ANATYOMY OF The thigh

Transcription

1 ANATYOMY OF The thigh

2 1- Lateral cutaneous nerve of the thigh Ι) Skin of the thigh Anterior view 2- Femoral branch of the genitofemoral nerve 1, 2 and 3 are From the lumber plexus 5- Intermediate cutaneous nerve of the thigh 3- Ilioinguinal nerve 6- Branches from the obturator nerve 7- Posterior cutaneous nerve of the thigh from the Sacral plexus 4- Medial cutaneous nerve of the thigh 4 and 5 are branches from the femoral nerve

3 The Lateral cutaneous nerve of the thigh Posterior cutaneous nerve of the thigh Intermediate cutaneous nerve of the thigh Branches from the obturator nerve

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6 Anterior view of the thigh Showing the lymphatic drainage of the Right Lower limb 3- Superficial inguinal lymph nods Lies below the inguinal ligament Divided into two groups; horizontal and vertical. A-The horizontal group lies below and parallel to the inguinal ligament. It divides into medial and lateral groups B-The vertical group lies along the terminal part of Saphenous vein.

7 The medial members of the horizontal group receive superficial lymph vessels from: 1-The anterior abdominal wall below the level of the umbilicus 2-The perineum 3-The urethra 4-The external genitalia of both sexes (EXCEPT the testes)?!!!!! 5-The lower half of the anal canal 6- The lower third of the vagina The lateral members of the horizontal group receive superficial lymph vessels from the back below the level of the iliac crests

8 The vertical group receives most of the superficial lymph vessels of the lower limbs Enlarged inguinal lymph nodes from a foot infection (arrows) They are located around the saphenous opening and receives lymph from the horizontal group and the skin of the thigh and the medial leg and foot. Its efferent vessels drain through the saphenous opening to the deep inguinal.

9 It is important to understand that the lateral side of the foot, calf and the deep tissues of the leg are drained to The popliteal group, a small group, lies in the popliteal fossa around

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11 The big toe drains to?

12 4- Superficial veins The most important superficial veins are the

13 G r e a t S a p h e n o u s v e i n 5-pierces the Saphenous opining and then joins the femoral vein about 4cm below and lateral to the pubic tubercle. 4-passes behind the knee and then curves around the medial side of the thigh. 3-ascends in a company with the Saphenous nerve. in the superficial fascia over the medial side of the leg. 2-passes directly in front of the medial malleolus of the tibia. 1-drains the medial end of the dorsal venous arch

14 S m a l l S a p h e n o u s v e i n 4-passes behind the knee and pierces the deep fascia of the popliteal fossa where it joins the popliteal vein 3-ascends in a company with the Sural nerve. in the superficial fascia 2-passes directly behindof the lateral malleolus of the fibula. 1-drains the lateral end of the dorsal venous arch

15 Just anterior and superior to the medial malleolus the great saphenous vein can readily be located and is frequently used for an emergency venous cutdown. The great saphenous vein is also commonly used to bypass blocked coronary arteries in a coronary artery bypass graft (CABG) operation known as a cabbage procedure. It is reversed so that its valves do not obstruct the arterial blood flow.

16 B- Deep fascia of the thigh (fascia lata) Forms on the anterio-medial side of the thigh the Saphenous opening (fossa ovalis). Saphenous opening (fossa ovalis) is a gap in the fascia lata which is covered by loose connective tissue called cribriform fascia. The cribriform fascia is pierced by: 1- Great Saphenous vein superficial branches of the femoral artery 3- Lymphatics.

17 Saphenous opening (fossa ovalis)

18 Fascia lata is connected to the linea aspera by three intermuscular septa; 1- Medial intermuscular septum 2- Lateral intermuscular septum 3- Posterior intermuscular septum Thus the deep fascia and septa divide the thigh into three compartment; Anterior Posterior Medial.

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20 Contents of the Anterior Fascial Compartment of the Thigh 1-Muscles: Sartorius, iliacus, psoas, pectineus, and quadriceps femoris 2-Blood supply: Femoral artery 3-Nerve supply: Femoral nerve Note: that not all the contents of the anterior compartment have the Same function. For example psoas is the m a i n f l e x o r of the thigh at the hip joint while quadriceps femoris is the m a i n e x t e n s o r of the leg at the knee joint.

21 S a r t o r i u s Origin: Anterior superior iliac spine Insertion: Upper medial surface of shaft of tibia Nerve supply: Femoral nerve Actions: Flexes, abducts, laterally rotates thigh at hip joint Flexes and medially rotates leg at knee joint

22 P e c t i n e u s Origin: Superior ramus of pubis Insertion: Upper end of linea aspera of shaft of femur Nerve supply: Femoral nerve? Actions: Flexes and adducts thigh at hip joint

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24 P s o a s m a j o r Origin: Transverse processes, bodies, and intervertebral discs of the 12th thoracic and five lumbar vertebrae I l i a c u s Origin: Iliac fossa of hip bone Both muscles pass behind the inguinal ligament

25 Insertion This means that the iliopsoas crosses anterior to hip joint Any muscle crosses anterior to hip joint will flex it, therefore, it Flexes thigh on trunk; if thigh is fixed (The insertion is fixed while the origin is moving) It flexes the trunk on thigh as in sitting up from lying down. sit-up exercise

26 Nerve supply Psoas major muscle: Lumbar plexus Iliacus muscle: by the Femoral nerve in the pelvis before it passes behind the inguinal ligament Iliopsoas may be tested clinically by actively flexing the hip against resistance, in the supine position with hip and knee flexed.

27 Both psoas and iliacus may be the sites of pathological collections of fluid. An abscess (typically tuberculous) of vertebral origin may track down through psoas and present as a mass in the thigh. Haematoma or infection within the iliacus fascia may present as a mass or as a flexion deformity of the hip

28 The quadriceps femoris muscle R e c t u s f e m o r i s Consisting of: 1- The rectus femoris 2- The vastus intermedius 3- The vastus lateralis 4- The vastus medialis V a s t u s l a t e r a l i s V a s t u s m e d i a l i s Origin : Upper end and shaft of femur (linear origin) Origin : Upper end and shaft of femur (linear origin)

29 R e c t u s f e m o r i s V a s t u s l a t e r a l i s V a s t u s m e d i a l i s

30 V a s t u s i n t e r m e d i u s

31 V a s t u s i n t e r m e d i u s Origin: Anterior and lateral surfaces of shaft of femur

32 R e c t u s f e m o r i s Originates by two heads Straight head from anterior inferior iliac spine Reflected head from ilium above acetabulum Flexion of the hip joint Rectus can flex the hip and extend the knee simultaneously.

33 Insertion: the four heads are attached to the patella and, via the ligamentum patellae, to the tibial tuberosity (the real insertion)

34 Actions: the quadriceps femoris muscle Any muscle crosses anterior to the knee joint, will extend it Extends the leg at knee joint; flexes thigh at hip joint (only the rectus femoris head). Quadriceps femoris is the main extensor of the knee joint Testing The quadriceps group is tested by extending the knee against resistance, in the supine position with the hip flexed. Nerve supply : femoral nerve

35 Vastus medialis, lateralis and intermedius of quadriceps are attached to the shaft of the femur and so the pull is lateral lateral vector on the patella during knee motion The patella tends to be dislocated laterally What prevents it from being dislocated? 1-Notice that the lateral condyle of femur is a bit longer than the medial which prevents patellar dislocation Lateral condyle of femur (OUTR) Medial condyle of femur (INNER) prevents lateral dislocation of the patella Longer than the medial

36 2-Vastus medialis and vastus medialis obliquu The lowest fibres of vastus medialis are nearly horizontal and form a bulge in the living subject, medial to the upper half of the patella. Some authors distinguish this part of the muscle as The vastus medialis obliquus It plays an important role in the function of patellofemoral joint. What if vastus medialis obliquus has been weakened???

37 PATELLOFEMORAL SYNDROME Pain deep to the patella often results from excessive running, especially downhill; hence, this type of pain is often called runner's knee. The pain results from repetitive microtrauma caused by abnormal tracking of the patella relative to the patellar surface of the femur, a condition known as the patellofemoral syndrome. This syndrome may also result from a direct blow to the patella and from osteoarthritis of the patellofemoral compartment (degenerative wear and tear of articular cartilages). In some cases, strengthening of the vastus medialis corrects. What should we do about it (treatment)?

38 In some cases, strengthening of the vastus medialis would correct it A systematic review by Smith et al. in 2009, recommended that clinicians should not focus on VMO strengthening, but instead focus on general quadriceps training.

39 F e m o r a l N e r v e It is the largest branch of the lumbar plexus (L2, 3, and 4). It emerges from the lateral border of the psoas muscle enters the thigh lateral to the femoral artery and the femoral sheath, behind the inguinal ligament. it terminates by dividing into anterior and posterior divisions. lateral

40 Anterior Division The anterior division gives off two cutaneous branches 1- The medial cutaneous nerve of the thigh. 2- The intermediate cutaneous nerve of the thigh and two muscular branches. Nerve to sartorius and nerve to pectineus muscles.

41 Posterior Division The posterior division gives off one cutaneous branch The Saphenous nerve and muscular branches to the quadriceps muscle. THE SAPHENOUS NERVE runs downward and medially. It emerges between the tendons of sartorius and gracilis It then runs down in company with the great Saphenous vein. It passes in front of the medial malleolus and along the medial border of the foot, where it terminates in the region of the ball of the big toe

42 The saphenous nerve accompanies the femoral artery through the adductor canal, but does not pass through the adductor hiatus with the femoral artery. Rather, the saphenous nerve penetrates directly through connective tissues near the end of the canal to appear between the sartorius and gracilis muscles on the medial side of the knee. Here the saphenous nerve penetrates deep fascia and continues down the medial side of the leg to the foot, and supplies skin on the medial side of the knee, leg, and foot.