Lower Limb Regional

REGIONAL ANATOMY

Classification of Human anatomy Gross anatomy : systematic anatomy regional anatomy Microscopic anatomy : histology cytology

Four major regions cranium head face

anterior region of neck

neck posterior region of neck back thorax trunk abdomen pelvis and perineum upper limb limbs lower limb

lower limb Anterior boundary: fold of groin Lateral boundary: iliac crest Posterior boundary: iliac crest, superior border of the sacrum glutear region, thigh, knee, leg, ankle,foot.

lower limb Surface landmarks iliac crest

adductor

anterior

superior iliac spine

medial

tubercle

of iliac crest

lateral

posterior pubic

superior iliac spine

tubercle

tibial

tubercle

condyle of tibia condyle of tibia

tuberosity

medial

border of tibia

ischial

tuberosity

fibular

head

greater

trochanter

medial

malleolus

patella medial lateral

lateral

condyle of femur condyle of femur

malleolus

3.posterior

1. 2.

iliac crest

anterior superior iliac spine iliac tuberosity 5.

4.

pubic tubercle

tubercle of iliac crest

6. ischial tuberosity

superior iliac spine

greater trochanter

lateral epicondyle adductor tubercle

lateral condyle medial condyle medial epicondyle

patellar ligament

lateral condyle medial condyle tibial tuberosity

lateral malleolus medial malleolus

fibular head

lateral head of gastrocnemius

soleus

medial head of gastrocnemius

tendo calcaneus

Femoral artery: It corresponds to the upper twothirds of a line joining two points, midinguinal point and adduct tubercle. . The upper one-third of the line represents the upper half of the artery lying in the femoral triangle. The middle one-third of the line represents the lower half of the artery lying in the adductor canal.

Sciatic nerve : It is marked by joining the three points. The first point is at 2.5 cm lateral to the midpoint between the posterior superior iliac spine and the ischial tuberosity. The second point is just medial to the midpoint between the ischial tuberosity and the greater trochanter. The third point is in the midline of the back of the thigh at the junction of its upper two-thirds and lower one-third.

Common peroneal nerve It is marked by joining two points. The first point is at the upper angle of the popliteal fossa. The second point is on the back of the neck of the fibula.

Layer arrangement of lower limb skin superficial fascia deep fascia intermuscular septum bone

Layer arrangement of lower limb Skin: The skin of thigh in the region around pubic symphysis, is studded with hair. The skin over the lateral and posterior aspects of the thigh are thick and lesser movable. The skin over the gluteal region is thick. The skin over the posterior aspect of leg is thinner and more freely movable than that over the anterior aspect of leg. The skin of the sole is thick for protection, firmly adherent to the underlying plantar aponeurosis.

Layer arrangement of lower limb Superficial Fascia: The superficial fascia of the front of thigh has two layers, a superficial fatty layer and a deep membranous layer. The superficial fasciae of the gluteal region is heavily laden with fat. It is tough and stringy over the ischial tuberosity where it forms an efficient cushion for supporting the body weight in the sitting posture. The superficial fascia contains cutaneous veins, cutaneous arteries, cutaneous nerves, and the superficial lymph nodes.

Cutaneous Veins in the Superficial fascia great saphenous vein superficial iliac circumflex vein superficial lateral femoral vein

superficial epigastric vein external pudendal vein superficial medial femoral vein great saphenous vein

In the leg, the saphenous nerve runs in front of the great saphenous vein. . saphenous nerve

Cutaneous Veins in the Superficial fascia Characteristic of great saphenous vein

Cutaneous Veins in the Superficial fascia Small saphenous vein The medial sural cutaneous nerve accompanies the upper part of the small saphenous vein and the sural nerve accompanies its lower part. small saphenousvein sural nerve

Superficial fascia superficial vein dorsal venous arch of foot great saphenous vein small saphenous vein

popliteal vein

femoral vein

国 small saphenous vein dorsal venous arch of foot great saphenous vein

Cutaneous Arteries in the Superficial fascia Superficial epigastric artery:

Superficial iliac circumflex artery : External pudendal artery :

Cutaneous Nerves in the Superficial fascia Lateral cutaneous nerve of the thigh :

Medial cutaneous nerve of the thigh :

Intermediate cutaneous nerve of the thigh :

Cutaneous Nerves in the Superficial fascia Saphenous nerve :

Posterior femoral cutaneous nerve

Cutaneous Nerves in the Superficial fascia

lateral sural cutaneous nerve medial sural cutaneous nervesural nerve

Superficial Lymph Nodes in the Superficial fascia Superficial inguinal lymph nodes:

Superficial Lymph Nodes in the Superficial fascia Popliteal Lymph Nodes:

Deep fascia Deep fascia of the thigh ( fascia lata )

Deep fascia Deep fascia of the gluteal region :

Deep fascia of the leg:

Deep fascia Deep fascia of the foot:

Dissection (First time) 1.Dissect the skin: According to the picture 1 to draw the lines on the cadaver, and then make the skin incisions along these lines. That means to make a vertical incision along the medial side of the lower limb, and its distal end reaches to the inferior margin of the medial malleolus; to make one oblique incision from the anterior superior iliac spine to the pubic tubercle; to make two horizontal incisions at the levels of keen and ankle. Reflect the skin laterally, exposing the superficial fascia.

Dissection (First time) 1.Dissect the skin: According to the picture 1 to draw the lines on the cadaver, and then make the skin incisions along these lines. That means to make a vertical incision along the medial side of the lower limb, and its distal end reaches to the inferior margin of the medial malleolus; to make one oblique incision from the anterior superior iliac spine to the pubic tubercle; to make two horizontal incisions at the levels of keen and ankle. Reflect the skin laterally, exposing the superficial fascia. 2. Examine the surface landmarkings of the lower limb, such as iliac crest, anterior superior iliac spine, tubercle of iliac crest, posterior superior iliac spine, pubic tubercle, ischial tuberosity, greater trochanter, patella, medial condyle of femur, lateral condyle of femur, adductor tubercle, medial condyle of tibia, lateral condyle of tibia, tibial tuberosity, fibular head, medial malleolus, lateral malleolus, tendo calcaneus and calcaneal tuberosity.

Dissection (First time) 3. Examine the important structures in the superficial fascia: (1) try to find the superficial inguinal lymph nodes below the inguinal ligament and along the upmost part of the great saphenous vein; (2) identify the great saphenous vein (you can begin to find it posterior to the medial femoral condyle or in front of the medial malleolus ) and its five tributaries at its upper part before piercing the cribriform fascia;. Review its course and characteristics; (3) find out the cutaneous nerves on the anterior surface of the thigh: the lateral cutaneous nerve pierces the fascia lata below the anterior inferior iliac spine about 8 to 10 centimeter and emerges in the superficial fascia; the intermediate cutaneous nerve of the thigh pierces the fascia lata at the junction of the upper one-third and middle one-third of the thigh; the medial cutaneous nerve of the thigh pierces the fascia lata on the medial side of the thigh at the junction of the middle one-third and the lower one-third of the thigh; (4) identify the saphenous nerve and its companion, great saphenous vein, in the medial surface of the leg.

Dissection (First time) 4. Save the structures you have found in the superficial fasia, remove the superficial fascia, and then begin to examine the deep fascia and its forming structures: (1) The iliotibial tract situates in the lateral part of the thigh; (2) The saphenous opening, an oval opening, locates inferior and lateral to the pubic tubercle; (3) The falciform margin is a sharp crescentic lateral margin of the saphenoud opening; (4) Around the ankle, the deep fascia is thickened to form bands called retinacula. 5. Place the cadaver in the prone position, incise and reflect the skin according to the picture 2. 6. Try to find the posterior femoral cutaneous nerve. It descends deep to the deep fascia in the posterior surface of the thigh and pierces the deep fascia superior to the popliteal fossa and then emerges in the superficial fascia.

Dissection (First time) 7. In the posterior surface of the leg, identify the small saphenous vein along the midline and its accompanies, the sural nerve and the medial sural cutaneous nerve. Find out the lateral sural cutaneous nerve. 8. Save the structures you have found in the superficial fascia, and then remove the superficial fascia to expose the deep fascia. 9. The deep fascia above and in front of the gluteus maximus , i.e over the gluteus medius, is thick, dense , opaque and pearly white; over the gluteus maximus is thin and dense.

Muscles and principal blood vessels and principal nerves Muscles of the lower limb: Muscles of pelvic girdle:

anterior group iliopsoas tensor fasciae latae gluteus maximus posterior group gluteus medius gluteus minimus piriformis

psoas major iliacus psoas major tensor fasciae latae

gluteus maximus gluteus medius gluteus minimus piriformis obturator internus quadratus femoris

Muscles and principal blood vessels and principal nerves Muscles of the lower limb: Muscles of the Thigh sartorius anterior group quadriceps femoris gracilis, pectineus medial group adductor longus adductor brevis adductor magnus posterior group biceps femoris semitendinosus semimembranosus

tensor fasciae latae sartorius rectus femoris vastus lateralis vastus medialis iliotibial tract

patellar ligament

Muscles and principal blood vessels and principal nerves Muscles of the lower limb: Muscles of the Thigh sartorius anterior group quadriceps femoris gracilis, pectineus medial group adductor longus adductor brevis adductor magnus posterior group biceps femoris semitendinosus semimembranosus

vastus intermedius. vastus lateralis vastus medialis

Muscles and principal blood vessels and principal nerves Muscles of the lower limb: Muscles of the Thigh sartorius anterior group quadriceps femoris gracilis, pectineus medial group adductor longus adductor brevis adductor magnus posterior group biceps femoris semitendinosus semimembranosus

pectineus adductor longus gracilis

Muscles and principal blood vessels and principal nerves Muscles of the lower limb: Muscles of the Thigh sartorius anterior group quadriceps femoris gracilis, pectineus medial group adductor longus adductor brevis adductor magnus posterior group biceps femoris semitendinosus semimembranosus

pectineus adductor brevis adductor magnus adductor longus gracilis

Muscles and principal blood vessels and principal nerves Muscles of the lower limb: Muscles of the Thigh sartorius anterior group quadriceps femoris gracilis, pectineus medial group adductor longus adductor brevis adductor magnus posterior group biceps femoris semitendinosus semimembranosus

semitendinosus semimembranosus biceps femoris

Muscles and principal blood vessels and principal nerves Muscles of the lower limb: Muscles of the leg: tibialis anterior anterior group extensor hallucis longus extensor digitorum longus lateral group

posterior group

peroneus longus peroneus brevis superficial layer: gastrocnemius soleus deep layer: flexor hallucis longus tibialis posterior flexor digitorum longus

tibialis anterior extensor digitorum longus extensor hallucis longus

Muscles and principal blood vessels and principal nerves Muscles of the lower limb: Muscles of the leg: tibialis anterior anterior group extensor hallucis longus extensor digitorum longus lateral group

posterior group

peroneus longus peroneus brevis superficial layer: gastrocnemius soleus deep layer: flexor hallucis longus tibialis posterior flexor digitorum longus

tibialis anterior extensor digitorum longus

extensor hallucis long

Muscles and principal blood vessels and principal nerves Muscles of the lower limb: Muscles of the leg: tibialis anterior anterior group extensor hallucis longus extensor digitorum longus lateral group

posterior group

peroneus longus peroneus brevis superficial layer: gastrocnemius soleus deep layer: flexor hallucis longus tibialis posterior flexor digitorum longus

peroneus longus peroneus brevis

Muscles and principal blood vessels and principal nerves Muscles of the lower limb: Muscles of the leg: tibialis anterior anterior group extensor hallucis longus extensor digitorum longus lateral group

posterior group

peroneus longus peroneus brevis superficial layer: gastrocnemius soleus deep layer: flexor hallucis longus tibialis posterior flexor digitorum longus

lateral head of gastrocnemius medial head of gastrocnemius

Muscles and principal blood vessels and principal nerves Muscles of the lower limb: Muscles of the leg: tibialis anterior anterior group extensor hallucis longus extensor digitorum longus lateral group

posterior group

soleus

peroneus longus peroneus brevis superficial layer: gastrocnemius soleus deep layer: flexor hallucis longus tibialis posterior flexor digitorum longus

tendo calcaneus

Muscles and principal blood vessels and principal nerves Muscles of the lower limb: Muscles of the leg: tibialis anterior anterior group extensor hallucis longus extensor digitorum longus lateral group

posterior group

peroneus longus peroneus brevis superficial layer: gastrocnemius soleus deep layer: flexor hallucis longus tibialis posterior flexor digitorum longus

tibialis posterior flexor digitorum longus flexor hallucis longus

blood vessels and nerves arteries femoral artery

　

popliteal artery

anterior tibial artery

posterior tibial artery

dorsal artery of foot medial plantar artery lateral plantar artery

blood vessels and nerves nerves femoral nerve saphenous nerve sciatic nerve tibial nerve common peroneal nerve superficial peroneal nerve deep peroneal nerve

Regional structures Lacuna musculorum Lacuna vasorum Femoral triangle 　 Femoral sheath Femoral canal Femoral ring Adductor canal Space deep to gluteus maximus Posterior space of thigh Popliteal fossa Posterior space of leg Malleolar canal

Lacuna musculorum Boundaries anterior: inguinal ligament posterior: ilium medial: iliopectineal arch 　

Contents iliopsoas femoral nerve Communicating Superiorly:fascial inferior cavity Inferiorlu:femoral triangle

lacuna musculorum

Lacuna vasorum Boundaries anterior: inguinal ligament posterior: pectineal ligament Lateral: iliopectineal arch 　 medial: lacunar ligament Content femoral sheath femoral vessels femoral canal

lacuna vasorum

Communicating Superiorly: posterior space of peritoneum Inferiorlu: femoral triangle

Femoral triangle Position:It is a triangular depression on the front of the upper one-third of the thigh immediately below the inguinal ligament. 　 Boundaries: lateral: medial border of sartorius medial: medial border of the adductor longus

base: inguinal ligament roof : skin, superficial

fascia, deep fascia floor: adductor fasciae longus, their pectineus, iliopsoas and

Femoral triangle Communicating: superiorly: lacuna musculorum lacuna vasorum inferiorly: adductor canal 　 Contents: (from laterally to medially) femoral nerve, femoral artery, femoral vein, femoral canal

femoral sheath

Femoral artery superficial branches superficial epigastric a. superficial iliac circumflex a. external pudendal a. deep branches deep femoral a. deep external pudendal a. muscular branches

external iliac a. femoral a.

external iliac artery superficial iliac circumflex artery deep femoral artery lateral femoral circumflex artery

superficial epigastric artery femoral artery medial femora circumflex artery

Femoral artery superficial branches superficial epigastric a. superficial iliac circumflex a.

deep branches

external pudendal a.

deep femoral a. deep external pudendal a. muscular branches

external iliac a. deep femoral a. lateral femoral circumflex a. perforating a.

Femoral artery deep femoral artery medial femoral circumflex a. lateral femoral circumflex a. three perforating arteries

femoral a. medial femoral circumflex a.

femoral artery Pulsations of the femoral artery can be felt at the midinguinal point. A bilateral absence or feebleness of the femoral pulse may result from coarctation or narrowing of the aorta, or thrombosis . It can be compressed at the midinguinal point against the head of the femur or against the superior ramus of the pubis to control bleeding from the distal part of the limb. Since the femoral artery is quite superficial in the femoral triangle, it can be easily exposed for ligation or for passing a cannula or a thick needle.

Femoral vein It locates medially to the femoral artery at the base of the femoral triangle, but posteromedially to the artery at the apex. It is commonly used for intravenous infusions in infants and in patients with peripheral circulatory failure. . Stab wounds at the apex of the femoral triangle may cut all the large vessels of the lower limb because the femoral artery and vein, and the profunda femoris artery and vein are arranged in one line from before backwards at this site.

Femoral nerve anterior division muscular branch: sartorius branch cutaneous branch: medial cutaneous nerves intermediate cutaneous nerve posterior division muscular branch: rectus femoris branch three vasti branch cutaneous branch: saphenous nerve The hip joint is supplied by the nerve to the rectus femoris. The knee joint is supplied by the nerves to the three vasti.

Femoral nerve In the thigh, it lies in the groove between the iliacus and the psoas major, outside the femoral sheath, and lateral to the femoral artery. . It not only supply the hip joint, but also the knee joint. Therefore, diseases of the hip may produce referred pain in the knee and also in the cutaneous area innervated by its branch.

Deep inguinal lymph nodes: The deep inguinal lymph nodes are about four to five in number, and lie medial to the upper part of the femoral vein. These nodes receive afferents from (a) the superficial inguinal lymph nodes; (b) the popliteal lymph nodes; (c) glans penis or clitoris; and (d) the deep lymphatics of the lower limb.

Femoral sheath

femoral sheath

It is a funnel-shaped sleeve of fascia enclosing the upper 3 to 4 cm of the femoral vessels. The anterior wall of the sheath is 　 formed by the transverse fascia; and the posterior wall is formed by the iliac fascia. Inferiorly, the sheath merges with connective tissue around the femoral vessels. It is divided into the following three compartments by septa. The lateral compartment contains the femoral artery. The intermediate compartment contains the femoral vein. The medial compartment is known as the femoral canal.

Femoral canal

femoral ring

Posotion: medial compartment of the femoral sheath Shape: It is conical in shape and about 1.5 cm long. Content: a lymph node, areolar tissue 　 Communicating: superiorly: abdominal cavity

Femoral ring

femoral canal

The upper end of the femoral canal is called the femoral ring. Boundaries: anterior : inguinal ligament medial: lacunar ligament posterior: pectineus and its covering fascia lateral: septum separating it from the femoral vein

Adductor canal Posotion: on the medial side of the middle one-third of the thigh Shape: triangular on cross-section Boundaries: anterior 　 wall: vastus medialis medial wall : a strong fibrous membrane posterior wall: adductor longus, adductor magnus Content: saphenous nerve, femoral artery , femoral vein Communicating: superiorly: femoral triangle Inferioe: popliteal fossa

adductor canal

Adductor canal The femoral artery enters the canal at the apex of the femoral triangle. Within the canal it gives off muscular branches and a descending genicular branch. . The 　

femoral vein lies posterior to the femoral artery in the upper part, and lateral to the artery in the lower part of the canal. The saphenous nerve leaves the canal with the saphenous artery by piercing the the fibrous membrane. . The femoral artery is exposed in the adductor canal for various surgical procedures.

Space deep to gluteus maximus Posotion: deep to gluteus maximus Content: superior gluteal artery, vein and nerve; saiatic nerve. 　 femoral cutaneous nerve; posterior inferior gluteal artery, vein and nerve; internal pudendal artery, vein and pudendal nerve; Communicating: deeply: pubic cavity anterioinferiorly: below the hip joint inferiorly: posterior space of thigh medialinferiorly: ischiorectal fossa

gluteus maximus gluteus medius gluteus minimus piriformis obturator internus

　

quadratus femoris

The piriformis divides the greater sciatic foramen into two parts: suprapiriform foramen and infrapiriform foramen. .

suprapiriform foramen: superior gluteal artery, vein and nerve infrapiriform foramen: saiatic nerve. posterior femoral cutaneous nerve; inferior gluteal artery, vein and nerve; internal pudendal artery, vein and pudendal nerve;

Posterior space of thigh Position: between the posterior group muscles of the thigh 　 Content: sciatic nerve Communicating: superiorly: space deep to gluteus maximus Inferiorly: popliteal fossa

sciatic nerve

Popliteal fossa Position:a diamond-shaped depression lying behind the knee joint. Boundaries: superolaterally: biceps femoris superomedially: semitendinosus , popliteal artery 　 semimembranosus inferolaterally: lateral head of gastrocnemius inferomedially: medial head of gastrocnemius roof: deep fascia of popliteal fascia floor : popliteal surface of the femur , capsule of the knee joint, popliteal fascia covering the popliteal muscle

common peroneal nerve

tibial nerve popliteal vein

Popliteal fossa Contents and arrangement: 1.on the midline of the popliteal fossa,from the superficial to deep: tibial nerve, popliteal vein and popliteal artery 2.crossing the fossa obliquely from the superior angle to the lateral 　 angle, along the medial border of the biceps femoris: common peroneal nerve common peroneal nerve 3.popliteal lymph nodes and fat Communicating: popliteal artery superiorly: popliteal fossa inferiorly: malleolar canal The common peroneal nerve can be palpated against the posteriolateral side of the neck of the fibula. It may be injured in this area.

tibial nerve

popliteal vein

Posterior space of leg Position:between the superficial and deep layer muscles of the posterior group of leg. 　 Contents: posterior tibial artery, veins and tibial nerve fibular artery and veins Communicating: superiorly: popliteal fossa inferiorly: malleolar canal

posterior tibial artery fibular artery tibial nerve

Malleolar canal Position:inferior to the medial malleolus Constitution: flexor retinaculum and calcaneus popliteal artery

　 Contents: from anterior to posterior tendon of tibialis posterior tendon of flexor digitorum longus posterior tibial artery posterior tibial veins tibial nerve flexor pollicis longus

common peroneal nerve tibial nerve popliteal vein

Dissection (Second time) 1. Reflect the deep fascia. 2. Examine the muscles located in the anterior surface and medial surface of the thigh, make certain the boundaries of the femoral triangle, and then identify its contents e.g., from laterally to medially, they are femoral nerve, femoral artery and femoral vein. On lifting the middle one-third of sartorius, a part of deep fascia stretches between vastus medialis and adductor muscles is exposed. On longitudinal division of this strongfascia, the adductor canal is visualised. Dissect its contents. From superficial to profundal, they are saphenous nerve, femoral artery, and femoral vein. Find out and examine the femoral artery and its branched. 3. Examine the muscles located in the anterior surface and lateral surface of the leg, try to find out the anterior tibial artery and its accompanies anterior tibial veins; deep peroneal nerve; superficial peroneal nerve.

Dissection (Second time) 4. Place the cadaver in the prone position, and reflect the deep fascia. 5. Reflect the gluteus maximus to examine the underlying structures. For this, first identify the lower border of the gluteus maximus; then insert a forceps on the deep surface of gluteus maximus; finally cut it from below upwards lateral to its origin 1 centimeter. Reflect gluteus maximus lateroinferiorly. Piriformis is the key muscle of the gluteal region, define its superior and inferior margins; blood vessels and nerves which pass through the suprapiriform foramen and infrapiriform foramen. 6. Examine the posterior group muscles of thigh, define the posterior space of the thigh and find out the sciatic verve.

Dissection (Second time) 7.Examine the boundaries of the popliteal fossa, remove the fat and then dissect the popliteal artery and its branches, the popliteal vein and its tributaries, the tibial nerve and its branches; the common peroneal nerve and its branches. 8. Examine the posterior group muscles of leg; cut off the lateral head of gastrocnemius and the medial head of gastrocnemius and then reflect them laterally; observe the soleus. Cut off the soleus and expose the posterior space of leg; try to find out the posterior tibial artery, veins and tibial nerve on the midline, find out the fibular artery, veins laterally. 9. Posterior to the medial malleolus, cut off the flexor retinaculum and expose the malleolar canal. From anteriorly to posteriorly, identify the tendon of tibialis posterior, tendon of flexor digitorum longus, posterior tibial artery, posterior tibial veins, tibial nerve, and flexor pollicis longus.