Block II Review Winter 2023

Abdomen, Pelvis, & Lower Limb

Dr Douglas A Cotanche
[email protected]
Gross & Developmental Anatomy
Final Exam

Date: Monday April 17th

Time: 8AM- 9:15AM

 Final Exam Question Breakdown

Block 1 Block 2

Spinal column, spinal nerves- 3 Abdomen- 11

Upper Limb- 7 Pelvis-Perineum- 3

Thorax- 7 Lower Limb- 6

Embryology- 3

Block 3

Head & Neck- 10

 Final Exam Grade
Final NBME Anatomy Exam- 100 points

Final Class Grade

Block 1- your score out of possible 100

Block 2- your score out of possible 100
Block 3- your score out of possible 100
Final- your score out of possible 100

Total Grade- Sum of the 4 scores out of possible 400/4

A= 90-100+
B= 80-89
C= 70- 79
F= 69 or below
Lymphatics And Superficial Veins
Of Anterolateral Abdominal Wall
Abdominal Oblique Muscles
 Rectus Sheath

Above arcuate line

Below arcuate line

In lower 1/4th all the 3 aponeuroses move anterior to the rectus muscle. From this
point inferiorly, the rectus abdominis muscle is in direct contact with the
transversalis fascia.
Marking this point of transition is an arch of fibers known as arcuate line;
Deep Inguinal Ring And The
Transversalis Fascia
 Inguinal Canal and Spermatic Cord

Contents:
• Ductus Deferens
• Testicular Artery
• Artery of the ductus
deferens
• Cremasteric muscle
• Pampiniform Plexus of veins
• Sympathetic nerve fibers
• Genital Branch of the
Genitofemoral Nerve
• Lymphatics
 Indirect Inguinal Hernia

• Lateral to Inferior
Epigastric Vessels

• Follows path of
Spermatic Cord

• Inside all 3 fascial

coverings of the
Spermatic Cord

• Goes through both the

Deep and Superficial
Inguinal Rings

• Commonly enters the

scrotum
 Direct Inguinal Hernia

• Medial to Inferior
Epigastric Vessels

• Outside of cremasteric
fascial covering of the
Spermatic Cord

• Goes through Superficial

Inguinal Ring only

• Rarely enters the

scrotum
 Hesselbach’s Triangle

Deep inguinal ring

Hesselbach’s (indirect inguinal
triangle hernia)
(direct
inguinal
hernia)

inferior
direct inguinal epigastri
hernia – medial to c artery
inferior epigastric Deep
artery inguinal
ring
Endoscopic
view (from
inside)
Characteristics of Inguinal Hernias
Abdominal Cavity
Autonomic Innervation of the GI System
 Innervation Of Abdominal Viscera
• Sympathetic supply
Foregut (T5-T9 via greater Sympathetic NS Parasympathetic NS
splanchnic n) (Esophagus,
Stomach, Duodenum (1st and 2nd
parts), Liver, Gallbladder , Superior
portion of pancreas, Spleen)
Midgut (via lesser (T10, 11)
& least (T12) splanchnic n)
(Duodenum (3rd and 4th parts),
Jejunum, Ileum, Cecum, Appendix,
Ascending colon, Hepatic flexure of
colon, Transverse colon (proximal
two-thirds) Lesser to aorticorenal g
Hindgut (L1-L2 via lumbar
splanchnic n) (1/3 of transverse
colon + splenic flexure, descending
colon, sigmoid colon, rectum,
upper part of the anal canal)
• Parasympathetic supply
–Vagus n(anterior and posterior trunks)
to level of splenic flexure (Superior
mesenteric artery supply replaced by
inferior mesenteric a)
– Pelvic splanchnic nn(S2-4) supplies
descending & sigmoid colon,
rectum & pelvic organs
 Sympathetic Nerves- Splanchnics
• The preganglionic sympathetic nerves to the abdomen leave the
ventral ramus of spinal nerves T5-L2, enter the sympathetic trunk
ganglia, but DO NOT SYNAPSE there. They pass out of the
sympathetic ganglia as the splanchnic nerves and travel caudally down
the bodies of the thoracic vertebrae to pass through the diaphragm and
enter the abdomen

Splanchnic nerve
 Sympathetic Nerves- Splanchnics

The Splanchnic Nerves:

• Greater Splanchnic (T5-T9) to celiac ganglion
• Lesser Splanchnic (T10-T11) to superior mesenteric
ganglion
• Least Splanchnic (T12) to aorticorenal ganglion
• Lumbar Splanchnics (L1-L2) to inferior mesenteric ganglia

All these splanchnic nerves are preganglionic sympathetic

fibers!
Pre-Aortic Ganglia
 Postganglionic Sympathetics

• The postganglionic sympathetic nerve fibers leave the pre-aortic

ganglia and travel along the abdominal branches of the arteries to reach
their targets. Thus, they travel out along the various branches of the:

• celiac trunk (foregut)

• superior mesenteric artery (midgut)
• inferior mesenteric artery (hindgut)

to reach their destination organs.

The Parasympathetic Nervous System
“Rest & Digest”
Cranio-Sacral in origin from the Brain & Spinal Cord
The Cranial Parasympathetic neurons have their cell bodies in specific
cranial nerve nuclei in the brainstem. They are associated with 4 Cranial
Nerves:
CNIII, CNVII, CNIX, and CNX.
The sacral parasympathetics arise from S2, S3, & S4 spinal nerves.
 The Vagus Nerve GVE Innervation
The Vagus nerve (CNX) provides preganglionic parasympathetic
innervation to the organs and glands in the neck, thorax, and
abdomen down through the splenic flexure of the large intestine.
 The Pelvic Splanchnic GVE Innervation
The descending colon, sigmoid colon, rectum and anal canal and
pelvic organs receive their preganglionic parasympathetic
innervation from the pelvic splanchnic nerves. The cell bodies of
these fibers are in the intermedio-lateral horn of the S2, S3, and S4
segments of the spinal cord. Their preganglionic fibers exit through
the ventral root of the spinal cord and project laterally into the pelvic
plexus where they join the preganglionic sympathetic fibers from the
sacral sympathetic ganglia.

X According to several
sources the kidney
has NO
parasympathetic
innervation!
 The Vagus Nerve- CNX
The Vagus Nerve (cranial nerve X) provides the parasympathetic
innervation to most of the GI tract. It provides preganglionic
parasympathetic fibers to the:
• Esophagus
• Stomach
• Liver
• Pancreas
• Spleen
• Duodenum
• Jejunum
• Ileum
• Cecum
• Ascending colon
• Transverse colon (first 2/3 of it)
The postganglionic parasympathetic neurons are in the walls of these
organs
 The Vagus Nerve- CNX

• The preganglionic parasympathetic nerve fibers of the Vagus nerve

pass through the pre-aortic ganglia but DO NOT SYNAPSE there! They
travel along the abdominal branches of the arteries to reach their
targets along with the postganglionic sympathetic fibers. Thus, they
travel out along the branches of the:

• celiac trunk (foregut)

• superior mesenteric artery (midgut)

to reach their destination organs and glands.

 The Pelvic Splanchnic Nerves
The Pelvic Splanchnic nerves (S2, S3, & S4) provide the
parasympathetic innervation to the hindgut portion of the GI tract
They provides preganglionic parasympathetic fibers to the organs of the
hindgut:
• Transverse colon (last 1/3 of it)
• Descending colon
• Sigmoid colon
• Rectum
• Pelvic organs

The preganglionic parasympathetic fibers in the pelvic splanchnic

nerves DO NOT travel along blood vessels to reach the hindgut organs.
They travel in the mesenteries independent of the blood vessels.

The postganglionic parasympathetic neurons are in the walls of these

organs
 Visceral Pain Sensation (GVA)
Visceral pain sensation in GVA fibers tend to follow back along the
pathway of the sympathetic postganglionic and then preganglionic fibers
to reach the CNS.

Sensations monitoring normal visceral functions pass back to the CNS

along the parasympathetic motor fibers (GVE; vagus or pelvic
splanchnics).

The cell bodies of these GVA fibers are in the Dorsal Root Ganglion!!
 Hirschsprung’s Disease

In children with Hirschsprung's disease, nerves fail to form in all or part of

the large intestine (colon). Waste from digestion cannot pass through the
part of the colon lacking nerve tissue. The normal colon swells with blocked
stool. Neural crest cells fail to migrate to the colon!
 Derivatives of the Foregut
Pharynx and its derivatives,
Lower respiratory tract,
Esophagus, Stomach
Foregut
Duodenum up to the major duodenal
papilla
Liver, Biliary apparatus and Pancreas

Midgut Derivatives of the Midgut

Duodenum distal to the major
duodenal papilla,
Jejunum & Ileum; Cecum & Appendix,
Ascending colon & right 2/3 of
Hindgut
transverse colon

Derivatives of the Hindgut

Left 1/3 of Transverse colon,
Arteries
Descending colon, Sigmoid colon &
• Foregut – coeliac trunk (coeliac
rectum
artery)
• Midgut – superior mesenteric artery Anal canal up to the pectinate line
• Hindgut – Inferior mesenteric artery Urinary bladder & most of Urethra
 Peritoneal Status of GI Organs
• Retroperitoneal viscera (never in peritoneal cavity)- esophagus to
diaphragm and rectum
• Intraperitoneal viscera-(always projecting into peritoneal cavity)
abdominal esophagus, some of gall bladder, stomach, some of
duodenum, jejunum, ileum, cecum, vermiform appendix, transverse
colon, sigmoid colon
Small Intestine
Duodenum,
Jejunum and Ilium

32
 Celiac Trunk Arterial Supply

Hepatic Portal Venous Drainage

Celiac trunk:
•Common hepatic
•gastroduodenal
• right gastric
• proper hepatic
•Left gastric
• short esophageal
• connects with right gastric
•Splenic
• short gastric
• pancreatic
• left gastro-omental
Transverse section demonstrating the epiploic foramen and the
horizontal extent of the omental bursa (lesser sac)
 Pringle Maneuver

Compression of free edge of lesser omentum known as

‘Pringle’ maneuver, can control bleeding from liver.

Hepatic
artery Stomach
Bile
duct
Portal Lesse
r
vein sac
Epiploic
foramen
IVC
Splenic artery
Pringle Ring, not to be confused with
Pringle Maneuver!
 Hepatobiliary Triangle

Borders:
• cystic duct,
• Common hepatic duct
• Inferior surface of the liver

Cystic artery runs from right hepatic

artery to gallbladder
Cystic lymph node often lies
superficial to cystic artery and
acts a landmark to locate this artery.

Cholecystectomy: Cystic artery

should be divided close to the
gallbladder to avoid injury to right
hepatic artery.

Lymphatic drainage of the gallbladder goes to cystic lymph nodes located near
the neck of the gallbladder and to hepatic lymph node.
 Arterial Supply to Duodenum

Duodenal papilla

Anterior and posterior superior pancreaticoduodenal arteries- A posterior duodenal

from gastroduodenal ulcer can rupture the
Anterior and posterior inferior pancreaticoduodenal arteries- gastroduodenal artery!
from superior mesenteric
Annular pancreas – probably due to bifid ventral
pancreatic bud. Ring of pancreas encircles the Bile duct
second part of duodenum & causes obstruction
Stomach Duodenum

Bile
duct
Site of duodenal
obstruction
Anular
pancreas
Bifid ventral
pancreatic bud

Dorsal pancreatic bud

Arterial Blood Supply To Small Intestines
Marginal a.

40
 Jejunal & Ileal Arcades
Jejunum
• proximal 2/5th
• larger in diameter
• Thicker wall than the ileum.
• Less prominent arterial arcades
• Long vasa recta (straight arteries)
• Less mesenteric fat

Ileum
• distal 3/5th of small intestine
• ileum has thinner walls,
• more arterial arcades
• shorter vasa recta
• more mesenteric fat

Ileum opens into cecum; ileocecal fold

surrounds the opening.
Ileocecal opening is narrow – large
gall stone can get obstructed here
 Large Intestine - Colon
Large intestine – a.k.a. the colon
• begins at the caecum
• vermiform appendix is attached to the caecum
• Ascending (retroperitoneal ) - Transverse colon (intraperitoneal) - Descending (retroperitoneal).
• Flexures: hepatic (right) flexure – splenic (left) flexure
• Key features of the large intestine:
• Haustra - Taenia coli - epiploic appendices Left
Left(splenic)
(splenic)colic
colicflexure
flexure Some Clinical Correlates: Intestines
Transverse Paracolic Gutters: are pathways for the flow of ascitic fluid and the spread of
Right
Right(hepatic)
(hepatic)colic
colicflexure
flexure intraperitoneal infections. Pus in the abdomen can be transferred along the
colon The picture can't be displayed.
paracolic gutters into the pelvis

Appendicitis: Is a condition in which there is acute inflammation of the appendix.

When secretions accumulate in the appendix, it begins to swell, stretching the
epiploic appendices: visceral peritoneum of the organ, causing initial vague pain in the periumbilical
Small fatty, omentum- region followed by intense right lower quadrant pain when the parietal peritoneum is
Ascending colon like projections eventually irritated

Taenia coli: Ileum Haustra:

thickened bands of sacculations in the
smooth muscle wall of the colon

Cecum
Note: The paracolic gutters
are spaces (grooves) between
Vermiform appendix Sigmoid colon
the lateral aspect of the
ascending and descsening colon Rectum
and the posterolateral abdominal
wall. Anal Canal
 Blood vessels and lymphatics of
ascending and descending colon
comes from medial side. Mobilization
can be done by cutting peritoneum
from lateral side.

Superior mesenteric artery –

caecum, appendix, ascending colon
and right 2/3rd of transverse colon.
Inferior mesenteric artery – left 1/3rd
of transverse colon, descending
colon, sigmoid colon, rectum and
upper ½ of anal canal.
Superior mesenteric artery branches
are jejunal, ileal, ileocolic, right colic
and middle colic.
Inferior mesenteric artery branches
are left colic, sigmoidal arteries,
superior rectal artery.
Left colic artery (marginal branch) anatomizes with middle colic
artery to form the marginal artery – if there is a block in any of the
two arteries blood supply can passes through anastomosis.
Mesenteric Ischemia
 Appendicitis
Initial pain is dull referred pain to the umbilical region
As inflammation spreads to parietal peritoneum, it gets
intensely painful and localized to McBurney’s Point
Intestinal Venous System
Portal Vein
• Right and left gastric veins
• Cystic vein
• Paraumbilical veins – connected to
veins on anterior abdominal wall

Splenic vein
• Short gastric veins – fundus and left
part of greater curvature of stomach
• Left gastro-omental vein
• Pancreatic veins
• Inferior mesenteric vein (starts as
superior rectal vein, joined by left colic
and sigmoidal veins)

Superior mesenteric vein

• Right gastro-omental vein
• Anterior and posterior inferior
pancreaticoduodenal veins
 Portal Hypertension & Portocaval Shunts

Portal hypertension is a common clinical condition, and for this reason portal-systemic anastomoses should be
remembered. If there is an obstruction to flow through the portal system (portal hypertension), blood can flow
in a retrograde direction and pass through anastomoses to reach the caval system. Sites for these
Middle rectal vein
anastomoses include:
l (1) esophageal veins
l (2) paraumbilical veins
l (3) rectal veins
Portal Vein to IVC or Renal Vein Shunt
 Cholelithiasis (gallstones)

The distal end of the hepato-pancreatic ampulla (Common bile duct ) is the narrowest part of
the biliary passages and is the MOST COMMON SITE for impaction of gallstones.
l As result of common hepatic (1), bile duct (2), or duodenal papilla (3) obstruction patient
will have yellow (icteric) sclera and jaundice.
l Gallstones may also lodge in the cystic duct. A stone lodged in the cystic duct (4) causes
biliary colic (intense, spasmodic pain in the gallbladder) but doesn't produce jaundice.
Spleen- Splenectomy
 Development of the Spleen

Pancreas
Aorta kidney Dorsal
Spleen
mesogastrium

Spleen

Stomach

Liver
Stomach
Greater
omentum

The spleen is derived from mesenchymal cells between the layers of

dorsal mesogastrium (5th week). spleen is lobulated in the fetus
 Pain referred to T10 dermatome
Meckel’s Diverticulum
Remnant of the vitelline duct (yolk stalk) of
the embryo. Most common congenital
anomaly of gut.
Rule of 2’s:
– Occurs about 2’ (60cm) proximal to the
ileocecal junction.
– Occurs in ~2% of the population.
– 2% are symptomatic
– 2 inches long; 2 cm wide
– Contains 2 kinds of secretory tissue: gastric
& pancreatic
– Mimics signs of 2 problems: appendicitis &
peptic ulcer
– M>F (2:1)
– Children> adults; <2 years old
– Can produce periumbilical pain and internal
bleeding

Treatment:
Surgical resection of both
Meckel’s diverticulum and
adjacent bowel segment.
 Hemorrhoids

Hemorrhoids are masses that typically protrude from ANUS during defecation.
External hemorrhoids are dilated tributaries of the INFERIOR rectal veins [1] (IRV) BELOW
the pectinate line and are PAINFUL because the mucosa is supplied by somatic afferent fibers of
the inferior rectal nerves (from pudendal).
Internal hemorrhoids are dilated tributaries of the SUPERIOR rectal veins (SRV)
ABOVE the pectinate line and are NOT PAINFUL because the mucosa is supplied by visceral
afferent fibers. It frequently develops in chronic alcoholics because of liver cirrhosis and portal
hypertension syndrome.
The Diaphragm represents the upper limit to the abdominopelvic cavity. Various structures travel through
the diaphragm to gain access to the abdomen or thorax. These sites represent potential weaknesses in the
diaphragm and therefore sites foe herniation.

Structures passing through the diaphragm Structures passing through the diaphragm
Large openings Small openings
Aortic hiatus Crura-greater and lesser splanchnic nerves
• Aorta + thoracic duct + Hemi-azygos vein at T12 Left crus- hemiazygos vein
Esophageal hiatus Medial arcuate ligament -sympathetic trunks
• esophagus + vagal trunks + esophageal branches lt. gastric a/v
at T10
Caval opening
• inferior vena cava + right phrenicnerve at T8
 Apertures Through The Diaphragm

• I ate (8)
• 10 Eggs
• At 12 noon

• I ate= IVC at T8

• 10 Eggs= Esophagus at T10

• At 12= Abdominal aorta at T12

 Hiatal Hernias

Applied:

– HIATAL HERNIA- can be repaired ;

– CONGENIAL DIAPHRAGMATIC HERNIA- a

medical emergency, baby will die if not
fixed.
Ascent of the Metanephric Kidney
Descent of the Gonads
 Horseshoe Kidney
• Clinical consideration
• Horseshoe kidney
occurs when the
inferior poles of the
kidneys fuse during fetal
development.

• The horseshoe kidney

becomes trapped
behind the inferior
mesenteric arteryas the
horseshoe kidney
attempts to ascend
toward the normal
adult location.
 Umbilical Ligaments/ Folds

• Median umbilical ligament – (single in midline) runs from the apex of

the bladder to the umbilicus, remnant of urachus.
• Medial umbilical ligaments – (two) remnants of the obliterated umbilical
arteries.
• Lateral umbilical folds – (two) overlying the inferior epigastric vessels.

MediaN
MediaL
Lateral
 The Pelvis

Lumbosacral trunk (L4-L5)

Piriformis m.

Pudendal n.
and internal
pudendal a.

Thanks to Tom Gest

Innervation Of Pelvic Viscera
 Pelvic Nerves
Sympathetic nerves
Parasympathetic nerves

Superior hypogastric
plexus

Left & right

hypogastric nerves
Pelvic splanchnics
(S2, S3, S4)
Inferior hypogastric
plexus

Both Sympathetic and

Parasympathetic
nerves
 Pelvic Autonomic Plexus
Sympathetic nerves
Parasympathetic nerves

Thanks to Tom Gest

 Prostate or Rectal Cancer Surgery
Side Effects

The most common side effects of a radical prostatectomy are

leaking urine, known as urinary incontinence, and erectile
dysfunction.

Surgeons will try to save the nerves that control erections, but this is
not always possible. Even if the surgeon manages to save the
nerves, many men still have difficulty achieving and maintaining
erections after a prostatectomy.

All types of surgical approaches have similar side effect incidence

for both urinary incontinence and erectile dysfunction.

But laparoscopic or robotic prostatectomy are much less invasive

and lead to a quicker recovery.
Male Urethra Urinary
Ureter

bladder

Ampulla

Seminal
vesicle

Prostatic urethra Prostate

Ejaculatory
duct
gland
Bulbourethral
Membranous urethra Prostatic
urethra gland

Bulb
Membranous
urethra Crus
Spongy (penile) Ductus deferens Corpus
spongiosum
urethra
Corpus
cavernosum

Efferent
ductules Testis

Epididymis

Spongy (penile)
urethra

Glans of penis

(b) Posterior view Penis

 Internal Iliac Artery: Anterior Division Male

1
2
1. Umbilical a
2. Obturator a
3. Superior vesical a
4. Inferior vesicular a
6
5. Middle rectal a
6. Inferior gluteal a
7. Internal pudendal a
4
3 7

5
Internal Iliac Artery- posterior division – supply walls of the pelvis.
• Iliolumbar artery - runs superiolaterally
• Lateral sacral arteries - gives rise to spinal branches, which enter the anterior sacral
foramina.
• Superior gluteal artery - usually between lumbosacral trunk and S1
Arteries Of The The Male Superficial Perineum
 Internal Iliac Artery: Anterior Division Female

1. Umbilical a
2. Obturator a
3. Superior vesicular a
4. Vaginal a ♀
5. Uterine a ♀
6. Middle rectal a
7. Inferior gluteal a
8. Internal pudendal a

4 Vaginal
 Female Internal Iliac Artery:
Anterior Division
Anastomosis!

(water runs under bridge)

Posterior view
Female Water Under the Bridge!

ANTERIOR VIEW
(water runs under bridge)
 Blood Supply of the Rectum
1

1. Superior rectal
from IMA

2. Middle rectal
from internal iliac

3. Inferior rectal
from internal
pudendal 2

3
Lower Limb
Lower Limb- Dermatomes

Lower Limb Dermatomes

Gluteal region- L3 – S4
Anal region- S5
Anterior thigh- L2, L3, L4
Medial thigh- L1, L2, L3
Posterior thigh- L5, S1, S2
Knee- L4
Anterior calf- L4, L5, S1
Posterior calf- S1, S2
Medial malleolus- L4
Lateral malleolus- S1
Big toe- L4, L5
Sole of foot- L4, L5
Lower Limb- Compartments

3 in each!
 Lower Limb- Nerves
Each compartment has its own nerve!

Thigh-
Anterior Compartment:
Femoral n.

Medial Compartment:
Obturator n.

Posterior Compartment:
Sciatic n. (tibial & common
fibular)

Leg-
Anterior compartment:
Deep fibular n.

Lateral compartment:
Superficial fibular n.

Posterior compartment:
Tibial n.
Lower Limb- Arteries

Arteries in the Lower Limb-

Thigh:
Femoral
Deep Femoral (with perforating branches)
Medial & Lateral Circumflex femoral

Knee:
Popliteal (continuation of femoral)

Leg:
Anterior tibial
Posterior tibial
Fibular

Foot:
Lateral plantar (from posterior tibial)
Medial plantar (from posterior tibial)
Gluteal Bursae Gluteal Injections
Trendelenburg Test

Gluteus medius
Muscles of Gluteal Region
 Nerves of the Gluteal Region

Pudendal nerve
Superior gluteal
nerve
Piriformis
Nerve to obturator internus

Inferior gluteal
nerve

Posterior femoral cutaneous

nerve
Sciatic nerve
 The Femoral Sheath
*The femoral nerve is lateral
to, and NOT contained within
the femoral sheath.
*The femoral sheath is
subdivided into three
separate compartments:
*Lateral Compartment:
Houses the femoral artery Femoral Nerve
Femoral Sheath
*Intermediate Compartment:
Houses the femoral vein
*Medial Compartment
(Femoral Canal): This space
contains loose connective
tissue and lymphatic vessels,
and allows expansion of the
femoral vein.
*NAVEL
Femoral Sheath and Ring: Femoral Hernia
Femoral Artery
Branches of the
Femoral Artery in
Medial the Anterior Thigh
Circumflex Profunda
Femoral
Femoris
Artery
Artery
The lateral circumflex artery has a
descending branch that will
anastamose with the popliteal
artery near the knee (collateral
Lateral circulation)
Circumflex
Femoral *Branches of the medial and
Artery lateral circumflex arteries are the
main blood supply to the hip joint.
Descending
branch of *Additional blood supply to the
Lateral hip joint comes from the artery
Circumflex to the head of the femur a
Femoral branch of the obturator artery
which runs in the ligament of
Perforating the head of the femur.
Femoral
Arteries
Artery
 Blood Supply to the Hip Joint
*The circumflex femoral arteries
(Medial and Lateral) encircle the
uppermost shaft of the femur and
anastomose around the femoral neck.
These vessels supply thigh musculature and
the proximal end of the femur.
*Branches of the medial circumflex
femoral artery are of particular importance
because they supply blood to the hip joint
(specifically the head and neck of the
femur).

*Fractures to the neck of the femur referred to as

“Hip fractures” are especially common in women
over 60 due to the increased prevalence of
osteoporosis in women of this age. Hip fractures
may tear the branches of the medial circumflex
femoral artery disrupting blood supply to the head
of the femur.
*Additional blood supply to the hip joint comes
from the artery to the head of the femur a
branch of the obturator artery which runs in the
ligament of the head of the femur. In the case
of hip fractures, this vessel is often inadequate
when blood supply from the medial circumflex
femoral artery is compromised. Avascular
necrosis, or death of the bone of the head of the
femur may result necessitating a hip
replacement.
The Ligament to the Head of the Femur
Avascular Necrosis Of the Femoral Head
Lateral And Medial Rotators Of Hip
 Anterior Thigh Note:
*Only the rectus
femoris part of the
quadriceps crosses
the hip joint, and
therefore it is the
Rectus
only part of the
Femoris
quadriceps that
Sartorius
flexes the thigh at the
Sartorius
Rectus Femoris hip.

Vastus
*The iliopsoas
Intermedius muscle is a much
Vastus more powerful hip
Lateralis Vastus
Medialis flexor.
Vastus Vastus
Lateralis Medialis *All innervated by
the femoral nerve!

The main action of

the quadriceps is to
extend the leg at
the knee!
Medial Thigh- Muscles

The medial
compartment of the
thigh

All muscles innervated by the

obturator nerve!
Medial Thigh- Muscles

Layer 1

Pectineus*

Adductor longus

Gracilis

All muscles innervated

by the obturator nerve!
Medial Thigh- Muscles

Layer 2

Obturator
externus

Adductor brevis

All muscles innervated

by the obturator
nerve!
Medial Thigh- Muscles

Layer 3

Adductor
magnus*

Adductor hiatus

All muscles innervated

by the obturator nerve!
 Posterior Thigh- Muscles
All are innervated by the
Sciatic nerve:
The Hamstrings
Tibial:
Semitendinosus
Semimembranosus
Long head of biceps femoris

Common Fibular:
Short head of biceps femoris

Biceps femoris (long head)

Semitendinosus

Semimembranosus
Posterior Thigh- Nerves

Sciatic Nerve (L4-S3)-

In posterior thigh it splits

into:

Tibial n. & Common

fibular nerve

In the thigh the tibial n.

innervates the
semimembranosus,
semitendinosus, and long
head of the biceps femoris.

The common fibular n.

innervates the short head
of the biceps femoris.
 Knee Joint

Vastus
Medialis
Vastus
Lateralis Quadriceps Semimembranosus
Femoris tendon
tendon
Iliotibial tract
Medial Oblique
collateral popliteal
Lateral
ligament ligament
collateral
ligament
Semitendinosus
Patellar Gracilis
tendon
Popliteus
(ligament) Sartorius The
popliteus
“unlocks”
the knee
Pes anserinus
joint to
initiate knee
flexion
Knee Joint
 Dorsal view of tibia, menisci and ligaments of the knee joint

Anterior Cruciate Patellar

ligament ligament

Medial
meniscus

Medial collateral Lateral collateral

ligament ligament

Posterior Cruciate Lateral meniscus

ligament
The menisci are plates of fibrocartilage on the articular surface of the tibia that improve
congruency between the femoral and tibial condyles and play a role in shock absorption.

The medial meniscus firmly attachments to the tibia, the joint capsule, and the medial (tibial)
collateral ligament (MCL) making it less mobile than the lateral meniscus. The firm attachment to
the MCL makes the medial meniscus susceptible to injury when the MCL is injured. The “unhappy
triad” refers to an injury where the medial meniscus, the MCL, and the anterior cruciate are
collectively torn.
 Knee Joint
Cruciate Ligaments

ACL

PCL
Drawer Sign Tests
Collateral ligament test
Anterior cruciate lig

Tibial (medial)
collateral lig

Medial meniscus

Unhappy triad
 Posterior Compartment of the Leg

Superficial group-

Gastrocnemius
Plantaris
Soleus

Deep group-

Popliteus
Flexor digitorum longus
Tibialis posterior
Flexor hallucis longus
All innervated by the Tibial N.!
 Nerves
Sciatic n.
Common Fibular n.
Tibial n.
Common Fibular n.
Neck - Fibula
Deep Fibular n.

Superficial Fibular n

Anterior
Lateral Compartment Posterior
Compartment Compartment
 Anterior Compartment of the Leg

Anterior compartment muscles

Tibialis anterior

All innervated by the

Deep Fibular N.!
Extensor digitorum longus
(& fibularis tertius)

Extensor hallucis longus

 Deep Fibular Nerve
• Supplies the muscles of the
anterior compartment of the leg
• Passes thru the extensor
digitorum longus.
• Descends over the interosseous
membrane
• In the foot it divides into lateral
and medial branches
• Lateral: extensor hallucis brevis
and extensor digitorum brevis
• Medial: skin of the adjacent sides
of the first and second toes.
• Cc: foot drop with characteristic
high stepping gait.

Deep fibular nerve

Lateral Compartment of the Leg

Lateral compartment-

Only 2 muscles!

Both innervated by the

Superficial fibular n.

Fibularis longus

Fibularis brevis
Note:
The common fibular Deep fibular nerve
nerve crosses the neck of
the fibula before Superficial fibular nerve
dividing!!!

So any injury at the

fibular neck will damage
both the Superficial
AND Deep fibular Perforating branches to
nerves! lateral compartment from
fibular artery
Dorsiflexors, Plantarflexors, Inverters, &
Everters of the Foot
Dorsiflexors: Inverters:
Tibialis anterior Tibialis anterior
Extensor hallucis longus Tibialis posterior
Extensor digitorum longus

Plantar Flexors:
Gastrocnemius & Soleus Everters:
(through Achilles tendon) Fibularis longus
Tibialis posterior Fibularis brevis
Fibularis longus Fibularis tertius
Tom, Dick & Harry at the Ankle

Tom

Dick

An’

Harry
Dorsal Pedis Artery Pulse
Cutaneous Innervation LL
 Good Luck on the Final!

Stay calm, focus, read questions properly and mark the correct answer!
Don’t change your answers!!!