Subinguinal hiatus, femoral triangle, adductor canal, etc… Ákos Lukáts M.D., Ph.D. 22.11. 2015. (lukats.akos@med.semmelweis-univ.hu)

In and out from the pelvis Greater schiatic foramen - suprapiriform hiatus - infrapiriform hiatus Lesser schiatic foramen (to perineum) Obturator canal Subinguinal hiatus (from pelvis major)

Schiatic foramina Greater schiatic foramen Obturator canal Subinguinal hiatus Sacrospinous lig. Sacrotuberous lig. Inguinal lig. Lesser schiatic foramen Obturator membrane (+ m. obt. Ext, int.)

Lesser sciatic foramen : They enter the ischiorectal fossa! Gluteal region - sacral plexus Suprapiriform hiatus : superior gluteal a., v., n. Infrapiriform hiatus: inferior gluteal a., v., n. sciatic n. (committing a.) posterior femoral cut. n. internal pudendal a., v. pudendal n. Lesser sciatic foramen : internal pudendal a., v. pudendal n. They enter the ischiorectal fossa! Sobota - Atlas of Human Anatomy

Intramuscular injection Triangular technique (trochanter major, anterior superior iliac spine, iliac crest) NOT to hit: superior gluteal a., v., n. Sobota - Atlas of Human Anatomy

Subinguinal hiatus – lumbal plexus, a. et v. Iliopectinate arch Lacuna musculonervosa: lateral cutaneus femoral n. m. iliopsoas femoral n. Lig. lacunare Lacuna vasorum: femoral a., v. genitofemoral n. (femoral br.) Lacuna lymphatica (herniosa): lymph vessels Inner opening of femoral canal!! (anulus femoralis) Sobota - Atlas of Human Anatomy

Femoral triangle / iliopectineal fossa Borders of the femoral trigone: m. sartorius (lat), m. adductor longus (med) fascia lata (spf. - sapheneal hiatus – cribriform plate – spf. connection) m. iliopsoas, m. pectineus (deep) subinguinal hiatus (sup. connection) Adductor canal (inf. connection)

Femoral triangle / iliopectineal fossa Borders of iliopectineal fossa: m. iliopsoas, m. pectineus (iliopectineal fascia) fascia lata (sapheneal hiatus – cribriform plate

Femoral triangle / iliopectineal fossa Connections: subinguinal hiatus : femoral a., v., genitofemoral n. (femoral br.), lymph vessels, (femoral n.) sapheneal hiatus : greater saphenous v. genitofemoral n. (femoral br.), lymph vessels adductor canal : femoral a., v., saphenous n. Femoral nerve runs under the iliopectineal fascia!!! Sobota - Atlas of Human Anatomy

Femoral artery in superficial position – risk of injury!!! Sobota - Atlas of Human Anatomy Palpatable femoral artery! First aid!! Arterial puncture! Regions supplied by spf. and deep inguinal lymph nodes: lower extremity, inferior superficial part of abdominal wall, external genital organs (NOT THE TESTIS!!!) drain further to the pelvic nodes near the. Iliac artery. Lymph node enlargement is fairly common, mostly caused by banal infection.

Palpation and Compression of the Femoral Artery.

Sobota - Atlas of Human Anatomy Adductor canal Borders: m. vastus medialis (lat.), m. adductor longus et magnus (med.) lamina vastoaductoria (spf.) – m. sartorius above Content: femoral a., v., sapheneus n. (ARTERY SUPERFICIAL) Connections: femoral triangle (iliopectineal fossa ): femoral a., v., sapheneus n. adductor hiatus : femoral a., v. – popliteal a., v. The sapheneus n. and the descending genicular artery penetrate the lamina vastoaductoria. Sobota - Atlas of Human Anatomy

m. semitendinosus et semimembranosus ant. cut. fem. nn. Femoral a., v., sapheneus n. Extensors Greater saphenous v. m. rectus femoris Flexors m. vastus intermedius m. sartorius Adductors m. vastus medialis m. vastus lateralis m. adductor longus lat. cut. fem. n. r. cut. of obturator n. m. adductor magnus sciatic n., a commitans n. ischiadici, aa. perforantes m. gracilis m. biceps femoris m. semitendinosus et semimembranosus post. cut. fem. n Sobota - Atlas of Human Anatomy

Popliteal fossa Borders: m. semitendinosus et semimembranosus (sup. med.) m. biceps femoris (sup. lat.) m. gastrocnemius medialis et lateralis (inf. med / lat.) Base: femur (popliteal surface), m. adductor magnus, capsule of knee joint, m. popliteus Deep outflow under the origin of soleus m. Covered superficially by popliteal fascia. Contents: popliteal a., v., tibial n. , common peroneal n. (sciatic n.), lesser saphenous v., lymph vessels, med. and lat. cut. surral nerve. (surral n.), collateral arteries/veins of the knee. Palpatable popliteal artery! Sobota - Atlas of Human Anatomy

Sobota - Atlas of Human Anatomy Connections: adductor hiatus : femoral a., v. – popliteal a., v. From the groove between flexors of the knee: tibial n., common peroneal n. (sciatic n.) Under the origin of soleus m : popliteal a. (ant/post tibial a.), tibial n. Penetrating the popliteal fascia: lesser saphenous v., lymph vessels, med. and lat. cut. surral n. (surral n.) common peroneal n. Sobota - Atlas of Human Anatomy

Subinguinal hiatus – femoral canal. Lacuna musculonervosa: lateral cutaneus femoral n. m. iliopsoas femoral n. Lig. lacunare Lacuna vasorum: femoral a., v. genitofemoral n. (femoral br.) Lacuna lymphatica (herniosa): lymph vessels Inner opening of femoral canal!! (anulus femoralis) Sobota - Atlas of Human Anatomy Femoral canal: septum femorale, l. lymphatica, femoral triangle (iliopectineal fossa), saphenous hiatus Femoral herniation (especially common in females)c

About 1.3cm long , and its upper opening is called the femoral ring Contains: a little loose fatty tissue, a small lymph node, and some lymph vessels.

Femoral canal: septum femorale, l Femoral canal: septum femorale, l. lymphatica, femoral triangle (iliopectineal fossa), saphenous hiatus Femoral herniation (especially common in females)

Femoral hernia From: Google search.com

Corona mortis Corona mortis Netter: Atlas of Human Anatomy Corona mortis Corona mortis Anastomosis between external iliac and obturator arteries. Danger during femoral hernia operation!

Spermatic cord and opened inguinal canal Details: next semester

Inguinal canal deep inguinal ring superficial inguinal ring Borders: Sobota - Atlas of Human Anatomy Borders: Anterior: fascia of external oblique abdominal muscle Superior: internal oblique abdominal muscle, transversus abdominis muscle Inferior: inguinal ligament Posterior: transversalis fascia, peritoneum Content: Spermatic cord in males, round ligament of the uterus in females

Inguinal herniation deep inguinal ring superficial inguinal ring More common in males. Starts above the inguinal ligament Sobota - Atlas of Human Anatomy Indirect inguinal herniation: Starts at the deep inguinal ring, positioned in between the components of the spermatic cord, travels through the inguinal canal and can reach as far as the testis (testicular herniation). Direct inguinal herniation: Starts more medially, at the superficial inguinal ring. Not within, but next to the spermatic cord, usually do not reach the testis

Indirect (B) és direct (C) inguinal herniation

Netter: Atlas of Human Anatomy

Obturator canal Obturator foramen covered by obturator membrane and two muscles, obturator externus and internus. Only a small canal is left: obturator canal It connects the pelvis to the adductor compartment of the thigh. Contents: obturator artery, vein, nerve "obturator herniation„ - rare

Obturator herniation

Literature Szentagothai J, Réthelyi M: Funkcionális anatómia, Medicina, 1989 Sobota - Atlas of Human Anatomy, 20th edition, Urban and Schwarzenberger, 1993 Renner Antal: Traumatológia, 2nd edition, Medicina, Budapest, 2003 Vízkelety Tibor: Az ortopédia tankönyve, 2nd edition, Semmelweis Kiadó, 1999 Radiologic images: http://rad.usuhs.mil/medpix/index.html