局部解剖學(xué)課件：第八章 下肢

2016-3第八章下肢第一節(jié)概述一、境界與分區(qū)上界：髂嵴、腹股溝、股會(huì)陰溝分區(qū)：臀部、股部、膝部、小腿、足2016-3二、表面解剖（一）體表標(biāo)志髂嵴、髂前/后上棘，髂結(jié)節(jié)，坐骨結(jié)節(jié)，恥骨結(jié)節(jié)股骨大轉(zhuǎn)子股骨內(nèi)、外側(cè)髁，脛骨內(nèi)、外側(cè)髁：髕骨，髕韌帶：脛骨粗隆，脛骨內(nèi)側(cè)面，內(nèi)踝，腓骨頭，腓骨頸，外踝臀大肌，股四頭肌，半腱肌腱、半膜肌腱，股二頭肌腱腓腸肌兩個(gè)頭，跟腱臀股溝，腘窩橫紋ThelowerlimbSection1Intruction1.Boundariesanddivisions2.Surfaceanatomy(1)ThesurfacelandmarksBoundaries:

Inguinalgrooves,iliaccrest,pudendal-thighsulcus.Divisions:

Thelowerlimbisdividedintotheglutealregion(buttock),thigh,knee,leg,ankleandfoot.2016-3iliaccrestanteriorsuperioriliacspineposteriorsuperioriliacspinetubercleofiliaccrestischialtuberositygreatertrochanterpubicsymphysispubiccrestpubictubercleinguinalligamentGlutealregionandthigh2016-3KneePatellapatellaligamenttibialtuberositylateralandmedialcondylesoffemurlateralandmedialepicondylesoffemurAdductortuberclelateralandmedialcondylesoftibiaFibularheadtendonofbicepsfemoristendonsofsemitendinosusandsemimembranosus2016-32016-32016-3Leg,Ankleandfootanteriorborderoftibiaheadoffibulaneckoffibulamedialandlateralmalleoluscalcanealtuberosity

tuberosityofnavicularbonetuberosityoffifthmetatarsalbone

2016-31233445672016-3（二）對(duì)比關(guān)系1、Nelaton線(Nelaton'sLine

(alsoknownasthe

Roser-Nélatonline)側(cè)臥，髖關(guān)節(jié)半屈位。自坐骨結(jié)節(jié)至髂前上棘的連線。此線恰通過(guò)股骨大轉(zhuǎn)子尖，若大轉(zhuǎn)子尖向此線上方或下方移位，多見于髖關(guān)節(jié)脫位或股骨頸骨折法國(guó)2016-32、Kaplan交點(diǎn)仰臥位，兩腿伸直并擾，兩髂前上棘處有同一平面，由左、右大轉(zhuǎn)子尖經(jīng)過(guò)同側(cè)髂前上棘作延長(zhǎng)線。2016-3頸干角頸干角125-130度大于：髖外翻小于：髖內(nèi)翻2016-3膝外翻角外側(cè)夾角170度小于：膝外翻，X大于：膝內(nèi)翻，O2016-3

（四）體表投影臀上動(dòng)、靜脈與神經(jīng)臀下動(dòng)、靜脈與神經(jīng)坐骨神經(jīng)股動(dòng)脈腘動(dòng)脈脛前動(dòng)脈脛后動(dòng)脈足背動(dòng)脈2016-3臀上動(dòng)、靜脈和神經(jīng)髂后上棘與股骨大轉(zhuǎn)子尖連線的中、內(nèi)１/3交點(diǎn)為臀上動(dòng)、靜脈和神經(jīng)出入盆腔的投影點(diǎn)2016-3臀下動(dòng)、靜脈和神經(jīng)髂后上棘與坐骨結(jié)節(jié)連線的中點(diǎn)為臀下動(dòng)、靜脈和神經(jīng)出入盆腔的投影點(diǎn)。2016-3坐骨神經(jīng)坐骨神經(jīng)出盆腔的投影點(diǎn)在髂后上棘與坐骨結(jié)節(jié)連線的中點(diǎn)外側(cè)2-3cm處。2016-3坐骨神經(jīng)干在臀部和股后部的投影位置為股骨大轉(zhuǎn)子與坐骨結(jié)節(jié)連線的中、內(nèi)1/3交點(diǎn)至股骨內(nèi)、外側(cè)髁之間中點(diǎn)（或腘窩上角）的連線。122016-3股動(dòng)脈由髂前上棘至恥骨聯(lián)合連線的中點(diǎn)至收肌結(jié)節(jié)連線的上２／３段1232016-3足背動(dòng)脈內(nèi)、外踝前面連線的中點(diǎn)至第１跖骨底外側(cè)緣的連線拇長(zhǎng)肌腱和趾長(zhǎng)肌腱之間位置表淺，其搏動(dòng)易于觸摸2016-31.Superiorgluteala.,v.,andn.2.Inferiorgluteala.,v.,andn.3.Sciaticn.4.Femorala.andv.5.Popliteala.6.Anteriortibiala.7.Posteriortibiala.

8.DorsalarteryoffootTheprojectionsofthebloodvesselsandnerves2016-3less-than1250:

coxavara髖內(nèi)翻(itoccursinfracturesoftheneckofthefemurandslippingofthefemoralepiphysis)greaterthan

1300:

coxavalga髖外翻(incasesofcongenital先天性的dislocationofthehip)Normalangleofinclination1250-1300

neck-shaftangle2016-3NormalalignmentGenuvarum(bowleg)膝內(nèi)翻

Genuvalgum膝外翻1700

>1700<17002016-3TheorientationofthepelvisinthestandingpositionInthestandingpositiontheplaneofthelineaterminalisisusuallyinclinedatanangleofabout600tothehorizontal.Theanteriorsuperiorspineandthepubicsymphysisareinapproximatelythesameverticalplane.2016-3alsoknownastheRoser-Nélatonlinealinedrawnfromtheanteriorsuperiorlilacspinetotheischialtuberosity,passingoverornearthetopofthegreatertrochanter.Thetrochantercanbefeltsuperiortothislineinapersonwhichdislocatedhipjointorfracturedfemoralneck.

Nelaton’slinenormalabnormal2016-32.Kapian’spoint(shoemaker’ssign)Thepatientliessupinewithstretchedlegs.Joinalinefromtheapexofthegreatertrochantertotheanteiorsuperioriliacspine.Normally,itsprolongedlinepassesthroughorabovetheumbilicus.Ifthelinepassesbelowtheumbilicus,itindicatesthepresenceofsuperiordisplacementofthegreatertrochanter.normalabnormal2016-3Bryantlineandbryanttriangle2016-32016-3一、股部(1)：股前內(nèi)側(cè)區(qū)1.皮膚2.淺筋膜2016-3大隱靜脈greatsaphenousvein起始：足背靜脈弓的內(nèi)側(cè)端。行程：內(nèi)踝前方、股骨內(nèi)側(cè)髁后方約2cm、恥骨結(jié)節(jié)外下方穿隱靜脈裂孔注入股靜脈。2016-3大隱靜脈的高位屬支：旋髂淺靜脈腹壁淺靜脈陰部外淺靜脈股內(nèi)側(cè)淺靜脈股外側(cè)淺靜脈2016-32016-3臨床意義：

①大隱靜脈切開②大隱靜脈曲張

2016-3淺動(dòng)脈

superficialartery腹壁淺動(dòng)脈superficialepigastricartery旋髂淺動(dòng)脈superficialcircumflexiliacartery陰部外淺動(dòng)脈Superficialexternalpudendalartery2016-3股部皮神經(jīng)有：股前皮神經(jīng)股內(nèi)側(cè)皮神經(jīng)股外側(cè)皮神經(jīng)閉孔神經(jīng)皮支生殖股神經(jīng)股支髂腹股溝神經(jīng)隱神經(jīng)股后皮神經(jīng)腓腸內(nèi)側(cè)皮神經(jīng)

腓腸外側(cè)皮神經(jīng)③皮神經(jīng)

cutaneousnerve股外側(cè)皮神經(jīng)生殖股神經(jīng)股支髂腹股溝神經(jīng)股前皮神經(jīng)髂腹下神經(jīng)生殖股神經(jīng)閉孔神經(jīng)股內(nèi)側(cè)皮神經(jīng)隱神經(jīng)腓淺神經(jīng)股外側(cè)皮神經(jīng)生殖股神經(jīng)股支股前皮神經(jīng)髂腹股溝神經(jīng)股內(nèi)側(cè)神經(jīng)隱神經(jīng)腓腸外側(cè)皮神經(jīng)腓淺神經(jīng)前面觀2016-3股內(nèi)側(cè)皮神經(jīng)腓腸內(nèi)側(cè)皮神經(jīng)腓腸神經(jīng)足底外側(cè)神經(jīng)足底內(nèi)側(cè)神經(jīng)腓腸外側(cè)皮神經(jīng)股后皮神經(jīng)股外側(cè)皮神經(jīng)髂腹下神經(jīng)臀上皮神經(jīng)臀內(nèi)側(cè)皮神經(jīng)臀下皮神經(jīng)閉孔神經(jīng)股部皮神經(jīng)有：股前皮神經(jīng)股內(nèi)側(cè)皮神經(jīng)股外側(cè)皮神經(jīng)閉孔神經(jīng)皮支生殖股神經(jīng)股支髂腹股溝神經(jīng)隱神經(jīng)

股后皮神經(jīng)腓腸內(nèi)側(cè)皮神經(jīng)腓腸外側(cè)皮神經(jīng)③皮神經(jīng)股內(nèi)側(cè)皮神經(jīng)股后皮神經(jīng)股外側(cè)皮神經(jīng)閉孔神經(jīng)

隱神經(jīng)

腓腸內(nèi)側(cè)皮神經(jīng)

腓總神經(jīng)

腓腸外側(cè)皮神經(jīng)后面觀2016-3④淋巴管腹股溝淺淋巴結(jié)上群收納臍以下腹壁、臀部、會(huì)陰、外生殖器、肛門的淋巴。下群收納足和小腿內(nèi)側(cè)，大腿的淺淋巴、臀部、會(huì)陰的部分淋巴。腹股溝淺淋巴結(jié)的輸出管注入腹股溝深淋巴結(jié)或髂外淋巴結(jié)。Superficialstructure1.Skin2.Superficialfascia2016-3Superficialarteries:Superficialepigastrica.2.Superficialiliaccircumflexa.3.Superficial

externalpudendala.1232016-3SuperficialveinsgreatsaphenousveinOrigin:fromthemedialsidesofadorsalvenousarchinthefoot.

Course:passesupwarddirectlyinfrontofthemedialmalleolus,thenascendsonthemedialsideoftheleg,knee,andthightopassthroughthesaphenoushiatusindeepfasciaandjoinwiththefemoralvein.2016-3Tributariesofthegreatsaphenousvein

①Superficialiliaccircumflexv.②Superficialepigastricv.

③Externalpudendalv.④Superficialmedialfemoralv.

⑤Superficiallateralfemoralv.①②③④⑤2016-3Typesoftributariesofthegreatsaphenousvein2016-3臨床意義：

①大隱靜脈切開②大隱靜脈曲張

Varicoseveinsnormalabnormal2016-3腔鏡下交通支結(jié)扎術(shù)微創(chuàng)刨吸術(shù)2016-3Origin:fromthelateralsidesofadorsalvenousarchinthefoot.

Course:passesbehindthedistalendofthefibula(lateralmalleolus)andupthebackofthelegtopenetratedeepfasciaandjointhepoplitealveinposteriortotheknee.Smallsaphenousvein

2016-3⑧⑦①④Superficialperonealn.②⑤Cutaneousnerves:股部皮神經(jīng)有：anteriorfemoralcutaneousn.medialfemoralcutaneousn.lateralfemoralcutaneousn.cutaneousbr.ofobturatorn.

saphenousn.femoralbr.ofgenitofemoraln.iliohypogastricn.ilioinguinaln.③⑥2016-3Lateralsuralcutaneousn.⑧⑦①④Superficialperonealn.②⑤Cutaneousnerves:股部皮神經(jīng)有：anteriorfemoralcutaneousn.medialfemoralcutaneousn.lateralfemoralcutaneousn.cutaneousbr.ofobturatorn.

saphenousn.femoralbr.ofgenitofemoraln.iliohypogastricn.ilioinguinaln.③⑥2016-3Superficialinguinallymphnodes:

superiorgroupinferiorgroupreceivelymphdrainagefromtheentirelowerlimb,thesuperficialstructuresoftheperineumandabdominalwallbelowtheumbilicus.Efferentvesselsdrainintothedeepinguinalorexternaliliaclymphnodes.2016-32016-3股前內(nèi)側(cè)區(qū)深層結(jié)構(gòu)一、深筋膜:闊筋膜,

fascialata

,大腿的深筋膜的特稱。為全身最厚的深筋膜，致密堅(jiān)韌。2016-3闊筋膜在股部形成下列三種結(jié)構(gòu):股后肌間隔股外側(cè)肌間隔股內(nèi)側(cè)肌間隔（1）髂脛束（2）隱靜脈裂孔(卵圓窩)（3）三個(gè)肌間隔2016-3分別容納各群的肌肉、血管和神經(jīng)。二、骨筋膜鞘Osteofascial

compartments;fascial

compartments

由闊筋膜、三個(gè)肌間隔及股骨骨膜共同圍成三個(gè)骨筋膜鞘。前骨筋膜鞘內(nèi)側(cè)骨筋膜鞘后骨筋膜鞘2016-3骨筋膜鞘綜合癥：腔內(nèi)壓力大于30mmHg必須積極治療，超過(guò)24小時(shí)造成功能損害；超過(guò)72小時(shí)只能截肢2016-3vastusmedialisvastuslateralisrectusfemoris大腿肌（前群、內(nèi)側(cè)群

后群）及神經(jīng)、血管1、大腿肌前群：

股四頭肌quadricepsfemoris（股直肌、股內(nèi)側(cè)肌、股外側(cè)肌、股中間肌）

縫匠肌sartoriusmuscle2、神經(jīng)支配：股神經(jīng)3、營(yíng)養(yǎng)血管：股A2016-3肌肉：恥骨肌長(zhǎng)收肌短收肌大收肌股薄肌神經(jīng)支配：閉孔N血液供應(yīng)：閉孔AV大腿肌內(nèi)側(cè)群及神經(jīng)、血管123452542016-3神經(jīng)血管前：股A、V、N內(nèi)：閉孔A、V、N2016-3局部結(jié)構(gòu)肌腔隙與血管腔隙股三角收肌管2016-3位置：位于腹股溝韌帶與髖骨之間。是腹、盆腔與股前區(qū)的重要通道，被髂恥弓分為二部：1、肌腔隙

2、血管腔隙

1、肌腔隙與血管腔隙2016-3

肌腔隙：境界：前界:腹股溝韌帶后界:髂骨內(nèi)側(cè)界:髂恥弓肌腔隙通過(guò)的結(jié)構(gòu):髂腰肌股神經(jīng)股外側(cè)皮神經(jīng)2016-3血管腔隙：境界：前界：腹股溝韌帶后界：恥骨肌筋膜及恥骨梳韌帶內(nèi)側(cè)界：腔隙韌帶外側(cè)界：髂恥弓2016-3血管腔隙通過(guò)的結(jié)構(gòu):股鞘：腹橫筋膜與髂筋膜向下延續(xù)包繞于股動(dòng)、靜脈上部形成的筋膜鞘呈漏斗形，包圍下列結(jié)構(gòu)：①股動(dòng)脈②股靜脈③股管：股管的開口為股環(huán)，其外為股靜脈，后為恥骨，僅前、內(nèi)為韌帶，是擴(kuò)大股管的部位。2016-3股三角境界：上界：腹股溝韌帶下外界：縫匠肌內(nèi)側(cè)緣下內(nèi)界：長(zhǎng)收肌內(nèi)側(cè)緣前壁：闊筋膜后壁：髂腰肌、恥骨肌、長(zhǎng)收肌向下通收肌管。2016-3股三角內(nèi)容：

肌腔隙通過(guò)的結(jié)構(gòu):髂腰肌、股神經(jīng)、股外側(cè)皮神經(jīng)

從外向內(nèi)依次為：股動(dòng)脈股靜脈股管股鞘為腹橫筋膜和髂筋膜向下延伸的筋膜鞘,被二個(gè)縱向的纖維隔分為外、中、內(nèi)三部分。股神經(jīng)股動(dòng)脈股靜脈淋巴結(jié)縫匠肌髂腰肌恥骨肌長(zhǎng)收肌2016-3（１）股動(dòng)脈femoralartery:是股三角內(nèi)的中心結(jié)構(gòu)，有四大分支。向前發(fā)出三條動(dòng)脈即：腹壁淺動(dòng)脈、旋髂淺動(dòng)脈和陰部外動(dòng)脈。向后發(fā)出股深動(dòng)脈，股深動(dòng)脈又發(fā)出旋股內(nèi)、外側(cè)動(dòng)脈和穿動(dòng)脈，股動(dòng)脈與股深動(dòng)脈幾乎處于同一垂線上。

2016-3股管位置：股鞘最內(nèi)側(cè)，長(zhǎng)約1-2cm。下端為盲端，適對(duì)隱靜脈裂孔。上口為股環(huán)，被薄層疏松結(jié)締組織覆蓋，稱股環(huán)隔，上面襯有腹膜。從腹腔面觀察，此處有一小凹，稱股凹，位置高與管環(huán)約1cm。股環(huán)周界:前界:腹股溝韌帶；內(nèi)側(cè)界:腔隙韌帶后界:恥骨梳韌帶；外側(cè)界:股靜脈內(nèi)側(cè)的纖維隔2016-3

腹內(nèi)壓升高時(shí)，腹盆腔臟器可被推向股凹，經(jīng)股環(huán)至股管而形成股疝，以老年女性為多見。股疝的形成:股疝在8407個(gè)疝患者中，股疝有442例，占5。3％它與腹股溝疝比約為1︰17在442例股疝中，女性有327例，占74％2016-3股疝特點(diǎn)●女性發(fā)病率高于男性●股疝容易嵌頓An87year-oldwomanpresentedwithapainfulleftgroinbulge.Becausethebulgewasmostlybelowalinedrawnbetweentheanteriorsuperioriliacspineandthepubictubercle,adiagnosisoffemoralheriawasmade.Agentleattemptatreductionwasunsuccessful.sacofparietalperitoneum2016-3Foursuturesof2-0prolenewereplacedfrombelowtheinguinalligament.Inguinalligamentandiliopubictractweresuturedtothepectineusfasciadirectlyposteriorly,closingthefemoralcanal.Thecompletedrepairisshown.2016-32016-3腹股溝深淋巴結(jié)

位于股靜脈上部周圍和股管內(nèi)。收納下肢、會(huì)陰部、臀部等處的淋巴，其輸出管注入髂外淋巴結(jié)。2016-3收肌管(Hunter管)位置：股前內(nèi)側(cè)區(qū)中1/3段，長(zhǎng)約15cm。境界：前內(nèi)側(cè)壁:

縫匠肌及大收肌腱板前外側(cè)壁:

股內(nèi)側(cè)肌后壁:

長(zhǎng)收肌、大收肌上口:

接股三角（尖）下口:

收肌腱裂孔，通腘窩,又稱股腘管。2016-3通過(guò)結(jié)構(gòu)及位置關(guān)系

從前向后為:隱神經(jīng)saphenousnerve股動(dòng)脈femoralartery股靜脈femoralvein2016-3股內(nèi)側(cè)區(qū)的血管、神經(jīng)閉孔動(dòng)脈obturatorartery閉孔神經(jīng)obturatornerveThedeepstructuresDeepfascia–fascialata

P352

2016-3Thestructuresformedbyfascialata:

（1）Iliotibialtract（2）Saphenoushiatus--falciformmargin--cribriformfascia（3）threeintermuscularseptaAnt.osseofascialcompartmentsMedialintermuscularseptaposteriorintermuscularseptaLateralintermuscularseptaMed.osseofascialcompartmentsPost.osseofascialcompartments2016-3ThelacunamusculorumandlacunavasorumPosition：thegapbetweeninguinalligamentandhipbone.Ailiopectinealarchextendingfromtheinguinalligamenttotheiliopectnealeminence.LacunamusculorumlacunavasorumLacunamusculorumlacunavasorumiliopectinealarch2016-3Boundies：anteriorly:

inguinalligament

posterolaterally:

iliumMedially:Theiliopectinealarch

ThelacunamusculorumContents:

Theiliopsoas

Thefemoralnerve

Thelateralfemoralcutaneousn.2016-3Boundies:anteriorly:inguinalligamentposteromedially:fasciaofpectineusandpectinealligamentmedially:lacunarligamentlaterally:iliopectinalarchlacunavasorumContents:FemoralsheathFemorala.,v.andfemoralcanal

Femeralbranchofgenitofemoraln.

Lymphaticvessels股神經(jīng)股動(dòng)脈股靜脈股管2016-3femoraltriangleTheboundaries：Superiorly:inguinalligamentInfralaterally:med.borderofthesartoriusmedially:med.borderoftheadductorlongusanteriorwall:

fascialataposteriorwall:adductorlongus,pectineusandiliopsoas2016-3ThestructurespassthroughtheMuscularlacuna:

iliopsoasfemoraln.lateralfemoralcutaneousn.Contentsofthefemoraltriangle股神經(jīng)股動(dòng)脈股靜脈股管縫匠肌髂腰肌恥骨肌長(zhǎng)收肌2016-3Contentsofthefemoraltrianglefromlateraltomedialside：femorala.femoralv.femoralcanal股神經(jīng)股動(dòng)脈股靜脈股管縫匠肌髂腰肌恥骨肌長(zhǎng)收肌Thestructurespassthroughthevascularlacuna:femoralsheathisaafunnel-shapedsheath,derivedfromtransversalisfasciaanteriorlyandiliacfasciaposteriorly.Itsurroumdsthefemoralvesselsandlymphaticabout2.5cmbelowertheinguinalligamemt.2016-3股外側(cè)皮神經(jīng)生殖股神經(jīng)股支股前皮神經(jīng)髂腹股溝神經(jīng)股內(nèi)側(cè)神經(jīng)隱神經(jīng)腓腸外側(cè)皮神經(jīng)腓淺神經(jīng)Femoralnerve

(L2,L3,L4)：Muscularbranche:Suppliesthemusclesoftheanteriorcompartmentofthethigh,includingpectineusandiliopsoas.Cutaneousbranches:

Anteriorcutaneousn.ofthethighSaphenousn.。2016-3

位于股靜脈上部周圍和股管內(nèi)。收納下肢、會(huì)陰部、臀部等處的淋巴，其輸出管注入髂外淋巴結(jié)。deepinguinallymphnodes2016-3Theadductorcanal(Hunter管)位置:

anaponeurotictunnelinthemiddlethirdofthethigh,extendingfromtheapexofthefemoraltriangletotheopeningintheAdductormagnus,theAdductorhiatus.2016-3femoralcanalItisthemedialcompartmentofthefemoralsheathabout2

cmlong.containslymphaticvessels,alymphnodeandsmallamountofloosefattytissue.Itsupperopeningiscalledthefemoralring.Thefemoralcanalisbordered:Anteriorlybytheinguinallig.Posteriorlybythepectineallig.Mediallybythelacunarlig.Laterallybythefemoralvein2016-3FemoralherniaIfaloopofintestineisforcedintothefemoralring,itexpandstoformaswellingintheupperpartofthethigh.2016-3An87year-oldwomanpresentedwithapainfulleftgroinbulge.Becausethebulgewasmostlybelowalinedrawnbetweentheanteriorsuperioriliacspineandthepubictubercle,adiagnosisoffemoralheriawasmade.Agentleattemptatreductionwasunsuccessful.sacofparietalperitoneum2016-3knuckleofdeadbowelsacofparietalperitoneum2016-3Foursuturesof2-0prolenewereplacedfrombelowtheinguinalligament.Inguinalligamentandiliopubictractweresuturedtothepectineusfasciadirectlyposteriorly,closingthefemoralcanal.Thecompletedrepairisshown.2016-3Theadductorcanal(Hunter管)上口:

接股三角尖下口:

收肌腱裂孔，通腘窩。Boundaries:Anteriorly:sartoriusandadductorlaminaAnterolaterally:vastusmedialisPosteriorly:adductorlongusand

adductormagnus2016-3

通過(guò)結(jié)構(gòu)及位置關(guān)系：

從前向后為:

saphenousn.

femorala.

femoralv.2016-3Bloodvesselsandnerveofmedialsideofthigh

Obturatora.

Obturatorn.

2016-32016-3膝前區(qū)淺層結(jié)構(gòu)深層結(jié)構(gòu)皮膚淺筋膜髕前皮下囊髕韌帶髕支持帶髕上囊膝前區(qū)淺層結(jié)構(gòu)深層結(jié)構(gòu)皮膚淺筋膜髕前皮下囊鵝足髕韌帶髕內(nèi)、外側(cè)支持帶髕上囊2016-3鵝足pesanserinustendon2016-3是縫匠肌、股薄肌、半腱肌三塊肌肉之腱性部分在脛骨近段內(nèi)側(cè)的附著點(diǎn)，外形類似鵝足，故稱鵝足。在其下與脛骨之間有一滑囊稱鵝足腱囊。由于反復(fù)應(yīng)力的作用，如活動(dòng)過(guò)多等，可造成此處產(chǎn)生無(wú)菌性炎癥，稱之為鵝足炎或鵝足腱囊炎。鵝足腱2016-3小腿前外側(cè)區(qū)

一、淺層結(jié)構(gòu)（一）淺靜脈大隱靜脈greatsaphenousvein隱神經(jīng)saphenousnerve2016-3二、深層結(jié)構(gòu)骨筋膜鞘Osteofascial

compartments;fascial

compartments小腿骨間膜及前、后肌間隔將小腿為三個(gè)骨筋膜鞘，即：前骨筋膜鞘外側(cè)骨筋膜鞘后骨筋膜鞘2016-3

1.前骨筋膜鞘（1）肌肉脛骨前肌拇長(zhǎng)伸肌趾長(zhǎng)伸肌腓骨第三?。?）血管和神經(jīng)支配脛前動(dòng)脈-足背動(dòng)脈腓深神經(jīng)deepfibularnerve

2016-32.外側(cè)骨筋膜鞘（1）肌肉腓骨長(zhǎng)肌腓骨短?。?）腓淺神經(jīng)Superficialfibularnerve:

分布于小腿外側(cè)群肌肉、小腿外側(cè)及足背皮膚。腓總神經(jīng)損傷Lesionsofthecommonfibularnerve馬蹄內(nèi)翻足畸形足不能背屈，足下垂、內(nèi)翻，趾不能伸，“馬蹄”內(nèi)翻足，感覺(jué)障礙在小腿外側(cè)和足背明顯。Dropfoot2016-3TheAnteriorandLateralRegionsofTheLeg1.Thesuperficialstructures

（1）Thesuperficialfascia

SuperficialveinsandnervesThegreatsaphenousv.Thesaphenousn.Superficialperonealn.2016-3Thedeepfascia:Surroundsthelegandformsanteriorandposteriorintermuscularseptatobeattachedtothefibula.Dividedthelegintothreecompartments:anterior,lateralandposterior,eachofwhichcontainsagroupofmuscles,thevesselsandthenerves.2.Thedeepstructurescruralinterosseousmembrane2016-3Thecontentoftheanteriorosseofascialcompartment(Osteofascial

compartments,fascial

compartments)（1）muscles①tibialisanterior②extensorhallucislongus③extensordigitorumlongus

④peroneustertius（2）血管神經(jīng)

anteriortibiala.andv.dorsalarteryoffootdeepperonealnerve(deepfibularnerve)2016-3Thecontentofthelateralosseofascialcompartment（1）muscles

Theperoneuslongus

Theperoneusbrevis（2）superficialperonealn.(superficialfibularnerve)

suppliesperoneuslongusandbrevisandskinonanteriorsurfaceofleganddorsumoffoot2016-3Injurytothecommonperonealnerve

(commonfibularnerve)Thelossofeversionofthefootanddorsiflexionoftheanklecausesfoot-drop.

thepatienthasahighstepping(‘steppage”)gait,raisingthefootashighasnecessarytokeepthetoesfromhittingtheground.2016-3Youmustidentifyfollowstructures！AnteriorandMedialRegionofThighMusclesPsoasIliacusSartoriusQuadricepsfemorisRectusfemorisVastusmedialisVastuslateralisVastusintermediusPatellarligamentPectineusAdductorlongusAdductorbrevis,AdductormagnusGracilisVesselsGreatsaphenousv.Femorala.Deepfemorala.Nervesfemoraln.Saphenousn.Obturatorn.2016-3Youmustidentifyfollowstructures！AnterolateralcruralregionanddorsumofthefootMusclesTibialisanteriorExtensorhallucislongusExtensordigitorumlongusPeroneuslongusPeroneusbrevisVesselsGreatsaphenousv.Anteriortibiala.Dorsalispedis

a.NervesCommonperonealn.Deepperonealn.Superficialperonealn.2016-32016-3下肢后區(qū)臀部Glutealregion股后區(qū)膝部后（腘窩）小腿后區(qū)足底2016-3二、表面解剖（一）體表標(biāo)志臀裂、臀溝髂嵴（兩側(cè)髂嵴最高點(diǎn)的連線平對(duì)第4腰椎棘突）后上棘，髂結(jié)節(jié)，坐骨結(jié)節(jié)，股骨大轉(zhuǎn)子：內(nèi)踝，腓骨頭，腓骨頸，外踝臀大肌半腱肌腱、半膜肌腱，股二頭肌腱腓腸肌兩個(gè)頭，跟腱臀股溝，腘窩橫紋2016-31、境界：髂嵴、臀裂、臀溝2、淺層結(jié)構(gòu)3、深層結(jié)構(gòu)

深筋膜、肌、N、血管一、臀部SurfaceanatomyGlutealregionandthighposteriorsuperiorandinferioriliacspinestubercleofiliaccrestischialtuberosity坐骨結(jié)節(jié)Mediansacralcrest骶正中嵴Sacralcornu骶角Sacralhiatus骶管裂孔SurfaceanatomyGlutealregionandthighposteriorsuperiorandinferioriliacspinestubercleofiliaccrestischialtuberosity坐骨結(jié)節(jié)Mediansacralcrest骶正中嵴Sacralcornu骶角Sacralhiatus骶管裂孔1232016-3natalcleft：interglutealcleft；

buttcrack；

臀裂glutealsulcus臀溝：alsoknownastheglutealfoldorhorizontalglutealcreasebackoftheknee-poplitealfossatendonofbicepsfemoristendonofsemitendinosustendonofsemimembranosus2016-31、境界2、淺層結(jié)構(gòu)3、深層結(jié)構(gòu)

深筋膜、肌、N、血管一、臀部2016-3臀部的淺層結(jié)構(gòu)

皮膚厚而堅(jiān)韌，富于皮脂腺和汗腺，易患癤、癰，淺筋膜很發(fā)達(dá)，有許多纖維束連接皮膚與深筋膜，其間充滿豐富的皮下脂肪，形成軟墊，承受坐位時(shí)的壓力。2016-3臀上動(dòng)、靜脈和神經(jīng)體表投影髂后上棘與股骨大轉(zhuǎn)子尖連線的中、內(nèi)１/3交點(diǎn)為臀上動(dòng)、靜脈和神經(jīng)出入盆腔的投影點(diǎn)2016-3臀下動(dòng)、靜脈和神經(jīng)髂后上棘與坐骨結(jié)節(jié)連線的中點(diǎn)為臀下動(dòng)、靜脈和神經(jīng)出入盆腔的投影點(diǎn)。2016-3坐骨神經(jīng)坐骨神經(jīng)出盆腔的投影點(diǎn)在髂后上棘與坐骨結(jié)節(jié)連線的中點(diǎn)外側(cè)2-3cm處。坐骨神經(jīng)干在臀部和股后部的投影位置為股骨大轉(zhuǎn)子與坐骨結(jié)節(jié)連線的中、內(nèi)1/3交點(diǎn)至股骨內(nèi)、外側(cè)髁之間中點(diǎn)（或腘窩上角）的連線。2016-3健美的臀部是個(gè)體美的重要標(biāo)志之一臀圍是顯示人體曲線美的重要三圍之一，尤其于女性美顯得更為重要。一般據(jù)女性臀部的形態(tài)，體積和皮膚的彈性，分為四型2016-31．上翹型：2．標(biāo)準(zhǔn)型：3．下垂型：4．扁平型：2016-3臀部脂肪沉積的類型

2016-3臀區(qū)的淺筋膜內(nèi)含有四組皮神經(jīng)（1）臀上皮神經(jīng)：L1－3（2）臀中皮神經(jīng)：S1－3（3）臀下皮神經(jīng)：發(fā)自股后皮神經(jīng)（4）髂腹下神經(jīng)的外側(cè)皮支：布于臀前部的皮膚。臀部行去脂術(shù)時(shí)，勿損傷這些神經(jīng)，以免影響感覺(jué)2016-3臀部的皮血管主要有2支臀上動(dòng)脈皮支：從梨狀肌上緣和臀中肌后緣之間淺出，主要供應(yīng)臀大肌上部及相應(yīng)的皮膚。臀下動(dòng)脈皮支：于臀大肌下緣淺出，主要供應(yīng)臀中、下部的皮膚。臀部吸脂術(shù)的相對(duì)禁區(qū)

superiorclunealn.medialclunealninferiorclunealn.lateralfemoralcutaneousn.posteriorcutaneousn.ofthighcutaneousbr.ofobturatorn.medialsuralcutaneousn.lateralsuralcutaneousn.suralnerve⑨Cutaneousnerves:⑧⑦①④②⑤③⑥2016-3monperonealn.Cutaneousnerves:

superiorclunealn.medialclunealninferiorclunealn.lateralfemoralcutaneousn.posteriorcutaneousn.ofthighcutaneousbr.ofobturatorn.medialsuralcutaneousn.lateralsuralcutaneousn.suralnerve③⑥④⑤⑧⑦2016-32016-33、深層結(jié)構(gòu)1、臀部的深筋膜稱臀筋膜，上方附于髂嵴，向下續(xù)于闊筋膜。

Thedeepfascia–theglutealfascia

2016-3肌層分三層:

淺層:臀大肌、闊筋膜張肌中層:臀中肌、梨狀肌深層:臀小肌、上孖肌、閉孔內(nèi)肌、下孖肌

3layersGluteusmaximus,tensorfasciaelatae

Gluteusmedius,Piriformis,quadratusfemorisgluteusminimusThemusclesoftheglutealregion2016-3梨狀肌

piriformis起于第2、3、4骶椎前面，分布于小骨盆的內(nèi)面，穿出坐骨大孔，而將其分成梨狀肌上孔與下孔，止于股骨大轉(zhuǎn)子后面。主要是協(xié)同其它肌肉完成大的外旋動(dòng)作。

RegionalstructuresGreatersciaticforamenSuprapiriformforameninfrapiriformforamenLessersciaticforamen2016-3梨狀肌上、下孔穿行的結(jié)構(gòu)為盆腔血管神經(jīng)至臀部和下肢的通路。梨狀肌上孔－臀上NAV梨狀肌下孔－坐骨N、股后皮N、臀下NAV、陰部?jī)?nèi)AV、陰部N坐骨小孔－陰部?jī)?nèi)A、V、陰部Nsuprapiriformandinfrapiriformforamensuprapiriformforamen:

superiorglutealn.,a.andv.Infrapiriformforamen:

sciaticn.

,posteriorfemoralcutaneousn.

inferiorglutealn.,ernalpudendala.andv.,pudendaln.Lessersciaticforamen:internalpudendala.andv.,pudendaln.

2016-3坐骨神經(jīng)與梨狀肌的關(guān)系2016-32016-3PiriformisSyndrome

指由于梨狀肌損傷而壓迫坐骨神經(jīng)所引起的一側(cè)臀腿疼痛為主的病癥。2016-3PiriformisSyndrome

isaneuromusculardisorderthatoccurswhenthesciaticnerveiscompressedorotherwiseirritatedbythepiriformismusclecausingpain,tinglingandnumbnessinthebuttocksandalongthepathofthesciaticnervedescendingthelowerthighandintotheleg.臀上神經(jīng)髂后下棘坐骨神經(jīng)坐骨結(jié)節(jié)大轉(zhuǎn)子髂前上棘臀中肌髂結(jié)節(jié)大轉(zhuǎn)子坐骨神經(jīng)髂結(jié)節(jié)臀中肌髂前上棘臀上神經(jīng)臀部肌肉注射部位2016-3髖關(guān)節(jié)動(dòng)脈網(wǎng)

以“臀部十字吻合”為重要，位于臀大肌深面。組成：①兩側(cè)為旋股內(nèi)、外側(cè)動(dòng)脈的分支②上部為臀上、下動(dòng)脈的分支③下部為第一穿動(dòng)脈

2016-3

臨床意義：手術(shù)結(jié)扎一側(cè)的髂內(nèi)動(dòng)脈，通過(guò)此動(dòng)脈吻合建立側(cè)支循環(huán)，血液仍可到達(dá)髂內(nèi)動(dòng)脈的分布區(qū)。2016-3二、股后區(qū)1、肌肉：股二頭肌半腱肌半膜肌bicepsfemorissemitendinosussemimembranosus2016-33、大腿肌后群：（外側(cè)→內(nèi)側(cè)）股二頭肌、半腱肌、半膜肌bicepsfemoris

semitendinosussemimembranosusThebackofthethigh1.Themuscles:bicepsfemorissemitendinosussemimembranosus.2016-3

2.股后區(qū)的血管神經(jīng)血管：主要為股深動(dòng)脈-旋股內(nèi)、外側(cè)動(dòng)脈-3-4個(gè)穿動(dòng)脈神經(jīng)：坐骨神經(jīng)：于股二頭肌長(zhǎng)頭與大收肌之間下降至腘窩上角分為脛神經(jīng)和腓總神經(jīng)。坐骨神經(jīng)分支至股后群?。ò腚旒?、半膜肌、股二頭肌長(zhǎng)頭、大收?。?。股二頭肌短頭由腓總神經(jīng)支配。Thesciaticnerve：2.Bloodvesselsandnerves

Itarisesfromthesacralplexusandpassesthroughinfrapiriformforamenintotheglutealregion,passingmidwaybetweenthegreatertrochanteroffemurandischialtuberositytobackofthigh,itusuallyendshalf-waydownthebackofthethighbydividingintothecommonperonealandtibialnerves.Distribution:semitendinosus,semimembranosus,thebicepsfemorisandhipandkneejointsPerforatingarteries2016-3股后區(qū)的動(dòng)脈吻合①由臀下動(dòng)脈，旋股內(nèi)、外側(cè)動(dòng)脈和第1穿動(dòng)脈形成的十字吻合。②各穿動(dòng)脈之間的吻合。③由股深動(dòng)脈的終支與腘動(dòng)脈肌支形成的吻合。2016-3壓痛點(diǎn)(薄弱區(qū))臀大肌下緣與股二頭肌長(zhǎng)頭外側(cè)緣的夾角處。2016-3三、膝后區(qū)（P239）1、腘窩poplitealfossa境界：上外側(cè)壁:股二頭肌上內(nèi)側(cè)壁:半腱肌、半膜肌下內(nèi)、外側(cè)壁:腓腸肌內(nèi)、外側(cè)頭頂:腘筋膜底:股骨腘面、膝關(guān)節(jié)囊后部腘斜韌帶、腘肌2016-32.腘窩內(nèi)容及位置

中央由淺到深為：脛神經(jīng)腘靜脈腘動(dòng)脈腘窩外上緣有：腓總神經(jīng)

血管周圍有：腘深淋巴結(jié)

臨床上股骨下端骨折易損傷腘動(dòng)脈。2016-3腘動(dòng)脈的分支：（1）肌支

（2）5條關(guān)節(jié)支膝上內(nèi)、外側(cè)動(dòng)脈膝中動(dòng)脈膝下內(nèi)、外側(cè)動(dòng)脈2016-3二、膝關(guān)節(jié)動(dòng)脈網(wǎng)組成：①腘動(dòng)脈的5條關(guān)節(jié)支②旋股外側(cè)動(dòng)脈的降支③膝降動(dòng)脈(股動(dòng)脈在收肌管內(nèi)的分支)④脛前返動(dòng)脈⑤第3、4穿動(dòng)脈意義：若腘動(dòng)脈阻塞，此動(dòng)脈網(wǎng)有一定的代償作用。PoplitealFossaTheboundaries:Upperlateral:

BicepsfemorisUppermedial:

SemitendinosusandsemimembranosusLowerlateral:

lateralheadofthe

gastrocnemiusLowermedial:

medialheadofthegastrocnemiusRoof:

poplitealfasciaFloor:

Poplitealsurfaceoffemur,jointcapsuleofthekneejoint,obliquepoplitealligament,andpopliteuswithitsfasciasuperficialtodeepincentral：

Tibialn.

Poplitealv.

Popliteala.Commonperonealn.Poplitealdeeplymphnodes2.Contents臨床上股骨下端骨折易損傷腘動(dòng)脈。

2016-3腓總神經(jīng)：行程：腓骨頸(易受損傷)。分支：

腓腸外側(cè)皮神經(jīng)

腓淺神經(jīng)腓深神經(jīng)2016-3四、小腿后區(qū)（P244）（一）淺層結(jié)構(gòu)小隱靜脈腓腸內(nèi)側(cè)皮神經(jīng)腓腸外側(cè)皮神經(jīng)腓腸神經(jīng)2016-3（二）深層結(jié)構(gòu)

（1）肌肉腓腸肌、比目魚肌、[跖肌(zhí)]腘肌趾長(zhǎng)屈肌拇長(zhǎng)屈肌脛骨后肌2016-33、小腿肌后群（淺層）：小腿三頭肌:腓腸肌Gastrocnemius比