anatomy 1106 mod 2 week 1 cmcc

8/13/2019 Anatomy 1106 Mod 2 Week 1 CMCC

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AN 1106 MOD 2 WEEK 1 Johnny Cheong [email protected]

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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 BONES REGIONS JOINTS

I. PELVIC GIRDLE Hip Bones Sacrum Gluteal region: Hips (lat. prominence)

Buttocks (post. part) Pubic symphysis Sacroilliac J. Hip J.

II. FREE PART OFLOWER LIMB

Femur (thigh bone) Patella (knee cup,sesamoid) Thigh (femoral) region:Knee (genicular) region Knee J.

Tibia (shin bone) Fibula (pin bone) Leg (crus/crural) region: Calf = sura: post.aspect of leg

Ankle (talocrural region)

Proximal and distaltibiofibular J.

Ankle J. Interossesus membrane

Tarsal bones (calcaneus,talus, navicular, cuboid,

cuneiforms) Metatarsals Phalanges (digital bones)

Foot (pes) region:

a) Dorsum/dorsal aspectb) Sole/plantar aspectc) Toes:15thd) Hallux = 1st= great toe

Subtalar J. Midtarsal J. Tarsometatarsal J. Metatarsophalangeal J. Intephalangeal J.

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.


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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 andplantar aspect. From proximal to distal is the

tarsus, metatarsus and phalanges.


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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 acetabularnotch. 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 thebody of the pubis, body of the ischium, inferior

ischial ramus and inferior pubic ramus.


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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 theiliopubic eminence. Symphyseal surfacepermanent

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 hurdlecauses secondary ossification center to avulse, this occurs in

the age of adolescence because secondary centers of

ossification usually develop after puberty.


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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 bonysurface 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 Obturatorforamen, 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 tischial 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.


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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 arteriesthat 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.


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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 posterioraspect 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 greatertrochanter will result in the dysfunction of all muscles

that attach to it. Pectineal line is attachment for

pectineal muscle.


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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


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Slipped capital femoral epiphysis (SCFE):

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.


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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 bandattaches 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 onthe 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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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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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 includesmetatarsal and phalangeal


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If hindfoot and

midfoot are irregular

bones, the forefoot

bones are the long

tubular bones andhave apical structures

(base, body, head).

First toe is called the

hallus and only have

proximal and distal, no

middle.


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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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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 thepelvic 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 partbodies + IVD + fibrous arches over

VB, completely covers the posterior part of the

psoas major. T12L5 VB and IVD. Both parts ofpsoas 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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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 plexuscausing 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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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, thesuperficial 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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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, at1 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.

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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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 nerveterminates in the fibrous

capsule for knee joint.

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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Blood flows only in one direction. If valves do

not work properly, there will be the formation

of varicose veins.


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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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1. Fascia lata:

Laterally is thickened forming Iliotibial tract/band Bifurcates within femoral triangle into 2 laminae: superf.&

deep

2. Saphenous opening Saphenous varix (abnormaldilation 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 crusregion 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 continuouswith 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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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. Posteriorcompartment 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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FROM TO INNERV FUNCTION

1. Sartorius M.

L2L3

tailors muscle

Ant. Sup. il. sp. Notch below spine Proximal medial surfaceof tibial shaft N. to sartorius (femoral) Flexes thigh Flexes leg

Lat. rotates &abducts thigh & leg2. Quadriceps

femoris

L2L3L4

a) Rectus femoris

common tendon

via patellar lig. and

medial and lateral

patellar retinacula

tibial tuberosity &

anterior proximal

aspect of tibial condyles

Extends leg Rectus fem. flexes

thigh at hip joint

Ant. inf. il. sp. ilium sup. to acet. fibrous cap. of hip j.

N. to rectus f. (femoral)

b) Vastus lateralis greater throcanter prox. 2/3intertroch. line lat. lip. (prox. ) lat. intermuscular s.

N. to vastus lat. (femoral)

c) Vastus medialis medial lip inf. intertrochan. line spiral line medial intermuscular s.

N. to vastus med.

(femoral)

d) Vastus

intermedius

ant. + lat. surf. of prox. 2/3femoral shaft +lat.lip

N. to vastus interm.

(femoral)

3. Articularis

genusL2L3

Ant. inf. part of femoralshaft

Synovial membrane

(suprapatellar reflexion)

of knee joint

Femoral N.: n. to vastus

intermedius

Retracts synovialsuprapatellar reflexion

from entrapment

between artic. surf.

during knee extension


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Anterior Thigh: Muscles

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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Quadriceps Femoris

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 theanterior 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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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 paindeep 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 f lexion 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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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 formedby 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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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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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 archenclosing thevascular 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 sheathis the connective tissue that enwraps your femoral artery,

femoral vein and femoral lymph nodes.


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Summary

Femoral Triangle

Boundaries:

- Superioringuinal liagement- Medialadductor longus (medial border)- Lateralmedial border of sartorius

Floorilliopsoas muscle, pectineus muscle, adductor muscle, deep

lamina of fascia lata

Contents:

1. Neuromuscular lacunailiopsoas and femoral nerve2. Vascular lacunafemoral sheath

a. Femoral arteryb. Femoral veinc. Femoral ring with deep inguinal lymphatic node

Femoral sheath

- Femoral sheath: formed by prolongation for transversalisand iliopsoas fasciae posterior to the inguinal ligament

- There are 3 compartments:o Lateral compartmentfemoral artery and femoral

branch of genitofemoral nerve

o Intermediate compartmentfemoral veino Medial compartmentfemoral ring with deep

inguinal lymph node

- Femoral ring boundaries:o Mediallacunar ligamento Lateralconnective tissue septumo Posteriorpectineal ligamento Anterioringuinal ligament

- Femoral ringcovered by the parietal peritoneuminternally ad by the deep lymphatic node externally

- Femoral ringsite of femoral herniation

Femoral canal

- Internal opening: femoral ring (deep inguinal lymphaticnode, peritoneum)

- External openingsaphenous opening- Walls:

o Anteriorsuperficial (anterior) lamina of fascia latao Posteriordeep (posterior) lamina of fascia latao Lateralfemoral veino Medialfused two laminae of fascia lata at the

medial border or adductor longus muscle

- Clinical: femoral herniation (more often in females)


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Subsartorial Canal

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 canalwhich starts at inferior

angle of triangle descending to the posterior

region of the knee opening into the popliteal

fossa. The medial wallof subsartorial canal is

formed by the adductor magnus, the lateral

wallis formed by the vastus medialisand the

anterior wall is formed by the membranethat

bridges adductor magnus and vastus medialis.

The openings within the tunnels are the superior

entrance, inferior opening and anterior

opening. We cantsee the inferior opening

because it opens to the posterior aspect of the

knee. Femoral artery and veinenter 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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Summary

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

- Superiorat the apex for femoral triangleo Femoral Arteryo Femoral Veino Saphenous Nerveo Nerve to Vastus Medialiso Perivascualr Sympathtic nerve plexus

- Anteriorin the vastoadductorial membraneo Saphenous Nerveo Descending Genicuar Artery & Vein

- Inferiorbetween tendon of adductor magnus (adductor hiatus)o Femoral Arteryo Femoral Veino Articular branch of post. Division of the Obturator Nerve


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Clinical Implications

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.

anatomy 1106 mod 2 week 1 cmcc

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