Lower Limb Part C

Gross Anatomy

Muscles of the gluteal region muscles?

gluteus maximus, gluteus medius, and gluteus minimus

piriformis, gemellus superior, obturator internus, gemellus inferior, obturator externus, quadratus femoris

What’s the origin and insertion of gluteus maximus, gluteus medius, and gluteus minimus?

origin is external surface of ilium

insertion is the greater trochanter

The gluteus maximus performs what action and is innervated by what nerve?

extends a flexed femur and the hip joint

inferior gluteal nerve

Gltues medius and Gluteus Minimus have a similar action and nerve innervation. What is it?

They both abduct the femur at the hip joint

they both are innervated by the inferior gluteal nerve

What is the Trendelenburg sign? What structures are affected?

The superior gluteal nerve is affected, and this is described as a sign demonstrated by asking the patient to stand on one limb. When standing on the affected limb, the pelvis severely drops over the swing limb due to weakness of the gluteus medius and minimus on the stance side.

What is Trendelenburg’s sign caused from?

damage/compression of the superior gluteal nerve, disc herniation, muscle injury to the gluteus medius/minimus

With trendelenburg’s sign how is gait affected?

abnormal gait; abductor muscles are weakened allowing the pelvic tilt inferior over the swing limb, and the patient compensates for the pelvic drop by lurching the trunk to the stance side

What is the OIAN of piriformis?

origin: anterior surface of the sacrum

insertion: greater trochanter

action: laterally rotates femur at the hip joint

innervation: nerve to the piriformis (S1,S2)

When the hip is flexed past 60 degrees, what two muscles become internal rotators of the hip?

piriformis and superior gamellus

What is piriformis syndrome and what structures are affected?

it’s a neuromuscular condition where the piriformis muscle compresses or irritates the sciatic nerve, which leads to a radiation of symptoms in the lower limb

this is non-discogenic sciatica

What are the causes of piriformis syndrome?

muscle spasms, fibrosis, hypertrophy or inflammation of the piriformis leading to symptoms

can occur from repetitive movements, overuse, prolonged sitting or direct trauma to the area

What is the treatment for piriformis syndrome?

includes trigger point therapy, stretching, PT/chiropractic, and if severe, can require surgery

in 90% of people the sciatic nerve runs _______ to the piriformis, and 1.5-15% of people, the sciatic nerve runs ______ or through to the piriformis

inferior

superior

Gemellus superior OIAN

o: ischial spine

I; greater trochanter

A: laterally rotates femur at the hip joint

N: nerve to obturator internus

Obturator internus OIAN

O: anterolateral wall of true pelvis

I: greater trochanter

A: laterally rotates femur at hip joint

N: nerve to obturator internus

Gemellus Inferior OIAN

O; ishcial tuberosity

I: greater trochanter

A: lateral roation of femur at hip joint

N: nerve to quadratus femoris

Quadratus Femoris OIAN

O: lateral aspect of ischium

I: quadrate tubercle

A: laterally rotates femur at hip

N: nerve to quadratus femoris

Tensor fascia lata OIAN

O: iliac crest
I: iliotibial tract
A: stabilizers knee in extension
N: superior gluteal nerve

Which 2 muscles insert on the iliotibial tract?

tensor fascia lata and gluteus maximus

Injury to the _______ nerve results in Trendelenburg’s sign

superior gluteal nerve

The superior gluteal nerve originates from?

internal iliac artery

The superior gluteal artery primarily supplies?

muscles and skin in the gluteal region

Describe the superior gluteal nerve

it is the largest branch of the internal iliac artery and it leaves the greater sciatic foramen above piriformis muscle

The inferior gluteal artery originates from?

internal iliac artery

The inferior gluteal artery primarily supplies?

muscles and skin in the gluteal region

Describe the inferior gluteal artery.

forms an anastomoses w/a network of blood vessels around the hip joint, the cruciate anastomosis

it leaves the greater sciatic foramen below the piriformis muscle

What is a branch of the obturator artery?

acetabular artery, which enters the hip joint through the acetabular notch and contributes blood supply to the head of the femur

where does the obturator artery originate?

internal iliac artery

The obturator artery primarily supplies?

medial compartment of the thigh

Describe what’s importance of the obturator artery

it lies w/in the obturator externus

The femoral artery originates from?

external iliac artery

the femoral artery primarily supplies?

medial compartment of the thigh and anterior

Describe the femoral artery and its importance.

it passes vertically through the femoral triangle and continues down the thigh in the adductor canal; it leaves the adductor canal by passing through the adductor hiatus and becomes the popliteal artery behind the knee

What are some branches of the femoral artery?

superifical epigastric artery

superficial external iliac artery

superficial external pudendal artery

deep external pudendal artery

deep artery of the thigh

The deep femoral artery originates from the femoral artery and primarly supplies?

all 3 compartments of the thigh, directly or indirectly

Describe the deep femoral artery.

it is the largest branch of the femoral artery

What are the branches of the deep femoral artery?

lateral femoral circumflex artery

medial femoral circumflex artery

perforating branches

The medial circumflex artery originates from the _____ artery of the thigh and primarily supplies?

the femoral head and hip joint

The lateral femoral circumflex artery originates from the deep brachial artery and supplies the _____ & ______ thigh

anterior and lateral

branches of the lateral and medial femoral circumflex arteries participate w/other branches to form the ______ _______

cruciate anastomosis

What do the perforating arteries originate from? how many are there?

deep artery of the thigh

1st, 2nd, and 3rd perforating artery originates where?

superior to adductor brevis

anterior to adductor bevis

inferior to adductor brevis

All 3 perforating arteries penetrate through the ______ ______ to enter and supply the _____ compartment of the thigh

adductor magnus

posterior

What blood vessels make up the cruciate anstomosis?

medial and lateral femoral circumflex artery

inferior gluteal artery

first perforating artery

MILF is a mnemonic for?

Medial femoral circumflex artery

Inferior gluteal artery

Lateral femoral circumflex artery

First perforating artery

What are the major deep veins of the lower limb?

the femoral vein, superior/inferior gluteal veins, and popliteal vein

Where does the femoral vein drain into?

the external iliac vein

What does the superior and inferior gluteal veins, and obturator veins drain into?

internal iliac vein

What vein drains into the femoral vein?

popliteal vein

Major superficial veins consist of 2. What 2?

Great saphenous and lesser (small) saphenous veins

The great saphenous vein originates on the dorsal _____ arch and drains into what vein?

venous; femoral vein

The great saphenous vein ascends up the ____ side of the leg and passes through the saphenous opening in the proximal thigh before draining into the _____ vein

medial; femoral

The lesser saphenous vein originates on the dorsal ____ arch and drains into what vein?

venous; popliteal vein

The lesser saphenous vein ascends up the _____ surface of the leg amd penetrates deep fascia to join what vein posterior to the knee?

posterior; popliteal vein

What causes varicose veins? Where are these commonly seen?

extra pressure on distal valves causes a dilated tortuous superficial veins, commonly seen in the greater and lesser saphenous vein systems

Varicose veins typically occur at 3 junctions

great saphenous vein and femoral vein

perforating veins in the midthigh

lesser saphenous vein and popliteal vein

The perforating artieris pierce through which muscle?

adductor magnus

the inferior gluteal artery is a branch of the _____

internal iliac artery

The anterior compartment of the thigh contains muscles that mainly extend the leg at what joint?

knee jointthe

posterior compartment of the thigh contains muscles that mainly extend the thigh at the ____ joint and flex the leg at the _____ joint

hip; knee

the medial compartment of the thigh consists of muscles that mainly ____ the thigh at the ____ joint

adduct; hip

anterior compartment consists of what nerve?

femoral nerve

posterior compartment consists of what nerve?

sciatic nerve

medial compartment consists of what nerve?

obturator nerve

What is the femoral triangle made up of?

base; inguinal ligament

lateral border; sartorius

medial border; medial border of adductor longus

floor; pectineus, adductor longus, iliopsoas

apex; continuous w/adductor canal

What are the contents of the femoral triangle?

femoral artery, femoral vein, and lymphatics are w/in the femoral sheath. the femoral nerve is lateral to the femoral sheath (VAN - medial to lateral)

What is the femoral sheath?

a funnel-shaped sleeve of fascia in the femoral triangle, allowing smooth movement beneath the inguinal ligament during hip movement

The femoral sheath is made up of what 4 things? VAN and what?

femoral vein, femoral artery, femoral nerve, and lymphatics

What is the fascia lata and what’s important about it?

its an outer layer of deep fascia forming a thick membrane that covers the superficial fascia in the thigh and gluteal region

the fascia lata has multiple structures associated w/it?

inguinal ligament, iliac crest, sacrum and coccyx, sacrotuberous ligament, and the body and rami of the pubic bone

inferiorly, the fascia late is continuous with what?

deep fascia of the leg

the iliotibial tract (band) has a prxoimal attachment and distal attachment. What are they?

tubercle of the iliac crest

Gerdy’s tubercle

What two muscles insert on the iliotibial tract?

tensor fascia lata and gluteus maximus

What do the tensor fascia lata and gluteus maximus muscles do to the IT band and what does it act on?

it holds the leg in extension once other muscles have extended the knee

IT Band Syndrome affects what structures?

compression of the IT band against the lateral femoral epicondyle

IT band Syndrome is caused by:

repetitive knee flexion, associated with poor mechanics and/or weakness of the hip abductors

Describe IT band syndrome

an overuse condition of the IT band causes lateral knee pain

Clinically, what’s important of IT Band Syndrome

treatment consists of load management, strengthening hip muscles (glut’s external rotators, core muscles); gait retraining and soft tissue work as well

Major nerve of anterior compartment of thigh

femoral nerve

major nerve of medial compartment of thigh

obturator nerve

major nerve of posterior compartment of thigh

sciatic nerve

Femoral nerve originates on lumbar plexus roots of?

L2-L4

Femoral nerve passes through what gap, and supplies what compartment?

passes through the inguinal ligament gap and pelvic bone; and supplies the anterior compartment of the thigh.

Femoral nerve supplies the anterior compartment of the thigh and also?

skin on anterior/medial aspects of the thigh and via the saphenous nerve, supplies skin on the medial sides of the leg and foot

The femoral nerve has 3 branches…

anterior cutaneous branches: supply on front of thigh and knee

motor nerves: supply quadriceps, femoris muscles, sartorius, and pectineus

saphenous nerve: supplies skin on medial side of knee, leg, and foot

Saphenous nerve originates from?

femoral nerve

Saphenous nerve provides _____ innervation to the:

sensory; medial side of knee, leg, ankle, and foot

Obturator nerve originates on lumbar plexus roots of?

L2-L4

The obturator nerve enters the medial compartment of the thigh by passing through what canal? Supplies?

obturator canal; supplies most of adductor muscles and skin on medial aspect of the thigh

The sciatic nerve originates on the sacral plexus of what nerves?

L4-S3

Sciatic nerve passes through the greater sciatic foramen _____ to piriformis and supplies?

inferior; supplies all muscles of posterior compartment of the thigh

Two terminal branches of sciatic nerve

tibial nerve and common fibular nerve

The _______ is located within the femoral triangle but not w/in the femoral sheath

femoral nerve

the proximal attachment of iliotibial tract is the?

tubercle of the iliac crest