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Femoral triangle and venous drainage in the lower limg
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Femoral triangle and venous drainage in the lower limg

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  • 1. Dr. Akram Jaffar Dr.AkramJaffar The Femoral TriangleThe Femoral Triangle Akram Jaffar, Ph.D.
  • 2. Dr. Akram Jaffar Dr.AkramJaffar References and suggested reading • Moore KL & Dalley AF (2006): Clinically oriented anatomy. 5th ed. Lippincott Williams & Wilkins. Baltimore • Snell RS (2006): Clinical anatomy by systems. Lippincott Williams & Wilkins. Baltimore
  • 3. Dr. Akram Jaffar Dr.AkramJaffar Objectives After completion of this session, it is expected that the students will be able to •Musculoskeletal Anatomy: Describe the deep fascia of the thigh: iliac fascia, inguinal ligament & lacunar ligament, fascia lata & iliotibial tract, cribriform fascia, obturator membrane, compartments (anterior, posterior, medial) and the intermuscular septa (lateral & medial); List the muscles of the femoral triangle: psoas major, iliacus, sartorius, pectineus, adductor longus •Neurovascular Anatomy: Describe: the course and branches of the femoral artery, the course and branches of the profunda femoris artery: medial and lateral circumflex arteries and the perforating arteries, the course and branches femoral nerve, the course and tributaries of the: great saphenous vein, femoral vein; the origin of the femoral nerve from the lumbar plexus; the cutaneous innervation of the thigh •Regional Anatomy: Describe: the borders and contents of the femoral triangle: •Surface Anatomy: Define: the femoral triangle, saphenous opening; Locate: pubic tubercle, the iliac spines and crest, the ischial tuberosity, the greater trochanter of the femur, the adductor tubercle, femoral condyles and epicondyles; Delineate: the course of the femoral artery, nerve and vein in the femoral triangle, the great saphenous vein; Demonstrate: the inguinal ligament, the iliotibial tract, femoral pulse •Clinical Anatomy: Explain the clinical significance of: the midpoint of the inguinal ligament: palpation, compression and cannulation of the femoral artery. the femoral canal; Femoral hernia: More common in females, Liable to strangulate and difficult to reduce, Does not become of very big size; Cannulation of the femoral vein to reach the right side of the heart; Cannulation of the femoral artery coronary angiography; Formation of varicose veins; The use of great saphenous vein in grafting to bypass obstruction in blood vessels; Deep venous thrombosis and mechanism of venous return to the heart. •Indicate: Effects and diagnosis of femoral artery: Sudden occlusion, Gradual occlusion; Arterial anastomosis in femoral artery occlusion; The site of femoral artery and vein puncture; The method, consequences and indications for femoral nerve block; The differential diagnosis of a femoral triangle lump; The site, mechanism and effects of fractured shaft of femur; Dermatomes of the thigh and overlap in sensory innervation; The area affected in meralgia parasthetica; Saphenous nerve injury in venous cut down in front of the medial malleolus; The importance of the pubic tubercle in differentiating femoral from inguinal hernia. •Radiological Anatomy: Identify: the antero-posterior and lateral views of the proximal femur; the greater trochanter, lesser trochanter and neck of femur; the pubic symphysis, body and superior and inferior rami of the pubis; the ramus of the ischium and the ischial tuberosity; femoral angiograms and venograms and know major branches of the femoral artery as seen on an angiogram; inguinal lymphangiogram
  • 4. Dr. Akram Jaffar Dr.AkramJaffar Superficial thigh structures • The fat of the front of the thigh contains: – Cutaneous nerves – Termination and tributaries of the great saphenous vein – Cutaneous branches of the femoral artery – Lymphatic vessels and nodes.
  • 5. Dr. Akram Jaffar Dr.AkramJaffar Inguinal ligament • The lower border of the aponeurosis of the external oblique muscle. • Extends between the anterior superior iliac spine and the pubic tubercle. External oblique aponeurosis Inguinal lig. Pubic tubercle ASIS
  • 6. Dr. Akram Jaffar Dr.AkramJaffar Cutaneous nerves • Subcostal nerve (T12) • Ilioinguinal nerve (L1) • Femoral branch of the genitofemoral nerve (L1 & L2) • Cutaneous branch of the obturator nerve • Medial and intermediate cutaneous nerves of the thigh (branches of the femoral nerve L2, 3 & 4) • Lateral cutaneous nerve of the thigh which is a separate branch of the lumbar plexus (L2 & 3). intermediate cutaneous n. of thigh Femoral of genitofemoral medial cutaneous n. of thigh Cut. Br. obturator n. Ilioinguinal n. Lat. cutaneous n. of thigh Subcostal n.
  • 7. Dr. Akram Jaffar Dr.AkramJaffar Lateral cutaneous nerve of the thigh • Enters the thigh by passing through or beneath the inguinal ligament just medial to the anterior superior iliac spine • Meralgia parasthetica – Pressure on the nerve at this site by protrusion of the abdomen in fat people may lead to tingling sensation on the lateral side of the thigh at the region of distribution of this nerve. Lat. cutaneous n. of thigh ASIS Inguinal lig. Lat. cutaneous n. of thigh area of distribution
  • 8. Dr. Akram Jaffar Dr.AkramJaffar Femoral triangle • Location: – Supero-medial part of the front of the thigh. • Boundaries: – Superiorly (base of the triangle): • Inguinal ligament – Laterally: • medial border of sartorius muscle – Medially: • medial border of adductor longus muscle • Therefore, adductor longus muscle lies in the floor of the triangle. – The apex • where the medial border of sartorius and adductor longus meet. • The floor of the triangle (from medial to lateral) – adductor longus, pectineus, psoas major, iliacus. – The floor is gutter-shaped since all the muscles forming the floor pass to the posterior aspect of the femur. • Roof: – Skin, superficial and deep fascia of the thigh. Inguinal lig. sartorius Adductor longus pectineus Psoas major iliacus
  • 9. Dr. Akram Jaffar Dr.AkramJaffar Femoral triangle • Contents: – femoral nerve, artery, and vein (from lateral to medial) and their branches and tributaries – Superficial and deep inguinal lymph nodes. Femoral n. Femoral a. Femoral v. Inguinal L.N.
  • 10. Dr. Akram Jaffar Dr.AkramJaffar Saphenous opening • Gap in the top of the stocking of the fascia lata. • Located 4cm inferolateral to the pubic tubercle. • Has a sharp crescentic falciform margin. • Closed by sieve-like cribriform fascia. • Allows the passage of – Lymphatic vessels from superficial  deep inguinal lymph nodes. – Great saphenous vein and its tributaries. Great saphenous v. Femoral v.. Pubic tubercle Falciform margin
  • 11. Dr. Akram Jaffar Dr.AkramJaffar • As in the upper limb, the venous return in the lower limb is by way of • Superficial veins • Lie in the superficial fascia • Not accompanied by corresponding arteries. • Play a major role in temperature regulation • Deep veins • Lie deep to the deep fascia • Accompany arteries . Venous return in the lower limb
  • 12. Dr. Akram Jaffar Dr.AkramJaffar • A vein leaves each side of the dorsal arch. • Preaxial veins • The great (long) saphenous vein in the lower limb, and the cephalic vein in the upper limb, leave the preaxial side of the dorsal venous arch. • Run to the root of the limb. • Pierce the deep fascia to open into the main vein of the limb (the femoral vein in the lower limb and the axillary vein in the upper limb). Pre-axial and post-axial veins
  • 13. Dr. Akram Jaffar Dr.AkramJaffar • Post axial veins: • The small saphenous vein in the lower limb and the basilic vein in the upper limb drain the post axial side of the dorsal venous arch. • Pierce the deep fascia proximal to the root of the limb • Join the popliteal vein and the venae comitantes of the brachial artery respectively Pre-axial and post-axial veins
  • 14. Dr. Akram Jaffar Dr.AkramJaffar • The word "saphenous" is an Arabic derivation of the word "‫"صافن‬ which means standing because it does not pulsate. • Begins at the medial end of the dorsal venous arch of the foot and passes anterior to the medial malleolus of the tibia • The vein in front of the medial malleolus is accompanied by a cutaneous nerve (the saphenous nerve), this relation should be remembered so that not to injure the nerve while cutting down for the vein The great saphenos vein
  • 15. Dr. Akram Jaffar Dr.AkramJaffar • Ascends to the medial aspect of the knee about a hand’s breadth posterior to the medial border of the patella • Ascends to the saphenous opening where it perforates the cribriform fascia to end in the femoral vein; this point is located about three-five centimeters below and lateral to the pubic tubercle. The great saphenos vein
  • 16. Dr. Akram Jaffar Dr.AkramJaffar • Before piercing the deep fascia, the saphenous vein receives tributaries, which correspond to the superficial branches of the femoral artery. • The superficial and deep external pudendal veins drain the external genitalia and are responsible for vulval varicosity, which may accompany varicosity of the great saphenous vein. • Lateral and anterior cutaneous veins. Superficial epigastric Superficial circumflex iliac Superficial & deep External pudendal Tributaries of the great saphenous vein Lateral & anterior cutaneous vv.
  • 17. Dr. Akram Jaffar Dr.AkramJaffar Tributaries of the great saphenous vein • Accessory saphenous vein – From the medial and posterior aspect of the thigh. – Often communicates with the small saphenous vein. Accessory saphenous v. Accessory saphenous v. Accessory saphenous v. small saphenous v.
  • 18. Dr. Akram Jaffar Dr.AkramJaffar • The small saphenous vein begins posterior to the lateral malleolus • Ascends lateral to the tendo calcaneus. • Inclines medially to the midline of the calf • Passes between the heads of the gastrocnemius • Pierces the deep fascia (popliteal fascia) • Terminates in the popliteal vein above the knee joint in the popliteal fossa. • The vein behind the lateral malleolus is accompanied by a cutaneous nerve (the sural nerve). The small (short or external) saphenous vein
  • 19. Dr. Akram Jaffar Dr.AkramJaffar Perforating (communicating) veins • Penetrate the deep fascia from the superficial to the deep vein. • Contain valves that allow unidirectional flow of blood from the surperficial to the deep vein. • Are compressed when muscles contract and pressure increases in the deep fascia. • Muscle contraction propel blood in the deep veins toward the heart.
  • 20. Dr. Akram Jaffar Dr.AkramJaffar Mechanisms of venous return Arterial pulsation help compress and blood in the veins
  • 21. Dr. Akram Jaffar Dr.AkramJaffar Varicose veins • Dilated and tortuous superficial veins. • Results from incompetent valves in the perforating veins.
  • 22. Dr. Akram Jaffar Dr.AkramJaffar Lymphatic drainage of the lower limb • Superficial inguinal lymph nodes: • Arrangement: – T-shape, one row of nodes runs parallel to and below the inguinal ligament, while the other row is arranged vertically along the great saphenous vein. Superficial Inguinal LN (horizontal gp) Superficial Inguinal LN (vertical gp) Great saphenous v Inguinal lig.
  • 23. Dr. Akram Jaffar Dr.AkramJaffar Lymphatic drainage of the lower limb • Superficial inguinal lymph nodes: • Drainage area: – Superficial tissues (everything superficial to the deep fascia) – Lower limb (including the buttocks) except posterolateral part of the calf (drains to popliteal lymph nodes) – Lower abdominal wall below the umbilicus. – External genitalia (excluding the testes). – Perineum, the lower part of anal canal and vagina – Cornu of the uterus by means of lymphatics that follow the round ligament. Superficial Inguinal LN (horizontal gp) Superficial Inguinal LN (vertical gp) Great saphenous v popliteal LN Inguinal lig.
  • 24. Dr. Akram Jaffar Dr.AkramJaffar Lymphatic drainage of the lower limb • Deep inguinal lymph nodes: Three of four nodes. Lie medial to the femoral vein, one being in the femoral canal. • Drainage area: – Deep lymphatics that accompany the femoral vessels from the popliteal fossa – Glans penis (or clitoris). – Efferent lymphatics from the superficial inguinal nodes that pass through the cribriform fascia. • Efferent vessels from the deep inguinal lymph nodes pass through the femoral canal to enter the external iliac group of lymph nodes. External iliac LN Deep inguinal LN Femoral a & v Femoral ring Deep inguinal LN Superficial Inguinal LN External iliac LN Femoral ring Cribriform fascia
  • 25. Dr. Akram Jaffar Dr.AkramJaffar Inguinal lymphangiogram
  • 26. Dr. Akram Jaffar Dr.AkramJaffar • Funnel-shaped fascial prolongation of extraperitoneal fascia (transversalis fascia anteriorly and iliac fascia posteriorly) • Extends beneath the inguinal ligament. • Terminates by fusing with the adventitia of the femoral vessels about 4cm inferior to the inguinal ligament. Femoral sheath Inguinal lig Femoral a. Femoral v. Femoral sheath Extraperitoneal fascia
  • 27. Dr. Akram Jaffar Dr.AkramJaffar Femoral sheath • In the abdomen, the aorta and its branches, the inferior vena cava and its tributaries lie within the extraperitoneal fascia; while spinal nerves lie behind it • Thus, the vessels which pass from the abdominal cavity into the thigh must pierce the fascial envelope while the femoral nerve does not do so and is thus located outside the femoral sheath. Femoral a. Femoral v. Femoral sheath Extraperitoneal fascia Femoral n. Femoral n. Extraperitoneal fascia peritoneum psoas fascia transversalis fascia Femoral a.
  • 28. Dr. Akram Jaffar Dr.AkramJaffar Femoral sheath • The femoral sheath is pierced – Anteriorly: femoral branch of the genitofemoral nerve (to supply skin over the femoral triangle). – Medially: great saphenous vein as it joins the femoral vein. Femoral of genitofemoral n. Great saphenous v. Femoral v.. Great saphenous v. Femoral v..
  • 29. Dr. Akram Jaffar Dr.AkramJaffar Femoral sheath • The femoral sheath is subdivided by two fascial septa into three compartments: – Lateral compartment for the femoral artery – Intermediate compartment for the femoral vein – Medial compartment called the femoral canal Femoral a. Femoral v. Femoral sheath Femoral canal
  • 30. Dr. Akram Jaffar Dr.AkramJaffar Femoral canal • Medial compartment of the femoral sheath. • Allows the femoral vein to expand • Contains lymph vessels, a lymph node, and connective tissue. • Conical in shape, widest at its abdominal end which is called the femoral ring. L.N. of cloquet Femoral v. Lymph vessel Femoral ring
  • 31. Dr. Akram Jaffar Dr.AkramJaffar Lacunar ligament • Triangular ligament. • Extends horizontally backwards from the medial end of the inguinal ligament to the pectineal line on the pubis. • Has a crescentic free lateral edge. • Forms the medial margin of the femoral ring. Femoral ring Lacunar lig. Inguinal lig. Pectineal line
  • 32. Dr. Akram Jaffar Dr.AkramJaffar Femoral ring • Boundaries: – Laterally: femoral vein – Posteriorly: superior ramus of the pubis covered by pectineus muscle – Medially: lacunar ligament – Anteriorly: inguinal ligament. Femoral ring Lacunar lig. Inguinal lig. Pectineal line Femoral v.
  • 33. Dr. Akram Jaffar Dr.AkramJaffar Femoral ring • The femoral ring is closed by extraperitoneal tissue called the femoral septum which is pierced by lymph vessels connecting the deep inguinal with external iliac lymph nodes. Deep inguinal L.Ns External iliac L.Ns Femoral ring Lymph vessel
  • 34. Dr. Akram Jaffar Dr.AkramJaffar Femoral hernia • The femoral ring is a weak area in the anterior abdominal wall and allows the formation of a femoral hernia. • Hernia through the femoral ring. • ♀ > ♂ because the femoral ring is larger owing to the greater breadth of the female pelvis. Femoral hernia intestine Femoral hernia
  • 35. Dr. Akram Jaffar Dr.AkramJaffar Femoral hernia • Strangulation may occur due to the rigid boundaries of the femoral ring especially the lacunar ligament. • Initially the hernia is located within the femoral canal and is thus small, but it can enlarge by passing through the saphenous opening into the subcutaneous tissue of the thigh. Femoral hernia Saphenous opening
  • 36. Dr. Akram Jaffar Dr.AkramJaffar Femoral hernia • The saphenous opening lies below the point of attachment of superficial fascia of the anterior abdominal wall to fascia lata; therefore a femoral hernia emerging from the saphenous opening (contrary to an inguinal hernia) can never come to lie within the space beneath Scarpa’s fascia of the anterior abdominal wall. • Thus a femoral hernia is always felt below the inguinal ligament and can never become very large since it emerges into ordinary subcutaneous tissue. Femoral hernia inguinal hernia Scarpa fascia Inguinal lig. cSaphenous opening Femoral hernia
  • 37. Dr. Akram Jaffar Dr.AkramJaffar Femoral artery • Direct continuation of the external iliac artery. • enters the thigh deep to the inguinal ligament, half way between the anterior superior iliac spine and the pubic tubercle. • Pulsations can be felt in the femoral triangle 2-3cm inferior to midpoint of the inguinal ligament (ASIS-Pubic tubercle). • The head of the femur lies posterior to the artery, separated from it by psoas major muscle. External iliac a. Femoral a.
  • 38. Dr. Akram Jaffar Dr.AkramJaffar Femoral artery • Occupies the lateral compartment of the femoral sheath. • The femoral vein is medial to the artery, but at the apex of the triangle the vein spirals to become posterior to the artery. • Branches in the femoral triangle: – Cutaneous branches: small branches distributed to the lateral thigh, lower abdomen, and external genitalia – Deep femoral a.: largest branch, is the chief artery of the thigh. Superficial circumflex iliac a. Superficial epigastric a. Superficial external pudendal a. Deep external pudendal a. Profunda femoris a. Femoral v.
  • 39. Dr. Akram Jaffar Dr.AkramJaffar Profunda femoris artery • Arises from the lateral side of the femoral artery, within the femoral triangle. • Spirals to pass posterior to the femoral artery and vein. • Leaves the femoral triangle between pectineus and adductor longus muscles. Profunda femoris a. Femoral a.
  • 40. Dr. Akram Jaffar Dr.AkramJaffar Branches of the profunda femoris artery • lateral and medial circumflex femoral arteries: – given in the femoral triangle – encircle the shaft of the femur. • Perforating branches: – Four. – Perforate the muscles they meet. – The fourth is the termination of the vessel. – The upper two arise in the femoral triangle Femoral a. Lat. Circumflex Femoral a. Med. Circumflex Femoral a. Profunda femoris a. Ascending Br. Transverse Br. Descending Br. perforating Br. Femoral a. Profunda femoris a.
  • 41. Dr. Akram Jaffar Dr.AkramJaffar Profunda femoris artery • Lateral circumflex artery: – Passes laterally between the branches of the femoral nerve. – Leaves the femoral triangle beneath sartorius. – Breaks up into three branches: ascending, transverse, and descending. The descending branch slopes downward accompanied by the nerve to vastus lateralis. • Medial circumflex artery: – Passes posteriorly. – Leaves the femoral triangle between psoas major and iliacus. – Breaks into ascending and transverse branches. Descending Br. n. to vastus laterlais Femoral n. Lat. Circumflex Femoral a. sartorius
  • 42. Dr. Akram Jaffar Dr.AkramJaffar Trochanteric anastomosis • Provides the main source of blood for the supply of the head of the femur. • Lies near the trochanteric fossa, hence the name. • Formed by the anastomosis of the descending branch of the superior gluteal artery and the ascending branch of the lateral and medial circumflex femoral arteries. The inferior gluteal artery usually participating by an anastomotic branch. Lat. circumflex femoral a. Med. circumflex femoral a. Sup. gluteal a. Trochanteric fossa
  • 43. Dr. Akram Jaffar Dr.AkramJaffar Cruciate anastomosis • Located at the level of the lesser trochanter. • Cruciform in shape hence the name. • The transverse limb is formed by the transverse branches of the medial and lateral circumflex femoral arteries. • The vertical limb is formed by a descending branch from the inferior gluteal artery (from internal iliac artery) and an ascending branch from the first perforating artery. Lat. circumflex femoral a. Med. circumflex femoral a. Profunda femoris a. Perforating a. Femoral a.
  • 44. Dr. Akram Jaffar Dr.AkramJaffar Occlusion of the femoral artery • Anastomosis of branches of the femoral artery with other arteries that cross the hip joint may supply blood to the lower limb. Perforating a. Medial circumfelx femoral a. Lateral circumfelx femoral a. Inferior glutea a. Superior glutea a. 4th perforator Popliteal a.
  • 45. Dr. Akram Jaffar Dr.AkramJaffar Compression of the femoral artery • Just inferior to the midpoint of the inguinal ligament (midway between ASIS & pubic tubercle). • Pressing posteriorly against superior pubic ramus, psoas major and femoral head. Femoral a. Psoas major Head of femur ASIS Inguinal lig. Pubic tubercle
  • 46. Dr. Akram Jaffar Dr.AkramJaffar Cannulation of the femoral artery • Inferior to the midpoint of the inguinal ligament. • A slender catheter is passed into the femoral artery  external iliac a.  common iliac a.  aorta  coronary arteries or left ventricle. catheter aorta Coronary a. Femoral a. Common iliac a. External iliac a. aorta
  • 47. Dr. Akram Jaffar Dr.AkramJaffar Femoral angiogram Femoral a. Profunda femoris a. Lat. circumflex a. Femoral a. perforating Br.
  • 48. Dr. Akram Jaffar Dr.AkramJaffar Femoral vein • Ends posterior to the inguinal ligament where it becomes the external iliac vein. • Its tributaries correspond to the branches of the femoral artery. • It also receives the great saphenous vein into which the cutaneous veins of the inguinal region drain. Femoral v. Great saphenous v.
  • 49. Dr. Akram Jaffar Dr.AkramJaffar Femoral venogram • Valves form an essential part of the venous pumping mechanisms returning blood from the lower limbs against gravity
  • 50. Dr. Akram Jaffar Dr.AkramJaffar Femoral nerve • Is the nerve of the anterior compartment of the thigh. • Branch of the lumbar plexus in the abdomen (L2, 3, & 4). Femoral n.
  • 51. Dr. Akram Jaffar Dr.AkramJaffar Femoral nerve • Enters the thigh deep to the inguinal ligament lateral to the femoral artery and outside the femoral sheath • Lies on iliacus. • An inch distal to the femoral sheath it breaks up into a number of branches through which pass the lateral circumflex femoral artery. Femoral n. iliacus Lat. Circumflex Femoral a.
  • 52. Dr. Akram Jaffar Dr.AkramJaffar Branches of the femoral nerve • Muscular branches: – Sartorius – Four heads of quadriceps femoris. – May also supply pectineus, which is also supplied by the obturator nerve. – Iliacus is supplied by the femoral nerve in the iliac fossa. • Articular branches: – The nerve to rectus femoris sends an articular branch to the hip joint. – The nerve to vastus medialis sends an articular branch to the knee joint. • Cutaneous branches: – Medial and intermediate cutaneous nerves of the thigh – saphenous nerve, which becomes cutaneous in the leg and foot.
  • 53. Dr. Akram Jaffar Dr.AkramJaffar Femoral nerve block • Two cm inferior to the inguinal ligament and lateral to the femoral artery. • Inserting the needle results in a twitch of quadriceps femoris muscle. • Results in loss of sensation in the anterio-medial thigh and saphenous nerve distribution (medial leg), as well as quadriceps muscle relaxation