Download 39-L.L. (Updated 21st April)

Superficial Fascia of the Thigh
It is differentiated into a superficial fatty
layer & deep membranous layer.
Fatty layer of superficial fascia : it is
downward continuation of that on anterior
abdominal wall
Deep membranous layer becomes
adherent to the deep fascia of the thigh
(Fascia Lata) along a horizontal line ½ inch
below the inguinal ligament.
Deep Fascia of the Thigh (Fascia Lata)
T.S of middle of
right thigh
Superiorly : it is attached to the pelvis +
inguinal ligament.
Laterally : it is thickened to form the
iliotibial tract which is attached above to iliac
tubercle /and below to lateral condyle of
tibia. -Iliotibial tract receives insertion of :
tensor fascia latae + gluteus maximus
muscle.
Inferioly : it is attached to capsule of knee
joint + patella + upper end of tibia & fibula.
Posteriorly ( in Gluteal region) : it forms
sheaths, which enclose the tensor fasciae
latae & gluteus maximus muscles.
Its deep surface is attached to back of femur by
3 intermuscular septa…. Lateral/ medial /&
posterior.
Deep Fascia of the Thigh
(Saphenous Opening)
It is an oval opening in the deep
fascia of the thigh. opening –
It lies in front of thigh just below
inguinal ligament.
It transmits : great saphenous vein +
branches of femoral artery (superficial
epigastric, superficial circumflex iliac &
superficiial external pudendal) + lymph vessels.
It is located 1,5 in. below and lateral
to pubic tubercle. It has margin called
Falciform margin which is sharp
superiorly, laterally and inferiorly. It is
filled with loose C.T called cribriform
fascia.
Fascial Septae and Compartments of
Thigh
3 fascial septa pass from inner
aspect of deep fascial sheath of
thigh to linea aspera of femur,
dividing the thigh into 3
compartments : anterior, medial
and posterior.
Contents of Anterior
compartment :
1-Muscles : sartorius, iliacus, psoas,
pectineus, and Quadriceps femoris
Ms.
2-Blood supply : femoral vessels.
3-Femoral nerve.
Muscles of Anterior Compartment of Thigh
Quadriceps Femoris Insertion
Femoral Sheath
It is funnel-shaped tube of fascia that
surround the upper 1 in. of femoral vessels &
lymphatics, below inguinal ligament.
The upper end of sheath opens into
abdomen, while lower end fuses with the walls
of femoral vessels (tunica adventitia).
Its anterior wall is formed of downward
continuation of fascia transversalis of anterior
abdominal wall.
Its posterior wall is formed of downward
continuation of the fascia iliaca of posterior
abdominal wall.
 it is divided by 2 fibrous septa into 3
compartments : 1-lateral compartment :
contains femoral artery. 2-intermediate comp. :
contains femoral vein. 3-medial comp. :
femoral canal transmitting lymph vessels.
Femoral Canal
It is the medial compartment of femoral sheath.
It is about ½ in. long.
It contains lymph vessels + fatty C.T
Its upper end opens into abdomen and is called
femoral ring, which is closed by femoral septum
(condensation of extraperitoneal tissue of fatty tissue
& lymph).
Boundaries of Femoral Ring :
-Anteriorly : inguinal ligament.
-Posteriorly : superior ramus of pubis.
-laterally : femoral vein.
-Medially : lacunar ligament.
Its lower end is closed by fusion of its walls.
Applied anatomy : femoral hernia.
Femoral hernia
Femoral hernia is more common in female
because of wider pelvis and femoral canal, it
should always be treated surgically.
The neck of the herniated sac lies below
and lateral to pubic tubercle, while In
Inguinal hernia, the neck of swelling lies
above and medial to pubic tubercle.
It may be difficult to push it up to return to
abdomin. –irreducible hernia..
After coughing or straining, a piece of
bowel may be forced through the neck, and its
blood vessels may be compressed by femoral
ring performing strangulated hernia.
Femoral Triangle
It lies in the upper part of medial side of
the thigh.
Boundaries :
-superiorly (base) : inguinal ligament.
-laterally : sartorius.
-medially : medial border of adductor
longus.
Floor : from lateral to medial :
-iliopsoas, pectineus & adductor longus.
Roof : skin & fascia of the thigh.
Contents : femoral nerve & its branches,
femoral sheath, femoral artery & its
branches, femoral vein & its tributaries, and
deep inguinal lymph nodes.
Femoral Artery
It begins behind the midinguinal point,
(between ant.sup.iliac spine & pubic
tubercle of symphysis pubis), as a
continuation of external iliac artery.
It descends through the femoral triangle,
then vertically toward the adductor
tubercle of femur.
ends at opening in adductor magnus
muscle to enter the popliteal fossa as
popliteal artery.
Relation of Femoral Artery
Anteriorly : its upper part is
covered by skin & fascia. Its
lower part is covered by sartorius
muscle.
Posteriorly : iliopsoas,
pectineus, and adductor longus.
Femoral vein is behind femoral
artery in the lower part of
femoral triangle.
 Medially : femoral vein
(in upper part of femoral triangle)
Laterally : femoral nerve & its
branches.
Branches of Femoral Artery
Superficial circumflex iliac artery : to
the region of anterior superior iliac spine.
Superficial epigastric artery : to region
of umbilicus.
Superficial external pudendal artery :
to supply skin of scrotum (or labium majus).
Deep external pudendal artery : to
supply skin of scrotum (or labium majus).
Profunda femoris artery : is a large and
important branch arising from lateral side
of femoral artery, about 1,5 in. below
inguinal ligament. It passes medially behind
femoral vessels to enter medial side of thigh.
Branches of Femoral Artery
Profunda femoris artery :
-it ends by becoming 4th
perforating artery.
-at its origin it gives off medial
and lateral femoral circumflex
arteries.
-during its coarse it gives off three
perforating arteries.
Descending genicular artery :
near its termination to supply
knee joint.
Femoral vein
It enters thigh by passing through
opening in adductor magnus as a
continuation of popliteal vein.
It ascends in the thigh, lying at
first laterally to femoral artery, then
posterior and finally medially.
It leaves thigh by passing behind
inguinal ligament to become the
external iliac vein.
Tributaries : great saphenous vein
+ branches correspond to that of
artery.
Superficial circumflex iliac, superficial
epigastric, and external pudendal veins
drain into great saphenous vein.
Femoral Nerve
It is the largest branch of lumbar
plexus (L2,3&4).
It arises from lateral side of psoas
major ms. within abdomen to descend in
interval between posas & iliacus.
It enters thigh behind inguinal
ligament, lying outside the femoral
sheath, but within the femoral triangle
lateral to femoral artery.
It terminates about 1,5 in. below
inguinal ligament, by dividing into
anterior & posterior divisions.
It supplies all Ms. of anterior
compartment of thigh.
Branches of Femoral Nerve
Anterior division :
- 2 cutaneous branches : medial
cutaneous N. of thigh + intermediate
cutaneous N.
-2 muscular branches : to sartorius +
pectineus.
Posterior division :
-1 cutaneous branch : Saphenous N.
-Muscular branches : to quadriceps
femoris Ms.
-Articular branches to knee joint.
Saphenous Nerve
It descends medially
crossing the femoral artery.
It emerges on the medial
side of knee between the
tendons of sartorius & gracilis.
It then descends on the
medial side of leg in company
with great saphenous vein.
It passes in front of medial
malleolus and along medial
border of foot to end in big
toe.
Superficial inguinal Lymph Nodes
They are arranged into Horizontal &
Vertical groups.
Horizontal group :
-lies below and parallel to inguinal
ligament.
-The medial members of this group
receive afferent vessels from :
1-superficial lymph vessels from anterior
abdominal wall below umbilicus.
2-lymph vessels from perineum, + urethra
+ lower ½ of anal canal + external
genitalia (except lymph drainage of
testes ends in lumbar (para-aortic) L.Ns.
at level of L1 vertebra.
-The lateral members of this group
receive afferent vessels from back
below level of iliac crest (skin of gluteal
region)
Superficial inguinal Lymph Nodes
Vertical group :
-Lies along terminal part of great
saphenous vein.
-They receive most of afferent superficial
lymph vessels of the lower limb
(except lateral sides of foot & leg
drained into popliteal L.Ns. +
gluteal region drained by lateral membres
of horizontal group.
Efferent lymph vessels from vertical
& horizontal groups of superficial
inguinal L.Ns. : pass through
saphenous opening to end in deep
inguinal L.Ns. (lying along medial side of
femoral vein).
Deep Inguinal Lymph Nodes
They are located beneath the
deep fascia along medial side of
femoral vein.
They receive afferent lymph
vessels from :
-superficial inguinal L.Ns.
-popliteal L.Ns.
-deep structures of thigh.
Their efferent lymph vessels
pass through femoral canal to end
into external iliac lymph nodes.
Contents of Medial compartment of thigh
Muscles: Gracilis , adductor longus ,
adductor brevis , adductor magnus ,
obturator externus.
 Blood supply: Profunda femoris Ar.
+Obturator Ar.
 Nerve supply : Obturator nerve .

Muscles of medial fascial
compartment of thigh
Muscles of medial fascial
compartment of thigh
- Adductor part ( pubic part )
- Hamstring part ( ischial part)
+
+
Trochanteric fossa
( lateral area )
Adductor (Subsartorial) Canal :
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


It is an intermuscular cleft lies
in the middle third of medial
side of the thigh beneath
sartorius muscle.
Its upper end lies at the apex
of femoral triangle, while its
lower end lies at the opening
of Adductor magnus.
What are the walls of
Adductor canal ?
What are the contents of
Adductor canal ?
Boundaries and Contents of
Adductor Canal
Cross section
of the middle
of thigh
Anteromedial wall (roof) :
sartorius & its fascia.
Posterior wall ( floor) :
addctor longus + adductor magnus.
Lateral wall : vastus medialis.
Contents :
1- Terminal part of femoral artery.
2- Femoral vein.
3- Saphenous nerve.
4- N.to vastus medialis.
5- Terminal part of obturator N.
6- Deep lymph vessels.
Profunda Femoris Artery
It arises from the lateral side of femoral
artery, about 4cm. Below inguinal ligament.
It descends with anterior division of
femoral N. between adductor longus & brevis,
then lying on adductor magnus, where it ends
as 4th perforating artery.
Branches :
1- Medial femoral circumflex artery :
passes backward between Ms. that form floor
of femoral triangle. It takes part in cruciate
anastomosis. It gives off : ascending,
transverse, muscular and acetabular branches.
2- Lateral femoral circumflex artery :
passes laterally and gives off : ascending,
transverse and descending branches.
It takes part in cruciate anastomosis.
Profunda Femoris Artery
3- Four perforating arteries : 3 of these are
branches of profunda, the 4th perforating is
the terminal part of profunda.
-They terminate by anastomosing with one
another at the back of femur.
-The 1st perforating artery takes part in
cruciate anastomosis by anastomosing with
the inferior gluteal artery.
- The 4th perforating artery ( terminal part
of profunda ) anastomosing with the
muscular branches of popliteal artery.
Profunda Femoris Vein
It receives tributaries corresponding to the
branches of the artery.
It drains into femoral artery.
Obturator Artery
It arises in the pelvis from internal
iliac artery.
It enters thigh by passing through
the obturator canal (upper part of
obturator foramen ) with company
the obturator nerve.
 It divides into medial & lateral
branches, which form a circle on the
outer surface of obturator membrane
It gives off : muscular branches +
articular branch to hip joint and head
of femur by passing through the
acetabular notch and along the
ligament of head of femur into the
fovea.
Obturator Nerve
It arises from lumbar plexus (L2,3,4)
emerging on the medial border of psoas
muscle within the abdomen.
It runs on lateral wall of pelvis to reach
upper part of obturator foramen, where it
divides into anterior & posterior divisions.
Anterior division :
- it descends in front of adductor brevis/
behind pectineus + adductor longus.
-it gives muscular branches : to gracilis,
adductor brevis, adductor longus /
occasionally to pectineus.
-it gives articular branches : to hip joint.
-it supplies skin of medial side of thigh.
Obturator Nerve
Posterior division :
-it pierces obturator externus to
descends behind the adductor brevis
and in front adductor magnus.
-it terminates by passing through
opening in adductor magnus
( adductor hiatus) to supply knee
joint.
- it gives muscular branches : to
obturator externus, adductor part of
adductor magnus /occasionally
adductor brevis.
Cruciate Anastomosis
It lies in the back of thigh at the level
of lesser trochanter of femur.
It provides a connection between
internal iliac & femoral arteries.
The following arteries take part in
the anastomosis :
1- inferior gluteal artery ( from intenal
iliac artery).
2- medial femoral circumflex artery
( transverse branch).
3- lateral femoral circumflex artery :
(transverse branch).
4- 1st perforating artery ( branch of
profunda artery).
Cutaneous Nerves of Front of Thigh
From the lumbar plexus :
1- Ilio-inguinal N. (L1 ).
2- Femoral branch of genitofemoral N.
( L1,2 ).
3- Lateral cutaneous N. of thigh. /
L2,3
From Femoral N. :
1- Intermediate cutaneous N. of thigh.
2- Medial cutaneous N. of thigh.
Obturator N./ on medial side of thigh.
Patellar plexus : it is a network of nerves in
superficial fascia in front of patella and
ligamentum patellae.
-It is formed of :
-infrapatellar branch of saphenous N.
-Lateral, intermediate and medial cutaneous nerves
Blood supply of femoral head and Neck Fracture
In the young, epiphysis of of head
is supplied by small branch of obturator
artery, which passes to head along
ligament of head of femur.
The neck of femur receives a profuse
blood supply from medial femoral
circumflex artery. These branches pierce
capsule and ascend the neck.
As long as epiphyseal cartilage
remains, no communication occurs.
In adult, after disappearance of
epiphyseal cartilage, anastomosis occurs.
Fracture of the neck interfere with
blood supply from neck to head, so
ischemic necrosis gradually takes place.
The neck of femur /coxa valga/coxa
vara
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
The angle btween neck and
shaft of femur
(angle of femoral inclination)
is about 160 in child /and 125
in adult.
Increase in the angle is
referred to as coxa valga/as in
congenital dislocation of hip/
adduction of hip joint is
limited.
A decrease in the angle is
referred to coxa vara/ as in
fracture of neck of femur /
abduction of hip is limited.
The gluteal region
The ligaments : Sacrotuberous, Sacrospinous.
 The foramina : 1-Greater Sciatic Foramen.
2-Lesser Sciatic Foramen.
 The muscles : Gluteus Max.,Med.,Minimus.
Tensor fascia latae ,Piriformis,Obturator int.,
sup.&inf.gemelli, Quadratus femoris.
 The nerves: Sciatic N., Post.cut.N.of the thigh,
Sup.&inf.gluteal N. , N.to Q.F., Pudendal N.,
N.To Ob.int.
 The arteries: Sup.,&inf.gluteal arteries.

What are structures passing
through the greater sciatic foramen?
Piriformis.
 Structures above piriformis: Sup.gluteal
N.&vessels.
 Structures below piriformis:
 Inf.gluteal N.&vessels.
Sciatic N.
 Post.cut.N.of the thigh.
N.to Q.femoris.
 N.to obt.internus.---Pudendal N.---Int.pudendal
vessels

What are structures passing through
the lesser sciatic foramen?
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Tendon of obturator internus muscle.
N.to obturator internus .
Pudendal N.
Internal pudendal vessels.
The Sciatic Nerve in gluteal region.
Origin : sacral plexus (L4,5,S1,2,3) in pelvis.
 Course and relation: it leaves pelvis through
grater sciatic foramen below piriformis.
It crosses from above downwards:
ischium,obturator int.&and 2gemilli,quadratus
femoris.
It leaves buttok by passing deep to long head of
biceps femoris to enter the back of thigh.
 Branches: No branches in the gluteal region.

Structures deep to Gluteus Maximus
Muscles: 1-gluteus medius.
2-lateral rotators of the thigh.
 Ligaments: 1- sacrotuberous. 2-sacrospinous.
 Bones: Lat.: greater trochanter.
Med.: ischial tuberosity.
 Three synovial bursae .
 Foramina : 1-greater sciatic F.
2-lesser sciatic F.

Anastomosis in the gluteal region
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The cruciate anastomosis: provide connection
between the internal iliac &femoral arteries.
It lies at the level of Lesser trochanter.
The following arteries take part in the
anastomosis :1-Inf.gluteal , 2-1st perforating ,
3-Med.femoral circumflex.
4-Lat.femoral circumflex.
Anastomosis in the gluteal region


The Trochanteric anastomosis : provides the
main blood supply of the head of femur. the
arteries pass along femoral neck beneath the
capsule of hip joint.
The following arteries take part in the
anastomosis: 1-Sup.gluteal.Ar. 2-Inf gluteal.Ar
3-Med. Femoral circumflex Ar.
4-Lat. Femoral circumflex Ar.