Introduction of the nervous system

The Lower limbMuhammad Iqbal BasriAnatomy DepartmentHasanuddin University

Overview of arteries of lower limbA. Iliaca communisA. Iliaca external Internal iliac arteryFemoral arteryProfunda femoral arteryPopliteal arteryAnterior tibial arteryPosterior tibial arteryPeroneal arteryDorsalis pedis arteryMedial plantar arteryLateral plantar arteryPlantar arch

2Deep veins of lower limbCommon iliac veinInternal iliac veinExternal iliac veinFemoral veinProfunda femoris veinPopliteal veinAnterior tibial veinsPosterior tibial veinsPeroneal veinDorsal venous archPlantar venous arch

3Arteri iliaca externaa. femoralisa.popliteaa.tibialis anteriora.tibialis posteriora.epigastrica inferiora.circumflexa ilium profundaa.peroneaCabang-cabang pada pedisArteries of lower limb Arteri femoralisContinuation of the a.iliaca externa. Begins midpoint of inguinal ligamentPrincipal branch deep femeral a. : arises from the posterolateral surface of the femoral artery about 5 cm below the inguinal ligament. Distributed to all three muscle compartments by medial and lateral femoral circumflex and four perforating arteries of deep femoral a.

A. PopliteaContinuation of femoral a. at adductor hiatusDivided into anterior and posterior tibial arteries at lower border of poplitus A.Tibialis posteriorPasses downwars deep to gastrocnemius and soleus Passes behind medial mallealus by dividing into medial and lateral plantar arteriesBranches: peroneal a., medial and lateral plantar a,

A.Tibialis anteriorDescends on anterior surface of interosseous membraneIn front of ankle joint becomes dorsal a. of footA.Dorsalis pedisPasses forward between tendons of extensor longus and extensor digitorum longus to the proximal End of first intermetatarsal space

A.ObturatoriusBranch of internal iliac a.Passes through the obturator foramen and enters medial compartment of thighsupplies obturator externus, pectineus, adductors of thigh, and gracilis

Veins of lower limb Deep veins: anterior and posterior tibial v. popliteal v. femoral v. external iliac v.V.Saphena magnaBegins the medial end of dorsal venous arch of foodPasses anterior to the medial malleolus and ascends on the medial side of the leg, then passes behind the knee and curves forward around the medial side of the thigh Inclines anteriorly through the thigh to enter the femoral vein through the saphenous opening which lies about 3~4 cm below and lateral to the pubic tubercleTributaries: Superficial medial femoral v.Superficial lateral femoral v.External pudendal v.Superficial epigastric v.Superficial iliac circumflex v.

Superficial epigastric v.External pudendal v.Superficial circumflex iliac v. Great saphenous v.Superficial lateral femoral v.

Superficial medial femoral v.

V.Saphena parvaArises from the lateral part of the dorsal venous arch of footAscends behind lateral malleolus and then passes upward to the midline of the clft Pierces the deep fascia and enters the popliteal v.It drains the lateral side of the foot and ankle and the back of the leg.

INNERVASIEXTREMITAS INFERIOR

Overview of motor innervation of lower limbFemoral nerve (L2-L4)Obturator nerve (L2-L4)Common peroneal nerve (L4-S2)Superficial peroneal nerve (L4-S1)Deep peroneal nerve (L5-S2)Sciatic nerveTibial nerve (L4-S3)Common peroneal nerve (L4-S2)Medial plantar nerve (L4-L5)Lateral plantar nerve (S1-S2) `14Asal innervasi dariRami anteriores Nn.spinales L1-S3 sbg

Rami posterior Nn.spinales L1-S3 sbg1.PLEXUS LUMBALIS (L1-4)2.PLEXUS SACRALIS (L4-S3)1.Nn.CLUNIUM SUPERIORES (L1-3)2.Nn.CLUNIUM MEDII (S1-3) Nerves of lower limbN.Femoralis :supplies anterior thigh muscles (quadriceps, sartorius and pectineus), hip and knee joint, and skin on anteromedial side of thigh, saphenous nerve is distributed to skin of medial side of leg and footN. Obturatorius: enters thigh through obturator foramen; supplies medial group of muscles of thigh, obturator externus, and skin of medial side of thigh

Branches of sacral plexus N.Gluteus superior: leaves pelvis through suprapiriform foramen and passes between gluteus medius and minimus to supplies these muscles and tensor fasciae lataeN.Gluteus inferior: leaves pelvis through infrapiriform foramenand supplies gluteus maximusN.cutaneus femoralis posterior: leaves pelvis through infrapiniform foramen,runs deep to gluteus maximus, and emerges from ite inferior border to supply skin of buttock and then surface skin over posterior of thigh and calf

Sciatic n. (N.ischiadicus)Leaves pelvis through infrapiriform foramen to enter gluteal region, runs inferiorly laterally deep to gluteus maximus, passing midway between the greater trochanter of femur and ischial tuberosity to back of thigh, lying deep to long head of biceps femoris, normally divided into tibial and common peroneal nerves just above popliteal fossaInnervates semitendinosus, semimembranosus and biceps femoris and has articular branches to hip and knee joints

N.Peroneus communis passes over posterior aspect of head of fibula and then winds around neck of fibula, deep to peroneus longus, where it divides into deep and superficial peroneal nervesN. Peroneus profunda descends on interosseous membrane and enters dorsum of foot; supplies anterior muscles of leg, and skin of first interdigital cleftN. Peroneus superficialis supplies peroneus longus and brevis and skin on anterior surface of leg and dorsum of foot

N. TibialisRuns inferiorly with posterior tibial vessels and terminates beneath flexor retinaculum by dividing into medial and lateral plantar nervesSupplies posterior muscles of leg and knee joint

Regional anatomy of the lower limbMuh.Iqbal Basri

Anterior and Medial Region of ThighSuperficial structuressuperficial fasciaSuperficial arteries: superficial epigastric a. superficial iliac circumflex a. external pudendal a.Superficial veinsgreat saphenous v.,superficial epigastric v.superficial iliac circumflex v.external pudendal v.superficial medial femoral v.superficial lateral femoral v.Superficial inguinal lymph nodes: superior group inferior group Cutaneous nerves:lateral femoral cutaneous n. anterior and medial cutaneous branches of femoral n.

Lacuna vasorum

Bounded by medial portion of inguinal ligament anteriorly, pectineal ligament posteromedially, lacunar ligament medially, and iliopectinal arch posterolaterallyContents: femoral sheath, femoral a. and v., genital branch of genitofemoral n. and lymphatic vessels, femoral ring

Femoral a.Femoral v.

Femoral ring

Femoral triangleThis triangle is bounded by: the inguinal ligament (base) superiorly; the medial border of sartorius laterally; the medial border of adductor longus medially. Inferiorly, the apex of the triangle is continuous with adductor canal.The anterior wall is fascia lataThe posterior wall consists of adductor longus, pectineus and iliopsoas , from medial to lateral side.

Contents of the femoral triangle1. The femoral artery and its branchesthe profunda femoris arteryThe lateral and medial circumflex arteriesThe deep external pudendal2. The femoral vein and its tributaries.3. Three or four deep inguinal lymph nodes lie along the medial side of the femoral vein. 4. The femoral nerve.5. The femoral canal.

Femoral sheath The femoral sheath is a a funnel- shaped sheath , derived from transversalis fascia anteriorly and iliac fascia posteriorly. It surroumds the femoral vessels and lymphatic about 2.5cm belower the inguinal ligamemt. Its lower end disappears at the lower margin of the saphenous opening where the sheath fuses with the adventitia of the vessels.

The femoral sheath is divided into three compartments by two fibrous septa. The femoral artery occupies the lateral compartment of the sheath. The femoral vein lies the middle compartment. The medial compartment is small, called the femoral canal.

The femoral canal It is about 1.3cm long , and its upper opening is called the femoral ring . The boundaries of the femoral ring are: the inguinal ligament, anteriorly; the lacunar ligament medially; the pecten of pubis, posteriorly; the femoral vein, laterally. covered by femoral septum superiorly. The canal contains a little loose fatty tissue, a small lymph node, and some lymph vessels.

Femoral hernia A femoral hernia is common in women than in men (possibly due to a wider pelvis and femoral canal ). If a loop of intestine is forced into the femoral ring, it expands to form a swelling in the upper part of the thigh.

Nervus femoralisIt arises from the lumbar plexus in the abdomen, and enters the thigh posterior to the inguinal ligament and lateral to the femoral artery. It ends by dividing into a number of branches 2 cm below the inguinal ligament. Muscular branche to: pectineus, sartorius, quadriceps femoris

Cutaneous branches: (1) Anterior cutaneous nerves of the thigh (medial and lateral). (2) Saphenous nerve is the longest branch of the femoral nerve. It accompanies the femoral vessels in the adductor canal, then accompanies the great saphenous vein to the medial side of the leg and food.

A.FemoralisThis is the main artery of the lower limb and is directly continuous with the external iliac artery of the abdomen behind the inguinal ligament at the mid- inguinal point. It becomes the popliteal artery by passing through the adductor tendinous opening.

A. Profunda femoris which arises from the posterolateral surface of the femoral artery about 5 cm below the inguinal ligament. A. Circumflexus lateral It arises from the profunda near its origin and runs laterally among the branches of the femoral nerve and then deep to rectus femoris. Here it divides into ascending, transverse, and descending branches. A. Circumflexus medialis arises either from the profunda near its origin or occasionally direct from the femoral artery. Vena femoralisThis is the direct continuation of the popliteal vein. It begins at the adductor tendinous opening and accompanies the femoral artery to the inguinal ligament behind which it becomes the external iliac vein. The femoral vein contains several valves.

Adductor canalExtends from apex of femoral triangle to adductor hiatusBounded by vastus medialis laterally, adductors longus and magmus posteriorly, and adductor lamina and sartorius anteriorlyContents saphenous nerve, femoral a., femoral v., lymphatic vessels, and loose connective tissue

Blood vessels and nerve of medial side of thigh A. Obturatorius : arises from internal iliac artery in the lesser pelvis, passes through the obturator canal where it divides into anterior and posterior branches. N. Obturatorius : arises from the lumbar plexus in the abdomen. It enters the thigh through the obturator canal where it divides into anterior and posterior branches. The anterior branch descends anterior to the adductor brevis. The posterior branch descends between adductors brevis and magnus supplying both.

Front of the leg and dorsum of the foot

Superficial veinsThe dorsal venous arch lies on the distal parts of the bodies of the metatarsals. It drains the dorsum of the foot and toes.The small saphenous vein runs posteriorly, passing first inferior and then posterior to the lateral malleolus. It ascends to the popliteal fossa in the back of the leg.The great saphenous vein passes posterioriy on the medial side of the foot. It ascends anterior to the medial malleolus, then obliquely across the distal third of the medial surface of the tibia.

Cutaneous nerves The upper two-thirds of the front of the leg is supllied by the saphenous nerve (L3,4) medially, and the lateral cutaneous nerve of the calf laterally. The lower third is supplied by the superficial peroneal and saphenous nerves. The dorsum of the foot is mainly supplied by the medial and intermediate cutaneous branches of the superficial peroneal nerve. However, the lateral margin is supplied by the sural nerve and the medial margin by the saphenous nerve proximally and the superficial peroneal distally. The first interdigital cleft and the skin immediately proximal to it are supplied by the deep peroneal nerve.

Deep peroneal nerve It arises from the common peroneal nerve between the neck of the fibula and the peroneus longus muscle It descends in the anterior compartment of the leg with the anterior tibial vessels.It supplies all the muscles of the anterior compartment of the leg and extensor digitorum brevis. If the nerve is destroyed, dorsiflexion of the ankle and extension of the metatarsophalangeal joints is lost, and inversion is weakened the condition known as drop foot.

Anterior tibial artery It from the popliteai artery at the lower border of popliteus. It passes forwards above the interosseous membrane, and turns downwards on the anterior surface of that membrane with the deep peroneal nerve. It becomes the dorsalis pedis artery, midway between the malleoli.The anterior tibial veins are closely applied to the artery.

Dorsalis pedis artery It begins on the anterior surface of the ankle joint and runs with the deep peroneal nerve it divides into the arcuate artery and the first dorsal metatarsal artery at the proximal end of the first intermetatarsal space. On the dorsum of the foot it lies on the tarsal bones and is readily palpated against them between the tendons of extensor hallucis longus and extensor digitorum longus.

Superficial epigastric v.External pudendal v.Superficial circumflex iliac v.Lateral cutaneous n. of thighAnterior cutaneous n. of thighGreat saphenous v.Dissection Superficial lateral femoral v.Superficial medial femoral v.

Femoral n.Femoral a.Femoral v.

Profunda femoral a.Latral circumflex a.Medial circumflex a.Saphenous n.

Obturator n.

Superficial peroneal n. Deep peroneal n.

Anterior tibial a.Dorsal a. of footTibialis anterior Extensor hallucis longusExtensor digitorum longusThe gluteal region and back of thigh and legMuh.Iqbal Basri

Cutaneous nervesSuperior cluneal n.Medial cluneal n.

Inferior cluneal n.

suprapiriform forameninfrapiriform foramen

Structures passing suprapiriform foramenSuperior gluteal n., a., v. from lateral to medial sideStructures passing infrapiriform foramenSciatic n., posterior femoral cutaneous n., inferior gluteal n., a.,v., internal pudendal v., a., and pudendal n. from lateral to medial side

Pudendal nerve, internal pudendal artery These structures enter the gluteal region through the infrapiriform foramen. They then curve forwards to enter the perineum through the lesser sciatic foramen.

Sciatic nerve Course: It arises from the sacral plexus and passes through infrapiriform foramen into the gluteal region, deep to gluteus maximus, passing midway between the greater trochanter of femur and ischial tuberosity to back of thigh, the nerve lies deep to the long head of biceps on the posterior surface of adductor magnus. The sciatic nerve usually ends half-way down the back of the thigh by dividing into the common peroneal and tibial nerves. Distribution: semitendinosus, semimembranosus and biceps femoris and has articular branches to hip and knee joints

Relationship of sciatic n. to the piriformis

Boundaries of the popliteal fossaDiamond-shaped Upper lateral boundary: Biceps femoris Upper medial boundary: semimembranosus and semitendinosus Two lower boundaries are the heads of gastrocnemius Posterior wall: deep fascia Anterior wall: popliteal surface of the femur, the posterior capsule of the knee joint, and the fascia covering poplitells

Contents of the popliteal fossa Tibial and common peroneal nerves and their branchesPopliteal vein and its tributariesPopliteal artery and its branches Popliteal lympn nodesFatty tissue

Popliteal arteryIt begins at the adductor tendinous opening in. Here it is continuous with the femoral artery. It ends at the lower border of the popliteus muscle where it divides into anterior and posterior tibial arteries.Branches: 1. Superior, inferior, and middle genicular arteries 2. Muscular branches

Popliteal veinThis is formed by the junction of the anterior and posterior tibial veins near the lower border of the popliteus muscle. Popliteal lymph nodes There may be one or two nodes just under the deep fascia, close to the popliteal fossa vessels. They drain the deep tissues of the leg and foot and the knee joint. They also receive superficial lymph vessels from the lateral side of the foot, the heel, and the back of the calf. These drain along the line of the small saphenous vein.The back of the legFind the small saphenous veinFind the Sural nerve and Peroneal communicating nerve

Find outGastrocnemius Soleus Plantaris Tibial nerve Popliteal artery and branches (Peroneal artery )Popliteus Flexor hallucis longus Flexor digitorum longus Tibialis posterior

Malleolar canalFormed by midial surface of calcaneus, flexor retinaculum and medial malleolusStructures passing Malleolar canalTibialis posterior Flexor digitirum longusPosterior tibial a. v. and n.Flexor hallucis longus