L2 Thigh PDF Lecture Notes

Thigh Moore pp. 680-687, 696-708, 713-726, 738-741 John Gassler DPT DOSYS 701 Lecture 2, January 8, 2025 2  Learning Objectives At the end of this lecture the student will be able to: Iden...

Thigh Moore pp. 680-687, 696-708, 713-726, 738-741 John Gassler DPT DOSYS 701 Lecture 2, January 8, 2025 2  Learning Objectives At the end of this lecture the student will be able to: Identify and describe the superficial nerves and veins of the thigh region. Name the boundaries of the femoral triangle, its contents and their relationships in it. Name and describe the attachments, nerve supply and actions of the muscles of the thigh. Name, identify, and describe the course and relationships of the named nerves and blood vessels in the thigh. 3 3  Distal Femur Anterior Posterior Linea aspera Medial and lateral condyles Medial and lateral epicondyles Intercondylar notch Adductor tubercle Adductor tubercle Medial and lateral condyles Medial and lateral epicondyles Adductor tubercle 4 Patellar articular surface Gilroy Fig 31.4B, p. 406 4  Proximal Tibia and Fibula Head of fibula Medial and lateral condyles Superior tibiofibular joint Tibial plateau Tibial tuberosity Moore Fig 7.10, p. 685 Intercondylar region 5  Knee Joints Lateral Anterior Lateral epicondyle Tibiofemoral Patellofemoral Superior Tibiofibular Gilroy Fig 32.2A, p. 428 Gilroy Fig 32.2C, p. 429 6 6 Great Saphenous V. 7 7 Great Saphenous Vein 8 8  Saphenous Hiatus Hiatus is an opening in the fascia lata in femoral triangle Greater saphenous v. ascends across medial thigh Passes through Great Saphenous v. saphenous hiatus Drains into femoral v. 9 Gilroy Fig 34.26A, p. 480 9  Inguinal Lymph Nodes Gilroy Fig 34.29, p. 482 10 10  Superficial Lymphatic Drainage Superficial lymphatic drainage is to popliteal nodes in the popliteal fossa and superficial inguinal nodes in the femoral triangle Popliteal nodes drain to deep inguinal nodes All inguinal nodes drain to external iliac nodes 12 Moore Fig 7.17, p. 701 11  Cutaneous Nerves of Thigh Anterior cutaneous branches A Lateral femoral cutaneous n. Anterior cutaneous branches (from femoral n.) Saphenous n. (from femoral n.) 12 Gilroy Fig 34.26A, p. 480 12  Cutaneous Nerves of Thigh Anterior cutaneous br. Femoral Lateral femoral cutaneous n. nerve Anterior cutaneous br. (from femoral n.) Saphenous n. (from femoral n.) Posterior femoral cutaneous n. Gilroy Fig 34.27A, p. 481 13 13  Thigh Compartments Anterior Medial Thigh mm. are divided into compartments by intermuscular septa that extend from the fascia lata to the femur Posterior 14 Gilroy Fig 35.1A, p. 494 Gilroy Fig 35.1A, p. 494 14  Anterior Compartment Iliopsoas Hip Sartorius flexion Pectineus Rectus Femoris Quadriceps Vastus medialis Knee femoris Vastus intermedius extension Vastus lateralis Nerve: Femoral (L2,3,4) 15 Gilroy Fig 31.11A, p. 412 15  Iliopsoas m. -Psoas Major m. -Anterior rami L1,2,3 -Iliacus m. -Femoral n. I: Lesser trochanter of femur A: Flex thigh at hip joint Iliopectineal (iliopsoas) bursa 16 Netter Plate 505 Gilroy Fig 31.18, p. 419 16  Pectineus O: Superior ramus of pubis I: Pectineal line on femur Pectineus Action: Flexion and adduction of thigh at hip joint Lesser trochanter Pectineal line 17 Gilroy Fig 31.11A, p. 412 17  Sartorius m. Rectus Femoris m. Sartorius Sartorius O: ASIS Rectus femoris I: Pes anserinus Action: Flexion, abduction, lateral rotation of thigh (hip), flexion of leg (knee) Rectus femoris O: AIIS I: Patella Action: Flexes thigh (hip), extends leg Gilroy Fig 31.23B (knee) 18 18  Pes Anserinus - Anserine bursa S G T Anserine bursa S GT Pes anserinus attaches to the medial tibia inferior to the medial tibial condyle 19 Netter Plate 516 Moore Fig 7.27, p. 719 19 Pes Anserinus 20 20  Vasti Mm. Vastus medialis and lateralis O: Linea aspera on femur I: Patella via quadriceps tendon Vastus medialis Vastus intermedius Vastus intermedius O: shaft of femur Vastus lateralis I: Patella via quadriceps tendon Action: All three muscles extend the leg at the knee joint 21 Gilroy Fig 31.23C p. 424 21 Quadriceps Tendon Patellar Ligament Patella is a sesamoid bone All four quadriceps muscles form a common tendon - Quadriceps tendon attaches to patella Patellar ligament attaches to the tibial tuberosity 22 Gilroy Fig 31.23B, p. 424 22 Medial Compartment Gracilis m. Adductor longus Adductor brevis Adductor magnus O: Body of pubis, inferior pubic ramus Nerve: Obturator (exception – part of adductor magnus) Gilroy Fig 31.13, p. 415 23 23  Medial Compartment Pectineus Adductor Longus m. Gracilis O: Body of pubis O: Body of pubis I: Linea aspera on femur I: Pes anserinus (medial Action: adducts thigh at hip joint tibia) Action: Adducts thigh (hip), Flexes tibia (knee) 24 Gilroy Fig 31.11C, p. 413 24 Medial Compartment Obturator Externus Adductor Brevis Adductor Brevis m. O: Pubis I: Linea aspera on femur Action: adducts thigh at Adductor Magnus hip joint Gilroy Fig 31.11D, p. 413 25 25  Adductor Magnus m. Adductor part: O: Ischiopubic ramus I: Linea aspera on femur Action: Adducts thigh at hip joint Hamstring part: O: Ischial tuberosity I: Adductor tubercle Action: Extends thigh at hip joint Gilroy Fig 26.22B, p. 401 26 26 Adductor Magnus m. Posterior View Innervation -Adductor part -Obturator n. -Hamstring part -Sciatic n. (Tibial) Gilroy Fig 31.14D, p. 417 27 27 Posterior Thigh -Semitendinosus m. -Semimembranosus m. -Biceps Femoris m., long head -Tibial n. -Biceps Femoris m., short head -Common Fibular n. Gilroy Fig 31.14A, p. 416 28 28 Posterior Thigh Mm. -Semitendinosus m. -Semimembranosus m. -Biceps Femoris m., long head O: Ischial tuberosity Gilroy Fig 31.24B, p. 425 29 29 Posterior Thigh mm. Semitendinosus O: Ischial tuberosity I: Pes anserinus on tibia Semimembranosus O: Ischial tuberosity I: Posterior medial condyle of tibia Biceps Femoris m., short head O: Linea aspera on posterior femur I: Head of fibula (both heads) 30 Gilroy Fig 31.24C, p. 425 30  Hamstrings Distal attachments Action: Extend thigh (hip), Flex leg (knee) Additionally: with knee Popliteal fossa joint flexed to 90o, medial hamstrings can medially rotate the leg, b. femoris can laterally rotate the leg (Medial tibia) (Biceps femoris) (Semitendinosus) 31 Gilroy Fig 31.24B, p. 425 31  Iliotibial Tract Biceps Femoris Distal Attachment Lateral tibial tubercle Gilroy Fig 31.16, p. 419 32 32  Retro-inguinal Structures entering the anterior Space thigh deep to the inguinal ligament Iliopsoas m. Pectineus m. Femoral nerve Femoral a. and v. Lateral femoral cutaneous n. Lymph vessels Moore Fig 7.29A, p. 721 33 33  Femoral Triangle Boundaries: -Inguinal ligament -Lateral border of adductor longus m. -Medial border of sartorius m. Floor: -iliopsoas m. -pectineus m. Roof -Fascia lata Moore Fig 7.30, 722 34 34 Femoral Triangle Contents -Femoral n. -Femoral a. -Femoral v. -Lymph nodes (NAVL) * (Lateral to Medial) Femoral Sheath Femoral artery Femoral vein Femoral canal *Femoral canal – medial to femoral v. Moore Fig 7.29B, p. 721 35 35 Femoral Hernia Moore Fig B7.17, p. 730 36 36  Nerve Supply Anterior Thigh Femoral N. L2,3,4 Medial Thigh Obturator N. L2,3,4 (except tendinous part of adductor magnus) Gilroy Fig 34.34B, p. 486 37 Andrew N. Fleischman MD, Richard H. Rothman MD, PhD, Javad Parvizi MD, FRCS. Femoral Nerve Palsy Following Total Hip Arthroplasty: Incidence and Course of Recovery https://doi.org/10.1016/j.arth.2017.10.050 J. Arthroplasty 33(4):1194- 199, 2018 37  Femoral Nerve L2,3,4 Anterior rami of L2-4 Travels between iliacus and psoas major mm. Travels under inguinal ligament Saphenous n. Enters femoral triangle Sensory Anterior femoral cutaneous Saphenous Motor All anterior compartment mm. - muscular branches 38 Gilroy Fig 34.16, p. 475 38  Femoral n. -Saphenous n. Travels in adductor canal with femoral a. and v. Does not go through adductor hiatus Innervates skin on anterior knee and medial side of leg Saphenous n. Gilroy Fig 34.16, p. 475 39 39 John D. Hermann, DO 40 40 Obturator Nerve Obturator canal Superior pubic ramus Netter Obturator membrane Plate357 41 41  Obturator n. L2,3,4 Travels in lateral wall of pelvis Leaves pelvis through obturator canal Splits into anterior and posterior branches Branches travel anterior and posterior to adductor brevis m. 42 Gilroy Fig 34.15, p. 474 42  Sciatic Nerve in Thigh Muscular branches: - Tibial N. Semitendinosus Semimembranosus Long head of biceps f. Hamstring part of adductor magnus - Common Fibular N. Short head of biceps f. 43 Gilroy Fig 34.35B, p. 487 43  Obturator Artery Small artery in thigh that provides blood supply to origins of muscles attaching to pubis and ischium, and to head of femur Gives off branch that runs in ligament of the head of the femur (artery of ligament of head of femur) Gray’s Fig 6.65, p. 602 44 44 Femoral Artery Proximal branches supply skin in anterior abdominal and inguinal regions, and external genitalia Netter Plate 509 45 45  Femoral Artery Deep femoral a. (deep artery of the thigh, profunda femoris a.) Femoral a. and v. Adductor canal Netter Plate 509 46 46  Deep Femoral A. -Lateral femoral circumflex -ascending -descending Circumflex femoral -transverse arteries arise from femoral a. above -Medial femoral circumflex bifurcation, at bifurcation, or from either the femoral or -Perforating deep femoral aa. after -3 to 4 branches the bifurcation The deep femoral a. and its branches * are the major blood supply to thigh muscles Netter Plate 510 47 47  Perforating Branches to Posterior Thigh Perforating branches from profunda femoris a. pierce the adductor magnus m. near femur Blood supply to hamstring and skin of posterior thigh Inferior gluteal and medial femoral circumflex aa. also supply proximal posterior compartment (cruciate anastomosis) 48 Gray’s Fig 6.64, p. 601 48 Adductor Canal (Sub-sartorial Canal) Contents entering: Femoral a. Femoral v. Saphenous n. Saphenous n. enters canal but does not pass through adductor hiatus (leaves adductor canal) Gilroy Fig 34.34B, p. 486 49 49  Adductor Canal Moore Fig 7.33, p. 725 50 50  Femoral Artery Femoral a. and v. pass through Adductor hiatus adductor hiatus to enter popliteal fossa 51 Gilroy Fig 34.1A, p. 466 51