Download 26-arches+venous&lymphatics2008-05

Function of Arches of
the Foot :
They act as a weight bearing.
They act as a locomotive part of the
body in walking & running.
They provide space in the sole of foot
to contain and protect the muscles,
nerves and blood vessels of the sole.
Arches of Foot
Medial longitudinal arch :
-it is formed of calcaneum, talus,
navicular, 3 cuneiform bones, and first
3 metatarsal bones.
Lateral longitudinal ligament :
-it is formed of calcaneum, cuboid,
4th & 5th metatarsal bones.
Transverse arch :
-it is formed of bases of metatarsal
bones, cuboid and 3 cuneiform
bones.
Factors maintaining
arches of Foot :
Medial longitudinal arch
Factors maintaining
medial longitudinal arch :
1- The shape of bones :
-the sustenticulum tali holds up
the talus.
-concavity of proximal surface
of navicular bone receives the
rounded head of talus, which is
the keystone in the center of the
arch.
-concavity of proximal surface of
medial cuneiform bone receives
the navicular.
Medial longitudinal arch
2-the inferior edges of the
bones are tied together by :
-Plantar ligaments, The most
important ligament is plantar
calcaneo-navicular ligament
(spring ligament).
-Tendon of tibialis posterior
insertion (enter sole of foot
into all tarsal bones except
talus + bases of 2,3,4
metatarsal bones).
Medial longitudinal arch
Tibialis anterior
3-tying the ends of the arch
together by :
-Plantar aponeurosis (extends
from calcaneum to heads of
metatarsal bones)
-Medial part of flexor digitorum
longus + Medial part of flexor
digitorum brevis.
-Abductor hallucis.
-Tendon of Flexor hallucis longus
+ Flexor hallucis brevis.
4-Suspending the arch from
above by :
-Tibialis anterior (descends in
front of tibia to be inserted into
medial sides of medial cuneiform
bone + base of 1st metatarsal
bone)
-Posterior & Medial ligament
(deltoid ligament) of ankle joint.
Lateral longitudinal arch
Factors maintaining lateral
longitudinal arch :
1-shape of bones : the minimal
shaping of distal end of calcaneum &
proximal end of cuboid. The cuboid is
the keystone.
2-the inferior edges of the bones are
tied together by :
long plantar ligament + short plantar
(plantar calcaneo-cuboid) ligament +
short muscles of the forepart of foot.
3-Tying the ends of the arch together
: by plantar aponeurosis + abductor
digiti minimi + lateral part of flexor
digitorum longus & brevis.
4-Suspending the arch from above :
peroneus longus & brevis.
Transverse arch
Factors maintaining transverse
arch:
1-Shape of bones : the wedge shape of
cuneiform bones + the bases of
metatarsal bones.
2-the inferior edges of the bones are
tied together by :
-Particully, the dorsal interossei +
transverse head of adductor hallucis.
-Deep interosseus transverse ligaments +
long & short plantar ligaments.
3-Tying the ends of the arch together :
by peroneus longus tendon.
4-Suspending the arch from above : by
the peroneus longus tendon + peroneus
brevis.
Pes planus (Flat Foot)
The medial longitudinal arch is depressed,
so the forefoot is displaced laterally and
everted.
The head of talus descends downward &
medially between calcaneum & navicular bone
The plantar calcaneo-navicular ligament +
medial ligaments of ankle become
permanently stretched + the bones change
shape + muscles & tendons are also
permanently stretched.
The causes of flat foot : are both
congenital & acquired.
It occurs after fatigue or disease of muscles
of leg & foot e.g. after long standing, long
walking, overweight or illness, so the weak
muscles & ligaments are stretched and pain is
produced after walking for a short distance.
Pes Cavus (Clawfoot)
The medial longitudinal arch
becomes too high.
It is produced by shortening of
muscles or tendons of leg or
sole, in most cases due to
poliomyelitis.
Veins of the lower limb
Superficial veins :
1-Great & small saphenous veins +their tributaries.
-They have numerous valves along its course.
-They are situated in superficial fascia, the constant position
of great saphenous vein in front of medial malleolus should
be remmembered for patients recquiring blood transfusion.
Deep veins :
1-venae comitantes of anterior & posterior tibial arteries.
2-Popliteal vein & Femoral vein + their tributaries.
-They have valves to allow blood to pass upwards only .
Perforating veins:
-Many of these veins are found in ankle & medial side of
lower part of leg.
-They connect superficial veins with the deep veins.
-They possess valves which allow blood to pass from
superficial to deep veins, But prevent passage of blood from
deep veins (high blood pressure) to superficial veins (low
blood pressure)…. Venous pump
Great Saphenous Vein
 In the foot : It drains the medial end of dorsal
venous arch of foot.
It passes upward in front of medial malleolus.
In the leg : It ascends in company with
saphenous nerve in superficial fascia of
medial side of leg, then behind knee and curves
forward on medial side of thigh.
It pierces the cribriform fascia
of saphenous opening in the deep fascia of
thigh to join femoral vein.
It has numerous valves and is connected to
small saphenous vein by anastomotic vein
passing behind knee.
It is connected with deep veins via perforating
valved veins along medial side of calf.
Varicose Veins
 A varicose vein is a vein which becomes
dilated, elongated and tortuous.
 It affects the superficial veins of the lower
limb.
 It is produced when the valves of the
perforating veins become incompetent
(so, allow blood to pass from deep veins to
superficial veins).
 As a result, the blood passes from deep veins
(high pressure) to superficial veins (low
pressure), so the superficial veins become
dilated, elongated and tortuous.
Great Saphenous Vein
 It receives 3 tributaries at
saphenous opening in the deep fascia
of thigh :
1-superficial circumflex iliac vein.
2-superficial epigastric vein.
3-superficial external pudendal vein.
Another tributary is known as
accessory vein, usually joins the great
saphenous vein about the middle of the
thigh.
Many small veins on medial& lateral
sides of the thigh drain into great
saphenous vein, but lower part of back
of thigh drain into the small saphenous
vein in the popliteal fossa.
Small Saphenous Vein
In the foot : it arises from lateral part of
dorsal venous arch.
It ascends behind lateral malleolus,
in company with sural nerve.
It ascends over back of leg in the
superficial fascia, then pierces deep
fascia to pass between 2 heads of
gastrocnemius to end in popliteal vein.
It has numerous valves along its
course.
Tributaries :
1-Numerous small veins from back of leg.
2-Communicating veins with deep veins
of foot.
3-Anastomotic branches that run upward
& medially to join great saphenouds vein.
Dorsal venous arch
It lies in superficial fascia of dorsum of
foot , over heads of metatarsal bones.
It drains medially into the great
saphenous vein, which ascends in front of
medial malleolus into medial side of leg.
It drains laterally into the small
saphenous vein, which ascends behind
lateral malleolus into back of leg.
It receives blood from the foot via digital
& communicating veins, which pass
through the interosseous spaces.
Popliteal Vein
It begins at lower border of popliteus
muscle by union of venae comitantes of
anterior & posterior tibial arteries.
It passes upwards in the popliteal fossa.
It passes medial to popliteal artery at its
lower part, then behind at its middle part,
and lateral to the artery at its upper part.
It ends by passing through opening in
adductor magnus to become the femoral
vein.
Tributaries :
1-Small saphenous vein, which perforates
deep fascia to pass between 2 heads of
gastrocnemius to end in popliteal vein.
2-Veins that correspond to branches of
popliteal artery (5 genicular branches to
knee joint + muscular branches)
Femoral Vein
It enters the thigh by passing opening
in adductor magnus as a continuation of
popliteal vein.
It ascends in the thigh, lying at first on
lateral side of the artery,then posterior
,and finally on its medial side.
It leaves thigh in the intermediate
compartment of femoral sheath to
becom external iliac vein.
Tributaries :
1-great saphenous vein.
2-veins that correspond to branches of
artery :
-Profunda femoris vein.
-Lateral & medial cicumflex femoral
veins.
-Deep external pudendal vein.
-Muscular veins.
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
+ external genitalia (except lymph
drainage of testes ends in lumbar
(para-aortic) L.Ns. at level of L1 vertebra
+ lower ½ of anal canal.
-The lateral members of this group
receive afferent superficial lymph
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 horizontal group
of inguinal L.Ns.).
Efferent lymph vessels from vertical
& horizontal groups of superficial
inguinal L.Ns. : pass through
saphenous opening in the deep fascia to
end in deep inguinal L.Ns. (lying along
medial side of femoral vein).
Popliteal Lymph Nodes :
They are lying in popliteal fossa.
Their afferent lymph vessels from :
1-superficial lymph from skin of lateral
side of foot & leg.
2-lymph from knee joint.
3-Deep lymph vessels accompaning
anterior & posterior tibial arteries.
Their efferent lymph vessels pass
into : deep inguinal lymph nodes
(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.
The Propulsive action of
Foot :
 During running :
1-the weight is born on the forepart of foot,
and the heel does not touch the ground.
2-the forward thrust to the body is provided by
mechanisms described for walking.
The Propulsive action of
Foot :
 During Standing immobile : the body
weight is distributed via :
1-the heel… behind. and
2-the heads of metatarsal bones… in front
(including 2 sesamoid bones under head of
1st metatarsal)
The Propulsive action of
Foot :
 During Walking :
1-the body is thrown forward by the action of
gastrocnemius & soleus (plantarflexion of ankle joint), so the
heel rises from ground, and the body weight is born on the
lateral margin of foot + heads of metatarsal bones.
2-as the heel rises, the toes are extended at metatarsophalangeal joints, and plantar aponeurosis is streched
leading to increasing arches of foot.
3-the toes are strongly flexed at inter-phalangeal joints
by long & short flexors of foot.
4-lumbricals & interossei contract to keep toes extended
at interphalangeal joints, so that they do not flexing during
strong action of flexor digitorum longus.
Great Saphenous Vein Cut Down
A & B at the ankle.
Great saphenous vein is constantly
found in front of medial malleolus of tibia.
C & D at the groin.
Great saphenous vein drains into
femoral vein 2 fingerbreadths below &
lateral to pubic tubercle.
Exposure of the vein through a skin
incision (a ‘cut down’) is usually
performed at ankle, but this site has
disadvantages of phlebitis (inflammation
of the vein wall) as a complication.
In the groin, phlebitis is rare because
the larger diameter of the vein at this site
allows the use of large-diameter
catheters and rapid infusion of large
volumes of fluids.
Great Saphenous Vein in
Coronary Bypass surgery
 In occlusive coronary disease, the diseased
arterial segment can be bypassed by inserting a
graft from great saphenous vein.
 At the donor sit, the superficial venous blood
ascends the lower limb against gravity by
passing through perforating veins into the deep
veins.
 Great saphenous vein can also be used to
bypass obstructions of brachial or femoral
arteries.
Femoral Vein Catheterization
The femoral vein lies medial to femoral
artery just about 2 fingerbreadths below
inguinal ligament and is easily
cannulated.
Because of high incidence of
thrombosis and fatal pulmonary
embolism, the catheter should be
removed once the patient is stabilized.