![BRANCHES
• [1. ] Cutaneous branches are two .
(A) Lateral cutaneous nerve of the calf - descends to supply the
skin of
the upper two -thirds of the lateral side of the leg
(B). Sural communicating nerve - arises in the upper part of the
Foss.
It runs on the posterolateral aspect of calf and
joins the sural nerve.](https://image.slidesharecdn.com/143852b2-7c8a-4be4-9a13-f22e93572bc4-230821055636-4ee624d6/85/143852b2-7c8a-4be4-9a13-f22e93572bc4-pptx-47-320.jpg)
143852b2-7c8a-4be4-9a13-f22e93572bc4.pptx
- 2. • Femoral triangle is a triangular on the front of the upper one-third of the thigh immediately below the inguinal ligament.
- 3. • Laterally – Medial border of sartorius • Medially – Medial border of the adductor longus Base – Inguinal ligament . Apex – Directed downward, is formed By the point where the medial and lateral boundaries cross . • The apex is continuous, below with the adductor canal. BOUNDARIES :-
- 4. • The roof of femoral triangle is formed by:- • A) skin • B) Superficial fascia containing the superficial inguinal lymph nodes, the femoral branch of the genitofemoral nerve, branches of the ilioinguinal nerve, superficial branches of the femoral artery with accompanying veins, and the upper part of the great saphenous vein. • Deep fascia, including the cribriform fascia covering the saphenous opening. ROOF:-
- 5. • This is an oval shape opening in fascia Lata. • The center of opening is 4 cm below and 4 cm lateral to pubic tubercle. • It is 2.5 cm long and 2 cm broad. • Lateral margin – sharp cresentic • Medial margin – ill defined margin lies at deeper level formed by fascia overlying pectineus. • The saphenous opening is closed by cribriform fascia formed by modification of superficial fascia which covers opening SAPHENOUS OPENING
- 6. • Medially – adductor longus and pectineus • Laterally – psoas major and iliacus FLOOR:-
- 7. • The contents of the femoral triangle are as follows: • Femoral artery and its branches:- The femoral artery traverses the triangle from its base at the midinguinal point to the apex. In the triangle, it gives off six branches, three superficial and three deep. • Superficial branches - 1) Superficial external pudendal • 2) superficial epigastric • . 3) superficial circumflex iliac • Deep branches – 1) profunda femoris • . 2) Deep external pudendal • . 3) muscular branches • Femoral vein and its tributaries:- The femoral vein accompanies the femoral artery. The vein is medial to the artery at the base of triangle, but posteromedial to artery at the apex. The femoral vein receives the great saphenous vein, circumflex veins and veins corresponding to the branches of femoral artery. CONTENTS :-
- 8. • The femoral sheath encloses the upper 4 cm of the femoral vessels • Nerves:-A) The femoral nerve lies lateral to the femoral artery, outside the femoral sheath, in the groove between the iliacus and the psoas major muscles. It is described later • B) The nerve to the pectineus arises from the femoral nerve just above the inguinal ligament. It passes behind femoral sheath to reach the anterior surface of pectineus. • C) The femoral branch of the genitofemoral nerve occupies the lateral compartment of the femoral sheath along with the femoral artery. It supplies most of the skin over the femoral triangle.
- 9. • D) The lateral cutaneous nerve of the thigh l the lateral angle of the triangle. Runs on the lateral side of thigh. • The deep inguinal lymph nodes lie deep to the deep fascia. These lie medial to upper part of femoral vein and receive lymph from superficial inguinal lymph nodes, from glans penis or clitoris and deep lymphatics of lower limb.
- 10. • This is a funnel-shaped sleeve of fascia enclosing the 3 to 4 cm of the femoral vessels. • The sheath is form downward extension of two layers of the fascia abdomen. • The anterior wall of the sheath is form the fascia transversalis which lies in the anterior abdominal wall deep to the transversus abdominis; • The posterior wall is formed by the fascia iliaca, which covers the iliacus muscle • Inferiorly, the sheath merges with connective tissue around the femoral vessels. FEMORAL SHEATH
- 11. • The femoral sheath is asymmetrical. • Lateral wall -- vertical, • medial wall -- oblique being directed downward and laterally • The sheath is divided into the following three by compartments by septa . • A.The lateral or arterial compartment contains the femoral artery and the femoral branch of the genitofemoral nerve. • B. The intermediate or venous compartment contains the femoral vein. • C. The medial or lymphatic compartment is the smallest of all, and is known as the femoral canal.
- 12. This is the medial compartment of the femoral sheath. It is conical in shape-- wide above or at base narrow below. About. 1.5 cm Long 1.5 cm wide at the base The base or upper end of femoral canal is called femoral ring. bounded anteriorly : inguinal ligament posteriorly : pectineus medially : lacunar ligament laterally : septum separating it from femoral vein. FEMORAL CANAL
- 13. • Contains • Lymph node of Cloquet or Rosenmüller, lymphatics, and a small amount of areolar tissue. • The lymph node drains the glans penis in males and the clitoris in females.
- 14. FEMORAL HERNIA • The femoral canal is an area of potential weekness in the abdominal wall through which abdominal contents may bulge out forming a femoral hernia. • A femoral hernia is more common in female because the femoral canal is wider. • This is associated with the wider pelvis,and the smaller size of the femoral vessel,in the female.It is never congenital. CLINICAL ANATOMY
- 15. HERNIAL SAC WITH LOOP OF BOWEL • Hernia comprises a neck and a sac. Coverings are the various layers on the sac • Mostly the content of hernial sac is a loop of bowel.
- 16. • The course of an enlarging hernial sac is typical. • First it passes downwards through the femoral canal,then forwards through the saphenous opening,and finally upwards along with the superficial epigastric and superficial circumflex iliac vessel . • For reduction of such a hernia the reverse course has to be followed.
- 17. • In case of strangulation of a femoral hrnia,the surgei has to enlary the femoral ring. • This is possible only by cutting the lacunar ligament, which forms the medial boundary of the ring. • Normally, this can be done with out danger • Occasionally however,an abnormal obturator artery may lie along the edge of the lacunar ligament,and cutting it may cause alarming haemorrhage.
- 18. ABNORMAL OBTURATOR ARTERY • The normal obturator artery is a branch of the internal iliac. • It gives a pubic branch which anastomoses with the pubic branch of the inferior epigastric artery. • Occasionally, this anastomosis is large and the obturator artery then appears to be branch of the inferior epigastric. • Usually, the abnormal artery passes lateral to the femoral canal in contact with the femoral vein and is safe in an operation to the enlarge the femoral ring. • Such an srtery is likely to be cut if an attempt is made to enlarge the femoral ring by cutting lacunar ligament.
- 19. • Injury to femoral nerve results in sensory loss on the anterior aspect of thigh and front of leg including medial border of foot till the ball of big toe- position A1 and A2 in figure. • Lateral cutaneous nerve of thigh may get entangled in the inguinal ligament.This leads to pain on lateral side of thigh.It is called Meralgia paraesthetica- position B in figure. • The femoral artery is exposed in the adductor canal for various surgical procedures.
- 21. ADDUCTOR CANAL • Adductor canal is also called the Subsartorial canal or Hunter’s canal. • Hunter’s canal was named on scientist John Hunter. • The adductor canal is an intermascular space situated on the medial side of the middle one-third of the thigh. • It is 15 cm long • It serves as a passage way for structures moving between anterior thigh and posterior leg.
- 22. Extent • The canal extends from the apex of the femoral traingle,above to the opening in adductor magnus named adductor hiatus. • Adductor hiatus is also called tendinous opening in adductor magnus Shape • The canal is traingular in shape on cross section.
- 23. BOUNDARIES • Adductor canal has anterolateral, posteromedial and medial walls • Posteromedial wall is also called floor • Medial wall is also called roof • Anterolateral wall is fromed by the vastus medialis. • The posteromedial or floor is formed by adductor longus above and adductor magnus below. • The medial wall or roof is formed by a strong fibrous membrane joining the anterolateral and posteromedial(floor) walls. • The sabsartorial plexus of nerves lies on the fibrous roof of the canal under cover of the sartorius. • The plexus is fromed by branches from the medial cutaneous nerve of the thigh,the saphenous nerve, and the anterior division of the obturator nerve • It supplies the overlying fascia lata and the neighbouring skin.
- 24. CONTENTS OF ADDUCTOR CANAL • 1.The femoral artery • 2. The femoral vein • 3. Saphenous nerve • 4. Nerve to vastus medialis • 5. Obturator nerve
- 25. 1.Femoral Artery: • The femoral artery enters the canal at the apex of the femoral traingle. • Within the canal it gives off muscular branches and a descending genicular branch. • The descending genicular artery is the last branch of the femoral artery arising just above the hiatus magnus. • It divides into a superficial saphenous branch that accompanies the saphenous nerve, and a deep muscular branch that enters the vastus medialis and reaches the knee. • Femoral artery leaves the adductor canal through the opening in adductor magnus muscle to continue as popliteal artery in the poplitel fossa.
- 26. • 2.Femoral vein: • Femoral vein begins as the upward continuation of popliteal vein from the popliteal fossa. • The femoral vein lies posterior to the femoral artery in the upper part, and lateral to the artery in the lower part of the canal. • 3.Saphenous nerve: • The saphenous nerve crosses the femoral artery anteriorly from lateral to medial side. • It leaves the canal with the saphenous artery by piercing the fibrous roof.
- 27. • 4.Nerve to vastus medialis • The nerve to the vastus medialis lies lateral to the femoral artery, and enters the vastus medialis in the upper part of the canal. • 5.Obturator nerve: • The obturator nerve divides into anterior division and posterior division. • The anterior division emerges at the lower border of the adductor longus • Then, it gives branches to the Subsartorial plexus • In the end, it supplies the femoral artery. • The posterior division of obturator nerve runs on the anterior surface of the adductor magnus • Then it accomplies the femoral and popliteal arteries • It ends by supplying the knee joint.
- 30. 1. The popliteal artery and it’s branches 2. The popliteal vein and its tributaries 3. The tibial nerve and its branches 4. The common peroneal nerve and its branches 5. The posterior cutaneous nerve of the thigh 6. The genicular branch of the obturator nerve 7. The popliteal lymph nodes 8. Fat: Surrounds and supports all the above structures. CONTENTS
- 31. • The popliteal vessels and the tibial nerve cross the fossa vertically, and are arranged one over the other. The tibial nerve is most superficial; the popliteal vein lies deep or anterior to tibial nerve; and the popliteal artery is deepest of all. The artery is crossed posteriorly by the vein and by the nerve. • ln the upper part of the fossa, from medial to lateral side artery, vein and nerve (A, V, N). • In the middle part, from behind forwards-nerve,vein and artery (N, V, A). • In the lower part, from medial to lateral side-nerve, vein and artery (N, V, A). • The common peroneal nerve crosses the fossa obliquely from the superior angle to the lateral angle, along the medial border of the biceps femoris, lying in the same superficial plane as the tibial nerve
- 32. POPLITEAL ARTERY • Beginning • Popliteal artery is the continuation of the femoral artery. • It begins at the opening in the adductor magnus or hiatus magnus, i.e. At the junction of middle one-third with the lower one-third of thigh. Course It runs downwards and slightly laterally, to reach the lower border of the popliteus . Terminates It terminates at the lower border of popliteus by dividing into the anterior and posterior tibial arteries.
- 33. • Relolions • The popliteal artery is the deepest structure in the popliteal fossa. It has the following relations. Anterior or deep to the artery, from above downwards, there are: The popliteal surface of the femur. The back of the knee joint. The fascia covering the popliteus muscle posterior or superficinlly:To the tibial nerve Laterally: Biceps femoris and the lateral condyle of the femur in the upper part, plantaris and the lateral head of the gastrocnemius in the low
- 34. • Mideally: Semimembranosus and the medial condyle of the femur in the upper part. The lower part of the artery is related to the tibial nerve, the popliteal vein, and the medial head of the gastrocnemius in the lower part
- 35. • Blonches Several large muscularbranches are given off. The upper (two or three) muscular branches supply the adductor Magnus and the hamstrings, and terminate by anastomosing with the fourth perforating artery. The lower muscular or sural branches supply the gastrocnemius, the soleus and the plantaris. Cutaneous branches arise either directly from the popliteal attety, or indirectly from its muscular branches. One cutaneous branch usually accompanies the small saphenous vein. Genicularbranches are five innumber, two superior, two inferior and one middle. The middle genicular artery pierces the oblique popliteal ligament of the knee, and supplies the cruciate ligaments and the synovial membrane of the knee joint
- 36. • The medial and lateral superior genicular arteries wind around the corresponding sides of the femur immediately above the corresponding condyle, and pass deep to the hamstrings. The medial and lateral inferior genicular arteries wind round the corresponding tibial condyles, and pass deep to the collateral ligaments of the knee. All these arteries • reach the front of the knee and take part in forming the anastomoses around the knee.
- 37. • Clinical anatomy • Blood pressure in the lower limb is recorded from the popliteal artery. In coarctation of the aorta, the popliteal pressure is lower than the brachial pressure. Constant pulsations of the popliteal artery against the unyielding tendon of the adductor magnus may cause changes in the vessel wall, leading to narrowing and occlusion of the artery. Sudden occlusion of the artery may cause gangrene up to the knee, but this is usually prevented by the collateral circulation through the profunda femoris artery.
- 38. • The popliteal artery is fixed to the capsule of the knee joint by a fibrous band present just above the femoral condyles. This may be a source of continuous traction or stretching on the artery, causing primary thrombosis of the artery in young subjects. When the popliteal artery is affected by atherosclerosis, the lower part of artery usually remains patent where grafts can be tried. The popliteal artery is more prone to aneurysm than many other arteries of the body.
- 39. POPLITEAL VEIN • It begins at the lower border of the popliteus by the union of veins accompanying the anterior and posterior tibial arteries . It is medial to the popliteal artery in the lower part of the fossa; posterior to the artery in the middle; and posterolateral to it in the upper part of the fossa. The vein continues as the femoral vein at the opening in the adductor magnus. The popliteal vein receives: • • 1 The small saphenous vein. • 2 The veins corresponding to the branches of the popliteal artery.
- 40. • LONG SAPHENOUS VEIN • • 1 The dorsal venous arch lies on the dorsum of the foot over the proximal parts of the metatarsal bones. It receives four dorsal metatarsal veins each of which is formed by the union of two dorsal digital veins . • • 2 The great or long saphenous vein is formed by the union of the medial end of dorsal venous arch with the medial marginal vein which drains the medial side of great toe. It passes upwards in front of the medial malleolus, crosses the lower one-third of the medial surface of tibia obliquely, and runs along its medial border to reach the back of the knee. The saphenous nerve runs in front of the great saphenous vein. • • 3 In the thigh, it inclines forwards to reach the saphenous opening where it pierces the cribriform fascia and opens into the femoral vein. Before piercing the cribriform fascia, it receives three named tributaries corresponding to the three cutaneous arteries, and also many unnamed tributaries . • • It contains about 10 to 15 valves which prevent back flow of the venous blood, which tends to occur because of gravity. One valve is always present at the saphenofemoral junction. Incompetence of these valves makes the vein dilated and tortuous leading to varicose veins. • • The vein is also connected to the deep veins of the limb by perforating veins. There are three medial perforators just above the ankle, one perforator just below the knee, and another one in the region of the adductor canal .The perforating veins are also provided with valves which permit flow of blood only from the superficial to the deep veins. Failure of the valves also gives rise to varicose veins
- 42. TIBIAL NERVE IN POPLITEAL FOSSA • Root value: ventral divisions of ventral Rami of L4,5,S1,2,3 • Course • This is the larger terminal branch of the sciatic nerve. It lies superficial or posterior to the popliteal vessels.it extends from the superior angle to the inferior angle of the popliteal fossa, crossing the popliteal vessels from lateral to medial Side .it continuesbin the back of leg
- 43. • Branches • • 1 Three genicular or articular branches arise in the upper part of the fossa. These are: • • a. Superior medial genicular nerve lies above the medial condyle of femur, deep to the muscles. • • B. Middle genicular nerve pierces the posterior part of the capsule of the knee joint to supply structures in the intercondylar notch of femur . • C. Inferior medial genicular nerve lies along the upper border of popliteus and reaches inferior to • the medial condyle of tibia. • • 2 Cutaneous nerve is called sural which originates in the middle of the fossa and leaves it at the inferior angle. It supplies the skin of lower half of back of leg and whole of lateral border of the foot till the tip of little toe. 3 Muscular branches arise in the distal part of the fossa • • for the lateral and medial heads of gastrocnemius, • • soleus, plantaris and popliteus. • • The nerve to the popliteus crosses the popliteal artery, runs downwards and laterally, winds round the lower border of the popliteus, and supplies it from its deep (anterior) surface. In addition to the popliteus, the nerve also supplies the tibialis posterior, the superior tibiofibular joint, the tibia, the interosseous membrane, and the inferior tibiofibular joint.
- 44. CLINICAL ANATOMY • CLINICAL ANATOMY • • • Most of the muscular branches of tibial nerve arise from its lateral side except to medial head of gastrocnemius. So the medial side of the nerve is safe. • • • Damage to tibial nerve causes motor and sensory loss. • • A. Motor loss: Superficial and deep muscles of calf and intrinsic muscles of sole. • • B. Sensory loss: Loss of sensation on whole of sole of foot, plantar aspect of digits and nail beds on dorsum of foot
- 45. COMMON PERONEAL NERVE • • • • ROOT VALUE = Dorsal divisions of Ventral rami of L4, L5, S1, S2. • COURSE :-. This is smaller terminal branch of the SCIATIC NERVE • It lies in the same superficial plane as the tibial nerve • . It extends from the superior angle of the fossa to the • lateral angle, along the medial border of the biceps femoris. • Continuing downwards and forwards, • it winds round the posterolateral aspect of the neck of the fibula • , pierces the peroneus longus, and divides into the superficial. • and deep peroneal nerve
- 47. BRANCHES • [1. ] Cutaneous branches are two . (A) Lateral cutaneous nerve of the calf - descends to supply the skin of the upper two -thirds of the lateral side of the leg (B). Sural communicating nerve - arises in the upper part of the Foss. It runs on the posterolateral aspect of calf and joins the sural nerve.
- 48. (2). ARTICULAR BRANCHES: (A). SUPERIOR LATERAL GENICULAR NERVE – accompanies the artery of the same name and lies above the lateral femoral condyle. (B). INFERIOR LATERAL GENECULAR NERVE also runs with the artery of the same name to the lateral aspect of knee joint above the head of fibula. (C). RECURRENT GENICULAR NERVE - arises where common peroneal . nerve divides into superficial and deep . peroneal nerves. It ascends anterior to the knee joint . and supplies tibialis anterior muscle in addition to the . knee joint
- 49. • (3). Muscular branches -. • do not arise from this nerve. • However, it may give a branch to the • short head of biceps femoris..
- 50. POSTERIOR CUTENWOUS NERVE OF THIGH • It is a content of the upper half of the popliteal fossa. • It pierces the deep fascia about the middle of the fossa, • and supplies the skin up to the middle of the back of • the Leg. GENICULAR BRANCH OF OBTURATOR NERVE This is the continuation of the posterior division of the obturator nerve. It runs on the posterior surface of the popliteal artery, pierces the oblique popliteal ligament, and supplies the capsule of the knee joint . POPLETEAL LYMPH NODES . These lie deep to the deep fascia near the termination of the small saphenous vein. They receive afferents from lateral part of sole, both superficial and deep parts Of back of leg and knee joint. The efferents end in deep inguinal lymph nodes.
- 51. CLINICAL ANATOMY • The common peroneal nerve can be palpated against the posterolateral side of the neck of the fibula. • It may be injured in this area. It is the most frequently • injured nerve in the lower limb. • This nerve is relatively unprotected. • It may get entrapped between the attachments of peroneus • longus to the head and shaft of fibula. • Patients present “foot drop” which is usually painless. • There is weakness of dorsiflexion of ankle and of eversion • of the foot. • Inversion and plantar flexion are normal and ankle jerk is
- 52. • Popliteal lymph nodes get enlarged in infection on lateral side of sole/foot. These are lying along the short saphenous vein. • Short saphenous vein pierces • deep fascia to drain into popliteal vein
- 53. • Guidence by, 1. Gajendra Sir 2. Jignesh sir • Presented by, 1. Chauhan Darshna 2. Hadiyal Pooja 3. Hasti Vadariya 4. Seema Mer 5. Jay Parmar 6. Manas Joshi 7. Mahesh Vaja 8. Kamaliya Dinesh 9. Gangawala Dev
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