Osteology of the Lower Limb - PowerPoint Presentation

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Osteology of the Lower Limb

ANA 208

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Lecture Schedule

Introduction /

Osteology of Lower limbInguinal regionGluteal regionCompartments of the thighFemoral triangle and adductor canalPopliteal fossaFlexor and extensor compartments of the legFoot and its archesJoints of the lower limbBlood supply and innervation of the lower limb / DermatomesLumbosacral plexus

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Hip Bone (L.

os

coxae)Fusion of three primary bones—ilium, ischium, and pubis.Each of the three bones is formed from its own primary center of ossification; five secondary centers of ossification appear later.At birth, the three primary bones are joined by hyaline cartilage.At puberty, the three bones are still separated by a Y-shaped triradiate cartilage. The bones begin to fuse between 15 and 17 years of age; fusion is complete between 20 and 25 years of age

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Adolescent

Innominate

Bone5

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Innominate

bone

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Tibia and Fibula

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Inguinal Canal / Region

Oblique intermuscular slit about 4 cm long lying parallel and above the medial half of the inguinal ligament.

Hiatus in the tissues of the anterior abdominal wallSize and form vary with age, it is most well developed in the male. In the newborn, the canal is short.

Commences at the deep inguinal ring, ends at the superficial inguinal ring

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Inguinal Canal

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Superficial Structures in the inguinal Region

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Contents

Spermatic cord in the male Round ligament of the uterusIlioinguinal nerve Genitofemoral nerve

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Superficial inguinal ring

End of the inguinal canal and lies superior to the pubic tubercleExit by which inguinal contents emerges from the inguinal canal.Formed by evagination of the

external oblique

aponeurosis

Triangular

Form the margins called

crura

.

Lateral

crus

attaches to the pubic tubercle, stronger and reinforced by

fibres

of the inguinal ligament

Medial

crus

attaches to the pubic crest, thin.

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Does not extend beyond the medial one-third of the inguinal ligament.

Some fibres arch above the apex as intercrural fibres

which prevent the

crura

from spreading apart

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In the male, the lateral

crus

forms a groove, in which the spermatic cord rests.

Smaller in the female.

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Deep (internal) inguinal ring

Lateral to inferior

epigastric vesselsSituated in the transversalis fascia and projected as the

internal spermatic fascia

around the spermatic cord

Midway between the anterior superior iliac spine and the

symphysis

pubis

1.25 cm above the inguinal ligament.

Oval

Size varies between individuals, larger in the male.

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In the female they are replaced by the obliterated

processus

vaginalis, the round ligament and lymphatics from the uterus.Ilioinguinal nerve does not enter the canal through the deep ring, but pierces the internal oblique muscle, and leaves the canal through the superficial ring

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Boundaries

Anteriorly

- skin, superficial fascia and aponeurosis of external oblique, its lateral one-third is reinforced by internal oblique muscle. Posteriorly - inguinal ligament, the conjoint tendon (inguinal falx

) and the

transversalis

fascia.

Superiorly - internal oblique and

transversus

abdominis

forming the conjoint tendon.

Inferiorly - union of the

transversalis

fascia with the inguinal ligament and, at the medial end, the

lacunar

ligament.

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INGUINAL LIGAMENT AND ILIOPUBIC TRACT

Extend from the ASIS to the pubic tubercle

The inguinal ligament (of Poupart) is a dense band constituting the

inferiormost

part of the external oblique

aponeurosis

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Most fibers of the ligament’s medial end insert into the pubic tubercle, some attach to the superior pubic

ramus

, forming

lacunar

ligament (of

Gimbernat

)

The most lateral of these fibers continue to run along the

pecten

pubis as the

pectineal

ligament (of Cooper).

Iliopubic

tract

is the thickened inferior margin of

the

transversalis

fascia, running parallel and posterior to the inguinal ligament

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Relations

Posteriorly

, inferior epigastric vessels lie on the transversalis fasciaLateral to the artery are the vas deferens in the male and the round ligament of the uterus in the female.Inguinal triangle lies in the posterior wall of the canal.

Overlies the medial inguinal

fossa

and, in part, the

supravesical

fossa

.

Lacunar

ligament

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Inguinal triangle (of

Hesselbach

) Area of potential weakness through which herniation can occurLaterally by the inferior

epigastric

artery

Medially by the lateral border of the rectus muscle

Inferiorly by the inguinal ligament

Contents

Layers of the abdominal wall

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Lacunar

ligament

A triangular band of tissue lying posterior to the medial end of the inguinal ligament. Measures 2 cm from base to apex and is a little larger in the male.Formed from fibres of the medial end of the inguinal ligament and

fibres

from the fascia

lata

of the thigh.

Apex of the triangle is attached to the pubic tubercle.

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Pectineal

ligament of Astley CooperExtends laterally along the pectineal line from the pectineal

attachment.

Forms the lower extension of the medial border of the femoral canal and femoral sheath.

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INGUINAL HERNIA

Protrusion of an organ or fascia through the walls of the that normally contains it

eg inguinal region of the abdominal wall.32

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Indirect inguinal hernia

CommonerCaused by failure of processus vaginalis to regress

Peritoneal sacs and loops of bowel enter or expand the inguinal canal through the deep inguinal ring (

transversalis

fascia)

Arises lateral to the inferior

epigastric

vessels.

Related to the congenital persistence of the vaginal process.

Acquired as a result of weakening of the lateral and posterior walls of the canal.

Small hernias are covered by the

spermatic cord, internal spermatic fascia, external spermatic fascia

and

cremasteric

muscle

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Direct inguinal hernia

Peritoneal sac bulges into the inguinal canal via the posterior wall

Caused by weakness of the inguinal triangle in the medial posterior wall of the canalArises medial to the inferior epigastric vessels.Acquired, usually in adulthoodExtend through the anterior wall of the canal or superficial ring.

Protrude through the

transversalis

fascia, between the conjoint tendon and the inferior

epigastric

vessels, and enter the inguinal canal.

Arise either between the

fibres

of the conjoint tendon

Covered by

external spermatic fascia

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Femoral hernia

Protrudes through the femoral ring closed by a femoral septum, a weak spot.

In females, the ring is large and subject to changes during pregnancy, more common in women. Section of intestine bulges through the ring and descends along the femoral canal to the saphenous opening.Coverings of a femoral hernia are: peritoneum, femoral septum and sheath,

cribriform

fascia, superficial fascia and skin.

The intestine reaches only to the

saphenous

opening in incomplete femoral hernia.

Site of strangulation may be at the neck of the

hernial

sac; or it may be at the

saphenous

opening.

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A

hernial

sac passing lateral to the artery (i.e. through the deep ring) is an indirect hernia, one passing medial to the artery (through the inguinal triangle) is a direct herniaInguinal hernia emerges through the superficial inguinal ring it lies above and medial to the pubic tubercleWhile the neck of a femoral hernia is below and lateral to the pubic tubercle. Pubic tubercle distinguishes inguinal from femoral hernias

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Clinical Application

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