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ANATOMY

2.04 LOWER LIMBS: BLOOD AND NERVE SUPPLY


Dr. Nakpil | September 27, 2016

LE 2
OUTLINE Artery to the sciatic nerve
I. Arteries Anastomoses with perforating branches in femoral
a. Gluteal artery
b. Thigh Passes through the lower part of the Greater Sciatic
c. Leg foramen and comes out inferior to the piriformis
d. Foot
muscle
II. Vein
a. Superficial Vein
b. Perforating Vein b. Superior gluteal artery
c. Deep Vein Bifurcates into:
III. Lymphatic i. Superficial branch
IV. Innervation ii. Deep branch
a. Lumbosacral
Passes through the upper part of the Greater Sciatic
a.1. Lumbar
a.2. Sacral foramen and comes out superior to the piriformis
b. Nerves Of Gluteal Region muscle
c. Nerves Of The Thigh
d . Dermatomes c. Internal pudendal artery
V. References Supplies skin, external genitalia, muscles in perineal
VI. Appendix
region
OBJECTIVES: Enters the gluteal region through the Greater sciatic
At the end of the lecture, the student should be able to: foramen but leaves it through the Lesser Sciatic
1. To conceptualize the importance of learning the art of foramen
healing thousand/ millions years ago as it evolutionized
to our modern practice.
2. To realize that there are ancient healing practices being
recognized up to the present day medical practice.
3. To describe cultures, practices, beliefs of prehistoric
times onto the different eras of civilization.
4. To familiarize the primitive and ancient medical practices
with different tribes worldwide.

Legend:
Remember Previous
Lecturer Book Trans Com
(Exams) Trans

G U & 4 !

INTRODUCTION

Arteries
o Main arterial trunks of lower limbs, branches &
distribution
o Collateral pathways around hip, knee and ankle
Veins
o Venous drainage from lower limbs back to heart Figure 1. Arteries of gluteal region
o Saphenous venous pattern of superficial veins
Lymphatics B. ARTERIES OF THE THIGH
o Regional lymph nodes
Innervation Femoral triangle
o Formation of lumbosacral plexus Wedge-shaped depression formed by the muscles of the
o Parts/branches of lumbosacral plexus upper thigh
o Dermatomes Boundaries
o Base: Inguinal ligament
I. ARTERIES & Superiorly: Inguinal ligament (Snell, 2012)
o Medial border: Adductor longus
A. ARTERIES OF THE GLUTEAL REGION o Lateral margin: Sartorius
From internal iliac artery o Floor: Pectineus & adductor longus and iliopsoas
a. Inferior gluteal artery
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& Roof: Skin and fascia of the thigh (Snell, 2012) Nerve to vastus medialis
o Apex: Continuous with adductor canal & Deep lymph vessels
Contents: & Terminal part of the obturator nerve (Snell, 2012)
o Femoral nerve
1. Femoral artery
& Femoral sheath (Snell, 2012)
Fascia surrounding femoral artery, vein and Arises from External Iliac artery
lymphatic vessels o Beyond the inguinal ligament, it is now called the
Does not enclose Femoral nerve Femoral artery
Medial compartment: Femoral canal Supplies MOST of the thigh and ALL of the leg and foot
Contains lymphatic vessels Cluster of small branches
Site for femoral hernias o Supply cutaneous regions of upper thigh, lower
o Femoral artery abdomen and perineum
o Femoral vein Deep artery of the thigh or Profunda Femoris a.
& Deep inguinal lymph nodes (Snell, 2012) o Largest branch
o Major source of blood supply to thigh
& Arises from the lateral side of the femoral a. ~1.5 below
the inguinal ligament
& Passes medially behind the femoral vessels and enters
the medial fascial compartment of the thigh. It ends by
becoming the fourth perforating a.. At its origin, it
gives of the medial and lateral circumflex arteries,
and during its course it gives off three perforating a..
(Snell, 2012)

Figure 2. Femoral triangle

Adductor canal or Femoral canal or Hunters Canal or


Subsartorial canal

& An intermuscular cleft situated on the medial aspect of the


middle third of the thigh beneath the satorius muscle.
Commences above at the apex of the femoral triangle and
ends below at the opening in the adductor magnus.
& Anteromedial wall: Satorius ms. and fascia
& Posterior wall: Adductor longus and magnus
& Lateral wall: Vastus medialis (Snell, 2012)
o Not surrounded by femoral sheath
o Contains
Femoral artery and vein
Saphenous nerve
Figure 3. Femoral Artery

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Deep artery of the thigh 2. Obturator artery


Lateral circumflex femoral artery Branches from internal iliac artery
Medial circumflex artery Bifurcates into:
Perforating arteries o Anterior branch
o Landmark: Adductor brevis muscle o Posterior branch
st
o 1 : perforating artery above Acetabular vessel
nd
o 2 : anterior Branch in posterior
rd
o 3 : below Supplies head of the femur

Figure 6. Obturator artery

C. ARTERIES OF THE LEG


The Femoral artery will go down to the anterior aspect of the
thigh, go posteriorly into the Adductor Hiatus (opening below
the Adductor magnus muscle), and becomes the Popliteal
artery -> contained in the Popliteal Fossa.

Popliteal Fossa
Figure 4. Arteries and nerves of the thigh Diamond-shaped space behind knee joint
Margins:
Branches of Lateral circumflex femoral artery o Superiolaterally Biceps femoris
Ascending branch & Superiomedially Semimembranous and
o Supplies head and neck of femur semitendinousus (Snell, 2012)
o Connects with the medial branch of circumflex femoral o Inferolaterally Lateral head of gastrocnemius
Descending branch o Inferomedially Medial head of gastrocnemius
o Connects with a branch of the popliteal artery o Posteriorly skin + popliteal fascia
o Descend deep to Rectus Femoris & Anterior wall or floor: popliteal surface of the femur,
Transverse branch posterior ligament of the knee jt., and the popliteus ms.
o Participates in cruciate anastomosis around hip Major contents of popliteal fossa (Deep to superficial)
o Popliteal artery and vein
o Tibial nerve
o Common fibular nerve
o Posterior cutaneous nerve
o Popliteal lymph node
o Lymph vessels
& Other contents of the fossa according to Snell:
o Small saphenous vein
o Common peroneal nerve
o Common tibial nerve
o Genicular branch of the obturator nerve
o Connective tissue

Anastomoses of arteries around knee


From thigh
o Descending and genicular branches from femoral,
popliteal & lateral circumflex femoral arteries
Figure 5. Lateral circumflex femoral artery
From leg

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o Circumflex fibular artery Lateral malleolar branch


o Recurrent branches from anterior tibial artery Join in the anastomoses of ankle
o Circumflex fibular artery
Anastomoses with the inferior lateral malleolar
artery

Anterior Tibial Artery


Supplies anterior compartment of leg
Pass forward interiorly through an aperture in the
interosseous membrane of the proximal leg
Branches:
o Recurrent branch
Figure 7. Arteries of knee
Anastomotic network around knee
The Popliteal artery will bifurcate into the Anterior Tibial and o Perforating branches
Posterior Tibial arteries at the landmark of the Popliteus o Anterior medial malleolar & anterior lateral
muscle. malleolar
Anastomostic network around ankle
1. Popliteal artery o Dorsalis Pedis a.
Continuation of the femoral artery Nutrient artery of the Tibia
Major blood supply to the leg and foot
Deepest structure in the popliteal fossa Can arises from either posterior or anterior tibial artery
Enters the posterior compartment Largest nutrient artery in the body
Tibialis Posterior
Branches of the Popliteal artery
Anterior Tibial Artery
Posterior Tibial Artery
Sural Artery
o Supplies the gastrocnemius, soleus, and plantaris
muscles

Genicular Artery

Descending genicular artery


Superior lateral genicular artery
Superior medial genicular artery
Inferior lateral genicular artery
Forms genicular anastomosis around knee joint
Supplies the capsules and ligaments of the joint

Popltieal artery will bifurcate into posterior tibial artery and


fibular artery

Posterior tibial artery Figure 8. Arteries in the leg


The Posterior Tibial artery will continue down to the back of the
Supplies the posterior and lateral compartments of the leg
leg -> enter the sole of the foot through the Tarsal Tunnel.
and continues to the sole of the foot
Branches
Tarsal Tunnel
o Fibular artery
Posteromedial side of the ankle
Largest branch
Structures: Tom, Dick And Very Nervous Harry
Branches:
o Tom: Tibialis Posterior tendon
Nutrient artery of fibula
o Dick: Flexor Digitorum longus tendon
Perforating branch o And: Posterior Tibial Artery
Anastomoses with arcuate artery o Very: Posterior TIbial Vein
Lateral calcaneal branches o Nervous: Tibial Nerve
Supplies the Heel o Harry: Flexor Hallucis Longus tendon

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Figure 10. Arteries and nerves of foot


Figure 9. Structures located in Tarsal Tunnel

D. ARTERIES OF THE FOOT


Terminal branches of posterior tibial artery (plantar arteries)
and anterior tibial artery (dorsalis pedis artery)
A. Plantar Aspect
Continues from the posterior tibial artery
1. Lateral plantar artery
o Deep plantar arch
Joins with deep plantar artery (of dorsalis pedis)
Digital branch to lateral side of little toe
4 Plantar metatarsal arteries
Plantar digital arteries
3 Perforating arteries
Anastomose with vessels on dorsal aspect of
foot
2. Medial plantar artery
o Deep branch
Muscles of great toe
o Superficial branch
Join plantar metatarsal arteries from deep palmar
arch Figure 11. Summary of Branching in Arteries

B. Dorsalis pedis artery II. VEINS


1. Deep plantar artery
Join deep plantar arch in sole of foot VENOUS DRAINAGE OF LOWER LIMB
2. Lateral and medial tarsal arteries Superficial veins
Anastomoses with network of vessels around ankle o Location: in subcutaneous tissue
3. Arcuate Artery o Run independent from named arteries
Dorsal metatarsal arteries o Drain into a dorsal venous arch
o Dorsal digital arteries Deep veins
4. First dorsal metatarsal artery o Location: internal to / deep to / beneath deep fascia
Dorsal digital branches adjacent to sides of great and o Accompany all major arteries
nd
2 toes o Usually occur as paired (frequently interconnecting
veins that flank the artery they accompany)
o Contained within vascular sheath with the artery
(pulsations of artery help compress and move blood in
the veins

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Penetrate deep fascia close to their origin from


superficial veins at an oblique angle
Contain venous valves that allow blood to flow only from
superficial veins to deep veins (note: venous blood flow:
superficial deep)
Importance:
o Muscle contracts increased pressure inside deep
fascia compression of perforating veins
prevent blood from flowing from deep to superficial
veins; enabling blood propulsion towards heart
against gravity (musculovenous pump)

B. DEEP VEINS OF THE LOWER LIMBS


Path: perforating veins medial and plantar veins
posterior tibial veins; posterior tibial and fibular veins
popliteal vein femoral vein (+ profunda femoris)
external iliac vein
th
Figure 12. Left femoral vessels. Grays Anatomy (40 Edition). Anterior tibial vein: anterior leg
Medial and lateral plantar veins: plantar aspect of foot
A. SUPERFICIAL VEINS OF THE LOWER LIMBS Posterior tibial and fibular veins: posterior to lateral
1. Great saphenous vein (U great/big toe side great malleolus
saphenous) Fibular vein: posterior to medial malleolus
Medial Popliteal vein: posterior to knee; where anterior and
From union of dorsal vein of great toe with dorsal posterior tibial veins, medial and lateral plantar veins, and
venous arch of foot fibuluar vein flows into
Path: Femoral vein: thigh; occupies middle of femoral sheath
o Ascends anterior to medial malleolus (note: femoral triangle); where popliteal vein flows into
o Passes posterior to medial condyle of femur Profunda femoris vein: thigh; joins terminal portion of
o Anastomoses freely with small saphenous vein femoral vein; drain blood from thigh muscles
o Traverses the saphenous ring in the fascia lata External iliac vein: femoral vein passing deep to the
o Empties into femoral vein inguinal ligament
Tributaries:
o Accessory saphenous vein: medial and posterior
aspect of thigh; main communication between
great and small saphenous veins
o Lateral and anterior cutaneous veins: inferior part of
thigh
o Superficial circumflex iliac, superficial epigastric and
external pudendal veins: near great saphenous
veins termination
2. Small saphenous vein (U small/little toe side small
saphenous)
Lateral
From union of dorsal vein of little toe with dorsal venous
arch of foot
Path:
o Ascends posterior to lateral malleolus
o Passes along lateral border of calcaneal tendon
o Inclines to midline of fibula and penetrates deep
fascia
o Ascends between heads of gastrocnemius
o Empties into popliteal vein
3. Perforating Veins
Figure 13. Summary of the Veins in the Lower Limbs

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III. LYMPHATIC DRAINAGE OF THE LOWER LIMB Terminal branches on the posterior wall of the abdomen
Path: popliteal lymph nodes deep and/or superficial and posterolateral wall of the pelvis enter the lower limbs
inguinal lymph nodes external iliac lymph nodes from the abdomen and the pelvis.
common iliac lymph nodes lumbar lymphatic trunks Major nerves include the following: femoral nerve, obturator
Superficial lymphatic vessels nerve, sciatic nerve, superior gluteal nerve, and inferior
o Converge on and accompany the saphenous veins and gluteal nerve.
their tributaries Nerves which supply skin or muscle include: the lateral
o Superficial inguinal lymph nodes: where lymphatic cutaneous nerve of the thigh, nerve to obturator internus,
vessels accompanying the great saphenous vein enter nerve to quadratus femoris, posterior cutaneous nerve of
o Deep inguinal lymph nodes: where some lymphatic thigh, perforating cutaneous nerve, and branches of the ilio-
vessels accompanying the great saphenous vein enter; inguinal and genitofemoral nerves.
located under deep fascia on medial aspect of femoral
vein I. Lumbar Plexus
o Popliteal lymph nodes: where lymphatic vessels
accompanying the small saphenous vein enter;
surround popliteal vein in the fat of popliteal fossa
o External iliac lymph nodes: where most lymph from
superficial and deep inguinal lymph nodes passes
directly; along external iliac artery
o Internal iliac lymph nodes: where lymph from the
gluteal region passes; along internal iliac artery
Deep lymphatic vessels
o Accompany deep veins
o Popliteal lymph nodes deep inguinal lymph nodes

Mnemonics: I Get Loved On Fridays


1. Iliolinguinal (L1)
L1 superior division
No motor function in lower limbs
Innervates lower abdominal wall muscles (external
oblique, internal oblique, transversus abdominis)
Sensory nerve of the skin over the anteromedial part of
the upper thigh and adjacent skin of the perineum.
2. Genitofemoral (L1-L2)
(L1- inferior division and L2- superior division)
No motor function in lower limb
Genital branch innervates cremaster muscle in the wall
of the spermatic cord in men
Cutaneous innervation:
Figure 14. Superficial veins and lymphatics of lower limb.
th o Femoral branch innervates skin on anterior central
Moores Clinically Oriented Anatomy (7 edition).
part of upper thigh;
o Genital branch innervates skin in anterior part of
IV. INNERVATIONS
perineum (anterior scrotum in men, and mons pubis
A. LUMBROSACRAL PLEXUS and anterior labia majora in women)
Nerves supplying the lower limbs arising from roots L1-S4 3. Lateral Cutaneous nerve of the thigh (L2-L3)
Composed of the lumbar plexus and the sacral plexus Sensory nerve of the Parietal peritoneum in iliac fossa;
skin over anterolateral thigh
L1 L4: Lumbar Part of the Lumbosacral Plexus
4. Obturator nerve (L2-L4)
L4-S4: Sacral Part of the Lumbosacral Plexus

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Innervates all muscles in the medial compartment of


thigh (except pectineus and the hamstring part of 1. Superior Gluteal N. (L4-S1)
adductor magnus attached to the ischium supplied Innervates gluteus medius, gluteus minimus, tensor
by the sciatic nerve) also innervates obturator fasciae latae
externus 2. Inferior Gluteal N. (L5-S2)
Cutaneous innervation: Skin over upper medial Innervates gluteus maximus
copmartment of thigh 3. Posterior Femoral Cutaneous N. (S1-S3)
5. Femoral nerve (L2-L4) Cutaneous innervation: skin over gluteal fold and upper
Innervates all muscles in the anterior compartment of medial aspect of thigh and adjacent perineum, posterior
thigh; aspect of thigh and upper posterior leg
In the abdomen, also gives rise to branches that supply a. Nerve to quadratus femoris (L4-S1)
iliacus and pectineus o Gemellus inferior & quadratus femoris
3 branches: b. Nerve to the obturator internus (L5-S2)
i. Anterior cutaneous branches o Gemellus superior & obturator internus
Skin on front of thigh and knee 4. Pudendal N. (S2-S4)
ii. Motor nerves Major somatic nerve of perinuem
Quadriceps femoris muscles Passes through gluteal region but does not innervate
Sartorius any muscle in that area
iii. Saphenous nerve 5. Sciatic N. (L4-S3)
Skin on anteromedial side of leg and medial Principal nerve in the lower limbs
side of foot Largest nerve in the body
Accompanies femoral artery through adductor Innervates all muscles in the posterior compartment of
canal thigh and the Hamstring part of adductor magnus
From anterior rami of L4-L5 and S1-S4Also innervates
II. Sacral Plexus all muscles in the leg and foot
2 nerves in one fascia(usually separates at the popliteal
fossa; may have anatomical variations :
o Tibial nerve-Posterior divisions of L4-S2
o Common fibular nerve-Anterior divisions L4-S3
Internal iliac artery provide the blood supply
Cutaneous Innervation: Skin over lateral side of leg and
foot, and over the sole and dorsal surface of foot

One nerve enters the gluteal region by passing directly through


sacrotuberous ligament.
1. Perforating cutaneous nerve (S2-S3)
Does not enter through the greater sciatic foramen
Leaves the sacral plexus in the pelvic cavity by piercing
the sacrotuberous ligament.
Loops around the lower border of the gluteus maximus
B. NERVES OF GLUTEAL REGION Supplies skin over the medial
Mnemonic: SIPPS

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o All muscles of posterior compartment of leg


o All intrinsic muscles in sole of foot
2. Medial calcaneal nerve
o Skin on medial surface & sole of heel
3. Medial sural cutaneous nerve
o Skin on lower posterolateral surface of leg and lateral
side of foot and little toe
o Joins sural communicating branch (of common fibular
nerve -> Sural Nerve
4. Medial calcaneal branches
o Supply heel
5. Medial plantar nerve
o Skin on most of anterior two-thirds of sole
o Adjacent surfaces of medial three & toes
o Abductor halluces, flexor digitorum brevis, flexor
st
halluces brevies, & 1 lumbrical
a. Proper plantar digital nerve
Figure 14. Tibial Nerve piercing piriformis Medial side of great toe
b. Common Plantar digital nerves
C. NERVES OF THE THIGH Proper plantar digital branches
Safe area for injection: Upper Lateral quadrant 6. Lateral plantar nerve
Remember: MAP OF Philippine Seas o Superficial branch
o (M) Medial aspect of thigh (O)Obturator Nerve a. Proper plantar digital nerve
o (A)Anterior Compartment of Thigh (F) Femoral Nerve Skin on lateral side of little toe
o (P) Posterior Compartment of Thigh (S) Sciatic Nerve Flexor digiti minimi brevis
Dorsal & plantar interossei bet metatarsals IV&V
b. Common plantar digital nerve
Proper plantar digital nerves to skin on adjacent
sides of toes IV & V

REMEMBER: If theres LPA = bed weather, leading to high


incidence of STDs
Lateral Compartment of the leg = Superficial Fibular
Nerve/ Superficial Peroneal Nerve
Posterior Compartment = Tibial Nerve
Anterior Compartment=Deep Fibular Nerve

1. Common Fibular Nerve


o Swing around the neck of the fibula
o Supplies the short head of the biceps femoris muscle
o Very superficial location which is why it the most
common injured nerve in the lower limb
o Damage to this drop results in Foot Drop
o loss of dorsiflexion and unopposed inversion of the foot
2. Sural communicating nerve
o Joins the medial sural cutaneous branch (of tibial nerve)
-> Sural Nerve
3. Lateral sural cutaneous nerve
o innervates skin over upper lateral leg
Figure 15. TIbial nerve 4. Superficial fibular nerve
o Lateral compartment
1. Tibial Nerve o Dorsal areas of foot & toes except
nd
o All hamstring muscles Web space between the great & 2 toes (deep
Except short head of biceps femoris fibular nerve)

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Lateral side of little toe (sural branch of tibial nerve)


o Skin on dorsal aspect of foot & toes except
Skin on adjacent sides of toes 1&11 (deep fibular
nerve)
Skin on lateral side of foot & little toe (sural nerve)
o Cutaneous branches
o Dorsal Digital nerves
5. Deep fibular nerve
o Innervates anterior compartment of the leg and the skin
nd
bet. Greater and 2 toe
6. Sural nerve
o Lateral side of the foot and the dorsal lateral surface of
the little toe
7. Saphenous nerve
o Cutaneous branch of femoral nerve
o Supplies the medial side of proximal foot

D. DERMATOMES OF LOWER LIMBS


Adjacent dermatomes overlap considerably, except along
the axial line.
Area of skin supplied by spinal nerves
L1: test dermatomal level at area of inguinal ligament
L2: anterior thigh
L3: medial part of the thigh
L4: medial side of the leg until great toe
L5: Lateral side of the leg
S1: little toe
S2: Posterior of the thigh
S3: Gluteal area
REFERENCES:
References:
Moore, K., Dalley, A., & Agur, A. (2014). Clinically
th
Oriented Anatomy (7 ed.). Philadelphia, PA: Lippincott
William & Wilkins.
th
Netter, F.H., (2014). Atlas of Human Anatomy (6 ed.)
Philadelphia, PA: Saunders Elsevier
th
Snell, R. (2012). Clinical Anatomy By Regions (9 ed.).
Philadelphia, PA: Lippincott William & Wilkins.
Figure 16. Dermatomes of the Lower Limb
Standring, S. (Ed.). (2008). Grays Anatomy (40th ed.).

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APPENDIX: Figure 18. Superficial veins of right lower limb. Snells Clinical
th
Anatomy By Regions (9 Edition).

Figure 17. Femoral triangle in left lower limb. Snells Clinical


th
Anatomy By Regions (9 Edition).

Figure 19. Veins of lower limb. Moores Clinically Oriented


th
Anatomy (7 edition).

Figure 20 Cutaneous innervation of sole


Chart from 2019C Trans of Blood and Nerve Supply

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from 2019C transes

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