THE LOWER LIMB

Dr.Ahmed SalmanAssistant Prof. of Anatomy. The University Of Jordan

The University Of Jordan Faculty Of Medicine

Gluteal Region

1. Lateral cutaneous branch of subcostal nerve(T12)2. Lateral cutaneous branch of iliohypogastric nerve (L1).3. Cutaneous branches from dorsal rami of upper 3 lumbar nerves

(L1, L2, L3) and upper 3 sacral nerves (S1, S2, S3).4. Lateral cutaneous nerves of the thigh (L2, L3).5. Posterior cutaneous nerves of the thigh (S1, S2, S3)

Cutaneous nerve supply of (Gluteal region)

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Upper Medial quadrant

Lower Medial quadrant

Lower Lateralquadrant

Upper Lateral quadrant is supplied by the:Lateral cutaneous branch of subcostal nerve(T12)Lateral cutaneous branch of iliohypogastric nerve (L1).

Upper Medial quadrant is supplied by the:Cutaneous branches from dorsal rami of upper 3 lumbar nerves (L1, L2, L3) and upper 3 sacral nerves (S1, S2, S3).Lower Lateral quadrant is supplied by the:Lateral cutaneous nerves of the thigh (L2, L3).

Lower Medial quadrant is supplied by the:Posterior cutaneous nerves of the thigh (S1, S2, S3)

Cutaneous nerve supply of (Gluteal region)

Iliotibial tract

Fascia lata Is a strong fibrous sheet that surrounds the whole of

the thigh like a tight trousersThe deep fascia of the thigh is thickened laterally to form iliotibial tract Attachment :

Above : iliac tubercle Below : the lateral condyle of the tibia.

It receives the insertion of the tensorfasciae latae and gluteus maximus muscles Function : extends the knee

All are innervated by the Superior gluteal nerve EXCEPT

Gluteal maximus by inferior gluteal nerve

Origin :1-Back of Ilium behind the posterior

gluteal line, 2-Back of sacrum and coccyx and

sacrotuberous ligament

Insertion : Gluteal tuberosity of femur (1/4),

iliotibial tract (3/4)

Nerve Supply: Inferior gluteal nerve, L5;S1,2

Action :Extends thighlateral rotation and abduction of thigh.Also extend knee

Gluteus maximus

STRUCTURES UNDER THE COVER OF GLUTEUS MAXIMUS MUSCLE

Dr Amjad Shatarat

STRUCTURES UNDER THE COVER OF GLUTEUS MAXIMUS MUSCLE

Dr Amjad Shatarat

– Origin : iliac crest

– Insertion : iliotibial tract

– Nerve Supply : Superior

gluteal nerve . (L4,L5)

– Action : Extend knee,

flexion,abduction and

medial rotation of thigh

Tensor fasciae latae

Gluteus medius and minimus

– Origin:Ilium outer surface – Insertion : Greater trochanter of

femur – Nerve supply : Superior gluteal

nerve– Action :Abduction, medial rotation

• Medius and minimus help stabilize• hip to allow balanced walk.

1. In unilateral paralysis of G. medius and minimus, the patient

exhibits a lurching gait with a positive Trendelenburg's sign.

In standing on the affected side, the pelvis will tilt towards the

unsupported side. causes Lurching gait

2. In bilateral paralysis of G. medius and minimus, the patient

exhibits a waddling gait in which the trunk is flexed from side

to side with each step during walking.

On standing on the diseased side the sound side sags

Clinical Anatomy:

The positive Trendelenburg test is seen if:

A- The hip abductors are paralysed (e.g. poliomyelitis)

B-Congenital dislocation of the hip

C-The head of the femur has been destroyed by disease

Or removed operatively (pseudarthrosis),

D-There is an un-united fracture of the femoral neck

E-There is a very severe degree of coxa vara

CLINICAL ANATOMY

• I.M (Intramuscular injection)

Which the most suitable

quadrangle for IM injection?

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Clinical Notes

The great thickness of gluteus

maximus muscle makes it ideal

for intramuscular injections.

To avoid injury to the underlying

sciatic nerve, the injection should

be given well forward on the

upper outer quadrant of the

buttock.

However, the upper lateral

quadrant, most likely to be made

by the Gluteus medius muscle

Dr Amjad Shatarat

Muscle Origin Insertion Nerve Supply Action

Gluteus maximus Outer surface of ilium, sacrum,

coccyx, sacrotuberous ligament

Iliotibial tract

and gluteal

tuberosity of

femur

Inferior gluteal

nerve

Extends and

laterally

rotates hip

joint; through

iliotibial tract,

it extends

knee joint

Gluteus medius Outer surface of ilium Lateral surface

of greater

trochanter of

femur

Superior

gluteal nerve

Abducts thigh

at hip joint;

tilts pelvis

when walking

to permit

BALANCED

WALK

Gluteus minimus Outer surface of ilium Anterior

surface of

greater

trochanter of

femur

Superior

gluteal nerve

Abducts thigh

at hip joint;

tilts pelvis

when walking

to permit

BALANCED

WALK

Tensor fasciae

latae

Iliac crest Iliotibial tract Superior

gluteal nerve

Assists gluteus

maximus in

extending the

knee joint

Lateral rotators of the thigh (Hip)

1. Piriformis

2. Quadratus femoris

3. Superior gemillus

4. Inferior gemillus

5. Obturator internus

6. Obturator externus

Piriformis

Quadrates Femoris

Obturator internus and two Gemelli

Lateral Rotators

Origin of piriformis

N.SupplyInsertionOriginThe Muscle

1st and 2nd sacral nerves of the sacral plexus

greater trochanter of the femur (top)

pelvic surface of the middle 3 pieces of the sacrum

1-piriformis

Nerve to obturator internus from the sacral plexus.

medial surface of the greater trochanter of the femur

pelvic surface of the obturator membrane and the bones surrounding the obturator foramen

2.Obturator internus

N. to obturator internus

tendon of the obturatorinternus muscle

ischial spine3.Superior gemellus

N. to quadratus femoris of the sacral plexus

tendon of the obturatorinternus muscle

ischial tuberosity4.Inferior gemellus

N. to quadratus femoris of the sacral plexus

Into the quadrate tubercle of the inter-trochanteric crest of the femur

ischial tuberosity5.Quadrats femoris

Posterior division of the obturator N. of the lumbar plexus

trochanteric fossa external surface of the obturator membrane and the adjacent margin of the obturator foramen

6.Obturator externus

Lateral rotators of the thigh (Hip)

Lateral rotators of the thigh

1-PiriformisN.S: L5,S1,S2

2-Obturator internusN.S: Nerve to obturator internus (L5,S1)

3-Superior gemillusN.S: Nerve to obturator internus (L5,S1)

4-Quadratus femorisNerve to quadratus femoris. (L5,S1)

5-Inferior gemillusN.S: Nerve to quadratus femoris. (L5,S1)

6-Obturator externus:N.S: Obturator nerve (L3,L4)

F

Identify the marked muscles and their nerve supply

A-

B-

C-

D-

E-

F-

G-

H-

G

H

Greater and lesser sciatic foramens

Sacrospinous ligament between ischial spine and back of sacrum& coccyx

Sacrotuberous ligamentBetween ischial tuberosity and back of sacrum& coccyx

Greater sciatic foramenBetween greater sciatic notch, sacrospinous and sacrotuberous ligaments.

Lesser sciatic foramenBetween lesser sciatic notch, sacrospinous and sacrotuberous ligaments.

Structures Passing in Greater and Lesser Sciatic Foramina

Greater sciatic foramen (7 nerves+3 vesseles+1 muscle)

Above PiriformisSuperior gluteal nerve and vesselsBelow Piriformis

• Sciatic nerve• Posterior cutaneous nerve of the thigh• Inferior Gluteal nerve and vessels• Nerve to Quadratus femoris• Pudendal nerve• Internal pudendal vessels• Nerve to Obturator Internus

Lesser Sciatic foramen• Tendon of Obturator Internus Muscle• Pudendal nerve• Internal pudendal vessels• Nerve to obturator internus

1-Superior Gluteal Artery

is a branch from the internal iliac artery

enters the gluteal region through the

greater sciatic foramen above the piriformis

2-Inferior Gluteal Artery

is a branch of the internal iliac artery

enters the gluteal region through the

greater sciatic foramen, below the

piriformis

Arteries of the Gluteal Region

It divides into superficial

and deep branches.

The superficial branch

supplies the gluteus maximus

muscle

The deep branch supplies

the glutei medius and

minimus.

It divides into numerous branches that are

distributed throughout the gluteal region.

Dr Amjad Shatarat

Posterior Compartment of thigh - Hamstring

1. Biceps femoris (long and short heads)

2. Semitendinosus

3. Semimembranosus

4. Adductor Magnus (Ischial head)

All above are innervated by tibial branch of Sciatic nerve.

EXCEPTShort head of biceps femoris by common peroneal branch of

Sciatic nerve

M

Origin :

All from ischial tuberosity EXCEPT Short head of biceps femoris from

linea aspera and lateral supracondylar line.

Insertion :

Biceps femoris : styloid process of the fibula.

Semitendinosus: upper part of medial surface of the tibia (SGS).

Semimembranosus: medial condyle of the tibia

Adductor Magnus (Ischial head) :Adductor tubercle of femur

All are Extends the hip and flexes the kneeLateral muscle rotate the knee laterallyMedial muscle rotate the knee medially

The Muscle Origin Insertion N.Supply Action

1- Biceps Femoris

2-Semitendinosus

3-Semimembranosus

4-Adductor magnus

(Ischial head)

Muscle Origin Insertion Nerve Supply Action

Biceps femoris Long head:

Ischial tuberosity

Short head: linea

spera, lateral

supracondylar

ridge of shaft of

femur

Head of fibula Long head: tibial

portion of sciatic

nerve

Short head: common

peroneal portion of

sciatic nerve

Flexes and laterally

rotates leg at knee joint;

long head also extends

thigh at hip joint

Semitendinosus Ischial tuberosity Upper part of

medial surface

of shaft of tibia

Tibial portion of

sciatic nerve

Flexes and medially

rotates leg at knee joint;

extends thigh at hip

joint

Semimembranosus Ischial tuberosity Medial

condyle of

tibia

Tibial portion of

sciatic nerve

Flexes and medially

rotates leg at knee joint;

extends thigh at hip

joint

Adductor

magnus

(hamstring

portion)

Ischial tuberosity Adductor

tubercle of

femur

Tibial portion of

sciatic nerve

Extends thigh at hip

joint

Anterior/Posterior thigh compartments

ANTERIOR COMPARTMENT

POSTERIOR COMPARTMENT

MOVEMENT

MUSCLES

NERVES …………………nerve

(…………….plexus)

…………………nerve

(…………….plexus)