Post on 01-Feb-2016
description
Lower LimbsLower Limbs
Lu XiaoliLu Xiaoli
Regional Anatomy & Operative SurgeryRegional Anatomy & Operative Surgery
China Medical UniversityChina Medical University
32 Bones 32 Bones Hip Bone (1) Hip Bone (1) Femur (1) Femur (1) Patella (1) Patella (1) Tibia (1) Tibia (1) Fibula (1) Fibula (1) Tarsals (8) Tarsals (8) Metatarsals (5) Metatarsals (5) Proximal Phalanges (5) Proximal Phalanges (5) Intermediate PhalangeIntermediate Phalange
s (5) s (5) Distal Phalanges (4) Distal Phalanges (4)
HipHip
Femoral Femoral Bone Bone
Patella Patella
Tib
ia &
Fibu
la
Tib
ia &
Fibu
la
Proximal End of Left Tibia Proximal End of Left Tibia
Gluteal RegionGluteal Region
Iliac Crest Iliac Crest
Gluteal Crease Gluteal Crease
Superficial Layers Superficial Layers SkinSkinSuperficial FasciaSuperficial Fascia
Deep LayersDeep LayersDeep FasciaDeep FasciaMusclesMusclesSuprapiriform & Infrapiriform ForamenSuprapiriform & Infrapiriform ForamenLesser Sciatic ForamenLesser Sciatic Foramen
HipHip Joint Joint
Superficial FasciaSuperficial Fascia
the middle part is thinnestthe middle part is thinnestContains Superficial blood vessels, Contains Superficial blood vessels,
lymphatic vessels and cutaneous lymphatic vessels and cutaneous nervesnerves
Bedsore (Decubitus Ulcer)Bedsore (Decubitus Ulcer)
Arteries Arteries
Superficial branches ofSuperficial branches of 44thth lumbar artery lumbar arteryInferior gluteal arteryInferior gluteal arteryLateral sacral arteryLateral sacral arterySuperior gluteal arterySuperior gluteal arteryInferior gluteal arteryInferior gluteal artery
Cutaneous NervesCutaneous Nerves
branches of the subcostabranches of the subcostal nerve (T12) l nerve (T12)
dorsal rami of lumbar nedorsal rami of lumbar nerves rves
dorsal rami of sacral nervdorsal rami of sacral nerves es
inferior cluneal nerves inferior cluneal nerves posterior femoral cutaneposterior femoral cutane
ous nerveous nerve
Deep Fascia Deep Fascia
Attach to iliac crest superiorlyAttach to iliac crest superiorly Invest gluteus maximusInvest gluteus maximus Attach to Sacral bone and coccyx Attach to Sacral bone and coccyx
mediallymedially Continuous with fascia lata laterally Continuous with fascia lata laterally
Muscles Muscles
SuperficialSuperficial
MiddleMiddle
DeepDeep
Gluteus MaximusGluteus MaximusTensor Fasciae LataeTensor Fasciae Latae
Glluteus MediusGlluteus MediusPiriformisPiriformis
Superior Gemellus Superior Gemellus Obturator Internus Obturator Internus Inferior Gemellus Inferior Gemellus
Quadratus FemorisQuadratus Femoris
Gluteus MinimusGluteus MinimusObturator ExternusObturator Externus
Gluteus MaxinusGluteus Maxinus Tensor Fasciae LaTensor Fasciae La
taetae
Glluteus MediusGlluteus MediusPiriformisPiriformisSuperior Gemellus Superior Gemellus Obturator Internus Obturator Internus Inferior Gemellus Inferior Gemellus Quadratus FemorisQuadratus Femoris
Gluteus MinimusGluteus Minimus Obturator ExternuObturator Externu
ss
Suprapiriform ForamenSuprapiriform Foramen
Infrapiriform ForamenInfrapiriform Foramen
Sciatic n.Sciatic n. Tibial n.Tibial n. Common Fibular n.Common Fibular n.
66.3% 27.3%
6.4%
Tibial n. Common Fibular n.
Piriformis Piriformis SyndromeSyndrome
Pain radiates Pain radiates down the back down the back of the leg of the leg
Ischial Ischial tuberosittuberosityy
Iliac crestIliac crest
Lesser Sciatic ForamenLesser Sciatic Foramen BoundariesBoundaries
front: tuberosity of ischium front: tuberosity of ischium above: spine of ischium & sacrospinous lig.above: spine of ischium & sacrospinous lig.behind: sacrotuberous lig. behind: sacrotuberous lig.
ContentsContentstendon of Obturator internustendon of Obturator internus internal pudendal a.internal pudendal a. internal pudendal v. internal pudendal v. pudendal n.pudendal n.
HipHip
AnteriorAnterior
Posterior Posterior
It is based on this capsular attachment tIt is based on this capsular attachment that fractures of the neck of femur are clahat fractures of the neck of femur are classified as:ssified as: INTRACAPSULAR: within the capsular attachINTRACAPSULAR: within the capsular attach
ment. ment. EXTRACAPSULAR: outside the attachment oEXTRACAPSULAR: outside the attachment o
f the capsule f the capsule MixedMixed
IntracapsulaIntracapsular r
Lig. of head Lig. of head of femurof femur
Transverse Transverse acetabular acetabular lig.lig.
ExtracapsularExtracapsular(Anterior)(Anterior)
Iliofemoral lig.Iliofemoral lig.Pubofemoral Pubofemoral
lig.lig.
ExtracapsularExtracapsular(posterior)(posterior)
IschiofemoraIschiofemoral lig.l lig.
Zona Zona orbicularisorbicularis
Superior gluteal a.Superior gluteal a. Inferior gluteal a.Inferior gluteal a.Lateral circumflex femoral a.Lateral circumflex femoral a.Medial Circumflex femoral a.Medial Circumflex femoral a.Branches of Obturator a.Branches of Obturator a.11stst perforating branches of deep perforating branches of deep
femoral a.femoral a.Femoral nutrient a.Femoral nutrient a.
Blood SupplyBlood Supply
Superior gluteal Superior gluteal a.a.
Inferior gluteal Inferior gluteal a.a.
11stst perforating perforating branches of branches of deep femoral a.deep femoral a.
Medial Circumflex Medial Circumflex femoral a. femoral a.
Lateral circumflex Lateral circumflex femoral a.femoral a.
Superior retinacular a. Superior retinacular a. Anterior retinacular a.Anterior retinacular a. Inferior retinacular a.Inferior retinacular a.
Branches of Branches of Obturator Obturator
a.a.
Femoral Femoral nutrient a.nutrient a.
If the head of the femur is dislocated If the head of the femur is dislocated postero-medially, compression of which postero-medially, compression of which nerve is likely to result? nerve is likely to result?
A.A. FemoralFemoralB.B. Lumbosacral trunkLumbosacral trunkC.C. ObturatorObturatorD.D. SciaticSciaticE.E. Superior gluteal Superior gluteal
What muscle passes through the lesseWhat muscle passes through the lesser sciatic foramen? r sciatic foramen?
A.A. Gluteus minimusGluteus minimusB.B. Obturator internusObturator internusC.C. PiriformisPiriformisD.D. Quadratus femorisQuadratus femorisE.E. Superior gemellus Superior gemellus
In order to avoid injury to the In order to avoid injury to the sciatic nerve, intramuscular injections sciatic nerve, intramuscular injections should be given in which quadrant of should be given in which quadrant of the buttock? the buttock?
A.A. upper medialupper medial
B.B. upper lateralupper lateral
C.C. lower mediallower medial
D.D. lower laterallower lateral
E.E. middle middle
Of the branches of the internal iliac arOf the branches of the internal iliac artery, the one exiting from the greater sciattery, the one exiting from the greater sciatic foramen superior to the piriformis muscic foramen superior to the piriformis muscle is the: le is the:
A.A. Iliolumbar arteryIliolumbar arteryB.B. Internal pudendal arteryInternal pudendal arteryC.C. Lateral sacral arteryLateral sacral arteryD.D. Superior gluteal artery Superior gluteal artery
Thigh Thigh
Anterior compartment Anterior compartment Posterior Posterior
compartmentcompartment
Superficial iliac circumflex a.Superficial iliac circumflex a.Superficial epigastric a.Superficial epigastric a.External pudendal a.External pudendal a.Superficial lateral femoral a.Superficial lateral femoral a.Superficial medial femoral a.Superficial medial femoral a.
Groin Flap Groin Flap
Great Saphenous V.Great Saphenous V.
70 70 ~~ 80 cm 80 cm
femoral v.femoral v.fossa ovalisfossa ovalis
medial side of thigh medial side of thigh medial condyles of tibia & femurmedial condyles of tibia & femur
medial side of leg medial side of leg medial malleolusmedial malleolus
dorsal venous arch of footdorsal venous arch of foot
Tributaries
Superficial iliac circumflSuperficial iliac circumflex v.ex v.
Superficial epigastric v.Superficial epigastric v. External pudendal v. External pudendal v. Superficial lateral femorSuperficial lateral femor
al v.al v. Superficial medial femorSuperficial medial femor
al v.al v.
in emergency, great saphenous veiin emergency, great saphenous vein may be opened surgically for intrn may be opened surgically for intravenous drip for the patients sufferavenous drip for the patients suffering from insufficiency of body fluid.ing from insufficiency of body fluid.
great saphenous vein as venous gragreat saphenous vein as venous graft can be used in the coronary bypaft can be used in the coronary bypass surgery for coronary heart diseasss surgery for coronary heart disease. e.
one-way valves one-way valves become weak & don't close properlybecome weak & don't close properly
Superficial inguinal Superficial inguinal LNLN
Horizontal groupsHorizontal groupsVertical groupsVertical groups
Fascia LataFascia Lata
Iliotibial tractIliotibial tract Saphenous hiatus (fossa ovalisSaphenous hiatus (fossa ovalis
) ) fascia cribrosafascia cribrosa Falciform marginFalciform margin
Lacuna musculorum & vasorumLacuna musculorum & vasorum
between inguinal lig. and hip bone, anbetween inguinal lig. and hip bone, and separated by iliopectineal archd separated by iliopectineal arch lateral: lacuna musculorum lateral: lacuna musculorum medial: lacuna vasorum medial: lacuna vasorum
Lacuna musculorumLacuna musculorum Boundaries:Boundaries:
ant.ant. :: inguinal lig.inguinal lig.post.post. :: iliumiliummed.med. :: iliopectineal archiliopectineal arch
Contents:Contents: iliopsoasiliopsoas lat. femoral cutaneous n. lat. femoral cutaneous n. femoral n.femoral n.
Lacuna vasorumLacuna vasorum Boundaries: Boundaries:
ant.ant. :: inguinal lig.inguinal lig.post.post. :: pectineal lig.pectineal lig.med.med. :: lacunar lig.lacunar lig. lat.lat. : : iliopectineal archiliopectineal arch
Contents:Contents: femoral sheathfemoral sheath femoral a., v.femoral a., v. femoral canalfemoral canal femoral br. of genitofemoral n.femoral br. of genitofemoral n.
Femoral Femoral sheathsheath
Femoral canalFemoral canal
1-1.5 cm1-1.5 cm Boundaries:Boundaries:
Ant. : inguinal lig. superior corner of falciforAnt. : inguinal lig. superior corner of falciform margin and femoral septumm margin and femoral septum
Post. : pectineal lig., pectineusPost. : pectineal lig., pectineusLat. : fibrous septum of femoral v.Lat. : fibrous septum of femoral v.
femoral ringfemoral ring
A 63-year-old female patient says that A 63-year-old female patient says that she has pain in her groin and upper thigh. she has pain in her groin and upper thigh. Upon examination, you palpate a lump locUpon examination, you palpate a lump located below the inguinal ligament lateral tated below the inguinal ligament lateral to its attachment to the pubic tubercle. Yoo its attachment to the pubic tubercle. You suspect that this may be a hernia passinu suspect that this may be a hernia passing through the:g through the:
A.A. femoral canalfemoral canalB.B. adductor hiatusadductor hiatusC.C. obturator canalobturator canalD.D. deep inguinal ringdeep inguinal ringE.E. superficial inguinal ringsuperficial inguinal ring
The femoral canal contains the: The femoral canal contains the: A.A. Deep inguinal lymph node(s)Deep inguinal lymph node(s)B.B. Femoral arteryFemoral arteryC.C. Femoral nerveFemoral nerveD.D. Femoral veinFemoral veinE.E. Ilioinguinal nerveIlioinguinal nerve
The pulse of the femoral artery is best The pulse of the femoral artery is best felt at which superficial reference point? felt at which superficial reference point?
A.A. Anterior to the ankle joint Anterior to the ankle joint B.B. Femoral triangleFemoral triangleC.C. Mid-thighMid-thighD.D. Popliteal fossaPopliteal fossaE.E. Right lateral portion of the hypogastriRight lateral portion of the hypogastri
um um
At which site could one expect to enteAt which site could one expect to enter the femoral vein with a simple percutaner the femoral vein with a simple percutaneous (through the skin) introduction of an ious (through the skin) introduction of an instrument? nstrument?
A.A. Above the middle of the inguinal ligaAbove the middle of the inguinal ligament ment
B.B. Lateral to the femoral arterial pulseLateral to the femoral arterial pulseC.C. Lateral to the pubic tubercleLateral to the pubic tubercleD.D. Medial to the femoral arterial pulseMedial to the femoral arterial pulseE.E. Medial to the pubic tubercle Medial to the pubic tubercle
A serious complication of fractures of tA serious complication of fractures of the femoral neck is avascular necrosis of thhe femoral neck is avascular necrosis of the femoral head. This usually results from rue femoral head. This usually results from rupture of which artery? pture of which artery?
A.A. Acetabular branch of obturatorAcetabular branch of obturatorB.B. Deep circumflex iliacDeep circumflex iliacC.C. Descending branch of lateral circumfleDescending branch of lateral circumfle
x femoralx femoralD.D. Medial circumflex femoralMedial circumflex femoralE.E. Second perforating branch of lateral ciSecond perforating branch of lateral ci
rcumflex rcumflex
A ruptured aneurysm in the most proxA ruptured aneurysm in the most proximal portion of the deep femoral artery wimal portion of the deep femoral artery would result in a hematoma located initially ould result in a hematoma located initially in the: in the:
A.A. Adductor canal.Adductor canal.B.B. Femoral canal.Femoral canal.C.C. Femoral triangle.Femoral triangle.D.D. Inguinal canal.Inguinal canal.E.E. Popliteal fossa. Popliteal fossa.
Childhood immunizations are sometiChildhood immunizations are sometimes given via intramuscular injections intmes given via intramuscular injections into the quadriceps muscles of the anterior to the quadriceps muscles of the anterior thigh. At the mid-thigh level, a needle passhigh. At the mid-thigh level, a needle passing into the space deep to the sartorius ming into the space deep to the sartorius muscle might pierce the femoral vessels as uscle might pierce the femoral vessels as they lie in the: they lie in the:
A.A. Adductor canalAdductor canalB.B. Adductor hiatusAdductor hiatusC.C. Adductor triangleAdductor triangleD.D. Femoral canalFemoral canalE.E. Femoral ringFemoral ring
Which of the following is NOT located Which of the following is NOT located within the adductor canal? within the adductor canal?
A.A. Saphenous nerveSaphenous nerveB.B. Femoral arteryFemoral arteryC.C. Nerve to vastus medialisNerve to vastus medialisD.D. Femoral veinFemoral veinE.E. Deep femoral arteryDeep femoral artery