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Important Points From

LOWER LIMB

GLUTEAL REGION

Iliotibial TRACT originates from medial side(iliac crest) and inserts in lateral

condyle of tibia.

2 muscles give insertion in iliotibial tract,GLUTEUS MAX and TENSOR

FASCIA LATA.(medial to lateral)

Cutaneous nerve supply to gluteal region:

Upper lateral:L1,T12(iliohypogastric,thoracic)

Upper medial:L1,L2,L3,S1,S2,S3

Lower lateral:L2,L3(lat cut and of thigh)

Lower medial:S1,S2,S3(pos cut and of thigh)

Muscles in this region abducts extends and laterally rotates the femur relative to

pelvic bone.

Superficial group:tensor fascia lata(stabilize the knee joint),gluteus max,med.min

FUNCTION as abductor and extends hip.

Deep group:piriformis,obturator internus,gamellus superior,inferior,quadratusfemoris FUNCTION as lateral rotator of femur at hip joint.

Gamellus SUPERIOR is innervated by OBTURATOR INTERNUS and gamellusinferior is innervated by Nerve. to QUADRATUS FEMORIS.

QUADRATUS FEMORIS is the most inferior muscle of the deep group musclesof the region.

GLUTEUS MED+MIN abducts the lower limb at hip joint and reduces the pelvic

drop over the opposite swing limb during walking by securing the position ofpelvis on the stance limb.


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7 nerves enter the gluteal region from pelvis through greater sciatic foramen and 1

directly from sacrotuberous ligament(perforating cut. N)

Sup gluteal N=> gluteus max+min+tensor fascia lata (only this 1 passes from

above the piriformis)

Inf gluteal N=> GLUTEUS MAX

SCIATIC Nerve.=> to all muscles of post compartment which flexes knee and allmuscles that work on foot and ankle joint.

NERVES and VESSEL N to QUADRATUS FEMORIS=> quadratus femoris+gamellus inferior

N to obturator internus=> obturator internus+gamellus superior

Post cut. Nerve. of thigh=> skin on post thigh and leg (and labiummajora+scrotum skin) its med to sciatic N

Pudendal Nerve.=> major somatic nerve of the perineum no branch in glutealregion because it passes back to perineum by passing through lesser SCIATIC

foramen by sacrotuberous ligament.

Perforating cut. Nerve. of thigh=> supply the skin over medial side of GLUTEUSMAX(enters directly through sacrotuberous ligament in gluteal region)

2 arteries enter the gluteal region through greater sciatic foramen

INFERIOR GLUTEAL ARTERY: branch of ANTERIOR TRUNK of internal iliacARTERY,supplies to this region and makes anastomosis (cruciate+trochanteric)

and also gives branch to SCIATIC Nerve.

SUPERIOR gluteal artery:branch of POSTERIOR TRUNK of internal iliacartery,supplies to HIP JOINT+its superficial branch to gluteus maximus+deep

branch to GLUTEUS MED+MIN

In the pelvis PELVIC plexus OF VEINS

Peripherally anastomosis which drain into FEMORAL VEINS.

DEEP lymph into pelvic region in internal iliac nodes and superficial in the

superficial inguinal lymph nodes.


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THIGH

Anterior Is separated from the abdomen by INGUINAL LIGAMENT(anteriorSUP iliac supine to pubic tubercle )

Anterior Compartment is known as extensors

Posterior compartments is known as flexors

Medial compartments is known as adductors

EXTENSOR GROUP IS MORE POWERFUL THAN FLEXORCOMPARTMENT.

LATERAL ROTATOR IS MORE POWERFUL THAN MEDIAL ROTATOR

.IMPORTANT BONY POINTS OF

FEMUR Angle of neck and shaft is normally 125.(less in females due to wider pelvis)

Angle of ante-version is 15 (b/w transverse axes of upper and lower ends of femur)

Angle of torsion is the angle of head-neck is 7 in males and 12 in females

Blood supply:

Head of femur is by epiphyseal artery derived from obturator+ ascendingbranch of med circumflex femoral artery.

LATERAL HEAD by retinacular branches of medial circumflex femoralartery.

FOR NECK retinacular arteries derived from medial circumflex FEMORAL

ARTERY.

PES ANSERI=insertion of sartorius+gracilis+semitendinosis(goose foot)

Horse rider muscle=Adductor longus

GERDYs tubercle=point of insertion of iliotibial tract on anterolateral surfacebelow TIBIAL CONDYLE.

ADDUCTOR CANAL=sub-sartorial canal=hunter,s canal

LYMPH RELATED POINTS There are two main places where all the lymph of lower limb drains.1

st is inguinal


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lymph nodes(femoral canal) 2nd is popliteal lymph nodes(in popliteal fossa).

Inguinal lymph nodes are of primary importance.

Inguinal lymph nodes are divided in 2 types. Superficial and deep.

Superficial is in superficial fascia and joins the deep group by efferent lymph

vessels by passing through saphenous opening.

Superficial group is divided in 2 types.horizontal (2 medial,lateral 3),vertical(5)

Horizontal receives from the perineum and level of umbilicus,but vertical groupreceives most drainage of LOWER LIMB.

Popliteal lymph nodes are 6 in number ,they receive drainage from lateral side ofLEG and FOOT,knee joint+anterior.post tibial artery.And they are accompanied

by Small saphenous vein in popliteal fossa.

Important Points Related MUSCLES Here We will divide muscles of THIGH on the basis of their ACTIONS:

SHORT ROTATORS(6):piriformis+obturator internus+externus+superiorgamellus+inferior+quadratus femoris(when limb is fixed lateral rotation by

pulling back of femur medially)(when limb is free rotation of trunk to opposite

side)

Iliopsoas originates from posterior wall of abdomen and descends in the upper

part of anterior Compartment of thigh(that's y it is not included in femoralsheath)

Quadricep femoris mainly extends knee and stabilize the position of patella duringKNEE JOINT MOVEMENT.(vastus muscles originates from femur but rectusfemoris from pelvic bone)

Vastus lateralis is the largest muscle of VASTI.

Articularis genus is the tinny muscle originates from inferior to vastus intermediusand inserts into suprapatellar bursa associated with knee joint.

Rectus femoris lies anterior to vastus intermedius

Sartorius is the most superficial muscle of anterior COMPARTMENT ofthigh,weak flexor.

The long head of BICEP FEMORIS is innervated BY TIBIAL division of sciaticNerve. and short head from common peroneal division


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Gracilis is the most superficial muscle of the MED.COMPARTMENT of thigh.

Insertion of pes anseri anteromedial to tibial condyle:gracilis is sandwiched b/wsartorius front and semitendinosis behind.

Pectineus is below the inguinal ligament and makes the floor of med. Half of the

femoral triangle.

ADD.longus forms the proximal posterior wall of the add.canal and ADD.magnusforms the distal wall of add.canal and is the largest and deepest muscle in the

medial compartment.

Abductor and Adductors 3 Abductors

Gluteus MIN+MED+ fascia lata of iliotibial tract

Cause ABDUCTION,and help tilt the hip bone in passing the ground by nottouching foot to ground.

5 Adductors

Adductor longus+brevis +magnus+Pectineus+ gracilisThere insertion is on the medial side of femur.They Cause ADDUCTION

Extensor and flexors

4 extensors,2 medial and 2 lateral.

2 medial are semitendinosis+semimembranosus, acts at hip and knee joint.

2 lateral are bicep femoris+gluteus MAX, hip extension+knee flexion+standingup from sitting position(anti gravity muscle)help in propelling body duringwalking

4 flexors,2 acts on hip joint,2 acts on hip and knee joints.

The 2 acting at hip joint are iliacus and psoas major, when limb is fix help insitting up from bedded position and when not fix help in flexion at hip.

The 2 acting at hip and knee are rectos femoris+sartorius

Weak hip flexor and lateral rotators of hip.

ARTERIAL SUPPLY TO THIGH AORTACommon iliac artery(l&m)external iliac artery(below inguinal


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ligament)+internal iliac artery(passes from greater sciatic foramen and supplies to

gluteal region)

External iliac ARTERYobturator artery(in pelvic region)+femoral artery

Obturator artery(medial comp of thigh)ant,post(anastomosis in hip joint)

Femoral arterysmall,large

Small branch of F.Asuperficial circumflex(ANTERIOR COMP OF

THIGH),external pudendal (SKIN OF SCROTUM AND LABIUM MAJORA)

Large branch of F.ADeep femoral (behind add.longus,b/w add.magnus andmagnus,goes posterior to thigh and supply there)lateral circumflex F.A+medial

circumflex F.A(CRUCIATE ANASTOMOSIS)

INTERNAL iliac ARTERYsup.GLUTEAL Nerve.+inf.GLUTEAL Nerve.

Arterial supply to leg

Femoral artery is named as popliteal artery in POPLITEAL FOSSA.

Popliteal artery(in lower border of popliteal fossa)anterior tibial+post tibial

artery and also gives genicular branches to knee joint.

Anterior TIBIAL ARTERY pierce the intermuscular septa and enters in theanterior compartment of leg.

On passing below EXTENSOR RETINACULA it enters foot called asDORSALIS PEDIS ARTERY.

DPA gives 3 branches,lateral tarsal artery+arcuate artery and 1st dorsal

metatarsal artery.

And joins with the lateral planter artery on 1st metatarsal and completes plantar

dorsal arch.

Posterior TIBIAL ARTERY passes beneath the flexor retinaculum and gives 2branches, lateral planter artery+medial planter artery.

Medial is smaller than lateral planter artery.

On the level of 5th

metatarsal lateral planter artery curves medially and joins theDPA and completes the planter arch.

LUMBER PLEXUS L1ilioinguinal+iliohypogastric


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L1+L2Genitofemoral

L2+L3Lateral cutaneous nerve

L2+L3+L4femoral(post)+obturator(ant)

L4+L5+S1Superior gluteal nerve

S1+S2+S3posterior cut.N.of thigh

S2+S3+S4pudendal Nerve.

L5+S1+S2inf. Gluteal Nerve.

L4+L5+S1+S2+S3sciatic Nerve.common peroneal(L4+L5+S1+S2),tibial

Nerve.(L4+L5+S1+S2+S3)

Nerve Supply of Leg Sciatic nerve gives 2 branches in lower 2/3 of thigh. Tibial nerve+Common

peroneal nerve

Tibial nerve goes in posterior compartment of leg,and enters the foot bellowflexor retinaculum and gives 2 branches med and lateral planter Nerve.

Common peroneal nerve supplies the lateral compart and anterior compartment ofleg,on the level of fibular neck it gives 2 branches.deep peroneal+superficial

peroneal.

Deep peroneal supplies to anterior compartment of leg and superficial peronealsupplies to lateral compartment of leg.

Superficial p.n on entering the foot becomes cutaneous and deep p.n by passing

below extensor retinacula innervates by giving 3 branches,medial+lat+terminal

branch.

SURAL Nerve. which is cutaneous nerve of leg is branch of tibial Nerve.

Nerve Supply of Thigh Sup.GLUTEAL Nerve. supplies gluteus MIN+MED+tensor fascia lata

Inf.GLUTEAL Nerve. supplies gluteus MAX

FEMORAL Nerve. supplies anterior Comp of thigh (iliacus+quadricepfemoris+Pectineus+sartorius)


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Sciatic Nerve. supplies semitendinosis+semimembranosus+bicep femoris+post

part of ADD.magnus

Obturator Nerve. (med to psoas muscle on lat side & enters to supplies medialcompartment of thigh by add canal) ,obt.externus+adductors+magnus(anterior

Part)

Saphenous Nerve. passes along with F.A but does not pass from add.hiatus butpasses from medial side of knee b/w sartorius and gracilis.(branch of F.N)

IMPORTANT ANASTOMOSIS

Cruciate ANASTOMOSIS,in hip joint at the level ofLESSER TROCHANTERof FEMUR.it si in b/w: inf gluteal artery+med femoral circumflex+lat femoral

circumflex+1st

perforating artery(branch of profunda which is cutaneous branch of

F.A) it is to make connection b/w F.A & INTERNAL iliac ARTERY

Trochanteric anastomosis,main blood supply to FEMORAL HEAD,it si b/wfollowing: sup.gluteal+inf.gluteal+lat.circumflex+med.circumflex arteries,IT IS

AT THE LEVEL OF GREATER TROCHANTER.

Anastomosis around knee joint is b/w the followings: 5 genicular branches of

P.A+descending branch of F.A+descending branch of lateral circumflex of F.A+2recurrent artery of A.T.A+circumflex fibular of P.T.A

IMPORTANT RELATIONS Femoral sheath covers the femoral vessels and lymph.and itself lies in depressioncalled FEMORAL TRIANGLE.

Most medial is femoral canal(lymph sac),It is covered by femoral ring,femoralseptum closes the ring.

Lateral to it is FEMORAL VEIN.(intermediate comp)

Lateral to F.V is FEMORAL ARTERY(lateral comp)

MOST LATERAL ofFEMORAL TRIANGLE not the femoral sheath isFEMORAL Nerve.

Popliteus is important muscle of UNLOCKING but not the LOCKING of kneejoint.

Popliteus muscle gives origin on medial condyle of tibia and insertion on lateralcondyle of femur.


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Pulsation of P.A can be felt when knee is flexed.(and that of posterior tibial in

normal posture and that of DPA in little dorsiflexed)

TIBIAL CONDYLES=TIBIAL PLATES

Condyles of tibia are convex shape menisci provides it convexity.

Medial menisci is lunate shape and lat.menisci is fully rounded.

Thickened knee joint capsule on posterior Side prevents HYPEREXTENSIONof knee joint

Plantaris is a vestigial muscle.

Flexor accessories=quadratus plantae (in foot)

Fibrous septum&deep fascia separates the leg in compartments there are 3 fibrous

septum:

Transverse intermuscular septum=beneath soleus

Posterior crural septa=in front of soleus

Anterior crural septa

Hamstring muscles= semitendinosis+semimembranosus+ bicep femoris (&part ofadd.magnus),they are POWERFUL flexors of leg+extensors of hip.

Graciles and sartorius are weak flexor of leg.

Popliteus is a minor flexors cause medial rotation of tibia (unlocking)

Dorsiflexors=tibialis anterior+long extensors of foot(EDL+EHL)

Planterflexors=gastrocnemius+soleus+plantaris

Inversion=tibialis anterior +tibialis post

Eversion= peroneus longus+peroneus brevis+peroneus tertius

(foot planter-ed)LOCKING:*Extension of musclesfemur rotates medially(ligaments are taut meniscicompress)

(foot planter-ed)UNLOCKING:*Flexion of muscles(ligaments &menisci relaxes)tibia rotates laterally

(foot off the ground)LOCKING:*Extension of musclesTibia rotates laterally(ligaments taut,menisci compress)


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(foot off the ground)LOCKING:*Flexion of muscles(ligaments &menisci relaxes)femur rotates medially

ANKLE JOINT:Active dorsiflexion can be of 10 degreeActive Planterflexion can b of 20 degree,

In passive movements thus can b doubled

SOME POINTS ABOUT HIP

JOINT

Blood supply to hip joint,s intracapsular structure is by TROCHANTERICanastomosis

Normal range of flexion is 120 degree

Normal range of extension is 20 degree

Adduction is of about 30 degree

Abduction is of 60 degree

Rotation in either direction is about 40 degree

MOVEMENTS of KNEE JOINT ITS OF HINGE TYPE SO extension and flexion are primary movements,but little

bit of lateral and medial rotation of femur and tibia also occur so as to perform

locking and unlocking

Flexion can be till 150 degreeand normal extension to 30 degree

But can be increase of 5-10 degree of hyperextension in locking by passively

medial rotation of femur on tibia when on the ground,but when foot is free to move

it can be due to passive lateral rotation of tibia......

UNLOCKING is opposite to locking and its due to popliteus

Remember directions of CRUCIATE ligaments

These are 2 intracapsular ligaments in knee joint:Anterior cruciate ligament goes lateralis backward and attached to posterior

side of medial surface of femur.....

And reverse for posterior cruciate you just have to remember this dat name


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to ligament is given according to position on TIBIA....

Maintenance of arches depends on the following things:

Shape of the bones

LigamentsMuscle tone

But the last one is not important as much because when you are standingfor long periods your ligaments are getting affected and causing your arches todisappear

Small muscles peroneus longus and tibialis anterior play no role in normal staticcontrol.

Femoral Hernia:Lymph nodes lie in the most medial compartment of femoral sheath

called femoral canal,the wall of femoral sheath is strictly bound to vessels of

femoral sheath but not strictly bound to lymph vessels,so there presents a potential

weak area,a protrusion of any anatomical structure can lead to bulging of this areaall this condition is named femoral hernia,

Why femoral nerve is outside the femoral sheath?????femoral sheath is formed by fascia iliaca posteriorly and fascia transversalis

anteriorly,

Retroinguinal space is divided into two compartments by iliopsoasfascia,,,muscular and vascular,nerve descends in muscular compartment,,as fascia

transversalis doesn't extend into muscular part of retroinguinal space and so

femoral nerve is not inside femoral sheath.. it lies behind the fascia iliaca

Gateways to gluteal regions:Lesser sciatic foramen:

It is for reentry of structures left from greater sciatic foramen and exit fostructure of perineum

IN PTI

I:INTERNAL PUDENDAL ARTERY

N:NERVE TO OBTURATOR INTERNUS

P:PUDENDAL NERVET:TENDON TO OBTURATOR INTERNUS MUSCLEI:INTERNAL PUDENDAL VEIN

Gateways to gluteal regions:

Greater sciatic foramina which is further separated by piriformis in upper and

lower part...Structures passing from greater sciatic foramen:

PSP IN SSP G

P:PIRIFORMIS

S:SCIATIC NERVEP:POST CUTANEOUS NERVE OF THIGH


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I:INTERNAL PUDENDALARTERY and VEIN

N:NERVE TO OBTURATOR and QUADRATUS FEMORIS

S:SUP and INF GLUTEAL NERVESS:SUP and INF GLUTEAL ARTERIES and VEINS

P:PUDENDAL NERVES

G:GAMELLUS

Remember the significance of piriformis and dividing this foramen in upper andlower is just to Separate sup and infer gluteal nerves and vessels

2ND

HEART OF THE BODY IS IN LEG ,VENOUS PLEXUS IN SOLEUS

Gastrocnemius helps you to win long jumps but soleus is slow in action

Eversion and inversion is at midtarsal & transverse tarsal joint(talocalcaneonavicular & calcaneocuboid) but not at ankle joint.

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