The lower limb(1)

1. The lower limb(1) 山东大学医学院 解剖教研室 李振华

2. Muscles of lower limb The muscles of lower limb are divided into: the muscles of hip, thigh, leg and foot. Muscles of hip • anterior group • Iliopsoas 髂腰肌 • iliacus 髂肌 • psoas major 腰大肌 • Psoas minor 腰小肌 • Tensor fasciae latae 阔筋膜张肌

3. Posterior group • Gluteus maximus 臀大肌 • Gluteus medius 臀中肌 • Gluteus minimus 臀小肌 • Piriformis 梨状肌 • Obturator internus 闭孔内肌 • Quadratus femoris 股方肌 • Obturator externus 闭孔外肌

5. Muscles of thigh Anterior group • Sartorius 缝匠肌 • Quadricep 股四头肌 • Rectus femoris 股直肌 • Vastus medialis 股内侧肌 • Vastus lateralis 股外侧肌 • Vastus intermedius股中间肌

6. Medial group • Pectineus 耻骨肌 • Adductor longus 长收肌 • Adductor brevis 短收肌 • Adductor magnus大收肌 • Gracilis 股薄肌 adduct thigh at hip joint

7. Posterior group • Biceps femoris 股二头肌 • Semitendinosus 半腱肌 • Semimembranosus 半膜肌 flex the leg at knee joint extend the thigh at hip joint

8. Muscles of leg Anterior group • Tibialis anterior 胫骨前肌 • Extensor hallucis longus 拇长伸肌 • Extensor digitorum longus 趾长伸肌 • Peroneus tertius 第三腓骨肌

9. Lateral group • Peroneus longus 腓骨长肌 • Peroneus brevis 腓骨短肌 plantarflex and evert the foot

10. Posterior group • Superficial lager triceps surae小腿三头肌 • Gastrocnemius 腓肠肌 • Soleus 比目鱼肌 • Deep layer • Popliteus 腘肌 • Flexor digitorum longus趾长屈肌 • Flexor hallucis longus拇长屈肌 • Tibialis posterior 胫骨后肌

11. Muscles of foot • Muscles on dorsum: extensor digitorum brevis • Muscles in sole: medial, lateral and intermediate groups

12. Major muscles of lower limb Iliopsoas • Origin: • Psoas major: transverse processes and lateral surface of bodies of lumbar vertebrae • Iliacus: iliac fossa • Insertion: lesser trochanter of femur • Action: flexes thigh on trunk • Nerve supply: lumbar plexus

13. Gluteus maximus • Origin: gluteal surface of ilium and dorsal aspect of sacrum • Insertion: gluteal tuberosity of femur and iliotibial tract • Action: extends and laterally rotates thigh at hip joint; raises trunk when the lower limb is fixed • Nerve supply: inferior gluteal n.

14. Piriformis • Origin: anterior surface of sacrum • Insertion: greater trochanter of femur • Divided the greater sciatic foramen into suprapiriform foramen 梨状肌上孔and infrapiriform foramen 梨状肌下孔 • Action: rotates thigh laterally at hip joint • Nerve supply: sacral plexus

15. Sartorius • Origin: anterior superior iliac spine • Insertion: upper medial surface of tibia • Action: flexes hip and knee joints; rotates flexed knee medially • Nerve supply: femoral n.

16. Quadriceps femoris • Origin: • Rectus femoris: anterior inferior iliac spine • Vastus medialis: medial lip of linea aspera • Vastus lateralis: lateral lip of linea aspera • Vastus intermedius: anterior surface of femur • Insertion: tibial tuberosity via patellar ligament • Action: extends leg at knee joint; rectus femoris also flexes thigh at hip joint • Nerve supply: femoral n.

17. Tibialis anterior • Origin: lateral surface of tibia • Insertion: medial cuneiform and base of 1st metatarsal • Action: dorsiflexes and inverts foot • Nerve supply: deep peroneal n.

18. Triceps surae • Origin: • Gastrocnemius: medial and lateral condyles of femur • Soleus: soleal line of tibia and upper third of fibula • Insertion: calcaneum via tendo calcaneus • Action: flexes knee joint and plantarflexes foot at ankle joint; steadies leg on foot during standing • Nerve supply: tibial n.

19. Tibialis posterior • Origin: posterior surface of tibia and ffibula and interosseous membrane • Insertion: tuberosity of navicular, all cuniforms • Action: plantarflexes and inverts foot • Nerve supply: tibial n.

20. Arteries of lower limb Femoral a. • Continuation of the external iliac a. • Begins midpoint of inguinal ligament • Principal branch deep femeral a.股深动脉: arises from the posterolateral surface of the femoral artery about 5 cm below the inguinal ligament. • Distributed to all three muscle compartments by medial and lateral femoral circumflex旋股内、外侧动脉and four perforating arteries 穿动脉of deep femoral a.

21. Popliteal a. • Continuation of femoral a. at adductor hiatus • Divided into anterior and posterior tibial arteries at lower border of poplitus Posterior tibial a. • Passes downwars deep to gastrocnemius and soleus • Passes behind medial mallealus by dividing into medial and lateral plantar arteries • Branches: peroneal a., medial and lateral plantar a,

22. Anterior tibial a. • Descends on anterior surface of interosseous membrane • In front of ankle joint becomes dorsal a. of foot Dorsal a. of foot • Passes forward between tendons of extensor longus and extensor digitorum longus to the proximal • End of first intermetatarsal space

23. Obturator a. • Branch of internal iliac a. • Passes through the obturator foramen and enters medial compartment of thigh • supplies obturator externus, pectineus, adductors of thigh, and gracilis

24. Veins of lower limb Deep veins: anterior and posterior tibial v. → popliteal v.→ femoral v. → external iliac v. • Great saphenous v. 大隐静脉 • Begins the medial end of dorsal venous arch of food • Passes anterior to the medial malleolus and ascends on the medial side of the leg, then passes behind the knee and curves forward around the medial side of the thigh • Inclines anteriorly through the thigh to enter the femoral vein through the saphenous opening which lies about 3~4 cm below and lateral to the pubic tubercle • Tributaries: • Superficial medial femoral v. • Superficial lateral femoral v. • External pudendal v. • Superficial epigastric v. • Superficial iliac circumflex v.

25. Superficial epigastric v. Superficial circumflex iliac v. External pudendal v. Superficial medial femoral v. Superficial lateral femoral v. Great saphenous v.

27. Small saphenous v. • Arises from the lateral part of the dorsal venous arch of foot • Ascends behind lateral malleolus and then passes upward to the midline of the clft • Pierces the deep fascia and enters the popliteal v. • It drains the lateral side of the foot and ankle and the back of the leg.

28. Lymph nodes and vessels of lower limb Popliteal ln. • Embedded in the fatty connective tissue of popliteal fossa • Receive superficial lymphatic vessels from posterolateral part of calf, and from deep lymphatic vessels accompanying anterior and posterior tibial a. • Efferents pass to the deep inguinal ln.

29. Superficial inguinal lymph nodes • Superior group: • Lies just distal to the inguinal ligament • Receive lymph from anterior abdominal wall below umbilicus, gluteal region, perineal region, external genital organs • Inferior group: • Lies vertical along the terminal great saphenous v. • Receives all superficial lymphatics of lower limb, except for those from the posterolateral part of calf • Efferent vessels drain into the deep inguinal ln. or external iliac ln.

30. Deep inguinal lymph nodes • Lie medial to the femoral v. • Receive deep lymphatics of lower limb, perineal region, and efferent lymphatics from the superficial inguinal ln. • Drain into the external iliac ln.

31. Nerves of lower limb • Femoral n.: supplies anterior thigh muscles (quadriceps, sartorius and pectineus), hip and knee joint, and skin on anteromedial side of thigh, saphenous nerve is distributed to skin of medial side of leg and foot • Obturator n.: enters thigh through obturator foramen; supplies medial group of muscles of thigh, obturator externus, and skin of medial side of thigh

32. Branches of sacral plexus • Superior gluteal n. leaves pelvis through suprapiriform foramen and passes between gluteus medius and minimus to supplies these muscles and tensor fasciae latae • Inferior gluteal n. leaves pelvis through infrapiriform foramen，and supplies gluteus maximus • Posterior femoral cutaneous: leaves pelvis through infrapiniform foramen,runs deep to gluteus maximus, and emerges from ite inferior border to supply skin of buttock and then surface skin over posterior of thigh and calf

33. Sciatic n. 坐骨神经 • Leaves pelvis through infrapiriform foramen to enter gluteal region, runs inferiorly laterally deep to gluteus maximus, passing midway between the greater trochanter of femur and ischial tuberosity to back of thigh, lying deep to long head of biceps femoris, normally divided into tibial and common peroneal nerves just above popliteal fossa • Innervates semitendinosus, semimembranosus and biceps femoris and has articular branches to hip and knee joints

34. Common peroneal n. 腓总神经passes over posterior aspect of head of fibula and then winds around neck of fibula, deep to peroneus longus, where it divides into deep and superficial peroneal nerves • Deep peroneal n. 腓深神经descends on interosseous membrane and enters dorsum of foot; supplies anterior muscles of leg, and skin of first interdigital cleft • Superficial peroneal n. 腓浅神经supplies peroneus longus and brevis and skin on anterior surface of leg and dorsum of foot

35. Tibial n. 胫神经 • Runs inferiorly with posterior tibial vessels and terminates beneath flexor retinaculum by dividing into medial and lateral plantar nerves • Supplies posterior muscles of leg and knee joint

36. Regional anatomy of the lower limb 山东大学医学院 解剖教研室 李振华

37. Parts and regions of the lower limb • Gluteal region－between iliac crest superiorly and gluteal fold inferiorly • Thigh－between hip and knee • knee－joint between leg and thigh • Leg－between knee and foot • Ankle • Foot

38. Surface anatomy • Gluteal region and thigh－anterior superior and inferior iliac spines，tubercle of iliac crest，ischial tuberosity，greater trochanter, pubic tubercle, pubic crest, superior border of pubic symphysis • Knee－patella ligament, tuberosity of tibia, medial and lateral condyles and epicondyles, tendon of biceps femoris, tendons of semitendinosus and semimembranosus, head of fibula • Leg－anterior border of tibia, neck of fibula • Ankle and foot－medial and lateral malleolus, calcaneal tuberosity, tuberosity of navicular bone, and tuberosity of fifth metatarsal bone

39. Anterior and Medial Region of Thigh Superficial structures－superficial fascia • Superficial arteries: • superficial epigastric a. • superficial iliac circumflex a. • external pudendal a. • Superficial veins－great saphenous v., • superficial epigastric v. • superficial iliac circumflex v. • external pudendal v. • superficial medial femoral v. • superficial lateral femoral v. • Superficial inguinal lymph nodes: • superior group • inferior group • Cutaneous nerves: • lateral femoral cutaneous n. • anterior and medial cutaneous branches of femoral n.

41. Deep fascia – fascia lata 阔筋膜 • Iliotibial tract 髂胫束 • Saphenous hiatus 隐静脉裂孔 • falciform margin 镰状缘 • cribriform fascia 筛筋膜

42. Lateral femoral cutaneous n. Iliopsoas Femoral n. Iliopectinal arch Lacuna musculorum肌腔隙 • Bounded by lateral portion of inguinal ligament anteriorly, ilium posterolaterally, iliopectinal arch medially • Contents: iliopsoas, femoral n. and lateral femoral cutaneous n.

43. Femoral a. Femoral v. Femoral ring Lacuna vasorum 血管腔隙 • Bounded by medial portion of inguinal ligament anteriorly, pectineal ligament posteromedially, lacunar ligament medially, and iliopectinal arch posterolaterally • Contents: • femoral sheath, femoral a. and v., genital branch of genitofemoral n. and lymphatic vessels, femoral ring

44. Femoral triangle • This triangle is bounded by: the inguinal ligament (base) superiorly; the medial border of sartorius laterally; the medial border of adductor longus medially. Inferiorly, the apex of the triangle is continuous with adductor canal. • The anterior wall is fascia lata • The posterior wall consists of adductor longus, pectineus and iliopsoas , from medial to lateral side.

45. Contents of the femoral triangle 1. The femoral artery and its branches－the profunda femoris artery，The lateral and medial circumflex arteries，The deep external pudendal． 2. The femoral vein and its tributaries. 3. Three or four deep inguinal lymph nodes lie along the medial side of the femoral vein. 4. The femoral nerve. 5. The femoral canal.

46. Femoral sheath • The femoral sheath is a a funnel- shaped sheath , derived from transversalis fascia anteriorly and iliac fascia posteriorly. It surroumds the femoral vessels and lymphatic about 2.5cm belower the inguinal ligamemt. Its lower end disappears at the lower margin of the saphenous opening where the sheath fuses with the adventitia of the vessels.

47. The femoral sheath is divided into three compartments by two fibrous septa. The femoral artery occupies the lateral compartment of the sheath. The femoral vein lies the middle compartment. The medial compartment is small, called the femoral canal.

48. The femoral canal • It is about 1.3cm long , and its upper opening is called the femoral ring . • The boundaries of the femoral ring are: the inguinal ligament, anteriorly; the lacunar ligament腔隙韧带medially; the pecten of pubis, posteriorly; the femoral vein, laterally. covered by femoral septum股环隔superiorly. • The canal contains a little loose fatty tissue, a small lymph node, and some lymph vessels.

49. Femoral hernia A femoral hernia is common in women than in men (possibly due to a wider pelvis and femoral canal ). If a loop of intestine is forced into the femoral ring, it expands to form a swelling in the upper part of the thigh.

50. Femoral nerve • It arises from the lumbar plexus in the abdomen, and enters the thigh posterior to the inguinal ligament and lateral to the femoral artery. It ends by dividing into a number of branches 2 cm below the inguinal ligament. • Muscular branche to: pectineus, sartorius, quadriceps femoris