Femoral Triangle and Adductor Canal Dr. Heba Kalbouneh Associate Professor of Anatomy and Histology Femoral Triangle and Adductor Canal Femoral triangle Is a triangular depressed area located in the upper part of the medial aspect of the thigh immediately below the inguinal ligament. Superiorly: Inguinal ligament (the base of the triangle) Laterally: Medial border of sartorius Medially: Medial border of adductor longus The apex: directed downwards and is formed by the meeting point of sartorius and adductor longus Floor: Gutter shaped from lateral to medial is made by: A. Iliacus A B. Psoas B C. Pectineus D. Adductor longus C D Roof: Formed by 1-Skin 2-Superficial fascia and its contents 3-Deep fascia containing the saphenous opening Superficial inguinal lymph nodes Genitofemoral nerve (femoral branch) Great saphenous vein Ilioinguinal nerve Contents of the femoral Lateral triangle cutaneous 1-Femoral nerve and its nerve of the branches thigh 2-Femoral artery and its branches 3-Femoral vein and its tributaries 4-Deep inguinal lymph Femoral vein nodes 5- Femoral sheath!!! 6-Femoral branch of genitofemoral nerve 7-Lateral cutaneous nerve of the thigh Femoral Deep inguinal lymph nodes nerve Femoral Genitofemoral nerve artery (femoral branch) Nerve Artery Vein Inguinal lymph nodes NAVI gate The femoral triangle from lateral to medial Femoral sheath The femoral sheath The femoral sheath is a funnel shaped sheath of fascia surrounding the upper 1.5 inches of femoral vessels The femoral sheath is formed by a downwards extension of the abdominal fascia Anterior wall: is a downward prolongation of the fascia transversalis of the anterior abdominal wall Posterior wall: is a downward prolongation of the fascia iliaca of the posterior abdominal wall Two Anterio-posterior septa divide the sheath into 3 compartments: 1-Lateral compartment (arterial) occupied by the femoral artery and femoral branch of the genitofemoral nerve 2-Intermediate compartment (venous) occupied by the femoral vein 3-Medial compartment (lymphatic) occupied by the lymph vessels and one of the deep inguinal lymph nodes (femoral canal) Femoral canal Is the small medial compartment of the femoral sheath. 0.5 inch in length (just admits the tip of the little finger) Base: directed upwards, towards the abdominal cavity called the femoral ring The femoral ring is closed by a condensation of extraperitoneal tissue called femoral septum Apex: directed downwards, its closed by fusion of its wall The Femoral canal contains: 1-a plug of fat 2-a constant lymph node—the node of the femoral canal or Cloquet’s gland, and lymph vessels The canal has two functions: first, as a dead space for expansion of the distended femoral vein and, second, as a lymphatic pathway from the lower limb to the external iliac nodes The femoral ring is the base of the femoral canal. Part of the intestine can sometimes pass through the femoral ring into the femoral canal pushing the femoral septum before it and causing a femoral hernia Note: the femoral ring is wider in females because of their wider pelvis and therefore, femoral hernia is commoner in females than in males Inguinal ligament The boundaries of the femoral ring are: Pectineal ligament Anteriorly: Inguinal ligament Ilium Medially: Lacunar ligament (the sharp free edge that connects the inguinal ligament to the pectineal ligament) Laterally: Femoral vein Posteriorly: Pectineal ligament (the thickened periosteum along the pectineal line of the superior pubic ramus and continues medially with the lacunar ligament) Lacunar ligament Inguinal ligament Pectineal ligament Because of these anatomic structures, the neck of the sac is unable to expand. Ilium Once an abdominal viscus has passed through the neck into the body of the sac, it may be difficult to push it up and return it to the abdominal cavity (irreducible hernia). Furthermore, after the patient strains or coughs, a piece of bowel may be forced through the neck, and its blood vessels may be compressed by the femoral ring, seriously impairing its blood supply (strangulated hernia). Lacunar ligament A femoral hernia is a dangerous condition and should always be treated surgically Pectineal ligament Inguinal ligament Lacunar ligament A protrusion of abdominal parietal peritoneum down through the femoral canal to form hernial sac The neck of the hernial sac is located below and lateral to the pubic tubercle in femoral hernia While in the inguinal hernia The neck of the hernial sac is located above and medial to the pubic tubercle Inguinal canal Differential diagnosis of a femoral hernia Consider diseases that may involve other anatomic structures close to the inguinal ligament. Inguinal hernia: The swelling lies above and medial to the pubic tubercle. Superficial inguinal lymph nodes: Usually, more than one lymph node is enlarged. In patients with inflammation of the nodes (lymphadenitis), carefully examine the entire area of the body that drains its lymph into these nodes. Great saphenous vein: A localized dilatation of the terminal part of the great saphenous vein (saphenous varix) Psoas sheath: Tuberculous infection of a lumbar vertebra can result in the extravasation of pus down the psoas sheath into the thigh. Femoral artery: Aneurysm of the femoral artery Femoral triangle Surface anatomy Adductor canal (Subsartorial) or Hunter’s canal John Hunter described the exposure and ligation of the femoral artery in this canal for aneurysm of the popliteal artery; this method has the advantage that the artery at this site is healthy and will not tear when tied, as may happen if ligation is attempted immediately above the aneurysm Adductor (Subsartorial) Canal Is an intermuscular canal in the middle 1/3 of the medial side of the thigh beneath the sartorius It begins above at the apex of the femoral triangle It ends below at adductor hiatus (the opening in the adductor magnus). In cross section it is triangular (has 3 walls) 1-Anteromedial wall 2-Anterolateral wall 3-Posterior wall (floor) 2 1 3 4 The Anteriomedial wall is formed by: Sartorius and fascia The Anterolateral wall is formed by: Vastus medialis The posterior wall (floor) is formed by: Adductor longus and magnus Transverse section through the middle of the left thigh as seen from above The posterior wall is Adductor longus formed by: Adductor magnus Adductor longus and magnus The adductor canal contains 1- Femoral artery 2- Femoral vein 3- Saphenous nerve 4- Nerve of vastus medialis 5- Obturator nerve 6- Subsartorial plexus of nerves Subsartorial plexus of nerves: Located on the fascia under the sartorius and is formed by branches from 1- Medial cutaneous nerve of the thigh 2- Saphenous nerve 3- Obturator nerve The femoral artery 1-Enters the thigh from behind the inguinal ligament as a continuation of the external iliac artery. 2-Lies midway between the anterior superior iliac spine and the symphysis pubis Midinguinal point 3-Its upper half lies superficial in the femoral triangle while in the lower half it lies deep in the subsartorial (adductor) canal (what does this mean?) See next slides 4-Ends at adductor hiatus by entering the popliteal fossa as THE POPLITEAL ARTERY External iliac artery Inguinal ligament Femoral artery Saphenous nerve Adductor hiatus Popliteal artery In the upper part of its course, femoral artery lies in the femoral triangle (superficial) covered by skin and fascia 1-Exposed to injuries 2-Good approach for taking femoral pulse 3- Femoral Artery Catheterization Branches of the femoral artery THREE superficial branches TWO deep branches Superficial branches They supply cutaneous 1-Superficial circumflex iliac artery regions of the upper 2-Superficial epigastric artery thigh, lower abdomen, 3-Superficial external pudendal artery and perineum. Deep branches 1-Deep external pudendal artery 2-Profunda femoris artery Branches of the femoral artery in the adductor canal Descending genicular artery Superficial epigastric artery Superficial circumflex iliac artery Superficial external pudendal artery Pudendal “to be ashamed” in latin. Refers to the external genitalia Deep external pudendal artery The femoral vein lies medial to the artery in the upper part of the femoral triangle, then it lies posterior and finally lateral to the artery at the apex of the femoral triangle Saphenous Femoral artery nerve Saphenous nerve crosses femoral artery anteriorly Adductor hiatus Popliteal artery The profunda femoris artery (Deep artery of thigh) arises from the posterolateral side of the femoral artery about (4 cm) below the inguinal ligament it gives off A) Medial femoral circumflex artery B) Lateral femoral circumflex artery C) Perforating arteries External Common iliac artery iliac artery Internal iliac artery Obturator Artery Obturator Artery The obturator artery is a branch of the internal iliac artery It passes forward on the lateral wall of the pelvis and accompanies the obturator nerve It gives off muscular branches and an articular branch to the hip joint Femoral Vein Profunda Enters the thigh by passing through the femoris adductor hiatus as a continuation of the artery popliteal vein Great saphenous Ascends through the thigh, lying at first on vein the lateral side of the artery, then posterior to it, Femoral vein and finally on its medial side Leaves the thigh in the intermediate compartment of the femoral sheath and passes behind the inguinal ligament to become the external iliac vein. Tributaries The tributaries of the femoral vein are the great saphenous vein and veins that correspond to the branches of the femoral artery drain into the great saphenous vein 1- Superficial circumflex iliac vein 2- Superficial epigastric vein 3- Superficial external pudendal vein Superficial epigastric vein Superficial circumflex iliac vein Superficial external pudendal vein Great saphenous vein Femoral vein Test Your Knowledge 1-Mention Branches of Femoral artery……………………………………………… 2-Boundaries of adductor canal…………………………………………………… 3-Branches of femoral nerve ……………………………………………………… .