AN 1106

MOD 2

WEEK 1

Johnny Cheong

jcheong@cmcc.ca

Skeleton
Learning outcomes Classify the regions of the lower limb. Identify the bones and the related joints of the each region. Define the Pelvic girdle. Describe the main features of the following bones: hip bone, femur, tibia, fibula, calcaneus, talus, cuboid, navicular, cuneiform bones, metatarsals, phalangeal bones. Identify the skeletal structures involved in the frequent injuries of the lower limb skeleton. SKELETON I. PELVIC GIRDLE BONES Hip Bones Sacrum Femur (thigh bone) Patella (knee cup,sesamoid) Tibia (shin bone) Fibula (pin bone) REGIONS Gluteal region: Hips (lat. prominence) Buttocks (post. part) Thigh (femoral) region: Knee (genicular) region Leg (crus/crural) region: Calf = sura: post. aspect of leg Ankle (talocrural region) JOINTS Pubic symphysis Sacroilliac J. Hip J. Knee J.

II. FREE PART OF LOWER LIMB

Proximal and distal tibiofibular J. Ankle J. Interossesus membrane Subtalar J. Midtarsal J. Tarsometatarsal J. Metatarsophalangeal J. Intephalangeal J.

Tarsal bones (calcaneus, talus, navicular, cuboid, cuneiforms) Metatarsals Phalanges (digital bones)

Foot (pes) region: a) Dorsum/dorsal aspect b) Sole/plantar aspect c) Toes:1 5th d) Hallux = 1st = great toe

Know this table. We know that the spine is the axial skeleton, the lower anatomy limb are part of the appendicular skeleton. Lower limb is separated into two parts: pelvic girdle and free part of lower limb. Girdle means belt. It is called the free part of the lower limb because you can move it freely, while the pelvic girdle cannot be moved freely.

AN 1106

MOD 2

WEEK 1

Johnny Cheong

jcheong@cmcc.ca

Pelvic girdle includes the hip bone and the sacrum. You can see hip bone and sacrum. Sacrum is transient, it belongs to axial skeleton and also the pelvic girdle of the lower limb. It is the connection between axial and appendicular skeleton. Free part of lower limb includes the femur, tibia, fibula, and the foot (latin: pes). Around the pelvic girdle is the gluteal region. The most prominent part is the anterior part. The part facing the posteriorly is the buttock. Around the femur is the thigh region. Connection between the femur, patella and tibia is the knee region. Between the knee and the ankle is the leg region or crural region which is the latin word for leg. Posterior aspect for crural region is he calf. The foot has the dorsal and plantar aspect. From proximal to distal is the tarsus, metatarsus and phalanges.

AN 1106

MOD 2

WEEK 1

Johnny Cheong

jcheong@cmcc.ca

Acetabulum incorporates hyaline cartilage in a moon shape and incorporates all three bodies of the hip, this hyaline cartilage is called the lunate surface. Articular surface is not completely continuous. There is an inferiorly facing acetabular notch. The acetabulum is a synestosis joint. Know the names of all the lines (posterior gluteal line, anterior gluteal line, and inferior gluteal line), where they start and terminate (this is wear gluteal muscles attach to). Abdominal muscles attach to iliac crest and also the IT band. Iliac tubercle is attachment of IT band. Ischial tuberosity and both notches are important. She always asks the border of the obturator foramen which consists of the body of the pubis, body of the ischium, inferior ischial ramus and inferior pubic ramus.

AN 1106

MOD 2

WEEK 1

Johnny Cheong

jcheong@cmcc.ca

What attaches to the iliac tuberosity - sacroiliac interosseous ligament. There is also the auricular surface which forms the sacroiliac joint which is synovial. Border between greater pelvis and lesser pelvis is called the arcuate line. The eminence between ilium and pubis is the iliopubic eminence. Symphyseal surface permanent symphesis joint.

Complete ossification at 13-15 years. Younger than 13-15, we can see dark lines where the epiphyseal lines are on the bones. Complete fusion of ischial pubic ramus at 6-8. Fusion of ilium, ischium pubis occurs from 18-25 years of age. Triradiate cartilage is the cartilage that joins the three. Avulsion fractures occurs at the ischial tuberosity which is the site of attachment of the hamstring, shape movement over hurdle causes secondary ossification center to avulse, this occurs in the age of adolescence because secondary centers of ossification usually develop after puberty.

AN 1106

MOD 2

WEEK 1

Johnny Cheong

jcheong@cmcc.ca

Inguinal ligament ASIS attaching to pubic symphesis and pubic tubercle, area above is the groin region. It is the connective tissue dense regular fibrous, tendon of the external oblique abdominal muscle, the most inferior part of it, fixed to the bony surface of the pubic symphesis and ASIS. It is the imaginary border of the abdomen and thigh region. It reflects on the superior pubic ramus and is called the lacunar ligament. It passes over the superior pubic ramus and is called the pectineal ligament. They become border of the femoral canal. Obturator membrane is fibrous tissue that interconnects the pubic bone and ischial bone and is a syndesmosis, not completely cover Obturator foramen, under the superior pubic ramus there is a groove called the Obturator groove, between the OG and the OM is the Obturator canal. Through the canal there are numerous structures, the most important, if there is a fracture through the pubic ramus, those structures will be affected. It is anterior medial to acetabulum. Sacroiliac joint, Ilio lumbar, sacroiliac, sacrospinous ligament all transfer force from pelvic surface of sacrum t ischial spine. From the PSIS is the sacrotuberous ligament which attaches to the long posterior, ischial tuberosity. Sacrotuberous ligament also attaches the hamstring, erector spinae aponeurosis, sacral iliac ligament, and many other structures.

AN 1106

MOD 2

WEEK 1

Johnny Cheong

jcheong@cmcc.ca

Long tubular bone. Greater trochanter and lesser trochanter. Trochanter means wheel. GT is very easily palpable. In between then is the intertrochanteric line. As we move down to the shaft, there are many openings on the surface of the bone which are for nutrient arteries that enter the femur. Nutrient arteries are needed to perforate into the medullary cavity which contains red and yellow bone marrow and compact and trabecular bone. Patellar surface, two condyles, and epicondyles above the condyles. The most prominent part of the medial epicondyle is called the adductor tubercle.

AN 1106

MOD 2

WEEK 1

Johnny Cheong

jcheong@cmcc.ca

Posterior aspect of the femur. Linea aspera (aspera means rough) separated into two lips: medial and lateral. Almost all thigh muscles attach to the linea aspera. Medial lip proximal part is called the spiral line. All muscles of the thigh attach on the posterior aspect of the femur except for one muscle. They all attach to the linea aspera. The proximal part of the medial lip is called the spiral and the distal part is called the medial supraconylar line. The proximal part of the lateral lip is called the gluteal tuberosity and the distal part of it is called the lateral supracondylar line. Piriformis muscle attaches on the medial aspect of the greater trochanter and serves as the major stabilizer of the lower limb Avulsion fracture of the greater trochanter will result in the dysfunction of all muscles that attach to it. Pectineal line is attachment for pectineal muscle.

AN 1106

MOD 2

WEEK 1

Johnny Cheong

jcheong@cmcc.ca

Neck fracture is the most common. Not his hip on the xray. Your weight is transferred through the femoral neck. Why the femoral neck? Your weight is transferred through the sacroiliac joint through he femoral head then the neck. T

AN 1106 Slipped capital femoral epiphysis (SCFE):

MOD 2

WEEK 1

Johnny Cheong

jcheong@cmcc.ca

The epiphysial growth plate is weakened or fractured femoral head may slip away from the femoral neck adolescents 10-17 years of age male patients 2-3 times more often

The secondary center of ossification is located in the neck. The weakness of the epiphyseal growth plate results in slip of the head from the neck. Usually happens in adolescents due to unfused epiphyseal plate. Main symptom is referred pain to the knee.

AN 1106

MOD 2

WEEK 1

Johnny Cheong

jcheong@cmcc.ca

Tibia is a tubular bone. On proximal epiphysis are two condyles. The lateral and medial condyle. Between condyles is the intercondylar eminence. Anterior sruface of tibia has the tibial tuberosity, just lateral to it is where the IT band attaches on the Gerdys tubercle. Anterior border is easily palpable and is quite often injured in soccer players. Note that the anterior border is subcutaneous (lacking in musculature attachment). Medial malleolus can be easily palpated. Head and neck of fibula is easily palpable and is site of injury. The lateral malleolus is located on the distal epiphysis with fractures commonly occurring in this area. The interosseous membrane attaches on the interosseous border and forms a syndesmosis joint. Fusion of epiphyseal plates occurs at the age of 19. Compression fractures commonly occur in the tibia and/or fibula.

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AN 1106

MOD 2

WEEK 1

Johnny Cheong

jcheong@cmcc.ca

Lateral tibial condyle is circular. Medial concydle is more C shaped.

Lateral malleolus has a fossa with ligaments that attach to that fossa. There are grooves on both the lateral and medial malleolus for the fibularis and tibialis posterior tendon respectively.

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AN 1106

MOD 2

WEEK 1

Johnny Cheong

jcheong@cmcc.ca

Foot is organized to hindfoot, midfoot and forefoot. Hindfoot has the talus and calcaneus. Midfoot formed by tarsal bones 1-5, cuneiforms (LIM), cuboid, navicular. Forefoot includes metatarsal and phalangeal

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AN 1106 If hindfoot and midfoot are irregular bones, the forefoot bones are the long tubular bones and have apical structures (base, body, head). First toe is called the hallus and only have proximal and distal, no middle.

MOD 2

WEEK 1

Johnny Cheong

jcheong@cmcc.ca

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MOD 2

WEEK 1

Johnny Cheong

jcheong@cmcc.ca

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AN 1106

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Johnny Cheong

jcheong@cmcc.ca

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AN 1106

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Johnny Cheong

jcheong@cmcc.ca

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AN 1106

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WEEK 1

Johnny Cheong

jcheong@cmcc.ca

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AN 1106

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WEEK 1

Johnny Cheong

jcheong@cmcc.ca

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AN 1106

MOD 2

WEEK 1

Johnny Cheong

jcheong@cmcc.ca

Anterior Thigh I
Lecture outcomes Understand the general organization of the Lumbar plexus, main branches. Describe the morphology of the psoas major & iliacus muscles. Define: superficial fascia, fascia lata, cribriform fascia, saphenous opening, falciform margin. Describe superficial veins: great & small saphenous & medial marginal. Define the perforating veins & direction of the blood flow through them. Describe the cutaneous nerves of the anterior aspect of the thigh region: femoral br. of genitofemoral, ilioinguinal n, lateral femoral cutaneous n (anterior & posterior divisions), anterior intermediate cutaneous femoral n & anterior medial cutaneous femoral n. Describe: lateral cutaneous br. of APR T12 & L1 spinal nn. Understand the lymphatic drainage of the lower limb.

Moore KL, Dalley AF, Agur AM. Clinically Oriented Anatomy. Wolters Kluwer/Lippincott Williams&Wilkins, 7th edition, 2014, pp: 532- 537; 539 -541.

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AN 1106

MOD 2

WEEK 1

Johnny Cheong

jcheong@cmcc.ca

Psoas major is deep to quadratus lumborum, multifidus, and erector spinae. Compression of the nerve within the muscle causes many problems in the lower limb. The extrapelvic abdominal part of the psoas muscle crosses the pelvic wall and attaches on the lesser trochanter. Extension of hip stresses psoas. Osteoarthritis of hip joint in patient + extension will cause the fibers of the psoas to press on the fibrous capsule, resulting in pain. Posterior part of Psoas major attaches to TVPs of lumbar vertebra. Anterior part bodies + IVD + fibrous arches over VB, completely covers the posterior part of the psoas major. T12 L5 VB and IVD. Both parts of psoas major border the IVF, anterior part is anterior to IVF and posterior part is posterior to IVF. Through the foramen exits the lumbar spinal nerves. Hip extension Tight psoas compression of lumbar plexus (lumbar spinal nerves). The psoas major muscle descends along the iliac crest and attaches to the iliacus muscle. The iliacus muscle completely fills the iliac fossa The two muscles form the iliopsoas which descends superficial to the hip joint. Iliacus uses the fibrous capsule of the hip joint. As iliopsoas contracts, there will be flexion and external rotation. Myotomal innervation of the psoas major is mainly the L1 and L2 with some L3 L4. Iliacus muscle is innervated by myotomal L2 L3. Nerve supply of psoas major is by APR and iliacus is innervated by the femoral nerve.

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AN 1106

MOD 2

WEEK 1

Johnny Cheong

jcheong@cmcc.ca

Plexuses are formed by APRs. Lumbar plexus is formed by the APR of T12-L4. This plexus is between the anterior and posterior parts of the psoas muscle. Psoas major syndrome means that the muscle is tight compressing the nerve plexus causing peripheral neuropathy. Impingement or inflammation of certain areas will cause pain and dysfunction of lower limbs. Its important to know placement of lumbar plexus nerves in order to isolate the exact area of injury. Iliohypogastric is L1-T12 and ilioinguinal nerve L1. Anterior part of L2 L3 L4 join and each of the nerves that passes through the obturator canal pass to the medial thigh and is called the obturator nerve. Femoral nerve is formed by the posterior part of L2 L3 L4. Lateral femoral cutaneous nerve supplies the skin of the lateral thigh region formed by the posterior portion of APR of L2 L3. How the nerve exits will not be asked on the exam, but still we should be familiar with it. Genitofemoral nerve branches, innervating area skin just anterior thigh over the groin, inguinal ligament and proximoanterior thigh and second branch into the genitalia. Thus, appendicitis cases referred pain to these areas because increased inflammation compresses the genitofemoral nerve.

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AN 1106

MOD 2

WEEK 1

Johnny Cheong

jcheong@cmcc.ca

Iliac fascia covers iliac muscle and descends to form fascia lata. IN the area just inferior to the inguinal ligament is the femoral triangle. In the femoral triangle, the fascia lata divides into two layers, the superficial layer of fascia lata and the deep layer lies about psoas major and iliacus, in between the two muscles is the femoral nerve.

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AN 1106 Lateral femoral cutaneous nerves crosses the iliac fossa (usually appendix is here) perforates the inguinal ligaments deep to fascia lata and from that point we cant see it, at 1 inch below, it bifurcates to two branches. LFC does not supply inferior to ASIS, instead we have the lateral cutaneous branches T12-L1 iliohypogastric nerve. Lateral femoral nerve separates fascia about one inch below the spine and the becomes cutaneous supplying lateral skin for lateral aspect of thigh. Genitofemoral nerves have the femoral and genital branch. Femoral branches perforate deep to inguinal ligament and then they start to perforate the superficial layer of fascia lata which means this branches supplies skin just below inguinal ligament.

MOD 2

WEEK 1

Johnny Cheong

jcheong@cmcc.ca

Within the femoral triangle L1 dermatome and L2 dermatome within this triangle we have femoral branch of genitofemoral nerve and laterally are two more nerves, T12 lateral cutaneous and iliohypogastric L1 also lateral cutaneous nerve, at anteromedial aspect is the ilioinguinal nerve passing through the inguinal canal supplying the skin for the anteromedial aspect of the femoral triangle. Area below the iliac crest is innervated by the lateral cutaneous branches of T12 lateral cutaneous and L1 iliohypogastric, femoral branches of genitofemoral nerve and ilioinguinal nerve. I will clarify this and post updates.

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AN 1106 Femoral nerve descends deep to inguinal ligament and immediately splits into anterior part and posterior part. Anterior part goes to the skin. Posterior part provides motor branches. Femoral nerve does not supply any skin in femoral triangle. It perforates the fascia at three inches below inguinal ligament. Anterior part innervates midline, lateral and anteromedial skin and the knee joint. The nerve terminates in the fibrous capsule for knee joint.

MOD 2

WEEK 1

Johnny Cheong

jcheong@cmcc.ca

Lateral femoral cutaneous nerve goes through iliac fossa and then can pass either deep or superficial to inguinal ligament/sartorius but will be deep to fascia lata. Poster branch of LFC supplies skin over greater trochanter down to midpoint of posterolateral thigh. Anterior branch perforates fascia a little lower and takes over anterolateral skin down to the knee joint. Compression of this nerve causes neuroalgia parasthetica.

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AN 1106

MOD 2

WEEK 1

Johnny Cheong

jcheong@cmcc.ca

Blood flows only in one direction. If valves do not work properly, there will be the formation of varicose veins.

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AN 1106

MOD 2

WEEK 1

Johnny Cheong

jcheong@cmcc.ca

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AN 1106

MOD 2

WEEK 1

Johnny Cheong

jcheong@cmcc.ca

Anterior compartment of the thigh II

Learning outcomes Describe the fascia lata & the compartments of the anterior thigh region. Describe the muscles of the anterior compartment of the thigh. Define: neuromuscular & vascular lacunae (contents), femoral sheath, femoral triangle, femoral canal, & femoral hernia. Describe the boundaries, walls, contents of the above structures. Describe the walls & contents of the adductor canal. Describe the femoral artery & its branches within the anterior thigh region. Describe the femoral nerve: divisions, nerve branches. Define the spinal cord segments tested by the Patellar Deep tendon reflex. Understand the clinical applications of the muscular & neurovascular structures of the anterior thigh region.

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AN 1106

MOD 2

WEEK 1

Johnny Cheong

jcheong@cmcc.ca

1. Fascia lata: Laterally is thickened forming Iliotibial tract/band Bifurcates within femoral triangle into 2 laminae: superf.& deep 2. Saphenous opening Saphenous varix (abnormal dilation of terminal part of GSV) 3. Crural fascia 4. Popliteal fascia 5. Dorsal & Plantar deep fasciae of foot 6. Retinaculae 7. Intermuscular septa

As soon as you dissect the subcutaneous tissue, you will see the deep fascia which has a special name in the thigh, it is called the fascia lata because it is very wide. FL as it descends into the crus region becomes the crural fascia and then the plantar fascia. FL has fibers in multiple directions to prevent subluxation from forces from different angles. On the top we have the inguinal ligament which is dense regular CT. This is the approximate border of abdomen and thigh region. FL within the triangular space called the femoral triangle bifurcates, one layer is superficial and one is deep. Superficial layer of FL has falciform margin and it borders the saphenous opening, great saphenous vein which is superficial vein of lower limb which passes in front of malleolus it is continuous with medial marginal vein on the anteromedial aspect of leg region and hidden behind knee condyle and emerges crossing superficial layer of FL into the saphenous opening draining into femoral vein. If femoral vein is blocked for some reason (pregnancy), preventing drainage there will be saphenous varix, dilation of distal portions of veins renaming it varicose.

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AN 1106

MOD 2

WEEK 1

Johnny Cheong

jcheong@cmcc.ca

This is the mid-thigh region. Femur in the middle. Orange and purple layers are the skin and subcutaneous tissue. Note that the great saphenous vein is in the superficial layer. FL form the extension towards the bone and this extension serves as site of muscle attachment in thigh region, these are called the intermuscular septum and their primary purpose is for muscle attachment. Lateral side has one and medial side has two. IS isnt meant to divide, it provides attachment of different compartments of the thigh region. Lateral, posterior and medial compartments are all attached to FL and contraction of one compartment will stimulate opposite contraction of the opposite muscle. Posterior compartment has hamstring muscles and sciatic nerve. Medial compartment has adductor muscles. Anterior compartment has the quadriceps femoris muscles, there are four heads and superficial to those four heads is the tailors muscle (this is another name for the sartorius). Since quadriceps are huge, instead of calling them heads, they are called vastus. Femoral in the anterior compartment. Obturator in the medial compartment. Sciatic in the posterior compartment.

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AN 1106

MOD 2

WEEK 1

Johnny Cheong

jcheong@cmcc.ca

FROM 1. Sartorius M. L2L3 tailors muscle Ant. Sup. il. sp. Notch below spine

TO Proximal medial surface of tibial shaft

INNERV N. to sartorius (femoral)

FUNCTION Flexes thigh Flexes leg Lat. rotates & abducts thigh & leg Extends leg Rectus fem. flexes thigh at hip joint

2. Quadriceps femoris L2L3L4 a) Rectus femoris b) Vastus lateralis

Ant. inf. il. sp. ilium sup. to acet. fibrous cap. of hip j. greater throcanter prox. 2/3 intertroch. line lat. lip. (prox. ) lat. intermuscular s. medial lip inf. intertrochan. line spiral line medial intermuscular s. ant. + lat. surf. of prox. 2/3 femoral shaft +lat.lip Ant. inf. part of femoral shaft

common tendon

N. to rectus f. (femoral)

via patellar lig. and medial and lateral patellar retinacula

N. to vastus lat. (femoral)

c) Vastus medialis

tibial tuberosity & anterior proximal aspect of tibial condyles

N. to vastus med. (femoral)

d) Vastus intermedius 3. Articularis genus L2L3

N. to vastus interm. (femoral) Synovial membrane (suprapatellar reflexion) of knee joint Femoral N.: n. to vastus intermedius Retracts synovial suprapatellar reflexion from entrapment between artic. surf. during knee extension

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AN 1106 Anterior Thigh: Muscles

MOD 2

WEEK 1

Johnny Cheong

jcheong@cmcc.ca

Deepest layer is a small muscle located in the inferior 1/3 of the anterior thigh region. It attaches to synovial membrane of the knee joint. Flexion of knee stretches the fold. When you extend your knee, the fold is pulled taut by the articularis muscle to prevent pinching by the knee joint because the fold is elastic. Next of the muscle is the vastus intermediate which attaches on the shaft proximal to the upper third of the shaft on the anterolateral aspect and lateral to the linea aspera. It covers the articularis genus muscle.

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AN 1106 Quadriceps Femoris

MOD 2

WEEK 1

Johnny Cheong

jcheong@cmcc.ca

There are three other heads of the quadriceps femoris. On the lateral side is the vastus lateralis, medial side is the vastus medialis, and in the middle is the rectus femoris muscle. Vastus lateralis is the largest head attaching on the proximal 2/3 of the intertrochanteric line of greater trochanter and attaches lateral intermuscular septum all the way down and at the back laterally of the linea aspera femoris and forms the common tendon. VL is covered up by the IT band. In hip replacement, they cut the IT on the lateral band which exposes the femoral neck. Vastus medialis attaches on the inferior 1/3 of the innertrochanteric line and then it attaches on the medial intermuscular septum all the way down and the medial side of linea aspera. On the distal end of the vastus medialis, we can see that the muscle fibers change direction and become oblique to counteract the pulling force of the vastus lateralis on the patella. It is covered by Sartorius. You can only see the anterior 1/3. Rectus femoris has two heads, a straight head and an oblique head. Straight head of Rectus femoris attaches on AIIS. The oblique head attaches just superior of acetabulum just below AIIS, fusing with the fibrous capsule of hip joint. The distal head of the rectus femoris attaches to the common tendon of the knee. The common tendon of the knee attaches to the superior surface of patella, lateral and medial surfaces of the patella, over the patella over its apex and descends from apex as a chord like ligament attaching on tibial tuberosity. Some fibers from vastus lateralis and vastus medialis attach to the tibial condyles of their respective sides and these fibers are called the lateral patellar retinaculum and

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AN 1106

MOD 2

WEEK 1

Johnny Cheong

jcheong@cmcc.ca

medial patellar retinaculum respectively. It is important to note that the quadriceps femoris tendon keeps the patella in its articular facet keeping it in the middle so if one of the heads is somehow weakened by neuropathy, then patella will be displace causing pain deep to the patella, inflammation, calcification of cartilage, etc. Sartorius attaches to the ASIS and small groove below, descends superior to vastus medialis and posterior to medial condyles of femur and tibia attaching to the anteromedial side just inferior to the tibial tuberosity. When Sartorius contracts, we have flexion of the knee and the hips and externally rotates and abduct thigh. This is the position of the tailors when they are sowing, hence why the Sartorius is also called the tailors muscle. Rectus femoris is the only head that crosses the hip joint. Entire quadriceps femoris muscle extends the leg at knee joint and only one head (rectus femoris) flexes thigh at hip joint.

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AN 1106

MOD 2

WEEK 1

Johnny Cheong

jcheong@cmcc.ca

Femoral triangle is made up of three borders. Superior border is the inguinal ligament. Lateral border is the medial border of the Sartorius. Medial border is the medial margin of the adductor longus muscle. Part of the FT is formed by the extrapelvic part of the iliopsoas that attaches to the lesser trochanter. The other two muscles will be touched on next week. The fascia within the FT is bifurcated to superficial and deep. Nerves, arteries and veins enter/exit the FT and the fascia bifurcates to protect these structures. Note that the fascia lata is not included in this diagram.

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AN 1106

MOD 2

WEEK 1

Johnny Cheong

jcheong@cmcc.ca

Femoral triangle: borders, walls, contents, surface anatomy Femoral nerve branches right away and you can see subcutaneous nerves already in the diagram. Note that it is important to know the surface anatomy. There may be a picture on the exam of a leg and you will need to identify the muscle, so know the image to the right.

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AN 1106

MOD 2

WEEK 1

Johnny Cheong

jcheong@cmcc.ca

Inguinal ligament from ASIS to pubic symphisis. Some fibers reflect on the superior pubic ramus called the lacunar ligament. Some fibers proceed to superior pubic ramus changing names to pectineal ligament. PL passes towards inguinal ligament forming the iliopectineal arch enclosing the vascular lacuna. Inside the lacuna are the femoral artery, femoral vein and femoral lymph. There is also the neuromuscular lacuna just posterolateral to the vascular lacuna which has nerves passing through and the illiopsoas. The iliopectineal arch is incredibly strong just like bone, why? Why is there the need to separate the nerve from other strucutres? Herniations occur when there is displacement of structures form one region to another. In this situation, the small intestines are displaced into the anterior thigh through the femoral canal which is why this herniation is called the femoral herniation. If abdominal pressure increases pushing small intestines into the femoral ring displacing the femoral lymph nodes entering the femoral canal between the two layers of the fascia lata and exits through the femoral saphenous opening. Initial stage of herniation results in a bump in the anterior thigh. If there is an inguinal herniation, there will be a bump above the inguinal ligament. Femoral sheath is the connective tissue that enwraps your femoral artery, femoral vein and femoral lymph nodes.

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AN 1106 Summary

MOD 2

WEEK 1

Johnny Cheong

jcheong@cmcc.ca

Femoral Triangle Boundaries: - Superior inguinal liagement - Medial adductor longus (medial border) - Lateral medial border of sartorius Floor illiopsoas muscle, pectineus muscle, adductor muscle, deep lamina of fascia lata Contents: 1. Neuromuscular lacuna iliopsoas and femoral nerve 2. Vascular lacuna femoral sheath a. Femoral artery b. Femoral vein c. Femoral ring with deep inguinal lymphatic node Femoral sheath - Femoral sheath: formed by prolongation for transversalis and iliopsoas fasciae posterior to the inguinal ligament - There are 3 compartments: o Lateral compartment femoral artery and femoral branch of genitofemoral nerve o Intermediate compartment femoral vein o Medial compartment femoral ring with deep inguinal lymph node - Femoral ring boundaries: o Medial lacunar ligament o Lateral connective tissue septum o Posterior pectineal ligament o Anterior inguinal ligament - Femoral ring covered by the parietal peritoneum internally ad by the deep lymphatic node externally - Femoral ring site of femoral herniation

Femoral canal - Internal opening: femoral ring (deep inguinal lymphatic node, peritoneum) - External opening saphenous opening - Walls: o Anterior superficial (anterior) lamina of fascia lata o Posterior deep (posterior) lamina of fascia lata o Lateral femoral vein o Medial fused two laminae of fascia lata at the medial border or adductor longus muscle - Clinical: femoral herniation (more often in females)

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AN 1106 Subsartorial Canal

MOD 2

WEEK 1

Johnny Cheong

jcheong@cmcc.ca

Sartorius, rectus femoris, IT band is cut. We can see the vastus medialis, lateralis and intermedius. We can also see the adductors. At the inferior angle of the femoral triangle, the contents disappear deep to the Sartorius into the subsartorial canal which starts at inferior angle of triangle descending to the posterior region of the knee opening into the popliteal fossa. The medial wall of subsartorial canal is formed by the adductor magnus, the lateral wall is formed by the vastus medialis and the anterior wall is formed by the membrane that bridges adductor magnus and vastus medialis. The openings within the tunnels are the superior entrance, inferior opening and anterior opening. We cant see the inferior opening because it opens to the posterior aspect of the knee. Femoral artery and vein enter the tunnel and pass through the entire length of the tunnel and enter the posterior aspect of knee changing names to popliteal artery and vein. The femoral nerve enters the neuromuscular lacuna immediately splits to anterior and posterior divisions. Anterior divisions split to three nerves, sartorius, and anterior femoral cutaneous nerves (intermediate and medial) which are cut in this diagram. First nerve goes to rectus femoris. Second nerve goes to vastus lateralis descending to the knee joint. Third nerve goes to intermedius. Two nerves enter the canal. The most medial nerve that enters the canal is the saphenous nerve which exits through the anterior saphenous opening deep to Sartorius, follows the Sartorius exiting at the tendon of the sartorius medial to the tibial tuberosity, penetrating the crural fascia. To do nerve point technique, you must press medial to tibial tuberosity to hit the saphenous nerve.

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AN 1106 Summary

MOD 2

WEEK 1

Johnny Cheong

jcheong@cmcc.ca

Adductor canal/subsartorial/hunter canal Walls: Medial: adductor longus (superiorly) + adductor magnus Lateral: vastus medialis Anterior: aponeurotic fibrous membrane (vastoadductorial) between vastus medialis and adductors (longus and brevis)

Openings Superior at the apex for femoral triangle o Femoral Artery o Femoral Vein o Saphenous Nerve o Nerve to Vastus Medialis o Perivascualr Sympathtic nerve plexus Anterior in the vastoadductorial membrane o Saphenous Nerve o Descending Genicuar Artery & Vein Inferior between tendon of adductor magnus (adductor hiatus) o Femoral Artery o Femoral Vein o Articular branch of post. Division of the Obturator Nerve

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AN 1106 Clinical Implications

MOD 2

WEEK 1

Johnny Cheong

jcheong@cmcc.ca

Stretch reflex causes contraction of quadriceps resulting in extension of knee. Patellar reflex tendon reflex is used to test the femoral nerve and L2 L3 L4 spinal cord segments.

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