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Common femoral artery
Semimembranosus
Semitendinosus
Sural communicating
Popliteal vein
Popliteal artery
(deepest)
Gastrocnemius
(medial head)
Fig. 4.10 The right popliteal fossa.
CHAPTER 4 The Lower Limb
Sciatic nerve
Tibial nerve
Popliteal surface
of femur
Plantaris
Common peroneal
nerve
nerve
Gastrocnemius
(lateral head)
Sural nerve
Profunda femoris artery
91
(Superficial) femoral
artery
Popliteal artery
Fig. 4.11 MRA of thigh showing the (common) femoral artery and its branches.
• Relations:
• anteriorly: skin, supercial fascia, deep fascia, femoral branch of genitofemoral nerve, sartorius, saphenous nerve
• posteriorly: psoas tendon, profunda vessels, pectineus, adductor longus, femoral vein (at apex of
• Branches include:
• supercial epigastric artery
• supercial circumex iliac artery
• supercial external pudendal artery
• deep external pudendal artery
• profunda femoris artery.
femoral triangle and in subsartorial canal), tendon
of adductor magnus
• medially: femoral vein (in femoral triangle), adductor longus
• laterally: femoral nerve, sartorius (in femoral triangle), vastus medialis.
Profunda Femoris
• Arises posterolaterally from femoral artery, 5 cm distal
to the inguinal ligament.
• Passes distally in femoral triangle lying on iliacus, psoas,
pectineus, adductor brevis and adductor magnus.
92
Posterior tibial artery
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Fig. 4.12 MRA of popliteal artery and its branches.
SECTION I Anatomy
Popliteal artery
Tibioperoneal trunk
Anterior tibial artery
Peroneal artery
• Adductor longus passes supercial to it.
• Separated from femoral artery by femoral vein and pro-
• Terminates in the lower third of the thigh by perforating
• Branches include:
• Branches supply the muscles of the thigh.
• Acts as collateral channels linking the arterial anasto-
Popliteal Artery
• Continuation of femoral artery at hiatus in adductor
• Passes to lower border of popliteus where it divides into
• Relations include:
• Branches include:
funda veins and adductor longus.
adductor magnus.
• lateral circumex artery
• medial circumex artery
• four perforating branches.
moses around knee and hip.
magnus.
anterior and posterior tibial arteries.
• overlapped by semimembranosus in upper part of
fossa
• covered below by gastrocnemius and plantaris
• lies deep within the fossa, covered supercially by
the popliteal vein and more supercially by the tibial
nerve.
• muscular
• geniculate to the knee joint
• anterior tibial artery
• posterior tibial artery.
Posterior Tibial Artery
• Terminal branch of popliteal artery.
• Extends from lower border of popliteus to the lower
margin of the exor retinaculum at the ankle, where it
divides into medial and lateral plantar arteries.
• Relations include:
• upper two-thirds covered by soleus and gastrocnemius
• lower third lies supercially between medial border
of tendo calcaneus and medial border of tibia
• tibial nerve is at rst medial but soon crosses poste-
riorly to reach lateral side
• lies on tibialis posterior, exor digitorum longus,
tibia and back of ankle joint
• accompanied by venae comitantes and tibial nerve.
• Branches include:
• peroneal artery (the artery of lateral compartment):
arises 2.5 cm below popliteus, runs on posterior
aspect of bula, supplies adjacent muscles, gives
a nutrient branch to the bula, gives a perforating
branch, which pierces interosseous membrane and
anastomoses with arteries on dorsum of foot
• medial plantar artery
• lateral plantar artery.
CHAPTER 4 The Lower Limb
93
Anterior Tibial Artery
• Terminal branch of popliteal artery.
• Arises at lower border of popliteus.
• Extends in front of ankle joint where it becomes dorsalis
pedis artery.
• Artery of the anterior compartment.
• Relations include:
• lies deeply on interosseous membrane
• becomes supercial just above ankle between tendons
of extensor hallucis longus and tibialis anterior
• crossed supercially by tendon of extensor hallucis
longus just proximal to ankle joint.
• Branches include:
• small branches, which form collaterals with vessels
around the knee joint and ankle joint
• dorsalis pedis, which runs from front of ankle to
rst interosseous space; plunges deeply between rst
and second metatarsals to anastomose with lateral
plantar artery to form plantar arch supplying plantar
aspect of toes
• lies between tendons of extensor hallucis lon-
gus and extensor digitorum longus on dorsum
of foot.
Clinical Points
• e femoral artery may be palpated at the midinguinal point—halfway between the anterior superior iliac
spine and the pubic symphysis.
• Arterial puncture for blood gases and arteriography is
oen performed at this site.
• A venous sample may be obtained from the femoral vein,
which lies immediately medial to the femoral artery.
• e femoral artery is quite supercial in the femoral triangle where it may be easily injured, e.g. butchers, bullghters, stabbings in the groin.
• e popliteal artery may be palpated in the lower part
of the popliteal fossa by compressing it against the posterior surface of the upper end of the tibia. It cannot
be palpated easily in the upper part of the fossa as it is
pushed into the intercondylar notch.
• e relation of the popliteal artery to the lower end of the
femur makes it vulnerable in supracondylar fractures.
• A popliteal artery aneurysm may cause pressure on
adjacent structures, e.g. vein (leading to DVT), tibial
and common peroneal nerve (leading to pain and nerve
palsies).
• e posterior tibial artery is palpable behind the medial
malleolus midway between the latter and the tendo
calcaneus.
• e dorsalis pedis artery is palpable on the dorsum of
the foot lying between the tendon of extensor hallucis
longus (medial) and extensor digitorum longus to the
second toe (lateral).
• ere is a rich anastomosis between the femoral artery
and its branches, which is important in the development
of collaterals in arteriosclerotic disease.
THE VEINS OF THE LOWER LIMB
ese are divided into supercial and deep. e deep veins
accompany the major arteries of the limb. Supercial veins
are the great and small saphenous veins.
Great (Long) Saphenous Vein
• Commences on the medial side of the dorsal venous
arch of the foot.
• Ascends immediately in front of the medial malleolus
(accompanied by the saphenous nerve).
• Passes a hand’s breadth behind the medial border of the
patella.
• Ascends obliquely up the medial aspect of the thigh,
piercing the deep fascia to terminate in the femoral vein
at the saphenous opening 4 cm inferolateral to the pubic
tubercle.
• Tributaries include:
• supercial epigastric vein
• supercial circumex iliac vein
• supercial external pudendal vein
• lateral accessory vein, which joins the main vein at
midthigh.
Small (Short) Saphenous Vein
• Commences on the lateral side of the dorsal venous arch
of the foot.
• Passes behind the lateral malleolus.
• Courses up the back of the thigh, perforating the deep
fascia over the popliteal fossa to enter the popliteal vein.
• Accompanied in its course by the sural nerve.
• Communicates with the deep veins of the foot and the
great saphenous vein.
Clinical Points
• e relationship of the great saphenous vein to the
medial malleolus is constant. It may therefore be used
for life-saving cannulation.
• e saphenous nerve is immediately adjacent to the vein
and may be caught in a ligature while doing a cutdown
or during varicose vein surgery.
• e tributaries of the great saphenous vein at the saphenofemoral junction are important when carrying out a
high tie during varicose vein surgery. Failure to ligate
all tributaries may result in recurrence. Patterns of these
veins are variable.
94
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SECTION I Anatomy
LEG COMPARTMENTS
Thigh
e deep fascia (fascia lata) of the thigh surrounds muscles
and sends septa in between the principal groups. e thigh
is divided into compartments as follows.
• Anterior compartment of the thigh, containing:
• quadriceps muscles: vastus lateralis, vastus intermedius, vastus medialis, rectus femoris
• sartorius.
• Medial compartment of the thigh, containing:
• obturator externus, adductor magnus, adductor brevis, adductor longus, pectineus, gracilis.
• Posterior compartment of the thigh, containing:
• hamstring muscles: semitendinosus, semimembranosus, biceps femoris.
Lower Leg
• e deep fascia of the leg divides it into three compartments:
• anterior compartment
• posterior compartment
• lateral compartment.
Anterior Compartment
• Contains the following:
• tibialis anterior
• extensor hallucis longus
• extensor digitorum longus
• peroneus tertius.
• All muscles are supplied by the deep peroneal nerve.
• e artery of this compartment is the anterior tibial
ar tery.
Posterior Compartment
• Contains the following:
• gastrocnemius
• soleus
• plantaris
• popliteus
• exor hallucis longus
• exor digitorum longus
• tibialis posterior.
• All muscles are supplied by the tibial nerve.
• e artery of this compartment is the posterior tibial
ar tery.
Lateral Compartment (Peroneal Compartment)
• Contains the following:
• peroneus longus
• peroneus brevis.
• e nerve of this compartment is the supercial peroneal nerve.
• e artery of this compartment is the peroneal artery.
The Nerves of the Lower Limb
ese are derived from the lumbar and sacral plexuses.
LUMBAR PLEXUS (Fig. 4.13)
• Formed from the anterior primary rami of L1–4 (with a
contribution from T12).
• Formed in the substance of psoas major.
• Trunks emerge from lateral border of psoas with the
exception of the obturator nerve (medial border) and
the genitofemoral nerve (anterior aspect).
• e principal branches of the lumbar plexus are:
• femoral nerve
• obturator nerve
• ilioinguinal nerve
• lateral cutaneous nerve of thigh
• genitofemoral nerve.
Femoral Nerve
• Root value L2–4.
• Passes through substance of psoas major, emerging on
lateral aspect.
• Passes under inguinal ligament lateral to femoral artery
lying on iliopsoas.
• About 5 cm below inguinal ligament breaks up into its
terminal branches.
• Branches include:
• muscular: quadriceps, sartorius, pectineus
• cutaneous: medial cutaneous nerve of thigh, inter-
mediate cutaneous nerve of thigh, saphenous nerve
• articular branches to hip and knee.
Obturator Nerve
• Root value L2–4.
• Emerges from medial aspect of psoas.
• Runs downwards and forwards deep to internal iliac
vessels to reach the upper part of the obturator foramen.
• Enters the thigh through the obturator foramen accompanied by the obturator vessels.
• Branches include:
• anterior branch: descends in front of the adductor
brevis, behind pectineus and adductor longus; supplies gracilis, adductor longus, adductor brevis and
skin over medial aspect of thigh and hip joint
• posterior branch: passes through the obturator exter-
nus and behind adductor brevis; supplies adductor
magnus, obturator externus, knee joint and occasionally adductor brevis.
nerve of thigh
IIioinguinal nerve
L1
L2
L3
L4
L5
Obturator nerve
IIiohypogastric nerve
Lateral
cutaneous
CHAPTER 4 The Lower Limb
95
Femoral nerve
Genitofemoral nerve
Fig. 4.13 The lumbar plexus.
Other Branches of Lumbar Plexus
• Ilioinguinal nerve: enters the inguinal canal and is
important in hernia surgery. It supplies the skin of the
groin and the anterior part of the scrotum.
• Lateral cutaneous nerve of thigh: arises directly from
lumbar plexus and enters thigh deep to inguinal ligament. Occasionally it pierces the inguinal ligament. May
be trapped by inguinal ligament, resulting in pain and
numbness in its distribution (meralgia paraesthetica).
• Genitofemoral nerve:
• formed within psoas major from L1, 2
• emerges on anterior surface of psoas major
• runs inferiorly passing posteriorly to the ureter
• divides into genital and femoral branches
• in the male, the genital branch enters the deep ingui-
nal ring in company with the vas deferens and supplies the cremaster muscle
• emerging from the supercial inguinal ring, it sup-
plies the skin of the scrotum
• in the female, it ends in supplying the skin of the
labium majus
• femoral branch passes deep to the inguinal ligament
within the femoral sheath to supply the skin just
inferior to the ligament.
Lumbosacral trunk
SACRAL PLEXUS (Fig. 4.14)
• Formed from the anterior primary rami of L4–5, S1–4.
• Sacral nerves emerge from the anterior sacral foramina
and unite in front of piriformis, where they are joined by
the lumbosacral trunk (L4, 5).
Branches
Muscular
• Piriformis.
• Obturator internus.
• Quadratus femoris.
• Gemelli.
Superior Gluteal
• L4, 5, S1.
• Passes out of the greater sciatic foramen above piriformis.
• Accompanies superior gluteal vessels.
• Supplies gluteus medius, gluteus minimus and tensor
fascia lata.
Inferior Gluteal
• L5, S1, 2.
• Passes out of the pelvis below piriformis.
• Supplies gluteus maximus.
L4
L5
S1
S2
S3
S4
Posterior cutaneous nerve of thigh
Common
Superior
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96
gluteal
nerve
Inferior
gluteal
nerve
peroneal
nerve
SECTION I Anatomy
Tibial
nerve
Perforating cutaneous nerve
Pudendal nerve
Pelvic splanchnic nerve
Fig. 4.14 The sacral plexus. The anterior division has
lighter shading.
Pudendal Nerve
• Root value S2, 3, 4.
• Passes out of the greater sciatic foramen between piriformis and coccygeus.
• Lies medial to sciatic nerve.
• Winds over sacrospinous ligament medial to internal
pudendal artery.
• Re-enters pelvis through lesser sciatic foramen.
• Enters pudendal canal in obturator fascia (accompanied
by vessels) on the lateral wall of the ischiorectal fossa
and divides into three branches: inferior rectal (haemorrhoidal), perineal, dorsal nerve of penis.
Sciatic Nerve
• Root value L4, 5, S1, 2, 3.
• Largest nerve in the body.
• Nerve emerges from the greater sciatic foramen below
piriformis.
• Covered by gluteus maximus.
• Crosses posterior surface of ischium.
• Descends on adductor magnus lying deep to the
hamstrings.
• Crossed by the long head of biceps femoris.
• Divides into tibial nerve and common peroneal nerve.
• e level of division is variable and the nerves may be
separate entities even at their origin from the sacral
plexus.
• Branches include:
• muscular to biceps femoris, semimembranosus,
semitendinosus and part of adductor magnus (also
supplied by the obturator nerve)
• tibial nerve
• common peroneal nerve.
Tibial Nerve
• Root value L4, 5, S1, 2, 3.
• Larger terminal branch of sciatic nerve.
• Traverses popliteal fossa supercial to popliteal vein and
artery, crossing from lateral to medial side of artery.
• Descends deep to soleus in calf.
• Accompanied by posterior tibial vessels.
• Passes behind medial malleolus.
• Divides into medial and lateral plantar nerves.
• Branches include:
• in the popliteal fossa:
• muscular: gastrocnemius, popliteus, soleus
• cutaneous: sural nerve (accompanies small saphenous vein)
• articular: knee joint.
• in the leg and foot:
• muscular: the exor hallucis longus; exor digitorum longus; tibialis posterior; intrinsic muscles of
the foot
• cutaneous: skin of the sole of the foot; lateral plantar nerve supplies lateral part and lateral one-anda-half toes; medial plantar nerve supplies medial
half and medial three-and-a-half toes (compare
median nerve and ulnar nerve in hand).
Common Peroneal Nerve
• Root value L4, 5, S1, 2.
• Smaller terminal branch of sciatic nerve.
• Enters popliteal fossa lateral to tibial nerve.
• Passes along medial border of biceps tendon.
• Winds round neck of bula deep to peroneus longus,
where it divides into supercial and deep peroneal nerves.
Deep Peroneal Nerve
• Pierces extensor digitorum longus.
• Descends (accompanied by anterior tibial vessels) over the
anterior interosseous membrane and across the ankle joint.
• Branches:
Iliohypogastric
cutaneous nerve of thigh
plantar nerve
AB
Dorsal rami S1, S2, S3
Dorsal rami L1, L2, L3
Lateral cutaneous
nerve of thigh
Obturator nerve
Medial cutaneous
nerve of thigh
Posterior cutaneous
nerve of thigh
nerve
Subcostal nerve
CHAPTER 4 The Lower Limb
Femoral branch of
genitofemoral nerve
Ilioinguinal nerve
Obturator nerve
Medial and intermediate
97
Fig. 4.15 The cutaneous nerve supply of the lower limb. (A) Posterior view. (B) Anterior view.
Superficial Peroneal Nerve
• Muscular: peroneus longus, peroneus brevis.
• Cutaneous: distal two-thirds of the lateral aspect of the
Cutaneous Nerve Supply of the Leg
(Fig. 4.15)
Dermatomes of the Leg
(Fig. 4.16)
Tendon Reflexes of the Lower Limb
• Knee: quadriceps (L3, 4 via femoral nerve).
• Ankle: gastrocnemius (S1 via sciatic nerve—tibial
Saphenous nerve
Sural
Tibial nerve
Medial plantar nerve
nerve
Lateral
• muscular: tibialis anterior, extensor hallucis longus,
extensor digitorum longus, extensor digitorum brevis, peroneus tertius
• cutaneous: to the skin of the web space between rst
and second toes.
leg, the dorsum of the foot (except the rst web space).
branch).
Saphenous nerve
Lateral cutaneous
nerve of calf of leg
Superficial peroneal nerve
Clinical Points
• Nerve supply to the hip joint and knee joint involves the
same nerves (femoral, obturator, sciatic). Pain from hip
disease therefore may be referred to the knee.
• An obstructed or strangulated obturator hernia may
press on the obturator nerve at the obturator foramen.
is may cause pain in its cutaneous distribution on the
medial aspect of the thigh. Intestinal obstruction associated with pain in the cutaneous distribution of the obturator nerve may indicate obturator hernia.
• e relationship of the pudendal nerve to the ischial
spine is important in obstetrics. e ischial spine can
be palpated per vaginam and a needle directed to the
nerve to deliver local anaesthetic. Bilateral block of the
pudendal nerve leads to loss of anal reex, relaxation of
muscles of pelvic oor and loss of sensation to vulva and
lower third of vagina.
• Sciatic nerve injury may result from posterior dislocation of the hip, direct penetrating injuries or inappropriately placed injections (Fig. 4.17). Nerve injuries to the
lower limb are dealt with below.
98
S3
Safe area for
iliac spine
tuberosity
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SECTION I Anatomy
• e common peroneal nerve may be damaged where it
L1
S4
S5
S4
L2
L3
L1
S3
L2
S2
winds round the neck of the bula. Car-bumper injuries, below-knee plasters and the Lloyd–Davies position for abdominoperineal resection of the rectum may
compromise the nerve.
NERVE INJURIES
Sciatic Nerve
• Paralysis of hamstrings and all muscles of leg and foot
supplied by nerve.
• All movement is lost below the knee joint, with foot
drop (see below).
• All sensation is lost below the knee except that supplied
by the saphenous nerve (branch of femoral), i.e. over
medial malleolus and medial border of foot to great toe.
Tibial Nerve
• Isolated injury of this nerve is rare and likely to be
caused by penetrating injury.
Anterior
L4
L4
L5
L5
Posterior
• Loss of active plantarexion.
S1
L5
S1
• Loss of sensation over the sole of the foot.
Common Peroneal Nerve
• Injury is not uncommon.
Fig. 4.16 Dermatomes of the lower limb.
• Foot drop results.
• Components of foot drop include:
• failure of dorsiexion owing to paralysis of anterior
compartment muscles (deep peroneal nerve)
• failure of eversion owing to paralysis of lateral com-
partment muscles (supercial peroneal nerve)
injection
Posterior
superior
1
/
2
• patient exaggerates exion of hip and knee when
walking to li foot well clear of ground to prevent
scung toe of shoe
• loss of sensation over lower lateral leg, dorsum of
Greater
trochanter
1
1
/
/
2
2
1
/
2
Ischial
foot except medial aspect (saphenous nerve) and lateral aspect (sural nerve).
JOINTS
Hip Joint (Fig. 4.18)
• Largest joint in the body.
Fig. 4.17 Surface marking of the sciatic nerve in the
buttock, showing the safe area for injection.
• An artery accompanies the sciatic nerve running in its
substance (arteria comitans nervi ischiadici). Bleeding
can be troublesome when the nerve is divided in an
above-knee amputation. It must be carefully teased out
and ligated in isolation to avoid ligation of nerve bres
with subsequent pain and neuroma formation.
• Ball-and-socket joint.
Articular Surfaces
• Femoral head: two-thirds of a sphere.
• Acetabulum deepened by the brocartilaginous labrum
acetabulare.
• Non-articular acetabular notch is closed by the transverse acetabular ligament.
• Ligament teres passes from this notch to the fovea of the
femoral head.
Gluteus medius
Obturator externus
Ligamentum tere
Ilium
Gluteus minimus
CHAPTER 4 The Lower Limb
Lumbar vertebra
Psoas major
Iliacus
99
Acetabulum
s
Vastus lateralis
Fig. 4.18 Coronal MRI of hip joint and its relations.
Capsule
• Attached proximally to acetabulum and transverse acetabular notch.
• Attached distally along the intertrochanteric line, the
bases of greater and lesser trochanters and posterior
to the femoral neck about 1.2 cm from the trochanteric crest. Capsular bres are reected from the distal attachment onto the femoral neck, i.e. retinacular
bres.
Ligaments
• Iliofemoral: from anterior inferior iliac spine, bifurcating to attach at each end of the trochanteric line
(inverted Y—strongest of the three ligaments).
• Pubofemoral: from iliopubic junction to blend with
medial aspect of the capsule.
• Ischiofemoral: from ischium to attach to base of greater
trochanter.
Synovium
• Covers the nonarticular surfaces.
• May form or connect with a bursa anteriorly beneath
psoas tendon, where this crosses the anterior aspect of
the joint.
Nerve Supply
• Obturator.
• Sciatic.
• Femoral.
Head of femur
Greater trochanter
Adductor group of
muscles
Movements
• Flexion: iliacus, psoas major, rectus femoris, sartorius,
pectineus.
• Extension: gluteus maximus, biceps, semimembranosus, semitendinosus.
• Adduction: adductor longus, adductor brevis, adductor
magnus, gracilis, pectineus.
• Abduction: gluteus medius, gluteus minimus, tensor
fasciae latae.
• Lateral rotation: gluteus maximus (chiey), obturator
internus, obturator externus, gemelli, quadratus femoris.
• Medial rotation: tensor fasciae latae, anterior bres of
gluteus medius and gluteus minimus.
Relations
• Anterior: iliacus, psoas, pectineus, femoral artery, femoral vein.
• Posteriorly: obturator internus tendon and gemelli,
quadratus femoris, sciatic nerve, and gluteus maximus
overlying these.
• Laterally: tensor fasciae latae, gluteus medius, gluteus
minimus.
• Superiorly: reected head of rectus femoris.
• Inferiorly: obturator externus passing back to be
inserted into the trochanteric fossa.
Clinical Points
• e sciatic nerve is a close posterior relation of the hip
and is in danger in dislocation of the hip.
100
e
Lateral femoral condyl
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SECTION I Anatomy
Femur
Fig. 4.19 Sagittal MRI of right knee joint through medial aspect of lateral femoral condyle.
• Surgical exposure of the hip joint may be carried out in
three ways.
1. Lateral approach: involves splitting the bres of ten-
2. Anterior approach: between gluteus medius and
3. Posterior approach: through an angled incision com-
Knee Joint (Figs. 4.19 and 4.20)
• Hinge joint.
Articular Surfaces
• Lower end of femur (condyles).
• Upper end of tibia (condyles).
• Patella.
Quadriceps tendon
Patella
e
Infrapatellar pad of fat
Patellar ligament
sor fasciae latae, gluteus medius and gluteus minimus to reach the femoral neck. If further access is
required, the greater trochanter may be detached
with its gluteal insertions.
minimus laterally and sartorius medially—the
reected head of rectus femoris is then divided to
expose the anterior aspect of the hip joint.
mencing at the posterior superior iliac spine passing
to the greater trochanter and then extended vertically downwards. Gluteus maximus is split in the line
of its bres and incised along its tendinous insertion.
Gluteus medius and gluteus minimus are detached
from their insertions into the greater trochanter.
Biceps femoris
Popliteal vein
Anterior cruciate
ligament
Gastrocnemius
Posterior cruciat
ligament
Tibia
Capsule
• Attached to margins of articular surfaces.
• Communicates with suprapatellar bursa (between lower
part of femur and quadriceps).
• Communicates posteriorly with bursa on the medial
head of gastrocnemius.
• Oen communicates with bursa under semimembranosus.
• Capsule perforated posteriorly by popliteus.
Ligaments
• Medial collateral ligament: passes from medial epicondyle of femur to tibia (posterior bres attached to the
medial meniscus).
• Lateral collateral ligament: passes from lateral epicondyle of femur to head of bula; it is free from the
capsule.
• Ligamentum patellae and retinacula:
• continue through the patella with the quadriceps
tendon
• strong and thick and strengthen capsule anteriorly
• attached to tibial tuberosity
• retinacula are expanded parts of quadriceps tendon
going to the tibia and reinforcing the ligamentum
patellae.
• Oblique ligament: expansion of semimembranosus
tendon blending with the joint capsule posteriorly.
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