Topographic anatomy of the femoral triangle. Topographic anatomy of the hip Operations on the vessels of the lower limb

Region boundaries. The upper border of the thigh is represented in front by the inguinal folds, and behind by the gluteal folds. The lower border is drawn 6 cm above the epicondyles of the femur.

Layers. Skin, subcutaneous fat and superficial fascia make up the superficial layers of the area

Fascial frame of the thigh. The fascia proper of the thigh, or fascia lata, has three features. Firstly, it gives rise to three intermuscular septa (medial, lateral and posterior, the posterior being less pronounced). The intermuscular septa are fixed to the femur (except for the posterior one, which is displaced laterally in the lower third). The septa enclose the thigh muscles in three musculofascial beds: anterior, posterior and medial. Secondly, not all thigh muscles lie in fascial sheaths; three muscles have their own fascial sheaths. This is m. sartorius, T. gracilis and T. tensor fascii lata. Thirdly, in the upper third of the thigh, in the femoral triangle (skarpovekom), the fascia lata of the thigh has two leaves: superficial and deep. The superficial layer of the fascia lata has two sections. The lateral section, more dense, is called margo falciformis - crescent-shaped edge and limits the oval opening. The internal section is represented by a perforated plate (lamina cribrosa), through which lymphatic vessels and saphenous veins pass, flowing into the femoral vein. The largest of them is v. saphena magna. The deep layer of the fascia lata of the thigh (fascia pectinea) is a continuation of the fascia iliaca to the thigh. When forming the femoral canal, the hernial sac separates two layers of the femoral fascia.

Thigh muscles. In the anterior muscular-fascial bed is the quadriceps femoris muscle, consisting of four heads connected by a common tendon: the rectus muscle, the internal, external and intermedius muscles. The posterior muscle-fascial bed contains the biceps, semitendinosus and semimembranosus muscles of the thigh. In the inner bed there are the long, short and magnus adductor muscles of the thigh, and the pectineus muscles. The sartorius muscle, the gracilis muscle and the tensor fascia lata muscle, as noted above, lie in their own cases.

Vessels and nerves. There are two large neurovascular bundles on the thigh. The main neurovascular bundle is represented by the femoral artery, femoral vein and femoral nerve with its branches. The second neurovascular bundle is represented by the sciatic nerve and its accompanying vessels.

In the upper third of the thigh the main neurovascular pu- | ; | Ch chok (femoral artery, femoral

ff? / vein and femoral nerve) lies in

i! femoral (Skarpovsky) treu

golnik (Fig. 47).

Its boundaries: above - the inguinal ligament, laterally - the sartorius muscle, medially - the long adductor muscle. It is necessary to highlight the main topographical and anatomical features of the course of the neurovascular bundle:

1. The femoral vessels (artery and vein) lie under the femoral fascia proper in the recess between the muscles in the iliopectineal fossa on the pectineal fascia.

2. The main branches arise from the femoral artery. Superficial: superficial epigastric, superficial, circumflex iliac and external pudendal arteries. Deep: deep femoral artery, which is the main accessory collector. The medial and lateral arteries, the circumflex femoral arteries and the perforating arteries depart from the deep femoral artery. The first perforating artery departs at the level of the gluteal fold, the second and third - every

6 cm below the previous one. These arteries pierce the adductor muscles and pass to the back of the thigh through holes in the tendons of these muscles. The adventitia of the vessels is fused with the edges of these openings, so the vessels gape when wounded. These arteries can be damaged by fractures of the femur and the hematoma, growing, can spread into the popliteal fossa.

3. The femoral nerve is divided into cutaneous and muscular branches 2-3 cm below the inguinal ligament, and the saphenous nerve will then go with the femoral vessels.

4. In the region of the femoral (Skarpovsky) triangle, 3 cm below the pubic tubercle, the obturator canal opens, from which the obturator neurovascular bundle emerges.

In the middle third of the thigh, the main neurovascular bundle of the thigh (femoral artery, femoral vein and n. saphenus) from the femoral triangle passes into the anterior groove of the thigh, formed by the vastus medialis muscle and the long adductor muscle (m. adductor longus) , the groove is covered from above by the sartorius muscle. In the lower third of the thigh, the main neurovascular bundle of the thigh from the groove enters the muscular-fascial canal. This canal is called the adductor canal, the femoropopliteal canal, or the Gunter's canal. The canal has a triangular shape, it is limited: from the outside by the vastus medialis, from the inside by the adductor magnus, and in front by the lamina vastoadductoria, which is stretched between these muscles. The canal is covered in front by the sartorius muscle (m. sartorius). The channel has one inlet and two outlets. The neurovascular bundle of the femur enters the canal through the entrance hole at the upper edge of the lamina vastoadductoria. There are two exit openings: the anterior opening in the lamina vastoadductoria, through which the saphenous nerve (p. saphenus) and the descending knee artery (a. genu descendes) exit, and the lower opening (hiatus adductorius), through which the femoral vessels enter the popliteal fossa (Fig. 48).

The relationships between the vessels and nerves of the thigh in the middle third are shown on a cross section of the thigh (Fig. 49).

The sciatic nerve, the largest nerve in the human body, runs in the posterior compartment of the thigh. In the upper third of the thigh, the nerve emerges from under the edge of the gluteus maximus muscle and on the short
segment is covered only by the ossinal fascia. Here it is crossed by the long head of the biceps muscle and the nerve lies in the groove between the semitendinosus and semimembranosus muscles on one side and the biceps muscle on the other side and goes to the popliteal fossa. Throughout the entire posterior bed of the thigh, the sciatic nerve lies on the adductor magnus muscle, separated from it by the posterior intermuscular septum. In the upper corner of the knee fossa, the nerve is divided into the tibial nerve and the common peroneal nerve (n. tibialis and n. peronaeus communis) (Table 6).

Topographic anatomy of the popliteal fossa. Region boundaries. The popliteal fossa makes up the back of the knee area. The popliteal fossa is bounded superiorly and laterally by the tendon of the biceps femoris muscle, superiorly and medially by the tendon of the semitendinosus and semimembranosus muscles, and inferiorly by the heads of the gastrocnemius muscle.

Layers. The superficial layers of the area are made up of skin, subcutaneous fat and superficial fascia. The proper fascia of the popliteal fossa is a continuation

We eat the fascia lata of the thigh, here it is thicker and has an aponeurotic character - the popliteal aponeurosis. On the sides, the fascia is fused with the condyles of the femur and tibia, anteriorly it continues into the retinaculum patellae. Inferiorly, the fascia passes into the fascia of the lower leg. The bottom of the popliteal fossa is formed by the triangular platform of the femur, the back of the knee joint capsule with the oblique popliteal ligament that strengthens it, and the popliteal muscle.

Vessels and nerves. Immediately under the fascia proper in the popliteal fossa lie the branches of the sciatic nerve: the tibial nerve and the common peroneal nerve (Fig. 50).

The common peroneal nerve (n. peronaeus communis) runs outward along the inner edge of the biceps tendon, crosses the posterior surface of the outer head of the gastrocnemius muscle, adjoins the fibrous capsule of the knee joint and passes to the lateral side of the fibula. The nerve then runs along the posterior surface of the head of the fibula, bends around its neck, closely adjacent to the periosteum, and enters the superior canal of the peroneal muscles, which will be discussed below. The tibial nerve (p. tibialis), being a direct continuation of the sciatic nerve, forms with the popliteal vessels! popliteal neurovascular bundle. Deeper and medially from the tibial nerve lies the popliteal vein v. poplitea, and even deeper, between the condyles of the femur, the popliteal artery, a. poplitea, here it sharply narrows due to the emergence of lateral branches. The popliteal artery is a continuation of the femoral artery and enters the popliteal fossa from the anterior surface of the thigh through the hiatus adductorius. From the popliteal fossa, the neurovascular bundle passes to the back surface of the lower leg.

Projection lines of vessels and nerves of the thigh area:

1. The suprapiriform foramen of the gluteal region (foramen suprapiriforme) corresponds to a point that is located on the border between the upper and middle thirds of a line drawn from the posterior superior iliac spine to the apex of the greater trochanter of the femur.

2. The infrapiriform foramen (foramen infrapiriforme) corresponds to a point that is located on the border between the middle and lower thirds of a line drawn from the posterior superior iliac spine to the outer edge of the ischial tuberosity.

3. Femoral artery (a. femoralis). The projection line (Kan line) is drawn from the middle of the distance between the anterior superior iliac spine and the symphysis to the internal epicondyle of the femur (tuberculum adductorium): provided that the limb is bent at the hip and knee joints and rotated outward (Fig. 51 ).

4. Sciatic nerve (n. ischiadic us). The projection line is drawn:

a) from the middle of the distance between the greater trochanter and the ischial tuberosity to the middle of the popliteal fossa;

I ^___ „- b) from the middle of the gluteal fold to

\/(, / the middle of the distance between the supramycelium

hips at the back (Fig. 52).

5. Popliteal artery (a. poplitea). The projection is carried out 1 cm inward from the midline of the popliteal fossa.

6. Common peroneal nerve (p. peroneus communis). Projection line pro-

d leads from the upper corner of the popliteal fossa to the outer surface of the neck of the fibula; on the lower leg, the projection corresponds to a horizontal plane drawn through the base of the head of the fibula.

Cellular spaces of the thigh. In the anterior fascial bed of the thigh there are four cellular spaces:

1) fascial sheath of the neurovascular bundle;

2) superficial (muscular-fascial) space under the proper fascia of the thigh;

3) deep intermuscular space between the intermedius muscle and the posterior surfaces of the vastus lateralis and vastus medialis:

4) deep periosteal cellular space, where phlegmons form during purulent osteomyelitis.

The fiber of the periosteal space can communicate with the superficial muscular-fascial space and the fiber of the popliteal fossa. In the posterior bed of the thigh, a posterior interfascial tissue space is distinguished, in which the sciatic nerve lies.

Hip joint

One of the largest joints in the human body. In shape it is a nut-shaped variety of a ball-and-socket joint. Tazo
The femoral joint is formed by the articular surface of the femoral head and the acetabulum of the pelvic bone. There is no cartilage on the lower internal surface of the acetabulum; there lies a fatty body - a cushion.

The hip joint is enclosed on all sides in a very dense fibrous capsule. The fibrous capsule starts from the edge of the acetabulum and is attached to the distal end of the femoral neck, which is very important. Anteriorly, the capsule is attached to the intertrochanteric line. Thus, the entire neck of the femur is located in the joint cavity. The articular cavity is divided into cervical and acetabular, therefore femoral neck fractures, which are quite common in clinical practice in the elderly and senile, are classified as intra-articular fractures. The fibrous capsule tightly covers the neck, in addition, the high congruence of the articular surfaces determines the small capacity of the joint, only 15-20 cm 3, and explains severe bursting pain even with minor hemorrhage into the joint cavity or the formation of exudate during inflammation. The density of the fibrous capsule is complemented by ligaments: lig. iliofemoral (U-shaped), ligament of Bertini, 1 cm of it can withstand stretching up to 350 kg, lig. pubofemoral, lig. ishiofemorale, lig. transversum, zona orbicularis Weberi, lig. capitis femoris, an intra-articular ligament with a length of 2 to 4 cm and a thickness of up to 5 mm, can withstand up to 14 kg of tearing, and is endowed with great holding force.

However, the fibrous capsule of the hip joint has weak points, which is due to the nature of the course of the ligament fibers. Weak spots are located between the ligaments. The first is in the anterior internal section of the capsule. The second is between the ligament of Bertini and the pubofemoral

bunch. The third is in the lower part of the capsule, between the pubofemoral and ischiofemoral ligaments. The fourth is behind, between the iliofemoral and ischiofemoral ligaments. In these places, the fibrous capsule ruptures during traumatic hip dislocations, which are less common than dislocations in the upper limb, but compared to dislocations of other limb segments, they are quite common (from 5 to 20%, according to various sources). Depending on the direction of displacement of the femoral head, hip dislocations can be posterior, anterior, or iliac. The hip joint is surrounded on all sides by powerful muscles; it is well protected from traumatic influences, so dislocation of the femoral head is possible only when exposed to significant forces. This usually occurs with road accidents.

The hip joint has a large range of motion with pronounced stability. Joint stability is ensured by: 1) strong muscles; 2) a strong fibrous capsule, well strengthened by ligaments; 3) deep position of the femoral head in the articular cavity, deepened by the cartilaginous lip.

Between m. iliopsoas and eminentia iiiopectinea of ​​the ilium there is a mucous bursa (bursa iiiopectinea). In addition, there are trochanteric and ischiogluteal mucous bursae.

Close to the anterior surface of the hip joint is the femoral artery. Therefore, one of the symptoms of damage to the hip joint is increased pulsation of the femoral artery (Girgolav’s symptom), for example, with anterior dislocations and fractures of the femoral neck. And, conversely, with posterior and iliac dislocations of the hip, the pulsation disappears. It should be noted that the head of the femur is projected approximately 1 cm outward from the pulsation of the artery.

The sciatic nerve lies on the posterior surface of the hip joint capsule. Hip dislocations are sometimes accompanied by sciatic nerve injury. The correctness of the anatomical relationships in the area of ​​the hip joint during examination of patients is confirmed by a number of reference lines (Fig. 53).

1. Roser-Nelaton line. This is a straight line connecting three points: the anterior superior iliac spine (spina
iliaca anterior superior), greater trochanter and ischial tuberosity. When the thigh is flexed at the hip joint to 35°.

2. Shemaker line. This is a straight line connecting three points: the greater trochanter, the anterior iliac spine and the umbilicus.

3. Briand's triangle, the sides of which are the axis of the femur, going through the greater trochanter, and a line drawn from the anterior superior spine posteriorly, connecting, they form a right triangle, the legs of which are approximately equal.

Practical lesson

Topographic anatomy of the lower limb (continued). Topographic anatomy of the leg and foot. Topographic anatomy of the knee joint

Boundaries of the lower leg area. The lower leg area is limited at the top by a horizontal plane passing through the tuberosity of the tibia, and at the bottom by a plane passing over the bases of both ankles.

Layers. The superficial layers of the area are made up of skin, subcutaneous fat and superficial fascia. The fascia of the leg (fascia cruris) has significant density and is firmly fused with the periosteum of the anterior surface of the tibia. Two spurs extend from the proper fascia to the fibula, playing the role of partitions: the anterior (septum intermuscular© anterius) and the posterior (septum intermusculare posterius). Together with both bones of the leg and the interosseous membrane, these septa form three muscular-fascial beds: anterior, external and posterior. In the posterior muscular-fascial bed, near the fascia of the lower leg, a deep layer is distinguished, which divides the muscles of the posterior bed into two layers: superficial and deep.

Calf muscles. The anterior muscle-fascial bed contains the tibialis anterior muscle, extensor digitorum longus and extensor digitorum longus. In the posterior muscle-fascial bed in the superficial layer there are the gastrocnemius, soleus and plantaris muscles. These muscles form the triceps surae. The deep layer of the posterior bed contains the tibialis posterior muscle, flexor digitorum longus and flexor digitorum longus. The outer bed of the leg is represented by the short and long peroneus muscles.

Vessels and nerves of the leg. The main neurovascular bundle of the leg is represented by the posterior tibial artery, two veins and the tibial nerve. The neurovascular bundle is located in the posterior muscular-fascial bed, it occupies the ankle-popliteal canal (Gruber canal). In the area of ​​the ankle joint, the neurovascular bundle passes into the medial malleolar canal. In the anterior musculofascial bed lie the anterior tibial artery, veins and the deep branch of the peroneal nerve. In the external bed there is a superficial branch of the peroneal nerve, located in the superior canal of the peroneal muscles. A feature of the topography of the neurovascular bundles of the lower leg is their location in the muscular-fascial canals (Table 7, Fig. 54).

Table 7

M. tibialis

Musculofascial channels of the leg:

1. The ankle-popliteal canal (Gruberian) is located in the posterior muscular-fascial bed of the leg under the deep layer of its own fascia. In front, the canal is limited by the tibialis posterior muscle, and behind by the deep layer of the fascia propria and the adjacent soleus muscle, the medial long flexor of the digitorum, and the lateral long flexor of the thumb. The main neurovascular bundle of the leg passes through the canal: the posterior tibial artery, two veins and the tibial nerve. The channel has one inlet and two outlets. The entrance to the canal is limited by the arcus tendineus m. solei and m. popliteus. Through the entrance hole into the canal passes, which is a continuation of the popliteal artery, the posterior tibial artery, accompanied by veins and the tibial nerve. Exit openings: 1) the anterior opening is located at the top, in the interosseous membrane. The anterior tibial artery passes through it to the anterior surface of the leg; 2) the lower opening is limited by the tibialis posterior muscle and the Achilles tendon. Through it, the posterior tibial artery, vein and tibial nerve enter the medial malleolar canal.

2. The inferior canal of the peroneal muscles is a branch of Gruber's canal. The peroneal artery and veins pass through it. The artery arises from the posterior tibial artery in the upper third of Gruber's canal. The canal is bounded posteriorly by the flexor 1st toe longus and anteriorly by the fibula and tibialis posterior muscle. The peroneal artery runs downward and outward to supply the peroneal muscles. At the base of the lateral malleolus, the peroneal artery gives off lateral malleolar and calcaneal branches, which participate in the formation of the arterial network of the lateral malleolus and calcaneus.

3. The superior canal of the peroneal muscles is located in the outer bed of the leg between the long peroneal muscle and the head of the fibula. The canal has two sections: upper and lower. In the upper part of the canal, the common peroneal nerve bends around the neck of the fibula and divides into the deep and superficial peroneal nerves. The deep peroneal nerve goes into the anterior bed of the leg, and the superficial one goes in the lower part of the canal, first between the muscles, and then goes into the subcutaneous tissue.

4-6. Three fibrous canals are located on the anterior surface of the ankle joint area. In the distal part of the leg in the area of ​​the ankle joint, the fascia proper becomes even more dense and forms the tendon retinaculum - retinaculum. From them, spurs extend to the periosteum of the tibia, forming three fibrous canals for the tendons of the muscles of the anterior bed of the leg. The neurovascular bundle of the anterior bed of the leg passes in the middle canal next to the extensor tendon of the 1st finger. Next, the neurovascular bundle from this canal will move to the dorsum of the foot.

7. The medial ankle canal (Fig. 55) is formed due to the compacted area of ​​its own fascia - the flexor retinaculum (retinaculum musculorum flexomm). which extends from the medial malleolus to the calcaneus. The rope passes the flexor tendons, posterior tibial artery, vein and tibial nerve coming from Gruber's rope to the plantar surface of the foot. Thus, the medial ankle canal is the connecting link between the deep cellular space of the posterior bed of the tibia and the sole.

8. The flurogova canal is located in the upper half of the posterior surface of the leg, where v. passes through the splitting of the own fascia. saphena parva. "

Projection lines of the neurovascular bundles of the lower leg area:

1. The anterior tibial artery (a. tibialis anterior) and the deep peroneal nerve are projected from the middle of the distance between the head of the fibula and the tibial tuberosity to the middle of the distance between the ankles in front (Fig. 56).

2. The projection line of the posterior tibial artery (a. tibialis posterior) and tibial nerve is drawn:

a) one transverse finger posterior from the medial crest of the tibia to the middle of the distance between the posterior edge of the inner malleolus and the medial edge of the Achilles tendon;

b) from the middle of the popliteal fossa to the middle of the distance between the posterior edge of the inner malleolus and the medial edge of the Achilles tendon.

The skin of the anterior thigh area is thin and mobile at the top, denser at the bottom, and less mobile on the outer surface than on the inner surface.

The subcutaneous tissue in front consists of two layers, separated from each other from each other by a sheet of superficial fascia. In the latter, in turn, two layers are distinguished, between which lie, in addition to fiber, superficial nerves, blood and lymphatic vessels and nodes.

Cutaneous nerves arise from the lumbar plexus. Ramus femoralis n. genitofemoralis penetrates the thigh along with the femoral artery and supplies the skin directly under the inguinal fold. The skin of the outer surface of the thigh is supplied by n. cutaneus femoris lateralis, penetrating the fascia lata of the thigh downwards and slightly inside the anterior superior iliac spine. The skin of the anterior and inner surface of the thigh is supplied by rami cutanei anteriores, branches of the femoral nerve. All of these cutaneous nerves pierce the fascia lata at points located approximately on the same straight line, which connects the anterior superior iliac spine with the internal condyle of the tibia.

The sensory branch of the obturator nerve appears under the skin in the middle of the thigh, spreading along its inner surface to the patella.

Superficial arteries, including three, originate from the femoral artery: a. epigastrica superficialis goes up, towards the navel, and. circumflexa ilium superficialis - laterally, to the anterior superior iliac spine, a. The pudenda externa is directed medially, supplying the skin of the scrotum in men, and the skin of the labia majora in women. Usually there are two aa. pudendae externae (upper and lower): one is deeper, the other is superficial. The veins of the same name accompany the arteries and flow into v. saphena magna and v. femoralis. V. saphena magna is located on the inner side of the thigh and flows into v. femoralis, at a distance of approximately 3 cm downwards from the inguinal ligament.

Lymph nodes on the thigh form three groups, two of which (nodi lymphatici inguinales and subinguinales superficiales) lie in the superficial layers, on the lata fascia (their number on average is 12-16), the third - nodi lymphatici inguinales profundi - deeper, under the superficial layer fascia lata (in the amount of 3-4).

The superficial inguinal nodes are located parallel to the inguinal ligament and receive superficial lymphatic vessels coming from the skin of the anterior abdominal wall (downward from the navel), gluteal region, perineum, anus and external genitalia.

The superficial infrainguinal lymph nodes are located parallel to the course of the femoral artery and receive the vast majority of the superficial lymphatic vessels of the lower extremity.

The deep inguinal nodes accompany the femoral vein, with the largest of them, known as the Rosenmüller-Pirogov node, reaching the femoral ring. These nodes receive vessels from the deep layers of the lower limb and superficial nodes, and their discharge paths are directed to the iliac nodes, located along the external iliac vessels.

The proper fascia of the thigh, fascia lata (fascia lata), forms the vagina m. tensor fasciae latae and is strengthened by the tendon fibers of this muscle and the gluteus maximus. As a result, a dense aponeurotic cord is formed on the outer surface of the thigh, resembling a stripe in shape and position and called the iliotibial tract (tractus iliotibialis). It extends from the iliac crest to the tubercle of the Perch on the lateral condyle of the tibia (the main part of the tract is attached here).

On the anterior surface of the thigh, the fascia lata forms the sheath of the sartorius muscle and medially from the latter, in the upper half of the thigh, it is divided into two plates: superficial and deep.

The deep plate runs behind the femoral vessels (a. and v. femoralis) and covers the iliopsoas and pectineus muscles. It is also called fascia iliopectinea. Its medial part is attached to the crest of the pubic bone, the lateral part to the inguinal ligament.

The superficial leaf of the fascia lata passes in front of the vessels, is attached to the inguinal ligament at the top, and from the inside - on the pectineus muscle - merges with the deep leaf and then goes to the medial and posterior surface of the thigh.

The superficial leaf consists of two sections: a denser one - lateral and a looser one - medial. The border between them is formed by a dense crescent-shaped edge of the fascia (margo falciformis). It distinguishes between the upper horn - cornu superius and the lower - cornu inferius. The superior horn extends over the femoral vein and, at its inner edge, tucks under the inguinal ligament, merging with the lig. lacunare. The inferior horn passes behind v. saphena magna and merges with fascia pectinea.

The inner part of the superficial leaf is made up of a loosened part of the fascia lata - fascia cribrosa (in this place it is penetrated by numerous lymphatic and blood vessels). It is pierced, in particular, by v. saphena magna, which, spreading over the lower horn of the falciform edge, flows into the femoral vein.

Upon removal of the cribriform fascia, an oval-shaped fossa is revealed, bounded by the crescent-shaped edge of the fascia lata; at the bottom of the fossa a small segment of the femoral vein is visible.

Femoral triangle

Inguinal ligament at the top and muscles - m. sartorius (lateral) and m. adductor longus (medially) form the femoral (Skarpovsky) triangle. Its apex is located at the intersection of these muscles, and the base is the Poupartian ligament.

Under the superficial layer of the fascia lata within the femoral triangle there are the main femoral vessels surrounded by the vagina - a. and v. femoralis. They lie in the depression formed by the muscles of the bottom of the femoral triangle, covered with a deep layer of fascia lata: m. liopsoas (lateral) and m. pectineus (medially); the first of these muscles is attached to the lesser trochanter, the second - to the femur immediately under the lesser trochanter.

The depression formed by these muscles is triangular in shape and is called trigonum, s. fossa iliopectinea. The base of the small triangle enclosed by the intrafemoral triangle is the inguinal ligament, and the apex lies on the lesser trochanter.

In the upper half of the femoral triangle, the femoral vein lies from the inside, outside of it is the femoral artery and outside of the artery at a distance of approximately 1-1.5 cm is the femoral nerve, separated from the artery by a deep layer of fascia lata. The closer to the apex of the femoral triangle, the more the femoral vein slopes posteriorly and outward and, finally, in the middle third of the thigh it almost completely disappears behind the artery.

Within the femoral triangle, the following branches depart from the femoral artery: immediately under the inguinal ligament - a. epigastrica superficialis, a. circumflexa ilium superficialis and aa. pudenda externae; at a distance of 3-5 cm from the inguinal ligament, the femoral artery gives off its largest branch - a. profunda femoris. The latter is the main source of supply to the thigh area and, close to the place of origin, gives off branches: aa. circumflexa femoris medialis and lateralis, which often arise from the femoral artery, and below are three perforating arteries (aa. perforantes).

The femoral nerve, which supplies motor branches mainly to the sartorius and quadriceps femoris muscles, already at a distance of approximately 3 cm from the inguinal ligament begins to divide into muscle and cutaneous branches. The longest cutaneous branch is the n. saphenus, which accompanies the femoral artery for most of its length.

Muscular lacuna, vascular lacuna

The fascia iliaca, which covers the iliacus and psoas muscles in the pelvis, is firmly fused at its lateral edge at the level of the inguinal ligament. The medial edge of the iliac fascia is tightly attached to the eminentia iliopectinea. This section of fascia is called the iliopectineal arch - arcus iliopectineus (or lig. ilio "pectineum). It divides the entire space enclosed between the inguinal ligament and bones (iliac and pubic) into two sections: the muscle lacuna - lacuna musculorum (external, larger, section) and a vascular lacuna - lacuna vasorum (internal, smaller, section). The muscular lacuna contains m. iliopsoas, n. femoralis and n. cutaneus femoris lateralis, if the latter is located near the femoral nerve or is its branch. The vascular lacuna passes the femoral vessels of which the artery (accompanied by the ramus genitalis n. genitofemoralis) is located on the outside (2 cm inward from the middle of the inguinal ligament), the vein on the inside. Both vessels are surrounded by a common vagina, in which the artery is separated from the vein by a septum.

The muscle lacuna has the following boundaries: in front - the inguinal ligament, behind and outside - the ilium, from the inside - arcus iliopectineus. Due to the fact that the iliac fascia is firmly fused with the inguinal ligament, the abdominal cavity along the muscle lacuna is firmly separated from the thigh.

The vascular lacuna is limited by the following ligaments: in front - the inguinal ligament and the superficial layer of the fascia lata fused with it, behind - the pectineal ligament, outside - arcus iliopectineus, inside - lig. lacunare.

The practical significance of the muscle lacuna is that it can serve as an outlet for septic ulcers arising from the vertebral bodies (usually lumbar) in cases of tuberculosis on the thigh. In these cases, the abscesses pass under the inguinal ligament in the thickness of m. iliopsoas or between the muscle and the fascia covering it and are retained at the lesser trochanter. Abscesses of the hip joint can also flow here, making their way through the joint capsule and bursa ilipectinea. In extremely rare cases, femoral hernias emerge through the muscle lacuna.

Under the pectineal muscle and the adductor brevis lying deeper than it are the external obturator muscle and the vessels and nerve emerging from the obturator canal.

Canalis obturatorius is an osteofibrous canal leading from the pelvic cavity to the anterior inner surface of the thigh, in the bed of the adductor muscles. Its length usually does not exceed 2 cm, and its direction is oblique, coinciding with the course of the inguinal canal. The canal is formed by a groove on the horizontal branch of the pubic bone, which closes the groove with the obturator membrane and both obturator muscles. The outlet is located behind m. pectineus.

The contents of the obturator canal are a. obturatoria with vein and n. obturatorius. The relationship between them in the obturator canal is often as follows: the nerve lies outside and in front, the artery lies medially and posteriorly from it, and the vein medially from the artery.

N. obturatorius supplies the adductor muscles of the thigh. Upon leaving the canal or in the canal, it is divided into anterior and posterior branches.

A. obturatoria (usually from a. iliaca interna, less often from a. epigastrica inferior) in the canal itself or at the exit from it is divided into two branches - anterior and posterior. They anastomose with aa. glutea superior, glutea inferior, circumflexa femoris medialis, etc.

Hernias (herniae obturatoriae) sometimes emerge through the obturator canal.

Gluteal region (regio glutea)

Region boundaries: upper - iliac crest, lower - gluteal fold, or groove (sulcus gluteus), medial - midline of the sacrum and coccyx, lateral line running from the anterior superior iliac spine to the greater trochanter.

Osseous-ligamentous basis The areas include the ilium and ischium, the lateral half of the posterior surface of the sacrum, the sacrospinous and sacrotuberous ligaments (ligg.sacrospinale and sacrotuberale), the bursa of the hip joint, the femoral neck and the greater trochanter. The sacrospinous and sacrotuberous ligaments transform the greater and lesser sciatic notches into two openings: the upper, larger one – foramen ischiadicum majus and the lower, smaller one – foramen ischiadicum minus.

The iliac crest, greater trochanter, and ischial tuberosity are well identified by palpation.

The skin is thick and contains a large number of sebaceous glands. The subcutaneous tissue is abundantly developed and permeated with fibrous fibers running from the skin to the gluteal fascia. In this regard, the superficial fascia of the area is almost not expressed. The upper, middle and lower nerves of the ischium (nn.clunium superiores, medii, inferiores) pass through the subcutaneous tissue.

Gluteal fascia(fascia glutea) starts from the bony boundaries of the region. In the superolateral region, it covers the gluteus medius muscle. Throughout the rest of the area, it forms the sheath of the gluteus maximus muscle, and numerous processes extend from the superficial layer of the fascia to the muscle. As a result, the fascia is quite firmly connected to the muscle and can only be separated from it by a sharp means. This explains the fact that suppuration in the thickness of the gluteus maximus muscle, which sometimes occurs after intramuscular injections, has the character of limited infiltrates, causing significant tissue tension and severe pain. Upwards and inwards the fascia glutea passes into the fascia thoracolumbalis, downwards and outwards into the fascia lata.

Under the gluteal fascia there is the first layer of muscles, which consists of the m.gluteus maximus and the upper part of the m.gluteus medius. The lower part of the gluteus medius muscle is covered by the gluteus maximus.

The gluteal fold (groove) on the skin does not correspond to the lower edge of the muscle, but crosses it at an acute angle. Under the gluteus maximus muscle there is a deep plate of the gluteal fascia, much less dense than the superficial one. Under the deep plate is the next layer, consisting of muscles, blood vessels, nerves and loose fatty tissue.

The muscles of this layer are located from top to bottom in the following order: gluteus medius, piriformis (m.piriformis), internal obturator (m.obturatorius internus) with the twins (mm. gemelli) and quadratus femoris (m.quadratus femoris). The gluteus medius and piriformis muscles attach to the greater trochanter, the obturator internus and gemini muscles attach to the trochanteric fossa, and the quadratus muscle attaches to the femur. A hole is formed between the lower (posterior) edge of the gluteus medius muscle and the upper edge of the piriformis muscle (suprapiriforme - foramen suprapiriforme).

The obturator internus muscle, upon exiting the pelvis, fills almost the entire small sciatic foramen and is then directed to the gluteal region. Together with the muscle, a neurovascular bundle (internal pudendal vessels and pudendal nerve) passes through the lesser sciatic foramen.

An opening (infrapiriforme - foramen infrapiriforme) is formed between the lower edge of the piriformis muscle and the upper edge of the sacrospinous ligament.

Deeper than the described muscle layer there are two more muscles: at the top - the gluteus minimus muscle (m.gluteus minimus), at the bottom - the external obturator muscle (m.obturatorius externus). The gluteus minimus muscle is covered by the gluteus medius and goes to the greater trochanter. The obturator externus muscle crosses the posterior neck of the femur and is attached to the vertical fossa and capsule of the hip joint; in the gluteal region the muscle is covered by the m.quadratus femoris.

Synovial bursae form under the tendons of the piriformis and gluteal muscles, in the area of ​​their attachment to the greater trochanter and femur. Some muscles (for example, the gluteus maximus) have 2-3 such bags.

A.glutea superior with the accompanying veins and the nerve of the same name exits the pelvis through the foramen suprapiriforme, and the nerve is located somewhat laterally and downward from the artery. Upon exiting the pelvis, the superior gluteal artery almost immediately disintegrates into muscular branches, so that the extrapelvic part of the artery is very short. The branches of the superior gluteal artery anastomose with aa.glutea inferior, circumflexa ilium profunda, circumflexa femoris lateralis, etc. The superior gluteal nerve innervates the gluteal medius and minimus muscles and m.tensor fasciae latae.

Exiting through the foramen infrapiriforme, outward from the lig.sacrotuberale, the neurovascular bundle consists of: vasa glutea inferiora, nn.ischiadicus, gluteus inferior and cutaneus femoris posterior, vasa pudenda interna and n.pudendus. The relationship of these elements of the neurovascular bundle is as follows: from the inside, closest to the ligament, the pudendal nerve and internal pudendal vessels pass; further, the inferior gluteal nerve, the posterior cutaneous nerve of the thigh, the inferior gluteal vessels and the sciatic nerve pass outward.

A.glutea inferior immediately upon leaving the pelvis breaks up into branches to the gluteal muscles and to the sciatic nerve (a.comitans n.ischiadici). The inferior gluteal nerve innervates the gluteus maximus muscle.

N. ischiadicus at the lower edge of the gluteus maximus muscle lies relatively superficially, directly under the fascia lata, at the level of the vertical, which passes through the border between the medial and middle third of the line connecting the ischial tuberosity with the greater trochanter. Next, at the thigh, the sciatic nerve goes under the long head of the biceps femoris muscle. Vasa pudenda interna and n.pudendus, upon exiting the pelvis, bend around the ischial spine and sacrospinous ligament and through the lesser sciatic foramen penetrate into the perineum, reaching the ischiorectal fossa. On the posterior surface of the sacrospinous ligament, the pudendal nerve is often located medially to the internal pudendal vessels.

Fiber, located between the gluteus maximus muscle and the muscles of the deep layer, surrounds the vessels and nerves located in this space. She reports:

1) through the greater sciatic foramen (under the piriformis muscle) with the pelvic tissue;

2) through the lesser sciatic foramen with the tissue of the ischiorectal fossa;

3) downwards it passes into the tissue surrounding the sciatic nerve; as a result, ulcers arising in the gluteal region sometimes reach the popliteal fossa;

4) in the anterior direction, the deep tissue of the gluteal region communicates with the deep tissue of the adductor muscle region along the branches of the ramus posterior a.obturatoriae; these branches pass through the gap between the obturator externus muscle and the quadratus femoris muscle and anastomose with the inferior gluteal artery.

Foramen infrapiriforme and foramen ischiadicum minus in very rare cases serve as sites for hernias (so-called sciatic hernias - herniae ischiadicae).

Posterior thigh area (regio posterior)

Skin of the posterior thigh innervate: outside – branches n.cutaneus femoris, lateralis; inside – branches nn.genitofemoralis, femoralis and obturatorius, the rest of the posterior surface – n.cutaneus femoris posterior. The latter runs along the midline of the thigh between the leaves of the fascia lata and usually becomes superficial in the lower third of the thigh. The branches of the posterior cutaneous nerve of the thigh along the way pierce the fascia lata and innervate the integument.

The muscles are represented by the muscles that flex the lower leg. There are three of them: biceps femoris (m.biceps femoris), semitendinosus (m.semitendinosus) and semimembranosus (m.semimembranosus), they all start from the ischial tuberosity). More lateral than the others is the long head of the biceps muscle, which connects with the short head that starts below (from the line aspera), forming a common tendon with it. Medial to the m.biceps femoris lies the m.semitendinosus, and further medially and anteriorly – the m.semimembranosus. The tendons of both muscles pass onto the inner surface of the tibia. Toward the popliteal fossa, the listed muscles diverge, limiting the upper angle of the popliteal fossa.

The sciatic nerve and branches of the deep femoral artery with accompanying veins pass between the muscles of the posterior thigh. Coming from under the edge of the gluteus maximus muscle, the nerve lies for a short distance directly under the fascia lata, without being covered by muscles, then it is covered by the long head of the m. biceps, and even more distally it passes in the groove between the flexor muscles, having the m.adductor magnus everywhere on the thigh in front of it.

Topographic anatomy of the fingers. Features of the structure and topography of fibrous vaginas, significance in pathology and during operations.

The skin of the palmar surface of the fingers has well-developed horny, malpighian and papillary layers. Lots of sweat glands, no sebaceous glands and hair. PFA of the palmar surface - the nature of spherical accumulations, separated by fibrous bridges running vertically to the periosteum. On the back of the fingers the skin is thinner and sometimes covered with hair. On the finger, an abundant network of lymphatic capillaries, merging, form 1-2 efferent trunks, which in the area of ​​​​the interdigital folds pass to the back of the hand. Lymph from the IV-V fingers - into the ulnar lymph nodes, from the rest - into the axillary lymph nodes, from 2-3 to the sub- and supraclavicular lymph nodes along the v.cephalica. Superficial veins are better expressed on the back. The digital arteries lie on the lateral surfaces, the dorsal ones are weakly expressed. The dorsal arteries do not reach the end of the phalanges, and the palmar arteries form the rete mirabele. Bundles of fascia form annular and cruciate ligaments that hold the tendons in place of flexion. The superficial flexor tendons bifurcate and attach to the middle phalanx, the deep flexor tendons to the nail. Synovial membranes have parietal and visceral layers; at the junction of the tendons, vessels and nerves pass, forming the mesentery of the tendon. Synovial sheaths end on the nail phalanges. Proximally at 2-4 fingers begin at the level of the heads of the metacarpal bones, where a blind sac is formed. In fingers 1 and 5, they move to the palm and form synovial sacs. The extensor tendons on the back of the phalanges turn into tendon stretches (dorsal aponeurosis of the fingers), which is divided into 3 legs: the middle one - to the base of the middle phalanx, the lateral ones - to the base of the terminal phalanx.

Innervation of the fingers. "DIE" rule. I finger - branches of the radial and median, P finger - branches of the entire median and radial up to 2/3, W finger - branches of the entire median, radial and ulnar up to 2/3, IV finger - branches of the median laterally, ulnar - up to 2/3, radial medially, V finger - entirely ulnar.

Topographic anatomy of the gluteal region. Composition and topography of neurovascular bundles. Pathways for the spread of mental processes. Anatomical basis of drainage of superficial and deep phlegmon.

Borders: superior - iliac crest; lower - gluteal fold; medial - midline of the sacrum and coccyx; lateral - line from the PV spine to the greater trochanter. The skin is thick with sebaceous glands. The pancreas is penetrated by the superficial fascia. In PZhK: nn.clunium superiores, medii, inferiores. The gluteal fascia forms septa in the m.gluteus maximus.

1 and muscle layer: m.gluteus maximus (GYAM), m.gluteus medius (SYAM). The lower part of the SYAM is covered by the BYAM. Under the MU is a deep plate of fascia, under it is the 2nd layer: 1) MU, 2) piriformis, 3) obturator internus, 4) gemini, 5) quadratus femoris. The SOM and piriformis are attached to the greater trochanter, the obturator internus and geminiformes are attached to the trochanteric fossa, and the quadrate femoris is attached to the femur. Between the SAM and the piriformis there is the supragiriform foramen. The obturator internus and the genital vessels and nerves exit through the lesser sciatic foramen. Between the lower edge of the piriformis muscle and the sacrospinous ligament - under the piriformis foramen. 3rd layer of muscles: 1) MAM, 2) obturator externus. The MMN goes to the greater trochanter, the external obturator goes to the vertical fossa and the capsule of the hip joint.

A.glutea superior with veins and nerve exit through the foramen suprapiriforme. The artery immediately breaks up into muscular branches, anastomoses with aa.glutea inferior, circumflexa ilium profunda, circumflexa femoris lateralis. The superior gluteal nerve innervates the SMN, MMN and m.tensor fascia latae. Through foramen infrapiriforme: vasa glutae inferiora, nn.ischiadicus, gluteus inferior, cutaneus femoris poisterior, vasa pudenda interna, n.pudendus. A.glutea inferior splits into muscular branches and to n.ischiadicus. N.ischiadicus passes at the lower edge of the MU at the border of the medial and middle third of the line between the ischial tuberosity and the greater trochanter, then passes under the long head of the 2-head femoris muscle. Vasa pudenda interna and n.pudendus go around the ischial spine and through the lesser sciatic foramen penetrate into the perineum to the ischiorectal fossa.

Pathways for suppuration: a vast cellular space under the gluteus maximus muscle and an intermuscular gap under the gluteus medius muscle, covered with its own fascia. It is possible for pus to spread to adjacent areas: thigh, ischiorectal fossa, pelvic cavity.

Topographic anatomy of the anterior thigh (femoral triangle).

Boundaries of the anterior thigh. Above - the inguinal ligament from the pubic tubercle to the PV, from the outside - a line from the PV to the lateral epicondyle of the femur, from the inside - a line from the pubic tubercle to the medial epicondyle, from below - a transverse line 6 cm above the patella. Under the inguinal ligament there are muscular and vascular lacunae. The femoral artery is projected along Ken's line (the line between the "middle of the distance between the PV and the pubic symphysis" and the "adductor tubercle on the medial epicondyle of the femur"), the femoral vein - inward from it, the femoral nerve - outward. 1-2 cm inward and downward from the PV - the lateral cutaneous nerve emerges, along the projection of the m.sartorius the anterior cutaneous nerves emerge. L\u: superficial inguinal and subinguinal.

Femoral triangle (Scarpa). Outside - sartorius, inside - long adductor, above - inguinal ligament. At its bottom there is fossa iliopectinea. The skin is thin, delicate and mobile. In the pancreas there are blood vessels, lymph nodes, and cutaneous nerves. A.epigastrica superficialis runs from the middle of the inguinal ligament to the navel. A.circumflexa ilium superficialis from annulus saphenus to the PV parallel to the inguinal ligament. Aa.pudendae externae go medially, in front of the femoral vein. N.genitofemoralis - from the vascular lacuna, innervates the skin under the medial part of the inguinal fold. N.cutaneus femoris lateralis - near the PV, rr.cutanei anteriores - along the projection of m.sartorius. The branch n.saphenus minor joins v.saphena magna. R.cutaneus n.obturatorii - from the side wall of the pelvis along the inner side of the thigh to the level of the patella (the cause of pain in the knee joint with inflammation in the hip). The fascia lata divides the thigh into three beds: anterior (leg extensors), posterior (flexors), medial (adductors). Between the deep and superficial plates of the fascia: a.et v.femoralis. This space communicates with the subperitoneal floor of the pelvis - through the vascular lacuna, with the subcutaneous tissue of the thigh - through the ethmoidal fascia, with the outer region of the hip joint - along the lateral artery surrounding the thigh, with the bed of the adductor muscles - along the medial artery surrounding the thigh, with the posterior we place the thigh - through the vascular openings in the tendons, with the adductor canal - along the course of the femoral vessels. FNA: femoral artery; femoral nerve; deep femoral artery; medial femoral artery; lateral artery surrounding the thigh; femoral vein, with v.saphena magna flowing into it.

11. Topographic anatomy of the posterior thigh. Neurovascular formations. Ways of spread of purulent leaks. Above - a transverse gluteal fold, below - a circular line 6 cm above the patella, from the inside - a line connecting the pubis

symphysis with the medial epicondyle of the femur, outside - a line from the PV to the lateral epicondyle of the femur.

The ischial seal is projected along a line from the middle of the distance between the ischial tuberosity and the greater trochanter to the middle of the popliteal

pits. In the pancreas - n.cutaneus femoris lateralis, n.cutaneus femoris posterior. Anastomosis of v.saphena magna with v.saphena parva. Fiber

the space of the posterior bed of the thigh communicates with the space under the BNM - along the course of the sciatic nerve; with the popliteal fossa - along the way

same nerve; with the anterior bed of the thigh - along the perforating arteries and the medial circumflex femoral artery.

SNP: sciatic nerve between the m.adductor magnus and the flexors. A.commitans n.ischiadici, arising from the inferior gluteal artery. Chain

anastomoses of perforating arteries. Before entering the popliteal fossa, the nerve is usually divided into n.tibialis et n.pcroneus communis.

12. Topographic anatomy of the neurovascular formations of the popliteal fossa. Ways of spread of suppurative
processes.

The popliteal vessels and tibial nerve are projected along a vertical line coming from the upper corner of the popliteal fossa through its

middle. The peroneal from the same point is directed along the inner edge of the biceps femoris tendon to the outer surface of the neck

fibula.

N.tibialis - superficially under the popliteal fascia. Branches to muscles: m.gastrocnemius, m.soleus, m.plantaris, m.popliteus and cutaneous branch:

n.cutaneus surae medialis (accompanies v.saphena parva).

N.peroneus communis - adjacent to the inner edge of the biceps tendon. Gives n.cutaneus surae lateralis.

A.poplitea. 4 sections: initial (between semimembranosus and vastus medialis) - gives off branches to the gracilis, sartorius and semimembranosus

muscles; the second (between semimembranosus and gastrocnemius) - five arteries to the knee joint and branches to the muscles; third (at lig.popliteum

obliquum) - branches to the muscles; fourth (between popliteus and tibialis posterior under the tendinous arch of the soleus muscle). Upper and

The inferior articular arteries of the knee joint form two anastomotic branches on its surface: superficial and deep.

The space of the popliteal fossa communicates with the posterior bed of the thigh, with the space under the BMN - along the course of the sciatic nerve; with adductor

canal and femoral triangle - along the course of the femoral vessels; with a deep space in the back of the lower leg - along the popliteal.

Femoral (Skarpovsky) triangle) (trigonum femorale) located within the upper third of the thigh immediately below the inguinal ligament.

Triangle boundaries:

ü above– inguinal ligament (lig. inguinal);

ü laterally– sartorius muscle (m. sartorius);

ü medially– adductor longus muscle (m. adductor longus).

Iliopsoas (m. iliopsoas) and comb (m. pectineus) the muscles form the bottom of the femoral triangle and are located in such a way that a depression is formed between them - the iliopectineal fossa (fossa iliopectinea).

In the upper half of the femoral triangle from the inside lies the femoral vein (v. femoralis), lateral to it is the femoral artery (a. femoralis), lateral from the artery – femoral nerve (n. femoralis).

Within the femoral triangle, 3 superficial branches arise from the femoral artery: the superficial epigastric artery (a. epigastrica superficialis), superficial artery, circumflex ilium, (a. circumflexa ilium superficialis) and external genital artery (aa.pudenda externa). At a distance of 3 - 5 cm from the inguinal ligament, the largest branch departs - the deep artery of the femur (a. profunda femoris), which gives off 2 large branches: the medial and lateral arteries that circumflex the femur (aa. circumflexa femoris medialis et lateralis). The deep artery of the thigh, going down, ends with 3 to 5 perforating arteries, which, through the thickness of the adductor muscles, enter the posterior surface of the thigh and supply blood to the muscles of the posterior group.

The femoral nerve at a distance of about 3 cm from the inguinal ligament is divided into muscular and cutaneous branches, the longest of which is the saphenous nerve (n. saphenus).

Thus, in the lower third of the femoral triangle, the neurovascular bundle is represented by the femoral artery, femoral vein and saphenous nerve, with the nerve located laterally, and the vein passes to the posterior surface of the femoral artery and in the lower third lies lateral to the femoral artery.

3.7 Topography of the obturator canal (canalis obturatorius)

In the deep layers of the femoral triangle, under the pectineus muscle and the short adductor muscle lying deeper than it, there is the obturator canal, which is an osteofibrous canal leading from the pelvic cavity to the anterior inner surface of the thigh, in the bed of the adductor muscles. Its length usually does not exceed 2cm. The canal is formed by the obturator groove (sulcus obturatorius) on the horizontal ramus of the pubis and the obturator membrane and both obturator muscles. The outlet is located behind m. pectineus. The internal (pelvic) opening of the canal faces the prevesical or lateral cellular space of the small pelvis. Content: obturator nerve (n. obturatorius)(located in the canal outside and in front), obturator artery (a. obturatoria)(located medially and posteriorly from the nerve) together with the vein (lies medially from the artery).

3.8 Surgical anatomy of the femoral canal (canalis femoralis)

The femoral canal is normally absent. This term refers to the path that a femoral hernia takes from the femoral ring to the subcutaneous fissure. The length of the channel ranges from 0.5 – 1 cm to 3 cm. It has the shape of a triangular prism.

Between the femoral vein and the lacunar ligament in the vascular lacuna there remains a space filled with fiber and the Pirogov-Rosenmüller lymph node. This space is a deep ring (entrance) of the femoral canal, unlike the canal that is normal in every person and is a weak point of the anterior abdominal wall. Thigh ring (annulus femoralis) facing the pelvic cavity and bounded anteriorly by the inguinal ligament, posteriorly by the pectineal ligament (Cooper’s ligament), medially by the lacunar ligament, and laterally by the femoral vein. On the inner surface of the abdominal wall, this ring is covered by the transverse fascia, which here has the appearance of a perforated plate - the femoral septum (septum femorale).

The subcutaneous (superficial) ring (outlet) of the femoral canal corresponds to the subcutaneous fissure (hiatus saphenus). It is covered by the cribriform fascia (fascia cribrosa).

Canal walls: in front – superficial plate of the fascia lata of the thigh (lamina superficialis fasciae latae), behind – deep plate of the lata fascia of the thigh (lamina profunda faciae latae), covering the pectineus muscle (pectineal fascia), outside - the sheath of the femoral vein.

The width of the femoral ring (the distance between the femoral vein and the lacunar ligament) is on average 1.2 cm in men, 1.8 cm in women. Larger femoral rings predispose femoral hernias to occur more frequently in women.

3.9 Topography of the adductor (Gunter's) canal (canalis adductorius, seu canalis vastoadductorius, seu canalis Hunteri)

In the middle third of the thigh, from the apex of the femoral triangle to the inlet of the adductor canal, the femoral vessels and saphenous nerve lie in the femoral groove (sulcus femoralis anterior), serving as a continuation of the iliopectineal fossa. This groove is formed by the vastus medialis muscle (m vastus medialis)(lateral) and adductor longus muscle (m. adductor longus)(medially). The vessels are covered in front by the sartorius muscle.

In the lower third of the thigh, the vessels pass through the femoropopliteal, or adductor canal - canalis femoropliteus, s. adductorius(otherwise called Gunther's canal). The canal has a triangular shape; the main role in its formation belongs to the dense aponeurotic plate with transversely running fibers - lamina vastoadductoria, which stretches from the tendon of the adductor magnus muscle to the vastus medialis muscle.

Channel walls The adductor muscles are as follows:

ü front And laterally– medial intermuscular septum and vastus medialis muscle (septum intermusculare mediale et m. vastus medialis);

ü behind And medially– adductor magnus muscle (m. adductor magnus);

ü medially And front– lamina vastoadductoria.

The channel has three holes: top, front and bottom.

The upper opening is limited by the same structures that form the walls of the canal. The neurovascular bundle of the anterior surface of the thigh (femoral vessels and saphenous nerve) enters it from the femoral groove.

The front hole is in lamina vastoadductoria. The saphenous nerve leaves the canal through it, accompanied by the descending genicular artery (a. genus descendens), which arises from the femoral artery within the adductor canal.

The inferior opening is the tendon gap of the adductor magnus muscle. (hiatus tendineus adductorius). The femoral vessels leave the adductor canal through this opening and pass into the popliteal fossa, where they become popliteal vessels.

3.10 Topographic anatomy of the posterior thigh (regio femoris posterior)

Borders:

ü above– gluteal fold;

ü from below– a conventional circular line drawn two transverse fingers above the level of the base of the patella;

ü laterally And medially– vertical lines drawn upward from both epicondyles of the femur.

Layer-by-layer topography:

2) subcutaneous fatty tissue,

3) superficial fascia,

4) fascia lata of the thigh. Presented in one sheet.

The fascia lata is supported by transverse connective tissue bundles and gives off intermuscular septa that delimit the fascial beds of the thigh:

ü external intermuscular septum ( septum intermusculare femoris laterale), strong, demarcates the anterior and posterior fascial beds of the thigh;

ü posterior intermuscular septum ( septum intermusculare femoris posterior), loose, demarcates the posterior and inner thigh beds.

5) The musculature of the area is represented by 3 muscles: semimembranosus (m. semimembranosus) and semitendinosus (m. semitendinosus)(lie medially) and biceps femoris (m. biceps femoris)(lateral). Toward the popliteal fossa, the listed muscles diverge, limiting the upper angle of the popliteal fossa.

The sciatic nerve and branches of the deep femoral artery with accompanying veins pass between the muscles of the posterior thigh. Coming from under the edge of the gluteus maximus muscle, the nerve lies for a short distance directly under the fascia lata, without being covered by muscles, then it is covered by a long head m. biceps, and even more distally it passes in the groove between the flexor muscles, having everywhere on the thigh in front of it m. adductor magnus.

At the thigh or in the upper corner of the popliteal fossa, the sciatic nerve divides into the common peroneal nerve (n. peroneus communis) and tibial nerve (n. tibialis). The common peroneal nerve deviates to the lateral side and is located along the inner edge of the biceps femoris tendon, then bends around the neck of the fibula and enters the anterior surface of the leg into the superior musculofibular canal.

The tibial nerve maintains the direction of the sciatic nerve and runs from the superior angle of the popliteal fossa to the inferior angle along with the popliteal artery and vein.

6) Femur (femur).