Anterior and Medial Thigh

part of the femoral vein is susceptible to deep vein thrombosis

-*After the deep femoral artery branches off*, the main artery is then *termed the superficial femoral artery*. This nomenclature can be misleading and potentially dangerous since the femoral artery, and the femoral vein that accompanies it, are *still deep structures*. This part of the femoral vein is *susceptible to DVT*, a potentially life-threatening condition that would not occur directly from a "superficial" vein

Femoral artery trauma

-*Cardiac catheterization to the left side of the heart* is one of the causes of femoral artery false aneurysm (pseudoaneurysm).

*profunda femurs vein*

- formed by the union of perforating veins that correspond to the perforating branches of the profunda femoris artery.

vastus intermedius

- lies deep to the other three parts of the quadriceps femoris. It arises from an extensive portion of the anterior and lateral surfaces of the femoral shaft

*great saphenous vein*

- typically enters the femoral vein several centimeters below the inguinal ligament.

*medial and lateral femoral circumflex veins*

- typically run with the arteries and terminate in the femoral vein, but could terminate in profunda femoris vein instead.

femoral ring

-The small, proximal abdominal opening of the femoral canal -The femoral ring is the *site of femoral hernias*. These hernias are *more common in females* because they tend to have a wider pelvis. -Because of the rigidness of the femoral rings, herniated structures can become strangulated when their blood supply is compromised

Adductor brevis

-This muscle lies *deep to the pectineus* and adductor longus. -It *originates from the body and inferior ramus of the pubis* -*it inserts* into the lower 2/3's of the pectineal line and upper half of the medial lip of the linea aspera. -It *adducts the thigh and weakly flexes it*.

perforating branches

-Typically *three branches leave the profunda femoris artery and pass posteriorly* close to the femur through perforations in the adductor magnus muscle. *The termination of the profunda femoris* artery is considered the *fourth perforating branch* -supplies the adductor muscles, gluteus maximus, and posterior thigh muscles.

Patella

-a large *sesamoid bone* within the tendon of the quadriceps femoris. -*articular (posterior) surface has two facets* for *articulating with the medial and lateral condyles of the femur*. -The patella functions to *protect the knee joint and to improve the angle of approach of the quadriceps* femoris tendon to the tibial tuberosity

Femoral canal

-a potential space that contains a slight amount of loose connective tissue and a few lymphatic vessels and the *deep inguinal lymph nodes*

Muscles in the gluteal region are largely?

-abductors and lateral rotators of the thigh.

deep vein thrombosis (DVT)

-predisposed to forming during *vascular stasis* (e.g. due to limb immobility), *injury to vessel wall* (e.g. vessel trauma), or under *hypercoagulability conditions* (e.g. pregnancy and cancer). -DVT may produce local pain, redness, and swelling. A potentially lethal sequelae to DVT is pulmonary embolism.

angle of torsion (angle of declination)

-the *angle between the axis of the femoral neck and the transverse axis* that passes through the femoral epicondyles. -Normally this angle is about 12 -14°. -*Anteversion* is an increase in the angle of torsion and leads to a *"toeing in"* gate -*retroversion* is a decrease in this angle and leads to a *"toeing out"* gate

Angle of inclination

-the angle between the axis of the femoral head and neck and the axis of the shaft. -This angle changes with age, being large in youth and smaller in old age. The average adult angle is 126° -A decrease in this angle leads to *coxa vara* which shortens the lower limb and limits abduction of the hip. An increase in this angle leads to *coxa valga* which lengthens the lower limb

muscular branches

-to anterior and medial thigh muscles

medial circumflex femoral artery

-usually arises from the medial aspect of the profunda femurs artery -passes deeply between the pectineus and the iliopsoas (and then the obturator externus and adductor brevis muscles) and reaches the gluteal region by passing between the quadratus femoris and the adductor magnus -distribution - to the adductor compartment and gluteal muscles, and to the hip joint

Movements at knee

Flexion, extension, internal rotation, and external rotation

profunda femoris artery

a large vessel *arising from the lateral and posterior portion of the femoral artery*, about 2-5 cm inferior to the inguinal ligament -course - Initially lies lateral to the femoral artery. It then passes posterior to the femoral artery and vein. It lies anterior to the pectineus and adductor brevis and passes posterior to the adductor longus on the medial side of the femur. It ends as the fourth perforating branch that pierces the adductor magnus near the femur -branches a. medial circumflex femoral artery b. lateral circumflex femoral artery c. perforating branches d. cruciate anastomosis

Branches of the Femoral artery

a. superficial circumflex iliac artery b. superficial epigastric artery c. superficial external pudendal artery d. deep external pudendal artery e. muscular branches f. profunda femoris artery g. descending genicular artery

Femoral artery

-*begins immediately below the inguinal ligament* as the *continuation of the external iliac artery* -After passing deep to the inguinal ligament, the *femoral artery bisects the femoral triangle*. It courses *through the adductor canal* and passes *through the adductor hiatus*, at which point it *enters the popliteal fossa* -->*termed the popliteal artery*

The posterior muscle group contains

-*extensors of the hip* and *flexors of the knee* and is *innervated by the tibial portion of the sciatic nerve*.

Nerves to anterior and medial thigh muscles

-Femoral nerve -Obturator nerve -Tibial nerve

vastus medialis

-arises from the lower portion of the intertrochanteric line, the medial lip of the linea aspera, and the medial intermuscular septum

Obturator vein

-begins *in the adductor compartment of the thigh*. It *enters the pelvis through the obturator canal* and empties *into the internal iliac vein*.

Popliteal artery

-continuation of the femoral artery *after it passes through the adductor hiatus*. -*femoral artery* is the main vascular channel that spans from the inguinal ligament *to the adductor hiatus*

The medial muscle group

-formed by *hip adductors* and is *innervated by the obturator nerve*

cruciate anastomosis

-formed by branches from four arteries around the hip joint. These vessels are the inferior gluteal, medial and lateral circumflex, and first perforating arteries.

node of Cloquet or Rosenmüller

-one of the deep inguinal lymph nodes lies in the femoral ring

The *fibula*

-the thin, lateral bone of the leg that has a knob-like head that is surmounted by an apex.

common sites for deep vein thrombosis

-The femoral, deep femoral, and popliteal veins

Obturator nerve

-*arises from anterior branches of L2, L3, and L4*. It passes through the obturator canal into the thigh and divides into an anterior and a posterior branch. -*The anterior branch* descends on the surface of the adductor brevis, deep to the pectineus and adductor longus. -*The posterior branch* descends posterior to the adductor brevis, under the deep fascia of the adductor magnus. *distribution*: 1) muscular branches to adductor longus, gracilis, adductor brevis, adductor magnus, obturator externus, and sometimes to pectineus. 2) articular branches to hip and knee joints 3) variable cutaneous branches to medial aspect of lower thigh.

Femoral nerve

-*arises from the lumbar plexus*, from the posterior divisions of the ventral rami of L2, L3, and L4. -enters the thigh posterior to the inguinal ligament, deep to the iliac fascia, where it lies on the surface of the iliopsoas muscle, just lateral to the femoral artery.-breaks up into a number of muscular and cutaneous branches. *distribution*: 1) muscular branches to sartorius, quadriceps femoris, iliacus, and usually pectinous 2) cutaneous branches - anterior femoral cutaneous and saphenous nerves 3) articular branches to hip and knee.

Obturator artery

-*arises within the pelvis from the internal iliac artery*. -passes on the lateral wall of the pelvis to the obturator canal which it passes through to reach the thigh. -*branches and distribution*: a. *anterior* - helps to *supply the obturator externus, pectineus, adductor muscles, and gracilis*. b. *posterior* - helps to *supply the hip joint and the muscles that attach to the ischial tuberosity*.

The anterior group of thigh muscles

-*contains flexors* of the hip and *extensors of the knee* and is *innervated by the femoral nerve*

lateral circumflex femoral artery

-*from the lateral aspect of the profunda femurs* artery -passes laterally *between the divisions of the femoral nerve* and deep to the sartorius and rectus femurs -branches and distribution (1) *ascending* - courses superiorly, deep to the tensor fasciae latae to the lateral aspect of hip. (2) *transverse* - courses laterally and winds around the femur below the greater trochanter and participates in the cruciate anastomosis. (3) *descending* - courses inferiorly, deep to the rectus femoris and anterior to the vastus lateralis to the knee where it participates in the genicular anastomosis

Tibial nerve

-*part of the sciatic nerve and has L4 - S3 spinal cord segments* -*leaves the pelvis via the greater sciatic foramen* and passes inferior to the piriformis muscle. It descends between the greater trochanter and ischial tuberosity along the back of the thigh. *distribution*: In the thigh, the tibial nerve *innervates the hamstring muscles* which includes the ischiocondylar part of the adductor magnus.

Medial thigh muscles

-All these muscles arise from the external surface of the pubic ramus and/or the ramus of ischium and are *innervated by the obturator nerve*. -*Most of these muscles are adductors*. They are separated from the extensors of the knee by the medial intermuscular septum (at least distally)

Iliopsoas

-As seen in the thigh, this muscle is a *combination of the distal parts of, the iliacus and the psoas major*. -These muscles converge in a strong tendon that passes posterior to the inguinal ligament and anterior to the hip joint capsule before *attaching to the lesser trochanter*. -It is a *strong flexor of the thigh*

Deep Veins of anterior and medial thigh

-Femoral vein -Obturator vein

Movements of thigh at hip joint

-Flexion, extension, abduction, adduction, internal rotation, external rotation, and circumduction

Gracilis

-Found on the medial side of thigh as a long, thin muscle. -*Arises from the inferior pubic ramus* -*inserts into uppermost portion of shaft of tibia* as part of the *pes anserinus*. -*It adducts the thigh and assists in flexing and medially rotating the leg*

Boundaries of Femoral Ring

-Lateral = partition between the femoral canal and femoral vein -Medial= lacunar ligament -Posterior =superior ramus of pubis covered by pectineus -Anterior = medial part of inguinal ligament.

Obturator externus

-Lies *deep to the origins of the adductor muscles*. -It *arises from the external part of the superior and inferior pubic rami, ramus of ischium and the external surface of the obturator membrane* -*inserts into the trochanteric fossa* after passing posterior to the capsule of the hip joint. This muscle *laterally rotates the thigh*

quadriceps tendon/patellar ligament rupture

-Rupture of the quadriceps tendon is most common in *people over 40*, while patellar ligament rupture occurs more often in *people under 40*. -This injury frequently occurs *during a forceful eccentric contraction of the quadriceps muscle*, such as if the knee where in a semi-flexed position with the foot planted when the quadriceps contracted strongly. -The rupture *can be partial or complete*, and frequently occurs in tendons or ligaments that previously were damaged. -*In a complete rupture*, the *patella usually lies more inferiorly than normal in quadriceps tendon ruptures* and *more superiorly than normal in patellar ligament ruptures*. -Patient may have an inability to extend the knee. -*Treatment* for complete ruptures is *surgical repair*

Adductor magnus

-The adductor magnus is a large, triangular muscle that is a combination of *two muscles with differing innervations*. -It arises *from the inferior pubic ramus, the ramus of the ischium, and from the ischial tuberosity*. -*It attaches* to the whole length of *the linea aspera*. -The uppermost fibers are horizontal and are sometimes called the adductor minims. -The most medial fibers of the main muscle (ischiocondylar portion) run vertically downward after arising from the ischial tuberosity and ultimately form a rounded tendon that ends on the adductor tubercle. -The aponeurosis of insertion has openings adjacent to the femur for passage of the perforating vessels. -This muscle is *a powerful adductor of the thigh*. The adductor minimus portion *may assist in flexion* of the thigh, while the ischiocondylar portion extends the thigh.

Femoral sheath

-The femoral sheath is a *fascial sleeve formed around the proximal portions of the femoral artery and vein* by extensions of the fascial laminae that line the abdominal cavity. The sleeve fuses with the vascular fascia about 3 - 4 cm distal to the inguinal ligament -two septa pass between the anterior and posterior lamina and thus form *three compartments*: a. lateral compartment contains the *femoral artery* b. intermediate compartment contains the *femoral vein* c. medial compartment contains the *femoral canal*

Adductor (subsartorial, Hunter's ) canal

-an *intermuscular tunnel* which runs between the extensors of the knee and adductors of the thigh muscles. -It is *roofed over by the sartorius* and *conducts the femoral vessels* through the middle third of the thigh -*starts* where the sartorius crosses the adductor longs -*ends* at the upper limit of the adductor hiatus -*Anterolateral is* the fascia of the vastus medialis. -*Posteromedially is* the fascia of the adductor longus and adductor magnus. -*Anteromedial or superficial is* the deep layer of the fascial sheath of the sartorial -*Content*: the femoral artery and femoral vein, *artery anterior to the vein*. *The saphenous nerve* enters the adductor canal lateral to the vessels, crosses them anteriorly, and lies medial to them at the lower end of the canal. Also found within the canal is *the nerve to the vastus medialis*. -*Only the femoral vein and artery pass through the adductor hiatus*.

Femoral triangle

-an intermuscular space in the upper 1/3 of the anteromedial thigh that lies deep to the fascia lata -sides - *the base* is the inguinal ligament, *the lateral border* is the sartorius and the *medial border* is the adductor longus. -*floor* - formed by the *iliopsoas laterally* and *pectineus medially*. These two muscles slope towards each other such that the floor forms a sulcus. -*roof - formed by fascia lata* -*content*: from lateral to medial are the *femoral nerve, femoral artery, femoral vein, deep inguinal lymph nodes and lymphatics*

superficial epigastric artery

-arises *from proximal portion of femoral artery* and ascends *anterior to the inguinal ligament* as it passes with the superficial fascia towards the *umbilicus* to supply superficial structures

superficial circumflex iliac artery

-arises *from proximal portion of femoral artery* and passes laterally, *parallel to the inguinal ligament* toward the *crest of the ilium* to supply superficial structures.

descending genicular artery

-arises *from the distal femoral artery* within the adductor canal. It immediately *divides into a saphenous branch and an articular branch to the knee*

superficial external pudendal artery

-arises *from the medial aspect of the proximal femoral artery* and courses anterior *to the spermatic cord* (round ligament) to supply the skin of the lower abdomen and of the perineum.

deep external pudendal artery

-arises *from the medial aspect of the proximal femoral artery* more deeply than SE pudendal A. It crosses the pectineus and adductor longus on its way *to the perineum*.

rectus femoris

-arises by *two heads*. The *straight head is attached to the AIIS* and the *reflected head arises from a point just above the margin of the acetabulum*. -The two tendons of origin *combine into a fusiform muscle belly*. Because the rectus femoris arises above the hip joint, it also flexes the hip, besides extending the knee.

Femoral vein

-forms as the continuation of the popliteal vein. -Passes *through the adductor canal* and lies *medial to femoral artery in the femoral triangle*. As it passes deep to the inguinal ligament, it *becomes the external iliac vein* -Tributaries 1. *profunda femurs vein* 2. *medial and lateral femoral circumflex veins* 3. *great saphenous vein*

Proximal portions of leg bones

-he *medial bone of the leg is the tibia* whose shaft flares out superiorly into medial and lateral condyles. -*The proximal end of the anterior border* of the tibia presents the *tibial tuberosity*.

A pseudoaneurysm

-is a dilated artery with disruption of one or more layers of the arterial wall (versus an aneurysm where the dilated artery has intact layers.) -The pseudoaneurysm *can compress surrounding structures* such as nerves and veins, leading to localized or radiating pain and impaired venous flow and edema. -Additional complications include *emboli or thrombus* formation, atriovenous fistulae, and infection. -Management can include close observation to await *spontaneous healing, compression (either blind or ultrasound-guided), ultrasound-guided percutaneous thrombin injection, or open surgical repair*

Pectineus

-is a flat, quadrangular muscle that *forms the medial part of the floor of the femoral triangle*. -It arises *from the pecten pubis* and *inserts into the pectineal line of the femur*. -It *adducts and flexes the thigh*

Sartorius

-is a long, strap-like muscle that crosses both the hip and the knee. -It *arises from the ASIS* -*inserts on the upper medial surface of the tibial shaft* (close to two other muscles, the gracilis and semitendinosus. This trio of tendons forms the *pes anserinus*). -*flexes both the hip and knee* and assists in *lateral rotation*, as well as *abduction of the femur*

articularis genu

-is a small muscle that lies deep to the inferior part of the vastus intermedius. -It arises from the distal, anterior surface of the femur and inserts into the suprapatellar bursa which it can *retract during knee extension*, presumably to prevent entrapment of the bursa between the patella and femur

Adductor longus

-is the *most anterior* of the three adductor muscles. -It lies in the same plane and just medial to the pectineus. The adductor longus *arises from the superior ramus of the pubis* -*inserts* by a thin, wide tendon into the middle 1/3 of the medial lip of the linea aspera. -This muscle *adducts the thigh and assists in its flexion*.

vastus lateralis

-it covers most of the lateral surface of the femur -it is separated from the bone by the underlying vastus intermedius. -it arises mainly from the posterior surface of the femur on the *lateral lip of the linea aspera*, also from the *gluteal tuberosity*, the anterior inferior border of greater trochanter and the superior part of intertrochanteric line.

Quadriceps femoris

-on the anterior aspect of thigh -*four heads* have different origins, but they insert together via a common tendon -*strong extensor of the knee* and is very important in stabilizing the knee in any position other than full extension -The common tendon of the quadriceps femoris attaches to the base and medial and lateral borders of the patella -subdivisions: rectus femoris, vastus lateralis, vastus medialis, vastus intermedius and articularis genu