Anterior And Medial Thigh

Front 1

Lower Limb Overview

Back 1

- Major function of lower limbs is support weight of body and minimal expenditure of energy

When standing erect, center of gravity (COG) is anterior to second sacral vertebra (S2)

Vertical line through COG falls slightly posterior to hop joints and anterior to knee and ankle joints.

Provides almost circular support formed by feet and holds knee/hip joints in extension.

Ligaments around hip and knee joints facilitate "locking" of these joints into extension when standing.

This reduces muscular energy required to maintain a standing position.

Front 2

Second function of lower limb

Back 2

Second major function is locomotion.

During ambulation, many features of the lower limbs contribute to minimizing fluctuations in body's COG thereby reducing energy expenditure throughout the gait cycle (this includes pelvic rotation, tilt, knee movement toward midline, flexion and extension of knees)

Thus: only 5cm vertical/lateral fluctuation of gait cycle.

Front 3

Transition areas in the lower limbs

Back 3

1) Femoral triangle (provides passage of femoral artery, femoral vein and femoral nerve from abdomen to thigh)
2) Popliteal fossa (located posterior to knee, provides passage of neurovascular structures between thigh and leg)
3) Tarsal tunnel (provides passage for neurovascular structures and flexor tendons entering the foot)

Front 4

Fascia of lower limb

Back 4

Two layers:

1) Superficial fascia contains cutaneous nerves, superficial vessels/lymphatics and variable amounts of fat

2) Deep fascia invests the lower limb like a sleeve

Deep fascia of thigh is also called the fascia lata. It attaches superiorly to inguinal ligament and the iliac crest and sacrum.

Front 5

Intermuscular septum/compartments

Back 5

Arising from deep fascia, there are 3 intermuscular septum that attach to femur (linea aspera).

From three compartments:
1) anterior (hip flexors, knee extensors)

2) Medial (hip adductors)

3) Posterior

Front 6

Fascia Lata thickening

Back 6

Thickens in area known as iliotibial band.

This receives aponeurotic contributions from gluteus maximus and tensor fascia lata muscle.

Distally, band inserts into lateral condyle of tibia (Gerdy's tubercle) and patellar retinaculum.

The thickening provides lateral stability to both hip and knee joints.

Front 7

Tensor Fascia Lata Muscle

Back 7

- Tenses iliotibial band
- Helps extend the knee
- Assists with hip flexion/abduction

Innervated by superior gluteal nerve (L4/L5/S1)

Front 8

Veinous drainage of lower limb

Back 8

There are superficial, deep and perforating veins which all contain one way valves.

Superficial veins course in subcutaneous tissue, deep veins accompany major arteries throughout limbs.

Perforating veins allow blood to flow from superficial to deep veins (communication between deep and superficial).

Front 9

Superficial Veins of lower limb

Back 9

Great and small saphenous, both arise in foot and ascend within subcutaneous tissue.

Small saphenous pierces deep fascia behind knee, enters popliteal vein.

Great saphenous ascends up leg and thigh, passes through saphenous opening in fascia lata to enter femoral vein.

Musculovenous pump (contraction of leg muscles) assists venous blood return form lower limb to heart.

Front 10

More about the great saphenous

Back 10

Just inferior to inguinal ligament, great saphenous traverses saphenous hiatus where it joins femoral vein.

Commonly used for vascular bypass grafts.

Front 11

Varicose veins

Back 11

Some of the venous blood in skin/subQ tissues flow into superficial veins.

From there into perforating veins, finally into deep veins.

Deep veins ultimately drain into iliacs, then into IVC.

When venous valves become incompetent, blood backs up into superficial veins causing large dilated tortuous varicose veins.

Front 12

Lymphatic drainage of lower limb

Back 12

Most lymphatic vessels in lower limb eventually drain into superficial and deep inguinal nodes (just inferior to inguinal ligament).

Superficial inguinal nodes receives lymph from superficial tissues (skin, subcutaneous area). Also receive lymph from perineum, gluteal region, lower abdominal wall.

Deep inguinal nodes receive lymph from muscles, tendons and joints (deeper structures).

They are located in femoral canal beside femoral vein.

Both nodes drain into external iliac nodes.

Front 13

Anterior and medial thigh muscles

Back 13

Anterior muscles are hip flexors and knee extensors.
Mostly femoral nerve innervated (few exceptions).

Medial thigh muscles are hip adductors. Mostly obdurator nerve innervated.

Front 14

Flexors of hip joint

Back 14

- Psoas major
- Iliacus
- Pectineus
- Sartorius
- Tensor fascia lata

Pass anterior to hip joint, so they are hip flexors.

Femoral nerve (L2, 3, 4) except tensor fascia lata by superior gluteal nerve.

Pectineus muscle is hip flexor and hip adductor.

Front 15

Iliopsoas muscle

Back 15

Formed by combo of psoas major and iliacus.

Chief flexor of hip (thigh).

Passes deep to inguinal ligament, inserts into lesser trochanter femur.

Also assists with lateral hip rotation.

Front 16

Hip Fractures

Back 16

- Fractures of the neck of femur above insertion of iliopsoas proded characteristic appearance of affected limb.

Fractured extremity is externall rotated and shortened (iliopsoas action)

Front 17

Sartorius

Back 17

- Arises from ASIS
- Inserts into medial tibial condyle
- Flexes, abducts and laterally rotates the hip

Also assists in knee flexion.

Femoral nerve innervated.

Front 18

Extensors of the Knee: Quadriceps Femoris

Back 18

Four headed muscle: great extensor of the leg.

All four parts insert into quadriceps tendon and function in knee extension.

Patellar (seasmoid bone) is located within the quadriceps tendon.

Quadriceps tendon continues as patelllar tuberosity, inserts into tibial tuberosity.

Innervated by femoral nerve (L2/3/4).

Four parts:
1) Rectus femoris crosses hip, assists with hip flexion (big quad)
2) Vastus lateralis
3) Vastus medialis
4) Vastus intermedius - deepest

Front 19

Pediatric clinic: osgood schlatter

Back 19

OSD is common pediatric knee problem. Affects active athletic youth 10-15 yo.

Stress from quads inflames underdeveloped tibial tuberosity.

Kids complain of pain below knee cap and along top of shin.

Self limiting condition, goes away after 1-3 years.

Respond well to local therapy (rest, ice, decrease activity).

Occasionally need cast.

Front 20

Femoral nerve

Back 20

Formed by ventral rami of L2/3/4 (posterior divisions).

Passes beneath inguinal ligament.

Innervated quads, sartorius and pectineus.

Gives rise to anterior femoral cutaneous branches to anterior thigh.

Terminates as saphenous nerve (cutaneous nerve along medial lower leg and foot).

Front 21

Adductor muscles of hip

Back 21

- Adductor longus
- Adductor brevis
- Adductor magnus
- Gracilis
- Obturator externus (actually lateral rotator of hip)

Five muscles in medial compartment which adduct the thigh.

Innervated by obturator nerve (L2, 3, 4).

Front 22

Adductor Magnus

Back 22

Larges and most powerful medial thigh muscle.

Adductor portion (attaches to linea aspera) and hamstring portion (attaches to adductor tubercle of femur).

Adductor part is obturator, hamstring is sciatic innervated.

Between the two parts is adductor hiatus. Secures/protects passage of femoral artery and vein as they enter popliteal fossa.

Front 23

Other adductor muscles of hip

Back 23

- Pectineus (flex and adduct hip, so can be innervated by femoral or obturator)

Gracilis: long thin adductor muscle (can use in muscle grafts)

Sartorius (or Taylor's muscle) long thin muscle that abducts, externally rotates and flexes hip.

Gracilis and sartorius insert into pes anserinus (goose foot) on medial tibia.

Front 24

Gateways to lower limb

Back 24

1) Obturator canal: passage of obturator nerve/vessels, innervate medial thigh compartment. Obturator canal contains nerve (L2,3,4) which divides into anterior and posterior divisions. Anterior branch lies on anterior surface of adductor brevis and gives off small sensory branch.

2) Beneath inguinal ligament is crescent shaped gap between pelvic bone and inguinal ligament.
Divided into muscular (lateral) and vascular (medial) lacuna.
Many structures pass through here.

Front 25

Muscular lacuna (lateral)

Back 25

- Iliopsoas muscle
- lateral femoral cutaneous nerve
- femoral nerve

Front 26

Vascular (medial) lacuna

Back 26

- Femoral artery
- Femoral vein
- Femoral branch of genitofemoral nerve
- Lymphatics

Front 27

Structures go under inguinal ligament and emerge into...

Back 27

...femoral triangle!

Borders:
- superior: inguinal ligament
- medial: adductor longus
- lateral: sartorius
- roof: skin and overlying fascia
- floor: iliopsoas, pectineus, adductor longus

Contents:
- femoral nerve/artery/nerve/sheath

Front 28

Femoral sheath

Back 28

Funnel shaped fascial tube beneath inguinal ligament.

Extends from deep fascia, encloses proximal portions of femoral vessels/canal.

Eventually becomes continuous with adventitia (outer layer) of femoral vessels.

Does not enclose femoral nerve.

Sheath allows artery/vein to slide under inguinal ligament during hip movement.

Three compartments:
- lateral compartment (femoral artery)
- internal compartment (femoral vein)
- medial compartment (femoral canal, i.e. lymphatics)

Front 29

Femoral hernia

Back 29

Protrusion of abdominal viscera through femoral ring at the top of femoral canal
Initially contained in canal, but can enlarge with time, go through saphenous hiatus into subQ tissues.

Mass palpated within femoral triangle.

Occasionally lacunar ligament can strangulate bowel. Leads to necrosis.

More common in females than males.

Front 30

Adductor's Canal (Hunter's canal)

Back 30

Femoral artery/vein exits femoral triangle and enters adductor canal deep to sartorius.

Canal is in middle third of thigh beneath sartorius.

Extends down to adductor hiatus in tendon of adductor magnus.

Structures that go through:
1) Femoral artery/vein
2) Saphenous nerve
3) Nerve to vastus medialis

Femoral artery and vein pass through adductor hiatus, become popliteal vein/artery.

Front 31

Femoral Artery

Back 31

Chief artery to lower limb.

Enters femoral triangle and gives off large branch (deep profunda artery of thigh).

Arising from the latter:
1) Circumflex (medial/lateral) supply muscles and proximal femur/head.
2) Perforating branches (3-4) are large vessels that pierce adductor magnus and help vascularize muscles in posterior compartment.

Goes through adductor canal, becomes popliteal artery.

Front 32

Cutaneous innervation of thigh

Back 32

Conveyed to CNS via cutaneous nerves.

Lateral femoral cutaneous nerve (L2/3).

Femoral nerve (L2-L4) has many cutaneous branches.

Saphenous nerve (L3/L4) - branch of femoral nerve supplies sensation to medial leg and foot.

Obturator nerve (L2/L3).

Front 33

NAVEL

Back 33

Order of things below inguinal ligament
Nerve (femoral)
Artery (femoral
Vein (femoral)
Empty Space (within femoral canal)
Lacunal ligament