局解绪论和下肢

系统解剖学：以人体的功能系统为基础。,1，什么是局部解剖学?,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、排列关系、毗邻、临床意义,注意事项：1，尊重大体、珍惜机会。2，分工合作、知识共享。3，准确描述、留意变异。4，废弃分类、保持清洁。,2，如何学习局部解剖学？,中心环节：解剖观察和解剖操作解剖操作的目的：1，对原位、三维结构的视觉观察和触觉感受。2，学习、训练操作技术；培养良好的操作习惯。,A 工具包：镊子（2把，有齿、无齿各1）；血管钳（2把，弯、直各1）；组织剪（1把）；解剖刀（柄2把，刀片1包）,B 方法：1，操作前、后：预习和复习。2，操作进行时：按要求操作，勿随意“探索”。保持觉知。,3，如何进行解剖操作,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)。先分离、后切除。3，清理Clean。,Skinning,Blunt dissection,The essence of good dissection is to display each structure fully, clearly, and cleanly. 完全、清晰地显露重要结构。,It is vital to the understanding of a region that it should be reviewed as a whole when its dissection in completed. 及时回顾、复习解剖完成的每个局部区域。,J.C.B. Grant Excerpt from the 5th edition of Grants dissector, 1959,下 肢LOWER LIMB,解剖学姿势Anatomical position,仰卧位Supine position,概述,与腹部、会阴和脊柱区交界前界：腹股沟；后界：髂嵴分部 1、臀部 Hip 2、股部 Thigh 3、小腿 Leg 4、足 Foot,Surface anatomy,股动脉Femoral artery,下肢的神经支配和血液供应, 腰丛和骶丛Lumbar plexus & Sacral plexus,解剖分区,股前内侧区Anterior & medial region of the thigh,臀区、股后区和腘窝Gluteal region, back of the thigh & popliteal fossa,小腿后区Posterior region of the leg,小腿前、外侧区和足背Anterior and lateral region of the leg & the dorsum of the foot,下肢前区 the anterior lower limb,1, 皮肤切口Skin incisions:, D - F - E （腹股沟韧带下方1横指，经股内侧转至股后区), F - G （纵切口）, 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),2, 浅筋膜内的浅静脉、浅淋巴结和皮神经,下肢前区 the anterior lower limb,下肢的深筋膜,大腿：阔筋膜 Fascia lata; （外侧部纵行增厚形成髂胫束 iliotibial tract)小腿：小腿筋膜 Crural fascia足：足筋膜 Pedal fascia,iliotibial tract,髂胫束,大隐静脉Great Saphenous Vein,起、止与行程:起于足背静脉弓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,大隐静脉,近侧段五条主要属支：,大隐静脉,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Venous valves的功能：防止血液逆流,瓣膜功能障碍，血液逆流，导致静脉曲张,GSV (Great Saphenous Vein) graft,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。分为上组和下组。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：注入髂外淋巴结。,股前、内侧区皮神经,股外侧皮神经：Lateral femoral cutaneous n.(发自腰丛)股中间皮神经、股内侧皮神经：Intermediate & medial femoral cutaneous n.(发自股神经)闭孔神经皮支：Cutaneous branch of obturator n.生殖股神经的股支Femoral branch of Genitofemoral n.,股前内侧区Anterior & Medial Region of the Thigh,右侧股部骨筋膜鞘(下面观)Compartments of the right thigh from an inferior view,髋肌 Muscles of Hip,前群,1，髂腰肌Iliopsoas,1,2,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,前,后,主要内容,1. 肌腔隙和血管腔隙 Lacuna musculorum & lacuna vasorum 2. 股鞘、股管和股环 Femoral sheath, femoral canal & femoral ring3. 股三角 Femoral triangle4. 收肌管 Adductor canal,隐静脉裂孔边缘,股三角 Femoral Triangle,境界:“SAIL”外 缝匠肌内侧缘 Sartorius内 长收肌内侧缘 Adductor longus 上 腹股沟韧带 Inguinal Lig.,位于股前区上1/3的三角形筋膜下区域。,底 髂腰肌、耻骨肌、长收肌,顶阔筋膜,股三角 Femoral Triangle,尖与收肌管相交通,内容（由外向内）： 股神经、股动脉、股静脉、股管 “NAVy” for Nerve, Artery, Vein,股动脉及其分支股深动脉,（股深动脉的分支有：旋股内侧动脉、旋股外侧动脉、穿动脉）,股动脉,股深动脉,股神经及其分支隐神经,股神经,隐神经,临床意义：下肢压迫止血Stop bleeding in the leg血管成形术和血管造影术入路Surgical Approach for angioplasty and angiography,股三角 Femoral Triangle,angioplasty,股动脉的体表投影,股动脉和股静脉自股三角尖端穿出后，经收肌管至股下部内侧，穿收肌腱裂孔至腘窝，更名为腘动脉和腘静脉。,收肌管Adductor Canal ( Canal of Hunter ),管内穿经结构: 股静脉Femoral V. 股动脉Femoral A. 隐神经Saphenous N.,后,前,境界:前壁: 缝匠肌和收肌腱板 Sartorius & adductor lamina后壁：长收肌和大收肌 Adductor longus & magnus外侧壁: 股内侧肌 Vastus medialis,收肌管,位于缝匠肌中1/3段深面。,肌腔隙 Lacuna Musculorum 血管腔隙 Lacuna Vasorum,腹股沟韧带和髋骨之间的间隙，腹部结构经此与股前区交通。,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,位于股三角内，包裹股血管上端和淋巴管的漏斗型的筋膜鞘。上方与腹横筋膜和髂腰筋膜延续，下方与股血管外膜融合。其内被两个筋膜隔分隔成三部： 外侧腔容纳：股动脉中间腔容纳：股静脉内侧腔（即股管 ）容纳：淋巴管,股鞘,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,股环 Femoral Ring,The femoral ring is potentially a weak point in the lower abdomen and is the site for femoral hernias.,股疝 Femoral Hernia,腹腔内容物通过股环突入到股管，在大腿根部前内侧可见或可触及。,1, 观察阔筋膜和隐静脉裂孔后 ，除去阔筋膜，保留髂胫束。2, 显露股三角和收肌管，修洁相关肌肉、血管和神经。,解剖步骤,髂胫束,闭孔动脉 Obturator artery,闭孔神经来自腰丛Obturator nerve, a branch from lumbar plexus,Branches of the obturator nerve,闭孔神经的分支,腰丛Lumbar plexus,Question 1:In a presurgical patient, the great saphenous vein is cannulated in the vicinity of the ankle. During the procedure, the patient experiences severe pain that radiates along the medial border of the foot. Which one of the following nerves was accidentally included in a ligature during this procedure?a. Medial femoral cutaneous nerveb. Saphenous nervec. Superficial fibular nerved. Sural cutaneous nervee. Tibial nerve,Question 2: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 arteryb. Halfway between the anterior superior iliac spine and the pubic tubercle, with the femoral n. lateral and the femoral v. medial to the femoral a.c. Two-thirds of the way between the anterior superior iliac spine and the pubic tubercle, with the femoral n. lateral and the femoral v. medial to the femoral a.d. Halfway between the anterior inferior iliac spine and the pubic tubercle, with the femoral n. medial and the femoral v. lateral to the femoral a.e. Halfway between the anterior inferior iliac spine and the pubic tubercle, with the femoral n. lateral and the femoral v. medial to the femoral a.,下肢后区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连线，接近足底, 弧形切口：沿髂嵴iliac crest上方约一指,2, 浅筋膜内的浅静脉和皮神经：, 腓肠神经Sural nerve, 股后皮神经Posterior cutaneous nerve of the thigh, 小隐静脉Small saphenous vein,下肢后区the posterior lower limb,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,maximus,medius,minimus,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,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 Semitendinosus,半膜肌 Semimembranosus,大腿肌后群,腘绳肌Hamstrings,浅层：小腿三头肌 Triceps surae （腓肠肌 Gastrocnemius & 比目鱼肌 Soleus）,小腿肌后群,跟腱 calcaneus tendon (Achilles tendon),主要内容,臀区 Gluteal region1.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股后区：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) 坐骨神经和股后皮神经 Sciatic n. & 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.,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injection的安全区： 臀区的上外1/4 Superolateral quadrant of the gluteal region,坐骨神经,两终支:胫神经 Tibial n. 腓总神经 Common peroneal n.,坐骨神经与梨状肌位置关系的变异 Variations,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。,腓总神经最易受损,腘窝 Popliteal Fossa,膝关节后方深筋膜深部菱形的凹陷是沟通大腿和小腿（后区）的血管和神经通道。,SSV,腘窝 Popliteal Fossa,内容: 腓总神经胫神经腘静脉腘动脉腘深淋巴结,境界:上外 股二头肌(长头、短头） 上内 半腱肌、半膜肌 下外 腓肠肌外侧头 下内 腓肠肌内侧头,膝关节动脉网的组成,腘动脉的关节支：膝上内侧动脉膝上外侧动脉膝下内侧动脉膝下外侧动脉膝中动脉,膝降动脉（自股动脉）旋股外侧动脉（自股深动脉）的降支,胫前返动脉,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（此区的关键结构）。 清理此区的血管和神经（切开臀中肌，显露臀小肌）。注意：1，保留坐骨直肠窝。2，平行于臀大肌的肌纤维方向，清理、去除臀大肌表面的筋膜。3，注意观察坐骨神经的变异。,How to cut and reflect the gluteal maximus muscle?,解剖股后区和腘窝,整理、修洁股后区的肌肉和坐骨神经；整理、修洁腘窝边界及其内容。,试辨认股部横断面上各结构,Question 3:A 40-year-old man presents to the ED 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 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 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 femorisb. Adductor longus, adductor magnus, and gracilisc. Semitendinosus, semimembranosus, and adductor magnusd. Semitendinosus, semimembranosus, and biceps femorise. Semitendinosus, semimembranosus, and gracilis,小腿后区Posterior Region of the Leg,浅层：小腿三头肌 Triceps surae （腓肠肌 Gastrocnemius & 比目鱼肌 Soleus）,小腿肌后群,跟腱 calcaneus tendon (Achilles tendon),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,深层,小腿肌后群,趾长屈肌 Flexor digitorum longus 胫骨后肌 Tibialis posterior足母长屈肌 Flexor hallucis longus,深层,主要内容,深层结构胫后血管和胫神经 Posterior Tibial Vessels & Tibial N.,踝管 Malleolar Canal,位于内踝后方，由屈肌支持带和跟骨围成沟通小腿后区和足底，穿行有肌腱、血管和神经穿经结构 (由前向后): 1, 胫骨后肌腱 tibialis posterior 2, 趾长屈肌腱 flexor digitorum longus 3, 胫后血管和胫神经 Posterior tibial artery, vein and tibial n. 4, 足母长屈肌腱 flexor hallucis longus,静止动神马？胫、趾、动、神、足母,屈肌支持带Flexor Retinaculum,Tom, Dick ANd Harry,解剖步骤：,小腿三头肌切断、翻开，显露深层结构。找到并追踪胫后血管和胫神经至踝管，并辨认胫后动脉的分支腓动脉。观察屈肌支持带（深筋膜局部增厚）后切开，修洁踝管并辨认其主要内容。,小腿三头肌上端切断、下翻，显露深层结构,切断前，注意钝性分离肌与深层结构,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,腓骨长肌 Peroneus longus腓骨短肌 Peroneus brevis,小腿肌外侧群,主要内容,回顾浅层结构1，足背静脉弓 Dorsal Venous Arch，DVA2，大隐静脉和隐神经GSV and saphenous n. 3，腓浅神经Superficial peroneal n.,主要内容,深层结构：1. 胫前血管和腓深神经Anterior tibial vessels & Deep peroneal n. 2. 腓浅神经Superficial peroneal n.,胫前动脉移行为足背动脉（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，可触及其搏动。,清理小腿前群肌和外侧群肌。前骨筋膜鞘内，找到胫前动脉与伴行的腓深神经；并追踪胫前动脉至其移行为足背动脉处，确认踝关节前方足背动脉所在部位。外侧骨筋膜鞘内，找到腓浅神经。,解剖步骤,试辨认小腿横断面上各结构,the principal muscle groups of the leg,Question 4:A 12-year-old boy was riding his bicycle across an intersection when an elderly woman tried to pull out into the busy street just as the boy was riding in front of her, hitting the boy. Fortunately the boy landed on the hood of the car, but the bumper 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 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 broke