下肢的前面解剖.ppt

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,概述,下肢前面可分为四个区域：,股前区、,膝前区、,小腿前区、,足背。,本次课主要操作股前区和小腿前区。,股前区与腹、盆腔之间有许多结构是相互延续的。,这些结构往往通过二个重要的通道：肌腔隙与血管腔隙。,小腿前外侧区深筋膜较致密。,在胫侧，与胫骨体内侧面的骨膜紧密融合；,在腓侧，发出前、后肌间隔止于腓骨骨膜。,这样，前、后肌间隔，胫、腓骨骨膜与骨间膜共同围成,前、外侧骨筋膜鞘，容纳相应肌群及血管、神经。,CLINICAL ANATOMY OF FEMORAL HEAD AND NECK,股前内侧区,（一）浅层结构,1、皮肤薄厚不均，内侧较薄而柔软，外侧较厚。,2、浅筋膜浅筋膜近腹股沟处分为两层，,浅层为脂肪层，与腹前下壁的脂肪层,（,Camper,筋膜）相续；,深层为膜性层，与腹前下壁的膜性层,（,Scarpa,筋膜）相续。,膜性层在腹股沟韧带下方约,1cm,处于股部深筋膜,（阔筋膜）相融合。,（1）浅动脉：,旋髂浅动脉、腹壁浅动脉、,阴部外动脉,（2）浅静脉：大隐静脉及其5条属支,旋髂浅静脉、腹壁浅静脉、阴部外静脉、,股外侧浅静脉、股内侧浅静脉,（3）浅皮神经：,股外侧皮神经 来自腰丛,股神经前皮支 来自股神经,股神经内侧皮支 来自股神经,The course of great saphenous vein,The great saphenous vein,the longest vein in the body,is located in the,superficial fascia,it,begins at the medial end of the dorsal venous arch of the foot and ends in the femoral vein about 3 cm below the inguinal ligament.,The course of,great saphenous vein,It ascends in front of the,medial malleolus,and along the medial side of the leg in relation with the,saphenous nerve,.It runs upward behind the,medial condyles,of the tibia and femur and along the medial side of the thigh and,passing through the,fossa ovalis,ends in the,femoral vein,.,Clinical note:,First,in emergency,great saphenous vein may be opened surgically for intravenous drip for the patients suffering from insufficiency of body fluid.,Clinical note:,S Second,it provides anatomical basis for high ligature of great saphenous vein for patient with varicose vein.,Clinical note:,Third,great saphenous vein as venous graft can be used in the coronary bypass surgery for coronary heart disease.,Surface projection of,great saphenous vein,Surface view of,great saphenous vein,Tributaries:,At the ankle it receives branches from the sole of the foot through the medial marginal vein;,in the leg it anastomoses freely with the small saphenous vein,communicates with the anterior and posterior tibial veins and receives many cutaneous veins;,in the thigh it communicates with the femoral vein and receives numerous tributaries;,near the fossa ovalis it is joined by the Superficial circumflex iliac vein,Superficial epigastric vein,Superficial lateral thigh vein,Superficial medial thigh vein,External pudendal vein,Tributaries near,the end of great,saphenous vein,Superficial circumflex iliac vein,Superficial epigastric vein,Superficial lateral thigh vein,Superficial medial thigh vein,External pudendal vein,Variations of tributaries of great saphenous vein,Saphenous opening,Saphenous opening,（4）浅淋巴结：,上群（近侧群、斜群）26个淋巴结，,位于腹股沟韧带的下方，又可分为,内、外侧两组,下群（远侧群、纵群）27 个淋巴结，,沿大隐静脉末段纵行排列又可分为,内、外侧两组,腹股沟浅淋巴结,输出管注入腹股沟深淋巴结或髂外淋巴结。,（二）深层结构,1、深筋膜大腿的深筋膜称阔筋膜或大腿固有,筋膜，上方附于腹股沟韧带及髂嵴，与臀筋膜和,会阴筋膜相续，下方与小腿筋膜、腘筋膜相续。,阔筋膜坚韧致密，在大腿外侧份增厚，形成髂胫束。,（1）髂胫束：后缘与臀大肌肌间相续；下端附与胫,骨外侧髁、腓骨头和膝关节囊下部。上份分为两层，,包裹阔筋膜张肌。临床上常用髂胫束作为体壁缺损、,薄弱部位和膝关节交叉韧带修补重建的材料。,（2）隐静脉裂孔：为腹股沟韧带中、内1/3交点下方约,1横指处阔筋膜的卵圆形薄弱区。表面覆盖一层疏松结,缔组织称筛筋膜（外筛板），有大隐静脉及其属支进入。,2、前、内侧骨筋膜鞘,阔筋膜向大腿深部发出股内侧、股外侧和股后3个肌间隔，,附着于股骨粗线，,与骨膜及阔筋膜共同,形成3个股筋膜鞘。,分别容纳相应的,肌肉、血管、神经。,3.肌腔隙和血管腔隙：,腹股沟韧带与髋骨间被髂耻弓分隔为,内侧部的血管腔隙和外侧部的肌腔隙。,（1）肌腔隙：,前界：腹股沟韧带外侧部；,后外界：髂骨；,内侧界：髂耻弓。,内容：髂腰肌、股神经和,股外侧皮神经。,FEMORAL SHEATH,（2）血管腔隙：,前界：腹股沟韧带内侧部；,后内界：耻骨肌筋膜及耻骨梳韧带；,内侧界：腔隙韧带；,后外界：髂耻弓。,内容：,股鞘、股、动静脉，,生殖股神经和淋巴管,4、股三角,（1）境界:,上 界:腹股沟韧带,外侧界:缝匠肌内测缘,内侧界:长收肌外侧缘,前壁:阔筋膜,后壁凹陷,髂腰肌、耻骨肌及其筋膜,（或长收肌及其筋膜）,（2）内容,有股鞘、股管、股动脉、股静脉、,股神经、腹股沟深淋巴结、淋巴管,及脂肪组织。,股鞘：为腹横筋膜和髂筋膜向下延续包绕股动、静脉,上部形成的筋膜鞘。,股鞘内有两条纵行的纤维隔，将股鞘腔分为三部分：,外侧部容纳股动脉、中间部容纳股静脉、内侧部为股管。,股管：位于股鞘的内侧份，长约11cm。,前 界：腹股沟韧带及镰缘上角和筛筋膜,后 界：耻骨梳韧带、耻骨肌及其筋膜,内侧界：腔隙韧带及股鞘内侧壁,外侧界：股静脉内侧的纤维隔,股管的上口为股环由腹股沟韧带、腔隙韧带、耻骨梳韧带、,股静脉内侧的纤维隔围成。,股环上面覆盖一薄层疏松的结缔组织为股环隔或内筛板。股环隔上面衬有腹膜，成一小凹为股凹。,股动脉：经股鞘进入股三角，穿收肌腱裂孔移行为腘动脉。,发出：腹壁下动脉、,旋髂浅动脉、,阴部外动脉及,股深动脉,股静脉：与股动脉伴行。,腹股沟深淋巴结：位于股静脉上部及,股管附近，有34个，收纳下肢的神淋巴、,会阴的淋巴以及腹股沟浅淋巴结下群的输出管；,其输出管注入髂外淋巴结。,股神经：起于腰丛，经肌腔隙进入股三角。,其末支为隐神经，在股动脉前面进入收肌管。,5、收肌管（Hunter管）:,前壁：大收肌腱板,外侧壁：股内侧肌,后壁：长收肌、大收肌。,收肌管的上口接股三角，下口为收肌腱裂孔。,管内由前向后通过：,隐神经、股动脉、股静以及周围淋巴管。,在下段，由股动脉发出膝降动脉（膝最上动脉），,再分为关节支和隐支，隐支与隐神经伴行。,6、闭孔血管神经束,闭孔动脉沿盆侧壁与同名静脉和神经伴行。,膝前区：,（一）浅层结构,皮肤薄松弛，皮下脂肪少，易移动。,皮肤与髌韧带之间有髌前皮下囊。,浅筋膜内：,有股外侧皮神经、股中间皮神经、,股内侧皮神经、隐神经的髌下支、,腓肠外侧皮神经末梢分布。,大隐静脉的属支及与小隐静脉的交通支。,（二）深层结构：,深筋膜与深面的肌腱相融合。,股四头肌腱附着于髌骨底及两侧，,继而向下延伸为髌韧带附着于胫骨粗隆。,在髌骨两侧，股四头肌腱与阔筋膜一起形成髌支持带。,股四头肌腱与股骨之间，有髌上囊。,小腿前区,（一）浅层结构,1.皮肤：移动性小，血液供应差。,2.浅筋膜：疏松含少量脂肪，弹性差。,内有浅的血管和神经。,大隐静脉的属支；,隐神经及腓浅神经分布。,（二）深层结构,深筋膜致密，与小腿前、后肌间隔、骨间膜及胫骨、,腓骨共同构成小腿外侧骨筋膜鞘和小腿前骨筋膜鞘。,1、肌肉：,前群,（1）,胫骨前肌,（2）指长伸肌,（3）拇长伸肌,外侧群（1）腓骨长肌,（2）腓骨短肌,2、小腿外侧骨筋膜鞘：,有腓骨长肌、腓骨短肌和腓浅神经。,腓浅神经，下行于腓骨长、短肌之间在小腿中、,下1/3交界处，经腓骨长肌前缘穿深筋膜浅出，,分布于小腿外侧及足背的皮肤,。,3、小腿前骨筋膜鞘：,包括小腿前群肌、胫前动、静脉及腓深神经。,（1）,胫前动脉：,起于腘动脉，经胫骨后及及骨间膜的上缘,进入小腿前区，至伸肌支持带下缘延续为,足背动脉。,（2）胫前静脉：有两支，与同名动脉伴行。,（3）,腓深,神经：穿腓骨长肌起始部及前肌间隔,进入,小腿前骨筋膜鞘，与胫前血管伴行。,