FRONT OF THIGH

 

CHAPTER – 1

FRONT OF THIGH               

For introduction to lower limb, watch this video:

https://youtu.be/n75zDKXo-vk 

Thigh has three compartments:

1.     Front of thigh

2.     Medial side of thigh

3.     Back of thigh

FRONT OF THIGH


Skin

Cutaneous nerves from lumbar plexus – ventral rami of the first three lumbar nerves.

Superficial fascia: contains inguinal lymph nodes, great saphenous vein and its tributaries (terminal)

Inguinal lymph nodes (Superficial)

·       Upper horizontal group – drains lymph from the gluteal region, lower part of anterior abdominal wall, perineum, lower part of the anal canal below the pectinate line.

·       Lower vertical group – drains most of superficial lymphatics from the lower limb.

Deep fascia of thigh

            Called as fascia Lata because of its wide extent.


It has two modifications

a)     Thickened along the lateral surface of thigh to form the iliotibial tract

b)    Oval gap slightly below and lateral to the pubic tubercle – saphenous opening.

Iliotibial tract

●      Thickened band of Fascia Lata

●      2.5cm in width

●      Extends from the level of greater trochanter to the anterior surface of lateral condyle of tibia.

●      In the upper part, splits to enclose two muscles- tensor fascia latae and ¾ of gluteus maximus

●      Maintains the knee in extended position when the knee is straight.



Saphenous opening



●      Oval gap in fascia lata (3 to 4 cm)

●      Centre of the opening lies 3 cm below and lateral to the pubic tubercle

●      Opening is closed by cribriform fascia


Cribriform fascia is pierced by

a)     Great saphenous vein

b)    Superficial epigastric and superficial external pudendal arteries

c)     A few branches of medial femoral cutaneous nerve

d)    A few lymph vessels connecting superficial and deep inguinal lymph nodes.

Muscles in front of thigh

1)    Sartorius

2)    Quadriceps Femoris – three vasti muscles and rectus femoris

For dissection of muscles of front of thigh, watch this video:

https://youtu.be[c1] /NIE-r6S1q_s

Sartorius

‘SARTOR’ means tailor and the actions of the muscle cause the necessary movements in the hip and knee joints for the tailoring work.

Origin:

Anterior superior iliac spine

Insertion:

Upper part of medial surface of shaft of tibia

Nerve Supply:

Anterior division of femoral nerve

Actions:

·       Flexor, abductor and lateral rotator of hip joint

·       Flexor, medial rotator of knee joint

Quadriceps femoris

Has four muscles:

1.     Rectus Femoris

Origin:

Two heads-

a)     Straight head: Upper part of anterior inferior iliac spine

b)    Reflected head: from a groove above the acetabulum

2.     Vastus medialis

Origin: continuous linear origin from the following-

a)     Lower part of intertrochanteric line

b)    Spiral line

c)     Medial lip of Linea aspera

d)    Upper two thirds of the medial supra condylar line of femur

3.     Vastus lateralis

Origin: from the following-

  1. Upper part of intertrochanteric line
  2. Root of greater trochanter
  3. Lateral lip of gluteal tuberosity
  4. Lateral lip of Linea aspera

4.     Vastus intermedius

Origin:

From the anterior and lateral surfaces of upper 2/3rd of the shaft of tibia.

Insertion of quadriceps femoris: in to the-

a)     Base of patella

b)    Medial and lateral borders of patella

Nerve supply:

Posterior division of femoral nerve

Actions: Extensor of knee joint



Femoral triangle

A triangular depression in the upper one third of front of thigh

Boundaries:

Laterally – Medial border of Sartorius

Medially- Medial border of adductor longus

Base- Formed by the inguinal ligament

Apex- Meeting point of Sartorius and adductor longus.

Floor-

From lateral to medial side by: Iliacus, psoas tendon, pectineus and adductor longus


Contents of femoral triangle:

a)     Femoral artery, vein, nerve

b)    Deep inguinal lymph nodes

For dissection of femoral triangle, watch this video:

https://youtu.be/YZ-Qsq1jomY

Femoral artery

Origin:

Continuation of external iliac artery behind the midinguinal point

Extent:

 From the midinguinal point to the fifth osseo- aponeurotic opening in the adductor magnus where it continues as popliteal artery


The femoral artery courses in the

A)   Femoral triangle

B)   Adductor canal

Relations in the femoral triangle:

Anteriorly:

·       Fascia lata                  

·       Femoral sheath

·       Femoral branch of genito femoral nerve

·       Crossed by medial femoral cutaneous nerve from lateral to medial side

 


Laterally:

·       In the upper, lies the trunk of the femoral nerve, outside the femoral sheath

·       In the lower part, medial femoral cutaneous nerve and saphenous nerve – branches of femoral nerve accompany laterally

 Medially:

·       Femoral vein lies medial to the artery in the upper part and

·       behind the artery in the lower part

Posteriorly:

Proximo distally, the artery rests on-

·       psoas tendon

·       pectineus

·       adductor longus

 Branches of femoral Artery: (in femoral triangle)

a)     Superficial Epigastric artery

b)    Superficial circumflex iliac artery

c)     Superficial external pudendal artery

d)    Profunda femoris artery

e)     Deep external pudendal artery


Profunda femoris artery

Origin:

Arises from the lateral side of femoral artery about 3.5 cm below the inguinal ligament.

Course:

●      After its origin, it spirals medially behind the femoral vessels.

●      It leaves the femoral triangle between pectineus and adductor longus (in floor)

●      It descends successively between adductor longus and brevis and adductor longus and adductor magnus

●      Finally, it pierces the adductor magnus as the 4th perforating artery


 

Branches of profunda femoris artery:

a)     Lateral circumflex femoral artery

b)    Medial circumflex femoral artery

c)     Four perforating arteries– 4th is the continuation of profunda femoris artery

Applied anatomy of femoral artery in femoral triangle:

1)    Femoral pulse can be palpated in relation to the psoas tendon behind the mid inguinal point

2)    Femoral artery is cannulated in the femoral triangle for various interventional radiological procedures

    

For the detailed description of femoral artery, watch this video:

https://youtu.be/zyPV-ZAtWTw

Femoral sheath

            Fascial prolongation around the proximal 3 to 4 cm of the femoral vessels

Shape: Funnel shaped

●      Lateral wall of the sheath is vertical

●      Medial wall slopes downwards and laterally

Formation:

Anterior wall:  By fascia transversalis

Posterior wall: By fascia iliaca

Sub divisions:

●      Three compartments in the sheath-

Lateral Compartment – contains the femoral artery and femoral branch of genitor femoral nerve.

Middle compartment – contains femoral vein

Medial compartment – known as femoral canal

Femoral canal

It is a potential or dead space containing lymph node

-       Conical shape

-       1.25cm long

-       Base directed above – known as femoral ring

Femoral ring

·       Wider in females

·       Oval in shape

 


 

Boundaries:

·       Infront - by the inguinal ligament

·       Behind - by the pectineus muscle and its covering fascia.

·       Medially - by the lacunar ligament

·       Laterally - by the femoral vein

Applied anatomy of femoral sheath:

●      Femoral ring is closed by the femoral septum formed by extra peritoneal tissue and presents a peritoneal depression known as femoral fossa above the septum.

●      Femoral hernia bulges downward through femoral ring into the femoral canal, then pushes forward through the saphenous opening and finally turns upward when complete.

For detailed description of femoral sheath, watch this video:

https://youtu.be/WyOdsKAScSM

Femoral nerve

●      Largest branch of lumbar plexus

Course:

In iliac fossa – under cover of fascia iliaca in the interval between psoas major and iliacus

In femoral triangle- enters the femoral triangle behind the inguinal ligament on the lateral side of femoral sheath,

Termination:

The trunk of the nerve splits about 3cm below the inguinal ligament into anterior and posterior divisions.

 


   Branches:                                                                                        

From the trunk - to the iliacus, pectineus

From the anterior division:

a)     Intermediate femoral cutaneous nerve

b)    Medial femoral cutaneous nerve

c)     Muscular branch to the sartorius

From the posterior division:

a)     Saphenous nerve – largest cutaneous nerve of the body

b)    Muscular branches to the quadriceps femoris

 

Adductor canal

Other names: Hunter canal, Sub sartorial canal

Situation:

In the middle third of the front of thigh-approximately 15 cm long

Boundaries:

Anteriorly and laterally- vastus medialis

Posteriorly- adductor longus ad adductor magnus

Medially- sartorius forming the roof below which sub sartorial plexus of nerves is present

Contents:

1.     Femoral artery

2.     Femoral vein

3.     Saphenous nerve

4.     Nerve to vastus medialis

Femoral artery in the adductor canal:

·       Femoral artery enters the adductor canal from the apex of the femoral triangle and

·       Leaves the adductor canal through the 5th osseo-aponeurotic opening in the adductor magus and enters the popliteal fossa as the popliteal artery

·       In the canal, the femoral vein lies posterior to the artery in the upper part and lateral to the artery in the lower part

·       Saphenous nerve crosses the artery from medial and lateral in the middle of the canal

·       Nerve to vastus medialis lies medial to the artery in the upper part

 


Branch of femoral artery in the adductor canal:

·       Descending genicular artery- which gives a branch called saphenous artery as it accompanies the saphenous nerve

Sub sartorial plexus

 

The sub sartorial plexus is formed by:

·       the medial cutaneous nerve of the thigh (a branch of the femoral nerve)

·       the saphenous nerve (a branch from femoral nerve)

·      the cutaneous branch of anterior division of the obturator nerve.

 

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