1. Dr. Fadel Naim Orthopedic Surgeon IUG
The Thigh I
Dr. Fadel Naim
Orthopedic Surgeon
IUG
DR FADEL NAIM
IUG

2. Surface anatomy of the thigh
Surface features of the Thigh
Sartorius muscle
Quadriceps femoris muscle
Adductor longus muscle
Hamstring muscles
Femoral triange

3. VEINS OF THE LOWER LIMB
The veins of the lower limb can be divided into three groups:
Superficial
Deep
perforating.
The superficial veins
consist of the great and small saphenous veins and their tributaries
situated beneath the skin in the superficial fascia.
The constant position of the great saphenous vein in front of the medial malleolus should be remembered for patients requiring emergency blood transfusion.
The deep veins are
the venae comitantes to the anterior and posterior tibial arteries
the popliteal vein
the femoral veins and their tributaries.
The perforating veins
communicating vessels that run between the superficial and deep veins.
Many of these veins are found particularly in the region of the ankle and the medial side of the lower part of the leg.
They possess valves that are arranged to prevent the flow of blood from the deep to the superficial veins.
DR FADEL NAIM
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4. Superficial Veins The great saphenous vein
Drains the medial end of the dorsal venous arch of the foot
Passes upward directly in front of the medial malleolus
It then ascends in company with the saphenous nerve in the superficial fascia over the medial side of the leg.
The vein passes behind the knee and curves forward around the medial side of the thigh
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5. Superficial Veins The great saphenous vein
It passes through the lower part of the saphenous opening in the deep fascia and joins the femoral vein about 1.5 in. (4 cm) below and lateral to the pubic tubercle
The great saphenous vein possesses numerous valves
Connected to the small saphenous vein by one or two branches that pass behind the knee.
Several perforating veins connect the great saphenous vein with the deep veins along the medial side of the calf
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6. At the saphenous opening in the deep fascia, the great saphenous vein usually receives three tributaries:
The superficial circumflex iliac vein
the superficial epigastric vein
the superficial external pudendal vein.
These veins correspond with the three branches of the femoral artery found in this region.
An additional vein, known as the accessory vein, usually joins the main vein about the middle of the thigh or higher up at the saphenous opening.
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7. VENOUS PUMP OF THE LOWER LIMB
Venae comitantes are subjected to intermittent pressure at rest and during exercise in the closed fascial compartments of the lower limb.
The pulsations of the adjacent arteries help move the blood up the limb.
The contractions of the large muscles within the compartments during exercise compress these deeply placed veins and force the blood up the limb.
The superficial saphenous veins, are not subject to these compression forces.
The valves in the perforating veins prevent the high-pressure venous blood from being forced outward into the low-pressure superficial veins.
As the muscles within the closed fascial compartments relax, venous blood is sucked from the superficial into the deep veins.
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8. DR FADEL NAIM
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9. Venous pump of lower limb

10. VARICOSE VEINS
A varicosed vein is one that has a larger diameter than normal and is elongated and tortuous.
Commonly occurs in the superficial veins of the lower limb
Responsible for considerable discomfort and pain.
Many causes:
Hereditary
Weakness of the vein walls
Incompetent valves
Elevated intra-abdominal pressure
Thrombophlebitis of the deep veins
By incompetence of a valve in a perforating vein:
High-pressure venous blood escapes from the deep veins into the superficial veins and produces a varicosity
Operative treatment of varicose veins
The ligation and division of all the main tributaries of the great or small saphenous veins, to prevent a collateral venous circulation from developing
It is imperative to ascertain that the deep veins are patent before operative measures are taken.
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12. GREAT SAPHENOUS VEIN CUT DOWN
Usually performed at the ankle
Disadvantage that phlebitis is a potential complication
Also at the groin in the femoral triangle,
Phlebitis is relatively rare
Larger diameter of the vein
Use of large-diameter catheters
Rapid infusion of large volumes of fluids.
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13. The Great Saphenous Vein In Coronary Bypass Surgery
In occlusive coronary disease caused by atherosclerosis, the diseased arterial segment can be bypassed by inserting a graft consisting of a portion of the great saphenous vein.
The venous segment is reversed so that its valves do not obstruct the arterial flow.
Following removal of the great saphenous vein at the donor site, the superficial venous blood ascends the lower limb by passing through perforating veins and entering the deep veins.
The great saphenous vein can also be used to bypass obstructions of the brachial or femoral arteries
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14. Inguinal Lymph Nodes
The inguinal lymph nodes are divided into superficial and deep groups.
Superficial Inguinal Lymph Nodes
lie in the superficial fascia below the inguinal ligament
divided into a horizontal and a vertical group
The horizontal group
lies just below and parallel to the inguinal ligament
The medial members of the group receive superficial lymph vessels from the anterior abdominal wall below the level of the umbilicus and from the perineum
urethra, the external genitalia of both sexes (but not the testes)
the lower half of the anal canal
The lateral members of the group receive superficial lymph vessels from the back below the level of the iliac crests
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15. Superficial Inguinal Lymph Nodes
Horizontal Group
Vertical Group
Dr. Vohra

16. Inguinal Lymph Nodes The vertical group
Lies along the terminal part of the great saphenous vein and receives most of the superficial lymph vessels of the lower limb
The efferent lymph vessels from the superficial inguinal nodes pass through the saphenous opening in the deep fascia and join the deep inguinal nodes.
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17. Inguinal Lymph Nodes Deep inguinal lymph nodes
Located beneath the deep fascia and lie along the medial side of the femoral vein
The efferent vessels from these nodes enter the abdomen by passing through the femoral canal to lymph nodes along the external iliac artery
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18. LYMPHATICS OF THE LOWER LIMB
The superficial and deep inguinal lymph nodes drain:
All the lymph from the lower limb
Drain lymph from the skin and superficial fascia of:
The anterior and posterior abdominal walls below the level of the umbilicus;
Lymph from the external genitalia and the mucous membrane of the lower half of the anal canal
Patient may present with an enlarged, painful inguinal lymph node caused by lymphatic spread of pathogenic organisms that entered the body through a small scratch on the undersurface of the big toe.
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19. SUPERFICIAL FASCIA OF THE THIGH
The membranous layer of the superficial fascia of the anterior abdominal wall extends into the thigh and is attached to the deep fascia (fascia lata) about a fingerbreadth below the inguinal ligament
The fatty layer of the superficial fascia on the anterior abdominal wall extends into the thigh and continues down over the lower limb without interruption
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20. DEEP FASCIA OF THE THIGH (FASCIA LATA)
The deep fascia encloses the thigh like a trouser leg
At its upper end is attached to the pelvis and the inguinal ligament
On its lateral aspect, it is thickened to form the iliotibial tract
The iliotibial tract receives the insertion of
Tensor fasciae latae
Greater part of the gluteus maximus muscle
In the gluteal region, the deep fascia forms sheaths, which enclose
The tensor fasciae latae
The gluteus maximus
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21. Saphenous Opening
The saphenous opening is a gap in the deep fascia in the front of the thigh just below the inguinal ligament.
It transmits:
the great saphenous vein
some small branches of the femoral artery
lymph vessels
The saphenous opening is situated about 1.5 in. (4 cm) below and lateral to the pubic tubercle.
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22. Saphenous Opening
The falciform margin is the lower lateral border of the opening, which lies anterior to the femoral vessels
The border of the opening then curves upward and medially, and then laterally behind the femoral vessels, to be attached to the pectineal line of the superior ramus of the pubis.
The saphenous opening is filled with loose connective tissue called the cribriform fascia.
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23. FASCIAL COMPARTMENTS OF THE THIGH
Three fascial septa pass from the inner aspect of the deep fascial sheath of the thigh to the linea aspera of the femur
the thigh is divided into three compartments, each having muscles, nerves, and arteries.
The compartments are
Anterior
Medial
posterior
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25. Anatomy of the thigh
Thigh innervations: Anterior compartment from femoral nerve L2,3,4. Medial compartment from obturator nerve L2,3,4. Posterior compartment from sciatic nerve L4,5,S1,2,3 (sacral plexus).

26. Thigh innervations Anterior compartment- Extensors of the knee
Femoral Nerve
femur
medial
lateral
Medial compartment-
Adductors of the knee
Obturator Nerve
Posterior compartment-
Flexors of the knee
Sciatic Nerve

27. CONTENTS OF THE ANTERIOR FASCIAL COMPARTMENT OF THE THIGH
Muscles:
Sartorius
Iliacus
Psoas
Pectineus
quadriceps femoris.
Blood supply:
Femoral artery.
Nerve supply:
Femoral nerve.
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28. Sartorius
A narrow, strap-shaped muscle that covers the femoral artery in the middle one third of the thigh.
Origin:
From the anterior superior iliac spine.
Insertion:
The muscle fibers run downward and medially
Attached to the upper part of the medial surface of the shaft of the tibia.
Nerve supply:
Femoral nerve.
Action:
At the hip joint
Flexes
Abducts
Laterally rotates the thigh
At the knee joint
Medially rotates the leg.
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29. Iliacus Origin: Insertion: Nerve supply: Action:
This fan-shaped muscle arises from the iliac fossa within the abdomen
Insertion:
The fibers converge and join the tendon of the psoas to form the iliopsoas muscle
Nerve supply:
A branch of the femoral nerve within the abdomen.
Action:
Flexes the thigh on the trunk at the hip joint
If the thigh is fixed, it flexes the trunk on the thigh
Medially rotates the thigh.
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30. Psoas
A long fusiform muscle that arises within the abdomen and descends into the thigh.
Origin:
From the 12th thoracic to the 5th lumbar vertebrae
From the roots of the transverse processes,
The sides of the vertebral bodies
The intervertebral discs,
Insertion:
The fibers run downward and laterally
Leave the abdomen to enter the thigh by passing behind the inguinal ligament.
The iliopsoas tendon is attached to the lesser trochanter of the femur.
A bursa intervenes between the tendon and the hip joint
May communicate with the joint.
Nerve supply:
Branches from the lumbar plexus.
Action:
The iliopsoas flexes the thigh on the trunk at the hip joint
If the thigh is fixed, it flexes the trunk on the thigh.
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31. Psoas minor
The psoas minor is a long, slender skeletal muscle which, when present, is located in front of the psoas major muscle
This muscle does not exist in About half the human population
Origin
From sides of vertebrae T12 and L1, I.V. discs and transverse processes
Insertion
To superior ramus of pubic bone (pectineal line).
Action
It is a weak muscle and has no significant role in human body.
It acts as a weak flexor of the lumbar vertebral column.
Nerve supply
Anterior primary rami of L1

32. Psoas Muscles
Psoas major muscle
Psoas minor muscle

33. Pectineus Origin: Insertion: Nerve supply: Action:
From the superior ramus of the pubis
Insertion:
The muscle fibers pass downward, backward,and laterally
Attached to the upper end of the linea aspera just below the lesser trochanter.
Nerve supply:
Femoral nerve
Occasionally, it receives a branch from the obturator nerve
Action:
Flexes and adducts the thigh at the hip joint
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34. Quadriceps Femoris
The quadriceps femoris muscle consists of four parts:
Rectus femoris
Vastus lateralis
Vastus medialis
Vastus intermedius
A common tendon of insertion into the upper, lateral, and medial borders of the patella
Via the ligamentum patellae, into the tubercle of the tibia.
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35. DR FADEL NAIM
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36. Rectus Femoris Origin: Insertion: Nerve supply:
A straight head from the anterior inferior iliac spine
A reflected head from the ilium above the acetabulum
Insertion:
The two heads unite in front of the hip joint,
The bipennate muscle is inserted into the quadriceps tendon and so into the patella.
Nerve supply:
Femoral nerve
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37. Vastus lateralis Origin: Insertion: Nerve supply:
From the intertrochanteric line
The base of the great trochanter
The linea aspera of the femur
Insertion:
The fibers pass downward and forward to be inserted into the quadriceps tendon and so into the patella.
Some of the tendinous fibers join the capsule of the knee joint and strengthen it.
Nerve supply:
Femoral nerve
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38. Vastus Medialis Origin: Insertion: Nerve supply:
From the intertrochanteric line
the linea aspera of the femur
Insertion:
The fibers pass downward and forward
inserted into the quadriceps tendon and so into the patella.
Some of the tendinous fibers join the capsule of the knee joint and strengthen it.
The lowest muscle fibers are almost horizontal in direction and prevent the patella from being pulled laterally during contraction of the quadriceps muscle.
Nerve supply:
Femoral nerve
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39. Vastus Intermedius Origin: Insertion: Nerve supply:
From the anterior and lateral surfaces of the shaft of the femur
Insertion:
The fibers pass downward
join the deep aspect of the quadriceps tendon.
Nerve supply:
Femoral nerve
The articularis genus
a small part of the vastus intermedius
inserted into the upper part of the synovial membrane of the knee joint.
It serves to retract the synovial membrane superiorly during extension of the knee joint.
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40. Action of Quadriceps Femoris Muscle (Quadriceps Mechanism)
a powerful extensor of the knee joint.
Some of the tendinous fibers of the vastus lateralis and vastus medialis form bands, or retinacula, that join the capsule of the knee joint and strengthen it.
The lowest muscle fibers of the vastus medialis are almost horizontal and prevent the patella from being pulled laterally during contraction of the quadriceps muscle.
The tone of the quadriceps muscle greatly strengthens the knee joint.
The rectus femoris muscle also flexes the hip joint.
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41. DR FADEL NAIM
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42. QUADRICEPS FEMORIS AS A KNEE JOINT STABILIZER
The quadriceps femoris is a most important extensor muscle for the knee joint.
Its tone greatly strengthens the joint
Carefully examined
Both thighs should be examined
Size
Consistency
Strength
Reduction in size caused by muscle atrophy can be tested by measuring the circumference of each thigh a fixed distance above the superior border of the patella.
The vastus medialis muscle extends farther distally than the vastus lateralis.
The vastus medialis is the first part of the quadriceps muscle to atrophy in knee joint disease and the last to recover.
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43. RUPTURE OF THE RECTUS FEMORIS
The rectus femoris muscle can rupture in sudden violent extension movements of the knee joint.
The muscle belly retracts proximally, leaving a gap that may be palpable on the anterior surface of the thigh.
In complete rupture of the muscle, surgical repair is indicated.
RUPTURE OF THE LIGAMENTUM PATELLAE
This can occur when a sudden flexing force is applied to the knee joint when the quadriceps femoris muscle is actively contracting.
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44. Femoral sheath
a funnel- shaped sheath , derived from transversalis fascia anteriorly and iliac fascia posteriorly.
It surroumds the femoral vessels and lymphatic about 2.5cm blow to the inguinal ligament.
Its lower end disappears at the lower margin of the saphenous opening where the sheath fuses with the adventitia of the vessels.

45. The femoral artery occupies the lateral compartment of the sheath.
Femoral v.
Femoral ring
The femoral sheath is divided into three compartments by two fibrous septa.
The femoral artery occupies the lateral compartment of the sheath.
The femoral vein lies the middle compartment.
The medial compartment is small, called the femoral canal.

46. Dr. Vohra

47. The femoral canal It is about 1.3cm long
its upper opening is called the femoral ring .
The boundaries of the femoral ring are:
the inguinal ligament, anteriorly
the lacunar ligament, medially
the pecten of pubis, posteriorly
the femoral vein, laterally.
covered by femoral septum superiorly.
Femoral a.
Femoral v.
Femoral ring

48. The Femoral Canal Contains: Fatty connective tissue
All the efferent lymph vessels from the deep inguinal lymph nodes
One of the deep inguinal lymph nodes.
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49. The Femoral Canal
The femoral sheath is adherent to the walls of the blood vessels and inferiorly blends with the tunica adventitia of these vessels.
The part of the femoral sheath that forms the medially located femoral canal is not adherent to the walls of the small lymph vessels
It is this site that forms a potentially weak area in the abdomen.
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50. FEMORAL SHEATH AND FEMORAL HERNIA
Femoral hemia
A protrusion of peritoneum could be forced down the femoral canal, pushing the femoral septum before it.
The hernial sac descends through the femoral canal within the femoral sheath.
More common in women than in men (possibly because of their wider pelvis and femoral canal).
The hernial sac passes down the femoral canal, pushing the femoral septum before it.
It expands to form a swelling in the upper part of the thigh deep to the deep fascia
With further expansion, the hernial sac may turn upward to cross the anterior surface of the inguinal ligament.
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51. The neck of the sac is narrow and lies at the femoral ring.
The neck of the sac always lies below and lateral to the pubic tubercle
The inguinal hernia lies above and medial to the pubic tubercle.
The neck of the sac is narrow and lies at the femoral ring.
Irreducible hernia
Once an abdominal viscus has passed through the neck into the body of the sac, it may be difficult to push it up and return it to the abdominal cavity
strangulated hernia
Furthermore, after the patient strains or coughs, a piece of bowel may be forced through the neck, and its blood vessels may be compressed by the femoral ring, seriously impairing its blood supply
A femoral hernia is a dangerous condition and should always be treated surgically.
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52. Differential Diagnosis Of A Femoral Hernia
When considering the differential diagnosis of a femoral hernia, it is important to consider diseases that may involve other anatomic structures close to the inguinal ligament.
An inguinal hernia
Lymphadenitis
A localized dilatation of the terminal part of the great saphenous vein
Tuberculous infection of a lumbar vertebra
Aneurysm of the femoral artery
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53. Femoral Artery
Enters the thigh by passing behind the inguinal ligament
A continuation of the external iliac artery
It lies midway between the anterior superior iliac spine and the symphysis pubis.
The main arterial supply to the lower limb.
It descends almost vertically toward the adductor tubercle of the femur
Ends at the opening in the adductor magnus muscle
Enters the popliteal space as the popliteal artery.
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54. Relations of Femoral Artery
Anteriorly:
In the upper part
superficial and is covered by skin and fascia.
In the lower part
passes behind the sartorius muscle
Posteriorly:
The artery lies on the psoas,which separates it from the hip joint, the pectineus, and the adductor longus
The femoral vein intervenes between the artery and the adductor longus.
Medially:
It is related to the femoral vein in the upper part of its course
Laterally:
The femoral nerve and its branches
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55. Branches of Femoral Artery
The superficial circumflex iliac artery small branch that runs up to the region of the anterior superior iliac spine
The superficial epigastric artery is a small branch that crosses the inguinal ligament and runs to the region of the umbilicus
The superficial external pudendal artery is a small branch that runs medially to supply the skin of the scrotum (or labium majus).
The deep external pudendal artery runs medially and supplies the skin of the scrotum (or labium majus) .
The profunda femoris artery is a large and important branch that arises from the lateral side of the femoral artery about 1.5 in. (4 cm) below the inguinal ligament It passes medially behind the femoral vessels and enters the medial fascial compartment of the thigh
It ends by becoming the fourth perforating artery.
At its origin, it gives off the medial and lateral femoral circumflex arteries
it gives off three perforating arteries
The descending genicular artery is a small branch that arises from the femoral artery near its termination. It assists in supplying the knee joint.
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56. DR FADEL NAIM
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57. DR FADEL NAIM
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58. FEMORAL ARTERY CATHETERIZATION
A long, fine catheter can be inserted into the femoral artery as it descends through the femoral triangle.
The catheter is guided under fluoroscopic view along the external and common iliac arteries into the aorta.
The catheter can then be passed into the inferior mesenteric, superior mesenteric, celiac arteries, or renal arteries.
Contrast medium can then be injected into the artery under examination and a permanent record obtained by taking a radiograph.
Pressure records can also be obtained by guiding the catheter through the aortic valve into the left ventricle.
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59. Femoral Vein
Enters the thigh by passing through the opening in the adductor magnus as a continuation of the popliteal vein
it ascends through the thigh, lying at first on the lateral side of the artery, then posterior to it, and finally on its medial side
It leaves the thigh in the intermediate compartment of the femoral sheath
Passes behind the inguinal ligament to become the external iliac vein.
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60. FEMORAL VEIN CATHETERIZATION
When rapid access to a large vein is needed.
The femoral vein has a constant relationship to the medial side of the femoral artery just below the inguinal ligament and is easily cannulated.
Because of the high incidence of thrombosis with the possibility of fatal pulmonaryembolism, the catheter should be removed once the patient is stabilized.
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61. The deep inguinal lymph nodes
Variable in number, but there are commonly three.
Along the medial side of the terminal part of the femoral vein, and the most superior is usually located in the femoral canal
All the lymph from the superficial inguinal nodes via lymph vessels that pass through the cribriform fascia of the saphenous opening.
Lymph from the deep structures of the lower limb that have ascended in lymph vessels alongside the arteries, some having passed through the popliteal nodes.
The efferent lymph vessels from the deep inguinal nodes ascend into the abdominal cavity through the femoral canal and drain into the external iliac nodes.
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62. Femoral Triangle
A triangular depressed area situated in the upper part of the medial aspect of the thigh just below the inguinal ligament
Superiorly
By the inguinal ligament
Laterally
The sartorius
Medially
The medial border of the adductor longus muscle.
Its floor is gutter shaped
Formed from lateral to medial
Iliopsoas
The pectineus
The adductor longus
Its roof is formed by the skin and fasciae of the thigh.
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63. Femoral Triangle The femoral triangle contains:
The terminal part of the femoral nerve and its branches
The femoral sheath
The femoral artery and its branches
The femoral vein and its tributaries
The deep inguinal lymph nodes
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64. DR FADEL NAIM
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66. Adductor (Subsartorial) Canal
The adductor canal is an intermuscular cleft situated on the medial aspect of the middle third of the thigh beneath the sartorius muscle
It commences above at the apex of the femoral triangle and ends below at the opening in the adductor magnus.
In cross section it is triangular
The anteromedial wall
The sartorius muscle and fascia.
The posterior wall
The adductor longus and magnus.
The lateral wall
The vastus medialis.
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67. Adductor (Subsartorial) Canal
The adductor canal contains:
The terminal part of the femoral artery
The femoral vein
The deep lymph vessels
The saphenous nerve
The nerve to the vastus medialis
The terminal part of the obturator nerve.
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