Organization of the Lower Limb Audrone Biknevicius, Ph.D. Dept. Biomedical Sciences, OU HCOM at Dublin Clinical Anatomy Immersion 2014
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1 Organization of the Lower Limb Audrone Biknevicius, Ph.D. Dept. Biomedical Sciences, OU HCOM at Dublin Clinical Anatomy Immersion
2 LIMB FUNCTION choco-locate.com blog.coolibar.com Mobility versus Body weight support Dexterity Locomotion Equilibrium Stability 2
3 Pectoral Girdle Pelvic Girdle Mobility versus Body weight support Dexterity Locomotion Equilibrium Stability 3
4 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) 4
5 RULE #1 (continued) Limbs are outgrowths of the ventral body wall that undergo distal growth, differentiation and rotation Week 7 5
6 Before rotation en.wikipedia.org Pollex and hallux both preaxial Anteriomedially-directed palms and soles 6
7 Post rotation embryology.med.unsw.edu.au Upper limb rotates 90 laterally: -extensor mm. on posterior surface -future elbow directed dorsally -pollex positioned laterally Lower limb rotates 90 medially: -extensor mm. on anterior surface -future knee directed ventrally -hallux positioned medially -foot fixed in prone position 7
8 Limb Muscle Compartments Upper Limb Lower Limb Arm Thigh Ant Forearm Lat Post Med Leg Hand Developmentally-ventral vs. Developmentally-dorsal Foot 8 Stern Essential of Gross Anatomy
9 RULE #2: Innervation of lower limb mm. established in early embryogenesis Spinal nerve Dorsal primary ramus Ventral primary ramus (L2-S3) Anterior (ventral) division Posterior (dorsal) division limb axis 9 Stern Essential of Gross Anatomy
10 Lumbar Plexus accessphysiotherapy.mhmedical.com Ventral division Dorsal division Obturator Nerve (L2,3,4) Lumbosacral trunk (to sacral plexus) 10
11 antranik.org No motor distribution distal to knee *pectineus usually innervated by femoral n. 11
12 Lower Limb Muscle Compartments Femoral n. Obturator n. Thigh Ant Lat Med Post Leg Lat Dorsum Med Foot Stern Essential of Gross Anatomy Plantar 12
13 Sacral Plexus accessphysiotherapy.mhmedical.com Ventral division Dorsal division Peroneal = Fibular 13
14 antranik.org 14
15 Lower Limb Muscle Compartments Femoral n. Obturator n. Thigh Ant Tibial n. Lat Med Post Leg Lat Dorsum Plantar Med Tibial n. Tibial n. Foot 15 Stern Essential of Gross Anatomy
16 antranik.org 16
17 Lateral compartment Anterior compartment dorsum of foot! 17
18 Lower Limb Muscle Compartments Femoral n. Gluteal nn. or Common fibular n. Obturator n. Thigh Ant Tibial n. Lat Med Post Deep fibular n. Leg Lat Dorsum Plantar Med Superficial fibular n. Tibial n. Tibial n. Deep fibular n. Foot 18 Stern Essential of Gross Anatomy
19 Anterior compartment Femoral n. Posterior compartment Tibial n. Medial compartment Obturator n. 19 medical-dictionary.thefreedictionary.com
20 Compartmental Organization of the Thigh Posterior Tibial n. Anterior Femoral n. Medial Obturator n. Lateral Common fibular n. (biceps femoris, short head) Superior gluteal n. (tensor fasciae latae) 20
21 Related to ischial tuberosity Biarticular mm.: Biceps femoris (long head), Semitendinosus & Semimembranosus mm. Tibial n. Posterior compartment of thigh Hip extension; knee flexion Exception: Biceps femoris (short head); lateral compartment; common fibular n.; knee flexion 21
22 Anterior Compartment of Thigh Hip flexion; knee extension Related to ilium: Hip flexion, knee extension: Rectus femoris m. (biarticular mm.) Hip flexion, knee flexion: Sartorius Hip flexion: iliopsoas mostafasalamapt.wordpress.com Knee extension rest of Quadriceps femoris Femoral n. 22
23 Medial Compartment of Thigh Hip adduction Attachment to pubis Gracilis, Adductor longus, Adductor brevis, Adductor magnus (pubofemoral part) Obturator n. 23
24 Adductor magnus Adductor part: -Attaches to pubis -Obturator n. Hamstring part: -Attaches to ischial tuberosity -Tibial n. 24
25 Pectineus the exception Pectineus m. mostly innervated by femoral n. (~25% by obturator n.) Attaches to superior ramus of pubis All other mm. attaching to pubis are innervated by obturator n. danslararen.blogspot.com 25
26 Relative positions of muscles producing movements of hip joint Gluteal group (externally) Iliopsoas (internally) Hamstring & lat rotator grp Adductor grp 26 Adapted from Moore et al., Essential Clinical Anatomy, Fig 5.46
27 Gluteal group (externally) Iliopsoas (internally) Hip Extensors Tibial n.: biceps femoris (long head), semitendinosis, semimembranosus, adductor magnus (posterior) Inferior gluteal n.: Gluteus maximus Hip Flexors Femoral n.: iliopsoas, sartorius, rectus femoris, pectineus Superior gluteal n.: tensor fasciae latae Obturator n.: adductor longus, brevis & magnus (anterior), gracilis Hamstring & lat rotator grp Adductor grp 27 Adapted from Moore et al., Essential Clinical Anatomy, Fig 5.46
28 Gluteal group (externally) Iliopsoas (internally) Abductors Superior gluteal n.: gluteus medius & minimum, tensor fasciae latae Hamstring & lat rotator grp Adductor grp Adductors Obturator n.: adductor longus, brevis & magnus (anterior), gracilis Tibial n.: adductor magnus (posterior) Femoral n.: Pectineus 28 Adapted from Moore et al., Essential Clinical Anatomy, Fig 5.46
29 Gluteal group (externally) Iliopsoas (internally) Medial Rotators Superior gluteal n.: gluteus medius & minimum, tensor fasciae latae Hamstring & lat rotator grp Adductor grp 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 29 Adapted from Moore et al., Essential Clinical Anatomy, Fig 5.46
30 Compartmental Organization of the Leg Anterior Deep fibular n. Lateral Superficial fibular n. Posterior Tibial n. (no medial compartment; tibial shaft) 30
31 Anterior Compartment of Leg Dorsiflexor (extensor) Compartment Also toe extension: Extensor hallicus longus Extensor digitorum longus Also foot inversion: Tibialis anterior anatomyproartifex.blogspot.com Also foot eversion: Fibularis (peroneus) tertius Deep fibular n. 31
32 Anterior Compartment of Leg Evertor Compartment Fibularis (peroneus) longus Fibularis (peroneus) brevis (also plantarflexors) Superficial fibular n. blog.corewalking.com 32
33 Posterior Compartment of Leg Plantarflexor Compartment web.duke.edu Superficial mm.: Gastrocnemius (also knee flexor) Soleus Plantaris Tibial n. Deep mm.: Popliteus (unlocks knee) Flexor digitorum longus Flexor hallucis longus Tibialis posterior (also inversion) 33
34 Dorsiflexion (flexion) Deep fibular n.: Tibialis anterior, EHL, EDL, fibularis tertius dorsiflexion plantarflexion Plantarflexion (extension) Tibial n.: gastrocnemius, soleus, plantaris, tibialis posterior (Superficial fibular n.: weak fibularis longus & brevis) * Triceps surae: medial and lateral gastrocnemius and soleus 34
35 Eversion: Fibularis longis & brevis (superficial fibular n.) Fibularis tertius (deep fibular n.) Inversion: Tibialis anterior (deep fibular n.) Tibialis posterior (tibial n.) 35
36 Plantar (posterior) Compartment of Foot Abductor hallucis Flexor digitorum brevis Abductor digit minimi Quadratus plantae Lumbricals Flexor hallucis brevis Adductor halluces Flexor digit minimi brevis Tibial n.: medial and lateral plantar nn. Plantar interossei Dorsal interossei 36
37 Central/Axial Lines en.wikipedia.org Third digit in hand Second digit in foot 37
38 Dorsal interossei muscles en.wikipedia.org 38
39 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)
40 Dorsiflexion-Plantarflexion Inversion-Eversion S2,3 Toe Abduction-Adduction 40
41 RULE #4 MIXED FUNCTIONAL MODALITIES Most 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
42 Obturator n. Cutaneous brs. web.uni-plovdiv.bg 42
43 Femoral n. Anterior femoral cutaneous nn. Saphenous n. web.uni-plovdiv.bg 43
44 Common Fibular n. Lateral sural cutaneous n. Superficial fibular n. Dorsal digital nn. web.uni-plovdiv.bg 44
45 Tibial n. Medial sural cutaneous n. 45
46 Tibial n. Medial calcaneal br. Medial and lateral plantar nn. 46
47 47
48 Lumbar Plexus purely cutaneous nn. accessphysiotherapy.mhmedical.com Ventral division Dorsal division Obturator Nerve (L2,3,4) Lumbosacral trunk (to sacral plexus) 48
49 Femoral br. genitofemoral n. Ilioinguinal n. 49 quizlet.com
50 RULE #5: Cutaneous Nerve vs. Dermatomes Distribution L2-S3 Lower Limb
51 Cutaneous Nerve Distribution vs. Dermatomes web.uni-plovdiv.bg 51
52 Dermatomes Lumbar spinal cord - Anterior and medial aspects Upper sacral cord - Posterior aspect *Lower sacral cord largely confined to perineum 52
53 Dermatomes S1 L4 L4: Medial side of ankle and foot L5: Middle toe and center of dorum and sole of foot S1: Lateral side of ankle and foot L5 53
54 Cutaneous Innervation of Foot Dorsum Superficial fibular n. (deep fibular between digits I & II) Plantar Tibial n. Medial Femoral n. (saphenous n.) 54 web.uni-plovdiv.bg
55 Deep Tendon Reflexes (DTR) Knee (jerk) reflex Patellar tendon reflex (L2, L3, L4) Ankle (jerk) reflex Achilles tendon reflex (S1, S2)
56 spinal cord Radiculopathy brain Cervical spinal nerve Caudal equina Lumbar spinal nerves 56
57 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 57
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