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Lower Extremity I Trans

Lower Extremity I Trans

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Publicado porfielvirata
gluteal region, posterior leg and thigh, sole feet and hip joint

trans by: nica, fiel and abby (PLM)
gluteal region, posterior leg and thigh, sole feet and hip joint

trans by: nica, fiel and abby (PLM)

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Published by: fielvirata on Aug 24, 2009
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GROSS ANATOMY: LOWER EXTREMITY 1 Dr. Damasco August 12, 2009 trans by Nica, Fiel, & Abby I. GLUTEAL REGION – buttocks A.

BOUNDARIES Superior: Iliac crest Inferior: Inferior gluteal folds (kuyukot) Lateral: sides of thigh Medial: Intergluteal canal (between two cheeks) * Each cheek is divided into four quadrants Upper lateral, Upper medial, lower lateral, lower medial B. CUTANEOUS NERVES >The upper medial quadrant is supplied by the posterior rami of the upper three lumbar nerves and the upper three sacral plexus. >The upper lateral quadrant is supplied by the lateral branches of the iliohypogastric (L1) and 12th thoracic nerves (anterior rami) >The lower lateral quadrant is supplied by branches from the lateral cutaneous nerve of the thigh (L2 and 3, anterior rami) >The lower medial quadrant is supplied by branches from the posterior cutaneous nerve of the thigh (S1, 2, and3, anterior rami)

C. MUSCLES MUSCLES OF THE GLUTEAL REGION INSERTION NERVE SUPPLY ; NERVE ROOT 1. Gluteus Outer surface of ilium, Iliotibial tract and Inferior gluteal maximus^ sacrum, coccyx, gluteal tuberosity of nerve; sacrotuberous ligament femur L5, S1, 2 2. Gluteus Outer surface of ilium Lateral surface of Superior gluteal medius^ greater trochanter of nerve; femur L5, S1 3. Gluteus Outer surface of ilium Anterior surface of Superior gluteal minimus^ greater trochanter of nerve; femur L5, S1 4. Tensor Iliac crest Iliotibial tract Superior gluteal fascia latae^ nerve; L4, 5 5. Piriformis* Anterior surface of sacrum Upper border of 1st and 2nd greater trochanter of sacral nerves; femur L5, S1, 2 6. Obturator Inner surface of obturator Upper border of Sacral plexus; internus* membrane greater trochanter of L5, S1 femur 7. Gemellus Spine of ischium Upper border of Sacral plexus; superior* greater trochanter of L5, S1 femur 8. Gemellus Ischial tuberosity Upper border of Sacral plexus; inferior* greater trochanter of L5, S1 femur 9. Quadratus Lateral border of ischial Quadrate tubercle of Sacral plexus; femoris* tuberosity femur L5, S1 Table Legend: (above) ^ - gluteal muscles * - small lateral rotators of the hip joint MUSCLE ORIGIN ACTION

Extends and laterally rotates hip joint; through iliotibial tract, it extends knee joint Abducts thigh at hip joint; tilts pelvis when walking to permit opposite leg to clear ground Abducts thigh at hip joint; tilts pelvis when walking to permit opposite leg to clear ground Assists gluteus maximus in extending the knee joint Lateral rotator of thigh at hip joint Lateral rotator of thigh at hip joint Lateral rotator of thigh at hip joint Lateral rotator of thigh at hip joint Lateral rotator of thigh at hip joint

*Gluteus maximus: largest muscle in the body *Iliotibial tract: thickening of the fascia on the lateral side

*Gluteus maximus and Tensor fascia latae: maintains extension of knee joint

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GROSS ANATOMY: LOWER EXTREMITY 1 Dr. Damasco August 12, 2009 trans by Nica, Fiel, & Abby D. LIGAMENTS OF THE GLUTEAL REGION Fxn: stabilize the sacrum and prevent its rotation at the sacroiliac joint by the weight of the vertebral column 1. Sacrotuberous Ligament: connects the back of the sacrum to the ischial tuberosity 2. Sacrospinous Ligament: connects the back of the sacrum to the spine of the ischium E. FORAMINA OF THE GLUTEAL REGION 1. Greater Sciatic Foramen : formed by the greater sciatic notch of the hip bone and the sacrotuberous and sacrospinous ligaments :provides an exit from the pelvis into the gluteal region Structures that exit the foramen: - Piriformis - sciatic nerve - posterior cutaneous nerve of the thigh - superior and inferior gluteal nerves - nerves to the obturator internus and quadratus femoris - pudendal nerve - superior and inferior gluteal arteries and veins - internal pudendal artery and vein 2. Lesser Sciatic Foramen : formed by the lesser sciatic notch of the hip bone and the sacrotuberous and sacrospinous ligaments :provides an entrance into the perineum from the gluteal region Structures that pass through the foramen: - tendon of obturator internus muscle - nerve to obturator internus - pudendal nerve - internal pudendal artery and vein Note: Intramuscular injection in the gluteal region should be done in the upper lateral quadrant to avoid hitting the sciatic nerve. F. NERVES TO THE GLUTEAL REGION 1. Sciatic nerve (L4, L5, S1, S2, S3) : largest nerve in the body and branches into tibial and common peroneal nerves *Sciatica (fat wallet syndrome) – occurs in rich people; pain in the posterior aspect of the thigh, the posterior and lateral sides of the leg, and the lateral part of the foot 2. Posterior Cutaneous Nerve of the Thigh :passes downward on the posterior surface of the sciatic nerve; runs down the back of the thigh beneath the deep fascia. Branches: a. Gluteal branches to the skin over the lower medial quadrant of the buttock b. Perineal branch to the skin of the back of the scrotum or labium majus c. Cutaneous branches to the back of the thigh and the upper part of the leg 3. Superior Gluteal Nerve : leaves the pelvis through the upper part of the greater sciatic foramen above the piriformis : supplies both gluteus medius and minimus and ends by supplying tensor fascia latae 4. Inferior Gluteal Nerve :leaves the pelvis through the lower part of the greater sciatic foramen below the piriformis :supplies gluteus maxmius 5. Nerve to Quadratus Femoris :leaves the pelvis through the lower part of the greater sciatic foramen :ends by supplying quadratus femoris and the inferior gemellus 6. Pudendal nerve and Nerve to Obturator Internus :leaves the pelvis through the lower part of the greater sciatic foramen, below the piriformis : pudendal nerve supplies structures in the perineum : nerve to obturator internus supplies the obturator internus muscle on its pelvic surface G. ARTERIES OF THE GLUTEAL REGION 1. Superior gluteal artery : largest branch from the internal iliac artery and enters the gluteal region through the upper part of the grater sciatic foramen above the piriformis : supplies gluteus maximus (superficial) and gluteus medius and minimus (deep) 2. Inferior gluteal artery : branch from the internal iliac artery and enters the gluteal region through the lower part of the grater sciatic foramen below the piriformis : supplies hamstring muscle, hip joint 3. Trochanteric anastomoses :main blood supply to the head of the femur :arteries that take part include superior gluteal artery, inferior gluteal artery, medial femoral circumflex artery and lateral femoral circumflex artery.

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GROSS ANATOMY: LOWER EXTREMITY 1 Dr. Damasco August 12, 2009 trans by Nica, Fiel, & Abby 4. Cruciate Anastomosis : at the level of the lesser trochanter of the femur and, together with the trochanteric anastomosis, provides a connection between the internal iliac and the femoral arteries : arteries that take part include inferior gluteal artery, medial femoral circumflex artery, lateral femoral circumflex artery and the first perforating artery (branch of the profunda artery) II. POSTERIOR THIGH : refers to the posterior compartment of the thigh (Thigh is divided into compartments by the intermuscular septum

MUSCLES OF THE POSTERIOR THIGH (HAMSTRINGS) MUSCLE ORIGIN INSERTION NERVE SUPPLY A. MEDIAL HAMSTRINGS 1. Semitendinosus Ischial Upper part of the medial Sciatic nerve (tibial tuberosity surface of the shaft of part) (L5,S1, S2) tibia 2. Semimebranosus Ischial Medial condyle of the tibia Sciatic neve (tibial tuberosity part) (L5, S1, S2) B. LATERAL HAMSTRINGS 3. Biceps Long Ischial Head of fibula Sciatic neve (tibial femoris Head tuberosity part) (L5, S1, S2) Short Head Linea aspera Common peroneal (fibular) nerve (L5, S1, S2) Sciatic neve (tibial part) (L3, L4)) : popliteus 4. Roof: deep fascia of thigh : superficial fascia : skin B. Contents 1. Popliteal vessels a. Popliteal Artery (medial) Level

ACTION Flexion and medial rotation of the leg Flexion and medial rotation of the leg Flexion and lateral rotation of the leg; thigh extension Flexion and lateral rotation of the leg

C. HAMSTRINGS OF THE ANTERIOR THIGH 4. Adductor magnus Ischial Adductor tubercle of (hamsting part) tuberosity femur : The muscle fibers of the semimembranosus expands to support the capsule on the back of the knee joint. This fibrous expansion is called the oblique popliteal ligament. :Cutaneous Innervation: posterior cutaneous nerve of the thigh Nerve Supply of the Posterior Thigh Sciatic Nerve: branch of the sacral plexus : divides at the lower third of the thigh into: 1. tibial nerve (medial) 2. common peroneal nerve (lateral) III. POPLITEAL FOSSA : diamond-shaped intermuscular space at the back of the knee joint : most prominent in knee flexion : counterpart of the cubital fossa A. Boundaries 1. Medially: semitendinosus and semimembranosus (above) : medial had of gastrocnemius (below) 2. Laterally: biceps femoris (above) : lateral head of gastrocnemius and plantaris (below) 3. Floor: popliteal surface of femur : posterior ligament of knee joint

Thigh extesion

Femoral artery

Popliteal fossa (entrance through opening in adductor magnus Popliteal artery

Popliteus (lower border)

Anterior tibial artery Posterior tibial artery

*Guide to understanding the table (and all similar tables): The femoral artery, upon entering the popliteal fossa through the opening in the adductor magnus, becomes the popliteal arterr. At the level of the lower border of the popliteus, the popliteal artery divides into the anterior and posterior tibial arteries.

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GROSS ANATOMY: LOWER EXTREMITY 1 Dr. Damasco August 12, 2009 trans by Nica, Fiel, & Abby b. Popliteal vein (lateral) Level Popliteus (lower border Popliteal vein opening in adductor magnus Femoral vein 2. Small Saphenous Vein Level Behind lateral malleolus Small saphenous vein Popliteal fossa (Between the 2 heads of the gastrocnemius) Branch 1 Popliteal vein

Venae comitantes of anterior and posterior tibial arteries Small saphenous vein

Lateral part of the dorsal venous arch of the foot

3. Common peroneal and tibial nerves Level Sciatic nerve Lower third of thigh Tibial nerve (larger) Popliteal fossa (Between the 2 heads of the gastrocnemius) Peroneus longus Flexor retinaculum Medial plantar nerve Lateral plantar nerve

Sural nerve Common peroneal nerve (smaller) Superficial peroneal nerve Deep peroneal nerve

*Guide: The sciatic nerve, divides into the tibial and common peroneal nerves at the lower third of the thigh. The tibial nerve gives off a branch, the sural nerve, at the level of the popliteal fossa, between the 2 heads of the gastrocnemius. Upon reaching the flexor retinaculum, the rest of the tibial nerve divides into the medial and lateral plantar nerves. Meanwhile, the common peroneal nerve divides into the superficial and deep peroneal nerves at the level of the peroneus longus

4. Posterior cutaneous nerve of the thigh: terminates by supplying the skin over the popliteal fossa 5. Genicular branch of the obturator nerve: terminates by supplying the knee joint 6. Connective Tissue 7. Lymph nodes: 6 lymph nodes : receives from superficial and lymphatic vessels

IV. POSTERIOR LEG A. CUTANEOUS INNERVATION NERVE ORIGIN 1. Posterior cutaneous nerve of the thigh 2. Saphenous nerve 3. Lateral cutaneous nerve of the calf 4. Sural nerve Femoral nerve Common peroneal nerve Tibial nerve

SUPPLIED PARTS Skin over popliteal fossa Upper part of posterior leg Posteromedial leg Upper part of posterolateral leg Lower part of posterolateral leg

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GROSS ANATOMY: LOWER EXTREMITY 1 Dr. Damasco August 12, 2009 trans by Nica, Fiel, & Abby B. MUSCLES MUSCLES OF THE POSTERIOR LEG I. SUPERFICIAL GROUP MUSCLE 1. Gastrocnemius Lateral head Medial head ORIGIN Lateral condyle of femur Medial condyle of femur Lateral supracondylar ridge of femur Shafts of tibia and fibula INSERTION Posterior surface of calcaneum (via tendo calcaneus) Posterior surface of calcaneum Posterior surface of calcaneum (via tendo calcaneus) Posterior surface of shaft of tibia above soleal line NERVE SUPPLY Tibial nerve (S1) ACTION Flexion of leg Plantarflexion

2. Plantaris

Tibial nerve (S1) Tibial nerve (S2)

Flexion of leg Plantarflexion Powerful plantarflexor Main propulsive force in running and walking Flexion of leg Unlocks knee joint by lateral rotation of femur on tibia Slackens ligaments of joint Plantarflexion Flexion of distal phalanges of lateral four toes Supports medial and lateral longitudinal arches of foot Plantarflexion Flexion of distal phalanx of big toe Supports medial longitudinal arch of foot Plantarflexion Inversion at subtalar and transverse tarsal joints Supports medial longitudinal arch of foot

3. Soleus

II. DEEP GROUP 1. Popliteus

Lateral surface of the lateral condyle of femur

Tibial nerve (L4, L5, S1)

2. Flexor digitorum longus

Posterior surface of shaft of fibula

Bases of distal phalanges of lateral four toes

Tibial nerve (S2)

3. Flexor hallucis longus

Posterior surface of shaft of fibula

Base of distal phalanx of big toe

Tibial nerve (S2)

4. Tibialis posterior

Posterior surface of shafts of tibia and fibula Interosseous membrane

Tuberosity of navicular bone

Tibial nerve (L4, L5)

C. STRUCTURES PASSING BEHIND THE MEDIAL MALLOLUS (medial to lateral) 1. Tibialis posterior 2. Flexor digitorum longus 3. Flexor hallucis longus

D. CRURAL FASCIA: deep fascia of the leg : leg counterpart of the fascia lata of the thigh

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GROSS ANATOMY: LOWER EXTREMITY 1 Dr. Damasco August 12, 2009 trans by Nica, Fiel, & Abby

E. POSTERIOR TIBIAL ARTERY Level Popliteus Popliteal artery Anterior tibial artery (smaller) Posterior tibial artery (larger) *posterior tibial pulse near medial mallolus

Behind fibula

Fibula

Flexor retinaculum

Ankle joint Dorsalis pedis artery *dorsal pedis pulse in dorsum

Peroneal artery

Arterial anastomoses of ankle *made up of the lateral calcaneal and lateral malleolar branches nutrient artery of tibia

Posterior tibial artery

Medial plantar artery Lateral plantar artery

F. TIBIAL NERVE Level Lower third of thigh Sciatic nerve Tibial nerve (larger)

Popliteal fossa (Between the 2 heads of the gastrocnemius)

Peroneus longus

Flexor retinaculum Medial plantar nerve Lateral plantar nerve

Sural nerve Common peroneal nerve (smaller) Superficial peroneal nerve Deep peroneal nerve : laterally attached to the intertrochanteric line of the femur and posterior aspect of the neck of the bone behind : fibers are accompanied by blood vessels that are reflected upward and are called retinacula - Movements : flexion-extension : abduction-adduction : medial and lateral rotation - Blood Supply: :Superior and Inferior Gluteal Arteries : Medial and Lateral Femoral Circumflex Arteries - Innervation: Femoral and Obturator Nerves - Capsule:encloses the joint and is attached to the acetabular labrum medially

V. HIP JOINT -is the articulation between the head of the femur and acetabulum of the hip bone - links the lower extremity to the pelvic girdle - most often dislocated posteriorly after a severe force to the knee - the articular surface of the acetabulum is horse shoe shaped and is deficient inferiorly at the acetabular notch - cavity of the acetabulum is deepened by the fibrocartilaginous rim called acetubular labrum - labrum bridges across the acetabular notch and is called transverse acetabular ligament - hyaline cartilages cover the artivular surfaces - Type: Synovial Ball and Socket Joint

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GROSS ANATOMY: LOWER EXTREMITY 1 Dr. Damasco August 12, 2009 trans by Nica, Fiel, & Abby A. ANATOMICAL CHARACTERISTICS OF THE HIP JOINT 1. Labrum acetabulare - a fibrocartilaginous rim - deepens the acetabulum - forms the transverse acetabular ligament 2. Fibrous capsule - restricts free movement - encloses femoral head and neck - proximally attached to the acetabulum and transverse acetabular ligament - distally attached to the greater trochanter, intertrochanteric line, and base of the neck B. LIGAMENTS OF THE HIP JOINT 1. Iliofemoral ligament - strongest and most important ligament of the hip joint - inverted Y reinforcing the fibrous capsule anteriorly - Attachments: a. Proximal (Base of the Ligament): Anterior Inferior Iliac Spine b. Distal: Intertrochanteric Line of Femur - Function: Prevents overextension during standing, resists hyperexyension and medial rotation of the hip 2. Pubofemoral ligament - triangular - supports anterior and inferior part of the hip joint - Attachments: a. Proximal (Base of the Ligament): Superior Ramus of the Pubis b. Distal (Apex of the Ligament): Lower Part of the Intertrochanteric Line - Function: Resists excessive extension and abduction of the hip 3. Ischiofemoral ligament - spiral shaped - supports posterior part of the hip joint - thinnest hip joint ligament - Attachments: a. Proximal: Body of the Ischium near the Acetabular Margin b. Distal: Greater Trochanter - Function: Resists extension and medial rotation of the hip 4. Transverse acetabular ligament - formed by the acetabular labrum as it bridges the acetabular notch - converts notch into a tunnel where blood vessels enter

5. Ligament of the head of the femur - also called Ligamentum Teres Femoris - flat and triangular - Attachments: Proximal (Base of the Ligament)Fovea Capitis : Distal (Apex of the Ligament)Transverse Ligament and Margins of the Acetabular Notch - ensheathed by the synovial membrane Function: Resist abduction of hip in children VI. SOLE OF THE FOOT : divided into four layers A. FIRST LAYER - Abductor Hallucis - Flexor Digitorum Brevis - Abductor Digiti Minimi B. SECOND LAYER - Quadratus Plantae - Lumbricals (4) - Flexor Digitorum Longus Tendon - Flexor Hallucis Longus Tendon C. THIRD LAYER - Flexor Hallucis Brevis - Adductor Hallucis - Flexor Digiti Minimi Brevis D. FOURTH LAYER - Dorsal Interossei (4) -Plantar Interossei (3) - Peroneus Longus Tendon - Tibialis Posterior Tendon MUSCLES OF THE SOLE OF THE FOOT Muscle Nerve Supply Action

FIRST LAYER 1. Adbuctor Medial Hallucis Plantar Nerve 2. Flexor Medial Digitorum Plantar Brevis Nerve 3. Abductor Lateral Digiti Minimi Plantar Nerve Flexes and abducts big toe; braces medial longitudinal arch Flexes lateral four toes; braces medial and lateral longitudinal arches Flexes and abducts fifth toe; braces lateral longitudinal arch

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GROSS ANATOMY: LOWER EXTREMITY 1 Dr. Damasco August 12, 2009 trans by Nica, Fiel, & Abby SECOND LAYER 1. Quadratus Plantae 2. Lumbricals (4) Lateral Assists flexor digitorum Plantar Nerve longus in flexing four lateral toes First Extends toes Lumbrical: interphalengeal joints Medial Plantar Nerve; Remainder: Lateral Plantar Nerve at 2. Plantar Lateral Interossei Plantar (3) Nerve 3. Peroneus Longus Tendon Superficial Peroneal Nerve FOURTH LAYER 1. Dorsal Lateral Interossei Plantar (4) Nerve Abduction of toes; flexes metatarsophalangeal joints and extends interphalangeal joints Adduction of toes; flexes metatarsophalangeal joints and extends interphalangeal joints Plantar flexes foot at ankle joint; everts foot at subtalar and transverse tarsal joints; supports lateral longitudinal and transverse arches of the foot Plantar flexes the foot at ankle joint; inverts foot at subtalar and transverse tarsal joints; supports medial longitudinal arch of the foot

3. Flexor Tibial Nerve Digitorum Longus Tendon

Flexes distal phalanges of lateral four toes; plantar flexes the foot at ankle joint; supports medial and lateral longitudinal arches of the foot Flexes distal phalanx of big toe; plantar flexes foot at ankle joint; supports medial and longitudinal arch of the foot

4. Flexor Tibial Nerve Hallucis Longus Tendon

4. Tibialis Tibial Posterior Nerve Tendon

THIRD LAYER 1. Flexor Medial Plantar Flexes Hallucis Nerve metatarsophalangeal Brevis joints of big toe; supports medial longitudinal arch 2. Adductor Deep Branch Flexes Hallucis of the Lateral metatarsophalangeal joint Plantar Nerve of big toe; holds together metatarsal bones 3. Lateral Flexes Flexor Digiti Plantar Nerve metatarsophalangeal joint Minimi of little toe Brevis

PLANTAR ARCHES - assists the foot in locomotion, and coping with different land surfaces 1. Medial Longitudinal Arch: consists of calcaneum, talus, navicular, and three cuneiform 2. Lateral Longitudinal Arch: consists of calcaneum, cuboid, fourth and fifth metatarsal 3. Transverse Arch: consists of bases of the metatarsal bones, cuboid, and three cuneiform
for questions and clarifications; Fiel – Gluteal Region Abby – Posterior Thigh, Popliteal Fossa, Posterior Leg Nica – Hip Joint, Sole of Foot For I know the plans I have for you, declares the Lord, plans to prosper you and not to harm you, plans to give you hope and a future. Jeremiah 29:11 God bless! :)

-abby-fiel-nicaDid you know? A 2007 episode of popular TV series Desperate Housewives (season 4) made a joke about medical schools in the Philippines that has been the cause for outrage by a lot of Filipinos. In a scene in which Susan was told by her gynecologist that she might be hitting menopause, she replied, “Can I just check those diplomas because I just want to make sure that they are not from some med school in the Philippines.” Interpretations of nature from junior high, high school, and college test papers and essays submitted to science and health teachers (spelling errors preserved).... *"The body consists of three parts - the brainium, the borax and the abominable cavity. The brainium contains the brain, the borax contains the heart and lungs, and the abominable cavity contains the bowls, of which there are five - a, e, i, o, and u." *Water is composed of two gins, Oxygin and Hydrogin. Oxygin is pure gin. Hydrogin is gin and water."

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