Within the pelvic girdle and free lower limb muscles limit topographic-anatomical formations (lacunae, triangles, canals, pits and grooves) in which neurovascular bundles pass, has important applied significance
Piriformis muscle, m. piriformis - passing through foramen ischiadicurr. majus, does not fill the hole completely, but leaves two holes: supragiriform and pidpiriform.
Suprapiriform foramen, foramen suprapiriforme- part of the large gluteal opening, located above the piriformis muscle. The superior gluteal vessels and nerve pass through the openings. According to L. B. Simonova, part of the greater gluteal opening should be considered the supragiriform canal. It is formed above by the upper edge of the greater gluteal notch, and below and on the sides by the fascia piriformis, middle and small sciatic muscles. The length of the supragiriform canal is 4-5 s.
width 0.5-1 cm. It connects the pelvic cavity with the fascial cell spaces of the gluteal region.
Infrapiriform foramen, foramen infrapiriforme - limited by the lower edge of the piriformis muscle, lig. sacrotuberale, and superior gemellus muscles. Through the pyriform opening from the small pelvis exit: sciatic nerve, posterior cutaneous nerve of the thigh, lower gluteal neurovascular bundle (a. glutea inferior, veins and nerve of the same name) and genital neurovascular bundle (a. pudenda interna, veins of the same name and n. pudendus).
Obturator canal, canalis obturatorius (BNA) - located in the outer upper edge of the obturator foramen. It is directed from back to front. The canal is formed from the outside and above by the obturator groove of the pubis, and from the middle and down by the upper outer edge of the membrana obturatoria. The canal contains the obturator artery, the veins of the same name, and the obturator nerve.
Muscular and vascular lacuna. The space under the inguinal ligament and pelvic bones is divided by the iliopectineal arch, arcus iliopectineus, into two lacunae: muscular, lacuna musculorum, and vascular, lacuna vasorum.
Muscle lacuna, lacuna musculorum - limited to: crest ilium(outside), inguinal ligament (in front), body of the ilium and supraglobular fossa (back) and iliopectineal arch (inside). Iliopectineal arch, arcus iliopectineus (old name lig. Iliopectineum), originating from lig. inguinale and attaches to eminentia iliopectinea. It is directed obliquely from front to back, from outside to inside and is closely intertwined with the fascia of the iliopsoas muscle. The shape of the muscle lacuna is oval, the diameter of the lacuna is on average 8-9 cm. The contents of the lacuna are the iliopsoas muscle and the femoral nerve.
Vascular lacuna, lacuna vasorum - limited: anteriorly - by the inguinal ligament, posteriorly - lig. pectineale (old name lig. pubicum Cooperi), outside - iliopectineal arch, and inside - lig. lacunare. The vascular lacuna has a triangular shape, it contains the femoral artery and vein, n. genitofemoralis, lymph node and tissue.
Femoral canal, canalis femoralis - is located in the vascular lacuna under the medial part of the inguinal ligament, to the middle of the femoral vein. This term refers to the path that a femoral hernia takes (in the absence of a hernia, the canal does not exist). The femoral canal has the shape of a triangular pyramid, 0.5-1 cm long.
The walls of the femoral canal are: outside - the femoral vein, in front - the superficial layer of the fascia lata of the thigh and the superior horn of the falciform edge, behind - the deep layer of the fascia lata (Gimbernati). The inner wall is formed by the fusion of two layers of the fascia lata of the thigh and the fascia of the pectineus muscle.
The femoral canal has two rings (openings): deep, anulus femoralis internus, and superficial, anulus femoralis externus. The deep ring of the canal is limited in front by the inguinal ligament, lig. inguinale (Pouparti), externally - femoral vein, v. femoralis, posteriorly - by the crested ligament, lig. pectineale, medially - lig. lacunare (Gimbernati). The hole is closed by the transverse fascia of the abdomen. Naturally, the deeper the ring, that is, the wider the distance from lig. lacunare (Gimbernati) in the femoral vein, the Better conditions for release of femoral hernias. This distance is on average 1.2 cm in men, and 1.8 cm in women, so femoral hernias occur much more often in women than in men. The external opening of the canal is the subcutaneous fissure, hiatus saphenus s. ovalis (BNA), which is bounded by the crescent-shaped edge, maigo falcitormis, and its upper and lower angle.
The subcutaneous fissure is covered by a cribriform loose plate, a lymph node (Pirogov-Rosenmühler) and the mouth of the great saphenous vein and the veins that flow into it. Loosening the fascia lata of the thigh in the area of the oval fossa facilitates the release of the femoral hernia.
There are anatomical variants when the deep opening of the femoral canal is limited on all sides by blood vessels. This is observed in cases where a. obturatoria arises from the inferior supracabdominal artery, and outside the opening is the femoral vein, from the inside - the obturator artery and ramus pubicus of the inferior supracabdominal artery, which runs along the posterior surface of the lig. lacunare. IN clinical practice This arrangement of blood vessels is called the “crown of death”, corona mortis, which must be taken into account during surgical interventions for femoral hernias.
Femoral triangle, trigonum femorale (Scarpa's triangle, Scarpa), - located within the upper third of the thigh. The triangle is limited: from the outside - by the medial edge of m. sartorius, from the middle - lateral edge of m. adductor longus, above - inguinal ligament. The apex of the femoral triangle is where the inner edge of the cranialis muscle collides with the outer edge of the adductor longus muscle. The height of the femoral triangle is on average 8-10 cm. Within the femoral triangle there is an iliopectineal groove, which is limited by the medial pectineus muscle, and on the side by the iliopsoas muscle. The iliopectineal groove passes into the femoral groove, which at the apex of the femoral triangle passes into the adductor canal. In the iliopectineal groove there are blood vessels(femoral artery and vein).
Drive channel, canalis adductorius (femoral-popliteal, or Gunter's canal) 1 - connects the anterior surface of the thigh with the popliteal fossa. It is a triangular slit-shaped gap, which is directed from front to back and from the middle to outside. The canal is limited by three walls: medial - m. adductor magnus, lateral - m. vastus medialis, and the anterior aponeurotic plate, lamina vastoadductoria, located between these muscles. The lamina vastoadductoria is covered by the sartorius muscle. The canal has a length of 6-7 cm.
The drive channel has three openings: upper, lower and front. The superior opening is the terminal part of the funnel-shaped space of the femoral triangle, covered by the sartorius muscle. Through this hole, the femoral vessels penetrate from the cavity of the femoral triangle into the canal. The lower opening of the drive canal is called the tendon gap, hiatus tendineus, which is located on the back of the thigh, in the popliteal fossa. The anterior opening of the canal is located in a fibrous plate, which has 1-2 openings through which pass: a. genu descendens, accompanied by a vein, and n. saphenus. The drive canal contains: the femoral artery, the femoral vein and the saphenous (hidden) nerve, n. saphenus.
Popliteal fossa, fossa poplitea - has a diamond shape, the upper sides of the rhombus are longer than the lower ones. The upper corner of the popliteal fossa is limited on the medial side by the semimembranosus muscle, and on the lateral side by the biceps femoris muscle. The inferior angle is located between the medial and lateral heads of the gastrocnemius muscle. The bottom of the popliteal fossa is formed by the popliteal surface femur, fades poplitae femoris, capsule of the knee joint, lig. popliteum obliquum, lig. popliteum arcuatum. Posteriorly, the popliteal fossa is closed by the own fascia of the posterior portion of the knee. The popliteal fossa is filled with fatty tissue, lymphatic vessels and nodes, neurovascular bundle (according to the anatomical code "NEVA" - n. tibialis, vena et a. poplitea).
The ankle-popliteal canal, canalis cruropopliteus (BNA) (Gruber's canal) 1 - occupies the space between the superficial and deep muscle groups of the lower leg. The popliteal canal of the leg has three openings: one inlet and two outlet. The anterior wall of the canal in the upper section is formed by mm. tibialis posterior and flexor digitorum longus, and in the lower part - mm. flexor digitorum longus and flexor hallucis longus. The posterior wall is formed by the soleus muscle. The channel is calculated: the final section of the popliteal artery, the initial section of the anterior tibial artery, the posterior tibial artery, their accompanying veins, the tibial nerve and tissue. The entrance hole is a gap between the arcus tendineus m. solei and m. popliteus. This gap includes the popliteal artery and the tibial nerve. The upper inlet is a triangular gap between the neck fibula(outside), m. popliteus (above) and m. tibialis posterior (from the middle and below). Through this hole, the anterior tibial artery emerges from the canal into the anterior bed of the leg. The inferior outlet is a narrow fascial gap between the superficial and deep layers of the intrinsic fascia of the leg. This gap is located on the border of the middle and lower third of the leg at the lower inner edge of the soleus muscle. Here the posterior tibial neurovascular bundle emerges from the canal. The popliteal canal of the leg along the neurovascular bundle connects with the popliteal fossa, ossicular, calcaneal and plantar canals.
Inferior musculofibular canal, canalis musculoperoneus inferior - extends from the ankle popliteal canal in the middle third of the leg in the lateral direction. The walls of the canal are: in front - the posterior surface of the fibula, in the back - the long flexor of the big toe. The canal contains the peroneal artery and the veins that accompany it.
Superior musculofibular canal, canalis musculoperoneus superior - located in the upper third of the leg, limited by the lateral surface of the fibula and the peroneus longus muscle. The superficial peroneal nerve passes through the canal.
Ossicular canal, canalis malleolaris - located in the area of the medial malleolus between the retinaculum mm. flexorum and calcaneus. Upper limit the ossicular canal is the base of the medial malleolus, the lower border is the upper edge of the abductor muscle thumb. The outer wall of the canal is formed by the medial malleolus, ankle capsule and calcaneus. The inner wall is formed by the flexor muscle holder, retinaculum musculorum flexorum. The flexor tendons and the neurovascular bundle pass through the ossicular canal. There are two grooves on the plantar surface of the foot: the medial plantar groove, sulcus plantaris medialis, and the lateral plantar groove, sulcus plantaris lateralis. The medial plantar groove is located between mm. flexor digitorum brevis et abductor hallucis. The lateral plantar groove is located between the flexor digitorum brevis et abductor digiti minimi. The plantar grooves contain neurovascular bundles.
1.
2.
3.
4.
Femoral canal located between the superficial and deep layers of the fascia lata. Femoral canal It has two holes- deep and superficial, and three walls. The deep opening of the femoral canal is projected onto the inner third of the inguinal ligament. The superficial opening of the femoral canal, or subcutaneous fissure, hiatus saphenus, is projected 1-2 cm downward from this part of the inguinal ligament.
Coming out of abdominal cavity the hernia enters the canal through deep hole - thigh ring, anulus femoralis. It is located in the most medial section vascular lacuna and has four edges.
Front thigh ring limits inguinal ligament, posteriorly - pectineal ligament, lig. pectineale, or Cooper's ligament, located on the crest of the pubic bone (pecten ossis pubis), medial lacunar ligament, lig. lacunare, located in the angle between the inguinal ligament and the crest of the pubic bone. On the lateral side it is limited by the femoral vein.
Thigh ring facing the pelvic cavity and on the inner surface abdominal wall covered by the transverse fascia, which here has the appearance of a thin plate, septum femorale. Within the ring is the deep inguinal lymph node Pirogov-Rosenmüller.
Superficial ring of the femoral canal (hole) is subcutaneous fissure, hiatus saphenus, a defect in the superficial layer of the fascia lata. The hole is closed by the cribriform fascia, fascia cribrosa (Fig. 4.8).
Femoral canal and femoral hernia.1 - m. iliacus; 2 - m. psoas major,
3 - spina iliaca anterior superior; 4 - n. femoralis;
5 - arcus ilio-pectineus; 6 - lig. inguinal;
7 - margo falciformis et cornu superior, 8 - a, v. femoralis;
9 - os pubis; 10 - saccus herniae (hernial sac);
11 - v. saphena magna.
Walls of the femoral canal
Walls of the femoral canal They are a three-sided pyramid.
Anterior wall of the femoral canal formed by the superficial layer of the fascia lata between the inguinal ligament and the upper horn of the subcutaneous fissure - cornu superius.
Lateral wall of the femoral canal- medial semicircle of the femoral vein.
Posterior wall of the femoral canal- a deep layer of fascia lata, which is also called fascia iliopectinea.
Medial wall of the femoral canal no, since the superficial and deep layers of fascia at the long adductor muscle grow together.
Femoral canal length(the distance from the inguinal ligament to the superior horn of the hiatus saphenus) ranges from 1 to 3 cm.
Topographic anatomy allows us to describe in detail the layer-by-layer structure of the muscular apparatus of the lower extremities, their blood supply and innervation.
Location
The femoral canal is located in the area of the femoral triangle (its location is limited at the top by the inguinal ligament, sartorius and long adductor muscles, located on the side and in the middle), formed at the place where femoral hernias (protrusions) emerge from the body internal organs outward in the form of a fold in the groin area), passes between the sheet of fascia lata through the arcuate space (ring). There is an external opening on the superficial layer of the fascia lata of the thigh. Blood vessels (femoral vein and artery) extend through it, and hernias that exist in the area of intracavitary organs enter in the same way.
Topography
Let's consider the main components of education.
Holes
There are several of them in the channel:
- Deep (femoral ring).
- Superficial: subcutaneous fissure, anomaly muscle structure. Blood and lymphatic channels pass through it. Located 2 cm lower than the inguinal ligament.
The channel runs through the first passage, washed by the artery and vein passing through this part of the leg.
Thigh ring
The Latin name is anulus femoralis. Indicates the place in the triangle in which the muscular and vascular lacunae are located. The first contains the iliofemoral muscle and the nerve of the same name, the second contains large vessels that supply the thigh.
Highlight:
- deep femoral ring (internal);
- superficial (subcutaneous fissure of the femoral canal).
The first, limiting the space with a small plate, is directed towards the pelvis. It is based on several connections:
- inguinal (located in front);
- comb (posterior);
- medial lacunar (lies in the groin area in the medial space);
- Cooper (encompassing the edge of the pubic bone).
It has a small depression (oval fossa) at the edge of the abdominal cavity; inside there is a lymph node.
The second is located below the inguinal fold and includes the genital and epigastric veins, afferent lymph vessels, and nerve processes.
Walls of the femoral canal
There are three of them (they form a pyramid-shaped space):
- Front. Created by a corresponding sheet of fascia lata, it is located in the area of the interinguinal ligament near the top of the saphenous fissure.
- Lateral – formed venous vessel hips.
- Posterior - created by a deep sheet of fascia lata.
Symptoms of disorders
The appearance of space indicates the presence of hernia-like formations, and the appearance of specific symptoms is associated with this.
Characteristic:
- pain in the groin;
- swelling localized in the lower abdomen;
- rumbling sounds of bowel function;
- wave-like movement of protrusion during coughing;
- swelling and numbness in the leg (observed due to compression of nearby blood vessels).
There may be problems with urination and bowel movements. This happens if the hernial sac gets urinary tract and organs.
If the disease is not treated in a timely manner, inflammation occurs, accompanied by an increase in temperature, redness of the skin, and an increase in edema and swelling.
Diagnosis of pathologies
The presence of an abnormal formation can be determined visually, judging by the rounded bulge in the upper thigh and lower groin.
The external examination of the patient is complemented by diagnostic examinations. The patient is prescribed:
- Ultrasound of the lower abdomen (bladder, pelvic organs);
- irrigocopy (ultrasound examination of the colon by introducing a contrast agent into it).
It is important to distinguish abnormal cavity formation from:
- Venous varicose veins: when pressed, they collapse and quickly return to their original form.
- Tuberculosis (stretches along the iliopsoas muscle to the thigh with pathology of the spinal column in the lumbar region; pain is determined by palpation; to exclude an anomaly, an x-ray of the corresponding area is prescribed).
Studying the topographic structure of the femoral canal of the limb allows for correct and successful surgical intervention and elimination of femoral hernias.
In the area of the lower limb girdle, a suprapiriform foramen (foramen suprapiriforme) is distinguished; infrapiriform foramen (foramen infrapiriforme); obturator canal (canalis obturatorius); muscle lacuna (lacuna musculorum); vascular lacuna (lacuna vasorum).
Suprapiriform foramen (foramen suprapiriforme)and infrapiriform foramen ( foramen infrapiriforme) located above and below the piriformis muscle (m. piriformis) in the greater sciatic foramen. Arteries, veins and nerves pass through the supragiriform and infrapiriform openings.
Obturator canal (canalis obturatorius) located in the upper part of the obturator foramen between the obturator groove of the superior ramus of the pubis and the upper edge of the obturator internus muscle and the obturator membrane. In the obturator canal there are vessels and nerves of the same name. The obturator canal connects the pelvic cavity with the medial thigh.
Muscular lacuna (lacuna musculorum) and vascular lacuna (lacuna vasorum) are formed as a result of the division of the space under the inguinal ligament by a section of the iliac fascia, which is called . This arch fuses with the inguinal ligament on top and with the periosteum of the pubic bone below. Outside the arcus iliopectineus is located muscle lacuna(lacuna musculorum), it contains the iliopsoas muscle (musculus iliopsoas) and the femoral nerve (nervus femoralis). Inward from the arcus iliopectineus there is a vascular lacuna (lacuna vasorum), limited on the medial side lacunar ligament (ligamentum lacunare, Zhimbernatova), from the lateral side – iliopectineal arch (arcus iliopectineus), above - inguinal ligament, below – pectineal ligament (lig. pectineale). The lacuna contains the femoral artery (arteria femoralis) (laterally) and the femoral vein (vena femoralis) (medially).
Through muscular and vascular lacunae, the pelvic cavity communicates with the anterior region of the thigh.
In the hip area there is a femoral triangle (trigonum femorale); subcutaneous fissure (hiatus saphenus); femoral canal (canalis femoralis) (in case of femoral hernias); iliopectineal groove (sulcus iliopectineus), anterior femoral groove (sulcus femoralis anterior); adductor canal (canalis adductorius).
Femoral triangle (trigonum femorale) stands out on the front surface of the thigh. Its boundaries are: the inguinal ligament (ligamentum inguinale) (superior), the sartorius muscle (musculus sartorius) (laterally) and the edge of the long adductor muscle (musculus adductor longus) (medially).
Subcutaneous fissure (hiatus saphenus) located below the medial part of the inguinal ligament and is represented by a small depression covered by a section of the superficial layer of the fascia lata of the thigh; this area of fascia is called cribriform fascia (fascia cribrosa). The subcutaneous gap is limited crescent-shaped edge (margo falciformis), which has upper horn (cornu superius) and lower horn (cornu inferius). In front of the lower horn there is a large saphenous vein(vena saphena magna) at its confluence with the femoral vein. As a rule, a lymph node is located in the subcutaneous cleft.
Femoral canal (canalis femoralis)(normally absent, but formed when a femoral hernia occurs) is located in the medial part of the vascular lacuna (lacuna vasorum). It has 3 walls: 1 – front wall formed by the inguinal ligament (ligamentum inguinale) and the upper horn of the falciform margin (cornu superius margo falciformis) fused with it; 2 – back wall represented by a deep layer of the fascia lata of the thigh; 3 – lateral wall formed by the femoral vein. From the abdominal cavity, the femoral canal has internal femoral ring (anulus femoralis)(channel inlet); its borders: on the medial side – lacunar ligament), on the lateral side – the femoral vein, on the top – the inguinal ligament, on the bottom – the pectineal ligament (lig. pectineale); external (outlet) hole The femoral canal is limited by a crescent-shaped edge (margo falciformis).
Iliopectineal groove (sulcus iliopectineus) located in the upper part of the femoral triangle and is represented by a depression between the pectineus muscle (medially) and the iliopsoas muscle (laterally). At the bottom of this groove (pit) are the femoral artery, vein and saphenous nerve.
Anterior femoral groove (sulcus femoralis anterior) is a distal continuation of the iliopectineal groove. Its walls are formed by the long adductor and large adductor muscles (m. adductor longus et m. adductor magnus) (medially) and the vastus medialis (m. vastus medialis) (laterally). In front, the femoral groove is covered by the sartorius muscle (m. sartorius).
Adductor canal (canalis adductorius, Gunterov)– continuation of the femoral groove downwards. It has three walls: 1 – lateral wall, formed by the vastus medialis muscle (m. vastus medialis); 2 – medial wall, represented by the large adductor muscle (m. adductor magnus); 3 – front wall, which is a section of the fascia lata of the thigh that passes from the vastus medialis muscle to the adductor magnus muscle and is called lamina vastoadductoria. The adductor channel has 3 holes: 1 – top hole limited by the same formations as the walls of the adductor canal; 2 – bottom hole presented tendon gap (hiatus tendineus) in the tendon of the adductor magnus muscle; 3 – front hole - a small gap in the anterior wall of the adductor canal through which the descending artery of the knee and the saphenous nerve emerge. Pass in the channel femoral artery, vein and saphenous nerve (partially).
III. Calf muscles
Posterior muscle group
Normally, this is a slit-like space called thigh ring, filled with loose connective tissue medial to the vascular lacuna.
· Closed at the top by a lymph node.
· On the side of the abdomen it is closed by the peritoneum, which in this place forms a fossa - fossa femoralis.
- Thigh ring(annulus femoralis) formed:
laterally- femoral vein (v. femoralis),
top and front- lig. inguinale and the upper horn (cornu superius) of the crescent-shaped edge of fascia lata,
medially– continuation of the lateral leg of lig. inguinale, folded down - lacunar ligament(lig. lacunare),
below and behind– continuation of the lacunar ligament along the os pubis - pectineal ligament (lig. pectineale).
- When a femoral hernia forms, a canal is formed that will have three walls and two openings - internal and external.
· Walls of the femoral canal:
lateral- femoral vein (v. femoralis);
back- deep leaf fascia lata;
front– lig. inguinale and cornu superius of the crescent-shaped edge of the fascia lata.
- Femoral canal openings:
- internal hole(input) - this is the femoral ring described above, corresponds to the location of the lateral inguinal fossa on the peritoneum of the anterior abdominal wall.
- outer hole(output) - corresponds to the subcutaneous fissure (area of the oval fossa), limited to:
laterally – crescent-shaped edge (margo falciformis),
above – upper horn of the falciform edge (cornu superius margo falciformis)
from below – lower horn of the falciform edge (cornu inferius margo falciformis)
The anatomical and physiological prerequisites for the occurrence of femoral hernias are stretching of the ligamentous apparatus of the femoral canal region, which is primarily facilitated by an increase in intra-abdominal pressure caused by repeated pregnancies, cough, constipation, obesity and heavy physical labor. Of particular importance is the weakening of the lacunar ligament, which in older women often looks flabby, drooping and easily succumbs to the pressure of a hernial protrusion.
In the occurrence of rare forms of femoral hernias, the main role is played by congenital predisposition in the form of defects in the ligamentous aponeurotic apparatus and protrusions of the peritoneum. Trauma, in particular hip dislocation or reduction of congenital hip dislocation, is of some importance.
In the process of formation, a femoral hernia goes through three stages:
1) initial, when the hernial protrusion does not extend beyond the internal femoral ring. This stage of the hernia is clinically difficult to distinguish, and at the same time, insidious parietal (Richter’s) infringements may be noted at this stage,
2) incomplete (canal), when the hernial protrusion does not extend beyond the surfaces of the fascia and does not penetrate the subcutaneous fatty tissue Scarpa's triangle, and is located near vascular bundle. With this form of hernia, searching for the hernial sac during surgery usually causes difficulties;
3) complete, when the hernia passes the entire femoral canal, its internal and external openings and exits into subcutaneous tissue hips. This stage of hernia is most often observed.
The contents of femoral hernias are usually loops small intestine or oil seal. Less often in hernial sac The large intestine is found, the sigmoid intestine is on the left, and the cecum is on the right. Sometimes the bladder comes out into the hernia. Occasionally, the contents of a femoral hernia may be an ovary with an epididymis, and in men, a testicle.
According to the passage of vessels and nerves, the following grooves and canals are distinguished on the lower limb:
