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Lower Limb Anatomy Muhammad Arsal TaimoorLearning Objectives • associated muscles, ligaments, and neurovascular structures.hip bones, joint (including stabilizing factors), and • Lumbosacral Plexus: Identify major branches and their functions. • Femur & Thigh Anatomy: Explain the osteology of the femur and identify muscles, nerves, and blood supply relevant to movement and injections in the gluteal region. • Knee Joint: Describe the anatomy, ligaments, movements, and structures (bones, menisci, and bursae) that maintain stability and function. • Ankle Joint: Outline the bony surfaces, ligaments, and movements, focusing on their role in stability and locomotion. • Neurovascular Supply: Describe the blood supply and innervation of the lower limb, including hip, knee, and ankle • Clinical Relevance: Highlight safe injection sites and functional anatomy essential for medical practice. Muhammad Arsal Taimoor1 - Hip Anatomy Muhammad Arsal Taimoor T opic 1 - Hip Anatomy (Ilium) The ilium is the largest portion of the pelvic girdle located superiorly The body of the ilium forms part of the acetabulum which makes up the hip socket The external surface provides attachment to gluteal muscles The internal surface provides attaFigure 1a. Lateral view of the hip LMuhammad Arsal TaimoorT opic 1 - Hip Anatomy (Ilium) Gluteal surface Iliac crest (external surface) Sacroiliac joint Anterior Superior Iliac Spine (ASIS) ASIS Iliac fossa (internal Greater sciatic Anterior Inferior surface) notch Iliac Spine (AIIS) Acetabulum Acetabular labrum Figure 2a. Anterior view of the hip Figure 1a. Lateral view of the hip ANTERIOR VIEW LATMuhammad Arsal TaimoorT opic 1 - Hip Anatomy (Ilium) Gluteal surface Iliac crest (external surface) Sacroiliac joint Anterior Superior Iliac Spine (ASIS) ASIS Iliac fossa (internal Greater sciatic Anterior Inferior surface) notch Iliac Spine (AIIS) Acetabulum Acetabular labrum Figure 2a. Anterior view of the hip Figure 1a. Lateral view of the hip ANTERIOR VIEW LATMuhammad Arsal Taimoor Topic 1 - Hip Anatomy (Ischium) The ischium forms the posteroinferior portion of the pelvic girdle The ischial body forms part of the acetabulum The iliac spine sits posteromedially to the ischial body The ischial tuberosity sits posteroiFigure 1b. Lateral view of the hip LMuhammad Arsal TaimoorTopic 1 - Hip Anatomy (Ischium) Figure 2a. Anterior view of the hip Ischial spine Lesser sciatic Obturator foramen notch Ischial tuberosity Ischial ramus Ischial body ANTERIOR VIEW Figure 1b. Lateral view of the hip LATERAL VIEW Muhammad Arsal TaimoorTopic 1 - Hip Anatomy (Ischium) Figure 2a. Anterior view of the hip Ischial spine Lesser sciatic Obturator foramen notch Ischial tuberosity Ischial ramus Ischial body ANTERIOR VIEW Figure 1b. Lateral view of the hip LATERAL VIEW Muhammad Arsal Taimoor Topic 1 - Hip Anatomy (Pubis) The pubis forms the anterior portion of the pelvic girdle The pubic body, located medially, forms part of the acetabulum, and articulates with the opposite pubic body at the pubic symphysis The superior and inferior pubic rami form part of the obturator foramen The mid-inguinal point can be palpated as the midway between the ASIS and pubic symphysis Figure 1c. Lateral view oMuhammad Arsal TaimoorTopic 1 - Hip Anatomy (Pubis) Figure 2b. Anterior view of the hip Pubic tubercle Superior pubic ramus Pubic symphysis Inferior pubic ramus Body of the pubis Obturator foramen Ischiopubic ramus LATERAL VIEW ANTERIOR VIEW Figure 1c. Lateral view of the hip Muhammad Arsal TaimoorTopic 1 - Hip Anatomy (Pubis) Figure 2b. Anterior view of the hip Pubic tubercle Superior pubic ramus Pubic symphysis Inferior pubic ramus Body of the pubis Obturator foramen Ischiopubic ramus LATERAL VIEW ANTERIOR VIEW Figure 1c. Lateral view of the hip Muhammad Arsal Taimoor Topic 1 - Hip Anatomy (Ligaments) Sacroiliac ligaments - reinforces the sacroiliac joint Origin: Sacrum Insertion: Ischial tuberosity Sacrospinous ligament - forms the greater sciatic foramen Origin: Sacrum Insertion: Ischial spine Sacrotuberous ligament - forms the lesser sciatic foramen Origin: Sacrum Figure 3. Anterior view of Rt. hip Insertion: Ischial tuberosity ANTERIOR VIEW Muhammad Arsal Taimoor Topic 1 - Hip Anatomy (Capsular Ligaments) Iliofemoral ligament - (anterior) resists hyperextension of the hip Origin: ASIS Insertion: Intertrochanteric line of the femur Figure 4. Hyperextension Ischiofemoral ligament - (posterior) resists excess internal rotation of the hip joint Origin: Ischial body Insertion: Anteromedial portion of the greater trochanter Pubofemoral ligament - (anteroinferior) resists excess hip extension and abduction Origin: Superior pubic ramus Insertion: Intertrochanteric line Figure 5. Hip capsule ligaments Muhammad Arsal Taimoor Topic 1 - Hip Bone (Summary) Figure 6. Gray’s Anatomy illustration of the Hip Bone Muhammad Arsal TaimoorTopic 1 - Hip Anatomy (Joints) The hip joint is a ball and socket synovial joint that enables the mobility of the lower limbs It is an articulation between the pelvic girdle (hip bone) and the head of the femur. The acetabulum deepens the socket to increase surface area and stability Figure 7. Anterior view of hipMuhammad Arsal Taimoor Topic 1 - Understanding muscle action Principle 1: The origin is the fixed point at the proximal end of a limb, while the insertion is the movable point at the distal end. Principle 2: If the origin becomes mobile and the insertion becomes fixed, their roles are reversed. Principle 3: The orientation of the muscle fibres relative to the origin and insertion, and the position of the joint, determines the direction of action of said muscle. Muhammad Arsal TaimoorTopic 1 - Gluteal Muscles (Superficial) Gluteus Maximus - The big big one Origin- Gluteal surface + Iliac crest + sacrum + coccyx Insertion- Iliotibial tract + gluteal tuberosity of the femur Action- Extension + Lateral rotation of hip Innervation- Inferior gluteal nerve (L5, S1, S2) Gluteus Medius & Minimus - Trendelenburg ones Origin- Gluteal surface (medius), Ilium (minimus) Insertion- Lat. greater trochanter (medius), Ant. greater trochanter (minimus) Action- Abducts + Internal rotation of hip (both) Innervation- Superior gluteal nerve (L4, L5, S1) Figure 8. Posterior view of gluteal region Muhammad Arsal TaimoorPoll time! QUESTION 1… Topic 1 - Trendelenburg sign Figure 9. Trendelenburg sign Muhammad Arsal TaimoorTopic 1 - Gluteal Muscles (Deep) Gluteus Maximus Piriformis - The inflamed one Origin- Anterior sacral wall Gluteus Medius Insertion- Superior aspect of greater trochanter Gluteus Minimus Action- Abducts + Lateral rotation of hip Innervation- Nerve to piriformis Superior & Inferior gemelli - The thieves Origin- Ischial spine (sup.) + Ischial tuberosity (inf.) Insertion- Posterior aspect of greater trochanter Action- Abducts + Lateral rotation of hip Innervation- Nerve to the obturator internus (sup.) + Nerve to quadratus femoris (inf.) Obturator Internus - The muscle that gets squished Origin- Obturator membrane (medial surface) Insertion- Posterior aspect of greater trochanter Action- Abducts + Lateral rotation of hip Innervation- Nerve to obturator internus Quadratus femoris - The odd one out in action Origin- Ischial tuberosity Insertion- Quadrate tubercle (on intertrochanteric crest) Action- Lateral rotation of hip Special mention - Obturator externus! Innervation- Nerve to quadratus femoris Figure 8. Posterior view of gluteal region Muhammad Arsal TaimoorTopic 1 - Tensor fascia lata The Iliotibial tract is a thickening of the lateral aspect of the fascia lata (from iliac crest to lateral tibial condyle) Tensor fascia lata - the IT muscle! Origin- ASIS + Iliac crest Insertion- Anterior aspect of iliotibial tract (distal end of middle 2/3rds of thigh) Action- Flexion + Abduction + Internal rotation of hip Innervation- Superior gluteal nerve (L4-S1) Figure 9a. Anterior right lower limbad Arsal Taimoor Topic 1 - Injection sites (Ventrogluteal) The ventrogluteal site is used for intramuscular injections mainly in adults and children over 7. Place an outstretched hand over the lateral side of the hip, with the palm on the greater trochanter and the index finger on the ASIS. Next make a wide V-shape between the index and middle finger so there is enough space to make an injection in between those fingers. Figure 10. Ventrogluteal Muhammad Arsal Taimoor Topic 1 - Injection sites (Dorsogluteal) The dorsogluteal injection site is used mainly in children aged between 3 and 7. Divide the glute you have chosen to inject into a quadrant, and inject in the upper outer quadrant you have imagined. This technique is now considered risky due to the proximity to major nerves (e.g. sciatic nerve) and blood vessels (e.g. gluteal artery). Figure 11. Dorsogluteal injection site Muhammad Arsal Taimoor2 - Lumbosacral plexus Muhammad Arsal TaimoorTopic 2 - Lumbosacral plexus “The lumbosacral plexus is a combined network of nerves that arises from the anterior rami of the sacral and lumbar spinal nerves.” The lumbar plexus is formed from L1-4 spinal nerves The sacral plexus is formed from L4-S4 spinal nerves L4 and L5 branches combine to form the lumbosacral trunk, which contributes to the sacral plexus. Muhammad Arsal Taimoor Topic 2 - Lumbar plexus “IGLOF” - MNEMONIC TO REMEMBER! Ilioinguinal - L1 Genitofemoral - L1, L2 Lateral femoral cutaneous nerve - L2, L3 Obturator nerve - L2, L3, L4 Femoral nerve - L2, L3, L4 The femorals arise from the posterior divisions of the spinal nerve roots, whereas the rest arise from the anterior divisions… Figure 12. Lumbar plexus Muhammad Arsal TaimoorPoll time! QUESTION 2…Topic 2 - Lumbar plexus dissection image A F E C D B Figure 13. Prosection of lumbar nerves Muhammad Arsal Taimoor Topic 2 - Sacral plexus “SISPP” - MNEMONIC TO REMEMBER! Superior gluteal - L4, L5, S1 Inferior gluteal - L5, S1. S2 Sciatic nerve - L4, L5, S1, S2, S3 Posterior femoral - S1, S2, S3 Pudendal - S2, S3, S4 Salmon is so perfectly pink (SISPP) Figure 14. Sacral plexuMuhammad Arsal Taimoor Topic 2 - Sciatic nerve route 1. Piriformis- 2. Gluteal muscles- Lumbosacral plexus- Passes over the adjacent to lumbar posterior surface of vertebrae + posterior these muscles pelvic wall 3. Posterior Compartment-et’s go through the route Enters thigh between greater together! Greater sciatic foramen- trochanter and ischial Passes through the tuberosity foramen 4. Adductor magnus & Biceps femoris- 5. Popliteal fossa- Over posterior surface of Add. mag. Divides into tibial and + under ant. surface of long head of common peroneal biceps femoris superior to the fossa M hammad Arsal TaimoorTopic 2 - Cutaneous Distribution Figure 15a. Cutaneous distrMuhammad Arsal Taimoor3 - Femoral and Thigh anatomy Muhammad Arsal Taimoor Topic 3 - Femur osteology Head of the femur Neck of the femur Greater trochanter Intertrochanteric crest Lesser trochanter Pectineal line Gluteal tuberosity https://www.purposegames Linea aspera M L L M .com/game/femur-quiz-quiz Lateral supracondylar line Osteology quiz you can try for yourself! Medial supracondylar line Medial epicondyle Adductor tubercle Lateral epicondyle Medial condyle Lateral condyle Figure 16. Anterior and posterior femur Muhammad Arsal TaimoorTopic 3 - Posterior Compartment (Thigh) Biceps femoris (Long head) - Like a bicep Origin- Ischial tuberosity Insertion- Head of the fibula Action- Extension of hip + Flexion of knee + Lateral rotation of both l Innervation- Tibial part of sciatic nerve (L4-S3) ater Biceps femoris (Short head) - The odd one out L Origin- Linea aspera of the femoral shaft Insertion- Head of the fibula Action- Extension of hip + Flexion of knee + Lateral rotation of both Innervation- Common peroneal part of sciatic nerve (L4-S2) M ed il Semitendinosus - The goose foot muscle Origin- Ischial tuberosity l Insertion- pes anserinus (medial aspect of tibia below the knee joint) ter Action- Extension of hip + Flexion of knee + Medial rotation of both La Innervation- Tibial part of sciatic nerve (L4-S3) Semimembranosus - The fat one M ed il Origin- Ischial tuberosity Insertion- medial tibial condyle Action- Extension of hip + Flexion of knee + Medial rotation of both Innervation- Tibial part of sciatic nerve (L4-S3) Figure 8b. Posterior view of thigh region Muhammad Arsal TaimoorTopic 3 - Medial Compartment (Deep) Obturator externus - A deep muscle of the glutes + adductors! Origin- External surface of obturator membrane Insertion- Posterior aspect of greater trochanter Action- Adduction + Lateral rotation of the thigh Innervation- Obturator nerve (L2-4) Adductor brevis - The smallest of the three Origin- Body of pubis + inferior pubic ramus Insertion- Linea aspera (superior part) Action- Adduction of the thigh Innervation- Obturator nerve (L2-4) Adductor Longus - Part of the femoral triangle Origin- Body of pubis Insertion- Linea aspera (middle third) Action- Adduction of the thigh Innervation- Obturator nerve (L2-4) Adductor Magnus - Adductor and Hamstring Components Origin- inferior pubic ramus (adductor) + ischial tuberosity (hamstring) Insertion- Linea aspera (adductor) + Adductor tubercle and medial supracondylar line (hamstring) Action- Adduction (both) + Flexion (adductor) + Extension (hamstring) of the thigh Innervation- Obturator nerve (L2-4) Figure 17. Adductor muscles Muhammad Arsal TaimoorTopic 3 - Medial Compartment (Adductors) Figure 18. Folded cartoon fan The adductors are like a folding fan, sharing an origin (with exceptions!) and ‘fanning out’ inferolaterally onto the linea aspera. Figure 17. Adductor muscles Muhammad Arsal TaimoorTopic 3 - Medial Compartment (Superficial) Gracilis - The Superficial Adductor Origin- Inferior pubic ramus and pubic body Insertion- Pes anserinus + medial aspect of proximal tibia Action- Adduction of the thigh + flexes knee Innervation- Obturator nerve (L2-4) Figure 9b. Anterior right lower limb Muhammad Arsal TaimoorTopic 3 - Anterior Compartment (Quadriceps Femoris) Figure 9b. Anterior right lower limb Rectus Femoris - Two Tendon Femoris (inferiorly) Origin- ASIS (anterior) + Supraacetabular groove (posterior) Insertion- Patellar base via quadriceps tendon Action- Flexion of thigh at hip + Extend leg at knee Innervation- Femoral nerve (L2-4) Vastus Lateralis - Laterally lipped (inferolaterally) Origin- Greater trochanter + Lateral lip of linea aspera Insertion- Patellar base via quadriceps tendon Figure 19. Sartorius stretch pose Action- Extends knee + stabilizes patella Innervation- Femoral nerve (L2-4) Vastus Medialis - Obliquus (inferomedially + horizontally) Origin- Intertrochanteric line of femur + Medial lip of linea aspera Insertion- Patellar base via quadriceps tendon Action- Extends knee + stabilizes patella Innervation- Femoral nerve (L2-4) Sartorius - Seat belt muscle (inferomedially) Origin- ASIS Insertion- Pes anserinus Action- Flexes + Abducts + Laterally rotates thigh, Flexes + Medially rotates knee Innervation- Femoral nerve (L2-4) Muhammad Arsal TaimoorTopic 3 - Anterior Compartment (VMO) Figure 20. Vastus Medialis Vastus Medialis Obliquus resists lateral displacement by the patella Vastus Medialis - Obliquus (inferomedially + horizontally) Origin- Intertrochanteric line of femur + Medial lip of linea aspera Insertion- Patellar base via quadriceps tendon Action- Extends knee + stabilizes patella Innervation- Femoral nerve (L2-4) Figure 9b. Anterior right lower limb Muhammad Arsal TaimoorTopic 3 - Anterior Compartment (Thigh) Vastus Intermedius - Sits underneath RF Origin- Anterolateral surface of femoral shaft Insertion- Patellar base via quadriceps tendon Action- Extends knee + stabilizes patella Innervation- Femoral nerve (L2-4) Pectineus - Bipolar innervation Origin- Pectineal line of superior pubic ramus Insertion- Pectineal line of posterior femur Action- Adducts + Flexes thigh at hip Innervation- Femoral nerve (L2-4) + Obturator nerve (sometimes!) Figure 9b. Anterior right lower limb Figure 21. Vastus muscles cartoon Arsal Taimoor Topic 3 - Arterial supply (Femoral artery) External iliac artery Common femoral artery At the crossing of the inguinal ligament Common femoral artery The medial circumflex wraps around the posterior proximal femur. Profunda Femoris Superficial Femoral The lateral circumflex wraps around the The deeper branch (comes off at femoral anterolateral proximal femur. triangle) that supplies the femoral shaft They both contribute to the extracapsular arterial ring. Common femoral artery Profunda Femoris Superficial Femoral The continuation of the CFA which descends past femoral triangle into adductor canal Figure 22. Femoral artery anatomy Muhammad Arsal TaimoorPoll time! QUESTION 3…Topic 3 - Femoral nerve route Femoral nerve arises from the lumbar plexus in the abdomen Passes through the psoas major, giving branches to iliacus and psoas It passes underneath the inguinal ligament and enters the femoral triangle at the mid-inguinal point Figure 23. Lumbar plexus visuaFigure 25. Nervio safenoammad Arsal TaimoorTopic 3 - Femoral nerve route In the femoral triangle, the nerve sends articular branches to supply the knee and hip joint After it passes through the triangle, the continuation of the nerve is the saphenous nerve (terminal cutaneous) The saphenous nerve enters the adductor canal, and later supplies sensation to the medial side of the leg and foot Figure 25. Nervio safeno Muhammad Arsal Taimoor Topic 3 - Femoral Triangle REMEMBER ‘NAVEL’! ‘E’ FOR EMPTY SPACE! N A V L Superior border = Inguinal ligament Lateral border = Sartorius Medial border = Adductor longus Figure 26. Femoral Triangle Muhammad Arsal Taimoor4 - Knee, Ankle, and Foot anatomy Muhammad Arsal TaimoorTopic 4 - Knee joint The knee joint is a hinge-type synovial joint that enables flexion and extension of the knee (as well as some rotation) Figure 28. Patellofemoral view of distal femur It is formed from two articulations: tibiofemoral and patellofemoral It is supplied by the genicular anastomosis formed from the popliteal artery Figure 29. Knee vasculature Remember! Epicondyles = a prominence above the condyles where tendons/ligaments attacFigure 27. Knee joint (Anterior)Topic 4 - Popliteus function Popliteus (superolateral) Origin- Proximal posterior tibial shaft Insertion- Lateral femoral condyle + meniscus Action- Unlocks the knee joint + Lateral rotation of femur Innervation- Tibial nerve (L4-S3) When the knee is fully extended it locks due to medial rotation of the femur on the tibia. The popliteus rotates the femur laterally to ‘unscrew’ the knee Figure 30. Popliteus highlightedad Arsal Taimoor Topic 4 - Patella Base Apex Figure 31. Anterior and posterior patella view It’s functions: protection of the knee, reduces friction, acts as a fulcrum for the quadriceps tendon Muhammad Arsal TaimoorTopic 4 - Knee joint ligaments & Menisci Medial meniscus Anterior cruciate ligament ‘The menisci are C-shaped fibrocartilaginous rings’ Transverse ligament They shock absorb by increasing surface area They increase stability of the knee joint by deepening the articulating surface Intercondylar tubercles (in between is the intercondylar eminence) Posterior cruciate ligament Posterior Lateral meniscus meniscofemoral Figure 32a. Superior view of proximal tibial head ligament Muhammad Arsal Taimoor Topic 4 - Knee joint ligaments & Menisci Patellar ligament Origin: Apex of the patella Insertion: Tibial tuberosity Function: Continuation of the quadriceps femoris tendon Medial Collateral Ligament Origin: Medial femoral epicondyle Insertion: Medial tibial condyle Function: Resists lateral angulation of tibia on the femur Lateral Collateral Ligament Origin: Lateral femoral epicondyle Insertion: Head of the fibula Function: Resists medial angulation of tibia on the femur Figure 33. Ankle ligaments Muhammad Arsal TaimoorTopic 4 - Knee bursae Key things to note: ● 6 bursae ● x4 patellar bursae ● x2 other (semimembranosus and pes anserinus) Muhammad Arsal Taimoor Topic 4 - Knee joint ligaments & Menisci Figure 34. Femoral condyles Anterior Cruciate = “cross” Anterior Cruciate Ligament Origin: Posteromedial aspect of the lateral femoral condyle Insertion: Anterior intercondylar area of the tibia Function: Resists lateral angulation of tibia on the femur Posterior Posterior Cruciate Ligament Anterior Origin: Anteromedial aspect of the medial femoral condyle Insertion: Posterior intercondylar area of the tibia Function: Resists medial angulation of tibia on the femur Figure 32b. Superior view of proximal tibial head Posterior Muhammad Arsal TaimoorTopic 4 - Popliteal fossa Semimembranosus Biceps femoris Superomedial border Superolateral border Medial head of Lateral head of gastrocnemius Inferomedial border gastrocnemius Inferolateral border Contents of the popliteal fossa: Popliteal artery & vein Tibial & Common peroneal nerve Popliteal lymph nodes Short saphenous vein Figure 35. Popliteal fossa visualised Muhammad Arsal TaimoorTopic 4 - Tibia and Fibula Medial tibial plateau Lateral tibial plateau Gerdy’s tubercle Soleal line Fibular head Tibial tuberosity Interosseous membrane- not seen in this image, usually covers the gap in between the two bones, with an opening for the anterior tibial vessels Shaft of the fibula Fibular notch (on tibia) Medial malleoli Lateral malleolus Figure 36. John Hawks ‘Tibia and Fibula’ Muhammad Arsal Taimoor Topic 4 - Bones of the foot Talus foo t Ankle joint (surior) H i d Subtalar jnt inferor) dfoo t Talonavicular joint (anterior) M i Tara l Calcaneus refoot Fo Sub taar ont (superior) trsals Calcaneocub od jont (ateror) M eta es Calcaneal tuberosity P haln g Achillesendoninserion II The 3 Cuneiforms II The medial (1st), intermediate IV (2nd), and lateral (3rd) V N avicular Cu boid cuneiforms are wedge shaped and articulate with navicular, Figure 37. Foot bones lateral view ththetals, Aricuatesw h theIVan d V cuboid, and I-III metatarsals cuboid,andcuneiorm s metatarals +calaneus Muhammad Arsal Taimoor Topic 4 - Architecture of the foot arches Long plantar ligament Spring ligament Peroneus longus Transverse Arch tendon Medial longitudinal arch Lateral longitudinal arch Bones: calcaneus, talus, navicular, three Bones: calcaneus, cuboid, and IV-V cuneiforms, and I-III metatarsals metatarsals Ligaments: plantar ligaments (spring Ligaments: plantar ligaments (spring ligament, long/short plantar) ligament, long/short plantar) Muscles: tibialis anterior, fibularis longus Muscles: fibularis brevis Figure 38. Posterior view of foot bones & arches Muhammad Arsal TaimoorTopic 4 - Ankle joint Anterior and posterior inferior tibiofibular ligament The ankle joint is a hinge-type synovial joint between the tibia, fibula, and talus bone. Anterior talofibular ligament The tibia and fibula join via the Posterior talofibular ligament anterior and posterior inferior tibiofibular ligaments. Lateral calcaneofibular ligament They form a mortise-shaped socket for the talus to fit in which creates the ankle joint. Lateral ligaments! The lateral and medial ligaments of the ankle further stabilize the joint! Figure 39. Lateral view of ankle joint Muhammad Arsal TaimoorTopic 4 - Ankle joint Medial ligament Figure 40. Medial and lateral views of the foot bones Muhammad Arsal TaimoorPoll time! QUESTION 4… Topic 4 - Ankle joint actions & Muscles Fibularis longus & brevis (Superficial fibular nerve) Lateral Compartment Fibularis tertius Tibialis anterior Gastrocnemius Soleus Extensor digitorum longus Tibialis posterior Extensor hallucis longus Flexor digitorum longus Flexor hallucis longus Figure 41. Dorsiflexion and plantarflexion visualized Posterior Compartment (Tibial nerve) (Deep fibular nerve) Anterior Compartment Muhammad Arsal Taimoor Topic 4 - Ankle joint actions & Muscles Lateral Compartment Tibialis anterior Fibularis tertius Tibialis posterior Fibularis longus & brevis Figure 42. Eversion and Inversion visualized Posterior Compartment Anterior Compartment Muhammad Arsal TaimoorTopic 4 - Leg & Foot Cutaneous Distribution Figure 15b. Leg cutaneous sensory distribution Muhammad Arsal Taimoor Topic 4 - Anterior Muscle Compartment Innervated by the Deep fibular nerve (L4-5) Name Origin Insertion Action Tibialis Anterior Lateral surface of the tibia Medial cuneiform & base of Dorsiflexion, Inversion of metatarsal I the foot Extensor Digitorum Lateral tibial condyle, medial Divides into 4 tendons at the Dorsiflexion, extension of Longus surface of fibular shaft, extensor retinaculum -> inserts lateral 4 digits interosseous membrane onto middle/distal phalanges 2-5 Extensor Hallucis Medial surface of fibular shaft Base of distal phalanx of big toe Dorsiflexion, extension of Longus big toe Medial surface of distal fibular Base of metatarsal V Dorsiflexion, eversion of Fibularis Tertius shaft (right underneath EDL foot origin) Muhammad Arsal Taimoor Topic 4 - Lateral Muscle Compartment Innervated by the Superficial fibular nerve (L4-S1) Name Origin Insertion Action Fibularis Longus Proximal lateral surface of Medial cuneiform & base of Plantarflexion, eversion of fibula & lateral tibial condyle metatarsal I foot Fibularis Brevis Inferolateral surface of fibular A tubercle on the base of Plantarflexion, eversion of shaft metatarsal I foot Muhammad Arsal Taimoor Topic 4 - Posterior Muscle Compartment Innervated by the tibial nerve (L4-S3) Name Origin Insertion Action Gastrocnemius Medial and lateral femoral Achilles tendon inserts onto Plantarflexion, knee flexion condyle (two heads) calcaneal tuberosity Soleus Soleal line of tibia & proximal Achilles tendon inserts onto Plantarflexion fibula calcaneal tuberosity Tibialis posterior Interosseous membrane & Plantar aspect of medial Plantarflexion, inversion of posterior tibia and fibula cuneiform and navicular bone foot Flexor Digitorum Longus Medial tibial surface Divides into 4 tendons and Plantarflexion, flexion of (FDL) inserts onto lateral 4 distal lateral 4 toes, inversion of phalanges midfoot Flexor Hallucis Longus Posterior fibular surface Plantar base of distal phalanx Plantarflexion, flexion of big (FHL) of big toe toe, inversion of midfoot Muhammad Arsal TaimoorTopic 3 - Tarsal Tunnel Tom- Tibialis posterior Dick- flexor Digitorum longus And- posterior tibial Artery Very- posterior tibial Vein Nervous- tibial Nerve Harry- flexor Hallucis longus Figure 43. Tarsal Tunnel ‘Tom, Dick, And Very Nervous Harry’ (Medial to Lateral) Muhammad Arsal Taimoor4 - Lower limb pathologies https://radiopaedia.org/cMuhammad Arsal Taimoorg=gb Topic 4 - Hip Fractures A 60 year old man fell from a 3-metre height where he landed on his left pelvis and presented with no pain or deformity noted in other parts of his body. Radiopedia RID: 149369 Muhammad Arsal Taimoor Topic 4 - Hip Fractures A 60 year old man fell from a 3-metre height where he landed on his left pelvis and presented with no pain or deformity noted in other parts of his body. Left non-displaced intracapsular neck of femur fracture Radiopedia RID: 149369 Muhammad Arsal TaimoorTopic 4 - Hip Fractures Etiology: Elderly (Falls - why?), Young adults (High-energy trauma) Types of NOF #s: Intracapsular, Extracapsular (subtrochanteric, intertrochanteric) Clinical Features: Pain ++, Inability to weight bear; Leg shortened, externally rotated Bedside/Initial Investigations: A-E assessment , Order a hip series x-ray (AP, Lateral), Bloods - what tests? Muhammad Arsal TaimoorTopic 4 - Hip Fractures Initial Management: Appropriate analgesia (what types?), treat any immediate life threatening injuries Definitive Management: Intracapsular (Cannulated hip screws/Total Hip Replacement/Hemiarthroplasty), Intertrochanteric (Dynamic Hip Screws), Subtrochanteric (Anterograde IM nail) Complications: Post-traumatic osteoarthritis, prosthetic joint infections, periprosthetic fractures Post-operative management: PT/OT - Physiotherapy/Occupational Therapy Muhammad Arsal Taimoor References Henry Gray - ‘Gray’s Anatomy 20th Edition’ (1918) (Figure 2, 7, 8, 9, 14, 17, 23, 30, 32, 34..etc.) Henry Morris - ‘Morris' human anatomy : a complete systematic treatise, 9th ed.’ (1933) Radasch, Henry Erdmann- Page 92 of ‘a manual of anatomy’ (1917) https://www.flickr.com/photos/internetarchivebookimages/14773159801 (Figure 16) John Hawks - ‘Tibia and fibula’ https://johnhawks.net/tibia-and-fibula/ (Figure 36) S. Bhimji - ‘Trendelenburg gait’ (2020) https://www.ncbi.nlm.nih.gov/books/NBK541094/figure/article-30566.image.f3/ (Figure 9) Osteomyoamare- ‘Plantarflexion dorsiflexion’ (2010) https://commons.wikimedia.org/wiki/File:Plantarflexion_dorsiflexion.png (Figure 41) Robert Steele MS DO- ‘RobertSteele SuralNerve GraysMODified’ (2022) https://commons.wikimedia.org/wiki/File:RobertSteele_SuralNerve_GraysMODified.png (Figure 35) Y.Yang- ‘Structures within the tarsal tunnel’ ‘Fine dissection of the tarsal tunnel in 60 cases’ (2017) https://doi.org/10.1038/srep46351 (Figure 43) InjuryMap- ‘Sciatic nerve and tibial nerve’ ‘InjuryMap- Free Human Anatomy Images and Pictures’ (2019) https://www.injurymap.com/free-human-anatomy-illustrations (Slide 30) OpenStax College- ‘Knee Joint’ ‘Anatomy & Physiology, Connexions Web site’ (2013) http://cnx.org/content/col11496/1.6/ (Figure 40) Muhammad Arsal Taimoor References FerIndigo97- ‘Nervio Safeno’ (2018) https://commons.wikimedia.org/wiki/File:Nervio_safeno.jpg (Figure 25) Athikhun.suw- ‘Tensor vastus intermedius muscle’ (2016) https://commons.wikimedia.org/wiki/File:Tensor_vastus_intermedius_muscle.jpg (Figure 21) O’ Dea- ‘Roman chair (hyperextension) animation’ (2012) https://en.m.wikipedia.org/wiki/File:Roman_chair_%28hyperextension%29_animation.gif (Figure 4) Saira Mould ‘Guidance on the administration of intramuscular injections’ ‘NHS Oxford Health’ (2023) (Figure 10-11) Chloe Wilson- ‘Vastus Medialis Exercises’ https://www.knee-pain-explained.com/vastus-medialis-exercises.html (Figure 20) Ninovalder, Mcstrother- ‘Plan of lumbar plexus’ (2010) https://commons.wikimedia.org/wiki/File:Lumbar_plexus.svg (Figure 23) Anatomist90- ‘Dissection of lumbar plexus’ (2010) https://commons.wikimedia.org/wiki/File:Lumbar_plexus.jpg (Figure 13) K. D. Schroeder- "Sciatic nerve2.jpg from Wikimedia Commons by K. D. Schroeder, CC-BY-SA 4.0" (2016) https://commons.wikimedia.org/wiki/File:Sciatic_nerve2.jpg (Slide 30) Jānis Šavlovskis- "Anatomy Standard - Drawing Hip bone (os coxae): lateral view - no labels" by Jānis Šavlovskis and Kristaps Raits, license: CC BY-NC (Figure 1) Radiopedia- “Intracapsular fracture neck of femur’ (2022) https://doi.org/10.53347/rID-149369 Muhammad Arsal Taimoor Thank you! Email: mat50@student.le.ac.uk