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Sveinn Runar Sigurdsson, group 6. 2nd year. 2009.

1. Bones, joints and ligaments of the pelvic girdle.

Divided to greater (abdomen protection) and lesser pelvis (framework for pelvic cavity and perineum). Covered anteriorly (inferior anterolateral abdominal wall), posterolaterally (gluteal region), inferiorly (perineum).ö

Perineum: the area of surface of trunk between the thighs and buttocks, extending from coccyx to pubis, and to shallow compartment lying superior, also inferior to pelvic diaphragm. (anus, external genitalia).

Pelvic girdle:

Bears weight of upper body Transfers weight from axial to lower appendicular skeleton Attachment for muscles of locomotion and abdominal wall

Bones:

Right and left hip bones:

Ilium: superior fan shaped, ala/wing of ilium has iliac crest which goes in either direction to anterior/posterior superior/inferior iliac spine. Then comes the iliac fossa. Has auricular surface posteriorly and iliac tuberosity for synovial and syndesmotic articulation with the sacrum. Ischium: has body and ramus. Body forms part of obturator foramen. Ischial tuberosity post.inf. at junction of ramus and body there is the ischial spine. Between that and tuberosity is lesser sciatic notch above is greater schiatic notch (formed part by ilium). Pubis: superior pubic ramus helps form acetabulum. Inferior pubic ramus helps form the obturator foramen. Thickening on anterior part of body of pubis = pubic crest and that ends in pubic tubercle. The pubic arch is formed by the ischiopubic rami. Meet at pubic symphysis. Inferior borders define the subpubic angle, with determined by distandce btw right and left ischial tuberosities. Pelvic intlet (superior pelvic aperture) is formed by the

Promontory and ala of sacrum Right and left linea terminalis (acruate line on inner ilium) pecten Pelvic outlet (inferior pelvic aperture) formed by the

Pubic arch anteriorly Ischial tuberosities laterally Inferior margin of sacrotuberous ligament posterolaterally Tip of coccyx posteriorly True pelvis: concave superior surface of musculofascial pelvic diaphragm forms the floor. Convex inferior surface of pelvic diaphragm forms the roof of perineum.

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Are united by triradiate in infants and fuse after puberty in the acetabulum. The hip bones are joined together anteriorly by symphysis pubis and posteriorly at sacrum by sacroiliac joints..

Sacrum:

Five fused sacral vertebrae in adults after 20 years. Forms the roof and posterosuperior wall of the posterior pelvic cavity. Provides strength and stability to the pelvis, transmits the weight of the body to the pelvic girdle. Sacral canal: continuation of the vertebral canal, contains spinal nerve roots inferior to the L1 vertebra (cauda equina). Posterior are 4 pairs of sacral foramina exit of posterior and anterior rami of spinal nerves. Anterior foramina larger than posterior ones. Base of sacrum: formed by superior surface of S1. sacral promontory on the anterior. Apex of sacrum: oval facet for articulation with the coccyx. Pelvic surface: smooth and concave. Dorsal surface: rough convex and marked by 5 prominent longitudinal ridges.

Median sacral crest (spinous processes) Intermediate sacral crest (articular processes) Lateral sacral crest (transverse processes) U shaped hiatus: absence of the laminae and spinous processes of S5, leads into the sacral canal. Sacral cornua: inferior articular processes of S5 project on each side of hiatus.

Auricular surface on lateral surface.synovial part of sacroiliac joint btw. Sacrum and ilium.

Coccyx

fusion of the 3-5 rudimentary coccygeal vertebrae. Remanant of embryonic tail in embryos from the end of 4th week until beginning of 8th week. Pelvic surface: smooth and concave. Posterior surface: articular processes. Articular processes from Co1 form the coccygeal cornua which articulate with the sacral cornua. Provides attachments for parts of gluteus maximus, coccygeus muscles and anococcygeal ligament.

Joints:

Sacroiliac joints: link axial skeleton and inferior appendicular skeleton.

Anterior synovial joint between the auricular surfaces of the sacrum and ilium.

Limited mobility, transmit weight to hip bones. Posterior syndesmosis between the tuberosities of the same bones. Pubic symphysis joint: cartilaginous joint, fibrocartilaginous interpubic disc and surrounding ligaments, unite the pubic bones in a median plane.

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Interpubic disc: wider in women, ligaments joining the bones thickened superior and inferior of symphysis Lumbosacral joints: L5 and S1 vertebrae articulate at ant. Intervertebral joint formed by the 4th disc between their bodies and at two post. Zygapophysial joints btw. The articular processes of the vertebrae. Strengthened by iliolumbar ligaments. sacrococcygeal joints: secondary cartilaginous joint with an 4th disc. Fibrocartilage and ligaments join the apex of sacrum to base of coccyx.

Ligaments:

Sacroiliac joint ligaments:

Anterior sacroiliac ligaments: ant. Part of fibrous capsule of synovial part of sacroiliac joint. Interosseous sacroiliac ligaments: lie deep btw. Tuberosities of sacrum and ilium.

Transfer weight of upper body to ilia. Posterior sacroiliac ligaments: post. Ecternal continuation of the same mass of fibrous tissue. Run obliquely out and up from sacrum.

Are joined inferiorly by fibers from the posterior ilium and the base of coccyx to form sacrotuberous ligaments. They pass from post. Ilium and lateral sacrum/coccyx to ischial tuberosity transforming the sciatic notch of the hip bone into a large sciatic foramen.

Sacrospinous ligament: passes from lateral sacrum and coccyx to ischial spine and divides the foramen further to greater & lesser sciatic foramina. Pubic symphysis joint ligaments: Superior pubic ligament: connects sup. Pubic bodies and interpubic disc. Extend to pubic tubercles. Inferior (arcuate) pubic ligament: thick arch of fibers connects inferior pubic bodies and rounds off subpubic angle and forms apex of pubic arch.

Lumbosacral joint ligaments: Iliolumbar ligaments radiate from the transverse processes of L5 vertebrae to ilia.

Sacrococcygeal joint ligaments: Sacrococcygeal ligaments: long strands, reinforce the joint

Pelvic fractures:

anteroposterior compression = fracture of pubic rami lateral compression = acetabulum and ilium fracture weak areas are: pubic rami, acetabulum, sacroiliac joint, ala of ilium. Fractures in puboobturator area area common and complicated because of relationship with urinary bladder & urethra

Male vs female pelvis:

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Male

Thick, heavy Greater pelvis deep Lesser pelvis narrow, deep Pelvic inlet heart shaped Pelvic outlet small Pubic arch narrow <70° Obturator foramen round Acetabulum large Greater sciatic notch narrow 70° Female

Thin, light Greater pelvis shallow Lesser pelvis wide and shallow Pelvic inlet oval and rounded Pelvic outlet large Pubic arch wide >80° Obturator foramen oval Acetabulum small Greater sciatic notch almost 90°

2. Gluteal muscles. Blood vessels and nerves of the gluteal region.

Gluteal region: includes clunes/buttocks posteriorly, coax/hip laterally. Bounded superiorly by the iliac crest. Medially by the intergluteal(natal) cleft and inferiorly by the skin fold underlying the buttock (gluteal fold/sulcus glutealis).

Skin innervation:

Lateral cutaneous branch of the iliohypogastric nerve (lumbar plexus) supplies superolateral quadrant of buttock. Superior clunial nerves (L1-3 post rami) supply skin in superior and central parts of buttocks. Medial clunial nerves (S1-3 post rami) supply skin of medial buttock and intergluteal cleft. Inferior clunial nerves (post cutaneous nerve of thight) supply skin of inferior buttock (gluteal fold).

Intergluteal cleft separates the buttocks

Ligaments:

Sacrotuberous and sacrospinous ligaments convert the sciatic notches in the hip bones into the lesser and greater sciatic foramina.

Lesser foramen (structures from/to perineum – pudendal n.)

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Greater foramen (structures from/to pelvis – sciatic n.)

Muscles:

Superficial layer: mainly extensors, abductors and medial rotators of thigh.

Gluteus maximus:

Prox. attachment: ilium, dorsal sacrum & coccyx and sacrotuberous ligament. Dist. Attachment: most fibers end in iliotibial tract, some (deep fibers of inferior part of muscle) attach to gluteal tuberosity of femur. Innervation: Inferior gluteal nerve enter the deep in middle muscle. Arteries: inferior and superior gluteal arteries. Sciatic nerve passes deep to the gluteus. Function: extension and lateral rotation of the thigh. Gluteal bursae separate the gluteus maximus from adjacent structures:

Trochanteric bursa: separates sup. Fibers of glut.max. from greater trochanter (largest bursa). Ischial bursa: separates inf. Of glut. max. from ischial tuberosity (often absent) Gluteofemoral bursa: separates the iliotibial tract from sup. Part of prox. Attachment of vastus lateralis. Gluteus medius:

Prox. Attachm: ext. surface of ilium btw. Ant. & post. Gluteal lines. Dist. Attachm: lateral surface of greater trochanter of femur. Innervation: superior gluteal nerve Arteries: superior gluteal artery Function: abduct and medially rotate thigh Gluteus minimus:

Prox, attachm: ext. surface of ilium btw. Ant. & post. Gluteal lines. Dist. Attachm: ant. Surface of greater trochanter of femur Innervation: superior gluteal nerve Arteries: superior gluteal artery Function: abduct and medially rotate thigh Tensor fascia lata:

Prox, attachm: ant.sup. iliac spine, ant. Part of iliac crest. Dist. Attachm: iliotibial tract (attaches to lateral condyle of tibia) Innervation: superior gluteal nerve Arteries: deep branch of superior gluteal artery Function: flexor of the thigh (with iliopsoas and rectus femoris – when iliopsoas is paralyzed the tensor becomes hypertrophic to compensate), tenses fascia lata and iliotibial tract. Deep layer: lateral rotators of thigh and stabilize the hip joint.

Piriformis:

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Superior gluetal vessels and nerve emerge superior to it Inferior gluteal vessels and nerve emerge inferior to it Prox, attachm: ant. Surface of sacrum, sacrotuberous ligament. Dist. Attachm: sup. Border of greater trochanter of femur, Innervation: branches of ant. Rami of S1, S2 Arteries: Function: laterally rotates and abducts thigh, fastens femoral head in acetabulum Obturator internus:

Prox, attachm: pelvic surface of obturator membrane and surrounding bones. Dist. Attachm: medial greater trochanter of femur. Innervation: nerve to obturator internus Arteries: inferior gluteal artery Function: laterally rotates and abducte thigh, fastens femoral head in acetabulum Obturator internus bursa: movement of muscle over post. Ischium. Superior & inferior gemelli:

Prox, attachm:

Superior: ischial spine Inferior: ischial tuberosity Dist. Attachm: medial greater trochanter of femur Innervation:

Superior: nerve to obturator internus Inferior: nerve to quadratus femoris Arteries: Function: laterally rotate and abduct thigh, fasten femoral head in acetabulum Quadratus femoris:

Prox, attachm: lateral border of ischial tuberosity Dist. Attachm: quadrate tubercle on intertrochanteric crest of femur Innervation: nerve to quadratus femoris Arteries: inferior gluteal artery Function: laterally rotates thigh and fasten femoral head in acetabulum Triceps coxae: obturator internus, gemelli sup. And inf.

3. Subinguinal hiatus. Femoral canal.

Subinguinal region:

Superiorly: inguinal ligament.

Inferiorly: transverse line across the gluteal groove.

Laterally: line perpendicular to the ant.sup.iliac spine

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Medially: medial edge of the thigh.

Inguinal ligament actually a flexor retinaculum

Superficial arteries:

Originate from femoral artery and pass through saphenous hiatus toward the navel:

Superficial epigastric Superficial circumflex iliac External pudendal artery

Cutaneous nerves:

Lateral femoral cutaneous nerve (medial to ant.sup.iliac spine) Anterior femoral cutaneous nerve (along medial/lateral margins of Sartorius) Femoral branch of the genitofemoral nerve (exits from saphenous hiatus)

Veins:

Great saphenous vein ascends medially and joins femoral vein aftera passing through the saphenous hiatus

Subinguinal hiatus:

Borders:

Superior: subinguinal ligament

Inferior: ant.sup. iliac spine – ant border of ala ileum – iliopubic eminence – sup. Ramus of pubis – body of pubis – pectineal fascia and muscle – pubic tubercle.

Divided into 3 compartments:

Lacuna musculonervosa

Lateral part of subinguinal hiatus. Borders:

Superior: Inguinal ligament Inferior: ant.sup.iliac spine, iliopubic eminence, ramus of pubis. Iliopsoar muscle (iliacus laterally and psoas major medially) and femoral nerve pass through from greater pelvis to ant. Thigh medial to iliopectineal arch (thickening of iliopsoas fascia divides ligament into compartments). Lateral cutaneous femoral nerve Lacuna vasorum

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Middle compartment, femoral sheat surrounds the vessels. Borders:

Superior: Inguinal ligament Lateral: psoas part of iliopsoas muscle Medial: lacuna lymphatica and pectineus fascia (lines pectineus muscle) Passage of major vascular structures (veins, arteries, lyphatics) enter femoral triangle and the names of vessels change from external iliac to femoral! Lateral to medial content:

Lateral: femoral artery Middle: femoral branch of genitofermoral nerve Medial: femoral vein Lacuna lymphatica

Medial corner Lymphatic vessels from lower limb to abdominal cavity Borders:

Superior: Inguinal ligament Inferior: pectineal fascia and muscle, conjoint ligament Lateral: lacuna vasorum Contents:

Femoral hiatus closed by femoral septum Lacunar ligament Rosenmüller lymph nodes

Femoral canal

This is the smallest and the most medial compartment of the femoral sheath. Located around the femoral ring. Is a virtual space unless hernia and femoral septum is broken.

4. Femur. Hip joint.

Longest, heaviest bone in the body. Transmits weight from hip bone to tibia.

Proximal head:

Head, neck, 2 trochanters (greater/lesser) Head: fovea for ligament of the head of femur also artery of the head of femur. Angle of inclination: greatest at birth until 115-140°, less in females because of wider pelvis. Angle of declination: 7° in males 12° in females. Abductors and rotators of thigh attach mainly on greater trochanter Flexors of thigh attach on lesser trochanter

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Where neck joins shaft: lesser and greater trochanter (intertrochanteric line – ileofemoral ligament attaches)

Greater laterally Lesser medially Intertrochanteric crest joines the trochanters posteriorly – on crest is quadrate tubercle near the greater trochanter. Shaft: posteriorly is linea aspera – provides aponeurotic attachment for adductors of the thigh. Area divided to medial and lateral lips (lateral lip blends with gluteal tuberosity)

Pectineal line from central part of linea aspera to the base of lesser trochanter. Inferiorly the linea aspera divides to medial and lateral supraepicondylar lines. Medial and lateral femoral condyles on distal head.

Articulate with menisci and tibial condyles to form knee joint. Separated by intercondylar fossa/notch posteriorly Merge anteriorly to form patellar surface Above the medial epicondyle is the adductor tubercle

Hip joint

Multiaxial ball and socket type of synovial joint. Femoral head = ball, acetabulum = socket. Articular surface: round head of femur articulates with cup like acetabulum of hip bone.

All head of femur covered with articular cartilage exept fovea for ligament and artery of head of femur. Acetabulum: hemispherical, hollow on lateral aspect, fusion of 3 bones. Lunate surface of acetabulum and acetabular labrum form ¾ of a circle the ¼ is acetabular notch inferiorly. The transverse acetabular ligament bridges the acetabular notch in continuation from labrum. Acetabular fossa is deep and non articular part formed by ischium. Fat pad in fossa. Joint capsule of the hip joint:

External fibrous layer and internal synovial membrane. Fibrous layer attaches proximally to acetabulum and distally to femoral neck at intertrochanteric line. Spirals from hip bone to intertrochanteric line and some pass circularly around neck forming orbicular zone. Thick parts of fibrous layer form ligaments of hip joint. Draws femoral head into acetabulum. Iliofemoral ligament: ant. & sup.Y-shaped attaches to :

ant.inf.iliac spine and acetabular rim proximally inertrochanteric line distally bodys strongest ligament prevents hyperextension during standing. Pubofemoral ligament: comes from obturator crest of pubic bone and passes laterally & inferiorly to merge with fibrous layer.

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Blends with medial part of iliofemoral ligament Tightens during extension and abduction Prevents overabduction Ischiofemoral ligament: from ischial part of acetabular rim

Weakest of three ligaments. Spirals superolaterally to femoral neck medial to base of greater trochanter. Synovial folds cover neck, retinacular arteries (branches of medial and lateral circumflex femoral artery) supply femoral head and neck in synovial folds. Ligament of head of femur: attaches to foeva for ligament of head and artery.

Movements of hip joint:

Degree of flexion/extension of hip joint depends on position of knee. 60° abduction when thigh is extended, more when flexed Iliopsoas: strongest flexor of hip Adductor magnus flexor/extensor also in addition to adductor. Muscles participate in both flexion and adduction

Pectineus, gracilis, all three adductor muscles Ant. Gluteus medius and minimus are in addition to abduct also medial rotators. Gluteus maximus primary extensor from flexed to straight position and also lateral rotator.

Blood supply to hip joint:

Medial and lateral circumflex femoral arteries – branches of deep artery of thigh or branches of femoral artery. Artery to head of femur – branch of obturator artery Main blod supply from retinacular arteries from circumflex femoral (medial most) (lateral least-penetrate iliofemoral ligament) arteries.

Nerve supply to hip joint:

Flexors innervated by femoral nerve pass anterior to hip joint = femoral nerve innervates anterior hip joint. Lateral rotators pass inferior & posterior to hip joint = obturator nerve innervates inferior hip joint, nerve to quadratus femoris innervates posterior hip joint. Adductors innervated by superior gluteal nerve pass superior to hip joint = gluteal nerve innervates superior hip joint. Flexors of hip joint: 9

Iliopsoas Sartorius Tensor fascia lata Rectus femoris Pectineus

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Adductor longus Adductor brevis Adductor magnus (ant part) gracilis Adductors of hip joint: 6

Adductor longus Adductor brevis Adductor magnus Gracilis Pectineus Obturator externus Lateral rotators of hip joint: 8

Obturator externus Obturator internus Gemelli Piriformis Quadratus femoris Gluteus maximus Extensors of hip joint: 5

Hamstrings (semitendinosus, semimembranosus, longhead biceps femoris) Adductor magnus (post part) Gluteus maximus Abductors of hip joint: 3

Gluteus medius Gluteus minimus Tensor fascia lata Medial rotators of hip joint: 3

Gluteus medius (ant. Part) Gluteus minimus (ant. Part) Tensor fascia lata

5. Muscles, blood vessels and nerves of the anterior and medial compartments of the thigh.

Great saphenous vein

Fascia lata turns to iliotibial tract laterally

Sartorius and gracilis have own fascial sheaths

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Femoral artery and vein, saphenous nerve in groove formed by extensors and adductors and goes under Sartorius.

Cutaneous nerves:

Ant. Cutaneous branch of femoral nerve (medial and ant thigh) Cutaneous branch of obturator nerve (middle medial thigh) Lateral cutaneous nerve of thigh (from lumbar plexus) (ant and lat thigh) Genitofemoral nerve (lumbar plexus) (femoral branch -lat.femoral triangle ; genital branch – ant. Scrotum and labia majora) Ilioinguinal nerve (lumbar plexus) (medial femoral triangle)

Muscles: flexors of hip and extensors of knee

Pectineus:

Proximal attachm: superior ramus of pubis Distal attachm: pectineal line of femur Innervation: femoral nerve (also possible branch from obturator nerve) Artery: Function: adducts/flexes thigh, assist medial rotation of thigh Iliopsoas:

Proximal attachm:

Major: sides of T12-L5, transverse processes Minor: sides of T12-L1 Iliacus: iliac crest/fossa, ala of sacrum, ant. Sacroiliac ligaments Distal attachm:

Major: lesser trochanter of femur Minor: pectineal line, iliopectineal eminence Iliacus: tendon of psoas major, lesser trochanter and femur Innervation:

Major: ant. Rami of lumbar nerves 1-3 Minor: ant. Rami of lumbar nerves 1-2 Iliacus: femoral nerve Artery: Function: flex thigh at hip joint. Stabilize joint. Sartorius:

Proximal attachm: ant.sup.iliac spine Distal attachm: superior medial tibia Innervation: femoral nerve Artery:

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Function: flex, abduct and laterally rotate thigh at hip joint. Flex leg at knee joint. Quadriceps femoris: is rectus femoris and the vastus muscles!

Rectus femoris:

Proximal attachm: ant.inf.iliac spine and ilium sup. To acetabulum. Distal attachm: quadriceps tendon and aponeourosis of patella Innervation: femoral nerve Artery: Function: extend leg at knee joint and steady hip joint, helps iliopsoas flex thigh Vastus lateralis:

Proximal attachm: Distal attachm: quadriceps tendon and aponeourosis of patella Innervation: femoral nerve Artery: Function: extend leg at knee joint Vastus medialis

Proximal attachm: Distal attachm: quadriceps tendon and aponeourosis of patella Innervation: femoral nerve Artery: Function: extend leg at knee joint Vastus intermediate:

Proximal attachm: Distal attachm: quadriceps tendon and aponeourosis of patella Innervation: femoral nerve Artery: Function: extend leg at knee joint

Muscles: medial thigh muscles, adductor group

Adductor longus:

Proximal attachm: body of pubis inf. To pubic crest Distal attachm: middle third of linea aspera Innervation: obturator nerve, branch of ant. division Artery: Function: adducts thigh Adductor brevis:

Proximal attachm: body and inf. Ramus og pubis Distal attachm: pectineal line and proximal linea aspera Innervation: obturator nerve, branch of ant. division

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Artery: Function: adducts thigh Adductor magnus:

Proximal attachm:

Adductor part: inferior ramus of pubis, ramus of ischium Hamstring part: ischial tuberosity Distal attachm:

Adductor part: gluteal tuberosity, linea aspera, medial supracondylar line Hamstring part: adductor tubercle of femur Innervation:

Adductor part: obturator nerve, branch of post. division Hamstring part: tibial part of sciatic nerve Artery: Function: adducts thigh

Adductor part: flexes thigh Hamstring part: extends thigh. Gracilis:

Proximal attachm: body & inf. Ramus of pubis Distal attachm: sup. Medial tibia Innervation: obturator nerve Artery: Function: adducts thigh, flexes leg and helps medial rotation. Obturator externus:

Proximal attachm: margins of obturator foramen and membrane Distal attachm: trochanteric fossa Innervation: obturator nerve Artery: Function: lat rotation of thigh, steadies head of femur in acetabulum.

6. Femoral triangle. Adductor canal.

Femoral triangle:

Subfacial space. Appears as a triangular depression inferior to the inguinal ligament. Borders: Superior: inguinal ligament forms the base of the triangle. Medial: adductor longus Lateral: Sartorius Apex: lateral border of Sartorius crosses the medial border of adductor longus.

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Floor: iliospoas laterally and pectineus medially Roof: fascia lata and cribriform fascia, subcutaneous tissue, skin. Contents from lateral to medial:

Femoral nerve and its terminal branches. Femoral artery and several of its branches Femoral vein and its proximal tributaries (great saphenous and deep femoral) Deep inguinal lymph nodes and associated lymphatic vessels.

femoral artery and vein pass through the apex into and from the adductor canal (intramuscular passage way).

Adductor hiatus:

Opening/gap btw. Aponeurotic distal attachment of adductor part of adductor magnus and tendinosus distal attachment of hamstring. 15 cm narrow passageway in middle third of thigh. Extends from apex of femoral triangle to the adductor hiatus in the tendon of adductor magnus. Transmits the femoral artery and vein from adductor canal in the thigh to the popliteal fossa. Also the sapheonus nerve and the nerve to vastus medialis. Opening is lateral & superior to adductor tubercle of femur. Borders:

Anterior & lateral: vastus medialis. Posterior: adductor longus & magnus Medial: Sartorius it also forms the roof of the canal.

7. Muscles, blood vessels and nerves of the posterior compartment of the thigh.

Flexor muscles lat (biceps femoris) med (semitendinosus) beneath (semimembr)

Sciatic nerve between flexors and add magnus

Posterior femoral cutaneous nerve

Small saphenous vein (vein of giacomini)

Muscles: 3 of 4 are hamstrings

Semitendinosus:

Prox. Attach: ischial tuberosity Distal attach: medial superior tibia Innervation: tibial division of sciatic nerve Artery: Function: extend thigh, flex & med rotate flexed knee

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Semimembranosus:

Prox. Attach: ischial tuberosity Distal attach: post medial condyle of tibia Innervation: tibial division of sciatic nerve Artery: Function: extend thigh, flex & med rotate flexed knee Biceps femoris long head

Prox. Attach: ischial tuberosity Distal attach: lateral head of fibula Innervation: tibial division of sciatic nerve Artery: Function: flex and laterally rotates leg Biceps femoris short head

Prox. Attach: linea aspera and lat.supracondylar line Distal attach: lateral head of fibula Innervation: common fibular division of sciatic nerve Artery: Function: flex and laterally rotates leg

8. Popliteal fossa. Knee joint.

Popliteal fossa /posterior genicular region

Borders: diamond shaped

Superiorly: 3 fingers above midpopliteal groove

Superolateral: biceps femoris Superomedial: semimembranosus Inferiorly: 3 fingers below midpopliteal groove

Inferolateral: lateral head of gastrocnemius Inferomedial: medial head of gastrocnemius Medially & laterally: vertical line from epicondyle of femur and capitulum og fibula. Superficial structures: posterior femoral cutaneous nerve – posterior femoral cutaneous vein – lateral & medial sural cutaneous nerve Popliteal fascia continues sup: fascia lata and inf: deep fascia of leg. Often pierced by small saphenous vein. Forms floor of fossa! Contents of fossa:

Termination of small saphenous vein

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Small saphenous vein passes from post. Of lateral malleolus into fossa, pierces the fascia and enters popliteal vein. Popliteal arteries and veins, branches

Popliteal artery: continuation of femoral artery – femoral passes through adductor hiatus.

popliteal artery divides after fossa into anterior and posterior tibial arteries 5 genicular branches supply the capsule and ligaments of knee joint. Genicular anastomosis (blood flow during flexion of knee)

Superior lateral genicular artery Superior medial genicular artery Middle genicular artery Inferior lateral genicular artery Inferior medial genicular artery Other contributions to the anastomosis are:

Descending genicular branch of femoral artery (sup.med) Descending branch of lateral femoral circumflex artery (sup.lat) Anterior tibial recurrent branch of anterior t ibial artery (inf.lat) popliteal vein: continuation of posterior tibial vein – lies close to popliteal artery but superficial to it in same sheath.

Superiorly to the vein it becomes the femoral vein as it traverses the adductor hiatus. Small saphenous vein passes from post. Of lateral malleolus into fossa, pierces the fascia and enters popliteal vein. Tibial and common fibular nerves – branches from sciatic nerve!

Tibial medial and larger and most superficial. Tibial gives branches to soleus, gastrocnemius, plantaris and popliteus. Tibial (anterior division of anterior rami L4-S3)

Medial sural cutaneous nerve – branches from tibial nerve → joined by the sural communicating branch of the common fibular nerve to form the Sural nerve (suppl. Lateral leg and ankle) Common fibular is lateral and smaller (posterior division of anterior rami L4-S2).

Follows medial border of biceps femoris and its tendon in fossa and leaves passing superficial to the lateral gastrocnemius head – post. Head of fibula around fibular neck and divides into terminal branches. Posterior cutaneous nerve of thigh

Supplies skin over fossa Popliteal lymph nodes and vessels

Superficial popliteal lymph nodes: small in subcutaneous tissue.

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Deep popliteal lymph nodes: surround the vessels receive lymph from joint capsule and lymph vessels from leg. Vessels from popliteal lymph nodes follow femoral vessels to the deep inguinal lymph nodes.

Knee joint, articulate. genus:

Largest most superficial joint. Hinge joint, synovial also glide and roll with rotation around vertical axis. Has 3 articulations: (fibula not involved in the joint)

Lateral femorotibial articulation (btw. Lateral femoral and tibial condyles) Medial femorotibial articulation (btw. Medial femoral and tibial condyles) Femoropatellar articulation (btw. Patella and femur) Most important muscle in stabilizing the knee joint = quadriceps femoris (inferior fibers of vastus medialis and lateralis). Is most stable in extended position (collateral and cruciate ligaments are taut) Joint capsule of the knee joint:

External fibrous layer

Superiorly: attaches to femur Posteriorly: encloses condyles and intercondylar fossa (has opening on lateral tibial condyle for tendon of popliteus to go out and attach to tibia) Inferiorly: attaches to tibial plateau, articular margin og the tibia. Anteriorly: the quadriceps tendon, patella and patellar ligament replace the fibrous layer Internal synovial membrane

Attaches to periphery of articular cartilage covering femoral and tibial condyles, posterior patella and menisci. Posteriorly: it goes into intercondylar region and covers cruciate ligaments and infrapatellar fat-pad creating a median infrapatellar synovial fold. Almost divides the cavity to left and right cavities.

Lateral & medial alar folds cover inner surface of fat pads. Continues superiorly as lining of suprapatellar bursa Articular muscle of the knee attaches to the membrane and retracts bursa in extension of knee. Menisci: fibrocartilaginous discs between the tibial and femoral articular surfaces. Laterally the tendon of the popliteus muscle passes out of the joint. Extracapsular ligaments of knee joint:

Joint capsule strengthened by 5 ingrinsic ligaments: also called (external ligaments)

Patellar ligament:

Distal part of quadriceps tendon, passes from apex of patella to tibial tuberosity. Strong attachment

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Is the anterior ligament of knee joint Laterally receives medial and lateral patellar retinacula (make up joint capsule on each side of patella) and aponeurosis of vastus medialis/lateralis. Fibular collateral ligament:

Is lateral collateral ligament – strong, rounded and cordlike Inferiorly from lateral epicondyle of femur to lateral fibular head. Dendon of popliteus passes deep to it, separating it from the lateral meniscus. Tendon of biceps femoris split into two parts by it. Tibial collateral ligament:

Medial collateral ligament – strong (weaker than FCL, more often damaged) From medial epicondyle of femur to medial condyle and superior medial tibia. Firmly attached to medial meniscus Oblique popliteal ligament:

Expansion of tendon of semimembranosus posteriorly and spans intracondylar fossa. Passes post. To medial tibial condyle and passes sup.lat toward lateral femoral condyle. Arcuate popliteal ligament:

From posterior fibular head, passes sup.med over endon of popliteus and goes over post. Surface of knee joint. Intra articular ligaments of knee joint:

Cruciate ligaments:

Crisscross within joint capsule but outside synovial cavity. In center of joint and cross each other obliquely like X Menisci Popliteal tendon also during part of its course

9. Bones of the leg. Muscles, blood vessels and nerves of the anterior and lateral compartments of the leg.

Femur

head of the femur: project superomedially and slightly anteriorly neck of the femur the angle between the neck and the head is 115-140° lesser trochanter rounded conical greater trochanter intertrochanteric line intertrochanteric crest quadrate tubercle trochanteric fossa body of the femur

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linea aspera (broad line of the femur medial and lateral lips, or margins gluteal tuberosity spiral line (the medial lip continue in a spiral rough line) pectineal line medial and lateral supracondylar lines intercondylar fossa patellar surface lateral epicondyle medial epicondyle adductor tubercle

Tibia

medial and lateral epicondyles superior articular surface tibial plateau intercondylar eminence intercondylar fossa fibial articular surface body of the tibia tibial tuberosity anterior border of the tibia medial malleolus interosseus membrane soleal line inferior articulating surface nutrient foramen

Fibula

head of the fibula facies articularis capitis fibulae apex of the fibula body of the fibula the distal part is rather triangular margo interosseus lateral malleolus facies articularis malleoli

Anterior compartment: Dorsiflexor (extensor) compartment is anterior to the interosseous membrane. Divided by tibia and anterior intermuscular septum. Has 4 muscles: Tibialis anterior, extensor digitorum longus and extensor hallucis longus and fibularis tertius. Inferior there are 2 band like thickenings of the fascia to form retinacula that bind the tendons of the ant. Muscles before & after they cross the ankle joint.

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Superior extensor retinaculum: strong broad band from fibula to tibia proximal to the malleoli. Inferior extensor retinaculum: Y shaped attaches laterally to anterosuperior calcaneus, loops around the tendons of fibularis tertius and extensor digitorum longus. Muscles: Tibialis anterior: most medial and superficial (lies against lateral tibia), strongest dorsiflexor.

Origin: lateral condyle and sup.lat. tibia and interosseous membrane. Attachment: medial and inferior surface of medial cuneiform and base of 1st metatarsal Innvervation: deep fibular nerve Artery: anterior tibial artery Function: dorsiflexion and invertion Extensor digitorum longus: most lateral, has common synovial sheath with fibularis tertius. Each tendon forms a extensor expansion over dorsum of phalanges

Origin: lateral condyle of tibia, sup. ¾ of fibula and interosseous membrane. Attachment: middle & distal phalanges of lat. 4 digits Innvervation: deep fibular nerve Artery: anterior tibial artery Function: extends digits and dorsiflexion Extensor hallucis longus: lies deep between TA and EDL

Origin: middle ant. Fibula and interosseous membrane Attachment: dorsal base of distal phalanx of hallux Innvervation: deep fibular nerve Artery: anterior tibial artery Function: extend hallux and dorsiflexion Fibularis tertius: separate part of extensor digitorum longus (shares it´s synovial sheath). Most common sprained ligament of the body and the muscle is not always present.

Origin: inferior 1/3 ant. Fibula and interosseous membrane Attachment: dorsum of base of 5th metatarsal Innvervation: deep fibular nerve Artery: anterior tibial artery Function: dorsiflexion and aids in inversion Nerve:

Deep fibular nerve one of the two terminal branches of the common peroneal (fibular) nerve. Comes btw. Fibularis longus muscle and neck of fibula. Accompanies the anterior tibial artery along the leg. Lesion to it: inability to dorsiflex (footdrop)

Artery: Anterior tibial artery supplies anterior structures. It is the smaller terminal branch of the popliteal artery. Pierces interosseous membrane to go anteriorly. It becomes the dorsal artery of the foot at the ankle.

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Lateral compartment Smallest compartment, has the evertors. Medially bounded by fibula, anteriorly by anterior intermuscular septum and posteriorly by posterior intermuscular septum. The compartment ends inferiorly at the superior fibular retinaculum. The tendons enter a common synovial sheath passing through the retinaculum. Muscles: Fibularis longus:

Origin: head and sup. 2/3 of lat. fibula Attachment: base of 1st metatarsal and medial cuneiform Innervation: superficial fibular nerve Artery: Function: eversion and weak plantarflexion Fibularis brevis:

Origin: inferior 2/3 of lat. fibula Attachment: dorsal tuberosity on lat. Base of 5th metatarsal Innervation: superficial fibular nerve Artery: Function: eversion and weak plantarflexion Nerves:

Superficial fibular nerve a terminal branch of the common peroneal nerve. After innervating the muscles it continues as a cutaneous nerve. (dorsal digital cutaneous nerve) Blood vessels:

Has no artery, just perforating branches of the anterior tibial artery proximally and perforating branches of the fibular artery inferiorly 10. Bones of the leg. Muscles, blood vessels and nerves of the posterior compartment of the leg.

Femur

head of the femur: project superomedially and slightly anteriorly neck of the femur the angle between the neck and the head is 115-140° lesser trochanter rounded conical greater trochanter intertrochanteric line intertrochanteric crest quadrate tubercle trochanteric fossa body of the femur linea aspera (broad line of the femur medial and lateral lips, or margins gluteal tuberosity spiral line (the medial lip continue in a spiral rough line)

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pectineal line medial and lateral supracondylar lines intercondylar fossa patellar surface lateral epicondyle medial epicondyle adductor tubercle

Tibia

medial and lateral epicondyles superior articular surface tibial plateau intercondylar eminence intercondylar fossa fibial articular surface body of the tibia tibial tuberosity anterior border of the tibia medial malleolus interosseus membrane soleal line inferior articulating surface nutrient foramen

Fibula

head of the fibula facies articularis capitis fibulae apex of the fibula body of the fibula the distal part is rather triangular margo interosseus lateral malleolus facies articularis malleoli

posterior compartment: largest of the 3 compartments. Divided to deep (4) and superficial (3). By transverse intermuscular septum. NB!! The deep compartment is tightly packed between the two leg bones, interosseous membrane and the transverse intermuscular septum, and nerve and blood vessels supplying the posterior compartment and sole of the foot pass through it. So when swelling occurs it leads to a compartment syndrome that can damage foot. Gastrocnemius and soleus = calcaneal tendon and called triceps surae Calcaneal tendon:

Most powerful and tickest tendon in the body. Inserts on the posterior calcaneal tuberosity

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Subcutaneous calcaneal bursa between skin and tendon. Deep bursa of calcaneal tendon between tendon and calcaneus Superficial muscles: Gastrocnemius:

Origin:

Lateral head: lateral condyle of femur Medial head: popliteal surface of femur Attachment: posterior surface of calcaneus via calcaneal tendon Innervation: Tibial nerve Artery: Function: plantarflexion, rais ankle Soleus: has proximally tendinous arch of soleus : popliteal artery and tibial nerve exit popliteal fossa by passing through it.

Origin: post. Head of fibula Attachment: posterior surface of calcaneus via calcaneal tendon Innervation: Tibial nerve Artery: Function: plantarflexion Plantaris: short belly and loooong tendon (fools nerve) absent in 5-10%

Origin: inferior lateral supracondylar line of femur and oblique popliteal ligament Attachment: posterior surface of calcaneus via calcaneal tendon Innervation: Tibial nerve Artery: Function: assist in plantarflexion Deep muscles: Popliteus: acts on knee joint not on ankle and toes like the others. Popliteus bursa: deep to popliteus tendon

Origin: lateral condyle of femur and lateral meniscus Attachment: posterior tibia superior to soleal line Innervation: tibial nerve Artery: Function: weak flexion of knee Flexor hallucis longus:

Origin: inferior 2/3 post. Fibula and inferior interosseous membrane Attachment: base of distal phalanx of hallux Innervation: tibial nerve Artery: Function: flex toe, weak plantarflexion and supports medial longitudinal arches of foot. Flexor digitorum longus:

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Origin: medial post. Tibia inferior to soleal line Attachment: base of distal phalanges Innervation: tibial nerve Artery: Function: flex digits, plantarflexion and support longitudinal arches Tibialis posterior:

Origin: interosseous membrane, post tibia Attachment: navicular tuberosity, cuneiform and cuboid, base of 2, 3, 4th metatarsals Innervation: tibial nerve Artery: Function: plantarflexion and invertion Nerves:

Tibial nerve supplies both deep and superficial is larger of 2 terminal sciatic branches. Divides at ankle to medial and lateral plantar nerves. Medial sural cutaneous nerve also merges with the lateral sural cutaneous nerve (from common peroneal) to form Sural nerve Blood vessels:

Posterior tibial and fibular vessels supply both larger and more direct branch of popliteal artery. Posterior tibial artery gives largest branch the fibular artery.

Most important and largest branch of tibial artery, descends obliquely towards fibula and passes along medial side. Gives perforating branch: pierces interosseous membrane and passes to dorsum of foot and anastomosis with arcuate artery. Runs between tendons of Harry and Dick and divides to medial and lateral plantar arteries.

11. Ankle joint. Medial and lateral malleolar regions.

Tibiofibular joints

proximal and distal tibiofemoral joint

proximal tibiofibular joints

articular surface of the fibula posterolaterally of the tibia

articular capsule

fibrous capsule anterior ligament of the head of the fibula passes superomedially from the anterior aspect of the fibular head to the anterior part of the lateral tibial condyle posterior ligament of the head of the fibula popliteus bursa

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distal tibiofibula joint

syndesmosis

articular surface

interosseus ligament

Ankle joint

hinge type of joint (talocrural articulation)

articular surface of the ankle joint

distal ends of the fibula and tibia and the pulley shaped trochlea of the talus the medial surface of the lateral malleolus articulates with the lateral surface of the talus the tibia articulate two places: inferior surface forms the roof of the mortise, the medial malleolus articulates with the medial surface of the talus

Articular capsule of the ankle joint

fibrous capsle: thin anteriorly and posteriorly but supported each side by strong ligaments

Ligaments of the ankle joint

lateral ligaments

anterior talofibular ligament: from the lateral malleolus to the neck of the talus posterior talofibular ligament: runs horizontally medially and slightly posteriorly from the malleolar fossa to the lateral tubercle of the talus calcaneofibular ligament passes posteriorly from the tip of the lateral malleolus to the lateral surface of the calcaneus

medial ligament deltoid ligament (from the malleolus to the talus, calcaneus and navicular)

tibionavicular ligament anterior and posterior tibiotalar ligament tibiocalcaneal ligament

Movement of the ankle joint

dorsiflexion (muscles in ant.compartment of leg, limited by triceps surae) plantarflexion (muscles in post.compartment of leg)

Blood supply of the ankle

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the malleolar branches of the fibular and anterior and posterior tibial arteries

Nerve supply

tibial nerve deep fibular nerve division of common fibular nerve

Lateral ankle (regio malleolaris lateralis)

Borders

line above 1 cm to the lateral malleolus lateral part of the sole anteriorly the side of the fibula until the apex of the malleolus lateralis and to the V metatarsal tuberosity posteriorly the midline

Vein

smaller saphenous vein rete malleolare laterale

Nerve

surralis nerve nervus cutaneus dorsalis pedis

Muscle

the tendon of the fibularis longus and brevis abductor digiti minimi tendon of the Achilles (corpus adiposum subachilleum) bursa tendinis calcanei

Osteofibrous canal

lateral malleolus talus calcaneus retinaculum extensorum peroneum

retinaculum peroneus superius retinaculum peroneus inferius

Artery

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malleolaris posterior lateralis rr. calcanei laterales terminal branch of the arteria fibularis

Lateralis parittya sling

peroneus brevis peroneus tercius arcus plantarisokat tartja

Medial ankle

greater saphenus vein saphenus nerve posteriorly tibialis posterior flexor digitorum longus posterior tibial artery tibial nerve flexor hallucis longus retinaculum flexorum

Medial Ankle

Border

horizontal line in the middle of the medial malleolus midline of the heel anteriorly line from the caput tali until the sole of the foot

Nerve

saphenous nerve smaller saphenous vein

Retinaculum musculorum flexorum

tibial nerve posterior tibial artery

Septums of the retinaculum

Tom, Dick and Harry

Medial sling

tibialis posterior tibialis anterior

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Stirrup or stapes

peroneus longus tibialis anterior

12. Bones, joints and ligaments of the foot. Arches of the foot.

Bones of the foot

7 tarsal bones, 5 metatarsal bones, 14 metatarsal bones

Tarsus

calcaneus (heel bone) longer the talus largest and strongest bone anteriorly articulate with the cuboid, superiorly the talus sustentaculum tali: project from the superior border of the medial surface( facies articularis talaris media fibular trochlea: lateral oblique ridge calcaneal tuberosity: posterior prominence tuber calcanei: attachment of the achilles tendon letaral, medial, anterior tubercles facies articularis talaris posterior sulcus calcanei sinus tarsi facies articularis talaris anterior facies articularis cuboidea sulcus tendinis musculi flexoris hallucis longi

talus

it has a body tail and neck articulate with the fibula, calcaneus, and navicular bone it has no muscular and tendineous attachment trochlea tali convex cartilaginous surface, it is wider anteriorly, the middle a little depressed talar head rest in the sustentaculum tali on the body groove of the talus facies articulareis calcanea posterior facies articulareis calcanea media facies articulareis calcanea anterior processus lateralis tali processus posterior tali sulcus tendinis musculi flexoris hallucis longi lateral tubercle, medial tubercle

navicular (little ship)

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it is between the talar head and the three cuneiforms anteriorly navicular tuberosity: projection from the medial surface

cuboid

cubical shape the most lateral bone in the distal row of the tarsus tuberosity of the cuboid groove on the lateral and inferior surface: sulcus tendinis musculi peronei longi

cuneiform bones

medial cuneiform is the largest similar to a half moon the intermediate cuneiform is the smallest lateral cuneiform articulate with the cuboid the others with the navicular bone

Metatarsus

the first metatarsal is shorter the 2nd is the longest bases articulate with the cuneiform and cuboid bones the 5th metatarsal has a large tuberosity on the plantar surface of the 1st medial and lateral semasoid bones

Phalanges

1st digit is the greater two phalanges Body proximal distal end Three phalanges

Foot joints

Transverse tarsal joint

formed by the talonavicular part of the talocalcaneonavicular and calcaneocuboid joints surgical amputation of the foot

subtalar joint

the place where the talus rests on the calcaneus the fibrous capsule is supported by medial, lateral, posterior, and interosseus talocalcaneal ligaments

Ligaments of the foot

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plantar calcaneonavicular ligament : extends from the sustentaculum tali to the posteriorinferior surface of the navicular, maintain the longitudinal arch of the foot long plantar ligament: passes through the plantar surface of the calcaneus to the groove on the cuboid and form the longitudinal arch of the foot plantar calcaneocuboid ligament: deep to the long plantar ligament, anterior surface of the calcaneus to the inferior surface of the cuboid ligamentum bifurcatum: the calcaneocuboideum and the dorsal navicular ligament

Movement

Eversio Inversion

Arches of the foot

the tarsal and metatarsal bones are arranged in longitudinal and transverse arches that add to the weightbearing capabilities of the foot

Longitudinal arch of the foot

medial longitudinal arch: higher than the lateral, composed of the calcaneus, talus, navicular and the 3 cuneiforms, and 3 metatarsals, the tibialis anterior attach to the 1st metatarsal and medial cuneiform, helps strengthening the medial longitudinal arches lateral longitudinal arches: much flatter than the medial. Composed of calcaneus, cuboid, lateral 2 metatarsal

Transverse arch of the foot

it is formed by the cuboid, cuneiforms, and the bases of the metatarsals the tendon of the fibularis longus cross the sole oblique and maintain the curvature of the transverse arch

Amputation lines

Lissfranck line: the line of the metatarsotasal joint Chopart line S shaped line (talus calcaneus and cuboideum and naviculare)

13. Muscles, blood vessels and nerves of the sole (plantar region).

Plantar region

Fascia

plantar aponeurosis it arises posteriorly from the calcaneus and divides into 5 branch medial and lateral plantar fascia vertical septa of the aponeurosis extend deeply from 3 compartments

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- medial compartment(abductor hallucis, flexor hallucis brevis, medial plantar nerve and vessels)

- central compartment( flexor digitorum brevis and longus, quadratus plantae, lumbricals, proximal part of the tendon of the flexor hallucis longus, and the lateral plantar nerve and vessels)

- lateral compartment( abductor and flexor digiti minimi

Muscles

1st layer of plantar muscles

abductor hallucis flexor digitorum brevis abductor digiti minimi

2nd layer of plantar muscles

quadratus plantae tendons of the flexor hallucis longus and flexor digitorum longus lumbricals

3rd layer of plantar muscles

flexor hallucis brevis adductor hallucis flexor digiti minimi brevis

4th layer of the plantar muscles

3 plantar interossei 4 dorsal interossei Plantar interossei adduct Dorsal interossei abduct

Nerves of the foot

Tibial nerve divides posterior to the medial malleolus into the medial and lateral plantar nerve

Cutaneous nerve supply

Saphenous nerve

branch of the femoral nerve passes anterior to the medial malleolus to the dorsum of the foot

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Sural nerve

formed by the tibial and fibular branches enters the foot posterior to the lateral malleolus

superficial and deep fibular nerve

Medial plantar nerve

passes deep to the abductor hallucis runs anteriorly flexor digitorum brevis on the lateral side of the medial plantar artery

Lateral plantar nerve

begins deep to the flexor retinaculum and abductor hallucis runs medial to the lateral plantar artery

Artery

medial plantar artery lateral plantar artery

- form the deep plantar arch

- plantar metatarsal arteries

- perforating arteries

- plantar digital arteries

14. Muscles, blood vessels and nerves of the dorsum of the foot.

Dorsum of the foot

Borders

the line beween the 2 ankle proximally bases of the phalange distally meidally ankle to the head of the talus and than to the medial side of the sole laterally from the ankle to the tuberosity of the V.th metatarsal

Deep fascia of the foot

superior extensor retinaculum inferior extensor retinaculum 4 septums

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- tendon of the tibialis anterior

- n fibularis profundus, a. v. dorsalis pedis

- tendon of the extensor hallucis longus

- tendon of the extensor digitorum longus

it continous with the plantar fascia the thick of this fascia forms the plantar aponeurosis

Deep muscles

extensor hallucis brevis extensor digitorum brevis

Veins

arcus venosus dorsalis pedis saphena parva, magna

Nerves

superficial and deep fibular nerve, supply between the 2 ankle (nervus dorsalis pedis) medial cutaneous nerve pedis, intermedial cutaneous nerve pedis, deep cutaneous nerve pedis, nervus cutaneus dorsalis (skin next to the little finger)

Atery

arteria tibialis anterior – arteria dorsalis pedis deep plantar artery (between the two tendon of the hallucis longus and digitorum longus) plantar arch malleolaris anterior medialis and lateralis from the arteria dorsalis pedis a tarsae laterals mediales arteria arcuata: arises the base of the II metatarsus deep to the tendons of the brevis extensors anastomise with the lateral tarsal artery

15. Blood and lymphatic vessels, and cutaneous innervation of the lower limb.

Superficial fascia

Deep fascia

fascia lata

- it attaches superiorly to the inguinal ligament, pubic arch, body of the pubis, pubic tubercle

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- laterally and posteriorly to the iliac crest

- posteriorly to the sacrum, coccyx, sacrotuberous ligament, ischial tuberosity

- distally it attaches around the knee and continuous in the crural fascia

- the longitudinal tract forms the iliotribial tract

- tensor of fascia lata, broad band of fibers form an aponeurosis

crural fascia lateral intermuscular septum

Openings of the fascia

saphenous opening

- inferior to the medial part of the inguinal ligament

- 4 cm inferolaterally to the pubic tubercle

- it is 3,75 cm length

- 2,5 cm breadth

- the great saphenous vein passes through

- inguinal lymph nodes

Crural fascia

attach medially to the medial part of the tibia it is very thick in the proximal part of the anterior aspect of the leg extensor retinacula

Veins of the lower limb

Great saphenous vein

formed by the dorsal venosus arch of the foot it ascends anterior to the medial malleolus passes posterior to the medial condyle of the femur anastomoses with the small saphenus vein emties to the femoral vein valves in the vein 10-12 lateral and anterior cutaneous veins

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Small saphenous veins

lateral side of the foot from the union of the dorsal of the small toe with the dorsal venous arch ascend posterior to the lateral malleolus as a continuation of the lateral marginal vein passes along the lateral border of the calcaneal tendon penetrates the deep fascia midleine of the fibula ascends between the head of the gastrocnemius muscle empties to the popliteal muscle

Lymphatic nodes

superficial lymph nodes external iliac lymph nodes deep inguinal lymph nodes popliteal lymph nodes

Cutaneous innervation of the lower limb

iliohypogastric nerve divides into lateral and anterior cutaneous branches ilioinguinal nerve supply the scrotum and the labium majus genitofemoral nerve inferior to the middle part of the inguinal ligament lateral femoral cutaneous nerve, direct branch of the lumbal plexus, the anterior branches become superficial from 10 cm to the inguinal ligament supply the skin lateral and anteriorly the porsterior branch supply the skin from the greater trochanter to the middle area until the knee femoral nerve: 2nd, 3rd, 4th lumbal nerve some branches to the medial and anterior region anterior femoral cutaneous nerves: from the femoral nerve, arise in the femoral triangle, pierce the fascia lata along the sartorius muscle, supply medial and anterior obturator nerve: passes the medial side of the knee communicates with the saphenous nerve, anterior medial, posterior, surface proximally posterior femoral cutaneous nerve, plexus of the sacral plexus posteriorly, over the popliteal fossa sciatic nerve, from the sacral plexus passes through the greater sciatic foramen into the inferior gluteal region posteriorly, apex of the popliteal fossa, divides into 2 parts, common fibular and tibial nerves Nervus clunium medii, superioris, inferiors

saphenous nerve anterior part of the tibia lateral surae cutaneous nerve lateral to the tibia medial surae cutaneous nerve medial to the tibia sural nerve

nervus cutaneus dorsalis pedis lateralis, the lateral part of the foot until the hallux branches of the superficial fibular nerve: nervus cutaneus dorsalis pedis intermedius, medialis the 2nd and the 3rd digit surface facing each other n. peroneus profundus under the medial ankle n cutaneous surae medialis the plantar surface with 7 side of the digits n. plantaris medialis lateral side and 3 side of digits n. plantaris lateralis

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Arteries

femoral artery descend through the femoral triangle, transverse the adductor canal, and become popliteal artery anterior tibial artery poaterior tibial artery lateral and medial plantar artery

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