LOWER LIMB Anterior Compartment of the Thighs & Femoral Triangle Dr. Kumar K.V 02.11.2009

Superficial structures Great saphenous vein Drains the medial end of dorsal venous arch of foot Passes upward directly in front of the medial malleolus. Then ascends on medial side of the leg. Passes behind the knee and curves forward around the medial side of the thigh. Passes through the saphenous hiatus in the deep fascia and joins the femoral vein about 4 cm below and lateral to the pubic tubercle.

Veins Deep Veins: Mostly share names of arteries Superficial Veins Ultimately empty into Inferior Vena Cava Plantar Tibial Fibular Popliteal Femoral External/internal iliac Common iliac Superficial Veins Dorsal venous arch (foot) Great saphenous (empties into femoral) Small saphenous (empties into popliteal)

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

Superficial epigastric v. Superficial circumflex iliac v. External pudendal v. Superficial lateral femoral v. Superficial medial femoral v. Great saphenous v.

Varicose veins

Superficial structures Superficial fascia Superficial arteries: superficial epigastric a. superficial iliac circumflex a. external pudendal a. Cutaneous nerves: lateral femoral cutaneous n. anterior and medial cutaneous branches of femoral n. cutaneous branches of obturator n.

Cutaneous Nerves lateral femoral cutaneous n. anterior and medial cutaneous branches of femoral n. Cutaneous branches of obturator n.

Superficial structures Superficial inguinal lymph nodes . Superior group: Lies just distal to the inguinal ligament Receive lymph vessels from anterior abdominal wall below umbilicus, gluteal region, perineal region, external genital organs Inferior group: Lies vertical along the terminal great saphenous v. Receives all superficial lymph vessels of lower limb, except for those from the posterolateral part of calf Efferent vessels drain into the deep inguinal ln. or external iliac ln.

Deep fascia of the thigh Fascia lata The deep fascia encloses the thigh like a trouser leg. Saphenous hiatus A gap in the deep fasica which lies about 4 cm below and lateral to the pubic tubercle. The falciform margin is the lower lateral border of the opening, which lies anterior to the femoral vessels. Filled with loose connective tissue called the cribriform fascia

Deep fascia of the thigh Iliotibial tract laterally the deep fascia forms a thick band, from the iliac tubercle to the lateral condyle of tibial. The fascia lata sends intermuscular septa to the linea aspera of the femur. These separate the thigh into three compartments each of which contains a group of muscles, the vessels and the nerves.

Inguinal Ligament & Femoral Sheath Boundaries: Anteriorly: lateral portion of inguinal ligament Posterolaterally: ilium Medially: iliopectinal arch Contents: Iliopsoas femoral n. lateral femoral cutaneous n. Lateral femoral cutaneous n. Iliopsoas Iliopectinal arch Femoral n.

Femoral Ring & Femoral Sheath Boundaries: Anteriorly: medial portion of inguinal ligament Posteriorly: fascia of pecteineus and pectineal ligament Medially: lacunar ligament Laterally: iliopectinal arch Contents: Femoral sheath Femoral a. and v. Genital branch of genitofemoral n. Lymphatic vessels Femoral a. Femoral v. Femoral ring

Femoral triangle Femoral sheath A funnel- shaped sheath Derived from transversalis fascia anteriorly and iliac fascia posteriorly It surroumds the femoral vessels and lymphatic about 2.5cm belower the inguinal ligamemt. Its lower end disappears at the lower margin of the saphenous opening where the sheath fuses with the adventitia of the vessels.

Femoral sheath Femoral sheath Lateral compartment: femoral a. Divided into three compartments by two fibrous septa Lateral compartment: femoral a. Middle compartment: femoral v. Medial compartment: femoral canal

The femoral canal About 1.3cm long , and its upper opening is called the femoral ring Contains: a little loose fatty tissue, a small lymph node, and some lymph vessels. The boundaries of the femoral ring Anteriorly: the inguinal ligament Medially: the lacunar ligament Posteriorly: the pecten of pubis Laterally: the femoral vein Superior: covered by femoral septum

Femoral hernia If a loop of intestine is forced into the femoral ring, it expands to form a swelling in the upper part of the thigh. Such a condition is known as a femoral hernia. A femoral hernia is more common in women than in men (possibly because their wider pelvis and femoral canal ).

Femoral triangle Boundaries A triangular depressed area situated in the upper part of the medial aspect of the thigh just below the inguinal ligament Boundaries Superiorly (base) : the inguinal ligament Laterally: medial border of sartorius Medially: medial border of adductor longus Apex: continuous with adductor canal Anterior wall: fascia lata Posterior wall: consists of iliopsoas, pectineus and adductor longus from lateral to medial side

Femoral triangle Contents Femoral nerve Femoral sheath Femoral a. and its branches Femoral vein and its tributaries. Femoral canal Deep inguinal lymph nodes Fatty tissue VAN – VEIN, ARTERY, NERVE

Contents of the anterior fascial compartments of the thigh Psoas major Iliopsoas Iliacus Sartorius Vastus lateralis Quadriceps femoris Rectus femoris Vastusintermedius Vastus medialis

Contents of the medial fascial compartments of the thigh Pectineus Adductor longus Adductor brevis Adductor magnus Gracilis Adductor tendinous opening

Femoral artery Femoral a. Continuation of the external iliac a. Begins midpoint of inguinal ligament Ends at the adductor tendinous opening by entering the popliteal fossa as the popliteal artery Principal branch－deep femeral a. arises from the posterolateral surface of the femoral artery about 5 cm below the inguinal ligament. Medial femoral circumflex lateral femoral circumflex Four perforating arteries

Profunda femoris Arises from the posterolateral surface of the femoral artery about 5 cm below the inguinal ligament. Branches: Lateral circumflex artery. Medial circumflex artery. Perforating arteries

deep femeral a. Medial circumflex a. Lateral circumflex a. perforating arteries

Femoral vein Begins at the adductor tendinous opening Continues as external iliac vein deep to inguinal ligament Contains several valves

The deep inguinal lymph nodes Lie medial to the femoral v. Receive deep lymphatics of lower limb, perineal region, and efferent lymphatics from the superficial inguinal ln. Drain into the external iliac ln.

Femoral nerve Arises from the lumbar plexus in the abdomen, and enters the thigh posterior to the inguinal ligament and lateral to the femoral artery. It ends by dividing into a number of branches 2 cm below the inguinal ligament. Muscular branches to: pectineus, sartorius, quadriceps femoris

Femoral nerve Cutaneous branches: Anterior cutaneous nerves of the thigh Saphenous nerve is the longest branch of the femoral nerve. It accompanies the femoral vessels in the adductor canal, then accompanies the great saphenous vein to the medial side of the leg and food. Saphenous nerve 隐神经 is the longest branch of the femoral nerve. It accompanies the femoral vessels in the adductor canal, then accompanies the great saphenous vein to the medial side of the leg and food.

Femoral n. Femoral a. Femoral v. Saphenous nerve

Muscles of the Anterior Compartment of the Thigh Sartorius. Iliacus. Psoas major. Pectineus. Quadriceps Femoris.

Sartorius Origin: Anterior superior iliac spine. Insertion: Upper part of the medial surface of the shaft of the tibia. Nerve Supply: Femoral nerve. Action: -Flexion, abduction and lateral rotation of the thigh. -Flexion and medial rotation of the leg.

Tensor Fasciae Latae Origin: Outer lip of iliac crest. Insertion: Through the ilio-tibial tract to the lateral condyle of the tibia Nerve Supply: Superior gluteal nerve. Action: Abduction of the thigh (with gluteus medius and minimus). Maintenance of the extended knee (with gluteus maximus).

Iliacus Origin: Iliac fossa. Insertion: Lesser trochanter of the femur. Nerve Supply: Femoral nerve. Action: Flexion of the thigh. Helps in Medial rotation of thigh.

Psoas major Origin: Transverse processes and sides from 12th thoracic to 5th lumbar vertebrae. Insertion: Lesser trochanter of the femur. Nerve Supply: Branches from lumbar plexus. Action: Flexion of the thigh. Helps in Medial rotation of thigh.

Pectineus Origin: Superior pubic ramus. Insertion: Upper end of linea aspera of femur. Nerve Supply: Femoral nerve. Obturator nerve. Action: Flexion of the thigh. Adduction of the thigh.

Quadriceps Femoris Rectus Femoris Origin: Ant. Sup. Iliac Spine + Ilium above acetabulum Insertion: Quadriceps tendon and patella. Nerve Supply: Femoral nerve. Action: Extension of the knee joint.

Quadriceps Femoris Vastus Lateralis Origin: Inter-trochanteric line + linea aspera Insertion: Quadriceps tendon and patella. Nerve Supply: Femoral nerve. Action: Extension of the knee joint.

Quadriceps Femoris Vastus Medialis Origin: Inter-trochanteric line + linea aspera Insertion: Quadriceps tendon and patella. Nerve Supply: Femoral nerve. Action: Extension of the knee joint.

Quadriceps Femoris Vastus Intermedius Origin: Anterior and lateral surfaces of the shaft of the femur Insertion: Quadriceps tendon and patella. Nerve Supply: Femoral nerve. Action: Extension of the knee joint.

Adductor canal An intermuscular cleft situated on the medial aspect of the middle third of the thigh beneath the sartorius. Extends from apex of femoral triangle to adductor tendinous opening Boundies Anterior wall: adductor lamina and sartorius Lateral wall : vastus medialis Posteomedial wall: adductors longus and magmus Contents Saphenous n. Femoral a. and femoral v. lymphatic vessels and loose connective tissue

Blood vessels and nerve of medial side of thigh Obturator a. Arises from internal iliac artery in the lesser pelvis passes through the obturator canal where it divides into anterior and posterior branches. Obturator n. Arises from the lumbar plexus in the abdomen. Enters the thigh through the obturator canal where it divides into anterior and posterior branches. Supplies medial group of muscles of thigh, obturator externus, and skin of medial side of thigh

Obturator n.

Arteries External iliac becomes……. Femoral becomes…… Femoral Once passes the inguinal ligament Lower limb Branches into Deep femoral Adductors, hamstrings, quadriceps Branches into Medial/lateral femoral circumflex Head and neck of femur Femoral becomes…… Popliteal (continuation of femoral) Branches into: Geniculars Knee Splits into: Anterior Tibial Anterior leg muscles, further branches to feet Posterior Tibial Flexor muscles, plantar arch, branches to toes

Anterolateral crural region Superficial veins Dorsal venous arch: lies in the subcutaneous tissue over the heads of the metatarsal bones and drains on the medial side into the great saphenous v. and on the lateral side into the small saphenous v. Great saphenous v.: Drains the medial end of dorsal venous arch of food and passes upward directly in front of the medial malleolus. Then ascends in company with the saphenous n. in the superficial fascia over the medial side of the leg.