Kaan Yücel M.D., Ph.D.

1. thigh • & • poplitealfossa • IN 30 QUESTIONS • Kaan Yücel M.D., Ph.D. • 28.February.2013 Thursday

2. INTRODUCTION TO THIGH

3. The femoral region (thigh)lies between the gluteal, abdominal, and perineal regions proximally and the knee region distally: • anteriorly separated from the abdominal wall • by the inguinal ligament • posteriorly separated from the gluteal region • by the gluteal foldsuperficially • by the inferior margins of the gluteus maximus & quadratus femorison deeper planes

4. Structures enter and leave the top of the thigh by 3 routes: • Posteriorlycontinuous with the gluteal region • sciatic nerve • Anteriorlyabdominal cavity via aperture between inguinal ligament & pelvic bone • Mediallythigh & pelvic cavity communicates via obturator canal Vessels and nerves passing between the thigh and leg pass through the popliteal fossa posterior to the knee joint.

5. Superficial Fascia of the Thigh Attached to the deep fascia below the inguinal ligament. Deep Fascia of the Thigh (Fascia Lata) Encloses the thigh like a trouser leg. Saphenous opening A gap in the deep fascia in front of the thigh just below the inguinal ligament. Great saphenous vein via hiatus saphenus drains into femoral vein. Filled with loose connective tissue called the cribriform fascia.

6. Fascial Compartments of the Thigh 3 fascial septa pass from the inner aspect of the deep fascial sheath of the thigh to the linea aspera of the femur. • Anterior compartment of thigh Femoral nerve • muscles extend the leg at the knee joint. • Medial compartment of thigh Obturator nerve • muscles adduct the thigh at the hip joint. • Posterior compartment of thigh Sciatic nerve • muscles extend the thigh at the hip joint & flex the leg at the knee joint.

7. MUSCLES OF THE ANTERIOR COMPARTMENT OF THE THIGH IN 3 QUESTIONS

8. 1. Which muscles are in the anterior part of the thigh? Sartorius Quadriceps femoris Rectusfemoris Vastuslateralis Vastusmedialis Vastus intermedius Insertion base of patella indirectly via patellar ligament to tibial tuberosity femoral nerve Origin Anterior inferior iliac spine & ilium superior to acetabulum Origin ASIS & superior part of notch inferior to it Insertion Superior part of medial surface of tibia

9. 2…iliopsoasmuscle In addition, the terminal ends of the psoas major and iliacus muscles pass into the upper part of the anterior compartment from sites of origin on the posterior abdominal wall. Iliacus+psoas major Ilıopsoas

10. 3. Functions of the anterior thigh muscles Quadriceps femoris Extends leg at knee joint. Rectus femoris also steadies hip joint & helps iliopsoas flex thigh. • Sartorius Flexes, abducts, and laterally rotates thigh at hip joint. Flexes leg at knee joint (medially rotating leg when knee is flexed). Flexion of thigh at hip joint Rectus femoris Sartorius Extension of leg at knee joint Quadriceps femoris Abduction of thigh at hip joint Sartorius Lateral rotation of thigh at hip joint Sartorius

11. MUSCLES OF THE MEDIAL • COMPARTMENT • OF THE THIGH IN 3 QUESTIONS

12. 1. Whichmusclesare in themedialpart of thethigh? 1.Gracilis 2. Pectineus 3. Adductor longus 4. Adductor brevis 5. Adductor magnus 6.Obturator externus

13. 2. Functions of themedialthighmuscles Lateral rotation of thigh Adduction of thigh Flexion of thigh Extension of thigh Adductor longus Adductor brevis Adductor magnus Adductor brevis Adductor magnus “adductor part” Adductor magnus “hamstrings part” Obturator externus Gracilis Adducts thigh; flexes leg; helps rotate leg medially Pectineus

14. 3. Adductorhiatus A gap between the aponeurotic distal attachment of the adductor part of the adductor magnus & tendinous distal attachment of the hamstring part. Transmits femoral artery & vein from the adductor canal in the thigh to the popliteal fossa. Located lateral and superior to the adductor tubercle of the femur.

15. MUSCLES OF THE POSTERIOR COMPARTMENT OF THE THIGH IN 2 QUESTIONS

16. 1. Whichmusclesare in theposteriorpart of thethigh? Biceps femoris Short head • Biceps femoris • Long head • Semitendinosus • Semimembranosus

17. 2. Features of hamstringmuscles • Proximal attachment to ischial tuberosity • deep to the gluteus maximus. • Distal attachment to the bones of the leg. • Thus act on two joints, producing • extension @ hip joint & flexion @ knee joint. • Innervation by tibial division of the sciatic nerve.

18. ARTERIES OF THE THIGH IN 3 QUESTIONS

19. 1. Whicharteriesenterthethigh? Femoral artery largest & main artery of lower limb Obturatorartery Inferiorglutealartery Inferiorglutealartery Obturatorartery Femoralartery

20. 2. Femoralartery Distalcontinuation of externaliliacartery. Passesundertheinguinalligament. Entersthefemoraltriangle midpointof theinguinalligament (midwaybetweenASIS & pubictubercle). Continuesdownthethigh in theadductorcanal. Becomespoplitealarterybehindtheknee.

21. 3. .. branches of the femoral artery • 1. Superficial circumflex iliac artery • 2. Superficial epigastric artery • 3. Superficial external pudendal artery • 4. Deep external pudendal artery • 5. Profunda femoris artery • Large and important branch • Arises from the lateral side of the femoral artery below the inguinal ligament • 6. Descending genicular artery

22. VEINS OF THE THIGH IN 2 QUESTIONS

23. 1 . Which veins are seen in the thigh? • Superficial & deep veins Great saphenous vein Largest superficial vein in the thigh Originates from a venous arch on the dorsal aspect of the foot. Ascends along the medial side of the lower limb. Passes through the saphenous ring. To connect with the femoral vein in the femoral triangle.

24. 2. Otherveins in thethigh Femoralvein Continuationof thepoplitealveinproximaltotheadductorhiatus. Entersthefemoralsheath Endsposteriortotheinguinalligament, becomesexternaliliacvein ProfundaFemorisVein drainsintothefemoralvein. ObturatorVein drainsintotheinternaliliacvein.

25. NERVES OF THE THIGH IN 6 QUESTIONS

26. 1. Majornerves of thethigh 3 major nerves in the thigh, each associated with one of the 3 compartments: • Femoral nerve • anterior compartment of thigh • Obturator nerve • medial compartment of thigh • Sciatic nerve • posterior compartment of thigh

27. 2. ..femoralnerve (L2-L4) • Largestbranch of thelumbarplexus. • Entersthethighlateraltothefemoralarteryandthefemoralsheath, behindtheinguinalligament. • Inthefemoraltrianglelieson thelateralside of thefemoralartery

28. 3… obturatornerve • Entersthemedialcompartment of thighthroughtheobturatorcanal. • Suppliesmost of theadductormusclesand skin on themedialaspect of thethigh.

29. 4… sciaticnerve • Descendsin themidline of thethigh. • Endsbydividingintothetibialandcommonperonealnerves. • Innervatesallmuscles in theposteriorcompartment of thighandthenitsbranchescontinueintothelegandfoot.

30. 5… cutaneousnerves of thethigh Lateralcutaneousnerve of thethigh branch of thelumbarplexus (L2& 3) Medialcutaneousnerve of thethigh branch of thefemoralnerve Intermediatecutaneousnerve of thethigh branch of thefemoralnerve Posteriorcutaneousnerve of thethigh branch of thesacralplexus

31. NeurovascularStructuresandRelationships in AnteromedialThigh IN 6 QUESTIONS

32. 1. Femoraltriangle • Superiorlyinguinalligament • Mediallylateralborder of adductorlongus • Laterallysartorius Contents; fromlateraltomedial • Femoralnerve • Femoralsheath • Femoralartery • Femoralvein • Deepinguinallymphnodes

33. 2. Femoralsheath A funnel-shaped fascial tube Passes deep to the inguinal ligament Encloses proximal parts of the femoral vessels and creates the femoral canal medial to them. Formed by an inferior prolongation of transversalis & iliopsoas fascia • Subdivided into three smaller compartments • Lateral compartment • for the femoral artery. • Intermediate compartment • for the femoral vein. • Medial compartment • constitutes the femoral canal

34. 3. femoralcanal • Smallest of the 3 compartments of the femoral sheath • Lies between the medial edge of the femoral sheath and the femoral vein.

35. 4. femoral ring Upperopening of thefemoralcanalformedbythesmallopening at itsabdominalend. • Boundaries • Laterallyverticalseptumbetweenfemoralcanal& femoralvein. • Posteriorlysuperiorramus of thepubiscoveredbythepectineusmuscleanditsfascia. • MediallylacunarligamentAnteriorlymedialpart of theinguinalligament.

36. 5. femoralhernia Femoralsheathblendswiththetunicaadventitia of bloodvessels. a potentiallyweakarea in the abdomen Thepart of thefemoralsheaththatformsthemediallylocatedfemoralcanal is not. femoralhernia A protrusion of peritoneumforceddownthefemoralcanal, pushingthefemoralseptumbeforeit

37. 6. ..adductorcanal • Intermuscularcleft in themiddle1/3 of thethighbeneaththesartoriusmuscle • Extendsfromtheapex of thefemoraltriangletotheadductorhiatus

38. 6. ..adductorcanal • Contains • terminal part of thefemoralartery • femoralvein (liesbehindtheartery) • deeplymphvessels • saphenousnerve • nervetothevastusmedialis • terminal part of theobturatornerve • Boundaries • Anteriorlyandlaterallyvastusmedialis • Posteriorlyadductorslongus& magnus • Mediallysartorius, roofof thecanal

39. PoplIteal fossa IN 5 QUESTIONS

40. 1. Where is popliteal fossa located? • An area of transitionbetweenthethighandleg • Majorroutebywhichstructurespassfromoneregiontotheother. • Formedbetweenmuscles in theposteriorcompartments of thighandleg.

41. 2. Whataretheboundaries of thepopliteal fossa? • Superolaterally • Bicepsfemoris • Superomedially • Semimembranosus • Inferolaterallyandinferomedially • Gastrocnemius • Posteriorly • Skin & poplitealfascia (roof)

42. 3. Whatarethecontents of thepopliteal fossa? • Termination of thesmallsaphenousvein • Poplitealarteriesandveinsandtheirbranchesandtributaries • Tibialandcommonfibularnerves • Posteriorcutaneousnerve of thigh • Popliteallymphnodesandlymphaticvessels

43. 4. Nerves in thepopliteal fossa The sciatic nerve usually ends at the superior angle of the popliteal fossa by dividing into tibial nerve & common fibular nerve

44. 4. Nerves in thepopliteal fossa • tibial nerve,medial and larger terminal branch of the sciatic nerve, descends vertically through the popliteal fossa and exits deep to the margin of plantaris muscle to enter the posterior compartment of leg. • common fibular nerve, lateral, smaller terminal branch of the sciatic nerve, exits by following the medial border of the biceps femoris tendon over the lower lateral margin of the popliteal fossa, and continues to the lateral side of the leg where it swings around the neck of the fibula and enters the lateral compartment of leg

45. 5. Poplitealartery/vein • Continuation of the femoral artery • Begins as the femoral artery passes through the adductor hiatus. • Ends lateral to the midline of the leg by dividing into anterior& posterior tibial arteries. • Popliteal veinis superficial to and travels with the popliteal artery. (formationby ant. & post. tibialveins), becomesfemoralvein.