Lower limb from the Thigh to Obturator Canal

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The Thigh

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Skeleton & Inguinal Ligament

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ASIS Iliac crest Pubic tubercle Pubic arch

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Sacrum ASIS Tubercle of iliac crest Ischeal tuberosity

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Iliac crest Sacrotuberous ligament Ischeal tuberosity Posterior aspect of root of thigh Back of sacrum

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Pubic arch Iliac crest A.S.I.S. Pubic tubercle Knee region

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Dr. Sherif Fahmy Inguinal ligament Aponeurosis of ext. oblique muscle

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Fasciae of the Thigh A-Superficial Fascia (2 layers): 1. Superficial fatty. 2. Deep membranous. B-Deep fascia It is named fascia lata = broad.

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Superficial Fascia It is composed of 2 layers: 1. Superficial fatty. 2. Deep membranous.

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Inguinal ligament Line of fusion between membranous layer of superficial fascia and fascia lata

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Contents of Superficial Fascia 1- Superficial inguinal lymph nodes. 2- Cutaneous nerves. 3- Superficial inguinal vessels.

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Great saphenous vein Superficial inguinal arteries Superficial inguinal lymph nodes

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Fascia Lata (Deep Fascia of Thigh) (Page 48)

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Strong non-elastic stocking around thigh. Attachments of Fascia Lata 1- Upper: to root of thigh: ➢inguinal ligament (anterior) ➢Pubic arch (medially) ➢Iliac crest (lateral & posterior) ➢Sacrum & sacrotuberous ligament (posterior) 2- Lower: to knee region ➢Two tibial condyles, two femoral condyles and patella.

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Inguinal ligament Pubic arch Iliac crest A.S.I.S. Pubic tubercle Knee region

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Inguinal ligament Iliac crest Pubic arch Fascia lata Knee region

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Iliac crest Sacrotuberous ligament Ischeal tuberosity Posterior aspect of root of thigh Back of sacrum

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Features of Fascia Lata It has: 1. Lateral thickening (Ilio-tibial tract). 2. Saphenous opening. 3. Inter-muscular septa.

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Ilio-tibial Tract

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Ilio-tibial tract Tensor fasciae latae muscle Patella Anterolateral aspect of upper end of tibia (lateral tibial condyle) Tubercle of iliac crest Fibula Lateral Medial

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Ilio-tibial tract Tensor fasciae latae muscle Superficial ¾ of Gluteus maximus muscle

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Functions of Ilio-tibial Tract ➢It extends the action of gluteus maximus and tensor fasciae latae muscles to knee joint to: 1. Extends the knee. 2. Abduct the thigh at hip j. ➢Stabilizes knee & hip joints.

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Saphenous Opening

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Falciform margin of saphenous opening Saphenous opening Great saphenous vein Superficial inguinal arteries Superficial inguinal lymph nodes

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Femoral sheath Femoral artery Femoral vein Femoral nerve Dr. Sherif Fahmy Femoral canal

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Compartments of Thigh

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Lateral intermuscular septum Medial intermuscular septum Posterior intermuscular septum Anterior compartment Posterior compartment Medial compartment T.S. of the Thigh Dr. Sherif Fahmy Linea aspera Fascia lata Lateral Medial

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Muscles of Front of the Thigh (Anterior Compartment) (Page 56) A- Two muscles from the abdomen: 1- Psoas major. 2- Iliacus. B- Two muscles in the thigh: 1- Sartorius. 2- Quadriceps femoris.

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Sartorius m. Quadriceps femoris muscle Ilio-psoas muscle Inguinal lig. Dr. Sherif Fahmy

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T12

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Iliac fossa of hip bone Lesser trochanter Ala of sacrum Inguinal lig.

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Psoas Major Muscle

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Psoas major m. T12 Lumbar vertebrae Ilio-psoas tendon to lesser trochanter & 1 inch below Inguinal lig.

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Lumbar arteries

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Iliacus Muscle

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Psoas major m. Ilio-psoas tendon to lesser trochanter & 1 inch below Inguinal lig. Iliacus m.

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Upper 3 lumbar nerves Femoral nerve

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Sartorius Muscle (page 57)

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Origin of sartorius (ASIS) Insertion of Sartorius in the upper medial side of Tibia. Hip joint Knee joint Dr. Sherif Fahmy

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Sartorius m. Inguinal lig. ASIS Upper medial side of tibia Dr. Sherif Fahmy

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Sartorius m. Gracilis m. Semitendinosus m. Guy rope muscles

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Sartorius m Gracilis m. Semitendinosus m. Guy Rope Muscles

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Important Relations of Sartorius Muscle

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Sartorius m. Inguinal lig. Femoral triangle Relation of Sartorius to Femoral triangle Dr. Sherif Fahmy

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Sartorius (cut) Adductor canal Relations of Sartorius to Adductor (Subsartorial ) Canal Dr. Sherif Fahmy

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Quadriceps Femoris Muscle (Page 59)

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Sartorius m. Quadriceps femoris m Ilio-psoas muscle Tensor fascia lata Dr. Sherif Fahmy

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Heads of Quadriceps 1- Rectus femoris. 2- Vastus Intermedius. 3- Vastus lateralis. 4- Vastus medialis.

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Rectus femoris Vastus medialis Vastus lateralis Dr. Sherif Fahmy

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Rectus femoris m. (cut) Vastus medialis Vastus intermedieus Vastus lateralis Dr. Sherif Fahmy

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Origin of Quadriceps femoris Muscle

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Rectus Femoris

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Origin of rectus femoris m. Dr. Sherif Fahmy

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Origin of rectus femoris Dr. Sherif Fahmy

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Anterior inferior iliac spine Straight head of rectus femoris Reflected head of rectus femoris

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Vastus Intermedius

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Origin of vastus intermedius from upper 2/3 of anterior and lateral surfaces of shaft of femur Dr. Sherif Fahmy

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Vastus Lateralis & Medialis

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Intertrochantric line Spiral line Gluteal tuberosity Linea aspera Medial supracondylar line Back Front Greater trochanter Less trochanter Dr. Sherif Fahmy

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Upper part of origin of vastus medialis Upper part of vastus lateralis Dr. Sherif Fahmy Intertrochanteric line

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Origin of vastus medialis Origin of vastus lateralis

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Vastus lateralis Vastus medialis

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Insertion of Quadriceps Femoris Muscle

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Common tendon Base of patella Ligamentum patellae Tibial tuberosity Patellar retinacula

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Articularis Genu M.

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Articularis genu muscle Upper part of synovial membrane of knee joint Dr. Sherif Fahmy

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Articularis genu m. Synovial membrane of knee joint (Supra-patellar bursa)

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Nerve Supply of Muscles of Front of Thigh Femoral nerve supplies all muscles of anterior compartment of thigh except psoas major which is supplied by upper 3 lumbar nerves.

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Femoral nerve

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Spotting

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ASIS Sartorius m. Rectus femoris Tensor fascia lata V.medialis Iliacus m Psoas major m. Ilio- psoas m. Inguinal ligament Pectineus m. Adductor longus m. Gracilis m. Dr. Sherif Fahmy

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Muscles of Medial Compartment (Adductors) of the Thigh (Page 57)

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Orientation of Muscles of Anterior and Medial Compartment of Thigh Dr. Sherif Fahmy

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ASIS Sartorius m. Rectus femoris Tensor fascia lata V.medialis Iliacus m Psoas major m. Ilio-psoas m. Inguinal ligament Pectineus m. Adductor longus m. Gracilis m. Dr. Sherif Fahmy V. Lateralis Ilio-tibial tract

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Rect us Femo ris Sartor ius (cut) iliopso as Pectin eus Adduct or longus Adduct or magnu s Adducto r hiatus Vastus lateral is Vastu s media lis Gracili s Lat. Med. Dr. Sherif Fahmy

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Sartor ius (cut) Rectu s femori s Vastu s lateral is Vastus medial is Ilio- psoas Pectin eus (cut) Obtura tor extern us Adduct or longus (cut) Adduct or brevis Adduct or magnu s Adduct or hiatus Gracil is L. M. Dr. Sherif Fahmy

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Adductor Muscles 1- Pectineus. 2- Gracilis. 3- Adductor longus. 4- Adductor brevis. 5- Adductor magnus.

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Medial compartement (adductors) of the thigh Site of Medial Compartment of Thigh

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Origin of Adductor Muscles

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Pectineal surface Pubic body Inferior pubic ramus Ischeal ramus Lower lateral part of lower triangular area of ischeal tuberosity Pubic crest Dr. Sherif Fahmy Pubic tubercle

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pectineus adductor longus gracilis Adductor brevis Adductor magnus Dr. Sherif Fahmy

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Insertion of Adductor Muscles

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Pectineal line Linea asper a Medial supracondylar line Adductor tubercle Dr. Sherif Fahmy Gluteal tuberosity

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Pectineus & Adductor longus Muscles (Page 57 & 59)

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Pectineu s Pectineal surface and line Pectineal line Rounded tendon below pubic crest Adductor longus Linea aspera Dr. Sherif Fahmy

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Adductor Brevis & Gracilis

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Adductor brevis m. Lower ½ of pectineal line and upper part of linea aspera Gracilis m. Sartorius m. L M Pubic body & inferior pubic ramus Upper medial side of tibia Dr. Sherif Fahmy

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Adductor Magnus (Page 59)

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Pubic part Ischeao-pubic ramus (outer surface of pubic arch) Medial margin of gluteal tuberosity Medial lip of linea aspera Medial supracondylar line Lateral area of lower triangular part of ischeal tuberosity Ischial part Adductor tubercle Adductor hiatus Dr. Sherif Fahmy

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Nerve Supply of Adductor Muscles -All adductors are supplied by obturator nerve except: -Pectineus is supplied by femoral nerve, accessory obturator or anterior division of obturator n. -Ischial part of adductor magnus is supplied by tibial part of sciatic nerve. N.B. Anterior division of obturator nerve supplies adductor brevis, adductor longus, Gracilis. Posterior division of obturator nerve supplies Dr. Sherif Fahmy

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Action of Adductor Muscles 1- All are adductors of thigh. 2- Adductor longus, brevis and pubic part of magnus are medial rotators of thigh. 3- Pectineus flexes hip and gracilis flexes and medially rotates leg. 4- Ischial part of adductor magnus extends hip j. Dr. Sherif Fahmy

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Relations of Adductor Magnus

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Anterior Posterior Sciatic n. Hamstring ms Anastomosi s between perforating arteries Cruciate anastomosis Gracilis m. is medial. Dr. Sherif Fahmy

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Relations of Adductor Magnus Anterior: Pectineus, adductor longus, adductor brevis, femoral vessels, profunda vessels and posterior division of obturator. Posterior: Hamstring muscles, sciatic nerve and anastomosis between perforating arteries. Medial: Gracilis muscle. Perforations: It is perforated by 4 perforating arteries. Femoral vessels pass through adductor hiatus. Cruciate anastomosis: Above the upper border of the muscle on the back of thigh.

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➢ Muscle strains (overstretch, pulled muscle, tear of some muscle fibers) of the adductor longus may occur in horseback riders and produce pain (rider’s strain). ➢ Ossification sometimes occurs in the tendons of adductor muscles. ➢ The ossified tendons are called riders’ bones. Applied Anatomy of Adductor Muscles

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Obturator Nerve (Page 82)

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L1 L2 L3 L4 Accessory obturator n. if present Obturator n. L5 Dr. Sherif Fahmy

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Obturator n. Lumbo- sacral trunk Psoas major m. Dr. Sherif Fahmy

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Obturator n. Obturator n. in obturator canal Dr. Sherif Fahmy

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Obturator nerve Obturator externus Adductor brevis Adductor longus m. Anterior division Posterior division Gracilis Dr. Sherif Fahmy The nerve passes forewords in the lateral pelvic wall till it reaches obturator canal

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Pectineus (cut) Obturator externus Anterior division of obturator nerve Adductor brevis Posterior division of obturator n. Gracili s Adductor longus (cut) Adductor magnus Dr. Sherif Fahmy Dr. Sherif Fahmy

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Branches of Obturator Nerve Anterior division: A-Muscular: To adductor brevis, adductor longus, gracilis and may give a branch to pectineus. B-Articular: To hip joint. C-Cutaneous: To small area in the middle of medial surface of the thigh. Posterior division: A-Muscular: To obturator externus, adductor brevis and pubic part of adductor magnus. B-Articular: To knee joint.

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Obturator Artery (Page 81)

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Internal iliac art. Dr. Sherif Fahmy Obturator artery

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Obturator art. Anterior division Posterior division Acetabular br. Obturator membrane Dr. Sherif Fahmy

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Abnormal Obturator Artery

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Inferior epigastric artery Obturator artery from internal iliac artery Pubic branch of inferior epigastric a. Pubic branch of obturator artery Inner aspect of anterior abdominal wall Abnormal obturator artery Abnormal obturator artery (30 % of cases) External iliac artery Inner aspect of superior pubic ramus Dr. Sherif Fahmy

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Abnormal obturator artery: ➢In 30 % of cases, obturator artery is absent (not arising from internal iliac artery). ➢In this case, pubic branch of inferior epigastric artery is enlarged to replace the absent obturator. ➢It is named abnormal obturator artery. ➢Abnormal obturator artery may be injuried in femoral hernia operation.