Femoral triangle topography. Topographic anatomy of the femoral triangle. Sternum - clavicular - mastoid region: borders, external landmarks, layers, fascia and cellular spaces, vessels and nerves

The femoral triangle is formed by:

1. top- inguinal ligament (base of the femoral triangle);

2. laterally- tailor's muscle;

3. medially- a long adductor muscle.

Under the superficial sheet of the broad fascia in the femoral triangle, surrounded by a common vagina, the femoral artery and vein pass.

At the base of the triangle femoral vein lies medially, the femoral artery is laterally, the femoral nerve is outward from the artery under a deep sheet of the fascia lata. Towards the apex of the femoral triangle, the vein deviates posterior to the femoral artery.

femoral nerve 3-4 cm down from the inguinal ligament is divided into muscle and skin branches. The largest cutaneous branch of the femoral nerve is n. saphenus, which accompanies the femoral artery further.

femoral artery is a continuation of the external iliac artery. In the vascular lacuna, it is located on the pubic bone, where it can be pressed when bleeding from its branches. From the femoral artery in the triangle, the deep artery of the thigh departs - the main collateral in the development of roundabout blood circulation. Its branches are a. circumflexa femoris lateralis and a. circumflexa femoris medialis.

Bottom of the femoral triangle are the iliopsoas and pectineus muscles, the edges of which form the sulcus iliopectineus. It passes into the sulcus femoralis anterior in the middle third of the thigh. Under its own fascia, femoral vessels and n.saphenus pass here, covered with a tailor's muscle. Three perforating arteries depart from the deep artery of the thigh, which go through the intermuscular septa to the posterior fascial bed of the thigh.

Wide fascia lata, fascia lata, especially dense on the outer surface of the thigh, where the ilio-tibial tract, tractus iliotibialis, is formed.

It gives off three intermuscular septa: external, internal and posterior, septa intermuscularia femoris laterale, mediale etposterior, which are attached to the femur along a rough line, linea aspera, and divide the entire subfascial space of the thigh into three fascial beds:

anterior, containing muscles - extensors of the lower leg,

posterior - flexors and

The medial compartment contains the adductor muscles of the thigh.

In the region of the femoral triangle, the wide fascia at the inner edge of the sartorius muscle is divided into two plates. The deep plate goes medially behind the femoral vessels and connects with the fascia of the iliopsoas and pectineus muscles.

The superficial plate goes in front of the femoral vessels and connects to the inguinal ligament at the top. It is heterogeneous in its structure: dense in the outer part, covering the femoral artery, forming a sickle-shaped edge, margo falciformis, and loosened, perforated in the medial part, suprafemoral vein - ethmoid fascia, fasciacribrosa.

In margo falciformis, the upper and lower horns, cornua superius et inferius, are distinguished, limiting the subcutaneous ring of the femoral canal, hiatus saphenus.

The lower horn is easily identified by v. Saphena magna, which flows into the femoral vein within the hiatus saphenus.

The cellular space of the femoral triangle, located between the superficial and deep plates of the fascia lata. Contains the femoral artery and vein.

It is reported

along the course of the femoral vessels through the vascular lacuna, lacuna vasorum, with the subperitoneal floor of the pelvis;

along the superficial branches of the femoral vessels through the holes in the cribriform fascia that fills the hiatus saphenus - with the subcutaneous tissue of the femoral triangle;

along the lateral artery surrounding the thigh - with the outer region of the hip joint;

along the medial artery surrounding the thigh - with a bed of adductor muscles;

along the perforating arteries, through holes in the tendons of the adductor muscles - with the posterior femoral bed and

along the course of the femoral vessels - with the afferent canal.

Fascia lata, along with the fascial bed of the femoral vessels, forms cases for the muscles of the surface layer: m. tensor fasciae latae, inside of it - for mm. sartorius et adductorlongus, and even more medially - for m. gracilis.

In the deep layer of the femoral triangle are two muscles:

· outside lies m. iliopsoas, attached to the lesser trochanter,

inside - m. pectineus, starting from pecten ossis pubis and also attached to the lesser trochanter.

On m. pectineus anteriorly from arcus iliopectineus, the femoral vessels pass in the vascular lacuna: the artery is outside, the vein is inside. Together with m. iliopsoas, under its fascia and arcus iliopectineus, the femoral nerve passes through the muscular lacuna, which is divided into branches 2–3 cm below the inguinal ligament.

The femoral triangle in topographic anatomy is the area of ​​the thigh located in its upper part and resembling a triangular figure along the borders. In this area of ​​the lower limb, muscles, arteries and veins, lymph nodes and nerve endings are intertwined.

Muscle tissues

The base of the femoral triangle in the anatomy is formed by the inguinal ligament, behind which there are vascular and muscular gaps, and femoral hernias can occur under it. The long adductor muscle passes medially, and the sartorius muscle laterally. The top of this area is located 10 cm from the inguinal ligament.

The lower part of the triangle is limited by the iliopsoas and pectineus muscles. Between these fibers, an empty space is formed, which is called the iliopectineal fossa.

Arteries and veins

According to topography, the femoral triangle is endowed with the following vascular beds passing through the gap hiatus saphenus:

• Great saphenous vein (saphena magna).
• superficial arteries.
• Sexual and epigastric femoral vessels.
• The femoral artery and femoral vein, located between the superficial and deep leaves of the wide fascia of the thigh.
• Deep femoral artery.

A femoral canal is formed next to the vein.

Nerve endings

In the triangle under consideration, there is the genitofemoral nerve, which is responsible for the innervation of the skin in the area of ​​the medial surface of the inguinal ligament. A little lower through the fascia lata passes the lateral cutaneous nerve. Then along the tailor's muscle tissue are the anterior cutaneous branches of the femoral nerve.

In the inner region of the thigh is the obturator nerve canal, which goes to the knee.

muscle training

To strengthen and maintain muscle tone, it is required to engage in special physical exercises aimed at the femoral part of the legs. Training is carried out both at home and in gyms, using simulators.

Before the main exercises, a light warm-up is required.

When the muscles are ready, they go directly to classes. There are a huge number of exercises, so the complex is compiled individually.

The effectiveness of muscle training is observed when using the following actions:

1. Lie on your back, place your arms along the body, bend your legs at the knee joint. Then lift the pelvis up. Having reached the maximum position, you should linger for a few seconds and slowly lower yourself to the initial state.
2. Stand up straight, take one leg back, bend at the knee, grab it with your hand and pull it to the buttocks. Hold this position for a while, then repeat the exercise with the other leg.
3. Lie on your side, lift your leg up. Then roll over to the other side and continue the manipulation with the second limb.
4. Stand up straight and do regular squats.

In addition to a set of exercises, such sports activities as running, swimming, cycling well develop muscles.

You need to start strengthening the muscles of the legs correctly. The set of exercises should be adjusted. First, simple actions are required, then the complexity gradually increases as the hips adapt to the load. Subsequently, for the greatest effect, training is carried out with weights.

femoral triangle limited from above by the inguinal ligament, from the outside by the sartorius muscle, from the inside by the long adductor muscle. The height of the triangle - the distance from the inguinal ligament to the intersection of the sartorius muscle with the long adductor muscle - reaches 10-15 cm in adults.

The skin within the femoral triangle is thin, elastic, mobile.

Subcutaneous adipose tissue is well developed; superficial fascia divides it into two layers. In the subcutaneous tissue are located superficial arterial, venous and lymphatic vessels, lymph nodes and nerves (see Fig. 6).

Superficial arterial vessels are branches of the femoral artery. External pudendal artery, a. pudenda externa, often double, goes inwards - to the scrotum in men and the labia majora in women. Epigastric superficial artery, a. epigastrica superficialis, goes up, crosses the inguinal ligament and, located in the subcutaneous tissue of the anterior abdominal wall, goes to the navel. The superficial artery surrounding the ilium, a. circumflexa ilium superficialis, directed towards the anterior superior iliac spine. The listed arteries are accompanied by the veins of the same name, which flow into the saphenous vein of the lower limb, v. saphena magna, and into the femoral vein at a site located 3-4 cm below the inguinal ligament. V. saphena magna, located in the subcutaneous tissue of the femoral triangle, passes between the sheets of the superficial fascia along the anterointernal surface of the thigh and often consists of 2-3 venous trunks that merge with each other.

The innervation of the skin in the area of ​​the femoral triangle is carried out by the branches of the lumbar plexus. Branch n branches under the inguinal ligament. genitofemoralis-ramus femoralis, which passes to the thigh along with the femoral artery and then through the hiatus saphenus is sent to the subcutaneous fatty tissue. Outside forks n. cutaneus femoris lateralis, which penetrates the subcutaneous tissue of the thigh somewhat lower and anterior to the spina iliaca anterior superior. Branches of the femoral nerve, rr branch out in front and inside. cutanei anteriores n. femoralis.

Superficial lymph nodes in the amount of 15-20 are located on the surface sheet of the proper fascia of the thigh and are divided into two groups: inguinal and subinguinal nodes, nodi inguinales superficiales et nodi subinguinales superficiales. Superficial inguinal lymph nodes lie along the inguinal ligament and receive lymph from the lower parts of the anterior abdominal wall, lumbar region, gluteal region, perineum and external genital organs. Superficial subinguinal lymph nodes are located according to the direction of the femoral artery and receive lymph from the lower limb.

Own, or wide, fascia, fascia lata, in the region of the femoral triangle consists of two sheets: superficial and deep. The superficial sheet of fascia is located in front of the femoral vessels; at the top, it is fused with the inguinal ligament, and medially on the comb muscle merges with the deep leaf. The superficial leaf of the fascia, in its outer part is more dense, loosened inward and pierced by numerous holes; the loosened area of ​​the superficial leaf of the fascia is called lamina cribrosa (Fig. 90). The border between the dense and loose parts of the superficial fascia sheet is its compacted edge, which has a crescent shape and is called margo falciformis. It distinguishes between the upper horn, cornu superius, and the lower horn, cornu inferius. The superior horn passes over the femoral vein, at the top it connects to the inguinal ligament, and medially to the lacunar ligament. The lower horn is located under v. saphena magna, above the comb muscle, it merges with a deep leaf of the wide fascia of the thigh. The sickle-shaped edge and its upper and lower horns limit the oval fossa, fossa ovalis (BNA) s. hiatus saphenus (Fig. 91).

90. Area of ​​the femoral triangle.

1 - aponeurosis m. obliqui externi abdominis; 2 - anulus inguinalis superficialis; 3 - funiculus spermaticus; 4 - m. pectineus; 5-v. saphena magna; 6 - n. cutaneus femoris lateralis; 7 - lamina cribrosa; 8 - m. sartorius; 9-lig. inguinale.

91. Hiatus saphenus.

1-a. et v. femoralis; 2-a. et v. pudenda externa; 3-v. saphena magna; 4 - m. pectineus; 5 - m. sartorius; 6 - n. cutaneus femoris lateralis; 7 - cornu inferius; 8 - margo falciformis; 9 - cornu superius; 10-lig. inguinale.

A deep sheet of fascia is located behind the femoral vessels, covering the iliopsoas and scallop muscles; medially, it is attached to the crest of the superior branch of the pubic bone, laterally and superiorly, to the inguinal ligament.

Iliopsoas muscle, m. iliopsoas, located in the outer part of the femoral triangle. Passing under the inguinal ligament, it deviates inward and attaches to the lesser trochanter of the femur. Comb muscle, m. pectineus, starts from the superior branch and crest of the pubic bone, superior pubic ligament and attaches to the lesser trochanter of the femur. Between these muscles there is a depression, fossa incisiva, the apex of which corresponds to the lesser trochanter.

The iliopsoas muscle, femoral vessels, and also the femoral nerve exit into the thigh region through the space located under the inguinal ligament, which is divided into two lacunae: muscular, lacuna musculorum, and vascular, lacuna vasorum (Fig. 92). These gaps are separated by a ligament, arcus iliopectineus, stretched between eminentia iliopectinea and lig. inguinale.

92. Lacuna musculorum et lacuna vasorum.

1 - aponeurosis m. obliqui externi abdominis; 2-lig. inguinale; 3-a. et v. femoralis; 4 - septum femorale; 5 - nodus lymphaticus; 6-lig. lacunar; 7 - m. pectineus; 8-n. obturatorius; 9-a. et v. obturatoria; 10 - arcus iliopectineus; 11-n. femoralis; 12 - m. iliopsoas.

The muscle gap is bounded outside and behind by the ilium, in front - by the inguinal ligament, inside - by arcus iliopectineus. Through it, the iliopsoas muscle and the femoral nerve exit to the thigh.

Femoral nerve, n. femoralis, a branch of the lumbar plexus, at the exit from the muscular lacuna, is located outward from the femoral artery, being separated from it by a deep plate of its own fascia. Slightly lower (1-3 cm) of the inguinal ligament, the femoral nerve fan-shapedly divides into its terminal branches.

The vascular lacuna is limited from the inside by the lacunar ligament, lig. lacunare, in front - inguinal ligament, lig. inguinale, behind - the periosteum of the pubic bone, outside - arcus iliopectineus. Through the vascular lacuna, the femoral artery, accompanied by the vein of the same name, enters the thigh.

Femoral artery and vein, a. et v. femoralis, are surrounded by a connective tissue sheath, which has a septum that separates the artery from the vein.

The projection of the femoral artery corresponds to a line running from the middle of the inguinal ligament to the apex of the femoral triangle or to the internal condyle of the thigh.

From the femoral artery, in addition to superficial branches (a. pudenda externa, a. circumflexa ilium superficialis, a. epigastrica superficialis), within the femoral triangle, the deep artery of the thigh departs, a. profunda femoris. It is a rather thick arterial trunk extending from the posterior semicircle of the femoral artery 3-5 cm below the inguinal ligament.

Two branches depart from the initial part of the deep artery of the thigh: a. circumflexa femoris medialis and a. circumflexa femoris lateralis.

The femoral vein under the inguinal ligament is located medially from the femoral artery; distally, at the apex of the femoral triangle, it lies behind the femoral artery. The valves in the femoral vein are usually located above the confluence of v. saphena magna.

Inward from the femoral vein, on a deep sheet of the broad fascia of the thigh, there are deep inguinal and subinguinal lymph nodes, nodi lymphatici inguinales profundi et nodi lymphatici lubinguinales profundi and lymphatic vessels that drain lymph from the deep sections of the lower limb to the pelvic lymph nodes.

The femoral vessels do not completely fill the vascular lacuna; medially from them there is a space 1.2-1.8 cm wide (A.P. Prokunin), filled with fatty tissue and lymph nodes. Here, in the presence of a femoral hernia, a femoral canal is formed (Fig. 93). It has a trihedral shape and reaches 1-3 cm in length.

93. Canalis femoralis.

1 - ileo-pubic ligament; 2 - anulus femoralis; 3-lig. lacunar; 4-lig. inguinale; 5-a. et v. femoralis; 6-v. saphena magna; 7 - cornu inferius; 8 - margo falciformis; 9 - cornu superius; 10 - arcus ileopectineus; 11 - m. psoas major; 12 - m. iliacus.

The anterior wall of the femoral canal is the superficial sheet of the fascia lata, the posterior wall is the deep sheet of the same fascia, the outer wall is the femoral vein with the connective tissue sheath covering it. On the inside, the channel is limited by the fusion of the superficial and deep sheets of the wide fascia of the thigh at m. pectineus.

The external opening of the femoral canal is an oval fossa, hiatus saphenus, which is present in the surface sheet of the fascia lata of the thigh.

The internal opening - anulus femoralis, is deeper and limited: from above - by the inguinal ligament, from the outside - by the femoral vein and its vagina, from the inside - by the lacunar ligament and from below - by the iliopubic ligament, tightly fused with the periosteum of the pubic bone. From the side of the abdominal cavity, the internal opening of the femoral canal is closed by the transverse fascia of the abdomen, which is loosened here and is called the septum femorale. Deep lymphatic vessels of the thigh pass through the openings in the septum femorale, draining lymph into the lymphatic vessels and nodes of the pelvis.

During surgery for a strangulated femoral hernia, when it becomes necessary to dissect the internal opening of the femoral canal, it should be remembered that it is limited from the outside by the femoral vein, and from above by the inguinal ligament, to which the stem a. epigastric inferior. Only the inner wall of this hole remains avascular, i.e. lig. lacunare, which should be dissected in such cases. However, often (28.5% of cases) a. obturatoria, which is usually a branch of a. iliaca interna, departs from a. epigastrica inferior and, heading to the small pelvis, and then to the obturator canal, passes posteriorly from the lig. lacunaris. In such cases, the internal opening of the femoral canal is limited by a semicircle of vessels: outside - v. femoralis, in front - a. epigastrica inferior and inside - a. obturatoria (Fig. 94). Such an arrangement of vessels has long been called corona mortis, since earlier, when dissecting the internal opening of the femoral canal blindly, by means of a herniotome, significant bleeding occurred, which often ended in death.

94. Departure options a. obturatoriae.

I - a. et v. iliaca communis; 2-a. et v. circumflexa ilium profunda; 3-a. et v. iliaca externa; 4-a. et v. iliaca interna; 5 - n.obturatorius; 6 - ductus deferens; 7-a. umbilicalis; 8-a. glutea superior; 9 - a.sacralis lateralis; 10-a. rectalis media;

II - aa. vesicales superiores; 12-a. vesicalis inferior; 13-a. pudenda interna; 14-a. glutea inferior; 15 - vesicula seminalis; 16 - vesica urinaria (pulled down); 17 - symphysis; 18 - ramus pubicus a. obturatoriae; 19-a. et v. obturatoriae; 20-lig. lacunar; 21-lig. inguinale; 22 - a.et v.epigastrica inferior; 23-lig. interfoveolare.

Inguinal ligament at the top and muscles - m. sartorius (laterally) and m. adductor longus (medially) form the femoral (Skarpovsky) triangle. Its apex is located at the intersection of these muscles, and the pupart ligament serves as the base.

Under the superficial sheet of the broad fascia within the femoral triangle are the main femoral vessels surrounded by the vagina - a. and v. femoralis. They lie in the recess, which is formed by the muscles of the bottom of the femoral triangle, covered with a deep leaf of the broad fascia: m. liopsoas (laterally) and m. pectineus (medially); the first of these muscles is attached to the lesser trochanter, the second - to the femur immediately under the lesser trochanter.

The recess formed by these muscles has a triangular shape and is called trigonum, s. fossa iliopectinea. The base of the small triangle, enclosed by the intrafemoral one, is the inguinal ligament, and the apex lies on the lesser trochanter.

In the upper half of the femoral triangle, the femoral vein lies from the inside, the femoral artery is located outward from it, and outward from the artery at a distance of about 1-1.5 cm is the femoral nerve, separated from the artery by a deep leaflet of the fascia lata. The closer to the apex of the femoral triangle, the more the femoral vein deviates posteriorly and outwardly, and, finally, in the middle third of the thigh, it is almost completely hidden behind the artery.

Within the femoral triangle, the following branches depart from the femoral artery: immediately under the inguinal ligament - a. epigastric superficialis, a. circumflexa ilium superficialis and aa. pudenda externae; at a distance of 3-5 cm from the inguinal ligament, the femoral artery gives off the largest branch - a. profunda femoris. The latter is the main source of supply for the thigh region and gives off branches close to the place of origin: aa. circumflexa femoris medialis and lateralis, which often depart from the femoral artery, and below - three perforating arteries (aa. perforantes).

The femoral nerve, which supplies motor branches mainly to the tailor and quadriceps muscles of the thigh, already at a distance of about 3 cm from the inguinal ligament begins to divide into muscle and skin branches. The longest cutaneous branch is p. saphenus, which accompanies the femoral artery for most of its length.

Muscular lacuna, vascular lacuna

The iliac fascia, covering the iliac and psoas muscles in the pelvis, is firmly fused at its lateral margin at the level of the inguinal ligament. The medial edge of the iliac fascia is tightly attached to the eminentia iliopectinea. This section of the fascia is called the iliac-scallop arch - arcus iliopectineus (or lig. ilio "pectineum). It divides the entire space between the inguinal ligament and the bones (iliac and pubic) into two sections: the muscular gap - lacuna musculorum (external, larger, department) and the vascular lacuna - lacuna vasorum (internal, smaller, department). The muscular lacuna contains m. iliopsoas, n. femoralis and n. cutaneus femoris lateralis, if the latter is located near the femoral nerve or is its branch. The vascular lacuna passes the femoral vessels, of which the artery (accompanied by ramus genitalis n. genitofemoralis) is located outside (2 cm medially from the middle of the inguinal ligament), the vein is from the inside Both vessels are surrounded by a common vagina, in which the artery is separated from the vein by a septum.

The muscle gap has the following boundaries: in front - the inguinal ligament, behind and outside - the ilium, from the inside - arcus iliopectineus. Due to the fact that the iliac fascia is firmly fused with the inguinal ligament, the abdominal cavity along the muscle gap is firmly separated from the thigh.

The vascular lacuna is limited by the following ligaments: in front - the inguinal and the superficial leaf of the broad fascia fused with it, behind - the scallop, outside - arcus iliopectineus, inside - lig. lacunar.

The practical significance of the muscular lacuna is that it can serve as a place of exit to the thigh of stagnation abscesses arising from the bodies of the vertebrae (often lumbar) with their tuberculosis. In these cases, the abscesses pass under the inguinal ligament in the thickness of m. iliopsoas or between the muscle and the fascia covering it and linger at the lesser trochanter. Abscesses of the hip joint can also flow here, making their way through the joint capsule and bursa ilipectinea. In extremely rare cases, femoral hernias come out through the muscle gap.

Under the comb muscle and the short adductor lying deeper than it are the external obturator muscle and the vessels and nerve emerging from the obturator canal.

Canalis obturatorius is an osteofibrous canal leading from the pelvic cavity to the anterior-inner surface of the thigh, in the adductor muscle bed. Its length usually does not exceed 2 cm, and its direction is oblique, coinciding with the course of the inguinal canal. The channel is formed by a groove on the horizontal branch of the pubic bone, closing the groove with the obturator membrane and both obturator muscles. The outlet is located behind m. pectineus.

The contents of the obturator canal are a. obturatoria with vein and n. obturatorius. The relationship between them in the obturator canal is often as follows: outside and in front lies the nerve, medial and posterior to it is the artery, medially from the artery is the vein.

N. obturatorius supplies the adductor muscles of the thigh. Upon leaving the canal or in the canal, it divides into an anterior and a posterior branch.

A. obturatoria (more often from a. iliaca interna, less often from a. epigastrica inferior) in the canal itself or at the exit from it is divided into two branches - anterior and posterior. They anastomose with aa. glutea superior, glutea inferior, circumflexa femoris medialis, etc.

Sometimes hernias (herniae obturatoriae) come out through the obturator canal.

69. Topography of the femoral canal.

The femoral artery and vein fill the vascular gap not entirely, but only within its two outer thirds. The inner third of the vascular lacuna, corresponding to the gap between the femoral vein and the lacunar ligament, is called the femoral ring (anulus femoralis). This is the most pliable part of the vascular lacuna: it is performed by fatty tissue, lymphatic vessels and the Rosenmuller-Pirogov lymph node, adjacent to the sheath of the femoral vein with its outer surface. Anteriorly, the femoral ring is bounded by the inguinal ligament, posteriorly by the scalloped ligament and the scalloped fascia starting from it, internally by the lacunar ligament, and externally by the sheath of the femoral vein.

The fiber that performs the femoral ring communicates towards the thigh with the fiber of the oval fossa, and towards the abdominal cavity goes directly into the subperitoneal tissue. In some cases, however, a septum (septum femorale) closes the inner ring from the side of the abdominal cavity.

The latter is formed by a process of the transverse fascia and is permeated with holes through which the lymphatic vessels pass.

From the side of the parietal peritoneum, the femoral ring corresponds to the fossa (fessa femoralis), located under the inguinal ligament, on the same vertical as the internal inguinal fossa (fossa inguinalis medialis), located above the pupart ligament.

The width of the inner femoral ring, determined by the distance between the femoral and lacunar ligament, is on average 1.2 cm in men and 1.8 cm in women. degrees explain the fact that femoral hernias are much more common in women than in men.

In case of protrusion of the peritoneum in place of the femoral ring and the exit of the viscera, a femoral hernia is formed. The path laid by this hernia is called the femoral canal. This is a short (1-2 cm) gap between the oval fossa and the femoral ring, which has a direction almost parallel to the axis of the body. The canal has a triangular shape and its walls are: the falciform edge of the wide fascia - in front, the scalloped fascia - behind and from the inside, the sheath of the femoral vein - outside.

Femoral hernias come out from under the inguinal ligament within the upper half of the oval fossa, medially from the femoral vein. The layers covering the hernial sac consist of skin with subcutaneous tissue, superficial fascia and subperitoneal fat (fascia cribrosa, as well as the septum femorale formed by the transverse fascia, loosens completely under the pressure of the hernial protrusion).

In rare cases, hernias can exit laterally from the femoral vessels or directly in front of them, and sometimes behind them. But a common anatomical feature of femoral hernias is their protrusion under the inguinal ligament; this is also their main difference from inguinal hernias, emerging under the inguinal ligament.
70. Topography of the popliteal fossa.

The boundaries of the popliteal fossa: from above and outside - the tendon of the biceps femoris; from above and from the inside - the tendons of the semiperionate muscle and the semitendinosus lying more superficially and outward; from below and outside - the lateral head of the gastrocnemius muscle (m. gastroenemius) with the plantar muscle (m. plantaris) located deeper than it and partially above it; from below and from the inside - the medial head of the gastrocnemius muscle. Both heads of the latter originate on the posterior surface of the condyles of the femur and slightly higher than them, and the plantar muscle - from the lateral condyle.

The bottom of the popliteal fossa is formed by: 1) planum popliteum - a triangular platform on the femur, limited by lips of a rough line diverging towards the mice; 2) the back of the bag of the knee joint with the lig that strengthens it. popliteum obliquum; 3) popliteal muscle (m. popliteus), running from the outer condyle of the femur to the tibia.

The popliteal fossa is made of fatty tissue surrounding the vessels and nerves located in it; it communicates: 1) at the top - with the tissue of the posterior thigh (through loose tissue in the circumference of the sciatic nerve) and through it further - with the tissue of the gluteal region and pelvis; 2) through the hiatus adductorius along the popliteal vessels with the tissue of the anterior thigh region; 3) below - through the hole, limited by the tendon arc m. soleus, - with fiber in the posterior deep space of the leg. The inner section of the popliteal fossa passes into a depression, sometimes called the zhoberovy fossa. The fossa is limited by the following formations: in front - the tendon of the large adductor muscle, behind - the tendons of the semitendinosus, semimembranosus and tender muscles, from above - the edge of the tailor muscle, from below - the internal head of the gastrocnemius muscle and the internal condyle of the femur.

The location of large vessels and nerves in the popliteal fossa is as follows: the most superficial, along the midline (N. I. Pirogov), passes n. tibialis, deeper and medially from it lies v. poplitea, and even deeper and inside, closest to the bone, - a. poplitea. Thus, going from the surface to the depth and from outside to inside, we meet such an arrangement of elements of the neurovascular bundle: nerve, vein, artery.

N. tibialis is a continuation of the trunk of the sciatic nerve. Usually in the upper corner of the popliteal fossa, the latter is divided into two large nerves (n. tibialis and n. peroneus communis). N. tibialis goes to the lower corner of the popliteal fossa, and then under the tendon arch m. soleus passes along with vasa tibialia posteriora to the back surface of the lower leg (in canalis cruropopliteus). N. peroneus communis on the inner edge of the biceps tendon passes to the lateral side of the fibula, bending around its neck, and then appears in the anterior region of the lower leg.

In the popliteal fossa, muscle branches depart from the tibial nerve (to both heads of the gastrocnemius muscle, to the soleus, plantar and popliteal muscles) and the cutaneous nerve - n. cutaneus surae medialis, which goes in the groove between the heads of the gastrocnemius muscle and then passes to the lower leg. From the common peroneal nerve within the popliteal fossa, the cutaneous nerve departs - n. cutaneus lateralis.

A. and v. poplitea are surrounded by a common sheath, in which the artery is separated from the vein by a septum. The vessels pass into the popliteal fossa through the hiatus adductorius (the lower opening of the canal of the adductor muscles). From a. poplitea branch off to the muscles and joint. There are two aa. genus superiores (lateralis et medialis), a genus media and two aa. genus inferiores (lateralis et medialis). The branches of these vessels surround the capsule of the knee joint, forming the rete articulate genus, and participate with the branches of the femoral artery in creating collateral arches in the joint area (see Fig. PO). At the level of the lower edge m. popliteus, the popliteal artery enters the canalis cruropopliteus and immediately divides into a. tibialis posterior and a. tibialis anterior. The latter, through a hole in the interosseous membrane, passes into the anterior region of the lower leg, in the extensor bed.

Three groups of popliteal lymph nodes are located floor by floor. The deep group is formed by nodes adjacent to the back of the caprule of the knee joint, the middle group is formed by nodes lying along the popliteal vessels, and the superficial group is formed by nodes lying directly under the dense own popliteal fascia.

Phlegmons of the popliteal fossa are often referred to as adenophlegmons, since in most cases their source is purulent inflammation of the popliteal lymph nodes. Adenophlegmons of the popliteal fossa occur as a result of purulent gonitis, as well as pyo-dermatitis or suppurating wounds in the posterior and postero-outer part of the heel region and in the region of the Achilles tendon, since the superficial lymphatic vessels of these departments end in the popliteal lymph nodes. Deep lymphatic vessels from the deep tissues of the foot and lower leg also flow into the latter, accompanying the anterior and posterior tibial arteries. Therefore, for example, a fracture of the lower leg bones complicated by a secondary infection can be the cause of the development of popliteal adenophlegmon.

71. Topography of the knee joint.

The knee joint is formed by: the lower epiphysis of the femur with both condyles, the upper epiphysis of the tibia with its condyles and the patella. The fibula does not take part in the formation of the joint, although the joint between the head of the fibula and the external condyle of the tibia communicates with the knee joint in about 20% of cases.

The line of the knee joint is best defined in front, with a bent knee, by transverse grooves located on the sides of the patellar ligament. The joint gap here can easily be determined by palpation of the upper edge of the condyles of the tibia; the gap corresponds to the gap between them and the condyles of the femur.

On the back surface of the knee, the articular line approximately corresponds to the transverse fold that forms on the skin with slight flexion of the limb.

The articular surfaces of the bones that form the knee joint are covered with cartilage almost throughout. Between the articular ends, special cartilage formations located on the condyles of the tibia are included - menisci (menisci), which are connected by the outer surface to the joint capsule; of these, the outer one has the shape of the letter O, the inner one has the shape of the letter C. A bundle of fibrous fibers is stretched between their anterior convex edges - lig. transverse genus.

In front, the joint is covered by formations that generally make up the holding apparatus of the patella, formed mainly due to the tendon elements of the quadriceps femoris. In the midline, down from the patella, its own ligament stretches - lig. patellae. On the sides of the patella and its ligaments are the retaining ligaments of the patella (retinacula), arising from the lateral parts of the tendon of the quadriceps muscle. On top of these formations is the own fascia of the knee region, thickened in the outer section due to the tendon fibers of the iliac tibial tract, and in the inner section due to the tendon fibers of the sartorius muscle. All this makes up the fascial-aponeurotic apparatus of the knee joint.

Behind the joint is protected by muscles, tendons and other soft tissues of the popliteal fossa.

The ligamentous apparatus of the joint, in addition to the ligaments of the patella, is represented by the following ligaments.

Lig. collateral tibiale and fibulare are stretched along the lateral surface of the joint between the epicondyles of the femur and tibia.

Lig. Popliteum obliquum and lig. popliteum arcuatum strengthen the joint capsule at the back.

Lig. cruciatum anterius and posterius, the cruciate ligaments, are the internal ligamentous apparatus of the knee joint and become visible when it is opened. They firmly connect the femur and tibia, being the main ones in the ligamentous apparatus of the joint. The posterior cruciate ligament and the medial condyle of the thigh are connected to the lateral meniscus through a ligament (lig. meniscofemorale).

The joint capsule consists of fibrous and synovial membranes. The first is better expressed on the back surface of the joint. In front, the pterygoid folds of the synovial membrane (plicae alares) strongly protrude into the joint cavity, which stretch along the sides of the patella from its base to the anterior edges of the menisci.

Attachment of the bag on the thigh occurs at a distance of 1-2.5 cm from the edges of the cartilaginous cover and reaches the level of the lateral ligaments (the epicondyles remain outside the bag). Heading further down, it attaches to the tibia, immediately below the articular margin.

The epiphyseal line of the femur lies in the joint cavity, and only its lateral sections are outside the cavity. The epiphyseal lines of the tibia descend below the joint and are outside its cavity.

The joint cavity increases due to the fact that the synovial membrane forms a series of protrusions - the so-called inversions, of which five are located in the anterior part of the articular cavity, four in the back. The largest is located in front - the upper inversion (recessus superior). It is formed by the passage of the synovial membrane from the posterior surface of the quadriceps tendon to the femur. AT 85% cases, it communicates with the synovial bag of the quadriceps muscle - bursa synovialis suprapatellaris. In addition to the anterior upper (median), there are the following inversions: anterior superior (medial and lateral), anterior inferior (medial and lateral), posterior superior and inferior (medial and lateral).

The practical significance of torsion lies in the fact that, increasing the joint cavity, they are places of accumulation of pathological fluids (pus, blood, etc.). The posterior torsions, being delimited from the anterior ones (in inflammatory processes), may be places of pus retention. It should be borne in mind that the posterior (upper) inversions communicate with synovial bags: bursa m. can open into the external inversion. poplitei, and in the inner one - bursa m. semimembranosi and bursa capitis medialis m. gastrocnemia. With purulent inflammation of the knee joint, pus can flow into these bags,
72. Topography of the lower leg.

The lower leg area is limited by two horizontal planes: the upper one, passing through the tuberosity of the tibia, and the lower one, passing over the bases of both ankles. The area is divided into two - regio cruris anterior and regio cruris posterior. The border between these areas runs along the inner edge of the tibia (medially) and the groove separating the peroneal muscles from the gastrocnemius muscle (laterally).

Own fascia of the lower leg for most of its length has a significant density. Strong plates depart from its inner surface towards the fibula, playing the role of partitions: septum intermusculare anterius and posterius, of which the first is attached to the anterior cranial) of the fibula, the second to the posterior. Together with both bones of the lower leg and the interosseous membrane, these septa delimit three bone-fibrous enemies, or muscle beds: anterior, external and posterior.

The anterior-inner surface of the tibia is not covered with muscles and therefore is palpable throughout. The medial malleolus, crista tibiae, tuberositas tibiae and the medial edge of the bone are easily accessible for examination on the tibia. The fibula is surrounded by muscles for most of its length, so that only its head (above) and the lateral malleolus with the adjoining part of the bone (below) can be felt.

In the anterior-outer part of the lower leg, palpation determines the groove that separates the group of external (peroneal) muscles from the group of the anterior (extensor) muscles. The Achilles tendon is easily palpable in the hind leg.

femoral triangle, Scarpovsky, or, more correctly, Scarpa's triangle, limited from lateral side tailor muscle, m. sartorius, with medial- long adductor muscle, m. adductor longus; his vertex formed by the intersection of these muscles, and base- inguinal ligament. The height of the femoral triangle is 15-20 cm.

Layers of the anterior thigh. Superficial arteries and veins in the area of ​​the femoral triangle

The skin in the area of ​​the femoral triangle is thin and mobile.

The subcutaneous tissue contains blood vessels, lymphatic vessels and nodes, and skin nerves. Superficial arteries (an exception to the rule; most named arteries are located under their own fascia) exit from under their own fascia through the fascia cribrosa in the area subcutaneous fissure, hiatus saphenus(Fig. 4.2).

Superficial epigastric artery, a. epigastrica superficialis, goes in the subcutaneous tissue of the thigh to the middle of the projection of the inguinal ligament and then in the subcutaneous tissue of the anterior abdominal wall towards the navel.

Superficial circumflex iliac artery, a. circumflexa ilium superficialis, goes from the subcutaneous fissure to the superior anterior iliac spine parallel to the inguinal ligament.

Superficial external pudendal artery, a. pudenda externa superficialis, goes inward, to the perineum.

arteries, as usual, are accompanied by the veins of the same name (these veins are involved in the formation of porto-caval and cavo-caval anastomoses).