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6. Upper and Lower Extremity Procedures

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6. Upper and Lower Extremity Procedures BWH 2015 GENERAL SURGERY RESIDENCY PROCEDURAL ANATOMY COURSE 6. UPPER AND LOWER EXTREMITY PROCEDURES Contents LAB OBJECTIVES ........................................................................................................................................................... 2 Knowledge objectives. ............................................................................................................................................. 2 Preparation for lab ................................................................................................................................................... 2 6.1 ORGANIZATION OF THE LIMBS .............................................................................................................................. 3 Upper limb superficial layers ................................................................................................................................... 3 Upper limb investing deep fascia and muscle compartments ................................................................................ 3 Lower limb superficial layers ................................................................................................................................... 5 Lower limb investing deep fascia and muscle compartments ................................................................................ 5 6.2 ORGANIZATION OF MAJOR ARTERIES AND VENAE COMITANTES ........................................................................ 7 Upper limb arteries and venae comitantes ................................................................................................................. 7 Lower limb arteries and venae comitantes ............................................................................................................. 9 LOWER EXTREMITY PROCEDURES ............................................................................................................................. 11 1 Lower extremity fasciotomy: Double‐incision technique .................................................................................. 11 2 Thigh fasciotomy ................................................................................................................................................. 13 3 Foot fasciotomy: 5 compartments – medial, lateral, superficial, calcaneal, and interosseus ......................... 13 4 Forearm fasciotomy: Volar, lateral and extensor compartments‐ ................................................................... 14 5a Popliteal artery exposure: Posterior approach ................................................................................................ 15 5b Popliteal artery exposure: Medial approach for proximal popliteal artery: .................................................... 15 6 Open femoral artery access ................................................................................................................................ 16 6a Femoral endarterectomy/patch angioplasty ................................................................................................... 17 7 Great saphenous vein harvest ............................................................................................................................ 20 Adapted from Clinical Anatomy: The Logical Approach. © T. Van Houten, 1997. All rights reserved. BWH 2015 GENERAL SURGERY RESIDENCY PROCEDURAL ANATOMY COURSE 6. UPPER AND LOWER EXTREMITY PROCEDURES LAB OBJECTIVES Skills objectives 1. Lower extremity fasciotomy: Double‐incision technique 2. Thigh fasciotomy 3. Foot fasciotomy: 5 compartments – medial, lateral, superficial, calcaneal, and interosseus 4. Forearm fasciotomy: Volar, lateral and extensor compartments 5. Popliteal artery exposure: Posterior approach 6. Popliteal artery exposure: Medial approach for proximal popliteal artery: 7. Open femoral artery access 8. Femoral endarterectomy/patch angioplasty 9. Great saphenous vein harvest Knowledge objectives. 1. Describe the fascial compartments and septa of the arm. Of the forearm. List four major neurovascular structures vulnerable at the wrist during a volar forearm compartment release or carpal tunnel release. 2. Describe the fascial compartments and septa of the thigh. Of the crus. Explain the position of the fibular (peroneal) nerve over the proximal fibula. 3. In the adult upper limb, the flexor surfaces of all upper limb joints face anteriorly. In the adult lower limb, the flexor surface of the hip and the dorsiflexor surface of the ankle joint face anteriorly whereas the flexor surfaces of the knee and digits face posteriorly. In general, blood vessels tend to run on the flexor surfaces of joints and to avoid the extensor surfaces. Applying this basic principle, a. Describe the pathways of the cephalic vein and basilic vein in the upper limb from the dorsal venous arch of the hand to their entries into deeper veins proximal to the shoulder joint and elbow joint respectively. b. Describe the pathways of the great saphenous vein and small saphenous vein in the lower limb from the dorsal venous arch of the foot to their entries into deeper veins proximal to the hip joint and knee joint respectively. c. Explain how the (superficial) femoral artery travels from the anterior compartment of the thigh to the posterior surface of the knee joint. Explain how the anterior tibial artery travels from the posterior surface of the knee joint to the anterior compartment of the crus. Preparation for lab Read this guide. Watch videos Adapted from Clinical Anatomy: The Logical Approach. © T. Van Houten, 1997. All rights reserved. BWH 2015 GENERAL SURGERY RESIDENCY PROCEDURAL ANATOMY COURSE 6. UPPER AND LOWER EXTREMITY PROCEDURES 6.1 ORGANIZATION OF THE LIMBS Very generally, the organization of the limbs consists of a superficial layer (skin and subcutaneous fat) and musculoskeletal compartments (bones, joints, and muscles surrounded by investing deep fascia and separated into functional compartments by fascial septa (Figures 6‐1 and 6‐2). The subcutaneous fat (superficial fascia) of the limbs consists of fatty loose connective tissue deep to, and functionally supporting, the skin. The subcutaneous fat of the limbs often contains a distinct membranous layer similar to the Scarpa fascia over the inferior abdomen. Structures found within the subcutaneous fat of the limbs include superficial veins, lymphatic vessels and nodes accompanying superficial veins, and cutaneous nerves and vessels supplying the skin but arising from structures within the deep fascial compartments. The thick investing deep fascia of the limbs is a continuous layer surrounding the muscles, bones, and joints and muscles of the limbs. The deep fascia of the limbs forms distinct fascial compartments by sending fascial septa inward to fuse with the periosteum of the underlying bones and with the fibrous capsules of the joints. Structures within each deep fascial compartment include muscles sharing common functions and the major blood supply and motor innervation of those muscles. Cutaneous nerves and perforating blood vessels supplying the overlying skin leave the deeper neurovascular structures within the fascial compartments and pierce the deep investing fascia surrounding the compartments to enter the subcutaneous fat. Upper limb superficial layers The superficial veins of the upper limb begin at the dorsal venous arch of the hand. The cephalic vein leaves the radial side of the dorsal arch, crosses to the anterior side of the forearm, contributes to the medial cubital vein, and enters the axillary vein proximal to the shoulder joint (Figure 6‐1). The basilic vein leaves the ulnar side of the dorsal venous arch, contributes to the medial cubital vein, and enters the brachial vein proximal to the elbow joint. Upper limb investing deep fascia and muscle compartments The brachial fascia is the deep investing fascia of the arm (brachium). The antebrachial fascia is the deep investing fascia of the forearm (antebrachium). The brachial and antebrachial fascia are continuous at the elbow joint where they fuse with the fibrous joint capsule. At the wrist, the antebrachial fascia thickens to form the extensor and flexor retinacula. Brachial compartments. Lateral and medial intermuscular fascial septa divide the arm muscles into anterior and posterior compartments (Figure 6‐1). Muscles in the anterior brachial compartment flex the shoulder and/or elbow joint and receive their neurovascular supply from the brachial artery and musculocutaneous nerve. The triceps muscle in the posterior brachial compartment extends the elbow joint and receives its neurovascular supply from the radial nerve and deep brachial artery. Antebrachial compartments. The interosseous membrane and the lateral and medial intermuscular fascial septa divide the forearm muscles into anterior and posterior compartments (Figure 6‐1). Thinner transverse fascial septa divide the anterior and posterior compartment muscles into superficial and deep groups. Muscles in the anterior antebrachial compartment flex the wrist and digits and receive their neurovascular supply from the median and ulnar nerves and the radial and ulnar arteries. Muscles in the posterior antebrachial compartment extend the wrist and digits and receive their neurovascular supply from the radial nerve and posterior interosseous branch of the ulnar artery. The mobile wad (of Henry) is a subdivision of the posterior compartment consisting of the brachioradialis, extensor carpi radialis longus, and extensor
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