Regional anatomy of the lower limb

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

2. 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

3. 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 tuberosity of fifth metatarsal bone Surface anatomy of lower limb

4. Nelaton’s line • a line drawn from the anterior superior lilac spine to the ischial tuberosity, passing over or near the top of the greater trochanter. The trochanter can be felt superior to this line in a person which a dislocated hip or a fractured femoral neck.

5. Kaplan point

6. Normal angle of inclination 1250-1300 Coxa valga 髋外翻(abnormally increased angle of inclination, in cases of congenital dislocation of the hip) Coxa vara 髋内翻 (abnormally decreased angle of inclination, it occurs in fractures of the neck of the femur and slipping of the femoral epiphysis ) 颈干角

7. 1700 <1700 >1700 Genu valgum 膝外翻 Normal alignment Genu varum (bowleg) 膝内翻

8. Anterior and Medial Region of Thigh

9. Skin incisions • Make the skin incisions indicated in figure and reflect the skin flaps.

10. Superficial structures Great saphenous vein大隐静脉 • Drains the medial end of dorsal venous arch of foot • Passes upward directly in front of the medial malleolus. • Then ascends on medial side of the leg. • Passes behind the knee and curves forward around the medial side of the thigh. • Passes through the saphenous hiatus in the deep fascia and joins the femoral vein about 4 cm below and lateral to the pubic tubercle.

11. Superficial structures • Tributaries: • Superficial lateral femoral v. 股外侧浅静脉 • Superficial medial femoral v. 股内侧浅静脉 • External pudendal v. 阴部外静脉 • Superficial epigastric v. 腹壁浅静脉 • Superficial iliac circumflex v. 旋髂浅静脉

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

13. Varicose veins

14. Superficial structures Superficial fascia • Superficial arteries: • superficial epigastric a. • superficial iliac circumflex a. • external pudendal a. • Cutaneous nerves: • lateral femoral cutaneous n. • anterior and medial cutaneous branches of femoral n. • cutaneous branches of obturator n.

15. lateral femoral cutaneous n. anterior and medial cutaneous branches of femoral n. Cutaneous branches of obturator n.

16. Superficial structures Superficial inguinal lymph nodes 腹股沟浅淋巴结 • Superior group: • Lies just distal to the inguinal ligament • Receive lymph vessels 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 lymph vessels of lower limb, except for those from the posterolateral part of calf • Efferent vessels drain into the deep inguinal ln. or external iliac ln.

17. Deep fascia of the thigh • Fascia lata阔筋膜The deep fascia encloses the thigh like a trouser leg. • Saphenous hiatus隐静脉裂孔 • A gap in the deep fasica which lies about 4 cm below and lateral to the pubic tubercle. The falciform margin 镰状缘is the lower lateral border of the opening, which lies anterior to the femoral vessels. • Filled with loose connective tissue called the cribriform fascia 筛筋膜

18. Deep fascia of the thigh • Iliotibial tract髂胫束 laterally the deep fascia forms a thick band, from the iliac tubercle to the lateral condyle of tibial. • The fascia lata sends intermuscular septa to the linea aspera of the femur. These separate the thigh into three compartments each of which contains a group of muscles, the vessels and the nerves.

19. Contents of the anterior fascial compartments of the thigh Psoas majo腰大肌 Iliopsoas髂腰肌 Iliacus髂肌 Sartorius 缝匠肌 Vastus lateralis 股外侧肌 Quadriceps femoris 股四头肌 Rectus femoris 股直肌 Vastusintermedius 股中间肌 Vastus medialis 股内侧肌

20. Contents of the medial fascial compartments of the thigh Pectineus 耻骨肌 Adductor longus 长收肌 Adductor brevis 短收肌 Adductor magnus 大收肌 Gracilis 股薄肌 Adductor tendinous opening 收肌腱裂孔

21. Lacuna musculorum 肌腔隙 • Boundaries: • Anteriorly: lateral portion of inguinal ligament • Posterolaterally: ilium • Medially: iliopectinal arch • Contents: • Iliopsoas • femoral n. • lateral femoral cutaneous n. Lateral femoral cutaneous n. Iliopsoas Iliopectinal arch Femoral n.

22. Femoral a. Femoral v. Femoral ring Lacuna vasorum 血管腔隙 • Boundaries: • Anteriorly: medial portion of inguinal ligament • Posteriorly: fascia of pecteineus and pectineal ligament • Medially: lacunar ligament • Laterally: iliopectinal arch • Contents: • Femoral sheath • Femoral a. and v. • Genital branch of genitofemoral n. • Lymphatic vessels

23. Femoral triangle 股三角 A triangular depressed area situated in the upper part of the medial aspect of the thigh just below the inguinal ligament Boundaries • Superiorly (base) : the inguinal ligament • Laterally: medial border of sartorius • Medially: medial border of adductor longus • Apex: continuous with adductor canal • Anterior wall:fascia lata • Posterior wall:consists of iliopsoas, pectineus and adductor longus from lateral to medial side

24. Femoral triangle 股三角 Contents • Femoral n. • Femoral sheath • Femoral a. and its branches • Femoral vein and its tributaries. • Femoral canal • Deep inguinal lymph nodes • Fatty tissue

25. Femoral triangle 股三角 Femoral sheath股鞘 • 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.

26. Femoral sheath股鞘 Femoral sheath股鞘 Divided into three compartments by two fibrous septa • Lateral compartment: femoral a. • Middle compartment: femoral v. • Medial compartment: femoral canal股管

27. The femoral canal 股管 • About 1.3cm long , and its upper opening is called the femoral ring股环 • Contains: a little loose fatty tissue, a small lymph node, and some lymph vessels. • The boundaries of the femoral ring • Anteriorly: the inguinal ligament • Medially: the lacunar ligament 腔隙韧带 • Posteriorly: the pecten of pubis • Laterally: the femoral vein • Superior: covered by femoral septum 股环隔

28. Femoral hernia股疝 • If a loop of intestine is forced into the femoral ring, it expands to form a swelling in the upper part of the thigh. Such a condition is known as a femoral hernia 股疝. • A femoral hernia is more common in women than in men (possibly because their wider pelvis and femoral canal ).

29. Femoral artery 股动脉 Femoral a.股动脉 • Continuation of the external iliac a. • Begins midpoint of inguinal ligament • Ends at the adductor tendinous opening by entering the popliteal fossa as the popliteal artery • 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. • Medial femoral circumflex旋股内侧动脉 • lateral femoral circumflex旋股外侧动脉 • Four perforating arteries 穿动脉

30. Profunda femoris 股深动脉 • Arises from the posterolateral surface of the femoral artery about 5 cm below the inguinal ligament. • Branches: • Lateral circumflex artery 旋股外侧动脉. • Medial circumflex artery旋股内侧动脉. • Perforating arteries穿动脉

31. deep femeral a. Medial circumflex a. • Lateral circumflex a. • perforating arteries

32. Femoral vein 股静脉 • Begins at the adductor tendinous opening • Continues as external iliac vein deep to inguinal ligament • Contains several valves

33. The deep inguinal lymph nodes腹股沟深淋巴结 • 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.

34. Femoral nerve 股神经 • 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

35. Femoral nerve 股神经 • Cutaneous branches: • Anterior cutaneous nerves of the thigh • Saphenous nerve 隐神经is the longest branch of the femoral nerve. It accompanies the femoral vessels in the adductor canal, then accompanies the great saphenous vein to the medial side of the leg and food.

36. Femoral n. Femoral a. Femoral v. Saphenous nerve

37. Adductor canal 收肌管 • An intermuscular cleft situated on the medial aspect of the middle third of the thigh beneath the sartorius. • Extends from apex of femoral triangle to adductor tendinous opening • Boundies • Anterior wall: adductor lamina and sartorius • Lateral wall : vastus medialis • Posteomedial wall: adductors longus and magmus • Contents • Saphenous n. • Femoral a. and femoral v. • lymphatic vessels and loose connective tissue

38. Blood vessels and nerve of medial side of thigh • Obturator a.闭孔动脉 • Arises from internal iliac artery in the lesser pelvis • passes through the obturator canal where it divides into anterior and posterior branches. • Obturator n.闭孔神经 • Arises from the lumbar plexus in the abdomen. • Enters the thigh through the obturator canal where it divides into anterior and posterior branches. • Supplies medial group of muscles of thigh, obturator externus, and skin of medial side of thigh

39. Obturator n.

40. Anterolateral crural region and dorsum of the foot

41. Anterolateral crural region Superficial veins • Dorsal venous arch: lies in the subcutaneous tissue over the heads of the metatarsal bones and drains on the medial side into the great saphenous v. and on the lateral side into the small saphenous v. • Great saphenous v.: • Drains the medial end of dorsal venous arch of food and passes upward directly in front of the medial malleolus. • Then ascends in company with the saphenous n. in the superficial fascia over the medial side of the leg.

42. Anterolateral crural region Cutaneous nerves • Lateral cutaneous n. of the calf:supplies the skin on the upper part of the anterolateral surface of the leg • Superficial peroneal n.supplies the skin of the lower part of the anterolateral surface of the leg and dorsum of the foot • Saphenous n.supplies the skin on the anteromedial surface of the leg • Deep peroneal n.supplies the skin of the adjacent sides of the big and second toes

43. Deep fascia • Surrounds the leg and forms two intermuscular septa to be attached to the fibula. • Divided the leg into three compartments－anterior, lateral and posterior－each of which contains a group of muscles, the vessels and the nerves. • Superior extensor retinaculum伸肌上支持带 • Inferior extensor retinaculum伸肌下支持带

44. Contents of the anterior fascial compartment of the leg Muscles: • Tibialis anterior • Extensor digitorum longus • Extensor hallucis longus • Peroneus tertius Blood supply: Anterior tibial a. Nerve supply: Deep peroneal n.

45. Contents of the anterior fascial compartment of the leg • Anterior tibial artery胫前动脉 • Beginning: Arises from the popliteai artery at the lower border of popliteus. It passes forwards above the interosseous membrane, and turns downwards on the anterior surface of that membrane with the deep peroneal nerve. • Ending: In front of ankle joint becomes the dorsalis pedis a. • The anterior tibial veins胫前静脉are closely applied to the artery.

46. Contents of the anterior fascial compartment of the leg • 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 nerve腓深神经 • Arises from the common peroneal nerve between the neck of the fibula and the peroneus longus muscle • Descends in the anterior compartment of the leg with the anterior tibial vessels. • Supplies all the muscles of the anterior compartment of the leg and extensor digitorum brevis.

47. Contents of the lateral fascial compartment of the leg Muscles • Peroneus longus • Peroneus brevis Blood supply:branches from the peroneal artey Nerve supply:superficial peroneal n.

48. Contents of the lateral fascial compartment of the leg • Superficial peroneal n.腓浅神经supplies peroneus longus and brevis and skin on anterior surface of leg and dorsum of foot

49. Anterior tibial a. Tibialis anterior Extensor digitorum longus Extensor hallucis longus Dorsal a. of foot Superficial peroneal n. Deep peroneal n.

50. Injury to the common peroneal nerve • The common fibular nerve may be severed during fracture of the fibula neck or severely stretched when the knee joint is injured of dislocated. • Severance of the common fibular n. results in paralysis of all muscles in the anterior and lateral compartments of the leg. The loss of eversion of the foot and dorsiflexion of the ankle causes foot-drop. • The foot drops and the toes drag of the floor when walking. Because it is impossible to make the heel strike the ground first, the patient has a high stepping (‘steppage”) gait, raising the foot as high as necessary to keep the toes from hitting the ground.