Posterior intramuscular septum Femur Iliotibial tract Medial intramuscular septum Lateral intramuscular septum Thigh has posterior, anterior, and medial compartments. Thigh is divided by Lateral, medial, and posterior intramuscular septa. Posterior intramuscular septum Sciatic n. Plate 493

Medial intramuscular septum Femur Femoral artery Lateral intramuscular Fascia lata encircles all of the muscles of the thigh Medial compartment is the adductor compartment Anterior compartment is the extensor compartment of the thigh (kicking muscles) Great saphenous vein Sciatic nerve Posterior intramuscular septum Fascia lata

L1 L3 L4 L5 S1 Plate 470

Saphenous opening Femoral v. Lateral cutaneous n. of thigh Great saphenous v. Great saphenous vein – Vein that runs down length of medial aspect of thigh. It crosses knee on posterior aspect. Saphenous opening – opening in the fascia lata where the great saphenous vein dives deep to join the femoral vein Great saphenous v. Saphenous n. Superficial fibular n. Plate 471

Great saphenous v. Plate 473 Superficial inguinal nodes – lymph nodes that lie along great saphenous vein and inguinal ligament superficial to the fascia lata that drain: The external genetalia (except for the testicle which goes to aortic nodes) Inferior portion of anal canal below pectinate line Anterior abdominal wall inferior to the umbilicus (superior to umbilicus drains into the axillary nodes All of the superficial part of lower limb A fissure in the anal canal or a lesion on dorsum of foot, for example, could cause these nodes to enlarge Plate 473

Inguinal ligament Pectineus m. Femoral n. Adductor longus m. Deep inguinal nodes – lymph nodes that lie medial to the femoral vein and receive lymph from: Deep structures and muscles of the lower limb Superficial inguinal nodes Sartorius m. Femoral a. Great saphenous v. Plate 473

Iliopsoas m. Tensor fascia lata m. Pectineus m. Adductor longus m. Gracilis m. Rectus femoris m. Sartorius m. Muscles of the anterior extensor compartment are sartorius and quadricepts (may incldue psoas and articularis genu): Sartorius muscle – means “tailor” Origin: laterally (at ASIS – not mentioned in lecture) Insertion: tibia Action: “helps tailors sit indian style:” Lateral rotation of the hip Flexion of the knee Flexion of the hip Four quadriceps muscles that insert into a common quadriceps tendon: Vastus medialis – medial most muscle; origin from femur; only flexes knee joint Vastus lateralis – lateral most muscle; origin on femur; only flexes knee joint Rectus femoris – in the middle between the two vasti muscles; origin at anterior inferior iliac spine, so also a week flexor of hip joint (Iliopsoas is the powerful hip flexor) Vastus intermedius – deep to rectus femoris; orgin on femur (viewable on next slide); only flexes knee joint Patella – a sesamoid bone embedded in the common quadriceps tendon that forms the knee cap, which serves as a fulcrum of the knee joint Ligamentum patella – the continuation of the common quadriceps tendon after the patella that inserts into the tibial tuberosity Patella creates a fulcrum at the knee joint Tensor fascia lata may be considered with anterior group but it gets its nerve supply from the superior gluteal nerve Vastus lateralis m. Vastus medialis m. Plate 480

Pectineus m. Adductor longus m. Iliopsoas m. (cut) Gracilis m. Vastus intermedius m. Rectus femoris is cut to reveal vastus intermedius right under rectus femoris Vastus lateralis m. Vastus medialis m. Plate 480

Iliopsoas m. Tensor fascia lata m. Pectineus m. Adductor longus m. Gracilis m. Rectus femoris m. Sartorius m. Vastus lateralis m. Vastus medialis m. Plate 480

Psoas major m. Iliacus m. Iliopsoas m. Plate 484 Illustrates how iliopsoas is formed and attaches to lesser trochanter Iliacus m. Iliopsoas m. Plate 484

Pectineus m. Adductor longus m. Iliopsoas m. (cut) Gracilis m. Vastus intermedius m. Medial compartment of the thigh (primarily supplied by the obturator nerve, which divides into an anterior and posterior division): Gracilis muscle – (L. “slender”) runs down the medial side of thigh Origin: Pubis Insertion: proximal end of tibia body Action: Adduction of the lower limb (weakest member of adductor group) Frequently harvested for transplants Pectineus m. -- dif Insertion: Shaft of femur (mostly linea aspera) Action: Hip adduction Innervation: obturrator n. and femoral n. Adductor longus Action Hip Adduction Vastus lateralis m. Vastus medialis m. Plate 480

Obturator externus m. Obturator n. Adductor magnus m. Adductor Adductor brevis – deep to pectineus, Origin: External aspect of obturrator foramen and obturator membrane Insertion: Greater trochanter Action: weak adductor Sandwiched by the anterior and posterior division of the obturrator nerve Red circle is the adductor hiatus (see next slide) Adductor brevis m. Adductor longus m. (cut) Adductor magnus m. Plate 527

Obturator externus m. Pectineus m. (cut) Adductor magnus m. Adductor (Everything taken off except adductor Magnus.) Adductor Magnus – fills in medial side of femur; part of it is a hamstring Origin: Inferior pubic ramus to ischial tuberosity Insertion: proximal femur [linea aspera] down to medial condyle Action: Adduction of thigh; extension of hip Innervations: adductor portion by obturator nerve; hamstring portion by tibial portion of sciatic nerve Perforating arteries – Arteries that travel from the medial compartment through a series of small holes in the adductor magnus tendon to supply the posterior compartment of the thigh Adductor hiatus – A gap between the adductor magnus m. and the femur that allows the passage of the femoral a. and v. to the popliteal fossa where they become the popliteal a. and v. Thus, there are two muscles in the medial compartment that receive dual innervation: Pectineus: obturator n. and femoral n. Adductor magnus: obturator n. and tibial n. The three adductor muscles from superficial to deep are Adductor longus Adductor brevis Adductor magnus The only muscle of adductor compartment that can act on knee joint is gracilius, but it’s a relatively weak muscle Adductor brevis m. (cut) Adductor longus m. (cut) Plate 481

Lasteral cutaneous n. of thigh Femoral n. Femoral a. Femoral v. Iliopsoas m. Anterior and medial compartment don’t have a clearly defined boundaries. Femoral triangle Borders: Laterally bordered by sartorious Medially bordered by adductor longus Superiorly borded by the inguinal ligament (the bas) The apex is where sartorious and adductor longus cross The floor consists of iliopsoas laterally and pectineus/adductor longus medially The roof is the fascia lata Contents (medial to lateral): Empty femoral canal Femoral vein Femoral artery Femoral nerve Femoral hernia – Bowel protruding through femoral canal; tends to occur in females because shape of pelvis makes opening wider Branches: Superficial epigastric artery – (and vein) ascend between the two layers of superficial fascia toward the umbilicus Superficial circumflex iliac vessels (external pudendal) Caput medusae– engorgement of periumbilical [due to portal hypertension; blood flows through superficial eipigastric v. to femoral v. to IVC] Greater saphenous vein – ascends over the posterior border of the medial epicondyle of the femur bone and then courses anteriorly to penetrate the fascia lata in the saphenous opening to join with the femoral vein in the femoral triangle Sartorius m. Adductor longus m. Plate 488

Sartorius m. (cut) Deep a. of thigh Femoral n. Femoral a. Femoral v. Sartorious is cut The femoral nerve gives several branches Vasti and Sartorius, for example receive braches of femoral nerve Sartorial canal (adductor canal or hunter’s canal) – the canal deep to the sartorius muscle that is traversed by the femoral artery and vein as they descend the leg anteriomedially from the apex of the femoral triangle contains Femoral a. Femoral v. Saphenous n. Nerve to vastus medialis Only femoral artery and vein pass through the adductor hiatus Saphenous nerve – a branch of the femoral that passes down the sartorial canal emerges from the canal to travel with the saphenous vein along the leg. Mainly supplies cutanous sensation to the medial leg Saphenous n. Rectus femoris m. Vastus medialis m. Plate 488

Fascia lata (reflected) Great saphenous v. Plate 255 Femoral canal, artery, and vein bring out fascia from abdomenal canal Femoral sheath – contains filmy investing fascia that surrounds femoral artery, vein, and canal. NOT the femoral nerve because it’s already outside of external transversalis fascia. 3 compartments—one for artery one for vein, and one for canal From Book (P553): Femoral sheath – funnel shaped fascia tube that passes deep to the inguinal ligament, lining the vascular compartment of the retro-inguinal space. It blends in with the adventitia of the vessels Formed by an interior prolongation of the transveralis and iliopsoas fascia from the abdomen It does not enclose the femoral nerve because the nerve passes through the muscular compartment Allows the femoral artery and vein to glide deep to the inguinal ligament during movements of the hip joint Subdivided by vertical septa of extraperitoneal connective tissue into three comparments: Lateral compartment for artery Intermediate compartment for vein Medial compartment for femoral canal Allos femoral vein to expand Contains loose CT,fat, and a few lymph vessels, and sometimes a ndoe Femoral ring – entrance to femoral canal which has borders: Medially: lecunar ligament Laterally: verticle septum between the femoral canal and femoral vein Posteriorly: superior pubic ramus covered by pectineus muscle and fascia Anteriorly: medial part of the inguinal ligament Great saphenous v. Plate 255

Lat. cut. N. of thigh External iliac a. and v. Pectineus m. Netter as cut hole in femoral sheath Thus there are two layers—fasica lata and femoral sheath Pectineus m. Fascia lata (reflected) Femoral sheath Sartorius m. Adductor longus m. Plate 255

Femoral a. (cut) Adductor brevis m. Obturator n. Perforating aa. Deep a. of thigh Adductor longus m. (cut) Gracilis m. Femoral artery and vein are cut Profunda Femoris (Deep artery of the thigh) – A branch of the femoral artery just inferior to the inguinal ligament, which supplies the medial adductor compartment Perforating arteries – branches of profunda femoris that perforate the tendon of adductor magnus to supply the posterior compartment (hamstrings) The last perforating branch terminates the profunda femoris Perforating arties also supply adductor magnus as they pass through Obturator comes off internal iliac to supply the posterior compartment of the thigh as well (smaller player) Femoral a. and v. Plate 489

Perforating aa. Biceps femoris m. (long head) Semitendinosus m. Biceps femoris m. (short head) Semimembranosus m. Tibial n. Popliteal a. Common fibular n. Popliteal v. Small saphenous v. Plate 490

Iliopsoas m. Femoral a. (cut) Medial femoral circumflex a. Pectineus m. Femoral artery does not supply anything in the thigh; it is the major pipline passing through Deep artery of the thigh supplies much of the thigh muscles in all 3 compartments Circumflex femoral arteries – Contribute to the anastomic circulation around the hip joint Lateral femoral circumflex – branch directly courses laterally Descending branch of lateral circumflex femoral artery – is the blood supply to the quadriceps. Medial femoral circumflex – branches courses medially first Lateral femoral circumflex a. Deep a. of thigh Plate 492

Deep a. of thigh Perforating aa. Femoral a. Popliteal a. Plate 500 Femoral artery passes through adductor hiatus to form popliteal artery that enters the leg Popliteal a. Plate 500

Pectineus m. Saphenous n. Plate 526 Saphenous nerve descends and comes out at the level of the knee and becomes a subcutaneous sensory nerve along medial leg It does not go through adductor hiatus. It parts company with the vessels and goes superficial Saphenous nerve goes all of the way down to the foot Saphenous n. Plate 526

Obturator externus m. Adductor brevis m. Adductor hiatus Plate 527 Obturrator nerve mainly supplies adductor (medial compartment) Adductor brevis m. Adductor hiatus Plate 527

Gluteus medius m.(covered by gluteal fascia) Crest of ilium Gluteus medius m.(covered by gluteal fascia) Tensor fascia lata m. Gluteus maximus m. Biceps femoris m. (long head) Semitendinosus m. Posterior view Popliteal fossa formed by: Superiomedially: Semimembranousis, semitendonsis, Superiolaterally: bicepts femors Inferior borders: gastrocnemous Semimembranosus m. Biceps femoris m. (short head) Plate 495 Common fibular n. Gastrocnemius m. (lateral head) Plate 483

Gluteus medius m. Gluteus maximus m. Gluteus minimus m. Superior gluteal a. Piriformis m. Inferior gluteal n. Sciatic n. Pudendal n. Biceps femoris m. (long head) Sciatic nerve comes down the length of the posterior thigh The common fibular nerve passes laterally to the popliteal fossa and closely associates with head and neck of fibula Contained within the popliteal fossa is: Popliteal artery, a continuation of the femoral artery Popliteal artery gives off genicular arteriesin the fossa that provide collateral circulation along the knee joint Popliteal vein, a precursor to the femoral vein Short (small) Saphenous vein meets up with the popliteal vein Tibial nerve Short saphenous vein [originates at the 5th digit] and crosses ankle on lateral side Great saphenous vein originates on dorsal side of the foot [near the first digit] Post. cutaneous n. of thigh Semiitendinosus m. Semimembranosus m. Popliteal a. Plate 490

Intercondylar eminence Head of fibula Tuberosity of tibia Anterior border (shin) Tibea medially Fibula laterally Bony (palpable) landmarks of the leg Shin – the anterior, SQ border of the tibia Knee joint = tibea + patella Maleoli Tibial tuberosity – where patellar ligament attaches (continuation of quadriceps tendon) Fibula has head, narrow neck, and a shaft Fibula is buried deep in muscle Medial malleolus Lateral malleolus Plate 501

Head of fibula Soleal line Lateral malleolus Medial malleolus Posterior view Soleal line – diagonal ridge of bone on posterior edge of tibia. The soleus muscle takes origin here Lateral malleolus Medial malleolus Plate 501

Interosseous membrane True interoseus membrane connecting the two. There are openings at the proximal and distal end Plate 502

Interosseous membrane Anterior intermuscular septum Interosseous membrane Tibia Transverse intermuscular septum Fibula Crural Fascia – the fascia that surrounds the leg The crural fasica blends with the periostium of the tibia anteriorly Anterior and posterior intermuscular septaeattach to fibula to divide the legs into Anterior, Lateral, and Posterior compartments There is also a septum that separates the posterior compartment into a superficial and deep part Posterior compartment Posterior intermuscular septum Crural fascia Plate 510

Superficial posterior compartment Anterior compartment Tibia Fibula Lateral compartment The lateral compartment has no artery, but it does have a nerve One compartment without an artery is the lateral (but there is a nerve) Short saphenous vein found in the SQ tissue above posterior compartment Deep posterior compartment Superficial posterior compartment Plate 522

Common fibular n. Small saphenous v. Gastrocnemius Gastrocnemius m. m. (lateral head) Gastrocnemius m. (medial head) Gastrocnemious Origin: femur Insertion: calcaneal tendon (about midcalf) Action: Plantar flexion, flexon of knee joint Calcaneal tendon Plate 504

Plantaris m. Soleus m. Gastrocnemius m. (cut) Tendon of plantaris m. Soleus – found just deep to gastroc Origin: soleal line (tibia) Insertion: calcaneus tendon Action: plantar flexion Achilles (calcaneal tendon) –the combined tendon of soleus and achilles tendon Plantaris – muscle belly crosses medially and becomes tendonous, which is used for harvest [Origin: femur] Insertion: calcaneus bone Action: Flex the knee joint, plantar flex the ankle joint (neither action is significant) When achilles ruptures there is a loud pop and there is a knot of that muscle bellies When plantaris ruptures there is no knotting or need for repair Plate 505

Tibial n. Popliteal a. Posterior tibial a. Popliteus m. Flexor hallucis longus m. Flexor digitorum longus m. Gastrocnemius and plantaris and soleus are cut to expose the four muscles of the deep posterior compartment of the thigh (medial is left, lateral is right) Three of the muscles have tendons that cross the medial aspect of the ankle posterior to the medial maleolus and are weakly involved in plantar flexion: Flexor Hallucis longus – thick and fleshy powerful muscle Origin: mainly the fibula Insertion: plantar surface of distal phalanx of digit 1 Tibialis posterior Origin: mainly the innerosseus membrane Insertion: Action: Flexor digitorum longus Origin: mainly the tibia Insertion: distal phalanges of digits 2-5 At full extension, the knee joint rotates 5 degrees so it can lock and that the extensor muscles can relax because of: Popliteaus muscle – runs on a transverse plane to cross the knee joint posteriorly Origin: Lateral condylar portion of the femur Insertion: Tibia above soleal line Action: Unlocks the knee by rotating the knee joint 5 deg The nerve supply to the entire posterior leg (superficial and deep) is tibial The last thing that leaves the floor when you push off is the big toe Tibialis posterior m. Plate 506

Popliteal a. Anterior tibial a. Posterior tibial a. Fibular a. When popliteal artery crosses the popliteaus muscle it divides into it’s terminal branches: Posterior tibial artery – continues down the deep posterior compartment and crosses medial maleolus of ankle Fubluar artery – branch of posterior tibial artery that passes laterally in the deep posterior compartment and enters muscle belly of flexor hallucis longus Anterior tibial artery – originates in deep posterior compartment and moves into anterior compartment through gap in proximal end of interosseus membrane There is no artery in the lateral compartment of the leg. It is supplied by perforating branches of the fibular artery that pierces the intermuscular septum Popliteal artery supplies the muscular belly of Gastrocnemus

Extensor hallucis longus m. Tibialis anterior m. Tibia Anterior compartment of the leg has three long muscles (medial to lateral) that will all dorsiflex that ankle joint: Tibialis anterior – runs along lateral aspect of the shaft of the tibia Origin: mainly the tibia Insertion: Action: helps in dorsiflexion, inversion Extensor hallucis longus – buried, but can see the tendon heading to the great toe Origin: mainly interosseus membrane Action: Extensor digitorum longus – has five tendons going Origin: mainly fibula Insertion: toes 2-5 and an the extra tendon of fibularis tertius (the inferior fibers of EDL) Inversion – turing foot inward so weight is on little toe side (sole of foot is facing medially) Eversion – turning foot outward so weight is on big toe (sole of foot is facing laterally) Extensor hallucis longus m. Extensor digitorus longus m. Extensor retinaculum Plate 507

Tibialis anterior m. Deep fibular n. Anterior tibial a. Superficial fibular n. In the popliteal region, the components of the sciatic nerve part in company Common fibular nerve Only innervates the shorthead of biceps femoris Passes laterally towards neck of the fibula and will divide into Superficial fibular nerve – supplies lateral compartment Deep fibular nerve – supplies anterior compartment Is quite superficial and prone to trauma (automobile bumper, compression from leg cast, etc.) Compression of common fibular nerve (or damage to deep fibular branch) would give symptoms of foot drop because power plantar flexors are now unopposed Trauma to the common fibular nerve ( or the superficail fibular nerve) would cause eversion (because inverters are lost) Anterior tibial artery appears in anterior compartment. It will link up with the deep fibular nerve and will run parallel through anterior compartment Artery and nerve will come down onto the dorsum of the foot Plate 508

Continuation of superficial fibular nerve (it’s the cutaneus branch) Common fibular n. Fibularis longus m. Gastrocnemius m. Continuation of superficial fibular nerve (it’s the cutaneus branch) Superficial fibular nerve—innervated that lateral compartment and then becomes cutaneus The two muscles in the lateral compartment originate on the shaft of the fibula and course posterior to the lateral maleuolus and instert onto the plantar surface of the foot: Fibularis longus – more superficial and performs eversion since it attaches to the 1st metatarsal Fibularis brevis – attaches to the 5th metatarsal bone These muscles are plantar flexors because they are posterior to the lateral maleolus (the folcrum) Blood supply to the of lateral compartment – small branches of the fibular artery from the posterior compartment In summary: 3 Fibularis muscles: Fibularis longus – attaches to the 1st metatarsal (plantar side) Fibularis brevis – attach to the 5th metatarsal (plantar side) Fibularis tertus – attaches to the 5th metatarsal (plantar side) The plantar flexors include All muscles of the deep posterior compartment of the leg except popliteal Fibularis longus and brevis Fibularis brevis m. Soleus m. Extensor retinaculum Fibularis tertius m. Fibular retinaculum Plate 509

Common fibular n. Deep fibular n. Superficial fibular n. Plate 530 Deep fibular nerve innervates the muscles of the anterior compartment and continues to the foot Superficial fibular nerve two muscles of the lateral compartment and then becomes sensory nerve that takes care of the distal part o f the leg and the dorsum of the foot Plate 530