Morph Plan LL 22-23(1).pptx

Morphological Plan of the Lower Limb Dr Catherine Hennessy [email protected] Learning Outcomes • Describe the skeletal organisation of the lower limb. • Describe the movements of the lower limb. • Describe the muscle compartments of the lower limb. • Describe the anatomy of the gluteal region...

Morphological Plan of the Lower Limb Dr Catherine Hennessy [email protected] Learning Outcomes • Describe the skeletal organisation of the lower limb. • Describe the movements of the lower limb. • Describe the muscle compartments of the lower limb. • Describe the anatomy of the gluteal region and thigh. • Describe the nerve and blood supply to the lower limb. Lower Limb versus Upper Limb Lower limbs closer together / under trunk Adapted for locomotion – weight bearing and high stress Medial rotation during development brings posterior compartment anterior Extensors are anterior Flexors are posterior Week 68 Skeleton Pelvis Femur Fibula Tibia Tarsal bones (x7) Metatarsals (x5) Phalanges (x14) Pelvis Acetabulum Sacroiliac joints Ant Superior Iliac spine Greater sciatic notch Greater sciatic foramen Sacrotuberous ligament Ant Inferior Iliac spine Pubis Sacrospinous ligament Ischiopubic Ischial tuberosity ramus Obturator foramen Ilium Femur Posterior Anterior Head Greater trochanter Neck Lesser trochanter Gluteal tuberosity Linea aspera Adductor tubercle Lateral epicondyle Medial epicondyle Lateral/medial condyles Tibia, Fibula and Foot Lateral and medial condyles Tarsals Tibial tuberosity Metatarsals 5 1 Lateral malleolus Medial malleolus Phalanges Limb Movements Flexion/Extension Abduction/Adduction Lateral (external) /medial (internal) rotation Circumduction No opposition! Joints and Movements Hip joint Knee joint Joints and Movements Ankle joint Dorsiflexion (or extension) Dorsal surface of foot Plantar surface of foot Plantarflexion (or flexion) Joints of the foot Medial Inversion, eversion Extension, flexion Functional Compartments Gluteal Thigh: Anterior (Extensors of knee joint) Posterior (Flexors of knee joint) Medial (Adductors of hip joint) Leg: Anterior (Extensors of the ankle joint) Posterior (Flexors of the ankle joint) Lateral (Evertors of the ankle joint) Foot Examine in this lecture Gluteal Region and Thigh Gluteal Muscles Three major muscles: S D - Gluteus maximus - Extension + lateral rotation of the hip joint - Gluteus medius - Abduction + medial rotation - Gluteus minimus - Abduction + medial rotation Gluteus maximus also supports the extended knee via iliotibial tract Important muscles for locomotion Gluteus Maximus Origin: Sacrum and Ilium Tensor fascia lata Gluteus maximus Tensor Fascia Lata Inserts: - Gluteal tuberosity - Iliotibial tract Origin ASIS Insertio n IT tract Action Stabilises the knee joint NS Origin Superior gluteal Gluteus Maximus nerve Posterior ilium and sacrum Insertion Gluteal tuberosity of femur Iliotibial tract Action Extension and lateral rotation of the hip joint Gluteus Medius and Minimus Origin: Ilium Gluteus medius Insert: Greater trochanter Gluteus minimus (deeper) Gluteus maximus Gluteus Medius and Minimus Origin Posterior ileum Insertion Greater trochanter of femur Action Abduction and medial rotation of the hip joint Small Muscles of the Gluteal Region Equivalent to rotator cuff - Stabilize hip - Lateral rotation of the hip joint Origin: sacrum Piriformis Origin Sacrum Insertion Greater trochanter of femur Action Lateral rotation of the hip joint Nerve Supply S1 and S2 Piriformis Insert: Greater trochanter * Gemellus superior Obturator internus Gemellus inferior Quadratus femoris Note sciatic nerve under piriformis Ischial tuberosity Anterior Compartment of the Thigh Quadriceps - Extension of the knee joint - Flexion of the hip joint (Rectus femoris only) Sartorius (anterior superior iliac spine to tibia) Origin: anterior inferior iliac spine + femur 1. Rectus femoris 2. Vastus lateralis Insert: Tibial tuberosity 3. Vastus medialis 4. Vastus Intermedius (behind rectus femoris) Supplied by femoral nerve Quadriceps Anterior inferior iliac spine 1. Rectus femoris 2. Vastus lateralis 3. Vastus medialis 4. Vastus Intermedius Quadriceps tendon Patella Patellar ligament Tibial tuberosity Anterior Compartment of the Thigh Quadriceps Origin Rec fem: AIIS and above acetabulum Vastus L/M: Linea aspera (posterior femur) Vastus I: Anterior thigh Insertion Tibial tuberosity Action Extension of the knee joint Flexion of the hip joint (RF only) Nerve Supply Femoral nerve Sartorius Origin ASIS Insertion Superior medial tibia Action Flexion of hip joint External rotation of hip joint Flexion of knee joint Nerve Supply Femoral nerve Posterior Compartment of the Thigh Hamstrings - Extension of the hip joint - Flexion of the knee joint - Medial rotation of the knee joint - Lateral rotation of the knee Origin: ischial tuberosity joint Biceps femoris Long head Short head Origin: Femur Semimembranosus Semitendinosus Insert: tibia Supplied by sciatic nerve fibula Posterior Compartment of the Thigh Semimembranosus Biceps Femoris Origin LH: Ischial tuberosity SH: Posterior femur Insertion Head of the fibula Action Extension of hip joint Flexion of knee joint Lateral rotation of the knee joint Nerve Supply Sciatic nerve Origin Ischial tuberosity Insertion Posterior aspect of medial tibial condyle Action Extension of hip joint Flexion of knee joint Medial rotation of the knee joint Nerve Supply Sciatic nerve Semitendinosus Origin Ischial tuberosity Insertion Superior medial tibia Action Extension of hip joint Flexion of knee joint Medial rotation of the knee joint Nerve Sciatic nerve Medial Compartment of the Thigh Adductors - Adduction of the hip joint - Medial rotation of the hip joint Origin: Pubis Insert: Linea aspera Superficial Pectineus Adductor Longus Gracilis Supplied by obturator nerve (except pectineus) Medial Compartment of the Thigh Adductors - Adduction of the hip joint - Medial rotation of the hip joint Origin: pubis Mid Adductor Brevis Insert: Linea aspera Supplied by obturator nerve Medial Compartment of the Thigh Adductors - Adduction of the hip joint - Medial rotation of the hip joint - Extension of the hip joint Deep (hamstring part) Origin: pubis and ischium Adductor Magnus  Adductor part (ischiopubic ramus to linea aspera) Adductor hiatus  Hamstring part Insert: Linea aspera (ischial tuberosity to adductor tubercle) * * Supplied by obturator nerve (ad part) and sciatic nerve (ham part) Medial Compartment of the Thigh Adductor Longus and Brevis Pectineus Origin Pubis (Brevis is deeper) Origin Pubis Insertion Linea aspera of the femur Insertion Action Adduction, flexion and medial rotation of hip joint Femur (below the lesser trochanter) Action Nerve Supply Obturator nerve Adduction and flexion of hip joint Nerve Supply Femoral nerve Adductor Magnus Gracilis Origin Pubis Insertion Superior medial tibia Action Adduction of hip joint Flexion of knee joint Nerve Supply Obturator nerve Origin Ad part: Ischiopubic ramus Hm part: Ischial tuberosity Insertion Ad part: Linea aspera of femur Hm part: Adductor tubercle of femur Action Ad part: Adduction and flexion of hip joint Hm part: Extension of the hip joint Nerve Supply Ad part: Obturator nerve Movements of the Hip Joint FLEXION Rectus femoris Sartorius Iliopsoas (Iliacus and psoas major) EXTENSION Gluteus maximus Hamstrings Hamstring part of adductor magnus Insert: lesser trochanter ABDUCTION Gluteus medius Gluteus minimus ADDUCTION Adductor longus Adductor brevis Adductor part of adductor magnus Pectineus Gracilis MEDIAL and LATERAL ROTATION Gluteal muscles, hamstrings, adductors and short rotators Hip Flexors Iliacus Psoas Major Origin Iliac fossa Origin Insertion Lesser trochanter of the femur Bodies and transverse processes of T12 –L5 Insertion Lesser trochanter of the femur Action Flexion of hip joint Flexion of the trunk Action Flexion of hip joint Flexion of the trunk Nerve Supply Femoral nerve Nerve Supply L1 and L2 Blood and Nerve Supply Nerve Supply L1 L2 L3 LUMBAR PLEXUS Anterior rami L1 to L4 L4 L5 S1 S3 Femoral nerve (L2-L4) SACRAL PLEXUS Anterior rami L4 and L5 (via lumbosacral trunk) Anterior rami S1 to S4 Obturator nerve (L2-L4) Sciatic nerve (L4-S3) Femoral Nerve From lumbar plexus Inguinal ligament Femoral nerve (L2-L4) Saphenous nerve (Sensory – medial leg/foot) Motor: Anterior compartment of thigh Sensory: Skin over anterior thigh, knee, medial side of leg and foot Obturator Nerve From lumbar plexus Obturator foramen Motor: Medial compartment of thigh (except pectineus and hamstring part of adductor magnus) Sensory: Skin over medial thigh Obturator nerve (L2-L4) Sciatic Nerve From sacral plexus Greater sciatic foramen Sciatic nerve (L4-S3) Popliteal fossa Tibial nerve Sural nerve (sensory – lateral foot) Common fibular / peroneal nerve Superficial fibular Deep fibular Motor: Posterior compartment of thigh, and leg and foot (+hamstring part of adductor magnus) Sensory: Skin over leg and foot (except medial side) Blood Supply External iliac artery Inguinal ligament Femoral artery thigh) - Profunda femoris artery (to posterior Adductor hiatus Popliteal artery Anterior and posterior tibial arteries Femoral Triangle Femoral artery enters femoral triangle Femoral nerve LATERAL Femoral nerve Sartorius Inguinal ligament Femoral artery/vein Femoral artery Femoral vein Adductor longus Lymphatics Femoral sheath Femoral canal Clinical: Femoral hernia (femoral canal), angioplasty, femoral nerve block, venepuncture Femoral Artery Femoral artery runs under sartorius before passing through the adductor hiatus Anterior Femoral artery Adductor magnus Adductor hiatus Popliteal Vessels Femoral artery enters the popliteal fossa as the popliteal artery Posterior Sciatic nerve Popliteal artery Popliteal fossa Medial Tibial Arteries Popliteal artery divides in leg as anterior/posterior tibial arteries Popliteal artery Anterior tibial artery - Anterior compartment of leg Tibial nerve Posterior tibial artery - Posterior compartment of leg Deep flexors Posterior Posterior tibial artery Flexor retinaculum Medial Venous Drainage Deep veins follow arteries Two major superficial veins: Great or long saphenous vein Small or short saphenous vein Drain from the dorsal venous arch of foot Clinical: Varicose veins - Damage to valves in perforating veins leads to pooling of blood in superficial veins – varicosities - Perforating veins connect superficial to deep veins Great Saphenous Vein Longest vein in body Drains medial side of arch Medial side of limb Great saphenous vein Drains into femoral vein in femoral triangle Dorsal venous arch Short/small Saphenous Vein Drains lateral side of arch Pierces deep popliteal fascia Drains into popliteal vein Short saphenous vein Lymphatic Drainage Follows general pattern of superficial and deep veins Superficial inguinal nodes Drain skin and superficial fascia of lower limb Deep inguinal nodes Beside femoral vein Dermatomes of the Lower Limb L1 L2 L3 S2 S1 L4 L5 S1 L5