Borders: proximal - a horizontal line drawn one transverse finger proximal to the styloid process of the radius; distal - a horizontal line drawn distal to the pisiform bone, corresponding to the distal transverse folds of the wrist. Vertical lines drawn through the styloid processes of the radius and ulna separate the anterior region of the wrist from the posterior region of the wrist.
Layers:
Front surface
Leather thin, mobile, has three transverse folds of the wrist - proximal, middle and distal.
Pc adipose tissue is poorly developed. Near the borders with the posterior region of the wrist, the following formations occur in fat deposits:
From the elbow side - v. basilica and n. cutaneus antebrachii medialis.
From the radial side -v. cephalica and n. cutaneus antebrachii lateralis.
In the middle - r. palmaris n. mediani.
Own fascia the forearm thickens upon transition to the wrist and forms a retinaculum flexorum.
In the openings of the flexor retinaculum and behind it, channels are formed containing tendons, vessels and nerves.
Lateral to the pisiform bone in the flexor retinaculum is located canalis carpi ulnaris , through which the ulnar vessels and nerve ( vasa ulnaria et n. ulnaris ) pass to the brush.
Medial to the trapezium bone in the flexor retinaculum is located canalis carpi radialis , in which the tendons of the so-called flexor carpi radialis pass, lateral to the tendon of the radial flexor of the wrist is the radial artery (a. radialis), which under the tendons of the long muscle, abducting the thumb and short extensor of the thumb, passes into the radial fossa located in the posterior region of the wrist.
Forms between the flexor retinaculum and the wrist bones canaliscarpi, through which the tendons of the superficial and deep flexors of the fingers, surrounded by a common synovial sheath, pass. In its own synovial vagina, the tendon of the long flexor of the thumb passes through the canal of the wrist, as well as the median nerve and the artery that accompanies the median nerve, projecting onto a line drawn in the middle of the wrist.
Bones of the wrist.
Rear surface
Leather thin, mobile, has a hairline, more pronounced in men.
Fatty deposits are more pronounced than in the anterior region of the wrist. In the fatty deposits of the lateral part of the region, there are tributaries v. cephalica and r . superficialis NS. radialis . In the fatty deposits of the medial part of the region, there are tributaries of the medial saphenous vein of the arm v. basilica and the dorsal branch of the ulnar nerve r . dorsalis ulnaris .
Own fascia the forearm, when passing to the wrist, thickens and forms an extensor retinaculum , which spreads between the styloid processes of the radius and ulna, gives off spurs to the radius, dividing the space under the extensor retainer into 6 channels.
The tendons of the muscles of the posterior group of the forearm, surrounded by synovial sheaths, pass through the canals of the posterior region of the wrist. The synovial sheaths start from the proximal edge of the extensor retinaculum and extend to the base of the metacarpal bones.
The first channel is m. abductor pollicis longus and m. extensor pollicis brevis.
The second channel is the so-called extensor carpi radialis brevis et m. extensor carpi radialis longus.
The third channel is the so-called extensor pollicis longus.
The fourth channel is the so-called extensor digitoni and the so-called extensor indicis.
The fifth channel is the so-called extensor digiti minimi.
The sixth channel is the so-called extensor carpi ulnaris.
Stenosing ligamentitis of the retinaculum extensorum (extensor retinaculum). Among the ligamentitis of the retinaculum extensorum, stenosis of the I channel (de Quervain's disease) is of practical importance.
De Quervain's disease is also a polyetiological disease, but more often it occurs after overstrain of the hand, mainly in women against the background of age-related diseases. The disease begins sometimes acutely, immediately, with precise localization of pain in a strictly limited area of the wrist, corresponding to zone I of the dorsal canal (see Fig. 51). Then, extension and abduction of the thumb, adduction of the hand, flexion and opposition of the thumb to the base of the little finger become painful. When palpating in this area, a painful compaction of soft tissues is determined. X-ray examination first shows the compaction of soft tissues, then - osteoporosis, and later - sclerosis of the cortical layer of the styloid process of the radial bone.
Surgical treatment: before anesthesia with blue, the course of the skin incision is outlined. The operation is performed under local infiltration or regional anesthesia with 0.5 or 1% novocaine solution in an amount of 30 to 50 ml, without exsanguination. An oblique or transverse incision is made over the painful protrusion. Immediately under the skin lies the venous network and a little deeper, in the loose tissue - the superficial branch of the radial nerve. They must be carefully removed with a blunt hook to the rear, and the fascia must be opened. Then the retinaculum extensorum is exposed and the I channel is examined; movement of the thumb (extension and abduction) checks the degree of canal stenosis. If possible, a grooved probe is inserted between the tendon sheath and the ligament, with careful sawing movements the ligament is dissected, lifted, and part of it is excised. After that, the tendons are completely exposed and one can judge the variant of the canal structure and pathological changes. Extending, leading and retracting I finger, it is necessary to make sure that the tendon is completely free to slide. Occasionally, with a far-reaching scleropathic process and aseptic inflammation, adhesions are observed that fix the tendons to the posterior wall of the vagina and the periosteum. In such cases, adhesions that prevent the tendons from sliding are excised. The operation ends with a thorough hemostasis, then 2-3 catgut thin sutures are applied on the subcutaneous tissue and fascia, sutures on the skin, aseptic dressing on the wound; the hand rests on the kerchief. The stitches are removed on the 8-10th day, and depending on the specialty of the patient, on the 14th day, he can start working.
Carpal tunnel syndrome.
In this case, compression neuropathy of the median nerve develops, passing in the carpal canal together with the tendons.
In the absence of the effect of conservative therapy and a protracted course of the disease, surgery is recommended. The operation is performed under intraosseous, intravenous - regional anesthesia with exsanguination. A transverse or flap L-shaped incision at the base of the palm along the carpal skin fold 4-5 cm long provides the necessary access. With Farabef's hooks, the wound is pushed apart, the aponeurosis is dissected, and the retinaculum flexorum is exposed. The dissection is done along the Kocher probe or over the Buyalsky's scapula carefully, under the control of the eye, since here the branch of the median nerve passes to the muscles of the eminence of the thumb, the superficial branch of the radial artery and the sheath of the flexor tendons. The operation ends with excision of the retinaculum flexorum strip. After excision, the synovial bags are examined, then the condition of the ulnar nerve is checked. Scars and adhesions are eliminated. Thorough hemostasis, the imposition of two or three catgut sutures on the fascia and tissue, a blind suture of the wound.
35. Topographic anatomy of the palmar surface of the hand. Borders, layers, fascial beds, vessels and nerves, bursae. Ways of spreading purulent processes. Technique of opening and drainage of superficial and deep phlegmon of the hand. Phlegmon of Pirogov-Paron space.
Border: horiz. flat held 1 transverse toe higher than the styloid process of the ray. There are 3 parts: wrist, metacarpus, fingers.
FASCY BRUSH
Fascia manus propria consists of 2 parts: palmar and back. Palmar (f.palmaris) is divided into 2 plates: superficial and deep. The superficial one fuses with the superficial fascia and forms an aponeurosis (aponeurosis palmaris). the superficial plate in the area of the tenor and hypothene is less pronounced. The deep plate is the interosseous fascia.
The fascia of the forearm, passing to the wrist, thickens and forms supporters of the flexors and extensors.
The flexor retainer distally passes into the palm's own fascia, which covers the muscles of the thumb and little finger eminences with a thin plate, and in the center of the palm is represented by a dense palmar aponeurosis (aponeurosispalmaris), which consists of longitudinal and transverse beams.
Longitudinal bundles - a continuation of the tendon of the long palmar muscle, located superficially, diverge in a fan-like manner. Longitudinal bundles are divided into four parts, passing to the palmar surface II-V fingers and involved in the formation of fibrous sheaths of the fingers (vag. fibrosae digitorum manus).
The transverse beams are located behind the longitudinal ones. The distal edge of the transverse bundles delimits three commissural openings connecting the subgaleal tissue with the subcutaneous layer at the interdigital folds.
From the lateral edge of the palmar aponeurosis, the lateral intermuscular septum departs, which bends around the tendons of the superficial and deep flexors of the fingers and attaches to NS metacarpal bone. From the medial edge of the palmar aponeurosis to the V metacarpal bone, the medial intermuscular septum stretches. The lateral and medial intermuscular septa form three fascial beds in the palm of the hand: the lateral one, which contains the muscles of the tenor, the middle one, in which the tendons of the superficial and deep flexors of the fingers are located, and the medial one, which contains the hypothene.
A deep plate of the fascia of the hand lines the interosseous muscles and separates them from the flexor tendons of the fingers, limiting the middle fascial bed from behind.
In the formation of fibrous sheaths of the fingers of the hand, in addition to the longitudinal bundles of the palmar aponeurosis, transverse bundles are involved - the annular part of the fibrous vagina (pars annularis vag. fibrosae), overlapping bundles - cruciform part of the fibrous vagina (pars cruciformis vag. fibrosae).
MUSCLES OF THE BRUSH
In the area of the palmar surface of the hand, there are own muscles and tendons that penetrate the hand from the forearm. The intrinsic muscles of the hand are divided into three groups: the muscles of the eminence of the thumb, the muscles of the eminence of the little finger, and the middle muscle group of the hand.
Muscles of the eminence of the thumb
In the formation of the eminence of the thumb (eminentia thenaris) four muscles are involved.
Short abductor muscle of the thumb (T.abductor pollicis brevis) ;
Short flexor of the thumb (m. Flexor pollicis brevis) 2 heads: superficial - from retinaculum flexorum; deep - from lig.carpi radiatum & os trpezoideum. attached to the proximal phalanx of the thumb from the lateral side.
M. opposing thumb (m. Opponens pollicis)
Muscle adductor thumb (m. Adductor pollicis brevis) 2 heads: transverse - from the 3rd metacarpal bone; oblique - from lig. carpi radiatum & os capitatum. attached to the proximal phalanx of 1 finger.
Muscles of the eminence of the little finger
Short palmar muscle (m.palmaris brevis) in the subcutaneous tissue of the hypotenre from retinaculum flexorum to the skin of honey. edges of the brush.
Muscle abductor little finger (T. abductor digiti minimi ), starts from the pisiform bone and attaches to the base of the proximal phalanx of the little finger; takes away the little finger.
Short little finger flexor (T. flexor digiti minimi brevis ) adjacent to the previous muscle from the ulnar side; starts from the flexor retainer { retinaculum flexorum ) and attaches to the base of the proximal phalanx of the little finger, which it flexes.
Muscle opposing the little finger (T. opponens digiti minimi ), located under the two previous muscles; starts from the flexor retinaculum { retinaculum flexorum ) and is attached to the medial edge of the V metacarpal bone. The muscle opposes the little finger to the thumb.
All four muscles of the little finger eminence are innervated by the ulnar nerve.
The middle muscle group of the hand
Four vermiform muscles (vols. lumbricales ) start from the deep flexor tendons on the palmar side of the hand. The vermiform muscles from the radial side bend around the metacarpophalangeal joints, heading to the dorsum of the fingers, where they attach to the bases of the proximal phalanges and are woven into the lateral bundles of tendon extension of the extensor digitorum attached to the dorsal surfaces of the distal phalanges. The muscles provide flexion in the metacarpophalangeal joints and extension in the interphalangeal joints.
Three palmar interosseous muscles (vols. interossei palmares ) located in the interosseous spaces of the II-V metacarpal bones. The first palmar interosseous muscle starts from the ulnar side of the second metacarpal bone and attaches to the ulnar side of the base of the proximal phalanx of the second finger. The second and third palmar interosseous muscles start from the radial side of the IV and V metacarpals and are attached respectively to the radial side of the proximal phalanges of the IV and V fingers. The palmar interosseous muscles bring the fingers to the middle finger and at the same time bend their first phalanges; innervated by the ulnar nerve.
Dorsal interosseous muscles (vols. interossei dorsales ) start from the surfaces of the metacarpal bones facing each other and occupy all four spaces between them. The first and second dorsal interosseous muscles are attached to the radial sides of the proximal phalanges of the index and middle fingers, respectively, the third and fourth dorsal interosseous muscles - to the ulnar side of the proximal phalanges of the middle and ring fingers, respectively. The dorsal interosseous muscles move the index and ring fingers away from the middle; innervated by the ulnar nerve.
Topography of the synovial sheaths and flexor tendons of the fingers
Synovial sheaths provide a reduction in friction during the passage of tendons in the osteo-fibrous canals.
Superficial and deep flexor tendons of the fingers surrounded by a common synovial flexor sheath ( vag . synovialis communis mm . flexorum ), penetrate the hand under the flexor retainer ( retinaculum flexorum ) in the canal ( canalis carpi ). extends proximally 3-4 cm above the flexor retainer Pyrogoea-Parona), distally, the border is the middle of the metacarpal bones for the tendons of the II-IV fingers, and only the tendons of the V finger are covered to the base of the distal phalanx.
The tendon of the long flexor of the thumb, surrounded by the synovial sheath, passes through the canal of the wrist. It starts 2 cm above the flexor retinaculum and extends to the distal phalanx. The proximal part of the tendon sheath of the long flexor of the thumb, like the common synovial flexor sheath, limits the space in front Pirogov - Parona.
Brush channels:
Retinaculum flexorum, spreading over the sulcus of the wrist, is fixed on the eminentia carpi radialis et ulnaris, forming:
1.Canalis carpi - osteo-fibrous canal pass: the common synovial sheath of the deep and superficial flexors of the fingers, the sheath of the long flexor of the thumb and the median nerve.
2. Canalis carpi radialis: pass the flexor radial tendon of the wrist.
3. Canalis carpi ulnaris: ulnar nerve, ulnar artery and veins.
The palmar aponeurosis forms 4 fascial spaces: 1) tenor 2) hypotenor 3) production for the flexor tendons of the fingers and worm. muscles 4) interosseous muscles
INVERSION
Median nerve(NS. medicinus ) h-z channel of the wrist.
Muscle branches retreat ( rami musculares ), innervating the abductor thumb muscle (T. abductor pollicis brevis ), opposing thumb (T. opponents pollicis ), superficial head of the short flexor of the thumb ( caput superficiale m. flexoris pollicis longi), as well as two vermiform muscles 1 and 2 (vols.lumbricales)
3 common palmar digital nerves, in the area of the metacarpal head bones are divided into own palmar digital nerves. Innervate the skin of the 1st, 2nd, 3rd and the radial half of the 4th finger.
Palmar branch, (ramus palmaris nervi mediani) - Skin of the lateral side of the palmar surface of the hand
Ulnar nerve- h-z the ulnar canal, divided on top. and deep. branches.
Surface: nn. digitales palmaris propii - skin 5 and honey side of 4 fingers
Deep: muscle branches to the honey group of the hand, 3 and 4 worm-worm muscles, interosseous, m. Adductor thumb, deep flexor head of the thumb.
BLOOD SUPPLY:
Arterial blood supply
Ulnar artery ( a . ulnaris ) on the wrist gives the palmar carpal branch ( ramus carpeus palmaris ), which, behind the flexor tendons, is directed laterally, where it anastomoses with the branch of the same name, the radial-palmar network of the wrist.
Further penetrates the hand through the ulnar canal , located at the lateral edge of the pisiform bone ( os pisiform ae), where ripple can be detected.
Distal to the pisiform bone, a deep palmar branch departs from the ulnar artery (G. palmaris profundus ), anastomoses with deep palmar arch ( arcuspalmaris profundus ) .
Further, the trunk of the ulnar artery is bent laterally, forming a superficial palmar arch ( arcuspalmarissupetflcialis ) ... The superficial palmar arch is located on the common synovial sheath of the flexor tendons of the fingers under the palmar aponeurosis; the arc is projected onto the skin of the palm along a transverse line running along the lower edge of the eminence of the thumb in the position of its maximum abduction. Four common palmar digital arteries extend from the superficial palmar arch (aa. digifales palmares communes ), three of which go to the three interdigital spaces of the II-V fingers, and the fourth goes to the elbow side of the little finger. Common palmar digital arteries merge with palmar metacarpal arteries (aa. metacarpeaepalmares ) - branches of the deep palmar arch. Each of the common palmar digital arteries at the level of the metacarpal heads divides into two own digital arteries (aa. digitales palmares propriae ), passing along the sides of the P-V fingers facing each other.
Radial artery ( a . radialis ) along the lateral canal of the forearm ( canalis antebrachii lateralis ) penetrates the wrist and gives up the palmar carpal and superficial palmar branches.
Palmar carpal branch (G. carpeus palmaris ) anastomoses with the branch of the ulnar artery of the same name.
Superficial palmar branch (G. palmaris superficialis ) anastomoses with the superficial palmar arch ( arcus palmaris superficialis ). Further, at the level of the styloid process of the radial bone, the radial artery passes into the radial fossa ( foveola radialis ), bounded laterally by the tendons of the abductor thumb muscle (T. abductorpollicis longus ), medially by the extensor longus tendon of the thumb (T. extensorpollicis longus ). The dorsal carpal branch departs there (r. carpeus dorsalis ), which gives off the dorsal metacarpal arteries. Each of the dorsal metacarpal arteries at the level of the metacarpophalangeal joints is divided into the dorsal digital arteries (aa. digitales dorsates ).
Under the extensor longus tendon of the thumb, the radial artery gives off the first dorsal metacarpal artery, which supplies the dorsum of the facing sides of the thumb and index fingers.
Further, the radial artery passes between the I and II metacarpal bones through the first dorsal interosseous muscle, gives the artery of the thumb of the hand ( a . princeps pollicis ) and radial artery of the index finger ( a . radialis indicis ), then on the anterior surface of the interosseous muscles forms a deep palmar arch ( arcus palmaris profundus ), anastomosing with the deep palmar branch of the ulnar artery. The deep palmar arch is located at the level of the base of the II-IV metacarpal bones, its projection is the transverse line, carried through the middle of the returnbush thumb... Palmar metacarpal arteries extend from the deep palmar arch (aa. metacarpeae palmares ), anastomosed with the common digital arteries ( a . digitales palmares communes ) - branches of the superficial palmar arch. The artery of the thumb of the hand is divided into two branches - the own palmar digital arteries (aa. digitales palmares propriae ) , running along the sides of the thumb.
Each finger is supplied with blood by its own palmar digital arteries passing along the sides, and on the back of the hand, near the lateral surfaces of the fingers, by the dorsal digital arteries.
Phlegmon brush
Superficial phlegmon of the palmar space... It is opened with an incision in the central part of the palm along its midline. The skin and aponeurosis are dissected (necrotic aponeurosis is excised within healthy tissues)
Deep phlegmon of the median palmar space (tendinous) are opened in a similar way. After dissection of the palmar aponeurosis, manipulations must be performed in a blunt way, fearing damage to the palmar arterial arches. If necessary, mo wn o resort to ligation of vessels with catgut.
Method Izlena
Distal interdigital incisions with phlegmon of the median palmar space recommends using Izlen .
The disadvantage of distal incisions is the lack of sufficient conditions for the outflow of purulent discharge, especially when the necrotic focus is located in the proximal part of the palm.
Method Voino-Yasenshchy
V.F. Voino-Yasenetsky recommended opening the phlegmon of the median palmar space with an incision connecting the middle of the wrist with the radial edge of the metacarpophalangeal joint of the second finger (see Fig. 4-123, a). A finger inserted into the wound under the first vermiform muscle and tendon easily penetrates into the deep median space and, for the purpose of revision, onto the back of the first intercarpal space, bending around the free edge of the interosseous muscle.
For severe phlegmon of the median palmar space, complicated by the breakthrough of pus on the forearm through the carpal canals, a zigzag incision is recommended, which allows not only to drain purulent leaks in the median palmar space, but also to evacuate pus from the space Pirogov-Parona after dissection of the palmar transverse ligament of the wrist.
Phlegmon of the V finger eminence
The phlegmon of the fascial-cellular space of the eminence of the V finger must, with the appropriate clinical picture, be opened with a linear incision in the place of the most pronounced fluctuation and hyperemia. After emptying the purulent-necrotic cavity, it must be drained.
Phlegmons of the I toe
When opening the phlegmon of the eminence of the first finger, it is necessary to beware of damage to the branch of the median nerve, the intersection of which will significantly limit the function of the hand.
interdigital fold. After dissecting the skin and tissue in a blunt way, they carefully penetrate the interosseous muscle into the space of the elevation of the first finger, the abscess is emptied and drained. The hand is fixed in a functionally advantageous position with some abduction of the first finger. The disadvantages of this method include the formation of coarse scar tissue in the first interdigital space with the subsequent limitation of the function of the hand due to a violation of the abduction of the first finger.
By method Canavella the phlegmon of the eminence of the first finger is opened with an incision carried out somewhat outward from the skin fold, delimiting the eminence of the first finger from the middle part of the palm. The length of the incision depends on the zone of pronounced fluctuation, thinning and changes in the skin. Usually, the lower border of the incision does not reach 2-3 cm to the distal transverse skin fold of the wrist. After dissection of the skin and tissue, further manipulations are carried out in a blunt way. Carefully penetrating deep with a finger, they eliminate all purulent streaks and pockets.
U-shaped phlegmon of the hand
With a U-shaped phlegmon of the hand with a breakthrough of pus into space Pirogov-Parona drain the tendon sheaths of the I and V fingers and space Pirogov-Parona .
Commissural phlegmon
The inflammatory process arises and is localized in the commissural spaces, the projection of which corresponds to the pads of the distal palm. These phlegmons are opened with linear incisions of the corresponding interosseous spaces. An incision about 2-3 cm long is made parallel to the hand axis. If necessary, an additional incision should be made in the adjacent commissural space.
In cases of the spread of the inflammatory process through the commissural spaces to the dorsum of the hand, it is necessary to drain purulent streaks through an additional incision on the dorsum of the hand.
When pus breaks out into the median palmar space, it is necessary to continue the incision in the proximal direction, dissect the aponeurosis and eliminate purulent streaks.
Commissural phlegmon mo wn o open and drain also with semi-arched incisions in the distal palm at the base of the finger in the corresponding commissural space.
36. Topographic anatomy of the fingers. Synovial sheaths. The concept of felon. Types of felon. Methods of surgical treatment of various types of felon.
LAYER-LAYER TOPOGRAPHY OF THE FINGER SURFACE OF THE FINGERS (Fig. 2-77)
1) Leather (cutis) the palm surface of the finger is dense, has a large number of sweat glands, there are no sebaceous glands and hair follicles.
2) body fat (panniculus adiposus) have a great thickness and density, are penetrated by connective tissue bridges, stretching from the skin to the fibrous sheath of the finger. As a result, the purulent process in the fatty deposits on the palmar surface of the finger usually extends inward.
Palmar digital arteries run in fat deposits on the sides of the finger. (aa.digitales palmarespropriae), which form an arterial network on the distal phalanges.
Palmar digital nerves (pp.digitales palmares) - branches of the median and ulnar nerves; passing along with the palmar digital arteries, they innervate the palmar surface of the proximal and middle phalanges, as well as the palmar and dorsal surfaces of the distal phalanx.
In the fatty deposits of the finger there is an abundant network of lymphatic capillaries that carry out the lymph through the lymphatic vessels passing along the lateral surfaces of the fingers and in the area of the metacarpophalangeal joints passing to the rear of the hand.
3) Fibrous sheaths of the fingers (vagg. flbrosae digitorum manus) begin at the level of the metacarpophalangeal joints and end at the base of the distal phalanx. At the level of the phalanx body, the fibrous vagina consists of strong transverse fibers -
vagina ( pars annularis vaginae flbrosae ), at the level of the joints consists of mutually intertwined oblique fibers - the cruciate part of the fibrous sheath ( pars cruciformis vaginae flbrosae ).
. Synovial sheaths of fingers ( vagg . synoviales digitorum manus ) contain the tendons of the superficial and deep flexors of the fingers.
4) The synovial sheath, covering the tendons from all sides, forms two sheets - parietal, called perithendinium ( peritendineum ), fixed to the walls of the osteo-fibrous canals, and visceral, lining the tendon. These sheets pass one into the other with the formation of a duplication, called mesotendinium. ( mesotendineum ) , between the leaves of which the vessels fit the tendon.
The superficial flexor tendon at the level of the metacarpophalangeal joint divides into two legs that attach to the base of the middle phalanx. The deep flexor tendon passes between the legs of the superficial flexor tendon, crossing the tendons ( chiasma tendinum ), and attaches to the base of the distal phalanx. The tendons of the superficial and deep flexors fit the tendon ligaments ( vinculo tendinum ), stretching from the back wall of the synovial sheath and containing vessels that supply blood to the tendons.
5) The phalanges of the fingers, covered with the periosteum, and the interphalangeal joints.
REAR FINGER LAYERS
1) Leather (cutis) on the dorsum of the fingers it is thinner and more mobile than on the palmar, it has sebaceous glands and hair.
Subcutaneous tissue ( panniculus adiposus ) represented by a thin, loose, almost fat-free layer in which the dorsal digital arteries run along the sides of the fingers ( aa . digitales dorsales ) and dorsal digital nerves (pp. digitales dorsales ), reaching the distal interphalangeal joint. In the subcutaneous tissue of the rear of the finger, the formation of the venous network of the rear of the hand begins ( rete venosum dorsale manus ), from which through the inter-head veins (w. intercapitales) there is an outflow into the dorsal metacarpal veins (w. metacarpeae dorsales).
2) Tendon extension on the back of the toe (Fig. 2-78) is formed due to the fusion of the extensor tendon of the fingers with the tendons of the interosseous and vermiform muscles. The extensor tendon of the fingers forms the central pedicle of the tendon stretch and attaches to the base of the middle phalanx. Side n och and tendon stretching are formed due to the tendons of the interosseous and vermiform muscles and are attached to the base of the distal phalanx.
3) In case of damage to the extensor tendon on the forearm and hand, extension in the metacarpophalangeal joint is impossible.
When the tendon extension of the finger is torn off from the distal phalanx, extension in the distal interphalangeal joint is disturbed, which eventually leads to flexion contracture in it.
With an isolated injury of the middle leg of the tendon extension of the finger, extension in the proximal interphalangeal joint is impossible while maintaining extension in the distal one. Over time, the ego leads to the formation of flexion contractures in the proximal and extensor contractures in the distal interphalangeal joint.
Under the tendon stretch on the back of the finger, the phalanges and interphalangeal joints covered with the periosteum are located. To construct the projection of the joint space of the metacarpophalangeal joint, a transverse line is drawn 8-10 mm distal to the convexity of the metacarpal bone head. The distal part of the line drawn in the middle of the lateral surface of the phalanx with the interphalangeal joint bent at a right angle corresponds to the projection of its joint space.
Blood supply and innervation - see previous question.
Felon
purulent inflammation of the tissues of the finger. from localization:
periungual (paronychium)
subcutaneous
tendinous
articular
pandactylitis
Operations:
Incisions are not allowed: at the level of interphalangeal folds and on the palmar surface.
Klyushkoobr incision with felon of the nails of the phalanx.
Tendon - Linear lateral incisions, drainage.
with paronychia - wedge-shaped, P-arr, paired lateral cuts.
Subunculate - resection of the nail plate, trepanation, removal of the entire nail.
Bone - resection or complete removal of the phalanx
37. Topography of the hip joint: bag-ligamentous apparatus, blood supply. Joint puncture: indications, technique. Arthrotomy: indications, technique. Hip joint, art. coxae, formed from the side of the pelvic bone by the hemispherical acetabulum, acetabulum, or rather her facies lunata, which includes the head of the femur. A fibro-cartilaginous rim runs along the entire edge of the acetabulum, labium acetabulare, which makes the depression even deeper, so that, together with the rim, its depth exceeds half the ball. This rim is over incisura acetabuli spreads over in the form of a bridge, forming lig. transversum acetabuli... The acetabulum is covered with hyaline articular cartilage only for facies lunata, a fossa acetabuli occupied by loose adipose tissue and the base of the ligament of the femoral head. The articular surface of the femoral head articulating with the acetabulum is generally equal to two-thirds of the ball. It is covered with hyaline cartilage, with the exception of fovea capitis, where the head ligament is attached. The hip joint capsule is attached around the entire circumference of the acetabulum. The attachment of the articular capsule to the thigh from the front goes along the entire length of the linea intertrochanterica, and from the back runs along the femoral neck parallel crista intertrochanterica, departing from it in the medial direction. Due to the described location of the line of attachment of the capsule on the femur, most of the neck is located in the joint cavity. Ligaments: extra- and intra-articular. Inside: 1. lig. transversum acetabuli, 2.lig. capitis femoris. It starts from the edges of the acetabulum notch and from the lig. transversum acetabuli, with the tip attached to fovea capitis femoris. The ligament of the head is covered with a synovial membrane, which rises to it from the bottom of the acetabulum. It is an elastic pad that cushions the shock experienced by the joint and also serves to guide it into the head of the femur a. lig. capitis femoris extending from a. obturatoria. Outside: 1. Iliofemoral ligament, lig. iliofemorale, or bertinium *, located on the front side of the joint. With its apex, it attaches to the spina iliaca anterior inferior, and with the extended base, to the linea intertrochanterica. Its width here reaches 7-8 cm, thickness - 7-8 mm. It inhibits extension and prevents the body from falling backwards when standing upright. This explains the greatest development of the bertinic ligament in humans, in whom it becomes the most powerful of all the ligaments of the human body, withstanding a load of 300 kg. 2. Pubic-femoral ligament, lig. pubofemorale, is located on the lower medial side of the joint. Starting from the eminentia iliopubica and the lower horizontal branch of the pubic bone, it attaches to the lesser trochanter. The ligament delays abduction and inhibits outward rotation. 3. Ischio-femoral ligament, lig. ischiofemorale, strengthens the medial part of the joint capsule. It starts behind the joint from the edge of the acetabulum in the area of the ischium, goes laterally and upward above the femoral neck and, woven into the bursa, ends at the anterior edge of the greater trochanter. 4. Circular zone, zona orbicularis, has the form of circular fibers that are embedded in the deep layers of the articular bag under the described longitudinal ligaments and form the basis of the fibrous layer of the articular capsule of the hip joint. The fibers of the zona orbicularis encircle the femoral neck in a loop, growing up to the bone under the spina iliaca anterior inferior
Blood supply to the joint: 1. R.acetabularis from a.obturatoria from a.iliaca int 2. R.acetabularis from a.circumflexa femoris med from a.profunda femoris from a.femoralis 3. Rr.musculares from a.circumflexa femoris med / lat from a.profunda femoris from a.femoralis
Puncture of the joint: Puncture of the hip joint can be performed from the anterior and lateral surfaces. The position of the patient on the back, the hip is straightened, somewhat abducted and rotated outward. To determine the point of injection, the established joint projection scheme is used. To do this, draw a straight line from the greater trochanter to the middle of the pupar ligament. The middle of this line corresponds to the head of the femur. At the point established in this way, the needle is injected, that is, the point of injection during puncture from the outer surface is above the apex of the greater trochanter, which can be easily felt (Fig. 180). At the set point, a needle is injected, which is carried out perpendicular to the plane of the thigh to a depth of 4-5 cm until it reaches the neck of the thigh. Then the needle is turned a little inward and by further advancing it deep into the joint cavity. When punctured from the front, the puncture point is located under the pupar ligament, somewhat retreating outward from the femoral artery, passing the needle perpendicular to the long axis of the thigh. As it penetrates the tissue, the needle rests on the femoral neck. Having given the needle a slightly cranial direction, they fall into the joint. Arthrotomy: Indications: treatment of inflammatory processes (purulent arthritis, chronic synovitis, etc.); damage or consequences of injuries to the joints. Patient position: on a healthy side, the operated limb is bent at the hip and knee joints at an angle of 120 °. Access by Kocher. The incision is made from the outer surface of the base of the greater trochanter up to the front edge of its apex and then continues angularly upward and inward, along the fibers of the gluteus maximus muscle. The skin, subcutaneous tissue and superficial fascia are dissected. The own fascia is opened along the grooved probe. The fibers of the gluteus maximus muscle are stratified in a blunt way, while exposing the greater trochanter. The gluteus medius and lesser muscles are cut off from the greater trochanter. The joint capsule is opened along the posterior surface with a linear incision. Completion of the operation: a drainage perforated PVC tube is inserted into the joint cavity, the free end of which is brought out through a separate puncture of the soft tissues in the gluteal region. On the postoperative wound, interrupted sutures and an aseptic dressing are applied in layers.
38. Topographic anatomy of the anterior region of the femur: borders, layers, femoral triangle, neurovascular bundle, projection line of the femoral artery (see 41) Topography of the adduction canal, relationship of the elements of the neurovascular bundle in the adductor canal. Ways of spreading purulent processes. Technique of opening the phlegmon of the anterior surface of the thigh. The upper border of the anterior region of the thigh- the line connecting the spina iliaca anterior superior and the pubic tubercle (projection of the inguinal ligament); lateral border of the anterior region of the thigh- a line drawn from this spine to the lateral epicondyle of the thigh; medial border of the anterior region of the thigh- the line going from the pubic symphysis to the medial epicondyle of the thigh; lower border of the anterior thigh- a transverse line drawn 6 cm above the patella.
Departments - thigh tr-k, thigh channel, obturator region, hunter channel.
The skin is thin, mobile. PZhK, vessels - pudenda ext (2), epigastr superf, circumfl ilium superf, veins - correspondence, flow into safena magna or femoral. Under the inguinal ligament, the skin is innervated by n.lumboinguinalis, late pov - n cut fem lat, anterior - femora; is (r cut ant). LU - superficial inguinal, superficial inguinal, deep inguinal. Own fascia - two leaves - superficial and deep .. Superficial - from 2 sections - late is dense, medial loose. Inside part of the surface of the leaf - f cribrosa. Thigh Triangle bounded from above by the inguinal ligament, outside by the sartorius muscle and inside by the long adductor muscle. The bottom of the triangle is mm. iliopsoas and pectineus. Muscles - surface (tensor f lata, Sartorius, gracilis, adductor longus), deep (pectineus, ilipsoas)
Lacunae - arcus iliopectineus divides into two holes. Outside the lacuna musculorum, through it, m. iliopsoas and m. femoralis. Lacuna vasorum lies inwardly from the previous one. It contains a. femoralis (outside) and v. femoralis (inside). Medial to the femoral vein is the inner opening of the femoral canal. The femoral artery in the femoral triangle is directed from the middle of the inguinal ligament to its apex. From the femoral artery, in addition to the above branches within this triangle, at a distance of 3-5 cm below the inguinal connection a. femoris profunda. She gives aa. circumflexa femoris medialis et lateralis and ends with three aa. perforantes. The femoral vein is located under the inguinal ligament medially from the artery, and at the apex of the femoral triangle, deeper than the artery. V flows into the femoral vein. saphena magna. Deep lymphatic vessels pass near the femoral vein and, near the inguinal ligament, flow into 5-6 nodes that receive lymph from the deep layers of the lower limb. N. femoralis (from the lumbar plexus) extends to the thigh, located on the front surface of m. iliopsoas. At the base of the femoral triangle, the nerve is outward from the femoral artery, separated from it by a deep leaf of the fascia lata of the thigh and splits into muscle and cutaneous branches. Only its long branch n. saphenus leaves with the vessels into the femoral-popliteal canal. Femur canal - inner ring: in front - groin ligament, behind - Cooper's ligament, honey - lacunar, late - thigh vein. Superficial (outer) ring of the femoral canal is an subcutaneous fissure, hiatus saphenus, a defect in the superficial layer of the fascia lata. The opening is closed with a latticed fascia, fascia cribrosa. Walls - Anterior wall of the femoral canal formed by the superficial sheet of the wide fascia between the inguinal ligament and the superior horn of the subcutaneous fissure - cornu superius. Lateral wall of the femoral canal- the medial semicircle of the femoral vein. Posterior wall of the femoral canal- a deep leaf of the wide fascia, which is also called fascia iliopectinea. The obturator canal is formed outside the bony obturator groove of the pubic bone, and from the inside by the upper outer edge of the membrana obturatoria with the muscles starting from it: from the side of the inlet - m. Obturatorius internus, from the side of the outlet - m. Obturatorius externus. The obturator artery with the veins of the same name and the obturator nerve, surrounded by fiber, pass through the canal. More often the nerve is located inward or in front of the vessels. The adducting canal (hunter, femoral-popliteal) is in the lower third of the thigh, in it is an artery, a vein, n.saphenus. Walls: outside - septum intermusc mediale, vastus med; inside and back - adductor magnus; front - l.vastoadductoria. 3 holes - upper - through it the SNP enters, lower - hiatus adductorius - the thigh vessels go to the posterior thighs and pass into the popliteal, the anterior - into the lamina vastoadd, through which the n.saphenus and the branch of the femoral artery emerge. (Genus descendens) Distribution: 1 ) fiber of the femoral triangle along the course of the femoral vessels through the vascular lacuna is connected with the subperitoneal floor of the pelvis; 2) along the superficial branches of the femoral vessels through the holes in the ethmoid fascia filling the hiatus saphenus, it is connected with the subcutaneous tissue of the femoral triangle; 3) along the lateral artery around the femur, - with the gluteal region; 4) along the medial artery around the femur, - with a bed of adductor muscles; 5) along the femoral vessels- with a leading channel; 6) along the perforating branches of the deep artery of the thigh, aa. perforantes, - with the posterior fascial bed of the thigh. For opening the anterior bed (4-headed m), incisions along the anterior-external thigh. With deep phlegmon - cuts along the honey and armor edges of the rectus femoris. The bed of the adductor muscles - incisions along the anterior-honey of the thighs, missing 2-3 cm from the projection of the line of the femoral hip.
39. Topographic anatomy of the posterior region of the thigh. Borders, layers, muscle-fascial sheaths, vessels and nerves. Ways of spreading purulent processes. Technique of opening and draining phlegmon. The upper border of the back of the thigh- transverse gluteal fold, plica glutea, lower border of the back of the thigh- a circular line drawn 6 cm above the patella, medial border of the posterior thigh- the line connecting the pubic symphysis with the medial epicardium of the femur, lateral border of the posterior region of the thigh- a line drawn from the spina iliaca anterior superior to the lateral epicondyle of the thigh.
The skin is thin, easily movable (innerve outside - cutaneus femoris lat, inside - genitofemoralis, fem, obtur, the rest - cut fem post). PZhK - well expressed. The superficial fascia is in the thickness of the pvc. Wide f - 1 layer, in the medial part of it departs the septum intermusc post (separates the adductors and flexors). Muscles - flexion of the lower leg, 2 groups (semitendinosus, semembranosus - medially, biceps - late). N.ischiadicus goes in the furrow between them, is divided into tibialis and peroneus communis.
Opening of phlegmon and leaks - longitudinal cuts along the lat edge of the biceps femoris or along the semitendinosus m.
40. Exposure of the sciatic nerve in the gluteal region and upper third of the thigh. Projection line, access, sciatic nerve block.
Projection line: from the middle of the distance between the ischial tuberosity and the greater trochanter (from the border between the inner and middle third line, connecting these points) to the middle of the popliteal fossa. Access: Roundabout? In the gluteal region: an arcuate skin incision (with a bulge outward) starts from sp.iliaca post.sup. and to the outer part of the greater trochanter through the gluteal fold to the thigh. The gluteal fascia is incised at the upper and lower edges of m.glut.max and penetrate with a finger under this muscle. Under the protection of a finger (probe), its tendon is crossed. A deep leaf of the gluteal fascia is dissected, the skin-mouse flap is pulled upward and medially, with a swab it has corroded the tissue covering m.piriformis, and n.ischiadicus is found at the lower edge of this muscle. (Hagen-Thorn access). In the thigh area - an incision medial to the projection of the nerve, along a line drawn from the middle of the distance between the sciatic tuberosity and the greater trochanter to the middle of the poplite fossa. The fascia lata is dissected, penetrated between the biceps and semitendinosus muscles, and the sciatic nerve is found.
The sciatic nerve block is performed using two possible techniques. When using the first technique, the patient is placed on his side so that the limb to be blocked is on top, which is slightly bent at the knee and hip joints. The puncture point of a long needle (12 cm) is marked 3-4 cm distal and perpendicular to the line connecting the greater tubercle and the posterior superior iliac spine. When using the second technique, the patient remains on his back on a hard surface. The knee joint is slightly bent (using padding). The needle insertion point is located 3 cm distal to the large tubercle. The needle is held in a horizontal plane to a depth of 6-7 cm.
The manual introduces the technique of basic operations, examines the relative position of organs and tissues in different parts of the body. For students of higher medical schools.
LECTURE 11. TOPOGRAPHIC ANATOMY OF THE BRUSH REGION
1. Borders. The hand is delimited from the forearm by a line 2 cm above the styloid process of the ray. Areas of the hand - wrist, metacarpus, fingers. By the radial and ulnar edges, it is divided into the palmar and dorsal regions. External landmarks- styloid processes of the ulna and radius, skin folds of the wrist, grooves and folds of the palm, palmar-digital and interdigital folds, the heads of the metacarpals and phalanges of the fingers.
2. Palmar area... At the level of the styloid processes, three transverse skin folds are visible. At the ulnar edge of the palm, the pisiform bone is proximal. Lateral to it is the neurovascular bundle. The middle wrist fold serves as the projection line of the wrist joint. Between the two elevations formed by the muscles of the I and V fingers is triangular palmar cavity, apex facing proximally. It corresponds to the location of the palmar aponeurosis. The proximal third of the longitudinal skin fold delimiting the thenar from the palmar aponeurosis - restricted area of Canavela, here is the motor branch of the median nerve muscles of the 1st finger. Opposite the interdigital folds, there are three elevations - pads. They correspond commissural openings of the palmar aponeurosis. The synovial sheaths of the tendons of the II – IV fingers are projected into the grooves between the pads. The transverse folds of the palmar surface of the fingers correspond to the ligaments that strengthen the fibrous canals of the flexor tendons. Leather thick, inactive. In the subcutaneous layer, at the base of the hypothenar, there are transverse bundles of the short palmar muscle. At the lateral edge of the wrist, r passes. palmaris superficialis a. radialis. Fascia is a thickening of the distal fascia of the forearm. Near the pisiform bone, the fascia forms a canal where the neurovascular bundle passes. The flexor tendon retainer is a ligament consisting of transverse fibers thrown in the form of a bridge over the bony edges of the palmar surface of the wrist. The ligament is stretched between the scaphoid and trapezius bones on one side, and the pisiform and uncinate bones on the other. This place is formed wrist canal, through which the flexor tendons and the median nerve pass. The anterior wall of the canal is the superficial leaf of the ligament, the posterior wall is the bones of the wrist and the deep leaf of the ligament. The intrinsic fascia of the palm is unevenly expressed. The muscles of the eminences of the I and V fingers are covered with a thin plate, and on the palmar cavity it is represented by the palmar aponeurosis.
The longitudinal fibers of the aponeurosis are combined into 4 bundles, heading to the bases of the II and V fingers. The intervals between the longitudinal and transverse bundles of the aponeurosis are called commissural holes... From the longitudinal bundles of the aponeurosis to the deep transverse metacarpal ligaments, proximally under the aponeurosis, there are vertical tendon septa forming fibrous the intercarpal canals, where the worm-like muscles are located. There are two fascial intermuscular septa: lateral and medial. Lateral- goes vertically inward, then, horizontally forming a fold in the form of a fold, and attaches to the V metacarpal bone. Medial- attaches to the V metacarpal bone. Fascial beds - lateral, median and medial. Lateral, in front - own fascia; behind - deep fascia and I metacarpal bone; medial - lateral intermuscular septum; laterally - due to the attachment of its own fascia to the I metacarpal bone. It contains the muscles of the first finger - m. abductor pollicis brevis, m.flexor pollicis longus, m.flexor pollicis brevis, m. opponens pollicis, m. adductor pollicis ... Medial, in front and medially - its own fascia, attached to the V metacarpal bone, behind - the V metacarpal bone, laterally - in the medial intermuscular septum. It contains the muscles of the V finger: m. abductor digiti minimi, m. opponens digiti minimi, m.flexor digiti minimi brevis. Median: in front - palmar aponeurosis, behind - deep fascia, laterally and medially - intermuscular septa of the same name. The flexor tendons are located in it, dividing it into two slits: subgaleal and subtendinous, in which the superficial and deep arterial arches are located. The flexor tendons of the II-V fingers are located in the common synovial sheath from Pirogov's space to the middle of the metacarpal bones. The tendon of the V finger further lies in a separate synovial sheath and ends at the base of the distal phalanx.
3. The area of the back of the hand: In the area of the wrist at the radial edge of the hand, when abducting the first finger, a fossa is visible - anatomical snuffbox... The radial artery and scaphoid bone are projected in it. At the apex of the styloid process of the ulna, a branch of the ulnar nerve is projected, which innervates the skin of the V, IV and ulnar side of the III finger. At the apex of the styloid process of the ray, the branches of the radial nerve are projected, innervating I, II and the radial side of the III finger. Projection wrist joint goes along an arc, the apex of which is 1 cm above the line connecting the tops of the styloid processes. The projection of the joints of the interphalangeal joints is determined in the position of full flexion of the fingers by 2-3 mm. below the protuberances of the phalanx heads. The joint gap of the metacarpophalangeal joints corresponds to a line located at 8–10 mm. below the heads of the metacarpal bones. The skin is thin, mobile. The subcutaneous tissue is loose, it contains superficial vessels and nerves. The fascia at the level of the wrist joint is thickened and forms extensor retinaculum... Below it is 6 osteo-fibrous canals... The canals contain the extensor tendons of the hand and fingers. In the area of the metacarpus between its own and deep fascia is subgaleal space where the extensor tendons of the fingers are located. On the back of the fingers extensor tendon consists of three parts, the middle one is attached to the base of the middle one, and two lateral ones - to the base of the distal phalanx. Above the proximal phalanx there is an aponeurotic extension, into the edges of which the tendons of the vermiform and interosseous muscles are woven. The interphalangeal joints are reinforced with lateral ligaments.
BRUSH AREA (REGIO MANUS)
The hand refers to the distal part of the limb located to the periphery of the line connecting the tops of the styloid processes of the forearm bones. On the skin, this line almost coincides with the proximal (upper) carpal fold, from which there are two more folds downward; middle and distal (lower).
The proximal part of the hand area is distinguished under the name of the "wrist area" (regio carpi), distal to which is the metacarpus (regio metacarpi), and even more distal - the fingers (digiti).
On the hand, the palmar surface is distinguished - the palma manus (vola manus - BNA) and the back - the dorsum manus.
Outdoor landmarks
In the area of the wrist, from the ulnar side, in front, you can easily feel the pisiform bone, as well as the ulnar flexor tendon attached to it. Below the pisiform bone, the hook of the uncinate bone (hamulus ossis hamati) is felt. On the radial side of the palmar surface, right along the tendon of the renal flexor of the hand, the tubercle of the scaphoid is palpable. On the back side from the ulna side, the trihedral bone is well defined, located distal from the ulna.
Distal from the apex of the styloid process of the radius - when the thumb is abducted - there is a triangular depression called an "anatomical snuffbox". Along the bottom of this depression, formed by the scaphoid and large polygonal bones, a.radialis passes (from the palmar surface to the back).
The metacarpal (metacarpal) bones can be felt from the back of their entire length.
The lateral parts of the palm look like elevations formed by the muscles of the thumb (thenar) and the little finger (hypothenar). The middle section looks like a depression and contains the flexor tendons of the fingers (with worm-like muscles) and interosseous muscles.
On the back of the hand, the dorsal metacarpal veins are visible, forming the venous plexus, as well as the extensor tendons of the fingers; sometimes the transverse ligaments are also visible, connecting the tendons of this muscle. When the thumb and forefinger are brought together, on the back of the hand between I and II) the metacarpal bone becomes visible elevation formed by the I dorsal interosseous muscle.
Palm (palma manus)
The skin (with the exception of the wrist area) is dense and low in mobility due to the fact that it is firmly connected with the palmar aponeurosis; it is rich in sweat glands and hairless. All layers of the skin of the palm are significantly diffuse, and the epithelium of the stratum corneum forms several tens of rows of cells.
The subcutaneous tissue is permeated with dense fibrous, vertically arranged bundles that connect the skin with the aponeurosis. As a result, the fiber appears to be enclosed in fibrous nests, from which it bulges out in the form of separate fatty lobules during skin incisions. Small veins pass through the tissue, as well as the palmar branches of the median and ulnar nerves, which innervate the skin in the wrist, thenar and hypothenar and branches of the common palmar digital nerves.
Deeper than the skin and subcutaneous tissue in the area of the wrist and thenar is its own fascia. In the area of the wrist, it thickens, as a result of which it acquires the character of a ligament, which was formerly called lig.carpi volare (BNA). The tendon of the long palmar muscle, which runs approximately along the midline of the forearm, is closely connected with it.
Under the skin of the hypothenar, the small palmar muscle is superficially located, deeper than which is its own fascia, which covers the rest of the muscles of the eminence of the small toe.
The central part of the palm region, between thenar and hypothenar, is occupied by the palmar aponeurosis (aponeurosis palmaris). It has a triangular shape with the apex facing the wrist and the base toward the fingers. The palmar aponeurosis consists of superficial longitudinal fibers (continuation of the tendon of the palmaris longus.) And deep transverse
In the distal part of the hand, the longitudinal and transverse fibers of the palmar aponeurosis are limited by three so-called commissural holes through which the digital vessels and nerves pass into the subcutaneous layer. Correspondingly to the commissural openings, the subcutaneous tissue of the palm forms fatty "half-pieces", which are visible in the form of protrusions between the heads of the II-V metacarpal bones with the fingers extended. These fatty accumulations are limited by connective tissue cords connecting the palm skin with the longitudinal fibers of the palmar aponeurosis; the areas of the palm occupied by adipose tissue are called commissural spaces. The fiber surrounding the digital neurovascular bundles connects the subcutaneous tissue of the commissural spaces with the middle fiber space of the palm.
In the commissural space, phlegmon (commissural phlegmon) may develop on the basis of corn suppuration. Pus with this phlegmon can spread through the tissue that accompanies the digital vessels and nerves, into the middle cellular space of the palm, resulting in a subgaponeurogic phlegmon of the palm.
The palmar aponeurosis with partitions extending from it and the intrinsic fascia of the palm form three chambers, usually called fascial beds. There are two lateral beds (lateral and medial) and one middle.
Middle bed passes proximally into the carpal canal, while the lateral and medial beds are relatively closed containers and, under normal conditions, communicate only with the middle bed along the vessels and nerves.
At the borders with thenar and hypothenar, intermuscular septa depart from the palmar aponeurosis: lateral and medial. The lateral septum consists of two parts: vertical and horizontal. Vertical; part of the septum is located medially from the main mass of the thenar muscles, and the horizontal one goes in front of the adductor muscle of the thumb, attaching to the III metacarpal bone. In the hypothenar region, the septum limits the hypothenar bed from the outside, goes inward and attaches to the V metacarpal bone.
Lateral palm bed(bed thenar) contains the muscles of the eminence of the thumb, starting from the transverse ligament and the bones of the wrist: m.abductor pollicis brevis lies most superficially, deeper - m.opponens pollicis (lateralpo) and m.flehog pollicis brevis (medially). The adductor muscle of the thumb, starting with two heads from II-III of the grazed bones, belongs, like the interosseous muscles, to the layers located in the depths of the middle part of the palm. Through the lateral bed, between the two heads of the long flexor of the thumb, passes the tendon of the long flexor of the thumb, surrounded by the synovial sheath. Branches of the median nerve and radial artery also pass in the thenar bed.
Medial palms(the hypothenar bed) contains the muscles of the elevation of the thumb: mm.abductor, flexor and opponens digiti minimi (quinti - BNA), of which the abductor lies at the ulnar edge of the palm. On top of these muscles, outside the medial bed, is the above-mentioned fourth muscle of the eminence of the small toe - m.palmaris brevis. In the hypothenar bed are the branches of the ulnar nerve and ulnar artery.
Middle palm contains the tendons of the superficial and deep flexors of the fingers, surrounded by the synovial sheath, three vermiform muscles and the vessels and nerves surrounded by fiber; superficial palmar arterial arch with its branches, branches of the median and ulnar nerves. Deeper than the middle bed, the interosseous muscles, the deep branch of the ulnar nerve and the deep palmar arterial duta are recognized
In the proximal palm, under the aponeurosis, there is an associated retaining flexor ligament (retinaculum flexorum), formerly called the transverse wrist ligament (lig.carpi transversum - BNA). It spreads in the form of a bridge over the groove, which is formed from the side of the palm by the bones of the wrist, covered with deep ligaments. This creates a carpal tunnel (canalis carpi), in which the 9 flexor tendons of the fingers and the median nerve pass. Lateral to the carpal tunnel is another canal (canalis carpi radialis), formed by the sheets of the transverse ligament and a large polygonal bone; it contains the tendon of the radial flexor of the hand, surrounded by the synovial sheath.
Vessels and nerves
On the radial side of the area, on top of the muscles of the eminence of the thumb or through the thickness of these muscles, a branch of a.radialis - r.palmaris superficialis passes. It participates in the formation of the superficial palmar arch, while the radial artery itself passes under the tendons of the dorsal muscles of the thumb, through the "anatomical snuffbox", to the back of the hand.
In the carpal tunnel, as already mentioned, the median nerve passes along with the flexor tendons. Here it is located between the long flexor tendon of the thumb, which runs laterally from the median nerve, and the tendons of both flexors of the fingers, which runs medially from the nerve. Already in the carpal tunnel, the median nerve divides into branches leading to the fingers.
On the elbow side of the wrist area are vasa ulnaria and n.ulnaris. This neurovascular bundle goes in a special channel (canalis carpi ulnaris, s.spatium interaponeuroticum), located at the pisiform bone. The canal is a continuation of the ulnar groove of the forearm and is formed due to the fact that between the lig.carpi volare (this was the former name of the thickened part of the fascia of the wrist) and the retinaculum flexorum there is a gap: the artery and nerve pass here immediately outside the pisiform bone, and the nerve lies inward from the artery.
Superficial palmar arch
Directly under the palmar aponeurosis, in the layer of tissue, is located superficial palmar arch, arcus palmaris (volaris - BNA) superficialis. The main part of the palmar arch is more often formed due to a.ulnaris, anastomosing with r.palmaris superficialis a.radialis. The ulnar artery appears in the palm of the hand after it has passed through the canalis carpi ulnaris. The superficial branch of the radial artery merges with the superficial branch of the ulnar artery distal to the retaining flexor ligament. The resulting palmar arch lies with its convex part at the level of the middle third of the third metacarpal bone.
Three large arteries aa.digitales palmares communes arise from the palmar arch, which, at the level of the heads of the metacarpal bones, emerge from under the palmar aponeurosis through the commissural openings and, taking in the metacarpal arteries arising from the deep incense arch, divide into their own digital arteries supplying the facing each other to the other side of the II, III, IV and V fingers. The ulnar edge of the little finger receives a branch from the ulnar artery (before it forms an arc), the thumb and radial edge of the index finger receives supply, usually from the branch of the terminal section of the radial artery (a.princeps policis).
Immediately under the palmar arch are the branches of the median nerve (lateral) and the superficial branches of the ulnar nerve (medial): here, according to the arteries, there are nn.digitales palmares communes, dividing into nn.digitales palmares proprii; they also exit through the commissural openings and go to the fingers. It is believed that the median nerve gives the sensitive branches of the I, II, III fingers and the radial side of the IV finger, the ulnar nerve - the V finger and the ulnar side of the IV finger.
However, as the study of differences in the structure of the median and ulnar nerves has shown, only the skin of the thumb is innervated by one median nerve, just as only the skin of the ulnar side of the little finger is innervated by one ulnar nerve. The rest of the zones of cutaneous innervation of the fingers should be considered as zones of mixed innervation.
The deep branch of the ulnar nerve is predominantly motor. It separates from the common nerve trunk at the base of the hypothenar, and then goes deep, between mm.flexor and abductor digiti minimi, together with the deep branch of the ulnar artery, which participates in the formation of the deep palmar arch.
The deep branch of the ulnar nerve and the median nerve innervate the muscles of the palm as follows. The deep branch of the ulnar nerve innervates the muscles of the eminence of the V finger, all the interosseous muscles, the adductor muscle of the thumb and the deep head of the short flexor of the thumb. The median nerve innervates a portion of the muscles of the eminence of the thumb (abductor muscle, superficial flexor head, opposing muscle) and the vermiform muscles. However, some of these muscles have double innervation.
Immediately upon exiting the carpal tunnel into the middle palmar bed, the median nerve gives a lateral branch to the muscles of the eminence of the thumb. The place where this branch departs from the median nerve is designated in surgery as a "forbidden zone" due to the fact that incisions made within this zone can be accompanied by damage to the motor branch of the median nerve to the muscles of the thumb and dysfunction of the latter. Topographically, the "exclusion zone" roughly corresponds to the proximal half of the thenar region.
Deep palmar arch
Arcus palmaris profundus lies on the interosseous muscles, under the flexor tendons, being separated from the latter by fiber and a plate of the deep palmar fascia. In relation to the superficial, the deep arch lies more proximally. The deep arch is formed mainly by the radial artery, passing from the rear through the first intercarpal space and anastomosing with the deep palmar branch of the ulnar artery. Aa.metacarpeae palmares depart from the arch, which anastomose with the dorsal arteries of the same name and flow into aa.digitalеs palmares communes.
Synovial sheaths of the palm
The flexor tendons of the fingers have synovial sheaths. On the I and V fingers, the synovial sheaths of the flexor tendons continue into the palm, and only in rare cases is the digital section of these sheaths separated from the palmar by the septum. The palmar parts of the sheaths of the I and V fingers are called synovial sacs or bags. Thus, two bags differ: radial and ulnar. The radius contains one tendon (flexor hallucis longus); the ulnar, in addition to the two flexors of the little finger, also contains the proximal part of the flexor tendons of the II, III and IV fingers; in total, therefore, eight tendons: four superficial tendons and four - deep flexor of the fingers.
In the proximal part of the hand, both bags, radial and ulnar, are located in the carpal tunnel, under the retinaculum flexorum; the median nerve passes between them.
The proximal blind ends of both synovial sacs reach the forearm, located on a square pronator, in the tissue of the Pirogov space; their proximal border is 2 cm up from the apex of the radial styloid process.
Cellular spaces of the palm
The cellular spaces of the palm in each fascial bed of the palm has its own cellular space: in the thenar muscle bed - the lateral palmar space, in the hypothenar mouse bed - the medial palmar space, on average: the bed - the middle palmar cellular space. In practice, the most important are two spaces - lateral and middle.
Lateral cellular space known in the surgical clinic as the thenar slit, stretches from the third metacarpal bone to the first interdigital membrane, more precisely to the tendon of the long flexor of the thumb, surrounded by the radial synovial bursa. The thenar space is located on the anterior surface of the transverse head of the adductor muscle of the thumb, laterally from the middle cellular space of the palm, and is separated from the latter by a lateral intermuscular septum. The horizontal part of this septum covers the front of the thenar slit.
Medial cellular space, otherwise - the gap of the hypotenar, is located within the medial fascial bed. This gap is tightly delimited from the middle cellular space.
Middle palmar tissue space from the sides it is limited by intermuscular septa, from the front - by the palmar aponeurosis, from the back - by the deep palmar (interosseous) fascia. This space consists of two slots: superficial and deep. The superficial (subgaponeurotic) gap is located between the palmar aponeurosis and the flexor tendons of the fingers, the deep (subtendinous) gap is between the tendons and the deep palmar fascia. In the subgaleal fissure are the superficial palmar arterial arch and branches of the median and ulnar nerves. Along the course of the vessels and nerves, the tissue of this gap communicates through the commissural openings with the subcutaneous tissue in the region of the heads of the metacarpal bones. The subtendinous cellular cleft of the palm distally leads to the back surface of the III, IV and V fingers along the channels of the worm-like muscles: this is how the connective tissue gaps are noted in practical surgery, in which the worm-like muscles, surrounded by fiber, pass. Through these channels, pus from the middle cellular space of the palm can reach the dorsum of the fingers. The tendon cleft of the palm can communicate through the carpal tunnel with Pirogov's deep cellular space on the forearm.
The suppurative process in the synovial sheaths of the fingers is denoted by the term "purulent tendovaginitis of the finger", and purulent inflammation of the palmar synovial sacs is called "purulent tendobursitis of the palm." spaces of the palm.
If the synovial sacs of the palm are affected by the purulent process, then the further spread of the process can go in three directions: 1) pus from one synovial sac can pass into another synovial sac, resulting in the so-called V-shaped, or cross, phlegmon of the hand. This transition of pus may be due to the presence (in 10% of cases) of communication between the radial and ulnar synovial sac or the fact that pus melts the adjacent walls of both sacs; 2) rupture of the palmar synovial sacs leads to the development of a suppurative process in the cellular spaces of the palm; with lesions of the radial synovial sac - in the thenar tissue space, with lesions of the ulnar synovial sac - in the middle cellular space of the palm; 3) if the rupture of the synovial sacs occurs in their proximal (carpal) section, then purulent streaks are formed in the Pirogov space of the forearm; may be involved in the purulent process and the wrist joint.
Brush (manus)- the distal part of the upper limb.
Brush border
The area of the upper limb located distal to the plane drawn through the tops of the styloid processes of the forearm bones.
The hand is divided into three parts: the wrist area ( carpus), distal to which is the metacarpal region (metacarpus) and fingers (digiti manus) .
The palmar surface is distinguished on the hand (palma manus) and back (dorsum manus) ... The lateral parts of the palm look like elevations formed by the muscles of the thumb. (thenar) and little finger (hypothenar) ... The middle part of the palmar cavity contains the flexor tendons of the fingers (with worm-like muscles) and the interosseous muscles.
On the radial side on the back of the hand, with the thumb abducted, a triangular depression is defined, called "Anatomical snuffbox".
Borders are
from the radial side tendons m. abductor pollicis longus and m. extensor pollicis brevis,
with elbow- tendon m. extensor pollicis longus.
By bottom this depression, formed by the scaphoid and large polygonal bones, passes (from the palmar surface to the back) the radial artery (a. radialis) , which in case of bleeding can be pressed against the scaphoid bone.
Wrist
abovelimited a horizontal line extending 1cm. proximal to the styloid processes of the radius and ulna,
from below- a line drawn distal to the pisiform bone (corresponds to the distal transverse folds of the wrist).
Lines passing through the styloid processes divide the wrist into anterior and posterior regions.
The bone base is made up of eight wrist bones arranged in two rows. Proximal row from the radial side - scaphoid (os scaphoideum) , lunar (os lunatum) , triangular (os triquetrum) and pea (os pisiforme) ;
distal row- bone trapezoid (os trapezium) , trapezoidal (os trapezoideum) , capitate (os capitatum) and hooked (os hamatum) .
The bones of the proximal row, with the exception of the pisiform, are involved in the formation of the wrist joint. An intercarpal joint is formed between the first and second row.
2.2 Topographic anatomy of the wrist joint (articulatio radiocarpea).
Wrist joint educated articular surface radius which articulates with scaphoid and crescent bones. The head of the ulna does not reach the bones of the wrist, and the lack of bone is made up for by the cartilage - fibrocartilago triangularis, which serves as an articular surface for the trihedral bone.
Articular capsule attached at the edges of the articular surfaces and strengthened following ligaments:
behind dorsal wrist (lig. radiocarpeum dorsale),
in front palmar wrist ( lig. radiocarpeum palmare)
palmar elbow (lig. ulnocarpeum palmare) ,
laterally radial collateral ( lig. collaterale carpi radiale) ,
medially ulnar collateral (lig. collaterale carpi ulnare).
Weak spots wrist joint:
synovial saccular volvulus (recessus saccifomis)
cartilage - fibrocartilago triangularis
Blood supply: rete carpi palmare et dorsale formed by the branches of the radial, ulnar and interosseous arteries.
Innervation: branches of the radial, ulnar, anterior and posterior interosseous nerves.
Projection joint:
In front, the joint is projected onto the proximal palmar skin fold of the wrist.
Leather the palmar surface of the fingers is distinguished by the development of all layers, contains a large number of sweat glands; has no hair and sebaceous glands.
Subcutaneous tissue on the palmar side, it contains a large amount of adipose tissue, which is divided by fibrous bundles connecting the papillary layer with the periosteum of the terminal phalanges, and with the fibrous sheaths of the flexor tendons. On the dorsum of the fingers, the skin is thinner and the subcutaneous fat layer is poorly developed.
The skin and subcutaneous tissue has a developed network lymphatic capillaries, especially on the palmar surface. Small vessels, merging on the lateral surfaces of the fingers, form 1–2 abducent trunks, which, in the area of the interdigital folds, pass to the rear of the hand.
The presence of loose fiber and a dense network of lymphatic capillaries explains the fact that with purulent inflammation on the palmar surface of the fingers and hand, edema of the back of the hand is usually observed.
Osteo-fibrous canals
The palmar fascia of the fingers, attaching itself along the edges of the palmar surface of the phalanges, and to their periosteum, form dense fibrous channels for the tendons on the fingers, which are surrounded by synovial sheaths.
Longitudinal bundles of the palmar aponeurosis are also involved in the formation of bone-fibrous canals, which, passing onto the fingers, are attached along the edges of the palmar surface of the phalanges.
Fibrous sheaths are strengthened by ligaments (annular, oblique, cruciform), thanks to which the tendons of the fingers are pressed against the phalanges and do not move away from them when bent.
The flexor tendons located in the fibrous canals are covered with synovial sheaths from the heads of the metacarpal bones to the base of the nail phalanges.
Synovial membranes
Synovial sheaths have two sheets, passing one into the other:
1) Parietal leaf - peritendinium (peritendineum)- lines the fibrous canal from the inside.
2) Visceral leaf (epithenon - epitenon) covers the entire circumference of the tendon, with the exception of a small area in the back, where the supply vessels approach the tendon. This area is called the tendon mesentery (mesotendinium - mesotendineum). Here the parietal leaf passes into the visceral leaf.
With purulent processes, the exudate compresses the vessels, because the vaginal cavity is narrow, and the walls of the fibrous canal, in which the synovial vagina is located, are not very malleable. As a result of compression, tendon necrosis can occur.
Each finger on the palmar surface has two tendons:
ü the tendon of the superficial flexor, splits into two legs and attaches to the base of the middle phalanx;
ü The deep flexor tendon passes between these legs and attaches to the base of the nail phalanx.
Blood supply
Each toe has 4 digital arteries. The digital arteries run in the subcutaneous tissue and lie on the lateral surfaces. The dorsal arteries do not reach the terminal phalanges, while the palmar arteries form an arc on the terminal phalanges, from which small branches arise, forming an arterial network in the tissue of the fingers. Arteries are not accompanied by veins.
Venous outflow
Blood from the palmar surface of the fingers flows to the rear.
Innervation
The innervation of the fingers is carried out:
on the palmar surfaces - median and ulnar nerves,
on the back- radial and ulnar.
The dorsal nerves reach the middle phalanges, the palmar nerves supply the skin of the palmar and dorsal surface of the terminal phalanges.
Lymphatic drainage
Lymph from the skin of the fingers flows mainly into the axillary nodes. However, lymphatic drainage from the V and IV fingers can first be carried out into the ulnar nodes, and then the nodes of the axillary region. A feature of the lymphatic drainage of the II and III fingers is the presence of a separate trunk that runs along v. cephalica and ends in the subclavian or even supraclavicular nodes. Thus, with panaritium of the II and III fingers, purulent inflammation of the sub- or supraclavicular lymph nodes may occur.
Topography of neurovascular formations of the hand
Blood supply
Superficial arterial arch (arcus palmaris superficialis)
Situated in the tissue in the subgaleal fissure of the median bed.
Formed mainly due to the ulnar artery (a. ulnaris) that anastomoses with the superficial branch of the radial artery (ramus palmaris superficialis a.radialis).
Three common palmar digital arteries are formed from the palmar arterial arch (a.a.digitalis palmares communes), which in the commissural foramina, taking in the metacarpal arteries from the deep arterial arch, are divided, each into two own palmar digital arteries (a.a.digitales palmares propriae).
Superficial palmar arterial arch projection
Vertex superficial palmar arterial arch projected in the middle of a line drawn from the pisiform bone to the medial edge of the palmar-digital fold of the index finger.
Deep arterial palmar arch (arсus palmaris profundus)
Situated under the deep own fascia of the palm on the interosseous muscles.
Formed mainly due to the continuation of the main trunk of the radial artery, which passes from the rear through the I intercarpal space and the deep palmar branch of the ulnar artery.
Four palmar metacarpal arteries ( a.a.metacarpeae palmares), which give off perforating branches ( r.r.perforantes). They anastomose to the dorsal metacarpal arteries from the dorsal network of the wrist.
Deep palmar arterial arch projection
Vertex deep palmar arterial arch is projected 1.5 cm proximal to the projection of the superficial palmar arch or at the level of the fusion of the palmar folds of the elevations of the I and V fingers.
Dorsal arterial network of the wrist
In the formation of the dorsal arterial network of the wrist, the dorsal carpal branch of the ulnar artery, the anterior and posterior interosseous arteries take part.
Blood supply to the thumb
Penetrating into the palm, the radial artery gives off the artery of the thumb of the hand (a.princeps pollicis), which goes to both sides of the first finger and to the radial side of the second finger ( a. radialis indicis).
On the back of the hand from the radial artery where it enters the thickness of the first interosseous muscle is separated first dorsal metacarpal artery (a.metacarpalis dorsalis prima), which gives off a branch to the radial side of the I finger and to the adjacent sides of the I and II fingers.
Innervation
Palmar surface of the hand
Under the superficial palmar arch are the branches of the median nerve (r.n. medianus) and superficial branches of the ulnar nerve (r. superficialis n. ulnaris). From these branches, the common palmar digital nerves are formed. (n.n.digitales palmares communes), which, approaching the fingers, are divided into their own palmar digital nerves (n.n.digitales palmares propria)... The median nerve supplies the I, II, III and radial side of the IV finger, the ulnar - the V and ulnar side of the IV finger.
The back of the hand innervated by the superficial branch of the radial and dorsal branch of the ulnar nerves. Radial - provides sensitive innervation of the I, II and radial sides of the III fingers, ulnar - IV, V and ulnar sides of the III finger.
Forbidden zone "of the hand, its boundaries, anatomical rationale
Upon exiting the carpal canal into the middle palmar bed, the median nerve gives a branch laterally to the muscles of the eminence of the thumb.
The place where this branch departs from the median nerve is designated in surgery as the “forbidden zone” of the hand according to Canavel due to the fact that incisions within this zone can be accompanied by damage to the motor branch of the median nerve to the muscles of the thumb and to their dysfunction.
Canavel brush projection
The "forbidden zone" of the hand according to the Canavel is projected onto the proximal third of the eminence of the thumb ( thenar).
CHAPTER 3
TOPOGRAPHIC ANATOMY OF THE BUTT REGION, HIP JOINT, THIGH REGION,
PREKLENE FOOSTER
3.1 Topography of the gluteal region (regio glutealis)
Region boundaries:
upper- iliac crest;
bottom- gluteal fold;
medial- the median line of the sacrum and coccyx;
lateral- a conditional line running from the anterior superior iliac spine to the greater trochanter.
Layered topography
1) Leather.
2) Subcutaneous adipose tissue well developed and permeated with fibrous fibers running from the skin to the gluteal fascia. In this regard, the superficial fascia of the region is almost not pronounced. In the subcutaneous tissue, the upper (nn. clunium superiores)(from the posterior branches of the lumbar spinal nerves), middle (nn. clunium medii)(from the posterior branches of the sacral spinal nerves) and lower (nn. clunium inferiores)(from the posterior cutaneous nerve of the thigh) the nerves of the buttocks. In the upper-outer part, the subcutaneous tissue is divided by a spur of the superficial fascia into the superficial and deep layers. The deep layer passes over the iliac crest into the lumbar region and is called the lumbosacral fat pad (massa adiposa lumboglutealis).
3) Gluteal fascia (fascia glutea)... In the upper-lateral region, it covers the gluteus medius muscle. For the rest of the area, it forms the sheath of the gluteus maximus muscle, and numerous spurs extend from the superficial leaf of its own fascia to the muscle. This explains the fact that suppuration in the thickness of the gluteus maximus muscle that occurs after intramuscular injections has the character of limited infiltrates that cause severe pain.
4) Muscle the gluteal region lie in 3 layers:
ü the superficial layer of the muscles is the gluteus maximus muscle (m. gluteus maximus);
ü middle muscle layer (location indicated from top to bottom): middle gluteal (m. gluteus medius), pear-shaped (m. piriformis), upper twin (m. gemellus superior), internal locking (m. obturatorius internus), lower twin (m. gemellus inferior) and square femoris (m. quadratus femoris);
ü the deep layer is represented by two muscles: at the top, the gluteus maximus muscle (m. gluteus minimus), below the external obturator muscle (m. obturatorius externus).
The topography of the epigastric ( foramen suprapiriforme) and under-ear holes ( foramen infrapiriforme) , the main neurovascular bundles of the gluteal region
Sacrospinous (lig.sacrospinale) and sacro-tuberous (lig.sacrotuberale) ligaments turn the major and minor sciatic notches into two holes: the large and small ischial foramen (foramina ischiadica majus et minus).
Through the large sciatic foramen, the piriformis muscle exits the pelvic cavity. The muscle does not completely fill the large sciatic foramen, but above and below it there are cracks - the supra-pyriform and sub-pyriform foramen.
The internal obturator muscle passes through the small sciatic foramen.
Through the supra-piriform opening (between the lower edge of the gluteus medius and the upper edge of the piriformis muscle) the superior gluteal artery leaves the pelvic cavity (a. glutea superior) with veins and nerves of the same name (n. gluteus superior)... The branches of the superior gluteal artery are anastomosed with the inferior gluteal artery and the lateral artery that surrounds the femur.
Projection upper gluteal SNP: a point on the border of the medial and middle third of the line connecting the superior posterior iliac spine with the apex of the greater trochanter. This point coincides with the position of the supra-pear-shaped opening.
Through the pear-shaped opening (between the lower edge of the piriformis muscle and the upper edge of the sacrospinous ligament)
exit: sciatic nerve (n. ischiadicus), lower gluteal artery (a. glutea inferior), vein and nerve (n. gluteus inferior), internal genital artery and vein (a. et v. pudendae internae), pudendal nerve (n. pudendus), posterior cutaneous nerve of the thigh (n. cutaneus femoris posterior).
The arrangement of the elements in the lateral-medial direction: sciatic nerve, posterior cutaneous nerve of the thigh, lower gluteal nerve, lower gluteal vessels, internal genital vessels, pudendal nerve.
Piriform hole projected in the middle of a line drawn from the posterior superior iliac spine to the lateral edge of the ischial tubercle. The sciatic nerve at the lower edge of the gluteus maximus muscle lies relatively superficially, directly under the broad fascia, at the level of the vertical, which passes through the middle of the line connecting the sciatic tubercle with the greater trochanter.
Cellular spaces and ways of spreading purulent streaks
In the gluteal region, 2 cellular spaces are distinguished: superficial- between the gluteus maximus muscle and the middle layer of the muscles (communicating),
deep- a closed fibrous cellular space, in which the gluteus medius and small muscles are enclosed.
Ways of spreading purulent streaks:
1) Through the podhiriform opening along the neurovascular bundles with fiber of the middle floor of the pelvic cavity.
2) Through the small sciatic foramen along the genital neurovascular bundle with the tissue of the sciatic-rectal fossa;
3) With the posterior fascial bed of the thigh along the sciatic nerve.
4) In the anterior direction, the gluteal tissue communicates with the deep tissue of the adductor muscle region along the branches of the obturator artery.
3.2 Topography of the hip joint (articulatio coxae)
The hip joint is formed by the acetabulum of the pelvic bone (acetabulum) and the head of the femur (caput ossis femoris)... The articular surface of the acetabulum is complemented by the acetabular (cartilaginous) lip (labrum acetabulare).
Capsule and ligamentous apparatus
The capsule of the hip joint is attached to the pelvic and femur bones in such a way that most of the cartilaginous ring and the entire anterior surface of the femoral neck are in the joint cavity, behind the lateral quarter of the neck remains outside the joint cavity.
The joint is strengthened with intra- and extra-articular ligaments.
Intra-articular ligament - femoral head ligament (lig capitis femoris).
In the thickness of the articular bag lies a circular zone - zona orbicularis, it covers in the form of a loop the neck of the femur.
There are three extra-articular ligaments: ilio-femoral (lig.iliofemorale), pubic-femoral (lig. pubofemorale), ischio-femoral (lig. ischiofemorale).
Blood supply
Blood supply: branches of the superior and inferior gluteal arteries (from the system of the internal iliac artery), branches of the medial and lateral arteries that bend around the femur (from the system of the femoral artery), as well as the acetabular branch of the obturator artery, which penetrates into the cavity of the hip joint.
Venous outflow occurs through the veins accompanying the listed arteries.
Innervation: branches of the lumbar plexus (femoral, obturator nerves) and sacral plexus (lower gluteal, sciatic nerves).
Weak spots
Between the external ligaments of the joint, the joint capsule is weakly strengthened, and these spaces between the ligaments are weak points, since under certain conditions dislocations occur in this area.
To determine the presence of a dislocation, a line is drawn through the anterosuperior iliac spine and the sciatic tubercle (Roser-Nelaton line)... The displacement of the greater trochanter from the level of this line indicates the presence of a dislocation in the joint or a fracture of the femoral neck.
Under the lower edge of the ischio-femoral ligament, a protrusion of the synovial membrane (posterior-inferior joint weakness) may form.
Between lig. iliofemorale and lig. pubofemorale on the one hand and m. iliopsoas on the other side downwards and somewhat outwards from eminentia iliopectinea is a large bursa iliopectinea(anterior joint weakness).
Projection
If you slightly bend the hip at the hip joint, then the apex of the greater trochanter will be on the line connecting the anterior superior iliac spine with the apex of the ischial tuberosity (Roser-Nelaton line).
The perpendicular passing through the middle of the inguinal ligament divides the head of the femur into two equal parts, i.e. determined hip projection.
Puncture points
Puncture is performed from the anterior or lateral surface.
When punctured from the front, the needle is inserted strictly in the anteroposterior direction to a point located in the middle of the line drawn from the apex of the greater trochanter of the femur to the border between the inner and middle thirds of the inguinal ligament. The injection is made outward from the pulsation of the femoral artery.
When puncturing the joint from the outside, the needle is inserted above the apex of the greater trochanter in the frontal plane.
3.3 General characteristics of the thigh area (femur)
Borders:
ü front and top - inguinal ligament;
ü behind and above - gluteal fold;
ü lower - a conditional circular line drawn two transverse fingers (4cm) above the level of the base of the patella.
Two vertical lines drawn upward from both epicondyles of the femur divide the thigh area into two sections: anterior and posterior.
The muscles of the thigh are presented in 3 groups: anterior (extensors), posterior (flexors) and medial (adductor muscles).
These muscle groups are separated from each other by intermuscular septa (medial, lateral, posterior), which extend from the fascia lata of the thigh and are attached to the femur.
Thus, each muscle group is enclosed in a separate fascial bed.
The anterior bed with the extensors and the medial bed with the adductor muscles belongs to the anterior surface of the thigh, the posterior bed to the posterior surface.
3.4 Topography of the anterior surface of the thigh (regio femoris anterior)
Borders:
ü above- inguinal ligament;
ü from below- a conditional circular line drawn two transverse fingers above the level of the base of the patella;
ü laterally and medially- vertical lines drawn upward from both epicondyles of the femur.
Layered topography:
1) Leather. Thin, mobile. Innervated by the femoral branch of the femoral genital nerve (r. femoralis n. genitofemoralis), anterior cutaneous branches of the femoral nerve (rr. cutanei anteriores), lateral cutaneous nerve of the thigh (n. cutaneus femoris lateralis), cutaneous branch of the obturator nerve (r. cutaneus nervi obturatorii).
2) Subcutaneous adipose tissue. The superficial branches of the femoral artery pass, accompanied by the veins of the same name: superficial epigastric artery (a. epigastrica superficialis), superficial artery, the circumflex of the ilium (a. circumflexa ilium superficialis), external genital arteries (aa. pudendae externae).
3) Superficial fascia. Consists of two sheets, between which the cutaneous nerves and the great saphenous vein of the leg pass (v. saphena magna).
4) Wide fascia of the thigh (fascia lata)... In the upper third of the thigh, medially from the sartorius muscle, the fascia splits into 2 sheets: deep (goes behind the femoral vessels, covering the iliopsoas muscle, the comb muscle with the femoral nerve) and superficial (runs anterior to the femoral vessels and connects with a deep leaf inward from the femoral vein ). In the superficial leaflet, an oval-shaped hole is determined - a subcutaneous fissure (hiatus saphenus)... The hole is covered with a lattice fascia (fascia cribrosa)- many lymphatic vessels pass through it, carrying lymph from the superficial inguinal nodes to the deep ones. The lateral edge of the slit is thickened, has a sickle shape - a sickle edge (margo falciformis)... The upper part of it is called the upper horn (cornu superius), lower - lower horn (cornu inferius)... The upper horn merges with the inguinal ligament, the lower horn - with the deep plate of the wide fascia covering the comb muscle.
5) The muscles of the anterior and medial beds. Anterior group: quadriceps femoris (m. quadriceps femoris) - consists of 4 heads - rectus femoris (m. rectus femoris), lateral (m. vastus lateralis), medial (m. vastus medialis) and intermediate (m. vastus intermedius) broad thigh muscles; sartorius (m. sartorius)... Medial group: comb (m. pectineus), long and short leading (m. adductor longus et m. adductor brevis), large leading (m. adductor magnus) and thin muscles (m. gracilis).
6) Femur (femur).
On the front surface of the thigh, a number of practically important formations are distinguished: the femoral triangle, the femoral groove, the adductor canal, the femoral canal (normally absent) (see below).
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