局解绪论和下肢-ty-20111103

局部解剖学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。境界、层次、内容、毗邻、临床意义,1，什么是局部解剖学?,甲状腺,需要注意的事项：1，尊重和爱惜尸体标本。2，小组成员间分工合作，全班同学间成果共享。3，准确描述解剖结构，注意变异。4，分类收纳废弃物，保持清洁。,中心环节：解剖观察和解剖操作解剖操作的目的：1，建立对人体结构及其位置关系的三维立体理解和实际感受。2，学习解剖操作技术，培养良好的操作习惯。,2，如何学习局部解剖学？,A 工具：镊子（有、无齿各1）；血管钳（止血钳2）；组织剪1；解剖刀（刀柄2，刀片1包）,B 方法：1，课前预习，成竹在胸。2，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。保持清醒，知道自己在干什么。3，解剖完成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skinning2，钝性分离Blunt dissection ：用血管钳或组织剪插入然后打开。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、干净地显露每一个结构,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, 1959,下 肢LOWER LIMB,Anatomical position,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,Lumbar plexus & Sacral plexus腰丛和骶丛,Femoral artery股动脉,下肢血液供应和神经支配来源,分区解剖：,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（和足底）Posterior region of the leg (& the sole of the foot),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),下肢前区的浅静脉和皮神经,2, 浅筋膜, 大隐静脉 Great saphenous vein,隐神经 Saphenous nerve,腓浅神经 Superficial fibular nerve,腹股沟浅淋巴结 Superficial inguinal lymph nodes,3, 深筋膜,阔筋膜 Fascia lata (髂胫束 iliotibial tract) ; 小腿筋膜 Crural fascia;足筋膜 Pedal fascia,髋肌 Muscles of Hip,前群,1，髂腰肌Iliopsoas,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。,大隐静脉,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,Venous Valves,瓣膜功能障碍导致静脉曲张,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。,股前部皮神经,股外侧皮神经：发自腰丛lateral femoral cutaneous nerve股中间皮神经、股内侧皮神经：发自股神经intermediate & medial femoral cutaneous nerve闭孔神经皮支：发自闭孔神经cutaneous branch of obturator nerve生殖股神经的股支:发自腰丛,In a presurgical patient, the great saphenous vein is cannulated 插管 in the vicinity of 在附近 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 结扎 during this procedure?a. Medial femoral cutaneous nerveb. Saphenous nervec. Superficial fibular nerved. Sural cutaneous nervee. Tibial nerve,第一部分股前、内侧区Anterior & Medial Region of the Thigh,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,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 Saphenous opening,股三角 Femoral Triangle,境界:“SAIL”外 缝匠肌 Sartorius内 长收肌 Adductor longus 上 腹股沟韧带 Inguinal Lig.,位于股前上、内1/3的三角形区域。,底 髂腰肌、耻骨肌、长收肌,股三角 Femoral Triangle,顶- 阔筋膜尖- 与收肌管相交通,内容: 股血管和股神经由外向内股神经、股动脉、股静脉、股管 “NAVY” for Nerve, Artery, Vein &YES!,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，血管成形术入路Surgical Approach for angioplasty,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,Adductor Canal ( Canal of Hunter ),穿经结构: 隐神经Saphenous n. (anteriorly)股动脉Femoral a. 股静脉Femoral v. (posteriorly),肌腔隙 Lacuna Musculorum 和 血管腔隙 Lacuna Vasorum,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。,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,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 arteryb. Halfway between the anterior superior iliac spine and the pubic tubercle, with the femoral nerve lateral and the femoral vein medial to the femoral arteryc. 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 arteryd. Halfway between the anterior inferior iliac spine and the pubic tubercle, with the femoral nerve medial and the femoral vein lateral to the femoral arterye. 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,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,(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,Piriformis梨状肌Superior gemellusObturator internus闭孔内肌Inferior gemellusQuadratus femoris股方肌,Lateral rotators,坐骨大孔 Greater Sciatic Foramen & 坐骨小孔 Lesser Sciatic Foramen,Piriformis 梨状肌,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,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,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.,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,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。,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,了解：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,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 femorisb. adductor longus, adductor magnus, and gracilisc. semitendinosus, semimembranosus, and adductor magnusd. semitendinosus, semimembranosus, and biceps femorise. 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,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,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,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 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,Tom, Dick ANd Harry,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,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、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