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Organization of the Lower Limb Audrone Biknevicius, Ph.D. Dept. Biomedical Sciences, OU HCOM at Dublin Clinical Anatomy Immersion 2015 LIMB FUNCTION
choco-locate.com
blog.coolibar.com Mobility versus Body weight support Dexterity Locomotion Equilibrium & Stability
2 Pectoral Girdle Pelvic Girdle
Mobility versus Body weight support Dexterity Locomotion Equilibrium & Stability
3 Arm – forearm – hand Thigh – leg – foot
4 CORRECTED SLIDE #5 The upper and lower limbs are innervated by: A. Posterior (dorsal) rami of spinal nn. B. Anterior (ventral) rami of spinal nn. 50% 50%
Posterior (dorsal) rami of spin.. Anterior (ventral) rami of sp... 5 Week 5
RULE #1 Limbs are outgrowths of the ventral body wall
Upper limb: C5-T1 trunk segments
Lower limb: L2-S3 trunk segments (morphogenesis ~1-2 days later)
6 Week 7 RULE #1 (continued) Limbs are outgrowths of the ventral body wall that undergo distal growth, differentiation and rotation
7 Before rotation en.wikipedia.org
• Pollex and hallux both preaxial • Anteriomedially-directed palms and soles
8 Post rotation embryology.med.unsw.edu.au
Upper limb rotates 90◦ laterally: Lower limb rotates 90◦ medially: -Extensor mm. on posterior surface -Extensor mm. on anterior surface -Future elbow directed posteriorly -Future knee directed anteriorly -Supine hand in anatomical position -Foot fixed in prone position -Pollex positioned laterally -Hallux positioned medially
9 RULE #2: Innervation of lower limb mm. established in early embryogenesis – resulted in dedicated nerve-compartment relationships
Spinal nerve Dorsal primary ramus Ventral primary ramus (L2-S3) Anterior (ventral) division Posterior (dorsal) division
limb axis 10
Stern Essential of Gross Anatomy “Roots of BP” Brachial Plexus (=ventral rami) (right side; simplified) C5 Trunks C6
Divisions U C7 Cord M C8 Lat L Terminal T1 Branches Post Musculocutaneous n.
Stern Stern Med
Essential Essential of Gross Anatomy Median n. Radial n. Ulnar n. Anterior (ventral) division Posterior (dorsal) division 11 Lumbar Plexus accessphysiotherapy.mhmedical.com
Lumbosacral trunk Obturator Nerve (to sacral plexus) (L2,3,4) Ventral division Dorsal division 12 Sacral Plexus accessphysiotherapy.mhmedical.com
Ventral division Dorsal division 13 As a result of the opposite rotation of the lower limb, in which compartment will the developmentally dorsal muscles be located?
A. Anterior compartment 50% 50% B. Posterior compartment Week 7
Anterior compartment Posterior compartment 14 Developmentally ventral vs. dorsal mm.
Upper Limb Lower Limb
Arm Thigh
Ant
Lat Med Stern Stern
Forearm Post Leg Essential of Gross Anatomy
Hand Foot
Hence, posterior division nn. serve anterior compartments in LL 15 The fact that the anterior compartment muscles are innervated by posterior division nerve is …
A. Functionally relevant 50% 50% B. Downright confusing
Downright confusing Functionally relevant 16 Limb Muscle Compartments
Upper Limb Lower Limb
A A Arm M Thigh Ant P P Lat Med
Post A Forearm A L Leg P P
Palmar Dorsum Hand Med Lat Lat Med Foot Dorsum Plantar
Compartments: Anterior Posterior Medial Lateral 17 No motor distribution distal to knee *pectineus usually innervated by femoral n.
18 antranik.org Lower Limb Muscle Compartments
Ant Femoral n. Lat Med
Post Obturator n. Thigh
Leg
Compartments: Anterior Posterior Medial Lateral
Foot
19 Compartments: Dorsum Plantar The Sacral Plexus
20 antranik.org Lower Limb Muscle Compartments
Ant Femoral n. Lat Med
Post Obturator n. Thigh Common fibular n.: Tibial n. Biceps femoris short head Including Adductor magnus (hamstring part)
Leg Tibial n.
Compartments: Anterior Posterior Medial Lateral
Foot Tibial n. 21 Compartments: Dorsum Plantar The Sacral Plexus
22 antranik.org Common fibular n.
Deep fibular n. Superficial fibular n. Lateral Anterior compartment compartment
dorsum of foot! “Peroneal” = “Fibular”
23 Lower Limb Muscle Compartments
Ant Femoral n. Lat Med
Post Obturator n. Thigh Common fibular n.: Tibial n. Biceps femoris short head Including Adductor magnus Deep fibular n. (hamstring part) Superficial fibular n. Leg Tibial n.
Compartments: Anterior Posterior Medial Lateral Deep fibular n. Foot Tibial n. 24 Compartments: Dorsum Plantar Compartmental Organization of the Thigh
Fascia lata (& intermuscular septa)
Anterior – Femoral n.
Medial – Obturator n. (exception: Femoral n. – adductor magnus, hamstring part)
Posterior – Tibial n. (exception: Common fibular n. – biceps femoris, short head)
Primary functions: Hip & Knee
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medical-dictionary.thefreedictionary.com
Anterior compartment Flexors of thigh Femoral n. Medial compartment Adductors of thigh Obturator n.
Tibial n. Tibial Extensors of thigh Posterior compartment Many are biarticular muscles thatalso the knee joint affect Posterior compartment of thigh Hip extension; Knee flexion Attached to ischial tuberosity: • Thigh extension, Leg flexion: Biceps femoris (long head)*, Semitendinosus* & Semimembranosus* mm. • Thigh extension, Thigh adduction: Adductor magnus (hamstring part) * biarticular mm.
Tibial n.
Exception: Biceps femoris (short head); common fibular n.; knee flexion
27 Adductor magnus
Hamstring part: -Attaches to ischial tuberosity -Tibial n.
Adductor part: -Attaches to pubis www.studyblue.com -Obturator n.
28 Anterior Compartment of Thigh Hip flexion; Knee extension
Attached to ilium: • Thigh flexion: Iliopsoas • Thigh flexion, Leg flexion: Sartorius* • Thigh flexion, Leg extension: Rectus femoris m.*
• Leg extension (no action at mostafasalamapt.wordpress.com hip) – remainder of Quadriceps femoris (vasti)
* biarticular mm.
Femoral n. 29 Medial Compartment of Thigh Hip adduction; Hip flexion
Attachment to pubis: • Thigh adduction: Adductor longus, Adductor brevis, Adductor magnus (pubofemoral part) • Thigh adduction, Leg flexion: Gracilis
Obturator n.
30 Pectineus – “the exception”
Attaches to superior ramus of pubis
Pectineus m. mostly innervated by femoral n. (~25% by obturator n.)
All other mm. attaching to pubis are innervated by obturator n. danslararen.blogspot.com
31 Relative positions of muscles producing movements of hip joint
Gluteal group (externally) Iliopsoas (internally)
Hamstring & lat Adductor grp rotator grp
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Adapted from Moore et al., Essential Clinical Anatomy What are the actions of muscles attached to the anterior aspect of the hip? A. Thigh extension B. Thigh flexion 50% 50%
Gluteal group (externally) Iliopsoas (internally)
Hamstring & lat Adductor grp Thigh flexion rotator grp Thigh extension 33 Gluteal group (externally) Iliopsoas (internally)
Hip Extensors Hip Flexors Tibial n.: biceps femoris Femoral n.: iliopsoas, (long head), sartorius, rectus femoris, semitendinosis, pectineus semimembranosus, Superior gluteal n.: tensor adductor magnus fasciae latae (posterior) Obturator n.: adductor Inferior gluteal n.: Gluteus longus, brevis & magnus maximus (anterior), gracilis
Hamstring & lat Adductor grp rotator grp
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Adapted from Moore et al., Essential Clinical Anatomy What are the actions of muscles attached to the superolateral aspect of the hip? A. Thigh adduction B. Thigh abduction 50% 50%
Gluteal group (externally) Iliopsoas (internally)
Hamstring & lat Thigh adduction Thigh abduction Adductor grp 35 rotator grp Gluteal group (externally) Iliopsoas (internally)
Abductors Superior gluteal n.: gluteus medius & minimum, tensor fasciae latae
Adductors Obturator n.: adductor longus, brevis & magnus (anterior), gracilis Tibial n.: adductor magnus (posterior) Hamstring & lat Femoral n.: Pectineus Adductor grp rotator grp
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Adapted from Moore et al., Essential Clinical Anatomy Gluteal group (externally) Iliopsoas (internally)
Medial Rotators Superior gluteal n.: gluteus medius & minimum, tensor fasciae latae
Lateral Rotators N. obturator internus: obturator internus, superior gemellus N. quadratus femoris: quadratus femoris, inferior gemellus Obturator n.: obturator externus N. piriformis: piriformis Inferior gluteal n.: gluteus maximus Hamstring & lat Adductor grp rotator grp
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Adapted from Moore et al., Essential Clinical Anatomy Compartmental Organization of the Leg
Crural fascia of leg (& intermuscular septa)
Anterior – Deep fibular n.
Lateral – Superficial fibular n.
Posterior – Tibial n.
(no medial compartment; tibial shaft)
Primary Actions: Ankle & Foot
38 Primary Movements of Foot Ankle Joint (Talocrural Joint) legacy.owensboro.kctcs.edu
Subtalar joints antranik.org
39 What is the likely action of the muscles of the anterior compartment at the ankle? A. Foot dorsiflexion B. Foot plantarflexion 50% 50% dorsiflexion plantarflexion
Foot dorsiflexion Foot plantarflexion 40 What is the likely action of the muscles of the lateral compartment of the leg at the subtalar joints? A. Foot eversion 50% 50% B. Foot inversion
Medial malleolus
Lateral malleolus
Foot eversion Foot inversion 41 Anterior Compartment of Leg Dorsiflexor (extensor) Compartment
Also foot inversion: Tibialis anterior
Also foot eversion: Fibularis (peroneus) tertius
Also toe extension: Extensor hallicus longus
anatomyproartifex.blogspot.com Extensor digitorum longus
Deep fibular n.
42 Lateral Compartment of Leg Evertor Compartment
Fibularis (peroneus) longus Fibularis (peroneus) brevis (also weak plantarflexors)
Superficial fibular n. blog.corewalking.com
43 Posterior Compartment of Leg Plantarflexor Compartment web.duke.edu
Superficial mm.: Deep mm.: Gastrocnemius (also knee Popliteus (unlocks knee) flexor) Flexor digitorum longus Soleus Flexor hallucis longus Plantaris Tibialis posterior (also inversion)
Tibial n. 44 Dorsiflexion (flexion) Deep fibular n.: Tibialis anterior, EHL, EDL, fibularis tertius dorsiflexion plantarflexion
Plantarflexion (extension) www.foothyperbook.com Tibial n.: gastrocnemius, soleus, plantaris, tibialis posterior (Superficial fibular n.: weak fibularis longus & brevis)
* Triceps surae: medial and lateral gastrocnemius and soleus 45 Eversion: Inversion: www.foothyperbook.com Fibularis longis & brevis Tibialis anterior (deep fibular n.) (superficial fibular n.) Tibialis posterior (tibial n.) Fibularis tertius (deep fibular n.) 46 Central/Axial Lines 3rd digit in hand 2nd digit in foot www.ripthelifeiknew.com en.wikipedia.org
Dorsal interossei muscles en.wikipedia.org
47 Plantar (posterior) Compartment of Foot
1st layer: Abductor hallucis Flexor digitorum brevis Abductor digit minimi
2nd layer: Quadratus plantae Lumbricals
3rd layer: Flexor hallucis brevis Adductor hallucis Flexor digit minimi brevis www.stepbystepfootcare.com 4th layer: Plantar interossei Dorsal interossei Tibial n.: medial and lateral plantar nn. 48 Plantar (posterior) Compartment of Foot Medial plantar n. (“median n. of foot”): Abductor hallucis Flexor hallucis brevis 1st lumbrical
Flexor digitorum brevis
Lateral plantar n. (“ulnar n. of foot”): Abductor digiti minimi Flexor digiti minimi brevis
Dorsal interossei Plantar interossei Adductor hallucis Remaining lumbricals
Quadratus plantae 49 RULE #3: Proximal-to-Distal Rule
Upper roots of the lumbosacral plexus innervate proximal muscles (hip, knee)
Lower roots of the lumbosacral plexus innervate distal muscles (ankle, toes) Inversion-Eversion
Dorsiflexion-Plantarflexion 51 Deep Tendon Reflexes (DTR)
Patellar tendon reflex Achilles tendon reflex “Knee (jerk) reflex” “Ankle (jerk) reflex” (predominantly L3, L4) (S1, S2) RULE #4A
“MIXED FUNCTIONAL MODALITIES”
Some terminal branches of the lumbosacral plexus are cutaneous nerves. What of the following functional modalities is NOT present in neurons contained within cutaneous nerves? A. Somatic motor B. Somatic sensory 33% 33% 33% C. Sympathetics
Obturator Nerve (L2,3,4)
Somatic motor Sympathetics Somatic sensory 54 RULE #4 B
“MIXED FUNCTIONAL MODALITIES”
All terminal branches of the lumbosacral plexus are mixed fiber nerves:
1. Somatic motor and somatic sensory (prioprioception) to skeletal mm.
2. Then, cutaneous innervation with somatic sensory and sympathetics to skin Obturator n.
Cutaneous brs. web.uni - plovdiv.bg 56 Femoral n.
Anterior femoral cutaneous nn.
Saphenous n. web.uni - plovdiv.bg 57 Common Fibular n.
Lateral sural cutaneous n.
Superficial fibular n.
Dorsal digital nn.
Deep fibular n.
Dorsal digital nn. web.uni - plovdiv.bg 58 Tibial n.
Medial sural cutaneous n.
59 60 Cutaneous Innervation of Foot
Dorsum – Superficial fibular n. web.uni - (deep fibular between digits I & II) plovdiv.bg Plantar – Tibial n. (medial & lateral plantar nn. Medial – Saphenous n. (femoral n.) Lateral – Sural n. 61 RULE #5: Cutaneous Nerve vs. Dermatomes Distribution
L2-S3 Lower Limb Cutaneous Nerve Distribution vs. Dermatomes web.uni - plovdiv.bg
63 Dermatome Maps
Foerster (1933) - Clinical Keegan & Garrett (1948) - Development web.uni - plovdiv.bg
64 Dermatomes
Lumbar spinal cord Upper sacral cord Anterior & medial Mostly posterior aspects aspect Most of lateral aspects
65 *Lower sacral cord largely confined to perineum Autonomous Sensory Zones
L1: Over inguinal ligament
L2: Lateral side of thigh S3
L3: Lower medial side of thigh
L4: Medial malleolus, Medial side of foot (medial side of hallux)
L5: Medial side of digit II
S1: Lateral malleolus; Lateral side of foot (lateral side of little toe)
S2: Back of thigh
S3: Skin over gluteal fold 66 Radiculopathy
brain
Cervical spinal nerve spinal cord spinal
Caudal equina
Lumbar spinal nerves
67 Which dermatome is affected in a L4/L5 disk herniation?
A. L4 B. L5 33% 33% 33% C. S1
L4 L5 S1 68 Where will pain from a L4/L5 disk herniation radiate?
A. Medial aspect of leg, ankle (medial malleolus) & hallux 33% 33% 33% B. Lateral leg to dorsum of foot C. Lateral aspect of ankle (lateral malleolus) & lateral side of digit V
Lateral leg to dorsum of foot Lateral aspect of ankle (later.. Medial aspect of leg, ankle ... 69 Dermatomes
70 CORRECTED SLIDE #71 Which deep tendon reflex will a longstanding L4/L5 disk herniation weaken?
A. Knee jerk/patellar tendon 33% 33% 33% B. Ankle jerk/Achilles tendon C. Neither
Neither
Knee jerk/patellar tendon Ankle jerk/Achilles tendon 71 LOWER LIMB RADICULAR SYNDROMES
IVD Root Sensory Loss Motor Weakness L3-L4 L4 Medial ankle Patellar tendon reflex
L4-5 l5 Dorsum of foot
L5-S1 S1 Lateral ankle Achilles tendon reflex painmd.tv
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