LOWER LIMB

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LOWER LIMB
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Matching

• 1. Bucket handle tear A. Gluteus maximus
• 2. House maids knee B. Gluteus medius
• 3. Clergymans knee C. Sesamoid bone
  in the adductor longus
• 4. Running muscle D. Prepatellar bursitis
  
• 5. Walking muscle E. Lumbricals
• 6. Riders bone F. Contusion of rectus
  femoris
• 7. Weavers bottom G. Synovial effusion in
  the popliteal fossa
• 8. Hammer toe H. Infrapatellar bursitis
• 9. Bakers cyst I. Medial meniscus
• 10. Cricket thigh J.
  Subischial bursitis

3

• 2. A 45-year-old man has trouble walking. At his
  physician's clinic, when he is asked to stand on
  his right foot, his left hip drops. Which of the
  following nerves is most likely damaged, causing
  his problem?
• Left inferior gluteal
• Right inferior gluteal
• Left superior gluteal
• Right superior gluteal

4

• 3. Saphenous cut down is carried out to give
  intravenous infusion to patients in whom the
  other superficial veins in the body are either
  collapsed or invisible. In such situations, which
  of the following should be the site of incision
  to have an access to the vein?
• In front of the medial malleolus
• Behind the medial malleolus
• In front of the lateral malleolus
• Behind the lateral malleolus

5

• 4. A 45-year-old woman arrives at the casualty
  after being injured in an automobile collision.
  Her right foot is in a dorsiflexed and everted
  position. If a nerve injury is suspected, which
  of the following has most likely been injured?
• Common peroneal
• Superficial peroneal
• Deep peroneal
• Tibial

6

• 5. A 22-year-old man is examined by the team
  physician after injuring his right leg during a
  football game. The physician is able to
  demonstrate significant anterior movement of the
  tibia in relation to the femur. Which of the
  following structures is most likely torn?
• Anterior cruciate ligament
• Posterior cruciate ligament
• Fibular collateral ligament
• Tibial collateral ligament
• Lateral meniscus

7

• 6. A 77-year-old woman has difficulty climbing
  stairs because of weakness in her limb. Her knee
  jerk reflex is normal and she is able to stand on
  her heels and on the "balls" of her feet. Injury
  to which of the following nerves is the most
  likely cause of these findings?
• A. Tibial
• B. Obturator
• C. Inferior gluteal
• D. Femoral
• E. Common peroneal

8

• 7. A 12-year-old girl is brought to the emergency
  department after falling on the sharp edge of a
  tin can. She has a deep cut, which has injured a
  tendon immediately posterior to the medial
  malleolus. The tendon of which of the following
  muscles is injured in this case?
• Flexor hallucis longus
• Flexor digitorum longus
• Tibialis posterior
• Tibialis anterior

9

• 8. A 30-year-old man has numbness of the
  anterolateral surface of his right leg and dorsum
  of his right foot when he wears tight, knee-high
  boots during his dance routine. Which of the
  following nerves is most likely compressed?
• Tibial
• Saphenous
• Medial plantar
• Femoral
• Common fibular (peroneal)

10

• 9. Housemaids knee is associated with the
  inflammation of which of the following bursae?
• Suprapatellar
• Subcutaneous infrapatellar
• Prepatellar
• Deep infrapatellar

11

• 10. A 28-year-old woman develops degenerative
  joint disease of the feet and ankles from years
  of Bharatha Natyam Kuchipudi dancing. X-ray
  films show severe degenerative changes at the
  articular surfaces of the talus and at each of
  the bones that articulates with the talus. Which
  of the following bones has most likely been
  spared from this degenerative process?
• Calcaneus
• Cuboid
• Fibula
• Navicular
• Tibia

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Clinical anatomy of lower limb
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• The thigh and leg are divisible into three
  compartments.
• Each compartment is innervated by a particular
  nerve.

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Anterior compartment of thigh

• The quadriceps femoris composed of four muscles
  rectus femoris, vastus medialis, lateralis and
  intermedius forms the prominent feature of this
  compartment.
• They are supplied by the femoral nerve, a nerve
  from lumbar plexus.
• Quadriceps femoris is the chief extensor of the
  knee.
• The sartorius, the longest muscle in the body is
  in this compartment.
• There is a triangular area in the upper part of
  this compartment, known as femoral triangle.
• There is a funnel shaped sheath, known as femoral
  sheath within this triangle.
• It transmits the femoral vessels and presents a
  canal medially known as femoral canal.

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Sartorius
Rectus femoris
Vastus lateralis
Vastus medialis
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Iliacus
Iliopsoas
Psoas major
Pectineus
Adductor longus
Femoral triangle
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Femoral nerve (L 2,3,4)
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Femoral nerve
Femoral artery
Femoral vein
Femoral ring
Femoral sheath
Femoral canal
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Pecten pubis or iliopecteneal eminence
Septum separating the femoral vein
Femoral ring
Inguinal ligament
Lacunar ligament
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Adductor or medial compartment of thigh

• This compartment contains four muscles- adductor
  longus, adductor brevis and adductor magnus and
  gracilis.
• They are supplied by the obturator nerve, another
  nerve from lumbar plexus.
• This compartment presents a neurovascular canal
  in its middle third. This canal is known as
  adductor canal or Hunters canal or subsartorial
  canal.
• It transmits the femoral vessels and a cutaneous
  nerve.

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Medial or adductor compartment of thigh
Sartorius
Adductor canal
Femoral vein
Femoral artery
Saphenous nerve
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Posterior compartment of thigh

• This compartment contains mainly three muscles
  biceps femoris, semitendinosus and
  semimembra-nosus
• They are supplied by the sciatic nerve
• They produce extension at the hip and flexion at
  the knee.
• On the lateral aspect, the deep fascia of the
  thigh is thickened to form the iliotibial tract,
  which stabilizes the lateral aspect of the knee
  joint.

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Gluteus maximus
Semitendinosus
Biceps femoris
Semimembranosus
Popliteal fossa
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Sciatic nerve
Tibial nerve
Common peroneal nerve
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Gluteus maximus
Iliotibial tract
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Gluteal region

• This region contains three gluteal muscles
  gluteus maximus, medius and minimus and some
  small muscles.
• The gluteal muscles are supplied by the gluteal
  nerves.
• The gluteus maximus is the outer prominent muscle
  of the gluteal region. It is the chief extensor
  of the hip. Therefore, this muscle is also known
  as running muscle.
• The gluteus medius and minimus produce abduction
  and medial rotation of the hip, which are the
  essential movements in walking. Therefore, these
  muscles are also called walking muscles.
• The nerves supplying the muscles of the gluteal
  region, back of thigh and the entire leg and foot
  come out of the pelvis through the gluteal
  region.
• The sciatic nerve, the largest nerve in the body
  forms a prominent feature of the gluteal region.
  

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Glu.medius
Glu.maximus
Glu.minimus
Piriformis
Sciatic nerve
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Site of intramuscular injection in the gluteal
region
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Glutesus medius minimus
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Popliteal fossa

• This is a diamond shaped fossa behind the knee.
• It contains the popliteal vessels and the
  divisions of the sciatic nerve the tibial and
  common peroneal nerves.
• The tibial nerve descends into the back of the
  leg to supply all the muscles in it.
• The common peroneal nerve leaves the fossa by
  winding round the neck of the fibula. It divides
  into superficial and deep peroneal nerves.

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Popliteal fossa
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Anterior compartment of the leg

• There are several muscles in this compartment
• They are supplied by the deep peroneal nerve.
• They produce dorsiflexion (elevation) of the
  foot.

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Tibialis anterior
Extensor hallucis longus
Extensor digitorum longus
Peroneus tertius
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Lateral or Peroneal compartment of the leg

• There are two muscles in this compartment
  Peroneus longus and peroneus brevis.
• They are supplied by the superficial peroneal
  nerve
• They produce eversion of the foot.

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Peroneus longus
Peroneus brevis
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Common peroneal nerve
Deep peroneal nerve
Superficial peroneal nerve
First interdigital cleft
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Posterior compartment of leg

• The gastrocnemius and soleus are the two
  prominent muscles of this compartment, in
  addition to some other muscles.
• They form the strongest tendon, the
  tendocalcaneus or Achillus tendon of the body.
• They are supplied by the tibial nerve.
• They produce plantar flexion (depression) of the
  foot.
• The tibialis anterior of the anterior compartment
  and the tibialis posterior of this compartment
  produce inversion of the foot.
• The contraction of the soleus is mainly
  responsible for the venous return from the lower
  limb. Therefore, this muscle is also known as the
  peripheral heart.
• The neurovascular bundle and some muscles of this
  compartment enter the sole of the foot along the
  medial side of the ankle. They pass beneath the
  flexor retinaculum.

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Gastrocnemius
Tendocalcaneus
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Applied anatomy of the individual nerves
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Femoral nerve
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Obturator nerve (L 2,3,4) Cutaneous innervation
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Glutesus medius minimus
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Glu.medius
Glu.maximus
Glu.minimus
Piriformis
Pudendal nerve
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Motor impairment related to level of Spinal cord
injury
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Sciatic nerve (L 4,5, S 1,2,3)
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Posterior dislocation of hip
Foot drop
Sciatic nerve
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Site of palpation of common peroneal nerve
Common peroneal nerve
Neck of fibula
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Common peroneal nerve (L 4,5, S 1,2,)
Cutaneous innervation
Lat. Cut. Nerve of calf
(Com.peroneal nerve)
Superficial peroneal nerve
Peroneal communicating via sural nerve
Deep peroneal nerve
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Common peroneal nerve palsy
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High stepping gait
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• FOOT DROP

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DERMATOMES
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Dermatome - foot
L4
Saphenous Nerve
L5
S.P.N
S1
Sural nerve
D.P.N
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Arteries
Femoral artery
Popliteal artery
Ant. Tibial artery
Post. Tibial artery
Peroneal artery
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Popliteal artery
Popliteus
Anterior tibial artery
Posterior tibial artery
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Sites of Arterial pulsations
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Femoral artery
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Popliteal artery
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Posterior tibial artery
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Dorsalis pedis artery
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Venous drainage of lower limb
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Great Saphenous vein
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Great short saphenous veins and their
tributaries
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Saphenous opening
Pubic tubercle
4 cm
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Saphenous cutdown
Saphenous nerve
Great Saphenous vein
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Factors facilitating venous return from lower limb

• Negative thoracic pressure
• Venous valves ensuring unidirectional blood flow
• Calf muscle pump

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Calf muscle venous pump
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Varicose vein
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Factors responsible for development of varicosity
of veins of lower limb

• Congenital weakness of valves, smooth muscle
  lining the wall of the vein, calf muscles and the
  deep fascia covering them
• Thrombophlebitis of deep veins
• Increased abdominal pressure due to tumours or
  multiple pregnancy

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Lymphatic drainage
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Inguinal Popliteal lymph nodes
Superficial inguinal LN. Horizontal group
Superficial inguinal LN. Vertical group
Popliteal LN.
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Superficial Deep Inguinal Lymph nodes
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Lymph vessels Nodes of Abdomen, Pelvis
Inguinal region
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Bones Joints
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Iliofemoral ligament (Y ligament of Bigelow)
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Foot drop
Sciatic nerve
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Necrotic change
Artery of head of femur
Medial circumflex a.
Lateral circumflex a.
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Profunda femoris artery
Artery of head of femur
Medial circumflex a.
Lateral circumflex a.
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Tear of anterior cruciate ligament
Posterior cruciate ligament
Anterior cruciate ligament
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Tibial collateral lig.
Deep part
Superficial part
Medial meniscus
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Suprapatellar bursa
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Housemaids knee
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Dorsi flexion of the foot is the stable position
of ankle joint
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C
C
C
Cuboid
Navicular
Talus
Calcaneus
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Talus
Keystone
93
Plantar aponeurosis
Tie beam
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Congenital club foot ( congenital talipes
equinovarus)
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Matching

• 1. Bucket handle tear A. Gluteus maximus
• 2. House maids knee B. Gluteus
  medius
• 3. Clergymans knee C. Sesamoid bone
  in the adductor longus
• 4. Running muscle D. Prepatellar bursitis
  
• 5. Walking muscle E. Lumbricals
• 6. Riders bone F. Contusion of rectus
  femoris
• 7. Weavers bottom G. Synovial effusion in
  the popliteal fossa
• 8. Hammer toe H. Infrapatellar bursitis
• 9. Bakers cyst I. Medial meniscus
• 10. Cricket thigh J.
  Subischial bursitis

96

• 2. A 45-year-old man has trouble walking. At his
  physician's clinic, when he is asked to stand on
  his right foot, his left hip drops. Which of the
  following nerves is most likely damaged, causing
  his problem?
• Left inferior gluteal
• Right inferior gluteal
• Left superior gluteal
• Right superior gluteal

97

• 3. Saphenous cut down is carried out to give
  intravenous infusion to patients in whom the
  other superficial veins in the body are either
  collapsed or invisible. In such situations, which
  of the following should be the site of incision
  to have an access to the vein?
• In front of the medial malleolus
• Behind the medial malleolus
• In front of the lateral malleolus
• Behind the lateral malleolus

98

• 4. A 45-year-old woman arrives at the casualty
  after being injured in an automobile collision.
  Her right foot is in a dorsiflexed and everted
  position. If a nerve injury is suspected, which
  of the following has most likely been injured?
• Common peroneal
• Superficial peroneal
• Deep peroneal
• Tibial

99

• 5. A 22-year-old man is examined by the team
  physician after injuring his right leg during a
  football game. The physician is able to
  demonstrate significant anterior movement of the
  tibia in relation to the femur. Which of the
  following structures is most likely torn?
• Anterior cruciate ligament
• Posterior cruciate ligament
• Fibular collateral ligament
• Tibial collateral ligament
• Lateral meniscus

100

• 6. A 77-year-old woman has difficulty climbing
  stairs because of weakness in her limb. Her knee
  jerk reflex is normal and she is able to stand on
  her heels and on the "balls" of her feet. Injury
  to which of the following nerves is the most
  likely cause of these findings?
• A. Tibial
• B. Obturator
• C. Inferior gluteal
• D. Femoral
• E. Common peroneal

101

• 7. A 12-year-old girl is brought to the emergency
  department after falling on the sharp edge of a
  tin can. She has a deep cut, which has injured a
  tendon immediately posterior to the medial
  malleolus. The tendon of which of the following
  muscles is injured in this case?
• Flexor hallucis longus
• Flexor digitorum longus
• Tibialis posterior
• Tibialis anterior

102

• 8. A 30-year-old man has numbness of the
  anterolateral surface of his right leg and dorsum
  of his right foot when he wears tight, knee-high
  boots during his dance routine. Which of the
  following nerves is most likely compressed?
• Tibial
• Saphenous
• Medial plantar
• Femoral
• Common fibular (peroneal)

103

• 9. Housemaids knee is associated with the
  inflammation of which of the following bursae?
• Suprapatellar
• Subcutaneous infrapatellar
• Prepatellar
• Deep infrapatellar

104

• 10. A 28-year-old woman develops degenerative
  joint disease of the feet and ankles from years
  of Bharatha Natyam Kuchipudi dancing. X-ray
  films show severe degenerative changes at the
  articular surfaces of the talus and at each of
  the bones that articulates with the talus. Which
  of the following bones has most likely been
  spared from this degenerative process?
• Calcaneus
• Cuboid
• Fibula
• Navicular
• Tibia