WINDSOR UNIVERSITY SCHOOL OF MEDICINE

1. DEPARTMENT OF ANATOMY WINDSOR UNIVERSITYSCHOOL OF MEDICINE Lower limb Dr. SREEKANTH THOTA

2. Muscle compartments in the thigh • In the thigh, there are medial (adductor), anterior (extensor), and posterior (flexor) compartments.

3. Anterior Compartment of the Thigh • Muscles: Sartorius, iliacus, psoas, pectineus, and quadriceps femoris • Blood supply: Femoral artery • Nerve supply: Femoral nerve

4. Anterior Thigh Muscles • Anterior thigh muscles are the flexors of the hip and extensors of the knee.

6. SARTORIUS • Origin : A.S.I.S. • Insertion : Upper medial surface of • shaft of tibia • N. supply: Femoral nerve • Action :1.Flexion, abduction and • Lateral rotation of thigh at hip joint. • 2. Flexion leg at knee joint

7. ILIACUS • Origin : Iliac fossa of hip bone • Insertion : Along with psoas into lesser trochanter of femur • N. supply: Femoral nerve • Action :Flexes thigh on trunk • Eg.: Sitting up from lying down

8. PSOAS T12 12345 • Origin : Transverse process, bodies & I.V.D.’S of T12 & L 1-L5 vertebrae • Insertion : Along with Iliacus into lesser trochanter of femur • N. supply: Lumbar plexus • Action : Flexes thigh on trunk • Eg.: Sitting up from lying down

9. PECTINEUS • Origin : Superior ramus of Pubis • Insertion : Upper end of lineaaspera of shaft of femur • N. supply: Femoral nerve • Action :Flexion, adduction of thigh at hip joint

10. QUADRICEPS FEMORIS • Origin : Straight Head: • A.I.I.S • Reflected Head: • Ilium (Above Acetabulum) • Insertion : • Quadriceps tendon in to patella • Via lig.patellae in to tibial tubercle • N. supply: Femoral nerve • Action : Flexion of thigh at hip joint • Extension of Leg at Knee joint RECTUS FEMORIS :

11. Patellar ligament • The patellar ligament  is the central portion of the common tendon of the Quadriceps femoris, which is continued from the patella to the tuberosity of the tibia.

12. VASTUS LATERALIS • Origin : Upper end & shaft of femur • Insertion : Quadriceps tendon in to patella via Lig.patellae in to tubercle of tibia • N. supply: Femoral nerve • Action : Extension of Leg at Knee joint

13. VASTUS MEDIALIS • Origin : Upper end & shaft of femur • Insertion : Quadriceps tendon in to patella Via Lig.patellae in to tubercle of tibia • N. supply: Femoral nerve • Action : Extension of Leg at Knee & Stabilizes Patella

14. VASTUS INTERMEDIUS • Origin : Anterior & lateral surface of shaft of femur • Insertion : Quadriceps tendon in to patella Via Lig.patellae in to tubercle of tibia • N. supply: Femoral nerve • Action : Extension of Leg at Knee joint

15. Summary of Ant compt of thigh Muscle Movements • Anterior compartment • Flexors of hip • Sartorius (also abducts and laterally rotates hip and flexes and medially rotates knee) • Iliopsoas • Pectineus (also adducts hip) • Extensor of knee • Quadriceps femoris • Rectus femoris(also flexes hip) • Vastuslateralis • Vastusintermedius • Vastusmedialis(also stabilizes patella)

16. Patellar tendon reflex • Tapping the patellar ligament with a hammer elicits the patellar tendon reflex (knee jerk) • Tests the L2-L4 nerves • Diminution or absence—result from interruption of innervation of quadriceps .

17. Medial compartment of thigh • Blood supply: Profundafemoris artery and obturator artery. • Nerve supply: Obturator nerve Muscles: Gracilis, adductor longus, adductor brevis, adductor magnus, and obturatorexternus.

19. GRACILIS • Origin : Inferior ramus of Pubis & ramus of Ischium • Insertion :Medial aspect of upper part of shaft of tibia • N. supply: Obturator nerve • Action : Adduction of thigh at hip joint Flexion of Leg at Knee joint

20. ADDUCTOR LONGUS • Origin : Body of Pubis, medial to pubic tubercle • Insertion : Posterior surface of shaft of femur • N. supply: Obturator nerve • Action : Adduction of thigh at hip joint Assists Lateral rotation

21. ADDUCTOR BREVIS • Origin : Inferior ramus of pubis • Insertion : Posterior surface of shaft of femur • N. supply: Obturator nerve • Action : Adduction of thigh at hip joint Assists Lateral rotation

22. ADDUCTOR MAGNUS • Origin : Inferior ramus of pubis Ramus of ischium Ischialtuberosity (HAMSTRING PORTION) • Insertion :Posterior surface of shaft of femur Adductor tubercle of femur (HAMSTRING PORTION) • N. supply: Obturator + Sciatic nerves • Action : Adduction of thigh at hip Assists Lateral rotation & Extension of thigh at hip joint

23. Adductor Hiatus • The adductor hiatus is an opening or gap between the aponeurotic distal attachment of the adductor part of the adductor magnus and the tendinous distal attachment of the hamstring part. • The adductor hiatus transmits the femoral artery and vein from the adductor canal in the thigh to the poplitealfossaposterior to the knee.

24. OBTURATOR EXTERNUS • Origin : Outer surface of Obturator membrane Pubic & Ischial rami • Insertion :Medial surface of greater trochanter • N. supply: Obturator nerve • Action : Lateral rotation of thigh at hip joint

25. Obturator nerve • As the obturator nerve enters the thigh, it divides into two branches, an anterior branch and a posterior branch, which are separated by the adductor brevis muscle: • Anterior branch: adductor longus, gracilis, and adductor brevismuscles, and often contributes to the supply of the pectineus muscle, and cutaneous branches innervate the skin on the medial side of the thigh. • Posterior branch: obturatorexternusand adductor brevis muscles and the part of adductor magnusthat attaches to the lineaaspera

26. Obturator nerve

27. Obturator nerve

28. Deep artery of thigh (Profundafemoris artery) • Branches :lateral and medial circumflex femoral branches and four perforating branches. • Lateral circumflex femoral artery: 3 branches • 1. Ascending branch • 2. Descending branch • 3. Transverse branch • Medial femoral circumflex artery: It takes part in the formation of the cruciateanastomosis.

30. Obturator Artery • The obturator artery is a branch of the internal iliac artery. • It gives off muscular branches and an articular branch to the hip joint.

31. Gluteal Region • The gluteal region lies posterolateral to the bony pelvis and proximal end of the femur. • Muscles in the region mainly abduct, extend, and laterally rotate the femur relative to the pelvic bone.

32. Ligaments of the Gluteal Region • Sacrotuberous Ligament: sacrotuberous ligament connects the back of the sacrum to the ischialtuberosity • Sacrospinous Ligament: sacrospinous ligament connects the back of the sacrum to the spine of the ischium.

34. Foramina of the Gluteal Region • Greater Sciatic Foramen:The greater sciatic foramen is formed by the greater sciatic notch of the hip bone and the sacrotuberous and sacrospinous ligaments. • It provides an exit from the pelvis into the gluteal region.

35. Lesser Sciatic Foramen: • Formed by the lesser sciatic notch of the hip bone and the sacrotuberous and sacrospinous ligaments. • It provides an entrance into the perineum from the gluteal region.

36. Nerves of the Gluteal Region • Sacral Plexus: • The sacral plexus lies on the posterior pelvic wall in front of the piriformis muscle . • It is formed from the anterior ramiof the lumbar nerves and the anterior ramiof the sacral nerves.

37. Posterior wall of the pelvis

38. Branches • Branches to the lower limb that leave the pelvis through the greater sciatic foramen . • 1. Sciatic (L4, L5, S1, S2, S3): Articular branches to hip joint and muscular branches. • It is the largest nerve in the body and consists of the tibial and common peroneal nerves bound together with fascia. • Innervates all muscles in the posterior compartment of the thigh that flex the knee and all muscles that work the ankle and foot. llmusclein leg and foot

40. 2. Superior gluteal (L4, L5, S1) : Gluteus medius and gluteus minimus muscles • 3. Inferior gluteal (L5, S1, S2): Gluteus maximus

41. 4. Nerve to obturatorinternus( L5, S1, S2) : Obturatorinternus and superior gemellus muscles • 5. Nerve to quadratusfemoris(L4, L5, S1) : Quadratusfemoris and inferior gemellus muscles • 6. Posterior cutaneous nerve of the thigh(S2, S3) : Cutaneous branches to buttock and uppermost medial and posterior surfaces of thigh.

42. Branches to the pelvic muscles, pelvic viscera, and perineum: • 1. Pudendal (S2, S3, S4) : Structures in perineum: sensory to genitalia; muscular branches to perineal muscles, external urethral sphincter, and external anal sphincter • 2. Nerve to piriformis(S1, S2) : Piriformis muscle

44. Muscles of the Gluteal Region • Muscles of the gluteal region are mainly in two groups: • Superficial group of larger muscles: Gluteus minimus, gluteus medius, and gluteus maximus-and tensor fasciae latae. 2. Deep group of small muscles: Piriformis, obturatorinternus, gemellus superior, gemellus inferior, and quadratusfemoris.

45. Muscles of GlutealRegion (Superficial group) • Extensor of hip • Gluteus maximus (also helps in lateral rotation) • Abductors of hip (help in Medial rotation) • Gluteus medius • Gluteus minimus • Tensor Fascia lata (also stabilizes knee in extension) • Function of all 3 • Contract to prevent sagging of unsupported side of hip during locomotion, enabling opposite foot to swing through (e.g., Trendelenburg test)

47. Gluteus maximus • Origin: Outer surface of ilium, sacrum, coccyx, sacrotuberous ligament Insertion :Iliotibial tract and glutealtuberosity of femur • N. supply:Inferiorgluteal nerve • Action :Extends and laterally rotates hip joint

48. Gluteus medius • Origin : Outer surface of ilium Insertion :Lateral surface of greater trochanter of femur • N. supply: Superior gluteal nerve • Action :Abducts thigh at hip joint; tilts pelvis when walking to permit opposite leg to clear ground

49. Gluteus minimus • Origin : Outer surface of ilium Insertion :Anterior surface of greater trochanter of femur • N. supply: Superior gluteal nerve • Action :Abducts thigh at hip joint; tilts pelvis when walking to permit opposite leg to clear ground

50. Positive Trendelenburg's sign • If right gluteus medius and minimus muscles are paralyzed, the unsupported left side of the pelvis falls (sags) instead of rising; normally, the pelvis rises.