Download Muscles, osteofascial compartments, vessels, and nerves of the

Muscles, osteofascial
compartments,
vessels, and nerves of
the lower limb
Institute of Anatomy, First Faculty of
Medicine
Paul Mozdziak
Visiting Professor
Muscle is Important
Regional Anatomy
Surface Anatomy
General Structure of Muscle-Review
Overview of muscle groups
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Muscles of the hip joint (3 groups)
Thigh muscles (3 groups)
Muscles of the leg (3 groups)
Muscles of the foot (2 groups)
Muscles of the hip joint (musculi coxae)
• Anterior group (flexors)
• Posterior group:
- gluteal (superficial)
- pelvitrochanteric (deep)
Muscles of the hip joint (musculi coxae)
• Anterior group muscles:
-iliacus
-psoas major
-(psoas minor)
• Function: flexors
• Innervation: lumbar plexus (Th12 - L4)
Muscles of the hip joint (musculi coxae)
• Posterior group muscles – gluteal group
- gluteus maximus
- gluteus medius-abduction
- gluteus minimus-abduction
- tensor fasciae latae
• Function: abductors, extensors, rotators
• Innervation: sacral plexus (L4 - S2), directly or
via gluteal nerves
SR
IP
OI
G
N
G
D
GX
P
Muscles of the hip joint (musculi coxae)
• Posterior group muscles - deep (aka.
pelvitrochanteric) muscles
- piriformis
- mm. gemelli (superior and inferior)
- obturator internus (tendon - landmark)
- quadratus femoris
• Function (aka): small lateral rotators
• Innervation: sacral plexus (L4 - S2)
Thigh muscles (musculi femoris)
• Ventral (anterior) group (quadriceps, sartorius knee extensors)
• Medial group (adductors)
• Posterior (dorsal) group (knee flexors)
Thigh muscles (musculi femoris)
• Ventral (anterior) group
- m. sartorius - tailor’s muscle
- quadriceps femoris (4 heads):
rectus femoris
vastus medialis,
intermedius,
lateralis
• Innervation: femoral nerve (L2 - L4)
Thigh muscles (musculi femoris)
• Medial group muscles (inner thigh):
- pectineus
- gracilis
- adductor longus, brevis, magnus
- obturatorius externus
• Innervation: obturator nerve (L2 - L4); pectineus
and add. magnus bineural
Thigh muscles (musculi femoris)
• Posterior group muscles (hamstring):
- biceps femoris
- semitendinosus
- semimembranosus
• Innervation: sciatic nerve (n. ischiadicus, L4 S2)
Leg muscles (musculi cruris)
• Anterior group (digit and foot extensors and foot
supinators)
• Lateral group (supplemental foot flexors and
pronators)
• Dorsal (calf) group (foot and digit flexors)
• Tough fascial compartments - compartment
syndrome!
Leg muscles (musculi cruris)
• Anterior group
- tibialis anterior
- extensor hallucis longus
- extensor digitorum longus
• Innervation: deep peroneal nerve (n. peronaeus
profundus, L4 - S1)
Leg muscles (musculi cruris)
• Lateral group
- peronaeus longus
- peronaeus brevis
• Inervation: n. peronaeus superficialis (L5 - S1)
Leg muscles (musculi cruris)
• Posterior group
- superficial layer:
- triceps surae,
- plantaris
– deep layer:
- popliteus
- tibialis posterior
- flexor digitorum longus
- flexor hallucis longus
• Innervation: n. tibialis (L4 - S2)
Tight heel cord
• Clinically important that gastrocnemius crosses
the knee joint
• Soleus does not cross the knee joint
• Can be used to determine the cause of a tight
knee cord
• Silfverskiöld test
– Ankle Joint
– Flex Knee Relaxes Gastrocnemius
– If more dorsiflexion of ankle is possible with knee
flexed, cause of tightness is gastrocnemius
– If no change in dorsiflexion regardless of position of
knee, soleus is responsible
Silfverskiöld test
Foot muscles (musculi pedis)
• Plantar muscles:
- muscles of the big toe (medial compartment)
- muscles of the little toe (lateral compartment)
- central compartment
- mm. interossei
Inervation: n. plantaris medialis et lateralis via
n. tibialis (S1-S2)
• Muscles of the dorsum of the foot (extensors)
- ext. digitorum brevis and ext. hallucis brevis
Inervation: n. peronaeus profundus (L4-S1)
Foot muscles (musculi pedis)
- medial (big toe) compartment • M. abductor hallucis
• M. flexor hallucis brevis
• M. adductor hallucis
Foot muscles (musculi pedis)
- lateral (little toe) compartment • M. abductor digiti minimi
• M. flexor digiti minimi brevis
• M. opponens digiti minimi
Foot muscles (musculi pedis)
- central compartment • M. flexor digitorum brevis
• Mm. lumbricales
• M. quadratus plantae
Foot muscles (musculi pedis)
- musculi interossei • Mm. interossei plantares (3 ; 3., 4., 5. toe)
• Mm. interossei dorsales (4; axis = 2. toe)
• M. quadratus plantae
Plantar
Dorsal
Foot Arch
Factors
Affecting
The
Arches
Supporting Foot Arch
• Foot arch Medial is supported by ligaments
– Staples
• Short Plantar
• Long Plantar
• Spring Ligament
Muscles Supporting the Medial Foot Arch
• Longitudinal muscles (“tie beam”):
- flexor digitorum longus-Medial portion
- flexor hallucis longus
- abductor and flexor hallucis brevis
Muscles Supporting the Medial Foot Arch
• Tibialis Anterior
• Tibialis Posterior
Lateral Longitudinal
• Tie Beams
– Abductor Digiti minimmi, Flexor Digitii minimmi
– Lateral portion of Flexor Digitorum
• Sling
– Tendon of Peroneus Brevis
– Peroneus longus—long course, underneath foot.
Transverse Arch
• Tie Beams
– Tendon of Peroneus longus
– Tendon of Tibialis posterior
• Sling
– Tibialis anterior medially
– Peroneus brevis and tertius laterally
• Factors that maintain the longitudinal arches
also maintain the transverse arch
Coming up next time:
Vessels and nerves of the lower
limb
Lower limb vessels
• Arteries - femoral artery and its branches
• Veins:
- deep system (accompanies arteries)
• Popliteal and femoral
– superficial system - great and small saphenous vv. varices, by-pass grafts
• Lymphatic vessels
• Embryology-Time Permitting
Femoral Artery
• Femoral artery is the
continuation of the
external iliac artery:
– Begins deep to the inguinal
ligament.
– Enclosed within the femoral
sheath
• transversalis fascia anteriorly
and the iliac fascia posteriorly;
Femoral Artery
• Superficial epigastric
artery:
• Passes through or close to the
saphenous hiatus.
• Crosses inguinal ligament
toward the umbilicus.
• Anastomoses with inferior
epigastric artery.
Femoral Artery
• Superficial circumflex iliac
artery:
– Passes through or close to
the saphenous hiatus.
– Passes along inguinal
ligament toward the ASIS.
– Anastomoses with deep
circumflex iliac artery.
Femoral Artery
• External pudendal
artery:
– Passes through or
close to the saphenous
hiatus.
– Passes medially
toward external
genitalia.
Deep Femoral Artery
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Medial femoral circumflex.
Lateral femoral circumflex.
Perforating arteries (3).
Descending genicular.
Deep Femoral Artery
– Arises from deep
side of femoral
artery within femoral
triangle.
– Largest branch.
– Passes posterior to
adductor longus
muscle.
– Medial and lateral
– Perforating arteries.
Medial femoral circumflex
– Leaves femoral triangle between the
iliopsoas and pectineus muscles.
– Ascending branch anastomoses with
inferior gluteal artery.
– Transverse branch anastomoses with
lateral femoral circumflex artery.
– Supplies hip joint, muscles of upper
thigh, gluteal region.
Lateral femoral circumflex
– Ascending branch
anastomoses with
superior gluteal artery.
– Transverse branch
anastomoses with medial
femoral circumflex artery.
– Descending branch
anastomoses with genicular
arteries.
– Supplies hip joint, muscles
of upper thigh, gluteal
region.
Descending genicular
• Arises in adductor canal.
• Musculoarticular branch:
– Part of genicular anastomosis.
• Saphenous branch:
– Runs with saphenous nerve.
Femoral angiography
• Profunda femoris + rami
perforantes I-III
• Circumflexa femoris medialis
et lateralis
Blood supply to the
posterior thigh
muscles
• Deep Femoral +
perforating arteries
• A. poplitea and
anastomoses around the
knee joint
• Topography in the
popliteal fossa:
AVeN!
(from deep to superficial)
Popliteal Artery
• Continuation of femoral
artery.
• Begins at adductor
hiatus.
• Ends at inferior border of
popliteus muscle:
– Branches into anterior and
posterior tibial arteries.
• Most anterior structure in
popliteal fossa.
• A. poplitea and
anastomoses around
the knee
• A. tibialis anterior
• A. tibialis posterior
et a. fibularis
Posterior Tibial Artery
• Terminal branch of popliteal
artery.
• Begins at inferior border of
popliteus muscle.
• Accompanied by tibial
nerve.
• Descends on posterior
surface of tibialis posterior
muscle.
• Medial plantar artery.
• Lateral plantar artery.
Arteries of the foot plantar view
• posterior tibial artery
passes behind the
medial malleolus
• arterial arch
analogous to palmar
• individual variations
• lower limb ischemia
in diabetes:
gangrene
=>amputation
Anterior Tibial Artery
• Terminal branch of popliteal
artery:
– Inferior border of popliteus
muscle.
• Accompanied by deep
peroneal (fibular) nerve.
• Anterior compartment of
leg.
• Branches:
– Anterior tibial recurrent
– Lateral malleolar artery.
– Medial malleolar artery.
Arteries of the foot dorsal view
• A. dorsalis pedis
• palpable between
the tendons
• m. extensor
hallus longus
• extensor
digitorum longus
Veins of the lower limb
• Deep system (follows the
arteries).
• Superficial network great and
small saphenous vein
– varices (in valvar insufficiency)
– potentially redundant => material for
by-pass (of clogged coronary
arteries)
– deep venous thrombosis => lung
embolism
Femoral vein and its
tributaries
Great saphenous vein
Relationship of structures
in Femoral Triangle
under the inguinal
ligament:
(Clo)VAN
significance:
catheterization of
femoral artery and vein
Lymphatic drainage of the lower limb
• Follows the course of veins
– Superficial
– Medial vessels
• Great saphenous vein.
– Lateral Vessels
• Small saphenous vein
• Popliteal nodes
– Deep
• Fewer than superficial counterparts.
• 3 main groups:
– Anterior tibial, posterior tibial and peroneal.
» Entering the popliteal lymph nodes.
Lymphatic vessels of the lower limb
• Superficial Inguinal Nodes
– Below the inguinal ligament
– Receive lymph from the penis, scrotum,
perineum, buttock and abdominal wall.
• Superficial Sub-Inguinal Nodes
– Proximal section of the great saphenous
vein.
• Deep Sub-Inguinal Nodes
– Medial aspect of the femoral vein
• Knowledge of the lymphatic system is
necessary to understand tumor
spreading.
Nerves of the lower limb
• Thigh:
- Anterior group – Femoral nerve (L2-L4)
- Adductors – Obturator nerve (L2-L4)
- Posterior group - sciatic (L4-S2)
Nerves of the thigh
Nerves of the lower limb
• Leg:
- anterior group – Deep peroneal nerve.
- lateral group – Superficial peroneal nerve
- posterior group – Tibial nerve.
Nerves of the leg
Nerves of the lower limb
• foot:
- plantar muscles
– n. plantaris medialis
– lateralis
• via n. tibialis
– Extensors
• Deep peroneal nerve
Embryology of the Lower Limb
Embryology Development-Muscles
•
Somites
– L1-L5, S1-S2
– at the limb bud site
•
Sequence of Events (wk5)
– migration – mesoderm from
somites (myotomes)
migrates into the limb bud
forming posterior and
anterior condensations
– condensation – mesoderm
condenses and differentiates
into myoblasts;
condensations split into
recognizable muscles
Bone Development
• Lateral plate mesoderm
(LPM)
– primary ossification centersfemur and tibia
• Rotation takes place as
the limb extends ventrally
– medial 90° rotation on the
longitudinal axis
– Future knee becomes
ventral; extensor muscles
anterior
Vascular Development
• Umbilical a.
– Axis a.
• anterior tibial
• mostly regresses
– Terminal plexus
• (but for deep plantar
arch
• External Iliac a.
– femoral artery
• profunda femoris a.
Innervation of the Limbs
• Lumbosacral Plexus - Ventral Primary Rami
(L2-L5, S1-S3)
• Motor Axon from the Spinal cord innervate limb
tissues
– Local cues guide axons
– Sensory axons use motor axons for guidance
Muscle groups and their nerves
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Dorsal group - extensors:
-dorsal hip joint group (glutei mm. and nn.)
-anterior group of the thigh (femoral n.)
-anterior and lateral group of the leg (peroneal n.)
-dorsum of the foot (deep peroneal n.)
•
Ventral group - flexors:
-posterior group of the thigh (hamstrings, sciatic n.)
-medial group of thigh (adductors, obturator n.)
-calf muscles (tibial nerve)
-muscles of the sole of the foot (branches of tibial n.)
References
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Cihák: Anatomie 1, 3
Netter: Anatomical atlas (CD version)
Sobotta: Atlas of anatomy
Grim M, Druga R et al.: Základy anatomie 5.
Anatomie krajin těla
• Snell’s Clinical Anatomy
• Grey’s Anatomy
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