venous drainage and Lymphatics of lower limb DR.QUDSIA SULTANA

Veins of lower limb Superficial veins Great saphenous vein Small saphenous vein Deep veins Venae comitantes Perforating veins Communicating veins

Veins of the lower limb Superficial: Great (long) saphenous vein Short (small) saphenous vein Many tributaries of the above veins Deep veins: accompany arteries Anterior tibial Posterior tibial Popliteal Femoral Plantar arch and its tributaries

Deep veins Anterior tibial vein: Veins accompanying dorsal metatarsal arteries end in the dorsal venous arch (arcuate artery) Venous arch continues as the anterior tibial vein Finally joins with the posterior tibial vein to form popliteal vein

Deep veins Posterior tibial vein: Plantar metatarsal veins join to for plantar arch (continues as lateral plantar vein) This will join the medial plantar vein and continue as posterior tibial vein This vein is joined by the peroneal or fibular vein

Deep veins Posterior tibial vein combines with the anterior tibial vein and continues as popliteal vein These veins receive many tributaries corresponding to the branches of the arteries of same name

Femoral vein Continuation of the popliteal vein Receives profunda femoris vein and its tributaries Many muscular veins form other tributaries of this vein Continues as external iliac vein

Factors Responsible for Venous Return from Lower Limb General factors : Negative intra thoracic pressure( Recumbent position ). The pulsations of accompanying arteries. The valves allows the blood to flow in upward direction only. The deep veins lie in the tight fascial compartment. ( upright position). Pics

Local factors: Venous : Veins of lower limb are more muscular. Greater number of valves Muscular : When the limb is active, muscular contraction compresses the deep veins and drives the blood in them upwards. Fascial : Tight sleeve of deep fascia makes the muscular compression of the veins much more effective by limiting outward bulging of the muscles.

Superficial Veins Lie in superficial fascia. Drain into deep veins at their termination. Connected to deep veins through perforating veins. Superficial Veins are: Dorsal Venous arch. Great or long saphenous vein. Small saphenous vein

Dorsal Venous Arch

Great Saphenous Vein Longest Vein of the body . Meaning of saphenous

Great saphenous vein Longest vein Continuation of medial end of dorsal venous arch Front of medial malleolus A fingers breadth behind the medial border of tibia One hands breadth posterior to patella

Pierces cribriform fascia of Saphenous opening to drain into femoral vein

Structures accompanying In thigh Medial femoral cutaneous nerve. At knee Saphenous branch of descending genicular artery. In leg and foot Saphenous nerve Medial femoral cutaneous nerve Saphenous nerve

Valves in the Great Saphenous vein Saphenofemoral valve is functionally important.

Tributaries Posterior arch vein Anterior leg vein Anterolateral vein Superficial circumflex iliac vein Superficial epigastric V external pudendal V Femoral V Great Saphenous V Saphenous nerve Medial malleolus Antero lateral vein Dorsal venous arch Posteromedial vein Anterior leg vein Posterior arch Tributaries Posterior arch vein Anterior leg vein Anterolateral vein Postero- medial vein Superficial epigastric Superficial circumflex iliac Superficial external pudendal Deep external pudendal

Thoracoepigastric vein : Connects superficial epigastric vein with the lateral thoracic vein. Establishes a connection between femoral and axillary veins.

Two types : Direct Indirect

Indirect Perforators: Pass from: superficial veins muscular veins deep veins. Direct Perforators: Pass from superficial veins deep veins. constant in number and site

Musculovenous Pump Soleus is regarded as the peripheral heart.

Perforating veins Mid- Hunter: Hunters Canal, connects Femoral with Great Saphenous Vein. Knee: Connects post tibial With Great Saphenous Vein. Ankle: Medial ankle – 3, Connects post tibial With GSV Lateral ankle -1, Communicates the SSV with peroneal vein

Perforating veins or Perforators

Small saphenous vein Continuation of lateral end of dorsal venous arch Popliteal vein Continuation of lateral end of dorsal venous arch Lateral to tendo calcaneous Sural nerve on lateral side Dips into popliteal fossa Drains into popliteal vein Small saphenous vein

Bifurcates to drain into : Great saphenous vein Popliteal vein

Applied anatomy

Applied aspects Varicosities: Thrombosis of deep veins Increased intra abdominal pressure Incompetency of valves Incompetency of sapheno-femoral valve Incompetency of valves in perforating veins

4 layered compression bandage technique. Increases venous return. Helps in healing of venous ulcers within 8 weeks .

Tests to know the site of incompetence BRODIE TRENDELENBURG TEST: -for sapheno femoral valve first empty the veins---sapheno femoral junction is compressed with the thumb --- patient is asked to stand up---pressure released --- varices fill from above---- sapheno femoral valve incompetency--- positive test to test the communicating system--- pressure is maintained—gradual filling of veins

Tourniquet Test Localize the site of saphenous opening: 4cm below & lateral to the pubic tubercle Elevate the patients limb & empty the L.L. veins 2 Apply the tourniquet below the saphenous opening 3 1 4 As the patient stands, the V.V. fill rapidly from above. This means that the incompetent connection between the deep & superficial system is NOT the sap-fem junction (which is controlled by the tourniquet), but it is below it. The site of incompetent perforator is suspected by a palpable fascial defect, multiple tourniquet & confirmed by Duplex 5

Varicose ulcers

Venous cut down

Accessible and muscular

Lymphatic drainage of lower limb

Superficial inguinal lymph nodes Horizontal group Superficial inguinal lymph nodes Upper (Horizontal) Lateral group Medial group Lower (Vertical) Vertical Group

Deep inguinal lymph nodes 1-3 Medial side of femoral vein Afferents deep lymph vessels accompanying the femoral vessels Glans penis or glans clitoridis Few from superficial inguinal nodes Deep inguinal lymph nodes

LYMPHATIC DRAINAGE OF LOWER LIMB Popliteal lymph nodes: They lie in popliteal fossa They receive lymph from: knee joint Deep lymph vessels from leg along anterior & posterior tibial arteries Some superficial lymph vessels from leg & foot along small saphenous vein Their efferents drain into deep inguinal lymph nodes

Applied anatomy Lymphedema- Filaria Enlargement of lymph nodes Syphilitic lesions