The femoral region including anterior and middle thigh

Anatomy of the lower limb

1. The Thigh/ Femoral region Dr Kiryowa Haruna Muhmood

2. Lecture objectives To define the femoral region To describe the bone of the femoral region To outline the cutaneous supply of the femoral region To describe the facial compartments of the femoral region To outline the blood supply and lymphatic drainage of the femoral region.

3. Introduction The thigh or femoral region is part of the lower limb between the hip joint and knee joint. It is the equivalent of the arm in the upper limb The bone of the thigh is the femur, the longest bone in the body

4. Cutaneous nerve supply of the thigh It is segmentally supplied by branches of the lumbar plexus The lateral cutaneous nerve(L2,3) enters the thigh behind the lateral end of the inguinal ligament. Divides into anterior and posterior branches that supply the lower lateral quadrant of the buttocks, and the lateral aspects of the thigh and knee

5. Femoral branch of the GFN(L1, 2): Enters the thigh behind the middle of the inguinal ligament.supplies a small area of skin Ilioinguinal nerve(L1): enters the thigh through the superficial inguinal ring. Supplies skin over the root of the penis/clitoris, part of the scrotum/labia majora and a small part below the medial part of the inguinal region

6. Medial cutaneous nerve of the thigh: a branch of the femoral nerve. Supplies medial aspect of the thigh. Joins patella plexus Intermediate cutaneous nerve of the thigh: a branch of femoral. Supplies anterior aspect of thigh. Joins patella plexus Obituirator nerve: its anterior division gives off branches that supply the medial aspect of the thigh

7. Patella plexus: lies in front of the knee. Formed by branches of medial, intermediate and lateral cutaneous nerves of the thigh and the infrapatella branch of the saphenous nerve

8. Posterior cutaneous nerve of the thigh: a branch of the sacral plexus. Leaves gluteal region below lower border of gluteus maximus Descends below deep fascia, crosess biceps femoris , enters popliteal fascia, pierces deep fascia and supplies skin on the back of the thigh and leg

9. Superficial veins They include the small and great saphenous veins and their tributaries Great saphenous vein: Drains medial and dorsal venous arches of the foot. Passes upwards infront of the medial malleolus , accompanied by the saphenous nerve in superficial fascia of the medial surface of the leg, passes behind the knee, ascends around medial aspect of the thigh, passes through saphenous opening in deep fascia and joins the femoral vein 4cm below and lateral to the pubic tubercle.

10. Has numerous valves and is connected to the small saphenous vein by one or two branches behind the knee. A number of perforating veins connect it with the deep veins along the medial aspect of the calf. At the saphenous opening in deep fascia, it receives three tributaries: superficial circumflex iliac, superficial epigastric and superficial external pudendal An additional accessory vein usually joins it around the middle of the thigh or higher up at the saphenous opening

11. Small saphenous vein Arises from the lateral aspect of the dorsal venous arch Ascends behind the lateral malleous accompanied by the sural nerve, follows the lateral border of tendocalcanoeus , runs up the middle of the back of the leg, pierces deep fascia and passes between the two heads of Gastcnemius . Ends in the popliteal vein

12. Has a number of tributaries: Numerous veins that drain the back of the leg Communicating veins with the deep veins of the foot Veins that join the great saphenous vein Its termination is variable: majoin popliteal vein, grat saphenous vein or other veins joining the great saphenous vein

13. Varicose veins Enlargement of veins Usually become tortuous and elongated Not life threatening but causes discomfort and pain Due to genetics, increased intrabdominal pressure, multiple pregnancies, incompetent valves Treatment: ligating all main tributaries, stripping all superficial veins or conservative treatment( sockings )

14. Lymphatics of the thigh Divided into superficial and deep inguinal lymphnodes . Superficial group lie below the inguinal ligament. Divided into vertical and horizontal group horizontal group has lateral and medial groups. The former receives lymphatics from the back below the iliac crest. The later from the anterior abdominal wall below umblicus , the external genitalia, lower half of the anal canal and urethra

15. The vertical group is located along the terminal part of the great saphenous vein. Receives majority of lymphatics from the lower limb. Efferents from the superficial lymphatics pass through saphenous opening and join the deep group Deep group: lie along the medial aspect of the femoral vein. Efferents pass through femoral canal and join external iliac nodes

16. Fascia of the thigh Divided into superficial and deep fascia Superficial fascia: has a membranous layer and fatty layer Membranous layer: extension of similar layer of anterior abdominal wall, attached to deep fascia a finger breadth below inguinal ligament Fatty layer: extend from the anterior abdominal wall to the thigh and leg uninterrupted

17. Deep fascia: encloses the thigh like a trouser leg. upper part attached to pelvic ligaments. Lateral parts froms the ilial tibial tract( btn iliac tubercle and lateral tibial condyle ) In the buttocks, it forms a sheath that enclose TFL and GM Has a saphenous opening below the inguinal ligament that is filled with loose connective tissue called cribriform fascia.

18. Fascial compartments of the thigh 3 fascia septa arise from the deep fascia of the thigh to the linea aspera dividing the thigh into anterior, posterior and lateral compartments

19. Anterior fascial compartment of the thigh Muscles; Sartorius, Iliacus , Psoas , Pectineus and quadriceps femori Blood supply: Femoral artery Nerve supply: Femoral nerve

20. Muscles of the anterior compartment of the thigh.

21. Summary of actions of muscles of anterior compartment Muscle Action Sartorius Flexion, adduction and lateral rotation of hip Iliacus Flexion and medial rotation of the thigh Psoas Flexion of the hip Pectineus Flexion and adduction of the thigh Quadriceps femoris Extension of the knee

22. Femoral triangle femoral triangle is a hollow in the anterior thigh region. Many large neurovascular structures pass through this area, and can be accessed relatively easily. Thus, it is an area of both anatomical and clinical importance. In this article, we shall look at the borders, contents and clinical correlations of the femoral triangle.

23. Borders of the Femoral Triangle Superior border - Formed by the inguinal ligament Lateral border - Formed by the medial border of the sartorius muscle. Medial border - Formed by the medial border of the adductor longus muscle. The rest of this muscle forms part of the floor of the triangle. Anteriorly , the roof of the femoral triangle is formed by the fascia lata Posteriorly, the floor of the femoral triangle is formed by the pectineus , iliopsoas and adductor longus muscles.

24. Contents of the triangle from lateral to medial; The femoral triangle contains some of the major neurovascular structures of the lower limb. The contents of the femoral triangle (lateral to medial) are: Femoral nerve – Innervates the anterior compartment of the thigh, and provides sensory branches for the leg and foot. Femoral artery – Responsible for the majority of the arterial supply to the lower limb. Femoral vein – The great saphenous vein drains into the femoral vein within the triangle. Femoral canal - A structure which contains deep lymph nodes and vessels. The femoral artery, vein and canal are contained within a fascial compartment – known as the femoral sheath .

25. Femoral canal: most medial component of the femoral vein. Contains fatty connective tissues, deep inguinal nodes and efferents from deep inguinal nodes Upper end of the canal is called femoral ring and is bounded by inguinal ligament anteriorly , superior ramus of pubis posteriorly , femoral vein laterally and lacunar ligament medially. Canal is passage of intra- abdominal contents into thigh= femoral hernia

26. Access to the Femoral Artery Within the femoral triangle, the femoral artery is located superficially, and thus easy to access. This makes it suitable for a range of clinical procedures. One such procedure is coronary angiography. Here, the femoral artery is catheterised with a long, thin tube. This tube is navigated up the external iliac artery, common iliac artery, aorta, and into the coronary vessels. A radioactive dye is then ejected into the coronary vessels, and any wall thickening or blockages can be visualised via x-ray imaging. The femoral artery can also be catheterised to draw blood for arterial blood gases.

27. Clinical Relevance of the Femoral Triangle Femoral Pulse Just inferior to where the femoral artery crosses the inguinal ligament, it can be palpated to measure the femoral pulse. The femoral artery crosses exactly midway between the pubis symphysis and anterior superior iliac spine. The presence of a femoral pulse means that blood is reaching the lower extremity.

28. Other uses of femoral triangle Embalming Femoral vein cutdown

29. Blood supply of anterior compartment Femoral artery: enters the thigh by passing behind inguinal ligament btn ASIS and PT Main blood supply to lower limb.ends by passing through adductor canal to become popliteal artery Relations Anteriorly : skin, fascia, sartorius , medial cutaneous nerve of thigh and saphenous nerve Posteriorly : psoas , pectineus , adductor longus Medially: Femoral vein Laterally: Femoral nerve

30. Branches Superficial circumflex iliac Superficial epigastric Superficial external pudendal Deep external pudendal Profunda femoris The first three pass through the saphenous opening Descending genicular artery

31. Femoral vein Strats at the level of the adductor canal as a continuation of the popoliteal vein Ascends into the thigh intially lying lateral, then posterior and finally medial to the femoral artery Leaves the thigh in the intemediate compartment of the femoral sheath, crosses the inguinal ligament and becomes external iliac vein Has tributaries that correspond to branches of the femoral artery, and through great saphenous vein

32. Femoral nerve Largest branch of the lumbar plexus Emerges from lateral border of psoas within the abdomen, runs btn iliacus and psoas , passes behind fascia lata and enters thigh lateral to femoral artery, divides into anterior and posterior divisions 4 cm below inguinal ligament Anterior division: gives off medial and intermediate cutaneous nerves and muscular branches to all except QF Posterior divison : one cutaneous branch, saphenous nerve and muscular branches to QF

33. Saphenous nerve Runs downwards and medially, crosses femoral artery, pierces deep fascia on medial side of the knee, passes btn gracilis and sartorius enters the leg accompanied by great saphenous vein, passes infront of medial malleolus , along medial side of foot and terminates along medial aspect of big toe.

34. Medial fascial compartment Muscles: Gracilis , adductor longus , adductor brevis and adductor portion of adductor magnus Nerve supply: Obiturator nerve Blood supply: Obituirator artery and profunda femoris artery

35. Muscles of the medial compartment

36. Obituirator nerve Arises from lumbar plexus(L2,3,4), emerges on lateral border of psoas , runs forward on lateral wall of pelvis, passes through obituirator foramen and divides into anterior and posterior divisions Anterior division: runs infront of adductor brevis and obituirator externus and behind pectineus and adductor longus . Supplies Adductor longus and brevis , gracilis , hip joint, femoral artery, skin over medial aspect of thigh Posterior divison : pierces obituirator externus , supplies it plus adductor magnus and occassionary adductor brevis

37. Obituirator artery A branch of internal iliac. Passes downwards and forward on lateral wall of pelvis accompanied by obituirator nerve, passes through obituirator foramen Divides medial and lateral branches Also gives off articular branches to the hip and muscular branches to medial compartment.

38. Profunda femoris artery Arises from lateral aspect of femoral artery in femoral triangle Leaves anterior compartment by passing behind adductor longus , descends btn longus and brevis , then lies on magnus and ends as 4 th perforating artery.

39. Branches Medial femoral circumflex: Participates in cruciate anastomosis Laterla femoral circumflex: ,, 4 perforating arteries:

40. Obituirator vein Receives tributaries that correspond to the obituirator artery

41. Profunda femoris vein Receives tributaries that correspond to branches of the profunda femoris artery

42. Posterior fascial compartment Muscles: Semimembranosus , semitendinosus , biceps femoris , hamstring portion of adductor magnus Nerve supply: Tibial and common peroneal nerves Blood supply: Profunda brachii artery

43. Posterior compartment.

44. Blood supply of posterior fascial compartment 4 perforating branches of profunda femoris artery Veins follow arteries

45. Sciatic nerve Arises from lumbosacral plexus(L4,5,S1,2,3) Leaves gluteal region deep to long head of biceps femoris . Descends in midline of thigh behind biceps femoris and semimembranosus , then adductor magnus Midway the thigh, divides into Tibial and Common peroneal nerves. Supplies muscles of posterior compartment

46. THE END