Skin of Lower Limb, Vein and Artery PDF

Skin of lower limb, Vein and Artery Prepared by: Dr. Randa A. Alasalahi Senior specialest ortopedic surgeon Buttock Cutaneous nerve of the buttock are : 1. Upper medial quadrant by : Posterior rami of upper three lumber & upper three sacral nerv...

Skin of lower limb, Vein and Artery Prepared by: Dr. Randa A. Alasalahi Senior specialest ortopedic surgeon Buttock Cutaneous nerve of the buttock are : 1. Upper medial quadrant by : Posterior rami of upper three lumber & upper three sacral nerve ( L 1,2,3 & S 1,2,3) 2. Upper lateral quadrant : Lateral branches of subcostal (T12) & iliohypogastric nerves (L1) 3. Lower medial quadrant : Branches of posterior cutaneous nerve of thigh (S1,2,3). 4. Lower lateral quadrant : branches of lateral cutaneous nerve of thigh ( L2,3). 5. Skin over coccyx ( in natal cleft “ between bottock”) Branches of lower sacral & coccygeal nerves. The thigh The thigh region receives cutaneous innervation from three main nerves (femoral, posterior cutaneous and lateral cutaneous). The superomedial aspect of the thigh also has contributions from several smaller branches of the lumbar plexus  Femoral nerve – arises from the lumbar plexus. It gives rise to anterior, medial and intermediate branches which supply the majority of the skin of the anterior thigh. Posterior cutaneous nerve of thigh – supplies the lower medial quadrant of the gluteal region, posterior aspect of the thigh and knee. Lateral cutaneous nerve of thigh – supplies the lower lateral quadrant of the gluteal region, lateral aspect of the thigh and knee  Femoral branch of the genitofemoral nerve – arises from the lumbar plexus. It supplies the skin overlying the lateral aspect of the femoral triangle. Ilioinguinal nerve – arises from the lumbar plexus. It supplies the skin overlying the medial aspect of the femoral triangle. Obturator nerve – arises from the lumbar plexus. Branches from the anterior branch of the obturator nerve supply skin over the medial aspect of the thigh The leg The cutaneous innervation to the leg is from the following peripheral nerves: Posterior cutaneous nerve of thigh – supplies the skin over the central superior and posterior leg. Saphenous nerve – a sensory branch of the femoral nerve. It supplies the skin over the anteromedial aspect of the leg and medial aspect of the foot  Superficial fibular nerve – a branch of the common fibular nerve. It supplies the skin over the anterolateral aspect of the leg and dorsum of the foot. Sural nerve – formed by contributions from the tibial and common fibular nerves. It supplies the posterolateral aspect of the leg and lateral margin of the foo The foot and Ankle The ankle and foot receive cutaneous innervation from branches of the tibial nerve, common fibular nerve and femoral nerve: Deep fibular nerve – supplies the space between 1st and 2nd toes on the dorsum of the foot. Superficial fibular nerve – supplies the dorsum of the foot (except the space between the 1st and 2nd toes).  Medial and lateral plantar nerves – terminal branches of the tibial nerve. The medial plantar nerve supplies the medial two thirds of the sole of the foot. The lateral plantar nerve supplies the lateral third. Medial calcaneal nerve – branch of the tibial nerve. It supplies the medial aspect of the heel  Sural nerve – formed by contributions from the tibial and common fibular nerves. It supplies the lateral margin of the hindfoot and midfoot. Saphenous nerve – branch of the femoral nerve. It supplies the medial margin of the hindfoot and midfoot Superficial vein of lower limb 1. Dorsal venous arch: ❖Site : over head of metatarsal bones. ❖Tributaries : recives digital veins & veins from sole> ❖End : forming great & small saphenous veins. 2. Great saphenous vein : “ long saphenous v.” ❖Beginning : from medial end of dorsal venous arch. ❖End : by draining into femoral vein about 4cm (1.5 inch) below & lateral to pubic tubercle (by passing saphenous opening ) ❖Course : passes in front of medial malleolus & ascend in super fascia over medial aspect of leg ( accompanied by saphenous N. ). Pass behind the knee ( joining small saphenous ). Curves forward around medial aspect of thigh , passes through saphenous opening piercing cripriform fascia. It has numerous valves & connected with deep veins of lower limb by perforating veins (1. at mid of thigh , 2. just below knee , 3. above medial malleolus by 5,10&15 cm ). Tributaries of great saphenous veins 1. Superficial circumflex iliac vein. 2. Superficial epigastric vein. It joins lateral thoracic vein to form thoracoepigastric vein ( joininig SVC& IVC). 3. Superficial external pudendal vein. 4. Accessory vein. 5. Unnamed veins. Applied anatomy : Intravenous infusion (venous cutdown) May used as graft for diseased coronary association. If dilated ,tortuous called varicous veins. 3. Small saphenous vein “short saph”: ❖Beginning : from lateral end of dorsal venous arch. ❖End: by draining into popliteal vein. ❖Course : assend behind lateral malleolus ( accompanied by sural N) Follows lateral border of tendo-calcaneus. Runs up to meddle of back of leg , pierces deep fascia and passes between 2 heads of gastrocnemius in lower part of popliteal fossa. ❖Tributaries : 1. small veins from back of leg. 2. anastomosing vein with great saphenous vein. 3. communicating veins with foot deep veins. Arteries of lower limbs Arteries of lower limbs 1) Femoral A. ❖ Beginning : at inguinal ligament at as a continuation of external iliac artery at mid inguinal point. ❖End : at adductor hiatus by becoming popliteal artery. ❖Course: enter the thigh behind inguinal ligament. Inside the femoral sheath ( at mid inguinal point ) Then enters the femoral triangle & leaves the apex of triangle entering into adductor hiatus becoming popliteal artery.( it desend vertical toward adductor tubercle of femure ) ❖Relation : in the femoral triangle – lateral : femoral nerve. -medial : femoral vein. -anterior : skin & fascia. -posterior : psoas & Pectineus. In adductor canal : -anteromedial : Sartorius. -anterolateral : Vastus medialis. -posteriorly : add.longus & magnus. ❖Branches of femoral artery : 1. Superficial circumflex iliac artery ( runs toward ASIS). 2. Superficial epigastric artery ( runs toward umbilicus). 3. Superficial external pudendal artery (supply scrotum , labius majuor). 4. Deep external pudendal artery ((supply scrotum , labius majuor). 5. Profundus femoris artery. 6. Descending genicular artery ( the last branch ) supply knee joint. 2) Obterator artery : ❖Beginning : branch of internal iliac artery ( ant. Division ). ❖End : by division into anterior & posterior division. ❖Course : enter the thigh with Obturator nerve through the Obturator canal to medial compartment of thigh. ❖Branches : 1. Visceral : to urinary bladder. 2. Muscular : to neighboring muscles. 3. Articular : to hip joint anter into lig. Of head of femur ( ligamentum teres) to supply head of femur 4. Pubic branch. 3) Popliteal artery : ❖Beginning : at add. Hiatus as continuation of femoral artery. ❖End : at lower border of Popliteus muscle by division into anterior and posterior tibial arteries. ❖Descend in popliteal fossa : first medial to popliteal nein then deep to it & finally lateral to the vein. ❖Relation : anterior ( from above down ward ) 1. Popliteal surface of femur. 2. Knee joint. 3. Popliteal muscle. Posterior ( from superficial to deep) 1. Skin & fascia. 2. Tibial nerve. 3. Popliteal vein. ❖Branches : 1. Muscular : to muscles beside. 2. Ant.& pot. Tibial arteries ( terminal branches). 3. Middle genicular artery. 4. Superior medial genicular artery. 5. Superior lateral genicular artery. 6. Inferior medial genicular artery. 7. Inferior lateral genicular artery. 4) Anterior tibial artery. ❖ Beginning : the smaller terminal branches of popliteal artery at the lower border of popliteal muscle. ❖End : continuation as dorsalis pedis artery in front of ankle ❖Course : enter the anterior compartment of leg through opening in the upper part of interosseous membrane. Running down with deep peroneal nerve. Leave the leg by passing deep to superior extensor retinaculum ( between ext. hallucis longus –medially & deep peroneal nerve & extensor digitorum longus – laterally ) here the artery is superficial & can be palpable. ❖Branches : 1. Muscular : to muscles beside it. 2. Nutrient : to the bones. 3. Anterior & posterior tibial recurrent arteries. 4. Medial & lateral malleolar arteries. Dorsalis pedis artery : ❖Beginning : continuation of anterior tibial artery in front of ankle ❖End : in the sole of foot between 1st & 2nd toes to join the planter arch. ❖Course : descend in dorsum of foot just lateral & parallel to tendon of extensor hallucis longus between big& second toe. ❖Branches : 1. Medial & lateral tarsal arteries. 2. First planter & dorsal metatarsal artery – gives digital to big toe & medial side of second toe. 3. Arcuate artery – gives 4 metatarsal arteries – gives digital branches to lateral 3 and ½ fingers. 5) Posterior tibial artery : ❖Beginning : the larger terminal branches of popliteal artery at lower border of Popliteus muscle. ❖End : by dividing into medial & lateral planter arteries. Behind medial malleolus ( deep to flexor retinaculum ) ❖Course : enter the posterior compartment of leg between soleus and gastrocnemius above it & ( tibia & tibialis post. Ms) below it. Running with tibial nerve ( the nerve first medial then superficial & finally lateral to artery.  In the lower part of leg is superficial covered only by skin & fascia ( in front of medial border of tendocalcanes. ❖Branches : 1. Muscular : to muscles beside. 2. Nutrient : to tibia. 3. Peroneal artery & communicating br. To peroneal artery. 4. Medial malleolar. 5. Medial calcaneal. 6. Medial and lateral planter ( terminal ) 7. Circumflex fibular.  Peroneal artery : ❖Beginning : from post. tibial artery. ❖End : behind inferior tibiofibular joint dividing into calcaneal branches. ❖Course : running in lat. Comp. with superficial peroneal nerve. ❖Branches : 1. Muscular branches. 2. Nutrient : to fibula. 3. Lateral malleolar. 4. Lateral calcaneal. 5. Perforating branch. 6. Communicating branch to post. Tibial artery. Nerve of lower limb Nerve of lower limb 1)femoral nerve : is one of the major peripheral nerves of the lower limb. Overview ❖Nerve roots: L2-L4 ❖Anatomical Course: The femoral nerve is the largest branch of the lumbar plexus. It is derived from the anterior rami of nerve roots L2, L3 and L4. After arising from the lumbar plexus, the femoral nerve travels inferiorly through the psoas major muscle of the posterior abdominal wall. It supplies branches to the iliacus and pectineus muscles prior to entering the thigh.  The femoral nerve then passes underneath the inguinal ligament to enter the femoral triangle. Within this triangle, the nerve is located lateral to the femoral vessels (unlike the nerve, the femoral artery and vein are enclosed within the femoral sheath). Approximately 4cm below the inguinal ligament, the femoral nerve divides into anterior and posterior divisions ❖Anterior division of the femoral nerve: 1. Anterior cutaneous branches 2. Branch to sartorius 3. Branch to Pectineus ❖Posterior division of the femoral nerve: 1. Saphenous nerve 2. Branches to quadriceps femoris  The terminal cutaneous branch of the femoral nerve is the saphenous nerve. It travels through the adductor canal (accompanied by the femoral artery and vein) and exits prior to the adductor hiatus. The saphenous nerve innervates the medial aspect of the leg and the foot. 2) sciatic nerve : is a major nerve of the lower limb. It is a thick flat band, approximately 2cm wide – the largest nerve in the body. ❖Nerve roots: L4-S3. ❖Anatomical Course The sciatic nerve is derived from the lumbosacral plexus. After its formation, it leaves the pelvis and enters the gluteal region via greater sciatic foramen. It emerges inferiorly to the piriformis muscle and descends in an inferolateral direction. As the nerve moves through the gluteal region, it crosses the posterior surface of the superior gemellus, obturator internus, inferior gemellus and quadratus femoris muscles. It then enters the posterior thigh by passing deep to the long head of the biceps femoris.  Within the posterior thigh, the nerve gives rise to branches to the hamstring muscles and adductor magnus. When the sciatic nerve reaches the apex of the popliteal fossa, it terminates by bifurcating into the tibial and common fibular nerves.  The sciatic nerve also indirectly innervates several other muscles, via its two terminal branches: 1)Tibial nerve – the muscles of the posterior leg (calf muscles), and some of the intrinsic muscles of the foot. 2)Common fibular nerve – the muscles of the anterior leg, lateral leg, and the remaining intrinsic foot muscles. In total, the sciatic nerve innervates the muscles of the posterior thigh, entire leg and entire foot. 3) tibial nerve : is a major peripheral nerve of the lower limb. It has several cutaneous and motor functions in the leg and foot. ❖Nerve roots: L4-S3 ❖Sensory: Innervates the skin of the posterolateral leg, lateral foot and the sole of the foot. ❖Motor: Innervates the posterior compartment of the leg and the majority of the intrinsic foot muscles ❖Anatomical Course The tibial nerve is a branch of the sciatic nerve, and arises at the apex of the popliteal fossa. It travels through the popliteal fossa, giving off branches to muscles in the superficial posterior compartment of the leg. Here, the tibial nerve also gives rise to branches that contribute towards the sural nerve, which innervates the posterolateral aspect of the leg. The tibial nerve continues its course down the leg, posterior to the tibia. During its descent, it supplies the deep muscles of the posterior leg.  At the foot, the nerve passes posteriorly and inferiorly to the medial malleolus, through a structure known as the tarsal tunnel. This tunnel is covered superiorly by the flexor retinaculum. Within this tunnel, branches arise from the tibial nerve to supply cutaneous innervation to the heel Immediately distal to the tarsal tunnel, the tibial nerve terminates by dividing into sensory branches, which innervate the sole of the foot  The tibial nerve also supplies all the sole of the foot via three branches: 1)Medial calcaneal branches: These arise within the tarsal tunnel, and innervate the skin over the heel. 2)Medial plantar nerve: Innervates the plantar surface of the medial three and a half digits, and the associated sole area. 3)Lateral plantar nerve: Innervates the plantar surface of the lateral one and a half digits, and the associated sole area. 4) common fibular nerve: is a peripheral nerve of the lower limb ❖Nerve roots: L4 – S2 ❖Anatomical Course The nerve begins at the apex of the popliteal fossa, where the sciatic nerve bifurcates into the tibial and common fibular nerves. The common fibular nerve follows the medial border of the biceps femoris, running in a lateral and inferior direction, over the lateral head of the gastrocnemius.  At this point, the nerve gives rise to two cutaneous branches, which contribute to the innervation of the skin of the leg. To enter the lateral compartment of the leg, the nerve wraps around the neck of the fibula, passing between the attachments of the fibularis longus muscle. Here, the common fibular nerve terminates by dividing into the superficial fibular and deep fibular nerves ❖Motor Functions The common fibular nerve innervates the short head of the biceps femoris muscle (part of the hamstring muscles, which flex at the knee) ❖In addition, its terminal branches also provide innervation to muscles: 1) Superficial fibular nerve: Innervates the muscles of the lateral compartment of the leg; fibularis longus and brevis. These muscles act to evert the foot. 2)Deep fibular nerve: Innervates the muscles of the anterior compartment of the leg; tibialis anterior, extensor digitorum longus and extensor hallucis longus. These muscles act to dorsiflex the foot and extend the digits. It also innervates some intrinsic muscles of the foot. ❖In addition to these nerves, the terminal branches of the common fibular nerve also have a cutaneous function: 1)Superficial fibular nerve: Innervates the skin of the anterolateral leg, and dorsum of the foot (except the skin between the first and second toes). 2)Deep fibular nerve: Innervates the skin between the first and second toes 5) superficial fibular nerve :(superficial peroneal nerve) is a nerve of the lower limb. ❖Nerve roots: L4-S1 ❖Anatomical Course The superficial fibular nerve is a terminal branch of the common fibular nerve. It arises at the neck of the fibula, descending between the fibularis muscles and the lateral side of the extensor digitorum longus.  Here, it gives rise to motor branches, which supply the fibularis longus and brevis. The nerve continues its descent, with a purely cutaneous function, providing sensory innervation to the anterolateral aspect of the lower leg. When the superficial fibular nerve reaches the lower third of the leg, it pierces the deep crural fascia and terminates by dividing into the medial and intermedial dorsal cutaneous nerves. These nerves enter the foot to innervate the majority of its dorsal surface 6) deep fibular nerve :(deep peroneal nerve) is a nerve of the leg. It is one of the terminal branches of the common fibular nerve. ❖Nerve roots: L4-S1. ❖Anatomical Course The deep fibular nerve is a terminal division of the common fibular nerve (itself a branch of the sciatic nerve). It arises within the lateral compartment of the leg, between the fibularis longus muscle and the neck of the fibula.  The nerve then travels medially, pierces the intermuscular septum, and enters the anterior compartment of the leg. Accompanied by the anterior tibial artery, it descends in a plane initially between the tibialis anterior and extensor digitorum longus, and then distally between the tibialis anterior and extensor hallucis longus. During its descent, the deep fibular nerve is initially lateral, then anterior and finally medial to the anterior tibial artery  At the ankle, the deep fibular nerve travels underneath the extensor retinaculum. It then divides within the dorsum of the foot into two branches: 1)Lateral branch – innervates two of the intrinsic muscles of the foot (extensor digitorum brevis and extensor hallucis brevis). 2)Medial branch – innervates the skin of the webbed space between the 1st and 2nd toes