www.thestudio1.co.za 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 Med Essential of Gross Anatomy Gross of Essential 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 Forearm Post Leg Anatomy Gross of Essential 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 25 Anterior compartment Flexors of thigh Femoral n. medical - dictionary.thefreedictionary.com Medial compartment Posterior compartment Adductors of thigh Extensors of thigh Obturator n. Tibial n. Many are biarticular muscles that also affect the knee joint 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 32 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 34 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 36 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 37 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