The front of the thigh

Transcription

1 The front of the thigh

2 Femoral triangle(scarpa s triangle) Is a triangular depressed area located in the upper part of the medial aspect of the thigh immediately below the inguinal ligament. B o u n d a r i e s Superiorly:The inguinal ligament (the base of the triangle) Laterally:The medial border of sartorius muscle Medially:The medial border of adductor longus muscle The apex: directed downwards and is formed by the meeting point of Sartorius and adductor longus muscles Floor: gutter shaped from lateral to medial is made by The iliopsoas muscle The pectineus muscle The adductor longus

3 Roof : Formed by 1- skin 2- superficial fascia which contains: A-superficial inguinal lymph nodes B-femoral branch of the genitofemoral nerve C- branches of ilioinguinal nerve D-superficial branches of the femoral artery and corresponding veins E- terminal part of the great saphenous vien 3- deep fascia containing the Saphenous opining

4 C o n t e n t s o f t h e f e m o r a l t r i a n g l e 1-Terminal part of the femoral nerve and its branches. 2- The femoral sheath 3- The femoral artery and its branches. 4- The femoral vein and its tributaries. 5- Deep inguinal lymph nodes 6- femoral branch of genitofemoral nerve 7- lateral cutaneous nerve of the thigh

5 The femoral sheath Is a funnel-shaped sleeve of fascia surrounded the femoral artery and vein and the associated lymphatic vessels in the femoral triangle for 2.5 cm below the inguinal ligament. The femoral sheath is formed by a downwards extension of the abdominal fascia. Anterior wall: fascia transversalis Posterior wall: fascia iliaca Two Anterio-posterior septa divide the sheath into 3 compartments: Lateral compartment (arterial) occupied by the femoral artery and femoral branch of the genitofemoral nerve Intermediate compartment (venous) occupied by the femoral vein Medial compartment (lymphatic) occupied by the lymph vessels (also Called femoral canal

6 Is the small medial compartment for the lymph vessels. 1.3 cm In length. F e m o r a l c a n a l Its upper opening is called the femoral ring. The femoral septum (is a condensation of extraperitoneal tissue), closes the ring. The femoral ring has the following important relations: Anteriorly : the inguinal ligament Posteriorly: the superior ramus of the pubis attached to it pectineus and its covering fascia Medially : the lacunar ligament Laterally : Septa separating it from the femoral vein The femoral canal contains: 1- fatty connective tissue 2-all the efferent lymph vessels from the deep inguinal lymph nodes and one of the deep inguinal lymph nodes. Note: the femoral ring is wider in femals because of their wider pelvis and therefore, femoral hernia is commoner in femals than in males

7 The part of the femoral sheath that forms the femoral canal is not adherent to the walls of the small lymph vessels; it is this site that forms a potentially weak area in the abdomen. A protrusion of peritoneum could be forced down the femoral canal, pushing the femoral septum. Such a condition is known as a femoral hernia. The lower end of the canal is normally closed by the adherence of its medial wall to the tunica adventitia of the femoral vein.

8 A protrusion of abdominal parietal peritoneum down through the femoral canal to form hernial sac Femoral hernia In femoral hernia The neck of the hernial sac is located below and lateral to the pubic tubercle While in the inguinal hernia The neck of the hernial sac is located above and medial to the pubic tubercle

9 Adductor canal Adductor (Subsartorial) Canal is an intermuscular cleft situated on the medial aspect of the middle third of the thigh beneath the sartorius muscle Transverse section through the middle of the right thigh as seen from above anterior It commences above at the apex of the femoral triangle and ends below at the opening in the adductor magnus. In cross section it is triangular, having. 1-Anteromedial wall 2-Posterior wall 3-Lateral wall

10 The Anteriomedially wall is formed by: The sartorius muscle and fascia. The posterior wall is formed by: The adductor longus and magnus The lateral wall is formed by: The vastus medialis The adductor canal contains : 1-The terminal part of the femoral artery 2-The femoral vein 3-The deep lymph vessels 4-The saphenous nerve 5-The nerve to the vastus medialis 6-The terminal part of the obturator nerve Subsartorial plexus of nerves: Located on the fascia under the sartorius muscle Formed by branches from 1-Medial cutaneous nerve of the thigh 2-Saphenous nerve 3-The anterior division of obturator nerve

11 The femoral artery 1- It enters the thigh from behind the inguinal ligament as a continuation of the external iliac artery. 2-It lies midway between the anterior superior iliac spine and the symphysis pubis (midinguinal point) 3-As the femoral artery descends downwards, its upper half lies superficial in the femoral triangle while in the lower half it lies deep in the subsartorial (adductor) canal

12 4- The femoral artery then descends almost vertically toward the adductor tubercle of the femur and ends at the opening (Adductor hiatus) in the adductor magnus muscle by entering the popliteal space as THE POPLITEAL ARTERY

13 Medially: the femoral vein lies medial to the artery in the upper part of the femoral triangle, then it lies posteromedial and finally posterior to the artery at the apex of the femoral triangle 5-Relations In the upper part of its course, femoral artery lies in the femoral triangle (superficial) 1- Exposed to injuries 2- Good approach for taking femoral pulse Anteriorly : (in the femoral triangle) The femoral artery is covered by skin and fascia Its upper part (1.5 inch) is covered by the anterior wall Of the femoral sheath and crossed by the femoral branch of genito-femoral nerve Its lower part is crossed by the saphenous Nerve Laterally: The femoral nerve and Its branches. Posteriorly: 1-Psoas major muscle, which separates it from the hip joint 2-The pectineus muscle with profunda femoris vessels in between 3-The adductor longus muscle with femoral vein in between

14 Because the femoral artery lies in the femoral triangle (superficial) The following procedure can be done Read only Femoral Artery Catheterization 1-Fine catheter can be inserted into the femoral artery as it descends through the femoral triangle. 2-The catheter is guided under fluoroscopic view along the external and common iliac arteries into the aorta. 3-The catheter can then be passed into the inferior mesenteric, superior mesenteric, celiac, or renal arteries. 4-Contrast medium can then be injected into the artery under examination and a permanent record obtained by taking a radiograph. Femoral Vein Catheterization 1-Femoral vein catheterization is used when rapid access to a large vein is needed. 2-The femoral vein has a constant relationship to the medial side of the femoral artery just below the inguinal ligament and is easily cannulated. 3- Because of the high incidence of thrombosis with the possibility of fatal pulmonary embolism, the catheter should be removed once the patient is stabilized. Anatomy of the Procedure 1-The skin of the thigh below the inguinal ligament is supplied by the genitofemoral nerve; this nerve is blocked with a local anesthetic. 2-The femoral pulse is palpated midway between the anterior superior iliac spine and the symphysis pubis, and the femoral vein lies immediately medial to it. 3-At a site about two fingerbreadths below the inguinal ligament, the needle is inserted into the femoral vein.

15 6- Branches of the femoral artery In the femoral triangle THREE superficial branches and TWO deep branch I-Superficial branches 1-The superficial circumflex iliac artery 2-The superficial epigastric artery 3-The superficial external pudendal They supply cutaneous regions of the upper thigh, lower abdomen, and perineum.

16 II- DEEP BRANCHES 1-The deep external pudendal artery 2-The profunda femoris artery (Deep artery of thigh) arises from the lateral side of the femoral artery about (4 cm) below the inguinal ligament it gives off: A) lateral femoral circumflex artery B) The medial femoral circumflex artery C) Perforating arteries.

17 A) lateral femoral circumflex artery: Normally originates proximally from the lateral side of the profunda femoris artery, but may arise directly from the femoral artery Read only It divides into three terminal branches: 1-ascending branch, supplies the neck and head of the femur; 2-descending branch: connects with a branch of the popliteal artery near the knee 3-transverse branch: anastomoses with branches from the medial femoral circumflex artery, the inferior gluteal artery, and the first perforating artery to form the cruciate anastomosis around the hip. Profunda femoris artery

18 B) The medial circumflex femoral artery normally originates proximally from the posteromedial aspect of the profunda femoris artery but may originate from the femoral artery It gives off : Read only a) Acetabular branch: which enters the hip joint through the acetabular notch and anastomoses with the acetabular branch of the obturator artery. profunda femoris artery b) Ascending branch: shears in the trochonteric anastomosis c) Transverse branch: shears in the cruciate anastomosis C) Perforating arteries. The profunda femoris artery gives off perforating branches. The first three arteries arise as branches of the profunda femoris artery, while the fourth one is the termination of the profunda femoris artery

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20 In the lower part of its course, the femoral artery passes behind the sartorius ( deep) muscle in the subsartorial canal (adductor canal). Relations of the femoral artery In the subsartorial canal Anteriomedially: Skin and fascia Sartorius muscle and fibrous roof of the canal Saphenous nerve which crosses from lateral to medial Anterolaterally: vastus medialis Nerve to vastus medialis Posteriorly: femoral vein

21 Branches of the femoral artery in the adductor canal It gives off only one branch The descending genicular artery Other arteries that shear in the blood Supply of the lower limb Obturator Artery The obturator artery is a branch of the internal iliac artery It passes forward on the lateral wall of the pelvis and accompanies the obturator nerve It gives off muscular branches and an articular branch to the hip joint