Lower Limb from Gluteal region to Anterior part of Leg

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Gluteal Region (Page 87)

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Gluteal Region 1- Skeleton. 2- Ligaments and sciatic foramina. 3- Muscles: A- Gluteus (maximus, medius and minimus) muscles. B- Lateral rotator muscles. 4- Nerves of gluteal region. 5- Vessels of gluteal region.

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iliac crest Gluteal fold

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Skeleton of Gluteal Region

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Sacrum Ischeal spine ischial tuberosity Gluteal surface of ilium Coccyx Dr. Sherif Fahmy Bursa on greater trochanter Bursa on ischial tuberosity Greater trochanter

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Posterior gluteal line Anterior gluteal line Inferior gluteal line

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Gluteal ligaments and Sciatic Foramina

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Sacrospinous ligament Sacrotuberous ligament Greater sciatic foramen Lesser sciatic foramen Dr. Sherif Fahmy

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Tensor fasciae Latae m. Dr. Sherif Fahmy Gluteus maximus

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Gluteus maximus Deep ¼ inserted into gluteal tuberosity Superficial ¾ inserted into ilio-tibial tract Dr. Sherif Fahmy Muscles of the back of the thigh (Hamstring)

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Gluteus medius (cut) Gluteus minimus muscle Dr. Sherif Fahmy

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Piriformis muscle Superior gemellus muscle Obturator internus muscle Inferior gemellus muscle Quadratus femoris muscle

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Vessels & Nerves of the Gluteal Region

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Dr. Sherif Fahmy

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Arteries of Gluteal Region (Page 92)

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Superior gluteal artery Superificial division Deep division Inferior gluteal artery Internal pudendal artery Cruciate anastomosis

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Nerves of the Gluteal Region (Page 93)

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Superior gluteal nerve Sciatic nerve with nerve to quadratus femoris deep to it Posterior cutaneous nerve of the thigh Inferior gluteal nerve Nerve to obturator internus Pudendal nerve Piriformis muscle

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Sacral Plexus (Page 97) Dr. Sherif Fahmy

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Site, Relations & Formation of Sacral Plexus

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Sacral plexus Dr. Sherif Fahmy Lumbar plexus Site

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Ala of sacrum Ventral primary rami of S1-4 leaving anterior sacral foramena Hip bone Sacrum Sciatic nerve Pudendal nerve Lumbo-sacral trunk (L4,5) Dr. Sherif Fahmy Piriformis m 5th lumbar vertebra

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L4 L5 S1 S2 S3 S4 Dr. Sherif Fahmy Formation of Sacral Plexus Anterior division Posterior division Roots Sciatic nerve Divide Converge

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Branches of Sacral Plexus From roots: -N. to piriformis (S1,2) -Pelvic splanchnic nerve (S2,3,4). From posterior surface (posterior divisions): -Superior gluteal n. (L4,5,S1) -Inferior gluteal n. (L5,S1,2)

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From anterior surface of the plexus: - N. to obturator internus (L5, S1,2). - N. to quadratus femoris (L4,5,S1). Cutaneous branches: - Posterior cutaneous nerve of thigh (S1,2,3). - Perforating cutaneous nerve (S2,3) Terminal branches: - Sciatic (L4,5, S1,2,3). - Pudendal (S2,3,4).

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Ligaments and Foramina of Gluteal Region

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Ligaments of Gluteal Region ➢Sacrospinous ligament. ➢Sacrotuberous ligament.

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Sacrospinous ligament Sacrotuberous ligament Dr. Sherif Fahmy

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Functions of gluteal ligaments ➢Prevent foreword tilt of sacrum at sacroiliac joint, under the effect of the weight of vertebral column. ➢They convert sciatic

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Foramina of Gluteal Region 1- Greater sciatic foramen. 2- Lesser sciatic foramen.

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Sacrospinous ligament Sacrotuberous ligament Greater sciatic foramen Lesser sciatic foramen Dr. Sherif Fahmy

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Contents of Sciatic Foramina

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Superior gluteal vessels Posterior cutaneous nerve of thigh Sciatic nerve with nerve to quadratus femoris (deep to its upper part) Inferior gluteal vessels N.To obturator internus Pudendal nerve Piriformis m. Dr. Sherif Fahmy Internal pudendal a. Tendon of obturator internus m. Inferior gluteal nerve Superior gluteal nerve

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Safe Area for Intramuscular Injection

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Area of intramuscular injection Dr. Sherif Fahmy

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Anterior (Extensor) & Lateral (Peroneal) Compartments of Leg (Page 123) Dr. Sherif Fahmy

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Lateral compartment of leg Anterior intermuscular septum Posterior intermuscular septum Lateral surface of fibula Dr. Sherif Fahmy Lateral surface of tibia Anterior surface of fibula Interosseous membrane Anterior compartment

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Anterior Compartment It contains: 1- Dorsiflexor (extensor) muscles. 2- Anterior tibial artery. 3- Anterior tibial (deep peroneal) nerve. Dr. Sherif Fahmy

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Dorsi-flexor (Extensor) muscles 1- Tibialis anterior muscle. 2- Extensor digitorum longus muscle. 3- Extensor hallucis longus muscle. 4- Peroneus tertieus muscle (if present). Dr. Sherif Fahmy

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Tibialis anterior muscle Extensor digitorum longus muscle Extensor hallucis longus muscle Peroneus tertius muscle Extensor retinaculae Medial Lateral Dr. Sherif Fahmy

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Attachments of Dorsiflexor (Extensor) Muscles Dr. Sherif Fahmy

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Lateral surface of tibia Anterior surface of fibula Interosseous membrane Dr. Sherif Fahmy

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Tibialis anterior m. (from upper 2/3 of lateral surface of tibia) Extensor hallucis longus m. (from middle 2/4 of anterior surface of fibula) Extensor digitorum longus m. (from upper ¾ of anterior surface of fibula) Peroneus tertius m. (from lower ¼ of anterior surface of fibula) Origin of dorsiflexor (extensor) muscles Interosseous membrane Dr. Sherif Fahmy

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Insertion of tibialis anterior m. (Medial aspects of medial cuneiform bone and base of 1st metatarsal bone) Insertion of Extensor halluces longus (Dorsal aspect of base pharynx of big toe) Insertion of peroneus tertius m. (Dorsal aspect of base of 5th metatarsal bone) Insertion of extensor digitorum longus (extensor expansion to dorsum of all phalanges of lateral 4 toes) Insertion of Dorsiflexor (extensor) muscles Dr. Sherif Fahmy

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Actions of the Muscles of Leg Dorsi flexion of the foot is done by any muscle that reaches the foot infront the ankle between 2 malleoli. Planter flexion is done by any muscle that reaches the foot behind the ankle and the 2 malleoli. Any muscle named tibialis will produce inversion of foot and support the medial longitudinal arch. Any muscle named peroneus will produce eversion of foot and support the lateral longitudinal arch. Dr. Sherif Fahmy

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Tibialis Anterior Muscle Dr. Sherif Fahmy

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Tibialis anterior m. Origin: Upper 2/3 of lateral surface of tibia and interosseous membrane Insertion: into medial aspects of medial cuneiform and base of 1st metatarsal bone Dr. Sherif Fahmy

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Action & nerve supply Action: 1- Dorsiflex (extends) the foot at ankle j. 2- Inversion of foot at subtalar and talo- calcaneonavicular joints. 3- Supports medial longitudinal arch. Nerve supply: - Anterior tibial (deep peroneal) nerve from common peroneal nerve. Dr. Sherif Fahmy

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Extensor Digitorum Longus Dr. Sherif Fahmy

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Insertion: Extensor expansion of lateral 4 toes Dr. Sherif Fahmy Extensor digitorum longus muscle Origin: Upper ¾ of anterior surface of fibula & interosseous membrane

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Action & Nerve Supply Action: 1- Extends all joints of lateral 4 toes. 2- Dorsiflex foot at ankle joint. Nerve supply: - Anterior tibial (deep peroneal) nerve from common peroneal nerve. Dr. Sherif Fahmy

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Extensor Hallucis Longus M. Dr. Sherif Fahmy

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Extensor hallucis longus muscle Origin: From middle 2/4 of anterior surface of fibula & interosseous membrane Insertion: Into dorsum of base of terminal phalanx of big toe Dr. Sherif Fahmy

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Action & Nerve Supply Action: 1- Extends all joints of big toe. 2- Dorsi-flexes foot at ankle joint. Nerve supply: - Anterior tibial (deep peroneal) nerve from common peroneal nerve. Dr. Sherif Fahmy

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Peroneus Tertius Muscle Dr. Sherif Fahmy

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Peroneus tertius Origin: From lower ¼ of anterior surface of fibula & interosseous membrane Insertion: Into dorsum of base of 5th metatarsal Dr. Sherif Fahmy

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Action & Nerve Supply Action: 1- Dorsi-flexes foot at ankle joint. 2- Eversion of foot at subtalar joint. 3- Supports lateral longitudinal arch. Nerve supply: - Anterior tibial (deep peroneal) nerve from common peroneal nerve. Dr. Sherif Fahmy

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Lateral (Peroneal) Compartment of the Leg (Page 132) Dr. Sherif Fahmy

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Lateral compartment of leg Anterior intermuscular septum Posterior intermuscular septum Lateral surface of fibula Dr. Sherif Fahmy

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Contents of Lateral Compartment Muscles: -Peroneus longus muscle. -Peroneus brevis muscle. Nerve: -Superficial peroneal Dr. Sherif Fahmy

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Attachments of Muscles of Lateral compartment of Leg Dr. Sherif Fahmy

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Origin of peroneus longus m. from upper 2/3 of lateral surface of fibula & intermuscular septa Origin of peroneus brevis m. from lower 2/3 of lateral surface of fibula & intermuscular septa Insertion of peroneus brevis to tuberosity of base of 5th metatarsal bone Insertion of peroneus longus muscle Groove on lower surface of cuboid Peroneal trochlea Cuboid Lateral malleolus Lateral surface of Calcaneus Dr. Sherif Fahmy

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Peroneus longus muscle Peroneus brevis Lateral malleolus Calcaneus Dr. Sherif Fahmy

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Peroneus Longus Muscle Dr. Sherif Fahmy

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Peroneus longus m. Cuboid bone Tendon of peroneus longus in sole of foot Lateral aspect of base of 1st metatarsal bone Lateral aspect of medial cuneiform bone Long plantar ligament Dr. Sherif Fahmy

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Action & Nerve Supply of Peroneus Longus Muscle Action: 1- Planter flexion of foot at ankle. 2- Eversion of foot at subtalar joint. 3- Supports lateral and transverse arches. Nerve supply: - Superficial peroneal (musculo-cutaneous) nerve. Dr. Sherif Fahmy

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Peroneus Brevis Muscle Dr. Sherif Fahmy

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Peroneus brevis m. Lateral malleolus Dr. Sherif Fahmy

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Action & nerve supply Action: 1- Planter flexion of foot at ankle. 2- Eversion of foot at subtalar joint. 3- Supports lateral arch. Nerve supply: - Superficial peroneal (musculo-cutaneous) nerve. Dr. Sherif Fahmy

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Anterior Tibial (Deep peroneal) Nerve (Page 126) Dr. Sherif Fahmy

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Common peroneal nerve Lateral angle Dr. Sherif Fahmy

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Lateral popliteal nerve (common peroneal nerve) Head of fibula Neck of fibula Dr. Sherif Fahmy

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Common peroneal nerve Deep peroneal nerve Superficial peroneal nerve Peroneus longus Extensor digitorum longus Tibialis anterior m. Dr. Sherif Fahmy

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Tibialis anterior m. Anterior tibial a. Extensor digitorum longus m. Anterior tibial nerve Extensor hallucis m. Superior extensor retinaculum Inferior extensor retinaculum Medial division Lateral division Dr. Sherif Fahmy

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Branches of Anterior Tibial Nerve 1- Muscular to muscles of anterior compartment of the leg. 2- Articular to ankle joint. 3- Terminal branches: - Medial to skin between big and second toes. - Lateral to extensor digitorum brevis and intertarsal joints of foot. Dr. Sherif Fahmy

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Injury of Anterior Tibial Nerve Cause: Fracture neck of fibula. Motor loss: Paralysis of dorsiflexor muscles and extensor digitorum brevis muscle. Sensory loss: Loss of sensation between big and 2nd toes. Disability & deformity: -Loss of dorsiflexion of foot (foot drop). -Loss of extension of all toes. -Week inversion. Late wasting changes: Decrease of the size of anterior compartment. Dr. Sherif Fahmy

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Anterior Tibial Artery (Page 129)

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Course of Anterior Tibial artery

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Anterior tibial a. Popliteal artery Interosseous membrane Begins Popliteus muscle

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Branches of Anterior Tibial Artery 1- Posterior tibial recurrent. 2- Anterior tibial recurrent. 3- Muscular. 4- Anterior medial malleolar. 5- Anterior lateral malleolar. Anastomosis around Knee Anastomosis around ankle

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Anterior tibial recurrent Muscular branches Anterior medial malleolar Anterior lateral malleolar

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Surface Anatomy

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Midway between head of fibula and tibial tuberosity Midway between 2 malleoli

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Superficial Peroneal (Musculo-cutaneous ) Nerve (Page 135) Dr. Sherif Fahmy

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Common peroneal nerve Superficial peroneal (musculocutaneous) Dr. Sherif Fahmy

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Superficial peroneal nerve Dr. Sherif Fahmy

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Injury of Superficial peroneal Nerve Dr. Sherif Fahmy

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Cause: Fracture neck of fibula. Motor loss: Paralysis of peroneal muscles. Sensory loss: Loss of sensation in anterior surface of lower 1/3 of leg and dorsum of foot except ????. Disability & deformity: -Loss of eversion. -Weak plantar flexion. -The foot is inverted and dorsiflexed. Late wasting changes: Decrease of the size of lateral compartment. Dr. Sherif Fahmy

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Injury of Common Peroneal Nerve Cause: Fracture neck of fibula. Motor loss: Paralysis of dorsiflexor muscles, peroneal and extensor digitorum brevis muscle. Sensory loss: Loss of sensation infront of lower 1/3 of leg and dorsum of foot except lateral margin (sural) and medial margin till metatarsophalangeal j. of big toe (saphenous). Disability & deformity: -Loss of dorsiflexion and eversion of foot -Loss of extension of all toes. -Foot drop and inverted foot. Late wasting changes: Decrease of the size of anterior and lateral compartments. Dr. Sherif Fahmy