Anatomy Revision Session 2

slides are available online atSlideshare.net/muradalshehry

After this session

The Upper Limb

Anatomy Revision Session 1

Objectives of this session

• To be able to Identify the muscles and their functions of the upper limb.

• Know relations of muscles to important nerves.

• There will be a few pop Quiz…. Stay focused ☺

Orientation and Movement REVISION

adduction

abduction

flexionextension

circumduction

rotation

elevation

depression

supination

pronation

protraction

retraction

Orientation and Movement REVISION

Flexor digitorum superficialis

• Medial epicondyle of humerus and coronoid process of ulna to middle phalanges (lateral) of digits 2-5 (i.e. all except thumb)

• Flexion of metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joint

• Median nerve (C7,C8,T1)

Flexor digitorum profundus

• Ulna and interosseous membrane to distal phalanges digits 2-5 (palmar)

• Flexion of MCP, PIP and distal interphalangeal joint (DIP) of digits 2-5

• Ring and little fingers = ulnar nerve (C8,T1)

• Index and middle fingers = median nerve (C8,T1 anterior interosseous)

Flexor digitorum muscles:

Superficialis Splits in two, To Permit Profundus Passing through.

Flexor pollicis longus

• Radius and interosseous membrane to base of distal phalanx of thumb (palmar)

• Flexion of MCP and IP of thumb, wrist

• Median nerve (C8, T1 anterior interosseous)

Pronator quadratus

• Distal anterior ulna to distal anterior radius

• Pronation and help to stabilise distal radioulnar joint

• Median nerve (C8, T1 anterior introsseous)

Anterior forearm muscles: superficial group There are five, like five digits of your hand.Place your thumb into your palm, then lay that hand palm down on your other arm. PFPF [pass/fail, pass/fail]:Pronator teresFlexor carpi radialisPalmaris longusFlexor carpi ulnarisYour thumb below your 4 fingers shows the muscle which is deep to the otherfour: Flexor digitorum superficialis.

Median nerve

• C6-T1 fibres, medial and lateral cords

• Major nerve of anterior compartment of forearm, THROUGH carpal tunnel

• Main nerve of thumb side of hand

Ulnar nerve and artery

• C7-T1 fibres from medial cord, medial epicondyle of humerus, pisiform ABOVE carpal tunnel

• Branch brachial artery, interosseous branches, little finger side, superficial palmar arch

median

ulnar

radialant. interosseous

anterior interosseous

Median nerve passes between the heads of pronator teres

Anconeus

• Lateral epicondyle of humerus to olecranon of ulna

• Extension of the elbow

• Radial nerve (C7-C8)

Brachioradialis

• Distal humerus (supra-epicondylar ridge) to radius proximal to styloid process

• Puts the forearm into the semi-prone position, flexion of elbow

• Radial nerve (C5, C6, C7) (before division into deep and superficial)

Posterior compartment of the forearm

• Common extensor origin = lateral epicondyle of the humerus

• Extensors of the digits, wrist

• Abductor of the thumb

• Supinator

• Radial nerve

Extensor carpi radialis longus and brevis

• Extensor carpi radialis longus from distal humerus (supra-epicondylar ridge) to base of 2nd metacarpal

• Wrist extension and abduction

• Radial nerve (C6,C7) (pre-division)

• Extensor carpi radialis brevis from lateral epicondyle of humerus to base of 3rd metacarpal

• Wrist extension and abduction

• Radial nerve (C7,C8) (deep = posterior interosseous)

extensor carpi radialis longus

extensor carpi radialis brevis

Extensor carpi ulnaris

• Lateral epicondyle of humerus (small slip from ulna) to base of 5th metacarpal

• Wrist extension and adduction

• Radial nerve (posterior interosseous) (C7, C8)

Extensor digitorum

• Lateral epicondyle of humerus to dorsal expansion of digits 2-5 (NOT thumb)

• Extension of principally MCP, but also PIP and DIP extension of digits 2-5

• Radial nerve (posterior interosseous) (C7,C8)

Extensor digiti minimi

• Lateral epicondyle of the humerus to dorsal expansion of 5th digit (little finger)

• MCP, PIP, DIP extension of little finger

• Radial nerve (posterior interosseous) (C7,C8)

Extensor indices

• Posterior surface of ulna (and interosseous membrane) to dorsal expansion of digit 2 (index finger)

• MCP, PIP, DIP extension of index finger

• Wrist extension

• Radial nerve (posterior interosseous) (C7,C8)

Extensor pollicis longus• ‘Pollicis’ = thumb

• Ulna and interosseous membrane to base of distal phalanx of thumb

• CMC, MCP and IP extension of thumb

• Radial nerve (posterior interosseous) (C7, C8)

Extensor pollicis brevis

• Radius and interosseous membrane to base of proximal phalanx of thumb

• Carpometacarpal and MCP thumb joint extension

• Radial nerve (posterior interosseous) (C7,C8)

Abductor pollicis longus

• Radius, interosseous membrane and ulna to base of 1st metacarpal

• Abducts thumb and extends it at carpometacarpal joint

• Radial nerve (posterior interosseous) (C7,C8)

Supinator

• Crest of ulna, lateral epicondyle of humerus, radial collateral and annular ligament of radius to lateral radius (proximal third)

• Supination of forearm (rotates radius)

• Radial nerve (posterior interosseous)(C7,C8)

Radial nerve passes through the lamina of supinator

posterior

interosseous

anterior interosseous

deep branch of radial

common interosseous

superficial

artery

artery

artery

The Hand

Flexor retinaculum• Roof of carpal tunnel

• Medial = pisiform, hook of hamate

• Lateral = tubercle of scaphoid and ridge on trapezium

• Septum from trapezium – flexor carpi radialis

• Attach thenar and hypothenar structures

Carpal tunnel

Carpal tunnel syndrome causes MEDIAN TRAP:

MyxoedemaEdema premenstruallyDiabetesIdiopathicAgromegalyNeoplasmTraumaRheumatoid arthritisAmyloidosisPregnancy

Bones and joints

carpals

metacarpals

proximal phalanx

middle phalanx

distal phalanx

interphalangeal (IP) joints = synovial hinge

metacarpophalangeal (MCP) joints = synovial condyloid

carpometacarpal (CMC) joints = synovial saddle (thumb), plane (digits)

intercarpal = synovial plane

Palmar aponeurosis

aponeurosis

palmaris longus

Palmaris brevis

• Palmar aponeurosis and flexor retinaculum to dermis

• Grip• Ulnar nerve (superficial

C8,T1)

Intrinsic muscles of the hand

abductor pollicis brevis = intrinsic muscle

tendon of flexor digitorum superficialis = extrinsic muscle

Intrinsic muscles – thenar eminence• Abductor pollicis brevis = scaphoid

and trapezium to base proximal phalanx of thumb – CMC joint abduction – median nerve (recurrent C8,T1)

• Flexor pollicis brevis = flexor retinaculum, capitate, trapezium to base proximal phalanx of thumb – CMC joint flexion – Median (recurrent) and some texts also ulnar nerve (C8,T1)

• Opponens pollicis = trapezium to first metacarpal – CMC joint opposition – median nerve (recurrent C8,T1)

abductor pollicis brevis

flexor pollicis brevis

opponens pollicis

Adductor pollicis • Transverse head from 3rd metacarpal; oblique head from capitate and 2nd/3rd metacarpals to base of proximal phalanx of thumb

• Adduction of CMC joint of thumb

• Flexion of MCP joint of thumb

• Ulnar nerve (deep C8,T1)

transverse head

oblique head

Hypothenar eminence • Abductor digiti minimi = pisiform

bone to base of 5th proximal phalanx and dorsal digital expansion – abduction and flexion MCP joint little finger – ulnar nerve (deep C8,T1)

• Flexor digiti minimi = hamate, flexor retinaculum to base of 5th proximal phalanx – Flex MCP joint of little finger – ulnar nerve (deep C8,T1)

• Opponens digiti minimi = hamate and flexor retinaculum to 5th metacarpal – weak opposition of little finger – ulnar nerve (deep C8,T1)

abductor digiti minimi

flexor digiti minimi

opponens digiti minimi

Lumbricals• 4 small muscles from tendons of

flexor digitorum profundus

• 1st (index) and 2nd (middle) unipennate

• 3rd (ring) and 4th (little) usually bipennate

• Insert into dorsal digital expansion

• MCP joint flexion and IP joint extension for digits 2-4

• 1st and 2nd = median nerve (digital C8,T1)

• 3rd and 4th = ulnar nerve (deep C8,T1)

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34

lumbrical

Lumbricals action 

Lumbricals action Lumbrical action is to hold a pea, that isto flex the metacarpophalangeal joint and extend the interphalangeal joints.When look at hand in this position, can see this makes an "L" shape, since Lis for Lumbrical.

Palmer interossei

• Between metacarpal bones

• 1st from 2nd metacarpal to base of 2nd proximal phalanx and dorsal expansion

• 2nd from 4th metacarpal to base of 4th proximal phalanx and dorsal expansion

• 3rd from 5th metacarpal to base of 5th proximal phalanx and dorsal expansion

• Adduction towards middle finger (flex MCP, extend IP)

• Ulnar nerve (deep C8,T1)

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3

Dorsal interossei • From sides of 2 adjacent metacarpals, eg, 1st dorsal interossei from 1st and 2nd metacarpals

• 1st inserts into 2nd proximal phalanx and dorsal digital expansion

• 2nd and 3rd inserts into the 3rd proximal phalanx and dorsal digital expansion

• 4th inserts into 4th proximal phalanx and dorsal digital expansion

• Abduction (MCP flexion, IP extension)

• Ulnar nerve (deep C8,T1)123

4

Interossei muscles

: actions of dorsal vs. palmar in hand "PAdand DAb":The Palmar Adduct and the Dorsal Abduct.· Use your hand to dab with a pad.

Intrinsic muscles of hand (palmar surface)

"A OF A OF A":· Thenar, lateral to medial:Abductor pollicis longusOpponens pollicisFlexor pollicis brevisAdductor pollicis.· Hypothenar, lateral to medial:Opponens digiti minimiFlexor digiti minimiAbductor digiti minimi

Synovial sheaths

• Synovial membrane plus fluid

• Around tendons at wrist, palm and into digits

Cutaneous supply

median

ulnar ulnar

radial

Cutaneous upper limb

ANT POST

Carpal bones"Stop Letting Those People Touch The Cadaver's HandProximal row, lateral-to-medial: Scaphoid Lunate Triquetrum PisiformDistal row, lateral-to-medial: Trapezium Trapezoid Capitate Hamate

Or

"Happy Cat Tom Took Pie To Little Sister":HamateCapitateTrapezoidTrapeziumPisiformTriquitalLunateScaphoid

Lower Limb

Gluteal Region and Hip Joint

Outline

• Innominate (Hip) Bone• Proximal Femur• Muscles of the gluteal region• Nerves and Vessels of the gluteal region• Hip Joint

ObturatorForamen

AuricularSurface

Iliac crest

Iliac fossa

ASIS

AIIS

PSIS

PIIS

Arcuate Line

Ischial Tuberosity

Ischial Spine

Lesser SciaticNotch

Greater SciaticNotch

Pubis

Innominate: Medial

view

Innominate: Lateral

view

Iliac crest

ASIS

AIIS

PSIS

PIIS

Ischial Tuberosity

Ischial Spine

Lesser SciaticNotch

Greater SciaticNotch

Pubis

PosteriorGluteal Line Anterior

Gluteal Line

InferiorGluteal Line

Acetabulum

Pubic Tubercle

Ischium

Greater and Lesser Sciatic Foramina

Muscles of Gluteal Region

Lateral Rotators of Hip• Gluteus Maximus

(extensor)• Piriformis• Obturator internus• Gemelli• Quadratus femoris

Medial Rotators and Abductors of Hip

• Gluteus Medius• Gluteus Minimus

Support• Tensor fascia lata

Gluteus Maximus

• Sacrum, S/T ligament and ilium behind posterior gluteal line Iliotibial tract (3/4) and gluteal tuberosity of femur (1/4)

• Extends hip; assists lateral rotation

• Inferior gluteal nerve • (L5, S1, 2)

Tensor Fascia Lata

• Ant. Iliac Crest and ASIS Iliotibial tract

• Tenses fascia lata and iliotibial tract; Supports femur on tibia during standing

• Superior Gluteal nerve• (L4, 5, S1)

GluteusMaximus

Iliotibial tract

Gluteus Medius

• Ilium between posterior and anterior gluteal lines greater trochanter (lateral surface)

• Abducts and medially rotates hip

• Superior gluteal nerve• (L4, 5, S1)

Gluteus Minimus

• Ilium between anterior and inferior gluteal lines greater trochanter (anterior surface)

• Abducts and medially rotates hip

• Superior gluteal nerve • (L4, 5, S1)

Piriformis

• Anterior Sacrum and S/T lig. Greater Trochanter (superior border)

• Passes through greater sciatic foramen

• Laterally rotates hip

• Anterior rami of L5, S1, 2

Obturator internus

• Pelvic surface of Obturator mem. and surrounding bones Trochanteric Fossa of greater trochanter

• Passes through lesser sciatic foramen

• Laterally rotates hip

• Nerve to obturator internus (L5, S1)

Gemelli

• Superior: Ischial spine• Inferior: Ischial tuberosityBlend with tendon of obturator

internus (Trochanteric fossa)

• Laterally rotate hip

• Superior: Nerve to obturator internus

• Inferior: Nerve to quadratus femoris

Quadratus femoris

• Ischial tuberosity Quadrate tubercle on intertrochanteric crest of femur

• Laterally rotates hip

• Nerve to quadratus femoris (L5, S1)

Obturator externus

• Outer surface of obturator mem. Trochanteric fossa

• Laterally rotates hip

• Obturator nerve• L3, 4

Anterior

Lateral Rotators

"Play Golf Or Go On Quacking":· From top to bottom:PiriformisGemellus superiorObturator internusGemellus inferiorObturator externusQuadratus femoris· Alternatively: "P-GO-GO-Q".

Sciatic nerve

• L4, 5, S1, 2, 3• Tibial always leaves below

piriformis • Common Peroneal may leave

below, above or through piriformis

Gluteal vessels and nerves

• Superior gluteal artery and nerve

• Inferior gluteal artery and nerve

• Piriformis

Posterior cutaneous nerve of thigh

• Lies on posterior aspect of sciatic nerve

• (S1, 2, 3)• Inferior Clunial nerves to skin of

inferior half of buttock

Cutaneous Nerves – Gluteal and Posterior Thigh

Superior Clunial(posterior rami L1,2,3)

Middle Clunial(posterior rami S1,2,3)

Posterior Cuntaneous n. of Thigh with Inferior Clunial branches

Hip Joint

• Articular surfaces• Capsule attachments• Ligaments• Relations of the Joint

Articular Surfaces

Capsule attachments

Iliofemoral ligament

• AIIS → Intertrochanteric line• Upper and lower bandsLimits:• Extension• Lateral rotation• Adduction (upper)• Abduction (lower)

Pubofemoral ligament

• Iliopubic eminence → Lower part of intertrochanteric line

Limits:• Extension• Lateral rotation• Abduction

Ischiofemoral ligament

• Posterior aspect of acetabulum → Greater trochanter

Limits:• Extension• Medial rotation• Adduction

Blood Supply to the Hip Joint

Anterior and Medial Thigh

Outline• Compartments of the Thigh• Features of the femur• Muscles of Anterior Compartment• Muscles of Medial Compartment• Adductor Canal• Nerves• Arteries

Compartments of Thigh

Flex Hip; Extend Knee

Anterior CompartmentSubcutaneous tissue

Fascia Lata

Medial Compartment

Posterior Compartment

Great Saphenous vein

Intermuscular Septum

Iliotibial tract

Extend Hip; Flex Knee

Adduct Hip

Proximal femur (anterior)Head

Greater trochanter

Intertrochanteric line

Lesser trochanter

Shaft

Fovea

Neck

Proximal femur (posterior)

Greater trochanter

Trochanteric Fossa

Intertrochanteric crest

Lesser trochanter

Pectineal line

Gluteal tuberosity

Anterior Thigh

Hip Flexors• Iliacus• Psoas major• Pectineus• Sartorius

Knee Extensors• Quadriceps

• Rectus femoris• Vastus medialis• Vastus lateralis• Vastus intermedius

Hip Flexors – Iliopsoas

• Iliacus• Iliac crest, fossa, ala of sacrum, ant. sacroiliac

lig. → Psoas tendon, lesser trochanter• Femoral nerve (L2, 3)• Flex hip

• Psoas major• T12-L5, IV discs, lumbar transverse processes

→ Lesser trochanter• Anterior rami L1-3• Flex hip

Hip Flexors – Pectineus

• Pectineus• Superior ramus of pubis →

Pectineal line of femur• Femoral nerve (L2, 3) [occassionally br.

from obturator]• Adduct and flex hip; assist with medial

rotation

Hip Flexors – Sartorious

• Sartorious• ASIS →

Superior part of medial surface Tibia

• Femoral nerve (L2, 3)

• Flex, abduct, laterally rotate hip; flex knee

Knee Extensors – Quadriceps• Rectus femoris

• AIIS, ilium above acetabulum• Vastus lateralis

• Gr. Trochanter & Lat. Linea Aspera• Vastus medialis

• Intertrochanteric line & Med. Linea Aspera• Vastus intermedius

• Ant. and Lat. Shaft of femur

• → Quadriceps tendon then tibial tuberosity via Patellar lig.

• Extend knee (rectus fem. also flexes hip)• Femoral nerve (L2,3,4)

RectusFemoris

VastusLateralis

VastusMedialis

VastusIntermedius

Anterior Thigh

Rectus Femoris

Vastus Lateralis

Vastus Medialis

Sartorious

Iliopsoas

Pectineus

Femoral nerve

• Passes deep to inguinal ligament, medial to ASIS, on tendon of iliopsoas m.

• Muscular branches: anterior thigh• Articular branches: hip and knee• Cutaneous branches: anteromedial thigh

• Saphenous nerve is terminal cutaneous br. – anteromedial knee, leg and foot

Iliacus

Rectusfemoris

Vastimuscles

Pectineus

Medial Thigh

Hip Adductors• Gracilis• Adductor Longus• Adductor Brevis• Adductor Magnus• Obturator Externus

Hip Adductors – Gracilis

• Gracilis• Body and Inf. ramus of Pubis →Superior

Medial surface Tibia

• Obturator (L2, 3)

• Adducts hip; flexes knee

Hip Adductors – Adductor Longus

• Adductor Longus• Body pubis → Middle ⅓ Linea aspera

• Obturator (L2,3,4)

• Adducts thigh

Hip Adductors – Adductor Brevis

• Adductor Brevis• Body and Inf. ramus of Pubis →Pectineal Line

and proximal Linea aspera

• Obturator (L2,3,4)

• Adducts thigh (may assist flexion)

Hip Adductors – Adductor Magnus

• Adductor Magnus

• Ischiopubic ramus and Ischial tuberosity →Linea aspera, Med. Supracondylar line, Adductor tubercle

• Obturator (L2,3,4); Hamstring part – tibial part Sciatic n. (L4)

• Adducts thigh; Adductor part flexes and hamstring part extends thigh

Hip Adductors – Obturator Externus• Obturator Externus

• Margins obturator foramen and Obturator membrane →Trochanteric fossa

• Obturator (L3,4)

• Laterally rotates thigh

Medial Thigh

AdductorLongus

Gracilis

AdductorBrevis

AdductorMagnus

ObturatorExternus

AdductorMagnus

Obturator Nerve

Obturator externus

Adductor Brevis

Adductor Longus

Adductor Magnus

Gracilis

• Anterior divisions L2-4• Runs along lateral wall of pelvis to the

obturator canal• Anterior and Posterior branches• Muscular branches to medial thigh• Anterior branch – cutaneous to middle part of

medial thigh ObturatorExternus

AdductorBrevis

PosteriorBranch

AnteriorBranch

PosteriorBranch

AnteriorBranch

Adductor Canal

• Apex of Femoral Triangle Adductor Hiatus (in adductor magnus)

• Underlies the distal half of sartorius m.

• Femoral vessels travel in canal and pass through Hiatus to reach Popliteal fossa

• Saphenous nerve runs in canal then passes between sartorius and gracilis to supply skin of anteromedial knee, leg and foot

Femoral a. and v. entering adductor canal

Saphenous n.

Sartorius forming roof of adductor canal

Arterial Supply

Femoral artery – Continuation of Ext. Iliac a.• Femoral triangle → Adductor canal → Adductor hiatus to become Popliteal

a.• Supplies anterior and anteromedial thigh

Profunda femoris → br. of Femoral• Runs posterior to Adductor Longus → 3/4 perforating br.s through Add.

Magnus to supply mm in med., post. and lat. part of ant. Compartment• Also gives Medial and Lateral Circumflex femoral br.s

Obturator artery (from Int. Iliac a.) • Through obturator foramen to medial compartment → ant. and post. br.s• Anterior branch: muscles of medial compartment• Posterior branch: muscles attached to ischial tuberosity

Femoral

ProfundaFemoris

ExternalIliac

CommomIliac

Lateral CircumflexFemoral

Femoral

ProfundaFemorisMedial Circumflex

Femoral

PerforatingBranches

Popliteal

Obturator

AdductorMagnus

AdductorHiatus

Openings forPerforating br.s

Anterior Posterior

CruciateAnastomosis

Posterior thigh and popliteal fossa

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Outline

• Muscles of posterior thigh• Sciatic nerve• Popliteal fossa

• Roof• Boundaries• Contents• Floor

• Popliteal artery and branches

Posterior Thigh

• Hamstrings• Semitendinousus• Semimembranosus• Biceps Femoris

• Extend hip, Flex knee

Semitendinosus

• Semitendinosus• Ischial tuberosity Medial

surface of superior tibia

• Tibial division of Sciatic• L5,S1,S2

Semimembranosus

• Semimembranosus• Ischial tuberosity

Posterior surface of Medial Condyle of tibia

• Tibial division of Sciatic• L5,S1,S2

Biceps Femoris

• Biceps femoris• Long head: Ischial tuberosity• Short head: Linea aspera and

Lat. Supracondylar line of femur Head of Fibula

• Long head = Tibial division of Sciatic (L5,S1,S2)

• Short head = Common peroneal division of Sciatic (L5,S1,S2)

Rotation of Knee

• Knee Flexed:• Lateral rotation by:

• Biceps Femoris• Medial rotation by:

• Semimembranosus• Semitendinosus• Gracilis• Sartorius

Sciatic Nerve

• L4-S3

• Deep to long head of biceps femoris

• Tibial and Common Peroneal (fibular) Divisions

Tibialnerve

Common Peroneal

nerve

Right

Popliteal Fossa – Roof

• Deep fascia

• Pierced by:• Sural nerve • Short saphenous vein

Sural nerve

Short SaphenousVein

Popliteal Fossa – Boundaries

• Superiorly: Diverging tendons of Hamstrings• Biceps femoris laterally• Semimembranosus and Semitendinosus

medially

• Inferiorly: Medial and Lateral heads of Gastrocnemius

Popliteal Fossa – Contents

• Popliteal artery

• Popliteal vein

• Terminal branches of Sciatic• Tibial nerve• Common peroneal nerve

Medial& Deep

Lateral &Superficial

Popliteal artery

Popliteal vein

Tibial nerve

Common Peroneal nerve

• medial to lateral arrangment "Serve And Volley Next Ball":Semimembranosus/ SemitendonosusArteryVeinNerveBiceps femoris· Lateral and medial heads of Gastrocnemius are inferior borders.

Popliteus

Joint capsule

Femur

Popliteal Fossa – Floor

• Popliteal surface of femur

• Capsule of Knee Jt.

• Popliteus muscle

Popliteal Fossa – Floor

• Oblique popliteal ligament• Expansion of Semimembranosus• Reinforces knee joint capsule

• Middle Genicular vessels • Pierce joint capsule to supply cruciate

ligaments

Popliteal Artery

• Continuation of femoral• Adductor hiatus →Inferior

border of Popliteus• 5 genicular branches• Terminal branches:

• Anterior Tibial artery• Posterior Tibial artery

Medial SuperiorGenicular artery

Lateral SuperiorGenicular artery

Medial InferiorGenicular artery

Lateral InferiorGenicular artery

Anterior and Lateral Leg

Dorsum of Foot

Outline

• Compartments of the leg• Interosseous membrane and superior tibiofibular joint• Muscles of Lateral Compartment• Muscles of Anterior Compartment• Extensor Retinacula• Dorsum of Foot• Peroneal nerves• Arteries of the Leg and Dorsum of Foot

Compartments of the Leg

Interosseous membrane

• Provides a surface for muscle attachment

• Fibres pass inferolaterally from Tibia to Fibula

• Helps resist the downward pull of muscles attached to the fibula

Superior tibiofibular joint

Anterior and Lateral Compartments

Anterior Compartment:4 MusclesExtensors of ankle jt. and digitsTendons anterior to ankle jt.

Lateral Compartment2 MusclesEvertors of the footTendons posterior to lateral malleolus

Lateral Compartment

Peroneus Longus:Head and upper ⅔ of lat. Fibula

® base of 1st Metatarsal and Medial Cuneiform

Superficial Peroneal Nerve (L5,S1,S2)

Lateral Compartment

Peroneus Brevis:Inf. ⅔ of lat. Fibula

® Tuberosity on Lat. side of Base of 5th Metatarsal

Superficial Peroneal Nerve (L5,S1,S2)

Lateral Compartment

Peroneus Longus TendonPeroneus Brevis Tendon

Peroneal Trochlea of Calcaneus

Cuboid

5th Metatarsal

Calcaneus

Talus

Anterior compartment• Tibialis anterior• Extensor digitorum longus• Extensor hallucis longus• Peroneus tertius

• All supplied by Deep Peroneal Nerve

• L4, L5

Tibialis Anterior

Lat. condyle of Tibia, Sup. ½ of Lat. Tibial surface, Interosseous mem.

→ Med. and Inf. surfaces of Medial Cuneiform and base of 1st metatarsal

Dorsiflexes ankle; Inverts foot

R

R

Extensor Digitorum Longus

Lat. Condyle Tibia, Sup. ¾ of med surface Fibula, Interosseous membrane

®Middle and distal Phalanges of Lateral 4 digits

Extends lateral 4 digits; Dorsiflexes ankle

R

Inf. ⅓ anterior Fibula and Interosseous membrane

®Dorsum of base of 5th Metatarsal

Dorsiflexes ankle; Assists in eversion of foot

Peroneus Tertius

R

Extensor Hallucis Longus

Middle ant. surface Fibula, Interosseous membrane

®Dorsal aspect of distal Phalanx of Hallux

Extends Hallux; Dorsiflexes ankle

Extensor Retinacula

Superior Extensor Retinaculum

Ant. Border of Tibia Lower end of Fibula

Inferior Extensor Retinaculum (Y-shaped)

Stem attached to Calcaneus laterally

Upper Limb attached to Medial Malleolus

Lower Limb passes round medial border of foot to blend with dense fascia over abductor hallucis

Anterior muscles of leg 

"The Hospitals Are Not Dirty Places":

T: Tibialis anteriorH: extensor Hallucis longusA: anterior tibial ArteryN: deep fibular NerveD: extensor Digitorum longusP: Peronius tertius [aka fibularis tertius]

Dorsum of Foot

Muscles of Dorsum of Foot

Superior surface of Calcaneus, Inferior Extensor Retinaculum

Extensor Hallucis BrevisBase of Proximal Phalanx of Hallux

Extensor Digitorum Brevis Long extensor tendons of toes 2-4

Deep Peroneal nerveL5/S1

Superficial peroneal nerve

• Branch of common peroneal between peroneus longus and neck of fibula

• Lateral compartment of leg supplying muscles and continuing as cutaneous nerve

• Cutaneous innervation to distal anterior surface of leg and most of dorsum of foot

Deep Peroneal Nerve• Branch of common peroneal

between peroneus longus and neck of fibula

• Passes through extensor digitorum longus and travels with anterior tibial a. supplying all anterior compartment mm.

• Crosses the ankle jt. to supply ext. digitorum brevis and ext. hallucis brevis

• Cutaneous innervation to skin between digits 1 and 2

Cutaneous InnervationAnterior Cutaneous

branches of Femoral

Saphenous nerve(from Femoral)Lateral Sural

Cutaneous nerve

Superficial Peroneal nerve

Deep Peroneal nerve

Lateral Dorsal Cutaneous nerve of foot

(Termination of Sural n.)

Arteries of the Leg

• Popliteal a. gives anterior and posterior tibial aa.

• Anterior tibial a. – through interosseous membrane and descends on this

• Posterior tibial a. – gives the fibular a. that provides perforating br.s to lateral compartment

AnteriorTibial a.

PosteriorTibial a.

Fibular a.

• Dorsalis Pedis artery is a continuaton of Anterior Tibial a.

• Gives Deep Plantar artery to sole of the foot

• Gives Arcuate artery which runs across metatarsals to anastomose with Lateral Tarsal a.

• Metatarsal and digital aa.

Arteries of Dorsum of FootAnterior Tibial a.

Dorsalis Pedis a.

Deep Plantar a.

Arcuate a.

Lateral Tarsal a.

Posterior Leg and Ankle Joint

Outline

• Posterior aspect of the bones of the leg• Superficial and deep muscles of the posterior compartment• Flexor retinaculum• Posterior arteries • Tibial nerve• Inferior Tibiofibular joint• Ankle joint

Posterior Aspect of Leg Bones

Popliteal area

Soleal line

Apex

Head

Neck

Medial Malleolus Lateral Malleolus

Tibia Fibula

Fibula

Groove for Peroneus longus and brevis tendons

The FibuLA is LAteral.

Muscles of the Posterior Compartment

• 7 muscles• 3 superficial; 4 deep

• Superficial muscles all insert on posterior surface of calcaneous via Tendocalcaneous

• Tendons of deep muscles pass behind medial malleolus to plantar surface of foot

Superficial Muscles - Gastrocnemius

Medial Head:Popliteal surface of femur sup. to medial condyle

Lateral Head:Lateral aspect of lateral condyle of femur

Tibial nerve (S1, 2)

Plantarflexes ankle; Flexes knee

Medial

Lateral

Medial

Lateral

Right

Superficial Muscles - Plantaris

Lateral supracondylar line of femur (proximal to lateral head of gastrocnemius)

Tibial nerve (S1, 2)

Assists Plantarflexion of ankle

Right

Superficial Muscles - Soleus

Soleal line of TibiaUpper ⅓ posterior Fibula Tendinous arch between bony attachments

Tibial nerve (S1, 2)

Plantarflexes ankle joint

Right

Deep Muscles - Popliteus

Pit for popliteus (lateral condyle of femur) and Lateral meniscus

→Popliteal area of tibia (above soleal line)

Tibial n. (L4, 5, S1)

Unlocks knee joint by laterally rotating femur on fixed tibia

Right

Deep Muscles – Flexor Digitorum Longus

Posterior Surface of Tibia

→Base of distal Phalanx of digits 2-4

Tibial nerve (L5, S1, 2)

Flexes lateral 4 digitsWeak plantarflexor of ankle

Right

Deep Muscles – Flexor Hallucis Longus

Posterior Surface of Fibula

→Base of distal Phalanx of Hallux

Tibial nerve (L5, S1, 2)

Flexes HalluxWeak plantarflexor of ankle

Right

Deep Muscles – Tibialis Posterior

Posterior Surface of Tibia and Fibula, Interosseous membrane

→Tuberosity of Navicular, Cuneiforms, Cuboid, Sustentaculum tali of Calcaneus, base of 2nd, 3rd, and 4th Metatarsals

Tibial nerve (L4, 5)

Plantar flexes ankleInverts foot

Right

Inversion vs. Eversion Muscles in leg 

Second letter rule for inversion/eversion:

· Eversion muscles:pErineus longuspErineus brevispErineus terius

· Inversion muscles:tIbialis anteriortIbialis posterior

Plantarflexion vs. Dorsiflexion 

Plantar flexionoccurs when you squish a Plant with your foot.

Dorsiflexion

Look at your toe nails

Tendons of Deep Muscles

Tibialis Posterior tendon passes deep to Flexor Digitorum Longus Groove posterior to the medial malleolus

Flexor Hallucis Longus grooves the posterior surface of the lower end of the tibia, the posterior surface of the talus

Medial to lateral arrangement of tendons at ankle joint: Tibialis Posterior, Flexor Digitorum Longus and Flexor Hallucis Longus (Tom, Dick and Harry)

TPFDL

FHL

Flexor Retinaculum

Medial Malleolus→ Calcaneous

Posterior tibial vessels and tibial nerve found between FDL and FHL tendons

Right

Tarsal tunnel: contents

"Tiny Dogs Are Not Hunters“ Or :From superior to inferior:T: Tibialis posteriorF: flexor Digitorum longusA: posterior tibial ArteryN: tibial NerveH: flexor Hallucis longus

Arteries of Posterior Leg

Posterior Tibial Artery: terminal branch of popliteal arteryBetween heads of gastrocnemius and deep to soleus to run on surface of TP and FDL

Gives Fibular artery as a branchTerminates as Medial and Lateral Plantar arteries in the foot

Fibular artery: runs medial to fibula, usually within FHL

Tibial a.

Fibular a.

Cutaneous InnervationPosterior Cutaneous

nerve of Thigh

Lateral Sural Cutaneous nerve

Medial Sural Cutaneous nerve

(Sural Nerve)

Saphenous nerve(from Femoral)

Tibial nerve• Passes between the heads of

gastrocnemius and deep to tendinous arch of soleus, with Post. Tibial a.

• Lies between flexor hallucis longus and flexor digitorum longus at the ankle jt.

• Gives terminal branches that supply the sole of the foot: Medial and Lateral Plantar nn

Inferior tibiofibular joint

Ankle joint

Distal ends of Tibia and Fibula form: Malleolar Mortise

Trochlea of Talus

Ankle joint

Range of movement

Capsule and Ligaments

Attaches around articular marginsAnteriorly extends onto neck of talus

Weak anteriorly and posteriorly

Supported laterally and medially by strong Collateral Ligaments

Anterior and posterior views with weak parts of capsule removed

Lateral Collateral Ligaments

Anterior Talofibular → neck of talusPosterior Talofibular → lateral tubercle of talusCalcaneofibular → lateral surface of calcaneous

Lateral Collateral Ligaments

CalcaneofibularAnt. talofibular

Posterior talofibular Post. talofibular

Right

Right

Medial Collateral Ligament (Deltoid)

Fans out from Medial malleolus and has 4 parts:

1) Anterior Tibiotalar2) Tibionavicular3) Tibiocalcaneal4) Posterior Tibiotalar

12

3

4

3 4

Plantar Surface of Foot

Outline

• Bones of the foot• Deep fascia• The four layers of the foot• Plantar arteries• Plantar nerves• Cutaneous nerves of the foot

Foot – Dorsal View

Phalanges

Metatarsals

Tarsals

Navicular

TalusCuboid

Calcaneus

Cuneiforms(medial, intermediate, lateral)

Foot – Ventral View

Phalanges

Metatarsals

Tarsals

Navicular

SustentaculumTali

Cuboid

Calcaneus

Tubercle ofCalcaneus

Cuneiforms

Sesamoid bones within Flexor Hallucis Brevis tendon

Head of Talus

The Tarsal Bones

“The Circus Needs More Interesting Little Clowns”.• T: Talus• C: Calcaneus• N: Navicular• M: Medial cuneiform• I: Intermediate cuneiform• L: Lateral cuneiform• C: Cuboid Sustentaculum

Tali

Cuboid

Calcaneus

Tubercle ofCalcaneus

Cuneiforms

Head of Talus

Deep Fascia & Plantar Aponeurosis

Deep Fascia:Thick central portionWeaker medially and laterally

Plantar Aponeurosis:Superficial Ligament formed by central portion of deep fascia

Proximal attachment to CalcaneusDivides into 5 bands distally – continuous with fibrous digital sheaths

Vertical intermuscular septae: Medial, Central and Lateral compartments

Compartments of the Foot

Lateral CompartmentMuscles of the little toe:Abductor Digiti MinimiFlexor Digiti Minimi Brevis

Medial CompartmentMuscles of the great toe:Abductor HallucisFlexor Hallucis Brevis

Central CompartmentFlexor Digitorum BrevisMuscles associated with tendon of FDL (lumbricals and quadratus plantae)Adductor Hallucis

InterosseiPlantar and Dorsal interossei

Muscles of Dorsum of FootExtensor Digitorum BrevisExtensor Hallucis Brevis

Foot – Layer 1

Abductor Hallucis (1)

Med. Tubercle of Calcaneus; Flex. Retinaculum

→ Med. Base proximal Phalynx

Flexor Digitorum Brevis (2)

Medial Tubercle of Calcaneus

→ Middle Phalanges of lateral 4 toes

Abductor Digiti Minimi (3)

Tubercle of Calcaneus

→ Lat. Base proximal Phalynx

1

2

1

2

3

3

Foot – Layer 2

Long flexor tendons to the toes:

FDL and FHL

Lumbricals *

Tendons of FDL

→ Med. side of dorsal tendon expansion

Quadratus Plantae (QP)

Med. and Lat. surfaces of Calcaneus

→ Lateral side of FDL tendon

* * **

QPQP

FDLFDL

FHL

FHL

* * **

Layers 1 & 2

Foot – Layer 3Flexor Hallucis Brevis

Cuboid and Lat. Cuneiform

→ Both sides base Proximal Phalanx

Adductor Hallucis

Transverse head: Plantar ligament of MTPJoints

Oblique head: Base metatarsals 2&4

→ Lat. side base Proximal Phalanx

Flexor Digiti Minimi Brevis*

Base 5th Metatarsal

→ Base Proximal Phalanx

FHB

FHB FHB

Ad H

Ad H

Ad H

Ad H

**

Foot – Layer 4

Interossei3x Plantar Interossei

Bases and Med. side of Metatarsals 3-5 (unipennate)

→ Med. side of proximal phalanx of 3rd -5th digit

PAD – Plantar ADduct

4x Dorsal Interossei

Adjacent sides of Metatarsals 1-5 (bipennate)

→ 1st on med. side proximal phalanx of 2nd digit

→2nd-4th on lat. side proximal phalanx of 2nd -4th digits

DAB – Dorsal ABduct

Plantar interossei

12

3

Dorsal Interossei

1

12

2

3

3

4

4

Layer 4

Tendons:

Peroneus Longus *

Tibialis Posterior (TP)

LongPlantar

Long

Plantar

*

**

*

TP

TP

TPTP

Layers 3&4

Plantar Nerves

Terminal branches of Tibial nerve deep to flexor retinaculum

Enter foot deep to Abductor Hallucis

Medial Plantar Nerve: Between Abductor Hallucis and FDB

Lateral Plantar Nerve: Between Layers 1&2Deep and Superficial branches

Deep branch btwn Layers 3&4 Tibialnerve

Suralnerve

Medial Plantar Nerve:Abductor HallucisFlexor digitorum brevis1st Lumbrical Flexor hallucis brevis

Lateral Plantar Nerve:

All other muscles

S2, 3

Innervation of Muscles of Foot

MedialPlantar n.

LateralPlantar n.

Cutaneous Innervation of the Foot

SuperficialPeroneal

DeepPeroneal

Saphenous

Saphenous

Dorsal LateralCutaneous of Foot

Dorsal LateralCutaneous of Foot

MedialPlantar

LateralPlantar

CalcanealBranches

Plantar Arteries

Terminal branches of Posterior Tibial artery deep to flexor retinaculum

Enter foot deep to Abductor Hallucis

Medial Plantar artery: Muscles of hallux and overlying skinOccassionally: Superficial Plantar Arch

Lateral Plantar artery: Initially btwn Layers 1 and 2

Deep Plantar Arch btwn Layers 3 and 4Deep Plantar a. from Dorsalis Pedis

Plantar Metatarsal and Digital aa.

MedialPlantar a.

LateralPlantar a.

SuperficialPlantar Arch

DeepPlantar Arch