Download Femoral nerve

First Stage
1
19/1/2016
Lower limb
Lec
‫إيمان‬.‫د‬
The lower limbs are divided into different regions :
The gluteal region , the thigh ,the knee, the leg, the ankle, and the
foot.
The Thigh
The region of the thigh includes the area from the iliac crest to the knee, The
bones of the thigh are the hip and the femur.
The Superficial fascia
Consist of a thick fatty superficial layer and a deeper membranous layer.
The superficial layer is a loose fatty layer continuous with the similar
layer of the abdomen, the back, perineum, and the leg . In the gluteal region
the fat deposited in a thick layer which form the transverse fold of the
buttock.
The membranous layer of the superficial fascia of the anterior
abdominal wall extends into the thigh and is attached to the deep fascia (fascia lata)about
finger breadth below the inguinal ligament
Superficial nerves, superficial vessel, & superficial inguinal lymph nodes are
present between these two layers
The deep fascia ( fascia lata) the thigh is surrounded by thick strong
fascia, like stock. It is thin anteriorly and medially while its thick laterally.
the most thickened part is attached to iliac crest above and to the lateral tibial
condyle below known as the ilio-tibial tract . fascia lata fuses above to the
inferior concave border of the inguinal ligament. ,
Fascia lata has three characteristic features :
1-laterally it forms a thick band extend from the iliac tubercle to the lateral
tibial chondyle called the iliotibial tract; Two muscles inserted in this tract,
the greater part of the gluteus maximus posteriorly and tensor fasciae latae
anteriorly.
2- medially it forms an opening called saphenous opening
3- sends intermuscular septa to the linea aspera of the femur these septa
separate the thigh in to 3 compartments:
1- Anteriorly and laterally the extensor compartment. Supplied by the
femoral nerve.
2- Medially the adductor compartment. Supplied by the obturator nerve.
3- Posteriorly the muscles compartment (Hamstring muscles) supplied by
the sciatic nerve.
Saphenous opening
It is an oval opening in the deep fascia(fascia lata)
situated in the front of the upper part of the thigh, the great saphenous vein
passes through it to terminates in the femoral vein. its center is located 4cm
below the inguinal ligament lateral to the pubic tubercle, The opening is
covered by a thin and perforated fascia called ciribriform fascia. the lateral
margin of the opening is sharp called falciform margin. It transmit:
• The great saphenous vein
• The superficial arteries from the femoral artery.
• Efferent vessels from the superficial inguinal lymph nodes.
•
Superficial veins: the Superficial veins of the leg are great and small
saphenous veins and their tributaries
Great saphenous vein
It is the longest and thickest walled superficial vein in the body. It begins
at the junction of the medial end of the dorsal venous arch and the medial
dorsal vein of the great toe runs upwards and backwards anterior to the
medial malleolus accompanied by the saphenous nerve in the medial side of
the leg then ascend to the posteromedial surface of the knee, it inclines
anterolaterally in the thigh to enter the femoral vein through the saphenous
opening. It receives tributaries from the dorsum of the foot, the heel, the leg
and the calf. It also receives the large accessory saphenous vein which drains
the medial and posterior parts of the thigh. just before it pass through the
saphenous opening the great saphenous vein receives the superficial
epigastric, superficial circumflex iliac and superficial external pudendal
veins. The valves of the vein is varied between 10-20, these valves assist in
the support of the column of the blood that fills the vein.
Superficial inguinal lymph nodes :divided into two groups
1-horizontal group lies just below and parallel to the inguinal lig.
2-vertical group lies along the terminal part of great saphenous vein
The efferent lymphatic vessels from Superficial inguinal lymph nodes pass
through the saphenous opening and join the deep inguinal nodes.
Inguinal ligament
It is the lower free border of the aponeurosis of the external oblique
muscle of the abdomen. It extends from the pubic tubercle medially to the
anterior superior iliac spine laterally. Fascia lata attached to the external
surface of the ligament .
The anterior compartment of the thigh
muscles of the anterior compartment of the thigh are sartorius, the
quadriceps femoris which include ( rectus femoris, vastus lateralis,
vastus medialis, and vatus intermedialis muscles) and the articularis
genu muscle, all are supplied by the femoral nerve
Name
muscle
Rectus
femoris
of Origin
Vastus
medialis
Vastus
lateralis
Vastus
intermedialis
a- Straight head from
ant. Inf. Iliac spine
b- Reflected
head
from just above
acetabulum
-From lower part of
intertrochantric line
-medial lip of linea
aspira
From upper part of
intertrochantric line
-lateral lip of linea
aspira
From ant. And lat.
Surfaces of the shaft of
insertion
Common insertion
via
guadriceps
tendone
which
attaches
to
circumference of
patella and then
via
patellar
ligament to tibial
tuberosity
femur
sartorius
iliacus
Psoas major
From ant. Sup. Iliac Upper part of
spine
medial surface of
shaft of tibia
From iliac fossa of hip Common tendon
bone
inserted ito lesser
Transverse process , trochanter
bodies
and
intervertebral discs of
T12-L5
Iliacus +psoas are main flexor at hip joint they also flexes thigh on
abdomen
Guadriceps are main extensor at knee joint . Sartorius are abduct and
laterally rotate at hip joint.
Femoral artery
It is the direct continuation of the external iliac artery of the abdomen,
it enters the thigh below the inguinal ligament at the mid-inguinal point
medial to the femoral nerve and lateral to the femoral vein. in the femoral
triangle the artery covered only by skin and fascia. Then it descends to the
adductor canal at the apex of the femoral triangle anterior to the adductor
longus m. it become the popliteal artery by passing through the adductor
hiatus.
Branches:
1- . Superficial arteries (
2- Deep external pudendal artery.
3- . Profunda femoris artery
4- Muscular arteries. To m. of ant. Comparetment
5- Descending genicular artery. Arise from the femoral artery short
distance above the adductor hiatus and share in the anastomose around
the knee joint.
Profunda femoris artery. It is the principle artery of the thigh, arise from the
posterolateral part of the femoral artery 5cm below the inguinal ligament, it
descend deeply in the thigh between adductor longus and brevis m, behind the
femoral artery and vein on the medial side of the femur. In the lower third of
the thigh the artery ends as the fourth perforating artery which pierces the
adductor magnus and distributes to the muscles of the posterior compartment
(hamstring muscles) at the back of the thigh. 4cm below the inguinal ligament
in the femoral triangle it gives following branches
A- Lateral circumflex artery. Which is the largest branch of the profunda
artery it runs laterally among the branches of the femoral nerve then
deep to rectus femoris m.
B- Medial circumflex artery, either arise from the profunda or directly
from the femoral artery passes backwards between pectinus and
iliopsoas muscles and continue backward under the neck of the femur.
C- 3 perforating branches to muscles of the back of the thigh . and
D- Finally the profunda femoris terminates as 4th perforating branch.
The medial side (adductor) of the thigh
Includes the adductor muscles which arise from the external surfaces
of the pubic rami and the ramus of the ischium. they concerned with
adduction at the hip joint, the muscles are:
pectineus, adductor longus, adductor brevis, adductor magnus, gracilis.
Name of m.
origin
insertion
gracilis
From medial margin of
pupic arch
Superior ramus of pupis
Upper medial side
of tibia
Spiral line
between lesser
trochanter and
linea aspera
Adductor longus
Pupic bone just below
and medial to pupic
tubercle
Linea asperaa
Adductor brevis
From body and
inferior ramus of
pupis
Linea aspera
pectineus
Adductor magnus
a-Adductor part from
inferior pupic ramus and
ischial tuberosity
b-hamsting part from
ischial tuberosity
To Linea aspera
Adductor tubercle
The nerve supply of these muscles is the obturator nerve (L2, 3, 4).except the hamstring
portion of adductor magnus from sciatic N. and pectineus m. receive nerve supply from
both femoral and obturator N.
The obturator nerve: arises from the lumbar plexus in the abdomen
it descends medial to the psoas m. at the lateral wall of the pelvis here it
join the obturator vessels and enters the obturator canal where it divides
into anterior and posterior branches:
Anterior branch: descends in the thigh between adductor longus and
adductor brevis muscles it sends branches to the these two muscles and
gracilis m it also supply the hip joint.
Posterior branch: pierces the obturator externus m. and descends
between adductor brevis and magnus muscles. Supply these 3 muscles and
ends as an articular branch through adductor magnus to the back of the
knee joint.
The obturator artery: arises from the internal iliac artery it
accompany the obturator nerve through the obturator canal divides into
anterior and posterior branches which forms an arterial circle on the
obturator membrane.
The anterior branch runs forward and downward on the outer surface of
the obturator membrane supply obturator externus and internus and the
adductor magnus and brevis muscle. anastomosed with the posterior
branch and the medial circumflex femoris arteries.
The posterior branch runs along the posterior margin of the obturator
membrane, it supply the origin of adductor magnus muscle and gives the
acetabular branch which enters the hip joint through the acetabular notch
supply the ligamentum capitis of the femur.
.
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FEMORAL TRIANGLE
Occupy the upper third of the front of thigh.
Bounderies:
Superiorly(base): the inguinal ligament.
dr. eman
Medially: the medial border of the adductor longus muscle.
Laterally: medial border of the sartorious muscle.
Inferiorly (apex): is formed as Sartorius crosses over the lower part of
adductor longus m. continuous with the adductor canal.
The anterior wall of the triangle: composed of the skin and the fascia. In the
superficial fascia there are the following structures:
1- The upper part of the great saphenous vein.
2- Superficial inguinal lymph nodes and vessels.
3- Femoral branch of the genitofemoral nerve.
4- Superficial branches of the femoral vessels.
5- Branches of the ilioinguinal nerve.
The posterior wall (the floor): composed of muscles, from medial to lateral:,
adductor longus, pectineus, psoas major and iliacus muscles ( iliopsoas )
Contents of the triangle
1-Femoral sheath
It is an extension of the transveralis fascia of the abdominal cavity which
surrounds the upper 2-3 cm of the femoral vessels below the inguinal
ligament. The sheath is divided into 3 compartments, the femoral artery
occupy the lateral part of the sheath while the vein is intermediate, medial to
the femoral vein is the tubular femoral canal, through which femoral hernia
may pass.
Femoral canal
It is a short fascial tube about 0.5 inch occupy the medial compartment of
the femoral sheath, inferiorly it is rapidly decreased in width and closed by
fusion of its walls. The wide upper end called the femoral ring which is
separated from the abdominal cavity only by peritoneum. It contains fatty
connective tissues, efferent lymph vessels from the deep inguinal lymph nodes
and one or two of the deep inguinal lymph node.
Boundaries of the femoral ring:
Inguinal ligament------------anteriorly
The sharp edge of the lacunar ligament---------- medially
The pectin pubis-------- posteriorly
The femoral vein ------- laterally
2-The femoral vessels enters the triangle behind the midpoint of the
inguinal ligament traverse the triangle from the base to the apex. The
vein is medial to the artery at the base, but it lies behind the artery at
the apex.
3- Profunda femoris artery. It is the main artery of the thigh arise from
the posterolateral side of the femoral artery, curves behind it and passes
posterior to the adductor longus muscle. The profunda vein lies anterior
to the artery and ends in the femoral vein.
4- The lateral and medial circumflex arteries, arise from the profunda
artery near its origin. The lateral circumflex passes among the branches
of the femoral nerve and leaves the triangle posterior to the sartorious
muscle. The medial one passes backwards between psoas and pectineus
muscle. The circumflex veins end in the femoral vein.
5- Deep external pudendal artery it is small branch arise from the medial
side of the femoral artery runs medially to the scrotum in male and the
labium majus in female.
6- 3-4 deep inguinal lymph nodes lie along the medial side of the femoral
vein, receive afferent vessels from the superficial inguinal lymph nodes
and popliteal lymph nodes and from the deep structures of the limb.
Efferent vessels pass from the deep inguinal lymph nodes to the
external iliac nodes.
7- The femoral branch of the genitofemoral nerve supply skin over the
triangle.
8- Lateral cutaneous nerve of the thigh L2 L3.
9- Femoral nerve (L2,3,4) arise from the lumber plexus in the abdomen
descend in groove between psoas and iliacus muscles and give branch
to iliacs . it enters the thigh posterior to the inguinal ligament and lateral
to the femoral sheath. 2cm below the inguinal ligament it ends by
dividing into anterior and posterior branches.
The anterior division gives:
a- Cutaneous nerves includes the anterior cutaneous nerve of the thigh.
b- muscular branches to the sartoris and through which it gives genicular
branch to the hip joint.
The posterior division gives:
a- Saphenous nerve (L3 L4). It is the longest branch of the femoral nerve it
arise in the femoral triangle and accompany the femoral vessels in the
adductor canal deep to sartorious muscle, it leaves the canal in the distal
quarter of the thigh here it give the infrapatellar branch then it emerges
between the tendon of the sartorious and gracilis muscle. It lies posteromedial
to the knee and pierces the deep fascia in the leg accompanies the great
saphenous vein and ends in the skin of the medial side of the foot.
b- Muscular branches to the quadriceps femoris muscle (rectus femoris,
vastus lateralis, medialis and intermedius(.
The adductor canal
It is an intermuscular canal situated on the medial aspect of the middle of
the thigh beneath the sartorius m. it conducts the femoral vessels through the
middle 1/3 of the thigh, it begins about 15cm below the inguinal ligament at
the apex of the femoral triangle and ends at the upper limit of the adductor
hiatus (a separation in the tendinous insertion of the adductor magnus muscle
allows the femoral vessels to pass to the back of the knee). it is triangular in
section.
Boundaries of the canal are:
Sartorius muscle anteromedially.
Vastus medialis anterolaterally.
Adductor longus and magnus posteromedially.
The contents of the adductor canal are:
1- The femoral vessels.
2- Saphenous nerve.
3- Nerve to vastus medialis.