Transcript 23-lower limb2008-05

Skin of the thigh
1
2
5
4
3
Cutaneous Nerves
1- The femoral branch of the genitofemoral
nerve. It enters the thigh behind the middle
of the inguinal ligament and supplies small area
of skin . It is a branch of the lumbar plexus ( l 1
& l 2 ).
2- The ilioinguinal nerve, a branch of the
lumbar plexus ( l1 ), enters the thigh through
the superficial inguinal ring. It supplies a small
skin area below the medial part of the inguinal
ligament.
3- The medial cutaneous nerve of the thigh, a
branch of the femoral nerve ( l2 , 3 ) , supplies
the medial aspect of the thigh & joins the
patellar plexus.
4- The intermediate cutaneous nerve of the
thigh, a branch of the femoral nerve ( l1, 2 ). It
divides into 2 branches that supply the anterior
aspect of the thigh & joins the patellar plexus.
6
6
55
5- Branches from the anterior division of
the obturaror nerve ( l2, 3 ; 4 ) supply area
of the skin on the medial aspect of the
high.
6- The lateral cutaneous nerve of the thigh,
a branch of the lumbar plexus ( L2; 3 ). It
enters thigh behind the lateral end of the
inguinal ligament. It divides into A & P
branches to supply the skin of the lateral
aspect of the thigh & knee . Also, the skin
of the lower lateral quadrant of the buttock
Superficial fascia of the thigh
The membranous layer of the superficial fascia of the anterior abdominal wall extends
into the thigh and is attached to the deep fascia ( fascia lata ) about a fingerbreadth ( .8
cm) below the inguinal ligament .
The fatty layer of the superficial fascia on the anterior abdominal wall extends into the
thigh and continues down over the lower limb without interruption.
Femoral sheath
It is a downward protrusion into the thigh of the fascial envelope lining the abdominal
walls. Its anterior wall is continuous above with the fascia transversalis; its posterior wall
with the fascia iliaca. The sheath surrounds the femoral vessels & lymphatics for about
2. 5 cm below the inguinal ligament .
Deep fascia of the thigh ( fascia Lata)
It encloses the thigh like a trouser leg. At its upper
end is attached to the pelvis & inguinal ligament.
On its lateral aspect, it is thickened to form the
iliotibial tract which is attached above to the iliac
tubercle & below to the lateral condyle of the tibia .
The iliotibial tract receives the insertion of the
tensor fasciae latae & the greater part of the
gluteus maximus muscles.
Deep fascia
In it, there is a gap in the front of the
thigh just below the inguinal ligament.
It is the Saphenous opening which
transmits the great saphenous vein,
small branches of the femoral artery;
lymph vessels. It is situated about 4 cm
below & lateral to the pubic tubercle.
The lower lateral border of the opening
is called the falciform margin . It lies
anterior to the femoral vessels.
The border of the opening then curves
upward & medially then laterally behind
the femoral vessels, to be attached to
the pectineal line of the superior ramus
of the pubis.
The saphenous opening is filled with
loose connective tissue called the
Cribriform fascia .
Rectus femoris
Vastus lateralis
Fascial Compartment of
the Thigh
Three fascial septa pass
from the inner aspect of the
deep fascial sheath of the
thigh to the linea aspera of
the femur.
The 3 compartments are
anterior , medial ; posterior
in position.
Sartorius:It Covers the middle third of the femoral vessels .
Origin: From the anterior superior iliac spine .
Insertion: The upper part of the medial surface of the shaft of
tibia .
Psoas major:The fibers enter the thigh behind the inguinal
ligament .
Origin: From the roots of the T. processes; sides of the vertebral
bodies; the intervertebral discs, from the 12th thoracic to the 5th
lumbar vertebrae.
Insertion: Into the lesser trochanter of the femur.
Iliacus :
Origin : Arises from the iliac fossa within
the abdomen .
Insertion : Its fibers join the tendon of the
psoas to form the iliopsoas muscle which
are inserted into the lesser trochanter of
the femur & the adjoining area .
Pectineus
Origin : From the superior ramus of the
pubis .
Insertion : It is attached to the upper end
of the linea aspera just below the lesser
trochanter .
Muscles of the anterior
compartment of the thigh
1- Sartorius : N . Supply : femoral nerve.
Action : flexes both hip & knee joints. Abduct
; laterally rotates the thigh and medially
rotates the leg at the knee .
2- Iliacus : N. supply : A branch of the
femoral nerve within the abdomen.
Action : The iliopsoas flexes the thigh on the
trunk at the hip joint or if the thigh is fixed ,
it flexes the trunk on the thigh ; it medially
rotates the thigh .
3- Psoas : N. supply : Branches from the
lumbar plexus.
Action : like the iliacus .
Pectineus : N. supply : femoral & a branch
from the obturator nerves .
Action : Flexes & adducts the thigh at the hip
joint .
Origin of quadriceps femoris
1-Rectus femoris : A straight head from the A. inferior iliac spine & A reflected head
from the ilium above the acetabulum .
2- Vastus lateralis : From the upper part of intertrochanteric line , the base of the
greater trochanter , lateral margin of gluteal tuberosity & linea aspera of the femur .
3- Vastus medialis : from lower part of intertrochanteric line ; spiral line ; linea aspera of
the femur & upper part of medial supracondylar ridge .
4Vastus intermedius: From the upper 2l3 of the A.& Lat surfaces of the shaft of the femur
Insertion of The Quadriceps
Femoris
The four muscles have a common
tendon of insertion into the upper,
lateral; medial borders of the patella &
then via the ligamentum patellae into
the tubercle of the tibia. So, They are
inserted into the quadriceps tendon & so
into the patella .
N. B. The Vastus intermedius fibers join
the deep aspect of the quadriceps
tendon.
The articularis genus is a small part of
the vastus intermedius that is inserted
into the upper part of the synovial
membrane of the knee joint. It serves to
retract the synovial membrane superiorly
during extension of the knee joint .
Quadriceps Femoris
N. Supply : femoral nerve
Action : Together they provide a
powerful extensor of the knee
joint.
Some of the tendinous fibers of
the vastus lateralis & medialis
form bands or retinacula, that join
the capsule of the knee joint &
strengthen it .
The lowest muscle fibers of the
vastus medialis are horizontal and
prevent the patella from being
pulled laterally during contraction
of the quadriceps muscle.
Their tone strengthens the knee
joint .
The rectus femoris flexes hip joint
Femoral sheath
It is a downward protrusion into the thigh of the fascial envelope lining the abdominal
walls. Its anterior wall is continuous above with the fascia transversalis; its posterior wall
with the fascia iliaca. The sheath surrounds the femoral vessels & lymphatics for about
2. 5 cm below the inguinal ligament .
Femoral Sheath
The femoral artery occupies the
lateral compartment of the sheath.
The femoral vein occupies the
intermediate compartment and is
separated from the artery by a
fibrous septum.
The lymph vessels , as they leave
the thigh ,are separated from the
vein by a fibrous septum & occupy
the most medial compartment .
The femoral canal is a compartment
for the lymph vessels. It is about 1.3
cm long ; its upper opening is
referred to as the femoral ring. This
ring is closed by a condensation of
extraperitoneal tissue called femoral
septum.
This canal contains fatty connective
tissue ; all the efferent lymph vessels
( come out ) from the deep inguinal
lymph nodes and one of the deep
inguinal lymph nodes.
The femoral sheath
It is adherent to the walls of the
blood vessels and inferiorly blends
with the tunica adventitia of these
vessels.
It is not adherent to the walls of
the lymph vessels & this site is a
potentially weak area in the
abdomen.
A protrusion of the abdominal parietal peritoneum into the canal push the
femoral septum, forming a femoral hernia .
The upper end of the canal ( ring ) is related Anteriorly: to the inguinal
ligament
Posteriorly: to the superior ramus of the pubis .
Medially : into the lacunar ligament .
Laterally : The femoral vein .
The lower end of the canal is closed by the adherence of its medial wall to the
tunica adventitia of the femoral vein. It lies close to the saphenous opening in
the deep fascia of the thigh.
Femoral Hernia
It is more in female than male ( because
of their wide pelvis & femoral canal ).
The hernial sac ( abdominal parietal
peritoneum ) passes through the femoral
canal pushing the femoral septum before
it . At the lower end of the femoral canal it
expands to form a swelling in the upper
part of the thigh deep to the deep fascia .
The hernial sac may turn upward to cross
the anterior surface of the inguinal
ligament .
The neck of the sac is narrow & lies at the
femoral ring . It can not expand due to
the surrounding anatomic structures .
It is irreducible hernia .
After coughing a piece of bowel may be
forced through the neck , and its blood
vessels may be compressed by the
femoral ring forming strangulated hernia.
It is dangerous & should treated surgically
Femoral Hernia
The Neck of the sac is narrow &
lies at the femoral ring .
The neck of the sac lies below &
lateral to the pubic tubercle. This
serves to differentiate it from the
inguinal hernia which lies above
& medial to the pubic tubercle .
Femoral triangle
It is situated at the upper part of the
medial aspect of the thigh just below the
inguinal ligament .It is bounded
superiorly by the inguinal ligament ,
Laterally by sartorius & medially by
medial border of the adductor longus
muscle .
Its floor is formed from lateral to medial
by the iliopsaos , pectineus; adductor
longus .
Its roof is formed by skin & fasciae of
the thigh .
It contains the terminal branches of the
femoral nerve ,F. A. and its branches ; F.
v. And its tributaries ; F. sheath and deep
inguinal lymph nodes .
Adductor canal ( Subsartorial )
It is an intermuscular cleft situated on the medial
aspect of the middle third of the thigh beneath
the sartorius muscle . It begins above at the apex
of the femoral triangle & ends below at the
opening in the adductor magnus .
In cross section it is triangular having
anteromedial ; posterior and lateral walls .
The anteromedial wall is formed by sartorius
muscle .
The posterior wall is formed by the adductor
longus & magnus ,
The lateral wall is formed by the vastus medialis .
It contains the terminal part of the femoral artery
; femoral vein ; saphenous nerve ;nerve to vastus
medialis ; the terminal part of the obturator
nerve and the deep lymph vessels .
Femoral Nerve
It is the largest branch of the lumbar
plexus ( l2;3;4 ) . It emerges from the
lateral margin of the psoas muscle
within the abdomen .
It lies behind the fascia iliaca & behind
the inguinal ligament .
It passes downward in the interval
between the psoas and iliacus.
It enters the thigh lateral to the
femoral artery & femoral sheath .
About 4cm below the inguinal ligament
it terminates by dividing into anterior
& posterior divisions .
Femoral Nerve
Branches
Anterior Division 1;2;3 and 4 .
1
2
3
4
Posterior Division : 1- muscular
to quadriceps . The branch to
rectus femoris also supplies
the hip joint ; the branches to
the 3 vasti also supply the
knee joint .
2- saphenous N:It is cutaneous
It runs downward & medially.
It crosses the femoral artery
from the its lateral to its
medial side .
It emerges on the medial side
of the knee between the
tendon of sartorius & gracilis .
It runs down the medial side of
the leg in company with the
great saphenous vein . It
passes in front of medial
malleolus
Femoral Artery
It is a continuation of the external iliac
artery. It passes behind the inguinal
ligament . It lies midway between the
Relations
anterior superior iliac spine & the
Anteriorly : It is superficial in its upper part symphysis pubis . It descends vertically
toward the adductor tubercle . It ends at
and is covered by skin & fascia . In the
the opening in the adductor magnus
lower part it is covered by sartorius .
muscle by entering the popliteal space as
Medially : It is related to femoral vein in the the politeal artery.
upper part .
:
Posteriorly : It lies on the psoas which
separates it from the hip joint ; pectineus;
adductor longus . The femoral vein
intervenes between it and the adductor
longus .
Branches
1234-
Laterally : the femoral nerve & its branches
superficial circumflex iliac artery : It runs up to the region of the A. S . iliac spine.
Superficial epigastric artery : It crosses the inguinal ligament & runs to the umbilicus.
Superficial external pudendal artery : It runs medially to supply the skin of scrotum.
Deep external pudendal artery: It runs medially to supply the scrotum or labia majora
5- Descending genicular artery: It arises from the femoral artery near its termination . It
supply the knee joint .
6-Profunda femoris artery :
It is a large branch that arises from the lateral side of the femoral artery about 4 cm
below the inguinal ligament .
It passes medially behind the femoral vessels & enter the medial fascial compartment .
It descends in the interval between the adductor longus & adductor brevis , then lies on
the adductor magnus , where It ends by becoming the 4th perforating artery .
Branches
Medial femoral circumflex artery : It passes backward between the muscles of the floor
of the femoral triangle and gives off muscular branches to the muscles of the medial
fascial compartment . It shares in the formation of the cruciate anastomosis.
Lateral femoral circumflex artery : It passes laterally between the terminal branches of
the femoral nerve . It gives off muscular branches to this area and shares in the
formation of the cruciate anastomosis .
Four perforating arteries : They run backward and supply the surrounding muscles .
They are anastomosing with one another & with the inferior gluteal & circumflex femoral
arteries above & the muscular branches of the popliteal artery below .
Femoral Artery Catheterization
A long fine catheter can be inserted into the
femoral artery as it descends through the femoral
triangle . The catheter is guided under
fluoroscopic view along the external & common
iliac arteries into the aorta .
The catheter then can pass into inferior & superior
mesenteric arteries, celiac & renal arteries .
Contrast medium can also, be injected .
Pressure records can be obtained by guiding the
catheter through the aortic valve into the left
ventricle .
Femoral Vein
It
enter the thigh by passing through the
opening in the adductor magnus as a
continuation of the popliteal vein .
It
ascends at first on the lateral side of the
artery then behind it and finally on its medial
side .
It leaves the thigh in the intermediate
compartment of the femoral sheath and
passes behind the inguinal ligament to
become the external iliac vein .
Tributaries
1- Veins that correspond to the branches of
the femoral artery ( profunda femoris vein ) .
2- Great saphenous vein : The superficial
circumflex iliac ; the superficial epigastric ;
the external pudendal veins drain into it .
Femoral Vein Catheterization
It is used when rapid access to a large vein is
needed .
It is easily cannulated due to its relation to
the medial side of the femoral artery below
the inguinal ligament .
The catheter should be removed once the
patient is stabilized .
Procedure :
1- The genitofemoral nerve is blocked with a
local anesthetic .
2- The vein is demonstrated by the artery .
3- Two fingerbreadths below the inguinal
ligament the needle is inserted into the
femoral vein .
Muscles of the medial compartment
1- Gracilis
Origin : From the outer surface of the inferior ramus
of the pubis and the ramus of the ischium.
Insertion : Upper part of the medial surface of the
tibia .
2- Adductor longus
Origin : From the front of the body of the pubis
below and medial to the pubic tubercle .
Insertion : Linea aspera .
3- Adductor brevis
Origin : From the outer surface of the inferior ramus
of the pubis .
Insertion : Linea aspera .
4- Adductor magnus
Origin : From the outer surface of the inferior ramus
of the pubis ; the ramus of the ischium and the
ischial tuberosity
Insertion : The adductor portion is attached to the
posterior surface of the shaft of the femur .
The hamstring portion : On the adductor tubercle.
5- Obturator externus : Origin: From the outer
surface of the obturator membrane and pubic &
ischial rami .
Insertion : Onto the medial surface
of the greater trochanter of the femur .
N. B. The adductor brevis lies posterior to
the pectineus & adductor longus .
N.B. The adductor hiatus is a gap in the
attachment of the adductor magnus to the
femur, it is a passage for the femoral vessels
from the adductor canal downward into the
popliteal space .
Nerve supply :
Obturator Nerve . Except : The hamstring
portion of adductor longus by the sciatic
nerve .
Action :
All the muscles adduct the thigh at the hip
joint . Except :
1- Obturator externus : Laterally rotates the
thigh at the hip joint .
2- The hamstring portion of the adductor
magnus extends the thigh.
3- Also, Gracilis : flexes the leg at the knee
joint .
4- Also, The adductor longus & brevis and
the adductor part of the magnus . Assist in
lateral rotation of the thigh .
Obturator Nerve
It arises from the lumbar plexus . It emerges on
the medial border of the psoas major muscle
within the abdomin .
It runs forward on the lateral wall of the pelvis
to reach the upper part of the obturator
foramen. Where it divides into the anterior &
posterior division .
Branches :
The anterior division passes downward in front
of the obturator externus. The adductor longus.
It
8
gives muscular branches to gracilis ; adductor
brevis and adductor longus. Also to pectineus. It
gives articular branches to hip joint and
terminates as a small nerve that supplies the
femoral artery . Also, 7.
Posterior division : pierces the obturator externus
and passes downward behind the adductor brevis
and in front of the adductor magnus.
It terminates by descending through the opening
in the adductor magnus to supply the knee joint.
It supplies obturator externus; 8 ; 9 .
7
99
9
Obturator Artery
It is a branch of the internal iliac
artery .
It passes forward on the lateral
wall of the pelvis and
accompanies the obturator nerve
through the obturator canal .
On entering the medial fascial
compartment of the thigh , it
divides into medial & lateral
branches, which pass dnd circle
around the outer surface of the
obturator membrane .
It gives muscular branches and 9
articular branche to hip joint . 9