D. J. (Daniel John) Cunningham.

Cunningham's manual of practical anatomy (Volume 1) online

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250 THE INFERIOR EXTREMITY

the twig which springs from it and pierces the fibrous capsule
of the joint; then clean the straight head of the rectus femoris
to its origin from the anterior inferior spine of the ilium, and
follow the reflected tendon backwards to the upper border of
the acetabulum where it is embedded in the fibrous stratum of
the capsule of the hip joint. Note that tha interval between
the tensor fasciae and the sartorius is a path by which the surgeon
gets easy access to the front of the hip joint without endangering
any structures of importance. Clean and define the anterior
borders of the glutaeus medius and minimus. The nerve to the
tensor fascias emerges between the closely apposed borders of
the two muscles and indicates the line of separation. Not
uncommonly the anterior border of the medius is blended with
the deep surface of the tensor fascias ; if that is the case, separate
the two muscles with the scalpel.

Turn now to the medial side of the middle third of the thigh,
and pull the sartorius laterally. Posterior to it there is an
angular interval bounded laterally by the vastus medialis and
medially by the adductor longus above and the adductor magnus
below. The interval is crossed by a strong layer of fascia which
forms the roof of the adductor canal (Hunter'sj (Figs. 114, 115).
On the fascia lies some loose areolar - issue in which is embedded
the subsartorial plexus of nerves. The plexus is not always easily
demonstrable, but if the dissector is successful he will find that
it is formed by interlacing twigs from the medial cutaneous,
the saphenous, and the obturator nerves. Clean the plexus and
areolar tissue away and clean the fascial roof of the canal. It
is attached laterally to the vastus medialis, and medially to the
adductors magnus and longus. Its proximal extremity fades
away indefinitely at the apex of the femoral triangle, but at its
distal end it terminates in a sharp crescentic border which extends
from the vastus medialis to the adductor magnus, at the junction
of tha middle and distal thirds of the thigh. The saphenous
nerve accompanied by the saphenous branch of the arteria genu
suprema will be seen emerging from the canal behind the distal
crescentic border of the fascial roof. To display the contents
of the canal, divide the fascial roof by a vertical incision extending
from its proximal to its distal end, and then clean the contents,
which are the femoral artery, the femoral vein, the saphenous
nerve, and the nerve to the vastus medialis.

M. Sartorius. The sartorius is a long slender muscle,
which arises from the anterior superior spine of the ilium and
the upper part of the notch on the anterior border of the bone
immediately below the spine. It crosses the front of the
proximal third of the thigh obliquely, and, gaining the medial
side of the limb, it takes a nearly straight course distally to a
point beyond the medial prominence of the knee. There it
turns forwards, and ends in a thin, expanded aponeurotic
tendon, which is inserted into the medial surface of the body
of the tibia, posterior to the tuberosity (Fig. 139, p. 322).
By its distal border the tendon is connected with the fascia



THE THIGH



25 1



of the leg, whilst by its proximal border it is joined to the
capsule of the knee joint.

In its proximal, oblique part, the sartorius muscle forms the
lateral boundary of the femoral triangle, and lies anterior to



M. sartorius



Muscular artery
M. adductor longus

Saphenous nerve

Nerve to vastus medialis

Femoral artery

M. rectus femoris



Fascial roof of adductor
canal (Hunter's)'



M. vastus medialis -



M. sartorius _




Medial cutaneous nerve
of the thigh



Great saphenous vein

Skin

Superficial fascia



'- Fascia lata



M. adductor magnus

Fascial roof of adductor
canal (Hunter's)



Femoral vein



M. semimembranosus



. Saphenous nerve



Medial intermuscular

septum

Tendon of adductor

magnus

Art. genu suprema

(O.T. anastomotic)

Branches of medial

cutaneous nerve

of the thigh



FIG. 114. Dissection of the Adductor Canal (Hunter's) in the right lower
limb. A portion of the Sartorius has been removed.



the iliacus, the rectus femoris, and the adductor longus muscles.
More distally, it is placed anterior to the femoral vessels as
far as an opening in the adductor magnus through which
they pass into the popliteal fossa. At its insertion its ex-
panded tendon lies anterior and superficial to the tendons of



2 5 2



THE INFERIOR EXTREMITY



insertion of the gracilis and semitendinosus, but is separated
from them by a bursa. The sartorius is supplied by the
femoral nerve. It is a flexor of the knee and a medial
rotator of the leg, a flexor of the hip joint and a lateral
rotator of the thigh.

Canalis Adductorius Hunteri (O.T. Hunter's Canal).
When the femoral artery leaves the femoral triangle it is con-
tinued distally, in the medial region of the thigh, in a deep
furrow, which is bounded anteriorly by the vastus medialis
muscle, and posteriorly by the fascia on the anterior surfaces of
the adductor longus and magnus muscles, which is the medial
intermuscular septum of the thigh. At its proximal end this
furrow is continuous with the deeper, wider, and more apparent



M. vastus medialis



M. vastus intermedius



M. sartorius



Femoral vessels and

saphenous nerve in

adductor canal

(Hunter's)




M. adductor longus



Femur



M. vastus lateralis
FIG. 115. Transverse Section through the Adductor Canal.

hollow, which has been described as the femoral triangle.
Further, the furrow is converted into a canal, triangular on
transverse section, by a strong fibrous membrane which stretches
across it, and upon the surface of which the sartorius muscle is
placed (Fig. 115). The tunnel thus formed is called the
adductor canal ( Hunter's). The fibrous expansion which roofs
in the canal stretches from the adductor longus and the
adductor magnus posteriorly to the vastus medialis anteriorly.
When it is traced proximally, it is seen to become thin and
ill-defined as it approaches the femoral triangle ; when traced
in the opposite direction, however, it becomes dense and
strong, and below the opening in the adductor magnus,



THE THIGH 253

at the distal end of the canal, it presents a thick, sharply
denned margin. In its distal part the posterior wall of
the canal, where it is formed by the adductor magnus,
presents a deficiency or aperture which leads backwards
into the popliteal fossa. The appearance and construc-
tion of this aperture will be studied at a later stage. It
is called the hiatus tendimus or opening in the adductor
magnus.

The femoral vessels and the saphenous nerve traverse the
adductor canal. Whilst the femoral artery is in the canal it
gives off some muscular twigs and the arteria genu suprema.
The femoral vessels leave the canal at its distal end by inclin-
ing posteriorly through the opening in the adductor magnus
and entering the popliteal fossa. The saphenous nerve,
accompanied by the saphenous branch of the arteria genu
suprema, escape from the canal by passing under cover of
the distal thickened margin of the fibrous expansion which
forms the roof. They can be seen in the present stage of
the dissection in that situation.

Arteria Femoralis (O.T. Femoral Artery, Common and
Superficial). By the dissections which have been made the
whole of the femoral artery has been exposed, and its course
and relations may now be studied. It is the direct con-
tinuation of the external iliac artery and is the great arterial
trunk of the inferior extremity. It begins at the inguinal
ligament, behind which it enters the thigh, and it extends,
distally, through the proximal two-thirds of the thigh to the
opening in the adductor magnus, through which it passes into
the popliteal fossa and becomes the popliteal artery. The
course of the femoral artery may be marked on the surface,
when the t^iigh is slightly flexed, abducted and rotated later-
ally, by a line drawn from a point situated midway between
the anterior superior spine of the ilium and the symphysis
pubis to the adductor tubercle on the medial condyle of the
femur.

The relations which the artery bears to the femur are im-
portant. As it enters the femoral triangle it leaves the brim of
the pelvis and lies in front of the medial part of the head of
the femur, from which it is separated by the psoas major
muscle. Although its relation to the head of the femur is fairly
intimate, that situation should not be chosen for applying com-
pression, for, on account of the mobility of the head of the



254 THE INFERIOR EXTREMITY

bone, the vessel is apt to slip from under the fingers. It is much
safer to compress it against the hip bone. Distal to the head
of the femur, during the remainder of its course through the
femoral triangle, the artery is not in direct relation to the
bone. It crosses anterior to the angular interval between
the neck and body of the femur. Towards the apex of the
triangle, however, it comes into relation with the medial side
of the body of the femur, and that position it holds to its
termination.

In the triangle the proximal part of the femoral artery is
enveloped by the femoral sheath, and is separated from the
surface by the skin, superficial fascia, and deep fascia ; whilst
more distally it is crossed by the medial cutaneous branch
(O.T. internal cutaneous) of the femoral nerve, which runs
along the medial border of the sartorius muscle. The extent
of the artery which lies in the femoral triangle varies with
the development of the sartorius muscle, but as a rule it
measures from 7.5 to 10 cm. At the apex of the triangle the
artery enters the adductor canal.

In the adductor canal the artery lies more deeply, and is
separated from the surface not only by the skin, superficial
fascia and deep fascia, but also by the sartorius muscle, the
sub-sartorial plexus of nerves, and the fascial roof of the
canal, and, at the mid-length of the canal, the saphenous
nerve crosses the front of the artery from the lateral to the
medial side.

Lateral to the artery, in the proximal part of the femoral
trigone, is the femoral nerve. The two are not, however, in
close contact, for the lateral part of the femoral sheath and
the projecting lateral border of the psoas major muscle
intervene between them. In the distal part of tjie triangle
the medial cutaneous nerve lies lateral to the artery, but it is
replaced, in the proximal half of the adductor canal, by the
saphenous nerve, and beyond the middle of the adductor
canal, where the saphenous nerve passes to the front of the
artery, the artery itself is in relation, on its lateral side, with
the vastus medialis muscle.

In the proximal part of the femoral triangle the femoral
vein lies medial to the artery, separated from it by the lateral
septum of the femoral sheath. Beyond the femoral sheath
the vein passes behind the artery and no other structure
forms a direct medial relation till the distal part of the



THE THIGH 255

adductor canal is reached, where the saphenous nerve lies
along the medial face of the distal part of the artery.

Posterior to the artery are the psoas, the pectineus, the
adductor longus and the adductor magnus muscles, but the
artery is separated from the psoas by the posterior part of
the femoral sheath and the nerve to the pectineus, and from
the pectineus by fatty areolar tissue in which lie the femoral
vein, which has passed from the medial to the posterior
aspect of the artery, the profunda vein and the profunda
artery, in that order from before backwards. It is separated
from the adductors longus and magnus by the femoral vein
alone, because the profunda vein and artery dip backwards
between the pectineus and the adductor longus and descend
behind the latter muscle.

The branches which the artery gives off in the femoral
triangle have already been enumerated, and some of them
have been followed to their terminations, whilst others will
be traced in later dissections. The branches which arise in
the adductor canal are muscular twigs which supply adjacent
muscles and the arteria genu suprema.

Arteria G-enu Suprema (O.T. Anastomotic). The arteria
genu suprema springs from the femoral trunk, a short distance
proximal to the point where the latter enters the popliteal
fossa by passing through the opening in the adductor magnus.
Almost immediately after its origin it divides into a saphenous
and a musculo-articular branch : frequently, the two branches
have separate origins from the femoral artery.

The saphenous branch accompanies the saphenous nerve ;
it leaves the adductor canal by passing under cover of the
distal border of the fibrous expansion which is stretched
over the canal. On the medial side of the knee it appears
between the gracilis and sartorius, and it ends in branches
to the integument on the medial aspect of the proximal part
of the leg.

The musculo-articular branch enters the substance of the
vastus medialis and proceeds distally, anterior to the tendon
of the adductor magnus. It gives some twigs to the vastus
medialis and others which spread out over the proximal and
medial aspects of the knee joint, and it anastomoses with
branches of the medial genicular arteries. One well-marked
branch runs laterally, proximal to the patella, to anastomose
with the lateral superior genicular artery.



256 THE INFERIOR EXTREMITY

Vena Femoralis. The femoral vein is the direct proximal
continuation of the popliteal vein. It begins at the opening
in the adductor magnus, through which it enters the adductor
canal ; its proximal end passes behind the inguinal ligament
and becomes continuous with the external iliac vein. It ac-
companies the femoral artery, but the relations of the two
vessels to each other differ at different stages of their course.
In the distal part of the adductor canal the vein lies posterior
to the artery and on its lateral side, but it inclines medially
as it ascends, and in the proximal part of the thigh it lies on
the medial side of the artery and on the same plane. The
crossing from one side to the other takes place posterior to the
artery and is very gradual, so that for a considerable distance
the femoral vein lies directly posterior to the femoral artery.
For a distance of two inches distal to the inguinal ligament
it is enclosed within the femoral sheath, of which it occupies
the intermediate compartment.

As it ascends in the thigh the femoral vein receives
tributaries which, for the most part, correspond with the
branches of the femoral artery. At the fossa ovalis it
is joined by the great saphenous vein. The dissector
should slit the femoral vein open with the scissors. Several
valves will then be seen. One is almost invariably found
immediately proximal to the entrance of the vein which
corresponds to the profunda artery.

Nervus Femoralis (O.T. Anterior Crural). The femoral
nerve is a large nerve which arises, within the abdomen,
from the lumbar plexus. It enters the thigh by passing
distally in the interval between the psoas and iliacus muscles,
posterior to the inguinal ligament and the fascia iliaca. In
the proximal part of the thigh it lies to the lateral side of the
femoral artery, and is separated from it by a small portion of
the psoas major muscle and the femoral sheath (Fig. 1 1 1 ).
A short distance below the inguinal ligament it divides into
an anterior and a posterior portion ; they at once resolve
themselves into a large number of cutaneous and muscular
branches which are named in the following list :

Kami musculares, / To the pectineus.

\ ,, sartorius.
Anterior division, -{ f Intermediate cutaneous

Kami cutanei anteriores J "Tf of f the thl S h '

' | Medial cutaneous nerve

I of the thigh.



THE THIGH 257



Posterior division,



Rami musculares,



f To the rectus femoris.
,, vastus medialis.
,, vastus lateralis.
,, vastus inter-

medius.
m. articularis



genu.

Ramus cutaneus, Saphenous nerve.

Rami articulares.

With the exception of the saphenous nerve, which is distributed
upon the medial side of the leg and foot, the distribution of the
cutaneous branches of the femoral nerve has been already
examined (p. 230).

The nerve to the pectineus arises a short distance distal to
the inguinal ligament and turns medially, posterior to the
femoral vessels, to reach its destination. The branches to the
sartorius are two or three in number. As a rule, they take
origin in common with the intermediate cutaneous nerve.

The intermediate cutaneous nerve (O.T. middle cutaneous)
sometimes pierces the proximal border of the sartorius.
It divides into two branches which perforate the fascia lata
about three or four inches distal to the inguinal ligament.

The medial cutaneous nerve (O.T. internal cutaneous} inclines
distally and medially, crosses anterior to the femoral artery
at the apex of the femoral triangle, and divides into an
anterior and a posterior portion, which become superficial, at
different levels, on the medial side of the limb. From the
trunk of the nerve a few cutaneous twigs are given to the
skin over the proximal and medial parts of the thigh. The
anterior branch crosses the sartorius muscle and makes its
appearance through the fascia lata in the distal part of the
thigh, a short distance anterior to the great saphenous vein.
The posterior branch runs distally, along the posterior border
of the sartorius, and pierces the deep fascia on the medial
side of the knee, behind the sartorius and the saphenous
nerve.

A short distance distal to the middle of the thigh the posterior branch of
the medial cutaneous nerve forms, with filaments from the obturator nerve
and the saphenous nerve, a plexiform interlacement, the sub- sartorial plexus >
which is placed deep to the sartorius muscle as it lies over the adductor
canal (Hunter's). The twig from the obturator nerve appears at the medial
border of the adductor longus.

The saphenous nerve (O.T. internal saphenous nerve] is the
longest branch of the femoral nerve. It springs from the
VOL. i 17



258 THE INFERIOR EXTREMITY

posterior division of that nerve and runs distally at first on the
lateral side of the femoral artery. In the adductor canal it
crosses in front of the femoral artery. It emerges from the
distal end of the canal by passing under cover of the thickened
border of the fibrous expansion which stretches between the
vastus medialis and the adductor muscles, and, accompanied
by the saphenous branch of the arteria genu suprema, it
escapes from under cover of the sartorius, passing between
it and the tendon of the gracilis. Then it pierces the
deep fascia at the medial side of the knee. After it quits
the adductor canal it gives off the infrapatellar branch^ which
pierces the sartorius and appears on the surface of the fascia
lata on the medial side of the knee (Fig. 107).

Several large branches of the posterior part of the
femoral nerve enter the four segments which compose the
great quadriceps extensor muscle of the thigh. From some
of the branches, articular filaments are given either to the hip
or to the knee joint.

The branch to the rectus femoris sinks into the deep surface
of that muscle. It supplies an articular twig to the hip joint.
The large branch to the vastus medialis accompanies the
saphenous nerve and enters the proximal part of the adductor
canal. It can readily be distinguished, because it sinks
into the medial aspect of the vastus medialis, about the
middle of the thigh. In the substance of the muscle it
extends distally, and near the knee joins the articular branch
of the arteria genu suprema. It gives an articular nerve
to the synovial layer of the knee joint. The nerve to the
vastus lateralis is associated with the descending branch of the
lateral circumflex artery. Very frequently it gives an articular
twig to the knee joint. The nerves to the vastus intermedius
are two or three in number, and they sink into its anterior
surface. The most medial of them is a long slender nerve,
which can be traced distally, under the anterior border of the
vastus medialis, to the articular muscle of the knee. Its
terminal twigs are given to the synovial stratum of the
knee joint.

Thus, one filament from the femoral nerve goes to the
hip joint ; two, and frequently three, filaments go to the
knee joint.

Tractus Ilio-tibialis of the Fascia Lata (O.T. Ilio-tibial
Band). The thick band of fascia lata on the lateral aspect



THE THIGH 259

of the thigh which receives this name should now be
examined, and its connections ascertained. It is attached
superiorly to the tubercle on the outer lip of the crest of the
ilium, behind the tensor fasciae latae, and, inferiorly, to the
lateral condyle of the tibia and the head of the fibula. On
the lateral condyle of the tibia it is attached to a prominent
ridge which extends from the fibular facet forwards and
downwards to the tuberosity. It is covered by skin and
superficial fascia, and from above downwards it lies superficial
to part of the glutaeus medius, the greater trochanter, the
vastus lateralis, the lower lateral part of the vastus intermedius,
the lateral condyle of the femur, and the lateral border of the
knee joint. Two muscles are inserted into it : the glutaeus
maximus posteriorly at the level of the greater trochanter,
and the tensor fasciae anteriorly in the proximal third of the
thigh. Above the insertion of the glutaeus maximus its
posterior border is continuous with the thick fascia on the
superficial surface of the glutaeus medius, and its anterior
border splits into a superficial and a deep lamella, both of
which have already been cleared away ; for the superficial
lamella covered the superficial surface of the tensor fasciae,
and the deep lamella is the layer on the deep surface of the
tensor fasciae which extends medially to become continuous
with the tendon of the rectus femoris and the front of the
capsule of the hip joint (see p. 248). In the distal half of the
thigh its deep surface is attached to the lateral supracondylar
ridge of the femur and to the lower part of the linea aspera
by the lateral intermuscular septum.

M. Tensor Fasciae Latse (O.T. Tensor Fasciae Femoris).
The tensor of the fascia lata is a small muscle which is
placed on the lateral and anterior aspect of the proximal
third of the thigh. It lies between the two lamellae of the
proximal part of the ilio-tibial tract, in the interval between
the sartorius muscle anteriorly and the glutaeus medius
muscle posteriorly. Its nerve of supply, a branch of the
superior gluteal nerve which enters the deep surface of the
muscle a little above the middle of its length, has already
been exposed (p. 249).

The tensor fascia latce. arises from a small portion of the
anterior part of the outer lip of the crest of the ilium ; from
the upper part of the margin of the notch below the anterior
superior spine of the ilium; and by some fibres from the fascia



260



THE INFERIOR EXTREMITY



covering the glutaeus medius. It extends distally, with a
slight inclination posteriorly, and is inserted into the ilio-
tibial tract of the fascia lata.

Arteria Circumflexa Femoris Lateralis (O.T. External
Circumflex Artery). The lateral femoral circumflex artery is
the largest branch which springs from the profunda femoris
artery. It arises near the origin of the latter, and runs
laterally, between the divisions of the femoral nerve and then



M. rectus femoris (straight head of origin)

M. rectus femoris (reflected head of origin)
Attachment of the
-ilio- femoral ligament M. adductor longus (origin)

M. pyramidalis abdominis (01
[. rectus abdominis (01



M. seniimem-

branosus (origin)

M. quadratus

femoris (origin)

Mm. biceps and

semitendinosus

(origin)




M. gracilis (origin)
M. adductor brevis (orig



FIG. 116. External Surface of the Pubis and Ischium, with the Attachments
of Muscles mapped out.

under cover of the sartorius, to the deep surface of the rectus
femoris muscle, where it ends by dividing into ascending,
transverse, and descending branches.

The ascending branch reaches the external surface of the
upper part of the ilium by ascending along the inter-
trochanteric line of the femur under cover of the deep surface
of the tensor fasciae latse. As it ascends it gives a branch to
the hip joint, twigs to the adjacent muscles, and its terminal
twigs anastomose with branches of the superior gluteal artery.



THE THIGH 261

The transverse branch is of small size. It passes to the deep



Online LibraryD. J. (Daniel John) CunninghamCunningham's manual of practical anatomy (Volume 1) → online text (page 26 of 44)