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T H E L OW E R L I M B.

T ABLE OF C ONTENTS
Hip Bone ................................................................................................................... 3
Femur ......................................................................................................................... 4
Saphenous Veins ...................................................................................................... 4
Cutaneous nerves ..................................................................................................... 6
Fascia Lata ................................................................................................................. 6
Lymphatic Drainage of Anterior Thigh ............................................................... 7
Adductor Muscles .................................................................................................... 8
Obturator Nerve & Artery ..................................................................................... 9
Flexor Muscles........................................................................................................ 10
Boundaries .............................................................................................................. 12
The Subsartorial Canal .......................................................................................... 12
Femoral Vein .......................................................................................................... 12
Femoral Artery ....................................................................................................... 13
Femoral Sheath....................................................................................................... 15
Femoral Nerve........................................................................................................ 16
Gluteal Muscles ...................................................................................................... 17
Gluteal Nerves........................................................................................................ 19
Gluteal Arteries ...................................................................................................... 21
Gluteal Veins .......................................................................................................... 21
Posterior Thigh Muscles ....................................................................................... 22
Articular Surfaces ................................................................................................... 23
Inrinsic Ligaments ................................................................................................. 24
Innervation to Hip Joint ....................................................................................... 24
Arterial Supply to Hip Joint ................................................................................. 25
Articular Surfaces ................................................................................................... 26
Articular Capsule .................................................................................................... 26

P REPARED

BY

M ICHAEL C. D AVID

Synovial Capsule..................................................................................................... 26
External Intrinsic Ligaments ................................................................................ 27
Internal Intrinsic Ligaments ................................................................................. 28
Menisci of the knee joint ...................................................................................... 29
Bursae Of the Knee ............................................................................................... 30
Superficial Muscles................................................................................................. 31
Deep Muscles.......................................................................................................... 33
Tibial Nerve ............................................................................................................ 34
Structures Under The Flexor Retinaculum ........................................................ 34
Arterial Supply ........................................................................................................ 35
Extensor Retinacula ............................................................................................... 36
Boundaries............................................................................................................... 36
Muscles Of The Anterior Compartment............................................................ 37
Deep Peroneal Nerve ............................................................................................ 39
Anterior Tibial Artery ............................................................................................ 39
Boundaries............................................................................................................... 40
Peroneal RetinaculA .............................................................................................. 40
Superficial Peroneal Nerve ................................................................................... 40
Arterial Supply ........................................................................................................ 40
Muscles of Lateral Compartment ........................................................................ 41
Articular Surfaces ................................................................................................... 42
Ligaments ................................................................................................................ 42
Neurovascular Supply to Ankle ........................................................................... 43
Movements.............................................................................................................. 43
Talo-Calcaneal Joint (SUB-TALAR JOINT) ........................................................... 44
Talo-Calcaneo-Navicular Joint............................................................................. 44

ON

23/08/08.

P AGE 1

OF

52

Intrinsic Ligaments ................................................................................................ 45


Movements.............................................................................................................. 45
Calcaneo-Cuboid Joint .......................................................................................... 46
1st Layer of Plantar Muscles ................................................................................. 47
2nd Layer of Plantar Muscles ................................................................................ 47
3rd Layer of Plantar Muscles ................................................................................. 48

P REPARED

BY

M ICHAEL C. D AVID

4th layer of Plantar Muscles................................................................................... 48


Muscles of Dorsum of Foot................................................................................. 50
Supports of Arches of Foot ................................................................................. 50
Arterial Supply To Foot ........................................................................................ 51
Cutaneous Nerve Distribution in The Foot ...................................................... 52

ON

23/08/08.

P AGE 2

OF

52

T HE H IP AND T HIGH A REAS


H I P B ON E

Consists of three separate bones that only fuse together at the Acetabulum at 15-17 years. Complete fusion only after 23.
ILIUM

Iliac crest form superior border of Ilium, with an internal and external lip. It terminates anteriorly at the Anterior Superior Iliac Spine, and posteriorly at the
Posterior Superior Iliac Spine. Highest point of Iliac Crest lies at level of L4.
Posterior part of internal surface of ilium articulates with the sacrum at the sacroiliac joint. Inferior to this is the greater sciatic notch.
ISCHIUM

Inferior end of body, has a rough projection = Ischial Tuberosity.


Ischial spine separates the greater sciatic notch from the lesser sciatic notch.
Sacrospinous ligament spans the greater sciatic notch, converting it to the greater sciatic foramen.
Sacrotuberous & Sacrospinous ligaments convert the lesser sciatic notch into the lesser sciatic foramen.
Ramus of the Ischium passes medially, to form the Ischiopubic Ramus, that inferiorly bounds the Obturator Foramen.
PUBIS

Superior Ramus travels supero-laterally, up to the Acetabulum, where it fuses with the Ischium and the Ilium.
Inferior Ramus travels poster-inferiorly, to form the Pubic Arch and the Ischiopubic Ramus.
Body of Pubis lies medially, and joins body of opposite Pubis, at the Pubic Symphysis. Superior border of pubis is thickened = Pubic Crest.
Pubic Tubercle projects anterior, and lies 2.5-cm lateral from the median plane.
From here two ridges diverge laterally: the Pecten Pubis (Pectineal Line), and the Obturator Crest.

P REPARED

BY

M ICHAEL C. D AVID

ON

23/08/08.

P AGE 3

OF

52

FEMUR

Head is smooth and spherical, and directed supero-antero-medially, into the acetabulum.
A little inferior and posterior to its centre, is the fovea / pit. This is where the Ligament of Head is attached.
Angle between shaft and neck = 125.
If angle reduced Coxa Vara through fracture of neck.
If angle greater Coxa Valga through congenital dislocation of the hip.
Greater Trochanter is lateral, and Lesser Trochanter is medial. Connected anteriorly by Intertrochanteric Line (produced by Iliofemoral ligament), and
posteriorly by the Intertrochanteric Crest.
Anterior shaft is featureless.
Posterior shaft has:
Linea Aspera = rough ridge of bone with medial and lateral lips.
Gluteal Tuberosity = proximal divergence of lateral lip of Linea Aspera.
Spiral Line = proximal divergence of medial lip of Linea Aspera, terminating anteriorly at the Intertrochanteric Line.
Lateral Supracondylar Line = distal divergence of lateral lip of Linea Aspera, that bounds the lateral Condyle of the Femur.
Medial Supracondylar Line = distal divergence of medial lip of Linea Aspera, that bounds the medial Condyle of the Femur, and terminates as the
Adductor Tubercle.
S A P H E N OU S V E I N S

GREAT SAPHENOUS VEIN

Begins at medial end of dorsal venous arch of the foot.


Passes anteriorly to medial malleolus of tibia, accompanied by the Saphenous nerve.
Ascends obliquely up antero-medial aspect of tibia to medial side of knee. Here it lies superficial to the medial epicondyle, a handbreadth posterior to the
medial border of the patella.
Ascends superolaterally, up the femur, to the Saphenous opening, where it turns posteriorly, and pierces the anterior femoral sheath, to drain into Femoral
Vein.

P REPARED

BY

M ICHAEL C. D AVID

ON

23/08/08.

P AGE 4

OF

52

Drains:
Dorsal Venous Arch of the foot.
Medial Dorsal Vein of the great toe.
Medial Marginal Veins of sole of foot.
Numerous tributaries from leg and thigh alternatively these can form the Accessory Saphenous vein.
Communications from the Small Saphenous Vein.
Lateral & Anterior Cutaneous Veins, from networks of veins in the inferior thigh.
Superficial Circumflex Iliac Vein from lateral groin.
External Pudendal Veins drains superficial aspects of external genitalia.
Superficial Epigastric Vein from superficial abdominal veins below umbilicus.
SMALL SAPHENOUS VEIN

Begins posterior to the lateral malleolus, from the union of veins arising from:
The lateral part of the Dorsal Venous Arch of the foot.
The dorsum of the 5th digit.
The lateral edge of the foot and sole.
Passes on lateral side of foot with the Sural nerve. Passes lateral to tendo calcaneus, and ascends tibia in the deep fascia between the two heads of Gastrocnemius.
At popliteal fossa, it perforates the deep popliteal fascia, and terminates as the Popliteal Vein.
GENERAL VENOUS DRAINAGE

Three groups of veins:


Superficial saphenous veins.
Deep formed by Venae Comitantes of arteries.
Perforating connects deep and superficial veins, and are found in ankle & lower leg.
Veins have valves to help the return of blood to the heart. Perforating Veins have specialised valves that prevent blood from passing from deep to superficial
veins. Deep veins have muscles and arteries close by that raise the pressure, but superficial veins carry blood at low pressure. Thus valves oppose the natural
pressure gradient, that would otherwise distend the superficial veins. Damage of these valves causes varicose veins.

P REPARED

BY

M ICHAEL C. D AVID

ON

23/08/08.

P AGE 5

OF

52

C U TA N E O U S N E RV E S

Anterior thigh, is innervated directly/indirectly by the Lumbar Plexus, situated in the posterior abdominal wall, and formed by the ventral primary rami of L1 to L4.
NERVE.

ROOT.

INNERVATION

Femoral Br. Of Genitofemoral Nerve

L1, L2

Skin immediately below central


third of Inguinal Ligament, on
anterior thigh.

Ilio-inguinal nerve

L1

Lateral Cutaneous Br. Of Subcostal n.


Lateral Cutaneous Br. Of Iliohypogastric n.
Medial Cutaneous n. of Thigh
Femoral Intermediate Cut. Nerve of
Nerve
Thigh
Saphenous nerve

T12
L1
Posterior branches
of L2 & L3

Lies in hollow femoral sheath of saphenous


opening.
Passes superficially through sheaths anterior wall,
and Fascia Lata.
1. Lowest part of anterior abdominal wall
2. Medial branches innervate external genitalia.
3. Main branch supplies skin under medial end of Inguinal Ligament.
Skin anterior to greater Trochanter of Femur.
Innervates skin over lateral part of anterior thigh, below the Iliac Crest.

Anterior and medial thigh, up to knee.

L4

Skin below knee joint.

L2, L3

Skin over lateral part of anterior


thigh.

Lateral Cutaneous nerve of Thigh

Passes underneath Inguinal Ligament, deep to


Fascia Lata.
Pierces Fascia Lata, 4 cm below Inguinal Ligament,
Passes superficially.

FA S C I A L A TA

Deep fascia of thigh, that forms a sleeve around the muscle, to increase their efficiency, by allowing them to move across each other.
Anteriorly attached to: Pubis (medially), the external lip of the Iliac Crest (laterally), and the Curved Lower border of the Inguinal Ligament.
Just below medial end of Inguinal Ligament, it splits into 2 overlapping layers: a deeper medial layer, and a lateral layer.
Between these layers is the Saphenous Opening, in which lies the Femoral Sheath.

P REPARED

BY

M ICHAEL C. D AVID

ON

23/08/08.

P AGE 6

OF

52

LY M P H A T I C D R A I NA G E O F A N T E R I OR T H I G H

Superficial Inguinal Lymph Nodes, in superficial fascia below Inguinal Ligament.


Horizontal group.
Lies inferiorly and parallel to the Inguinal Ligament.
Medial nodes drain:
Superficial vessels of anterior abdominal wall below umbilicus
Superficial vessels of Perineum (= external genitalia, and lower half of anal canal, but NOT
testes).
Lateral nodes drain:
Superficial vessels from back, below level of Iliac Crests.
Vertical Group.
Lies along terminal part of Great Saphenous Vein (i.e. proximal femur)
Drains majority of superficial vessels of lower limbs.
Superficial Inguinal Nodes, themselves drained by vessels passing through the Saphenous Opening, to
the Deep Inguinal Lymph Nodes.
Deep nodes lie medial to Femoral Vein.

P REPARED

BY

M ICHAEL C. D AVID

ON

23/08/08.

P AGE 7

OF

52

M EDIAL C OMPARTMENT OF T HIGH


A D D U C TO R M U S C L E S

NAME.
Pectineus
Adductor Longus

ORIGIN.
Pecten Pubis on superior ramus
of Pubis
Body of Pubis (inferior Ramus
to the Pubic Crest)

INSERTION

INNERVATION
1. Femoral nerve (L2, L3)
2. Branch of Obturator nerve
Anterior branch of Obturator
nerve (L2, L3, L4)

Pectineal Line of Femur


Middle third of Linea Aspera
1. Pectineal (Spiral) Line
2. Proximal part of Linea
Aspera
Adductor
1. Gluteal Tuberosity
2. Medial lip of Linea Aspera
3. Medial Supracondylar Line
Hamstring
Adductor Tubercle of Femur

Adductor Brevis

1. Body of Pubis
2. Inferior Ramus of Pubis

Adductor Magnus

1. Adductor Ischiopubic
Ramus
2. Hamstring Ischial
Tuberosity

Gracilis

1. Body of Pubis
2. Inferior Ramus of Pubis

Superior part of medial surface


of Tibia

Obturator Externus

1. Obturator Foramens
margins
2. Obturator membrane

Greater Trochanter of Femur (as


Obturator Nerve (L3, L4)
a single tendon)

P REPARED

BY

M ICHAEL C. D AVID

ON

ACTION
1. Adducts thigh
2. Flexes thigh
Adducts thigh

Obturator Nerve (L2, L3, L4)

1. Adducts thigh
2. Partially flexes thigh

1. Adductor Obturator nerve


(L2, L3, L4)
2. Hamstring Tibial portion of
Sciatic nerve (L4)

1. Adducts thigh
2. Adductor flexes thigh
3. Hamstring extends thigh

Obturator Nerve (L2, L3)

23/08/08.

1.
2.
3.
1.
2.

Adducts thigh
Flexes leg
Medial rotation of leg
Lateral rotation of thigh
Steadies head of Femur in
Acetabulum.

P AGE 8

OF

52

OB T U R A TO R N E RV E & A R T E RY

OBTURATOR NERVE

Nerve of medial compartment.


Branch of Lumbar Plexus, within Psoas Major on posterior abdominal wall.
Anterior divisions of ventral primary rami of L2, L3, L4.
Anterior and posterior divisions straddle Adductor Brevis.
Gives a cutaneous supply to the medial skin of thigh in some cases.
Gives articular branches to Hip & Knee joints.

OBTURATOR ARTERY

P REPARED

BY

Enters medial compartment through Obturator Canal, along with the Obturator nerve.
Supplies medial compartment, and hip joint.
Originates as a branch of the Internal Iliac Artery, in the pelvic cavity.
A branch of its posterior division forms the Artery to head of Femur.

M ICHAEL C. D AVID

ON

23/08/08.

P AGE 9

OF

52

A NTERIOR C OMPARTMENT OF T HIGH

NAME.

Quadriceps Femoris

Rectus
Femoris

Vastus
Lateralis

Vastus
Medialis

Vastus
Intermedius

ORIGIN.
1. Straight head Anterior
Inferior Iliac Spine
2. Reflected head outer surface
of Ilium, above Acetabulum
1. Half way up
Intertrochanteric line
2. Greater Trochanter
3. Gluteal tuberosity
4. Lateral lip of Linea Aspera
1. Mid-point of
Intertrochanteric Line
2. Lesser Trochanter
3. Spiral Line
4. Medial lip of Linea Aspera
5. Upper half of Medial
Supracondylar Line

Extensive aponeurosis on
deep aspect of muscle
belly.

Extensive aponeurosis on
deep aspect of muscle
belly.
Extensive aponeurosis on
deep aspect of muscle
belly.

Anterior and lateral surfaces of


shaft of Femur

P REPARED

INSERTION
1. Reflected head
merges with posterior
aspect of Straight
Head.
2. Fused bellies becomes
tendonous, and fuses
with aponeurosis

BY

M ICHAEL C. D AVID

Common tendon inserts on the base of the patella, and via


the patella ligament, to the Tibial tuberosity

F L E XOR M U S C L E S

ON

INNERVATION

ACTION

Femoral nerve (posterior


divisions of L2, L3, L4)

Vastus Medialis
1. Lower fibres run
horizontally, and fix Patella,
preventing its lateral
displacement
Rectus Femoris
2. Steadies hip joint
3. Helps Iliopsoas to flex thigh
Quadriceps
4. Extends leg at knee joint

23/08/08.

P AGE 10

OF

52

Iliopsoas

Psoas Major

Iliacus

1. Sides of T12 to L5 vertebrae


2. intervertebral discs between
them
1. Iliac crest
2. Iliac fossa
3. Ala of Sacrum
4. Anterior Sacroiliac ligaments

Bellies fuse, and pass behind


lateral two-thirds of Inguinal
Ligament, to insert onto the
Lesser Trochanter of the Femur.

Ventral rami of L1, L2, L3

Femoral nerve (L2, L3)

Tensor Fasciae Lata

1. Anterior Superior Iliac Spine


Iliotibial tract, that attaches to
2. Anterior part of external lip
the lateral condyle of Tibia
of Iliac crest

Superior Gluteal nerve (L4, L5)

Sartorius

1. Anterior Superior Iliac Spine


Superior part of medial surface
2. Superior part of Sciatic
of Tibia
notch (just inferior to it)

Femoral nerve (L2, L3)

P REPARED

BY

M ICHAEL C. D AVID

ON

23/08/08.

1. Flex thigh at hip


2. Stabilise joint
3. Allows sitting up from
supine position, if thigh is
fixed.
4. Where it crosses hip joint
cavity, is a Psoas Bursa.
1. Abducts thigh
2. Medially rotates thigh
3. Flexes thigh
4. Helps keeps knee extended
5. Steadies trunk on thigh
1. Flexes thigh at hip
2. Abducts thigh at hip
3. Laterally rotates thigh at hip

P AGE 11

OF

52

T HE F EMORAL T RIANGLE
B O U N DA R I E S

T H E S U B S A RTO R I A L C A N A L

Superior = Inguinal Ligament


Medial = medial border of Adductor Longus
Lateral = medial border of Sartorius
Floor = Adductor Longus, Pectineus & Iliopsoas muscles (medial
lateral)
Roof = overlying Fascia Lata (including Cribiform fascia that covers the
Saphenous Opening)
Ends inferiorly as the Adductor / Subsartorial canal.

15 cm long, narrow fascia tunnel, deep to central third of Sartorius.


Ends at Adductor Hiatus of Adductor Magnuss extensive aponeurosis.
Lateral boundary = Vastus Medialis
Postero-medial boundary = Adductor Longus
Anterior boundary = Sartorius (+ subsartorial fascia contains
subsartorial nerve plexus that supplies overlying skin)
Contain the Femoral Artery (medial) and Vein (lateral), but not the
Profunda Femoris vessels.
Contains the Saphenous nerve (a cutaneous branch of the Femoral
nerve) medial to Femoral Artery
Contains the Nerve To Vastus Medialis (accompanies the proximal part
of the Femoral Artery.

F E M OR A L V E I N

Begins at the Adductor Hiatus


Ends at the Inguinal Ligament, where it continues on as the External Iliac Vein.
Superiorly in triangle, it lies medial to the Femoral Artery. As it runs down, it moves posteriorly, and then lateral to the Femoral artery.

P REPARED

BY

M ICHAEL C. D AVID

ON

23/08/08.

P AGE 12

OF

52

F E M OR A L A RT E RY

Continuation of External Iliac artery, as it passes deep to the Mid-Inguinal Point.


mid-inguinal point is between Anterior Superior Iliac Spine and Pubic Symphysis
mid-point of Inguinal Ligament is between the Anterior Superior Iliac Spine and the Pubic Tubercle ( a little more lateral)
Passes inferiorly down the triangle, and passes inferiorly at the Femoral Triangles apex, deep to Sartorius, and enters the Sub-Sartorial Canal.
At distal end of canal, it passes through the Adductor Hiatus, to enter the posterior aspect of the Femur, and passes along posterior aspect of knee, as the
Popliteal Artery.
Separated from Femur by Vastus Medialis protected.
Three proximal branches within Femoral Sheath:
Superficial Circumflex Iliac Artery
Superficial Epigastric Artery lower part of abdominal wall, up to umbilicus
External Pudendal Artery external genitalia.
Below the sheath, there is only one major branch = Profunda Femoris artery.
Branch occurs at lateral aspect of Femoral artery, 4 cm inferior to Inguinal Ligament.
Profunda Femoris
Turns inferiorly to lie on lower part of Iliopsoas tendon, and runs parallel to the Femoral artery, on Pectineus muscle, before passing deep to Add. Longus.
Lies close to Linea Aspera on Femur at risk of injury during fracture.
Proximal branches:
Lateral Circumflex artery:
Ascending branch goes to Greater Trochanter
Transverse branch continues laterally (deep to Rectus Femoris), and enters cleft between Vastus Intermedius and Lateralis.
Descending branch declines through Quadriceps Femoris, to medial aspect of knee.
Medial Circumflex artery
Originates from posterior aspect of Profunda Femoris
Travels posteriorly to Cleft between Iliopsoas and Pectineus, and then beneath Neck of Femur & Articular Capsule, onto the posterior aspect of
the thigh. Supplies head & neck of Femur (i.e. clinically important).
At upper and lower margins of Quadratus Femoris, it terminates into an Ascending & Transverse branch.

P REPARED

BY

M ICHAEL C. D AVID

ON

23/08/08.

P AGE 13

OF

52

P REPARED

BY

M ICHAEL C. D AVID

ON

23/08/08.

P AGE 14

OF

52

F E M OR A L S H E A T H

Oval, funnel-shaped fascial tube that encloses the proximal parts of the femoral vessels. Does not enclose the Femoral nerve.
In abdomen, external iliac vessels lie within the extra-peritoneal fatty tissue plane, and grow down into 2nd diverticulum, to form the femoral sheath.
Nerves lie between the muscle wall and the fascial envelope grow outside the Femoral sheath, since they lie in a different plane.
A diverticulum (inferior prolongation) of fascia lining the abdomen:
Transversalis fascia, anteriorly.
Iliac fascia, posteriorly.
Ends 4 cm inferior to the Inguinal Ligament, by merging with the adventitious tissue of the femoral vessels.
Allows the femoral vessels to slide in and out, beneath the Inguinal Ligament, during hip movement.
Pierces medially by Great Saphenous Vein & Lymphatics.
Sheath is divided by two vertical septa, into three compartments
A lateral compartment to hold the Femoral artery, and the Femoral branch of the Genitofemoral Nerve.
Nerve lies between muscle wall, and fascial envelope. Pierces the extra-peritoneal fatty tissue.
Genital branch enters the Internal Spermatic Fascia.
Femoral branch enters lateral compartment, by piercing the anterior wall supplies skin below central third of Inguinal Ligament, on anterior thigh.
An intermediate compartment to hold the Femoral Vein.
A medial compartment/space = Femoral Canal.
Femoral Canal:
Begins at Femoral Ring, and ends at the Saphenous Opening allows expansion of Femoral vein, during increased venous return.
Contains loose connective and fatty tissue, which merges with extra-peritoneal fatty tissue of abdomen. Merging occurs at Femoral Ring.
Contains a few lymph vessels, and a Deep Inguinal Lymph Node (1 of 3) drains Superficial Inguinal Lymph nodes, and sends lymph to the External Iliac
Lymph Nodes.
Femoral Ring: - mouth of Femoral Canal only, about 1 cm wide.
Closed by extra-peritoneal fatty tissue = Femoral Septa (pierced by Lymph vessels connecting Inguinal and External Iliac Nodes).
Anterior margin = Inguinal Ligament
Posterior margin = Pectineal Line on Superior Pubic Ramus
Medial margin = Fibrous Septa (medial to Femoral Vein)
Lateral margin = fibres of Inguinal Ligament that insert into Pectineal Line of Superior Pubic Ramus = Lacunar Ligament.

P REPARED

BY

M ICHAEL C. D AVID

ON

23/08/08.

P AGE 15

OF

52

F E M OR A L N E RV E

Largest branch of the Lumbar Plexus (L2, L3, L4) forms in the abdomen, within Psoas Major.
Passes lateral to the Femoral Artery, outside the Femoral Sheath.
Enters thigh beneath the Mid-point of the Inguinal Ligament (a little lateral to the mid-inguinal point. Travels 1 inch inferiorly, and then divides:
Muscular branches to Pectineus, Sartorius and Quadriceps Femoris (anterior thigh muscles)
Medial Cutaneous Nerve of Thigh.
Antero-medial cutaneous distribution (L2, L3)
Intermediate Cutaneous Nerve of Thigh.
Saphenous Nerve (L3, L4):
Accompanies the Femoral artery within the Subsartorial Canal.
At Adductor Hiatus, it becomes superficial, by passing between Sartorius and Gracilis.
Then passes across medial knee, and accompanies the Great Saphenous vein down the leg.
Cutaneous supply to antero-medial aspects of knee, leg and foot.

P REPARED

BY

M ICHAEL C. D AVID

ON

23/08/08.

P AGE 16

OF

52

G LUTEAL R EGION
GLUTEAL MUSCLES

NAME.
Gluteus Maximus

Gluteus Medius
Gluteus Minimus
Piriformis
Obturator Internus

ORIGIN.
1. External surface of Ala of
Ileum
2. Dorsal surface of Sacrum,
Coccyx and Sacrotuberous
ligament
External surface of Ilium,
between Anterior Superior Iliac
Spine and Posterior Superior
Iliac Spine.
External surface of Ilium
(inferiorly)
1. Anterior surface of Sacrum
2. Sacrotuberous ligament
1. Pelvic surface of Obturator
membrane
2. Surrounding bone

Superior Gamellus

Ischial spine

Inferior Gamellus

Ischial tuberosity

Quadratus Femoris

Lateral border of Ischial


Tuberosity

P REPARED

INSERTION

INNERVATION

1. Gluteal Tuberosity
2. Deep Fibres Iliotibial Tract
(inserts onto lateral condyle
eof Tibia)

Inferior Gluteal nerve (L5, S1,


S2)

Lateral surface of Greater


Trochanter of Femur.

Superior Gluteal Nerve (L5,S1)

Anterior surface of Greater


Trochanter of Femur
Superior border of Greater
Trochanter of Femur

Medial surface of Greater


Trochanter of Femur

Nerve to Obturator Internus


(L5, S1)
Nerve to Quadratus Femoris
(L5, S1)

Quadrate Tubercle on
Intertrochanteric Crest of Femur
+ inferior to this.

M ICHAEL C. D AVID

ON

1. Abducts thigh
2. Medially rotates thigh
3. Steadies pelvis (damage
results in Waddlers Gait /
Trendelenburg Sign)

Direct branches from ventral


Rami of S1 & S2.
Nerve to Obturator Internus
(L5, S1)

BY

ACTION
1. Extends thigh
2. Assists lateral rotation
3. Steadies thigh
4. Assists in raising trunk,
from a flexed position.

1. Laterally rotates extended


thigh (in addition to Obturator
Externus)
2. Abduction of flexed thigh
(not Quadratus Femoris)
3. Steadies femoral head in
Acetabulum

Nerve to Quadratus Femoris


(L5, S1)

23/08/08.

P AGE 17

OF

52

P REPARED

BY

M ICHAEL C. D AVID

ON

23/08/08.

P AGE 18

OF

52

G L U T E A L N E RV E S

ROOT.
Lateral branches of dorsal rami of L1, L2, L3

Middle Cluneal Nerves

Lateral branches of dorsal rami of S1, S2, S3

Inferior Cluneal Nerves

Gluteal Br. Of Posterior Femoral Cutaneous


Nerves (ventral rami of S1, S2, S3)

Superior Gluteal Nerve

Posterior divisions of ventral rami of L4, L5

Inferior Gluteal nerve

Sciatic Nerve

Posterior Femoral Cutaneous


Nerve
Nerve to Quadratus Femoris
Nerve to Obturator Internus
Pudendal nerve

Branches of Sacral Plexus, which leave the


pelvis via the Greater Sciatic Foramen, and
emerge inferior to Piriformis.

NERVE.
Superior Cluneal Nerves

Posterior divisions of ventral rami of L5, S1, S2

Ventral rami of L4, L5, S1, S2, S3

1. Posterior divisions of ventral rami of S1, S2


2. Anterior divisions of ventral rami of S2, S3
Anterior divisions of ventral rami of L4, L5, S1
Anterior divisions of ventral rami of L5, S1, S2
Anterior divisions of ventral rami of S1, S2, S3

P REPARED

BY

M ICHAEL C. D AVID

ON

INNERVATION
Cutaneous supply to superior two-thirds of buttocks
Cutaneous supply to skin over sacrum, and adjacent area of
buttocks
Curves around inferior border of Gluteus Maximus
Cutaneous supply to inferior third of buttocks
Travels through superior part of Greater Sciatic Foramen
with superior gluteal artery
Superior branch supplies Gluteus Maximus
Inferior branch supplies Gluteus Medius & Minimus, and
Tensor Fascia Latae
Accompanies inferior gluteal artery
Breaks up into several branches supplying Gluteus Maximus
Large flattened band + most lateral structure of inferior part
of Greater Sciatic Foramen
Runs infero-laterally through Gluteal area, supplying nothing
Two-thirds down posterior thigh, divides:
Tibial nerve (supplies flexors)
Common Peroneal nerve (supplies abductors &
extensors, before entering Peroneum tissue)
Posterior divisions supply skin of inferior part of buttocks
Anterior divisions supply peroneum
Skin of posterior thigh and proximal posterior leg.
Supplies hip joint, Quadratus Femoris & Superior Gamellus
Passes through Greater Sciatic foramen, winds around Ischial
spine to supply Superior Gamellus. Re-enters pelvis via
Lesser Sciatic Foramen, supplying Obturator Internus.
Supplies perineum (genitalia, sphincters of urethra and anus)

23/08/08.

P AGE 19

OF

52

P REPARED

BY

M ICHAEL C. D AVID

ON

23/08/08.

P AGE 20

OF

52

Allows collateral circulation between Internal and External Iliac


arteries.

G L U T E A L A RT E R I E S

SUPERIOR GLUTEAL ARTERY

INTERNAL PUDENDAL ARTERY

Main branch of Internal Iliac artery, in pelvic cavity.


Leaves pelvic cavity through Superior part of Greater Sciatic Foramen,
superior to Piriformis.
Divides immediately into:
Superficial branch supplies Gluteus Maximus and skin over its
proximal attachment.
Deep branch supplies Gluteus Medius, Gluteus Minimus and Tensor
Fascia Latae muscles.
Other branches terminate at Trochanteric Anastomosis, where at the
Greater Trochanter, they meet the Ascending branch of the Lateral
Circumflex Humoral artery.

Arises in pelvic cavity, as a branch of the Internal Iliac artery.


Leaves pelvic cavity through Inferior part of Greater Sciatic Foramen,
inferior to Piriformis.
Descends posterior to Ischial Spine, and re-enters the pelvis through the
Lesser Sciatic Foramen.
Enters perineum, lateral to Pudendal nerve.
Supplies external genitalia and muscles in pelvic and gluteal regions.
GLUTEAL VEINS

Tributaries of the Internal Iliac Veins.

INFERIOR GLUTEAL ARTERY

Arises in pelvic cavity, as a branch of the Internal Iliac artery.


Leaves pelvic cavity through Inferior part of Greater Sciatic Foramen,
inferior to Piriformis.
Lies lateral to Internal Pudendal artery.
Supplies Gluteus Maximus, Obturator Internus, Quadratus Femoris and
superior part of Hamstrings.
May anastomose with Superior Gluteal artery.
Cruciate anastomosis lies at junction of gluteal region and thigh.
Descending branch of Inferior Gluteal artery + top perforating
branch of Profunda Femoris artery
Transverse branches of Lateral & Medial Circumflex Femoral
arteries.

P REPARED

BY

M ICHAEL C. D AVID

GLUTEAL VEINS

Superior and inferior gluteal veins accompany the corresponding arteries


though the Greater Sciatic Foramen, as venae comitantes.
Anastomose with tributaries of Femoral Vein, to allow a collateral
circulation.
INTERNAL PUDENDAL VEINS

Venae comitantes of corresponding arteries.


Forms a single vein that joins the Internal Iliac Vein.
Drains external genitalia and perineal region.

ON

23/08/08.

P AGE 21

OF

52

P OSTERIOR C OMPARTMENT OF T HIGH


P O S T E R I OR T H I G H M U S C L E S

NAME.

ORIGIN.

INSERTION
Medial surface of superior part
of Tibia

Semitendonosus
Ischial Tuberosity

Posterior part of medial condyle


of Tibia

Semimembranosus

Biceps Femoris

1. Long head Ischial


Tuberosity
2. Short head lateral lip of
Linea Aspera & lateral
Supracondylar line

P REPARED

1. Lateral side of head of


Fibula
2. Tendon is split at this site by
the Fibular Collateral
Ligament of knee

BY

M ICHAEL C. D AVID

ON

INNERVATION
Tibial division of Sciatic nerve
(L5, S1, S2)
Long head - Tibial division of
Sciatic nerve (L5, S1, S2)
Short head Fibular division of
Sciatic nerve (L5, S1, S2)

23/08/08.

ACTION
1. Extend thigh
2. Flex leg
3. Medial rotation of leg
4. When thigh & leg are flexed,
it can extend trunk
1. Flexes leg
2. Laterally rotates leg
3. Long head extends thigh

P AGE 22

OF

52

H IP J OINT
A RT I C U L A R S U R FA C E S

Acetabulum lunate surface


Floor is non-articular = acetabular fossa occupied by a fat pad, and covered by synovial membrane.
Acetabular notch = inferior deficiency in rim bridged by transverse acetabular ligament (not in contact with bone, but continuous with Ligament of Head of
Femur
Acetabular Labrum = ring of fibrocartilage attached to rim of acetabulum. Free edge clasps head of Femur, to increase stability.
Head of Femur except for Pit, which is attached to Ligament of Head of Femur.
Articular Capsule:
Strong and dense.
Proximally attached to rim of Acetabulum (just distal to Labrum).
Distally attached to Intertrochanteric Line & root of Greater Trochanter (anteriorly), and the neck proximal to the Intertrochanteric Crest (posteriorly).
Forms a cylindrical sleeve that encloses the hip joint and most of the neck of the femur.
Most fibres run spirally to lateral portion of Intertrochanteric line.
Circular fibres around neck of Femur form an Orbicular zone constricts capsule, and help hold head of Femur in the Acetabulum.
Deep Longitudinal fibres (Retinacula), contain blood vessels that nourish the head and neck of femur reflected back along superior surface of neck of
femur.
Further longitudinal capsular fibres form Intrinsic Ligaments.
Anterior ligaments spiral inferolaterally
Flexion will thus slacken the ligaments, and
Posterior ligaments spiral superolaterally
extension will tighten them.

Synovial Membrane lines internal surface of articular capsule, and is reflected onto neck of femur.
Forms a sleeve to exclude the Ligament of Head of Femur.
Lines acetabular fossa, and fat-pad. Attached to edges of fossa and transverse acetabular ligament
Protrudes inferior to Articular Capsule posteriorly, to form the Obturator Externus Bursa.

P REPARED

BY

M ICHAEL C. D AVID

ON

23/08/08.

P AGE 23

OF

52

INRINSIC LIGAMENTS

NAME.

PROXIMAL ATTACHMENT

DISTAL ATTACHMENT

Iliofemoral Ligament

1. Anterior Superior Iliac Spine


2. Acetabulum rim

Runs inferolaterally to
Intertrochanteric line of Femur

Pubofemoral Ligament

1. Pubic part of Acetabulum rim


2. Iliopubic eminence

Ischiofemoral Ligament

Ischial part of Acetabulum rim

Blends with medial part of


Iliofemoral Ligament
Spirals superolaterally to neck of
femur (medial to base of Greater
Trochanter)

Ligament of Head of
Femur

1. Margins of Acetabular notch


2. Floor of Acetabular fossa
3. Inner margin of Transverse
Acetabular Ligament

Fovea / Pit of head of Femur

FUNCTIONS / NOTES
1. Prevents hyperextension during standing maintains
erect posture
2. Screws head of femur into acetabulum joint integrity
1. Strengthens the Articular Capsule anteriorly + inferiorly
2. Relatively weak, but prevents hyperabduction of thigh
1. Strengthens the Articular Capsule posteriorly
2. Prevents hyperextension, by screwing femoral head
medially into acetabulum during extension
1. Intra-capsular
2. Contains the small artery to head of femur (branch of
obturator artery) atrophies after 7-8 years old.
3. Surrounded by a sleeve of Synovial membrane
4. Tightens during Adduction + lateral rotation

I N N E RVA T I ON T O H I P J OI N T

Femoral nerve (via Nerve to Rectus Femoris)


Obturator Nerve (anterior division)
Sciatic nerve (via Nerve to Quadratus Femoris)
Superior Gluteal Nerve

P REPARED

BY

M ICHAEL C. D AVID

ON

23/08/08.

P AGE 24

OF

52

A RT E R I A L S U P P LY TO H I P J OI N T

P REPARED

BY

M ICHAEL C. D AVID

ON

23/08/08.

P AGE 25

OF

52

T HE K NEE J OINT
A RT I C U L A R S U R FA C E S

Large curved condyles of the femur


The flattened condyles of the tibia
Facets of the Patella
On the superior surface of each tibial condyle, there is an articular area for the corresponding femoral condyle.
These medial & lateral tibial plateaux, are separated by a narrow non-articular ridge, that widens anteriorly and posteriorly to form the anterior & posterior
intercondylar areas.
A RT I C U L A R C A P S U L E

Superiorly attached to the femur, just proximal to articular margins of the condyles, and to the intercondylar line posteriorly.
Deficient on the lateral condyle, to allow tendon of Popliteus out, to attach to Tibia.
Inferiorly attached to the articular margin of the Tibia.
Except where the tendon of Popliteus crosses here the fibrous capsule is prolonged inferolaterally, to loop over Popliteus, and onto the head of the
Fibula = Arcuate Popliteal Ligament.
Five external intrinsic ligaments strengthen fibrous capsule.
S Y N OV I A L C A P S U L E

Lines inner aspect of fibrous capsule, and is reflected onto the articulating bones, as far as their articular cartilages.
Attached to the periphery of the Patella. Separated from the Patella Ligament by the Infrapatella Fatpad.

P REPARED

BY

M ICHAEL C. D AVID

ON

23/08/08.

P AGE 26

OF

52

E X T E R NA L I N T R I N S I C L I G A M E N T S

PATELLA LIGAMENT

TIBIAL COLLATERAL LIGAMENT

Strong, flat band. 8 to 9 cm long.


Extends from medial epicondyle of femur to the medial condyle &
supero-medial part of tibia.
Thickening of fibrous capsule, which is partly continuous with the
tendon of Adductor Magnus.
Inferiorly, separated from the tibia by the medial-inferior genicular
vessels and nerve.
Deep fibres firmly attached to fibrous capsule and medial meniscus.

Continuation of tendon of Quadriceps Femoris.


Patella is a sesamoid bone within this tendon.
Continuous with the fibrous capsule of the knee.
Superior part of its deep surface is separated from the synovial
membrane of the knee, by the loose infrapatella fatpad.
Inferior part of ligament separated from anterior Tibia by the
infrapatella bursa.

FIBULAR COLLATERAL LIGAMENT

Round cord, 5 cm long.


Extends inferiorly from the lateral epicondyle of the femur, to the lateral
surface of the head of the fibula.
Tendon of Popliteus passes deep to it separating it from the lateral
Meniscus.
Tendon of Biceps Femoris, split by Fibular Collateral Ligament.
Fuses with fibrous capsule superiorly = intrinsic.
Inferiorly, separated by fat from fibrous capsule = extrinsic.

OBLIQUE POPLITEAL LIGAMENT

Expansion of Semimembranosus muscle.


Strengthens fibrous capsule posteriorly.
Arises from the medial condyle of tibia.
Passes superolaterally, to attach to the central part of the posterior aspect
of the fibrous capsule.

ARCUATE POPLITEAL LIGAMENT

Strengthens articular capsule posteriorly.


Arises from posterior aspect of head of fibula.
Passes supero-medially over tendon of Popliteus, spreading out over
posterior surface of knee joint.
Inserts onto posterior intercondylar area of tibia + posterior aspect of
lateral epicondyle of femur.

P REPARED

BY

M ICHAEL C. D AVID

ON

23/08/08.

P AGE 27

OF

52

I N T E R NA L I N T R I N S I C L I G A M E N T S

Cruciate ligaments are named according to their site of attachment on the Tibia. They are essential to the antero-posterior stability of the knee joint, especially when flexed.
Damage to either can result in the anterior/posterior Drawer Sign.

ANTERIOR CRUCIATE LIGAMENT

POSTERIOR CRUCIATE LIGAMENT

Arises from the anterior part of the intercondylar area of the Tibia just
posterior to the attachment of the medial meniscus.
Extends superiorly, posteriorly and laterally to attach to the posterior part
of the medial side of the lateral condyle of the femur.
Prevents posterior displacement of the femur on the tibia, and
hyperextension of the knee.

Arises from the posterior part of the intercondylar area of the Tibia.
Passes superiorly and anteriorly, to the medial side of the Anterior
Cruciate.
Inserts onto the anterior part of the lateral surface of the medial condyle
of the femur.
Prevents anterior displacement of the femur on the tibia, and
hyperflexion of the knee.
Main stabilising factor of the weight bearing knee (e.g. when walking
downhill).

P REPARED

BY

M ICHAEL C. D AVID

ON

23/08/08.

P AGE 28

OF

52

M E N I S C I OF T H E K N E E J OI N T

MEDIAL MENISCUS

LATERAL MENISCUS

Attached to anterior intercondylar area of tibia anterior to the


attachment of anterior cruciate ligament.
Attached to posterior intercondylar area of tibia just anterior to the
attachment of posterior cruciate ligament.
Between attachments of posterior lateral meniscus, and the posterior
cruciate ligament.
Medial meniscus is firmly attached to the deep surface of the Tibial
Collateral Ligament.

Nearly circular, and more freely moveable. Covers a larger area of


articular surface than medial meniscus.
Anterior and posterior horns are attached close together, in the anterior
and posterior intercondylar areas of the tibia.
Posterior Meniscofemoral Ligament joins the lateral meniscus to the posterior
cruciate ligament + the medial femoral condyle.
Separated from the deep surface of the Fibula Collateral Ligament by the
tendon of Popliteus.

Superior, concave surfaces accept femoral condyles.


Inferior, flattened surfaces rest on Tibia.
Peripherally thick, while thin internally.
Act as shock absorbers.
They deepen the articular surfaces of the tibia.
Flexible to accept the different shape of the femur, in
flexion-extension.
Divide the joint, to allow two planes of movement.
Between femur + menisci = flexion-extension.
Between menisci + tibia = rotation.

P REPARED

BY

M ICHAEL C. D AVID

ON

23/08/08.

P AGE 29

OF

52

BU R S A E OF T H E K N E E

BURSA
Suprapatellar (Quadriceps) Bursa
Popliteus Bursa
Anserine Bursa
Gastrocnemius Bursa
Semimembranosus Bursa
Subcutaneous Pre-Patellar Bursa
Subcutaneous Infra-Patellar Bursa
Deep Infra-Patellar Bursa

LOCATION / FUNCTION
1. Passes superiorly between femur and quadriceps femoris muscle extends 8 cm above base of Patella
2. Allows free movement of Quadriceps tendon over distal end of Femur allows full extension and flexion at knee.
Lies between tendon of Popliteus and lateral condyle of Tibia.
Several diverticuli that separate tendons of Gracilis, Sartorius & Semitendinosus, from the proximal part of the medial
surface of the Tibia.
Lies deep to proximal attachment of medial head of Gastrocnemius separates tendon from Femur.
Lies between medial head of Gastrocnemius, and the Semimembranosus tendon often a prolongation of Gastrocnemius
Bursa.
1. Lies between skin and anterior surface of Patella allows movement of skin over patella during flexion-extension.
2. Easily inflamed Housemaids Knee.
1. Lies between skin and Tibial Tuberosity
2. Allows skin to glide over Tibial Tuberosity, and withstand pressure during kneeling.
1. Lies between Patellar Ligament and anterior surface of Tibia (superior to Tibial Tuberosity).
2. Separated from knee joint cavity by the Infra-Patellar Fat Pad.

P REPARED

BY

M ICHAEL C. D AVID

ON

23/08/08.

P AGE 30

OF

52

P OSTERIOR C OMPARTMENT OF L EG
SUPERFICIAL MUSCLES

NAME.

Triceps Surae

Gastrocnemius

Soleus

Plantaris

ORIGIN.
Lateral head lateral aspect of
lateral condyle of femur.
(Possible presence of sesamoid
Fabella bone)
Medial head popliteal surface of
femur, superior to medial
condyle.
Heads merge at inferior margin of
Popliteal Fossa

INSERTION

P REPARED

BY

ACTION

Tibial nerve (S1, S2)

1. plantar-flexes foot
2. raises heel during walking
3. flexes knee joint
Most powerful muscle in compartment,
but cannot do both at maximum
tension, together.
4. Rapid contraction provided
by vertical fibres

Tibial nerve (S1, S2)

1. Plantar-flexes foot
2. Steadies leg on foot, against
gravity
3. Multipennate fibres passing
postero-inferiorly, between
two aponeurotic sheets
4. Aids in Calf Pump, to
return blood to heart.

Tibial nerve (S1, S2)

Weakly assist Gastrocnemius in


plantar-flexing foot & flexing
knee.

Posterior surface of Calcaneus


by Calceneal Tendon

Achilles Tendon
1. 15 cm long
2. Strongest tendon
3. Bursa between tendon and
bony Calcaneus
1. Posterior aspect of head of
4. Fibres spiral through 90, to
Fibula
allow elongation & elastic
2. Superior quarter of posterior
recoil allows storage and
Fibula
release of energy during
3. Soleal line & medial border
locomotion.
of Tibia
1. Inferior end of lateral
supracondylar line of Femur
2. Oblique popliteal ligament

INNERVATION

Lies between Gastrocnemius


and Soleus. Fibres merge with
them, and the common
Calceneal Tendon

M ICHAEL C. D AVID

ON

23/08/08.

P AGE 31

OF

52

P REPARED

BY

M ICHAEL C. D AVID

ON

23/08/08.

P AGE 32

OF

52

DEEP MUSCLES

Separated from superficial group, by the Superficial Transverse Septum. This lies between the medial border of the Tibia, and the posterior border of the
Fibula. The Deep Transverse Septum lies between the vertical line of the Tibia, and the medial crest of the Fibula.
NAME.

ORIGIN.

INSERTION

INNERVATION

Popliteus

Lateral surface of lateral condyle


of Femur + lateral meniscus

Posterior surface of Tibia


(superior to the Soleal Line)

Tibial Nerve (L4, L5, S1)

Flexor Hallucis
Longus

1. Inferior 2/3 posterior Fibula


2. Inferior part of Interosseous
Membrane

Base of distal phalanx of Hallux


(big toe)

Tibial Nerve (S2, S3)

Flexor Digitorum
Longus

1. Medial part of posterior


surface of Tibia (inferior to
Soleal Line)
2. Broad aponeurosis to Fibula

Bases of distal phalanges of


lateral 4 digits

Tibial Nerve (S2, S3)

Tibialis Posterior

1. Interosseous membrane
2. Posterior Tibia (inferior to
Soleal Line)
3. Posterior surface of Fibula

1. Tuberosity of navicular,
cuneiform & cuboid bones
2. Bases of 2nd, 3rd, & 4th
Metatarsals

Tibial Nerve (L4, L5)

P REPARED

BY

M ICHAEL C. D AVID

ON

23/08/08.

ACTION
1. Weakly flexes knee
2. Unlock knee from screw
home position, by laterally
rotating Femur on fixed
Tibia (or vice-versa).
1. Flexes Hallux at MP and IP
joints
2. Plantar-flexes foot
3. Supports longitudinal arch
of foot
1. Flexes lateral 4 digits at MP
and IP joints
2. Plantar-flexes foot
3. Supports longitudinal arch
of foot
1. Plantar-flexion at ankle
2. Inversion at sub-Talar joint
complex

P AGE 33

OF

52

T I B I A L N E RV E

S T RU C T U R E S U N D E R T H E F L E XO R R E T I N A C U L U M

Supplies all muscles of the posterior compartment.


Arises as the larger of the two terminal branches of the Sciatic Nerve.
Contains anterior branches of the ventral primary rami of L4 to S3.
Descends through popliteal fossa, posterior to Popliteal vessels.
Descends deep to tendonous arch of origin of Soleus, and descends leg,
deep to Soleus.
Runs inferiorly on Tibialis Posterior, with Posterior Tibial vessels.
Leaves leg, by passing beneath Flexor Retinaculum, between medial
malleolus and Calcaneus lies between Posterior Tibial vessels, and
Flexor Hallucis Longus.
Postero-inferiorly to Medial Malleolus, it divides into Medial & Lateral
Plantar Nerves.
Branches:
Muscular branches to all muscles in posterior compartment.
Medial Sural Cutaneous Nerve unites with communicating branch of
Common Peroneal nerve, to form the Sural Nerve.
Sural Nerve supplies skin on postero-lateral of inferior third of
leg + lateral foot.
Articular branches to knee joint.
Medial Calcaneal branches to skin of heel (including weight-bearing
surface).
Damaged during lacerations of the popliteal fossa, or posterior
displacements of the knee:
Paralysis of posterior compartment muscles + intrinsic muscles of
sole.
Unable to curl toes or stand on them.
Loss of plantar-flexion.
Loss of sensation to sole of foot vulnerable to pressure sores.

P REPARED

BY

M ICHAEL C. D AVID

From medial to lateral:


1.
2.
3.
4.
5.

ON

Tibialis Posterior
Flexor Digitorum Longus
Posterior Tibial Artery
Tibial Nerve
Flexor Hallucis Longus

23/08/08.

P AGE 34

OF

52

A RT E R I A L S U P P LY

The Popliteal artery is a continuation of the Femoral artery. It terminated by dividing into the Anterior and Posterior Tibial arteries, at the inferior border of
Popliteus. The Anterior Tibial artery leaves the posterior compartment above or through the Interosseous membrane.
POSTERIOR TIBIAL ARTERY

Descends deep to the origin of Soleus. Accompanies by Tibial nerve and 2 venae comitantes (deep to Transverse Intermuscular Septum)
Runs posterior to Medial Malleolus separated from it by tendons of Tibialis Posterior and Flexor Digitorum Longus.
Runs deep to Flexor Retinaculum, between tendons of FDL and FHL.
Here it divides into Medial & Lateral Plantar arteries.
Branches include: muscular branches:
Peroneal Artery
Circumflex Fibula Artery arises near the Posterior Tibial arterys origin, and passes laterally over neck of Fibula, to join the anastomosis at the knee.
Nutrient Artery to Tibia proximal branch that enters nutrient foramen, just distal to Soleal Line on posterior surface of Tibia.
(medial) Calceneal branches joins branches from Peroneal artery, to form an anastomosis around the ankle.

PERONEAL ARTERY

Branches 2.5 cm inferior to lower border of Popliteus.


Descends obliquely towards Fibula, and then along medial side of Fibula lies in a fibrous tunnel, in front of or within FHL.
Muscular branches to Popliteus + other muscles in posterior & lateral compartments of leg.
Supplies Nutrient Artery to Fibula + communicating branch to Posterior Tibial artery.
Lateral Calceneal branches, contribute to anastomosis around ankle.
Pierces interosseous membrane, enters dorsum of foot, and anastomoses with Arcuate Artery.
All arteries are accompanied by venae comitantes, which drain into the Popliteal Vein.

P REPARED

BY

M ICHAEL C. D AVID

ON

23/08/08.

P AGE 35

OF

52

E XTENSOR C OMPARTMENT OF L EG
E X T E N S O R R E T I NA C U L A

B OU N DA R I E S

1.
2.
3.
4.
5.

SUPERIOR EXTENSOR RETINACULUM

Broad, rectangular shaped. (2 cm deep).


Proximal to ankle joint.
Attached to:
Medial surface of Tibia
Triangular subcutaneous surface of Fibula.

Lateral surface of Tibia


Interosseous Membrane
Extensor Surface of Fibula
Anterior (Crural) Intermuscular Septum
Overlying (Crural) Fascia

INFERIOR EXTENSOR RETINACULUM

Y-shaped, lying transversely.


Stem attached to upper surface of Calcaneus.
Proximal limb attached to medial malleolus of Tibia.
Distal limb blends with deep fascia on medial side of foot.

Tendons that pass inferior to the retinacula, have synovial sheaths.


Inflammation of sheaths = tendosynovitus
Pain, local swelling and Crepitis sound of crinkling tissue paper.

P REPARED

BY

M ICHAEL C. D AVID

ON

23/08/08.

P AGE 36

OF

52

M U S C L E S O F T H E A N T E R I OR C OM PA RT M E N T

NAME.

ORIGIN.

Tibialis Anterior

1. Lateral condyle of Tibia


2. Superior 2/3 of lateral
surface of Tibia
3. Interosseous membrane

Extensor Hallucis
Longus

1. Central part of extensor


(anterior) surface of Fibula
2. Adjacent interosseous
membrane

INSERTION
1. Circumpennate fibres form
a tendon that splits superior
extensor retinaculum.
2. Medial & inferior surfaces
of medial cuneiform
3. Base of 1st metatarsal

ACTION

Deep Peroneal Nerve (L4, L5)

1. Dorsi-flexion at ankle
2. Inversion at sub-talar joint
complex

Dorsal aspect of base of distal


phalanx of Hallux

Extensor Digitorum
Longus
(unipennate)

1. Lateral condyle of Tibia


2. Superior of extensor
surface of Fibula
3. Interosseous membrane

Peroneus Tertius

1. Distal extensor surface of


Fibula
2. Interosseous membrane

P REPARED

INNERVATION

BY

1. Extends big toe


2. Dorsi-flexes foot at ankle

1. Tendon divides into 4, deep


to inferior extensor
retinaculum.
2. Dorsal expansion at
proximal phalanx of 2nd to
5th digit
3. Central slip attaches to base
of middle phalanx
4. 2 collateral slips attach to
base of distal phalanx
Base of dorsum of 5th metatarsal
an expansion continues down
its superior surface.

M ICHAEL C. D AVID

ON

Deep Peroneal Nerve (L5, S1)

23/08/08.

1. Extension of lateral 4 toes


2. Dorsi-flexion at ankle
3. May assist eversion at subtalar joint complex

1. Eversion
2. Dorsi-flexion

P AGE 37

OF

52

Extensor Digitorum
Brevis

1. Upper surface of Calcaneus


2. Stem of Inferior Extensor
Retinaculum

1. Base of proximal phalanx of


Hallux
2. Under tendons of EDL, to
respective dorsal expansion

Deep Peroneal Nerve

1st Dorsal
Interosseous

1st and 2nd metatarsal sides

Extensor expansion of 2nd toe

Lateral Plantar Nerve (S2, S3)

P REPARED

BY

M ICHAEL C. D AVID

ON

23/08/08.

1. Aids extension of MP and


IP joints.
2. EDB action is independent
of ankle joint
compensates for the
weakened action of EDL
prior to take-off (when
ankle is dorsi-flexed)
1. Abducts 2nd digit medially
2. Flexes MP joint

P AGE 38

OF

52

D E E P P E RO N E A L N E RV E

A N T E R I O R T I B I A L A RT E RY

Terminal branch of the Common Peroneal Nerve begins between


Fibula and Peroneus Longus
Exposed here dangerous:
Easily pressed against bone
Damaged during fracture of neck of Fibula
Pressure from plaster-cast
Damage could lead to motor and sensor problems. (Foot drop)

Runs infero-medially down Fibula, deep to EDL.


Pierces Anterior Intermuscular Septum, and EDL.
Descends anterior compartment of leg, over interosseous membrane.
Travels down between Extensor Hallucis Longus and Tibialis Anterior
accompanied by Anterior Tibial Artery.
Passes deep to Superior Extensor Retinaculum, enters centre of foot
(between two malleoli).
Deep to Inferior Extensor Retinaculum, divides into a medial and lateral
branch.
Medial branch passes over Tarsals, and 1st Dorsal Interossei.
Divides to supply skin in cleft between 1st & 2nd digit.
Lateral branch supplies Extensor Digitorum Brevis.
Supplies:
All muscles of anterior compartment
Branches to Posterior Tibial and Peroneal arteries
Articular branches to ankle and tarsal joints.
Cutaneous supply between 1st and 2nd digits

P REPARED

BY

M ICHAEL C. D AVID

Smaller terminal branch of Popliteal artery begins opposite the inferior


margin of Popliteus.
Descends down the leg with the Deep Peroneal nerve, between Extensor
Hallucis Longus and Tibialis Anterior muscles.
Distally in leg, it lies more superficially on the Tibia.
Terminates at ankle joint, as it enters the foot, centrally between the two
malleoli hereafter called the Dorsalis Pedes artery.
Supplies:
Muscles of anterior compartment
Anterior Tibial recurrent arteries join anastomosis around knee.
Medial & lateral Anterior Malleoli arteries join anastomosis around
ankle.
DORSALIS PEDES ARTERY

Runs down tarsals gives off Lateral Tarsal Artery


Which forms Arcuate artery.
Arcuate artery runs across bases of tarsals
Gives off 3 dorsal metatarsal arteries.
Each of these then divide into 2 digital branches that supply the toes.
At 1st metatarsal space, it gives off 1st Dorsal Metatarsal artery
Enters the sole of the foot, where it forms the Plantar Arch, by
anastomosis with the Lateral Plantar artery.

ON

23/08/08.

P AGE 39

OF

52

P ERONEAL (L ATER AL ) C OMPARTMENT OF L EG


B O U N DA R I E S

1.
2.
3.
4.

S U P E R F I C I A L P E R ON E A L N E RV E

lateral surface of Fibula


Anterior (Crural) Intermuscular Septum
Posterior (Crural) Intermuscular Septum
Overlying (Crural) Fascia
P E R O N E A L R E T I NA C U L A

Superior Peroneal Retinaculum holds tendons of Peroneus muscles


against the back of the Lateral Malleolus.
Origin = Lateral Malleolus
Insertion = Calcaneus
Inferior Peroneal Retinaculum divided into a Superior Compartment
(Peroneus Brevis), and an Inferior Compartment (Peroneus Longus).
Lies over the Peroneal Trochlea of the Calcaneus (lateral aspect).

P REPARED

BY

M ICHAEL C. D AVID

Terminal branch of the Common Peroneal Nerve begins between


Fibula and Peroneus Longus
Lies antero-lateral to Fibula, in between Peroneal Muscles, and Extensor
Digitorum Longus.
Supplies peroneal muscles.
Pierces deep fascia, to lie superficial in distal 1/3 of leg travels along
anterior margin of Peroneus Brevis.
Cutaneous supply to:
(via medial & intermediate terminal branches)
Distal part of anterior surface of leg.
Nearly all of dorsum of foot.
Most of the digits.
A RT E R I A L S U P P LY

There are no arteries in the Peroneal Compartment, except for muscular


branches of the Peroneal Artery (branch of Posterior Tibial artery), to the
Peroneal muscles.

ON

23/08/08.

P AGE 40

OF

52

M U S C L E S OF L A T E R A L C OM PA RT M E N T

NAME.

ORIGIN.

Peroneus Longus

1. Head of Fibula
2. Superior 2/3 of lateral
surface of Fibula

Peroneus Brevis

Inferior 2/3 of lateral surface of


Fibula
(Brevis in front of Longus at overlap)

P REPARED

BY

INSERTION
1. Crosses lateral edge of
Calcaneus of foot, to the
base of 1st metatarsal
2. Medial Cuneiform bone
Dorsal surface of tuberosity on
lateral side of base of 5th
metatarsal
Tuberosity of 5th metatarsal can be
avulsed during violent inversion of foot;
causing damage to superficial peroneal
nerve paralysed inverted foot.

M ICHAEL C. D AVID

ON

INNERVATION

ACTION

Superficial Peroneal Nerve


(L5, S1, S2)

1. Eversion of foot
2. Weak plantar-flexion

23/08/08.

P AGE 41

OF

52

T HE A NKLE J OINT
A RT I C U L A R S U R FA C E S

Articular surface of Lateral Malleolus of Fibula (faces medially).


Inferior surface of Tibia wider anteriorly than posteriorly.
Lateral surface of Medial Malleolus of Tibia.
Trochlea of Talus convex antero-posteriorly, concave side to side, and wider anteriorly.
Lateral aspect of Talus triangular facet.
Medial aspect of Talus comma-shaped facet.
Neck of Talus is enclosed within capsule. Related to an intra-capsular, but extra-synovial fat pad.
LIGAMENTS

LATERAL COLLATERAL

MEDIAL COLLATERAL (DELTOID)

Anterior Talo-Fibular Ligament


Superficial Part crosses ankle and sub-talar joint complex.
Flat band weak.
Apex = Medial Malleolus of Tibia
Lateral malleolus neck of Talus.
Base =
Posterior Talo-Fibular Ligament
Tuberosity of Nacicular
Thick, strong band.
Medial edge of Spring Ligament
Malleolar Fossa of Fibula Lateral Tubercle of posterior process of
Sustentaculum Tali of Calcaneus
Talus
Medial tubercle of posterior process of Talus
Calcaneo-fibular Ligament
Deep Part crosses ankle only
Round cord
Medial Malleolus area below comma-shaped facet on medial
Tip of lateral malleolus of Fibula lateral surface of Calcaneus
aspect of Talus.
(runs postero-inferiorly)
Anterior parts resists Plantar-flexion, while posterior parts resists Dorsi-flexion.

P REPARED

BY

M ICHAEL C. D AVID

ON

23/08/08.

P AGE 42

OF

52

N E U ROVA S C U L A R S U P P LY TO A N K L E

Malleolar anastomosis between Anterior Tibial artery, and Posterior Tibial & Peroneal arteries.
Articular nerves are branches of Tibial & Deep Peroneal nerves.
M OV E M E N T S

DORSI-FLEXION

Range of motion is 0 to 35
Maximum congruence between articulating surfaces during dorsi-flexion
stability.
Also: maximum tension in ligaments.
This is the position used for the origin of all locomotive movements.
Aids stability when walking down a slope.
Involves:
Tibialis Anterior
Extensor Hallucis Longus
Extensor Digitorum Longus
Peroneus Tertius

P REPARED

BY

M ICHAEL C. D AVID

PLANTAR-FLEXION

Range of motion is 0 to -55


Smallest area of Talus in contact with mortise less stable.
Involves:
Triceps Surae (Gastrocnemius & Soleus)
Plantaris Longus
Flexor Hallucis Longus
Flexor Digitorum Longus
Tibialis Posterior
Peroneus Longus
Peroneus Brevis

ON

23/08/08.

P AGE 43

OF

52

S UB -T ALAR J OINT C OMPLEX


Sub-talar joint complex comprises of the TC joint, and the TC part of the TCN joint.
TA L O - C A L C A N E A L J O I N T ( S U B - TA L A R

JOINT)

TA L O - C A L C A N E O - NAV I C U L A R J OI N T

Articular Facets:
Oval facet on posterior (inferior) surface of Talus
Oval facet on upper surface of Calcaneus.
Long axis of facet lies obliquely.

Multi-axial, ball and socket joint. Socket facets:


Calcaneus:
Facet on upper surface of Sustentaculum Tali.
Facet on anterior part of superior surface.
Concave articular facet on posterior surface of Navicular.
Fibrous capsule attached close to articular margins short fibres.
Spring Ligament (Plantar Calcaneo-navicular Ligament).
Origin = anterior margin & medial border of Sustentaculum
In front of articular surfaces are:
Tali.
Sulcus Tali
Insertion = plantar surface of Navicular.
Sulcus Calcaneus Form the Tarsal Canal (contains 2 intrinsic ligaments)
Function = prevents body weight driving Talus head
downwards + prevents collapse of medial longitudinal arch.
Associated with transmission of body weight to lateral longitudinal arch.
(Tendon of Tibialis Posterior acts as a sling, to provide
inferior support for the ligament).
Medial Limb of Bifurcate Ligament.
Base of V attached to dorsal surface of Calcaneus.
Medial limb attached to Navicular.
(Lateral limb attached to Cuboid).

Ball = head of Talus, and neck of Talus up to Sulcus Tali.


Fibrous capsule attached to articular margins, and articular ligaments.
Lined with synovial membrane (covering non-articular surfaces).
Associated with transmission of body weight to medial longitudinal arch.

P REPARED

BY

M ICHAEL C. D AVID

ON

23/08/08.

P AGE 44

OF

52

INTRINSIC LIGAMENTS

interosseous Talo-Calcaneal Ligament


Lies within the Tarsal Canal, as a thickening of the adjacent fibrous
capsules of the TC & TCN joints.
Resists eversion.
Ligament of Neck of Talus
Origin lateral end of Tarsal Canal.
Attachment Calcaneus & Neck of Talus.
Tight in inversion.
Talus bound to Calcaneus by:
Fibrous capsule of TC and TCN joint.
Interosseous Talo-Calcaneal Ligament.
Ligament of Neck of Talus.
Parts of medial & lateral Collateral Ligaments of ankle.
M OV E M E N T S

Axis for inversion:


from lateral process of Calcaneus
Runs supero-medially, and bisects the Tarsal Canal.
Lies below TC joint, and above TCN joint.
Inversion:
Eversion:

By Tibialis Anterior & Posterior muscles.


Checked by: 1. Calcaneo-Fibula Ligament (laterally)
2. Ligament of Neck of Talus
By Peroneus Longus, Brevis & Tertius, and by EDL.
Checked by: 1. Deltoid Ligament (medially)
2. Interosseous Talo-Calcaneal Ligament

P REPARED

BY

M ICHAEL C. D AVID

ON

23/08/08.

P AGE 45

OF

52

C A L C A N E O - C U B OI D J O I N T

Articular surfaces: (quadrilateral, reciprocally convex/concave)


Anterior surface of Calcaneus
Posterior surface of Cuboid
Simple capsule, thickened above & below.
CC joint + TN part of TCN joint = Transverse Tarsal Joint.
Transverse Tarsal joint involves inversion/eversion, as well as some gliding/rotation.
INTRINSIC LIGAMENTS

Plantar Calcaneo-Cuboid Ligament (Short Plantar Ligament)


Origin = just behind articular margin of Calcaneus
Insertion = plantar surface of Cuboid, up to groove for Peroneus Longus.
Long Plantar Ligament
Origin = posterior surface of Calcaneus
Insertion = distal on Cuboid + 1st, 2nd & 3rd Metatarsals.
Converts groove for Peroneus Longus, into a tunnel.
Lies superficial to Short Plantar Ligament covers it, except for its medial edge.
Lateral Limb of Bifurcate Ligament supports dorsal aspect of CC Joint.

P REPARED

BY

M ICHAEL C. D AVID

ON

23/08/08.

P AGE 46

OF

52

T HE F OOT
1 S T L A Y E R OF P L A N TA R M U S C L E S

NAME.

ORIGIN.

INSERTION

INNERVATION

Abductor Hallucis

Calcaneus

Medial side of base of proximal


phalanx of hallux
Medial Plantar Nerve (S2, S3)

Flexor Digitorum
Brevis

Calcaneus

Middle phalanges of 2nd to 5th


toes

Abductor Digiti
Minimi

Calcaneus

Lateral side of base of proximal


phalanx of 5th digit

Lateral Plantar Nerve (S2, S3)

ACTION
1. Abducts big toes
2. Flexes bit toe
3. Supports medial longitudinal
arch
1. Flexes lateral four toes
2. Supports medial and lateral
longitudinal arches
1. Abducts little toe
2. Flexes little toe
3. Supports lateral longitudinal
arch

2 N D L A Y E R OF P L A N TA R M U S C L E S

NAME.
Flexor Digitorum
Accessorius (Plantae
Quadratus)

ORIGIN.

INSERTION

INNERVATION

ACTION

2 heads from plantar surface of


Calcaneus

Postero lateral margin of tendon


of Flexor Digitorum Longus

Lateral Plantar Nerve (S2, S3)

Assists FDL in flexing lateral 4


toes

1. Medial sides of proximal


1. Flex MP-joints of lateral 4
Medial 1: Medial Plantar Nerve
phalanges of lateral 4 toes
toes
Lumbricals
Tendon of FDL
Lateral 3: Lateral Plantar Nerve
2. Extensor expansions of
2. Extend IP-joints of lateral 4
(S2, S3)
tendons of EDL
toes
Tendon of Flexor Hallucis Longus and tendons of Flexor Digitorum Longus, will act as muscular tie-bars to support the medial and lateral longitudinal arches.

P REPARED

BY

M ICHAEL C. D AVID

ON

23/08/08.

P AGE 47

OF

52

3 R D L A Y E R O F P L A N TA R M U S C L E S

NAME.

ORIGIN.

INSERTION
Both sides of proximal phalanx
of hallux (passes over 2
sesamoid bones)

Flexor Hallucis
Brevis

1. Cuboid
2. Lateral Cuneiform

Adductor Hallucis

Oblique head bases of 2nd to 4th


metatarsals
Transverse head plantar
ligaments of MP-joints

Both heads lateral side of base


of proximal phalanx of hallux

Flexor Digiti Minimi

Base of 5th Metatarsal

Base of proximal phalanx of 5th


digit

INNERVATION
Medial Plantar Nerve

ACTION
(S1, S2)

1. Flexes big toe at MP-joint

1. Adducts big toes


Lateral Plantar Nerve (deep
2. Flexes big toes
branch)
3. Transverse head Assists
(S2, S3)
maintaining transverse arch
of foot
Lateral Plantar Nerve
(superficial branch)
Aids flexion of little toe.
(S2, S3)

4 T H L AY E R O F P L A N TA R M U S C L E S

NAME.

ORIGIN.

Plantar Interossei (3)

Bases and sides of 3rd to 5th


metatarsals (unipennate)

Dorsal Interossei (4)

Adjacent sides of 1st to 5th


metatarsals (bipennate)

INSERTION
Medial sides of bases of
proximal phalanges of 3rd-5th
toes
1st medial side of proximal
phalanx of 2nd digit
2nd to 4th lateral sides of 2nd to
4th digits

INNERVATION

ACTION
1. Adducts 2nd to 4th digits
2. Flexes MP-joints

Lateral Plantar Nerves (S2, S3)


1. Abducts 2nd to 4th digits
2. Flexes MP-joints

Tendon of Tibialis Posterior muscle lies in this layer. The tendon for Peroneus Longus also acts as a tie-bar for the transverse arch of the foot.

P REPARED

BY

M ICHAEL C. D AVID

ON

23/08/08.

P AGE 48

OF

52

P REPARED

BY

M ICHAEL C. D AVID

ON

23/08/08.

P AGE 49

OF

52

M U S C L E S OF D O R S U M OF F O OT

NAME.

ORIGIN.

Extensor Digitorum
Brevis

1. Anterior part of dorsum of


Calcaneus
2. Inferior Extensor
Retinaculum

Extensor Hallucis
Brevis

INSERTION
Lateral edge of corresponding
tendon of EDL, to the 2nd to 4th
digit.
Base of proximal phalanx of
Hallux

INNERVATION

ACTION

Deep Peroneal Nerve (S1, S2)

Extends 2nd to 4th digits at MPjoints.


Extends big toes at MP-joint.

S U P P ORT S O F A R C H E S O F F O OT

MEDIAL LONGITUDINAL ARCH

LATERAL LONGITUDINAL ARCH

TRANSVERSE ARCH

1.
2.
3.
4.
5.

1.
2.
3.
4.

1. Peroneus Longus
2. Transverse head of Adductor Hallucis
3. Deep Transverse Ligament

Plantar Aponeurosis
Flexor Hallucis Longus
Abductor Hallucis
Spring Ligament
Tibialis Anterior (pulls on arch)

5.
6.

P REPARED

BY

Plantar Aponeurosis
Flexor Digitorum Brevis
Abductor Digiti Minimi
Long Plantar Ligament
Short Plantar Ligament
Peroneal Muscles (pull on arch)

M ICHAEL C. D AVID

ON

23/08/08.

P AGE 50

OF

52

A RT E R I A L S U P P LY TO F OOT

P REPARED

BY

M ICHAEL C. D AVID

ON

23/08/08.

P AGE 51

OF

52

C U TA N E O U S N E RV E D I S T R I BU T I ON I N T H E F OOT

P REPARED

BY

M ICHAEL C. D AVID

ON

23/08/08.

P AGE 52

OF

52