BFM 3 Femoral region, Anterior and Medial Compartments of the Thigh.pptx

Femoral region, Anterior and Medial Compartments of the Thigh Body Movement and Function Dr Sara Sulaiman [email protected] Learning outcomes By the end of this lecture, you should be able to: • Describe the bones of the pelvis and lower limb • Identify the fascia lata and intramuscular septae of...

Femoral region, Anterior and Medial Compartments of the Thigh Body Movement and Function Dr Sara Sulaiman [email protected] Learning outcomes By the end of this lecture, you should be able to: • Describe the bones of the pelvis and lower limb • Identify the fascia lata and intramuscular septae of the lower limb • Describe the anatomy of the long and short saphenous veins • Explain how varicose veins may develop and why complications may arise from treatment • Discuss the muscles and innervation of the anterior and medial compartments of the thigh • Describe the boundaries and contents of the femoral triangle • Understand how femoral hernias may occur and how these present clinically • Demonstrate clinical landmarks on examination of the anterior and medial thigh and Interpret radiological imaging of the bones and vessels of the thigh and pelvis Recommended reading • Abrahams, Peter H. et al. McMinn & Abrahams’ Clinical Atlas of Human A natomy . Seventh edition. Maryland Heights, Missouri: Elsevier Mosby, 2013. Print • Drake, Richard L. Gray’s Anatomy For Students . 4th. ed. Philadelphia: Elsevier, Inc., 2020. Print. • Moore, Keith L., Arthur F. Dalley, and A. M. R. Agur. Essential Clinical Anatomy. 4th ed. Philadelphia, Pa.; London: Lippincott Williams & Wilkins, 2011. Print. • Netter, Frank H. (Frank Henry). Atlas of Human Anatomy. 5th ed. Philadelphia, Pa.; London: Saunders, 2010. Print. • Smith, C., Dilley, A., Mitchell, B. and Drake, R.L., 2017. Gray’s Surface Anatomy and Ultrasound: Gray’s Surface Anatomy and Ultrasound E-Book. Elsevier Health Sciences. • Spratt, J., Salkowski, L.R., Loukas, M., Turmezei, T., Weir, J. and Abrahams, P.H., 2020. Weir & Abrahams' Imaging Atlas of Human Anatomy. Elsevier Health Sciences. Lower limb • Divided into: • • • • Gluteal Thigh Leg Foot Femoral triangle Thigh Popliteal fossa (back of the knee) • Femoral, popliteal and ankle are important transition areas. Leg Tarsal tunnel (medial side of the ankle) • Function to: • Support the body weight • Locomotion and balance Foot Pelvic bones Greater Sciatic notch • The pelvic bone is irregular in shape and is made up: the ilium, pubis and ischium. Iliac crest Lesser Sciatic notch Ilium ASIS OF AIIS Ischial spine Ischial tuberosit y Ischiu m Pubis Pubic tubercle Body of pubis PSIS PIIS Pubis Ischia l ramu s Superior pubic ramus Inferior pubic ramus Sacrum Sacral canal Ala Promontory Anterior sacral foramina Anterior view Sacral hiatus Posterior view Lateral view Head Femur Head Fovea for the ligament of the head of the femur Neck Greater trochanter Greater trochanter Lesser trochanter Intertrochanteric crest Intertrochanteric line Linea aspera Shaft Lateral epicondyl e Medial epicondyl e Medial condyle Intercondylar fossa Lateral condyle Deep fascia of the thigh • Very strong-stocking like. • In the thigh and gluteal region, it is called fascia lata. • It limits the outward extension of contacting muscles thus, muscle contracting is efficient in compressing veins. • Facisa lata is thickened laterally and forms the iliotibial tract (IT tract) • From the tuberculum of iliac crest to just below the knee • Tensor fascia lata and gluteus maximus attach to the IT tract and work to hold the leg in extension once the leg is extended. Tensor fascia lata Saphenous opening Fascia lata Iliotibial tract Gluteus maximus Superficial veins of the leg • Small saphenous vein • • • • Lateral side of the dorsal venous arch Pass posterior to the lateral malleolus Ascend in the posterior leg Drain into the popliteal vein • Great saphenous vein • Medial side of the dorsal venous arch • Pass anterior to the medial malleolus • Pass upward in the medial side of the leg, knee and thigh • Drain into the femoral vein Great saphenous vein Short saphenous vein Dorsal venous arch Varicose veins of the leg • In healthy veins, valves prevent blood from flowing backwards • Return of venous blood from lower limbs to heart requires a pump (think: gravity) • Varicose: leaflets of valves no longer meet properly • Blood can accumulate in superficial veins • Varicose veins are dilated, elongated, and tortuous superficial veins with incompetent or congenitally absent valves. • Most common in superficial veins of legs • High pressure when standing (great saphenous vein) • Varicose veins are painful & lead to leg swelling, skin thickening, ulceration • Treatment: vein obliteration, support stockings, elevating legs, exercise MSK rules • All muscles pass at least one joint. • If a muscle passes a joint • IT WILL WORK ON THAT JOINT • A movement is not produced by the action of one muscle • Prime movers: a muscle primarily responsible for producing a movement • Antagonists: A muscle with the opposite action of a muscle • Synergists: work and assist the prime movers General arrangement Anterior compartment • Muscles: Femur • Quadriceps group and Sartorius (extensors of the leg) • Iliopsoas (flexor of the trunk/hip) • Tensor fascia lata • Femoral nerve (except tensor fascia lata) Intermuscular septum Three intermuscular septa that attaches to the linea aspera of the femur Posterior compartment Medial compartment • Hamstring group • Extend the thigh (except the short head of biceps femoris) • Flex the knee • Sciatic nerve • Adductors of the thigh • Obturator nerve (except pectineus and hamstring part of adductor magnus) Anterior thigh Rectus femoris* • From AIIS to quadriceps femoris tendon • Extends the leg at the knee, flex the thigh at the hip • Femoral nerve *These four muscles are called the Quadriceps femoris group Vastus intermedius* Vastus lateralis* • From femur to quadriceps femoris tendon and lateral patella • Extends the leg at the knee • Femoral nerve Quadriceps femoris tendon Patellar tendon • From femur to quadriceps femoris tendon and lateral patella • Extends the leg at the knee Vastus medialis* • Femoral nerve • From femur to quadriceps femoris tendon and medial patella • Extends the leg at the knee • Femoral nerve Anterior compartment Psoas • Posterior abdominal wall, lumbar vertebrae and discs (T12-L5) • Innervated by L1-3 Iliopsoas • Inserts into the lesser trochanter of femur • Flex the thigh at the hip (most powerful flexor) Sartorius • From ASIS to medial tibia • Flexes thigh at hip and flexes the leg at knee • Abducts the thigh and laterally rotates (as when resting the foot on the opposite knee) • Femoral nerve Iliacs • From iliac fossa • Innervated by femoral nerve Iliopsoas Pectineus • From pectineal line to femur • Adducts and flex the thigh • Femoral nerve Pectineus (cut) Adductor longus • From pubis to midfemur • Adducts and medially rotates thigh • Obturator nerve Adductor brevis • From pubis to proximal femur • Adducts and medially rotates thigh • Obturator nerve Gracilis • From inferior pubic ramus to tibia • Adducts thigh and flex the leg, medially rotates leg • Obturator nerve Adductor longus (cut) Obturator externus • Obturator membrane to trochanteric fossa • Laterally rotates the thigh at the hip and stabilizes the femur in the acetabulum • Obturator nerve Adductor magnus • Adductor part: • Ischiopubic ramus to femur (lower third) • Obturator nerve • Hamstring part: • Ischial tuberosity to the femur (adductor tubercle) • Sciatic (Tibial) • Adducts and medially rotates the thigh Medial compartment Testing the Quadriceps group • Apply one hand to the posterior aspect of the thigh and other slightly superior to the ankle • Extend leg against practitioner’s resistance • Watch for the individual leaning backwards and recruiting hip flexors or exclusively using rectus femoris Femoral triangle • A wedge-shaped depression formed by muscles in the upper thigh. For boundaries think SAIL! For content think NAVEL! (from lateral to medial) • Boundaries: • Superior boundary: Inguinal ligament • Medial boundary: Medial margin of the adductor longus • Lateral boundary: Medial margin of the sartorius muscle • Floor: • Adductor longus • Pectineus • Iliopsoas • Roof: Fascia lata • Contents: • • • • Femoral nerve Femoral artery Femoral vein Lymph nodes Empty space • The great saphenous vein penetrates the roof of the triangle to drain into the femoral vein Great saphenous vein Femoral triangle For boundaries think SAIL! For content think NAVEL! (from lateral to medial) • The apex of the triangle is continuous with a fascial canal (adductor canal) • Pass through the adductor hiatus and open into the popliteal fossa • Only the femoral artery and vein pass through the hiatus Great saphenous vein Femoral sheath • The femoral sheath surrounds the femoral artery and vein (the femoral nerve is not contained within the femoral sheath) • Each structure is in its own separate compartment. • Lateral: femoral artery • Intermediate: femoral vein • Medial: femoral canal- Contains loose connective tissue, fat and lymphaticsentrance of the canal is the femoral ring • The sheath continues: • Superiorly with transversalis fascia • Inferiorly with connective tissue around vessels. • Allows the femoral artery and vein to glide during hip movement. Femoral hernia • Abdominal content protrudes through the femoral ring (weak area). • Boundaries of femoral ring: • Anterior: inguinal ligament • Lateral: femoral vein • Medial: lacunar ligament • Posterior: pectineal ligament • Femoral hernias can occur at this site. • Abdominal content protrudes into the canal • More common in females • Can present as a swelling below and lateral to the pubic tubercle Nerves Femoral nerve Obturator nerve Saphenous nerve Case • A 25-year-old man is rushed to the emergency department following a car accident. • During physical examination, you notice pain, swelling and bruising to the front of the knee and two lumps (as shown in the image). Case courtesy of Pir Abdul Ahad Aziz Qureshi, Radiopaedia.org, rID: 60697 • As the patient was stable, you send him for imaging. Xray is provided. • What is the most likely diagnosis? Case Case courtesy of Paul Simkin, Radiopaedia.org, rID: 32161 • A 20-year-old man is brought to the emergency department after injuring his knee during a rugby game. • During physical examination, you notice pain, swelling and bruising around the knee. • As the patient was stable, you send him for imaging. X-ray is provided. • What is the most likely diagnosis? Patellar fracture and dislocation Patellar fracture Patellar dislocation • Among most common knee injuries, usually from hard blow to front of knee • Non-displaced fracture: 4-6 wks immobilization in cast • Displaced fracture: surgical treatment followed by quadriceps strengthening • Injury of knee by a direct blow or sudden twist of leg • Patella slips out of normal position in the patellofemoral groove (intense pain); tends to slip laterally • Manual repositioning by extending leg or orthopaedic reduction • Swelling & impaired mobility • Rehabilitation 6-16 wks Blood supply to the thigh External iliac artery Medial circumflex artery • Femoral artery • Continuation of the external iliac artery Femoral artery • Palpable in the femoral triangle at the midinguinal point, inferior to the inguinal ligament • Passes in the adductor canal and hiatus and becomes the popliteal artery at the Lateral circumflex popliteal fossa. artery • Main branches: • Deep (profunda) artery of the thigh-main artery of the anterior compartment. It gives off: • Lateral and medial circumflex femoral branches • Perforating branches • Superficial epigastric artery • Superficial circumflex iliac artery • Superficial and deep external pudendal artery Deep femoral (profunda) artery Perforating branches (4x) Popliteal artery Obturator artery • Main artery of the medial compartment • Branch of the internal iliac artery Deep veins Anterior & posterior tibial t La Dorsal veinous arch ly al r e M ed ia lly Small saphenous Great saphenous Popliteal Femoral External iliac IVC Fibular Common iliac Deep femoral Deep venous thrombosis • If blood in the veins becomes stagnant (due to inactivity or injury) the blood within them can form clots in the lumen, called thrombi. • Serious medical condition • If these thrombi break loose, they become emboli that can get lodged in a vessel. • Clot that prevents circulation from continuing • Leads to swelling in peripheral tissues • Presence of clot in deep (larger) veins • Generally in lower extremities • It may propagate into the femoral veins Lymphatics • Superficial inguinal nodes (approx. 10) drain to the external iliac nodes • Will receive lymph from the gluteal region, lower abdominal wall, lateral thigh, perineum • Deep inguinal nodes (approx. 3) interconnect with the superficial inguinal nodes. • Will receive lymph from deep thigh, leg, lymph from popliteal nodes and superficial inguinal nodes Thank you