6/10/2016. Anatomy #7. Jamaledin Abu Ghaida Hussein Al-Sa di. The adductor canal & the popliteal fossa

Transcription

1 6/10/2016 Anatomy #7 The adductor canal & the popliteal fossa Jamaledin Abu Ghaida Hussein Al-Sa di

2 Hello This lecture is short (9 pages) and easy. It includes the records of both groups; A and B. I included the slides in the end of the sheet (the last 4 pages). I tried to make them more understandable because most of them are written in Latin words and are organized differently, and that s why I didn t include them within the context because I thought that would confuse you. So please read them after you finish the sheet. These are the objectives of this lecture: Describe the femoral triangle. Describe the subsartorial (adductor) canal Classify the muscles of the thigh according to function Describe the popliteal fossa and its contents. ***** (و إ ذ إ م ر ض ت ف ه و ي ش ف ي ( So what s our role? You have to appreciate the privilege that Allah gave you to be a reason in giving a new life to people - Dr. Jamal Abu Ghaida ***** 1

3 In the last lecture we said that if we dissect the upper anterior aspect of the thigh (i.e. to remove the overlying skin and the subcutaneous tissue (which is the superficial fascia)), we will reach the deep fascia surrounding the whole thigh. This deep fascia that surrounds the whole thigh was given a name to distinguish it from any other deep fascia in the body it s called Fascia lata (the broad fascia). In this figure you can tell that the fascia lata was removed because you can see the muscles. However, it isn t removed completely as you can see a part of it on the lateral side of the thigh which resembles a thickened tract that extends from the region of the anterior superior iliac spine down to the Tibia. This is the iliotibial tract (the dashed rectangle). The iliotibial tract is an important structure due to its attachment to the tibia; because when you pull it upward you will pull the tibia as well and thus extending the knee or keeping it extended with the minimal effort when you re standing, otherwise you will expend much more energy to keep the knee extended by using the quadriceps muscles (will be discussed later). o What are the muscles that tense/pull the iliotibial tract? Two muscles act on the tract to keep it taut/tensed: - The Gluteus maximus: Two thirds of this muscles insert into the iliotibial tract. - The Tensor fasciae latae. So; Gluteus maximus & Tensor fasciae latae tensed iliotibial tract Extended knee Standing with minimal energy usage. 2

4 We also talked about the femoral triangle and its boundaries: - Superiorly by the Inguinal ligament; which extends from the anterior superior iliac spine of the ilium and the pubic tubercle of the pubic bone. - Medially by the Adductor longus muscle. - Laterally by the Sertorius muscle (one of the anterior compartment muscles) This femoral triangle takes its importance from its contents; starting from the midpoint just below the inguinal ligament there s the femoral artery (where you can feel its pulse), medial to it is the femoral vein and lateral it is the femoral nerve which is a branch of the lumbar plexus. The femoral nerve in its location in the triangle is already branched into motor (muscular) and sensory branches for the anterior aspect of thigh. ******* If you look at the figure above, you will notice the presence of a canal medial to the femoral vein which is the femoral canal. Through this canal you can go up and reach the pelvic cavity. But why is the femoral canal important? Because it s the passageway of lymphatics All lymphatics of the lower limbs whether superficial or deep go up through this canal to reach the deep pelvic (iliac) lymph nodes.. Note: Rosenmuller lymph node is a deep inguinal lymph node that lies within the femoral canal. However, lymphatic vessels are very delicate structures and don t need a wide canal to pass through. So normally, the femoral canal s width is as small as the lymphatics that pass through it it s almost closed! The importance of this canal emerges in the abnormal conditions because of its connection to the abdomen. If structure in the pelvis or the abdominal cavity press against this canal they can open and pass through it, a condition called Hernia. 3

5 So Femoral Hernia: is the protrusion of the intra-abdominal (Intra-pelvic) viscera out of the abdominal cavity through the almost closed femoral canal. This type of hernia is more common in females in contrast to inguinal hernia which is more common in males. We will learn about inguinal hernia next semester. ** So if you have a female patient with a swelling on the medial side of the thigh think about femoral hernia, or inguinal hernia if the patient is male. As this femoral canal is very narrow, structures passing through it are susceptible to strangulation. In the regard of femoral hernia, orthopedics and surgeons are aware of something called Corona Mortis. The doctor asked us to search about it as an assignment. This is what I found: The "corona mortis" is an anatomical variant, an anastomosis between the obturator and the external iliac or inferior epigastric arteries or veins. It is located behind the superior pubic ramus at a variable distance from the symphysis pubis (range mm). The name "corona mortis" or crown of death testifies to the importance of this feature, as significant hemorrhage may occur if accidentally cut and it is difficult to achieve subsequent hemostasis. It constitutes a hazard for orthopedic surgeons especially in the anterior approach to the acetabulum. ( This vascular structure could be endangered in a laparoscopic procedure for inguinal or femoral hernia repair and a staple or tack is driven blindly into the pectineal (Cooper's) ligament. ( 4

6 Now we ll talk about muscles of the anterior compartment of the thigh: The Quadriceps femoris. This muscle is located directly posterior to the Sartorius muscle, and as its name implies, has four heads of origin. However, because of their large size, these four heads are considered as 4 separate muscles. These muscles are: Three Vasti muscles: Vastus lateralis on the lateral side of femur Vastus Intermedius in the middle Vastus Medialis on the medial side of femur The three Vasti muscles originate from the femur These are 3 heads The fourth head is: Rectus femoris muscle: The only muscle (head) of the quadriceps femoris muscle that originates from the pelvis, specifically from the anterior inferior iliac spine. ** Vastus intermedius is directly posterior to Rectus femoris muscle. The 4 heads of the quadriceps femoris join into one large tendon called the Quadriceps Tendon. This tendon inserts on the Tibial tuberosity and as it passes to insert there, it encloses a sesamoid bone which is the Patella. *Sesamoid bone; is any bone within a tendon. The largest sesamoid bone in the body is the patella. 5

7 Anatomists called the part of the tendon from the patella to the tibial tuberosity as Patellar Ligament; a continuation of the quadriceps tendon. Action: Extension of the leg * Quadriceps femoris is the major extender of the knee. It s a very strong muscle due to its importance in resisting the gravity when standing (Anti-Gravity muscle) where you need to keep the knee extended in order not to succumb down! The Sartorius muscle: - It s a very long muscle that originates from the anterior superior iliac spine, it descends downward and medially and passes behind the medial condyle of the femur to insert on the Tibia. - It s called the tailor s muscles الخي اطية( )العضلة Why? Look at the image; Tailors usually when they sew something, they need to rest on their leg so they sit in a position similar to that in the image as you can see The Hip is flexed and laterally (outer) rotated The Knee is flexed and medially (inner) rotated These are the Sartorius muscle actions Interesting ha! :3 Note: Although the Sartorius muscle is one of the anterior compartment of the thigh (the extensors of the knee), its action on the knee is flexion not extension. - The Sartorius muscle divides the thigh into medial and lateral regions: The lateral region; which is occupied by the major extensors of the knee (the anterior group) it s poor in vessels and nerves. The medial region is occupied by the adductor muscles of the thigh. Also, it s the side that is rich in vessels and nerves that s why this region is clinically very important. So clinically, as a surgeon you can use the Sartorius muscle as a guide to know the location of vessels and where each group of muscles is. 6

8 The Adductor muscles (the medial compartment of the thigh): - They re adductors of the hip joint (the thigh) - They re supplied by the Obturator nerve - They re group of muscles that have common origins which are all the bones surrounding the obturator foramen. - They all insert on the femur medially, except Gracilis which inserts on the Tibia and builds the medial boundary of the whole thigh. This group includes: 1. Adductor Longus 2. Adductor Brevis 3. Adductor Magnus (most posteriorly) 4. Pectineus 5. Gracilis (the most medial) 6. Obturator Externus So some of the adductor muscles are posterior and some are anterior; the most superficial muscle is the adductor longus posterior to it is the adductor brevis and most posteriorly is the adductor magnus. 7

9 Flexors of the Knee (the posterior compartment): - They all originate from the ischial bone. - They re divided according to their site of insertion into two groups: Medial: 2 muscles which insert on the Tibia medially. - Semi-membranosus - Semi-tendinosus Lateral: It s only one muscle; Biceps Femoris It inserts on the Fibula laterally. - This group of muscles has 3 different names: The flexors of the knee The Ischiocrural muscles; this name indicates the origin (ischio, the ischium) and the insertion (crural: adjective the name: crus means leg, either tibia or fibula). The Hamstring muscles - All are innervated by the Sciatic nerve. - Their action: On the Hip: Extension (and minor action: Adduction) On the knee: - All do Flexion - Rotation: Biceps Femoris Lateral Rotation Semimembranosus & Semitendinosus Medial rotation. 8

10 Wait! We know that the knee joint is a hinge joint and this type of joints cannot rotate so what are we talking about? The typical hinge joint can only flex and extend but can t rotate. The knee joint is an atypical (modified) hinge joint and thus can rotate but only in the flexed position; it can t rotate when the knee is extended. Look at the figure in the previous page again You can see that tendons of the Semimembranosus & Semitendinosus lie on the medial side and tendon of the Biceps femoris lies on the lateral side But what about the middle space between these tendons posteriorly? Yes there s a gap! Also, if we look at the leg posteriorly, we will find a similar behavior; a muscle of the leg that diverges when it reaches the same gap! This is the Gastrocnemius muscle This muscle has two parts/heads; a medial hesd and a lateral head. Now we have a rhombus/diamond-like space formed by: - Two groups of muscles from above (Biceps femoris and the Semi-muscles) - One muscle from down (Gastrocnemius) This muscular gap is the Popliteal fossa that lies behind the knee... This is a very important space because of its contents. ** Contents of the popliteal fossa: The popliteal fossa contains vessels and nerves, which are 1. continuation of femoral vessels found in the femoral triangle; meaning the femoral artery and vein continue to reach the popliteal fossa, 2. The nerve you see in the figure below is the Sciatic nerv, Which descends down from the posterior compartment of the thigh. However, a branch (not the whole nerve) of the femoral nerve passes through the canal (discussed next) but leaves when it reaches halfway of the canal. 9

11 So, the popliteal fossa contains: continuation of the femoral vessels (now called popliteal vessels) and the Sciatic nerve with its branches (common peroneal and tibial nerves) But the question is: How do the femoral vessels reach this posterior region from the anterior femoral triangle? Answer: 1) Firstly, vessels descend down from the femoral triangle through a muscular canal. This canal runs on the anterior and medial aspects of the thigh; it starts from the site where vessels disappeared in the femoral triangle they go below the Sartorius muscle which covers the canal anteriorly. This muscular canal is called the Adductor Canal. This canal has boundaries formed by muscles: Vastus Medialis laterally Adductor Magnus & Adductor Longus posteriorly Vastoadductor membrane. anteromedialy The fact that it lies under cover of the Sartorius muscle led to the name Sub-sartorial canal and is also called Hunter's canal. 10

12 2) Vessels pass from the anterior aspect of the thigh to the posterior aspect through the adductor canal. The canal ends at the adductor hiatus. This opening marks the end of the adductor canal. This opening is formed by the Adductor Magnus muscle. So vessels pass through this opening from the anterior aspect to the posterior aspect of the thigh and then reach the popliteal fossa. Once vessels pass through Adductor Hiatus they re called popliteal vessels. *** Watch this video to ensure that you understand what is the adductor canal: And lastly, look at the figure below carefully: - The adductor longus muscle is removed - The Sartorius muscle is also removed So now we re looking at the subsartorial region. If you follow the femoral artery and vein downward, you will see that they pass through the adductor canal (notice its boundaries) deep to the Sartorius muscle. 11

13 Slides: Topographic division of the anterior region of the Thigh by the Sartorius muscle: Lateral region (poor with vessels and Nerves) Medial region (rich with vessels and nerves) Deep in the adductor region: - Obturator canal with obturator artery and the Obturator nerve: obturator region (adductoria) vs Subinguinal region. Boundaries of femoral triangle: - Sup.: Inguinal lig - Lat.: Sartorius - Med.: add. Longus - Floor: iliopsoas, pectineus - Roof: skin, deep fascia Contents: Femoral Nerve, femoral sheath with fem. Vessels, deep inguinal Lymph nodes Importance of the femoral triangle It Contains: - Femoral artery - Superficial inguinal lymph nodes - Great saphenous vein and tributaries Varicosities (Varicose veins) - Site of femoral hernia (below medial 1/3 of inguinal ligament) Position of Femoral Artery: just medial of midpoint of inguinal lig. (Superior anterior iliac spine to Tuberculum pubicum (pubic tubercle) Pressure against Eminentia iliopectinea (Iliopubic eminence) 12

14 Relations of Femoral Artery - Anterior: skin and fascia superiorly, Sartorius, anterior wall of subsartorial canal, medial femoral cutaneous nerve saphenous nerve. - Posterior: psoas (separating hip joint), pectineus - Medial: femoral vein - Lateral: femoral Nerve Superficial region: Between skin and fascia lata: * It contains: Superficial inguinal lymph nodes and superficial veins Oblique group (parallel to the ligament) from ventrolateral abdominal wall, superficial gluteal region, outer genitalia (Female External Genitalia (Vulva)), perineum, anus and fundus uteri Longitudinal group (parallel to the great saphenous vein) from superficial lower limb: Superficial veins build venous star: 1) The superficial epigastric artery 2) V. circumflexa ilium superficialis, 3) Superficial external pudendal artery 4) The great saphenous vein, passes through Hiatus saphenous (Fossa ovalis). Arteries: branches of Femoral Artery Nerves: Branches of lumbar plexus: 1) N.cut.femoris lat., 2) Nn. Cut. Anteriores,, (Anterior cutaneous nerve) 3) R.fem.N. genitofemoralis, (Genitofemoral nerve) 4) R.cut.N.obturatorii. 13

15 Deep Region: - Hiatus saphenous: weak region of fascia lata with Lamina cribrosa, - The deepest region is fossa iliopectinea with lacunae musculorum (muscular lacuna) and vasorum: lateral iliopsoas and the femoral nerve (branched already), femoral vein and artery (with deep lymph vessels to internal iliac LNN from subfascial structures of anterior and medial thigh and pass medially between sup. Pubic ramus, lacunar ligament and inguinal ligament: Anulus femoralis (Femoral ring) with septum femoralis ans Nodus lymph. Annuli femoralis-rosenmueller. Hernia femoralis and Corona mortis. Femoral nerve: muscular branches, Nn cut anteriores, has long sensory branch: the saphenous nerve, the greater saphenous vein Adductor canal (Hunter): - Just below middle of thigh fibers of adductor longus and magnus build membrane vastoadductoria which attaches to vastus medialis. - Adductor canal ends at Hiatus adductorius (Adductus Hiatus). - Allows femoral vessels to reach popliteal fossa - Membrane is pierced by saphenous nerve and Vasa genus descendentia Walls of subsartorial canal: Anteromed: membrane vastoadductoria (membrane of adductor canal) deep to Sartorius Post: adductor longus and magnus Lat.: vastus Medialis Contents: Femoral vessels, deep lymph vessels, saphenous nerve, n. to vast med, terminal part of obturator N. 14

16 The knee region (Regio genus) includes: Regio genus anterior (Anterior knee joint) contains skeletal parts of knee joint, and Regio genus posterior (popliteal fossa) contains soft structures (muscles) and supplying structures of the leg Borders of popliteal fossa: Superiorly by biceps femoris (leading structure of N.peroneus commumis (The common peroneal nerve)) and semitendinosus and semimembranosus inferiorly heads of gastrocnemius. Contains: corpus adiposum popliteum (Fat pads), popliteal vessels, small saphenous vein, common peroneal and tibial nerves, post. Fem. Cut. N., genicular branch of obt. N., Lnn. Superficial region: The small saphenous vein runs in popliteal fascia Deep region: Rhombus popliteus, Spatium popliteum receives two routes: 1. Stratum subgluteum along N. ischiadicus via space betw, ischiocrural muscles and add.magnus. 2. Regio femoris anterior via adductor Canal vasa femoralia. - Neurovascular bundle: N.ischiadicus divides at upper border of region into tibial and common peroneal. Tibial nerve lies midposition, common peroneal runs on med margin of biceps. In upper 2/3 from lateral to medial and dorsal to ventral NeVA. NLL popolitei Edited by: Nihad Al-Yousfi The End 15