1. venous drainage and Lymphatics of lower limb
DR.QUDSIA SULTANA

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

3. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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.

12. 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

13. Dorsal Venous Arch

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

15. 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

16. Pierces cribriform fascia of Saphenous opening to drain into femoral vein

17. 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

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

19. 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

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

22. Two types :
Direct
Indirect

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

24. Musculovenous Pump
Soleus is regarded as the peripheral heart.

25. 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

26. Perforating veins or Perforators

28. 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

29. Bifurcates to drain into :
Great saphenous vein
Popliteal vein

30. Applied anatomy

31. 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

33. 4 layered compression bandage technique.
Increases venous return.
Helps in healing of venous ulcers within 8 weeks .

34. 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

35. 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

38. Varicose ulcers

39. Venous cut down

40. Accessible and muscular

43. Lymphatic drainage of lower limb

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

46. 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

48. 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

50. Applied anatomy Lymphedema- Filaria Enlargement of lymph nodes
Syphilitic lesions