M uscles -> T o p o g ra p h y -► S ections
Joints of the foot
Lig. m e ta ta rs a le tra n s ve rsu m p rofun dum A rtic u latio n es m e tatars o p h a lan g e a le s
Os sesam oideum
Ligg. m e tatars a lia plan taria
M . fibularis [peroneus] brevis, Tendo M. fibularis [peroneus] longus, Tendo
Ligg. ta rs o m e ta ta rs a lia plan taria
Os cuboideum M. tibialis anterior, Tendo
Lig. c alc an e o c u b o id eu m plan tare Ligg. ta rsi plan taria
Tuber calcanei Lig. cuboideonaviculare plantare
M . tib ialis posterior, Tendo
Lig. calc an e o n a vic u lare plan tare
Fig. 4.91 Joints of th e fo ot, Articulationes pedis, right side, w ith
ligam ents; plantar view ; after removal of the Lig. plantare longum.
i- Clinical Rem arks------------------------------------ proaches attem pt to correct the deform ity by paralysing the adduc
in g m uscle (M. adductor hallucis) w ith injections o f botulinum toxin.
The m o s t com m on d e fo rm ity in th e firs t m etatarsophalangeal joint In th e h a m m er to e d e form ity, th e proxim al interphalangeal jo in t is
is th e hallux valgus, in w h ic h the head o f th e firs t m etatarsal bone fixed in a flexe d position. In c la w to e de form itie s, th e m etatarsopha
deviates and protrudes medially, w hereas th e big to e (hallux) is langeal joints are hyperextended and the proximal phalanx may even
adducted laterally. This condition may cause severe pain in th e m e slide above the metatarsals.
tatarsophalangeal jo in t and may cause so ft tissue sw elling. This
frequently requires surgical correction. Current therapeutic ap
287
Lower Extremity Surface a n a to m y -► Skeleton -► Im aging
Ankle joint and other joints of the foot
neonavicular jo in t
35° 20°
Inversion Eversion
Figs. 4.92a to c Range o f m o ve m en t in th e ankle jo in t and th e outwards) of the foot. These m ovem ents of the hindfoot are com ple
talocalcaneonavicular jo in t, (according to [1]) m ented by the m ovem ents o f the other fo o t joints (CHOPART's and
The an kle jo in t is a classical hinge jo in t (ginglym us) allow ing fo r dor- LISFRANC's joint) to perm it supination (lifting the medial margin of the
siflexion (extension) and plantarflexion o f th e fo o t (a). The trans foo t) and pron ation (lifting th e lateral margin o f th e foo t) (b).
verse axis o f th e jo in t projects through both M alleoli (c). Range of movement:
The talocalcaneonavicular jo in t is an atypical p ivo t jo in t (A rticulatio • ankle joint: dorsiflexion (extension) - plantarflexion: 3 0 ° - 0 ° - 50°
trochoidea) fo r w hich a sim plified axis w as defined w hich enters the • talocalcaneonavicular joint: eversion - inversion: 2 0 °- 0°-35°
neck o f th e Talus fro m a m edial superior direction and e xits th e Cal • talocalcaneonavicular jo in t and fo o t joints: pronation - supination:
caneus at th e lateral po sterior side (c). This jo in t enables inversion
(sole m oving to w a rd s th e m edian plane) and eversion (sole moving 30°- o °- 60°
Figs. 4.93a and b Range of m ovem ent of the phalangeal joints. the active m ovem ents o f th e toes is the ir passive resistance during the
(according to [1]) rolling m otion of the fo o t w hen walking.
The metatarsophalangeal joints are condyloid joints which are lim ited to Range of m ovem ent of the m etatarsophalangeal joints:
tw o axes of m ovem ent by tig h t ligam ents (rotational m ovem ents are • dorsiflexion (extension) - plantarflexion: 6 0 °- 0 ° - 40°
not possible; a). The proxim al and inte rm ed iate phalangeal jo in ts are • adduction - abduction: 2 0 ° - 0 °-1 0 ° (adduction here is th e m ove
hinge jo in ts and only a llo w fo r m inim al flexion (b). M o re im po rtan t than
m ent to the midline o f the foot)
288
M uscles -► T o p o g ra p h y -► S ections
Plantar arch
Ossa cuneiform ia Os cuboideum Os cuboideum O ssa cuneiform ia
Os naviculare C a lc a n e u s C a lc a n e u s Os naviculare
T a lu s Talus
# C ontact points
to floor
Figs. 4.94a and b Bones o f th e plan tar arch, righ t side; dorsal (a) us. Thus, a m edially open lo ngitud inal arch is form ed . The transverse
and plantar (b) view s. arch o f the fo o t is form ed by the wedge-shaped Ossa cuneiform ia and
W hile the heads o f th e metatarsal bones are positioned in the plantar the bases of the metatarsal bones. Due to these arches, the fo o t has
plane, th e Ossa cuneiform ia, Os naviculare and Talus, particularly to only three contact points w ith the floor: at the heads of the metatarsal
w ards their posterior aspect, position them selves on top of their lateral bones I and V and at the Tuber calcanei.
skeletal parts, resulting in th e Talus to be placed on to p o f th e Calcane
Os naviculare
O ssa cuneiform ia
O s m e ta ta rsi II
Os m etatars: 1
H a llu x Phalanx proxim alis C a lc a n e u s
P h a la n x
Lig. calcan eo n avicu lare
p la n ta re
A poneurosis plan taris Lig. p lan tare longum
Fig. 4.95 Ligam ents of th e lo ngitud inal plantar arch, rig h t side; band system to counteract the body w eight. The ligam ents can be
medial view. categorized into three superim posing levels:
The ligam ents of the fo o t passively maintain the longitudinal arch of the • upper level: Lig. calcaneonaviculare plantare
foot. They are actively supported by the tendons o f the M . tibialis pos • m iddle level: Lig. plantare longum
te rio r and M . fibularis longus (-» Fig. 4.148) and th e sho rt m uscles on • low er level: Aponeurosis plantaris
the sole of the foot. These supporting structures provide the tension
Clinical Rem arks------------------------------------ failure of the ligam entous support system . The acquired flatfoot
buckles m edially because the Talus is displaced inferiom edially. This
Foot deform ities are very com m on. The m ost com m on deform ity in turn forces th e heads o f th e m etatarsal bones apart and results
o f th e extre m itie s is th e co ngenital clu bfoot in w h ic h th e fo o t is in flo o r co n ta ct o f th e m etatarsal bones II—V. This m ay cause painful
fixed in plantarflexion and supination. This position is caused by com pression sym ptom s at the sole of the foot.
an insufficient regression of this intrauterine physiological position
(-► p. 132). M o re fre q u e n tly are th e adult de fo rm itie s caused by a
289
Lower Extremity Surface a n a to m y -► Skeleton — Im aging -►
Pelvis
C rista iliaca O s sacrum , Pars lateralis
Spina iliaca posterior superior A rticulatio sacroiliaca
Basis ossis sacri
S pina iliaca posterior inferior Os sacrum
Linea arcuata Fossa acetabuli
Fovea capitis fem oris
Spina ischiadica
Tuber ischiadicum
C aput fem oris Foramen obturatum
Trochanter m ajor
O s coccygis
C ollum fem oris S ym physis pubica
C rista intertrochanterica
Trochanter m inor
Femur
Ram us o ssis ischii
Ramus superior ossis pubis
Ramus inferior ossis pubis
Fig. 4.96 Pelvis of a m an; radiograph in an tero poste rior (AP) beam
projection; upright standing position.
i- Clinical Remarks-----------------------------------------------------------------------------------------------------
Plain radiological images o f the pelvis are taken frequently. They help degenerative changes (arthrosis) or local alterations o f the bone,
to diagnose fractures and m alpositions of the skeletal elem ents of such as métastasés,
th e hip jo in t and the pelvic girdle. They also enable th e detection of
290
M uscles -> T o p o g ra p h y -► S ections Hip joint
C orpus o ssis ilii A rticulatio sacroiliaca
Linea term inalis
Caput fem oris Fossa acetabuli
Fovea capitis fem oris
Collum fem oris
T rochanter m ajor Foramen obturatum
Femur, C orpus Tuber ischiadicum
Trochanter m inor
Fig. 4.97 Hip jo in t, A rticu latio coxae, righ t side; radiograph in
an tero poste rior (AP) beam projection; up right standing position. * clinical term : roof of the acetabulum
* * clinical term : notch at th e roof of the acetabulum
O s ilium
Incisura ischiadica
m ajor
C aput fem oris Spina ischiadica
Trochanter m ajor
Incisura ischiadica
m ino r
Trochanter m inor Foramen obturatum
Tuber ischiadicum
Fig. 4.98 Hip jo in t, A rticu latio coxae, righ t side; radiograph in
LAUENSTEIN projection (abduction and flexion o f th e thigh in supine
position).
i- Clinical Rem arks-----------------------------------------------------------------------------------------------------
Suspecting a disease o f the hip joint, special radiographic im ages in projection in abduction and flexion o f th e thigh fo r a b e tte r assess-
various joint positions can be perform ed, such as the LAUENSTEIN m ent of the joint bodies.
291
Lower Extremity Surface a n a to m y -► Skeleton — Im aging -►
Knee joint Basis patellae
Corpus fem oris E picondylus medialis
E picondylus lateralis Apex patellae
Fossa intercondylaris
Femur, C ondylus m edialis
Femur, C ondylus lateralis Tibia, C ondylus m edialis
Tibia, C ondylus lateralis
Apex capitis fibulae T u b e rc u lu m
A rticulatio tibiofibularis intercondylare m ediale I Emjnentia
C aput fibulae
T u b e rc u lu m [ intercondylaris
C orpus fibulae
intercondylare laterale J
4.99
Linea epiphysialis
Corpus fem oris
C orpus tibiae
Patella, Facies articularis Facies poplitea
Apex patellae Fossa intercondylaris
Femur, C ondylus m edialis
Femur, C ondylus lateralis Eminentia intercondylaris
Apex capitis fibulae
Linea epiphysialis A rticulatio tibiofibularis
Tuberositas tibiae C aput fibulae
C orpus fibulae
C orpus tibiae
4.100
Fig. 4.99 and Fig. 4.100 Knee jo int, A rticulatio genus, radiographIt has to be considered tha t the contours of the medial and lateral fem o-
in an tero poste rior (AP) beam projection (-» Fig. 4.99) and in lateral ral condyles are n o t congruent,
beam projection (-► Fig. 4.100); in supine position.
i- Clinical Remarks------------------------------------
Concerning diseases o f the knee joint, radiographic images are o f the Tibia. The fem ora l condyles, how ever, are b e tte r inspected in
generally taken in tw o planes. The an tero poste rior (AP) beam projec lateral beam projection. In addition to fractures, also m alpositions,
tion allows for the assessm ent o f the articular cavity and the socket and degenerative diseases such as gonarthrosis can be diagnosed.
292
M uscles -► T o p o g ra p h y -► S ections
Knee joint
M . vastus lateralis Fossa Linea epiphysialis
Femur, C ondylus lateralis in te r c o n d y la r is
Condylus
T ibia, C ondylus lateralis Femur, lateralis
M e n isc u s lateralis C o n d y lu s Capsula articularis;
C aput fibulae m e d ia lis M. gastrocnem ius,
Lig. c o lla te rale fibulare Lig. Tendo
c o lla te ra le
tib iale M en iscu s lateralis,
M eniscus (C ornu posterius)
m edialis
M. popliteus,
T ib ia , Tendo
C o n d y lu s
m e d ia lis C aput fibulae
4.102 A rtic u la tio
tib io fib u la ris
T ib ia
Facies articularis superior,
C o ndylus lateralis
M en iscu s lateralis, (C ornu anterius)
C o rp us a diposum infrapatellare
Lig. patellae
Fig. 4.101 Knee jo in t, A rticu latio genus, righ t side; m agnetic reso
nance imaging (MRI) sagittal section; ventral view.
P a te lla
Femur
Lig. c ruciatum Fossa
a n te riu s intercondylaris
Lig. c ru cia tu m Lig. c ruciatum
p o s te riu s p o s te riu s
Area Area
in te r c o n d y la r is in te r c o n d y la r is
a n te rio r p o s te rio r
T ib ia
Corpus adiposum infrapatellare
C orpus a diposum infrapatellare
4.103 4.104
Fig. 4.102 to Fig. 4.104 Knee jo in t, A rticu latio genus, righ t side;
m agnetic resonance imaging (MRI) sagittal sections; medial view.
Com pact bone appears dark w ith this imaging technique.
i- Clinical Rem arks------------------------------------ nance im aging (MRI) is perform ed. If this technique does not clear
ly exclude injuries, endoscopic diagnostic procedures (arthroscopy;
Injuries to ligam ents and menisci of the knee joint cannot be imaged -» p. 281) should be considered.
w ith conventional radiographic techniques w hich only de tect bony
structures. In case o f suspected s o ft tissue injury, m agn etic reso
293
Lower Extremity Surface a n a to m y -► Skeleton — Im aging -►
Ankle joint and talocalcaneonavicular joint
Syndesm osis tibiofibularis Linea epiphysialis
A rticu latio talocruralis Trochlea tali
M alleolus medialis
M alleolus lateralis
Trochlea tali
4.105 M alleolus medialis
M alleolus lateralis
Linea epiphysialis ta lo c a lc a n e o n a v ic u la ris
A rtic u latio talocruralis Os naviculare
Proc. posterior tali
A rticu latio subtalaris
Sinus tarsi
S ustentaculum tali
Tuber calcanei
4.106
Fig. 4.105 and Fig. 4.106 Ankle joint (talocrural joint), and
talocalcaneonavicular joint, Articulationes talocruralis and
talocalcaneonavicularis, righ t side; radiograph in anteroposterior
(AP) beam projection (-» Fig. 4.105), and in lateral beam projection
( - Fig. 4.106).
294
M uscles -> T o p o g ra p h y -► S ections
Fractures of the ankle joint
4.107 4.108
Fig. 4.107 and Fig. 4.108 Ankle jo int (talocrural joint), A rticulatio
M em brana interossea talocruralis, rig h t side, w ith m alleolar fractu re (WEBER ty p e B);
Syndesm osis tibiofibularis radiograph in an tero poste rior (AP) beam projection [-* Fig. 4.107), and
(Lig. tibiofibulare) in lateral beam projection (-» Fig. 4.108). [17]
M alleolus Fracture lines are marked w ith arrows.
T ib ia
M alleolus
m e d ia lis
Fig. 4.109 Classification of ankle jo int fractures according to
WEBER types A , B, and C.
Clinical Remarks • WEBER B: The fra cture line goes through th e syndesm osis
w hich may be injured.
Fractures o f th e distal end o f th e Tibia are called WEBER fractures
and - depending on the involvem ent of the Syndesmosis tibiofibula- • WEBER C: The fra cture is located above th e torn syndesm osis. A
ris - fu rth e r classified in three types: W EBER C fra cture results in a severe instability o f th e ankle joint.
WEBER A: The M alleus lateralis is fractured beneath th e intact
s y n d e s m o s is .
295
Lower Extremity S urface a n a to m y -► Skeleton Im aging
Fascias of the low er extrem ity
S pina iliaca Lig. inguinale
anterior superior
M . ten so r fasciae C rista iliaca
latae V. sa ph en a m a g na (Fascia glutea)
M argo falciform is M. tensor
M . q uadriceps fem oris, fasciae latae
Tractus iliotibialis Tendo Sulcus glutealis
Tractus iliotibialis
Fascia lata P a te lla Fascia lata
Bursa subcutanea
Retinaculum p re p a te lla ris Fascia cruris
patellae laterale Lig. patellae
Bursa subcutanea M . gastrocnem ius,
C aput fibulae in fra p a te lla ris Tendo
F a sc ia cruris Tendo calcaneus
gastrocnem ius
Retinaculum m usculorum
extensorum superius T ib ia
M . extensor digitorum M . tib ia lis anterior,
longus, Tendines Tendo
4.110 R etinaculum m usculorum
extensorum inferius
M. e xte n sor hallucis longus,
Tendo
Fascia dorsalis pedis
4.111
Fig. 4.110 and Fig. 4.111 Fasciae o f th e th ig h . Fascia lata, th e
leg. Fascia cruris, and th e dorsum of th e fo o t. Fascia dorsalis
pedis, righ t side; ventral (-» Fig. 4.110) and dorsal (-» Fig. 4.111)
v ie w s .
M uscles -» T o p o g ra p h y -► S ections
{M . ilia c u s ---------- M uscles of the hip and low er extrem ity
M . iliopsoas < M. pectineus
M . psoas m ajor M. a d d u cto r longus
M. gracilis
M. ten so r fasciae latae
M. sartorius
M. vastus lateralis
M. quadriceps M. rectus fem oris
fem oris
M. vastus medialis
M. fibularis [peroneus] longus M . gastrocnem ius, C aput m ediale
M. tib ialis anterior M. soleus
M. extensor digitorum longus
M. extensor hallucis longus
Fig. 4.112 Ventral muscles of th e hip, thigh and leg, right side;
ventral view.
T 42, 44, 45, 47, 48
Lower Extremity S urface a n a to m y -► S keleton -► Im aging -►
M uscles of the hip and low er extrem ity
M. gluteus m edius
M. gluteus m axim us
M . sem itendinosus M . biceps fem oris
M. gracilis
M. sem im em branosus
M. gastrocnem ius
M . soleus
Tendo calcaneus
Fig. 4.113 Dorsal muscles of th e hip, th ig h and leg, righ t side;
dorsal view.
-► T 43, 46, 49
298
M uscles -> T o p o g ra p h y -> S ections M uscles of the hip and thigh
M . gluteus m axim us M . obliquus externus abdom inis
Tractus iliotibialis C rista iliaca, Labium externum
Spina iliaca anterior superior
M. b icep s fem oris, C aput longum
M. sem im em branosus M . sartorius
M. ten so r fasciae latae
M . biceps fem oris, C aput breve
M . gastrocnem ius, C aput laterale M . rectus fem oris
C aput fibulae M . vastus lateralis
Tra ctu s iliotibialis
Lig. patellae
Fig. 4.114 M uscles o f th e hip and th ig h , rig h t side; lateral view . This principle is referred to as tension band effect.
The Tractus iliotibialis serves as reinforcem ent of the fascia o f the -» T 43, 44, 46
thigh (Fascia lata) and con nects th e ilium w ith th e Tibia. It cou nter
balances the body w eight-induced m edial forces on the thigh bone.
Lower Extremity S urface a n a to m y -► Skeleton Im aging
M uscles of the hip and thigh
C rista iliaca A rticulatio sacroiliaca
M. iliacus Os sacrum
M. psoas m ajor
(M. psoas minor), Tendo (Foramen suprapiriform e)
S pina iliaca anterior superior
M. piriform is
Lig. inguinale (Foramen infrapiriform e)
M . ischiococcygeus [coccygeus]
Pecten ossis pubis
Ramus superior ossis pubis Foramen ischiadicum minus
Lig. sacrotuberale
M. sartorius M . obturatorius internus
S ym physis pubica Tuber ischiadicum
Ram us ossis ischii
(Arcus tendineus M. gluteus m axim us
m u scu li le va to ris ani) M. b icep s fem oris, C a pu t longum
Ramus inferior ossis pubis M . sem itendinosus
M . a d d u cto r longus M. sem im em branosus
M. adductor magnus
Fig. 4.115 Muscles of th e hip and thigh, right side; medial view.
-► T 20a, 4 2 -4 6
M uscles -» T o p o g ra p h y -► S ections
M. psoas m ajor M uscles of the hip and thigh
M . iliopsoas
M . ten so r fasciae latae
M. iliacus M. sartorius
4.116
T ra ctu s
M. rectus fem oris M . pectineus
M. adductor
4.117a M. a dd ucto r longi
M. adductor magnus M. gracilis
vastus mediaiis
M . quadriceps fem oris
vastus interm edius
M. va stu s lateralis
Lig. patellae
4.117b
Fig. 4.116 to Fig. 4.118 V entral m uscles of th e hip and th ig h and tensor fasciae latae is also counted am ong the dorsolateral hip
m edial muscles of th e thigh, right side; ventral view. m u s c le s .
The m uscles of the hip and thigh are equally im portant to erect the The four-headed M. quadriceps fe m o ris (-» Fig. 4 .1 17b) is th e only ex
body fro m the supine position, to maintain an upright position, and fo r te n so r o f th e knee jo in t and is essential to erect th e body fro m a
the normal gait. The ventral muscles o f the hip com prise the M. ilio squatting position. Its M . rectus fem oris spans tw o joints and also
psoas (-» Fig. 4.116) w h ic h fu n ctio n s as m ost im p o rta n t fle xo r o f the flexe s th e hip.
hip. Located at the lateral thigh, the M . tensor fasciae latae Located medially, the m uscles of the adductor group (M m . adducto-
(-» Fig. 4 .1 17a) fu n ctio n s as tension band via its insertion on th e ilio res, -» Fig. 4.118) are th e m o st im po rtan t adductors o f th e thigh and
tibial tract and protects th e thigh bone fro m fractures by reducing stabilise the hip during standing and walking.
bending stress. To geth er w ith th e M. sartorius (-» Fig. 4.117a), th e M.
tensor fasciae latae flexes the hip joint. Due to its innervation, the M. - » T 42-45
Lower Extremity S urface a n a to m y -► Skeleton Im aging
M uscles of the hip and thigh (M. psoas m inor)
A rcus iliopectineus
M. psoas m ajor M . p ectin eu s
M . a d d u c to r longus
M . iliopsoas
Lig. inguinale
M . iliopsoas
M . te n s o r fasciae latae
M . rectus fem oris
M . vastus lateralis M . gracilis
Fascia lata, T ractus iliotibialis M . vastus m edialis
(Bursa subtendinea prepatellaris) Lig. patellae
C aput fibulae
Bursa subcutanea infrapatellaris
Fig. 4.119 Ventral muscles of th e hip and th igh , and medial M. adductor longus, and M . gracilis are visible. The four heads of the M .
muscles o f th e th ig h , rig h t side; ventral v ie w ; a fte r rem oval o f the quadriceps fem oris (M. rectus fem oris, M m . vasti lateralis, medialis,
Fascia lata ventral to th e Tractus iliotibialis. and interm edius) lie distally and laterally o f th e M . sartorius. Their com
The M . ilio p s o a s is com posed o f tw o diffe ren t m uscles w hich origi m on tendon incorporates the Patella as a sesam oid bone before the
nate from the lumbar part o f the vertebral colum n (M. psoas) and the fibres continue as Lig. patellae to the Tuberositas tibiae.
Fossa iliaca (M . iliacus). Inferior to th e inguinal ligam ent, only a short M o s t laterally, th e M . te n so r fasciae latae inserts in th e Tractus ilio
portion of both parts of the m uscle courses to the com m on insertion tibialis. The com m on insertion of the M m . sartorius, gracilis, and sem i-
site at the Trochanter minus. ten dinosu s inferior to th e m edial tibial condyle is o fte n referred to as
The M . sartorius is en sheathed by a sp lit portion o f th e Fascia lata and the "Pes anserinus superficialis".
crosses the anterior aspect o f the thigh to insert at the medial aspect of
th e Tibia po sterior to th e transverse axis o f th e knee. Thus, it flexe s the -► T 42, 45, 46
hip and the knee.
Medially, the m uscles of the adductor group are located on top of
each o th e r in several layers o f w h ic h o n ly th e superficial M . pectineus,
302
M uscles -» T o p o g ra p h y -► S ections M uscles of the hip and thigh
M. iliacus M. p s o a s m ajor
M. sartorius
M. tensor fasciae latae M. piriformis
M. g lu te u s m edius
Pecten ossis pubis
M . q uad rice p s fem oris*
M. pectineus
M. vastus lateralis M. a d d u c to r longus
M. gracilis
M. vastus medialis C a n a l i s a d d u c t o r i u s ; A.; V. fem oralis
Se p tu m interm usculare
vastoad du cto riu m
M. sartorius
Fascia lata
M. re c tu s fem oris, Tendo
Patella
Lig. p atellae
Fig. 4.120 Ventral muscles of the hip and thigh, and medial The four heads of the M . quadriceps fem oris (M. rectus fem oris, Mm .
muscles of th e th igh , right side; ventral view ; after removal of the vasti lateralis, m edialis and interm edius) are located laterally to the ad
Fascia lata, th e M . sartorius, and th e M. te n s o r fasciae latae. ductor canal.
A fte r removal of the M . sartorius, the entrance to the adductor canal
(Canalis adductorius) is visible w hich is dem arcated dorsally by the * The fourth head o f the M. quadriceps fem oris, the M . vastus inter
M. adductor longus. In its anterior portion, th e canal is covered by the medius, lies beneath th e M. rectus fem oris.
Septum intermusculare adductorium w hich connects the fasciae of
the M . vastus medialis, M m . adductores longus and magnus. -► T 4 2 , 4 5 , 46
i- Clinical Remarks------------------------------------ Considering th e course o f th e m uscle, it is obvious th a t only a small
portion of the m uscle fibres can be blocked by injection fro m be
In th e case o f conditions such as spasticity or dystonia, w hich in neath the inguinal ligam ent. Therefore additional injections into the
volve a perm anently flexed hip jo in t due to the contraction of the lumbar parts of the M . psoas m ajor may be required.
M. iliopsoas, standing in an upright position is im possible. Thera
peutically, the M. iliopsoas is paralysed by injection o f botulinum
toxin w hich relaxes th e m uscle by blocking cholinergic synapses.
303
Lower Extremity S urface a n a to m y -► Skeleton Im aging
M uscles of the hip and thigh M. iliopsoas
Spina iliaca anterior superior M. piriformis
M. sa rto riu s B ursa su b ten d in ea iliaca
Pecten ossis pubis
,. . , . ƒM. rectu s fem oris < C„ ap u t re c tu m ---------
C a p u t reflex u m ------ M. a d d u c to r longus
M. g lu te u s m ed iu s M. pectineus
Lig. iliofem orale M. a d d u ctor brevis
M. ilio p so as M. gracilis
M. a d d u c to r lo n g u s
M. v a s tu s lateralis M. adductor m agnus
Hiatus adductorius
Fascia lata M. v a s tu s m edialis
M . v a stu s interm edius
M. re c tu s fem oris, M. sarto riu s, Tendo
Lig. p atellae (Pes anserinus superficialis)*
Fig. 4.121 Ventral muscles of th e hip and thigh, and deep medial to r muscles, th e M . adductor brevis and parts of the M . adductor
muscles of th e thigh, right side; ventral view ; after removal o f the magnus.
Fascia lata, M m . sartorius, rectus fem oris, and adductor longus, and * com m on insertion of the M m . sartorius, gracilis and sem itendinosus
partial removal of the M. iliopsoas at the area of the hip joint.
The M . rectus fem oris and a part o f the M. adductor longus are - f T 42, 45, 46
reflected superiorly. A fte r removal o f the M . rectus fem oris, the M.
vastus interm edius o f the M. quadriceps fem oris is visible. The resec
tion of th e M . sartorius and M . adductor longus reveals the deep adduc
304
M uscles -» T o p o g ra p h y -► S ections M uscles of the hip and thigh
M. iliopsoas M. piriformis
M. sarto riu s C an a lis obturatorius
M. re c tu s fem oris
B ursa subtendinea iliaca M. p e c tin e u s
M. g lu te u s m ed iu s M. adductor longus
M . iliop so a s M . obturatorius externus
Trochanter m inor M. adductor brevis
M. pectineus M . quad ratus fem oris
M. a d d u c to r brevis M. add u ctor m inim us
M. vastus lateralis M. adductor m agnus
M. a d d u c to r longus
M. v a s tu s m edialis M. gracilis
M. vastus intermedius H iatus add uctorius
Femur M. a d d u c to r m ag n u s, Tendo
I M. sarto riu s, Tendo M. gracilis, Tendo
(P e s a n serin u s superficialis) < M. gracilis, Tendo
B ursa subtendinea m usculi sartorii
I M. se m ite n d in o su s, Tendo Bursa anserina
Fig. 4.122 V entral m uscles of th e hip and th ig h , and deep m edial neus and M . adductor brevis. The Canalis obtu ratorius is displayed as
muscles of th e thigh, right side; ventral view ; after alm ost com plete opening w ithin the Membrana obturatoria. It serves as neurovascular
resection of the superficial and som e of the deep muscles. passageway betw een the small pelvis and the thigh. Caudal of this
Upon reflecting the superficial adductor m uscles and the M. adductor opening, the alm ost horizontal fibres of the M . obturatorius externus
brevis laterally, the M . adductor m agnus becom es visible. Its upper and the M . quadratus fem oris are revealed, both o f w hich belong to
portion is also referred to as M . adductor m inim us. The M . adductor the pelvitrochanteric group of dorsal hip m uscles (-* p. 306). These
magnus and its tendon form the adductor hiatus (Hiatus adductorius) m uscles are often not displayed during the dissection classes and thus,
through w h ic h th e blood vessels o f th e thigh (A./V. fem oralis) pass to th e ir classes is m ore d iffic u lt to envision.
reach the popliteal fossa. Proximal, the insertion o f the M . iliopsoas at
th e Trochanter m ino r is recognisable a fte r resection o f th e M . pecti- -» T 4 2 -4 5 , 47
305
Lower Extremity S urface a n a to m y -► Skeleton Im aging
M uscles of the hip and thigh M. gluteus m edius
M. tensor
fasciae latae
M. obturatorius
externus
4.123b
M. sem itendinosus
M. g lu te u s m inim us C aput longum M. b ice p s
M. piriformis breve fem o ris
M. g e m ellu s su p erio r M. s e m im e m b ra n o su s
M. o b tu rato riu s
internus
M. g e m e llu s inferior
M. q u a d ra tu s fem oris
4.124
4.123c
Figs. 4.123a to c Dorsal muscles of th e hip, righ t side; dorsal Fig. 4.124 Dorsal (ischiocrural, ham string) muscles of th e th igh ,
vie w . right side; dorsal view.
The dorsal m uscles o f th e hip are categorized in a dorsolateral and a The dorsal (ischiocrural, ham string) m uscles (-* Fig. 4.124) on the
pelvitrochanteric group. posterior side o f th e thigh originate fro m the Tuber ischiadicum and in
The dorsolateral group com prises the M m . glutei maxim us, m edius sert to both bones o f the low er leg. These m uscles span tw o joints and
and m inim us. According to its innervation, the M . tensor fasciae latae facilitate extension in th e hip jo in t w h ile serving as stro ngest flexors in
(-» Fig. 4.117a) also m ay be counted am ong th is group. The M . gluteus th e knee joint. In addition, th e lateral M . biceps fe m o ris fu n ctio n s in
m axim us (-» Fig. 4.123a) is th e m o st im po rtan t extensor and lateral lateral rotation on both joints, whereas the medial M . sem itendino
ro ta to r o f th e hip and fo r exam ple necessary w h e n clim bing stairs. In sus and M . sem im em brano su s fun ction in m edial rotation .
contrast, the sm aller gluteal m uscles (M m . glutei medius and m ini
m us, -» Figs. 4.123b and c) are th e m o s t im po rtan t abductors and -» T 43, 44, 47
m edial rotators of the thigh. Their action stabilises the hip during
standing and w alking and prevents the tilting o f the pelvis to the con
tralateral side w hen standing on one leg (for the function o f the small
gluteal m uscles and th e TRENDELENBURG'S sign -» p. 335).
The pelvitrochanteric group (M. priform is, M m . obturatorii internus
and externus, M m . gem elli superior and inferior, M . quadratus fem oris
-* Fig. 4.123c) com prises exclusively lateral rotators.
306
M uscles -» T o p o g ra p h y -► S ections
M uscles of the hip and thigh
F a scia thoracolu m balis C rista iliaca Fig. 4.125 and Fig. 4.126 Dorsal m uscles of th e hip and thigh,
M. glute us m edius, righ t side; dorsal v ie w ; a fte r sp litting o f th e Fascia lata (-» Fig. 4.125)
4.125 Fascia and separation o f th e M . gluteus m axim us (-► Fig. 4.126).
The illustration show s the superficial and the deep origins and inser
M . glute us m axim u s tions of the M . gluteus m axim us. Superficially, the m uscle originates
Trochanter major fro m th e posterior side o f th e sacrum , th e Crista iliaca and th e Fascia
thoracolum balis as w ell as deeply from th e Lig sacrotuberale. Its mus
T ra c tu s iliotibialis cle fibres course in an oblique w ay, w hereas th e M . gluteus m edius
beneath has an alm ost vertical orientation. The M. gluteus maxim us
has superficial insertions at th e Fascia lata and th e Tractus iliotibialis
and deep insertions on the Tuberositas glutea o f th e Femur. Separation
and lateral reflexion of the M . gluteus m axim us reveals the other parts
o f the M . gluteus medius and the pelvitrochanteric muscles.
The M . piriform is divides the Foramen ischiadicum majus into the Fo
ram ina suprapiriform e and infrapiriform e w hich serve as im portant
passageways fo r neurovascular structures fro m th e pelvis. It should be
noted tha t the M . obturatorius internus frequently continues as a ten
dinous structure fro m its deflecting point (hypomochlion) at the Incisura
ischiadica m inor to its insertion at the Fossa trochanterica.
Fascia lata - * T 43, 44, 47
M . glute us m axim u s Fascia lata, (Fascia glutea)
M . glute us m edius
Foram en (Foram en suprapiriform e)
ischiad icu m m ajus (Fo ram e n infrapiriform e) M . piriform is
M. ge m ellu s su p erior
Spina ischiadica M . obtu ratorius internus
Fo ram en ischiad icu m M . g e m e llu s inferior
m inus Bursa trochanterica
m usculi glutei maximi
Lig. sa c ro tu b e ra le M. quad ratus fem oris
M. g lu te u s m axim us
Tuber ischiadicum M. adductor minimus
M. a d d u c to r m ag n u s
M. gracilis T u b e rosita s glutea
M. a d d u c to r m ag n u s
M. sem itendinosus dissection link 307
M. b ic e p s fem oris, C a p u t longum
4.126
Lower Extremity S urface a n a to m y -► Skeleton Im aging
M uscles of the hip and thigh
M. g lu te u s m axim us M . glute us m inim us
(Foram en infrapiriforme) (Foramen suprapiriforme)
M. obturatorius internus M. piriformis
M. g e m e llu s su p erio r
Lig. s a cro tu b era le M. tensor fasciae latae
M. o b tu ra to riu s internus M. gem ellu s inferior
M. q u a d ra tu s fem oris
Tuber ischiadicum
M. g lu te u s m ed iu s
M. a d d u c to r Trochanter major
Bursa trochanterica
M. gracilis m usculi glutei maximi
M . sem itend inosus
M . b ic e p s fem oris, C ap u t lo n gu m M. gluteus maximus
M. a d d u c to r m inim us
M . se m im em b ran o su s
M. se m ite n d in o su s, Tendo M. adductor m agnus
M. se m im e m b ra n o su s,
M. g a stro c n em iu s, C a p u t m ediale M. vastus lateralis
M . b ic e p s fem oris, C a p u t breve
b ic e p s fem oris, C ap u t lo n gu m
A. p o p litea
M. g a stro c n e m iu s, C a p u t laterale
Fig. 4.127 Dorsal muscles of th e hip and thigh, right side; dorsal m edially is the M . sem itendinosus (named after its long tendon) and
view ; after partial resection of the M m . glutei m axim us and medius. beneath the M . sem im em branosus (named after its flat tendon); posi
A fte r cutting the M . gluteus m edius in addition to the M. gluteus maxi tioned laterally is the M . biceps fem oris. The Caput longum o f the lat
m us, the M . gluteus m inim us is visible. C ollectively, th e M m . glutei te r originates from th e Tuber ischiadicum, w hereas the Caput breve
medius and m inim us are referred to as small gluteal muscles. Both originates fro m the distal thigh (Labium laterale o f the Linea aspera).
m uscles serve fo r hip abduction and stabilisation of the pelvis during
one-leg stand. -♦ T 43, 47
The dorsal side of the thigh contains the ham string muscles which
span fro m the Tuber ischiadicum to the bones o f the low er leg. Located
308
M uscles -» T o p o g ra p h y -► S ections M uscles of the hip and thigh
M. g lu te u s m axim us M. g lu te u s m ed iu s
M. piriformis M. gluteus minimus
(Foram en infrapiriforme) M. g e m ellu s inferior
M. gem ellus superior M. obturatorius internus, Tendo
B ursa trochanterica m usculi glutei medii
M. obturatorius internus Trochanter major
B ursa ischiadica m usculi obturatorii interni M . obturatorius externus
M. q uad ratus fem oris
Lig. s a cro tu b era le
M . b ic e p s fem oris, C a p u t lo n gu m B ursa trochanterica m usculi glutei maximi
M. iliopsoas, Tendo
M. sem ite n d in o su s Trochanter minor
Foram en ischiadicum minus M. gluteus m axim us
M. sem im em branosus, Tendo M . add u ctor m inim us
M. gracilis M. v a s tu s lateralis
M. adductor m agnus M . b ic e p s fem oris, C a p u t lo n gu m
M . b icep s fem oris, C ap u t breve
M. sem im em branosus
F ossa poplitea
M. sem itendinosus, Tendo
M. sem im em branosus, Tendo M. g a stro c n em iu s, C a p u t laterale
M. g a stro c n em iu s, C a p u t m ediale
Fig. 4.128 Deep dorsal muscles o f th e hip and th igh , rig h t side; nent originates fro m the inferior pubic ramus (this part is som etim es
dorsal view ; after alm ost com plete resection of the superficial gluteal referred to as M . adductor minimus) and the ischial ramus. The poste
and ham string muscles. rior part derives from the Tuber ischiadicum and, according to its func
Upon splitting the M. quadratus fem oris, the deeper M . obturatorius tion and innervation, is counted am ong th e ham string m uscles.
externus is visible; its course is often d ifficu lt to imagine. Removal of
the long head of the M . biceps fem oris exposes the deep com ponents -► T 43, 44, 46, 47
o f the adductor group. The M . adductor m agnus has tw o functionally
independent m uscle parts w ith distinct innervation. Its major com po
Lower Extremity S urface a n a to m y -► Skeleton Im aging
Muscles of the thigh
M. v a s tu s m edialis M . sem itend inosus
M . se m im em b ran o su s
M . sartorius M . gra cilis, Tendo
M. s e m im e m b ra n o su s, Tendo
Patella
Retinaculum patellae m ediale M. s e m ite n d in o su s, Tendo
C orpus adiposum infrapatellare M. gastrocnem ius, C aput m ediale
Lig. p atellae
(Pes anserinus superficialis)
4.129—
M. a d d u c to r m ag n u s M. v a s tu s lateralis
M. b ic e p s fem oris, C a p u t b rev e
M. gracilis Femur, Linea a sp era
Hiatus adductorius
M. vastus medialis M. b ic e p s fem oris, C a p u t longum
M. a d d u c to r m ag n u s, Tendo
Femur, F o ssa poplitea
M. s e m im e m b ra n o s u s M. plantaris
Articulatio genus, C apsula articularis
M. sartorius
M . sem im em b ranosus, biceps femoris, Tendo
Tendo (Pes anserinus profundus)
M. gastrocnem ius, C aput m ediale
M . gra cilis, Tendo M. g a stro c n em iu s, C a p u t laterale
M . se m ite n d in o su s, Tendo
4.130
Fig. 4.129 and Fig. 4.130 Muscles in th e region of th e knee jo int, rinus superficialis". The deeply located insertion of the M . sem im em b
rig h t side; m edial (-* Fig. 4.129) and dorsal (-* Fig. 4.130) view s. ranosus is called "P es anserinus pro fu n d u s".
The com m on insertion o f the M m . sartorius, gracilis, and sem itendino
sus beneath th e m edial condyle o f th e Tibia is referred to as " Pes anse- —►T 4 5 -4 7
310
M uscles -► T o p o g ra p h y -► S ections
M uscles of the leg
plantaris
M. tibialis f Caput M. tibialis
anterior I laterale digitorum longus posterior
M. g a stro c n em iu s
M. e x te n so r I Caput M. s o le u s M. flexor
digitorum longus l m ediale hallucis longus
M. e x te n so r M. fibularis [peroneus]
hallucis longus longus
M. fibularis [peroneus]
brevis
Tendo
calcaneus
4.131
4.133a
4.132
Fig. 4.131 to Fig. 4.133 Muscles of th e leg, righ t side; ventral and function as plantarflexors in the ankle jo in t due to the ir tendons
(-» Fig. 4.131), lateral (-» Fig. 4.132), and dorsal (-* Fig. 4.133) view s. positioned behind the flexion-extension axis. Dorsally located are the
The leg has three m uscle groups. To understand their function, the tru e fle xo r m uscles (plantarflexors) w h ich can be divided in a superficial
position in relation to th e axes o f m o v e m e n t in th e jo in ts o f th e ankle and a deep group.
and fo o t are im portant. All m uscles coursing anterior to the transverse The M . triceps surae (-» Fig. 4.133a) is part o f th e superficial dorsal
axis o f the ankle jo in t are extensors (dorsiflexors), all m uscles dorsal m uscles and com prises the tw o-headed M . gastrocnem ius and the
to this axis are flexors (plantarflexors) of th e foot. All m uscles w ith M . soleus beneath. The M. triceps surae is the strongest flexo r and
tendons coursing m edial to the oblique axis of the talocalcaneonavicu m ajor supinator o f th e foo t. The M . plantaris is rather insignificant.
lar joint function as supinators and lift the medial margin o f the foot. The deep dorsal m uscles (flexors; -» Fig. 4.133b) are largely equivalent
M uscles w ith tendons lateral to this axis lift the lateral margin of the to th e extensors on th e ventral side. The M . tib ialis po sterio r is a fle
foot and thus perform pronation. xor and a strong supinator. The M . flexor digitorum longus and M.
The ventral m uscles o f th e leg fun ction as extensors (-► Fig. 4.131). flexor hallucis longus flex the phalangeal joints. A special role has the
They extend the ankle joint and the talocalcaneonavicular joint, M . popliteus w hich stabilises the knee joint. Above the medial M alleo
together w ith the oth er joints of the foot, they mainly support prona lus, the tendon o f the M . flexo r digitorum crosses the tendon o f the M.
tion. The M . tib ialis anterior is th e m ost im portant extensor tibialis posterior (Chiasma cruris) and at the level of the sole o f the
(-» Fig. 4.131), w hereas th e M . exten sor digito ru m longus and M . foot, it crosses the tendon o f the M . flexor hallucis longus (Chiasma
extensor hallucis longus also extend the toes. plantare).
The lateral (fibular) m uscles o f the leg (-* Fig. 4.132) com prise th e M m .
fibularis longus and brevis. They are the m o st im portant pronators —►T 4 8 -5 1
311
Lower Extremity S urface a n a to m y -► Skeleton Im aging
M uscles of the leg Patella
Tuberositas tibiae
T ractu s iliotibialis
Lig. p atellae M. gastrocnem ius
M . fibularis [peroneus] lo n g u s Tibia, F acies m edialis
M . tibialis anterior
M. tibialis anterior, Tendo
M . e x te n so r d igitoru m lo n g u s M alleolus medialis
M . fibularis [pe rone us] brevis Retinaculum m u sculoru m extensorum
Septum interm usculare cruris anterius M. e x te n s o r hallucis longus, Tendo
M. e x te n s o r hallucis brevis
M. e x te n so r hallucis longus, Tendo
M alleolus lateralis
M. extensor digitorum longus,
M . fib u la ris [p e ro n e u s] tertius, T e nd o
M. extensor digitorum brevis
Fig. 4.134 Ventral and lateral muscles of th e leg and th e foot, the fascia o f the leg, the R etinaculum m usculorum extensorum . The
rig h t side; ventral view . retinacula of the fo o t function as retainers and prevent the tendons
The M . tibialis anterior o f the extensor group can be palpated near the from lifting o ff the bones during extension of the foot. Both m uscles of
margin o f the Tibia. Since its tendon courses medial to the axis o f the the fibularis group (M m . fibulares longus and brevis) belong to the
talocalcaneonavicular joint, it functions as a (although weak) supinator lateral group and originate fro m the proximal and distal Fibula. Clinically,
in con trast to th e o th e r extensors. The M . extensor digito ru m longus th e y are o fte n referred to by th e ir old nam e as peroneal m uscles (fibula,
derives fro m th e proxim al Tibia and Fibula, and th e M . extensor hallu greek: perone).
cis longus is located b e tw een th e o th e r tw o extensors at th e distal leg.
Occasionally, the M. extensor digitorum longus show s a separation -► T 48, 49
th a t inserts at the Os m etatarsi V and is confusingly called M . fibularis
te rtiu s. In th e distal part, th e ten don s are guided by a re in force m en t of
312
M uscles -♦ T o p o g ra p h y -► S ections
M uscles of the leg
Fig. 4.135 Muscles of th e leg and th e fo o t, rig h t side; lateral view . tatarsi V, w hereas the tendon o f the M. fibularis longus extends be
In th e lateral v ie w , all th re e m uscle groups o f th e leg are visible. neath the sole of the fo o t and inserts at the Os metatarsi I and Os cu-
Laterally behind the anterior group o f extensors lie the fibularis m us neiform e mediale, thus actively supporting the plantar arch. It should
cles, dorsally lie the flexors. Since the deep flexors o f the rear side are be noted th a t th e M . extensor hallucis longus is found distally be
directly adjacent to th e bones o f the leg, only the superficial m uscles tw een the M . tibialis anterior and the M . extensor digitorum longus.
(M. triceps surae), the M . gastrocnem ius and the M . soleus, can be
seen. The tendons of th e fibularis group are guided by the Retinacula -► T 4 8 - 5 0 , 52
m usculorum fibularium . The M . fibularis brevis inserts at the Os m e
313
Lower Extremity S urface a n a to m y -► S keleton - * Im aging
M uscles of the leg M. b ic e p s fem oris
M . plantaris
M. sem ite n d in o su s
M. sem im em branosus M . g a stro c n e m iu s, C a p u t laterale
M. gracilis
M. sem itendinosus, Tendo
M. se m im e m b ra n o su s, Tendo
M . g a stro c n e m iu s, C a p u t m ediate
M . soleu s M. soleu s
M alleolus lateralis
M . plantaris, T e nd o
Fascia cruris
M alleo lu s
Tendo c a lc a n e u s (ACHILLES ten d o n )
Tuber calcanei
Fig. 4.136 Superficial layer of th e dorsal muscles of th e low er and the strongest supinator of the foot, even stronger than the M . tibi
leg, right side; dorsal view. alis posterior. If it is paralysed, such as after a disc herniation w ith result
The superficial group of flexors com prises the M . triceps surae and the ing injury to th e spinal cord se g m e n t S1 or a lesion o f th e N. tibialis,
M . plantaris. The strong M. triceps surae includes the two-headed standing on one’s toes is im possible.
M . gastrocnem ius and th e subjacent M . soleus. All superficial dorsal
m uscles insert at the Calcaneus via the ACHILLES tendon (Tendo cal —►T 50
caneus). The M. triceps surae is the strongest flexor o f the ankle joint
314
M uscles -♦ T o p o g ra p h y -► S ections M uscles of the leg
M. gastrocnem ius, C aput M. biceps femoris
M. s e m im e m b ra n o su s M. g a stro c n em iu s, C a p u t laterale
Lig. popliteum arcu atu m
Bursa subtendinea musculi
gastrocnem ii medialis M. gastrocn em ius
M. fibularis [peroneus] longus
Bursa m usculi sem im em branosi
Lig. popliteum obliquum
Tibia, Condylus
M . plantaris
A.; V. poplitea; A rcus te n d in e u s m usculi solei
M. soleu s
M . plantaris, T endo
M . fle xo r d igitoru m lo n g u s M . flexor h allu cis lo n g u s
M . tibialis posterior, T endo Septum interm usculare cruris posterius
M alleolus m edialis Retinaculum m usculorum
Tendo c a lc a n e u s (ACHILLES ten d o n ) fibularium [peroneorum]
R e tin aculum m u sc u lo ru m flexorum
Tuber calcanei
Fig. 4.137 Superficial layer of th e dorsal m uscles of th e lo w er ACHILLES tendon after removal o f the Fascia cruris. Their tendons are
leg, right side; dorsal view ; after dissecting the origins of the M. guided by the Retinaculum musculorum flexorum at th e medial
ga strocn em ius. m a lle o lu s.
A fte r re flecting th e M . gastrocnem ius inferiorly, th e M . plantaris is
visible proximal of the M . soleus. The m uscle bellies o f the deep fle —►T 51
xors are located further distally and are visible on both sides of the
315
Lower Extremity S urface a n a to m y -► Skeleton Im aging
M uscles of the leg Femur, Facies poplitea
biceps femoris
M. gastrocnem ius, Caput
M. g a stro c n e m iu s, C a p u t laterale
Bursa subtendinea musculi M. plantaris
gastrocnem ii medialis
M . p op liteus
Bursa m usculi sem im em branosi
M. sem im em branosus,
Lig. popliteum obliquum
M . tibialis posterior, T endo M. soleu s
Fibula, M argo interosseus
M . flexor digitorum lo n g u s
M . tibialis M. fibularis [peroneus] longus
M . flexor hallu cis lo n g u s
(C hiasm a
M . flexor digitorum longus, Tibia
M. flexor hallucis longus, Tendo
M alleolus medialis
M. tibialis posterior, Tendo R etinaculum m usculorum fibularium
Retinaculum m usculorum flexorum [peroneorum]
T en d o c a lc a n e u s (ACHILLES ten d o n ) Tuber calcanei
Fig. 4.138 Deep layer o f th e dorsal m uscles of th e leg, rig h t side; tendon of the M. tibialis posterior (Chiasma cruris). Proximal, the M .
dorsal view ; after removal of the superficial flexors. popliteus originates fro m the Condylus lateralis and from the posterior
A fte r removal of th e superficial flexors the deep m uscles are visible. horn of th e lateral meniscus. The m uscle inserts on the posterior as
The M . tib ialis po sterio r is located b e tw e e n both fle xo r m uscles of pect o f th e proxim al Tibia and fu n ctio n s as a relatively stro ng m edial
th e toes. The M . flexor digitorum longus originates furthest m edially rotator. Thus, the prim ary function o f the M . popliteus is to actively
follow ed by the M . tibialis posterior and further distal by the M . flexor stabilise the knee and to prevent an extensive lateral rotation.
hallucis longus. Their tendons m eet beneath the medial malleolus
w here they are covered by the Retinaculum musculorum flexorum . —►T 51
In th is course th e tendon o f th e M. fle x o r d igito rum longus crosses the
316
M uscles -» T o p o g ra p h y -► S ections M uscles of the leg
B u rsa subtendinea m usculi M. g a stro c n em iu s, C a p u t m ediate
g a stro c n e m ii m e dialis M. plantaris
M. popliteus
B u rsa m usculi se m im em b ran osi biceps fem oris, Tendo
Tibia, Condylus m edialis
M . popliteus R e c e ss u s su b p op liteu s
Tibia Fibula, M argo interosseus
M. s o le u s
M. flexor digitorum longus
M. flexor hallucis longus
M. tibialis
M. flexor hallucis lo n g u s, Tendo
M. tibialis posterior, M. fibularis [peroneus] brevis
M. flexor digitorum longus, Retinaculum m usculorum fibularium
Retinaculum m usculorum flexorum [peroneorum]
Tendo c a lc a n e u s (ACHILLES ten d o n )
Fig. 4.139 Deep layer of th e dorsal muscles o f th e leg, righ t side; sae are present beneath th e tendinous origins and insections of the
dorsal view ; after removal of the superficial flexors and splitting of the dorsal muscles (Bursa musculi sem im em branosi and Bursae sub-
M. popliteus. tendineae m usculorum gastrocnem ii m edialis and lateralis). These
Upon s p litting o f th e M . popliteus, th e Bursa subpoplitea is exposed. also may com m unicate w ith the jo in t cavity (-* p. 280).
This bursa frequently com m unicates w ith the joint cavity of the knee
jo in t and is often referred to as Recessus subpopliteus. Additional bur —►T 51
317
Lower Extremity S urface a n a to m y -► Skeleton Im aging
Synovial sheaths of the foot M. tibialis anterior, Tendo
M. e x te n s o r hallucis longus
M. e x te n s o r digitorum longus M alleolus medialis
Lig. tibiofibulare a n teriu s V agin a te n d in is m u sc u li tibialis anterioris
V agin a ten d in is m u sc u li e x te n so ris hallu cis longi
Retinaculum m usculorum
extensorum V agin a ten d in um m u sc u li e xte n so ris
d igitoru m p e d is longi
Malleolus lateralis
M . tib ialis anterior, T e nd o
Retinaculum m usculorum fibularium M. extensor hallucis brevis
[peroneorum]
C orpus ossis m etatarsi I
V agin a c o m m u n is ten d in um m u scu loru m M. e x te n s o r hallucis brevis, Tendo
fib ularium [peroneorum ]
M . e x te n so r h allu cis longus,
M . fibularis [pe rone us] brevis, Tendo Tendo
M. e x te n s o r digitorum brevis
T uberositas o ssis m etatarsi quinti
M. a b d u c to r digiti minimi
M . fib u la ris [p e ro n e u s] tertius, T e nd o
(M. o p p o n e n s digiti minimi)
M . e x te n so r d igitoru m lo n gu s, T endines
Mm. interossei dorsales pedis
Fig. 4.140 Synovial sheaths, Vaginae tendinum , of th e foot, right tractions. Each exte nsor m uscle has its o w n synovial sheath (Vagina
side; dorsal v ie w in relation to th e dorsum o f th e foot. tendinis) w h ich encloses all tendons o f th e respective m uscle and
The Fascia cruris w as rem oved except fo r the Retinaculum m usculo serves as guiding tub e as w e ll as gliding surface. In contrast, th e te n
rum extensorum . The retinacula of the fo o t serve as retaining straps dons of the M . fibularis longus and M . fibularis brevis have a com m on
and prevent the tendons from lifting o ff the bones during m uscle con synovial sheath.
318
M uscles -» T o p o g ra p h y -► S ections
Synovial sheaths of the foot
V agina te n d in is m usculi tibialis a n terio ris Vagina tendinis m usculi
tibialis posterioris
R etinaculum m usculorum extensorum inferius Vagina tendinis m usculi
V agina te n d in is m usculi e xten s o ris h allu cis longi fle xo ris d ig ito ru m longi
V agina te n d in is m usculi fle xo ris h allu cis longi V agina tendinis m usculi
M . a b d u cto r hallucis, Tendo fle xo ris h allu cis longi
Tendo calcaneus
Retinaculum m usculorum
fle x o ru m
V agina tendinis m usculi
tibialis posterioris
M. a bd ucto r hallucis
V aginae tendinum V agina tendinis m usculi M. fle xor d igitorum brevis
digitorum pedis fle xo ris d ig ito ru m longi
4.141
M. extensor hallucis longus, Tendo V ag in a te n d in u m m usculi e xten s o ris d ig ito ru m longi
M. extensor digitorum longus, Tendo R etinaculum m usculorum extensorum inferius
M. fibularis [peroneus] brevis V agina te n d in is m usculi e xten s o ris hallucis longi
M . extensor hallucis brevis
Fibula
M. fibularis [peroneus] longus M. extensor digitorum
longus, Tendines
Tendo calcaneus
Retinaculum m usculorum
fibularium [peroneorum]
Vagina c om m unis tendinum m usculorum M. extensor digitorum brevis
fibularium [peroneorum ] M . fibularis [peroneus] tertius, Tendo
4.142 M. fibularis [peroneus] brevis, Tendo
Fig. 4.141 and Fig. 4.142 Synovial sheaths. V aginae te n d in u m , of retinacula. The Retinaculum m usculorum flexorum form s the m alleo
th e fo o t, rig h t side; m edial (-» Fig. 4.141) and lateral (-» Fig. 4.142) lar canal behind the medial malleolus w hich serves as a passageway
vie w s . fo r th e neurovascular stru cture s (N. tibialis, A./V. tibialis posterior) to the
The synovial sheaths surround the tendons o f all three m uscle groups sole o f the foot.
o f the leg particularly w here the tendons are fixed to the bones by the
Lower Extremity S urface a n a to m y -► Skeleton Im aging
Muscles of the foot M. tibialis anterior, Tendo
M alleolus medialis
M. extensor hallucis longus
M . extensor digitorum longus M . tib ialis anterior, Tendo
M . extensor hallucis longus, Tendo
M alleolus lateralis M . e xten s o r hallucis brevis
Retinaculum m usculorum extensorum
M. fibularis [peroneus] brevis, Tendo
R etinaculum m usculorum fibularium
[pe ro n eo ru m ]
M . e xten s o r dig ito ru m brevis
M. fibularis [peroneus] tertius, Tendo
M. extensor d igito ru m longus, Tendines
M. a bd ucto r digiti
M m . interossei
Fig. 4.143 Muscles of th e dorsum of th e fo ot, right side; dorsal nally into the dorsal aponeurosis. Therefore, th e y contribute to the ex
view. ten sion in th e phalangeal jo in ts and th e m etatarsophalangeal jo in t of
Beneath the tendons o f th e long extensor muscles, w hich have their the big toe. The M m . interossei dorsales are also visible, but they are
m uscle bellies at the ventral side o f the leg, there are tw o short exten grouped w ith th e plantar m uscles (-* p. 325).
sors. The M . extensor digitorum brevis and M . extensor hallucis
brevis originate on the dorsal side of the Calcaneus and their tendons -» T 48, 52, 54
insert from lateral into the tendons o f the long extensors and additio
320
M uscles -» T o p o g ra p h y -► S ections Muscles of the foot
M. fibularis [peroneus] tertius M. tibialis anterior, Tendo
M. extensor digitorum longus M. e xtensor hallucis longus
Retinaculum m usculorum extensorum
M alleolus lateralis
M. fibularis [peroneus] brevis, Tendo M . e xten s o r hallucis brevis
M . e xten s o r dig ito ru m brevis M m . interossei dorsales
M. fibularis [peroneus] tertius, Tendo
M. a b d u cto r digiti minim i
M. e xtensor d igito ru m longus,
T e n d in e s
Fig. 4.144 M uscles o f th e dorsum of th e fo o t, righ t side; dorsal the big to e (M. extensor hallucis brevis). These m uscles originate from
view. the dorsal side o f the Calcaneus and project to the dorsal aponeurosis
The Retinaculum m usculorum extensorum was split and the tendon of of the second to fourth phalanges or to the dorsal side of th e big toe.
the M . extensor digitorum longus partially removed to dem onstrate the
m uscles of the dorsum of the foot. They com prise the short extensor -► T 4 8 , 5 2 , 5 4
m uscles of th e lateral fo u r toes (M. extensor digitorum brevis) and of
321
Lower Extremity S urface a n a to m y -► Skeleton Im aging
Muscles of the foot
Fasciculi transversi Lig. m e ta ta rs a le transversum
A poneurosis plantaris s uperficiale
Fasciculi longitudinales
M alleolus lateralis M alleolus medialis
M. a b d u cto r hallucis
Bursa subcutanea calcanea
Fig. 4.145 Plantar aponeurosis. Aponeurosis plantaris, of th e by transverse fib re s (Fasciculi transversi). These transverse fibres are
fo o t, rig h t side; plantar view . collectively referred to as Lig. m etatarsale transversum superficiale.
The plantar aponeurosis is a plate o f dense connective tissue w ith a Tw o septa course fro m the plantar aponeurosis to the bones, thus,
strong medial and tw o w eaker lateral parts. The Fasciculi longitudina creating spaces fo r three plantar m uscle groups.
les project fro m th e Tuber calcanei to th e ligam ents o f th e m etatarso
phalangeal joints. A t the level o f the Ossa m etatarsi they are connected
322 —* d is s e c tio n lin k
M uscles -♦ T o p o g ra p h y -► S ections Muscles of the foot
Vaginae tendinum digitorum pedis Pars cruciform is Vagina tendinis m usculi
Pars anularis fle xo ris hallucis longi
M m . lu m b rica le s p e d is I—IV
M. a dd ucto r hallucis, C aput transversum M. fle x o r hallucis longus, Tendo
M. fle xor hallucis brevis
M . in terosse us p la n ta ris III
M . a b d u c to r digiti m inim i M . a b d u c to r hallucis
M. fle xor digiti m inim i brevis
M . fle x o r d igitorum brevis
A poneurosis plantaris
Tuber calcanei
Fig. 4.146 Superficial layer of plantar muscles, right side; plantar The m uscles of the superficial layer com prise the M . abductor hallu
view ; after removal of the plantar aponeurosis. cis, M . flexor digito ru m brevis and M . abductor digiti m inim i. The
In contrast to th e hand, th e m uscles o f th e sole o f th e fo o t do n o t serve tendons o f the M . flexor digitorum brevis are pierced by the tendons of
fo r diffe re n tia te d m o ve m e n ts o f individual toes b u t serve in actively the long flexors. A t th e level of th e toes, the tendons of the flexor
bracing th e plantar arch as a functional m uscle unit. The plantar m us m uscles have separate synovial sheaths (Vaginae ten dinum ) w h ic h do
cles support the ligam ents w hich accom plish a passive stabilisation. not com m unicate w ith those at the tarsal level. The synovial sheaths
The plantar m uscles are separated into three different groups (medial, are reinforced by ligam ents containing anular (Pars anularis) and cruci
interm ediate and lateral) by tw o septa w hich project fro m the plantar fo rm (Pars cruciform is) com ponents.
aponeurosis to the bones. These groups are not easily separated during
dissection, and it is easier to dissect four layers of muscles. -► T 5 2 - 5 5
323
Lower Extremity S urface a n a to m y -► Skeleton Im aging
Muscles of the foot
M . fle xor hallucis longus, Tendo
Vaginae ten d inu m d igito ru m pedis
M. fle xor digitorum brevis, M. a d d u cto r hallucis,
Tendines C aput transversum
M. fle xor hallucis brevis
M m . lu m b r ic a le s p e d is I—IV
M. fle xor digiti m inim i brevis M . fle x o r digitorum longus, Tendo
M . a bd ucto r d igiti minim i M . fle x o r hallucis longus, Tendo
M . in terosse us p la n ta ris III
M . in te ro sse u s d o rs a lis p e d is IV M . a bd ucto r hallucis
M . fibularis [peroneus] longus, Tendo
M. fle xor d igitorum brevis
M . quadratus plantae Tuber calcanei
M . a b d u cto r d igiti m inim i
Fig. 4.147 M iddle layer of th e plantar muscles, right side; plantar serves as origin fo r th e M . qu adratus plan tae w h ich fu n ctio n s as an
view ; after dissection of the M . flexor digitorum brevis. accessory flexo r supporting the long flexo r muscle. The tendon also
The m uscles lie in fo u r layers on to p o f each other. Upon resection of serves as origin fo r th e fo u r M m . lum bricales w hich insert from m e
the M . flexor digitorum brevis, the m uscles and tendons of the second dial on th e proxim al phalanges o f th e toes (II—V).
layer are visible. It consists o f the tendons of the long flexors (M . flexor
hallucis longus and M . flexor digitorum longus) and of tw o muscles —►T 5 3 -5 5
of the interm ediate group. The tendon of the M. flexor digitorum longus
324
M uscles -♦ T o p o g ra p h y -► S ections Muscles of the foot
M. fle x o r d igito ru m longus, Tendines
M m . lu m b rica le s p e d is I—IV M. fle xor hallucis longus, Tendo
M . interosseus d orsalis pedis III M. fle x o r d igito ru m brevis, Tendines
M m . in te ro s s e i p la n ta re s III e t II
C aput transversum 1
M . interosseus d orsalis pedis IV M . a d d u c to r hallucis
M . o p p o n e n s digiti m inim i
— C aput obliquum I
M . fle x o r digiti m inim i brevis M . fle x o r hallucis brevis
M. a b d u cto r d igiti m inim i
M. a bd ucto r hallucis
M . fibularis [peroneus] longus, Tendo M . fle xor hallucis longus, Tendo
M . tibialis posterior, Tendo
M . quadratus piantae (C hiasm a plan tare)
M . fle xo r digitorum longus, Tendo
Lig. plantare longum
M. a bd ucto r digiti minim i fle xor hallucis longus, Tendo*
M . a bd ucto r hallucis
A poneurosis plantaris M. fle xor digitorum brevis
Fig. 4.148 Deep and deepest layers of th e plantar muscles, righ t The deepest layer com prises three M m . interossei plantares and
side; plantar vie w ; after removal o f both superficial m uscle layers and four M m . interossei dorsales as w e ll as the tendons of the M . tib ia
the long flexor tendons. lis posterior and M . fibularis longus.
W ithin the deep layer the M . flexor hallucis brevis and M . adductor
hallucis are located medially, the M . flexor digiti m inim i brevis and * The crossing of the M. flexor digitorum longus tendon over the M.
the inconsistent M . opponens digiti m inim i laterally. flexo r hallucis longus tendon is also referred to as Chiasma plantare.
M m . interossei M m . interossei
d o rsa le s p e d is I—IV plantares l-lll
4.149 4.150
Fig. 4.149 and Fig. 4.150 M m . interossei dorsales (-» Fig. 4.149) Thus, the m uscles can flex the metatarsophalangeal joints, abduct the
and plantares (-» Fig. 4.150) of th e fo ot, right side; dorsal toes II to IV laterally, and additionally adduct th e second toe.
(-* Fig. 4.149) and plantar (-» Fig. 4.150) view s. The three M m . interossei plantares (l-lll) have only one head and
The fo u r M m . interossei dorsales (I—IV) are tw o-headed and originate originate fro m th e plantar side o f th e Ossa m etatarsi III to V. They insert
fro m opposing sides o f th e bases o f th e Ossa m etatarsi I to V. They on the medial side of the respective toes. They serve for flexion o f the
insert on the proximal phalanges o f the second to fourth toes in such a metatarsophalangeal joints and adduction o f the toes.
w a y th a t m uscles I and II p roject m edial and lateral to th e second toe,
w hereas m uscles III and IV course lateral to th e third and fo u rth toe. - » T 53-55
325
Lower Extremity S urface a n a to m y -► Skeleton Im aging
Plexus lumbosacralis
R. cu ta n e u s lateralis Plexus lum balis
N. iliohypogastricus (T 12, L1)
N. ilioinguinalis (T12, L1)
N. g e n ito fe m o ra lis (L 1 , L2) fem oralis
R. gen italis
N. cu ta n e u s fe m o ris la teralis (L 2 , L3)
N. fem o ralis (L2-L4) Plexus sacralis
N. obtu ratorius (L2-L4) P le x u s
coccygeus
N. g lu teu s su p erio r (L4, L5; S1)
Truncus lum bosacralis (L4-L5)
N. g lu teu s in fe rio r (L5; S 1 , S2)
N. fibularis
N. is c h ia d ic u s I communis
(L4, L5; S 1-S 3) |
N. tibialis
N. cutaneus fem oris posterior (S 1-S 3) N .a n o c o c c y g e u s
N. pudendus (S 2-S 4)
Rr. m u s cu la res *
N. coccygeus
Fig. 4.151 Lumbosacral plexus, Plexus lumbosacralis (T12-S5, trom edial aspect o f the leg. The N. obturatorius conveys m o tor fibres
Co1): segm ental organisation of the nerves, right side; ventral view. to the adductor m uscles and sensory fibres to the medial thigh. The
The low er e xtrem ity is innervated by the Plexus lumbosacralis. The strongest and longest branch o f the Plexus sacralis is the N. ischiadi
plexus is com posed o f Rr. anteriores o f th e spinal nerves w h ich origina cus. W ith both o f its divisions (N. tibialis and N. fibularis) th e N. ischia
te fro m the lumbar, sacral, and coccygeal segm ents o f the spinal cord dicus provides m otor innervation to the hamstring m uscles (extensors
and com bine to form the Plexus lum balis (T12-L4) and the Plexus in th e hip and fle xo rs in th e knee) and to all m uscles in th e leg and th e
sacralis (L4-S5, Co1). The seg m ents S4-Co1 are also referred to as fo o t as w ell as sensory innervation to the calf and foot. The Nn. glutei
Plexus coccygeus. Both plexuses are connected by the Truncus lum superior and inferior innervate the gluteal m uscles w hich represent
bosacralis w hich conveys nerve fibres from th e spinal cord segm ents th e m ajor extensors, rotators, and abductors o f th e hip. The INI. puden-
L4, L5 fro m the Plexus lumbalis to the small pelvis. The functionally dus provides m otor innervation to the m uscles of the perineal region
m o st im po rtan t nerves o f th e Plexus lum balis are th e N. fem ora lis and and sensory innervation to the external genitalia. The m uscles o f the
th e N. obturatorius. pelvic floor are innervated by direct branches (*) of the sacral plexus.
The N. fem oralis provides m otor innervation to the ventral m uscle
group o f the hip and thigh (flexors in th e hip and extensors in th e knee) -►T40
and sensory innervation to the ventral aspect of the thigh and the ven
326
M uscles -» T o p o g ra p h y -► S ections
Innervation of the lower extrem ity by the Plexus lumbosacralis
N. iliohypogastricus N. gluteus superior
N . ilioinguinalis
N. cutaneus N. gluteus inferio r
N .pudendus
fe m o ris lateralis
N. genitofem oralis N. cutaneus
fe m o ris p o sterio r
N . fem oralis N. ischiad icus
N. obturatorius
N .saphenus■
N. fib u la ris c o m m u n is ----------- 4 N. cutaneus surae N. tibialis
m e d ia lis
N. fibularis profundus ■ N. fibularis com m unis
N. fibularis superficialis N. cutaneus surae lateralis
R. c o m m u n ic a n s fib u la ris Plexus lumbalis (T 12-L 4)
N .sa p h e n u s
N. su ra lis m otor branches to the M . iliopsoas and
N. cutaneus dorsalis M . quadratus lum borum (T12-L4)
interm edius N. cutaneus dorsalis lateralis N. iliohypogastricus (T12, L1)
N. plantaris lateralis N. ilioinguinalis (T12, L1)
N. cutaneus dorsalis medialis N. plantaris medialis N. ge nitofe m ora lis (L1, L2)
N. cutaneus fe m o ris lateralis (L2, L3)
Nn. digitales dorsales pedis 4.153 N. fem ora lis (L2-L4)
N. ob tura torius (L2-L4)
4.152
Plexus sacralis (L 4 -S 5 , C ol)
Fig. 4.152 and Fig. 4.153 Lum bosacral plexus. Plexus
lumbosacralis (T12-S5, Co1): nerves of th e lo w er extrem ity, right m otor branches fo r the pelvitrochan-
side; ventral (-* Fig. 4.152) and dorsal (-» Fig. 4.153) view s. teric m uscles of the hip (M.
The nerves o f the Plexus lum balis (T12-L4) course ventral to the hip obturatorius internus, M m . gemelli
jo in t and innervate the inferior part of the anterolateral abdominal wall superior and inferior, M . quadratus
and the ventral aspect of the thigh. The branches of th e Plexus sacralis fem oris, M. piriformis; L4-S2)
course dorsal to the hip joint. They innervate the posterior side o f the N. gluteus superior (L4-S1)
thigh, the major part of the leg and the w hole foot. N. gluteus infe rior (L5-S2)
N. ischiadicus (L4-S3)
N. cutaneus fe m o ris po sterior (S1-S3)
cutaneous branches to the skin of the
ischial tu b e ro sity (N. cutaneus
perforans, S2, S3) and coccyx (N.
anococcygeus, S5-Co1)
N. pudendus (S2-S4)
Nn. splanchnici pelvici (preganglionic
parasympathetic fibres; S2-S4)
m otor branches to the pelvic floor
(M. levator ani and M . ischiococcygeus,
S3, S4)
327
Lower Extremity S urface a n a to m y -► Skeleton Im aging
Innervation of the skin
N. ilioh ypogastricus, Nn. lum bales, N. iliohypogastricus,
R. cu ta n e u s lateralis clun ium superiores R. cutaneus lateralis
N. cutaneus
fe m o ris lateralis
R. fem oralis N. ilioh ypogastricus,
R. cutaneus anterior
N. genito- Nn. sacrales,
fem oralis N. ilioinguinalis, N n . clun ium m edii
Nn. scrotales anteriores
R. genitalis i= ïO
N. obturatorius,
R. cutaneus N . cutaneus N. cutaneus
fe m o ris posterior, fem oris lateralis
Nn. clunium inferiores
N . cutaneus /
fem o ris po sterio r
N. fem oralis,
Rr. cu ta n e i a n te rio re s
N. obturatorius,
R. cu ta n eu s
/
N. fibularis com m unis,
N. cutaneus surae lateralis
(N. ischiadicus)
N. fibularis com m unis, N .sa p h e n u s,
N. cutaneus surae lateralis Rr. cu ta n e i cru ris
m ediales (N. fem oralis)
(N. ischiadicus)
N. saphenus,
Rr. cu ta n e i cru ris m e d iales
(N. fem oralis)
N. suralis, N. cutaneus. N. fibularis profundus, N. suralis
dorsalis lateralis Nn. digitales dorsales pedis (N. ischiadicus)
(N. ischiadicus)
(N. cutaneus 4.155
d o r s a lis
interm edius
N. cutaneus ■
dorsalis medialis
4.154
Nn. lum bales N. iliohypogastricus N. genitofem oralis N. obturatorius N. fibularis
Nn. sacrales N. cutaneus fem oris lateralis N. fem oralis N. cutaneus fem oris posterior N. suralis
Fig. 4.154 and Fig. 4.155 Cutaneous nerves of th e low er Plexus sacralis. The gluteal region is innervated by Rr. posteriores
ex tre m ity, rig h t side; ventral (-» Fig. 4.154) and dorsal (-» Fig. 4.155) fro m th e lum bar (Nn. clunium superiores) and sacral (Nn. clunium m e
v ie w s . dii) spinal nerves. The dorsal side o f the w hole lo w e r e xtrem ity and the
All nerves of the Plexus lumbalis contribute to the sensory innerva sole o f the fo o t are innervated by branches o f the Plexus sacralis.
tion of the inguinal region and the ventral thigh. The lateral aspect of
the leg and the dorsum o f the fo o t are supplied by branches of the
Clinical Remarks tum our, th e pain is referred to th e an terio r aspect o f th e thigh. W ith
com pression o f th e Plexus sacralis, th e pain radiates to th e dorsal
The course of the nerves fro m the Plexus lumbalis and Plexus sa side of th e thigh and th e leg (ischialgia).
cralis influences the pattern of referred pain originating in the area
o f the plexus. If the Plexus lum balis is affected by haematoma or a
328
M uscles -* T o p o g ra p h y -► S ections
Innervation of the skin
Fig. 4.156 and Fig. 4.157 S egm en tal in nervation o f th e skin not correspond w ith the cutaneous area supplied by the peripheral
(derm atom es) of th e lo w er extrem ity, right side; ventral nerves (-» p. 328). In con trast to th e circular orientation o f th e de rm ato
(-» Fig. 4.156) and dorsal (-» Fig. 4.157) view s. mes of the trunk, derm atom es on the ventral side o f the low er
D istinct areas of the skin are supplied by a single spinal cord segm ent. e x tre m ity are obliquely oriented in a lateral superior to m edial inferior
These cutaneous areas are referred to as derm atom es. Since the peri direction. On th e dorsal side th e y are orie nted in a nearly longitudinal
pheral cutaneous nerves of the low er extrem ity convey sensory fibres direction, (see D evelopm ent, -» p. 133).
from several spinal cord segm ents, the borders of the derm atom es do
r- Clinical Rem arks------------------------------------
The localisation o f de rm atom es is clinically im po rtan t in th e d iag fibres fro m the L4 segm ent innervate the m edial m argin of th e
nostics of frequently occurring cases of disc prolapse. Disc her foot, the big toe and the second to e are supplied by the L5 seg
niation/prolapse occurs m ostly in the low er lum bar vertebral colum n m ent. The w h o le lateral side o f th e fo o t, including th e fifth to e , is
and may com press the L4-S1 spinal nerve roots. W hereas nerve supplied by S I.
329
Lower Extremity S urface a n a to m y -► Skeleton Im aging
Plexus lumbalis M. psoas major
N. iliacus
N. ilioinguinalis o b tu ra to riu s
N . fem oralis
N. genitofem oralis
N. c u ta n eu s fe m o ris lateralis M. sartorius
R. cu ta n eu s lateralis, (N. iliohypogastricus) M . pectineus
M . rectus fem oris
R. genitalis, (N. genitofem oralis) M . obturatorius externus
R. fem oralis, (N. genitofem oralis) M . a dd ucto r longus
R. cu ta n e u s anterior, (N. ilio h yp o g a stricu s) N . obturatorius
N. c u ta n eu s fe m o ris lateralis N .sap h en u s
R. fem oralis, (N. genitofem oralis) M . a dd ucto r brevis
Rr. cu ta n e i ante rio re s
N. M . a dd ucto r longus
R. genitalis, (N. genitofem oralis) M . vastus interm edius
M . vastus lateralis
M. R. c u ta n e u s, (N. o b tu ra to riu s)
M. adductor magnus M. sartorius
M . vastus m edialis
N. saphenus
Fig. 4.158 Course and ta rg et areas of th e nerves of th e Plexus fibres fo r the lateral side of th e thigh. The N. fem oralis courses m edi
lumbalis (T12-L4); ventral view ; cutaneous branches are highlighted ally through the Lacuna m usculorum and im m ediately splits fan-like
in purple. into several branches. Rr. cutanei anteriores supply th e skin on th e ven
The N. iliohypogastricus and N. ilioinguinalis (further caudal) cross tral side o f th e thigh. The Rr. m usculares provide m o to r fib re s to the
th e M. quadratus lum borum behind the kidney and then pass betw een anterior m uscles of the hip (M. iliopsoas) and the thigh (M. sartorius
th e M . transversus abdom inis and the M . obliquus internus abdominis and M. quadriceps fem oris) and in part to the M . pectineus. Its term inal
to the ventral side. Both innervate the inferior parts of these abdominal branch is th e N. saphenus w h ich enters th e adductor canal (-» p. 351)
m uscles. The N. iliohypogastricus also provides sensory innervation to and exits it through the Septum intermusculare vastoadductorium at
th e skin above th e inguinal ligam ent, th e N. ilioinguinalis provides sen the medial side of the knee jo in t to supply sensory innervation to the
sory innervation to the anterior aspect of the external genitalia. The N. medial and anterior aspects o f the leg. The N. obturatorius initially
genitofem oralis pierces the M . psoas major, crosses posterior to the courses medial to the M. psoas major and then passes through the
ureter, and divides into tw o branches: The lateral R. fe m o ralis enters Canalis obturatorius (-* p. 351) to the medial aspect of the thigh. One
the anterior thigh through the Lacuna vasorum and provides cutaneous o f its branches reaches th e M. obturatorius externus. The N. ob turato
innervation infe rior to th e inguinal ligam ent. The m edial R. genitalis rius then divides into th e R. an terior and th e R. po sterior (anterior and
courses through the inguinal canal to the Scrotum and conveys sensory posterior to the M. adductor brevis) which convey m otor fibres to the
fibres to the anterior aspects of the external genitalia and m otor fibres m uscles o f th e adductor group. The R. an terior also provides cutaneous
to the M . crem aster in m en. The N. cutaneus fem oris lateralis pro innervation to the skin o f the medial thigh.
jects laterally through the Lacuna m usculorum and provides sensory
330
M uscles -» T o p o g ra p h y -► S ections Plexus lumbalis
N. iliohypogastricus N. fem oralis
N. N. obturatorius
N. genitofem oralis saphenus
N. cutaneus fem oris lateralis N. obturatorius
Fig. 4.159 Lesions of nerves of th e Plexus lumbalis; ventral view.
Cutaneous branches are highlighted in purple. Frequent locations fo r
lesions are marked by black bars.
Clinical Rem arks------------------------------------
Lesions of the N. iliohypogastricus, N. ilioinguinalis and N. ge- a result, the restriction of hip flexion and the irability to extend the
nitofem oralis are rare due to th e ir protected position. However, knee make it im possible to clim b stairs. The patellar tendon reflex
the ir close proxim ity to the kidney and the ureter may result in pain (knee-jerk reflex) is lacking and sensation on the anterior thigh and
radiatin g to th e inguinal region or th e external genitalia in certain m edial leg is absent.
diseases of the kidney (inflam m ation o f the renal pelvis, pyeloneph The N. obturatorius is at risk o f injury w hen passing through the
ritis, ureter concrements). Canalis obturatorius. Pelvic fractures as w e ll as obturator hernias
The N. cutaneus fem oris lateralis may be pinched underneath the or extensive ovarian carcinomas may cause nerve lesions. Loss of
inguinal ligam ent by tig h tly fittin g pants or may be injured during hip function o f the obturator m uscles causes unstable standing, weak
surgery w ith an anterior access. This may result in loss o f sensation ness w ith leg adduction and makes it im possible to cross one's legs.
or pain at th e lateral aspect o f th e thigh (m eralgia paraesthetica). S ensory loss m ay occur at th e m edial thigh. Pain and paraesthesia
Injury to the N. fem oralis m ost frequently occurs in the groin may radiate and sim ulate diseases of th e knee joint (ROMBERG's
during surgery or diagnostic m anoeuvres (e.g. cardiac catheter). As knee phenomenon).
331
Lower Extremity S urface a n a to m y -► Skeleton Im aging
Plexus sacralis gluteus m edius
M . gluteus m axim us
Lig.
N .pudendus gluteus m inim us
ten so r fasciae latae
Rr. m u s cu la res fo r Foramen suprapiriform e
pelvitro ch an teric m uscles gluteus superior
piriform is
N. ischiadicus gluteus inferio r
Foramen ischiadicum m inus Foram en infrapiriform e
gem ellus superior
M . biceps fem oris obturatorius internus
M. sem itendinosus gem ellus inferior
quadratus fem oris
M. sem im em branosus
N. tibialis N. c utaneus fem o ris po sterio r
N. fibularis com m unis
Fig. 4.160 Course and ta rg et areas of th e nerves of the Plexus aspect: innervated by th e N. saphenus o f th e N. fem oralis) and th e foo t.
sacralis (L4-S5, Co1). Dorsal view ; cutaneous nerves are highlighted The N. cutaneus fem o ris posterior exits th e pelvis through th e Fora
in purple. men infrapiriform e and branches o ff the sensory Nn. clunium inferiores
The N. gluteus superior exits the small pelvis through the Foramen fo r th e skin o f th e infe rior gluteal region. It descends in th e subfascial
suprapiriform e and provides m otor innervation to the small gluteal layer to the middle of the thigh and provides sensory innervation to the
m uscles (m ost im portant abductors and medial rotators of the hip joint) posterior thigh.
and the M. ten sor fasciae latae. The N. gluteus inferior exits through The N. pudendus has a com plicated course. It exits the pelvis through
th e Foramen infrapiriform e and innervates the M . gluteus maximus, the Foramen infrapiriform e and, together w ith the corresponding blood
th e strongest extensor and external rotator of the hip joint. vessels, w inds around the Spina ischiadica and courses through the
The N. ischiadicus is the strongest nerve o f the human body. It con Foram en ischiadicum m inus m edially into th e ischioanal fossa. The N.
sists o f tw o divisions (N. tibialis and N. fibularis com m unis) w h ich are pudendus courses in a fascial duplication o f the M . obturatorius inter-
com bined to one com m on nerve fo r a variable distance only by a con nus (ALCOCK's canal; pudendal canal). The N. pudendus innervates the
nective tissue sheath (epineurium ). The N. ischiadicus exits th e pelvis external sphincter m uscle of the anal canal (M. sphincter ani externus)
through the Foramen infrapiriform e and descends to the popliteal fossa and all m uscles o f the perineum . It supplies sensory innervation to the
underneath the M . biceps fem oris. posterior aspects of the external genitalia (posterior scrotum /labia ma-
In m o st cases, INI. tib ialis and N. fib ularis co m m un is separate at the jora; all o f penis/clitoris).
level of th e distal third o f the thigh. Occasionally (12% of cases), both The m otor branches fo r the pelvitrochanteric m uscles also exit through
nerves already e xit th e pelvis separately (high division) in w h ic h case the Foramen infrapiriform e, w hereas those fo r the pelvic flo o r do not
th e N. fibularis often pierces th e M . piriform is. A t th e level o f th e thigh, exit the small pelvis. Parasympathetic nerves also remain w ithin the
th e N. tibialis provides m o to r innervation to th e ham string m uscles and pelvis. The sm all cutaneous branches pierce th e Lig. sacrotuberale (N.
th e po sterior head o f th e M. adductor magnus. The N. fibularis innerva cutaneus perforans) o r th e M . ischiococcygeus (N. anococcygeus).
te s th e Caput breve o f th e M. biceps fem oris. Both portions o f th e N.
ischiadicus tog ethe r innervate all m uscles o f the leg and th e fo o t and -► T 40
provide sensory innervation to the skin o f the leg (except fo r the medial
332
M uscles -» T o p o g ra p h y -► S ections Plexus sacralis
N .pudendus N. cutaneus fem oris posterior
Rr. m u scu la re s fo r
pelvitrochanteric muscles
N. tibialis
N. fibularis com m unis
Fig. 4.161 Lesions of th e m ost im p o rta n t nerves of th e Plexus sho w n . On th e le ft side, th e possible site o f injury to th e N. ischiadicus
sacralis. Dorsal view . Cutaneous branches are highlighted in purple. due to fra cture s o f th e pelvis or hip surgery is indicated.
On the right side, the potential injury, such as w ron gly placed intraglu-
teal injections, to th e nerves at th e level o f th e ir e xit fro m th e pelvis is * lesion w ith w ron gly placed intragluteal injection
i- Clinical Remarks------------------------------------ tients increase com pensatory hip and knee flexion (steppage gait).
Standing on o n e 's to e s is n o t possible anym ore since plantarflexion
Lesions of th e nerves of th e Plexus sacralis - part 1 (part 2 is lost. Cutaneous innervation is alm o st co m p le te ly absent in th e leg
-» p. 335) (except ventrom edial) and fo o t (for isolated lesions o f th e N. tibialis
W ith a high division o f th e N. ischiadicus, th e N. fibularis co m and N. fibularis -» pages 336 and 337). Lesions o f isolated m o tor
m unis may be irritated w hen piercing the M . piriform is (piriform is branches to the pelvitrochanteric m uscles or cutaneous branches
syndrom e). The resulting pain m ay be ve ry sim ilar to th e pain caused are o f no functional relevance. M o tor branches to the m uscles o f the
by a disc herniation. The N. ischiadicus may also be injured during pelvic floor and parasym pathetic nerves, however, may be injured
intragluteal injections or by com pression during extended sitting pe during surgical procedures in th e small pelvis, such as rectum and
riods, after pelvic fractures and in the case o f hip luxations or hip prostate surgery. Fecal and urinary incontinence may result from
surgery. The resulting paralysis of the ham string m uscles affects pelvic flo o r insufficiency. Injury to the parasym pathetic nerves result
extension in th e hip joint, b u t m ore im portantly, flexion and rotation in erectile dysfunction in m en and an equally insufficient filling of
in th e knee joint. If th e N. tibialis and N. fibularis are dam aged com th e cavernous body o f th e clitoris in w om e n.
pletely, all m uscles o f th e leg and fo o t are paralysed and standing
or w alking is im possible. W hen lifting the leg, the fo o t cannot be
dorsiflexed and drags along the ground (foot drop). As a result, pa
333
Lower Extremity S urface a n a to m y -► S keleton - * Im a g in g ->
Intragluteal injections M . gluteus m edius
C rista iliaca M . gluteus m axim us
N. gluteus superior (Foramen suprapiriform e) Foram en
Foramen ischiadicum m ajus (Foramen infrapiriform e) is c h ia d ic u m
m ajus
N. ischiadicus
N. gluteus inferio r M. piriform is
T rochanter major
N .pudendus Tuber ischiadicum
Lig. sacrospinale
cu tan eu s fem o ris posterior
Lig. sacrotuberale
Fig. 4.162 Surface projection of th e skeletal contour and th e N. interna and th e N. pudendus are w e ll protecte d as then course m edially
ischiadicus in th e gluteal region. and pass through the Foramen ischiadicum m inus to reach the ischio-
W ith w ron gly positioned intragluteal injections in the M . gluteus maxi anal fossa. Therefore, injections should always be applied into the
m us principally all neurovascular stru cture s passing through th e Fora M. gluteus m edius (-* Fig. 4.163).
m en ischiadicum m ajus are at risk o f injury. O nly th e A. and V. pudenda
Fig. 4.163 Ventral intragluteal injections (according to placed onto at the Spina iliaca anterior superior and the palm o f the
HOCHSTETTER) hand over the Trochanter major. The only nerve rem aining at risk is the
To avoid dam aging o f im po rtan t neurovascular stru cture s in th e gluteal m o to r branch projecting fro m th e N. gluteus superior to th e M . ten sor
region, intragluteal injections are perform ed w ithin a triangular field fasciae latae.
b e tw e e n tw o splayed fing ers and th e Crista iliaca. The index fin g e r is
334
M uscles -» T o p o g ra p h y -► S ections
Figs. 4.164a to c TRENDELENBURG'S sign and DUCHENNE's gait b W ith fun ctiona l insufficie ncy o f the sm all gluteal m uscles, such as in
w ith loss of function of th e sm all gluteal muscles on the right side hip dysplasia or w ith lesions o f th e N. gluteus superior, th e pelvis
(b, c). drops to th e healthy side w hen standing on the leg of the affected
a The gluteal m uscles abduct the ipsilateral leg if th e body side (TRENDELENBURG'S sign),
w e ig h t is shifte d to the o th e r leg. In one-legged stand, the
ipsilateral m uscles stabilise the pelvis and prevent the tilting of the c The pelvis o f the healthy side is elevated by shifting the trunk
pelvis to the contralateral side. tow a rds th e a ffe cte d side (DUCHENNE's gait).
r- Clinical Remarks------------------------------------ ischiadicus may be affected. The intragluteal injection according to
HOCHSTETTER is applied to th e M. gluteus m edius (-* Fig. 4.163).
Lesions of th e nerves of th e Plexus sacralis - part 2 (part 1 Lesions o f the N. gluteus superior cause paralysis o f the small
- p. 333) gluteal m uscles (m ost im portant abductors and medial rotators
Due to its protecte d course, lesions o f th e N . pudendus are rare. o f the hip) and the M . ten sor fasciae latae. Paralysis o f the small
Sym ptom s are caused by the m alfunction of the perineal m uscles gluteal m uscles m akes it im possible to stand one-legged on the
and the sphincter m uscles of the biadder and rectum and may result affected side because the pelvis tilts to the contralateral side
in urinary and fecal incontinence. Sensory loss in the genital region (TRENDELENBURG'S sign).
m ay cause disturbances in sexual functions. During parturition, W ith lesions of the N. gluteus inferior the loss of function of the
loss o f sensory fun ction in th e perineogenital region is desired and a M . gluteus m axim us com prom ises extension in th e hip. W ith normal
pudendal nerve block m ay be perform ed to reduce pain. Thereby, gait, th is de ficit can partly be com pensated fo r by the action o f the
th e Spina ischiadica is palpated through the vagina and th e N. puden ham string muscles. However, activities such as clim bing stairs, jum
dus is anaesthetised prior to its entrance in th e ALC O C K's canal by ping, and a fa s t w alking pace w ill not be possible.
injections approxim ately 1 cm lateral and cranial of the ischial spine. Lesions of the N. cutaneus fem oris posterior cause sensory defi
W ro n g ly placed in tram u scu lar injections in th e gluteal region may cits on the posterior side of the thigh.
injure the neurovascular structures w hich leave the Foramina supra-
and infrapiriform e. Not only blood vessels but also the Nn. glutei
superior and inferior, th e N. cutaneus fe m o ris posterior, and th e N.
335
Lower Extremity S urface a n a to m y -► Skeleton Im aging
N. tibialis
M. sem im em branosus -------f-------M . b ic e p s fe m o ris , C a p u t lo ng u m
N. tibialis ------------- N . is c h ia d ic u s
M. gastrocnem ius M. plantaris
M . popliteus N. fib u la ris co m m u n is
N. c u ta n eu s s u rae m edialis N. tibialis
M. fle xor digitorum M. tibialis posterior
M. gastrocnem ius M. flexor hallucis longus
M. soleus
M alleolar canal N. suralis
R etinaculum m usculorum flexorum
N. plan taris lateralis
N. plan taris
Fig. 4.165 N . tib ia lis : s e n s o ry in n e rv a tio n b y c u ta n e o u s n erve s dial m alleolus. In th e popliteal fossa the N . c u ta n e u s s u ra e m e d ia lis
(p u rp le ), and m o to r in n e rv a tio n b y m u s c u la r bran ch e s, rig h t side; branches o ff to supply the medial calf and splits into the N . s u ra lis for
dorsal view. the distal calf and the N . c u ta n e u s d o rs a lis la te ra lis fo r the lateral
The N. is c h ia d ic u s often divides at the transition from the middle to margin of the foot. The latter often com m unicates w ith a cutaneous
th e low er third of the thigh into the medial N . tib ia lis and the lateral N. branch fro m th e N. fibularis com m unis. W hen passing underneath the
f ib u la r is c o m m u n is . The N. tibialis innervates the dorsal m u scles of Retinaculum m usculorum flexorum (m a lle o la r c a n a l), the N. tibialis
the thigh (hamstring m uscles and dorsal part o f the M . adductor mag- splits into its tw o term inal branches (N n. p la n ta re s m e d ia lis and la te
nus). The N. tibialis con tinues in th e direction o f th e N. ischiadicus to ra lis ) fo r th e innervation o f th e sole o f th e foo t. Thus, th e N. tibialis
pass the popliteal fossa and descends betw een the heads o f the M. provides m o to r innervation to all fle xo r m uscles o f th e calf and all plan
gastrocnem ius beneath the tendinous arch of the M . soleus (A rc u s tar m uscles of the fo o t as w ell as sensory innervation to the m iddle calf
te n d in e u s m u s c u li s o le i). It furth e r courses together w ith the A. and and, a fte r fo rm in g th e N. suralis, to th e lo w e r calf and th e lateral margin
V. tibialis po sterior b e tw e e n th e superficial and deep fle xo rs to th e m e- of the foot.
i- Clinical R e m a r k s -------------------------------------- c la w fo o t deform ity. Lesions at the level of the popliteal fossa ad
ditionally cause a loss o f fun ction in all flexo rs o f th e leg (negative
L e s io n s o f th e N . tib ia lis are rare, but may occur during injuries o f ACHILLES tendon reflex). Plantarflexion is w eak and only supported
th e knee jo in t o r a fte r com pression in th e m a lle o la r c a n a l to tibial by the m uscles of the fibularis group. An increased p r o n a tio n a n d
fractures or injuries o f the ankle joint (m e d ia l ta rs a l tu n n e l s y n d ro d o r s ifle x io n p o s itio n o f th e fo o t is th e result. Standing on o n e's
m e ). The tarsal tunnel syndrom e is characterised by burning pain toes is im possible.
sensations at the sole o f the fo o t and loss o f fun ction o f the plan
ta r m uscles. Flexion, adduction, o r splaying o f to e s is im possible.
Paralysis o f the M m . interossei and M m . lumbricales results in the
336
The words you are searching are inside this book. To get more targeted content, please make full-text search by clicking here.
Discover the best professional documents and content resources in AnyFlip Document Base.
Search