Snell's Clinical Anatomy Lower Limb Chapter 11 PDF

n 18-year-old student was doing part-time work The attending physician made the diagnosis of paralysis A delivering pizzas on his motorcycle. His boss insisted on quick delivery, so the student tended to weave in and out of traffic whenever there was a holdup. On o...

n 18-year-old student was doing part-time work The attending physician made the diagnosis of paralysis A delivering pizzas on his motorcycle. His boss insisted on quick delivery, so the student tended to weave in and out of traffic whenever there was a holdup. On one occasion, of the common fibular nerve secondary to blunt trauma to the lateral side of the left fibula. The radiographic examina- tion Nied out the possibility of fracture of the neck of the he misjudged the gap between two vehicles, and a car bumper fibula. violently struck the outer surface of his left knee. Examination in To be in a position to make such a diagnosis, physicians the emergency department showed he had extensive paralysis must be cognizant of the detailed anatomy of the course of of the musdes of the anterior and lateral compartments of the the common fibular nerve as it winds around the outer side left leg. A:s a result. the patient was unable to dorsiflex the of the neck of the fibula. Knowledge of the distribution of the ankle joint (which showed footdrop} and avert the foot. In addi- branches of this nerve enables physicians to eliminate other tion, he had diminished sensation down the anterior and lateral nerve injuries. Moreover, they are able to assess the degree of sides of the leg and tops of the foot and toes, including the nerve damage by testing the strength of the various muscles medial side of the big toe. A series of radiographs of the knee supplied by this nerve and conducting suitable tests to assess region showed no evidence of bone fractures. the sensory deficits. CHAPTER OUTLINE Overview Thigh Fascia! Compartments and Lymph Vessels Olteology Muscles Leg Fascia! Compartments and Os Coxae Anterior Fascia! Compartment Muscles Femur Contents Anterior Fascia! Compartment Patella Medial Fascia! Compartment Contents Tibia Contents Lateral Fasclal Compartment Fibula Posterior Fascia! Compartment Contents Foot Bones Contents Posterior Fascial Compartment Contents Gluteal Region PopUteal Fossa Skin Boundaries Ankle Fascia Muscles Anterior Aspect Llgaments and Popllteal Artery Posterior Aspect Foramlna Arterial Anastomosis around Knee Gluteal Region Muscles Joint Foot Gluteal Region Nerves Popllteal Vetn Sole Gluteal Region Arteries Popllteal Lymph Nodes Dorswn Nerves Thigh Joints Fascia Leg Hip Joint Cutaneous Nerves Fascia Knee Joint Superficial Veins Cutaneous Nerves Proximal Tibtofi.bular Joint Inguinal Lymph Nodes Superficial Veins Distal Tibiofibular Joint 512  Osteology 513 Ankle Joint Foot as Functional Unit Inguinal Region Tarsal Joints Arches Femoral Triangle Tarso111etatarsaland Foot Propulsive Action Adductor Canal Intennetatarsal Joints Knee Region Metatarsophalangeal Radiographic Anatomy Tibia and Interphalangeal Surface Anatomy Ankle Region and Foot Joints Gluteal Region LEARNING OBJECTIVES The purpose of thls chapter Is to review the anatomy of the femoral sheath, canal, and ring. Describe the the lower limb in relation to common clinical conditions. anatomical basis of a femoral hernia. 9. Define the boundaries of the popliteal fossa 1. Identify the prbnary regions of the lower llmb and and describe its contents. Note the spatial the defining boundaries of each. relationships of the major neurovascular 2. Identify the bones of the lower ltmb and their structures in the fossa. Identify the main major features. Describe the functional aspects of components of the arterial anastomoses around these structures. the knee. 3. Identify the muscles of the gluteal region, 10. Trace the 8ow of blood from the common iliac Indicating their attachments, innervation, and artery through the lower limb. Note: major actions. Note the roles of the gluteal a. The different sources of arterial supply, their muscles during locomotion. pathways, and their maJor branches 4. Describe the topographic relationships of the b. The significance of the obturator canal, fem~ neurovascular structures In the gluteal region and ral sheath, adductor canal, adductor hiatus, the consequences of intragluteal injections into greater sciatic foramen, and lesser sciatic specific quadrants of the region. foramen 5. Describe the arrangement and mechanical c. The composition and significance of the crucl- significance of the deep fascia in the lower ate anastomosis limb. Identify the fascia lata, lllotlbial tract, and d. The territories supplled by and the pathways lntennuscular septa In the hip and thigh. of the maJor peripheral vessels 6. Define the osseofasclal co111partlllents of the 11. Trace the venous drainage of the lower lbnb lower lbnb. through the saphenous tract to the pelvic cavity. a. Identify the muscles contained In each Describe the significance of the saphenous veins co111partlllent. in terms of common clinical conditions. b. Describe the attachments, Innervation, and 12. Describe the pattern of lymphatic drainage of major actions of each muscle. the lower lbnb, Including the relationship of this c. Describe the innervation and maJor actions of drainage with those of the abdominal wall and each co111partlllent as a whole. groin regions. d. Predict the functional consequences of loss of 13. Determine the movements that occur at the knee action of each muscle and each compartment. joint during normal locomotion. Describe the 7. Trace the course of cutaneous and motor mechanics of "locking" and "unlocldng" of the Innervation in the lower limb. knee. a. Identify the lumbosacral plexus and its com- 14. Identify the extrinsic and intrinsic muscles of the ponent parts, from spinal segmental sources foot, indicating their attachments, innervation, to 111ajor terminal branches. and major actions. Compare and contrast the b. Identify the spinal segmental level(s) of origin patterning and functions of muscles of the hand and relationship of each 111ajor peripheral and foot. nerve to the lumbosacral plexus. 15. Describe the arrangements of Oexor, extensor, c. Predict the functional consequences of lesions and peroneal retinacula, and maJor tendons to specific spinal levels and lndlvtdual periph- around the ankle, including the functional eral nerves. slgntftcance of these arrangements. 8. Define the boundaries and contents of the 16. Identify the bony components, major supportJng femoral triangle. Describe the composition of ligaments, key accessory structures, and 111ovements  LHAl-'ltR 11 Lower Umb permitted at the hip, knee, and ankle joints. 18. Compare and contrast the pattern of development Descrtbe the features of major traumas to each of the lower limb with that of the upper limb. joint. 19. Identify the bones of the lower limb and their 17. Identify the medial and lateral longitudinal and major features in standard radiographic images. transverse arches of the foot. Describe the roles 20. Locate the projections and palpation points of of bones, ligaments, and muscles in maintaining the major structures of the lower limb In a basic these arches. surface examination. OVERVIEW arthritis, varicose veins, vascular deficiencies, frac- tures, dislocations, sprains, lacerations, knee effusions, The primary functions of the lower limbs are to support leg pain, ankle injuries, and peripheral nerve injuries. the weight of the body and produce locomotion. The lower limbs are very stable and can bear the weight of the body because the two hip bones articulate poste- OSTEOLOGY riorly with the trunk at the strong sacroiliac joints and anteriorly with each other at the symphysis pubis. This The bones of the lower limb are the os coxae (hip stability also provides the foundation for standing In bone), femur, patella, tibia, fibula, metatarsal bones, the upright posture, walking, and running. tarsal bones, and phalanges. The general arrangement Each lower limb Is organized Into the piteaI region, the of the bones Is very similar to that In the upper limb. lhlgb, the popllteal fm8a, the leg, the ankle, and the foot The thigh and the leg are compartmentallzed, and each OsCoxae compartment has its own muscles that perform group The os coxae (hip bone) is topographically and func- functions and its own distinct nerve and blood supply. tionally the equivalent of the upper limb clavicle and Lower limb problems are some of the most common scapula. It forms the lower limb girdle that attaches the dealt with by health professionals, whether working in limb to the vertebral column. general practice, surgery, or an emergency department. Three skeletal elements, the ilium, ischium, and Some of the many conditions physicians encounter are pubis, form the os coxae (Figs. 11.l to 11.3). These Rough surface for attachment of lllac crest lnterosseous ligament Posterior superior iliac spine Lasser sciatic notch Obiurator foramen - Pubis A lschlal ramus B Flgurv 11.1 Medial surface (A) and lateral surface (B) of the right os coxae. Note the lines of fusion between the three bones (the ilium, the ischium, and the pubis) along the triradiate cartilage.  Osteology 515 Gluteus mecius , Teneorfuclaa lata& Sartorius Inferior gtuteel tine Anterior Inferior Iliac aplne Straight head of rectus femorls Reflected head of recllls f8morts _...__.._...;...,~~Acetabularfona Saaospinoua ligament Pectineal tin& Gemetrus eupenor Superior ramus of pubis L&888r SC:iatie notch Peetineus Gemellus inferior Pubic crest Inguinal Hgament Sacrotllberous llgement-f_m2~1\l, ~::.'1fif::~- Pubic U>el'cle Semlmembnanosus Adductor tongue Body Of f)U>is Adductor brevl& Inferior ramus Of f)U>is GraciIis Adcb:lor magnua - Oblurator extemus Ramim of lachlum Acetab\Ur notch Obturator foramen Figure 11.2 Muscles and ligaments attached to the external surface of the right os coxae. Gluteus medius Tensor faaclae lalae Gemellus superior Gluteus medius Obturator a>ctemus Semitendinosus _ _.....,..u1 _.......j,.-...,..- Quadratus femorls Biceps femoris Adductor magnus Gluteus maxlmua Semlmembranoeus Psoas Vastus intennedius Iliacus Pectineus Adductor brevis Adductor longus Vaatus medlalls Figure 11.3 Muscles attached to the extemal surface of the right os coxae and the posterior surface of the femur. 516 CHAPTER 11 Lower Limb bones meet one another at the acetabulum via the symphysis pubis faces upward and backward and the Y-shaped trlradlate cartllage. Theos coxae articulate anterior surface of the sacrum is directed forward and with the sacrum at the sacroiliac joints and form the downward. anterolateral walls of the pelvis. They also articu- The important muscle and ligament attachments late with one another anteriorly at the symphysis to the outer surface of the hip bone are shown In pubis. The detailed structure of the internal (pelvic) Figures 11.2 and 11.3. aspect of the bony pelvis ls considered in Chapter 8. The important features found on the outer (gluteal) surface of the os coxae in the gluteal region are as Femur follows. The femur articulates above with the acetabulum to The Ulum, which is the upper flattened part of the form the hip joint and below with the tibia and the bone, possesses the iliac crest (see Figs. 11.1 and 11.2). patella to form the knee joint. This can be felt through the skin along its entire length. The upper end of the femur has a head, a neck, and It ends in front at the anterosuperlor Ulac spine and greater and lesser trochanters (Fig. 11.4). The head behind at the po8terosuperior iliac spine. The iliac forms about two thirds of a sphere and articulates mbercle Iles about 2 in. (5 cm) behind the anterosu- with the acetabulum of the os coxae to form the hip perior spine. Below the anterosuperior iliac spine is a joint (see Fig. 11.3). In the center of the head is a small prominence, the anterolnferlor Ulac spine. A similar depression, called the fovea capltls, for the attachment prominence, the poateroinferlor iliac spine, is located of the ligament of the head (see Fig. 11.4). Part of the below the posterosuperior iliac spine. The ilium pos- blood supply to the head of the femur from the obtura- sesses a large notch, the greater sciatic notch, above tor artery is conveyed along this ligament and enters and behind the acetabulum. the bone at the fovea. The ischlum is L shaped, possessing an upper The neck, which connects the head to the shaft, thicker part, the body, and a lower thinner part, the passes downward, backward, and laterally and makes ramus. The ischlal spine projects from the posterior an angle of about 125° (slightly less in the female) with border of the ischium and intervenes between the the long axis of the shaft. Disease can alter the size of greater and lesser sdadc notches. The lschlal blberoe- this angle. lty is the large roughened area that forms the posterior The greater and lesser trochanters are large emi- aspect of the lower part of the body of the bone. The nences situated at the junction of the neck and the greater and lesser sciatic notches are converted into shaft. The lntertrochanterlc line connects the trochan- greater and lesser sciatic foramina by the presence of ters anteriorly, where the iliofemoral ligament attaches. the sacrospinous and sacrotuberous ligaments (see A prominent lntertrochanterlc crest connects the tro- below). chanters posteriorly. The pubis Is divided Into a body, a superior ramus, The shaft of the femur is smooth and rounded on its and an inferior ramus. The bodies of the two pubic anterior surface but posteriorly has a ridge, the linea bones articulate with each other in the midline ante- aspera, to which are attached muscles and intermus- riorly at the symphysis pubis. The superior ramus cular septa. The margins of the linea aspera diverge joins the ilium and ischium at the acetabulum, and above and below. The medial margin continues below the inferior ramus joins the ischial ramus below as the medial supracondylar ridge to the adductor the obturator foramen. The obturator membrane tubercle on the medial condyle. The lateral margin fills in the obturator foramen in life (see Chapter 8). becomes continuous below with the lateral supracon- The pubic crest forms the upper border of the dylar ridge. The gluteal tuberosity is on the posterior body of the pubis, and it ends laterally as the pubic surface of the shaft below the greater trochanter. The tubercle. shaft becomes broader toward its distal end and forms The outer surface of the hip bone has a deep depres- a flat, triangular area on its posterior surface called the sion termed the acetabulum. This articulates with the popllteal surface. almost spherical head of the femur to form the hip The lower end of the femur has lateral and medial joint. The inferior margin of the acetabulum is deficient condyles, separated posteriorly by the lntercondylar and is marked by the acetabular notch (see Fig. 11.2). notch. The anterior surfaces of the condyles are joined The articular surface of the acetabulum ls limited to by an articular surface for the patella. The two con- a horseshoe-shaped area and is covered with hyaline dyles take part in the formation of the knee joint. The cartilage. The floor of the acetabulum is nonarticular medial and lateral eplcondyles are above the condyles. and is called the acetabular fossa. The adductor tubercle is continuous with the medial In the anatomic position, the front of the symphysis epicondyle. pubis and the anterosuperior iliac spines lie in the same The important muscle and ligament attachments to vertical plane. This means that the pelvic surface of the the femur are shown in Figure 11.4.  Osteology 517 Ligament of head - Head Greater trochanter Ligament of Obtlirator axternus Fovea capllia head of fem1o1r lachlofemoral luteus medlus ligament --- -uactrate tubercle ;u.,._- Capsule of hip joint Capsule of hip joint...,....,,...,.._~ntertrocllanterlc crest fiubofefnoral ligament Psoas l..esser trochanter Vastus int&rmiillus vastus medialis Vastus lateralls Adductor longus Biceps farnorts (Short head) Sits of hiatus of Laleral supracondylar adductor rnagnus rtdge... Medial supracondylar ridge Popllteal surface I ,\ Gastrocnemlus (medial head) ~ Adductor magnus;_...,.,. Patellar surface ~ "' /:; < Adductor tubercle..,:...f ~:;.,...;~~~ Medial eplcondyl8 Lateral.:~ Medial oondyle ligament \ A ~ B Figure 11.4 Bony features and muscle and ligament attachments on the anterior (A) and posterior (B) surfaces of the right femur. fa Clinical Notes Head of Femur Tenderness and Hip of the obturalor artery, which passes to the head along Joint Arthritis the llpmeDt of the femoral head. The upper part of the neck of the femur receives a profuse blood supply from the The part of the head of the femur that Is not lntra-acetabular medial femoral dn:um8eJ[ artery. These branches pierce can be palpated on the anterior aspect of the thigh Just Inferior the Joint capsule and ascend the neck deep to the synovlal to the Inguinal ligament and Just lateral to the puJsatlng membrane. As long as the epiphyseal cartilage remains, no femoral artery. Tenderness over the head of the femur usually communication occurs between the two sources of blood. indicates the presence of arthritis of the hip joint. In the aduJt, after the epiphyseal cartilage disappears, an anastomosis between the two sources of blood supply Is Blood Supply to Femoral Head and established. Fractures of the femoral neck Interfere with Neck Fractures or completely Interrupt the blood supply from the root of the femoral neck to the femoral head. The scant blood Oow Avascular necrosis of the head of the femur can occur along the small artery that accompanies the round ligament after fractures of the neck of the femur. In the young, may be Insufficient to sustain the viability of the femoral the epiphysis of the head is supplied by a small branch head, and lschemlc necrosis gradually takes place. (continued) 518 CHAPTER 11 Lower Limb Neck of the Femur and Coxa Valga and Vara line is extracapsular, and both fragments have a profuse blood supply. If the bone fragments are not Impacted, the The neck of the femur ls Inclined at an angle with the shaft. pull of the strong muscles will produce shortening and This angle ls about 160° ln the young child and about 125° lateral rotation of the leg, as previously explalned. in the adult. An Increase in this angle is referred to as cox.a Fractures of the shaft of the femur usually occur In valga, and it occurs, for example, in cases of congenital young and healthy persons. In fractures of the upper third dislocation of the hip. Jn this condition, adduction of the of tbe abaft of the femur, the proximal fragment is flexed by hip joint ts limited. A decrease in this angle ls referred to as the lllopsoas; abducted by the gluteus medlus and mlnimus; cou. vara, and It occurs ln fractures of the neck of the femur and laterally rotated by the gluteus maxlmus, the plriformls, and ln slipping of the femoral eplphysls. In this condition, the obturator lntemus, the gemelll, and the quadratus abduction of the hip joint is limited. Shenton's line Is a femoris (Fig. 11.6). The lower fragment Is adducted by the useful means of assessing the angle of the femoral neck on adductor muscles, pulled upward by the hamstrings and a radiograph of the hip region (see Fig. 11.71). quadriceps, and laterally rotated by the adductors and the weight of the foot. Femur Fractures Jn fractures of the middle ddrcl of lhe lhaft of the femur, the distal fragment ls pulled upward by the hamstrings and Fractures of the neck of the femur are common and are the quadriceps, resultlng In considerable shortening. The of two types, subcapltal and trochanterlc. The sabaapltal distal fragment is also rotated backward by the pull of the fracture occurs in the elderly and is usually produced by two heads of the gastrocnemius. a minor trip or stumble. Subcapital femoral neck fractures Jn fractures of the dlltal third of the lhaft of the femur, are particularly common In women after menopause. the same displacement of the distal fragment occurs This gender predisposition ls because of a thinning of the as seen In fractures of the middle third of the shaft. cortical and trabecular bone caused by estrogen deficiency. However, the dlstal fragment Is smaller and is rotated Avascular necrosis of the head is a common complication. If backward by the gastrocnemius muscle to a greater the fragments are not impacted, considerable displacement degree and may exert pressure on the popltteal artery occurs. The strong muscles of the thigh, including the rectus and Interfere with the blood fiow through the leg and femorls, the adductor muscles, and the hamstring muscles, foot. pull the distal fragment upward, so that the leg Is shortened From these accounts, lt Is clear that knowledge of the (as measured from the anterosuperlor Wac spine to the different actions of the muscles of the leg is necessary to adductor tubercle or medial malleolus) (Flg. 11.5). The understand the displacement of the fragments of a fractured gluteus maximus, the piriformis, the obturator internus, the femur. Considerable traction on the distal fragment Is gemelll, and the quadratus femorls rotate the distal fragment usually required to overcome the powerful muscles and laterally, as seen by the toes pointing laterally. restore the limb to Its correct length before manipulation Trodumterlc fracturea commonly occur In the young and operative therapy to bring the proximal and distal and middle-aged as a result of direct trauma. The fracture fragments into correct alignment. ,\ cf\"'~' __....._~'":: l GM "'"P (-,-1 A. I./ · -\. rI RF ~.....· Pl / ,: 01 '.\ ' ~.- I A AM ' GE I HS '· \ QF ~ I Type1 Type2 '·~,!.~i : ,1 \"r~. / :,1-... II ,a I ~ {_.:. , ·'.'> / '..... ~:..'-..., I ,. '· '. I / r· L ~ 1 ~. ,· \ 1r1 · I." '·'· ' ,\·l II J.., ,. ( A 1\'P93 Type4 B t',,., Figure 11.5 A. Fractures of the neck of the femur. B. Displacement of the lower bone fragment caused by the pull of the powerful muscles. Note in particular the outward rotation of the leg so that the foot characteristically points laterally. AM, adductor muscles; GE, gemelli; GM, gluteus maximus; HS, hamstring muscles; 01, obturator internus; Pl, piriformis; OF, quadratus femoris; RF, rectus femoris.  Osteology 519 ~~~ k:~-· /.·IP.,..,.., I. f.. ' l.. GM C. Pl , , I ,.... Jlt. ' (_' I 01 '.... r'' GE I AM QF.--\ l ' ~ rv'/ i.1 /·' GAST ~ '' AM, , I ) QD~ i" i r AM Popllteel - - artery.A t....A- '" ·. ~... \.......... ) ! /.. - -,. - ,,. ,.i G>ST1 I, A B c Figure 11.6 Fractures of the shaft of 1he femur. A. Upper 1hird of the femoral shaft. Note the displacement caused by the pull of the powerful muscles. I. Middle 1hird of the femoral shaft. Note 1he posterior displacement of the lower fragment caused by the gastrocnemius muscle. C. Lower third of the femoral shaft. Note 1he excessive displacement of the lower fragment caused by the pull of the gastrocnemius muscle, threatening the integrity of the popliteal artery. AM, adductor muscles; GAST.. gastrocnemius; GE, gemelli; GM, gluteus maximus; GME, gluteus medius; GMI, gluteus minimus; HAM, hamstrings; IP, iliopsoas; 01, obturator intemus; Pl, piriformis; QDF, quadri- ceps femoris; QF, quadratus femoris. Patella condyles of the femur and the head of the fibula above and with the talus and the distal end of the fibula below. It has The patella (lmeecap; Fig. 11.7) Is the largest sesamold an expanded upper end, a smaller lower end, and a shaft. bone (i.e., It develops within the tendon of the quad- The lateral and medial condyles (sometimes called riceps femoris muscle in front of the knee Joint). It Is lateral and medial dblal plateaus) are at the upper end. triangular, and its apex lies inferiorly. The apex Is con- These articulate with the lateral and medial condyles nected to the tuberoslty of the tibia by the llgamentum of the femur and the intervening lateral and mecllal patellae (patellar ligament). The posterior surface mealld.. Anterior and poeterlor lntercondylar areas articulates with the condyles of the femur. The patella is separate the upper articular surfaces of the tibial con- situated in an exposed position in front of the knee joint and is easily palpable through the skin. It is separated dyles. The lnten:ondylar eminence Iles between these from the skin by an important subcutaneous bursa, the areas (see Fig. 11.7). The lateral condyle possesses a prepatellar buna (see Fig. 11.59). The upper, lateral, small circular articular facet for the head of the fibula and medial margins give attachment to the different on its lateral aspect. The lhaft of the tibia is triangular in cross sec- parts of the quadriceps femorls muscle. tion, presenting three borders and three surfaces. Its anterior and medial borclen, with the medial surface Tibia between them, are subcutaneous. The anterior border The tibia ts the large weight-bearing medial bone of the is prominent and forms the shin. The tuberoelty of the leg (Fig. 11.8; also see Fig. 11.7). It articulates with the dbla Is at the Junction of the anterior border with the 520 CHAPTER 11 Lower Limb Flgun111.7 Muscles and ligaments attached to the anterior surfaces of the right tibia and fibula. Attachments to the patella are also shown. Anterior border Laleral surface- Llgamentum pa!Bllae Madal surface Medial malleolus Medial ligament of ankle joint Lateral malleol Capsule of ankle joint upper end of the tibia and receives the attachment of the ligamentum patellae. The anterior border becomes rounded below, where it is continuous with the medial Head of fltda malleolus. The lateral (lateroneoua) border gives attachment to the interosseous membrane. The pos- terior surface of the shaft shows an oblique line, the aoleal llne, for the attachment of the soleus muscle. The lower end of the tibia Is slightly expanded and shows a saddle-shaped articular surface for the talus on its inferior aspecL The lower end is prolonged downward Tibialis posterior medially to fonn the large medial malleolus. The lateral surface of the medial malleolus articulates with the talus. Ver11cal line The lower end of the tibia shows a wide, rough depres- Medial borde sion on its lateral surface for articulation with the fibula The important muscles and ligaments attached to the tibia are shown in Figures 11.7 and 11.8. FIED' suriace of trochanter SuperiC>' I gluteal nerve LS; 5 ---'- Abducts thigh at hip joint; tilts pelvis when walking of femur I to permit opposite leg to Tensor I Iliac crest - motibiel.... I SuperiO< - I L4,5 clear ground Assists gluteus maximus in fasciae latae gluteal nerve extending the knee joint surfac~per border of - l Piriformis Anterior First and LS; 51, 2 Lateral rotator of thigh at of sacrum greater trochanter second sacral hip joint of femur nerves 1 Obturator Inner surface Upper border of J : aaal plexul LS; 51 Lateral rotator of thigh at internus of obturator I greater trochanter hip joint membrane of femur pine of isch~ Upper border of ~ Gemellusl superior greater trochanter of femur Sacral plexus l LS; $1 Lateral rotator of thigh at hip joint Gemellus lschial tuberosity Upper border of Sacral plexus LS; S1 Lateral rotator of thigh at inferior greater trochanter hip joint of femur. 1 Quadratu~teral border of Quadrate tubercle ~al plex;;-i LS; S1 Lateral rotator of thigh at femoris "' I i;hial tuberosity of femur hip joint "The predominant nerve root supply is indicated by boldface type. and nerves from the inferior gluteal vessels and Sciatic Nerve nerves. The sciatic nerve (IA and 5; S 1, 2, and 3) emerges from The obturator lntemus ls a fan-shaped muscle that the pelvis through the lower part of the greater sciatic lies within the pelvis at lts origin. Its tendon emerges foramen (see Figs. 11.17 and 11.18). It is the largest through the lesser sciatic foramen to enter the glu- nerve in the body and consists of the tibial and com- teal region (see Figs. 11.17 and 11.18). The tendon mon fibular (peroneal) nerves bound together with is joined by the superior and inferior gemelll and ls fascia (Figs. 11.19 and 11.20). The nerve appears below inserted into the greater trochanter of the femur. the plrlformls muscle and curves downward and later- Three bursae are usually associated with the gluteus ally, lying successively on the root of the lschlal spine, ma:x:imus: between the tendon of insertion and the the superior gemellus, the obturator lntemus, the infe- greater trochanter, between the tendon of insertion rior gemellus, and the quadratus femoris to reach the and the vastus lateralis, and overlying the ischial back of the adductor magnus muscle (see Fig. 11.17). It tuberosity. ls related posteriorly to the posterior cutaneous nerve of the thigh and the gluteus maximus. It leaves the but- tock region by passing deep to the long head of the Gluteal Region Nerves biceps femoris to enter the back of the thigh. All the following nerves of the gluteal region originate Occasionally, the common fibular nerve leaves the from the sacral plexus. sciatic nerve high ln the peMs and appears In the 530 CHAPTER 11 Lower Limb fJ Clinical Notes Gluteus Maximus and Intramuscular Injections with excessive amounts of fluid and can be extremely painful. The bursae associated with the gluteus maximus The gluteus maximus Is a large, thick muscle with coarse are prone to inflammation. fasclculi that can be easily separated without damage. The great thickness of this muscle makes It ideal for intramuscular injections. The Injection should be given Gluteus Medius and Minimus and Poliomyelitis wen forward on the upper outer quadrant of the buttock to avoid injury to the underlying sciatic nerve. The superior gluteal nerve (IA, 5, and SI) supplies the gluteus medlus and mlnlmus muscles. They may be Gluteus Maximus and Bursitis paralyzed when poliomyelitis Involves the lower lumbar and sacral segments of the spinal cord. Paralysis of these Bursitis, or inftammation of a bursa, can be caused by acute muscles seriously Interferes with the ability of the patient or chronic trauma. An Inflamed bursa becomes d15tended to tilt the pelvis when walking. Sciatic nerve L4 L5 S1 S2 S3 Pelvis Sacral plexus Sciatic ne1'119 Tibial nerw Gluteal region ~ -------- +- - -------------~ --------- I Common fibular nerw ~---- I~ --- 1 Back of thigh Biceps lemoris (short head) Lateral cutBneous nan/8 of calf Abular1s longus Lower leg Fibularis brvvis Skin of leg Extensor Skin of lateral dlgllorum brevis Skin of dorsum of foot side of foot Foat and little toe Skin of deft between first and second toes Figure 11.19 Summary of the origin of the sciatic nerve and the main branches of the common fibular (peroneal) nerve.  Gluteal Region 531 Sciatic nerve PeMs L4 LS S1 S2 SS Sacral plexus Tibial nerve Gluteal region ~-- Common fibular nerve ------------- ~~lRJQlnt- -~.+ ------ ~-~-- Semitendinosus ----i --- Biceps femoris Back of thigh (long head) Semlmembranosus Adductor magnus (hamstring part) Gas!rocnemlus Lower leg Tiblalls posterior Aexor digiturum longus Flexor halluds longus Skin of ankle - - - - - - - - __ _Ankl~int - -. Sole of foot Abduccor hallucis Flexor digitorum brevis Flexor dlgltorum accessorfus Flexor hallucls brevls Abductor digit! minim! Flexor digiti minimi brevis First lumbrical Second, third, fourth lumbricals All interossei FltJure 11.20 Summary of the origin of the sciatic nerve and the main branches of the tibial nerve. gluteal region by passing above or through the pirifor- foramen below the plrlfonnls muscle (see Fig. ll.l'l). It mis muscle. passes downward on the posterior surface of the sciatic The sciatic nerve usually gives no branches in the nerve and runs down the back of the thigh beneath the gluteal region. deep fascia. It supplies the skin in the popliteal fossa. Poatertor Cutaneous Nerve of the 'lbtgh Branches The posterior cutaneous nerve of the thigh enters the Gluteal branchee to the skin over the lower medial gluteal region through the lower part of the greater sciatic quadrant of the buttock (see Fig. 11.12) 532 CHAPTER 11 Lower Limb Perineal branch to the skin of the back of the scro- It distributes branches that run throughout the gluteal tum or labium majus region, including a major supply to the gluteus maximus Cutaneous branches to the back of the thigh and the muscle. upper part of the leg Trochanteric Anastomosis Superior Gluteal Nerve The trochanteric anastomosis provides the main blood The superior gluteal nerve leaves the pelvis through supply to the head of the femur. The nutrient arteries the upper part of the greater sciatic foramen above the pass along the femoral neck beneath the capsule. The plriformls (see Fig. 11.17). It runs forward between the following arteries take part in the anastomosis: the gluteus medius and minimus, supplies both, and ends superior gluteal artery, the inferior gluteal artery, by supplying the tensor fasciae latae. the medial femoral circumflex artery, and the lateral femoral circumflex artery. Inferior Gluteal Nerve The inferior gluteal nerve leaves the pelvis through the Cruciate Anastomosis lower part of the greater sciatic foramen below the piri- The cruciate anastomosis is situated at the level of the formis (see Figs. 11.17 and 11.18). It supplies the gluteus lesser trochanter of the femur and, together with the maximus muscle. trochanteric anastomosis, provides a collateral connec- tion between the internal iliac and the femoral arteries. Nerve to Quadratus Femorls The following arteries take part in the anastomosis: the inferior gluteal artery, the medial femoral circumflex The nerve to the quadratus femoris leaves the pelvis artery, the lateral femoral circumflex artery, and the through the lower part of the greater sciatic foramen (see Fig. 11.18). It ends by supplying the quadratus first perforating artery, a branch of the profunda artery. femoris and the inferior gemellus. Pudenda! Nerve and Nerve to Obturator lnternus THIGH The pudendal nerve and nerve to the obturator inter- The thigh Is the proximal segment of the lower limb nus leave the pelvis through the lower part of the proper, from the hip to the knee. The femur is the bony greater sciatic foramen, below the piriformis (see core of the thigh. Figs. 11.17 and 11.18). They cross the ischial spine with the internal pudendal artery and immediately reenter Fascia the pelvis through the lesser sciatic foramen. They then lie in the posterior aspect of the ischioanal fossa (see The fatty layer of the superficial fascia on the anterior Chapter 10). The pudendal nerve supplies structures abdominal wall extends into the thigh and continues in the perineum. The nerve to the obturator intemus down over the lower limb without interruption (see supplies the obturator internus muscle on its pelvic Fig. 11.28). surface. The membranous layer of the superficial fuda of the anterior abdominal wall extends into the thigh and attaches to the deep fascia (fascia lata) about a finger- Gluteal Region Arteries breadth below the inguinal ligament (see Figs. 11.14 The superior and inferior gluteal arteries are the pri- and 11.28). This relationship is important in connection mary vessels supplying the gluteal region. Both are with extravasatlon of urine after a rupture of the ure- branches of the internal iliac artery within the pelvic thra (see Chapter 6). cavity. Both contribute to major collateral networks The deep fuda (fuda lata) encloses the thigh like around the hip. a spandex legging (Fig. 11.21). Its upper end attaches to the pelvis and the inguinal ligament. It is thickened Superior Gluteal Artery on its lateral aspect to form the Ulotlblal tract (see Figs. 11.16 and 11.21), which is attached above to The superior gluteal artery enters the gluteal region through the upper part of the greater sciatic foramen the iliac tubercle and below to the lateral condyle of the tibia. The iliotibial tract receives the insertion of the above the piriformis (see Figs. 11.17 and 11.18). It tensor fasclae latae and the greater part of the gluteus divides Into branches that distribute throughout the maximus muscle. In the gluteal region, the deep fascia gluteal region, but has a primary flow through the fas- cia] space between the gluteus medius and minlmus forms investing sheaths that enclose the tensor fasciae Iatae and the gluteus maximus muscles. muscles. The saphenom opening is a gap in the deep fascia in the front of the thigh just below the inguinal liga- Inferior Gluteal Artery ment. It is filled with loose connective tissue called the The inferior gluteal artery enters the gluteal region crlbrlform. fascia. It transmits the great saphenous through the lower part of the greater sciatic fora- vein, some small branches of the femoral artery, and men, below the piriformis (see Figs. 11.17 and 11.18). lymph vessels (see Fig. 11.14). The saphenous opening  Thigh 533 Rectus femorts Vastus intermedius Profunda femoris artery lliotibial tract Mecllll Posterior cutaneous nerve of thigh Figure 11.21 Transverse section through the middle of the right thigh as seen from above. Is situated about 1.5 ln. (4 cm) below and lateral to The medial c:utaneou nerve of the thigh, a branch the pubic tubercle. The faldform. margin is the lower of the femoral nerve, supplies the medial aspect of the lateral border of the opening, which lies anterior to thigh and joins the patellar plexus. the femoral vessels (see Fig. 1I.14A). The border of the The Intermediate cutaneous nerve of the thigh, a opening then curves upward and medially, and then branch of the femoral nerve, divides Into two branches laterally behind the femoral vessels, to attach to the that supply the anterior aspect of the thigh and joins pectineal line of the superior ram.us of the pubis. the patellar plexus. Branches from the anterior dlvlalon of 1he obtura· Cutaneous Nerves tor nerve supply a variable area of skin on the medial aspect of the thigh. The lateral cutaneous nerve of the thigh, a branch of The patellar pleros lies in front of the knee and is the lumbar plexus (L2 and 3), enters the thigh behind formed from the terminal branches of the lateral, Inter- the lateral end of the inguinal ligament (see Fig. ll.13). mediate, and medial cutaneous nerves of the thigh and Having divided into anterior and posterior branches, it the infrapatellar branch of the saphenous nerve. supplies the skin of the lateral aspect of the thigh and The posterior cutaneous nerve of the thlgb, a knee. It also supplies the skin of the lower lateral quad- branch of the sacral plexus, leaves the gluteal region by rant of the buttock (see Fig. 11.12). emerging from beneath the lower border of the gluteus The femoral branch of the genltofemoral nerve, a maximus muscle (see Fig. 11.12). It descends on the branch of the lwnbar plexus {Ll and 2), enters the thigh back of the thigh, and in the popliteal fossa, it pierces behind the middle of the Inguinal ligament and supplies the deep fascia and supplies the skin. It gives off numer- a small area of skin (see Fig. 11.13). The genital branch ous branches to the skin on the back of the thigh and supplies the cremaster muscle. the upper part of the leg. The Wolngulnal nerve, a branch of the lumbar plexus (Ll), enters the thigh through the superficial Inguinal ring. It distributes to the skin of the root of Superfidal Veins the penis and adjacent part of the scrotum (or root of The superficial veins of the leg are the great and small the clitoris and adjacent part of the labium majus in the saphenous veins and their tributaries (Fig. 11.22). They female) and to a small skin area below the medial part are comparable to the basilic and cephalic veins in the of the inguinal ligament. upper limb and have significant clinical importance. 534 CHAPTER 11 Lower Limb Anterior superior - -' t iliac spine Superftclal eplgastrlc vein Saphenous opening Pubic bJbercle Femoral vein Femoral artery -r--.......:~i-"i.J Superftclal extemal pudenda! vein Great saphenous vein Accessory vein Great saphenous vein j \ (....\ ( \ \'/r..;j) Small ·Y saphenous vein Perforating vein Muacle Superficial - - Lateral malleolus fascia Skin '.iledial malleolus Venae comitantes Dorsal venous arch 'Venous pump' Figure 11.22 Superficial veins of the right lower limb. Note the importance of the valved perforating veins in the "venous pump. The peat phenoaa vein drams the medial end of joins the femoral vein about 1.5 in. (4 cm) below and the donal venom arch of the foot and passes upward lateral to the pubic tubercle (see Figs. 11.14 and 11.22). directly in front of the medial malleolus (see Fig. 11.22). The great saphenous vein possesses numerom It then ascends in company with the saphenous nerve in valves and is connected to the small saphenous vein by the superficial fascia over the medial side of the leg. The one or two branches that pass behind the knee. Several vein passes behind the knee and curves forward around perforadng veins connect the great saphenous vein the medial side of the thigh. It passes through the lower with the deep veins along the medial side of the calf part of the saphenous opening in the deep fascia and (see Fig. 11.22).  Thigh 535 The great saphenous vein usually receives three thigh or higher up at the saphenous opening (see tributaries that are variable in size and arrangement at Fig. 11.22). the saphenous opening in the deep fascia: the 1Uper- Many small veins from the back of the thigh curve fldal drcumflex Wac vein, the 111perficlal eplgaatric around the medial and lateral aspects of the thigh vein, and the superfldal e:x.1erDal pudendal vein (see and ultimately drain into the great saphenous vein. Figs. 11.14 and 11.22). These veins correspond with the Superficial veins from the lower part of the back of the like-named three branches of the femoral artery found thigh join the small saphenous vein in the popliteal in this region. fossa. An additional vein, known as the accessory vein, The small saphenous vein Is described later in this usually joins the main vein about the middle of the chapter, with the back of the leg. r @ Clinical Notes L_:. Umb Veins intra-abdominal pressure as a result of multiple pregnancies or abdominal tumors, and thrombophleblUs of the deep The veins of the lower 11mb are organized tnto ~ groups: veins, which results in the superficial veins becoming superflclal, deep, and perforatlng (see Fig. 11.22). The the main venous pathway for the lower limb. It ls easy super8dal ~ consist of the great and small saphenous to understand how this condition can be produced by veins and their tributaries, which are situated beneath the Incompetence of a valve in a perforating vein. Every time skin in the superficial fascia. The constant position of the the patient exercises, high-pressure venous blood escapes great saphenous vein tn front of the medial malleolus should from the deep veins Into the superficial veins and produces be remembered for patients requiring emergency blood a vartcoslty, which might be localized to begin with but transfusion. The deep ftlm are the venae comltantes to the becomes more extensive later. anterior and posterior tibial arteries, the poplfteal vein, and The successful operative treatment of varicose veins the femoral veins and their tributaries. The per1'ondblg ~ depends on the ligation and division of all the main are communicating vessels that run between the superficial tributaries of the great or small saphenous veins to prevent and deep veins. Many of these veins are found particularly In a collateral venous circulation from developing, and the the region of the ankle and the medial side of the lower part Jlgatlon and division of all the perforating veins responsible of the leg. They possess ftha that are arranged to allow the for the leakage of high-pressure blood from the deep to the flow of blood only from the superficial veins to the deep veins. superficial veins. Jn addition, a common practice ls now to remove or strip the superficial veins. Needless to say, Lower Limb Venous Pump it is imperative to ascertain that the deep veins are patent before taking operative measures. Within the dosed fascia! compartments of the lower limb, the thin-walled, valved venae comltantes are subJected to Intermittent pressure at rest and during exercise. The Great Saphenous Vein Cutdown pulsations of the adjacent arteries help move the blood up Exposure of the great saphenous vein through a skin Incision the limb. However, the contractions of the large muscles (Clddown) ts usually performed at the ankle (Fig. 11.23A). within the compartments during exercise compress these This site has the disadvantage that phlebitis (inflammation deeply placed veins and force the blood up the limb. of the vein wall) is a potential complication. The great The superficial saphenous veins, except near their saphenous vein also can be entered at the groin in the termination, lie within the superficial fascia and are not femoral triangle (Ftg. 11.23C), where phlebitis ts relatively subject to these compression forces. The valves in the rare. The larger diameter of the vein at this site permits the perforating veins prevent the high-pressure venous blood use of large-diameter catheters and the rapid Infusion of from being forced outward into the low-pressure superficial veins. Moreover, as the muscles within the closed fasclal large volumes of fluids. compartments relax, venous blood ls sucked from the superficial Into the deep veins. Anatomy of Ankle Vein Cutdown The procedure ls as follows: Varicose Veins 1. The sensory nerve supply to the skin immediately A varicosed vein is one that has a larger diameter than in front of the medial malleolus of the tibia Is from normal and is elongated and tortuous. This condition branches of the saphenous nerve, a branch of the commonly occurs In the superficial veins of the lower femoral nerve. The saphenous nerve branches are limb and, although not We threatening, Is responsible for blocked with local anesthetic. considerable discomfort and pain. 2. A transverse incision is made through the skin and Varicose veins have many causes, induding hereditary subcutaneous tissue across the long axis of the vein weakness of the vein walls, incompetent valves, elevated fust anterior and superior to the medial malleolus (see (continued) 536 CHAPTER 11 Lower Limb Sephenous nerveM Great saphenous vein ~ Anterior superior lllacsplne Edge of saphenous opening in deep fascia \ Pubic ,..Femoral win ,.. y tubercle - - - - -~ c =- ~ D '!¥~r-- Great saphenous win Figure 11.23 Great saphenous vein cutdown. A.B. At the ankle. The great saphenous vein is constantly found in front of the medial malleolus of the tibia. C,D. At the groin. The great saphenous vein drains into the femoral vein two fingerbreadths below and lateral to the pubic tubercle. Fig. 1I.23A,B). The vetn is constantly found at this site, In the deep fascia to join the femoral vetn about 1.5 in. even though it may not be visible through the skin. (4 cm), or two fingerbreadths below and lateral to the 3. The vein is easily identified, and the saphenous nerve pubic tubercle. It is important to understand that the should be recognized. The nerve usually lies just great saphenous vein passes through the saphenous anterior to the vein (see Fig. 11.23). opening to gain entrance to the femoral vetn. However, the size and shape of the opening are subject to variation. Anatomy of Groin Vein Cutdown 1. Branches of thelllolDgalnalneneand thelD.termedlate Great Saphenous Vein in Coronary Bypass cutaneou nerve of the thigh supply the area of thigh Surgery skin below and lateral to the scrotum or labium majus. The branches of these nerves are blocked with local In patients with occlusive coronary disease caused by anesthetic. atherosclerosis, the diseased arterial segment can be 2. A transverse incision Is made through the skin and bypassed by inserting a graft consisting of a portion of the subcutaneous tissue centered on a point about 1.5 great saphenous vein. The venous segment Is reversed so In. (4 cm) below and lateral to the pubic tubercle that its valves do not obstruct the arterial flow. Following (Fig. 11.23C,D). H the femoral pulse can be felt (it may removal of the great saphenous vein at the donor site, the be absent in patients with severe shock), the incision is superficial venous blood ascends the lower limb by passing carried medially Just medial to the pulse. through the perforating veins and entering the deep veins. 3. The great saphenous vein lies in the subcutaneous fat The great saphenous vein can also be used to bypass and passes posteriorly through the saphenous opening obstructions of the brachia! or femoral arteries.  Thigh 537 Inguinal Lymph Nodes The inguinal lymph nodes are divided into superficial and deep groups. ~@ Clinical Notes Lower Limb Lymphatics Superfldal Inguinal Lymph Nodes The superficial nodes Ile In the superficial fascia below The superficial and deep Inguinal lymph nodes not only the inguinal ligament and can be divided into a horizon- drain all the lymph from the lower limb but also drain lymph from the slc:in and superficial fascia of the anterior tal and a vertical group (see Figs. 11.14 and 11.15). and posterior abdominal walls below the level of the The horlzontal group lies just below and parallel umb!llcus. Lymph from the external genitalia and the to the inguinal ligament. The medial memben of the mucous membrane of the lower half of the anal canal also group receive superficial lymph vessels from the ante- drains into these nodes. Remember the large distances rior abdominal wall below the level of the umbilicus and the lymph has had to travel in some instances before it from the perinewn (see Fig. 11.15). The lymph vessels reaches the inguinal nodes. For example, a patient may from the urethra, the external genitalia of both sexes present with an enlarged, painful inguinal lymph node (but not the testes), and the lower half of the anal canal caused by lymphatic spread of pathogenic organisms drain by this route. The lateral members of the group that entered the body through a small scratch on the receive superficial lymph vessels from the back below undersurface of the big toe. the level of the lilac crests. The vertical group Iles along the terminal part of the great saphenous vein and receives most of the superfi- cial lymph vessels of the lower limb (see Figs. 11.14 and The compartments are anterior, medial, and posterior 11.15). Lymph from the skin and superficial fascia on In position. This general pattern of organization of the the back of the thigh drains upward and forward into limb into defined compartments ls the same in both the the vertical group. upper and lower limbs. The efferent lymph vessels from the superficial inguinal nodes pass through the saphenous opening in the deep Anterior Fascial Compartment Contents fascia and join the deep inguinal nodes (see Fig. 11.15). Mmdea: Sartorius, iliopsoas, pectineus, and quadri- ceps femorls Deep Inguinal Lymph Nodu Blood. supply: Femoral artery The deep nodes are located beneath the deep fascia Nerve sapply: Femoral nerve and lie along the medial side of the femoral vein (see Fig. 11.28). The efferent vessels from these nodes enter the Anterior Fudal Compartment Muscles abdomen by passing through the femoral canal to lymph The muscles are Illustrated In Figures 11.21, 11.24, 11.25, nodes along the external iliac artery (see Fig. 11.15). and 11.26 and are summarized In Table 11.2. Recall that The deep inguinal lymph nodes are variable in nwn- the lllacus and psoas major are separate muscles In the ber, but there are commonly three. They lie along the abdomen, but merge together in the thigh to form a medial side of the terminal part of the femoral vein, single lllopsoas muscle. and the most superior ls usually located In the femoral canal (see Figs. 11.15 and 11.28). They receive all the Action ofQuadrlcep& Femorls Muscle (Qaadrlceps lymph from the superficial inguinal nodes via lymph Mechant.m) vessels that pass through the crlbrlform fascia of the The quadriceps femoris muscle (consisting of the rec- saphenous opening. They also receive lymph from the tus femorls, the vastus intermedius, the vastus lateralis, deep structures of the lower limb that have ascended and the vastus medlalis) Inserts into the patella and, via in lymph vessels alongside the arteries, some having the llgamentum patellae (patellar ligament), attaches passed through the popliteal nodes. The efferent lymph to the tibial tuberosity (Fig. 11.27). Together, they pro- vessels from the deep inguinal nodes ascend into the vide a powerful extensor of the knee joint. Some of the abdominal cavity through the femoral canal and drain tendinous fibers of the vastus lateralis and vastus medi- into the external iliac nodes. alis form bands, or rednacola, which join the capsule of the knee joint and strengthen it. The lowest muscle fibers of the vastus medlalls are almost horizontal and Thigh Fascial Compartments and Muscles prevent the patella from being pulled laterally during Three fascial septa pass from the inner aspect of the contraction of the quadriceps muscle. The tone of the deep fascial sheath of the thigh to the linea aspera of quadriceps muscle greatly strengthens the knee Joint. the femur (see Fig. 11.21). This arrangement divides The rectus femoris muscle is the only component of the the thigh into three compartments, ea.ch having its quadriceps that crosses the hip joint, and it flexes the own complement of muscles, nerves, and arteries. hip in addition to extending the knee. 538 CHAPTER 11 Lower Limb Anterior superior iliac spine Lateral cutaneous nerw of thigh. \. Femoral artery ' Femoral vein ' Femoral sheath Femoral canal Inguinal llgament Lateral femoral ~~~~::--- Pubic tubercle dn::umtlex artery Gracllls Vastus lntermedlus Vastus medlalls Shaft of femur Saphenous nerve lliotibial tract Figure 11.2' Femoral triangle and adductor (subsartorial) canal in the right lower limb.  Thigh 539 Tensor fasclae latae Muscular branches of femoral nerve Profunda femoris artery Lateral femoral circumflex Adductor artery longus Vastus lateralls Intermediate cutaneous nerve of the thigh Rectus femoris Flgul'9 11.25 Dissection of the femoral triangle in the left lower limb. Femoral nerve.,....,.........,,~ Anterior division l- Obturator nerve - Posterior division Profunda femorls artery Adductor magnus Flgul'911.26 Relationship between the obturator nerve and the adductor muscles in the right lower limb. 540 CHAPTER 11 Lower Limb Table 11.2 Muscles of Anterior Fascial Compartment of Thigh Sartorius Anterosuperior iliac Upper medial surface of Femoral nerve L2,3 Flexes, abducts, laterally spine shaft of tibia rotates thigh at hip ~o..i joint; flexes and medially Iliacus I --+-1r,-a-. to... of h;p bone w;th.,.,, ;nto 1.... trochanter of femur neM> rotates leg at knee joint --+- Flexes thigh on trunk; if thigh is fixed, it flexes the trunk on the thigh as ~I in sitting up from lying down Psoas r,.""'""......,,... bodies, and I w;th m..,, ;nto ,.... trochanter of femur Lumba ' '"" I L1, 2, 3 Flexes thigh on trunk; if thigh is fixed, it flexes intervertebral discs of the trunk on thigh as the 12th thoracic and in sitting up from lying five lumbar vertebrae down Pectineus1 uperiommus of pubis IUpper end of J;nea aspera of shaft of femur Femo..t ner.e (sometimes L2,3 Flexes and adducts thigh at hip joint obturator nerve) ~~- -~~----'-- Quad rl cep 1 Femorls Rectus Straight head: ~adriceps tendon - - y emoral nerve L2. 3, 4 Extension of leg at knee fem oris anteroinferior iliac into patella, then via joint; flexes thigh at hip spine Reflected ligamentum patellae into joint head: ilium above acetabulum tubercle of tibia I Vastus Upper end and shaft Quadriceps tendon Femoral ner1e L2, 3, 4 Extension of leg at knee lateralis of femur into patella, then via joint ligamentum patellae into I tubercle of tibia -- Vastus medialis Upper end and shaft of femur Quadriceps tendon into patella, then via I Femoral nerve L2, 3, 4 Extension of leg at knee joint; stabilizes patella -- ligamentum patellae into I tubercle of tibia Vastus Anterior and lateral Quadriceps tendon Femoral ner1e L2, 3, 4 Extension of leg at intennedius surfaces of shaft of into patella, then via knee joint; articularis femur ligamentum patellae into genus retracts synovial -- tubercle of tibia