Anatomy of the lower limb

Front of the thigh

Dr. Hayder

The thigh is the part of the lower limb between the hip and knee joints. For descriptive purposes, the thigh is divided
into three regions—front of the thigh, medial side of the thigh, and back of the thigh. The front of the thigh
corresponds to the back of arm.

Bones of the leg

The femur is the longest bone in the body accounting for about 1/4th of the body height. It articulates with the hip
superiorly at the hip joint and with the tibia and patella inferiorly at the knee joint.
The proximal end
This is represented by the head, neck & trochanter. The head represents 2/3 rd of a sphere and is directed medially
and anterosuperiorly. It is lodged in the acetabular fossa and has a small pit at its summit; the fovea capitis; that
marks the entrance of a small nutrient artery and the attachment of a short ligament from the non-articular depth of
the acetabulum. The neck is slender and relatively long. It is attached obliquely with the shaft making an angle of
125˚. It is ridged longitudinally by bundles of fibers; retinacula; from the fibrous capsule of the hip joint transmitting
many small blood vessels and creating many small nutrient foramina. The greater trochanter limits the neck laterally
and extends anteriorly and posteriorly. The medial surface of the trochanter is concaved by the trochanteric fossa.
The lesser trochanter projects posteromedially from the junction of the neck with the shaft. The pectineal line
descends for a short distance downwards on the posterior surface of the upper part of the shaft from the lesser
trochanter. The two trochanters are joined anteriorly by the intertrochanteric line that marks the attachment of the
iliofemoral ligament. Posteriorly, the trochanters are joined by the intertrochanteric crest. On this crest lies a small
elevation for the insertion of quadratus femoris muscle called the quadrate tubercle.

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The shaft
The shaft of the femur is round; i.e. circular in cross section; and is convex anteriorly. The surface is smooth
throughout except posteriorly where the linea aspera extends longitudinally as a sharp long ridge giving attachments
to muscles and to the intermuscular septa of the thigh. The linea aspera has two lips which diverge superiorly and
inferiorly. Superiorly, the 2 lips diverge on each side of the pectineal line where the medial lip continues as the spiral
line that passes anteromedially towards the intertrochanteric line, and the lateral lip continues posterolaterally to
the gluteal tuberosity. Inferiorly, the two lips diverge and continue as the medial and lateral supracondylar ridges or
lines. These 2 supracondylar lines mark the lower part of the posterior surface of the femur called the popliteal
surface.
The distal end
This consists of the medial and lateral epicondyles at the end of the corresponding supracondylar lines. The medial
epicondyle bears a small bony prominence called the adductor tubercle. Each epicondyle leads to a larger condyle.
The medial and lateral condyles are separated posteriorly by the intercondylar fossa. Anteriorly, the 2 condyles are
joined at the intercondylar line. The medial condyle is larger than the lateral one.

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Surface landmarks:
 Fold of groin is a shallow curved groove extending from
the pubic tubercle to the iliac spine. It corresponds to the
underlying inguinal ligament and separates the anterior
abdominal wall from the front of the thigh.
 Anterior superior iliac spine is palpated at the lateral end
of the fold of the groin.
 Pubic tubercle is a small bony projection felt at the
medial end of the fold of groin.
 Greater trochanter lies a hand’s breadth below the
tubercle of the iliac crest and forms a prominence in front
of the hollow on the side of the hip.
 Midinguinal point is a point midway between the
anterior superior iliac spine and the pubic symphysis.
 Midpoint of inguinal ligament is a point midway
between the anterior superior iliac spine and the pubic
tubercle.
 Medial and lateral condyles of femur and tibia form
large bony masses on the medial and lateral sides of the
knee, respectively. The most prominent points on the condyles are called epicondyles.
 Fleshy swelling above the medial condyle of the femur is formed by the lower part of the vastus medialis
muscle.
 Patella (knee cap) is easily felt as a triangular bone in front of the knee. It is freely mobile when the knee is
extended but becomes rigid when the knee is flexed.
 Tibial tuberosity is easily felt as a bony prominence on the front of the upper end of the tibia.
 Ligamentum patellae can be felt as a strong fibrous band stretching between patella and tibial tuberosity.
 Adductor tubercle can be felt just above the medial condyle of the femur and on deep pressure a cord-like
tendon of adductor magnus is felt above the tubercle.

The superficial fascia

The superficial fascia of the front of the thigh is continuous with that of the anterior abdominal wall which is composed
of 2 layers below the level of the umbilicus;
 A superficial fatty layer which is continuous from the fatty layer of the abdomen and extends over the whole length
of the lower limb.
 A deeper membranous layer continues for a short distance only at the uppermost part of the thigh where it fuses
with the deep fascia of the thigh (fascia lata) at a line lying a fingerbreadth below the inguinal ligament and extending
medially to the pubic tubercle. The line of fusion passes from the pubic tubercle on the front of the body of the pubis,
the sides of the pubic arch and backwards to the ischial tuberosity and the perineal body. Here, the membranous
layer is called the superficial perineal membrane (Colle's fascia). This fascia forms a tubular sheath for the penis or
clitoris and separates the thigh from the submembranous area of the anterior abdominal wall and the perineum.
Therefore, a fluid accumulation in that area of the abdominal wall or the perineum will not extend down the thigh
because of the linear fusion.
The superficial fascia on the front of the thigh contains:
1. Cutaneous nerves.
2. Cutaneous arteries.
3. Termination of saphenous vein and its tributaries.
4. Superficial inguinal lymph nodes.
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Cutaneous innervation of the front of thigh
The skin on the front of the thigh is supplied by seven cutaneous nerves which are derived from the lumbar plexus.
These are 6 nerves in number as follows:
1. Ilioinguinal nerve.
2. Femoral branch of the genitofemoral nerve. Above the line
3. Cutaneous branch of the obturator nerve. of sartorius
4. Intermediate cutaneous nerve of the thigh.
5. Medial cutaneous nerve of the thigh.
6. Lateral cutaneous nerve of the thigh (lateral femoral cutaneous
nerve).

The ilioinguinal nerve (L1) emerges through the superficial inguinal

ring and supplies the skin at the root of the penis, and the anterior
one-third of the scrotum in male; and mons pubis and anterior one-
third of labium majus in female; and the skin of the upper medial
aspect of the thigh.

The femoral branch of the genitofemoral nerve (L1, L2) pierces the
femoral sheath and the overlying deep fascia 2 cm below the
midinguinal point, and supplies the skin over the femoral triangle

The cutaneous branch of the obturator nerve (L2, L3) supplies the skin of the lower anteromedial side above the line
of sartorius.

The intermediate and medial cutaneous nerves of the thigh from the femoral nerve supply the anterior and
anteromedial sides from the line of sartorius to the knee.
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The lateral cutaneous nerve of the thigh (L2, L3) It enters the thigh by passing behind or through the lateral end of
the inguinal ligament, a centimeter medial to the anterior superior iliac spine, and divides into anterior and posterior
branches. It supplies the skin on the anterolateral side of the upper thigh.

Clinical correlation: The lateral cutaneous nerve of the thigh is sometimes compressed as it passes through the
inguinal ligament, causing pain and paresthesia (altered sensations) in the upper lateral aspect of the thigh leading
to a clinical condition called ‘meralgia paresthetica’. The surgical treatment of this condition requires division of the
inguinal ligament and releasing nerve from the compression.

The inguinal ligament

The inguinal ligament represents the posteriorly
curved, thickened free lower border of the
aponeurosis of the external oblique muscle of the
anterior abdominal wall. It extends from the anterior
superior iliac spine to the pubic tubercle. Just lateral
to the pubic tubercle, the deep surface of the
inguinal ligament extends posteriorly to be attached
to the pecten pubis as the triangular lacunar
ligament. The apex of the lacunar ligament is
attached to the pubic tubercle while its base forms a
sharp free crescentic margin. The strong deep fascia
of the thigh (fascia lata) attaches to the inguinal
ligament and pulls it downwards and is therefore
responsible for its downward curvature.

The deep fascia (fascia lata)

The deep fascia of the thigh is very strong and envelops the thigh like a sleeve. It
is called fascia lata because it encloses a wide area of the thigh (Latin Latus
_broad). Its attachments are as follows:
1. Superiorly, on the front of the thigh, it is attached to the anterior superior iliac
spine, inguinal ligament, and pubic tubercle. Laterally it is attached to the iliac
crest; posteriorly (through the gluteal fascia) to the sacrum, coccyx, and
sacrotuberous ligament; and medially it is attached to the pubis, pubic arch, and
ischial tuberosity.
2. Inferiorly on the front and sides of the knee, it is attached to subcutaneous
bony prominences and the capsule of the knee joint.

Modifications of fascia lata

The deep fascia of the thigh presents two modifications iliotibial tract and
saphenous opening

Iliotibial tract
The tensor fasciae latae & gluteus maximus muscles, working through their
attachments to the iliotibial tract, hold the leg in extension once other muscles
have extended the leg at the knee joint, hence it is used constantly during walking
and running. The iliotibial tract and its two associated muscles also stabilize the hip joint by preventing lateral
displacement of the proximal end of the femur away from the acetabulum. On leaning forward with slightly flexed

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knees the iliotibial tract is the main support of the knee against gravity and prevents the individuals from falling
forward.

Saphenous opening
This is an oval opening in the fascia lata in the upper medial
part of the front of the thigh. The center of the opening is
about 4 cm below and lateral to the pubic tubercle. Its vertical
length measures about 3–4 cm. The opening is bounded
inferolaterally by a sharp crescentic (falciform) margin. It is
formed by the superficial stratum of the fascia lata, which lies
in front of the femoral sheath. The medial margin of the
opening is illdefined and formed by the deep stratum which
lies at a deeper level and becomes continuous with the fascia
overlying the pectineus (pectineal fascia). It lies behind the
femoral sheath.
The saphenous opening is closed by the membrane of areolar
tissue the – cribriform fascia which is pierced by number of
structures making it sieve-like, hence the name cribriform.
Structures that pass through the cribriform fascia into the
saphenous opening are;
1- The great saphenous vein draining into the femoral
vein.
2- Efferent lymph vessels from the superficial to the deep inguinal lymph nodes.
Structures that pass through the cribriform fascia out of the saphenous opening are the three superficial branches of
the femoral artery;
1- The superficial external pudendal artery.
2- The superficial epigastric artery.
3- The superficial circumflex iliac artery

The inguinal lymph nodes

These are divided into superficial and deep groups.
The superficial inguinal lymph nodes
These nodes lie in the superficial fascia and have a T-shaped
arrangement with a horizontal group parallel to and below the
inguinal ligament, and a vertical group around the upper part of the
great saphenous vein. The superficial inguinal lymph nodes drain
lymph from the following areas;
 The trunk below the level of the umbilicus including the
perineum, the anal canal, the lower vagina and urethra and the
external genitalia and scrotum with the exception of the testes
(drained to the lumbar nodes) and glans penis (drained to the deep
inguinal nodes).
 The fundus and body of the uterus through vessels along the round ligament.
 The skin and fascia of the whole lower limb except the heel and the lateral side of the foot which drain to the
popliteal nodes.
 The efferent lymph vessels of the superficial inguinal lymph nodes pass through the cribriform fascia to drain
lymph to the deep inguinal lymph nodes.
The deep inguinal lymph nodes
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These nodes lie vertically in the femoral triangle along the medial side of the femoral vein. They receive lymph from;
 The superficial lymph nodes.
 The glans penis.
 The popliteal nodes.
 The deep structures of the lower limb.
The efferent lymph vessels of the deep nodes pass along the femoral vessels towards the external iliac nodes in the
pelvis.
Femoral sheath
It is a funnel-shaped fascial sheath enclosing
upper 3.5-4 cm of femoral vessels. The base
of the sheath is directed upward toward the
abdominal cavity and apex merges with the
tunica adventitia of the femoral vessels. The
anterior wall of the femoral sheath is formed
by the downward prolongation of the fascia
transversalis and the posterior wall by the
downward prolongation of the iliacus fascia.
The femoral sheath is not symmetrical. Its
lateral wall is vertical whereas its medial wall
is oblique being directed downward and laterally.
The interior of the femoral sheath is divided into three compartments by two anteroposterior fibrous septa.
 Lateral compartment lodges the femoral artery and genital branch of the genitofemoral nerve.
 Middle compartment contains the femoral vein.
 Medial compartment is relatively empty and called femoral canal. It contains lymph node of Cloquet and
fibrofatty tissue.

Femoral canal
It is a short fascial tube (medial compartment of femoral
sheath) which diminishes rapidly in width from above
downward and is closed inferiorly by the fusion of its walls.
The upper end of the femoral canal, which opens into the
abdominal cavity is called femoral ring. A fatty areolar tissue
called femoral septum normally closes it. Cloquet’s node is a
lymph node situated in the femoral canal. The canal provides
a dead space for the expansion of femoral vein during
increased venous return.
BOUNDARIES
Anterior: Inguinal ligament
Medial: Sharp edge of the lacunar ligament
Posterior: Pecten pubis
Lateral: Femoral vein
Below the inguinal ligament, the canal lies posterior to the saphenous opening and thin cribriform fascia, and anterior
to the fascia covering the pectineus muscle.
Clinical correlation: Femoral hernia: The protrusion of abdominal contents (a loop of intestine) through the femoral
canal is called femoral hernia. The femoral ring is the site of potential weakness of the groin when the femoral ring is
enlarged due to the abdominal distention with weakness of abdominal muscles, e.g., pregnancy. Any condition, which
raises the intraabdominal pressure, e.g., repeated forceful coughing or straining forces the loop of intestine into the
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femoral ring, it carries with it the peritoneal covering of the abdominal opening of the canal in front of it. This forms
the hernia sac, which descends in the femoral canal posterior to the weak cribriform fascia and bulges forward through
it into the superficial fascia of the thigh close to the saphenous vein. If hernial sac continues to enlarge, it expands
superolaterally in the superficial fascia. Consequently, the entire hernia becomes U-shaped. The femoral hernia
presents as a globular swelling in groin inferolateral to the pubic tubercle below the inguinal ligament. The femoral
hernia is common in female because the femoral ring is larger due to greater width of the pelvis.