Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Lower Limb T&O st (1 session) Adam Hussain Vetted by: Mr. TanThanks to our partners!Lower Limb anatomy Adam HussainContents: • Hip: bones, stability of joint, movements • Muscles in gluteal region • Lumbosacral plexus • NV structures • Sites for IM injection • Thigh: osteology of femur • Muscles around the femur • NV supplyBony pelvis • Pelvic girdle consists of 2 hip bones, sacrum and coccyx • Hip bone consists of 3 bones: Ilium, ischium and pubis, which fuse at puberty • symphysis [cartilaginous joint] special joint called Pubic • Posteriorly anchored to axial skeleton at Sacrum by Sacroiliac joints • Functions: Weight bearing, locomotion, attachment for various muscles • Acetabulum: forms a socket which femoral head [ball] sits inIlium • Blade/fan shaped bone contains 2 parts: Body + Wing [Ala] • 3 Surfaces: • gluteal line. Also contains Anterior + Posterior gluteal lines • Iliac surface [iliac fossa]: superiorly by inner lip, inferiorly by arcuate line, posteriorly by iliac tuberosity + auricular surface • Sacropelvic surface: from posterior iliac fossa to posterior and iliac tuberosity [attachment site]rface which forms SIJ • 4 Borders: • Superior: Iliac crest containing inner and outer lips • Anterior: ASIS, AIIS to Acetabulum • Inferior: PSIS, PIIS, upper body of greater sciatic notch • Medial: Iliac crest to Ilio-pubic eminence [lower part forms Pectineal line]Ischium + Pubis • Ischium: L-shaped bone, forms posterolateral portion of hip bone, 2 parts: body + ramus • Body contains 3 surfaces: medial, femoral + posterior, • Femoral surface of body forms part of Superior border of Obturator foramen • Posterior surface: conical projection called Ischial spine, below lies the Lesser Sciatic foramen, Ischial tuberosity • Inferior Ischial ramus: meets with the inferior pubic ramus forming Ischiopubic ramus [inferior border of Obturator foramen] Pubis: smallest and anterior most portion. Contains body, superior and inferior ramus • Body: articulates with opposite pubic body: Pubic Symphysis, contains pubic crest superiorly which extends laterally as Pubic tubercle • Superior ramus: forms parts of Acetabulum laterally • Inferior ramus: forms inferior border of Obturator foramen Hip joint • Synovial articulation between the hemi-spherical head of femur and lunate surface of acetabulum forming multi-axial ball and socket joint • Designed for stability at the expense of mobility • Acetabulum: inferiorly marked by an Acetabular notch [allows passage of vital NV structures]. • Articular surface [lunate surface]: smooth, crescent shaped, transmits most of body’s weight through pelvis. Covered in hyaline cartilage along with femoral head • Non-articular surface: rough, shallow depression called Acetabular fossa. Continuous with notch. • Movements: flexion, extension, abduction, adduction, medial + lateral rotation + circumduction • Synovial membrane + fibrous membranes enclose entire hip joint • Key Ligaments: reinforce external surface of hip joint providing stability • Iliofemoral: triangular/Y shaped, from AIIS to acetabulum, base attached alone intertrochanteric line • Pubofemoral: triangular shaped, from Iliopubic eminence medially to blending with fibres of Iliofemoral ligament • Ischiofemoral: posterior reinforcement of joint, from ischium medially to greater trochanter laterally • Transverse acetabular ligament: converts notch into foramen • Ligament of the head of the femur: from fovea on head of femur to acetabular fossa, TAL and margins of notch.Stability of hip joint • Osseous congruency: allows entire head of femur to fit into socket [unlike shoulder joint where only small portion of head enters glenoid cavity] • Labrum: fibrocartilage ring around head of femur, increased depth of acetabulum creating more stability, and acts as a suction seal around femoral head to maintain it within the joint • Ligaments: Iliofemoral [limits hyperextension, abduction and Lateral rotation], ischiofemoral [limits forward flexion and medial rotation], pubofemoral [limits abduction], zona orbicularis [annular ligament]: wraps around neck of femur to provide stability • Capsule: articular fibrous capsule extends from acetabular rim to intertrochanteric crest, reinforce joint • 21 muscles cross hip joint: notably Iliopsoas and Rectus femoris which act as dynamic stabilizersGateways to lower limb • Greater sciatic foramen • Boundaries: greater sciatic notch, upper borders of Sacrospinous and Sacrotuberous ligaments, lateral Sacrum • Content [above Piri]: SG NAV • Content [below Piri]: Sciatic, IG NAV, Nerves: Pudendal, Femoriserve to Ob internus, Sup + Inf Gemellus, Quadratus • Lesser sciatic foramen • Boundaries: Sup [Ischial spine + Sacrospinous lig], Ant [Ischial body], Post [Sacrotuberous lig] • Between inguinal lig + pelvic bone • Obturator canal: • Boundaries: Sup [Obturator groove on Superior pubic Externus muscles]rator membrane and Ob internus + • Contents: Obturator NAVSuperficial muscles of the gluteal region Overall function: abduct and extend thigh TFL: crosses knee joint so acts on leg as well SGN innervates all except G. Max [Inf]Deep muscles of the gluteal region Patched Goods Often Go On Quilts: Piriformis, Gemellus superior, Obturator Internus, Gemellus Inferior, Obturator Externus, Quadratus femoris Function: ER of thigh, Abd of thigh from a flexed hip [except QF], stabilityFemur • The femur is the longest bone in the body • Plays an important role in transmitting body weight, our ability to stand and ability to move Femur has 3 distinct parts: proximal, shaft and distal • Proximal • Head: articulates with acetabulum to form hip joint, covered in hyaline cartilage except at the fovea, where ligamentum teres attaches • Neck: cylindrical, projects supero-medially from shaft, normally 135 degrees • Greater Trochanter: lateral-most projection, attachment site • Lesser trochanter: smaller projection, located postero-medially • Intertrochanteric line: bony ridge between trochanters, • Isurfacechanteric crest: bony ridge between trochanters, posterior • Coxa Valga: angle between femoral shaft and neck is increased [>139] • Coxa vara: angle is reduced [<120]What’s happened here + why is it important? AP view of a neck of femur fracture - Old: most common cause is falls - Young: most common cause is high-energy trauma e.g. Vehicle collision or fall from height Blood supply to femoral neck: - Medial + Lateral circumflex arteries, branches of Profunda femoris - Form an arterial ring at base of neck, from here penetrating branches enter joint capsule and supply head - Reinforced by artery of ligamentum teres NOF fractures - Interrupt blood supply to the femoral head resulting in avascular necrosis [death of bone tissue from lack of blood supply]. - This can manifest as significant pain, limited ROM and crackling sounds on movement. - Management involves core decompression which reduces pressure and promotes blood flow. In severe cases total hip replacement may be required. Femur [continued] • Shaft: longest bone in body, descends in a medial direction allowing knees to come closer to the body’s centre of gravity for stability. • Linea aspera: rough ridge on posterior surface, splits in the proximal 1/3 to form pectineal line [medial] + gluteal tuberosity [laterally] • Gluteal tuberosity: attachment for G. Max • Pectineal line: • Distally, linea aspera separates into medial + lateral supracondylar lines. MSL ends as the adductor tubercle where the Adductor Magnus attaches • Distal • Medial + Lateral condyles: anterior surfaced articulate with Patella whilst Posterior articulates with Tibia • Medial + Lateral epicondyles: bony elevations on the non-articular areas of condyles, origin point of MCL + LCL • Intercondylar fossa: deep notch between condyles, attachment sites for ACL + PCLFemoral triangle Femoral triangle: wedge-shaped depression forming a junction between the abdomen and the lower limb. • Boundaries • Base: inguinal ligament • Medial: medial margin of adductor longus • Lateral: medial margin of sartorius • Floor: Pectineus + Adductor longus [medially], Iliopsoas [Laterally] • Apex: continuous with fascial canal [Adductor canal] which descends medially and posteriorly through Adductor Magnus. • Contents: Femoral NAV + Lymphatics. Femoral sheath surrounds the femoral artery, vein and Lymph. Each of these 3 structures are covered individually their own sheaths as well.Muscular compartments + Femoral triangle Muscles of the thigh are separated into 3 compartments by intermuscular septum: anterior, posterior and medial • Anterior: contains Sartorius + 4 large quadriceps. All supplied by Femoral nerve • Medial: contains 6 muscles: Gracilis, pectineus, Adductor longus, magnus, brevis and Obturator externus. All innervated by Femoral nerve except Adductor magnus [Sciatic] and Ob externus [Obturator nerve] • Posterior: contains 3 hamstrings, all innervated by sciatic nerveMuscles of anterior thighMuscles of medial thighMuscles of posterior thigh • Biceps femoris: lies lateral in the posterior compartment. Long head crosses the posterior thigh obliquely from medial to lateral and joins with the Short head distally. Expansions from tendon blend with ligaments on the lateral knee. • Semitendinosus: medial to BF • Semimembranosus: lies deep to ST. Expansions from SM tendons reinforce the ligaments + fascia around the knee joint.Lumbar plexus Lumbar plexus: formed from Anterior Rami of L1-4. These forms cords which come together to form 6 major peripheral nerves which descend the posterior Abdominal wall to the lower limb • Iliohypogastric nerve: L1 • Motor: Internal oblique + transversus Abdominus • Sensory: posterolateral gluteal skin • Ilioinguinal: L1 • Motor: Internal oblique • Sensory: superior antero-medial thigh, skin on root of penis + anterior scrotum in males. In females, supplies skin over mons pubis + labia majora • Genitofemoral: L1,L2 • Motor: cremasteric muscle • Sensory: anterior scrotum skin, females: mons pubis + labia majora • Lateral femoral cutaneous nerve of the thigh: L2,L3, Sensory: innervates anterior and lateral thigh down to the knee • Obturator: L2,3,4. Motor: Medial compartment. Sensory: skin over medial thigh • Femoral: L2,3,4. Motor: Anterior compartment. Sensory: anterior + medial thighSacral plexus Formed by anterior rami of S1-4. Forms cords which come together to form 5 major peripheral nerves which descend the posterior pelvic wall destined for either the Greater sciatic foramen or remain in the pelvis. • Superior gluteal nerve: L4,5,S1. Leaves via GSF. Motor: G. Min, Med, TFL • Inferior gluteal nerve: L5,S1,S2. Motor: G. Max • Sciatic: L4-S3. • Motor: Tibial portion supplies posterior compartment + Hamstring muscles in anterior and lateral compartments of leg [knee down]ll • Sensory: Tibial [skin on posterolateral leg, lateral foot + sole], Common fibular [skin on lateral leg + dorsum of foot] • Posterior femoral cutaneous: S1-3. Sensory: posterior surface of thigh + leg. Also skin on perineum • Pudendal:S2-4. • Motor: muscles in perineum, external urethral sphincter, external anal sphincter, levator ani • Sensory: innervates penis, clitoris, most of the skin of the perineumIM injections • Must avoid damaging neurovascular structures [mainly Sciatic nerve] • Divide gluteal region into 4 quadrants by 2 lines • Vertical line: Highest point on iliac crest to a horizontal plane through the ischial tuberosity • Horizontal line: halfway between line 1 • Sciatic runs through the inferior medial quadrant, so safest site is the superior lateral region on the buttocks to avoid injury Artery supply + Venous drainage • and External iliac at the pelvic brim, in front of the SIJ • Internal iliac: gives off Obturator artery, Inferior and Superior Gluteal arteries to supply gluteal region • External iliac artery becomes Femoral artery at the Inguinal ligament • Femoral artery passes down the thigh and leaves via Adductor canal • Gives off one major branch laterally in the femoral triangle: Deep artery of the thigh [Profunda Femoris] • Deep artery gives off Medial and Lateral circumflex arteries and perforating branches.Venous drainage • Velandmarks as Arteries [Deep vein of thigh, femoral vein, EIV]. Superficial veins drain into deep veins via perforating veins. • Deep: • Foot and leg: dorsal venous arch, drains into superficial veins mostly, but some penetrate deep into the leg, forming anterior tibial vein. Medial and posterior tibial and fibular veins. On posterior surface of knee, anterior tibial, posterior tibial and fibular veins combine to form popliteal vein • Once popliteal vein enters thigh, it empties into distal femoral vein [drains thigh compartment through perforating veins]. Femoral vein leaves thigh underneath inguinal ligament, and is then called external iliac vein • empty into the internal iliac vein.ferior and superior gluteal veins, which • Superficial: • Great Saphenous [from medial aspect of dorsal venous arch] ascends anterior to medial malleolus and posteriorly to the medial condyle at the inguinal ligament]by drainage into femoral vein immediately inferior to • Small Saphenous [from dorsal venous arch of foot and dorsal vein of little toe] ascends on the posterior side of leg, along lateral border of calcaneal tendon into popliteal vein [between 2 heads of gastrocnemius muscle]See future sessions and watch recordings at: SUPTA.UK