Vessels of Lower Limb PDF

Vessels of Lower Limb Femoral artery  It begins at the mid-inguinal point (midway between symphysis pubis and ASIS), behind the inguinal ligament , as continuation of external iliac artery.  It ends at the junction of upper 2/3 & lower 1/3 of thigh by passing...

Vessels of Lower Limb Femoral artery  It begins at the mid-inguinal point (midway between symphysis pubis and ASIS), behind the inguinal ligament , as continuation of external iliac artery.  It ends at the junction of upper 2/3 & lower 1/3 of thigh by passing through an opening in the adductor magnus muscle (adductor hiatus) where it enters the popliteal fossa to continue as popliteal artery.  Course and relations : Its upper 1/2 is superficial and lies in the femoral triangle while its lower l/2 is deep and lies in the adductor canal. Its upper 1.5 inches lies within the lateral compartment of the femoral sheath. Anterior relations : In femoral triangle: Skin, superficial fascia, deep fascia and anterior wall of femoral sheath. In adductor canal: Sartorius. 1 Vessels of Lower Limb 2 Vessels of Lower Limb Posterior relations : Muscles in the floor of femoral triangle and posterior wall of adductor canal , from above downwards are: 1- Iliopsoas : separates the artery from head of femur. 2- Pectineus is separated from the femoral artery by profunda femoris vessels. 3-Adductor longus : separates the femoral artery from profunda femoris vessels. 4- Adductor magnus. 3 Vessels of Lower Limb Medial relations : Femoral vein is medial to femoral artery at base of femoral triangle then behind it in apex of the triangle then postero- lateral to it in the lower of adductor canal (triple relations). Lateral relations: The femoral nerve & femoral branch of genito-femoral nerve is lateral to the femoral artery at base of femoral triangle. 4 Vessels of Lower Limb The saphenous nerve is lateral to the femoral artery in the femoral triangle then crosses in front of the artery in the adductor canal to become medial to the artery in the lower part of adductor canal (triple relations). Vastus medialis & its nerve. ⁕ N.B.: At the apex of the femoral triangle the arrangement of the vessels in relation to the adductor longus is as follows: (from anterior to posterior) femoral artery, femoral vein, adductor longus, profunda vein and profunda artery. 5 Vessels of Lower Limb  Relations of saphenous Nerve to femoral artery.  Branches of femoral artery  Branches: a) 3 Superficial branches : They pierce the cribriform fascia and run in the superficial fascia to supply the skin: 1- Superficial circumflex iliac artery: runs laterally to share in the anastomosis around ASIS. 2- Superficial epigastric artery: ascends to the anterior abdominal wall. 3- Superficial external pudendal artery: runs medially superficial to femoral vein and spermatic cord to reach the external genital organs. 6 Vessels of Lower Limb b) 3 Deep branches: I) Deep external pudendal artery: (highest branch) It runs medially deep to femoral vein and spermatic cord to reach the external genital organs. II) Descending genicular artery: (lowest branch) It arises in the adductor canal. It gives muscular branches, saphenous artery, and articular branches to knee joint. III) Profunda femoris : It is the largest & most important branch and main blood supply of thigh. It arises from the postero-lateral aspect of femoral artery 4 cm below the inguinal ligament. It Ends by piercing the adductor magnus to become the 4th perforating branch. Course and relations: ▪ It curves downwards and medially between: 1. Femoral vessels (anteriorly) and pectineus (posteriorly), then between. 2. Adductor longus (anteriorly) and adductor brevis (posteriorly), then between. 3. Adductor longus (anteriorly) and adductor magnus (posteriorly). Branches: 1. Lateral circumflex femoral artery: ▪ It runs laterally between sartorius and rectus femoris muscles where it gives off 3 anastomotic branches: 7 Vessels of Lower Limb a. Ascending branch: ascends deep to tensor fascia lata to share in the anastomosis around ASIS. b. Transverse branch: passes transversely to wind around the lateral aspect of femur to share in the cruciate anastomosis. c. Descending branch: descends along the anterior border of vastus lateralis to share in the anastomosis around the knee. 8 Vessels of Lower Limb 2. Medial circumflex femoral artery: ▪ It passes immediately backwards, at first between the pectineus and psoas major, then between the adductor brevis and obturator externus, and finally it appears on the back of the thigh between the quadratus femoris and adductor magnus muscles. ▪ Branches: a. Acetabular branch: to the hip joint via the acetabular foramen. b. Ascending branch: accompanies the tendon of obturator externus to the trochanteric fossa and shares in the cruciate anastomosis. c. Transverse branch: turns around the medial aspect of the shaft of the femur to anastomose with the transverse branch of lateral circumflex femoral artery. 9 Vessels of Lower Limb 10 Vessels of Lower Limb 3. Perforating arteries: ▪ These are 4 arteries which perforate the insertion of the adductor magnus to reach the back of the thigh. ▪ The 1st, 2nd and 3rd arteries arise as branches of the profunda femoris artery while the 4th perforating artery is the termination of the profunda itself. ▪ They anastomose in the back of the thigh with :  Each other.  The inferior gluteal and circumflex femoral arteries in the cruciate anastomosis.  Muscular branches of the popliteal artery near the lower end of femur. 11 Vessels of Lower Limb Mid-inguinal point  Surface Anatomy: It is represented by the upper 2/3 of a line extending from the mid-inguinal point Upper 2/3 (point lies midway between the A.S.I.S. & symphysis pubis) to the adductor tubercle. Adductor tubercle Surface anatomy of femoral artery 12 Vessels of Lower Limb  Applied anatomy : 1) Femoral pulsation is felt in the mid-inguinal point against the head of femur. 2) In order to arrest severe hemorrhage in the lower limb we must press the femoral artery against the superior pubic ramus or head of femur midway between the ASIS and the symphysis pubis. 3) Catheterization of the femoral artery is used for left heart or renal angiography. A long slender catheter is inserted into the femoral artery as it passes through the femoral triangle. Contrast medium is injected and a record is obtained by taking a radiograph. 4) If there is obstruction of external iliac or femoral artery above origin of profunda femoris , blood is supplied to the lower limb through the cruciate anastomosis. 13 Vessels of Lower Limb Popliteal Artery  It begins in the adductor hiatus as a continuation of femoral artery.  It ends at the lower border of popliteus muscle by dividing into anterior & posterior tibial arteries. 14 Vessels of Lower Limb  Relations : Popliteal artery lies as the deepest structure in the popliteal fossa. It passess downwards and laterally from the upper medial boundary of popliteal fossa to its lower angle. Superficial relations : 1) In the upper part of popliteal fossa: It is overlapped by semimembranosus muscle. 2) In the center of popliteal fossa:The popliteal vein and tibial nerve cross from lateral to medial superficial (posterior) to the popliteal artery, from above downwards (triple relations) 3) In the lower part of popliteal fossa: It is overlapped by plantaris and gastrocnemius. 15 Vessels of Lower Limb  Branches: 1- Muscular branches: Anastomose with the 4th. Perforating branch of profunda femoris and supply hamstring and calf muscles. 2- Five articular branches: superior and inferior medial genicular, superior and inferior lateral genicular and middle genicular arteries which share in anastomosis around the knee. 3- Terminal branches: anterior and posterior tibial arteries. Popliteal artery and its branches 16 Vessels of Lower Limb  Surface anatomy of popliteal artery: It is represented by a line extending between 2 points: 1- A proximal point: at the junction of middle and lower thirds of back of thigh, a little medial to its central line. 2- A distal point: at the level of head of fibula, on the middle of the back of the leg.  Applied anatomy :  Popliteal pulsation is felt in the center of popliteal fossa against the pper part of tibia. 17 Vessels of Lower Limb Anterior Tibial Artery  It begins as the smaller of 2 terminal branches of popliteal artery in the back of the leg , at the lower border of popliteus muscle.  It ends in front of the ankle joint , midway between the 2 malleoli to continue as dorsalis pedis artery.  Course and relations : It is accompanied by 2 venae comitantes throughout its course ( as all arteries below the knee ). It pierces the upper part of interosseous membrane medial to the neck of fibula ,to reach the anterior compartment of leg Deep fibular (peroneal) nerve is lateral , anterior then return again lateral to the anterior tibial artery ( triple relations). In upper 1/3 of leg: At first the artery descends between tibialis anterior (medially) and extensor digitorum longus (laterally). In middle 1/3 of leg: The artery descends between tibialis anterior (medially) and extensor hallucis longus (laterally). In lower 1/3 of leg : The tendon of extensor hallucis longus crosses in front of the artery from lateral to medial then the artery descends between extensor hallucis longus (medially) & extensor digitorum longus (laterally). (Tom Has Very Nice Dog & Pig) It passes deep to superior extensor retinaculum.  Branches: 1) Anterior and posterior tibial recurrent arteries: They both arise close to the knee joint and share in the anastomosis around it. 2) Muscular branches: to all muscles of anterior compartment of leg. 18 Vessels of Lower Limb 3) Anterior lateral and medial malleolar branches: They arise close to the ankle joint and share in the anastomosis around it. 19 Vessels of Lower Limb Anterior tibial artery & nerve 20 Vessels of Lower Limb 21 Vessels of Lower Limb  Surface anatomy of the anterior tibial artery: It is represented by a line drawn between: A proximal point on the front of the leg midway between the head of fibula and the tuberosity of tibia. A distal point on the front of the ankle midway between the 2 malleoli.  Applied anatomy :  Anterior tibial pulsation is felt just above a point midway between the 2 malleoli. 22 Vessels of Lower Limb Dorsalis Pedis Artery  It begins in front of ankle joint , at a point midway between the 2 malleolli , as a continuation of anterior tibial artery.  It ends by passing to the sole of the foot through the proximal end of 1st interosseous space ,between the 2 heads of the 1st dorsal interosseous muscle ) ,to anastomose with the plantar arch.  Course and relations: It runs forwards on the dorsum of foot, lying superficial throughout its course. Its proximal part is crossed by the inferior extensor retinaculum. Its distal part is crossed by the extensor hallucis brevis muscle. It crosses the neck of talus, navicular and intermediate cuneiform bones. The tendon of extensor hallucis longus lies medial to it. The medial branch of deep fibular (peroneal) nerve and the tendon of extensor digitorum longus lie lateral to it.(Remember Has Very Nice Dog).  Branches : 1) The medial and lateral tarsal arteries: join the anatomosis around the ankle. 2) The arcuate artery: (the longest and most important branch) It passes laterally across the bases of the metatarsal bones, deep to the extensor digital tendons then it anastomoses with the lateral tarsal artery. It gives the 2nd, 3rd and 4th dorsal metatarsal arteries in the lateral 3 clefts. Each dorsal metatarsal artery gives 2 dorsal digital arteries to supply the lateral 3 ½ toes. 23 Vessels of Lower Limb 3) The 1st dorsal metatarsal artery: Arises on the dorsum of foot, just before the dorsalis pedis passes to the sole. It supplies the dorsal aspect of the medial 1 ½ toes  Surface & applied anatomy : Dorsalis pedis pulsation is felt just distal to a point midway between the 2 malleoli , lateral to the tendon of extensor hallucis longus , to point at the proximal end of 1st interosseous space. 1 2 14 3 4 13 5 6 7 8 10 12 24 Vessels of Lower Limb 25 Vessels of Lower Limb Posterior Tibial Artery  It begins as the larger of 2 terminal branches of popliteal artery at the lower border of popliteus muscle.  It ends deep to flexor retinaculum midway between medial malleolus and medial tubercle of calcaneus by dividing into lateral & medial plantar arteries.  Course and relations : The artery enter the back of leg deep to the tendentious arch of soleus which extends between tibia and fibula. In upper 2/3 of back of leg : It descndes deep with tibial nerve in between the following structures: Superficial : deep surface of soleus. Deep : Tibialis posterior. In the lower 1/3 of back of leg: Superficial: The artery becomes superficial covered only by skin & fascia. Deep: lying directly on the posterior surface of tibia. The tibial nerve is medial to the upper part of posterior tibial artery then crosses behind the artery and finally the nerve descends lateral to posterior tibial artery (triple relation). It passes deep to flexor retinaculum (Tom Does Very Nice Hat) 26 Vessels of Lower Limb Posterior tibial nerve and artery 27 Vessels of Lower Limb 28 Vessels of Lower Limb 29 Vessels of Lower Limb 30 Vessels of Lower Limb  Branches: 1) Circumflex fibular: Winds around the neck of fibula to join the anastomosis around the knee. 2) Fibular (peroneal)artery: It is the largest & longest branch of tibial artery and main arterial supply of the back of the leg. It arises just below the origin of posterior tibial artery It passes downwards & lateral then vertically along the back of the fibula (liable for injury in fracture fibula) and deep to the flexor hallucis longus muscle. It ends by dividing into terminal branches on the back of the inferior tibio-fibular joint. Branches : a. Muscular branches. b. Nutrient branch to fibula. c. In the lower part of leg it gives a perforating branch which pierces the lower part of interosseous membrane (It may replace dorsalis pedis artery). d. Lateral malleolar & lateral calcanean branches share in anastomosis around the ankle. 3) Muscular branches. 4) Nutrient branch to tibia. 5) Medial malleolar & medial calcanean arteries share in anastomosis around the ankle. 6) Terminal branches :Medial and lateral plantar arteries. 31 Vessels of Lower Limb Posterior tibial and peroneal arteries 32 Vessels of Lower Limb 33 Vessels of Lower Limb  Surface anatomy : a vertical line drawn between 2 points: A proximal point : in the middle of the back of leg at the level of the head of fibula. A distal point : midway between medial malleolus and medial tubercle of calcaneus  Applied anatomy :  Posterior tibial pulsation is felt behind the medial malleolus or a point midway between medial malleolus and medial tubercle of calcaneus against the medial malleolus. 34 Vessels of Lower Limb Medial Plantar Artery  It begins deep to the flexor retinaculum as one of 2 terminal branches of posterior tibial artery  It accompanies the medial plantar nerve in its course.  Branches: muscular and digital branches. Lateral Plantar Artery  It begins deep to the flexor retinaculum as one of 2 terminal branches of posterior tibial artery  Course and relations: It runs forwards and laterally between the 1st and 2nd layers of the sole to the base of the 5th metatarsal bone, with the lateral plantar nerve medial to it. Then it curves deep and medially between the 3rd and 4th layers of sole, forming the plantar arch. The plantar arch is concave backwards with the deep branch of lateral plantar nerve in its concavity. This arch ends by joining the dorsalis pedis artery at the proximal end of 1st interosseous space.  Branches: 1) 4 plantar metatarsal arteries:  Each of these arteries gives plantar digital arteries to the clefts between the toes. 2) Plantar digital artery: for the lateral side of the little toe. 3) 3 perforating arteries: they pass upwards through the interosseous spaces to join the lateral 3 dorsal metatarsal arteries. 35 Vessels of Lower Limb 36 Vessels of Lower Limb  Remember the following important points: 1- Mid-inguinal point 2-Adductor hiatus 3- Lower border popliteus. 4-Midway between 2 malleoli. 5- midway between medial malleolus and medial tubercle of calcaneus Arterial Anastomosis in the Lower Limb  Anastomosis around 5- Midway A.S.I.S: bet. med. It is & malleolus anastomosis between med. tubercle external of calcaneus. and internal iliac arteries. 1. Superficial circumflex iliac (from femoral artery) 2. Deep circumflex iliac (from external iliac artery) 3. Termination of ilio-lumbar artery (from internal Iliac artery) 4. Ascending branch of lateral circumflex femoral (from profunda femoris artery). 5. Superior gluteal artery. 37 Vessels of Lower Limb  Cruciate Anastomosis in the Back of the Thigh:  It is coss shaped anastomosis in the back of thigh below the greater trochanter between internal iliac & profuna femoris arteries. 1. Transverse branches of medial circumflex femoral artery. 2. Transverse branch of lateral circumflex femoral artery. 3. Descending branch of inferior gluteal artery. 4. Ascending branch of 1st. perforating branch of profunda femoris artery.  If there is obstruction of external iliac or femoral artery above origin of profunda femoris , blood is supplied to the lower limb through the cruciate anastomosis. 38 Vessels of Lower Limb  Trochanteric Anastomosis: 1. Medial & lateral circumflex femoral artery 2. Obturator artery 3. Inferior glutel artery  Anastomosis around the Knee: It is a relatively poor anastomosis: 1. Descending genicular artery from femoral artery. 2. Descending branch of lateral circumflex femoral artery. 3. Five genicular branches from popliteal artery. 4. Anterior & posterior tibial recurrent branches from anterior tibial artery. 5. Circumflex fibular from posterior tibial artery. 39 Vessels of Lower Limb  Anastomosis around ankle: Around Medial Maleolus Around Lateral Maleolus  Medial calcanean & medial maleoular  Perforating branch ,lateral calcanean & (from posterior tibial artery) lateral maleoular (from fibular artery)  Medial tarsal (from dorsalis pedis  Lateral tarsal (from dorsalis pedis artery) artery)  Anterior medial maleoular (from  Anterior lateral maleoular (from anterior tibial artery) anterior tibial artery) 40  Vessels of Lower Limb  Applied anatomy : anastomosis in the lower limb is poor specially around the knee , therefore arterial obstruction in the lower limb usually leading to ischaemia and gangrene. 41 Vessels of Lower Limb Veins of Lower Limb  All veins of lower limbs have bicuspid unidirectional valves which allow blood to pass from distal to proximal and from superficial to deep. These are divided into 2 groups: I) Deep veins: Lie deep to the deep fascia & they including femoral vein , popliteal vein and vena commitants of the arteries below the knee. These veins drain the structures deep to the deep fascia & receive blood from the superficial veins through the perforating veins. Popliteal Vein: It begins by union of the venae comitantes of both anterior and posterior tibial arteries at the lower border of the popliteus muscle.It ends by passing through the opening in the adductor magnus to become the femoral vein. It crosses the popliteal artery from medial to lateral as it ascends in the popliteal fossa (it lies medial to the artery in the lower part, superficial in the middle part and posterolateral to it in the upper part of the fossa). Tributaries: 1- Muscular veins. 2. Articular veins that correspond to the branches of the popliteal artery. 3. Short saphenous vein. 42 Vessels of Lower Limb 43 Vessels of Lower Limb Femoral Vein: It begins at the opening in the adductor magnus as the continuation of the popliteal vein. It enters the adductor canal then the femoral triangle where it ends by passing behind the inguinal ligament to become the external iliac vein. In the lower part of adductor canal: it lies postero-lateral to the femoral artery. At the apex of the femoral triangle: it lies posterior to the artery. At the base of the femoral triangle: it lies medial to the artery and occupies the middle compartment of the femoral sheath. Tributaries: 1- Great saphenous vein. 2- Deep external pudendal vein. 3- Profunda femoris vein. 4- Medial and lateral circumflex veins. Applied anatomy: For cardiac angiography a long catheter is usually inserted into the femoral vein as it passes in base of the femoral triangle. II)Superficial veins: They lie superficial to the deep fascia (i.e. unsupported in the S.C. tissue and liable for dilatation , elongation & tortousity i.e varicose veins ). They drain the skin & S.C. tissues of lower limb. 44 Vessels of Lower Limb Superficial veins include: 1. Long (great) saphenous vein : It is the longest vein in the body. It begins on the dorsum of foot as continuation of medial end of dorsal venous arch of the foot. It passes on medial aspect of foot then ascends in front of medial malleolus (commonest site for venous cut down) , medial aspect of leg along medial border of tibia (accompanied by saphenous nerve which is anterior to the vein) , behind the medial condyles of tibia & femur then on antero- medial aspect of thigh to the saphenous opening. It ends by piercing the cribriform fascia to join the femoral vein at the sapheno- femoral junction (4 cm below & lateral to the pubic tubercle). Tributaries and communications:  Superficial veins from foot, leg and thigh.  Communicating veins: connect short & long saphenous veins.  Perforating veins: pierce the deep fascia to reach the deep veins. Superficial inguinal veins:Superficial circumflex iliac ,Superficial epigastric & Superficial external pudendal vein. Surface anatomy: from point just in front of medial malleolus → 4 fingers behind medial border of patella → point 4 cm below & lateral to pubic tubercle. 45 Vessels of Lower Limb 1 3 4 5 46 Vessels of Lower Limb 47 Vessels of Lower Limb 2. Short (Lesser) Saphenous Vein: It begins on the dorsum of foot as continuation of lateral end of dorsal venous arch of the foot. It passes on lateral aspect of foot, below & behind the lateral malleolus , on lateral border of tendo-calcaneus to reach the back of leg to ascend in the center of the calf (accompanied by sural nerve). It penetrates the deep fascia and ascends between the two heads of the gastrocnemius muscle to enters the popliteal fossa. It ends in the popliteal fossa by joining the popliteal vein. Surface Anatomy: A point cm behind lateral malleoleus to a point in the center of popliteal fossa.  Applied anatomy: 1- Valves direct the blood from superficial to deep veins 2- Varicose veins are dilated elongated tortuous superficial veins of the lower limbs ( not in the deep veins which are supported by muscles ). 2- Long saphenous vein can be used in arterial by pass graft. 3- Venous cut down operation is usually done at the lower end of the long saphenous vein just above the medial malleolus.Take care from injury of saphenous nerve which leads to sensory loss on the medial aspect of foot. 48 Vessels of Lower Limb Lymph Drainage of Lower Limb  The lymph is a colorless clear fluid drained from the extra-cellular fluid by fine lymph vessels (lymphatics) which containing valves.  The lymph is filtered in the lymph nodes.  Lymph passes to the lymph nodes in afferent lymphatics and comes out from the lymph nodes in efferent lymphatics.  Finally, the collected lymph pass to the veins.  Lymphatic drainage of the limbs accompanies the veins  The lymphatic system is formed mainly of lymph vessels and lymph nodes. I- Lymph vessels of lower limb : A) Superficial lymph vessels: Drain the structures superficial to the deep fascia (skin and subcutaneous tissue). The majority of the superficial lymph vessels run medialy accompany the great saphenous vein to the vertical part of superficial inguinal lymph nodes. The minority of the superficial lymph vessels runs lateraly accompany the small saphenous vein to the popliteal lymph nodes. B) Deep lymph vessels: Drain the structures beneath the deep fascia. Accompany the deep vessels to the deep inguinal lymph nodes. 49 Vessels of Lower Limb 50 Vessels of Lower Limb II- Lymph nodes:  They are superficial and deep, in relation to the deep fascia. A) Superficial lymph nodes: Superficial inguinal lymph nodes which drains skin & S.C tissues. They form 2 groups arranged in T shaped manner : b)Vertical group: along the end of the great saphenous vein, receive lymph from lower limb. 51 Vessels of Lower Limb 2-Horizontal group: below and parallel to the inguinal ligament and drains the followings: Anterior abdominal wall below the umbilicus. Its lateral part drains gluteal region Its medial part drains skin of genitalia , perineum, lower 1/2 of anal canal and lower part of vagina. Their efferent lymphatics pass through the saphenous opening to the deep inguinal lymph nodes. B) Deep lymph nodes : a) Popliteal lymph nodes: Deep in popliteal fossa, along popliteal vessels. They receive afferent lymphatics (from foot and leg) accampaning short saphenous vein and send efferents to deep inguinal lymph nodes. 52 Vessels of Lower Limb b) Deep inguinal lymph nodes: They lie along the medial side of the end of femoral vein. Receive lymph from the superficial inguinal lymph nodes, the deep tissues of the lower limb and vessels from popliteal lymph nodes. Their efferent lymphatics pass through femoral canal & ring to the external iliac nodes inside the pelvis.  Applied anatomy: Obstruction of the lymphatics of the lower limb leads to progressive lymphatic oedema. When the limb acquires a large size, the condition is called elephantiasis. Normally lymph nodes are not seen nor felt. Lymph nodes less than 5mm without progressive enlargement is clinically insignificant. 53 Vessels of Lower Limb Inguinal lymph nodes are enlarged in inflammation , malignancy , blood diseases or autoimmunity. Enlargement of lymph nodes is called lymphadenopathy. Inflammation of the lymph vessels is called lymphangitis. Inflammation of the lymph nodes is called lymphadenitis. Usually the commonest swelling in the anatomical site of lymph nodes ( eg. Femoral triangle) is lymph nodes enlargement. Any multiple rounded or oval swelling in the anatomical site of lymph nodes should be diagnosed an lymph nodes enlargement. Lymph node biopsy is the sure diagnosis of the cause of lymphadenopathy. 54 Vessels of Lower Limb 55 Vessels of Lower Limb 56 Vessels of Lower Limb 57 Vessels of Lower Limb 58