Skin of the thigh

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Skin of the thigh Cutaneous Nerves 1- The femoral
branch of the genitofemoral nerve. It enters
the thigh behind the middle of the inguinal
ligament and supplies small area of skin . It is
a branch of the lumbar plexus ( l 1 l 2 ). 2-
The ilioinguinal nerve, a branch of the lumbar
plexus ( l1 ), enters the thigh through the
superficial inguinal ring. It supplies a small
skin area below the medial part of the inguinal
ligament. 3- The medial cutaneous nerve of the
thigh, a branch of the femoral nerve ( l2 , 3 ) ,
supplies the medial aspect of the thigh joins
the patellar plexus. 4- The intermediate
cutaneous nerve of the thigh, a branch of the
femoral nerve ( l1, 2 ). It divides into 2
branches that supply the anterior aspect of the
thigh joins the patellar plexus.
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2
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4
3
2
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5- Branches from the anterior division of the
obturaror nerve ( l2, 3 4 ) supply area of the
skin on the medial aspect of the high. 6- The
lateral cutaneous nerve of the thigh, a branch of
the lumbar plexus ( L2 3 ). It enters thigh
behind the lateral end of the inguinal ligament.
It divides into A P branches to supply the skin
of the lateral aspect of the thigh knee . Also,
the skin of the lower lateral quadrant of the
buttock
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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 ( .8 cm) 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. Femoral
sheath

It is a downward protrusion into the
thigh of the fascial envelope lining the
abdominal walls. Its anterior wall is continuous
above with the fascia transversalis its
posterior wall with the fascia iliaca. The sheath
surrounds the femoral vessels lymphatics for
about 2. 5 cm below the inguinal ligament .
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Deep fascia of the thigh ( fascia Lata) It
encloses the thigh like a trouser leg. At its
upper end is attached to the pelvis inguinal
ligament. On its lateral aspect, it is thickened
to form the iliotibial tract which is attached
above to the iliac tubercle below to the
lateral condyle of the tibia . The iliotibial
tract receives the insertion of the tensor
fasciae latae the greater part of the gluteus
maximus muscles.
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Deep fascia In it, there is a gap in the front of
the thigh just below the inguinal ligament. It is
the Saphenous opening which transmits the great
saphenous vein, small branches of the femoral
artery lymph vessels. It is situated about 4 cm
below lateral to the pubic tubercle. The lower
lateral border of the opening is called the
falciform margin . It lies anterior to the
femoral vessels. The border of the
opening then curves upward medially 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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Rectus femoris Vastus lateralis
Fascial Compartment 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 3 compartments are anterior ,
medial posterior in position.
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SartoriusIt Covers the middle third of the
femoral vessels . Origin From the
anterior superior iliac spine .
Insertion The upper part of the medial
surface of the shaft of tibia .

Psoas majorThe fibers enter the thigh
behind the inguinal ligament .

Origin From the roots of the T. processes
sides of the vertebral bodies the intervertebral
discs, from the 12th thoracic to the 5th lumbar
vertebrae.
Insertion Into the
lesser trochanter of the femur.
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Pectineus
Origin From the superior ramus of the pubis
. Insertion It is attached to the upper end of
the linea aspera just below the lesser trochanter
.
Iliacus

Origin Arises from the iliac fossa
within the abdomen . Insertion Its fibers join
the tendon of the psoas to form the iliopsoas
muscle which are inserted into the lesser
trochanter of the femur the adjoining area .
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Muscles of the anterior compartment of the
thigh 1- Sartorius N . Supply femoral nerve.
Action flexes both hip knee
joints. Abduct laterally rotates the thigh and
medially rotates the leg at the knee . 2- Iliacus
N. supply A branch of the femoral nerve
within the abdomen.
Action The iliopsoas flexes the thigh on the
trunk at the hip joint or if the thigh is fixed ,
it flexes the trunk on the thigh it medially
rotates the thigh . 3- Psoas N. supply
Branches from the lumbar plexus.
Action like the
iliacus . Pectineus N. supply femoral a
branch from the obturator nerves .
Action Flexes adducts the
thigh at the hip joint .
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Origin of quadriceps
femoris
1-Rectus femoris A straight
head from the A. inferior iliac spine A
reflected head from the ilium above the
acetabulum .
2- Vastus
lateralis From the upper part of
intertrochanteric line , the base of the greater
trochanter , lateral margin of gluteal tuberosity
linea aspera of the femur .

3- Vastus medialis from
lower part of intertrochanteric line spiral
line linea aspera of the femur upper part of
medial supracondylar ridge .
4- Vastus intermedius From the
upper 2l3 of the A. Lat surfaces of the shaft of
the femur .
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Insertion of The Quadriceps Femoris
The four muscles
have a common tendon of insertion into the upper,
lateral medial borders of the patella then via
the ligamentum patellae into the tubercle of the
tibia. So, They are inserted into the quadriceps
tendon so into the patella . N. B. The
Vastus intermedius fibers join the deep aspect of
the quadriceps tendon.
The articularis genus is a small
part of the vastus intermedius that is 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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Quadriceps Femoris N. Supply femoral nerve
Action Together they provide a powerful
extensor of the knee joint.
Some of the tendinous fibers of the
vastus lateralis medialis form bands or
retinacula, that join the capsule of the knee
joint strengthen it .
The lowest muscle fibers of the vastus medialis
are horizontal and prevent the patella from being
pulled laterally during contraction of the
quadriceps muscle. Their tone strengthens
the knee joint .
The rectus femoris flexes hip joint
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Femoral sheath


It is a downward protrusion into the thigh of
the fascial envelope lining the abdominal walls.
Its anterior wall is continuous above with the
fascia transversalis its posterior wall with the
fascia iliaca. The sheath surrounds the femoral
vessels lymphatics for about 2. 5 cm below the
inguinal ligament .
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Femoral Sheath The femoral artery occupies the
lateral compartment of the sheath. The femoral
vein occupies the intermediate compartment and is
separated from the artery by a fibrous septum.
The lymph vessels ,
as they leave the thigh ,are separated from the
vein by a fibrous septum occupy the most medial
compartment . The femoral canal is a compartment
for the lymph vessels. It is about 1.3 cm long
its upper opening is referred to as the femoral
ring. This ring is closed by a condensation of
extraperitoneal tissue called femoral septum.
This canal
contains fatty connective tissue all the
efferent lymph vessels ( come out ) from the deep
inguinal lymph nodes and one of the deep
inguinal lymph nodes.
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The femoral sheath It is adherent to the walls
of the blood vessels and inferiorly blends with
the tunica adventitia of these vessels.
It is not
adherent to the walls of the lymph vessels this
site is a potentially weak area in the abdomen.
A protrusion of the abdominal parietal
peritoneum into the canal push the femoral
septum, forming a femoral hernia . The upper end
of the canal ( ring ) is related Anteriorly to
the inguinal ligament Posteriorly to the
superior ramus of the pubis . Medially into the
lacunar ligament . Laterally The femoral vein .
The lower end of the canal is closed by the
adherence of its medial wall to the tunica
adventitia of the femoral vein. It lies close to
the saphenous opening in the deep fascia of the
thigh.
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Femoral Hernia It is more in female than male (
because of their wide pelvis femoral canal
). The hernial sac ( abdominal parietal
peritoneum ) passes through the femoral canal
pushing the femoral septum before it . At the
lower end of the femoral canal it expands to form
a swelling in the upper part of the thigh deep
to the deep fascia . The hernial sac may turn
upward to cross the anterior surface of the
inguinal ligament . The neck of the sac is narrow
lies at the femoral ring . It can not expand
due to the surrounding anatomic structures . It
is irreducible hernia . After coughing a piece of
bowel may be forced through the neck , and its
blood vessels may be compressed by the femoral
ring forming strangulated hernia. It is dangerous
should treated surgically
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Femoral Hernia The Neck of the sac is narrow
lies at the femoral ring . The neck of the sac
lies below lateral to the pubic tubercle. This
serves to differentiate it from the inguinal
hernia which lies above medial to the pubic
tubercle .
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Femoral triangle It is situated at the upper
part of the medial aspect of the thigh just below
the inguinal ligament .It is bounded superiorly
by the inguinal ligament , Laterally by sartorius
medially by medial border of the adductor
longus muscle . Its floor is formed from lateral
to medial by the iliopsaos , pectineus adductor
longus . Its roof is formed by skin fasciae of
the thigh . It contains the terminal branches of
the femoral nerve ,F. A. and its branches F. v.
And its tributaries F. sheath and deep inguinal
lymph nodes .
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Adductor canal ( Subsartorial ) It is an
intermuscular cleft situated on the medial aspect
of the middle third of the thigh beneath the
sartorius muscle . It begins above at the apex of
the femoral triangle ends below at the opening
in the adductor magnus . In cross section it is
triangular having anteromedial posterior and
lateral walls . The anteromedial wall is formed
by sartorius muscle . The posterior wall is
formed by the adductor longus magnus , The
lateral wall is formed by the vastus medialis
. It contains the terminal part of the femoral
artery femoral vein saphenous nerve nerve to
vastus medialis the terminal part of the
obturator nerve and the deep lymph vessels .
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Femoral Nerve It is the largest branch of the
lumbar plexus ( l234 ) . It emerges from the
lateral margin of the psoas muscle within the
abdomen . It lies behind the fascia iliaca
behind the inguinal ligament . It passes downward
in the interval between the psoas and iliacus.
It enters the thigh lateral to the femoral
artery femoral sheath . About 4cm below the
inguinal ligament it terminates by dividing into
anterior posterior divisions .
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Femoral Nerve Branches

Anterior Division 123 and 4 . Posterior
Division 1- muscular to quadriceps . The branch
to rectus femoris also supplies the hip joint
the branches to the 3 vasti also supply the knee
joint . 2- saphenous NIt is cutaneous
It runs
downward medially. It crosses the femoral
artery from the its lateral to its medial side
. It emerges on the medial side of the knee
between the tendon of sartorius gracilis . It
runs down the medial side of the leg in company
with the great saphenous vein . It passes in
front of medial malleolus
2
1
3
4
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Femoral Artery It is a continuation of the
external iliac artery. It passes behind the
inguinal ligament . It lies midway between the
anterior superior iliac spine the symphysis
pubis . It descends vertically toward the
adductor tubercle . It ends at the opening in the
adductor magnus muscle by entering the popliteal
space as the politeal artery.
Relations
Anteriorly It is superficial in its upper part
and is covered by skin fascia . In the lower
part it is covered by sartorius . Medially It
is related to femoral vein in the upper part .
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Posteriorly It lies on the psoas which
separates it from the hip joint pectineus
adductor longus . The femoral vein intervenes
between it and the adductor longus . Laterally
the femoral nerve its branches
Branches
1-
superficial circumflex iliac artery It runs up
to the region of the A. S . iliac spine.
2-
Superficial epigastric artery It crosses the
inguinal ligament runs to the umbilicus.
3-
Superficial external pudendal artery It runs
medially to supply the skin of scrotum.
4-
Deep external pudendal artery It runs medially
to supply the scrotum or labia majora
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5- Descending genicular artery It arises from
the femoral artery near its termination . It
supply the knee joint . 6-Profunda femoris artery
It is a large branch that arises from the
lateral side of the femoral artery about 4 cm
below the inguinal ligament .


It passes medially behind the femoral
vessels enter the medial fascial compartment .

It descends in the interval between the
adductor longus adductor brevis , then lies on
the adductor magnus , where It ends by becoming
the 4th perforating artery .

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Branches Medial femoral circumflex artery It
passes backward between the muscles of the floor
of the femoral triangle and gives off muscular
branches to the muscles of the medial fascial
compartment . It shares in the formation of the
cruciate anastomosis. Lateral femoral circumflex
artery It passes laterally between the terminal
branches of the femoral nerve . It gives off
muscular branches to this area and shares in the
formation of the cruciate anastomosis . Four
perforating arteries They run backward and
supply the surrounding muscles . They are
anastomosing with one another with the inferior
gluteal circumflex femoral arteries above the
muscular branches of the popliteal artery below .

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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 common iliac arteries into
the aorta . The catheter then can pass into
inferior superior mesenteric arteries, celiac
renal arteries . Contrast medium can also, be
injected . Pressure records can be obtained by
guiding the catheter through the aortic valve
into the left ventricle .
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Femoral Vein It enter the thigh by passing
through the opening in the adductor magnus as a
continuation of the popliteal vein . It ascends
at first on the lateral side of the artery then
behind it and finally on its medial side . It
leaves the thigh in the intermediate compartment
of the femoral sheath and passes behind the
inguinal ligament to become the external iliac
vein . Tributaries 1- Veins that correspond to
the branches of the femoral artery ( profunda
femoris vein ) . 2- Great saphenous vein The
superficial circumflex iliac the superficial
epigastric the external pudendal veins drain
into it .
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Femoral Vein Catheterization It is used when
rapid access to a large vein is needed . It is
easily cannulated due to its relation to the
medial side of the femoral artery below the
inguinal ligament . The catheter should be
removed once the patient is stabilized
. Procedure 1- The genitofemoral nerve is
blocked with a local anesthetic . 2- The vein is
demonstrated by the artery . 3- Two
fingerbreadths below the inguinal ligament the
needle is inserted into the femoral vein
.
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Muscles of the medial compartment 1- Gracilis

Origin From the outer surface of the inferior
ramus of the pubis and the ramus of the ischium.


Insertion Upper part of the medial surface of
the tibia . 2- Adductor longus
Origin From the front of
the body of the pubis below and medial to the
pubic tubercle .

Insertion Linea aspera
. 3- Adductor brevis
Origin From the outer surface of
the inferior ramus of the pubis .

Insertion Linea
aspera . 4- Adductor magnus
Origin From the outer surface of
the inferior ramus of the pubis the ramus of
the ischium and the ischial tuberosity

Insertion The adductor portion is attached to
the posterior surface of the shaft of the femur .

The hamstring portion On
the adductor tubercle. 5- Obturator externus
Origin From the outer surface of the obturator
membrane and pubic ischial rami .
Insertion Onto the medial surface of the
greater trochanter of the femur .


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N. B. The adductor brevis lies posterior to the
pectineus adductor longus . N.B. The adductor
hiatus is a gap in the attachment of the adductor
magnus to the femur, it is a passage for the
femoral vessels from the adductor canal downward
into the popliteal space . Nerve supply
Obturator Nerve . Except The hamstring portion
of adductor longus by the sciatic nerve . Action
All the muscles adduct the thigh at the hip
joint . Except 1- Obturator externus
Laterally rotates the thigh at the hip joint . 2-
The hamstring portion of the adductor magnus
extends the thigh. 3- Also, Gracilis flexes
the leg at the knee joint . 4- Also, The adductor
longus brevis and the adductor part of the
magnus . Assist in lateral rotation of the thigh
.
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Obturator Nerve It arises from the lumbar plexus
. It emerges on the medial border of the psoas
major muscle within the abdomin . It runs forward
on the lateral wall of the pelvis to reach the
upper part of the obturator foramen. Where it
divides into the anterior posterior division
. Branches The anterior division passes
downward in front of the obturator externus. The
adductor longus.
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It gives muscular branches to gracilis adductor
brevis and adductor longus. Also to pectineus. It
gives articular branches to hip joint and
terminates as a small nerve that supplies the
femoral artery . Also, 7. Posterior division
pierces the obturator externus and passes
downward behind the adductor brevis and in front
of the adductor magnus.

It
terminates by descending through the opening in
the adductor magnus to supply the knee joint.


It supplies obturator externus 8 9 .
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Obturator Artery It is a branch of the internal
iliac artery . It passes forward on the lateral
wall of the pelvis and accompanies the obturator
nerve through the obturator canal . On entering
the medial fascial compartment of the thigh , it
divides into medial lateral branches, which
pass dnd circle around the outer surface of the
obturator membrane . It gives muscular branches
and articular branche to hip joint .
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