Anatomy 1

HIP (551 and 572)

Neurovascular structures and relationships in anteromedial thigh

Femoral triangle:

1. You can see it when hip is flexed, lateraly rotated and abducted.
2. Formed by inguinal lig. + adductor longus + sartorius
3. Medially : pectineus, laterally: iliopsoas.

Deep to inguinal lig.  retro- inguinal space.

RETRO- INGUINAL SPACE DIVIDED BY ILIOPSOAS FASCIA (ILIOPECTINEAL ARCH)

2 DIVISIONS: muscular (iliopsoas and femoral nerve) and vascular (all veins arteries – name changes – from external iliac to
femoral )

Adductor canal is an intermuscular

passageway deep to the sartorius
by which the major neurovascular
bundle of the thigh traverses the
middle third of the thigh.

FEMORAL NERVE – in lumbar

plexus (L2-L4) branches to hip and
knee joint.

BRANCHES: SAPHONEUS NERVE

(supply the skin and fascia on the
anteromedial aspects of the knee,
leg, and foot)

FEMORAL SHEATH – lines the

vascular compartment of retro-
inguinal space. Created by
transversalis and iliopsoas fascia.
Femoral sheath allows femoral
artery and vein to glide during hip
movements.

Femoral sheath is divivded:

1. Lateral compartment for the femoral artery.

2. Intermediate compartment for the femoral vein.
3. Medial compartment, which is the femoral canal.

FEMORAL ARTERY: biggest artery of leg.

a. PROFUNDA FEMORIS ARTERY – largest branch. Arises from the lateral or posterior side of the femoral artery. Gives
off 3 -4 perforating arteries that supply adductor magnus, hamstrings, and vastus lateralis.

CIRCUMFLEX FEMORAL ARTERIES:

a. MEDIAL CIRCUMFLEX FEMORAL ARTERY supplies femur head and nech via posterior retinacular arteries.
b. LATERAL CIRCUMFLEX ARTERY supplies muscles of lateral thigh.

OBTURATOR: obturator artery helps the profunda femoris artery supply the adductor muscles via anterior and posterior
branches, which anastomose.
FEMORAL VEIN: continuation of popliteal vein.
Becomes external iliac vein. In the inferior part
of the femoral triangle, the femoral vein
receives the profunda femoris vein, the great
saphenous vein, and other tributaries

ADDUCTOR CANAL: It extends from the apex of

the femoral triangle, where the sartorius
crosses over the adductor longus, to the
adductor hiatus in the tendon of the adductor
magnus.

The adductor canal provides an intermuscular

passage for the femoral artery and vein, the
saphenous nerve, and the slightly larger nerve
to vastus medialis, delivering the femoral
vessels to the popliteal fossa where they
become popliteal vessels.

The adductor canal is bounded

• Anteriorly and laterally by the vastus

medialis.

• Posteriorly by the adductors longus and

magnus.

• Medially by the sartorius, which overlies the

groove between the above muscles, forming
the roof of the canal.

Neurovascular structures of gluteal and posterior thigh regions

Sacral plexus nerves supply gluteal region, perineal region and thigh.
Clunial – skin, most vulnearble.

All other nerves exept clunial are DEEP GLUTEAL NERVES.

Sciatic (tibial nerve + common fibular nerve) – runs between greater trochanter and ischial tuberosity.

Supplies most skin of leg and foot and articular branches of joints.

Superior gluteal – superior branch – gluteus medius. – inferior branch – gluteus medius, gluteus minimus, tensor fascia
latae.

Arteries:

Arteries of gluteal region arises from internal iliac arteries.

Posterior thigh doesnt get blood from one artery it gets from : inferior gluteal artery, medial circumflex femoral artery,
perforating and popliteal arteries.

Superior gluteal – largest, passses posteriorly between lumbosacral trunk and S1.

Inferior gluteal – passes posteriorly through parietal pelvic fascia between S1 and S2.

Perforating – 4 arteries.

Veins:

Superior and inferior gluteal - provide alternative routes for blood if there is problem with femoral vein. Communicate with
tributaries of femoral artery.

Internal pudendal – takes blood from external genitalia and pudendum

Perforating – takes blood from perforating arteries. Drain blood to the deep vein of the thigh.

Lymph:

FROM DEEP TISSUES:

Follows gluteal vessels to superior and

inferior gluteal lymph nodes and then to
internal, external and common iliac
lymph nodes and then to lateral lumbar
lymph nodes.

superior and inferior gluteal lymph

nodes  internal, external and common
iliac lymph nodes  lateral lumbar
lymph nodes

FROM SUPERFICIAL TISSUES:

Enters superficial inguinal lymph nodes

 external iliac lymph nodes.

Hip joint (626)

Acetabular labrum – fibrocartilage, increasing acetabular area by 10 %.

Accetabular fossa - non articular, formed mainly by ischium.

Head of femur and acetabulum are most congruent when hipi s 90 deg in flexion 5 deg abduction and 10 deg lat. Rot.

CAPSULE:

Fibrous (loose) layer and synovial membrane. Fibrous layer attached to the acetabulum next to the rim and to neck of
femur anteriorly at the interthrochanteric line and root of greater trochanter. On posterior side it crosses intertrochanteric
crest but NOT attached to it!

Some fibers make orbicular zone.

Flexion unwinds ligaments and extension restricts them.

Iliofemoral ligament: anteriorly and superiorly. Attaches to AIIS and rim and intertrochanteric line. Prevents
hyperextention.

Pubofemoral ligament: anteriorly and inferiorly. Attaches to obturator crest of pubic bone and to the fibrous layer of
capsule. Binds with medial part of iliofemoral ligament. Tightens during extension and abduction. Prevents hyper
abduction.

Ischiofemoral ligament: weakest. Attaches to ischial part of acetabular rim and to

femoral neck medial to base of greater trochanter.

Medial and lateral rotators are important to maintaining structural integrity of the joint.

Retinacula – synovial folds. Retinacular arteries (branches of circumflex a.) course within
synovial folds.

Fat pad in acetabular fossa fills the space that not occupied with hip ligament.

Hip ligament attaches to margins of acetabular notch and to fovea.

Obturator internus covers part of joint thats not covered with ligaments.

Pain perceived as coming from the hip joint may be misleading because pain can be referred from the vertebral column.

Joint innervated according Hilton‘s law.

Flexors innervated by the femoral nerve pass anterior to the hip joint; the anterior aspect of the hip joint is innervated by
the femoral nerve.

Lateral rotators and extensors pass inferior and posterior to the hip
joint; the inferior aspect of the joint is innervated by the obturator
nerve, and the posterior aspect is innervated by the nerve to the
quadratus femoris.

Abductors innervated by the superior gluteal nerve pass superior to

the hip joint; the superior aspect of the joint is innervated by the
superior gluteal nerve.

Knee joint (634)

Knee joint is hinge type synovial

joint. The joint has 3 articulations.
2 femorotibial and 1
femoropatelar.

There is fibrous layer opening in

the posterior part of capsule to
allow popliteus pass joint capsule
to attach tibia.

Quadriceps tendon, patella and

patellar ligament replaces capsule
anteriorly.

Synovial membrane lines cruciate ligaments and infrapatellar fat pad, so

they are excluded from the capsule.

LIGAMENTS

Patellar ligament: anteriorly, receives patellar retinacula from lateral and

medial sides. Patellar retinacula – extensions of vastus medialis and
vastus lateralis and overlying deep fascia.

Q-angle gives patella lateral displacement.

Collateral ligaments: taut when extending knee. Thats why rotation is

only allowed when knee is flexed.

FCL – splits biceps femoris into 2 parts. Popliteus passes under it and
separates FCL from meniscus. Extracapsular.

TCL - intracapsular (intrinsic). Weaker than FCL. Connected with medial

meniscus.
Oblique popliteal ligament : from medial inferior to lateral superior. Continuation of semimembranosus tendon. Reinforces
capsule posteriorly.

Arcuate popliteal ligament : from lateral inferior to medial superior.

Cruciate ligaments: unwind during lateral rotation, so 60 deg of lateral rotation is posible whereas only 10 deg of medial
rotation is possible. They are intracapsular but extrasynovial.

ACL – weaker. From anterior inferior medial to posterior superior and lateral. Prevents femur roling posteriorly on tibial
plateu during extention, converting it to spin.

PCL – from posterior inferior medial to anterior superior lateral. Prevents anterior rolling of femur on tibia and prevents
hyperflexion.

Menisci – fibrocartilage.

Coronary ligaments extend from menisci to tibial condyles.

Transverse ligament – joins anterior edges on menisci.

Medial meniscus is less mobile on tibial plateu.

Popliteus attaches to
LATERAL meniscus.

Posterior
meniscofemoral
ligament joins lateral
meniscus and PCL and
medial femoral
condyle.

Blood supply:

10 vessels that supply

knee joint form
periarticular genicular
anastomoses that
formed from femoral,
popliteal, anterior
and posterior
recurrent branches of
the anterior tibial
recurrent and
circumflex tibial arteries.

Popliteal artery supply ACL ( less supplied than PCL) and PCL, synovial membrane, and peripheral margins of menisci.

Hilton‘s law for innervation apply to knee:

Supply from femoral nerve, tibial nerve and common fibular nerve on anterior, posterior and lateral aspects.

Supply from obturator and saphoneus nerves in medial aspect.

Bursae:

4 bursae that communicate with the synovial cavity: suprapatellar bursa, popliteal bursa, anserine bursa, gastrocnemius
bursa.
Infection in suprapatellar bursa can easily go in knee joint!!

ANTERIOR COMPARTMENT OF THE LEG (587)

4 fascial compartments formed by intermuscular septa, interosseus membrane and 2 leg bones.

Anterior compartment of the leg, or dorsiflexor (extensor) compartment, is located anterior to the interosseous
membrane.

Retinacula bind the tendons of the

anterior compartment muscles before
and after they cross the ankle joint!

1. tibialis anterior – furthest from

axis so giving most mechanical
advantage to dorsiflex.
2. Extensor digitorium longus –
covered by common synovial
sheat.
3. Extensor hallucis longus –
4. Fibularis tertius – covered by
same sheat as EDL, attaches to
metatarsal. Important as
protection of sprained anterior
tibiofibular lig.

Supplied by deep fibular nerve that comes

from common fibular nerve.

Blood from anterior tibial artery

Course :

Femoral a.  Popliteal a.  (near popliteus inferior

border) tibial a. (crosses membrane to anterior) (near
ankle between malleoli ) dorsalis pedis a.
LATERAL COMPARTMENT OF THE LEG (595)

Evertor compartment. Ends inferiorly at superior fibular retinaculum.

Muscles in compartment protect foot from getting inverted since its most vulnerable position of the foot.

1. Fibularis Longus – shares sheat with fibularis brevis that goes to inferior fibular retinaculum. But also croses
superior fibular retinaculum. Inferior to fibular trochlea
2. Fibularis brevis – superior to fibular trochea
Nerve: superficial fibular (branch of common fibular)  cutaneous nerve

Blood: superior : perforating branches of anterior tibial artery; inferior : perforating branches of fibular artery.

POSTERIOR COMPARTMENT OF THE LEG (596)

Deep and superficial compartment divided by transverse intermuscular septum.

The transverse intermuscular septum ends as reinforcing transverse fibers that extend between the tip of the medial
malleolus and the calcaneus to form the flexor retinaculum

Superficial muscles :

1. Gastrocnemius - fusiform, two-headed, two-joint, fast-twitch.

2. Soleus – Proximally has tendinous arch. Popliteal artery and tibial nerve pass through it. Slow twitch, always active
during standing.
3. Plantaris

All innervated by tibial nerve.

1. Popliteus – rotating femur when knee is locked, so flexion can occur. It has a fleshy distal attachment to the tibia
that is covered by investing fascia reinforced by a fibrous expansion from the semimembranosus muscle (investing
fascia of popliteus. During flexion at the knee, it assists in pulling the lateral meniscus of the knee joint posteriorly.
2. flexor digitorum longus – goes under sustentaculum tali. Lumbricals attach to it.
3. flexor hallucis longus -
4. tibialis posterior – main role is to support or maintain (fix) the medial longitudinal arch during weight-bearing.

Nerve : tibial nerve  (posterior to medial maleolis) medial and lateral plantar nerves

Arteries : posterior tibial artery (branch of popliteal artery)  medial and lateral plantar arteries

Posterior tibial artery runs posterior to the medial malleolus, from which it is separated by the tendons of the TP and FDL
(Fig. 5.61B). Inferior to the medial malleolus, it runs between the tendons of the FHL and FDL.

FIBULAR ARTERY BRANCHES FROM TIBIAL ARTERTY

SKIN AND FASCIA OF FOOT (610)

Fibrous septa – divides fat in weight bearing areas of the sole.

Dorsal fascia - continous with inferior extensor retinaculum.

On the lateral and posterior aspects, fascia continues with plantar fascia (middle of it called plantar sponeurosis).

Fibrous digital sheaths!!!

Superficial transverse metatarsal ligament!!!

COMPARTMENTS of sole!

1. medial compartment of the sole is covered superfi cially

by thinner medial plantar fascia. It contains the
abductor hallucis, flexor hallucis brevis, the tendon of
the flexor hallucis longus, and the medial plantar nerve
and vessels.
2. central compartment of the sole is covered superficially
by the dense plantar aponeurosis. It contains the flexor
digitorum brevis, the tendons of the flexor hallucis
longus and flexor digitorum longus, plus the muscles
associated with the latter, the quadratus plantae and
lumbricals, and the adductor hallucis. The lateral
plantar nerve and vessels are also located here.
3. lateral compartment of the sole is covered superficially
by the thinner lateral plantar fascia and contains the
abductor and flexor digiti minimi brevis

MUSCLES OF THE FOOT (611)

Plantar interossei ADduct (PAD) and arise from a single metatarsal as unipennate muscles.

Dorsal interossei ABduct (DAB) and arise from two metatarsals as bipennate muscles.
Deep neurovascular layer between 1 and 2 layers (medial and lateral plantar nerve)

Superficial neurovascular layer between 3 and 4 th layers (branches of med. And lat. Plantar nerves.)
NEUROVASCULAR STRUCTURES AND RELATIONSHIPS IN FOOT (614)
ARTERIES OF THE FOOT

Dorsum:

Dorsalis pedis – direct continuation of anterior tibial artery. Passes inferior to inferior extensor retinaculum. Goes to
interosseous space, divides in 1st dorsal metatarsal artery and a deep plantar artery. Joins lateral plantar artery and forms
deep plantar arch.

Lateral tarsal artery – supply extensor digitorium brevis and tarsal joints (branch of dorsalis pedis artery)

1st dorsal metatarsal artery – supplies 1 toe and medial part of 2 nd toe.

Arcuate artery - goes deep to extensors and splits in 2nd 3rd and 4th dorsal metatarsal arteries

Sole:

Medial plantar artery : smaller branch of posterior tibial artery. Mainly supply big toe.

Lateral plantar artery : bigger branch runs between FDB and quadratus plantae.

Deep plantar arch : union of the lateral plantar artery and the deep plantar artery (aka dorsalis pedis).

VEINS:

Dorsal digital veins  dorsal metatarsal veins (receive branches from plantar digital veins) These veins drain to the dorsal
venous arch of the foot, proximal to which a dorsal venous network covers the remainder of the dorsum of the foot.

Plantar venous network either drain around the medial border of the foot to converge with the medial part of the dorsal
venous arch and network to form a medial marginal vein  great saphenous vein, or drain around the lateral margin to
converge with the lateral part of the dorsal venous arch and network to form the lateral marginal vein small saphenous
vein.

LYMPHATIC DRANAIGE:

Begin in subcutaneous plexuses.

Medial superficial lymphatic drain  converge at great saphenous vein  superficvial inguinal lymph nodes

Lateral superficial lymphatic drain  acompony small saphenous vein  popliteal lymph nodes

Deep lymphatic vessels follow main vessels

TIBIOFIBULAR JOINT (645)

Superior – plane, 2 ligaments strengthen it (from fibular head to tibial condyle)

Blood supply: the inferior lateral genicular and anterior tibial recurrent arteries.

Nerve supply : common fibular nerve and the nerve to the popliteus

Inferior – syndesmosis. Anterior, posterior tibiofibular ligaments + interosseus ligament.

Blood supply: perforating branch of the fibular artery and from medial malleolar branches of the anterior and posterior
tibial arteries.

Nerve supply: deep fibular, tibial, and saphenous nerves.

Both joints move slightly during dorsiflexion.

ANKLE JOINT (647)

Hinge type synovial joint.

Ligaments:
1. anterior talofibular
2. posterior talofibular
3. Calcaneofibular
4. Deltoid ligament (tibionavicular, tibiocalcaneal, anterior and posterior tibiotalar parts.)

Blood supply: malleolar branches of the fibular and anterior and posterior tibial arteries.

Nerve supply: tibial nerve and the deep fibular nerve, a division of the common fibular nerve.

FOOT JOINTS (650)

Subtalar joint- synovial plane joint

Blood supply: posterior tibial and fibular arteries

Nerve supply: medial or lateral plantar nerve (plantar aspect); deep fibular nerve (dorsal aspect)

Ligaments : medial, lateral, posterior talocalcaneal ligaments and interosseus ligament.

Interosseus talocalcaneal ligament separates subtalar and talocalcaneonavicular ligament.

Transverse tarsal joint = talonavicular joint + calcaneocuboid joint
Plantar calcaneonavicular ligament: spring ligament, supports longitudinal arch.

Long plantar ligament: calcaneocuboid. Some heads go to metatarsals. Maintains longitudinal arch. Forms tunnel for
fibularis longus.

Short plantar ligament: calcaneocuboid. Maintains longitudinal arch.