Introduction Lower limb is designed to support the body, its weight & it is mainly responsible for gait Organization of the Lower Limb Lower limb has four parts i)Thigh ii) Leg iii)Ankle Foot Superficial fascia of the lower Limb Fatty & Membranous layers Superficial nerves, superficial vessel, & superficial inguinal lymph nodes are present b/w these two layers. 1

pelvis Dr. Vohra2

Hip bone Dr. Vohra3

femur Dr. Vohra4

Movement at hip joint Dr. Vohra5

Deep fascia of the lower limb Fascia Lata (deep fascia of the thigh) Crural Fascia (deep fascia of the leg) Iliotibial Trat Saphenous Opening 6

supe fascial Veins: Great Saphenous Vein Small Saphenous Vein An opening or a gape in the deep fascia in the front of the thigh 4cm inferolateral to the pubic tubercle. The saphenous opening is covered by loose CT called CRIBRIFORM fascia. 7

Fascial Compartments of the Thigh Three fascial septa pass from the inner aspect of the deep fascial sheath of the thigh to the linea aspera of the femur. Making Anterior posterior & Medial compartments. Having muscles, nerves & arteries. Dr. Vohra8

The anterior compartment of the thigh muscles of the anterior compartment of the thigh are sartorius, the quadriceps femoris which include ( rectus femoris, vastus lateralis, vastus medialis, and vatus intermedialis muscles) all are supplied by the femoral nerve Dr. Vohra9

Muscles of the Anterior Fascial Compartments of the Thigh 10

Muscles of the Anterior Fascial Compartments of the Thigh Quadriceps Femoris Dr. Vohra11

Blood Supply of the Anterior Fascial Compartments of the Thigh Femoral Artery main artery of lower limb Origin Continuation of Ext. Iliac artery below the inguinal ligament. Enters the thigh midway between the ant. Sup. Iliac spine & pubic Symphysis Termination Ends at the opening in the adductor magnus muscle by entering the popliteal fossa as popliteal artery Branches Superficial: Sup. Ext. Pudendal Sup. Epigastric Sup circumflex iliac Deep: Profunda femoris Deep Ext. pudendal Descending genicular Lat. Cir femoral Med. Cir. Femoral 4 perforating a 12

Femoral artery Dr. Vohra13

Femoral nerve (L2,3,4) arise from the lumber plexus in the abdomen descend in groove between psoas and iliacus muscles and give branch to iliacs. it enters the thigh posterior to the inguinal ligament and lateral to the femoral sheath. 2cm below the inguinal ligament it ends by dividing into anterior and posterior branches. The anterior division gives: a-Cutaneous nerves includes the anterior cutaneous nerve of the thigh. b-muscular branches to the sartoris and through which it gives genicular branch to the hip joint. The posterior division gives: a- Saphenous nerve (L3 L4). It is the longest branch of the the medial side of the foot. b- Muscular branches to the quadriceps femoris muscle (rectus femoris, vastus lateralis, medialis and intermedius(. Dr. Vohra14

Femoral Triangle A triangular depressed area situated in the upper part of the frontof the thigh just below the inguinal ligament 15

Bounderies: Superiorly(base): the inguinal ligament. Medially: the medial border of the adductor longus muscle. Laterally: medial border of the sartorious muscle. Inferiorly (apex): is formed as Sartorius crosses over the lower part of adductor longus m. continuous with the adductor canal. Dr. Vohra16

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Contents of the triangle 1-Femoral sheath It is an extension of the transveralis fascia of the abdominal cavity which surrounds the upper 2-3 cm of the femoral vessels below the inguinal ligament. The sheath is divided into 3 compartments, the femoral artery occupy the lateral part of the sheath while the vein is intermediate, medial to the femoral vein is the tubular femoral canal, through which femoral hernia may pass. Dr. Vohra18

Femoral canal It is a short fascial tube about 0.5 inch occupy the medial compartment of the femoral sheath, inferiorly it is rapidly decreased in width and closed by fusion of its walls. The wide upper end called the femoral ring which is separated from the abdominal cavity only by peritoneum. It contains fatty connective tissues, efferent lymph vessels from the deep inguinal lymph nodes and one or two of the deep inguinal lymph node. Boundaries of the femoral ring: Inguinal ligament anteriorly The sharp edge of the lacunar ligament medially The pectin pubis posteriorly Dr. Vohra19

2-The femoral vessels at the apex. 3- Profunda femoris artery. 4-The lateral and medial circumflex arteries,. 5-Deep external pudendal artery deep inguinal lymph. 7-The femoral branch of the genitofemoral nerve supply skin over the triangle. 8-Lateral cutaneous nerve of the thigh L2 L3. 9-Femoral nerve Dr. Vohra20

The medial side (adductor) of the thigh Includes the adductor muscles which arise from the external surfaces of the pubic rami and the ramus of the ischium. they concerned with adduction at the hip joint, the muscles are: pectineus, adductor longus, adductorbrevis, adductor magnus, gracilis The nerve supply of these muscles is the obturator nerve (L2, 3, 4).except the hamstring portion of adductor magnus from sciatic N. and pectineus m. receive nerve supply from both femoral and obturator N. Dr. Vohra21

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Adductor M. Insertion Origin Dr. Vohra23

The obturator nerve : arises from the lumbar plexus in the abdomen it descends medial to the psoas m. at the lateral wall of the pelvis here it join the obturator vessels and enters the obturator canal where it divides into anterior and posterior branches: Anterior branch: descends in the thigh between adductor longus and adductor brevis muscles it sends branches to the these two muscles and gracilis m it also supply the hip joint. Posterior branch: pierces the obturator externus m. and descends between adductor brevis and magnus muscles. Supply these 3 muscles and ends as an articular branch through adductor magnus to the back of the knee joint Dr. Vohra24

OBT. N Dr. Vohra25

Obturator artery: It is a branch of Internal iliac artery,passes through obturator canal,divides into anterior and posterior brancheswhich form a circle andanastomoses with medial circumflex femoral artery. Supplies the neighbouring muscles and hip joint. Dr. Vohra26

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adductor canal Dr. Vohra28 An intermuscular cleft situated on the medial aspect of the middle 3 rd of the thigh Contents of adductor canal Femoral artery & vein Saphenous nerve Nerve to vastus med Obturator nerve Profunda femoris

Femoral artery & vein Catherization Varicose veins Veinous cut down Saphenous vein in coronary bypass surgery Femoral hernia Clinical Notes 29

gluteal region Extends from the iliac crest above to the gluteal fold below. The superficial fascia is thick dense and fatty, Dr. Vohra30

The greater &lesser sciatic foramen: Sacrotuberous ligament,Sacrospinous ligament

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Structures which enter the gluteal region from the pelvis which include 1-Superior gluteal vessels and nerves. 2-the piriformis muscle 3-.inferior gluteal vessels and nerves 4-sciatic nerve, 5-the posterior cutanous of the thigh 6-pudendal nerve 7—nerve to quadrates femoris The lesser sciatic foramen:, transmits structures between the gluteal region and the perineum these include; the internal pudendal vessels, pudendal nerve and nerve to obturator internus muscle. Dr. Vohra33

Muscles of the gluteal region : Superficial abductors and extenders – A group of large muscles that abduct and extend the femur. It includes the gluteus maximus, gluteus medius, gluteus minimus and tensor fascia lata. Deep lateral rotators – A group of smaller muscles, that mainly act to laterally rotate the femur. It includes the quadratus femoris, piriformis, gemellus superior, gemellus inferior and obturator internus and obturator externus.

Glut. region Dr. Vohra35

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Greater S.F transmit : 1. piriformis 2. sup. Gluteal n. and vessels. 3.infer. Glut. N. and vessels. 4sciatic n. 5. post. Cut. N of thigh. 6. pudendal n. 7. nerve to quadratus femoris m. lesser s. f. transmit pdendal n., internal pudendal art. And nerve to obtur. Intern. M.. Dr. Vohra37

Artery of gluteal region Superior gluteal arteryI nferior gluteal artery

Gluteal nerve Dr. Vohra39

Deep lateral rotators Dr. Vohra40

The back of the thigh The muscles of the back of the thigh are the hamstring muscles which are extensors of the hip joint and flexors of the knee joint, all arise from the ischial tuberosity except the short head of the biceps m. and all are inserted in the bones of the leg. These muscles include: biceps femoris, semitendinosus and semimembranosus. All supplied by the sciatic nerve. Dr. Vohra41

Action hamstring muscles are extensors of the hip joint and flexors of the knee joint. In addition both semiten.and semimem.act as medial rotaters of leg when knee joint semiflexed.biceps femoris act as lateral rotater of leg when knee joint semiflexed Dr. Vohra42

Sciatic nerve (L4 L5 S1 S2 S3): it is the thickest nerve in the body arise from the lumbo sacral plexus, pass inferior to the piriformis m through the greater sciatic foramen, deep to the gluteus maximus m. in the upper part of its course it descends over 1-ischial wall of the acetabulum. 2-Obturator internus m. and the 2 gemelli ms. 3 -Quadratus femoris m. It leaves the buttock by passing deep to the long head of the biceps femoris, it supply the hamstring ms from the tibial side of the nerve except the short head of biceps muscle receive its nerve supply from the common peroneal side, it also gives articular branch to the hip joint. the sciatic nerve then descends on the posterior surface of the adductor magnus m. at the lower third of the thigh it divided into medial branch (tibial nerve) and lateral branch (common peroneal nerve). Dr. Vohra43

The popliteal fossa Contents of the fossa These include: 1- The popliteal vessels. 2- Branches of the sciatic nerve the tibial and common peroneal nerves. 3- Popliteal lymph nodes. 4- Posterior cutaneous nerve of the thigh. Dr. Vohra45

HIP JOINT it is a synovial joint of ball and socket type, the joint formed between the head of the femur and the acetabulum, the articular surface of which is horseshoe shaped and is deficient inferiorly at the acetabular notch. The cavity of the acetabulum is deepened by the presence of a fibrocartilaginous rim called the acetabular labrum, the labrum is connected across the acetabular notch by the transverse acetabular ligament. The strength and stability of the joint depend on : 1-depth of the acetabulum which increased by the labrum acetabulae. 2-The strong ligaments and m

Ligaments of the joint 1-iliofemoral ligament is a strong ligament lie in the front of the joint. it is inverted Y shaped. 2-Pubofemoral ligament it is triangular ligament lie in the lower anterior part of the capsule. 3-Ischiofemoral ligament it is spiral in shape lie posteriorly. 4-The transverse acetabular ligament it converts the notch into a tunnel through which the blood vessels and nerves enter the joint. 5-Ligaments of the head of the femur it is flat attached to the pit on the head of the femur and by its base to the transverse acetabular ligament.

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