局解绪论和下肢ty.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,*,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,*,Regional Anatomy,给医学生,这是我的身体,是我曾在此世界存在的一个证明,我把它献给你们,作为对这个世界的最后馈赠,我曾经拥有生命、感受生活,用这些，曾经属于我的,老旧的,骨头、韧带、,肌肉和神经,我愿意,让我体内曾经旺盛的生命力再次闪耀,将知识和力量,传递给你们,让生命的奇迹,不断延续,解剖遗体捐赠者,向为医学事业和人类健康福祉无私奉献遗体的逝者表达我们崇高的敬意！,让我们静静地,领受他们的馈赠之心,绪 论,1,，什么是局部解剖学,?,2,，如何学习局部解剖学？,3,，如何进行解剖操作？,系统解剖学：,以人体的功能系统为基础。,局部解剖学：,以人体各个局部区域的结构及其位置关系为基础。关键词：,境界、层次、内容、毗邻、临床意义,1,，什么是局部解剖学,?,A,工具：,镊子（有、无齿各,1,把,）；血管钳（止血钳,2,把,）；,组织剪,1,把,；解剖刀（刀柄,2,把,，刀片,1,包）,B,方法：,1,，解剖前：预习，成竹在胸。,2,，解剖时：严格按照教师要求或课本操作程序进行操作，禁止随意,“,探索,”,和切割。觉知自己正在做什么。,3,，解剖后：复习回顾解剖内容，绘制简单的结构示意图。,3,，如何进行解剖操作,工具、方法和技术,C,技术：,1,，,翻皮,skinning,2,，,钝性分离,Blunt dissection,：用血管钳或组织剪，,插入然后打开,（,insert&spread),。,3,，,找到,并钝性分离重要结构后，,再去除,周围无关组织。,4,，深层结构（肌肉、血管或神经）可按需切断，但禁止切除。,5,，清理,clean,3,，如何进行解剖操作,Skinning,Blunt dissection,The essence of good dissection is to,display each structure fully,clearly,and cleanly.,完全、清晰、干净地显露每个结构,It is vital to the understanding of a region that,it should be reviewed as a whole when its dissection in completed.,每个区域解剖完成后，把其作为一个整体来回顾,J.C.B.Grant,Excerpt from the 5th edition of,Grants dissector,概述,前界：腹股沟；后界：髂嵴,与腹部、会阴和脊柱区交界,分部,1,、臀部,Hip,2,、股部,Thigh,3,、小腿,Leg,4,、足,Foot,Surface anatomy,腰丛和骶丛,Lumbar plexus&Sacral plexus,股动脉,Femoral artery,下肢血液供应,和神经支配来源,下肢前区的浅静脉和皮神经,Superficial vein and cutaneous nerve of the anterior lower limb,1,皮肤切口,Skin incisions:,D -F -E,（,or 2 cm inferior to),F-G,胫骨粗隆水平横切口,At the level of tibial tuberosity,内外踝水平横切口,Between medial malleolus and lateral malleolus,足趾根部横切口,At the webs of the toes(H to H),髋肌,Muscles of Hip,前群,1,，,髂腰肌,Iliopsoas,2,，,阔筋膜张肌,Tensor fascia lata,髂胫束,Iliotibial band,1,2,大隐静脉,Great Saphenous Vein,行程,:,起于足背内侧,经,内踝前方,沿小腿内侧上行,经膝关节后内侧,在股内侧前方上行,隐静脉裂孔,（,Saphenous hiatus,）,处穿筛筋膜,注入股静脉,隐静脉裂孔,是阔筋膜上一个自然形成的卵圆形开口。,五条主要属支,大隐静脉近侧端,腹壁浅静脉,Superficial epigastric v.,阴部外静脉,External pudendal v.,股内侧浅静脉,Superficial medial femoral v.,股外侧浅静脉,Superficial lateral femoral v.,旋髂浅静脉,Superficial iliac circumflex v.,股前部的,浅动脉,与同名浅静脉伴行,旋髂浅动脉、腹壁浅动脉、阴部外动脉,静脉瓣防止血液返流,静脉瓣,Venous Valves,下肢静脉曲张,Varicosity of the lower limb,瓣膜功能障碍导致静脉曲张,GSV(Great Saphenous Vein)graft,倒转移植静脉段,冠状动脉旁路移植术,腹股沟浅淋巴结,Superficial Inguinal Lymph Nodes,位于腹股沟韧带下方与大隐静脉近侧段周围，,T,形排列。分为上组淋巴结和下组淋巴结。,收纳：下肢大部分浅层结构、腹前壁下部、臀区、会阴和外生殖器的淋巴。,输出管：穿筛筋膜，主要注入腹股沟深淋巴结。,第一部分,股前、内侧区,Anterior&Medial Region of the Thigh,右大腿骨筋膜鞘,(,下面观,),Compartments of the right thigh from an inferior view,大腿肌,前群,Rectus,缝匠肌,Sartorius,股四头肌,Quadriceps femoris,股直肌,Rectus femoris,股中间肌,Vastus,intermedius,股外侧肌,Vastus,lateralis,股内侧肌,Vastus,medialis,1,耻骨肌,Pectineus,长收肌,Adductor longus,短收肌,Adductor brevis,大收肌,Adductor magnus,股薄肌,Gracilis,大腿肌,内侧群,收肌腱裂孔,Adductor hiatus,1,2,3,4,5,隐静脉裂孔,Saphenous opening,股三角,Femoral Triangle,境界,:,“SAIL”,外,缝匠肌,S,artorius,内,长收肌,A,dductor longus,上,腹股沟韧带,I,nguinal,L,ig.,位于股前上、内,1/3,的三角形区域。,底,髂腰肌、耻骨肌、长收肌,外侧,内侧,股动脉及其主要分支：股深动脉（旋股内侧动脉、旋股外侧动脉、穿动脉）,Branches of the femoral nerve,股神经,Femoral n.,隐神经,Saphenous,n.,股静脉,Femoral v.,股神经及其分支：隐神经是其最长分支,Femoral Triangle,临床意义：,1,，下肢压迫止血,Stop bleeding in the leg,2,，血管成形术和血管造影术入路,Surgical Approach for angioplasty and angiography,股三角,Femoral Triangle,收肌管是位于缝匠肌中,1/3,段深面的肌筋膜腔隙。,股动脉和股静脉自股三角尖端穿出后，穿经收肌管至大腿下部内侧，终于收肌腱裂孔。,收肌管,Adductor Canal(Canal of Hunter),境界,:,前界,:,缝匠肌和收肌腱板,Sartorius&adductor lamina,后界,：长收肌和大收肌,Adductor longus&magnus,外侧界,:,股内侧肌,Vastus medialis,收肌管,(Canal of Hunter),穿经结构,:,隐神经,Saphenous n.(anteriorly),股动脉,Femoral a.,股静脉,Femoral v.(posteriorly),V,A,N,腹股沟韧带,陷窝韧带,耻骨梳韧带,肌腔隙,Lacuna Musculorum,和,血管腔隙,Lacuna Vasorum,髂耻隆起,髂耻弓,腹股沟韧带和髋骨之间的间隙，腹部结构借此与股前区交通。,肌腔隙,Lacuna Musculorum,境界,:,前,腹股沟韧带,Inguinal Lig.,后外,髂骨,Ilium,内,髂耻弓,Iliopectineal arch,穿经结构,:,髂腰肌,Iliopsoas,股神经,Femoral N.,股外侧皮神经,Lat.Femoral Cutaneous N.,境界,:,前,腹股沟韧带,Inguinal lig.,后,耻骨梳韧带,Pectineal lig.,外,髂耻弓,Iliopectineal arch,内,陷窝韧带,Lacunar lig.,穿经结构,:,股血管,Femoral vessels,股管,Femoral canal,（含淋巴管和淋巴结）,血管腔隙,Lacuna Vasorum,股鞘,Femoral Sheath,腹横筋膜,和,髂腰筋膜,向下延伸包裹股血管上端形成的漏斗型的筋膜鞘。,其内被两个筋膜隔分隔成三个部分。外侧腔容纳：股动脉,Femoral A.,中间腔容纳：股静脉,Femoral V.,内侧腔，,即,股管,Femoral Canal,股环,Femoral Ring,股管的上口,.,境界,:,外,-,股静脉,Femoral V.,后,-,耻骨梳韧带,Pectineal Lig.,内,-,陷窝韧带,Lacunar Lig.,前,-,腹股沟韧带,Inguinal Lig.,股环,Femoral Ring,股环,股管的上口,.,境界,:,外,-,股静脉,Femoral V.,后,-,耻骨梳韧带,Pectineal Lig.,内,-,陷窝韧带,Lacunar Lig.,前,-,腹股沟韧带,Inguinal Lig.,股疝,Femoral Hernia,腹腔内容物通过,股环,突入到,股管,。,腰丛,Lumbar plexus,股外侧皮神经,Lateral femoral cutaneous n.,股神经,Femoral n.,闭孔神经,Obturator n.,生殖股神经,Genitofemoral n.,1,回顾阔筋膜,fascia lata,和隐静脉裂孔,saphenous opening,，,保留髂胫束,iliotibial band,。,2,显露和解剖股三角,femoral triangle,和收肌管,adductor canal,。,3,修洁此区肌肉、血管和神经。,解剖步骤：,髂胫束,A third year medical student on cardiology service receives a transfer patient from the ED.The 52-year-old woman is having chest pain and her cardiac enzymes and ECG suggest that she may have had a myocardial infarction.The attending cardiologist is about to perform a cardiac catheterization to insertion of the catheter into her femoral artery.The attending cardiologist asks the medical students,”what are the landmarks for finding the femoral artery just under the inguinal ligament and what is on each side of it if we miss?”which of the following is the best answer?,a.Halfway between the anterior superior iliac spine and the pubic tubercle,with the femoral nerve medial and the femoral vein lateral to the femoral artery,b.Halfway between the anterior superior iliac spine and the pubic tubercle,with the femoral nerve lateral and the femoral vein medial to the femoral artery,c.Two-thirds of the way between the anterior superior iliac spine and the pubic tubercle,with the femoral nerve lateral and the femoral vein medial to the femoral artery,d.Halfway between the anterior inferior iliac spine and the pubic tubercle,with the femoral nerve medial and the femoral vein lateral to the femoral artery,e.Halfway between the anterior inferior iliac spine and the pubic tubercle,with the femoral nerve lateral and the femoral vein medial to the femoral artery,下肢后区的浅静脉和皮神经,Superficial vein and cutaneous nerve of the posterior lower limb,1,皮肤切口,Skin incisions,:,臀区后正中切口,A midline incision,斜切口,J-K,纵切口,E-I,横切口：胫骨粗隆,tibial tuberosity,水平,横切口：,内、外踝,medial and lateral malleolus,水平,弧形切口：沿髂嵴,iliac crest,上方约一指,2,浅筋膜,：,腓肠神经,Sural nerve,股后皮神经,Posterior cutaneous nerve of the thigh,小隐静脉,Small saphenous vein,股后皮神经,(Deep to the deep fascia),下肢后区的浅静脉和皮神经,Superficial vein and cutaneous nerve of the posterior lower limb,第二部分,臀区、股后区和腘窝,Gluteal Region,Back of the Thigh&Popliteal Fossa,髋肌,Muscles of Hip,后群,臀大肌,Gluteus maximus,臀中肌,Gluteus medius,臀小肌,Gluteus minimus,Lateral view,梨状肌,Piriformis,上孖肌,Superior gemellus,闭孔内肌,Obturator internus,下孖肌,Inferior gemellus,股方肌,Quadratus femoris,臀大肌,臀中肌,臀小肌,梨状肌,外旋肌组,Lateral rotators,坐骨大孔,Greater Sciatic Foramen,&,坐骨小孔,Lesser Sciatic Foramen,梨状肌,Piriformis,梨状肌上孔,Suprapiriform foramen,梨状肌下孔,Infrapiriform foramen,股二头肌,Biceps femoris,半腱肌,Semitendinosu,s,半膜肌,Semimembranosus,大腿肌,后群,1,1,2,3,腘绳肌,Hamstrings,小腿三头肌,Triceps surae,腓肠肌,Gastrocnemius,&,比目鱼肌,Soleus,跟腱,(Achilles tendon),小腿肌,后群,腓肠肌,比目鱼肌,主要内容,臀区,Gluteal region,1.,坐骨大孔,Greater sciatic foramen,梨状肌上孔,Suprapiriform foramen,梨状肌下孔,Infrapiriform foramen,2.,坐骨小孔,Lesser sciatic foramen,坐骨神经,Sciatic nerve,腘窝,Popliteal fossa,臀区的血管和神经,穿经梨状肌下孔,(,由外向内，大致排列顺序,),坐骨神经,Sciatic n.,股后皮神经,Posterior femoral cutaneous n.,臀下神经、动脉和静脉,Inferior gluteal n.,a.&v.,阴部内静脉、动脉和阴部神经,Internal pudendal v.,a.&pudendal n.,1,2,3,坐骨神经与梨状肌位置关系的个体差异,Variations,臀区的血管和神经,由外向内大致排列顺序：经,梨状肌上孔,：,臀上神经、动脉和静脉,Superior gluteal n.,a.&v.,经,坐骨小孔：,阴部内静脉、动脉和阴部神经,Internal pudendal v.,a.&pudendal n.,臀部肌肉注射的安全区,：,臀区的上外,1/4,Superolateral quadrant of the gluteal region,坐骨神经,L4,L5,S1,S2,S3,S4,S5,Co,臀上神经,臀下神经,股后皮神经,阴部神经,坐骨神经,骶丛,两终支,:,胫神经,Tibial n.,腓总神经,Common peroneal n.,坐骨神经,坐骨神经在股部的体表投影：,自,坐骨结节与大转子之间的中点稍内侧,到,股骨内外侧髁之间中点,的连线的上,2/3,段。,坐骨神经痛,时，此投影线上出现压痛。,坐骨神经,胫神经,腓总神经,腓深神经,腓浅神经,腓总神经容易受损,腘窝,Popliteal Fossa,浅层结构：,小隐静脉和腘浅淋巴结，皮神经,深层结构：,腘筋膜,腘窝的境界和内容,腘窝是膝关节后方的菱形凹陷。,腘窝,Popliteal Fossa,境界,:,上外,股二头肌 上内,半腱肌、半膜肌 下外,腓肠肌外侧头 下内,腓肠肌内侧头,内容,:,胫神经、腓总神经,腘,静脉腘动脉腘深淋巴结,浅,深,臀区的解剖,臀大肌起点处切开臀大肌，并向外翻开。,找出,梨状肌,（此区的中心结构）。,仔细清理相关血管和神经。,注意：,1,，清除臀大肌表面的筋膜时，平行于臀大肌肌纤维方向。,2,，保护坐骨直肠窝。,3,，注意坐骨神经与梨状肌位置关系的个体差异。,How to cut and reflect the gluteal maximus muscle,解剖股后区和,腘窝,整理、修洁股后区的肌肉、血管和神经；,整理、修洁,腘窝及其内容。,The principal muscle groups of the thigh,iliopsoas,Gluteal maximus,A 40-year-old man presents to the emergency department barely able to walk.He finds it painful to sit down.He was waterskiing and was trying to learn to water ski backwards when his left ski,滑水橇,caught the water“wrong”and he fell.He has intense pain in the left gluteal region.Examining him in the prone position,a bulging of the left hamstring muscles is noted with significant pain upon palpation of the left ischial tuberosity.An avulsion,撕裂,of the hamstring muscles from their origin on the ischial tuberosity is suspected.Which three muscle origins most likely avulsed a piece of bone from the ischial tuberosity when his ski caught the water?,a.Adductor longus,adductor magnus,and biceps femoris,b.adductor longus,adductor magnus,and gracilis,c.semitendinosus,semimembranosus,and adductor magnus,d.semitendinosus,semimembranosus,and biceps femoris,e.semitendinosus,semimembranosus,and gracilis,第三部分,小腿后区,Posterior Region of the Leg,小腿三头肌,Triceps surae,腓肠肌,Gastrocnemius,&,比目鱼肌,Soleus,跟腱,(Achilles tendon),小腿肌,后群,腓肠肌,比目鱼肌,趾长屈肌,Flexor digitorum longus,胫骨后肌,Tibialis posterior,足母,长屈肌,Flexor hallucis longus,小腿肌,后群,2,3,4,小腿肌,后群,2,3,4,趾长屈肌,Flexor digitorum longus,胫骨后肌,Tibialis posterior,足母,长屈肌,Flexor hallucis longus,2,3,4,2,3,4,主要内容,深层结构,胫后血管和胫神经,Posterior Tibial Vessels&Tibial N.,腘动脉,Popliteal artery,胫后动脉,Posterior tibial artery,胫前动脉,Anterior tibial artery,腓动脉,Fibular artery,4,.,踝管,Malleolar Canal,小腿后区和足底间的肌腱、神经和血管通路，位于内踝后方，由屈肌支持带和跟骨围成。,穿经结构,(,由前向后,):,1,胫骨后肌腱,t,ibialis posterior,2,趾长屈肌腱,flexor,d,igitorum longus,3,胫后血管,和,胫神经,Posterior tibial,a,rtery,vein and tibial,n,.,4,足母,长屈肌腱,flexor,h,allucis longus,屈肌支持带,T,om,D,ick,AN,d,H,arry,静止动神马？,胫、,趾、动、神、,足母,解剖步骤：,观察屈肌支持带（深筋膜局部增厚形成）后切开。,修洁本区内的肌肉、血管和神经。,修洁踝管并辨认其主要内容。,小腿三头肌切断、下翻，显露深层结构,第四部分,小腿前、外侧区和足背,Anterior and Lateral Region of the Leg&Dorsum of the Foot,胫骨前肌,Tibialis anterior,趾长伸肌,Extensor digitorum longus,足母,长伸肌,Extensor hallucis longus,小腿肌,前群,1,2,3,腓骨长肌,Peroneus longus,腓骨短肌,Peroneus brevis,小腿肌,外侧群,1,2,主要内容,回顾浅层结构,1,，足背静脉弓,Dorsal Venous Arch,，,DVA,2,，大隐静脉和隐神经,GSV and saphenous n.,3,，腓浅神经,Superficial peroneal n.,SSV,DVA,主要内容,深层结构,1.,胫前血管、腓浅神经和腓深神经,Anterior tibial vessels,superficial peroneal n.&deep peroneal n.,2.,足背动脉,Dorsal Artery of the Foot,在,踝关节前方,行于,拇长伸肌腱和趾长伸肌腱之间,，位置表浅，体表易触诊其搏动。,清理主要的肌肉、血管、神经。,找到,足背动脉,。,解剖步骤：,A 12-year-old boy was riding his bicycle across an intersection when an elderly woman tried to pull out,驶出,into the busy street just as the boy was riding in front of her,hitting the boy.Fortunately the boy landed on the hood,发动机罩,of the car,but the bumper,保险杠,struck the boys legs just below the knees and created a very large cut.The boy presents to the ED bleeding and walking with a distinct left foot-drop.The boy has also lost most of his ability to dorsiflex his left ankle or evert,外翻,his left foot and he has lost sensation on the lateral side of his leg distal to the cut.Plain film shows that there are no broken bones and examination of the knee reveals that it is intact.A plastic surgeon is consulted to reanastomose which one of the following?,a.Sciatic nerve,b.tibial nerve,c.Common fibular nerve,d.deep fibular nerve,e.obturator nerve,As one grows older peripheral vascular disease may develop.Because it is a long distance from the heart the pulse of the dorsalis pedis artery is often evaluated.The pulse in the dorsalis pedis artery may be palpated in which one of the following locations in the foot?,a.Between the tendons of the extensor digitorum longus and fibularis(peroneus)tertius muscle,b.Between the tendons of extensor hallucis and extensor digitorum muscles,c.Between the tendons of the tibialis anterior and extensor hallucis longus muscles,d.Immediately anterior to the lateral malleolus,e.Immediately posterior to the medial malleolus,大隐静脉的行程及其五条主要属支,阔筋膜的概念,肌腔隙、血管腔隙、股鞘、股管和股环,股三角、收肌管,穿经梨状肌上孔、梨状肌下孔和坐骨小孔的血管和神经,坐骨神经的行程及其两大终支；坐骨神经的体表投影,腘窝、踝管,下肢的主要血管和神经,下肢重点内容,大隐静脉,小隐静脉,股动脉,腘,动脉,胫前动脉,胫后动脉,股神经,隐神经,坐骨神经,胫神经,腓总神经,腓浅神经,腓深神经,足背动脉,足背静脉弓,下肢的主要血管 和 神经,足底内、外侧动脉,足底内、外侧神经,