Femoral Region, Anterior and Medial Compartments of the Thigh V2.0 2024 PDF

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 Anatomy. 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: Femoral triangle Gluteal Thigh Leg Thigh Foot Popliteal fossa (back of the knee) Femoral, popliteal and ankle are important transition areas. Leg Function to: Tarsal tunnel (medial side of the ankle) 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 PSIS Ischial spine PIIS Pubic Ischial Ischiu tubercle Pubis Pubis tuberosit m Superior y Body of pubis pubic Ischia ramus l Inferior ramu pubic s ramus  Sacrum Ala Sacral canal Promontory Anterior sacral Sacral foramina hiatus Lateral view Anterior view Posterior view  Head Head Fovea for the Femur ligament of the head of the femur Neck Greater trochanter Greater trochanter Lesser trochanter Intertrochanteric crest Intertrochanteric line Linea aspera Shaft Medial Intercondylar epicondyl fossa Lateral e epicondyl e Medial Lateral condyle condyle Deep fascia of the thigh Very strong-stocking like. Tensor fascia lata In the thigh and gluteal region, it is Gluteus maximus called fascia lata. Saphenous opening It limits the outward extension of contacting muscles thus, muscle contracting is efficient in compressing Fascia veins. lata Fascia lata is thickened laterally and Iliotibial tract 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. 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-close relationship with the sural nerve Drain into the popliteal vein Great saphenous vein Great saphenous vein Short Medial side of the dorsal venous arch saphenous vein Pass anterior to the medial malleolus Saphenous nerve Pass upward in the medial side of the Sural nerve leg (close relationship with the saphenous nerve), knee and thigh Drain into the femoral 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: Quadriceps group (extensors of the leg) Iliopsoas (flexor of the Femur trunk/hip) Sartorius (flex thigh and flex leg) 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 Adductors of the thigh the short head of biceps Obturator nerve (except femoris) pectineus and hamstring Flex the knee part of adductor magnus) Sciatic nerve Anterior thigh Rectus femoris* *These four muscles From AIIS to quadriceps are called the femoris tendon Quadriceps femoris Extends the leg at the group knee, flex the thigh at the hip Femoral nerve Vastus intermedius* Vastus lateralis* From femur to From femur to quadriceps femoris quadriceps femoris tendon and lateral tendon and lateral patella patella Extends the leg at the Extends the leg at the knee knee Vastus medialis* Femoral nerve Femoral nerve Quadriceps femoris tendon From femur to quadriceps femoris tendon and medial patella Patellar tendon Extends the leg at the knee Femoral nerve  Anterior compartment Psoas Posterior abdominal wall, lumbar Iliopsoas vertebrae and discs Inserts into the (T12-L5) Innervated by L1-3 lesser trochanter of femur Flex the thigh at Sartorius Iliacs the hip (most From ASIS to From iliac powerful flexor) medial tibia fossa Flexes thigh at Innervated by hip and flexes the femoral leg at knee nerve Abducts and laterally rotates Iliopsoas the thigh (as when resting the Flexes thigh at hip foot on the (most powerful hip opposite knee) flexor) Femoral nerve  Pectineus Obturator externus From the pectineal line of Obturator membrane to pubis to oblique line of trochanteric fossa femur Laterally rotates the thigh at Adducts and flex the thigh Pectineus (cut) the hip and stabilises the femur Femoral nerve in the acetabulum Obturator nerve Adductor longus From pubis to mid- femur Adductor magnus Adducts and medially Adductor part: rotates thigh Ischiopubic ramus to Obturator nerve femur Obturator nerve Hamstring part: Adductor brevis Ischial tuberosity to the From pubis to the proximal femur (adductor femur (upper 1/3 linea tubercle) aspera) Sciatic (Tibial) Adducts and medially Adducts and medially rotates thigh rotates the thigh Medial Gracilis Obturator nerve From inferior pubic ramus to Adductor longus tibia compartmen (cut) Adducts thigh and flex the leg, medially rotates leg Obturator nerve t 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 For boundaries think SAIL! For content think A wedge-shaped depression formed NAVEL! (from lateral by muscles in the upper thigh. 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 (medial) Pectineus (medial) Iliopsoas (lateral) Roof: Fascia lata Contents: Femoral nerve Femoral artery Femoral vein Empty space Lymph nodes Great saphenous vein The great saphenous vein penetrates the roof of the triangle to drain into the femoral vein  For boundaries think SAIL! Femoral triangle 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 lymphatics- entrance 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 Obturator nerve (L2-L4): Motor: Adductor longus, brevis and part of magnus and gracilis Sensory: Skin of medial thigh Femoral nerve (L2- L4) Obturator nerve Femoral nerve (L2-L4): Motor: Sartorius, Pectineus, Quadriceps Sensory: Skin of anterior thigh, and medial side of the leg (saphenous 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. X- ray is provided. What is the most likely diagnosis?  Case courtesy of Paul Simkin, Radiopaedia.org, rID: 32161 Case 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, Injury of knee by a direct blow or usually from hard blow to front of sudden twist of leg knee Patella slips out of normal position in the Non-displaced fracture: 4-6 wks patellofemoral groove (intense pain); immobilization in cast tends to slip laterally Displaced fracture: surgical treatment Manual repositioning by extending leg or followed by quadriceps strengthening orthopaedic reduction Swelling & impaired mobility Rehabilitation 6-16 wks  Blood External iliac supply External Femoral iliac Medial circumflex Inguinal ligament Lateral circumflex Medial circumflex Profunda Lateral artery artery Femoral femoris circumflex Perforating Deep femoral branches (profunda) artery Anterior Dorsalis Perforating tibial pedis arteries Posterior Adductor hiatus tibial Posterior Medial and Popliteal lateral tibial Popliteal planter Anterior tibial Fibular fibular Blood supply to the External iliac Medial circumflex artery thigh artery Femoral artery Continuation of the external iliac artery Palpable in the femoral triangle at the mid- Femoral artery inguinal point, inferior to the inguinal ligament Passes in the adductor canal and hiatus and becomes the popliteal artery at the popliteal fossa. Lateral circumflex artery Main branches: Deep (profunda) artery of the thigh-main artery of the anterior compartment. It gives Deep femoral off: Perforating (profunda) artery Lateral and medial circumflex femoral branches (4x) branches Perforating branches (x4)-penetrate adductor magnus Superficial epigastric artery Superficial circumflex iliac artery Popliteal artery Superficial and deep external pudendal artery Obturator artery Main artery of the medial compartment Branch of the internal iliac artery  Deep veins Anterior & posterior tibial Fibular ly ral t e Small saphenous Popliteal La Dorsal veinous arch M ed Deep ia Great saphenous Femoral lly femoral External iliac Common IVC iliac 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