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1. THE MUSCLES OF THE PELVIS, THIGH, LEG AND FOOT

2. THE TOPOGRAPHY OF THE LOWER EXTREMITY

3. FASCIAE, SYnoVIAL BURSAE AND SHEATHS OF THE LOWER EXTREMITY

LESSON № 11

Theme 1. THE MUSCLES OF THE PELVIS, THIGH, LEG AND FOOT

Musculature of lower limb divides into muscles of the pelvic girdle and free limb.

Pelvic (Gluteal) Musculature

External group:

Tensor fasciae latae

• Origin:

1.anterior aspect of iliac crest 2.anterior superior iliac spine (ASIS)

• Insertion: anterior aspect of IT band, below greater trochanter • Action:

1.hip flexion 2.medially rotate & abduct a flexed thigh 3.tenses IT tract to support femur on the tibia during standing

• Blood:

1.superior gluteal artery 2.lateral femoral circumflex artery

• Nerve: superior gluteal nerve, L4,5,S1

Gluteus maximus

• Origin:

1.outer rim of ilium (medial aspect) 2.dorsal surface of sacrum and coccyx 3.sacrotuberous ligament

• Insertion:

1.IT band (primary insertion) 2.gluteal tuberosity of femur

• Action:

1.powerful extensor of hip 2.laterally rotates thigh 3.upper fibers aid in abduction of thigh 4.fibers of IT band stabilize a fully extended knee

• Blood:

1.inferior gluteal artery (primary) 2.superior gluteal artery

• Nerve: inferior gluteal nerve, L5,S1,2

VIDEO

Gluteus medius

• Origin:

1.outer aspect of ilium (between iliac crest and anterior and posterior gluteal lines) 2.upper fascia (AKA gluteal aponeurosis)

• Insertion: superior aspect of greater trochanter • Action:

1.anterior and lateral fibers abduct and medially rotate the thigh 2.posterior fibers may laterally rotate thigh 3.stabilizes the pelvis and prevents free limb from sagging during gait

• Blood: superior gluteal artery • Nerve: superior gluteal nerve, L4,5,S1

Gluteus minimus

• Origin: outer aspect of ilium (between anterior and inferior gluteal lines) • Insertion:

1.greater trochanter (anterior to medius) 2.articular capsule of hip joint

• Action:

1.abduct and medially rotate the thigh 2.stabilizes the pelvis and prevents free limb from sagging during gait

• Blood: superior gluteal artery • Nerve: superior gluteal nerve, L4,5,S1

Piriformis

• Origin: pelvic surface of sacrum (anterior portion) • Insertion: medial surface of greater trochanter (through greater sciatic foramen) • Action:

1.lateral rotation of extended thigh 2.abducts a flexed thigh

• Blood:

1.superior gluteal artery 2.inferior gluteal artery

• Nerve: nerve to piriformis, S1,2

Superior gemellus

• Origin: ischial spine • Insertion: medial aspect of greater trochanter via upper tendon of obturator internus • Action:

1.laterally rotates femur 2.abducts thigh when flexed

• Blood: inferior gluteal artery • Nerve: nerve to obturator internus, L5,S1,2

The Obturator externus.

Inferior gemellus

• Origin: ischial tuberosity • Insertion: medial aspect of greater trochanter via lower tendon of obturator internus • Action: laterally rotates femur • Blood: inferior gluteal artery • Nerve: nerve to quadratus femoris, L4,5,S1

Obturator externus

• Origin:

1.medial surface of obturator foramen 2.external surface of obturator membrane

• Insertion: trochanteric fossa of femur • Action:

1.laterally rotates thigh 2.assists in flexion of hip joint

• Blood: obturator artery • Nerve: obturator nerve, L2,3,4

 

VIDEO

Quadratus femoris

• Origin: lateral aspect of ischial tuberosity • Insertion: quadrate line (along posterior aspect of femur and intertrochanteric crest) • Action: laterally rotates femur • Blood: inferior gluteal artery • Nerve: nerve to quadratus femoris, L4,5,S1

Muscles of internal group:

Obturator internus

• Origin:

1.internal aspect margins of obturator foramen 2.obturator membrane

• Insertion: medial aspect of greater trochanter (through lesser sciatic foramen) • Action:

1.laterally rotates femur 2.abducts thigh when flexed

• Blood: inferior gluteal artery • Nerve: nerve to obturator internus, L5,S1,2

Iliopsoas muscle = Psoas major and minor muscles + Iliacus

 

Psoas major and minor

• Origin:

1.transverse processes of L1-L5 2.vertebral bodies of T12-L4 and the intervening intervertebral discs

• Insertion: iliopsoas tendon to the lesser trochanter of the femur • Action:

1.hip flexion 2.lateral rotation

• Blood: muscular branches of medial femoral circumflex artery • Nerve: ventral rami, L1,2,3

Iliacus • Origin: inner surface of upper iliac fossa • Insertion: iliopsoas tendon to the lesser trochanter of the femur • Action:

1.powerful hip flexion 2.lateral rotation

• Blood: muscular branches of medial femoral circumflex artery • Nerve: femoral nerve, L3,4

Posterior Thigh Musculature

Semitendinosus

• Origin: ischial tuberosity • Insertion:

1.medial aspect of tibial shaft 2.contributes to the pez anserine

• Action:

1.extends hip 2.flexes knee 3.medially rotates tibia

• Blood:

1.perforating branches of profunda femoris 2.inferior gluteal artery (to upper)

• Nerve: tibial nerve of sciatic bundle, L5,S1,2

 

 

Semimembranosus

• Origin: ischial tuberosity • Insertion:

1.posterior medial aspect of medial tibial condyle 2.fibers join to form most of oblique popliteal ligament (& medial meniscus)

• Action:

1.flexes knee 2.extends hip 3.medially rotates tibia 4.pulls medial meniscus posterior during flexion

• Blood:

1.perforating branches of profunda femoris 2.inferior gluteal artery (to upper)

• Nerve: tibial nerve of sciatic bundle, L5,S1,2

Biceps femoris

• Origin:

1.long head: ischial tuberosity 2.short head: lateral lip of linea aspera and the lateral intermuscular septum

• Insertion:

1.head of fibula 2.maybe to the lateral tibial condyle

• Action:

1.flexor at the knee (mainly short head) 2.laterally rotates thigh if flexed at the knee 3.extends hip (long head)

• Blood:

1.perforating branches of profunda femoris 2.inferior gluteal artery (to upper)

• Nerve:

1.long head - tibial nerve, L5,S1,2 2.short head - common peroneal nerve, L5,S1

Adductor magnus, posterior fibers are sometimes considered part of this group. Its information is listed below with the other thigh adductors.

Medial (Adductor) Thigh Musculature

Note: The muscles in this group may also receive blood from obturator artery.

Pectineus

• Origin:

1.pectineal line of the pubis 2.superior pubic ramus

• Insertion:

• the pectineal line of the femur • (just below the lesser trochanter on the posterior aspect of the femur)

• Action:

1.flexes hip 2.adducts thigh 3.medially rotates thigh

• Blood: muscular branches of medial femoral circumflex artery • Nerve:

• femoral nerve, L3,4 OR • obturator nerve, L2,3,4 OR • femoral L3,4 and accessory obturator L3,4

Adductor longus

• Origin: anterior surface of pubis, just inferior to the pubic tubercle • Insertion: medial lip of linea aspera on middle half of femur • Action:

1.adducts thigh 2.flexes thigh 3.may laterally rotate thigh at the hip

• Blood: muscular branches of femoral artery • Nerve: obturator nerve, L2,3,4

Adductor brevis

• Origin: body & inferior ramus of pubis • Insertion: superior portion of linea aspera • Action:

1.adducts thigh (major) 2.aids in flexion of thigh 3.may laterally rotate thigh at the hip

• Blood: muscular branches of femoral artery • Nerve: obturator nerve, L2,3,4

 

Adductor magnus

• Origin:

1.anterior fibers: inferior pubic ramus 2.oblique fibers: ischial ramus 3.posterior fibers: ischial tuberosity

• Insertion:

1.proximal 1/3 of linea aspera 2.adductor tubercle

• Action:

1.adducts the thigh 2.posterior fibers also extend and laterally rotate thigh

• Blood:

1.muscular branches of profunda femoris

• Nerve:

1.anterior fibers: obturator nerve, L2,3,4 2.posterior fibers: tibial nerve of sciatic bundle, L4,5

Gracilis • Origin: body of pubis & inferior pubic ramus • Insertion:

1.medial surface of proximal tibia, inferior to tibial condyle 2.contributes to the pez anserine

• Action:

1.adducts thigh 2.flexes knee 3.medially rotates tibia

• Blood: obturator artery • Nerve: obturator nerve, L2,3,4

Anterior Thigh Musculature

Sartorius

• Origin: anterior superior iliac spine (ASIS) • Insertion:

1.upper medial surface of body of tibia 2.contributes to pez anserine

• Action:

1.flexes hip and knee 2.laterally rotates thigh if flexed at the hip

• Blood:

1.muscular branches of profunda femoris artery 2.saphenous branch of descending genicular artery

• Nerve: branches of femoral nerve, L2,3

Quadriceps femoris consists of:

1. Rectus femoris

• Origin:

1.anterior head: anterior inferior iliac spine (AIIS) 2.posterior head: ilium just above the acetabulum

• Insertion:

1.common quadriceps tendon into patella 2.tibial tuberosity via patellar ligament

• Action:

1.extends knee 2.flexes hip

• Blood: lateral femoral circumflex artery • Nerve: branches of femoral nerve, [L2],3,4

2. Vastus lateralis

• Origin:

1.greater trochanter 2.lateral lip of linea aspera 3.lateral intermuscular septum

• Insertion:

1.common quadriceps tendon into patella 2.tibial tuberosity via patellar ligament

• Action:

1.extends knee 2.can abnormally displace patella

• Blood: lateral femoral circumflex artery • Nerve: branches of femoral nerve, [L2],3,4

 

VIDEO

3. Vastus intermedius

• Origin: anterior lateral aspect of the femoral shaft • Insertion:

1.common quadriceps tendon into patella 2.tibial tuberosity via patellar ligament

• Action: extends knee • Blood: lateral femoral circumflex artery • Nerve: branches of femoral nerve, [L2],3,4

4. Vastus medialis

• Origin:

1.intertrochanteric line of femur 2.medial aspect of linea aspera

• Insertion:

1.common quadriceps tendon into patella 2.tibial tuberosity via patellar ligament

• Action: extends knee

• Blood: 1.muscular branches of profunda femoris artery 2.saphenous branch of descending genicular artery

• Nerve: branches of femoral nerve, [L2],3,4

VIDEO

Posterior Leg Musculature

Superficial:

Gastrocnemius m. + Soleus m. = Triceps surae

Gastrocnemius

• Origin:

1.medial head: just above medial condyle of femur 2.lateral head: just above lateral condyle of femur

• Insertion: calcaneus via lateral portion of calcaneal tendon • Action:

 

 

Plantaris

1.plantarflex the ankle 2.knee flexion (when not weight bearing) 3.stabilizes ankle & knee when standing

• Blood:

1.sural branches of popliteal artery 2.muscular branches of peroneal artery 3.posterior tibial artery

• Nerve: tibial nerve, S1,2

Soleus

• Origin:

1.upper fibula 2.soleal line of tibia

• Insertion: calcaneus via medial portion of calcaneal tendon • Action: plantarflex the foot • Blood:

1.sural branches of popliteal artery 2.muscular branches of peroneal artery 3.posterior tibial artery

• Nerve: tibial nerve, S1,2

 

• Origin: above the lateral head of gastrocnemius on femur • Insertion: calcaneus, medial to calcaneal tendon, or blending with the calcaneal tendon • Action: like a weak gastrocnemius • Blood:

1.sural branches of popliteal artery 2.muscular branches of peroneal artery 3.posterior tibial artery

• Nerve: tibial nerve, S1,2

Deep:

Popliteus

• Origin:

1.lateral femoral condyle 2.arcuate popliteal ligament 3.lateral meniscus 4.knee joint capsule

• Insertion: posterior tibial surface above the soleal line • Action:

1.insertion fixed: laterally rotates femur on tibia & unlocks knee 2.origin fixed: medially rotates tibia on femur & unlocks knee

• Blood: sural branches of popliteal artery • Nerve: tibial nerve, L5,S1

Flexor digitorum longus

• Origin:

1.posterior surface of tibia 2.crural fascia

• Insertion: plantar surface of bases of the 2-5th distal phalanges • Action:

1.primarily flexes 2nd - 5th toes 2.weak plantarflexor 3.weak inversion & adduction of foot

• Blood: 1.peroneal artery 2.posterior tibial artery

• Nerve: tibial nerve, L5,S1

Tibialis posterior

• Origin:

1.posterior, proximal tibia 2.interosseous membrane 3.medial surface of fibula

• Insertion:

1.navicular tuberosity (principle) 2.all 3 cuneiforms (plantar surface) 3.bases of 2nd-4th metatarsals 4.cuboid 5.sustentaculum tali of calcaneus

• Action:

1.stabilizes ankle 2.inversion & adduction of foot 3.prevents hyperpronation while in gait 4.weak plantarflexion of ankle

• Blood:

1.peroneal artery 2.posterior tibial artery

• Nerve: tibial nerve, L5,S1

Flexor hallucis longus

• Origin:

1.posterior, inferior 2/3 of fibula 2.interosseous membrane 3.crural fascia & posterior intermuscular septum

• Insertion: plantar surface of distal phalanx of hallux • Action:

1.flexes big toe (hallux) 2.weak plantarflexion of the foot 3.weak inversion & adduction of foot

• Blood:

1.peroneal artery 2.posterior tibial artery

• Nerve: tibial nerve, L5,S1,2

Lateral Leg Musculature

Peroneus longus

• Origin:

1.head of the fibula 2.proximal 2/3 of lateral fibula 3.adjacent intermuscular septum

• Insertion:

1.plantar surface of cuboid 2.base of 1st & (2nd) metatarsal 3.plantar surface of medial cuneiform

• Action:

1.eversion & abduction of the foot 2.weak plantarflexion of the foot at the transverse tarsal joint

• Blood: muscular branches of the peroneal artery • Nerve: superficial peroneal nerve, L4,5,S1

Peroneus brevis

• Origin:

1.distal 2/3 of lateral fibula 2.posterior and anterior intermuscular septum

• Insertion: tuberosity on lateral aspect of base of 5th metatarsal • Action:

1.eversion & abduction of the foot 2.weak plantarflexion of foot

• Blood: muscular branches of the peroneal artery • Nerve: superficial peroneal nerve, L4,5,S1

Anterior Leg Musculature

Tibialis anterior

• Origin:

1.lateral tibial condyle 2.proximal 2/3 of anteriolateral surface of tibia 3.interosseous membrane 4.anterior intermuscular septum & crural fascia

• Insertion:

1.medial & plantar surface of base of 1st metatarsal 2.medial & plantar surface of the cuneiform

• Action:

1.strongest dorsiflexor 2.inverts & adducts the foot

• Blood: anterior tibial artery • Nerve: deep peroneal nerve, L4,5,S1

Extensor hallucis longus

• Origin:

1.medial aspect of the fibula 2.interosseous membrane 3.crural fascia

• Insertion: dorsal surface of base of proximal and distal phalanx of hallux • Action:

1.extends distal phalanx of big toe 2.weak dorsiflexor 3.weak inversion & adduction

• Blood: anterior tibial artery • Nerve: deep peroneal nerve, L4,5,S1

 

VIDEO

Extensor digitorum longus

• Origin:

1.lateral condyle of the tibia 2.upper anterior surface of fibula 3.interosseous membrane 4.crural fascia

• Insertion:

• dorsal surface of the bases of the middle & distal phalanxes of the 2nd-5th rays • (via 4 tendons and giving a fibrous expansion)

• Action:

1.extends the lateral 4 toes 2.weak dorsiflexor & everts foot

• Blood: anterior tibial artery • Nerve: deep peroneal nerve, L4,5,S1

Peroneus tertius

• Origin:

1.distal 1/3 of anterior fibula 2.distal & lateral aspect of extensor digitorum

• Insertion: dorsal surface of base of 5th metatarsal • Action:

1.extends the 5th toe 2.weak dorsiflexor & everts foot

• Blood: anterior tibial artery • Nerve: deep peroneal nerve, L4,5,S1

Foot Musculature

Medial group

Abductor hallucis

• Origin:

1.medial process of calcaneal tuberosity 2.flexor retinaculum 3.plantar aponeurosis 4.medial intermuscular septum

• Insertion: medial aspect of base of proximal phalanx of hallux • Action:

1.flexes the big toe (primary action) 2.may assist in abduction of big toe

• Blood: medial plantar artery • Nerve: medial plantar nerve, L5,S1

• Action: flexes hallux at MTP • Blood: medial plantar artery • Nerve: medial plantar nerve, L5,S1

Adductor hallucis

• Origin:

1.oblique head: base of 2nd-4th metatarsals & long plantar ligament 2.transverse head: deep transverse metatarsal ligament & plantar ligaments at MTP joints

• Insertion: lateral aspect of base of proximal phalanx of hallux • Action:

1.adduction of hallux at MTP 2.flexes hallux at MTP

• Blood: lateral plantar artery • Nerve: lateral plantar nerve, S1,2

Flexor digitorum brevis

• Origin:

1.medial process of calcaneal tuberosity 2.plantar aponeurosis

• Insertion:

• both sides of the bases of the middle phalanx of rays 2-5 • (each of the 4 tendons splits forming tunnel for FDL)

• Action: flexes toes 2-5 • Blood: medial plantar artery • Nerve: medial plantar nerve, L5,S1

 

Flexor hallucis brevis

• Origin:

1.medial aspect of the cuboid 2.lateral cuneiform

• Insertion:

1.medial aspect of base of proximal phalanx of hallux 2.lateral aspect of base of proximal phalanx of hallux

Middle group

Quadratus plantae

• Origin:

1.medial head: medial calcaneus 2.lateral head: lateral calcaneus & long plantar ligament

• Insertion:

• lateral margin of tendon of flexor digitorum longus (FDL) • may send slips into the distal tendons

• Action:

1.assists FDL in flexing the distal phalanxes of 2nd-5th toes 2.corrects FDL from pulling toes medially

• Blood: lateral plantar artery • Nerve: lateral plantar nerve, S1,2

 

Lumbricals

• Origin: from tendons of FDL:

1.1st: medial aspect of tendon to 2nd ray 2.2nd-4th: two heads between the tendons in which they lie

• Insertion: extensor tendons of EDL on dorsal foot • Action:

1.flex proximal phalanges at MTP 2.extend middle & distal phalanges at IP

• Blood:

1.1st: medial plantar artery 2.2nd-4th: lateral plantar artery

• Nerve:

1.1st: medial plantar nerve, L5,S1 2.2nd-4th: lateral plantar nerve, S1,2

Plantar interossei (3 muscles)

• Origin: medial aspect of 3rd-5th metatarsals (each muscle has a single head) • Insertion: medial aspect of base of proximal phalanx of the same ray (of 3rd-5th rays) • Action:

1.adduct toes 3-5 2.flex toes 3-5

• Blood: lateral plantar arch • Nerve: lateral plantar nerve (deep branch), S1,2

Dorsal interossei (4 muscles)

• Origin: from both metatarsals between which they lie • Insertion: base of proximal phalanx closest to the axis of the foot (2nd ray) • Action:

1.abduct toes 2-4 2.flexes toes 2-4 at MTP

• Blood: lateral plantar arch • Nerve: lateral plantar nerve (deep branch), S1,2

 

Lateral group

Abductor digiti minimi

• Origin:

1.lateral & medial processes of the calcaneal tuberosity 2.plantar aponeurosis 3.lateral intermuscular septum

• Insertion: lateral aspect of base of proximal phalanx of 5th ray • Action:

1.abducts 5th toe 2.aids in flexing

• Blood: lateral plantar artery • Nerve: lateral plantar nerve, S1,2

Abductor ossis metatarsi quinti

• Origin: from fibers of abductor digiti minimi • Insertion: into the 5th metatarsal • Action: abducts the 5th ray • Blood: lateral plantar artery • Nerve: lateral plantar nerve, S1,2

Flexor digiti minimi brevis

• Origin:

1.base of 5th metatarsal 2.digital sheath of peroneus longus

• Insertion: lateral aspect of base of proximal phalanx of 5th ray • Action: flexes the 5th toe at MTP • Blood: lateral plantar artery • Nerve: lateral plantar nerve, S1,2

Opponens digiti minimi brevis

• Action: opposes the digiti minimi

• Blood: lateral plantar artery • Nerve: lateral plantar nerve, S1,2

Dorsal foot muscles

Extensor hallucis brevis

• Origin:

1.upper anterolateral calcaneus 2.inferior extensor retinaculum

• Insertion: base of proximal phalanx of hallux • Action: extends hallux • Blood: dorsalis pedis artery • Nerve: deep peroneal nerve, L4,5

Extensor digitorum brevis

• Origin:

1.upper anterolateral calcaneus 2.inferior extensor retinaculum

• Insertion: middle & distal phalanges of 2nd-4th rays (via EDL) • Action: extends 2nd-4th rays • Blood: dorsalis pedis artery • Nerve: deep peroneal nerve, L4,5

Theme 2. THE TOPOGRAPHY OF THE LOWER EXTREMITY

Topographic features of of the lower limb

Piriform muscle passing through the major ischiadic foramen does not fill it fully, so as result suprapiriform foramen and infrapiriform foramen appear.

Internal and external obturatorius muscles close obturatum foramen and make up obturatorius canal.

There is a space between inguinal ligament and iliac bone. It divided into two orifices lacuna vasorum (medially) and lacuna musculorum (laterally) by iliоpectineal arch that attached to iliоpectineal eminence. Lacuna vasorum contains femoral artery and vein; lacuna musculorum carries iliоpsoas muscle and femoral nerve.

Femoral annulus (positioned in lacuna vasorum) during passing of the femoral hernia convert into deep annulus of femoral canalу. It bordered laterally by femoral vein, medially - lacunar ligament, anteriorly – inguinal ligament and from behind – by pectinal ligament.

The first 4 cm. of the vessel is enclosed, together with the femoral vein, in a fibrous sheath—the femoral sheath. In the upper third of the thigh the femoral artery is contained in the femoral triangle (Scarpa’s triangle), and in the middle third of the thigh, in the adductor canal (Hunter’s canal).

The femoral sheath (crural sheath) is formed by a prolongation downward, behind the inguinal ligament, of the fasciæ which line the abdomen, the transversalis fascia being continued down in front of the femoral vessels and the iliac fascia behind them. The sheath assumes the form of a short funnel, the wide end of which is directed upward, while the lower, narrow end fuses with the fascial investment of the vessels, about 4 cm. below the inguinal ligament. It is strengthened in front by a band termed the deep crural arch (page 419).

  The lateral wall of the sheath is vertical and is perforated by the lumboinguinal nerve; the medial wall is directed obliquely downward and lateralward, and is pierced by the great saphenous vein and by some lymphatic vessels. The sheath is divided by two vertical partitions which stretch between its anterior and posterior walls. The lateral compartment contains the femoral artery, and the intermediate the femoral vein, while the medial and smallest compartment is named the femoral canal, and contains some lymphatic vessels and a lymph gland imbedded in a small amount of areolar tissue.

The relations of the femoral and abdominal inguinal rings, seen from within the abdomen. Right side.

The femoral canal is conical and measures about 1.25 cm. in length. Its base, directed upward and named the femoral ring, is oval in form, its long diameter being directed transversely and measuring about 1.25 cm. The femoral ring is bounded in front by the inguinal ligament, behind by the Pectineus covered by the pectineal fascia, medially by the crescentic base of the lacunar ligament, and laterally by the fibrous septum on the medial side of the femoral vein.

Saphenous opening at the upper and medial part of the thigh, a little below the medial end of the inguinal ligament, is a large oval-shaped aperture in the fascia lata; it transmits the great saphenous vein, and other, smaller vessels, and is termed the fossa ovalis. The fascia cribrosa, which is pierced by the structures passing through the opening, closes the aperture and must be removed to expose it. The fascia lata in this part of the thigh is described as consisting of a superficial and a deep portion.

The Lacunar Ligament (ligamentum lacunare [Gimbernati]; Gimbernat’s ligament) is that part of the aponeurosis of the Obliquus externus which is reflected backward and lateralward, and is attached to the pectineal line. It is about 1.25 cm. long, larger in the male than in the female, almost horizontal in direction in the erect posture, and of a triangular form with the base directed lateralward. Its base is concave, thin, and sharp, and forms the medial boundary of the femoral ring. Its apex corresponds to the pubic tubercle. Its posterior margin is attached to the pectineal line, and is continuous with the pectineal fascia. Its anterior margin is attached to the inguinal ligament. Its surfaces are directed upward and downward.

The Reflected Inguinal Ligament (ligamentum inguinale reflexum [Collesi]; triangular fascia).—The reflected inguinal ligament is a layer of tendinous fibers of a triangular shape, formed by an expansion from the lacunar ligament and the inferior crus of the subcutaneous inguinal ring. It passes medialward behind the spermatic cord, and expands into a somewhat fan-shaped band, lying behind the superior crus of the subcutaneous inguinal ring, and in front of the inguinal aponeurotic falx, and interlaces with the ligament of the other side of the linea alba .

The fossa ovalis.

 

The inguinal and lacunar ligaments.

Ligament of Cooper.—This is a strong fibrous band, which was first described by Sir Astley Cooper. It extends lateralward from the base of the lacunar ligament along the pectineal line, to which it is attached. It is strengthened by the pectineal fascia, and by a lateral expansion from the lower attachment of the linea alba (adminiculum lineæ albæ).

The superficial portion of the fascia lata is the part on the lateral side of the fossa ovalis. It is attached, laterally, to the crest and anterior superior spine of the ilium, to the whole length of the inguinal ligament, and to the pectineal line in conjunction with the lacunar ligament. From the tubercle of the pubis it is reflected downward and lateralward, as an arched margin, the falciform margin, forming the lateral boundary of the fossa ovalis; this margin overlies and is adherent to the anterior layer of the sheath of the femoral vessels: to its edge is attached the fascia cribrosa. The upward and medial prolongation of the falciform margin is named the superior cornu; its downward and medial prolongation, the inferior cornu. The latter is well-defined, and is continuous behind the great saphenous vein with the pectineal fascia.

  The deep portion is situated on the medial side of the fossa ovalis, and at the lower margin of the fossa is continuous with the superficial portion; traced upward, it covers the Pectineus, Adductor longus, and Gracilis, and, passing behind the sheath of the femoral vessels, to which it is closely united, is continuous with the iliopectineal fascia, and is attached to the pectineal line.

  From this description it may be observed that the superficial portion of the fascia lata lies in front of the femoral vessels, and the deep portion behind them, so that an apparent aperture exists between the two, through which the great saphenous passes to join the femoral vein.

Theme 3. FASCIAE, SYnoVIAL BURSAE AND SHEATHS OF THE LOWER EXTREMITY

Pelvic fascia is continuation of endoabdominal fascia and part of fasciae that cover iliacus and iliоpsoas muscles (iliac fascia). Pelvic fascia passes into thigh and forms fascia lata femoris. This fascia makes up sheathes for femoral muscles also lateral intermuscular septa and medial intermuscular septa that separate anterior group of femoral muscles from medial and posterior groups.

Fascia lata femoris has superficial lamina and profundus lamina. Profundus lamina of fascia lata femoris extends along the thigh and its most dense part forms tendon of musculus tensor fasciae latae which also called iliоtibial tract. Superficial lamina of of fascia lata lays in femoral trigone and terminetes below by falciform margin that has superior cornu and inferior cornu. Superior cornu inosculates with inguinal ligament, inferior cornu - with deep sheet of fascia lata femoris. Hiatus saphaenus is formed under falciform margin that covered by cribriform fascia (thinnest part of fascia lata). While femoral hernia happened hiatus saphaenus convert into external annulus of  femoral canal.

Cross-section through the middle of the thigh.

Femoral canal does not exist at norm (!), it can appear only during forming the cal femoral hernia (pathology). Canal has three walls:

• lateral wall - femoral vein;

• anterior wall - superficial lamina of fasciae latae, inguinal ligament and superior cornu of the falciform margin;

• posterior wall - deep lamina of fasciae latae.

While femoral canal made up femoral annulus is its deep ring and hernia can exit under skin through the hiatus saphaenus (deep ring).

Femoral artery and vein passing through the lacuna vasorum run in iliоpectineus sulcus (between iliacus and pectineus muscles). Then femoral vessels positioned in anterior femoral sulcus which dispoced between adductor magnus medially and medial vastus muscle - laterally. On anterior surface of thigh they can notice femoral trigone, bordered by inguinal ligament above, medially – adductor longus muscle and laterally - sartorius muscle. Femoral trigone by its lower angle passes into adductorius canal (Hunter`s canal), that disposed between adductor magnus medially, vastus medialіs laterally and fibrous laminae between these muscles. Adductorius canal opens below by hiatus into popliteal fossa. Saphaenus nerve also as descendent genu artery and vein pass through anterior hiatus.

Popliteal fossa formed on back surface where thigh passes into leg. It has a diamond shape, bordered above by biceps femoris muscle, semitendonous and semimembranous muscles - medially.

The Reflected Inguinal Ligament (ligamentum inguinale reflexum [Collesi]; triangular fascia).—The reflected inguinal ligament is a layer of tendinous fibers of a triangular shape, formed by an expansion from the lacunar ligament and the inferior crus of the subcutaneous inguinal ring. It passes medialward behind the spermatic cord, and expands into a somewhat fan-shaped band, lying behind the superior crus of the subcutaneous inguinal ring, and in front of the inguinal aponeurotic falx, and interlaces with the ligament of the other side of the linea alba .

Popliteal fossa bordered below by lateral and medial heads of gastrocnemius muscle, its floor is popliteal surface of femoral bone and rear surface of knee joint. Here crurо-popliteal canal (Hruber`s canal) originates and passes downward in leg between superficial and deep posterior muscles of the leg. Inferior musculofibular canal branches off from this canal. It is bordered by fibula and flexor hallucis longus muscle. Superior musculofibular canal is independent which dispoced between lateral surface of fibulae and musculus fibularis longus.

Cross-section through middle of leg.

Fascia lata femoris passes into leg as crural fascia, which forms sheathes for muscles of the leg. Anterior intermuscular septa cruris and posterior intermuscular septa cruris spring from it that separate lateral group leg muscles from the anterior and posterior groups. When crural fascia transites on foot some fibrous stripes form:

1)   superior retinaculum musculorum extensorum pedis

2)   inferior retinaculum musculorum extensorum pedis

3)   superior retinaculum musculorum fibulorum

4)   inferior retinaculum musculorum fibulorum

5)   retinaculum musculorum flexorum pedis

6)   

Retinaculum musculorum flexorum pedis covers three osseofibrous canals for tendons of deep posterior crural muscles and fibrous canal for vessels and nerves. Under retinaculum musculorum extensorum pedis three osseofibrous canals for tendons of anterior crural muscles and one fibrous canal for vessels and nerves. Superior retinaculum musculorum fibulorum covers one osseofibrous canal for tendons of peroneus longus and brevis muscles. Inferior one contains two osseofibrous canals for separate tendons of peroneal muscles. Tendons of muscles passing under retinaculum covered by synovial membrane which forms their synovial vaginae of tendons.

Fascia cruris passes into foot, forming dorsal fascia pedis and plantar fascia. Plantar fascia has superficial lamina and deep lamina. Profundus lamina forms synovial vaginae for plantar muscles, also lateral intermuscular septa and medial intermuscular septa, that separate middle group of muscles from medial and lateral groups. Superficial lamina of plantar fasciae forms plantar aponeurosis, which strengthens the vault of foot. There are medial plantar sulcus between flexor digitorum brevis and abductor hallucis and lateral plantar sulcus between flexor digitorum brevis and abductor digiti minimi where plantar vessels and nerves pass.

The Fascia Covering the Psoas and Iliacus is thin above, and becomes gradually thicker below as it approaches the inguinal ligament.

Muscles of the iliac and anterior femoral regions.

 

  The portion covering the Psoas is thickened above to form the medial lumbocostal arch, which stretches from the transverse process of the first lumbar vertebra to the body of the second. Medially, it is attached by a series of arched processes to the intervertebral fibrocartilages, and prominent margins of the bodies of the vertebræ, and to the upper part of the sacrum; the intervals left, opposite the constricted portions of the bodies, transmit the lumbar arteries and veins and filaments of the sympathetic trunk. Laterally, above the crest of the ilium, it is continuous with the fascia covering the front of the Quadratus lumborum (see page 419), while below the crest of the ilium it is continuous with the fascia covering the Iliacus.

  The portions investing the Iliacus (fascia iliaca; iliac fascia) is connected, laterally to the whole length of the inner lip of the iliac crest; and medially, to the linea terminalis of the lesser pelvis, where it is continuous with the periosteum. At the iliopectineal eminence it receives the tendon of insertion of the Psoas minor, when that muscle exists. Lateral to the femoral vessels it is intimately connected to the posterior margin of the inguinal ligament, and is continuous with the transversalis fascia. Immediately lateral to the femoral vessels the iliac fascia is prolonged backward and medialward from the inguinal ligament as a band, the iliopectineal fascia, which is attached to the iliopectineal eminence. This fascia divides the space between the inguinal ligament and the hip bone into two lacunæ or compartments, the medial of which transmits the femoral vessels, the lateral the Psoas major and Iliacus and the femoral nerve. Medial to the vessels the iliac fascia is attached to the pectineal line behind the inguinal aponeurotic falx, where it is again continuous with the transversalis fascia. On the thigh the fasciæ of the Iliacus and Psoas form a single sheet termed the iliopectineal fascia. Where the external iliac vessels pass into the thigh, the fascia descends behind them, forming the posterior wall of the femoral sheath. The portion of the iliopectineal fascia which passes behind the femoral vessels is also attached to the pectineal line beyond the limits of the attachment of the inguinal aponeurotic falx; at this part it is continuous with the pectineal fascia. The external iliac vessels lie in front of the iliac fascia, but all the branches of the lumbar plexus are behind it; it is separated from the peritoneum by a quantity of loose areolar tissue.

Superficial Fascia.—The superficial fascia forms a continuous layer over the whole of the thigh; it consists of areolar tissue containing in its meshes much fat, and may be separated into two or more layers, between which are found the superficial vessels and nerves. It varies in thickness in different parts of the limb; in the groin it is thick, and the two layers are separated from one another by the superficial inguinal lymph glands, the great saphenous vein, and several smaller vessels. The superficial layer is continuous above with the superficial fascia of the abdomen. The deep layer of the superficial fascia is a very thin, fibrous stratum, best marked on the medial side of the great saphenous vein and below the inguinal ligament. It is placed beneath the subcutaneous vessels and nerves and upon the surface of the fascia lata. It is intimately adherent to the fascia lata a little below the inguinal ligament. It covers the fossa ovalis (saphenous opening), being closely united to its circumference, and is connected to the sheath of the femoral vessels. The portion of fascia covering this fossa is perforated by the great saphenous vein and by numerous blood and lymphatic vessels, hence it has been termed the fascia cribrosa, the openings for these vessels having been likened to the holes in a sieve. A large subcutaneous bursa is found in the superficial fascia over the patella.

 

Deep Fascia.—The deep fascia of the thigh is named, from its great extent, the fascia lata; it constitutes an investment for the whole of this region of the limb, but varies in thickness in different parts. Thus, it is thicker in the upper and lateral part of the thigh, where it receives a fibrous expansion from the Glutæus maximus, and where the Tensor fasciæ latæ is inserted between its layers; it is very thin behind and at the upper and medial part, where it covers the Adductor muscles, and again becomes stronger around the knee, receiving fibrous expansions from the tendon of the Biceps femoris laterally, from the Sartorius medially, and from the Quadriceps femoris in front. The fascia lata is attached, above and behind, to the back of the sacrum and coccyx; laterally, to the iliac crest; in front, to the inguinal ligament, and to the superior ramus of the pubis; and medially, to the inferior ramus of the pubis, to the inferior ramus and tuberosity of the ischium, and to the lower border of the sacrotuberous ligament. From its attachment to the iliac crest it passes down over the Glutæus medius to the upper border of the Glutæus maximus, where it splits into two layers, one passing superficial to and the other beneath this muscle; at the lower border of the muscle the two layers reunite. Laterally, the fascia lata receives the greater part of the tendon of insertion of the Glutæus maximus, and becomes proportionately thickened. The portion of the fascia lata attached to the front part of the iliac crest, and corresponding to the origin of the Tensor fasciæ latæ, extends down the lateral side of the thigh as two layers, one superficial to and the other beneath this muscle; at the lower end of the muscle these two layers unite and form a strong band, having first received the insertion of the muscle. This band is continued downward, under the name of the iliotibial band (tractus iliotibialis) and is attached to the lateral condyle of the tibia. The part of the iliotibial band which lies beneath the Tensor fasciæ latæ is prolonged upward to join the lateral part of the capsule of the hip-joint. Below, the fasciæ lata is attached to all the prominent points around the knee-joint, viz., the condyles of the femur and tibia, and the head of the fibula. On either side of the patella it is strengthened by transverse fibers from the lower parts of the Vasti, which are attached to and support this bone. Of these the lateral are the stronger, and are continuous with the iliotibial band. The deep surface of the fascia lata gives off two strong intermuscular septa, which are attached to the whole length of the linea aspera and its prolongations above and below; the lateral and stronger one, which extends from the insertion of the Glutæus maximus to the lateral condyle, separates the Vastus lateralis in front from the short head of the Biceps femoris behind, and gives partial origin to these muscles; the medial and thinner one separates the Vastus medialis from the Adductores and Pectineus. Besides these there are numerous smaller septa, separating the individual muscles, and enclosing each in a distinct sheath.

Bursæ—Three bursæ are usually found in relation with the deep surface of GLUTEUS muscle. One of these, of large size, and generally multilocular, separates it from the greater trochanter; a second, often wanting, is situated on the tuberosity of the ischium; a third is found between the tendon of the muscle and that of the Vastus lateralis.

 

 

 

 

 

Prepared by

Reminetskyy B.Y.