DR FATIMA ZAHARA

MBBS,MRCEM PRIMARY,
MD(AESTHETIC MED AND COSMETOLOGY)
 LOWER LIMB

Lower limb divided into:

• Gluteal region
• Thigh
• Leg
• Foot
 GLUTEAL REGION
Gluteal Muscles
Gluteus Maximus
The gluteus maximus is the main extensor of the thigh at the hip joint and also acts to laterally rotate and
abduct the thigh. Through its insertion into the iliotibial tract, it also stabilises the knee and hip joints. The
gluteus maximus is innervated by the inferior gluteal nerve.

Gluteus Medius and Gluteus Minimus

The gluteus medius and gluteus minimus act to abduct and medially rotate the thigh at the hip joint, and also
act to secure the pelvis, reducing pelvic drop on the opposite swing side during walking. They are both
innervated by the superior gluteal nerve.

Piriformis
The piriformis acts to abduct and laterally rotate the thigh at the hip joint. It is innervated by the nerve to the
piriformis, originating from the sacral plexus (S1, S2). The obturator internus, gemelli and quadratus femoris
muscles act as synergistic femoral lateral rotators and hip stabilisers.
Superior Gluteal Nerve Injury

Damage to the superior gluteal nerve may occur in association with pelvic
fractures, with space-occupying lesions within the pelvis extending into the
greater sciatic foramen, and following hip surgery. Trendelenburg's sign is seen in
people with weak/paralysed abductor muscles of the hip, namely the gluteus
medius and gluteus minimus muscles innervated by the superior gluteal nerve.
The Trendelenburg sign is said to be positive if, when standing on one leg (the
'stance leg'), the pelvis drops on the side opposite to the stance leg.
The muscle weakness is present on the side of the stance leg.
Gluteal Quadrants

The gluteal region can be divided into quadrants by 2 lines: one line
descending vertically from the highest point of the iliac crest, the other line
passing horizontally through the first line midway between the highest point
of the iliac crest and the ischial tuberosity. The sciatic nerve passes through
the lower inner quadrant.
Intramuscular injections in the buttocks should
always be given in the upper outer quadrant of the gluteal region to avoid
damage to the sciatic nerve.
 THIGH
Anterior Thigh Muscles
The sartorius, iliacus, psoas major and pectineus (in addition to the rectus femoris of the
quadriceps femoris muscle) are all flexors of the thigh at the hip joint.
Sartorius
The sartorius is innervated by the femoral nerve. It acts to flex the thigh at the hip joint and flex the leg at the knee joint. It also abducts the
thigh and rotates it laterally, as when resting the foot on the opposite knee when sitting.

Iliopsoas
The iliacus and psoas major muscles originate as separate muscles but insert by a common tendon onto the femur and together are referred
to as the iliopsoas muscle, which is a powerful flexor of the thigh at the hip joint and also contributes to lateral rotation of the thigh at the
hip joint. The iliacus is innervated by the femoral nerve. The psoas major is innervated by the anterior rami of spinal nerves L1 - L3.

Pectineus
The pectineus is innervated by the femoral nerve. It acts to adduct and flex the thigh at the hip joint.
Quadriceps Femoris Muscle
The quadriceps femoris is made up of four individual muscles; the rectus femoris, the vastus
medialis, the vastus intermedius (deep to the rectus femoris) and the vastus lateralis which all
insert onto the patella by the common quadriceps femoris tendon. Because the vastus muscles
insert into the margins of the patella as well as into the quadriceps femoris tendon, they stabilise
the position of the patella during knee joint movement.
Function
The quadriceps femoris muscles are the main extensors of the leg at the knee joint. The
rectus femoris crosses both the knee and the hip joint (in contrast to the vastus muscles
which only cross the knee joint), and therefore also assists in flexion of the thigh at the hip
joint.

Innervation
The quadriceps femoris muscles are innervated by the femoral nerve.
 VEINS OF LOWER LIMB
Saphenous Veins
The great and small saphenous veins originate from the medial and lateral sides respectively of the
dorsal venous arch in the foot.

Great Saphenous Vein

The great saphenous vein passes anterior to the medial malleolus, travels up the medial side of the leg, knee and
thigh to pass through the saphenous opening in the deep fascia covering the femoral triangle and join with the
femoral vein just below the inguinal ligament.

Small Saphenous Vein

The small saphenous vein passes posterior to the lateral malleolus and up the back of the leg to pierce the deep
fascia and join the popliteal vein in the popliteal fossa posterior to the knee
 Deep and Superficial Inguinal Lymph Nodes

The inguinal nodes are found in the upper aspect of the femoral triangle.

Superficial Inguinal Nodes

The superficial inguinal lymph nodes (about 10 in number) are located in the superficial fascia,
forming a line below the inguinal ligament, and medially extending inferiorly along the terminal
part of the great saphenous vein. They receive lymph from the gluteal region, lower abdominal
wall, perineum and superficial regions of the lower limb.

Deep Inguinal Nodes

The deep inguinal lymph nodes (about 1 - 3 in number) lie medial to the femoral vein within the
femoral canal. They receive lymph from deep lymphatics associated with the femoral vessels and
from the glans penis or clitoris in the perineum. The inguinal lymph nodes drain to the external
iliac lymph nodes associated with the external iliac artery in the abdomen.
Medial Thigh Muscles
There are five muscles in the medial compartment of the thigh (adductor longus, adductor brevis, adductor
magnus, obturator externus, gracilis), which collectively adduct the thigh at the hip joint
Innervation
These muscles are all innervated by the obturator nerve (except for the hamstrings portion of
the adductor magnus, innervated by the tibial division of the sciatic nerve).

Function
The adductor longus, brevis, and magnus are the prime adductors of the thigh at the hip joint
and also assist in medial rotation. The obturator externus muscle acts to laterally rotate the thigh
at the
hip joint.
The gracilis adducts the thigh at the hip joint and flexes the leg at the knee joint.
Testing of the medial thigh muscles can be performed with the patient lying supine and the
knee straight. The patient is asked to adduct the thigh against resistance and the strength
assessed (if the adductors are normal the proximal ends of the gracilis and adductor longus
can easily be palpated)
Obturator Nerve
The obturator nerve arises from the lumbar plexus, formed from the anterior rami of L2 - L4.
Anatomical Course
The obturator nerve descends along the posterior abdominal wall, passes through the pelvic cavity and enters the
medial thigh by passing through the obturator canal.
Function
The obturator nerve innervates all of the muscles of the medial compartment of the thigh (except for the hamstring part of
the adductor magnus innervated by the tibial portion of the sciatic nerve). It also gives off a cutaneous branch that supplies
skin on the medial side of the upper thigh.
Function
The hamstrings act together to flex the leg at the knee joint and extend the thigh at the hip joint. The biceps femoris also
acts to laterally rotate the thigh at the hip joint and the leg at the knee joint. The semimembranosus and semitendinosus
also act together to medially rotate the thigh at the hip joint and the leg at the knee joint.

Innervation
The hamstring muscles are all innervated by the tibial division of the sciatic nerve (L5 - S2), except for the short head of
the biceps femoris innervated by the common fibular division.

Assessment
To test the hamstrings the patient flexes their leg against resistance. Normally these muscles, especially their tendons on
each side of the popliteal fossa, are prominent as they bend the knee.
Hamstring Muscles
The hamstrings are composed of three individual muscles; the biceps femoris, the
semitendinosus and the semimembranosus.
Sciatic Nerve
The sciatic nerve is derived from the lumbosacral plexus and receives fibres from L4 - S3.
Anatomical Course
The sciatic nerve leaves the pelvis and enters the gluteal region via the greater sciatic foramen inferior to the piriformis
muscle before descending through the gluteal region and entering the posterior thigh. In the posterior compartment of the
thigh, the sciatic nerve lies on the adductor magnus muscle and is crossed by the long head of the biceps femoris muscle.
Within the posterior thigh, the sciatic nerve gives rise to branches to the hamstring muscles and adductor magus. The sciatic
nerve terminates at the apex of the popliteal fossa by dividing into the tibial (anterior divisions of L4 – S3) and the common
fibular (posterior divisions of L4 – S2) nerves.
Function
Motor Supply:
The sciatic nerve innervates all of the muscles in the posterior compartment of the thigh (biceps femoris, semimembranosus
and semitendinosus) and the hamstring portion of the adductormagnus. Through its terminal branches, it indirectly
innervates all of the muscles in the leg and the foot
Sensory Supply:
The sciatic nerve has no direct sensory function but through its terminal branches, it indirectly supplies the skin of the
lateral leg and foot, the heel and both the dorsum and sole of the foot.
Femoral Triangle
The femoral triangle is a wedge-shaped depression formed by muscles in the upper thigh at the junction between
the anterior abdominal wall and the lower limb
Borders
The femoral triangle is bordered superiorly by the inguinal ligament, laterally by the medial border of the sartorius muscle
and medially by the medial border of the adductor longus muscle. The roof is formed by the fascia lata and the floor is
formed by the pectineus, iliopsoas and adductor longus muscles.
Contents
The contents of the femoral triangle include (from lateral to medial):
• The femoral nerve
• The femoral sheath containing:
• The femoral artery
• The femoral vein
• The femoral canal containing:
• Lymphatic vessels and deep inguinal nodes
 Femoral Canal and Femoral Ring
Femoral canal
The femoral canal lies between the femoral vein and the medial edge of the femoral sheath. The
femoral canal contains loose connective tissue, lymphatic vessels, deep inguinal lymph nodes
and empty space. The femoral canal allows the femoral vein to expand, for example, when
venous return from the leg is increased, or when increased intra-abdominal pressure causes a
temporary stasis.
Femoral ring
 Femoral ring
The femoral ring is formed by the proximal abdominal opening of the femoral canal, and is important
clinically, as it is a common site of hernia. It is bordered anteriorly by the inguinal ligament, posteriorly by the
pectineal ligament,medially by the lacunar ligament and laterally by the femoral vein.

Femoral Sheath
The femoral sheath originates as a prolongation of extraperitoneal fascia and encloses the femoral artery,
femoral vein and femoral canal. The femoral nerve does NOT lie within the sheath, but instead lies lateral
to it. The femoral sheath terminates inferiorly by blending with the adventitia of the femoral vessels
approximately 4 cm inferior of the inguinal ligament.
 Femoral Artery
The major artery supplying the lower limb is the femoral artery.
Anatomical Course
The femoral artery is the continuation of the external iliac artery, beginning as the vessel passes under the inguinal ligament to enter the
femoral triangle in the anterior thigh. The femoral artery can be palpated in the femoral triangle as it passes over the femoral head, just
inferior to the inguinal ligament, midway between the anterior superior iliac spine and the pubic symphysis (at the mid-inguinal point). The
femoral vein lies immediately medial to this pulsation, which is an important landmark for central venous line insertion. Medial to the
femoral vein is the femoral canal which contains lymphatics and lies immediately lateral to the pubic tubercle. The femoral nerve lies lateral
to the femoral artery. The femoral artery gives rise to the deep profunda femoris artery in the femoral triangle which is a major source of
blood supply to the medial and posterior compartments of the thigh and the proximal femur. After exiting the femoral triangle, the
femoral artery continues down the anterior surface of the thigh via the adductor canal. During its descent it supplies the anterior thigh,
giving rise to numerous superficial cutaneous branches.
The femoral artery becomes the popliteal artery after entering the posterior compartment of the thigh through the adductor hiatus just
proximal to the knee
Femoral Nerve
The femoral nerve arises from the lumbar plexus, receiving fibres from the anterior rami
of L2 - L4.
Anatomical course
The femoral nerve descends from the lumbar plexus in the posterior
abdomen through the substance of the psoas major muscle, emerging from
the lower lateral border of the psoas major. Continuing its descent, the
femoral nerve lies between the lateral border of the psoas major and the
anterior surface of the iliacus muscle. It is deep to the iliacus fascia and
lateral to the femoral artery as it passes posterior to the mid-inguinal point
to enter the femoral triangle in the anterior compartment of the thigh,
before dividing into an anterior and posterior division
Branches
Function
Cutaneous innervation of lower limb
Thankyou