Lower Limb Part 1-hip joint/ gluteal region/ compartments of thigh

compartments of femoral sheath

ArVeC It has 3 compartments: Lateral compartment: the femoral artery Intermediate compartment: the femoral vein Medial compartment: femoral canal **Not including femoral n.! contains femoral a., v. & lymph node!

An obese 48-year-old woman presents with a painful lump in her proximal thigh, just medial to the femoral vessels. Examination reveals the herniation of some abdominal viscera, which passes under the inguinal ligament. Through which of the following openings has this hernia passed to enter her thigh? A. Deep inguinal ring B. Femoral ring C. Fossa ovalis D. Obturator canal E. Superficial inguinal ring

B

common lesion sites + clinical signs of femoral n.

Common lesion site: -Lateral psoas major muscle abscess -Significant trauma to the pelvic girdle Clinical signs: -Weakness in knee extension (Loss of quadriceps muscle) -Slight weakness in hip flexion -Sensory loss on skin of anterior thigh and on the medial side of leg and ankle -saphenous nerve

common lesion sites + clinical signs of obturator n.

Common lesion site: -Surgery and tumors affecting lateral pelvic wall -Childbirth -Medial psoas major muscle abscess Clinical signs: -Weakness in hip adduction ( Loss of adductor compartment muscles) -Weakness in medial rotation of the hip -Limited sensory loss on medial side of the thigh

A 22-year-old man suffers a dislocation of the right hip in a car accident. During recovery he finds he has an abnormal gait which his left hip sinks when he lifts that foot to take a step. This problem may be the result of damage to which of the following structures? A. Right gluteus maximus and inferior gluteal nerve B. Left gluteus maximus and superior gluteal nerve C. Left gluteus medius and inferior gluteal nerve D. Right gluteal medius and superior gluteal nerve E. Right gluteus minimus and inferior gluteal nerve

D **positive trendelenberg sign

femoral triangle contents

NAVEL From lateral to medial, are as follows: -Femoral nerve and its (terminal) branches -Femoral artery and several of its branches -Femoral vein and its proximal tributaries (e.g., the great saphenous vein and profunda femoris vein) **empty space bw vein and lymph -Deep inguinal lymph nodes and associated lymphatic vessels

Lymphatic drainage of lower limb

Superficial inguinal nodes: receives lymph from the thigh, perineum, gluteal region and lower abdominal wall Deep inguinal nodes: receives lymph from superficial inguinal nodes and all the deep structures of the lower limb Popliteal nodes: receives lymph from the heel, lateral side of the foot & back of the leg. **Superficial and deep inguinal nodes drain into external iliac nodes

Trochanteric and Ischial Bursitis

Trochanteric bursitis: -It is characterized by point tenderness over the greater trochanter; -the pain often radiates along the iliotibial tract. Ischial bursitis: - results from excessive friction between the ischial bursae and the ischial tuberosities (e.g., as from cycling)

Surface anatomy & Skeleton of lower limb-Pelvic girdle

a bony ring composed of the sacrum and right and left hip bones joined anteriorly at the pubic symphysis

medial compartment of thigh

adduct thigh includes the: -adductor longus -adductor brevis -adductor magnus -pectineus -gracilis obturator n.

weight transmission

cranium-> upper limb-> lower vertebral column-> sacro-iliac joint-> head of femur->neck of femur-> shaft of femur-> humeral trochanters-> tibia-> foot=tarsal bones

anterior compartment of thigh

flex hip/thigh, extend knee/leg -iliacus -psoas major -sartorius -pectineus -quadriceps femoris...rectus femoris, vastus lateralis/medialis/intermedius -femoral n.

posterior compartment of thigh

flex knee/leg & extend hip/thigh -biceps femoris -semitendinosus -semimembranosus tibial n. (sciatic n. branch)

innervation of obturator n.

muscle innervation: medial thigh sensory innervation: skin of medial side of thigh

longest cutaneous n. in body

saphenous n....branches from femoral n. & associated w great saphenous v.

Coxa Vara and Coxa Valga

vara= decreased angle of inclination valga= increased angle of inclination --The femur L-shaped, so that the long axis of the head and neck project superomedially at an angle to that of the obliquely oriented shaft --This obtuse angle of inclination in the adult is 115-140 degrees, averaging 126 degrees. -The angle is less in females. --The angle of inclination varies with age, sex, and development of the femur. --It also may change with any pathological process that weakens the neck of the femur (e.g., rickets)

femoral triangle boundaries/borders

***located on the anterosuperior aspect of the thigh Base of the triangle: Inguinal ligament Lateral boundary: Sartorius muscle Medial boundary: Adductor longus muscle Apex : Medial border of the sartorius crosses the lateral border of the adductor longus. Floor: IPA from lateral to medial, are as follows: Iliopsoas muscle Pectineus Adductor longus

Adductor canal/ subsartorial canal/Hunter canal

**Extends from the apex of the femoral triangle - to the adductor hiatus in the tendon of adductor magnus. Provides passage for: -Femoral artery -Femoral vein -Saphenous nerve Roof : sartorius muscle

femoral pulse/compartment blood supply

**Summary of blood supply to the compartments of the thigh: Femoral artery --Anterior compartment muscles Obturator artery --Medial compartment muscles Perforating arteries (deep femoral) --Posterior compartment muscles

Cannulation of Femoral vein

**can provide access to the right side of the heart for angiography, pressure measurements --secure blood samples and take pressure recordings from the chambers of the right side of the heart and/or from the pulmonary artery and to perform right cardiac angiography, a long, slender catheter is inserted into the femoral vein as it passes through the femoral triangle. Under fluoroscopic control, the catheter is passed superiorly through the external and common iliac veins into the inferior vena cava and right atrium of the heart. **The femoral vein position can be located by feeling the pulsations of the femoral artery, which lies just lateral to it.

femoral ring + boundaries

**formed at the base of the femoral canal (approximately 1 cm in diameter) --Proximal opening at its abdominal end SSuLI --The boundaries: Laterally: a femoral septum between the femoral canal and the femoral vein; Posteriorly: the superior ramus of the pubis covered by the pectineal ligament; Medially: the lacunar ligament; Anteriorly: the medial part of the inguinal ligament.

femoral canal

**medial comp of femoral sheath --Extends distally till the saphenous opening --Function: -allows the femoral vein to expand during increased venous return from the lower limb or intra-abdominal pressure causes a temporary stasis in the vein --Contents: -loose connective tissue, fat, a few lymphatic vessels, and sometimes a deep inguinal lymph node (Cloquet node)

femoral hernia

**more common in females **site: femoral ring --characterized as protrusion of abdom viscera-> thru fem ring-> in2 fem canal **enlarges if passes thru saphenous opening in2 subcut tissue of thigh **Strangulation of a femoral hernia may lead to vascular impairment resulting in death of the tissues.

Femoral Pulse and Cannulation of Femoral Artery

**palpable inferior 2 midpoint of inguinal l. **fem a. manually compressed @ l. midpoint 4 arterial bleeding ctrl after trauma **fem a. may be cannulated just inferior to the midpoint of the inguinal ligament **left cardiac angiography, a long slender catheter is inserted percutaneously into the femoral artery and passed superiorly in the aorta to the openings of the coronary arteries.

Superior Gluteal Nerve (L4-5, S1) Trauma or compression in gluteal region

-Loss of pelvic stability during walking -Positive Trendelenburg sign: -is characterized by the pelvis falling and drooping to the side where the foot is raised off the floor (unsupported or swing side) during walking. -The patient will shift the weight of the trunk to the nerve lesion side (supported or stance side) to help maintain balance and center of gravity. -The patient presents with a waddling gait (Duchenne limp) Weakened hip abduction. -The weakness results from paralysis of the gluteus medius and minimus muscle on the side opposite the raised foot.

Arterial supply of hip joint

-Medial circumflex femoral arteries gives - retinacular artery -Main supply to the head of femur -Lateral circumflex femoral arteries -Artery to the head of femur, a branch of the obturator artery that traverses the ligament of the head of hip bone

innervation of femoral n.

-Muscle innervation: Front of thigh muscles -Sensory innervation: skin of anterior thigh and on the medial side of leg and ankle (saphenous nerve)

gluteal region deep layer

-Piriformis -Obturator internus -Superior & inferior gemelli -Quadratus femoris

common lesion sites sciatic n.

-Posterior dislocation of the head of the femur -Herniated lumbar discs -Improperly placed intramuscular injection -Piriformis entrapment syndrome -Car accidents -Hip implant

Femoral Neck Fx

--These fractures are especially common in individuals older than 60 years of age, especially in women because their femoral necks are often weak and brittle as a result of osteoporosis. --The retinacular arteries are the branches of medial circumflex artery are often torn when the femoral neck is fractured, or the hip joint is dislocated. --The fractured fragment may undergo avascular necrosis (AVN—also called osteonecrosis)

gluteal region superficial layer

-Gluteus maximus -Gluteus medius -Gluteus minimums -Tensor fasciae latae

Ligaments of the hip joint

-Iliofemoral -Pubofemoral -Ischiofemoral -labrum -Transverse acetabular -Ligamentum teres -capsular

Surface anatomy & Skeleton of lower limb-Foot or foot region

-Includes the tarsus, metatarsus, and phalanges (toe bones). -The superior surface is the dorsum of the foot; -the inferior, ground-contacting surface is the plantar region (sole).

Injury to sciatic nerve

-Incomplete section of the sciatic nerve (e.g., from a stab wound) may involve the inferior gluteal and/or the posterior femoral cutaneous nerves. -A pain in the buttocks may possibly result from compression of the sciatic nerve by the piriformis muscle (piriformis syndrome).

Intragluteal Injections

-Injections into the buttocks are safe only in the superolateral quadrant of the buttocks -Complications of improper technique include nerve injury, hematoma, and abscess formation. **out and up**

medial rotators of hip joint

-anterior prts of gluteus medius & minimus -tensor fasciae latae

Extensors of hip joint

-gluteus maximus -hamstring (bicep femoris, semitendinosus, semimembranosus) -post part of adductor magnus

Abductors of hip joint

-gluteus medius -gluteus minimus -tensor fascia lata

lateral rotators of hip joint

-obturator externus and internus -piriformis -gemelli -quadratus femoris -gluteus maximus

adductors of hip joint

-pectineus -adductor longus -adductor brevis -adductor magnus -obturator externus -gracilis

Hamstring injuries

-tear at the proximal attachment of the hamstrings -Common in people who run and/or kick hard (e.g., quick-start sports such as sprinting, baseball, and soccer)

posterior hip dislocation

1. Force applied to a flexed knee, extremity appears shortened 2. Tx = closed reduction under conscious sedation 3. Complications = sciatic nerve injury, avascular necrosis

femoral and obturator nerves

L2-L4 femoral n. comes from posterior region obturator n. comes from anterior region

obturator n.

L2-L4 origin: Anterior division,

sciatic nerves

L4-S3 nerve extending from the base of the spine down the thigh, lower leg, and foot --2 divisions: -->tibial n. (flexors) = back of thigh/leg & plantar surface of foot -->common fibular/peroneal n. (extensors) = anterior & lateral leg, dorsum of foot

Surface anatomy & Skeleton of lower limb-Thigh or femoral region

It has the femur, which connects the hip and knee joints.

Deep venous thrombosis (DVT)

---One or more of the deep veins of the lower limb is characterized by swelling, warmth, and erythema (inflammation) and infection. ---Venous stasis (stagnation) is an important cause of thrombus formation. ---Venous stasis may be caused by the following: -Incompetent, loose fascia that fails to resist muscle expansion, diminishing the effectiveness of the Musculo-venous pump -External pressure on the veins from bedding during prolonged institutional stays or from a tight cast, bandages, or bands of stockings -Muscular inactivity (e.g., during an overseas flight) DVT with inflammation around the involved veins (thrombophlebitis) may develop. A large thrombus that breaks free from a lower limb vein may travel to a lung, forming a pulmonary thrombo-embolism (obstruction of a pulmonary artery). A large embolus may obstruct a main pulmonary artery and may cause death.

Venous drainage of lower limb

---Superficial veins: -Great saphenous vein -Small saphenous vein ---Deep veins: (L. venae comitantes) accompany the major arteries ---Perforating veins: -Penetrate the deep fascia as they pass between the superficial and deep veins -They contain valves that allow blood to flow only from the superficial to the deep veins. -The perforating veins penetrate the deep fascia at oblique angles so that when muscles contract and pressure increases inside the deep fascia, the perforating veins are compressed, preventing blood from flowing from the deep to the superficial veins. -This pattern of venous blood flow, from superficial to deep, is important for proper venous return from the limb because it enables muscular contractions to propel blood toward the heart against the pull of gravity -Musculo-venous pump.

Developmental dysplasia of the hip (DDH)/ congenital dislocation of the hip/hip dysplasia

--Abnormal acetabulum development in the newborns --The socket of the hip is too shallow, and the femoral head is not held tightly in place, so the hip joint is loose. --In severe cases, the femur can come out of the socket (dislocate).

Compartments of thigh

--Anterior compartment =Nerve: Femoral =Flexors of hip joint & Extensors of Knee j. --Medial compartment/ adductor group =Nerve: Obturator --Posterior compartment /Hamstring =Nerve: Sciatic =Extensors of hip joint & flexors of Knee joint

dislocation of hip joint

--Congenital -occurring in approximately 1.5 per 1,000 live births; it affects more girls and is bilateral -Dislocation occurs when the femoral head is not properly located in the acetabulum. The affected limb appears (and functions as if) shorter -resulting in a positive Trendelenburg sign (hip appears to drop to one side during walking). -Inability to abduct the thigh is characteristic of congenital dislocation. --Acquired -may occur during an automobile accident when the hip is flexed, adducted, and medially rotated, the usual position of the lower limb when a person is riding in a car.

femoral a.

--Descends through the femoral triangle and the anterior compartment of the thigh. **extension of external iliac a.** --The femoral artery passes through the adductor hiatus to become the popliteal artery in the popliteal fossa at the posterior knee Branches: -The deep femoral (profunda femoris) artery -Perforating arteries Branches of profunda femoris artery: -Medial circumflex -Lateral circumflex Branches of the popliteal artery: -Anterior tibial and -posterior tibial arteries.

Transplantation of gracilis

--Gracilis muscle (medial compt) is used for grafting --Surgeons often transplant the gracilis, or part of it, with its nerve and blood vessels to replace a damaged muscle in the forearm or to create a replacement for a nonfunctional external anal sphincter, for example.

clinical correlates sciatic n.

--Herniation of the lower lumbar disc produces radiating pain into the leg and foot (sciatica) --Sensory loss on posterior aspect of the thigh, leg, and sole of the foot --Femoral head dislocation typically occurs with head-on auto collisions when the knee hits the dashboard and results in a shortened, adducted, and medially rotated limb

Deep fascia of the thigh/Fascia lata

--It invests the limb like an elastic stocking --limits outward extension of contracting muscles, making muscular contraction more efficient in compressing the veins to push blood toward the heart . --it is thickened to form the iliotibial tract --The saphenous opening is a gap or hiatus in the fascia lata inferior to the medial part of the inguinal ligament --The great saphenous vein and some lymphatics pass through the saphenous opening

Slipped Capital Femoral Epiphysis (SCFE)

--It is a disorder of adolescents in which the growth plate is damaged and the femoral head moves ("slips") with respect to the rest of the femur. --The head of the femur stays in the cup of the hip joint while the rest of the femur is shifted.

femoral sheath

--It is a is a funnel -shaped, fascial tube of varying length (usually 3 -4 cm) --passes deep to the inguinal ligament and encloses proximal parts of the femoral vessels ---The sheath is formed by: -The transversalis and iliopsoas fascia from the abdomen/greater pelvis -Its medial wall is pierced by the great saphenous vein and lymphatic vessels

Enlarged Inguinal Lymph Nodes

--Lymph nodes enlarge wterm-75hen diseased. --Abrasions with minor sepsis, caused by pathogenic microorganisms or their toxins in the blood may produce moderate enlargement of the superficial inguinal lymph nodes (lymphadenopathy) --They are easily palpable if enlarged because they are in subcutaneous tissue

innervation of the sciatic n.

--Posterior compartment of the thigh --Anterior, posterior and lateral compartment of leg and foot

Thigh Muscle Injuries

--Pulled muscles (muscle "strain," actually a partial tearing of a muscle-tendon unit) from overstretching, or actual muscle tears, which can cause significant focal bleeding. --Groin injuries usually involve the adductor longus muscle. --The hamstring muscles become pulled or torn if not adequately stretched and loosened before vigorous use. --A "charley horse" is muscle pain or stiffness often felt in the quadriceps muscles of the anterior compartment or in the hamstrings. --Quadriceps muscle tears and tendon disruptions can occur, especially in athletes .

Femoral Fx

--The neck of the femur is most frequently fractured, especially in females secondary to osteoporosis. --Fractures of the proximal femur can occur at several locations -Transcervical -Intertrochanteric -Spiral fracture of the shaft of the femur

Surface anatomy & Skeleton of lower limb-Gluteal region

It includes the buttocks and hip region

Flexors of hip joint

-Sartorius -Iliopsoas -pectineus -Tensor fasciae latae -Rectus femoris tendon -adductor longus -adductor brevis -anterior prt adductor magnus -gracilis

Nerves of the Gluteal Region

-Superior (L4-S1) and inferior (L5-S2) gluteal nerves -Sciatic nerve (tibial->L4-S3 & common fibular->L4-S2) -Posterior femoral cutaneous nerve (S1-S3) -Nerves to the obturator internus (L5-S2) and quadratus femoris (L4-S1) muscles -Pudendal nerve (S2-S4)

Arteries of the gluteal region

-Superior gluteal artery: Branch arising from posterior division of internal iliac artery. -Inferior gluteal artery: Branch arising from anterior division of internal iliac artery. -Internal pudendal artery: Branch arising from anterior division of internal iliac artery.

Varicose veins

-The great saphenous vein and its tributaries become varicose (dilated and/or tortuous so that the cusps of their valves do not close). -Varicose veins are common in the posteromedial parts of the lower limb and may cause discomfort -Valves in varicose veins, incompetent due to dilation or rotation, no longer function properly. The resulting reverse flow and the weight of long, unbroken columns of blood produces varicose veins

gluteal region bursae

-Trochanteric bursa -Ischial bursa -Gluteofemoral bursa

Hip joint

-Type: Multiaxial ball & socket synovial joint -Articular surfaces: -Head of the femur -Acetabulum of hip bone -Ligaments: -Joint capsule -Transverse acetabular ligament -Y shaped Iliofemoral ligament -Pubofemoral ligament -Ischiofemoral ligament

femoral n.

L2-L4 Origin: Posterior division, enters the femoral triangle by passing deep to the inguinal ligament

A 43-year-old woman visits her primary care physician for abdominal cramping and muscle weakness in her left thigh. Physical examination shows atrophy of the patient's left thigh muscles when compared to the right. Muscle tests determined weakness in adduction of the left thigh. A pelvic exam reveals a mass, potentially an ovarian tumor, growing on the lateral wall of the left pelvis. Which of the following nerves is most likely being compressed by the mass in this patient? A. Femoral B. Superior gluteal C. Sciatic D. Perineal E. Obturator

E

Surface anatomy & Skeleton of lower limb-Knee region

Includes the distal femur, the proximal tibia and fibula, and the patella & the popliteal fossa.

Surface anatomy & Skeleton of lower limb-Ankle or talocrural region

Includes the narrow distal leg and ankle (talocrural) joint.

Surface anatomy & Skeleton of lower limb-Leg or crural region

Includes the tibia and fibula; the calf (L. sura) of the leg is the posterior prominence.