on the right side of the body of L5 vertebra. It ascends in front of the vertebral column, on the right side of the aorta, grooves the posterior surface of the liver, pierces the central tendon of the diaphragm at the level of the T8 vertebra, and opens into the INFERIOR VENA CAVA Tributaries The common iliac veins. The 3rd and 4th lumbar veins. The right testicular or ovarian (gonadal vein). The renal veins (left and right). The left gonadal vein and left suprarenal veins join the left renal vein. The right suprarenal vein. The hepatic veins 3 and many small veins LYMPH NODES OF POSTERIOR ABDOMINAL WALL These are the external iliac, common iliac and lumbar or aortic nodes. They receive afferent from:- Inguinal lymph nodes. Deeper layers of infraumblical part of the anterior abdominal wall. Adductor region of the thigh. Glans penis or clitoris. Membranous urethra. Prostate. Cervix of uterus. Parts of the vagina. MUSCLES OF THE POSTERIOR ABDOMINAL WALL These are the psoas major, psoas minor, iliacus and quadratus lumborum. Some additional facts about the psoas major are given here, that, the psoas major lies in 3 regions, namely lowest part of thorax, posterior abdominal wall and anterior compartment of the thigh. NERVES OF THE POSTERIOR ABDOMINAL WALL LUMBAR PLEXUS. Iliohypogastric nerve. Ilioinguinal nerve. Genitofemoral nerve. Lateral cutaneous nerve of thigh. Femoral nerve. Obturator nerve. Lumbosacral trunk. LUMBOSACRAL TRUNK The lumbosacral trunk, ventral rami of L4,5, is formed by union of the descending branches of L4 with nerve L5. In the pelvis, it takes part in the formation of sacral plexus. THORACOLUMBAR FASCIA OR LUMBAR FASCIA Lumbar fascia is the fascia enclosing the deep muscles of the back. It is made up of 3 layers, posterior, middle and anterior. The posterior layer is thickest and anterior is thinnest. EXTENT. The posterior layer covers the loin and is continued upwards on the back of thorax and neck. The middle and anterior layers Thoracolumbar fascia posterior layer Medially posterior layer is attached to tips of lumbar and sacral spines and the interspinous ligaments. Laterally it blends with middle layer at the lateral border of erector spines. Superiorly it continues onto the back of thorax where it is attached to vertebral spines and angles of ribs. Inferiorly it is attached to posterior 1/4th of Thoracolumbar fascia