THE REGIONS OF THE INFERIOR LIMB

1. THE UNDER-INGUINAL REGION(REGIO SUB-INGUINALIS)

The region is situated on the anterior aspect of the the root of the inferior limb. Under the skin the superficial muscles are delineating a “N” shape (lateral musculus tensor fascia lata, medial musculus adductor longus and in between them in diagonal musculus sartorius; the last two muscles plus upwards the inguinal ligament are delimiting the “femoral triangle of Scarpa” in wich we found the femoral vessels).

1. The borders of the region are:- superior: the inguinal ligament (ligamentum inguinalis “Poupart”)- inferior: a horizontal line wich represents the anterior continuation of plica

fesiera- lateral: a vertical line in between spina iliaca antero-superior and trochanter

major- medial: a vertical line from spina ossis pubis to the inferior border- profound: until the articulation of the hip

2. The covering plane- the skin – thin and mobile (exception at the level of inguinal ligament

where it is not mobile) and with hair on the medial side of the region- the subcutaneous layer has a variable depth and contains:

- superficial arterial branches (a. epigastrica superficialis, a. circumflexa ilium superficialis and aa. pudendae externaes) from a. femoralis

- vena saphena magna (interna) wich makes here a “U” torn (crosa venae safena) going to the profound part of the region for draining in vena femoralis; the crosa collects at this level the satellite veins of the superficial arteries

- cutaneous nervous branches:- n. cutaneus femoris lateralis (for the lateral side of the region)- n. femoralis (for the middle part)- ramus femoralis from n. genito-femoralis (for the medial part)

- nodi limphatici inguinales superficiales arranged in the horizontal group (parallel with ligamentum inguinalis – they drain the limpha from infraumbilical abdominal wall, the hip and perineum) and the vertical group (along crosa vena saphena – they drain the lympha from the superficial part of the inferior limb)

- the fascia lata comes from the lateral side of the tigh and makes a sheat for m. tensor fasciae lata and for m. sartorius, then is passing to medial side

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above the femoral triangle (in the central part of the femoral triangle the fascia lata presents a hole named hiatus saphenus or fossa ovalis with its lateral margin being thicker and named ligamentum falciformis wich ends superiorly and inferiorly with cornu superius and cornu inferius; the hiatus safenus in covered by fascia cribrosa named like this because is perforated by vena saphena, the superficial arteries and their satellite veins)

3. The under-fascial layer containsa. the muscles disposed in two layers:

- the superficial layer (from lateral to medial):- m. tensor fascia lata- m. sartorius- m. adductor longus (the last two muscles plus ligamentum inguinalis delimits trigonum femoralis of Scarpa)

- the profound layer (from lateral to medial) - in the lateral side: - m. vastus lateralis- m. rectus femoris- m. ilio-psoas- m. pectineus (in the medial side = femoral triangle; in between these last two muscles there is a depression called fossa ileo-pectinea covered by fascia ileo-pectinea; the muscles plus the fascia togheter delimit the ileo-pectineum space)

b. the osteo-fibrotic spaces (= lacunas) from the root of the inferior limb wich are passages for the muscles, vessels and nerves; the ligamentum inguinalis “Poupart” extends in between spina iliaca antero-superior and tuberculum pubicum, so in between this ligament and the anterior part of the coxal bone there will be an ovalar oste-fibrotic space wich is divided in two smaller ones (= lacunas) by arcus ileo-pectineus (a ligament wich extends in between the middle part of ligamentum ingiunalis and eminentia ileo-pubica):

- lacuna musculorum (the lateral muscular space) is bordered by the lateral half of ligamentum inguinalis, arcus ileo-pectineus and the anterior part of os coxae; it contains:

- musculus ilieo-psoas- nervus femoralis – situated on the medial side of the lacuna, it

will spred here in motor and sensitive anterior branches; it will be continued by n. saphenus

- nervus cutaneus femoris lateralis - in between spina iliaca anterior-superior and spina iliaca anterior-inferior

- lacuna vasculorum (the medial vascular space) is bordered by the medial half of ligamentum inguinalis (at the pubian end of it with ligamentum lacunare “Gimbernat”), arcus ileo-pectineus and the anterior part of os coxae (with ligamentum pectineale “Cooper”); it contains:

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- arteria femoralis - (wich continues arteria iliaca externa from the inguinal ligament) is situated on the lateral side of the lacuna and goes downwards to the tip of the femoral triangle; at this level it gives superficial branches (mentioned before) and profound branches (a. femoralis profunda, a. circumflexa femoris lateralis and a. circumflexa femoris medialis – these branches will anastomose with those from a iliaca interna giving the pericoxal anastomotic circle)

- vena femoralis - situated medially to the artery; receives here vena saphena magna (4 cm under the inguinal ligament) and the satellite veins of the profound arterial branches

- ramus femoralis of nervus genito-femoralis - situated on the anterior aspect of arteria femoralis

- nodi limphatici inguinales profundi - 2 or 3, situated medially to the femoral vein; the biggest one of them being named the “Cloquet-Rosenmuller” nodulus; they collect the limpha from nodi superficiales and from the profound network and will drain it to nodi iliaci

c. canalis femoralis is a space situated medially to vena femoralis and represents a weak part of the abdominal wall (here we have the femoral hernias); it has 3 –4 cm length, has vertical disposition and contains adipous tissue and the profound lymphatic inguinal nodes; it is bordered by:

- anterior: fascia cribrosa- lateral: vena femoralis- medial (and posterior): musculus pectineus and his fascia- the superficial opening: hiatus saphenus plus fascia cribrosa- the profound opening (named annulus femoralis): represents the weak

point being situated in between vena femoralis and ligamentum lacunare Gimbernat; it is oriented to the abdominal cavity from wich is separated only by septum femoralis (part of fascia transversalis).

2. THE ANTERIOR REGION OF THE THIGH (REGIO FEMORALIS ANTERIOR)

The region is situated on the anterior aspect of the inferior limb, in between the hip and the knee.

1. The borders of the region are:- superior: a horizontal line wich represents the anterior continuation of plica

fesiera- inferior: a horizontal line 4 cm above the base of the patella

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- lateral: a vertical line in between trochanter major and epicondylus lateralis of the femor bone

- medial: a vertical line in between tuberculum pubicum and epicondylus medialis of the femor bone

2. The covering plane:- the skin – thick, mobile and with hair on the medial side of the region- the subcutaneous layer has a variable depth and contains:

- superficial arterial network- superficial venous network- vena saphena magna (interna) wich goes up on the medial side of the region collecting at this level:

- vv. saphenae accessories (from the posterior region of the thigh)- vena femuro-poplitea “Giacomini” (wich connects crosa of vena

saphena parva with vena saphena magna)- cutaneous nervous branches:

- n. cutaneus femoris lateralis (for the lateral side of the region)- n. femoralis (for the middle part)- ramus cutaneus from n. obturatorius (for the medial part)

- superficial lymphatic network- the fascia lata (the fascia of the thigh), thick ans resistant; makes a sheat

for m. tensor fasciae lata and for m. sartorius; on the lateral side is even dense giving tractus ilio-tibialis “Maissiat”; also sends profoundly two septums intermuscularis: lateralis (thicker and complete) and medialis (thinner and incomplete) wich are inserted labium laterale and mediale of linea aspera; these septums are going to split the muscles of the thigh in two groups: the extensors (anterior) and the flexors (posterior); the adductor muscles group is situated posterior to septum intermuscularis medialis. The fascia, these two septums and the femoris bone delimit an anterior and posterior osteo-fibrotic compartments wich contain the subfascial anatomical structures of the region.

3. The under-fascial layer contains:a. the muscles disposed in two layers:

- the anterior group with- superficial layer: m. tensor fascia lata, m. sartorius- the profound layer: m. quadriceps femoris

- medial group with- superficial layer: m. gracilis, m. adductor longus- middle layer: m. adductor brevis- profound group: m. adductor magnus

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b. canalis adductorius “Hunter” is a space through wich the anterior femoral region communicates with the posterior region of the knee; it has 7–10 cm length, has vertical-oblique disposition (oriented downwards and medially) and it is situated under the middle third of m. sartorius; it is bordered by:

- anterior: membrana vasto-adductoria covered by m. sartorius- lateral: musculus vastus medialis- medial (and posterior): musculus adductor magnus- the superior opening: is situated on the tip of trigonum femoralis

“Scarpa” (the inferior part of fossa ileo-pectinea)- the inferior opening (named hiatus tendineus): delimited by the tendon of

m. adductor magnus and the femoris bone

The content of the chanell is represented by the femoral vasculo-nervous package (wich has a common membranous sheat):

- arteria femoralis superficialis - goes downwards in the axis of the chanell; gives here a branch: a. descendens genus wich perforates membrana vasto-adductoria and goes to the anterior side of the knee

- vena femoralis superficialis - goes upwards in the chanell by making a spiral around the artery: inferior is situated laterally, than it is placed posterior and superiorly is situated on the medial side of the artery

- nervus saphenus - continues nervus femoralis being situated on the anterior aspect of the artery; it will perforate membrana vasto-adductoria and goes under m. sartorius to the medial side of the knee

- the profound lymphatic network - drained in nodi lymphatici inguinales profundi

3. THE ANTERIOR REGION OF THE KNEE(REGIO GENUS ANTERIOR)

The region is situated on the anterior surface ot the knee (genus). Phisiologically the long axis of the shank (gamba) it is not in the continuation of the long axis of the thigh, in between them existing an angle open to lateral (170 degrees), situation called “genu valgum fisiologicus”.

1. The borders of the region:- superior: a transversal line 3 cm above the base of the patella- inferior: a transversal line through the tuberositas tibiae- medial and lateral: a vertical line through the corresponding epicondyls- profound: until the articulation of the knee

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2. The covering plane:- the skin is thin and mobile, without hair- the subcutaneous layer contains:

- superificial arterial network - superificial venous network- vena saphena magna - situated on the medial side of the region,

posterior to condylus medialis of the femor and tibia- cutaneous nervous branches - superiorly:

- n. cutaneus femoris lateralis (for the lateral side of the region)

- n. femoralis (for the middle part)- ramus cutaneus from n. obturatorius (for the medial part)

- cutaneous nervous branches - inferiorly: - n. cutaneus surae lateralis (for the lateral side of the

region)- n. saphenus (for the medial part)

- bursa subcutanea prepatellaris- bursa subcutanea tuberositas tibiae- superficial lymphatic vessels are being drained into the nodi

lymfatici inguinales superficiales- the fascia of the genus continues fascia lata being very adherent to the

surfaces of the bones situated under the skin (patella, tuberositas tibiae, the condyls of the femor and tibia, caput fibulae); on its lateral side the fibers of tractus ilio-tibialis are inserted on the tuberculum “Gerdy” from condylus lateralis tibiae.

3. The under-fascial layer contains:a. the muscles: m. quadriceps femoris made by four parts:

- m. rectus femoris (superficially in the middle)- m. vastus intermedius (profoundly in the middle)- m. vastus lateralis (on the lateral side)- m. vastus medialis (on the medial side)The common tendon of m. quadriceps femoris is inserted on the basis

patellae (superficially the tendon of m. rectus femoris, profoundly the tendon of m. vastus intermedius and in the middle the tendons of m. vastus lateralis and medialis); then continues as ligamentum patellaris wich will be inserted on tuberositas tibiae.

Also the common tendon of m. quadriceps femoris sends two fibrous juxtapatellar expansions (retinaculum patellae lateralis and medialis) wich will be inserted on the corresponding condyls of the tibia

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b. pes anserinus (=goose leg) is a fibrotic structure wich represents the common insertion on the medial condyl of tibia of the tendons of:

- m. sartorius (superficially)- m. gracilis (in the middle)- m. semitendinosus (profoundly)

c. bursas of the patella:- bursa suprapatellaris (in between the tendon of musculus quadriceps femoris and os femoris)- bursa subfascialis prepatellaris (in between fascia genus and tendon of musculus quadriceps femoris)- bursa subtendinea prepatellaris (in between the tendon of musculus quadriceps femoris and basis patellae)- bursa infrapatellaris profunda (in between ligamentum patellaris and tuberositas tibiae- bursa anserina (in between pes anserinus ans condylus medialis tibiae)

d. rete articulare genus represents the arterial network of the knee and it is siuated profoundly on capsula articularis, being made by:

- a. genicularis supero-lateralis and supero-medialis (anastomotic circle around the femoral condyls)- a. genicularis infero-lateralis and infero-medialis (anastomotic circle around the tibial condyls)- a. descendens genus- a. recurrens tibialis anterior and posterior

4. THE ANTERIOR REGION OF THE SHANK (REGIO CRURALIS ANTERIOR)

The region is situated on the anterior aspect of the inferior limb, in between the knee and the foot wrist.

1. The borders of the region are:- superior: a horizontal line through tuberositas tibiae- inferior: a horizontal line through the baisis of the malleolas- lateral and medial: a vertical line in between the femoral epicondyls and the

corresponding malleola

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2. The covering plane:- the skin - thick, adherent to facies medialis tibiae and mobile on the lateral

side of the region; with hair- the subcutaneous layer is thin and contains:

- superficial arterial network- superficial venous network- vena saphena magna (interna) wich goes up on the medial side of

the region at the border with the posterior region of the shank- vv. perforans - veins wich are connecting trans-fascially the

superficial venous system with the profound one- vv. communicantes - veins wich are connecting epi-fascially the main

components of the superficial venous system - cutaneous nervous branches:

- n. cutaneus surae lateralis (for the lateral side of the region), - n. saphenus (for the medial side)

- superficial lymphatic network- the fascia cruralis (the fascia of the shank), thick ans resistant, in the

superior part of the region being adherent to facies medialis tibiae and to the muscles; also sends profoundly two septums intermuscularis cruris: anterius and posterius wich are inserted to the corresponding margins of the fibula; these two septums are going to split the muscles of the shank in two groups: the extensors (anterior) and the fibular (lateral). The fascia, these two septums, the membrana interossea and the bones of the shank delimit two osteo-fibrotic compartments wich contain the subfascial anatomical structures of the region.

3. The under-fascial layer contains:a. the anterior (extensor) compartment is delimited by the osteo-membranous plane, the margo lateralis tibiae and septum intermuscularis cruris anterius; it contains:

- the muscles:- lateral: m. extensor digitorum longum, m. fibular is tertius- middle: m. extensor hallucis longus- medial: m. tibialis anterior

- the tibial anterior vasculo-nervous package:- a. tibialis anterior - comes into the region by passing the orifice in between the superior extremities of the tibia and fibula and the superior margin of membrane interossea- vv. tibiales anteriores (satellite)- n. fibularus profundus (comes into the region by perforating septum intermuscularis cruris anterius; superiorly situated on the lateral side of the artery and inferiorly on the medial side)- profound lymphatic network

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b. the lateral (fibular, peroneal) compartment is delimited by the facies lateralis fibulae and septum intermuscularis cruris anterius and posterius; it contains:

- the muscles- superficial: m. fibularis longus- profound: m. fibularis brevis

- n. fibularis communis - on the lateral side of the collum fibulae, covered here by the origin of m. fibularis longus it will divide in:

- n. fibularis superficialis - goes downwards in between the muscles of the compartment

- n. fibularis profundus - perforates septum intermuscularis cruris anterius and goes into the anterior compartment

5. THE ANTERIOR MALLEOLAR REGION(REGIO MALLEOLARIS ANTERIOR)

The region is situated on the anterior aspect of the inferior limb and connects the shank with the foot.

1. The borders of the region are:- superior: a horizontal line through the basis of the malleolas- inferior: a oblique plane oriented backwards to the tip of the malleolas and

situated 2 cm lower than the articulation line in between the tibia and the talus

- lateral and medial: a vertical line tangent to the corresponding malleolas

2. The covering plane:- the skin – thin and mobile; without hair- the subcutaneous layer is thin and contains:

- superficial arterial network- superficial venous network- vena saphena magna (interna) - situated anterior to malleola medialis- cutaneous nervous branches:

- n. cutaneus surae lateralis (for the lateral side of the region)- n. fibularis superficialis (for the middle part)- n. saphenus (for the medial side)

- superficial lymphatic network- the fascia of the region presents two thicker and more resistant zones called

retinacles of extensors:- retinaculum extensorum superius - situated above the articulation in between the inferior extremities of the tibia and fibula

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- retinaculum extensorum inferius - situated under the articulation and having a horinzontalised “Y” shape: the common branch (leaves from the lateral surface of the calcaneum), the superior branch (reaches the malleola medialis) and the inferior branch (reaches the medial side of the foot and goes to the fascia of the sole); it presents superficial and profound fibres wich delimit three fibrotic chanells for the tendons of the extensor muscles

3. The under-fascial layer contains:a. the tendons of the extensor muscles - each of them having their own sinovial sheat (wich starts above retinaculum superius and ends at the tarso-metatarsal articulation line); they are situated in the same plane in the tunnels of the retinaculum extensorius inferius and they have the following disposition:

- lateral: tendo m. extensor digitorum longus- middle: tendo m. extensor hallucis longus- medial: tendo m. tibialis anterior

b. the under-tendinous layer - adipous tissue wich contains:- a. tibialis anterior – situated in between tendo m. extensor digitorum longus (lateral) and tendo m. extensor hallucis longus (medial); gives here a. malleolaris lateralis and a. malleolaris medialis- vv. tibiales anteriores (satellite)- n. fibularus profundus - situated on the medial side of the artery- profound lymphatic network

6.THE DORSAL REGION OF THE FOOTREGIO DORSALIS PEDIS

The dorsal region of the foot has a convex shape being possible at this level the palpation of several bony repers (on the lateral side tuberculum ossis metatarsi V; on the medial side tuberculum ossis metatarsi I and tuberculum ossis navicularis).

1. The BORDERS OF THE REGION are:- superior: a oblique plane oriented backwards to the tip of the malleolas and

situated 2 cm lower than the articulation line in between the tibia and the talus

- inferior: the comissura digitalis- lateral and medial: the lateral and medial margins of the foot

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2. The COVERING PLANE:- the skin - thin and mobile; without hair- the subcutaneous layer is thin and contains:

- superficial arterial network- superficial venous network – visible through the skin; also here arcus venosus dorsalis pedis wich will be continued by vena marginalis lateralis (wich will give vena saphena parva) and vena marginalis medialis (wich will give vena saphena magna)- cutaneous nervous branches:

- n. cutaneus dorsalis lateralis (from n. suralis - for the lateral side of the region)- n. cutaneus dorsalis intermedius (from n. fibularis superficialis - for the middle-lateral part)- n. cutaneus dorsalis medialis (from n. fibularis superficialis - for the middle-medial part)- n. saphenus (for the medial side)

- superficial lymphatic network- the fascia of the region derives from retinaculum extensorum inferius and

it is continued on the margins of the fascia of the sole

3. THE UNDER-FASCIAL LAYER CONTAINS:a. the tendons of the extensor muscles - each of them having their own sinovial sheat (wich starts above retinaculum superius and ends at the tarso-metatarsal articulation line); they have the following disposition:

- lateral: tendo m. fibularis tertius (goes to os metatarsi V) tendo m. extensor digitorum longus (it splits in four tendons for fingers II-V)

- middle: tendo m. extensor hallucis longus (goes to the base of the distal phalang of hallux)- medial: tendo m. tibialis anterior (goes to the medial margin of the foot)

b. the muscles - situated under the tendons:- lateral: m. extensor digitorum brevis (it splits in four tendons for fingers II-V)- medial: m. extensor hallucis brevis (goes to the base of the proximal phalang of hallux)

c. the dorsal vasculo-nervous package of the foot - situated profoundly under the previous layers:

- a. dorsalis pedis – continues a. tibialis anterior and goes into the direction of the first intermetatarsal space where splits in:

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- a. arcuata – makes an arch (concavity upwards) at the base of the metatarsal bones; from here will emerge 3 a. metatarsale dorsales wich will divide at the base of the fingers in a. digitales dorsales

- a. metatarsalis dorsalis hallucis- a. plantaris profunda (perforates the first intermetatarsal space

and goes to arcus plantaris profundus)- a. tarsalis lateralis- a. tarsalis medialis

- satellite veins- n. fibularus profundus - situated on the medial side of the arteria dorsalis pedis and goes to the first intermetatarsal space- profound lymphatic network

7. THE DORSAL REGION OF THE FINGERS OF THE FOOT(REGIO DORSALIS DIGITI PEDIS)

The region represents the dorsal surface of the fingers of the foot. In between the base of the fingers we identify the interdigital comissura. On the distal phalanx there is the nail (unguis) wich presents a freea margin, a body and a base with a white zone (lunula). The nail is adherent to the skin in the bed of the nail (lectulus), around the nail being a space (sinus) covered laterally and posterior by the skin (vellum laterale and posterius).

1.The BORDERS of the region are:- superior: the corresponding line of the metatarso-phalanx articulation - inferior: the tip of the finger- medial and lateral: a vertical line the lateral and medial margin of the finger- profound: until the osteo-articular plane

2. The COVERING PLANE:- the skin is mobile, whith some hair; corresponding to the articulations in

between the phalanx the fingers presents transversal plicas with redundancy of the skin (necessary for the flexion mouvements of the fingers)

- the subcutaneous layer communicates with the same layer of the foot; it contains:

-aa. digitales plantares dorsales proprii (and the satellite veins) – coming from arteriae metacarpals dorsales for each margin of each finger; they will anastomose in between them and with that ones from the anterior surface of the finger, realising like this a “peri-finger network”

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- nn. digitales plantares dorsales proprii - for each margin of the fingers originating in the following manner:

- from n. fibularis profundus for adiacent margins of the fingers I and II - from n. cutaneus dorsalis medialis for the adiacent margins of the fingers II and III plus for the medial margin of the hallux- from n. cutaneus dorsalis intermedius for the adiacent margins of the fingers III – V- from n. cutaneus dorsalis lateralis for the lateral margin of the fingers V

- the tendons of m. extensor digitorum longus (for the fingers II – V) will be inserted on the aponeurosis dorsalis of these fingers (at this aponeurosis dorsalis will take part also the mm. interosseus dorsalis)

- the tendons of m. extensor digitorum brevis (for the fingers II – V) - they go togheter with / on the tendons of the extensor longus

- the tendons of m. extensor hallucis brevis and longus are inserted on the proximal (brevis) and distal (longus) phalang

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9. THE GLUTEAL REGIONREGIO GLUTEALIS

The region is situated on the posterior aspect of the the root of the inferior limb. The external relief of the gluteal muscles are delineating the shape of the buttock (nates); in between the buttocks there is a vertical groove (sulcus inter-nates), and at the inferior border in between the buttock and the posterior region of the thigh there is a horizontal groove (sulcus glutealis).

1. The borders of the region are:- superior: crista iliaca- inferior: sulcus glutealis- lateral: a vertical line in between spina iliaca antero-superior and trochanter

major- medial: sulcus inter-nates- profound: until the articulation of the hip

2. The covering plane- the skin - thick and mobile - the subcutaneous layer has adipous tissue and contains:

- superficial arterial network- superficial venous network- cutaneous nervous branches:

- nn. clunium (gluteales) superiores (from plexus lumbalis - for the superior part)

- nn. clunium (gluteales) mediales (from plexus sacralis - for the medial part)- nn. nlunium (gluteales) inferiores (from n. cutaneus femoris

posterior - for the inferior part)- superficial lymphatic network – drained in the horizontal group of nodi

limphatici inguinales superficiales- bursa subcutanea trochanter major- bursa subcutanea tuberositas inchiadica

- the fascia glutealis is very thick and sends profoundly fibrotic septums to m. glutealis maximus

3. The under-fascial layer containsa. the muscles disposed in two layers:

- the superficial layer (from superficial to profound):- m. gluteus maximus- m. gluteus medius (superficial only in the supero-lateral part of the region)

- the profound layer (from superior to inferior):

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- m. gluteus minimus- m. piriformis- m. gemmelus superior- m. obturatorius internus (his tendon is situated in between the gemmelus muscles)- m. gemmelus inferior- m. quadratus femoris

b. the under-gluteal space is situated in between the two muscular layers, it contains adipous tissue and the profound part of fascia glutealis (wich covers the profound surface of m. gluteus maximus); also here it will be the opening of the osteo-muscular communication orifices (hiatus) in between the pelvis and region glutelis:

- hiatus suprapiriformis (belong to foramen ischiadicum majus) is bordered by the superior part of incisura ischiadica major and the superior margin of m. piriformis; it contains:

- the superior gluteal vasculo-nervous package:- a. glutealis superior (gives r. superficialis and r. profundus)- vv. gluteales superiores- n. glutealis superior (situated laterally to the artery)- profound lymphatic network

- hiatus infrapiriformis (belong to foramen ischiadicum majus) is bordered by the inferior part of incisura ischiadica major and the inferior margin of m. piriformis; it contains:

- the inferior gluteal vasculo-nervous package:- a. glutealis inferior (gives a. comitans n. ischiadici)- vv. gluteales inferiores- n. glutealis inferior (situated medially to the artery)- profound lymphatic network

- the sciatic vasculo-nervous package (situated laterally to the inferior gluteal v-n package):

- n. ichiadicus- a. comitans n. ischiadici- n. cutaneus femoris posterior (situated postero-medially to the n. ischiadicus)

- the internal pudendal vasculo-nervous package (situated medially to the inferior gluteal v-n package) - goes around spina ischiadica through canalis pudendalis (wich belong to foramen ischiadicum minus) to fossa ischio-rectalis:

- a. pudenda interna- vv. pudenda internaes- n. pudendus internus

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10. THE OBTURATOR REGION (REGIO OBTURATORIA)

The region is situated on the medial aspect of the root of the inferior limb, intercalated in between the perineum and the thigh.

1. The borders of the region are:- superior: plica genitor-femoralis- inferior: the anterior continuation of plica fesiera posterior- anterior: a vertical line along the anterior margin of musculus gracilis- posterior: a vertical line along the medial margin of musculus adductor

magnus

2. The covering plane:- the skin - thin, mobile- the subcutaneous layer has a variable depth and contains:

- superficial arterial network- superficial venous network- cutaneous nervous branches:

- n. genitofemoralis- superficial lymphatic network

- the medial, thinner continuation of the fascia of the thigh (medial part of fascia lata).

3. The under-fascial layer containsa. the muscles disposed in two groups:

- superficial layer:- m. gracilis- m. adductor magnus

- middle layer:- m. adductor longus- m. adductor brevis

- profound layer:- m. obturator externus

b. canalis obturatorius is a space through wich the obturator region communicates with the pelvis; it has 6–7 cm length, has horizontal-oblique disposition (oriented downwards and medially); it is bordered by:

- superior: sulcus obturatorius (of os coxae)- inferior: membrana obturatoria (wich covers foramen obturatum of os

coxae); at its superior end is fortified by a fibrotic part named bandeleta infra-pubica

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- the external opening: is situated on under the origin of musculus pectineus (in between m. pectineus and m. adducor brevis)

- the internal opening: is situated in the pelvis

The content of the chanell is represented by the obturator vasculo-nervous package (wich has a common membranous sheat):

- arteria obturatoria - situated in the middle in the axis of the chanell; it divides here in two branches:

- r. anterior- r. posterior wich gives r. acetabularis

- vv. obturatoriaes - are situated on the inferior aspect of the artery- nervus obturatorius - is situated on the superior aspect of the artery; it

divides here in two branches:- r. anterior wich gives r. cutaneus- r. posterior

- the profound lymphatic network - drained in nodi lymphatici inguinales profundi

11. THE POSTERIOR REGION OF THE THIGH (REGIO FEMORALIS POSTERIOR)

The region is situated on the posterior aspect of the inferior limb, in between the hip and the knee.

1. The borders of the region are:- superior: plica fesiera- inferior: the posterior continuation of the horizontal line 4 cm above the

base of the patella- lateral: a vertical line in between trochanter major and epicondylus lateralis

of the femor bone- medial: a vertical line in between tuberculum pubicum and epicondylus

medialis of the femor bone

2. The covering plane:- the skin – thick, mobile and with hair- the subcutaneous layer has a variable depth and contains:

- superficial arterial network- superficial venous network

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- vena saphena magna (interna) wich goes up on the infero-medial side of the region to the supero-medial side of the anterior region of the thigh:- vv. saphenae accessories- vena femuro-poplitea “Giacomini” (wich crosses the region going to the anterior region of the thigh)- cutaneous nervous branches:

- n. cutaneus femoris lateralis (for the lateral side of the region)- n. cutaneus femoris posterior (for the middle and supero-medial

part)- ramus cutaneus from n. obturatorius (for the infero-medial part)

- superficial lymphatic network- the posterior fascia of the thigh (posterior part of fascia lata), thick and

resistant; togheter with the two septums intermuscularis (lateralis and medialis) plus the femoris bone (its posterior aspect) delimit an posterior osteo-fibrotic space wich contains the subfascial anatomical structures of the region.

3. The under-fascial layer containsa. the muscles disposed in two groups:

- lateral group with:- superficial layer: caput longum m. biceps femoris- profound layer: caput brevis m. biceps femoris

- medial group with:- superficial layer: m. semitendinosus- profound group: m. semimembranosus

b. the arteries - they are important not by caliber but by the anastomoses that they realize in between the circulation of the gluteal, femoral anterior, femoral posterior and popliteal region:

- aa. perforantes (3) - terminal branches of a. profunda femoris; they are coming here from region femoralis anterior by perforating the tendon of m. adductor magnus and each of them have a r. superior and r. inferior wich anastomose in between and with:

- a. glutealis inferior - the superior branch of the first a. perforans anastomose with the inferior branch of this artery- a. poplitea - the inferior branch of the last a. perforans anastomose with this artery

- r. descendens a. circumflexa femoris lateralis- r. profundus a. circumflexa femoris medialis- a. comitans n. ischiadici

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c. the nerves:- n. ischiadicus - situated profoundly in between the lateral and medial muscular group; superiorly is crossed by anterior by caput longum m. biceps femoris wich goes laterally; just before reaching the inferior border of the region or even higher it splits in its terminal branches:

- n. fibularis communis (lateral)- n. tibialis (medial)

- n. cutaneus femoris posterior superior – situated more superficially then n. ischiadicus but still under the fascia until the middle of the region where perforates the fascia and goes superficially to the skin

12. THE POSTERIOR REGION OF THE KNEE (REGIO GENUS POSTERIOR)

or(REGIO POPLITEA)

The region is situated on the posterior aspect of the inferior limb, in the back of the knee. With the shank in mild flexion the region appears with a longitudinal surface depression (fossa poplitea) wich is bordered on its sides by four muscular columns (in a rhombic disposition). On the transversal axis of this rhombus the skin presents a cutaneous flexion plica. With the shank in mild extension the region appears with a bulging due to the external expansion of corpus adiposum popliteum.

1. The borders of the region are:- superior: the posterior continuation of the horizontal line 3 cm above the

base of the patella- inferior: the posterior continuation of the horizontal line through the

tuberositas tibiae- medial and lateral: a vertical line through the corresponding epicondyls- profound: until the articulation of the knee

2. The covering plane:- the skin - thin, mobile and without hair- the subcutaneous layer has a variable depth and contains:

- superficial arterial network- superficial venous network- vena saphena parva (externa) wich goes up in the inferior angle of the rhombus into a doubeling of the fascia; here makes a “U” torn (crosa vena saphena parva) going to the profound part of the region

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for drainig in vena poplitea; from this crosa leaves vena femuro-poplitea “Giacomini” going to vena saphena magna- cutaneous nervous branches:

- n. cutaneus surae lateralis (for the lateral side; comes from profound part of the region by perforating the fascia)

- n. cutaneus femoris posterior (for the middle side)- n. obturatorius (for the supero-medial side)- n. saphenus (for the infero-medial side)

- superficial lymphatic network- the posterior fascia of the genus is thin and represents the continuation of

the fascia of the thigh; it presents the doubling in wich enters vena saphena parva (by coming from a suprafascial disposition on the posterior aspect of the shank from superficial to a profound direction); also is perforated by n. cutaneus surae lateralis (from profound to superficial direction)

3. The under-fascial layer contains:a. the popliteum space is a space situated profound in the back of the knee; the posterior region of the knee communicates at this level with the anterior and posterior regions of the thigh and with the anterior and posterior regions of the shank; it has a rhombic shape bordered by:

- supero-lateral: tendo m. biceps femoris- supero-medial: tendo m. semitendinosus (superficial)

tendo m. semimembranosus (profound)- infero-lateral: caput lateralis m. gastrocnemius (superficial)

m. plantaris (profound)- infero-medial: caput medialis m. gastrocnemius

- anterior wall: the posterior aspect osteo-fibrotic plane of the articulation of the genus; this wall is covered partially by musculus plantaris (wich goes in diagonal: infero-medial direction in the tibial triangle of the rhombus)

- posterior wall: the covering plane of the region

- the superior openings: - superior angle of the rhombus (communication with regio femoralis posterior)- hiatus tendineus (communication with regio femoralis anterior: canalis adductorius “Hunter”)

- the inferior openings: - inferior angle of the rhombus (communication with regio cruralis posterior - profound compartment)

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- inferior angle of the rhombus (communication with regio cruralis anterior - anterior compartment)

The content of the spatium popliteum is represented adipous tissue (corpus adiposum popliteum) in wich there is the popliteal vascular package (wich has a common membranous sheat) and the branches of nervus ischiadicus:

- arteria poplitea - continues arteria femoralis superficialis from hiatus tendineus of musculus adductor magnus; it has a profound disposition (on the osteo-fibroric plane of the articulation) and goes downwards vertically in the long axis of the rhombus; gives here several branches:

- a. tibialis anterior - terminal branch, goes anteriorly to the anterior compartment of region cruralis anterior

- a. tibialis posterior - terminal branch, goes posteriorly to the profound compartment of region cruralis posterior

- a. genicularis supero-lateralis- a. genicularis supero-medialis- a. genicularis infero-lateralis- a. genicularis infero-medialis- a. genicularis media (goes into the articulation)

- vena poplitea – it is a single vein and goes upwards being situated postero-lateral to the artery; receives here:

- v. saphena parva - terminal branch, goes anteriorly to the anterior compartment of region cruralis anterior

- vv. satellites of the arteries of the genus- nervus fibularis communis - it is the lateral division of nervus ischiadicus having the trajectory situated on the medial margin of the tendo musculi biceps femoris and it will leave the region by going around the head of the fibula; gives here a branch:

- n. cutaneus surae lateralis- nervus tibialis - it is the medial division of nervus ischiadicus and continues its trajectory being situated postero-lateral to the popliteal vein and it will leave the region through arcus solearis; gives here several branches:

- rr. musculares (for the muscles of the posterior region of the shank)- n. cutaneus surae medialis

- m. popliteus - it has a profound disposition (on the osteo-fibroric plane of the articulation) and goes oblique infero-medially in the tibial triangle of the rhombus- the profound lymphatic network - drained in nodi lymphatici inguinales profundi

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13. THE POSTERIOR REGION OF THE SHANK (REGIO CRURALIS=SURAE POSTERIOR)

The region is situated on the posterior aspect of the inferior limb, in between the knee and the foot wrist.

1. The borders of the region are:- superior: the posterior continuation of the horizontal line through

tuberositas tibiae- inferior: the posterior continuation of the horizontal line through the baisis

of the malleolas- lateral and medial: a vertical line in between the femoral epicondyls and the

corresponding malleola

2. The covering plane:- the skin - thick, mobile and with hair- the subcutaneous layer is thin and contains:

- superficial arterial network- superficial venous network- vena saphena parva (externa) wich goes up vertically on the median

line of the region- vv. perforans - veins wich are connecting trans-fascially the

superficial venous system with the profound one- vv. communicantes - veins wich are connecting epi-fascially the main

components of the superficial venous system - cutaneous nervous branches:

- n. suralis (for the lateral side of the region) - on the lateral side of v. saphena parva - n. saphenus (for the medial side)

- superficial lymphatic network- the fascia cruralis=surae posterior (the posterior superficial fascia of the

shank), thick ans resistant, makes a sheat around the muscles and it is perforated by vv. perforantes;

- the fascia cruralis=surae posterior profunda (the posterior profound fascia of the shank) it is an expansion of fascia cruralis in between the lateral margin of fibula and the medial margin of tibia; these two fascias, the membrana interossea and the bones of the shank delimit two osteo-fibrotic compartments wich contain the subfascial anatomical structures of the region.

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3. The under-fascial layer contains:a. the superficial compartment is delimited by the two fascia cruralis posterior of the region (superficialis and profunda); it contains m. triceps suralis wich represents the superficial layer of the muscles of the region:

- the muscles:- m. gastrocnemius (caput laterale, caput mediale)- m.solearis

- inferiorly the tendons of these two muscles are making togheter a common tendon (tendo m. triceps suralis = the “Achille’s” tendon)

- on the medial side of this tendon it will be added the tendo m. plantaris

b. the profound compartment is delimited by the profound fascia, membrana interossea and facies posterior of fibula and tibia; it contains:

- the muscles- lateral: m. flexor hallucis longus- middle: m. tibialis posterior- medial: m. flexor digitorum longus

- the tibial posterior vasculo-nervous package:- a. tibialis posterior - has initially a vertical trajectory then goes

oblically to the posterior aspect of maleolla medialis; gives here several branches:

- a. fibularis goes oblically to the posterior aspect of maleolla lateralis- r. communicans with a. fibularis- r. circumflexa fibularis

- vv. tibiales posteriores (satellite)- vv. fibulares (satellite)- n. tibialis (goes downwards with a. tibialis posterior being situated on the lateral side of the artery)- profound lymphatic network

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14. THE POSTERIOR MALLEOLAR REGION(REGIO MALLEOLARIS POSTERIOR)

The region is situated on the posterior aspect of the inferior limb and connects the shank with the foot.

1. The borders of the region are:- superior: the posterior continuation of the horizontal line through the basis

of the malleolas- inferior: the posterior continuation of the oblique plane oriented backwards

to the tip of the malleolas and situated 2 cm lower than the articulation line in between the tibia and the talus

- lateral and medial: a vertical line tangent to the corresponding malleolas

2. The covering plane:- the skin - thick and adheret to the subcutaneous layer; without hair- the subcutaneous layer is thin and contains:

- superficial arterial network- superficial venous network- vena saphena parva (externa) - situated posterior to malleola

lateralis- cutaneous nervous branches:

- n. suralis (for the lateral side of the region)- n. saphenus (for the medial side)

- superficial lymphatic network- bursa subcutanea calcanearis (of the achilean tendon)

- the fascias of the region presents two thicker and more resistant zones called retinacles of flexors; these fascias (superficialis and profunda), the retinacles and the bones of the region are delimiting three compartments (lateral, posterior and medial)

- retinaculum musculorum fibularium=peroneorum superius et inferius – two narrower ones situated one above the other one in between the maleolla lateralis and the lateral aspect of calcaneus; they present superficial and profound fibres wich delimit two fibrotic tunells for the tendons of the fibular muscles- retinaculum musculorum flexorum - is broader anf thicker and situated in between maleolla medialis and the medial aspect of calcaneus; it presents superficial and profound fibres wich delimit three fibrotic tunells for the tendons of the profound flexor muscles of the shank

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3. The under-fascial layer contains:a. the lateral compartment (fibular or peroneal) - situated in between the lateral surface of the calcaneus and retinaculum of the fibular=peroneal muscles (extends from the posterior margin of maleolla lateralis to calcaneus) and contains two tunnels for the tendons of the peroneal muscles and their own sinovial sheat:

- lateral: tendo m. fibularis (peroneus) brevis- medial: tendo m. fibularis (peroneus) longus

b. the posterior compartment (achillean) - situated posterior to calcaneus (extends in between fascia superficialis and profunda and contains a tunnel for the tendons of the posterior superficial muscles of the shank:

- lateral: tendo m. triceps suralis (=tendo calcaneus=Achille’s tendo)- medial: tendo m. plantaris- bursa tendinis calcanei- corpus adiposum sub-calcanei tendo

c. the medial compartment (canalis calcanearis “Richet”) - situated in between the medial surface of the calcaneus and retinaculum of the flexor muscles (extends from the posterior margin of maleolla medialis to calcaneus); the inferior part of the chanell is covered by the origin of m. abductor hallucis; it contains three tunnels for the tendons of the posterior profound flexor muscles and their own sinovial sheat:

- supero-medial: tendo m. tibialis posterior (posterior to maleolla medialis and above sustentaculum tali)

- middle: tendo m. flexor digitorum longus (posterior to tendo m. tibialis posterior and above sustentaculum tali)

- infero-lateral: tendo m. flexor hallucis longus (posterior to tendo m. flexor digitorum longus, in his own groove from talus and calcaneus and under sustentaculum tali)

- the tibialis posterior vasculo-nervous package (goes through the chanell being situated more superficially than the tendons - in the groove in between tendo m. flexor digitorum longus and tendo m. flexor hallucis longus):

- a. tibialis posterior - gives here:- a. plantaris lateralis- a. plantaris medialis

- vv. tibiales posteriores (satellite)- n. tibialis - situated on the posterior aspect of the artery; it divides

here in:

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- n. plantaris lateralis- n. plantaris medialis

- profound lymphatic network15. THE REGION OF THE SOLE OF THE FOOT

(REGIO PLANTARIS)

The region presents on its posterior end a proeminent relief: the heel (calx) due to the inferior part of tuberis calcanei; the medial half of the middle part is escavated (fornix pedis) and anteriorly presents five smaller convexities (the heads of the metatarsal bones). At the base of each finger we identify the plica digito-plantaris.

The BORDERS of the region are :- posterior: a vertical line tangent to the posterior end of tuberis calcanei - anterior: plica digito-plantaris- medial and lateral: a horizontal line corresponding to the lateral and medial

margin of the last respectve first metatarsal bone - profound: until the metacarpal bones plane

The COVERING PLANE :- the skin is thick, whithout hair, reach in sudoripar gland and very adherent

to the underlying plane; an important issue is that here the skin is without any redundancy, so there is no excess to use in case of loss

- the subcutaneous layer presents numerous vertical fibrotic expansions in between the skin and the aponeurosis of the sole wich has two roles: to fixate very well the skin to the underlying layer and to compartimentate the adipous tissue from here so it will give elasticity to the sole; it communicates with the subcutaneous layer of the anterior surface of the fingers and through the interdigital spaces with the back of the foot; it contains:

- rete calcaneus- superficial venous network- superficial lymphatic network- nervous sensitive branches:

- rr. nervi tibialis- n. plantaris lateralis for the antero-lateral third of the sole- n. plantaris medialis for the antero-medial two thirds of the thenar

- bursa subcutanea calcanea under tuber calcanei- the aponeurosis plantaris is situated in the middle of the sole and represents

a thicker part of fascia of the sole, on its lateral and medial sides being continued with fascia of the dorsum of the foot (wich is thinner); it has a triangular shape with the base oriented to the fingers. In front of interdigital spaces the fascicles of

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the aponeurosis delimits by fibrotic arches 4 windows (canales lombricales), through wich the lombrical muscles and the vasculo-nervous packages are passing to the fingers.

The under-aponeurotic plane is situated under the aponeurosis plantaris, in between it and fascia plantaris profunda (wich covers the inferior surface of the metatarsal bones and intermetatarsal spaces). The aponeurosis plantaris send two septums (septum plantaris lateralis and medialis) wich will be inserted on the inferior margin of the os metacarpi V respective on the inferior margin of the os metacarpi I plus os cuneiforme mediale and os navicularis, so the under-aponeurotic plane will be split in three compartments:

1. Lateral compartment – situated laterally to septum plantaris lateralis, being completely separated from the other compartments of the sole; it contains:- m. abductor abductor digiti minimi - situated laterally- m. flexor digiti minimi - situated medially- a. digitalis plantaris communis - from a. plantaris lateralis- rr. senstiva and motoria - from n. plantaris lateralis

2. Medial compartment – situated medially to septum plantaris medialis and communicating through small orifices with medio-plantar compartment and with canalis calcanearis “Richet”; it contains:- muscles:

- m. abductor hallucis - situated superficially and medial- m. flexor hallucis brevis - situated profound and lateral; distally it

will split in two fascicles- tendons:

- tendo m. flexor hallucis longus - comes from canalis calcanearis, situated on m. flexor hallucis brevis and going through his fascicles to the base of the distal phalang of hallux- tendo m. tibialis posterior - comes from canalis calcanearis and goes to its insertion on tuberositas ossis navicularis - tendo m. fibularis (peroneus) longus - goes profoundly to its insertion on os cuneiforme medialis and os metatarsi I

- the plantar medial vasculo-nervous package:- a. plantaris medialis - goes along m. flexor hallucis brevis and

gives here a branch: - r. superficialis – for the hallux

- r. profundus - it will anastomose with a. plantaris lateralis- n. plantaris medialis - goes on the lateral side of the artery and

gives several branches:- rr. musculares

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- n. digitales plantares communes (3-4) for the intermetatarsal space I-III, wich will give the sensitive nn. digitales propriae for the first seven margins of the fingers

3. Intermediar (medio-plantar) compartment – situated in between septum plantaris lateralis and medialis, being incompletely separated from the other compartments of the sole: it communicates through small orifices with the medial compartment, with canalis calcanearis “Richet” and anteriorly through canales lombricales with the subcutaneous layer of the sole and of the fingers; it contains:- muscles and arranged in three superposed layers:

- m. flexor digitorum brevis - situated superficially - m. quadratus plantae - situated in the middle- mm. lumbricales (I-IV) - situated in the middle- m. adductor hallucis (with caput obliqum and caput

transversum) - situated profoundly- tendons:

- tendo m. flexor digitorum longus - comes from canalis calcanearis, situated under m. flexor digitorum brevis with an oblique trajectory having attached m. quadratus plantae; it will split in four tendons (that will have attached the m. lumbricales)- tendo m. fibularis (peroneus) longus - goes profoundly to its insertion on os cuneiforme medialis and os metatarsi I

- the plantar lateral vasculo-nervous package is situated in between the superficial and the middle muscular layers:

- a. plantaris lateralis - at the anterior margin of m. quadratus plantae perforates m. adductor hallucis and goes profoundly to the interosseus compartment by giving:

- arcus plantaris profundus - it will anastomose with r. profundus of a. plantaris medialis and with a. plantaris profunda of a. dorsalis pedis

- n. plantaris lateralis - goes on the medial side of the artery and gives several branches:

- r. profundus - goes with arcus planaris profundus- r. superficialis - wich will give:

- rr. musculares - for digiti minimi-n. digitalis plantaris communis - for the intermetatarsal space IV, wich will give the sensitive nn. digitales propriae for the last three margins of the fingers

4. the profound compartment - situated under fascia plantaris profunda, in between it and the metatarsal plane; it contains:

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- interosseus muscles being arranged in two superposed layers:- superficial layer – m. interossei plantares (3)- profound layer – m. interossei dorsales (4)

- arcus plantaris profundus - with the concavity oriented posterior and being made by r. profundus of a. plantaris lateralis (main component) wich will anastomose with r. profundus of a. plantaris medialis and with a. plantaris profunda of a. dorsalis pedis; it will give several branches from the convexity of the arch:

- aa. metatarsales plantares wich are going to the base of the fingers where they will give:

- aa. perforans (3) - wich will go through interosseus spaces and will anastomose with arteriae metatarsales dorsales

- aa. digitales plantares communes wich will give at the base of the fingers:

- aa. digitales plantares propriae- r. profundus - of n. plantaris lateralis

16. THE PLANTAR REGION OF THE FINGERS OF THE FOOT(REGIO PLANTARIS DIGITI PEDIS)

The region represents the plantar surface of the fingers of the foot. In between the base of the fingers we identify the interdigital comissura.

1.The BORDERS of the region are:- posterior: the corresponding line of the metatarso-phalanx articulation - anterior: the tip of the finger- medial and lateral: a horizontal line on the lateral and medial margin of the

finger- profound: until the osteo-articular plane

2. The COVERING PLANE:- the skin is mobile, whithout hair; corresponding to the articulations in

between the phalanx the fingers presents transversal plicas with no redundancy of the skin

- the subcutaneous layer presents vertical fibrotic expansions in between the skin and the sheat of the flexor muscles; it communicates with the same layer of the sole and with the back of the foot; it contains:

- aa. digitales plantares proprii (and the satellite veins) - for each margin of each finger; they will anastomose in between them and with that ones from the dorsal surface of the finger, realising like this a “peri-finger network”

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- nn. digitales plantares proprii - for each margin of each finger (first seven margins from nervus plantaris lateralis and the last three margins from nervus plantaris medialis)

The osteo-fibrotic channel of the finger (vaginae fibrosae digitorum manus) it si situated in between the osteo-articular plane of the finger and the fibrotic sheat of the flexor muscles of the finger. Corresponding to the corpus of the phalanx this channel if fortified by annular (pars annularis) and crossed (pars cruciformis) ligaments, thus forming two pulleys at tha level of the proximal and the middle phalanx. The channel contains:

- the tendons of musculus flexor digitorum brevis (II-V) - at the level the proximal phalang is going to divide in two parts wich will be oriented laterally and medially, creating like this a “window” through wich will pass the tendon of m. flexor digitorum longus; afterwards the two parts wil reunite into a single “perforated” tendon wich will insert on the middle phalang

- the tendons of musculus flexor digitorum longus (II-V) - at the level the proximal phalang is going to pass through those two parts of the splitted tendon of m. flexor digitorum brevis; afterwards this “perforans” tendon will insert on the distal phalang

- the sinovial sheat of the tendons – for the fingers II – IV this sheat will be interrupted at the middle of the sole (these fingers will have each their own sinovial sheat starting from the inter-metatarso-phalangian line); for the finger V the sinovial sheat it is not interrupted in the sole, being continuous to the finger

- the tendon of musculus flexor pollicis longus and its sinovial sheat wich it is interrupted in the sole

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