leg - doctor 2017 - ju medicine€¦ · (posterior compartment of leg) tibialis posterior origin:...
TRANSCRIPT
Leg
Dr. Heba Kalbouneh
Associate Professor of Anatomy and Histology
Medially:
The saphenous nerve, a branch of the
femoral nerve supplies the skin on the
medial surface of the leg
Laterally:
Upper part
The lateral cutaneous nerve of the calf, a
branch of the common fibular nerve supplies
the skin on the upper part of the lateral
surface of the leg
Skin of the Leg
Posteriorly:
The posterior cutaneous nerve of the
thigh supplies the skin over the
popliteal fossa and the upper part of the
back of the leg
Cutaneous Nerves
Laterally:
Lower part
Anterolaterally
The superficial fibular nerve, a terminal
branch of the common fibular nerve
supplies the skin on the lower part of the
anterolateral surface of the leg
Posterolaterally
The sural nerve, a branch of the tibial nerve
supplies the skin on the lower part of the
posterolateral surface of the leg
Fascial Compartments of the Leg
The deep fascia of the leg forms Two
intermuscular septa
(anterior and posterior) which are
attached to the fibula
These, together with the interosseous
membrane divide the leg into:
Three compartments:
Anterior
Lateral
Posterior
Each having its own muscles, blood
supply, and nerve supply.
Sciatic nerve
Tibial nerve Common fibular nerve
Superficial
fibular nerve
Deep
fibular nerve
Posterior compartment
of leg
Anterior compartment
of leg
Lateral compartment
of leg
Superior
Extensor
Retinaculum Inferior
Extensor
Retinaculum
Retinacula of the Ankle
The retinacula are thickenings of the deep
fascia that keep the long tendons around the
ankle joint in position and act as pulleys.
Superior Extensor Retinaculum
Inferior Extensor Retinaculum
Superior Fibular Retinaculum
Inferior Fibular Retinaculum
Flexor Retinaculum
Anterior view
Superior Extensor
Retinaculum
between tibia and fibula
above the malleoli Inferior Extensor
Retinaculum
Y-shaped band located in front
of the ankle joint.
Originates from calcaneus
separates into two bands:
Upper: passes to the medial
malleolus
Lower: to the navicular and
medial cuneiform bones
Anterior view
Flexor Retinaculum
Extends from medial malleolus to calcaneus
Posterior view
Superior Fibular
Retinaculum
Inferior Fibular Retinaculum
Posterior view
Popliteal artery
Anterior tibial artery
Posterior tibial artery
Popli
teus
Posterior view
Anterior tibial artery passes
forward through an opening
in the upper part of the
interosseous membrane and
enters the anterior
compartment of the leg.
It continues onto the dorsal
aspect of the foot
Posterior view
Ant view
Anterior tibial artery
Fibular artery
Posterior tibial artery
Popliteal artery
Posterior tibial artery
Posterior view
Supplies posterior and
lateral compartments of
the leg and continues into
the sole of the foot
Is a branch from posterior
tibial artery and runs parallel
to it, it supplies the posterior
and lateral compartments of
the leg
Tibial nerve
Common fibular nerve
Popliteal artery
Popliteal vein
Posterior view
Superficial fibular nerve
Supplies the muscles of the lateral
compartment of the leg
Deep fibular nerve
Supplies the muscles of
the anterior compartment
of the leg
Anterior view
Tibial nerve
Supplies the muscles of the
posterior compartment of the
leg
Posterior view
Cross section in the shaft of fibula
Late
ral
su
rfa
ce
Provides origin to
The muscles of the
lateral
compartment of the leg
Provides origin to some
of the posterior
compartment of the leg
(Flexor surface)
Provides origin to
the anterior compartment of the
leg
(Extensor surface)
Muscles:
Tibialis anterior
Extensor digitorum longus
Extensor hallucis longus
Fibularis (Peroneus) tertius
Blood supply: Anterior tibial artery
Nerve supply: Deep fibular (peroneal) nerve
Anterior Fascial Compartment of the Leg
Action: All dorsiflex of the foot.
Hallucis: Extends big toe
Digitorum : Extends four toes
Tibialis: Inverts of the foot
Fibularis: Everts of the foot
All the muscles of the anterior compartment of the leg originate from
fibula EXCEPT Tibialis anterior from Tibia.
The main actions of these muscles are:
Extension of the foot at the ankle joint (dorsiflextion) to raise the toes up
(in other words to stand up on the heels)
In addition any muscle that got (tibialis) in its name
Inverts the foot at subtalar and transverse tarsal joints
while any muscle got (fibularis/ peroneus) in its name
Everts foot at subtalar and transverse tarsal joints
Nerve supply of all the muscles of the anterior compartment of the leg:
Deep fibular nerve
Insertion?
Tibialis anterior
Origin: lateral surface of shaft
of tibia and interosseus
membrane
Insertion: medial cuneiform
and base of first metatarsal
bone
Nerve supply: Deep fibular
nerve
Action: dorsiflexion of foot at
ankle joint, inversion of foot at
subtalar and transverse tarsal
joints, holds up medial
longitudinal arch of foot
Extensor hallucis longus
Origin: anterior surface of
shaft of fibula
Insertion: base of distal
phalanx of big toe
Nerve supply: Deep fibular
nerve
Action: extends big toe,
dorsiflexion of foot at ankle
joint
Extensor digitorum longus
Origin: anterior surface of
shaft of fibula and extends
superiorly onto the lateral
condyle of tibia
Insertion: via extensor
expansion into bases of middle
and distal phalanges of lateral
four toes
Nerve supply: Deep fibular
nerve
Action: extends toes,
dorsiflexion of foot at ankle
joint Fibularis tertius is
considered part of
extensor digitorum longus
and inserts into the base
of 5th metatarsal
Action: dorsiflexion and
eversion
Tom Has Very Nice Dogs and Frogs
FROM MEDIAL TO LATERAL
In front of the medial malleolus
Anterior
tibial
artery
Tibialis anterior
Extensor Hallucis longus
Extensor
Digitorum
Anterior tibial artery Deep fibular nerve
Medial Lateral
Note: The two extensor
retinacula hold the tendons of the
extensor muscles in place and
prevent bowing during extension
of the foot and toes
Lateral Fascial Compartment of the Leg
Muscles:
Fibularis longus
Fibularis brevis
Nerve supply: Superficial fibular nerve
Blood supply: Branches from the fibular artery
(branch from posterior tibial artery)
Fibularis
brevis
Fibularis
longus
Fibularis longus:
Origin: Lateral surface of
shaft of fibula
Insertion: Base of first
metatarsal and the medial
cuneiform bone
Nerve supply: Superficial
fibular nerve
Action: Plantar flexes the foot
at the ankle joint, everts the
foot at the subtalar and
transverse tarsal joints,
supports lateral longitudinal
and transverse arches of foot
Fibularis brevis:
Origin: Lateral surface of shaft
of fibula
Insertion: Base of fifth
metatarsal bone
Nerve supply: Superficial fibular
nerve
Action: Plantar flexes the foot at
the ankle joint, everts the foot at
the subtalar and transverse tarsal
joints, supports lateral
longitudinal arch of foot
Superior and inferior
fibular retinacula bind the
tendons of fibularis longus
and brevis as they pass from
the lateral compartment of the
leg into the lateral side of the
foot
Posterior Fascial Compartment of the Leg
Superficial group of
muscles
Gastrocnemius
Plantaris
Soleus
Deep group of muscles
Popliteus
Flexor digitorum longus
Flexor hallucis longus
Tibialis posterior
Blood supply: Posterior tibial artery
Nerve supply: Tibial nerve
In the posterior compartment, a transverse septum further
divide the posterior compartment into layers of superficial
and deep muscles
Gastrocnemius
Origin: Lateral head from lateral condyle of
femur
Medial head from above medial condyle
Insertion: Via calcaneal tendon into
posterior surface of calcaneus
Nerve supply: Tibial nerve
Action: Plantar flexes foot at ankle joint,
Flexes knee joint
Superficial group of muscles (Posterior compartment of leg)
Plantaris
This muscle sometimes is absent
Origin: Lateral supracondylar ridge of femur
Insertion: Posterior surface of calcaneus
Nerve supply: Tibial nerve
Action: Plantar flexes foot at ankle joint,
Flexes knee joint
Superficial group of muscles (Posterior compartment of leg)
Soleus
Origin: Shafts of tibia (soleal line) and
fibula
Insertion: Via calcaneal tendon into
posterior surface of calcaneus
Nerve supply: Tibial nerve
Action: Together with gastrocnemius is
powerful plantar flexor of ankle
joint; provides main propulsive force in
walking and running
Superficial group of muscles (Posterior compartment of leg)
As a unit, these muscles are large and
powerful because they propel the body
forward off the planted foot during walking
and can elevate the body upward onto the
toes when standing
Deep group of muscles
(Posterior compartment of leg)
Popliteus
Origin: lateral surface of
lateral condyle of femur (popliteal groove)
Insertion: posterior surface of
of tibia above soleal line
Nerve supply: Tibial nerve
Action: flexes leg at knee
joint, unlocks the extended
knee at the initiation of flexion
by lateral rotation of femur on
tibia, medial rotation of tibia,
and slackens ligaments of knee
joint
Unlocking means Lateral
rotation of the femur
Or Medial rotation of the
tibia
Locking means…………..
rotation of the femur Or
…………rotation of the
tibia
Deep group of muscles
(Posterior compartment of leg)
Tibialis posterior
Origin: posterior surface of
tibia and fibula and
interosseous membrane
Insertion: tuberosity of
navicular bone and other
neighboring bones
Nerve supply: Tibial nerve
Action: plantar flexes foot at
ankle joint, inversion of foot at
subtalar and transverse tarsal
joints, supports medial
longitudinal arch of foot
Deep group of muscles
(Posterior compartment of leg)
Flexor digitorum longus
Origin: posterior surface of
tibia
Insertion: bases of distal
phalanges of lateral four toes
Nerve supply: Tibial nerve
Action: flexes distal
phalanges of lateral four toes,
plantar flexes foot at ankle
joint, supports medial and
lateral longitudinal arches of
foot
Flexor hallucis longus
Origin: posterior surface of
fibula
Insertion: base of distal
phalanx of big toe
Nerve supply: Tibial nerve
Action: flexes distal phalanx
of big toe, plantar flexes foot
at ankle joint, supports medial
longitudinal arch of foot
Deep group of muscles
(Posterior compartment of leg)
Behind the medial malleolus
From Anterior to Posterior
Tibialis posterior
Flexor digitorum
longus
Posterior tibial vessels
Tibial nerve
Flexor hallucis longus
Tom Does Very Nice Homework
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Tib
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Hal
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Tarsal tunnel is formed on the posteromedial side of the ankle
and covered by flexor retinaculum
Provides channels for the tendons of flexor muscles as they pass from the posterior
compartment of the leg into the sole of the foot
Surface anatomy
Popliteal Fossa
Dr. Heba Kalbouneh
Associate Professor of Anatomy and Histology
Is a diamond-shaped intermuscular space
situated at the back of the knee
Boundaries
Laterally:
Above
Biceps femoris
Below
Lateral head of gastrocnemius and Plantaris
Medially:
Above
Semimembranosus and semitendinosus
Below
Medial head of gastrocnemius
Popliteal Fossa
Lateral
The floor (anterior wall) of the
fossa is formed by:
Popliteal surface of the femur
Capsule of the knee joint
Popliteus muscle
The roof is formed by:
Skin
Superficial fascia
Deep fascia
Contents of popliteal fossa:
1- Popliteal artery
2-Popliteal vein
3- Common fibular nerve (lateral popliteal nerve)
4- Tibial nerve
(medial popliteal nerve)
5- Small saphenous vein
(termination)
6- Connective tissue
7- Lymph nodes
Popliteal artery
Popliteal vein
Tibial nerve
Common
fibular nerve
Small
saphenous
vein
At the middle of the fossa
The popliteal artery is the deepest structure
While the vein is intermediate
and the tibial nerve is most superficial
Enters the popliteal fossa through the
adductor hiatus as a continuation of the
femoral artery
The deepest structure in the fossa
It ends at the level of the lower border
of the popliteus muscle by dividing into
anterior and posterior tibial arteries
Gives genicular branches to knee joint
Popliteal artery
Anterior tibial artery
Posterior tibial artery
Popli
teus
Femoral
artery
When examining a lump in the popliteal region, think of these possibilities:
Skin and soft tissues—sebaceous cyst, lipoma
Vein—varicosities of the short saphenous vein in the roof of the fossa
Artery—popliteal aneurysm
Lymph nodes—infection secondary to suppuration in the foot
Knee joint—joint effusion
Tendons—enlarged bursae, especially those beneath semimembranosus
and the heads of gastrocnemius
Bones—a tumour of the lower end of femur or upper end of tibia
The popliteal fossa is a good example of the value of thinking
anatomically when considering the differential diagnosis of
a mass situated in a particular anatomical area.
A baker’s cyst (or popliteal cyst)
refers to the inflammation and
swelling of the
semimembranosus bursa
Tibial
nerve
Sciatic nerve
Common
fibular
nerve
Origin :
From sciatic nerve at the lower third of the
thigh
Course:
It enters popliteal fossa from upper angle
and leaves it at its lower angle to enter the
posterior compartment of the leg
Termination:
It ends deep to flexor retinaculum by
dividing into medial and lateral plantar
nerves.
Tibial nerve
Femoral
vein
Femoral
artery
Sural
nerve
Small
saphenous
vein
Sural nerve Small saphenous
vein
Sural nerve
Supplies skin on
posterolateral side of lower part
of leg and lateral side of foot
The sural nerve accompanies
the small saphenous vein
behind the lateral malleolus
The small saphenous
vein pierces the
popliteal fascia to empty
into the popliteal vein
The sural nerve pierces
the deep fascia
The small saphenous vein
Starts at the lateral side of the
dorsal venous arch in the foot
Passes behind the lateral
malleolus
Ascends vertically in the
superficial fascia on the back of
the leg
Penetrates the deep fascia at the
back of the knee
Drains into popliteal vein
Tibial nerve
Sciatic nerve
Popli
teus
Tibial nerve enters the
posterior compartment of
the leg by passing beneath
the soleus muscle
Medial plantar nerve
Lateral plantar nerve
Tibial nerve
Sural
Medial
calcaneal
Saphenous
Medial
plantar
Lateral
plantar
Medial
calcaneal nerve
(Tibial nerve)
(Tibial nerve)
(Tibial nerve)
(Tibial nerve)
Muscular Sensory
All muscles in posterior compartment of thigh (except
short head of biceps), all muscles in posterior
compartment of leg, most intrinsic muscles of the foot
Sural nerve:
Supplies skin on posterolateral side
of lower part of leg and lateral side
of foot
Medial calcaneal branch:
Supplies the skin over the medial
surface of the heel.
Medial plantar nerve: sensory to
Medial 2/3 of sole and medial
three and a half toes.
Lateral plantar nerve: sensory to
Lateral 1/3 of sole and lateral one
and a half toes
Also
Motor to most intrinsic muscles
of the foot
Tibial nerve injury
Motor Sensory
Paralysis of all muscles in the posterior
compartment of the leg
Paralysis of most intrinsic foot muscles
Loss of plantar-flexion at the ankle
Weakness of inversion
Foot is dorsiflexed and everted
Sensory loss from:
Posterolateral side of lower part of leg
Sole of the foot
Injury to tibial nerve
Because of its deep and protected position, its rarely
injured
Complete damage results in:
Paralysis of all muscles in the back of the leg and
most intrinsic muscles of the foot
The anatagonistic muscles (dorsiflexors and evertors)
will take over leading to an attitude called:
(Calcaneovalgus)
Foot is dorsiflexed and
everted
Tibial nerve
Sciatic nerve
Common
fibular
nerve
Origin:
From sciatic nerve at the lower third of the
thigh
Course:
It descends from the superior to the lateral
angle of the popliteal fossa close to the medial
border of biceps femoris.
Termination:
It ends at the neck of fibula where it divides
into superficial and deep fibular nerves
Branches:
Common fibular nerve
Muscular Sensory
Short head of
biceps femoris
1- Sural communicating
branch
2- Lateral cutaneous nerve
of the calf: supplies the skin
on the upper part of the
lateral side of the leg
Lateral
cutaneous nerve
of the calf
Lateral
cutaneous nerve
of the calf
Superficial
fibular nerve
Muscular Sensory
Muscles of anterior
compartment of leg
Some of the intrinsic muscles of
foot
Skin between big toe and
second at dorsum of foot
Muscular Sensory
Muscles of lateral
compartment of leg
Supplies skin on
anterolateral side of
lower part of leg
Supplies skin of
intermediate part of
dorsum of foot
Superficial fibular nerve
Deep fibular nerve
Superficial
fibular
nerve
Deep
fibular
nerve
Common
fibular
nerve
The superficial fibular
nerve
Also called the
musclocutaneous
nerve of the leg
Supplies two muscles in
the lateral compartment
of the leg and then
becomes cutaneous
where it supplies the
skin over the
anterolateral side of
lower part of leg and the
intermediate part of
dorsum of foot
(except the cleft of skin
between the 1st and 2nd
toes)
Common fibular nerve injury Cause: most common cause is fracture neck of fibula
Motor Sensory
Paralysis of muscles of the anterior and
lateral compartments of the leg
Loss of dorsiflexion at the ankle
Foot drop
Loss of eversion
Inversion of the foot is weakened
Foot is plantarflexed and inverted
Sensory loss from:
Anterolateral side of lower part of leg
Intermediate area of dorsum of foot
Dorsum of the toes except the lateral side of
the little toe
Foot drop
Common fibular nerve is in an exposed position as it
leaves the popliteal fossa and winds around the neck
of fibula
Injury to common fibular nerve
Paralysis of extensor muscles (supplied by deep
fibular nerve)
This means loss of dorsiflexion of the foot
Paralysis of fibularis muscles (supplied by
superficial fibular nerve)
This means loss of eversion of the foot
The anatagonistic muscles (plantar-flexors and
invertors) will take over leading to an attitude called:
(Equinovarus)
Foot drop and inversion
Injury to common fibular nerve
Plantarflexion (Foot drop) and inversion
of foot
Injury to superficial fibular nerve
Inversion of foot
Injury to deep fibular nerve
Plantarflexion (Foot drop)
Injury to tibial nerve
Dorsiflexiom and eversion of foot
Saphenous nerve
Deep fibular nerve
Lat cutaneous
nerve of the calf
Superficial fibular nerve
Deep fibular nerve
Lat cutaneous nerve
of the calf
Superficial fibular nerve Sural nerve
Lat cutaneous nerve
of the calf
Medial calcaneal nerve
Sural nerve
Saphenous nerve
Post cutaneous nerve
of the thigh