Lower Limb from posterior part of Leg to Hip joint

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Posterior (Flexors) Compartment of Leg (Page 146) 1- Muscles of back of leg (plantar flexors). 2- Posterior tibial nerve. 3- Posterior tibial vessels. 4- Flexor retinaculum.

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General Orientation

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Small saphenous vein

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Sural nerve

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Tendo Achilis Gastrocnemius Tibialis posterior tendon Tendon of flexor hallucis longus Tendon of flexor digitorum longus Medial Lateral Medial malleolus Medial tubercle of calcaneus

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Soleus m Gastrocnemius (cut) Plantaris m Popliteus m Tendo calcaneus

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popliteus m Medial popliteal nerve Soleus (cut) Posterior tibial nerve Flexor digitorum longus Tibialis posterior Flexor hallucis longus Back of lower end of tibia Flexor retinaculum Posterior tibial art. Popliteal art Lateral Medial Tendinous arch

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Muscles of the Back of Leg (Page 146)

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Muscles of the back of leg Superficial 1- Gastrocnemius. 2- Soleus. 3- Plantaris. N.B. Gasrtocnemius and soleus form triceps surae Deep 1- Popliteus. 2- Tibialis posterior. 3- Flexor hallucis longus. 4- Flexor digitorum longus.

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Important bone Features

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Popliteal surface of femur Lateral supracondylar line Lateral epicondyle Soleal line Head of fibula Back of knee region

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Lateral epicondyle Groove for popliteus Lateral meniscus Lateral aspect of knee region

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Soleal line Medial border Vertical line Head of fibula Neck of fibula Medial crest Back of Fibula & Tibia

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Superficial Muscles 1- Gastrocnemius. 2- Soleus. 3- Plantaris.

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Origin of Superficial Muscles

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Medial head of gastrocnemius Popliteal surface above medial femoral condyle Lateral head of gastrocnemius Lateral surface of lateral femoral condyle above lateral epicondyle Plantaris Lower part of lateral supracondylar line Origin of Gastrocnemius and Plantaris Medial Lateral

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Middle 1/3 of medial border of tibia Soleal line Tendinous arch Back of head of fibula and upper 1/3 of the back of shaft Origin of Soleus

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Insertion of Superficial Muscles

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Middle of the back of calcaneus

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Tendo calcaneus (tendo Achilis) Middle of the back of calcaneus Bursa

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Gastrocnemius

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Tendo Achilis to the middle part of the back of calcaneus Medial head of Gastrocnemius Popliteal surface above medial femoral condyle Area above lateral femoral epicondyle Lateral head of gastrocnemius

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Soleus

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Middle 1/3 of medial border of tibia Soleal line Tendinous arch Back of head of fibula and upper 1/3 of the back of shaft Origin of Soleus

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Soleus Tendo calcaneus Middle of medial border of tibia Soleal line Upper 1/3 of back of fibula Tendinous arch

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Plantaris

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Plantaris Lower part of lateral supracondylar line Tendon of plantaris Medial Lateral Tendo Achilis oblique popliteal ligament

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Tendo calcaneus (tendo Achilis) Middle of the back of calcaneus Bursa

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Action of Superficial Muscles 1- All produce plantar flexion of foot at ankle during walking, running and ballet dancing. 2- Gastrocnemius and plantaris help flexion of knee. 3- Soleus acts as muscle pump that helps venous return.

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Nerve Supply - All are supplied by Tibial nerve in the popliteal fossa (medial popliteal). - Soleus is supplied also by posterior tibial nerve in the back of the leg.

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Deep Muscles (Page 150) Muscle acting on knee J.: - Popliteus. Muscles acting on ankle J.: - Tibialis posterior. - Flexor hallucis longus. - Flexor digitorum longus.

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Popliteus Muscle

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Origin

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Anterior part of the groove below lateral epicondyle (intracapsular extrasynovial) Lateral aspect of knee region

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Anterior part of groove below lateral epicondyle Lateral meniscus

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Insertion

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Back of tibia above soleal line

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Site of exite from the capsule of knee joint Back of tibia above soleal line Lateral Medial

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Action of Popliteus 1- Medial rotation of tibia. 2- Lateral rotation of femur. So, it unlocks the locked knee at the beginning of flexion. 3- Pull the lateral meniscus backwards protecting it against crushing.

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Nerve Supply -Popliteus is supplied by medial popliteal nerve that curves around the lower border and enters the deep surface of the muscle.

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Deep Muscles Acting on Ankle Joint 1- Tibialis Posterior. 2- Flexor hallucis longus. 3- Flexor digitorum longus.

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Origin

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Flex.digit. Long Middle 1/3 of back of tibia medial to vertical line. Tibialis posterior Upper 2/3 of: -Back of tibia lateral to vertical line. -Back of interosseous membrane. -Back of fibula medial to medial crest. Flex.Hallucis longus Lower 2/3 of back of fibula lateral to medial crest Vertical line Medial crest

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Insertion

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Navicular tuberosity for main tendon of tibialis posterior Tendon of flex. Hallucis longus Plantar surfaces of bases of terminal phalanges of lateral 4 toes for flex. Digit. longus

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Tibialis Posterior

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Tibialis posterior Inserted into navicular tuberosity with extensions Origin from upper 2/3 of back of tibia, fibula and interosseous membrane Lateral Medial

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Flexor Hallucis Longus

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Flexor halluces longus Inserted into plantar surface of base of terminal phalynx of big toe Origin from lower 2/3 of back fibula lateral to medial crest & interosseous membrane Lateral Medial

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Grooves for tendon of flexor hallucis longus Lower end of tibia Talus Sustentaculum tali

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Flexor Digitorum Longus

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Flexor digitorum longus Inserted into plantar surfaces of bases of terminal phalynges of lateral 4 toes Origin from middle 1/3 of back of tibia medial to vertical line and below soleal line Lateral Medial

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Relations between Deep Muscles - At lower part of leg, flexor digitorum longus crosses superficial to tibialis posterior. - Deep to flexor retinaculum, tendons are arranged as follow fro medial to lateral: - Tibialis posterior, flexor digitorum longus, vessels and nerve and flexor halluces lonus. - At sustentaculum tali, they are arranged as follow: tibialis posterior above, flexor digitorum at while flexor halluces is below. - Tendon of flexor digitorum crosses tendon of flexor halluces in the second layer of sole.

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Flexor digitorum longus Tibialis posterior Lateral Medial

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Posterior tibial nerve Posterior tibial artery Flexor halluces longus Flexor digitorum longus Tibialis posterior Flexor retinaculum

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Tibialis posterior tendon above sustentaculum Flexor digit. Longus at sustentacul um Flexor halluces below sustentaculum Sustentaculum tali Deltoid ligament

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Action of Deep Muscles on Ankle - All are plantar flexors. - Tibialis posterior invertes the foot and supports medial arch. - Flexor halluces longus flexes big toe and supports medial arch. - Flexor digitorum longus flexes lateral 4 toes.

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Posterior Tibial Nerve(Tibial Nerve in back of leg) (Page 154)

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Course & Relations

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Lower border of popliteus Medial popliteal nerve Tendinous arch Soleus Posterior tibial nerve Flexor digitorum longus Tibialis posterior Flexor hallucis longus Back of lower end of tibia Flexor retinaculum Lateral Medial

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Posterior tibial nerve Flexor retinaculum

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Posterior tibial nerve Posterior tibial artery Flexor halluces longus Flexor digitorum longus Tibialis posterior Flexor retinaculum

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Posterior tibial nerve Medial plantar nerve Lateral plantar nerve

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Branches of Posterior Tibial Nerve 1- Muscular to Soleus, tibialis posterior, flexor hallucis longus and Flexor digitorum longus. 2- Calcanean (cutaneous) branch to medial side of calcaneus. 3- Articular to ankle and tibio-fibular joints. 4- Terminal: medial and lateral plantar nerves.

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Injury of Tibial Nerve Cause: Cut wound Rsults: Motor loss: paralysis of muscles of back of leg and sole of foot. Sensory loss: Decrease of sensation over back of leg, sole and toes.

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Disability and deformity: -Weak plantar flexion and loss of flexion of toes. -Weak inversion of foot. -The foot is dorsiflexed and everted with extension of toes. Late wasting changes: -Wasting of back of leg and sole of foot.

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Posterior Tibial Artery (Page 157)

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Course

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Lower border of popliteus popliteal artery Tendinous arch Soleus (cut) It ends deep to flexor retinaculum midway between medial malleolus and medial tubercle of calcaneus by giving 2 plantar arteries The artery passes downwards between superficial and deep muscles In the lower part of leg the artery lies between lower end of tibia and skin & fascia Posterior tibial artery

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Relations 1- Superficial. 2- Deep. 3- Lateral. 4- Medial. 5- Tripple relation with the nerve.

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Superficial & Deep

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Tendinous arch Soleus Posterior tibial artery Flexor digitorum longus Tibialis posterior Back of lower end of tibia Flexor retinaculum Ankle joint Superficial Deep The artery is covered by skin and fascia

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Lateral & Medial

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Posterior tibial artery Flexor digitorum longus Flexor hallucis longus Tendon of flexor retinaculum Posterior tibial nerve Medial Lateral Tendon of flexor halluces longus Posterior tibial nerve

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Branches

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Posterior tibial artery Circumflex fibular artery Peroneal artery Communicating Medial malleolar Medial calcanean Nutrient to tibia Muscular brs.

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Surface Anatomy

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Middle of back of leg at level of head of fibula Midway between medial malleolus and medial tubercle of calcaneus

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Peroneal Artery

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Course & Relations

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Peroneal artery Flexor hallucis longus Medial Lateral Posterior tibial artery Lateral malleolar art. Lateral calcanean

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Branches of Peroneal Artery

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Communicating Peroneal artery Nutrient to fibula Muscular branches Lateral calcanean Lateral malleolar Perforating

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Flexor Retinaculum

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Flexor Retinaculum Medial tubercle of calcaneus Medial malleolus Tendon of tibialis posterior Tendon of flex.digit. longus Posterior tibial vessels and nerve Tendon of flex.Hallucis longus

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Deep Fascia of the Leg Dr. Sherif Fahmy

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Deep fascia of the leg (fascia cruris) Retinaculae around ankle Dr. Sherif Fahmy

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Skin Superficial fascia Deep fascia (fascia cruris) Interosseous membrane Anterior intermuscular septum Posterior intermuscular septum Medi al Late ral Transverse Section Anterior border of tibia Posterior border of tibia Anterior border of fibula Posterior border of fibula T F Dr. Sherif Fahmy Anterior compartment Posterior compartment Lateral compartment

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Thickening of Deep Fascia Around Ankle (Retinaculae) Dr. Sherif Fahmy

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Thickenings of Deep Fascia Around Ankle (Retinacula) Extensor (Superior & Inferior) Flexor Retinaculum Peroneal retinacula (Inferior & Superior ) Dr. Sherif Fahmy

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Joints of Lower Limb Dr. Sherif Fahmy

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Hip Joint Dr. Sherif Fahmy

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Type: Synovial, multiaxial. Variety: ball & socket. Articular surfaces: 1- Head of femur. 2- lunate surface of acetabulum. 3- Labrum acetabular. Dr. Sherif Fahmy

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Dr. Sherif Fahmy

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Articular capsule: Attachements: A- To margin of acetabulum outside labrum and transverse acetabular lig. B- To neck of femur: 1- Anteriorly: intertrochanteric line. 2- Posteriorly: middle of back of neck. Dr. Sherif Fahmy

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Intertrochanteric line Anterior aspect of capsule Dr. Sherif Fahmy

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Posterior aspect of capsule Dr. Sherif Fahmy

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Synovial Membrane -It lines the capsule and covers intracapsular structures except the articular surfaces. -It covers the ligamentum teres. Dr. Sherif Fahmy

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Ligaments of hip joint: 1- Ilio-femoral. 2- Pubo-femoral. 3- Iscio-femoral. 4- Transverse acetabular. 5- Round lig. of head of femur. Extracapsular Intra-capsular Dr. Sherif Fahmy

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Ilio- femoral lig. Pubo-femoral lig Dr. Sherif Fahmy Ilio-pubic eminence and superior pubic ramus Anterior inferior iliac spine Intertrochant eric line

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Posterior aspect of capsule Dr. Sherif Fahmy

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Transverse acetabular lig. Ligamentum teres Dr. Sherif Fahmy

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Relations of Hip Joint

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Anterior relations: 1- Pectineus m. 2- ilio-psoas m. 3- Straight head of rectus femoris m. 4- Femoral vessels and nerve. Dr. Sherif Fahmy

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Dr. Sherif Fahmy

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Posterior relations: 1- Piriformis m. 2- Obturator internus m. & 2 gemelli 3- Obturator externus m. 4- sciatic nerve. Dr. Sherif Fahmy

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Dr. Sherif Fahmy

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Dr. Sherif Fahmy

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Superior relations: 1- Reflected head of rectus femoris m. 2- Gluteus minimus m. 3- Gluteus medius m. Lateral relations: 1- Tensor fascia lata m. 2- Gluteus minimus m. 3- Gluteus medius m. Dr. Sherif Fahmy

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Inferior relations: 1- Pectineus m. 2- Obturator externus m. Dr. Sherif Fahmy

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Dr. Sherif Fahmy

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Blood supply: 1- Superior & inferior gluteal arteries. 2- Acetabular branches of medial circumflex and obturator arteries. 3- Lateral & medial circumflex femoral arteries. Nerve supply: 1- Femoral n. through nerve to rectus femoris. 2- Obturator nerve (anterior division). 3- Sciatic nerve. 4- Nerve to quadratus femoris. Dr. Sherif Fahmy

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Movement Muscles Flexion Extension Abduction Adduction Medial rotation Lateral rotation Circumduction lio-psoas, sartorius and rectus femoris. Gluteus maximus, hamstrings and ischial part of adductor magnus. Gluteus midium & minimus, tensor fascia lata. Adductor muscles. Gluteus medius & minimus (anterior fibers), adductor longus, brevis, pubic part of magnus. Piriformis, obturators, 2 gemelli, quadratus femoris, sartorius and gluteus maximus. Combination of all movements Dr. Sherif Fahmy

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Stability of the Hip Joint 1- Bony Factor: Head of femur fits well inside the larger acetabulum. 2- Ligaments: Strong ligament specially ilio-femoral lig. 3- Muscular factor: By surrounding muscles. Dr. Sherif Fahmy

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Clinical points: 1- Fracture of neck of femur: common in old age specially in females. Types: 1- Subcapital & cervical lead to avascular necrosis to head so, synthetic prosthesis is needed. 2- Basal & inter-trochanteric fractures lead to saving the head because capsular vessels are preserved. 2- Dislocation: congenital or accidental. 3- Referred pain: from hip to knee. Dr. Sherif Fahmy

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Abnormalities of Neck-Shaft Angle: Coxa Valga: ➢Increased angle, may be associated with congenital dislocation of hip joint. ➢Adduction is limited. Coxa Vara: ➢Decreased angle, may be associated with fracture neck of femur. ➢Abduction is limited.