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Lower Limbs Lu Xiaoli Regional Anatomy & Operative Surgery China Medical University China Medical University.

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Presentation on theme: "Lower Limbs Lu Xiaoli Regional Anatomy & Operative Surgery China Medical University China Medical University."— Presentation transcript:

1 Lower Limbs Lu Xiaoli Regional Anatomy & Operative Surgery China Medical University China Medical University

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3 32 Bones 32 Bones Hip Bone (1) Hip Bone (1) Femur (1) Femur (1) Patella (1) Patella (1) Tibia (1) Tibia (1) Fibula (1) Fibula (1) Tarsals (8) Tarsals (8) Metatarsals (5) Metatarsals (5) Proximal Phalanges (5) Proximal Phalanges (5) Intermediate Phalanges (5) Intermediate Phalanges (5) Distal Phalanges (4) Distal Phalanges (4)

4 Hip

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9 Femoral Bone

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13 Patella

14 Tibia & Fibula

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17 Proximal End of Left Tibia

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24 Gluteal Region

25 Iliac Crest Gluteal Crease

26 Superficial Layers Superficial Layers Skin Skin Superficial Fascia Superficial Fascia Deep Layers Deep Layers Deep Fascia Deep Fascia Muscles Muscles Suprapiriform & Infrapiriform Foramen Suprapiriform & Infrapiriform Foramen Lesser Sciatic Foramen Lesser Sciatic Foramen Hip Joint Hip Joint

27 Superficial Fascia the middle part is thinnest the middle part is thinnest Contains Superficial blood vessels, lymphatic vessels and cutaneous nerves Contains Superficial blood vessels, lymphatic vessels and cutaneous nerves

28 Bedsore (Decubitus Ulcer)

29 Arteries Superficial branches of 4 th lumbar artery 4 th lumbar artery Inferior gluteal artery Inferior gluteal artery Lateral sacral artery Lateral sacral artery Superior gluteal artery Superior gluteal artery Inferior gluteal artery Inferior gluteal artery

30 Cutaneous Nerves branches of the subcostal nerve (T12) branches of the subcostal nerve (T12) dorsal rami of lumbar nerves dorsal rami of lumbar nerves dorsal rami of sacral nerves dorsal rami of sacral nerves inferior cluneal nerves inferior cluneal nerves posterior femoral cutaneous nerve posterior femoral cutaneous nerve

31 Deep Fascia Attach to iliac crest superiorly Attach to iliac crest superiorly Invest gluteus maximus Invest gluteus maximus Attach to Sacral bone and coccyx medially Attach to Sacral bone and coccyx medially Continuous with fascia lata laterally Continuous with fascia lata laterally

32 Muscles Superficial Middle Deep Gluteus Maximus Tensor Fasciae Latae Glluteus Medius Piriformis Superior Gemellus Obturator Internus Inferior Gemellus Quadratus Femoris Gluteus Minimus Obturator Externus

33 Gluteus Maxinus Gluteus Maxinus Tensor Fasciae Latae Tensor Fasciae Latae

34 Glluteus Medius Glluteus Medius Piriformis Piriformis Superior Gemellus Superior Gemellus Obturator Internus Obturator Internus Inferior Gemellus Inferior Gemellus Quadratus Femoris Quadratus Femoris

35 Gluteus Minimus Gluteus Minimus Obturator Externus Obturator Externus

36 Suprapiriform Foramen

37 Infrapiriform Foramen

38 Sciatic n. Sciatic n. Tibial n. Tibial n. Common Fibular n. Common Fibular n.

39 66.3%27.3% 6.4% Tibial n.Common Fibular n.

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41 Piriformis Syndrome Pain radiates down the back of the leg

42 Ischial tuberosity Iliac crest

43 Lesser Sciatic Foramen Boundaries Boundaries front: tuberosity of ischium front: tuberosity of ischium above: spine of ischium & sacrospinous lig. above: spine of ischium & sacrospinous lig. behind: sacrotuberous lig. behind: sacrotuberous lig. Contents Contents tendon of Obturator internus tendon of Obturator internus internal pudendal a. internal pudendal a. internal pudendal v. internal pudendal v. pudendal n. pudendal n.

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47 Hip Anterior Posterior

48 It is based on this capsular attachment that fractures of the neck of femur are classified as: It is based on this capsular attachment that fractures of the neck of femur are classified as: INTRACAPSULAR: within the capsular attachment. INTRACAPSULAR: within the capsular attachment. EXTRACAPSULAR: outside the attachment of the capsule EXTRACAPSULAR: outside the attachment of the capsule Mixed Mixed

49 Intracapsular Lig. of head of femur Lig. of head of femur Transverse acetabular lig. Transverse acetabular lig.

50 Extracapsular (Anterior) Iliofemoral lig. Iliofemoral lig. Pubofemoral lig. Pubofemoral lig.

51 Extracapsular (posterior) Ischiofemoral lig. Ischiofemoral lig. Zona orbicularis Zona orbicularis

52 Superior gluteal a. Superior gluteal a. Inferior gluteal a. Inferior gluteal a. Lateral circumflex femoral a. Lateral circumflex femoral a. Medial Circumflex femoral a. Medial Circumflex femoral a. Branches of Obturator a. Branches of Obturator a. 1 st perforating branches of deep femoral a. 1 st perforating branches of deep femoral a. Femoral nutrient a. Femoral nutrient a. Blood Supply

53 Superior gluteal a. Superior gluteal a. Inferior gluteal a. Inferior gluteal a. 1 st perforating branches of deep femoral a. 1 st perforating branches of deep femoral a.

54 Medial Circumflex femoral a. Medial Circumflex femoral a. Lateral circumflex femoral a. Lateral circumflex femoral a. Superior retinacular a. Superior retinacular a. Anterior retinacular a. Anterior retinacular a. Inferior retinacular a. Inferior retinacular a.

55 Branches of Obturator a.

56 Femoral nutrient a. Femoral nutrient a.

57 If the head of the femur is dislocated postero-medially, compression of which nerve is likely to result? A. Femoral B. Lumbosacral trunk C. Obturator D. Sciatic E. Superior gluteal

58 What muscle passes through the lesser sciatic foramen? A. Gluteus minimus B. Obturator internus C. Piriformis D. Quadratus femoris E. Superior gemellus

59 In order to avoid injury to the sciatic nerve, intramuscular injections should be given in which quadrant of the buttock? A. upper medial B. upper lateral C. lower medial D. lower lateral E. middle

60 Of the branches of the internal iliac artery, the one exiting from the greater sciatic foramen superior to the piriformis muscle is the: A. Iliolumbar artery B. Internal pudendal artery C. Lateral sacral artery D. Superior gluteal artery

61 Thigh

62 Anterior compartment Anterior compartment Posterior compartment Posterior compartment

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64 Superficial iliac circumflex a. Superficial iliac circumflex a. Superficial epigastric a. Superficial epigastric a. External pudendal a. External pudendal a. Superficial lateral femoral a. Superficial lateral femoral a. Superficial medial femoral a. Superficial medial femoral a.

65 Groin Flap

66 Great Saphenous V. 70 ~ 80 cm femoral v. fossa ovalis medial side of thigh medial condyles of tibia & femur medial side of leg medial malleolus dorsal venous arch of foot

67 Tributaries Superficial iliac circumflex v. Superficial iliac circumflex v. Superficial epigastric v. Superficial epigastric v. External pudendal v. External pudendal v. Superficial lateral femoral v. Superficial lateral femoral v. Superficial medial femoral v. Superficial medial femoral v.

68 in emergency, great saphenous vein may be opened surgically for intravenous drip for the patients suffering from insufficiency of body fluid. in emergency, great saphenous vein may be opened surgically for intravenous drip for the patients suffering from insufficiency of body fluid. great saphenous vein as venous graft can be used in the coronary bypass surgery for coronary heart disease. great saphenous vein as venous graft can be used in the coronary bypass surgery for coronary heart disease.

69 one-way valves become weak & don't close properly

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71 Superficial inguinal LN Horizontal groups Horizontal groups Vertical groups Vertical groups

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73 Fascia Lata Iliotibial tract Iliotibial tract Saphenous hiatus (fossa ovalis ) Saphenous hiatus (fossa ovalis ) fascia cribrosa fascia cribrosa Falciform margin Falciform margin

74 Lacuna musculorum & vasorum between inguinal lig. and hip bone, and separated by iliopectineal arch between inguinal lig. and hip bone, and separated by iliopectineal arch lateral: lacuna musculorum lateral: lacuna musculorum medial: lacuna vasorum medial: lacuna vasorum

75 Lacuna musculorum Boundaries: Boundaries: ant. : inguinal lig. ant. : inguinal lig. post. : ilium post. : ilium med. : iliopectineal arch med. : iliopectineal arch Contents: Contents: iliopsoas iliopsoas lat. femoral cutaneous n. lat. femoral cutaneous n. femoral n. femoral n.

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77 Lacuna vasorum Boundaries: Boundaries: ant. : inguinal lig. ant. : inguinal lig. post. : pectineal lig. post. : pectineal lig. med. : lacunar lig. med. : lacunar lig. lat. : iliopectineal arch lat. : iliopectineal arch Contents: Contents: femoral sheath femoral sheath femoral a., v. femoral a., v. femoral canal femoral canal femoral br. of genitofemoral n. femoral br. of genitofemoral n.

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80 Femoral sheath

81 Femoral canal cm cm Boundaries: Boundaries: Ant. : inguinal lig. superior corner of falciform margin and femoral septum Ant. : inguinal lig. superior corner of falciform margin and femoral septum Post. : pectineal lig., pectineus Post. : pectineal lig., pectineus Lat. : fibrous septum of femoral v. Lat. : fibrous septum of femoral v.

82 femoral ring

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85 A 63-year-old female patient says that she has pain in her groin and upper thigh. Upon examination, you palpate a lump located below the inguinal ligament lateral to its attachment to the pubic tubercle. You suspect that this may be a hernia passing through the: A. femoral canal B. adductor hiatus C. obturator canal D. deep inguinal ring E. superficial inguinal ring

86 The femoral canal contains the: A. Deep inguinal lymph node(s) B. Femoral artery C. Femoral nerve D. Femoral vein E. Ilioinguinal nerve

87 The pulse of the femoral artery is best felt at which superficial reference point? A. Anterior to the ankle joint B. Femoral triangle C. Mid-thigh D. Popliteal fossa E. Right lateral portion of the hypogastrium

88 At which site could one expect to enter the femoral vein with a simple percutaneous (through the skin) introduction of an instrument? A. Above the middle of the inguinal ligament B. Lateral to the femoral arterial pulse C. Lateral to the pubic tubercle D. Medial to the femoral arterial pulse E. Medial to the pubic tubercle

89 A serious complication of fractures of the femoral neck is avascular necrosis of the femoral head. This usually results from rupture of which artery? A. Acetabular branch of obturator B. Deep circumflex iliac C. Descending branch of lateral circumflex femoral D. Medial circumflex femoral E. Second perforating branch of lateral circumflex

90 A ruptured aneurysm in the most proximal portion of the deep femoral artery would result in a hematoma located initially in the: A. Adductor canal. B. Femoral canal. C. Femoral triangle. D. Inguinal canal. E. Popliteal fossa.

91 Childhood immunizations are sometimes given via intramuscular injections into the quadriceps muscles of the anterior thigh. At the mid-thigh level, a needle passing into the space deep to the sartorius muscle might pierce the femoral vessels as they lie in the: A. Adductor canal B. Adductor hiatus C. Adductor triangle D. Femoral canal E. Femoral ring

92 Which of the following is NOT located within the adductor canal? A. Saphenous nerve B. Femoral artery C. Nerve to vastus medialis D. Femoral vein E. Deep femoral artery

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