Lower LimbsLower Limbs

Lu XiaoliLu Xiaoli

Regional Anatomy & Operative SurgeryRegional Anatomy & Operative Surgery

China Medical UniversityChina Medical University

32 Bones 32 Bones Hip Bone (1) Hip Bone (1) Femur (1) Femur (1) Patella (1) Patella (1) Tibia (1) Tibia (1) Fibula (1) Fibula (1) Tarsals (8) Tarsals (8) Metatarsals (5) Metatarsals (5) Proximal Phalanges (5) Proximal Phalanges (5) Intermediate PhalangeIntermediate Phalange

s (5) s (5) Distal Phalanges (4) Distal Phalanges (4)

HipHip

Femoral Femoral Bone Bone

Patella Patella

Tib

ia &

Fibu

la

Tib

ia &

Fibu

la

Proximal End of Left Tibia Proximal End of Left Tibia

Gluteal RegionGluteal Region

Iliac Crest Iliac Crest

Gluteal Crease Gluteal Crease

Superficial Layers Superficial Layers SkinSkinSuperficial FasciaSuperficial Fascia

Deep LayersDeep LayersDeep FasciaDeep FasciaMusclesMusclesSuprapiriform & Infrapiriform ForamenSuprapiriform & Infrapiriform ForamenLesser Sciatic ForamenLesser Sciatic Foramen

HipHip Joint Joint

Superficial FasciaSuperficial Fascia

the middle part is thinnestthe middle part is thinnestContains Superficial blood vessels, Contains Superficial blood vessels,

lymphatic vessels and cutaneous lymphatic vessels and cutaneous nervesnerves

Bedsore (Decubitus Ulcer)Bedsore (Decubitus Ulcer)

Arteries Arteries

Superficial branches ofSuperficial branches of 44thth lumbar artery lumbar arteryInferior gluteal arteryInferior gluteal arteryLateral sacral arteryLateral sacral arterySuperior gluteal arterySuperior gluteal arteryInferior gluteal arteryInferior gluteal artery

Cutaneous NervesCutaneous Nerves

branches of the subcostabranches of the subcostal nerve (T12) l nerve (T12)

dorsal rami of lumbar nedorsal rami of lumbar nerves rves

dorsal rami of sacral nervdorsal rami of sacral nerves es

inferior cluneal nerves inferior cluneal nerves posterior femoral cutaneposterior femoral cutane

ous nerveous nerve

Deep Fascia Deep Fascia

Attach to iliac crest superiorlyAttach to iliac crest superiorly Invest gluteus maximusInvest gluteus maximus Attach to Sacral bone and coccyx Attach to Sacral bone and coccyx

mediallymedially Continuous with fascia lata laterally Continuous with fascia lata laterally

Muscles Muscles

SuperficialSuperficial

MiddleMiddle

DeepDeep

Gluteus MaximusGluteus MaximusTensor Fasciae LataeTensor Fasciae Latae

Glluteus MediusGlluteus MediusPiriformisPiriformis

Superior Gemellus Superior Gemellus Obturator Internus Obturator Internus Inferior Gemellus Inferior Gemellus

Quadratus FemorisQuadratus Femoris

Gluteus MinimusGluteus MinimusObturator ExternusObturator Externus

Gluteus MaxinusGluteus Maxinus Tensor Fasciae LaTensor Fasciae La

taetae

Glluteus MediusGlluteus MediusPiriformisPiriformisSuperior Gemellus Superior Gemellus Obturator Internus Obturator Internus Inferior Gemellus Inferior Gemellus Quadratus FemorisQuadratus Femoris

Gluteus MinimusGluteus Minimus Obturator ExternuObturator Externu

ss

Suprapiriform ForamenSuprapiriform Foramen

Infrapiriform ForamenInfrapiriform Foramen

Sciatic n.Sciatic n. Tibial n.Tibial n. Common Fibular n.Common Fibular n.

66.3% 27.3%

6.4%

Tibial n. Common Fibular n.

Piriformis Piriformis SyndromeSyndrome

Pain radiates Pain radiates down the back down the back of the leg of the leg

Ischial Ischial tuberosittuberosityy

Iliac crestIliac crest

Lesser Sciatic ForamenLesser Sciatic Foramen BoundariesBoundaries

front: tuberosity of ischium front: tuberosity of ischium above: spine of ischium & sacrospinous lig.above: spine of ischium & sacrospinous lig.behind: sacrotuberous lig. behind: sacrotuberous lig.

ContentsContentstendon of Obturator internustendon of Obturator internus internal pudendal a.internal pudendal a. internal pudendal v. internal pudendal v. pudendal n.pudendal n.

HipHip

AnteriorAnterior

Posterior Posterior

It is based on this capsular attachment tIt is based on this capsular attachment that fractures of the neck of femur are clahat fractures of the neck of femur are classified as:ssified as: INTRACAPSULAR: within the capsular attachINTRACAPSULAR: within the capsular attach

ment. ment. EXTRACAPSULAR: outside the attachment oEXTRACAPSULAR: outside the attachment o

f the capsule f the capsule MixedMixed

IntracapsulaIntracapsular r

Lig. of head Lig. of head of femurof femur

Transverse Transverse acetabular acetabular lig.lig.

ExtracapsularExtracapsular(Anterior)(Anterior)

Iliofemoral lig.Iliofemoral lig.Pubofemoral Pubofemoral

lig.lig.

ExtracapsularExtracapsular(posterior)(posterior)

IschiofemoraIschiofemoral lig.l lig.

Zona Zona orbicularisorbicularis

Superior gluteal a.Superior gluteal a. Inferior gluteal a.Inferior gluteal a.Lateral circumflex femoral a.Lateral circumflex femoral a.Medial Circumflex femoral a.Medial Circumflex femoral a.Branches of Obturator a.Branches of Obturator a.11stst perforating branches of deep perforating branches of deep

femoral a.femoral a.Femoral nutrient a.Femoral nutrient a.

Blood SupplyBlood Supply

Superior gluteal Superior gluteal a.a.

Inferior gluteal Inferior gluteal a.a.

11stst perforating perforating branches of branches of deep femoral a.deep femoral a.

Medial Circumflex Medial Circumflex femoral a. femoral a.

Lateral circumflex Lateral circumflex femoral a.femoral a.

Superior retinacular a. Superior retinacular a. Anterior retinacular a.Anterior retinacular a. Inferior retinacular a.Inferior retinacular a.

Branches of Branches of Obturator Obturator

a.a.

Femoral Femoral nutrient a.nutrient a.

If the head of the femur is dislocated If the head of the femur is dislocated postero-medially, compression of which postero-medially, compression of which nerve is likely to result? nerve is likely to result?

A.A. FemoralFemoralB.B. Lumbosacral trunkLumbosacral trunkC.C. ObturatorObturatorD.D. SciaticSciaticE.E. Superior gluteal Superior gluteal

What muscle passes through the lesseWhat muscle passes through the lesser sciatic foramen? r sciatic foramen?

A.A. Gluteus minimusGluteus minimusB.B. Obturator internusObturator internusC.C. PiriformisPiriformisD.D. Quadratus femorisQuadratus femorisE.E. Superior gemellus Superior gemellus

In order to avoid injury to the In order to avoid injury to the sciatic nerve, intramuscular injections sciatic nerve, intramuscular injections should be given in which quadrant of should be given in which quadrant of the buttock? the buttock?

A.A. upper medialupper medial

B.B. upper lateralupper lateral

C.C. lower mediallower medial

D.D. lower laterallower lateral

E.E. middle middle

Of the branches of the internal iliac arOf the branches of the internal iliac artery, the one exiting from the greater sciattery, the one exiting from the greater sciatic foramen superior to the piriformis muscic foramen superior to the piriformis muscle is the: le is the:

A.A. Iliolumbar arteryIliolumbar arteryB.B. Internal pudendal arteryInternal pudendal arteryC.C. Lateral sacral arteryLateral sacral arteryD.D. Superior gluteal artery Superior gluteal artery

Thigh Thigh

Anterior compartment Anterior compartment Posterior Posterior

compartmentcompartment

Superficial iliac circumflex a.Superficial iliac circumflex a.Superficial epigastric a.Superficial epigastric a.External pudendal a.External pudendal a.Superficial lateral femoral a.Superficial lateral femoral a.Superficial medial femoral a.Superficial medial femoral a.

Groin Flap Groin Flap

Great Saphenous V.Great Saphenous V.

70 70 ～～ 80 cm 80 cm

femoral v.femoral v.fossa ovalisfossa ovalis

medial side of thigh medial side of thigh medial condyles of tibia & femurmedial condyles of tibia & femur

medial side of leg medial side of leg medial malleolusmedial malleolus

dorsal venous arch of footdorsal venous arch of foot

Tributaries

Superficial iliac circumflSuperficial iliac circumflex v.ex v.

Superficial epigastric v.Superficial epigastric v. External pudendal v. External pudendal v. Superficial lateral femorSuperficial lateral femor

al v.al v. Superficial medial femorSuperficial medial femor

al v.al v.

in emergency, great saphenous veiin emergency, great saphenous vein may be opened surgically for intrn may be opened surgically for intravenous drip for the patients sufferavenous drip for the patients suffering from insufficiency of body fluid.ing from insufficiency of body fluid.

great saphenous vein as venous gragreat saphenous vein as venous graft can be used in the coronary bypaft can be used in the coronary bypass surgery for coronary heart diseasss surgery for coronary heart disease. e.

one-way valves one-way valves become weak & don't close properlybecome weak & don't close properly

Superficial inguinal Superficial inguinal LNLN

Horizontal groupsHorizontal groupsVertical groupsVertical groups

Fascia LataFascia Lata

Iliotibial tractIliotibial tract Saphenous hiatus (fossa ovalisSaphenous hiatus (fossa ovalis

) ) fascia cribrosafascia cribrosa Falciform marginFalciform margin

Lacuna musculorum & vasorumLacuna musculorum & vasorum

between inguinal lig. and hip bone, anbetween inguinal lig. and hip bone, and separated by iliopectineal archd separated by iliopectineal arch lateral: lacuna musculorum lateral: lacuna musculorum medial: lacuna vasorum medial: lacuna vasorum

Lacuna musculorumLacuna musculorum Boundaries:Boundaries:

ant.ant. ：： inguinal lig.inguinal lig.post.post. ：： iliumiliummed.med. ：： iliopectineal archiliopectineal arch

Contents:Contents: iliopsoasiliopsoas lat. femoral cutaneous n. lat. femoral cutaneous n. femoral n.femoral n.

Lacuna vasorumLacuna vasorum Boundaries: Boundaries:

ant.ant. ：： inguinal lig.inguinal lig.post.post. ：： pectineal lig.pectineal lig.med.med. ：： lacunar lig.lacunar lig. lat.lat. ： ： iliopectineal archiliopectineal arch

Contents:Contents: femoral sheathfemoral sheath femoral a., v.femoral a., v. femoral canalfemoral canal femoral br. of genitofemoral n.femoral br. of genitofemoral n.

Femoral Femoral sheathsheath

Femoral canalFemoral canal

1-1.5 cm1-1.5 cm Boundaries:Boundaries:

Ant. : inguinal lig. superior corner of falciforAnt. : inguinal lig. superior corner of falciform margin and femoral septumm margin and femoral septum

Post. : pectineal lig., pectineusPost. : pectineal lig., pectineusLat. : fibrous septum of femoral v.Lat. : fibrous septum of femoral v.

femoral ringfemoral ring

A 63-year-old female patient says that A 63-year-old female patient says that she has pain in her groin and upper thigh. she has pain in her groin and upper thigh. Upon examination, you palpate a lump locUpon examination, you palpate a lump located below the inguinal ligament lateral tated below the inguinal ligament lateral to its attachment to the pubic tubercle. Yoo its attachment to the pubic tubercle. You suspect that this may be a hernia passinu suspect that this may be a hernia passing through the:g through the:

A.A. femoral canalfemoral canalB.B. adductor hiatusadductor hiatusC.C. obturator canalobturator canalD.D. deep inguinal ringdeep inguinal ringE.E. superficial inguinal ringsuperficial inguinal ring

The femoral canal contains the: The femoral canal contains the: A.A. Deep inguinal lymph node(s)Deep inguinal lymph node(s)B.B. Femoral arteryFemoral arteryC.C. Femoral nerveFemoral nerveD.D. Femoral veinFemoral veinE.E. Ilioinguinal nerveIlioinguinal nerve

The pulse of the femoral artery is best The pulse of the femoral artery is best felt at which superficial reference point? felt at which superficial reference point?

A.A. Anterior to the ankle joint Anterior to the ankle joint B.B. Femoral triangleFemoral triangleC.C. Mid-thighMid-thighD.D. Popliteal fossaPopliteal fossaE.E. Right lateral portion of the hypogastriRight lateral portion of the hypogastri

um um

At which site could one expect to enteAt which site could one expect to enter the femoral vein with a simple percutaner the femoral vein with a simple percutaneous (through the skin) introduction of an ious (through the skin) introduction of an instrument? nstrument?

A.A. Above the middle of the inguinal ligaAbove the middle of the inguinal ligament ment

B.B. Lateral to the femoral arterial pulseLateral to the femoral arterial pulseC.C. Lateral to the pubic tubercleLateral to the pubic tubercleD.D. Medial to the femoral arterial pulseMedial to the femoral arterial pulseE.E. Medial to the pubic tubercle Medial to the pubic tubercle

A serious complication of fractures of tA serious complication of fractures of the femoral neck is avascular necrosis of thhe femoral neck is avascular necrosis of the femoral head. This usually results from rue femoral head. This usually results from rupture of which artery? pture of which artery?

A.A. Acetabular branch of obturatorAcetabular branch of obturatorB.B. Deep circumflex iliacDeep circumflex iliacC.C. Descending branch of lateral circumfleDescending branch of lateral circumfle

x femoralx femoralD.D. Medial circumflex femoralMedial circumflex femoralE.E. Second perforating branch of lateral ciSecond perforating branch of lateral ci

rcumflex rcumflex

A ruptured aneurysm in the most proxA ruptured aneurysm in the most proximal portion of the deep femoral artery wimal portion of the deep femoral artery would result in a hematoma located initially ould result in a hematoma located initially in the: in the:

A.A. Adductor canal.Adductor canal.B.B. Femoral canal.Femoral canal.C.C. Femoral triangle.Femoral triangle.D.D. Inguinal canal.Inguinal canal.E.E. Popliteal fossa. Popliteal fossa.

Childhood immunizations are sometiChildhood immunizations are sometimes given via intramuscular injections intmes given via intramuscular injections into the quadriceps muscles of the anterior to the quadriceps muscles of the anterior thigh. At the mid-thigh level, a needle passhigh. At the mid-thigh level, a needle passing into the space deep to the sartorius ming into the space deep to the sartorius muscle might pierce the femoral vessels as uscle might pierce the femoral vessels as they lie in the: they lie in the:

A.A. Adductor canalAdductor canalB.B. Adductor hiatusAdductor hiatusC.C. Adductor triangleAdductor triangleD.D. Femoral canalFemoral canalE.E. Femoral ringFemoral ring

Which of the following is NOT located Which of the following is NOT located within the adductor canal? within the adductor canal?

A.A. Saphenous nerveSaphenous nerveB.B. Femoral arteryFemoral arteryC.C. Nerve to vastus medialisNerve to vastus medialisD.D. Femoral veinFemoral veinE.E. Deep femoral arteryDeep femoral artery