Section 2 - Lower Limb Anatomy

DEPARTMENT OF HUMAN ANATOMY
UNIVERSITY OF NAIROBI
GROSS ANATOMY LABORATORY

GUIDE
MBChB and BDS Students User’s

Manual
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PREFACE
This practical guide is for first year medical and dental students whose course work in Human
Anatomy involve practical visualization of various body structures in the laboratory. As you
begin your anatomical learning adventure, use this guide to prepare for the laboratory. It is
particularly designed to help you prepare for and get the most out of each of the laboratory
sessions. There is a chapter for each of the labs that has a list of objectives that you should use
to prepare for lab. If you follow these objectives you will arrive at lab prepared and you will
maximize your learning efforts.
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SECTION OUTLINES
SECTION 1: INTRODUCTORY THEMES
SECTION 2: LOWER LIMB ANATOMY
SECTION 3: UPPER LIMB ANATOMY
SECTION 4: NEUROANATOMY
SECTION 5: HEAD AND NECK ANATOMY
SECTION 6: ANATOMY OF THE THORAX
SECTION 7: ANATOMY OF THE ABDOMEN
SECTION 8: ANATOMY OF THE PELVIS AND PERINEUM
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SECTION 2:
LOWER LIMB
ANATOMY
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TABLE OF CONTENTS
PREFACE ......................................................................................................................................................... 2
SECTION OUTLINES ..................................................................................................................................... 3
SECTION 2: LOWER LIMB ANATOMY ..................................................................................................... 4
TABLE OF CONTENTS ................................................................................................................................. 5
1. THE GLUTEAL REGION........................................................................................................................... 8
1.1 INTRODUCTION ........................................................................................................................... 8
1.2 CHAPTER OBJECTIVES ................................................................................................................. 8
1.3 THE BONES OF THE GLUTEAL REGION......................................................................................... 8
1.3.1 PELVIC BONE ........................................................................................................................ 8
1.3.2 THE PROVIMAL FEMUR ........................................................................................................ 9
1.4 CUTANEOUS NERVES OF THE GLUTEAL REGION ......................................................................... 9
1.5 SKIN AND SUPERFICIAL FASCIA ................................................................................................. 10
1.6 MUSCLES AND THEIR NEUROVASCULATURE............................................................................. 10
1.6.1 THE THREE LARGE GLUTEAL MUSCLES ............................................................................... 10
1.6.2 THE SCIATIC NERVE ............................................................................................................ 12
1.6.3 THE SIX SMALL GLUTEAL MUSCLES .................................................................................... 13
1.7 SCIATIC NOTCHES AND FORAMINA ........................................................................................... 14
1.7.1 THE GREATER SCIATIC FORAMEN ....................................................................................... 14
1.7.2 THE LESSER SCIATIC FORAMEN .......................................................................................... 15
2. POSTERIOR ASPECT OF THE THIGH & POPLITEAL FOSSA ........................................................ 16
2.1 INTRODUCTION ......................................................................................................................... 16
2.2 CHAPTER OBJECTIVES ............................................................................................................... 16
2.3 BONY LANDMARKS OF POSTERIOR THIGH ................................................................................ 16
2.3.1 ISCHIUM ............................................................................................................................. 16
2.3.2 THE FEMUR ........................................................................................................................ 16
2.3.3 THE PROXIMAL TIBIA AND FIBULA ..................................................................................... 17
2.4 SKIN AND FASCIAE OF POSTERIOR THIGH ................................................................................. 17
2.5 MUSCLES OF THE POSTERIOR THIGH ........................................................................................ 18
2.6 THE SCIATIC NERVE ................................................................................................................... 19
2.7 POSTERIOR THIGH VASCULATURE............................................................................................. 20
2.8 THE POPLITEAL FOSSA ............................................................................................................... 22
2.8.1 THE ROOF OF POPLITEAL FOSSA ........................................................................................ 22
2.8.2 WALLS OF THE POPLITEAL FOSSA ....................................................................................... 22
2.8.3 CONTENTS OF THE POPLITEAL FOSSA ................................................................................ 23
2.8.4 FLOOR OF THE POPLITEAL FOSSA ....................................................................................... 24
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3. ANTEROMEDIAL THIGH & HIP JOINT .............................................................................................. 25
3.1 INTRODUCTION ......................................................................................................................... 25
3.3 OSTEOLOGY............................................................................................................................... 25
3.3.1 PELVIC BONE ...................................................................................................................... 25
3.3.2 FEMUR ............................................................................................................................... 26
3.3.3 THE PROXIMAL TIBIA .......................................................................................................... 26
3.4 ANATOMICAL LANDMARKS....................................................................................................... 26
3.5 SKIN AND SUPERFICIA FASCIA ................................................................................................... 26
3.6 FASCIA LATA .............................................................................................................................. 28
3.7 MUSCULATURE AND THEIR INNERVATION ............................................................................... 28
3.7.1 MUSCLES OF THE ANTERIOR COMPARTMENT OF THE THIGH ........................................... 28
3.7.2 MUSCLES OF THE MEDIAL COMPARTMENT OF THE THIGH ............................................... 30
3.8 ANATOMICAL SPACES AND THEIR CONTENTS........................................................................... 31
3.8.1 THE FEMORAL TRIANGLE ................................................................................................... 31
3.8.2 THE ADDUCTOR (HUNTER’S) CANAL .................................................................................. 32
3.9 THE HIP JOINT ........................................................................................................................... 34
3.9.1 THE PROXIMAL FEMUR ...................................................................................................... 34
3.9.2 THE ACETABULUM ............................................................................................................. 35
3.9.3 HIP JOINT CAPSULE & LIGAMENTS ..................................................................................... 36
4. KNEE JOINT ANATOMY ........................................................................................................................ 38
4.1 INTRODUCTION ......................................................................................................................... 38
4.3 OSTEOLOGY OF THE KNEE ......................................................................................................... 38
4.3.1 OSTEOLOGY OF THE DISTAL FEMUR ................................................................................... 38
4.3.2 OSTEOLOGY OF THE PATELLA............................................................................................. 39
4.3.3 OSTEOLOGY OF THE PROXIMAL TIBIA ................................................................................ 40
4.4 KNEE JOINT CAPSULE & LIGAMENTS ......................................................................................... 41
5. ANATOMY OF THE LEG ........................................................................................................................ 44
5.1 INTRODUCTION ......................................................................................................................... 44
5.3 SURFACE ANATOMY OF THE LEG .............................................................................................. 44
5.4 OSTEOLOGY OF THE LEG ........................................................................................................... 45
5.4.1 OSTEOLOGY OF THE TIBIA .................................................................................................. 45
5.4.2 OSTEOLOGY OF THE FIBULA ............................................................................................... 46
5.5 SUPERFICIAL STRUCTURES OF THE LEG ..................................................................................... 46
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5.5.1 SUPERFICIAL VEINS OF THE LEG ......................................................................................... 46
5.5.2 SUPERFICIAL NERVES OF THE LEG ...................................................................................... 47
5.6 THE FASCIA CRURIS ................................................................................................................... 48
5.7 MUSCLES OF THE LEG AND THEIR NEUROVASCULAR SUPPLY ................................................... 49
5.7.1 THE ANTERIOR (EXTENSOR) COMPARTMENT .................................................................... 49
5.7.2 DORSUM OF THE FOOT ...................................................................................................... 50
5.7.3 THE LATERAL (PERONEAL) COMPARTMENT ....................................................................... 50
5.7.4 THE POSTERIOR (FLEXOR) COMPARTMENT ....................................................................... 51
5.8 SUMMARY ................................................................................................................................. 54
6. ANKLE JOINT ANATOMY ..................................................................................................................... 55
6.1 INTRODUCTION ......................................................................................................................... 55
6.3 SURFACE ANATOMY OF THE ANKLE REGION ............................................................................ 55
6.4 OSTEOLOGY OF THE ANKLE JOINT............................................................................................. 55
6.4.1 OSTEOLOGY OF THE DISTAL TIBIA ...................................................................................... 55
6.4.2 OSTEOLOGY OF THE DISTAL FIBULA ................................................................................... 56
6.4.3 OSTEOLOGY OF THE TALUS ................................................................................................ 56
6.5 ANKLE JOINT CAPSULE & LIGAMENTS ....................................................................................... 57
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1. THE GLUTEAL REGION
(Dr. Kirsteen Awori)
1.1 INTRODUCTION
The gluteal region has muscles crucial to the execution of bipedal locomotion. The gluteus
maximus has evolved to be a large muscle relevant in rising up from squatting position and
climbing through hip extension. The gluteus medius and minimus play a major role in lateral
balance control during the gait cycle. They keep the pelvis stable when one foot is off the
ground, failure to which results to a waddling gait. The sciatic nerve exits the pelvis in this
region. Its location therein influences the site of preference in administration of intramuscular
injections in this region.
1.2 CHAPTER OBJECTIVES

1. To name the parts of the hip bone
2. To identify key landmarks on the hip bone, articulated pelvis and the femur provided.
3. To map the cutaneous nerves in the gluteal region
4. To state the formation, course and relations of the sciatic nerve in the gluteal region
5. To state the attachments of gluteal muscles, including their blood supply, innervation
and actions.
6. To describe the formation and contents of the sciatic foramina
1.3 THE BONES OF THE GLUTEAL REGION

You are provided with a hip bone (or an articulated pelvis) and a femur. Orientate yourself on
the anatomical positions, and siding of these bones, where possible.
1.3.1 PELVIC BONE

Identify the following parts of the hip bone provided. Use your atlases to guide you in
identifying the parts:
a) Ilium, ischium and pubis

b) Sacrum and sacroiliac joints
c) Acetabulum
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d) Iliac crest, tubercles and spines
e) Anterior, posterior and inferior gluteal lines
f) Pubic symphysis, rami and crests
g) Ischial spines, tuberosities and ramus
h) Lesser and greater sciatic notches (converted into foramina by ligaments)
Some of these are important in muscle attachment. Note that the areas between the gluteal lines
represent the proximal attachment of the main gluteal muscles.
1.3.2 THE PROVIMAL FEMUR

Identify the following parts of the proximal femur on the femur bone provided. Use your atlases
to guide you in identifying the parts:
a) Femoral head
b) Fovea capitis
c) Femoral neck
d) Greater and lesser trochanters
e) Intertrochanteric line – separating the two trochanters anteriorly
f) Intertrochanteric crest – separating the two trochanters posteriorly
g) Quadrate tubercle – on the intertrochanteric crest
h) Piriformis fossa – at the summit of the intertrochanteric crest
i) Trochanteric fossa – on the medial upper aspect of the greater trochanter.
j) Gluteal tuberosity – posterior and just inferior to the lesser trochanter
1.4 CUTANEOUS NERVES OF THE GLUTEAL REGION

These are from the dorsal rami of the lumbar and sacral nerve roots as direct branches or
through the perforating cutaneous, posterior cutaneous nerve of the thigh, branches of the
subcostal, iliohypogastric and lateral cutaneous nerve of the thigh. These nerves are variably
exposed. Appreciation of the pattern and direction in the skin is more important than trying to
locate each individual nerve in the thick subcutaneous tissue.
Use your atlas to establish the territory of these nerves in the gluteal region.
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Task 1.1
Use a labelled diagram to illustrate the sensory innervation of the gluteal region.
1.5 SKIN AND SUPERFICIAL FASCIA

The skin and superficial fascia have been incised and flaps reflected for you. Lift the flaps to
expose the gluteus maximus. Appreciate the gluteal aponeurosis as it arises from the fascia lata
to lie between the iliac crest and the superior border of gluteus maximus. You may see the
gluteal branch of posterior cutaneous nerve of the thigh and the perforating cutaneous nerves
at the inferior border/aspect of this muscle.
1.6 MUSCLES AND THEIR NEUROVASCULATURE

The muscles of the gluteal region consist of three large gluteal muscles and six small lateral
rotators of the hip. The three large gluteal muscles are the gluteus maximus, gluteus medius
and gluteus medius. The six small lateral rotators are the quadratus femoris, pirifomis, superior
and inferior gamelli and obturator internus and externus.
1.6.1 THE THREE LARGE GLUTEAL MUSCLES

The gluteus maximus (G.Max) has its proximal attachment to the posterior part of the iliac
crest, the sacrum, the sacrotuberous ligament in addition to the gluteal aponeurosis. The muscle
has been incised across its fibres at the lower border to help you appreciate better its
attachments, how blood vessels and nerves enter its belly to supply it and to expose the
structures deep to it. At this point, lift the lower part of the muscle to see its continuity into the
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iliotibial band (most of it) and a smaller portion inserts into the gluteal tuberosity. Trace the
inferior gluteal vessels (IGV) and nerve (IGN) from the lower portion of the muscle to the
greater sciatic foramen. The superior part of the muscle is supplied by a branch of the superior
gluteal artery (See SGV below) also emerging from the greater sciatic foramen but above
piriformis (P).
Task 1.2
State the following regarding the gluteus maximus:
a) Pattern of insertion
b) Actions
c) Clinical relevance
Gluteus medius (G.Med) and minimus (G.Min) are hip joint abductors and internal (medial)
rotators. Through the former function, they are important in lateral balance control of bipedal
locomotion. Trace the proximal attachment of gluteus medius on the posterior part of the ilium
between the anterior and posterior gluteal lines and just above piriformis. The gluteus minimus
arises between the anterior and inferior gluteal lines of the ilium. Both these muscles are
supplied by the superior gluteal vessels (SGV) and nerve (SGN).
Task 1.3
State the insertion of the gluteus medius and minimus, and identify these on the femur
bone provided.
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1.6.2 THE SCIATIC NERVE
Identify the sciatic nerve (SN), the largest nerve in the body. It arises from the pelvis and exits
through the greater sciatic foramen below piriformis muscle. In the gluteal region, it is
surrounded by fat and lies on the following structures from superior towards the thigh: the
inferior margin of the greater sciatic foramen, the superior and inferior gamelli around the
tendon of obturator internus and the quadratus femoris muscle. Further down in this region, the
nerve is accompanied by a companion artery from the inferior gluteal artery. We will follow
this nerve in the posterior thigh till it terminates by dividing into the tibial and common
peroneal nerves in the popliteal fossa in the next task.
Occasionally, the sciatic nerve may arise from the pelvis with its two components already
separate: the common peroneal nerve usually in this case pierces piriformis muscle while the
tibial nerve emerges below this muscle. Check on the other tables if such a pattern is
demonstrated. Further reading on the root value, surface landmarks and possible sites of injury
can be done in standard textbooks of gross anatomy.
Task 1.4
Describe the anatomy of the sciatic nerve in the gluteal region under the following
subheadings:
a) Root value
b) Course and surface landmarks
c) Common sites and clinical effects of its injury
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1.6.3 THE SIX SMALL GLUTEAL MUSCLES
Just above and deep to the sciatic nerve are small muscles from the pelvis to the proximal
femur. They play an important role in dynamic hip joint stabilization during external rotation.
➢ Follow piriformis from the greater sciatic foramen as it arises from the anterior aspect
of the middle three sacral segments to insert into the piriformis fossa at the tip of the
greater trochanter. Its innervation is by the ventral rami of sacral nerves S1 and S2
within the pelvis.
➢ By carefully reflecting the sciatic nerve laterally, you will appreciate the small external
rotators of the hip deep to piriformis. It is easier to locate the tendon of obturator
internus towards the greater trochanter and track it backwards to its origin in the pelvis
through the lesser sciatic foramen.
➢ On either side of the tendon of obturator internus are the superior and inferior
gamellus muscles forming a tricipital insertion into the posterior aspect of the greater
trochanter. The nerve to obturator internus may be seen at this point. This nerve also
supplies the superior gamellus.
➢ Just distal to the three above, is the quadratus femoris which is appreciable by its
quadrate shape lying between the quadrate tubercle of the greater trochanter and the
posterior aspect of the ischium. Trace the nerve to this muscle from the greater sciatic
foramen below piriformis to its belly. It also supplies the inferior gamellus muscle.
➢ The tendon of obturator externus passes deep to the quadratus femoris muscle. The
muscle itself is best demonstrated under pectineus, in the proximal aspect of the anterior
thigh.
Task 1.5
Using an atlas with the articulated pelvis or hip bone and femur provided to map the
attachments of these muscles.
State the attachments (origin and insertion) of each of these small gluteal muscles
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1.7 SCIATIC NOTCHES AND FORAMINA
The greater and lesser sciatic notches are converted into greater and lesser sciatic foramina by
sacrotuberous and sacrospinous ligaments. These foramina traverse various neurovascular
structures and muscles into or from the gluteal region.
1.7.1 THE GREATER SCIATIC FORAMEN

The greater sciatic foramen is formed by the greater sciatic notch, sacrotuberous ligament and
sacrospinous ligaments. The piriformis muscle passes through the foramen and occupies most
of its volume, dividing it into two compartments, namely the supra-pirifomic and the infra-
pirifomic compartments.
➢ Identify the superior gluteal neurovascular bundle in the supra-pirifomic compartment

of the greater sciatic notch. Follow these and note that they lie in the plane between
gluteus medius and gluteus minimus.
Task 1.6
State the following regarding the superior gluteal nerve:
a) Root value
b) Course
c) Motor distribution
d) Clinical effect of its injury
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➢ Identify the following structures in the infra-pirifomic compartment of the greater
sciatic foramen, from medial to lateral:
a) Pudendal nerve
b) Internal pudendal vessels
c) Nerve to obturators internus
d) Posterior cutaneous nerve of the thigh
e) Inferior gluteal neurovascular bundle
f) Nerve to quadratus femoris
g) Sciatic nerve
1.7.2 THE LESSER SCIATIC FORAMEN

The lesser sciatic foramen is formed by the lesser sciatic notch, sacrotuberous ligament and
sacrospinous ligament. Confirm that this foramen traverses the following structures:
a) Obturator internus
b) Pudendal nerve
c) Internal pudendal vessels
d) Nerve to obturator internus
Notice that the neurovascular structures that exit the gluteal region via the lesser sciatic
foramen had entered the gluteal region via the infra-pirifomic compartment of the greater
sciatic foramen.
Task 1.7
State the root value and distribution of the following nerves:
a) Pudendal nerve
b) Inferior gluteal nerve
c) Posterior cutaneous nerve of the thigh
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2. POSTERIOR ASPECT OF THE THIGH &
POPLITEAL FOSSA
(Dr. Kirsteen Awori)
2.1 INTRODUCTION
The posterior aspect of the thigh extends from the gluteal fold to the popliteal fossa. It contains
the hamstrings and the sciatic nerve. The further apart attachments of these muscles make then
more vulnerable to tears during vigorous movements like in sports. The popliteal fossa is the
potential space behind the knee that traverses various neurovascular structures to the leg.

1. To study the bony landmarks of the posterior aspect of the femur, the proximal tibia
and fibula.
2. To study the course and branches of the sciatic nerve.
3. To exposure the popliteal fossa and appreciate its boundaries and its contents
2.3 BONY LANDMARKS OF POSTERIOR THIGH

The osteology of concern in this region is with regard to the ischium, femur and proximal tibia
and fibula.
2.3.1 ISCHIUM
You have already seen the ischium, and the ischial tuberosity on the hip bone. You can revisit
this if you are not sure.
2.3.2 THE FEMUR

Identify the following on the femur bone provided. Use your atlases to guide you on this task.
a) The linea aspera, with its two lips

b) Pectineal line, spiral line and gluteal tuberosity
c) The supracondylar lines
d) The femoral condyles and intercondylar notch
e) Popliteal surface of femur
f) Adductor tubercle – on the medial condyle
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2.3.3 THE PROXIMAL TIBIA AND FIBULA
Identify the tibia and fibula bones and use key features to side these bones.
Identify the following on the proximal tibia. Use your atlases to guide you on this:
a) Tibial condyles
b) Soleal line
c) Popliteal surface of tibia
Identify the following on the proximal fibula. Use your atlases to guide you on this:
a) Fibular apex
b) Fibular head
c) Fibular neck
2.4 SKIN AND FASCIAE OF POSTERIOR THIGH

Place the cadaveric limb in prone position. The skin and fasciae have been incised into a flap.
Note that the skin of the posterior thigh is supplied largely by the posterior cutaneous nerve of
the thigh.
The deep fascia of the thigh is known as the fascia lata. This fascia has already been reflected
for you expose the posterior thigh muscles. Check to see the posterior cutaneous nerve of the
thigh on the fascia lata. It can be located further proximally between the long head of biceps
femoris and semitendinosus muscles before it pierces the fascia lata.
Check in your atlases to see how this nerve courses in the back of the thigh. Sometimes you
may be able to see some perforating branches of this nerve in the superficial fascia of the back
of the thigh.
Task 2.1
State the dermatome of the skin over the following regions:
a) Ischial tuberosity
b) Middle region of the back of the thigh
c) Popliteal fossa
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2.5 MUSCLES OF THE POSTERIOR THIGH
With the help of an atlas, note the proximal arrangement of the hamstrings as they arise from
the ischial tuberosity. The hamstring part of adductor magnus is the most medial, followed by
semitendinosus and then the long head of biceps femoris. The semimembranosus muscle also
arises from the ischial tuberosity, deep to these. The iliotibial band and the lateral intermuscular
septum form the lateral limit of the hamstrings.
➢ Identify the long head of the biceps femoris muscle. The proximal attachment of the
long head of the biceps femoris muscle is the ischial tuberosity and its distal attachment
is the head of the fibula. Now retract the long head of the biceps femoris muscle laterally
to observe the short head of the biceps femoris muscle. The proximal attachment of
the short head of the biceps femoris is the lateral lip of the linea aspera of the femur.
The tendons of the two join and descend to insert into the head of the fibula. Biceps
femoris muscle extends the thigh at the hip joint and flexes the leg at the knee joint.
Follow branches of the sciatic nerve to the two heads of this muscle.
➢ On the medial side of the thigh, identify the semitendinosus muscle (named from the
word half tendon due to a significant portion of it being tendinous). The proximal
attachment of the semitendinosus muscle is the ischial tuberosity while its distal
attachment is the medial surface the proximal tibia as part of the tendon insertion within
the bursa anserinus. The semitendinosus muscle extends the thigh at the hip joint and
flexes the leg at the knee.
➢ Now separate the semitendinosus muscle from the semimembranosus muscle (“half
membrane”). The proximal attachment of the semimembranosus muscle is the ischial
tuberosity and its distal attachment is the posteromedial part of the medial condyle of
the tibia. This muscle has similar actions to those of semitendinosus and both are
innervated by the tibial component of the sciatic nerve.
➢ To complete the exposure of the hamstring muscles, verify that the hamstring part of
the adductor magnus muscle arises from the ischial tuberosity deep to the other
hamstrings and inserts into the adductor tubercle of the femur. Note the origin from the
ischiopubic ramus to the linea aspera for its adductor part. Adductor magnus is a
powerful adductor and hip extensor. It has dual innervation from the tibial nerve to the
hamstring part and obturator nerve to the adductor part.
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Task 2.2
Name the components and state the common characteristics of the hamstring group of
muscles.
Explain why the short head of biceps femoris is not considered a hamstring muscle
2.6 THE SCIATIC NERVE

Now separate semitendinosus and the long head of biceps femoris. Under the latter, visualize
the sciatic nerve and follow it inferiorly to its bifurcation at the apex of the popliteal fossa into
the tibial and common peroneal nerves. This nerve has a companion artery from the inferior
gluteal artery and also gets twigs from arteries around the long head of biceps femoris.
Trace the surface landmarks of this nerve as it arises from the pelvis via the greater sciatic
foramen located between the posterior superior iliac spine and the ischial tuberosity. Note its
position mid-way between the ischial tuberosity and the greater trochanter to its termination.
Identify the two terminal branches of the sciatic nerve, namely the tibial nerve (coursing
directly inferior) and the common peroneal nerve (coursing inferolaterally). There are
instances in which the nerve terminates into the two components in the pelvis. In such cases,
usually, the common peroneal nerve pierces piriformis muscle while the tibial nerve exits
below piriformis in the greater sciatic foramen.
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Task 2.3
Review the origin, course and landmarks, distribution and clinical relevance of the sciatic
nerve
2.7 POSTERIOR THIGH VASCULATURE

The arteries that supply the posterior compartment of the thigh primarily the perforating
branches of the profunda femoris (deep femoral) artery, which run in the anterior thigh. These
perforating branches are four (named 1st, 2nd, 3rd and 4th perforators), and they go through the
adductor magnus muscle to reach the posterior thigh.
Identify some of these perforating vessels as they go through the adductor magnus muscles.
These perforators communicate with each other in the posterior thigh to constitute the so called
“longitudinal anastomosis”.
The circumflex branches of either the common or deep femoral arteries, together with the
branches of the gluteal arteries, also aid in supplying the proximal aspects of the back of the
thigh, and gluteal region. These arteries communicate around the proximal femur to form the
cruciate and trochanteric anastomoses.
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Task 2.4
Use a labelled diagram to illustrate the formation of the following anastomoses,
indicating the specific site and contributing arterial pedicles for each:
a) Trochanteric anastomosis
b) Cruciate anastomosis
c) Longitudinal anastomosis
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2.8 THE POPLITEAL FOSSA
This is a shallow diamond shaped space posterior to the knee. It traversers neurovascular
structures to the leg.
2.8.1 THE ROOF OF POPLITEAL FOSSA

The skin and popliteal fascia that are already reflected aside cover this space, otherwise
conventionally called the roof. The popliteal fascia is the posterior inferior aspects of the fascia
lata, over the popliteal fossa. Attempt to find the following structures on the roof, on the
popliteal fascia:
a) Terminal branches of the posterior cutaneous nerve of the thigh

b) Termination of the small saphenous vein
c) Sural nerve
2.8.2 WALLS OF THE POPLITEAL FOSSA

Reflect the roof and confirm that the muscles that form the upper boundaries of this diamond
(popliteal fossa) are the semitendinosus and semimembranosus for the superomedial boundary,
and biceps femoris for the superolateral boundary. These had already been studied.
The lower boundaries of this space are completed by the two heads of the gastrocnemius muscle
with the medial head inferomedially and the lateral one inferolaterally. Identify these from the
specimen, with the aid of your atlases.
Task 2.5
Use a labeled diagram to illustrate the walls of the popliteal fossa
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2.8.3 CONTENTS OF THE POPLITEAL FOSSA
➢ The termination of the sciatic nerve in the apex of this space gives rise to the common
peroneal and the tibial nerves.
➢ Follow the common peroneal nerve next to the tendon of biceps femoris muscle
towards the fibula head. The nerve winds around the fibular neck and divides into its
terminal branches, the deep and superficial peroneal nerves. Identify the lateral
cutaneous nerve of the calf, and the sural communicating nerve from the common
peroneal nerve, before its bifurcation to its terminal branches.
Task 2.6
Name four branches of the common peroneal nerve, given in the popliteal fossa
➢ Follow the tibial nerve as it descends to the leg alongside and superficial to the
popliteal vessels. Locate the sural nerve leaving the tibial nerve. Motor branches of
the tibial nerve to the gastrocnemius and soleus muscles are evident at the lower part of
the fossa. Tibial nerve also gives off three articular branches to the knee joint, named
superior medial, middle and inferior medial genicular nerves. Attempt to identify these
delicate nerves if they are still present.
➢ Deep to the tibial nerve, identify the popliteal vessels. Locate the termination of the
small saphenous vein into the popliteal vein. Confirm that the popliteal vein is located
superficial to the popliteal artery. Note the multiple tributaries from the small saphenous
and from the knee joint into this vein. Some have been cleared to enable you appreciate
the popliteal artery deep to the vein.
➢ The popliteal artery intimately lies on the anterior wall of the popliteal fossa
(conventionally referred to as the its floor). The artery is a continuation of the
superficial femoral artery beyond the adductor hiatus. Follow the artery from its
beginning at the adductor hiatus lying on the floor of the popliteal fossa to its
termination at the lower border of the popliteus muscles into the anterior and posterior
tibial arteries. Follow the genicular branches of the popliteal artery including the
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superior medial and lateral genicular arteries, the inferior medial and lateral genicular
arteries and finally, the branch that pierces the capsule of the knee joint posteriorly to
the intercondylar notch. The latter practically anchors the popliteal artery to the knee
making it vulnerable to injury in cases of knee dislocation or in fractures of the
supracondylar femur.
Task 2.7
Review the extents, branches and clinical relevance of the popliteal artery.
➢ Within the fossa, there is fat surrounding the blood vessels and nerves.
➢ Popliteal lymph nodes are embedded within this fat. These lymph nodes receive
lymphatic vessels accompanying the small saphenous vein and the popliteal vein.
2.8.4 FLOOR OF THE POPLITEAL FOSSA

As already mentioned, the floor of the popliteal fossa is its anterior boundary. Confirm from
the specimen that this comprise the following, from above downwards:
a) Popliteal surface of the femur

b) Posterior capsule of the knee joint, reinforced by the oblique popliteal ligament
c) Popliteus muscle, and the fascia covering it.
24
3. ANTEROMEDIAL THIGH & HIP JOINT
(Dr. James Kigera & Dr. Beda Olabu)
3.1 INTRODUCTION
The anteromedial thigh has many important structures. It is home to the femoral vessels and
their branches and is innervated by branches of the femoral and obturator nerves. The main
muscles in this region are the quadriceps anteriorly and the adductors medially. The deep fascia
has important modifications. ADD HIP JOINT

1. To study the sensory innervation and dermatomes of the anterior and medial thigh
2. To study the modifications of the fascia lata
3. To study the musculature of the anterior and medial compartments of the thigh and state
the innervation of each
4. To study the vascular tree of the anterior and medial thigh
5. To study the boundaries and contents of the femoral triangle and adductor canal
6. ADD HIP JOINT OBJECTIVES
3.3 OSTEOLOGY
The osteology of concern in this region has already been covered in the previous sessions.
3.3.1 PELVIC BONE

Review the following parts of the pubic bone, pelvic bone specimen.
a) Pubic body
b) Superior pubic ramus
c) Pubic crest
d) Pecten pubis
e) Inferior pubic ramus and ischiopubic ramus
f) Pubic tubercle
g) Anterior superior iliac spine
h) Anterior inferior iliac spine
25
3.3.2 FEMUR
Review the following parts of femur:
a) Head of femur and fovea capitis

b) Femoral neck
c) Intertrochanteric line and crest
d) Greater and lesser trochanter
e) Trochanteric fossa
f) Nutrient foramina
g) Spiral line
h) Pectineal line
i) Femoral diaphysis and linea aspera
j) Patella surface
k) Adductor tubercle – on the medial condyle
l) Lateral epicondyle
3.3.3 THE PROXIMAL TIBIA

Review the following parts of proximal tibia:
a) Tibial condyles
b) Tibial tuberosity
3.4 ANATOMICAL LANDMARKS

In the proximal part of the anteromedial thigh are important landmarks. The Anterior superior
iliac spine (ASIS) is palpable laterally. Medially the pubic tubercle and symphysis are also
palpable. In the living the pulsations of the femoral artery are palpable midway between these
structures. Distally, the medial epicondyle of the femur is palpable.
3.5 SKIN AND SUPERFICIA FASCIA

Place the cadaveric limb in supine position. Take note of the skin of the region and note any
differences with the other areas you have already dissected. The skin and fasciae have been
incised into a flap. Identify a few cutaneous nerves in the superficial fascia of the skin. Review
the cutaneous innervation of the anteromedial thigh before proceeding.
26
Task 3.1
Describe the sensory innervation of the skin of the anterior and medial thigh
State the dermatomes of the skin over the following sites:

a) Anterior knee
b) Femoral triangle
c) Lateral thigh
On the superficial fascia, identify the great saphenous vein on the medial aspect. It ascends
upwards to the saphenous opening. It is joined by some superficial veins just before it
terminates into the femoral vein. Superficial inguinal lymph nodes are around its termination.
Task 3.2
Describe the origin, course, tributaries and clinical relevance of the great saphenous vein
Describe the organization and territory of drainage of the superficial inguinal nodes
27
3.6 FASCIA LATA
Identify the deep fascia of the thigh also called ‘fascia lata’. Note how well developed it is.
Identify the following modifications of the fascia lata:
a) Iliotibial band, a lateral thickening of the fascia lata. Trace this proximally and note
that it forms the insertion of gluteus maximus muscle and tensor fascia lata.
b) Intermuscular septa, which divide the thigh into three muscular compartments,
namely the anterior, medial and posterior compartments.
c) Saphenous opening, which is an opening in the proximal anterior thigh, traversing
some neurovascular structures.
Task 3.3
Use a labelled diagram to illustrate the muscular compartments of the thigh
3.7 MUSCULATURE AND THEIR INNERVATION

The fascia lata has been incised to expose and identify the muscles.
3.7.1 MUSCLES OF THE ANTERIOR COMPARTMENT OF THE THIGH

Identify a long muscle arising from the anterior superior iliac spine and crossing the anterior
thigh inferomedially to the medial aspect of the leg. This is sartorius muscle. Confirm that the
muscle receives its innervation from the femoral nerve, on its proximal aspects.
28
Task 3.4
State the actions of the sartorius muscle
The major muscle of the anterior compartment is the quadriceps femoris muscle. Identify it and
its four parts namely:
a) Rectus femoris muscle located on the anterior aspect of the thigh

b) Vastus lateralis muscle located on the lateral side of the thigh
c) Vastus medialis muscle located on the medial side of the thigh
d) Vastus intermedius muscle located deep to portions of the other three parts
Identify the nerves that inter the muscles and trach them proximally to their parent nerve, the
femoral nerve. Trace the origin and insertion of the quadriceps femoris unit. Also take note of
the joints crossed by each of the components of the quadriceps muscle. Importantly, note that
the four muscles form a common tendon, the quadriceps tendon, through which they attach to
the patella. From the patella identify the patella tendon (also called ligamentum patella) to the
tibial tuberosity.
Examine the vastus lateralis and medialis muscles and consider their attachments to the patella.
Thinking about the mechanics of their action, consider how they will move the patella.
Task 3.5
State the attachments and actions of the quadriceps femoris unit
29
3.7.2 MUSCLES OF THE MEDIAL COMPARTMENT OF THE THIGH
Identify the following muscles in the medial compartment. Use your atlases to guide you.
a) Gracilis – a slender muscle on the medial aspect

b) Adductor longus, brevis and magnus antero-posteriorly
c) Pectineus
Identify the major branches (or divisions) of the obturator nerve, which are closely associated
with the adductor brevis muscle. The anterior division of the obturator nerve passes anterior to
adductor brevis muscle; the posterior division of the obturator nerve passes posterior to
adductor brevis muscle. Note that the posterior division passes between the adductor brevis
muscle and adductor magnus muscle and gives branches to both of them.
Deep to the adductor brevis muscle, identify the obturator externus muscle, which attaches to
the external surface of the obturator membrane and covers the obturator foramen. The obturator
nerve can now be more easily seen as it passes through the obturator foramen and divides into
its anterior and posterior divisions. Identify the branches of the obturator artery that accompany
the branches of the obturator nerve.
Identify the adductor magnus muscle once again and note that it has two parts; adductor part
that has horizontally oriented fibers and attaches to the linea aspera of the femur and the
hamstring part that has more vertically oriented fibers and attaches to the adductor tubercle.
The adductor magnus has a wide origin which begins at the inferior pubic ramus and runs
posteriorly along the outer surface of the ramus of the ischium to the ischial tuberosity.
Task 3.6
State origin, course, sensory and motor distribution of the following nerves:
a) Femoral nerve
b) Obturator nerve
30
3.8 ANATOMICAL SPACES AND THEIR CONTENTS
There are two important anatomical spaces to study here, the femoral triangle and the adductor
canal.
3.8.1 THE FEMORAL TRIANGLE

In the proximal portion of the thigh, identify the boundaries and contents of the femoral
triangle.
➢ Confirm that it is bordered superiorly by the inguinal ligament, medially by the medial
border of adductor longus muscle, and laterally by the medial border of sartorius
muscle.
➢ Its roof is formed by the skin and fascia lata of the thigh.
➢ The floor of the femoral triangle is formed medially by adductor longus muscle and
pectineus muscle and laterally by the iliopsoas muscle.
In the superior part of the femoral triangle, identify the great saphenous vein as it passes
through the saphenous hiatus, an opening in the fascia lata, to join the femoral vein. An
investing fascial sheath, called the femoral sheath, surrounds the femoral vein, femoral artery,
and associated deep inguinal lymph nodes.
The femoral sheath is divided into three compartments by two vertical partitions. The lateral
compartment contains the femoral artery, the middle compartment contains the femoral vein;
and the medial compartment contains lymphatics and loose connective tissue. Note that the
femoral nerve is within the femoral triangle, but not within the femoral sheath.
Inspect the medial compartment of the femoral sheath, which is also called the femoral canal.
Place a probe in the femoral canal and note the boundaries. The abdominal opening of the
femoral canal is called the femoral ring. Confirm that this opening is bordered anteriorly by the
inguinal ligament, posteriorly by pubic crest, laterally by the femoral vein, and medially by the
lateral border of the lacunar ligament.
A helpful mnemonic to remember the relative position of these structures as they cross the
inguinal ligament, is the word "NAVEL." The structures located from lateral to medial are in
the sequence: femoral Nerve, femoral Artery, femoral Vein, "empty space" with the
lymphatics, and the Lacunar ligament.
31
Clean the femoral artery and study its branches. The accompanying veins have the same names.
➢ Identify the common femoral artery and it two large terminal branches, the deep
femoral (profunda femoris) and superficial femoral arteries.
➢ Follow the course of the profunda femoris artery. It passes superficial to the pectineus
muscle and deep to the adductor longus muscle. Along its course it usually gives rise
to four perforating branches, which pass through openings in the adductor magnus
muscle to supply the structures of the posterior thigh.
➢ The circumflex arteries may be branches of either the common femoral artery or
profunda femoris artery. Identify the medial femoral circumflex artery and follow it
course as it disappears between the adjoining borders of iliopsoas muscle and pectineus
muscle.
➢ The lateral femoral circumflex artery leaves the femoral triangle, it passes deep to the
sartorius muscle and rectus femoris muscle.
3.8.2 THE ADDUCTOR (HUNTER’S) CANAL

At the apex of the femoral triangle, reflect the inferior portion of the sartorius muscle and
identify in intermuscular tunnel called the adductor canal which serves as a conduit through
which vessels pass from the femoral triangle to the posterior aspect of the knee (popliteal fossa).
The tunnel extends from the apex of the femoral triangle to an opening in the tendon of the
adductor magnus muscle (the adductor hiatus).
Identify the muscles which form the walls of the adductor canal.
➢ The anterolateral wall of the canal is formed by vastus medialis muscle.

➢ The posteromedial wall is formed by the adductor longus muscle above and adductor
magnus muscle below.
➢ The anteromedial wall (or roof) is formed by the sartorius muscle.
Study the anatomical relationship of the superficial femoral vessels within the adductor canal
and note that the femoral vein lies posterior to the femoral artery. The relative position of the
vein and artery is a constant relationship from the apex of the femoral triangle and throughout
the adductor canal. As these vessels pass through the adductor hiatus, their names change to
the popliteal vein and artery, respectively. In addition to the superficial femoral vessels,
identify the saphenous nerve and nerve to vastus medialis, within this canal.
32
The saphenous nerve is a branch of the femoral nerve. The saphenous nerve accompanies the
femoral artery and vein in the adductor canal, but it does not pass through the adductor hiatus.
Instead, on the medial side of the knee, it passes anterior to the tendon of adductor magnus
muscle and pierces the deep fascia between the tendons of the sartorius muscle and gracilis
muscle.
Task 3.7
State the contents and clinical relevance of the adductor canal
Just beneath the sartorius muscle there is sub-sartorial fascia that contains sub-sartorial plexus
of nerves.
Task 3.8
Name the nerves that constitute the sub-sartorial nerve plexus
33
3.9 THE HIP JOINT
The hip joint is a synovial joint of ball-and-socket variety. The ball is formed by the femoral
head, while the socket is formed by the acetabulum. It is a multiaxial joint, allowing a variety
of movements, with variable degrees of freedom.
3.9.1 THE PROXIMAL FEMUR

Study the anatomy of the proximal femur once again and take note of the following:
➢ The superior end of the femur consists of the rounded head, the narrow neck, and the
two trochanters (greater and lesser).
➢ The head of the femur is angled superiorly, medially and anteriorly. Such angulation
increases the degrees of freedom of the joint.
➢ The femoral neck-shaft angle is about 130º (± 7º) in adults, but is larger at birth and
decreases with age. An abnormally lesser angle is termed coxa vara, while abnormally
larger angle is termed coxa valgus.
➢ The greater trochanter is a bony prominence on the anterolateral surface of the proximal
shaft of the femur, distal to the femoral neck. It forms the attachment of gluteus medius
and minimus, obturator externus and internus, superior and inferior gamelli and
pirifomis.
Task 3.9
Pin-point the specific sites of attachment of the above muscles on the greater
trochanter.
34
➢ The lesser trochanter is a bony prominence on the proximal medial aspect of the femoral
shaft, just distal to the femoral neck.
➢ The intertrochanteric line is a raised area that extends from the greater to the lesser
trochanter anteriorly.
➢ The intertrochanteric crest is a raised area that extends from the greater to the lesser
trochanter posteriorly.
3.9.2 THE ACETABULUM

The acetabulum is the cup-shaped socket on the lateral aspect of the pelvis, which is formed
by parts of the ilium, ischium, and pubis. At birth these three bones are separated by a Y-shaped
triradiate cartilage centred in the acetabulum. Their fusion begins around 15-17 years, and is
completed by 20-25 years of age.
Study the anatomy of the acetabulum as you take note of the following:
➢ The margin of the acetabulum is deficient inferiorly, at the acetabular notch.

➢ The rough depression in the floor of the acetabulum is the acetabular fossa, which is
continuous with the acetabular notch.
➢ The lunate surface is the articular surface of the acetabulum to the femoral head.
➢ Check in any available wet specimen in the lab (or from an atlas) and note that:
o There is an additional fibrocartilaginous margin of the acetabulum, known as
the acetabular labrum. It functions to deepen the acetabulum, thus holding the
femoral head more securely.
o The transverse acetabular ligament is located along the inferior aspect of the
acetabulum; it prevents the femoral head from moving inferiorly by deepening
the acetabulum inferiorly.
35
3.9.3 HIP JOINT CAPSULE & LIGAMENTS
The capsule is best appreciated from a wet specimen. In the absence of one, use your atlases to
note the following:
➢ The capsule attaches proximally to the acetabulum and transverse acetabular ligament
and distally to the neck root of the neck
➢ There are three thickenings of the capsule, termed capsular ligaments:

o The iliofemoral ligament (the Y ligament of Bigelow) reinforces the capsule
anteriorly. It arises from the anterior inferior iliac spine and inserts onto the
intertrochanteric line. It is the strongest capsular ligament of the hip, and it
prevents hyperextension of the hip joint.
o The ischiofemoral ligament reinforces the capsule posteriorly. It originates on
the ischial part of the acetabular rim and spirals superolaterally to the neck of
the femur, medial to the greater trochanter.
o The pubofemoral ligament reinforces the capsule anteriorly and inferiorly. It
begins from the obturator crest of the pubic bone and passes inferolaterally to
join the fibrous capsule of the hip joint. This ligament prevents over abduction
of the hip joint
➢ Retinacular fibers are deep longitudinal fibers of the capsule that go superiorly and
medially from the root of the femoral neck and blend with the periosteum of the bone.
These fibers carry blood vessels, termed retinacular (metaphyseal) arteries that supply
the head of femur. On the dry specimen of femur, note the innumerable nutrient
foramina at the proximal part of the femoral neck, representing the points of entry of
the retinacular vessels.
➢ The ligament of the femoral head is weak. It attaches to the fovea capitis from the
margins of the acetabular notch and the transverse acetabular ligament. Usually the
ligament contains a small artery to the head of the femur, especially significant in
younger individuals.
36
Task 3.10
Describe the anatomy of the hip joint under the following subtitles:
(a) Articulating surfaces
(b) Static stability factors
(c) Dynamic stability factors
(d) Blood supply to the head of femur in younger and older individuals, and the
clinical significance of this
(e) Muscular and neurovascular relations of the hip joint
(f) Movements of the hip joint and the muscles responsible for each
37
4. KNEE JOINT ANATOMY
(Dr. Kevin Ongeti & Dr. Beda Olabu)
4.1 INTRODUCTION
The knee joint is the articulation between distal femur, proximal tibia and the patella. It is the
largest joint in the body, classified as compound synovial joint of condylar (tibiofemoral) and
saddle (patellofemoral) varieties. It is considered a modified hinge joint since it can
accommodate some degrees of rotation, to a limited extend.

1. To describe the articular surfaces of the knee joint.
2. To describe the stability factors of the knee joint.
3. To describe the muscular and neurovascular relations of the knee joint.
4. To describe the movements of the knee joint.
4.3 OSTEOLOGY OF THE KNEE

You will look at the anatomy of the distal femur, proximal tibia and the patella
4.3.1 OSTEOLOGY OF THE DISTAL FEMUR

Study the anatomy of the distal femur once again and take note of the following:
➢ The distal end of the femur consists of two condyles, the medial and lateral condyles
and separated by an intercondylar notch.
Task 4.1
Study the two femoral condyles and state which condyle:
a) Is wider transversely
b) Has a longer antero-posterior tibial articular surface
c) Is more curved
d) Has a more prominent buttress
e) Groove for insertion of the tendon of popliteus muscle
38
➢ Identify the patellar surface of femur and note that the lateral patellar surface has a
larger surface area, and is more raised, than the medial patellar surface. This is one of
the stability mechanisms of the patella.
➢ Identify the epicondyles which are above each condyle. The medial epicondyle is
more prominent than the lateral epicondyle, and forms the attachment of the hamstring
component of the adductor magnus muscle. The lateral epicondyle is the attachment
of the fibula collateral ligament.
➢ The intercondylar notch has attachment sites of the anterior and posterior cruciate
ligaments. The anterior cruciate ligament attaches on the posteromedial aspect of the
lateral condyle, while the posterior cruciate attaches on the anterolateral aspect of the
medial condyle. Identify these sites on the bony specimen provided.
➢ Identify the supracondylar lines which extend from each condyle proximally, to merge
with the corresponding lips of the linear aspera.
Use the anatomy of the distal femur you have studied to side the femur bones available to you.
4.3.2 OSTEOLOGY OF THE PATELLA

The patella is a sesamoid bone which develops between ages 3 to 6 years after birth from 3 to
six cartilaginous parts along the tendon of the quadriceps pull. In rare occasions those parts fail
to fuse forming a bipartite or tripartite patella.
Study the anatomy of the patella as you take note of the following:
➢ The base of the patella is superior while the apex faces inferiorly.
➢ It has two surfaces, the posterior smooth articular surface, while the non-articular
surface is rough and anterior.
➢ A vertical ridge that separates the medial from the lateral articular surfaces. The medial
articular surface is smaller than the lateral articular surface.
With these features in mind, attempt to side the patella you have on the table, and any other
that may be available for you, until you master the concept.
An easier and simpler way of siding the bone is to place it on a flat surface with shinny articular
surface facing downwards and the apex pointing away from you. Note that it will always fall
on its side!
39
4.3.3 OSTEOLOGY OF THE PROXIMAL TIBIA
The proximal tibia is widened and form the lateral and medial tibial condyles, with each
condyle having a relatively flat superior surface termed the tibial plateau. The region between
the medial and lateral tibial plateau is the intercondylar eminence. Note the following regarding
the proximal tibia:
➢ The lateral articular surface is almost circular, with a shorter anteroposterior axis.
➢ The medial articular surface is oval with a longer anteroposterior axis.
➢ The differences in the anatomy of the medial and lateral tibial plateau are reflected in
the shapes of the menisci that lie on them. If a wet specimen is available, check to
confirm the structure of the corresponding menisci. In the absence of a wet specimen,
check the attachments of the menisci in the atlas of Anatomy.
Task 4.2
State the following regarding the knee menisci:
a) Histological structure
b) Differences between the medial and lateral menisci
c) Pattern of blood supply to the meniscus and its clinical relevance
d) Functions of the knee menisci
40
➢ Identify the following parts of the intercondylar eminence:
o Anterior intercondylar area, which forms the distal attachment of the anterior
cruciate ligament
o Posterior intercondylar area, which forms the distal attachment of the
posterior cruciate ligament
o Intercondylar tubercles, that form the attachments of the anterior and posterior
cornu of the menisci.
➢ The tibial tuberosity is a projection in the proximal anterior tibial shaft. It forms the
insertion of the patella tendon.
Use the anatomy of the proximal tibia you have studied to side tibial bones available to you.
4.4 KNEE JOINT CAPSULE & LIGAMENTS

The knee joint capsule is best appreciated from a wet specimen. In the absence of one, use your
atlases to note the following:
➢ The capsule attaches proximally to the margins of the articular surface of the femoral
condyles and the intercondylar area. Anteriorly the capsule is attached to the patella
retinacula, blending all the way to the ligamentum patella. The patella ligament
extends from the apex of the patella to the tibial tuberosity.
➢ Medial and lateral collateral ligaments are visible on either side of the joint. The
medial collateral ligament is flat and triangular and extends from medial femoral
condyle just distal to the adductor tubercle to the proximal medial tibia. Assess the
lateral collateral ligament which is a cord like band extending from lateral epicondyle
below the origin of the lateral head of gastrocnemius to the head of the fibula.
Task 4.3
Study the key function of each of the collateral ligaments of the knee.
Suggest a way you can clinically test if a collateral ligament is completely torn in
a patient, as opposed to just a minor tear
41
➢ The oblique popliteal ligament is a posterior capsular reinforcement in the floor of the
popliteal fossa, as an extension of the tendon of the semimembranosus insertion.
➢ Appreciate the presence of the arcuate popliteal ligament, which is Y shaped
thickening of the capsule. The stem of this ligament originates from the head of the
fibula, with its fibers arching over the tendon of popliteus muscle to the intercondylar
region of the tibia.
➢ Note the presence of intra capsular ligaments namely the anterior and posterior cruciate
ligaments. The anterior cruciate ligament is attached to the anterior intercondylar
region of the tibia, extending to the posteromedial aspect of the lateral femoral condyle.
The posterior cruciate ligament crosses from the posterior intercondylar region to the
anteromedial aspect of the medial femoral condyle. The two ligaments cross each other
in the intercondylar region in a cruciform manner.
Task 4.4
State the following for each of the cruciate ligaments:
(a) Attachments
(b) Course/orientation within the knee joint
(c) Blood supply
(d) Functions
(e) How to clinically test for a complete tear of the ligament
42
Task 4.5
Complete the anatomy of the knee joint by discussing the following questions in your
groups:
(e) Static stability factors
(f) Dynamic stability factors
(g) Bursae around the knee and the clinical relevance of some of them
(h) Components of the genicular anastomosis
(i) Muscular and neurovascular relations of the knee joint
(j) Movements of the knee joint and the muscles responsible for each
43
5. ANATOMY OF THE LEG
(Dr. Gichambira Gikenye)
5.1 INTRODUCTION
The leg is the region between the knee and the ankle joints. It is part of the lower limb and from
a functional point the limb should be viewed as one organ with specific functions. However,
for purposes of detailed study the structures in this region will be studied to some degree in
isolation from the rest of the limb. As it will become clear, some structures not only traverse
the knee into the leg, but also traverse the leg into the foot.

1. To study the cutaneous innervation of the leg
2. To study the course of the superficial veins of the leg
3. To study the attachments and modifications of the deep fascia of the leg
4. To describe the osteofascial compartments of the leg and state the contents and
functions of each
5. To study the course of the tibial, deep peroneal and superficial peroneal nerves within
the leg
5.3 SURFACE ANATOMY OF THE LEG

Look at your own leg and appreciate the following:
➢ That the proximal part is thicker in girth than the distal. Most of the fleshy parts of the
muscles are found in this thicker proximal part.
➢ That the bone is superficial on the anteromedial aspect of the leg. Followed distally this
leads you to a prominence distally and medially – the medial malleolus.
➢ Feel the patella and follow it distally, to a prominence just inferior to it anteriorly, this
is the tibial tuberosity.
➢ The tibial tuberosity continues distally as a sharp border which is palpable for most of
the leg anteriorly.
➢ Turn your attention to the lateral aspect of the leg. Below the level of the inferior pole
of the patella feel a bony prominence. This is the head of the fibula.
44
➢ Most of the rest of the fibula is difficult to feel because it is covered by muscle.
However, you should feel the lateral malleolus opposite the medial malleolus. It is the
most distal part of the fibula.
➢ Posteriorly and distally feel the tough cord just deep to the skin - the Achilles tendon.
➢ Anteriorly at the ankle level you may be able to feel a pulsation of an artery that you
will encounter later – dorsalis pedis.
➢ A similar pulsation may be felt posterior to the medial malleolus this is another artery
– posterior tibial.
5.4 OSTEOLOGY OF THE LEG

This is formed by two bones – tibia and fibula. The tibia is the larger of the two. They articulate
at the proximal and distal tibiofibular joints. Make sure that you can correctly hold the two
bones together as they articulate in life. The proximal articular surface of the tibia forms part
of the knee joint and the distal part articulates with the talus to form the ankle joint.
The inferior tibia, medial malleolus and lateral malleolus form a mortise to hold the talus.
5.4.1 OSTEOLOGY OF THE TIBIA

With the aid of your atlases, identify the following parts of the tibia bone provided:
a) Medial condyle
b) Lateral condyle
c) Intercondylar eminence and tubercles
d) Popliteal surface of tibia
e) Soleal line
f) Tibial tuberosity
g) Medial surface of the shaft
h) Lateral surface of the shaft
i) Anterior border of the shaft
j) Medial malleolus
k) Tibial plafond
l) Nutrient foramina
45
5.4.2 OSTEOLOGY OF THE FIBULA
With the aid of your atlases, identify the following parts of the fibula bone provided:
a) Head
b) Neck
c) Shaft
d) Lateral malleolus
e) Malleolar fossa
Use the malleolar fossa to side the fibula bones provided.
5.5 SUPERFICIAL STRUCTURES OF THE LEG

Like the rest of the body, the leg is covered by skin. Note that over the joints the skin tends to
be lax to allow for movement. Do not have the mistaken notion that the skin is excessive. This
skin will have variable amount of hair depending on the individual.
Just deep to the skin there is a layer of subcutaneous tissue consisting of fat whose thickness
depends on individual’s nutrition and hormonal functions. In this layer you will find named
and unnamed superficial veins and nerves.
5.5.1 SUPERFICIAL VEINS OF THE LEG

The superficial venous system of the leg is largely by the saphenous veins and their perforators:
➢ Identify the great saphenous vein, a large vein that starts anterior to the medial
malleolus and winds posteromedially at the knee. In the leg it is kept company by the
saphenous nerve.
➢ Identify the small saphenous vein, found on the lateral malleolus and winds posteriorly
on the leg towards the popliteal fossa. It is kept company by the sural nerve.
➢ The blood flow in these superficial veins is from distal to proximal and from superficial
to deep. The latter pattern of flow is through communicating vessels called the
perforators that connect the superficial veins to the deep veins.
In the specimens provided, due to the stiffness of the skin after the fixation, some of the
superficial veins have been lifted off with the skin and you may have to look at the skins
remnant to see the veins referred to above.
46
5.5.2 SUPERFICIAL NERVES OF THE LEG
Superficial nerves of the leg are the saphenous nerve, sural nerve, superficial peroneal nerve
and lateral cutaneous nerve of the calf:
➢ Identify the saphenous nerve, is a terminal branch of the femoral nerve which becomes
subcutaneous after the adductor canal to run with the great saphenous nerve. It supplies
the skin of the medial aspect of the leg as well as the medial aspect of the foot.
➢ Identify the medial sural nerve that runs with the small saphenous nerve near the
popliteal fossa. This nerve arises from the tibial nerve in the popliteal fossa, and is
joined by the lateral sural nerve (also called “sural communicating nerve” if you
consider the medial sural nerve as “sural nerve”). The union of the two occurs
somewhere mid to lower leg, to form the sural nerve which continues to run with the
small saphenous nerve. The sural nerve supplies the skin of the posterolateral aspect of
the leg as well as the lateral aspect of the foot.
➢ Identify the superficial peroneal nerve in the anterolateral aspect of the distal third of
the leg. This is a branch of the common peroneal nerve that supplies the lateral
compartment of the leg then becomes subcutaneous to supply an inverted-V skin region
in the distal anterolateral aspect of the leg and the skin of the dorsum of the foot.
➢ The lateral cutaneous nerve of the calf is a branch of the common peroneal nerve
given at or just after the popliteal fossa.
Task 5.1
State the dermatomes of the skin of over the following regions:
a) Anterior knee
b) Medial leg
c) Lateral foot
d) Medial foot
47
5.6 THE FASCIA CRURIS
The deep fascia of the leg is called fascia cruris. This is the thick membranous tissue that cloth
the leg like stocking with some modifications. (It is this fascia that is pierced by the perforators
drain blood from the superficial to the deep veins). The fascia has been dissected off the
muscles and they are exposed. Where remnant of the fascia has been left in place, it is white
tough and superficial to the muscles and their tendons.
Note the following about fascia cruris:
➢ It is continuous with fascia lata and therefore attached to the proximal tibia
➢ On the anteromedial surface of the tibia, it is adherent to the periosteum
➢ It thickens distally to form tendon sheaths for various extensor, flexor and peroneal
tendons
➢ It gives of anterior and posterior intermuscular septae to the fibular which, together
with the interosseous membrane, divides the leg into three osteofascial compartments.
➢ Staying superficial to the muscles anteriorly and following them distally, you find the
thickening of the fascia called extensor retinaculum with its superior and inferior
bands.
➢ Look for similar structures on the medial and the lateral aspects at the level of the ankle
joint. The lateral one (peroneal retinaculum) is an extension of the extensor
retinaculum over the peronei tendons.
➢ The flexor retinaculum is found on the medial aspect of the ankle and is attached to
the medial malleolus and the bone calcaneus.
Task 5.2
Use a labelled diagram to illustrate the osteofascial compartments of the leg. Name the
main structures in each compartment.
48
5.7 MUSCLES OF THE LEG AND THEIR NEUROVASCULAR SUPPLY
The muscles of the leg are arranged into three groups: The anterior compartment, the lateral
compartment, the posterior compartment.
5.7.1 THE ANTERIOR (EXTENSOR) COMPARTMENT

Find this compartment between the lateral surface of the tibia and the anterior intermuscular
septum. The muscles in this compartment dorsiflex the ankle joint.
➢ Find the tibialis anterior muscle most medial arising from the upper 2/3 of the lateral
of the tibia and continues with a tendon towards the base of the first metatarsal.
➢ Find the extensor hallucis longus arising partly from fibula and partly from the
interosseus membrane. Follow its tendon to the last phalanx of the big toe (if you
can).
➢ The most lateral muscle superiorly is the extensor digitorum longus whose origin is
fully from the fibula. Follow its four tendons to the four lateral toes.
➢ A small muscle that is found most lateral distally is the peroneus tertius arising from
the distal ¼ of the medial surface of the fibula. Find its tendon inserted into the base of
the fifth metatarsal.
Identify the neurovascular bundle of the anterior compartment in front of the interosseous
membrane between tibialis anterior muscle and extensor digitorum longus proximally, or
between the tendons of extensor hallucis longus and extensor digitorum longus at the level of
the ankle joint, whichever is easier. This bundle contains:
➢ The deep peroneal nerve, a branch of the common peroneal given of after the fibular
neck. It continues into the dorsum of the foot to supply the extensor digitorum brevis,
and the skin of the 1st web space. Confirm the continuation of this nerve proximally to
the common peroneal nerve around the fibular neck.
➢ The anterior tibial vessels, with the veins forming a vena commitantes around the
artery. Confirm that the artery is a branch of the popliteal artery, and passes above the
interosseous membrane to reach the anterior compartment. On the dorsum of the foot
the artery becomes the dorsalis pedis.
49
Task 5.3
State the insertions and actions of each of the muscles of the anterior leg compartment
5.7.2 DORSUM OF THE FOOT

The structures in the dorsum of the foot are largely the continuation of the anterior leg compartment.
Confirm the continuation of these structures here. The deep fascia has been incised to expose extensor
digitorum brevis. This muscle arises from the superior calcaneus surface and the deep surface of the
inferior extensor retinaculum. It passes obliquely across the dorsum of the foot and gives off four
tendons to the medial four toes. This muscle is innervated by the deep peroneal nerve.
5.7.3 THE LATERAL (PERONEAL) COMPARTMENT

Find this compartment lateral to the anterior intermuscular septum. There are two muscles
here, and one nerve:
➢ Identify the peroneus longus, a more superficial muscle, arising from the fibula upper
2/3.
➢ The peroneus brevis arises from the lower 1/3 of the lateral surface of the fibula.
➢ Identify the superficial peroneal nerve between the two muscles. It becomes
subcutaneous distally, lying over the extensor retinaculum, as earlier described.
Confirm its origin from the common peroneal nerve proximally.
Follow the tendons of peroneus longus and brevis distally, behind the lateral malleolus deep to
the fibular part of extensor retinaculum (peroneal retinaculum). The tendons of these muscles
lie flat upon each other and may appear like one tendon unless you carefully separate the two.
50
Task 5.4
State the insertions and actions of the peroneus longus and brevis muscles.
Task 5.5
State the following regarding the common peroneal nerve:
a) Origin
b) Course
c) Branches and their distribution
d) Clinical anatomy (state possible sites of its entrapment, and outline the clinical
symptoms of these entrapments)
5.7.4 THE POSTERIOR (FLEXOR) COMPARTMENT

To view the muscles of this compartment, the specimen must be turned over. There are two
parts, a superficial and a deep. The gastrocnemius, soleus and plantaris are in the superficial
compartment while the flexor digitorum longus, flexor hallucis longus and tipialis posterior are
in the deep compartment.
51
➢ See the gastrocnemius with two heads. They form a V of which is the apex of popliteal
fossa inferiorly. Each arm of the V is a border of each of the heads that arise from
posterior inferior parts of the femoral condyles. The two bellies join and inferiorly
evolve into a dense connective tissue tendon that is the tendo Achilles and on to the
calcaneus. In some of the specimens a muscle with a long tendon and slender belly will
be found running with the lateral head of gastrocnemius. This muscle is called
plantaris.
➢ Deep to gastrocnemius is the muscle soleus. The origin extends from the fibular head
across to the soleal line on the tibia. (note that there is no origin from the interosseus
membrane which allows for the passage of posterior tibial artery and tibial nerve).
Confirm that soleus and gastrocnemius insert through the same tendon distally, the
tendo Achilles.
➢ Deep to the soleus and arising from the tibia inferior to the soleal line find flexor
digitorum longus. Follow the tendons to the flexor retinaculum at the tarsal tunnel on
their way to the four lateral toes.
➢ On the fibular side find the flexor hallucis longus arising from the fibula. It is quite
fleshy distally where other muscles have evolved into tendons. Its tendon disappears
deep to the flexor retinaculum and crosses the foot towards the large toe into which it
is inserted. Its tendon makes a groove on the posterior talus as it passes through the
tarsal tunnel.
➢ Between the hallucis and the digitorum longus and somewhat deep to both, find the
tibialis posterior arising from both the tibia and the fibula and intervening interosseus
membrane. The area of origin is below the soleal line. Tendon goes deep to the flexor
retinaculum to navicular bone tuberosity and other tarsus except the talus.
➢ Superior to the origin of soleus, find the tibial nerve and the popliteal vessels at the
floor of the popliteal fossa. Deep to these strictures is the muscle popliteus.
Task 5.6
State the attachments and actions of the of each of the muscles of the posterior leg
compartment
52
Separate the two heads of gastrocnemius from each other below and superiorly the
semitendinosus and semimembranosus medially from the biceps femoris laterally. Identify the
popliteal artery, the popliteal vein and the tibial nerve in that order medial to lateral. Follow
the tibial nerve proximally to confirm its origin from the sciatic nerve, together with the
common peroneal nerve. The common peroneal nerve stays closer to the medial border of the
biceps femoris as it descends towards the neck of the fibula. (You may feel this nerve on
yourself- a cord inferior to the fibular head).
➢ Genicular arteries are given off by the popliteal almost at right angles to the main
artery. Follow the popliteal artery distally and confirm that it divides into two terminal
branches: the anterior tibial artery which turns anteriorly over a hiatus in the
interosseus membrane, and the posterior tibial artery which runs with the tibial nerve
and supplies the posterior compartment.
➢ Confirm that the posterior tibial artery together with the tibial nerve run deep to a
fibrous arch (part of the origin of the soleus) to gain access to the deep muscles of the
posterior compartment. Confirm that it lies partly on tibialis posterior and somewhat
between the flexor hallucis longus and flexor digitorum longus. Followed distally it
goes under the flexor retinaculum at the tarsal tunnel on its way to the foot.
➢ Identify the peroneal branch of posterior tibial artery given very proximally and runs
deep to flexor hallucis longus. It supplies the structures in the lateral compartment via
perforating branches.
➢ The tibial nerve accompanies the posterior tibial artery giving off muscular branches
to the muscles of the posterior compartment. Confirm that you can see the branches
from the nerve to the muscles. At the tarsal tunnel, both tibial nerve and posterior tibial
artery bifurcates into medial plantar and lateral plantar branches.
Task 5.7
State the following regarding the tarsal tunnel:
a) Boundaries
b) Contents in order
53
Task 5.8
Use a labelled cross-sectional diagram to illustrate the osteofascial compartments of the

leg, indicating the location of the major neurovascular structures.
Define compartment syndrome and give the anatomical basis of the clinical symptoms
seen in anterior compartment syndrome
5.8 SUMMARY
The leg consists of the skeleton tibia and fibula. It is covered by skin with subcutaneous tissue
of varying depth in which cutaneous nerves and vessels are found. The pattern of flow in these
superficial veins has a clinical bearing. Deep to this is the deep fascia and with its attachment
to the tibia and the two septae divide the leg into three compartments. The fact that the fascia,
septae and bone are no elastic is of clinical significance. All the muscles in each compartment
are supplied by one specific nerve. The muscles are inserted in different parts of the foot and
will either cause movements at the ankle or more distally. The study of the legs be better
understood when that of the foot is complete.
54
6. ANKLE JOINT ANATOMY
(Dr. Kevin Ongeti & Dr. Beda Olabu)
6.1 INTRODUCTION
The ankle joint, also known as the talocrural articulation, is a synovial hinge joint connecting
the distal ends of the tibia and fibula in the lower limb with the proximal end of the talus. The
shape of the talus and its tight fit between the tibia and fibula is largely responsible for its
stability, but there are important ligaments that also contribute to its structural integrity.

1. To study the surface anatomy of the ankle region
2. To describe the articular surfaces of the ankle joint.
3. To describe the stability factors of the ankle joint.
4. To describe the muscular and neurovascular relations of the ankle joint.
5. To describe the movements of the ankle joint.
6.3 SURFACE ANATOMY OF THE ANKLE REGION

Look at your own ankle region and appreciate the following:
➢ Medial malleolus
➢ Lateral malleolus
➢ Achilles tendon
➢ Tendons of tibialis anterior, EHL and EDL
6.4 OSTEOLOGY OF THE ANKLE JOINT

You will look at the anatomy of the distal tibia, distal fibula and the talus
6.4.1 OSTEOLOGY OF THE DISTAL TIBIA

Study the anatomy of the distal tibia once again and take note of the following:
a) Medial malleolus
b) Tibial plafond
55
6.4.2 OSTEOLOGY OF THE DISTAL FIBULA
Study the anatomy of the distal fibula once again and take note of the following:
a) Lateral malleolus
b) Articular surface
c) Malleolar fossa
6.4.3 OSTEOLOGY OF THE TALUS

Study the anatomy of the talus and take note of the following:
a) Head: Identify the articular surfaces for navicular bone, spring ligament and calcaneus
b) Neck: Note the various nutrient foramina in this region
c) Body: Note that its predominantly covered by articular cartilage
d) Trochlear surface: Note that the trochlear is wider anteriorly and narrower posteriorly;
convex antero-posterioly and concave transversely.
e) Medial articular surface (comma shaped)
f) Lateral articular surface (triangular in shape)
g) Articular surfaces for calcaneus
h) Sulcus tali – which, together with sulcus calcani form the sinus tarsi
i) Posterior process with medial and posterior talar tubercles
j) Groove for flexor hallucis longus tendon
k) Lateral process
l) Expected location of os trigonium
Take note that most of the surfaces of talus is covered by articular hyaline cartilage, which is
avascular. There are also no muscles that make their attachment to talus.
Task 6.1
Describe how the body of talus receives its nutrients and state the clinical relevance of
this
56
6.5 ANKLE JOINT CAPSULE & LIGAMENTS
The articular capsule surrounds the joints, and is attached, above, to the borders of the articular
surfaces of the tibia and malleoli; and below, to the talus around its upper articular surface. The
joint capsule anteriorly is a broad, thin, fibrous layer, posteriorly the fibres are thin and run
mainly transversely blending with the transverse ligament and laterally the capsule is
thickened, and attaches to the hollow on the medial surface of the lateral malleolus. The
synovial membrane extends superiorly between tibia & fibula as far as the interosseous
tibiofibular ligament.
The capsule is reinforced both laterally and medially by collateral ligaments complexes:
➢ The medial collateral ligament is known as the deltoid ligament. Confirm that it
attaches proximally to the medial malleolus and fan out to attach distally to the talus,
calcaneus and navicular bones. It is triangular in shape and consists of superficial and
deep layers.
➢ The lateral ligament complex attaches on the lateral malleolus and consists of anterior
talofibular ligament, posterior talofibular ligament and calcaneofibular ligament.
Attempt to identify these ligaments in the specimens provided.
The mortise of the joint is formed by the tibial plafond, medial malleolus and lateral malleolus.
The integrity of the mortise is primarily maintained by the syndesmotic joint between the distal
tibia and fibular, termed the distal lower extremity syndesmosis (DLES): Identify the anterior
and posterior tibiofibular ligaments, which constitute this syndesmosis.
The posterior tibiofibular ligament extends inferiorly over the joint cavity as the transverse
ligament.
Task 6.2
State the role of the various ligaments of the talocrural articulation
57
Task 6.3
Complete the anatomy of the ankle joint by discussing the following questions in your
groups:
a) Muscular and neurovascular relations
b) Key movements and the muscles responsible for each
c) Anastomosis around the ankle joint
58

Section 2 - Lower Limb Anatomy

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Section 2 - Lower Limb Anatomy

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DEPARTMENT OF HUMAN ANATOMY

GROSS ANATOMY LABORATORY

MBChB and BDS Students User’s

SECTION 1: INTRODUCTORY THEMES

SECTION 2: LOWER LIMB ANATOMY

SECTION 3: UPPER LIMB ANATOMY

SECTION 5: HEAD AND NECK ANATOMY

SECTION 6: ANATOMY OF THE THORAX

SECTION 7: ANATOMY OF THE ABDOMEN

SECTION 8: ANATOMY OF THE PELVIS AND PERINEUM

1.2 CHAPTER OBJECTIVES

1.3 THE BONES OF THE GLUTEAL REGION

1.3.1 PELVIC BONE

a) Ilium, ischium and pubis

1.3.2 THE PROVIMAL FEMUR

1.4 CUTANEOUS NERVES OF THE GLUTEAL REGION

1.5 SKIN AND SUPERFICIAL FASCIA

1.6 MUSCLES AND THEIR NEUROVASCULATURE

1.6.1 THE THREE LARGE GLUTEAL MUSCLES

b) Course and surface landmarks

c) Common sites and clinical effects of its injury

1.7.1 THE GREATER SCIATIC FORAMEN

➢ Identify the superior gluteal neurovascular bundle in the supra-pirifomic compartment

d) Clinical effect of its injury

1.7.2 THE LESSER SCIATIC FORAMEN

b) Inferior gluteal nerve

c) Posterior cutaneous nerve of the thigh

2.2 CHAPTER OBJECTIVES

2.3 BONY LANDMARKS OF POSTERIOR THIGH

2.3.2 THE FEMUR

a) The linea aspera, with its two lips

2.4 SKIN AND FASCIAE OF POSTERIOR THIGH

b) Middle region of the back of the thigh

2.6 THE SCIATIC NERVE

2.7 POSTERIOR THIGH VASCULATURE

2.8.1 THE ROOF OF POPLITEAL FOSSA

a) Terminal branches of the posterior cutaneous nerve of the thigh

2.8.2 WALLS OF THE POPLITEAL FOSSA

2.8.4 FLOOR OF THE POPLITEAL FOSSA

a) Popliteal surface of the femur

3.2 CHAPTER OBJECTIVES

3.3.1 PELVIC BONE

a) Head of femur and fovea capitis

3.3.3 THE PROXIMAL TIBIA

3.4 ANATOMICAL LANDMARKS

3.5 SKIN AND SUPERFICIA FASCIA

State the dermatomes of the skin over the following sites:

3.7 MUSCULATURE AND THEIR INNERVATION

3.7.1 MUSCLES OF THE ANTERIOR COMPARTMENT OF THE THIGH

a) Rectus femoris muscle located on the anterior aspect of the thigh

a) Gracilis – a slender muscle on the medial aspect

3.8.1 THE FEMORAL TRIANGLE

3.8.2 THE ADDUCTOR (HUNTER’S) CANAL

➢ The anterolateral wall of the canal is formed by vastus medialis muscle.

3.9.1 THE PROXIMAL FEMUR

3.9.2 THE ACETABULUM

➢ The margin of the acetabulum is deficient inferiorly, at the acetabular notch.

➢ There are three thickenings of the capsule, termed capsular ligaments:

(b) Static stability factors

(c) Dynamic stability factors

(e) Muscular and neurovascular relations of the hip joint

4.2 CHAPTER OBJECTIVES

4.3 OSTEOLOGY OF THE KNEE