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Important Points From

LOWER LIMB
GLUTEAL REGION
Iliotibial TRACT originates from medial side(iliac crest) and inserts in lateral condyle of tibia. 2 muscles give insertion in iliotibial tract,GLUTEUS MAX and TENSOR FASCIA LATA.(medial to lateral) Cutaneous nerve supply to gluteal region: Upper lateral:L1,T12(iliohypogastric,thoracic) Upper medial:L1,L2,L3,S1,S2,S3 Lower lateral:L2,L3(lat cut and of thigh) Lower medial:S1,S2,S3(pos cut and of thigh) Muscles in this region abducts extends and laterally rotates the femur relative to pelvic bone. Superficial group:tensor fascia lata(stabilize the knee joint),gluteus max,med.min FUNCTION as abductor and extends hip. Deep group:piriformis,obturator internus,gamellus superior,inferior,quadratus femoris FUNCTION as lateral rotator of femur at hip joint. Gamellus SUPERIOR is innervated by OBTURATOR INTERNUS and gamellus inferior is innervated by Nerve. to QUADRATUS FEMORIS. QUADRATUS FEMORIS is the most inferior muscle of the deep group muscles of the region. GLUTEUS MED+MIN abducts the lower limb at hip joint and reduces the pelvic drop over the opposite swing limb during walking by securing the position of pelvis on the stance limb.

7 nerves enter the gluteal region from pelvis through greater sciatic foramen and 1 directly from sacrotuberous ligament(perforating cut. N) Sup gluteal N=> gluteus max+min+tensor fascia lata (only this 1 passes from above the piriformis) Inf gluteal N=> GLUTEUS MAX SCIATIC Nerve.=> to all muscles of post compartment which flexes knee and all muscles that work on foot and ankle joint.

NERVES and VESSEL


N to QUADRATUS FEMORIS=> quadratus femoris+gamellus inferior N to obturator internus=> obturator internus+gamellus superior Post cut. Nerve. of thigh=> skin on post thigh and leg (and labium majora+scrotum skin) its med to sciatic N Pudendal Nerve.=> major somatic nerve of the perineum no branch in gluteal region because it passes back to perineum by passing through lesser SCIATIC foramen by sacrotuberous ligament. Perforating cut. Nerve. of thigh=> supply the skin over medial side of GLUTEUS MAX(enters directly through sacrotuberous ligament in gluteal region) 2 arteries enter the gluteal region through greater sciatic foramen INFERIOR GLUTEAL ARTERY: branch of ANTERIOR TRUNK of internal iliac ARTERY,supplies to this region and makes anastomosis (cruciate+trochanteric) and also gives branch to SCIATIC Nerve. SUPERIOR gluteal artery:branch of POSTERIOR TRUNK of internal iliac artery,supplies to HIP JOINT+its superficial branch to gluteus maximus+deep branch to GLUTEUS MED+MIN In the pelvis PELVIC plexus OF VEINS Peripherally anastomosis which drain into FEMORAL VEINS. DEEP lymph into pelvic region in internal iliac nodes and superficial in the superficial inguinal lymph nodes.

THIGH
Anterior Is separated from the abdomen by INGUINAL LIGAMENT(anterior SUP iliac supine to pubic tubercle ) Anterior Compartment is known as extensors Posterior compartments is known as flexors Medial compartments is known as adductors EXTENSOR GROUP IS MORE POWERFUL THAN FLEXOR COMPARTMENT. LATERAL ROTATOR IS MORE POWERFUL THAN MEDIAL ROTATOR

. IMPORTANT BONY POINTS OF FEMUR


Angle of neck and shaft is normally 125.(less in females due to wider pelvis) Angle of ante-version is 15 (b/w transverse axes of upper and lower ends of femur) Angle of torsion is the angle of head-neck is 7 in males and 12 in females Blood supply: Head of femur is by epiphyseal artery derived from obturator+ ascending branch of med circumflex femoral artery. LATERAL HEAD by retinacular branches of medial circumflex femoral artery. FOR NECK retinacular arteries derived from medial circumflex FEMORAL ARTERY. PES ANSERI=insertion of sartorius+gracilis+semitendinosis(goose foot) Horse rider muscle=Adductor longus GERDYs tubercle=point of insertion of iliotibial tract on anterolateral surface below TIBIAL CONDYLE. ADDUCTOR CANAL=sub-sartorial canal=hunter,s canal

There are two main places where all the lymph of lower limb drains.1st is inguinal

LYMPH RELATED POINTS

lymph nodes(femoral canal) 2nd is popliteal lymph nodes(in popliteal fossa). Inguinal lymph nodes are of primary importance. Inguinal lymph nodes are divided in 2 types. Superficial and deep. Superficial is in superficial fascia and joins the deep group by efferent lymph vessels by passing through saphenous opening. Superficial group is divided in 2 types.horizontal (2 medial,lateral 3),vertical(5) Horizontal receives from the perineum and level of umbilicus,but vertical group receives most drainage of LOWER LIMB. Popliteal lymph nodes are 6 in number ,they receive drainage from lateral side of LEG and FOOT,knee joint+anterior.post tibial artery.And they are accompanied by Small saphenous vein in popliteal fossa.

Important Points Related MUSCLES


Here We will divide muscles of THIGH on the basis of their ACTIONS: SHORT ROTATORS(6):piriformis+obturator internus+externus+superior gamellus+inferior+quadratus femoris(when limb is fixed lateral rotation by pulling back of femur medially)(when limb is free rotation of trunk to opposite side) Iliopsoas originates from posterior wall of abdomen and descends in the upper part of anterior Compartment of thigh(that's y it is not included in femoral sheath) Quadricep femoris mainly extends knee and stabilize the position of patella during KNEE JOINT MOVEMENT.(vastus muscles originates from femur but rectus femoris from pelvic bone) Vastus lateralis is the largest muscle of VASTI. Articularis genus is the tinny muscle originates from inferior to vastus intermedius and inserts into suprapatellar bursa associated with knee joint. Rectus femoris lies anterior to vastus intermedius Sartorius is the most superficial muscle of anterior COMPARTMENT of thigh,weak flexor. The long head of BICEP FEMORIS is innervated BY TIBIAL division of sciatic Nerve. and short head from common peroneal division

Gracilis is the most superficial muscle of the MED.COMPARTMENT of thigh. Insertion of pes anseri anteromedial to tibial condyle:gracilis is sandwiched b/w sartorius front and semitendinosis behind. Pectineus is below the inguinal ligament and makes the floor of med. Half of the femoral triangle. ADD.longus forms the proximal posterior wall of the add.canal and ADD.magnus forms the distal wall of add.canal and is the largest and deepest muscle in the medial compartment.

Abductor and Adductors


3 Abductors Gluteus MIN+MED+ fascia lata of iliotibial tract Cause ABDUCTION,and help tilt the hip bone in passing the ground by not touching foot to ground. 5 Adductors Adductor longus+brevis +magnus+Pectineus+ gracilis There insertion is on the medial side of femur.They Cause ADDUCTION Extensor and flexors 4 extensors,2 medial and 2 lateral. 2 medial are semitendinosis+semimembranosus, acts at hip and knee joint. 2 lateral are bicep femoris+gluteus MAX, hip extension+knee flexion+standing up from sitting position(anti gravity muscle)help in propelling body during walking 4 flexors,2 acts on hip joint,2 acts on hip and knee joints. The 2 acting at hip joint are iliacus and psoas major, when limb is fix help in sitting up from bedded position and when not fix help in flexion at hip. The 2 acting at hip and knee are rectos femoris+sartorius Weak hip flexor and lateral rotators of hip.

ARTERIAL SUPPLY TO THIGH


AORTACommon iliac artery(l&m)external iliac artery(below inguinal

ligament)+internal iliac artery(passes from greater sciatic foramen and supplies to gluteal region) External iliac ARTERYobturator artery(in pelvic region)+femoral artery Obturator artery(medial comp of thigh)ant,post(anastomosis in hip joint) Femoral arterysmall,large Small branch of F.Asuperficial circumflex(ANTERIOR COMP OF THIGH),external pudendal (SKIN OF SCROTUM AND LABIUM MAJORA) Large branch of F.ADeep femoral (behind add.longus,b/w add.magnus and magnus,goes posterior to thigh and supply there)lateral circumflex F.A+medial circumflex F.A(CRUCIATE ANASTOMOSIS) INTERNAL iliac ARTERYsup.GLUTEAL Nerve.+inf.GLUTEAL Nerve. Arterial supply to leg Femoral artery is named as popliteal artery in POPLITEAL FOSSA. Popliteal artery(in lower border of popliteal fossa)anterior tibial+post tibial artery and also gives genicular branches to knee joint. Anterior TIBIAL ARTERY pierce the intermuscular septa and enters in the anterior compartment of leg. On passing below EXTENSOR RETINACULA it enters foot called as DORSALIS PEDIS ARTERY. DPA gives 3 branches,lateral tarsal artery+arcuate artery and 1st dorsal metatarsal artery. And joins with the lateral planter artery on 1st metatarsal and completes plantar dorsal arch. Posterior TIBIAL ARTERY passes beneath the flexor retinaculum and gives 2 branches, lateral planter artery+medial planter artery. Medial is smaller than lateral planter artery. On the level of 5th metatarsal lateral planter artery curves medially and joins the DPA and completes the planter arch.

LUMBER PLEXUS
L1ilioinguinal+iliohypogastric

L1+L2Genitofemoral L2+L3Lateral cutaneous nerve L2+L3+L4femoral(post)+obturator(ant) L4+L5+S1Superior gluteal nerve S1+S2+S3posterior cut.N.of thigh S2+S3+S4pudendal Nerve. L5+S1+S2inf. Gluteal Nerve. L4+L5+S1+S2+S3sciatic Nerve.common peroneal(L4+L5+S1+S2),tibial Nerve.(L4+L5+S1+S2+S3)

Nerve Supply of Leg


Sciatic nerve gives 2 branches in lower 2/3 of thigh. Tibial nerve+Common peroneal nerve Tibial nerve goes in posterior compartment of leg,and enters the foot bellow flexor retinaculum and gives 2 branches med and lateral planter Nerve. Common peroneal nerve supplies the lateral compart and anterior compartment of leg,on the level of fibular neck it gives 2 branches.deep peroneal+superficial peroneal. Deep peroneal supplies to anterior compartment of leg and superficial peroneal supplies to lateral compartment of leg. Superficial p.n on entering the foot becomes cutaneous and deep p.n by passing below extensor retinacula innervates by giving 3 branches,medial+lat+terminal branch. SURAL Nerve. which is cutaneous nerve of leg is branch of tibial Nerve.

Nerve Supply of Thigh


Sup.GLUTEAL Nerve. supplies gluteus MIN+MED+tensor fascia lata Inf.GLUTEAL Nerve. supplies gluteus MAX FEMORAL Nerve. supplies anterior femoris+Pectineus+sartorius) Comp of thigh (iliacus+quadricep

Sciatic Nerve. supplies semitendinosis+semimembranosus+bicep femoris+post part of ADD.magnus Obturator Nerve. (med to psoas muscle on lat side & enters to supplies medial compartment of thigh by add canal) ,obt.externus+adductors+magnus(anterior Part) Saphenous Nerve. passes along with F.A but does not pass from add.hiatus but passes from medial side of knee b/w sartorius and gracilis.(branch of F.N)

IMPORTANT ANASTOMOSIS
Cruciate ANASTOMOSIS,in hip joint at the level of LESSER TROCHANTER of FEMUR.it si in b/w: inf gluteal artery+med femoral circumflex+lat femoral circumflex+1st perforating artery(branch of profunda which is cutaneous branch of F.A) it is to make connection b/w F.A & INTERNAL iliac ARTERY Trochanteric anastomosis,main blood supply to FEMORAL HEAD,it si b/w following: sup.gluteal+inf.gluteal+lat.circumflex+med.circumflex arteries,IT IS AT THE LEVEL OF GREATER TROCHANTER. Anastomosis around knee joint is b/w the followings: 5 genicular branches of P.A+descending branch of F.A+descending branch of lateral circumflex of F.A+2 recurrent artery of A.T.A+circumflex fibular of P.T.A

IMPORTANT RELATIONS
Femoral sheath covers the femoral vessels and lymph.and itself lies in depression called FEMORAL TRIANGLE. Most medial is femoral canal(lymph sac),It is covered by femoral ring,femoral septum closes the ring. Lateral to it is FEMORAL VEIN.(intermediate comp) Lateral to F.V is FEMORAL ARTERY(lateral comp) MOST LATERAL of FEMORAL TRIANGLE not the femoral sheath is FEMORAL Nerve. Popliteus is important muscle of UNLOCKING but not the LOCKING of knee joint. Popliteus muscle gives origin on medial condyle of tibia and insertion on lateral condyle of femur.

Pulsation of P.A can be felt when knee is flexed.(and that of posterior tibial in normal posture and that of DPA in little dorsiflexed) TIBIAL CONDYLES=TIBIAL PLATES Condyles of tibia are convex shape menisci provides it convexity. Medial menisci is lunate shape and lat.menisci is fully rounded. Thickened knee joint capsule on posterior Side prevents HYPEREXTENSION of knee joint Plantaris is a vestigial muscle. Flexor accessories=quadratus plantae (in foot) Fibrous septum&deep fascia separates the leg in compartments there are 3 fibrous septum: Transverse intermuscular septum=beneath soleus Posterior crural septa=in front of soleus Anterior crural septa Hamstring muscles= semitendinosis+semimembranosus+ bicep femoris (&part of add.magnus),they are POWERFUL flexors of leg+extensors of hip. Graciles and sartorius are weak flexor of leg. Popliteus is a minor flexors cause medial rotation of tibia (unlocking) Dorsiflexors=tibialis anterior+long extensors of foot(EDL+EHL) Planterflexors=gastrocnemius+soleus+plantaris Inversion=tibialis anterior +tibialis post Eversion= peroneus longus+peroneus brevis+peroneus tertius (foot planter-ed)LOCKING: *Extension of musclesfemur rotates medially(ligaments are taut menisci compress) (foot planter-ed)UNLOCKING: *Flexion of muscles(ligaments &menisci relaxes)tibia rotates laterally (foot off the ground)LOCKING: *Extension of musclesTibia rotates laterally(ligaments taut,menisci compress)

(foot off the ground)LOCKING: *Flexion of muscles(ligaments &menisci relaxes)femur rotates medially ANKLE JOINT: Active dorsiflexion can be of 10 degree Active Planterflexion can b of 20 degree, In passive movements thus can b doubled

SOME POINTS ABOUT HIP JOINT


Blood supply to hip joint,s intracapsular structure is by TROCHANTERIC anastomosis Normal range of flexion is 120 degree Normal range of extension is 20 degree Adduction is of about 30 degree Abduction is of 60 degree Rotation in either direction is about 40 degree

MOVEMENTS of KNEE JOINT


ITS OF HINGE TYPE SO extension and flexion are primary movements,but little bit of lateral and medial rotation of femur and tibia also occur so as to perform locking and unlocking Flexion can be till 150 degree and normal extension to 30 degree But can be increase of 5-10 degree of hyperextension in locking by passively medial rotation of femur on tibia when on the ground,but when foot is free to move it can be due to passive lateral rotation of tibia...... UNLOCKING is opposite to locking and its due to popliteus Remember directions of CRUCIATE ligaments These are 2 intracapsular ligaments in knee joint: Anterior cruciate ligament goes lateralis backward and attached to posterior side of medial surface of femur..... And reverse for posterior cruciate you just have to remember this dat name

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

Maintenance of arches depends on the following things: Shape of the bones Ligaments Muscle tone But the last one is not important as much because when you are standing for long periods your ligaments are getting affected and causing your arches to disappear Small muscles peroneus longus and tibialis anterior play no role in normal static control. Femoral Hernia: Lymph nodes lie in the most medial compartment of femoral sheath called femoral canal,the wall of femoral sheath is strictly bound to vessels of femoral sheath but not strictly bound to lymph vessels,so there presents a potential weak area,a protrusion of any anatomical structure can lead to bulging of this area all this condition is named femoral hernia, Why femoral nerve is outside the femoral sheath????? femoral sheath is formed by fascia iliaca posteriorly and fascia transversalis anteriorly, Retroinguinal space is divided into two compartments by iliopsoas fascia,,,muscular and vascular,nerve descends in muscular compartment,,as fascia transversalis doesn't extend into muscular part of retroinguinal space and so femoral nerve is not inside femoral sheath.. it lies behind the fascia iliaca Gateways to gluteal regions: Lesser sciatic foramen: It is for reentry of structures left from greater sciatic foramen and exit fo structure of perineum IN PTI I:INTERNAL PUDENDAL ARTERY N:NERVE TO OBTURATOR INTERNUS P:PUDENDAL NERVE T:TENDON TO OBTURATOR INTERNUS MUSCLE I:INTERNAL PUDENDAL VEIN Gateways to gluteal regions: Greater sciatic foramina which is further separated by piriformis in upper and lower part... Structures passing from greater sciatic foramen: PSP IN SSP G P:PIRIFORMIS S:SCIATIC NERVE P:POST CUTANEOUS NERVE OF THIGH

I:INTERNAL PUDENDAL ARTERY and VEIN N:NERVE TO OBTURATOR and QUADRATUS FEMORIS S:SUP and INF GLUTEAL NERVES S:SUP and INF GLUTEAL ARTERIES and VEINS P:PUDENDAL NERVES G:GAMELLUS Remember the significance of piriformis and dividing this foramen in upper and lower is just to Separate sup and infer gluteal nerves and vessels 2ND HEART OF THE BODY IS IN LEG ,VENOUS PLEXUS IN SOLEUS Gastrocnemius helps you to win long jumps but soleus is slow in action Eversion and inversion is at midtarsal & transverse tarsal joint (talocalcaneonavicular & calcaneocuboid) but not at ankle joint.

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