Lower Limb from Back of Thigh to Femoral Artery

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Back pf Thigh & Knee

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Back of Thigh & Knee 1- Hamstring muscles. 2- Sciatic nerve. 3- Popliteal fossa. 4- Popliteal vessels. 5- Popliteal nerves.

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Sciatic nerve Gluteal Region Back of the thigh Biceps femoris Semitendinosus Semimembranosus Popliteal artery Popliteal vein Popliteal nerves Popliteal fossa Medial Lateral Dr. Sherif Fahmy

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Muscles of the Back of Thigh

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Hamstring Muscles 1- Semimembranosus. 2- Semitendinosus. 3- Biceps femoris.

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Orientation of Hamstring Muscles

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Biceps femoris Semitendinosus Popliteal fossa Gluteus maximus Gastrocnemius Dr. Sherif Fahmy

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Ischeal tuberosity Biceps femoris Semitendinosus Semimembranosus Popliteal fossa Adductor magnus Dr. Sherif Fahmy

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Biceps femoris Semimembranosus Dr. Sherif Fahmy

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Short head of biceps Long head of biceps (cut) Sciatic nerve Dr. Sherif Fahmy

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Attachments of Hamstring Muscles

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Origin of Hamstring Muscles

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Upper quadrangular part of ischeal tuberosity Dr. Sherif Fahmy

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Upper & lateral area (for semi- memranosus) Lower medial area (for semitendinosus & biceps femoris) Upper quadrangular part Dr. Sherif Fahmy

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Short head of biceps femoris

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Insertion of Hamstring Muscles

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Sartorius Gracilis Semitendinosus biceps femoris Anterior view of knee region Dr. Sherif Fahmy

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Groove for semimembranosus Insertion of biceps femoris Posterior view of knee region Soleal line Dr. Sherif Fahmy

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Semimembranosus Muscle

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Upper lateral area of upper quadrangular part of ischeal tuberosity Semimembranosus Muscle Groove for semimembranosus Oblique popliteal ligament Fascia covering popliteus m. Soleal line Dr. Sherif Fahmy

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Semitendinosus Muscle

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Lower medial area of upper quadrangular part of ischeal tuberosity Upper medial side of tibia behind gracilis Semitendinosus Dr. Sherif Fahmy

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Biceps Femoris Muscle

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Lower medial area of upper quadrangular part Long head Short head of biceps Linea aspera and lateral supracondylar line Head of fibula Dr. Sherif Fahmy

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Action of Hamstring Muscles 1- All hamstring muscles flex the knee. 2- All hamstring muscles extend the hip except short head of biceps. 3- Semi-membranosus and semi-tendinosus medially rotate the knee. 4- Biceps femoris laterally rotates the knee. 5- Semitendinosus (one of the guy ropes) stabilizes pelvis over femur. Dr. Sherif Fahmy

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Nerve Supply of Hamstring Muscles -All hamstring muscles are supplied from tibial part of sciatic -Except short head is supplied by common peroneal part of sciatic nerve. Dr. Sherif Fahmy

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Sciatic Nerve (Page 114)

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Sciatic nerve Gluteal Region Back of the thigh Dr. Sherif Fahmy

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Course of Sciatic Nerve

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Piriformis Greater sciatic foramen Back of ischium Posterior superior iliac spine Ischeal tuberosity Tip of greater trochanter Capsule of hip joint Sciatic nerve Dr. Sherif Fahmy

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Greater sciatic foramen Common peroneal nerve. Tibial nerve Sciatic Nerve Dr. Sherif Fahmy

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Relations of Sciatic Nerve 1- Superficial. 2- Deep.

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Superficial Relations

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Dr. Sherif Fahmy Long head of biceps femoris Posterior cutaneous n. of thigh Sciatic nerve

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Deep Relations

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Sciatic nerve Nerve to quadratus femoris Dr. Sherif Fahmy

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Back of ischium Superior gemellus Tendon of obturator internus Inferior gemellus Quadratus femoris Adductor magnus Dr. Sherif Fahmy

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Branches of Sciatic Nerve Tibial division: to semimembranosus, long head of biceps femoris, semitendinosus and ischeal part of adductor magnus. Common peroneal division: To short head of biceps femoris. Articular branch: to hip joint. Terminal: Gives Tibial (medial popliteal) and common peroneal (Lateral popliteal).

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High Division of Sciatic Nerve

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Tibial part Common peroneal part Piriformis Dr. Sherif Fahmy

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Surface Anatomy of Sciatic Nerve

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Posterior superior iliac spine Ischeal tuberosity Tip of greater trochanter Below middle of the back of the thigh Dr. Sherif Fahmy

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Applied Anatomy Causes: 1- Posterior dislocation of hip j. 2- Wrong IM injection. 3- Stab wound or gun shot. Results: 1- Loss of sensation of foot and leg except medial side and upper part of the back of leg. 2- Paralysis of hamstring muscles and all muscles of leg and foot leading to foot drop. N.B. Sciatica: Pain in the back of lower part body, thigh and leg due to pressure on roots of sciatic nerve by tumor or inflammation

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Site of Intra-muscular Injection Dr. Sherif Fahmy

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Popliteal Fossa (Page 121)

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Site, Shape & Boundaries

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Dr. Sherif Fahmy

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Popliteal fossa Dr. Sherif Fahmy

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Biceps femoris Plantaris Semi- memranosus muscle Semi- tendinosus muscle Medial head of gastrocnemius muscle Lateral head of gastrocnemius muscle Lateral Medial Superior angle Inferior angle Lateral angle Medial angle Dr. Sherif Fahmy

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Roof

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Skin and deep fascia of roof of popliteal fossa Posterior cutaneous nerve of thigh Short saphenous vein Dr. Sherif Fahmy

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Floor

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Popliteal surface of femur Capsule of knee joint Oblique popliteal ligament Popliteal muscle and covering fascia Lateral Medial Dr. Sherif Fahmy

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Contents of Popliteal Fossa 1- Popliteal artery and branches. 2- Popliteal vein and tributaries. 3- Popliteal nerves (lateral & medial). 4- Termination of posterior cutaneous of thigh. 5- Termination of small saphenous vein. 6- popliteal lymph nodes and fat.

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Lateral popliteal (common peroneal) n. Medial popliteal (tibial) n. Popliteal vein Popliteal artery Lateral Medial Dr. Sherif Fahmy

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Popliteal Artery (Page 123)

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Course

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Adductor hiatus Popliteal artery Lower border of popliteus m. Posterior tibial art Anterior tibial art It begins It ends Lateral Medial Dr. Sherif Fahmy

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Relations of Popliteal Artery 1- Superficial (Posterior). 2- Deep (Anterior). 3- Lateral. 4- Medial.

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Superficial Relations

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Medial popliteal (tibial) n. Popliteal vein Popliteal artery Lateral Medial Sem-imembranosus Gastrocnemius

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Deep Relations

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Popliteal artery Popliteal surface of femur Capsule of knee joint Oblique popliteal lig. Popliteus muscle and covering fascia

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Lateral & Medial Relations

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Medial popliteal (tibial) n. Popliteal vein Popliteal artery Lateral Medial Sem- imembranosus Lateral head of gastrocnemius Biceps femoris Popliteal nerves Plantaris Medial head of gastrocnemius Popliteal vein

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Branches of Popliteal Artery

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Upper lateral genicular a. Upper medial genicular a. Lower medial genicular a Posterior tibial a. Anterior tibial a. Lower lateral genicular a. Middle genicular a.

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Nerves in the Popliteal Fossa

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Nerves in the Popliteal Fossa 1- Tibial (medial popliteal) n. 2- Common peroneal (lateral popliteal) n. 3- Termination of posterior cutaneous n. of thigh.

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1- Tibial (medial popliteal nerve)

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Medial popliteal nerve (Tibial) Lateral popliteal nerve (common peroneal nerve) Head of fibula Neck of fibula Popliteus Posterior tibial nerve

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Lateral popliteal (common peroneal) n. Medial popliteal (tibial) n. Popliteal vein Popliteal artery Lateral Medial

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2-Lateral popliteal (common peroneal )n.

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Lateral popliteal nerve (common peroneal nerve) Head of fibula Neck of fibula

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Lateral popliteal (common peroneal) n. Lateral Medial Biceps femoris Plantaris Lateral head of gastrocnemius

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Branches of Popliteal Nerves Medial popliteal 1- Genicular (upper medial, lower medial and middle). 2- Cutaneous (sural). 3- Muscular (to gastrocnemius, soleus, popliteus and plantaris). Lateral popliteal 1- Genicular (upper lateral, lower lateral and recurrent). 2- Cutaneous (sural communicating, lateral cutaneous n. of calf)

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Tibial nerve Common peroneal n. Sural nerve Sural communicati ng

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Popliteal Vein

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Medial popliteal (tibial) n. Popliteal vein Popliteal artery Lateral Medial

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Femoral Triangle

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Femoral Triangle (Page 61) It is intermuscular space in front of upper 1/3 of the thigh. Shape: Inverted triangle.

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Femoral Triangle Lateral Medial

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Boundaries

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Medial border of Sartorius muscle Medial border of adductor longus muscle Inguinal ligament Lateral Medial

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Roof

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Ilio-inguinal nerve Femoral branches of genito-femoral nerve Great saphenous vein Fascia lata Superficial inguinal veins

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Superficial inguinal lymph nodse

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Floor

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Iliopsoas muscle Pectineus m. Adductor longus m.

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Contents

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Sartorius (cut) Femoral art. Femoral vein Femoral nerve Femoral branch of genito-femoral nerve Lat. Cut. N. of thigh Medial cut. N. of thigh Saphenous nerve Dr. Sherif Fahmy

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Deep inguinal lymph nodes

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Fascia transversalis Fascia iliaca Femoral artery in the lateral compartment Femoral vein in the middle compartment Femoral canal Lymph node of Cloquet Femoral sheath

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Femoral Canal (Page 65) It is the medial compartment of femoral sheath. Shape: Conical (has apex and base): Apex: Lower closed end (fused anterior & posterior walls of the femoral sheath). Base: Femoral ring which is closed by femoral septum (extraperitoneal fat) Length: 1.5 cm Contents: -Lymph node of Cloquet, Lymph vessels, Fat. Clinical importance: -Allows dead space for distension of femoral vein. -Gives passage of lymph vessels from lower limb to abdomen. -May give a passage for intestine (femoral hernia). Dr. Sherif Fahmy

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Femoral vein Femoral canal (medial compartment of femoral sheath) Lateral Medial Dr. Sherif Fahmy 1.5 cm

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Pectineal lig Femoral ring Femoral vein Dr. Sherif Fahmy Lacunar lig. Inguinal lig. Femoral septum (Extraperitoneal fat) Aponeurosis of external abdominal oblique m. (cut)

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Hernia (Page 66)

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Fundus Hernia is the protrusion of intestine or omentum (peritoneum attached to stomach) through a defect in abdominal wall. Causes: 1- Increased intraabdominal pressure for example in case of chronic cough or constipation. 2- Weakness of the abdominal wall.

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Femoral Hernia (Page 66)

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Femoral hernia: Protrusion of intestine inside femoral canal. Frequency: it is more common in females due to wider femoral ring secondary to wider pelvis. Structure (formation): It is formed of loop of intestine covered with peritoneum. It has neck, body and fundus.

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Direction of descent of the hernia: It takes a U-shaped course. It descends downwards through femoral ring and canal. Then, it passes forewards through saphenous opening. Then, it passes upwards and laterally. Direction of reduction: Reverse to the course of descent. Coverings (from inside to outside): Extraperitoneal fat (femoral septum), fascia transversalis, cribriform fascia, superficial fatty layer and skin.

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Dr. Sherif Fahmy Femoral hernia

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Pubic tubercle Femoral hernia Site of protrusion of femoral and inguinal hernia

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Adductor Canal (Subsartorial or Hunter’s) (Page 68)

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Shape & boundaries of the Canal Sartorius Adductor magnus Vastus medialis Med. Lat Fibrous roof

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Position, Boundaries and Contents

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Sartorius m. Vastus medialis m. Adductor longus m. Adductor magnus m.

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Sartorius m. (cut) Adductor longus m. Adductor magnus m. Vastus medialis m. Femoral artery Femoral vein Saphenous nerve Nerve to vastus medialis Adductor hiatus

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Anastomoses of Lower Limb

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Around Anterior Superior Iliac Spine

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Cruciate

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Femoral Artery (page 75)

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

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Inguinal lig. ASIS Pubic tubercle Sartorius m. Rectus femoris m. V.Lateralis V.Medialis Adductor longus m. Pectinus m. Ilio-psoas m. Adductor magnus m. Gracilis m. Muscles of front & medial side of thigh Medial Lateral Dr. Sherif Fahmy

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Rectus Femoris Sartorius (cut) iliopsoas Pectineus Adductor longus Adductor magnus Adductor hiatus Vastus lateralis Vastus medialis Gracilis Lat. Med. Dr. Sherif Fahmy

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Sartorius (cut) Rectus femoris Vastus lateralis Vastus medialis Ilio- psoas Pectineus (cut) Obturator externus Adductor longus (cut) Adductor brevis Adductor magnus Adductor hiatus Gracilis L. M. Dr. Sherif Fahmy

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Sartorius (cut) Ext iliac art. Femoral art. Adductor hiatus Inguinal ligament Femoral vein Femoral nerve Femoral branch of genito-femoral nerve Lat. Cut. N. of thigh Medial cut. N. of thigh Saphenous nerve Nerve to vastus medialis Dr. Sherif Fahmy Medial Lateral Mid-inguinal point

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Femoral Artery (page 75)

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Course of Femoral Artery It begins ……………………….. It passes ……………………….. It ends ……………………………

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External iliac art. Femoral art. Inguinal ligament Dr. Sherif Fahmy At mid-inguinal point

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Sartorius (cut) Ext iliac art. Femoral art. Course of femoral artery Begins at mid-inguinal point Subsartorial (adductor) canal Adductor hiatus Ends Inguinal ligament Femoral triangle Dr. Sherif Fahmy Medial Lateral

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

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Relations 1- Superficial (anterior). 2- Deep (posterior). 3- Medial. 4- Lateral.

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Anterior (Superficial) Relations

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Sartorius (cut) Femoral art. Femoral branch of genito-femoral nerve Medial cut.n. of thigh Saphenous nerve Anterior (superficial Relations) Dr. Sherif Fahmy Medial Lateral Femoral sheath

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Deep (posterior) Relations

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Psoas part of ilio-poas m. Pectineus m. Adductor longus m. Femoral vein Adductor magnus m. Deep (posterior) relations Dr. Sherif Fahmy Medial Lateral

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Femoral a. Adductor longus Adductor magnus Cont. deep relations Psoas part of ilio-psoas m. Pectineus m. Dr. Sherif Fahmy Medial Lateral

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Medial Relations

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Femoral vein Medial relations Saphenous nerve Dr. Sherif Fahmy Medial Lateral

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Lateral Relations

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Femoral branch of genito-femoral nerve V. Medialis N. To v.medialis Femoral n. Saphenous nerve Lateral relations Dr. Sherif Fahmy Medial Lateral

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Branches of Femoral Artery Superficial branches: -Superficial epigastric. -Superficial external pudendal. -Superficial circumflex iliac. Deep branches: -Deep external pudendal. -Descending genicular. -Profunda femoris.

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1-Superficial circumflex iliac a 2-Superficial epigastric 3-Superficial external pudendal 4-Deep external pudendal Femoral a. 5-Descending genicular a. Dr. Sherif Fahmy Medial Lateral

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Surface Anatomy of Femoral Artery (Page 77)

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Mid-inguinal point Adductor tubercle Upper 2/3 of a line between midinguinal point and adductor tubercle. Dr. Sherif Fahmy Surface Anatomy of Femoral Artery

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Clinical points related to femoral artery:(Page 78) ➢To stop sever bleeding in the lower limb, press the artery against superior pubic ramus at mid-inguinal point. ➢On ligation of femoral artery above origin of profunda femoris artery, blood passes to lower limb through cruciate anastomosis. ➢Catheterization of femoral artery for left heart and kidney angiography.

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Profunda Femoris Artery (Page 78)

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Course of Profunda Femoris Artery

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Femoral a. Pectineus Adductor longus Adductor magnus Dr. Sherif Fahmy 4 cm Medial Lateral

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Profunda femoris artery Femoral artery Femoral vein Pectineus Adductor longus (Cut) Adductor brevis Adductor magnus Dr. Sherif Fahmy 4th perforating Medial Lateral

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Branches of Profunda Femoris Artery Two Circumflex Arteries: 1- Lateral circumflex femoral artery. 2- Medial circumflex femoral artery. Four Perforating arteries: 1- First perforating. 2- Second perforating. 3- Third perforating. 4- Fourth perforating. Dr. Sherif Fahmy

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Circumflex Arteries

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Lateral circumflex femoral artery Medial circumflex femoral artery Dr. Sherif Fahmy Ascending br. Transverse br. Descending branch Medial Lateral

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Medial circumflex femoral artery Transverse branch Ascending branch Branch to anastomosis around greater trochanter Transverse branch of lateral circumflex femoral a. Ascending branch of 1st perforating artery Descending branch of inferior gluteal artery Quadratus femoris m. Adductor magnus m. Dr. Sherif Fahmy Medial Lateral

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Perforating Arteries

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4 perforating arteries Dr. Sherif Fahmy Medial Lateral

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1st perforating artery 2nd perforating artery 3rd perforating artery 4th perforating artery Dr. Sherif Fahmy Medial Lateral Back of Adductor Magnus

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Applied anatomy of femoral artery: -To stop sever bleeding in the lower limb, we should press over the artery against superior pubic ramus at the beginning of the artery. -Catheterization of femoral artery is needed to examine renal angiogram and left side of the heart. -If femoral artery is ligated, blood reaches the lower limb through cruciate anastomosis. Dr. Sherif Fahmy

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Anastomoses of Femoral Artery

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Anastomosis of the Femoral Artery It shares in the following anastomosis: 1- Cruciate anastomosis. 2- Around anterior superior iliac spine. 3- Around Greater trochanter. 4- Around knee. Dr. Sherif Fahmy

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Cruciate Anastomosis It is composed of: Transverse limb: 1- Transverse branch of lateral circumflex femoral a. and transverse branch of medial circumflex femoral a. Vertical limb: 1- Ascending branch of 1st perforating a. (lower part) 2- Ascending branch of medial circumflex femoral a. 3- Descending branch of inferior gluteal a. N.B. 2,3 forms the upper part of vertical limb.Dr. Sherif Fahmy

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Back of Thigh & Gluteal Region Transverse br. of lateral circumflex femoral a. Transverse br. of medial circumflex femoral a. Ascending br. of 1st perforating a. Ascending branch of medial circumflex femoral a. Descending branch of inferior gluteal a. Cruciate anastomosis Dr. Sherif Fahmy Medial

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Anastomosis Around Anterior Superior Iliac Spine It is composed of the following arteries 1- Superficial circumflex iliac artery (from femoral artery). 2- Deep circumflex iliac artery (from external iliac artery). 3- Ascending branch of lateral circumflex iliac artery. 4- Superior gluteal artery. Dr. Sherif Fahmy

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External iliac artery 1-Deep circumflex iliac artery Femoral artery 2-Superficial circumflex iliac artery 3-Ascending branch of lateral circumflex femoral artery 4-Superior gluteal artery Dr. Sherif Fahmy

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Anastomosis Around Greater trochanter 1- Superior gluteal artery. 2- Inferior gluteal artery. 3- Ascending branch of medial circumflex femoral artery.

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Superior gluteal a. Dr. Sherif Fahmy Inferior gluteal a. Ascending branch of medial circumflex femoral a. Anastomosis around greater trochanter

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Anastomosis of the Femoral Artery It shares in the following anastomosis: 1- Cruciate anastomosis. 2- Around anterior superior iliac spine. 3- Around Greater trochanter. 4- Around knee.

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Descending branch Medial circumflex femoral artery Descending

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Transverse branch of lateral circumflex femoral Transverse branch of medial circumflex femoral art Ascending branch of first perforating art.

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1-Superficial circumflex iliac a 2-Superficial epigastric 3-Superficial external pudendal 4-Deep external pudendal Femoral a. 5-Descending genicular a. Dr. Sherif Fahmy